GC207 Trauma Evaluation And Management (TEAM)
Trauma Evaluation and Management (TEAM) is a systematic educational framework that teaches the structured clinical approach to assessing, prioritizing, and managing injured patients using primary and secondary survey principles derived from ATLS.
This lecture is the TEAM (Trauma Evaluation And Management) programme — an ACS (American College of Surgeons) standardized curriculum based on the ATLS® (Advanced Trauma Life Support) course, adapted for medical students. It teaches you the systematic, reproducible approach to assessing and managing a trauma patient from the moment they arrive.
Why this matters for your exam: TEAM/ATLS principles are tested in nearly every trauma question — MCQs, SAQs, minicases, and OSCEs. Examiners are checking whether you follow the correct sequence (A → B → C → D → E), whether you know when to intervene vs. investigate, and whether you understand the physiological rationale behind each step. This is not a lecture where you pick and choose — every element is fair game.
How the lecture fits together:
- Why trauma matters (epidemiology, trimodal death distribution)
- Principles (treat the greatest threat first, time is of the essence)
- Preparation (prehospital + inhospital)
- Primary Survey (ABCDE + simultaneous resuscitation)
- Adjuncts (monitoring + diagnostic tools)
- Secondary Survey (AMPLE history, head-to-toe examination)
- Special Populations (children, pregnancy, elderly)
- Burns and Cold Injury
- Transfer and Definitive Care
Secondary Survey Adjuncts
The following special diagnostic tests may be performed during or after the secondary survey [1]:
- Blood tests
- Urinalysis
- X-rays (targeted)
- CT
- Urography
- Angiography
- Ultrasonography
- Echocardiography
- Bronchoscopy
- Oesophagoscopy
Do not delay transfer for diagnostic tests! [1]
1. Epidemiology & The Need for Early TEAM
Trauma is the leading cause of death in ages 1 through 44. [1]
Disabilities exceed deaths by a ratio of 3:1. [1]
Trauma-related costs > $400 billion per year. [1]
Lack of public awareness for injury prevention. [1]
Why this matters from first principles: Trauma disproportionately kills young, economically productive people. Unlike cancer or heart disease, these deaths are preventable with rapid systematic care. The "golden hour" concept exists because the second peak of death (early deaths) occurs within hours — and this is the window you, as a doctor, can influence.
| Peak | Timing | Causes | Intervention |
|---|---|---|---|
| 1st (Immediate) | Seconds to minutes | Aortic rupture, major vessel laceration, severe brain injury | Prevention (seatbelts, helmets, airbags) — these patients rarely survive regardless of care |
| 2nd (Early) | Minutes to hours | Epidural/subdural haemorrhage, haemopneumothorax, splenic/hepatic laceration, pelvic fractures with haemorrhage | TEAM/ATLS approach — this is where systematic care saves lives |
| 3rd (Late) | Days to weeks | Sepsis, multi-organ failure | Optimal ICU care, early definitive management |
High Yield - Trimodal Death Distribution
The trimodal distribution is the fundamental framework justifying the ATLS/TEAM approach. The second peak (early deaths) is the one you can change. Nearly all exam questions about "why systematic trauma management matters" come back to this concept. The third peak (late deaths) is reduced by preventing the "lethal triad" of hypothermia, acidosis, and coagulopathy. [1]
A – Analyse injury data, B – Build local coalitions, C – Communicate the problem, D – Develop prevention activities, E – Evaluate the interventions. [1]
This is a public health mnemonic — less commonly examined in clinical exams but may appear in community medicine or "system-based" questions.
Treat greatest threat to life first. Definitive diagnosis less important. Physiologic approach. Time is of the essence. Do no further harm. Teamwork required for TEAM to succeed. [1]
Unpacking each principle:
| Principle | Why It Matters |
|---|---|
| Treat greatest threat to life first | A bleeding patient who also has a fractured femur — you stop the bleeding first. The fracture can wait; exsanguination cannot. |
| Definitive diagnosis less important | You don't need a CT to diagnose tension pneumothorax — you needle decompress based on clinical findings. Delaying intervention for a definitive diagnosis kills patients. |
| Physiologic approach | Assess function (Is the airway patent? Is breathing adequate? Is there perfusion?) rather than cataloguing anatomical injuries. |
| Time is of the essence | The "golden hour" — mortality rises exponentially with delays in haemorrhage control and airway management. |
| Do no further harm | Log-roll for spine protection, avoid blind clamping, warm fluids to prevent hypothermia. |
| Teamwork | One person cannot do everything simultaneously. TEAM = Together Everyone Achieves More. |
Goals of Trauma Care
Rapid, accurate, and physiologic assessment. Resuscitate, stabilize, and monitor by priority. Prepare for transfer to definitive care. Team work for optimal, safe patient care. [1]
These four goals underpin every TEAM principle — they define the purpose of the systematic approach before you begin the ABCDE sequence.
Exam Trap
A common MCQ distractor: "Obtain a CT scan to confirm diagnosis before needle decompression for suspected tension pneumothorax." This is WRONG. In ATLS/TEAM, you treat immediately based on clinical diagnosis. Definitive diagnosis is secondary to saving life.
