Initial Assessment and Management
The patient should be assessed, and treatment priorities should be determined based on vital signs, type of injury, mechanism of injury, and location of injury. For patients with severe trauma, management generally includes a rapid initial assessment, resuscitation of vital functions, a more detailed secondary survey, and definitive treatment.
Primary Assessment
Initial Assessment
This is typically conducted on site or in the emergency department (trauma resuscitation unit). The goal is to rapidly identify life-threatening conditions, often following the "ABCDE" sequence. These steps usually take no more than 2–5 minutes. If multiple life-threatening issues are present, they are addressed concurrently.
A (Airway)
The airway is assessed to determine whether it is clear. This involves observing (for agitation, cyanosis, respiratory distress), listening (for abnormal breath sounds), and palpating (to check if the trachea is midline). If the patient is able to communicate normally, the risk is considered low, though reassessment is necessary. Patients with severe head injuries or altered consciousness typically require assisted ventilation. Particular attention is given to the risk of cervical spine injury during airway management.
B (Breathing)
The neck and chest are exposed to evaluate for jugular vein distension, tracheal deviation, and chest wall movement. Inspection and palpation can detect chest wall injuries that impair ventilation. Both lungs are auscultated and percussed. Life-threatening injuries that can rapidly compromise ventilation include tension pneumothorax, flail chest, massive hemothorax, and open pneumothorax, and these should be recognized promptly.
C (Circulation)
Hemorrhage is the leading preventable cause of trauma-related death. Identification and control of bleeding is therefore critical. Clinical assessment includes evaluation of consciousness level, skin color, and pulse. Common sites of internal bleeding include the thoracic cavity, abdominal cavity, retroperitoneum, pelvis, and long bones such as the femur.
D (Disability)
Neurological assessment includes evaluating consciousness level, pupil size and light response, the presence of hemiplegia, and level of spinal cord injury. Decreased consciousness may indicate cerebral hypoperfusion or direct brain injury. Hypoglycemia, alcohol, and narcotics can also alter consciousness.
E (Exposure/Environment)
Full exposure of the patient is performed to facilitate comprehensive assessment, while measures are taken to maintain body temperature. The treatment environment should also be assessed for safety before starting resuscitation.
Adjuncts to the Primary Survey
Adjunctive measures during the initial assessment include ECG monitoring, urinary catheter placement, gastric tube insertion, arterial blood gas analysis, monitoring of blood oxygen saturation and blood pressure, chest and pelvic X-rays, diagnostic peritoneal lavage, and focused assessment with sonography in trauma (FAST).
Treatment
Airway Protection
Airway obstruction can quickly lead to asphyxiation and death. Airway protection is critical in all patients. Common methods include:
- Suction of blood and secretions using negative-pressure suction devices
- Opening the airway using a jaw thrust or head-tilt chin-lift maneuver
- Use of oropharyngeal, nasopharyngeal, or laryngeal airway devices for initial airway management
- Endotracheal intubation via oral or nasal routes
- Surgical airway techniques (such as cricothyroidotomy) in cases of glottic edema, pharyngeal fracture, severe oropharyngeal bleeding, or when intubation is not possible
Breathing Management
Tension pneumothorax requires immediate decompression, initially with a large-bore needle inserted in the second intercostal space at the midclavicular line on the affected side. Definitive treatment involves placement of a chest tube in the fifth intercostal space along the anterior axillary line.
Initial management of open pneumothorax involves sealing the chest wall defect with a sterile dressing.
Flail chest is initially managed with adequate ventilation and fluid resuscitation.
Massive hemothorax can result in hemorrhagic shock; initial treatment includes fluid resuscitation, blood transfusion, chest tube placement, and surgical intervention if necessary.
Volume Resuscitation and Hemorrhage Control
Patients with severe trauma typically require at least two large-bore peripheral IV lines. Venous cutdown or central venous catheter placement may be necessary. Initial resuscitation usually involves administering 1–2 liters of crystalloid solution, followed by blood transfusion as indicated. All IV fluids should be warmed, using infusion warming devices when available.
Definitive control of bleeding may involve surgery or interventional embolization. For open wounds, the type of bleeding should be identified and controlled accordingly:
- Arterial bleeding appears bright red, fast, and spurting
- Venous bleeding is dark red and flows continuously
- Capillary bleeding presents as bright red oozing
Common hemostatic techniques include:
Manual Compression
This involves pressing an artery against a bony surface to stop bleeding. For upper extremity bleeding, compression of the axillary or brachial artery may be used; for lower extremity bleeding, the femoral artery is compressed. Manual compression is a temporary measure, as collateral circulation limits its effectiveness. Other methods should be used when appropriate.
Pressure Dressing
This is the most commonly used method for controlling bleeding from small arteries and veins. Sterile gauze or dressing is placed on the wound, covered with additional gauze pads, and secured with a pressure bandage. The bandage should be applied evenly and cover a sufficient area. Elevating the injured limb promotes venous return and reduces bleeding.
Packing
Packing is used for oozing from muscle or fracture sites. Large sterile gauze layers are placed over the wound, with additional gauze strips or bandages packed into the wound and then secured with a pressure dressing.
