TRAUMA

Introduction & Definition

Trauma refers to any physical injury caused by an external force, including blunt force,
penetrating injuries, burns, crush and blast injuries. It is a leading cause of morbidity and
mortality worldwide. Trauma management follows ATLS (Advanced Trauma Life Support)
principles, emphasizing rapid assessment and intervention.

Epidemiology

• 9 people die every minute due to trauma-related injuries.

• Trauma accounts for 12% of the global disease burden.
• Road Traffic Accidents (RTAs) alone cause 1 million deaths annually.
• Trauma-related costs exceed $500 billion per year.
• 90% of RTAs occur in developing countries.
• Trimodal death distribution: Immediate (seconds-minutes), Early (hours), and Late
(days-weeks).

Classification of Trauma
A. Based on Mechanism of Injury

1. Blunt Trauma – Caused by impact (e.g., RTAs, falls, assaults).

2. Penetrating Trauma – Sharp objects or projectiles breaching body structures (e.g.,
gunshot wounds, stab injuries).
3. Burns & Chemical Injuries – Thermal, electrical, radiation, or corrosive injuries.
4. Blast Trauma – Due to explosions, causing mixed blunt and penetrating injuries.
5. Crush Injury – Prolonged compression of body parts leading to tissue ischemia,
necrosis, and systemic complications (e.g., crush syndrome, rhabdomyolysis).

B. Based on Severity

• Minor Trauma: Soft tissue injuries, simple fractures.

• Major Trauma: Life-threatening injuries requiring urgent intervention.

C. Based on Body System Involved

1. Head Trauma – Skull fractures, Traumatic Brain Injury (TBI), concussion, intracranial
hemorrhage.
2. Chest Trauma – Rib fractures, pneumothorax, hemothorax, cardiac contusion.
3. Abdominal Trauma – Liver, spleen, kidney injuries, bowel perforation, internal
bleeding.
4. Spinal Trauma – Cervical, thoracic, or lumbar spine injuries, spinal cord damage,
paralysis.
5. Limb Trauma – Fractures, dislocations, crush injuries, compartment syndrome.
6. Vascular Trauma – Arterial or venous injuries, hemorrhage, deep vein thrombosis
(DVT).

Pathophysiology of Trauma
• Primary Injury: The initial impact causing tissue damage.
• Secondary Injury: Ischemia, hypoxia, infection, inflammatory response leading to
further damage.
• Tertiary Injury: Late complications like sepsis, multi-organ failure.
• Systemic Effects: Trauma-induced coagulopathy, systemic inflammatory response
syndrome (SIRS), multi-organ dysfunction syndrome (MODS).

Trauma Assessment & Management

A. Prehospital Care

Goals:
• Airway maintenance.
• External bleeding control.
• Prevention of shock.
• Spinal immobilization.
• Rapid transport to a hospital.

First Responder Actions

• Ensure Scene Safety: Avoid hazards before approaching the patient.
• Rapid Assessment & Triage: Identify life-threatening injuries.
• Initiate Early Transport: Preferably to a trauma center.
• Communicate with Hospital: Relay vital signs, injuries, estimated arrival time.

Primary survey (ABCDE Approach):

• A - Airway with C-Spine Control

➢ Assess airway patency; clear obstruction, place airway adjuncts if suction needed.
➢ Jaw-thrust, chin-lift, head-tilt (avoid head tilt in suspected C-spine injury).
➢ Immobilize cervical spine.
• B - Breathing
➢ Check breathing (rate, depth, effort), auscultate chest.
➢ Provide oxygen via a non-rebreather mask or bag-valve-mask (BVM) if
avalable.
➢ Recognize tension pneumothorax (needle decompression if trained).

• C - Circulation with Hemorrhage Control

➢ Control bleeding by compression and support
➢ Assess BP, pulse, skin color, capillary refill.
➢ Establish IV access, initiate fluid resuscitation if available.
.
• D - Disability (Neurological Status - GCS Score)
➢ Assess Glasgow Coma Scale (GCS): Eye Opening (4), Verbal Response (5),
Motor Response (6)
➢ Check pupil reaction, motor/sensory deficits.

• E - Exposure & Environment Control

➢ Completely expose the patient, prevent hypothermia.
➢ Transport: Rapid evacuation to a trauma center with appropriate resuscitation.

