ATLS Advanced Trauma Life Support For Doctors Student Course Manual 8th Edition PDF

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.----- BRIEF C O N T E N T S
1 Initial Assessment and Management 1

SKILL STATION 1: INITIAL ASSESSMENT AND MANAGEMENT 19
2 Airway and Ventilatory Management 25

SKILL STATION II: A I RWAY AND VENTILATORY MANAGEMENT 43
... SKILL STATION Ill: CRICOTHYROIDOTOMY 51
3 Shock 55
... SKILL STATION IV: SHOCK ASSESSMENT AND MANAGEMENT 73
._._ SKILL STATION V: VENOUS CUTDOWN (OPTIONAL STATION) 83
4 Thoracic Trauma 85
._._ SKILL STATION VI: X-RAY IDENTIFICATION OF THORACIC INJURIES 103
._. SKILL STATION VII: CHEST TRAUMA MANAGEMENT 107
5 Abdominal and Pelvic Trauma 111

._ SKill STATION VIII: DIAGNOSTIC PERITONEAL LAVAGE 127
6 Head Trauma 131

._ SKILL STATION IX: HEAD AND NECK TRAUMA: ASSESSMENT AND MANAGEMENT 153
1 Spine and Spinal Cord Trauma 157

SKILL STATION X: X-RAY IDENTIFICATION OF SPINE INJURIES 175
... SKILL STATION XI: SPINAL CORD INJURY: ASSESSMENT AND MANAGEMENT 181
8 Musculoskeletal Trauma 187

... SKill STATION XII: MUSCULOS KELETAL TRAUMA: ASSESSMENT AND MANAGEMENT 205
9 Thermal lnjuries 211

10 Pediatric Trauma 225
11 Geriatric Trauma 247

12 Trauma in Women 259
13 Transfer to Definitive Care 269
APPENDICES 277
A Injury Prevention 279
B Biomechanics of Injury 283
C Trauma Scores: Revised and Pediatric 289

D Sample Trauma Flow Sheet 293
E Tetanus Immunization 297
F Ocular Trauma 299
G Austere Environments: Military Casualty Care and Trauma Care in
Underdeveloped Areas and Following Catastrophes 305
H Disaster Management and Emergency Preparedness 321
I Triage Scenarios 335
INDEX 351
Advanced Trauma Life Support

for Doctors

STUDENT COURSE MANUAL

EIGHTH EDITION
'
American College of Surgeons

,
Committee on Trauma
Chair of COIII/1/tl/ec 011 Trauma: John rildes, MD, l-ACS

Medical Director ofTmwnn Program: J. Wayne Meredith, MD, PACS
ATLS Subcommittee Clwmnnn: John Kortbeek, MD, fRCSC, FACS
ATLS Progmm Manager: Will Chapleau, LMT-P, RN, TNS
Project Ma11agcr: Claire Merrick
Del'elopmcllt hlllon: Nancy Peterson and fulie Scardiglia
ProductiMt <)enires: Laura Horowit:r. and Anne Seitz, Hearthside Publishing Services
,\;fee/in Serl'ices: Steve Kidd and A11gie Ellioll, Delve Production
Desig11er: Terri Wnght Design
Artist: Dragonfly .MedJa Group
EIGllTI J LDJTJO'J
Copyright(<) 200R American College of Surgeons

n33 N. Saint Clair Street '
Chicago, lL 60611-3211
Previous editions copyrighted 19110, 1982, 1984, 1993, 1997, and 2004 by Lhe
American College t>f Surgeons.
Copyright enforceable internationally under the Bern Convention .md the Unif(Hm
Copyright Conven Lion. All rights reserved. This manual is protected by copyright.
t'\o part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any mean. clec.lmnit, mc<:hanic:al, photocopying, recording, or
otherwie. without wrillcn permission from the American College of Surgeons.
The American College of Surgeon:., its Committee on Trauma, and contributing

authors have taken care that the doses of drugs and recommendations for treatment
contained herein arc correct and compatible with the standards generally accepted at
the time of publication. llowever, ;1S new research and clinical experience broaden
our knowledge, change in treatment and drug therapy may become necessary or
appropriate. Readers ,md p.1rticipants of thi:. course are advised to check the most
current product information provided hy the ma_nufacturer of each drug to be
administered to verify the rewmmended dose, the method and duration of .
administration, .md contra indications. It i1> the responsibility of the licensed

practitioner Lobe informed in all aspects of patient care and determine the best
treatment for each individual patient. 'I he American College of Surgeons, its
Committee on lbuma, and contributing auLhors disclaim any liability, loss, or
damage incurred as a consequence, directly or indirectly, of the use and application
of any of the content of this 8'" edition of the ATLS Program.
Advanced Trauma l ife Support ;lnd the acronym ATLS are marks of the
American College of Surgeons.
Printed an the United States of America.
Ad1ranced Trauma Life Support Student Course Manual

Library of Congress Control Number: 2008905266
ISBJ\ 978 I 880696 3 I 6
-
The 8th Edition of ATLS is dedicated to Jrvene Hughes, RN. Ms. Hughes has
served as a guidi11g light for ATLS fr om its inception in Nebraska, to its adoption
by the American College of Surgeons, through seven editions published from her
desk over 25 years. Trvene's commitment to quality, devotion to the program, and
tireless efforts on behalf of the ATLS family were instrumental to the success of this
international treasure. We, as her ATLS family, wish to thank lrvene for setting
the example we attempt to follow.
. -
........ -
FO R E W O R D
..
For more th<m a quarter century, the American College of Surgeons Committee on Trauma
has taught the ATLS course to over 1 million doctors in more than SO countries. ATLS has
become the foundation of care for injured patients by teaching a common language and a
common approach. The 8th edition was created using an international, multidisciplinary, and
evidence-based <lpproacb. The result is an ATLS program that is contemporary and mean

in gful in the global commlmity.
-Jo/111 Fildes, MD, FACS

Clwir, AMERICAN COLLEGE 0 SURGEONS COMMITTEE 01'\ TllAUrvtA
'
v
PREFACE
..
Role of the American College of have participated in the revision process, and the KI'LS Sub
committee apprec iates their outstanding contributions. Na
Surgeons Committee on Trauma tional and internati on a l educators review the educational
materials to en sure that the course is conducted in a man
The American College of Sur geo ns (ACS) was founded to n er tha t facili tate s l earning. All of the course content is
improve the care of su rg ical pat ients and it has long been a
,
available in other resources, such as textbooks and j omnals.
leader in establishing and mai ntaining lhe high quality of However, theJ\TLS Course is a spec ific entity and the man
,
surgical practice in North America. ln accordance with that uals, slides, skill procedu res and other resources are used
,
role, the ACS Com mittee on Trauma (COT) has worked to for the e ntire course on ly and cannot be fragmented in lo
esta blish guideline s for the care of injured pati ents. sepmate, freestan ding l e ct ures or p ractical sessions. Mem
Accordingly, the COT sponsors and contributes to the bers of the ACS COT and the ACS Regional and
continued development of the Advanced Trauma Life Sup State/Provincial Committees, as well as t he ACS ATLS Pro
port (ATLS) Program for Doctors. The ATLS Student gram Office staff members, a re responsible for maintain
Course does not present new concepts in lhe field of trauma ing the high quality of the program. By i nt ro ducing this
care; rather, it teaches established treatment methods. A sys course and maintain ing its hi gh q ua li t y the COT h ope s to
,
tematic concise approach to the early care of trauma pa

,
provide another instrument by which to reduce the mor
tients is the hallmark of the A TLS Program. tality and mor bidity related to trauma. The COT recom
This eighth edition was developed for lhe ACS by mem mends that doctors participating in the ATLS St ude nt
bers of the Subcommittee on ATLS and the ACS COT, other Course re verify their status every four years to maintain
inruvidual FeUows of the CoUege, members of the interna both their current status in tbe program and their knowl
tional ATLS comJnLmity, and n onsL U gi cal consultants to the

edge of current ATLS core content .
Subcommittee who were selected for their special compe
tence in trauma care and their expertise in medical educa
tion. (Please see the listing at the end of the Preface and the
Ackn owledgements section for names and affiliations of New to this Edition
these individuals.) The COT believes that those inruviduals
who arc r esponsi ble f o r c ari ng for injured patients will fmd This eighth edition of the Advanced Tr auma Life Support
t he informati on extrem el y valuable. The principles of pa
for Doctors Student Course Manual reflects several changes
tient care presented in this manual may also be beneficial designed to enhance the educational content and its visual
for the care of patients with nontrauma-related diseases. presentati on.
Injured patients present a w.ide range of complex prob
lems. The ATLS Swdent Course presents a concise approach
to a ssessi ng and managing multiply i njured patients. The CONTENT UPDATES
course presents doctor s vrith knowledge and techniques that
All chapters were rewritten and revised to ensure clear cov
are comprehensive and ea sily adapted to fit their needs. The
erage of the moslup-to-date tedmical content, which is also
skills described in this manual represent one safe way to per
represented in updated references. New to this edition are:
form each technique. The ACS recognizes that there are
other acceptable appr oaches. However, the knowledge and New Sample Trauma Flow Sheet (Appendix D)
skills taught in the course are easily adapted to all venues for
Disaster Management and Emergency
the care of lhese patients.
Preparedness (Appendix H)
The ATLS Program is revised by the ATLS Subcom
mittee approximately every four years to respond 10 Skill X-8: Atlanto-occipital Joint Assessment
cha nges in available knowled ge and incorporate newer and
Updated airway management algorithm
perhaps even safer skiUs. A'TLS Committees in other coun-
1ri es and regions where the Program has been introduced Updated pelvic fracture management algorithm
VII
viii PREFACE
SKILLS VIDEO terms to facilitate understanding by all students and teach

ers of the Program.
You'll also note the inclusion of a DV D with this edition.
Advanced Trauma Life Support and ATLS are pro
Tllis new course component includes video of critical skills prietary trademarks and service marks owned by the
that doctors should be famili,tr with before taki ng the'" American College of Su rgeo ns and cannot be used by in
course. Skill Stations during the course will allow doctors dividual:. or entitie outside the ACS COT organization
the opportunity to fine tune skill performance in prepara for their goods and service without ACS approval. Ac
tion for the practical a:.essmenl. Review of the demon cordingly, any reproduction of either or both marks in
strated skills prior to participating in the skills stations will direct conjunction with the ACS ATLS Program within
enhance the learner's experience. the ACS Commillee on Trauma organization must be
accompanied by the common law symbol of trademark
TEXTBOOK FEATURES ownership.
This edition features a new full-color design, along'A-'ith new

color photographs and medical illustrations. Content was
presented in a narrative lormat rather Limn outline for ease
of readab ili ty In addition, an effort was made to augment
. American College of Surgeons
the pedagogical features of the textbook to improve student
comprehension and retention of knowledge. Look for the
Committee on Trauma
following features:
John Fildes, MD, FACS
Committee on Trauma, Chair
Professor of Su rgery, \fire Choir Department of Surgery. Program
CHAPTER OUTLINE: Thts feature provides a "road map" to Director, Gmcml Surgery Residency Chit'[ Division ofTrauma &
the chapter conten t Critical Care
University of Nevada shool of Medicine
KEY QUESTIONS: These questions are aligned with the

Las Vegas, Nevada
U nited Sta te
instructor's PowerPoint presentations to
prepare students for key discussions ). Wayne Meredith, MD, FACS
during lectures Trauma Program, Medical Director
Director of the Diviion o(Surgical Sciences. Rich;rd T. Myers
KEY POINTS: Sentences appear in red font to Profes.wr ancl Chairman
attract the reader's attention to key Wake rorest Uniw r si ty
points ofinfo rmation. School of Medicine
Win1.ton-Salem, North Carol in;,
LINKS _. Cross-references to other chapters , United Stnlcs
Skill Stations, and additional resources
help to pull all of the information together
PITFALLS PITFALL
These boxes hig hlight critical pitfalls to Subcommittee on Advanced Trauma

avoid while ca r ing for trauma patients life Support of the American College
SUMMARY CHAPTER SUMMARY of Surgeons Committee on Trauma
Chapter summaries tie back to the C ha p
ter Objectives to ensure understanding of John B. Kortbeck, MD, FRCSC, FACS
the most pert inent chap ter content ATLS Subcoromjttee, Chair
Professor Department., <lf.Surger} .md CritiCJ/ C1rc
U niversity of Calgary and Calgary llcalth Region
Calgary, Albcrtn
Editorial Notes Cnn ada
Christoph R. K:wfrnann, MD, MPH, FACS

The ACS Committee on Trauma is referred to as the ACS
ATLS Subcommittee, International Course D i rector
COT or the Committee, and the State/Provincial Chair(s) is A.>sociate Mcdiml f)ircctor
referred to as S/P Cha ir(s). Traumn crviccs. Legacy t:.ma nucl [ lospital
The international nature of this edition of 1 he ATLS Porliand, Ore gon
Student Manual may ncccssil<tle changes in commonly used United States
PREFACE IX
Janteel Ali, MD, M.Med.Ed, FRCS, FACS Jolm H. McVicker, MD, FACS
Professor ofSurgery Neurosurgeon
University of Toronto Coloratlo Neurological
,. lnslitute, Swedish Medical Center
St. Michael's Hospital, Division of General Surgery/Trauma Engelwood, Colorado

"lbronto, Ontario United States
Canada
Cl1arles N. Mock, MD, PhD, MPH
Karen Brasel, MD, FACS
Professor of Surgery, !oim appointment, Pro fessor of
Associate Professor Trauma Surgery & Critical Care
Epidemiology
Froedtcr1 Hospital & Medical College nf Wisconsin, Trauma
Department of Surgery, Harborview Medical Center, University
Surgery Division
of Washington
Milwaukee, Wisconsin
Seattle, Washington
United Stales
United States
David G. .Burris, MD, FACS
Professor & Clwirman Frederick Moore, MD, FACS
USl.JHS, Norman M Rich Dep art ment of Surgery Head, Division of Surgical Critical Ca.re and r1cute Care Surgery
Be[hesda, Maryland Methodist Hospital
United States Houston, 'fex:as
United States
William G. Cioffi, MD, FACS
ChidofSwgcry
Steven N. Parks, MD, FACS
Rhode Island Hospital, Department of Surgery Professor ofClinice!l Swgery
Professor and Chairman Unjversit y of California, San Francisco, Department of Surgery,
The Warren Alpert Medical Schnol of Brown University, Community Regional Medical Center
Department of Surgery Fresno, California
Providence, Rhode Island United States
United States
Artbu.r Cooper, MD, MS, FACS, FAAP, FCCM Renato Sergio Poggetti, MD, FACS
Professor ofSurgery Director orEmergency Surgjcal Service
Columbia University Medical Center Hospita.l das Clinicas Un iversidad de Sao Paulo
Affiliation at Harlem Hospital Brazil
New York, New York
United States Thomas M. Scalca, MD, FACS
Physician jn Chief
Michael Hollands, M B BS, FRACS, PAC$ R Adarns Cowley Shock Trauma Center
J-Je:.1d of Hepato!Jjfiary and Gastro-oesophage<ll Surgery Pmncis X Kelly Professor of Trauma Surgeq, Director Program
Westmcad Hospital in 7iauma
Sydney, New South Wales University of Maryland School of Medicine
Australia Baltimore, Maryland
United States
Claus Falck Larsen, MD, clr.mcd., MPA, FACS
Medical Director
R. Stephen Smith MD, RDMS, PACS
The Abdominal Centre, University of Copenhagen, Rigshopit;,lel
Vice Ch<lir and Director of Surgkcal Education
Denmark
Department of Surgery, The Virginia 1ech- Carillon Medical
Copenhagen
School
Denmark
Roru1okc, Virginia
United St<Jtes
West livaudais, )r, MD, FACS
Thoracic Surgeon
Southwest Wound Healing Center, Southwest Wahington Richard Bell, MD, PACS (CON)
Medical Center Pro(essor and Chairman, Department ofSurgery
Vancouver, 'vVashington Universill' of South Carolina
United States Columbia, South Carolina
United States
Fred A. Luchette, MD, FACS
Director, Division of Trauma, Critical Care, and Bums Brent E. Krantz, MD, FACS (CON)
Department of Surgery, Stritch School o[Medicine, Loyola Professor orSurgery
University of Chicago University of South Carolim
Maywood, lllinois Columbia, South Carolina
United States United States
X PREFACE
Associate Members to the Mary van Wijngaarden-Stephens, MD, FACS

Associate Clinical Professor Department ofSurgery!Dilision
Subcommittee on Advanced Trauma Critical Care
life Support of the American College_ Trauma Director

University of Alberta Hospita ls
of Surgeons Committee on Trauma Edmonto n, Alberta
Canada
Regina ld BlLrton, MD, FACS
Robert J. Wincbell, MD, FACS
Director, Trauma Program and Surgical Critical Care
f-le<Jd, Division ofTmuma and Bum Surgery
B rya n l.GH Medical Center, West
Maine Medical Center
Li ncoln Neb rask a
,
Associate CliJJic<tf Professor ofSurgery

Un ited St ales
Un iversity ofVermont School of Medicine
Portla nd Ma ine
,
Ronald Gross, MD, FACS
United States
Associate Director of'Trauma

Depa rtment of Eme rgency Medicin e/Tra um a, Hartford Hospital

H artford, Connecticut
United States
Sharon M. Henry, MD, FACS

Associate Professor of'Surgery American Society of Anesthesiology
Director Wound Healing Service and Metabolism SCJ-vice
liasion to the Subcommittee on
University of Maryl and , R. Adams Cowley Shock Trauma Center
Baltimore, Maryland Advanced Trauma life Support of the
United States American College of Surgeons
Salvador Martin Mandujano, MD, l'ACS
Committee on Trauma
General Swgeon
Nleclical Director Ji11 A. Antoine, MD
Cozumel Medkal Center Associate Professor of Clinical Anesthesia
Cozumel, Quintana Roo Univers ity o[ California, S<Hl r: ra ncisco, Department of
Mex ico Anesthesia and Pcriopcra tive Ca re
San Francisco, California
Charles E. Morrow Jr, MD, FACS
,
United States
As.sistant Professor
Assistant Program Director. General Surgery
Medical Directo1; Trtwma Sw-gery
Department or Trauma Spartanburg Regional Medical Center
,
Spartanburg, South Carol ina

Un ited Stat es
American College of Emergency
Frank Sacco, MD, FACS Physicians liasion to the
Director ofTrauma, Chief ofSwgery
Alaska Native Medical Center, Deparlment of Surgery
Subcommittee on Advanced Trauma
Anchorage Alaska, life Support of the American College
United States of Surgeons Committee on Trauma
Martil1 A. Schreiber, MD, FACS
Associ<lle Professor oFSurgery Richard C. Hunt, MD, FACEP
ChiefofTnwma and Surgical Critical Care Direct01; Division oFTnjury Response
Oregon Health & Science Universit,y Trauma & Critical Care Section Cent ers for Disease Con l rol anJ Prev en tion
Po rtl a n d O regon
, Atlanta, Georgia
United States United States
PREFACE XI
Acknowledgments
CONTRIBUTORS Ber ge n Ma ;J.S tri cht

1\orway The 'letherlands
During development of this revision, we re Karim Brohi, MD
Margareta Behrhohm Fallsherg, PhD BSc ,
ceived a great deal of assistance froti1 many Constlil<wt Omsulrnnt in Ttauma, v.scular and Critical
individuals - wh eth er reviewing infonna Co ns ul t ing firm/ small business Cttre Surgery
tion at meetings, submitting images, or eval Linkoping l'be Royal London Hospital
uating research. ATLS" thanks r.he follow ing Sweden London
contributors for their t ime and effort in the United Kingdom
Rcnato Bcssa de Mclo, MD
development of the 8th edition: Assiscmte /-lospicalar Laura Bruna, RN
Melissa V. Abad Scrvi<;o de Cirurgia Geral, llospital dt! S.}oao ltalilltl Nationa] Coordinawr
Regional Program Coordinator, CM Porto Assit ra um a
Coonlin,Jtur (ur Tr.Hifflil Programs Portuga l Torino

Italy
t\merican College of Surgeons ATLS Program Mike l:leL7.ncr MD

Office: Erwrgeucy Plrysicillll Jacqueln

i e Bustraan, MSc
C hic ago, !IIi nnis
Senior Med i cal Director STARS Air Ambulance Educacional Cun.wltanl 1111d Rese-Mcher
United S tate s Calgary Health Region, PLATO, <.:en tre for Research
and Development
Joe Acker, Ill. MS, MPH, EMT-P Calgary, Alberta of Education and Training, L.e.iden University
F.xr:cutive J)irector Canada L dtlen
.
Bim1ingham Regional EM$ CJinicaJ L ecrmer. Univers ity of Calgary Netherlands

Birmingham. A labama
Ken Boffard, MB BCh, fRCS, FRCS (Ed), Vilma Cabading
United Slates ATLS Natiolllll CotJrdi11otor, Saudi Aml,ia
FACS
Saud AI 'l'urki. MD, fRCS, ODTS, EACA, FACS Professor nnd Clillicnl Head Academic Affajrs De part ment
Director Department of Surgery, Johannesburg Hospital . King Abdulazi7 Medical City-NGHi\
Trnuma C,ourses Oflice, Postgradua te Education & Uni ve rsit y of Lhe Witwatersrand Riyadh
Academic ABair, King Alxlula:1. Medical City
t.i
Jo ha nnesburg Kingdom of $;ntdi Arabia
R iyadh Solllh Africa Gerardo Cuauhtemoc Alvizo Cardenas
Kingdom of Saudi A.ra bio
Raphael Bonvin, MD, PhD Asistant and Special Projects Coordinator
l'atimah Alhorracin, RN Unite de pedagogic Medicale, Faculte de American College of Swgeons ATIS Program Office
Senior Officer Chicago, Illinois
l>iologie e t de medicine
Life Support Training U:nter, rawam I !ospital, I ausonnc United States
afftliate of Johns Hopkins Medidne Switzerhmd
AI Ain, Abu Dhabi Carlos Carvajal Hafcmann, MD, FACS
United Arab [mirates Bertil Bouillon, MD Professor ofSurgery
ProfessCJr /Jircctor ofSurgery of the east C1mpus
Celia Aldana
Uni,ersity of 'Nitten l lcrdecke, Cologne, Universidad de Chi le
A7'/.S Cnnrdi na rnr
Merheim Medical Center, Department of Santi a go
Committe on Tra uma , Chile
Trauma t1lld Orthopedic Surgery Chile
Santiago
Cologne
Chile Gustavo Ca s tagneto , MD, PACS
German)'
Donna Allerton, RN Professor ofSurg(!ry
Critical Care, Coordinator- ATLS Prvgram M a ri anne Hrandt Buenos Aires British Hospital, Department of
McMaster University Medical Centre Special Educmion /eacher Surger y
,
H am il ton On tario Diabetes F.ducator Buenos Aires
Canad11 Caracas, Mtrando Argentino

Venezud,t
!Jeri Aminuddin, MD June Sau-rllmg Chan
Neurosurg<'On Fred Brenneman, MD, P RCSC FACS , SkiUs Development Center, University of I long
Gatot Soebroto Central Amty Hospital Chid; Trauma Program Kong Medica l Ce nt re
Jakarta Timur, Ja karta Sunnybrook Health Sciences Cent er Queen Mary Hospi tal Department of Surgery
,
Indonesia AssucitJte Professor !long Kong

Depar tmen t of Surgery, University of Toronto Chi na
John A. And r oulnkis, MD, FACS
lf.mcrillL Professor p(Surgery
'Jbronto, Ontario
Will C ha plea u, EMT-1', RN, TNS
Canad a
wniversity Hospital of Patras ATI.S Program Mamrgcr
Patra > Ase Brinchmann-Hansen, PhD American College of Surgeons ATLS Program Office
Greece ;\!/:waging Educational Consulmnt C hi cago T llinois
,
Guillermo A rana , MD, PACS The Norwegian Medical Association, United States
General Surgeon Ilepartment of Professional Affairs
Zafarullah Chaudhry, MD, FRCS, FCPS, FACS
1\a tion a l Hos pital o,lo
Professor of Surgl.'l")
Panama Cit)' Norway
National HospiraJ and Medical C enter
Pa nama Peter Brink, MD, PhD President
Ivar Austlid Chic(, Department of Tt"lwnm tology College of Physicians and Sur geons Pakistan
])epamnent of Anaethesia and Intensive Care UnivC'rsity Hospital Maastricht, Department of Labore
Ha ukcland Unive rs ity Ho spital Traumatology Pakis tan
XII PREFACE
Peggy Chehardy, EdD, CH F.S Rantlolph, 1\"ew Jersey Jorge Esteban Foinnini, MD, FACS
Ai.\t;lllf Professor and Oirtctor of Surgical United States (,enerul Surgeon
Ptlucatiun nirtror
Anne-Michele D rom:
Tulane Univerit)' School of \kdidne, l'oianini Clink
A1LS Na tional Coorduwtor. SwitzcrJ.md
D ep artment of Surg ery 'ianta Cruz
1\"cw Orleans, Louisiana
S" i" Society o f Surge on, .
Bolivi.t
B.t.,d
United State.s
Swillerland Knut Fredr iksen , MD, PhD
Robert A. Cherry, MD, FACS Cnmultant & Assoti.ltc: i'role.\oor
Herman us Jacobu:. Christoffel Du P le ssi s M B, .
Tr,wnw Program Medio1l mrcc:tor Dep.ITlment of Erncrgcnq Mcdic,1l Serv ices,

ChB, MMed(Surg), FCS(SA), FACS
Penn Stnte Milton S. Hershey Medical Center Un iversity Hosp ital of 1\'cwth Norway
Chic(<;(lrgeon, Colonel
Colle ge of Medicine l: a cult y of Med icin e,
SAMHS (South Afrkan Military Health
Hershey, Pen nsylvania University of Tromso
Senrcc>)
United '\tato:> l'romso
Ik.1tl oftl!e Departmmt nfSurg<'rJ ;md
NonMy
mmanuel Chrysos, MD, PhD, FACS lnt,mive C.1re
thooci.rte Pro(e,;ur olSurstry l Militar y Hospital Suanne frjsteen, RN
DcpurtmcrH of Gene ral '>urf(Cry, Unive rsity Adjunct Pmfes.mr o(Surgu)' lorma ATLS No1ticmal Coordinator. Denm.1rk

llopital uf Crele University of Preloriu Danih Trauma Society

l lcraklion, Crete Pretoria Cnp.m h agen
<.reece South Africa Denmark
Chin Hung Chung, MB BS, FACS Lesley Dunstall Christine Gaarder, MU

ChrdofService FMSTIATLS NaticmJI Coordiuotur, Austr.rli<l HeJd ofTraumJ Unit, (;<'llt'rJi ,md G/ \Urg<'CJil
Department of Accident & Emergency North .
Royal Austr alas i an College of S urge o ns l!mcrgency Divisiou, Ullcvaal Uni versity
l>btricl llosp i tal North Adelaide, South Austr.1lia llospital
llnng Kong AulraJia o,Jn
Chin.r Norway
Candida Duriio
Francisco Coller e Silva, MD, flAGS, PhD (mcd) A'tl.S National Coordio.rtor. Ponug.1/ Subnsh Gaut am, MD, M HBil, FRCS, FACS
Mt'Cfic.ll /)fx.-tor Pmt uguese Society of Su r geon 'Ienior Cansult.Jnt anti Ht.Jtl ofDepartment of
Emergency Surgical Ser\icc>, Ho>pital das Lhbon Surger.r
C li nica of the Uni,crsity of S.io Paulo Portugal haj.1irah HospitJI

Sao Paulo lujairah
Ruth D yson, BA(hons)
Gr.1711 United Arah Emirates
A'/'L'i Co-ordinJtor
The Hoyt I College of Su rgc ons of Engl;md Aggclos Geranios, MD
Jaime Cortes, MD
l.tmdon C:t:m:ral Surgeon, lntctl.,ivi\t
Chid; General SurgerJ
"iatl t>nJI Children's IJ n spi t ll
Unite d Kin gdo m Sur. Clinic of li vad e i<t Ru r.tJ Hospital
Prnli-ssor Athen>
David Eduardo Eskena7i, MD, FAC'.S
(.re>ce
Univer:.ity of Costa Rlc.1 ('httt; General and ThorJcic .urgerr
San loc lltJJ. A. Oiiativia Michael Gerazou.nis, M0
CoMa Rica
T3Lrcno> Aires (;rcece
Argentina
Scott D'Amours MC.CM. FRCS(C), FRACS
,
Javier Gonzalez-Urinrlc, MD, PhD, EBSQ,

Ji/) ComultJnt Vagn Norgaard Eskcscn MD ,
FSpCS
Royal Adelaide Hospital
A.,sodJte Profe.or Gcncml Surgeon
Adelaide
U niversity Uinic or l\'curosurgery, Nati ona l llopital de Cruces, Bi lbao, l.iver Transplant
Au>tralia Hospital - Copenhagen Uniwity Hospital I;nit
Copenhagen
uu
t ra Lee Demmons, RN, MBA Bilbao
I JcnmJrk
t\l,uwgN Sp<tin
Critical Care Transport, Umvt'rsil}' llospital Denis Evoy MCH, r:nCSI
,
John Greenwood
nirminghum, Alabama C:nnsultnnt Gemn1l Surgt'<lll (Breast Endocrim)
J)frectclr
United States Si Vinccmts Pr iv ate l(o,pi t,ll, Con>ultants Cli n ic
Bur ns U ni te Roya l Adel.1ide IJosp itaJ
.
Il ublin
A lejandr o De Gracia , MD, MCS, MAAC Adelaide, South Australia
IreiJmJ
('hid. Gener,1/ Surgery Australta
Agudo' P.trmemo Pu'lcm (,cncral Hospital l'roilan A. Fernandc1 MD
Bueno Alre Jl<lttltGll Director Enwrg,nq .Service
Rusell L. Gruen MBB!>, PhD, FRACS
,
Argent i n a 1\,,wdatt Prolessor

llmpital del Trab<jador
University of Melbourne
SJutiugo
Mauricio Di Silvio Lopez, MD, FACS '1hwmu Surgt'Oil
Cll ile
ClinicJi Rcsidency and Rcstatdl Ptvp.ram Director l'llc Ro)al Melbourne 11\)Spitul
20 de Novicmbre National .McdicJI Ce nt er, Cornelia Rita Maria Gctruda Fluit, MD, Melbourne
ISSSTF MEdSd Au,tralm
Mcxrco City. Districto Federal Smior Consultant in MtJK.tl FduGJtion
Niels Gudmundsen-Vetrc
\-lexreo University Medical Centre N i)megen, Quality
M.JJor
Frank Doto, M S .1nd Development of Medical Educa tion
D.tnish Armed Force' llc,tllh Service
Pmlessor ofI Jealth Educlllion
Dcp.irllnent
llcllcrup
Coun ty Coll e g e of Morris
Nijmegen
Denmark
rhe Nether lands
...
PREFACE XIII
Jeffrey S. <..uy, MD, MSc, I'ACS Peggy Knudson, MD, i"ACS Hong Kong
Die tor Rcgiorwl Hum C
r c , cmer Professor ot'Surycr,v China
A-.ociatc Profe,.or of Surgery Univcrity of California, 'ian Franc1sco General
Helen Livanios, RN
v,1ntlerbih University t-lo)pit.Jl, Dep.mment uf Surgery
IC Unit Staff' Nurse
Nashville, I'N San l'rdncio. California
Meditcrrano llospital
United t.nes UmteJ States
Athens
Enrique /\. Gu1.n1nn Cottallnt, MD. FACS Amy Koestner, RN, MSN Greece
i"-1''-urourgc.n fr wm l Progmm ManJger
. .
Chong )eh Lo, MD, fACS
I>iphmlill in PubliC Healc!J 1\orgcss Mcdk.1l Center Assoc i:llc Prvko.\Or ofSurgery
I>ir,ctor. Neuro.wrgtry Service> KalamMOO, Michigon Nntion.1l Chen Kung Universit) Medical
(,uayaquil Hospual Unjted Swo Center
Guayaquil
Tainan
Ftuador Radko Komadim1 , MD, flhD
Taiw,m
CenerJI Surgecm, Profe"1" ofSurgc:n; llt'.ld of
Arthur l l ieh, MA, NREMT-P /Jep.ll'lmen! (ar Medic.!l lesmrch Nur Roehmat Luhis, MD
s,,,, Fr.n.:i.:o PMJmeJic Association Gencr.ll .md "fi:<Khing llospital Cclje St.Jff/Jtpartnwnt olSurgery
SJn l'ranlisco, Colifumia Celjc
M. Hocsin Gcncral llospual, Medical Faculty
United States Slovenia Sriwijnya Univcrsiry
Richard llenn, RN, BSN, M.ED Palemhang, South Sum.ura
Digna R. Kool, MD
[)irectnr. fduc.llion [)ep.ll'l men/ Indonesia
Rtliologi
. st, /:nH.'I'gCilq /I,JJiology
Northern Arizon.1 1Teallhare
Department ol Rauiology. RadhouJ Univcrsirv J.S.K. J.uits. MD
rlagtafT. Arizona Trawn.JSurgron
"''ijmcgcn Mcdk;u Cntre
United States Medic11l Director b'nH:rgcncy lkp;lrtmcnt
Nijmegen
Walter Hcnny, MD The Netherland" Traum1 . Counlinator
Furmerly of Er.1smus Medical Center Academic McJical Center
Rom(1JI Kosir, MD Av Tilburg
Rotterd.1m
Assiswu of Surytry Nethnland.\
"'cthcrl.ullh
Univcr!>ity Chn"al Center Manbur, Department
Grace l lcrrera-llcrnandel of I\'amatology Jaime Manzano, MD, flACS
tiT! C,)()rdin.uor Maribor c,na.ll Surg<on
College nf Phyidan:. and 'ourgeon of Co:.t,t Rica Slovcni.t Hopital Mctmpolitano
SJn jo:.e Quito
)on R. Krohmcr, MD, IACEP Ecuotlnr
Costa Rit.t
f)eputy As;,isc.mt Secrt't,Jrv or
f Health AfT'air..
Jlcrgal llickey, FRCS, FRCS Ed.(A&E), DA( UK), Patrizio Mao, MD, FACS
Deputv Chid Medic.1f 011icer
I'Cf.M Rtsp<>nsabik UrgcnLe Chirurgithe
Department nf Homcl.1nd Secunt)
Consu/c.wr in emergency Medicine Chirurgia Gcncrale Univcrsitana, A.S.O. San
Washintttoo, DC
Emergency Dep.1rtmen1. Sligo General Hospital Luigi Uonz"!(a eli Orhassano
United States
Sligo Torino
Ireland Ada Lui Yin Kwok Italy
Skills llcvelopmcnt l.cntcr. Univcr>ity of I long
Emily Martem
Scott Holmes Kung M>dical Centre
Duke Umvcrsity Lifefiight
Rcgion.JI Pwgr.1m CoordinJCOr, Surgital Skills
Queen Mary l lospiwl, Department of Surgery
Progmm Coordimllor
Durham, Korth C.m>lin.l Hong Kong
American College nf Surgeom ATLS Program
L'nitcd St.llcs China
Office
Joe Marla }over Navalon, MD, FACS LAM 'luk-Ching, BN. Mll1\1 Chic.1go, IUiwis
Chiefof Hepatopancre<lll<' and Uili.1ry Surgc:r> Admnccd Pra<'lice Nurst' United State'
Htl<pit,tl llnivcrttrio de l
oclfc, Department Queen Mary Hospital Salvijus Mihtius, MD
of General !>urgery Ilong Kong Ch1dof P
rimJn
Soldier> 11t".1/th G'.Jre C<nter in
Lc:tafe Chin; KJuna;
!>pain
Military Medic.tl Scnices, Lithuanian Armed
Maria L'tmpi, BSc, RN
Aage W. Karlsen Fore
Narim1.1/ AT/..'i Coordin.110r
ATl.S (
oordin,,rnr Kaunas
Centre ll>r Teaching & Research i 11 Disaster
Norwt>gi.m Air Ambulance Lithuania
Medicine and Traumatology, University Hospit.ll
Drobak Linkopmg Soledad MontOI\1 MD
Norw.ty Sweden Geueml Surgeon
Darren Kilroy, FRCSEd, FCEM, M.Ed Department uf General Surgery, Hospital
LEO Picn Ming MBBS, MRCS (Edin),
Comult.JIJI in m<'rgt'IK,V ,'v(edidnt> Ga roa Orcuyen
M.Mcd(Orthopaedics)
Stockport NH Foundauon TruM Estdla
Changi General l lospit.ll, L.cneral
Che.hirc Spain
Orthopaedic, Department of Orthop<tcdics
UniteJ Kingdom New[()n Djin Muri, MD
Sing<pore
lena Klarin, RN Republic of Smgaporc Gcntral Sull(con
Former ATLS N .uional C.nordin.uor, Sweden Emergency Surgical Services,
Wilson Li, MD Hospital das Clinicas Universidad de
Sahlgreo\ka Universitcts)jukhuet
l l Offinr
Senior J'>,lcdk.
(;orchorg S.iu Paulo
Department of Orthop<ledic> & TraunJ.IIology,
Sweden Silo Paulo
Queen Elizabeth Hospital Bra1il
XIV PREFACE
Giorgio Olivero, MD, PACS Martin Richardson Adv.111ced Life Support {oi"Olip - NL
JJmfessor orSurgery l'hc Epwonh Centre Hid
Univeri ty of Torino, Department of Medicine Richmond, Victoria 'I he Netherlands
.tnu urgery, St. John thc Baptist Hospital AuMraua
1bnno
Domenic Scharplatz MD, rACS
,
haly Uo Richter 1/md Surgeon

MJior Hospit.ll of Thusi
Steve A. Olson, MD, PACS Dani.sh Armed For'<.'li llcalth Scnoiccs Thuis, Grisons
Prnltssor, Dep:mmenr o{Sur!,wr}' Na.:stvcd 'iwllzcrland
ChidOrtlwpa<:dic Tmumu Denmar k
ChidMedical 0117ccr
Inger B. Schipper, MD, PhD
Rosalind Roden, Ft=AF.M Mcdk.JI /Jin'Ctor o( the Snuth West Net}Jcrland
Duke University Hopital
Durham, N orth Carolin.1 C.bn.wltant in Emergemy Medicine 'Ir.wmacentcr
United States Leeth Tea<hing IIo,pnal, NlIS Trust University Hopit.tl Fr,\\mu' MC, Department
Yorkshue ofTrauma Surgery

Gon1.alo Ostria, MC, FAC'.S United Kingdom Rol lerdam
fJmcur The 'lctherland\
Centro Me.lico Foianini Diego Rodriguez, MD
anla Cru Mccliwl Dinctor Patrick Sc:hoetlker, MD, M.13.R.
llospital Clinica San Agtl'tin SwJTSpecialist
llolivi<t
S.lll Agulin lkpartment of Anc\thcsinlogy, University
Fatima Pardo, M D huauor s
llo pital Vaud
r.eneml Surgeon LJuannc
ABC Medical Center Vicente Rodriguez, MD Switzerland
Mcxko City, Districto Fcder.1l Prole:or
Mexico l lnspital Clinica San Agusti n
Kuri Schroder Hansen, MD
Consultant General Sttrgtr.v
5un Agustin
Andrew Pearce, BScllons MBI3S, PACEM Department of Surgtry, I l.wkdand Univcrsil y
Euodor
trauma Surgeon l lopital
Li verpool Ho spi tal Olav R1ise, MD, PhD Bergen
Sydney Ch,urman or tilt' Divi.;ion nfNturoscicncc and \lorway
Au\tralia Muoculoskelet.11 Mt-dinn<"
Bolivar Serrano, MD, fACS
vllcvll Universi ty Hospital
Nicolas Pcloponissios, M [) Cttwral Surgeon
()In
Cmcr.t/, Trauma, and AbdominJ/ Surgeon llospit.tl Lalinoamericano
Norway
Dcp< rtment of Surgery, Dalcr I lospital Cucnc'
Pribnurg Daniel Rui'l., MD, FACS l cuador
Swl lcrl and C.mliovascular Sw'Bcon
Juan Carlos Serrano, MD, h\C'I
< MIC Clinic
Pedro Moniz Pereira, MD, FACS Ucparlment ofTraum;l /)inxtcJr
Neuquen
n.
C neralSurgcoil I hl\pital Santa Inc,
Argentina
Scrvio de Cirurgia. Hosp1tal (iarci.t de Orta Cuenca
Almada Octavio Ruix, MD, FACS Ecuador
Portug l lltad ofTransplant Scntin.>
'
Mark Sheridan, M BI3S, MMedS c, FRACS

American British Cowtlr,Jy McuicaJ Center
Danicllc Poretti, RN A.mciate
Professor
Mexi co Ci ty, Di>tricto Federal
San.ixis, SA Dirl'clur uf Surl:\cry nd Directur of
Mexico
Renens.Vaud \lcurosurgery, Liverpool Hopital
Swit7cr1Jnd Jeffrey P. Salomone, M 1), I'ACS Sydney, ew South Wales
thocJate Professor of Surgery Au.\tralia
lesper Ravn, MD
l.mory Unrversity, Department of Surgery
Om>uiiJnt, Head orr.cncral rhnradc Dcy.Jrtmcnt Richard K. Simons, M 11, BChir, FRCS, PRCSC.
Oeputy Chiefot'Surgu}'
Car<!iothoracic Surgery Righopita let,
, I'ACS
( rmly Memorial l losp1tal
Copenhagen University Asq>ciate Professor,Mtdicol Director. 1i'1Utll.?
Atlunla, Georgia
Copenhagen Services
United tares
l>cnmJrk Dq>Jrtmcnt of Surgery, UBC, Vancouver
Rocio Sanchcz-Aedo, RN Coastal Health
Marcelo Recalde Hidrobo, MD, MCS
Former ATIS National Omrdmator, Mexico Vancouver, Bntih Columbia
Prof..:.wr orOncologic.ll .md Ccneral Surgerie
(.ommittee on Traum,t, kxko C.
11a
1 da
{)).1 University; Internationa l Unh-ers1ty, Ecuador;
I
Mexico City, Dtstrictu Fedcr.1l
Metropol itan Hospital Preecha Siritongtaworn, MD, FACS
Mexico
Qui to ChH:I; Divtsion of'lraww1 Surgcr.r
l:coudor Mi\rtin Sand berg, MD, PhD Dcp<Jrtmcnt of Surgc1y, Fatully nf Medicine
&nior Consultant in AII<'Hthcsiolop,)' Siriraj Hospital, Mahidol University
Peter Rhee, MD, MPll, FACS, FCCM, OMCC
Air Ambulance Department, Ullcval University B.lngkok
l'mf..!>sor ofSurgery
Hmpital Thailmd
Chid, Set:tion ofTraum,!, Critic.U C
_.ue, and
(),(o
Fmergency Surgery Nib Oddvar Skaga, MD
Norway
Ariwna Health Sciences Center, Department of CludAna(>sthe.,iologiM li>r 7hwma
Surgery Nicole Schaapveld, R N UllcvaJ University Hospi tal
'l\1cnll, Arizona Mun.Jgmg Dirccror I Nation.1/ Coordinator Oslo
United States A'/'IS NL Nonvay
PREFACE XV
Peter Skippen, MBBS, FRCPC, FIF'ICM, Wa'cl S. 1aha, MD Eugenia Vns.ilopoulou, MD

MilA A.ssiMant Pmft,wr of.'iurger) Attc.nding Ane.thesiologist
:\lecltc;t/ /Jir.anr .rnd I>tl ;,ion 1/.td Deputy Director ofTr.wm,, Couoc.'>
r Pro:mm (,cneral llospital of Aigion
UinicJI A"'nn.lt<' Pmfl.<..,or n(Critic.tl CJfe Department Orthopedic Surgery, Kinj! A1gton
BC Ch1ldrn Hospital, l)cp.mment of Abdulazn,..\4cdical City (.rc.xc
Pcd1.1tri" Ripdh
Antigoni Vavarouta
\'ancouwr, Britih Columbia Kingdom of Saudi Arnh1a
Afl,\ C.'oordin,ttor
Canada
Gustavo Tisminct.7ky, Ml), ..ACS, MAAC linivcrsity uf Parras
Tone Sl.\kc Professor ofSurgerr P.ll ra'
ATLS N.JtinnJl C
oordin.JIIIf, Norl\.1}' Univcrs1dad de Buenos Aire. Escuda de GrccLc
Norwgi.m Air AmbukuKc Mcdicina Hospital Italiano de 13ut'nos Aires,
Tore Vikstri}m, MD, PhD
nrnh.lk )efe Vnidad d e Urgcncia l lop 11 .11 Fcrn.111dct
T>in-ctor .md Jlc.Jd, Consultant G
enentl
Nurw.Jy Buenos Ain,
Sugcr)'
Argentina
13irgiuc <iochu Pm(esssor of /)is1ster A
. lcdicinc &
11'1'1. N.Hion;/ ('mmlin.Jfvr, })ellmark Philip Truskett , MB BS, FRACS Ttaumttology
.
Dan bh Truuma Society The Prince of Wale; Hospital Centrc for Teaching & R$earch in Di saster
Br111SI111j Sydney, New South Wales Medicine and TrattmatolOg)', University

1Jem11.1rk Aust ralia Hospi1al
Linkilpi ng
Elizabeth de Solczio, MA, PhD Wolfgang Ummenhofer, MD, DEAA
S\,rctlcn
Advisor, Ecu,!<lnri.ltr S,, rt'tllr)' o(St JIt' Culture Professor ofAnesthcsiologr 1111d lmc.tr:.ivc. Cart
HureJu Univer>ity Hopit.;ll, Bacl. l>ep.rtmcnl ol Eric Voigtio, MD, PhD, FACS, FRCS
Commillre on 'l'r.1uma, Ecuador Anesthesia and [ntensive Care Senior Lecturer. Consultilllt Surgeon
QUIttl Basel Dcparlment nf Emergency Surgcry,
....cuadnr Switzerland U111vNsiLy llospitals of Lyon, Centre
Hospitalier Lyon-Sud
Michael Stavropoulo. MD, F'ACS Yvonne van den fndc
f'lcrrc-I:!Cnitc
tls\/!IIJ/11 Pmt<.,sor n{Suryt'r> 0/Jice Manager
France
Surg<'ry Dep.lrlmcnt, Patra L'mvcsil)
r MediCal Stichting Advanced Life Support Gwup
St.hool Rid Dal")l Williams, I BBS, FANZCA,GDipBusAd,
Patra Th.: Netherlands GdipCR
(jrccc \.'0.\oci.Jt<' Proft:..,or, Uninrsitv
' ofMelhoume
Armand Robert van Kanten, MD
Rt)yal Melbourne liospital, DeparUnent of
Spyritlon Stcrgiopoulos, MD General Surgeon, 1-Jc.1d nf Jr.wmJ
Anaesthcsia
hsociJI<' Pmfe,,,,nr nfSurgery University Hospital Paramoribo
Director Anaesthesia
Attikon l'nivcr,it) Ifo,pital, llh Surgical Paramaribo
Melbourne 1-lospit.tl, University of Melbourne
Department !>uriname
Melbuurne
Atl1cn
Endre Varga, MD, PhD Aw.tr<llia
\lice C
hairman, Proe,,,,or
( of'Jhwm.l Sur[.:c.'ry
Robert Winter, FRCP, FRCA, DM
Pnul-Mnrtin Sutler, M 1.) Dcparuncn t of Trnw11aLology, Albert
Cotrwlt.mt in Critical Care Medicine
Dcparllnnt nl Surgery, Spitalzcntrum Szcnt:,ryorgyi Medical and l'harmaccut iLal
Mid f'rcn1 Critical Cnre Ncrwork and
Bicl Center, University of Szegcd
Noui ngham University Hospitals
Sw itzcr l md
, Szeged
Nt>11 ingha m
t-lu ngary
Lars no Svendsen, MD, D M Sd United Ki ngdom
A>,oci.llt' Pmfi.mr Surgery Edina V5rkonyi
Nopntlol Wora-Urai, MD, FACS
Cnpcnh.1gen Uni versity, t>cpanmcnt of Department ofTraum,ttology, University ut
Pr,;,ident Eleu, Royal College o(Surgeons
Abdominal Surgery aml Transplanta non Szcgcd
Roy.,] Colkg<' of Surgeons of Th.lli3Ild
,
Righu;pitaJct Szeged
Rang
Copcnh.1gen Hungary
l>enm.trk Wai-Key Yuen, MB BS, FRCS, FRACS, FACS
Pantelcimon Vassiliu, MD, PhD
Consulr.ltlt
Vasso Tagkalakis Attending Surgeon
Dep.trtmnt of Surgery. Queen Mary
ATLS NotionJI <ll<Jrdin.Jtnr, (;r,'C.:e General Surgical Clinic
llthpit.d
Umwr,it)' of l'atra' Attikon linivcrsiL) llospital
I lung Klmg
Patra Athens
(hma
(jrc'c Greece
R.1ymund H. Alexander, MD, FACS

HONOR ROll search and lhat our course s i designed to im
prove patient outcome:,. J'he 8lh edition of P.1reed Ali, MD, 1-'RC$ (C l
Over the pal 30 yeasr ATI$ has grown fi-om
.
ATI,S reflects the elfort of the following m ),tmcel Ali, MD, MMed .Ed, FRCS (C), FACS
a local course training Nebraska doctors to dividuals who contributed to Ihe !irst even Charles Aprahamian, MD, FACS
care for lr<Htmu pa t ient lO a f tm ily of .
cditons, and we honor them here. Guillermo Mana, MIJ, I'ACS
trauma spcciJiists from more th<n 50 coun Ana Lltisa Argomedo Manriq ue
tries who volunteer their lime to ensure that Sabas P. Abuabara, MD, FACS
Gonl..alu Aviles
our materials rdlcct the most cu rrcnt re- Joe E. Acker, Ill, MS, MPII, EMT Hichnrd Bnillot, MD
XVI PREFACE
B.trbara A. ll,trlow, MA, MD, FAC:S lone E. Heilman. 1I>, PAC Jean Peloquin, ID
)ame' B.uonc, MD, FACS David M. Heimhach, Ml>, FACS Philip W. Perdue, I\
II>, FAC:S
)<)hn ll,mcn, MD, IACS D.wid N. Herndon. M 0, fACS J. W. Rod ney Peytnn , FRCS (Eel), MRCP
Pit!rrc Llc,lllmont, MD Lrwin F. Hirsch MD, . Pi\CS Lawrence H. Pills, Mil FACS
...
Ricltartl M. Bell, MD, FACS J'ra ncisco Holguin. M D Galen V. l'nnle, M 1>, FACS
Fugcne 1.. Berg MD. FACS
, David B. Hoyt, MD, PAC Ernest Prgcnl, M I)
RichorJ Brgcron, MD lrvene K. Hughes, RN Richard R. Price, MD, FACS
Franol\ Bertrand. MD Rkh<trd C. Hunt, MD, FACF.P :s
llerl>crt l'rottnr, M l >. FA<
Emtdto Bianco. t-ID, Jl) Mile> H. Irving, FRC'> (Ed), I'I{CS (Eng) j,1cques Provo.,I, .\t I>
Don E. Boyl e. M 1>. h\CS Jo Maria )over Navalon, MD, FAU; Paul Pudimat, M I>
Rca Brown, \II>, FACS Richard 1.. Judd, PhD Max I. Ramcnnf,kv, MD, FACS
Allen I Bro"nl', MD. FACS lregory ). Jurkovich, MD, FACS Marcelo Rel.tldc, \Jl), FACS
(;crry Aunting. ID Chritoph R. Kaufmann, MD, FAC:S John Reed, fl.lD
Andrew It Burgess, MD, FACS Howa rd B. Keith, MD, fACS Marleta Reynold;, MD, ACS

Richard E. Ourucy, MD, FACS lome F. Kellam, M 1), FllCS . I'ACS Stuar t A. Rcynulds, MD. FACS
D:IVid Burris, MD. li\CS Steven ). KHkcnrt)', M )), JlACS Bernard Riky, I'IARCS
Sylvia C.lmpbcll, MD, FACS Jnhn B. Kortbcck, MD. FACS Charles Ri IIkcr. M n. FACS
C. lame' C.trrico, MD. FACS 13rcnt Krantz., MD, Ft\CS Avraham Rivkind, Mil
C. Gen.- Cayten, \tiD, FAGS Inn R. Krohmer, MO, FACEP Ronald F Rn,enth.tl , MD, FACS
!>avid F.< lark , J\iD, FACS Katherine lane, PhD Gran R<>t)ki, MD, FACS
Paul F. Col hcott, \
iD, FACS Franru l;. Lapi<tna, ID. Fi\CS J. Octavin Ruiz Sp<'Jrc, MD, MS, Fi\CS
Arthur Cooper. M D . MS, FACS Pedro L,1rio Amar lame;, t-1. Ryan, ICh, l RCS (Engl. RA..\IC
Ronald 1>. Cr.ug. M[) Ann.t \1. Lcdgcrwoml, MD, F'ACS ),tmes M. Salandcr, MD. FACS
Doug l>.wey, MD Dcnni G. Leland, MD, FACS Gueidcr Sal.t>, .1\ID
Eli7.
. thcthJe '>olzio, PhD lr,tnk Lewi s, MD, FACS Rocin S:inchct-Acdo LinJrc>
Subtow ). Deb, M L) Edward B. Lucci, MD. F1\ChP Thomao G. Saul, Mll. IACS
Ronald Dt!ni>. MD Eduardo Luck, Ml J, 11ACS William P. Schetter, Ml>, I'ACS
)e.,us Dial l'ortoc.trrcro, /Vli), ...ACS Thoma.' G. Luerssen, M 1), 1'1\CS Tho rna' E. Swu, M I>, l"t\CS
Frank X. Duto, MS ArnolJ Lutcrman, M l>, J'ACS Stu.trt R. Stin, :vJD. FACS
M.trguc ril<' l>upre, M () hrn,tndn Ma gal lanes Negrete, MD Steven It Shackford, MD, FACS
Brent l',tMrll.m, MD, FACS l>on,tld W. Iarion, MD, F'Al'S Marc ). Shaptm, \t[), FACS
!'rank r l.hrlich, MD, FACS 1\!i,hael R. laruhn. DO. FACS Thomas E. Sh,tvcr, 'Ill>. FACS
\1artin R. Lichdbcrgcr, MD, FAGS Barr) D. Martin. Yll> Richard C. Simmtmd,, DVM, !liS
David hl u,udu F\kcn.vi, MD, FAGS '>.tlvador Martin YlanduJano, f\.11 ) ...ACS , D:IVid V. Skinna. HCS (Ed), FRCS (Eng)
William E la llun, J r, MD, FACS Kimball L Maull, M 0, FACS Arnold Sbdcn, M I>, I'ACS
llavid V. FcliLi.uto, MD, FACS MMy C. McCarthy, MD. FACS Ricardo Surmchc>rn, MD. FACS
Fmil.m Fcrmmdcz. MD Grald McCull.ough, MD, I;ACS Gerald 0. Str;luch, MD, IACS
C.trlos Fcrnamlc7-Bttcllo, MD ltltll E. McDermou, MD. IACS Luther M. Strayer, i l l , MD
John ). Fikk,, MD, FACS J,unc; A. McGo.!hee. DVM, MS )ames K. Styncr, MIl
Ronald P. Hschcr, MD, FACS William E McMan u,, MD, FAC:S John E. Sulltln, )r, .\1 [), FACS
Lc'b M Flint, Jr. M0, FACS Norman 1. McSwain, )r., MD, FAC'> joseph ). l'cpa. lll, MD, I'ACS
Swvcn'>un l l.migan, MD, FACS PhilipS. Met?, MD. FACS Stcphanc l .:t raeauh, fU
r,tch.tn FoiJnini G., MD, FACS Cynthia L. Meyer, M D Gregory 1\. l'imbcriJke, MD. FACS
Jnrge f loianini, MD FACS . IrJnk B. Miller, MD, FACS Peter r;. Trahon MD. FACS
Rich.ud l'ruhling. MD Sid ney F. Miller, MD, FACS Stanler Troobrn, MD. lACS
Sylvain G.tgnon, MD l:.me>l E. Moore, MD. I'ACS David Tuggle, M n. Ft\l..S
Rkh.tri G:unclli, MD, FACS Juh;ulne Morin, MD h1y Uprrght
Thoma A. Gcn na rclli, M 0, FACS D.tvid Mulder, MD. I'ACS Antonio Vern 11olc;
Pclltl Gcbh.tnl Raj K. Naraya n, MD, I;AC:S Alan Verdant, Mil
),tmcs A. c,.:iJing, .MD, FCCP J,tmes 13. Nichols, DVM, MS 1. Leone! Villuviccncio, M 11, FACS
John I!. (;cnrge, PhD ..ola
Marlr n Odrio \ID
, . , FACS Franklin C. \\I;Jgncr, MD. FACS
Roger litlhcrton, .1\ID hankhn COlson, EdD Raymond 1.. Warpcha, J\.1D. l-i\CS
Robert \\'. Gillespie, MD, FACS Gon1.alo O>trta P. MD, I'ACS Clark Wam, !Ill>, rACS
\l.tr< l;irou\, MD Arthur Page, MD John A. Wctgch, \II>, FACS
). Ab ll.tllcr. Jr., MD. FACS )u.se Pa.iz Tejada John \\-'c.t, Ml>. IACS
Burton I!. ll,tms. MD. IACS Steven X. Parks, MD, FACS Robert ). \Vlutc. Ml>, Fi\CS
M kh.td L l lowki ns, MD, fACS Chester (Chet} Paul, Ml> Frcnwn t P. Wrrth MD, IAC!'>
,
lon l l tywood, IRC:S (Eng), MRCS,

. LRCI' Muk D. Pearlman, M 0 Bradley D. Wong, MIl, FACS
)ll ntcs I>. Ik'kman, MD, FACS 1\ndrcw B. Peizman,
t MD, FACS Peter H. Worluck, DM, ... RCS (Ed), FRCS ( Eng)
C 0 U R S E 0 V ERV I E W: The Purpose, History, and

Concepts of the ATLS Program
Program Goals 2 Establi:.h management priorities in a trauma situa

tion.
3. Initiate primary and secondary management neces

The Advanced Trauma Life Support (ATLS) course provides
sary within the golden hour for the emergency man
its participants with a safe and reliable method for the im
agement of acute life-threatening conditions.
mediate treatment of injured patients and the basic knowl
edge necessary to: 4 . In a given simulated clinical and surgical skills
practicum, demonstrate the following skills, which are
1 Assess a patient's condition rapidly and accurately. often required in the initial a'>sessment and treatment
of patients with multiple injuries:
2. Resuscitate and stabilize patient according to prior
a. Primary and secondary assessment of a patient
ity.
with simulated, multiple injudes
3. Determine whether a patient's needs exceed a facility's b. Eswblishment of a patent airway and initiation of
resources and/or a doctor's cap1bilitics. one- and two-person ventilation
c. Orotracheal intubation on adult and infant
4. Arrange appropriately for a patient's interhospital or
manikins
intrahospital transfer (what, who, when, and how).
d. Pulse oximetry and carbon dioxide detection in ex
5. Ensure that optimal care is provided and that th level haled gas
of care docs not deteriorate at any point during the e. Cricothyroidotomy
evaluation, resuscitation, or transfer processes. f. Assessment and treatment or a patient in shock,
particularly recognition of life-threatening hemor
rhage
g. Venous and intraosseous access
Course Objectives h . Pleural decompression via needle thoracentsis
and chest tube insertion
i. Recognition or cardiac tnmponade (and perform
The content and skills presented in this course aYe designed to
ance of pericardiocentesis)
assist doctors in providing emergency care for trauma pa
j. Clinical and radiographic identification of thoracic
tients. The concept of the "golden hour" emphasizes the ur . . .
ll1JUfleS
gency necessary for successful treatment of injured patients
k. U:.c of peritoneal lavage, ultrasound, and computed
and s
i not intended to represent a "fixed" time period of 60
tomography (CT) in abdominal evaluation
minutes. Rather, it is the window of opportunity during
I. Evaluation and treatment of a patient with brain
which doctors can have a positive impact on the morbidity
injury, including use of the Glasgow Coma S:alc
and mortality associated wilh injury. The ATLS course pro
score and CT of lhe brain
vides the essential information and skills for doctors to iden
m. Assessment of head and f<Kial trauma by phy!>ical
tify and treat life-threatening and potentially life-threatening
examination
injuries w1der the extreme pressures associated with the care
n. Protection of the spinal cord, <md radiographic
of these patienb in the fast-paced environment and anxiety of
and clinical evaluation of spine injuries
a trauma room. The ATLS course is applicable to all doctors
o. Muculoskeletal trauma a:.sessment and manage
in a variety of clinical situations. It is just as relevant to doc
ment
tors in a large teaching facility in North America or Europe as
p. Estimation of the size and depth of burn injury
it is in a developing nation with rudimentary facilities.
and volume resuscitation
Upon completion of the ATLS student course, tbe doc
tor will be able to:
q Recognition of the special problems of injuries in
infants, the elderly. and pregnant \vomen
1 . Demonstrate the concepts and principles of the pri r. Understanding of the principles of disaster man
mary and secondary patient assessments. agement
. .
XVII
XVIII COURSE OVERVIEW
THE NEED when it is realized that trauma strikes down a society's

youngest and potentially most productive members. Re
Injury deaths worldwide were estimated at more than 5 mil
search dollars spent on communicable di5cascs such as polio
lion in 2000 (Figure I). The burden of injury is even more and diphtheria have nearly eliminated the incidence of these

significant, accounting tor 12o/o of the world's burden of dis-

diseases in the United States. Unfortunately the disease of
C<lse. Motor vehicle crashes {road traffic injuries, in Figure 2)
1rauma has not captured the public allent ion in tile same
alone cause more than I million deaths annually and an es
way.
timated 20 million to SO million significont injuries; they
Injury is a disease. It has a host (the patient) and it has
arc the leading cause of death due to injury worldwide. Im
a vector of transmission (eg, motor vehicle, firearm, etc).
provements in injury control efforts are having an impact
Many significant changes have improved the care of the in
in most developed countries, where trauma remains the
jured patient since the first edition of the ATLS Program ap
leading cause of death in persons l through 44 years of age.
peared in 1980. The need for the program and for sustained,
Significantly, more than 90% of motor vehicle crashes occur
aggressive efforts to prevent injuries ili as great now as it has
in the developing world. Injury-related deaths are expected
ever been.

t.o rise dramatically by 2020, with deaths due to motor ve
hicle crashes projected to increase by 80% from current rates
in low- and middle-income countries. By 2020 it is esti
mated that more than 1 in 10 people will die from injuries.
Global trauma-related costs are cstim.lled to exceed
Trimodal Death Distribution
$500 billion annually. These costs arc much higher i f one
considers lost wages, medical expenses, insurance adminis first described in 1982, the tri modal distribution of
tration costs, property d<1mage, fire loss, employer costs, and deaths implies that death due to injury occurs in one of
indirect loss from work-related injuries. Despite these stag three periods, or peaks ( F igure 3). The lil-st peak occurs
gering costs, less than 4 cents of each federal research dollar within seconds to minutes of injury. During this early pe
in the United States arc spent on trauma research. As mon riod, deaths generally result from apnea due to severe
umental as these data .tre, the true cost can be measured only brain or high spinal cord injury or rupture of the heart,
., .. .
.
. .

Mortality rate
(per 1 00,000)
\ ,
120.0-1 3 1 . 1 "'

95.0- 1 1 9 . 9
70.0-94.9
45.0-69.9
No data
Figure 1 Global Injury-Related Mortality.

Reproduced w1th permiSSIOn from The Injury Chart Boo A Graphical Overview uf 1/JL' Gluba/ 8urden of lnJUtte. Geneva World Health Org,H11ldllon Departm!'nt
ol lnJulies and V1olence Prevention, Noncommun,cable Diseases and Mental Ht>allh Cluster; 2002.
COURSE OVERVIEW XIX
hematomas, hemopneumothorax, ruptured spleen, lac

Road traffic erations of the liver, pelvic fractures, and/or multiple
injuries other injuries associated with significant blood loss. The
25%
..
golden hour of care after injury is characterized by the
need for rapid assessment and resuscitation, which are
the fundamental principles of Advanced Trauma Life
Self-inflicted Su ppo r t .
violence Fires The third peak, which occurs several days to weeks
16% 5% after the initial i njury, is most often due to sepsis and mul
tiple organ system dysfunction. Care provided during
Poisoning each of the preceding periods impacts on outcomes dur
6%
ing this stage. The first and every sub sequen t person to
Interpersonal
violence care for the injured patient has a direct effect on long
10% Drowning War term outcome.
9% 6% The temp oral distribution of deaths reflects local ad
vances and capabilities of trauma systems. The development
Figure 2 Distribution of Global Injury Mortality of standardized trauma training for doctors, beller prehos
by Cause. pital care, and the development of trauma centers with ded
Reproduced w1th perm1ss1on from The InJury Chart Book. A Graphtcal
icated trauma teams and established protocols to care for
Overvrew of the Global Burden of InJurieS Geneva World Health Orgamzation injured patients has altered the picture. A recent study in
Department of lnJunes and V1olence Prevention. Noncommunicable D1seases
and Mental Health Cluster, 2002.
California demonstrated that approximately 50% of pat ients
died at the scene or wi thin the first hour, supporting con
tinued emphasis on injury-prevention programs. Both the
aorta, or other large blood vessels. Very few of these pa mechanism of i njury and the body area injured were im
l ien ts can be saved b eca use of the severity of their injuries. portant determinants of the subsequent clinical course and
Only prevention can significan tly reduce this peak of the temporal risk of death. Eighty percent of deaths due to
trauma-related deaths. severe chest trauma occurred within the first 6 hours,
The second peak occurs within minutes to several whereas 90% of deaths from head injury occurred during
hours following injury. Deaths that occur during this the fust week. The incidence of late deaths was m uch lower
period are usuaJly due to subdural and epidural in this series (8%).
350
"'
300 J
.c.
-
f'O 250
Q)
-o
0 200
....
Immediate Early Late
] deaths deaths deths
E 150
I
:::1
z
100
50
1 2 J 4 2 3 4 5
Hours Weeks
Tlme after Jnjury Figure 3 Trimodal Death
Distribution.
xx COURSE OVERVIEW
)anUJr}' 1980. Canada became an active participant in the

History ATLS Program in 1981. Cou nt ri es in I.atin and South Amer
ica joined the ACS COT in 1 986 and implemented the ATLS
The delivery of tra um a care by doctors in the United States .. Prog ram. Under the auspices of the ACS Military Commit
bcltlre 191:!0 was at best inconsistent. A tragedy occurred in tee on Trauma, the p rogra m has bee n conducted for U.S.
Febnw ry 1976 t hat changed trauma care in the "first hour" military doctors in other cou ntrics.
for injured patien ts in the Un ited Stall'S and in much of the The program has grown each year in the number of
rest of the world. An orthopedic l>Urgeon Wall piloting his both courses and pa rt icipants. By 2007, the course had
plane and crashed in a rural Nebrallka cornfield. The sur trained approximately 1 miUion doctors in more than
geon sustained serious injurie!>, three of his children sus 60,000 courses around the world. Cu rrently an average of
,
tained critical i njuries, and one child sustained minor 40,000 d octors arc trained each year in approximately 2600
injuries. His wife was kil led in sta nt ly. The care that he and course!>. The greatest growth in recent years has been in the
his family subsequently received was inadequate by the day s ' international community, and thii. group currently repre
standards. The surgeon, recognizing how inadequate their ents .1pproximatcly more than half of all ATLS activity.
treatment was, stated: "vVhen I can pmvide better care in The text for the course is revised a pp roximately every 4
the field with limited resource!> than what my chi ldren and years a nd incorpo rates new methods of evaluation and
1 received a t the pri mary care facili ty there is something
, treatment that have becom e accepted parts of the arma
wrong with the system, and the system has to be changed." mentarium of doctors who treat trauma pati ents Course .
A group of private-practice surgeons and doctors in revisions incorporate suggestion!. from members of the Sub
t'ebraska, the Lincoln Medical Education Foundation, and committee on XfLS; members of the ACS COT; members of
the Lincoln-area Mobile Heart Team Nurses, with the help the international ATLS family; rcpreentatives to the ATLS
of the University of Nebraska Medical Center, the Nebraska Sul)lornmittee from the American College of Emergency
State Committee on Trauma (COT) of t he American Col Phy:.ici ans and the American College of Anesthesiologists;
lege of Surgeon s (ACS), <md the Southeast Nebraska Emer and course instructors, coordinators, educators, and partic
gency Medical S:rvice identified the need for t rain i ng in ipants. Changes that are made to the program reflect ac
advanced trauma life support. A combin ed educational for cepted verified practice patterns. not culli ng edge"
, "
mat of lectures, lifesaving skiU dcmon!ltration, and pr acti techn ology or experi ment al methods. The international na
cal laboratory experiences formed the first prototype ATLS ture.' of the program manda tes that the course be adaptable
course for doctors. to a var ie ty of geograp hic, economic, social, and medical
A new approach to the provision of care for individu practice situations. To retain a current status in the ATLS
als who suffer major, life-threatening injury premiered in Program, an individual must reverify with the latest edition
1978, the year of the first ATLS coure. This prototype ATLS o f the materials.
course was field-tested in conju ncti o n with the Southeast A parallel course to the ATLS course is the Prehopital
Nebraska Emergency Medical Services. One year later, the Trauma Life Support (PHTLS) course, which is sponsored
ACS COT, recog nizi ng trauma as a su rg ica l disease, ent h u by the National Association of Emergency Medical Techni
sias tica lly adopted the course under the im primat ur of the cians (NAEMT). The PHTLS cours e, developed i n cooper
Col lege and incorporated it as an educational program. ation with the ACS COT, is based on the concepts of the ACS
This course was based on the as1.umption that appropri ATLS Progra m for Doctors and is conducted for emcrgem.-y
ate and timely care could significantly improve the outcome medical technicians, paramedics, and nurses who are
of injured patients. Tbe original intent of the ATLS Program providers of prehospital trauma care. Other courses have
was to train doctors who do not manage major trauma on a been developed with sinlllar concepts and philosophies. for
daily basis, and the primary audiem:e for the course has not example, the Society ofTrauma Nur:.es offers the Advanced
changed However, today the ATLS method is accepted a<; a

. Trauma Care for Nurses (ATCN), which is also developed
Mandan.! fcw the "first hour" of trauma care by many who pro in coop erat ion with the ACS COT. The ATCN and ATLS
vide care for the injured, whether the patient is treated in an courses are conducted parallel to each other with the nurses
is ola ted rural area or a state-of the-art trau ma cen ter. aud i tin g the ATLS lec tures and then partici pati ng in skill
stations separate from th e ATLS skill stations conducted for
doctors. The benefits of havi ng both prehosp ital and in
hospital trauma personnel speaking the same "language" arc
Course Development app.1rent.
and Dissemination
INTERNATIONAL DISSEMINATION
THE 1980c; AND 1990s As a pi lo t project, the ATLS Progr am was exported outside
The Al LS course was conducted natiom1lly for the first t ime of North America in 1986 to the Rep ubi ic of Tr i nidad and
under rhe a uspices of the AmeriGln College of Surgeons in Tobago. The ACS Board of Regen ts gave permission in 1 987
COURSE OVERVIEW XXI
for promulgation of the ATLS Program in other countries. 27. Netherlands, The (Dutch Trauma Society)
The ATLS Progrru:n may be requested by a recognized sur
28. New Zealand ( Royal Australasian College of
gical organization or ACS Chapter in another country by
Surgeons)
conespondlng with the ATLS Subcommittee Chairperson,
care of the ACS ATLS Program Of(icc, Chicago, IL. At Lhc 29. Norway (Norwegian Surgical Society)
time of publication, 47 cow1tries were actively providing the
30. Pakistan (College of Physicians and Surgeons
ATLS course lo their doctors. These countries include:
Pakistan)
31. Panama (ACS Chapter and Committee on Trauma)

1 . Argentina (ACS Chapter and Committee on Trauma)
32. Papua New Guinea (Royal Australasian College of
2. Australia { Royal Australasian CoUcgc of Surgeons)
Surgeons)
3. Bahrain (Kingdom of Saudj Arabia ACS Chapter and
33. Peru (ACS Chapter and Committee on Trauma)
Committee on Trauma)
34 . Portugal (Portuguese Society of Surgeons)
4. Bolivia ( Bolivian Surgeons Society)
35. Qatar (Kingdom of Saudi Arabia ACS Chapter and
5. Brazil (ACS Chapter and Committee on Trauma)
Committee on Trauma)
6. Canada {ACS Chapters and Provi ncial Committees
36. Republic of China, Taiwan (Surgical Association of
on Trauma)
the Republic of China, Taiwan)
7. Chile (ACS Chapter and Committee on Trauma)
37. Republic of Singapore (Chapter of Surgeons,
8. Colombia (ACS Chapter and Committee on Trauma) Academy of Medicine)
9. Costa Rica (College of Physicians and Surgeons of 38 . Republic of South Africa (South African Trauma
Costa Rica) Society)
1 0. Cyprus (ACS Chapter and Committee on Trauma, 39. Spain (Spanish Society of Surgeons)
Greece)
40. Sweden (Swedish Society of Surgeons)
1 1 . Denmark (Danish Trauma Society)
41 . Switzerland (Swiss Society of Surgeons)
1 2 . Ecuador (ACS Chapter and Commillee on Trauma)
42 . Thailand (Royal College of SllTgeons of Thailand)
13. Fiji and the nations of the Southwest Pacific (Royal
43. 11-i.nidad and Tobago (Society of Surgeons of Trinidad
Australasian College of Surgeons)
and Tobago)
14. Germany (German Society for Trauma Surgery and
44. United Arab Emirates (Surgical Advisory Committee)
Task Force for Early Trauma Care)
45. United Kingdom { Royal College of Surgeons of
1 5 . Greece (ACS Chapter and Committee on Trauma)
England)
16. Grenada (Society of Surgeons of Trinidad and 'lbbago)
46. United States, U.S. territories (ACS Chapters and State
17. Hong Kong (ACS Chapter and Committee on Committees on Tra uma)
Trauma)
47. Venezuela (ACS Chapter and Committee on Trauma)
18. Hungruy ( Hungarian TraLm1a Society)
1 9. Indonesia ( Indonesian Surgeons Association)
20. Ireland ( Royal College of Surgeons in lrebnd)

The Concept
21 . Israel (Israel Sw-gical Society)
22. Italy (ACS Chapter and Committee on Trauma) The concept behind the ATI.S course has remained simple.
Historical ly, the approach to treating injured patients, as
23. Jamaica (ACS Chapter and Committee on Twuma)
taught in medical schools, was the same as that for patients
24. KjJ1gdom of Saudi Arabia (ACS Chapter and with a previously undiagnosed medical conrution: an ex
Committee on Traw11a) tensive history inclurung past merucaJ history, a physical e...x
amination starting at the top of the head ru1d progressing
25. Lithuania (Lithuanian Society of Traumatology and
down the body, the development of a differential ruagnosis,
Orthopaedics)
and a list of adjuncts to confirm the diagnosis. .AJthough this
26. Mexico (ACS Chapter and Committee on Trauma) approach was adequate for a patient with diabetes mellitus
XXII COURSE OVERVIEW
and many acute surgical illnesses, it did not satisfy the needs
The Impact
of patients suffering life-threatening injuries. The approach ,
required change.
Three underlying con cepts of the ATLS Program were. ATLS training for doctors i n a developing country has re
initially difficult to accept: sulted i n a decrease i n injury mortality. Lower per capita
rates of deaths from i nj uries arc observed in areas where
1 . Treat the greatest threat to life first. doctors have ATLS train ing In one study, a small trauma
.
team led by a doctor with AT LS experience had equivalent

2. The lack of a definitive diagnosis should never im
patient survival when compared with a larger team with
pede the application of an indicated treatment.
more doctors in an urba11 setting. l n addition, there were
3. A detailed history is not essential to begin the evalua more unexpected survivors than fatalities. There is abun
tion of a patient with acute injuries. dant evidence tJ1at ATLS training improves the knowledge
base, the psychomotor skills and their use in resuscitation,
The result was the development of the ABCDE approach to and the confidence and performance of doctors who have
the evaluation and treatment of injured patients. These con taken part in the program. The organization and procedural
cepts are also in keeping with the observation that the care skills taught in the course are retained by course participants
of injured patients in many circumstances is a team effort, for a t least 6 years, which may be the most significant impact
allowing medical personnel with special skills and expertise of all.
to provide care s.imultaneously wi th surgical leadership of
the process .
"n1e ATLS course emphasizes that injury kills i n certain

reproducible time frames. For example, the loss of an air
way kills more quickly than does lhe loss of the ability to
Acknowledgments
breathe. The latter kills more quic kly than loss of ci_rculating
blood volume. The presence of an expanding intracranial The COT of Lhe ACS and the ATLS Subcommittee gratefully
mass lesion is the next most lethal problem Thus, the
. acknowledge tbe following organizations for their time and
mnemonic ABCDE defines the speci fie, ordered evalua Lions efforts in developing and field testing the Advanced Traw11a
and interventions that should be followed in all injured Life Support concept: The Lincoln Medical Education FoUil
patients: dation, Southeast Nebraska Emergency Medical Services,
the University of Nebraska College of Medicine, and the Ne
Airl.vay with cervical spine protection braska State Committee on Trauma of the ACS. The com
mittee also is indebted to the Nebraska doctors who
Breathing
supported the devel opment of this course and to tl1e Lin
Circulation, stop the bleeding coln Area Mobile Heart Team Nurses who shared their time
and ideas to help build it. Appreciation is extended to the
Disability or neurologic status
organizations identified previously in this overview for their
Exposure (undress) and Environment (temperature support of the worldv.ride promulgation of the course. Spe
control) cial recognition is given to tbe spouses, significant others,
children, and practice partners of the ATLS instructors and
students. The time that doctors spend away from their
homes and practices and effort afforded to this voluntary
program are essential components for the existence and suc
Course Overview cess of the ATLS Program .
The AILS course emphasizes the rapid initial assessment

and primary treatment of in j ured patients, starting at the
time of injury and continuing through initial assessment,
lifesaving intervention, reevaluation, stabilization, and,
Summary
when needed, transfer to a trauma center. The course
consists of precourse and postcourse lests, core content The ATLS course provides an easily remembered approach
lectures, in teract ive case presentations, discussions, to the eva luation and treatment of injured patients for any
development or lifesaving skills, practical laboratory ex doctor, irrespective of practice specialty, even under the
periences, and a final performance proficiency evaluation. stress, anxiety, and intensity that accom panies the resusci
Upon completion of the course, doctors should feel con tation process. In addition, the program provides a common
fident in implementing the skills taught in the ATLS language for all providers who care for injured patients. The
course. ATLS course provides a foundation for evaluation, treat-
...
COURSE OVERVIEW XXIII
ment, education, and quality assurance-i nshort, a system surgical medical background. Eur I Emcrg Mcd 1997;4:1 1
of trauma care that is meaurable, reproducible, and com 14.
prehensive. 12. B erger LR, MoiMn ]): Injury Control: A Global View. Delhi,
The ATLS Program has had a positive i mpa<;_t on the India: Oxford Un iversity Press; 1996.
care prov ided to injured pa t ients worldwide. This has re
13. Blumenrield A, Ben Abn1ham R, Stei n M, et al. Cogn itivt
sulted from the improved skills and knowledge of the doc
knowledge decline ,, fter Ad voneed Trauma Life Support
tors a nd ot her health ca re p rov iders who have been course
courses. I Trauma 1998;44:5 13-516.
participants. The AILS course establishes an organized and
systematic approach for the evaluation and treatment of pa 14. Burt CW. Injuryrelated visits to hospita l emergenq depart
ments: United St<lles, 1 992. tldv D.lt<l 1995;26 1 : 1 20.
tients. promotes minimum standards of care, and recognizes -
injury as a world health care issue. Morbidity and mortali ty 15. Demetriades 0, I<imbrell B, SJiim A, et al. Trauma deaths in ,,
have been reduced , but the need to eradicate injury remains. mature urban trau ma system: "trimodaJ" cllitribution a valid
The ATLS Program has changed and will continue to change concept? JAm Coil Sw-g 2005;201 :343-348.
as advances occur in medici n e and the needs and ex pect a -
16. lJeo SD, Knottenht'lt JD, Peden MM. Evaluation of a small
1 ions of our societies ch a nge. 1 rauma team for mLtjn r resuscitation. Tnjury 1997;28:633-637.
17. Di reccao Geral de Vic.1o, Lisboa, Portugal, data p rovided by

Pedro Ferreira Muniz Perdra, MD, FACS.
18. Fingerhut LA, Cox

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gency medicine for physician.. 1/.m:fu.Ih 1997; 132:695-697, 743.
vanced trauma life support s)'stcm in a mass casualty situation
R, Stei n M, K luger Y, et al. The impact of Ad
J I . Ben Abrah am by non-trauma e Kp erienced physicians: Grenada 1983. / Fmct
.
vanced Trauma Life Support Cou rse on graduates with non- Med 1989;7: 175- 1 80.
XXIV COURSE OVERVIEW
3!. Williams MJ, Lockey AS, Cutshaw MC. Improved trauma 33. World Health Organization. \liolence and Injury Prevention
management wilh Advanced Trauma Life Support (ATLS) and Disability ( VIP). http://www.who.int/violence_injur)_
training. I Accident .Emerg Med 1.997;14:8 1.-83. prevention/publica Lions/other_injuryIchartb/en/index.hLml.
Accessed January 9, 2008.
32. World Health Organization. The Injury Chart Boo]\: a Graph
ical Overview oftl1e Global Burden ofInjuries. Geneva: VVorld 34. World Health Organiz.ation. World Report on Road Tmflic In
Health Organization Department of Injuries and Violence lJre jury Prevention. Geneva: World Health Organization.
vention. Noncommunicable Di.seascs and Mental T lealth Ch.ls
ter; 2002.

