Primary survey key principles

• Use simple dressings with direct pressure to control external haemorrhage.
• In patients with major limb trauma use a tourniquet if direct pressure has failed to control haemorrhage.
• It may be appropriate to use a tourniquet first line in some situations.  A second tourniquet is sometimes required.  Check the tourniquet after patient movement and consider replacing with a pneumatic tourniquet following resuscitation.

• Perform CXR and/or eFAST in all patients with haemodynamic instability or severe respiratory compromise.
• Decompress the chest using an open thoracostomy followed by intercostals chest drain insertion. 
• Perform immediate CT in other patient with significant chest injury.
• Open pneumothorax -> Apply chest seal and then insert chest drain
• Massive haemothorax -> Insert chest drain and monitor output. May require theatre if large output
• Flail chest and respiratory distress -> consider intubation and ventilation for ventilator failure

• Look for the ‘Hateful Eight’ signs of exsanguinating haemorrhage to help identify patients likely to be in haemorrhagic shock. These signs are an expert-based clinical tool, not a validated scoring system
  • Pale
  • Clammy
  • ‘Air Hunger’
  • Venous collapse
  • Hypotension (low volume or absent peripheral pulses)
  • Low/falling ETCO2
  • Tachycardia or relative bradycardia
  • Altered mentation
• Stop the bleeding
  • External: as above
  • Internal: Damage control surgery, interventional radiology or other definitive interventions
• Vascular access
  • Two large bore IV lines are first-line
  • If IV is difficult or time-critical, place an intraosseous line.
  • Central access (e.g. subclavian, femoral) may be needed
• Haemorrhage control is the priority.  Titrate volume to a central pulse.
• Permissive hypotension
  • For penetrating torso trauma, consider keeping SBP ~80-90 mmHg until bleeding is controlled
  • Avoid if TBI is the priority or if the hypotensive period exceeds ~ 1hour
  • No permissive hypotension in paediatrics
• Fluids & Blood products
  • Minimise crystalloids; favour balanced blood product transfusion
  • Start with a fixed-ratio protocol for blood components and change to lab/ROTEM/VBG guided once available
  • TXA as per local guidance
  • Keep the patient warm. Use under-patient bair hugger for enhanced and code red trauma calls. Ensure fluids or blood are warmed with Ranger or Belmont.
• Vasopressers?
  • Generally avoid in haemorrhagic shock, as they do not address the root cause (blood loss) and may reduce organ perfusion
  • Exceptions include:
    • Neurogenic shock with bradycardia and vasodilatation
    • Cardiogenic or mixed shock states
    • TBI where maintaining a higher MAP is crucial for cerebral perfusion, but only after haemorrhage control is underway
• Imaging
  • Limit imaging to CXR, Pelvis XR and FAST in patients not adequately responding to volume to direct early surgical intervention.
  • A negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.
  • Use immediate CT in haemodynamically normal patients/volume responders

Bleeding mimics

Not all hypotension or shock in trauma stems purely from haemorrhage. Common mimics include:

• Tension pneumothorax
• Cardiac tamponade
• Neurogenic shock
• Cardiogenic shock

Tranexamic Acid (TXA)

The following adults should receive 1g TXA *

• • At risk of bleeding or with confirmed bleeding and a HR >110 and/or SBP <90mmHg
  • GCS<13 with evidence of a head injury 
• Give a further 1g bolus if there is:
  • bleeding requiring ongoing resuscitation and/or haemorrhage control
  • confirmed intracranial haemorrhage in patients with GCS <13
  • hyperfibrinolysis on viscoelastic studies

*Do not give first dose of TXA >3hours from injury unless evidence of hyperfibrinolysis. 

The maximum total dose is 2g. 

Where all criteria are met it may be appropriate to administer a 2g bolus

Disability 

• Use intravenous morphine 1st line (5mg aliquots, reduced in elderly).
• Use intravenous ketamine 2nd line (0.2-0.5mg/kg).
• Consider intranasal ketamine if IV access not established (0.7mg/kg).
• Correct hypoglycaemia

Environment

• Fully undress but prevent hypothermia
• Use fluid warming devices, warm blankets and a BAIR HUGGER in all major trauma patients where haemorrhage is suspected or proven.
• Hypothermia -> coagulopathy -> worsened bleeding