Trauma Surgery

01 ATLS Principles & Trauma Activation

Trauma surgery is an acuity-driven specialty. Every encounter begins with a structured, time-critical assessment framework derived from Advanced Trauma Life Support (ATLS), the American College of Surgeons Committee on Trauma (ACS COT) curriculum now in its 10th edition. ATLS standardizes the approach to a critically injured patient: identify and treat life-threatening problems in the order in which they will kill the patient. The trauma scribe's first job is to understand ATLS because nearly every word said in the trauma bay maps to an ATLS step.

Trauma Team Activation

Verified trauma centers (Levels I–V) stratify incoming patients by physiologic and mechanistic criteria. A Level 1 (highest tier) activation is reserved for patients with immediate life-threatening injuries; a Level 2 activation captures serious but more stable patients; consultations or "trauma alerts" are lower acuity. Activation criteria follow the CDC Field Triage Criteria and include physiologic (SBP < 90, GCS < 14, RR < 10 or > 29), anatomic (penetrating torso/neck/groin, flail chest, two or more proximal long bone fractures, crush, pelvic fracture, open/depressed skull fracture, paralysis), and mechanistic (ejection, death in same vehicle, fall > 20 ft, auto-pedestrian) criteria.

02 Scribe Documentation Framework

Trauma documentation differs fundamentally from clinic documentation. You are not writing a SOAP note in real time; you are writing a trauma flow sheet that captures a resuscitation, then an admission H&P, then operative notes, and finally ICU progress notes. Each format has different rules.

03 Primary & Secondary Survey (ABCDE) Core

The primary survey is the first 60 seconds of the resuscitation. Its only purpose is to identify and treat immediately life-threatening problems. It follows the ABCDE mnemonic: Airway with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability (neurologic), Exposure and environmental control.

A — Airway with C-Spine Protection

Can the patient speak clearly? A patient phonating normally has a patent airway and adequate cerebral perfusion. Look for stridor, gurgling, pooled blood or secretions, facial burns or soot, expanding neck hematoma, and altered mental status. Patients with GCS ≤ 8 generally require a definitive airway. Always maintain manual in-line stabilization of the cervical spine during airway maneuvers until the C-spine is cleared clinically or radiographically.

B — Breathing and Ventilation

Inspect, palpate, percuss, and auscultate the chest. The six immediately life-threatening thoracic injuries (the "lethal six") identified in the primary survey are: airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest with pulmonary contusion, and cardiac tamponade. Pulse oximetry, capnography, and a STAT portable chest X-ray follow immediately.

C — Circulation with Hemorrhage Control

Assess perfusion by mental status, skin color/temperature, and pulses. External bleeding is controlled with direct pressure, packing, tourniquets (extremity), and junctional devices (groin/axilla/neck). Two large-bore IVs (16G or 14G) go in bilateral antecubitals; if unable, place an IO or central access (IJ/femoral cordis). Draw a trauma panel (type & cross, CBC, CMP, coags, lactate, ABG, ethanol, tox, urine HCG, troponin, fibrinogen, TEG or ROTEM). Initiate balanced resuscitation with blood products if there is any concern for hemorrhagic shock.

D — Disability (Neurologic)

Rapid neurologic assessment: GCS (E/V/M), pupils (size, symmetry, reactivity), gross motor exam of all extremities, and any focal deficit. Check for lateralizing signs (unilateral weakness, fixed/dilated pupil). Document the Glasgow Coma Scale by component.

E — Exposure and Environment

Completely undress the patient, log-roll to inspect the back, and then cover with warm blankets and a Bair Hugger to prevent hypothermia. The lethal triad of trauma — hypothermia, acidosis, and coagulopathy — is worsened by a cold patient. Core temperature should be monitored (rectal or esophageal).

