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POLYTRAUMA MANAGEMENT - EDIC Part 2 Viva Note

GUIDELINE FRAMEWORK - Which to Use in the Viva

For EDIC Part 2: Use ATLS 11th Edition (ACS, 2025) as your primary structural framework (xABCDE, damage control resuscitation, team-based care). Supplement with the European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma, 6th Edition (Rossaint et al., Crit Care 2023; PMID 36859355) for haemostasis, transfusion targets, and coagulopathy management - this is the guideline most aligned with European ICU practice and EDIC expectations. Reference NICE NG39 (Major Trauma: Assessment and Initial Management, 2016, reviewed 2022) for UK-specific thresholds. The Brain Trauma Foundation (BTF) 4th Edition Guidelines (2016/updated 2020) govern TBI management.

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SECTION 1 - PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION (xABCDE)

KEY CHANGE IN ATLS 11 (2025): xABCDE replaces ABCDE

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x - EXSANGUINATING HAEMORRHAGE CONTROL

• Direct pressure, wound packing with haemostatic dressings (e.g. Combat Gauze / kaolin-impregnated gauze)
• Tourniquet application for extremity haemorrhage - apply as proximally as practical; document time of application
• Pelvic binder at the level of the greater trochanters for suspected pelvic ring injury

• Blunt trauma: multiple simultaneous sources common; pelvic binder and limb tourniquets before transfer
• Penetrating trauma: tourniquet priority for limb wounds; junctional haemorrhage (neck/axilla/groin) requires wound packing and junctional tourniquets (JETT/SAM device)

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A - AIRWAY WITH C-SPINE PROTECTION

• Look, listen, feel; assess for stridor, hoarseness, tracheal deviation, subcutaneous emphysema
• GCS <8 or inability to protect airway = definitive airway required

• Pre-oxygenate with 100% O2 for 3 minutes
• Volume resuscitation prior to induction - avoid peri-intubation cardiovascular collapse
• Video laryngoscopy now preferred as primary intubation tool [ATLS 11, 2025]
• Ketamine 1-2 mg/kg IV preferred induction agent in haemodynamically unstable patients (sympathomimetic effect maintains BP); avoid propofol in shocked patients
• Rocuronium 1.2 mg/kg IV paralysis (can be reversed with sugammadex 16 mg/kg if failed intubation)
• Surgical airway (cricothyroidotomy - needle then surgical) if failed: "can't intubate, can't oxygenate"

• Manual in-line stabilisation during intubation
• ATLS 11 change: Spinal motion restriction is now selective and criteria-based - rigid collars de-emphasised, particularly in penetrating neck trauma (risk of venous obstruction outweighs benefit)
• Canadian C-Spine Rule or NEXUS criteria guide C-spine clearance
• MRI or CT is required before collar removal in unconscious patients

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B - BREATHING AND VENTILATION

• Clinical diagnosis - do NOT wait for CXR
• Signs: absent breath sounds, hypotension, tachycardia, distended neck veins (may be absent if hypovolaemic), tracheal deviation (late/unreliable)
• Decompression: 14G needle 2nd ICS MCL, or 4th/5th ICS AAL (ATLS 11 preferred site, higher success rate in muscular patients); follow with formal chest drain

• SpO2 94-98% (avoid hyperoxia), PaO2 10-13 kPa
• PaCO2 4.5-5.0 kPa (normocapnia); avoid hypocapnia unless active cerebral herniation
• Tidal volume 6 mL/kg IBW, PEEP 5-8 cmH2O

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C - CIRCULATION AND HAEMORRHAGE CONTROL

Vascular Access

• Two large-bore (14-16G) peripheral IVs as minimum; if unsuccessful after two attempts, proceed to intraosseous (IO) access (humeral or tibial)
• Do NOT delay resuscitation to place central line
• Arterial line for invasive monitoring once resuscitation initiated

Haemorrhagic Shock Classification (ATLS 11)

ATLS 11 change: Shock classification now incorporates base deficit and lactate alongside HR and BP as better indicators of physiological derangement - recognising that HR and BP are insensitive early markers.

