Trauma Nursing Guide

ATLS Primary Survey — ABCDE Framework

The ATLS primary survey is a systematic, life-saving approach. Identify and treat life threats in order of priority. Do not proceed to the next step until the current threat is managed.

A — Airway with C-Spine Protection

C-spine rule: Assume cervical spine injury in ALL blunt trauma patients until proven otherwise. Apply hard collar + backboard immediately.

Airway Opening Techniques

Jaw thrust only — no head tilt-chin lift in trauma (risks C-spine displacement)
Suction oropharynx to clear blood, vomit, secretions
Oral airway adjunct (OPA) if gag reflex absent; nasopharyngeal airway (NPA) if gag intact
High-flow O₂ via non-rebreather mask at 15 L/min

Definitive Airway — RSI Indications

GCS ≤8, inability to maintain or protect airway, respiratory failure
RSI sequence: Pre-oxygenate → ketamine 1–2 mg/kg IV (maintains BP) + succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV → in-line stabilisation during intubation
Confirm tube position: capnography (gold standard), bilateral chest rise, auscultation

B — Breathing and Ventilation

Assessment: Look, Feel, Listen

Inspect: respiratory rate, chest symmetry, wounds, use of accessory muscles, tracheal position
Palpate: crepitus, surgical emphysema, rib tenderness, flail segments
Percuss: hyper-resonance (pneumothorax), dullness (haemothorax)
Auscultate: bilateral breath sounds, equality

Immediately Life-Threatening Chest Injuries

Condition	Signs	Immediate Action
Tension Pneumothorax	Absent breath sounds, hypotension, tracheal deviation (late), raised JVP, tachycardia	Needle decompression: 2nd ICS midclavicular → followed by chest drain (4th ICS anterior axillary line)
Open Pneumothorax	Sucking chest wound, air movement through wound	3-sided dressing (flutter valve) immediately; formal chest drain separately
Massive Haemothorax	Dull to percussion, absent breath sounds, shock	Large-bore chest drain 4th–5th ICS; activate MTP if >1500 mL immediate drainage
Flail Chest	Paradoxical chest movement, pain-limited breathing, hypoxia	Positive pressure ventilation (PPV); aggressive analgesia (intercostal block or epidural)

C — Circulation with Haemorrhage Control

Stop the bleeding first. External haemorrhage: direct pressure > tourniquet > wound packing. Do not delay haemorrhage control for IV access.

Vascular Access & Labs

Two large-bore IV cannulas: 14–16G bilateral antecubital fossae
Bloods on insertion: crossmatch (6 units), FBC, U&E, coagulation (PT/APTT/fibrinogen), glucose, lactate, VBG, BHCG in females of childbearing age
Intraosseous (IO) access if IV fails — tibia or humeral head

Fluid Resuscitation Strategy

Initial bolus: 1 L warm crystalloid (Hartmann's / Normal Saline) — not 2 L (outdated ATLS guideline revision)
Permissive hypotension (damage control resuscitation): target SBP 80–90 mmHg in penetrating trauma until surgical haemorrhage control achieved
Blunt trauma with head injury: target SBP ≥90 mmHg (CPP maintenance)
Early activation of MTP: see Tab 2 for ratios and protocols
Warm all fluids — prevent hypothermia

D — Disability (Neurological Status)

GCS: Eyes (1–4) + Verbal (1–5) + Motor (1–6) = total 3–15
AVPU: Alert | Voice | Pain | Unresponsive — rapid bedside assessment
Pupils: size, symmetry, reactivity — unilateral fixed dilated pupil = herniation until proven otherwise
Blood glucose level (BGL): treat hypoglycaemia (<4 mmol/L) — can mimic GCS deterioration
Any lateralising signs (focal neuro deficit) → urgent CT head

E — Exposure and Environment

Full exposure: remove ALL clothing — cut if necessary; every garment
Log roll (5-person technique with manual in-line stabilisation) to examine entire back, spine, and perineum
Rectal exam if indicated (sphincter tone, high-riding prostate, blood)
Prevent hypothermia: warm blankets, warm IV fluids (38–40°C), warm ambient temperature — hypothermia worsens coagulopathy (lethal triad)
Document all injuries found and exact time of examination

Trauma Team — Nursing Roles

Airway NurseAssists with jaw thrust, suction, OPA/NPA, RSI drug preparation, tube confirmation documentation

Circulation NurseIV access, blood sampling, fluid/blood administration, tourniquet checks, external haemorrhage control

Documentation NurseReal-time vital signs recording, timestamps on all interventions, medication log, GCS trends

Family Liaison NurseCommunicates with family, provides updates, cultural and language considerations (Arabic, Urdu, Tagalog common in GCC)

Closed-loop communication: Receive instruction → repeat back → confirm completion. Designate one team leader. Avoid bystander effect — assign roles by name.

