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Direct pressure -> Wound packing with hemostatic gauze -> Arterial tourniquet high & tight
1:1:1 MTP (1 PRBC : 1 FFP : 1 Platelet pack); avoid crystalloids
1g IV bolus over 10 min administered < 3 hours from injury, then 1g over 8 hours
Apply commercial binder centered over greater trochanters for suspected pelvic fracture
Administer 1g Calcium Chloride IV for every 4 units of blood products to treat hypocalcemia
Bottom-Line Clinical Pearl
Hemorrhage is the leading cause of preventable trauma death. Stop external exsanguinating hemorrhage first (MARCH algorithm). Follow the ATLS ABCDE primary survey with rigid cervical spine protection. Activate the Massive Transfusion Protocol (1:1:1 PRBCs : FFP : Platelets) early for severe shock (ABC score >= 2 or Shock Index > 1.0). Administer Tranexamic Acid (1g IV bolus) within 3 hours of injury. Never give cold saline—prevent the lethal triad of hypothermia, acidosis, and coagulopathy.
The primary survey identifies and treats life threats in hierarchical order of lethality. Modern military and civilian trauma protocols prioritize catastrophic external hemorrhage above all else, integrating the MARCH paradigm into standard ATLS ABCDE:
| Phase | Clinical Focus | Immediate Interventions | Life-Saving Diagnostic Targets |
|---|---|---|---|
| M: Massive Hemorrhage | Exsanguinating external bleeding | Apply commercial limb tourniquet 2–3 inches proximal to wound; pack junctional wounds (groin/axilla) with hemostatic gauze | Arrest catastrophic arterial bleeding before addressing airway. |
| A: Airway with C-Spine | Airway patency & cervical spine stabilization | Rigid cervical collar, manual inline stabilization; suction blood/vomitus; jaw thrust (NO head tilt); rapid RSI or surgical cricothyroidotomy | Establish definitive airway if GCS <= 8, severe facial smash, or expanding neck hematoma. |
| B: Breathing & Respiration | Tension pneumo, open pneumo, flail chest | Decompress tension pneumothorax (5th ICS anterior axillary line); seal sucking chest wound on 3 sides; chest tube placement (28–32 Fr) | Assess chest rise, bilateral breath sounds, tracheal position, and chest wall integrity. |
| C: Circulation & Shock | Internal hemorrhage, pelvic stability, pulses | Bilateral 14–16G peripheral IVs; eFAST ultrasound; apply pelvic binder over greater trochanters; activate 1:1:1 MTP | Check central/peripheral pulses, cap refill, Shock Index (HR/SBP > 1.0 indicates severe hemorrhage). |
| D: Disability (Neuro) | Gross neurologic status & brain injury | Glasgow Coma Scale (GCS 3–15), pupil size and light reactivity, motor movement in all 4 extremities | Identify acute intracranial herniation; check fingerstick glucose immediately. |
| E: Exposure & Environment | Complete inspection & hypothermia prevention | Completely remove all clothing; log-roll with spinal precautions to inspect back, spine, and rectal tone; apply warm blankets/warm fluids | PREVENT HYPOTHERMIA: Core body temperature < 35°C cripples coagulation enzymes. |
Damage Control Resuscitation (DCR) abandons large-volume crystalloid infusions in favor of balanced blood component therapy and permissive hypotension. Crystalloids dilute clotting factors, strip endothelial glycocalyx, and worsen coagulopathy. Permissive hypotension targets a Systolic BP of 80–90 mmHg (MAP 50–60 mmHg) until surgical or angiographic hemorrhage control is achieved (except in severe traumatic brain injury, where SBP must be maintained >= 100–110 mmHg to preserve cerebral perfusion).
