11/13/24, 7\:37 PM Guide | Major trauma

Major trauma

Table of contents

Introduction

This guide provides an overview of the recognition and immediate management of a major trauma patient using
a (C)ABCDE approach.
Usually, airway compromise is the fastest cause of mortality. However, in trauma, catastrophic haemorrhage must be
considered. Therefore, in trauma management the ABCDE approach is slightly altered\:
Catastrophic haemorrhage
Airway (with c-spine protection)
Breathing
Circulation
Disability
Exposure
Each stage of the (C)ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not
intended to be relied upon for patient care. Please note that this guide refers to the management of adult major trauma.

Background

What is major trauma?

Major trauma can be de
b e c a u s e i t m a y r e s u l t i n l o n g-t e r m d i s a b i l i t y .
”
1
Hence, anything causing injury or injuries that threaten life would be considered major trauma. Examples may include\:
Road tra
Injuries from sports or extreme sports or equestrianism
Fall from height
Assault
Workplace related injury
Major trauma is the leading cause of death in people under the age of 45.
1
However, in de
standing height, may not cause signi
patients with multiple comorbidities.
Therefore, the threshold for considering something a major trauma, and initiating a trauma assessment, should be lower in
such patients. These cases are sometimes referred to as “silver trauma.
”

Initial steps

Introduce yourself to the team, including your name and role.
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In practice, there is usually a team leader who is separate from the doctor carrying out the primary survey. In an OSCE
scenario, you may be ful
If feasible, it is sensible to have a team brief before the arrival of a trauma patient, where everyone introduces themselves,
makes an initial plan, and divides up management (for instance, in real-life settings, major trauma calls are usually attended by
an anaesthetist – it would be sensible for airway management to be handled by them!)

Handover

Usually, you will receive a brief handover from a team member about the patient. This may be in SBAR or ATMIST and should
include the patient’s details (if known), the circumstances of their injury, and any information gathered from prehospital/nursing
assessment.
During the handover, everyone should remain quiet and still if possible to ensure nothing is missed, this is known as a “hands-
o
Maintaining a calm and quiet environment around the patient avoids causing them further stress and allows for better
communication within the team.

Patient introduction

Introduce yourself to the patient including your name and role.
In the context of major trauma, this may not be possible due to impaired consciousness.

Catastrophic haemorrhage

Clinical assessment

While we will look more closely at haemorrhage management in the second “C” section of this assessment, it is important to
identify any large volume external bleeding at this stage. Look for any obvious high-volume blood loss.

Interventions

If any large bleeds are present, take immediate action to promote haemostasis. This could involve direct pressure,
haemostatic dressing application, or tourniquets.

Airway (with c-spine protection)

Clinical assessment (airway)

Look
Without moving the patient, visibly inspect the neck for any obvious injuries. In major trauma, certain injuries are more likely to
be associated with airway compromise. These include signi
Listen
assessing the c-spine.
Listen to how the patient sounds. If they are talking normally, then their airway is patent. If this is the case, you can move on to
If they have a hoarse voice, or you can hear stridor (a harsh sounding inspiratory noise) or a snoring sound, this indicates partial
airway compromise.

Consciousness level

It is also widely said that patients with a GCS score of eight or less cannot maintain their airway (“GCS eight – intubate!”). This is
not always the case, but you should be aware that reduced levels of consciousness can a
their airway.

Interventions (airway)

De
If a patient cannot maintain their airway, then a de
anaesthesia and intubation, as soon as possible.
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In practice, this is usually performed in hospital by an anaesthetist. However, it may be performed by a prehospital or
emergency medicine doctor with appropriate training.
Very rarely, if the airway is exceptionally di
(scalpel-bougie-tube method) rather than needle cricothyroidotomy.
13
If a hard collar has been
should be done by a separate person to the intubator and the airway assistant.
Simple manoeuvres and airway adjuncts
While awaiting a de
1. Identify the angle of the mandible.
2. With your index and other
the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
The head-tilt chin-lift should be avoided in trauma, to avoid exacerbating a c-spine injury.
Airway adjuncts such as oropharyngeal, nasopharyngeal, or laryngeal mask airways can also be used. 8
A nasopharyngeal
airway should be avoided if there are signs of a base of skull fracture including otorrhoea, panda eyes, or battle’s sign.

