What are the initial steps in managing a trauma case?

Initial Trauma Management

Immediately control life-threatening hemorrhage with tourniquets for extremity bleeding and apply pelvic binders for suspected pelvic trauma before addressing airway concerns, then rapidly transport to a designated trauma center while maintaining restricted fluid resuscitation and normoventilation. 1

Pre-Hospital Phase: Critical First Actions

Hemorrhage Control (First Priority)

• Apply tourniquets immediately for life-threatening extremity bleeding before airway management, as hemorrhage control takes precedence over traditional ABC priorities 1
• Tourniquets should remain in place until surgical control is achieved, ideally within 2 hours 1
• For suspected pelvic trauma (shock or altered consciousness), apply external pelvic compression as soon as possible using pelvic binders positioned around the greater trochanters, not the iliac crests 2, 1
• All trauma patients with shock or altered consciousness should be systematically considered as having pelvic trauma 2

Airway and Ventilation Management

• Control the airway through tracheal intubation with mechanical ventilation and end-tidal CO2 monitoring, even in the pre-hospital period for severe traumatic brain injury patients 2
• Maintain normoventilation—never hyperventilate trauma patients routinely unless signs of imminent cerebral herniation, as hyperventilation increases mortality through cerebral vasoconstriction and decreased venous return 2, 1
• Monitor end-tidal CO2 to verify correct tube placement and maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia 2

Hemodynamic Management

• Target systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) using restricted fluid resuscitation until bleeding is controlled 1
• Critical exception: In traumatic brain injury (GCS ≤8), maintain MAP ≥80 mmHg to ensure adequate cerebral perfusion 1
• Never give large-volume crystalloid resuscitation pre-hospital—volumes >2000ml increase coagulopathy to >40% 1
• Initiate crystalloid fluids but maintain restricted volume strategy 1

Temperature Management

• Remove wet clothing, apply warm blankets, and shield from wind/ground contact to prevent hypothermia 1
• Hypothermia exacerbates coagulopathy and worsens outcomes in trauma patients 1

Transport Decisions

• Transport all severe trauma patients directly to a designated Level 1 trauma center, not the nearest hospital 2, 1
• Admission to designated trauma centers leads to 20% decrease in overall trauma mortality and 30% decrease in severe trauma mortality 2
• Pre-hospital medical care delivered by physicians has led to 30% mortality rate decrease in severe trauma 2

Hospital Phase: Trauma Bay Assessment

Initial Assessment

• Assess hemorrhage severity using a combination of patient physiology, anatomical injury pattern, mechanism of injury, and response to initial resuscitation 2
• Assess traumatic brain injury severity using the Glasgow Coma Scale, specifically the motor response, as well as pupillary size and reactivity 2
• Record core temperature immediately using esophageal, bladder, or rectal measurement—peripheral measurements are unreliable 1

Immediate Diagnostic Approach

• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedure unless initial resuscitation measures are successful 2
• Patients presenting with hemorrhagic shock and an unidentified source of bleeding should undergo immediate further investigation 2
• Early imaging (ultrasonography or CT) should be employed to detect free fluid in patients with suspected torso trauma 2
• Patients with significant free intraabdominal fluid and hemodynamic instability should undergo urgent intervention 2
• Hemodynamically stable patients should undergo further assessment using CT 2

Monitoring and Laboratory Assessment

• Use serum lactate or base deficit measurements to estimate and monitor the extent of bleeding and shock—single hematocrit measurements should not be employed as isolated markers 2
• Early, repeated, and combined measurement of PT, APTT, fibrinogen, and platelets should be employed to detect post-traumatic coagulopathy 2
• Viscoelastic testing should be used to assist in characterizing coagulopathy and guiding hemostatic therapy 2

Neurosurgical Considerations for Severe TBI

Early Neurosurgical Indications

Neurosurgical intervention is indicated at the early phase for 2:

• Removal of symptomatic extradural hematoma whatever its location
• Removal of significant acute subdural hematoma (thickness >5mm with midline shift >5mm)
• Drainage of acute hydrocephalus
• Closure of open displaced skull fracture
• Closed displaced skull fracture with brain compression (thickness >5mm, mass effect with midline shift >5mm)

Intracranial Pressure Management

• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 2
• Consider decompressive craniectomy to control intracranial pressure at the early phase where refractory intracranial hypertension exists, in multidisciplinary discussion 2
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique, with good outcomes (GOS 4-5) achieved in 40-57% of patients versus 28-32% in controls 2

Critical Pitfalls to Avoid

• Never hyperventilate routinely—this increases mortality through cerebral vasoconstriction 1
• Never apply permissive hypotension in TBI patients—they require MAP ≥80 mmHg 1
• Never place pelvic binders incorrectly—they must be positioned around the greater trochanters 1
• Never overlook temperature documentation—hypothermia significantly worsens outcomes 1
• Never delay transport to reach the nearest hospital—go directly to a trauma center 2, 1

Implementation Strategy

• Each institution should implement an evidence-based treatment algorithm for the bleeding trauma patient 2
• Treatment checklists should be used to guide clinical management 2
• Each institution should include an assessment of adherence to the institutional algorithm as part of quality management 2
• ATLS training has been shown to reduce preventable or potentially preventable mortality, particularly in the first 60 minutes after admission 3, 4