CCFP priority topic 98 of 105
Trauma on the CCFP exam
12 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 12 key features for Trauma. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 12
Primary survey first
Work through every injured patient in a fixed order, fixing threats first and watching for new ones.
CFPC skill Clinical reasoningPhase Treatment, physicalSources Health Canada
On the exam
A man with rib fractures from a fall turns breathless and “not right” on the ward. Expect one best answer: your first step.
Pick the first thing to do.
Common mistakes
A rectal exam, a look at his hip or spine, or a standing blood pressure. All belong later. Repeat the primary survey first.
Approach
- Primary survey, in order: airway with the neck held still, breathing, circulation and bleeding, level of consciousness and pupils, then undress and cover again.
- Fix each problem as you find it, before you move on.
- Repeat the primary survey whenever the patient changes. New breathlessness or confusion sends you back to the airway.
- Judge blood flow lying down: skin, pulse and mental state. Never stand an injured, breathless patient to test for blood loss.
- Start the secondary survey only once the primary survey is stable: head-to-toe exam and full history.
- The rectal exam is no longer routine. Do it only when the findings point there.
- Check tetanus before the patient leaves your care, even if transfer is planned. The table shows who needs what.
| Tetanus history | Clean, minor wound | All other wounds |
|---|---|---|
| Unsure, or fewer than 3 doses | Vaccine | Vaccine plus tetanus immune globulin, at a separate site |
| 3 or more doses | Vaccine if more than 10 years since the last booster | Vaccine if more than 5 years since the last booster |
| 3 or more doses, and a known antibody immune deficiency | Vaccine if more than 10 years since the last booster | Vaccine if more than 5 years, plus tetanus immune globulin |
Key feature 2 of 12
Chest threats
Spot the injuries that kill within minutes, such as air or blood under pressure, and treat them at once.
CFPC skill SelectivityPhase Treatment, diagnosis
On the exam
Shock and one quiet, dull side of the chest after a fall, with fluid on the film. Expect one best answer for the procedure.
Pick the procedure, and where to do it.
Common mistakes
A needle in the chest for blood, not air: it drains nothing and adds an injury. Sending the patient on a long trip with the chest undrained is wrong too.
Approach
- Tension pneumothorax (air under pressure in the chest): distress, low blood pressure, no breath sounds on one side, swollen neck veins. Decompress now. Do not wait for a film.
- A needle or a finger through the chest wall buys time. A chest tube follows.
- Massive hemothorax (blood in the chest): shock with a dull, quiet side. Place a large chest tube and start blood.
- Do not stop a trauma chest drain early. What drains tells you how fast the patient bleeds.
- Tamponade (blood around the heart): low blood pressure, swollen neck veins and quiet heart sounds after chest injury. Bedside ultrasound confirms it. Drain it and call surgery.
- Drain the chest before transfer. Transfer comes after the tube, not in its place.
| Threat | Clue | First move |
|---|---|---|
| Tension pneumothorax | No breath sounds on one side, swollen neck veins, shock | Needle or finger decompression, then a chest tube |
| Massive hemothorax | Dull, quiet side, shock, fluid on the film | Large chest tube and blood |
| Tamponade | Swollen neck veins, quiet heart sounds, shock | Bedside ultrasound, drain the fluid, call surgery |
| Open chest wound | Air sucking in and out of the wound | Vented dressing, then a chest tube |
Key feature 3 of 12
Many patients at once
When injured people outnumber your staff, sort them by urgency and by what your site can do.
CFPC skill SelectivityPhase Treatment
On the exam
A van crash brings several injured people to a small hospital at night. Expect a short menu (pick several from a list) of priorities.
Rank who gets care first.
Common mistakes
Treating the loudest patient first, or putting the whole team on one patient who cannot be saved. Both cost lives you could save.
Approach
- Call for help early. Start your site's plan for many casualties and warn the trauma centre.
- Sort fast. Failing airway, failing breathing and shock come first. People who walk and talk can wait.
- Check that a quiet patient is not unconscious. Silence is not stability.
- Match care to what you have. If saving one person costs several others, the many come first.
- Sort again often. Patients move between groups as they get better or worse.