Gather information for Hospital Triage:

• Time of injury
• Mechanism of injury
• Patient history
• Events leading to injury

B. Hospital Management

Triage In Hospital

• Sorting of patients based on severity and hospital resources.

o Multiple Casualties: Facility can handle all patients.
o Mass Casualties: Facility exceeds capacity, requiring prioritization.
• Treatment is based on ABC priorities.

Primary Trauma Survey (ABCDE)

1. Airway with Cervical Spine Protection

• Check for airway obstruction (blood, vomitus, foreign body).
• Signs of Airway Obstruction:
o Agitation, Cyanosis (Hypoxia)
o Obtundation (Hypercarbia)
o Stridor, Snoring, Gurgling
o Tracheal deviation
• Managements:
o Suctioning to clear the airway.
o Chin-lift or jaw-thrust maneuver (if cervical injury is suspected).
o Orotracheal (Gold standard) or nasotracheal intubation for airway
compromise. (Intubation if GCS <8)
o Cricothyroidotomy or tracheostomy (if intubation fails).

2. Breathing and Ventilation

• Assess respiratory rate, oxygen saturation, chest movement, tracheal position.
• Look for pneumothorax, hemothorax, flail chest (Dullness = Hemothorax,
Hyperresonance = Pneumothorax).
• Managements:
o Oxygen via non-rebreather mask (if breathing is intact).
o Needle thoracostomy: For tension pneumothorax.
o Chest tube (28–32 Fr): For hemothorax, open pneumothorax.
o Positive pressure ventilation: For flail chest.

3. Circulation with Hemorrhage Control

• Assess skin color, pulse, blood pressure, capillary refill, and signs of shock.
• Control external bleeding using direct pressure, tourniquets (if severe).
• Managements:
o Control the bleeding to resist significant blood loss (e.g.; Pelvic binder for
pelvic fractures).
o Two large-bore IV cannulas (18G or larger) for fluid resuscitation.
o IV fluids (Ringer's lactate, normal saline).
o Blood transfusion if hemorrhage is significant.
o Massive transfusion protocol (MTP): If class III/IV shock.
o Vasopressors (dopamine, norepinephrine): If hypotension persists.

4. Disability (Neurological Status)

• Use Glasgow Coma Scale (GCS):
o Mild (GCS 13-15) – Minor injury.
o Moderate (GCS 9-12) – Needs close monitoring.
o Severe (GCS ≤8) – Intubate.
• Check pupil size, limb movement, signs of increased ICP(Intracranial Pressure).
• Managements:
o Mannitol, hypertonic saline for raised ICP. (Normal ICP- 5 to 15 mmHg)
o Secure airway if GCS <8.
o Neurosurgical intervention: For hemorrhage or skull fractures.
o Spinal immobilization: For suspected spinal cord injury.

5. Exposure and Environmental Control

• Completely expose the patient to identify injuries.
• Prevent hypothermia using warm blankets, fluid warmers.
• Examine joints, bones, abdomen, other systems
• Look for identification marks
• Managements:
o Direct pressure, tourniquets, hemostatic agents.
o Surgical exploration: If bleeding is uncontrolled.
o Pelvic binder: For pelvic fractures.

Secondary Trauma Survey

• History: AMPLE (Allergies, Medications, Past Illness, Last Meal, Events leading to
injury).
• Blood Work: CBC, coagulation profile, cross- matching, electrolytes, blood gas analysis.
• Neurological exam (GCS, pupils, motor response).
• Spinal assessment (log-roll, palpation for tenderness/deformity).
• Physical Examination: Complete head-to-toe assessment.
• Use required tubes like catheter, Ryle's tube.
• Diagnostic Imaging: FAST (Focused Assessment with Sonography for Trauma), CT, X-
ray, ECG.

o FAST (Focused Assessment with Sonography for Trauma )

Definition:
FAST is a rapid bedside ultrasound to detect free fluid (blood) in the
peritoneal, pericardial, and pleural cavities in trauma patients.

Indications:

• Blunt or penetrating trauma to the abdomen or chest.

• Hemodynamically unstable trauma patients.
• Suspected hemoperitoneum, hemothorax, or cardiac tamponade.

Views Examined:

1. Pericardial – Cardiac tamponade.

2. Right upper quadrant (Morrison’s pouch) – Liver/kidney injury.
3. Left upper quadrant (Splenorenal recess) – Splenic injury.
4. Pelvic (Pouch of Douglas) – Free fluid in the pelvis.

