Major Trauma in Adults

Quick Reference

Critical Alert: ### Immediate Life-Threatening Conditions | Condition | Recognition | Immediate Action | |-----------|-------------|------------------| | Airway obstruction | Stridor, apnoea, inability to speak | Jaw thrust, suction, definitive airway | | Tension pneumothorax | Hypotension + JVD + absent breath sounds + tracheal deviation | Finger thoracostomy (4th/5th ICS, mid-axillary line) | | Massive haemothorax | > 1500 mL initial drainage or > 200 mL/hr ongoing | Large-bore chest tube, urgent thoracotomy | | Cardiac tamponade | Beck's triad: hypotension, muffled heart sounds, JVD | Pericardiocentesis or resuscitative thoracotomy | | Massive haemorrhage | Class III-IV shock, obvious exsanguination | Haemorrhage control, activate MTP, 1:1:1 transfusion | | Unstable pelvic fracture | Haemodynamic instability + pelvic instability | Pelvic binder, avoid log-roll, MTP |

Key Principles

• ABCDE approach saves lives: Systematic primary survey identifies life threats [1]
• Haemorrhage is the leading preventable cause of death: Control bleeding early and aggressively [2]
• Permissive hypotension: Target SBP 80-90 mmHg until surgical haemorrhage control (NOT in TBI) [3]
• Massive transfusion protocol: 1:1:1 ratio of RBC:FFP:Platelets reduces mortality [4]
• TXA within 3 hours: 1g IV bolus significantly reduces mortality from bleeding [5]
• Damage control resuscitation: Addresses the lethal triad (hypothermia, acidosis, coagulopathy) [6]
• C-spine precautions: Maintain until clinically or radiologically cleared [1]

Critical Time Targets

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Overview

Major trauma, also termed polytrauma, represents one of the leading causes of death and disability worldwide, particularly among young adults. The World Health Organization estimates that injuries account for approximately 4.4 million deaths annually, representing 8% of all deaths globally. [9] In patients aged 1-44 years, trauma remains the leading cause of death, with road traffic accidents, falls, and interpersonal violence constituting the primary mechanisms. [2]

Major trauma is defined as injury to one or more body regions with at least one injury being life-threatening, or an Injury Severity Score (ISS) greater than 15. The management of these patients requires a systematic, protocol-driven approach that has been codified through the Advanced Trauma Life Support (ATLS) programme, first developed by the American College of Surgeons in 1980 and now adopted in over 80 countries worldwide. [1]

The fundamental principle underlying trauma resuscitation is the simultaneous assessment and treatment paradigm, where life-threatening conditions are identified and addressed immediately as they are discovered during the primary survey. This contrasts with traditional medical approaches where diagnosis precedes treatment. The goal is to identify and treat immediately life-threatening conditions while simultaneously preparing for definitive care, whether surgical, interventional, or intensive care management.

Clinical Pearl: The Golden Hour Concept: First described by R Adams Cowley, this principle emphasises that critically injured patients have the best outcomes when definitive care is delivered within one hour of injury. Modern trauma systems are designed around this principle, with pre-hospital systems, trauma team activation, and streamlined pathways aimed at minimising time to definitive haemorrhage control. [10]

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Epidemiology

Global Burden

Trimodal Death Distribution

The temporal pattern of trauma deaths was first described by Trunkey in 1983 and remains relevant to understanding trauma system design: [13]

Risk Factors for Major Trauma

UK-Specific Data (TARN)

The Trauma Audit and Research Network (TARN) provides comprehensive UK trauma data: [14]

• Approximately 20,000 patients with major trauma (ISS > 15) annually in England and Wales
• Median age of major trauma patients: 55 years (reflecting demographic shift)
• Falls now account for > 50% of major trauma in patients > 65 years
• In-hospital mortality for ISS > 15: approximately 10%
• Regional trauma networks established 2012 have improved survival

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Pathophysiology

The Lethal Triad of Trauma

The lethal triad represents a self-perpetuating cycle of physiological derangement that, if uncorrected, leads to irreversible shock and death. Understanding this triad is fundamental to damage control resuscitation. [6,15]

