What investigations should be prioritized in the management of major trauma in a primary care setting?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 17 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

In a primary care setting, the prioritized 'investigations' in the management of major trauma primarily involve rapid clinical assessment and history taking to identify the need for immediate emergency transfer to a hospital or major trauma centre ,. The optimal destination for patients with major trauma is usually a major trauma centre .

  • Clinical Assessment: The initial aim is to rapidly identify indications for emergency transfer to hospital . This includes following basic and advanced adult or paediatric trauma life support protocols . Key assessments include:
    • Assessing the level of consciousness using the Glasgow Coma Scale (GCS) . A GCS score of less than 15 on initial assessment is a risk factor for intracranial complications and necessitates immediate transfer .
    • Assessing vital signs, looking for hypoxia or signs of shock such as tachycardia, hypotension, or reduced capillary refill time . Evidence of shock is an indication for immediate transfer .
    • Examining for visible trauma to the scalp, skull, head, and neck .
    • Assessing cranial nerves, including pupil size and reactivity .
    • Looking for signs of focal neurological deficit, such as problems with visual or speech disturbance, balance, walking, loss of muscle power, or paraesthesia .
    • Identifying signs of basal skull fracture, which may include clear fluid leaking from the ear(s) or nose, periorbital haematoma(s), bleeding from one or both ears, or Battle's sign .
    • Assessing for neck tenderness and range of neck movements, as midline cervical spine tenderness or inability to rotate the neck 45 degrees may indicate cervical spine injury . If risk factors for cervical spinal injury are present, full cervical spine immobilisation should be attempted .
  • History Taking: Gather information to identify :
    • How and when the head injury occurred, including the mechanism of injury . Dangerous or high-energy mechanisms (e.g., fall from a height greater than 1 metre or 5 stairs, high-speed motor vehicle collision, rollover accident, or ejection from a motor vehicle) are indications for immediate transfer .
    • Current symptoms since the injury, such as loss of consciousness, confusion, amnesia, seizure, vomiting, headache, neck pain, or diplopia . Any loss of consciousness or post-traumatic seizure after the injury indicates immediate transfer .
    • Recent alcohol or drug intake .
    • Current anticoagulant medication, as this is a risk factor for intracranial complications and requires a CT head scan within 8 hours of head injury .
    • Past medical history, including pre-injury level of functioning, bleeding disorders, surgery, and previous head trauma . A history of bleeding or coagulation disorders or previous brain surgery are indications for immediate transfer .

Definitive imaging investigations, such as CT scans or eFAST, are typically performed in a hospital setting after transfer ,. Plain X-rays of the skull are not routinely used to diagnose important traumatic brain injury . Patients with risk factors for intracranial complications or cervical spine injury should be transported to a hospital with age-appropriate resources for further resuscitation, investigation, and initial management of multiple injuries . The referring professional should inform the destination hospital by phone of the impending transfer .

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Educational content only. Always verify information and use clinical judgement.