Major Trauma | Acute Management | (C)ABCDE

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This guide provides an overview of the recognition and immediate management of a major trauma patient using a (C)ABCDE approach.

Usually, airway compromise is the fastest cause of mortality. However, in trauma, catastrophic haemorrhage must be considered. Therefore, in trauma management the ABCDE approach is slightly altered:

• Catastrophic haemorrhage
• Airway (with c-spine protection)
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the (C)ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified, and the patient is re-assessed regularly to monitor their response to treatment.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care. Please note that this guide refers to the management of adult major trauma.

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Background

What is major trauma?

Major trauma can be defined as “an injury or combination of injuries that are life-threatening and could be life-changing because it may result in long-term disability.” ¹

Hence, anything causing injury or injuries that threaten life would be considered major trauma. Examples may include:

• Road traffic collisions
• Injuries from sports or extreme sports or equestrianism
• Fall from height
• Assault
• Workplace related injury

Major trauma is the leading cause of death in people under the age of 45.¹

However, in defining major trauma, it is important to consider frailty and comorbidity. Smaller traumas, such as falls from standing height, may not cause significant trauma in young healthy patients but can cause significant injury to older, more frail patients with multiple comorbidities.

Therefore, the threshold for considering something a major trauma, and initiating a trauma assessment, should be lower in such patients. These cases are sometimes referred to as “silver trauma.”

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Initial steps

Introduction

Introduce yourself to the team, including your name and role.

In practice, there is usually a team leader who is separate from the doctor carrying out the primary survey. In an OSCE scenario, you may be fulfilling both roles.

If feasible, it is sensible to have a team brief before the arrival of a trauma patient, where everyone introduces themselves, makes an initial plan, and divides up management (for instance, in real-life settings, major trauma calls are usually attended by an anaesthetist – it would be sensible for airway management to be handled by them!)

Handover

Usually, you will receive a brief handover from a team member about the patient. This may be in SBAR or ATMIST and should include the patient’s details (if known), the circumstances of their injury, and any information gathered from prehospital/nursing assessment.

During the handover, everyone should remain quiet and still if possible to ensure nothing is missed, this is known as a “hands-off handover” (although it may be necessary to initiate treatment immediately).

Maintaining a calm and quiet environment around the patient avoids causing them further stress and allows for better communication within the team.

Patient introduction

Introduce yourself to the patient including your name and role.

In the context of major trauma, this may not be possible due to impaired consciousness.

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Catastrophic haemorrhage

Clinical assessment

While we will look more closely at haemorrhage management in the second “C” section of this assessment, it is important to identify any large volume external bleeding at this stage. Look for any obvious high-volume blood loss.

Interventions

If any large bleeds are present, take immediate action to promote haemostasis. This could involve direct pressure, haemostatic dressing application, or tourniquets.

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Airway (with c-spine protection)

Clinical assessment (airway)

Look

Without moving the patient, visibly inspect the neck for any obvious injuries. In major trauma, certain injuries are more likely to be associated with airway compromise. These include significant facial trauma, facial burns, and haemorrhage.

Listen

Listen to how the patient sounds. If they are talking normally, then their airway is patent. If this is the case, you can move on to assessing the c-spine.

If they have a hoarse voice, or you can hear stridor (a harsh sounding inspiratory noise) or a snoring sound, this indicates partial airway compromise.

Consciousness level

It is also widely said that patients with a GCS score of eight or less cannot maintain their airway (“GCS eight – intubate!”). This is not always the case, but you should be aware that reduced levels of consciousness can affect a patient’s ability to maintain their airway.

Interventions (airway)

Definitive airway

If a patient cannot maintain their airway, then a definitive airway should be secured with rapid sequence induction (RSI) of anaesthesia and intubation, as soon as possible.⁷

In practice, this is usually performed in hospital by an anaesthetist. However, it may be performed by a prehospital or emergency medicine doctor with appropriate training.

Very rarely, if the airway is exceptionally difficult, a surgical airway may be required often via surgical cricothyroidotomy (scalpel-bougie-tube method) rather than needle cricothyroidotomy.¹³

If a hard collar has been fitted, this needs to be removed for intubation. Manual in-line stabilisation should be performed, this should be done by a separate person to the intubator and the airway assistant.

Simple manoeuvres and airway adjuncts

While awaiting a definitive airway, the airway can be supported with a jaw thrust manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upward and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

The head-tilt chin-lift should be avoided in trauma, to avoid exacerbating a c-spine injury.

Airway adjuncts such as oropharyngeal, nasopharyngeal, or laryngeal mask airways can also be used.⁸ A nasopharyngeal airway should be avoided if there are signs of a base of skull fracture including otorrhoea, panda eyes, or battle’s sign.