Exam Detail: ### Trauma-Induced Coagulopathy (TIC)

Trauma-induced coagulopathy is present in up to 25-35% of severely injured patients on arrival to hospital and is associated with a 3-4 fold increase in mortality. [16] The pathophysiology involves:

1. Tissue Factor Pathway Activation: Massive tissue injury releases tissue factor, activating extrinsic coagulation
2. Protein C Activation: Hypoperfusion leads to thrombomodulin expression and protein C activation, which inhibits factors Va and VIIIa
3. Hyperfibrinolysis: Tissue plasminogen activator (tPA) release exceeds plasminogen activator inhibitor-1 (PAI-1), leading to clot breakdown
4. Endothelial Glycocalyx Shedding: Shock causes endothelial injury and glycocalyx degradation, contributing to coagulopathy and capillary leak
5. Factor Consumption and Dilution: Ongoing bleeding depletes clotting factors, exacerbated by crystalloid resuscitation

Viscoelastic Testing: Point-of-care tests (TEG, ROTEM) can identify coagulopathy patterns and guide targeted component therapy. [17]

Haemorrhagic Shock Classification

The ATLS classification of haemorrhagic shock guides resuscitation strategy: [1]

Clinical Pearl: Limitations of Shock Classification: The traditional ATLS shock classification has limitations. Elderly patients may not mount tachycardia (beta-blockers, pacemakers). Athletes have high vagal tone. Pregnant patients have expanded blood volume. Base deficit and lactate are more reliable indicators of shock severity. A lactate > 4 mmol/L or base deficit worse than -6 indicates significant hypoperfusion regardless of vital signs. [18]

Systemic Inflammatory Response

Major trauma triggers a massive systemic inflammatory response that, while initially adaptive, can become pathological:

1. Immediate Phase (0-4 hours): Damage-associated molecular patterns (DAMPs) released from injured tissue activate innate immunity
2. Early Phase (4-72 hours): Cytokine storm (IL-1, IL-6, TNF-α), complement activation, neutrophil priming
3. Late Phase (> 72 hours): Can progress to SIRS, ARDS, and MODS in ~20-30% of major trauma patients
4. Second Hit Phenomenon: Secondary insults (surgery, infection, transfusion) can amplify the inflammatory response

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Trauma Team Activation

Major Trauma Centre Criteria (UK NHS)

Patients should be taken directly to a Major Trauma Centre (MTC) if any of the following criteria are met: [7]

Physiological Criteria

Anatomical Criteria

Mechanism Criteria

Trauma Team Composition

A typical Major Trauma Centre trauma team includes:

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Primary Survey (ATLS)

The primary survey follows the systematic ABCDE approach, with simultaneous resuscitation of life-threatening conditions as they are identified. [1]

Pre-Hospital Handover: MIST/ATMIST

A - Airway with Cervical Spine Protection

Simultaneous priorities: Establish patent airway while maintaining cervical spine immobilisation.

Assessment

Airway Interventions - Escalating Approach

C-Spine Immobilisation

Indications for immobilisation (any of): [19]

• GCS less than 15
• Focal neurological deficit
• Paraesthesia in limbs
• Neck pain or tenderness
• Distracting injury
• Intoxication
• High-risk mechanism

Technique:

• Manual inline stabilisation (MILS) during airway manoeuvres - remove front of collar
• Semi-rigid collar plus head blocks and tape/straps
• Minimise time on spinal board (less than 30 minutes to prevent pressure injury)
• Scoop stretcher or lateral transfer for prolonged immobilisation

Clinical Pearl: Collar Removal Decision: The Canadian C-Spine Rule and NEXUS criteria allow clinical clearance in alert, non-intoxicated patients without midline tenderness, focal neurology, or distracting injury. If not clinically clearable, CT C-spine is required. In intubated/unconscious patients, CT C-spine with CT angiography if concerning mechanism. MRI may be required for obtunded patients with normal CT. [19,20]

B - Breathing and Ventilation

Expose the chest and assess for immediately life-threatening thoracic injuries.

