Management of trauma patients

Trauma is one of the leading causes of death worldwide and, in the United States, the leading cause of death in young adults. Traumatic injuries range from isolated wounds to life-threatening multi-organ injuries. Advanced trauma life support (ATLS) is a framework for the systematic evaluation of trauma patients to improve outcomes and reduce missed injuries. Prehospital trauma care involves life-saving interventions and basic life support in the field by emergency medical services while providing rapid transportation to the nearest appropriate hospital. In the hospital, the assessment of trauma patients begins with a primary survey in which life-threatening conditions are identified and treated using the sequential ABCDE approach. After the patient is stabilized, the secondary survey is performed, which involves a thorough history and physical examination as well as diagnostic testing to identify other injuries. The tertiary survey is performed within 24 hours of presentation to identify missed injuries. If at any point during the evaluation the patient's needs exceed the hospital's capabilities, the process to transfer the patient to a trauma center should be initiated. Trauma management of pregnant, geriatric, and pediatric patients requires additional considerations given their unique physiology.

See also “Blunt trauma” and “Penetrating trauma.”

• Trauma center ^[1]
  • A health facility that provides specialized care to patients with serious traumatic injuries.
  • Different levels (e.g., I–V) of trauma center can be designated
• Trauma team ^[1]
  • A multidisciplinary team that provides care to patients at trauma centers
  • Consists of specialists from trauma surgery, emergency medicine, intensive care, and nursing
  • Members typically include a team leader, airway manager, assessment physician, proceduralist, trauma nurse, trauma technician, respiratory therapist, radiographer, and scribe.
  • See also “Criteria for trauma team activation.”
• Advanced trauma life support (ATLS) ^[1]
  • A framework for managing patients with serious injuries in prehospital and hospital settings.
  • Describes management sequences (e.g., ABCDE algorithm) that prioritize the most immediately life-threatening injuries first.
  • Aims to standardize trauma care across centers with varying resources and experience with trauma management
• Polytrauma: severe injuries occurring in more than one anatomic region that cause systemic physiological disturbances ^[2]

Trauma care varies based on patient injuries, receiving center resources (e.g., equipment, consultants), and institutional and regional guidelines. Recommendations in this article are consistent with the 2018 Advanced Trauma Life Support guidelines. ^[1]

Overview of ATLS ^[1]

Sequence of trauma care

1. Prehospital trauma care and transportation to hospital
2. Primary survey
3. Transfer to trauma center (if needed)
4. Secondary survey
5. Tertiary survey

Key components of ATLS

Overview of injury mechanisms

Overview of immediately life-threatening injuries

Prehospital trauma care is situation-dependent and centered on field stabilization of the patient and prompt transport to the closest trauma center.

Bystanders ^[1][3]

• Shout for help and/or call 911.
• Assess scene safety prior to providing assistance.
• Remove the patient from dangerous situations.
• Initiate basic life support (BLS).
• Perform life-saving interventions.
  • Airway opening maneuvers
  • Hemorrhage control
  • Spinal immobilization

Emergency medical services (EMS) ^[1][4]

Prehospital trauma care provided by physicians varies regionally. ^[5]

• EMS typically perform an abbreviated version of the primary survey.
• Provide life-saving interventions.
  • Airway management for respiratory distress or altered mental status
  • Hemorrhage control (e.g., use of tourniquets or pressure bandages)
  • Immediate hemodynamic support (e.g., IV fluids)
• Prevent additional injury.
  • Spinal immobilization (e.g., cervical collar placement, backboard)
  • Fracture stabilization
• Provide parenteral analgesia, as needed.
• Rapidly transport the patient to the closest appropriate hospital. ^[6][7]
• Notify the receiving hospital.
• Signout of patient to trauma team lead upon arrival

The ABCDE algorithm in ATLS provides a sequence to help prioritize treating the most rapidly life-threatening injuries first. In clinical practice, trauma team members evaluate and treat these simultaneously, continually reassessing each injury's severity throughout the resuscitation. ^[1]

Airway (and C-spine stabilization) ^[1]

Identify and treat airway obstruction (e.g., due to blood, direct injury, edema) and/or loss of airway protective reflexes, (e.g., due to AMS or coma), while preventing further C-spine injury.