- Name one leader who tracks every patient, and the beds, staff and blood on hand.
Key feature 4 of 12
Airway
Manage an injured patient's airway while you guard the neck and prepare for the plan failing.
CFPC skill Clinical reasoning, selectivityPhase Treatment, hypothesis generation
On the exam
An unconscious driver with facial injuries and vomit in the mouth. Expect one best answer for how to manage the airway.
Pick the airway plan.
Common mistakes
Tilting the head back to open the airway, or sedating with no plan if it fails. Waiting for neck films before you act is wrong too.
Approach
- Treat every seriously injured patient as having a neck injury. Hold the head and neck in line by hand while you work.
- Open the airway with a jaw thrust, not a head tilt. Suction out blood and vomit.
- Look for a hard airway before you start: facial or neck injury, blood, swelling, a short neck, or a mouth that barely opens.
- Before you intubate, have suction, a bougie (a guide for the tube), and a supraglottic airway (a tube that sits above the vocal cords) ready.
- Cannot intubate and cannot get oxygen in: do a cricothyrotomy (a cut through the front of the neck into the airway). Do not delay it.
- Sedation for a painful procedure needs monitoring and someone skilled with airways at the bedside.
Key feature 5 of 12
Shock
Recognize poor blood flow to the organs, judge how bad it is and its kind, and treat it.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, diagnosis, physical, treatmentSources Choosing Wisely Canada
On the exam
Low blood pressure and a slow pulse after a fall with a cord injury. Expect a short menu (pick several from a list), then one best answer.
Name the shock type, then treat it.
Common mistakes
Litres of saline for every low blood pressure, or high-dose steroids for a cord injury. Rule out bleeding, then treat neurogenic shock with a vasopressor.
Approach
- Early shock hides behind a normal blood pressure. Look at the pulse, skin, mental state and urine.
- In trauma, assume bleeding first. Look on the floor, and in the chest, abdomen, pelvis and long bones.
- Bleeding: stop it with pressure, a tourniquet or a pelvic binder. Give blood early and keep saline small; large volumes thin the clotting factors.
- Blood pressure that rises with blood, then drifts down again, means ongoing bleeding. Hemoglobin lags behind the loss.
- Uncrossmatched O-negative red cells are for O-negative patients, and for females who could bear children when the group is unknown.
- Neurogenic shock: low blood pressure, a slow pulse and warm skin after a cord injury. Rule out bleeding first.
- Once modest fluid fails in neurogenic shock, start a vasopressor (a drug that tightens the vessels). More saline risks fluid in the lungs.
| Type | Clues | First treatment |
|---|---|---|
| Bleeding (hypovolemic) | Fast pulse, cool pale skin, anxious or confused | Stop the bleeding, give blood early, keep saline small |
| Neurogenic | Slow or normal pulse, warm skin, cord injury | Rule out bleeding, modest fluid, then a vasopressor |
| Obstructive | Swollen neck veins, one-sided chest signs or quiet heart sounds | Decompress the chest or drain around the heart |
| Septic | Later, with fever and a source such as a dirty open wound | Cultures, antibiotics and fluid |
Key feature 6 of 12
Keep them warm
Look for a low body temperature when the patient arrives, and keep checking through care.
CFPC skill Clinical reasoningPhase Hypothesis generation, physical
On the exam
An older woman found on her floor after a fall, now being resuscitated. Expect a short menu (pick several from a list) of steps to prevent heat loss.
Pick the steps that keep her warm.
Common mistakes
One temperature at triage and none after. Undressing her, cold fluids and cold blood keep cooling her while the team works.
Approach
- Take a core temperature on arrival. Repeat it through the resuscitation.
- Undress to examine, then cover again. Warm the room.
- Warm all fluids and blood. Use warm blankets or a forced-air warmer.
- Cold makes bleeding worse: clotting slows, and the heart becomes irritable.
- Take off wet clothes early. Older adults, children, intoxicated patients and anyone found outdoors cool fastest.
- A very cold patient can look dead. Rewarm before you decide resuscitation has failed.
Key feature 7 of 12
Why it happened
Think of an illness, a drug or self-harm as the reason the injury happened.