Clinical assessment (c-spine)

The cervical spine should be assessed using the Canadian c-spine rules.⁹

In practice, most major trauma patients will have a distracting injury and/or dangerous mechanism, meaning the c-spine must be imaged before an injury can be excluded. They are likely to arrive with their c-spine already immobilised by the pre-hospital team. 

Investigations & procedures (c-spine)

Urgent imaging of the c-spine with a CT scan should be arranged in all cases of suspected c-spine injury. However, the patient needs to be stable enough to be taken to CT.

Interventions (c-spine)

If the patient has any high-risk factors or is low-risk but cannot rotate their head 45 degrees, then you should immobilise the c-spine.

Hard collar

A hard collar may be used if there is no airway compromise or deformity of the neck. If a hard collar is used, the airway should be reassessed after it is placed.⁹

Head blocks

Head blocks are solid foam blocks which are placed on either side of the head and then secured in place with tape.

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Breathing

In trauma, there are six widely recognised life-threatening chest injuries to be aware of. The acronym TOM CAT is used to recall them. These injuries should be considered as you work through the (C)ABCDE assessment.

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Bradypnoea in trauma may be secondary to raised ICP and is seen as part of the Cushing’s reflex. Consider other causes of a reduced RR such as opioid toxicity.
• Tachypnoea in trauma may be due to chest injury (haemothorax, pneumothorax or flail chest), direct airway injury or obstruction, diaphragmatic rupture, shock, acidosis, pain or anxiety

Review the patient’s oxygen saturations (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high risk of CO₂ retention.
• Hypoxaemia may be due to airway obstruction or injury, chest injury such as pneumothorax, aspiration or bradypnoea, amongst other causes.

See our guide to performing observations/vital signs for more details.

General inspection

From the end of the bed, observe the patient for signs of increased work of breathing, such as accessory muscle use or intercostal muscle recession. Look for any obvious cyanosis (blue tinge to the extremities or lips).

Look for any visible injury or deformity of the chest, such as a sucking chest wound (open pneumothorax, resulting in a visible wound that bubbles and/or makes a sucking noise during respiration).

Inspect the chest for uneven movement, which may indicate a pneumothorax or flail chest.

Tracheal position

Warn the patient before you palpate the trachea (“I am going to feel the middle of your neck”) as it can be uncomfortable or frightening. Then gently feel for the position of the trachea. The trachea should sit in the centre of the neck. 

In trauma, the most likely cause of acute tracheal deviation is a tension pneumothorax.

Chest wall assessment

Inspect and palpate the chest to assess its movement. The chest should expand and contract equally with each breath. In trauma, causes of unequal or uneven chest expansion include:

• Flail chest: where multiple adjacent ribs are fractured in multiple places, a chest section becomes “detached” from the chest wall and moves paradoxically during respiration. While the rest of the chest is expanding during inspiration, decreased pressure pulls the flail segment inwards, and vice versa during expiration. This can cause significant pain, further injury to the lung, and difficulty breathing.
• Pneumothorax/tension pneumothorax: injury to the chest damages the lung tissue and allows air to enter the chest cavity. This prevents expansion of the lung on the affected side. Therefore, the affected side will not rise and fall with respiration, leading to uneven chest movements.

Percussion

Systematically percuss the chest, working from the apex to the base of each side. Listen to the resulting sound, which should be resonant in a healthy person.

• Hyper-resonant percussion suggests underlying reduced density, such as air in the chest cavity (i.e. pneumothorax)
• Dullness indicates increased underlying density, such as from fluid (pleural effusion) or blood (haemothorax) in the chest cavity

Auscultation

Use a stethoscope to auscultate the patient’s chest. Clinical findings in trauma may include:

• Quiet or absent breath sounds, which may indicate reduced air entry, such as from pneumothorax or haemothorax
• Loud cracking, grinding, or popping sounds can originate from a rib fracture

Investigations and procedures

X-ray

In unstable patients (e.g those with severe respiratory or haemodynamic compromise), or who are not responding to resuscitation measures, a portable X-ray can be used to provide bedside imaging. The patient does not have to be moved from the resuscitation room, and the interruption to treatment is minimised.

CT scan

In the stabilised trauma patient, a CT scan can be used to provide more comprehensive imaging of the chest.¹¹

Interventions

Oxygen

If the patient has not already been intubated and ventilated and has low SpO₂, an increased respiratory rate, or increased work of breathing, you should administer oxygen. Typically, this will be 15 litres of oxygen via a non-rebreathe mask, aiming for a SpO₂ greater than 94%. The amount of oxygen administered can then be titrated down.

