Road Traffic Injuries & Trauma Care Guidelines

Posted on by Soumya Ranjan Parida
Community Health Nursing: Road Traffic Injuries & Trauma Care Guidelines

Community Health Nursing: Road Traffic Injuries & Trauma Care Guidelines

A comprehensive guide for nursing students on road traffic injuries, risk factors, and operational guidelines for trauma care facilities on highways

Table of Contents
  1. Introduction
  2. Epidemiology of Road Traffic Injuries in India
  3. Risk Factors for Road Traffic Injuries
    1. Human Factors
    2. Vehicle Factors
    3. Environmental Factors
    4. System Factors
  4. Trauma Care Facilities on Highways
    1. Levels of Trauma Care Facilities
    2. Operational Guidelines
    3. Infrastructure Requirements
    4. Human Resource Requirements
  5. The Golden Hour Concept in Trauma Care
  6. Role of Nurses in Trauma Care
    1. Pre-Hospital Care
    2. Care at Trauma Facilities
    3. Community Health Nursing Interventions
  7. Nursing Management of Road Traffic Injury Cases
  8. Prevention Strategies
  9. Global Best Practices in Road Safety and Trauma Care
  10. Conclusion
  11. References

1. Introduction

Road traffic injuries (RTIs) constitute a major public health concern globally, particularly in developing countries like India. As community health nurses, understanding the risk factors, prevention strategies, and management of trauma care facilities is crucial to reduce morbidity and mortality associated with road traffic accidents.

Road trauma care systems are designed to provide timely and effective care to victims of road traffic accidents. In India, road accidents claim approximately 1.5 lakh lives annually, making it one of the countries with the highest number of road deaths globally. The mortality rate in India is 11.6 per 100,000 population compared to 10.3 in Europe. The rate of fatalities per 10,000 vehicles in India is as high as 10.5, compared to less than 2.0 in developed countries.

Trauma care facility on highway with ambulance arriving, medical staff ready at entrance

A modern trauma care facility on a highway with emergency medical services

2. Epidemiology of Road Traffic Injuries in India

Key Statistics

  • India has one of the highest numbers of road deaths globally
  • Approximately 1.5 lakh (150,000) lives lost annually
  • Mortality rate: 11.6 per 100,000 population
  • Road traffic crashes are one of the major causes of disability, morbidity, and mortality
  • Road-traffic accidents are increasing at an alarming annual rate of 3%
  • In India, an estimated 10% of deaths are due to trauma
  • 60% of head injuries are attributable to road traffic accidents

The incidence of road traffic injuries varies across different states in India, with more urbanized and industrialized states reporting higher numbers of accidents. However, the fatality rate may be higher in rural areas due to delay in accessing trauma care services and inadequate trauma management facilities.

According to the Ministry of Road Transport and Highways (MoRTH), road injuries are one of the top four leading causes of death and health loss among persons of age group 15-49 years. In 2017, there were 4,64,910 reported road accidents causing injuries to 4,70,975 persons and claiming 1,47,913 lives. This translates to an average of 53 accidents and 16 deaths every hour in India.

3. Risk Factors for Road Traffic Injuries

Understanding the risk factors for road traffic injuries is essential for developing effective prevention strategies and improving trauma care systems. These risk factors can be categorized into four main groups:

3.1 Human Factors

Human-Related Risk Factors

  • Speeding: Exceeding speed limits increases the risk of crashes and the severity of injuries
  • Driving under the influence: Alcohol and drugs impair judgment, reaction time, and coordination
  • Distracted driving: Using mobile phones, eating, or other activities that divert attention
  • Failure to use safety equipment: Not using seatbelts, helmets, or child restraints
  • Fatigue and drowsy driving: Particularly common among long-distance drivers
  • Inexperience: Young or newly licensed drivers have higher crash rates
  • Aggressive driving: Road rage, improper overtaking, and running red lights
  • Medical conditions: Epilepsy, diabetes, vision problems, etc.

