Early management

Airway management

Patients with pulmonary contusions are at high risk for respiratory distress and pneumonia. Methods should be implemented early to improve oxygenation and ventilation. The goal of treatment should focus on re-expansion of the atelectatic regions through appropriate titration of PEEP.

Ventilation strategies should include:
  • Low Tidal Volume: (4-8mL/kg)
  • Limited plateau pressure <30mmHg
  • FiO2 level as low as possible to obtain SaO2 >90%
  • Optimal PEEP, incrementally added

Fluid resuscitation

Undetected bleeding is one of the most preventable causes of death after injury. (29) Therefore, the detection of bleeding is paramount, along side a balanced approach to fluid administration – this should be discussed early when establishing treatment goals.

Resuscitation goals:
  • The main goal of blood volume resuscitation in trauma is to preserve vital organ perfusion until bleeding can be controlled.
  • Blood pressure goals for penetrating chest trauma or uncontrollable haemorrhage are generally lower than for blunt trauma in the absence of a major head injury.
  • Permissive hypotension is acceptable practice until definitive care and surgical intervention can be accessed.
  • Tissue perfusion can be assessed in several ways. These include:
    • Skin color- pale, cool, and clammy versus mottled and blue.
    • Capillary refill time
    • Conscious state- decrease conscious state is an indicator of poor cerebral perfusion.
    • Blood gases- acidosis is often mixed in severe chest injury, however increasing base deficit, and increasing lactate are reliable indicators of tissue hypo-perfusion.
    • Urine output – Although this takes time to become evident.
  • If possible, all blood/fluid administered to a major trauma patient should be warmed with a fluid warmer.

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  • HR / RR / BP / SPO2 / GCS / Temperature
  • Reassess every 15/60 or more frequently if indicated.
  • Fluid Balance Chart – keep an accurate record of input / output.
  • Serial Blood Gas assessment of pH, base-deficit and lactate levels provide good monitoring of tissue oxygenation, circulatory status and response to resuscitation.


  • Tetanus Prophylaxis: updated in the case of significant or contaminated wounds. The tetanus immunoglobulin vaccine should be given to patients who have not received a complete primary immunisation. Even if patients have up-to-date tetanus vaccinations all tetanus-prone wounds must be disinfected and where appropriate, have surgical treatment. (30)
  • IV antibiotics: Recommended on insertion of an intercostal catheter and in penetrating trauma.

Wound Care

In a major trauma patient, early wound closure (pre-transfer) is not a priority (except for bleeding control).
  • Remove gross contamination and irrigate the wound.
  • Gain haemostasis through pressure and elevation where possible, ensure bleeding has ceased.
  • Simple dressings with saline, gauze, combine and moderate compression bandages are generally adequate.
  • Suture simple wounds if time allows.
The priorities for further investigation and treatment should now be considered and a plan for definitive care should be established.

Retrieval and Transfer