Emergency Medicine Major Trauma

🚨 Major Trauma

Overview

Major trauma is severe injury to multiple body regions or a single severe injury that can result in significant morbidity or mortality. It requires a systematic, rapid, and multidisciplinary approach to assessment and management, following ATLS principles. UK care is delivered through a tiered trauma system, aiming for definitive care at a Major Trauma Centre (MTC).

Recognition

Recognise major trauma based on mechanism of injury (e.g., high-speed RTA, fall from height, penetrating injury) and physiological parameters (e.g., GCS <13, systolic BP <90 mmHg, respiratory rate <10 or >29). Look for obvious injuries, deformities, and signs of haemorrhage.

Initial Assessment (ABCDE)

A: Airway with C-spine control. B: Breathing and ventilation, assess for pneumothorax/haemothorax. C: Circulation with haemorrhage control, assess for shock, establish IV access, and take bloods. D: Disability - neurological assessment (GCS, pupils). E: Exposure and environmental control, prevent hypothermia, full body examination.

Red Flags

Deterioration in GCS, persistent hypotension despite fluid resuscitation, uncontrolled haemorrhage, increasing respiratory distress, or signs of herniation. Any of these indicate worsening condition and require immediate re-evaluation and intervention.

Investigations

Bedside: Pulse oximetry, continuous cardiac monitoring, blood pressure monitoring, blood glucose, arterial blood gas. Bloods: FBC, U&Es, coagulation screen, Group & Save, lactate. Imaging: Chest X-ray, pelvic X-ray, FAST scan (Focused Assessment with Sonography for Trauma). CT scan (whole body CT in MTCs) is the definitive imaging for stable major trauma patients.

Immediate Management

Follow the ATLS primary survey (ABCDE) and resuscitate simultaneously. Secure airway, provide high-flow oxygen, control external haemorrhage with direct pressure, administer intravenous fluids and blood products as indicated. Address life-threatening injuries (e.g., tension pneumothorax decompression, pelvic binder). Prevent hypothermia. Prepare for transfer to definitive care.

Escalation Triggers

Immediate senior trauma team leader (Consultant/Registrar) involvement for all major trauma. Early surgical consultation (general surgery, orthopaedics, neurosurgery) depending on injuries. Transfer to a Major Trauma Centre (MTC) if not already there, for definitive multidisciplinary care. ICU referral for patients requiring ongoing critical care support.

MLA High-Yield Notes

The 'golden hour' concept highlights the importance of rapid assessment and intervention. Remember the 'lethal triad' of trauma: acidosis, hypothermia, and coagulopathy. Always assume C-spine injury until cleared. The primary survey identifies and treats life-threatening conditions; the secondary survey is a head-to-toe examination once stable.

References

  • Resuscitation Council UK: Adult Advanced Life Support Guidelines
  • National Institute for Health and Care Excellence (NICE) Guideline: Major trauma: assessment and initial management
  • Royal College of Emergency Medicine: Major Trauma Management Guideline