---

POLYTRAUMA MANAGEMENT - EDIC Part 2 Viva-Ready Note

---

WHICH GUIDELINE TO USE IN EDIC PART 2? Use European Guideline (Rossaint 2023, 6th Ed) as your primary reference for coagulopathy and haemorrhage management - it is pan-European, directly relevant to European ICU practice and is what EDIC examiners expect. Use ATLS 11 (2025) for the primary survey framework (xABCDE) and resuscitation principles. Cite NICE CG174 for UK-specific decisions (e.g. whole-body CT timing, TXA in prehospital). BTF 4th Ed is the go-to for TBI targets.

---

SECTION 1 - OVERVIEW AND KEY DEFINITIONS

1. Uncontrolled haemorrhage (39% of trauma deaths) - most preventable
2. Airway obstruction
3. Tension pneumothorax

---

SECTION 2 - PRIMARY SURVEY: xABCDE

ATLS 11 KEY CHANGE: The mnemonic is now xABCDE - the "x" stands for exsanguinating haemorrhage control FIRST, before airway. [ATLS 11, 2025 - Level evidence-based expert consensus]

x - Exsanguinating Haemorrhage Control

• Act first on any life-threatening external bleeding before moving to A
• Tourniquet for limb haemorrhage (apply within 2-3 minutes)
• Wound packing + direct pressure for junctional/truncal bleeding
• Pelvic binder for suspected pelvic fracture with haemodynamic instability
• Think: "STOP THE BLEED" before everything

---

A - Airway with C-spine Protection

• Assume C-spine injury in any significant mechanism until cleared
• Look: agitation, stridor, use of accessory muscles, cyanosis
• Act: chin lift/jaw thrust, suction, airway adjunct (OPA/NPA)
• Definitive airway (RSI + ETT) if: GCS ≤8, airway compromise, respiratory failure, haemodynamic instability with thoracic injury

• Ketamine 1-2 mg/kg IV (preferred - maintains BP, bronchodilates)
• Rocuronium 1.2 mg/kg IV (use with sugammadex available)
• Avoid etomidate (adrenal suppression) if prolonged ICU stay anticipated
• C-spine precaution: in-line manual stabilisation during laryngoscopy

Q: When do you intubate a trauma patient? A: GCS ≤8, inability to protect airway, RR <10 or >29, SpO2 <90% despite O2, anticipated deterioration (burns to face/airway, expanding neck haematoma), combative patient requiring imaging.

---

B - Breathing and Ventilation

Q: What is the landmark for needle thoracostomy in ATLS 11? A: ATLS 11 now recommends 4th/5th ICS AAL as primary site due to better success rates. The 2nd ICS MCL is still acceptable. After needle decompression always insert a chest drain.

---

C - Circulation with Haemorrhage Control

---

D - Disability (Neurological Assessment)

• GCS (full scoring)
• Pupils: size, reactivity, asymmetry (unilateral fixed dilated = transtentorial herniation)
• AVPU (rapid bedside)
• Blood glucose - always check (hypoglycaemia mimics brain injury)
• Drugs/alcohol: consider as confounding

Q: A trauma patient has GCS of 9, unequal pupils. What do you do? A: Immediate CT head; if scan delayed and clinical herniation suspected, give 20% mannitol 0.25-1g/kg IV or 3% NaCl and ensure SBP >90mmHg + SpO2 >90%; neurosurgical referral urgently.

---

E - Exposure and Environmental Control

• Full exposure: log roll, check back, axillae, perineum, all skin folds
• Prevent hypothermia: warm blankets, warm IV fluids, warm environment
• Target temperature: >35°C actively; treat if <35°C with active warming
• Hypothermia (<35°C) worsens coagulopathy significantly

---

SECTION 3 - SIMULTANEOUS RESUSCITATION (Run in parallel with primary survey)

3.1 - Damage Control Resuscitation (DCR)

• Target SBP 80-90 mmHg (MAP ~50 mmHg) until surgical haemostasis achieved
• Exception: avoid in TBI (see below) - maintain SBP ≥110 mmHg if TBI coexists
• Time-limited: only until haemorrhage controlled; do not maintain for >60-90 minutes
• Avoid large crystalloid boluses - causes haemodilution, hypothermia, ARDS, abdominal compartment syndrome