3. Preparation
Closest, appropriate facility. Transport guidelines/protocols. On-line medical direction. Mobilization of resources. Periodic review of care. [1]
Key concept: "Closest appropriate facility" — not just the nearest hospital. A trauma patient with a penetrating chest wound needs a trauma centre with surgical capabilities, not a small clinic. This concept is the basis of trauma system design.
Preplanning essential. Team approach. Trained personnel. Proper equipment. Lab/x-ray capabilities. Standard precautions. Transfer agreements. QI program. [1]
Standard Precautions (PPE for trauma):
Cap, Gown, Gloves, Mask, Shoe covers, Goggles/face shield. [1]
Why all of these? Trauma involves high-velocity blood exposure. Universal precautions assume every patient is potentially infectious (HIV, Hepatitis B/C). This is both an infection control and an ethical/legal standard.
Sorting of patients according to: ABCDEs, Available resources, Other factors (e.g. salvageability). [1]
Two triage scenarios:
- Multiple casualties (patients > resources but manageable): Treat the most severely injured first (most salvageable who need immediate intervention)
- Mass casualties (patients overwhelm resources): Treat those with the greatest chance of survival — a philosophical shift. You may bypass a patient who needs a 3-hour surgery for 10 patients who each need 15-minute interventions.
4. Primary Survey (ABCDE) — The Core of TEAM
The primary survey priorities are the same for all! [1]
The cardinal rule: You MUST complete A before moving to B, B before C, etc. If at any point a problem is identified, you address it immediately before moving on. If the patient deteriorates, you go back to A and start again.
The lecture presents the overall TEAM sequence as a cyclical process with four phases [1]:
- Rapid primary survey — ABCDE + Adjuncts
- Detailed secondary survey / reevaluation — Head-to-toe + Adjuncts
- Safe transfer
- Definitive care
What the TEAM “clock” diagrams show: a cyclical sequence (primary → secondary → transfer → definitive care), not a one-pass checklist — if the patient deteriorates you spin back to ABCDE. Team-role slides label TL (team leader) vs procedure roles so someone owns the sequence. [1]
Critically, assessment and resuscitation occur simultaneously — the primary survey and resuscitation of vital functions happen at the same time, as do the secondary survey and reevaluation of vital functions. [1]
Assess for airway patency: Snoring, Gurgling, Stridor, Rocking chest wall motions, Maxillofacial trauma / laryngeal injury. [1]
Why these signs matter:
- Snoring → tongue/soft palate obstruction (most common cause in unconscious patients)
- Gurgling → fluid/blood/vomit in the airway
- Stridor → partial upper airway obstruction (laryngeal injury, foreign body)
- Rocking/see-saw chest wall motions → attempts to breathe against an obstructed airway (paradoxical abdominal/chest movement)
Resuscitation — Establishing a Patent Airway:
Chin lift / Modified jaw thrust. Look, listen, feel. Remove particulate matter. Definitive airway as necessary. Reassess frequently. [1]
| Manoeuvre | When to Use | Rationale |
|---|---|---|
| Chin lift | Basic airway opening | Lifts tongue off posterior pharyngeal wall |
| Modified jaw thrust | Suspected c-spine injury | Opens airway WITHOUT extending the neck |
| Suction | Fluid/blood in airway | Clears secretions |
| OPA/NPA | Unconscious patient (OPA) or conscious with nasal patency (NPA) | Maintains airway patency as adjunct |
| Definitive airway (ETT/surgical) | GCS ≤ 8, inability to maintain airway, apnoea, burns with inhalation injury | Only a cuffed tube in the trachea is "definitive" |
High Yield - C-spine Protection
Always assume cervical spine injury until proven otherwise. Use manual in-line stabilisation during intubation. Never use head-tilt chin-lift in trauma — always jaw thrust. C-spine injuries should be suspected with: injury above clavicles, altered level of consciousness, other severe painful injuries (distracting injuries). [1]
Contraindications for nasogastric tube / nasopharyngeal airway insertion — signs of base of skull fracture:
CSF rhinorrhea/otorrhea, periorbital ecchymosis (raccoon eyes), mid-face instability, hemotympanum [1]
If any of these are present, use the orogastric route instead of nasogastric to avoid intracranial passage.