Mnemonic: “ACCIDENT”

To remember key human risk factors for road traffic injuries:

  • A – Alcohol and drugs
  • C – Carelessness and cognitive distractions
  • C – Cell phone use
  • I – Inexperience and impatience
  • D – Drowsiness and fatigue
  • E – Emotional distress (road rage)
  • N – Non-compliance with safety measures
  • T – Time pressure (hurrying)

3.2 Vehicle Factors

  • Vehicle condition: Poor maintenance, defective brakes, tires, or lights
  • Vehicle design: Lack of safety features like airbags, ABS, ESC
  • Overloading: Carrying more passengers or cargo than designed for
  • Size and type of vehicle: Two-wheelers are more vulnerable to serious injuries

In India, two-wheelers account for about 25% of total road crash deaths, followed by pedestrians (23%) and cyclists (5%). The high proportion of vulnerable road users significantly influences the type of trauma care services needed.

3.3 Environmental Factors

  • Road design: Poor road geometry, inadequate visibility, lack of pedestrian facilities
  • Road condition: Potholes, uneven surfaces, lack of proper signage
  • Weather conditions: Rain, fog, snow reducing visibility and traction
  • Traffic density: Congestion increases minor collision risk
  • Lack of street lighting: Particularly dangerous at night
  • Natural hazards: Landslides, flooding affecting road conditions

The Ministry of Road Transport & Highways and State Governments maintain a database of “Accident Blackspots” – locations where road traffic accidents have historically been concentrated. These blackspots often arise due to improper road engineering, unsafe driving behavior, absence of pedestrian crossings, etc., and contribute to almost 2/3rd of accidental deaths in India.

3.4 System Factors

  • Inadequate enforcement: Of traffic laws and regulations
  • Poor emergency response: Lack of integrated emergency medical services
  • Insufficient trauma care facilities: Especially along highways and in rural areas
  • Lack of coordination: Between various agencies responsible for road safety
  • Inadequate public awareness: About road safety measures
  • Poor post-crash care: Missing the crucial “golden hour” for treatment

Critical System Risk

Trauma care in India has been described as “disorganized” and “inadequate” in multiple studies. At the national level, India does not have a central government agency, such as a division within the Ministry of Health, that specifically oversees trauma care. Data to describe national trauma-related outcomes and trends are scarce, making system-level improvements challenging.

4. Trauma Care Facilities on Highways

Given the high incidence of road traffic injuries, the Government of India initiated a project during the 9th Five Year Plan titled “Pilot Project for Strengthening Emergency Facilities along the Highways” with the objective to reduce preventable deaths in road accidents. This evolved into the scheme “Capacity Building for Developing Trauma Care Facilities in Government Hospitals on National Highways” during the 11th Five Year Plan.

4.1 Levels of Trauma Care Facilities

Under India’s national trauma care system, facilities are categorized into four distinct levels based on their capabilities, resources, and the complexity of cases they can handle:

Level Description Capabilities Facility Type
Level IV Mobile Units Basic life support, first aid, and patient transport Ambulances strategically positioned along highways at every 50km
Level III Initial Care Initial evaluation and stabilization (surgically if appropriate); comprehensive medical and surgical inpatient services for stable patients District/tehsil hospitals with 100-200 beds
Level II Definitive Care Definitive care for severe trauma; emergency physicians, surgeons, orthopedicians, and anesthetists in-house and immediately available Medical colleges or hospitals with 300-500 beds
Level I Comprehensive Care Highest level of definitive and comprehensive care; all major super specialties available 24/7; referral center for complex cases Medical college hospitals with more than 500 beds

Strategic Positioning

The trauma care network has been designed so that no trauma victim has to be transported for more than 50 kilometers, with a designated trauma care facility available at every 100 km along national highways. For every 1,400 km stretch, the system envisions:

  • 2 Level I Trauma Centers
  • 6 Level II Trauma Centers
  • 6-8 Level III Trauma Centers
  • 28 Level IV Mobile Units (Ambulances)

4.2 Operational Guidelines

The overall objective of India’s trauma care system is to reduce preventable deaths from road accidents to 10% by developing a pan-India trauma care network. The main strategies include:

  1. Golden Hour Treatment: Ensure definitive treatment for the injured within the first hour after injury
  2. Ambulance Distribution: Basic Life Support Ambulances at every 50km and Advanced Life Support Ambulances at trauma care facilities for inter-facility transfers
  3. Facility Placement: Designated Trauma Care Facilities (Level I, II, III) at every 100km
  4. Communication Network: Integrated system enabling public access and inter-component communication
  5. Human Resource Development: Skill training for doctors, nurses, paramedics, and other staff
  6. Surveillance: Development of National Injury Surveillance System & Trauma Registry
  7. Public Awareness: Spreading awareness about injury prevention and road safety

The establishment of new trauma care facilities prioritizes locations near identified “Accident Blackspots” – areas with historically high rates of accidents. Preference is given to existing hospitals within 100km radius of these blackspots, especially where mortality due to trauma has remained high despite road safety interventions.