Secondary Survey

After the primary survey and initial resuscitation stabilize the patient, the secondary survey is a head-to-toe exam to catalog every injury. This is where you identify injuries that won't kill the patient in the next 5 minutes but will complicate care if missed (facial fractures, extremity fractures, tendon injuries, small hemothorax, solid organ injuries). The AMPLE history is taken here. A tertiary survey is typically repeated within 24 hours to catch missed injuries, which occur in 2–15% of multi-trauma patients.

04 Airway Management & RSI in Trauma Airway

Airway compromise kills trauma patients faster than anything else. The decision to intubate in trauma is based on inability to protect the airway (GCS ≤ 8, massive facial trauma, expanding neck hematoma, inhalation injury), inability to oxygenate/ventilate, expected clinical course (combative patient requiring imaging, transport to OR), or hemodynamic collapse requiring sedation/paralysis for resuscitation.

Rapid Sequence Intubation (RSI)

RSI is the simultaneous administration of a sedative induction agent and a neuromuscular blocker to achieve optimal intubating conditions with minimal risk of aspiration. Classic sequence: preoxygenation → pretreatment (optional) → paralysis with induction → positioning → placement with proof → post-intubation management.

Surgical Airway (Cricothyroidotomy)

When intubation fails and bag-mask ventilation is inadequate ("cannot intubate, cannot oxygenate"), an emergent surgical cricothyroidotomy is performed: a vertical skin incision over the cricothyroid membrane, a horizontal stab through the membrane, tracheal hook to elevate, and a 6.0 cuffed tracheostomy or ETT inserted. Needle cricothyroidotomy with jet ventilation is a temporizing measure in children < 12 years, in whom surgical crich is relatively contraindicated.

05 Hemorrhagic Shock & Resuscitation Shock

Hemorrhage is the leading cause of preventable death after trauma. The ATLS classification of hemorrhagic shock is based on estimated blood loss and physiologic parameters.

Balanced Resuscitation & MTP

Modern trauma resuscitation is hemostatic and blood-product based. Crystalloid is minimized (< 1 L) to avoid dilutional coagulopathy and worsening acidosis. The Massive Transfusion Protocol (MTP) delivers packed red blood cells, fresh frozen plasma, and platelets in a balanced 1:1:1 ratio, supported by the landmark PROPPR trial and observational PROMMTT study. Whole blood, when available, is increasingly preferred.

Permissive Hypotension

In penetrating torso trauma without TBI, targeting an SBP around 80–90 mmHg (MAP ~65) until surgical hemorrhage control reduces rebleeding from clot disruption. This is contraindicated in patients with TBI, where SBP must be kept ≥ 110 to preserve cerebral perfusion pressure.

Tranexamic Acid (TXA)

Per the CRASH-2 trial, TXA (1 g IV over 10 min, then 1 g over 8 h) reduces all-cause mortality when given within 3 hours of injury in bleeding trauma patients. CRASH-3 extended TXA benefit to mild-to-moderate TBI within 3 hours.

REBOA

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a temporizing measure for non-compressible torso hemorrhage. A balloon catheter is placed via the common femoral artery into either Zone 1 (supraceliac, above T12) for abdominal/pelvic bleeding or Zone 3 (infrarenal, below renals) for pelvic/junctional bleeding. Zone 2 (paravisceral) is generally avoided. REBOA buys time until definitive surgical control.

06 Damage Control Surgery & Resuscitation Core

Damage control surgery (DCS) is an abbreviated operative approach for the physiologically compromised trauma patient. Instead of completing a definitive repair, the surgeon controls hemorrhage and contamination, leaves the abdomen open, and returns the patient to the ICU to correct the lethal triad. After 24–48 hours of warming, correction of acidosis, and correction of coagulopathy, the patient returns to the OR for definitive repair.

Damage control resuscitation (DCR) is the parallel ICU/ED strategy: early balanced blood product transfusion, minimal crystalloid, permissive hypotension (where appropriate), TXA, and aggressive warming. DCR and DCS are inseparable concepts in modern trauma.