Assessment:
Chest rise and symmetry. Air entry. Rate/Effort. Color/Sensorium. [1]
Why each matters:
- Asymmetry → pneumothorax, haemothorax, flail chest
- Absent air entry on one side → tension pneumothorax until proven otherwise in a hypotensive trauma patient
- Tachypnoea → pain, pneumothorax, metabolic acidosis from shock
- Cyanosis → severe hypoxia
Resuscitation — Breathing:
Administer supplemental oxygen. Ventilate as needed. Tension pneumothorax: Needle decompression. Open pneumothorax: Occlusive dressing. Reassess frequently. [1]
Oxygen for all trauma patients. [1]
Caution during breathing assessment: Always consider tension pneumothorax and open pneumothorax as immediately life-threatening conditions requiring intervention before proceeding. [1]
| Life-Threatening Chest Injury | Clinical Findings | Immediate Treatment |
|---|---|---|
| Tension Pneumothorax | Hypotension, distended neck veins, absent breath sounds (unilateral), tracheal deviation (late sign) | Needle decompression (2nd ICS MCL or 4th/5th ICS MAL) → followed by chest tube |
| Open Pneumothorax ("sucking chest wound") | Wound in chest wall with air sucking in/out | Occlusive dressing taped on 3 sides (acts as flutter valve) → then chest tube |
| Massive Haemothorax | > 1500 mL blood in chest; dullness to percussion, absent breath sounds, shock | Volume resuscitation + tube thoracostomy → if > 1500 mL initial output or > 200 mL/hr ongoing → thoracotomy [2] |
| Cardiac Tamponade | Beck's triad: hypotension, muffled heart sounds, distended neck veins | Pericardiocentesis → operative repair [1] |
| Flail Chest | Paradoxical segment movement, crepitus, underlying pulmonary contusion | Oxygen, analgesia, consider intubation + ventilation if respiratory failure |
Oxygen for all trauma patients. [1]
Hemorrhagic shock — External: Apply direct pressure. Internal: Chest, abdomen, pelvis, retroperitoneum. Identify: History, physical, and investigation. [1]
First principle: In trauma, assume shock is hypovolaemic/haemorrhagic until proven otherwise. The most common cause of shock in trauma is haemorrhage.
Where is the blood? Five places to look for occult haemorrhage:
- Chest (haemothorax)
- Abdomen (solid organ injury — spleen, liver)
- Pelvis (pelvic fracture)
- Retroperitoneum (renal, great vessel injury)
- External / "on the floor"
Long bone fractures (femur) can also harbour significant blood loss (up to 1.5L per femur).
Assessing Organ Perfusion:
Level of consciousness. Skin color. Pulse rate and character. [1]
| Sign | Physiological Basis |
|---|---|
| Altered consciousness | Brain is exquisitely sensitive to hypoperfusion; confusion/agitation = early shock |
| Pale, cool, clammy skin | Sympathetic vasoconstriction shunts blood from skin to vital organs |
| Tachycardia | Baroreceptor reflex → increased HR to maintain cardiac output |
| Narrow pulse pressure | Increased diastolic (vasoconstriction) + decreased systolic (reduced stroke volume) |
| Weak/thready pulse | Reduced stroke volume |
| Decreased urine output | Renal vasoconstriction + ADH → oliguria is an early sign of inadequate perfusion |
Resuscitation — Circulation:
Obtain venous access. Restore circulating volume — Ringer's lactate, 1-2 L. PRBCs if transient response or no response. Reassess frequently. [1]
2 large-caliber IVs [1]
Why Ringer's Lactate? It is an isotonic crystalloid that closely matches plasma electrolyte composition. The lactate is metabolised to bicarbonate by the liver, providing a mild buffering effect. Normal saline is an alternative but carries risk of hyperchloraemic metabolic acidosis with large volumes.
Classification of Haemorrhagic Shock
Class I: < 15% (750 mL), Responder, Crystalloid. Class II: 15-30% (1500 mL), Transient responder, Crystalloid. Class III: 30-40% (2000 mL), Transient responder, Crystalloid + blood, ?OR. Class IV: > 40% ( > 2000 mL), Non-responder, Crystalloid + blood + OR. [1]
| Parameter | Class I | Class II | Class III | Class IV |
|---|---|---|---|---|
| Blood loss (mL) | < 750 | 750–1500 | 1500–2000 | > 2000 |
| Blood loss (% BV) | < 15% | 15–30% | 30–40% | > 40% |
| Heart rate | < 100 | 100–120 | 120–140 | > 140 |
| Blood pressure | Normal | Normal | Decreased | Decreased |
| Pulse pressure | Normal/↑ | Decreased | Decreased | Decreased |
| Respiratory rate | 14–20 | 20–30 | 30–40 | > 35 |
| Urine output (mL/hr) | > 30 | 20–30 | 5–15 | Negligible |
| Mental status | Slightly anxious | Mildly anxious | Anxious, confused | Confused, lethargic |
| Response to fluid | Responder | Transient | Transient | Non-responder |
| Fluid replacement | Crystalloid | Crystalloid | Crystalloid + blood | Crystalloid + blood + OR |
High Yield - Shock Classification
The key discriminator between Class II and III is blood pressure — it remains normal in Class II but drops in Class III. This is because young, healthy patients can compensate with tachycardia and vasoconstriction up to ~30% blood loss before systolic BP falls. Tachycardia is often the earliest sign — don't wait for hypotension. [1] [2]
Populations that modify shock response:
Children (vigorous initial response but decompensate rapidly), Elderly (diminished reserve, may be on beta-blockers masking tachycardia), Athletes (high baseline fitness, compensate longer), Pregnancy (expanded blood volume — can lose 30-35% before signs appear), Medications (beta-blockers, calcium channel blockers blunt tachycardic response). [1]
Non-Haemorrhagic Shock in Trauma:
Cardiac tamponade. Tension pneumothorax. Neurogenic. Septic (late). [1]
| Type | Mechanism | Key Differentiator |
|---|---|---|
| Cardiac tamponade | Blood in pericardial sac compresses heart → reduced filling | Beck's triad; distended neck veins |
| Tension pneumothorax | Pressure in pleural space → mediastinal shift → compressed vena cava | Absent breath sounds, tracheal deviation, distended neck veins |
| Neurogenic shock | Loss of sympathetic tone below spinal cord lesion | Hypotension WITH bradycardia (not tachycardia!) + warm, pink extremities |
| Septic (late) | Occurs days later, not on initial presentation | Fever, warm peripheries, high cardiac output |
Exam Trap - Neurogenic vs Hypovolaemic Shock
Neurogenic shock presents with hypotension + bradycardia + warm peripheries (loss of sympathetic tone). Hypovolaemic shock presents with hypotension + tachycardia + cool, clammy peripheries. If you see a spinal cord injury patient who is hypotensive but bradycardic — think neurogenic. But ALWAYS rule out haemorrhage first; spinal cord injury patients can bleed too.
