Initial Assessment and Shock

1.) Airway
a. Patent = speak full sentences, bilateral breath sounds
b. Someone who needs urgent intervention has a patent
airway but can anticipate airway compromise (e.g.
expanding hematoma of neck, cutaneous emphysema)
c. Someone who needs emergent intervention (cant protect
own airway)
i. GCS less than 8 = intubate
ii. Gurgling breath sounds/gasping
iii. Stridor
2.) Breathing (does patient need ventilations? How about a
ventilator?)
a. Sp02, ETCO2 (gold standard, should be ~ 40)
b. RR 12-20
Airway Algorithm (1.) O2 Bag valve mask ET cricothyrotomy)
- never do tracheostomy in ED (only OR) because likely to fail
and patient will die, can do bedside trach but takes too long
3.) Circulation (is patient in shock? American Heart Association says
SBP < 90mmhguop < 0.5cc/kg/hrpale/cool/diaphoretic)
- MAP = CO x SVR.CO = S.V. x HR.SV = Preload x
Contractility
- So 4 things comprise MAP = HR, Preload, Contractility,
SVR
- 1.) HR = brady heart fills fine but not fast enough to meet
sufficient cardiac output vs tachy compromise diastolic
filling, cant meet adequate cardiac output
- 2.) preload = volume down, dehydrated state (usually 2/2
hemorrhage or obstruction, e.g. tension pneumothorax or
pericardial tamponade)
- 3.) Contractility (usually think about this in setting of a.
heart failure or b. MIin trauma, myocardial contusion can
mimic MI)
- 4.) SVR (massive vasodilation, sepsis/anaphylaxis, spinal
trauma autonomic nervous system is lost, spinal anesthetic,
dysfunctional autonomic nervous system e.g. elderly diabetic)
Life threatening trauma conditions that need emergent intervention
1.) Hemorrhage
- flat neck veins, drop in hgb/hct, tachy (in response to decr
preload)
- dx = if hemorrhage not noticeable, bleeding could be
intraperitoneal (FAST exam)
- tx = 2 large bore IV, Type and cross, IVF, Blooddo this on the
way to the OR

2.) Tension pneumothorax

- air gets into pleural space but becomes trapped -> lung
collapsed
- engorged neck veins, absent lung sounds on affected side
(hyperresonant), tracheal deviation away from affected side
- tx = needle decompression (14-16 gauge over 2nd ICS mid
clavicular) followed by thoracostomy (chest tube)not
thoracotomy; note: goal of needle is not to re-expand the lung
but to relieve the pressure on vena cava
3.) Pericardial tamponade (rapidly evolving pericardial effusionR
ventricle is looser and floppier than left ventricle so will collapse,
cannot filllike an acute diastolic heart failureso because blood
cant get into heart but theres enough preload there, blood
backs up into neck veins => engorged)
a. Lung sounds are clear
b. Becks triad (engorged neck veins, distant heart sounds,
hypotension)
c. Tx = pericardiocentesis
Note: engorged neck veins + pulmonary edema -> contractility issue
(vs traumatic problem); dx = echo; tx = medically
4.) vasomotor shock (pt will have warm extremities despite a low BP
2/2 vasodilation)vs shock related to HR, preload and
contractility (cold extremities because vasoconstriction to shunt
blood back to core)
a. tx = vasopressin
Head Trauma
1.) basilar skull fx (raccoon sign = black and blue around both
eyes; Battles sign = black and blue aka hematoma behind
ear; clear rhinorrhea/otorrhea)
a. get CT SCAN of head
2.) epidural hematoma (trauma to temple -> damage of middle
meningeal a.); lens shaped hematoma on CT scan
a. trauma to head -> loc -> lucid interval -> death
b. must get CT if +loc
c. tx = craniotomy
3.) Acute Subdural (young patients, may be sign of abuse e.g.
shaken baby syndrome, or adolescent usually severe trauma,
e.g. mva collision 80mph)
a. Crescent shaped lesion
b. keep ICP down (1.) elevate head, 2. Hyperventilation co2
washout/vasoconstriction, 3. Mannitol)
c. tx = craniotomy
4.) Chronic Subdural (older, alcoholics 2/2 smaller brain which
stretch bridging veins become taught, get damaged 2/2 shear
stress after falls or minor trauma)