4.3 Infrastructure Requirements

The trauma care facility infrastructure varies according to the designated level, but all facilities should include the following core areas:

Core Infrastructure Components

  1. Patient Access Areas:
    • Ambulance entrance
    • Walking entrance
  2. Patient Care Areas:
    • Triage & Reception area
    • Resuscitation area (Red Area)
    • Treatment area (Yellow Area)
    • Ambulatory care area
    • Observation Ward
    • Isolation rooms
  3. Clinical Support Services:
    • Laboratory Services
    • Radiology
    • Blood Bank
    • Pharmacy
    • Communications
  4. Support Facilities:
    • CSSD (Central Sterile Services Department)
    • Medical Gas Manifold
    • Security
  5. Facilities for Relatives:
    • Waiting Area
    • Communication Room
    • Toilets
    • Refreshment Area
  6. Staff Facilities:
    • Changing rooms
    • Shower and toilets
    • Dining area
    • Administrative offices

Level-Specific Infrastructure Requirements

Infrastructure Level I Level II Level III
ICU beds 30 beds (10 ICU, 20 General trauma) 20 beds (10 ICU, 10 General trauma) 10 beds (5 ICU, 5 General trauma)
Operation Theaters 4 2 1
Resuscitation Area Minimum 25m² per bay Minimum 25m² per bay Minimum 25m² per bay
Treatment Area Minimum 12m² per cubicle Minimum 12m² per cubicle Minimum 12m² per cubicle

Design Principle

“What needs to be understood is that a Trauma Center is not an infrastructure concept but a SYSTEMS CONCEPT in which the appropriate infrastructure, equipment, and human resources work in tandem to provide the necessary trauma care services to a patient.”

4.4 Human Resource Requirements

The success of a trauma care facility depends significantly on the availability and competence of its human resources. The staffing pattern varies according to the level of the facility:

Human Resource Level I Level II Level III
Neurosurgeon 4 1 –
Radiologist 2 2 –
Plastic Surgeon 1 – –
Anesthetist 6 3 2
Orthopedic Surgeon 4 3 2
General Surgeon 6 2 2
Casualty Medical Officer 30 8 6
Staff Nurse (including Trauma Nurse Coordinators) 100 40 25
Nursing Attendant 24 16 13
OT Technician 10 5 5
Radiographer 4 4 4
Lab Technician 4 2 2
MRI Technician 2 – –
Multi-task Worker 40 15 12
Total 237 101 73

In addition to the required staffing, ongoing training is essential. The National Trauma Care Programme in India has established various capacity-building initiatives, including:

  • Pre-hospital Trauma Technician (PTT) course
  • First Aid courses
  • Training of Trainers (TOT) for Medical Officers
  • Basic Life Support (BLS) training for nurses and paramedics
  • Advanced Trauma Life Support (ATLS) training for doctors

5. The Golden Hour Concept in Trauma Care

The Golden Hour

The “Golden Hour” refers to the first 60 minutes after a traumatic injury, during which prompt medical treatment is most likely to prevent death. It is a critical concept in trauma care that emphasizes the importance of rapid response, assessment, and intervention.

The concept of the Golden Hour is foundational to India’s trauma care system. The critical elements include:

  1. Rapid Recognition and Notification: Early identification of life-threatening injuries and immediate activation of emergency medical services
  2. Prompt Transport: Quick evacuation to an appropriate trauma facility, ideally within 30 minutes of the incident
  3. Efficient Triage: Rapid assessment and prioritization of injuries upon arrival
  4. Immediate Resuscitation: Addressing airway, breathing, circulation (ABC) priorities
  5. Early Definitive Care: Surgical intervention if necessary within the first hour

Research has shown that the probability of survival decreases by approximately 10% for each 10-minute delay in definitive care for critically injured patients. This underscores the importance of the strategic distribution of trauma care facilities at regular intervals along highways.

