01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Major trauma is defined by the risk and consequences of serious injury, not by the dramatic appearance of one wound. A small penetrating injury may conceal vascular damage, while an older person can sustain major injury after a lower-energy mechanism. Initial information should identify the mechanism, time, physiological trend and treatments already given so that the team prepares the appropriate personnel, blood products and destination.
The first assessment searches for injuries that kill before a complete diagnosis is available. External haemorrhage, airway obstruction, tension pneumothorax and internal bleeding need coordinated action. The second task is to prevent avoidable deterioration from hypoxia, hypothermia, coagulopathy and delayed definitive treatment. Repeated examination is essential because pain, distraction, intoxication and evolving physiology can hide injuries during the first pass.
Key points
- Control catastrophic haemorrhage at the start while the team assesses airway, breathing and circulation in parallel.
- A normal initial haemoglobin does not exclude substantial acute blood loss; use physiology, mechanism and repeated measurements.
- In hospital, active traumatic bleeding requires blood-product resuscitation rather than repeated crystalloid loading.
- Decompress a suspected tension pneumothorax before imaging when there is haemodynamic instability or severe respiratory compromise.
- A suspected bleeding pelvic fracture after high-energy blunt trauma needs a purpose-made binder positioned over the greater trochanters.
- CT is for patients whose physiological state and response permit it; an unstable non-responder may require immediate haemorrhage control.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Blunt mechanisms
Collisions, falls and crush injuries distribute force across several body regions. Internal organ damage can occur despite limited external signs, particularly when acceleration or deceleration produces shearing forces.
Penetrating mechanisms
Stab wounds and projectiles may injure vessels, hollow organs or the heart along a tract that is not apparent externally. Surface wound size is a poor measure of internal severity.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Haemorrhagic shock
Loss of circulating blood reduces oxygen delivery and may initially provoke compensatory tachycardia and vasoconstriction. Continued loss eventually overwhelms compensation, causing tissue hypoperfusion, acidaemia and organ dysfunction.
- 2Traumatic coagulopathy
Tissue injury, hypoperfusion and disordered fibrinolysis impair haemostasis; dilution, hypothermia and low calcium can worsen the problem during resuscitation. Control of bleeding and physiological correction must proceed together.
- 3Obstructive thoracic physiology
Rising pleural pressure in tension pneumothorax impairs ventilation and venous return. Decompression can rapidly reverse a lethal obstruction, but concurrent haemorrhage may still require definitive treatment.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Look for bleeding into the chest, abdomen, retroperitoneum and pelvis, or around major long-bone fractures. Preserved blood pressure in a young adult does not prove adequate circulating volume; trajectory and peripheral perfusion matter.
Severe breathlessness, unilateral loss of air entry and shock raise concern for tension pneumothorax. Tracheal deviation is a late and unreliable requirement; treatment should follow the overall clinical picture when instability is present.
Assess GCS components, pupils and focal movement while maintaining appropriate spinal protection. Avoid attributing altered consciousness solely to alcohol or shock, and prevent hypoxia and hypotension that can worsen brain injury.
Anticoagulant use, frailty, pregnancy and pre-existing cardiopulmonary disease can change risk substantially. Record these early, together with entrapment, penetrating trajectories and the possibility of additional injuries beyond the painful site.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Blood gas, lactate and serial haemoglobinFirst step - Why
- Assess perfusion and follow the response to haemorrhage treatment.
- Interpretation and limitations
- An early haemoglobin can appear normal because plasma and red cells have been lost together. Repeat values, lactate and clinical response inform assessment; a single result must not delay blood or surgery.
- 02
Group and crossmatch with coagulation testing - Why
- Support blood-product delivery and detect evolving haemostatic failure.
- Interpretation and limitations
- Send full blood count, coagulation studies and fibrinogen, with viscoelastic testing where available. Continue emergency product delivery when clinically necessary before all laboratory results return.
- 03
Immediate bedside imaging in instability - Why
- Answer a question that changes an urgent intervention without an unsafe transfer.
- Interpretation and limitations
- Chest radiography and focused ultrasound may help localise injury, but a negative FAST does not exclude abdominal or retroperitoneal bleeding. Limit imaging to what is necessary to direct immediate treatment in a non-responder.
- 04
Whole-body CT for appropriate blunt major trauma - Why
- Identify multiple injuries and plan definitive treatment when physiology permits.
- Interpretation and limitations
- Adults with blunt major trauma and suspected multiple injuries may need whole-body CT. Contrast imaging should be coordinated with the trauma team and must not substitute for immediate intervention in an unstable non-responder.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Haemorrhagic versus obstructive shock
Both may present with hypotension and tachycardia after injury. Examine the chest while searching for bleeding, because tension pneumothorax needs decompression rather than blood replacement alone.
Neurogenic shock
High spinal injury may cause hypotension with inappropriate relative bradycardia and warm skin. Exclude haemorrhage and other immediately lethal causes before attributing traumatic shock to autonomic disruption.
Medical collapse preceding injury
Arrhythmia, seizure, hypoglycaemia or stroke may cause a collision or fall. Continue a medical differential when the mechanism or injuries do not adequately explain the original collapse.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Worked casePelvic haemorrhage after a motorcycle collisionFirst stepA rider has pelvic pain, cool peripheries, heart rate 132/min and systolic pressure 78 mmHg after a high-energy collision. There is no major external bleeding.+
- 1Activate the trauma and major-haemorrhage responses, support oxygenation and obtain large-bore access while checking for an immediately treatable thoracic cause.