CFPC skill Clinical reasoningPhase Hypothesis generation
On the exam
A driver hits a pole on a straight, dry road at noon. Expect a short menu (pick several from a list) of causes to look for.
Pick what could explain the crash.
Common mistakes
Treating only the injuries and never asking why. A one-car crash with no clear reason may be a seizure, low blood sugar, a heart rhythm problem or a suicide attempt.
Approach
- Check a bedside glucose early in any injured patient whose level of consciousness has changed.
- Ask witnesses what happened just before: collapse, shaking, chest pain or a racing heart.
- Get an electrocardiogram (ECG) after an unexplained crash or fall. A rhythm problem or heart attack may have come first.
- Look for alcohol and drugs when the story or exam points to them. Intoxication can hide a head injury.
- Ask directly about suicide after a crash or fall with no clear cause.
- In older adults, look for a stroke, an infection or a new medicine behind the fall.
Key feature 8 of 12
Stay in the room
Keep a patient who may crash in the resuscitation area, and bring the tests to them.
CFPC skill Clinical reasoningPhase Treatment, investigationSources Choosing Wisely Canada
On the exam
A man in shock on the ward after a chest injury, with fluid seen on bedside imaging. Expect one best answer for the next test.
Pick the test you do at the bedside.
Common mistakes
A computed tomography (CT) scan for more detail, or upright films in the department. Both move a shocked patient away from resuscitation for detail the next step does not need.
Approach
- Unstable means CT waits. Image at the bedside: a portable chest film, a pelvic film and ultrasound.
- Bedside ultrasound looks for free fluid in the abdomen, in the chest and around the heart.
- A plain abdominal film cannot show free blood in the abdomen. Ultrasound can.
- Skull films cannot show bleeding inside the head. Use CT once the patient is stable.
- Stable after a minor head injury: use a decision rule before CT. The Canadian CT Head Rule for adults; CATCH or PECARN for children.
- Stable after a neck injury: a negative Canadian C-spine rule means no neck X-ray.
- If the patient is unstable, the next step is treatment or transfer, not more images.
Key feature 9 of 12
When to transfer
Decide which injured patients need care your hospital cannot give, and send them on.
CFPC skill Selectivity, clinical reasoningPhase Treatment, referral
On the exam
An infant with a thin bleed over the brain, at a hospital with no neurosurgery. Expect one best answer for where the infant goes.
Decide whether to keep or transfer.
Common mistakes
Watching a small bleed overnight, or a phone consult in place of transfer. If the bleed grows or the infant seizes, no one on site can operate.
Approach
- Transfer when the injury needs a service you lack: neurosurgery, a trauma surgeon or intensive care for children.
- A bleed inside the head goes to a site with neurosurgery, even when it looks small.
- Ongoing bleeding with no surgeon on site needs a trauma centre. Blood pressure that drifts back down after blood is the signal.
- Call the trauma centre early, before every test is done. They can image on arrival.
- Do not wait for a bleed to grow on repeat imaging. That spends the window when travel is safe.
- Do not let tests for suspected abuse delay transfer. The receiving centre can do them.
Key feature 10 of 12
Safe transfer
Prepare the patient for the trip, and choose the fastest safe way to get there.
CFPC skill Clinical reasoningPhase Treatment, referral
On the exam
A bleeding patient far from a trauma centre: an ambulance can leave now, a helicopter later. Expect one best answer for the transfer.
Pick how and when to send.
Common mistakes
Taking the ambulance because it leaves first, or running in litres of saline for the road. Pick the vehicle that arrives first with a crew that can transfuse.
Approach
- Before you send: secure the airway, drain the chest, run blood, splint fractures and warm the patient.
- Intubate before the trip if the airway might fail on the road. It is much harder in a moving vehicle.
- Choose by total time to arrival and the care the crew can give, not by who leaves first.
- A crew that cannot give blood is the wrong crew for ongoing bleeding.
- Talk doctor to doctor. Send the notes, images and blood results.
- Keep monitoring and treating until handover. A transfer is not a pause in care.