a. Crescent shaped lesion

b. Presents as headache with progressive dementia
c. Tx = craniotomy
5.) Concussion (sports injury, +loc, amnesia usually retrograde)
- newtons first law (object in montion will not change velocity
unless external force acts upon it)
- coup/contrecoup injury brain is bruised by CT scan is neg
- can go home but only if have family members who can
monitor, must stay awake
6.) Diffuse axonal injury (angular trauma, e.g. MVA in car that spins
a lot)
- CT = blurring of grey-white junction
- Poor prognosis; degree of axonal injury correlates with length
of trauma
Note: anyone with head injury or loc should get head CT (to look for
hematomas and fractures)
Neck Trauma
- three zones: 1.) middle (surgery is most liberal) = ;2.) upper
(conservative); 3.) lower (most conservative)
- note: if anyone has expanding hematoma, gurgling sounds, or
shock related to neck trauma -> go to SURGERY!
- Gsw is different from knife wounds (knife wounds always get
arteriogram to look for active bleeding and U/S to look for
expanding hematoma) vs (GSW to upper zone = arteriogram,
middle zone = surgery, lower zone = further investigation,
e.g. lungs w/ bronchoscopy, esophagram, arteriogramCTA)
CTA useful because can also assess c-spine in addition to
vessels(do it regardless of blunt or penetrating injury)
- Spinal cord anatomy: 1.) ALS decussates at level it enters
cord, 2.) DCMLS ascends and crosses at medulla, 3) motor
crosses in medulla and descends
o Hemisection = ipsilateral loss of vibratory + positional
sense but also contralateral loss of P+T
- cord syndromes (focal neurologic damage = ED, urinary/fecal
incontinence)note: original trauma unless it caused
transection does not do the damageits the subsequent
edemaso important to give dexamethasone first then can
get MRI
- complete transection = 1.) at site of lesion = LMN
symptoms aka paralysis, 2.) below = UMN symptoms
(Babinski, hyperreflexia) + loss of all sensory and P/T
- Hemisection (brown-sequarde.g. from sharp knife wound)
= 1.) ipsilateral motor + sensory, contralateral = P/T
- Central Cord lesion (elderly w/ hyper-extension of neck s/p
mva)

o p/w paralysis, lose motor function bilaterally, burning

pain in extremities
- Anterior Cord Syndrome (syringomyelia; loss of p/t in capelike distribution); neurosx can remove the syrinx
Chest Trauma
1.) Rib fx usually from blunt trauma but since pointy, can induce
penetrating injury; soany blunt injury to chest can also be
penetrating (can cause ptx)
a. Chest pain = splinting (not going to breath much -> risk of
atelectasis and pna)
b. Dx = cxr; tx = pain control (but not too much because of
resp depression)
2.) PTX (c/o dyspnea), hyperresonance with decr breath sounds
a. Dx = CXR (vertical lung shadow -> air in chest)
b. Tx = thoracostomy (chest tube)place it up high to reexpand lung
3.) Hemothorax (same mechanism as ptx = penetrating trauma or
blunt trauma with rib fx leading to penetrating; c/o dyspnea)
but since blood is fluid, obeys laws of gravity so lung gets
compressed in a different way (fluid settles out at bottom,
forming a meniscus aka air/fluid level aka lung/fluid level),
dullness to percussion with decreased breath sounds
a. DX = cxr will show meniscus, air/fluid level
b. TX = thoracostomy (place it down low)
c. But need to investigate (puncture peripheral artery or
pulmonary vasculature); pulmonary vasculature = low
pressure, may clot off easily vs peripheral = high pressure,
may not stop bleeding w/o intervention; so look for output
(1500cc at insertion or >600cc/6hr indicates puncture of
peripheral vesselwill need surgery, thoracotomy)
4.) Sucking chest wound can lead to tension ptx (has to be
penetrating injury from outside)flap is createdso with each
breath in air is allowed to go in but with exhalation, flap closes
and air gets stuck
a. p/w dyspnea and tension pneumo
b. dx = visual inspection
c. tx = if +tension ptx then needle decompression but if just
sucking chest wound then need semi-occlusive dressing
(taped on 3 sides so that as exhale flap opens, with inhale
flap closes)also do thoracostomy to re-expand
5.) flail chest (HUGE blunt trauma) will see paradoxical
movementneed 2+ ribs to be broken at 2+ Places; so with
inhalation, thoracic cage expands but flail segment feels the neg
intrathoracic pressure and gets sucked in vs as chest relaxes,
thoracic cage relaxes, flail segment gets pushed out from
positive intrathoracic pressure

