Critical Alerts

• ABCDE approach saves lives: Systematic primary survey identifies life threats
• Hemorrhage is leading preventable death: Control bleeding early
• Permissive hypotension for hemorrhage: Target SBP 80-90 until surgical control (except TBI)
• Massive transfusion protocol: 1:1:1 ratio of RBC:FFP:Platelets
• TXA within 3 hours: Reduces mortality if given early
• Log-roll with C-spine precautions: Until cleared

Key Diagnostics

Emergency Treatments

Overview

Major trauma (polytrauma) refers to injury to multiple body systems with at least one potentially life-threatening injury. It requires a systematic approach using ATLS (Advanced Trauma Life Support) principles, with simultaneous assessment and resuscitation. The goal is to identify and treat immediately life-threatening conditions while preparing for definitive care.

Criteria for Trauma Team Activation

Physiological Criteria:

• GCS ≤13
• SBP <90 mmHg
• RR <10 or >29 (or intubated)
• Penetrating injury to head, neck, torso, extremities proximal to knee/elbow

Anatomical Criteria:

• Flail chest
• Two or more proximal long bone fractures
• Crushed, degloved, or mangled extremity
• Amputation proximal to wrist or ankle
• Pelvic fracture
• Open or depressed skull fracture
• Paralysis

Mechanism Criteria:

• Fall >20 feet (6 meters)
• High-speed MVC (>40 mph with intrusion, ejection, rollover)
• Motorcycle crash >20 mph
• Pedestrian/cyclist struck at significant speed
• Death in same vehicle
• Extrication time >20 minutes

Classification by Injury Severity

Epidemiology

• Leading cause of death: Ages 1-44 years
• Global deaths: 4.4 million annually from injuries
• Trimodal death distribution:
  • Immediate (50%): At scene from severe brain/vascular injury
  • Early (30%): Within hours from hemorrhage, airway compromise
  • Late (20%): Days to weeks from sepsis, MODS

Immediate Life Threats

Indicators of Severe Injury

• GCS ≤8
• SBP <90 despite fluids
• Lactate >4
• Base deficit worse than -6
• Need for massive transfusion

Bedside Diagnostics

eFAST (Extended Focused Assessment with Sonography for Trauma):

Interpretation:

• Positive eFAST in unstable patient → OR
• Negative eFAST doesn't exclude injury (hollow viscus, retroperitoneal)

Portable Imaging:

• CXR: Pneumothorax, hemothorax, widened mediastinum
• Pelvis XR: Pelvic fracture

Laboratory Studies

CT Imaging ("Pan-Scan")

When Patient Stabilized:

CT Should NOT Delay:

• OR for unstable hemodynamics
• Critical interventions

Immediate OR Indications

• Positive eFAST with hemodynamic instability
• Massive hemothorax
• Class III-IV hemorrhagic shock with identified surgical source
• Penetrating torso trauma with instability
• ED thoracotomy survivors

ICU Admission

• All major trauma
• Need for mechanical ventilation
• Ongoing resuscitation
• Monitoring for delayed complications

Transfer Considerations

• Transfer to trauma center if Level I/II care not available
• Stabilize before transfer
• Do not delay transfer for non-essential imaging

Tertiary Survey

Within 24 Hours:

• Repeat head-to-toe exam
• Review all imaging
• Identify missed injuries (up to 10% initially missed)

Condition Explanation

• "Your family member has been seriously injured in multiple parts of the body."
• "We are focusing on stopping any bleeding and making sure they can breathe."
• "They may need surgery and will be in the intensive care unit."

Expected Course

• Multiple surgeries may be needed
• ICU stay likely prolonged
• Rehabilitation will be important
• Psychological support available

Involvement

• Designated family contact for updates
• Social work and chaplain services
• ICU family meetings

Pediatric Trauma

• Higher surface area to volume → rapid heat loss
• Blood volume ~80 mL/kg
• Immature skeleton → internal injury without fractures
• Head is disproportionately large
• Cardiac output depends on heart rate

Geriatric Trauma

• Lower physiologic reserve
• Pre-existing anticoagulation
• May not mount tachycardia (beta-blockers)
• Consider TBI with even minor mechanism
• Frailty impacts outcomes

Pregnant Trauma Patients

• Prioritize mother: Best care for fetus is care for mother
• Left lateral tilt or manual uterine displacement
• Rhogam if Rh-negative
• Obstetrics consultation
• Early fetal monitoring
• Emergency cesarean if maternal arrest and >24 weeks

Anticoagulated Patients

• Reverse anticoagulation early
• 4-factor PCC for warfarin
• Idarucizumab for dabigatran
• TXA still indicated

Burns + Trauma

• Airway priority (inhalation injury)
• Fluid resuscitation for burns
• Escharotomy for circumferential burns

Performance Indicators

Documentation Requirements

• Mechanism and pre-hospital information
• Primary survey findings
• Secondary survey findings
• Imaging and lab results
• Procedures performed
• Blood products given
• Time stamps for key interventions

Diagnostic Pearls

• Primary survey is treatment: Intervene as you find problems
• eFAST positive + unstable = OR: Don't delay for CT
• Lactate is a resuscitation marker: Rising lactate = ongoing hypoperfusion
• Don't trust initial hemoglobin: May be normal despite massive blood loss
• Log-roll to examine the back: Don't miss posterior injuries
• CT pan-scan when stable: Identifies occult injuries

Treatment Pearls

• Lethal triad kills: Warm, stop acidosis, give blood
• Permissive hypotension: SBP 80-90 until bleeding controlled (NOT in TBI)
• TXA works: Give within 3 hours
• 1:1:1 transfusion: Don't resuscitate with crystalloid
• Pelvic binder early: For pelvic fractures
• ED thoracotomy has role: Penetrating arrest with brief down time

Disposition Pearls

• All major trauma to trauma center: Transfer if needed
• Tertiary survey finds missed injuries: Do within 24 hours
• ICU admission standard: For monitoring and ongoing resuscitation
• Family communication early: Assign liaison