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SECTION 2 - DAMAGE CONTROL RESUSCITATION (DCR)

DCR is the cornerstone of modern trauma resuscitation. It combines permissive hypotension, haemostatic resuscitation (blood products in balanced ratios), and early surgical haemorrhage control. [European Guideline 6th Ed, Rossaint et al., Crit Care 2023, PMID 36859355, Grade 1C]

2.1 Permissive Hypotension

• Target SBP 80-90 mmHg (MAP ~50-65 mmHg) until surgical haemorrhage control is achieved
• Rationale: prevents clot disruption, reduces ongoing blood loss, avoids dilutional coagulopathy
• Contraindications:
  • TBI (concurrent TBI): maintain SBP >100-110 mmHg - permissive hypotension not safe [Schwartz's Principles of Surgery 11th Ed; BTF Level III]
  • Spinal cord injury: MAP target ≥85 mmHg [Sabiston 21st Ed; ACS evidence-based]
  • Elderly patients (comorbidities: coronary disease, carotid stenosis)
  • Blunt trauma (more complex than penetrating trauma - use cautiously)
• Time limit: permissive hypotension is time-limited - haemorrhage control must be achieved as rapidly as possible; not intended for prolonged periods

2.2 Minimise Crystalloids

• Large-volume crystalloid is harmful - causes dilutional coagulopathy, hypothermia, acidosis (lethal triad), abdominal compartment syndrome, ARDS
• Crystalloids limited to small volumes (e.g. 250-500 mL) only as bridge while blood products are prepared
• Colloids (especially starches) are contraindicated in major trauma coagulopathy

2.3 Haemostatic Resuscitation - Blood Products

• ABC Score ≥2 (penetrating mechanism, SBP ≤90, HR ≥120, positive FAST): sensitivity ~75%
• Shock Index (HR/SBP) ≥1.0 - simple bedside tool
• Trauma-Associated Severe Haemorrhage (TASH) score

• pRBC : FFP : platelets = 1:1:1 (reconstituted whole blood equivalent)
• Target: platelet count >50 x10⁹/L (>100 x10⁹/L if TBI); PT/APTT <1.5x normal; fibrinogen >1.5 g/L (>2.0 g/L in ongoing haemorrhage)
• Whole blood (where available): superior to component therapy - maintains platelets, clotting factors, and RBC function; increasingly used in major trauma centres

• Give if fibrinogen <1.5 g/L or <2.0 g/L with ongoing haemorrhage
• Dose: 10 units cryoprecipitate raises fibrinogen by ~1 g/L
• Contains: fibrinogen, factor VIII, vWF, factor XIII

• 25-50 units/kg for reversal of anticoagulant-associated coagulopathy or refractory coagulopathy
• Faster and more concentrated than FFP; does not require thawing

• Hypocalcaemia is universal after massive transfusion (citrate chelation)
• Give calcium chloride 10 mL 10% IV (or calcium gluconate 10-20 mL 10%) for every 4 units of blood
• Ionised calcium target: >1.1 mmol/L

• TEG (thromboelastography) or ROTEM (rotational thromboelastometry) - guide targeted transfusion over fixed-ratio strategies
• ROTEM can direct specific product use (fibrinogen, PCC, platelets) and reduce over-transfusion
• European Guideline 6th Ed recommends VHA-guided therapy where available [Grade 1B]
• Fixed 1:1:1 ratio is the default when VHA is not available

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SECTION 3 - TRANEXAMIC ACID (TXA)

TXA is one of the most evidence-based interventions in trauma and must be known in detail for the EDIC viva.

• Standard (CRASH-2 protocol): 1 g IV over 10 minutes, followed by 1 g IV over 8 hours
• Prehospital bolus: In UK prehospital practice, 1 g IV/IO bolus is given pre-hospital (by paramedics/HEMS)
• Military/JTTS protocol (US): 2 g IV bolus (single dose), given as close to time of injury as possible, in 100 mL normal saline over 10 minutes

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SECTION 4 - LETHAL TRIAD AND TRAUMA COAGULOPATHY

• Acidosis (pH <7.35) - impairs clotting factor function
• Hypothermia (<35°C) - inhibits enzymatic coagulation cascade
• Coagulopathy - dilutional, consumptive, or hyperfibrinolysis-driven

• Warm all blood products and IV fluids; keep patient warm (blankets, forced-air warming)
• Target pH >7.35, base deficit <-6
• Target core temperature >36°C

• Present in ~25-30% of severely injured patients on arrival
• Driven by shock, tissue hypoperfusion, and systemic fibrinolysis - independent of dilution
• Recognised by PT/APTT prolongation, high fibrin degradation products, low fibrinogen, abnormal ROTEM/TEG
• Treat with FFP, cryoprecipitate, platelets, TXA, PCC as guided by VHA