Extended FAST (eFAST):

• Adds lung views to assess for pneumothorax/hemothorax.

Key Points:

➢ Quick (2–5 min), non-invasive, repeatable.

➢ Avoids radiation exposure.
➢ Operator-dependent, may miss small injuries.

FAST is a first-line tool in trauma for rapid internal bleeding assessment.

Tertiary Survey

• Examine all orifices like P/R, PN, etc.

• Performed within 24 hours to detect missed injuries.
• Includes repeat clinical exam, detailed imaging (CT, MRI, X-rays).

Specific Trauma Conditions & Management

A. Head Trauma

• Types:
o Concussion- A mild traumatic brain injury (TBI) caused by a blow to the head,
leading to temporary loss of brain function.
o Contusion- A localized brain bruise due to trauma, causing bleeding and swelling
within brain tissue.
o Skull fractures- Breaks in the skull bone that may be linear, depressed, or involve
the base.
o Scalp lacerations- Cuts or tears in the scalp.
o Intracranial hemorrhage (EDH, SDH, SAH)-
▪ Epidural Hematoma (EDH) – Arterial bleeding between the skull and dura
mater.
▪ Subdural Hematoma (SDH) – Venous bleeding between the dura and
arachnoid mater.
▪ Subarachnoid Hemorrhage (SAH) – Bleeding into the subarachnoid space.
• Examine the eyes, nose, ears for CSF leakage.
• CT Brain for all moderate-severe head injuries.
• Sign of Brain Herniation: (Brain tissue shifts abnormally due to increased ICP)
o Fixed, dilated pupil.
o Decerebrate posturing.
o Cushing’s Triad (Hypertension, Bradycardia, Irregular breathing).
• Signs of Basal Skull Fracture: (A fracture at the skull base)
o Battle’s Sign (Mastoid Ecchymosis)- Bruising behind the ear over the mastoid
process.
o Raccoon Eyes (Periorbital Ecchymosis)- Bruising around both eyes.
o CSF Otorrhea, Rhinorrhea- Leakage of cerebrospinal fluid from the ear (otorrhea)
or nose (rhinorrhea).
• Management:
o Initial Assessment- ABCDE approach
o Control Bleeeding
o Maintain oxygenation and BP; avoid hypotension.
o Specific Treatment:
▪ Concussion: Rest, observation.
▪ Contusion & Skull Fractures: Monitor, surgery if needed.
▪ EDH/SDH/SAH: Surgery if large; ICP management.
▪ Brain Herniation: Mannitol, hypertonic saline, neurosurgery.
▪ CSF Leak: Head elevation, avoid nose blowing, possible surgery.
▪ Monitoring & ICU Care

B. Neck Trauma

• Types:
o Blunt Neck Trauma:
▪ Common in road traffic accidents (RTAs), falls, sports injuries.
▪ Can cause vascular, airway, esophageal, or spinal cord injury.
o Penetrating Neck Trauma:
▪ Gunshot wounds, stab wounds, shrapnel injuries.
▪ Can damage major vessels (carotid, jugular), trachea, esophagus, or vertebrae.
• ZONES OF THE NECK (Neck injuries are divided into three anatomical zones)
o Zone I: Base of skull to cricoid cartilage
▪ Injury Risk: Subclavian artery, trachea, esophagus, brachial plexus.
o Zone II: Cricoid cartilage to angle of the mandible (most common)
▪ Structures at Risk: Carotid artery, Jugular vein, Larynx, Esophagus.
o Zone III: Above the angle of the mandible
▪ Injury Risk: Vertebral artery, Skull base, Cranial nerves.
• Physical Exam: Palpate trachea, check voice changes, swelling.
• Imaging:
o X-ray: Cervical spine alignment.
o CT Angiography: Vascular injury.
o Bronchoscopy/Laryngoscopy: Airway evaluation.
• Management:
o Primary survey: ABCDE approach
o Airway Protection: Intubation or surgical airway (tracheostomy/ cricothyroidotomy)
if needed.
o Bleeding Control: Direct pressure, hemostatic agents, surgical repair.
o Spinal Immobilization: C-collar if cervical spine injury is suspected.
o Oxygen, fluids, blood transfusion if needed.

C. Chest Trauma

• Inspect, palpate, auscultate for rib fractures, pneumothorax.

