Trauma and Musculoskeletal Emergencies
Core concepts
Trauma care is the primary survey, repeated: catastrophic hemorrhage control (direct pressure, tourniquet, pelvic binder at the level of the greater trochanters), airway with cervical protection, breathing (breath sounds, chest wall integrity), circulation (two large-bore IVs, type and cross), disability (GCS, pupils, glucose), and exposure with log-roll plus prevention of hypothermia. Hemorrhagic shock triggers massive transfusion in a balanced ratio (approximately 1:1:1), tranexamic acid within 3 hours, and damage-control surgery. Permissive hypotension (SBP 80–90) applies to hemorrhage without traumatic brain injury, while TBI targets SBP ≥110. FAST identifies free fluid; hemodynamically stable patients proceed to CT. Clear the cervical spine using NEXUS or the Canadian C-spine rule - a collar is not a treatment. Extremity emergencies: compartment syndrome (pain with passive stretch, tense compartment, paresthesias - pulses usually persist), knee dislocation with popliteal artery injury, open fractures requiring antibiotics and irrigation, and crush injury with rhabdomyolysis and hyperkalemia.
Traps
Young patients maintain blood pressure until they crash; hypotension means class III hemorrhage or worse. Elderly patients on anticoagulants can bleed fatally from a trivial head strike - image and reverse. Do not miss posterior wounds, axillary or groin lacerations, or a distended abdomen attributed to a seatbelt bruise. Pelvic binders placed at the iliac crests or knees do nothing.
Rule of thumb
Blood hides in five places - chest, abdomen, pelvis/retroperitoneum, long bones, and on the floor. If the patient is unstable and the source is not obvious, look there and act.