Mnemonic: “SCORE”

To remember the key components of Golden Hour trauma management:

  • S – Stabilize vital functions (ABC)
  • C – Control hemorrhage
  • O – Obtain accurate assessment of injuries
  • R – Rapid transport to appropriate facility
  • E – Early definitive care and intervention

6. Role of Nurses in Trauma Care

Nurses play a pivotal role in all aspects of trauma care, from pre-hospital care to rehabilitation. Their responsibilities vary based on the setting but are crucial at every stage of trauma management.

6.1 Pre-Hospital Care

In the pre-hospital setting, especially in ambulances (Level IV trauma care), nurses may serve as:

  • First Responders: Providing immediate emergency care at the accident site
  • Triage Nurses: Assessing and categorizing victims based on injury severity
  • Transport Nurses: Providing care during transport to maintain stability

Key nursing interventions in pre-hospital care include:

  1. Airway management
  2. Controlling external hemorrhage
  3. Immobilization of fractures
  4. Pain management
  5. Fluid resuscitation
  6. Documentation of vital signs and interventions
  7. Communication with the receiving facility

6.2 Care at Trauma Facilities

At trauma care facilities (Levels I, II, and III), nurses have specialized roles:

Trauma Resuscitation Nurse

  • Participates in the trauma team activation
  • Assists with airway management
  • Establishes intravenous access
  • Administers blood products and medications
  • Monitors vital signs and patient response
  • Documents interventions and patient status

Trauma ICU Nurse

  • Provides continuous monitoring of critically injured patients
  • Manages mechanical ventilation
  • Administers complex medication regimens
  • Prevents complications (DVT, pressure ulcers, VAP)
  • Provides neurological assessment for TBI patients
  • Maintains hemodynamic stability

Trauma Nurse Coordinator

  • Coordinates care across multiple disciplines
  • Serves as a liaison between departments
  • Facilitates patient transfer between facilities
  • Participates in trauma quality improvement activities
  • Educates staff on trauma protocols
  • Contributes to trauma registry data collection

6.3 Community Health Nursing Interventions

Community health nurses play a significant role in both prevention of road traffic injuries and post-trauma community reintegration:

Prevention Activities

  • Conducting road safety awareness programs in schools and communities
  • Educating about proper use of safety equipment (helmets, seatbelts)
  • Advocating for road safety policy implementation at local level
  • Participating in community health assessment to identify high-risk areas
  • Training community members in basic first aid for accident victims

Post-Trauma Community Care

  • Home visits for discharged trauma patients
  • Wound care and monitoring for complications
  • Rehabilitation support and follow-up
  • Psychological support for trauma survivors and families
  • Facilitating access to disability services
  • Reintegration support for return to work/school

Nursing Approach

Community health nurses should adopt a holistic approach to trauma care, addressing not only the physical aspects of injury but also the psychological, social, and financial implications for both patients and their families. This approach is particularly important in the Indian context, where the burden of care often falls heavily on families after hospital discharge.

7. Nursing Management of Road Traffic Injury Cases

The nursing management of road traffic injury victims requires a systematic approach based on the type and severity of injuries. Common injuries from road traffic accidents include:

  • Traumatic Brain Injuries (TBI)
  • Spinal Cord Injuries
  • Thoracic and Abdominal Trauma
  • Musculoskeletal Injuries (fractures, dislocations)
  • Soft Tissue Injuries (lacerations, contusions)
  • Facial and Maxillofacial Injuries
  • Burns (in case of vehicle fires)

The nursing process for managing road traffic injury cases includes:

1. Assessment

  • Primary survey (ABCDE approach)
    • A – Airway maintenance with cervical spine protection
    • B – Breathing and ventilation
    • C – Circulation with hemorrhage control
    • D – Disability (neurological status)
    • E – Exposure/Environmental control
  • Secondary survey (head-to-toe examination)
  • Ongoing monitoring of vital signs
  • Pain assessment using appropriate scales
  • Psychological assessment for acute stress reactions

