Emergency & Toxicology

Initial trauma assessment: ATLS primary and secondary survey

Clinical Overview and When to Suspect Major Trauma

— Physiologic: SBP <90, RR <10 or >29, GCS ≤13, SpO₂ <90%

— Anatomic: penetrating injury to head/neck/torso/proximal extremity, flail chest, ≥2 proximal long-bone fractures, crushed/degloved/mangled/pulseless extremity, amputation proximal to wrist/ankle, pelvic fracture, open/depressed skull fracture, paralysis

— Mechanism: fall >20 ft (adult) or >10 ft or 2–3× height (peds), high-risk MVC (intrusion >12 in, ejection, death in same compartment, auto-pedestrian/bicyclist thrown or run over >20 mph)

— Comorbid: age >55, anticoagulation/bleeding disorder, burns, pregnancy >20 wk, EMS judgment

Board pearl: On Step 3, the correct next step is almost never a CT scan if the primary survey is incomplete — fix airway, breathing, and circulation problems in order before leaving the trauma bay. A hypotensive penetrating-torso patient goes to the OR, not the scanner.

ATLS framework standardizes the initial 0–60 minute resuscitation of injured patients, prioritizing identification and treatment of immediately life-threatening conditions before definitive diagnosis

Sequence: Preparation → Triage → Primary survey (ABCDE) with simultaneous resuscitation → Adjuncts → Reassess → Secondary survey (head-to-toe + AMPLE) → Definitive care

Suspect major trauma and activate trauma team when any of:

Golden hour concept: morbidity/mortality from hemorrhage and hypoxia is time-dependent — every minute of hypotension or hypoxia in TBI roughly doubles mortality

Trimodal death distribution: immediate (seconds–minutes, lethal CNS/cardiac/great vessel — prevention is the only intervention), early (minutes–hours, the ATLS-targeted window — airway loss, tension PTX, hemorrhage), late (days–weeks, sepsis/MOF — ICU-driven)

Team roles assigned before patient arrival: team leader (hands-off), airway MD, two procedure MDs, RN meds, RN documentation, tech for exposure/IV access

Presentation Patterns and Key History

— Mechanism (blunt vs penetrating, energy transfer, restraint use, airbag deployment, helmet, speed, intrusion)

— Injuries identified and interventions performed (tourniquet, needle decompression, intubation, fluids, TXA, blood)

— Vitals trend en route — a falling SBP or rising HR predicts ongoing hemorrhage

— Time of injury (relevant for TXA <3 h window, reperfusion windows, last meal for OR)

— Allergies

— Medications (anticoagulants, antiplatelets, beta-blockers blunting tachycardia, insulin)

— Past medical/surgical history

— Last meal (aspiration risk for intubation/OR)

— Events and Environment of injury

— Frontal MVC unrestrained: head/face injury, C-spine, sternal/cardiac contusion, aortic injury, "dashboard" posterior hip dislocation, patellar/femur fracture

— Lateral impact: contralateral neck strain, ipsilateral rib/pulmonary contusion, splenic (left) or hepatic (right) laceration, pelvic ring fracture

— Rollover/ejection: any injury — ejection alone is a level-1 trigger

— Pedestrian struck: Waddell triad (femur, torso, contralateral head)

— Fall from height: calcaneal + lumbar burst (Don Juan), wrist

— Penetrating chest below nipple line (T4) anterior or scapular tip posterior: assume abdominal injury

Step 3 management: For a warfarin/DOAC patient with head strike, order non-contrast head CT immediately and do not wait for symptoms; have reversal agent (4-factor PCC, idarucizumab, andexanet) ready in parallel.

Trauma history is gathered in parallel with the primary survey — never delay resuscitation for a story

Prehospital SBAR from EMS is high-yield:

Once primary survey is stable, complete AMPLE history:

Pattern recognition by mechanism:

Anticoagulated elderly with even minor head trauma require CT head and observation — ground-level falls are the most common missed serious mechanism

Physical Exam Findings and Hemodynamic Assessment

— Talk to the patient: a clear answer in normal voice confirms patent airway, adequate ventilation, and cerebral perfusion

— Look for stridor, gurgling, facial/neck burns or soot, expanding hematoma, blood/teeth/vomit, GCS ≤8

— Maintain in-line cervical stabilization; jaw-thrust (not head-tilt) if obstructed

— Expose chest, inspect for asymmetry/flail/wounds, palpate for crepitus, percuss, auscultate bilaterally, check SpO₂ and trachea

— Immediate threats: tension PTX, open PTX, massive hemothorax, flail chest, tracheobronchial injury, cardiac tamponade (overlaps C)

— Two large-bore (≥16 g) peripheral IVs; central or IO if failed

— Assess perfusion: mental status, skin color/temp, capillary refill, pulse character, BP

— Identify external hemorrhage — direct pressure, tourniquet, pelvic binder, junctional pressure