Assessment

Life-Threatening Thoracic Injuries (Primary Survey)

Exam Detail: ### Chest Tube Insertion Technique

Position: Supine, arm abducted and externally rotated Site: 4th or 5th intercostal space, mid-axillary line (safe triangle) Technique (Seldinger vs Open):

1. Preparation: Sterile technique, local anaesthesia if time/patient conscious
2. Incision: 3-4 cm incision along rib (above rib to avoid neurovascular bundle)
3. Dissection: Blunt dissection through subcutaneous tissue and intercostal muscles
4. Pleural Entry: Controlled push through parietal pleura with finger or clamp
5. Finger Sweep: Digital exploration to confirm pleural space and sweep adhesions
6. Tube Insertion: Direct tube posteriorly and apically, all holes within chest
7. Secure: Suture in place, connect to underwater seal or flutter valve
8. Confirm: CXR, look for swing/bubbling

Size: 28-32 Fr for haemothorax, 24-28 Fr for pneumothorax (recent evidence suggests smaller tubes may be adequate) [21]

C - Circulation with Haemorrhage Control

Assess and treat shock, with a focus on haemorrhage as the most common cause in trauma.

Assessment of Circulation

Sources of Major Haemorrhage

"Blood on the floor and four more":

Vascular Access

D - Disability (Neurological Assessment)

Rapid Neurological Assessment

Glasgow Coma Scale

GCS Categories: Mild TBI (13-15), Moderate TBI (9-12), Severe TBI (3-8) [22]

Critical Alert: Signs of Raised Intracranial Pressure/Herniation:

• Decreasing GCS (especially motor score)
• Unilateral or bilateral fixed, dilated pupils
• Cushing's triad (hypertension, bradycardia, irregular respiration) - late sign
• Posturing (decorticate or decerebrate)

Immediate Actions:

• Secure airway (RSI)
• Prevent secondary injury: maintain PaO2 > 13 kPa, PaCO2 4.5-5.0 kPa, SBP > 90 mmHg
• Head-up position (30°) if no spinal injury
• Urgent neurosurgical referral and CT head
• Consider hypertonic saline or mannitol if evidence of herniation

E - Exposure and Environmental Control

Complete Examination

• Remove all clothing for complete examination
• Log-roll with spinal precautions to examine back, spine, buttocks, perineum
• Document all injuries found
• Insert urinary catheter (if no contraindication)
• Insert gastric tube (orogastric if suspected base of skull fracture)

Prevent Hypothermia

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Damage Control Resuscitation

Damage control resuscitation (DCR) represents a paradigm shift from traditional crystalloid-based resuscitation to a strategy that addresses the lethal triad from the outset. [6,23]

Principles of Damage Control Resuscitation

Clinical Pearl: Permissive Hypotension Contraindications:

• Traumatic brain injury: Maintain SBP > 90 mmHg (MAP > 80) to prevent secondary brain injury
• Spinal cord injury: May need higher MAP targets (85-90) for spinal cord perfusion
• Elderly patients: May have reduced physiological reserve, poor tolerance of hypotension
• Coronary artery disease: Risk of myocardial ischaemia with hypotension

In these patients, balance the risks of ongoing haemorrhage against the risks of hypoperfusion to critical organs. [3]

Massive Transfusion Protocol (MTP)

Activation Criteria

Multiple scoring systems exist to predict need for massive transfusion:

ABC Score (Assessment of Blood Consumption): [24]

TASH Score (Trauma Associated Severe Haemorrhage): Uses Hb, base excess, HR, SBP, gender, presence of free fluid, pelvic fracture

Clinical Criteria for MTP Activation:

• 4 units RBC anticipated within first hour

• Obvious massive haemorrhage
• Haemodynamic instability despite initial resuscitation
• Clinical judgment of experienced trauma team leader

MTP Blood Product Ratios

PROPPR Trial Key Findings (2015): [4]

