MULTIPLE
TRAUMA
TRAUMA CARE IS A RACE AGAINST PHYSIOLOGIC FAILURE
Primary survey first
Use a standardized, rapid ABC approach to identify and treat immediately life-threatening problems.
eFAST early
Bedside ultrasound can rapidly identify intraperitoneal fluid, pleural air/fluid, and pericardial effusion.
Control bleeding
Hemorrhage control is treatment. Fluids are supportive—not a substitute for source control.
Balanced resuscitation
When blood is required, use a protocol-driven balanced component strategy and avoid excessive crystalloid.
TXA when indicated
Clinically significant hemorrhage or shock may warrant early tranexamic acid, ideally within the first hour.
Special populations
Older adults, anticoagulated patients, children, and pregnancy can mask severity or alter thresholds for action.
FROM ARRIVAL TO DISPOSITION
CAN THE PATIENT PROTECT THE AIRWAY?
Protection is likely adequate when
- GCS is not severely depressed
- Respiratory effort is sufficient
- No active vomiting or major oropharyngeal bleeding
- No major airway obstruction
If the airway is threatened
- Remove suctionable / visible obstruction
- Optimize mask ventilation
- Consider brief neurologic exam if time permits
- Use RSI with cervical spine stabilization when appropriate
- Video-assisted laryngoscopy may reduce neck movement
OXYGENATION + VENTILATION + LETHAL CHEST INJURY
Is breathing adequate?
- Respiratory rate and work
- Chest excursion
- SpO₂ and mental status
- Ventilation / end-tidal CO₂ when available
Respiratory distress?
- Tachypnea
- Accessory muscle use
- Cyanosis / agitation
- Asymmetric chest findings
Breath sounds bilateral?
- If absent/asymmetric: tension pneumothorax, open pneumothorax, massive hemothorax
- If present: think flail chest, cardiac injury, pulmonary contusion
ASSUME HEMORRHAGE UNTIL PROVEN OTHERWISE
Shock in trauma is most commonly hypovolemic from blood loss, but obstructive, cardiogenic, neurogenic, and septic causes must remain on the differential.
Signs of shock
- Tachycardia
- Hypotension
- Delayed capillary refill
- Cool / mottled extremities
- Mental-status change
Remember
- Normal vitals do not rule out hemorrhage
- Athletes and children can compensate
- Medications can blunt expected responses
- More than one shock type can coexist
LOCATE BLEEDING. RESUSCITATE. CONTROL THE SOURCE.
Find the hemorrhage
- External
- Thoracic
- Abdominal
- Pelvic
- Long-bone
- Retroperitoneal
Rapid adjuncts
- Physical exam
- eFAST
- Chest / pelvis radiography when useful
- CT in sufficiently stable patients
- Warm fluids and blood products
- Avoid unnecessary large-volume crystalloid
- Correct hypothermia and monitor calcium
- Consider TXA for significant bleeding / shock
SPECIAL CONSIDERATIONS DURING THE PRIMARY SURVEY
Airway
- Severe maxillofacial injury
- Cervical spine immobilization
- Consider awake technique when appropriate
- Vascular injury
- Significant bleeding
- Airway displacement / obstruction
Breathing
- Chest contusions
- Flail segment
- Bowel sounds in chest
- Chest injury
- Significant bleeding
- Sucking chest wound
Circulation
- Positive FAST
- Unstable pelvis
- Long-bone fracture
- Retroperitoneal bleeding
- Obvious vascular injury
- External hemorrhage
HEAD-TO-TOE, AFTER IMMEDIATE LIFE THREATS ARE CONTROLLED
MECHANISM PREDICTS WHAT YOU MUST LOOK FOR—NOT WHAT YOU CAN EXCLUDE
| Mechanism | High-yield injury pattern | Clinical cue |
|---|---|---|
| Head-on MVC | Facial injury, lower-extremity injury, aortic injury | Dashboard / steering-wheel energy transfer |
| Rear-end MVC | Hyperextension injury of cervical spine | Neck pain / neurologic symptoms can be delayed |
| Lateral (T-bone) | Thoracic, splenic/liver, pelvic, clavicle/rib injury | Side-impact intrusion increases torso injury |
| Rollover / ejection | Crush and spinal injury; high multisystem burden | Ejection = major-energy mechanism |
| Seat belt / restraint | Chest wall, abdominal, flexion-distraction spine injury | Seat-belt sign can signal internal injury |
| Pedestrian struck | Lower-extremity, trunk, craniofacial, multisystem injury | High-speed impact predicts greater injury burden |
| Bicycle | Closed head injury, handlebar abdominal injury | Consider spleen/liver and occult intra-abdominal injury |
| Fall | Calcaneus/leg, pelvis, spine, head injury | Vertical vs horizontal impact changes injury distribution |
LABS SHOULD ANSWER CLINICAL QUESTIONS
Blood loss / baseline
CBC helps frame anemia and platelet status, but early hemoglobin can underestimate acute blood loss.