CONTENTS
-
Foreword v
..
Preface VII
Course Overview xviii
1 Initial Assessment and Management 1
OBJECTIVES 1 Other Monitoring 10

Introduction 2 X-Ray Examinations and Diagnostic Studies 10
Preparation 2 Consider Need for Patient Transfer 10
Prehospital Phase 2 Secondary Survey 11
Hospital Phase 2 History 11
Triage 4 Physical Examination 12
Multiple Casualties 4 Adjuncts to the Secondary Survey 16
Mass Casualties 4 Reevaluation 16
Primary Survey 4 Definitive Care 17
Airway Maintenance with Cervical Disaster 17
Spine Protection 5 Records and Legal Considerations 17
Breathing and Ventilation 6 Records 17
Circulation with Hemorrhage Control 7 Consent for Treatment 17
Disability (Neurologic Evaluation) 7 Forensic Evidence 17
Exposure/Environmental Control 7 CHAPTER SUMMARY 18
Resuscitation 8 BIBLIOGRAPHY 18
Airway 8 SKILL STATION 1: Initial Assessment
Breathing/Ventilation/Oxygenation 8 and Management 19
Circulation and Bleeding Control 8 Skill I-A: Primary Survey and Resuscitation 20
Adjuncts to Primary Survey
Skill l-8: Secondary Survey
and Resuscitation 9
and Management 21
Electrocardiographic Monitoring 9
Skiii i-C: Patient Reevaluation 24
Urinary and Gastric Catheters 9
Skill t-O: Transfer to Definitive Care 24
2 Aiway and Ventilatory Management 25

OBJECTIVES 25 Airway Management 28
Introduction 26 Airway Maintenance Techniques 29
Airway 26 Definitive Airway 32
Problem Recognition 26 Airway Decision Scheme 39
Objective Signs of Airway Obstruction 27 Management of Oxygenation 39
Ventilation 28 Management of Ventilation 39
Problem Recognition 28 CHAPTER SUMMARY 40
Objective Signs of Inadequate Ventilation 28 BIBLIOGRAPHY 41
XXV
CONTENTS

XXVI
SKILL STATION II: Airway and Skiii ii-F: Laryngeal Tube Airway (LTA)
Ventilatory Management 43 Insertion 46
Skiii ii-H: Infant Endotracheal Intubation 46
Skill 11-A: Oropharyngeal Airway Insertion 44

Skill Il-l: Pulse Oximetry Monitoring 47
Skill ll-8: Nasopharyngeal Airway Insertion 44
Skiii ii-J: Carbon Dioxide Detection 48
Skill 11-C: Bag-Mask Venti lation: Two-Person
Scenarios 49
Technique 44
Skill ll-0: Adult Orotracheal lntubation (with SKILL STATION Ill:
and without Gum Elastic Bougie Device) 45 Cricothyroidotomy 51
Skill li-E: Laryngeal Mask Airway (LMA) Skill Ill-A: Needle Cricothyroidotomy 52
Insertion 45 Skill 111-8: Surgical Cricothyroidotomy 52
3 Shock 55
OBJECTIVES 55 Equating Blood Pressure with Cardiac Output 66
Introduction 56 Advanced Age 67
Shock Pathophysiology 56 Athletes 67
Basic Cardiac Physiology 56 Pregnancy 67
Blood Loss Pathophysiology 56 Medications 67
Initial Patient Assessment 57 Hypothermia 67
Recognition of Shock 58 Pacemaker 67
Clinical Differentiation of Cause of Shock 58 Reassessing Patient Response and
Hemorrhagic Shock in Injured Patients 59 Avoiding Complications 68
Definition of Hemorrhage 60 Continued Hemorrhage 68
Direct Effects of Hemorrhage 60 Fluid Overload and CVP Monitoring 68
Fluid Changes Secondary to Soft Tissue Injury 61 Recognition of Other Problems 69
Initial Management of Hemorrhagic CHAPTER SUMMARY 69
Shock 62 BI BLI OG RA PHY 69
Physical Examination 62
SKILL STATION IV: Shock Assessment
Vascular Access Lines 62 and Management 73
Initial Fluid Therapy 63
Skill IV-A: Peripheral Venous Access 74
Evaluation of Fluid Resuscitation
and Organ Perfusion 64 Skiii iV-8: Femoral Venipuncture: Seldinger
Technique 74
Urinary Output 64
Acid/Base Balance 64 Skiii iV-C: Subclavian Venipuncture:
Infraclavicular Approach 76
Therapeutic Decisions Based on
Response to Initial Fluid Resuscitation 64 Skiii iV-0: Internal Jugular Venipuncture:
Middle or Central Route 76
Rapid Response 65
Transient Response 65 Skiii iV-E: lntraosseous Puncture/Infusion:
Proximal Tibial Route 77
Minimal or No Response 65
Blood Replacement 66 Skill IV-F: Broselow'M Pediatric Emergency
Tape 78
Crossmatched, Type-Specific, and Type 0 Blood 66
Warming Fluids-Plasma and Crystalloid 66 Scenarios 79
Autotransfusion 66
SKILL STATION V: Venous Cutdown
Coagulopathy 66
(Optional Station) 83
Calcium Administration 66
Special Considerations in the Diagnosis Skill V-A: Venous Cutdown 84
and Treatment of Shock 66
C O NTENTS

XXVII
4 Thoracic Trauma 85
OBJECTIVES
85 Subcutaneous Emphysema 98
Introduction 86 Crushing Injury to the Chest (Traumatic Asphyxia) 98
Primary Survey: life-Threatening Injuries 86 Rib, Sternum, and Scapular Fractures 98
Airway 86 Other Indications for Chest Tube Insertion 98
Breathing 86 CHAPTER SUMMARY 99
Circulation 90 BIBLIOGRAPHY 100
Resuscitative Thoracotomy 92
Secondary Survey: Potentially
SKILL STATION VI: X-Ray Identification
of Thoracic Injuries 103
Life-Threatening Chest Injuries 92
Simple Pneumothorax 93 Skill VI-A: Process for Initial Review of
Chest X-Rays 1 04
Hemothorax 93
Pulmonary Contusion 94 Thorax X-Ray Scenarios 106
Tracheobronchial Tree Injury 94
SKILL STATION VII: Chest Trauma
Blunt Cardiac Injury 94 Management 107
Traumatic Aortic Disruption 95
Skill VIl-A: Needle Thoracentesis 108
Traumatic Diaphragmatic Injury 96
Blunt Esophageal Rupture 96 Skill VII-B: Chest Tube Insertion 108
Other Manifestations of Chest Injuries 97 Skill VII-C: Pericardiocentesis 109
5 Abdominal and Pelvic Trauma 111
OBJECTIVES 111 Specific Diagnoses 121

Introduction 112 Diaphragm Injuries 121
External Anatomy of the Abdomen 112 Duodenal Injuries 121
Internal Anatomy of the Abdomen 112 Pancreatic Injuries 121
Peritoneal Cavity 112 Genitourinary Injuries 121
Retroperitoneal Space 113 Small Bowel Injuries 121
Pelvic Cavity 113 Solid Organ Injuries 121
Mechanism of Injury 113 Pelvic Fractures and Associated Injuries 122
Blunt Trauma 113 CHAPTER SUMMARY 124
Penetrating Trauma 113 BI BLIOGRAPHY 124
Assessment 115
History 115
SKILL STATION VIII: Diagnostic
Peritoneal lavage 127
Physical Examination 115
Adjuncts to Physical Examination 116 Skill VIll-A: Diagnostic Peritoneal lavage:
Evaluation of BluntTrauma 118 Open Technique 128
Evaluation of Penetrating Trauma 119 Skill VIII-B: Diagnostic Peritoneal Lavage:
Indications for laparotomy in Adults 120 Closed Technique 128
6 Head Trauma 131
OBJECTIVES 131 Meninges 133

Introduction 132 Brain 134
Anatomy 132 Ventricular System 135
Scalp 132 Tentorium 135
Skull 132 Physiology 135
XXVIII CONTENTS
Intracranial Pressure 135 Barbiturates 148

Monro-Kellie Doctrine 135 Anticonvulsants 148
Cerebral Blood Flow 136 Surgical Management 148
Classifications of Head Injuries 137 Scalp Wounds 1 48
Mechanism of Injury 137 Depressed Skull Fractures 148
Severity of Injury 138 Intracranial Mass Lesions 148
Morphology 138 Penetrating Brain Injuries 148
Management of Minor Brain Injury Prognosis 149
(GCS Score 13-15) 140 Brain Death 149
Management of Moderate Brain Injury CHAPTER SUMMARY 150
(GCS Score 9- 1 2) 142 BIBLIOGRAPHY 150
Management of Severe Brain Injury
SKILL STATION IX: Head and Neck
(GCS Score 3-8) 142
Trauma: Assessment and Management 153
Primary Survey and Resuscitation 142

Skill IX-A: Primary Survey 154
Secondary Survey 144
Diagnostic Procedures 144 Skiii iX-8: Secondary Survey and
Medical Therapies for Brain Injury Management 154
146
Intravenous Fluids 146 Skiii iX-C: Evaluation of CT Scans of the
Head 154
Hyperventilation 146
Mannitol 146 Skiii iX-D: Helmet Removal 155
Steroids 147 Scenarios 156
7 Spine and Spinal Cord Trauma 157
OBJECTIVES 1 57 Blunt Carotid and Vertebral Vascular Injuries 166

Introduction 158 X- Ray Evaluation 166
Anatomy and Physiology 158 Cervical Spine 166
Spinal Column 158 Thoracic and Lumbar Spine 168
Spinal Cord Anatomy 159 General Management 168
Sensory Examination 160 Immobilization 168
Myotomes 160 Intravenous Fluids 170
Neurogenic Shock versus Spinal Shock 161 Medications 170
Effects on Other Organ Systems 162 Transfer 171
Classifications of Spinal Cord Injuries 162 CHAPTER SUMMARY 172
Level 162 BIBLIOGRAPHY 172
Severity of Neurologic Deficit 162
Spinal Cord Syndromes 163
SKILL STATION X: X-Ray
Identification of Spine Injuries 175
Morphology 163
Specific Types of Spinal Injuries 163 Skill X-A: Cervical Spine XRay Assessment 176
Atlanto-Occipital Dislocation 163 Skill XB: Atlanto-Occipital Joint Assessment 1 77
Atlas Fracture (C1) 164 Skill X-C: Thoracic and Lumbar X-Ray
C1 Rotary Subluxation 164 Assessment 178
Axis (C2) Fractures 164 Skill X-D: Review Spine X-Rays 1 78
Fractures and Dislocations (C3 through C7) 165 Spine X-Ray Scenarios 178
Thoracic Spine Fractures (T1 through T1 0) 165
Thoracolumbar Junction Fractures SKILL STATION XI: Spinal Cord Injury:
(T1 1 through L1) 166 Assessment and Management 181
Lumbar Fractures 166 Skill XIA: Primary Survey and Resuscitation-
Penetrating Injuries 166 Assessing Spine Injuries 182
CONTENTS XXIX
Skill XIB: Secondary Survey-Neurologic Skill XID: Treatment Principles for

Assessment 182 Patients with Spinal Cord Injuries 183
Skill XIC: Examination for Level of Skill XIE: Principles of Spine
Spinal Cord Injury ..
182 Immobilization and Logrolling 183
8 Musculoskeletal Trauma 1 87
OBJECTIVES 1 87 Femoral Fractures 199

Introduction 188 Knee Injuries 200
Primary Survey and Resuscitation 188 Tibia Fractures 200
Adjuncts to Primary Survey 188 Ankle Fractures 200
Fracture Immobilization 188 Upper-Extremity and Hand Injuries 200

X-Ray Examination 189 Pain Control 200

Secondary Survey 189 Associated Injuries 201
History 189 Occult Skeletal Injuries 201
Physical Examination 190 CHAPTER SUMMARY 202
Potentially Life-Threatening Extremity BIBLIOGRAPHY 202
Injuries 192
SKILL STATION XII: Musculoskeletal
Major Pelvic Disruption with Hemorrhage 192
Trauma: Assessment
Major Arterial Hemorrhage 193
and Management 205
Crush Syndrome (Traumatic Rhabdomyolysis} 194
limb-Threatening Injuries 194 Skill XII-A: Physical Examination 206
Open Fractures and Joint Injuries 194 Skill XIIB: Principles of Extremity
Vascular Injuries, Including Traumatic Immobilization 207
Amputation 195 Skill XII-C: Realigning a Deformed Extremity 207
Compartment Syndrome 196 Skill XIID: Application of a Traction Splint 208
Neurologic Injury Secondary to Skill XII-E: Compartment Syndrome:
Fracture Dislocation
- 197 Assessment and Management 209
Other Extremity Injuries 197 Skill XII-F: Identification and
Contusions and Lacerations 197 Management of Pelvic Fractures 209
Joint Injuries 199 Skill XII-G: Identification of Arterial Injury 210
Fractures 199 Scenarios 210
Principles of Immobilization 19 9
9 Thermal Injuries 21 1
OBJECTIVES 211 Airway 213

Introduction 212 Breathing 213
Immediate lifesaving Measures for Circulating Blood Volume 216
Burn Injuries 212 Secondary Survey and Related Adjuncts 217
Airway 212 Physical Examination 217
Stop the Burning Process 212 Documentation 217
Intravenous Access 212 Baseline Determinations for Patients with
Assessment of Patients with Burns 213 Major Burns 217
History 213 Peripheral Circulation in Circumferential
Body-Surface Area 213 Extremity Burns 217
Depth of Burn 213 Gastric Tube Insertion 217
Primary Survey and Resuscitation Narcotics, Analgesics, and Sedatives 217
of Patients with Burns 213 Wound Care 217
XXX CONTE NTS
Antibiotics 217 Types of Cold Injury 219

Tetanus 218 Management of Frostbite and Nonfreezing
Special Burn Requirements 218 Cold Injuries 220
Chemical Burns 218 Cold Injury: Systemic Hypothermia 221
Electrical Burns 218 Signs 221
Patient Transfer 219 Management 221
Criteria for Tra nsfer 219 CHAPTER SUMMARY 223
Transfer Procedures 219 BIBLIOGRAPHY 224
Cold Injury: Local Tissue Effects 219
10 Pediatric Trauma 225

OBJECTIVES 225 Thermoregulation 237

Introduction 226 Chest Trauma 237
Types and Patterns of Injury 226 Abdominal Trauma 237
Unique Characteristics of Pediatric Assessment 237
Patients 226 Diagnostic Adjuncts 237
Size and Shape 226 Nonoperative Management 238
Skeleton 227 Specific Visceral Injuries 239
Surface Area 227 Head Trauma 239
Psychological Status 227 Assessment 239
Long-Term Effects 227 Management 241
Equipment 228 Spinal Cord Injury 241
Airway: Evaluation and Management 228 Anatomic Differences 241
Anatomy 228 Radiologic Considerations 241
Management 228 Musculoskeletal Trauma 242
Breathing: Evaluation and Management 232 History 242
Breathing and Ventilation 232 Blood Loss 242
Needle and Tube Thoracostomy 233 Special Considerations of the Immature
Circulation and Shock: Evaluation Skeleton 242
and Management 233 Principles of Immobilization 242
Recognition 233 The Battered, Abused Child 242
Fluid Resuscitation 234 Prevention 243
Blood Replacement 235 CHAPTER SUMMARY 244
Venous Access 235 BIBLIOGRAPHY 244
Urine Output 236
11 Geriatric Trauma 247
OBJECTIVES 247 Exposure and Environment 253

Introduction 248 Other Systems 253
Types and Patterns of Injury 248 Musculoskeletal System 253
Airway 250 Nutrition and Metabolism 254
Breathing and Ventilation 250 Immune System and Infections 254
Circulation 251 Special Circumstances 254
Changes with Aging 251 Medications 254
Evaluation and Management 251 Elder Abuse 255
Disability: Brain and Spinal Cord Injuries 252 End-of-Life Decisions 25 5
Changes with Aging 252 CHAPTER SUMMARY 256
Evaluation and Management 252 BIBLIOGRAPHY 257
CONTENTS XXXI
12 Trauma in Women 25 9.

OBJECTIVES 259 Mechanisms of Injury 263
Introduction 260 Blunt Injury 263
Anatomic and Physiologic Penetrating Injury 263
Alterations of Pregnancy 260 Severity of Injury 264
Anatomic Differences 260 Assessment and Treatment 264
Blood Volume and Composition 261 Primary Survey and Resuscitation 264
Hemodynamics 261 Adjuncts to Primary Survey and Resuscitation 265
Respiratory System 262 Secondary Assessment 265
Gastrointestinal System 262 Definitive Care 265
Urinary System 262 Perimortem Cesarean Section 266
Endocrine System 263 Domestic Violence 266
Musculoskeletal System 263 CHAPTER SUMMARY 267
Neurologic System 263 BIBLIOGRAPHY 267
13 Transfer to Definitive Care 269
OBJECTIVES 269 Transfer Protocols 274

Introduction 270 Information from Referring Doctor 274
Determining the Need for Patient Transfer 270 Information to Tra nsferring Personnel 274
Timeliness of Transfer 270 Documentation 274
Transfer Factors 270 Treatment Prior to Transfer 274
Transfer Responsibilities 273 Treatment During Transport 276
Referring Doctor 273 Transfer Data 276
Receiving Doctor 27 3 CHAPTER SUMMARY 276
Modes of Transportation 273 BIBLIOGRAPHY 276
Appendices 277
Appendix A: Injury Prevention 279
Classification of Injury Prevention 279 Develop and Test Interventions 281

Haddon Matrix 279 Implement Injury-Prevention Strategies 281
The Four Es of Injury Prevention 279 Evaluate Impact 281
Developing an Injury Prevention Appendix A Summary 281
Program-The Public Approach 280 BIBLIOGRAPHY 282
Define the Problem 280 RESOURCES 282
Define Causes and Risk Factors 280
Appendix B: Biomechanics of Injury 283
Introduction 283 Penetrating Trauma 286

Blunt Trauma 283 Velocity 286
Vehicular Impact 283 Bullets 287
Pedestrian Injury 285 Shotgun Wounds 287
Injury to Cyclists 285 Entrance and Exit Wounds 288
Falls 285 BIBLIOGRAPHY 288
Blast Injury 286
XXXII CONTENTS
Appendix C: Trauma Scores: Revised and Pediatric 289
Introduction 289 Level of Consciousness 289

Revised Trauma Score "'289 Musculoskeletal Injury 289
Pediatric Trauma Score 289 Use of the PTS 289
Size 289
Appendix D: Sample Tra uma Flow Sheet 293
Appendix E: Tetanus Immunization 297
Introduction 297 Passive Immunization 298

General Principles 297 BIBLIOGRAPHY 298

Surgical Wound Care 297
Appendix F: Ocular Trauma (Optional lecture) 299
OBJECTIVES 299 Injury to the Iris 301

Introduction 299 Injury to the Lens 301
Assessment 299 Vitreous Injury 301
Patient History 299 Injury to the Retina 302
History of Injury Incident 299 Globe Injury 302
Initial Symptoms 300 Chemical Injury 302
Physical Examination 300 Fractures 302
Specific Injuries 301 Retrobulbar Hematoma 303
Eyelid Injury 301 Fat Emboli 303
Corneal Injury 301 Appendix F Summary 303
Anterior Chamber Injury 301 BIBLIOGRAPHY 303
Appendix G: Austere Environments: Military Casualty Care and Trauma

Care in Underdeveloped Areas and Following Catastrophes (Optional lecture) 305
OBJECTIVES 305 Airway 308

Introduction 305 Ventilation and Oxygenation 309
Background 305 Chest Injuries 310
Austere and Hostile Environments: Management of Circulation 310
Context 305 Hemostasis 310
Personnel and Their Safety 306 Resuscitation 311
Communication and Tra nsportation 306 Pain Management 312
Equipment and Supplies 306 Management of Specific Injuries 312
Military Combat Casualty Care 306 Abdominal Injuries 312
Medical Units 307 Extremity Injuries 313
Other Challenging Environments 307 Burn Injuries 314
Preparation and Planning 307 Preparation for Transport 314
Travel to an Austere or Hostile Environment 307 Environmental Extremes of Heat
Preparation of a Hospital for Becoming an and Cold 315
Austere or Hostile Environment 308 Cold Injury and Hypothermia 315
Management of Airway and Breathing 308 Heat-Related Illness or Injury 315
...
CONTENTS XXXIII
Communications and Signaling 316 Appendix G Summary 318

Triage 317 BIBLIOGRAPHY 318
Appendix H: Disaster Management and Emergency Preparedness

(Optional lecture) 321
OBJEGIVES 321 Mitigation 326
Introduction 321 Response 327
The Need 321 Recovery 330
The Approach 324 Pitfalls 33 1
Phases of Disaster Management 324 Appendix H Summary 335

Preparation 324 B I BLIOGRAP H Y 335
Appendix 1 : Triage Scenarios 335
OBJECTIVES 337 Triage Is Continuous (Retriage) 338

Introduction 33 7 Triage Scenario 1: Gas Explosion in
Definition of Triage 337 the Gymnasium 339
Principles of Triage 337 Triage Scenario II: Gas Explosion in
Do the Most Good for the Most the Gymnasium (continued) 342
Patients Using Available Resources 337 Triage Scenario Ill: Tra iler Home Explo sion
Make a Decision 337 and Fire 344
Triage Occurs at Multiple Levels 337 Triage Scenario IV: Cold Injury 346
Know and Understand the Resources Available 338 Triage Scenario V: Car Crash 348
Planning and Rehearsal 338 Triage Scenario VI: Train Crash Disaster 350
Determine Triage Category Types 338
Index 351

C H APT E R
CHAPTER OUTLINE Upon completion of this topi c the student will demonstrate
,
the ability to a pply the p rinciples of emergency medical care

Objectives
to multiply InJUred pa lients. S pecific ally the doctor will be
,
Introduction able to
Preparation
Prehospital Phase OBJECTIVES
Hospital Phase
Triage Identify the correct sequence of priorities for as
Multiple Casualties sessment of a multiply i njured patient.
Mass Casualties
Apply the principles outlined in the primary and
Primary Survey
secondary evaluation surveys t o t h e assessment of
Airway Maintenance with Cervical Spine Protection
a multiply injured patient.
Breathing and Ventilation
Circulation with Hemorrhage Control Apply guidelines and techniques i n the initial re
Disability (Neurologic Evaluation) suscitative and definitive-care phases of treatment
Exposure/Environmental Control of a mu ltiply injured p a tient.
Resuscitation
Airway
Explain how a patient's medical h istory and the
BreathingfVentilation/Oxygenation
mechanism of injury contribute to the identifica
Circulation and Bleeding Control tion of injuries.
Adjuncts to Primary Survey and Resuscitation Identify the pitfalls associated with the initial as
Electrocardiographic Monitoring sessment and management of an injured patient
Urinary and Gastric Catheters and take steps to minimize their impact.
Other Monitoring
XRay Examinations and Diagnostic Studies Conduct an initial assessment survey on a simu
lated multiply injured patient, using the correct
Consider Need for Patient Transfer
sequence of priorities and explaining manage
Secondary Survey ment techniques for primary treatment and stabi
H istory l ization
.
Physical Examination
Adjuncts to the Secondary Survey
Reevaluation
Definitive Care
Disaster
Records and Legal Considerations
Records
Consent forTreatment
Forensic Evidence
Chapter Summary
Bibliography
2 CHAPTER 1 Initial Assessment and Management
Introduction
.
The treatment of serio usly inj ured pat ients requires rapid
assessment of the inju ries .md institution of life-preserving
therapy. Because time is of the essence, a systematic ap
proach that can be easily reviewed and pract iced is most ef
fective This process is termed ''initial assessment" and
.
includes:
Preparati on
Triage
Primary survey (A BCDEs)
Resu:.cital ion
Adju nc ts to primary survey and resuscitation
Cons i der need for patient transfer
Second try survey (head-to-toe evaluation and pa

,
tient history)
Adj uncts to the seconda ry survey
Cont in ued post rcsuscita tion mo nitoring and

PREHOSPITAL PHASE
reeval uation

Coordination with the prehospital agency and perso n nel
Definitive care
can greatly expedite treatment in the field. The prebospi tal
system !>houlcl be set up to not ify the receiving hos pital be
The primary and secondary surveys should be repeated fore personncl tramport the pati ent from the scene. This aJ
frequently to identify any deterioration in the patient's status Iow for mobili:ation of the hospital s trauma team
'
and to determine whether it is necessary to institute any treat

members so that <Ill necc!.sary personnel and resources are
ment when adverse changes are identified.
presen t in the em ergen cy depa rt ment (ED) at the time of
The assessment sequence presented in this chapter reflects
the pati en t s a rrival .
'
a linear, or long i tudi nal progression of event s Ln an actual clin

.
Du r i ng t he preho spi l al phase, emph asis should be
ical situation many of these activities occur in parallel or si
, ,
placed o n ai rway maintenance, control of exter nal bleed
multaneously. The lo ngitudina l progression of the assessment
ing and shock, i m mobi l izat i on of the pati en t and imme
,
process allows the doctor an opp ortuni ty to m entally review

diate tranoport to the cl osest a ppropri a te fa ci l i ty ,
the progress of nn actua l trauma resuscitation.

preferabl y n verified trau ma center. Every effort should be
ATLS principles guide the assessment and resuscita
made to minimize scene time (see Figure 1 - 1 ) Emphasis .
tion of injured patients. Judgment is required to determine

also should be placed on obtaining a nd reporting infor
which procedures are necessary, because not all patients re
mation needed for triage at the h ospital, (eg time of in
,
quire all ofthese procedures.

jury, events related to the i njury and pat ien t histo ry) The
, .
mechanisms of i njury Clll suggest the d egree of inj ury as

well as s pecific i nj uries for which the patient must be eval
uated .
Preparation The National Asso<..iation of Emergency Medical Tech

nicians' Prehmpital Trauma Life Suppo rt Committee, in co
I How do I prepare for a smooth operation with the Committee on Trauma (COT) of the
American College of Surgeons (ACS), has developed a
transition from the prehospita/ to the
course with a formal similar to the ATLS Course that ad
hospital environment?
drescs prehospital care for inju red patients.
Preparation for the trauma patient occurs in hvo different
clinical scllings. First, durin g the prehospital phase, all events
HOSPITAL PHASE
must be coord inaIt'd with I he doctors at t he receivin g hospi
tal. Second, du ri ng the lwspiral phase, preparations must be Advance planning for the trauma pa tien t s arrival is es
'
made to rapidly faci litate the trauma pat ien t s resuscitation.

' sential. I dea l l y, a resuscitation area is available for
PREPARATION 3
Measure Vital Signs and Level of Consciousness
Glasgow Coma Scale < 1 4 or Systolic blood pressure, mm Hg <90 or

Respiratory rate, /min <10 or >29 (<20 in infant less than 1 year)
Step 1
Take to trauma center. Steps 1 and 2 triage attempts to identify the most Assess anatomy of injury
seriously injured patients in the field. These patients would be transported
preferentially to the highest level of care within the trauma system.
All penetrating injuries to head, neck, torso and Amputation proximal to wrist and ankle
extremities proximal to elbow and knee Pelvic fracture
Flail chest Open and depressed skull fracture
lWo or more proximal longbone fractures Paralysis
Crush, degloved, or mangled extremity
Step 2
Take to trauma center. Steps 1 and 2 triage attempts to identify the most Assess mechanism of
seriously injured patients in the field. These patients would be transported injury and evidence
preferentially to the highest level of care within the trauma system. of high-energy impact
Falls Auto v pedestrian/bicyclist thrown, run over,

Adults: >20 ft (1 story 10 ft)
= or with significant (>20 mph) impact
Children: > 1 0 ft or 2 to 3 times the height of the child Motorcycle crash >20 mph
High-risk auto crash
Intrusion: >12 in, occupant site: >18 in, any site
Ejection (partial or complete) from automobile
Step 3 Death in same passenger compartment
Vehicle telemetry data consistent with high risk of injury
Transport to closest appropriate trauma center which, depending on Assess special patient or
the trauma system, need not be the highest level trauma center system considerations
Age Time-sensitive extremity injury

Older adults: Risk of injury/death increases after age 55 Pregnancy >20 weeks
Children: Should be triaged preferentially to EMS provider judgement
pediatric-capable trauma centers End-stage renal disease requiring dialysis
Anticoagulation and bleeding disorders
Burns
Step 4 Without other trauma mechanism: Triage to purn facility
With trauma mechanism: Triage to trauma center
Contact medical control and consider transport to Transport according

trauma center or a specific resource hospital to protocol
When in doubt, transport to a trauma center
Figure 1 - 1 Field Triage Decision Scheme.

4 CHAPTER 1 I n itia l Assessment and Management
trauma patients. Proper airway equipment (eg, laryngo Two types of triage situations usually exist: multiple ca
scopes and tubes) should be organized, tested, and sua I ties and mass casualties.
placed where it is immediately accessible. Warmed in
travenous crystalloid solutions shouJd be available ancL
MULTIPLE CASUALTIES
ready to infuse when the patient arrives. Appropriate
monitoring capabilities should be immediately available. In mtlltiple-casualty incidents, the 1mmber of patients and
A method to summon additional medical assistance the severity of their injuries do not exceed the ability of the
should be i n place, as well as a means to ensure prompt facility to render care. In such situations, patients with life
responses by laboratory and radiology personnel. Trans threatening problems and those sustaining multiple-system
fer agreements with verified trauma centers sbouJd be injuries arc treated first. The use of prehospital care proto
established and operational. rl' See American College o f cols and online medical direction can facilitate and improve
Surgeons Committee on Trauma (ACS COT), Resource:; care initiated in the field. Periodic multidisciplinary review
for Optimal Care of the lnj11red Patient, 2006. Periodk re of the care provided through quality improvement activi
view of patient care through the quality improvement ties is essenti<1l.
process is an essential component of each hospital's
trauma progra rn.
MASS CASUALTIES
All personnel who have contact with the patient must
be protected from communicable diseases. Most promi l n mass-casualty events, the number of patients and the
nent among these diseases are hepatitis and the acqui red severity of their injuries exceed the capability of the facility
immu nodeficiency syndrome (AlDS). The Centers for Dis and staff. In such situations, the patients with the greatest
ease Control and Prevention (CDC) and other health chance of smYival and requiring the least expenditure of
agencies strongly recommend the use of standard precau lime, eqLJipmenl, supplies, and personnel, are treated first.
tiom (eg, face mask, eye protection, water-impervious
apron, leggings, <tnd gloves) when coming into contact
with body fluids. The ACS COT considers these to be min Primary Survey
inwm precautions and protection for all health-care
What is a quick, simple way to assess

providers. Standard precautions are also an Occupational
Safety and Health Administration (OSHA) requirement in
1 he United States. the patient in 10 seconds?
Patients are assessed, and their treatment priorities are

established, bas<.:d on their injuries, vital signs, and the
Triage
Triage involves the sorting of patients based on their need
for treatment and the resources available to provide that
treatment. Treatment is rendered based on the ABC priori
ties (Ai rway with cervical spine protection, Breathing, and
Circulation with hemorrhage control), as outtined later in
this chapter
Triage also pert<lins t o the sorting o f patients in the
field and the decision regarding to which medical facil
ity they should be transported. It is the responsibility of
the prehospilal personnel and their medical director to
ensure Lhat appropriate patients arrive at appropriate
hospitals. For example, it is inappropriate for prehospi
tal personnel to deliver a patient who bas sustained se
vere trauma to a hospital that is not a trauma center if a
trauma center is available at another hospital (sec Fig
ure 1 - 1 ) Prehospital trauma scoring i s helpful in identi
.
fying severely injured patients who should be

transported to a trauma center. . See Appendix l: Triage
Scenarios and Appendix: C: Trnuma Scores: Revised and
Pediatric.
PRIMARY SURVEY 5
injury mechanisms. Tn severely inju red patients, logical physiologic stress caused by injury. ComorbidiLics such as
and sequential treatment priorities must be established diabetes, congestive heart failltre, coronary artery disease,
based on overall patient assessmenL The patient's vital restrictive and obstructive puJmonary disease, coagulopa
functions must be assessed quickly and efficien tly. Man thy, liver disease, and peripheral vascular disease are more
agement consists of a rapid primary survey, resuscitation common i n older patients and adversely affect outcomes
of vital functions, a more detailed secondary survey, and, fo llowing injury. In addition, the long-term use of medica
finaUy, the initiation of definitive care. This process con tions may alter the usual physiologic response to injury, and
stitutes the ABCDEs of trauma care and identifies Life the narrow therapeutic vv.indow frequently leads to over-re
threatening conditions by adhering to the rollowing suscitation or under-resuscitation i.n this patient popula
sequence: tion. As such, early, invasive mon.itOL-illg is frequently a
valuable adjunct to managemenl. Despite these facts, most
1 . Airway maintenance with cervical spine protection elderly trauma patients recover and return to their prein
jury level of independent activity i f appropriately treated.
2. Breathing and ventilation
Prompt, aggressive resuscitation and the early recognition
3. Circulation with hemorrhage control of preex isting medical conditions and medication use can
improve survival in Lhis patient group. rfl See Chapter 1 1 :
4. Disability: Neurologic status
Geriatric Trawna.
5. Exposure/Environmental control: Completely uml rcss
rhe patient, but prevent hypothermia
AIRWAY MAINTENANCE WITH
CERVICAL SPINE PROTECTION
During the primary survey, life-threatening conditions
arc identified, and. management is instituted simultaneously. Upon initial evaluation of a trauma patient, the airway
The prioritized assessment and management procedures de should be assessed first to ascertain patency. This rapid as
scribed in this chapter arc presented as sequential steps i n sessment for signs of airway obstruction should include in
order or importance and for the purpose of clarity. How spection for foreign bodies and facial, mandibular, or
ever, these steps are frequently accomplished simultane tracheal/laryngeal fractures that may result in airway ob
ously. struclion. Measures to establish a patent airway should be
Priorities for the care of pediatric patieuts are the same instituted while protecting ll1e cervical spine. Initially, the
as those for adults. Although the quantities of blood, fluids, chin-lift or jaw-tl1rust maneuver is recommended to achieve
and medications; size of the child; degree and rapidity of airway patency.
heat loss; and injury patterns may d iffer, the assessment and If the patient is able to communicate verbally, the air
management priorities are identical. rfl Specific issues re way is not likely to be in immediate jeopardy; however, re
lated to pediatric trauma patients are addressed in Chapter peated assessment of airway patency is prudent. In addition,
10: Pediatric Trauma. patients with severe head injmi.es who have an altered level
Priorities for the care ofpregnantfemales are similar to of consciousness or a Glasgow Coma Scale (GCS) score of8
those for nonpregnant females, but the anatomic <tnd phys or less usually require the placement of a definitive airway.
iologic changes of pregnancy may modify the patient's re The finding of nonpurposcful motor responses strongly
sponse to inju ry. Early recogn ition of pregnancy by suggests the need for ddlnitive airway managemenL Man
palpation of the abdomen for a gravid uterus and labora agement of the airway in pediatric patients requires knowl
tory testing (human chorionic gonadotropin, or hCG) and edge of the unique anatomic features of the position and
early fetal assessment are important for malernal and fetal size of the larynx in children, as well as special equipment.
survival. . Specific issues related to pregnant patients are rfl See Chapter I 0: Pediatric Trauma.
addressed in Chapter 12: Trauma in Women. While assessing and managing the patient's airway,
Trauma is a common cause of death in the elderly. With great care should be taken to prevent excessive movement
increasing age, cardiovascular disease and cancer overtake of the cervical spine. The patient's head and neck sbould not
the incidence of injmy as the leading causes of death. Inter be hyperextendcd, hyperflexcd, or rotated to establish and
estingly, the risk of deatb for any given injury at the lower maintain the airway. Based on a history or a traumatic inci
and moderate Injury Severity Score (lSS) levels is greater for dent, loss of stability of the cervical spine should be sus
elderly males than for elderly females. pected. Neurologic examination alone does not exclude a
Resuscitation of elderly patients warrants special at diagnosis of cervical spine injury. Protection of the patient's
tention. The aging process diminishes the physiologic re spinal cord with appropriate immobilization devices should
serve of elderly lrauma patients, and chronic cardiac, be accomplished and maintained. If immobilization devices
respiratory, and metabolic diseases can reduce the ability must be removed temporarily, one member of the trauma
of these patients to respond to injury i n the same ma_nner team should manually stabiJ.ize the patient's bead and neck
in which younger patients are able to compensate for the using inlinc i mmobilization techniques (Figure 1-2).
Despite the efforts of even the most prudent and

attentive doctor, there are circumstances in which
airway management is exceptionally difficult and
occasionally even impossible to achieve. Equip
ment failure often cannot be anticipated, for ex
ample, the light on the laryngoscope burns out or
the cuff on the endotracheal tube that was placed
with exceptional difficulty leaks because it was
torn on the patient's teeth during intubation.
Tragic pitfalls include patients in whom intubation
cannot be performed after paralysis and patients
i n whom a surgical airway cannot be established
expediently because of their obesity.
Endotracheal intubation of a patient with an un
known laryngeal fracture or incomplete upper air
Figure 1 -2 If immobilization devices must be way transection can precipitate total airway
removed temporarily, one member of the trauma occlusion or complete airway transection. This may
team should manually stabilize the patient's occur in the absence of clinical findings that sug
head and neck using inline immobilization gest the potential for an airway problem, or when
techniques. the urgency of the situation dictates the immedi
ate need for a secure airway or ventilation.
These pitfalls cannot always be prevented. However,
they should be anticipated, and preparations should
be made to minimize their im pact.
The stabilization equ i p ment used 10 protect the pa
l ienl's sp i na l cord should be left in pl ace u nt i l c ervi cal sp in e
i nju ry has been exc l u ded. Protection of the spine and spinal
cord is a critically important management princi pl e Cervi .
thora' du ri n g a noisy resuscitation may be d i ffi cu l t or
produce unreliable results.
cal spine radiographs may be obtained to confirm or ex
clude injury once immediate or poten t ial ly l ife-threatening Injuries that can impair ventilation in the short term in
conditions have been addressed. Assume a cervical spine in clude tension pneumothorax, flail che:.t with pulmonary con
jury in any patient with multisystem trauma, especially those tusion, massive hemothora,x, and open pneumothorax. These
with an altered level ofconsciousness or a blunt i njury above injuries should be identified during the primary sur vey. Sim
the clavicle. rl' See Ch apte r 7: Spine nnd Sp i nal Co rd ple pneumothorax or hemothorax, fractured ribs, and pul
Tr auma. monary contusion can compromise ventilation to a lesser

degree and arc usu ally identiricd during I he secondary su rvey.
Every effort should be made to promptly identify air
way compromise and secW'e a dcrinitive a i rway Equ al ly im .
portant is the necessity to recogni;e the potcntiaJ for

.
progressive airway loss. frequent reevaluation of airway pa ..
. .
PITFALLS ..,_
_..
.. .
.._
tency is esscntiaJ to identify and treat pa tients who are los
ing the abil ity to maintain an adequate airway. Differentiating between ventilation problems and
airway compromise can be difficult:
BREATHING AND VENTILATION A patient who has profound dyspnea and tachy
pnea gives the impression that his or her primary
Ai rway patency alone d ocs n o t ensu re a deq uat e ventila problem is related to an inadequate airway. How
tion. Adequate gas exchange i s requ i red to maxim i ze oxy ever, if the ventilation problem is caused by a
genation and carbon dioxide elimination. Ventilation pneumothorax or tension pneumothorax, intuba
requires adequate function of the lu ng chest waU, and di
.
tion with vigorous bag-valve ventilation can rap
idly lead to further deterioration of the patient.
aphr agm Lach component must he examined and evaJu
.
ared r api dly.

When mtubation and ventilation are necessary in
an unconscious patient, the procedure itself can
The pa t ien t s chest shou ld b e exp()sed to adequately
'
unmask o r aggravate a pneumothorax, and the

assess che:;t wall excursion. and a uscu l ta t i on should be
patient's chest must be reevaluated. Chest x-rays
perfo rm e d t() ensure gas flow in the lungs. Visual inspec
should be obtained as soon after intubation and
tion and palpation can detect injuries to the chest wall initiation of ventilation as is practical.
that mi gh t compromise ventilation. Percussion of th e
PRIMARY SURVEY 7
CIRCULATION WITH HEMORRHAGE CONTROL '
PITFALLS
-
-10
' ,14jH
: -
'-
Circulation issues to consider include blood volume and
l..o
cardiac output, and bleeding. Trauma respects no patient population barrier. The

elderly, children, athletes, and individuals with

chronic medical conditions do not respond to vol
Blood Volume and Cardiac Output
ume loss in a similar or even in a " normal" manner.
Hemorrhage is 1 he predominant cause of preventable deaths
Elderly patients have a limited ability to increase
after inju ry. Hypotension following injury must be consid
their heart rate in response to blood loss, which
ered to be hypovolemic in origin until proved otherwise;
obscures one of the earliest signs of volume de
therefore, rapid and accurate assessment of an injured pa
pletion-tachycardia. Blood pressure has little cor
tient's hemodynamic status is essential. The clements of relation with cardiac output in older patients.
clinical observation that yield important iJlformation within Anticoagulation therapy for medical conditions
seconds are level of consciousness, skin color, <1nd pulse. such as atrial fibrillation, coronary artery disease,
and transient ischemic attacks can increase blood
Level of Consciousness When circulating blood volwne loss.
is reduced, cerebral perfusion may be critically impaired, re Children usua ll y have abundant physiologic re
sulting in altered levels of consciousness. However, a conscious serve and often have few signs of hypovolemia,
patient also may have lost a significant amount of blood. even after severe volume depletion. When deteri
oration does occur, it is precipitous and cata
strophic.
Skin Color Skin color can be helpful in evaluating lhe in
Well-trained athletes have similar compensatory
jured patient who has hypovolemia. A patient with pink skin,
mechanisms, may have bradycardia, and may not
especially in the face and extremities, rarely has critical hypo
have the usual level of tachycardia with blood
volemia after injury. Conversely, the patient with hypovolemia
loss.
may have ashen, gray facial skin and white extremities.
Often, the AMPLE history, described later in this
chapter, is not available, so the health-care team is
Pulse The pulse, rypically an easily accessible central pulse
not aware of the patient's use of medications for
(femoral or carotid artery), should be assessed bilateraUy for chronic conditions.
quality, rate, and regularity. Pull, slow, and regular peripheral
Anticipation and an attitude of skepticism regard
pulses are usually signs of relative normovolemia in a patient ing the patient's "normal" hemodynamic status are
who is not taking B-adrcnergic blocking medications. A rapid, appropriate.
thready pulse is typically a sign of hypovolemia, but the con
dition may have other causes. A normal pulse rate does not
ensure Lhat a patient has normovolemia, bul an irregular
The GCS is a qui ck, simple method for determining tl1e
pulse does warn of potential c<1rdiac dysfunction. Absent cen
level of consciousness that is predictive of patient outcome-
tral pulses that are not attributable to local factors signify lhe
particularly the best motor response. [f it was not performed
need for inm1ediate resuscitative action to restore depleted
during the primary survey, the GCS should be performed as
blood volL1me and effective cardiac output.
part ofthe more detailed, quantitative neurologic examination
during the secondary smvey. ,. See Chapter 6: Head Trauma
Bleeding and Appendix C: 'frauma Scores: Revised and Pediatric.
External hemorrhage is identified and controlled during the A decrease in the level of consciousness may indicate
primary survey. Rapid, external blood loss is managed by di decreased cerebral oxygenation and/or perfusion, or it may
rect manual pressure on the wound. Pneumatic splinting be caused by direct cerebral iJljuty An altered level of con
devices aJso can help to control hemorrhage. These devices sciousness indica tcs the need for immediate reevaluation of
should be transparent lo allow for rnon.iloring of underlying the patient's OX')'genation, ventilation, and perfusion status.
bleeding. To urniquets are infrequently used to control se Hypoglycemia and alcohol, narcotics, and other ru-ugs also
vere bleeding. The use of hemostats can damage nerves and can alter the patient's level of consciousness. However, if
veins. The major areas of occult blood loss are the chest, ab these factors are excluded, changes i n the level of con
domen, retroperitoneum, pelvis, and long bones. sciousness should be considered to be of traumatic central
nervous system origin until proven otherwise.
DISABILITY (NEUROLOGIC EVALUATION)

EXPOSURE/ENVIRONMENTAL CONTROL
A rapid neurologic evaluation is performed at the end of the
primary survey. This neurologic evaluation establishes the The patient should be completely undressed, usuaUy by cut
patient's level of consciousness, pupillary size a11d reaction, ting off his or her garments to facilitate a thorough exami
lateralizing signs, and spinal cord injury level. nation and assessment. After the patient's clothing has been
injured patient should receive supplemental oxygen. lf not

PITFALL ...
' ..
intubated, the patient should have mrygen delivered by a
II
.'
_,
. , .
-
mask-reservoir device to achieve optimal oxygenation. The

Despite proper attention to all aspects of treating a use of the pulse oximeter is valuable in ensuring adequate
patient with a closed head injury, neurologic deteri-
hemoglobin saturation. .. See Chapter 2: Airway and Ven
oration can occur-often rapidly. The lucid interval
tilatory Management.
classically associated with acute epidural hematoma
is an example of a situation in which the patient will
"talk and die." Frequent neurologic reevaluation CIRCUlATION AND BlEEDING CONTROl
can minimize this problem by allowing for early de
tection of changes. It may be necessary to return to Definitive bleeding control is essential, and intravenous re
the primary survey and to confirm that the patient placement ofintravascular volume is important. A minimum
has a secure airway, adequate ventilation and oxy of two large-caliber intravenous (fV) catheters should be in
genation, and adequate cerebral perfusion. Early troduced. The maximum rate of flwd admiJ1istration is de
consultation with a neurosurgeon also is necessary termined by the internal diameter of ll1e catheter and
to guide additional management efforts. inversely by its length-not by the size of the vein i n whid1
the catheter is placed. Establishment of upper-extremity pe
ri pheral fV access is preferred. Other peripheral lines, cut
removed and the assessment completed, cover the patient downs, and central. venous lines should be used as necessary
with warm blankets or an external warming device to pre in accordance with the skill level of the doctor who is caring
vent hypothermia in the ED. hTt ravenous Ouids should be for the patient. .. See Skill Station IV: Shock Assessment and
warmed before being infused, and a warm environment Management, and Skill Station V: Venous Cutdmvu, in
(room temperature) should be maintajned. The patient's Chapter 3: Shock. At lhe Lime ofTV insertion, draw blood for
body temperature is more important than the comfort ofthe type and crossmatch and baseline hematologic studies, in
health-care providers. cluding a pregnancy test for all females of childbeariJ1g age.
Aggresis ve and continued volume resuscitation is not a sub
stitute for definitive control of hemorrhage. Definitive control
includes operation, angioembolization and pelvic stabilization.
Resuscitation IV fluid therapy \A.'ith crystalloids should be initiated. Such
bolus rv therapy may require the adminjstration of 1 to 2 L of
Aggressive resuscitation and the management oflife-threat an isotonic solution to achjeve an appropriate response in the
ening injuries as they are identified are essential to maximize adult patienL. All N solutions should be warmed either by stor
patient survival. Resusication also follows the ABC sequence. age in a warm environment (37'C to 40C, or 98.6 F to 104 F)
or fluid-warming devices. Shock associated with injury is most
often hypovolemic in origin. If the patient remaillS Lmrespon
AIRWAY
sive to bolus rv therapy, blood transfusion may be required.
The airway should be protected in all patients and secured Hypothermia may be present when the patient arrives,
when there is a potential for airway compromise. The jaw or il may develop quickly i n the ED if the patient is uncovered
thmst or chin-lift maneuver may suffice as an initial inter and tmdergoes rapid administration of room-1emperature
vention. If the patient is w1conscious and has no gag reflex, t1uids or refrigerated blood. Hypothermia is a potentially
the establishment of an oropharyngeal ainvay can be help lethal complication iJ1 injured patients, and aggressive mea-
ful temporarily. A definitive airway (ie, intubation) should be
established ifthere is any doubt about the patient's ability to
maintain airway integrity. -
PITFALL '- -
' .1
BREATHING/VENTilATION/OXYGENATION Injured patients can arrive i n the ED with hypother

mia, and hypothermia may develop i n some patients
Definitive control of the ai nvay in patients who have com who require massive transfusions and crystalloid re
promised ajnvays due to mechanical factors, have ventila suscitation despite aggressive efforts to maintain
tory problems, or are unconscious is achieved by body heat. The problem is best minimized by early
endotracheal jntubation. This procedure should be per control of hemorrhage. This can require operative in
tanned with continuous protection of tbe cervical spine. An
tervention or the application of a n external com
pression device to reduce the pelvic volume for
airway should be established surgically if intubation .is con
patients with certain types of pelvic fractures. Efforts
lramdicated or cannot be accomplished.
to rewarm the patient and prevent hypothermia
A tension pneumoll10rax compromises venLiJation and
should be considered as important as any other com
circulation dramatically and acutely; if one is suspected, ponent of the primary survey and resuscitation phase.
chest decompression should be started immediately. Every
ADJU NCTS TO PRIMARY SURVEY AND RESUSCITATION 9
sures should be taken to prevent the loss of body heat and re

store body temperature to normaL The temperature of Lhe
resuscitation area should be increased to minimize the Joss of
body heal. The use of a high-flow fluid wam1er or microwave Sometimes anatomic abnormalities (eg, urethral stric

ture or prostatic hypertrophy) preclude placement of
oven to heat crystalloid fluids to 39C (102.2F) is recom-
a n indwell in g bladder catheter, despite meticulous
mended. However blood products should not be warmed in
technique. Nonspecialists should avoid excessive ma
a microwave oven . .. See Chapter 3: Shock. nipulation of the urethra or use of specialized instru
mentation. Consult a urologist early .

found hypovolemia. vVhen bradycardia, aberrant conduc
and Resuscitation tion, and premature beals are p.resent, hypoxia and hypo
perfusion should be suspected immediately. Extreme
Adjuncts that are used during the primary survey and re hypothermia also produces these dysrhythmias. .. See
suscitation phases include electrocardiographic monitoring; Chapter 3: Shock.
urinary and gastric catheters; other monitoring, such as of
ventilatory rate, arterial blood gas (ABG) levels, pulse URINARY AND GASTRIC CATHETERS
oximetry, and blood pressure; and x-ray examination and
diagnostic studies. The placement of urinary and gastric catheters should be
considered as part of the resuscital ion phase. A urine spec
imen should be submitted for routine laboratory analysis.
ElECTROCARDIOGRAPHIC MONITORING
Electrocardiographic (ECG) monitoring of all trauma pa Urinary Catheters
tients is important. Dysrhythmias-including unexplained Urinruy oul-pul is a sensitive indicator of the patient's vol
tachycardia, atrial fibrillation, premature ventricular con ume status and rcllects renal perfusion. Monitoring of uri
tractions, and ST segment changes-can indicate blunt car nary output is best accomplished by the insertion of an
diac injury. PuJseless electrical activity (PEA) can indicate indwelling bladder catheter. Trru1surethral bladder caLheter
cardiac tamponade, tension pneumothorax, and/or pro- ization is contraindicated in patients in whom urethral tran
section is suspected. Urethral injury should be suspected in
the presence of one of the following:
Blood at the uretJ1 ral meatus
Perineal ecchymosis
Blood i n tJ1 e scrotum
High-riding or nonpalpable prostate
Pelvic fracture
Accordingly, a urinary catheter should not be lilSerted be

fore the rectum and genitalia have been e.xrunined. If urethral
injury is suspected, urethral integrity should be confirmed by
a retrograde urethrogram before the catheter is inserted.
Gastric Catheters
A gastric lube is indicated to reduce stomach clislcnLion and
decrease the risk of aspiration. Decompression of the stom
ach reduces the risk of aspiration, but does nol prevent it
entirely. Thick or semisolid gastTic con len Is will not return
through the tube, and actual passage of Lhe tube can induce
vomiting. For the tube to be effective, it must be positioned
properly, be altachcd lo appropriate suction, and be func
tional. Blood i n the gastric aspirate can be indicative of
oropharyngeal (swaJlowed) blood, traumatic insertion, or
actual injury to the upper digestive tract. If the cribriform

plate is known to be fractured or a fracture is suspected, the PITFALLS
gastnc tube should be inserted orally to prevent intracra
Placement of a gastric catheter may induce vomit
nial passage. In thil. situation, any nasopharyngeal instru
ing or gagging and produce the specific problem
mentation ill potentially dangerou!t.
that its placement is intended to prevent-aspira
tion. Functional suction equipment should be im
OTHER MONITORING mediately available.
Combative trauma patients occasionally extubate
Adequate resuscitation is bet <lSSCssed by improvement in
themselves. They can also occlude their endotra
physiologic parameters, such n pube rate, blood pressure, cheal tube or deflate the cuff by biting it. Fre
pulse pressure, ventilatory rate, ABG levd!>, body temperature, quent reeva luation of the airway is necessary.
and urinnry output, rather than the qualitative nssessment The pulse oximeter sensor should not be placed
done dul"i ng the primary survey. Actual values for these pa distal to the blood pressure cuff. Misleading in
rameters should be obtained as soon as is practical after com formation regarding hemoglobin saturation and
pleting the primary survey, and periodic reevaluation is prudent. pulse can be generated when the cuff is inflated
and occludes blood flow.
Ventilatory Rate and Arterial Blood Gases Normalization of hemodynamics in injured pa
tients requires more than simply a normal blood
Ventilatory rate and i\BG levels should be used to monitor the
pressure; a return to normal peripheral perfusion
adequacy of respirations. Endotracheal tubes may be dislodged
must be established. This can be problematic in
whenever tht: patient is moved. A colorimetric carbon diox the elderly, and consideration should be given to
ide detector il; a device capable of detecting carbon dioxide in early invasive monitoring of cardiac function in
exhaled gas. Colorimetry, or capnography, is useful in con these patients.
firming that the endot ratheal tube is properly located in the
respiratory trcKt of the patient on mechanical ventilation and
not in the esoph<lgu:.. However, it does not confirm proper
treatment, and pelvic films can show fractures of the pelvis
placement of the tube in the trachea. rl' See Chapter 2: Airway
that indicate the need for early blood transfusion. These films
and Ventilatory Management.
can be taken in the resuscitation area with a portable x-ray
unit, but hould not interrupt the resuscitation process.
Pulse Oximetry
During the econdary survey, complete cervical and tho
Pulse oximetry is a valuable adjunct for monitoring oxygena racolumbar spine fllms may be obtained with a portable x-ray
tion in injmed palicnb. The pulse oximeter measures the oxy w1it if the patient's care is not compromised and the mecha
gen saturation of hemoglobin colorimetrically, but it does not nism of injury suggests the possibility of spinal injury. lo a pa
measure the partial pressure of oxygen. It also docs not meas tient with obtundation who requires computed tomography
ure the partial pressure of carbon dioxide, which reflects the ( CT) of the bra in, Gr of the spine may be used as the method
adequacy of ventilation. A small sensor is placed on the fin of radiographic assessment. Spinal cord protection that was
ger, toe, earlobe, or another convenient place. Most devices established during the primary survey should be maintained.
display pulse rate and oxygen saturation continuously. An AJ> chest film and additional films pertinent to the site{s)
Hemoglobin saturation from the pulse oximeter should of suspected injury should be obtained. Essential diagnostic
be compared with the value obtained from the ABG analy x-rays should be obtained even in pregnant patients.
:.is. Inconsistenq' indic;Hes that at least one of the two de Focused asse:.sment sonography in trauma (FAST) and
terminations is in error. diagnotic peritoneal lavage (DPL) are useful tools for the
quick dctedion of occult intraabdominal blood. Their u:.e
Blood Pressure depends on the skill and ex11erience of the doctor. Identifi
The blood prc:.!>urc should be measured. It should be kept in cation of the source of occult intraabdominal blood loss may
mind, though that it may be a poor measure of actual tissue indicate the need for operative control of hemorrhage.
perfusion.
X-RAY EXAMINATIONS AND

DIAGNOSTIC STUDIES Consider Need for
X-ray examination hould be used judiciously and should not
Patient Transfer
delay patient resuscitation. Anteroposterior {AP) chest and
AP pelvic films often provide information that can guide re During the prim<try survey and resuscitation phase, the eval
suscitation eiTorts of pat icnts with blunt trauma. Chest x-rays uating doctor frequently has obtained enough information
cru1 show potentially life- threatening injuries that require to indicate the need Lo transfer the patient to another facil-
SECONDARY SURVEY 11
PITFALL TL-.:
,
.
. *'
Technical problems may be encountered when per
forming any diagnostic procedure, including fhose
necessary t o identify intraabdominal hemorrhage. id =- --
--
Obesity and intraluminal bowel gas can com promise

the images obtained by abdominal u lt rasonography.
Obesity, previous abdominal operations, and preg
nancy also can make diagnostic peritoneal lavage dif
ficult. Even in the hands of an experienced surgeon,
the effluent volume from the lavage may be minimal
or zero. In these circumstances, an alternative diag
nostic tool should be chosen. A surgeon should be in
volved in the evaluation process and guide further
diagnostic and therapeutic procedures.
ity. This transfer proces:. may be initiated immediately by

administrative personnel at the direction of the examining
doctor while additional evaluation and resuscitative meas
urcs arc being performed. Once the decision to transfer the
patient has been made, communication between the refer
ring and receiving doctors is essential.
tained from a patient who has sustained lrauma, and prc

Secondary Survey hopital personnel and family must be consulted to obtain
information that can enhance the understanding of the pa
I Wha t is the secondary survey, and tient':. physiologic state. The AMPLE history is a useful
when does it start? mnemonic for thi!> purpose:
The secondary survey does not begin until the primary survey A -Allergies
(ABCDEs) is completed, resuscitative efforts are underway, and
M -Medications currently used
the normalization ofvital functions has been demonstrated.
The secondary survey i!. a head to-toe evaluation of the P -Past illnesses/Pregn<U1cy
trauma patient, that is, a complete history and physical ex
L -Last meal
amination, including reassessment of all vital signs. Each re
gion of the body is completely examined. The potential for E -Events/Environment related to the injury
missing an injury or failure to appreciate the significance of
The patient's condition is greatly influenced by the mech
an injury is great, especially in an unresponsive or unstable
anism of injury. Prehospital personnel can provide valuable
patient. .,/' See Table 1-1: Sccund.uy Survey, in Skill Station
information on such mechanisms and should report perti
1: Initial Assessment and Management.
nent data to the exam in i ng doctor. Some injuries can be pre
During the secondary urvcy, ,, complete neurologiL ex
dicted based on the direction and amounl of energy behind
amination is performed, including a GCS score determin.t
the mechanism of i nj u ry. Injury usually is classified into two
tion, if it was not done du ri ng the primary survey, and
broad categories: blunt and penetrating trauma . .,/' See Ap
x-rays arc obtained, if indicated by the examination. Such
pendix B: Biomechanics of Injury. Other types of injuries lor
examinations can be in terspcrscd into the secondary survey
which historical information is impo1tant include thennal in
at appropriate times. Specirtl proc(dures, such as specific rn
juries and tJ1ose caused by cl h<lzardous environment.
diographic evaluations and laboratory studies, also are per
formed at this time. Complete patient evaluation requ i res
repeated physical examinatiun::.. Blunt Trauma
Blunt trauma often result!> frum automobile collisions, falls,
and other injuries related ro transportation, recreation, and
HISTORY
uccu pat ions.
Every complete medical assessment includes a histmy of the Important information to obtain about automobile col
mechanism of injury. Often, such a history cannot be ob- Iis ions includes seat-belt ue, steering wheel deformation,
debris, Lhe patient's attempt to escape a fire. lnhalation in

jury and carbon monoxide poisoning often complicate burn
injuries. Therefore, it is in1portant to know the ci.rClU11-
slances of the burn injury. Specifically, knowledge of the en
vironment in which the burn injury occurred (open or
dosed space), the substances consumed by the names (eg,
plastics and chemicals), and any possible associated injmies
sustained, is critical for patient treatment.
Acute or chronic hypothermia vvithout adequate pro
tection against heal loss produces either local or generalized
cold injuries. Significant heat loss can occur at moderate
temperatures ( lS"C to 20"C or 59"F lo 68F) if wet clothes,
decreased activity, and/or vasodilation caused by alcohol or
drugs compromise tbe patient's ability to conserve heaL
Such historical informalion can be obtained from prehos
pital personneL
Hazardous Environment
A history of exposure to chemicals, toxins, and radiation is
important to obtain for two main reasons: first, these agents
can produce a variety of pulmonary, cardiac, and internal
organ dysfunctions in injured patients. Second, these same
agents may also present a hazard to hcalthcare providers.
t=requentJy, the doctor's only means of preparation is to un
derstand the gencraJ principles of management of such con
ditions and establish immediate contact with a Regional
Poison Control Center.
direction of impact, damage to the automobile in terms of

major deformation or intrusion into the passenger com PHYSICAL EXAMINATION
partment, and whether the patient was ejected from the ve
During the secondary survey, physical examination follows
hicle. Ejection from the vehicle greatly increases the
the sequence of head, maxillofacial structUJes, cervicaJ spine
possibility of major injury.
and neck, chesl, abdomen, perineum/rectum/vagina, mus
Injury patterns can often be predicted by the mecha
culoskeletal system, and neurologic system.
nism of injury. Such i.njwy patterns also are influenced by
age groups and activities (see Table 1 - l : Mechanisms of In
jury and Related Suspected fnjury Patterns). Head
The secondary survey begins with evaluating the head and
Penetrating Trauma identi fying aJI related neurologic injuries and other sign ifi
The incidence of penetrating trauma (eg, injuries from cant injuries. The entire scal p and head should be examined
Cirearms, stabbings, and impalement) has increased. Fac for laceraLions, contusions, and evidence of fractures .
See
tors determining the type and extent of iJ1jury and subse Chapter 6: Head Trauma.
quent management include the region of the body that was Because edema around Lhe eyes can later preclude an
inj ured , the organs in the path of the penetrating object, in-depth examination, the eyes should be reevaluated for:
and the velocity of the missile. Therefore, in gunshot vic
tims, the velocity, caliber, presumed path of the bullet, and Visual acuity
distance from the weapon to the wound can provide im
Pupillary size
portant clues as to the extent of injury. rl' See Appendix B:
Biomechanics of Injury. Hemorrhage of the conjunctiva and/or fundi
Penetra ti ng injury
Thermal Injury
Contact lenses ( remove before edema occurs)
Burns are a significant type of trauma that can occur alone
Dislocation of the lens
or be coupled with blunt and penetrating trauma resulting
from, for example, a bur ning automobile, explosion, fall ing Ocular entrapment
SECONDARY SURVEY 13
TABLE 1-1 Mechanisms of Injury and Related Suspected Injury Patterns
MECHANISM OF INJURY SUSPECTED INJURY PATTERNS
Cervical spine fractu re

Frontal impact automobile collision
Bent steering wheel Anterior flail chest
Knee imprint dashboard
, Myocardial contusion
Pneumothorax
Bull's-eye fracture of the windshield
Traumatic aortic diSruption
Fractured spleen or liver

Posterior fracture/dislocation of hip and/or knee
Side impact automobile collision Contralateral neck sprain

Cerv1cal spine fraclure

Lateral flail chest

Pneumothorax
Traumatic aort1c d1srupt1on
Diaphragmatic rupture

Fractured spleen/liver and/or kidney, depending on side of im-
pact
FracLured pelvis or acetabulum
Cervical spine Injury

Rear impact automobile collision

Soft tissue injury to neck
Ejection from vehicle Ejection from the vehicle precludes meaningful prediction of
injury patterns. but places patient at greater risk from virtually
all Injury mechanisms
Pedestrian struck by motor vehicle Head injury

Traumallc aortic d
isrup lion

Abdominal VIsceral inJuries
Fractured lower extremities/pelvis
,
,___ _
__ _, ..
_,,,_ .............._,,_.,,. ..... ..... ..... ..... .........................-.........,_,,....
--
---
------ -
-
-"
" '
_ ,,
_,
,_
,_ ...
, ,_...,.
..,_.,-"'"'""'"'"
A quick visual-acuity examination of both eyes can be Cervical Spine and Neck
performed by asking the patient to read prin ted mater ial,
Patients with maxil lofacial or head trauma should be pre
fo r exam pl e a hand held Snellen chart, or words on an IV
,
sumed to have an unstable cervical spine injury (eg, fracture
container or dressing package. Ocular mobility should be andfor ligament injury), and the neck should be immobilized
evaluated to exclude entrapment of extraocular muscles due until all aspects of the cervical spine have been adequately
to orbital fractures. These procedures frequently identify studied and an injury has been excluded. The absence of neu
optic injuries that are not otherwise ap pa ren t rJI See Ap rologic deficit does not exclude injury to the cervical spine,
pendix F: Ocular Trauma.
Maxil lofacial Structures . I.

PITFALLS . ,-

Maxillofacial trauma that is not associated \vith airway ob

struction or major bleeding should he treated only after the Facial edema in patients with massive facial injury
patient is stabilized completely and life-threatening inj uries or in comatose patients can preclude a complete
eye examination. Such difficulties should not deter
have been managed. At Lbe djscretion of appropriate spe
the doctor from perform ing the components of
cialists, definitive management may be safely delayed with
the ocular examination that are possible.
out compromising care. Patients with (raclures o f the
Some maxillofacial fractures, such as nasal frac
midface can also have a fracture of the cribriform plate. For
ture, nondisplaced zygomatic fractures, and or
these patients, gastric intubation should be performed via
bital rim fractures, can be difficult to identi fy early
the oral route. rJI Sec Chapter 6: Head Trau ma, and Skill Sta
in the evaluation process. Therefore, frequent re
tion IX: Head and Neck Trauma: Assessment and Manage assessment is crucia l .
m en t.
14 CH APTER 1 Initial Assessment and Management
and such injury should be presumed until a complete cervical

'
spine radiographic series and CT is reviewed by a doctor ex PITFALLS ..

.
..
. -
perienced in detecting cervical spine fractures radiographi

cally. Blunt injury to the neck can produce injuries in

Exami11ation of the neck includes inspection, palpation, which the clinical signs and symptoms develop late
and may not be present during the initial exami
and auscultation. Cervical spu1e tenderness, subcutaneous
nation. Injury to the intima of the carotid arteries
emphysema, tracheal deviation, and laryngeal fracture can
is an example.
be discovered on a detailed examination. The carotid arter
The identification of cervical nerve root or brachial
ies should be palpated and ausculta1ed for bruits. Evidence plexus i njury may not be possible i n a comatose
of blunt injury over these vessels should be noted and, if patient . Consideration of the mechanism of injury
present, should arouse a high index of suspicion for carotid might be the doctor's only clue.
artery injury. Occlusion or dissection of the carotid artery I n some patients, decubitus ulcers can develop
can occur late in the injury process without antecedent signs quickly over the sacrum and other areas from im
or symptoms. Angiography or duplex ultrasonography may mobilization on a rigid spine board and from the
be required to exclude Lhe possibility of major cervical vas cervical collar. Efforts to exclude the possibil i ty
cular injury when the mechanism of injury suggests this of spinal injury should be i n itiated as soon as is
possibility. Most major cervical vascular injuries arc the re practical, and these devices should be removed.
SLllt of penetratu1g il1jury; however, blunt force to the neck However, resuscitation and efforts to identify life
or a traction injury from a shoulder-harness restraint can threatening or potentially life-threatening injuries
result in intimal disruption, dissection, and thrombosis. shou ld not be deferred.
rl' See Chapter 7: Spine and Spinal Cord Trauma.
Protection of a potentially unstable cervical spme in
jury is ilnperativc for patients who arc wearing any type of
and at the posterior bases for hemothorax. Although aus
protective helmet, and extreme care must be taken when re
cultatory findings can be difficult to evaluate in a noisy en
moving the helmet. r/' See Chapter 2: Airway and Ventilatory
vimnment, they may be extremely helpful. Distant heart
Management.
sounds and narrow pulse pressme can mdicate cardiac tam
Penetrating inju-ies to the neck can potentially injure
ponade. Tn addition, cardiac tamponade and tension pneu
several organ systems. Wounds that extend through the
mothorax are suggested by the presence of distended neck
platysma should not be explored manually, probed wiLh U1-
veins, although associated hypovolemia can minimize or
struments, or treated by individuals in the ED who are not
eliminate this finding. Decreased breath sounds, hyperres
trained to manage such injuries. The ED usually is not
onance to percussion, and shock may be the only indica
equipped to deal with the problems lJ1at can be encoun
Lions of tension pneumothorax and the need for immediate
tered in such a situation. These injuries require evaluation
chest decompression.
by a surgeon operatively or with specialized diagnostic pro
A chest x-ray may confirm the presence of a hemotho
cedures under the direct supervision of a Slngeon. The find
rax or simple pneumothorax. Rib fractures may be present,
ing of active arterial bleeding, an expanding hematoma,
hut they may not be visible on the x-ray. A widened medi
arterial bruit, or airway compromise usually requues oper
astinum or other radiographic signs can suggest an aortic
at ive evaluation. Unexplained or isolated paralysis of an
ruptme. rl' See Chapter 4: Thoracic Trauma.
upper extremity should raise the suspicion of a cervical
nerve root injury and should be accurately documented.
Abdomen
Abdominal injuries must be identified ru1d treated aggres
Chest sively. The specific diagnosis is not as important as recog
Visual evaluation of the chest, both anterior and posterior, nizing that an injury exists and initiating surgical
can identify conditions such as open pneumothorax and intervention, if necessary. A normal initial examination of
large flail segmenls. A complete evaluation of the chest wall the abdomen docs not exclude a significant intraabdominal
requires palpation of the entire chest cage, including the injury. Close observation and frcqucn t reevaluation of the
clavicles, ribs, and sternum. Sternal pressure can be painful abdomen, preferably by the same observer, is important in
i f the stermun is fractured or costochondral separations managu1g blunt abdominal trauma, because over time, the
exist. Contusions and hematomas of the chest waU should patient's abdommaJ findmgs can change. Early involvemen t
alert the doctor to tbe possibility of occult injury. of a surgeon is essential.
Significant chest injury can manifest with pain, dys Patients with unexplained hypotension, neurologic in
pnea, and hypoxia. Eval.uati.on includes auscultation of the jury, impaired sensorium secondary to alcohol and/or other
chest and a chest x-ray examination. Breath sounds are aus drugs, and equivocal abdominal findings should be consid
cultated high on the anterior chest wall for pneumothorax ered candidates for peritoneal lavage, abdominal ultra-
SECONDARY SURVEY 15
ations. l n addition, pregnancy tests should be performed on

,I
liT"
'''
.
PITFALLS I

-
! ,,._, ._
all females of c h i ldbea ring age.
Elderly patients may not tolerate even relatively

Musculoskeletal System
minor chest injuries. Progression to acute respira
tory insufficiency must be anticipated, and support The extremities should be i nspected for contusions and de
should be instituted before collapse occurs. formities. Palpation of the bones and examination for ten
Children often sustain significant injury to the in derness and <lbnormal movement aids in the idcnlitlcation
trathoracic structures without evidence of thoracic of occult fractures.
skeletal trauma, so a high index of suspicion is es Pelvic fractures can be suspected by the identification of
sential. ecchymosi s over the iliac wings, pu bi s, labia, or scrotum. Pai n
i g is ,111 i m portant finding in al ert
on palpation of the pclvi c r n
patients. Mobility of the pelvis in response to gentle a nterior
sonography, or, if hemodyn am i c {i ndings are normal, CT nf to-posterior presure with the heels of the hands on both an
rhe abdomen. Fractures of the pclvi or Lhe lower rib t.:nge terior iliac spines and the symphysis pubis can suggct pelvic
<Jiso can hinder accurate diagnostic examination of the ab ring disruption in unconscious pati en ts. BecnuM.' such ma
do men , because palpating the abdomen can elicit p<lin from nipu lation can initiate unwan ted bleedi ng, it should be done
these area:.. .. Sec Chapter 5: Abdom i nal and Pelvic Tr,ruma. only once (if at all), and p re ferably by the or thopedi c surgeon
respons ibl e for the pati ent s care. [n addition, assessment of
'
Perineum/Rectum/Vagina peri pheral pulses can identify vaM.ular injuries.

Si gn i fica nI ex trem i ty injuries can exist without frac
The peri neu m should be exa mined [or contusi o ns ,
tures being evident on exami nn ti on or x-rays. Ligament rup

hematomas lacerations a nd u rcl hr<l b l eeding. .. Sec Chap
, ,
tures produce joint instability. Muscle-tendon unit injuries

ter 5: Abdomi nal and Pelvic Trau m a.
interfere with active motion of the <lffected structures. Im
A rectal examination may be pcrfom1ed before plat.:ing a
paired sens<llion and/or loss of vo l untar y muscle contrac
u rinary catheter. If a rectal exam ination is required, the doctor
tion strength can be caused by nerve injury or ischemia,
shoul d aSSL'liS for the presence ofblood wi thin the bowel lumen,
incl udin g that due to compartment syndrom e.
a hi gh-ridin g prostate, the presence of pelvic fractures, the in
Thoracic and lumbar spi nal fractures and/or neurologic
tegrity of the rectal wall, and the qual i ty of sphi ncter tone .
i njuries must be considered based on physical findings and

Vaginal examination should be performed in patients
mechanism of i n ju ry. Other injuries can mask the phys i cal
who are at risk ofvaginal injury. T he doctor should assess for
fi nd i ngs ol sp i nal injuries, and they <:an remain undetected
the presence of blood in the vaginal vault and vagi nal Iacer
unless the doctor obtains t he tppropriae x-rays.
.
The m usculoskeletal examination is not com plete with

out an exam i nation of the pati ent s back. Unl ess the patient s
' '
PITFALLS '..
........: back is examined, significant injuries may be missed. rl' See
!.I...
.
Ch a p ter 7: S pi ne and Spi n al Cord Tra uma, and Cha pter 8:
Excessive manipulation of the pelvis should be Musculoskeletal Tra u ma.
avoided, because it may precipitate additional
hemorrhage. The AP pelvic x-ray examination, per
formed as an adjunct to the primary survey and re Neurologic
suscitation, can provide valuable information A com prehensive neu ro logic exam ination i n cludes not on l y
regarding the presence of pelvic fractures, which motor and sensory evaluation of the extrem i tiLs but reeval
,
are potentially associated with significant blood uation or the patient's lt:vd of co n sc i ousness and pupi l la ry
loss.
size and response. The GCS score facilitates detection of
Injury to the retroperitoneal organs may be diffi
early changes <tnd trends i n the neurol ogic status. .. Sec Ap
cult to identify, even with the use of CT. Classic ex
pendix C: Trauma Scores: Revised and Pediatric.
amples include duodenal and pancreatic injuries.
Early consultation with a neurosurgeon is required for
Knowledge of injury mechanism, identification of
patients with neurol ogic in j u ry. Patients should be fre
associated injuries, and a high index of suspicion
are required. Despite the doctor's appro priate dili quently monitored for deterioration in level of conscious
gence, some of these injuries are not diagnosed ness a nd c h an ges in Lhe neu rol og ic examination, as these
initially. find i ngs can reflect progression of the intracranial i nju ry. If
a pati ent wi th u head injury deterior<J lcs neurologically ox-y
,
Female urethral injury, while uncommon, does
occur in association with pelvic fractures and genation and perfusion of the brain and adequacy of venti
straddle injuries. When present, such injuries are lation (ie, the ABCDEs) must be reassessed . Int rac ra n ial
difficult to detect. su rgical intervention or measures for reducing intracranial
pressure may be necessary. The neurosurgeon will deci de
rioration in previously noted tindtng:.. As initial life-threat

PITFALLS ening injuries arc managed other equally life-threatening
,
problem1> and less severe injuries can become apparent. Un

Blood loss from pelvic fractures that increase derl yi ng medical problems that cnn significantly affect the
pelvic volume can be difficult to control, and fatal ultim;llc prognosis of the patient can become evident. A
hemorrhage can result. A sense of urgency should
high index of suspicion facilitates curly dingnosis and man
accompany the management of these injuries.
agement.
Fractures involving the bones of the hands, wrists,
Continuous monitoring of vital signs and urinary out
and feet are often not diagnosed i n the second
ary survey performed i n the ED. Sometimes, it is put is essential. For adult patient:., maintenance of urinary
only after the patient has regained consciousness output Jt 0.5 m L/kg/h r is desirable. In pediatric patients
and/or other major injuries are resolved that pain who arc older than I year, an output of l mUkg!hr is typi
i n the area of an occult injury is noted. cally ,luequate. ABG analyses and cardiac monitoring de
Injuries to the soft tissues around joints are fre vices should be used. Pulse oximetry on critically injured
quently diagnosed after the patient begins to re patients and end-tidal carbon dioxide monitoring on intu
cover. Therefore, frequent reevaluation is essential. bated patients should be considered.
A high level of suspicion must be mai ntained to The relief of severe pain is an important part of the
prevent the development of compartment syn treatment of trauma patients. Many injuries, especially mus
drome. culoskeletal injuries, produce pain and anxiety in conscious
patients. Effective analgesia usual ly requires the administra
tion of opiates or anx iolytics intravenously (intramuscular
injellions should be avoided). These agents should be used
whether conditions such as epidural and subdural
judiciow.ly and in small doses to a:.hicve the desired level of
hematomas require evacuation, and whether depressed skull
p.1tient comfort and relief of anxiety, while ,\voidi ng respi
fractures need operative intervention. rl' Sec Chapter 6:
ratory depression, the masking uf subtle injuries, aml
Head Tra uma, and Chapter 7: Spine aml SpinaJ Cord
changes in the patient's slatus.
Traum<l.
"
Adjuncts to the PITFALL
-
Secondary Survey Any increase in intracranial pressure (ICP) can reduce

cerebral perfusion pressure and lead to secondary
I How can I minimize missed injuries? brain injury. Most of the diagnostic and therapeutic
maneuvers necessary for the evaluation and care of
Specialized diagnostic tests may be performed during the patients with brain injury will increase ICP. Tracheal
secondary survey to identify specific injuries. These include intubation is a classic example; in patients with brain
additionlll x-ray examinations of the pine and extremities; injury, it should be performed expeditiously and as
smoothly as possible. Rapid neurologic deterioration
CT sc<tnS of the head, chest, abdomen, and spine; contrast
of patients with brain injury can occur despite the ap
urography and angiography; transesophageal ultrasound;
plication of all measures to controi iCP and maintain
b ronchoscopy ; esophagoscopy; and other diagnostic pro
appropriate support of the central nervous system.
cedures. Often these procedures require transportation of Any evidence of loss of sensation, paralysis, or
the patilnt to other areas of the hospital, where equipment weakness suggests major injury to the spinal column
and personnel to manage life-threatening contingencies or peripheral nervous system. Neurologic deficits
muy not be immediately available. Therefore, these special should be documented when identified, even when
ized tests shouJd not be performed until the patient has transfer to another facility or doctor for specialty care
been ca refully examined and his or hc.:r hemodynamic sta is necessary. Immobili zation of the entire patient,
tus has been normalized. using a long spine board, semirigid cervical collar,
and/or other cervical immobilization devices, must be
maintained until spinal injury can be excluded. The
common mistake of immobilizing the head but free
ing the torso allows the cervical spine to flex with the
Reevaluation body as a fulcrum. Protection of the spina l cord is re
quired at all times until a spine injury is excluded. Early
consultation with a neurosurgeon or orthopedic surgeon
Trauma patients must be reevaluated constantly to ensure is necessary ifa spinal injury is detected.
that new finuings are not overlooked and to discover dc.:te-
RECORDS AND LEGAL CONSID ERATIONS 17
developed, reevaluated, and rehearsed frequently to en

hance the possibili ty of saving the maximum number of in
jured patients. ATLS p roviders should understand their role
in disaster management within their health-care institu
t io ns and rememb er the princip les of ATLS relevant to pa
tient care.
Records and legal

Considerations
Specific legal considerations, i n cl uding records, consent for
treatment, and forensic evidence, are relevan t to ATLS
providers.
RECORDS
Meticulous record keeping, incl udi ng do cum en t in g the
t ime for all events, is very important. Often more than one
doctor cares for an individual pa tien t. Precise records are
essential to evaluate t he patient s needs and clinical status.
'
Accurate record keeping du rin g resuscitation can be facili

tated by a member of the nursing staff whose primary re
spon sib ility is to record and collate aJl p atient care
Definitive Care in formation.
M edicolegal problems arise freq uently, and precise
I Which patients do I transfer to a higher records are helpful for all ind iv iduals concerned. Chrono
logie reportin g with flowsheets helps bot h th e attendi ng
level of care? When should the transfer
occur? doctor and the consulting doctor to assess ch anges in the
patient's condition quickly. rJI See Appendix D: Sam p le
l n terh ospi ta l triage criteria will help determine the level, Trauma Flow Sheet, Chapter 13: Transfer to Defi n itive Care,
pace, and in tensity of ini t ia l treatment of the mu ltipl)' in and Figure 13. I : Sampie Tra nsfer Fo rm.
jured patient. rJI See ACS COT, Reso11rces for Optimal Care
ofthe Injured Patie11t, 2006. These criteria take into account
the patient's physiologic status, obvious anatomic i nju ry,
mechanisms of injury, concurrent diseases, and other fac
CONSENT FOR TREATMENT
tors th a t can alter the patient-'s prognosis. ED and surgical Consent is sought before lrealnlent, if possible. l n life
personnel should use these criteria to determine whether threatening emergencies, it is often not possi ble to obtain
the patien t req uires transfer to a trawna center or closest such consen I . In these cases, treatment shoul.d be provided
ap prop riate hospitaJ capable of p rovi d in g more speciaJized fi rst, with formal consent obtained later.
care. Th e closest appropriate l ocal facil ity should be cho
sen based on i t s overall capabil_ities to care Cor the injured
patient rJI Sec Chapter 13: Transfer to Definitive Ca re and
.
FORENSIC EVIDENCE
Fi gure 1 - 1 .
lf criminal activity is suspected in conjunction with a pa
tient's injury, the personnel caring for the pa tien t must pre
serve t heevidence. All items, such as clothing and bullets,
must be saved for law enforcemenl perso nn el . Laboratory
Disaster determinations of blood <tlcohol concentrations and other
drugs may be particularly p ert inent and have substantial
Disasters frequently overwhelm local and regional re legal implications. rJI See Appendix B: Biomechanics of ln
sources. Plans for management of such conditions must be .Jury.
CHAPTER SUMMARY
..
The correct sequence of priorities for assessment of a multiply injured patient is prepa
ration; triage; primary survey; resuscitation; adjuncts to primary survy and resuscita
tion; consider need for patient transfer; secondary survey, adjuncts to secondary survey;
reevaluation; and definitive care.
The principles of the primary and secondary surveys are appropriate for the assessment
of all multiply injured patients.
e The guidelines and techniques included in the initial resuscitative and definitive-care
phases of treatment should be applied to all multiply injured patients.
A patient's medical history and the mechanism of injury are critical to identifying in
JUnes.
Pitfalls associated with the initial assessment and management of injured patients must
be anticipated and managed to minimize their impact.
The initial assessment of a multiply injured patient follows a sequence of pnorities, as

do the management techniques for primary treatment and stabilization.
e.'l:pcrimental evidence to clinical routine. Advantages and dis

BIBLIOGRAPHY advantages of h)rperton ic sol utitms. Acta Anaestlzesiol Scand
2002;46:625-638.
I. American College of Surgeons Committee on Trauma. Re
9. Mallox KL, Feliciano DV, Moore EE, eds. Trauma. 4th ed. New
so11rces jor Optimal Care of the llljured Patient. Chicago, lL:
York, McGraw-Hill; 2000.
American College of Surgeons Committee on Trauma; 2006.
I 0. McSwain NE jr., Salomone }, et aJ., eds. Pre/wspita/ 7/munn Life
2. Ballistella FD. Emergency department evaluation of the pa Support: Basic muJ Advanced. 6th cd. St. Louis, MO: Mosby;
tien L with multiple injuries. In: Wilmore DW, Cheung LY, 2007.
Harken AH, et al., eds. Scien/ijic America11 Surgery. New York,
NY: Scientific i\merica11; 1988-2000. II. Morris JA, MacKinzie E], Daminso AM, t't al. Mortality in
trauma patients: interaction between host ltctors and sever
3. Bhardwaj A, Ul<tows ki JA. Hypertonic saline solutions in brain ity. I Trauma. 1990;30: 1 476-1482.
injury. Curr Opin Crit Care 2004;1 0: 126-131.
12. Murao Y, Hoyt DB, Loomis \V, eL al. Does Llle Liming of hy
4. Doyle )A, Davis DP, Hoyt DB. The usc of hypertonic saline in Lhe pertonic saline resuscitation affect its potential to prevent lung
treatmen1 of traumatic brain injury. / 7inlll11(1 200 I ;50:367-383. damage? Shock 2 000; 1 4 : t8-23.
5. Enderson BL. Retb DB, Meadors ), et al. The tertiar)' I rauma 13. Nahum Alv[, Melvin J, eds. The Biomechanics ofTrauma. Nor
survey: n prospective study of missed njury.
i. } Tmurna walk, CT: Appleton-Century-Crofts; 1985.
1990;30:666-670.
14. Pope A, Frtnch G, Longnecker DE, eds. Fluid lesuscitmion:
6. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit State ofrhe Scie11cefor Treating Com!Jat Casualties a11d Civilian
digital rectal exam in tramna patients: l'\o rmgers, no rectum, injuries. Washington, DC: National Academics Press; 1999.
no useful additional information. j Tmuma 2005;59(6}:1 3 1 4-
15. Rhodes M, Brader A, Lucke ), el al: Direct transport to the op
1319.
erating room for resuscitation of trauma patients. J Trauma
7. Esposito TJ, Kub)' A, Unfred C, et aJ. General surgeons and the 1989;29:907-915.
Advanced Tratmla Life Support course: Is it time to refocus? }
16. Rutstein OD. Novel strategies for immunomodulation after
Tmuma 1995;39:929-934.
trauma: rev i si t i ng hypertonic saline as a resuscitation stratcg)'
8. Krcimeier U, Messmer K. Small-volume resuscitation: from for hemorrhagic shock.} Timmw 2000;49:580-583.
S K I L L S TAT I O N
Performance at this skill station will allow the partici pant to practice and
Interactive Skill
demonstrate the following activities 1n a simulated clinical situation:
Procedures
THE FOLLOWING
PROCEDURES ARE INCLUDED OBJECTIVES

IN THIS SKILL STATION:

Communicate and demonstrate to the instructor the systematic initial
Skill I-A: Primary Survey and assessment and treatment of each patient.
Resuscitation
Using the primary survey assessment techniques, determine and
Skill l-8: Secondary Survey
demonstrate:
and Management
Airway patency and cervical spine control
Skili i-C: Patient Reevaluation Breathing and ventilation
Skili i-C: Transfer to Definitive Circulatory status with hemorrhage control
Ca re Disability: neurologic status
Exposure/environment: Undress the patient, but prevent
hypothermia.
0 Establish resuscitation (management) priorities in a multiply injured

patient based on findings from the primary survey.
Integrate appropriate history taking as an invaluable aid in patient

assessment.
Identify the injury-producing mechanism and describe the injuries

that may exist and/or may be anticipated as a result of the mechanism
of injury.
Using secondary survey techniques, assess the patient from head to

toe.
0 Using the primary and secondary survey techniques, reeva luate the
patient's status and response to therapy instituted.
Given a series of x-rays:

Diagnose fractures.
Differentiate associated injuries.
Outline the definitive care necessary to stabilize each patient in

preparation for possible transport to a trauma center or to the closest
appropriate facility.
As referring doctor, communicate with the receiving doctor (instruc

tor) in a logical, sequential manner:
Patient's history, including mechanism of injury
Physical findings
Treatment instituted
Patient's response to therapy
Diagnostic tests performed and results
Need for transport
Method of transportation
Anticipated time of arrival
19
20 SKILL STATION I Initial Assessment and Management
Skill 1-A: Primary Survey and Resuscitation

The student should: ( 1 ) outline preparations that musl be E. Altach a CO, monitoring device to the
made t o facilitate the rapid progression of assessment and endotracl1eal tube.
resuscitation of the patient; (2) indicate the need to wear F. Attach a pulse oximeter to the patient.
appropriate clothing to protect both lhe caregivers and the
palienl from communicable diseases; and (3) indicate that
CIRCULATION WITH HEMORRHAGE
the patient is to be completely undressed, but that hy
CONTROL
pothermia should be prevented. Note: Standard precautions
are required whenever caring for trauma patients. STEP 1 . Assessmen t
A. Identify source of external, exsanguinating
hemorrhage.

