The ABCs of Trauma, by Dr. Mountaintop

I spent a number of years doing trauma surgery in several Level 1 NYC hospitals, and I’d like to share some thoughts. I don’t usually like to give advice – it’s not my custom to tell another man or woman what to do. So please take this for what it’s worth – my experience and thoughts – and do with it whatever seems best to you.

DISCLAIMER: I am a licensed physician. However, this is not medical advice. For any Johnny-Rambo’s out there, if you need medical assistance, please pick up the phone. This is for when there is no dial tone.

Let me say first that I appreciate the wealth of information on this site. It’s very interesting to read, and humbling to implement, a lot of the solid advice offered here. I’m less of a talker, and more of a do-er, and the reality is, there is a lot to get done. Some would be tempted to think that with several Ivy-league degrees and an M.D., something like gardening would be easy. Of course, you know what the reality is: starting something new is hard. And smart people are notoriously dumb.

I mention this because trauma is like any other discipline, and there’s nothing magical about it.

If you go to the range and shoot flat-footed at paper targets, you’ll fail when your AR double-feeds on the run, with your heart pumping, sweat in your eyes, and the world swirling around you. Medicine is the same way. You might have a trauma bag, you might have read a lot, but when your wife, or best friend, or child is bleeding out and looking at you, your mind will go blank. Don’t be ashamed. That’s reality. The question is, how can we handle it?

My first piece of advice is:

You need to do some limited amount of training that involves moving your hands and feet.

Muscle memory is an incredible thing. I’ve spent most my life in martial arts. I have no idea exactly what I would do if someone grabbed me by surprise. Be certain, though, that I would do something decisive and unfriendly. You don’t need to become a paramedic, or make this a big time commitment, but you do need walk through handling a trauma. Your hands need to know. The more stressed you are while you practice, the better.

Spouses will generally support this. Taking a CPR course is a good start. Then, during dinner, or hanging out with like-minded friends, role-play it: “John just got shot in the neck/the propane tank exploded. What do we do?” Then have John lie down on the ground. Walk through what you would do, and do it. Do it every few months if you can. It takes 5 minutes. John will thank you one day.

The second thing is:

Keep things simple.

When your pistol malfunctions, it’s tap-rack-bang. It’s not complex. Don’t go for a Ph.D. Don’t rely on thinking. When it counts – and I’ve been covered in blood more nights than I care to count – you won’t be thinking. You’ll be reacting. So train to react. Here’s how:

Step 1: A-B-C. Airway. Breathing. Circulation.

Say it again and again and again. I can promise you no matter how many other tidbits you pick up, you will forget everything else but A-B-C when you get caught off-guard by a serious trauma.

Here’s my (humbling) anecdote: Years ago, as a first year medical student, I was in Costa Rica, hitch-hiking down some road. The car in front of us didn’t make the turn and went under a tractor-trailer. Immediate carnage. The young woman in the passenger seat was on the pavement and she wasn’t breathing.

Pause for a moment. If you’re honest, what flashed into your head? An image? A similar experience? But what didn’t occur to you? Did you immediately think: tilt back her head?

At that time I had already taken BLS (basic life-saving) which covers CPR, etc. I had all the book smarts in the world for this, but I didn’t react. I hesitated. Some random guy on the side of the road tried to pick her up and her airway opened. She started breathing. She lived.

My point is this: don’t concern yourself with complex trauma decision trees. Don’t worry about whether it’s Adenosine or Amiodarone. If you’ve got the meds, you’ve likely got the medical professionals to use them. The key in trauma management is to buy yourself (and the patient) enough time to get to the next step. That’s it.

How do you do that? Concentrate on ABC. Do each one, in order, and then move onto the next:

Airway: Make sure the airway is open. If they are awake and talking, they are breathing. If not, tilt the head back. If there’s blood or vomit in the mouth, get it out of there with your fingers. Get the airway clear. Textbooks will tell you to use a “jaw-thrust” maneuver if there is head or spinal trauma because of the theoretical risk you might dislodge a bone fragment and sever the spinal cord. This is nonsense. If you’ve got a broken neck, you’re not breathing, and there’s no medical help, you’re dead. Don’t screw around. Tilt the head back.