• Types: Rib fractures, pneumothorax, hemothorax, flail chest, cardiac tamponade.
• Perform FAST (Focused Assessment with Sonography for Trauma).
• Management: Chest tube placement, pericardiocentesis, ventilatory support.
o Initial Assessment- ABCDE approach.
o Control external Bleeeding.
o Maintain oxygenation and BP.
o Tension Pneumothorax → Needle Decompression (2nd ICS Midclavicular Line).
o Open Pneumothorax → 3-sided occlusive dressing + Chest Tube.
o Flail Chest → Oxygen, Positive Pressure Ventilation.
o Massive Hemothorax → Chest Tube + Blood Transfusion.
o Cardiac Tamponade (Beck's Triad) → Urgent pericardiocentesis
o ICU monitoring and care.

D. Abdominal Trauma

• Types: Liver, spleen, kidney injuries, bowel perforation.

• Mechanisms of Injury:
o Blunt Trauma:
▪ Commonly affects the spleen (40-55%) and liver (35-45%).
o Penetrating Trauma:
▪ Stab wounds: Small bowel (50%), colon (40%), liver (30%).
▪ Gunshot wounds: More severe, causing visceral damage.
• Clinical Examination:
o Palpate for peritonitis (guarding, rigidity, rebound tenderness).
o Bruising Signs:
▪ Grey-Turner Sign (Flank ecchymosis – retroperitoneal bleeding).
▪ Cullen Sign (Periumbilical ecchymosis – intraperitoneal bleeding).
▪ Kehr Sign (Left shoulder pain – splenic rupture).
▪ Balance Sign (LUQ dullness – splenic hematoma).
• Diagnosis:
o FAST (Focused Assessment Sonography for Trauma)
▪ Evaluates Pericardial, Hepatorenal, Splenorenal, Pelvic pouches.
▪ If positive for fluid → Emergency laparotomy.
o CT Scan (Gold Standard)
▪ Used in hemodynamically stable patients for detailed injury assessment.
o Diagnostic Peritoneal Lavage (DPL)
▪ Indications:
➢ Unstable patient with equivocal FAST.
➢ Findings: RBC > 100,000/mm³ or WBC > 500/mm³ → Laparotomy
indicated.

• Management:
o Initial Assessment- ABCDE approach.
o Control External Bleeeding.
o Fluid resuscitation and oxygen therapy.
o FAST ultrasound for bleeding in:
➢ Pericardium
➢ Hepatorenal fossa
➢ Splenorenal fossa
➢ Pelvis
o Non-Operative Management (NOM)- For hemodynamically stable patients
without peritonitis or ongoing hemorrhage, requires ICU monitoring, serial exams,
repeat imaging.
o Surgical (Exploratory Laparotomy) Indications:
➢ Hemodynamic instability with positive FAST.
➢ Peritonitis, Evisceration.
➢ Massive hemoperitoneum on imaging.
➢ Gunshot wounds involving peritoneal cavity.
➢ Free air under the diaphragm (suggests perforation).
o Damage Control Surgery (DCS)- For severe trauma with massive hemorrhage, it
involves:
➢ Hemorrhage control (packing, vessel ligation)
➢ Temporary abdominal closure
➢ Definitive repair after stabilization
o Pelvic Fractures:
➢ Apply pelvic binder.
➢ Consider angiographic embolization for bleeding.
o Antibiotics for hollow organ injuries
o ICU monitoring for shock, sepsis, and multi-organ failure

E. Spinal Trauma

• Types: Spinal cord contusion, vertebral fractures, complete/incomplete cord injury.

• Spinal Shock vs Neurogenic Shock:
o Spinal Shock: Loss of reflexes, flaccidity.
o Neurogenic Shock: Hypotension, bradycardia.
• Neurological Assessment: Check consciousness level (GCS, ASIA Scoring)), limb
movements, and sensation.
• Imaging: X-ray, CT, MRI
• Assess reflexes, motor, sensory functions.
• Check spinal cord injury signs (loss of sensation, paraplegia).
• Cord Syndromes:
o Central Cord Syndrome: Weakness upper limbs > lower limbs.
o Anterior Cord Syndrome: Paraplegia, loss of pain/temp.
o Brown-Sequard Syndrome: Ipsilateral motor loss, contralateral pain/temp loss.
• Complete a detailed neurological examination.