— Shock classes I–IV by % blood volume lost (∼70 mL/kg): I <15% (HR normal), II 15–30% (tachycardia, narrowed pulse pressure, anxious), III 30–40% (hypotension, confused), IV >40% (lethargic, anuric)

— GCS (E4 V5 M6), pupils (size, symmetry, reactivity), gross motor in 4 extremities, glucose

— Fully undress, log-roll with rectal tone and back inspection, then warm with blankets/fluid warmer to prevent the lethal triad: hypothermia + acidosis + coagulopathy

Key distinction: Tension pneumothorax is a clinical diagnosis (hypotension + absent breath sounds + tracheal deviation + JVD) — decompress with finger thoracostomy or 5th ICS anterior axillary needle before chest X-ray. Ordering imaging first is wrong on the exam.

Primary survey ABCDE — each letter is examined and treated before moving on:

A — Airway with C-spine protection:

B — Breathing:

C — Circulation:

D — Disability:

E — Exposure/Environment:

Diagnostic Workup — Initial Labs, Imaging, and Adjuncts to Primary Survey

— Continuous monitoring: ECG, SpO₂, ETCO₂, BP cycling q3–5 min, temperature, urine output via Foley (target 0.5 mL/kg/h adult, 1 mL/kg/h peds, 2 mL/kg/h infant)

— NG/OG tube (OG if midface fracture suspected — cribriform plate risk)

— Labs: type & crossmatch (priority), CBC, BMP, lactate, base deficit, coags/INR, fibrinogen, ABG, β-hCG, troponin if blunt cardiac, ETOH/tox, TEG/ROTEM if available

— Initial hemoglobin is unreliable acutely (no time to equilibrate) — trend it

— Base deficit >6 or lactate >4 = significant occult hypoperfusion

— Chest X-ray — PTX, hemothorax, widened mediastinum (aortic), diaphragm

— Pelvis X-ray — pelvic ring disruption (do not log-roll an unstable pelvis)

— eFAST ultrasound — free fluid in Morison's, splenorenal, pelvis, pericardial; lung sliding for PTX

— Positive FAST + hemodynamically unstable → OR for laparotomy, do not CT

— Positive FAST + stable → CT abdomen/pelvis with IV contrast

— Negative FAST + unstable → look elsewhere (chest, pelvis, retroperitoneum, neurogenic, "blood on the floor"); consider DPL or repeat FAST

— FAST misses retroperitoneal, hollow viscus, and diaphragm injuries

CCS pearl: In CCS, order "type and cross 4–6 units PRBC," "FAST exam," "portable CXR," and "portable pelvis XR" simultaneously on the unstable blunt trauma patient — sequential ordering wastes simulated minutes and lowers your score.

Adjuncts to the primary survey are obtained during resuscitation, not after:

Imaging trauma triad at bedside:

eFAST interpretation:

ECG for blunt chest trauma (arrhythmia screen for cardiac contusion); 12-lead also catches medical cause of crash (STEMI, AF)

Diagnostic Workup — Advanced and Confirmatory Studies

— High-energy mechanism with multisystem injury

— Altered mental status precluding reliable exam

— Distracting injury with concerning mechanism

— GCS <15, focal deficit, seizure, vomiting ≥2, anticoagulation, age >65, signs of basilar skull fracture (raccoon eyes, Battle sign, hemotympanum, CSF oto/rhinorrhea), suspected open/depressed fracture, amnesia, dangerous mechanism (Canadian CT Head Rule / New Orleans)

— NEXUS: no midline tenderness, no focal neuro deficit, normal alertness, no intoxication, no distracting injury → no imaging

— Canadian C-Spine: age ≥65, dangerous mechanism, or paresthesias → image; otherwise check rotation 45° bilaterally

— Obtunded/intubated patient: CT C-spine; if negative and exam unreliable, maintain collar; MRI for ligamentous injury if persistent concern

— Widened mediastinum, 1st rib fracture, scapular fracture, or deceleration mechanism → blunt aortic injury

— Penetrating neck zone I/III, expanding hematoma, bruit, neuro deficit → vascular neck injury

— Pelvic fracture with contrast extravasation → angioembolization

Board pearl: Never send an unstable patient to CT — "the CT scanner is the tunnel of death." If you must image, do it portable in the bay or go straight to OR/IR.

