Trauma and Injury Management
The primary survey is a resuscitation, not a checklist
X-ABCDE: control exsanguinating hemorrhage (direct pressure, tourniquet, wound packing, pelvic binder), then airway with cervical spine protection, breathing (breath sounds, oxygenation, needle decompression for tension physiology), circulation (two large-bore IVs, blood products), disability (GCS, pupils, glucose), exposure with active warming. Only after the primary survey and resuscitation do you move to the head-to-toe secondary survey, FAST, and imaging decisions.
Damage-control resuscitation
Blood products, not crystalloid: a balanced 1:1:1 ratio until labs guide component therapy, tranexamic acid within 3 hours of injury, calcium replacement during massive transfusion, and prevention of the lethal triad - hypothermia, acidosis, coagulopathy. In traumatic brain injury, avoid hypotension: keep systolic pressure at or above about 110 mmHg in adults.
Traps
- Hypotension is a late finding in young, healthy adults and in children; a normal blood pressure does not exclude class II–III hemorrhage.
- A negative FAST does not exclude retroperitoneal, hollow-viscus, or pelvic bleeding.
- Older adults on anticoagulants or antiplatelets need reversal and a low threshold for head imaging after apparently minor trauma.
- In pregnancy, resuscitate the mother first, displace the uterus to the left, and remember that fetal distress usually reflects maternal shock.
Rule of thumb
If the mechanism could kill the patient and you have not yet excluded it, treat it: a pelvic binder, a tourniquet, or a chest decompression costs little and buys time.