• Management:
o Suspect in all polytrauma cases.
o Primary Survey- ABCDE Approach (C-Spine control)
o Neurogenic Shock (Bradycardia, Hypotension) → IV Fluids, Vasopressors.
o Spinal Shock (Flaccid paralysis) → Supportive care.
o Immediate Immobilization with cervical collar and spine board.
o Thoracolumbar Brace for thoracic/lumbar injuries.
o Methylprednisolone (controversial, not routinely used).
o Surgical decompression or spinal fusion if needed.
o Bladder & Bowel Management for spinal cord injury patients.
o Pain Management
o Physiotherapy & Occupational Therapy to regain mobility.
F. Limb Trauma

• Types: Fractures, crush injuries, compartment syndrome.

• Check for deformity, swelling, wounds, or bruising.
• Neurovascular Assessment: Check sensation, motor function, and pulses
• Inspect for open fractures or penetrating injuries.
• Move the joints above and below the injury site (unless fracture is suspected)
• Imaging: X-ray, CT scan, MRI, or Droppler USG
• Management:
o Primary Survey- ABCDE Approach
o Closed Reduction: For simple fractures and dislocations.
o Open Reduction & Internal Fixation (ORIF): For unstable fractures.
o RICE Therapy (Rest, Ice, Compression, Elevation) for soft tissue injuries.
o Splinting or Casting: Provides immobilization and stability.
o External Fixation: Used for open fractures or severe soft tissue damage.
o Vascular Surgery: If limb ischemia is present, revascularization is needed.
o Fasciotomy for compartment syndrome.
o Early Mobilization: Prevents stiffness, muscle wasting.
o Wound Care: Wound cleaning, tetanus prophylaxis, suturing if needed, prevents
infection in open fractures.
o Physiotherapy: Improves strength and function.

G. Vascular Trauma

• Types:
o Transection: Complete disruption of the vessel.
o Laceration: Partial vessel tear.
o Contusion: Blunt trauma causing vessel wall damage.
o Thrombosis/Embolism: Blockage due to clot formation.
o Arteriovenous Fistula (AVF): Abnormal connection between artery and vein.
o Pseudoaneurysm: Blood leakage forming a contained hematoma.
• Focused Vascular Assessment ("5 P’s of Limb Ischemia")
o Pain (severe, out of proportion).
o Pallor (pale or mottled skin).
o Pulselessness (absent distal pulses).
o Paresthesia (numbness or tingling).
o Paralysis (loss of function, late-stage).
• Neurovascular Assessment: Check capillary refill, sensation, motor function, and peripheral
pulses.
• Limb Immobilization: Splint fractures to prevent further vascular injury.
• Imaging: Droppler USG (first line), CT Angiography (Gold Standard), Conventional
Angiography, or CT/ X-ray.
• Management:
o Primary Survey- ABCDE Approach
o Control Bleeding: Direct pressure, tourniquet (only for life-threatening hemorrhage),
hemostatic dressing.
o IV fluids (crystalloids), Blood transfusion to maintain circulation.
o Anticoagulation (if no risk of bleeding).
o Direct Repair (Primary Anastomosis): Suturing the damaged vessel.
o Vascular Grafting: Using autologous vein (e.g., saphenous) or synthetic grafts.
o Endovascular Stenting: For select arterial injuries.
o Thrombectomy/Embolectomy: Removing clots to restore blood flow.
o Physiotherapy & Limb Care: If prolonged ischemia occurred.
o Wound Care & Infection Prevention: Antibiotics for open wounds.

