Makindo Medical Notes

Trauma is the leading cause of death in the Western world for people aged 1–44. Globally, >5.8 million people die annually due to severe trauma. Massive bleeding and trauma-induced coagulopathy remain a major challenge. Key principle: Treat first what kills first.

📊 About

• Accounts for ~37% of ED visits
• Common causes of trauma death: motor vehicles, homicide, falls
• Organised trauma systems significantly improve outcomes
• Retention of ATLS principles is essential

📝 Causes

• Motor vehicle collisions
• Falls, burns, drowning, machinery accidents, electrocution
• Assaults with weapons (knives, guns, blunt trauma)
• Natural disasters: earthquakes, floods, avalanches, tsunamis
• Warfare injuries

🚨 Trauma Team Activation Criteria

• SBP < 90 mmHg
• RR <10 or >30 /min
• GCS < 12 with torso/extremity trauma
• Pregnancy >20 weeks with abnormal foetal HR
• Proximal amputations, ≥2 long-bone fractures
• Airway compromise, spinal cord injury, severe burns (>15% TBSA)
• Gunshot or penetrating trauma to chest/abdomen/neck/groin
• Falls >6m, ejection from vehicle, pedestrian struck
• ED clinician concern (“gut feeling” rule)

👥 Trauma Team

Led by an ED Consultant, the leader coordinates but does not touch the patient. Goal: identify and manage life threats within ~30 minutes.

• Team Leader
• Anaesthetist + ODP
• Primary survey doctor
• Nurses (ideally 2)
• Procedures doctor
• Scribe
• IV/bloods nurse
• Porter, family liaison

📉 Trimodal Distribution of Deaths

• Seconds–minutes: Major CNS or airway/vascular injury (often unsurvivable)
• Minutes–hours: Major head/chest/abdominal/pelvic injury, exsanguination (“golden hour”)
• Days–weeks: Sepsis, MODS in ICU

Note: Now thought of more as a continuum than rigid phases.

🩺 Primary Survey – CABCDE

• C – Catastrophic haemorrhage: control bleeding (direct pressure, tourniquet, haemostatic dressings)
• A – Airway + C-spine: suction, airway adjuncts, intubate if GCS <9 or airway threatened; avoid head-tilt if trauma
• B – Breathing: oxygen, exclude PTX/HTX, flail chest; use BVM or intubate if hypoventilating
• C – Circulation: control haemorrhage, 2x large-bore IV access, crossmatch, balanced resuscitation (early blood & TXA), avoid >1L crystalloid
• D – Disability: GCS/AVPU, pupils, check glucose; CT head if concern
• E – Exposure/Environment: fully examine, prevent hypothermia

🫁 Immediate Life-Threatening Causes to Exclude (“HOTTT-C”)

• Haemorrhage (external or internal)
• Obstructed airway
• Tension pneumothorax
• Tamponade (cardiac)
• Thoracic trauma (open PTX, flail chest)
• Coma / brain injury

🫀 Indications for Intubation (“4 Ps”)

• Poor ventilations / apnoea
• Protection of airway from aspiration
• Pending obstruction (burns, swelling)
• Persisting hypoxia

📸 Trauma Imaging

• Unstable: eFAST → theatre
• Stable: CT traumogram if suspicion of solid organ/pelvic injury
• IR (interventional radiology) considered for pelvic/liver/spleen bleeds

🚑 Pre-Transfer Checks (“SAFE”)

• Safe: ABCDE stable in last 5 minutes?
• Airway secure? Enough sedation if intubated?
• Functioning kit: oxygen, monitoring, ventilator battery
• Escort: staff, route cleared, destination informed

🔑 Exam Pearls

• Trauma leader = hands off
• TXA within 3h of major bleed reduces mortality
• Nasopharyngeal airway contraindicated in base of skull fracture
• Permissive hypotension until haemorrhage control (penetrating trauma)
• Always think “treat first what kills first”