• PT and APTT <1.5x normal
• Fibrinogen >1.5 g/L (>2.0 g/L with ongoing haemorrhage) [European Guideline Grade 1C]
• Platelets >50 x10⁹/L; >100 x10⁹/L if multiple trauma, CNS injury, or ongoing haemorrhage [European Guideline Grade 1C]
• Ionised calcium >1.1 mmol/L

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SECTION 5 - D: DISABILITY (NEUROLOGICAL ASSESSMENT)

• GCS: score E+V+M (3-15)
• Pupils: size, symmetry, reactivity; unilateral fixed dilated pupil = tentorial herniation (ipsilateral CN III compression) until proven otherwise
• Motor response: limb movement, localisation, posturing (decerebrate = worse prognosis)

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SECTION 6 - E: EXPOSURE AND ENVIRONMENT

• Full exposure including log roll (maintain spinal precautions)
• Core temperature recording - active warming if hypothermic
• FAST examination during primary survey (see imaging below)
• Record time of injury, mechanism, blood loss estimate

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SECTION 7 - INVESTIGATIONS AND IMAGING

Immediate Investigations (on arrival, parallel to primary survey)

• Point-of-care bloods: ABG with lactate, iCa, glucose; VBG acceptable if no arterial access
• Bloods: FBC, coagulation screen (PT, APTT, fibrinogen, D-dimer), U&E, LFT, crossmatch, TXA status
• ROTEM/TEG if available: guide haemostatic resuscitation
• ECG: arrhythmia, myocardial contusion (RBBB, ST changes post-blunt chest trauma)
• Urine output monitoring: target ≥0.5 mL/kg/hr

Imaging

• Performed during or immediately after primary survey
• Views: pericardial, right upper quadrant (hepatorenal), left upper quadrant (splenorenal), pelvis (pouch of Douglas)
• Detects free fluid (haemoperitoneum ≥200 mL, pericardial tamponade)
• Sensitivity for haemoperitoneum ~79-86% (not sensitive for retroperitoneal or hollow-viscus injury)
• eFAST adds bilateral lung windows for pneumothorax

• CT from vertex to pelvis, with IV contrast (portal venous phase for abdomen; arterial for vascular injury)
• Indication: any severely injured adult with deranged physiology or mechanism suggesting multisystem injury
• Should NOT be based on mechanism alone
• Goal: perform as rapidly as possible during resuscitation (CT suite in or adjacent to resuscitation bay in major trauma centres)
• Provides 'provisional hot report' within minutes for life-threatening pathology
• Not for haemodynamically unstable patients who require immediate surgical control - in these patients, an emergency pelvic XR and FAST (or immediate laparotomy/packing) are appropriate before CT

• Increasingly omitted in favour of rapid CT in major trauma centres
• Still relevant: CXR and pelvic XR when haemodynamically unstable and CT not immediately available

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SECTION 8 - SECONDARY SURVEY

• Head-to-toe physical examination
• Complete history: AMPLE (Allergies, Medications, Past medical history, Last meal, Events/environment)
• Reassess all injuries; log roll to examine back
• Adjuncts: urinary catheter (unless urethral injury suspected - blood at meatus, perineal bruising = retrograde urethrogram first), nasogastric tube (orogastric if base of skull fracture)
• Re-examine GCS, pupils, limb neurology

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SECTION 9 - THORACIC TRAUMA

Immediately Life-Threatening (Primary Survey - "ATOMIC")

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Instability of chest wall (flail chest)
• Cardiac tamponade

Potentially Life-Threatening (Secondary Survey - "CLASP")

• Contusion (myocardial/pulmonary)
• Laceration (aortic/great vessel)
• Airway disruption (tracheobronchial)
• Sign of oesophageal rupture
• Phrenix (diaphragmatic rupture)

Aortic Injury

• Mechanism: rapid deceleration (RTA, fall from height) - shear forces at aortic isthmus (ligamentum arteriosum)
• CT aortography is definitive investigation
• Unstable: emergency thoracotomy or TEVAR (thoracic endovascular aortic repair) - TEVAR now preferred in most centres
• Stable: urgent TEVAR or open repair

Cardiac Tamponade

• Beck's Triad: hypotension, muffled heart sounds, raised JVP (all three present in <50%)
• FAST: pericardial effusion is virtually diagnostic
• Penetrating trauma more common than blunt
• Emergency: pericardiocentesis (temporising); definitive = pericardiotomy/thoracotomy
• Blunt cardiac injury: ECG + troponin; echo if ECG abnormal