CT scanning is reserved for the hemodynamically stable or transient responder patient after the primary survey is complete and life threats addressed

"Pan-scan" (CT head, C-spine, chest/abd/pelvis with IV contrast) indications:

Head CT non-contrast:

C-spine clearance:

CT angiography for:

DPL (diagnostic peritoneal lavage) is largely replaced by FAST/CT but still appears: positive if gross blood >10 mL, RBC >100,000/μL, WBC >500, bile, food, bacteria

Local wound exploration for anterior abdominal stab wounds in stable patients; violation of anterior fascia → laparoscopy or laparotomy

Risk Stratification and Resuscitation Logic

— Class I–II: crystalloid (1 L warmed LR or plasmalyte) trial

— Class III–IV or non-responder to 1 L crystalloid: balanced blood products in 1:1:1 ratio (PRBC : FFP : platelets), activate massive transfusion protocol (MTP) when ≥10 U PRBC anticipated in 24 h or ≥4 U in 1 h

— Rapid responder (stable after bolus) — likely <20% blood loss; complete workup, admit/observe

— Transient responder — improves then deteriorates; ongoing hemorrhage; → CT vs OR/IR depending on stability

— Non-responder — exsanguinating; immediate OR or IR, continue MTP

— Limit crystalloid (worsens dilutional coagulopathy and ARDS)

— Early balanced products

— TXA 1 g IV over 10 min, then 1 g over 8 h if within 3 hours of injury (CRASH-2, CRASH-3)

— Calcium replacement (citrate in stored blood chelates Ca²⁺ → hypocalcemia → worsened coagulopathy and contractility) — give 1 g CaCl₂ per 4 U PRBC

— Warm everything; aim core temp >36°C

— Reverse anticoagulation: warfarin → 4F-PCC + vitamin K; dabigatran → idarucizumab; Xa inhibitors → andexanet alfa or 4F-PCC

Step 3 management: A trauma patient who needs >4 U PRBC in the first hour or has SBP <90 with positive FAST should have MTP activated and a surgeon scrubbing — do not wait for labs.

Hemorrhage classification drives the resuscitation strategy:

Response to initial fluid/blood stratifies management:

Permissive hypotension (target SBP 80–90 or MAP 50–65) until hemorrhage is controlled, except in TBI where SBP must be ≥110 to maintain CPP

Damage control resuscitation principles:

Pelvic binder at greater trochanters (not iliac crests) for suspected unstable pelvis; if persistent hypotension after binder + MTP → preperitoneal packing + angioembolization

Pharmacotherapy in the Trauma Bay

— Pre-oxygenate 100% O₂ × 3 min or 8 vital-capacity breaths

— Induction:

— Etomidate 0.3 mg/kg — hemodynamically neutral, preferred in shock (single dose adrenal suppression is rarely clinically significant)

— Ketamine 1–2 mg/kg — preserves BP, drug of choice in hypotensive trauma; safe in isolated TBI (does not raise ICP significantly per modern data)

— Avoid propofol (drops BP) and high-dose midazolam in shock

— Paralysis:

— Succinylcholine 1.5 mg/kg — fast on/off; avoid in crush injury >24 h, burns >24 h, denervation, hyperkalemia, suspected rhabdomyolysis

— Rocuronium 1.2 mg/kg — preferred when succ contraindicated

— Open fracture: cefazolin within 1 h (Gustilo I–II); add gentamicin or piperacillin-tazobactam for III; add penicillin for farm/soil/fecal contamination (clostridial)

— Penetrating abdominal: cefoxitin or pip-tazo pre-op

Board pearl: Ketamine + rocuronium is the canonical RSI combo for the hypotensive trauma patient on Step 3.

Rapid sequence intubation (RSI) for airway compromise, GCS ≤8, expanding hematoma, combative TBI, anticipated deterioration:

Analgesia: fentanyl 0.5–1 μg/kg IV titrated; avoid morphine boluses in unstable patients (histamine, hypotension)

TXA (see chunk 6) — earlier is better; no benefit and possible harm if >3 h after injury

Vasopressors only after volume/blood resuscitation is underway and hemorrhage is controlled; norepinephrine is first line if needed for refractory shock (especially neurogenic)

Antibiotics:

Tetanus prophylaxis: Td/Tdap if >5 y since last dose for tetanus-prone wounds; add TIG for dirty wounds in patients with <3 lifetime doses

Steroids are not indicated for spinal cord injury (NASCIS data refuted)

Procedures and Invasive Management

— Orotracheal RSI — first line

— Cricothyroidotomy — "can't intubate, can't oxygenate"; surgical (scalpel-bougie-tube) in adults, needle cricothyroidotomy with jet ventilation in children <12 y (cricoid is the narrowest part and only support of pediatric trachea)

— Immediate output >1500 mL or >200 mL/h for 2–4 h = thoracotomy

— Penetrating chest with signs of life within 15 min → strongly indicated

— Blunt trauma arrest → poor outcomes, generally not indicated except witnessed arrest in ED

— Goals: release tamponade, cross-clamp aorta, control cardiac/hilar bleeding, internal cardiac massage

CCS pearl: Penetrating chest + hypotension + muffled heart sounds + JVD → order "pericardial window" or "ED thoracotomy" — pericardiocentesis is a temporizer, not the answer.

