08 Trauma Assessment and Management

Priorities and scene assessment

Trauma care is time-critical: identify and treat immediate threats while arranging transport to an appropriate trauma center. Follow local medical director protocols, particularly for medications, resuscitation targets, spinal motion restriction, and destination decisions. A normal initial blood pressure does not rule out serious injury or early shock.

Assessment and priorities

Confirm scene safety, use appropriate personal protective equipment, and consider the mechanism, number of patients, hazards, and need for additional resources. Clues to hidden injury include vehicle intrusion, ejection, falls from height, blast exposure, penetrating wounds, and anticoagulant use. Mechanism helps guide suspicion but does not replace examination.

Primary survey

Use xABCDE when catastrophic external bleeding is possible; otherwise, begin with ABCDE. Treat threats as they are found and reassess after every intervention.

• x — Exsanguinating hemorrhage: Control immediately life-threatening external bleeding.

• A — Airway with cervical-spine awareness: Assess patency, voice, obstruction, and ability to protect the airway. Use appropriate airway maneuvers and adjuncts, and suction as needed. Consider early advanced airway planning if obstruction, declining consciousness, or facial or neck injury threatens patency.

• B — Breathing: Assess rate, effort, chest rise, breath sounds, oxygenation, and chest-wall injury. Support oxygenation and ventilation as indicated, and recognize and treat immediately life-threatening chest conditions.

• C — Circulation: Assess pulses, skin signs, capillary refill, mental status, and bleeding. Search for major blood-loss sources, including external wounds, chest, abdomen, pelvis, and long bones. Establish vascular access and resuscitate according to protocol without delaying transport or definitive hemorrhage control.

• D — Disability: Rapidly assess mental status, pupils, and motor and sensory function. Record and repeat the Glasgow Coma Scale (GCS). Check glucose when clinically appropriate, without letting it distract from trauma threats.

• E — Exposure and environment: Expose enough to find injuries, including the back when safe, then cover the patient and actively prevent hypothermia.

For an unstable patient, perform only the secondary assessment needed to guide immediate care and transport. Do not delay definitive care for a lengthy on-scene examination.

Secondary assessment and communication

When time and stability allow, obtain history, including allergies, medications, medical history, last oral intake, and events. Inspect and palpate systematically, document findings and trends, and repeat vital signs, GCS, skin assessments, and treatment checks. Communicate the mechanism, suspected injuries, response to treatment, and changes during transport.

Trauma field-triage criteria help guide destination selection; use current regional protocols. Clinical judgment should accompany trauma knowledge: prioritize physiology and evolving findings over a single sign or mechanism alone.

Hemorrhage control and shock

Act rapidly to control severe external bleeding. Apply firm direct pressure and a pressure dressing. For life-threatening extremity bleeding, apply a Tourniquet proximal to the wound, not over a joint. Tighten until bleeding stops; if it continues, tighten further or apply a second tourniquet as trained and permitted. Record the application time and leave the device visible.

For a suitable deep wound where a tourniquet cannot be applied, pack with hemostatic or plain gauze and maintain firm pressure, following product instructions and local protocol. Do not remove embedded objects; stabilize them and control bleeding around them. Do not pack the chest or abdomen. Reassess for ongoing bleeding and distal perfusion when relevant.

Recognizing shock

Hemorrhagic shock is the leading preventable cause of early trauma death. Early clues include anxiety or confusion, tachycardia, cool pale or clammy skin, weak peripheral pulses, and delayed capillary refill. Hypotension may be a late sign. Older adults, children, pregnant patients, and people taking medications that alter heart rate may show atypical signs.

Control bleeding, keep the patient warm, provide oxygen or ventilatory support as indicated, and transport promptly. Give IV/IO fluids or blood products only as available and directed by local protocol; avoid unnecessary large-volume crystalloid administration. Some protocols use a lower blood-pressure target before hemorrhage control for selected patients, but suspected traumatic brain injury changes the balance: hypotension can worsen brain injury, so avoid permissive hypotension in these patients.

Tranexamic acid (TXA) is protocol-dependent and may be considered for selected patients with significant hemorrhage risk when it can be given early. It is not a substitute for bleeding control or rapid transport.