Resuscitation considerations for C:
Tension pneumothorax: Needle decompression + tube thoracostomy. Massive haemothorax: Volume resuscitation + tube thoracostomy. Cardiac tamponade: Pericardiocentesis + direct operative repair. [1]
Bleeding? Find it! — Direct pressure, Operation, Avoid blind clamping. [1]
Why avoid blind clamping? You risk clamping nerves, veins, or uninvolved structures, causing iatrogenic injury. Direct pressure is safer and usually effective for external bleeding.
Baseline neurologic evaluation: GCS Score, Pupillary response, Neurosurgical consult as indicated. Reevaluate for neurologic deterioration. [1]
Glasgow Coma Scale (GCS):
Eye opening: Range 1–4. BEST Motor response: Range 1–6. Verbal response: Range 1–5. Score = E + M + V. Best = 15. Worst = 3. [1]
| Component | Response | Score |
|---|---|---|
| Eye Opening (E) | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Motor (M) | Obeys commands | 6 |
| Localises pain | 5 | |
| Withdrawal (flexion) | 4 | |
| Abnormal flexion (decorticate) | 3 | |
| Extension (decerebrate) | 2 | |
| None | 1 | |
| Verbal (V) | Orientated | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| None | 1 |
Intracranial Pressure (ICP) Curve:
The lecture shows the classic ICP vs. Volume of Mass curve. Initially, the brain compensates by displacing CSF and venous blood (flat part of the curve). Once compensatory mechanisms are exhausted, the point of decompensation is reached, and ICP rises exponentially with any further increase in mass (steep part). Beyond this is herniation. [1]
This is why early detection and intervention (evacuating haematomas) is critical — by the time the patient herniates, you've lost the window.
Pupillary response:
- Fixed, dilated pupil → ipsilateral uncal herniation compressing CN III → surgical emergency
- Bilateral fixed, dilated pupils → brainstem compression, grave prognosis
- Always check and document pupils during primary survey as a baseline
Completely undress the patient. Remove helmet if present. Look for visible/palpable injuries. Log roll, protect spine. Prevent hypothermia. [1]
Why undress completely? Injuries are missed under clothing. A stab wound to the back, an exit wound, perineal injuries — all invisible until the patient is fully exposed. The log roll (with spine protection) allows examination of the back, which is commonly the site of missed injuries.
Prevent hypothermia [1]
Why hypothermia is lethal in trauma — the "lethal triad":
- Hypothermia → impairs coagulation cascade (enzymatic reactions are temperature-dependent), impairs cardiac function
- Acidosis → from tissue hypoperfusion (lactic acidosis)
- Coagulopathy → dilutional (from crystalloid resuscitation) + consumptive (DIC) + hypothermia-induced
Each worsens the other in a vicious cycle. Preventing hypothermia means: warm IV fluids, warming blankets, warm room, minimise exposure time.
