What are the initial steps in managing trauma?

Initial Management of Trauma

The initial approach to trauma prioritizes immediate hemorrhage control, hemodynamic stabilization with restricted fluid resuscitation, and rapid transport to a Level 1 trauma center, with assessment following a structured algorithm based on hemodynamic stability. 1

Pre-Hospital Phase: Life-Saving Interventions

Hemorrhage Control (First Priority)

• Apply tourniquets immediately for life-threatening extremity bleeding before addressing airway concerns, as this is the most rapidly reversible cause of preventable death 1
• Tourniquets should remain in place until surgical control is achieved, ideally less than 2 hours 1
• For suspected pelvic trauma, apply a pelvic binder around the greater trochanters as soon as possible based on mechanism and clinical suspicion, without waiting for radiographic confirmation 1, 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
• Avoid large-volume crystalloid resuscitation pre-hospital—volumes >2000ml increase coagulopathy to >40% 1

Temperature and Transport

• Remove wet clothing, apply warm blankets, and shield from wind/ground contact to prevent hypothermia 1
• Transport all severe trauma patients directly to a designated Level 1 trauma center, not the nearest hospital, as this increases survival by 15-30% 1, 2

Hospital Phase: Trauma Bay Assessment

Airway and Ventilation

• Maintain normoventilation (avoid hyperventilation) unless signs of imminent cerebral herniation 1
• Never hyperventilate trauma patients routinely—this increases mortality through cerebral vasoconstriction and decreased venous return 1

Hemodynamic Assessment Algorithm

For Hemodynamically Unstable Patients (SBP <90 mmHg):

• Obtain pelvic X-ray upon arrival to identify fracture pattern 2, 3
• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to detect intra-abdominal bleeding, hemopericardium, and pneumothorax 4, 2, 3
• E-FAST has 97% positive predictive value for intra-abdominal hemorrhage in pelvic trauma patients 2, 3
• Initiate crystalloid fluids but maintain restricted volume strategy 1
• Proceed directly to operative management or interventional radiology without CT imaging in most cases 4

For Hemodynamically Stable Patients (SBP ≥90 mmHg):

• Do NOT obtain pelvic X-ray 2
• Proceed directly to CT scan of chest, abdomen, and pelvis with IV contrast 4, 2, 3
• Contrast-enhanced CT with multiplanar reformations is the standard imaging tool due to fast acquisition and excellent resolution 4
• CT angiography can identify active bleeding with 82-89% sensitivity 2

Clinical Assessment Priorities

• Clinically assess hemorrhage using mechanism of injury, physiology, anatomical pattern, and response to resuscitation 1
• Inspect the abdomen for distension, asymmetry, laceractions, abrasions, and "seat belt sign" that may indicate intraabdominal injury 3
• Significant abdominal rigidity and involuntary guarding indicate peritonitis and suggest bowel perforation 3
• Record core temperature immediately (esophageal, bladder, or rectal—peripheral measurements unreliable) 1

Management of Specific Abdominal Trauma

Non-Operative Management

• In patients with abdominal trauma without active peritoneal bleeding or bowel perforation, non-operative management should be recommended to reduce morbidity and mortality 4
• Non-operative management is now standard of care in more than 80% of abdominal trauma when hemorrhagic shock and bowel perforation are ruled out 4
• 90% of traumatic renal injuries and 70-80% of traumatic splenic and hepatic injuries are treated non-operatively 4

Interventional Radiology

• In patients with established ongoing intraperitoneal bleeding, emergent hemostatic angio-embolization should be considered among other therapeutic options 4
• Therapeutic angio-embolization can significantly reduce the failure rate of non-operative management in splenic, hepatic, kidney, and adrenal injuries with documented active bleeding 4
• In hemodynamically unstable patients showing transient response to fluid resuscitation, transcatheter arterial embolization has demonstrated 100% success rate 4

Penetrating Trauma Considerations

• In hemodynamically stable patients with penetrating abdominal trauma without clinical signs of peritonitis or evisceration, exploratory laparoscopy is recommended after initial radiologic survey to rule out peritoneal perforation 4
• Non-therapeutic laparotomy increases hospital length of stay and carries significant risk of complications (eventration and occlusion in 10-40% of cases) 4

Critical Pitfalls to Avoid

• Never apply permissive hypotension in TBI patients—they require MAP ≥80 mmHg for cerebral perfusion 1
• Never place pelvic binders incorrectly—they must be positioned around the greater trochanters, not the iliac crests 1, 2
• Never delay binder application for radiographic confirmation—apply based on mechanism and clinical suspicion 2
• Never overlook temperature documentation—hypothermia significantly worsens outcomes 1
• Be aware that 20% of intestinal injuries are missed on initial CT scan—serial examinations are critical for non-operative management 3