• Assess the airway.
  • Ask the patient to state their name; the ability to answer typically correlates with a patent airway.
  • Evaluate for signs of airway compromise and signs of respiratory distress.
  • Examine the airway for foreign bodies or injury (e.g., facial fractures, soot, burns).
• Perform initial interventions.
  • Suction oropharyngeal secretions and/or blood.
  • Perform airway opening maneuvers.
  • Insert basic airway adjuncts.
• Intubate patients with: ^[8]
  • Airway obstruction and/or respiratory failure
  • Depressed mental status (e.g., GCS ≤ 8) ^[8][9]
  • Severe shock and/or cardiac arrest
  • At-risk inhalation injury
• Stabilize the cervical spine.
  • Assume cervical spine injury in patients with significant blunt trauma.
  • Immobilize the cervical spine with a cervical collar.
  • Manually stabilize the cervical spine during airway management.

Perform cricothyrotomy in case of intubation failure.

Consider early intubation for impending airway obstruction in patients with signs of inhalation injury, moderate to severe facial and oropharyngeal burns, and extensive body burns. ^[8]

Breathing ^[1]

Identify and treat chest injuries, e.g., tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and tracheobronchial injuries.

• Assess oxygenation: Evaluate SpO₂ and start continuous pulse oximetry.
• Assess ventilation
  • Vital signs: Monitor rate and quality of respirations; consider EtCO₂ monitoring.
  • Neck: Inspect for jugular venous distension and tracheal deviation
  • Chest: Auscultate and inspect for chest wall injuries: e.g., penetrating wounds, subcutaneous emphysema, absent breath sounds, paradoxical chest movement
  • Consider eFAST to help identify pneumothorax at the bedside.
• Perform initial interventions.
  • Supplemental O₂
  • Emergency chest decompression for suspected tension pneumothorax.
  • 3-sided dressing for sucking chest wound
  • BMV or mechanical ventilation for respiratory failure

If traumatic pneumothorax is suspected in a patient requiring positive pressure ventilation, perform tube thoracostomy immediately to prevent progression to tension pneumothorax. ^[1]

Circulation ^[1]

Provide immediate hemodynamic support and hemostatic measures while identifying sources of bleeding, e.g., external hemorrhage, thoracic cavity, abdominal cavity, thighs, retroperitoneal space.

• Assess hemodynamic status.
  • Assess central pulses, level of consciousness, and capillary refill time.
  • Monitor vitals and continuous cardiac telemetry.
• Perform initial interventions.
  • Place two large-bore IVs (at least 18-gauge).
  • Consider intraosseous access if peripheral IV cannot be obtained.
  • Administer 1 L warmed isotonic crystalloid bolus.
  • If unresponsive to IV fluid, proceed to blood transfusion.
• Localize hemorrhage.
  • Perform FAST to rapidly identify hemopericardium, and intrathoracic, intraabdominal, and/or intrapelvic bleeding in unstable patients.
  • Identify obvious pelvic or long bone (e.g., femur) deformity.
  • Identify major bleeding vessels (e.g., in the neck, groin, chest, or proximal extremities).
  • Identify indications for immediate surgery (e.g., exploratory laparotomy, urgent thoracotomy) and/or angioembolization.
• Treat hemorrhagic shock.
  • Administer emergency transfusion with universal donor blood products (e.g., type O blood) if required.
  • Provide crossmatched blood products as soon as they are available.
  • Follow local massive transfusion protocol if indicated, e.g., plasma, platelets, and pRBCs at a 1:1:1 ratio.
  • Consider tranexamic acid (TXA). ^[10][11]
  • Consider reversal of anticoagulation.
  • Allow for permissive hypotension.
• Perform bedside hemorrhage control.
  • Apply pressure or tourniquet to control active external hemorrhage.
  • Apply pelvic binder for suspected bleeding pelvic fractures
  • Insert chest tube for suspected massive traumatic hemothorax
• Treat obstructive shock: e.g., chest tube insertion for tension pneumothorax, pericardial window for cardiac tamponade

If there is a loss of vital signs, treat traumatic cardiac arrest with emergency chest decompression and emergency thoracotomy.

Suspect cardiac tamponade in patients with penetrating chest injury with Beck triad and a positive FAST scan, and expedite urgent pericardial fluid drainage via thoracotomy.

Penetrating abdominal injury with signs of shock is usually an indication for exploratory laparotomy.

Disability ^[1]

Identify life-threatening traumatic brain injury (TBI), begin measures to limit secondary brain injury, and expedite definitive surgery if indicated.

• Perform rapid neurological evaluation.
  • Calculate GCS.
  • Assess pupillary light response.
  • Assess motor and sensation functions.
• Initiate TBI management.
  • Consult neurosurgery.
  • Start neuroprotective measures.
  • Start ICP management if a cerebral herniation syndrome is present.

