What is the initial management for a trauma patient?

Initial Management of Trauma Patients

The initial management of trauma patients must follow a systematic, prioritized approach beginning with immediate assessment of hemodynamic stability, airway control, and rapid identification of life-threatening injuries through clinical examination and focused imaging, with all interventions aimed at early hemorrhage control and prevention of secondary injury. 1

Immediate Assessment and Stabilization

Hemodynamic Status Assessment

• Assess hemodynamic stability immediately upon patient contact, defined as systolic blood pressure ≥90 mmHg and heart rate 50-110 beats per minute 1
• Evaluate mechanism of injury to identify patients at risk for significant traumatic hemorrhage 1, 2
• Use serum lactate or base deficit measurements to estimate and monitor the extent of bleeding and shock 1

Airway Management (First Priority)

• Secure the airway immediately in patients with apnea, gasping breathing (respiratory rate <6/min), hypoxia (SpO2 <90% despite oxygen), severe traumatic brain injury (GCS <9), hemodynamic instability (SBP <90 mmHg), or severe chest trauma with respiratory insufficiency (respiratory rate >29/min) 3
• Perform endotracheal intubation via the oral route using rapid sequence induction with manual in-line cervical spine stabilization 4, 3
• Use ketamine as the preferred induction agent; avoid etomidate due to adrenal suppression 3
• Confirm tube placement with capnography, which is absolutely mandatory 3
• Have alternative airway devices immediately available; consider alternative methods after maximum three unsuccessful intubation attempts 3

Ventilation Strategy

• Apply initial normoventilation unless signs of imminent cerebral herniation are present 1
• For suspected brain herniation: temporarily hyperventilate to PaCO2 30-35 mmHg as a temporizing measure only 5
• Maintain PaO2 between 60-100 mmHg 5
• Avoid prolonged hyperventilation beyond a few hours due to risk of cerebral ischemia 5

Hemorrhage Control Measures

Prehospital Interventions

• Apply tourniquets immediately for life-threatening bleeding from open extremity injuries 1
• Apply external pelvic compression as soon as possible in all patients with suspected severe pelvic trauma 1, 2
• Use pelvic binders (not sheet wrapping) placed around the greater trochanters 1, 2
• Transport all severe trauma patients directly to a designated trauma center 1, 2

Physical Examination

• Inspect the abdomen for distension, asymmetry, laceraciones, abrasions, and "seat belt sign" which alert to possible intra-abdominal injury 2
• Assess for significant abdominal rigidity and involuntary guarding, which indicate peritonitis and suggest intestinal content leakage 2

Diagnostic Imaging Strategy

For Hemodynamically Unstable Patients

• Perform portable chest and pelvic radiographs immediately upon arrival 1, 2
• Perform Extended Focused Assessment with Sonography for Trauma (E-FAST) at bedside 1
• E-FAST has 97% positive predictive value for intra-abdominal bleeding in pelvic trauma with associated abdominal trauma 1
• E-FAST findings of hemopericardium, pneumothorax, or free intraperitoneal fluid have significant implications for immediate surgical intervention 1
• Proceed directly to operative intervention for bleeding control without CT imaging in most cases 1
• Consider whole-body CT only if degree of instability is mild and CT scanner is immediately accessible, as this may help determine optimal surgical approach 1

For Hemodynamically Stable Patients

• Perform CT of chest, abdomen, and pelvis with IV contrast 1, 2
• Use early imaging (ultrasonography or CT) to detect free fluid in suspected torso trauma 1
• Contrast-enhanced CT with multiplanar reformations is the standard imaging tool due to fast acquisition and excellent resolution 1
• Multiphasic protocols with arterial phase improve identification of vascular injuries; portal venous phase is best for solid organ assessment 1

Coagulation Management

Monitoring

• Perform early, repeated, combined measurement of PT, APTT, fibrinogen, and platelets to detect post-traumatic coagulopathy 1
• Use viscoelastic testing to characterize coagulopathy and guide hemostatic therapy 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding 1

Resuscitation Strategy

• Initiate early and aggressive hemostatic resuscitation with prompt diagnosis of life-threatening injuries and early control of ongoing bleeding 1
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion 5
• Avoid excessive fluid restriction, which causes hypotension and reduced cerebral perfusion 5

Critical Pitfalls to Avoid

• Do not delay intervention in hemodynamically unstable patients with identified bleeding source; proceed immediately to bleeding control 1
• Intestinal injury remains one of the most commonly missed injuries on initial CT (20% undetected), requiring serial examinations 2
• Do not perform CT imaging without IV contrast in trauma patients; contrast administration is essential 1
• Avoid prolonged hyperventilation, which can cause cerebral ischemia 5
• Do not delay osmotherapy while waiting for neuroimaging in patients with clear signs of brain herniation 5

Institutional Protocol Requirements

Each institution must implement an evidence-based treatment algorithm for bleeding trauma patients with treatment checklists to guide clinical management and routine quality assessment of adherence 1