| Resuscitation Element | Standard Protocol/Ratio | Target Goal/Mechanism | Clinical Caveat |
|---|---|---|---|
| Balanced Transfusion (MTP) | 1:1:1 Ratio: 1 unit PRBC : 1 unit FFP : 1 unit Platelets | Reconstitutes whole blood physiology; prevents dilutional coagulopathy | Use uncrossed O-negative (women of childbearing age) or O-positive blood until crossmatched. |
| Assessment of Blood Consumption (ABC) Score | >= 2 Points triggers MTP | 1 point each: Penetrating mechanism, SBP <= 90 mmHg, HR >= 120 bpm, Positive FAST exam | Sensitivity 75%, Specificity 86% for massive transfusion requirement (> 10 units PRBC in 24h). |
| Tranexamic Acid (TXA) | 1g IV bolus over 10 min, then 1g IV infusion over 8h | Inhibits plasminogen activation; halts hyperfibrinolysis (CRASH-2 trial: 15% mortality reduction) | MUST BE ADMINISTERED WITHIN 3 HOURS OF INJURY. Giving TXA > 3h post-injury increases mortality. |
| Ionized Calcium Repletion | 1g Calcium Chloride IV (or 3g Calcium Gluconate) | Maintain ionized calcium > 1.0–1.1 mmol/L | Citrate in blood products chelates calcium; hypocalcemia causes profound hypotension and cardiac arrest. |
The eFAST examination is performed during the 'C' and 'B' phases of the primary survey. It rapidly detects hemoperitoneum, hemopericardium, and hemothorax/pneumothorax in under 2 minutes:
| eFAST Window | Transducer Position | Key Anatomical Landmarks | Positive Sonographic Finding |
|---|---|---|---|
| Right Upper Quadrant (RUQ) | Midaxillary line, 8th–11th intercostal space | Morison's pouch (hepatorenal recess), right kidney, liver, right diaphragm | Anechoic (black) fluid stripe in Morison's pouch or right pleural space above diaphragm (most sensitive abdominal view). |
| Left Upper Quadrant (LUQ) | Posterior axillary line, 6th–9th intercostal space | Splenorenal recess, spleen, left kidney, subdiaphragmatic space | Anechoic fluid stripe in splenorenal recess or subphrenic space (blood tracks superior to spleen). |
| Pelvic (Suprapubic) | Midline, 1–2 cm superior to pubic symphysis (transverse and sagittal) | Urinary bladder, rectovesical pouch (males)/rectouterine pouch of Douglas (females) | Anechoic free fluid posterior to the bladder or surrounding the uterus. |
| Pericardial (Subxiphoid) | Subxiphoid angle, directed toward left shoulder | Liver acoustic window, right ventricle, left ventricle, pericardial sac | Anechoic stripe separating visceral and parietal pericardium; right ventricular diastolic collapse. |
| Thoracic/Pleural (Bilateral) | Midclavicular line, 2nd–4th ICS; anterior axillary line, 5th–7th ICS | Rib shadows, pleural line, lung sliding | Absence of lung sliding + presence of 'lung point' (confirms pneumothorax); anechoic fluid above diaphragm (hemothorax). |
Critical Pitfall / Contraindication
Pelvic Fracture Hemorrhage & Proper Binder Placement: Open-book pelvic ring disruptions (Anterior-Posterior Compression (APC) fractures) lacerate the presacral venous plexus and internal iliac arterial branches, capable of holding the patient's entire blood volume. Diagnostic step: Palpate the pelvis ONCE with gentle inward compressive force; do NOT vigorously 'rock' the pelvis (dislodges nascent hemostatic clots). Management: Apply a commercial pelvic binder (or folded sheet) centered DIRECTLY OVER THE GREATER TROCHANTERS (not the iliac crests). Positioning over the iliac crests fails to close the pelvic volume.
Test Your Trauma Primary Survey & Hemorrhagic Shock Clinical Acumen
Directly launch an active-recall practice block from our validated question bank with comprehensive explanations and distractor analyses.
Distinguish primary life-threats from mimics. On board exams (COMLEX Level 1, 2-CE, 3 & USMLE), initial stabilizing interventions (airway, IV access, non-invasive ventilation, empiric reversal) always take precedence over diagnostic imaging.
Evaluate autonomic tone: Sympathetic viscerosomatics (T1–L2) cause acute paraspinal tissue texture changes (erythema, bogginess, hypertonicity). Suboccipital release (CN X Vagus) and rib raising normalize autonomic outflow and thoracic cage mechanics.