Major Trauma — UKMLA Guide 2026

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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

cABCDE approach: catastrophic haemorrhage control → Airway (with C-spine) → Breathing → Circulation → Disability → Exposure
Treat life-threatening problems AS FOUND — do not move to next step until preceding step is addressed
Catastrophic haemorrhage: direct pressure, tourniquet, haemostatic dressings, pelvic binder
Tranexamic acid 1 g IV within 3 hours of injury for all trauma with suspected significant haemorrhage (NICE NG39)
Activate major haemorrhage protocol early: O-negative blood, then crossmatched. Target 1:1:1 RBC:FFP:platelets
Secondary survey (head-to-toe): only after primary survey complete and life threats addressed. Includes log roll

Overview

Major trauma is defined as injury or a combination of injuries that is life-threatening and could be life-changing. It is a leading cause of death in people under 45 years in the UK. The structured approach uses cABCDE (catastrophic haemorrhage, Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure) to identify and treat life-threatening injuries in order of priority. The primary survey addresses immediately life-threatening conditions; the secondary survey is a comprehensive head-to-toe examination performed after stabilisation. The UK trauma network comprises major trauma centres (MTCs) providing specialist care (neurosurgery, cardiothoracic) and trauma units for less severely injured patients. Pre-hospital triage protocols identify patients who should bypass local hospitals and go directly to MTCs.

Epidemiology

Approximately 20,000 patients per year sustain major trauma in England. The most common mechanisms are road traffic collisions (~40%), falls (particularly in elderly — now the leading mechanism), and assaults. Major trauma is the leading cause of death in people aged 1–44 years. The introduction of the UK trauma network in 2012 has been associated with a significant reduction in trauma mortality (~20% reduction). Preventable deaths from major trauma are most commonly due to uncontrolled haemorrhage and airway compromise.

Clinical Features

Symptoms

History of significant mechanism of injury (high-speed RTC, fall >2 m, penetrating injury, ejection from vehicle)

Pain — may be localised or generalised

Breathlessness

Altered consciousness or confusion

Limb deformity or inability to move

Visible external haemorrhage

Signs

Catastrophic external haemorrhage — arterial bleeding, limb amputation

Airway compromise: stridor, gurgling, inability to speak, facial/neck injury

Tension pneumothorax: tracheal deviation, absent breath sounds, distended neck veins, hypotension

Massive haemothorax: dull percussion, absent breath sounds, shock

Flail chest: paradoxical chest wall movement, crepitus, pain

Abdominal distension and rigidity (intra-abdominal haemorrhage)

Pelvic instability (do NOT spring pelvis — apply binder)

GCS <15 (assess with AVPU initially, then GCS. Check pupils)

Investigations

First-line

eFAST (extended focused assessment with sonography in trauma)Detects free fluid (haemoperitoneum), pericardial effusion, pneumothorax. Rapid bedside assessment

Trauma bloodsFBC, U&Es, LFTs, coagulation screen, fibrinogen, crossmatch (group and save minimum), lactate, ABG/VBG, blood glucose

CXR and pelvic XRAP chest and pelvis — during primary survey (can be done with patient on trolley)

Second-line

CT trauma scan (whole-body CT)CT head, C-spine, chest, abdomen, pelvis with IV contrast — within 30 min for major trauma patients with suspected internal injuries

Point-of-care coagulation (ROTEM/TEG)Viscoelastic testing guides blood product replacement in massive haemorrhage

Specialist

CT angiographyActive arterial haemorrhage — identify source for IR embolisation or surgical intervention

Interventional radiologyEmbolisation for hepatic, splenic, pelvic haemorrhage

Management

NICE NG39 (Major trauma), 2016

c — Catastrophic haemorrhage control

Direct pressure on wound, haemostatic dressings (e.g. Celox)
Tourniquet for limb haemorrhage not controlled by pressure (apply high and tight)
Pelvic binder for suspected unstable pelvic fracture
Junctional haemorrhage (neck, axilla, groin): wound packing + direct pressure

A — Airway with C-spine protection

Manual in-line stabilisation of cervical spine (collar if indicated)
Open airway: jaw thrust (preferred in trauma — avoids neck extension)
Suction, remove foreign bodies, insert oropharyngeal/nasopharyngeal airway
Definitive airway (RSI + intubation) if: GCS ≤8, airway compromise, anticipated deterioration
Surgical airway (front-of-neck access) if unable to intubate

B — Breathing

High-flow oxygen 15 L/min
Tension pneumothorax: immediate needle decompression (2nd ICS MCL or 4th/5th ICS MAL) → chest drain
Open pneumothorax: cover with three-sided occlusive dressing → chest drain
Massive haemothorax: chest drain (position 5th ICS MAL) → may need thoracotomy if >1500 mL initial output or >200 mL/h ongoing
Flail chest: analgesia (regional anaesthesia), positive pressure ventilation if respiratory failure

C — Circulation

Two large-bore IV cannulae (14–16G antecubital fossae). IO access if IV fails
Tranexamic acid 1 g IV within 3 h of injury (CRASH-2 evidence)
Major haemorrhage protocol: O-negative blood immediately, then group-specific. Target 1:1:1 RBC:FFP:platelets
Avoid hypothermia (contributes to coagulopathy — "lethal triad" = hypothermia + acidosis + coagulopathy)
Permissive hypotension: target systolic 80–90 mmHg in bleeding patients (except TBI — target MAP ≥80)
Damage control surgery if not responding to resuscitation

D — Disability + E — Exposure

GCS assessment, pupil size and reactivity, blood glucose, limb movements
Full exposure (cut off clothes) but prevent hypothermia (warm blankets, warm fluids, warm environment)
Log roll with C-spine precautions: inspect back, per rectum if indicated, palpate spine
Secondary survey: comprehensive head-to-toe examination once primary survey complete

Complications

Death: Commonest causes: uncontrolled haemorrhage (early), traumatic brain injury (later), multi-organ failure (late)
Lethal triad: Hypothermia + acidosis + coagulopathy — each worsens the others. Aggressive prevention essential
Multi-organ dysfunction: From prolonged shock — ARDS, AKI, DIC, hepatic failure
Fat embolism syndrome: After long bone fractures — petechial rash, confusion, respiratory failure at 24–72 h
Missed injuries: Secondary survey and tertiary survey (at 24 h) to identify injuries missed during resuscitation

UKMLA Exam Tips

1cABCDE — remember the "c" for catastrophic haemorrhage control BEFORE airway. This was a major NICE NG39 change
2Tension pneumothorax: clinical diagnosis → immediate decompression. Do NOT wait for CXR. Exam favourite
3TXA 1 g IV within 3 HOURS of injury. Not after 3 hours (CRASH-2: no benefit and possible harm after 3 h)
4Lethal triad: hypothermia + acidosis + coagulopathy. Prevent by warming, early blood products, damage control surgery
5Pelvic fracture: do NOT "spring" the pelvis. Apply pelvic binder. eFAST + pelvic XR
6Permissive hypotension (target systolic 80–90) EXCEPT in TBI where you need MAP ≥80 (brain needs perfusion)
7eFAST: Focused Assessment with Sonography in Trauma. Detects free fluid, pneumothorax, pericardial effusion

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