Major Trauma — Symptoms, Causes & Treatment | MyMedicPlus

Major trauma refers to severe injury to one or more body systems causing significant risk of death or disability, typically defined as an Injury Severity Score (ISS) above 15. It is the leading cause of death in individuals aged 1-45 years globally, with 4.4 million annual deaths. Road traffic accidents, falls, violence, and workplace injuries are the main causes. Major trauma is defined as life-threatening injury from external physical force, typically classified by an Injury Severity Score (ISS) above 15. Common mechanisms include road traffic collisions (RTCs — accounting for 50% of major trauma), falls from height (above 2 metres), penetrating injuries (stab wounds, gunshot wounds), crushing injuries, and blast injuries. Major trauma is the leading cause of death in people aged 1-44 globally and the fourth leading cause of death overall. Polytrauma — significant injury to multiple body systems simultaneously — is the rule rather than the exception in major trauma. Primary survey follows the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure) per ATLS (Advanced Trauma Life Support) guidelines.

Road traffic accidents account for 29% of injury deaths globally. Falls are the leading cause in elderly patients and occupational settings. Penetrating injuries from firearms or stabbings are predominant in urban violence. Risk factors include male sex, age 15-45, alcohol and drug use, high-risk occupational exposure, and lack of protective equipment or seatbelts. Road traffic collisions generate high-energy deceleration injuries causing traumatic brain injury (TBI), thoracic injuries (aortic tears, pneumothorax, haemothorax), solid organ injuries (liver, spleen), and pelvic/long bone fractures. Falls from height cause spinal injuries, pelvic ring disruption, and lower extremity fractures. Blast injuries from improvised explosive devices cause penetrating injuries from fragmentation, primary blast wave injuries to air-filled organs (lungs, middle ear, bowel), and blunt force trauma from blast displacement. Sporting accidents — particularly equestrian sports, motor sports, and contact sports — generate TBI, spinal cord injuries, and thoracic trauma. Specific risk factors include non-use of seatbelts (5-8x increased injury severity in RTCs), motorcycle riding without a helmet (6x fatal head injury risk), alcohol and drug intoxication (present in 30-50% of trauma victims), and elderly patients with falls (bone fragility increases fracture and intracranial haemorrhage risk from low-energy mechanisms).

Presentations vary by injury mechanism. Hemorrhagic shock causes hypotension, tachycardia, pallor, and altered consciousness. Tension pneumothorax causes respiratory distress, absent breath sounds, and tracheal deviation. Traumatic brain injury presents with loss of consciousness, confusion, and focal neurological deficits. Abdominal trauma may show distension and peritonism. Clinical presentation varies by injury mechanism and anatomical region affected. TBI signs: reduced GCS (below 14 = moderate TBI; below 9 = severe TBI), focal neurological deficits, Cushing's triad (hypertension, bradycardia, irregular respiration — raised ICP), and pupillary abnormalities (fixed and dilated = uncal herniation — emergency). Haemodynamic instability (systolic BP below 90 mmHg, HR above 120 bpm, cold peripheries) indicates significant haemorrhage — internal bleeding may not be externally visible. Tension pneumothorax causes absent ipsilateral breath sounds, tracheal deviation, and cardiovascular collapse. External signs of fractures — deformity, swelling, crepitus — and open wounds indicating penetrating injury. Priapism or neurogenic shock (bradycardia with hypotension despite obvious haemorrhage) suggests spinal cord injury.

ATLS (Advanced Trauma Life Support) primary survey (ABCDE) assesses and treats life-threatening problems simultaneously. FAST (Focused Assessment with Sonography for Trauma) rapidly screens for intraperitoneal bleeding. CT scan of head, chest, abdomen, and pelvis (trauma pan-scan) provides definitive injury identification. Blood tests include FBC, coagulation, cross-match, and lactate. Trauma CT (whole-body CT — 'trauma scan' or CT from skull base to symphysis pubis) is the definitive imaging in haemodynamically stable major trauma — identifying TBI (haemorrhage, oedema, herniation), cervical spine injury, thoracic injuries (pneumothorax, haemothorax, aortic tear), solid organ injuries (liver, spleen, kidney), pelvic fractures, and bowel perforation. FAST ultrasound (Focused Assessment with Sonography in Trauma) rapidly detects intraperitoneal free fluid (haemoperitoneum), haemopericardium, and pneumothorax in the trauma bay — takes less than 2 minutes and guides immediate decisions. Blood investigations: FBC, cross-match, coagulation screen (PT, APTT, fibrinogen), ABG, lactate (above 4 mmol/L indicates class III-IV haemorrhage), and troponin (myocardial contusion). Trauma score/ISS calculation guides triage and resource allocation.