Haemorrhagic Shock Classification

Class	Blood Loss	% EBV	HR	BP/Pulse Pressure	RR	Urine Output	Mental Status
Class I	<750 mL	<15%	<100	Normal	14–20	>30 mL/h	Normal, anxious
Class II	750–1500 mL	15–30%	100–120	Normal / ↓ pulse pressure	20–30	20–30 mL/h	Mildly anxious
Class III	1500–2000 mL	30–40%	120–140	↓ SBP	30–40	5–15 mL/h (oliguria)	Confused, lethargic
Class IV	>2000 mL	>40%	>140	SBP <90 mmHg	>35	<5 mL/h (anuria)	Lethargic / unconscious

EBV = Estimated Blood Volume (~70 mL/kg adult). Class III–IV: activate Massive Transfusion Protocol.

Shock Class Estimator

Enter patient parameters to estimate haemorrhagic shock class.

Heart Rate (bpm)

Systolic BP (mmHg)

Respiratory Rate (/min)

Urine Output (mL/h)

Mental Status

Massive Transfusion Protocol (MTP)

MTP Activation Triggers (any one): SBP <90 mmHg + HR >120 bpm | >10 units pRBC in 24h | Ongoing uncontrolled haemorrhage | ABC score ≥2 (penetrating, SBP ≤90, HR ≥120, +FAST)

Target Transfusion Ratio — Damage Control Resuscitation

pRBC (Packed Red Blood Cells)

FFP (Fresh Frozen Plasma)

Platelets (Apheresis)

1:1:1 ratio replaces whole blood and prevents dilutional coagulopathy. Avoid large-volume crystalloid — worsens the lethal triad.

Additional MTP Components

Tranexamic acid (TXA): 1g IV over 10 min within 3 hours of injury, then 1g over 8 hours — CRASH-2 trial evidence. Inhibits fibrinolysis. Do NOT give if >3 hours post-injury (may increase thrombosis risk).
Calcium: CaCl₂ 10 mL of 10% solution IV for every 4 units pRBC administered — citrate in blood products chelates ionised calcium, causing hypocalcaemia and cardiac depression
Fibrinogen: Cryoprecipitate (10 units) or fibrinogen concentrate if fibrinogen <1.5 g/L — fibrinogen is the first clotting factor to fall in haemorrhage
Avoid hypothermia: blood warmers for all products, warm IV fluids, warm environment
TEG/ROTEM: viscoelastic testing guides targeted factor replacement if available

Lethal Triad of Trauma: Hypothermia + Acidosis + Coagulopathy — each worsens the others. MTP and damage control surgery aim to break this cycle.

Penetrating Trauma Special Considerations

Give TXA immediately on arrival — do not wait for labs
Activate MTP early; avoid dilutional resuscitation
Permissive hypotension (SBP 80–90) until surgical haemorrhage control
Damage Control Surgery (DCS): abbreviated laparotomy to control bleeding, pack cavities, plan for ICU stabilisation before definitive repair

Traumatic Brain Injury (TBI) — Classification

Mild TBI

GCS 13–15
LOC <30 min
PTA <24 hours
CT may be normal

Moderate TBI

GCS 9–12
LOC 30 min – 24 h
CT: contusions, SDH
ICU monitoring

Severe TBI

GCS ≤8
Intubate immediately
ICU, ICP monitoring
Neurosurgery consult

ICP Management — Nursing Priorities

Cushing's Triad — Late Sign of Herniation: Bradycardia + Hypertension + Irregular breathing (Cheyne-Stokes). This is a neurosurgical emergency — call immediately.

Neuroprotective Bundle

Head of bed 30° — neutral position (no neck rotation), avoids venous obstruction
MAP target 70–90 mmHg → CPP = MAP − ICP; target CPP 60–70 mmHg
Normocapnia: PaCO₂ 35–40 mmHg (hyperventilation causes cerebral vasoconstriction → use only for acute herniation, max 30 min)
Normoxia: SpO₂ ≥94%, PaO₂ >60 mmHg
Normoglycaemia: BGL 6–10 mmol/L (avoid hypoglycaemia AND hyperglycaemia)
Normothermia: treat fever aggressively (paracetamol, cooling blankets)
Normonatraemia: avoid hyponatraemia (<135) — worsens cerebral oedema
Avoid hypotension: SBP <90 mmHg doubles mortality in TBI
Prevent seizures: prophylactic levetiracetam 7 days post-severe TBI
Minimise stimulation: cluster care, reduce unnecessary suctioning

Osmotherapy

Mannitol 20%: 0.25–1 g/kg IV bolus — osmotic diuretic, use only if signs of herniation; requires intact BBB. Monitor serum osmolality (target <320 mOsm/kg). Risk: rebound oedema, hypovolaemia.
Hypertonic saline (3% NaCl): preferred for sustained ICP elevation or hypovolaemia — 150–250 mL bolus. Monitor Na⁺ (target 145–155 mmol/L for sustained ICP control).