Remain vigilant for signs of traumatic brain injury in intoxicated patients. ^[1]

Exposure (and environmental control) ^[1]

• Undress the patient completely.
• Examine the entire patient for signs of occult injury, including the axilla, groin, and back.
• Prevent and/or manage hypothermia with rewarming techniques.

Diagnostic adjuncts ^[1]

Consider the following studies during the primary survey if they are likely to impact immediate management:

• Portable CXR
• Portable pelvic x-ray
• FAST or eFAST
• Diagnostic peritoneal lavage (if POCUS is unavailable)
• See “Diagnostics in trauma” for details.

Use bedside studies for rapid diagnostics in patients that are too unstable for transport to imaging suites.

Traumatic circulatory arrest ^[1]

• Common causes include tension pneumothorax, cardiac tamponade, and hemorrhagic shock.
• Management
  • First line: bilateral chest decompression with finger thoracostomy
  • Consider emergency thoracotomy
  • Expedite definitive surgery and operative stabilization of survivors.

Traumatic cardiac arrest requires bedside surgical interventions by trained personnel and subsequent operative treatment and stabilization. Do not follow standard ACLS algorithms as these are unlikely to be effective.

Resuscitative thoracotomy ^[12]

The following is consistent with the 2015 Eastern Association for the Surgery of Trauma (EAST) recommendations on emergency department thoracotomy. Follow local policies as indications vary regionally. ^[12]

• Definition: a bedside procedure performed in the emergency department or trauma bay to obtain emergency access to the thoracic cavity to provide temporizing lifesaving measures in pulseless patients
• Purpose
  • Relieve cardiac tamponade via pericardiotomy and/or repair of myocardial injury
  • Control intrathoracic hemorrhage
  • Perform open cardiac massage
  • Cross-clamp the descending aorta
• Indications
  • Pulseless patients after penetrating thoracic injury
  • Pulseless patients after penetrating extrathoracic injury, excluding isolated cranial injuries
  • Pulseless patients with recently documented signs of life in the field or at the hospital after blunt injury
• Contraindication: pulseless patients without any documented signs of life in the field or at the hospital after blunt injury

Do not perform resuscitative thoracotomy unless a qualified surgeon is present. ^[1]

Interim management

Consider the following once the primary survey is complete:

• Reassess the effectiveness of life-saving bedside interventions.
• Prepare for urgent time-sensitive imaging (e.g., CT head) once the patient is stable enough.
• Determine if the patient needs immediate surgery, urgent interfacility transfer, or immediate specialty consult (see “Disposition”).
• Next steps: See “Secondary survey.”

If there is clinical deterioration at any time, repeat the primary survey to identify a critical cause.

Urgent interfacility transfer ^[1]

The following applies to patients initially evaluated at facilities that are not trauma centers:

• The decision to transfer a patient to a trauma center for definitive care is multifactorial.
• See “Criteria for trauma team activation” for conditions that typically require management by a trained trauma team.
• If tests are required prior to transfer, keep them limited to tests that will ensure a safe transfer.
• Communicate with the receiving physician and transportation team about clinical and diagnostic findings.

Do not delay an urgent transfer in order to complete an in-depth diagnostic evaluation.

The secondary survey is performed after the patient is stabilized and it involves a thorough history and physical examination as well as diagnostic testing to identify other injuries.

History ^[1]

Obtain the following to anticipate likely injuries and estimate patient's physiological reserve.

• AMPLE history: a focused history approach recommended in the rapid evaluation of patients with trauma
  • Allergies
  • Medications
  • Past medical history and pregnancy status
  • Last meal
  • Events and environment related to the injury
• Mechanism of injury
  • Injury patterns can provide clues to the mechanism of injury (e.g., direction, amount of energy).
  • Commonly divided into blunt trauma and penetrating trauma
    • See “Blunt trauma injury mechanisms.”
    • See “Gunshot injuries” and “Penetrating trauma.”

Obtain collateral information from EMS, family, and/or witnesses, especially if the patient is unable to provide a reliable history.

Physical examination ^[1]

A systematic head-to-toe physical examination must be completed to identify additional injuries.

• Assess each body part for open wounds, lacerations, abrasions, foreign bodies, and/or bruising.
• Identify any bony deformities, areas with focal tenderness, or edema.
• Document all findings.

Do not forget to log roll patients who are under C-spine precautions to examine the back and spine.

