Management of trauma patients

Last updated: November 6, 2023

Summarytoggle arrow icon

Trauma is one of the leading causes of death worldwide and, in the United States, the leading cause of death in young adults. Traumatic injuries range from isolated wounds to life-threatening multi-organ injuries. Advanced trauma life support (ATLS) is a framework for the systematic evaluation of trauma patients to improve outcomes and reduce missed injuries. Prehospital trauma care involves life-saving interventions and basic life support in the field by emergency medical services while providing rapid transportation to the nearest appropriate hospital. In the hospital, the assessment of trauma patients begins with a primary survey in which life-threatening conditions are identified and treated using the sequential ABCDE approach. After the patient is stabilized, the secondary survey is performed, which involves a thorough history and physical examination as well as diagnostic testing to identify other injuries. The tertiary survey is performed within 24 hours of presentation to identify missed injuries. If at any point during the evaluation the patient's needs exceed the hospital's capabilities, the process to transfer the patient to a trauma center should be initiated. Trauma management of pregnant, geriatric, and pediatric patients requires additional considerations given their unique physiology.

See also “Blunt trauma” and “Penetrating trauma.”

Definitiontoggle arrow icon

  • Trauma center [1]
    • A health facility that provides specialized care to patients with serious traumatic injuries.
    • Different levels (e.g., I–V) of trauma center can be designated
  • Trauma team [1]
  • Advanced trauma life support (ATLS) [1]
    • A framework for managing patients with serious injuries in prehospital and hospital settings.
    • Describes management sequences (e.g., ABCDE algorithm) that prioritize the most immediately life-threatening injuries first.
    • Aims to standardize trauma care across centers with varying resources and experience with trauma management
  • Polytrauma: severe injuries occurring in more than one anatomic region that cause systemic physiological disturbances [2]

Overviewtoggle arrow icon

Trauma care varies based on patient injuries, receiving center resources (e.g., equipment, consultants), and institutional and regional guidelines. Recommendations in this article are consistent with the 2018 Advanced Trauma Life Support guidelines. [1]

Overview of ATLS [1]

Sequence of trauma care

  1. Prehospital trauma care and transportation to hospital
  2. Primary survey
  3. Transfer to trauma center (if needed)
  4. Secondary survey
  5. Tertiary survey

Key components of ATLS

Overview of ATLS
Key components
Primary survey
Secondary survey
Tertiary survey
  • Detailed history and physical to identify missed injuries
  • Additional diagnostics (if needed)
  • Quality and safety measures
Special patient groups

Overview of injury mechanisms

Overview of injury mechanisms [1]
Mechanisms of injury Potential injuries

Blunt trauma

Penetrating trauma

Thermal injury
Blast injuries
Other environmental injuries

Overview of immediately life-threatening injuries

Recognition and initial management of common critical injuries
Suggestive findings Initial management
Airway compromise
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac tamponade
External hemorrhage
Internal hemorrhage

Prehospital trauma caretoggle arrow icon

Prehospital trauma care is situation-dependent and centered on field stabilization of the patient and prompt transport to the closest trauma center.

Bystanders [1][3]

Emergency medical services (EMS) [1][4]

Prehospital trauma care provided by physicians varies regionally. [5]

Primary surveytoggle arrow icon

The ABCDE algorithm in ATLS provides a sequence to help prioritize treating the most rapidly life-threatening injuries first. In clinical practice, trauma team members evaluate and treat these simultaneously, continually reassessing each injury's severity throughout the resuscitation. [1]

Airway (and C-spine stabilization) [1]

Identify and treat airway obstruction (e.g., due to blood, direct injury, edema) and/or loss of airway protective reflexes, (e.g., due to AMS or coma), while preventing further C-spine injury.

Perform cricothyrotomy in case of intubation failure.

