From the Guidelines
The primary management of trauma should follow a systematic approach, prioritizing life-threatening conditions first, as outlined in the most recent guidelines, such as the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. The management of trauma involves a step-wise approach, often remembered by the ABCDE mnemonic: Airway, Breathing, Circulation, Disability, and Exposure.
- First, secure the airway using manual maneuvers, oropharyngeal airways, or endotracheal intubation if needed, to ensure adequate oxygenation and ventilation.
- Next, ensure adequate breathing by providing supplemental oxygen, decompressing tension pneumothorax with needle thoracostomy if present, and supporting ventilation.
- Control hemorrhage through direct pressure, tourniquets for extremity bleeding, and fluid resuscitation with balanced crystalloids like Lactated Ringer's at 1-2 L initially for adults with hypotension, as recommended by recent guidelines 1.
- Assess neurological status using the Glasgow Coma Scale and pupillary responses to identify potential head injuries or other neurological deficits.
- Completely expose the patient to identify all injuries while maintaining normothermia to prevent hypothermia-related complications.
- Administer tranexamic acid 1g IV over 10 minutes within 3 hours of injury, followed by 1g over 8 hours for patients with significant bleeding, as this has been shown to reduce mortality due to bleeding 1.
- Pain management with IV opioids like fentanyl 25-50 mcg or morphine 2-4 mg titrated to effect is appropriate, while considering the patient's overall clinical condition and potential for opioid-related side effects.
- Consider tetanus prophylaxis and early broad-spectrum antibiotics for open wounds to prevent infection and promote healing. This systematic approach, as outlined in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, prioritizes life-threatening conditions first, addressing the most immediate physiological threats before moving to secondary assessment and definitive care.
From the Research
Primary Management of Trauma
The primary management of trauma involves several key strategies, including:
- Resuscitation and transfusion management to address hemorrhage, coagulopathy, and transfusion of blood and blood products 2
- Damage control resuscitation, which combines permissive hypotension, hemostatic resuscitation, and damage control surgery to treat severely traumatized patients in hemorrhagic shock 2
- Administration of tranexamic acid, an antifibrinolytic drug that has been shown to reduce deaths after traumatic injury, particularly when given early 3, 4, 5
- Rapid trauma injury assessment to guide resuscitation and decide on critical interventions in case of hemodynamic instability 6
Key Components of Trauma Management
Some key components of trauma management include:
- Avoiding metabolic acidosis, hypothermia, and treating coagulopathy to stabilize the patient as soon as possible 2
- Close monitoring of bleeding and coagulation to allow for goal-directed transfusions and optimize the patient's coagulation 2
- Use of tranexamic acid as part of a broader strategy of remote damage-control resuscitation (RDCR) to improve outcomes in prehospital trauma management 4
- Personalized approach to tranexamic acid dosing based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen 5
Initial Management of Severe Trauma Patients
The initial management of severe trauma patients at hospital admission involves:
- Stabilizing vital functions and following a rigorous injury assessment to define a therapeutic strategy 6
- Organizing care procedures to minimize loss of time and avoid conflicts of decision 6
- Use of imaging studies such as chest and pelvic X-ray, abdominal ultrasound, and whole body scanner with administration of intravenous contrast material to guide resuscitation and decide on critical interventions 6