07 Traumatic Brain Injury (TBI) Neuro

TBI is the leading cause of trauma mortality in young adults. Severity is graded by initial GCS: mild TBI (13–15), moderate TBI (9–12), severe TBI (3–8). The Brain Trauma Foundation severe TBI guidelines (4th edition) are the reference standard for ICU management.

Injury Patterns

Management of Severe TBI

Goals: cerebral perfusion pressure (CPP = MAP − ICP) 60–70 mmHg, ICP < 22, SBP ≥ 110, SpO2 ≥ 90, normocapnia (PaCO2 35–40), normothermia, euglycemia, Na 140–150. Head of bed 30°, loose C-collar, sedation/analgesia, seizure prophylaxis with levetiracetam for 7 days, and reversal of any anticoagulation. Tiered ICP management: sedation → hypertonic saline or mannitol → CSF drainage via EVD → paralysis → decompressive craniectomy or barbiturate coma.

Imaging severity is often described using the Marshall CT classification (I–VI, based on basal cisterns, midline shift, and lesion type) and the Rotterdam CT score (0–6, incorporating basal cisterns, midline shift, epidural mass, and IVH/SAH).

08 Maxillofacial & Neck Trauma Head/Neck

Le Fort Fractures

Neck Trauma Zones

Penetrating neck injuries are stratified by anatomic zone for management:

Modern management for all stable penetrating neck injuries is no-zone, CTA-first (EAST practice management guidelines): CT angiography of the neck, with selective operative exploration for hard signs (expanding hematoma, air bubbling, massive bleeding, pulse deficit, bruit/thrill). Unstable patients with hard signs go directly to the OR. Blunt cerebrovascular injury (BCVI) is screened with CTA per the Denver or modified Memphis criteria (mechanism + C-spine fracture, basilar skull fracture, Horner syndrome, etc.).

09 Cervical & Spinal Cord Injury Spine

Cervical spine clearance uses validated decision rules. The NEXUS criteria allow clinical clearance if all five are met: no midline tenderness, no focal neurologic deficit, normal alertness, no intoxication, no distracting injury. The Canadian C-spine rule offers similar clearance with additional high-/low-risk factor criteria. When clinical clearance fails, CT C-spine is the first-line imaging.

Spinal Cord Injury Syndromes

Complete cord injury: No sensory or motor function below the level. ASIA A.
Central cord syndrome: Hyperextension in a stenotic canal, upper > lower extremity weakness.
Anterior cord syndrome: Loss of motor, pain, and temperature; preserved proprioception and vibration.
Brown-Séquard syndrome: Hemisection of cord — ipsilateral motor/proprioception loss, contralateral pain/temperature loss.
Cauda equina syndrome: Saddle anesthesia, bowel/bladder dysfunction, lower extremity weakness. Surgical emergency.

10 Thoracic Trauma Chest

Chest injuries account for approximately 25% of trauma deaths. Most are managed non-operatively; only ~10–15% require thoracotomy. The EAST rib fracture guidelines are the reference standard for blunt chest trauma.

Rib Fractures & Flail Chest

Rib fractures cause pain-mediated hypoventilation, atelectasis, and pneumonia, especially in elderly patients. Flail chest = 3 or more contiguous ribs fractured in 2 or more places, producing a paradoxical segment. The main problem is the underlying pulmonary contusion, not the paradox itself. Management: aggressive analgesia (epidural, PCA, intercostal/paravertebral blocks, serratus anterior plane blocks), pulmonary toilet, early mobilization, and selective surgical stabilization of rib fractures (SSRF) for flail chest or severely displaced fractures.

Pulmonary contusion is bruising of lung parenchyma that produces hypoxemia and ARDS-like physiology over 24–72 hours. Blunt cardiac injury is screened with EKG and troponin; normal EKG and troponin effectively rule out clinically significant BCI per EAST BCI guidelines. Tracheobronchial injury presents with persistent large air leak after chest tube placement and requires bronchoscopy. Esophageal injury is suspected with pneumomediastinum without obvious cause, mediastinitis, or after penetrating transmediastinal injury; diagnosed with CT, esophagram, or endoscopy.