dx = visual inspection/cxr
tx = weights and binders to keep flail segment in placeand if
this fails then surgical placement of plate
note: anyone with major injury (flail chest, scapular fx, sternal fx) =>
evaluate for other injuries, e.g. pulmonary contusion (will lead to
noncardiogenic pulmonary edemawill need cxr but initially this will
be normal and then later pt will c/o dyspnea, pulmonary edematakes
about 48 hours s/p trauma to show bilateral white out)
- tx = avoid crystalloidscan give colloidsbut treat like ARDS
with PEEP
- note: also watch out for myocardial contusion (present
same way as pulmonary contusion)
dx = so if get any of the above injuries (flail chest, scapular fx,
sternal fx), get 12-lead serial ekg + CE
tx = control for HF and arrhythmias with MONA BASH
(morphine, o2, nitrates, asa; beta-blockers, ACEi, statins,
heparin)
6.) Aortic Dissection (traction injury from ligamentum arteriosum)
a. One way this presents, DOA
b. Incomplete transection (adventitial hematoma)
i. Dx = CXR (index of suspicion goes up if widened
mediastinum, abnormal blood pressure, tearing cp
rad to back
ii. Evaluate w/ CT scanif high IOS and neg CT, get
angiogram; if cxr was neg and ct scan was neg, can
stopprobably no need for angiogrambut
angiogram = best
iii. Tx = surgical repair but in mean time get SBP down
as low as possible (iv esmolol, titrate)
Abdominal Trauma
1. Penetrating
- any GSW to abd, below nipple line gets ex-lap -> run bowel,
determine line of trajectory)
- Knife injury: if a. evisceration, b. peritoneal signs, c. shock =>
SURGERY
i. otherwise, probe the wound (if enters peritoneum then go to
SURGERY but if does not enter peritoneum, can watch + wait)
2. Blunt
- FAST or CT scan; if theres any bleeding then go to SURGERY
- head holds 50cc blood (not enough to cause HD compromise but
enough to herniate brain), chest holds 500cc, arms about 100cc,
forearm 50cc, lower legs can hold 200cc, each thigh can hold 1L
(1/5 of cardiac output), pelvis can hold 2L (enough to kill), abdomen
holds 1.5L
- so if theres bleeding in abdomen -> EX LAP

- MCC bleeding s/p abdominal trauma = ruptured liver

- liver held in place by ligamentum teres (in trauma, liver
swings in deceleration injury but held back by ligamentum teres so
shreds liver in half)
- repairmay lead to lobectomy
- pringle maneuver = grab hepatoduodenal ligament (hepatic
artery, portal vein)can manage blood supply to liver while repair it
- RUPTURED spleen = massive bleeding
- easy to put back together because it has a capsule; try to repair
it but if cant then sacrifice it (e.g. massive abdominal trauma and
there are other lesions e.g ruptured liver or perforated bowelbecause
may not have time to save spleenor if grade of injury is super high)
- if remove spleen, must vaccinate against encapsulated
organisms
- Ruptured diaphragm (can cause HD instability compromising
oxygenationbowel will end up in thorax hear bowel sounds, Kehrs
sign = shoulder pain referred from diaphragm)
- can dx w/ cxr; tx = surgical
Pelvic Trauma (major trauma, e.g. pedestrian struck by car or fall
from high up)
- hip-rocking maneuver (elicit a lot of pain and pelvis will
move in different directions)
- gateway injury (look for ureteral injury -> do a DRE to
look for high-riding prostate, blood at meatusif get these
findings then do an IVP pyelogramdo NOT insert foley
can do suprapubic cath)
o can also get rectal injury (prophylactic proctoscopy)
o dx = CT scan
- never operatejust let them bleed into pelvis and give blood
and track h/h because after a while bleeding will tamponade
Burns
1st degree = erythema, warm, ttp NO BLISTERS (like sunburn)
2nd degree = erythema, warm, ttp, BLISTERS (
3rd degree = burn skin awaydeeper than dermis (into fascia or
muscle), painless but surrounded by second degree burns so will be
intense pain, will see white/charred lesions
- chemical: alkaline vs acid (alkaline usually worse)
- skin or swallowed; NEVER buffer because exothermic reaction
(will lead to thermal burn in addition to chemical burn)
treatment = IRRIGATE; if swallowed = never induce
vomitingcan buffer because its better to let chemical to
burn inside lining of stomach vs let chemic track through GI or
come back up and cause more widespread injury
- respiratory burns (closed fire/explosion), may have inhaled
chemicals or hot smokeso may have burned larynx and so