Acute Herniation — Emergency Interventions

Fixed, dilated pupil + declining GCS + posturing → herniation. Call neurosurgery NOW.

Hyperventilate briefly: PaCO₂ 30–35 mmHg (max 30 min — bridge to definitive treatment)
Mannitol 1 g/kg IV bolus OR hypertonic saline 250 mL 3% NaCl
HOB 30°, head neutral
Urgent CT head and neurosurgical decompression

C-Spine Clearance — NEXUS Criteria

ALL 5 criteria must be met to safely clear cervical spine without imaging:

No midline cervical tenderness to palpation
No focal neurological deficit
Alert and oriented (GCS 15)
Not intoxicated (alcohol or drugs)
No painful distracting injury (e.g. long bone fracture, significant burns)

If any criterion is NOT met: CT cervical spine (preferred over plain films in adults). Maintain collar and backboard until cleared.

Spinal Cord Injury — Nursing Management

Maintain spinal precautions until imaging complete
Neurogenic shock: bradycardia + hypotension + warm peripheries (vasodilation without compensatory tachycardia) → distinguish from haemorrhagic shock
Neurogenic shock management: fluid resuscitation + vasopressors (noradrenaline), atropine for bradycardia
Pressure injury prevention: padded backboard, log roll every 2 hours once stabilised
MAP target ≥85 mmHg for 7 days post-SCI (spinal cord perfusion)

GCC Context: Road traffic accidents (RTAs) are the leading cause of trauma deaths across the GCC. Contributing factors include seat belt non-compliance, speeding, distracted driving. Rural areas: camel-crossing accidents on highways cause high-velocity blunt trauma — beware of high-energy mechanisms even when presenting stable.

Chest Trauma

Rib Fractures

Most common chest injury from blunt trauma; elderly patients at highest risk of complications
Each rib fracture increases pneumonia risk — pain prevents deep breathing
Pain management is primary treatment: intercostal nerve block, thoracic epidural (gold standard for multiple rib fractures), IV paracetamol, NSAIDs (if no contraindications), opioids sparingly
Incentive spirometry every hour while awake; chest physiotherapy
Avoid respiratory depressants; monitor SpO₂ and RR closely

Flail Chest

≥3 contiguous ribs fractured in ≥2 places each = flail segment. Paradoxical movement: inward on inspiration, outward on expiration.

Underlying pulmonary contusion always present — true cause of hypoxia
Management: positive pressure ventilation (PPV) — intubate if SpO₂ <90% despite O₂, RR >35, increasing work of breathing
Aggressive analgesia (epidural preferred) to allow adequate tidal volume
Non-invasive ventilation (BiPAP) may be trialled in cooperative patients

Aortic Injury (Traumatic Aortic Disruption)

Mechanism: sudden deceleration (high-speed RTA, fall from height) — shear at aortic isthmus
CXR clues: widened mediastinum (>8 cm), loss of aortic knuckle, left haemothorax, deviation of trachea/oesophagus
Diagnosis: CT angiography of chest
Management: urgent vascular/cardiothoracic surgery; permissive hypotension (SBP 100–120) to reduce aortic wall stress; beta-blockers (esmolol) to reduce dP/dt
High suspicion in GCC: multi-vehicle highway accidents at speed

Abdominal Trauma

FAST Examination

FAST = Focused Assessment with Sonography for Trauma. Performed by trained clinicians at the bedside in under 3 minutes. Detects free fluid (blood) — does NOT identify specific organ injury.

4 views: Pericardial (subxiphoid) | Right Upper Quadrant (hepatorenal — Morison's pouch) | Left Upper Quadrant (splenorenal) | Pelvis (pouch of Douglas / rectovesical)
Positive FAST + haemodynamic instability → emergency laparotomy (no time for CT)
Negative FAST does not exclude injury in solid organs or bowel
Extended FAST (eFAST) adds bilateral pleural views for pneumothorax/haemothorax

Blunt Abdominal Trauma

Spleen: most commonly injured solid organ in blunt trauma (seat belt, steering wheel, sports)
Liver: second most common; right lobe injuries from direct right-sided impact
Haemodynamically stable: CT abdomen/pelvis with contrast — full assessment of injury grade
Haemodynamically unstable with positive FAST: urgent OR

Penetrating Abdominal Trauma

Stab wounds: selective non-operative management if stable + no peritonism + no evisceration
Mandatory laparotomy indications: haemodynamic instability, peritonitis, bowel evisceration, bullet trajectory through peritoneum
DPL (diagnostic peritoneal lavage): largely replaced by FAST + CT but used in select cases when CT unavailable

Pelvis Fracture

Open book pelvic fracture = haemorrhagic emergency. Pelvic ring disruption can accommodate 3–4 L of blood. Act immediately.