ED Resuscitative Thoracotomy

Per EAST guidelines on ED thoracotomy, the procedure is strongly recommended for pulseless patients with penetrating thoracic injury and signs of life on arrival; conditionally recommended for penetrating extra-thoracic injury with signs of life, and for blunt trauma with signs of life. The goals are: release pericardial tamponade, control pulmonary hemorrhage, cross-clamp the descending thoracic aorta, and perform open cardiac massage.

11 Abdominal Trauma Abdomen

Abdominal trauma is divided into blunt (MVC, fall, assault) and penetrating (GSW, stab). The approach differs radically.

FAST & E-FAST

The Focused Assessment with Sonography for Trauma (FAST) examines four views for free intraperitoneal fluid: right upper quadrant (Morison's pouch), left upper quadrant (splenorenal), pelvis (pouch of Douglas), and pericardium (subxiphoid). The Extended FAST (E-FAST) adds bilateral anterior lung views to assess for pneumothorax. FAST is highly specific but not sensitive for small-volume injury. A positive FAST in an unstable blunt trauma patient is an indication for immediate laparotomy.

Blunt Abdominal Trauma Decision Pathway

Unstable + positive FAST: OR for laparotomy.
Unstable + negative FAST: Look elsewhere (chest, pelvis, long bones, external); DPA may be used if diagnosis remains unclear.
Stable: CT with IV contrast is the gold standard.

Solid Organ Injury

Spleen is the most commonly injured solid organ in blunt trauma. EAST solid organ injury guidelines support non-operative management for hemodynamically stable patients, including higher-grade injuries, with adjunctive splenic artery embolization (SAE) for active extravasation, pseudoaneurysm, or AV fistula.

Liver is the most commonly injured organ in penetrating abdominal trauma and second in blunt. Non-operative management is preferred in stable patients. Operative options include hepatic packing, Pringle maneuver (occlusion of the portal triad with atraumatic clamp to reduce inflow), finger fracture, selective hepatic artery ligation, partial hepatectomy, and atrio-caval shunt for juxta-hepatic IVC injury.

Kidney injuries are graded I–V (AAST); non-operative management is preferred in most cases, even for grade IV with devascularization. Pancreas injuries are rare but morbid; management depends on ductal integrity (main pancreatic duct). Hollow viscus injuries (bowel, mesentery) often present with delayed peritonitis; CT findings include free air, free fluid without solid organ injury, mesenteric stranding, or bowel wall thickening.

Abdominal Compartment Syndrome (ACS)

Sustained intra-abdominal pressure > 20 mmHg with new organ dysfunction. Bladder pressure measurement is the standard. Treatment is decompressive laparotomy with temporary abdominal closure (open abdomen with ABTHERA vac).

12 Pelvic & Genitourinary Trauma Pelvis/GU

Pelvic fractures from high-energy blunt trauma are associated with significant mortality (5–20%), driven largely by retroperitoneal hemorrhage from the posterior venous plexus and small arterial branches. Two classification systems are used:

Hemorrhage Control

A pelvic binder applied at the level of the greater trochanters is the first step for any unstable pelvic fracture, closing the pelvic volume. Persistent instability requires an escalation pathway: external fixation, preperitoneal pelvic packing, REBOA (Zone 3), and/or angioembolization. Multidisciplinary protocols improve outcomes (WTA pelvic fracture algorithm).

Genitourinary Injuries

Urethral injury is suggested by blood at the meatus, high-riding prostate, or perineal ecchymosis after pelvic fracture — obtain a retrograde urethrogram before Foley placement. Bladder injury is intraperitoneal (requires repair) or extraperitoneal (managed with catheter drainage). Renal injury is graded I–V with non-operative management preferred. Rectal injury in pelvic trauma is evaluated with rigid or flexible proctoscopy; diverting colostomy may be required for destructive or penetrating rectal injuries.

