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Roadside Accident — Emergency Management & Treatment

Epidemiology

• Immediate deaths — within minutes, from catastrophic CNS injury or major vascular hemorrhage
• Early deaths — within hours, from ongoing hemorrhage and severe injury
• Late deaths — days to weeks later, from organ failure and sepsis (dramatically reduced with modern care)

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Phase 1: At the Scene (Bystander / Spontaneous Responder)

Scene Safety First

• Assess for ongoing hazards: moving traffic, fire, fuel spills, unstable vehicles
• Do NOT approach until the scene is safe
• Call emergency services immediately

Stop the Bleed (Public First Aid Priority)

1. Direct pressure — apply firm, continuous pressure to any bleeding wound
2. Wound packing — pack deep wounds with gauze/cloth and maintain pressure
3. Tourniquet — for severe limb bleeding that does not stop with pressure:
   • Apply 2–3 inches (5–8 cm) proximal to the wound
   • Apply on skin, not over clothing or a joint
   • Tighten until bleeding stops
   • Note the time of application

Tourniquet use in civilian trauma has demonstrated improved survival with no increase in complications.

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Phase 2: EMS Arrival — Prehospital Assessment

xABCDE Framework (current PHTLS/ATLS standard)

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x — Hemorrhage Control

• Direct pressure + wound packing with hemostatic gauze
• Tourniquet for uncontrolled extremity bleeding
• Exsanguinating hemorrhage is the #1 cause of preventable trauma death

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A — Airway (with C-spine protection)

• Ask patient their name — a coherent verbal response confirms airway is patent
• Signs of airway compromise: stridor, hoarseness, gurgling, agitation, use of accessory muscles
• Basic maneuvers: chin lift / jaw thrust → manual clearance → oropharyngeal or nasopharyngeal airway (NPA contraindicated if facial trauma present)
• Bag-valve-mask (BVM) ventilation with supplemental O₂
• Advanced: endotracheal intubation via RSI (Rapid Sequence Induction) if needed
• Surgical airway (cricothyroidotomy) if intubation fails
• For blunt trauma: maintain in-line cervical spine stabilization throughout

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B — Breathing

• Auscultate bilateral breath sounds; inspect chest rise
• Absent breath sounds → suspect hemothorax or pneumothorax
• Tension pneumothorax (tracheal deviation, JVD, cyanosis, hemodynamic instability) → immediate needle decompression then chest tube
• Flail chest / large pulmonary contusion → ventilatory support

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C — Circulation (Hemorrhagic Shock Recognition)

Blood pressure alone is NOT an early indicator of hemorrhagic shock — tachycardia appears first.

• Large-bore IV access (×2) → blood samples
• Balanced resuscitation: packed red cells + plasma + platelets (1:1:1 ratio)
• Massive transfusion protocol (MTP) if severe hemorrhage
• Tranexamic acid (TXA) — give within 3 hours of injury to reduce mortality from hemorrhage
• Avoid excessive crystalloid (worsens coagulopathy)

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D — Disability (Neurologic Assessment)

• GCS (Glasgow Coma Scale): Eyes + Verbal + Motor
• Pupil size and reactivity
• Assess for traumatic brain injury (TBI)
• Spinal cord injury: hypotension without tachycardia = neurogenic shock → fluids + vasopressors

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E — Exposure / Environment

• Fully expose patient (cut off clothing) to identify all injuries
• Prevent hypothermia — cover with blankets, use warm fluids
• Log roll to examine posterior body
• Check for: burns, penetrating wounds, seat belt sign, flank bruising, pelvic instability

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Phase 3: In-Hospital Management

Secondary Survey

• Head-to-toe physical examination after life-threatening conditions are controlled
• Focused FAST ultrasound (eFAST): assess for blood in abdomen, pelvis, pericardium, pleural spaces
• Imaging: CXR, pelvis X-ray, CT (head, c-spine, chest/abdomen/pelvis as indicated)

Differential Diagnosis of Shock in Trauma

Fracture & Extremity Management

• Splint long bone fractures
• Assess neurovascular status distal to each injury (pulses, sensation, motor)
• Hard signs of vascular injury (pulsatile bleeding, expanding hematoma, absent pulses) → urgent angiogram or surgical repair

Wound Care

• Irrigate and cover open wounds
• Antibiotics for contaminated/open fractures
• Tetanus prophylaxis

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Key Mnemonics Summary

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