listens for the correct tube placement on an
intubated trauma victim during a
search and rescue exercise
Pre-hospital The pre-hospital use of
stabilization techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a
trauma center as well as provide primary stabilization by checking and treating
airway, breathing, and circulation as well as assessing for disability and gaining exposure to check for other injuries.
Spinal motion restriction by securing the neck with a
cervical collar and placing the person on a
long spine board was of high importance in the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favor. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to indicate the need of these adjuncts. This may be accomplished with other medical transport devices, such as a
Kendrick extrication device, before moving the person. It is important to quickly control severe bleeding with direct pressure to the wound and consider the use of
hemostatic agents or
tourniquets if the bleeding continues. Conditions such as impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear, however, if this is best performed before reaching hospital or in the hospital. Rapid transportation of severely injured patients improves the outcome in trauma. Before arrival at the hospital, the availability of
advanced life support does not greatly improve the outcome for major trauma when compared to the administration of
basic life support. Evidence is inconclusive in determining support for pre-hospital
intravenous fluid resuscitation while some evidence has found it may be harmful. Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them, Improvements in pre-hospital care have led to "unexpected survivors", where patients survive trauma when they would have previously been expected to die. However these patients may struggle to rehabilitate.
In-hospital Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status. These steps may happen simultaneously or depend on the most pressing concern such as a
tension pneumothorax or major arterial bleed. The primary survey generally includes assessment of the cervical spine, though
clearing it is often not possible until after imaging, or the person has improved. After immediate life threats are controlled, a person is either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey is performed that is a more detailed head-to-toe assessment of the person. Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure. Examples of these indications include penetrating neck trauma, expanding neck hematoma, and being unconscious. In general, the method of intubation used is
rapid sequence intubation followed by ventilation, though intubating in shock due to bleeding can lead to arrest, and should be done after some resuscitation whenever possible. Trauma resuscitation includes control of active bleeding. When a person is first brought in, vital signs are checked, an
ECG is performed, and, if needed, vascular access is obtained. Other tests should be performed to get a baseline measurement of their current blood chemistry, such as an
arterial blood gas or
thromboelastography. In those with
cardiac arrest due to trauma chest compressions are considered futile, but still recommended. Correcting the underlying cause such as a
pneumothorax or
pericardial tamponade, if present, may help.
Intravenous fluids Traditionally, high-volume
intravenous fluids were given to people who had poor perfusion due to trauma. In general, however, giving lots of fluids appears to increase the risk of death. Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. or the re-establishment of peripheral pulses and adequate ability to think. As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed
Lactated Ringer's solution continues to be the solution of choice. If blood products are needed, a greater use of
fresh frozen plasma and
platelets instead of only
packed red blood cells has been found to improve survival and lower overall blood product use; a ratio of 1:1:1 is recommended.
Cell salvage and autotransfusion also may be used. These products are only available for general use in South Africa and Russia. It only appears to be beneficial, however, if administered within the first three hours after trauma. For severe bleeding, for example from
bleeding disorders,
recombinant factor VIIaa protein that assists blood clottingmay be appropriate. In those without previous factor VII deficiency, its use is not recommended outside of trial situations. Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury. Therefore, as of 2012 they have not been recommended.
Surgery The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur.
Damage control surgery is used to manage severe trauma in which there is a
cycle of
metabolic acidosis,
hypothermia, and
hypotension that may lead to death, if not corrected. ==Prognosis==