Key Facts

Major trauma is a time-critical condition requiring a systematic team approach. The UK Major Trauma Network, established in 2012, has significantly improved outcomes through regionalised care with dedicated major trauma centres.

Epidemiology

Major trauma affects approximately 20,000 people per year in England. It is the leading cause of death in those aged 1-40 years and a leading cause of disability. Road traffic collisions account for approximately 40%, falls 40%, and violence/other 20%. The establishment of the UK Trauma Network has reduced preventable death rates from approximately 30% to <5%.

Aetiology

Mechanism of injury:

• Blunt trauma (90% in UK): RTC, falls, assaults, sports
• Penetrating trauma (10%): Stab wounds, gunshot wounds
• Blast injuries: Explosive devices — primary (blast wave), secondary (fragments), tertiary (displacement), quaternary (burns, crush)

Pathophysiology

Trauma causes tissue injury, haemorrhage, and a systemic inflammatory response. The lethal triad of hypothermia, acidosis, and coagulopathy is the primary driver of mortality in bleeding trauma patients. Damage control resuscitation aims to prevent and treat this triad. Traumatic brain injury is the leading cause of death in polytrauma.

Primary Survey (ABCDE)

• A (Airway with C-spine protection): Assess patency, clear debris, jaw thrust, consider intubation. Assume C-spine injury until cleared.
• B (Breathing): Inspect, palpate, percuss, auscultate. Treat tension pneumothorax, open pneumothorax, massive haemothorax, flail chest immediately.
• C (Circulation with haemorrhage control): Direct pressure on external bleeding. Assess for shock (tachycardia, hypotension, cold peripheries). Two large-bore IV cannulae. Start fluid/blood resuscitation.
• D (Disability): GCS, pupil assessment, blood glucose, lateralising signs
• E (Exposure and Environment): Fully expose, log-roll, maintain temperature (warm blankets, warm fluids, warm environment)

Life-Threatening Injuries (Primary Survey)

• Airway obstruction, tension pneumothorax, open pneumothorax
• Massive haemothorax, flail chest with pulmonary contusion
• Cardiac tamponade
• Massive haemorrhage (external or internal)

Red Flags

• GCS drop of ≥2 points — repeat CT head, consider neurosurgical emergency
• Haemodynamic instability not responding to initial resuscitation — consider ongoing haemorrhage, activate massive transfusion
• Mechanism involving high energy transfer — maintain high suspicion for occult injuries
• Abdominal distension with shock — intra-abdominal haemorrhage, consider emergency laparotomy

Bedside

• Primary survey: Clinical assessment is the first 'investigation'
• FAST (Focused Assessment with Sonography for Trauma): Free fluid in abdomen, pericardium; haemothorax
• GCS: Serial assessment
• Blood glucose: Capillary

Bloods

• FBC, U&Es, coagulation, fibrinogen: Baseline
• Group and crossmatch: At least 4 units; activate MHP if needed
• Lactate: Tissue perfusion marker
• ABG/VBG: pH, base deficit, Hb, K⁺
• Point-of-care coagulation (TEG/ROTEM): Guide transfusion in massive haemorrhage

Imaging

• CXR: Pneumothorax, haemothorax, mediastinal widening, rib fractures
• AP pelvis X-ray: Pelvic fracture assessment
• CT trauma series: CT head, C-spine, chest, abdomen, pelvis — after primary survey stabilisation
• CT angiography: If vascular injury suspected

Special Tests

• Diagnostic peritoneal lavage (DPL): Rarely used now (replaced by FAST and CT)
• Focused neurovascular exam: Before and after any fracture manipulation

Non-pharmacological

• ATLS primary survey and resuscitation: Simultaneous assessment and treatment
• C-spine immobilisation: Until cleared clinically or by imaging
• Haemorrhage control: Direct pressure, tourniquets (extremity), pelvic binder, splints
• Temperature management: Warm fluids, blankets, warm theatre — prevent hypothermia
• Log-roll: Assess posterior injuries (C-spine, thoracolumbar spine, perineum)

Pharmacological

• Tranexamic acid 1g IV within 3 hours of injury (CRASH-2 trial) — reduces bleeding death by ~30%
• Massive transfusion protocol (1:1:1): pRBC:FFP:Platelets; target fibrinogen >1.5g/L (cryoprecipitate)
• Permissive hypotension: Target SBP 80-90 mmHg until surgical haemorrhage control (avoid in TBI — target SBP >110 in head injury)
• Antibiotics: For open fractures (co-amoxiclav 1.2g IV ± gentamicin for grade III), penetrating abdominal injuries
• Tetanus prophylaxis: For open wounds — check immunisation status
• VTE prophylaxis: LMWH when safe (balance against bleeding risk)

Surgical/Interventional

• Damage control surgery: Abbreviated surgery to control haemorrhage and contamination → ICU resuscitation → definitive repair
• Emergency thoracotomy: Penetrating chest trauma with cardiac arrest or imminent arrest
• Emergency laparotomy: Haemodynamically unstable abdominal trauma
• Interventional radiology: Embolisation for pelvic, hepatic, splenic haemorrhage
• External fixation: Pelvic fracture stabilisation
• Chest drain: Haemothorax, pneumothorax

Referral Criteria

• Major trauma (ISS ≥16) — major trauma centre
• Head injury with GCS ≤8 or deterioration — neurosurgery
• Spinal cord injury — spinal injuries centre
• Vascular injury — vascular surgery
• Burns >10% TBSA — burns centre

• Major trauma centre care: 20-25% mortality reduction compared with non-MTC care (TARN data)
• Preventable deaths: <5% in mature trauma systems (UK improved from ~30% to <5% since 2012)
• TBI: Leading cause of trauma death and disability; GCS ≤8 carries ~30% mortality
• Damage control resuscitation: Has significantly improved survival in haemorrhagic shock
• Rehabilitation: Early, structured rehabilitation improves functional outcomes; many trauma survivors require long-term support

ATLS Classification of Haemorrhagic Shock

Damage Control Resuscitation Principles