Road Traffic Injury

Multi-system trauma resulting from motor vehicle collisions, motorcycle/boda-boda crashes, or pedestrian impact : leading cause of trauma mortality globally, with disproportionately high burden in low and middle-income settings. Injury pattern reflects mechanism: frontal impact (chest/abdominal/lower limb), lateral impact (pelvic/thoracic), pedestrian (lower limb plus secondary head/torso injury from ground impact : Waddell's triad in children: femur fracture, truncal injury, head injury), motorcycle (head injury if unhelmeted, lower limb degloving).

Classified by injury severity: minor (isolated, hemodynamically stable), major trauma (multi-system, physiological derangement, ISS >15), and polytrauma (≥2 body regions with combined injuries producing a systemic response : SIRS, coagulopathy, immune dysfunction).

Primary survey (ATLS approach) drives assessment, not diagnosis-first thinking:

• Airway with C-spine control: stridor, obstruction, facial trauma, hoarseness

• Breathing: respiratory rate, chest wall movement, tracheal deviation, breath sounds, SpO2 ; assess for tension pneumothorax, flail chest, open pneumothorax, massive hemothorax

• Circulation with hemorrhage control: pulse, BP, capillary refill, external bleeding, signs of internal hemorrhage (abdominal distension, pelvic instability, thigh swelling)

• Disability: GCS, pupils, gross motor/sensory

• Exposure: full exposure, log-roll, prevent hypothermia

Classes of hemorrhagic shock (by % blood volume loss):

• Class I (<15%): minimal signs

• Class II (15-30%): tachycardia, narrowed pulse pressure

• Class III (30-40%): hypotension, tachypnea, confusion

• Class IV (>40%): profound hypotension, lethargy, immediately life-threatening

The "lethal triad" ; hypothermia, acidosis, coagulopathy ; each worsens the others and drives mortality if uncorrected.

Secondary survey (after primary survey/resuscitation): head-to-toe exam, AMPLE history (Allergies, Medications, Past history, Last meal, Events).

• FAST (Focused Assessment with Sonography for Trauma): free fluid in Morrison's pouch, splenorenal space, pelvis, pericardium ; rapid bedside triage tool for hemoperitoneum/hemopericardium

• CT trauma series (head, C-spine, chest, abdomen/pelvis with contrast) ; for hemodynamically stable patients only; unstable patients go to theatre or interventional radiology, not the CT scanner

• Plain films: CXR and pelvic X-ray as primary survey adjuncts in unstable patients

• Bloods: FBC, crossmatch/group and save, coagulation profile, lactate (resuscitation marker), blood gas, U&E, glucose, beta-hCG in women of reproductive age

• Extended FAST (eFAST): adds pleural views for pneumothorax/hemothorax

Differentials for deterioration after primary survey: missed injury (reassess ; tertiary survey), evolving intracranial hemorrhage, expanding retroperitoneal/pelvic bleed, tension pneumothorax, cardiac tamponade.

Resuscitation follows the ATLS sequence simultaneously with assessment, not after it.

• Airway: definitive airway (intubation) if GCS ≤8, airway compromise, or anticipated deterioration; maintain C-spine immobilization until cleared

• Breathing: needle decompression/chest drain for tension pneumothorax; high-flow oxygen

• Circulation: two large-bore IV access, balanced crystalloid initially, early blood products (massive transfusion protocol : 1:1:1 packed cells:FFP:platelets) for hemorrhagic shock rather than crystalloid-heavy resuscitation

• Tranexamic acid 1g IV over 10 min then 1g over 8 hours if within 3 hours of injury with significant hemorrhage (CRASH-2 mortality benefit)

• Hemorrhage control: direct pressure, tourniquet for exsanguinating limb hemorrhage, pelvic binder for suspected pelvic fracture with instability (apply at the level of the greater trochanters), damage control surgery or interventional radiology for ongoing internal hemorrhage

• Permissive hypotension (target SBP ~90mmHg) in penetrating trauma without head injury until hemorrhage controlled ; avoid in traumatic brain injury, which needs adequate cerebral perfusion pressure

• Analgesia: IV opioids titrated, do not withhold pending diagnosis

• Damage control resuscitation: minimize crystalloid, prioritize blood products, correct coagulopathy/hypothermia/acidosis aggressively, early surgical or radiological source control

Trauma team activation criteria: physiological (GCS <13, SBP <90, RR <10 or >29); anatomical (penetrating injury to head/neck/torso, flail chest, pelvic fracture, two or more long bone fractures, amputation proximal to wrist/ankle, spinal cord injury).

Disposition: ICU/HDU for major trauma, theatre for uncontrolled hemorrhage.