5. Adjuncts to Primary Survey
Vital signs, ABGs, ECG, Pulse oximetry, End-tidal CO2. [1]
| Monitor | What It Tells You |
|---|---|
| Vital signs | Trending HR, BP, RR — detecting early shock |
| ABG | Acidosis (base deficit = marker of under-resuscitation), oxygenation, ventilation |
| ECG | Arrhythmias (myocardial contusion), PEA (tamponade, tension pneumothorax) |
| SpO2 | Oxygenation (unreliable in hypothermia, poor perfusion, CO poisoning) |
| EtCO2 | Confirms ETT placement, monitors ventilation adequacy |
Chest / pelvis x-ray. C-spine x-rays when appropriate. FAST. DPL. [1]
| Tool | Purpose | Key Points |
|---|---|---|
| CXR | Haemothorax, pneumothorax, widened mediastinum (aortic injury), rib fractures | Done in resuscitation room — portable AP film |
| Pelvis XR | Pelvic fracture (source of massive haemorrhage) | Single AP view |
| C-spine XR | Cervical fracture/dislocation | Lateral + AP + odontoid (largely replaced by CT in many centres) |
| FAST (Focused Assessment with Sonography for Trauma) | Free fluid in abdomen/pelvis/pericardium | 4 windows: RUQ (Morrison's pouch), LUQ (splenorenal), pelvis (Douglas' pouch / retrovesical), subxiphoid (pericardium). Quick, repeatable, bedside |
| DPL (Diagnostic Peritoneal Lavage) | Intra-abdominal haemorrhage | Largely replaced by FAST/CT but still examined; positive if aspirate is grossly bloody or lavage fluid has > 100,000 RBCs/mm³ [2] |
Blood at meatus? Decompress bladder. Monitor urinary output. [1]
Contraindications to urethral catheterisation (suspect urethral injury):
Blood at meatus. Perineal ecchymosis/haematoma. High-riding prostate. [1]
If any of these are present → do NOT insert a urethral catheter → consult urology → suprapubic catheter.
Why monitor urine output? It is the best bedside marker of renal perfusion and therefore adequacy of resuscitation:
Blood or bile? Decompress stomach. [1]
When to use orogastric instead of nasogastric:
CSF rhinorrhea/otorrhea. Periorbital ecchymosis. Mid-face instability. Hemotympanum. [1]
These signs indicate base of skull fracture — a nasogastric tube could pass intracranially through the cribriform plate. Use orogastric route instead.
6. Secondary Survey
Start after: Primary survey completed. Resuscitation in process. ABCDEs reassessed. Vital functions returning to normal. [1]
The secondary survey is a head-to-toe physical examination combined with a focused history. It is never performed before the primary survey is complete and the patient is being resuscitated.
A – Allergies. M – Medications. P – Past illnesses / Pregnancy. L – Last meal. E – Events / Environment. [1]
| Component | Why It Matters |
|---|---|
| Allergies | Avoid anaphylaxis from antibiotics, contrast, etc. |
| Medications | Beta-blockers mask tachycardia; anticoagulants worsen bleeding; steroids mask inflammation |
| Past illnesses / Pregnancy | Comorbidities affect management; pregnancy changes physiology and X-ray decisions |
| Last meal | Aspiration risk during intubation/anaesthesia |
| Events / Environment | Mechanism of injury predicts injury pattern (e.g. unrestrained MVC → think thoracic aortic injury, cervical spine) |
Mechanism of injury → Pattern of injury [1]
This is a crucial concept. The mechanism tells you what injuries to actively look for:
| Mechanism | Expected Injury Pattern |
|---|---|
| Frontal MVC (unrestrained) | C-spine, anterior flail chest, myocardial contusion, aortic disruption, liver/spleen laceration, posterior hip dislocation |
| Lateral MVC | C-spine, lateral rib fractures, splenic/hepatic injury (depending on side), pelvic fracture |
| Pedestrian struck | Lower limb fractures (bumper injury), head injury, thoraco-abdominal injuries |
| Fall from height | Calcaneal fractures, thoracolumbar vertebral fractures, pelvic fractures, aortic injury |
| Penetrating (knife) | Injury generally limited to knife track; low velocity |
| Penetrating (gunshot) | Cavitation effect; injuries far from bullet track; consider trajectory |
Head: Complete neurologic exam, GCS Score, Comprehensive eye/ear exam [1]
Caution during head examination: Be aware of limitations in the unconscious patient, periorbital oedema (limiting eye exam), and occluded auditory canal (limiting ear exam). [1]
Maxillofacial: Bony crepitus/instability, Palpable deformity, Comprehensive oral/dental exams [1]
Caution during maxillofacial examination: Look for potential airway obstruction, cribriform plate fracture (contraindication to NG tube), and note that maxillofacial injuries are frequently missed. [1]
C-spine: Palpate for tenderness, Complete motor/sensory exams, Reflexes, C-spine imaging [1]
C-spine imaging is needed when:
Injury above clavicles. Altered LOC. Other severe, painful injury (distracting injury). [1]
Neck: Blunt vs penetrating. Airway obstruction, hoarseness. Crepitus, hematoma, stridor, bruit. Delayed symptoms/signs. [1]
High Yield - Neck Injury
Penetrating neck injuries can present with delayed symptoms/signs — vascular injuries may be initially contained by surrounding tissue, only to present hours later with expanding haematoma, airway compromise, or stroke. Any penetrating injury that breaches the platysma requires formal exploration or CT angiography. [1] [5]