Consider early intubation for impending airway obstruction in patients with signs of inhalation injury, moderate to severe facial and oropharyngeal burns, and extensive body burns. [8]

Breathing [1]

Identify and treat chest injuries, e.g., tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and tracheobronchial injuries.

If traumatic pneumothorax is suspected in a patient requiring positive pressure ventilation, perform tube thoracostomy immediately to prevent progression to tension pneumothorax. [1]

Circulation [1]

Provide immediate hemodynamic support and hemostatic measures while identifying sources of bleeding, e.g., external hemorrhage, thoracic cavity, abdominal cavity, thighs, retroperitoneal space.

If there is a loss of vital signs, treat traumatic cardiac arrest with emergency chest decompression and emergency thoracotomy.

Suspect cardiac tamponade in patients with penetrating chest injury with Beck triad and a positive FAST scan, and expedite urgent pericardial fluid drainage via thoracotomy.

Penetrating abdominal injury with signs of shock is usually an indication for exploratory laparotomy.

Disability [1]

Identify life-threatening traumatic brain injury (TBI), begin measures to limit secondary brain injury, and expedite definitive surgery if indicated.

Remain vigilant for signs of traumatic brain injury in intoxicated patients. [1]

Exposure (and environmental control) [1]

Diagnostic adjuncts [1]

Consider the following studies during the primary survey if they are likely to impact immediate management:

Use bedside studies for rapid diagnostics in patients that are too unstable for transport to imaging suites.

Traumatic circulatory arrest [1]

Traumatic cardiac arrest requires bedside surgical interventions by trained personnel and subsequent operative treatment and stabilization. Do not follow standard ACLS algorithms as these are unlikely to be effective.

Resuscitative thoracotomy [12]

The following is consistent with the 2015 Eastern Association for the Surgery of Trauma (EAST) recommendations on emergency department thoracotomy. Follow local policies as indications vary regionally. [12]

  • Definition: a bedside procedure performed in the emergency department or trauma bay to obtain emergency access to the thoracic cavity to provide temporizing lifesaving measures in pulseless patients
  • Purpose
  • Indications
    • Pulseless patients after penetrating thoracic injury
    • Pulseless patients after penetrating extrathoracic injury, excluding isolated cranial injuries
    • Pulseless patients with recently documented signs of life in the field or at the hospital after blunt injury
  • Contraindication: pulseless patients without any documented signs of life in the field or at the hospital after blunt injury

Do not perform resuscitative thoracotomy unless a qualified surgeon is present. [1]

Interim management

Consider the following once the primary survey is complete:

  • Reassess the effectiveness of life-saving bedside interventions.
  • Prepare for urgent time-sensitive imaging (e.g., CT head) once the patient is stable enough.
  • Determine if the patient needs immediate surgery, urgent interfacility transfer, or immediate specialty consult (see “Disposition”).
  • Next steps: See “Secondary survey.”

If there is clinical deterioration at any time, repeat the primary survey to identify a critical cause.

Urgent interfacility transfer [1]

The following applies to patients initially evaluated at facilities that are not trauma centers:

  • The decision to transfer a patient to a trauma center for definitive care is multifactorial.
  • See “Criteria for trauma team activation” for conditions that typically require management by a trained trauma team.
  • If tests are required prior to transfer, keep them limited to tests that will ensure a safe transfer.
  • Communicate with the receiving physician and transportation team about clinical and diagnostic findings.

Do not delay an urgent transfer in order to complete an in-depth diagnostic evaluation.

Secondary surveytoggle arrow icon

The secondary survey is performed after the patient is stabilized and it involves a thorough history and physical examination as well as diagnostic testing to identify other injuries.

History [1]

Obtain the following to anticipate likely injuries and estimate patient's physiological reserve.

Obtain collateral information from EMS, family, and/or witnesses, especially if the patient is unable to provide a reliable history.

Physical examination [1]

A systematic head-to-toe physical examination must be completed to identify additional injuries.