Diagnostic adjuncts ^[1]

Consider the following diagnostic studies and procedures during the secondary survey once the patient is stable:

• Whole-body CT (WBCT)
• CT head without IV contrast
• CT cervical spine without IV contrast
• CT thoracic and/or lumbar spine without IV contrast
• CT chest with IV contrast or CTA chest
• CT abdomen and pelvis with IV contrast
• X-rays of the extremities
• Laboratory studies
• Ancillary testing (e.g., bronchoscopy, esophagoscopy)
• See “Diagnostics in trauma” for details.

Further management

• Ensure imaging is ordered for all identifiable injuries.
• Consider using decision rule to clinically rule out C-spine injury and allow early removal of C-spine precautions.
• Order routine trauma laboratory studies, including any emergency preop diagnostics and tests required to evaluate medical comorbidies.
• Order appropriate monitoring, e.g., continuous cardiac monitoring, neurovitals.
• Provide adequate analgesia and other supportive care (e.g., antiemetics, maintenance fluids).
• Provide tetanus prophylaxis for open wounds.
• If intraperitoneal injury is suspected, administer empiric antibiotics for intraabdominal infections.
• Evaluate the need for admission, interfacility transfer, and further consults to address newly identified injuries (See “Disposition”).
• Next steps: See “Tertiary survey.”

Goal ^[1][13]

• Identify injuries undetected during primary and secondary surveys.
• Ensure patient safety.
• Complete the tertiary survey within 24 hours of presentation.

A standardized tertiary survey with high-quality imaging may limit the incidence of missed injuries. ^[14]

Approach ^[1][13]

• Obtain collateral information if trauma history remains unclear.
• Identify and rectify gaps in the patient's medical history (e.g., chronic conditions, medications, allergies).
• Repeat examination of the patient focusing on musculoskeletal injuries and detailed neurovascular examination.
• Review previously obtained diagnostic studies.
• Order additional studies based on tertiary survey findings.
• Screen for suicidality and nonsuicidal self-injury if self-harm is suspected.
• Screen for sexual violence, intimate partner violence, older adult abuse, and child abuse in at-risk individuals.

Hand and foot injuries are the most common missed injuries. ^[15][16]

Missed injuries ^[15][16][17]

Missed injuries are an important area of focus for quality and safety in trauma care, however, high-quality evidence is limited. ^[14]

Risk factors ^{[1][13][18][19]}

• Patient risk factors include:
  • Altered mental status
  • Concomitant TBI
  • Polytrauma with distracting injuries
  • Higher overall injury severity
  • Need for urgent surgery
  • Age > 30
  • Dangerous injury mechanism: e.g., assault, fall from height, MVC, pedestrian struck, GSW, stab wounds
• System-associated risk factors include:
  • Limited initial clinical evaluation
  • Radiological imaging lacking or delayed
  • Cognitive biases
  • See “Health care personnel-associated risk factors” in “Quality and safety” for details.

Beware of anchoring bias and premature closure bias during the tertiary survey.

Injuries at risk of missed or delayed diagnosis ^[14][15][16]

The following have a higher potential to remain undetected after initial evaluation.

Surface wounds

• Scalp, nose, and mouth
• Axillae
• Groin and perineum

Extremity

• MSK injuries involving the hand and foot
• Neurovascular injury
• Compartment syndrome
• Occult extremity fractures

Head, neck, and spine

• Small or delayed intracranial hemorrhages
• Occult facial fractures and C-spine fracture
• Carotid and vertebral artery injuries

Thorax

• Blunt cardiac injury
• Penetrating and blunt thoracic aortic injury
• Diaphragmatic injury
• Esophageal perforation

Abdominopelvic

• Hollow viscus injury
• Retroperitoneal injury (e.g., pancreatic and duodenal bulb injuries)
• Subtle liver or splenic laceration
• Genitourinary trauma (e.g., ureter injury)
• Penetrating rectal injury

Approach

• Consider clinical judgment, mechanism of injury, and patient factors (e.g., age, hemodynamic status) when choosing diagnostic studies.
• Weigh the need and timing of diagnostic studies against the need for urgent interfacility transfer or surgical intervention for each patient.
• Follow local policies on diagnostic imaging strategy (e.g., liberal vs. selective) as these vary by institution and region (see “CT imaging in trauma” for details).