- Inspect, auscultate, palpate, percuss
- Reevaluate frequently
- Chest x-rays
- Caution: Missed injury; monitor for ↑ chest tube drainage [1]
- Inspect, auscultate, palpate, percuss
- Reevaluate frequently
- Special studies: FAST, DPL, CT
- Caution: Hollow viscus and retroperitoneal injuries are easily missed; avoid excessive pelvic manipulation [1]
| Area | Findings to Assess |
|---|---|
| Perineum | Contusions, haematomas, lacerations, urethral blood |
| Rectum | Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood |
| Vagina | Blood, lacerations |
Caution: Always consider pregnancy in female patients of reproductive age. [1]
- Potential blood loss
- Limb or life threat (identified in primary survey)
- Missed fractures
- Soft-tissue or ligamentous injury
- Occult compartment syndrome — especially with altered LOC / hypotension [1]
- Examine patient's back (log roll with spine protection)
- Complete motor and sensory exams
- Imaging as indicated
- Maintain inline immobilisation
- Early neurosurgical consultation [1]
7. Special Populations
Leading cause of death. Immature, anatomic/mechanical features. Vigorous physiologic response. Limited physiologic reserve. Outcome depends on early, aggressive care. [1]
Size, dosage, equipment, surface area, and psychology. [1]
| Feature | Clinical Implication |
|---|---|
| Airway: Larynx anterior and cephalad, short tracheal length | More difficult intubation; use uncuffed ETT in children < 8 years (traditionally); risk of right mainstem intubation |
| Breathing: Chest wall pliable, mediastinal mobility | Rib fractures are rare (compliant ribs) — if present, suspect significant force; mediastinal shift occurs more readily with tension pneumothorax |
| Circulation: Vascular access difficult, fluid volume proportional | Use IO access if IV fails; fluid bolus = 20 mL/kg RL; blood volume ~80 mL/kg |
| Neurologic: Vomiting, seizures, diffuse brain injury | Open fontanelles may mask rising ICP initially; diffuse axonal injury more common than focal haematomas |
| Surface area: Large BSA:volume ratio | Hypothermia develops rapidly — aggressive warming essential |
| Psychology: Fear, regression | Explain procedures; parental presence when safe |
High Yield - Paediatric Shock
Children have a vigorous physiologic response — they maintain blood pressure until very late in haemorrhagic shock (up to 30-45% blood loss). When they decompensate, they crash rapidly. Tachycardia and poor capillary refill in a child are RED FLAGS for significant haemorrhage — don't be falsely reassured by a "normal" blood pressure. [1] [4]
Anatomic/physiologic changes modify response to injury. Need for fetal assessment. 1st Priority: Maternal resuscitation. Outcome depends on early, aggressive care. [1]
Gestation and position of uterus. Physiologic anemia. ↓ PCO2. ↓ Gastric emptying. Supine hypotension. Isoimmunization. Sensitivity of fetus. [1]
| Change | Clinical Implication |
|---|---|
| ↑ Blood volume (30-50%) | Can lose significant blood before signs of shock appear → delayed tachycardia/hypotension |
| Physiologic anaemia | Dilutional — Hb may be ~10-11 g/dL normally; lower threshold for transfusion |
| ↓ PCO2 (respiratory alkalosis) | Normal PCO2 ~30 mmHg in pregnancy; a "normal" 40 mmHg may indicate ventilatory failure |
| ↓ Gastric emptying | Aspiration risk is higher → early nasogastric tube, rapid sequence intubation |
| Supine hypotension | After 20 weeks, the gravid uterus compresses IVC → left lateral tilt or manual uterine displacement |
| Isoimmunization | Rh-negative mother exposed to Rh-positive fetal blood → give anti-D (RhoGAM) |
| Sensitivity of fetus | Fetal circulation is last to be preserved → fetal distress may be first sign of maternal compromise |
High Yield - Pregnancy and Trauma
The best treatment for the fetus is optimal resuscitation of the mother. Maternal resuscitation is always the first priority. Place the patient in the left lateral position (or tilt the spine board 15-30° left) to prevent IVC compression. If the mother is Rh-negative, administer anti-D immunoglobulin. [1] [6]
5th leading cause of death. Diminished physiologic reserve and response. Comorbidities: Diseases/Medications. Outcome depends on early, aggressive care. [1]
| Factor | Impact |
|---|---|
| Reduced cardiac reserve | Cannot increase heart rate/contractility as effectively → shock presents atypically |
| Medications | Beta-blockers prevent tachycardia; anticoagulants (warfarin, DOACs) worsen bleeding |
| Osteoporosis | Low-energy mechanisms can cause significant fractures |
| Reduced renal function | Drug metabolism altered; fluid overload risk |
| Pre-existing conditions | COPD, heart failure, diabetes — each complicates management |
8. Burns and Cold Injury
Inhalation injury: Intubate and administer 100% oxygen. [1]
Why early intubation? Airway oedema from thermal/chemical inhalation injury can progress rapidly. A patent airway now may become completely obstructed in 30 minutes. If you suspect inhalation injury (singed nasal hairs, facial burns, carbonaceous sputum, hoarseness, stridor, history of closed-space fire) — intubate early before oedema makes it impossible.