Definitive airway options (cuffed tube below cords):

Tension pneumothorax — finger thoracostomy or needle decompression at 5th ICS, anterior axillary line (adults; ATLS updated from 2nd ICS midclavicular due to chest wall thickness), followed by tube thoracostomy

Tube thoracostomy (28–32 Fr): 5th ICS, anterior to midaxillary line, over the rib

Resuscitative thoracotomy (ED thoracotomy):

REBOA (resuscitative endovascular balloon occlusion of aorta) — bridge for non-compressible torso/pelvic hemorrhage in select centers

Pericardiocentesis — temporizing for tamponade; definitive is subxiphoid window or thoracotomy

Laparotomy indications: hemodynamic instability + positive FAST, peritonitis, evisceration, GI bleeding from NG/rectum, gunshot to abdomen, diaphragm injury

Damage control laparotomy in coagulopathic/acidotic/hypothermic patient: control bleeding and contamination, pack and temporarily close, return to ICU, re-explore in 24–48 h

Angioembolization — solid organ (splenic blush, hepatic), pelvic arterial bleed

Special Populations — Elderly and Renal/Hepatic Impairment

— Ground-level falls cause severe injury — low threshold to activate trauma team

— Vital signs are misleading:

— Beta-blockers blunt the tachycardic response — HR 90 may mean class III shock

— Baseline hypertension means "normal" SBP 110 is relative hypotension; use SBP <110 (not <90) as the geriatric shock trigger

— Stiffer myocardium → poor tolerance of hypovolemia and of over-resuscitation (CHF)

— Polypharmacy: anticoagulants (warfarin, DOACs, antiplatelets) → low threshold for head CT, early reversal, repeat CT at 6 h if initial negative and on anticoagulation

— Cervical spine: higher rate of type II odontoid and central cord syndrome from minor mechanism; image liberally — NEXUS less reliable in elderly

— Rib fractures: each additional rib fracture increases mortality ~19% in elderly; aggressive pulmonary toilet, regional anesthesia (epidural, serratus block), consider rib fixation for ≥3 displaced fractures or flail

— Delirium prevention bundle, pressure ulcer prophylaxis, early PT

— Avoid IV contrast pre-hydration delays in unstable trauma — benefits of CTA outweigh CIN risk; treat AKI after

— Renal-dose adjust LMWH/enoxaparin VTE prophylaxis (use UFH if CrCl <30)

— Crush injury → rhabdomyolysis → AKI; IV fluids to UOP 200–300 mL/h, monitor K⁺

— Baseline coagulopathy + thrombocytopenia → worse hemorrhage; transfuse to clinical effect, give vitamin K, consider cryoprecipitate if fibrinogen <150

— Avoid acetaminophen >2 g/day for pain; use scheduled regional blocks and low-dose opioids

Key distinction: In an elderly patient on a beta-blocker, do not be reassured by a "normal" heart rate — assess perfusion (mentation, urine output, lactate, base deficit) instead.

Geriatric trauma (≥65 y) is the fastest-growing trauma population and is systematically under-triaged:

Renal impairment:

Hepatic impairment:

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— Resuscitate the mother first — best fetal resuscitation is maternal resuscitation

— After 20 weeks: left lateral tilt 15–30° or manual uterine displacement to relieve aortocaval compression

— Physiologic changes: HR baseline +15–20, BP −10/−15 in 2nd trimester, plasma volume +50% (can lose 30–35% before signs), respiratory alkalosis baseline

— All Rh-negative pregnant trauma patients get RhoGAM 300 μg within 72 h; Kleihauer-Betke to dose if large fetomaternal hemorrhage suspected

— Continuous CTG monitoring ≥4 h for any abdominal trauma >20 weeks; extend to 24 h if contractions ≥6/h, abdominal pain, vaginal bleeding, or non-reassuring tracing → placental abruption

— Perimortem C-section within 4 min of maternal arrest if fundus at/above umbilicus (≥20 wk) — improves both maternal and fetal survival

— Imaging: shield gravid uterus when feasible, but do not withhold indicated CT — fetal dose from pan-scan ~25 mGy (threshold for teratogenicity ~50–100 mGy)

— Hypotension is a late and ominous sign — children compensate with tachycardia until ~30% volume loss, then crash

— Estimate weight: Broselow tape; fluids 20 mL/kg LR × up to 2 boluses, then 10 mL/kg PRBC

— Larger head → flexion in supine → place a shoulder roll for neutral neck alignment

— SCIWORA (spinal cord injury without radiographic abnormality) — ligamentous laxity; MRI if neuro deficit with normal CT

— Non-accidental trauma red flags: posterior rib fractures, metaphyseal corner fractures, multiple fractures of varying age, retinal hemorrhages, story inconsistent with injury — mandatory report

Step 3 management: Pregnant trauma + Rh-negative + any abdominal mechanism → RhoGAM, CTG ≥4 h, and obstetrics consult regardless of how minor the mechanism seems.

