A 23-year old male was brought to the emergency department after being run over by a lorry. He would first be managed using the ABCDE approach - securing the airway, restoring breathing and circulation, assessing for injuries, and preventing hypothermia. As an immediate T1 priority requiring life-saving intervention, airway, breathing, and circulation would be restored through resuscitation. Following stabilization, a full examination would be performed while monitoring ABC. Proper triage and hemorrhage control including direct pressure and tourniquets are crucial for trauma management.

1. Assessment of a critically injured

3. Scenario
• A 23yr old male is brought to the Emergency
Department following being run over by a lorry.
• How is he first managed?
• Apparently there are few others people injured in
the accident where a loaded bus has collided with
a lorry and has overturned.
• How would you react to the incident?

4. Triage
What is triage?
Triage is the sorting of patients based on the need
for treatment and the available resources to provide
treatment.
NB. Following major incidents expect an ‘upside
down triage

5. Triage scoring
Physiological variable Value Score
Respiratory rate 10-29
>29
6-9
1-5
4
3
2
1
Systolic blood pressure >90
76-89
50-75
1-49
4
3
2
1
Glasgow Coma Scale 13-15
9-12
6-8
4-5
4
3
2
1
Score 1-10 indicates priority T1,
11 = T2, 12 = T3

6. Triage system
• T1 - requires immediate life-saving intervention
• T2 -Requiring significant intervention within 2-4
hours
• T3 -Requiring intervention but not within 4 hours
• T4 - Treatment at early stage would divert
resources from others with no benefit to casualty

7. Who should be doing the triage?
Trained assistant Surgeon

8. Patient assessed as T1
What do you do next?
Restoration of vital functions
ABC of resuscitation
•Airway with cervical spine control
•Breathing and ventilation
•Circulation with control of haemorrhage

9. Following ABC patient resuscitated and judged to
be stable (T2)
What do you do now?
•Dysfunction
– AVPU
– Glasgow Coma Scale
•Exposure
– Full examination maintaining privacy
NB. Keep an eye on ABC

10. The A-B-C-D approach
A -Airway maintenance with cervical spine protection
B - Breathing and ventilation
C – Circulation with haemorrhage control
D – Disability - Neurological status
E – Exposure (for thorough examination)
Environment control (prevent hypo / hyperthermia)
Remember the principle: Lack of ‘A’ kills quicker than Lack of ‘B’
Lack of ‘B’ kills quicker than Lack of ‘C’
In trauma scenario assessment and intervention proceed side by
side, rather than strictly one before other, as is common in other
areas of clinical medicine

11. Catastrophic Haemorrhage control
Airway - Secure early!
Breathing – Needle thoracentesis +/- chest drain insertion
Circulation - Haemostatic resuscitation & advanced
haemorrhage identification / control
Disability - neuroprotection
Exposure - Keep warm, complete examination

12. Catastrophic haemorrhage <C>
• Catastrophic haemorrhage <C>ABC
• Accounts for >50% of deaths caused by trauma
• Blood on the floor and 4 more
– External bleeding that we can see
– Internal bleeding into:
• Chest
• Abdomen
• Pelvis
• Long bones

13. Preserve rather than replace
• BLOOD ON THE FLOOR
• External haemorrhage
– Extremities/ Limb
– Lacerations to head, chest, abdomen
(internal/non compressible bleeding)

14. • .

15. Haemorrhage control - DDIT
• Direct pressure: expose and firm pressure
• Direct pressure: second dressing, don’t be
tempted to have a look
• Indirect Pressure: proximal artery compression
• Tourniquet: Tighten until bleeding stops (hurts!),
may need 2, only for limbs! Remember to record
time and check.