Breathing: If the airway is open and they’re not breathing, there is a reason for it. At this point, you don’t need to worry about what the reason is. You just need to start breathing for them, or they’ll be dead in less than two minutes. With their head tilted back, pinch the nose, open the mouth and blow in two huge breaths. Bonus points: look at their chest. Make sure it’s rising. Once air is moving in and out, take a closer look at the chest. Here’s what to look for:

  • Is the chest open?
  • Is there a wound/hole?
  • Is it collapsed/caved in?
  • Are there Rice-Krispies (air) under the skin?
  • An unusual hollow sound when you tap with your fingers?
  • Is the wind-pipe (in their neck) shifted away to the other side?

These would suggest a pneumothorax (air outside the lung, but inside the chest). What to do:

  • The patient needs a chest tube. If that’s outside your ability, and the patient is having a lot of difficulty breathing, you need to find another way to get the air out of the chest cavity, because it’s putting pressure on the lungs. Keep in mind, if you have to do this, the patient is in trouble:
    • Use a big needle to suck it out. Here’s how: Get some gloves on. Splash the chest with betadine and spread it around with some gauze. Get a big, long needle (at least 1 1/4″ inch long) preferably with a catheter, and stick it in through the top of your chest muscle. Go straight in about 1.5 inches on a normal person. Keep the syringe on the needle and keep sucking out air while they breathe.
    • If that isn’t working, here’s your last option: make a small incision between the ribs. Here’s how: find a space between the ribs just under the armpit in front of the lat muscle. Cut a one-inch incision parallel to the ribs, and using a clamp (or needle-nose pliers), push in, spread and repeat. Stay on the top side of the rib (instead of underneath where the blood vessels are). Don’t be afraid to use your fingers. When you enter the chest, you’ll feel a small pop and see air bubbles through the blood. Allow the pressurized air to come out and cover it with some vaseline gauze. Pray.

Circulation: If your own pulse is pounding, it’s hard to feel the patient’s pulse. Next time you go for a run (you do work out regularly, right?) practice feeling your pulse while you’re running. That’s about what it’s like in a trauma. Check the neck. Check the wrist. Really simple: Is there a pulse? This is harder than it sounds. If the patient is cold, low on blood, wet, or thrashing around, and you’re flooding adrenaline through your own veins, one of the harder things to do is say with confidence that something isn’t there. Be sure. Remember: fast is slow, slow is fast. Relax. It’s only life and death. If there is no pulse, start doing chest-compressions. Here’s how:

  • Get the patient onto something solid – the ground, the kitchen table – not the bed, not the sofa. Something hard.
  • Find where their belly meets their ribs. In the middle, on the ribs, push down hard with the heels of your hands twice per second. Fast.
  • How hard? On an old person, you may be breaking ribs. On a young person, they’ll feel like they got the ever-living crap kicked out of them. Don’t try to hurt them, but do it fast. Push down hard. You will be sweating like a fat man in a cake shop.
  • Recent AHA guidelines recommend that you do 30 chest compressions, then two breaths. I agree. 30 fast compressions, 2 huge breaths, and repeat. You’re breathing and pumping their heart for them. Don’t skimp.

The other part of “C” – circulation – is checking for hemorrhage (bleeding). I talk about bleeding below, but here’s the point: there’s bleeding you see (dribbling out some hole), and bleeding you don’t (internal). You want to keep both in mind and look for the signs of each (visible blood, fast/weak pulse, low blood pressure, a thigh or belly that’s fuller than it should be, etc.).

What’s next? Before we move on. Remember: ABC. Say it out loud. When your mind goes blank, A-B-C should enter it. If you remember nothing else, ABC.

There are two more letters after ABC. Not surprisingly, they are D and E. I separated them out because in my opinion, they are less applicable in a survival situation.

D is for Disability. Specifically, a neurologic evaluation. There is limited value to this (who is doing brain surgery on the back porch?) with one exception: triage. If a patient is flexing or extending their arms in a strange fashion, has no anal sphincter tone, doesn’t respond to painful stimuli (pinch their finger/toe), or their pupils are very dilated (or one is), these are signs of serious neurologic injury. It may be useful in a survival situation to know that this patient is unlikely to recover.