Key feature 11 of 12
Prevent the next one
Take each chance to advise patients on ways to avoid injury or make it less severe.
CFPC skill Clinical reasoningPhase Treatment
On the exam
A teen treated for a bike crash, riding without a helmet after drinking. Expect a short menu (pick several from a list) of advice to give.
Pick the advice that fits.
Common mistakes
Treating the wound and sending the teen home with no advice. A lecture with no questions about drinking misses the point too.
Approach
- Ask about seatbelts, helmets, and driving after alcohol or drugs.
- Ask about alcohol and other drug use after any injury. Offer brief advice and follow-up.
- For children: car seats or booster seats that fit, helmets for bikes and sports, and locked storage of medicines and firearms.
- For older adults: review falls, medicines that cause dizziness, and hazards at home.
- Ask about violence at home when the story of the injury does not fit.
Key feature 12 of 12
Child abuse
In an injured child, check that the account and the child's stage of development explain the findings.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis, hypothesis generation
On the exam
A 2-month-old vomiting after a reported roll off a bed, with bruises on the ear and arm. Expect a short menu (pick several from a list).
Pick the diagnosis and your duty.
Common mistakes
Accepting that a 2-month-old rolled off a bed. Waiting for a fracture, or for the receiving team, before you report is wrong too.
Approach
- Match the story to development. A baby who cannot yet roll should not have rolled off a bed.
- Bruises on a baby who is not yet mobile need a work-up. So do bruises on the ears, neck or trunk, and bruises with a shape, such as fingertips.
- Vomiting, fussiness and poor feeding after a fall: think of a head injury before a stomach bug.
- Report to child protection on reasonable suspicion. You need not prove it, and the duty is yours even if others will report.
- Do not question the suspected caregiver yourself. That is the agency's role. Think of brothers and sisters at home.
- Head imaging, a skeletal survey and a dilated eye exam by an eye specialist are part of the work-up. They must not delay transfer.
Flashcards
Answer it first, then check.
KF 1A ward patient with rib fractures becomes breathless and confused. What comes first?
Repeat the primary survey, starting with the airway and breathing. The head-to-toe exam waits.
KF 1A gravel-soiled graze. Full tetanus series, last booster 7 years ago. Booster?
Yes. For a dirty wound, give a booster once more than 5 years have passed. Source: Health Canada
KF 2Shock, a dull and quiet side of the chest, and fluid on the film. Needle or tube?
A chest tube. A needle releases air under pressure; it does not drain blood.
KF 5Cord injury, low blood pressure, slow pulse, warm feet, and no bleeding found. Next?
Treat neurogenic shock with a vasopressor once modest fluid has failed. More saline will not help.
KF 5An injured woman who could become pregnant needs blood now, group unknown. Which red cells?
O-negative. Keep it for O-negative patients and for females who could bear children. Source: Choosing Wisely Canada
KF 8A stable adult after a crash has a negative Canadian C-spine rule. Neck X-ray?
No. A negative rule in a stable patient means no neck film is needed. Source: Choosing Wisely Canada
KF 10Ongoing bleeding: an ambulance leaves now, a helicopter arrives first. Which do you choose?
The helicopter. It gets there first, and its crew can keep giving blood on the way.
KF 12Must you find a fracture before you report suspected abuse of an infant?
No. Reasonable suspicion is enough. Report now, even if the receiving team will report too.
FAQ
Which guideline does this topic follow?
No single Canadian guideline covers trauma care. The exam tests the standard order: primary survey, fix threats as you find them, then the head-to-toe exam, imaging and transfer.
Is the rectal exam still part of every trauma survey?
No. It is no longer done routinely. Do it when the findings point there. It never explains new breathlessness, so it never comes before a repeat primary survey.
Are large saline boluses still given for shock after injury?
Not as the main treatment. Large volumes thin the clotting factors and can worsen bleeding. Stop the bleeding, give blood early, and keep saline small.
Who reports suspected child abuse if the child is transferred?
You do. Each professional with reasonable grounds must report to child protection. The receiving team may report as well, but that does not replace your duty.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Drug Product DatabaseHealth Canada
- Choosing Wisely recommendationsChoosing Wisely Canada