• Use blood products NOT crystalloid as primary resuscitation fluid
• Target ratio: 1 pRBC : 1 FFP : 1 platelets (1:1:1)
• Fresh whole blood (FWB) is superior if available (1 unit replaces all three) [European Guideline 6th Ed, Grade 1B]
• Small volume crystalloid only as a bridge until blood products available
• PROMMTT & PROPPR trials showed reduced 24h mortality with 1:1:1 ratio

• Minimum surgery to stop bleeding and contamination
• Temporary vessel ligation, damage control packing, bowel stapling without anastomosis
• ICU resuscitation then planned re-look at 24-48h ("second look")
• Decision to go to DCS early - do not delay waiting for labs

---

3.2 - Tranexamic Acid (TXA)

• Drug: TXA - antifibrinolytic (inhibits plasminogen activation)
• Who gets it: all trauma patients with suspected significant haemorrhage OR SBP <110 mmHg OR HR >110 bpm
• Dose: 1g IV over 10 minutes LOADING, then 1g IV over 8 hours (maintenance)
• Timing: as early as possible; ideally in prehospital setting; MUST be given within 3 hours of injury - after 3 hours it may increase mortality
• In UK: given by paramedics prehospital - this is standard of care
• Do NOT wait for viscoelastic results before giving TXA

Q: When should TXA NOT be given? A: After 3 hours of injury (increases mortality). Relative caution in isolated TBI (MRC CRASH-3 - benefit in mild-moderate TBI if SBP <90mmHg, but not in severe TBI with pupils already blown). Avoid if known thromboembolic disease (relative contraindication).

---

3.3 - Fibrinogen Replacement

• Traumatic coagulopathy is characterised by LOW fibrinogen (often the first factor to fall)
• Give fibrinogen concentrate (4-8g IV) or cryoprecipitate if fibrinogen <1.5 g/L OR viscoelastic evidence of functional fibrinogen deficiency
• Target fibrinogen >1.5 g/L (some guidelines suggest >2.0 g/L in ongoing haemorrhage)

---

3.4 - Massive Transfusion Protocol (MTP)

• 10 units pRBC in 24h, OR

• 4 units pRBC in 1 hour, OR

• Clinical assessment: haemodynamic instability + ongoing haemorrhage

• 1:1:1 ratio pRBC:FFP:Platelets
• TXA within 3 hours
• Fibrinogen concentrate / cryoprecipitate
• Calcium replacement (ionised Ca falls with citrated blood products - give 10ml 10% CaCl2 every 4 units pRBC)
• Avoid hypothermia, acidosis (correct with bicarbonate if pH <7.1)
• Point-of-care viscoelastic testing (VHA - ROTEM/TEG) to guide replacement

• Hb >70-80 g/L (80-100 in TBI)
• Platelets >50 x 10^9/L (>100 in TBI or multiple injuries)
• PT/APTT <1.5 x normal
• Fibrinogen >1.5 g/L
• Ionised Ca >1.1 mmol/L

Q: What is the role of prothrombin complex concentrate (PCC) in trauma? A: 4-factor PCC (25-50 IU/kg) is used for: rapid reversal of warfarin/DOAC anticoagulation, or as adjunct in trauma coagulopathy if FFP not available or patient in fluid overload. European Guideline Grade 1C recommendation.

---

SECTION 4 - INVESTIGATIONS AND IMAGING

4.1 - Mandatory Investigations

• ECG (arrhythmia in cardiac contusion; RBBB in tension)
• ABG (pH, lactate, base excess, Hb, ionised Ca, glucose)
• FAST scan (Focused Assessment with Sonography in Trauma): 4 windows - hepatorenal, splenorenal, pericardium, pelvic
• CXR (portable)
• Pelvic X-ray (portable)

• FBC, U&E, LFTs, coagulation screen, fibrinogen, fibrin degradation products
• Troponin (cardiac contusion)
• ROTEM or TEG (viscoelastic haemostatic assay - preferred over standard coagulation in ongoing haemorrhage)
• Blood ethanol level, urine pregnancy test (females of reproductive age)

