What is the best approach for managing a patient involved in a road traffic accident in the casualty department?

Management of Road Traffic Accident in the Casualty Department

Immediately assess and manage life-threatening hemorrhage first, followed by airway with cervical spine protection, breathing, and circulation using the structured ATLS approach, prioritizing rapid hemorrhage control and transport to a trauma center within 60 minutes for patients in hemorrhagic shock. 1

Primary Survey: Systematic ATLS Approach

Step 1: Hemorrhage Control (Circulation First in Exsanguinating Hemorrhage)

• Apply direct pressure or tourniquets immediately for external bleeding - tourniquets should remain in place until surgical control is achieved, ideally within 2 hours, though survival has been documented up to 6 hours 1
• Assess hemorrhage severity using the ATLS classification system based on vital signs, mental status, and estimated blood loss 1
• Patients with Class III (1500-2000ml loss) or Class IV (>2000ml loss) hemorrhage require immediate surgical bleeding control - these patients show systolic BP <90mmHg, pulse >120-140, altered mental status, and urine output <15ml/h 1
• Initiate permissive hypotension strategy until definitive hemorrhage control, avoiding over-resuscitation that worsens coagulopathy 2

Step 2: Airway with Cervical Spine Protection

• Assume cervical spine injury in all road traffic accidents until proven otherwise - apply manual in-line stabilization (MILS) immediately by placing hands on either side of the patient's head 3, 4
• Apply rigid cervical collar combined with head-neck-chest stabilization for transport 3, 4
• For intubation, remove only the anterior portion of the cervical collar while maintaining MILS to improve mouth opening and glottic visualization 3, 4, 5
• Use rapid sequence intubation with direct laryngoscopy and gum elastic bougie; avoid Sellick maneuver as it increases cervical spine movement 3, 4, 5
• Critical exception: Do NOT perform routine spinal immobilization for penetrating trauma - this increases mortality without reducing neurological deficits 3

Step 3: Breathing and Ventilation

• Maintain normoventilation (normal PaCO2) - hyperventilation increases mortality in trauma patients by causing cerebral vasoconstriction and decreased venous return 1
• Monitor end-tidal CO2 continuously to maintain PaCO2 within normal range 1
• Avoid excessive positive end-expiratory pressure (PEEP) in severely hypovolemic patients as it decreases cardiac output 1
• Identify and immediately treat tension pneumothorax, flail chest, or open chest wounds 1

Step 4: Circulation and Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg (or MAP ≥85-90 mmHg for suspected spinal cord injury) - single episodes of hypotension <90mmHg significantly worsen outcomes 1, 3, 4
• Establish vascular access immediately; use intraosseous access if peripheral IV fails 2
• Administer vasopressors (phenylephrine, norepinephrine) immediately for hypotension - do not wait for delayed effects of fluid resuscitation or sedative adjustment 1
• Use blood products rather than excessive crystalloids to avoid fluid overload and coagulopathy 4, 2
• Administer tranexamic acid within 3 hours of injury for patients with significant hemorrhage 2

Step 5: Disability (Neurological Assessment)

• Assess Glasgow Coma Scale (GCS), pupillary response, and motor function 1
• GCS <14, systolic BP <90mmHg, or respiratory rate <10 or >29 breaths/min mandates immediate transport to highest-level trauma center 1
• Document any focal neurological deficits suggesting spinal cord injury 3, 4

Step 6: Exposure and Environmental Control

• Remove all clothing to identify injuries, but immediately prevent hypothermia - apply warming blankets, increase ambient temperature, and use warmed IV fluids 1
• Hypothermia (core temperature <35°C) worsens coagulopathy and increases mortality 1
• Passive rewarming alone is insufficient; use active warming devices 1

Secondary Survey: Anatomical Injury Pattern Assessment

High-Risk Anatomical Injuries Requiring Trauma Center Transfer

The following injuries mandate immediate transport to a trauma center: 1

• All penetrating injuries to head, neck, torso, or extremities proximal to elbow/knee 1
• Amputation proximal to wrist/ankle 1
• Pelvic fractures 1
• Flail chest or open/depressed skull fracture 1
• Two or more proximal long-bone fractures 1
• Paralysis or crushed/degloved/mangled extremity 1

High-Risk Mechanism of Injury

Transport to trauma center if: 1

• Falls >20 feet in adults (>10 feet in children) 1
• Motor vehicle crash with intrusion >12 inches occupant site or >18 inches any site 1
• Ejection from vehicle or death in same passenger compartment 1
• Pedestrian/bicyclist struck with impact >20 mph 1
• Motorcycle crash >20 mph 1

Special Patient Considerations

Contact medical control and consider trauma center transfer for: 1

• Age >55 years (increased mortality risk) 1
• Anticoagulation or bleeding disorders 1
• Pregnancy >20 weeks 1
• End-stage renal disease requiring dialysis 1

Critical Time-Sensitive Interventions

The 60-Minute Rule for Hemorrhagic Shock

• Establish a 60-minute emergency department time limit for patients in hemorrhagic shock - prolonged ED time before surgical control significantly increases mortality 1
• Patients with transient or no response to initial fluid resuscitation are candidates for immediate surgical bleeding control 1
• Penetrating torso trauma with shock requires immediate laparotomy without delay for imaging 1

Immediate Neurosurgical Indications

Transfer immediately for neurosurgical evaluation if: 1

• Symptomatic extradural hematoma (any location) 1
• Acute subdural hematoma >5mm thickness with midline shift >5mm 1
• Acute hydrocephalus requiring drainage 1
• Open displaced skull fracture requiring closure 1

Common Pitfalls to Avoid

• Never hyperventilate trauma patients - this increases mortality through cerebral vasoconstriction and decreased venous return 1
• Never delay tourniquet application for external hemorrhage - waiting for other interventions increases blood loss 1
• Never apply rigid cervical collars or backboards if untrained - improper application by lay providers causes harm 3
• Never perform routine spinal immobilization for penetrating trauma - this increases mortality 3
• Never allow core temperature to drop below 35°C - hypothermia worsens coagulopathy and increases mortality 1
• Never delay transport to trauma center beyond 60 minutes for hemorrhagic shock - prolonged ED time increases mortality 1
• Never use succinylcholine after 48 hours post-spinal cord injury - risk of life-threatening hyperkalemia; use rocuronium instead 3, 4

Transport Decision Algorithm

When in doubt, transport to a trauma center 1

1. Immediate highest-level trauma center transport if: Any Step 1 (vital signs) or Step 2 (anatomical injury) criteria met 1
2. Trauma center transport if: Step 3 (mechanism) criteria met - may be lower-level trauma center depending on system 1
3. Consider trauma center after medical control contact if: Step 4 (special considerations) criteria met 1