Trauma Patient Assessment

1. Introduction

Trauma is a leading cause of morbidity and mortality worldwide. Early assessment and intervention following Advanced Trauma Life Support (ATLS) guidelines are crucial to prevent secondary injuries and improve outcomes. 

2. Primary Survey (ABCDE Approach)

The primary survey is a structured, rapid assessment focused on identifying and treating life-threatening conditions.

A – Airway with C-Spine Control

✅ Assess Airway Patency (Look for obstruction, stridor, gurgling)

✅ Protect C-Spine (Assume C-spine injury in all trauma patients)

• Jaw thrust without head tilt

• Rigid cervical collar + manual in-line stabilization (MILS) during intubation

🔴 Indications for Immediate Airway Intervention:

• GCS ≤ 8 → Intubate for airway protection

• Airway obstruction → Foreign body, edema, bleeding

• Severe maxillofacial trauma → Consider cricothyroidotomy

🛑 Airway Management Challenges in Trauma:

• C-Spine immobilization limits neck movement → Use video laryngoscopy, fiberoptic intubation

• Facial trauma & bleeding → Use suction-assisted laryngoscopy

• Laryngeal trauma → Be prepared for emergency surgical airway

B – Breathing and Ventilation

✅ Look for signs of respiratory distress (tachypnea, cyanosis, paradoxical breathing)

✅ Assess Chest Expansion, Percussion, Auscultation

🔴 Life-Threatening Thoracic Injuries (Immediately Correctable)

🚨 Intubate if:

• Severe hypoxia (SpO₂ <90% despite O₂ therapy)

• Severe lung injury (ARDS, contusions)

C – Circulation with Hemorrhage Control

✅ Look for Shock (Tachycardia, Hypotension, Cold Extremities, Low UO)

✅ Check Central & Peripheral Pulses

🔴 Hemorrhagic Shock is the Most Common Cause of Death in Trauma

✅ Control External Bleeding – Direct pressure, tourniquet (if needed)

✅ Assess Major Internal Bleeding Sites (FAST Scan)

• Chest (Hemothorax)

• Abdomen (Splenic/Liver injury)

• Pelvis (Fractures)

• Long bones (Femur fracture)

🩸 Fluid Resuscitation (Permissive Hypotension Approach)

• IV Access: 2 Large Bore IV Cannulas (18G or bigger) or Central Line

• Fluids: Balanced Crystalloids (RL/Plasmalyte) → Avoid excessive normal saline

• Blood Transfusion: If massive hemorrhage (Use 1:1:1 Ratio for PRBC:FFP:Platelets)

🚨 Massive Transfusion Protocol (MTP) Indications:

• SBP <90 mmHg + Signs of Ongoing Bleeding

• ≥ 4 Units PRBC in 1 hour

• Shock Index (HR/SBP) >1

🔴 Avoid Coagulopathy of Trauma (Triad of Death: Hypothermia, Acidosis, Coagulopathy)

• Keep temperature > 36°C (use warm fluids, warming blankets)

• Maintain pH > 7.2 (correct acidosis with adequate resuscitation)

• Avoid dilutional coagulopathy (balance crystalloid with blood products)

D – Disability (Neurological Assessment)

✅ Assess Glasgow Coma Scale (GCS)

🔴 TBI Considerations in Trauma:

• GCS ≤ 8 → Intubate for airway protection

• Pupil asymmetry, dilated pupil → Raised ICP, Urgent CT Brain

• Mannitol 1g/kg or Hypertonic Saline for ICP control

E – Exposure & Environment

✅ Fully expose the patient → Look for hidden injuries

✅ Prevent Hypothermia (Major cause of Coagulopathy & Mortality)

• Use warm IV fluids, warming blankets, keep OR/ICU warm

3. Secondary Survey (Head-to-Toe Assessment)

Once the primary survey is complete and life-threatening conditions are addressed, conduct a detailed head-to-toe examination to identify other injuries.

Common Missed Injuries in Trauma

✅ Blunt Abdominal Trauma – Do FAST scan, CT Abdomen

✅ Pelvic Fractures – Check for instability, avoid excessive movement

✅ Spinal Cord Injury – Perform full neurological assessment, consider MRI

The AMPLE acronym is used in Advanced Trauma Life Support (ATLS) to obtain a focused and rapid history in trauma patients.

1. A – Allergies
• Ask about known drug, food, or environmental allergies.
• Critical for medication administration (e.g., antibiotics, analgesics, anesthetics).

2. M – Medications

• List all current medications (including OTC, anticoagulants, insulin, steroids, etc.).
• Important for assessing bleeding risks (anticoagulants) or steroid dependence.

3. P – Past Medical History / Pregnancy

• Previous surgeries, medical conditions (cardiac, respiratory, renal, diabetes, etc.).
• Pregnancy status is crucial in females of childbearing age.

4. L – Last Meal / Last Oral Intake

• Helps assess aspiration risk during intubation or surgery.
• Important for deciding on timing of anesthesia & surgery.

5. E – Events Leading to Injury / Environment

• Mechanism of trauma (blunt, penetrating, burns, falls, crush injuries).
• Circumstances of the incident (high-speed crash, fall from height, assault).
• Consider environmental exposure (hypothermia, drowning, hazardous material exposure).

4. Anesthetic Considerations for Trauma Surgery

Preoperative Considerations

✅ Optimize Hemodynamics – Resuscitate before surgery

✅ Assess Airway – Difficult airway in facial trauma, cervical spine precautions

✅ Correct Coagulopathy – TEG/ROTEM-guided transfusion

Intraoperative Management

✅ Choice of Anesthesia – GA with RSI preferred (aspiration risk)

✅ Induction Agents:

• Ketamine (Maintains BP in hypotensive patients)

• Etomidate (Stable hemodynamics, but suppresses adrenal function)

• Avoid Propofol in Shock (Causes profound hypotension)

✅ Ventilation Strategy:

• Maintain low tidal volume (6 mL/kg IBW) to prevent ARDS

• Adjust PEEP in chest trauma (avoid excessive PEEP in pneumothorax)

5. MCQs on Trauma Assessment

Q1. In trauma, the first priority is:

A) Airway

B) Breathing

C) Circulation

D) Disability

✅ Answer: A) Airway

Q2. Which airway maneuver is preferred in suspected cervical spine injury?

A) Head tilt-chin lift

B) Jaw thrust

C) Neck extension

D) None of the above

✅ Answer: B) Jaw thrust

Q3. In hemorrhagic shock, what is the best first-line fluid?

A) 5% Dextrose

B) Normal Saline

C) Ringer Lactate

D) Whole Blood

✅ Answer: C) Ringer Lactate