- 2Apply a purpose-made pelvic binder at the greater trochanters without repeatedly springing the pelvis. Immobilisation reduces movement; it does not establish that all bleeding is controlled.
- 3Begin adult blood-product resuscitation with an initial plasma:red-cell ratio of 1:1 under the major-haemorrhage protocol, and give early tranexamic acid when the injury is within three hours.
- 4DefinitiveAfter initial treatment the pressure remains 80 mmHg and perfusion remains poor. Treat this as ongoing shock: request immediate definitive haemorrhage-control planning with the trauma surgeon and interventional radiology, using only necessary bedside imaging.
- 5Verify haemostasis through physiological recovery and repeated laboratory assessment, then reassess for additional injuries. A binder-associated pressure rise alone is insufficient evidence of complete recovery.
02Thoracic branchSuspected tension pneumothorax in an unstable patientA chest-injured adult becomes severely breathless and hypotensive with markedly reduced unilateral air entry.+
- 1Request immediate experienced trauma help and prepare decompression while supporting oxygenation and ventilation; do not wait for a radiograph to confirm a time-critical clinical diagnosis.
- 2In hospital, an appropriately skilled clinician performs open thoracostomy followed by chest-drain placement under the trauma pathway, with ongoing resuscitation.
- 3Reassess air entry, oxygenation and circulation immediately. Failure to improve requires examination for drain malfunction, haemothorax, tamponade, bleeding elsewhere or another simultaneous problem.
03Definitive-care branchSafe transfer after initial stabilisationDefinitiveThe patient responds sufficiently to resuscitation for CT or transfer but still needs specialist trauma treatment.+
- 1Confirm the receiving team's acceptance and send the mechanism, injuries suspected or demonstrated, physiological trends, blood products, medicines and treatment times.
- 2Secure airway devices, vascular access, drains and the pelvic binder where present; provide warming and a transport team capable of managing the remaining risks.
- 3On arrival, repeat the primary assessment and reconcile all interventions. Arrange a documented secondary survey and later tertiary review to identify initially missed injuries.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Tranexamic acid for significant traumatic bleeding
Give 1 g IV over 10 minutes as soon as possible within 3 hours of injury, followed by 1 g IV over 8 hours, using the adult major-haemorrhage regimen.Do not routinely start after 3 hours unless hyperfibrinolysis is demonstrated. Record earlier doses and avoid rapid injection. Severe renal impairment or prior thrombosis requires specialist assessment of the applicable product and clinical circumstances.
Blood components in active haemorrhage
Activate the adult major-haemorrhage protocol; NICE recommends an initial plasma:red-cell ratio of 1:1, moving to laboratory-guided component replacement as soon as possible.Use correct emergency identification, warming and repeated assessment of ionised calcium, coagulation and temperature. Products cannot replace anatomical haemorrhage control; avoid automatic crystalloid substitution in hospital active bleeding.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Secondary cerebral injury
Hypoxia and hypotension worsen an injured brain even when the original lesion is not surgically treatable. Airway protection, oxygenation and appropriate perfusion remain central throughout transport and resuscitation.
Missed injury
Distracting pain, impaired consciousness and competing resuscitation demands can obscure important lesions. Repeat examination after stabilisation and a tertiary survey reduce the chance of delayed diagnosis.
Resuscitation-related harm
Hypothermia, hypocalcaemia, fluid overload and transfusion complications can accompany lifesaving treatment. Monitor actively and transition from initial protocol-driven replacement to a targeted plan when information becomes available.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Trend blood pressure, pulse, peripheral perfusion and mental state during every intervention, recording whether the patient is a sustained responder, transient responder or non-responder.
- Repeat blood gases, ionised calcium, haemoglobin and coagulation tests during substantial transfusion; correct physiological and haemostatic deficits with the major-haemorrhage team.
- Measure temperature and actively prevent heat loss through exposure, cold rooms and unwarmed fluids, while still examining concealed surfaces and injuries.
- Check neurovascular status distal to splints and injuries, review binder position and skin pressure, and complete the planned secondary and tertiary surveys.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Brain injury modifies resuscitation
A strategy accepting lower pressure during uncontrolled bleeding needs reconsideration when cerebral perfusion is threatened. Seek senior trauma and neurosurgical agreement on the balance of competing priorities.
Isolated head injury has a separate TXA pathway
NICE NG232 advises considering a 2 g IV bolus within two hours for adults with head injury, GCS 12 or less and no suspected active extracranial bleeding. Do not accidentally combine this with the bleeding-trauma regimen.
Normal ultrasound is incomplete reassurance
FAST has limited ability to exclude retroperitoneal bleeding and some abdominal injuries. Decisions about CT or operative control should follow the complete clinical assessment and response.
Analgesia supports assessment
Treat pain while resuscitating, using titrated analgesia and splinting with close respiratory and haemodynamic observation. Distress can impede examination; pain relief need not wait until every injury is diagnosed.
11Common pitfallsFrequent interpretation and management errors.
- 01
Do not repeatedly manipulate a suspected unstable pelvis to demonstrate instability; use the mechanism and clinical picture to guide protection and imaging.
- 02
Do not send an unstable non-responder away from effective resuscitation simply because whole-body CT is available.
- 03
Do not infer absence of significant haemorrhage from one normal haemoglobin or a negative focused ultrasound examination.
- 04
Do not let the most visible fracture distract from hypoxia, concealed haemorrhage, hypothermia or an evolving intracranial problem.