13 Vascular & Extremity Trauma Vascular/MSK

Hard vs. Soft Signs of Vascular Injury

Open Fractures & Compartment Syndrome

Open fractures are graded by the Gustilo-Anderson classification:

Early IV antibiotics (cefazolin for I–II; add aminoglycoside for III; add penicillin for farm/soil contamination) and tetanus prophylaxis are essential. Formal irrigation and debridement is performed in the OR.

Compartment syndrome presents with pain out of proportion, pain with passive stretch, paresthesia, and — late — pulselessness. Compartment pressures > 30 mmHg or a ΔP (diastolic BP minus compartment pressure) < 30 require emergent 4-compartment fasciotomy.

The Mangled Extremity Severity Score (MESS) incorporates skeletal/soft tissue injury, limb ischemia, shock, and age; a score ≥ 7 historically suggested amputation, though modern decision-making is more individualized.

Vascular trauma is managed with temporary shunts (Javid, Argyle, Pruitt-Inahara) during damage control, followed by definitive reconstruction (primary end-to-end repair, vein interposition graft from contralateral saphenous, or prosthetic graft in clean fields).

14 Burns & Environmental Trauma Burn/Env

TBSA and Depth

Total body surface area (TBSA) is estimated using the rule of nines (adult) or the more accurate Lund-Browder chart (pediatric). Only partial-thickness (second-degree) and full-thickness (third-degree) burns count toward TBSA.

Parkland Formula

Fluid resuscitation for burns ≥ 20% TBSA: 4 mL × weight (kg) × %TBSA of lactated Ringer's over 24 hours, with half given in the first 8 hours from the time of burn. Titrate to urine output 0.5 mL/kg/hr adult, 1 mL/kg/hr child. American Burn Association criteria trigger referral to a burn center for > 10% TBSA partial thickness, any full thickness, burns to face/hands/feet/genitalia/joints, inhalation injury, chemical/electrical burns, and burns with concomitant trauma.

Escharotomy is a full-thickness skin incision through circumferential burn eschar on the extremities (to restore perfusion) or the chest (to restore ventilation). Fasciotomy is required for electrical burns with muscle compartment involvement.

Inhalation Injury & Other Environmental Trauma

Inhalation injury is suspected with closed-space fire, singed nasal hairs, soot in oropharynx, carbonaceous sputum, hoarseness, or elevated carboxyhemoglobin. Early intubation is often mandatory. Cyanide toxicity is treated with hydroxocobalamin.

Electrical injury: risk of cardiac arrhythmia, rhabdomyolysis, compartment syndrome, and deep tissue injury out of proportion to skin findings. Lightning injury: often cardiac arrest (asystole), Lichtenberg figures. Drowning: focus on oxygenation, rewarming, consideration of ECMO. Hypothermia: graded mild (32–35°C), moderate (28–32°C), severe (< 28°C); severe cases may require ECMO rewarming. Blast injury: primary (barotrauma: tympanic membrane, lung, bowel), secondary (fragments), tertiary (displacement), quaternary (burns, crush).

15 Special Populations Special

Pediatric Trauma

Children have unique physiology: larger head relative to body (higher TBI risk), more compliant chest wall (pulmonary contusion without rib fracture), and maintained BP until late (tachycardia is the earliest sign of shock). Use weight-based resuscitation (20 mL/kg crystalloid ×1–2, then 10 mL/kg PRBC). The Broselow tape provides size-based dosing. Non-accidental trauma must be considered in any pediatric injury inconsistent with history.

Geriatric Trauma

Older adults have limited physiologic reserve. "Normal" vitals can mask shock. Age ≥ 65 is an independent predictor of mortality. Liberal CT imaging, early mobility, delirium prevention, and geriatric co-management improve outcomes. The EAST geriatric trauma guidelines recommend triage of elderly patients with ≥ 1 physiologic or anatomic criterion to a trauma center.

