Management of trauma is of crucial importance in Bangladesh where thousands die or are maimed by road accidents every year. The importance of trauma management has increased exponentially in the aftermath of the terrorist attack in Dhaka in the recent months particularly after the mayhem staged by terrorists in the Holey Bakery and Restaurant in Gulshan.
Trauma is responsible for 10% of global mortality, is the leading cause of death under 50 years of age and is the third largest cause of death worldwide. An estimated 16-20,000 traumatic deaths occur per day resulting in a staggering loss of 6.4 million lives every year across the modern world – one and a half times more than deaths from malaria, HIV and tuberculosis combined. It is also the greatest source of potential life years lost and for each fatality due to trauma, there are two with serious or permanent disability.
Road-traffic fatalities account for one-third of trauma deaths. Other modes of injury such as falls, burns, traumatic assault and self-inflicted injury account for the rest of the mortality. We are now increasingly observing deaths due to suicide attacks and terrorism.
Estimated deaths due to road traffic fatalities is 5.4 in the UK, 14.7 in the US, 36 in Thailand with a global average of 21.6 per 100,000 populations and though the available data puts the figure in Bangladesh similar to that of the US, it would not be surprising if the real figure inclines towards the higher incidence rate.
In the UK there are about 18,000 deaths per year due to trauma and it is still the leading cause of death under age 50. Surprisingly 60% of trauma patients in the UK receive a standard of care that is less than good practice in the country and one-third of trauma deaths are preventable and occur due to misdiagnosis, mismanagement of hypoxia and haemorrhage (bleeding) and inadequate and delayed surgery.
Trimodal death distribution
Immediate:
50% trauma deaths occur immediately due to apnoea (no breathing), disruption of heart and major vessels, and is not salvageable and may only be addressed by primary prevention.
Early:
Deaths occurring in the first few hours of injury account for 30% of fatalities secondary to trauma and are due to hypoxia (reduced oxygenation), haemorrhage (bleeding), subdural and extradural haematoma around the brain, and is preventable by the proper management of the ‘Golden Hour’ principle by early resuscitation and definitive care. Management of the Golden Hour, appropriate or not, is the difference between life and death.
Late:
Accounts for 20% of trauma deaths and are due to sepsis (infection) and multiple organs disorder syndrome, and is directly dependent on quality of early management and subsequent management of critical care.
Management of the golden hour in major trauma is vital for survival and is time critical. Survival falls with each passing minute. Rapid access to appropriate care is the most important determinant of survival. Good outcome is dependent on efficient pre-planning, effective organisation and skilful co-ordination between multi-professional and multi-organisational stakeholders involved in trauma management.
Every step in trauma management – be it the triage, primary survey, resuscitation, secondary survey or definitive care – is of critical importance and may determine the difference between life and death. Health professionals involved in managing victims of trauma must not panic, be mindful of the safety of everyone associated, take proper and accurate hand-over from pre-hospital paramedics and treat immediate life threats as identified. Systematic approach to airway + c-spine control, breathing, circulation + haemorrhage control, disability (neurological status) and exposure/environmental control, the algorithm ABCDE of trauma must be followed meticulously.
25% of deaths due to trauma occur with significant chest injury. Some chest trauma causing trapped air between the lung and the chest wall becomes rapidly lethal if the trapped air is not relieved immediately, and this may be achieved by straight forward uncomplicated manoeuvres. Chest trauma also contributes to a further 25% of trauma deaths. However, majority of chest injury can be managed by simple procedures and may involve liberal use of oxygen, adequate and appropriate pain relief, judicious use of fluids and sometimes insertion of chest drain. Only a few severe chest injuries may require more expert intervention.
Injury to the abdomen can be due to blunt or penetrating trauma. Abdominal injuries are a major source of missed diagnosis. Bleeding from the injury may cause minimum irritation, masking a serious situation inside the abdomen. Clinicians treating such patients need to have a high index of suspicion delineated from the mechanism of injury and injury pattern, and if the patient is unable to provide accurate indications due to reduced levels of consciousness.
Head trauma is responsible for half of the number of traumatic deaths. Good outcome from head trauma depends on quality of care provided, measures taken to limit subsequent brain injury, preventing lack of adequate oxygenation, avoiding accumulation of excess of carbon-dioxide in blood and correcting shock that causes fall in blood pressure leading to reduction in the blood supply to the brain. When there is accumulation of blood within the linings over the brain, early surgical evacuation of such intracranial blood collection leads to favourable outcomes.
It is imperative that the surgeons, anaesthetists, doctors, nurses and other health professionals engaged in trauma care anywhere in the world be familiar with the scale of trauma, be able to understand the mechanism of injury, be conversant with the understanding of the priorities for assessment of a poly-trauma patient, be well aware of the principles of primary and secondary survey, understand the pathophysiology of injury and be able to identify and know the treatment of life threatening injuries so as to maximise positivity of the outcome of any trauma situation, be it road traffic or terrorism.
Tuesday, July 21, 2026