E is for Environment. If possible, cut off the patient’s clothes, and keep them warm in preparation for the secondary survey. Again, trauma patients get cold easily. Cover them with blankets and keep them warm.

A-B-C-D-E is the primary survey. It’s quick and dirty and designed to address issues that might immediately kill the patient. Each step needs to be completed before moving onto the next. There’s no point trying to work on breathing if the airway is blocked. After all five steps are competed, it’s time to do a secondary survey.

The point of the secondary survey is to look for things that were missed, and to gather more information that might aid treatment. Examine the patient head-to-toe, front and back. Look under the arms, and between the legs. Many times on a patient (covered in blood) I’ve found another bullet or knife hole on secondary survey. Patients generally won’t know where they are injured. When you roll the patient, do a “log-roll” where their head is rolled at the same time as their body. This should provide some protection in case they have a spinal fracture. Check their spine by pressing on each vertebrae for unusual tenderness. If they yelp, keep them on their back and don’t let them sit up.

If at any time, the patient’s condition deteriorates, abandon your secondary survey and restart your primary survey – A-B-C. Again, no matter what happens, no matter where you are, if something unexpected happens, don’t think – just start doing ABC.

There are several common types of injury, and I will walk you through them:

Penetrating Trauma: Translation: you’re bleeding. Bullet, knife, chainsaw – it doesn’t matter. Nothing, and I mean nothing, stops bleeding like direct pressure. It’s not fancy, but if you see blood, particularly on an extremity (arms, legs, head), lean on it, push your weight onto it with the heels of your hands or your fingers. If you’re pressing hard enough, it should cut off the blood to your own fingers. You can stop any bleeding – including major arterial bleeds – with enough pressure. If it can’t be stopped with pressure, it can’t be stopped without operating.

No tourniquet, or other device – even a suture – is going to do the job in the first 3 minutes like you pushing down with everything you’ve got. The only reason you should ever even consider using a tourniquet is if you’re in a firefight and need both hands for your rifle. Quikclot and other similar hemostatic powders are useless in a real trauma with brisk bleeding. We use them all the time in the O.R., but they have no place in a trauma. Use direct pressure every day of the week and twice on Sunday. Remember that a hard surface underneath makes everything easier.

When the bleeding slows, get lots of gauze (or your t-shirt) onto the wound and keep pressing down hard. You may need to hold it up to half an hour if you’re all alone. If the patient stays awake and you’ve stopped the blood from flowing – you’re doing it right.

Blunt Trauma: Without an ability to do imaging, or blood work, or a long experience doing physical exams, it’s hard to know what’s going on with blunt trauma. If there is a blast injury (explosion) all bets are off. Don’t underestimate a blast injury. In many blunt traumas, but particularly blast injuries, there are lung injuries you can’t see initially. This will cause the lungs to fill up with fluid and the patient will drown. If you have oxygen, some ability to use an airway, or diuretics (like ferosemide / lasix), this is the time. Otherwise, don’t over-hydrate the patient if you suspect a lung injury (big chest bruising / gurgling / coughing up fluid).

For abdominal blunt trauma, here’s what to consider: is the spleen or liver bleeding? What to look for:

  • Is there a big welt on the skin below the ribs?
  • Does the patient look pale and waxy?
  • Pulse stays over 110, or rises?
  • Blood pressure 100 or lower?
  • More pain in their belly than you think they should have?
  • Do they feel faint and thirsty?

These are signs of internal bleeding. The very best thing you can do for internal bleeding (assuming you don’t have blood on hand) is to give IV fluids. Run in a couple of liters of normal saline or lactated ringers to start. Anybody who’s not already in heart failure can tolerate 2 liters – don’t be shy.

Keep the patient still. No moving or shifting around. You want the bleeding to clot off, and every time you move around, you risk starting it up again. Keep the patient warm. Cold patients have more trouble clotting.

If the patient gets worse, and passes out, and their pulse is weak, and their blood pressure drops to 80, they are bleeding to death.

Unless you’re in the mood to operate with a butter-knife, you have to hope the bleeding stops on its own. That may sound like a negligible hope, but as their blood pressure drops, it makes it easier for the body to clot off the bleeding. It may be enough for them to survive.

