Following trauma there is a trimodal death distribution:

• Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low.
• In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces
• In the days following injury. Usually due to sepsis or multi organ failure.

Aspects of trauma management

• ABCDE approach.
• Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
• External haemorrhage is managed as part of the primary survey. As a rule tourniquets should not be used. Blind application of clamps will tend to damage surrounding structures and packing is the preferred method of haemorrhage control.
• Urinary catheters and naso gastric tubes may need inserting. Be wary of basal skull fractures and urethral injuries.
• Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.

Thoracic trauma

• Simple pneumothorax insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax.
• Mediastinal traversing wounds These result from situations like stabbings. Exit and entry wounds in separate hemithoraces. The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below.
• Tracheobronchial tree injury Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina. Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax.
• Haemothorax Usually caused by laceration of lung vessel or internal mammary artery by rib fracture. Patients should all have a wide bore 36F chest drain.
  • Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.
• Cardiac contusions Usually cardiac arrhythmias, often overlying sternal fracture. Perform echocardiography to exclude pericardial effusions and tamponade. Risk of arrhythmias falls after 24 hours.
• Diaphragmatic injury Usually left sided. Direct surgical repair is performed.
• Traumatic aortic disruption Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest x-ray.