Secondary survey in trauma patients [1]
Examination Injuries
Cervical spine and neck

Abdomen and pelvis

Back and flank
  • Inspect upper and lower extremities for lacerations or deformities.
  • Palpate upper and lower extremities for tenderness.
  • Palpate peripheral pulses.
  • Assess motor and sensory functions of upper and lower extremities.

Do not forget to log roll patients who are under C-spine precautions to examine the back and spine.

Diagnostic adjuncts [1]

Consider the following diagnostic studies and procedures during the secondary survey once the patient is stable:

Further management

Tertiary surveytoggle arrow icon

Goal [1][13]

A standardized tertiary survey with high-quality imaging may limit the incidence of missed injuries. [14]

Approach [1][13]

Hand and foot injuries are the most common missed injuries. [15][16]

Missed injuries [15][16][17]

Missed injuries are an important area of focus for quality and safety in trauma care, however, high-quality evidence is limited. [14]

Risk factors [1][13][18][19]

Beware of anchoring bias and premature closure bias during the tertiary survey.

Injuries at risk of missed or delayed diagnosis [14][15][16]

The following have a higher potential to remain undetected after initial evaluation.

Surface wounds


Head, neck, and spine



Diagnosticstoggle arrow icon


  • Consider clinical judgment, mechanism of injury, and patient factors (e.g., age, hemodynamic status) when choosing diagnostic studies.
  • Weigh the need and timing of diagnostic studies against the need for urgent interfacility transfer or surgical intervention for each patient.
  • Follow local policies on diagnostic imaging strategy (e.g., liberal vs. selective) as these vary by institution and region (see “CT imaging in trauma” for details).

ECG [1]

Laboratory studies [1]

Normotensive patients with trauma may have subclinical hypoperfusion. Evaluate for other clinical features of shock and check hemodynamic parameters (e.g., serum lactate, base deficit).

FAST and eFAST [1][20]

See “Point-of-care ultrasound” (POCUS) for procedural details (e.g., image generation and troubleshooting).

Interpret FAST and eFAST alongside other diagnostic parameters and clinical judgment. POCUS does not replace definitive diagnostic studies. [20]

A positive FAST exam in a hemodynamically unstable patient with trauma is usually an indication for urgent operative intervention (e.g., exploratory laparotomy, urgent thoracotomy, pericardiotomy).

Radiography [1]

Bedside chest and pelvic x-rays are commonly performed during the primary survey, while extremity and spine X-rays are typically reserved for the secondary survey.


Pelvic X-ray

Extremity X-rays

Spinal X-rays

Spinal x-rays have been replaced by CT imaging in most trauma centers.

CT imaging in trauma [1]


  • Perform CT scans preferentially during the secondary survey in hemodynamically stable patients with no obvious indications for emergent laparotomy.
  • Make decisions about the timing, necessity, and sequence of CT scans together with all relevant specialists on the trauma team, especially for patients with polytrauma.
  • If a crucial CT scan cannot be delayed as it impacts operative management, ensure trauma teams are at the bedside with stabilizing treatments throughout the procedure.
  • Follow local protocols for CT imaging (e.g., WBCT vs. selective CT imaging) under specialist guidance. [21][22][23][24][25]

Avoid transporting unstable patients out of resuscitation areas to obtain CT scans whenever possible.

Whole-body CT (pan scan) [21]

  • May be performed to evaluate patients with multiple injuries after significant trauma
  • Commonly includes:
    • CT head without IV contrast
    • CT cervical spine without IV contrast
    • CT thoracic and lumbar spine with IV contrast
    • CT chest with IV contrast
    • CTA chest
    • CT abdomen and pelvis with IV contrast

CT head and spine

Consider imaging for spinal fractures in patients with evidence of high-energy trauma to the lower extremities (e.g., calcaneus fracture) after falling from a height.

