Trauma — ATLS, head & abdominal injuries

◆Primary survey (ABCDE)

• •A: Airway with cervical spine protection — intubate if GCS ≤8, severe facial trauma, expanding neck hematoma
• •B: Breathing — assess for tension PTX (clinical, NOT CXR — needle decompression at 2nd ICS or 4th–5th ICS midaxillary then chest tube)
• •C: Circulation — 2 large-bore IVs, 1L LR/NS bolus, type-and-crossmatch, control external bleeding with pressure
• •D: Disability — GCS, pupils, gross motor
• •E: Exposure — fully undress, prevent hypothermia

◆Head trauma & GCS

• •GCS = Eye (1–4) + Verbal (1–5) + Motor (1–6); max 15, min 3
• •GCS ≤8 → intubate (cannot protect airway)
• •Canadian CT Head Rule: GCS <15 at 2 hr, suspected skull fracture, basilar fracture signs (raccoon eyes, Battle sign, hemotympanum, CSF rhinorrhea), ≥2 episodes vomiting, age ≥65, dangerous mechanism
• •Epidural hematoma: lens-shaped on CT, MIDDLE MENINGEAL ARTERY, LUCID INTERVAL classic, biconvex; surgical evacuation
• •Subdural hematoma: crescent-shaped, BRIDGING VEINS, elderly/alcoholics; can be acute, subacute, or chronic
• •Subarachnoid: blood in cisterns/sulci; trauma OR aneurysm rupture
• •Diffuse axonal injury: high-velocity shear; punctate hemorrhages on CT, often poor outcome
• •Cushing triad (HTN + bradycardia + irregular respirations) = late sign of increased ICP

◆Increased ICP management

• •Elevate HOB 30°
• •Hyperosmolar therapy: mannitol or 3% hypertonic saline
• •Mild hyperventilation (PaCO2 32–35) — short-term only (vasoconstriction)
• •Maintain CPP (MAP – ICP) >60 mmHg
• •Surgical evacuation of hematoma if midline shift >5 mm or focal deficit
• •ICP monitoring (bolt) for severe TBI with GCS ≤8

◆Cervical spine clearance

• •NEXUS criteria (all 5 met to clear clinically without imaging): no posterior midline tenderness, normal alertness, no intoxication, no focal neuro deficit, no painful distracting injury
• •Canadian C-spine rule (alternative): age <65 + no dangerous mechanism + no paresthesias + low-risk factors (delayed onset of neck pain, sitting position in ED, ambulatory at any time, simple rear-end MVC) + able to rotate neck 45° each way → clear
• •If criteria not met → CT cervical spine
• •Spinal cord injury — high-dose steroids (methylprednisolone) is CONTROVERSIAL; current evidence does NOT support routine use

◆Chest trauma

• •Tension PTX: clinical diagnosis (hypotension, JVD, tracheal deviation, absent breath sounds, hyperresonance) — needle decompression FIRST, then chest tube
• •Open PTX: 3-sided occlusive dressing, then chest tube
• •Massive hemothorax: >1500 mL initial drainage or >200 mL/hr × 4 hr → thoracotomy
• •Cardiac tamponade: Beck triad (hypotension, muffled heart sounds, JVD) + pulsus paradoxus; FAST shows pericardial fluid; emergent pericardiocentesis or thoracotomy
• •Aortic injury: high-energy decel; widened mediastinum on CXR → CT angiography
• •Flail chest: ≥3 adjacent ribs with ≥2 fractures each → paradoxical chest wall motion; supportive ventilation, pain control

◆Abdominal trauma

• •Blunt + stable: CT abdomen/pelvis with contrast
• •Blunt + unstable: bedside FAST → if positive (free fluid), go to OR
• •Blunt + unstable + negative FAST: think extra-abdominal cause (chest, retroperitoneum, pelvic fracture)
• •Penetrating (gunshot to abdomen): explore everyone (mandatory laparotomy)
• •Penetrating (stab): selective — explore if peritonitis, hypotension, evisceration; CT or local exploration for stable
• •Spleen most common solid organ injured in blunt trauma — try to preserve (avoid splenectomy in kids if possible)
• •Liver lacerations: most can be managed nonoperatively if hemodynamically stable
• •Diaphragmatic injury: more common on LEFT (right shielded by liver); often missed
• •Pelvic fracture + hypotension: pelvic binder + interventional radiology for embolization or preperitoneal packing

◆Damage control & resuscitation

• •Massive transfusion protocol (MTP): 1:1:1 PRBCs:FFP:platelets
• •TXA within 3 hr of injury (CRASH-2)
• •Permissive hypotension (SBP target ~90) in penetrating trauma until source control
• •Damage control surgery: stop bleeding, control contamination, temporary closure → re-explore in 24–48 hr after warming, correcting coagulopathy
• •Lethal triad: hypothermia + acidosis + coagulopathy — prevent and reverse

Head bleed quick recognition