Introduction
Trauma is messy, noisy, and unpredictable. In the middle of it all, paramedics and students need a way to bring order to the chaos. That’s where the trauma primary survey comes in.
The primary survey is a structured, step-by-step assessment used worldwide. It ensures life-threatening problems are identified and treated in priority order. The golden rule? You don’t move onto the next step until the current one is fixed (ATLS, 2018).
In this guide, we’ll break down the CABCDE approach, add some memory tools, and highlight the evidence behind why this method saves lives.
What is the Trauma Primary Survey?
The trauma primary survey is a rapid, structured approach to assessing and managing trauma patients.
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It follows the mnemonic CABCDE: Catastrophic haemorrhage, Airway, Breathing, Circulation, Disability, Exposure.
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The goal is to identify and treat immediate life threats in order of priority.
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It’s performed on scene, in the back of the ambulance, and repeated as the patient’s condition evolves.
This method is recommended in ATLS (Advanced Trauma Life Support) (ATLS, 2018) and the UK JRCALC guidelines (JRCALC, 2024), forming the backbone of trauma assessment worldwide.
The Steps of CABCDE
1. Catastrophic Haemorrhage
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Deal with life-threatening bleeding first.
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Apply direct pressure, haemostatic dressings, or tourniquets.
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Remember: uncontrolled external haemorrhage can kill
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faster than an obstructed airway (ETC, 2019).
Example: A patient with a mangled lower limb from a road traffic collision — stop the bleed before you think about airway.
2. Airway with C-Spine Control
- Look for obvious obstructions (teeth, vomit, blood burns, foreign bodies)
- Listen for is the patient talking, gurgling, or silent?
- Feel for air movement
Protect the cervical spine in trauma — manual inline stabilisation or collar if indicated.
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Simple interventions: suction, jaw thrust, or adjuncts (OPA/NPA, supraglottic, ET, FONA).
Rule: Don’t progress until the airway is secure.
Example: A motorcyclist with a decreased GCS and noisy, obstructed airway — airway takes absolute priority.
3. Breathing
Once the airway is open, move on to breathing. Look, listen, and feel for effective ventilation.
Use the mnemonic FLAPS TWELVE (ETC, 2019):
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F – Feel for depth, equality and any instability.
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L – Look for injuries, scars, bruising, paradoxical movement
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A – Auscultate lung fields assessing air entry bi-laterally.
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P – Percuss the chest for dullness/ hyperresonance
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S – Sides and back
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T – Tracheal deviation
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W – Wounds, bruising or swelling.
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E – Emphysema (surgical)
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L – Laryngeal crepitus
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V – Venous engorgement
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E – Exclude open/ tension pneumothorax, flail segment, massive haemothorax.
Also consider abnormal breathing rates and patterns:
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Bradypnoea or tachypnoea
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Agonal, shallow, or irregular breathing
Key interventions: Oxygen, chest seals, decompression for tension pneumothorax, assisted ventilation.
4. Circulation
Check for signs of shock and major internal bleeding.
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Pulse rate, rhythm, and quality.
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Skin colour and temperature.
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Capillary refill (although unreliable in cold conditions).
- Reassess massive external haemorrhage which was controlled at C.
Remember: “Blood on the floor and four more” (chest, abdomen, pelvis, long bones) (JRCALC, 2024).
Interventions: Control external bleeding, pelvic binders, splinting, IV/IO access, fluids and TXA
5. Disability
Rapid neurological assessment.
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AVPU or GCS.
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Pupils: size and reactivity.
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Blood glucose — hypoglycaemia can mimic head injury.
Example: A fall from height with GCS 10 — early recognition directs urgent neuro care.
6. Exposure & Environment
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Fully expose the patient to look for hidden injuries.
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At the same time, protect them from the environment: hypothermia kills
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Use blankets, warm packs, or heat in the ambulance.
Why You Don’t Move On Until It’s Fixed
Each letter of CABCDE represents conditions that can kill in minutes. If you don’t fix them immediately, the patient may not survive long enough for you to get to the next step (ATLS, 2018).
For example:
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Controlling catastrophic bleeding takes priority over securing an airway.
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There’s no point recording a GCS if the patient isn’t breathing.
This “fix before move on” principle is what makes the primary survey so effective in trauma care.
Evidence Behind the Primary Survey
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ATLS (2018): Endorses the CABCDE sequence as the gold standard for trauma care, stressing “treat first what kills first.”
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European Trauma Course (ETC, 2019): Promotes catastrophic haemorrhage before airway, reflecting military and civilian trauma evidence.
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TARN (Trauma Audit and Research Network): UK trauma registry data shows structured trauma approaches reduce missed injuries and improve survival (TARN, 2022).
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JRCALC (2024): UK ambulance guidelines adopt the CABCDE format for both trauma and medical emergencies, ensuring consistency in pre-hospital care.
Common Pitfalls for Students
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Skipping catastrophic haemorrhage and jumping straight to airway.
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Not reassessing after interventions (tourniquet applied? Check it’s still working).
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Getting distracted by minor injuries before treating life threats.
Webinar: The Trauma Primary Survey in Detail
If you’ve found this guide helpful, why not take it a step further?
We’ve created a full webinar on the Trauma Primary Survey, available on our subscription platform.
In the session, we dive deeper into:
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Real-life case examples
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Common pitfalls in trauma assessment
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Practical tips to improve your speed and accuracy under pressure
👉 Join our membership site to watch the full webinar and unlock access to all of our training content.
Conclusion
The trauma primary survey isn’t just a tick-box exercise — it’s a life-saving sequence that ensures you don’t miss the things that kill fastest.
Remember:
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Fix each problem before moving on.
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Use structured mnemonics like FLAPS TWELVE and Blood on the floor & four more.
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Stay systematic, even when the scene feels chaotic.
If you want CABCDE at your fingertips, check out our pocket cards and notepads — designed for students, paramedics, and clinicians who need clarity when it counts.
References
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ATLS (2018). Advanced Trauma Life Support: Student Course Manual. 10th Edition. American College of Surgeons.
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JRCALC (2024). UK Ambulance Service Clinical Practice Guidelines. Class Professional Publishing.
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ETC (2019). The European Trauma Course Manual. European Resuscitation Council.
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TARN (2022). Major Trauma in England and Wales 2022: National Annual Report. Trauma Audit and Research Network.