Metabolic status
Electrolytes, renal function, liver tests, glucose, and comorbidity assessment.
Coagulation
Order in critical injury, ongoing transfusion, or anticoagulant use; INR is not a rapid full picture of clot function.
Transfusion readiness
Blood type, screen or crossmatch according to injury severity and likelihood of transfusion.
Lactate / base deficit
Useful markers of global hypoperfusion and resuscitation trend. Serial values matter more than a single snapshot.
TEG / ROTEM
In major bleeding, viscoelastic testing can support early recognition of trauma coagulopathy and guide products.
Pregnancy testing
Obtain in patients of childbearing potential when clinically appropriate; serum testing avoids delays from urine collection.
USE THE FASTEST TEST THAT CHANGES MANAGEMENT
eFAST
Early in multisystem or torso trauma; rapidly identifies free fluid, pleural pathology, and tamponade.
Chest ultrasound
Highly useful for pneumothorax / hemothorax and can outperform supine chest radiography for some findings.
Plain radiography
Portable chest or pelvis imaging can help in selected unstable patients when it will change immediate management.
CT
Head, cervical spine, chest, abdomen, pelvis—especially in stable patients with concerning exam or mechanism.
Decision rules
Validated rules such as NEXUS / Canadian C-spine can reduce unnecessary imaging in appropriate patients.
DO THE SIMPLE LIFE-SAVING THINGS EARLY
Priorities
- Secure / protect airway
- Support oxygenation and ventilation
- Control external hemorrhage
- Recognize / treat tension physiology
- Prevent heat loss
Transport matters
- Rapid transfer to the correct trauma center
- Communicate mechanism, vitals, trends, and treatments
- Spinal motion restriction when indicated
- Avoid prolonged scene time for interventions that do not change immediate outcome
FOUR GATES FOR DESTINATION DECISION-MAKING
Physiology
- GCS ≤13
- SBP <90 mm Hg
- RR <10 or >29 /min
- Need for ventilatory support
Anatomy
- Penetrating head/neck/torso
- Flail chest
- ≥2 proximal long-bone fractures
- Crushed/degloved/pulseless limb
- Pelvic fracture / paralysis
Mechanism
- Significant falls
- High-risk auto crash / intrusion
- Ejection / death in same compartment
- Pedestrian / cyclist high-impact event
- High-speed motorcycle crash
Special factors
- Older adults
- Children
- Anticoagulation / bleeding disorders
- Burns + trauma
- Pregnancy
- EMS judgment
PENETRATING CHEST TRAUMA — HIGHLY SELECTIVE RESUSCITATION
Signs of life on arrival?
Blood pressure, pulse, organized rhythm, respiratory effort, or echocardiographic cardiac activity / tamponade.
If yes
Proceed with full resuscitation and consider thoracotomy when penetrating mechanism and physiology fit accepted criteria.
If no
Echo for tamponade and prehospital signs of life / CPR duration become central to whether further resuscitation is reasonable.
Potentially favorable features
- Penetrating chest injury
- Short prehospital CPR
- Signs of life at scene or ED
- Echo evidence of tamponade / cardiac activity
Goals if performed
- Relieve tamponade
- Control major thoracic hemorrhage
- Open cardiac massage / repair selected injury
- Allow rapid transfer to definitive operative care
BLUNT TRAUMA — THE THRESHOLD IS MUCH HIGHER
- Outcomes are poor when there are no signs of life at the scene or ED.
- Prolonged prehospital CPR strongly predicts futility.
- Thoracotomy may be considered only in narrowly defined, potentially reversible circumstances.
SPECIAL POPULATIONS: LOWER THRESHOLD, HIGHER VIGILANCE
Older adults
Low-energy mechanisms can cause major injury. Comorbidity and reduced reserve increase morbidity, mortality, and length of stay.
Anticoagulation
Even minor trauma can produce significant occult bleeding. Lower thresholds for neuroimaging and careful coagulation assessment are appropriate.
Children
Compensation can be impressive until sudden decompensation. Use pediatric-capable trauma systems whenever possible.
Pregnancy
Maternal stabilization remains the priority; imaging and transfusion decisions should be individualized with fetal considerations.
THE RIGHT NEXT DESTINATION IS PART OF RESUSCITATION
Operating room / ICU
Ongoing hemorrhage, unstable physiology, critical injury, or need for immediate intervention.
Admission / observation
Injury requiring monitoring, serial exams, pain control, specialist management, or evolving diagnostic clarification.
Transfer
When required resources, specialists, or definitive capabilities are not available locally. Stabilize before departure and send complete records.