ECG ^[1]

• Indications: mechanisms that may result in cardiac injury (e.g., in blunt chest trauma)
• Findings
  • Blunt cardiac injury (e.g., dysrhythmia, ST segment changes)
  • Pericardial effusion and cardiac tamponade (e.g., electrical alternans, low voltage QRS)

Laboratory studies ^[1]

• Routine studies: CBC, BMP, LFTs
• Preoperative studies: coagulation studies, type and screen
• Pregnancy test (e.g., serum or urine β-hCG)
• POC glucose
• Urinalysis (See “Diagnostics in genitourinary trauma” for details.)
• Lactate
• ABG: to evaluate P_aO₂, P_aCO₂, pH and base deficit

Normotensive patients with trauma may have subclinical hypoperfusion. Evaluate for other clinical features of shock and check hemodynamic parameters (e.g., serum lactate, base deficit).

FAST and eFAST ^[1][20]

See “Point-of-care ultrasound” (POCUS) for procedural details (e.g., image generation and troubleshooting).

• Focused assessment with sonography for trauma (FAST): thoracoabdominal POCUS used in trauma patients to detect free fluid within the peritoneal, pericardial, and pleural cavities
• Extended FAST (eFAST): an extension of the FAST scan that includes evaluation of the chest for lung sliding
• Clinical applications in trauma
  • Can identify internal hemorrhage (e.g., hemoperitoneum, hemopericardium, hemothorax) requiring operative intervention in unstable patients
  • eFAST can additionally help identify pneumothorax
  • Used primarily as a diagnostic adjunct during the primary survey
  • Can be used as an adjunct for serial reassessments
• Limitations
  • Limited sensitivity in stable patients
  • Needs to be interpreted alongside other diagnostic and clinical findings
• Technique: Sonography of the subxiphoid, RUQ, LUQ, pelvic, and anterior thoracic regions is typically performed (see “FAST and eFAST” in “POCUS” for details).
• Findings: See “FAST and eFAST” in “POCUS” for details.
  • Free fluid can be seen in the following spaces:
    • Pericardial
    • Pleural
    • Hepatorenal
    • Splenorenal and/or subphrenic
    • Pelvic
  • Lung sliding may be absent in pneumothorax

Interpret FAST and eFAST alongside other diagnostic parameters and clinical judgment. POCUS does not replace definitive diagnostic studies. ^[20]

A positive FAST exam in a hemodynamically unstable patient with trauma is usually an indication for urgent operative intervention (e.g., exploratory laparotomy, urgent thoracotomy, pericardiotomy).

Radiography ^[1]

Bedside chest and pelvic x-rays are commonly performed during the primary survey, while extremity and spine X-rays are typically reserved for the secondary survey.

CXR

• Indications: blunt or penetrating trauma to the chest or abdomen
• Findings
  • Pneumothorax
  • Hemothorax
  • Pneumoperitoneum
  • Pneumomediastinum
  • Widened mediastinum

Pelvic X-ray

• Indications
  • Blunt or penetrating trauma to the abdomen
  • Unstable pelvis
• Findings: pelvic fracture

Extremity X-rays

• Indications: pain, redness, swelling, or deformity at the injury site
• Findings: fracture and/or dislocation

Spinal X-rays

Spinal x-rays have been replaced by CT imaging in most trauma centers.

• Indications
  • Spinal tenderness to palpation
  • Disruption of the vertebral process alignment (i.e., step-off deformity)
  • Extremity numbness, tingling, or weakness
  • Neurogenic shock
• Findings
  • Vertebral compression fracture
  • Burst fracture
  • Chance fracture
  • Transverse process fracture
  • Spinous process fracture
  • Spondylolisthesis

CT imaging in trauma ^[1]

Approach

• Perform CT scans preferentially during the secondary survey in hemodynamically stable patients with no obvious indications for emergent laparotomy.
• Make decisions about the timing, necessity, and sequence of CT scans together with all relevant specialists on the trauma team, especially for patients with polytrauma.
• If a crucial CT scan cannot be delayed as it impacts operative management, ensure trauma teams are at the bedside with stabilizing treatments throughout the procedure.
• Follow local protocols for CT imaging (e.g., WBCT vs. selective CT imaging) under specialist guidance. ^{[21][22][23][24][25]}

Avoid transporting unstable patients out of resuscitation areas to obtain CT scans whenever possible.

