What is the initial management of a patient with trauma?

Initial Management of Trauma Patients

The initial management of trauma patients should follow the ABCDE protocol (Airway, Breathing, Circulation, Disability, Exposure) with immediate identification and management of life-threatening conditions, while minimizing the time between injury and definitive bleeding control. 1

Primary Survey and Immediate Life-Saving Interventions

A - Airway Management

• Assess airway patency and protect the cervical spine
• For patients with suspected severe pelvic trauma, consider them at risk of airway compromise 2
• Maintain normoventilation (target PaCO2 35-40 mmHg) unless signs of imminent cerebral herniation 2, 1
• Avoid hyperventilation as it increases mortality in trauma patients 2

B - Breathing

• Identify and immediately treat life-threatening thoracic injuries:
  • Tension pneumothorax
  • Open pneumothorax
  • Massive hemothorax
  • Flail chest 1
• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to detect pneumothorax, hemothorax, and hemoperitoneum 2

C - Circulation and Hemorrhage Control

• Apply external pelvic compression immediately for suspected pelvic trauma using pelvic binders placed around the great trochanters 2
• Apply tourniquets immediately for life-threatening extremity bleeding with application time kept as short as possible (ideally <2 hours) 2, 1
• Assess hemorrhage severity using the ATLS classification:
  • Class I: <15% blood loss, pulse <100, normal BP, slightly anxious
  • Class II: 15-30% blood loss, pulse 100-120, normal BP, mildly anxious
  • Class III: 30-40% blood loss, pulse 120-140, decreased BP, anxious/confused
  • Class IV: >40% blood loss, pulse >140, decreased BP, confused/lethargic 2, 1

D - Disability

• Assess level of consciousness (AVPU or GCS)
• Evaluate pupillary size and reactivity
• Identify signs of increased intracranial pressure 1

E - Exposure and Environment

• Completely expose the patient to identify all injuries
• Prevent hypothermia using active warming measures:
  • Remove wet clothing
  • Apply warming blankets
  • Use warmed IV fluids
  • Maintain warm ambient temperature 1

Transport Decision

• All patients with severe trauma should be initially transported to a referral trauma center fully staffed and equipped to treat any aspect of trauma 2
• Rapid transfer of severe trauma patients to a referral Trauma Centre increases survival compared to transfer to the closest available non-specialized facility 2

Initial Diagnostic Workup

Imaging

• For hemodynamically unstable patients:

  • Obtain pelvic X-ray upon arrival 2
  • Perform E-FAST to detect free fluid in abdomen, chest, and pericardium 2

• For hemodynamically stable patients:

  • Proceed directly to whole-body CT scan with intravenous contrast 2
  • Skip pelvic X-ray as CT will provide more detailed information 2

Laboratory Studies

• Obtain baseline laboratory studies:
  • Complete blood count
  • Coagulation studies
  • Blood type and crossmatch
  • Arterial blood gas
  • Serum lactate or base deficit to estimate shock severity 1

Resuscitation Strategy

• Assess patient response to initial fluid resuscitation:

  • Rapid responders: Stabilize with crystalloids
  • Transient responders: Need surgical intervention and blood products
  • Non-responders: Require immediate surgical bleeding control 2

• For patients with hemorrhagic shock, consider a circulation-first approach that prioritizes restoration of circulation with blood products while maintaining basic airway interventions 3

Common Pitfalls and Complications

• Delayed recognition of shock: Vital signs may remain normal until >30% blood volume is lost; tachycardia and altered mental status are early signs 1
• Hyperventilation: Increases mortality in trauma patients; maintain normoventilation unless signs of imminent cerebral herniation 2, 1
• Delayed bleeding control: Increases mortality; minimize delays in transferring patients requiring surgical intervention 1
• Improper tourniquet use: Can lead to nerve paralysis and limb ischemia; apply correctly and minimize application time 2, 1
• Hypothermia: Exacerbates coagulopathy and increases mortality; implement active warming strategies early 1

Monitoring

• For patients at risk of intra-abdominal pressure elevation, monitor intra-abdominal pressure to detect abdominal compartment syndrome early 2
• For severe abdominal injury (AIS ≥3) treated non-operatively:
  • Admit to a facility with 24/7 capacity for emergency hemostatic laparotomy
  • Monitor continuously for at least 24 hours
  • Continue clinical and biological observation for 3-5 days minimum 2

By following this structured approach to trauma management, clinicians can systematically address life-threatening conditions in order of priority, minimize time to definitive care, and improve patient outcomes.