B. [denlify potential source(s) of internal
AIRWAY MAINTENANCE WITH CERVICAL
hemorrhage.
SPINE PROTECTION
C. Assess pulse: Quality, rate, regula1ity, and
STEP 1. Assessment paradox.
A. Ascertain patency. D. Evaluate skin color.
B. Rapidly assess for airway obstruction. E. Measme blood pressure, if time permits.
STEP 2. Management-Establish a patent airway STEP 2. Management
A. Perform a chin-lift or jaw-thrust maneuver. A . Apply direct pressure to external bleeding
B. Clear the airway of foreign bodies. site(s).
C. lnsert an oropharyngeal airway. B. Consider presence of internal hemorrhage
D. Establish a detinitive airway. and potential need for operative interve.ntion,
1) Intubation and obtain surgical consLdl.
2) Surgical cricolhyroidotomy C. Insert two large-caliber IV catheters.
E. Describe jet insufflation of the ai rwa)', noting D. Simultaneously obla in blood for hematologic
that it is only a temporary procedure. and chemical analyses; pregnancy test, when
appropriate; type and crossmatch; and ABGs.
STEP 3. Maintain the cervical spine i n a neutral position
E. initiate IV t1uid therapy with warmed
with mrumal m i mobilization as necessary when
crystalloid solution and blood replacement.
establishing an airway.
F. Prevent hypotJ1ermia.
STEP 4. Reinstate irru11obilization of the c-spine with
appropriate devices after establishing an airway.
DISABI LITY: BRIEF NEUROLOGIC
EXAMINATION
BREATHING: VENTILATION
STEP 1. Determine the level of consciousness using Lhe
AND OXYGENATION
GCS.
STEP 1. Assessment
STEP 2. Assess the pupils for size, equality, and reaction.
A . Expose the neck and chest, and ensure
immobilization of the head and neck.
B. Determine the rate and depth of respirations. EXPOSURE/ENVIRONMENTAL CONTROL
C. Inspect and palpate the neck and chest for
STEP 1 . Completely undress the patient, but prevent
tracheal deviation, unilateral ru1d bilateral
hypothermia.
chest movement, use of accessory muscles,
and any signs of injury.
D. Percuss the chest for presence of dullness or ADJUNCTS TO PR IMARY SURVEY AND
hyperresonance. RESUSCITATION
E. Auscultate rhe chest bilaterally.
STEP 1. Obtain ABG analysis and ventilatory rate.
STEP 2. Management
A. Administer high-concentration oxygen. STEP 2. Monitor the patient's exhaled C02 with an
B. Ven tilate with a bag-mask device. appropriate monitoring device.
C. Alleviate tension pneumothorax.
STEP 3 . Attach nn ECG monitor to the patient.
D. Seal open pneumothorax.
SKILL STATION I Initial Assessment and Management 21
STEP 4. Insert minary and gastric catheters Lmless STEP 6. Consider the need for and perform FAST or
contraindicated, and monitor tJ1e patient's DPL.
hourly output of urine.
STEP 5. Consider tJ1e need for and obtain AP chest and REASSESS PATIENT'S ABCDEs AND
AP pelvic x-rays. CONSIDER NEED FOR PATIENT TRANSFER
Skill l-8: Secondary Survey and Management

(Also See Table 1-1: Secondary Survey)
AMPLE HISTORY AND MECHANISM C. Auscultate the carotid arteries for bruits.
OF INJURY D. Obtain a CT of lhc cervical spine or a lateral,
cross-table cervical spine x-ray.
STEP 1. Obta in AMPLE history from patient, family, or
STEP 6. Management: Maintain adequate in-line
prehospital personnel.
immobilization and protection of the cervical
.
STEP 2. Obtain history of injury-producing event and spme.
identify injury mechanisms.
CHEST
HEAD AND MAXILLOFACIAL
STEP 7. Assessment
STEP 3. Assessment
A. Inspect the a11terior, lateral, and posterior
A. lnspect and paJpate entire head and face for
chest wall for signs of blunt and penetrating
lacerations, contusions. fractures, and Lhennal
. . injury, use of accessory breathing muscles,
mJury.
and bilateral respiratory excursions.
B. Reevaluate pupils.
B. Auscultate the anterior chest wall and
C. Reevaluate level of consciousness and GCS
posterior bases for bilateral breath sounds and
score.
heart sounds.
D. Assess eyes for hemorrhage, penetraling
C. Palpate the entire chest wall for evidence of
injury, visual awity, dislocation of lens, and
blunt and penetrating injury, subcutaneous
presence of contact lenses.
emphysema, tenderness, and crepitation.
E. Evaluate cnmial-nerve function.
D. Percuss for evidence of hyperresonance or
F. Inspect cars and nose for cerebrospinal fluid
dullness.
leakage.
STEP 8. Manageme11t
G. Inspect mouth for evidence of bleeding and
cerebrospinal fluid, soft-Ussue lacerations, A. Perform needle decompression of pleural
and loose teeth. space or tube thoracostomy, as indicated.
B. Attach the chest tube to an underwater seal-
STEP 4. Management
drainage device.
A. Maintain airway, and continue ventilation
C. Correctly dress an open chest wound.
and oxygenation as indicated.
D. Perfonn pericard.iocentesis, as indicated.
B. Control hemorrhage.
E. Transfer Lhe patient lo the operating room, i f
C. Prevent secondary brain injury.
indicated.
D. Remove contact lenses.
ABDOMEN
CERVICAL SPINE AND NECK
STEP 9. Assessment
STEP 5. Assessment
A. Inspect for signs of blunt and penetrating A. Inspect the anterior and posterior abdomen
injury, tracheal deviation, and use of for signs of blunt and penetrating injury and
accessory respilatory muscles. internal bleeding.
B. Palpate for tenderness, deformity, swelling, B. Auscultate for Lhe presence of bowel sounds.
subcu taneo us emphysema, tracheal deviaU.on, C. Percuss the abdomen to elicit subtle rebound
and symmetry of pulses. tenderness.
TABLE 1-1 Secondary Survey
ITEM ESTABLISHES/ CONFIRM

TO ASSESS IDENTIFIES ASSESS FINDING BY
level of Seventy of GCS score B. Severe head inJury CT scan

Consciousness head InJury 9-1 2, Moderate Repeat without
head InJUry paralyzmg agents
1 3-15, Minor head injury
Pupils Type of head InJury Stze Mass effect CT scan

Presence of eye injltry Shape Diffuse bram 1njury
Reactivity Ophthalmrc Injury
Head Sealp injury Inspect for lacerations Scalp laceration CT scan

Skull Injury and skull fractures Depressed skull fracture
palpable deretts Basilar skull fracture
Maxillofacial Soft-tissue injury Visual deformity Facial fracture Factal-bone x-ray

Bone injury Maloccluston Soft-tissue InJury CT scan of faoal bones
Nerve Injury Palpation for crepttatlon
Teeth/mouth injury
Neck Laryngeal injury Visual Inspection Laryngeal deform1ty C-sptne x-ray

C-spi ne injury Paipalton Subcutaneous Angtography/duptex
Vascular inJury Auscultation emphysema exam
Esophageal injury Hematoma Csophagoscopy
Neurologtc deficit Bruit Laryngoscopy
Platysma! penetration
Pa1n, tenderness
of c-sptne
Thorax Thoraoc-wail InJury Visual inspectton BrUJStng, deformity, or Chest x-ray

Subcutaneous Palpation paradoxical motion CT scan
emphysema Auscultation C hest-wall tenderness, Angtography
Pneumothorax/ crepitation Bronchoscopy
hemothorax Dtminished breath Tube thoracostomy
Bronchtal tntury sounds Pericardiocentesis
Pulmonary contusion MufHed heart tones TF tJilrasound

Thoracic aortic Med1ast1nal crepttation
disruption Severe back pain
AbdomenfFiank Abdominal-wall tnjury V1sual inspecton Abdominal-wall DPUultrasound

lntrapentoneal mJury PalpatiOn pau'l!tendemess CT scan
Retropentoneal tnJury Auscultation Pentoneal trntatton Laparotomy
Determine path Visceral injury Contrast Gl x-ray
of penetratton Retropentoneal organ stud1es
InjUry Angtography
Pelvis GU tract lnJu nes Palpate symphysis GU tract InJury Peiv1c x-ray
Pelvic fracture(s) pu bis for widening (hematuria) GU contrast studies
Palpate bony pelvis Pelvtc fracture Urethrogram
for tenderness Rectal, vaginal, and/or Cystogram
Determine pelvic perineal injury IVP
stability only once Contrast-enh anced CT
Inspect penneum
Rectallvagtnal exam
SKILL STATION I Initial Assessment and Management 23
ITEM ESTABLISHES/ CONFIRM

TO ASSESS IDENTIFIES ASSESS FINDING BY
Spinal Cord Cranial 1n1ury Mototresponse U nilateral cranial Pla1n spine x-rays
Cord injury Pain response mass effect CT Scan
Peripheral nerve(s) Quadriplegia MRI
InJUry Parap legia
Nerve root injury
Vertebral Column Column injury Verbal response to Fracture versus Plain x-rays
Vertebral 1nstab1hty pain, laterahzmg s1gns diSlocation CT scan
Nerve Injury Palpate for tenderness MRI
Deformtty
Extremities Soft-tissue tnJury Visual tnspection Swelling, bruisl ng, Speofic x-rays
Bony deformities Palpation pallor Doppler examination
J01nt abnormalities Malalign ment Compartment pressures
Neurovascular Pain, tenderness , Angiography
defeds crepitation
Absentldtmtnshed
pulses
Tense muscular
compartments
Neurologtc defiCitS

- -
-
-
--- --
D. Palpate the nbdomcn for tenderness, STEP 13. Vaginal assessment in selected patients. Assess
involuntary muscle guarding, unequivocal for:
rebound tendcrncs. and a gravid uterus. A. Presence of blood in vaginal vault
E. Obtain a pelvic. x-ray film. B. Vaginal lacerations
F. Perform DP!Jabdominal ultrasound, if
warranted.
MUSCULOSKELETAL
G. Obtain cr of Ihe abdomen if the patient is
hemodynamically normal. STEP 14. Assessment
A. lnspect the upper and lower extremities for
STEP 10. Management
evidence of blunt and penetrating injury,
A. Transfer the patient to the operating room,
including contusions, lacerations, and
if indicated.
deformity.
B. Wrap a sheet around the pelvis or apply a
B. Palpate tht: upper and lower extremities for
pelvic compression hinder as indicated to
tenderness, crepitation, abnormal
reduce pelvic volume and control
movement, and cnsation.
hemorrhage from a pelvic fracture.
C. Palpate all peripheral pulses for presence,
absence, nnd equality.
PERINEUM/RECTUM/VAGINA D. Assess the pelvis for evidence of fracture
and associated hemorrhage.
STEP 11 . Perineal assessment. Assess for:
E. Inspect ami palpnte the tl1oracic and lumbar
A. Contusions and hematomas
spines for evidence of blunt and penetrating
B. Lacerations
i njur)', including contusions, lacerations,
C. Urethral bleeding
tenderness, tkformity, and sensation.
STEP 12. Rectal assessment in selected patients. Assess F. Evaluate the pelvic x-ray film for evidence of
for: a fracture.
A. Rectal blood G. Obtain x-ray films of suspected fracture
B. Anal sphincter tone sites as indicated.
C. Bowel wall integrity
STEP 15. Management
D. Bony fragment!>
A. Apply and/or readjust appropriate splinting
E. Pros tate position
devices for extremity fractures as indica ted.
B. Maintain immobilization of the patient's C. Evaluate the upper and lower e>..'tremities for
thoracic and lumbar spines. motor and sensory functions.
C. Wrap a sheet around the pelvis or apply a D. Observe for lateralizing signs.
pelvic compression binder as indicated to
STEP 17. Mrumgement
reduce pelvic volume and control hemorrhage
A. Continue ventilation and oxygenation.
associated with a pelvic fractme.
B. Maintain adequate immobilization of the
D. Apply a splint to immobilize an e.Ktremity
entire palienl.
tnJury.
E. Administer tetanus i mrnun ization.
F. Administer medications as indicated or as ADJUNCTS TO SECONDARY SURVEY
directed by specialist.
STEP 18. Consider the need for and obtain these
G. Consider the possibility of compartment
diagnostic tests as the patient's condition
syndrome.
permits and warrants:
H. Perfonn a complete nemovascular
Spinal x-rays
examination of the extremities.
CT of the head, chest, abdomen, and/or spine
Contrast urography
NEUROLOGIC Angiography
Extrem i L-y x- rays
STEP 16. Assessment
Transesophageal ultrasound
A . Reevaluate the pupils and level of
. Bronchoscopy
COllSClOUSneSS.
Esophagoscopy
B. Detenninc the GCS score.
-- - --- - ---- - - - - - -.---:.

..,;:---- =-
Skiii i-C: Patient Reevaluation

Reevaluate the patient, noting, reporting, ru1d documenting t u tecl. Continuous monitoring of vital signs, urinary out
any changes in the patient's condition and responses to re put, and the patient's response to treatment is essential.
suscitative efforts. Judicious use of analgesics may be insti-
Skill l-0: Transfer to Definitive Care

Outline rationale for palient transfer, transfer procedures,
and patient's needs during transfer, and state the need for
direct doctor-to-doctor conununication.
C H APTE R
CHAPTER OUTLINE Upon completion of this topic the student will identify actual
,
or impending airway obstruction, explain the techniques of es

Objectives
tablishing a nd maintainin g a patent airway, and confirm the
Introduction adequacy of ventilation Specifica l ly the doctor will be able to:
,
Airway
Problem Recogn1t1on OBJECTIVES
Objective Signs of Airway Obstruction
Ventilation Identify the cl inica l situations in which airway
Problem Recognition compromise is like ly to occur.
Obje<t1ve Stgns of Inadequate Ventilation
Recognize the signs and symptoms of acute airway
Airway Management obstruction.
Airway Maintenance Techniques
Definitive Airway Describe the techniques for establishing and ma in
Airway Decision Scheme ta i n i ng a patent airway.
Management of Oxygenation Describe the tech ni q ues for confirming the ade
Management of Ventilation quacy of ventilation and oxygenation, including
pulse ox i metry and end-tidal C02 monitoring .
Chapter Summary
Bibliography Define the term definitive airway.
Outline the steps necessary for maintaining oxy

genation before, during, and after establishing a
defi nitive airway.
26 CHAPTER 2 Airway and Ventilatory Management
Introduction
The inadequate delivery of oxygenated blood Lo the brain ..
and other vital structures is the quickest killer of injured pa-

tients. Prevention of hypoxemia requires a protected, unob
structed airway and adequate ventilation, which take
priority over management of aU other conditions. An air
way must be secured, oxygen delivered, and ventilatory sup
port provided. Supplemental oxygen must be administered to
all trauma patients.
Early preventable deaths from airway problems after
trauma often result from:
Failure to recognize the need for an airway inter

vention.
lnabili ty to establish an airway.
Failure to recognize an incorrectly placed airw<l)'
Displacement of a previously established airway. and/or other dmgs, and patients with thoracic injuries all
can have a compromised ventilatory effort. In these pa
Failure to recognize the need for ventilation. tients, the purpose of endotracheal intubation is to pro
Aspiration of gastric contents. vide an airway, deliver supplementary oxygen, support
ventilation, and prevent aspiration. Maintaining oxygena
Airway and ventilation are the first priorities. tion and preventing hypercarbia are critical in managing
trauma patients, especially those who have sustained a head
InJUry.
Anticipating vomiting i n all injured patients and being
prepared to manage the situation are important. The pres
Airway ence of gastric conl'ents in the oropharynx represents a sig
nificant risk of aspiration with the patient's next breath.
EJ How do I know the airway is Immediate suctioning and rotation of the entire patient to
adequate? the lateral position are indicated.
The first steps toward identifying and managing potentially

Maxillofacial Trauma
life-threatening ai rway compromise are to recognize prob
lems involving maxillofacial, neck, and laryngeal trauma and Trauma to the face demands aggressive airvvay management.
to identify objective signs of airway obstruction. The mechanism for this injury is exemplified by an unbelted
automobile passenger who is thrown into the windshield
and dashboard. Trauma to the midtace can produce frac
PROBLEM RECOGNITION tures and dislocations that compromise the nasopharynx
Airway compromise can be sudden and complete, insidi and oropha rynx. Facial fractures can be associated vvith
ous and partial, and/or progressive and recurrent. Al hemorrh age, increased secretions, and dislodged teeth,
though it is often related to pain or anxiety or both, wbich cause additional difficulties in maintaini_ng a patent
tachypnea can be a subrle but early sign of airway or ven airway. Fractures of the mandible, especially bilateral body
tilatory compromise. Therefore, assessment and frequent fractures, can cause loss of normal airway support Airway
reassessment of airway patency and adequacy of ventila
tion are critical.
Patients with an altered level of consciousness are at
particular risk for airway compromise and often require a PITFALL -....:-:
:;:. '
Lri!
Ufll!l "
defmitive airway (a tube placed i n the trachea with the cuff
Trauma patients can vomit and aspirate. Functional
inflated, the tube connected to some form of oxygen-en
suction equipment must be immediate ly available to
riched assisted ventilation, and the airway secured in place aid doctors in ensuring a secure, patent airway in all
with tape). Unconscious patients with head injuries, pa trauma patients.
tients who are obtunded because of the use of alcohol
AIRWAY 27
obstruction can result if the patient is in a supine position. 1 . Hoarseness

Patients who refuse to lie down may be experiencing diffi
2. Subcutaneous emphysema
culty in maintaining their airway or handling secretions.
- 3. Palpable fracture
Neck Tra uma Complete obstruction of the airway or severe respira
Penet rating injury Lo the neck can cause vascular injury with tory distress warrants an attempt at intubation. Flexible en
significant hemorrhage, which can result in displacement doscopic intubation may be helpful in this situation, but
and obstruction of the airway. Emergency placement of a only if it can be performed promptly. If intubation is un
surgical airway may be necessary if this displacement and successful, an emergency tracheostomy is indicated, fol
obstruction make endotracheal intubation impossible. lowed by operative repair. However, a tracheostomy is
Hemorrhage from adjacent vasCLJlar injury can be massive, difficult ro perform under emergency conditions, it can be
and operative control may be required. associated with profuse bleeding, and can be time-consum
Blunt or penetrating injury to the neck can cause dis ing. Surgical cricothyroidotomy, although not preferred for
ruption of the larynx or trachea, resu lting in airway ob this situation, can be a lifesaving option.
struction and/or severe bleeding into the tracheobronchial Penetrating trauma to the larynx or trachea is overt ru1d
tree (Figure 2-1 ) . A defiJ1itive ainvay is urgentJy required in requires immediate management. Complete tracheal tran
this situation. section or occlusion of the ainvay v.rith blood or soft tissue
Neck injuries involvi_ng disruption of the larynx and can callSe acute airway compromise that requires immediate
trachea or compression of the airway from hemorrhage into correction. These injuries are often associated with trauma to
the soft tissues of the neck can cause partial a.irway ob the esophageus, carotid artery, or jugular vein, as well as ex
struction. fnitially, a patient with this type of serious airway tensive tissue destruction. Noisy breathing indicates partial
injury may be able to maintain airway patency and ventila airway obstruction that ca11 suddenly become complete,
tion. However, if airway compromise is suspected, a defini whereas absence of breathing suggests that complete ob
tive airway is required. To prevent extending an existing struction already exists. When the level of consciousness is
ainvay injury, a n endotracheal lube must be inserted cau depressed, detection of signiCicant airway obstruction is more
tiously. Loss of airway patency can be precipitous, and an subtle. Labored respiratory effort may be the only clue to air
early surgical airway usually is imlicated. way obstruction and tracheobronchial injury.
rf a fracture o f the larynx is suspected, based on the
mechanism of injury and subtle physical findings, computed
Laryngeal Trauma
tomography (CT) can help to identify this injury.
Although fracture of the larynx is a rare injury, it can pres During initial assessment of the ainvay, the "talking pa
ent with acute airway obstruction. lt is indicated by the fol tient" provides reassurance (at least for the moment) that
lowing triad of clinical signs: the airway is patent and not compromised. Therefore, the
most important eruly measme is to talk to the patient m1d
stimulate a verbal response. A positive, appropriate verbal
response indicates that the airway is patent, ventilation is in
tact, and brain perfusion is adequate. Failure to respond or
a n inappropriate response suggests a n altered level of con
sciousness, airway and ventilatory compromise, or both.
OBJECTIVE SIGNS OF AIRWAY OBSTRUCTION

Several objective signs of airway obstruction can be identi
fied by laking Lhe following steps:
1 . Observe the patient to detetmu1e whether he or she is

agitated or obtuncled. Agitation suggests hypoxia, and
obtundation suggests hypercarbia. Cyanosis indicates
hypoxemia due to inadequate oxygenation; it is iden
tified by inspection of the nail beds and circumoral
skin. Cyanosis is a late finding of hypoxia, and pulse
oximetry is used early in the assessment of airway ob
Figure 2-1 Traumatic Disruption of Trachea, as struction. Look for retractions and the use of acces
seen on radiograph. A definitive airway is urgently re sory muscles of ventilation that, when present,
quired in this situation. provide additional evidence of airway compromise.
28 CHAPTER 2 Airway and Ve ntil ato ry Management
2. Liste n for abnormal sounds. Noisy breath ing is ob 1 . Look for symmetrical rise and [ali of the chesl and ad
structed breathing. Snori ng, gurgl i ng, and crowing equate chest wall excursion. Asymmetry suggests
sounds (stridor) can be associated with pa rtial occlu splinting of the rib cage or a flail d1est. Labored
sion of the pharynx or larynx. Hoarseness (dyspho breathing may iJ)(Iicate <m imminent threat to the pa
nia) implies functional, la ryngeal obstruction. tient's ventilation.
Abusive and belligeren t patients may in fact have hy
2. Liste n for movement of air on both sides of tJ1e chest.
poxia and should not be presumed to be in toxicated.
Decreased or absent breath sounds over o ne or both
3. Peel for the location of the I rac hea and quickly deter hemithoracc:.. should alert the examiner to the pres
mine whether it is in t he midline posit io n. ence of thoracic injury. rl' See Chap ter 4: Th oracic
Trauma. Beware of a rapid respiratory rate-tachy
pnea can indicate respiratory d istres s.
Ventilation 3. Use a pulse oximeter. This device provides informa

tion regarding the patient's oxygen saturation and pe
ripheral perfusion , but does not measure the
Ensuring a patent airway is an important step in providing adequacy of ventilation.
oxygen to the pati en t but it is only t he first step. An u nob
,
structed airway is n ot likely to benefit the patien t unless

there is also adequate ventilation. The doctor must recog
nize problems with ventilation and look for objective signs
of inadequate venti lat ion . Airway Management
PROBLEM RECOGNITION I How do I manage the
airway of a trauma patient?
Ventilation can be compromised by airway obstruction, al
tered ventilatory mechanics, or central nervous system (CNS) Airway patency and a dequacy of ventilation must be as
depression. if a patient's breathing is not improved by clear sessed quickly and accu rately. Pulse oximetry and end-tidal
ing the airway, other causes of the problem must be identi C02 measurement are essential. lf problents arc identified
fied and managed Direct trauma to the chest, especially with
.
or suspected measmes should be instituted immedi a tely to
,
rib fractures, causes pain with breathing and leads to rapid, improve oxygenation and reduce the risk of furlher ventila
shallow ventilation and hypoxemia. Elderly patients and those tory compromise. These measures include airway mainte
,.,1.th pree.xisting pulmonary dysfunction are at significa nt risk nance tech n iq ues, definitive airway measures (including
for ventilatory failure under U1ese circumstances. Intracranial s urgica l ainvay), and methods of providing s upplemental
injury can cause abnoJmal breath ing patterns and compro ventilation. Because all of these actions can require some
mise adequacy of ventilation. Cervical spinal cord injury can neck motion, it is important to maintain cervical spine pro
result in diap hragmat ic breathing and interfere with U1e abil tection in all patien ts esp ecially those who are known to
,
ity to meet increased oxygen demands. Complete cervical have an unstable cervical sp ine injury and those who have
cord transection, which spares the phrenic nerves (C3 an d been incompletely evaluated and are at risk. The spinal cord
Ol), results in abdominal breathing and paralysis of the in must be pro lected until the possibility of a spinal injury has
tercostal muscles; assisted ventilation may be required. been excluded by clinical assessment and appropriate radi
ographic studies.
Patients who are wearing a helmet and require airway
OBJECTIVE SIGNS OF INADEQUATE VENTILATION management need their head and neck held in a neutral po
I How do I know ventilation sition while the helmet is removed. This is a two-person pro
is adequate ? cedure: One person provides in-line manual immobiUzation
from below, while the second person expands the helmet lat
Several objective signs of inadequate ventilation can be iden
eraUy and removes il liom above (Figure 2-2). Then, in-line
tified by taking the following steps:
manual immo bilizatio n is reestablished from above, and t he
patient s head and neck are secured during airway manage
'
ment. Removal of the helmet using a cast cutter while sta

PITFA LL bilizing the head and neck can minimi.ze cervical spine
motion in patients with known cervical spine injm y.
Patients who are breathing high concentrations of
High-flow oxygen is required both before and imme
oxygen can maintain their oxygen saturation al
diately after airway management mea.smes are instituted. A
though breathing inadequately. Measure a rteri al or
end-tidal carbon dioxide. rigid suction device is essential and should be readi ly avail
able. Patients with facial injuries can have associated cribri -
AIRWAY MANAGEMENT 29
A c
B D
Figure 2-2 Helmet Removal. Removing a helmet properly is a two-person pro
cedure. While one person provides manual in-line stabilization of the head and neck
(A), the second person expands the helmet laterally. The second person then removes
the helmet (B), with attention paid to the helmet clearing the nose and the occiput.
Once removed, the first person supports the weight of the patient's head (C), and the
second person takes over inline stabilization (D).
form plate fractures, and Lhe insertion of any rube through bring the chin anterior. The thumb of the same hand lightly
the nose can result in passage into the cranial vault. depresses U1e lower lip to open the mouth (Figure 2-3 ). The
thumb also may be placed behind the lower incisors and, si
multaneously, the chin is gently Hfted. The chin-lift maneu
AIRWAY MAINTENANCE TECHNIQUES
ver should not hyperextend the neck. This maneuver is
l n patients who have a decreased level of consciousness, the useful for trawna victims because it can prevent converting
longue can fall backward and obstrud the hypopharynx. a cervical fracture \Vithout cord injury into one with cord
This form of obstruction can be corrected readily by the lnJ ury.
chin-lift or jaw-thrust maneuver. The ainvay can then be
maintained with an oropharyngeal or nasopharyngeal air
way. Maneuvers used to establish an airway ca11 produce or Jaw-Thrust Maneuver
aggravate cervical spine injury, so in-line immobilizati.on of
The jaw-thrust maneuver is performed by grasping lhc an
the cervical spine is essential during these procedures.
gles o[ the lower jaw, one hand on each side, and displacing
Lhe mandible forward (Figure 2-4). When Lbis method is
Chin-Lift Maneuver used with the face mask of a bag-mask device, a good seal
In the chin-lift maneuver, the fingers of one hand are placed and adequate ventilation can be achieved. Care must be
under the mandible, which is then gently Hfted upward to taken to prevent neck extension.
..
Figure 2-3 Chin-lift Maneuver to Establish an

Airway. This maneuver is useful for trauma victims be
cause it can prevent converting a cervical fracture with B
out cord injury into one with cord injury.
Figure 2-5 In this alternative technique, the oral

irway is inserted upside down (A) until the soft palate
2-4 Jaw-Thrust Maneuver to Estab lish an 1s encountered, at which point the device is rotated 180
Fig u re
Airway. Care must be taken to prevent neck extension. degrees and slipped into place over the tongue. (B) This
method should not be used in children.
Oropharyngeal Airway
rotated 180 degrees, the concavity is directed inferiorly,
Oral airways are inserted in to the mouth behind the tongue.
and the device is supped into place over the tongue (Figure
The preferred technique is to use a tongue blade to depress
2-5). This alternative method should not be used in chil
lhe tongue and then insert the airway posteriorly, taking care
dren, because the rotation of the device can damage the
not to push the tongue backvvard, which would block
moulh and pharynx. rJ& See Skill Station I I : Airway and
rather than dear-the airwar This device must not be used
Ventilatory Management, Skil.l II-A.: Oropharyngeal Air
in conscious patients because it can induce gagging, vomit
way insertion.
ing, and aspiration. Patients wbo tolerate an oropharyngeal
airway aTe highly likely to require intubation.
An alternative technique is to insert the oral airway Nasopharyngeal Airway
upside down, so its concavity is directed upward, until the Nasopharyngeal ai rways are inserted in one nostril and
soft palate is encountered. At this point, with the device passed gently inlo the posterior oropharynx. They should
AI RWAY MANAGEMENT 31
be weU lubricated and inserted into the nostril that ap

pears to be unobstructed. If obstruction is encountered
during introduction of the airway, stop and try the other
nostril. .. See Skill Station 11: Airway and VeJ?.tilatory
Management, SkilJ Il-B: Nasopharyngeal Airway inser
tion.
Laryngeal Mask Ai rway

There is an established role for the laryngeal mask airway
(LMA) in the treatment of patients with difficult ainvays,
particularly if attempts at endotracheal intubation or bag
mask ventila tion have fail.ed (Figure 2-6). However, tbe
LMA does not provide a definitive airway, and proper
placement of this device is difficult without appropriate
training. When a patient has an LMA i n place on arrival i n
the emergency department (ED), the doctor must plan for
a definitive airway. .. See Skill Station 11: Airway and Ven
tilatory Management, Skill ll-E: Laryngeal Mask Airway In
sertion.
Multilumen Esophageal Airway

Multilumen esophageal airway devices are used by some
prehospital personnel to achieve an airway when a defini
tive airway is not feasible (Figure 2-7). One of the ports
communicates with the esophagus and tbe other with the
airway. The personnel who use this device are trained to ob
serve which occludes the esophagus and which will provide
air to the trachea. The esophageal port is then occluded with
a balloon, and the other port is ventilated. A C02 detector
improves the accuracy of this apparatus. The multilumen Figure 2-7 Example of a multilumen esophageal

esophageal airway device must be removed and/or a defin a1rway.

itive airway provided by the doctor after appropriate assess
ment.
Laryngeal Tube Airway
The laryngeal tube airway (LTA) is an extraglottic airway de
vice with capabilities similar to those of the LMA to provide
successful patient ventilation (Figure 2-8). The ITA is not a
definitive airway device, and plans to provide a definitive
airway are necessary. Like the LMA, the LTA is placed with
out direct visualization of the glottis and does not require
significant manipulation of the head and neck for place
ment. .. See Skill Station ll: Airway and Ventilatory Man
agement, Skill II-F: Laryngeal Tube Airway Lnsertion.
Gum Elastic Bougie

An excellent tool when faced with a djfficult airway is the
Eschmann Tracheal Tube Introducer ( ETT!), also known as
the gum elastic bougie (G EB) (Figme 2-9). First introduced
as an aid to difficult intubations in 1949 by Macintosh, its
use has been primarily in the operating room but has since
been e.x.-panded to tl1e ED and prehospital arena. It is a 60-
cm-long, 15-Frcnch intubating stylettc made from a woven
polyester base wit11 a resin coating, which is available in both
Figure 2-6 Example of a laryngeal mask airway. disposable and reusable packaging. It has a Coude tip that is
GEB-aided intubation was successful i n 100% of cases in

less than 45 seconds. Although operating-room conditions
are far superior to those of the ED and prchospit.al environ
..
ments, the GEB has been successfully plac<.:d in these set
lings also. This simple device has allowed rapid intubation
of nearly 80 percen t of prehospital patients in whom direct
laryngoscopy is difficult.
DEFIN ITIVE AI RWAY

A definitive airway requires a tube placed in the trachea with
the cuff inflated, the tube connected to some form of oxy
gen-emiched assisted ventilation, and the airway secured i n
pl ace with tape. There are three types of defulitive airways:
orotracheal tube, nasotracheaJ lube, and surgical airway
(cricothyroidotomy or tracheostomy ). The criteria for es
tablishing a definitive airway arc based on clinical findings
and include (see Table 2 - l ) :
Presence of apnea
Inability to maintain a patent airway by other

means
Need to protect the lower airway from aspiration of

blood or vomitus
lmpenc..ling or potential compromise of the air

way-for example, follmving inhal at ion injury, fa
cial fractures, retropharyngeal hematoma, or
sustained seizure activity
Figure 2-8 Example of a laryngeal tube airway.
Presence of a closed head injury requiring assisted
ventilation (Glasgow Coma Scale score <8)
angled at 40 degrees 3.5 em from the distal end, with I 0-cm
Inability to maintain adequate oxygenation by face
gradations. No special preparation is required; it comes
mask oxygen supplementation
ready to use.
The GEB is used when vocal cords cannot be visual
ized on direct laryngoscopy. With the Ia ryngoscope in place,
the GEB is passed blindly beyond the epiglottis, with the
angled tip positioned anteriorly. Tracheal position is con
finned by either feeling for clicks as the distal tip rubs along
the cartilaginous tracheal rings (65%-90%), the lube ro
tates to the right or left when entering the bronchus, or
when the Lube is held up at the bronchial tree ( L0%- 13%),
which is usually at about the 50-cm mark. None of these
indications occur if the GEB has entered the esophagus.
The proximal end is lubricated, and a 6.0-cm internal di
ameter or larger endotracheal tube is passed over the GEB
beyond the vocal cords. l [ the endotracheal tube is held up
at the arytenoids or aryepiglottic folds, the tube is with
drawn slightly and turned 90 degrees to facilitate advance
ment beyond the obstruction. The GEB is then removed,
and tube position is con tinned with auscultation of breath
sounds and capnography.
[n multiple operating room studies, successful intuba
tion was achieved at rates greater than 95% ,.nth the GEB. In Figure 2-9 Eschmann Tracheal Tube Introducer
cases in which potential cervical spine injury was suspected, (ETTI), also known as the gum elastic bougie.
TABLE 2-1 Indications for Definitive Airway

NEED FOR AIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATION
Unconscious Apnea
Neuromuscular paralysis

Unconscious
Severe maxillofacial fractures Inadequa te respira tory efforts

Tachypnea
Hypoxia

1-iyperca rbia

Cyanosis
Risk for aspiration Severe, closed headinjury with need for brief hyperventilation if

Bleeding acute neurologic deterioration occurs
Vom it1ng
Risk for obstruction Mass1ve blood loss and need for volume resuscitation

Neck hematoma
La ryngea I or trachea I injury

Stridor
......,_,_,,._.,,_,_,,................ ,,_,., ...._...,.. . . .
.............. .. ..., .... ..... "'' ................. ............ ...-..................... .... .... ................ ..................... .....,_.,,_.,,......................................... ...... ........... . . .
..... ....... ........ .... ........ .... .
..
The urgency of the situation and the circumstances in immobilization is necessary (Figure 2 - 1 1 ). If the patient has
dicating the need for ainvay intervention dictate the specific apnea, orotracheal intubation is indicated. See Skill Sta
route and method to be used. Continued assisted ventila tion II: Airway a11d Venlilalory Management, Skill U-D:
tion is aided by supplemental sedation, analgesics, or mus Adult Orotracheal Intubation (with and without Gum Elas
cle relaxants, as indicated. The use of a pulse oximeter can be tic BougieDevice,and Skill lT-G: Infant Endotracheal Intu
helpful in determining the need for a definitive airway, the bation.
urgency of the need, and, by inference, the effectiveness of
airway placement. The potential for concomitant cervical
spine ( c-spine) injury is of major concern in the patient re
IJ How do I know the tube
is in the right place?
quiring an airway. Figure 2-10 prov ides a schem e for decid
ing the appropriate route of ain-vay management. Follm-ving direct laryngoscopy and insertion of the orotracheal
tube, the cuff is inflated, and assisted ventilation instituted.
Proper placement of the tube is suggested-but not con
Endotracheal Intubation firmed-by bearing equal breath sounds bilaterally and de
Although it is important to establish lhe presence or absence tecting no borborygmi (ie, rumbling or gurgling noises) in the
of a cervical spi ne fracture, obtaining c-spine x-rays should epigastrium. The presence of borborygmi in the epigastrium
not impede or delay placement of a definitive airway when with inspiration suggests esophageal intubation and warrants
one is clearly indicated. The patient who has a GCS score of repositioning of the tube. A carbon dioxide detector (ideally a
8 or less regui res prom pi intubation. J f there is no inunedi capnograph, but, f i that is not available, a colorimetric CO,
ate need for intubation, x-rays o f the cervical spine may be monitoring device) is indicated to help confinn proper intu
obtained. However, a normal lateral cervical spine film does bation of the airway. The presence of COl in exhaled ai r i ndi
not exclude the possibility ofa c-spine injury. cates Lhat Lhe airway has been successfully intubated, but does
The most important determinant of whether to proceed noI ensure the correct position of the endotracheal tube. Tf
with orotracheal or nasotracheal intubation is the experience col is not detected, esophageal intubation has occurred.
ofthe doctor. Both techniques are safe and effective when per Proper position of the tube is best confirmed by chest x-ray,
formed properly. The orotracheal route is more commonly once the possibility of esophageal intubation is excluded. Col
used. Esophagea I occlusion by cricoid pressure is useful in orimetric col indicators are not useful for physiologic mon
preventing aspi ral ion. Laryngeal manipulation by backward, itoring or assessing the adequacy of ventilation, wbicb requires
upward, and rightward pressure (BURP) can aid in visual arterial blood gas analysis or continual end-tidal carbon djox
izing the vocal co rds. ide analysis. .. See Skill Station II: Ainvay and Ventilatory
lf the decision to perform orotracheal intubation is Managemen t, Skill ll-H: Pulse Oximetry Monitoring, aJ1d Skill
made, the two-person technique witl1 in-line cervical spine II-1: Carbon Dioxide Detection.
Be Prepared
Equipment:
Suction, 021 bag-mask, laryngoscope, gum elastic bougie
(GEB), laryngeal mask airway (LMA), laryngeal tube airway
(LTA), surgical or needle cricothyroidotomy kit,
endotracheal tube, pulse oximetry, col detection device,
drugs
Protect C-Spine!
Preoxygenate
02 +/- bag-mask +/- oral airway +/- nasal airway

Able to oxygenate?
I
Definitive airway Surgical airway
Assess airway anatomy

Predict ease of intubation (eg, LEMON)
Intubation-drug-assisted
Call for assistance, if available
Cricoid pressure
Consider adjunct
Consider awake intubation
(eg, GEB/LMA/LTA)
I
Definitive airway Surgical airway
The ATl.S airway algorithm provides a general approach to airway management In trauma, MJJny centers
have developed detailed airway management algorithms. lt ls Important to review and learn the standard
used by teams In your trauma system.
Figure 2-10 Airway Decision Scheme. Used for deciding the appropriate route of airway management.
Figure 2- 1 1 Orotracheal
intubation using two-person
technique with inline cervical
spine immobilization.
\A/hen the proper position of the tube is determined, it is of LEMON are more useful in tralllna. Look for evidence of
secured in place. 1f the patient is moved, tube placement is re a difficult airway (small mouth or jaw, large overbite, or fa
assessed by auscultation of both lateral lung fields for equal. cial trauma). Any obvious airway obstruction presents an
ity of breath SOW1dS and by reassessment for exhaled C02 immediate challenge. AJI blunt trauma patients will be in
If orotracheal in tubation is unsuccessful on the first at cervical spine immobilation, which increases the difficulty
tempt or if the cords are d ifficult to visualize, a gum elastic in establishing an airway. Clinical judgment and e>.:perience
bougie should be used. will determine whetl1er to proceed immediately with drug
Blind nasotracheal intubation requires spontaneous assisted intubation or to exercise caution.
breathin g. lt is contraindicated in the patient with apnea. The The use of anesthetic, sedative, and neuromuscular
deeper the patienl breathes, tJ1e easier it is to follow the airflow blocking drugs for endotracheal intubation in lrauma pa
through the larynx. Facial, frontal sinus, basilar skull, and crib tients is potentially dangerous. In certain cases, the need for
riform plate fractures are relative contraindications to nasa an airway justifies the risk of administering these drugs, but
tracheal intubation. Evidence of nasal fracture, raccoon eyes the doctor must understand their pharmacology, be skilled
(bilateral ecchymosis in the periorbital region ), Battle sign in the techniques of endotracheal intubation, and be able to
(postauricular ecchymosis). and possible cerebrospinal fluid obtain a surgical airway if necessary. In many cases in which
(CSF) leaks (rhinorrhea or otor-rhea) identify patients ,.vith an airway is acutely needed during the primary survey, the
these injuries. Precautions regarding cervical spine in1mobi use of paralyzing or sedating drugs is nol necessary.
lization should be followed, as with orotracheal intubation. The technique for rapid sequence intubation (RSl) is
A chest x-ray, C02 monitoring, oximetry, and physical as follows:
exam are necessary to confirm correct position of the en
dotracheal tube. The tube may have been inserted into the
1. Be prepared to perform a surgical airway in the event
that airway control is lost.
esophagus or a mainstem bronchus, or dislodged during
Lransport from the field or another hospital. A chest x-ray, 2. Ensure that suction, as well as the ability to deliver
C02 monitoring, and physical examination are necessary to positive pressure ventilation, is ready.
confirm the position of the tube. 3. Preoxygenate tl1e patient with lOOo/o oxygen.
B How do I predict a potentially 4. Apply pressure over the cricoid cartilage.

5. Administer an induction drug (eg, etomidate, 0.3
difficult airway?
mg/kg, or 20 mg) or sedate, according to local practice.
It is important to assess the patient's airway prior to at
6. Administer l to 2 mg!kg succinylcholine intra
tempting intubation to predict the likely difficulty. Factors
venously (usual dose, 100 mg).
that may predict difficulties with airway maneuvers include
cervical spine injury, severe arthritis of the cervical spine, 7. After the patient relaxes, intubate the patient orotracheally.
significant maxillofacial or mandibular trauma, lim ited 8. Inflate the cuff and confirm tube placement (auscul
mouth opening, and anatomical variations such as receding tate the patient's chest and determine presence of C02
chin, overbite, and a short, muscular neck. ln such cases, i n exhaled air).
skilled clinicians should assist in the event of difficulty. The
mnemonic LEMON .is helpfuJ as a prompt when assessing
9. Release cricoid pressure.
the potential for difficulty (Box 2- 1 ). Several components 10. Ventilate the patient.
BOX 2-1
LEMON Assessment for Difficult Intubation

L = Look Externally: Look for characteristics that are with a light to assess the degree of hypopharynx visi
known to cause difficult intubation or ventilation. ble. In supine patients, the Mallampati score can be
estimated by asking the patient to open the mouth
E Evaluate the 3-3-2 Rule (see the figure on
= fully and protrude the tongue; a laryngoscopy light is
page 37): To allow for alignment of the pharyngeal, then shone into the hypopharynx from above.
laryngeal, and oral axes, and therefore simple intuba
tion, the following relationships should be observed: 0 Obstruction: Any condition that can cause ob
=
struction of the airway will make laryngoscopy and

The distance between the patient's incisor teeth
ventilation difficult Such conditions include epiglotti
should be at least 3 finger breadths (3)
tis, peritonsillar abscess, and trauma.

The distance between the hyoid bone and the
chin should be at least 3 finger breadths (3) N = Neck Mobility: This is a vital requirement for suc

The distance between the thyroid notch and cessful intubation. It can be assessed easily by asking
floor of the mouth should be at least 2 finger the patient to place his or her chin onto the chest and
breadths (2) then exte nding the neck so that he or she is looking
toward the ceiling. Patients in a hard collar neck im
M = Mallampati (see below): The hypopharynx mobilizer obviously have no neck movement and are
should be visualized adequately. This has been done therefore more difficult to intubate.
traditionally by assessing the Mallampati classification. Modif1ed w1th permiSSIOn from Reed, MJ, Dunn MJG,
When poss1ble. the patient is asked to sit upright, McKeown DW. Can an airway assessment score pred ict dif
open the mouth fully, and protrude the tongue as far ficuiLy at Intubation 1n the emergency department? Emerg
as possible. The examiner then looks into the mouth Med J 2005;22:99-1 02.
Class 1: soft palate, uvula, Class II: soft palate, Class Ill: soft palate, Class IV: hard palate
fauces, pillars visible uvula, fauces visible base of uvula visible only visible
Mallampati Classifications. Used to visualize the hypopharynx. Class 1: soft palate, uvula, fauces,
pillars visible. Class II: soft palate, uvula, fauces visible. Class Ill: soft palate, base of uvula visible.
Class IV: hard palate only visible.
(Continued)
'
A c
B
The 3-3-2 Rule. To allow for alignment of the pharyngeal, laryngeal, and oral axes
and therefore simple intubation, the following relationships should be observed: The
distance between the patient's incisor teeth should be at least 3 finger breadths (A);
the distance between the hyoid bone and the chin should be at least 3 finger breadths
(B); and the distance between the thyroid notch and floor of the mouth should be at
least 2 finger breadths (C).
Etomidate does not have a significant effect on blood the potential for severe hyperkalemia, succinylcholine is not
pressure or intracranial pressure, btlt it can depress adrenal used in patients with severe crush injmies, major burns and
ftmction and is not universally available. This drug does pro electrical injuries, preexisting chronic renal failure, chronic
vide adequate sedation, which is advantageous in these pa paralysis, and chronic neuromuscular disease.
tients. Etomidate and other sedatives must be used with induction agents, such as Lhiopental and sedatives, are
great care 1.0 avoid loss of the airway as the patient becomes potentially dangerous in trauma patients with hypovolemia.
sedated. Then, succinylcholine, which is a short-acting drug, Small doses of diazepam or midazolam are <ppropriate to
is administered. I t has a rapid onset of paralysis (< 1 minute) reduce anxiety in paralyzed patients. .Flurnazenil must be
and a duration of 5 minutes or less. The most dangerous available lo reverse the sedative effects after benzod.iazepines
complication of using sedation and neuromuscular blocking have been admin istered. Practice patterns, drug preferences,
agents is the inability to establish an airway. If endotracheal <md specific procedures for airway management vary among
intubation is unsuccessful, the patient must be ventilated institutions. The principle that the individual using these
with a bag-mask device until the paralysis resolves; long-act techniques needs to be skilled in their usc, knowledgeable
ing drugs arc not routinely used for this reason. Because of of the inherent pitfalls associated with rapid sequence intu-
' 1'
. .
PITFALL -
,,...
,
,
...
.. _
Equipment failure can occur at the most inoppor

tune times and cannot always be anticipated. For ex
ample, the light on the laryngoscope burns out, the
laryngoscope batteries are weak, the endotracheal
tube cuff leaks, or the pulse oximeter does not func
tion properly, Have spares available.
hation, and capable of managing the potential complica

tions cannot be overst:lted.
Surgical Airway
The inability to intubate the trachea is a clear indication for
creating a surgical airway. A surgical airway is established
when edema of the glottis, fracture of the larynx, or severe
oropharyngeal hemorrhage obstructs the airway or an en
dotracheal tube cannot be placed through the vocal cords. A
surgical cricothyroidotomy is preferable to a tracheostomy
for most patients who require establishment of an emer Figure 2- 1 2 Needle Cricothyroidotomy.
gency surgical airway. A surgical cricothyroidotomy is easier Performed by pl acin g a large-caliber plastic cannula
to perform, is associated with less bleeding, and requires less through the cricothyroid membrane into the trachea
time to perform than an emergency tracheostomy. below the level of the obstruction.
Needle Cricothyroidotomy. Insertion of a needle

through the cricothyroid membrane or into the trachea is a pected. Although h igh pressure can expel the impacted ma
useful technique in emergency situations that provides oxy terial into the hypophtlrynx, where it can be removed read
gen on a short-term basis until a definitive airway can be ily, significant barotrauma can occur, including pulmonary
placed. Needle cricothyroidotomy can provide temporary, rupture with tension pneumothorax. Low flow rates ( 5 to 7
supplemental oxygenation so that intubation can be ac L/mi n) should be used when persistent glottic obstruction
complished on an urgent rather than an emergent basis. is present.
The jet insufflation technique is performed by placing
a large-caUber plastic cannula, 12- to 14-gauge for adults, Surgical Cricothyroidotomy. Surgi ca l cricothyro.idot
and 16- to 18-gauge in children, through the cricothyroid omy is performed by making a skin incision that extends
membrane into the trachea below the level of the obstruc through the cricothyroid membrane.A curved hemostat may
tion (Figure 2-12). The cannula is then connected to oxy be inserted to dilate the opening, and a small endotracheal
gen at IS L/min (40 to 50 psi) with a Y-connector or a side tube or tracheostomy rube (preferably 5 to 7 mm OD) can be
hole cut in the tubing between the oxygen source and the inserted. When an endotracheal tube is used, the cervical col
plastic cannula. Intermi ttent insufflation, I second on and 4 lar can be reapplied. It is possible for the endotracheal tube
seconds off, can then be achieved by placing the thumb over to become malpositioncd and therefore easily advru1ced into
the open end of the Y-connector or the side hole. a bronchus. Care must be taken, especially with children, to
The patient can be adequately O>..')'genated for only 30 to
45 minutes using this technique, and only patients with nor
mal pulmonary function who do not have a significant chest
injury may be O>..')'genated in this manner. During the 4 sec PITFALL ' -
,....-
onds that the oxygen is not being delivered under pressure,

some exhalation occurs. Because of the inadequate exhala The inability to intubate a patient expediently, to
tion CO: slowly accumulates, limiting the use of this tech
,
provide a temporary airway with a supraglottic de
nique, especially in patients with head injuriel.. vice, or to establish a surgical airway results in hy
poxia and patient deterioration. Remember that
rl' Sec Skill Station lll: Cricothyroidotomy, Skill III-A: Nee
performing a needle cricothyroidotomy with jet in
dle Cricothyroidotomy.
sufflation can provide the time necessary to estab
Jet insufflation must be used with caution when com lish a definitive airway.
plete foreign-body obstruction of the glotti c area is sus-
MANAGEMENT OF VENTILATION 39
avoid damage to the cricoid cartilage, which is the only cir

cwnferential support for the upper trachea. Therefore, sur I TABLE 2-2 Approximate Pa02 versus 02

gical cricothyroidotomy is not recommended for children Hemoglobin Saturation levels
under 12 years of age. rl' See Chapter
.
10: Pediatric Trauma.
.
ln recent years, percutaneous tracheostomy has been re- Pa02 LEVElS 02 HEMOGLOBIN SATURATION LEVELS
ported as an alternative to open tracheostomy. This is not a safe
procedure in the acute trauma situation, because the patient's 90 mm Hg 100%
neck must be hyperex:tended to properly position the head to
perform the procedure safely. Percutaneous tracheostomy re 60 mm Hg 90%
quires the use of a heavy guidewire and sharp dilator, or a
guidewire and multiple or single large-bore dilators. This pro 30 mm Hg 60%
cedure can be dangerous and time-consuming, depending on
See Skill Station ill: Cricothy
the type of equipment used. 27 mm Hg 50%
roidotomy, Skill In-B: Surgical Cricothyroidotomy.
AIRWAY DECISION SCHEME measure the oxygen saturation (02 sat) of arterial blood. It
The airway decision scheme shown in Figure 2-l 0 applies does not measure the partial pressure of oxygen (Pa02) and,
only to patients who are in acute respiratory distress (or who depending on the position of the oxyhemoglobin dissocia
have apnea), who are in need of an immediate airway, and tion curve, the Pa02 can vary widely (see Table 2-2). How
in whom a cervical spine injury is suspected because of the ever, a measured saturation of 95o/o or greater by pulse
mechanism of injury or suggested by the physical examina oximetry is strong corroborating evidence of adequate pe
tion. The first priority is to ensure continued oxygenation ripheral arterial oxygenation (Pa02 >70 mm Hg, or 9.3 kPa).
with maintenance of cervical spine m
i mobilization. This is Pulse oximetry requires intact peripheral perfusion and
accomplished initially by position (ie, chin-lift or jaw-thrust cam1ot distinguish oxyhrmoglobin from carboxyhemoglobin
mru1euver) and the preliminary airway techniques (ie, or methemoglobin, which limits its usefulness in patients with
oropharyngeal airway or nasopharyngeal airway) previously severe vasoconstriction and those with carbon monoxide poi
described. An endotracheal tube is then passed whil.e a sec soning. Profound anemia (hemoglobin <5 g/dL) and hy
ond person provides in-line immobilization. If ru1 endotra pothermia ( <30 C, or <86 F) decrease the reliability of the
cheaJ tube cannot be inserted and the patient's respiratory technique. However, in most trauma patients pulse oximetry
status is in jeopardy, ventilation via a laryngeal mask airway is useful, as the continuous monitoring of oxygen saturation
or other e.xtraglottic airway device may be attempted as a provides an irnmediate assessment of therapeutic interventions.
bridge to a deftnitive airway. If this fails, a cricothyroido
tomy should be performed.
Oxygenation and ventilation must be maintained be
fore, during, and immediately upon completion of insertion , Management of Ventilation
of the definitive airway. Prolonged periods of inadequate or
absent ventilation and oxygenation should be avoided.
a How do I know ventilation is adequate?
Effective ventilation can be achieved by bag-mask techniques.
However, one-person ventilation techniques using a bag-mask
. Management of Oxygenation are less effective than two-person techniques in which both
hands can be used to ensure a good seal. Bag-mask ventilation
a How do I know oxygenation is should be performed by two people whenever possible. rl' See
Skill Station 11: Ainvay and Ventilatory Mcmagement, Skill 11-
adequate?
C: Bag-Mask Ventilation: Two-Person Technique.
Oxygenated inspired air is best provided via a tight-fitting
oxygen reservoir face mask with a flow rate of at least I I
l!min. Other methods ( eg, nasal catheter, nasal cannula, and ..
PITFALL .
..
";,..... -
.-
nonrebreather mask) can improve inspired oxygen concen -
tration.
Gastric distention can occur when ventilating the pa
Because changes in oxygenalion occm rapidly ru1d are
tient with a bag-mask device, which can result in the
impossible to detect clinically, pulse oximetry should be used
patient vomiting and aspi rating. It also can cause dis
when difficulties are anticipated in intubation or ventilation,
tention of the stomach against the vena cava, re
including during transport of criticaliy injured patients. sulting in hypotension and bradycardia.
Pulse oximetry is a noninvasive method to continuously
Intubation of patients with hypo ven ti lat i on and/or With intubation of the trachea accomplished, assisted
apnea patients may not be successful initially and may re ventilation follows, using positive-pressure breathing tech
quire multiple attempts. The pati.enl must be ventilated pe niques. A volume- or pressure-regulated respirator can be
riodically during prolonged efforts to intubate. The doctor used, depending on availability of the equipment. The doc
. ..
should practice taking a deep breath a nd holding it when tor should be alert to the complications of changes in in
intubalion is first anempted. When the doctor must breatl1e, trathoracic pressure, which can convert a simple
the allempted i n t uba tio n is aborted, nnd the patient venti pneumothorax to a tension pnewnothorax, or even create a
lated. pneumothorax secondary to barotrauma.
CHAPTER SUMMARY
Clinical situations in which airway compromise is likely to occur include maxillofacial

trauma, neck trauma, laryngeal trauma, and airway obstruction.
Actual or impending airway obstruction should be suspected in all injured patients. Ob

jective signs of airway obstruction include agitation, presentation with obtundation,
cyanosis, abnormal sounds, and a displaced trachea.
f) Techniques for establishing and maintaining a patent airway 1nclude the chin-lift and
jaw-thrust maneuvers, oropharyngeal and nasopharyngeal airways, laryngeal mask air
way, multilumen esophageal airway, and the gum elastic bougie device. With all airway
maneuvers. the cervical spine must be protected by in-line immobilization. The selection
of orotracheal or nasotracheal routes for intubation is based on the experience and skill
level of the doctor.
A surgical airway is indicated whenever an airway IS needed and intubation is un
successfu I.
The assessment of airway patency and adequacy of ventilation must be performed

quickly and accurately. Pulse oximetry and end-tidal C02 measurement are essential.
A definitive airway requires a tube placed In the trachea with the cuff inflated, the tube
connected to some form of oxygen-enriched assisted ventilation, and the airway se
cured in place with tape. A definitive airway should be established if there is any doubt
on the part of the doctor as to the integrity of the patient's airway. A definitive airway
should be placed early after the patient has been ventilated with oxygen-enriched air,
to prevent prolonged periods of apnea.
Oxygenated inspired air is best provided via a tight-fitting oxygen reservoir face mask
with a flow rate of greater than 1 1 Umin. Other methods (eg, nasal catheter, nasal can
nula, and nonrebreather mask) can improve inspired oxygen concentration.
BIBLIOGRAPHY 41
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88(4 ):970-977.
17. Grein AJ, \!\Ieiner GM. Laryngea.l mask airway versus bag-mask
l. Alexander R, Hodgson P, Lomax D, Bullen C. A comparison
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of the laryngeal mask airway and Gucdel airway, bag'nnd face
tion. Cochrane Database Syst Rev 2005;(2):CD003314.
mask tor manual ventilatjon following formal training. Arwe.s
thesia 1993; 48(3):231-234. 18. Grmec S, Mally S. Prehospital determination of tracheal tube
placement in severe head injury. Emerg Med /2004; 2 1 (4):5 1 8-
2. Aprahamian C, Thompson HM, Finger WA, et al. Experimen
520.
tal cervical spine injury model: evaluation of airway manage
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13(11):584-587. tive study of techniques for opening an airway obstructed by
the tongue. ! Am Coli Emcrg Physicians 1 976;5:588-590.
3. Asai T, Shingu K. The laryngeal tube. l3r I Annesth 2005;
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Khurana S. An evaluation of the insert ion and function of a
4. Bergen JM, Smith DC. A review or etomiclate for rapid e
new supraglottic airway device, the !(jng LT, during sponta
quence intubation in the emergency department. } Emerg Med
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1 997; 1 5(2):22 1-230.
2 1 . .lserson .KV. Blind nasotracheal intubation. An11 Emcrg Med
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1 9 8 1 ; 1 0:468.
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diovasc Surg I 976;71 :72-81. 22. Jabre P, Combes X, Leroux B, Aaron E, Auger 11, Margenct A,
Dhonneur G. Usc of the gum clastic bougie for prehospital dif
6. Combes X. Dumerat. M, Dhonneur G. EmergenC)' gum elas
ficult intubation. A m } .Hmerg Med 2005;23( 4):552-555.
tic bougie-assisted tracheal intubation i n four patients with
upper airway distortion. Can / AnaestlJ 2004; 5 1 ( 1 0):1022- 23. Jorden RC, Moore EE, Marx JA, ct al. A comparison of PTV
1 024. anJ endotracheal ventilation i n an acute trauma model. I
1hwma 1985;25( 10):978-983.
7. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated
difficult airwa)' with recommendations for management. C;m 24. Kidtl JF, Dyson A, Latto JP. Successful difficult intubation. Use
I i\.naestb 1998; 45(8):757-776. of the gum clastic bougie. Anaesth esia 1988;43:437-438.
8 . Dal171 DF, Thomas DM. Nasotracheal intubation in the emer 25. Kress TD, et al. Cricothyroidotomy. Ann Emcrg Mcd
gency department. Grit Cart Med 1980;8( L l ):667-682. 1982; ll:l97.
9. Davies PR, Tighe SQ, Greenslade GL, Evans GH. LaryngeaJ 26. Latto IP, Stacey M, Mecklenburgh J, Vaughan RS. Survey of the
rnask airway and trachea l tube insertion by unskilled pe rson use or the gum elastic bougie in clinical pracl ice. Arwesthesia
nel. Lancet l990; 336(8721 ):977-979. 2002;57(4):379-384.
10. lJogra S, falconer Jt Latto JP. Succtssful difticult intubation. 27. .Levinson MM. Scuderi PE, Gibson RL. et al. Emergency per
Tracheal tube placement over a gum-elastic bougie. Anaesthe cutaneous and transtracheal ventilation. I Am Coli Bmerg
sia 1990; 45(9):774-776. Physicians 1979;8( 10):396-400.
1 1 . Dorges V, Ocker J-1, Wenzel V. Sauer C, Schmucker P. Emer 28. Levitan R, Ochroch EA. Airway management and direct laryn
gency airway management by non-anaesthesia house offi goscopy. A review and update. Grit Care Clin 2000; 16(3):373-
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18(2):90-94.
29. Macintosh RR. An nid to oral intubation. BM/1949; I :28.
l2. EI-Orbany Ml, Salem MR. Joseph NJ. The Eschmann tracheal
30. Majernick TG, Bieniek R, Houston i e
JB, et aJ: Cervical spn
tube introducer is not gum, clastic, or a bougie. Anesthesiology
movement during orotracheal intubation. Ann Emerg Med
2004; I 0 I ( 5); 1240; author reply 1242- 1240; author reply 1244.
1986;15{4):41 7-420.
13. l:rame S13, Simon JM, Kerstein MD, ct al. Percutaneous
3 1 . Morton T, Brady S, Clancy M. Difficult airwoy equipment in
transtracheal catheter ventilation (PTCV) in com plete ainvay
English emergency departments. Anaesthesia 2000;55(5):485-
obstructions canine model. J '/}auma 1989;29(6):774-781.
488.
14. Fremstad )D, Martin SH. Lethal complia1tion from insertion
32. Nocera A. A flexible solution for emergency intubation diffi
of nasogastric tube after severe basilar skull fracture. J
c ulties. Ann Emerg Med 1996;27(5):665-667.
Trauma 1978; 1 8:820-822.
33. Noguchi T, Koga K, Shiga Y, Shigen"Latsu i\. The gum elastic
15. Gataure PS, Vaughan RS, Latto I P. Simulated difficult intuba
bougie eases tracheal intubation v,rhile applying cricoid pres
tion: comparison of the gum elastic bougie and the stylet.
sure compared to a stylet. Can J Anaesth 2003;50(7):71 2-71 7.
Anaesthesia 1996; 1:935-938.
34. Nolan )P, Wilson ME. A11 evaluation of the gum elastic bougie.
16. Greenberg RS, Brimacombe J, Berry A, Gouzc V,
Piantad<JSi S,
Intubation times and incidence of sore throat. Anaesthesia
Dake EM. A randomjzed controlled trial comp<trLng the cuffed
1992;47( 10):878-88 1.
orophar)'ngeal airwa)' and the laryngeal mask airway in spon-
35. Nolan JP, Wilson ME. Orotracheal intubation in patients with Cornbitube in a Simulated Difficult Airwav Patient Encounter

potential cervical spine injuries. A n indication for the gum ( I n Process Citation ! . Acad Emerg Med 2007;14(5 Suppl
clastic bougie. Anaestlwsia 1993;48(7}:630-633. I ):S22.
36. Oczenski W, Krenn H, Dahaba AA, et al. Complications fol;;;. 42. Seshul MB Sr, SiJ1n DP, Gerlock AJ Jr. The Andy Gump fracture
lowing the use of the Combitube, tracheal tube and laryngeal of the mandible: a cause of respiratory obstruction or distress.
mask airway. Anaesthesia 1999;54 ( 12): 1 1 6 1 - 1 165. j Tiauma 1978;18:61 1-612.
37. Pennant JH, Pace NA, Gajraj NM. Role t)f the laryngeal mask 43. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out
airway in the immobile cervical spine. 1 Clin Anesth of-hospital usc of continuous end-tidal carbon dioxide mon
1993;5(3 }:226-230. itoring on the rate of unrecognized misplaced intubation
within a regional emergency medical services system. Ann
38. Phelan MP. Use of the endotracheal bougie introducer for dil:.
Emerg Med 2005;45( 5) :497-503.
ficuh intubations. Am 1 Emerg Med2004;22(6):479-482.
44. Smith CE, Dejoy $}. New equipment and techniques for air
39. Reed MJ, Dunn M), McKeown DW. Can an ainvay assessment
way management in trauma [ I n Process Citation]. Curr Op.in
score predict difficult-y at intubation Ln the emergency depart
Anaeschesiol 2001;14(2}:197-209.
ment? F.mcrg Med /2005;22(2):99- 102.
45. Walter J, Doris PE, Shaffer MA. Clinical presentation of pa
40. Reed MJ, Rennie LM, Dunn MJ, Gray AJ, Robertson CE, McK
tients with acute cervical spine injury. Ann 11merg Med
eown D\V. ls the 'LEMON' method an easily applied emer
1 984; 1 3(7):5 12-5 15.
gency ainvay assessment tool? Eur f Emerg Med
2004;1 1 (3);154- 157. 46. Yeston NS. Noninvasive measurement of blood gases. Infect
Swg 1990;90: 18-24.
4 I . Russi C, Miller L An Out-of-hospital Comparison of the King
LT to Endotracheal Intubation and the Esophageal-Tracheal

Performance at this skill station will allow the participant to evaluate a series
Interactive Skill
of clinical situations and acquire the cognitive skills for decision making in air
Procedures
way and ventilato ry management. The student will practice and demonstrate
Note: Accompanying some of the following skills on adult and infant intubation manikins:
the skills procedures for this

station is a series of scenarios,

wh ich are prov1ded at the OBJECTIVES
conclusion of the procedures for
you to rev1ew and prepa re for this Insert oropharyngeal and nasopharyngeal airways.
station. Standard precautions
are required whenever caring Using both oral and nasal routes, intubate the trachea of an adult in
for the trauma patient. tubation manikin (within the guidelines listed}, provide effective ven
tilation, and use capnography to determine proper placement of the
endotracheal tube. Discuss and demonstrate methods to manage dif
THE FOLLOWING ficult or failed airways, including LMA/LTA and GEB.
PROCEDURES ARE INCLUDED
Skill II-A: Oropharyngeal

0 Intubate the trachea of an infant intubation manikin with an endo
tracheal tube (within the guidelines listed} and provide effective ven
tilation.
Airway Insertion
Skill li-B: Nasopharyngeal
Airway Insertion
Describe how trauma affects airway management when performing
oral endotracheal intubation and nasotracheal intubation.
Skiii ii-C:Bag-Mask
Ventilation: Two Person
-
Using a pulse oximeter:
State the purpose of pulse oximetry monitoring.
Technique Demonstrate the proper use of the device .
Skill 11-D: Adult Orotracheal Describe the indications for its use, its functional limits of accuracy,
Intubation (with and without and possible reasons for malfunction or inaccuracy.
G urn Elastic Bougie Device} Interpret accurately the pulse oximeter monitor readings and re
late their significance to the care of trauma patients.
Laryngeal Mask
Skill 11-E:
Airway (LMA} Insertion Discuss the indications for and use of end-tidal C02 detector devices.
laryngeal Tube
Skiii ii-F:
Airway (LTA) Insertion
Skill 11-G: Infant Endotracheal
Intubation
SkillIIH: Pulse Oximetry

Monitoring
Skill 11-1: Carbon Dioxide
Detecti on
43
44 SKILL STATION II Airway and Ventilatory Management
... ' 0" L- --

" T- - "
-
-" "" -
- - '
"
Skill II-A: Oropharyngeal Airway Insertion

Note: Thi:. proccdwe is for temporary ventilation while adequately. Be careful not <.:ausc the patient to
preparing to intubate an unconscious pnlienl. gag.
STEP 1. Select the proper-size airway. A correctly sized STEP 4. I nsen Lhe airway posteriorly, gently sliding the
airway over the curvature or the tongue until the
airway extends from the corner of the patient's
device's flange rests on top of the patient's lips.
mouth to the external auditory canal.
The airway must not push the tongue backward
STEP 2. Open the patient's mouth with either the chin and block the airwa)'
lift maneuver or the crosloed finger technique
STEPS. Remove the tont,rue blade.
(scissors technique).
STEP 6. Ventilate the patient with a bag-mask device.
STEP 3 . Insert tongue blade on top of the patient's
a
tongue f;r enough back to depress the tonj,rue
- - --
- --
---- - -- - - - - .-. - ,
__
___
Skill li -B: Nasopharyngeal Airway Insertion

Note: This procedure is used when the patient would gag on STEP 4. Insert the tip of the airway into the nostril and
an oropharyngeal airway. direct it posteriorly and toward the ear.
STEP 5. Gcnlly insert Lhe nasopharyngeal airway through
STEP 1. Assess the nasal passages for any apparent
the nostril into the hypophar)'TlX with a slight
obstruction (eg, polyps, fractures, or
rotating motion until the flange re:.ts against the
hemorrhage).
nostril.
STEP 2. Select the proper-size .tirway, which will easily STEP 6. Apply ventilation with a b,tg-mask device.
pass the selected nostril.
STEP 3. Lubricate the Rasopharyng:al airway with a

water-soluble lubricant or tap water.
- - - -
- --- -
- -
---- - -- -
------
---
---
-
- --- - -- -- -
Skill 11-C: Bag-Mask Ventilation: Two-Person Technique

STEP 1. Select the proper-size mask to lit the patient's face. STEP 4. The first person applies the mask to the patient's
race, ascertaining a Ligh 1 seal with both hands.
STEP 2. Connect the oxygen tubing to the bag-mask
device and adjust I he llow of oxygen lo STEP 5. The second person applies v:ntilation by
12 L/min. queezi ngthe bag with both hands.
STEP 3. Ensure that the patient's airway is patent and STEP 6. Assess the adequacy of ventilntion by observing
secured according to preYiously described the patient's chest movement.
techniques. STEP 7. Apply ventilation in this manner every 5 seconds.
SKILL STATION I I Airway and Ventilatory Management 45
Skill l i-D: Adult Orotracheal lntubation

(with and without Gum Elastic Bougie Device)

STEP 1. Ensure that adequate ventilation and oxygenation STEP 11. Check the placement of the endotracheal tube
are in progress and that suctioning eqttipment is by bag-mask-to-tube ventilation.
immediately available in Lbe event that the patient
STEP 12. VisuaJJy observe chest excursions with
vomits.
ventilation.
STEP 2. Inflate the cuff of the endotracheal tube to
STEP 13. Ausc u l t a te Lhe chest and abdomen wilh a
ascet-tain that the balloon does not leak, and then
s tethoscope to ascertain tube positio n.
detJate the culT.
STEP 14. Secure the tube. ff the patient is moved, the tube
STEP 3. Connect the laryngoscope blade to the handle,
placement should be reassessed.
and check the bulb for brightness.
STEP 15. ff endotracheal intubation is noL accomplished
STEP 4. Assess the patient's ai rway for ease of intubation
within seconds or in tJ1e same time required to
(LEMON mnemonic).
hold your breath before exhaling, discontinue
STEP 5. Direct an assistant to manually immobilize the attempts, apply ventilation with a bag-mask
head and neck The patient's neck must not be device, and try again using the gum elastic bougie.
hyperextended or hyperllexed during the
STEP 16. Placement of the tube must be checked
procedure.
carefully. A chest x-ray exam is helpful to assess
STEP 6. Hold the laryngoscop e in the left hand. the posi tion of the tube, but it cannot exclude
esophagea l intubation.
STEP 7. lnsert the laryngoscope into the right side of the
patient's mou Lh displacing the tongtJe to the left.
, STEP 17. Attad1 a C02 detector to the endotracheal tube
between the adapter and the ventilating device
STEP 8. Visually ident ify the epiglottis and then the vocal
to confirm the position of the endotracheal tube
cords.
in lhe airway.
STEP 9. Gently insert the endotracheal tube into the
STEP 18. Attach a pulse oximeter to one of the patient's
trachea without applying pressure on the Leeth or
fingers (intact peripheral perfusion must exist)
oral tissues.
lo measure and monitor the patient's oxygen
STEP 10. Inflate the cuff with enough air to provide an saturation levels and provide an immediate
adequate seal. Do not overinflate tbe cuff. assessment of therapeutic interventions.
Ski ii i.I.- E : Laryngeal Mask Airway (LMA) Insertion

STEP 1. Ensure that adequate ventilation and oxygenation STEP 5. Choose the correct size LMA: 3 for a small
are in progress and that suctiouing equipment is woman, 4 fo r a large woman or small man, and 5
immediately available in the event that the for a large man.
pa tient vomits.
STEP 6. Hold the LMA with the dominant hand as you
STEP 2. lnOate the cuff of the LMA to ascertain that the would a pen, with the index finger placed at rhe
balloon does not leak. junction of the cuff and the shaft and the LMA
opening oriented over the tongue.
STEP 3. Direct an assistant to manually immobilize the head
and neck. The patient's neck must not be hyper STEP 7. Pass the LMA behind the upper incisors, with the
e>.1ended or hyperflexed during the procedure. shaft paraUel lo the patient s chest and the index
'
finger pointing toward the intubator.

STEP 4. Be fore attempting insertion, compl e tely deflate
the LMA cuff by p ress ing it firmly onto a flat STEP 8. Push U1c lllbricated LMA into position along the
surface and lubricate it. palatopharyngeal curve, wilh lhc index finger
maintaining pressure on the tube and guiding
46 SKILL STATION II Airway and Ventilatory Management
the LMA into the final position. STEP 10. Check the placement of the endotracheal tube
by bag-mask-to-tube ventilation.
STEP 9. Inflate the cuff with the correct volume of air
(indicated on the shaft of the LMA). STEP 11. Visually observe chest excursions with

ventilation.
Skill 1 1-F: Laryngeal Tube Airway (LTA) Insertion

STEP 1 . Ensure proper sterilization. behind the base of the tongue.
STEP 2. Inspect all components for visible damage. STEP 12. Rotate the tube back to the midline as the tip
reaches the posterior wall of the pharynx.
STEP 3. Examine the interior of the airway tube to

ensure that it is free from blockage and loose STEP 13. Without exerting excessive force, advance the
particles. LTA until the base of the connector is aligned
with teeth or gums.
STEP 4. Inflate the cuffs by injecting the maximum
recommended volume of air into the cuffs. STEP 14. Inflate the LTA cuffs to the minimum volume
necessary to seal the airway at the peak
STEP 5. Select the correct laryngeal tube size.
ventilatory pressure used (just seal volume).
STEP 6. Apply a water-based lubricant to the beveled
STEP 15. While gently bagging the patient to assess
distal tip and posterior aspect of the tube, taking
ventilation, simultaneously withdraw the airway
care to avoid introduction of lubricant into or
tmtil ventilation is easy and free Gowing (large
near the ventilatory openings.
tidal volwne with minimal airway pressure).
STEP 7. Preoxygenate the patient.
STEP 16. Reference marks are provided at the proximal
STEP 8. Achieve the appropriate depth of anesthesia. end of the LTA; when aligned with tl1e upper
teeth, these marks indicate the depth of
STEP 9. Position the head. The ideal head position for
insertion.
LTA insertion is the "sniffing position." However,
the angle and shortness of the tube also allow it STEP 17. Confirm proper position by auscultation, chest
to be inserted with the head in a neutral position. movement, and verification of C02 by
capnography.
STEP 10. Hold the LTA at the connector with the dominant
hand. With the nondominant hand, hold the STEP 18. Readjust cuff in flat ion to seal volwne.
mouth open and apply the chin-lift maneuver.
STEP 19. Secure LTA to patient using tape or other
STEP 11. With the LTA rotated laterally 45 to 90 degrees, accepted means. A bite block can also be used, if
introduce the tip into the mouth and advance it desired.
Skiii ii-G: Infant Endotracheal Intubation

STEP 1 . Ensure that adequate ventilation and oxygenation STEP 5. Insert the laryngoscope blade into the right side

are 10 progress. of the mouth, moving I he longue to the left .
STEP 2. Select the proper-size uncuffed tube, which should STEP 6. Observe the epiglottis and then the vocal cords.
be the same size as the infanl's nostril or little
STEP 7. Insert the endotracheal tube not more than 2 em
finger.
past the cords.
STEP 3. Connect the laryngoscope blade and handle;
STEP 8. Check the placement of the tube by bag-mask
check the light bulb for brill ianee.
to-tube ventilation.
STEP 4. Hold the laryngoscope in the left hand.
STEP 9. Check the placement of the endotracheal tube by helpfulto assess the position of the tube, but it
observing lw1g inflations and auscultating the crumot exdude esophageal i nt ubat i on .
chest and abdomen with a stethoscope.

STEP 13. Attach a C02 detector to the endotracheal tube
STEP 10. Secure the tube. If the patient is movcd,"'tube between the adapter and the venlilating device
placement should be reassessed. to confirm the position of the endotracheal tube
in the trachea.
STEP 11. If endotracheal intubation is not accomplished
within 30 seconds or in the same time required to STEP 14. Attach a pulse oximeter to one of the patient's
hold your breath before exhaling, discontinue fingers (intact peripheral perfusion must ex.isl)
attempts, ventilate the patient '.v-ith a bag-mask to measure and monitor the patient's oxrgen
device, and try again. saturation levels and provide an immediate
assessment of therapeutic interven lions.
STEP 12. Placement of the tube must be checked
carefully. Chest x-ray examination may be
Skiii ii-H: Pulse Oximery Monitoring

The pulse oximeter is designed to measure oxygen satma rnon sites for sensor application; however, both of these
tion and pulse rate in peripheral circulation. This device is areas can be subject to vasoconstriction. The fingertip (or
a microprocessor that calculates the percentage saturation toe tip) of an injured extremity or below a blood pressure
ygen in each
..
of o:-. pulse of arterial blood that flows past a cuff should not be used.
sensor. It simultaneously calculates the heart rate. \Vhen analyzing pulse oximctq results, evaluate the ini
The pulse oximeter works by a low-intensity light tial readings. Does the pulse rate correspond to the electro
beamed from a light-emitting diode (LED) to a light-re cardiographic monitor? Is lbe ox-ygen saturation
ceiving photodiode. Tvvo thin beams of light, one red and appropriate? I f the pulse oximeter is giving low readings or
the other infrared, are transmitted through blood and body very poor readings, look for a physiologic cause, not a me
tissue, and a portion is absorbed by the blood and body tis chanical one.
sue. The photodiode measures the portion of the ligbt that The relationship between partial pressure of oxygen in
passes through the blood and body tissue. The relative arterial blood (Pa02) and %Sa02 is shown in Figure I l - l
aJUount of light absorbed by oxygenated hemoglobin dif (on page 48). The sigmoid shape of this curve indicates that
fers from that absorbed by nonox-ygenated hemoglobin. The the relationship between %Sa02 and Pa02 is nonlinear. This
microprocessor evaluates these differences in the arterial is particularlr important in the middle range of this curve,
pulse and reports the values as calculated oxyhemoglobin where small changes in Pa02 will effect large changes in sat
saturation (%Sa02). Measurements are reliable and corre uration. Remember, the pulse oximeter measures arterial
late well when compared with a cooximeter that directly oxygen saturation, not arterial oxygen partial pressure.
measures Sa02 .. See Table 2-2: Approximate Pa02 versus 01 Hemoglobin
However, pulse oximetry is unreliable when the patient Saturation Levels in Chapter 2: Airway and Ventilatory
has poor peripheral perfusion, which can be caused by vaso Management.
constriction, hypotension, a blood pressure cuff that is in Standard blood gas measurements report both Pa02
llated above the sensor, hypothermia, and other causes of and o/oSa01. When OX')'gen saturation is calculated from
poor blood flow. Severe anemia can likewise influence the blood gas PaO, the calculated value can differ from the
reading. Significantly high levels of carboxyhemoglobin or oxygen saturation measured by the pulse oximeter. This
methemoglobin can cause abnormalities, and circulating difference can occur because an oxygen saturation value
dye (eg, indocyrmine green and mel hylen c blue) can inter tbat has been calculated from the blood gas PaO, has not
fere with the mcastuement. Excessive patient movement, necessaril)' been correctly adjusted [or the effects of vari
other electrical devices, and intense ambient light can cause ables Lhat shift the relationship between Pa01 and satura
pulse oximeters to maliunction. Lion. These variables include temperature, pH, PaC01
Using a pulse oximeter requires knowledge of the par (partial pressure o[ carbon dioxide), 2,3-DPG (diphos
ticular device being used. Different sensors are appropriate phoglycerates), and the concentration of fe tal hemoglo
for different patients. The fingertip and earlobe are combin.
48 SKILL STATION I I Airway and Ventilatory Management
100 !.,eft Shift

t pH ... -- - - - - - - - - - - - - - - - - - - - - - - - - - - -
-- -
-
-
90 l. Temperature -
-
-
J Paco2 ;;
; - - - - - - -- - - - -
- -- - - - - -
-- --
! 2,3-dpg , ;. --
--
--
, -
-
, -
c , -
-
0 ,
I , ,, Right Shift
ov ,
.._ 60 , ,,
:::J
....
, , l pH
ov
' ,
Vl
I , T Temperature
' ,
"' 50 ' ,
0 ' '
, t Paco2
' ,
'
' I t 2,3-dpg
' ,
I
I I
I ,
I I
I I
I
,
I
I ,
I ,
I I
, ,
I
,
, ,,
0
27 30 50 60 90 100
Pao2 (mm Hg/kPa)
Figure 11 -1 Relationship between partial pressure of oxygen in arterial blood (Pa02} and %Sa02
Skill Il- l : Carbon Dioxide Detection

When a patient is intubated, it is essential to check the po breaths, and the results or lhe colorimetJic test should not
sition of the endotracheal tube. If carbon dioxide is de be used until after at least six breaths. If the colorimetric de
tecteJ in the exhaled air, the tube is in the airway. Methods vice still shows an intermediate range, six additional breaths
of determining end-tidal CO,
-
should be readily available should be taken or given. If the patient sustains a cardiac ar
in all ED) and any other locations where patients require rest and has no cardiac output, col is not delivered to the
intubation. The preferred method is quantitative, such as lungs. In fact, with cardiac asystole, this can be a method of
capnography, capnornetry, or mas:. spectroscopy. Colori determining whether cardiopulmonary resuscitation is ad
metric devices use a chemically treated indicator strip that equate.
generally reflects the C01 level. At very low levels of C02, The colorimetric device is not used for the detection of
such as atmospheric air, the indicator turns purple. At elevated C02 levels. Similarly, it is not used to detect a main
higher co levels (eg, 2%-5%), the indicator turns yel l>tCm bronchial intubation. Physical and chest x-ray exami
l
low. A tan color indicates detection of C02 levels that arc nations are required to determine that the endotracheal
generally lower than those found in the exhaled tracheal tube is properly positioned in the airway. I n a noisy ED or
gases. when the patient is transported several times, this device is
It is important to note tl1at, on rare occasion, patients extremely reliable in differentiating between tracheal and
with gal>tric distention can have elevated C02 levels in the esophageal intubation.
esophagus. These elevated levels clear rapidly after several
SCENARIOS

SCENARIO 11-1 SCENARIO 11-3

A 22-year-old male is an unrestrained passenger in a motor A 3-year-old, unrestrained, front-seal passenger is injured
vehicle that collides head-on into a retaining wall. He has a when the car in which she is riding crashes into a stone
strong odor of alcohol on his breath. At the time of the colli wall. The child is unconscious at the injury scene. In the
sion, he hits the windshield and sustains a scalp laceration. At ED, bruises to her forehead, face, and chest wall are noted,
the injury scene, he is combative, and his GCS score is L 1. His and there is blood arom1d her mouth. The blood pressure
blood pressure is 120/70 mm 1-Ig, his heart rate is 100 is 105/70 mm Hg, the heart rate is l20 beats/minute, and
beats/min, and his respirations are 20 breaths/min. A semi Lhe respirations are rapid and shallow. The chiJd's GCS
rigid cervical collar is applied, and he is immobilized on a long score is 8.
backboard. He is receiving oxygen via a hi gh- flow oxygen
mask. Shortly after his arrival in the ED, he begins to vomit.