Whole-body CT (pan scan) ^[21]

• May be performed to evaluate patients with multiple injuries after significant trauma
• Commonly includes:
  • CT head without IV contrast
  • CT cervical spine without IV contrast
  • CT thoracic and lumbar spine with IV contrast
  • CT chest with IV contrast
  • CTA chest
  • CT abdomen and pelvis with IV contrast

CT head and spine

• CT head without IV contrast: See “Diagnostic imaging in traumatic brain injury.”
• CT cervical spine without IV contrast
  • Indications
    • Clinical suspicion of C-spine injury based on mechanism and examination
    • Inability to clear C-spine clinically using a validated tool (e.g., NEXUS C-spine criteria , Canadian C-spine rule (CCR) )
  • Findings
    • Bony deformity and/or fracture of the vertebral body or processes
    • Loss of alignment of the vertebral bodies
    • Increased distance between vertebrae
    • Narrowing of vertebral canal
    • Increased prevertebral soft tissue swelling
• CT thoracic and lumbar spine without IV contrast
  • Indications: clinical suspicion of T-spine and/or or L-spine injury based on mechanism and examination
  • Findings: similar to CT cervical spine

Consider imaging for spinal fractures in patients with evidence of high-energy trauma to the lower extremities (e.g., calcaneus fracture) after falling from a height.

Obtain CT cervical spine if C-spine injury cannot be ruled out using validated clinical decision tools. ^[26]

CT chest with IV contrast ^[27][28]

• Indications
  • Inability to rule out blunt chest trauma with validated clinical decision tools
  • Penetrating chest trauma
• Findings
  • Cardiac injury (e.g., blunt cardiac injury)
  • Lung injury (e.g., pneumothorax, hemothorax, pulmonary contusion)
  • Tracheal injury
  • Diaphragm injury
  • Esophageal injury
  • Chest wall injury (e.g., rib fracture)

CTA chest

• Indications
  • Inability to rule out blunt chest trauma with validated clinical decision tools
  • Penetrating chest trauma with concern for great vessel injury.
• Findings
  • Cardiac injury (e.g., blunt cardiac injury)
  • Blunt thoracic aortic injury
  • Vascular injury (e.g., penetrating chest trauma) ^[29]

Consider CTA chest to evaluate for blunt thoracic aortic injury in patients with high-energy trauma and a wide mediastinum on CXR.

CT abdomen and pelvis with IV contrast

• Indications
  • Blunt and/or penetrating abdominal trauma
  • Penetrating back and/or flank trauma with no other indications for immediate laparotomy
• Findings
  • Stomach injury
  • Splenic injury (e.g., splenic rupture)
  • Liver injury (e.g., liver hematoma)
  • Small and large bowel injuries (e.g., gastrointestinal perforation)
  • Kidney injury (e.g., renal laceration, renal hematoma)
  • Bladder injury (e.g., rupture of the bladder)
  • Pelvic fracture

Diagnostic peritoneal lavage (DPL)

• Definition: an invasive diagnostic test used to assess for hemoperitoneum or viscus perforation in abdominal trauma
• Indications: : may be performed after the primary survey for suspected hemoperitoneum with equivocal or unavailable FAST ^[1]
• Procedure: A catheter is placed into the abdomen and contents are aspirated to assess for the presence of blood or fecal matter. If neither is observed, a liter of warm saline is instilled and then collected for cytological analysis.
• Findings: The presence of bile, fecal matter, or ≥ 10 cc of blood is considered a positive test and is an indication for emergent laparotomy.

Ancillary testing

Additional testing may be performed depending on the mechanism of injury and clinical evaluation, and may include:

• Bronchoscopy for tracheobronchial injury
• Esophagoscopy for esophageal perforation
• Diagnostics for genitourinary trauma (e.g., CT urography, retrograde urethrogram): for renal, ureteral and urethral injuries
• Echocardiography for blunt cardiac injury

Consider diagnostics for genitourinary trauma (e.g., retrograde urethrogram) for patients with hematuria, blood at meatus, inability to void, need for pelvic binder, scrotal hematoma, or perineal ecchymosis.

Suspect tracheobronchial injury in patients with extensive subcutaneous emphysema.

Criteria for trauma team activation ^[1]

• Mechanism of injury
  • Falls from > 5 meters
  • Impact from high-speed MVC
  • Ejection from vehicle
  • Any MVC > 18 mph (29 km/h) involving impact with a pedestrian, cyclist, or motorcyclist
  • Death of a vehicle co-passenger
• Specific injuries
  • Injury to > 2 body regions
  • Penetrating injury to the head, neck, torso, or proximal limb
  • Traumatic amputation
  • > 15% estimated BSA burns in adults or > 10% in children; or signs of airway involvement
  • Airway obstruction
• Physiological derangements
  • Hypotension
  • Tachycardia
  • Bradypnea or tachypnea
  • GCS < 14
• Special patient groups
  • Pregnant patients > 24 weeks' gestation with chest and/or abdominal injury
  • Individuals > 70 years of age with chest injury

