Initial Assessment and Management of Car Accident Victims
Patients involved in car accidents should be rapidly assessed using a systematic approach prioritizing life-threatening injuries, with immediate transport to a trauma center for those meeting trauma triage criteria. 1
Primary Survey (First 5 Minutes)
Step 1: Physiologic Assessment
- Assess vital signs and level of consciousness:
- Glasgow Coma Scale (GCS) < 14
- Systolic blood pressure < 90 mmHg
- Respiratory rate < 10 or > 29 breaths per minute (> 29 in infants)
- Need for ventilatory support 1
Step 2: Anatomic Assessment
- Rapidly identify:
- Penetrating injuries to head, neck, torso, extremities
- Flail chest
- Two or more proximal long bone fractures
- Crushed, degloved, or mangled extremity
- Amputation proximal to wrist or ankle
- Pelvic fractures
- Open or depressed skull fractures
- Paralysis 1
Step 3: Mechanism of Injury Assessment
- High-risk mechanisms requiring trauma center transport:
- Falls: adults > 20 feet (one story = 10 feet); children > 10 feet
- High-risk auto crash features:
- Intrusion (including roof) > 12 inches at occupant site or > 18 inches at any site
- Ejection (partial or complete)
- Death in same passenger compartment
- Vehicle telemetry data consistent with high injury risk
- Auto vs. pedestrian/bicyclist: thrown, run over, or impact > 20 mph
- Motorcycle crash > 20 mph 1
Immediate Interventions
Airway Management
- Secure airway if compromised (intubation if necessary)
- Apply cervical spine immobilization for suspected neck injuries 1
Breathing
- Provide supplemental oxygen if needed
- Identify and treat tension pneumothorax, flail chest, or hemothorax
- Consider chest tube placement for severe thoracic trauma 1
Circulation
- Control external hemorrhage with direct pressure
- Apply pelvic binder for suspected pelvic fractures
- Place around the greater trochanters
- Apply as soon as possible in all patients with suspected severe pelvic trauma 1
- Establish IV access and begin fluid resuscitation for hypotensive patients 1
Secondary Assessment
Imaging
For hemodynamically unstable patients:
- Immediate pelvic X-ray
- FAST (Focused Assessment with Sonography for Trauma) or diagnostic peritoneal lavage 1
For hemodynamically stable patients:
- Whole-body CT scan with IV contrast 1
Critical Findings Requiring Immediate Action
- Free intra-abdominal fluid with hemodynamic instability requires urgent intervention 1
- Significant pelvic fractures with signs of bleeding require external stabilization 1
Transport Decisions
Trauma Center Transport Indications
- Any physiologic abnormalities (Step 1)
- Any significant anatomic injuries (Step 2)
- High-risk mechanism of injury (Step 3)
- Special considerations (age > 55, anticoagulation, pregnancy > 20 weeks) 1
Transport Destination
- Patients with severe pelvic trauma should be transported directly to a trauma center rather than the closest non-specialized facility 1
- Studies show a 15-30% decrease in mortality when patients are transported directly to trauma centers 1
Common Pitfalls and Caveats
- Undertriage: Using only physiologic and anatomic criteria without considering mechanism of injury can miss 25% of seriously injured patients 1
- Delayed Internal Bleeding: Some patients may initially appear stable but deteriorate due to occult internal injuries 1
- Inadequate Pelvic Stabilization: Pelvic binders must be placed correctly around the greater trochanters to be effective 1
- Missed Cervical Spine Injuries: Always maintain cervical spine precautions in high-risk mechanisms 1
- Rural Locations: Rural crash mortality is higher and only partially explained by time delays; rapid transport to definitive care is critical 2
Remember that the "golden hour" concept in trauma care is supported by evidence - early EMS intervention (first 30 minutes) and rapid transport to a hospital significantly improve survival outcomes 2.