• 1:1:1 vs 1:1:2 (RBC:FFP:Platelets)
• 1:1:1 associated with reduced death from exsanguination at 24 hours (9.2% vs 14.6%)
• No difference in 24-hour or 30-day mortality in intention-to-treat analysis
• More patients achieved haemostasis with 1:1:1

Adjunctive Therapies

Exam Detail: ### CRASH-2 Trial (2010) [5]

Design: Randomised, placebo-controlled trial in 274 hospitals across 40 countries Participants: 20,211 adult trauma patients with significant haemorrhage within 8 hours of injury Intervention: TXA 1g over 10 min, then 1g over 8 hours vs placebo Results:

• All-cause mortality: 14.5% TXA vs 16.0% placebo (RR 0.91, 95% CI 0.85-0.97)
• Death due to bleeding: 4.9% TXA vs 5.7% placebo (RR 0.85, 95% CI 0.76-0.96)
• No increase in vascular occlusive events Key finding: Benefit greatest when given within 3 hours; potential harm if given after 3 hours Conclusion: TXA should be given as early as possible to all bleeding trauma patients

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Secondary Survey

The secondary survey is a head-to-toe examination performed after the primary survey is complete and life-threatening conditions have been addressed. It includes a complete history and detailed physical examination. [1]

AMPLE History

Head-to-Toe Examination

Head and Face

Neck

Chest

Abdomen

Critical Alert: Pelvic Examination: Only examine pelvic stability ONCE. Repeated manipulation can disrupt clot formation and worsen haemorrhage. If instability detected or suspected based on mechanism, apply pelvic binder immediately and avoid log-roll if possible (use scoop stretcher for transfer).

Extremities

Back and Spine (Log-Roll)

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Imaging in Major Trauma

Extended Focused Assessment with Sonography for Trauma (eFAST)

The eFAST examination is a rapid bedside ultrasound protocol that can be performed during the primary survey to identify free fluid and pneumothorax. [25]

eFAST Views

Interpretation

Clinical Pearl: eFAST Limitations:

• Sensitivity for free fluid approximately 85-90% (operator dependent)
• Does NOT detect: Hollow viscus injury, retroperitoneal injury, small solid organ injuries without free fluid
• False negatives in early haemorrhage, obesity, subcutaneous emphysema
• Repeat eFAST at 30-60 minutes can improve sensitivity
• A negative eFAST does not exclude abdominal injury - serial examination or CT required

Plain Radiography

Traditionally, three X-rays were performed in the primary survey ("trauma series"):

Modern Approach: CT has largely replaced plain radiography in stable patients. CXR and pelvic XR remain useful in unstable patients who cannot go to CT.

CT Imaging in Trauma

CT "Pan-Scan": Head, C-spine, chest, abdomen, and pelvis with IV contrast (CT angiography if indicated). [7]

Indications for Whole-Body CT

CT Should NOT Delay

• Transfer to OR for unstable patients with identified surgical bleeding
• Critical interventions (airway, chest decompression)
• The unstable patient should NOT go to CT

Specific CT Findings

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Specific Injury Patterns

Pelvic Fracture Management

Pelvic fractures represent a major source of haemorrhage and require a coordinated approach. [26]

Classification (Young-Burgess/Tile)

Management Algorithm

1. Immediate: Pelvic binder at level of greater trochanters
2. Imaging: Pelvic XR or CT if stable
3. Resuscitation: MTP, damage control principles
4. Haemorrhage control:
   • Angioembolisation for arterial bleeding (contrast blush on CT)
   • Preperitoneal packing for venous bleeding
   • External fixation for mechanical stability
5. Definitive fixation: When physiologically optimised

Critical Alert: Pelvic Binder Application:

• Apply at level of greater trochanters (NOT iliac crests)
• Should reduce pelvic volume and tamponade venous bleeding
• Commercial binders preferred; sheet may be used if unavailable
• Avoid log-roll in unstable pelvic fractures - use scoop stretcher
• Leave in place until definitive management planned