Specialty consults

Indications for urgent trauma surgeon consult ^[4]

At level 1 trauma centers, a trauma surgeon's presence at the bedside within 15 minutes of patient arrival is indicated for any of the following:

• Systolic BP < 90 mmHg
• GSW to neck, thorax, abdomen, pelvis, or proximal extremities
• Prehospital endotracheal intubation
• Intubation for respiratory failure
• GCS < 8 due to trauma
• Emergency physician discretion

Other specialists

Consult all specialists outside the trauma team responsible for managing identified injuries:

• Thoracic surgery: e.g., for operative cardiopulmonary injuries
• Neurosurgery: e.g., for TBI
• Orthopedics: e.g., for operative fractures
• OB-GYN and/or urology: e.g., for genitourinary trauma
• Plastic surgery: e.g., for extensive soft tissue injuries such as degloving, burns
• Vascular surgery: e.g., for major vessel injuries
• Interventional radiology: e.g., for angioembolization
• Others: hand surgery, oromaxillofacial surgery, spine surgery

Interfacility transfers

• Initiate the transfer process to a higher level trauma center as soon as the patient's needs exceed the capability of the current hospital.
• Transfer decision depends on multiple factors, e.g.:
  • The patient's injuries
  • Resources and equipment available at the current hospital
  • Availability of consultant physicians
  • Institutional and regional guidelines
• Transfer to a burn unit may also be indicated (see “Treatment of burns” for details).

An indication for trauma team activation is generally an indication that the patient requires transfer to a trauma center. ^[1]

Surgical admission

• Operating room: transfer patients to the OR for operative management of critical findings.
  • Traumatic brain injury: See “Management of moderate and severe TBI.”
  • Thoracotomy: See “Resuscitative thoracotomy” and “Urgent thoracotomy.”
  • Laparotomy: See “Emergency exploratory laparotomy.”
• Trauma ICU
  • Admit all hemodynamically unstable or intubated patients to critical care settings.
  • Patients may require postoperative admission to ICU.

Discharge from emergency settings

• Most patients with major trauma require admission for treatment and observation.
• Consider discharge with outpatient follow-up for patients with all of the following after complete workup and observation:
  • Only minor injuries (e.g., isolated fracture)
  • Adequate analgesia
  • Normal mental status
  • Ability to function with ADLs and IADLs
  • Good social supports
  • No other indications for admission

Trauma in pregnant individuals

• Epidemiology ^[30]
  • Incidence: every 12^th pregnant woman experiences trauma
  • Trauma in pregnancy is the leading cause of nonobstetrical maternal death in the US.
• Etiology ^[31][32]
  • Unintentional trauma (e.g., due to falls, MVCs)
  • Intentional trauma:
    • Intimate partner violence
    • Assault
    • Suicide attempt
• Classification ^[33]
  • Minor trauma (90%): trauma for which obstetrical surveillance suffices
    • No abdominal involvement
    • No rapid compression or deceleration
    • No pain or vaginal bleeding
    • No loss of fluid
    • Normal fetal movement
  • Major trauma (10%): trauma that requires further assessment in a trauma center
    • Abdominal involvement with abdominal pain
    • Signs and symptoms of internal bleeding
    • Hematuria
    • Vaginal bleeding and/or loss of fluid
    • Loss of consciousness
    • Rapid compression and/or deceleration
    • Decreased fetal movement

• Complications
  • Due to physiological changes during pregnancy
    • Superior displacement of abdominal organs
      • Increased risk of gastrointestinal injury from chest or upper abdominal trauma
      • Increased risk of aspiration during intubation
    • Decrease of blood pressure (by 15–20 mmHg only during 2^nd trimester): increased risk of hypotensive complications (e.g., falls due to syncope) and missing pathological causes underlying hypotension
    • Increase of the heart rate (by 15–20 bpm only during 3^rd trimester): increased risk of complications from tachycardia (e.g., arrhythmias) and missing pathological causes underlying tachycardia
    • Increase of blood volume: increased risk of overlooked blood loss
  • Placental abruption and preterm labor
  • Fetal loss (60–70% caused by minor trauma, with placental abruption being the most common complication)
  • Supine hypotensive syndrome following trauma (see “Supine hypotensive syndrome” in “Other complications” below)
  • Uterine rupture and exsanguination
  • Maternal death
• Prevention
  • Screen all pregnant women for intimate partner violence; for more information see “Intimate partner violence.”