Head and spinal injury

Brain injury

Suspect traumatic brain injury after a significant mechanism, altered mental status, loss of consciousness, vomiting, seizure, skull deformity, or worsening headache. Assess GCS, pupils, and motor response serially; a declining GCS is a critical change. Prevent hypoxia and hypotension, support ventilation, and avoid routine hyperventilation. Hyperventilation may be considered only for signs of impending herniation and according to protocol, because excessive ventilation can reduce cerebral blood flow. Expedite transport for deteriorating mental status or other signs of severe injury.

Spinal injury

Suspect spinal injury with midline pain or tenderness, neurologic deficit, altered mental status, intoxication, distracting injury, or a concerning mechanism. Use selective spinal motion restriction (SMR) according to assessment criteria and protocol. Minimize unnecessary movement and maintain alignment during movement and transport. Routine prolonged immobilization on a long backboard is not the goal; boards are primarily extrication or transfer tools and can cause harm.

Chest, abdominal, and pelvic trauma

Chest injury

Look for respiratory distress, unequal chest rise, abnormal breath sounds, chest-wall instability, penetrating wounds, and signs of shock. Suspect a Tension pneumothorax when severe respiratory or circulatory compromise accompanies markedly diminished breath sounds on one side or other compatible findings. Do not wait for late signs such as tracheal deviation. Perform decompression only when indicated and authorized by protocol, reassess the response, and consider recurrence.

For an open chest wound, use the dressing specified by local protocol, often a vented chest seal, and monitor closely for worsening breathing or tension physiology. Do not remove impaled objects; stabilize them. Flail chest and pulmonary contusion can cause worsening respiratory failure, so reassess frequently and support ventilation as needed.

Abdominal and pelvic injury

Abdominal injury may be serious despite few visible findings. Consider internal bleeding with tenderness, distention, bruising, penetrating injury, or shock after blunt trauma. Do not probe wounds or push protruding organs back inside. Cover eviscerated tissue with a sterile moist dressing and protect it from pressure.

Suspected pelvic fracture with shock requires careful handling and prompt transport. Use a pelvic binder when indicated and according to protocol, positioning it over the greater trochanters, not the abdomen. Avoid repeated manipulation of an unstable pelvis.

Burn assessment and care

Stop the burning process and ensure scene safety. Remove jewelry and loose clothing near the injury, but do not pull away material stuck to the skin. For a thermal burn, cool with clean, cool running water when feasible; do not use ice or prolong cooling in a way that causes hypothermia. Cover with a clean, dry dressing and keep the patient warm.

Assess the airway early after enclosed-space smoke exposure, facial burns, hoarseness, stridor, or soot in the mouth. Airway swelling can progress, making early transport and airway planning essential.

Estimate burn size using the adult Rule of Nines or the patient’s palm for small or scattered burns; use a pediatric-appropriate chart for children. Count partial- and full-thickness burns, not superficial redness alone. Burn depth may evolve, so document appearance and reassess. The American Burn Association recommends immediate consultation with consideration for transfer for full-thickness burns, partial-thickness burns of at least $10\%$ TBSA, deep burns in critical areas, suspected inhalation injury, chemical injuries, and other listed high-risk circumstances.

For dry chemical powders, brush the material off before irrigating; then irrigate copiously as appropriate. Electrical injuries can cause deep tissue damage or dysrhythmias despite small skin wounds; assess for associated trauma and follow monitoring and transport protocols. Avoid routine aggressive fluid administration and follow local burn-resuscitation guidance, especially for extensive burns.

Applying clinical judgment

After a high-speed collision, a patient is awake but increasingly restless, pale, and tachycardic, with a normal initial blood pressure and no major external bleeding. Do not interpret the blood pressure as reassurance. Reassess ABCs, look for concealed chest, abdominal, pelvic, and long-bone bleeding, prevent heat loss, and expedite transport to a trauma center. Report the changing mental status and vital-sign trend, and treat findings as they emerge without delaying definitive care.

Across trauma care, use a rapid, repeated primary survey; control life-threatening bleeding; recognize shock before hypotension; and prevent secondary injury, especially hypoxia, hypotension, and hypothermia. Assess head, spine, chest, abdomen, pelvis, and burns systematically. Guide interventions and transport decisions by patient findings, local protocol, and the need for definitive care.

• Total body surface area (TBSA)