7 Advanced Trauma Practice Cases

Organize the primary survey

Use an organized primary survey, such as XABCDE, or a locally adopted equivalent. Control catastrophic external bleeding first, then assess the airway with cervical-spine precautions, breathing, circulation, disability or neurologic status, and exposure and environment. Assign tasks in parallel, obtain vital signs and a focused history, and repeat the survey after every intervention or change.

Recognize and control hemorrhage

A single blood-pressure reading, GCS, or reassuring scan does not establish that a patient is stable. Interpret observations as trends and use the whole clinical picture to recognize deterioration, including shock before profound hypotension.

For suspected active hemorrhage, prioritize direct pressure or a tourniquet for life-threatening limb bleeding, early activation of a hemorrhage protocol when indicated, warming, and rapid definitive bleeding control. Resuscitation and hemorrhage control proceed together. A negative FAST does not rule out significant abdominal or retroperitoneal bleeding; in an unstable nonresponder, imaging should not delay intervention.

Resuscitation strategy must account for brain injury. Avoid hypotension and follow local targets for cerebral perfusion rather than applying permissive hypotension indiscriminately.

Case one: multisystem trauma and hemorrhage

A 34-year-old driver arrives after a high-speed collision, pale, anxious, and intermittently confused. Initial findings are a heart rate of $124$ beats per minute, blood pressure of $108$ systolic and $72$ diastolic $\text{mm Hg}$, respiratory rate of $26$ breaths per minute, oxygen saturation of $95\%$ on supplemental oxygen, temperature of $35.7^\circ\text{C}$, and GCS of $13$. The patient has a scalp wound, chest-wall bruising, a tender, distended abdomen, and pelvic pain, but no major external bleeding is seen.

Begin the primary survey with simultaneous team actions. Protect the cervical spine while assessing airway and breathing. Expose enough to identify hidden bleeding while preventing further heat loss. Establish monitoring and access, obtain a repeat neurologic baseline, and look for hemorrhage in the chest, abdomen, pelvis, and long bones. Assess shock from the whole picture rather than being reassured by the initially near-normal systolic pressure.

Four minutes later, the heart rate is $142$ beats per minute, blood pressure is $82$ systolic and $54$ diastolic $\text{mm Hg}$, respiratory rate is $30$ breaths per minute, the skin is cool and clammy, and GCS is $11$. The pelvis remains painful and was unstable on the initial examination; eFAST shows free fluid in the abdomen. Treat this as evolving hemorrhagic shock: activate the local major-hemorrhage protocol, use warmed blood components according to protocol, and coordinate immediate definitive hemorrhage control. Apply a pelvic binder over the greater trochanters if pelvic bleeding is suspected, and limit diagnostic steps that delay control.

Continue oxygenation and neurologic reassessment. A falling GCS may reflect worsening cerebral injury, poor perfusion, hypoxia, or more than one cause. Recheck mental status, pupils, perfusion, respiratory status, temperature, and response to each resuscitation step. A temporary rise in blood pressure does not prove that bleeding has stopped.

Balance hemorrhage control with brain protection

The patient has suspected TBI as well as ongoing hemorrhage. Restrictive resuscitation can be appropriate in active bleeding, but TBI changes the balance because hypotension can worsen secondary brain injury. Do not allow avoidable hypotension; pursue blood-based resuscitation and definitive hemorrhage control together, using an age-appropriate TBI blood-pressure target guided by local protocol.

The Brain Trauma Foundation says maintaining systolic pressure at or above $110\ \text{mm Hg}$ may be considered for patients aged $15$–$49$ or over $70$, and at or above $100\ \text{mm Hg}$ for ages $50$–$69$. These are guideline considerations, not a substitute for individualized resuscitation.

Case two: respiratory and circulatory collapse

A 41-year-old with multiple rib fractures and suspected abdominal injury initially has a heart rate of $118$ beats per minute, blood pressure of $104$ systolic and $68$ diastolic $\text{mm Hg}$, respiratory rate of $28$ breaths per minute, and oxygen saturation of $93\%$. After becoming less alert, the patient is intubated. Shortly afterward, oxygen saturation falls to $82\%$, blood pressure to $76$ systolic and $48$ diastolic $\text{mm Hg}$, and breath sounds become markedly reduced on the left.

Suspect tension pneumothorax, particularly after positive-pressure ventilation, while continuing to consider hemorrhage and other causes of shock. With severe respiratory compromise or hemodynamic instability, treat immediately according to the responder’s training and local protocol; do not delay decompression for imaging. Immediately afterward, reassess chest movement, breath sounds, oxygenation, blood pressure, and tube and ventilation function. Continue searching for concurrent bleeding: a successful intervention for one threat does not exclude another.

Case three: neurologic deterioration

A 72-year-old falls down several steps. On arrival, the patient is awake, with GCS $14$, heart rate $96$ beats per minute, blood pressure of $156$ systolic and $84$ diastolic $\text{mm Hg}$, and oxygen saturation of $97\%$. A family member reports anticoagulant use. During observation, the patient becomes harder to rouse, GCS falls to $10$, and one pupil becomes larger and less reactive than the other. Blood pressure is $148$ systolic and $82$ diastolic $\text{mm Hg}$, while oxygen saturation remains $96\%$.

Treat this change as time-critical neurologic deterioration. Repeat and document GCS components and pupils; reassess airway protection, oxygenation, ventilation, and circulation; check bedside glucose; and consider other reversible causes, such as evolving shock or medication effects. Escalate immediately for trauma or neurosurgical evaluation and urgent head imaging when the patient can safely undergo it. Preserved blood pressure or oxygen saturation does not rule out worsening intracranial injury.

Prevent secondary injury by maintaining oxygenation and avoiding hypotension. Avoid routine prolonged prophylactic hyperventilation to very low $\text{PaCO}_2$. Hyperventilation may be used as a temporizing measure in selected cases of elevated intracranial pressure under expert direction, but definitive evaluation and management must proceed urgently.

Apply the reassessment principles

Across the cases, treat immediate threats, repeat the assessment after every intervention or deterioration, and interpret vital signs as trends. Look for occult bleeding even before profound hypotension, and do not let imaging delay intervention in an unstable nonresponder.

Hemorrhage control and resuscitation occur together. When TBI is suspected, avoid hypotension and account for cerebral-perfusion needs. Sudden hypoxia and hypotension with unilateral loss of breath sounds call for immediate consideration of tension pneumothorax. A declining GCS or changing pupils demands urgent reassessment and escalation, even when other observations appear reassuring.

• traumatic brain injury