Avoid examining the mother in the supine position in order to avoid possible supine hypotensive syndrome.

The mother should be evaluated and treated before the fetus. Early and optimal diagnostics and trauma management of the mother is the best treatment for the fetus.

Management of pregnant patients with trauma ^[1][34][35]

• All pregnant trauma patients
  • Begin initial resuscitation using the ABCDE approach.
  • Assess for signs of abruption and uterine rupture.
  • Perform a fetal status assessment.
  • Consider imaging: ultrasound and/or CT.
  • Obtain coagulation studies, including fibrinogen. ^[33]
  • Order a Kleihauer-Betke test.
  • Administer anti-D immunoglobulin for Rh-negative mothers.
  • Consult OB/GYN if there is any concern for obstetric injuries.
• Trauma patients > 20 weeks' gestation
  • Initiate tocodynamometry for at least 4–6 hours.
  • Continue monitoring for 24 hours if any of the following are present : ^[1][33]
    • High-impact mechanism of injury
    • ≥ 6 uterine contractions per hour
    • Vaginal bleeding, significant abdominal pain, or uterine tenderness
    • Rupture of the membranes
    • Abnormal fetal heart rate pattern
    • Maternal tachycardia (HR > 110/minute)
• Further management
  • Management of nonobstetric injuries as for nonpregnant patients
  • Emergency delivery in consultation with OB/GYN if there is nonreassuring fetal status or maternal hemodynamic instability
  • See also:
    • “Management of placental abruption”
    • “Management of uterine rupture”
    • “Management of preterm labor”

Even minor trauma poses a risk for placental abruption. ^[34][36]

Trauma in older adults ^[1][37]

Common mechanisms of injury

• Falls ^[1]
• Impact from MVCs
• Burns
• Penetrating injuries

General principles

• Consider any physiological events that may have led to the trauma (e.g., cardiac arrhythmia leading to syncope and resulting in a fall).
• Determine medication effects.
• Assess for older adult abuse.
• Determine goals of care.

Geriatric modifications to the primary survey

• Airway
  • Loss of protective airway reflexes
  • Dentures and arthritic changes may impede airway management.
• Breathing
  • Limited respiratory reserve with potential for rapid deterioration to respiratory failure
  • At risk for respiratory failure following rib fractures; provide adequate analgesia and pulmonary toilet.
• Circulation
  • Patients with preexisting hypertension may appear normotensive, but this may represent a relatively hypotensive state (e.g., hemorrhagic shock).
  • Use of cardiac medicine may blunt tachycardia.
  • Consider advanced monitoring (e.g., central venous pressure, ECHO) during resuscitative efforts.
• Disability
  • Increased risk for TBI
    • Cortical atrophy may delay signs of intracranial bleeding.
    • More likely in patients taking anticoagulant and antiplatelet medications
  • Preexisting neurological or psychiatric disease may impede evaluation.
• Exposure: Loss of subcutaneous fat puts patients at risk for hypothermia, as well as pressure injury from immobilization.

Trauma in children ^[1]

Common mechanisms of injury

• MVCs ^[1]
• Drowning
• House fires
• Intentional injury
• Falls

General principles

• Normal pediatric vital signs vary by age.
• Smaller body mass results in greater force applied per unit of body area, leading to a greater risk for multiple injuries than adults.
• Developmental age may hinder history and examination.
• Use Broselow tape to recommend common drug dosing and equipment sizes.
• Assess for signs of child maltreatment.
• Practice judicious use of CT scans. ^[38]

Pediatric modifications to the primary survey ^[1]

• Airway
  • Proportionally larger head results in passive cervical spine flexion, which may obstruct the airway.
  • Visualization during intubation is difficult.
    • Shorter airway is located higher in the neck.
    • Anterior attachment of vocal cords is located more inferiorly than the posterior attachment.
• Breathing
  • Higher normal respiratory rate than adults
  • Use a pediatric bag-valve-mask for children < 30 kg.
• Circulation
  • Higher normal heart rate and lower normal blood pressure than adults
  • Increased physiological reserve allows children to maintain normal systolic blood pressure during hemorrhagic shock.
  • See also “Basic life support in infants and children.”
• Disability
  • Proportionally larger head leading to an increased risk of TBI
  • Modified GCS may be used in children < 4 years of age.
• Exposure: at increased risk for accidental hypothermia because of greater body surface area to mass ratio than adults ^[39]