Traumatic Arrest - Resuscitative Thoracotomy (RT)

• Indications:
  • Penetrating thoracic trauma with witnessed cardiac arrest or loss of signs of life within 10 minutes
  • Blunt trauma: signs of life within 5 minutes (lower yield)
• Procedure: left anterior thoracotomy, aortic cross-clamp, open cardiac massage, repair cardiac wounds
• Contraindicated: blunt trauma with >15 min of CPR without ROSC; asystole without tamponade

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SECTION 10 - TRAUMATIC BRAIN INJURY (TBI)

Severity Classification

• Mild TBI: GCS 14-15
• Moderate TBI: GCS 9-13
• Severe TBI: GCS 3-8

Primary and Secondary Brain Injury

• Primary: at moment of injury (contusion, laceration, diffuse axonal injury, haematoma)
• Secondary: avoidable - caused by hypotension, hypoxia, hypercapnia, pyrexia, hyperglycaemia, seizures, elevated ICP

Immediate Management of Severe TBI

• Age 15-49 years or >70 years: SBP ≥110 mmHg [BTF Level IIB]
• Age 50-69 years: SBP ≥100 mmHg [BTF Level III]
• Permissive hypotension is contraindicated in TBI - hypotension is the single most harmful secondary insult

• Head elevation 30°
• Normoglycaemia (target 6-10 mmol/L)
• Normothermia (target 36-37°C)
• Seizure prophylaxis: levetiracetam 1 g loading dose, then 500 mg BD for 7 days [Schwartz's Surgery 11th Ed, Level IIA - BTF]
• Avoid steroids (CONTRAINDICATED - CRASH trial: methylprednisolone increased mortality RR 1.18) [CRASH trial, Level I; BTF Level I]
• Peptic ulcer prophylaxis

• Osmotherapy: Mannitol 0.25-1 g/kg IV bolus; repeat if serum osmolality <320 mOsm/kg and patient not hypovolaemic; or
• Hypertonic saline (3% NaCl): 150-250 mL bolus; preferable if hypotensive (does not cause diuresis); target serum Na 145-155 mmol/L [BTF Level IIA for osmotherapy]
• CSF drainage via EVD (external ventricular drain) if in situ

• Sedation optimisation (propofol or midazolam)
• Neuromuscular blockade (short-term)
• Mild permissive hypocapnia (PaCO2 4.0-4.5 kPa)

• Decompressive craniectomy (DECRA/RESCUEicp trials: reduces ICP, improves functional outcome in some patients) [RESCUEicp, Level I RCT, NEJM 2016]
• Barbiturate coma (thiopentone): last resort; profound haemodynamic effects
• Hypothermia: not recommended for neuroprotection post-TBI [BTF Level IIA against]

• Immediate CT (within 1 hour): GCS <13 on initial assessment, suspected open/depressed skull fracture, any sign of basal skull fracture, post-traumatic seizure, focal neurological deficit, >1 episode of vomiting in adults
• CT within 8 hours: amnesia >30 min, LOC with age ≥65, coagulopathy/anticoagulants

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SECTION 11 - SPINAL TRAUMA AND SPINAL CORD INJURY (SCI)

Spinal Immobilisation - ATLS 11 Changes

• Selective spine motion restriction - rigid collars are NOT mandatory for all trauma patients
• Penetrating neck trauma: rigid collar is NOT recommended - can obstruct venous drainage and mask haematoma expansion without reducing neurological injury [ATLS 11, 2025]
• Blunt trauma with mechanism/symptoms: immobilise with rigid collar and blocks + straps on a flat board until C-spine cleared by imaging
• Log roll with 4-person technique for thoracolumbar spine protection

• Conscious, cooperative, alert patient: Canadian C-Spine Rule or NEXUS criteria
• Unconscious patient or distracting injury: CT C-spine; if negative CT but neurological deficit, requires MRI (CT misses ligamentous injury)

Spinal Cord Injury Management

• Injury above T6 - disruption of descending sympathetic tracts
• Features: bradycardia + hypotension (warm peripheries, no tachycardia)
• Haemorrhagic shock: tachycardia + cold extremities
• Treatment: IV fluids; vasopressors if needed (noradrenaline first-line); target MAP ≥85 mmHg for 7 days post-injury to maintain spinal cord perfusion [Sabiston 21st Ed; ACS evidence-based, no RCT - observational Level III]

