What investigations should be prioritized in the management of major trauma in a primary care setting?

In a primary care setting, the prioritized 'investigations' in the management of major trauma primarily involve rapid clinical assessment and history taking to identify the need for immediate emergency transfer to a hospital or major trauma centre ¹,². The optimal destination for patients with major trauma is usually a major trauma centre ¹.

• Clinical Assessment: The initial aim is to rapidly identify indications for emergency transfer to hospital ². This includes following basic and advanced adult or paediatric trauma life support protocols ². Key assessments include:
  • Assessing the level of consciousness using the Glasgow Coma Scale (GCS) ². A GCS score of less than 15 on initial assessment is a risk factor for intracranial complications and necessitates immediate transfer ².
  • Assessing vital signs, looking for hypoxia or signs of shock such as tachycardia, hypotension, or reduced capillary refill time ². Evidence of shock is an indication for immediate transfer ².
  • Examining for visible trauma to the scalp, skull, head, and neck ².
  • Assessing cranial nerves, including pupil size and reactivity ².
  • Looking for signs of focal neurological deficit, such as problems with visual or speech disturbance, balance, walking, loss of muscle power, or paraesthesia ².
  • Identifying signs of basal skull fracture, which may include clear fluid leaking from the ear(s) or nose, periorbital haematoma(s), bleeding from one or both ears, or Battle's sign ².
  • Assessing for neck tenderness and range of neck movements, as midline cervical spine tenderness or inability to rotate the neck 45 degrees may indicate cervical spine injury ². If risk factors for cervical spinal injury are present, full cervical spine immobilisation should be attempted ².
• History Taking: Gather information to identify ²:
  • How and when the head injury occurred, including the mechanism of injury ². Dangerous or high-energy mechanisms (e.g., fall from a height greater than 1 metre or 5 stairs, high-speed motor vehicle collision, rollover accident, or ejection from a motor vehicle) are indications for immediate transfer ².
  • Current symptoms since the injury, such as loss of consciousness, confusion, amnesia, seizure, vomiting, headache, neck pain, or diplopia ². Any loss of consciousness or post-traumatic seizure after the injury indicates immediate transfer ².
  • Recent alcohol or drug intake ².
  • Current anticoagulant medication, as this is a risk factor for intracranial complications and requires a CT head scan within 8 hours of head injury ².
  • Past medical history, including pre-injury level of functioning, bleeding disorders, surgery, and previous head trauma ². A history of bleeding or coagulation disorders or previous brain surgery are indications for immediate transfer ².

Definitive imaging investigations, such as CT scans or eFAST, are typically performed in a hospital setting after transfer ¹,³. Plain X-rays of the skull are not routinely used to diagnose important traumatic brain injury ³. Patients with risk factors for intracranial complications or cervical spine injury should be transported to a hospital with age-appropriate resources for further resuscitation, investigation, and initial management of multiple injuries ². The referring professional should inform the destination hospital by phone of the impending transfer ².