In patients with known type 2 respiratory failure, who are at risk of CO₂ retention, the target saturations should be 88-92%, and this may be better achieved using a 24% or 28% venturi mask.

Management of specific conditions

Further management will depend on the underlying condition:

• Tension pneumothorax: when a tension pneumothorax is identified it should be treated immediately, due to the risk of cardiac arrest. This can be done through finger thoracostomy in the “triangle of safety” – bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, and between the axilla and the horizontal level of the nipple. A chest drain can be inserted subsequently.
• Haemothorax: haemothorax is managed with the insertion of a chest drain. Larger volumes of blood loss (>1.5L from the chest drain being considered a “massive haemothorax”) may necessitate surgical intervention.
• Open pneumothorax: when a penetrating chest injury results in a pneumothorax, it creates a “sucking chest wound.” Acutely, this is managed by covering the wound with a sterile dressing, securely taped on 3 sides. The open side creates a valve, allowing air to exit but not enter the chest cavity. Once stabilised, a chest tube can be inserted, and surgery may be considered later.
• Flail chest: this increases work of breathing significantly and can often lead to respiratory failure. Early intubation and ventilation are sometimes required, and later discussion with surgeons for repair.

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Circulation

Haemorrhage

Major haemorrhage is defined as:²

• Loss of more than one blood volume within 24 hours
• 50% of total blood volume lost in less than 3 hours
• Bleeding in excess of 150 mL/minute

However, in an acute scenario, you are unlikely to be able to calculate blood loss as above. Therefore, a major haemorrhage can be considered as bleeding (visible or presumed) which results in:²

• A blood pressure <90mmHg systolic
• A heart rate >110bpm

For locating a haemorrhage, remember “on the floor, and four more”.

Investigations and procedures

There are two main imaging modalities for identifying the location of a bleed in a trauma patient:⁴

• CT scanning: whole-body CT scan is the most accurate, but the patient must be stable enough to tolerate the scan
• Ultrasound: FAST ultrasound scanning is a relatively quick bedside imaging technique which can be used when immediate conveyance to CT is not feasible. However, it cannot rule out intra- or retroperitoneal bleeding

Interventions

Management of bleeding consists of three key elements: stopping the bleeding, replacing the lost blood volume, and avoiding the “lethal triad”.

Stopping the bleeding

For external (“on the floor”) bleeds, direct pressure and dressings can be used. In limb injuries, if this fails, you could consider a tourniquet. Internal bleeding from pelvic fractures can be controlled with a pelvic binder.

Pharmacological management with tranexamic acid, and reversal of anticoagulation, should also be considered at this point.

Uncontrollable/internal haemorrhage may need to be controlled surgically.

Replacing lost blood volume

Establish intravenous access (or, where this is not possible, intraosseous access) and replace lost volume early. In the United Kingdom, hospitals will have “major haemorrhage protocols” which should be followed. In general:⁴

• Crystalloids should not be used for volume replacement in hospital settings
• “Replace blood with blood”: a 1:1 ratio of units of plasma and red blood cells is recommended

Avoiding the lethal triad

The lethal triad in major haemorrhage refers to hypothermia, acidosis and coagulopathy. When they occur, they are irreversible and will result in death. Therefore, you should take early measures to avoid them:^5,6

• Hypothermia: keep warm with blankets, warmed air, use a blood warmer to give blood, and when examining the patient, limit their exposure to the minimum necessary
• Acidosis: maximise oxygenation and treat/prevent hypoventilation to prevent respiratory acidosis. Avoid giving crystalloids as this can exacerbate acidosis.
• Coagulopathy: avoid crystalloids or unbalanced blood products (see the ratio above) as they can cause dilutional coagulopathy^. Permissive hypotension (aiming for a target systolic of 80-100mmHg) can be used to avoid excessive fluid administration and prevent dilutional coagulopathy.

Other circulatory considerations

Observations

Review the patient’s heart rate:

• Causes of tachycardia (HR>99) may indicate hypovolaemia (e.g. a bleed), anxiety, or pain
• Causes of bradycardia (HR<60) may be a late sign of hypovolaemia

Elderly patients may not mount a tachycardia due to regular medications, such as beta-blockers.

Review the patient’s blood pressure:

• A normal blood pressure (BP) range is around 120/80mmHg
• Causes of hypertension include pain or anxiety
• Causes of hypotension include hypovolaemia/shock, tension pneumothorax and cardiac tamponade

Younger patients are likely to maintain their blood pressure through compensation and may present with tachycardia and a normal BP until severe decompensation occurs.