• MAP ≥85 mmHg (or at least 10 mmHg above patient's baseline if hypertensive) for 7 days post-injury
• After ensuring euvolaemia, vasopressors (noradrenaline) are often required
• Complete cervical SCI: vasopressors needed in ~90% [Sabiston 21st Ed, p.1809]

• NASCIS trials showed marginal benefit in narrow time window; subsequent analysis showed increased infection, sepsis, and mortality
• Most guidelines (ATLS 11, AANS/CNS) do not recommend routine methylprednisolone

• Early decompression (<24 hours) associated with improved neurological outcomes in incomplete SCI
• Unstable fractures require stabilisation (posterior instrumentation, anterior fusion)

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SECTION 12 - ABDOMINAL TRAUMA

Solid-Organ Trauma

• AAST (American Association for Surgery of Trauma) grading I-VI
• Haemodynamically stable: non-operative management (NOM) for grades I-III (and selected IV)
• CT with contrast required for staging
• Angioembolisation for arterial blush on CT (grade III-IV)
• Haemodynamically unstable: damage control laparotomy - packing of liver, temporary closure, ICU resuscitation, then re-look at 24-48 hours

• NOM successful in 80-90% of grade I-III
• Splenic angioembolisation for grade III-V with haemodynamic stability
• Splenectomy: haemodynamically unstable, failed NOM, grade V
• Post-splenectomy vaccinations: pneumococcal, Hib, meningococcal (give before discharge or within 2 weeks)

• NOM for most renal injuries (grades I-III); grade IV-V may need embolisation or surgery
• CT with delayed phase for urinoma/urinary leak

Hollow-Viscus Trauma

• Small bowel: most commonly injured by seatbelt in blunt trauma (Chance fracture association)
• Signs on CT: free air (pathognomonic for perforation), mesenteric stranding, bowel wall thickening
• Delayed presentation common - serial examinations required
• Treatment: laparotomy, resection and anastomosis or stoma (damage control: resect, staple, leave in situ, anastomose at re-look)
• Colon: primary repair if no contamination and low-velocity penetrating; resection + stoma for destructive/high-contamination injuries

• Blunt: left-sided > right (liver protective); missed on initial CXR in ~50%
• Penetrating: both sides; often subtle
• Diagnosis: CT thorax/abdomen (reformats); diagnostic laparoscopy
• Treatment: operative repair

Damage Control Surgery (DCS)

1. Phase 1 (OR): haemorrhage control (packing, clamping, shunts), contamination control (staple bowel, not anastomose), temporary abdominal closure
2. Phase 2 (ICU): resuscitation - correct lethal triad, warm, optimise coagulation
3. Phase 3 (OR, 24-48 hours): definitive repair, anastomosis, fascial closure

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SECTION 13 - PELVIC TRAUMA

Classification

• Young-Burgess classification: Lateral compression (LC), Anterior-posterior compression (APC), Vertical shear (VS), Combined mechanism (CM)
• APC III and VS most haemorrhagic - disrupt posterior pelvic ring and venous plexus

Pelvic Haemorrhage - Major Cause of Death in Blunt Trauma

1. Venous (pelvic venous plexus) - 80-85% of pelvic haemorrhage
2. Arterial (internal iliac branches, superior gluteal artery) - 15-20% but arterial haemorrhage is more rapidly lethal
3. Bony surface (cancellous bleeding)

Management Algorithm

• Reduces pelvic volume, tamponades venous haemorrhage
• Do NOT remove until pelvic fracture excluded
• Correctly positioned binder does NOT obstruct laparotomy

• Stable: CT to define fracture pattern, identify arterial blush
• Unstable with free abdominal fluid: laparotomy FIRST, then pelvic control

• Arterial blush on CT: Angioembolisation (trans-arterial embolisation, TAE) - first-line for arterial pelvic haemorrhage [European Guideline 6th Ed Grade 1B]
• Haemodynamically unstable without response to MTP: Preperitoneal pelvic packing (PPP) + external fixator - for venous/bony haemorrhage
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta): Zone III REBOA for pelvic haemorrhage; adjunct to surgical control; reduces aortic flow distal to balloon [emerging evidence, not yet standard of care - ATLS 11 mentions as adjunct]

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SECTION 14 - MAJOR LIMB TRAUMA

