What are the initial steps in managing a patient with major trauma?

Initial Steps in Managing Major Trauma

The initial management of major trauma patients should follow the ABCDE protocol with immediate identification and management of life-threatening conditions, while minimizing the time between injury and definitive bleeding control. 1

Airway Management

• Assess airway patency immediately:

  • Clear airway of foreign bodies, blood, or secretions
  • Consider early intubation for patients with GCS <8 or airway compromise
  • Maintain cervical spine immobilization until cleared 1
  • Use manual in-line stabilization during intubation to protect potential cervical spine injuries 2

• Difficult airway considerations:

  • Have backup airway equipment ready including laryngeal mask airways and surgical airway tools
  • Be prepared for cricothyroidotomy if standard intubation fails 1

Breathing Assessment

• Evaluate respiratory rate, chest excursion, and oxygen saturation
• Immediately identify and treat life-threatening conditions:
  • Tension pneumothorax: needle decompression followed by chest tube
  • Open pneumothorax: occlusive dressing
  • Massive hemothorax: chest tube placement and volume resuscitation 1
• Avoid hyperventilation in hypovolemic patients as it may worsen outcomes 2

Circulation Management

• Control external hemorrhage immediately:

  • Apply direct pressure to bleeding sites
  • Use tourniquets for life-threatening extremity bleeding 1
  • Establish large-bore IV access (two 16G or larger) 1

• Initial fluid resuscitation:

  • Target systolic blood pressure of 80-100 mmHg until major bleeding is controlled (permissive hypotension) 2, 1
  • Start with crystalloids, consider adding colloids within prescribed limits 2
  • For ongoing hemorrhage, initiate blood product resuscitation 1

• Hemorrhage control priorities:

  • Patients with identified bleeding source should undergo immediate bleeding control procedure unless initial resuscitation is successful 2
  • For unidentified bleeding sources, perform immediate further assessment 2

Disability Assessment

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

Exposure and Environmental Control

• 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 2, 1

Diagnostic Imaging

• For hemodynamically unstable patients:

  • Obtain portable chest and pelvic radiographs
  • Perform Extended Focused Assessment with Sonography for Trauma (E-FAST) to detect free fluid in abdomen, pneumothorax/hemothorax, and hemopericardium 1

• For hemodynamically stable patients:

  • Proceed directly to whole-body CT scan with IV contrast 1

Specific Trauma Management

• Pelvic fractures:

  • Apply external pelvic compression immediately using pelvic binders
  • Perform pelvic ring closure and stabilization for patients with pelvic ring disruption in hemorrhagic shock 2, 1
  • Consider angiographic embolization or surgical bleeding control for ongoing instability 2

• Damage control surgery:

  • Employ for severely injured patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, acidosis, or inaccessible major anatomic injury 2
  • Minimize time between injury and surgical bleeding control 2

Monitoring

• Use serum lactate and base deficit to estimate and monitor shock severity 2, 1
• Avoid reliance on single hemoglobin/hematocrit measurements 2
• Monitor vital signs continuously 1
• Obtain baseline laboratory studies:
  • Complete blood count
  • Coagulation studies
  • Blood type and crossmatch
  • Arterial blood gas
  • Serum lactate or base deficit 1

Common Pitfalls to Avoid

• Delaying airway management in patients with decreased level of consciousness
• Failing to recognize tension pneumothorax
• Aggressive fluid resuscitation causing dilutional coagulopathy
• Overlooking non-cavitary sources of bleeding (e.g., long bone fractures)
• Delayed recognition and treatment of hypothermia
• Focusing on non-life-threatening injuries before addressing ABCDE priorities
• Delaying transfer to definitive care when needed 1

Remember that all patients with severe trauma should initially be transported to a referral trauma center fully staffed and equipped to treat any aspect of trauma, as rapid transfer increases survival compared to transfer to the closest available non-specialized facility 1.