Pregnant trauma patient:

Pediatric trauma:

Burn patients: Parkland 4 mL × kg × %TBSA LR over 24 h, half in first 8 h; early intubation for inhalation/airway burns

Complications and Adverse Outcomes

— Missed injury — most common cause of preventable trauma death; mitigated by the tertiary survey (repeat head-to-toe within 24 h, awake patient)

— Acute traumatic coagulopathy — present in 25% of major trauma at admission, driven by tissue hypoperfusion, protein C activation, hyperfibrinolysis; addressed with balanced MTP and TXA

— Lethal triad: hypothermia, acidosis, coagulopathy — feed each other; correct simultaneously

— Transfusion complications: TRALI, TACO, hyperkalemia from old units, hypocalcemia from citrate, dilutional thrombocytopenia

— Abdominal compartment syndrome — bladder pressure >20 mmHg with new organ dysfunction → decompressive laparotomy

— Extremity compartment syndrome — pain out of proportion, pain with passive stretch, paresthesia (early); pulselessness is late; measure compartment pressures, fasciotomy if Δ (DBP − compartment) <30 mmHg

— VTE — initiate chemical prophylaxis within 24–48 h if hemorrhage controlled (LMWH preferred); IVC filter only if absolute contraindication to anticoagulation with documented or high-risk PE/DVT

— ARDS from pulmonary contusion, massive transfusion, aspiration

— Fat embolism — long-bone fracture 24–72 h post-injury: hypoxia + petechiae + neuro changes

— Acute kidney injury from rhabdo, hypoperfusion, contrast

— Ventilator-associated pneumonia, line infections, C. difficile

— Heterotopic ossification, chronic pain, PTSD, post-concussive syndrome, post-traumatic epilepsy (penetrating brain injury — consider levetiracetam ×7 days prophylaxis)

— Multiple organ dysfunction syndrome (MODS) — late peak of trimodal mortality

Board pearl: Pain out of proportion + tense compartment in a patient who had a tibial shaft fracture or revascularization → fasciotomy now, not Doppler studies.

Acute (trauma bay → first 24 h):

Subacute (24 h – 1 wk):

Late:

When to Escalate Care — Transfer, ICU, and Consultation

— GCS ≤14 from head injury, penetrating head/neck/torso, spinal cord injury, multisystem trauma, pelvic fracture, ≥2 long-bone fractures, burns with associated trauma, complex pediatric trauma

— Use EMTALA-compliant transfer: stabilize within capability, accepting MD and bed confirmed, copies of records and imaging sent, appropriate level of transport (often ALS or critical care transport with blood)

— Do not delay transfer for non-essential imaging that won't change initial management — "scan-and-go" wastes time if patient needs higher-level care

— Intubated, ongoing resuscitation, vasopressor requirement, severe TBI (GCS ≤8), spinal cord injury, pulmonary contusion with hypoxia, ≥3 rib fractures in elderly, post-laparotomy with damage control, large-volume transfusion

— Trauma/general surgery: all trauma activations

— Neurosurgery: any intracranial blood, depressed/open skull fracture, GCS deterioration, spinal cord injury

— Orthopedics: open fractures (within 1 h for irrigation/abx), unstable pelvis, dislocations, compartment syndrome

— Vascular: hard signs of vascular injury (pulsatile bleeding, expanding hematoma, bruit/thrill, pulselessness, distal ischemia)

— Interventional radiology: solid organ blush, pelvic arterial bleed

— Cardiothoracic: persistent chest tube output, suspected aortic injury, tracheobronchial injury

— OB: pregnant >20 wk with any abdominal trauma

— Burn center: per ABA criteria (partial >10% TBSA, full thickness, face/hands/feet/perineum/joints, electrical, chemical, inhalation, comorbidities, peds)

CCS pearl: On CCS, transfer a head-injured patient on warfarin from a community ED to a trauma center after obtaining CT head, reversing INR, and intubating if GCS ≤8 — sequence matters for the score.

Trauma center transfer criteria (per ACS-COT) if at a non-trauma facility:

ICU admission indications after primary/secondary survey:

Consult triggers:

Key Differentials — Same-Category (Shock Etiologies in Trauma)

— "Blood on the floor and four more": external, chest, abdomen, pelvis/retroperitoneum, long bones (femur fx can hide 1–2 L; pelvis 2–4 L+)

— Cool extremities, narrow pulse pressure, tachycardia, oliguria, rising lactate

— Tension pneumothorax — unilateral absent breath sounds, tracheal deviation, JVD, hypotension — needle/finger decompress

— Cardiac tamponade — Beck triad (hypotension, muffled heart sounds, JVD), pulsus paradoxus, positive pericardial FAST — pericardial window/thoracotomy

— Massive PE — uncommon acutely but consider in delayed trauma decompensation

— Air embolism from penetrating lung injury

— Blunt cardiac injury — sternal fracture, ECG abnormalities (RBBB, PVCs, sinus tach), elevated troponin, wall motion abnormality on echo

— Myocardial infarction — especially in elderly; consider as cause of MVC, not just consequence

— Aortic valve disruption from blunt deceleration

— Spinal cord injury above T6: hypotension + bradycardia (loss of sympathetic tone, unopposed vagal) + warm dry skin below lesion

— Treat with fluids → norepinephrine or phenylephrine; atropine for bradycardia; rule out hemorrhage first before attributing hypotension to neurogenic causes

Key distinction: Neurogenic shock = hypotension + bradycardia + warm skin. Hemorrhagic shock = hypotension + tachycardia + cool skin. A trauma patient with spinal cord injury and tachycardia is bleeding somewhere — find it.