while airway may be patent now, the subsequent edema can

cause airway compromise
o so pt w/ this hx and has soot in nostrils or mouth, be
suspicious of respiratory burn so need to evaluate
larynx and trachea with bronchoscopy and need to
protect airway with intubation (prophylactic to prevent
tracheostomy)
- electrical: lightning stirkes, high-voltage, small entrance +
large exit wound
o damage to things that conduct electricity well, e.g.
heart (conduction system in place) will be most likely
damaged, bone (also good conductor) heats up and
burns muscle in contact and lead to rhabdo; also work
on nerves => massive contraction of mm (posterior
dislocation
o dx = check CK, Cr
o tx = IVF + mannitol (reduce amount of time that ck is in
contact with nephron tubules to decr level of damage)
- circumferential burn: eschar has nowhere else to go
because its circumferential so it pinches off vasculature (no
blood flow distally); worse if at chest (can compromise
breathing) tx = escharatomy at bedside (doesnt hurt)
- burns => F/E problem
Parkland formula: rule of 9s and 50-50-8-16 rule
- note: rule of 9s = only 2nd and 3rd degree
o head (entirety) = 9, chest (front) = 9, chest (back) = 9,
A/P (front) = 9, A/P (back) = 9, each leg (front) = 9,
each leg (back) = 9, each arm in entirety = 9 with
remaining 1% at genitalia
o calculate %BSA involved (only 2nd and 3rd degree) and
apply to parkland formula
o %BSA involved * kg * 4cc = fluid loss
o replace 50% in 8 hours and then 50% in ensuing 16
hours in addition to maintenance
- early movement and early grafting prevent delayed healing
(adequate pain control, sulfadiazine and mafenide as ppx to prevent
infection)
Bites
1.) animal (if wild = capture + kill, do bx to determine if rabies vs if
domestic = observedand determine if it was provokedif
theres signs of rabies or if animal could not be caught -> give
vaccine + IgG otherwise if no signs of rabies then no need to do
anything); natural course of rabies = paresthesias at bite site
progressing to encephalopathy

2.) bee sting (is there anaphylaxis? If yes -> IM Epi 1:1000 + H1/H2
blockerif no -> remove pincer and dont need to do anything)
3.) snakes (identify if high risk/venomousslit-like eyes, cowl like
cobra, rattlers); in pt = look for skin changesif a lot of
erythema/edema or pain = suspect envenomation; tx = antivenom (but only works in first few hours); note: tourniquet,
sucking out venom, cutting dont work
4.) spiders
a. black-widow (totally black + red hour glass on belly)
usually p/w bite + abd pain or enzymatic signs of
pancreatitis
i. by the time see enzymatic signs of pancreatitistoo
late so need to tx w/ IVF and IV calcium (fat
saponification)
b. brown recluse (attic, old boxesespecially in southern US)
i. got bit last week now my hand is falling off
ii. starts off with small bite but progresses to necrotic
ulcer that has ring of erythema around it that
progressively grows
iii. dx = clinical; tx = debridement (over and over
again), consider skin grafting
5.) human bite (worst!)
- either adventurous sex act or fight bite (fist vs teeth)
- dx = clinical; tx = MUST do debridement, explore wound and
irrigate; also abx that cover oral flora e.g. amoxicillinnever
just send home with abx