---

4.2 - Whole-Body CT (WBCT)

• Gold standard investigation for haemodynamically stable polytrauma
• Head to pelvis with IV contrast ("pan-scan")
• Criteria: suspected multiple injuries OR deranged physiology
• Do NOT perform WBCT based on mechanism alone
• Do NOT delay WBCT if haemodynamically stable - scan should be done within the primary survey/resuscitation phase
• Time target: CT report within 30-60 minutes of arrival
• A "hot report" (provisional, within minutes) identifies immediate life threats

Q: When should you NOT send a trauma patient to CT? A: When haemodynamically unstable despite resuscitation - these patients need to go to theatre (or IR/angio suite) for haemorrhage control. CT delays definitive intervention. FAST scan + CXR/pelvic XR are the bedside alternatives.

---

SECTION 5 - THORACIC TRAUMA

5.1 - Blunt Thoracic Trauma

• Rib fractures (pain, splinting, pneumonia risk): analgesia (regional > systemic); >3 consecutive rib fractures = flail chest
• Flail chest: PPV if SpO2 <90%; epidural or paravertebral block for pain
• Pneumothorax: simple - aspiration/chest drain; tension - immediate needle then drain
• Haemothorax: chest drain 28-32Fr; >1500ml initial OR >200ml/h for 2-4h = thoracotomy
• Pulmonary contusion: ARDS risk; lung-protective ventilation (TV 6ml/kg IBW, PEEP 5-8, plateau P <30cmH2O)
• Aortic injury (traumatic aortic dissection): CT angiography; TEVAR (endovascular) preferred over open surgery; control HR + BP (target HR <80, SBP 100-120)

5.2 - Penetrating Thoracic Trauma

• All penetrating chest wounds: chest drain + 3-sided occlusive dressing for open wounds
• Cardiac tamponade: Beck's triad (hypotension, JVD, muffled heart sounds); confirm with FAST (pericardial fluid); immediate pericardiocentesis or ED thoracotomy
• Penetrating vs blunt: penetrating injuries more commonly involve single anatomical structure; blunt has more energy transfer causing multiple injuries

• Penetrating chest trauma with witnessed cardiac arrest OR loss of vital signs within 15 minutes
• NOT indicated in blunt trauma with >10 min CPR (some centres extend to <15 min penetrating)
• Goal: release tamponade, cross-clamp aorta, internal cardiac massage

Q: What are the indications for immediate thoracotomy in trauma? A: (1) Chest drain output >1500ml immediately, or (2) >200ml/h for 2-4 consecutive hours, (3) Cardiac tamponade not responding to pericardiocentesis, (4) Aortic/great vessel injury requiring repair, (5) Tracheobronchial injury. EDT for penetrating arrest with <15 min CPR.

---

SECTION 6 - TRAUMATIC BRAIN INJURY (TBI)

6.1 - Classification

6.2 - Primary vs Secondary Injury

• Primary: direct mechanical damage at time of impact - not reversible
• Secondary: hypoxia, hypotension, hyperthermia, hyperglycaemia, seizures, raised ICP - ALL PREVENTABLE

6.3 - Key Targets in Severe TBI (BTF 4th Ed)

6.4 - ICP Management Stepwise

• Head-up 30°
• Sedation + analgesia (propofol/morphine preferred)
• Normothermia
• Normovolaemia
• Normocapnia (PaCO2 4.5-5.0 kPa)
• Osmotherapy: 20% mannitol 0.25-1g/kg IV 4-6 hourly (target serum osmolality <320 mOsm/kg) OR hypertonic saline 3% NaCl 250ml over 30 min

• Sedation bolus (propofol)
• Neuromuscular blockade
• Mild hyperventilation (PaCO2 32-35 mmHg)
• Repeat CT to exclude surgical lesion

• Barbiturate coma (thiopentone)
• Decompressive craniectomy
• Hypothermia (controversial - EUROTHERM3235 trial showed harm)

6.5 - Anticoagulation Reversal in TBI

• Warfarin: 4-factor PCC (25-50 IU/kg) + Vitamin K 10mg IV
• DOACs: Idarucizumab (dabigatran reversal, 5g IV); Andexanet alfa (Xa inhibitors, 400-800mg IV)
• Antiplatelet agents: platelet transfusion (controversial, not routinely recommended)

Q: Why is permissive hypotension contraindicated in TBI? A: CPP = MAP - ICP. If ICP is already raised, any drop in MAP (BP) will critically reduce CPP and worsen secondary brain injury. Target SBP ≥110 mmHg overrides permissive hypotension protocol.

