Synopsis
Adapt trauma assessment to altered physiology, frailty and antithrombotic exposure while preserving standard life-saving priorities, timely imaging, haemorrhage control and medication reversal.
- Use the standard trauma sequence for all three groups; differences modify thresholds, positioning, doses and follow-up rather than replacing CABCDE priorities.
- Resuscitate the pregnant patient first and avoid supine aortocaval compression in later pregnancy with manual uterine displacement or left tilt that does not compromise spinal care.
- Do not withhold necessary CT or contrast because of pregnancy; discuss optimisation promptly, but maternal diagnosis and survival take priority over theoretical radiation risk.
- Involve obstetrics early, determine gestation and rhesus status, and arrange fetal assessment appropriate to viability after maternal stabilisation; give anti-D according to the maternity protocol when indicated.
- Treat low-energy falls in frail older people as potentially major: fully expose, examine spine, chest, pelvis and head, reconcile baseline cognition and mobility and use a lower imaging threshold.
- Identify anticoagulant name, indication, last dose, adherence, renal function and interacting drugs immediately; send coagulation tests but recognise routine PT or APTT may not exclude direct-oral-anticoagulant effect.
- For warfarin-associated traumatic intracranial haemorrhage, NICE supports immediate prothrombin-complex concentrate with intravenous vitamin K through the emergency reversal protocol.
- After haemostasis, reassess reversal, thromboprophylaxis and anticoagulant restart daily with the relevant specialist because both recurrent bleeding and thrombosis are time-dependent.
Key red flags
Pregnancy with shock, abdominal pain, vaginal bleeding, uterine tenderness, contractions or reduced fetal movement requires maternal resuscitation plus immediate obstetric assessment for abruption, uterine injury and fetal compromise.
An older person with new confusion, inability to mobilise, focal spine or groin pain, chest-wall tenderness or anticoagulant exposure may have major occult injury after a seemingly minor fall.
Head impact, neurological change, persistent vomiting, unexplained haemoglobin fall, expanding bruising or hypotension in an anticoagulated patient requires urgent imaging, drug identification and reversal planning.
Investigation priorities
Identify life threats and pregnancy modifiers without delaying resuscitation.
Diagnose maternal head, spine, thoracic, abdominal or pelvic injury accurately.
Management branches
A pregnant patient has sustained potentially significant trauma.
- Run CABCDE, provide spinal protection as indicated and use manual uterine displacement or compatible left tilt in later pregnancy while treating maternal threats.
- Activate trauma, anaesthetic and obstetric teams, establish gestation and rhesus status and control haemorrhage with standard maternal priorities.
- Proceed with the best indicated maternal imaging after rapid radiology optimisation; do not substitute limited ultrasound for necessary CT.
- After stabilisation, monitor fetus and uterine activity according to gestation and symptoms and follow the maternity anti-D and fetomaternal-haemorrhage pathway.