Thoracic Aortic Injury

Traumatic aortic injury occurs in high-energy deceleration mechanisms. 80-90% die at the scene; survivors typically have contained injuries at the aortic isthmus. [27]

Suspicion

• High-energy mechanism (high-speed RTC, fall from height)
• Widened mediastinum on CXR (> 8 cm or > 25% of chest width)
• First rib fracture, sternal fracture, scapula fracture (markers of high energy)

Diagnosis

• CT aortogram (100% sensitivity for significant injury)

Management

• Blood pressure control (SBP 100-120 mmHg, HR less than 100)
• Thoracic endovascular aortic repair (TEVAR) now first-line for most injuries
• Open repair reserved for selected cases

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Resuscitative Interventions

Resuscitative Thoracotomy (ED Thoracotomy)

Emergency department (resuscitative) thoracotomy is a salvage procedure for traumatic cardiac arrest. [28]

Indications

Technique (Left Anterolateral Thoracotomy)

1. Left 5th intercostal space incision, anterior to mid-axillary line
2. Extend through intercostal muscles into pleural cavity
3. Insert rib spreader
4. Open pericardium anterior to phrenic nerve (longitudinal incision)
5. Evacuate clot, repair cardiac injuries (finger/staples/suture)
6. Cross-clamp descending aorta (preserve cerebral and coronary perfusion)
7. Internal cardiac massage
8. Can extend to clamshell if required

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)

REBOA is an emerging technique for temporary haemorrhage control in non-compressible torso haemorrhage. [29]

Current evidence: Limited to case series and registry data. May be useful as bridge to definitive surgery in selected patients. Risk of ischaemia-reperfusion injury, limb ischaemia. Requires trained operators and should not delay definitive haemorrhage control.

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Special Populations

Pregnant Trauma Patients

Elderly Trauma Patients

Anticoagulated Patients

Paediatric Considerations

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Disposition and Definitive Care

Immediate OR Indications

Damage Control Surgery Principles

For patients with severe physiological derangement: [6]

1. Phase 1 - Abbreviated surgery (60-90 min): Control haemorrhage (packing, ligation, shunts), control contamination (staple, tie, drain), temporary abdominal closure
2. Phase 2 - ICU resuscitation: Correct hypothermia, acidosis, coagulopathy, optimise physiology
3. Phase 3 - Definitive surgery: Return to OR for definitive repair when physiologically stable (24-72 hours)

ICU Admission Criteria

All major trauma patients require ICU/HDU admission for:

• Ongoing resuscitation and monitoring
• Mechanical ventilation
• Haemodynamic monitoring and support
• Organ support (renal, coagulation)
• Serial examination and tertiary survey
• VTE prophylaxis when safe
• Nutrition initiation
• Rehabilitation planning

Tertiary Survey

Must be performed within 24 hours of admission: [8]

• Repeat comprehensive head-to-toe examination
• Review all imaging with radiology
• Identify and document any previously missed injuries (occur in up to 10%)
• Update injury documentation
• Plan any additional investigations or interventions

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Quality Metrics and Documentation

Performance Indicators

Documentation Requirements

• Time of arrival and trauma team activation
• Pre-hospital handover details (mechanism, interventions, vital signs)
• Primary survey findings and interventions with times
• Resuscitation details (fluids, blood products, medications)
• Secondary survey findings
• Imaging results
• Procedures performed with times
• Consultation and referral times
• Disposition decision and time
• Communication with family

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Common Exam Questions

Viva Questions

1. "A 25-year-old motorcyclist is brought in after a high-speed crash. GCS 14, HR 130, BP 85/60, RR 28. Talk me through your approach."

2. "What are the indications for massive transfusion protocol? How would you activate it?"

3. "Describe the role of TXA in trauma. What is the evidence?"

4. "An unstable patient has a positive FAST scan. What is your management?"

5. "What are the components of damage control resuscitation? Why has this replaced traditional approaches?"

6. "Describe the indications and technique for emergency thoracotomy."

7. "How do you manage an unstable pelvic fracture with haemodynamic instability?"