Clinical assessment (c-spine)

The cervical spine should be assessed using the Canadian c-spine rules.
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The Canadian c-spine rules
The patient is considered high risk if they meet one or more of the following criteria\:
Age 65 or older
Dangerous mechanism of injury (fall from over one metre or down
Paraesthesia in any limb(s)
The patient is low risk if they meet none of the “high risk” criteria and meet one or more of the following criteria\:
Involved in a minor rear-end motor vehicle collision
Comfortable sitting
Ambulatory since the injury
No midline cervical spine tenderness
Delayed onset of neck pain
There is no risk if the patient has no high-risk factors, one or more low-risk factors, and they can rotate their head 45
degrees actively to the left and right.
In practice, most major trauma patients will have a distracting injury and/or dangerous mechanism, meaning the c-spine
must be imaged before an injury can be excluded. They are likely to arrive with their c-spine already immobilised by the pre-
hospital team.

Investigations & procedures (c-spine)

Urgent imaging of the c-spine with a CT scan should be arranged in all cases of suspected c-spine injury. However, the patient
needs to be stable enough to be taken to CT.

Interventions (c-spine)

If the patient has any high-risk factors or is low-risk but cannot rotate their head 45 degrees, then you should immobilise the c-
spine.
Hard collar
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A hard collar may be used if there is no airway compromise or deformity of the neck. If a hard collar is used, the airway should
be reassessed after it is placed.
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Head blocks
Head blocks are solid foam blocks which are placed on either side of the head and then secured in place with tape.

Breathing

In trauma, there are six widely recognised life-threatening chest injuries to be aware of. The acronym TOM CAT is used to
recall them. These injuries should be considered as you work through the (C)ABCDE assessment.
Life-threatening chest injuries\: TOM CAT10
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Cardiac tamponade
Airway injury
Tracheobronchial injury

Clinical assessment

Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Bradypnoea in trauma may be secondary to raised ICP and is seen as part of the Cushing’s re
reduced RR such as opioid toxicity.
Tachypnoea in trauma may be due to chest injury (haemothorax, pneumothorax or
obstruction, diaphragmatic rupture, shock, acidosis, pain or anxiety
Review the patient’s oxygen saturations (SpO )\:
2
A normal SpO 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high risk
of CO retention.
2
Hypoxaemia may be due to airway obstruction or injury, chest injury such as pneumothorax, aspiration or bradypnoea,
amongst other causes.
See our guide to performing observations/vital signs for more details.
General inspection
From the end of the bed, observe the patient for signs of increased work of breathing, such as accessory muscle use or
intercostal muscle recession. Look for any obvious cyanosis (blue tinge to the extremities or lips).
Look for any visible injury or deformity of the chest, such as a sucking chest wound (open pneumothorax, resulting in a visible
wound that bubbles and/or makes a sucking noise during respiration).
Inspect the chest for uneven movement, which may indicate a pneumothorax or
Tracheal position
Warn the patient before you palpate the trachea ( “ I a m g o i n g t o f e e l t h e m i d d l e o f y o u r n e c k” ) as it can be uncomfortable or
frightening. Then gently feel for the position of the trachea. The trachea should sit in the centre of the neck.
In trauma, the most likely cause of acute tracheal deviation is a tension pneumothorax.
Chest wall assessment
Inspect and palpate the chest to assess its movement. The chest should expand and contract equally with each breath. In
trauma, causes of unequal or uneven chest expansion include\:
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Flail chest\: where multiple adjacent ribs are fractured in multiple places, a chest section becomes “detached” from the
chest wall and moves paradoxically during respiration. While the rest of the chest is expanding during inspiration, decreased
pressure pulls the
lung, and di
Pneumothorax/tension pneumothorax\: injury to the chest damages the lung tissue and allows air to enter the chest cavity.
This prevents expansion of the lung on the a
leading to uneven chest movements.
Percussion
Systematically percuss the chest, working from the apex to the base of each side. Listen to the resulting sound, which should
be resonant in a healthy person.
Hyper-resonant percussion suggests underlying reduced density, such as air in the chest cavity (i.e. pneumothorax)
Dullness indicates increased underlying density, such as from
cavity
Auscultation
Use a stethoscope to auscultate the patient’s chest. Clinical
Quiet or absent breath sounds, which may indicate reduced air entry, such as from pneumothorax or haemothorax
Loud cracking, grinding, or popping sounds can originate from a rib fracture

Investigations and procedures

X-ray
In unstable patients (e.g those with severe respiratory or haemodynamic compromise), or who are not responding to
resuscitation measures, a portable X-ray can be used to provide bedside imaging. The patient does not have to be moved
from the resuscitation room, and the interruption to treatment is minimised.
CT scan
In the stabilised trauma patient, a CT scan can be used to provide more comprehensive imaging of the chest.
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Interventions