SCENARIO 11-4
A 35-year-old male sustains blunt chest trauma during a
SCENARIO 11-2
single-motor-vehicle collision. [ n the ED, he is alert and
The patient described i n the first Scenario II- I is now W1fe has evidence of a right-chest-wall contusion. He has
sponsivc and has un dergon e endotracheal intubation. Ven point tenderness and fracture crepitation of several right
tilation with 100% oxygen is being applied. Part of his ribs. His GCS score is 14. He is immobilized with a semi
evaluation includes a CT scan ofhis brain. After he is trans rigid cervical spine collar and secured to a long back
ported to radiology for the scan, the pulse oxjmeter reveals board. High-ilm-v oxygen is being administered via a face
82% Sa01 mask.
Performance at th 1s skill station will allow the student to pract1ce and demon
Interactive Skill
strate the techniques of needle cricothyroidotomy and surgical cricothyroido
Procedures
tomy on a live anesthetized animal, a fresh human cadaver, or an anatomic
,
Note: Standard precautions are human body maniki n Specifically, the student will be able to:
.
required whenever caring for

trauma patients.
OBJECTIVES
THE FOLLOWING
Identify the surface markings and stru ctures t o be noted when per
forming needle and surgical cricothyroidotomies.
Skill lil-A: Needle State the indications and complications of needle and surgica l
Cricothyroidotomy cricothyroidotomies.
Skill 111-B: Surgical Perform needle and surgical cricothyroidotomies on a live, anes
Cricothyroidotomy thetized animal, a fresh human cadaver, or an anatomic human body
manikin, as outlined in this skil l station.
51
52 SKILL STATION Ill Cricothyroidotomy
Skill 111-A: NeedJe Cricothyroidotomy

STEP 1. Assemble and prepare oxygen tubing by cutting a STEP 10. Remove the syringe and withdraw the stylet,
hole toward one end of the tubing. Connect the \vhile gently advancing the catheter downward
other end of the oxygen tubing to an oxygen into position, Laking care not to perforate the
source capable of delivering 50 psi or greater at posterior wall of the trachea.
Lhe nipple, and ensure the free flow of oxygen
STEP 11. Attach Lhe oxygen tubing over the catheter
through the tubing.
needle hub, and secure the catheter to the
STEP 2. Place Lhe pa ti en t in a supine position. patien t s neck.
'
STEP 3. Assemble a 12- or 14-gauge, 8.5-crn, over-the STEP 12. Intermittent ventilation can be achieved bv '
needle catheter to a 6- to 12-mL syringe. occluding the open hole cut into the oxygen
tubu1g \.vith your thumb for 1 second and
STEP 4. Surgically prepare the neck using antiseptic

,
releasing it for 4 seconds. .After releasing your
swabs.
Lhumb from the hole in Lhe tubing, passive
STEP 5. Palpate the cricolhyroid membrane anteriorly exhalation occurs. Note: Adequate Pa02 can be
between the thyroid cartilage and the cricoid maintained fo r only 30 to 45 minutes, and C02
cartilage. Stabilize the trachea v.rilh the thumb accumulation can occur more rapidly.
and forefinger of one hand to prevent lateral
movement of the trachea during the procedure. STEP 1 3. Continue to observe lung inflations and
auscultate the chest for adequate ven tilation.
STEP 6. PuJJCture the skin in Lhe midline with a 12- or
14-gauge needle attached to a syringe, directly
over the cricothyroid membrane ( ie, COMPLICATIONS OF NEEDLE
midsagittally). A small incision with a number 1 1 CRICOTHYROIDOTOMY
blade facilitates passage of the needle through
Lhe skin. Inadequate ventilations, leading to hypoxia
and death
STEP 7. Direct the needle at a 45-degree angle caudally,
Aspuation (blood)
while applying negative pressure to the syringe .
Esophageal laceration
STEP 8. Carefully insert the needle through the lower half Hematoma
of the cricothyroid membrane, aspuating as the Perforation of the posterior tracheal wall
needle is advanced. Subcutaneous and/or mediastinal emphysema
Thyroid perforation
STEP 9. Note the aspiration of air, which signifies entry
into the tracheal lumen.
Skill lll -8: Surgical Cricothyroidotomy

(See Figure 1/1- 1)
STEP 1. Place tl1e patient in a supine position with the STEP 6. Make a transverse skin incision over the
neck in a neutral position. cricothyroid membrane, and carefully incise
through the membrane transversely.
STEP 2. Palpate the thyroid notch, cricothyroid interval,
and the sternal notch for orienlaLion. STEP 7. Insert hemostat or tracheal spreader into the
incision and rota te it 90 degrees to open the
STEP 3. Assemble Lhe necessary equipment. .
a1rway.
STEP 4. Snrgically prepaTe and anesthetize the area
STEP 8. insert a proper-size, cuffed endotracheal tube or
locally, if the patient i s conscious.
tracheostomy tube (usually a number 5 or 6) into
STEP 5. Stabilize the thyroid cartilage with the left hand the cricoLhyroid membrane incision, directing
and maintain stabilization until Lhe hachea is the tube distally into the trachea.
intubated.
SKILL STATION Ill Cricothyroidotomy 53
Step 2
Thyroid notch
[_-- Thyroid cartilage
Step 6 Step 7 Step 8
Figure 111- 1 Surgical Cricothyroidotomy. (Illustrations correlate with selected steps in Skill Ill-B.)
STEP 9. lnflale the cuff and apply ventilation. COMPLICATIONS OF SURGICAL

STEP 10. Observe lung inflations and auscultate the chest
CRICOTHYROIDOTOMY
for adequate ventilation. Aspiration (eg, blood)
Creation of a false passage into the tissues
STEP 11. Secure the endotracheal or tTacheoslomy tube to
Subglottic stenosis/edema
the patient to prevent dislodging.
Laryngeal stenosis
STEP 12. Caution: Do not cut or remove the cricoid Hemorrhage or hematoma formation
and/or thyroid cartilages. Laceration of the esophagus
Laceration of the trachea
Mediastinal emphysema
Vocal cord paralysis, hoarseness
C H A PT E R
CHAPTER OUTLINE Upon completion of this topic, the student will ident1fy and
apply princ1ples of management related to the in it ia l dia g no
Objectives
sis and t reatmenL of shock in injured patients. Specifically, the
Introduction doctor will be able to:
Shock Pathophysiology
Basic Cardiac Physiology OBJECTIVES
Blood Loss Pathophysiology
Initial Patient Assessment
Define shock and apply this definition to clinical
Recognition of Shock practice.
Clinical Different1at1on of Cause of Shock
Recognize the clinical shock syndrome and corre
Hemorrhagic Shock in Injured Patients late a patient's a cute clinical signs with the degree
Definition of Hemorrhage of volume deficit.
Direct Effects of Hemorrhage
FlUid Changes Secondary to Soft Tissue Injury Explain the importance of early identification a nd
control of the source of he morrhage i n trauma pa
Initial Management of Hemorrhagic Shock ti ents
.
Phys1cal Examination
Vascular Access Lmes Compare and contrast the clinical presentation of
Initial Fluid Therapy patients with various causes of the shock state.
Evaluation of Fluid Resuscitation and Organ
Describe the ma n agem ent a nd on goi n g evalua
Perfusion
tion of he mor rhag ic shock.
Uri nary Output
Acid/Base Balance Recog n ize t h e p hysi ol og ic responses to resuscita
Therapeutic Decisions Based on Response to tion in order to continually reassess patient re
Initial Fluid Resuscitation sponse and avo id com pl ications .
Rapid Response
Transient Response
Minimal or No Response
Blood Replacement
Crossmatched, Type-Specific, and Type 0 Blood Medications
Warming Fluids-Plasma and Crystalloid Hypothermia
Autotransfusion Pacemaker
Coagulopathy
Reassessing Patient Response and Avoiding
Calcium Administration
Complications
Special Considerations in the Diagnosis and Treatment Continued Hemorrhage
of Shock Fluid Overload and CVP Monitoring
Equatmg Blood Pressure w1th Cardiac Output Recogn i tion of Other Problems
Advanced Age
Chapter Summary
Ath letes
Pregnancy Bibliography
56 CHAPTER 3 Shock
Preload
Introduction
Myocardial contractility
The initial step in managing shock in injured patients is to Afterload

recognize its presence. No laboratory test diagnoses shock;

rather, the initial diagnosis is based on clinical appreciation Preload, the volume of venous return to the heart, is de
of the presence of inadequate tissue perfusion and oxy termined by venous capacitance, volume status, and the dif
genation. The definition of shock as an abnormality of the ference bel:\'oeen mean venous systemic pressure and right
circulatory system that results in inadequate organ perfu atrial presswe (Figure 3-1). This pressure differential deter
sion and tissue oxygenation also becomes an operative tool mines venous flow. The venous system can be considered a
for diagnosis and treatment. reservoir or capacitance system in which the volume of
The second step in the initial management of shock is blood is divided into two components. One component
to identify the probable cause of the shock state. In trauma docs not contribute to the mean systemic venous pressure
patients, this process is directly related to the mechanism and represents the volume of blood that would remain in

of injury. Most injured patients in shock have hypo this capacitance circuit if the pressure i n the system were
volemia, but they may suffer from cardiogenic, neurogenic, zero.
and even septic shock on occasion. fn addition, tension The second, more important, component represents
pneumothorax can reduce venous return and produce the venous volume that contributes to the mean systemic
shock; this diagnosis should be considered in patients who venous pressure. Nearly 70% of the body's total blood vol
may have injuries above the diaphragm. Neurogenic shock ume is estimated to be located in the venous circuit. The re
results from extensive injury to the central nervous system lationhip between venous volume and venous pressure
(CNS) or spinal cord. For all practical purposes, shock describes the compliance of the system. It is this pressure
does not result from isolated brain injuries. Patients with gradient that drives venous Oow and therefore the volume of
spinal cord injury may initially present in shock res ulting venous return to the heart. Blood loss depletes this compo
from both vasodilation and relative hypovolemia. Septic nent of venous volume and reduces the pressure gradient; as
shock is unusual, but must be considered in patients whose a consequence, venous return is reduced.
arrival at the emergency facility has been delayed by many The volume of venous blood returned to the heart de
hours. termines myocardial muscle fiber length after ventricular
The doctor's management responsibilities begin with filling at the end of diastole. Muscle fiber length is related to
recognizing the presence of the shock state, and treatment the contractile properties of myocardial muscle according
should be initiated simultaneously with the identification to Starling's law. Myocardial co11tractility is the pump that
of a probable cause. The response to initial treatment, drives the system. Afterload is systemic (peripheral) vascu
coupled with the findings during the primary and sec lar resistance or, simply stated, the resistance to the forward
ondary patient surveys, usually provides sufficient infor flow of blood.
mation to determine the cause of the shock state.
Hemorrhage is the most common cause of shock in the in
BLOOD LOSS PATHOPHYSIOLOGY
jured patient.
Early circulatory responses to blood loss are compensa
tory-progressive vasoconstriction of cutaneous, muscle,
and visceral circulation preserves blood flow to the kidneys,
heart, and brain. The response to acute circulating volume
Shock Pathophysiology depletion associated with injury is an increase in heart rate
in an attempt to preserve cardiac output. ln most cases,
I What is shock? tachycardia is the earliest measurable circulatory sign of
shock. The release of endogenous catecholamines increases
An overview of basic cardi.ac physiology and blood loss
peripheral vascular resistance, which in turn increases dias
pathophysiology is essential to understanding the shock
tolic blood pressure and reduces pulse pressure, but does lit
state.
tle to increase organ perfusion. Other hormones with
vasoactive properties are released into the circulation during
shock, including histamine, bradyki nin, B-endorphins, and
BASIC CARDIAC PHYSIOLOGY
a cascade of prostanoids and other cytokines. These sub
Cardiac output, which is defined as the volume of blood stances have profound effects on the microcircuJation and
pumped by the heart per minute, is determined by multi vascular permeability.
plying the heart rate by the stroke volume. Stroke volume, Venous return in early hemorrhagic shock is preserved
the amount of blood pumped with each cardiac contrac to some degree by the compensatory mechanism of con
tion, is classically determined by the following: traction of the volume of blood in the venous system, which
'
INITIAL PATIENT ASSESSMENT 57
Heart rate Stroke volume -

Cardiac output
X -
(beats /min) (eelbeat) (LI mm)
Preload Myocardial Afterload

contractility
Systemic arteries
Figure 3-1 Cardiac Output.
does not contribute to mean systemic venous pressure. marked increac m i ntersti t ial edema, which is caused by
However, this compensatory mechanism is limited. The "reperfusion injury" to the capillary interstitial membrane.
most effective method of restoring adequate cardiac output As a result, larger volumes of fluid may be required for re
and end organ perfusion i11 to restore venous return to nor suscitation than initially anticipated.
mal by volume repletion. The initial treatment of shock is directed toward restor
At the cellular level, inadequately perfused and m.:y ing cellular and organ perfusion wilh adequately m.')'genated
ge nated cells arc deprived of essential substrates for normal blood. Control of hemorrhage and restoration of adequate
aerobic metnbolism and enc.:rgy production. Initially, com circulating volume are the goals of treatment of hemor
pensation QCl.U rs by shifting to anaerobic metabolism, rhagic shock. With the possible exception of' penetrating
which rcsuhs in the formation of lactic acid and. the devel t nwma Lo the torso without bead injury, euvolemia should
opment of metabolic acidosi1.. l f shock is prolonged and be maintained. Vasopressors are contraindicated for the
substrate delivery for the generation of adenosine triphos trealment of hemorrhagic shock because they worsen tissue
phate (ATP) is inadequate, the ce!Jular membrane loses the perfusion. Frequent monitoring of the patient's indices of
ability to maintain its integrity, and the normal electrical perfusion is necessary to evaluate the response to therapy
gradient is lost. and detect deterioration in the patient's condition as early as
Swelling of the endoplasmic reticulum is the first ul possible.
trastructural evidence of cellular hypoxia. Mitochondrial Most injured patients who are in hypovolemic shock
da mage soon follows. Lysosomes rupture and release en- require early surgical intcrvcnlton to reverse the shock state.
7ymes that digest ot her intracellular structural elements. The presence ofshock in an injured patient warrants the im
Sodium and water enter the cel l and cellular swelling oc
, mediate involvement of a surgeon.
curs. Intracellular calcium deposition also occurs. I f the
process is not reversed, progressive cellular damage, addi
tional tissue swelling, and cellular death occur. This
process compound:. the impact of blood loss and hypo
perfusion.
Initial Patient Assessment
The administration l>f a sufficient quantity of isotonic
electrolyte solutions helps combat this process. Patient treat Optimally, doctors will recognize the shock state during the
ment is directed toward reversing the shock state by pro in it i<ll patient nlisessmen t. To do so, it is important to be fa
viding adequate oxygenation, ventilation, and appropriate miliar with the clinical differentiation of the causes of
lluid resuscitation. Resuscitation may be accompanied by a shock-chiefly, hemorrhagic and nonhemorrhagic.
58 CHAPTER 3 Shock
RECOGNITION OF SHOCK of the body to increase the heart rate also may he limited hy
the presence of a pacemaker. A narrowed pulse pressure sug
I Is the patient in shock? gests significant blood loss and involvement of compensa
Profound circulatory shock-evidenced by hemody; tory mechanisms.
namic collape with inad(!quate per fusion of the skin, Labor<tory values for hematocrit or hemoglobin con
kidney, and central nervou> system-is simple to recog centration are unreliable for estimating acute blood loss
ni;e. However, after the airway and adequate ventilation and inappropriate for diagnosing shock. Massive blood loss
have been ensured, careful evaluation of the patient's cir may produce only a minimal acute decrease in the hemat
culatory status is necessary to identify early man ifesta ocrit or hemoglobin concentration. Thus, a very low hcma
tions of shock, including tachycardia and cutaneous t<)Lrit value obtained shortly after injur)' suggests massive
vasoconstriction. blood loss or a preexisting anemia, whereas a nonnal hcma
Reliance solely on systolic blood pressure as an indi toCJit does not exclude significant blood loss. Base deficit
cator ol shock may result in delayed recognition of the and/or lactate levels may be useful in determining the pres
shock state. Compensatory mechanisms may preclude a ence and severity of shock. Serial measurement of these pa

measurable fall in systolic pressure until up to 30% of the rameters may be used to monitor a patient's response to
pa lien I':. blood vol u.me is lost. Spcci fie allen tion should therapy.
be directed to pulse rate, respiratory rate, skin circulation,
and pulse pressure (the difference between systolic and di CLINICAL D I FFERENTIATION
astolic pressure). Tachycardia and cutaneous vasocon OF CAUSE OF SHOCK
striction are the typical early physiologic responses to
volume loss in most adults. Any injured patient who is cool I What is the cause of the shock state?
and has tachycardia is considered to be in shock until Shock in a trauma patient is clasified as hemorrhagic or
proven otherwise. Occasionally, a normal heart rate or nonhemorrhagic. A patient with injuries above the di
even bradycardia is associated with an acute reduction of aphragm mil)' have evidence of inadequate organ perfusion
blood volume. Other indice> of perfusion must be moni due ro poor cardiac performance from blunt myocardial in
tored in these situations. jury, cardiac tamponade, or a tension pneumothorax Lhat
The normal heart rate varies with age. Tachycardia is produces inadequate venous return ( preload). A high index
present when the heart rate is greater than 160 in an infant, of suspicion and careful observation of the patient's re
140 in a preschool-age child, 120 in children from school l.ponsc to initial treatment will enable the doctor to recog
age to puberty, and 100 in an adult. Elderly patients may not nize and manage all forms of shock.
exhibit tachycardia because of their limited cardiac response Initial determination of the cause of shock depends on
to catecholamine stimulation or the concurrent usc of med taking an appropriate history and performing a careful
ications, such as B-adrenergic blocking agents. The ability physical examination. Selected additional tests, such as
monitoring central venous pressure (CVP) and obtaining
data from a pulmonary artery catJ1etcr, chest and/or pelvic
x-ray examinations, and ultrasonogrnphy, may provide con
li rma tory evidence for the cause of the shock state, but
should not delay aggressive volume restoration.
Hemorrhagic Shock
Hemorrhage is the most common cause of shock after in
jury, and virtually all patients with multiple injuries have an
dement of hypovolemia. ln addition, most non hemorrhagic
shock states respond partially or brieOy to volume resusci
tation. Therefore, iJ signs of shock arc present, treatment
usually is instituted as i f the pa ticnt is hypovolemic. How
ever, as treatment is instituted, it is important to identify the
small number of patients whoe >hock has a different cause
(eg, a secondary condition such all cardiac tamponade, ten
sion pneumothorax, spinal cord injury, or blunt cardiac in
jury, which complicates hypovolemic/hemorrhagic shock).
Specific information about the treatment of hemorrhagic
shock is provided in the next section of this chapter. The
primary focus in hemorrhagic shock is to identify and stop
hemorrhage promptly.
HEMORRHAGIC SHOCK IN INJURED PATIENTS 59
Nonhemorrhagic Shock
Nonhemorrhagic shock includes cardiogenic shock, cardiac PITFA LLS
tamponade, tension pnetunothorax, neurogenic shock, and Missing tension pneumothorax.
..
septic shock.
Assuming there is only one cause for shock.
Young, healthy patients may have compensation
Cardiogenic Shock Myocardial dysfunction may be for an extended period and then crash quickly.
caused by blunt cardiac injury, cardiac tamponade, an nir
embolus, or, rarely, a myocardial infarction associated with
the patient's injury. l3lunl cardiac injury should be suspected
when the mecha nism of injury to the thor<L'< is rapid decel
eration. All patients with blunt thoracic trauma need con Neurogenic Shock Isolated intracranial i njuries do not
stan t electrocardiographic (ECG) monitoring to detect cause shock. The presence of shock in a patient with a
injury patterns and dysrhytJ1mias. Blood creatine kinase (CK; head. injury necessitates a search for a cause other than a n
fo rmerly, creatine phosphokinase I CPKJ) i soenzymes and intracranial injury. Spinal cord injury may produce hy
specific isotope studies of the myocardium rarely assist the potension due to loss of sympathetic tone. Loss of sympa
doctor in diagnosing or treating patients in the emergency thetic tone compounds the physiologic effects of
department (ED). Echocardiography may be useful in the di hypovolemia, and hypo vo lemi a compounds the physio
agnosis of tamponade and valvular rupture, but it is often logic effects of sympalhetic denervation. The classic pic
not pradical or immediately available in the ED. Focused as ture of neurogenic shock is hypotension without
sessment sonography in trauma (FAST) in the ED can iden tachycardia or cutaneous vasoconstriction. A narrowed
tify pericardia! fluid and the likelihood of cardiac tamponade pulse pressure is not seen in neurogenic shock. Pa ticn ts
as the cause of shock. Blunt cardiac injury may be an indica who have sustained a spinal injury often have concurrent
tion for early CVP monitoring to guide fluid resuscitation i n torso trauma; therefore, patients with lUlown or suspected
this situation. neurogenic shock should be treated initially for hypov
Cardiac tamponade is most commonly identified in olemia. The failure of Auid resuscitation to restore organ
penetrating thoracic trauma, but it may occur as the result perfusion suggests either conti n u ing hemorrh age or neu
of blunt injury to the thorax. Tachycardia muffled heart
,
rogenic shock. CVP monitoring may he helpful in manag
sounds, and dilated, engorged neck veins with hypotension ing this sometimes complex problem . .. See Chapter 7:
resistant to lluid therapy suggest cardiac tamponade. How Spine and Spinal Cord Trauma.
ever, the absence o r these classic findings does not exclude
the presence of this condition. Tension pnew11othorax may Septic Shock Shock due to infection i m med ia tely after
mimic cardiac tamponade, but i t is differentiated from the injury is uncommon; however, if a patient's arrival at an
latter condition by the findings of absent breath sounds and emergency facility is delayed for several h ours, i t could
a hyperresonant percussion note over the affected hem i tho occur. Septic shock may occur in patients with penetrat
rax. Approp ri ate placement of a needle into the pleural ing abdominal injuries and contamination of the peri
space i n a case of tension pneumothorax tempo rar i ly re toneal cavity by intestinal contents. Patients \.vi.th sepsis
lieves this li fe-th reatening condition. Cardiac tamponade who also have hypotension and are afebrile arc clinically
is best managed by thoracotomy. Pericardiocentesis may be difficult to d is tinguish from those in hypovolemic shock,
used as a temporizing maneuver when tho racotomy is not as both groups may manifest tachycardia, cutaneous vaso
an available option. .. See Skill Station VII: Chest Trauma constriction, impaired urinary output, decreased systolic
Management, Skill V 11-C: Pericardiocentesis. pressure, and narrow pulse pressure. Patients with early
septic shock may have a normal circulating volume, mod
Tension Pneumothorax Tension pneumothorax is a est tachycardia, warm, pink skin, systolic pressure near
true surgical emergency that requires immediate diagnosis normal, and a wide pulse pressure.
and treatment. I t develops when air enters the pleural space,
but a flap-valve mechanism prevents its escape. LntrapleuraJ
pressure rises, causing total lung collapse and a shift of the
mediastimtm to the opposite side with a subsequent impair Hemorrhagic Shock
ment of venous return and fall i n cardiac output. The pres
ence of acute respiratory distress, subcutaneous emphysema,
in Injured Patients
absent breath souJ1ds, hyperresonance to percussion, and tra
cheal shift supports the diagnosis and warrants immediate Hemorrhage is the most common cause ofshock in trauma pa
thoracic decompression without waiting for x-ray confir tients. The trawna patient's response to blood loss is made
mation of the diagnosis . See Skill Station Vli: Chest more complex by shifts of fluids among the fluid compart
Trauma Management, Skill VI l-A: Needle Tho racentesis. ments in lhe body-particularly in the extracellular fluid com-
60 CHAPTER 3 Shock
partment. The classic response to blood loss must be consid It is dangerous to wait until the trauma patient fits a pre
ered in the context of fluid shifts associated with soft tissue in cise physiologic classification of shock before initiating ag
jwy. ln addition, the changes associated with severe, prolonged gressive volume restoration. Fluid resuscitation must be
shock and the pathophysiologic results of resuscitation and initiated when early signs and symptoms of blood loss are ap
rcpcrfusion must also be considered, as previously discussed. parent or suspected, not when the blood pressure is falling
or absent.
DEFINITION OF HEMORRHAGE
Class I Hemorrhage-Up to 1 5 %
Hemorrhage is defined as an acute loss o f circulating blood
Blood Volume loss
volume. Although there is considerable variability, the nor
mal adult blood volume is approximately 7% of body The clinical symptoms of volume loss with class I hemor
rhage arc minimal. In uncomplicated situations, minimal
weight For example, a 70-kg male has a ciTcnlating blood
tachycardia occurs. No measurable changes occur in blood
volume of approximately 5 L. The blood volume of obese
pressure, pulse pressure, or respiratory rate. For otherwise
adults is estimated based on their ideal body weight, because
healthy patients, this amount of blood loss does not require

calculation based on actual weight may result in significant
replacement Transcapillary refill and other compensatory
overestimation. The blood volume for a child is calculated as
mechanisms restore blood volume within 24 hours. How
8o/o to 91Yo of body weight (80-90 ml/kg) . .. Sec Chapter
ever, in the presence of other fluid changes, this amount of
10: Pediatric Trauma.
blood loss may produce clinical symptoms, in which case
replacemen1 of the primary fluid losses corrects the ci rcula
DIRECT EFFECTS OF HEMORRHAGE tory state, usually vvithout the need for blood transfusion.
The classitication of hemorrhage into four classes based on
clinical signs is a useful tool for estimating the percentage Class II Hemorrhage-15% to 30%
of ac1.1tc blood loss. These changes represent a continuum Blood Volume loss
or ongoing hemorrhage and guide initial therapy. Volume In a 70-kg male, volume loss \vith class II hemorrhage rep
replacement is guided by the patient's response to initial ther resents 750 to 1500 mL of blood. Clinical signs include
apy, not solely by the initial classification. This classification tachycard_ia (heart rate above 100 in an adult), tachypnea,
system is useful in emphasizing the early signs and patho and decreased pulse pressure; the Ia tter sign is related pri
physiology of the shock state. marily to a rise in the diastolic component due to an in
Class I hemorrhuge is exemplified by the condition of crease in circulating catecholamines. These agents produce
an individual who has donated a unit of blood. Class fl is an increase in peripheral vascular tone and resistance. Sys
uncomplicated hemorrhage for which crystalloid fluid re tolic pressure changes minimally in early hemorrhagic
suscitation is required. Class iii is a complicated hemor shock; therefore, it is important to evaluate pulse pressure
rhagic state in which at least crysta lloicl in fusion is required rather than systolic pressure. Other pertinent clinical fmd
and perhaps also blood replacement. Class IV hemorrhage is ings with thjs amount o f blood loss include subtle CNS
considered a preterminal event, and unless very aggressive changes, such as anxiety, f1ight, and hostil ity. Despite the
measures are taken, the patient \viii die within minutes. signit'icru1t blood loss and cardiovascular changes, minary
Table 3-1 outlines the estimated blood loss and other criti output is only mildly affected. The measured urine flow is
cal measures for patients in each classification of shock. usually 20 to 30 mL!honr in an adult.
Several contounding factors profoundly alter the classic Accompanying fluid losses can exaggerate the clinical
hemodynamic response to an acute loss of circulating blood manifestations of class rr hemorrhage. Some of these pa
volume, and these m LISt be promptly recognized by all ind i tients may eventually require blood transfusion, but may be
viduals involved in the in i Lial assessment and resuscitation stabilizd initially with crystalloid sQlutions.
of injured patients who are at risk for hemorrhagic shock.
These factors include:
Class Ill Hemorrhage-30% to 40%
Pat1ent s age
0 ,
Blood Volume loss
The blood loss wilh class m hemorrhage (approximately
Severity of injury, with special attention to type and
2000 mL in an adult) may be devastating. Patients almost
anatomic location of injury
always present with the classic signs or inadequate perfu
Time lapse between injury and initiation of treat sion, including marked tachycardia and tachypnea, signifi
ment cant changes in mental status, and a measurable fall in
systolic pressure. In an uncomplicated case, this is the least
Prehospital fluid therapy and application of a pneu
amount of blood loss that consistently causes a chop in sys
matic antishock garment ( PASG)
tolic pressure. Patients with this degree of blood loss almost
Medications used for chronic conditions always require transfusion. However, the priority of man-
HEMORRHAGIC SHOCK IN INJURED PATIENTS 61
TABLE 31 Estimated Blood lossa Based on Patient's Initial Presentationb
CLASS I CLASS II CLASS Ill CLASS IV
Blood loss (ml) Up to 7 50 750-1500 1 500-2000 >2000
Blood loss (% blood volume) Upto 1 5 % 1 5%-30% 30%-40% >40%
Pulse rate <100 100-120 1 20-140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output (mLJhr) >30 20-30 5-15 Negl igi ble
CNSimental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Fluid replacement Crystalloid crystalloi d crystalloid and blood Crystalloid and blood
For a 70-kg male.

"The gu1delines 1n th1s table are based on the 3-for-1 (3: 1) rule, which derives irom the emp1nc observation that most pat1ents m hem
orrhagiC shock requ1re as much as 300 ml of electrolyte solut1on for each 100 ml of blood loss. Applied blindly, these guidelines may
result in excessive or Inadequate fluid admimstration For example, a patient with a crush Injury to an extrem1ty may have hypotension
that is mrt of proportiOn lo his or her blood loss and may require fluids in excess of the 3:1 guidelines. In contrast, a pati ent whose on
going blood loss is being replaced by blood transfusion reqwes less than 3 I. The use of bolus therapy With careful monitoring of the
patient's response may moderate these extremes.
agement is to stop the hemorrhage, by emergency operation kg patient with hypotension who arrives at an ED or trauma
if necessary, in order to decrease the need for transfusion. center has lost an estimated 1470 mL of blood (70 kg x 7%
The decision to transfuse blood is based on the patient's re x 30% = 1.47 L, or 1470 mL). Nonresponse to flu.id admin
sponse to initial fluid resuscitation and the adequacy of end istration indicates persiste nt blood loss. unrecognized fluid
organ perfusion and oxygenation, as described later in this losses, or nonhemorrhagic shock.
chapter.
Class IV Hemorrhage-More than 40%

Blood Volume loss
The degree of exsan guination with class IV hemorrhage is
FLUID CHANGES SECONDARY
immediately Life-threatening. Symptoms include marked
TO SOFT TISSUE INJURY
tachycardia, a significant decrease in systolic blood pressure,
and a very narrow pulse pressure (or an unobtainable dias Major soft tissue injwies and fractures compromise the he
tolic pressure). Urinary output is negljgible, and mental sta modynamic status of injured patients in n.vo ways. First,
tus is markedly depressed. The skin is cold and pale. Patients blood is lost into the site of injury, particularly in cases of
with class rv hemorrhage frequently require rapid transfu major fractures. For example, a fractured tibia or humerus
sion and immediate surgical intervention. These decisions may be associated with the loss of as much as 1.5 units (750
are based on the patient's response to the initial manage mL) of blood. Twice that. amount (up to 1500 mL) is com
ment techniques described in this chapter. Loss of more monJy associated with femur fractures, and several liters of
than 50% of blood volume results in loss of consciousness blood may accumulate in a retroperitoneal hematoma asso
and decreased pulse and blood pressure. ciated with a pelvic fracture.
The clinical usefulness of this classification scheme is The second factor to be considered is the edema that
illustrated by the following example: Because class Ill hem occurs in injured soft tissues. The degree of this additional
orrhage represents the smallest volwne of blood loss that is volume loss is related to the magnitude of the soft tissue in
consistently associated '>vith a drop in systoli c pressure, a 70- jury. Tissue injury results in activation of a systemic in-
62 CHAPTER 3 Shock
with the rapid reestablishment of intravascular volume by

.
PITFALL '' .. - intr<lvenous fluid infusion. The adequacy of tissue perfusion
..
' "'
- <:_ . "
..
dictate:. the amount of 11uid resuscitation required. Surgery

Don't lose time focused on replacing fluid for blood. may Ol' requ ired to control i nternal hemorrhage

.
Find the source of bleeding.
Disability-Neurologic Examination
A brief neurologic examination will determine the level of
Oammatory response and production and release of mulli comciousness, eye motion and pupil1.1 ry response, best
plc cytokine:.. Many of these locally .H.live hormones have motor function, and degree of scmation. This information is
profound effects on the va:.cul.tr endothelium, which in useful in asessing cerebral perfusion, following the evolu
Lre<l!.es permeability. Tissue cdem.t 1:. the reslllt of slli fts in tion of neurologic disability, and predicting future recovery.
fluid primarily from the plasma into the extravascular, ex Alterations in CNS function in patients who have hypoten
traccllul<lr' space. Such shifts produce an additional deple .-. i on as a resuJt of hypovolemic shock do not necessarily
t ion in intravascular vol u me. i mply direct intracranial injury anc.l may reflect inadequate
brain perfusion. Restoration of cerebral perfusion and oxy
gcnal ion must be achieved before ascribing these findings to
See Chapter 6: Jlead Trauma.
inl rocranial injury.
Initial Management of
Hemorrhagic Shock Exposure Complete Examination
Afier lifeaving priorities are addre:.sed, the patient must be
completely undressed and carefu lly examined from head to
What can I do about shock?
toe to 1>earch for associated injuries. When undressing the
The di agnosis and treatment of shock must occur almost si patient, it is essential to prevent hypothermia. Tbe use of
mul ta neou ly. For mosl mmma patients, treatment is insti O u id warmers as well as external passive and acti ve warming
tuted as if 1 he pati ent has hypovolcm i;;. shock, unless there is techniques are essential to prevent hypothermia.
clear evidence that the shock stale has a different cause. The
basic management princi ple is to stop the bleeding and re Gastric Dilation-Decompression
place the volume loss. .
( ,astric dilation often occurs in trauma patients, especial/)'
i11 clllldrell, and may cause unexplained h)1JOtension or car
PHYSICAL EXAMINATION diac dysrhythmia, usually bradycardia from excessive vagal
stimulation. In unconscious patients, gastric distention i n
The physical examination is directed toward the immediate
creases the risk of aspiration of gastric contents, which is a
d iagno1>i of life-threa ten i ng i nj u rics and includes assess
potentially fatal complication. G,1s1 ric dccom pression is ac
ment of the ABCDEs. Base l i ne recordings nrc important to
complished by intubating the Sll)mach with a tube passed
monitor the patient's response to therapy. Vi ta l sign s uri
,
nasally or orally and attaching il to 5l1Ction to evacuate gas

nary output, and level of consciousnes:. arc essential. A more
I rk contents. However, proper posiI i<m i ng of the tube docs
detailed examination of the patient follow as lhe situation
not completely obviate the risk of aspiration.
permits. Sec Chapter I : Initial Ascssmcnt and Manage
ment.
Urinary Catheterization
Airway and Breathing Bladder catheteri7ation allows for assessment of the urine
for hcm,tturia and continuom evaluation of renal perfusion
E1>tahlishing a patent airway with adequate vcntihllion and
by monitoring urinary output. Blood at the urethral meatus
oxygenation is the first pri ority. Supplementa ry oxygen is
or a hi gh riding, mobile, or non palpable prostate in males is
-
supplied to ma i ntain oxygen saturation at greater than 95o/o.

nn absolutecontraindication to the insertion of a
. Sec Chapler 2: Airway a nd Vent ilatory Ma 11ageme nt.
Ira nsu rethral catheter prior to rad iogra phic confirmation
of a 11 intact urethra. rl' Sec Chapter 5: Abdominal and Pelvic
Circulation-Hemorrhage Control Trauma.
Priorities for the circulation include controlling obvious
hemorrhage, obtaining adequate intravenous access, and as
VASCULAR ACCESS LINES
sessing tissue perfusion. Bleeding from external wounds
usually can be controlled by direct pressure to the bleeding Access to the vascular system must be obtained promptly.
site. A PASG may be used to control bleeding from pelvic or Thill i best done by i nsen ing two large caliber (minimum
-
lower extremity fractures, but its u:.e should J/Ot in terfere of 16-gauge) peripheral in travenous cathetcrs before placing
I N ITIAL MANAGEMENT OF HEMORRHAGIC SHOCK 63
a central venous line is considered. The rate of flow is pro

portional to the fourth power of the radius of the cannula
and inversely related to its length ( Poiseuille's law). Hence,
short, large-caliber peripheral int ravenous lines ' re pre

ferred for the rapid infusion of large volumes of fluid. Fluid
warmers and rapid infusion pumps are used in the presence
of massive hemorrhage and severe hypotension.
The most desirable sites for peripheral, percutaneous
intravenous lines in adults are the forearms and antecubital
veins. If circumstances preven t the use of peripheral veins,
large-caliber, central venous (femoral, jugular, or subclavian
vein) access using the Seldinger technique or saphenous vein
cutdown is indicated, depending on the skill and e}..1'erience
of the doctor. See Skill Station fV: Shock Assessment and
Management, and Skill Station V: Venous Cutdown.
Frequently in an emergency situation, central venous
access is not accomplished under tightly cont1olled or com
pletely sterile conditiom. These lines should be changed in
a more controlled enviro1m1ent as soon as fue patient's con
d.ition permits. Consideration also must be given to the po
tential for serious complications related to attempted. central
venous catheter placement, such as pneumothorax or he The amount offluid and blood required for resuscitation
mothorax, in patients who may already be unstable. is difficult to predict on initial evaluation ofthe patient. Table
In children younger than 6 yems, the placement of m1 3-1 provides general guidelines for establishing the amount
intraosseous needle should be attempted before inserting a of fluid and blood likely required. A rough guideline for the
central line. The important determjnant for selecting a pro total amount of crystalloid volume required in the short
cedme or route for establishing vascular access is the expe term is to replace each 1 mL of blood loss with 3 mL of crys
rience and skill of the doctor. lntraosseous access with talloid Quid, thus allowing for restitution of plasma volume
specially designed equipment also is possible in adults. lost into the interstitial and intracellular spaces. This is
As intravenous lines arc started, blood samples arc knmvn as fue 3-for-1 rule. It is most important to assess the
drawn for type and crossmatch, appropriate laboratory patient's response to fluid resuscitation and evidence of ade
analyses, toxicology studies, and pregnancy testing for all fe quate end-organ perfusion and oxygenation (ie, via urinary
males of childbearing age. Arterial blood gas (ABG) analy output, level ofconsciousness, and peripheral perfusion). If,
sis is performed at this time. A chest x-ray must be obtaimd during resuscitation, the amount of fluid required to restore
after attempts at inserting a subclavian or internal jugular or maintain adequate organ perfusion greatly exceeds these
CVP monitoring line to document the position of the line estimates, a careful reassessment of the situation and a
and to evaluate for a pneumothorax or hemothorax. search for unrecognized injuries and oilier causes of shock
are necessary.
The goal of resuscitation is to restore organ perfusion.
INITIAL FLUID THERAPY
This is accomplished by the use of resuscitation fluids to re
Warmed isotonic electrolyte solutions, such as lactated place lost intravascular volume and guided by the goal of
Ringer's and normal saline, are used for initial resuscitation. restoring a normal blood pressure. Note, however, that if
This type of Ouid provides transient intravasculctr ex1'an blood pressure is raised rapidly before the hemorrhage has
sion and further stabilizes the vascular volume by replacing been definitively controlled, increased bleeding may occur.
accompanying fluid losses i.nto U1c interstitial and intracel This can be seen in the small suhset of patients in the tran
lular spaces. An al tcrnative initial fluid is hrpcrtonic saline, sient or non responder category. Persistent infusion oflarge
although there is no evidence of survival advantage .i n the volumes of fluids in an attempt to achieve a normal blood
current literaturc. pressure is not a substitute for definitive control of bleeding.
An initial, warmed fluid bolus is given as rapidly as pos Fluid resuscitation and avoidance of hypotension arc
sible. The usual dose is 1 to 2 L for adults and 20 mlfkg for important principles in the initial management of blunt
pediatric patients. This often requires application of pumping trauma patients, particularly those \:ith traw1mtic brain in
devices (mechanical or manual) to the fluid administration jury (TBJ). ln penetrating trauma wilb hemorrhage, delay
sets. The patient's response is observed during this initial ing aggressive fluid resuscitation until definitive control may
fluid administration, and further therapeutic and diagnos prevent additional bleeding. Although complications asso
tic decisions are based on this response. ciated with resuscitation injury are undesirable, the allerna-
64 CHAPTER 3 Shock
adequate resuscitation. This situation should stimulate fur

PITFALL ther volume replacement and diagnostic endeavors.
Recognize the source of occult hemorrhage. Re

member, B lood on the floor x fo ur more." Chest, ..
" ACID/BASE BALANCE
pelvis, retroperitoneum, and thigh.
Patients in early hypovolemic shock have respiratory alkalo
sis due to Lachypnea. Resp i ratory alkalosis is frequently fol
lowed by mild metabolic acidosis in the early phases of shock
and does not require treatmen t. Severe metabolic acidosis
Live of exsanguination is even less so. A careful, balanced ap may develop from long-standing or severe shock. Metabolic
proach with frequent reevaluation is required. acidosis is caused by anaerobic metabolism, which results
Balancing the goal of organ perfusion with Lhe r.isks from inadequate tissue perfusion and the production of lac
of rebleeding by accepting a lower-than-normal blood tic acid. Persistent acidosis is usually caused by inadequate re
pressure has been termed "controlled resuscitation," "bal suscitation or ongoing blood loss, and in he t normothermic
anced resuscitation," "hypotensive resuscitation," and "per patient in shock it should be treated with fluids, blood, and
missive hypotension." The goal is the balance, not t he consideration of operative intervention Lo control hemor
hypotension. Such a resuscitation strategy may be a bridge rhage. Base deficit and/or lactate can be useful in determining
to, but is not a substilute for, de fi ni Live surgical con trol of the presence and severily of shock. Serial measurement of
bleeding. Lhese parameters can be used to monitor tl1e response to ther
apy. Sodium bicarbonate should 110t be used routinely to treat
metabolic acidosis secondary to hn1o-volcmic shock.
Evaluation of Fluid Resuscitation

and Organ Perfusion
Therapeutic Decisions Based
I) What is the patient's response? on Response to Initial Fluid
The same signs and symptoms of inadequate perfusion that Resuscitation
are used to diagnose shock are useful determinants of pa
ti.enl response. The return of normal blood pressure, pulse The patient's response to initial fluid resuscitation is the key
pressure, and pulse rate are signs that suggest perfusion is to determining subsequent therapy. Having established a
returning to normal. However, these observations give no preliminary diagnosis and treatment plan based on the ini
information regarding organ perfusion. Improvements in tial evaluation, the doctor now modifies the plan based on
the CVP status and skin circulation are important evidence the patient's response. Observing the response to the initial
of enhanced perfusion, but are difficult to quantitate. The resuscitation identifies palients whose blood loss was greater
volmne of urinary outpul is a reasonably sensitive indica than estimated and those with ongoing bleeding who re
tor of renal perfusion; normal urine volumes generally quire operative control of internal hemorrhage Resuscita
.
imply adequate renal blood flow, if not modified by the ad tion in the operaLing room can accomplish simultaneously
ministration of diuretic agents. For this reason, urinary out the direct control of bleeding by the surgeon and the
put is one ofthe prime monitors of resuscitation and patient restoration of intravascular volume.ln addition, it limits the
response. Changes in CVP can provide useful information, probability of overtransfusion or unnecessary transfusion
and the risks incurred in the p lacement of a CVP line arc of blood in patients whose initial status was disproportion
justified for complex cases. Measurement of CVP is ade ate to the amount of blood loss.
quate for most cases. It is particularly im port ant to distinguish patients who
are "hemodynamically stable" from those who are "hemo
dynamically normal A hemodynamically stabl-e p at ient
."
URINARY OUTPUT
may have persistent tachycardia, tachypnea, and oliguria
\IVithin certain limits, urinary o u tp ut is used Lo monitor clearly underresuscitated and stiU in shock. In contrast, a he
renal blood flow. Adequate resuscitation volume replace modynamically normal patient is on e who exhibits no signs
ment should produce a urinary output of approximately 0.5 of inadequate tissue perfusion. The potential patterns of re
mL/kg/hr in adults, whereas 1 mL/kg!hr is an adequate uri sponse to initial fluid administration can be divided into
nary output for pediatric patients. For children under I year three groups: rapid response, transient response, and mini
of age, 2 mL/kg/hour should be maintained. The in ability mal or no response. Vital signs and management guidelines
to obtain urinary output at these levels or a decreasi ng uri for patients in each of these categories are outlined in Table
nary output with an increasing sp ecific grav ity suggests in-
- 3-2.
THERAPEUTIC DECISIONS BASED ON RESPONSE TO I N ITIAL FLUID RESUSCITATION 65
TABLE 3-2 Responses to Initial Fluid Resuscitationa

r

RAPID TRANSIENT MINIMAL OR
RESPONSE RESPONSE NO RESPONSE
Vital signs Return to normal Transient Improvement, Remain

recurrence of decreased abnorma l
blood pressure and
increased hean. rate
Estimated blood loss Minima l Moderate and Severe

(1 0%-20%) ongoing (>40%)
(20%-40%)
Need for more crystalloid Low Hrgh High
Need for blood Low Moderate to hgh Immediate
Blood preparation Type and Type-spedtic Emergency

crossmatch blood release
Need for operative Possibly Likely Hrghly likely

intervention
Early presence of Yes Yes Yes

surgeon
2000 mL of 1sotomc solution 1n adults; 20 mUkg bolus o1 Rnger's lactate in children.
RAPID RESPONSE tify patients who are s ti ll bleeding and require rapid sur
gical intervention.
Patients in this group, termed "rapid responders," respond
rapidly lo Lbe initial fluid bolus and remain hemodynam
ic ally normal after the initial fluid bolus has been given MINIMAL OR NO RESPONSE
and the fluids are slowed to maintenance rates. Such pa
Failure to respond to crystalloid and blood administration in
tients us ually have lost minimal (less than 20o/o) blood vol
the ED dictates the need for immediate, definitive interven
ume. No further fluid bolus or immediate blood
tion (eg, operation or angioembolization) to control exsan
administration is indicated for this group. Typed and
guinating hemorrhage. On very rare occasions, fa ilure to
crossmatched blood should be kept available. Surgical con respond may be due to pump failure as a result of blunt car
sultation and evaluation are necessary during initial assess diac injury, cardiac tamponade, or tension pneumothorax.
ment and treatment, as operative intervention may still be Nonhemorrhagic shock always should be considered as a di
necessary. agnosis in this group of patients. CVP monitoring or car
diac ultrasonography helps to di(ferentiate between the
TRANSIENT RESPONSE various causes of shock.

Patients in the second group, termed "transient respon

ders" respond to the initial fluid bolus. However. they
begin to show deterioration of perfusion indices as the ini
tial fluids are slowed to maintenance levels, indicating ei
ther an ongoing blood loss or inadequate resuscitation.
PITFALLS
Most of these patients initially have losl an estimated 20o/o
to 40% of their blood volume. Contin ued fluid adminis Delay in definitive management can be letha l.
tration and initiation of blood transfusion are imticated. A Do not overlook a source of bleeding.
transient response to blood administration should iden-
66 CHAPTER 3 Shock
lection, anticoagulation (generally with sodium citrate so

Blood Replacement lutions, not heparin), and retransfusion of shed blood. Col
lection of shed blood for autotransfusion should be
The decision to initiate blood transfusion is based on the considered for any patient with n major hemothorax.
patient's response, as described in the previous section.
COAGUlOPATHY
CROSSMATCHED, TYPE-SPECIFIC,
Severe injury and hemorrhage result in the consumption ofco
AND TYPE 0 BlOOD
agulation factors and early coagulopathy. Massive transfusion
The main purpose of blood transfusion i:.; to restore the with the resultant dilution of platelets and dotting factors,
m.-ygen-carrying capacity of the intravascular volume. Vol along with the adverse effect of hypothermia on platelet aggre
ume remcitation itself can be accomplished with crystal gation and he t clotting cascade, all contribute to coagulopathy
loids, with the added advantage that it contributes to in injured patients. Prothrombin time, partial thromboplastin
interstitial and intracellular volume restitution_ time, and platelet count are valuable baseline studies to obtain

fully crossmatched blood is preferable. However, the in the first hour, especially if the patient has a history of coag
complete crossmatching process requires approximately I ulation disorders, takes medications that alter coagulation (cg,
hour in most blood banks. For patients who stabilize rapidly, warfarin, aspirin, and nonsteroidal antiinflan1matory agents
crossm.llchcd blood should be obtained and made available [NSATDs]}, or a reliable bleeding history cannot be obtained.
for transfusion when indicated. Transfusion of platelets, cryoprecipitate, and fresh-frozen
lypc-specific blood can be provided by most blood plasma should be guided by these coagulation parameters, in
banks within I 0 minutes. Such blood i compatible with cluding fibrinogen levels. Routine Ul>C ofsuch products s i gen
ABO and Rh blood types, but incompatibilities of other erally not warranted unless the patient has a known coagulation
antibodies may exist. Type-specific blood is preferred for disorder or has undergone anticoagulation pharmacologically
patients who are transient responders, as described in the for management of a specific medical problem. Tn such cases,
previous seclion. If type-specific blood is required, com spcciflc f:1ctor replacement Lher<"py is immediately indicated
plete crossmatching should be pt:rformcd by the blood when there is evidence of bleeding, l>r the potential for occult
bank. blood loss exists (eg, head, abdominul, or thoracic injury).
II" type-specific blood is unavailable, type 0 packed However, consideration of early blood component therapy
cells arc indicated for patient:. with exl!.mg uinating hem should be given to patients with class IV hemorrhage.
orrhage. lo avoid sensitization and future complications, Patients with major brain injury are particularly prone
Rh negative cells are preferred for fem.tle of childbear to coagulation abnormalities as a result of substances, espe
ing age. For life-threatening blood loss, the usc o f un cially tissue thromboplastin, that arc released by damaged
matched, type-specific blood is prderrcd over type 0 neural tissue. Th.:se patients .:o.Jgul.lliPil P'r1'11c'lers need to
blood. This is I rue unless multiple, unidcntifiec.J casualties h do.l'il munilored.
are being treated simultaneously <nd the risk of inadver
l:ntly <HJministcring the wrong llllil or bJood tO a patient
CAlCIUM ADMINISTRATION
is great.
Most patients receiving blood transfusions do not need calcium
supplements. Excessive, supplemental calcium may be harmful.
WARMING FlUIDS-PlASMA
AND CRYSTAllOID
Hypothermia must be prevented and reversed if a patient
has hypothermia on arrival at the hospital. The use of blood Special Considerations in the
warmer!> in the ED is desirable, even if cumbersome. The
mot efficient way to prevent hypothermia in any patient re
Diagnosis and Treatment of Shock
ceiving massive volumes of crystalloid is to hcnt Lhe fluid to
39 C: ( I 02.2" F) before using it. This can be accomplished by !:lpecial considerations in the diagnosis and treatment of shock
storing crystalloids in a warmer or with the usc of a mi include the mistaken equation of blood pre!.stue with cardiac
crowave oven. Blood products cannot be warmed in a mi output; patient age; athletes in shock; pregnancy; patient med
crowave oven, but they can be heated by passage through ications; hypothermia; and the presence of pacemakers.
intravenous fluid warmers.
EQUATING BlOOD PRESSURE

AUTOTRANSFUSION WITH CARDIAC OUTPUT
Adaptations of standard tube thoracostomy collection de Trea tment of hypovolemic ( hemorrhagic) shock requires
VIces are commercially available; these allow for sterile col- correction of inadequate organ perfusion by increasing
SPECIAL CONSIDERATIONS IN THE DIAGNOSIS AND TREATMENT OF SHOCK 67
organ blood flow and tissue oxygenation. Increasing blood with prompt, aggressive resuscitation and careful monitor
flow requires an increase in cardiac output. Ohm's law ( V ing. rl' See Chapter 1 1 : Geriatric Trauma.
= I x R) applied to cardiovascular physiology states that
blood pressure ( V) is proportional to cardiac oulput (l)
ATHLETES
and systemic vascular resistance (R) (afterload). An in
crease in blood pressure should not be equated with a con Rigorous athletic training routines change the cardiovascu
comitant increase in cardiac output. An increase in lar dynamics of this group of patients. Blood volume may
peripheral resistance-fo r example, with vasopressor ther increase 15o/o to 20%, cardiac output sixfold, and stroke vol
apy-with no change i n cardiac output results in increased ume 50%, and the resting pulse can average 50. The ability
blood pressure, but no improvement in tissue perfusion or of athletes' bodies to compensate for blood loss is truly re
oxygenation. markable. The usual responses to hypovolemia may not be
manifested in athletes, even when significant blood loss has
occurred.
ADVANCED AGE

Elderly trauma patients require special consideration. The

PREGNANCY
aging process produces a relative decrease i n sympathetic
activity with respect to the cardiovascular system. This is Physiologic maternal hypervolemia requires a greater blood
thought to result from a deficit in the receptor response to loss to manifest perfusion abnormalities in the mother,
catecholamines, rather than fro m a reduction in cate which also may be reflected in decreased fetal perfusion.
cholamine production. Cardiac compliance decreases with rl' See Chapter 12: Trauma in Women.
age, and older patients are unable to increase heart rate or
the efficiency of myocardial contraction when stressed by
MEDICATIONS
blood volume loss, as are younger patients. Atherosclerotic
vascular occlusive disease makes many vital organs ex B-adrenergic receptor blockers and calcium-channel block
tremely sensitive to even the slightest reduction in blood ers can significantly alter a patient's hemodynamic response
flow. Many elderly patients have preexisting volume deple to hemorrhage. Insulin overdosing may be responsible for
tion resulting from long-term diuretic use or subtle malnu hypoglycemia and may have contributed to the injury-pro
trition. For these reasons, hypotension secondary to blood ducing event. Long-term diuretic therapy may explain un
loss is poorly tolerated by elderly trauma patients. B-adren expected hypokalemia, and NSATDs may adversely affect
ergic blockade may mask tachycardia as an early indicator of platelet function.
shock. Other medications may adversely affect the stress re
sponse Lo injury or block it completely. Because the thera
HYPOTHERMIA
peutic range for volume resuscitation is relatively narrow i n
elderly patients, it is prudent to consider early invasive mon Patients suffering from bypot.herm ia and hemorrhagic
itoring as a means to avoid excessive or inadequate volume shock do nol respond normally to the administration of
restoration. blood and fluid resuscitation, m1d coagulopatby often de
The reduction in pulmonary compliance, decrease in velops. Body temperature is an important vital sign to mon
diffusion capacity, and general weakness of the muscles of itor during the initial assessment phase. Esophageal or
respiration limit the ability of elderly patients to meet the bladder temperature is an accurate clinical measmement of
increased demands for gas exchange imposed by injury. This the core temperature. A trauma victim under the influence
compounds the cellular hypoxia already produced by a re of alcohol and exposed to cold temperature extremes is
duction in local oxygen delivery. Glomerular and tubular more likely to have hypothermia as a result of vasodilation.
senescence in the kidney reduces the ability of elderly pa Rapid rewarming in a environment witl1 appropriate exter
tients to preserve volume in response to the release of stress nal warming devices, beat lamps, thermal caps, healed res
hormones such as aldosterone, catecholamines, vasopressin, piratory gases, and warmed intravenous fluids and blood
and cortisol. The kidney also is more susceptible to the ef will generally correct hypotension and hyporhermia. Core
fects of reduced blood flow and nephrotoxic agents such as rewarming (irrigation of the peritoneal Ot' thoracic cavity
drugs, contrast agents, and the toxic products of cellular de with crystalloid solutions warmed to 39 C [ 1 02.2 F I or ex
struction. tracorporeal bypass) may occasionally be indicated. Hy
For all of these reasons, mortality and morbidity rates polhermia is best treated by prevention. rl' See Chapter 9:
increase directly with age and .long-term health status for Thermal Injuries.
mild and moderately severe injuries. Despite the adverse ef
fects of the aging process, comorbidities from preexisting
PACEMAKER
disease, and a general reduction n i the "physiologic reserve"
of geriatric patients, the majority of these patients may re Patients with pacemakers are unable to respond to blood
cover and return to their preinjury status. Treatment begins loss in the expected fashion, because cardiac output is di-
68 CHAPTER 3 Shock
sophisticated techniques are used. Early transfer of the pa

tient to an intensive care unit should be considered for el
derly patients and patients with nonhemorrhagic causes of
shock.
CVP monitoring is a relatively simple procedure used
as a slandard guide for assessing the ability o f the right
side o r the heart to accept a fluid load. Properly inter
preted, the response of the CVP to fluid administration
helps evaluate volume replacement. Several points to re
member are:
1 . The precise measure of cardiac function is the rela

tionship between ventricular end diastolic volume
and stroke volume. Right atrial pressure (CVP) and
cardiac output (as reflected by evidence of perfu
sion or blood pressure, or even by direct measure
ment) are indirect and, at best, insensitive estimates
of this relationship. Remembering these facts is im
portant to avoid overdependency on CVP monitor-
rectly related to heart rate. In tJ1e significant number or pa
mg.
tients with myocardial conduction Jefects who have such
devices in place, CVP monitoring is invaluable to guide J:luid 2. The initial CVP level and actual blood volume are
therapy. not necessarily related. The initial CVP is some
Limes high, even with a significant volume deficit,
especially i n patients ,.vith chronic obstructive pul
monary disease, generalized vasoconstriction, and
rapid fluid replacement. The initial venous pressure
Reassessing Patient Response and also may be high because of the application of
Avoiding Complications PASG or the inappropriate use o f exogenous vasa
pressors.
Inadequate volume replacement is the most common com 3. A minimal rise in the initially low CVP with fluid ther
plication of hemor rhagic shock. Immediate, appropriate, apy suggests the need for further volw11e expansion
and aggressive therapy that restores organ perfusion mini (minimal or no response to fluid resuscitation category).
mizes these problematic events.
4 . A declining CVP suggests ongoing fluid loss and the
need for additional fluid or blood replacement (tran
CONTINUED HEMORRHAGE sient response to lluid resuscitation category).
Obscure hemorrhage is the most common cause of poor re 5. An abrupt or persistent elevation in CVP suggests that
sponse to fiuid therapy. Patients with this condition are gen volume replacement is adequate or too rapid or that
erally included in the transient response category as defined cardiac function is compromised.
previously. Immediate surgical intervention may be neces 6. Pronounced elevations of CVP may be caused by hy
sary. pervolemia as a result of overtransfusion, caTdiac dys
function, cardiac tamponade, or increased
intrathoracic pressure from a tension pneumothorax.
FLUID OVERLOAD AND CVP MONITORING Catheter malposition may produce erroneously high
After a patient's initial assessment and treatment have been CVP measmements. .
completed, the risk of fluid overload is minimized by care
ful monitoring. Remember, the goal of Lherapy is restora Aseptic techniques must be used when central venous
tion of organ perfusion and adequate tissue o:xygenation, lines are placed. Multiple sites provide access to the cen
confirmed by appropriate urinary output, Cl'\S function, tral circulation, and the decision regarding which route to
skin color, and return of pulse and blood pressure toward use is determined by the skill and exper.ie.nce of the doc
normal. tor. The ideal position for the tip of the catheter is in the
Monitoring the response to resuscitation is best ac superior vena cava, just proximal Lo the right atrium.
complished for some patients in an environment in which rl' Techniques for catheter placement are discussed in de-
CHAPTER SUMMARY 69
tail in Skill Station IV: Shock Assessment and Manage RECOGNITION OF OTHER PROBLEMS
ment.
The placement of central venous l i nes carries the risk of When a patient faib to rc:.po nd to therapy, consider cardiac
potentially l ife- th reaten i ng com piications. Infections, vas tam pon ade, tension pneum o tho rax ventilatory problems,
,
u n recognized fluid loss, acute gastric distention, myocardial

cular injury, nerve i nj u ry, embolization, thrombosis, and
pneumothorax may resu I t . CV P m on itor in g ren ec ts righ l infarction, diabetic acidosis, hypoadrenalism, and nc u ro
heart fun ct ion . It may not be representative of left h ear t
genic shock. Constant reevalua tion especial ly when patients'
,
function in patient s with pr i mary myocardial dysfunct ion conditions deviate from expected patterns, is the key to rec
or abnormal pulmonar}' circu lation. ogni7ing such problem s as early a possible.
CHAPTER SUMMARY ------ -----
0 Shock
fusion and
of the circulatory system that results i n inade q uate organ per
is an ab norma lity
tissue oxygenation. Shock management, based on sound physiologic pnncl
ples, 1s usually successful
Hypovolemia is the cause of shock 1n most trauma pat1ents Pat1ents in shock are clas
sified as class I, class II, class Ill, or class IV, based on clinical s1gns and estimated blood
loss. Treatment of these pat1ents reqwes immed1ate hemorrhage control and flu1d or
blood replacement. In pat 1ents 111 whom these measures fail, operative control of con
tinuing hemorrhage may be necessary.
The diagnosis and treatment of shock must occ u r al most stm ulta neously. For most
trauma pa tie nts, treatment IS Instituted as 1f the pat1ent has hypovolemic shock, unless
there is clear evidence that the shock state has a d1fferent cause. The basiC manage
ment pnnc1ple is to stop the bleeding and replace the volume loss.
lnit1al assessment of a patient 1n shock reqwes careful phys1cal examination, looktng for
signs of tension pneumothorax. card1ac tamponade, and other causes of the shock state
The management of hemorrhag ic shock i nc lu des fluid resuscitation with crystalloids and
blood. Early identification and control of the source of hemorrhage is essential.
The classes of hemorrhage serve as an early gu1de to appropriate resuscitation. Careful

momtonng of phys1ologic response and the ability to control bleeding will dictate on
gomg resuscitatiOn efforts
11. Asensio )A, Berne J 11, Oemclriads D, et aL One hundred five

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447. -
Trauma 2000;48(3 ):376 379.
..
Performance at this skill station will allow the participant to practice the as
Interactive Skill
sessment of a patient in shock. determine the cause of the shock state, insti
Procedures
tute the initia l management of shock. and evaluate the patient's response to
Note: Accompanying some of treatment. Specifically the student will be able to:
,
the skills procedures for th1s

station is a senes of scenarios,
which are provided at the OBJECTIVES
conclus1on of the procedures for
you to rev1ew and prepare for this Recognize the shock state.
station. Tables pertaining to the
inilial assessment and Evaluate a patient to determine the extent of organ perfusion, in
management of the patient in cluding performing a physical examination and the relevant adjuncts
shock also are prov1ded for your to the primary survey.
rev1ew after the scenanos. Note:
Standard precautions are
Identify the causes of the shock state.
req u i red when caring for
Initiate the resuscitation of a patient in shock by identifying and con
trauma patients.
trolling hemorrhage and promptly initiating volume replacement.
THE FOLLOWING Identify the surface markings and demonstrate the techniques of vas
PROCEDURES ARE INCLUDED cular access for the following:
IN THIS SKILL STATION: Peripheral venous system
Femoral vein
Skill IV-A: Peripheral Venous
Internal jugular vein
Access
Subclavian vein
Skill IV-8: Femoral lntraosseous infusion i n children
Venipuncture: Seldinger
Technique Use adjuncts in the assessment and management of the shock state,
including:
Skiii iV-C: Subclavian
X-ray examination (chest and pelvic film)
Venipuncture: Infraclavicular
Diagnostic peritoneal lavage (DPL)
Approach
Abdominal ultrasound
Skiii iVD: Internal Jugular Computed tomography (CT)
Venipuncture: Middle or BroselowrM Pediatric Emergency Tape
Central Route
Identify patients who require definitive hemorrhage control or trans
Skiii iV-E: lntraosseous fer to the intensive care unit, where extended monitoring capabilities
Puncture/Infusion: Proximal are available.
Tibial Route
Identify which additional therapeutic measures are necessary based
Skill IVF: Broselow
on the patient's response to treatment and the clinical significance of
Pediatric Emergency Tape
the responses of patients as classified by:
Rapid response
Transient response
Nonresponse
73
74 SKILL STATION IV Shock Assessment and Management
Skill IV-A: Peripheral Venous Access

..
STEP 1 . Select an appropriate site on an extremity STEP 6. Remove the needle and tourniquet.
(antecubital, forearm, or saphenous vein).
STEP 7. If appropriate, obtain blood samples for
STEP 2. Apply an elastic tourniquet above the proposed laboratory tests.
puncture site.
STEP 8. Connect the catheter to the intravenous infusion
STEP 3. Clean the site with antiseptic solution. tubing and begin the infusion of warmed
crystalloid solution.
STEP 4. Puncture the vein with a large-caliber, plastic,
over-the-needle catheter. Observe for blood STEP 9. Observe for possible infiltration of the fluids into
return. the tissues.
STEP 5 . Thread the catheter into the vein over the needle. STEP 10. Secure the catheter and tubing to the skin of the
extrem.ity.
Skiii iV-8: Femoral Venipuncture: Seldinger Technique

(See Figure /V-1)
Note: Sterile technique should be used when performing STEP 7. When a free tlow of blood appears in the syringe,
this procedure. remove the syringe and occlude the needle with a
finger to prevent air embolism.
STEP 1 . Place the patient in the supine position.
STEP 8. Insert the guidewirc and remove the needle. Usc
STEP 2. Cleanse the skin around the venipuncture site an introducer if required.
well and drape the area.
STEP 9. Insert the catheter over the guidewire.
STEP 3. Locate the femoral vein by palpating the femoral
STEP 10. Remove the guidewire and connect the catheter
artery. The vein lies directly medial to the
to the intravenous tubing.
femoral artery (nerve, artery, vein, empty space).
A finger should remain on the artery to facilitate STEP 1 1 . Affix the catheter in place (with a suture), apply
anatomical location and avoid insertion of the antibiotic ointment, and dress the area.
catheter into the artery. Ultrasound can be used
STEP 1 2. Tape the intravenous tubing in place.
as an adjunct for placement of central venous
lines. STEP 1 3. Obtain chest and abdominal x-ray films to
confirm the position and placement of the
STEP 4. If Lhe patient is awake, usc a local anesthetic at
intravenous catheter.
the venipuncture site.
STEP 14. The catheter should be changed as soon as is
STEP S. Introduce a large-caliber needle attached to a 12-
practical.
mL syringe with 0.5 to l mL of saline. The
needle, directed toward the patient's head, should
enter the skin directly over the femoral vein.
Hold the needle ami syringe parallel to the
MAJOR COMPLICATIONS OF
frontal plane.
FEMORAL VENOUS ACCESS
Deep-vein thrombosb
STEP 6. Directing the needle cephalad and posteriorly,
Arterial or neurologic injury
slowly advance the needle while gently
Infection
withdrawing the plunger of the syringe.
Arteriovenous fistula
SKILL STATION IV Shock Assessment and Management 75
Step 5 Step 8
NeNe ------
Femoral artery --=
Femoral vein
creater Guidewire
saphenous and
vein introducer
Step 9
Guidewire -"'"'
Figure IV-1 Femoral Venipuncture: Seldinger Technique.

(Illustrations correlate with selected steps in Skill IV-B.)

-- . - -- .
. -. - . - -- -- .
-- -
'. .- -
-. .
-
- .
Skiii iV-C: Subclavian Venipuncture: Infraclavicular Approach

Note: Sterile technique should be used when perfonning hi&
t clavicle (toward the finger placed in the
procedure. suprasternal notch).
STEP 8. Slowly advance the needle while gently

STEP 1 . Place the patient in the supine position, with I he
head at least 15 degrees down to distend Lhe neck
veins and prevent air embolism. Only if a cervical STEP 9. When a free flow of blood appears in the syringe,
spine injury has been excluded can the patient's rotate the bevel of the needle caudally, remove
head be turned away from the venipuncture site. the syringe, and occlude the needle with a finger
to prevent air embolism.
STEP 2. Cleanse the skin around the venipuncture site
well and drape the area. STEP 10. insert the guidewire while monitoring the

electrocardiogram for rhythm abnormalities.
STEP 3. If the pat.ienl is awake, use a local anesthetic at
the venipuncture site. STEP 1 1 . Remove the needle while holding the guidewire
in place.
STEP 4. Lntroduce a large-caliber needle, attached to a 12-
mL sydnge with 0.5 to l mL of saline, 1 em STEP 1 2. Insert the catheter over the guidewire Lo a
below the junction of the middle and medial predetermined depth (the tip of Lhe catheter
thirds of the clavicle. Ultrasound can be used as should be above the right atrium for fluid
an adjunct for the placement of central venous administration).
lines
STEP 1 3. Connect the catheter to the intravenous tubing.
STEP S. After Lhe skin has been punctured, with the bevel
STEP 14. Affix the catheter securely to the skin (with a
of the needle upward, expel the skin plug that
suture), apply antibiotic ointmen t, and dress the
can occlude the needle.
area.
STEP 6. Hold the needle and syringe parallel to the
STEP 1 5. Tape the intravenous tubing in place.
frontal plane.
STEP 16. Obtain a chest x-ray film to confirm the
STEP 7. Direct the needle medially, slightly cephalad, and
position of the intravenous line and identify a
posteriorly behind the clavicle toward the
possible pneumothorax.
posterior, superior angle to the sternal end of the
Skill IV-D: Internal J:gular Venipuncture: Middle or Central Route

Note: Internal jugular catheterization is freq uently difficult center of the triangle formed by the two lower
in injured patients because of the immobilization necessary heads of the sternomastoid and the clavicle.
to protect the patient's cervical spinal cord. Sterile technique Ultrasound can be used as an adjunct for the
should be used when performing this procedure. placement of central venous lines.
STEP 5. After the skin bas been punctured, with the bevel
STEP 1 . Place the patient in Lhe supine position, with the
of the needle upward, expel the skin plug that
head at least 15 degrees down to distend the neck
can occlude tbe needle.
veins <md prevent an air embolism. Only if the
cervical spine has been cleared radiographically STEP 6. Direct the needle caudally, parallel to the sagittal
can the patient's head be turned away from the plane, at an angle 30 degrees posterior to the
venipuncture site. frontal plane.
STEP 7. Slowly advance the needle while gently
STEP 2. Cleanse the skin around the venipuncture site
1.vell and drape the area.
STEP 8. When a free Aow of blood appears in the syringe,
STEP 3. If Lhe p atien t is awake, use a local anesthetic at remove the syringe and occlude t.he needle with a
the venipuncture site. finger to prevent air embolism. If the vein is not
STEP 4. Introduce a large-caliber needle, attached to a 12- entered, withdraw the needle and redirect it 5 to
ml syringe with 0.5 to I mL of saline, into the I 0 degrees laterally.
STEP 9. Insert the guidewire while monitoring the ECG COMPLICATIONS OF CENTRAL
for rhythm abnormalities.
VENOUS PUNCTURE
STEP 10. Remove the needle while securing the guidewire Pneumothorax or hemothorax
.
and advance the catheter over the wire. e:onnect
Venous thrombosis
the catheter to the intravenous t ubing
Arterial or neurologic injury
STEP 1 1. AfflX the catheter in place to the skin (with suture}, Arteriovenous fistula
apply antibiotic ointment, and dress the area. Chylothorax
Infection
STEP 1 2. Tape the intravenous tubing in place. Air embolism

STEP 13. Obtai n a chest film to confum the position of

the intravenous line a11d identify a possible
pneumothorax.
(See Figure /V-2)

. . Tibial Route
Skiii iV- E: lntraosseous Puncture/Infusion: Proximal .. ... . .
Note: Sterile technique should be used when performing this seep:. from the upper end of the chicken or turkey bone
procedure. when the solution is injected (see Step 8).
The procedure described here is appropriate for chil
STEP 1 . Place the patient in the supine position. Select an
dren 6 years of age or younger for whom venous access is
uninjured lower extremity, place sufficient padding
impossible because of circulatory collapse or for whom per
under the knee to effect an approximate 30-degree
cutaneous peripheral venous cannulation has failed on two
flexion of the knee, and allow the patient's heel to
allempts. lntraosseous infusions should be limited to emer
rest comfortably on the gurney (stretcher}.
gency resuscitation of the child and discontinued as soon as
other venous access has been obtained. (Techniques for in STEP 2. Identify the puncture site-the anteromcdial
traoscous infusion in adults are not discussed here. See ref surface of the proxi m al tibia, approximately one
erence:. in the bi bliogra phy for Chapter 3: Shock for further fingerbrcadth ( I to 3 em) below the tubercle.
information.)
STEP 3. Cleanse the skin around the puncture site well
Methylene blue dye can be mixed with the saline or
and drape the area.
water for demons! ration purposes on chicken or turkey
bones only. When the needle is properly placed within the STEP 4. Lf the patient is awake, use a local anesthetic at
medu l lary canal, the methylene blue dye/saJjne solution th e puncture site.
Patella 1 finger
width
) J
Figure IV-2 lntraosseous Puncture/Infusion: Proximal Tibial Route.
STEP 5. Initially at a 90-degree angle, introduce a short STEP 9. Connect the needle to the large-caliber
(threaded or smooth), large-caliber, bone intravenous tubing and begin fluid infusion.
marrow aspiration needle (or a short, 18-gauge Carefully screw the needle further into the
spinal needle with stylet) into the skin and medullary cavity until the needle hub rests on
periosteum with the needle bevel directed toward the patient's skin and free flow continues. [fa
the foot and away from the epiphyseal plate. smooth needle is used, it should be stabilized at a
45- to 60-degree angle to the anteromedial
STEP 6. After gaining purchase in the bone, direct the
surface of the child's leg.
needle 45 to 60 degrees away from the epiphyseal
plate. Using a gentle twisting or boring motion, STEP 10. Apply antibiotic ointment and a 3-x-3 sterile
advance the needle through the bone cortex and dressing. Secure the needle and tubing in place.
tnto the bone marrow.
STEP 1 1 . Routinely reevaluate the placement of the
STEP 7. Remove the stylet and attach to the needle a 12- intraosseous needle, ensuring that it remains
mL syringe with approximately 6 mL of sterile through the bone cortex and in the medullary
0
saline. Gently draw on the plunger of the syringe. canal. Remember, intraosscous infusion should
Aspiration of bone marrow into the syringe be limited to emergency resuscitation of the
signifies entrance into the medullary cavity. child and discontinued as oon as other venous
access has been obtained.
STEP 8. Inject the saline into the needle to expel any clot
that can occlude the needle. [f the saline flushes
through the needle easily and there is no
COMPLICATIONS OF INTRAOSSEOUS
evidence of swelling, the needle IS likely in the
PUNCTURE
appropriate place. If bone marrow was not
aspirated as outlined in Step 7, but the needle Infection
Oushes easily when injecting the saline and there Through-and-through penetration of the bone
is no evidence of swelling, the needle is likely in Subcutaneous or subperiosteal infiltration
the appropriate place. In addition, proper Pressure necrosis or the skin
placement of the needle is indicated if the needle Physeal plate injury
remains upright \.vithout support and Hematoma
intravenous solution flows freely without
evidence of subcutaneous infiltration.
Skill IV-F: Broselow Pediatric Emergency Tape

A specific skill is not outlined for the BrosclowT"' Pediatric tape provides drugs and their recommended doses for the
Emergency Tape. However, participants need to be aware of pediatric patient based on weight. The other side stipulates
its availability and its use when treating pediatric trawna equipment needs for pediatric patients based on size. Par
patients. By measuring the height of the child, the d1ild's es ticipation at this station includes an orientation to the tape
timated weight can be determined readily. One side of the and its use.
' . - - --
- --
- ---
. --.. .. .. .. - .
. ...... - - . ... . . .
SCENARIOS

SCENARIO IV- 1 SCENARIO IV-3 (continuation of

previous scenario}
A -42-yc<lr-old woman was jcded from a vehicle during an
automobile collis1on. En route to the ED, prehospital per After the initiJtion of vascul.tr access and infusion of 2000
sonnel report th,ll her heart rate is 1 1 0 beats/min, her blood mL of warmed crystalloid solution, the patient's heart rate
presure is 88/46 mm Hg, ;tnd her respiratory rate is 30 has decreased to 90 bea ls/m in; the blood pressure is l l0/80
breaths/min. The p.ttient is t:onfused, and her pcripher,ll mm l lg and the respiratory rate is 22 breaU1s/min. The pa
capillary rcl'i ll is reduced. (ee Table IV- I . ) Her airway is tient is now .1ble to speak, her breathing is less labored, and
patent. !:lhe il> in respiratory distress with neck vein disten her peripheral perfus ion hal> improved. (See Table IV-2.)
tion, <lbsent breath ounds on the right and tracheal devia
tion to t he left .
SCENARIO IV-4 (continuation
of previous scenario)
SCENARIO IV-2 (continuation
The patient repond initially to the rapid infusion of 1 500
of previous scenario)
mL of warmed crystalloid solution by a transient increase in
After needle dewmpression and chest-tube insertion, the blond pressu re to I I 0/80 mm Hg, a decrease in the heart rate
patient's heart r<Jtc is 120 beats/min, the blood pressure is to 96 beats/min and i mprovements in level of consciousness
,
80/46 mm Hg, and the respiratory rate is 30 breaths/min. and peripheral perfusion. Fluid infusion is slowed to main
Her k111 1s pale, cool, and moi st to touch. She moans when tenance levels. Five minutes later, the assistant reports a de
stimulated. ()ee Table JV-2.) terioration in the blood pressure to 88/60 mm Hg, an
TABLE IV-1 Initial Assessment and Shock Management

ASSESSMENT
CONDITION (PHYSICAL EXAMINATION) MANAGEMENT
--
Tension pneumothorax Tracheal deviation Needle decompressiOn

Distended neck vein Tube thoracostomy
Tympany
Absenl breath sounds
Massive hemothorax Tracheal deviation Venous access

Flat neck veins Volume replacement
Percuss1on dullness Surg1cal consultation/thoracotomy
Absent brealh sounds Tube thoracos1omy
Cardiac tamponade Distended neck ve1ns Venous acces

Muffled heart tones Volume replacement
Ultrasound Peocard1otomy
Thoracotomy
Pencard1ocentesJs

lntraabdominal Distended abdomen Venous access

hemorrhage Utenne hft, if pregnant Volume replacement
DPUultrasonography SurgiCal consultation
Vag1nal examination Displace uterus from vena cava
Obvious external Identify source of D1rect pressure

bleeding obv1ous external bleedtng Splints
Closure of actively bleeding
scalp wounds
... " ....
. .... ..
.. ' ...... ... .... '-......
.. --- ._..,
.. .....
, ..
..
_.. ---
--
-
-
.............. ....... ' .. ' ......... I--""'" , .
. . " " '
... .... " "" ....
.... .....
. ...
. --.
. ...
.
,_ , . .____,_,,_
80 SKILL STATI ON IV Shock Assessment and Management
TABLE IV-2 Pelvic Fractures
IMAGE
CONDITION FINDINGS SIGNIFICANCE INTERVENTION

Pelvic fracture Pelvic x-ray
Pub1c ramus fracture Less blood loss than other types Volume replacement
Lateral compression mechanism Probable lransfuslon
Decreased pelvic volume
Open book Pelvic volume Increased Internal hip rotation
Major source of blood loss PASG
External f1xator
Vertical shear Major source of blood loss Angiography
Skeletal traction
Orthopedic consultation
Visceral organ CTscan

injury Jnlraabdominal hemorrhage Potential for conti nuing blood loss VoiJme replacement
Performed on1y in hemodynamically Poss1ble tr<;nsfusion
normal patients Surgical consultation
increase in the heart rate to 1 15 beats/min, and a return in pale, cool, and pulseless exlrem ilies. Endotracheal intuba
the delay of the peripheral capillary refill. (See Table TV-3.) tion and assisted ventilation are initiated. The rapid volume
Alternative Scenario: The rapid infusion of 2000 m L infusion of 2000 mL of warmed crystalloid solulion does
of warmed crystalloid solution produces only a modest in not inlprove her vital signs, and she does not demonstrate
crease in the patient's blood pressure Lo 90/60 m m Hg, and evidence of improved organ perfusion. (See Table IV-4.)
her heart rate remains at 1 10 beats/min. Her urinary out
put since the insertion of the urinary catheter has been only
SCENARIO IV-6
5 mL of very dark urine.
An 18-month-old boy is brought to th e ED by hi s mother,
who apparently experiences spousal abuse. The child has ev
SCENARIO IV-5
idence of multiple soft-tissue injuries about the chest, ab
A 42-year-old woman, ejected from her vehicle d u ri n g a domen, and extremities. His skin color is pale, he has a weak,
crash, arrives in the ED unconscious with a heart rate of l40 thready pulse rate of 160 beats/min, and he responds only to
beals/min, a blood pressu re of 60 m m Hg by pal pat ion an d , painful stimuli with a weak cry.
TABLE IV-3 Transient Responder
ADDlTIONAL
CAUSE PHYSICAL EXAM DIAGNOSTIC STEPS INTERVENTION
Underestimation of Abdom1nal distention DPL or ultrasonography Surgical consultation

:
blood loss or Pelvic fracture Volume infusion
continuing blood loss Extremity fracture B load transfus1on
Obvious external bleeding Apply appropriate splints

Nonhemorrhagic
Cardiac tamponade Distended neck veins Ec;hocardlogram Thoracotomy
Decreased heart sounds FAST
Normal breath sounds Pericardiocentesls
Rewrrentlpersistent Distended neck veins Clinical diagnosis Reevaluate chest

tension pneumothorax Tracheal shift Needle decompression
Absent breath sounds Tube thoracostomy
Hyperresonant chest percussion
TABLE IV-4 Nonresponder
..
ADDITIONAL
CAUSE PHYSICAL EXAM DIAGNOSTIC STEPS INTERVENTION
Massive blood loss

(Class Ill or IV)
lntraabdom1nal bleed1ng Abdominal distention DPL or ultrasonography lmmed1ate 1ntervenron
t
by surgeon
Volume restorauon
Operatrve resusotat1on
Nonhemorrhagic
Tensron pneumothorax Drstended neck veins Chmcal diagnos1s Reevaluate chest
Tracheal shift Needle decompression
Absent breath sounds Tube thoracotomy
Hyperresonant chest perCllssron
Card1ac tamponade Ditended neck veins Echocard iograrn Thoracotomy
Decreased heart sounds FAST
Normal breath sounds Pericardrocentesrs
Blunt cardrac injury Irregular heart rate lschem1c ECG changes Prepare for OR
Inadequate perfusion Echocardiogram 1nvas1ve momtoring
InotropiC support
Consrder operative intervention
lnvasrvEC> monitoring may be
requrred
..
Performance at this skill station will allow the participant to practice and
Interactive Skill
demonstrate on a live, anesthetized animal or a fresh, human cadaver the tech
Procedures
nique of peripheral venous cutdown. Specifically, the student will be able to:
Note: Standard precautions
are required when caring for

trauma patients.
OBJECTIVES
THE FOLLOWING PROCEDURE
Identify and describe the surface markings and structures to be noted
IS INCLUDED IN THIS SKILL
in performing a peripheral venous cutdown.
STATION:
Skill V-A: Venous Cutdown Describe the indications and contraindications for a peripheral venous
cutdown.
ANATOMIC CONSIDERATIONS
FOR VENOUS CUTDOWN
The primary site for a peripheral venous cutdown is the greater
saphenous vein at the ankle, which is located at a point approxi
mately 2 em anterior and superior to the medial malleolus. (See Fig
ure V-1.)
A secondary site is the antecubital medial basilic vein, located 2.5 em

lateral to the medial epicondyle of the humerus at the flexion crease
of the elbow.
'
83
84 SKILL STATION V Venous Cutdown
Skill V-A: Venous Cutdown

(See Figure V- 1)

STEP 1 . Prepare the skin or the ankle with antiseptic STEP 9. Introduce a plastic cannula through lhe
solution and drape the area. venotomy and secure i t i n place by tying the
upper ligature around the vein and cannula. The
STEP 2. Infi.Jlrate the skin over the vein with O.s<Yo
cannula should be inserted an adequate distance
lidocaine.
to prevent dislodging.
STEP 3. Make a full-thickness, transverse skin incision
STEP 10. Attach tl1e in travenous tubing to the cannula
through the anesthetized area to a length of 2.5
and close the incision witb interrupted sutures.
em.
STEP 1 1 . Apply a sterile dressing with a topical antibiotic
STEP 4. By blunt dissection, using a curved hemostat,
ointment.
identify the vein and dissect i t free from any
accompanying structures.
STEP 5. Elevate and dissect the vein for a distance of COMPLICATIONS OF PERIPHERAl VENOUS
appro:>rima.tely 2 ern to free it from its bed. CUTDOWN
STEP 6. Ligate the distal mobilized vein, leaving the Cellulitis
suture in place for traction. Hematoma
Phlebitis
STEP 7. Pass a tie arOlmd the vein in a cephalad direction.
Perforatjon of the posterior wall of the vein
STEP 8. Make a small, transverse venotomy and gently Venous thrombosis
dilate the venotomy with the tip of a closed Nerve transaction
hemostat. Arterial transaction
.,_ Saphenous vein

Saphenous
____
----- Saphenous nerve nerve
Incision ::;.;..;
Vein ;;
Figure V-1 Venous Cutdown

C H A PT E R
CHAPTER OUTLINE Upon completion of this topic the student will identify and
,
initiate treatment of common and life-threatening thoracic in

Objectives
Juries. Specincally the doctor will be able to:
,
Introduction
Primary Survey: Life-Threatening Injuries
Airway OBJECTIVES
Breathing
Circulation Identify and initiate treatment of the following in
Resuscitative Thoracotomy juries during the primary survey:
Airway obstruction
Secondary Survey: Potentially Life-Threatening
Chest Injuries Tension pneumothorax
Simple Pneumothorax Open pneumothorax
Hemothorax Flail chest and pulmonary contusion
Pulmonary Contusion
Massive hemothorax
Tracheobronchial Tree Injury
Blunt Cardiac Injury Cardiac tamponade
Traumatic Aortic Disruption
Traumatic Diaphragmatic Injury Identify and initiate treatment of the following
Blunt Esophageal Rupture potentially life-threatening injuries during the sec
ondary survey:
Other Manifestations of Chest Injuries
Simple pneumothorax
Subcutaneous Emphysema
Crushing Injury to the Chest (Traumatic Asphyxia) Hemothorax
Rib, Sternum, and Scapu lar Fractures Pulmonary contusion
Other Indications for Chest Tube Insertion Tracheobronchial tree injury
Chapter Summary Blunt cardiac injury
Traumatic aortic disruption
Bibliography
Traumatic diaphragmatic injury
Blunt esophageal rupture
Describe the significance and treatment of subcu

taneous emphysema, thoracic crush injuries and,
sternal, rib, and clavicular fractures:

86 CHAPTER 4 Thoracic Trauma
AIRWAY
Introduction
It is necessary to recognize and address major injuries af
IJ What life-threatening chest injuries ..

fc.:L Ling the a ir way during the primary survey. Airway pa
tency and air exchange should be assesseJ by listening for
should I recognize as causing major
.tir mnvement at the patient's nose, mouth, and lung fields;
pathophysiologic events?
inspecting the oropharynx for foreign-body obstruction;
Thoracic tnlUma is a significant L<lUM of mortality. Many and observing for intercostal and !>upraclavicular muscle rc
patients with thoracic trauma die after reaching the hos tr<ICtions.
pital, yet many of these deaths could be prevented with Laryngeal injury can accompany major thoracic
prompt diagnosis and treatment. Les than 10% of blunt trauma. Although the clinical presentation is occasionally
chest injuries and only 15% to 30% of penetrating chest subtle, acute airvvay obstruction from laryngeal trauma is a
injuries require thoracotomy. Most patients who sustain life- threatening injury. rJI Sec Chapter 2: Airway and Venti
thoracic tr<tuma can be treated by technical procedures lator }' Management .
within the capabili t ies of doctor who take this course. It is Injury to the upper che:.t can crcalt: a palpable defect in
i mp or ta nt Lo remember that i<l lrogen ic thoracic inj urics the region of the sternodavi.ular joint with posterior dis
Me cummon (eg, hemothorax or pneumothorax \-vilh cen lol.<ll it>n or the clavicular head, causing upper airway ob
tral line placement and esophage.d inju ry during en slruttion. Identification of thil> injury is made by
doscopy). observation of upper airway obstruction (stridor) or a
Hypoxi<l, hypercarbia, and acidosis often result from marked change i n the expected voice quality (if the patient
chest injurie. Tissue hypoxia results from inadequate de is ;tblc to talk). l\lanagement consists of a clo1.ed reduction
livery of oxygen to the tissues beLausc of hypovolemia of the inJury, which can he performed by extending the
(blood loss), pulmonary ventilation/perfusion mismatch shoulders or grasping the clavicle with a pointed clamp, such
(cg, contusion, hematoma, and :tlveolar collapse), and .1!-. a towel clip, and manually reducing the fracture. This in
1.h,tngcs in in Ira I hontcic pressu rc relat ionshi ps ( eg, ten sion jury, once reduced, usually is stable if the patient is in the
pneumothor<1X and open pneumothorax). H ype rca rbia supine pt>sition.
mot often results from inadequ,tl ventilation caused by rJI Other injuries affecting the ai rway are addressed in
chJngcs in intrathoracic pressun: rcl.ttionships and de Chapter 2: Airway and Ventilatory Management.
pres!>ed level of consciousness. Mel<tbolic acidosil> is caused
bv hypoperfusion of the tissues (shock).
BREATHING
Initial assessment and treatment of patients with tho
racic trauma comists of the primary survey, resuscitation of The patient's chest and neck should he completely exposed
vital functions, detailed secondary survey, and definitive to allow for assessment of breathing and the neck veins. Res
care. Because hypoxia is the most seriou feature of chest in pi ratory movement and quality of respirations are assessed
jury, the goaJ of early intervention is to prevent or correct by observing, palpating, and listening.
hypoxia. Injuries that are an im rmd i11 te threat to life are I mporta n t, yet often subtle, signs of chest injury or hy
1 rea ted a.s quickly and simply as is possible. Most I ife-threat poxia include an incn:ased respi ratory rate and change in the
ening thoracic injuries are treated by airway control or an breathing pattern, especially progressively more shallow res
appropriately placed chest tube or needle. The secondary pirations. Cya nosis is a late sign of hypo>.ia in trauma pa
survey is influenced by the history of thc mjury and a high trents. l lowcver, the absence of cyanosis does not necessarily
index of suspicion for specific inJuries. tmhcate adequate tissue oxygenation or an adequate airway.
The major thoracic injuries that affect breathing and that
must be recognized and addressed during the primary sur
vey include tension pneumothorax, open pneumothorax
(sucking chest wound), flail chest and pulmonary contu
Primary Survey: sion, and massive hemothorax.
Life-Threatening Injuries
-.
IJ What are the significant patho PITFALL

:-
.
..
.
- ..;
physiologic effects of chest injury that I After intubation, one of the common reasons for loss
should identify in the primary survey, of breath sounds i n the left thorax is a right main
and when and how do I correct them? stem intubation. During the reassessment, be sure to
check the position of the endotracheal tube before
The primary survey of patients with 1horaLic injuries begins assuming that the change in physical examination re
with the airway. Major problems should be corrected as they sults is due to a pneumothorax or hemothorax.
are identified.
PRIMARY S U RVEY: LIFE-THREATEN I N G INJURIES 87
Tension Pneumothorax large-caliber needle into the second intercostal space in

A tension pneumothorax dcvdop when a "one-way valw" the middavicular line of the ,1 ffected hemithorax ( f igure
air h:ak occurs from the lung or through the chest wall (Fig 4-2) . See Skill Station Vll: Chest Trauma Man age
ure 4-J ) . Air is forced into the thorac ic cavity without any ment, Skill VIl-A: Needle Thoracentesis. This mancuwr
means or escape, complercly collapsing the affected lung. converts the injury to a simple pneumothorax; however,
The mediastinum is displa ced 10 th( opposite side, decreas the possibility of subsequent ]Jncu.mothorax as a result
ing venous return and compresing the opposite lung. of the needle stick now exists. Repeated reassessment ol
!'he most common cause of tension pneumothorax is the patien t is neces sa ry. Definitive treatment usually re
mechanical ventilation with po1>itive-pressure ventilation in quires only the insertion o f a chest tube into the fifth In
patients with ''i!>ceral pleural injury. However, a tension tercostal space (usually the ni pple level), just anterior to
pneumothorax m:.r compl icate a simple pneumothorax fol the midaxillary line.
lowlllg penetrating o r h lun t chest trauma in which a
parenchymal lung injury fails to seal, or after a misguided
attempt at subclavian or internal jugular venous catheter in Open Pneumothorax (Sucking Chest Wound)
sertion. Occasionally, traumatic ddi.cts in the chesr wall also Large defects of the chest wall that remain open may result
may cause a tension pneumothorax if incorrectly covered in an open pneumothorax, or :-ucking chest wound (figure
with occlusive dressings or ir the defect itself constitutes a 4-3l. Equilibration between intrathoracic pressure and <ll
nap-valve mechani:..m . Tension pneumothorax also may mopheric pressure is immediate. If the opening in the chest
occur from marked!) displaced thoracic spine fracture). wall is approximately two-thirds the diameter of the trachea,
Tension pneumothorax is a clinical diagnosis reflecting tir passes preferentia lly through the chest wall defect with
.
air under pressure in the pleural space. Treatment should not each respiratorr effort, because air tends to follow the path
be delayed to wait for radiologic confirmation. Tension pneu of leas t resistance. Effective ventilation is thereby imp,1ircd,
mothorax is characterized by some or all of the following leading to hypoxia and hypercarbiu.
:.igns and symptoms: chest pain, air hunger, respiratory dis Initial management or an open pneumothorax is ac
t re1.s, tachycardia, hypotension, tracheal deviation, unilat cnrnplished by promptly closing the defect with a sterile oc
er;ll absence of breath ound, neck vein distention, and clusive dressing. The dressing should be large enough 10
cyanois (late manifest.1 tion). Because of the similarity in owrlap the wound's edges and then taped securely on three
their signs. tension pneumothorax may be confused initially sides in order to provide a llutter-type valve effect ( ligure
with cardiac tamponade. Differentiation can be made by .t 4-4). As the patient breathes in, the dressing occlude the
hyperresonant note on percussion and absent breath :.ounds wound, preventing air from entering. During exhal,uion,
over the affected hemithorax. the open end or the dressi ng ;lllows air to escape from the
Tension pneumothorax requires immediate decom pleural space. A chest tube remote from the wound :.hould
pression and is managtd inittally by rapidly inserting a be placed as soon as posiblc. Securely taping all edges of
Collapsed
Pneumothorax
Figure 4-1 Tension Pneumothorax. A

tension pneumothorax develops when a
"one-way valve" air leak occurs from the
cava
lung or through the chest wall. Air is forced
into the thoracic cavity, completely collaps
ing the affected lung.
sme of the defect is frequently required. .,. See Skill Sta

tion VLI: Chest Trauma Management, Skill Vll-B: Chest
Tube Insertion.
Flail Chest and Pulmonary Contusion

A flail chest occurs when a segment of the chest waU does
not have bony continuity with the rest or the thoracic cage
(Figure 4-5). This condition usually results from trauma
associated with multiple rib fractures-that is, two or
more ribs fractured in two or more places. The presence
of a flail chest segment results in severe disruption of nor
mal chest waU movement. If the injury to the underlying
lung is significant, serious hypoxia may result. The major
difficulty in flail chest stems from the injmy to the under
lying lung (pulmonary contusion). Although chest wall in
stability leads t o paradoxical motion of the chest wall
during inspiration and expiration, this defect alone does
nol cause hypoxia. Restricted chest wall movement asso
Figure 4-2 Needle Decompression. Tension
ciated with pain a11d underlying lung injury are important
pneumothorax is managed initially by rapidly inserting
causes of hypoxia.
a large-caliber needle into the second intercostal space
Flail chest may not be apparent initially because of
in the midclavicular line of the affected hemithorax.
splinting of the chest wall. The patient moves air poorly,
and movement of the thorax is asynunetrical and WlCO
ordinated. Palpation of abnormal respiratory motion and
crepitation of rib or cartilage fractures aid the diagnosis.
the dressing may cause air to accumulate in the thoracic A satisfactory chest x-ray film may suggest multiple rib
cavity, resulting in a tension pneumothorax unless a chest fractures, but may not show costochondral separation.
tube is in place. Any occlusive dressi11g (eg, plastic wrap or Arterial blood gas (ABG) analyses that suggest respira
petrolatum gauze) may be used as a temporary measme so tory failure with hypoxia also may aid in diagnosing a
that rapid assessment can continue. Definitive smgicaJ do- flail chest.
Collapsed lu
Pneumoth
Sucking
chest wound
ir
Figure 4-3 Open Pneumothorax.

