Acute Care 43: Initial Care of Major Trauma Patients

Prior to Arrival

Consider transfer potential, destination, and type of transport. Call for transport. Transport decisions and calls may be made while patient is in the field.

Upon Arrival

Combative patients require restraint; this can be accomplished mechanically while conducting initial assessment and treatment of life threats.

Initial Survey

Observe "10 seconds of silence" for the team leader to identify life threats needing immediate interventions (obstructed airway, tension pneumothorax, uncontrolled external hemorrhage, sucking chest wound, cardiac arrest). These conditions must be corrected before proceeding with routine measures.
Team actions include exposure, IV access, monitors, blood draws (in order of importance, type and crossmatch, hemoglobin/CBC, chemistry panel, PTT/INR, urinalysis, pregnancy test, alcohol/tox screen).
Consider advanced airway management techniques as needed. Indications for intubation include airway and breathing compromise, combative or uncooperative patients requiring significant sedation, and most critical patients requiring transport. If possible, perform mini-neuro exam prior to intubation.
Initiate fluid resuscitation as needed. Consider blood administration.

Focused Evaluation and Ongoing Care

Repeat initial survey during focused trauma evaluation. Remember to examine the back and rectum of a trauma victim.
Advanced airway management and ongoing fluid resuscitation may be needed.
In pediatric patients, 20 mL/kg IV boluses of normal saline may be initiated for hypovolemic shock.
Further tests, radiographs, and interventions are based on results of the focused trauma evaluation. The most important radiographs include chest, pelvis, and c-spine.
Treat and re-evaluate life threats. If the patient does not respond appropriately to the treatments provided or shows deterioration, return to the initial survey.
If patient is to be transferred emergently, do not attempt to investigate and treat each and every injury.