Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina

🚑 Introduction

• Pre-hospital trauma care is a rapidly developing specialty, combining clinical skills with rescue safety principles.
• ⚠️ Safety first: Rescuer safety always precedes patient care.
• Framework: MARCH (Massive haemorrhage → Airway → Respiration → Circulation → Head/Disability).

🚨 Arrival at the Scene

• 🚗 Position vehicle to protect the scene & warn other traffic (beacons/lights).
• 👷‍♂️ Safe exit & hazard check before approaching patient.
• 🦺 PPE: fire-retardant overalls, boots with toecaps, gloves, helmet, and eye protection.
• 🔥 Liaise with fire service to make the scene safe before patient contact.
• 🔍 "Read the wreckage": mechanism of injury predicts likely trauma pattern.
• 📡 Early communication → mobilises resources faster.
• 🚻 Triage if multiple casualties: prioritise based on physiology and survivability.
• 🚒 Fire service may be needed for access/extrication planning.

🌟 Exam Pearl: In major incidents, use Sieve & Sort triage. Immediate priority = airway obstruction, catastrophic haemorrhage, or compromised breathing.

🩸 Primary Survey – MARCH

• M = Massive Haemorrhage
  • Direct pressure → elevation → indirect pressure → wound packing → tourniquet → haemostatic agents.
  • Chest/abdominal bleeding ➝ rapid transfer to hospital (prehospital control not possible).
• A = Airway + C-spine
  • Manual in-line stabilisation (jaw thrust, avoid head tilt/chin lift).
  • Adjuncts: oropharyngeal/nasopharyngeal airway, supraglottic device if trained.
  • Definitive: Intubation if feasible.
  • Rescue: Surgical airway (scalpel–bougie–tube or Melker kit) if unable to ventilate.
• R = Respiration
  • High-flow O₂ as soon as safe.
  • Seal open/sucking chest wounds.
  • Needle decompression (2nd ICS mid-clavicular or 5th ICS anterior axillary) → chest drain.
  • Reassess RR, SaO₂, trachea, percussion note, chest expansion.
• C = Circulation
  • IV/IO access (do not delay transfer for IV attempts).
  • Permissive hypotension: Titrate fluids to palpable radial pulse (or carotid in chest trauma).
  • 250ml boluses isotonic saline if shocked. Prefer blood products if available (MHP).
  • Target higher BP if head injury (maintain CPP).
• H = Head / Disability
  • Assume C-spine injury until excluded → collar + blocks + tape.
  • Rapidly reverse hypoxia & hypotension.
  • Agitated/unconscious ➝ secure airway, prevent aspiration.
  • Transport urgently to neurosurgical centre.

👥 Trauma Team Activation Criteria

• SBP < 90 mmHg
• RR < 10 or > 30
• GCS < 12 with torso/extremity trauma
• Pregnant > 20 weeks with abnormal foetal HR
• Amputation proximal to elbow/knee
• ≥2 proximal long bone fractures
• Suspected spinal cord injury
• Severe airway-compromising maxillofacial trauma
• Burns > 15% TBSA
• Gunshot proximal to knee/elbow or trunk/head/neck
• Ejection from vehicle / pedestrian thrown
• Fall > 6 m
• ≥3 major trauma patients arriving simultaneously
• Or: Emergency doctor judgement

📝 Key Principle: In trauma, fix what kills first. Control haemorrhage, oxygenate, decompress chest, then stabilise for transfer. Definitive care is in hospital.