2. Nursing Diagnosis

  • Ineffective breathing pattern related to chest trauma
  • Decreased cardiac output related to hypovolemia
  • Acute pain related to physical injury
  • Risk for infection related to open wounds
  • Impaired physical mobility related to musculoskeletal injuries
  • Risk for ineffective cerebral tissue perfusion related to TBI
  • Anxiety/fear related to trauma experience

3. Planning and Interventions

  • Airway and Breathing
    • Maintain patent airway
    • Administer oxygen as prescribed
    • Assist with intubation if needed
    • Position patient to optimize ventilation
    • Monitor respiratory rate, depth, and pattern
  • Circulation
    • Control external bleeding with direct pressure
    • Administer IV fluids and blood products as ordered
    • Monitor vital signs frequently
    • Apply pressure dressings for hemostasis
    • Monitor for signs of shock
  • Neurological Management
    • Monitor level of consciousness using GCS
    • Assess pupillary responses
    • Monitor for signs of increased intracranial pressure
    • Maintain head elevation at 30° for TBI patients
    • Implement seizure precautions if indicated
  • Pain Management
    • Administer analgesics as prescribed
    • Use non-pharmacological pain relief measures
    • Maintain proper body alignment
    • Support injured extremities
    • Provide comfort measures
  • Wound Care
    • Clean wounds using aseptic technique
    • Apply appropriate dressings
    • Monitor for signs of infection
    • Administer tetanus prophylaxis if indicated
    • Provide wound care education
  • Psychological Support
    • Provide emotional support
    • Explain procedures and interventions
    • Allow family presence when appropriate
    • Assess for signs of acute stress disorder
    • Refer to mental health services if needed

4. Evaluation

  • Reassessment of vital signs and injury status
  • Pain level reassessment
  • Wound healing progress
  • Effectiveness of interventions
  • Psychological adaptation
  • Functional recovery and rehabilitation progress

8. Prevention Strategies

Prevention of road traffic injuries requires a multi-faceted approach addressing various risk factors. Community health nurses can contribute significantly to these preventive efforts:

Primary Prevention (Before Accident Occurs)

  • Education and Awareness:
    • School-based education programs
    • Community awareness campaigns
    • Media campaigns on safe driving practices
    • Promoting use of safety equipment
  • Advocacy:
    • Advocating for better road infrastructure
    • Supporting stricter enforcement of traffic laws
    • Promoting vehicle safety standards
  • Community Interventions:
    • Organizing community walkability assessments
    • Identifying and reporting hazardous road conditions
    • Promoting public transportation use

Secondary Prevention (Minimizing Injury Severity)

  • First Aid Training:
    • Training community members in basic first aid
    • Conducting CPR and basic life support workshops
    • Teaching bystander response to accidents
  • Emergency Response:
    • Promoting knowledge of emergency contact numbers
    • Helping establish community emergency response teams
    • Supporting Good Samaritan laws

Tertiary Prevention (Rehabilitation and Reintegration)

  • Rehabilitation Support:
    • Home-based rehabilitation programs
    • Connecting patients with rehabilitation resources
    • Educating families on continued care
  • Psychosocial Support:
    • Organizing support groups for trauma survivors
    • Providing counseling or referrals
    • Addressing post-traumatic stress
  • Community Reintegration:
    • Vocational rehabilitation support
    • Accessibility advocacy
    • Disability support services

Critical Prevention Need

In India, the enforcement of traffic laws, including those related to speeding, drunk driving, and helmet/seatbelt use, remains inconsistent. Community health nurses should emphasize the importance of personal safety behaviors regardless of enforcement levels, focusing on protection of self and loved ones as a primary motivator rather than just legal compliance.

