In emergency medicine, major trauma (MT) refers to one or more severe injuries that pose an immediate threat to life. These cases demand fast, structured assessment and action, often beginning at the roadside and continuing through hospital resuscitation. This article breaks down the ABCDE approach to trauma, the types of injuries involved, early warning signs, timing of deaths, and essential management steps, particularly suited for MBBS students, NEET PG aspirants, and junior doctors.
What is Major Trauma?
Definition: Major trauma refers to injury or injuries severe enough to pose a life threat, commonly resulting from accidents like road traffic collisions, falls, or violent incidents.
Common Causes of Major Trauma:
- Road traffic accidents (RTA)
- Falls from height
- Blunt force trauma (e.g., sports injuries, assault)
- Penetrating injuries (e.g., stab, gunshot)
ABCDE Approach to Major Trauma Management
Trauma resuscitation follows a structured, stepwise approach known as ABCDE, which stands for:
- Airway
- Breathing
- Circulation
- Disability (neurological status)
- Exposure (full-body examination)
Let’s look at each step in detail.
A – Airway with Cervical Spine Control
The first priority is to ensure that the airway is open and protected. Assume all trauma patients have cervical spine injury until proven otherwise.
Signs of Airway Compromise:
- Stridor
- Gurgling or snoring sounds
- Tracheal tug
- Accessory muscle use
- Intercostal recession
- Hypoxia signs: cyanosis, obtundation
Management:
- Manual in-line stabilization
- Jaw thrust for unconscious patients
- Suction to clear obstructions (blood, vomitus)
- Oropharyngeal/Nasopharyngeal airway
- Endotracheal intubation if apnoeic or GCS ≤8
- Emergency cricothyroidotomy in facial trauma/laryngeal disruption
B – Breathing and Ventilation
After the airway, check the respiratory status. Look, listen, and feel. Evaluate rate, rhythm, symmetry, and effort.
Life-threatening conditions:
1. Tension Pneumothorax
- Distended neck veins
- Tracheal deviation (away from affected side)
- Hyperresonant chest
- Decreased breath sounds
- Hypotension, tachycardia
- Treatment: Immediate needle decompression → chest drain thoracostomy
2. Large Haemothorax
- Decreased breath sounds (no BS)
- Dull percussion note
- Tracheal deviation
- Displaced apex beat
- Treatment: Chest drain; may require thoracotomy
3. Flail Chest
- Multiple rib fractures → paradoxical chest wall movement
- Cyanosis, tachypnoea
- Treatment: High-flow oxygen, mechanical ventilation if hypoxia persists
C – Circulation with Hemorrhage Control
Assess:
- Heart rate, blood pressure
- Jugular venous pressure
- Peripheral perfusion
- Signs of blood loss (cool extremities, pale skin)
Life-threatening circulatory issues:
1. Cardiac Tamponade
- Distended neck veins
- Muffled heart sounds
- Pulsus paradoxus
- Hypotension, tachycardia
- Treatment: Pericardiocentesis → thoracotomy
2. Aortic Rupture
- Chest X-ray: widened mediastinum, tracheal deviation
- Pleural capping, loss of aortic-pulmonary window
- Treatment: Urgent surgical repair via sternotomy
3. Cardiac Contusion
- Irregular ECG: AF, VEs, ST changes
- Hypotension, tachycardia
- Treatment: Supportive monitoring
Immediate Actions:
- Insert 2 large-bore IV cannulas
- Give warmed IV fluids (e.g., Hartmann’s or blood products)
- Draw blood for crossmatch, FBC, U&E
- Insert urinary catheter
D – Disability (Neurological Status)
Quick Neurological Check:
- GCS Score (Glasgow Coma Scale)
- Pupil response
- Limb movement and tone
- Lateralizing signs
If GCS ≤ 8:
- Intubate and ventilate
- CT head once stabilized
E – Exposure and Environment Control
Full Body Examination:
Strip the patient completely (prevent hypothermia)
Look for:
- Bruises
- Deformities
- Lacerations
- Open fractures
Prevent Hypothermia:
- Use warm blankets
- Warm IV fluids
- Keep room warm
Timing of Death Following Trauma
Understanding the "Three Peaks of Death" helps prioritize trauma care:
- 1st Peak: Seconds to minutes – e.g., brain injury, aortic rupture
- 2nd Peak: Minutes to hours – treatable with rapid intervention (e.g., chest drain)
- 3rd Peak: Days to weeks – due to sepsis, organ failure
Principles of Management
First Aid (Pre-Hospital Care)
- Stabilize C-spine
- Apply direct pressure to bleeding
- Rapid extraction and oxygen
Primary Survey (Hospital)
- ABCDE approach
- Identify and treat life-threatening conditions immediately
- Re-assess continuously
Secondary Survey
- Head-to-toe examination
- Take history (AMPLE)
- Imaging: CXR, pelvic X-ray, FAST scan
Definitive Treatment
- Surgery (if needed)
- ICU care
- Rehabilitation
Patterns of Injury
| Mechanism | Common Injuries |
|---|---|
| Restrained RTA | C-spine, sternum fracture, cardiac contusion, liver injury |
| Pedestrian Collision | Tibial/femoral fractures, head injury, knee ligament injuries |
Key Points Recap
- Treat all MT patients as having unstable C-spine.
- Airway is always priority.
- Start IV fluids early; monitor vitals.
- Chest injuries (e.g., pneumothorax) are often overlooked but treatable.
- Secondary survey is crucial; missed injuries lead to late mortality.
FAQs About Major Trauma
What is the most important step in trauma management?
The ABCDE primary survey is the most critical. Airway always comes first.
What are the signs of tension pneumothorax?
- Tracheal deviation
- Distended neck veins
- Absent breath sounds
When is cricothyroidotomy indicated?
In maxillofacial trauma or failure to intubate due to laryngeal disruption.
What is Beck's Triad?
Classic signs of cardiac tamponade:
- Hypotension
- Muffled heart sounds
- JVD (jugular venous distension)
Conclusion
Major trauma is survivable if handled systematically. The ABCDE approach saves lives by prioritizing what matters most: a patent airway, adequate breathing, and stable circulation. For every medical student, intern, or emergency doctor, mastering trauma basics isn't optional—it's essential.
