Trauma: Primary Survey (xABCDE)

• Run the primary survey xABDCE per ATLS 11th, controlling catastrophic bleeding first while resuscitating simultaneously; activate massive transfusion early and give TXA <3 h — TXA given >3 h after injury increases mortality, so never give it late.
• eFAST plus chest/pelvis X-ray in the bay; CT pan-scan once stable.
• Accept permissive hypotension (SBP 80–90) until hemorrhage is controlled, EXCEPT in TBI where SBP stays ≥100–110.
• Damage-control surgery stops bleeding/contamination; ICU resuscitation, definitive repair later.
• REBOA is an ATLS 11th option for non-compressible torso hemorrhage; low-titer group O whole blood is increasingly preferred where available.

Pelvic Ring Injury Management

• Pelvic ring injury suspected → plain films of pelvis may confirm
• Pelvic injury confirmed?
• Ortho consult
• Hemodynamics unstable? (SBP <90 or other evidence of inadequate tissue perfusion)
• Place pelvic binder (except with vertical shear injury)
• Hemodynamics still unstable?
• Extremis: straight to OR for emergent packing — notify IR that angio will be needed after the OR
• CT scan to evaluate injury and possible bleeding
• CT scan to evaluate injury and possible bleeding
• Angio needed? (CT findings · injury severity and type · evidence of ongoing bleeding · attending level discussion)
• Ready for angio? (patient factors on tolerating selective vs bilateral pelvic embo — extent of embolization can be decided after the diagnostic segment of the angio/embo procedure)
• Selective embo planned → trauma and IR attendings agree the plan: 1. Bilat embo · 2. Selective embo · 3. Embo based on angio findings → angio/embo → end of protocol
• Monitor in ICU or floor → reassess need for imaging/angio
• Monitor in ICU or floor → reassess need for imaging/angio
• End protocol
• Once VIR is ready for the patient: the VIR charge nurse notifies the appropriate area (ED, SICU, OR); that area CN notifies the responsible attending (Trauma/EM attending for ED, SICU attending for SICU, Trauma attending for OR) that VIR is ready; after discussion the CN relays the decision to the VIR CN · consider activating the SICU trauma bed and resources · individualized clinical judgment supercedes all written guidelines

Cervical Spine Evaluation in Trauma Patients

• Inclusion for this decision rule: adult with acute trauma to head or neck · GCS of 15, SBP >90, RR 10–24/min · neck pain, or no neck pain but ALL of: visible injury above the clavicles, nonambulatory, mechanism of injury present
• Any exclusion criteria? (unstable vital signs · GCS <15 · age <16 years · acute paralysis · prior cervical spine surgery · known cervical vertebral disease)
• Radiography
• ANY ONE high-risk factor? (1. Dangerous mechanism: MVC >60 mph, rollover, or ejection · a fall >3 ft. or 5 stairs · axial load to head · bicycle collision · collision with a recreational vehicle · 2. Age ≥65 years · 3. Paresthesia present)
• Radiography
• Low-risk factors — any one? (simple rear-end MVC* · sat up in the ED · ambulatory at any time · delayed-onset neck pain · no midline tenderness · NO painful distracting injury**)
• Can rotate neck actively without pain? 45 deg L and R
• No radiography
• CT of the cervical spine (radiography only where CT is unavailable)
• CT of the cervical spine (radiography only where CT is unavailable)
• Imaging complete and adequate; persistent concern for injury with no other neurologic findings → obtain CT of the C-spine if not originally obtained → normal CT scan
• The cervical collar can now be safely cleared. ONLY with high continued suspicion for injury is further work up warranted: if suspicion persists, d/c home in neck collar, instruct to avoid significant physical activity, seek immediate medical attention for increased pain or neuro symptoms, and refer for follow up in 1 week with Spine Service . NO FURTHER IMAGING NECESSARY UNLESS HIGH CLINICAL SUSPICION WARRANTS IT
• *Simple rear-end MVC excludes: pushed into oncoming traffic · struck by a bus, semi-trailer, or larger · struck by a vehicle traveling >55 mph · **Bony injury where the pain scale rating exceeds 5/10