If you have medical training and feel able, and the patient is hemodynamically unstable (is bleeding to death internally), you can take a shot at operating. Here’s how: Take a deep breath. Never start surgery with a full bladder or a full trash can. Make a midline incision top to bottom and go around the belly-button. Go straight down through the fat to the fascia (that’s the white, tough membrane that keeps your guts in). Stay in the midline. Pick up the fascia with some clamps, and ever so carefully make a little nick in it. Get your fingers in, lift it up, and cut between them. Don’t hit the bowel. Only cut what you can see. There will be blood everywhere. Don’t try to clean it up. Quickly reach way up high under the ribs on both sides and start packing the abdomen with towels. Pack up high all around, behind, and underneath the spleen and liver. Pack until you can’t fit any more. You’ll probably need 25-50 facecloth sized towels. If you can, count them as they are going in. I can’t see a scenario where a non-medical person would do this and improve the outcome.

Fractures: This is too big a topic to handle in any depth. Here is what to keep in mind:

Hip (pelvic) fractures are a big deal because you can bleed internally from them. You can check the pelvis by pushing down from the front and feeling for instability.

Rib fractures are only a big deal if there is a big section of the chest wall that is moving independently from the rest, or if they have punctured the lung.

Extremity (arm and leg) fractures can compromise the blood flow to that limb. Make sure the broken limb has a pulse. On the arms, check the radial (thumb-side) of the wrist. On the legs, check both feet behind the medial malleolus (the bony-bump on the inside of the ankle), and on top of the foot (check your wrists and feet now to find the pulses if you like). Not everyone will have both foot pulses. But if there is a difference between left and right limbs on your patient, particularly if the limbs look different (color, swelling, temperature, etc.) you need to reduce the fracture quickly.

To reduce the fracture, you’ll need to:

  • Pull it straight (away from the body) to line up the bone fragments, then
  • Have some type of support to keep it there (a splint)

Make sure you get your splint ready before you reduce the fracture. Depending on where the break is, you may need a lot of force. Do it once and do it right. Pull slowly and steadily – leaning back with your weight if necessary, but don’t jerk. If you can wait until a second person is available to help you, that’s better.

Keep in mind that in addition to being broken, the limb might be dislocated. If it’s dislocated, you need to put in back in place (reduce it). Here’s how:

  • For hips, they’re usually a posterior dislocation. That means the foot and knee will be turned inwards. With the patient on his or her back, flex the hip then pull the knee forward (skyward). Have a second person hold the patient’s hip down on the table – you need a lot of force to relocate a hip.
  • For knees, it’s the kneecap that slides laterally (away from the midline). Bend the knee, push the kneecap up and back towards the midline and straighten the leg.
  • For shoulders, the key is to get the patient to relax the shoulder muscles. There are lots of ways to do this. Generally, the Kocher method has the highest success: with the arm bent at 90 degrees, gently rotate it outward until you feel a bit of resistance. Then bring the whole arm forward as far as possible and rotate it back inward.
  • For elbows, have one person hold the biceps, and the other pull the wrist while the arm is slightly bent.
  • For fingers, slide your thumb up the side of the finger that is sticking out, and push the digit away from the body. Pulling on it doesn’t work very well because you make the tendons tighten around the bone.

Once you reduce a fracture, keep the traction (pull) on it, and stabilize it with a splint. Make sure the splint isn’t cutting off the circulation by slipping your finger between the patient’s skin and the split to check the tension. Then check the pulses again.

In some unusual cases, but particularly when there is a fracture, or a crush injury, you can get what’s known as a “compartment syndrome.” This means that pressure inside your calf or forearm is building up (from swelling or bleeding). The limb may go numb, pulses can disappear, get pale, and almost always you’ll have a lot of pain when you move the ankle or wrist even a bit.

If this occurs in the context of a trauma, you may need to surgically cut open the limb to release the pressure. This sounds extreme, but if you don’t, the pressure can kill the nerves and you’ll lose function of the limb permanently.

To do it on the leg, you want to open 4-5 inches on the outside of the shin. For the forearm, do it on the inside of the forearm for most of its length. Keep in mind that it’s not the skin you need to open – it’s the white-gray, tough tissue called “fascia” that’s under the skin, and under the fat. There are different compartments and it’s theoretically advisable to open each. In practice, however, it’s usually unnecessary. Don’t go any deeper than the fascia, and don’t do this unless you’re sure – you’re creating a large new wound with its own issues.

