What is the initial approach to managing a trauma patient?

Initial Approach to Trauma Management

The initial approach to trauma patients should follow a systematic primary survey using the ABCDE sequence (Airway, Breathing, Circulation, Disability, Exposure), with immediate control of exsanguinating hemorrhage taking priority even before airway management in patients with severe bleeding. 1

Pre-Hospital Phase: Immediate Priorities

Hemorrhage Control First

• Apply tourniquets immediately for life-threatening extremity bleeding before addressing airway concerns 1
• Tourniquets should remain in place until surgical control is achieved, ideally less than 2 hours, though military experience shows extremity survival up to 6 hours 1
• For suspected pelvic trauma, apply external pelvic compression (pelvic binder) as soon as possible, positioned around the greater trochanters 1

Circulation-First Approach in Hemorrhagic Shock

• In patients with severe hemorrhage and systolic blood pressure <90 mmHg, prioritize circulation management (blood transfusion/hemorrhage control) before intubation 2, 3
• Early intubation in hypotensive trauma patients causes post-intubation hypotension and significantly increases mortality (78% vs 50% when intubation precedes transfusion) 3
• The "x-ABC" sequence (exsanguinating hemorrhage-airway-breathing-circulation) reduces in-hospital mortality by 85% compared to traditional ABC in severe hemorrhage patients 2

Permissive Hypotension Strategy

• Target systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) using restricted fluid resuscitation until bleeding is controlled 1
• Aggressive fluid resuscitation increases mortality, coagulopathy, and need for damage control surgery 1
• Critical exception: In traumatic brain injury (GCS ≤8), maintain MAP ≥80 mmHg to ensure adequate cerebral perfusion 1

Hypothermia Prevention Begins Immediately

• Remove wet clothing, apply warm blankets, and shield from wind/ground contact 1
• Begin passive warming (Level 1 strategies) for all trauma patients even without temperature measurement 1

Transport Destination

• Transport all severe trauma patients directly to a designated Level 1 trauma center, not the nearest hospital 1
• Direct transport to trauma centers reduces mortality by 20-30% compared to non-specialized facilities 1

Hospital Phase: Trauma Bay Assessment

Primary Survey Sequence

Airway (with C-spine protection)

• Assess airway patency while maintaining cervical spine immobilization 1, 4
• Rapid sequence intubation with direct laryngoscopy remains the standard method when intubation is required 5
• Delay intubation in hypotensive patients until after initiating blood transfusion unless critical hypoxia or airway injury present 3

Breathing

• Immediately decompress tension pneumothorax, seal open pneumothorax, drain massive hemothorax 4
• Maintain normoventilation (avoid hyperventilation) unless signs of imminent cerebral herniation 1
• Hyperventilation increases mortality in trauma patients through decreased cerebral blood flow and impaired venous return 1

Circulation

• Clinically assess hemorrhage using mechanism of injury, physiology, anatomical pattern, and response to resuscitation 1
• Use ATLS classification: Class III (1500-2000ml loss, HR 120-140, decreased BP) and Class IV (>2000ml loss, HR >140, decreased BP) require immediate surgical control 1
• Initiate crystalloid fluids but maintain restricted volume strategy 1
• Avoid Ringer's lactate in severe head trauma patients 1

Disability

• Assess Glasgow Coma Score and pupillary response 4
• Identify signs of increased intracranial pressure or impending herniation 4

Exposure

• Record core temperature immediately (esophageal, bladder, or rectal—peripheral measurements unreliable) 1
• Remove all clothing to identify injuries, then cover with warm blankets 1

Temperature-Guided Warming Protocol

Temperature >36°C:

• Cover with two warm blankets, monitor every 15 minutes 1

Temperature 32-36°C (Moderate Hypothermia):

• Add Level 2 strategies: heating pads, forced-air warmers, warmed IV fluids (>37°C), humidified warm oxygen 1
• Monitor temperature every 5 minutes 1

Temperature <32°C (Severe Hypothermia):

• Add Level 3 strategies: consider peritoneal lavage with warmed fluids, extracorporeal rewarming 1
• Handle patient gently to avoid triggering arrhythmias 1
• Target minimum core temperature of 36°C; cease rewarming at 37°C as higher temperatures worsen outcomes 1

Imaging Strategy

Hemodynamically Unstable Patients:

• Obtain pelvic X-ray immediately in trauma bay 1
• Perform E-FAST to identify intra-abdominal bleeding and guide need for laparotomy 1

Hemodynamically Stable Patients:

• Skip pelvic X-ray and proceed directly to whole-body CT with IV contrast 1

Critical Pitfalls to Avoid

• Never hyperventilate trauma patients routinely—this increases mortality through cerebral vasoconstriction and decreased venous return 1
• Never give large-volume crystalloid resuscitation pre-hospital—volumes >2000ml increase coagulopathy to >40% 1
• Never apply permissive hypotension in TBI patients—they require MAP ≥80 mmHg for cerebral perfusion 1
• Never intubate hypotensive hemorrhaging patients before initiating transfusion—this causes post-intubation hypotension and doubles mortality 3
• Never overlook temperature documentation—one major trauma center documented temperature in only 38% of admissions 1
• Never place pelvic binders incorrectly—they must be positioned around the greater trochanters, not the iliac crests, to be effective 1

Response to Resuscitation Categories

Monitor patient response to initial fluid bolus to guide surgical intervention 1:

• Rapid responders (vital signs normalize and remain stable): Continue observation
• Transient responders (initial improvement then deterioration): Prepare for urgent surgical intervention
• Non-responders (no improvement): Immediate surgical hemorrhage control required