Major Trauma — Assessment, ATLS, Damage Control & Trauma Care Guide — Symptoms, Causes & Treatment | MyMedicPlus

Major trauma is defined as a physical injury of sufficient severity to potentially threaten life or limb, typically reflected by an Injury Severity Score (ISS) greater than 15. It encompasses blunt trauma (road traffic collisions — the most common cause globally; falls from height; crush injuries; sports injuries); penetrating trauma (stab wounds, gunshot wounds — predominant in North America and urban conflict zones); and blast injuries from explosions (military conflicts, terrorist attacks). Major trauma is the leading cause of death in people under 45 globally, accounting for approximately 4.4 million deaths annually. Critically, traumatic deaths follow a trimodal distribution: immediate (at scene — unrecoverable injuries); early (within hours — haemorrhage and raised intracranial pressure — the most preventable causes); and late (days to weeks — sepsis, multi-organ failure — preventable with modern trauma care). Trauma systems — including pre-hospital care, trauma team activation, designated Major Trauma Centres (MTCs), and specialist rehabilitation — have significantly reduced mortality.

Mechanism and injury patterns: Road Traffic Collisions (RTCs) are the global leading cause of major trauma, killing 1.35 million annually. Head-on collisions cause high-energy transfer injuries — aortic transection, thoracic injuries, and long bone fractures. Motorcycle collisions disproportionately cause severe injuries due to lack of protection. Falls from height: second most common globally; in the elderly, even low-height falls (from standing) can cause significant injury due to osteoporosis and anticoagulant use. Penetrating injuries: stab wounds cause injury along the wound tract; gunshot wounds cause cavitation injury extending beyond the wound tract. Specific injury patterns by mechanism: high-energy frontal collision — steering wheel aortic injury, patella fractures, posterior hip dislocation; lateral collision — liver and spleen lacerations; rear-end collision — cervical spine whiplash; fall from height — calcaneal fractures, vertebral compression fractures, pelvic ring fractures. Risk factors for major trauma: male sex (3:1 male:female ratio), age 15-44 (peak), alcohol and illicit drug use (major contributor to RTCs and falls), occupational exposure, and pre-existing anticoagulant therapy (significantly worsens bleeding outcomes).

Life-threatening conditions to identify in primary survey: airway obstruction (stridor, inability to vocalise, paradoxical breathing, noisy breathing); tension pneumothorax (absent breath sounds on one side, tracheal deviation, distended neck veins, hypotension — rapidly fatal if not immediately decompressed); massive haemothorax (dullness to percussion, absent breath sounds — blood filling the chest); flail chest and open pneumothorax; massive haemorrhage (pallor, tachycardia, hypotension, reduced consciousness from haemorrhagic shock); cardiac tamponade (Beck's triad: muffled heart sounds, distended neck veins, hypotension); and critical head injury (altered consciousness — Glasgow Coma Scale below 9, unequal pupils). Signs of severe internal bleeding: tachycardia above 120 bpm, systolic BP below 90 mmHg, cool clammy skin, altered mental status, prolonged capillary refill. Shock Index (HR/SBP) above 1.0 indicates haemorrhagic shock requiring immediate blood transfusion.

Advanced Trauma Life Support (ATLS) systematic approach — Primary Survey (ABCDE): A (Airway with cervical spine control), B (Breathing and ventilation), C (Circulation and haemorrhage control), D (Disability — neurological status: GCS and pupils), E (Exposure and environment — fully expose the patient, prevent hypothermia). FAST ultrasound (Focused Assessment with Sonography in Trauma): bedside ultrasound detecting free fluid (haemoperitoneum) in pericardial, perihepatic, perisplenic, and pelvic windows — performed within 90 seconds, identifies occult haemorrhage. X-ray (chest and pelvis in trauma bay): identifies pneumothorax, haemothorax, rib fractures, and pelvic ring disruption. CT trauma survey ('Pan-scan' — whole-body CT from vertex to thighs with IV contrast): performed after initial stabilisation in haemodynamically stable patients — the most important diagnostic study for identifying all injuries and planning operative management. Injury Severity Score (ISS) is calculated from the six anatomical regions — values above 25 predict significant mortality. Blood tests: FBC, coagulation screen (aPTT, PT, fibrinogen), blood gas (pH, base excess, lactate — guide resuscitation adequacy), massive haemorrhage protocol activation criteria.