Large defects of the chest wall that re
main open may result in an open pneu
mothorax, or sucking chest wound.
PRIMARY SU RVEY: LI FE-THREATENING INJURIES 89
achieved by using intravenous narcotics or various methods

of local anesthetic administration that avoid the potential
respiratory depression seen with systemic narcotics. The
choices for administration of local anesthetics include in
termittent intercostal nerve block(s) and intrapleural, ex
trapleural, or epidural anesthesia. VVhen used properly, local
anesthetic agents may provide excellent analgesia and avoid
the need for intubation. However, prevention of hypoxia is
of paramount importance for trauma patients, and a short
period of intubation and ventilation may be necessary unlil
diagnosis of the entire injury pattern is complete. A careful
assessment of the respiratory rate, arterial oxygen tension,
and the work of breathing will indicate appropriate timing
for intubation and ventilation.
Figure 4-4 Dressing for Treatment of Open Massive Hemothorax

Pneumothorax. Promptly close the defect with a ster
Accumulation of blood and fluid in a hemithorax may sig
ile occlusive dressing that is large enough to overlap
nificantly compromise respiratory efforts by compressing
the wound's edges. Tape it securely on three sides to
the Lung and preventing adequate ventilation. Such massive
provide a flutter-type valve effect.
lnitial therapy includes adequate ventilation, admin

istration of humidified oxygen, and fluid resuscitation. In
the absence of systemic hypotension, the administration Both tension pneumothorax and massive hemotho
rax are associated with decreased breath sounds on
of crystalloid intravenous solutions should be carefully
auscultation. Differentiation on physical examina
controlled to prevent overhydration.
tion is made by percussion; hyperresonance confirms
The definitive treatment is to ensure oxygenation as a pneumothorax, whereas dullness confirms a mas
completely as possible, administer fluids judiciously, and sive hemothorax.
provide analgesia to improve veutilation. This can be
Inspiration Expiration
Figure 4-5 Flail Chest. The presence of a flail chest segment results in severe disruption of normal chest wall
movement. If the injury to the underlying lung is significant, serious hypoxia may result.
90 CHAPTER 4 Tho rac ic Tra u m a
acute acwmulations of blood more dramatical ly present as patient's blood volume in the chest cavil}' (hgure 4-6). 11 is
hyp otensi on and shock, and arc discussed rurthcr below. most commonlr caued by J penet rat in g wound that dis
rupts the system ic or hilru vessels. Massive hemothorax nlso
CIRCULATION ..
may result from blunt traw11a .
Blood l oss i com plicated by hypoxia. The neck veins

The patient\ pulse hould be ascs:-.ed for qu alit y, rate, and may be flat as a result of severe hypovolemia, or they may be
regul<rity. In palie nts with hypovolemia, the radial and dor distended if there is an associated tension pncumothomx.
salis ped is pulses may he ab1>ent because of volume depletion. However, ra rel y will the mechanical effects of massive in
Blood pressure and pulse pressure is measured and the pc trathoracic blooJ shift the media:;tinum enough to C<IUse
ripheral drculation a:>essed by observing a nd palpating the d istend ed neck veins. A mass iv e hemothorax is discovered
skin for color and temperature. Neck veins shoultl be assessnl when shock is associated with the absence of breath sounds
for di::.tention, remembering that neck veins rn.ty not be dis or dullnc!.s to percussion on one side of the ches t .
tended in patients wtth hypovolemia and cardia: tamponade, Massive hemothora..x is init ially managed by the simul
ten::.ion pneumo thorax, or traum llic diaphragmatic injury.
,
taneou restoration of blood volume and decompression of
A cardi ac mon1tor and puh.c oximeter hould be at the chest cavity. Large-caliber intravenous lines and a rapid
tached to the p.tlicnl. Patients who sutain thoracic crystalloid infusion arc begun, and type-l>pec ific blood is ad
trauma-especially in the are.1 of the sternum or from ,1 ministered as soon as possible. Blood from the chest tube
rapid deceleration injury-are susceptible to myocardial in should be collected in a device suitable for autotr an sfusi on.
ju ry which may lead to dysrhythmias. Hypoxia and acido
,
A single chest tube (#38 French) is inserted, us ually at the
sis enhance this possibility. Oysrhythmia:. should be ni pple level, ju s t anterior to the rnidaxillary line, and rapid
managed accordi ng to standard protocols. Pulsdess elect ril: restor;ltion of volume contin ues as decomp res::.ion of the
activity (Pl.:.:\) is manifested b) an ECG that hows a rhythm chest cavity is completed. When massive hemothorax is sus
while the patient has no identifiable pulse. PEi\ may be pre:. pected prepare for autotransfusion. If 1500 mL is immedi
,
ent in cardiac tam pon u dc tension pneu moth orax profou nd

, ,
ately cvacua ted, il i s highly l ikely that an early thoracotomy
hypovokmia, and c.m.liac rupture. will be required.
The major thoratic injuries that affect circulation and Some patients who have an initial vol ume output of less
should be recognized and addressed during the pri mary sur than 1500 mL but cont i nue to bleed may require a thoraco
vey include massive hemoth orax a nd cardiac tampon ade . tomy. This decision is based not on the rate of continuing
blood loss (200 mL/hr for 2 to -l hr), but on the patient's
Massive Hemothorax phy1ologic status. A persistent need for blood transfusions
Massive hemothorax results from the rapid accum ul ati on is a n in<.lication for thoraco tomy. During patient resuscita
of mo re 1 han 1500 111 L of blood or one-third or more of the tion, the volume of blood initially drained limn the chest
Partially collapsed lung
Parietal pleura
Visceral pleura
Blood in
pleural space -r"""-=---=,:;
Figure 4-6 Massive Hemoth

orax. This condition results from
the rapid accumulation of more
than 1500 ml of blood or one-third
or more of the patient's blood vol
ume in the chest cavity.
PRIMARY SURVEY: LIFE-THREATENING INJURIES 91
Lube and the rate of continuing blood loss must be factored sess in the noisy emergency department, and distended neck
into the amount of intravenous Ouid required for replace veins may be absent due to hypovolemia. Additionally, ten
ment. The color of the blood ( indicating an arterial or ve sion pneumothorax, particularly on the left side, may mimic
nous source) is a poor indicator of the nece!l,.ity for cardiac tamponade. Kussmaul's sign (a rise in venous pres
thoracotomy. sure with inspiralion when breathing spontaneously) is a
Penetrating anterior chest wounds medial to Lhe nip tme paradoxical venous pressure abnormality associnted
ple line and posterior wounds medial to the scapula should with tamponade. PEA is suggestive of cardiac tamponade,
alert the doctor to the possible need for thoracotomy, be but has other causes, as listed above. Insertion of a central
cause of the likelihood of damage to the great vessels, hilar venous line witl1 measurement of central venous pressure
structures, and the heart, with the associated potential for (CVP) may aid diagnosis, but CVP can be elevated for a va
cardiac tamponade. Thoracotomy is not indicated unless a riety of reasons.
surgeon, qualified by training and experience, is present. Diagnostic methods include echocardiogram, focused
assessment sonogram in trauma (FAST), or pericardia! win
dow. Prompt transthoracic ultrasound (echocardiogram)
Cardiac Tamponade may be a valuable noninvasive method of assessing the peri

Cardiac tampom1de most commonly results from penetrat cardium, bul reports suggest it has a significant false-nega
i ng injuries. However, blunt injury also may cause the peri tive rate of about 5% to I Oo/o. fn hemodynamically
cardium to fill with blood from the hearl, greal vessels., or abnormal patients with blunt trauma, provided it does not
pericardia! vessels (Figure 4-7). The human pericardia] sac delay patient resuscitalion, an examination of lhe pericardial
is a fixed fibrous structure; only a relatively small amoun 1 sac for the presence of Ouid may be obtained as part of a fo
or blood is required to restrict cardiac activity and interfere cused abdominal ultrasound examination performed by
with cardiac filling. Cardiac tamponade may develop slowly, properly trained and credentialed SllJ'gical team in the emer
allowing for a more lcisUJ"cly evaluation, or may occur rap gency department. h\ST is a rapid and accurate method of
idly, requiring rapiJ diagnosis and treatment. The diagno imaging the heart and pericardium. It may be 90% accurate
sis of cardiac tamponade can be difficult. for Lhe presence of pericardia] tluid for tl1e experienced op
The classic diagnostic Beck's triad consists of venous erator. See Chapter 5: Abdominal and Pelvic Trauma.
pressure elevation, decline in arterial pressure, and muft1ed Prompt diagnosis and evacuation of pericardia! blood
heart tones. However, muffled heart tones are diff1cult to asis indicated for patients who do not respond to the usual
Normal Pericardia! tamponade
Pericardia! sac
Figure 4-7 Cardiac Tamponade. Cardiac tamponade results from penetrating or blunt injuries that cause the
pericardium to fill with blood from the heart, great vessels, or pericardia! vessels.
92 CHAPTER 4 Thoracic Tra uma
measures of resuscitation for hemorrhagic shock and have evacuation of pericardial blood causu1g tamponade
the potential for ca1diac tamponade. ff a qualified surgeon
direct control of exsanguiJ1ating intrathoracic hem
is present, surgery should be performed to relieve the tam
orrhage
ponade. Tlris is best performed in the operating room if th
patient's condition allows. Ifsurgical intervention is not avail open cardiac massage
able, pericardiocentesis can be diagnostic as well as thera
cross-clamping of the descending aorta to slow
peutic, but is not definitive treatment for cardiac tamponade.
blood loss below the diaphragm and increase perfu
_. For further information regarding FAST, see Chapter 5:
sion to the brain and heart
Abdominal and Pelvic Trauma.
Although cardiac tamponade may be strongly sus
Despite the value of these maneuvers, multiple reports con
pected, the initial administralion of intravenous n uid raises
firm that thoracotomy in the ED for patients with blunt
the venous pressme and improves cardiac output transiently
trauma and cardiac arrest is rarely effective.
while preparations are made for surgery. H subxyphoid peri
Once these and other immediately life-threatening in
cardiocentesis is used as a temporizing maneuver the use of
juries have been treated, attention may be directed to the
a plastic-sheathed needle or the Seldinger technique for in

secondary swvey.
sertion of a flexible catheter is ideal, but the urgent priority
is to aspirate blood from the pericardia! sac. If ultrasound
imagil1g is available, it can facilitate accurate insertion of the
needle into the pericardia! space. Because of the self-sealing
qualities of the injured myocardium, aspiration of pericar
Secondary Survey: Potentially
dia! blood alone may relieve symptoms temporarily. How life-Threatening Chest Injuries
ever, all patients with acute tamponade and positive
pericardiocentesis will require surgery for examination of
What adjunctive tests are used during
the heart and repair of the injury. Pericardiocentesis may
the secondary survey to allow complete
not be diagnostic or therapeutic when the blood in the peri
evaluation for potentially life
cardia! sac has clotted. Preparations for transfer of these pa
threatening thoracic injuries?
tients to an appropriate facility for definitive care are
necessary. Pericardiotomy via thoracotomy is indicated only The secondary survey involves further, in-depth, physical
when a qualified surgeon is available. examination, ru1 upright chest x-ray examination if the pa
tient's condition pernrits, ABG measurements, and pulse
oximetry and ECG monitoring. In addition to lw1g expan
sion and the presence of fluid, the chest film should be ex
amined for widening of the mediastinum, a shift of the
Resuscitative Thoracotomy midline, and loss of anatomic detail. Multiple rib fractures
and fractures of the first or second rib(s) suggest that a se
Closed heart massage for cardiac arrest or PEA is ineffec vere force has been delivered to the chest and underlying tis
tive u1 patients with hypovolemia. Patients with penetrat sues. _. See Skill Station VI: X-Ray Identification of
ing thoracic injuries who arrive pulseless, but with Thoracic Injuries.
myocardial electrical activity, may be candidates for im The following eight lethal injuries are described below:
mediate resuscitative thoracotomy. A qualified surgeon
Simple pneumothorax
must be present at the time ofthe patient's arrival to deter
mine the need and potential for success of a resuscitative Hemothorax
thoracotomy in the ED. Restoration of intravascular vol
Pulmonary contusion
ume is continued, and endotracheal intubation and me
chanical ventilation are essen tiaJ. Tracheobronchial tree injury
A patient who has sustained a penetrating wound and
Blunt cardiac injw-y
required CPR in the prehospit.al setting should be evaluated
for any signs of life. lf there are none, and no cardiac elec Traumatic aortic disruption
trical activity is present, no further resuscitative effo rt
Traumatic diaphragmatic injury
should be made. Patients who sustain blWlt injuries and ar
rive pulseless but with myocardial electrical activity (PEA) Blunt esophageal rupture
are not candidates for emergency department resuscitative
thoracotomy. Signs of life include reactive pupils, sponta Unlike immediately life-ti1Ieatenil1g conditions that are
neous movement, or organized ECG activity. recognized during the primary survey, the injuries listed
The therapeutic maneuvers that can be effectively ac here usually are not obvious on physicctl examination. Di
complished with a resuscitative thoracotomy are: agnosis requires a high index of suspicion and appropriate
SECONDARY SU RVEY: POTENTIALLY LIFE-THREATENING CHEST INJURIES 93
usc of adjunctive studies. These injuries are more often the midaxillary line. Observation and aspiration ofan asymp
missed than diagnosed during the initial posttraumatic pe tomatic pneumothorax may be appropriate, but the choice
riod; however, if overlooked, lives can be lost. should be made by a qualified doctor; otherwise, placement of

a chest tube should be performed. Once a chest tube is in
serted and connected to an under.'latcr seal apparatus with
SIMPLE PNEUMOTHORAX
or without suction, a chest x-ray examination is necessary to
Pneumothorax results from air entering the potential space confirm rcexpansion of the lung. Neither general anesthesia
between the visceral and parietal pleura (Figure 4-8). Both nor poit ive pressure ventilation should be administered in
penetrating and nonpenetrating trauma can cause this in a patient who has sustained a traumatic pneumothorax or
jury. Thoracic spine fracture dislocations also can be asso who is at risk Cor unexpected intraoperative pneumothorax
ciated with a pneumothorax. Lung laceration with air until a chest tube has been inserted. A simple pneumotho
leakage is the most common cause of pneumothorax re rax can readily convert to a life-threatening tension pneu
suJLing from blunt trauma. mothorax, particularly if it is initia!Jy unrecognized and
The thorax is normally completely filled by the lung, positive-pressure ventilation is applied. The patient with a
being held to the chest wall by surface tension betl.veen the pncumOI'horax should also undergo chest decompression
pleural surfaces. Air in the pleural space disrupts the cohe before he or she is transported via air ambuJance.
sive forces between the visceral and parietal pleura, which
allows the lung to collapse. A ventilation/perfusion defect
HEMOTHORAX
occurs because the blood that perfuses the nonventilated
area is not oxygenated. The primary cause of hemothorax (<1 500 mL blood) is
When a pneumothorax is present, breath sounds are lung laceration or laceration of an Lntercostal vessel or in
decreased on the affected side, and percussion demonstrates ternal mammary artery due to either penetrating or blunt
hyperresonance. An upright, expiratory x-ray film of the trauma. Thoracic spine fracture dislocations also may be as
chest aids in the diagnosis. sociated with a hemothorax. Bleeding is usually self-imited
l
Any pneumothorax is best treated with a chest tube and doc nor require operative intervention.
placed in the fourth or fifth intercostal space, just anterior to
Muscle layers
A
-
r- ....
_
- \ 1
--t-
- .....
Collapsed
Pneumothorax
pleura pleura
Figure 4-8 Simple Pneumothorax. Pneumothorax results from air entering the potential space between the
visceral and parietal pleura.
PITFALL PITFALL
A simple pneumothorax in a trauma patient should A simple hemothorax, not fully evacuated, may re
not be ignored or overlooked. It may progress to a sult in a retained, clotted hemothorax With lung en
tension pneumothorax. trapment or, if infected, develop into an empyema.
An acute hemothorax large enough to appear on a chest If lracheobronch ia 1 injury is suspected, immediate sur
x-ray film is best rreated with a large-caliber (36 French) gical consultation is warranted. Such patients typically pres
chest lube. The chest tube evacuates blood, reduces the risk ent with hemoptysis, subcutaneous emphysema, or tension
of a clotted hemothorax, and, importantly, provides a pneumothorax wilh a mediastinal shift. A pneumothorax
method fo r continuous monitoring of blood loss. Evacua associated with a persistent lcuge air leak after tube U1ora
tion of bluod and fluid also facilitates a more complete as costomy suggests a tracheobronchial injury. Bronchoscopy
sessment of potential diaphragmatic injury. Although many confirms the diagnosis of Lhe injury. Placement of more
factors are involved in the decision to operate on a patient than one chest tube often is necessary to overcome a very
with a hemothorax, the patient's physiologic slat us and the large leak and expand the lung. Tem pora ry intubation of the
volume of blood drainage from the chest tube are major fac opposite mainstcm bronchus may be required to provide
tors. As a guideline, if 1500 mL of blood is obtained imme adequate oxygenation.
diately through I he chest tube, if drainage of more than 200 Intubation of patients with tracheobronchial injuries is
m L/h r for 2 to 4 h r occurs, or if blood tJansfusion is re freq uenlly difficult because of anatomic distortion from
quired, operative exploration should be considered. paratracheal hematoma, associated oropharyngeal injuries,
and/or the tracheobronchial injury itself. For such patients,
immediate operative i11lcrvention is indicated. Tn more sta
PULMONARY CONTUSION
ble patients, operative treatment of tracheobronchial in
Pulmonary contusion may occur without rib fractures or juries may be delayed until the acute inflammation and
flail chest, particularly in young patients without completely edema resolve.
ossified ribs. However, pulmonary contusion is the most
common potentially lethal chest injury. The resultant respi
BLUNT CARDIAC INJ URY
ratory failure can be subtle, and it develops over time, rathcr
than occurring instantaneously. The plan for definitive man Blunt cardiac injury can result in myocardial muscle contu
agement may change \viU1 Lime, wananting careful moni sion, cardiac chamber rupture, coronary artery dissection
toring and reevaluation of the patient. and/or thrombosis, or valvular disruption. Can..liac rupture
Patients with significant hypoxia { ie, PaO: <65 m m Hg typically presents with cardiac injury tamponade and should
[8.6 k.Pal or SaO, <90;h) on room air may require intuba- be recognized during the primary survey. However, occa
tion and ventilation within the first hour after injwy. Asso- sionally tbe signs and symptoms of tamponade arc slow to
ciated medical conditions, such as chronic pulmonary develop with an atrial rupture. Early use of FAST can facil
disease and renal failure, increase tbe necessity o[ early in itate diagnosis.
LUbation and mechanical ventilation. Some patients with Patients ,.vith myocardial contusion may report chest
stable conditions may be treated selectively without endo discomfort, but this symptom is often attributed lo chest
tracheal intubation or mechanical ventilation. wall contusion or fractures of the sternum and/or ribs. The
Pulse oximetry monitoring,ABG determinations, ECG true diagnosis of myocardial contusion can be established
moniloring, and appropriate ventilatory equipment are nec only by direct inspection of the injured myocardium. The
essary for optimal treatment. Any patient with the afore clinically important sequelae of myocardial contusion are
mentioned preexisting conditions who is to be transferred
should Lmdergo intubation and ventilation.
PITFALL
TRACHEOBRONCHIAL TREE INJURY
Injury to the trachea or major bronchus is an unusual and Avoid underestimating the severity of blunt pul
monary injury. Pulmonary contusion may present as a
potentially fatal condition that is often overlooked on ini
wide spectrum of clinical signs that are often not well
tial assessment. In blunt trauma the majority of such in
correlated with chest x-ray find ings. Carefu I mon itor
juries occur within I in. (2.54 em) of the carina. Most ing of ventilation, oxygenation, and fluid status
patients wiLb this injury die at the scene. Those who reach is required, often for several days. With proper man
the hospital alive have a high mortality rate from associated agement, mechanical ventilation can be avoided .
lnJ unes.
.
SECONDARY SURVEY: POTENTIALLY LIFE-THREATENING CHEST INJURIES 95
hypotension, dysrhythmias, or wall-motion abnormality on

two-dimensional echocardiography. The electrocn rd io
Pulmonary artery
graphic changes are variable and may even indicate frank
myocardial intuction. Multiple premature ventriCLar con Aortic rupture
Lraclions, une.>-1Jiained sinus tachycardia, atrial fibrillation,
bundle-branch block (usually right), and ST segment -
changes are the most common ECG fi ndings. Elevated cen

tral venous pre$SUre in the absence of an obvious cause may
indicare right ventricular dysfunction second<rry to contu
sion. I t also is important to remember that Lhe traumatic Left atrial
event may have been precipitated by a myocardial ischemic
episode.
The presence of cardiac troponins may be diagnostic of
myocardial infarction. However, thei_r usc in diagnosing

blunt carcliac in.iury is inconclusive and offers no additional

information beyond that available from ECG. Therefore,
they have no role in the evaluation and treatment of patients
wiU1 blunt cardiac injury.
Patients with n blunt injury to the heart diagnosed by
conduction abnormalities are at risk for sudden dysrhyth
mias and should be monitored for the tlrst 24 hours. After
this interval, the risk of a dysrhythmia appears to decrease
substantially.
Figure 4-9 Aortic Rupture. Traumatic aortic rup
ture is a common cause of sudden death after an auto
TRAUMATIC AORTIC DISRUPTION mobile collision or fall from a great height.
Traumatic aortic rupture is a common cause of sudden
death after an automobile collision or fall from a great
s.istent or recurrent hypotension is usually due to a separate,
height (Figure 4-9). For survivors, recovery is freq uenUy
unidentified bleeding site. Although free rupture o( a tran
possible if aortic rupture is identified and treated immedi
secled aorta into the left chest does occur and may cause hy
ately.
potension, it usually is fatal unless lhe patient is operated
Patients vvith aortic mpturc, who may potentially sur
on within a few minutes.
vive, lend to have an incomplete laceration near the liga
Specific signs and symptoms of traumatic aortic dis
mentum nrleriosum of the aorta. Continuity maintained
ruption are frequently absent. A high index of suspicion
by an in tact adventitial layer or contained mediastinal
prompted by a history of decelerating force and character
hematoma prevents immediate dealh. Many surviving pa
istic findings on chest x-ray films should be maintained, and
tients die in the hospital if left untreated. Some blood can es
t.he patient should be further evaluated. Adjunctive radio
cape into the mediastinum, but one characteristic shared by
logic signs on chest x-ray films, which may or may not be
all survivors is that they have a contained hematoma. Per-
present, indicate the likelihood of major vascular i njury in
tl1e chest They include:
Widened mediastinum
PITFALL
Obi it.era tion of the aortic knob
Penetrating objects that traverse the mediastinum Deviation of the trachea to tl1e right
may injure the major mediastinal structures, such as
the heart, great vessels, tracheobronchial tree, and Depression of the left mainstem brohchus
esophagus. The diagnosis is made when careful ex
ami nation and a chest x-ray film reveal an entrance Elevation of the right mainstem bronchus
wound in one hemithorax and an exit wound or a Obliteration of the space between the pulmonary
missile lodged in the contralateral hemithorax. arte11 and the aorta (obscuration of the aortopul
Wounds in which metallic fragments from the missile
monary window)
are in proximity to mediastinal structures also should
raise suspicion of a mediastinal traversing injury. Deviation of the esophagus (nasogastric tube) to
Such wounds warrant careful consideration, and sur the right
gical consultation is man datory.
Widened paratracheal sttipe
Widened paraspinal interfaces "lechniques of endovascular repair are rapidly evolving as an

alternative approach for surgical repair of blunt traumatic
Presence of a pleural or apical cap
aortic injury.
Left hemothorax
Fractures of the first or second rib or scapula TRAUMATIC DIAPHRAGMATIC INJURY

Trawnatic diaphragmatic ruptures are more commonly di
False positive and false negative findings may occur
agnosed on the left side, perhaps because the liver obliterates
with each x-ray sign, and, rarely ( I %-2%), no mediastinal
the defect or protects it on the right side of the diaphragm,
or initial chest x-ray abnormality is present in patients with
whereas tl1e appearance of Lhe bowel, stomach, and nasa
great-vessel injury. If there is even a slight suspicion or aor
gastric (NG) tube is more easlly detected in the left chest.
tic injury, the patient should be evaluated at a facility capa
However, this fact may not represent the true incidence of
ble of repairing a diagnosed injury.
laterality. Blunt trauma produces large radial tears that lead
Helical contrast-enhanced computed tomography (CT)
Lo bern ia tion (Figure 4- I 0), whereas penetrating trauma
of tl1e chest has been shown to be an accurate screening
produces small perforations that often take some time, even
meth d for patients with suspected blunt aortic injury. CT
years, to develop into diaphragmatic hernias.
scannmg should be performed liberally, because the find
Diaphragmatic injuries are frequently missed initially
ings on chest x-ray, especially Lhe supine view, are unreli
when the chest film i1. misinterpreted as sbovving an ele
able. If Lhe results arc equivocal, aortography should be
va ted diaphragm, acute gastric d ila ta tion, loculated he
perfonncd. rn general, patients who are hemodynamically
mopneumothorax, or subpulmonary hematoma. If a
abnormal should not be placed in a CT scanner. The sensi
laceration of Lhe left diaphragm is suspected, a gastric tube
tivity and specificity of helical contrast-enlumced CT have
should be inserted. When the gastric tube appears i n the
been shown to be l 00% each, but this result is very tech
thoracic cavity on the chesl lilm, the need for special con
nology-dependent. If enhanced helical CT of the hest is
trast studies is eliminated. Occasionally, the condition is
negative for mediastinal hematoma and aortic rupture, no
not identified on tl1e i11itial x-ray film or until after chest
further diagnostic imaging of the aorta is necessary. When
tube evacuation ofthe left thorax. An upper gastTOintesti
the CT is positive for blunr aortic rupture, the extent or the
nal contrast study should be performed if the diagnosis is
injury may need to be further defined witl1 aortography.
not clear. The appearance of peritoneal lavage tluid in the
Transesophageal cchocardiography (TEE) also appears to be
hest tube drainage also confirms the diagnosis. Minimally
a ueful, less invasive diagnostic tool. The trauma surgeon .
mvas1ve endoscopic procedures ( cg, laparoscopy or thora
canng for the patient is in the best position to determine
coscopy) may be helpful in evaluating the diaphragm in
1vh ich, if aJ1y, other diagnostic tests are warranted.
indeterminate cases.
[n hospitals tl1at Lack the capability to care for cardio
Right diaphragmatic ruptures are rarely diagnosed in
thoracic inju ie, the decision to transfer patients with po
. the early postinjury period. The liver often prevents herni
tentl. l aorllC U1Jury may be difficult. A properly performed
ation of other abdominal organs into the chest. The ap
and 111terpreted helical CT that is normal may obviate the
pearance of <Ul elevated right diaphragm on chest x-ray may
need for transfer to a higher level of care to exclude thoracic
be the only finding.
aorlic injury.
Operation for other abdominal injuries often reveals a
A qualified surgeon should treat p<.ltients with blunt
diaphragmatic Lear. Treatment is by direct repair.
traumatic aortic injury and assist in the diagnosis. The treat
ment is either primary repair or resection of the torn seg
ment and replacement vvith an interposition graft. BLUNT ESOPHAGEAL RUPTURE
Esophageal trauma is most commonly penetrating in na
ture. Blunt esophagea 1 trau rna, although very rare, can be
'
lethal if unrecognized. Bllmt injury of the esophagus is
PITFALL .
-.,,

,.
.. . -
caused by the forceful expulsion of gastric con tents i nto the
._
..
.
Delayed or extensive evaluation of the wide medi

astinum without cardiothoracic surgery capabilities
may result in an early in-hospital rupture of the con PITFA L L
tained hematoma and rapid death from exsan
guina tion. All patients with a mechanism of injury Diaphragm injuries are notorious for not being di
.
and s1mple chest x-ray findings suggestive of aortic agnosed during the initial trauma evaluation. An un
disruption should be transferred to a facility capa diagnosed diaphragm injury can result in pulmohary
ble of rapid defin itive diagnosis and treatment of compromise or entrapment and strangulation of
this injury. peritoneal contents.
OTHER MANIFESTATIONS OF CHEST INJURIES 97
Lung
1- Abdominal
contents
Figure 4-1 0 Diaphragmatic

:-- Hernia Rupture. Blunt trauma produces
large radial tears that lead to herni
Diaphragm ation, whereas penetrating trauma
produces small perforations that
often take some time to develop
into diaphragmatic hernias.
esophagus from a severe blow to the upper abdomen. This

forcefuJ ejection produces a linenr tear in the lower eso pha
gus, aJlowi.ng leakage into t he mediastinum (Figure 4-1 1 ) .
The resul ting mediastinitis and immediate or delayed rup

ture into the pleural space cause em pyema .
The clinical picture of patients with blunt esophageal

rupture is identical to that of posternetic esophageal rup
ture. Esophageal injury should be considered i n any pa
tient who: ( 1) has a left pneumothorax or hemothorax
without a rib fracture; (2) has received a severe blow to the
lower stern u m or epigastrium and is in patn or shock out
of proportion to the apparent mjury; aml (3) has particu
late matter in the chest tube after the blood begins to clear.
Presence of mediastinal air also suggests the diagnosis,
which often can be confirmed by contrast studies and/or
esophagoscopy.
Treatment consists of wide drainage of the pleural space
and mediastinum with direct repair of the injury via thora
cotomy, iffeasible. Repairs performed wit.hin a few hours of
injury lead to a much better prognosis.
Other Manifestations
of Chest Injuries Figure 4-1 1 Radiograph showing rib fractures.
Fractures of the scapula, first or second rib, or the ster
Other significant thoracic injuries-including subcutaneous num suggest a magnitude of injury that places the
emphysema; crushing injury (traumatic asphyxia); and rib, head, neck, spinal cord, lungs, and great vessels at risk
sternum, and scapular fractures-should be detected dming for serious associated injury.
the secondary survey. Although these injuries may not be
immediately life-threatening, they have the potential to do
significant hann.
SUBCUTANEOUS EMPHYSEMA --
-
,.
Subcutaneous emphysema can result from airway injury,
PITFALL

'
',
":..
' '
. .
lung injury, or, rarely, blast i nj Ul'Y- Although it does not re Unde restimating the severe pathophysiology of rib
quire treatment, the underlying injury must be addressed': fractures is a common pitfall, pa rticu larly in patients
l f positive-pressure ventilation is required, tube thoracos at the extremes of age. Aggressive pain control with
tomy should he considered on the side of the subcutaneous out res pi ratory depression is the key management
emphysema ill <Jnticipation or a tension pneumothorx de p ri n cip le .
veloping.
CRUSHING INJURY TO THE CHEST rax or hemothorax. As a general rule, a young patient with
(TRAUMATIC ASPHYXIA) a more flexible chest wall is less likely to sustain rib fractures.
Therefore, the presence of multiple rib fractures in young
lindings associated with a crush injury to the chest include patients implies a greater transfer of force than in older pa
upper torso, facial, and arm plethora IArith petechiae sec tients. Fractures of the lower ribs ( 10 to 12) should increase
ondary to acute, temporary compression of the superior suspicion for hepatosplenic injury.
vena cava. Massive swelling and even cerebral edema may Localized pain, tenderness on palpation, and crepita
be present. Associated injuries must be treated. tion are present in patients witl1 rib ni jury. A palpable or vis
ible deformity suggests rib fractures. A ch.::st x-ray film
RIB, STERNUM, AND SCAPULAR FRACTURES should be obtained primarily to exclude other intrathoracic
injuries and not just to ident ify rib fractures. Fractures of
The ribs are the most commonly injured component of the anterior cartilages or separation of costochondral junctions
thoracic cage, and injuries to the ribs are often significant. have the same significance as rib fracwres, but will not be
Pain on motion typically results in splinting of the thorax, seen on the x-ray examinations. Special rib-technique x-ray
which impairs ventilation, m:ygenation, and effeclive cough lilms are expensive, may not detect all rib injuries, add noth
ing. The incidence of atelectasis and pneumonia rises sig ing to treatment, require painful positioning of the patient,
nificantly with preexisting lung disease. ond are not useful. .. See Skill Station VI: X-Ray Identifi
The upper ribs ( 1 to 3) are protected by the bony frame cation of Thoracic lnjuries.
work of the upper lin1b. The scapula, humerus, and clavicle, Taping, rib belts, and external splints are contraindi
along with their muscular attachments, provide a barrier to cated. Relief of pain is important to enable adequate venti
rib injmy. Fractures or the scapu Ia, fi rst or second rib, or the lalion. Intercostal block, epidural anesthesia, and systemic
sternum suggest a magnitude of injury that places the bead, analgesics are eiTt!ctive and may be necessary.
neck, spinal cord, lungs, and great vessels at risk for serious
associated injury. Because of the severity of the associated
injmies, mortality may be as high as 35%. Surgical consul
tation is warranted.
Sternal and scapular fractures are generally the result
Other Indications for
of a direct blow. Pulmonary contusion may accompany ster Chest Tube Insertion
nal fractures, and blunt cardiac injury should be considered
with all such fractures. Operative repair of sternal and
Other indications for chest tube insertion include:
scapular fractures occasionally is indicatecL Ra1ely, posterior
sternoclavicular dislocation results in mediastinal displace Selected patients with suspected severe lung injury,
ment of the clavicular heads with accompanyirlg superior especially those being transferred by air or ground
vena caval obstruction. lmm ediate reduction is required. vehicle
The middle ribs (4 to 9) sustain the majority of blunt
Individuals undergoing general anesthesia for treat
trauma. Anteroposterior compression of the thoracic cage
ment of other injuries (eg, cranial or extremity),
will bow the ribs outward with a fracture i n the midshaft.
who have suspected significant lung injury
Direct force applieJ to the ribs tends to fracture them and

drive the ends or tbe bones into the thorax, raising the po Individuals requiring positive-pressure ventilation
tential for more intrathoracic injury, such as a pneumotho- in whom substantial chest injury is suspected
CHAPTER SUMMARY 99
CHAPTER SUMMARY
..
Thoracrc trauma 1s common in the multiply mjured pat1ent and may be associated with
life-threatenmg problems. These patients can usually be treated or their conditions tem
porarily relieved by relatively simple measures such as intubation, ventilation, tube tho
racostomy, flUid resuscrtat1on. The ability to recognize these important inJuries and the
sk1ll to perform the necessary procedures can be lifesaving. The pnmary survey includes
management of the following conditions:
A1rway obstructio n-Ea rly assessment and recogn ition of the need for esta bl i sh ing
a cont rol led a1rway while ma1ntainmg in-line immobilization of t he cerv1cal sp1ne at
all limes.
Tension pneumothorax-C linica l diagnosis (decreased breath sounds and hyper
resonance) with immediate decompression of the pleu ra l space.
Open pneumothorax-Obvious chest wal l deformity w1th suck1ng chest wound JS
i n itial ly m a n aged with flutter-valve dressing
Fla1 l chest and p ulm onary contusion-Unstable segment of chest wall with para
doxical mot1on requires JUdicious flu1d resuscitation and adequate analgesia w1th se
lective intubation for pulmonary su pport

Mass1ve hemothorax-D1agnosed by find 1ng decreased breath sounds and dullness
to percussion on physical examination. Initial management requires evacuation with
insertion of a large (#36 French) chest tube. A qualified surgeon must be involved ,
1n the dec1S1on for thoracotomy.
Card1ac tamponade-D1agnos1s by clinical examination, w1th ultrasound examina
tiOn to confirm. lnit1al management mcludes flUid resuscitation and surgery. Peri
cardiocentesis may be used as a temporizmg maneuver if surgical intervention is not
Immediately available.
The secondary survey includes 1dentif1cation and 1nitial treatment of the following po
tentially life-threatemng lnJunes, ut11izmg adJunctive stud1es (x-rays. laboratory test, ECG):
Simple pneumothorax-Typically diagnosed by chest x-ray or CT scan and treated
with Lube t horacostomy.
Hemothorax-Typical ly d 1agnosed by chest x-ray or CT scan and treated with tube
thoracostomy.
Pulmonary cont us io n Ty pica lly di a gnosed by chest x-ray or CT scan. Management
-
includes j u dic ious fluid resuscitation and select1ve Intubation for pu l m on ary sup
port.
Tracheobronchial tree injury-Associated with hemoptysi s pn eu momediastin um
, ,
pneumope rica rdi u m persistent a1r leak from chest tube, or pers1stent pneumo
,
thorax afte1 insertion of a chest tube. Req u ires operative repair.

Blunt cardiac 1 nj ury-Most common complicatiOn IS arrhythm ias, which are man
aged accord1ng to standard protocols. Less common complications include acute
myocardial infarction and valvular disruption.
Traumatic aortic d1sruption-Early diagnosis requires a high index of suspicion. Most
common rad1ographic sign IS widened med1ast1num seen on anteropostenor chest
x-ray. DiagnosiS IS confirmed by dynamic helical CT scanning or aortography. Qual
ified surgeon must be involved m management.
Traumatic diaphragmatic injury-Early diagnosis reqUJres a h1gh index of suspicion.
Most common radiographic sign is elevation of diaphragm on involved s1de. Re
qwes early laparotomy for repair and to address associated inJuries.

Blunt esophageal rupture-Physical examination reveals pai n out of proportion for
InJUnes Assocrated w1th left pleural effus1on and/or pneumomediastinum. Early op
erative intervent1on by a q ua l ified surgeon reduces morbidity and mortality.
Several manifestations of thorac1c trauma are indicative of a greater risk of associated

InJUrieS.
Sub cutaneous emphysema is associated with airway or lung injury. Tube thoracos-
tomy should be considered for patients (e q u i ri ng positive pressure ventilation.
Crush inJunes of t he chest present with petech1ae and plethora of the head, neck,
and upper torso. Brain injury with progressive cerebral edema should be suspected.
Injuries to the upper ribs ( 1 -3), scapula, and sternum are associated with si g nifica nt
mechanisms of injury. Underlying head, spine, and cardiothoracic injury should be sus
peeled.
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ofbJunl aortic injury: multicenter trial of the American Asso
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1 , Owens WA. Emergency thoracotomy in
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9. Dunham CM, Barraco RD, Clark D, et al. Guidelines for
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emergency tracheal inLLJbation immediately following trau
diography i n blunt chest trauma: a transthoracic and trans
matic injury: an EAST Practi ce Management Guidelines
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I 0. Dyer DS, Moore E, Mestek M F, et al. Can chest CT be used to
22. Lang-Lazdunski L, Mourox J, Pons F, et al. Role of videotho
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27. Mattox KL. Wall M). Newer diagnostic measures and emer
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of stent graft treatment of thoracic aortic injuries. I S11rg Re
s
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blunt aortic injury: a case series and literature review. A111 Surg
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blunt thoracic trauma: an EAST Practice Management Guide
30. Mirvis SE, Shanmugantham K, Buell ), et al. Use of piral com
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puted tomography for the assessment of blunt trauma patients
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46. Smith MD, C1ssidy j!vl, Souther S, et al. Trnnsesophageal
3 1 . Moon M R, l.uchette FA, Gibson SW, et a I. Propective, ran
echocardiography in the diagnosis of traumatic rupture of the
domized comparison of epidural versus parenteral opiQid
aorta. N Eng/ } Med 1995;332:356-362.
analgesia in U1oracic trauma. Ann Surg 1 999;229:684-692.
47. S0reide K, S0iland II, l.ossius JIM, et al. Resuscitative emer
32. Peterson BG, fVlatsumura JS, Morasch MD, \Vest i'vlA, Eskan
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48. S0reide K, S0iland l f, Lossius HM, Vet rhus M, Soreide )A, Sor
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troponin T, CKMB-aclivity a.nd CKN!G-mas as marken for
injured patient requiring prehospital cardiopulmonary resus
the detection of myocardial cont usion in patients who experi
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cular repair of bluJlt traumatic thoracic aortic transections. /
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Met/ 1990;8:467-476.
-
Performance at this skill station will allow the part icip a n t to:
Interactive Skill
Procedures
OBJECTIVES
Note: This Skill Station includes a
systemati c method for evaluating
chest x-ray fil ms A senes of x
Describe the process for viewing a chest x-ray film for the purpose of
rays with related scenarios is then

identifying life-threatening and potentially life-threate ning thoracic
shown to students for their
injuries.
evaluation and management
Identify various thoracic injuries by using the fo l lowin g seven specific
decisions based on the findings.
anatomic guidelines for examining a series of chest x-rays:
Trachea and bronchi
THE FOLLOWING PROCEDURE Pleural spaces and lung parenchyma
IS INCLUDED IN THIS SKill Mediastinum
STATION: Diaphragm
Skill VIA: Process for Initial Bony thorax
Review of Chest X-Rays Soft tissues
Tubes and lines
Given a series of x-rays:

Diagnose fractures.
Diagnose a pneumothorax and a hemothorax.
Identify a widened mediastinum.
Delineate associated injuries.
Identify other areas of possible injury.
103
104 SKILL STATION VI X-Ray Identification of Thoracic Injuries
skiii VI-A: Process for Initial Review of Chest X-Rays

between tissue planes or outline them with
I . OVERVIEW
radiol ucency.
STEP 1 . Confirm that the film being viewed is of your
patient.
STEP 2. Assess for radjologic signs assocjated with card_iac
or major vascular injury.
STEP 2. Quickly assess for suspected pathology. a. Air or blood in the pericardium can result in
STEP 3. Use the patient's clinical findings to focus the an enlarged cardiac silhouelle. Progressive
review of the chest x-ray film, and use the x-ray changes in cardiac size can represen t an
fu1dings to guide further physical evaluation. expanding pneumopericardium or
hemopericardium.
b. Aortic rupture can be suggested by:
II. TRACHEA AND BRONCHI A widened mediastinum-most reliable tlnding

Fractures of the first and second ribs
STEP 1. Assess the position of the tube i n cases of Obliteration of the aortic knob
endotracheal in Lubation. Deviation of the trachea to the right
STEP 2. Assess for the presence of interstitial or pleural Presence of a pleural cap
air that can represent tracheobronchial injury. Elevation and rightward shift of the right
mainstem bronchus
STEP 3. Assess for tracheal lacerations that can present as Depression of the left mainstem bronchus
pneumomectiastinum, pnewnothorax, Obliteration of the space between the
subcutaneous and interstitial emphysema of the pulmonary artery and aorta
neck, or pneumoperitoneum. Deviation of the esophagus (NG tube} to
STEP 4. Assess for bronchial disruption that can present the right
as a free pleural communication and produce a
massive pneumothorax with a persistent air leak V. DIAPHRAGM
that is unresponsive to tube thoracostomy.
Note: Diaphragmatic rupture requires a high index of sus
picion, based on the mechanism of injury, signs and symp
Ill. PLEURAL SPACES AND LUNG toms, and x-ray findings. Initial chest x-ray examination
may not clearly identify a diaphragmatic injury. Sequential
PARENCHYMA
films or additional studies may be required.
STEP 1 . Assess the pleural space for abnormal collections
of Ouid thai can represent a hemothorax. STEP 1 . Carefully evaluate the diaphragm for:
STEP 2. Assess the pleural space for abnormal coUections a. Elevation (may rise to fourth intercostal space
of air tbat can represent a pneumothorax with full expiration)
usuaUy seen as an apical lucent area without b. Disruption (stomach, bowel gas, or NG tube
bronchial or vascular markings. above the diaphragm}
c. Poor identification ( irregular or obscure} due
STEP 3. Assess the lung fields for infiltrates that can to overlying fluid or soft-tissue masses
suggest puhnonary contusion, hematoma,
aspiration, etc. Pulmonary contusion appears as STEP 2. X-ray changes suggesting injury include:
air-space consolidation that can be irregular and a. Elevation, irrcgularil'y, or obliteration o[ the
patchy, homogeneous, diffuse, or extensive. diaphragm-segmental or total
b. A mass-like density above the diaphragm that
STEP 4. Assess the parenchyma for evidence of laceration.
can be due to a fluid-filled bowel, omentum,
Lacerations appear as a hematoma, vary
liver, kidney, spleen, or pancreas (may appear
according to the magnitude of injury, and appear
as a "loculated pneumothorax")
as areas of consolidation.
c. Air or contrast-containing stomach or bowel
above the diaphragm
d. Contralateral mediastinal shift
IV. MEDIASTINUM
e. Widening of the cardiac silhouette if the peri
STEP 1 . Assess for air or blood that can ctisplace toneal contents herniate into tbe pericardia] sac
mecliastinal structures or blur the demarcation f. Pleural effusion
SKILL STATION VI X-Ray Identification of Thoracic Injuries 105
STEP 3. Assess for associated injuries, such as splenic, a. Fracture, especially in two or more places (flail
pancreatic, renal, and liver. chest)
b. Associated injury, such as pneumothorax,

pulmonary contusion, spleen, liver, and/or
VI. BONY THORAX
kidney
STEP 1 . Assess the clavicle for evidence of:
STEP 6. Assess the stcrnomanubrial junction and sternal
a. Fracture body for evidence of fracture or dislocation.
b. Associated inju.ry, such as great-vessel injury (Sternal fractures can be mistaken on Lhe AP film
STEP 2. Assess Lhe scapula for evidence of: for a mediastinal hematoma. After Lhe patient is
stabilized, a coned-down view, overpenetrated
a. Fracture
film, lateral view, or CT may be obtained to
b. Associated injury, such as airway or great
better identify suspected sternal fracture.)
vessel injury, pulmonary contusion
STEP 7. Assess the sternum for associated injuries, such
STEP 3. Assess ribs I through 3 for evidence of:
as myocardial contusion and great-vessel injury
a. Fracture (widened mediastinum), alt.hough these
b. Associated injury, such as pneumothorax:, combinations are relatively irrfrequent.
major airway, or great-vessel injury
STEP 4. Assess ribs 4 through 9 for evidence of:
VII. SOFT TISSUES
a. Fracture, especially in lwo or more contiguous
ribs in two places (flail chest) STEP 1 . Assess for:
b. Associated injury, such as pneumothorax, a. Displacement or disruption of tissue planes
hemothorax, pulmonary contusion b. Evidence of subcutaneous air
STEP 5. Assess ribs 9 through 1 2 for evidence of:
TABLE Vl-1 Chest X-Ray Suggestions
FINDINGS DIAGNOSES TO CONSIDER
Respiratory distress Without x-ray findings CNS 1njury, aspiratJon, traum atic asphyxia
Any rib fracture Pneumothorax, pulmonary contuSIOn
Fracture of first three nbs or sternoclavicular Airway or great-vessel Injury

fractu re-d islocat ion
Fracture of lowei ribs 9 to 12 Abdominal Injury
Two or more rib fractures in two or more places Flail chest, pulmonary contusion
!
Scapular fracu re t Great-vessel InJury, pulmonary
conwsion, brachial plexus Injury
'
Mediastinal wtdemng Great-vessel injury, sternal fracture, thoracic spine 1n1ury

!
Pesistenr
r large pneumothorax or a1r leak B ronchtal tear
after chesttube lnsert1on ;
Mediastlna I air Esophageal disruption, lracheal injury, pneumoperitoneum
I
Gl gas pattern In the chest (loculate(! air) Diaphragmti<: rupture
N G tube In the chesl Diaphragmatic rupture or ruptured esophagus
Air fluid level tn the chest Hemopneumothorax or diaphragmatiC rupture i

Disrupted diaphragm Abdominal visceral injury

Free atr \J nder the dia hr p agm Ruptured hollow abdominal v1scus
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106 SKILL STATION VI X-Ray Identification of Thoracic Injuries
VIII. TUBES AND LINES uation of the initial chest film, additjonal x-rays or ra
diographic and/or imaging studies may be necessary as his
STEP 1 . Assess for placement and positioning of: torical facts and physical findings dictate. Remember, nei
a. Endotracheal tube ..
ther the physical examination nor the chest x-ray film should
b. Chest tubes be viewed in isolation. Findings on the physical examination
c. Central access Jjnes should be used to focus the review or the chest x-ray fiLn,
d. Nasogastric tube and findings on the chest x-ray film should be used to guide
e. Other monitoring devices the physical examination and rurect the use of ancillary dj
agnostic procedwes. For example, review of the previous x
ray film and repeal chest films may be i11dicated if significant
IX. X-RAY REASSESSMENT changes occur in the patient's status. Thoracic CT, thoracic
The patient's clinical findings should be correlated with the arteriography, or pericardia! ultrusonography/echocardiog
x-ray findjngs, and vice versa. After careful, systematic eval- raphy may be indicated for specificity of diagnosis.

THORAX X-RAY SCENARIOS
PATIENT Vl - 1 PATIENT Vl-7

X-ray ftlm of a 33-year-old bicyclist who was hit by a car. X-ray Ctlm of a 36-year-old male after treatment of an obvi
ous pneumothorax on the right side, still desaturated.
PATIENT Vl-2
X-ray lilm of a young female with a small stab wound above PATIENT Vl-8
the nipple on the right side with ipsilateral dinunishcd
X-ray film of a 45-year-old male motorcyclist who hit a tree
breath sow1ds.
at high speed. He was intubated by EMS and presents as he
mod)'11amically normal.
PATIENT Vl-3
X-ray film of a 56-year-old truck driver who hit an abut
PATIENT Vl-9
ment and reported left-sided chest pain and respiratory dis
tress. X-ray film of a 56-year-old motorcyclist who sustained a
collision with a truck. He was intubated and received a tho
PATIENT Vl-4 rax drain in the prehospital setting.
i a
X-ray film of a 22-year-old male in distress after a figbl n
bar (stab wound in the back, fourth intercostal tpace on left). PATIENT Vl- 1 0
X-ray film of an 18-year-old gang leader who was assaulted.
PATIENT Vl-5 He has multiple contusions, an altered level of conscious
X-ray film of a 42-year-old male in respiratory illstress after ness, and a small entrance wound on the right hemithorax.
sustaining a gunshot wound in a jewelry shop robbery. He has received initial resuscitation.
PATIENT Vl-6 PATIENT Vl-1 1

.
X-ray Ctlm of a motorcyclist with severe head 1 ra uma on ad- X-ray film of a 56-year-old male who fell off a ladder ( 6 m)
..
111ISS!On. with severe head injury.

..
Performance at lhis skill station will allow the student to practice and demon
Interactive Skill
strate on a live, anesthetized animal; a fresh, human cadaver; or an anatomic
Procedures
human body manikin the techniques of needle thoracic decompression of a
Note: Standard precautions tension pneumothorax, chest tube insertion for the emergency management
are required when caring for of hemopneumothorax, and pericardiocentesis. Specifically, the student also
trauma patients. will be able to:
OBJECTIVES
THE FOLLOWING
IN THIS SKILL STATION: Identify the surface markings and techniques for pleural decompres
sion with needle thoracentesis, chest tube insertion, and needle peri
Skill VIl-A: Needle cardiocentesis.
Thoracentesis
Describe the underlying pathophysiology of tension pn eu mothorax
Skill VII-B: Chest Tube and cardiac tamponade as a result of trauma.
Insertion
Skill VII-C: Pericard1ocentesis

Describe the complications of needle thoracentesis, chest tube inser
tion, and pericardiocentesis.
107
108 SKILL STATION VII Chest Trauma Management
Skill VIl -A : Needle Thoracentesis

Note: Thi::. procedure is appropriate for patients in critica1 STEP 9. Remove the Luer-Lok from the catheter and
condition with rapid deterioration who have a life-threat listen for the sudden escape or air when the
ening tension pneumothorax. I f tbis technique is used and needle enters the parietal pleura, indicating that
rhe patient docs not have a tension pneumothorax, a pneu the tension pneumothorax has been relieved.
mothorax and/or damage to the lung may occur.
STEP 1 0. Remove the needle. Leave the plastic catheter in
STEP 1 . A:,e:,s the patient's chest and re::.piratory status.

place and apply a bandage or small dressing
over the insertion site.
STEP 2. Administer high-tlow oxygen and apply
STEP 1 1. Prepare for a chest tube insertion, if necessary.
ventilation as necessary.
The chest tube is typically inserted at the nipple
STEP 3. Identify the second intercostal space, in the level just anterior to the midaxillary line of the
nlidclavicLJaI' line 011 the side of the tension affected hemithorax.

pneumothorax.
STEP 1 2. Connect the chest tube to an w1derwater-seal
STEP 4. t;urgically prepare the chest. device or a flutter-type valve apparatus and
STEP 5. Locally anesthetize the area if the patient is
remove the catheter used to relieve the tension
conscious and if time permits. pneumothorax initially.
STEP 1 3. Obtain a chest x-ray film.
STEP 6. Place the patient in an upright position if a
cervical spine injury has been excluded.
STEP 7. Keeping the Luer-Lok in the distal end of the COMPLICATIONS OF
catheter, insert an over-the-needle catheter (2 in. NEEDLE THORACENTESIS
[5 cml long) into the skin and direct the needle
Local hematoma
just over (ie, superior to) the rib into the
Pneumothorax
intercostal space.
Lung laceration
STEP 8. Puncture the parietal pleura.
Skill Vll-8: Chest Tube Insertion

STEP 1 . Determine the insertion site, usuaUy at the desired length. The tube should be directed
nipple level (fifth intercostal :.pace), just anterior posteriori)' along the inside of the chest wall.
to the midaxillary line on the affected side. A
STEP 7. Look for "fogging" of the chest tube with
:,econd chest tube may be used for a
expiration or listen for air movement.
hemothorax.
STEP 8. Connect the end of the thoracostomy tube to an
STEP 2 Surgically prepare and drape the chest at the
underwater-seal apparatus.
predetermined site of the tube insertion.
STEP 9. Suture the tube in place.
STEP 3. Locally anesthetize the skin and rib periosteum.
STEP 10. Apply a dressing, and Lap Lh Lube to the chest.
STEP 4. Make a 2- to 3-cm transverse (horizontal)
incision at the predetermined site and blunlly STEP 1 1 . Obtain a chest x-rny tilm.
dissect through the subcutaneous tissues, just
STEP 1 2. Obtain arterial blood gas values and/or institute
over the top of the rib.
pulse oximetry monitoring as necessary.
STEP 5. Puncture the parietal pleura with the tip of a
clamp and put a gloved finger into the incision to
avoid injury to other organs and to clear any COMPLICATIONS OF CHEST TUBE INSERTION
adhesions, clots, etc.
Laceration or puncture of intrathoracic and/or ab
STEP 6. Clamp the proximal end of the thoracostomy dominal organs, which can be prevented by using
tube and advance it into the pleural space to the the finger technique before inserting the chest tube
SKILL STATION VII Chest Trauma Management 109
Introduction of pleural infcction-eg, Large primary leak

thoracic empyema Leak at Lhe skin around the chest tube;
Damage to lhe intercostal nerve, artery, or vein suction on tube too strong
Converting a pneumothorax to a
Leaky underwater-seal apparatus
hemopneumothorax Subcutaneous emphysema, usually at tube site
Resulting in intercostal neuritis/neuralgia Recurrence of pneumothorax upon removal of
Incorrect tube position, extrathoracic or chest tube; seal of thoracostomy wound not
intrathoracic immediate
Chest tube kinking, clogging, or dislodging Lung fails to expand because of plugged
from the chest waJI, or disconnection from the bronchus; bronchoscopy required
underwater-seal apparatus Anaphylactic or allergic reaction to surgical
Persistent pneumothorax preparation or anesthetic
Skill VII-C: Pericardiocentesis

STEP 1 . Monitor the patient's vital signs and ECG before, injury pattern persist, withdraw the needle
during, and after the procedme. completely.
STEP 2. Surgically prepare Lhe xiphoid and subxiphoid STEP 11. After aspiration is completed, remove the
areas, if time allows. syringe, and attach a three-way stopcock, leaving
STEP 3. Locally anesthetize the puncture site, if necessary.
the stopcock closed. Seaure the catheter in place.
STEP 4. Using a 16- to 18-gauge, 6-in. ( 15-cm) or longer STEP 12. Option: Applying the Seldinger technique, pass a
over-the-needle catheter, attach a 35-mL empty flexible guidewire through the needle into the
syringe with a three-way stopcock. pericardia! sac, remove the needle, and pass a 14-
gauge tlex:ible catheter over Lhe guidewire. Remove
STEP 5. Assess the patien t for any mediastinal shift that the guidewire and attach a three-way stopcock.
may have caused the heart to shift significantly.
STEP 13. Should the cardiac Lamponade symptoms
STEP 6. Puncture the skin I to 2 em inferior to the left of persist, the stopcock may be opened and the
lhe xiphochondraJ junction, at a 45-degree a-11gle pericardia! sac reaspirated. The plastic
to Lhe skin. pericardiocentesis catheter can be sutured or
STEP 7. Carefully advance the needJe cephalad and aim taped in place and covered with a smaU dressi11g
toward the tip of the left scapula. to allow for continued decompression en route
to surgery or transfer to another care facility.
STEP 8. ff the needle is advanced too far (ie, into the
ventricular muscle), an injury pattern known as
the "current of inju1y" appears on the ECG
.. COMPLICATIONS OF PERICARDIOCENTESIS
monitor (eg, ex'treme ST-T wave changes or
widened and enlarged QRS complex). This Aspiration of ventricular blood instead of
pattern indicates that the pericardiocentesis pericardial blood
needJe shouJd be withdrawn until the previous Laceration of ventricular
baseline ECG tracing reappears. Premature cpicardium/myocardium
ventricular contractions also can occur, secondary Laceration of coronary artery or vein
to irritation of tl1e ventricular myocardium. New hemopericardium, secondaxy to
lacerations of lhe coronary artery or vein,
STEP 9. \Vhen the needle tip enters the blood-filled
and/or ventricular cpicardium/myocardiWil
pericardia! sac, withdraw as much nonclotted
Ventricular fibrillation
blood as possible.
Pneumothora.x, secondary to lung puncture
STEP 10. During the aspiJation, the epicardium Puncture of great vessels with worsening of
approaches the inner pericardiaJ surface again, pericardia! tamponade
as does the needle Li.p. Subsequently, an ECG Puncture of esophagus wilh subsequent
current of injury paltcrn may reappear. This mediastinitis
indicates that the pericardiocentesis needle Puncture of peritoneum with subsequent
should be withchawn slightly. Should this peritonitis or false positive aspirate
C H A PT E R
CHAPTER OUTLINE Upon completion or this topic. the student will identify com
mon patterns of abdominal trauma based on mechanism of
Objectives
injury and establish management priorities accordingly. Specif
Introduction ically, the doctor will be able to:
External Anatomy of the Abdomen
Internal Anatomy of the Abdomen OBJECTIVES
Peritonea l Cavity
Retroperitoneal Space Identify the key anatomic regions of the ab
Pelvic Cavity domen.
Mechanism of Injury Identify the patient at risk for abdominal and

Blunt Trauma pelvic injuries based on the mechanism of injury.
Penetrating Trauma
Apply the appropriate diagnostic procedures to
Assessment
i dent i fy ongoing hemorrhage and injuries that
History
can cause delayed morbidity and mortality
Physical Exammation
Adjuncts to Physical Examination Describe the short-term management of abdomi
Evaluation of Blunt Trauma nal and pelvic injuries.
Evaluation of Penetrating Trauma
Indications for Laparotomy in Adults
Specific Diagnoses
Diaphragm Injuries
Duodenal I njuries
Pancreatic lnjunes
Genitourinary Injuri es
Small Bowel lnjunes
Solid Organ I njuries
Pelvic Fractures and Associated Injuri es
Chapter Summary
Bibliography
112 CHAPTER 5 Abdominal and Pelvic Tra u ma
of the anterior abdomen, acts as a partial barrier to pene

Introduction trating wounds, particularly stab wounds.
The back is the area located posterior to the posterior
When should the abdomen be assessed axillary lines from the tip of the scapulae to the iliac crests.
in the treatment of multiply injured Similar to the abdominal-wall muscles i n the Aank, the thick
patients? back and parasp inal muscles act as a partial barrier to pen
etrating wounds.
Evaluation of the abdomen is a ch allengi ng component of
the initial assessment of i nj ured patients. The assessment of
circulation during the primary survey includes early evalua
tion of the possibility of occult hemorrhage in the abdomen
and pelvis in any patient who has sustained blunt trauma. Internal Anatomy of the Abdomen
Penetrating torso wounds between the nipple and perineum
also m ust be considered as potential causes of intraabdom The three distinct regions of the abdomen are the peritoneal
inal injury. The mechanism of injury, the force with which cavily, the retro peri toneal space, and the pelvic cavity. The
the injury was sustained, the location of inj ury and the he
,
pelvic cavi ty in fact, contains components of both the peri
,
modynamic status of the patient determine the best method toneal cavity and re troperitoneal spaces (F igure 5-l ).
of abdominal assessment.
Unrecognized abdominal injury continues to be a cause
of preventable death after truncal trauma. Rupture of a hol PERITONEAL CAVITY
low viscus and bleeding from a solid organ are not easily I t is convenient to divide the peritoneal cavity into two
recognized, and patient assessment is often comprom ised .
parts-upper and lower The upper p eri to neal cavity which ,
by alcohol intoxication, use of illicit drugs, injury to the is covered by the lower aspect of the bony thorax, includes
brain or spinal cord, and injury to adjacent structures such
as the ribs, spine, or pelvis. Significant am ounts of blood
the di ap h ragm l iver, spleen stomach, and transverse colon
, , .
may be present i n the abdominal cavity with no drarn<ltic
chru1ge in appearance or dimensions and with no obvious
signs ofperitoneal irritation. Any patient who has sustained
significant blunt torso injury from a direct blow, decelera
tion, or a penet rating torso injwy must be considered to
have an abdominal visceral or vascular injury until proven
othenvise.
Liver
External Anatomy of the Abdomen -r----4-- Retroperitoneal

space
The abdom en is partially enclosed by the lower thorax; the 'j----l-Duodenum
anter ior abdomen is defined as the area between the
t ransni ppl e line superiorly, the inguinal ligaments and sym
physis pubis inferiorly, and the anterior a,xillary unes later
ally.
The flank is the area between the ru1terior and poste
rior axillary lines from the sixth in tercostal space to the iliac
crest. The thick musculature of the abdominal waU in this
location, rather than the much Lhinne r aponeurotic sheaths
Pe lvic cavity
PITFA L L
Delay in recognizing intraabdominal or pelvic injury

leads to early death from hemorrhage or delayed Figure 5-1 Regions of Abdomen. The three dis
death from visceral injury. tinct regions of the abdomen are the peritoneal cavity,
retroperitoneal space, and pelvic cavity.
MECHANISM OF INJURY 113
as the result of a motor vehicle crash, can cause compres

PITFALL sion and crush ing injuxies to abdominal viscera. Such forces
deform solid and hollow organs and may cause rupture,
I nj u ries to hidden areas of t h e abdomen such as the with secon da ry hemorrhage contamination by visceral con
,
retroperitoneum must be suspected and evaluated.

tents, and peritonitis. Shearing inj uries are a form of aush
ing injury that may result when a reslraint device, such as a
lap-type seat bell or shoulder harness component, is worn
This area is also referred to as the "thoracoabdominal com improperly (Figure S-2). Patients injured in motor vehicle
ponent" of the abdomen. As the diaphragm rises to the crashes also may sustain deceleration injuries, in which there
fourth intercostal space during fuJI expiration, fractures of is a differential movement of fixed and non fixed parts of the
the lower ribs or penetrating wounds below the nippl e line body. Examples include the frequent lacerations of the I iver
may inj ure abdominal viscera. The lower peritoneal cavity and spleen, both movable organs, at the sites of their fixed
contains the small bowel, parts of the ascending and de supporting ligaments.
scending colons, the sigmoid colon, and, in (emales, the in Air-bag deployment does not preclude abdominal in
ternal reproductive organs. jury. ln patients who sustain blunt trauma, the organs
most frequently injured include the spleen (40%-55%),
RETROPERITONEAL SPACE liver (351Yo-4So/o) , and small bowel (So/o-10%). In addi
tion, there is a 15% incidence of retroperitoneal hema
This po ten tial space is the area posterior to the p eritoneal toma in patients ,.vho undergo laparotomy for blunl lrauma.
lining of the abdomen. Tt contains the abdominal aorta; the Although restraint devices prevent more major inj ur ies ,
inferior vena cava; most of the duodenum, pancreas, kid they may produce specific patterns of i njury as shown in
,
neys and ureters; the posterior aspects of Lhe ascending and Table 5 - l .
descending colons; and the retroperitoneal components of
the pelvic cavity. Injuries to the retroperitoneal visceral struc
tures are difficult to recognize because the area is remote PENETRATING TRAUMA
from physical examination, and injuries do not initially pre Stab wounds and Jowvelocity gunshot wounds cause tis
sent with signs or symptoms of peritonitis. Ln addition, this sue damage by lacerating and cutting. High-velocity gun
space is not sampled by diagnost ic peritoneal lavage (D PL). shot wounds transfer more kinetic energy to abdominal
rl' See Skill Station VIII: Diagnostic Peritoneal Lavage. viscera. High-velocity wounds may cause increased dam
age lateral to the track of the missile due Lo temporary cav
PELVIC CAVITY itation.
Stab wounds traverse adjacen t abdominal structures
The pelvic cavity, surrounded by the pelvi.c bones, is essen and most commonJy involve the Liver (40o/o ) , small bowel
t ial ly the l ower part of the retroperitoneal and intraperi
toneal spaces. It contajns the rectum, bladder, iliac vessels,
and, in females, internal reproductive organs. As with the
thoracoabdominal area, examination of pel vic structures is
compromised by overlying bones.
Mechanism of Injury
Why is the mechanism of injury

important?
Information provided by prehospital personnel or witnesses

c.u1 be very helpful in predicting injury patterns. This in
formation should always be considered and evaluated when

assessing trauma patients .
See Appendix B: Biomechanics
of Injury.
BLUNT TRAUMA
Figure 5-2 Lap Belt Injury. Injuries can result
A direct blow, such as contact with the lower rim of the when a restraint device, such as a lap-type seat belt or
steering wheel or a door intruding into the passenger space shoulder harness component, is worn improperly.
114 CHAPTER 5 Abdominal and Pelvic Trauma
TABLE 5-1 Truncal and Cervical Injuries from Restraint Devices
RESTRAINT DEVICE INJURY
Lap Seat Belt

Compression Tear or avulsion of mesentery
Hyperflexron Rupture of small bowel or colon
ThrombOSIS of iliac artery or abdom1nal aorta
Chance fracture of lumbar vertebrae
Pancreatic or duodenal inJury
Shoulder Harness
Sild1ng under the seat belt ("submarinrng") Intimal tear or thrombos1s 1n 1nnom1nate, carotid, subclavian.
Compress1 on or vertebral arteries
Frncture or d1slocat1on of cerv1cal spine
lnlimal tear or thrombosis in s u bclavian <r1<.>ry

Rib fractures
Pul monary contusion

Rupture of upper abdom1nal viscera
Air Bag
Contact Corneal abras1ons
ContacVdeceleration Abrasions of face. neck. and chest
Flexion (unrestrained) Cardrac rupture
Hyperextension (unrestrarnedl Cerv1cal or thoracic sprne fracture
I
Cervical sprne fracture
(40%), liver (30%). and abdominal vascular structures

( 25/cJ).
Lx pl osivc devices cau:.c injunes through several
mechanisms, including penetrating fragment wounds
and blunt i nj uri es caused by the patient being thrown or
1otrutk. Combined penetrating nnd blunt mechanisms
must be considered. Patients clo!.c to the source of the ex
plosion may have additional pulmonary injuries and in
juries lo the hollow viscera related to blast pressure. The
potential for high pressure i nju ry should not distract the
doctor from a systematic, ABC approach to identification
and treatment of the common blunt and penetrating in
juries.
:-
,,
PITFALLS
Figure 5-3 Stab wounds most commonly injure ..
;
:
.:
the liver, small bowel, diaphragm, and colon. Failure to understand the mechanism leads to a low
ered lndex of suspicion and missed injuries, such as:
Underestimation of energy del ivered to the ab
domen i n blunt trauma
(30%), diaphragm (20%), and colon ( 15%) (Figure S-3).
Visceral and vascular injuries caused by small ex
Gunshot wounds may cause additional intraabdominal
ternal low-velocity wounds, especially stab and
injuries based on the length of the missile's pat h through fragment wounds
the body, the greater kinetic energy, the possibil ity of ric
Underestimation of the amount of energy deliv
ochet off of bony structures, anJ the possibility of frag ered in high-velocity wounds, leading to missed in
mentation, creating secondary missiles. Gunshot wounds juries t a ngenti a l to the path of the missile
most corn monly involve the small bowel (50;(1), colon
ASSESSMENT 115
Assessment
PITFALL
I How do I know if shock is the res11/t of Hypothermia contributes to coagulopathy and on

an intraabdominal injury? going bleeding.
I n patients with hypotension, the doctor's goal is to rapidly

determine whether an abdominal injury is present and ings, whether pos i t ive or nega tive should be documented
,
whether it is the cause ofthe hypotension. The history may carefu lly i n the patien t's medi cal record.
predict, and Lhe ph}rsical exam, al ong with rapidly av<1ilabk

diagnostic tools, may con fr rm the presence of abdominal
Inspection
and pelvic inj uries th at req uire urgent cont rol of hemor
l 11 most c i rcu ms tc wces, Lhc patient must be ful ly undressed.
rhage. Hemodynamically normal patients without signs of
peritonitis may undergo a more detailed evaluation to deter
The an terior and posterior abdomen, as well as Lhc lower
mine whether specific inj uries that can cause delayed mor
chest and perineum, is inspected for abrasions, conLUsions
bidity and mortality are present. Th i s may i ncl ude repeated
from restraint devices, lacerations, penet rat in g wounds, im
paled foreign bodies, cvisceralion of omentum or small
examination to determine whether signs of bleeding or peri
bowel, and pregnancy. The patient should be caut iou sl y
toni! is develo p over time.
l ogrol l ed to facilitate a comp le te examination. At the con
clusion of tbe rapid physical exan1, the patient should be
HISTORY covered with warmed blankets to help prevent hypothermia.
\1\ hen assessi ng a pat i en t i njured in a motor vehicle crash,
T
pertinent historical information i ndudes speed of t he veh i Auscultation

de, type of collision (eg, frontal impact, lateral impact, side Auscultation of the abdomen may be difficult in a noisy
swipe rear impact, or ro llover) vehicle intrusion into Lhe
, , emergency depa rt men t but il may be used to co11firm the
,
passenger compartment, types of restraints used, deploy presence or absence or bowel sounds. Free intraperitoneal
ment of air bags, patient's position in the vehicle, and status bl ood or gastrointestinal con tents may prod uce an ileus, re
of passengers, if any. This infonnation may be provi ded by su l ting in the l oss of bowel sounds; however, this finding is
the patient, other passengers, Lhe pol ice, or emergency med nonspecific, as ileus may also be caused by extraabdom inal
ical person nel . Information about vital signs, obvious in inj uries These findings are most useful when they are normal
.
juries, and response to prehospiLal treatment also should be initially and then change over time.
prov i ded by the prehosp ital care prov ider s.
When assessing a patient who has sustained penetrating Percussion and Palpation
trauma, pertinent information includes the time of injury type ,
Percussion causes sl ight movement of the peritoneum and

of weapon (eg, kn ife, handgun, rifle, or shotgun), distance
may elicit signs of peritoneal i rri ta tion. When present, no
from the assailant ( par t icu larl y i mport ant with shotgun
additional evidence ofrebound tenderness need or should be
woun ds, as the lik.elibood of major visceral in jurie:> decreases
sought as such an examination may cause the patient un
beyond tJ1e 10- tool, or 3-meter, ra nge), number of stab or gun
necessary further pain .
shot wounds sustained, and the amou nt of external bleedi ng
Volu n t ary guarding by the patient may make the ab
noted at the scene. If possible to obtain it, important addi tional
dominal examination unreliable. In contrast, in voluntary
informat ion includes t he magn itude and l ocation of abdom
muscle guarding is a rel i ab le sign of peritoneal irritation.
i na l pai n and whet her t his pai n is referred to the shoulder.
P alpa t ion may also elicit and distinguish super fici al (ab
vVhen i nj ur i es are caused by an exp l osive device, the
dominal wall) and deep tenderness. The presence of a preg
likel ihood or visceral high pressure i nj ur ies is increased if
nant uterus as w ell as est imati o n of fetal age al so can be
, .
the explosi on occurred in an enclosed space and with de
determined.
creas ing distance of the patien t from Lhe ex.-plosion.
Assessment of Pelvic Stability

PHYSICAL EXAMINATION
Major hemorrhage may occur from a pelvic fracture in pa
I How do I determine whether there is tients who sustai_n blum truncal trauma. An ea rly assessment
an abdominal injury?
The abdominal examination should be conducted in a

PITFALL
meticulous, systematic fashion in the standard sequence: i n
spect ion , auscu lt a tion , percussion , and palpat i on. This is fol Repeated man ip u lat ion of a fractured pelvis can ag
lowed by assess ment of pelvic sta bi l ity ; uretb ral, perineal, gravate hemorrhage.
and rectal exam; vagina l exarn; and gluteal exam. The find-
of the likelihood of hemorrhage from this source can be suggests an injury to the esophagus or upper gastrointesti
made during the physical exam by evaluating pelvic stabil nal tract if nasopharyngeal and/or oropharyngeal sources
ity. This begins with manual compression of the anterosu arc excluded. If severe facial fractures exist or basilar skull
pcrior iliac spines or iliac crests. Abnormal movement or: fracture is suspected, the gastric tube should be inserted
bony pain suggests fracture, and the exam may stop with through the mouth to prevent passage of the tube through
this m<1neuver. If the pelvis seem:. :.table to compression, a the cribriform plate into the brain.
mancuvl.'r to distract the anterosupl.'rior lliac spines is ac
compli!>hcd, also evaluating for bony movement or pain. Urinary Catheter
Caution should be exercised, as this maneuver can cause or
The goals of inserting urinary cathcters early in the resusci
aggravate bleeding. \"/hen rapidly available, some doctors
tation process are to relieve retention, decompress the blad
substitute x-ray examination ofthe pelvis to avoid pain and
der before performing DPL, and allow for monitoring of
the potential for aggravating hemorrhage.
urinary output as an index of tissue perfusion. Hematuria is
a sign of trauma to the genitourinary tract and nonrenal in
Urethral, Perineal, and Rectal Examination traabdominal organs. The inability to void, unstable pelvic
The presence of blood at the urethral meatus strongly sug fracture, blood at the meatus, scrotal hematoma, or perineal
gest:. a urethral tear. Inspection of the scrotum and per ecchymoses and a high-riding prostate on rectal examination
ineum should be performed to look for ecchymoses or mandate retrograde urethrography to confirm an intact ure
hematoma, suggestive of the same injury. In patients who thra before inserting a urinary catheter. A disrupted urethra
have sustained blunt trauma, goals of the rectal examina detected during the primary or secondary survey may require
tion are to assess sphincter tone, determine the position of the insertion of a suprapubic tube by an experienced doctor
the prostate (a high-riding pro:.tate indicates urethral dis and may be performed more safely with ultrasound guidance.
ruption), .md identify any fracture!> of the pelvic bones. In
patients with penetrating wounds, the rectal examination is Other Studies
used to assess sphincter tone and look for gross blood from
With preparation and an organized team approach, the pre
a bowel perforation.
ceding evaluation can be performed very quickly. The fol
lowing additional studies trc chosen based on the
Vaginal Examination hemodynamic status of the patient and the suspected in
Laceration of the vagina may occur from bony fragments juries. When intraabdominal injury is suspected, a number
from pelvic fracture(s) or from penetrating wounds. Vaginal of studies can provide useful information; however, these
exam should be performed when inju ry is suspected (eg, in studies should not delay the transfer of a patient to defini
the presence of complex perineal laceration ). ,/' Also sec tive care.
Chapter I2: Trauma in V\'omen.
X-Ray Examination for Abdominal Trauma An
Gluteal Examination teropotcrior (AP) chest and pelvic x-r:Jy examinations are
recommended in the assessment of patients with multisys
The gluteal region extends from the iliac crests to the gluteal
tem blunt trauma. Patients with hemodynamic abnormali
folds. J>enet raling injuries to this uc<J tlre associated with an
ties who have penetrating abdominal wounds do not require
incidence of up to a 50% of significant intraabdominal in
screening x-ray examination in the emergency department
juries, including rectal injuries below the peritoneal reflec
( I:D). If the patient has no hemodynamic abnormalities and
tion. Gun:.hot and srab wounds are associated with
has penetrating trauma above the umbilicu or a suspected
intraJbdominal injuries; these wound!> mandate a search for
thoracoabdominal injury, an upright chest x-ray examina
uch injuries.
tion is useful to exclude an associated hemothorax or pneu
mothorax or to document the presence of intraperitoneal air.
ADJUNCTS TO PHYSICAL EXAMINATION With marker rings or dips applied to all entrance and exit
wound sites, a supine abdominal x-ray may be obtained in
Gastric and urinary catheters are frequcn tly inserted as part
patients with no hemodynamic abnormalities to determine
or the rcsu:.citation phase, once problem!. with the airway,
the track or the missile or presence or retroperitoneal air.
breathing, .md circulation are diagnosed and treated.
Gastric Tube
The therapeutic goals of inserting ga:.tric tubes early in the
PITFA L L
resuscitation process are to relieve acute gastric dilation, de
compress the stomach before performing a DPL, and re Avoid nasal gastric tube i n midface injury. Use oral
move gastric contents, thereby reducing the risk of gastric route.
aspiration. The presence of blood in the gastric secretions
ASSESSMENT 117
Focused Assessment Sonography in Trauma lo

cused assessment sonography in trauma (FAST) is one of the
two most rapid studies for the identification of hemotThagc
or the potential for hollow viscus injury. Ln FAST, ul;rasow1d
technology is used by properly trained individuals to detect
the presence of hemoperitoneum ( Figure 5-4). With specific
equi pment and in experienced hands, ul trasound has a sensi
tivity specificity, and accuracy in detecti ng intraabdominal
,
fluid comparable to DPL and abdominal computed tomogra

phy. Thus, ultrasound provides a rapid, noninvasive, accurate,
and inexpensive m ea ns of diagnosing hemoperitoneum that
can be repeated frequently. Ultrasound scanning can be done
at the bedside in the resuscitation room while simultaneously
performing other diagnostic or therapeutic procedures. The
iJ1dicalions for the procedure are tlle same as for D PL. Factors
that compromise the utility of ultraso und are obesity the pres
,
ence of subcutaneous air, and previous abdominal operations.

Figure 5-5 Diagnostic Peritoneal lavage (DPL).
DPL is a rapidly performed, invasive procedure that is
Ultrasound scanning to detect hemoperitoneum can be
accomplished rapidly. Furthermore, it can detect one of the
considered 98% sensitive for intraperitoneal bleeding.
nonhypovolemic reasons for hypotension: peri can:tial tam
ponade. Scans are obtained of the peri cardiaJ sac hepatore
,
Change i11 sensori um brain injury, alcohol intoxi
-
nal fossa, sp lenorenal fossa, and pelv is or pouch of Douglas.

cation, and use of illicit drugs
After the initial scan is completed, a second or "control" scan
should ideally be performed after an interval of 30 minutes. Ch a nge in sensation- injury to spinal cord
The control scan cru1 detect progressive hemoperitoneum
Inj ury to adjacent structures-lower ribs, pelvis,
in pa tie nts with a low rate of bleedi ng and short i n tervals
lumbar spine
from injury to the initial scan.
Equivoca l results on physical exa m i na tion
Diagnostic Peritoneal lavage Diagnostic peritoneal
Prolonged loss of contact with patient an t icipated
lavage (DPL) is the second of tl1e two most rapid studies for
general anesthesia for ex:traabdominal inj uri es,
the identificat-ion of hcmonhage or the potential for hollow
lengthy x-ray studies ( eg, a ngiog raph y in a patient
viscus inj ury. DPL is an invasive procedure that significantly
with or without hemodynamic abn ormalities)
a hers subsequent examinations of the patient ru1d is consid
ered 98o/o sensitive for intraperitoneal bleeding ( Figu re 5-5). La p belt sign ( abdomi nal wall contusion) with sus
-
I t should be performed by a surgical team caring tor a patien t picion of bowel injury
with hemodynamic abnormalities and mul tiple blw1t injuries,
especially when any of the follmving sit uation s exists: DPL also is indicated in pati en ts with no hemodynam ic
abnormalities when the same situations are present, but ul
trasound and co mputed tomography (CT) are not avai lable.
The only absolute contraindication to DPL is an existing in
dication for laparotomy. Relative contraindications include
previous abdominal operations, morbid obesity, advru1ced
ci rrhosis and preexisting coagulopatlly. Either an open or
,
closed ( Seldi nger) intiaumbil ical technique is acceptable in

the hands of trained doctors. In patients with pelvic frac
tures or advanced pregnancy, an open supra umbilical ap
proach is preferred to avoid entering a pe lvic hematoma or
PITFA L L
A si ng le p hys i cal exam or adjunct should not allay

clinical suspicion based on the mechanism of inj ury.
Figure 5-4 Focused Assessment Sonography in Repeated exams and complementary adjuncts may
Trauma (FAST). In FAST, ultrasound technology is used be necessary.
to detect the presence of hemoperitoneum.
damaging the enlarged uterus. Free aspiration ofblood, gas teriaJ is instilled with gentle pressure. A radiograph is taken
trointestinal contents, vegetable fibers, or bile through the with an oblique projection and with slight stretch ing of the
.
lavage catheter i n patients with hemodynamic abnormalities pems.

mandates the use oflaparotomy. ..
An intraperitoneaJ or extra peritoneal bladder rupture is
If gross blood (> 10 mL) or gastrointestinaJ contents are best diagnosed by a cystogram. A syringe barrel is attached
not aspi rated, lavage is performed with I 000 mL of warmed to the indwelling bladder catheter, held 40 em above Lhe pa
isotonic crystalloid solution ( 10 ruL/kg in a child). After en tient, and 300 mL of water-soluble contrast is allowed to
suring adequate mixing of peritoncaJ contents with the Oow into the bladder or until: ( I ) flow stops, (2) the patient
lavage fluid by compressing the abdomen and moving the voids spontaneously, or (3) the patient is in discomfort. AP,
patient by logrolling or tilting him or her into head-down obi ique, and postdrai nage views are essential to definitively
and head-up positions, the eftluent is sent to the laboratory exclude injury. CT evaluation of the bladder and pelvis (CT
for quantitative ana l ysi s if gastrointestinal contents, veg cystography) is an alternative study Lhat is paTticularly use
etable fibers, or bile are not obviously present. A positive test ful in providing additional information :bout the kidneys
for blunt trauma is indicated by> 100,000 red cells per cubic and pelvic bones.
millimeter, 500 white cells per cubic millimeter, or the pres Suspected urinary system injuries are best evaluated
ence of bacteria sho1vn on Gram staining. _. See Skill Sta by contrast-enhanced CT scan. If CT is not available, in
tion VITI: Diagnostic Peritoneal Lavage. travenous pyelography (rVP) provides an alternative. A
high-dose, rapid injection of renal contrast ("screening
Computed Tomography Computed tomography (CT) IVP") is best performed using the recommended dosage
is a diagnostic procedme that requires transport of the pa of 200 mg of iodine/kg body weight. This involves a bolus
tient to the scanner, administration of contrast, and scan injection of I 00 mL (standard, 1.5 mL/kg for a 70-kg in
ning of the upper and lower abdomen, as well as the pelvis. dividual) of a 60o/o io di n e solution performed through
It is a time-consuming procedure that should be used only in two 50-mL syringes over 30 to 60 seco nds lf only 30o/o
.
patients with no hemodynamic abnormalities in whom there iodine solution is available, the ideal dose is 3.0 ml/kg.
is no apparent indication for an emergency laparotomy. The The calyces of the kidneys should be visualized on a flat
CT scan provides information relative to specitic organ in plate x.-ray of the abdomen 2 minutes after the injection
jury and its extent, and can diagnose retroperitoneal and is completed. Unilateral nonfunctio.ning i n dica1es an ab
pelvic organ injuries that are difficuJt to assess by a physical sent kidney, 1 hrombosis, avulsion of the renal artery, or
examination, FAST, and peritoneal lavage. Relative con massive parenchymal disruption. Nonfunctioning war
traindications to the use of CT include delay until the scan rants further radiologic evaluation with contrast
ner is available, an uncooperative patient who cannot be enhanced CT or renal arteriography, or surgical exp l o
safely sedated, and aJiergy to the contrast agent when non ration, depending on the mechanism of injury and local
ionic contrast is not available. Some gastrointestinal, di availabiJity or expertise.
aphragmatic, and pancreatic injuries may be missed on CT. Isolated injuries Lo retroperitoneal gastrointestinal
In the absence of hepatic or splenic inj uries, the presence of structures (ie, duodenum, ascending or descending colon,
free fluid in the abdominal cavity suggests an injury to the rectum, biliary tract, and pancreas) may not cause peritoni
gastrointestinal tract andfor its mesentery, and many trauma tis and may not be detected on DPL. \1\fhen injury to one of
surgeons find this to be an indication for early operative in these structures is suspected, CT with contrast, specific
tervention. upper and lower gastrointestinal contrast studies, and pan
creaticobiliary imaging studies may be useful. These studies
Contrast Studies number ofcontrast studies can aid in
A should be guided by the surgeon who will ultimately care for
the diagnosis of specifically suspected inj u ries, but they the patient.
should not delay the care of patients with hemodynamic ab
normalities. These include:
EVALUATION OF BLUNT TRAUMA
Urethrography If there is early or obvious evidence that the patient will be
Cystography transferred to another facility, time-consuming tests, such as
contrast urologic and gastrointestinal studies, DPL, and CT,
lntravenOLIS pyelography
GastrointestinaJ contrast studies
Urethrography should be performed before inserting PITFALL

an indwelling urinary catheter when a urethral tear is sus
Evaluations should not delay the transfer of the pa
pected. It is performed with an ,'1.8 French urinary catheter tient to a more appropriate level of care for severe
secuTed in the meataJ fossa by balloon inflation to 1.5 to 2 injuries that have already been identified.
mL. Approximately 15 to 20 mL of tu1diluted contrast ma-
ASSESSMENT 119
should not be performed. Table 5-2 compares the use of rax, and it is not indicated in patients with peritonitis or hy
DPL, FAST, and CT, including their advantages and disad potension from suspected abdominal injury.
vantages, in the evaluation or blunt trauma. Because 25o/o to 33o/o of stab wounds to the anterior ab

domen do not penetrate the pe1itoncum, laparotomy for
such patients is often nonproductive. Under sterile condi
EVALUATION OF PENETRATING TRAUMA tions, local anesthesia is injected, and the wound track is fol
The evaluation of penetrating trauma involves speciaJ con lowed through the layers of the abdominal wall or until its
sideration to address penetrating wounds to the abdomen termination. Confirmation of penetration through the an
and thoracoabdominal region. Options include local wound terior fascia places the patient at higher risk for intraperi
exploration and serial phys ical examination. DPL, or CT in toneal injury, and many trauma surgeons view Lhis as an
anterior abdominal stab 'vounds. Double or triple contrast indication for laparotomy. Any patient in whom the track
CT are useful in tlank and back injmies. Smgery may be re cannot be followed because of obesity, lack of cooperation, or
quired for immediate diagnosis and treatment. soft-tissue hemorrhage or distortion should be admitted for
continued evaluation or surgical exploration (laparotomy).