Anticoagulation Reversal in Trauma

16 Trauma Procedures — A to Z

Procedures that a trauma scribe will see and document. Each procedure note follows a standard template: indication, consent (emergent or obtained), time-out, prep/drape, anesthesia, position, technique, findings, estimated blood loss, complications, disposition.

17 Trauma Imaging & Diagnostics

Plain radiographs: The "trauma series" traditionally includes chest, pelvis, and lateral C-spine X-rays during the primary survey. In modern Level 1 centers, portable chest and pelvis are obtained while CT is prepared.

CT "pan-scan": CT head without contrast, C-spine without contrast, and CT chest/abdomen/pelvis with IV contrast is the standard imaging work-up for the significantly injured blunt trauma patient. Oral contrast is generally not used. CT angiography is added for suspected vascular injury, BCVI, or TAI.

Ultrasound: FAST/E-FAST is the screening modality at the bedside. Critical care ultrasound is increasingly used for volume status and cardiac function.

Angiography: Therapeutic for splenic artery embolization, pelvic embolization, and extremity/visceral bleeding.

Key lab values to track: hemoglobin/hematocrit trend, lactate (resuscitation marker, goal < 2), base deficit (> 6 abnormal, > 10 severe), INR/aPTT/fibrinogen, TEG/ROTEM (goal-directed coagulation), calcium (ionized, maintain > 1.1 during massive transfusion), potassium (post-transfusion), ABG, troponin (blunt cardiac), CPK (rhabdo), tox screen, EtOH, urine HCG.

18 Medications You Must Know

19 Classification & Scoring Systems

Glasgow Coma Scale (GCS)

Total 3–15. Severe TBI 3–8, moderate 9–12, mild 13–15.

Abbreviated Injury Scale (AIS)

Per-injury anatomic severity code used in trauma registries: 1 = minor, 2 = moderate, 3 = serious, 4 = severe, 5 = critical, 6 = unsurvivable. Each injury is assigned an AIS by body region (head/neck, face, chest, abdomen, extremity, external).

Injury Severity Score (ISS)

Sum of squares of the three highest AIS scores from different body regions. Range 1–75. Any AIS of 6 automatically sets ISS to 75. Major trauma conventionally defined as ISS > 15.

Revised Trauma Score (RTS) & TRISS

RTS is a weighted physiologic score combining GCS, SBP, and RR. TRISS combines ISS, RTS, age, and mechanism to estimate probability of survival; it is the standard benchmarking tool for trauma centers via the ACS TQIP program.

AAST Organ Injury Grading (Highlights)

Additional Classifications

Gustilo-Anderson (open fractures): I, II, IIIA, IIIB, IIIC (see Section 13). Tile pelvic stability: A (stable), B (rotationally unstable), C (rotationally + vertically unstable). Young-Burgess pelvic mechanism: LC I–III, APC I–III, VS, CM. MESS: 1–11 total score, historical ≥ 7 cutoff for amputation. Marshall CT (TBI): I (no visible pathology), II (lesions < 25 cm³), III (cisterns compressed, midline shift 0–5), IV (midline shift > 5), V (any evacuated mass), VI (non-evacuated mass > 25 cm³). Rotterdam CT score: 0–6 based on basal cisterns, midline shift, epidural mass, IVH/SAH. Lund-Browder chart for pediatric TBSA.

20 Physical Exam — The Trauma Exam

The trauma exam is a rapid, systematic, head-to-toe assessment, documented region by region. A scribe should memorize the structure so it can be typed while the surgeon dictates.

21 Abbreviations Master List

Anatomy & Injury Patterns

Assessment & Scores

Procedures & Management

Medications, Labs, Blood Products

22 Sample HPI Templates

These templates show the documentation rhythm expected in a trauma bay and on the trauma admit service. Each template uses realistic mechanism, timing, and injury patterns.

23 References & Sources

Clinical Practice Guidelines

Landmark Clinical Trials

Diagram & Figure Sources