Pre-hospital stage and first aid
Providing care at the scene begins with assessing vital functions. If the patient has no breathing or heartbeat, cardiopulmonary resuscitation according to the international ABC algorithm is started immediately.
Concurrently, a set of anti-shock measures is deployed:
- Termination of the damaging factor.
- Control of external bleeding and restoration of circulating blood volume (CBV).
- Adequate analgesia and transport immobilization.
- Maintenance of cardiac activity and respiration.
To prevent infectious complications, aseptic dressings are applied to wounds and antibacterial therapy is initiated. If the trauma is severe, the fastest and most sparing transportation to a hospital is indicated. Mild uncomplicated injuries are treated on an outpatient basis.
Anti-shock operating room and routing
A key unit of a specialized trauma center is the anti-shock operating room. It operates around the clock on standby and receives critical patients directly from ambulance crews, completely bypassing the emergency department. Using this room for elective or routine emergency surgeries is strictly prohibited.
A multidisciplinary on-call team works with the patient: surgeons, orthopedic trauma surgeons, anesthesiologists-intensivists, neurosurgeons, cardiovascular surgeons, and endovascular/endoscopic surgeons. Immediately upon admission, central venous catheterization and parallel physical examination by physicians begin.
After shock is resolved and the patient's vital signs are stabilized, the patient is transferred to the surgical ICU (first stage), and then to a specialized department: traumatology, thoracic surgery, or polytrauma department (second stage).
Emergency diagnostics in severe trauma
In severe polytrauma, examination is performed right in the anti-shock operating room under conditions of severe time constraints. The diagnosis is often refined and adjusted during intensive care.
Main diagnostic and therapeutic steps:
- Airway management: endotracheal intubation, cricothyroidotomy, or tracheostomy is performed as needed. Personnel must be proficient in these skills, and tools to verify correct tube placement must be used to rule out errors (e.g., esophageal intubation).
- Instrumental screening: priority is given to imaging modalities. Plain radiography, ECG, and FAST (Focused assessment with sonography for trauma) ultrasound are performed to rapidly detect free fluid in the pericardium, pleural spaces, lesser pelvis, and subdiaphragmatic space.
- Laboratory tests: emergency blood and urine tests.
The inpatient stage also includes high-tech medical care — resource-intensive methods such as arthroplasty, arthroscopy, cell technologies, and complex spine surgeries.
Management of chest and spine injuries
Management tactics strictly depend on the localization and severity of injuries:
- Rib fractures: single uncomplicated fractures are treated on an outpatient basis. If three or more ribs are broken, or the 1st and 2nd ribs are injured, the patient is hospitalized (preferably in traumatology). In combined closed chest injuries, the patient is transferred to a multidisciplinary trauma center with a thoracic surgery department after recovering from shock.
- Spinal cord injury (SCI): early medical rehabilitation begins in the ICU. The main goal is to prevent secondary complications and post-intensive care syndrome (PICS), the risk of which increases with the duration of ICU stay. Strict immobilization is maintained until surgical stabilization of the spine, followed by gradual mobilization with mandatory spinal control when transitioning to a sitting position.
Assessing neurological deficits in SCI is extremely difficult due to "spinal shock" (lasting 4–12 weeks and presenting with lower motor neuron signs) and critical illness polyneuromyopathy arising against the background of prolonged mechanical ventilation and sedation.
The basic life support algorithm is easy to remember by the ABC acronym: A (Airway), B (Breathing), C (Circulation).
Class and exam questions
Who must be hospitalized for rib fractures?
Patients with fractures of three or more ribs, as well as injury to the first and second ribs. Hospitalization in the traumatology department is preferred.
What is the main feature of the anti-shock operating room's operation?
Severely injured patients are delivered there directly, bypassing the emergency department. A multidisciplinary team works there, and elective procedures are strictly prohibited.
Why is it difficult to assess neurological status in spinal injury during the first weeks?
Due to the development of "spinal shock", which lasts from 4 to 12 weeks, as well as critical illness polyneuromyopathy developing against the background of sedation and mechanical ventilation.
What else to study on this topic
- Technique of cricothyroidotomy and tracheostomy at the pre-hospital stage.
- FAST ultrasound protocol in traumatology.
- Injury severity scoring systems in polytrauma.
- Prevention of post-intensive care syndrome (PICS).
- High-tech medical care: arthroscopy and arthroplasty.
Master the entire topic in the "Traumatology" course
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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.