In a hypotensive trauma patient, work systematically through the five shock buckets — assume hemorrhage until proven otherwise:

1. Hemorrhagic (hypovolemic) shock — far and away most common:

2. Obstructive shock:

3. Cardiogenic shock:

4. Neurogenic shock:

5. Septic shock — late, not initial

Key Differentials — Other-Category Causes and Mimics

— Syncope (cardiac, neurologic, orthostatic) → MVC or fall — obtain ECG, glucose, troponin

— Seizure → head injury — get post-event history, prolactin/lactate, EEG if recurrent

— Stroke → fall — neuro exam, CT/CTA, glucose

— Hypoglycemia → altered mental status mimicking TBI — always check glucose in altered trauma patient

— Intoxication — does not explain a depressed GCS until structural injury is ruled out

— MI with shock causing the crash — 12-lead ECG, troponin

— Anaphylaxis from latex or antibiotics during resuscitation

— Adrenal insufficiency — chronic steroid users, hemorrhagic adrenal from sepsis; stress-dose hydrocortisone 100 mg

— Carbon monoxide / cyanide in fire victims — co-oximetry, hydroxocobalamin; SpO₂ is falsely normal in CO poisoning

— Hypothermia from cold-water immersion — "not dead until warm and dead," can mimic and worsen shock

— Drowning — hypoxia, ARDS, secondary cardiac arrest

— Electrical injury — entry/exit wounds, deep tissue and cardiac damage out of proportion to skin findings, rhabdomyolysis

— Sedation/anesthesia drop in BP

— Equipment artifact (poor cuff fit, kinked art line)

— Vagal response to NG placement or rectal exam

— Ruptured AAA in elderly "back pain after a fall"

— Ectopic pregnancy in young woman with abdominal pain post-minor trauma

Board pearl: Always ask "why did this patient have trauma?" Older patient with new arrhythmia + low-energy fall = work up cardiac/neuro syncope alongside trauma evaluation.

Medical causes of trauma must be considered — the crash may be the consequence, not the cause:

Distributive shock mimics in trauma:

Toxic/environmental causes co-existing with trauma:

Pseudo-shock states:

Non-trauma surgical emergencies presenting after a fall:

Secondary Survey, Definitive Care, and Discharge Planning

— Head-to-toe inspection and palpation, including scalp, eyes (fundi, EOM, visual acuity, foreign body), TMs (hemotympanum), nose (septal hematoma), mouth/teeth, neck (subq emphysema, hematoma), chest, abdomen, pelvis (compress once only, gently), perineum/GU (blood at meatus → retrograde urethrogram before Foley), rectal (tone, blood, prostate), back (log roll), all extremities (deformity, pulses, neuro), skin (burns, road rash)

— AMPLE history completed

— Identify all injuries and prioritize definitive treatment

— Operative repair (laparotomy, ORIF, craniotomy)

— Non-operative management (NOM) of solid-organ injuries in stable patients with serial exams, Hb, and bed rest

— Splinting, traction, wound care, irrigation and debridement

— Repeat exam after observation period

— Pain control plan (multimodal — acetaminophen + NSAID + short opioid course only if needed; 5-day max opioid prescription is best practice for acute pain)

— Wound care, suture/staple removal date

— Crutch/sling training, return-to-work and driving restrictions

— Return precautions in writing: worsening pain, fever, neuro symptoms, bleeding, vomiting (especially post head injury)

— Tetanus, rabies prophylaxis as indicated

— VTE prophylaxis plan for immobilized patients

— PCP follow-up within 1–2 weeks; specialty follow-up as indicated

Step 3 management: Every discharged head-injured patient gets a head-injury instruction sheet and a responsible adult to observe for 24 h; no driving, no alcohol, no contact sports until cleared.