Tourniquet Use
Tourniquets are used for severe extremity bleeding that cannot be controlled with pressure dressings. A wide contact area should be chosen to avoid nerve damage. The tourniquet should be applied proximally to the injury site. On-site, a windlass-type tourniquet is convenient and effective. In the emergency department, pneumatic tourniquets are preferred. If necessary, alternatives such as rubber tubing, triangular bandages, or elastic bandages may be used, with padding placed under the tourniquet. Key considerations when using a tourniquet include:
- Tightening only enough to stop bleeding
- Loosening the tourniquet for 1–2 minutes every hour, with total application time generally not exceeding 4 hours
- Marking the patient clearly and noting the application time, prioritizing transport
- Infusing fluids or blood before releasing the tourniquet, while preparing for hemostasis
- For cases where prolonged tourniquet use has led to distal limb necrosis, a new tourniquet should be applied proximally before performing amputation
Secondary Assessment
Secondary Survey
The secondary survey is performed only after completion of the primary survey. It involves a comprehensive head-to-toe evaluation of the trauma patient, including a complete medical history and physical examination.
History
It is sometimes not possible to obtain a complete history directly from the trauma patient. In such cases, additional information should be gathered from family members or prehospital emergency personnel. The "AMPLE" approach can be used to structure the history-taking process:
A (Allergies)
It is necessary to ascertain whether there is any allergy to medications or foods, with particular attention given to antibiotics or anesthetic agents commonly used in trauma patients.
M (Medications Currently Used)
It is important to note whether the patient has consumed alcohol or taken any medications, as this information is significant when assessing changes in consciousness. In addition, the patient’s history of using anticoagulant or antiplatelet medications should be clarified, as these can affect the amount of bleeding.
P (Past Illness/Pregnancy)
Relevant pre-existing medical conditions should be identified. For instance, in patients with a history of hypertension, post-injury blood pressure changes should be evaluated in the context of baseline values. If the patient has a history of diabetes, liver cirrhosis, chronic renal insufficiency, hematologic disorders, or long-term use of corticosteroids or cytotoxic drugs, the risk of post-traumatic infection or delayed wound healing may be elevated.
L (Last Meal)
The timing and type of the last meal should be determined, as this information helps assess gastric emptying status and the risk of aspiration.
E (Events/Environments Related to the Injury)
The environmental factors and mechanisms related to the injury should be clarified.
If the patient is unable to communicate (due to coma or other reasons), it is important to obtain information about the injury and symptoms from witnesses, transport personnel, or family members, and to document these details carefully.
Injury Details
The cause of injury should be determined to clarify the type, nature, and severity of trauma. For instance, stab wounds may appear minor externally but can damage deep vessels, nerves, or internal organs. Falls from height can result in multiple organ injuries. The time and place of injury, as well as factors such as the height of the fall and surface hardness, should be noted. For injuries caused by blunt force, information about the magnitude, location, mode (direct or indirect), and duration of the force is valuable. Body position at the time of injury can aid diagnosis; for example, the initial point of contact during a fall provides important clues. In gunshot wounds, body position at the time of injury is key to understanding the wound trajectory.
Post-Injury Presentation and Evolution
The clinical manifestations vary by injury site. For neurological injuries, key symptoms include loss of consciousness, projectile vomiting, and limb paralysis. Chest injuries may cause dyspnea, cough, or hemoptysis. For abdominal trauma, it is important to assess the initial location of pain, its severity and nature, and any spread of pain. In cases of open wounds with significant blood loss, the approximate volume and rate of bleeding should be recorded. Details of post-injury care—including first aid provided, medications used, and interventions (such as tourniquet application and duration)—should also be documented.
Physical Examination
The examination can follow the "CRASH PLAN" sequence, assessing the heart, respiration, abdomen, spine, head, pelvis, limbs, arteries, and nerves.
Adjuncts
During the secondary survey, specific diagnostic procedures may be conducted to identify particular injuries. These may include X-rays of the spine and limbs; CT scans of the head, chest, abdomen, pelvis, and spine; angiography and urography; ultrasonography; and bronchoscopy.
Treatment
When the treatment needs of a trauma patient exceed the capabilities of the receiving facility, transfer to a trauma center with appropriate resources should be considered. This decision requires a detailed assessment of both the patient's condition and the hospital’s capacity in terms of equipment, resources, and personnel.
Timely and accurate diagnosis of trauma is crucial for subsequent management. However, in critically ill patients, conflicts may arise between diagnostic and therapeutic priorities. The following considerations are important in such situations:
If life-threatening conditions such as airway obstruction, massive hemorrhage, or cardiac arrest are identified, immediate life-saving interventions should take precedence over diagnostic testing.
The examination process should be as streamlined as possible, with history-taking and physical examination conducted concurrently. Examination maneuvers should be performed gently to avoid exacerbating injuries.
Attention should be paid not only to obvious injuries but also to potentially hidden ones. For example, in a patient with fractures of the lower left ribs and splenic rupture, the pain from rib fractures may mask early symptoms of splenic injury, which can be more serious.
During mass casualty events, quiet or unresponsive patients should not be overlooked, as they may already be experiencing airway obstruction, shock, or coma and may be unable to call for help.
Injuries that are not initially diagnosable should be closely monitored during symptomatic management, with efforts made to confirm the diagnosis as soon as possible.
In patients with severe trauma, imaging studies such as CT scans should be performed only when vital signs are relatively stable to avoid life-threatening events during the examination.