Penetrating Wounds
Most gunshot wounds to the abdomen are managed by ex
Thoracoabdominal Lower Chest Wounds
ploratory laparotomy, as the incidence of significant in Diagnostic options in asymptomatic patients with possible
traperitoneal injury approaches go%. Tangential gunshot injmies to the diaphragm and upper abdominal structmes
wounds often are not truly tangential, and concussive and include serial physical and chest x-ray examinations, thora
blast injuries can cause intraperitoneal injury without coscopy, laparoscopy, and CT (for right thoracoabdominal
peritoneal penetration. Stab wounds lo the abdomen may wounds). Despite all these options, late posttraumatic left
be managed more selectively, but approximately 301).. do '1> sided diaphragmatic hernias continue to occur after thora
cause intraperitoneal injury. Thus, indications for laparo coabdominal stab wounds; thus early or immediate surgical
tomy in patients with penetrating abdominal wounds in exploration (laparotomy) for such wounds also is an option.
clude: ror left-sided thoracoabdominal gunshot wounds, the safest
alternative is laparotomy.
Any patient with hemodynamic abnormalities
Gunshot wound
Local Wound Exploration and Serial Physical
Examinations versus DPL in Anterior Abdom
Signs of peritoneal irritation inal Stab Wounds
Signs of fascial penetration Approximately SS%1 to 601Vo of patients with stab wounds
that penetrate Lhe anterior peritoneum have hypotension,
When there is suspicion that a penetrating wound is su peritonitis. or evisceration of omentum or small bowel.
perficial and does not appear to travel below the abdominal These patients require emergency laparotomy. In the re
musculoaponeurotic layer, an experienced surgeon may maining patients, in whom anterior peritoneal penetration
elect to explore the wound locally to determine the depth of can be confirmed or is strongly suspected after local wound
penetration. This procedure is not used with wowJds over exploration, approximately 50% eventually require opera
lying the ribs because of the risk of causing a pneumotho- tion. Laparotomy remains a reasonable option for all such
I
TABLE 5-2 Comparison of DPL, FAST, and CT in Blunt Abdominal Trauma
DPL FAST CT SCAN

Advantages Early diagnosrs Early d ragnosrs Most speerfie for rnJury

Performed rapidly Noninvasive Sensitive 92%-98% accurate
98% sensitive Performed rapidly
Detects bowel injury Repeatable
Disadvantages Invasive Operator-dependent C ost and time

Low specificity Bowel gas and subcutaneous Mrsses diaphragm, bowel, and
Misses injuries to air distortion some pancreatic injuries
diaphragm and Misses diaphragm, bowel , Transport required
retroperitoneum pancreatic, and solid organ injuries
- -
--
--
-

-

-
------- -
- ..... ..
.. .. .
_,,,
.
. .
- ..
... .-.......
....
- _
- .. -....
............. .. .... .
....... .
. -
-
...... .. .. .
. .... . .
..... ......- . .- .
....... ... ....... .-
...... ....
- Indications for laparotomy

...
--
"' '-. -
:'". ...
in Adults
.
Oc
'o.
--
These evaluations are seeking to prove that there is J
no injury in the patients with no hemodynamic ab-
normalities. They should not delay laparotomy in pa In which patients is a

tients with hemodynamic abnormalities that likely laparotomy warranted?
have an abdominal source. In individual patients, surgical judgment is required to deter
mine the timing and need for laparotomy. The following in
dications are commonly used to facilitate t11e surgeon's
patients. Less invasive diagnostic options for relatively decision-making process.
asymptom ati c patien Ls (who may have pajn at the site of the
stab wound) include serial physical examinations over a 24- Blunt abdominal. trauma with hypotension with a
hour period, DPL, or diagnostic laparoscopy. Although a positive FAST or clinical evidence of intraperi ton eal
positive FAST may be he l pfu l in this situation, a negative bleedjng
FAST does not exclude the possibility of significant intraab

Blunt abdominal tralm1a with positive DPL
dominal injury producing small volumes of fluid. Serial
physical examinations are labor-intensive, but have an over Hypotension with penetrating abdominal wound
all accuracy rate of 94%. DPL may allow for earlier iliagno
sis of injury i n relatively asymptomatic patients. The Gunshot wounds traversing the per iton eal cavity or
accuracy rate is greater tlum 90% when specific cell cow1ts, visceral/vascular ret roperitoneu m
rather than gross inspection of the fluid, are used. Use of Evisceration
!.ower thresholds for penetrating trauma increases sensitiv
ity and decreases specificity. Diagnostic laparoscopy can Bleeding from the stomach, rectum, or genitouri
confirm or exclude peritoneal penetra t i on , but it is less use
nary tract liom penetratn
i g trawna
ful in iden ti fying specific injuries. Peritonitis
Free air, retroperitoneal air, or r u pture of the

Serial Physical Examinations versus
h em idi aphrag m after blunt trauma
Double- or Triple-Contrast CT in Flank
and Back Injuries Ruptured gastrointesti n a l tract, intraperitoneal
bladder i11jury, ren al pedicl e injury, or severe
The thickness of the !lank and back muscles protects th e un
viscera l parenchymal injury after blunt or
derlying viscera from injury from many stab wounds and
some gunshot wounds to these areas. Although laparotomy penetrating t rauma, as demonst rated on
is a reasonable option for all such patients, less invasive di contrast-enhanced CT
agnostic options in patienLs who are initially asymptomatic
include serial physical examinations, double- or triple-con
trast CT, and DPL. Serial physical examination in patients
who are in it ial ly asymptomatic and then become sympto
matic is ve ry accurate in detec ti ng retrope r ito neal and in
traperitoneal injuries with wounds posterior to the anterior
axil l ary Ii ne.
Double- (intravenous and oral) or triple- (intravenous,
oral, and rectal) contrast-enhanced CT assesses the retroperi
toneal colon on the side of the wound. The accuracy is com
par able to that of serial physical examinations, but should
allow for earlier diagnosis of injury in relatively asympto
matic patients when CT is performed properly.
On rare occasions, these retropedtoneal. injuries may
be missed by serial examinations and contrast CT. Early out
patient follow- up is m anda tory after ilie 24-hour period of
in-hospital observation because of the subtle presentation
of certain colonic injuries.
DPL can also be used as an early screening test in such
patients. A positive DPL is an indication for an urgent la Surgica l judgment is required to determine the timing
parotomy. and need for laparotomy.
SPECIFIC DIAGNOSES 121
Specific Diagnoses tial underlying renal injury and warrant a n evaluation

(CT or fVP) of the urinary tract. Additional indications
for evaluating the urinary tract include gross hematuria
The liver, spleen, and kidney arc the organs predoJl!inantly or microscopic hematuria in patients with: ( 1 ) a pene
involved after blunt trauma, although the relative incidence trating abdominal wound, (2) an episode of hypotension
of hollow visceral perforation, lumbar spinal injuries, and (systolic blood pressure less than 90 m m Hg) i n con
uterine rupture increases with incorrect seat-belt usage (see junction with blunt abdominal trauma, and (3) in traab
Table 5- 1 ) . Difficulties in diagnosis may occur with i11juries dominal injuries associated with blunt trauma. Gross
to the diaphragm, duodenum, pancreas, genitourinary sys hematuria and microscopic hematuria in patients with
tem, or small bowel. an episode of shock indicate that they are at risk for non
renal abdominal injmies. A11 abdominal CT scan with fV
contrast can document the presence and extent of a blunt
DIAPHRAGM INJURIES
renal injury, 95% of which can be treated nonoperatively.
Blunt tears may occur i11 any portion of either diaphragm; Thrornbosis of the renal artery or disruption ol the renal

however, the left hemidiaphragm is more commonly in pedicle secondary lo deceleration is a rare upper tract
jured. The most common injury is 5 to 1 0 em in length injury in which hematuria may be absent, although
and involves the posterolateral left hcmidiaphragm. Ab the patient may have severe abdominal pain. Wilh either
normalities on the initial chest x-ray include elevation or injury, IVP, CT, or renal arteriography may be useful in
"blurring" of the hemidiaphragm, hemothora,x, an abnor diagnosis.
mal gas shadow that obscures the hemidiaphragm, or the An anterior pelvic fracture usually is present in patients
gastric tube being positioned in the chest. However, the with urethral injuries. UretluaJ disruptions are divided into
initial chest x-ray may be normal in a small percentage of those above (posterior) or below (anterior) the urogenital
patients. diaphragm. A posterior urethral inJury usually occurs in pa
tients with multisystem injuries and pelvic fractures. In con
trast, an anterior urethral injury results from a straddle
DUODENAL INJURIES
impact and may be an isolated injury.
Duodenal rupture is classically encountered in unrestrained
drivers involved in fron tal-impact motor vehicle collisions
and patients who sustain di reel blows to the abdomen, such SMAll BOWEl INJURIES
as from bicycle handlebars. Bloody gastric aspirate or
Blunt injury to the intestines generally resuJts f1om sudden
retroperitoneal air seen on a flat-plate x-ray film of the
deceleration with subsequent tearing near a fixed point of
abdomen or abdominal CT shouJd raise suspicion for this
attachment, especially if the patient's seat belt was used in
injury. An upper gastrointestinal x-ray series or double
correctly. The appearance of tra11sverse, linear ecchymoses
contrast CT is indicated for high-risk patients.
on the abdominal wall (seat-belt sign) or the presence of a
lumbar distraction fractme (Chance fracture) on x-ray ex
PANCREATIC INJURIES amination should alert the doctor to the possibility of in
testinal injury. Although some patients have early abdominal
Pancreatic injuries most often result from a djrect epigas
pain and tenderness, diagnosis may be difficult in others, es
tric blow that compresses the organ against the vertebral
pecially because only minimal bleeding may result from torn
column. An early normal serum amylase level does not ex
intestinal organs. Early ultrasound and CT are often not di
clude major pancreatic trauma. Conversely, lhe amylase
agnostic for these subtle injuries, and DPL is a better choice
level may be elevated from nonpancreatic sources. How
when abdominal wall ecchymoses are present.
ever, persistently elevated or rising serum amylase levels
should prompt further evaluation of the pancreas and
other abdominal viscera. Double-contrast CT may not iden
SOLID ORGAN INJURIES
tify significant pancreatic trauma in the immediate postin
jury period (up to 8 hours); it should be repeated later if Injuries to the Liver, spleen, and kidney lhal result in shock,
pancreatic injury is suspected. Should there be concern hemodynamic instability, or evidence of continuing bleed
after equivocal results on CT, surgical exploration of the ing are indications for urgent laparotomy. Solid organ in
pancreas is warranted. jury in patients with no hemodynamic abnormalities can
often be treated nonoperalively. Such patients must be ad
mitted to the hospital for careful observation, and evalua
GENITOURINARY INJURIES
tion by a surgeon is essential. Concomitant hollow viscus
Direct blows to the back or flank that result in contu injury occurs in less than 5% of patients initially thought to
sions, hematomas, or ecchymoses are markers of poten- have isolated solid organ injuries.
PELVIC FRACTURES AND ASSOCIATED INJURIES

IJ How do I treat patients Surgical consult
Initial Management
Pelvic wrap
with pelvic fractures?
..
The sacrum and innominate bones (ilium, ischium, and

pubis), along with many ligamentous complexes, comprise Intraperitoneal gross blood?
the pelvis. Fractures and ligamentous disruptions of the
pelvis suggest that major forces were applied to the patient.
Such injuries usually result from auto-pedestrian, motor ve
hicle, and motorcycle crashes. Pelvic fractures have a signif
icant association with injuries to intraperitoneal and Laparotomy Angiography
retroperitoneal visceral and vascular structures. The inci
dence of tears of the thoracic aorta also appears to be sig
nificantly increased in patients with pelvic fractures,
especially anteroposterior fractures. Therefore, hypotension Hemorrhage control fixation device
may or may not be related to the pelvic fracture itself when
blunt trauma is the mechanism of injury.
Palients with hemorrhagic shock and unstable pelvic Figure 56 Pelvic Fractures and Hemorrhagic
fractures have four potential sources of blood loss: ( 1 ) frac Shock-Management Algorithm.
tured bone surfaces, (2) pelvic venous plexus, (3) pelvic ar
terial injury, and ( 4) extrapelvic sources. The pelvis should be
temporarily stabilized or "closed" using an available com
mentous complex (sacroiliac, sacrospinous, sacrotuberous,
mercial compression device or sheet to decrease bleeding.
and fibromuscular pelvic floor) reprcse1itcd by a sacroiJiac
lnlraabdominal sources or hemorrhage must be excluded
fracture and/or dislocation or sacral fracture. Wilh opening
or treated operatively. Further decisions to control ongoing
of lhe pelvic ring, there may be hemorrhage from the pos
pelvic bleeding include angiographic emboljzation, surgical
terior pelvic venous complex and, occasionally, branches of
stabilization, and direcl swgical control (see Figure S-6).
the internal iliac artery. Figure 5-8 shows an "open book"
fracture.
Mechanism of Injury/Classification Lateral compression injuries often result from motor
The four patterns of force learung to pelvic fractures are the vehicle crashes and lead to internal rotation of the involved
foliowi.ng: ( 1) AP compression, (2) lateral compression, (3) hemipelvis. This rotation drives the pubis into the lower
vertical shear, and (4) complex (combination) pal rern. genitourinary system, injuring tJ1e bladder and/or urethra.
An AP compression injury may be caused by an The pelvic volume is actually compressed in such an injury,
auto-pedestrian collision or motorcycle crash, a direct so Iife-threatening hemorrhage is not common. Figure 5-7
crushing injury to the pelvis, or a fall from a height greater shows a "closed" fracture.
than 1 2 feet (3.6 meters). With disruption of the symphysis A high-energy shear force applied in a vertical plane
pubis, Lhere often is tearing of the posterior osseous Hga- across the anterior and posterior aspects of the ring disrupts
Lateral compression Anterior-posterior compression Vertical shear

(closed) 60-70% frequency (open book) 1 5-20% frequency 515% frequency
Figure 5-7 Closed Fracture. Figure 5-8 Open Book Fracture. Figure 5-9 Vertical Shear
Fracture.
SPECIFIC DIAGNOSES 123
Management
PITFALL Simple techniques may be used to splint unstable pelvic frac
tmes and close the increased pelvic volume prior to patient
Delay in stabilization of the pelvis al lows continued
Lransfcr and during the resuscitation with crystalloid fluids
hemorrhage.
and blood. These techniques include: ( 1 ) a sheet wrapped
arom1d Lhe pelvis as a sl ing, causing internal rotation of the
lower limbs, (2) commercially available pelvic splints, <md
(3) other pelvis-stabilizing devices (Figure 5- 10).
the sacrospinous and sacrotuberous ligaments and leads to
Reduction of an acetabular fracture by longi tudi n al
a majox pelvic instability. Fi gu re 5-9 shows a vertical shear traction of the lower extremity also can be useful. Although
fracture.
definitive management of pelvic fractures varies, one treat
ln some cases of severe injury, combinations of com ment algorithm based on the hemodynamic status for pa
pression and sh ear forces result in complex combination
tients i n emergency situations in sllown in Figure 5-6:
pallerns. These injuries are associated with major bleeding.
Management of Pelvic fractmes. Since significant resources
are required to care for patients with severe pelvic fractures,
Assessment early consideration of transfer to a trauma center is essential.
The Oank, scrotum, and perianal area should be inspected
quickly for blood at the urethral meatus; swelljng or brws
ing; or laceration in the perineum, vagina, rectum, or but
tocks, which is suggestive of an open pelvic fracture.
Palpation of a high-riding prostate gland also i s a sign of a
significant pelvic fracture.
Mecha.nical instability of the pelvic ring can be quickly
ascertained during physical examination of the pelvis. Once
instabiliL)' has been verified, a source of hemorrhage has
been suggested; no further maneuvers to demonstrate in
stability are necessary. A rapidly available x-ray may avoid
the pain and potential hemmorrhage associated with ma
nipulating the pelvis.
The fi rst indication of mechankal iJJStability is seen on
inspection for leg-length discrepancy or rotational deform it)' A
( usually external) without a fracture of that extremity. Be
cause the unstable pelvis is able to rotate extern ally the pelvis
,
can be closed by pushing on the iliac crests at the level of the

anterior superior iliac spine. Motion can be felt if the iliac
crests are grasped and the unstable hemipelvis is pushed in
ward and 1hen outward (compression Jjstraction maneu
ver). With posterior disruption, the involved hemipelvis can
be pushed cephalad as well as pulled caudally. This bansla
Lional motion can be felt by palpating the posterior iliac spine
and tubercle while pushing or pulJing the unstable
hemipelvis. When appropriate, an AP x-ray film of the pelvis
confirms the clinical examination. When time, availability,
and patient condition permit, the x-ray may be used in lieu
8
of manipulation to make th e diagnosis. rl' See Chapter 3:
Shock; and Skill Station N: Shock Assessment and Manage Figure 5- 1 0 Pelvic Stabilization. Pelvic binder
ment. (A) and pelvic stabilization using a sheet (B).
CHAPTER SUMMARY
..
The three distinct regions ot the abdomen are the peritoneal cavity, the retroperitoneal
space, and the pelvic cavity. The pelvic cavity contains components of both the peri
toneal cav1ty and retroperitoneal spaces.
Early consultation with a surgeon is necessary whenever a patient with possible in

traabdominal inju ries is brought to the emergency department. Once the patient's vital
functions have been restored, evaluation and management vary depending on the
mechanism of injury as described herein.
Patients with hemodynamic abnormalities and multiple blunt injuries should be rapidly
assessed for intraabdominal bleeding or contamination from the gastrointestinal tract
by performing a FAST or diagnostic peritoneal lavage. Patients with no hemodynamic ab
normalities and no peritonitis should be evaluated by contrast-enhanced CT. with the de
cision to operate based on the specific organ(s) involved and the magnitude of injury.
All patients with penetrating wounds in proximity to the abdomen and associated hy
potension, perito nitis, or evisceration require emergency laparotomy. Patients with gun
shot wounds that obviously traverse the peritoneal cavity or visceral/vascular area of the
retroperitoneum on physical or routine x-ray examination also require emergency la
parotomy. Asymptomatic patients with anterior abdominal stab wounds that are shown
on local wound exploration to penetrate the fascia or peritoneum are evaluated by se
rial physical examinations or DPL. However, laparoscopy or laparotomy remains an ac
ceptable option. Asymptomatic patients with flank or back stab wounds that are not
obviously superfiCial are evaluated by serial physical examinations or contrast-enhanced
CT. Exploratory laparotomy is an acceptable option with these patients as well. It is safer
to perform a laparotomy in patients with gunshot wounds to the flank and back.
Management of blunt and penetrating trauma to the abdomen and pelvis Includes:
Reestablishing vital functions and optimizing oxygenation and tissue perfusion
Prompt recognition of sources of hemorrhage with efforts at hemorrhage control
(such as pelvic stabilization)
Delineating the injury mechanism
Meticulous initial physical examination, repeated at regular intervals
Selecting special diagnostic maneuvers as needed, performed with a minimal loss
of time
Maintaining a high index of suspicion related to occult vascular and retroperitoneal
. . .
lflJUfleS
Early recognition for surgical intervention and prompt laparotomy
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388.

Performance at th1s sk1ll stat1onw1ll allow the participant to pradice and

Interactive Skill
dem onstrate the technique of d1agnostic peritoneal lavage (DPL) on a l1ve,
Procedure
anesthetized a n imal, a fresh human cadaver; or an a n atom 1c human body
,
Note: Standard precautions man1kin. Specifically, the doctor will be able to:

trauma patients.
OBJECTIVES
The preferred skill procedure for
peritoneal lava ge IS the open Identify the indications and contraindications of DPL.
techn1que, wh1ch avo1ds injury to
underlying structures. If an Perform the Seldinger procedure and the open procedure for DPL.
1nd1v1dual does not rout1 nely
perlorm an open DPL, use of the Describe the compl i cati ons of DPL .
Seld1nger techn1que 1s an
acceptable alterna uve for
doctors tramed 1n the techn1que
THE FOLLOWING
Skill VIll-A: Diagnostic

Peritoneal lavage: Open
Technique
Skill Vlll-8: Diagnostic

Peritoneal lavage: Closed
Technique
127
128 SKILL STATION VIII Diagnostic Peritoneal Lavage
Skill VIll-A: Diagnostic Peritoneal Lavage: Open Technique

STEP 1. Decompress the urinary bladder by inserting a STEP 12. [f the patient's cond itio n is stable, let tbe fluid
minary cat heter. remain a few minutes before placing the
crystalloid container on the floor and allowing
STEP 2. Decompress the stomach by inserring a gastric
tbe peritoneal fluid to draiJ1 fTom the abdomen.
tube.
Make sure the con tainer is vented to promote
STEP 3. Surgically prepare the abdomen (costal margiJ1 to flow of the fluid from the abdomen; adequate
the pubic area and flank to flank, anteriorly). tl uid return is >30% of the infused volume.
STEP 4. Inject local anesthetic al the midline, just below STEP 13. After the fluid returns, send a sample to the
the umbilicus. Use lidocaine with epinephrine to laboratory for Gram staining and eryth rocyte
avoid blood contamination from skin and and leukocyte cow1ts ( tmspun). Positive test
subcutaneous tissue. results and the need for surgical intervention

are indicated by I 00,000 red cells per cubic
STEP 5. Vertically incise the skin and subcutaneous
mi.llimeter or more, more than 500 white cells
tissues to t h e fascia.
per cubic millimeter, or a positi ve Gram stain
STEP 6. Grasp the fascial edges with clamps, and elevate for food tibers or bacteria. A nega ti ve lavage
and incise the fascia down to the peritoneum. does not exclude retroperitoneal injuries, such
Make a small nkk in the peritoneum, entering as pancreatic and duodenal injuries or
the peri tonea l cavi ty. diaphragmatic tears.
STEP 7. Insert a peritoneal dialysis catheter into the

peritoneal cavity.
COMPLICATIONS OF PERITONEAL LAVAGE
STEP 8. Advance the catheter into the pelvis.
Hemorrhage, secondary to injection oflocal
STEP 9. Connect the dialysis catheter to a syringe, and anesth etic or incision of the skin or
aspirate. subcutaneous tissues, which produces false
positive results
STEP 10. lf gross blood is not obtained, instill I L of
Peritonitis due to intestinal perforation from
wam1ed isotonic crystalJoid solution/normal
the catheter
saline ( 1 0 mL/kg in a chi ld) into the
L acerati on of u rinary bladder (if bladder not
peritoneum through the intravenous tubing
evacuated prior to procedure)
attached to the d ialysis catheter.
lnjury to other abdominal and retroperitoneal
STEP 1 1 . Gently agitate the abdomen to distribute the struc tu res requirin g operative care
Quid throughout the peritoneal cavity and Wound infection at the lavage site (late
increase mixing with the blood. com pl i ca tion )
Skill VIII-: Diagnostic Peritoneal Lavage: Closed TecHnjque

STEP 1 . Decompress the urinary bladder by inserting a STEP 5. Elevate the skin on either side of the proposed
tui nary catheter. need le insertion site wilh the fmgers or (creeps.
STEP 2. Decompress the stomach by inserting a gastric STEP 6. Lnsert an IS-gauge beveled needle attached to a
tube. syringe through the skin and subcutaneous tissue.
Resistance is encOlmtered when traversing the
STEP 3. Surgically prepare the abdomen ( costal margin to fascia and again when penetrating the peritoneum.
the pubic area and flank to flank, a nteriorly).
STEP 7. Pass the flexible end of the guidewire through the
STEP 4. Inject local 3Jlesthctic at the midline, just below 18-gauge needle until resistance l.s met or 3 em is
the umbilicus. Use lidocaine \Vith ep inep hri ne to still showing outside the needle. Remove the
avoid blood contamination from skin and needle from the abdominal cavity so that only
subculaJleous Lissue. the guidev.rire remains.
SKILL STATION VIII Diagnostic Peritoneal Lavage 129
STEP 8. Make a small skin incision at the entrance site of STEP 1 3. After the fluid has returned, send a sample to
the catheter, and inl>ert the peritoneal lavage the laboratory for Gram staining and
catheter over the guidewirc and into the erythrocyte and leukocyte counts ( unspu n). A
peritoneal cavity. Remove the guidewire fom the positive test and the need for surgical
abdominal cavity so that only the lavage catheter interveMion arc indicated by 100,000 red cells
.
remams. per cubic millimeter or more, more than 500
white cells per cubic millimeter, or a positive
STEP 9. Connect the dialysis catheter to a syringe. and
Gram stain for food fibers or bacteria. A
aspirate.
negative lavage does not exclude retroperitoneal
STEP 10. If gross blood is not obtained, instill I L of injurie1., such as pancreatic and duodenal
warmed isotonic crystalloid solution ( 10 mL/kg injurie1. or diaphragmatic tears.
in a child) into the peritoneum through the
intravenous tubing attached to the dialysis
COMPLICATIONS OF PERITONEAL LAVAGE
catheter.
Hemorrhage, secondary to injection of local
STEP 1 1 . Gently agitate the abdomen to distribute the
ancsthet ic or incision of the skin or
fluid throughout the peritoneal cavity and
subcutaneous tissues, which produces fabe
increase mixing with the blood.
positive results
STEP 12. If the patient's condition is stable, let the fluid Peritonitis due to intestinal perforation from
remain a few minutes before placing the the catheter
crystalloid container on the floor and allowing Laceration of urinary bladder (if bladder not
the peritoneal fluid to drain from the evacuated prior to procedure)

abdomen. Make sure the container is vented to Injury to other abdominal and retroperitoneal
promote now of the Ouiu from the abdomen; structures requiring operative care
adequate fluid return is >30%> of the infused Wound infection ot thc lavage site (late
volume. complication)
C H A PT E R
CHAPTER OUTLINE Upon completion of this topic, the student will demonstrate
the a bil ity to apply the techniques of assessment and explain
Objectives
the emergency management of head trauma. S pecifically the,
Introduction doctor will be able to

Anatomy
Scalp OBJECTIVES
Skull
Meninges Describe basic intracranial physiology.
Brain
Ventricular System Evaluate patients with head and brain injuries.
Tentorium
Perform a focused neurologic examination.
Physiology
Intracranial Pressure Explain the importance of adequate resuscitation
Monro-Kellie Doctrine in limiting secondary brain injury.
Cerebral Blood Flow
Determine the need for pati ent transfer, admis
Classifications of Head Injuries
sion. consultation, or discha rge.
Mechanism of Injury
Severity of Injury
Morphology
Management of Minor Brain Injury
(GCS Score 13-15)
Management of Moderate Brain Injury Surgical Management
(GCS Score 9-12) Scalp Wounds
Depressed Skull Fractures
Management of Severe Brain Injury (GCS Score 3-8)
Intracranial Mass Lesions
Primary Survey and Resuscitation
Penetrating Brain Injuries
Secondary Survey
Diagnostic Procedures Prognosis
Medical Therapies for Brain Injury Brain Death
Intravenous Fluids
Chapter Summary
Hyperventilation
Mannitol Bibliography
Steroids
Barbiturates
Ant1convulsants
132 CHAPTER 6 Head Trauma
Introduction
Head inj uries are among the most common types of traum
seen in N orth American em ergency d epartments (EDs),
with an estimated l million cases seen an nual ly. Many pa
tients with severe bra in inj uries die before reaching a hos
pital, and almost 90;b of prehospital trauma-related deatl1s
involve brain inju ry. About 70% of patients with brain in
juries who receive medical attention can be categorized as
having minor i njuries, 15% as moderate, and 15% as severe.
In 2003 there were an estimated 1,565,000 traumatic brain
injuries (TB!s) in the United Stales, i ncluding I ,224,000 ED
visits, 290,000 hospi talizations, and 51,000 deaths. Survivors

of TBI are often left with ncuropsychologic impai rmen ts

that result in disabilities affecti ng work and soci al activ ity.
Every year, an estimated 80,000 to 90,000 people in Lhe
Presence and type of associated injuries
United States exp erience Lhe on&el of long-term disability
from brain injury. In an average European country (Den Resul ts of d iagnostic stud ies, part icLtl arl y CT scan
mark), 363 per million inhabitants suffer mode rate to se (if available)
vere head inj uri es yearly, with more than one-third of these
Treatmen t or hypoten sion or hypoxia
requi ri ng brain inj ury rehabilitalion. Therefore, even a small
reduct ion in the mortality and morbidity resu l ting from
Do not delay patient transfer to obtain a CT scan or other
brain inju ry should have a major impact on publ ic heaiLh.
diagnostic tests.
The primary focus o f treatment for patients in whom a
severe brain injury is suspected should be to prevent sec
ondary brain injury. P roviding adeq uate oxygem1tion and
maintaining a blood pressure that is sufficient to perfuse the
brain arc the most importa nt ways to limit secondary brain Anatomy
damage and thereby improve the patient's outcome. Subse
quent to managing the ABCDEs, identification of a mass le
sion requiring surgical evacuation is critical , and t his is best
I What are the unique features of brain
anatomy and physiology, and how do
achieved by in1mcdia tely obtaining a computed tomo
they affect patterns of brain injury?
graphic (CT) scan of the head. However, obtaini ng a CT
scan should n ol delay patient transfer to a trauma center ca t\ review of craniaJ anatomy includes th e scaJp, skull,
pabl e of immediate and definitive neurosu rgicaJ interven m eni nges, brain, ventricular system, cerebrospinal lluid, and
tion. ten torium (Figure 6-1 ).
The triage of a patient with brain injury depends on the
sever ity of the i nj ury and the facilities available within a par
SCALP
ticular commu nity. For facilities without neurosurgical cov
erage, prear ra nged transfer agreements wiLh higher-level The scal p is made up of five layers of tissue ( mnemonic:
facilities should be in place. Consultation with a neu rosur SCALP) that cover lhe skull: ( 1 ) skin, (2) connective tiss ue,
geon ea rl y in the course or treatmen t is stron gly recom (3) aponeurosis or gaJea aponeurotica, ( 4) loose areolar tis
m ended, especial ly if the pati en t is comatose or brain inj u ry sue, and (5) pericran i tun . Loose areolar tissue separates the
is othenvise su spected. ga l ea from the pericra n i u m and is the site of subgal eal
In consul.ting a neurosurgeon about a patient with a hematomas. Because of the scalp's gene rous b l ooc.! supply,
brain injllly, tl1e following information is relayed : scalp lacerations may result in majo r bl ood l oss, especi ally in
infants and c hil d re n.
Age of pati en t and mechanism and time of injury
Resp iratory and cardiovascular s tat us ( parL icu larl y SKUll

blood pressure and oxygen sat uration )
The sku ll is composed of the cran iaJ vault (calvaria) and the
The neurologic examination, consist ing of the Glas base. The calvaria is es pec ially thin in the temporal regions,
gow Coma Scale (GCS) score (with particular em bu t is cu sh ioned here by the temporal i s muscle. The base of
phasis on th e motor response ) a nd p upil size and the skull is irregular, whi.ch may contribute to injtuy as the
reaction to Eght brain moves within the skull during acce l eration an d decel -
ANATOMY 133
Subarachnoid Third Choroid Superior

space ventricle plexus sagittal sinus
..H'l Straight sinus
Midb rain
,'i.,' :r4-'-T--Subarachnoid
space
) Fourth
Choroid plexus \11f=-----y{__ __: Central canal

of cord
'
Spinal cord '

'
'
' I
.. .. - '
Figure 6-1 Overview of Cranial Anatomy.
l
eration. The tloor of the cranial cavity is divided into hree Meningeal arteries lie between Lhe dura and the inter
distinct regions: the anterior, middle, and posterior cranial nal surface of the skuJJ ( the epidural space). Overlying skull
fossae. Simply put, the anterior fossa houses the frontal fractures may lacerate these arteries and cause an epidural
lobes, the middle fossa the temporal lobes, and Lhe poste hematoma. The most commonly injured meningeal vessel
rior fossa the lower brainstem and the cerebellum. i:. the middle meningeal artery, which is located over the
temporal fossa. An expanding hematoma from arterial in
jury in this location may lead to rapid deterioration and
MENINGES
death. Epidural hematomas may also result from injury to
The meninges cover Lhe brain, and consist of th ree layers: dural sinuses and from skull fractures, which tend to expand
tbe dura mater, arachnoid, and pia mater (Figure 6-2). The more slowly and to put less pressure on the underlying
dura mater is a tough, fibrous membrane that adheres firmly brain. However, most epidural hematomas represent a life
to Lhe internal surface of the skull. At specific sites the dura threatening emergency, and must be evaluated hy a neuro
splits inlo Lwo leaves that enclose the large venous sin uses surgeon as soon as possible.
that provide the major venous drainage from the brain. The Beneath the dura is a second meningeal layer, the thin
midline superior sagirtal sinus drains into the bilateral trans transparent arachnoid membrane. Because the dura is not
verse and sigm oid sinuses, which are usually larger on the attached to the w1derlying arachnoid, a potential space be
right side. Laceration of these venous sinuses may result in tween these layers exists (the subdural space), into which
massive hemorrhage. hemorrhage may occur. In brain injury, bridging veins that
Dura mater:
Periosteal layer
Meningeal layer
Arachnoid mater
Blood vessel------=:;
Pia mater -----
Brain: SinUS
Gray matter -!
White matter__
="-
- -1-
- - Falx cerebri
(in longitudinal
fissure only)
Figure 6-2 The Meninges. The meninges cover the brain and consist of three layers: the dura mater. arachnoid,
and pia mater.
travel from the surface of the brain to the venous sinuses in more than SS'Vo ofleft-handed people. The hemisphere that
within the dura may tear, leading lo the formation of a sub contains the language centers is referred to as the dominant
dural hematoma. hemisphere. The frontal lobe controls executive function,
The third layer, 1 he pia mater, is firmly attached to the emotions, motor function, and, on the dominant side, ex
surface of the brain. Cerebrospinal Ouid (CSF) tills the space pression of speech (motor speech areas). The parietal lobe di
between the watertight arachnoid and the pia mater (the rects sensory function and spatial orientation. The temporal
subarachnoid space), cushioning the brain and spinal cord. lobe regulates certain memory functions. Jn virtually all right
Hemorrhage into this tlu.id-fiJled space (subarachnoid hem handed and the majority of left:-handed people, the left tem
orrhage) is frequently seen i n brain contusion or injury to poraJ lobe contains areas responsible for speech reception and
major blood vessels at the base of the brain. integration. The occipital lobe is responsible for vision.
The brainstem is composed of the midbrain, pons, and
medulla. The midbrain and upper pons contain the reticu
BRAIN
lar activating system, which is responsible for the state of
The brain consists or Lhc cerebrum, cerebellum, and brain alertness. Vital cardiorespiratory centers reside i n the
stem (see Figure 6 - l ) . The cerebrum is composed of right and mecluUa, which continues on to form the spinal cord. Even
left hemispheres that arc sep<uated by the falx cerebri-a smaU lesions in Lhc brainstcm may be associated with severe
downward dural reflection from the inferior a:;pect of the murologic deficits.
midline superior sagittaJ sinus. The left hemisphere contains The cerebellum, responsible mainly for coordination
the language centers in virtually all right-handed people and and balance, projects posteriorly in the posterior fossa and
PHYSIOLOGY 135
forms connections with the spinal cord, brainstcm, and ul Physiology

timately, the cerebral hemispheres.
Physiologic concepts that relate to head trauma include in

VENTRICULAR SYSTEM tracranial pressure, the Monro-Kellie doctrine, and cerebral
The ventricles are a system of CSF-fillcd spaces and aque blood flow.
ducts within the brain. Located in the roof of the left and
right lateral ventricles <1nJ midline third ventricle is " lacy
INTRACRANIAL PRESSURE
structure called the choroid plexus. The choroid produces
CSF at a rate of approxi mately 20 mL/hr. The CSF circulates SeveraJ pathologic processes that affect the brain may cause
from the lateral ventricles of the brain through the foram elevation of intracranial pressure (ICP). Elevated JCP may
ina of Monro, the third ventricle, and Lhe aqued uct of reduce cerebral perfusion and cause or exacerbate ischemia.
Sylv iu s into the fourth ventricle in the posterior fossa. l l then The normal JCP in lhe resting slate is approximately I 0 mm
exits from the ventricLLlar system into the subarachnoid Hg. Pressures greater than 20 mrn Hg, particularly if sus
space overlying the brain and spinal cord and is reabsorbed tained a.nd reCractory to treatment, are associated with poor
into the venous circulation th rough arachnoid granulations outcomes.
that project into the superior sagittal sinus. The presence of
blood in the CSF may imp<1ir CSF reabsorption, resulting in MONRO-KELLIE DOCTRINE
increased i ntracranial pressure and enlarging ventricles
( postlrawmt Jic communicating hydrocephalus). Edema and The Monro-Kellie Doctrine is a simple, yet vitally impor
mass lesions (eg, hematomas) may cause effacement or tant, concept related to the understanding of TCP dynam
shifting of the usually symmetric ventricles th<lt c;.m be eas ics. It slate that Lhe total volume of tl1e intracranial contents
ily identi lied on CT scans of the brain. must remain constant, because the cranium is a rigid, non
expansile container. Venous blood and cerebrospinal fluid
may be compressed out of the container, providing a degree
TENTORIUM of pressure buffering (Figure 6-3 and figure 6-4). Thus, very
The tentorium cerebdli divides the head into the supra early after injury, a mass such as a blood dot may enlarge
tentorial compartment (comprising the anterior and mid while the JCP remains normaL However, once the limit or
dle fossae of the skull) and the infratentorial compartment disphKemenl of CSF and intravascular blood has been
(containing the posterior fossa ). The midbrain connects reached, ICP rapidly increases.
Lhc cerebral hemispheres to the rest of the brainstem (pons
and medulla oblongata) as it passes through a large aper
ture in the tentorium known as the tentorial incisura. The
oculomotor (cranial nerve HI) nerve runs along the edge Volume-Pressure Curve
of the tentorium and may become compressed against it
during temporal lobe herniation, which most commonly 60 - -
results from a supratentorial mass or edema. Parasympa 55 Herniat1on
thetic fibers that constrict the pupil lie on the surface of 50

the third cranial nerve. Compression o f these superficial 45
fibers during herniation causes pupilhuy dilation due to 40
unopposed sympathetic ac:tivity, often referred to as a 35
"blown" pupil. 30
The part of the brain that usually herniates th rough the 25 Point of
tentorial notch is Ll1e medial part or the temporal lobe, 20 Decompensation
known as the uncus. Uncal herniation also causes compres 15 \

sion of the corticospinal (pyramidal) tract in the midbr<1in. 10t--------------
The motor t ract crosses to the opposite side at the foramen
5 ------Com2pens=ation----J
Volume of Mass
magnum, so compression at the level of the midbrain re
sults in weakness of the opposite side of the body (con
tralateral hem ipares is). Ipsilateral pupillary dilation Figure 6-3 Volume-Pressure Curve. The intracra
associated with contralateral hemiparesis is the classic syn nial contents are initially able to compensate for a new
drome of uncal herniation. Lnfrequently, the mass lesio.n intracranial mass, such as a subdural or epidural
may push the opposite side o f the midbrain against the ten hematoma. Once the volume of this mass reaches a
torial edge, resulting in hemiparesis and <1 dilated pupil on critical threshold, a rapid increase in intracranial
the same side as the hematoma (Kernahan's notch syn pressure often occurs, which can lead to reduction or
drome). cessation of cerebral blood flow.
Normal state - ICP normal
Venous Arterial Brain CSF

volume volume
Compensated state - ICP normal
Venous Arterial Brain Mass CSF

volume volume
Decompensated state - ICP elevated
Brain
volume volume
75 ml 75 ml
Figure 6-4 The Monro-Kellie Doctrine regarding intracranial compensation for expanding mass. The volume
of the intracranial contents remains constant. If the addition of a mass such as a hematoma results in the squeezing
out of an equal volume of CSF and venous blood, the ICP remains normal. However, when this compensatory mecha
nism is exhausted, there is an exponential increase in ICP for even a small additional increase in the volume of the
hematoma, as shown in Figure 6-4. (Adapted with permission from Narayan RK: Head Injury, in Grossman RG,
Hamilton WJ (eds): Principles of Neurosurgery. New York, Raven Press, 1991.)
CEREBRAL BLOOD FLOW for days or weeks after injmy. There is increasing evidence
that such low levels of CBF are inadequate to meet the meta
Tn healthy adults, cerebral blood flow (CBF) is 50 ro 55 bolic demands of the brain early after injury and that re
mL/ I 00 g of brain tissue per minute. J n children, CBF may
gional, even global, cerebral ischemia is common.
be much higher, depending on age. At 1 year of age, CBF ap
The precapillary cerebral vasculaLure normally has Lhe
proximates adult levels, but at 5 years of age, normal CBF is ability to reflexively constrict or dilate in response to changes
approximalely 90 mL/ 100 g/min and then gradually declines
n
i cerebral perfusion pressure (CPP), which for clinical pm
to aduiL levels by Lhe mid to late teens. poses is defU1ed as mean arlerial blood pressure minus in
Brain injmy severe enough to cause coma may cause a
LracranjaJ presstLre. A CPP of 50 Lo 150 mm Hg is required
marked reduction in CBF during the first few hours after
to maintain a constant CBF (pressure autoregulation). These
injury. It usually increases over the next 2 to 3 days, but for
vessels also normaUy constrict or dilate in response Lo
patients who remain comaLose, CBF remains bdow normal changes in the Pao2 or Paco2 of the blood (chemical au-
CLASSIFICATIONS OF HEAD INJURIES 137
toregulation). Severe traumatic brain injury may disrupt salvageable brain tissue during the first few days after se
both of these autoregulatory mechanisms. vere TBL This pathophysiologic state is characterized by
Consequently, the traumatized brain is vulnerable lo is progressive inflam mation, vascular permeabil ity, and brain
chemia and infarction due to the severe reduction i.r blood tissue edema, culminating in intractably elevated ICP and
flow caused by the traumatic insult itself. This preex isting death.
ischemia may easiJy be exacerbated by the secondary insults
of hypotension, hypoxia, and hypocapnia, such as that
caused iatrogenically by overly aggressive hyperventilation.
Therefore, every effort should be made to enhance cerebral
perfusion and blood flow by reducing the elevated ICP, main Classifications of Head Injuries
taining normal intravascular volume, maintaining a normal
mean arterial blood pressure (MAP), and restoring normal Head injuries are classified in several ways. For practical pur
oxygenation and normocapnia. Hematomas and other le poses, the following th.ree descriptions are useful: ( I ) mech
sions that increase intracranial volume should be evacuated anism, (2) severity, and (3) morphology (Table 6-1).
early Maintaining the cerebral perfusion prcssme above 60

.
mm Hg helps to improve CBF (although significantJy

MECHANISM OF I NJURY
higher pressures have been implicated in worsening pul
monary outcomes). Once compensatory mechanisms are Brain injury may be broadly classified as blunt or penetrat
exhausted and there is an expo.nenliaJ increase in 1CP, brain ing. For practical purposes, the term blum /;rairl injury usu
perfusion is compromised, especially in patients with hy ally is associated with automobile collisions, falls, and
potension. Additional insults contribute to the potentially assaults with blw1t weapons. Penetrati11g brain injury usu
devastaLing "secondary injury" that may occur in otherwise ally resuJts from gunshot and stab wounds.
TABLE 6-1 Classifications of Brain Injury
Mechanism
Blunt Hig h velocrty (auwmobile collision) .
Low veloci ly (fall, assault}
Penetrating Gunshot wounds

Other penetrating injuries
Severity
M inor GCS score 13-15
Moderate GCS score 9-1 2

Severe GCS score 3-8
Morphology
Skull fractures
Vault Linear vs, stellate
Depressed/nondepressed
Open/closed
Basilar With/without CSF leak

With/without seventh-nerve palsy
I n tracra nial lesions

Focal Epidural
Subdural
Intracerebral
Diffuse Concussion
MuIllpie contusions
Hypoxdischem1c 1njury
Adapted with permission from Valadka AB. Narayan RK Emergency room management of the headmlured paLent In: Narayan RK,
Wilberger JE, Povlishock JT, eds Neurotrauma. New York, NY: McGraw-Hill; 1996:120
SEVERITY OF INJURY and help in itl> idtntification. These signs include periorbital
ecchymoi (r<tccoon eye). retroauricular ecchymosis (Bat
The GCS :,core i5 used a an objective clinical measure of the tle sign), csr. leakage from the noe (rhinorrhea) or ear
se,erity of brain i njury. Patient!> who open their eyes sponta (otorrhea), and seventh- and eighth-nerve dysfunction (fa
neously. obey commands, and are oriented score a total of 1 5 cial paralysis and heari ng loss), which may occur immedi
points on the CCS. whereas flaccid patients who do not open ately or a few days after the initial injury. In general, the
their eyes or vocalize sounds score the minimum (3 points) prognosis for the recovery of seventh-nerve function is bet
(Table 6-2). A GCS score of8 or less has become the generally ter in the delayed-onset variety, but the prognosis for recov
accepted definition ofcoma or severe brain injury. Patients with ery of eight h-nerve function i poor. Basal skull fractures that
a brain injury who have a GCS score of9 to 1 2 are categorized traverse the carotid canals may damage the carotid arteries
as "moderate," and t hoc with a GCS core of 13 to 15 are des (dissection, pseudo.1ncurysm, or t hrombosis ) , and consider
ignated as "minor." In assessing the GCS score, when there is ation should be given to cerebral arteriography.
right/left asymmetry, it is important to use the best motor re Open or compound skull fractures may provide a di
sponse in calculating the score because this is the most reliable rect communication between the scalp laceration and the
predictor ofoutcome. l lowever, one must record the actual re cerebral surface, because I he dura may be torn. The signifi
sponse on both sides. cance of a skull fracture should not be underestimated, since
It takes considerable force to fracture the skull. A linear vault
MORPHOLOGY fracture in conscious pa tients increases the likelihood of an
intracranial hematoma by 1hout 400 times.
,
Head trauma may include fractures, conlusions, hema

tomas, and diffuse injuries.
Intracranial Lesions
Skull Fractures Intracranial lesiom may be dassified as diffuse or focal, al

though these two forms frequently coexist. Focal lesions
Skull fracture!> m.ty be seen in the cranial vault or skull base.
include cpidur,ll hematoma!>, subdural hematomas, contu
They may be linear or stellate, and open or closed. Basal skull
sions, and intracerebral hematomas (see Table 6-1 and Fig
fractures usua lly require CT scanning with bone-window set
ure 6-5).
tings for identification. The presence of clinical signs of a
baal skull fracture should increase the index of suspicion
Diffuse Brain Injuries Diffu11e brain injuries range from
mild concussions, in which the CT scan of the head is usu
ally normal, to severe hypoxic ischemic injuries. With a con
cussion, the patient has a l ra nsicn t, non focal neurologic
TABLE 62 Glasgow Coma Scale (GCS) disturbance that often includes loss or consciousness. Severe
ili1Tuse injuries ortcn result from a hypoxic, ischemic insult to
ASSESSMENT AREA SCORE the brain due to prolonged shock or apnea occmring imme
diately nfler the trauma. ln such cases, the CT scan may ini
Eye opening (E)
Spontaneous 4 tially appear normll, or the brain may appear d iffusely
To speech 3 swollen, with loss of the normal gray- wh ite distinction. An
To pain 2 other diffuse pallern, o fte n seen i n h igh-velocity impact or
None 1
deceleration injuries, may produce multiple punctate hem
orrhages throughout t he cerebral hemispheres, which are
Best motor response (M)
often 5een in the border between the gray matter and white
Obeys commands 6
Localizes pam 5
matter. These "shearing injuries," referred to as diffuse ax
Normal flexion (withdrawal) 4 onal injury (l)Al), previously defined a clinical syndrome of
Abnormal flex1on (decortiCate) 3 severe brain injuqr with uniformly poor outcome. However,
Extens1on {decerebrate) 2 it may be more appropriate to restrict the use of this. term to
None {flacod) 1
case11 in which there i microscopic C\oidence of cerebral ax
onal injury, which may be seen in a wide spectrum of clini
Verbal response (V)
cal presentatiom.
Onented 5
Confused conversat1on 4
Inappropriate words 3 E pid ura l Hematomas Epidural hematomas are rela
Incomprehensible sounds 2 tively uncommon, occurring in about 0.5% of patients with
None 1
brain injuries and in 9% or those who arc comatose. These
hemaLOmas ty pically become biconvex or lenticular in shape
GCS score = (E + M + V); best possible score = 15; worst
as they push the adherent dur.l away rrom the inner table of
possible score = 3.
.... ' '""" .... "" ...... .... .... '"' ....... _,.,, "'' . .
....... ..4......
...
the skull. They arc mosl often located in the temporal ortem-
CLASSI FICATIONS OF HEAD INJURIES 139
B
A
c D
Figure 6-5 CT Scans of Intracranial Hematomas. (A) Epidural hematoma. (B) Subdural hematoma. (C) Bilat
eral contusions with hemorrhage. (D) Right intraparenchymal hemorrhage with right to left midline shift. Associated
biventricular hemorrhages.
poroparietal region and often result from a tear of Lhe mid cerebral cortex. I n contrast to I he len Licular shape of 1 n
Jlc mcni ngeal anery as I he result of a fracture. These clots epid ural hematoma on CT scan, subdural hematomas more
are classically arterial in origin; however, they also may re often appear to conform to the contours of the brain. Sub
sult from disruption of ,1 major venous sinus or bleed ing dural hematomas may grow to cover the entire surface of the
from a skul l fracture. hemisphere. Furthermore the brai n damage underlying an
,
acute subduraJ hematoma is I)'Pically much more severe than

Subdural Hematomas Subdural hematomas are more Ihat with epiduraJ he matoma!>.
common than ep idural hematomas, occurring in approxi
mately 30% of severe brain injuries. They often develop Jrom Contusions and Intracerebral Hematomas Cerebral
the shearing of smaJJ su rface or bridging blood vessels of the contusions are fairly common (present in about 20% to 30%
of sewn: brain injuries). The majoriry of contusions occur in with particular attention to any loss of consciousness. in
the frontal and temporal lobe:., although they may occur in cluding the length of time the patient was unresponsive, any
any p.trt of the brain. Contusions may, in a period of hours sei7.ure activity, and the subsequent level of alertness. De
or days, evolve to form ru1 intracerebral hematoma or a coa. termine the duration of amnesia both before (retrograde)
lcscent contusion with enough mass effect to require imme and after (antegrade) the accidenl. Grade the severity of
diate surgical evacuation. This occurs in as many a:. 20% of headache and note the length of time the patient requires to
patienb presenting "'rith contusions on initial CT scan of the return to a GCS score of 1 5 using serial examinations.
head. For this reason, patients with contusions should un CT scanning is the preferred method of imaging. A CT
dergo repeat CT scanning to evaluate for changes in the pat scan should be obtained in all patients with brain injury
tern ofcontusion 12 to 24 hours after the initial scan. who fail to reach a GCS score of 1 5 within 2 hours of injury;
who have a clinically suspected open skull fracture, any sign
of basal skull fracture, or more than hvo episodes of vomit
ing; or who are older than 65 years (Table 6-3). CT should
also be considered if the patient has had a loss of con
Management of Minor Brain scinusness for longer than 5 minutes, retrograde amnesia

Injury (GCS Score 1 3- 1 5) for longer than 30 minutes, a dangerous mechanism of in

jury, severe headaches, or a focal neurologic deficit attrib
What is the optimal treatment for utable to the brain. Caution should be applied in assessing
patients with TBl who are anticoagulated. The international
patients with brain injuries?
normalized ratio (Dffi) should be obtained and a Cf should
i\n estimated I million patients with head injuries are seen be performed expeditiouly in these patients when indi
in North American EDs annually. Approximately 80% of cated.
these patients arc categorized as having a minor brain in Applying these parameters to patients with a GCS score
jury. Minor traumatic brain injury ( MTRI) is defined by a of 13, approximately 25% will have a CT fmding indicative
history of disorientation, amnesia, Or tTlnsient loss of con of trauma, and 1.3% will require neuro:.urgical interven
sciousness in a patient who is conscious and talking. This tion. Using these rules in patients with a GCS score of 15,
correlates with a GCS score of 1 3 to 15. The definition of 10% will have the CT findings and 0.5% will require neuro
MTBI has often been distinguished lrom the term cOIICilS surgery. Based on current best evidence, no patients with
sHlll, which has been broadly defined as "a complex patho clinically important brain injury or patients requiring neu
phy!>iologic process affecting the brain, induced by rosurgical intervention will be missed.
traumatic biomechanical forces." The history of a brief loss If CT scanning is not avai !able, skull x-ray films may be
of consciousness can be difficult to confirm, and the picture obtained for blunt or penetrating head injury. If a skull x-ray
often is confounded by alcohol or other intoxicants. The tilm is obtained, look for the following features: ( I ) linear or
management of patients with minor brain injury i:. de depre:;sed skull fractures, (2) midline position of the pineal
scribed in Figure 6-6. gl<nd (if calcified), (3) air-nuid levels in the sinuses, {4)
Most patients with minor brain in.iury make unevent pncumocephalus, (5) facial fractures, and (6) foreign bod
ful recoveries. About 3% have unexpected deterioration, ies. Obtaining CT scans or skull films should not delay trans
posibly resulting in severe neurologic dysfunction unless fer of the patient.
the decline in mental status is detected early. Others strug If abnormalities are observed on the CT scan, or if the
gle with persistent morbidiry, including chronic headaches patient remains symptomatic or continues to have neuro
or memory and sleep disturbances. logic .tbnormalities, he or she should be admitted to the hos
The secondary survey is particularly important in eval pital and a neurosurgeon consulted.
uating patients with MTBI. Note the mechanism of injury, If patients are asymptomatic, are fully awake and alert,
and have no neurologic abnormalities, they may be observed
for several hours, reexamined, and, if still normal, safely dis
charged. Ideally, the patient is discharged to the care of a
PITFALL companion who can observe the patient continually over
the ncxt 24 hours. An instruction sheet directs both the pa
Patients with minor traumatic brain i nj uri es may ap tient and the companion to continue dose observation and
pear ne urologically normal but continue to be symp to return to the ED if headaches develop, there is a decline
tomatic for some time. Be sure that these patients in mental status, or focal ncurologit deficits develop. I n all
avoid any unnecessary risk of a "second impact"
cases, written discharge im.tructions should be supplied to
during the symptomatic period that can result in
and carefully reviewed with the patient and/or companion
devastating brain edema. Emphasize the need for
competent follow-up and clea rance before resum ( Figure 6 7). If the patient i not alert or oriented enough to
ing normal activities especi ally contact sports.
,
clearly understand the written and verbal instructions, the
decision for discharge should be reconsidered.
MANAGEMENT OF MINOR BRAIN INJURY (GCS SCORE 13-15) 141
Definition: Patient is awake and may be oriented (GCS 13-15)
History
Name, age, sex, race, occupation Subsequent level of alertness

Mechanism of injury Amnesia: Retrograde,
Time of injury antegrade
Loss of consciousness immediately Headache: Mild, moderate,
postinjury severe
General examination to exclude systemic injuries
Limited neurologic examination
Cervical spine and other x-rays as indicated
Blood-alcohol level and urine toxicology screen
CT scan of the head is indicated if criteria

for high or moderate risk of neurosurgical
intervention are present (see Table 6-3)
No CT scanner available Patient does not meet any of

Abnormal CT scan the criteria for admission
All penetrating head injuries Discuss heed to return if any
History of prolonged loss of problems develop and
conciousness issue a "warning sheet"
Deteriorating level of Schedule a follow-up visit
conciousness
Moderate to severe headache
Significant alcohol/drug
intoxication
Skull fracture
CSF leak: Rhinorrhea or
otorrhea
Significant associated injuries
No reliable companion at
home
Abnormal GCS score (<15)
Focal neurologic deficits
Figure 6-6 Algorithm for Management of Minor Brain Injury. (Adapted with permission from Valadka AB,
Narayan RK: Emergency room management of the head-injured patient, in Narayan RK, Wilberger JE, Povlishock JT
(eds): Neurotrauma. New York, McGraw-Hill, 1996.)
TABLE 6-3 Indications for a Scartning in MTBI
Head CT IS requred for patients w1th minor head 1n1une.s {ie. wrtnessed loss of conSCIOUSness. definrte amnesra or ,
witnessed drsonentation rna patient w1th a GCS score of 13 to 1 5} and any one of the followrng
High risk for neurosurgical intervention: Moderate risk for brain injury on CT:
GCS score less than 1 5 a t 2 hours after InJury Amnesia before 1mpact (more than 30 mrnutes)
Suspected open or depressed skull fract ure Dangerous mechanism (eg, pedestrian suuck by
Any s1gn ol basal skull fracture (eg, 11ernotympanum, motor vehicle, occupant ejected from mo1or veh1cle,
raccoon eyo?s, CSF otorrhea or rh1norrhea, Battle s1gnl fall from herght more than 3 feet or five stairs)
Vomiting (more than two episodes}
Age greater than 65 years
Adapled frorn Strcii iG, Wells GA. Wmdernhcen K, et al The Canadriln CT Head Rule for patrents wrth mrnor head rn1ury L<i!ncet
2001,357 1294
. ........ . .... ..... ' .... . .. '""' . - '"' ..
. . . .... ""' "" .
. ..... "" "" "" '"' . ........
... .. .... ""' ... .... ' .... "' .... '" ' ' "'" .. ....... -- ' ""'" ' "'' ....... . .....
Management of Moderate Brain Management of Severe Brain

Injury (GCS Score 9-1 2) Injury (GCS Score 3-8)
Approxim a tely IO'Vt> of patients with brain injury who arc Patients who have sus tain ed a severe brain injury arc unable
seen in the ED have ,1 moderate injury. They slill are able to follow simple commands, even after cardiopulmonary
to follow simple Lonunands, but usually are confuse d or stabilization. Although this definition includes a wide spec
somnolent and can have focal n cu rol ogil: deficits such a trum of brain injury, it identities the patients who are at
he miparesi s. Approxi m a tely IOo/o to 20% of these p ati e n t:. greatest risk of uffcring significant morbidity and mortal
deteriorate and la pe into coma. For thb reason, serial ity. A "wait and sec" approach i n l>liCh pa t ien ts can he disas
ne u ro logic examinations arc c r it i ca l to t re at these pa trow;, and prompt diagnosis and treatment are extremely
l ien ts. i m po rtan l. Do not delay patient transfer to obtain a CT scan.
The management of poticnts with moderate brain in The initial management of severe brain injury is oul
jury i described in Figure 6-8. lined in Figure 6-9.
On admissio n to the ED, a brief h 1story is obtained and
c<Hd iopulmonary stability is ensured before neurologic as
sessment. A CT scan of the head i:. ob ta i ned and a neuro ,
PRIMARY SURVEY AND RESUSCITATION
surgeon is contacted. All of these patients require admission Brain injury often is adversely affected by secondaTy insults.
for observati on in an intensive care unit ( ICU) or a similar The mor tali ty rate for patients vvith severe broin injury who
unit capable of close nursing observation and fn:quent neu have hypotension on admi ssi on is more than double that of
rologi c reassessment for at least the first 1 2 to 24 hours. A patients who do not have hypotenion. r he presence of hy
follow-up CT scan in 1 2 to 24 hours is recommended if the poxia in addition to hypotensi on is associated with mortal
initial CT scan il. abn ormal sooner if there tl> deterioration,
ity of approximately 75%. Therefore, it is imperative that
nf the pctient neu rologic status.
'
cardiopu lmonary stabilization be ach ieved rapidly in patients
with severe brain injury. See Box 6-1 f'or the pri ori ties of the
initial evaluation and triage of patients with severe brain in
juries. ,/' See Skill Station IX: Tlead and :--Jcck Trauma: As
essment and Management, Skill JX-A: Primary Survey.
PITFALL .
.
:
: .
. -
-
-
Airway and Breathing

Patients with moderate brain injury can have rapid Transient respiratory arrest and hypoxia arc common nnd
deterioration with hypoventilation or a subtle loss may cause second tH)' brain inju ry. Early endotracheal intu
of their ability to protect their airway from declin bation should be performed in comatose patients.
ing menta l status. Narcotic analgesics must be used
The patient should be ventilated with I00% oxygen
with caution. Avoid hypercapnia with close moni
until blood gas measurements are obtained, and then <lP
toring of respiratory status and the abil ity of pa
propriate a dj ustm e nts to the fraction of impired m.:ygcn
tients to manage their airway. Urgent intubation
may become a necessity under these circumstances. ( Ho2) are made. Pube oximetry is .1 u!>cful adjunct and oxy ,
gen saturations of >98A, a re desirable. l lypervenlilal ion

MANAGEMENT OF SEVERE BRAIN INJURY (GCS SCORE 3-8) 143
Cou nty
General
Hospital
Mild Traumatic Brain I nj ury Warning Discharge Instructions
Patient Name: ----
Date: ____________________
We have found no evidence to indicate that your head injury was serious.
However, new symptoms and unexpected complications can develop hours
or even days after the inj ury. The first 24 hours are the most crucial and
you should remain with a reliable companion at least d uring this period.
If any of the following signs develop, call your doctor or come back to the
hospital.
D Drowsiness or increasing difficulty in awakening patient

(awaken every 2 hours during period of sleep)
D Nausea or vomiting
IJ Convulsions or fits
!J Bleeding or watery drainage from the nose or ear
Iii Severe headaches
g Weakness or loss of feeling in the arm or leg
D Confusion or strange behavior
(1) One pupil (black part of eye) much larger than the other; peculiar
movements of the eyes, double vision, or other visual disturbances
f) A very slow or very rapid pulse, or an unusual breathing pattern.
If there is swelling at the site of the injury, apply an ice pack, making sure
that there is a cloth or towel between the ice pack and the skin. If
swelling increases markedly in spite of the ice pack application, call us or
come back to the hospital.
You may eat or drink as usual if you so desire. However, you should NOT
drink alcoholic beverages for at least 3 days after your injury.
Do not take any sedatives or any pain relievers stronger than

acetaminophen, at least for the first 24 hou rs. Do not use aspirin
containing medicines.
If you have any further questions, or in case of emergency, we can be

reached at: <telephone number>
Figure 6-7 Example of Head Physician's Signature ------
Injury Warning Discharge

Instructions.
should be used cautiously in patients with severe brain Hypotension is a marker of severe blood loss, which is
i njury and on ly wh en acute neurologic deterioration has not always obvious. Associated spi n al cord injury ( neuro
occ urred. gen ic shock), cardiac contusion or tamponade and tension
,
pneumothorax are also possi bl e causes .
While efforts are i n progress to determi ne the cause of

Circulation hypotension, volume replacem en t should be in it iated. FAST
Hypotension usually is not due to the brain injury itself, ex or DPL is used routinely in comatose patients with hypoten
cept in the terminal stages when medullary failure super sion, because a clinical examination for abdominal tender
venes. In tracr a J1 ial hemorrhage cannot cause hemorrhagic ness is not possible in such patients. rl' See Chapter 3:
shock. Euvolemia shoul d be established as soon as possible Shock. It must be emphasized that the neu rol ogic examina
if the patient has hypotension . tion of patie nts w ith hypoten sion is unreliable. Even if severe
144 CHAPTER 6 Head Tra u m a
[
intoxicated. The postictal state after a traumatic seizure
Definition: GCS Score 9-12
will typically W"Orsen the patient's responsiveness for
minutes or hours. In a co m atose patien t , motor re
I nitia l Exami nati o n
sponses may be el i ci ted by pinching tbe trapezius mus
Same as for mild head injury, plus baseline cle or with nail-bed pressure. If a patient demonstrates
blood work variable responses to stimulation, the best motor re
CT scan of the head is obtained in a l l cases sponse elicited is a more accurate prognostic indicator
Admit to a fadlity capable of definitive than the worst response. Testing for doll's eye move
neurosurgical care ments (o culoc e pha l i c ) , the caloric test with ice water
(oculovestibular), and testing of corneal responses are
deferred to a Doll's eye testing should
neurosurgeon.
After Admission never be attempted until an unstable cervical spine i n j u ry
Freq uent neurologic checks has been ruled out.
Follow up CT scan if condition deteriorates or It is important to obtain the GCS score and to perform a
preferably before discharge pupillary examination prior to sedating or paralyzing the pa
tient, because knowledge of the patient's clinical condition is
important for determining subsequent treatment. Long-act
ing paralytic and sedating agents should not be used during
the primary survey. Sedation should be avoided except when
a patient's agitated state may place him or her at risk. The
Discharge when I f the patient stops shortest-acting agent-s avai lable are rccorru11ended when
appropriate following simple pharmacologic paralysis or brier sedation is necessary for
Follow-up in clinic commands, repeat safe endotracheal intubation or obtaining good qua l ity eli
CT scan and manage
agnostic studies.
per servere brain
injury protocol
SECONDARY SURVEY
Serial examinations (GCS score, lateralization, and pup i l
lary reacti on ) should be performed to detect neurologic de
Figure 6-8 Algorithm for Management of terioration as early as possible. A well-known early sign of
Moderate Brain Injury. (Adapted with permission
temporal lobe (uncal) herniation is dilation of the pupil and
from Valadka AB, Narayan RK: Emergency room man
loss of the pupiJlary response lo l igh t. Direct trauma to the
agement of the head-injured patient, in Narayan RK,
eye also is a potential cause of abnormal pupillary response
Wilberger JE, Povlishock JT (eds): Neurotrauma. New
and may make pupil evaluation difficult. However, in the
York, MeG raw-Hill, 1 996.)
sett i ng of brain trauma, brai.n i n j u ry should be considered
first. .. See Skill S tati on IX: Head and Neck Trauma: As
sessment and Management, Skill IX-B: Secondary Survey
brain injury exists, hypotension .is a well-known cause of and Management.
secondary brain inj ury. Patients with hypotension who arc
u n responsive to any form of stimulation may revert to near
normal neurologically soon after normal blood pressure is
DIAGNOSTIC PROCEDURES
restored, and the primary source of the hypotension must be An emergency head CT scan must be obtained as soon as
urgently so ught a11d treated. possible after hemodynamic normalization. CT scanning
Neurologic Examination
IJ What is a focused neurological PITFALL , "
-

examination ? ,
". . ...
As soon as the patien t's cardiopulmonary status is cor In the past, severe traumatic brain injury was often
rected, a rapi d and directed neurologic examination is considered "unrecoverable," and a sense of n ih il ism
performed. It consists primarily of determining the GCS had frequently pre vai l ed . Vigorous management
score an<.! the pupillary l i g h t response. It is important to
and i m proved understanding of the pathophysiol
ogy of severe head injury, especial l y the role of hy
recognize confounding issues i n the evaluation of trau
potension, hypoxia, and cerebral perfusion, has
matic brain i nj u r y, i n c l ud i ng the presence of drugs, al
made a significant impact on patient outcomes. Do
cohol, and intoxicants and other injuries. Do not not give up too soon.
overlook a severe brain i nj ury because the pa ti ent is also
MANAGEMENT OF SEVERE BRAIN INJURY (GCS SCORE 3-8) 145
Definition: Patient is unable to follow even simple

commands because of impaired consciousness
(GCS Score 3-8)
Assessment and Management
ABCDEs Neurologic reevaluation: GCS

Primary survey and resuscitation Eye opening
Secondary survey a.nd AMPLE .Motor response
history Verbal response
Admit to a facility capable of Pupillary light response
definitive neurosurgical care
Theraputic agents (usually administered after consultation with
neurosurgeon)
Mannitol
Modera.te hyperventilation (Pc:z. = 35 mm Hg)
Anticonvulsants
..!. !.

CT scan
Figure 6-9 Algorithm for Initial Management of Severe Brain Injury. (Adapted with permission from Val
adka AB, Narayan RK: Emergency room management of the head-injured patient, in Narayan RK, Wilberger JE,
Povlishock JT (eds): Neurotrauma. New York, McGraw-Hill, 1996.)
Box 6-1
Priorities for the Initial Evaluation and Triage
of Patients with Severe Brain Injuries
0 All comatose patients with brain injuries tracranial mass, diagnostic burr holes or cran
should undergo resuscitation (ABCDEs) on ar iotomy may be undertaken in the OR while
rival in the ED. the laparotomy is being performed.
fJ As soon as the blood pressure (BP) is normal 9 lfthe patient's systolic BP is >100 mm Hg after
ized, a neurologic exam is performed (GCS resuscitation and the patient has clinical evi
score and pupillary reaction). If the BP cannot dence of a possible intracranial mass (unequal
be normalized, the neurologic examination is pupils, asymmetric results on motor exam), the
still performed, and the hypotension recorded. first priority is to obtain a CT head scan. A DPL
or FAST exam may be performed in the ED, CT
D If the patient's systolic BP cannot be brought area, or OR, but the patient's neurologic eval
up to > 100 mm Hg despite aggressive fluid re
uation or treatment should not be delayed.
suscitation, the priority is to establish the
cause of the hypotension, with the neurosur g In borderline cases-i.e., when the systolic BP
gical evaluation taking second priority. In such can be temporarily corrected but tends to slowly
cases, the patient undergoes a DPL or ultra decrease every effort should be made to get a
sound in the ED and may need to go directly head CT prior to taking the patient to the OR
to the operating room (OR) for a laparotomy. for a laparotomy or thoracotomy. Such cases call
CT scans of the head are obtained after the la for sound clinical judgment and cooperation be
parotomy. If there is clinical evidence of an in- tween the trauma surgeon and neurosurgeon.
also should be repeated whenever there is a change in the Hypovolemia in these patients is harmful. Care should also be
patient's clinical status and routinely at 1 2 to 24 hours after taken not to overload the patient with fluids. Hypotonic flu
injury for patients with a contusion or hematoma on the ids should not be used. Furthermore, the use of glucose
initial scan .
See Skill Station IX: Head and Neck Traum(\; containing fluids may re sult in hyperglycemia, which has
Assessment and Management, Skill IX-C: Evaluation of CT been shown to be harmful Lo the injured brain. Therefore, it
Scans of the Head. is recommended Ringer's lactate solution or normal saline
Findings of significance on the CT images include scalp be used for resuscitation. Serum sodium levels need to be
swelling or subgaleal hematomas at the region of impact. very carefully monitored in patients with head i njuries. Hy
Skull fractures may be seen better with bone windows, but ponatremia is associated with brain edema and should be
are often apparent even on the soft-tissue windows. The cru prevented.
cial findings on the CT scan are intracranial hematoma,
contusions, and shift of the midline (mass effect) (see Fig
HYPERVENTILATION
ure 6-5: CT Scans ofintracranial Hematomas). The septum
pellucidum, which lies between the two lateral ventricles, In most patients, normocarbia is preferred. Hyperventila

should be located in the midline. The midline can be deter tion acts by red ucing Paco2 and causing cerebral vasocon
mined by drawing a line from the crista gal li anteriorly to striction. Aggressive and prolonged hyperventilation may
the insertion of the falx at the internal occipital protuber actuall y produce cerebral ischemia by causing severe cere
ance posteriorly. The degree of displacement of the septw11 bral vasoconstriction and thus impaired cerebral perfusion.
pellucidum away from the side of the hematoma should be This is particularly true if the Paco2 is allowed to fall below
noted, and rhe actual degree of shift should be determined 30 nun Hg (4.0 kPa).
by using the scale lhat is printed on the side of the scan. A Hyperventilation should be used only in moderation and
sh ift of 5 mm or greater is often indicative ofthe need for sur for as limited a period as possible. ln general, it is preferable
gery to evacuate the blood clot or contusion causing tile shift. to keep the Paco2 at 35 mm Hg or above. Brief periods of hy
There is some evidence thai the addjtion of CT aJJgiogra perventilation (Paco2 25 to 30 mm Hg) are acceptable if
phy (CT-A) or cerebral arteriography may uncover unsus necessary fo r acute neurologic deterioration while other
pected vascular injury to the skull base that could place the treatments are initiated.
patient at risk for stroke. These studjes should be consid
ered when a high-energy mechanism of injury is present.
MANNITOL
rl' See Chapter 7: Spine and Spinal Cord Trauma for specific
criteria. Mannitol is used to reduce elevated ICP. The preparation
In patients whose blood pressure can be normalized, most commonly used is a 20o/o solution. The most widely
every effort should be made to obtain a head CT se<m prior accepted regimen is 0.25 to 1 g/kg administered intra
to taking the patient to the operating room. Such cases re venously as a bolus. Large doses of mannitol should not be
quire sound clinical judgment and cooperation between the
trauma surgeon and the neurosurgeon (see Figure 6-9).
Table 6-4 provides an overview of the management of
traumatic brain injury.
It is important to monitor the ICP if active ICP man

agement is being undertaken. For example, man
nitol may have a significant rebound effect on ICP,
Medical Therapies for Brain Injury and additional therapies may be indicated if on
going management is requ ired . Hypertonic saline
is being studied as a possibly safer and/or more ef
The primary aim of inlensive care protocols is to prevent sec fective alternative.
ondary d<1mage to an already injured brain. The basic princi
It is im portant to remember that seizures are not
ple is that ifinjured neural tissue is provided an optimal milieu con t ro ll ed with muscle relaxants. Prolonged
in which to recover, it may go on to regain normal function . seizures in a patient whose muscles are relaxed
However, i f the neural tissue is provided with a suboptimal pharmacologically can still be devastating to brain
or hostile milieu, it may die. Medical therapies for brain in function, and may go undiagnosed and untreated
jury include intnvenous Huids, hyperventilation, mannitol, if tonic-clonic muscle contractions are masked by a
furosemide, steroids, barbiturates, and anticonvulsants. neuromuscular blocker such as vecuronium or suc
cinylcholine. In a patient with a witnessed seizure,
make sure appropriate antiseizure therapy is
INTRAVENOUS FLUIDS being initiated and that the seizure is under con
trol before initiating neuromuscular blockade if at
Intravenous fluids should be administered as required to all possible.
resuscitate tbe patient and maintain normovolemia.
MEDICAL THERAPEIS FOR BRAIN INJURIES 147
TABLE 6-4 Management OVerview of Traumatic Brain Injury
AU PATIENTS: PERFORM ABCDEs WITH SPECIAL AITENTION TO HYPOXIA AND HYPOTENSION
13 TO 1 5 9TO 1 2 3 TO 8
GCS MILD TRAUMATIC MODERATE TRAUMATIC SEVERE TRAUMATIC
CLASSIFICATION BRAIN INJURY BRAIN INJURY BRAIN INJURY
May discharge 1f adm1s- Admit for Neurosurgery eval Urgent neurosurgery

s1on enteria not met IndiCations below requ1red consult requ1red
Initial Management AMPLE History a nd neurologic exam: "Pnmary survey and "Pnmary su rvey and
resuscitation resuscitation
Determ1ne mecha nism , No CT ava ilable CT , Arrange for transfer to .. Intubation & venti lation for
\lmes of injury, lnltiel abnormal, skull fracture, defiMive neurosurg1cal alrway protection
GCS, confusion, CSF leak evaluat1on and *Treat hypotension,
amnest1c Interval. management hypovolemia and hypoxia
seizure, headache
seventy, etc.
..Secondary survey Focal neurolog1c deficit *Focused neuro exam Focused neuro exam
1nclud1ng focused GCS does not return to Secondary survey and *Secondary survey a nd
neurolog1c exam 1 5 withi n 2 hours AMPLE h1story AMPLE history
Diagnostic *CT scanning as CT not available, CT cr scan 1n all cases CT scan in all cases
determined by head CT abnormal, skull fracture *Evaluate carefully for Evaluate carefully for other
rules (Table 3) other lnJunes rn]unes
slood/Unne EtOH & S1gnrf1Cant rntoxiCatlon *Full preop labs & x-rays *Full preop labs & x-rays
tax screens (admit or observe)
Secondary MGMT *Senal exam1nattons *Periorm serial serial exams Frequent senal neuro
until GCS is 1 5 and examinatrons cons1der follow-up CT examinations w/GCS
patient has no persever- *Perform follow-up CT in 12-1 8 h *Pea} 35+/-3
atJon or memory defidt scan 1f 1st is abnormal or .. Mannitol, Pco2 28-32 for
GCS remains less than I 5 detenoratton
Avoid Pco1 <28
*rule out Indication *repeat CT if neuro "Address Intracranial lesions
for CT (Table 3) exam deteriorates appropriately
Disposition Home If pal ient does Obtain neurosurgical Repeat CT i mmed1ately *Transfer as soon as p ossrble
not meet criteria for eva I rf CT or ne urologic for deteriora11on and to definitive neurosurgical

admiSSIOn exam is abnormal or manage as '" severe care

patient deteriorates bra1n injury (1 0%)
*DISCharge With head Arrange for mediCal
D1scharge w1th mediCal
1n1ury warn1ng sheet followup and neuropsych and neuropsychologtcal
and followup arranged evaluation as reqwed followup arranged
(may be done as when stable GCS
outpatient) 1 5 (90%)
Asterisk denotes acuon fl>qutted
given to patients with hypotension, because mannitol is a the CT scanner or directly to the operating room if the
potent osmotic diuretic. Acute neurologic deterioration. causative lesion already has been identified.
uch as the development of a dilated pupil, hemiparesis, or
loss or consciousness while the patient is being observed, is
STEROIDS
a strong indic<llion for administering mannitol. ln Lhis set
ting, a bolus of mannitol ( l g/kg) should be given rapidly Studies have not demonstrated any benel1cial effect of
(over 5 minutes) and the patient transported immediately to steroids in controlling increased ICP or improving out-
come from severe brain injury. Some studies have demon fracture or foreign material. CSF leakage indicates that there
stratrd an increase in mortality and complications associ i an associated dural tear. A neurosurgeon should be con
ated with the use of steroids in this setting. Therefore, sulted in all cases of open or depressed skull fractures. Not
steroid are not recommended in the management of acute infrequently, a subgaleal collection of blood can feel like a
..
brain injury. skull fracture. I n sud1 cases, the presence of a fracture can be
confirmed or excluded by plain x-ray cxaminaUon of the re
gion Jnd/or a CT scan.
BARBITURATES
Barbiturates are effective in reducing ICP refractory to otbrr
DEPRESSED SKUll FRACTURES
measures. They should not be used in the presence of h>
potension or hypovolemia. Furthermore, hypotension often Generally, a depressed skull fractu n.' needs operative eleva
result from their use. Therefore, barbiturates are not indi tion if the degree of depression is greater than the thickness
cated in the acute resuscitative phase. of the adjacent skull, or if it is open and grossly contami
nated. Less significant depressed fractures can often be man

aged with closme of the overlying scalp laceration, if present.

ANTICONVULSANT$
A CT scan is valuable in identifying the degree of depres
Posttraumatic epilepsy occurs in about So/o of patients ad sion, but more importantly in excluding the presence of an
mitted to the hmpital with closed head injuries and in 15% intracranial hematoma or contusion.
of those with severe head injuries. Three main factors are
linked to a high incidence of late epilepsy: ( I ) seizures oc
INTRACRANIAL MASS LESIONS
curring within the first week, (2) an intracranial
hematoma, and (3) a depressed skull fracture. A double Intracranial mass lesions typically are evacuated or treated
blind study found that prophylactic phenytoin reduced the by a neurosurgeon. If a neurosurgeon is not available in the
incidence of seizures in the tirst week of injury, but not facility initially receiving the patient with an intracranial
thereafter. Currently, phenytoin or fosphenyLoin is the mass lesion, early transfer to a hospital with a neurosurgeon
agent usually used i n the acute phase. For adults, the usual is essential. ln very exceptional circumstances, a rapidly ex
loading dose is 1 g of phenytoin given intravenously at a panding intracranial hematoma may be imminently life
rate no faster than 50 mg/min. The usual maintenance threatening and may not allow time for transfer if
dose is 1 0 0 mg/8 hours, with the dose titrated to achieve neurosurgical care is some di:.tancc away. Although this cir
therapeutic serum levels. For patients with prolonged cumstance is rare in urban settings, it may occur in rural
seizure!., diazepam or lorazepam arc used in addition to ucas. Under such conditions, emergency craniotomy may
phenytoin until the seizure stops. Control of continuous be considered if a surgeon properly trained in the procedure
seizures may require general anesthesia. I t is imperative is available. This procedure is especially important in a pa
that the seizure be controlled as soon as possible because tient whose neurologic status b rapidly deteriorating and
prolonged seizures (30 to 60 minutes) may cause second docs not respond to nonsurgical measures. Emergency cran
ary brnin injury. iotomy by a non-neurosurgeon should be considered only in
extreme circumstances, and the procedure should be done
only with the advice of a neurosurgeon.
The indications for a craniotomy performed by a non
Surgical Management neurosurgeon are few, and widespread use as a desperation

maneuver is neither recommended nor supported by the
Committee on Trauma. This procedure is justified only
Surgical management may be necessary for scalp wotmds, when definitive neurosurgical care is unavailable. The Com
depressed skull fractures, intracranial mass lesions, and pen mittee on Trauma strongly recommends that those who an
etrating brain injuries. ticipate the need for this procedure receive proper training
from a neurosurgeon.
SCALP WOUNDS
PENETRATING BRAIN INJURIES
It is important to clean the wound thoroughly before su
turing. The most common cause of infected scalp wounds is CT :.canning of the head ic; strongly recommended to eval
inadequate cleansing and debridement. Blood loss from uate patients with penetrating brain injury. Plajn radi
scalp wounds may be extensive, espel..ially in children. Scalp ographs of the head can be helpful in assessing bullet
hemorrhage usually can be controlled by applying direct tr<ljcc:tory and the presence of large foreign bodies and in
pressure and cauterizjng or ligating large vessels. Appropri t ratranial air. However, when CT is available, plain radi
ate sutures, clips, or staples may then be applied. Carefully ographs arc not essential. CT-A and/or conventional
inspect the wound under di reel vision for signs of a skull angiography is recommended when vascular injury is sus-
BRAIN DEATH 149
bridemenl of the cranial wound w i th open ing or removing

PITFALL a portion of the skull is necessary. Si gni ficant mass effect is
addressed by evacuation of in n.acran ial hematomas and de
Burr hole craniostomy-placing a 10-to-1 5-mm drill bridement of necrotic brain tissue and safely accessib le hone
hole in the skull-has been advocated as a mE!thod fragments. In the absence of s ign i fi can t mass effect, surgi cal
of emergently addressing hematomas i n patients
debridement of the missile track in the brain, routine sur
with rapid deterioration when neurosurgeons are
gical re moval of fragment s distant from the entry site, and
not readily available. Unfortunately, even in very ex
perienced hands, these drill holes are easily placed reoperation so lely to remove retained bone or missile [rag
incorrectly, and they seldom result in draining ments do not measurably improve outcome and are not rec
enough of the hematoma to make a clinical differ onunendecl. Repai r of open-air sinus i njuries and CSF leaks
ence. In patients who need an evacuation, bone flap that do not close spontaneo usl y (or wi th temporary CSF di
craniotomy (and not a simple burr hole) is the de version) is recommended, using caref ul watertight closure of
finitive lifesaving procedure to decompress the the dura. During the pri mar y surgery, every effort should
brain, and every attempt should be made to have a be made lo close the dura and prevent CSF leaks.
practitioner trained and experienced in doing the
procedure perform it in a timely fashion.
Prognosis
peeled, such as when a trajectory passes through or near the
skull base or a major du ral venous sin us. Substantial sub
arachno i d hemorrhage or delayed hematoma should also AJl patients should be treated aggress ivel y pending consul
prompt consideration of vascular i magi ng. Patients with a tation with a neurosurgeon. This i s pa1ticul arly true of chil
penetrating i njury involving the orbitofacial or pterional re dren, who occas i ona lly have a remarkable ability to recover
gions should undergo a ngi ograp hy to identify a traumatic from seemingly devastati ng injuries.
intracranial aneurysm or a rte rioveno us (AV) fistula. When
an aneurysm or AV fis tula is identified, surgical or endovas
cular management is recommended. MRJ ca n play a role in
evaluating injuries from pe netrati ng wooden or other non Brain Death
magnet i c objects, but i t is general l y not necessary in Lhe
evaluation of m i ssi le- i n duced inju ry. The presence on CT
of l arge contusions, hematomas, or intraventricular hemor
How do I diagnose brain death?
rhage i s associated with increased m orta l ity, esp ec i ally when The diagnosis of"brain death" i mpl ies that there is no pos
both hemisp heres are involved. si bility for recovery of brain function. Most experts agree
P rophylacti c broad-spectrum antibiotics are app ropri that the following criteria should be satisfied for the di ag
ate for p at ie n ts with penetrating bra i n injury. Antiseizure nosis of brain death:
medication in the first week after he t injmy is recommended
Glasgow Coma Scale score = 3
to prevent early posttraw11atic seizures. Prophylactic treat
ment with anticonvulsants beyond the first week after in Non react ive pupils
jury has not been shown to prevent new seizures, and is not
Absent brainstem reflexes (eg, oculocephalic,
reco m mended. Early ICP m on i tor ing is recommended
when the clinician is unable to assess the n eu rologic exam corneal, and Doll's eyes and no gag reflex)
ination accurately; the need to evacuate a mass lesion is un No spontaneous vent i latory effort on formal apnea
clear; or i ma ging studies suggest elevated T CP. testing
It is appropriate to ueat small bullet en tra nee wounds
lo the head with local woun d care and closure i n pati en ts Anci l la ry studies that may be used to confirm Lhe d i ag
whose scalp is not devitaJized and who have no major in nosis of brain death include:
tracranial pathology.
Electroencephalography: No activi ty at high gain
Objects that penetrate the intracra11i al compartment or
i nfratemporal fossa must be left in place until possible vas CBF studies: No CBF ( eg, isoto pe studies, Doppl er
cular injury has been evaluated an d definitive neurosurgical studies, xenon CBF studies)
management established. Disturbing or removing penetrat
ICP: Exceeds MAP or
f 1 hour or longer
i ng objects prematurely can lead to fatal vascular injury or
intracra ni a l hemorrhage. More extensive wounds with 11011- Cerebral angiography
vi abl e scalp, bone, or dma are carefully debrided before p ri
mary closure or grafting to secure a wate rt igh t wound. I n Certain reversibl.e conditions, such as h ypothermia or
pat i e nts with significant fragmen tation of the skull, de- barbiturate coma, may mi mi c the appearance of brain
death; therefore, this di agnosi s should be considered only especially in children, multiple serial exams spaced several
after all physiologic parameters are normalized and CNS hours apan are useful i n confirming the initial cl inical im
function is not potentially affected by medications. The re pression. LocaJ organ-procurement agencies should be no
markable ab il ity o f children to recover from seemingly dev- tified about all patients wi th the d i agnosi s or impending
..
astating brain injuries shotlld be carefully considered prior diagnosis of bra in death prior to discontinuing artificial life
to di agnosi ng brain death in ch i ldren . [f any doubt exi sts , support measures.
CHAPTER SUMMARY
Understanding basic intracranial physiology is key to understanding the management of

head injury.
learn to evaluate patients wit h head and brai n inJ uries effi cie ntly. In a comatose p!ii
tient, secure and maintain the airway by endotracheal intubation. Perform a n eurolog1c
examination after normalizing the blood pressure and before paralyzing the patient.
Search for associated injuries.
Practice performi n g a rapid and focused neurologic examination. Become familiar with
the Glasgow Coma Scale and practice its use . Freq ue ntly reassess the patient's neuro
logic status.
Adequate resuscitation is important in limitmg secondary brain Inj ury Prevent hypo .
volemia and hypoxemia. Treat shock ag gressively and look for its cause. Resuscitate with
Ringer's lactate solution, normal saline, or similar ISotonic solutions without dextrose. Do
not use hypotonic solutions. The goal in resuscitating the patient with brain injunes IS
to prevent secon dary brain injury.
Determine the need for transfer, admission, consultation or discharge. Contact a neu ro
surgeon as early as poss1ble. If a n eurosu rgeon is not available at your facility transfer ,
all patients with moderate or severe head injunes.
Bibliography 4. Boyle A, Santarius L., Maimaris C. Evaluation of the impact of

the Canadian CT head rule on British practice. Eutcrg ,\t/cd T
2004; 21(4):426-128.
l . Ami Tjamhidi A, Abbassioun K, Rahmat H. Minimal debride
5. Brain Trauma Foundation. Early Indicators of Prognosis in Se
ment or simple wound closure as the only surgical ucatmcnt
vere Tmumatic Brain Injury. http://www2.braintrauma.org/
il1 war victims with low-velocity penetrating bead injuries. In
guide I i nes/ down I oads/ b t f_progn osis_gui del ines. pdf?
dications and management protocol based upon more Lh<lll 8
BrainTrauma_Session- 1 157S80cb4d 126eb38 1748tt50:124bb99.
years follow-up of99 cases from Iran-Iraq conflict Surg Neu
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;\ccessed September S, 2007.

ro/ 2003;60(2 ): J 05-1 10: disc\lssion J l 0- 1 1 1 .
6. Brain Trauma Founda tion. Guidelines for the Management of
2. And rews BT, Chiles BW, Olsen WL. el aJ. The effect of intra
Severe Trn11mntic Brain Injury. hnp://wvvw2.bnlinlrauma.org/
cerebral hematoma location on the risk of brainstem com
guide Ii nes/downloads/JON_24_Supp 1 .pd f?BrainTrau ma_
pression and on clinical outcome. } Neurosurg
Session= l l 57580cb4d 126eb381748a50424bb99. Accessed Sep
J 988:69:5 18-522.
tember 8, 2007.
3. Au bry M, Cantu R, Dvorak J, el aL Summary and agreement
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statement of the first International Conference on Concussion
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lished in Br 1 Sports Med 2002;36:3-7 and Clin 1 Sport Med
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23. Smits M, Dippel DW, de Haan GG, et al. External validation of
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24. Stiell IG, Clement CM, Rowe BH, ct al. Comparison of the
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gw1shot injuries. Surg Neur()/ 2005;63( I ):24-30; discussion 3 1 .
25. Stiell lG, Lesiuk II, Wells GA, et al. Canadian CT head rule
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Scale assessment caused by prehospital treatment of patients Rule Study for patients with minor head injury: rationale ob ,
with head inj uries : results of a national survey. I "trnumn ject ives and methodo logy for ph ase I (dcrivation). Amr Emerg
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1994;36( I ):89-95. Mcd 2001; 38(2):1 60- 169.
IS. Marion DW, Spiegel TP. Changes in the management of severe 27. Stiell /G, Wells GA. \'cmdemhecn K. et a/. The Cmuuiirm CT
traumatic brain injury: 1991-1997. Crit Care Med 2000;28:16- Head Rille f
or patients with minor head injury. Lnncet 2001;
18. 357(9266): 1391 -1 396.
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, 28. Sultan HY, Boyle A, Pereira M, Antou n N, Maimari C. Appli
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Concussion in Sport, Prague 2004. Br I Sports Med i njuries in a UK emergency department.: implications for the
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2 1 (4):420-425.
17. Muizelaar JP, Marmarou A, 'Nard JD, et al. Adverse effects of
prolonged hyperventilation in patients with severe heaJ in 29. Surgical management of penetrating brain injury. I Tmuma
jury: a randomized clinical trial. J Neurosurg I. 991 ;75:73 1 -739. 2001; 51 (2 Suppl), S 16-25.
18. Neuroimaging in the management of penetrating brain injury. 30. Temkin NR, Dik.man SS, Wilensky AJ. et al . A random ized ,
J Tmuma 200 I ;51 (2 Su ppl ):S7-S I I . double-blind study of phenytoin for the prevention of post
traumatic seizures. N Engl j Med 1990;323:497 -502.
19. Part I : Guidelin e for the management of penetrating brain
injury. Introduction and methodology. J Tmwna 2001;51(2
Su ppi }:S3-S6.
-
..
Performance at th is station will allow the pa rticipant to practice and demon

Interactive Skills
strate the follow1 ng act1vit1es in a s1mulated clinical situation:
Procedure
Note: Standard preca ution s
OBJECTIVES
are requ ired when caring for

trauma patients.
Demonstrate assessment and diagnostic skills in determining the type
A se ries of scenarios accompanies and extent of injuries with a head trauma manikin.
some of the skills proced u res for
th1s station. The scenanos are Describe the significance of clinical signs and symptoms of brain
prov1ded at the conclusion of the trauma found through assessment.
procedures for your review and
preparation for this station. Establish priorities for the initial treatment of patients with brain
trauma.
THE FOLLOWING Identify diagnostic aids that can be used to detrmine the area of in
PROCEDURES ARE INCLUDED jury within the brain and the extent of the injury.
IN THIS SKILLS STATION:
Demonstrate proper helmet removal while protecting the patient's
Skill IX-A: Prlm ary Survey cervical spine.
Skiii iXB: Secondary Survey
Perform a complete secondary assessment and determine the pa
and Management
tient's Glasgow Coma Scale (GCS) score through the use of scenarios
Skiii iX-C: Evaluation of CT and interactive dialogue with the instructor.
Scans of the Head
Differentiate between normal and abnormal computed tomographic
Skiii iXD: Helmet Removal (CT) scans of the head, and identify injury patterns.
153
154 SKILL STATION IX Head and Neck Trauma: Assessment and Management
Skill IX-A: Primary Survey

..
STEP 1 . ABCDEs STEP 3. Perform a brief neurologic examination, l ooki ng
for:
STEP 2. Immobilize and stabilize the cervical spine.
A. Pupillary respon se
B. GCS score determination
SkiJJ IX- 8: Secondary Survey and Management

STEP 1 . Inspect the entire he<ld, including the face, B. Best li mb motor response
looking for: C. Verbal response

A. Lacerations D. Pupillary respo nse
B. Nose and ears for presence of cerebrosp inal
STEP 5. Examine the cervical spi ne.
fluid (CSF) leakage
A. Palpate for tenderness/pain and apply a
STEP 2. Palpate the entire head, includ mg the face, semirigid cervical collar, if needed.
looking for: B . Perform a cross-table lateral cervical spine x
A. Fractures ray examination a needed
B. Lacerations and underlying fractures
STEP 6. Determine the extent o f injury.
STEP 3. Inspect all scalp lacerations, look ing for:
STEP 7. Reassess the patient co nt in uo usly, observi ng for
A. Brain tissue
signs of deterioration.
B. Depressed skull fractures
C. Debris
A. Frequency
B. Parameters to be assessed
D. CSF leaks
C. Serial GCS scores and extremity motor
STEP 4. Determine the GCS score and pupillary response, assessment
i ncluding: D. Remember, reassess ABCOEs
A. bye open n
-i g response
Skill IX-C: Evaluation

' . of CT Scans of the Head
Diagnosis of abnormalities seen on GI scans of the head can STEP 2. Assess the scalp component for contusion or
be very subtle and difficult. Because of the inherent com swelling that can indicate the site of external
plexity in interpreting these scans, early review by a neuro trauma.
surgeon or radiologist is important. The :.teps outlined here
STEP 3. Assess for skull fractures. Keep in mind that:
for cvalu lt ing J cr scan of the head provide one approach to
.
A. Suture lines (join ing of the bones of the

assessing for significant, life-threatening pathology. Remem
cranial vault) may be mistaken for fractures.
ber, obtaining a CT scan of the head should not delay resus
B. Depressed skull fractures ( thickness of skull)
citation or transfer of the patient to a trauma center.
require neu rosurgical consultation.
C. Open fractures r equ ire neurosurgical
STEP 1 . Follow the process for initial review ofCT scans
consultation. Missile wound tracts may
of the head.
appear as linear areas of low attenuation.
A. Confirm that the images being reviewed arc
of the correct patient. STEP 4. Assess the gyri and sulci for symmetry. If
B. Ensure that the cr scan of the head was done aymmetry exists, consider these diagnoses:
without an intravenous contrast agent. A. Acute subdural hematoma:
C. Usc the patient's clinical findings to focus the Typically are areas of increased density
review of the CT scan, and use the image covering and comprcl!sing the gyri and sulci
findi ngs to en hance further physical over the entire hemisphere
eval uat ion . Appear within the skull
SKILL IX-D 155
Can cause a shift of the underlying C. Significant intracranial hypertension is often

ventricles across the midline associated with decreased ventricular size.
Occur more commonly than epidural D. Intraventricular hemorrhage appears as
hematomas regions of increased density (bright spots) in
Can have associated cerebral contusions the ven Lricles.
and intracerebral hematomas
STEP 7. Determine the shifts. Midline shifts may be
B. Acute epidural hematoma:
caused by a hematoma or swelling that causes the
Typically are lenticular or biconvex areas of
septum pellucidum, between the two lateral
increased density
ventricles, to shift away from the midline. The
Appear witbin the skull and compress the
midline is a line extending from the crista galli
underlying gyd and sulci
anteriorly to the tentJike projection posteriorly
Can cause a shift of the underlying
(injon). After measuring the distance from the
ventricles across the midline
midline to d1e septlun pellucidum, the actual
Most often are located in the temporal or
shift .is determined by correcting against the scale
temporoparietal region
on the CT print. A shift of 5 mm or more is
STEP 5. Assess the cerebral and cerebellar hemispheres. considered indicative of a mass lesion and the
A. Compare both cerebral and cerebellar need for surgical decompression.
hemispheres for similar density and
STEP 8. Assess the maxillofacial structures.
symmetry.
B. lntracerebral hematomas appear as large areas
A. Assess the facial bones for fracture-related
crepitus.
of high density.
B. Assess the sinuses and mastoid air cells for air
C. Cerebral contusions appear as punctate areas
fluid levels.
of higb density.
C. Facial bone fractures, sinus fractures, and
D. Diffuse axonal injury can appear normal or
sinus or mastoid air-fluid levels may indicate
have scattered, small areas of cerebral
basilar skull or cribriform plate fractures.
contusion and areas of Jow density.
STEP 6. Assess the ventricles. STEP 9. Look for the fou r Cs of increased density:
A. Check size and symmetry A. Contrast
B. Significant mass lesions compress and B. Clot
distort the ventricles, especially the lateral C. Cellularity (tu mor)
ventricles. D. Calcification (pineal gland, choroid plexus)

Skill'IX- 0: Helmet Removal
Patients wearing a helmet who require airway management side and the fingers on the other. The other hand
should have the head and neck held in a neutral position applies pressure from under the head at the
while the helmet is removed using the two-person proce occipital region. This maneuver transfers the
dure. Note: A poster titled "Techniques of Helmet Removal responsibility for in-line immobilization to the
from Injured Patients" is available from the American second person.
College of Surgeons (www.facs.org/trauma/publications/
STEP 4. The first person then exp<mds the helmet laterally
helmet.pdfP). This poster provides a pictorial and narrative
to clear the cars and carefully removes the
description of helmet removal There are some varieties of
helmet. Tf the helmet has a face cover, this device
helmet that have special removal mechanisms that should
must be removed first. If the heLnet provides fuJJ
be used i n accordance with the specific helmet.
facial coverage, the patient's nose will impede
STEP 1. One person stabilizes the patient's head and neck helmet removal. To clear Lhe nose, the heLnct
by placing one hand on either side of the helmet must be tilted backward and raised over the
. '
with the fingers on the patient's mandible. This pat1ent s nose.
position preven ts slippage if the strap is loose.
STEP 5. During this process, the second person must
STEP 2. The second person cuts or loosens the helmet maintain in-line immobilization from below to
strap aL the D-rings. prevent head tilt.
STEP 3. The second person then places one hand on the STEP 6. After the helmet is removed, in-line manual
mandible at the angle, with the thumb on one immobilization is reestablished from above, and
156 SKILL STATION IX Head and Neck Trauma: Assessment and Management
the patient's head and neck are secured during be stabilized during this procedure, which is
ain-vay management. accomplished by dividing the helmet in the coronal
pl<me through the ears. The outer rigid layer is
STEP 7. If atlempts to remove the helmet resll in pain and
removed easily, and the inside Styrofoam layer is
parestl1esia, l11e helmet should be removed with a
then incised and removed anteriorly. Majntaining

cast cutter. The helmet also should be removed
neutral alignment of the head and neck, the
with a cast cutter if there i evidence of a cervicaJ
posterior portions arc removed.
spine injury on x-ray film. The head and neck mut
SCENARIOS
SCENARIO IX-1 normal llexion response to painful stimuli on the right and
withdrawal on the left. His left pupil is now 2 mm larger

A 1 7-ycar-old bjgh-school football player, involved in a
than his right. Both pupils react sluggishly lo light. His ver
crushing tackle with a brief loss of consciousness, reports
bal response consists of incomprehensible sounds.
neck pain and paresthesia in his left arm. He is immobilized
on a long spine board with his helmet in place and trans
ported to the emergency department (ED). He is not in res SCENARIO IX-3
piratory distress, talks coherently, and is awake and alert.
A 2 1 -year-old man was thrown from and then kicked in the
face by a horse. He was initially unconscious for at least 5
SCENARIO IX-2 minute::.. lle now opens his eyes to speech, moves only to
painful stimuli by withdrawing his extremities, and utters
A 25- year-old man is transported to the ED after a car crash
inappropriate words. His blood pressure is 180/80 mm Hg,
while driving home from a tavern. I lis airway is dear, he is
and heart rate 64 beats/min.
breathing spontaneously without diflicwty, <md he has no
hemodynamic abnormalities. He has a calp contusion over
the left side of his head. There s
i a ::.trong odor of alcohol on
SCENARIO IX-4
hi breath, but he is able to answer questions appropriately.
His eyes are open, but he appears confused and pushes away A 40 year-old motorcyclist is brought to the ED with obvi
the examiner's hands when examined for response to pain. ous, isolated head trauma. The prchospital personnel report
He is thought to have suffered a concussion and to have al that he has unequal pupils and responds only to painful
cohol intoxication. He is kept in the ED for observation. stimuli by abnormally flexing his arms, opening his eyes,
One hour later, llle patient is more somnolent, briefly and speaking incomprehensibly. When not stimulated, his
opens his eyes to painful stimuli, and demonstTates an ab- respirations are very sonorous.