Oxygen
If the patient has not already been intubated and ventilated and has low SpO , an increased respiratory rate, or increased work
2
of breathing, you should administer oxygen. Typically, this will be 15 litres of oxygen via a non-rebreathe mask, aiming for
a SpO 2
greater than 94%. The amount of oxygen administered can then be titrated down.
In patients with known type 2 respiratory failure, who are at risk of CO 2
this may be better achieved using a 24% or 28% venturi mask.
retention, the target saturations should be 88-92%, and
Management of speci
Further management will depend on the underlying condition\:
Tension pneumothorax\: when a tension pneumothorax is identi
cardiac arrest. This can be done through
- bordered by the anterior border of
latissimus dorsi, the lateral border of pectoralis major, and between the axilla and the horizontal level of the nipple. A chest
drain can be inserted subsequently.
Haemothorax\: haemothorax is managed with the insertion of a chest drain. Larger volumes of blood loss (>1.5L from the
chest drain being considered a “massive haemothorax”) may necessitate surgical intervention.
Open pneumothorax\: when a penetrating chest injury results in a pneumothorax, it creates a “sucking chest wound.
” Acutely,
this is managed by covering the wound with a sterile dressing, securely taped on 3 sides. The open side creates a valve,
allowing air to exit but not enter the chest cavity. Once stabilised, a chest tube can be inserted, and surgery may be
considered later.
Flail chest\: this increases work of breathing signi
ventilation are sometimes required, and later discussion with surgeons for repair.

Circulation

Haemorrhage

Major haemorrhage is de
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Loss of more than one blood volume within 24 hours
50% of total blood volume lost in less than 3 hours
Bleeding in excess of 150 mL/minute
However, in an acute scenario, you are unlikely to be able to calculate blood loss as above. Therefore, a major haemorrhage
can be considered as bleeding (visible or presumed) which results in\:
2
A blood pressure \<90mmHg systolic
A heart rate >110bpm
For locating a haemorrhage, remember “on the
.
On the
“On the
injuries. This is what many people picture when imagining a major haemorrhage.
"Four more" refers to four potential spaces inside the body, where a large volume of blood may be lost\:
3
Chest cavity\: haemothorax, which in trauma is most likely caused by a rib fracture causing damage to the intercostal
blood vessels
Abdominal cavity\: from injury to a solid organ, such as the spleen, or major blood vessel
Pelvis\: classically from a pelvic fracture
Long bones\: fractured long bones, such as the femur, can account for a signi
Investigations and procedures
There are two main imaging modalities for identifying the location of a bleed in a trauma patient\:
4
CT scanning\: whole-body CT scan is the most accurate, but the patient must be stable enough to tolerate the scan
Ultrasound\: FAST ultrasound scanning is a relatively quick bedside imaging technique which can be used when immediate
conveyance to CT is not feasible. However, it cannot rule out intra- or retroperitoneal bleeding
Interventions
Management of bleeding consists of three key elements\: stopping the bleeding, replacing the lost blood volume, and
avoiding the “lethal triad”
.
Stopping the bleeding
For external (“on the
tourniquet. Internal bleeding from pelvic fractures can be controlled with a pelvic binder.
Pharmacological management with tranexamic acid, and reversal of anticoagulation, should also be considered at this point.
Uncontrollable/internal haemorrhage may need to be controlled surgically.
Replacing lost blood volume
Establish intravenous access (or, where this is not possible, intraosseous access) and replace lost volume early. In the United
Kingdom, hospitals will have “major haemorrhage protocols” which should be followed. In general\:
4
Crystalloids should not be used for volume replacement in hospital settings
“Replace blood with blood”
\: a 1\:1 ratio of units of plasma and red blood cells is recommended
Avoiding the lethal triad
The lethal triad in major haemorrhage refers to hypothermia, acidosis and coagulopathy. When they occur, they are
irreversible and will result in death. Therefore, you should take early measures to avoid them\:
5,6
Hypothermia\: keep warm with blankets, warmed air, use a blood warmer to give blood, and when examining the patient,
limit their exposure to the minimum necessary
Acidosis\: maximise oxygenation and treat/prevent hypoventilation to prevent respiratory acidosis. Avoid giving crystalloids
as this can exacerbate acidosis.
Coagulopathy\: avoid crystalloids or unbalanced blood products (see the ratio above) as they can cause dilutional
.
coagulopathy Permissive hypotension (aiming for a target systolic of 80-100mmHg) can be used to avoid excessive
administration and prevent dilutional coagulopathy.
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Other circulatory considerations

