What is the immediate management for a previously healthy adult with a vehicular accident injury?

Immediate Management of Vehicular Accident Injury

For a previously healthy adult injured in a vehicular accident, immediately assess and secure the airway, control life-threatening hemorrhage, ensure adequate oxygenation and circulation, and rapidly transport to a trauma center—all within 10 minutes on-scene when possible. 1, 2

Scene Safety and Initial Approach

• Move the patient only if the scene is unsafe for you or the victim; otherwise, leave them in the position found to avoid worsening potential spinal injuries. 1
• If the patient is unresponsive but breathing normally and no spinal injury is suspected, place them in a lateral recovery position (side-lying with head on extended arm, both legs bent for stability). 1
• Do not move patients with suspected neck, back, hip, or pelvic injuries unless absolutely necessary to open the airway or reach safety. 1

Primary Survey: ABCDE Approach

Airway with C-Spine Protection

• Immediately assess airway patency while maintaining cervical spine immobilization if trauma mechanism suggests spinal injury. 3, 4
• For patients with Glasgow Coma Scale ≤8, severe facial trauma with bleeding, or inability to protect their airway, perform rapid sequence intubation using direct laryngoscopy (or video laryngoscopy if available). 4
• Succinylcholine remains the recommended neuromuscular blocking agent for emergency intubation in trauma. 4

Breathing and Ventilation

• Ensure adequate oxygenation and avoid hyperventilation, particularly in patients with potential traumatic brain injury, as hypocapnia causes cerebral vasoconstriction and worsens outcomes. 1
• Monitor end-tidal CO₂ continuously in intubated patients, even during pre-hospital transport. 1
• Perform immediate needle decompression or chest tube placement if tension pneumothorax is suspected (absent breath sounds, tracheal deviation, hemodynamic instability). 1, 5

Circulation and Hemorrhage Control

Critical decision point: In hypotensive trauma patients with active hemorrhage, prioritize hemorrhage control BEFORE intubation when possible, as early intubation in hypovolemic patients significantly increases mortality through post-intubation hypotension. 6

• Apply direct pressure to sites of external bleeding immediately—this takes priority over calling for help if you are alone and bleeding is life-threatening. 1
• Target systolic blood pressure of 80-100 mmHg (permissive hypotension) until hemorrhage is controlled, EXCEPT in patients with suspected traumatic brain injury. 1, 2
• For suspected traumatic brain injury, maintain systolic blood pressure >110 mmHg (or mean arterial pressure ≥80 mmHg) from the outset. 1, 2
• Establish large-bore IV access or intraosseous access if IV fails; begin fluid resuscitation with 0.9% normal saline or balanced crystalloid. 1, 2, 5

Disability (Neurological Assessment)

• Rapidly assess Glasgow Coma Scale score and pupillary response. 1
• Any patient with GCS <14, loss of consciousness, or focal neurological deficits requires immediate transport to a trauma center. 1

Exposure and Environmental Control

• Remove clothing to identify all injuries, but prevent hypothermia as it worsens coagulopathy and outcomes. 1

Transport Decision

Transport immediately to a trauma center if any of the following are present: 1, 2

• Systolic blood pressure <90 mmHg at any point
• Respiratory rate <10 or >29 breaths/minute
• Glasgow Coma Scale <14
• Penetrating injuries to head, neck, torso, or proximal extremities
• Flail chest or two or more proximal long bone fractures
• Crushed, degloved, mangled, or pulseless extremity
• Amputation proximal to wrist or ankle
• Pelvic fractures
• Open or depressed skull fracture
• Paralysis or suspected spinal cord injury

For pedestrians struck by vehicles: Automatic trauma center transport is indicated if the patient was thrown, run over, or struck with impact >20 mph, as this mechanism carries the highest mortality rate in trauma. 1, 2

Critical Pitfalls to Avoid

• Do not delay transport for procedures that can be performed en route—on-scene time should be <10 minutes for critical trauma patients, as every 3 minutes of delay increases mortality by approximately 1%. 2, 7
• Do not intubate hypotensive patients before initiating hemorrhage control and volume resuscitation unless airway compromise is immediately life-threatening; post-intubation hypotension increases mortality from 19.6% to 33.2%. 6
• Do not hyperventilate patients, especially those with head injuries—maintain normal end-tidal CO₂ (35-40 mmHg). 1
• Do not assume normal initial hemoglobin excludes significant hemorrhage—acute bleeding may not immediately reflect in lab values due to lack of hemodilution. 2

Special Considerations for Elderly Patients

• Lower threshold for trauma center transport in patients >55 years, as mortality risk increases significantly with age even for similar injury patterns. 1, 2
• Elderly patients have decreased physiologic reserve, higher rates of anticoagulant use, and increased frailty—all of which worsen outcomes. 1, 2

Calling for Help

• Activate EMS (9-1-1) immediately unless you are alone with a patient who has imminent threats to airway, breathing, or circulation requiring immediate intervention (e.g., severe bleeding, airway obstruction). 1
• In those rare cases, provide basic life-saving care first (open airway, control severe bleeding), then call for help. 1