What are the guidelines for managing trauma patients?

Guidelines for Managing Trauma Patients

The management of trauma patients should follow the systematic ABCDE approach (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

Initial Assessment and Management

Airway Management

• Assess airway patency and clear of foreign bodies, blood, or secretions
• Consider early intubation for patients with GCS <8 or airway compromise
• Maintain cervical spine immobilization until cleared
• Use manual in-line stabilization during intubation 1

Breathing Management

• Evaluate respiratory rate, chest excursion, and oxygen saturation
• Immediately treat life-threatening conditions:
  • Tension pneumothorax
  • Open pneumothorax
  • Massive hemothorax
• Avoid hyperventilation in hypovolemic patients 1

Circulation Management

• Control external hemorrhage immediately:
  • Apply direct pressure to bleeding sites
  • Use tourniquets for life-threatening extremity bleeding
• Establish large-bore IV access (two 16G or larger)
• Target systolic BP of 80-100 mmHg until major bleeding is controlled (permissive hypotension)
• Prioritize blood products for hemorrhagic shock 1
• Classify 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 1

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 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

Special Trauma Populations

Elderly Trauma Patients

• Early trauma protocol activation in patients ≥55 years old 2
• Assess frailty in all elderly trauma patients using Geriatric Trauma Outcome Score (GTOS) and Trauma-Specific Frailty Index 2
• Lower threshold for trauma activation with triage set points of heart rate >90 bpm and systolic BP <110 mmHg 2
• Perform early blood gas for baseline base-deficit or lactate assessment 2
• Low threshold for initial CT imaging as diagnostic yield outweighs contrast-induced nephropathy risk 2
• Rapidly recognize and correct coagulation disorders related to trauma or chronic medication 2

Severe Limb Trauma

• Refer patients promptly to Level 1 or Level 2 Trauma Centers based on medical history and clinical examination 2
• Implement medical devices in prehospital setting to reduce blood loss 2
• Perform fracture fixation with appropriate timing and modalities 2
• Prevent infection with appropriate antibiotic prophylaxis 2
• Prevent thromboembolic complications 2
• Monitor for and treat limb compartment syndrome early 2
• Detect and prevent rhabdomyolysis-induced acute kidney injury 2

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

Hemorrhage Control

• Apply external pelvic compression immediately using pelvic binders for pelvic fractures
• Consider angiographic embolization or surgical bleeding control for ongoing instability
• Employ damage control surgery for severely injured patients with:
  • Deep hemorrhagic shock
  • Ongoing bleeding
  • Coagulopathy
  • Hypothermia
  • Acidosis
  • Inaccessible major anatomic injury 1
• Maintain platelet count above 50×10^9/l in patients with ongoing bleeding and/or traumatic brain injury 1
• Minimize time between injury and surgical bleeding control 1

Hypothermia Prevention and Management

• Implement warming strategies based on patient's recorded temperature:
  • Level 1: Basic warming measures (blankets, warm IV fluids)
  • Level 2: More aggressive warming for temperatures <36°C
• Continue warming protocols throughout transfers between units
• Target rewarming to minimum core temperature of 36°C but cease after 37°C 2

Pain Management in Trauma

• Administer analgesics early with focus on medications having minimal hemodynamic effects
• Use acetaminophen regularly (IV every 6 hours) unless contraindicated
• Use NSAIDs with caution in elderly patients due to risk of acute kidney injury and GI complications
• Consider opioids for moderate to severe pain while monitoring for respiratory depression
• Consider alternatives to opioids when appropriate:
  • N-methyl-D-aspartate receptor antagonists (ketamine, magnesium)
  • Membrane stabilizers (lidocaine)
  • Anticonvulsants (gabapentinoids)
  • Antidepressants (amitriptyline)
  • α-agonists (clonidine, dexmedetomidine) 2

Common Pitfalls and Caveats

1. Undertriage of elderly trauma patients: Use lower thresholds for trauma activation in patients ≥55 years old 2
2. Relying solely on hemoglobin/hematocrit as markers for bleeding: Use multiple parameters including lactate and base deficit 1
3. Delayed recognition of coagulopathy: Monitor coagulation early and implement correction strategies promptly 2
4. Inadequate temperature management: Implement active warming measures early and continue throughout care 2
5. Overreliance on traditional ABC approach in exsanguinating patients: Consider prioritizing circulation in patients with severe hemorrhage 3
6. Delayed transfer to appropriate trauma centers: Transport severe trauma patients directly to referral trauma centers fully equipped to treat all aspects of trauma 1

By following these guidelines systematically, healthcare providers can optimize outcomes for trauma patients through early identification and management of life-threatening conditions while providing definitive care.