Burns: Burns are probably one of the more likely injuries in a survival situation. They are very common in the third-world. Open cooking fires, burning refuse, combustion-based illumination and heating, and improvised equipment all increase the chance that you’ll get burned. I will not go into general burn-care here but rather I’ll focus on addressing burns in the context of trauma. This usually involves a flash fire or explosion.

First, drag the person away from the fire and make sure the fire is under control. Take a close look at the patient. Go through your ABCs! Remember that they may have other injuries besides the burn. Here’s the reality: for serious burns, there’s often little you can do to help outside of having access to real medical care.

If there are burns around the head, mouth and airway, you should worry. Even if the patient is talking, the clock may be ticking. Any questions you have to ask, should be asked now. Don’t wait. Not even an hour. Their airway or lungs may be burned, and without intubation and oxygen, death may be unavoidable.

If the burns are wide-spread, you’re at risk early-on for fluid loss and electrolyte imbalances (dehydration). Keep burn patients warm and very well hydrated. If they aren’t urinating, they need more fluid. Remember to use rehydration salts, not just water. IV fluids are best, but drink some pedialyte/gatorade if that’s all you can do.

Infection risk comes later. At the first sign of infection, start some broad spectrum antibiotics (that have gram-negative coverage, such as ciprofloxacin or erythromycin). Give a tetanus vaccine if you have it. (You have your tetanus vaccine up to date, right? Dying from tetanus is horrible and ranks next to peeing on an electric fence for preventable ways to die).

For the wounds, initially just put some dry dressings on the wounds. They will ooze. Later, topical silver (e.g. silvadene) and vaseline gauze or xeroform are a good place to start for deep wounds that need debridement. Don’t let them get too soupy. Give pain meds if you have them.

If the patient survives, handle the wound care (and contractures) the best you can. Pay close attention to circumferential burns (fingers, limbs, or chest). These may cut off the flow of blood, or make it difficult to breathe. If that’s the case, you need to cut just enough through the burn scar to allow the tissues to move. You usually will not need to do this.

Initial wound care is covered well in the SurvivalBlog article “Wound Care: An Emergency Room Doctor’s Perspective, by E.C.W., MD” . Burn wound care after the immediate trauma is a little different and would require a good deal of discussion, outside the scope of what I can cover here.

If you’d like to prepare to handle a trauma, here (in order of priority) is what you have on-hand that will make the most difference in changing the outcome:

  1. Bandages . Lots and lots of gauze and bandages. During a trauma, we use boxes and boxes of gauze. They don’t need to be fancy – just have a lot of them. I’ll add in here things like betadine (to clean) and saline (to irrigate), as well as gloves, tape, and linens.
  2. IVs and IV fluids. There are really only two reasons why life-expectancy in the developed world has doubled in the last century: Intravenous fluids and antibiotics. If you have the ability to keep (and rotate) some IV fluids and some large (18-20 gauge) IVs and lines, you are two steps ahead of anyone else. Whether it’s a trauma or a viral pandemic, the most important thing (sometimes the only thing) you can do is give IV fluids.
  3. Oxygen. A small home oxygen tank with a bag-mask buys you a lot. Any type of respiratory problem gets better with oxygen. If you add an LMA (laryngeal mask airway – a device that anybody can use to secure an airway) you are really cooking. Speaking of cooking – keep it away from combustion sources.
  4. Splints. Plaster, fiberglass, aluminum finger splints, slings, crutches are all great to have. You need to splint or cast most broken bones.
  5. A blood pressure cuff. You can figure out someone’s pulse or respiratory rate with your hands and eyes, but you need a blood pressure cuff and a stethoscope to know what their pressure is. Throw in a thermometer and you’re half-way to being a hospital.

In summary, if there’s a trauma, follow your A-B-Cs. Put pressure on bleeding, don’t move blunt traumas, reduce fractures and make sure the limb is getting blood, and pay close attention to burn patients. Walk through a trauma with your family and put each other on the spot to see how you’d actually react. One day you may need it. And remember, when your brain goes empty – A. B. C.