Special Considerations

1. Burn Trauma:
o Parkland formula: 4ml × kg × %TBSA for fluid
resuscitation (Ringer’s Lactate).
▪ 1st Half in 8 hours
▪ 2nd Half in next 16 hours
o Debridement: Remove necrotic tissue.
o Topical Antibiotics: Silver sulfadiazine,
bacitracin.
o Dressing: Non-stick, sterile dressing, change
daily
o Escharotomy for compartment syndrome.
o Skin Grafting: For deep burns to aid healing.
o Infection Prevention: Tetanus prophylaxis, Antibiotics.
o Oxygen Theraphy.
o Pain Management: NSAIDs, IV opoids.
2. Blast Trauma:
o Primary injury: Barotrauma (lung, ear, GI rupture).
o Secondary injury: Debris causing lacerations.
o Tertiary injury: Impact with objects.
o Focused Assessment with Sonography for Trauma (FAST), X-ray/ CT, CT
brain, Endoscopy.
o ABCDE approach
o Head to toe Examination
o Oxygen Theraphy (Mechanical ventilation if severe)
o Fasciotomy for compartment syndrome in crush injuries.
o IV fluids for rhabdomyolysis (to prevent kidney failure). (Avoid excessive IV
fluids can worsen pulmonary edema)
o Surgical Intervention.
3. Drowning Trauma:
o ABCDE support: Early intubation, ventilation.
o Remove from water immediately, ensuring rescuer safety.
o Assess responsiveness & breathing (Shout & Shake, Check Airway).
o If unresponsive & not breathing, begin CPR immediately.
o ABG, chest X-ray, electrolytes and renal function.
o Oxygen therapy (mask or nasal cannula).
o Rewarming: If hypothermic.
o Secure airway (intubation if needed).
o Mechanical ventilation with PEEP (to treat ARDS).
o CPR if in cardiac arrest (ACLS protocol).
o IV fluids carefully (avoid worsening pulmonary edema).
o Consider ECMO (Extracorporeal Membrane Oxygenation) in severe cases.

Shock in Trauma
A. Types of Shock

1. Hemorrhagic Shock: Most common; due to blood loss.

2. Cardiogenic Shock: Due to blunt cardiac injury, cardiac tamponade.
3. Neurogenic Shock: Spinal cord injury causing hypotension, bradycardia.
4. Septic Shock: Secondary to infections in trauma patients.
5. Obstructive Shock: Caused by tension pneumothorax, cardiac tamponade.

B. Management

• Fluid Resuscitation: Crystalloids (large bore cannulas or central line), blood transfusion
(Massive Transfusion Protocol in [Link] ratio if >10 units required in 24 hours).
• Control Bleeding: Direct pressure, surgical intervention, embolization.
• Ensure airway patency (intubate if GCS < 8) and provide 100% oxygen (face mask or
mechanical ventilation if needed).
• Correct Coagulopathy: FFP, platelets, TXA (Tranexamic Acid).
• Norepinephrine: First-line for neurogenic or septic shock.
• Dobutamine: For cardiogenic shock.
• Antibiotics for septic shoke.
• Needle decompression (tension pneumothorax), chest tube, pericardiocentesis.
• Monitor Vital Signs (BP, HR, SpO₂, urine output, Lactate Clearance).
• Temperature Control: Prevent hypothermia (warm fluids, blankets).

Damage Control Surgery & Massive Transfusion

• Damage Control Surgery (DCS)

o Initial surgery to control hemorrhage & contamination in severely injured trauma

patients.

o Delay definitive repair until patient stabilizes.

o Indications for Damage Control Surgery:

▪ Severe hemorrhagic shock (SBP < 90 mmHg, massive bleeding).
▪ Multiple life-threatening injuries (e.g., liver, spleen, major vessels).
▪ Severe coagulopathy (INR > 1.5, low platelets, prolonged PT/aPTT).
▪ Severe hypothermia (< 34°C).
▪ Acidosis (pH < 7.2, lactate > 4 mmol/L).
▪ Abdominal compartment syndrome (intra-abdominal hypertension).

• Massive Transfusion Protocol (MTP)

o Definition: Massive transfusion is defined as ≥10 units of packed red blood

cells (PRBCs) within 24 hours or ≥4 units in 1 hour in a trauma patient.
o Components:

▪ [Link] ratio of PRBCs, FFP, Platelets → Ideal for hemorrhagic shock.

▪ [Link] ratio (PRBC: FFP: Platelets) → Used in some cases.
▪ TXA (Tranexamic Acid) 1g IV within 3 hrs.
o Indications for MTP Activation:
▪ Penetrating trauma with SBP < 90 mmHg, HR > 120 bpm.
▪ Blunt trauma with pelvic or long bone fractures, massive bleeding.
▪ Positive FAST exam with free intra-abdominal fluid.
▪ Ongoing hemorrhage despite initial IV fluid resuscitation.
▪ Low base excess (< -6) or high lactate (> 4 mmol/L).

Trauma Scores & Prognostic Indicators

A. Glasgow Coma Scale (GCS)

• Measures neurological function (Eye, Verbal, Motor

response).
• Score range: 3 (worst) to 15 (best).
• Mainly used for head injury classification.

GCS Score Severity

13 - 15 Mild brain injury
9 - 12 Moderate brain injury
≤8 Severe brain injury (coma)

B. Revised Trauma Score (RTS)

• Based on GCS, Systolic BP (SBP), and Respiratory Rate (RR).