Pelvic binder immediately: apply at greater trochanters (NOT iliac crests) — reduces pelvic volume and tamponades venous haemorrhage
Activate MTP early — these patients exsanguinate rapidly
Definitive: angioembolisation (arterial source) or pre-peritoneal packing (venous source) — decision by trauma surgeon
Log roll contraindicated with suspected pelvic fracture — use scoop stretcher
Monitor urological injuries: urethral injury (blood at meatus, scrotal haematoma) → do NOT insert urinary catheter without urology advice

Burns — Overview

Rule of Nines (adult BSA estimation): Head 9% | Each arm 9% | Anterior trunk 18% | Posterior trunk 18% | Each leg 18% | Perineum 1%
Parkland formula: 4 mL × body weight (kg) × % BSA (2nd/3rd degree) = total mL in first 24 hours. Give 50% in first 8 hours, 50% in next 16 hours.
Fluid of choice: Hartmann's solution (lactated Ringer's)
Airway burns (facial burns, singed nasal hair, carbonaceous sputum, stridor): intubate early — airway oedema progresses rapidly
Refer to dedicated Burns Nursing Guide for wound care, infection management, and rehabilitation

Orthopaedic Trauma

Femur Fracture

Estimated blood loss: 1.5–2 L in closed femur fracture (thigh can expand to accommodate)
Traction splint (Thomas splint or Sager): reduces blood loss, pain, and fat emboli risk
Activate MTP consideration with bilateral femur fractures

Compartment Syndrome — The 6 Ps

Surgical emergency — permanent nerve and muscle damage within 6 hours if untreated.

Sign	Description
Pain	Severe, out of proportion to injury; worsened by passive stretch of muscles in affected compartment
Pressure	Compartment feels tense/woody on palpation
Paraesthesia	Tingling, numbness in distribution of nerves traversing compartment
Pallor	Skin pallor or mottling distal to compartment
Paralysis	Weakness or inability to move muscles in affected compartment — late sign
Pulselessness	Absent distal pulse — very late sign; do not wait for this before acting

Remove all circumferential dressings, splints, and casts immediately
Do not elevate limb above heart level (reduces perfusion pressure)
Measure compartment pressure: >30 mmHg or within 30 mmHg of diastolic BP → emergency fasciotomy
Urgent orthopaedic/surgical consult

Trauma Documentation Standards

Time of injury: document exact time reported, time of arrival in ED, and time of each intervention
Mechanism of injury: speed, type of vehicle, restraint use, airbag deployment, fall height, weapon type
Vital signs trend: document every 5 minutes during resuscitation — trend more important than single value
GCS serial documentation: record each component (E/V/M) not just total score; note time and who assessed
All interventions with exact timestamps: IV access, medications, transfusions, procedures
Fluid balance: all inputs (IV, blood products, oral) and outputs (urine, drains, estimated blood loss)

ATMIST Handover Framework

Letter	Stands For	Example
A	Age / Time of incident	"32-year-old male, incident at 14:30"
T	Type / Mechanism of injury	"High-speed RTA, unrestrained driver, frontal impact"
M	Mechanism details	"Vehicle rollover, airbag deployed, 30-min extrication"
I	Injuries found / suspected	"Open femur fracture right, suspected abdominal injury"
S	Signs / Vital signs	"HR 128, BP 88/60, SpO₂ 94%, GCS 13 (E3V4M6), RR 26"
T	Treatment given	"IV access ×2, 1L Hartmann's, traction splint, TXA 1g given 14:45"

GCC Trauma Centres

King Salman Trauma Centre, Riyadh (Saudi Arabia): Dedicated level I equivalent trauma centre; ATLS-trained multidisciplinary team; 24/7 trauma activations
Rashid Hospital, Dubai (UAE): Designated level I trauma centre for Dubai; ATLS and DSTC-trained staff; highest volume trauma centre in UAE
Hamad Trauma Centre, Doha (Qatar): Level I trauma centre within HMC; national trauma registry; ATLS standard
All nurses working in GCC trauma centres are expected to complete TNCC (Trauma Nursing Core Course) and ATLS observer training

Nurse Wellbeing: Secondary traumatic stress (STS) is common in trauma nurses — recurrent exposure to graphic injuries and patient deaths. Access psychological support: EAP (Employee Assistance Programmes), peer support teams, and debriefing after critical incidents. GCC hospitals increasingly recognise this; do not stigmatise help-seeking.