Q: A patient has polytrauma with severe TBI and haemorrhagic shock. What BP do you target? A: This is the classic conflict. Prioritise TBI - maintain SBP ≥110 mmHg. Use blood products to achieve this. Do not use permissive hypotension. The European Guideline (Rossaint 2023) and BTF 4th Ed both recommend MAP ≥80 mmHg (SBP ≥110) when TBI coexists.

---

SECTION 7 - SPINAL TRAUMA AND SPINAL CORD INJURY (SCI)

7.1 - ATLS 11 Change: Spinal Motion Restriction (SMR)

• Old ATLS: "immobilise the whole spine" routinely
• New ATLS 11: Selective spinal motion restriction (SMR) - only restrict if:
  • Abnormal neurology
  • Midline spinal tenderness
  • High-risk mechanism + unreliable examination (intoxicated, distracting injury, altered consciousness)
• Rigid cervical collars carry risks: raised ICP, pressure injuries, difficulty with airway
• Clearance tools: NEXUS criteria OR Canadian C-Spine Rule for cervical spine clearance in awake, alert patients

7.2 - Imaging

• CT (not plain XR) is now the standard for suspected spinal injury in major trauma
• MRI for: neurological deficit without bony injury on CT, ligamentous injury assessment, cord oedema

7.3 - Neurogenic vs Haemorrhagic Shock

Q: How do you distinguish neurogenic from haemorrhagic shock? A: Neurogenic shock = bradycardia + hypotension + warm skin (vasodilated). Haemorrhagic shock = tachycardia + hypotension + cold clammy skin. Always exclude haemorrhage FIRST before attributing shock to spinal injury.

7.4 - Management of Acute SCI

• Highly controversial - no longer routinely recommended
• NASCIS II/III protocols (methylprednisolone 30mg/kg bolus then 5.4mg/kg/h for 23-47h) showed marginal benefit but significant harm (infection, GI bleed, sepsis)
• Current consensus: NOT standard of care; may be considered in select blunt SCI within 8h as a clinician option, not a protocol requirement [PMID 40073287, German CPG 2025; Tintinalli]
• Penetrating SCI: methylprednisolone is CONTRAINDICATED (increases sepsis)

---

SECTION 8 - ABDOMINAL TRAUMA

8.1 - Solid Organ Trauma (Liver, Spleen, Kidney)

• NOM is now preferred for liver/spleen grades I-III in stable patients (avoid splenectomy risks: OPSI - overwhelming post-splenectomy infection)
• Post-splenectomy vaccines: Pneumococcus, Meningococcus, HiB (give before discharge or within 2 weeks); penicillin prophylaxis lifelong

8.2 - Hollow Viscus Trauma

• Small bowel most commonly injured in blunt deceleration trauma (seat belt sign!)
• Presentation can be delayed 12-24 hours
• CT: free air/fluid, bowel wall thickening, mesenteric fat stranding
• Management: surgery (bowel resection ± anastomosis vs stoma if contamination/unstable)

8.3 - Blunt vs Penetrating Abdominal Trauma

---

SECTION 9 - PELVIC TRAUMA

9.1 - Recognition

• Signs: instability on spring test, leg shortening/rotation, perineal/scrotal haematoma, blood at urethral meatus (urethral injury - do NOT catheterise; perform urethrogram first), high-riding prostate
• Key X-ray finding: open-book (AP compression), vertical shear, lateral compression fractures

9.2 - Immediate Management (Haemostasis Priority)

• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) Zone III - emerging UK practice for pelvic haemorrhage (placed in aorta at Zone III = infrarenal)
• Pre-peritoneal packing (PPP) + external fixation - surgical option
• Angioembolisation - for ongoing arterial haemorrhage after PPP; performed in IR suite

Q: A patient has an open-book pelvic fracture and SBP of 70 mmHg despite resuscitation. What do you do? A: (1) Pelvic binder on if not done; (2) Activate MTP; (3) Consider REBOA Zone III or take to pre-peritoneal packing; (4) Angioembolisation for arterial bleeding; (5) Do NOT take to CT if haemodynamically unstable.