Hemorrhage control is the immediate priority: direct pressure, tourniquets, and pelvic binders in the field; surgical hemostasis in the operating room. Damage control surgery (DCS) controls bleeding and contamination without definitive repair. Permissive hypotension (MAP 50-65 mmHg) and massive transfusion protocol (1:1:1 ratio of RBC:FFP:platelets) minimize coagulopathy. TBI requires ICP monitoring and neurosurgical intervention. Damage control resuscitation (DCR): 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets (massive haemorrhage protocol) avoids dilutional coagulopathy; tranexamic acid (1 g IV within 3 hours of injury — reduces haemorrhage mortality by 30%); permissive hypotension (systolic BP 80-90 mmHg) to minimise further haemorrhage until surgical haemostasis. Damage control surgery prioritises haemostasis and contamination control over definitive repair — temporary measures (packing, vascular shunts) allow resuscitation before definitive repair 24-48 hours later. Airway management: early definitive airway (RSI with cricoid pressure, or surgical airway if intubation fails) prevents hypoxia-driven secondary brain injury. Neurological emergencies: TBI with raised ICP requires neurosurgical consultation — decompressive craniectomy for refractory raised ICP; spinal immobilisation until C-spine clearance; emergent spinal decompression for cord compression. Orthopaedic damage control: external fixation for unstable pelvic fractures (reduces blood loss), provisional fracture stabilisation before definitive fixation.

Hemorrhagic shock and coagulopathy (lethal triad: hypothermia, acidosis, coagulopathy) cause early deaths. Acute respiratory distress syndrome (ARDS), sepsis, acute kidney injury, venous thromboembolism, fat embolism syndrome, and multi-organ dysfunction syndrome (MODS) are major late complications. Traumatic brain injury survivors may have permanent cognitive and motor deficits. Traumatic coagulopathy (TIC) develops in 25% of major trauma patients from the 'lethal triad' of hypothermia (below 35°C), acidosis (pH below 7.2), and dilutional coagulopathy — all inhibiting clotting enzyme function. ARDS complicates 5-25% of patients from lung injury, transfusion, and systemic inflammation. Abdominal compartment syndrome causes multi-organ failure from elevated intra-abdominal pressure. Sepsis and delayed multi-organ failure — driven by gut bacterial translocation and trauma-induced immunosuppression — are leading causes of delayed death. Fat embolism syndrome from long bone fractures causes hypoxia, confusion, and petechial rash 24-72 hours post-injury. Crush injuries cause rhabdomyolysis with myoglobinuria and acute tubular necrosis — requiring aggressive hydration (target urine output 200-300 mL/hour) and urinary alkalinisation to prevent acute kidney injury. Compartment syndrome in limb injuries requires emergency fasciotomy within 4-6 hours of pressure elevation to prevent permanent nerve and muscle damage.

Road safety measures include seatbelt use, helmet wearing, and anti-drunk driving enforcement. Fall prevention programs in elderly patients, occupational safety regulations, and violence prevention initiatives are key public health strategies. Rehabilitation is essential for functional recovery: physiotherapy, occupational therapy, neuropsychological support, and prosthetic fitting if needed. Population-level trauma prevention strategies have substantially reduced mortality. Road safety measures — mandatory seatbelt use (reduces mortality 45%), helmet laws for motorcyclists (reduces head injury by 70%), blood alcohol limits with breath testing enforcement, speed limits, and vehicle safety standards (airbags, crumple zones) — represent the most effective interventions. Workplace safety regulations for construction and industrial workers significantly reduce occupational major trauma. Falls prevention in the elderly: home hazard assessment and modification, hip protectors for high-fall-risk individuals, balance and strength training programmes (reducing fall incidence by 30%), and optimising vitamin D, calcium, and osteoporosis treatment. Sports injury prevention: rule enforcement (prohibit dangerous tackling techniques), protective equipment standards, and pitch surface standards.

Call emergency services (999 or 911) immediately after any high-energy mechanism: road traffic accident at speed; fall from height above 1 metre or 5 stairs; penetrating injury to the head, neck, chest, or abdomen; blast or explosion injury; or any injury causing loss of consciousness. Do not attempt to move a trauma victim with a possible spinal injury — stabilize the head and neck and await paramedics. After hospital discharge following major trauma, return to A&E urgently for: worsening headache, vomiting, increasing drowsiness, or one pupil larger than the other (signs of intracranial bleeding even after an initial clear CT); new shortness of breath or chest pain (pulmonary embolism — risk elevated for weeks after trauma); wound infection signs (increasing redness, heat, pus, fever). Book GP or specialist follow-up within 2–4 weeks for: ongoing pain, functional limitation, PTSD symptoms (nightmares, flashbacks, avoidance behaviour) — early psychological intervention after major trauma significantly improves long-term outcomes. Traumatic brain injury survivors should be assessed by a neuropsychologist — cognitive symptoms (memory, concentration, fatigue) may persist months after physical recovery and respond to targeted rehabilitation.