Obtain CT cervical spine if C-spine injury cannot be ruled out using validated clinical decision tools. [26]

CT chest with IV contrast [27][28]

CTA chest

Consider CTA chest to evaluate for blunt thoracic aortic injury in patients with high-energy trauma and a wide mediastinum on CXR.

CT abdomen and pelvis with IV contrast

Diagnostic peritoneal lavage (DPL)

  • Definition: an invasive diagnostic test used to assess for hemoperitoneum or viscus perforation in abdominal trauma
  • Indications: : may be performed after the primary survey for suspected hemoperitoneum with equivocal or unavailable FAST [1]
  • Procedure: A catheter is placed into the abdomen and contents are aspirated to assess for the presence of blood or fecal matter. If neither is observed, a liter of warm saline is instilled and then collected for cytological analysis.
  • Findings: The presence of bile, fecal matter, or ≥ 10 cc of blood is considered a positive test and is an indication for emergent laparotomy.

Ancillary testing

Additional testing may be performed depending on the mechanism of injury and clinical evaluation, and may include:

Consider diagnostics for genitourinary trauma (e.g., retrograde urethrogram) for patients with hematuria, blood at meatus, inability to void, need for pelvic binder, scrotal hematoma, or perineal ecchymosis.

Suspect tracheobronchial injury in patients with extensive subcutaneous emphysema.

Dispositiontoggle arrow icon

Criteria for trauma team activation [1]

  • Mechanism of injury
    • Falls from > 5 meters
    • Impact from high-speed MVC
    • Ejection from vehicle
    • Any MVC > 18 mph (29 km/h) involving impact with a pedestrian, cyclist, or motorcyclist
    • Death of a vehicle co-passenger
  • Specific injuries
  • Physiological derangements
  • Special patient groups
    • Pregnant patients > 24 weeks' gestation with chest and/or abdominal injury
    • Individuals > 70 years of age with chest injury

Specialty consults

Indications for urgent trauma surgeon consult [4]

At level 1 trauma centers, a trauma surgeon's presence at the bedside within 15 minutes of patient arrival is indicated for any of the following:

Other specialists

Consult all specialists outside the trauma team responsible for managing identified injuries:

Interfacility transfers

  • Initiate the transfer process to a higher level trauma center as soon as the patient's needs exceed the capability of the current hospital.
  • Transfer decision depends on multiple factors, e.g.:
    • The patient's injuries
    • Resources and equipment available at the current hospital
    • Availability of consultant physicians
    • Institutional and regional guidelines
  • Transfer to a burn unit may also be indicated (see “Treatment of burns” for details).

An indication for trauma team activation is generally an indication that the patient requires transfer to a trauma center. [1]

Surgical admission

Discharge from emergency settings

  • Most patients with major trauma require admission for treatment and observation.
  • Consider discharge with outpatient follow-up for patients with all of the following after complete workup and observation:
    • Only minor injuries (e.g., isolated fracture)
    • Adequate analgesia
    • Normal mental status
    • Ability to function with ADLs and IADLs
    • Good social supports
    • No other indications for admission

Special patient groupstoggle arrow icon

Trauma in pregnant individuals

Overview of trauma in pregnancy
Maternal Fetal
Clinical features
  • Minor trauma: obstetric surveillance
  • Major trauma: initial stabilization and resuscitation of the mother as needed; further assessment in trauma center (See “Primary survey””)

Avoid examining the mother in the supine position in order to avoid possible supine hypotensive syndrome.

The mother should be evaluated and treated before the fetus. Early and optimal diagnostics and trauma management of the mother is the best treatment for the fetus.

Management of pregnant patients with trauma [1][34][35]

Even minor trauma poses a risk for placental abruption. [34][36]

Trauma in older adults [1][37]

Common mechanisms of injury

General principles

Geriatric modifications to the primary survey

Trauma in children [1]

Common mechanisms of injury

General principles

Pediatric modifications to the primary survey [1]

Referencestoggle arrow icon

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