---

SECTION 10 - MAJOR LIMB TRAUMA

10.1 - Limb Haemorrhage

• Tourniquet (CAT or SOFTT-W) for proximal limb haemorrhage
• Time of application must be documented
• Tourniquet time: safe for ~2 hours; fasciotomy risk beyond 6 hours ischaemia
• Junctional haemorrhage (groin, axilla, neck): wound packing with haemostatic gauze (e.g. QuikClot, Celox) + sustained direct pressure

10.2 - Compartment Syndrome

• Must be actively sought in all crush injuries, prolonged tourniquet, tibial/forearm fractures
• 5 Ps: Pain (especially on passive stretch), Pressure (tense compartment), Paralysis, Paraesthesia, Pallor
• Compartment pressure: normal <10 mmHg; threshold for fasciotomy if >30 mmHg OR within 30 mmHg of diastolic BP (delta P ≤30 mmHg)
• Fasciotomy: 4-compartment fasciotomy of lower leg; cannot wait for MRI

10.3 - Vascular Injury in Limb Trauma

• Hard signs (immediate surgery): absent distal pulse, expanding haematoma, bruit/thrill, active haemorrhage, cold/white limb
• Soft signs (imaging first): reduced pulse, nerve deficit, proximity injury - CT angiography first

10.4 - Fracture Management in Polytrauma

• Damage control orthopaedics: temporary external fixation first; definitive fixation (IM nail, ORIF) delayed until patient physiologically optimised (pH >7.35, Temp >36°C, lactate <4 mmol/L)
• Early total care (immediate IM nailing) ONLY in physiologically stable patients

---

SECTION 11 - SECONDARY SURVEY

• Head: lacerations, haematomas, eye injury, facial fractures
• Neck: JVD, tracheal deviation, crepitus, haematoma
• Chest: full inspection/auscultation
• Abdomen: tenderness, rigidity, rebound, bowel sounds
• Pelvis: gentle spring test ONCE
• Perineum, rectum, vagina (if indicated)
• Extremities: deformity, neurovascular examination
• Neurological: GCS, reflexes, sensation, power
• History: AMPLE - Allergies, Medications, Past history, Last meal, Events/mechanism

---

SECTION 12 - TRAUMA COAGULOPATHY

Mechanisms

1. Acute Traumatic Coagulopathy (ATC): occurs within minutes of injury; driven by tissue hypoperfusion + activated Protein C pathway (hyperfibrinolysis, anticoagulation); NOT caused by dilution
2. Iatrogenic coagulopathy: dilution from crystalloids, hypothermia, acidosis
3. Disseminated Intravascular Coagulation (DIC): consumption + fibrinolysis in severe injury

Monitoring

• Standard labs: PT, APTT, fibrinogen, platelets
• Viscoelastic haemostatic assays (VHA): ROTEM or TEG - gold standard for guiding product replacement; faster than standard labs; provides clot formation, strength, fibrinolysis data

Treatment of Trauma Coagulopathy

---

SECTION 13 - PENETRATING vs BLUNT TRAUMA: KEY DIFFERENCES

---

SECTION 14 - TIME-CRITICAL ACTIONS AND TIME LIMITS SUMMARY

---

SECTION 15 - QUICK VIVA Q&A

---

SECTION 16 - GUIDELINE HIERARCHY FOR EDIC PART 2

Examiner tip: In EDIC Part 2, cite the European Guideline 6th Ed with its grade for haemorrhage and coagulopathy questions. Cite ATLS 11 for survey and initial actions. Cite BTF + NICE for TBI targets. This shows command of the European literature expected of a European intensivist.

---