Trauma
What to know
Trauma items follow the primary survey: catastrophic hemorrhage control, airway with cervical spine protection, breathing, circulation, disability, and exposure. Hypotension after trauma is hemorrhage until proven otherwise. Stop external bleeding with direct pressure or a tourniquet, and apply a pelvic binder for suspected pelvic fracture. Tension pneumothorax is a clinical diagnosis treated with needle decompression before chest tube placement. FAST identifies free fluid; an unstable patient with a positive FAST goes to the operating room, not the CT scanner. Balanced resuscitation uses blood products in roughly a 1:1:1 ratio with limited crystalloid, plus tranexamic acid within three hours for significant bleeding. Permissive hypotension is acceptable until hemorrhage control. Prevent the lethal triad of hypothermia, acidosis, and coagulopathy.
Traps
Do not remove impaled objects. Large crystalloid boluses dilute clotting factors. A normal blood pressure does not exclude significant loss in a young patient, and beta-blocked older adults may not mount tachycardia. Repeated pelvic examinations can dislodge clots. Assume spinal injury with high-risk mechanisms.
Worked example
A motorcyclist with a pelvic fracture has a blood pressure of 78/40 and a positive FAST. Apply the pelvic binder, activate the massive transfusion protocol, keep the patient warm, and move toward the operating room. Rule of thumb: in trauma, treat shock as blood loss - not as "give a liter and see."