Major Trauma in the Emergency Room and What Happens First
From Airway to Ultrasound How the Trauma Team Moves in Minutes
When an Ambulance Call Changes the Room
Minor trauma is common. Sprains, small cuts, simple fractures. Major trauma feels different the moment it arrives. A high speed collision, ejection from a vehicle, a fall from height, a penetrating injury. Even before arrival, the mechanism signals how serious the situation may be.
When a severely injured patient enters the trauma bay, the approach is structured. Trauma care is not chaos. It follows a disciplined sequence designed to prevent preventable death.
Is the Airway Open and Is the Patient Breathing?
The first step is the primary survey. Airway. Breathing. Circulation. Is the airway blocked by blood, swelling, or facial fractures? Is breathing effective, or is there a collapsed lung or blood in the chest? Are pulses present? Is blood pressure low, suggesting internal bleeding?
If circulation is unstable, hemorrhage is assumed until proven otherwise. In trauma, uncontrolled bleeding and airway failure are the most immediate threats to life. Stabilizing those threats buys critical time.
Level One Trauma Activation
In the most severe cases, a Level One trauma activation brings a full team to the bedside. Emergency physicians, trauma surgeons, nurses, respiratory therapy, blood bank, and radiology respond simultaneously. Each person has a defined role.
Vital signs and mental status guide urgency. Confusion or unconsciousness suggests possible brain injury. Low blood pressure and rapid heart rate suggest blood loss. Mechanism plus physiology determines how aggressive treatment must be.
The Secondary Survey Head to Toe
After immediate life threats are addressed, a systematic head to toe examination follows. The scalp, pupils, neck, chest, abdomen, pelvis, and extremities are assessed for deformities, bruising, tenderness, and neurological deficits.
Clothing is removed because injuries hide. Strength and sensation are evaluated. Open fractures, penetrating wounds, and spinal cord injuries must be identified early. Trauma does not tolerate missed findings.
How Is Internal Bleeding Detected Quickly?
A FAST exam, which stands for Focused Assessment with Sonography in Trauma, is performed at the bedside. This rapid ultrasound looks for free fluid inside the abdomen or around the heart. In trauma, free fluid is presumed to be blood until proven otherwise.
If a patient is unstable and the FAST exam is positive, immediate surgery may be required. If stable, CT scans provide a detailed map of injuries, including organ lacerations, brain bleeds, and spinal fractures.
Age Medications and Hidden Risk
Older adults may suffer severe internal injuries from relatively minor falls. Bones are more brittle and blood vessels less forgiving. Patients taking blood thinners bleed more rapidly and may require medication reversal to control hemorrhage.
Complications such as tension pneumothorax, cardiac tamponade, pelvic fractures, and vascular injuries must always be considered. Trauma care requires constant reassessment because stability can change within minutes.
THE BOTTOM LINE
• Major trauma is managed through a structured approach focused on airway, breathing, and circulation first
• Mechanism of injury, vital signs, and mental status determine urgency
• Bedside ultrasound and advanced imaging identify life threatening internal bleeding
Written by a Board-Certified Emergency Medicine Physician