Secondary survey begins only after primary survey is complete and resuscitation under way:

Tertiary survey within 24 h (when patient awake/extubated) catches missed injuries — required documentation in trauma quality programs

Definitive care pathway depends on injuries but common elements:

Discharge from ED (minor trauma) checklist:

Follow-Up, Monitoring Parameters, and Rehab/Counseling

— Vitals q15 min until stable then q1–2 h

— Serial abdominal exams q2–4 h for NOM of solid-organ injuries

— Serial Hb q4–6 h initially in active bleeding

— Neuro checks q1 h × 24 h after TBI, then q2–4 h

— ICP monitoring for GCS ≤8 with abnormal CT; target ICP <22, CPP 60–70

— Daily CBC, BMP, coags; lactate trend until normalized

— VTE chemoprophylaxis as soon as bleeding controlled (typically <48 h)

— Early enteral nutrition within 24–48 h when feasible

— Glucose control 140–180 in ICU

— Stress ulcer prophylaxis for intubated, coagulopathic, or burn patients

— Trauma surgery clinic at 2 weeks

— Orthopedic/specialty follow-up per fracture/injury

— PCP within 1–2 weeks for medication reconciliation, return-to-activity plan, vaccination updates

— Repeat imaging for splenic/hepatic injuries per grade

— Driving restriction after concussion until asymptomatic and cleared; SAAM/SCAT-5 for concussion

— Early PT/OT in hospital; inpatient rehab for moderate-severe TBI, spinal cord injury, multiple amputations

— Speech therapy for swallowing/cognitive impairment

— Pulmonary toilet (incentive spirometer q1 h awake) for rib fractures and contusions

— Alcohol screening (AUDIT) and brief intervention for all trauma patients — proven to reduce repeat trauma admission and is required by ACS-verified trauma centers

— Tobacco cessation, substance use referral

— Intimate partner violence screening — confidential, private

— Mental health screening at 1–3 months for PTSD and depression — 20–40% of major trauma survivors

— Helmet, seatbelt, gun safety counseling — context-appropriate

Board pearl: Alcohol-positive trauma patients who receive a 15-minute brief intervention before discharge have ~50% reduction in repeat trauma — the highest-yield "secondary prevention" intervention in this population.

In-hospital monitoring after major trauma:

Post-discharge follow-up cadence:

Rehabilitation:

Counseling and screening:

Ethical, Legal, and Patient Safety Considerations

— Emergency exception ("implied consent") allows life-saving treatment of an incapacitated patient without consent when delay would cause serious harm

— Reasonable effort to contact surrogate but never delay critical intervention

— Capacitated, intoxicated patients can refuse care only if they retain decision-making capacity (understand risks/benefits/alternatives); document carefully; involve ethics if borderline

— Jehovah's Witness adults with capacity may refuse blood — document specific products refused (some accept albumin, factor concentrates, cell saver); pediatric patients: court order if life-saving

— Gunshot and stab wounds → law enforcement (state-dependent)

— Suspected child abuse, elder abuse, dependent adult abuse → CPS/APS

— Intimate partner violence — not uniformly mandatory; patient autonomy preferred unless weapon involved or in select states

— Impaired drivers — DMV reporting per state law

— Animal bites → public health (rabies)

— Missed injuries are the leading preventable trauma harm — the tertiary survey is a safety net

— Handoff/transition errors — ED→OR→ICU→floor: use structured handoff (SBAR/I-PASS), explicit pending tests, anticoagulation status, allergies, family contact

— Wrong-site surgery — universal protocol, time-out, site marking

— Medication errors in MTP — pre-built order sets and pharmacy presence reduce error

— Forensic evidence preservation — keep clothing in paper (not plastic) bags, document wound characteristics objectively without "entry/exit" determinations (forensic role)

Step 3 management: An intoxicated trauma patient who tries to leave AMA requires a capacity assessment, not just a signature — if incapacitated, hold and treat under emergency exception and document the rationale.

Informed consent in trauma:

Mandatory reporting obligations:

Patient safety pitfalls:

Brain death and organ donation — declared by trained physicians using institutional protocol; OPO notification is mandatory for any imminent neurologic death

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: If a Step 3 stem mentions seatbelt sign + lumbar pain → Chance fracture + hollow viscus injury — admit, CT, and serial abdominal exams even if initial imaging looks benign.

GCS — eye 4, verbal 5, motor 6 (max 15); ≤8 → intubate; M6 = follows commands, M5 = localizes, M4 = withdraws, M3 = decorticate (flexion), M2 = decerebrate (extension), M1 = none

Cushing triad (HTN + bradycardia + irregular respirations) = impending herniation → hyperventilate transiently to PaCO₂ 30–35, mannitol 1 g/kg or 3% saline, neurosurgery

Beck triad (hypotension + JVD + muffled heart sounds) = tamponade

Cushing reflex vs neurogenic shock — opposite stories: TBI/herniation has HTN+bradycardia; spinal cord injury has hypotension+bradycardia

Pulsus paradoxus >10 mmHg → tamponade or severe asthma

Kehr sign — left shoulder pain from diaphragmatic irritation = splenic rupture

Grey Turner / Cullen signs = retroperitoneal / periumbilical bleeding

Battle sign / raccoon eyes / hemotympanum / CSF oto- or rhinorrhea = basilar skull fracture → no nasal NG, no nasal intubation

Seatbelt sign (abdominal ecchymosis) → high risk of hollow viscus injury and Chance fracture (lumbar flexion-distraction); CT and reassess