Viva Point: Opening Statement: "Major trauma is defined as injury to one or more body regions with at least one life-threatening injury, or an ISS greater than 15. The approach follows ATLS principles with simultaneous assessment and resuscitation. My priorities are to identify and treat immediately life-threatening conditions during the primary survey while activating damage control resuscitation for haemorrhaging patients."

Key phrases:

• "Systematic ABCDE approach"
• "Simultaneous assessment and resuscitation"
• "Damage control resuscitation addressing the lethal triad"
• "Permissive hypotension until haemorrhage control"
• "1:1:1 balanced transfusion based on PROPPR trial"
• "TXA within 3 hours based on CRASH-2"

Model Answer: Approach to Unstable Trauma Patient

"I would approach this patient using ATLS principles with a systematic primary survey while simultaneously initiating resuscitation.

Airway: I would assess for patency while maintaining C-spine immobilisation. If the patient cannot protect their airway or GCS is 8 or less, I would prepare for RSI with video laryngoscopy and manual inline stabilisation.

Breathing: I would expose the chest and look for immediately life-threatening injuries. If I identified tension pneumothorax, I would perform immediate finger thoracostomy before proceeding.

Circulation: Given the hypotension and tachycardia, this patient is in haemorrhagic shock. I would obtain large-bore IV access, activate the massive transfusion protocol, and begin damage control resuscitation with 1:1:1 blood products. I would administer 1g TXA immediately. I would perform eFAST to identify the source of bleeding. If positive with ongoing instability, the patient would go directly to OR for damage control laparotomy.

Disability: Rapid GCS assessment and pupillary examination.

Exposure: Complete examination while preventing hypothermia.

Following stabilisation, I would complete the secondary survey, obtain imaging as appropriate, and arrange definitive care."

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Clinical Pearls

Diagnostic Pearls

• Primary survey is treatment - intervene immediately when you find a problem
• eFAST positive + unstable = OR, not CT
• Lactate and base deficit are better shock indicators than vital signs
• Initial haemoglobin may be normal despite significant blood loss (haemodilution takes time)
• Always log-roll to examine the back - posterior injuries are commonly missed
• Repeat eFAST if initially negative but clinical suspicion remains

Treatment Pearls

• The lethal triad kills - warm the patient, stop the acidosis with perfusion, give blood not crystalloid
• Permissive hypotension (SBP 80-90) until haemorrhage control - but NOT in TBI
• TXA works and is cheap - give it early, within 3 hours
• 1:1:1 transfusion prevents coagulopathy better than delayed component correction
• Pelvic binder at greater trochanter level, not iliac crests
• ED thoracotomy has a role - best outcomes in penetrating cardiac injury with recent arrest

Disposition Pearls

• All major trauma patients should reach a Major Trauma Centre
• Tertiary survey within 24 hours identifies missed injuries in up to 10%
• Early rehabilitation planning improves outcomes
• Debrief the trauma team after each activation

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References

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018.

2. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-11. doi:10.1097/01.ta.0000199961.02677.19

3. Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):605-617. doi:10.1097/TA.0000000000001333

4. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. doi:10.1001/jama.2015.12

5. CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. doi:10.1016/S0140-6736(10)60835-5

6. Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375-382. doi:10.1097/00005373-199309000-00008

7. National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline [NG39]. 2016. Updated 2023. Available from: https://www.nice.org.uk/guidance/ng39

8. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990;30(6):666-669. doi:10.1097/00005373-199006000-00002

9. World Health Organization. Injuries and violence. 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/injuries-and-violence

10. Cowley RA, Hudson F, Scanlan E, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma. 1973;13(12):1029-1038. doi:10.1097/00005373-197312000-00001

11. World Health Organization. Global status report on road safety 2018. Geneva: World Health Organization; 2018. ISBN: 978-92-4-156568-4

12. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-1222. doi:10.1016/S0140-6736(20)30925-9

