Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 5

Letter D – Disability

The so-called disability refers to the patient’s neurological status. However, carrying out a complete neurological examination during the primary survey is absolutely out of discussion.

So then, what do we have to evaluate?

It is possible to divide this assessment into four steps:

  1. Level of consciousness: evaluate the Glasgow Coma Scale (GCS).
    Remember that you have already evaluated the level of consciousness during the assessment of the airways. However, now you need to calculate the GCS to determine the severity of the traumatic brain injury (TBI) and to have something to use to monitor the patient during time.
Eye opening responseSpontaneously
To speech
To pain
No response
Best verbal responseOriented to time, place, and person
Inappropriate words
Incomprehensible sounds
No response
Best motor responseObeys commands
Moves to localized pain
Flexion withdrawal from pain
Abnormal flexion (decorticate)
Abnormal extension (decerebrate)
No response
Glasgow Coma Scale
Total score:
– 13-15 →  Mild TBI
– 9-12 →  Moderate TBI
– 3-8 →  Severe TBI
If the patient is tubed, do not consider the best verbal response. Therefore, the score will be between 2 and 10, and it should be reported with a T (e.g. GCS 6T). consider also if the patient is pharmacologically sedated or not. 

As already stated in the section concerning the airway management, if your patient suffered a severe TBI (GCS <8), you must secure the airways. The reason behind this statement can be explained through three different aspects:

  • To maintain adequate cerebral oxygenation (cerebral hypoperfusion and low oxygenation may cause secondary brain injury, thus worsening patients’ outcomes)
  • To protect the airways (patients with severe TBI may present incoercible vomiting or bleeding from the mouth and, consequently, high risk of aspiration)
  • To better control ventilation (in patients with severe TBI causing intracranial hypertension, pCO2 should be kept at its lower limit (i.e. between 32-35 mmHg) to avoid cerebral vasodilation and a further increase in intracranial pressure). To keep pCO2 steadily below 30 is not recommended, even though it could be a bridge therapy

Remember that perfusion, as well as oxygenation, is vital to decrease the risk of secondary brain injury and death. Therefore, the systolic blood pressure must be kept around 100-110 mmHg. 

  1. Pupils: check their size, shape, symmetry, and reactivity to light.
SizeResponse to LightPathology
NormalAbsentToxic, midbrain injury
Pinpoint, symmetricMinimal or absentOpioids intoxication, pons injury
Semidilated, asymmetricAbsentMidbrain injury
Dilated, asymmetricAbsent on the dilated sideUncal herniation (intracranial hypertension)
Dilated, symmetricAbsentSevere coma, brain death
Asymmetric means that pupils’ diameters differ >1 mm; dilated means pupils’ diameter >4 mm; fixed means that pupils’ diameter changes <1 mm in response to bright light.
  1. Lateralizing signs: check, if possible, for gross differences both in motility and sensibility between the right and the left side.
  1. Spinal cord: look for paraplegia or quadriplegia.
    Paraplegia (i.e. the partial or complete paralysis of the lower half of the body) is the consequence of a spinal injury below T1, where quadriplegia (i.e. the partial or complete paralysis of both the arms and legs) represents an injury of the cervical spine (between C1 and T1). If quadriplegia is present beware of respiratory distress due to a loss of control to the centers of breathing. Moreover, if the patient has either paraplegia or quadriplegia and he/she is hypotensive, consider the possibility of an ongoing neurogenic shock, mainly if the hemodynamic instability is not responding to fluid resuscitation.

Remember that intoxication (e.g. alcohol, drugs…) and hypoglycemia may cause a decreased level of consciousness and pupils’ abnormalities. Nevertheless, intoxication may accompany TBI. Therefore, all patients with decreased GCS must be considered as having a central nervous system injury, until proven otherwise.

Letter E – Exposure & Environmental Control

This part is quite confusing. Basically, it can be resumed into the following steps:

  • Completely undress the patient (if not already done), usually cutting off his/her clothes (so that the patient does not need to move). Remember to remove all the jewelry; a trauma patient is at high risk of peripheral edema secondary to resuscitation. If he/she is still wearing a ring, this could get stuck, causing a compartment syndrome;
  • Warm the patient up with external warming device and with warm fluids (it seems stupid, but do not give warm fluids just to warm the patient; use warm fluids if the patient needs fluids);
  • Do a log-roll. This is a maneuver performed by 4 people, which allows the examination of the posterior aspect of the body keeping the patient’s spine in axis, thus reducing the risk of spinal cord injuries.
    During this operation you must:
    • Look for injuries (ecchymosis, excoriations, burns, cuts, gunshot wounds…);
    • Palpate the vertebral spinous processes. If the patient complains pain during this maneuver, appropriate imaging of the spine must be accomplished to exclude possible fractures;
    • Perform a digital rectal examination (DRE). This procedure can give you two vital information: the presence of blood inside the rectum, and maintenance of anal sphincter tone and contractility. The first element is a high index of suspicion for large bowel injury (e.g. if a patient with a pelvic fracture has blood at DRE, a rectal injury made by a bony fragment must be highly suspected). The second evidence may indicate a spinal cord injury.

During the “E phase” think also about tubes or catheters you may need, like an orogastric tube (yes, oral and not nasal!) or a urinary one.

