Table of Contents
Colour triage coding
- RED = most critical injury
- YELLOW = less critical injury
- GREEN = no life or limb threatening injury
- BLACK = death or fatal injury
Background
- Team members and their roles
- Emergency medicine consultant/registrar – lead
- Emergency medicine doctor – primary survey
- Anaesthetist – airway
- Orthopaedic doctor – manage pelvis and other bone injuries
- General surgery doctor – manage spleen/gut/chest
- Intensive care doctor – decide upon ICU admission
- Emergency medicine nurses x 2 – one for patient care (observations etc) and one for code red
- Health care assistant – help with getting things etc
- Operating department practitioner – organise theatre if required
- Trauma handover – ATMIST
- Age
- Time everything happens
- Mechanism
- Injuries
- Signs – observations, capillary refill
- Treatment so far – e.g. triple immobilised, pelvic binder, oxygen, tranexamic acid
- Prioritising injuries in polytrauma
- Life-threatening bleeding wounds e.g. splenic rupture, pelvic/thoracic injury
- Limb threatening injuries e.g. vascular injury, extensive limb bleeding requiring tourniquet to control blood loss
- Fractures, dislocations and wounds at risk of complications (e.g. infection, neurovascular damage, bleeding)
- Stable fractures and other non-urgent injuries are managed later and may even be best left until swelling has resolved
Preparation and triage
- Advance planning
- Gather equipment e.g. goggles, gloves, gowns, shoe covers, masks
- Call trauma team
Primary survey – C-ABCDE
Catastrophic haemorrhage
- Sources: external (usually from neck) or pericardial
- Management
- Emergency thoracotomy for penetrating chest trauma causing cardiac arrest
- Pressure over bleeding points
- Warmed blood transfusion
Airway maintenance with C-spine protection
- Look for causes of airway compromise: maxilla fracture (bleeds +++, ask to bite down to assess), laryngeal fracture (hanging), burns/inhalation, neck haematoma, GCS less than or equal to 8, neuromuscular paralysis, vomiting, stridor
- Management
- Airway manoeuvres e.g. jaw thrust
- Artificial airway e.g. nasopharyngeal/oropharyngeal, intubation, surgical cricothyroidotomy (see artificial airways notes)
- Remove foreign bodies
- Suction
- Triple immobilisation for C-spine until cleared by cervical spine X-rays and/or CT scan
- Hard collar
- Blocks or sandbags
- Tape over chin and forehead
Breathing
- Assessment
- Saturations, respiratory rate
- Look (cyanosis, respiratory effort, neck vein distention, bruises)
- Feel (surgical emphysema, tenderness over ribs)
- Expansion (haemothorax, pneumothorax, flail segment)
- Percuss (haemothorax, pneumothorax)
- Listen (haemothorax, pneumothorax)
- Management
- Chest drain for haemothorax/pneumothorax
- High flow oxygen
Circulation
- Assessment
- Heart rate, blood pressure
- Peripheral pulse (requires systolic pressure of 80mmHg)
- Heart sounds
- Lactate (>5 significant)
- Look for bleeding – “blood on floor (external) and 4 more”, working down:
- Chest → FAST scan, examination, CXR
- Abdomen → FAST scan, examination (e.g. bruising)
- Pelvis → Pelvic X-ray or CT scan
- Long bone → X-rays, examination
- Management
- Place 2 wide-bore IV cannulae and take blood (including G&S, FBC, clotting screen, fibrinogen)
- Aim for permissive hypotension
- Shock: Hartmanns 1-2L bolus (or 20ml/kg for child). Subsequent fluids depend on response
- No response: give O negative blood
- Transient response: give more fluids (crystalloid or gelofusine) and type-specific blood
- Massive haemorrhage (ie. SBP<90, poor response to fluid resus, suspected haemorrhage): activate ‘code red’ transfusion protocol, give tranexamic acid, keep patient warm
- Ensure all transfused blood/fluids are warmed and patient is kept warm
- Leave pelvic binder on until pelvis cleared
- Traction for long bone fractures
- Combat application tourniquet only if compression fails to control limb blood loss
Types of shock
- Haemorrhagic
- Cardiogenic: blunt cardiac trauma, tamponade, air embolus, MI
- Tension pneumothorax
- Neurogenic (↓BP + ↓HR)
- Septic
Classes of shock
- Class 1: 15% blood loss; normal observations
- Class 2: 15-30% blood loss; HR >100, normal BP, RR 20-30
- Class 3: 30-40% blood loss; HR >120, decreased BP, RR 30-40
- Class 4: >40% blood loss; HR >140, decreased BP, RR >35
Code red protocol
- Give pack 1 first, then pack 2 if needed, then alternate until haemorrhage controlled
- Pack 1 = 6U blood, 4U FFP
- Pack 2 = 6U blood, 4U FFP, 1U platelets, 2U cryoprecipitate
Disability
- Assessment
- Glasgow coma score
- Limb movements
- Pupils reactivity
- Management
- CT head if indicated (done after resuscitation)
Everything else
- Try not to expose (need to conserve heat) unless absolutely necessary e.g. stab check, can’t get CT scan
Resuscitation
- Oxygenation and ventilation
- Management of shock and bleeding
- Management of life threatening injuries
Adjuncts to primary survey and resuscitation
- Trauma CT (head, spine, chest, abdo, pelvis), or:
- X-rays:
- Broken bones
- C-spine
- Chest, pelvis
- FAST scan
- CT head if indicated
- X-rays:
- Urinary catheter
- Monitoring: ABG, end-tidal CO2, ECG, observations
Secondary survey
Takes place only after primary survey and resuscitation is established and there is demonstration of normalisation of vital functions.
- History – AMPLE
- Allergies
- Medication
- Past medical history/Pregnancy
- Last meal
- Events/Environment related to injury
- Top-to-toe exam – plot all injuries on a drawing

Adjuncts to secondary survey
- Trauma CT scan (head, chest, abdomen, spine)
- Further X-rays e.g. extremities, spine
- Ultrasound
- Other procedures required e.g. endoscopy/bronchoscopy, angiography, contrast urography
Post resuscitation monitoring and re-evaluation
- Regular observations
- Bloods
- Urine output monitoring (aim >0.5ml/kg/h)
- Others: ABG, cardiac monitoring
- Analgesia
Definitive care
- Treat/transfer