Widened mediastinum on CXR → blunt aortic injury (most commonly distal to left subclavian at ligamentum arteriosum) → CTA chest

First rib or scapular fracture = huge energy transfer; look for aortic, brachial plexus injuries

Posterior hip dislocation = "dashboard injury," leg shortened/adducted/internally rotated; reduce <6 h to limit avascular necrosis

Calcaneal fracture → look for lumbar burst fracture (Don Juan syndrome)

Pediatric handlebar injury = duodenal hematoma / pancreatic injury

TXA window = within 3 hours of injury

MTP ratio = 1:1:1 (PRBC:FFP:platelets)

Permissive hypotension target ~SBP 80–90, but ≥110 in TBI

Damage control triad = hypothermia + acidosis + coagulopathy

Board Question Stem Patterns

— "Restrained driver in MVC, hypotensive, absent left breath sounds, tracheal deviation right, distended neck veins" → needle/finger decompression 5th ICS anterior axillary line, then chest tube (not CXR first)

— "Stab wound to left chest, BP 80/60, muffled heart sounds, distended neck veins, FAST shows pericardial fluid" → pericardial window/thoracotomy (pericardiocentesis only as bridge)

— "MVC, BP 75/40 after 2 L LR, FAST positive for free fluid Morison's pouch" → emergent laparotomy, activate MTP, not CT

— "Pedestrian struck, unstable pelvis on exam, BP 80/50" → pelvic binder + MTP + angioembolization vs preperitoneal packing

— "85-year-old on warfarin falls, GCS 14, no focal deficit" → non-contrast head CT + reverse INR with 4F-PCC + vitamin K; admit for obs and repeat CT

— "Diver into shallow pool, quadriparesis, BP 80/50, HR 50, warm extremities" → fluids + norepinephrine; rule out hemorrhage; high-dose steroids not indicated

— "28-week pregnant restrained driver in MVC, stable vitals, mild contractions" → left lateral tilt, continuous CTG ≥4 h, RhoGAM if Rh-negative, Kleihauer-Betke

— "8-year-old, handlebar to abdomen, vomiting, epigastric pain, normal vitals" → suspect duodenal hematoma or pancreatic injury, CT abd/pelvis

— "78-year-old with 4 left rib fractures, SpO₂ 92%" → ICU/step-down, multimodal analgesia including epidural or regional block, aggressive pulmonary toilet

— "Tibial shaft fracture, pain out of proportion, pain with passive toe extension, tense compartment" → emergent fasciotomy (do not wait for pressure measurement if clinical picture is clear)

Key distinction: "Unstable + positive FAST" → OR. "Unstable + negative FAST" → search elsewhere (chest, pelvis, retroperitoneum, neurogenic). "Stable + positive FAST" → CT.

Stem 1 — Tension pneumothorax:

Stem 2 — Cardiac tamponade:

Stem 3 — Unstable blunt trauma with positive FAST:

Stem 4 — Pelvic fracture with hypotension:

Stem 5 — TBI with anticoagulation:

Stem 6 — Neurogenic shock:

Stem 7 — Pregnant trauma:

Stem 8 — Pediatric blunt trauma:

Stem 9 — Geriatric rib fractures:

Stem 10 — Compartment syndrome:

One-Line Recap

The ATLS primary survey (ABCDE) treats life-threatening problems in order — airway with C-spine, breathing, circulation with hemorrhage control, disability, exposure — using bedside adjuncts (CXR, pelvis XR, eFAST, type & cross) and a 1:1:1 balanced massive transfusion with TXA <3 hours, while permissive hypotension (except in TBI where SBP ≥110) and damage-control resuscitation prevent the lethal triad of hypothermia, acidosis, and coagulopathy; only after stabilization does the secondary survey (head-to-toe + AMPLE) and definitive imaging or OR follow.

Board pearl: When in doubt on a trauma question, return to the letter that isn't fixed yet — the right answer almost always lives in the earliest unresolved step of the primary survey, not in advanced imaging or specialty consultation.

Sequence wins: Never advance through ABCDE with an unfixed prior letter; never send an unstable patient to CT; unstable + positive FAST = OR, not scanner

Resuscitation core: Two large-bore IVs → warmed crystalloid trial → balanced blood products in MTP → TXA within 3 h → calcium replacement → reverse anticoagulation → permissive hypotension until hemorrhage controlled

Special populations: Geriatrics — beta-blocker blunts tachycardia, SBP <110 is shock, low threshold for CT and reversal; pregnancy — resuscitate mother first, left lateral tilt, CTG ≥4 h, RhoGAM, perimortem C-section <4 min; pediatrics — hypotension is late and ominous, beware NAT patterns

Disposition rules: Tertiary survey within 24 h to catch missed injuries; alcohol brief intervention and PTSD screening as evidence-based secondary prevention; structured handoffs prevent the most common preventable trauma harm