General inspection

Observe the patient for pallor, particularly of the extremities, which may indicate poor perfusion due to hypovolaemia.

Observe for any cyanosis or discolouration of injured limbs, which could indicate vascular compromise.

Palpation

Feel the temperature of the hands, they should be warm and well-perfused.

Assess the capillary refill time, it should be less than two seconds. If it is increased in all limbs, this may indicate hypovolaemia. If it is decreased centrally, then this indicates a more severe shock. If it is decreased in only one limb, then that may indicate vascular compromise as a result of injury.

Palpate the pulses, start with the radial pulse, if this cannot be palpated then check more centrally with the brachial, carotid or femoral pulses. If any limb is injured, assess the distal pulses in that limb, to ensure there is no vascular compromise.

Inspection of the JVP

Observe the neck for jugular venous distension. Jugular venous distension forms part of Beck’s triad, which indicates cardiac tamponade.

Auscultation

Using a stethoscope, auscultate the heart sounds. Muffled heart sounds can indicate cardiac tamponade.

Investigations and procedures

Cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests

Request the following blood tests:

• FBC
• U&Es
• LFTs
• Coagulation screen
• Group & save (+/- crossmatch)
• Toxicology screen (if you suspect drug overdose)
• Lactate (to assess for evidence of inadequate end-organ perfusion)

See our blood culture, blood bottle and investigation panel guides for more details.

ECG

Perform an ECG to identify any abnormal rhythms which may be contributing to poor perfusion.

In particular, look for ECG changes associated with cardiac tamponade:

• Low voltage QRS complexes
• Tachycardia
• Electrical alternans (where the QRS complexes alternate in height, due to the swinging motion of the heart within the pericardium)

Attach 3-lead continuous ECG monitoring if available.

See our guides to recording and interpreting an ECG for more details.

Interventions

The guidelines for the treatment of hypovolaemia in trauma have already been discussed under the “catastrophic haemorrhage” section.

Cardiac tamponade

A cardiac tamponade describes a large pericardial effusion and can be caused by blunt force or, more commonly, penetrating trauma to the chest.

The build-up of fluid around the heart prevents it from being able to pump blood effectively. It is treated by removing the fluid via pericardiocentesis – inserting a needle and aspirating the fluid, either using surgical landmarks or under ultrasound guidance. If pericardiocentesis is indicated, then the patient is likely to require cardiothoracic surgery and should be discussed with the cardiothoracic team.

Re-assessment

Make sure to re-assess the patient following any intervention.

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Disability

Clinical assessment

Consciousness level

Assess the patient’s level of consciousness by using the Glasgow Coma Scale (GCS) or AVPU scale.

A summary of the Glasgow coma scale is shown below. For a more detailed explanation, see the Geeky Medics guide to the Glasgow Coma Scale. 

Behaviour/domain	Response	Score
Eye-opening response	Eyes opening spontaneously	4
	Eyes opening to sound	3
	Eyes open to pain	2
	No eye opening	1
Verbal response	Orientated to time, place and person	5
	Confused	4
	Inappropriate sounds	3
	Incomprehensible sounds (e.g. groaning)	2
	No response	1
Motor response	Obeys commands for movement	6
	Moves towards pain/localises to pain	5
	Withdraws away from pain	4
	Abnormal flexion/decorticate posturing	3
	Abnormal extension/decerebrate posturing	2
	No motor response	1

The AVPU scale is a simpler method of assessing consciousness:

• Alert: fully alert, though not necessarily orientated
• Voice: responding to voice
• Pain: responding to pain
• Unresponsive: unresponsive to all stimuli

Pupils

Assess the patient’s pupils:

• Assess the size and shape of the patient’s pupils. A normal pupil diameter ranges from two to five millimetres.
• Assess the pupils for both direct and consensual responses to light using a pen torch.
• An oval-shaped pupil, sluggish reaction to light, “blown pupil” or deviated pupil suggests raised ICP or herniation.
• Bilaterally small or “pinpoint” pupils may be due to opioid toxicity.

Investigations and procedures

CT head

Organise an urgent CT head if there is any concern about intracranial bleeding and if a whole-body CT has not already been requested.

Interventions

Raised intracranial pressure (ICP)

Raised ICP can be managed with intravenous mannitol or hypertonic saline, and by raising the bed to 45 degrees. Further surgical intervention may also be required. 

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Exposure

Clinical assessment

Inspection

Expose the patient and examine them for visible injuries such as lacerations, abrasions or fractures. This should involve using a log roll technique to examine the patient’s back while protecting the spine.