Observations
Review the patient’s heart rate\:
Causes of tachycardia (HR>99) may indicate hypovolaemia (e.g. a bleed), anxiety, or pain
Causes of bradycardia (HR\<60) may be a late sign of hypovolaemia
Elderly patients may not mount a tachycardia due to regular medications, such as beta-blockers.
Review the patient’s blood pressure\:
A normal blood pressure (BP) range is around 120/80mmHg
Causes of hypertension include pain or anxiety
Causes of hypotension include hypovolaemia/shock, tension pneumothorax and cardiac tamponade
Younger patients are likely to maintain their blood pressure through compensation and may present with tachycardia and a
normal BP until severe decompensation occurs.
See our guide to performing observations/vital signs for more details.
General inspection
Observe the patient for pallor, particularly of the extremities, which may indicate poor perfusion due to hypovolaemia.
Observe for any cyanosis or discolouration of injured limbs, which could indicate vascular compromise.
Palpation
Feel the temperature of the hands, they should be warm and well-perfused.
Assess the capillary re
If it is decreased centrally, then this indicates a more severe shock. If it is decreased in only one limb, then that may indicate
vascular compromise as a result of injury.
Palpate the pulses, start with the radial pulse, if this cannot be palpated then check more centrally with the brachial, carotid or
femoral pulses. If any limb is injured, assess the distal pulses in that limb, to ensure there is no vascular compromise.
Inspection of the JVP
tamponade.
Observe the neck for jugular venous distension. Jugular venous distension forms part of Beck’s triad, which indicates cardiac
Beck’s triad (cardiac tamponade)
Beck's triad is made up of\:
Jugular venous distension
Quiet heart sounds
Hypotension
Beck's triad is not always uniformly present in trauma. Hypovolaemia may prevent jugular venous distension, and it can
be di
Heart sounds may be di
obstructive shock and distended JVP. Bedside ultrasound can di
examination is inconclusive.
Auscultation
Using a stethoscope, auscultate the heart sounds. Mu

Investigations and procedures

Cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
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Blood tests
Request the following blood tests\:
FBC
U&Es
LFTs
Coagulation screen
Group & save (+/- crossmatch)
Toxicology screen (if you suspect drug overdose)
Lactate (to assess for evidence of inadequate end-organ perfusion)
See our blood culture, blood bottle and investigation panel guides for more details.
ECG
Perform an ECG to identify any abnormal rhythms which may be contributing to poor perfusion.
In particular, look for ECG changes associated with cardiac tamponade\:
Low voltage QRS complexes
Tachycardia
pericardium)
Attach 3-lead continuous ECG monitoring if available.
Electrical alternans (where the QRS complexes alternate in height, due to the swinging motion of the heart within the
See our guides to recording and interpreting an ECG for more details.

Interventions

The guidelines for the treatment of hypovolaemia in trauma have already been discussed under the “catastrophic
haemorrhage” section.
Cardiac tamponade
A cardiac tamponade describes a large pericardial e
trauma to the chest.
The build-up of
via pericardiocentesis – inserting a needle and aspirating the
guidance. If pericardiocentesis is indicated, then the patient is likely to require cardiothoracic surgery and should be discussed
with the cardiothoracic team.

Re-assessment

Make sure to re-assess the patient following any intervention.

Disability

Clinical assessment

Consciousness level
Assess the patient’s level of consciousness by using the Glasgow Coma Scale (GCS) or AVPU scale.
A summary of the Glasgow coma scale is shown below. For a more detailed explanation, see the Geeky Medics guide to
the Glasgow Coma Scale.
Behaviour/domain Response Score
Eyes opening spontaneously 4
Eyes opening to sound 3
Eye-opening response
Eyes open to pain 2
No eye opening 1
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Verbal response
Motor response
Orientated to time, place and person 5
Confused 4
Inappropriate sounds 3
Incomprehensible sounds (e.g.
groaning)
2
No response 1
Obeys commands for movement 6
Moves towards pain/localises to pain 5
Withdraws away from pain 4
Abnormal
posturing
3
Abnormal extension/decerebrate
posturing
2
No motor response 1
The AVPU scale is a simpler method of assessing consciousness\:
Alert\: fully alert, though not necessarily orientated
Voice\: responding to voice
Pain\: responding to pain
Unresponsive\: unresponsive to all stimuli
Pupils
Assess the patient’s pupils\:
Assess the size and shape of the patient’s pupils. A normal pupil diameter ranges from two to
Assess the pupils for both direct and consensual responses to light using a pen torch.
An oval-shaped pupil, sluggish reaction to light,
“blown pupil” or deviated pupil suggests raised ICP or herniation.
Bilaterally small or “pinpoint” pupils may be due to opioid toxicity.