9. Global Best Practices in Road Safety and Trauma Care

Several countries have successfully reduced road traffic injuries through comprehensive approaches. These global best practices can inform nursing interventions and advocacy in India:

Sweden: Vision Zero

Sweden adopted a “Vision Zero” policy that aims for zero traffic fatalities. The approach places responsibility on system designers (road builders, vehicle manufacturers) rather than just road users. Key elements include:

  • Road design that accommodates human error
  • Speed limits based on the safety of the road
  • Separation of different types of road users
  • Focus on system-wide safety rather than individual behavior

Australia: Trauma System Integration

Australia has developed highly integrated trauma systems that coordinate pre-hospital care, hospital services, and rehabilitation. Features include:

  • Designated trauma hospitals with defined roles
  • Comprehensive trauma registries for quality improvement
  • Standardized trauma team activation criteria
  • Regular performance review and system improvements

Japan: Rapid Response System

Japan has developed an efficient emergency medical service system for trauma cases:

  • Doctor-staffed helicopter emergency medical services
  • Advanced telecommunications between ambulances and hospitals
  • Specialized trauma centers with 24/7 surgical capabilities
  • Continuous professional development for trauma teams

United Kingdom: Rehabilitation Integration

The UK has focused on integrating rehabilitation services into the trauma care pathway:

  • Early rehabilitation assessment in acute care
  • Dedicated rehabilitation coordinators
  • Community-based rehabilitation programs
  • Long-term follow-up and support systems

These global best practices highlight the importance of a systems approach to trauma care that addresses prevention, acute care, and rehabilitation in a coordinated manner. Community health nurses in India can advocate for adoption of these evidence-based approaches, adapted to the local context.

10. Conclusion

Road traffic injuries represent a significant public health challenge in India, requiring comprehensive approaches for prevention and management. Trauma care facilities on highways, stratified into different levels based on capabilities, form a crucial component of India’s response to this challenge.

The success of trauma care systems depends on multiple factors, including:

  • Strategic distribution of facilities to ensure access within the golden hour
  • Adequate infrastructure, equipment, and human resources
  • Standardized protocols and training for healthcare providers
  • Effective communication and coordination between system components
  • Ongoing quality improvement based on data and outcomes
  • Integrated approaches to prevention, acute care, and rehabilitation

Community health nurses play pivotal roles across the spectrum of trauma care, from prevention activities in communities to acute care in facilities to rehabilitation support after discharge. By understanding the risk factors for road traffic injuries and the operational guidelines for trauma care facilities, nurses can contribute more effectively to reducing the burden of road traffic injuries in India.

The future of trauma care in India lies in strengthening existing systems, expanding coverage in underserved areas, improving coordination between agencies, enhancing data collection and analysis, and continuously upgrading skills and resources. With dedicated efforts from all stakeholders, including community health nurses, the goal of reducing preventable deaths from road accidents to 10% can be achieved.

11. References

  1. Ministry of Health and Family Welfare, Government of India. “Capacity Building for Developing Trauma Care Facilities on National Highways: Operational Guidelines.” https://www.dmetodisha.gov.in/files/GoI_Operational%20Guidelines_Trauma.pdf
  2. World Health Organization. (2023). “Road Traffic Injuries Fact Sheet.” https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  3. Ministry of Road Transport and Highways, Government of India. (2023). “Road Accidents in India.” https://morth.nic.in
  4. Joshipura, M. K., Shah, H. S., Patel, P. R., & Divatia, P. A. (2004). “Trauma care systems in India – An overview.” Indian Journal of Critical Care Medicine, 8(2), 93-97.
  5. Roy, N., Murlidhar, V., Chowdhury, R., et al. (2017). “Learning from 2523 trauma deaths in India—opportunities to prevent in-hospital deaths.” BMC Health Services Research, 17, 142.
  6. Haghparast-Bidgoli, H., Hasselberg, M., Khankeh, H., et al. (2010). “Barriers and facilitators to provide effective pre-hospital trauma care for road traffic injury victims in Iran: a grounded theory approach.” BMC Emergency Medicine, 10, 20.
  7. Mock, C., Kobusingye, O., Anh, L. V., et al. (2005). “Human resources for the control of road traffic injury.” Bulletin of the World Health Organization, 83(4), 294-300.
  8. Ahmed, S. K., Mohammed, M. G. (2023). “Road traffic accidental injuries and deaths: A neglected global health issue.” Health Science Reports, 6(3).
  9. Indian Society for Trauma & Acute Care (ISTAC). “Trauma in India Fact File.” https://www.traumaindia.org/indiafactfile.aspx
  10. National Disaster Management Authority, Government of India. “Trauma Care.” https://ndma.gov.in/Capacity_Building/Mitigation/trauma-care

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