• Range: 0 (worst) to 12 (best).
• RTS < 4 → Indicates high mortality risk.
Parameter 4 Points (Normal) 3 Points 2 Points 1 Point 0 Points (Worst)
GCS 13 - 15 9 - 12 6 - 8 4-5 3
SBP (mmHg) ≥ 89 76 - 89 50 - 75 1 - 49 0
RR (breaths/min) 10 - 29 ≥ 30 6-9 1-5 0
• RTS Calculation Formula:
RTS=(GCS×0.936)+(SBP×0.732)+(RR×0.290)
• Higher RTS = Better survival chances.

C. Abbreviated Injury Scale (AIS)

• Each body region is scored from 1 (minor) to 6 (unsurvivable).

• Used in ISS (below).

D. Injury Severity Score (ISS)

• Measures trauma severity based on AIS scores for 3 worst-injured body regions.
• Formula:
ISS = (AIS1)2+(AIS2)2+(AIS3)2
• Score range: 0 to 75.
ISS Score Severity
<9 Minor Trauma
9 - 15 Moderate Trauma
16 - 24 Severe Trauma
≥ 25 Critical Trauma (High Mortality)
• ISS > 25 → High risk of mortality.

E. New Injury Severity Score (NISS)

• Similar to ISS, but considers three most severe injuries regardless of body region.
• More accurate for polytrauma patients.

F. Trauma and Injury Severity Score (TRISS)

• Predicts survival probability using ISS, RTS, and patient age.

• Formula:
Survival Probability (Ps) = 1÷{1 + e -b}
Where,
b = β0+(β1×RTS)+(β2×ISS)+(β3×Age)
• β- values differ for blunt & penetrating trauma.
• Ps > 0.5 → Higher survival chance.

H. CRAMS Score (Circulation, Respiration, Abdominal, Motor, Speech)

The CRAMS Score is a prehospital trauma triage tool used to assess the severity of trauma
and predict patient outcomes. It evaluates five parameters:
Score 2 Score 1 (Mild Score 0 (Severe
Category
(Normal) Impairment) Impairment)
Circulation (SBP mmHg) ≥ 100 50 - 99 < 50
Respiration (Rate & Effort) Normal Dyspnea or Abnormal Apnea
Abdomen/Thorax No Injury Minor Injury Major Injury
Motor Function (GCS Motor) Normal Weakness Paralysis
Speech (Verbal Response -
Normal Confused No response
GCS Verbal)
• Total Score Range: 0 to 10
• CRAMS ≤ 6 → Indicates need for hospital-based trauma care.
• Higher scores indicate better outcomes and lower mortality risk.

I. Shock Index (SI)

The Shock Index (SI) is a quick and effective tool for assessing the severity of shock in trauma
patients. It is calculated as:
SI = Heart Rate (HR) ÷ Systolic Blood Pressure (SBP)
• Normal SI: 0.5 - 0.7
• SI > 0.9: Suggests early shock and increased mortality risk
• SI > 1.0: Indicates severe shock and need for aggressive resuscitation
• Clinical Implications of SI:
Shock Index (SI) Clinical Interpretation
< 0.5 Normal, no shock
0.5 - 0.7 Mild stress, normal in healthy individuals
0.7 - 0.9 Early shock, monitor closely
> 0.9 High risk of hypovolemia/shock
> 1.0 Critical, immediate resuscitation needed

Complications of Trauma
1. Immediate
o Hemorrhagic shock, airway obstruction, cardiac tamponade, hypoxia, traumatic
arrest.
2. Early
o DIC (Disseminated Intravascular Coagulation), DVT, secondary brain injury,
pulmonary embolism, compartment syndrome, ARDS (Acute Respiratory
Distress Syndrome).
3. Late
o Sepsis, multi-organ failure, disability, paralysis, osteomyelitis, PTSD.
Trauma Prevention Strategies
• Road Safety Measures: Helmets, seat belts, speed limits.
• Workplace Safety: Protective equipment, training.
• Fall prevention : Secure handrails, proper lighting, remove hazards.
• Violence Prevention: Community programs, conflict resolution, self-defense training.
• Community Awareness: First aid training, emergency response teams.
• Early Diagnosis & Treatment: Quick medical intervention to prevent complications.
• Protective Equipment: Knee pads, sports gear, airbags in vehicles.