In trauma, every intubated patient will need a gastric tube, initially for decompression, and later for feeding. This tube, in elective surgery, goes through the nose. In trauma there is a high risk of fractures of the nose or the ethmoid cranial bone, meaning that your nasogastric tube might end into the brain! Therefore, in case of doubt, always use the oral way!

Adjuncts to the Primary Survey

During the primary survey, there are some procedures or devices you are allowed to use in order to better evaluate the patient and to correct any derangement from the normal status recorded during the assessment. This does not mean that you have to use them all.

Here is what you can use:

  • Monitoring: pulse oximetry, blood pressure cuff, electrocardiographic monitoring, arterial line, urinary catheter, capnography, nasogastric tube, blood gas, lab exams;
  • Devices: IV-lines, intraosseous access, central line, oxygen mask, endotracheal tubes, chest drain, tourniquet, pelvic binder, Philadelphia collar, spinal board, external warming devices.

But now we are at the end of our primary survey, we have completed the letter E and we are still missing something: the adjuncts!

Permanently stick in your mind to always ask for a chest X-Ray and a pelvic X-Ray for a trauma patient! They are easy to perform and will give you a lot of very interesting information (and sometimes they will also carry some surprises!).

  • Chest X-Ray: it will show you the thoracic situation. Consider that it will be done with a supine patient, so some information will be hard to interpret. Still, you can have information about: the trachea (in line or not?, is there a tube in or not?), lungs (expanded or not? PNX?), heart shadow, diaphragm, fluids in the pleura, lines or tubes set in during the primary survey, bullets or marks, bone fractures, etc…
  • Pelvic X-Ray: again it will give you information about the pelvic rings and their situation (are they regular, are there fractures?), you can also evaluate the trochanters, and the proximal part of the femurs. In a penetrating trauma you may get a better idea of the trajectory of the bullet.

Now something we are very enthusiastic about: e-FAST!

Ultrasound is been widely used and it is of extreme help! Before we start spending a few words on its usefulness, let us clarify a couple of things: 

  • We are speaking about ultrasound now and not before because we want you not to substitute semeiotic signs and findings with a machine. We want you to learn how to survive without it, and not rely too much on a great technology. Use your clinical abilities to evaluate the patient and then confirm your findings with ultrasounds (because your hands and ears don’t have a battery than may run out);
  • Secondly, we strongly suggest you to learn how to use the machine and how to properly do a complete abdominal and thoracic ultrasound evaluation before starting doing e-FASTs. If you only learn how to do a FAST you will not get the eyes’ sensibility to catch minor details among a grey screen (the sensibility and specificity of your exam will be extremely low). Moreover, you will also be able to recognize artifacts or para-physiological findings avoiding major errors (like mistaking a full stomach for a shattered spleen and sparing the patient a laparotomy – we saw that!). eFAST is a very mighty instrument, but with no brain in using it, it may be very dangerous!

Our last few words are about the Peritoneal Lavage: thanks to the spreading of ultrasound, this invasive technique is about to be abandoned. Keep it in the back of your mind if you find yourself in a very extreme situation, and you have nothing else to do. Sometimes could be better to take the patient to the OR and do a trauma laparotomy than trying to do a peritoneal lavage in the ED.
One more thing: if the patient has enough free fluid (abdominal or thoracic), and the situation is “stable”, you can try to suck some fluid under US-guidance. This may help you to confirm your suspect!

We know you are tired or reading, but try to stay strong for few more concepts.

Last things you have to check for your patient:

  • Tetanus vaccine: does the patient need it?
  • Antibiotics: should I give them to my patient?
  • Dressings: are there wounds needing to be dressed?


After you have completed the primary survey, the patient must be stable. This is the precise moment in which you must decide if you need to transfer the patient to a better-equipped hospital, or if you have everything you need to treat him/her adequately.

Do I have:

  • Enough experience to treat the patient?
  • Enough equipment to treat the patient (blood bank, ICDs, angiography suit…)?
  • Enough specialized-colleges to treat the patient (orthopedics, neurosurgeons, trauma surgeons, specialized nurses, interventional radiologists….)?
  • Enough in-hospital preparedness to treat the patient (ORs, ICUs, sub-intensive wards….)?

If the patient is not stable enough to be transferred, stabilize the patient first, and then transfer him/her. The patient must survive the journey to the other hospital!

If the patient can be safely transferred, do not delay this with additional procedures (do not lose time to wait for a CT scan that will be surely repeated in the receiving hospital!).

Lastly, before transferring the patient, you must communicate with the receiving hospital to arrange the transport, make sure that along the way there are enough personnel and equipment to treat any worsening of the patient’s clinical condition.

We know it has been a long trip, but you made it to the end of the primary survey.

Now take a deep restoring breath before sinking into the secondary survey…

See you soon!


  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Peitzman AB, et al. The Trauma Manual: trauma and acute care surgery; 4th Ed. Philadelphia, PA: Lippincott; 2013.
  3. European resuscitation Council and European Society for Trauma and Emergency Surgery. European Trauma Course: the team approach.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Disability & Exposure. Surgical Pizza. Published on August 1, 2020. Accessed on September 11, 2023. Available at [].

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