Investigations and procedures

CT head
requested.
Organise an urgent CT head if there is any concern about intracranial bleeding and if a whole-body CT has not already been

Interventions

Raised intracranial pressure (ICP)
Raised ICP can be managed with intravenous mannitol or hypertonic saline, and by raising the bed to 45 degrees. Further
surgical intervention may also be required.

Exposure

Clinical assessment

Inspection
Expose the patient and examine them for visible injuries such as lacerations, abrasions or fractures. This should involve using a
log roll technique to examine the patient’s back while protecting the spine.
When considering a fracture, look for\:
Bruising
Swelling
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Deformity
Immobility
Pain
Bladder injury is an uncommon yet serious complication of blunt force or penetrating abdominal trauma. Signs include
signi
Temperature
Assess body temperature, this should be between 36-37.5 degrees. Remember that hypothermia is part of the lethal triad in
haemorrhage.

Investigations and procedures

X-ray
Consider X-rays of any potential fractures. An X-ray can also ensure no gravel or debris remains inside a laceration.
CT scan
Request a CT scan to image the abdomen if there are any features of internal organ injury. CT cystoscopy can be used in
stable patients to identify bladder injuries.
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Management

Analgesia
Traumatic injuries can be incredibly painful. Give appropriate analgesia and regularly check with the patient about their pain
levels. Consider the use of regional blocks for limb injuries.
Wound care
Clean any wounds using a sterile wound pack/sterile saline and gauze. Remove any gravel or debris from the wounds.
Consider using sutures, staples or steri-strips in wounds with a clean edge, to promote healing and minimise scarring. Injuries
that require complex repair or may result in signi
dressings over the wounds.
Fractures
Simple, non-displaced fractures can be placed in a splint, sling or plaster cast.
If a fracture is displaced, you should consult a senior doctor to reduce it.
Open fractures should be washed out with saline and dressed in saline-soaked gauze until an orthopaedic opinion can be
sought. Antibiotic cover and tetanus prophylaxis should also be considered. Complex fractures, or patients with multiple
fractures, should also be discussed with orthopaedics.
Internal organ injury
Damage to the internal organs, identi
includes damage to the bladder or urethra.

Reassess ABCDE

Re-assess the patient using the (C)ABCDE approach to identify any changes in the patient's clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
If treatment response is inadequate, the patient may need to be transferred immediately to theatre/interventional radiology.
In this situation, the next steps below can be postponed until after the de

Next steps

Take a history
Once stabilised, take a thorough history from the patient if possible.
Head-to-toe examination
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Examine the patient thoroughly from head to toe and ensure you have excluded any 'FATAL TRAUMA' (although much of this
list will have been covered during the primary assessment).
Conditions to exclude\: FATAL TRAUMA
Flail chest
Airway compromise
Tamponade
Air leaks
Lung contusion
Tracheal injury
Ruptured diaphragm
Aortic disruption
Unseen haemorrhage
Myocardial injury
Any neurological injury
Consider any further imaging, treatments or referrals that may be required and make them at this point.
Document
the patient’s response.
Clearly document your (C)ABCDE assessment, including history, examination, observations, investigations, interventions, and
See our documentation guides for more details
Patient discussion
Communicate with the patient (if they are conscious). Provide information about what you’ve done, what you’ve found, and any
interventions you have planned. Answer any questions they have and ask if there is anything they need.
Debrief
Debrief with the trauma team. Ensure that everyone is ok and answer any questions. Give all team members a chance to
express any concerns or feedback they have on the event. Not only is this important for the well-being of the team, but it also
allows you to check there’s nothing you’ve missed.
Relative discussion
Once the patient is stabilised, with their consent (if conscious), contact and inform the next of kin. Answer any questions they
may have and (if practical and desired) allow them to see their relative.
Senior clinician discussion/handover
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist (e.g. neurosurgery)?
Should any changes be made to the current management of their underlying condition(s)?

Reviewer

Dr Laura Kennedy
Emergency Medicine Registrar

References

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