When considering a fracture, look for:

• Bruising
• Swelling
• Deformity
• Immobility
• Pain

Bladder injury is an uncommon yet serious complication of blunt force or penetrating abdominal trauma. Signs include significant pain and suprapubic tenderness, blood at the urethral meatus, a “high riding” prostate, and haematuria.

Temperature

Assess body temperature, this should be between 36-37.5 degrees. Remember that hypothermia is part of the lethal triad in haemorrhage.

Investigations and procedures

X-ray

Consider X-rays of any potential fractures. An X-ray can also ensure no gravel or debris remains inside a laceration.

CT scan

Request a CT scan to image the abdomen if there are any features of internal organ injury. CT cystoscopy can be used in stable patients to identify bladder injuries.¹²

Management

Analgesia

Traumatic injuries can be incredibly painful. Give appropriate analgesia and regularly check with the patient about their pain levels. Consider the use of regional blocks for limb injuries.

Wound care

Clean any wounds using a sterile wound pack/sterile saline and gauze. Remove any gravel or debris from the wounds.

Consider using sutures, staples or steri-strips in wounds with a clean edge, to promote healing and minimise scarring. Injuries that require complex repair or may result in significant scarring should be discussed with plastic surgeons. Apply clean dressings over the wounds.

Fractures

Simple, non-displaced fractures can be placed in a splint, sling or plaster cast.

If a fracture is displaced, you should consult a senior doctor to reduce it.

Open fractures should be washed out with saline and dressed in saline-soaked gauze until an orthopaedic opinion can be sought. Antibiotic cover and tetanus prophylaxis should also be considered. Complex fractures, or patients with multiple fractures, should also be discussed with orthopaedics.

Internal organ injury

Damage to the internal organs, identified with imaging, should be discussed urgently with the relevant surgical team. This includes damage to the bladder or urethra.

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Reassess ABCDE

Re-assess the patient using the (C)ABCDE approach to identify any changes in the patient’s clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

If treatment response is inadequate, the patient may need to be transferred immediately to theatre/interventional radiology. In this situation, the next steps below can be postponed until after the definitive treatment of life-threatening injuries.

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Next steps

Take a history

Once stabilised, take a thorough history from the patient if possible.

Head-to-toe examination

Examine the patient thoroughly from head to toe and ensure you have excluded any ‘FATAL TRAUMA’ (although much of this list will have been covered during the primary assessment).

Consider any further imaging, treatments or referrals that may be required and make them at this point.

Document

Clearly document your (C)ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details

Patient discussion

Communicate with the patient (if they are conscious). Provide information about what you’ve done, what you’ve found, and any interventions you have planned. Answer any questions they have and ask if there is anything they need.

Debrief

Debrief with the trauma team. Ensure that everyone is ok and answer any questions. Give all team members a chance to express any concerns or feedback they have on the event. Not only is this important for the well-being of the team, but it also allows you to check there’s nothing you’ve missed.

Relative discussion

Once the patient is stabilised, with their consent (if conscious), contact and inform the next of kin. Answer any questions they may have and (if practical and desired) allow them to see their relative.

Senior clinician discussion/handover

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist (e.g. neurosurgery)?
• Should any changes be made to the current management of their underlying condition(s)?

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Reviewer

Dr Laura Kennedy

Emergency Medicine Registrar

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Editor

Dr Chris Jefferies

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References

1. NICE UK. Major Trauma Services – service delivery for major trauma. Published 2016. Available from: [LINK]
2. JPAC. Transfusion management of major haemorrhage. Published April 2020. Available from: [LINK]
3. StatPearls. Haemothorax. Published January 2022. Available from: [LINK]
4. NICE UK. Management of haemorrhage in prehospital and hospital settings. Published February 2016. Available from: [LINK]
5. RCEM Learning. Managing major haemorrhage in the emergency department. Published February 2015. Available from: [LINK]
6. Life In The Fast Lane. Major haemorrhage in trauma. Published November 2020. Available from: [LINK]
7. NICE UK. Airway Management in prehospital and hospital settings. Published February 2016. Available from: [LINK]
8. Geeky Medics. Airway Equipment Explained. Published August 2022. Available from: [LINK]
9. NICE UK. Assessment for cervical spine injury. Published February 2016. Available from: [LINK]
10. RCEM Learning. Trauma induction. Published July 2020. Available from: [LINK]
11. NICE UK. Management of chest trauma in hospital settings. Published February 2016. Available from: [LINK]
12. Kang L., Geube A. Bladder Trauma. Published May 2022 . Available from: [LINK]
13. Difficult Airway Society. DAS guidelines for management of unanticipated difficult intubation in adults 2015. Published 2015. Available from: [LINK]

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