Administer 2–4 mL/kg/% BSA burn in 24 hours (+ maintenance in children). Monitor urinary output. Expose and prevent hypothermia. Chemical burns: Brush and irrigate. [1]
Parkland Formula:
- 4 mL × body weight (kg) × % TBSA burned = total fluid in first 24 hours
- Give half in the first 8 hours (from time of burn, not from time of arrival), the other half over the next 16 hours
- Use Ringer's Lactate
- Children need maintenance fluid in ADDITION to resuscitation fluid
- Titrate to urine output ≥ 0.5 mL/kg/hr (adult) or ≥ 1 mL/kg/hr (child)
Palm + fingers = approximately 1% BSA [1]
Rule of Nines:
| Body Region | Adult (%) | Child (%) |
|---|---|---|
| Head | 9 | 18 |
| Each upper limb | 9 | 9 |
| Anterior trunk | 18 | 18 |
| Posterior trunk | 18 | 18 |
| Each lower limb | 18 | 14 |
| Perineum | 1 | 1 |
| Total | 100 | 100 |
Children have proportionally larger heads and smaller legs compared to adults.
Frostbite: Rewarm with moist heat (40°C); wait for demarcation. [1]
Why 40°C? Temperatures above 42°C cause tissue burns. Below 37°C, rewarming is too slow. 40°C is the sweet spot for effective rewarming without additional injury. "Wait for demarcation" — early surgery leads to unnecessarily aggressive debridement. The tissue often demarcates over weeks, and what initially looks necrotic may recover.
Hypothermia: Passive or active rewarming. Monitor: Not dead until warm and dead. [1]
"Not dead until warm and dead" is a clinical axiom: hypothermic patients may appear clinically dead (pulseless, apnoeic) but can survive with full neurological recovery if rewarmed. The cold brain requires less oxygen — hypothermia is neuroprotective. You must rewarm to at least 32-35°C before pronouncing death.
If in doubt, establish definitive airway. Oxygen for all trauma patients. Chest tube may be definitive for chest injury. Stop the bleeding! 2 large-caliber IVs. Prevent hypothermia. [1]
10. Transfer and Definitive Care
Consider need for transfer [1]
When to transfer:
- Injuries beyond the capability of the receiving hospital
- Need for neurosurgical, cardiothoracic, or other specialist intervention
- Before transferring: stabilise ABCDEs, establish lines, secure airway, chest tubes as needed, communicate with receiving team
Safe transfer principles:
- Resuscitate before transfer
- Document all findings
- Send all imaging
- Ensure monitoring during transport
- Direct doctor-to-doctor communication
Slide-derived transfer principles: [1]
- Transfer when patient's needs exceed institutional resources
- Use time before transfer for resuscitation — do not waste it
- Do not delay transfer for diagnostic tests
- Physician-to-physician communication is mandatory
Transfer pathway: Local facility → (via transfer agreements / local resources) → Trauma centre or Specialty centre [1]
High index of suspicion. Frequent reevaluation. Continuous monitoring. Rapidly recognize patient deterioration. [1]
Missed injuries are a major source of preventable morbidity. Maintain vigilance through repeated ABCDE reassessment, especially after initial resuscitation stabilises the patient.
Relieve pain and anxiety as appropriate. Administer intravenously. Careful patient monitoring is essential. [1]
Analgesics should be given IV (not IM) in trauma — IM absorption is unpredictable in shocked patients with poor peripheral perfusion.
For mass casualty / disaster scenarios [1]:
- Simple plan
- Command structure
- Disaster triage scheme
- Traffic control system
TL – Team Leader, A – Airway Manager, N – Nurse, 1 – Assistant, 2 – Assistant. Together Everyone Achieves More. [1]
Team Leader:
- Directs the overall assessment
- Does NOT perform procedures (hands-off leadership)
- Coordinates communication
- Makes final decisions
Closed-loop communication: team member acknowledges orders verbally before executing. This prevents errors.
Summary Teaching Points
The lecture concludes with four overarching principles that tie the entire TEAM approach together [1]:
- One, safe way — a single standardised approach for every trauma patient
- Do no further harm
- Treat greatest threat to life first
- Teamwork
The assessment follows the ABCDE → Head-to-Toe sequence, with continuous reevaluation linking primary survey adjuncts → resuscitation → secondary survey adjuncts → safe transfer → definitive care in an interconnected cycle. [1]
Exam Intelligence
| Trap | Correct Answer | Why Students Get It Wrong |
|---|---|---|
| "What is the first step in managing a trauma patient?" | A – Airway with C-spine protection | Students jump to "Stop the bleeding" (C) because it sounds more dramatic |
| "Patient with suspected tension pneumothorax — next step?" | Needle decompression (NOT chest X-ray) | Tension pneumothorax is a clinical diagnosis; waiting for CXR kills the patient |
| "Neurogenic shock vs hypovolaemic shock" | Neurogenic = hypotension + bradycardia + warm skin | Students assume all shock = tachycardia |
| "When to start secondary survey?" | After primary survey is complete AND resuscitation is underway AND ABCDEs are reassessed | Students think secondary survey happens simultaneously |
| "Blood at meatus — next step?" | Do NOT insert urethral catheter → retrograde urethrogram first or suprapubic catheter | Students reflexively catheterise |
| "Pregnant trauma patient — first priority?" | Maternal resuscitation | Students focus on fetal monitoring first |
| "Parkland formula" | 4 mL × kg × %TBSA, half in first 8 hours | Students forget the "half in first 8 hours" detail or start timing from hospital arrival instead of time of burn |
| "Signs of base of skull fracture (contraindication to NG tube)" | Raccoon eyes, CSF rhinorrhoea/otorrhoea, Battle's sign, hemotympanum | Students insert NG tube through cribriform plate fracture |
| "Pelvic fracture management" | Volume resuscitation + reduce pelvic volume + external fixator ± angiography/embolisation | Students forget to reduce pelvic volume or consider angiography |
| "Pain management in trauma" | Give analgesia IV (not IM) with monitoring | Students give IM analgesia, which is unreliable in shock |
| "When to transfer" | When patient's needs exceed institutional resources — do NOT delay for diagnostic tests | Students order CT before arranging transfer |
| "GCS for intubation" | GCS ≤ 8 = intubate | Students use wrong threshold |
| "Class II vs III shock" | Class II: BP normal, HR 100-120. Class III: BP decreased, HR 120-140 | BP is the discriminator — drops in Class III |
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Tension pneumothorax vs cardiac tamponade: Both have distended neck veins and hypotension. Breath sounds differentiate: absent in tension pneumothorax, present in tamponade. Tracheal deviation occurs in tension pneumothorax (late), not tamponade.