16. Haemorrhage control - Extremities
• In Vietnam >50% of preventable deaths were due to
blood loss from extremity wounds
• Extremity wounds also common in Iraq/Afghanistan
war and lead to the development of new methods of
controlling blood loss
• Comparatively rare in civilian trauma but can occur
eg. Explosion, RTA

17. Haemorrhage control - DDIT
Pack wound and direct pressure for 3-5 minutes

18. Pelvic fracture compression -Position is the key
Not too high otherwise will
open up fracture, should be
over greater trochanters

19. TENSION PNEUMOTHORAX
One-way-valve mechanism either from lungs or thoracic wall into
pleural cavitycollapse of lung mediastinal shift  compromise
of opposite lung & decreased venous return
• Exclude Any Airway Obstruction
• Needs immediate decompression with a wide bore needle
in the second inter-costal space in the mid-clavicular line of
the affected side (converting into simple pneumothorax).
• One can hardly do any harm by inserting a needle in these
situation even if the diagnoses is incorrect.

20. Abdominal Injury
From management point however it is important to recognise
three clinical types: Haemorrhage group, Peritonitis group and
Mixed group
• In Haemorrhage and Mixed group - patients usually present
with shock due to blood loss. This group of patients after
initial resuscitation require immediate transfer to hospital,
and often surgery is needed to stop intra peritoneal bleeding.
• In peritonitis group- patients initially may have minimal signs
of shock or abdominal signs. However as peritonitis (due to
perforated viscera) progress patient gradually deteriorates. In
this group, unless vigilant, diagnosis can be missed for some
time leading to poorer prognosis.

21. Trauma in children
• Increased physiological reserve of a child allows
maintenance of nearly normal ‘vital signs’ even in
presence of shock.
• This early ‘compensated’ state may mask major loss of
circulatory volume.
• Tachycardia and poor skin perfusion are the keys to
recognising shock.
Hypotension in a child usually represents uncompensated
shock and severe fluid/blood loss.
(Systolic BP of a child is 80mm Hg plus twice the age in years
and diastolic is two-third of the systolic pressure)

22. Trauma in children
• In children approximately a 25% reduction in blood volume is
needed to produce minimal manifestation of shock.
• When shock is suspected, a fluid bolus of 20ml/kg of crystalloid
soln. should be given as initial bolus (represents 25% of normal
blood volume). No improvement may suggest continuing blood
/fluid loss urgent referral for surgery is needed and a second
bolus of 20ml/kg fluid should be given.
• The child’s dulled response to pain with this degree of blood
loss (25%-45% is often indicated by the decreased response
noted when an IV cannula is inserted.
• Due to high ratio of body surface to body mass hypothermia is
common and should be actively prevented.

23. Trauma in pregnancy
• Treatment priorities (ABC of care) for an injured pregnant
patient remains the same as non-pregnant patient but
resuscitation and stabilisation need to be modified to
accommodate the unique anatomic and physiologic changes in
pregnancy.
• Uterine compression of the vena cava reduces venous return
to heart, thereby decreasing cardiac output and aggravating
shock state. Unless a spinal injury is suspected, the pregnant
patient should be managed on her left side. If patient has to
be in a supine position, the right hip should be elevated and
uterus should be displaced manually to the left side to relieve
pressure on the vena cava (Supine position in late pregnancy
may reduce cardiac output by 30%due to vena caval
compression)

24. Trauma in pregnancy
• Because of the increased intra-vascular volume and the
rapid shunting of blood away from fetus, the pregnant
patient can loose up to 35% of her blood volume before
tachycardia, hypotension and other signs of
hypovolaemia occur.
• The fetus may be in shock and deprived of vital perfusion
while the mother appears stable. When a pregnant
woman has recognisable haemorrhagic shock, 80% of
patients have fetal loss.
• Vigorous fluid and blood replacement usually necessary
to prevent maternal as well as fetal hypovolaemic shock.

25. Trauma in pregnancy
• Assess uterine height and tenderness, foetal heart rate
and movements. Watch out for uterine contractions
suggestive of early labour, tetanic contractions with
vaginal bleeding suggesting placental separation. Vaginal
bleeding following trauma in pregnancy often suggests
impending foetal death.
• All patients with vaginal bleeding/ uterine instability,
evidence of hypotension, changes or absence of foetal
heart rate, leakage of amniotic fluid into vagina - require
immediate attention and resuscitation.