Haemorrhage control is the first priority — the leading preventable cause of early traumatic death. External haemorrhage: direct pressure, wound packing with haemostatic gauze (Combat Gauze, Celox), tourniquet application (proximal to limb wound — within 2 minutes of wounding ideally). Damage control resuscitation (DCR): 1:1:1 ratio of packed red blood cells, fresh frozen plasma (FFP), and platelets — permissive hypotension (target SBP 80-90 mmHg in penetrating trauma without head injury); tranexamic acid (TXA) within 3 hours of injury (CRASH-2 trial: 1 g IV over 10 minutes then 1 g over 8 hours — reduces mortality by 15%). Damage control surgery (DCS): abbreviated surgery to control haemorrhage and contamination without definitive repair — temporary packing and closure, return for definitive reconstruction when the patient is physioloically stable ('lethal triad' of hypothermia below 35°C, acidosis pH below 7.2, and coagulopathy — the triad must be corrected before definitive surgery). Traumatic brain injury (TBI): maintain intracranial perfusion (ICP below 22 mmHg, CPP above 60 mmHg); neurosurgical evacuation of haematomas when indicated; decompressive craniectomy for refractory raised ICP. Pelvic ring fracture with haemorrhage: pelvic binder/sheet to reduce fracture volume, REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) in extremis, or emergency angioembolisation. Spinal cord injury: methylprednisolone is no longer recommended routinely; maintain spinal alignment; early surgical decompression (within 24 hours) for incomplete injuries.

Major trauma causes a spectrum of immediate and delayed complications. Haemorrhagic shock is the leading early complication and cause of preventable death — from uncontrolled internal bleeding from solid organ injuries, pelvic fractures, or thoracic aortic injury. The 'lethal triad' of coagulopathy, hypothermia, and acidosis dramatically worsens haemorrhage mortality and must be reversed before definitive surgery. Traumatic brain injury (TBI) — affecting 40% of major trauma patients — causes primary axonal injury and secondary injury from raised intracranial pressure, hypoxia, and hypotension; severe TBI carries 30% mortality with up to 50% of survivors experiencing permanent neurological deficits. Acute Respiratory Distress Syndrome (ARDS) from pulmonary contusion, massive transfusion, or systemic inflammatory response develops in 5-20% of major trauma patients. Acute kidney injury from haemorrhagic shock and myoglobinuria (rhabdomyolysis from crush injury) is common and may require dialysis. Infection and sepsis: impaired immunity, contaminated wounds, aspiration pneumonia, and catheter infections significantly increase infectious morbidity. Venous thromboembolism (DVT and pulmonary embolism) is a major risk in immobilised trauma patients — prophylaxis must begin early. Long-term complications: chronic pain, post-traumatic stress disorder (PTSD — affecting up to 30% of survivors), physical disability requiring rehabilitation, and cognitive impairment from TBI.

Road safety interventions have the greatest impact: legislation for seatbelt use, helmet use for motorcyclists and cyclists, speed limits, drink-driving laws, and road design improvements. In high-income countries, road trauma deaths have fallen 50-70% since the 1970s through these measures. Workplace safety: falls from height are the leading cause of construction fatalities — fall arrest systems, guardrails, and safety training are mandatory. Domestic fall prevention in the elderly: remove trip hazards, improve lighting, install grab rails, ensure medication review (particularly sedatives and antihypertensives), and provide exercise programmes targeting balance and strength (tai chi). Bystander training: learning Bleeding Control (B-CON) techniques — tourniquet application, wound packing, and pressure — saves lives before EMS arrival. 'Stop the Bleed' and similar community training programmes are saving lives.

Call emergency services (999/112/911) immediately for any significant mechanism of injury — do not self-transport. Immediate emergency indicators include: loss of consciousness (even briefly); confusion or altered behaviour after any head injury; visible deformity of limbs; inability to weight-bear; chest pain or difficulty breathing after chest trauma; abdominal pain or distension after abdominal trauma; blood in urine after any significant abdominal or renal trauma; or any penetrating injury. After a seemingly minor trauma: seek medical assessment within 24 hours if you develop worsening headache, repeated vomiting, increasing confusion, weakness or numbness in any limb, or any new bleeding. Children and elderly patients with any significant mechanism of injury should be assessed by a healthcare provider regardless of apparent severity — they can appear deceptively well despite significant internal injury.