-
FAST vs DPL: FAST is non-invasive, repeatable, operator-dependent. DPL is invasive but highly sensitive. FAST has largely replaced DPL in most centres.
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Chin lift vs jaw thrust: Both open the airway. Jaw thrust is used when C-spine injury is suspected (it doesn't extend the neck).
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Pelvic fracture haemorrhage management: Volume resuscitation alone is insufficient — must also reduce pelvic volume (binder/sheet) and consider external fixation or angiography/embolisation.
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Secondary survey timing: Begins only after primary survey is complete, resuscitation is underway, ABCDEs are reassessed, AND vital functions are returning to normal — all four conditions must be met.
-
Missed injuries: Maintain a high index of suspicion with frequent reevaluation and continuous monitoring — missed injuries are a leading cause of preventable trauma deaths.
High Yield Summary
- TEAM/ATLS is the systematic approach to the injured patient. The key framework is
- Primary Survey: ABCDE — A (Airway + C-spine), B (Breathing + ventilation), C (Circulation + haemorrhage control), D (Disability/GCS), E (Exposure + prevent hypothermia). Treat each life threat AS you find it.
- Haemorrhagic shock is the most common cause of shock in trauma.** Classify by the 4-class system. Blood pressure drops only in Class III ( > 30% loss). Tachycardia is the earliest sign.
- Life-threatening chest injuries** diagnosed and treated during primary survey: tension pneumothorax (needle decompression), open pneumothorax (3-sided occlusive dressing), massive haemothorax (chest tube + resuscitation), cardiac tamponade (pericardiocentesis).
- GCS ≤ 8 = intubate.** Motor component is most prognostically important.
- Adjuncts:** CXR, pelvis XR, FAST, urinary catheter (check for meatal blood first), gastric catheter (use OG route if base of skull fracture signs).
- Secondary survey** starts only after primary survey is complete and resuscitation underway. AMPLE history + head-to-toe examination.
- Special populations:** Children compensate then crash; pregnant patients — resuscitate mother first, left lateral tilt, anti-D if Rh-negative; elderly — blunted responses, medications mask signs.
- Burns:** Parkland formula (4 mL/kg/%TBSA, half in first 8 hours). Intubate early for inhalation injury. Rule of Nines for BSA estimation.
- The lethal triad** (hypothermia + acidosis + coagulopathy) must be actively prevented.
- "Not dead until warm and dead" — do not pronounce death in hypothermic patients until rewarmed.
Active Recall - Trauma Evaluation and Management
[1] Lecture slides: GC 207. Trauma Evaluation and Management (TEAM).pdf [2] Lecture slides: GC 188. Hit by a van, in shock with internal bleeding Abdominal injury.pdf [3] Lecture slides: GC 208. Unconscious after an accident Head injury.pdf [4] Lecture slides: GC 145. A critically ill child childhood medical emergencies.pdf [5] Lecture slides: GC 182. Chopped and stabbed wound in gang fight Nerves and vascular injury; Classification of injuries.pdf [6] Lecture slides: CFB (OGPAE01-2) Perinatal Medicine, Antenatal Care and Pre-pregnant Counselling (Part II).pdf
GC205 The Newborn Baby Is Vomiting Repeatedly Neonatal Intestinal Obstruction And Other GI Emergencies
Neonatal intestinal obstruction and other gastrointestinal emergencies are conditions such as atresias, malrotation with volvulus, meconium ileus, and necrotizing enterocolitis that present with repeated vomiting in the newborn and require urgent diagnosis and intervention.
GC208 Unconscious After An Accident Head Injury
Unconsciousness following traumatic head injury is a state of impaired awareness resulting from brain damage due to external force, often involving concussion, intracranial hemorrhage, or diffuse axonal injury requiring urgent neurological assessment and management.