Vascular Injury

• Hard signs of vascular injury: pulsatile haemorrhage, expanding haematoma, bruit/thrill, absent distal pulse, limb ischaemia (6Ps: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Poikilothermia)
• Ankle-Brachial Index (ABI) <0.9 = significant vascular injury
• CT angiography or formal angiography
• Vascular surgery: shunting (damage control) vs primary repair vs bypass
• Ischaemia time limit: reperfusion within 4-6 hours to prevent irreparable muscle damage; >6 hours = high amputation/mortality risk

Compartment Syndrome

• Suspect after: long bone fracture, crush injury, reperfusion injury, circumferential burns, tight cast
• Clinical: tense compartment, pain out of proportion, pain on passive stretch (earliest reliable sign), paraesthesia, paralysis (late)
• Compartment pressure: measure if clinical doubt; pressure >30 mmHg or within 30 mmHg of diastolic BP = fasciotomy
• Fasciotomy: 4-compartment lower leg (medial and lateral incisions); upper arm; forearm
• Do NOT delay if clinical signs present

Fracture Management in Polytrauma

• Femoral fractures: external fixation (damage control) acutely; intramedullary nailing when physiology corrected (ideally 24-48 hours)
• Open fractures: BOAST/BAPRAS guidelines - wound irrigation and primary closure if possible; prophylactic antibiotics (co-amoxiclav + metronidazole); theatre within 24 hours (12 hours if highly contaminated); tetanus prophylaxis
• Fat embolism syndrome: follows long bone/pelvic fractures; triad of hypoxia, petechiae, confusion; treat supportively

Traumatic Amputation

• Tourniquet prehospital; document time
• Reconstruct if feasible and patient stable (orthopaedic + plastic surgery team)
• Replantation criteria: sharp amputation, young patient, <6 hours warm ischaemia time, <12 hours cold ischaemia

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SECTION 15 - BLUNT VS PENETRATING TRAUMA - KEY DIFFERENCES

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SECTION 16 - DAMAGE CONTROL RESUSCITATION - CONSOLIDATED TARGET SUMMARY

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SECTION 17 - KEY DRUG DOSES SUMMARY

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SECTION 18 - TIME-CRITICAL LIMITS

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VIVA QUICK-FIRE POINTS (Commonly Asked)

1. What is the first step in ATLS 11? - Control of eXsanguinating external haemorrhage (xABCDE)
2. TXA dose? - 1 g IV over 10 min, then 1 g over 8 hours; within 3 hours of injury
3. Why avoid crystalloids? - Lethal triad: dilutional coagulopathy, hypothermia, acidosis + ARDS + abdominal compartment syndrome
4. Blood product ratio for massive transfusion? - 1:1:1 (pRBC:FFP:platelets)
5. SBP target with TBI? - ≥110 mmHg (age 15-49 or >70); ≥100 (age 50-69)
6. Permissive hypotension SBP target? - 80-90 mmHg (not in TBI or SCI)
7. MAP target for SCI? - ≥85 mmHg for 7 days
8. Steroids in TBI? - CONTRAINDICATED (CRASH trial - increased mortality)
9. Steroids in SCI? - NOT recommended (NASCIS - marginal benefit, significant harm)
10. Needle decompression for tension pneumothorax - where? - 2nd ICS MCL or 4th/5th ICS AAL
11. What does ROTEM/TEG add? - Targeted haemostatic therapy (superior to fixed 1:1:1 when available); guides specific product use
12. Neurogenic shock vs haemorrhagic shock? - Neurogenic: bradycardia + hypotension; Haemorrhagic: tachycardia + cold peripheries
13. Most important change in ATLS 11? - xABCDE - haemorrhage control before airway; video laryngoscopy preferred; selective spinal motion restriction; selective spinal motion restriction criteria-based; DCR as central framework
14. European Guideline current edition? - 6th edition, Rossaint et al., Crit Care 2023 (PMID 36859355)
15. CRASH-2 primary outcome? - Significant reduction in all-cause mortality (RR 0.91, NNT ~67) with TXA within 3 hours

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SOURCES USED

Viva tip: For EDIC Part 2, the examiners expect you to lead with ATLS 11 structure (xABCDE, DCR), cite the European Guideline 6th edition for specific haemostasis/transfusion grades, reference BTF for TBI targets, and CRASH-2/CRASH-3 for TXA. Knowing the GRADE (1A vs 2C) after each recommendation signals high-level preparation.