13. Trunkey DD. Trauma. Sci Am. 1983;249(2):28-35. doi:10.1038/scientificamerican0883-28

14. Moran CG, Lecky F, Bouamra O, et al. Changing the system - major trauma patients and their outcomes in the NHS (England) 2008-17. EClinicalMedicine. 2018;2-3:13-21. doi:10.1016/j.eclinm.2018.07.001

15. Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. doi:10.1186/s13054-019-2347-3

16. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127-1130. doi:10.1097/01.TA.0000069184.82147.06

17. Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051-1059. doi:10.1097/SLA.0000000000001608

18. Mutschler M, Nienaber U, Brockamp T, et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013;84(3):309-313. doi:10.1016/j.resuscitation.2012.07.012

19. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. doi:10.1001/jama.286.15.1841

20. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. doi:10.1056/NEJM200007133430203

21. Bauman ZM, Kulvatunyou N, Joseph B, et al. A prospective study of 7-year experience using percutaneous 14-French pigtail catheters for traumatic hemothorax/hemopneumothorax at a Level-1 trauma center: size still does not matter. World J Surg. 2018;42(1):107-113. doi:10.1007/s00268-017-4168-3

22. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84. doi:10.1016/s0140-6736(74)91639-0

23. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310. doi:10.1097/TA.0b013e3180324124

24. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66(2):346-352. doi:10.1097/TA.0b013e3181961c35

25. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004;57(2):288-295. doi:10.1097/01.ta.0000133565.88871.e4

26. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma. 2011;71(6):1850-1868. doi:10.1097/TA.0b013e31823dca9a

27. Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008;64(3):561-570. doi:10.1097/TA.0b013e3181641b0c

28. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288-298. doi:10.1016/s1072-7515(99)00233-1

29. Brenner M, Inaba K, Aiolfi A, et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018;226(5):730-740. doi:10.1016/j.jamcollsurg.2018.01.044

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Complications of Major Trauma

Immediate Complications (0-24 hours)

Early Complications (1-7 days)

Late Complications (> 7 days)

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Rehabilitation and Recovery

Early Rehabilitation (ICU Phase)

Rehabilitation Pathway

1. Critical Care Phase: ICU, organ support, early mobilisation goals
2. Step-Down Phase: HDU/ward, increasing mobility, self-care activities
3. Inpatient Rehabilitation: Specialist rehabilitation unit if needed, intensive therapy
4. Community Rehabilitation: Outpatient therapy, return to work programmes, long-term follow-up

Outcome Measures

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Prevention and Trauma Systems

Primary Prevention

Trauma System Components

Clinical Pearl: Impact of Major Trauma Networks: Following the introduction of regional trauma networks in England in 2012, overall survival for major trauma patients improved by 19%, with an estimated 600 additional survivors per year. This demonstrates the importance of system-level organisation in trauma care.

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Medicolegal Considerations

Documentation Requirements

Consent in Major Trauma

Organ Donation Considerations

• Early referral to Specialist Nurse for Organ Donation (SNOD) for potential donors
• Donation after Circulatory Death (DCD) increasingly common in trauma
• Does not preclude aggressive resuscitation until donation discussed
• Family approach by trained SNOD, not treating team

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Summary: Key Take-Home Points

Critical Alert: ### Five Things Not to Miss in Major Trauma

1. Tension pneumothorax - Clinical diagnosis, immediate decompression, don't wait for imaging
2. Exsanguinating haemorrhage - Control bleeding, activate MTP early, give TXA within 3 hours
3. Cervical spine injury - Immobilisation until cleared, be especially vigilant in head injuries
4. Deteriorating conscious level - May indicate intracranial bleeding, requires urgent CT and neurosurgical referral
5. Missed injuries - Tertiary survey within 24 hours, systematic re-examination of all body regions

Key Evidence to Know

Quality Improvement Focus

• Door-to-CT time less than 30 minutes (stable patients)
• TXA administration within 3 hours
• MTP activated when clinically indicated
• Tertiary survey completed within 24 hours
• Documentation of hypothermia prevention
• VTE prophylaxis initiated when safe
• Family communication documented
• Trauma team debrief after each activation

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