C H APT E R
CHAPTER OUTLINE Upon completion of this topic, the student will be able to
demonstrate the techniques of assessment and explain the
Introduction
emergency management of spine and spinal cord trauma.
Anatomy and Physiology Specifically, the doctor will be able to:
Spinal Column
Spinal Cord Anatomy
OBJECTIVES
Sensory Examination
Myotomes
Neurogenic Shock versus Spinal Shock Describe the basic spinal anatomy and p hysi ology .
Effects on Other Organ Systems

Evaluate a patient with suspected spinal injury.
Classifications of Spinal Cord Injuries
level Identify the common types of spinal inju ries and
Severity of Neurologic Deficit their x-ray features.
Spinal Cord Syndromes
Morphology Appro pr iat ely treat pa t ients with spinal i njuries
during the first hour after i nj u ry .
Specific Types of Spinal Injuries

Atlanta-Occipital Dislocation Determine the appropriate di spositi on of patients
Atlas Fracture (C1) with spine tra um a .
Cl Rotary Subluxation
Axis (C2) Fractures
Fractures and Dislocations (0 through C7)
Thoracic Spine Fractures {Tl through Tl O)
Tho racolumbar Junction Fractures (T1 1 through l1)
lumbar Fractu res
Penetrating Injuries
Blunt Carotid and Vertebral Vascular Injuries
X-Ray Evaluation
Cervical Spine
Thoracic and lumbar Spine
General Management
Immobilization
Intravenous Fluids
Medications
Transfer
Chapter Summary
Bibliography
158 CHAPTER 7 Spine and Sp i n al Cord Trauma
neurogenic and spinal shock, and the effects on other organ

Introduction !>)'Stem.
Vertebn1J column injury, with or without neurologic deficit

SPINAL COLUMN
must always be considered in patients with multiple injuries.
Approximately So/o of patients will1 brain injury have an asso Th<: spinal column consists of 7 cervical, I 2 thoracic, a11d 5
ciated :.pinal injury, whereas 25o/o of patients with spinal in lumbar vertebrae, as weU as the sacrum and the coccyx (Fig
jury have at least a mild brain injury. Approximately 55o/o of ure 7- I ). The typical vertebra consists of the anteriorly
spinal injuries occur in the cervical region, lSo/o in the thoracic placed vertebral body, which forms the main weight-bear
region, 15% at the thoracolumbar junction, and lSo/o in the ing column. The vertebral bodies Jre separated by inter
lumbosacral area. Approximately 10% of patients witha cervi vertebral disks, and are held together anteriorly and
cal spine fracture have a second, noncontiguous vertebral col posteriorly by the anterior and posterior longitudinal liga
umn fracture. ments, respectively. Postcrolaterally, t\-vo pedides form the
Doctors and other medical personnel who care for pa pillars on which the roof of the vertebral canaJ (ie, the lam
tients with spine injuries must be constnntly aware that ex ina) rests. The facet joints, interspinous ligaments, and
cessive manipulation and inadequate immobilization of such paraspinal muscles aU contribute to the stability of the

patients may cause additional newologic damage and worsen :;p ne.
the patient's outcome. At least So/o of patients experience the The cervicaJ spine is the most vulnerable to injury, be
onset of neurologic symptoms or the worsening of preexist cause of its mobility and exposure. The cervical canaJ is wide
ing symptoms after reaching the emergency department. This in the upper cervical region-that b, from the foramen
is usuall)' due to s
i chemia or progression of spinaJ cord magnum to tJ1e lower part of C2. The majority of patients
edema, but it may also be the result of failure to provide ade with injuries at ll1is Level who survive arc ncurologicaUy in
quJtc immobilization. As long as the patient's spine is pro tact on arrival at the hospital. However, approximately one
tected, evaluation of the spine and exclusion of spinal injury third of patients with upper cervical spine injuries die at the
may be safely deferred, especially in the presence of systemic injury scene from apnea caused by loss of central innerva
instability, such as hypotension and respiratory inadequacy. tion of the phrenic nerves caused by spinal cord injury at
Excluding the presence of a spinal injury is simple in a pa C I . Below the level of C3 the diameter of the spinaJ canal is
tient who is awake and aJert. ln a neurologically intact patient, much smaller relative to the diameter of the spinal cord, and
the ab:;ence of pain or tenderness along the c;pine virtuaJJy ex vertebral column injuries are much more likely to cause
dudes the presence of a significant pinal injury. llowever, in a spinal cord i11juries.
p.ltient who s
i comatose or has a depressed level of conscious The mobility of the thoracic spine is much more re
ness, the process is not as simple. ln this case, it is incumbent on stricted than that of the cervical spine, and it has addi
the doctor to obtain the appropriate x-ray films to exclude a tional support from the rib cage. Hence, the incidence of
spinal injury. If d1e x-rays a1e inconclusive, the patient's spine thorttcic fractures is much lower, with most thoracic spine
should remain protected until fu rther testing can be performed. fractures being wedge compression fractures that arc not
Although the dangers of inadequate immobilization associ.atetl with spinal cord injury. llowever, when a frac
h<we been fairly weU documented, there also is some danger ture-dislocation in the thoracic spine does occur, it almost
in prolonged immobilization of patients on a hard surface always results in a complete :;pinal cord injury because of
such as a backboard. In addition to cau:.ing severe discomfort the relatively narrow thoracic canal. The thoracolumbar
in an awake patient, prolonged immobilization may lead to junction is a fulcrum between the inflexible thoracic re
the formation of serious decubitus ulcers in patients with gion and the stronger lumbar levels. This makes it more
spinal cord injuries. Therefore, the long backboard should vulnerable to injury, and 15% of all spinal injuries occur in
be used only as a patient transportation device, and every ef tl1 is region.
fort made to have Lhe patient evaluated by the appropriate
specialists and removed from the spine board as quickly as
SPINAl CORD ANATOMY
possible. I f this is not feasible within 2 hours, the patient -
should be removed from the spine bortrd and then logrolled The spinal cord originates at the caudal end of lhe medulla
every 2 hours, while maintaining the integrity of the spine, to oblongatn at the foran1en magnum. In adults, it usually ends
reduce the risk of the formation of decubitus ulcers. around the Ll bony level as ilie conus medullaris. Below this
level is the cauda equina, which is :.omcwhat more resilient
to injury. Of the many tract:. in the spinal cord, only three
can be readily assessed clinically: ( I ) the corticospinal tract,
Anatomy and Physiology (2) the spinothalamic tract, and (3) the posterior columns
(Figure 7-2). Each is a paired tract that may be injured on
The following review of the anatomy <11ld physiology of the one or both sides of the cord.
spine and spinal cord includes th<: spinal column, spinal The corlicospinaJ tract, which lies in the posterolateral
cord anatomy, sensory and motor examination, myotomes, segment of Lhe cord, controls motor power on the same side
ANATOMY AND PHYSIOLOGY 15 9
A B Spinous process
Superior Lamina Transverse

Cervical Cervical articular process process
curvature vertebrae
Facet for --- vertebral

tubercle of rib foramen
Body Pedicle
Thoracic Thoracic
curvature vertebrae
-v Intervertebral
discs
f&.
q "'" lntervertebral
6:.\ foramina
Lumbar Lumbar
curvature vertebrae
Sacral
curvature
Figure 7-1 The Spine. (A) The spinal column, right lateral and posterior views. (B) A typical thoracic vertebra,
. .
supenor vrew.
Fasciculus gracilis --------,.

Dorsal column
Fasciculus cuneatus -------...
Lateral corticospinal ----7'.;;'---

" -7 1:
tract
Figure 7-2 Of the many tracts in the spinal cord, only three can be readily assessed clinically: (1) the corti
cospinal tract, (2) the spinothalamic tract, and (3) the posterior columns. Each is a paired tract that can be injured on
one or both sides of the cord.
160 CHAPTER 7 Spine and Spinal Cord Trauma
of the body and is tested by vol un tary m uscle contractio ns

or involuntary response to painful stimuli. The sp in oth ala
mic tract, i n the anterolateral aspect of the cord, t ran smits PITFALLS
pain and temperature sensation from the o pposi te side of
Sensory examination may be confounded by pain.
the body. ln general, it is tested by pinprick and light touch.
Patients sometimes observe the examination itself,
The posterior co l umns carr)' pos i t ion sense (propriocep
which may alter the findings.
tion), vibration sense, and some l ight to uch sensation from
-
Altered level of consciousness limits the ability to

the same side of the body. These columns are tested by po
perform a definitive neurologic examination.
sition sense in the toes and fingers or vibration sense us ing
a tuni ng fork.
The state of no demonstrable sensory or motor func

tion below a certain level i s referred to as a com plete spi n al T 1 2-Symphysis pubis
cord i nju ry. During the first weeks after injury, this di ag
L4- Med ial aspect of the calf
nosis cannot be made wi th certain ty because of the possi
,
b il i ty of sp i nal shock. .. S ee Ch ap te r 3: Shock. An 15-Web space between the first and second toes
i ncom p l ete i nj ury is one in whi ch a ny moto r o r se nso ry
S I -Lateral border of t he foot
funct ion remains; th e prognosis for recovery is signi ficantl y
better than that for com plete sp i nal cord injury. Sparing of S3-lschial tuberosity area
sensation in the peri anal region (sacra] spar in g) may be t he
S4 and 55-Perianal region
on l y s ign of residual function. Sacral sparing can be
dem onstrated by preservation of some sensory percep tion
in the perianal regio n and/o r volu n ta ry contraction of t he MYOTOMES
rectal sphincter.
Each segmental nerve (root) innervates more than one mus
cle, and most muscles arc innervated by more than one roo t
( usually two). Nevertheless, for the sake of sim pl i city, cer
SENSORY EXAMINATION
tain muscles or muscle groups are identified as represent
IJ How do I assess the patient's ing a single spinal nerve segmenL. The important key
neurologic status? muscle(s) are (Figure 7-4):
A dermatome is the area of skin innervated by the sensory

C5-Delto id
axons wilhio a particular segmen ta l nerve root. Knowledge
of some o[ the major dermatome levels is invaluable in de C6-Wrist extensors (b iceps extensor carpi radial .is
,
ter mining Lhe leve.l of i nj ury and assessing neu rologic im longus a nd b rev is)
provemen t or deterioration. The sensory level is the lowest
C7-Elbow extensors (t ri ceps )
dermatome with normal sensory function and can often dif
fer on the two sides of the body. For practical ptl rposes, Ih e C8-Finger f.lexors to the m idd le fi nger (flexo r digi-
upper cervical dermatorn es (Cl to C4) are somewhat vari to rum profundus)
able in their cutaneous distribution and are n ot com monly
T l -Sm al l finger abductors (abductor digiti rninimi)
used for localization. However, it sho u ld be remembered
that the sup raclavicu lar nerves (C2 th ro ugh C4) provi de L2-Hip flexors ( iliopsoas )
sensory innervation to the regi on overlyi ng the pecto ra l is
L3, l4-Knee extensors (quadriceps, patellar re
muscle (cervical cape). The presence of sensati on i n th is re
flexes)
gion may confuse Lhe exami ner when he or she is tryi ng to
determine the sensory level in pati en ts with lower cervical 14, 15 to Sl -Knee Oexion (ham st ri ngs )
injuries. The key sensory points are (F igu re 7-3):
LS-AniJe and big toe dorsiflexors ( t ibia lis a nt erio r

and extensor hallucis longus)

CS-Area over the deltoid
S l-Ankl e p lantar flexors (gastrocnemius, soleus}
C6-Thu mb
C7-Middl e finger The key muscles should be tested for power on both
sides. Each muscle is g raded on a six-point scale from nor
C8 -Little finger
mal strength to paralysis (Table 7-l). Documenta tion of the
T4-N ipple power in key muscle groups helps to assess neurologic im
provement or deterioration on su bsequen l exami nat io ns. In
T8 -Xip histernum
addition, the external a n al sphi ncter should be tested for
Tl 0-Umbilicus vol untary contraction by digital examination.
ANATOMY AND PHYSIOLOGY 161
Key sensory
points
T2 TJ
T4
T5
T6
rr
T8

T9

Tf1)
T11

TU
i-1 L1
L3
51
Figure 7-3 Key Sensory Points by Spinal Dermatomes. (Adapted from American Spinal Injury Association:
International Standards for Neurological Classification of Spinal Cord lnjur revised 2002. Chicago, IL: American
Spinal Injury Association; 2002.
NEUROGENIC SHOCK VERSUS SPINAL SHOCK condition, the blood pressure may not be restored by fluid
IJ How do I identify and treat neurogenic infusion alone, and massive Uuid resuscitation may result
in Ouid overload and pulmonary edema. '"(he blood pres
and spinal shock?
sure may often be restored by the judicious use of vase
Neurogenic shock results from impairment of the de pressors after moderate volume replacement. Atropine
scending sympathetic pathways in Lhe cervical or upper may be used to counteract hemodynamically significant
thoracic spinal cord. This condition res ul ts in Lhc Joss of bradycardia.
vasomotor tone and i n sympaLhetic innervation to the "Spinal shock" refers Lo the naccidity (loss of muscle
heart. The former ca uses vasodilation of visceral and tone) and Joss of rellexes seen after spinal cord injury.
lower-extremity blood vessels, pooling of blood, and, con The "shock" to the injured cord may rn ake it appear
sequently, hypotension. Loss of cardiac sympathetic tone completely nonflJnctional, although all areas are not
may cause the development of bradycardia or at least a necessarily destroyed. The duration of thi1> state is vari
failure of tachycardia in response to hypovolemia. In this able.
162 CHAPTER 7 Spine and Spi na l Cord Trauma
CS Deltoid
TABLE 71 Muscle Strength Grading
C6 Wrist extensors (biceps, extensor
carpi radialis longus and brevis)
SCORE RESULTS OF EXAMINATION
C7 Elbow extensors (triceps)
-....o Finger flexors to the middle finger 0 Total paralysis
T1 Small ringer abductors
1 Palpable or v1s1ble contraction
(abductor digiti minimi)
2 Full range of motton w1th grav1ty el1mmated
- 3 Full range of mot1on against grav1ty
4 Full range of motion, but less than normal

strength
5 Normal strength
NT Not testable
L2 Hip flexors (iliopsoas) Adapted wtlh permission from Klr;hblum SC, M>mmo P. Kim N, Campag
\ r
t::;g--1
==l rL.> ,, ., Knee extensors (quadriceps, nolo D. Mtllls S. CompariSOn of the revtd 2000 American Sptnal lnjury
ASSOCiatton classification standards wtth the 1996 gUtdeltnes. Am J Phr..
" patellar reflexes) Mf'd Rehdbt/2002,81 :502-505
L4,5 to S1 Knee flexion (hamstrings)

LS Ankle and big toe dorsiflexors sides or the body. When the term SCIISory level is used, it refers
(tibialis anterior and
extensor hallucis longus)
to the most caudal segment of the spinal cord with normal
St:nl>Ory funct ion. The 1/lotor level is defined similarly with re
S1 Ankle plantar flexors spect lo motor function as the lowest key musde that has a
(gastrocnemius, soleus)
grade of at least 3/5 (see Table 7-1 ). I n complete injuries, when
Figure 7-4 Key Myotomes. some impaired sensory and/or motor function is found just
below the lowest nom1al segment, this is referred to as t he
zone of partial preservation. As described previously, the de
EFFECTS ON OTHER ORGAN SYSTEMS termination of the level of injury on both sides is important.
ll)'povcntilation due to paralysis of the intercostal muscles A broad distinction may be made between lesions above
may result from an injury involving the lower cervical or and below T l . lnjuries of the tirst eight cervical segments of
upper thoracic spinal cord. I f the upper or middle cervical the spinal cord result i11 quadriplegia, and lesions below the
cord is injured, the diaphragm rtlso is paralyzed because of T I level result in paraplegia. The bo11y lntcf of injury is the
involvement of the C3 to CS segments, which im1ervatc the vertebra at which the bones arc damaged, causing inju ry to
diaphragm via the phrenic nc.!rve. The i nability to perceive the spinal cord. The neurologic level of i11jury is determined
pain may mask a potentially serious injury elsewhere in the primarily by clinical examination. Frequently, there is a dis
body, such as the usual signs of an acute abdomen. crepancy between the bony and the neurologic levels be
cause t he spinal nerves enter the !>pinal canal through the
foramina and ascend or descend inside the spinal canal be
fore actually entering the spinal cord. The further caudal the
injury is, the more pronounced thi discrepancy becomes.
Classifications of Apart from the initial management to stabilize the bony in
Spinal Cord Injuries jury, all subsequent descriptions of the level of injury arc
based on the neurologic level. .
IJ When do I suspect spine injury?
SEVERITY OF NEUROLOGIC DEFICIT
Spinal cord injuries can be classified <lccording to ( 1 ) level,
(2) sever ity of neurologic deficit, ( 3) spi nal cord syndrome, Spinal cord injury may be catcgori L.cd as;
and ( 4) morphology.
Incomplete paraplegia ( incomplete thoracic)
Complete paraplegia (complete thoracic )
LEVEL
lm:omplete quadriplegia (incomplete cervical)
The neurologic level is rhe most caud<ll segment of the spinal
cord th<ll has normal sensory and motor function on both Complete quadriplegia (complete cervical injury)
SPECIFIC TYPES OF SPINAL INJURIES 163
It is important to assess for any sign of preservation MORPHOlOGY

of function of the long tracts of the spinal cord. Any motor
or sensory function below the level of the injury consti Spinal injuries can be described as fractures, fracture-dislo
tutes an incomplete injury. Signs of a11 incomplel: injury cations, spinal cord injury without radiographic abnormal
include any sensation (including position sense) or volun ities (SCIWORA), a11d penetrating injuries. Each of these
tary movement in the lower extremities, sacral spa1ing (ie, categories may be further described as stable or unstable.
perianal sensation), voluntary anal sphincter contraction, However, determining the stability of a particular type of
and volunta1y toe flexion. Sacral reflexes, such as the bul injury is nol always simple and, indeed, even experts may
bocavernosus reflex or anal wink, do not qualify as sacral disagree. Hence, especially in the initial treatment, all patients
spanng. with radiographic evidence of injury and all those with neu
rologic deficits should be considered to have an unstable
spinal injury. These patients should be immobilized until
SPINAl CORD SYNDROMES after consultation with an appropriately qualified doctor,
Certain characteristic patterns of neurologic injury are fre usually a neurosurgeon or orthopedic smgeon.

quently seen in patients with spinal cord injuries. These pat

terns should be recognized so they do not confuse the
.
exam mer.
Central cord synd1'ome is characterized by a dispropor Specific Types of Spinal Injuries
tionately greater loss of motor power in the upper extremi
ties than u1 the lower extremities, with varying degrees of
sensory loss. Usually this syndJ'Ome is seen after a hyperex Cervical spine injuries can result from one or a combina
tension injury in a patient with preexisting cervical canal tion of the following mechanisms of injury:
stenosis (often due to degenerative osteoarthritic cha11ges).
The history is commonly that of a forward fall that resulted Axial loading
ill a facial impact. Lt may occur with or without cervical flexion
spine fracture or dislocation. Recovery usually follows a
characteristic pattern, with the lower extremities .recovering Extension
strength first, bladder function next, and the proximal upper Rotation
extremities and hands last. The prognosis for recovery in
central cord injuries is sornewhat better than with other in Lateral bending
complete injuries. Central cord syndrome is hought
t to be Distraction
due to vascular compromise of the cord in the distribulion
of the anterior spinal artery. This artery supplies the central
portions of the cord. Because the motor fibers to the cervi The injuries identified in this chapter all involve the
cal segments are topographically arranged toward the cen spinal column. They are listed in matomic sequence (not
ter of the cord, the arms and hands are the most severely in order of frequency), progressing from the cranial to the
affected. caudal end of the spine.
Anterior cord syndrome is characterized by paraplegia
and a dissociated sensory loss with a loss of pain a11d tem
perature sensation. Posterior column flmction (position,
ATlANTO-OCCIPITAl DISlOCATION
vibration, and deep pressure sense) is preserved. Usua!Jy,
anterior cord syndrome is due to infarction of the cord in Craniocervical disruption injuries are uncommon and re
the territory supplied by the anterior spinal artery. This sult from severe traumatic flexion and distraction. Most of
syndrome has the poorest prognosis of the incomplete ill- these patients die of brainstem destruction and apnea or
. .
Junes. have profound neurologic impairments (are ventilator-de
Brown-Sequard syndrome results from hemisection of pendent and quadriplegic). An occasional patient may sur
the cord, usually as a result of a penetrating trauma; it is vive if prompt resuscitation is available at the injury scene.
rarely seen. Nevertheless, variations on the classic picture This injury may be identified u1 up to 19o/o of patients with
are not uncommon. l n its pure form, the syndrome con fatal cervical spine mjurics and is a common cause of death
sists of ipsilateral motor Joss (corticospinal tract) and loss in cases of shaken baby syndrome in which the infant dies
of position sense (posterior column), associated with con immediately after shaking. Cervical traction is not used in
tralateral loss of pain and temperature sensation begin patients with craniocervical dislocation. Spinal immobi
ning one to two Levels below the level of injury lization is recommended initially. rl' Aids to the identifica
(spinothalamic tract). Even if the syndrome is caused by tion of atlanto-occipital dislocation on spine films,
a direct penetrating injury to the cord, some recovery is including Power's ratio, are included in Skill Station X: X
usually seen. Ray Identification of Spine Injuries.
ATLAS FRACTURE (C1 ) may be conluing. ln tim injury, the odontoid is not equi
distant from the two lateral mascs of C l . The patient
The atla1> is a thin, bony ring with broad articular surfaces. should not be forted to overcome the rotation, but should
Fractures of the atlas represent approximately SOlo of acute be immobilized in thl' rotated position and referred for fur
cervical spine fral.lures. Approximately 40% of atlas frac:" ther specialized treatment.
tures arc assoctated with fractures of the axis (C:!). The most
common C l fracture is a burst fracture ( Jefferson fracture).
The usual mechanism of injuq' is axial loading, which oc AXIS (C2) FRACTURES
curs when a large load falls vertically on the head or a patient The axis is the largest cervie<tl vertebra and is the most un
land1> on the top of his or her head in a relatively neutral po usual in shape. Therefore, it i.s susceptible to various frac
sition. The Jefferson fneture involves disruption of both the tun.s depending on the force nnd direction of the impact.
anterior and posterior rings of C I wilh Ia teral displacement Acute frnctures of C2 represent approximately 18% of all
of the lateral masses. The fracture is best seen on an open ccrvic<ll spine iniurics.
mouth view of the C I to C2 region and axial CT scans ( Fig
ure 7-S). In patients who survive, these fractures usually are
not associated with spinal cnrd injuries. However, they arc
Odontoid Fractures
unstable and :.houiJ he initially treatcu with a cervical col Approximate!)' ()()CV!J of C2 fractures involve the odontoid
lar. Unil,llcral ring or latcr,ll mass fracture are not uncom process, a peg-shaped bony protuberance tl1at projects up
mon and Lend ro be stable injuries. However, they are treated ward and i normally poitioneJ in contact with the anterior
as unstable until the patient is examined by an appropriately arch of C I. The odontoid proces is held in place primarily
qualified doctor, uually a ncu rourgeon or orthopedic sur by the transvase ligament. Odontoid fractures are initially
geon. identified by a lateral cervical spine !ilm or on open-mouth
odontoiJ views. llowever, a CT :.can usually s
i required for
further dcline,ltion. Type I odontoid fractures typically in

C 1 ROTARY SUBLUXATION volve the tip of thl odontoid and .1 re relatively uncommon.
C l rot<lr)' o,ubluxation injuq is moM often seen in children. Type II odontoid fr.tctures occur through the base of the
Lt may occur spontlneously, after major or minor trauma, dens and are the most common odontoid fracture (Figure 7-
with an upper respiratory inlcttion, or with rheumatoid 6). In children rounger than 6 years of age, the epiphysis
arthritis. The patient present:. v>'ith a persistent rotation of may be prominent and may look like a fracture at tJ1is level.
the head (torticolli). Thb injury is also best diagnosed with y ypc I I I odontoid frncturcs occur at the base of the dens and
an open-mouth odontoid view, although the x-ray ftndings extend obliquely into the body of the axis.
Figure 7-5 Jefferson Fracture. Open-mouth view

radiograph showing a Jefferson fracture. Fig ure 7-6 Odontoid Fracture. CT view of a Type
II odontoid fracture.
SPECIFIC TYPES OF SPINAL INJURIES 165
Posterior Element Fractures of C2 morbidity is much worse, with l 6o/o incomplete and 84%
A hangman's fracture involves the posterior elements of complete spinal cord injuries.
C2-that is, the pars interarticu\aris (Figure 7-7). This type
of fracture represents approximately 20% or all ais frac THORACIC SPINE FRACTURES
tures and usually is caused by an extension-type injury. Pa (T1 THROUGH T1 0)
tients with this fracture should be maintained in external
immobilization until specialized care is available. Thoracic spinal fractures may be classified into four broad
Variations of a hangman's fracture include bilateral ca tegorics:
liacl u res through the la Lcral masses or pedides. Approxi
Anterior wedge compression injuries
mately 20% of all axis fractures arc nonodontoid and non
hangman's. These include fractures through the body, Burst injuries
pedicle, lateral mass, laminae, and spinous process.
Chance fractures (Figure 7-8)
Fracture-djslocations
FRACTURES AND DISLOCATIONS

(C3 THROUGH C7)
Axial loading with llexion produces an anterior wedge
A fracture of C3 is very uncommon, possibly because it is compression injury. The amount of wedging usually is quite
positioned between the more vulnerable axis and the small, and the anterior portion o[ the vertebral body rarely
more mobile "relative fulcrum" of the cervical spine is more than 25o/o shorter Lhan the posterior body. Because
that is, CS and C6-where the greatest tlexion and ex of the rigidity of the rib cage, most or these fractures are sta
tension o r the cervical spine occur. In adults, Lhe most ble. The second type of thoracic fracture is the burst injury,
common level of cervical vertebral fracture is CS, and the which is caused by vertical-axial compression. Chance frac
most common level of subluxation is C5 on C6. The most tures arc transverse fractures through the vertebral body.
common injury patterns identified at these levels are ver They are caused by Aex.ion about an axis anterior to the ver
tebral body fractures with or without subluxation, sub tebral column and are most frequently seen following motor
luxation of the articular processes (including unilateral vehicle crashes in which the patient was restrained b)' only
or bilateral locked facets), and fractures of the laminae, a lap bell. Chance fractures may be associated with
spinous processes, peclicles, or lateral masses. Rarely, lig retroperitoneal and abdominal visceral injuries. Fracture
arncntous disruption occurs without fractures or facet dislocations are relatively uncommon in the thoracic and
dislocations. I umbar spine because of the orientation of the facet joints.
The incidence of neurologic injury increases dramat These injuries almost always are due to extreme flexion or
ically with facet dislocations. [n the presence of unilateral severe blunt trauma to the spine, which causes disruption
facet dislocation, 80% of patients have a neurologic in of the posterior elements (pedicles, fa cets, and lamina) of
jury-approx.imately 30% have root injuries only, 40o/o in the vertebra. The thoracic spinal canal is narrow in relation
complete spinal cord injuries, and 30o/o complete spinal to the spinal cord, so fracture subluxations in the thoracic
cord injuries. r n the presence of bila teral locked facets, the spine commonly result in complete neurologic deficits.
A 8 c
Figure 7-7 Hangman's Fracture (arrows) demonstrated in axial (A), sagittal paramedian (B), and sagittal mid
line (C) CT reconstructions. Note the anterior angulation and excessive distance between the spinous processes of
C1 and C2 (double arrows).
PITFALLS
An inadequate secondary assessment may result in

the failure to recognize a spinal cord injury, par
ticularly an incomplete spinal cord injury.
Patients with a diminished level of consciousness
and those who arrive in shock are often difficult to
assess for the presence of spinal cord injury. These
patients require careful repeat assessment once
initial life-threatening injuries have been man
aged.
by combining information from the history, clinical exam
ination (entry and exit sites), plain x-ray films, and CT

scans. lf the path of injury passes directly through the ver
tebral canal, a complete neurologic deficit usually results.
Complete deficits also may result from energy transfer as
sociated lvith a high-velocity missile (eg, bullet) passing
close Lo the spi nal cord rather than through it. Penetrating
Figure 7-8 Chance Fracture. Radiograph showing injuries of the spine usually are stable injuries unless Lhe
the Chance fracture. missile destroys a large portion of the vertebra.
Sim pic com pression fractures are usual ly stable and BLUNT CAROTID AND VERTEBRAL VASCULAR
often treated with a rigid brace. Burst fiactures, Chance frac INJURIES
tures, and fracture-dislocations are extremely UJJstable and
131unt trawna to the head and neck has been recognized as
almost always require internal fixation.
a risk factor for carotid and vertebral arterial injuries. Early
recognition and treatment of these injuries may reduce the
THORACOLUMBAR JUNCTION FRACTURES
risk of stroke. Indications for screening are evolving, but
(T1 1 THROUGH L1)
suggested criteria for screening include:
Fractures at the level of the thoracolumbar junction are due
Cl-C3 fracture
to the relative immobility of the thoracic spine as compared
with the lumbar spine. They most often result from a com Cervical spine fracture with subluxation
bination of acute hyperflexion and rotation, and, conse
Fractures involving the foramen transversarium
quently, they are usually unstable. People who fall f1-om a
height and restrained drivers who sustain severe flexion en Approximately one-third of these patients will be
ergy transfer are at particular risk for this type of injury. shown to have blunt carotid and vertebral vascular injury
The spinaJ cord terminates as the conus medullaris at (BCVl ) on CT angiography of the neck ( Figure 7-9). The
approximately the level of Ll, and injury 1.0 this part of the treatment of these injuries is evolving, and the impact of
cord commonly results in bladder and bowel dysfuncl'ion, treatment is not well defined.
as well as in decreased sensation and strength in the lo"''er
extremities. Patients with thoracolumbar fractures are par
ticul arly vulnerable to rotational movement. Therefore,
logrolling should be performed with extreme care.
X-Ray Evaluation
LUMBAR FRACTURES I) How do I confirm the presence o;

absence of a significant spine injury?
The radiographic signs associated with a lumbar fracture arc
similar to those of thoracic and thoracolumbar fractures. How Both careful clinical examination and thorough radi
ever, because only the cauda equina is involved, lhe probability ographic assessment are critical in identifying significant
ofa complete neurologic deficit is much less with these injuries. spine injury. rl' See Skill Station X: X- Ray Tdentification of
Spine Injuries.
PENETRATING INJURIES
CERVICAL SPINE
The most common types of penetrating injuries are Lhose
caused by gunshot wounds or stabbings. It is important to Cervical spine radiography is indicated for all trauma pa
determine the path of the buUet or knife. This can be done tients who have midline neck pain, tenderness on palpation,
X-RAY EVALUATION 167
Figure 7-9 Blunt Vertebral Artery

Injury. CT and angiogram of blunt ver
tebral artery injury.
neurologic deficits referable to the cervical spine, or an al be obtained in injured patients without an altered level of
tered level of consciousness or in whom intoxication is sus consciousness, or in those who report neck pain, to detect
pected. Lateral, anteroposterior (AP) and open-mouth occult instability or determine the stability of a knovm frac
odontoid views should be obtained. ture, such as a laminar or compression fracture. It is possi
On the lateral view, the base of the skull, all seven cer ble for patients to have a purely ligamentous spine injury
vical vertebrae, and the tirst thoractc vertebra must be visu that results in instability without associated fracture, al
alil'ed. The patient's shoulders may need to be pulJed down though some studies suggest that if plain three-view cervi
when obtaining the lateral cervical spine x-ray film, to avoid cal spine radiographs with CT supplementation are truly
missing fractures or fracture-dislocations in the lower cer normal ( ie, no anterior soft-tissue swelling, no abnormal
vical spine. If all seven cervical vertebrae are not visualized C1ngulation), then significant instabiJily is unlikely.
on the lateral x-ray film, a swim mer's view of the lower cer In some patients with significant soft-tissue injury,
vical and upper thoracic area should be obtained. paraspinal muscle spasm may severely limit the degree of
The open-mouth odontoid view should include tl1e entire flexion and extension that the patient allows. In such cases,
odontoid process and the right and left Cl, C2 articulations. the patient is treated with a semirigid cervical collar for 2
The AP view of ilie c-spine assists in the identification ofa uni to 3 weeks before another allempt is made to obtain flcx
l.tteral facet dislocation in casl'S in which little or no dislocation ion-ex'tension views. Under no circumstances should rhe
i:. identified on the lateral film. Axial CT scans at 3-mm inter patient's neck be forced into a position that elicits pain. All
vab also should be obtained through suspicious areas identi movements must be volunt<Hy. These films should be ob
lied on the plain films or through the lower cervical spine if it tained under the direct supervision and control of a doc
is nor adequately visualized on the plain filins. Axial CT m
i ages tor experienced in the in rerpreta Lion of su_ch fi Ims.
through Cl and C2 may also be more sensitive than plain films Approximately 10% of patients with a cervical spine frac
for detection of fractures of these vertebrae. If these films are ture have a second, noncontiguous vertebral column fracture.
of good quality and are properly interpreted, unstable cervical This warrants a complete radiographic screening of the en
spine injuries can be detected with a sensitivity ofgreater than Lire spine in patients with a cervical spine fracture. Such
97%. The complete series of cervical spine radiographs must screening also is advisable in all comatose trauma patients.
be reviewed by a doctor experienced in the proper interpreta In the presence of neurologic deficits, magnetic reso
tion of these films before the spine is considered normal and nance imaging (MRI) i recommended to detect any soft tis
the cervical collar is removed. CT scans may be used in lieu of sue compressive lesion, su1..h a:. .1 spinal epidural hematom1
plain images to evaluate the cervical spine. or traumatized herniated disk, which cannot be detected
If the screening radiographs described above arc nor with plain films. M R.I may also detect spi:naJ cord contusions
mal, flexion-extension x-rny films of the cervical spine may or disruption, and paraspinal ligamentous and soft tissue in-
jury. However, M IU is frequently not feasible in patienLS with bending the spinal column. No effort should be made to rc
hcmodynamic instability. When MRJ is not <1Vailable or ap duce an obvious deformity. Children may have torticollis,
propriute, CT myelography may be used 10 exclude the pres and the elderly may have severe degenerative spine di1.easc
ence of acute spinal <.:ord compression caused by a traumati that causes them to have a nontraumatic kyphotic or angu
herniated disk or epid ural hematoma. These specialized lation deformity of the spine. Such patients should be im
studies usually are performed at the discretion of a spine sur mobilized on a backboard in a position of comfort.
gery consultant. Box 7-1 presents guidelines for screening Supplemental padding is often necess<1ry. Attempts to align
trauma patients with suspected spine injury, and may serve the spine for the purpose ofimmobilization on the backboard
ns a model for the development of hospital policies. are not recommended ifthey cause pain.
Immobilization of the neck with a emirigid collar
does not ensure complete stabilization of the cervical spine.
THORACIC AND LUMBAR SPINE
Immobilization using a spine board with appropriate bol
The indications for screening radiography of the thoracic stering devices is more effective in limiting certain neck
and lumbar spine ure the same as those for the cervical motions. The use of long spine boards is recommended.
spine. AP and lateral plain radiographs with axial CT scans Cervical spine injury requires continuous immobilization of
at 3-mm intervals through suspicious areas can detect the entire patient with a semirigid cervical collar, head im
more than 99% of unstable injuries. On the AP views, the mobi lization, backboard, tape, and straps before and during
vertical alignment of the pediclcs and the distance between transfer to a definitive-care facil ity (Figure 7-10). Extension
pedicles of each thoracic and lumbar vertebra should be or flexion of the neck :.hould be avoided because these
observed. Unstable fractures commonly C<tuse widening of movements are the most dangerous to the spinal cord. The
the interpedicular distance. The lateral films detect sub airway is of critical importance in patients with spinal cord
luxations, compression fractures, and Chnncc fractures. injury, and early intubation should be accomplished if there
CT scanning is particularly useful for detecting fractures is evidence of respiratory compromise. During intubation,
of I he posterior elements ( pediclcs, lam ina, and spinous the neck must be maintained in a neutral position.
processes) and determining the degree of canal compro Of special wnccrn is the maintenance of adequate im
mise caused by burst fractures. Sagittal reconstructions of mobilization of restless, agitated, or violent patients. This
axial CT images or plain tomography may be needed to condition can be due to pain, confusion asotiated with hy
adequately characterize Chance fractures. As with the cer poxia or hypotenion, <1icohol or drug usc, or simply a pe
vical spine, a complete series of good quality radiographs sonulity disorder. The doctor should search for and correct
must be properly interpreted as normal by an experienced the cause, if pos5 ibl c. If necessary, a sedative or paralytic
doctor before spine precautions are discontinued. agent may be administered, keeping in mind the need for
adequate airway protection, control, and ventilation. The
usc of sedatives or paralytic agents 111 this setting requires
considerable clinical judgment, skill, and experience. The
General Management usc of short-acting, reversible agents is advised.
Once the patient arrives at the emergency department,
n How do I treat patients with spinal

every effort should be made to remove the rigid spine board
as etlrly as possible to reduce the risk of decubitus ulcer for
cord injury and limit secondary injury? mation. Removal of the board is often done as part of the
General management pine and spinal cord trauma includes secondary survey when the patient b logrolled for in:.pec
immobilization, intravenous fluids, medications, and trans tion and palpation of the back. It should not be dehtyed
fcr, if appropriate. rl' Sec Skill Station XI: Spinal Cord In solely for the purpose of obtaining definitive spine radi
jury: Assessment and Management. l>graphs, part icularly if radiographic evaluation may not be
completed for several hours.
The safe movement, or logrolling, of a patient with an
IMMOBILIZATION unstable or potentially unstable spine, requires planning and
n How do I protect the spine during the assistance of four or more individuals, depending on the
size of the patient (Figure 7- 1 1 ) . Neutral anatomic align
evaluation and transport?
ment of the entire vertebral column must be maintained
Prchospital care personnel usually immobilize patients be while rolling or lifting I he patient. One person is assigned
fore their transport to the emergency department. Any pa to m<lintain in-line immobilization of the head and ncLk.
tient with a suspected sptne injury should be immobilized Individuals positioned on the same side of the patient's torso
above and below the suspected injury site until a fracture is manuaiJy prevent segmental rotation, flexion, extension, lat
excluded by x-ray examination. Remember, spinal protec eral bending, or sagging of the chest or abdomen during
tion should be maintained until a cervical pine injury is ex transfer of the patient. A fourth person is responsible for
cluded. Proper immobilization is achieved with the patient moving the legs and removing the spine board and exam
1n the neutral poition-that is, supine without rotating or ining the patien t's back.
GENERAL MANAGEMENT 169
BOX 7-1
Guidelines for Screening Patients
with Suspected Spine Injury
Suspected Cervical Spine Injury any ofthese films are suspicious or unclear, re
place the collar and obtain consultation from
0 The presence of paraplegia or quadriplegia is pre
a spine specialist.
sumptive evidence ofspinal instability.
9 Patients who have an altered level of con
f) Patients who are awake, alert, sober, and neu sciousness or are too young to describe their
rologically normal, and have no neck pain or symptoms: Lateral, AP. and open-mouth odon
midline tenderness: These patients are ex toid films with CT supplementation through
tremely unlikely to have an acute c-spine frac suspicious areas (eg, C1 and C2, and through
ture or instability. With the patient in a supine the lower cervical spine if areas are not ade
position, remove the c-collar and palpate the quately visualized on the plain films) should
spine. If there is no significant tenderness, ask be obtained for all such patients. In children,
the patient to voluntarily move his or her neck CT supplementation is optional. If the entire
from side to side. Never force the patient's neck. c-spine can be visualized and is found to be
When performed voluntarily by the patient, normal, the collar can be removed after ap
these maneuvers are generally safe. If there is propriate evaluation by a doctor/consultant
no pain, have the patient voluntarily flex and skilled in the evaluation/management of pa
extend his or her neck. tients with spine injuries. Clearance of the
Again, if there is no pain, c-spine films are not c-spine is particularly important if pulmonary
necessary. or other care of the patient is compromised
by an inability to mobilize the patient.
fil Patients who are awake and alert, neurologi
cally normal, cooperative, and able to con
g When in doubt, leave the collar on.
centrate on their spine but do have neck pain Consult: Doctors who are skilled in the eval
or midline tenderness: The burden of proof is uation and management of patients with
on the doctor to exclude a spinal injury. All spine injuries should be consulted i n all
such patients should undergo lateral, AP, and cases in which a spine injury is detected or
open-mouth odontoid x-ray examinations of suspected.
the c-spine with axial CT images of suspicious
D Backboards: Patients who have neurologic
areas or of the lower cervical spine if not ad
deficits (quadriplegia or paraplegia) should be
equately visualized on the plain films. Assess
evaluated quickly and taken off the backboard
the c-spine films for: (a) bony deformity, (b)
as soon as possible. A paralyzed patient who is al
fracture of the vertebral body or processes, (c)
lowed to lie on a hard board for more than 2 hours
loss of alignment of the posterior aspect of
is at high risk for serious decubitus ulcers.
the vertebral bodies (anterior extent of the
vertebral canal), (d) increased distance be (;) Emergency situations: Trauma patients who re
tween the spinous processes at one level, (e) quire emergency surgery before a complete
narrowing of the vertebral canal, and (f) in workup of the spine can be accomplished
creased prevertebral soft tissue space. If these should be transported carefully, assuming that
films are normal, remove the c-collar. Under an unstable spine injury is present. The c-collar
the care of a knowledgeable doctor, obtain should be left on and the patient logrolled
flexion and extension, lateral cervical spine when moved to and from the operating table.
films with the patient voluntarily flexing and The patient should not be left on a rigid back
extending his/her neck. If the films show no board during surgery. The surgical team
subluxation, the patient's c-spine can be should take particular care to protect the neck
cleared and the c-collar removed. However, if as much as possible during the operation. The
Continued
BOX 7-1
Continued
..
anest he siolog ist

should be informed of the !I Patients who have spine pain or tenderness
status of the workup. on palpation, neurologic deficits, or an al
tered level of consciousness or in whom in
Suspected Thoracolumbar Spine Injury toxication is suspected: AP and lateral
radiographs of the entire thoracic and lum
0 The presence of paraplegia or a level of sensory
bar spine should be obtained. Axial CT im
loss on the chest or abdomen is presumptive ev
ages at 3-mm intervals should be obtained
idence of spinal instability.
through suspicious areas identified on the
6 Patients who are awake, alert, sober, neuro plain films. All images must be of good quality
logically normal, and have no midline thoracic and interpreted as normal by an experienced
or lumbar back pain or tenderness: The entire doctor before discontinuing spine precautions.
extent of the spine should be palpated and in
spected. If there is no tenderness on palpation 9 Consult a doctor skilled in the evaluation and
or ecchymosis over the spinous processes, an management of spine injuries if a spine injury
unstable spine fracture is unlikely, and thora is detected or suspected.
columbar radiographs may not be necessary.
suspicion of neurogenic shock. Patients with hypovolemic

shock usually have tachycardia, whereas those with neu
rogenic shock classica l ly have bradycardia. If the blood
pressure does not improve after a fluid challenge, the ju
dicious use of vasopressors may be indicated. Phenyl e
phrine hydrochloride, dopamine, or norepinephrine is
recommended. Overzealous fluid administration may
cause pulmonary edema in patients with neurogenic
shock. When the ilu i d status is uncertain, the use of inva
sive monitoring may be helpful. A urinary calheter is in
serted to monitor urinary output and prevent bladder
distention.
MEDICATIONS
Figure 7-10 Cervical spine injury requires contin u
ous immobilization of the entire patient with a semi At present, there is insufficient evidence to support the rou
rigid cervical collar, head immobilization, backboard, tine use of steroids in spinal cord i nju ry.
tape, and straps before and during transfer to a defini
tive-care facility.
INTRAVENOUS FLUIDS PITFALL

In patients in whom spine injury is suspected, intravenous
Patients being transpo rted to a trauma center may
Ouids arc administered as they would usually be for re
have unrecogn ized spinal inju ries. These patients
suscitation of the trauma patient. If active hemorrhage is
should be maintained in complete spinal immobi
not detected or suspected, persistent hypotension despi te lization.
the administration of2 L or more of fluid should raise the
GENERAL MANAGEMENT 171
A B
a:..

c D
Figure 7-11 Four-Person logroll. Logrolling a patient to remove a spine board and/or examine the back
should be accomplished using four people. One person stands at the patient's head to control the head and c-spine,
and two are along the patient's sides to control the body and extremities (A). As the patient is rolled, these three
people maintain alignment of the spine, while the fourth person removes the board and examines the back (8 and
C). Once the board is removed, the patient is returned to the supine position, while maintaining alignment of the
spine (D).
TRANSFER
backboard, and/or semirigid cervical collar. Remember, cer
Patients with spine fractures or neurologic deficit should vical spine injuries above C6 can result in partial or total loss
be transferred to a definitive-care facility. The safest proce of respiratory function. lf there is any concern about the ad
dure is to transfer lhe patient after telephone consultatjon equacy of ventilation, the patient should be ntubated prior
with a spine specialist. Avoid unnecessary delay. Stabilize to transfer.
the pa ticnt's condition, and apply the nccessa ry splinls,
CHAPTER SUMMARY
..
The spinal column consists of cervical, thoracic and lumbar vertebrae. The spinal cord
contains three important tracts: the corticospinal tract, the spinothalamic tract and the
posterior columns.
Obtain lateral, AP. and open-mouth odontoid c-spine x-ray films, when indicated, as
soon as life-threatening injuries are controlled. Document the patient's history and phys
ical examination so as to establish a baseline for any changes in the patient's neurologic
status.
Spinal cord InJUries may be complete or incomplete and may involve any level of the
spinal cord.
Attend to life-tl1reatening injuries first, minimizing movement of the spinal column. Es

tablish and maintain proper immobilization of the patient until vertebrill fractures or
spinal cord injuries have been excluded. Obtain early consultation with a ne urosu rgeon
and/or orthopedic surgeon whenever a spinal injury is suspected or detected.
Transfer patients with vertebral fractures or spina l cord injuries to a definitive-care

facility.
Acute Spinal Cord Injury Randomized Controlled Trial. } Nu

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Performance at t his skill station will allow the participant to:

Interactive Skill
Procedure
OBJECTIVES
THE FOLLOWING
Identi fy various spine injuries by using specific anatomic guidelines
for examining a se ri es of spine x-rays.
Skill XA: Cervlcal Spine
X-Ray Assessment Given a series of spine x-rays and scenarios,
Skill X-8: Atlanto-Ocdpital Define limitations of examination.
Joint Assessment Diagnose fractures.
Skill XC: Thoracic and
Delineate associated injuries.
lumbar XRay Assessment Define other areas of possible injury.
Skill X-0: Review Spine

XRays
17 5
176 SKILL STATION X X-Ray Identification of Spine Injuries
Skill X-A: Cervical Spine X-Ray Assessment

(See Figures X-1, X-2, and X-3)
STEP 1 . Assess adequacy and alignment ( Figure X-1 ).

A. Identify the presence of aU 7 cervical
vertebrae and the superior aspect ofTL
B. Identify the:
Anterior vertebral line (Fig. X-1, line A)
Anterior spinal line (Fig. X-1, line B)
Posterior spinal line (Fig. X-1, line C)
Spinous processes (Fig. X-1, line D)
STEP 2. Assess the bone ( Figure X-2).
A. Examine all vertebrae for preservation of

height and integrity of the bony cortex.
B. Examine facets.
C. Examine spinous processes.
STEP 3. Assess the cartilage, including examining the
cartilaginous disk spaces for narrowing or
widening (see Figure X-2).
STEP 4. Assess the dens (Figure X-3 ) .

A. Examine the outline of the dens.
B. Examine t.he predental space (3 mm).
C. Examine the clivus; it should point to the
dens.
Figure X-2
Figure X-1 Figure X-3

SKILL STATION X X-Ray Identification of Spine Injuries 17 7
STEP 5. Assess the extraaxial l.oft tissues. B. Examine the dtstances between the spinous
A. Examine the extraaxial lopace and soft tissues processes.
7 mm at C3
3 em at C7
Skill X-8: Atlanta-Occipital Joint Assessment

(See Figures X-4 and X-5)
Detection of an atlanta-occipital dislocation can be chal margin of the foramen magnum I). Wackenheim's line runs
lcnging. Two useful findings include a Power's ratio > I along the posterior clivus nnd passes tangentially to the pos
( BC/OA, where BC is the dist1ncc from the basion I B I to terior tip of the dens. If an atlanto-occipital injury is sus
the posterior arch [C] ofCI .1 nd OA is the clistance from the pected, spinal immobilization should be preserved, and
anterior arch of CJ [A] to the opisthion [ 0-the posterior expert racliologic interpretation should be obtained.
NORMAL CO-C1 INSTABILITY

I
Wackenheim

-
.... .
.
BC/AO (Power's ratio) .s 1 BC/ AO (Power's ratio) > 1
Figure X-4
178 SKILL STATION X X-Ray Identification of Spine Injuries
>3mm <14mm
Figure X-5
Skill X-C: Thoracic and Lumbar X-Ray Assessment
ANTEROPOSTERIOR VIEW LATERAL VIEW

STEP 1 . Assess for: STEP 2. Assess fo r:
A. Al ign men t A. A lignment
of bodies/angulation of spine
B. Symmetry of pedicles B. Contour of bodies
C. Contour of bodies C. Presence of disk spaces
D. Height of disk spaces D. Encroachment of body on canal
E. Central position of spinous processes
Skill X-0: Review Spine X-Rays

Instructor will eliplay a ser ies of films to be interpreted and
discussed with students.
SPINE X-RAY SCENARIOS
PATIENT X- 1 PATIENT X-3
28 -year old male feU while mountain biking. No neurologic

- 8-year-old child fell down the stairs and is cryi ng. No neu
deficit. rologic deficit.
PATIENT X-2 PATIENT X-4

54 year-o ld male hit a tree while driv ing his car. Symptoms
- 62-ycar-old male hit an abutment while driving his car.
are only slight discomfort of his neck and some nwnbness There is no neurologic deficit, but patien t is unable to ac
in his digil V, left side. tively move his neck because of pain.
SKILL STATION X X-Ray Identification of Spine Injuries 179
PATIENT X-5 PATIENT X- 1 0

19-year-old female with head and neck trauma as the result 36-year-old male fel l from a height greater than 3 meters
of an assault. and has back pain.

PATIENT X6 PATIENT X- 1 1
22-year-old male struck a lree while riding his motorcycle. 30-year-old male involved in motorcycle crash. On exami
No neurologic deficit. nation, he appears to have a sensory and motor deficit in
volving both legs. Deep-tendon reflexes are absent.
PATIENT X-7
PATIENT X-12
Box fell on head. Painful neck, no neurologic deficit.
25-year-old female involved in motor vehicle crash. Pal icnt
was wearing a lap belt without shoulder harness. No neuro
PATIENT X8
logic de ficit
.
45-year-old woman attempted to hang hcrselr. GCS score of?.
PATIENT X9
30-year-old male in motor vehicle crash versus tree. Parient
was restrained, but there was no airbag. GCS score of I 5;
neurologic exam intact; patient reports neck pain.
..
Performance at th1s skill stat1on w1ll allow the part1opant to:

Interactive Skill
Procedure
OBJECTIVES
are req uired when caring for
Demonstrate the examination of a patient in whom spine and/or
trauma patients. This Skill
spinal cord i nj uries are suspected.
Station includes scenarios and
related x-rays for use in
Explain the principles for immobilizing and logrolling patients with
making evaluation and
neck and/or spinal injuries, including the indications for removing
management decisions based
protective devices.
on the findings.
Perform a neurologic examination and determine the level of spinal
THE FOllOWING
cord injury .

Determine the need for neurosurgical consultation.
IN THIS SKill STATION:
Skill XI-A: Primary Survey and Determine the need for lnterhospita l or intrahospital transfer, and
Resuscitation-Assessing describe how the patient should be properly immobil ized for transfer.
Spine Injuries
Skill Xl-8: Secondary

Survey-Neurologic
Assessment
Skill XI-C: Examination for

Level of Spinal Cord Injury
Skill XJ-D: Treatment

Principles for Patients with
Spina l Cord Injuries
Skill XI-E: Principles of Spine

Immobilization and Logrollmg
181
182 SKILL STATION XI Spinal Cord Injury: Assessment and Management
Skill XI-A: Primary Survey and Resuscitation Assessing Spine Injuries

Note: The patient should be maintained in a supine, neutral' B. Replace fluids for hypovolemia.
posi lion using proper immobilizatit)n tech niq ucs. C. If spinal cord injury is present, fluid
resuscitation should be guided by monitoring
STEP 1 . Airway : central venous pressure (CVP). (Note: Some
A. Assess the airway while protecting the cervical patients may need inotropic support.)
.
spme. D. When performing a rectal examination before
B. Establish a definitive airway as needed. inserting the urinary catheter, assess for rectal
sphincter tone and sensation.
STEP 2. Breathing: Assess and provide adequate
oxygenation and ventilatory support as needed. STEP 4. Disability-Brief Neurologic Examination:
STEP 3. Cirwlation: A. Determine level of consciousness and assess

pupils.
A. If the patient has hypotension, differentiate
B. Determine Glasgow Coma Scale (GCS) score.
hypovolemic shock (decreased blood
C. Recognize paralysis/paresis.
pressure, increased heart rate, and cool
extremities) from neurogenic shock
(decreased blood pressure, decreased heart
rate, and warm extremities).
Skill XI-B: Secondary Survey-Neurologi.c Assessment

STEP 1. Obtain A.t'vt:PLE 1-1 istory Contusions and lacerations/penetrating
A. History and mechani:.m of injury wounds
B. Medical history B. Assess for pain, paralysis, and paresthesia:
C. Identify and record drugs given prior to Presence/absence
patient's arrival and during assessment and Location
management phases t>:eurologic level
C. Test sensation to pinprick in all dermatomes
STEP 2. Reassess level of consciousness and pupils.
and record the most caudal dermatome that
STEP 3. Reassess GCS score. (eels the pin prick.
D. Assess motor function.
STEP 4. Assess the spine (See Skill XI C: Examination for
E. Measure deep tendon rencxc!t (least
Level of Spinal Cord Injury)
informative in the emergency setting).
A. Palpate the entire spine posteriorly by
F. Document and repeat-record the results of
carefully logrolling the patient and assessing
the neurologic examination and repeat motor
for:
and sensory examinations regularly until
Deformity and/or swelling
consultation is obtained.
Grating crepitus
Increased pain with palpation STEP 5. Reevaluate-Assess for aosociatcd/occult injuries.
Skill XI-C: Examination for level of Spinal Cord Injury

A patient wi th a spinal cord injury may have varying levels of Raises elbow to Jcvd of shoulder-deltoid, CS
neurologic deficit. The level of motor function <md sensation Flexes forearm-biceps, C6
must he reassessed frequently and carefully documented, be EA-rends forearm-triceps, C7
cause changes in the level of ftmction can occur. Flexes wrist and fingers, C8
preads fingers, Tl
STEP 1 . Best Motor Examination
B. Determining the level of paraplegia, nerve
A. Determi1Jing the level of quadriplegia, nerve
root level:
root level:
SKILL STATION XI Spinal Cord Injury: Assessment and Management 183
Flexe::. hip-iliopsoas, L2 Spine and Spinal Cord Trawna. Remember, lhe

Extends knee-quadriceps, L3-L4 cervical sensory dermatomes of C2 through C4
Flexes knee-hamstrings, L4-L5 to Sl form a cervical cape or mantle that can extend
Dorsiflexes big toe-extensor hallucis lngus, down as far as the nipples. Because of this
L5 unusual pattern, the examiner should not depend
Plantar Flexes ankle-gastrocnemius, S I on the presence or absence of sensation in the
neck and clavicular area, and the level of
STEP 2. Sensory Examination: Determining the level of
sensation must be correlaled with the motor
sensation is done primarily by assessing the
response Jevel.
dermatomes. rl' See Figure 7-3 in Chapter 7:
Skill Xl-0: Treatment Principles for Patients with Spinal Cord Injuries
STEP 1. Patients with suspected spine injury must be specilically needed for the management of
protec ted from further injury. Such protection shock. A cenLral venous calheler should be
includes applying a semirigid cervical. collar and inserled lo carefully monitor fluid
long back board, performing a modified logroll lo administration.
ensure neutral alignment of the entire spine, and B. Urinary catheter: A urinary catheter should
removing I he patient from the long spine board as be inserted dming the primary survey and
soon as possible. Paral}'zed patients who are resuscitation phases t.o monitor urinary
immobilized on a long spine board are at particular output and prevent bladder distention.
risk for pressure points and decubitus ulcers. C. Gastric catheter: A gastric calheter should be
Therefore, paralyzed patients should be removed inserted in all palients with paraplegia and
from the long spine board as soon as possible after quadriplegia to prevent gastric distention and
a spine injury is diagnosed, ie, within 2 hours. aspiration.
STEP 2. Fluid Resuscitation and Monil01ing:
A. CVP monitoting: Intravenous fluids usually
are limited Lo maintenance Levels u nless
Skill XI-E: Principles of Spine Immobilization and logrolling

STEP 2. Apply gentle, in-line manual immobilization to
ADULT PATIENT
the patient's head and apply a semirigid cervical
Four people are needed to perform the modified logrolling collar.
procedure and to immobilize the palient-for example, o n
STEP 3. Gently straighten and place the patient's arms
a long spine board: one person to maintain manual, in-line
immobilization of the patient's bead and neck; one for the (palm in) ne>-.'1 to the torso.
torso (including the pelvis and hips); one for the pelvis and STEP 4. Carefully straighten the patient's legs and place
legs; and one to direct the procedure and move the spine them in neutral alignment with the palient's
board. This procedure maintains the patient's enlire body spine. Tie tl1e ankles together with a roller-type
in neutral alignment, lhereby minimizing any untoward

dressing or cravat.
movement of the spine. This procedure assumes lhat any
STEP 5. While mai11taining alignment of tbe patient's
extremity suspected of being fractured has already been im
mobilized. head and neck, another person reaches across
and grasps the patient at tl1e shoulder and vvrist.
STEP 1 . Place Lhc long spine board wilh straps next to the A third person reaches across and grasps the
patient's side. Position the straps for fastening patient's hip just distal to the wrist with one hand
later across the pa tienl's thorax, just above the and with the other hand firmly grasps the roller
iliac crests, across the thighs, and just above the bandage or cravat that is securing the ankles
ankles. Straps or tape can be used to secure the together.
patient's head and neck to the long board.
STEP 6. At the direction of the person who is maintaining STEP 1 . As previously described, properly secure the
immobilization of the patient's head and neck, patient to a long spine board, which is the basic
cautiously logroll the patient as a unit toward the technique for splinting the spine. In general, this
two assistants at the patient's side, but only to the. is done in the prehospital setting, and the patient
least degree necessary to position the board arrives at the hospital already immobilized. The
under the patient. Maintain neutral alignment of long spine board provides an effective splint and
the entire body during this procedure. permits safe transfers of the patient with a
minimal number of assistants. However,
STEP 7. Place the spine board beneath the patient and
unpadded spine boards can soon become
carefully logroll the patient in one smooth
uncomfortable for conscious patients and pose a
movement onto the spine board. The spine board
significant risk for pressure sores on posterior
is used only for transferring the patient and
bony prominences (occiput, scapulae, sam1m,
should not be left under the patient for any
and heels). Therefore, the patient should be
length of time.
transferred from the spine board to a firm, well

STEP 8. Consider padding under the patient's head to padded gurney or equivalent surface as soon as it
avoid hyperextension of the neck and for patient can be done safely. Before removing the patient
comfort. from the spine board, c-spine, chest, and pelvis
x-ray films should be obtained as indicated,
STEP 9. Place padd.ing, rolled blankets, or similar
because the patient can be easily lifted and tl1e
bolstering devices on both sides of the patient's
x-ray plates placed beneath the spine board.
head and neck, and firmly secure the patient's
\Vhile the patient is immobilized on tl1e spine
head to the board. Tape the cervical collar,
board, it is very important to maintain
further securing the patient's head and neck to
inm10bilization of the head and the body
the long board.
continuously. The straps used to immobilize the
patient on the board should nol be removed
from the body whjJe the head remains taped to
PEDIATRIC PATIENT
the upper portion of the spine board.
A pediatric-sized long spine board is preferable when im
mobilizing a small child. If only an adult-sized board is
STEP 2. Remove the patient from the spine board as early
as possible. Preplanning is required. A good time
available, place blanket rolls along the entire sides of the
child to prevent lateral movement. A child's head is propor to remove the board from under the patient is
when the patient is logrolled to evaluate the back.
tionately larger than an adult's. Therefore, padding should
be pl aced under the shoulders to elevate the torso so that STEP 3. Safe movement of a patient vv:ith an unstable or
the large occiput of the child's head does not produce flex potentially unstable spine requires continuous
ion of the cervical spine; tllis maintains neutral alignment of maintenance of anatomic alignment of the
the child's spine. Such padding extends from the chlld's ltm1- vertebral colwm1. Rotation, flexion, extension,
bar spine to the top of the shoulders and laterally to the lateral bending, and shearing-type movements in
edges of the board. any direction must be avoided. Manual, in-line
immobilization best controls the head and neck.
No part of the patient's body should be allowed
COMPLICATIONS
to sag as the patient is lifted off the supporting
If left immobilized for any length of time (approximately 2 surface. The transfer options listed below may be
hours or longer) on tl1e long spine board, pressure sores may used, depending on available personnel and
develop at the occipu t scapulae, sacrum, and heels. There
, equipment resources.
fore, padding should be applied under these areas as soon as
STEP 4. Modified Logroll Technique: The modified
possible, and the patient should be removed from the long
logroll technique, previously outlined, is reversed
spine board as soon as his or her condition permits.
to remove the patient from the long spine board.
Four assistants are required: one to maintain
REMOVAL FROM A LONG SPINE BOARD manual, in-line immobilization of the patient's
head and neck; one for the torso (including the
Movement of a patient wiU1 an w1stable vertebral spine in
pelvis and hips); one for the pelvis and legs; and
jury can cause or worsen a spinal cord injury. To reduce
one to direct the procedure and remove the spine
the risk of spinal cord damage, mechanical protection is
board.
necessary for all patients at risk. Such protection should
be maintained until an unstable spine injury has been STEP 5. Scoop Stretcher: The scoop stretcher is an
excluded. alternative to using the modified logrolling
SKILL STATION XI Spinal Cord Injury: Assessment and Management 185
techniques for patient transfer. The proper use of to suspect that a c-spine and/or thoracolumbar spine in
this device can provide rapid, safe transfer of the jury may exist, based on mechanism of injury. In patients
patient from the long spine board onto a firm, witb multiple injuries with a diminished level of con
padded patient gurney. For example, thisevice sciousness, protecUvc devices should be lefl in place until
can be used to transfer the patient liom one a spine injury is excluded by clinical and x-ray examina
transport device to another or to a designated tions. .. See Chapter 7: Spine and Spinal Cord Trauma. If
place, eg, x-ray table. a patient i s immobil ized on a spine board and is para
plegic, spinal instability should be presumed and all ap
The patient must remain securely immobilized until a
propriate x-ray films obtained to determine the site o f
spine injury is excluded. After the patient is transferred from
spinal injury. However, if the patient is awake, alert, sober,
the backboard to the gurney (stretcher) and the scoop
neurologically normal; is not experiencing neck or back
stretcher is removed, the patient must again be immobilized
pain; and does not have tenderness to spine palpation,
securely on the gurney (stretcher). The scoop stretcher is not
spine x-ray examination and immobilization devices are
a device on '"'hich the patient is immobilized. In addition,
not needed.
the scoop stretcher is not used to transport the patient, nor
Patients who sustain multiple injuries and arc coma
should the patient be transferred to the gurney by picking
tose should be kept immobilized on a padded gurney
up only the foot and bead ends of tbe scoop stretcher. With
(stretcher) and logrolled to obtain the necessary x-ray films
out firm support under the stretcher, it can sag in the mid
to exclude a fTacture. Then, using one of the aforementioned
dle and result in loss of neutral alignment of the spine.
procedures, they can be transferred carefully to a bed for
better ventilatory support.
IMMOBILIZATION OF THE PATIENT WITH
POSSIBLE SPINE I NJURY
Patients frequently arrive in the ED with spinal protective
devices i n place. These devices should cause the examiner
SCENARIOS
SCENARIO Xl- 1 SCENARIO Xl-3

A IS-year-old boy is riding his bicycle through a parking lot. A 25-year-old male passenger sustains mulliple injuries in
He is distracted and hits a car at low speed when it backs a car collision. The driver died at the scene of the injury.
out of a parking space. He is Lhrown from his bicycle across The patient is transported to the ED imn1obilized on a
the trunk of the car and sustajns a mild abrasion and an ru1- long spine board with a semirigid cervical collar applied.
gled deformity of the left wrist. He is brought to the ED im Oxygen is being administered, and admin istration of
mobilized on a long spine board and with a semirigid warmed crystalloid fluids with two large-caliber intra
cervical collar in place. He is alert and cooperative and has venous l i nes is initiated. His blood pressure is 85/40 mm
no hemodynamic abnormalities. Hg, his heart rate 130 beats/min, and his respiratory rate
40 breaths/min. His respirations are shallow, and there is a
contusion over the chest wall. His eyes are open, and his
SCENARIO Xl- 2 verbal response is appropriate. He is able to shrug his
shoulders, b u t is unable to raise his elbow t0 Lhe shoulder
A 75-year-old male is walking to the store when he trips
level or move his legs.
and falls forward, striking his chin on a parked car. He is
transported to the ED immobilized o n a long spine board
with a semirigid cervical collar applied. He has ctn abra
SCENARIO Xl-4
sion on his chin and is alert and appropriately responsive.
Physical examination reveals paralysis o[ his hands, with This scenario is essentially the same as Scenario Xl-3, but
very little finger motion. He has some upper-extremity the instructor will make changes in the patient's neurologic
movement (grade 2/5), but is clearly weak bilaterally. Ex status as rhe student examines the patient.
amination of the lower extremities reveals weakness, but A 25-year-old passenger sustains multiple injuries i n
he is able t o !lex and extend both his legs at the hip and a car collision. The driver died at the scene of the injury.
knee. He has various areas of hypesthesia over his body. The passenger is transported to the ED immobilized on a
long spine hoard with a semirigid cervical collar applied. SCENARIO Xl-5
Oxygen is being administered, administration of warmed
crystalloid fluids with two large-caliber intravenous lines
A 6-year-old boy fell off his bicycle and hit the back of his
head. In the ED, his head and neck are in a flexed position,
is initiated.
and he reports pain in his neck. He is immobilized on an

unpadded long !>pine board without a cervical collar.
I
C H A PT E R
CHAPTER OUTLINE Upon completion of th1s top ic the stu dent will be able to i n i
,
tially assess and manage pati en ts with life-threatening and

Introduction
limb-threatening musculoskeletal Injuries. Specifically, the doc
Primary Survey and Resuscitation tor will be able to:
Fracture Immobi lization OBJECTIVES
X Ray Examination
-
Secondary Survey E xplai n the signi ficance

of musculoskeletal injuries
History in patients with multiple i njuri es .
Outline priorities in the assessment of muscu
Potentially Life-Threatening Extremity Injuries loskeletal trauma to identify life-threatening and
Major Pelvic Disruption with Hemorrhage limb threateni ng i njur ies
- .
Major Arterial Hemorrhage

Crush Syndrome (Traumatic Rhabdomyolysis) Explain the proper principl es of initial manage
ment for musculoskeletal injuries.
Limb-Threatening Injuries
Open Fractures and Joint Injuries
Vascular Injuries, Incl ud i ng Traumatic Amputation
Compartment Synd rome
Neurologic Injury Secondary to Fracture-Dislocation
Other Extremity Injuries
Contusions and Lacerations
Joint Injuries
Fractures
Principles of Immobilization
Femoral Fractures
Knee Injuries
Tibia Fractures
Ankle Fractures
Upper-Extremity and Hand I njuries
Pain Control

Associated Injuries
Occult Skeletal Injuries
Chapter Summary
Bibliography
188 CHAPTER 8 Musculoskeletal Trauma
Introduction
PITFA L L
Injuries to the musculoskel<.:ta l system occur in 85o/o of pa:. Musculoskeletal injuries are a potential source of oc
licnts who sustain blum trauma; they often appear dramatic, cult blood loss i n patients with hemodynamic ab
but rarely cause an immediate threat to l ife or limb. How normalities. Occult sites of hemorrhage are the
ever, musculoskeletal injuries must be assessed and man
retroperitoneum from unstable pelvic ring injuries,
the thigh from femoral fractures, and any open frac
aged p roperl y and appropriately o lift. and limb are not
ture with major soft tissue involvement in which
jeopardized. The doctor must recognize the presence of such
blood loss may be serious and occurs before the pa
injuric. be familiar with the anatomy of the injury, protect tient reaches the hospital.
the patient from further disabilit), and anticipate and pre
vent complications.
Major musculoskeletal injuries indicate that significant
forces were ustained by the body. Por example, a patie nt applic,llion of a sterile pre!>:..ure dressing us ually controls
with long-bone fractures above and bdow the diaph ragm hemorrhage. Aggressive lluid resuscitation is an i mp ortan t
supplement to these mechanical measures.
has an increased likelihood of associnted i ntcrnal torso in
juries. Unstable pelvic fractures and open femur [ractures
may be accompanied by brisk bleeding. Severe crush injuries
cause the rcleae of myoglobin, which may precipitate in the Adjuncts to Primary Survey
renal tubules and result in renal failure. Swelling into an in
tact musculofascial space may cause an acute compartment
Adjuncts to the primary survey of patients with muscu
srndromc that, if not diagnosed and treated, may lead to
loskeletal trauma include fracture immobilization and x-rav'
lating impairment and l oss of usc of the cxtremilies. Fat
exa mina tion .
embolism, an uncommon but highl y lethal complication of
l o ng-bone frndures, may lead to p ul monary Cailure and im
paired cerebral funct ion. FRACTURE IMMOBILIZATION
Musculoskeletal trauma does not warrant a reo rderi ng
The goal of initial fracture immobilization is to realign the
of the priorities of resuscitation (ABCDEs). However, the
inj ured extremity in as close to anatomic position a5 possi
precncc of significant musculo!>kcletal trauma docs pose a
ble and to prevent excessive fracture-site motion. Thi re
challenge to the treating doctor. Musculoskeletal injuries
alignment is accomplished by the application of in-line
cannot be ignored and treated at a later time. The doctor
traction to realign the extremity and maintained by an Im
must treat the whole patient, including musculoskeletal in
mobilization device. The proper application of a splint help!>
juries, to ensure an optimal outcome. Despite careful as
control blood loss, reduce pain, and prevent further soft tis
sessment and management of mul tipl e injuries, fractures
sue injury. Tf an open fracture is present, the doctor need
and soft tissue injuries may not be initi al ly recognized. Con
not be concerned about pulling exposed bone back into the
tinued reevaluation of the patient is necessary to identifY all
wound because all open fractures require su rg ica l debride
injuries.
ment. . See Skill Station XII: Muscul oskeletal Tra uma: As-
Primary Survey and Resuscitation
n What impact do musculoskeletal

injuries have on the primary survey?
During the primary survey, it is imperative to recognize and

control hemorrhage from musculoskeletal injuries. Deep
soh tissue lacerations may involve major vessels and lead to
ex:.anguinating hemorrhage. l lemorrbage control is best ef
fected by direct pressure.
Hemorrhage from long-hone fractures may be signifi
cant, and certain femoral fractures may result in up to 4
units of blood loss into the thigh. producing class I l l shock.
1\ppropriatc splinting of the fracture may significantly de
crease bleeding hy reducing motion and enhancing a tam Major musculoskeletal injuries indicate that significant
ponade ciTed of the muscle. I( the fracture is open, forces were sustained by the body.
SECONDARY SURVEY 189
sessment and Management, Skill XH-C: Realigning a De example, lateral compression fracture of the pelvis re
formed Extremity. sulting fTom a side impact in a vehicle colllsion.
Joint dislocations usually require splinting in the posi
2. What was the postcrash location of the patient-in
tion in which they are found. Tf a closed reduction has sue-

side the vehicle or ejected? Was a seal belt or airbag in
cessfully relocated the joint, immobilization in an anatomic
use? This information may indicate patterns of injury.
position may be accomplished in a number of ways: pre
If the patient was ejected, determine the distance the
fabricated splints, pillows, or plaster. These devices will
patient was throvvn and the landing conditions. Ejec
maintain the extremity in its umeduced position.
tion generally results in increased injury severity and
Splints should be applied as soon as possible, but they
unpredictable patterns of injury.
must nol take precedence over resuscitation. However,
splints may be very helpful during this phase to control 3. \.Yas there eJo..'ternal damage to the vehicle-for exam
hemorrhage and pain. ple, deformation to the front of the vehicle from a
head-on collision? This information raises the suspi
cion of a hip dislocation.
X-RAY EXAMINATION
4. Was there internal damage to the vehicle-for exam

X-ray examination of most skeletal injuries occurs as the ple, bent steering wheel, deformation to the dash
part of the secondary survey. Which x-ray films to obtain
board, or damage to the windscreen? These findings
and when to obtain them are determined by the patient's
indicate a greater likelihood of sternal, clavicular, or
initial and obvious clinical findings, the patient's hemody
spinal fnctures or hip dislocation.
namic status, and the mechanism of injury. An anteropos
terior (AP) view of the pelvis should be obtained early for all 5. Was the patient wearing a restraint? I f so, what type
patients with multiple injuries for whom a source of (lap or three-point safety belt)? Was the restraint
bleeding has not been identified. applied properly? Faulty application of safety re
straints may cause spinal fra'ctures and associated
intraabdomina1 visceral injuries. Was an air bag de
ployed?
6. Did the patient fall? If so, what was the distance of the
Secondary Survey fall, and how did the patient land? This information
helps identify the spectrum of injuries. Landing on
the feet may cause foot and ankle injuries with associ
Elements of the secondary survey of patients with muscu ated spinal fractures.
loskeletal injuries are the history and physical examination.
7. Was the patient crushed by an object? If so, identify
the weight of the crushing object, the site of the in
HISTORY jury, and duration of weight applied to the site. De
Key aspects of the patient history are mechanism of injury, pending on whether a subcutaneous bony surface or a
environment, preinjury status and predisposing factors, and muscular area was crushed, different degrees of soft
prehospital observations and care. tissue damage may occur, ranging from a simple con
tusion to a severe degloving extremity injury V\>'llh
compartment syndrome and tissue loss.
Mechanism of Injury
8. Did an explosion occur? lf so, what was the magni
Information obtained from the transport personnel, the
tude of the blast and what was lhe patient's distance
patient, relatives, and bystanders at the scene of the injury
from the blast? An individual dose to the explosion
should be documented and included as a part of the pa
may sustain primary blast injury from the force of the
tient's medical record. It is particularly important lo de
blast wave. A secondary blast injury may.occur from
termine the mechanism of inju ry, which may arouse
debris and other objects accelerated by the blast effect
suspicion of injuries that may not be immediately appar
(eg, fragments), leading to penetrating wounds, lacer
ent. rl" See Appendix B: Biomechanics of Injury. The doc
ations, and contusions. The patient also may be vio
tor shottld mentally reconstruct the injury scene, identify
lently throW11 to Lhe ground or against other objects
other potential injuries that the patienl may have sus
by the blast effect, leading to blunt musculoskeletal
tained, and determine as much of the following informa
a11d other in,iuries (tertiary blast effect).
tion as possible:
9. Was the patient involved in a vehicle-pedestrian colli
1 . In a motor vehicle crash, what was the precrash loca sion? Musculoskeletal injuries may follow predicted
tion of the patient in the vehicle-driver or passen patterns (eg, bumper injury to leg) based on the size
ger? This fact can indicate the type of fracture-for and age of the patient.
Environment
Ask prehospital care personnel for information about the
environment, including:

Patient exposure to temperature extremes
Patient exposure to toxk fumes or agents
Broken glass fragments (which may also injme the

examiner)
Sources of bacterial contamination (eg, dirt, animal

feces, fresh or sail water)
This information can help the doctor anticipate poten

tial problems and determine the initial antibiotic treatment.
Preinjury Status and Predisposing Factors The patient must be completely exposed for adequate
lt is important to determine the patient's baseline condition assessment.
prior to injury, because this information may alter the un
derstanding of the patient's condition, treatment regimen, pi tal. All prehospital observations and care must be reported
and outcome. The AMPLE history also should include in and documented.
formation about the patient's exercise tolerance and activity
level, ingestion of alcohol and/or olber drugs, emotional
problems or illnesses, and prev ious musculoskeletal injuries.
The patient must be completely undressed for adequate ex
Prehospital Observations and Care amination. Obvious extremity injuries are often splinted.
prior to the patient's arrival in the emergency department
Findings at the incident site that may help the doctor iden
(ED). There are three goals for tl1e assessment of trauma pa-
tify potential injuries include: .
tLents' extrem1tJes:
. .
Position in which the patient was found 1 . Identification of life-threatening injury (primary sur
Bleeding or pooling of blood at the scene, indu ding vey)
the estimated amount 2. Identification oflimb-threatening injmies (secondary
Bone or fracture ends thai may have been exposed survey)
Open wounds in proximity to obvious or suspected 3. Systematic review to avoid missing any otl1er muscu
fractures loskeletal injury (continuous reevaluation)
Obvious deformity or dislocation Assessment of musculoskeletal trauma may be achieved

by looking at and talking to the patient, as well as by palpa
Presence or absence of motor and/or sensory func tion of the patient's extrem ities and performance of a
tion in each extremity logical, systematic review of each extremity. The four com
Delays in extrication procedures or transport ponents that must be assessed are: ( I ) skin, which protects
the patient from excessive fluid loss and infection; (2) neu
Changes in limb function, perfusion, or nemologic romuscular function; ( 3) circulatory status; and ( 4 ) skeletal
state, especially after immobilization or during and ligamentous integrity. Using this evaluation prqccss re
transfer to the hospital
duces the risk of missing an injury. ,JI See Skili Station XU:
Reduction of fractures or dislocations during extri Musculoskeletal Trauma: Assessment and Management,
cation or splinting at the scene Skill XII-A: Physical Examination.
Dressings and splints applied, with special attention

Look and Ask
to excessive pressure over bony prominences that
may result i n peripheral nerve compression injuries, Visually assess the eA.'tremities for color and perfusion,
compartment syndromes, or crush syndromes. wot.mds, deformity (angulation, shortening), swelling, and
discoloration or bruising.
The time of the injury also should be noted, especially A rapid visual inspection of the entire patient is neces
if there is ongoing bleeding and delay in reaching the hos- sary to identify sites of major external bleeding. A pale or
SECONDARY SURVEY 191
white dist,JI e>.tremi ty is indicative of ,1 lack of arterial in usu<llly wnfirm the diagnosis of a fracture. If pain or ten
flow. l xtrem ities that arc swollen in the region of major derness is associated with painful abnormal motion through
muscle groups may indicate a crush injury with an im the bone, fracture is diagnosed. I Iowever, attempts to elicit
pending compartment S}'ndromc. welling or ecchyJ110sis in crepitation or denwnstr<lle abnormal motion are not
or around a .Jolllt and/or over the subcutaneow; surface of ,1 recommended.
bone is a s1gn of a musculoskeletal injury. Extremity defor At the time of logrolling, p.llp.th! the patient's back to
mity is an obvious sign of major ext remit}' injury (sec Table iden tify any laceratiom, palpable gaps between the spinous
8- I ). processes, hematoma, or defects in the posterior pelvic re
l nl>pcct the pat ien t's entire body for lacerations and gion that arc indicative of unstable axial skeletal injuries.
abrasiom. O pen wounds arc obvious unless they are located Closed :.oft tissue injuries are more difficult to cvalu
on the dorsum of the body. The patient must be carefu lly ate. Sofl t is:.uc avulsion may shear the skin from the deep
logml led to asses for an injury or skin laceration. If a bone fascia, a llowing lor significa nt accumulation of blood. Al
prot rudes or is viualized in the wo und an open fracture , tern a t ively th skin may bl' sheared from its blood supply
,
exist. Any open wound to a limb with an associated fracture and undergo necrosis over a few days. This area may have
also is considered an open fracture until proven otherwise local abrasions or bru iscd skin that arc clues to a more severe
by a su rgco n. degree of muscle damage and potential compartment or
Observe till patient s spon ta neous ex trem i ty motor
' crush syndromc.:s. These l>Oft tissue i njuri es are best evalu
fun...t ion to help identify any neuro log ic and/or muscular ated by k nowing the mechanism of injury and pal pati ng the
im pa irmen t. If the pa t ient is unconscious, absent sponta speci fic component involved .
neous ex tremit y movement may be the only sign of im )oint stability may be determined only by clinical ex
pa ired fUnction. With a coopemtive pat ient active voluntary , amination. Abnormal motion through a join t segment is in
muscle ,1nd peripheral nerve function may be assessed by dicative of a liga men rous rupture. PaJpate the joint to
asking the patient to contract major muscle groups. The identity any :.welling and tenderness of the ligaments as weU
ability to move all m<Jjor joints through a full range of mo a\ intraarticular fluid. l'ollowing this, cautious :.tress111g of
tion usually mdilate\ that the nerve-muscle unit is intact the speci fic ligaments Lan be performed. Excessive pain may
and the joint i stable. mak abnormal ligament motion because of guarding of the
joint by muscular contraction or spasm; this condition may
Feel need to be reassessed later.
Palpate' the extremities to determine sensation to the ski n
( neurologic func ti on) and identify areas of tenderness ( frac Circulatory Evaluation
ture or deep muscle injury). Loss of sensation to pain and Palpate the distal pulse in each extremi ty and assess capil
touch demonstrates the preence of a spinal or peripheral lary rc/111 <.1f the digi ts If hypotension limits digital exami
.
nerw injury. Areas of tenderness or pain over muscles may nation of the pulse, the use of a Doppler probe may detect
indicate a musde coni us ion or fracture. Pai n tenderness, , blood flow to an extremity. The Doppler signal must have a
swe ll ing mel deformity over <1 subcutaneous bony surface
, triphasic quality to ensure no proximal lesion. Loss of sen-
TABLE 8-1 Common Joint Dislocation Deformities
JOINT DIRECTION DEFORMITY
Shoulder Anterior SqucJred off

Posterior Locked 111 1nternal rotation
Elbow Postenor Olecranon prom1nent postenorty
Hip Anterior Flexed, abducted. externally rotated

Posterior Flexed, adducted, Internally rotated
Knee Anteropostenor loss of normal contour, extended
Ankle Lateral 1s most common Externa lly rotated, prominent medial malleolus
Subtalar joint Lateral is most com mon Laterally d1sptaced os calos

"'' '" ' "' ..... .... ''" ' """
'"
"" ........ ... '" ........... ..... ........ ........... .... .... .... ,..._ ,,,,,,_
........... . . -.. ...... ..
" ,,,
,.,, ..... ..... - ..... - ....,.,
_,,, .... - ..
MAJOR PELVIC DISRUPTION

PITFALL WITH HEMORRHAGE
Failure to perform a thorough secondary survey can Injury
result in missing potential life- and lim b-threatening Patients with hypotension who have pdvic fractures have a
I nJunes.
high mortality, and sou11d decision making is crucial. Pelvic
fra,t ure associated wjth hemorrhage commonly exhibit
disruption of t11e posterior osseous ligamentous (sacroiliac,
sation in a stocking or glove distribution is an early sign of sacrospinous, sacrotuberous, tnd the fibromuscular pelvic
vacular tmpairment. floor) complex from a :.acroiliac fracture and/or dislocation,
In pattents with no hemodynamic abnormalities, pulse or from a sacral fracture (Figure 8-1 ). The force vector opens
discrepancies, coolness, pallor, parethesia, and even motor the pelvic ring, rears the pelvic venous pl<.:xus, and occa
function abnormalities suggest an arterial injury. Open sionally dil>rupts the internnl iliac arterial system (antero
wounds ,wd liactures i n proximity to arteries can be a clue posterior compression injury). This mechanism of pelvic

to an ,H tl'rial injury. A Doppler nnkle/brachiuJ index of less ring injury may be caused by motorcych.: cwshes and pedes
than 0.9 is indicative of an abnormal arterial flow secondary trian vehicle collisions, direct crushing injury to the pelvis,
to injury or peripheral vascular disease. The ankle/brachial and !Ills from heights greater than 12 feet (3.6 meters). Mor
index is determined by taking the systolic blood pressure tality in patients with all types of pclvi<. fractures is approx
value as measured by Doppler at the ankle of the injured leg imately one in six (5o/o-30o/o). In patients with dosed pelvic
and dividing it by the Doppler-determined systolic blood fractures and hypotension, mortality rises to approximately
pressure of the uninjured arm. Auscultation can reveal a one in four ( I Oo/o-42%) . l lemorrhagc is the major re
bruit with an associated palpable thrill. Expanding verl>ihle contributing factor to mortaliI y.
hematomas or pulsatile hemorrhage from an open wound In motor vehicle collisions, a common mechanism of
also arc indicative of arterial injury. pelviL fracture is force applied t(> the lateral aspect of the
pelvb th:ll tends to rotate the involved hemipelvis internally,
X-Ray Examination dosing down the pelvic volume nnd relieving <my tension
on the pelvic vascular system (hiler:! I compression injury).
The clinical examination of patients with musculoskeletal
This rotational motion drives rhc pubis into the lower gcn
injuries often suggests the need for x ray examination. Any
itourinnry system, creating injury to the bladder and/or ure
area over a bone that is tender and deformed likely repre
thra. Hemorrhage from this injury, or its sequelae, rarely
sents a fracture. In patients who have no hemodynamic ab
result in death, as it does in the completely unstable pelvic
normalittes, an x-ray film :.hould he obtained. Joint
injury. .. See Skill Station X I I : Musculoskeletal Trauma:
effusionl>, abnormal joint tenderness, or joint deformity
Assessment and Management, Skill XIJ-F: identification and
represent a joint injury or dislocation that also must be x
Mn nngcmen t of Pelvic Fractures.
raycd. The only reason for electing not to obtain an x-ray
film prior to treatment of a dislocation or a frachtre is the
presence of vascular compromise or impending skin
bn:akdown. 1 his is seen commonly with fracture-disloca
tions of the ankle. If there is going to be a delay in obtain
ing x-rays. immediate reduction or realignment of the
extremity should be performed to reestablish the arterial
blood supply ,md reduce the pressure on the skin. Align
ment can be maintained by appropriate immobilization
techniques.
Potentially Life-Threatening
Extremity Injuries
I What are my priorities, and what are

my management principles?
Extremity iniu1ies that are considered potentially life-threat fi g ure 8-1 Radiograph showing pelvic fracture as
ening include major pelvic disruption with hemorrhage, sociated with hemorrhage. Notice the disruption of the
major <1rterial hemorrhage, and crush syndrome. posterior osseous-ligamentous complex.
POTENTIALLY LIFE-THREATENING EXTREMITY INJURIES 19 3
Assessment A sheet, pelvic binder, or other devices may apply sufCi

Major pelvic hemorrhage occurs rapidly, and the diagnosis cient stability for the unstable pelvis. These temporary
must be made quickly so that appropriate resuscitative methods are suitable to gain early pelvic stabilization. De
treatment can be initiated. Unexplained hypolenon may finitive care of patients with hemodynamic abnormalities
be the only initial indication of major pelvic disruption demands the cooperative efforts of a team that includes a
with instability in the posterior ligamentous complex. The lrauma surgeon a11d an orthopedic surgeon, as well as any
most imponan t physical signs are progressive flank, scrotal, other surgeon whose eA.-pertise is required because of the
or perianal swelling and bruising. This is associated with patient's injuries. .. See Chapter 5: Abdominal and Pelvic
failure t<> respond to initial lluid rcsuscitalion. Open frac Trauma.
Open pelvic fractures with obvious bleeding require
ture wounds about the pelvis (especially if the open area is
in the perineum, rectLUll, or buttocks), a high-riding pressure dressings to control hemorrhage, which is done by
packing the open wounds. Early surgical consultation is
prostate gland, blood at the urethral meatus, a nd demon
strable mechanical instability are signs of unstable pelvic essential.

nng lllJury.
.
Mechanical instability of the pelvic ring is tested by

manual manipulation of the pel vis. This procedure should
MAJOR ARTERIAL HEMORRHAGE
be performed only once during the physical examination,
as repeated testing ior pelvic instability can result in fur Injury
ther hemorrhage. The first indication o f mechanical in Penetrating wounds of an exn-emity may result in major ar
stability is leg-length d iscrepa ncy or rotational deformity terial vascular injury. Blunt tramna resulting in an extrem
(usually external} without a fracture of that extremity. The ity fracture or joint dislocation in close proxin1ity lo an
unstable hemipclvis migrates cephalad because of muscu artery also may disrupt the artery. These injuries may lead to
lar pull and rotates outward secondary to the effect of significant hemorrhage through the open wound or into the
gravity on the unstable hemipelvis. Because the unstable soft tissues. The use of a tourniquet to control bleeding may
pelvis is able Lo rotal:e externally, the pelvis can be dosed by be of benefit in select patients.
pus hi ng on the iliac crests at the level of the anterior su
perior iliac spine. Motion can be felt i f Lhe iliac crests are
grasped a nd the unstable hemipelvis is pushed inward and Assessment
then out\.Yard (compression distraction maneuver). With Assess injured extrem ilies for external bleedin g, loss of a
posterior disruption, the involved hemipelvis can be previously palpable pulse, and changes in pulse quality,
pushed cephalad as well as pulled caudally. This transla Doppler tone, and ankle/brachial index. A cold, pale, pulse
tional motion can be felt by palpating the posterior iliac less extremity indicates an i nterruptio n in arterial blood
spine and tubercle while pushing and pulling the unstable supply. A rapidly expanding hematoma suggests a si gn ifi
hemipelvis. The identification of neurologic abnormalities cant vascular injury. See Skill Station XII: Musculoskele
or open wounds in the flank, peri neum, and rectum may tal Trauma: Assessment and Management, Skill XII-G:
be evidence of pelvic ring instability. Wl1en appropriate, Identification of ArteriaJ Injury.
an AP x-ray of the pelvis confirms the cli nical examina
tion . .. See Skill Station IV: Shock Assessment and Man
Management
agement.
If a major arterial injury exists or is suspected, immediate
consultation 1-vith a surgeon is necessary. Management of
Management major arterial hemorrhage includes application of direct
Initial management of a major pelvic disruption associ pressure to the open wound and aggressive fluid resuscita
ated with hemorrhage requires hemorrhage control and tion.
rapid fluid resuscitation. Hemorrhage control is achieved The judicious use of a pnemnatic tourniquet may be

th rough mechanical stabilization or the pelvic ring and helpfl.tl and lifesaving (Figure 8-2). lt is not advisable to
external counterpressure. Patients with these injuries may apply vascular clamps into bleeding open wounds whjle the
be initially assessed and treated in hospitals that do not pari ent is in the ED, luucss a superficial vessel is clearly iden
have the resources to defi nitively manage the degree of as tified. If a fracture is associated with an open hemorr haging
sociated hemorrhage. Simple techniques can be used to wound, it should be realigned and splinted while direct pres
stabilize the pelvis before transferring the pa tient . Longi sure is applied to the open wound. A joint dislocation
tudinal traction applied through the skin or the skeleton simply requires immobilization; joint reduction may be ex
is a first-line method. Because these injuries externally ro tremely dif6.cult, and Lhereforc should be managed by emer
tate the hemipelvis, internal rotation of the lower limbs gency surgical intervention. The use of arteriography and
also reduces the pelvic volume. This procedme may be other investigations is indicated only in resuscitated patients
supplemented by applying a support directly to the pelvis. who have no hemodynamic abnormalities. Urgent consul-
194 CHAPTER 8 Musculoskeletal Trau ma
cipitation of myoglobin and is indicated in most patients. It

is recommended to majntain ilie patient's minary output at
100 ml/hr until the myoglobinuria is cleared.
limb-Threatening Injuries
Extremity injuries that are considered potentially limb
threatening include open fractures and joint injUJies;
vascular injuries, including traumatic amputation; com
partment syndrome; and neurologic injury secondary lo
fractme-dislocation.
Figure 8-2 Trauma patient with pneumatic tourni
quet in place. OPEN FRACTURES AND JOINT INJURIES
Injury
Open (raclures represen t a communication between the ex
Lation with a sttrgeon skilled in vascular and extremity
ternal environment and the bone (Figure 8-3). Muscle and
trauma is necessary.
skin must be injured for this to occur. The degree of soft tis
sue injury is proporlional to the energy appJjed. This dam
CRUSH SYNDROME (TRAUMATIC age, along with bacterial contamination, makes open
RHABDOMYOLYSIS) fractures prone to problems with infection, healing, and
function.
Injury
Cmsh syndrome refers Lo the clinical effects of injured mus Assessment
cle that, if left untreated, may lead to acute renal failure. This
condition is seen in individuals who have sustained a crush Diagnosis of an open fracture is based on the history of
the incident and physical examination of the extremity
injury of a significant muscle mass, most often a thigh or
calf. The muscular insult is a combination of direct muscle that demonstrates an open wound with or \lfithout sig
injury, muscle ischemia, and cell death witl1 release of myo nificant muscle damage, contamjn<ltion, and associated
globin. Muscular trauma is the most common cause of fracture. Management decisions should be based on a
rhabdomyolysis, which ranges from an asymptomatic iJlncss complete history of Lhe incident and assessment of the
with elevation of the creatine kinase level to a life-threaten InJUry.
ing condition associated wilh acute renal failure and dis
seminated intravascular coagulation (DIC).
Assessment
The myoglobin produces dark amber urine that tests posi
tive for hemoglobin. The myoglobin assay must be speci.fi
cally requested to confirm the presence of myoglobin.
Rhabdomyolysis may lead to hypovolemia, metabolic aci
dosis, hyperkalemia, hypocalcemia, and me.
Management
The initiation of early and aggressive intravenous fluid ther
apy during the period of resuscitation, along with the ad
ministration of sodium bicarbonate and electrolytes, is
critical to protecting the kidneys and preventing renal fail
ure. Myoglobin-induced renal failme may be prevented by
intravascu lar Uuid e>..rpansion and osmotic diuresis to main
tain a high rubular volume and urine flow. Alkalization of
the urine with sodium bicarbonate reduces intratubular pre- Figure 8-3 Example of an open fracture.
LIMB-THREATENING INJURIES 195
Documentation regarding the open wound begins dur Management

ing the prehospital phase, with the initial dcscLiption of the An acutely avascular extremity must be recognized promptly
injury and any treatment rendered at the scene. If the doc and treated emergently. Although controversial , the use of a
umentation is adequate, no further inspection of the open tourniquet may occasionally be lifesaving andfor limb-sav
wound is warranted. If the documentation or the 11istory is ing in the presence of ongoi ng hemorrhage uncontrolled by
inadequate, the dressing should bt: removed under as sterile direct pressure. A propcrly appl icd lourniquct, wh ilc en
conditions as possible to visually examine the wound. A ster dangering the limb, may save a lite. J\ tourniquet must oc
ilc drc11sing is then reapplied. At no time shouJd the wound elude arterial inflow, as occluding only the venous system
be probed. If a fracture and an open wound exist in the same can increase hemorrhage. The risks of tourniquet use in
limb segment, the fracture i:. considered open until proved crease with time. If a tourniquet must remain in place for
otherwise. a prolonged period to S<tve a life, the physician must be
If an open wound exists over or near a joint, it hould cognizant of the fact the choice of life over limb has been
be assumed that this injury connects with or enters the 111<ldC.
joint, and surgical consultation should be obtained. The Muscle docs not to kra tc a lack of arterial blood now
insertion of dye, saline, or any other material into the for longer than 6 hours before nccrosi:, begins. Ncrvts also
joint to determine whether 1 he joint cavity commun icates are very sensiUve to an anoxic environment Therefore, c<1 rly
with the wound is not recommended. The only safe way operative revascularization is required to restore arlcrinl
to determine communication between an open wound tlow to the impaired distal extremity. If there is an a!>Oci
and a joint is to surgically explore and debride the ated fracture deformity, it can be corrected quickly by gen
wound. tly realigning and .splinting the injured extremity.
If an arterial injury i:. <l!>ociatcd with a dislocation of a
Management joint, a doctor who is skilled in joint reduction may attempt
The presence of an open fracture or a joint injury should
one gentle reduction maneuver. Otherwise, splinting of the
dislocated joint and emergency surgical consultation are
be promptly determined. Apply appropriate immobiliza
necessary. Arteriography must not delay reestablishing ar
tion after an accurate description of the wouml is made
terial blood flow, and is indicated only after consul tal ion
and associated soft tissue, circulatory, and neurologic in
with a surgeon. CT <ngiography may be helpful in institu
volvement is determined. Prompt su rgical consultation
tions in which arteriography is not available.
ill necessary. The patient should he adequately res usc i
The potential for vallculer compromise also exbt:.
tated, with hemodynamic stability achieved if possible.
whenever an injured extremity is l>plirHed or placed in a cast.
Wounds then may be operatively debrided, fractures sta
Vascular compromise can be identified by the loss of or
bilized, and distal pulses confirmed. Tetanus prophylaxis
change in the distal pube, but exce:.sive pain after ca:.t .1p
should be admin istered .. See Appendix E: Tetanus Im
plication also must be investigated. The splint, cast, and any
munization. Antibiotics are used only after consultation
other circumferential dressings must be released promptly
with a surgeon.
and the vascular supply reassessed.
Amputation is a traumatic event for the patient both
VASCULAR INJURIES, INCLUDING physicaUy and emotionally. Traumatic amputation, a everc
TRAUMATIC AMPUTATION form of open fracture that results in loss of an extremity,
may benefit from tourniqu<.>t use and requires consultation
Injury with and intervention by a surgeon. Certain open fractures
A vascular injury should be strongly suspected in the pres with prolonged ischemia, neurologic injury, and muscle
ence of vascular insufficiency associated with a history of damage may require amputation. Amputation of an injured
blunt, crushing, twisting, or penetrating injw}' to an ex extremity may be lifesaving in patients with hemodynamic
tremit y. abnormalities who are diflicult to resuscitate.
Although the potential for repl anta t ion should be
.
considered, it must be put into perspective with the pa

Assessment
tient's other injuries. A patient with multiple injuries who
The limb may initially appe;1r viable because extremities requires intensive resuscitation and emergency surgery is
often have some collateral circulation that provides enough not a candidate for replantation. Replantation usually is
retrograde flow. Partial vascul;lr injury results in coolness performed with an injury of an isolated extremity. A pa
and prolonged capillary refill in the distal part of an ex tient with dean, sharp amputations of fingers or of a dis
tremity, as well as diminihcd peripheral pulses and an tal extremity, below the knee or elbow, should be
abnormal ankle/brachial index. Alternatively, the distal ex transported to an appropriate surgical team skilled 111
tremity may have a complete disruption of flow and be cold, the decision making for and management of replan Ia I ion
pale, and pulseless. procedures.
The amputated part should he th oro ughl y washed in Assessment

totonk :.olution (eg, Ringer's lact,He) and wrapped in ster
Any i nj ury to an ext remi ty ha> the poten tia l to cause a com
ik gau;c th.ll has been soaked in .tqueou> penicillin ( 100,000
partment syndrome. However, certain injuries are consid
units in 50 mL of Ringer's lactate solution). The amputated
ered high risk, including:
part i then wrapped in a similarly moistened sterile toweT,
placed in a plastic bag and trnnsported with the patient in
,
Tibial and forearm fractures
an insulated cooling chest with crushed ice. Care must be
taken not to freeze the amputated part. Injuries immobil jzed in tight dressings or casts
i jury to m usde
Severe crush n
COMPARTMENT SYNDROME Localized, prolonged external pressure to an ex

trem it y
Injury
Compartment syndrome develops when the pressure within Increased capillary permeability secondary to rcper
nn osteol:tscial compartment of muscle causes ischemia ami fusion of ischemic muscle
subsequent necrosis. This ischemia may be caused by an in

Burns
crease in compartment size (eg, swelling secondary to revas
cularizntion of an ischemic extremity) or by decreasing the Excessive exercise
compartment l>ize (eg, a constrkt iVl' dressing}. Compart
ment syndrome may occur in any site in which muscle is The key to the successful treatment of acute com
con tamed within a dosed fascial space. (Remember, the skin putment synd rome is earl)' diagn osi1-.. A high degree o f
a lso may act as a restricting membrnne in cer tai n circum awa re ness is important, C.'>peciall} if the patient has an
stances.) Common areas for compartment syndrome in altered mental sensorium and is un,tblc to respond ap
dude the lower leg, forearm, foot, hand, glu tea l region, and propriately to pain. . See Skill Station XII: Muscu
thigh ( rigu re 8-4 ). loskeletal Trauma: Assessment and Management, Skill
The end results of unchecked compartment syndrome Xll-E: Compartment Syndrome: Assessment and Man
arc ca tastropb ic. Tbey include neurologic deficit, muscle agement.
nccrosi, ischemjc contracture, infection, delayed healjng of The signs and symptoms of compartment syndrome
a fracture, and pos:..iblc amputation. indudc:
A B
Superficial posterior
compartment
.._.... Nerves and

blood vessels
Lateral-==:::::J.!
compartment Deep posterior
compartment
compartment
Figure 8-4 Compartment Syndrome. Develops when the pressure within an osteofascial compartment of
muscle causes ischemia and subsequent necrosis. (A) Normal calf. (B) Calf with compartment syndrome.
OTHER EXTREMITY INJURIES 19 7
Increasing pain greater lhan expected and oul of NEUROLOGIC INJURY SECONDARY TO
proportion to the stimulus FRACTURE-DISLOCATION
Palpable tenseness of the compartment Injury
..
Asymmetry of the muscle compa rtmenls Fractures and particularly dislocations may cause significant
neurologic injury because of lhe anatomic relationship and
Pain on passive stretch of the affected muscle
proximity of the nerve to the joint-for example, sciatic
Altered sensation nerve compression from posterior hip dislocation or axil
lary nerve injury from anterior shoulder dislocation. Opti
Absence of a palpable distal pulse usually is an uncom mal functional outcome is jeopardized unless this injury is
mon finding and shou ld not be rel ied upon to diagnose com recognized and treated early.
partment syndrome. Weakness or paralysis of involved
muscles and loss of pulses (because the compartment pres
Assessment
sure exceeds the systolic pressure) in the affected limb arc
lalc signs of compartment syndrome. A thorough examination of the neurologic system is essen
Remember, changes in distal pulses or capillary refill tiaJ in patients with nmswloskeletnl injury. Determination
limes are not reliable i n diagnosing compartment syn of nemologic impai1ment is important, and progressive
drome. Clinical diagnosis is based on the history of in changes must be documented.
jury and physical signs, coupled wiLll a high index of Assessment usually demonstrates a deformity of the
susp1c1o n. extremity. Assessment of nerve function usually requires
IntracompartmentaJ pressure measurements may be a cooperaivc patient. For each significant peripheral
helpful in diagnosing suspected compartment syndrome. nerve, voluntary motor function and sensation must be
Tissue pressw-es that are greater than 30 to 45 111111 Hg sug confirmed systematically (Tables 8-2 and 8-3). Muscle
gest decreased capillary blood tlow, which may result in in testing must include palpation of the contracring muscle.
creased muscle and nerve damage caused by anoxia. In most patients with multiple injmies, it is difficuJt to
Systemic blood. pressure is imporla nt: the lower the systemic in itially assess nerve function. However, assessment must be
pressure, the lower the compartment pressure rhat causes a repeated on an ongoing basis, especially after the patient is
compartment syndrome. Pressure measuremen L is indicated stabilized. Progression of neurologic findings is indicative
in all patients who have an aJtered response to pain. of continued nerve compression. The most important as
pect of any neurologic assessment is the documentation of
progression of neurologic findings. It also is an important
Management
aspect of surgical decision making.
All constrictive dressings, casts, and splints applied over the
affected extremity must be released. The patient must be
carefully monitored and reassessed clinically for the ne>..i 30 Management
to 60 minutes. If no significant changes occur, fasciotomy is The injured extremity should be immobilized in the dis
required. Compartment syndrome is a time-dependent con .located position, and surgical consultation obtained im
dition. 111e l1igher the compartment pressure and the longer mediately. If indicated and if the treating doctor is
i t remains elevated, the greater the degree of resulting neu knowledgeable, a careful reduction of Lbe dislocation ma)'
romuscular damage and functional deficit. Delay in per be attempted. After reducing a dislocation, neurologic
forming a fasciotomy may result in myoglobinuria, which function should be reevaluated and the limb splinted.
may cause decreased renal function. Surgical consultation
for diagnosed or suspected compartment syndrome must be
obtained early.
Other Extremity Injuries
Other significru1t extremity injuries include contusions and

PITFALL lacerations, joint injuries, and fractures.
Compartment syndrome is l imb-threateni ng. Clinical

findings must be recognized and surgical consulta CONTUSIONS AND LACERATIONS
tion obtained early. Remember that in unconscious
Simple contusions and/or lacerations should be assessed to
patients or those with severe hypovolemia, the clas
sic findings of acute compartment syndrome may be rule out vascular and/or neurologic injury. In generaJ, lac
masked. erations require debridement and closure. If a laceration
extends below the fasciaJ level, it requires operative
TABLE 8-2 Peripheral Nerve Assessment of Upper Extremities
NERVE MOTOR SENSATION INJURY
Ulnar Index finger abduction L1ttle finger Elbow injury
Median distal Thenar contraction Index f1nger Wnst dislocation

w1th opposrtion
Median, anterior Index Up rlexion S u pra condylar fracture of

interosseous humerus (Children)
Musculocutaneous Elbow flexion Lateral iorearm Antenor shoulder d1slocation

Radial Thumb, finger metocarpO First dorsal web space Distal humeral shaft, ante nor
phalangeal extension shoulder dislocation
Axillary Deltoid Lateral shoulder Antenor shoulder dislocation,

proximal humerus fractur
..
..
. . " .
. . ..
... ....
- ............... -- O<H-< HO OHO-OOOOoOOHO<H--<HO OW .... ................ ... ... ... .... "' ... .. .. .. ... ... ... ... .... ............ .... .... ................_
TABLE 8-3 Peripheral Nerve Assessment of Lower Extremities
NERVE MOTOR SENSATION INJURY
Femoral Knee extens1on Anterior knee Pubic rami fractures
Obturator Hip adduct 1on Medial th1gh Obturator ring fractures
Posterior tibial Toe f lexion Sole of foot Knee dislocation
Superficial peroneal Ankle eversion Lateral dorsum of fooL Fibular neck fractu1e,
knee d1slocat1on
Deep peroneal Ankle/toe dorsiflexion Dorsa I first to second Fibular neck fracture,
web space compartment syndrome
Sciatic nerve Plantar dorsiflexion Foot Postenor h1p dislocation
Superior gluteal Hip abduction Acetabular fracture
Inferior gluteal Glu teus maximus Acetabular fracture

hip extension
.. _ "" . .
. ..
''" "' "" .... . " ' .... .... "" "" "' "" "" "" ... ,
_ - -
-
-- - - ..._,,,,,-- _.... ,..._,_ _,,,, ...-..--- .

'
intervc.:ntion to more comp let el y debride Lhe wound and as Small wounds, especially those resulting from crush
sess for damage Lo un de rly i ng structu res. inj u ries may be significa n t . Vvbcn a very strong force
,
Contusions usu all y are recog n ized by pain in the area is applied very slowly over an ex t remi t y significant devas ,
and dccre<lsed function of the ex t rem ity. Palpation confirms cularization and crushing of muscle may occur with only a
localized swell ing and tenderness. The pati en t usually can small skin wound. Crush and degloving injuries can be very
not use the muscle or ex periences decreased fun ct ion bc subtle and must be suspected based on the mecha nism of
caw;e of pain in lhe affected extremity. If the palienl is seen LnJUI')'.
early, contusions are treated by l i miLing function of t he in The risk of tetanus is increased wilh wounds Lhat: ( l )
jured pari and applying co ld packs. are more than 6 holU's old, (2) are contused and/or abraded,
PRINCIPLES OF IMMOBILIZATION 199
( 3 ) are more than 1 em in depth, {4) result from high X-ray films taken at right angles to one another confirm
velocity missiles, (5) are due Lo burns or cold, and (6) have the history and physical examinations. Depending on the he
significant contamination (especially burn wounds and modynamic status of the patient, x-ray examination may have
wounds with denervated or ischemic I issue) . .. See Ap- to be delayed until the patient is stabilized. X-ray films through

pendix E: 1etanus Immunization. lhe joint above and below the suspected fracture site must be
included to exclude occult dislocation and concomitant injury.
JOINT INJURIES
Management
Injury
I nunobiJization must include the joint above and below the
)oint injuries that are not dislocated (ie, the joint is within its fracture. After splinting, the neurologic and vascular stalus
normal anatomic configuration but bas sustained significant of the extremity must be r"lsscssed. Surgical consultation is
ligamentous injury) usually uc not limb- threatening. How requin.:d for further treatment.
ever, such joint injuries may decrease the funclion of the limb.
Assessment
With jninl injuries, the patient usually reports some form Principles of Immobilization
of abnormal stress to the joint-for example, impad to the
anterior tibia that pushed the knee back, impact to the lat Splinting of extremity injuries, unless aBsociated with life
eral aspect of the leg that resulted in a valgus strain to the threatening injuries, usually can be accomplished during the
knee, or a fa ll onto an outstretched arm that caused a hy secondary survey. However, all such injuries must be splinted
perllexion in.iu ry lo the elbow. before a patient is tnmsported. Assess U1e limb's neurovascu
Physical examination reveals tenderness throughout the lar status after applying splints or realigning a fracture.
affected ligament. A hemarthrosis usually is present unless Specific types of splints can bt: applied for speci fie frc
the joint capSLLie is disrupted and the bleeding diffuses into turc needs. The pneumatic antishock gannent (PASG) is not
the soft tissues. Passive liga men to us tes r i ng of the affected gencraUy recommended as a lower-extremity splint. How
joint reveals instab.ility. X-ray examination usually reveals ever, it may be temporarily useful for patients with life
no significant injury. However, some small avulsion frac threatening hemorrhage from pelvic injuries or severe
tures from ligamentous insertions or origins may be present kw:er-e>:lremity injuries with soft tissue injury. Prolonged
radiographically. inflation (>2 hours) of the leg components in paticn ts vvith
hypotension may lead lo compartment syndrome.
Management A long spine board provides a total body splint for patients
joint injuries should be immobilized. The vascular and neu with multiple injuries who have possible or confirmed Lmsta
rologic status of the Limb distal to the injury should be re ble spine injuries. However, its hard, unpadded surface may
assessed. Surgical consultation usually is warranted. cause pressure sores on the patient's occiput, scapulae, sacrum,
and heels. Therefore, as soon as possible, Lhe patient should be
moved carefully loan equaUy supportive padded surface, using
FRACTURES a scoop-style stretcher or an appropriate logrolling maneuver
Injury to facilitate the transfer. The patient should be fully immobi
lized, and an adequate number of personnel should be available
fractures are defined as a break in the continuity of the bone
during this transfer. See Skill Station XJ: Spinal Cord l11jury:
cortex. They may be associated with abnormal motion,
Assessment and Management, and Skill Station XU: Muscu
some form of soft tissue injury, crepitation, and pain. A frac
loskeletal Trauma: Assessment and Management, Skill Xl1-B:
ture can be open or closed.
Principles of Extremity Immobilization.
Assessment
FEMORAL FRACTURES
Examination of the extremity demonstrates pain, swelling,
deformity, tenderness, crepitation, and abnormal motion at Femoral fractures are immobilized temporarily with trac
the fracture site. The cvaJm1tion for crep.itation and abnor tion splints ( Figure 8-5). The traction splint's force is ap
mal motion at the fracture ite may occasionally be neces plied distally at the ankle or through the skin. Proximally,
sary to make the diagnosis, but this is painful and may the splint is pushed into the thigh and hip areas by a ring
potentially increase soft tissue damage. These diagnostic that applies pressure to the buttocks, perineum, and groin.
tests mnst not be done routinely or repetitively. Usually the Excessive traclion can cause skin damage to the foot, ankle,
swelling, tenderness, and deformity are sufficient to confirm or perineum. Neurovascular compromise can result from
a fracture. It is important to periodically reassess the neu stretching the peripheral nerves. Hip fractures can be simi
rovascular status of a limb, especially if a splint is in place. larly immobiJized with a traction splint, but arc more suit-
200 CHAPTER 8 M usculoskeletal Trauma
TIBIA FRACTURES
Tibia fractlues are best immobilized with a well-padded
cardboard or metal gut te r l ong- leg spl in t . If readily avail
a ble pl aster sp l in ts immobilizing the lower leg, the knee,
,
and the ankle may be used.
ANKLE FRACTURES
Ankle fractures may be immobilized with a pi l l ow splint or
padded cardboard splint, thereby avoiding pressure over
bony prominences .
UPPER- EXTREMITY AND HAND INJURIES

A
The hand may be temporarily splinted in an anatomic, func

tio nal position, with the wrist sl ightly dorsiflexed and the
fingers gently flexed 45 degrees at the metacarpophal angeal
jo.ints. This position usuall y can be ach ie ved by gently im
mobilizing the hand over a l arge roll of gauze and using a
short-arm splint.
The forearm and wrist are inm1obilized flat on padded or
pi llow splints. The elbow usually is immobilized in a flexed po
sition, either by using padded spl ints or by direct immobiliza
tion with respect to the body using a sling and S\-vath device.
The upper arm usual ly is immobilized by sp l inti ng it to the
body or appl ying a sling or swath, which can be augmented by
a lhoracobrachial bandage. Shoulder injuries are managed by
a sling-and-swath device or a Velcro-type of dressing.
B
Figure 8-5 Traction Spl i nti ng Proper application
.
of a traction splint includes proper position against the Pain Control

crease of the buttock and sufficient length to apply trac
tion. The straps should be positioned above and below Analgesics are genera ll y indicated for joint injuries and frac
the knee, with the stand extended to suspend the leg. tures. However, the ad m inistration of pain medicati ons
Distal pulses should be evaluated before and after ap musl be tempered by the palient's clinicaJ situation. The ap
plication of the splint (A). It is improper to use the splint propriate use of spl ints significantly decreases the patient's
without proper placement of the straps and securing discomfort by controlling the amount of motion that oc
traction to the device (B). curs at the inj ured site.
Patients who do not appear to have significant pain ru1d
discomfort from a major fracture may have other associated
injuri es for examp le intracranial l esions or hypoxi a or
- , -
ably immobilized with skin traction or a foam boot traction may be under the influence of alcohol and/or other drugs.
with the knee in slight flexion . A simp le method of splinting Effective pain relief usually req u i res the administration
is to bind the injured leg to the opposite leg. rl' See Skill Sta of narcotics, which should be given in small dose$ intra
tion X I I : Musculoskeletal Trauma: Assessment and Ma n venousl y and repeated as needed. Muscle relaxants and seda
agement, Skill XII-D: App lica tion of a Traction Splint. tives should be admi nistered cauti ously in patients with
isolated extremity i njuries for example, reduction of a dis
-
location. Regiomtl nerve blocks have a role in pain relief and

KNEE INJURIES
Lhe reduction of appropriate fractures. It is essential to assess
The use of commerciall y available knee immobilizers or the and document any per ipheral nerve injury before adminis
application of a long l eg p l aster splint is very he l pful in
- trating a nerve block.
maintaining com fort an d stabi l ity. The leg should no t be Whenever analgesics, muscle relaxants, or sedatives are
immobilized in complete extension, but should be immo administered to an injwcd patient, the potential exists for
bilized with about I 0 degrees of Oexion to take pressure off respir a tory arrest . Con seq uentl y a ppropriate resusc itat ive
,
the neurovascular structures. eq uipm en t must be immed iatel y ava il able.

OCCULT SKELETAL INJURIES 201
Associated Injuries Occult Skeletal Injuries
Certain musculoskeletal injuri es, because of their common Remember, not all injuries can be d iagnosed dur ing the ini
mechanism of inju ry, are often associated with second in tial assessment and management o f injury. Joints or bones
juries thai are not immed ia tely apparent or may he missed that a re covered or well padded within muscular areas may
(see Table 8-4). Steps to ensure recogn itio n and manage cont ai n occ ul t in iuries. lt can be difficul t to identify nondis
.
ment of these injmies in dude: placed fractmes or joint liga ment ous injuries, especialJy if
the patient is unresponsive or there arc od1er severe injuries .
1 . Review the injury h isto ry, especia lly the mecha n ism of
It is important to recogn ize that injuries arc commonly dis
injury, to determine wh et her a not her i njury is present.
covered days a fter the i nj ur y incident for example, when
-
2. Thoroughly reexamine all extremities, placing spec ial the pat ien t is bei ng mobilized. Therefore, is it i mportant to
emphasis on the hands, wrists, feet, and the joi nt reassess t he patient routinely and ro relate thi s possib ili ty to
above and below a fracture or d isloca tion. other members of the I rauma learn and the pal ient s fami ly
' .
3. Visually examine t h e patient s dors um , in cludin g the

'
spine and pelvis. Open i njuries and closed s oft t issue

PITFA L L
injuries that may be i nd ica t ive of an uns ta ble injury
must be docu mented. Desp ite a thoro ug h examination, occult associated
injuries may not be appreciated during the initial
4. Review the x-rays obtained i n the seco ndary survey to evaluation. It is imperative to repeatedly reevaluate
identify subtle injuries that may be associated with the patient to assess for these injuries.
more obvious trauma.
'
TABLE 8-4 Injuries Associated with Musculoskeletal Injuries
INJURY MISSED/ASSOCIATED INJURY
Clavicula r fracture Major thoraoc InJury, especially pulmonary contus1on and

Scapular fracture rib fractures
Fracture and/or dislocation of shou lder
D1splaced thoracic sp1ne fracture Thoraoc aort1c rupture
Spine fracture lntraa bdomina l l njury
Fracture/dislocation of elbow Brachial artery injury

Median, ulnar, and radial nerve i nJ ury
Major pelvic disruption (rnotor vehicle ocwpant) Abdom i nal thoracic, or head inju ry
,
Major pelvic disruption (motorcyclist or pedestrian) Pelvic vascular hemorrhage
Femur 'fracture Femoral neck fractu re

Postenor hip dislocation
Posterior knee dislocauon Femora I fractLJre

Postenor hip dislocation
Knee dislocation or displaced tibial plateau fracture Popliteal artery and nerve Injuries
Calcaneal fracture Spine injury or fracture

Fracture-dislocation of h1ndfoot
Tibial p lateau fracture
Open fracture 70% 1ncidence of assooated nonskel etal mJ ury

-----------------------------"----..._,,, -
-
-----

-
---

-
-

-
-"'-
--
--
--
-
..
-
- ....
-- -"--"-"-------
CHAPTER SUMMARY

Musculoskeletal mjuries. while generally not life-threatening may pose delayed threats
to life and limb.
The goal of the initial assessment of musculoskeletal trauma IS to 1dent1fy InJuries that
pose a threat to hfe and/or hmb Although uncommon, hfe-threatemng musculoskele
tal inJUries must be properly assessed and managed. Most extremity injuries are appro
pnately diagnosed and managed during the secondary survey.
0 It is essential to recogmze and manage in a timely manner pelvic fractures, arterial in

juries, compartment syndrome. open fractures, crush injuries. and fracture-dislocations.
Knowledge of the mechanism of mjury and history of the mjury-producing event enables
the doctor to be aware of what assoCiated condit1ons potentially exist with the injured
extrem1ty. Early splinting of fractures and dislocations may prevent serious complications
and late sequelae In add1tion, an awareness of the patient's tetanus Immunization sta
tus, particularly in cases of open fractures or significantly contaminated wounds. may
prevent senous complications Armed with the proper knowledge and skills, as outlined
m th1s chapter. the doctor can sat1sfactonly provide the 101t1al management for most
musculoskeletal trauma.
Virkclysl C, Hougaard S, Kchlct II. Fascia iliaca compartment

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ference? J Trauma
do bicarbonate and mannitol make a dif
Lhe management of hemodynamica lly unstable pelvic fracture
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I Tr<HIInl. 2000;49{l }:18-24; di scussio n 24-25.
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dromc. I Bone }oint Surg Br 2003;85:625-630
I 7. KoMlcr W, Strohm PC, Sudkamp N P. Acute compartment syn
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1993;34:236. Surg 2005;1 3(7):436-444.
1'->. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for 27. Shah AJ, Kilclinc BA. Trauma i n pregnancy. flmerg Med Clin
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2006;171 (5 ):352-356. East NorwaU<, CT: Appleton & Lange; 1990.
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Orthop 71-auma 2002; 16(8):572-577.
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1993;34( 1): 1 16-119.

Performance at this skill station will allow th e participa nt to:

Interactive Skill
Procedure
OBJECTIVES
Perform a rapid assessment ofthe essential components ofthe mus
trauma patients.
culoskeletal system.
A series of x-rays with related
scenarios IS provided at the Identify life-threatening and limb-threatening injuries ofthe muscu
conclusion of this section for use loskeletal system, and institute appropriate initial management of
dunng th1s sta t1on m mak1ng these injuries.
evaluation and management
decisions based on the findings. Ide ntify patients who are at risk for compartment syndrome.
The goal of splint ing IS to prevent Explain the indications for and the value of app ropr iate splinting of
further soft tiss ue inJury and musculoskeletal injuries.
control bleeding and pain.
Consider the immobilization of Apply stan d ard sp l ints to the extremities, inc l u d ing a traction splint.
fractured extremities with the use
List the complications associated with the use of splints.
of splints as "secondary
resuscitation devices" Lhat aid in
Identify pelvic insta bili ty associated with pelvic fracture.
the control of bleeding.
Explain the value of the A P pelvic x-ray examination to identify the
THE FOLLOWING potential for massive blood loss, and describe the maneuvers that can
PROCEDURES ARE INCLUDED be used to reduce pelvic volume and control bleeding.
.... Skill XII-A: Physical

Examination
.,., Skill XII-B: Principles of

Extremity Immobil ization
.,., Skill XII-C: Realigning a

Deformed Extremity
.,., Skill XII-D: Application of a

Traction Splint
.,., Skill XII-E: Compartment

Syndrome: Assessment and
Management
.,., Skill XII-F: Identification and

Management of Pelvic
Fractures
.,., Skill XII-G: Identification of

Arterial Injury
205
206 SKILL STATION XII Musculoskeletal Trauma: Assessment and Management
Skrll XII-A: Physical Examination

compression-distraction and push-pull tests
LOOK, GENERAl OVERVIEW
should be done only once. These tests are
E>:ternal hemorrhage is identified by obvious external bleed d<mgcrous because they can dislodge clots and
ing from an extremity, pooling of blood on the stretcher or cause rebleed in g.
floor, blood-soaked dressings, and bleeding that occurs dur
ing transport to the hospital. The examiner needs to ask STEP 2. Palpate pulses in all ex-tremities and document
about characteristics of the injury incident and prehospital the findings. Any perceived abnormality or
care. Remember, open wounds may not bleed, but may be difference must be explained. Normal capillary
indicative of nerve injury or an open fracture. refill ( <2 seconds) of lhe pulp space or nail bed
provides a good indication of satisfactory blood
STEP 1 . Splint dcfonmd extremities, which are ind icative flow to the distal parts of the extremity. Loss or
of a fracture or joint injury, before patient diminishment of pulses with normal capillary
transport or as soon as is safely possible. refill indicates a viable extremity; however,
STEP 2. Assess the color of the extremity. The presence of su1gical consultation i:. required. If an extremity
bruising indicates muscle injury or signiricant has no pulses and no capillary refill, a surgical
soft tissue injury over bones or joints. These emergency exists. A Doppler device is useful to
changes may be associated with swelling or assess pulses and determine the ankle/ann
hematomas. Vascular impairment may be first systolk pressure ratio. Blood pressure is
l
measured at the anke and on an uninjured arm.
identified by a pale distal extremity.
The normal ratio exceeds 0.9. If the ratio is below
STEP 3. Note the positiun of Lhe extremity, 1vhich can be 0.9, a potentia I injury exists and surgical
helpful in determin.ing certain injtuy patterns. consultation is required.
Certain nerve deficits lead lo speci fie posit ions of
the extremity. For example, injury to the radial STEP 3. Palpate the muscle compartments of all the
nerve results in wrist drop, and injury to the extremities for compartmenL syndromes and
peroneal nerve results in fool drop. fractures. This is done by gentle palpation of lh.e
muscle and bone. I f a fractme is present, the
STEP 4. Observe spontaneous activity to help detem1inc conscious patient reports pain. l f the patient is
the severity of injury. Observing whether the unconscious, only abnormal motion may be felt.
patient spontaneously moves an e>.'tremity may A compartment syndrome should be suspected if
suggest to the examiner other obvious or occult the muscle compartment is hard, firm, or tender.
injuries. /\n example is a patient with a brain Compartment syndromes may be associated with
injury who does not follow commands and has fractures.
no spontaneous lower-extremity movement; this
patient coukl have a thoracic or lumbar liact ure. STEP 4. Assess joint stability by asking the cooperative
patient to move the joint through a range of
STEP 5. Note gender and age, which are important dues
motion. This should not be done if there is an
to potential injuries. Children may sustain
obvious fractme or deformity, or if the patient
growth plate injuries and fractures that may not
cannot cooperate. Palpate each joini for
manifest themselves (eg, buckle fractLlre}.
tenderness, swelling, and intraarticular fluid.
Females are less likely to have urethral injuries
Assess joint stability by npplying lateral, medial,
than vaginal injuries with a pelvic fracture. and anterior-posterior stress. Any deformed or
STEP 6. Observe drainage from the urinary catheter. If dislocated joint should be splinted and x-rayed
the urine is bloody or catheter insertion is before testing for stability.
difficult, the patient may have a pelvic fracture
STEP 5. Perform a rapid, thorough neurologic
and a urologic injury.
examination of the ex'tremities and document
the findings. Repeat and record testing as
FEEl indicated by the patient's dinic<tl condition. Test
sensation by ligbt touch and pinprick in each of
Life- and limh-Lhreatening injuries are excluded first.
the e..x.trem.ities. Progression of the neurologic
STEP 1 . Palpate the pelvis an tcriorly and posteriorly to findings indicates a potential problem.
asess fo r deformi ty, motion, and/or a gap that A. C5-Lateral aspect of the upper ann (also
indicates a potentially unstable pelvis. The axillary nerve)
SKILL STATION XII Musculoskeletal Trauma: Assessment and Management 207
B. C6-Palmar aspect of Lhe thumb and index D. Hand and wrist-Power grip tests
finger (median nerve) dorsiflexion of the wrist (radial nerve, C6)
C. C7-Palmar aspect of the long finger and flexion of the fingers (median and ulnar
D. C8-Palmar aspect of the litde fmger ( uh1ar nerves, C7 and C8) .

nerve) E. Finger add/abduction-Ulnar nerve, C8 and

E. Tl-lnncr aspect or Lhe forearm Tl
F. L3-lnner aspect of the thigh F. Lower ex.tremity-Dorsillex.ion or Lhe great
G. L4-I nner aspect of the lower leg, especially toe and ank l e tests the deep peroneal nerve,
over the medial malleolus LS, and plantar dorsiflexion tests the posterior
H . 1..5-Dorsum of the foot between the first and tibial nerve, S l .
second toes (common peroneal) G. Muscle power is graded in the standard form.
I. S .!-Lateral aspect of the foot The motor examination is specific to a variety
of voluntary movements of each extremity.
STEP 6. Perform motor examination of the extremities.
. See Chapter 7: Spine and Spinal Cord
A. Shoulder nbduction -Ax.iUary nerve, C5
Trauma.
B. Elbow flexion-Musculocutaneous nerve, CS
STEP 7. Assess the deep tendon reflexes.
and C6
C. Elbow extension-Radial nerve, C6, C7, and C8 STEP 8. Assess the patient's back.
Skill XII-B: Principles of Extremity Immobilization

STEP 1 . Assess the ABCDEs, and treat life-threatening STEP 7. Splint the cxtremiry in ttte position in which it is
situations first. found if distal pulses are present in the injured
eA'tremity. If distal pulses are absent, one attempt
STEP 2. Remove all clothing and completely expose the
should be made to realign the extremity. Gentle
patient, including Lhe extremities. Remove
traclion should be maintained until the splinting
watches, rings, bracelets, and oLher potentially
device is secured.
constricting devices. Remember to prevent the
development of hypothermia. STEP 8. Place the extremity in a splint if normally
aligned. I f malaligned, the extremity needs to be
STEP 3. Assess the neurovascular status of the extremity
realigned and then splinted. Do not force
before applying the splint. Assess for pulses and
realignment of a deformed extremity. If it is not
external hemorrhage, which must be controlled,
easily realigned, splint the extremity in Lhe
and perform a motor and sensory examination
position in which it is found.
or the extremity.
STEP 9. Obtain orthopedic consultation.
STEP 4. Cover any open wounds with sterile dressings.
STEP 10. Documenl the neurovascular status of the
STEP S. Select the appropriate size and type of splint for
extremity before and after every manipulation
the injured extremity. The device shottld
or splint application.
immobilize the joint above and the joint below
the injury site. STEP 1 1 . Administer appropriate tetanus prophylaxis.
. See Appendix E: Tetanus Immunization.
STEP 6. Apply padding over bony prominences that will
be covered by the splint.
Skill xu:.c: Realigning a Deformed Extremity

Physical examination determines whether a deformity is
HUMERUS
(rom a fracture or a dislocation. The principle of realigning
an extremity fracture is to restore length by applying gentle STEP 1. Grasp the elbow and manually apply distal
longitudinal traction Lo correct the residual angulation and traction.
then rotational deformities. vVhile maintaining realignment
STEP 2. Arter alignment is obtained, apply a plaster splint
with manual traction, a splint is applied and secured to the
and secure the arm to the chest wall with a sling
extremity by a n assistant. and swath.
FOREARM TIBIA
STEP 1 . Manually apply distal traction through the wrist STEP 1 . Manually apply distal traction at the ankle and
while holding the elbow and applying countertraction just above the knee, provided

countertraction. that the femur is intact
STEP 2. Secure a splint to the forearm and elevate the

injured extremity.
VASCULAR AND NEUROLOGIC DEFICITS
Fractures associated with neurovascular deficits require
FEMUR prompt realignment. lmmediate consultation with a sur
geon is necessary. If the vascular or neurologic status
STEP 1 . Realign the femur by manually applying traction
worsens after realignment and splinting, the splint should
through the ankle if the tibia and fibula are not
be removed and the extremity returned to the position
fractured.
in which blood flow and neurologic status are maxi
STEP 2. As the muscle spasm is overcome, the leg will mized. The extremity is then immobil ized in that posi
straighten and the rotational deformity can be tion.
corrected. This maneuver may take several
minutes, depending on the size of the patient.
Skill Xll-0: Application of a Traction Splint

Note: Application of this device requires two people-one STEP 7. Reassess the neurovascular status of the distal
person to handle the injured extremity, and the second to injured extremity after applying traction.
apply the splint.
STEP 8. Position the ankle hitch around the patient's
STEP 1 . Remove all clothing, including footwear, to

ankle and fool while the assistant maintains
expose the ext rem ily. manual traction on the leg. The bottom strap
should be slightly shorter than, or at least the
STEP 2. Apply sterile dressings to open wounds. same length as, the two upper crossing straps.
STEP 3. Assess the neurovascular status of the extremity. STEP 9. Attach the ankle hitch to the traction book while
the assistant maintains manual traction and
STEP 4. Cleanse any exposed bone and muscle of dirt and
debri.s before applying traction. Document that support. Apply traction in increments using the
windlass knob until the e>..'tremity appears stable,
the exposed bone fragments were reduced into
or until pain and muscular spasm are relieved.
the soft tissues.
STEP 1 0. Reassess the neurovascular status of the injured
STEP 5. Determine the length of the splint by measuring
extremity. If perfusion of the extremity distal to
the uninjured leg. The upper cushioned ring
the injury appears worse after applying traction,
should be placed under the buttocks and adjacent
gradually release the traction.
to the ischial tuberosity. The distal end of the
splint should extend beyond the ankle by STEP 1 1 . Secure the remaining straps.
approximately 6 inches ( 1 5 em). The straps on

STEP 1 2. Frequently reevnl uate t11e neurovascular slatus
the splint should be positioned to support the
thigh and calf. of the extremity. Document the neurovascular
status after every manipulation of the extremity.
STEP 6. Align the femur by manually applying traction
STEP 13. Administer tetanus prophylaxis, as indicated.
through the ankle. After realignment is achieved,
rl' See Appendix E: Tetanus Immunization.
gently elevate the leg to allow Ihe assistant to
slide the splint under the extremity so that the
padded portion of the splint rests against the
ischial tuberosity.
SKILL STATION XII Musculoskeletal Trauma: Assessment and Management 209
Skill XII-E: Compartment Syndrome: Assessment and Management

STEP 1 . Consider the foll ow ing important facts: Loss of pulses and other classic findings of
Compart me nt syndro me am develop ischemia occur late, after irreversible dam age
insid iously. has occurred.
Compartment syndrome can develop in an STEP 2. Palpate the muscular compartments of the
extremity as Lhe resul t of co mpression or extre mities, comparin g the compartment tension
crushin g forces and without obvious external in the injured extrem ity with that in the
injtuy or fracture. noninju red extremity.
Frequent reevaluation of the injured extremit y A. Asymmetry is a significant finding.
is essential. B. Frequent examination for tense muscul ar
The patient who has bad hypotension or is compartments is essential.
unconscious is at i_ncreased risk for C. Measu remen t of compartment pressures is
compartment syn d rome. hel pful.

Pain is the earliest symptom that heralds the
STEP 3. Ob tain orthopedic or general su rgical
onset of compartment ischemia, especially
consultation early .
pain on passive stretch of the involved

muscles of the ext remity.
Unconscious or intubated patients cannot
communicate th e early signs of extremity
ischemia.
I
Skill XII-F: Identification and Management of Pelvic Fractures

STEP 1 . rdentify the mechanism ofinjury, which can STEP 8. Deter m i ne pelvic stab ility by gently applying
suggest the possibil ity of a pel vic fracture-for anterior-posterior compression and lateral-to
example, ejection from a motor vehicle, crushing medial compression over the anterosuperior iliac
i nju ry, pedestrian veh icle collision, or motorcycle
- crests. Testing for axial mobil ity by gently
collision. pushing and pull ing on the legs will determine
stability in a cranial -ca udal d irection I mmob itize
.
STEP 2. Inspect the pelvic area for ecchymosis, perineal

the pelvis properly by using a sheet and/or a
or scrotal hem atom a, and. blood at the urethral
commercially available binder (eg, T-pod).
meatus.
STEP 9. Cautiously insert a uri nary catheter, if not
STEP 3. Inspect the legs for differences in le ngth or
con trai ndicated, or perform retrograde
asymmetry in rotation of the hips.
urethrography if a urethral i njury is suspected.
STEP 4. Perfor m a rectal examination, noting the position
STEP 10. I nterpret the pelvic x-ray film, giving special
and mobility of the prostate gland, any palpable
consideration to fracttues that are freq uently
fracture, or the presence of gross or occult blood
associated with significant blood loss-for
in the stool.
exan1ple, fractures that increase the pelvic vol ume.
STEP 5. Perform a vaginal examination, n oti ng palpable A. Co.nfum the patient's ident ifiat ion on the
fractures, the size and consistency of the uterus, film.
or the presence of blood. Remember, females of B. System atical l y evaluate the film for:
childbearing age may be pregnant . Width of the symphysis pubis-greater
than a 1-cm separation signifies
STEP 6. If Steps 2 through 5 are abnormal, or if the
significant posterior pelvic inj ury.
mecha nis m of injury suggests a pelvic fractwe,

integrity of the superior and inferior
obtain an AP x-ray film of the patient s pel vis.
'
pubic rami bilaterally.
(Note: Th e mechanism of injury may suggest the
[ntegrity of t h e acetabula, as well as
type of fracture )
.
femoral heads and necks.
STEP 7. If Steps 2 through 5 are normal, palpate the bony Symmetry of the ilium and width of the
pelvis to identify painful areas. sacroiliac joi nts.
Symmet ry of the sacral foramina by reduce a displaced symphysis, decrease the pelvic
evaluating the arcuate tines. volume, and serve as a tempera ry measure until
Fracture(s) of the transverse processes of LS. definitive treatment can be provided.
C. Remember, the bony pelvis is a ring t hat
STEP 3. Apply a pelvic external fixation device ( early
rarely sustains an injury in only one location.
orthopedic consultation).
Displacement of ringed structures implies two
fracture sites. STEP 4. Apply skeletal limb traction (early orthopedic
D. Remember, fractures that increase the pelvic consultation).
volume-for example, vertical shear and
STEP 5. EmboUze pelvic vessels via angiography.
open-book fractures, are often associated
with massive blood Joss. STEP 6. Obtain early su rg ical and orthopedic
consultation to determine prior i ties.
TECHNIQUES TO REDUCE BLOOD LOSS STEP 7. Place sandbags under each buttock if there is no
FROM PELVIC FRACTURES indication of spinal injury and other techlliques
to dose the pelvis arc not available.

STEP 1 . Avoid excessive and repeated manipulation of the
pelvis. STEP 8. Apply a pelvic binder.
STEP 2. Internally rotate the lower legs to close an open STEP 9. Arrange for transfer to a definitive-care facility if
book type fracture. Pad bony prom i nences and local resources are not available to manage this
tie the rotated legs together. This maneuver can LllJury.
Skill XII-G: Identification of Arterial Injury

STEP 1 . Recognize that ischemia is a limb-threatening STEP 4. Reevaluate peripheral pulses frequently,
and potentially life-threatening condition. especially if asymmetry is identified. Use Doppler
imaging to assess the presence and quality of
STEP 2. Palpate peripheral pulses bila te rally (dorsalis
distal pulses.
pedis, anterior tibial, femoral, radial, and
brachial) for quality and symmetry. STEP 5. Obtain early surgical consultation.
STEP 3. Document and evaluate any evidence of

asymmetry i n peripheral pulses.
SCENARIOS
SCENARIO Xll-1 Scenario B: A 34-year-old man is shot in the right leg while
cleaning his handgun. He is unable to walk because of knee
A 28-year-old man i s involved in a head-on motorcycle colli pain and states hat
t his lower extremity is painful, weak, and
sion with a car. At Lhe scene, he was combative, his systolic numb.
blood pressure was 80 mm Hg, his heart rate 120 beats/min,
and his respiratory rate 20 breaths/min. In the ED, his vital
signs have rehtrned to normal, and the patient reports pain in SCENARIO Xll -3
his right upper extremity and both lower extremities. His right A 16-year-old boy is thrown approximately I 00 feet (33
thigh and left lower extremity are deformed. Prebospital per meters) from the back of a pickup truck. In the ED his skin
sonnel report a large laceration to the left leg, to which they is cool, and he is lethargic and unresponsive. His systolic
applied a dressing. blood pressure is 75 mm Hg, his heart rate is 145
beats/min, and his respirations are rapid and shallow.
SCENARIO Xll- 2 Breath sounds are equal and clear on auscultation. Two
large-caliber lVs are i nitiated, and 2500 mL of warmed
Scenario A: A 20-year-otd woman is found trapped in her
crystalloid solution is infused. However, the patient's he
automobile. Several hours are required to extricate her
modynamic status does not i mprove significantly. His
because her leg was trapped and twisted beneath the dash
blood pressu re now is 84/58 mm Hg and his heart rate is
board. l n the hospital, she has no hemodynamic abnormal
I 3 5 beats/ min.
ities and is alert. She reports severe pain i n her left leg, which
is splinted.
C H A PT E R
CHAPTER OUTLINE Upon completion of this topic, the student will be able to iden
tify methods of assessment and outline measures to stabilize,
Objectives
treat, and transfer patients with thermal injuries. S pecifica ll y
,
Introduction
the doctor will be able to:
Immediate Lifesaving Measures for Burn Injuries
Airway OBJECTIVES
Stop the Burning Process
Intravenous Access
Given a patient with burn injury, estimate the
Assessment of Patients with Burns burn size and deter mine the presence of associ
History ated injuries.
Body-Surface Area
Depth of Burn Demonstrate the initial assessment and treatment
of patients with thermal i njuries .
Primary Survey and Resuscitation of Patients
with Burns Identify specia l problems encountered i n the
Airway treatment of patients with thermal injur i es, and
Breathing explain how to resolve them.
Circulating Blood Volume
Secondary Survey and Related Adjuncts List criteria for the transfer of patients with burns.
Documentation
Baseline Determinations for Patients with Major Burns
Periphera l Circulation in Circumferential Extremity Burns
Gastric Tube Insertion
Narcotics, Analgesics, and Sedatives
Wound Care
Antibiotics
Tetanus
Special Burn Requirements
Chemical Burns
Electrical Burns
Patient Transfer
Cntena for Tra nsfer
Transfer Procedures
Cold Injury: Local Tissue Effects
Types of Cold Injury
Management of Frostbite and Nonfreezing Cold Injuries
Cold Injury: Systemic Hypothermia
Signs
Management
Chapter Summary
Bibliography
212 CHAPTER 9 Thermal Injuries
Introduction obstruction may not be obvious immediately; however,

signs may be present that can warn the examiner of poten
tial airway obstruction. \'\'hen a patient is admitted to the
Thermal injurie5 arc major causes of morbidity and mor hospital after sustaining a burn injury, the doctor should be
tality. Attention to the basic principles of initial trauma re alert to the possibility of airway involvement, identify signs
suscitation and timely application of simple emergency of distress, and initiate supportive measures. Clinical indi
measures can help to minimize the morbidity and mortal cations of inhalation injury include:
ity caused by these injuries. These principles include a high
index of suspicion for the presence of airway compromise face and/or neck bums
following smoke inhalation, identification and management Singeing of the eyebrows and nasal vibrissae
of associated mechanical injuries, and maintenance o[ he
Carbon deposits and acute inflammatory changes in
modynamic normality with volume resuscitation. The doc
lor also must take measures to prevent and treat the the oropharynx
potential complications of thermal injuries, such as rhab Carbonaceous sputum
domyolysis and cardiac dysrhythmias, which arc sometimes
Hoarseness
seen in electrical burns. 1cmpcrature control and removal
from the injury-provoking environment also are major History of impaired mentation and/or confinement
principles of thermal 1njury management. in n burning envi ronmen t
Explosion with burns to head and torso
Carboxyhemoglobin level greater than lOo/o in pa

Immediate lifesaving Measures tient who W<lS involved in a fire
for Burn Injuries Any of the above findings suggests inhalation injury.
Transfer to a burn center is indicated if there is inhalation in
I What is my first priority? jury. If the transport time is prolonged, intubation should be
performed prior to transport to protect the airway. The symp
Lifesaving measure for patients with burn injuries include tom of stridor is an indication for immediate endotracheal in
establishing airway control, stopping the burning process, tubation. Circumferential burns of the neck can lead to
and establishing intravenou5 access. swelling of the tissues around the airway. Therefore, early in
tubation is indicated in this situation.
AIRWAY
I How do I identify inhalation injury? STOP THE BURNING PROCESS
Although the larynx protects the subglottic airway from di All clothing should be removed to stop the burning
rect thermal injury, the airway is ext remely susceptible to proces; however, do not peel off adherent clothing. Syn
obstruction as a consequence of exposure to heat. Airway thetic fabrics can ignite, burn rapidly at high tempera
tures, nnJ melt into hot residue thnt continues to burn the
patient. Any clothing that was b urned by chemicals should
be removed carefully. Dry chemical powders should be
brushed from the wound, with the individual caring for
the patient avoiding direct contact with the chemical, and
the involved body-surface areas should be rinsed with
copious amounts of tap water. The patient then should
be covered with warm, clean, dry linens to pevent
hypothermia.
INTRAVENOUS ACCESS
Any patient with burns over more than 20o/o of the body
surface requires fluid resuscitation. After establishing airway
d identifying and treating immediately life
patency .111
threatening injuries, intravenous access must be established.
large-caliber (at least # 16-gaugc) intravenous lines should
be introduced immediately in a peripheral vein. [f the ex-
PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 213
tent of the bum precludes placement of the catheter through DEPTH OF BURN
unburned skin, overlying burned skin should not deter
placement of he t catheter in an accessible vein. The upper The depth of burn is important i n evaluating the severity of
extremities are preferable to the lower extrem iLie for ve the burn, planning for wound care, and predicting func
nous access because of the high incidence of phlebitis and tional a11d cosmetic results.
septic phlebitis when saphenous veins are used for venous First-degree bums (eg, sunburn) are characterized by
access. Begin infusion with an isotonic crystalloid solution. erythema, pain, and the absence of blisters. They are not lite
Guidelines for establishing the flow rate are outlined later threatening, and generally do not require intravenous fluid
i n this chapter. replacement. This type of burn is not discussed further in
this chapter.
Partialthickness, or second-degree, burns are cl1aracter
ized by a red or mottled appearance with associated swelling
and blister formation (Figure 9-2A). The surface can have a
Assessment of Patients with Burns weeping, wet appearance and is painfully hypersensitive,
even to air current.
Full-thickness, or thirddegree, burns usually appear dark
The assessment of patients with burn injuries begins with
and leathery (Figure 9-2B). The skin also may appear
the patient history and is followed b y estimation of the
translucent, mottled, or waxy white. The surface is painless
body-surface area burned and the depth of the burn injury.
and generally dry; it may be red and does not blanch with
pressure.
HISTORY
The injwy history is extremely valuable in the treatment of
the burn patient. i\ssociated injuries can be sustained while ..
-_ ,, Primary Survey and Resuscitation
..
the victim attempts to escape he t fire, and injury from ex
plosions can result in internal injw-ies or fractures (eg, cen
of Patients with Burns
tral nervous system, myocardial, pulmonary, and abdominal
injuries). It is essential that the time of the burn injury be es AIRWAY
tablished. Burns sustained within an enclosed space suggest A history of confinement in a burnjng environment or early
the potential for inhalation injury.
signs of airway injury on arrival in the emergency depart
The history, from the patient or a relative, should in
ment (ED) necessitate evaluation of the airvvay and defini
clude a brief survey of preexisting illnesses ( eg, diabetes, hy
tive management. Pharyngeal thermal injuries can produce
pertension, cardiac, pulmonary, and/or renal disease) and
marked upper ainvay edema, and early maintenance of he t
drug therapy, as well as any allergies and drug sensitivities.
airway is important. The clinical manifestations of inhala
The patient's tetanus immunization status also should be
tion injury may be subtle, and frequently do not appear in
ascertained.
the first 24 hours. If the doctor waits for x-ray evidence of
pulmonary injury or change in blood gas determinations,
BODY-SURFACE AREA airway edema can preclude intubation, and a sw-gical air
\.vay may be required.
EJ How do I estimate burn
size and depth ?
BREATHING
The Rule of Nines is a useful and practical guide to deter
mine Lbe extent of the burn (Figure 9-1). The adult body The initial treatment of airway injuries is based on the signs
configuration i s divided into anatomic regions that rep and symptoms, which can result from the following possi
resent 9%, or multiples of 9o/o, of the total body surface. ble injuries:
Body-surface area (BSA) differs considerably for children.
Direct thermal injury, producing upper airway
The infant's or young child's head represents a larger pro
edema and/or obstruction
portion of the surface area, and the lower extremities rep
resent a smaller proportion than an adult's. The Inhalation of products of combustion (carbon par
percentage of total body surface of the infant's head is ticles) and toxic fumes, leading to chemical tracheo
twice that of the normal adult. The palmar surface (in bronchitis, edema, and pneumonia
cluding the fingers} of the patient's hand represents ap
Carbon monoxide (CO) poisoning
proximately 1% of the patient's body surface. This
guideline helps estimate the extent of burns with irregu Always assume CO exposure i n patients who were
lar outlines or distribution. burned in enclosed areas. The diagnosis of CO poisoning is

Pediatric
( 9% I 9%
)
I
I
IJ r
I t
/'?
I
..
;.>
.,.. 4.5%
-
\
4.5% ""
13%
18 %
/ .J
2.5.12.5%
f
' 7%

Adult
_....4.5%.
( .. -
.. .....
18%
18%
'
1%
9% 9% 9% 9%
Figure 9-1 Rule of Nines. This practical guide is used to evaluate the severity of burns and determine fluid
management. The adult body is generally divided into surface areas of 9% each and/or fractions or multiples of 9%.
PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 215
A
Partial
Epidermis
thickness ,
second

Dermis degree
Subcutaneous
layer
'
' '
'
' '
' '
' '
Blistering '
' '
'
' '
Painful ' '
' '
'
' '
Glistening '
' '
'
' '
wound bed '
'
'
B
Epidermis
Full
thickness ,
Dermis third
degree
Subcutaneous
layer
'
'
' ,
' '
' '
Leathery ' '
' '
' I
White to charred '
'
'
'
'
I
Dead tissue '
' '
' '
'
Surface is painless '
'
'
Figure 9-2 Depth of Burns. (A) Shallow partial-thickness or second-degree burn injury. (B) Deep partial, full
thickness or third-degree burn injury.
made primarily from a history of exposure and direct meas sociation curve to t he left. CO dissociates very slowly, und its
urement of carbo:>.:yhemoglobin ( HbCO). Patients with CO half-life is 250 minutes
(4 hours) while the patient is breath
levels of less than
20o/o usually have no physicaJ symptoms. ing room air, compared with 40 minutes while breathing
Higher CO levels can result in: ( 1 ) headache and nausea LOO% o.>rygen. Therefore, patients in whom CO exposure is
(20o/o-30o/o), (2) confusion (30%-40%), (3) coma suspected should receive high-flow oxygen via a nome
(40%-60%), and (4) death (>60%). Cherry-red skin color breathing mask.
i rare. Because of the increa:;ed affinity of CO for hemo Early management of inhaJation injury may require en
globin (240 times thi.lt of oxygen), it displaces oxygen from dotracheaJ intubation and mechnnical ventilation. Prior to
the hemoglobi n molecule and shi tsf the oxyhemoglobin dis- intubation, the patient should be preoxygenated with con
uresis (eg, gl ycosuria) . Therefore, an indwelling urinary

catheter should be inserted. A good rule to follow is to in fuse
flu ids at a rate sufficient to produce 1.0 mL of urine per kilo
gram of body weight per hour for children who weigh 30 kg
or less, and 0.5 to 1.0 mL of urine per kilogram of body
weight per hour in adults.
Patients with burns require 2 to 4 mL of Ringer's lactate
solution per kilogram of body weight per percent of second
degree and third-degree body-surface bums in the first 24
hours to maintain an adequate circulating blood volume
and provide adequate renal pe rfusio n. The calculated fluid
volume is then proportioned in the following manner: half
the total fluid is provided in the first 8 hours after the burn
injury has occurred, and the remaining half is administered
in the nexl l 6 hours. In children who weigh 30 kg or less, the
goal is to maintain an average uri nary output of 1 mlfkgfhr.
In these patients, it is necessary to administer maintenance
intravenous fluids containing glucose in addition to the burn
formula.
tinuous admini stration of oxygen. Intubation should be
Resuscitation formulas provide only an estimate of fluid
performed early in patients with suspected airway injury.
need. Fluid requirement calcu lations for infusion rates are
Because there is a high probability of tl1e need for bron
based on the time from injury, not urinary output from the
choscopy in burn patients wiili airway injury, an endot ra
time fluid resuscitation is in itiated. The amount of fluid

cheal tube of sufficient size should be chosen for a defin itive
given should be adjusted according to the individual pa
airway. Arterial blood gas determinations should be ob
tient's response-ie, urinary output, vi tal
signs, and general
tained as a baseline for the evaluation of the patient's pul
condition. Cardiac dysrhythmias may be ilie first sign of hy
monary status. However, measurements of arterial Pa0 do
2 poxia and electrolyte or acid-base abnom1alilies. Electro
not reliably predict CO poisoning, because a CO partial
cardiography (ECG) should be performed for cardiac
pressure of only 1 mm Hg results in a carboxyhemoglobin
rhythm disturbances. Persistent acidemia may be caused
level of 40o/o or greater. Therefore, baseline carboxyhemo
by cyanide poisoning. Consultation with a burn center or
globin levels should be obtained, and l OOo/o oxygen should
poison conLrol center should occur if this diagnosis is
be administered.
suspected.
lf the patient's hemodynamic condition p ermi ts and
spinal injury has been excluded, elevation of the head and
chest by 30 degrees helps to reduce neck and chest wall
edema. If a full-thickness burn of the anterior and late ral
chest wall leads to severe restriction of the chest wall mo
tion, even in the absence of a circumferential burn, chest
wall escharotomy may be required.
CIRCULATING BLOOD VOLUME

IJ Wha t is the rate and type of fluids
administered to patients with burns?
Evaluation of circ ulati ng blood volume is often difficult in

severely burned patients. ln add i tion these patients may
,
have accompanying injuries tllat cause hypovolemic shock.

Shock should be treated according to resuscitation princi
ples as previously outlined. rl' See Chapter 3: Sh ock Burn
.
resuscitation fluids also should be provided.

Blood pressure measurements can be difficult to obtain
and may be unreliable in patients with severe burn i njuries,
but monito ring of hourly urinary outputs can reliably as
sess circulating blood volume in the absence of osmotic di-
SECONDARY SURVEY AND RELATED ADJUNCTS 217
1 . Remove all jewelry on the patient's extremities.
2. Assess the status of distal circulation, checking for

Failure to recognize the increased fluid req uire cyanosis, impaired capiUary refilling, and progressive
ment for patients with inhalation injury and those neurologic signs, such as paresthesia and deep-tissue
with concomitant blunt or crush trauma and for pain. Assessment of peripheral pulses in patients with
pediatric burn patients. bums is best performed with a Doppler ultrasonic
Fail ure to adjust the fluid administration rate tlow meter.
based on a patient's physiologic response.
3. Reli eve circulatory compromise in a circumferentially
burned limb by escharotomy, always with surgical
consultation. Escbarotomies usual ly are not needed
Secondary Survey and within the first 6 hours after a burn i nj ury.
Related Adjuncts 4. Although fasciotomy is seldom required, it may be

necessary to restore circulation for patients with asso-
ciated skeletal trauma, crush injury, high-voltage elec

Key aspects of the secondary su rvey and its related ad
trical injury, and burns involving tissue beneath the
juncts include physical examination; documentation; base
investing fascia.
line determinations, including blood levels and x-rays;
maintenance of peripheral circulation in circumferential
extremity burns; gastric tube insertion; narcotics, anal
GASTRIC TUBE INSERTION
gesics, and sedatives; wound care; antibiotics; and tetanus
immunization. Insert a gastric tube and attach it to a suction setup if the
patient experiences nausea, vomiting, or abdominal disten
tion, or if burns involve more than 20% of the total BSA.
PHYSICAL EXAMINATION Prior lo transfer, it is essential that a gastric tube be inserted
l n order to plan and direct patient treatment, the doctor and functioning in patients with these symptoms.
must estimate the extent and depth of the burn, assess for
associated injuries, and weigh the patient.
NARCOTICS, ANALGESICS, AND SEDATIVES
Severely burned patients may be restless and anxious from
DOCUME NTATION
hypoxemia or hypovolemia rather than pain. Consequently,
A Aow sheet or other report that outlines the patient's treat hypoxemia and inadequate Ou.id resuscitation should be
ment should be initiated when the patient is admitted to the managed before administration of narcotic analgesics o.r
ED. This flow sheet should accompany the patient when sedatives, which can mask the signs of hypoxemia and hy
transferred to the burn unit. povolemia. Narcotics, analgesics, and sedatives should be
administered in smaU, frequent doses by the inLTavenottS
route only.
BASELINE DETERMINATIONS FOR PATIENTS
WITH MAJOR BURNS
Obtain samples for a complete blood count (CBC), type and WOUND CARE
crossmatch/screen, carboxyhemoglobin, serum glucose, Partial-thickness burns are painful when air currents pass
electrolytes, and pregnancy test in aU females of childbear over the burned surface. Gently covering the burn with clean
ing age. Arterial blood samples also should be obtained for linen relieves the pain and deflects air currents. Do not break
blood gas determinations to include measurement of blisters or apply ru1 antiseptic agent. Any applied medica
HbCO. tion must be removed before appropriate antibacterial top
A chest film also should be obtained, with repeat ftlms ical agents can be applied. Appli.cation of cold compresses
as necessary. Other x-rays may be indicated for appraisal of can cause hypothermia. Do not apply cold water to a patient
associated injuries. with e>..1:ensive burns (> 10% total BSA).
PERIPHERAL CIRCULATION IN CIRCUMFEREN ANTIBIOTICS

TIAL EXTREMITY BURNS
Prophylactic antibiotics are not indicated in the early post
In order lo maintain peripheral circulation in patients with burn period. Antibiotics should be reserved for the treat
circumferential extremity burns, the doctor should: ment of infection.
more serious than acid burns, because the alkalies pene

trate more deeply. Removal of the chemical and immedi
ate attention to wound care are essential. Chemical burns
arc influenced by the duration of contact, concentration
of the chemical, and amount o f the agent. Immediately
flush away the chemical with large amounts of water, for
at least 20 to 30 minutes, using a shower or hose if avail
able (Figure 9-3). Alkali burns require longer irrigation.
If dry powder is still present on the skin, brush i.t away be
fore irrigating with water. Neutralizing agents offer no ad
vantage over water lavage, because reaction with the
neutralizing agent can itself produce heat and cause fur
ther tissue damage. Alkali burns to the eye require con
tinuous irrigal ion during the first 8 hours after the burn.
A small-caliber cannula can be fixed in I he palpebral sui

CUi> for irrigation.
ELECTRICAL BURNS
Electrical burns result when a source of electrical power
makes contact with a patient's body. Electrical burns fre
quently are more serious than they appear on the body sur
face. The body can serve as a volume conductor of
electrical energy, and the heat generated results i n thermal
injury to tissue. Different rates of heat loss from superficial
and deep tissues allow for relatively normal overlying skin
to coexist with deep-muscle necrosis. Rhabdomyolysis re
TI=TANUS sults in myoglobin release, which can cause acute renal fail
Oelermination oft he patient's tetanus immunization stalus ure. Immediate trc<tment of a patient with a significant
is very important. rl' See Appendix E: Tetanus Immuniza electrical burn includes attenLion to the airway and breath
tion. ing, establishment of an intravenou line in an uninvolved
extremity, electrocardiographic monitoring, and place
ment of an indwelling catheter. If the urine is dark, assume
that hemochromogens are in the urine. Do not wait for
laboratory conlirmation before instituting therapy for
Special Burn Requirements myoglobinuria.
Patients with chemical burns and electrical burns require

special considerations in the ED and trauma care settings.
Ct-IEMICAL BURNS
Chemical injury can result from exposure to acids, alka
lies, and petroleum products. Alkali burns are generally
".,"..
'
PITFALLS
.':"
- '._-,,,
Failure to recognize development of the compart

ment syndrome.
Failure to adequately perform escharotomy.
lack of recognition that fasciotomies are seldom
necessary.
Failure to treat CO toxicity. Figure 9-3 Chemical Burn. Immediately flush
Failure to provide adequate pain relief. away the chemical with large amounts of water, for at
least 20 to 30 minutes.
COLD INJURY: LOCAL TISSUE EFFECTS 219
Fluid admin istration should be increased to ensure a

uri nary output of l 00 m l/hr in adults. [f the pigment does PITFALLS
not clear with increased tluid administration, 25 g of man
nitol should be administered, and 12.5 g of mannitol should Failure to secure the patient's airway.
..
be added to subsequent liters of fluid to maintain di uresis. Failure to provide adequate documentation of
Metabolic acidosis should be couected by maintaining ad treatment to the receiving facility.
equate perfusion and addi ng sodium bicarbonate to alka
lize the urine as necessary and increase the solubility of
myoglobin in the urine.
10. Ch i ldren with burn i nj u r ies who are seen in hospitals
without qualified personnel or equipment to manage
their care should be transferred to a burn center ,.\rith
Patient Transfer these capab il iti es
1 1 . Burn injury in patients who will require special social
EJ Who do I transfer to a burn center? and emoLional or long- term rehabiliLaLive support,
including cases involving suspec ted child abuse and
The cri ter i a for transfer must be met and procedures neglect
must be followed in the transfer of patients to burn cen
ters.
TRANSFER PROCEDURES
Transfer of any patient must be coordinated with the burn
CRITERIA FOR TRANSFER cen ter d octor. All pertinen t information regarding Lest re
The American Burn Association has identified the follow sults, tem perature, pulse, fluids administered, and urinary
output should be documented on Lhe burn/trauma flow
ing types of burn injuries that typica lly requ ire referral to a
burn center: sheet and sent with the patient. Any other information
deemed important by the referring or receiving doctor also
1 . Partial-thickness and full-thickness burns of greater

is sent with the patient.
than 10% of the BSA in pat ien ts less than I 0 rears or
over 50 years of age
2. Partial-thickness and full-thickness burns on greater

than 20% of the BSA in other age groups
Cold Injury: local Tissue Effects
3. Part ial- thickness and full-thickness burns involving
the face, eyes, eats, bands, feet, genitalia, and per
EJ How does cold affect my patient?
ineum, as well as those that involve skin overlying The severity of cold injury depends on temperature, dura
major join ts tion of exposure, environmental conditions, amount of
protective clothing, and the pati en t's general state of
4. Full-thickness burns on greater than So/o of the BSA in
health. Lower temperatures, i mmo bilization, prolonged
any age group
exposure, moisture, the presence of peripheral vascular
5. Significant electrical burns, including lightning injury disease, and open wounds all increase the severity of the
. .
(significant volumes of t issue beneath the surface can UlJury.
be i nj ured and result in acute renal failure and otl1er
complications)
TYPES OF COlD INJURY
6. Significant chemical burns
I How do I recognize a cold injury?
7. Inhalation injury
Three types of cold injury are seen in trauma pa tients: frost
8. Burn injury in patients with preexisting illness Lhal nip, (roslbite, and nonfreezing injury.
could complicate treatment, prolong recovery, or af
fect mortality Frostnip
9. Any patient with a burn injury who has concomi Frostnip is the mildest fom1 of cold injury. lt is characterized
tant trauma poses a n increased risk of morb id ity or by initial pain, pallor, and numbness of the <:tffected body
mortality, and may be treated initially in a trauma part. lt is reversible with re\varming and does not resultin
center until stable before being transferred to a tissue loss, unless the inj ury is repeated over many yea rs ,
burn center which causes fat pad loss or atrophy.

Frostbite exposed to the environment. It is characterized by pru

ritic, red-purple skin lesions (papules, macules, plaques,
Frostbite is due to freezing of tissue with intracellular ice
or nodules). With continued exposure, ulcerative or he
crystal formations, microvascular occlusion, and subsequent
morrhagic lesions appear and progress to scarring, fibro
tissue anoxia. Some of the tissue damage also can result frolil1
sis, or atrophy, with itching replaced by tenderness and
reperfusion injury that occurs on rewarming. Similar
pain. This condition is more annoying and chronic than
to thermal burns, frostbite is classified into first-degree,
destructive. Careful protection from further exposure and
second-degree, third-degree, and fourth-degree according
the use of anliadrenergics or calcium-channel blockers are
to depth of involvement.
often helpful.
1 . First-degree frostbite: Hyperemia and edema wilhout

skin necrosis MANAGEMENT OF FROSTBITE AND
NONFREEZING COLD INJURIES
2. Second-degree frostbite: Large, clear vesicle formation
accompanies the hyperemia and edema with partial EJ How do I treat local cold injuries?
thickness skin necrosis

Treatment should be im mediate to decrease th.e duration of
3. Third-degree frostbite: FuU-thickness and subcuta tissue freezing, although rewarming should not be wlder
neous tissue necrosis occurs, commonly with hemor taken if there is the risk of refreezing. Constricting, damp
rhage vesicle formation clothing should be replaced by warm blankets, and the pa
tient should be given hot Quids by mouth, if he or she is able
4. Fourth-degree frostbite: Full-thickness skin necrosis,
to drink.
including muscle and bone with gangrene
Place the injured part in circulating water at a constant
40 C ( J 04 F) until pink color and perfusion return (usually
Although the affected body part is typically initially within 20 to 30 minutes). This is best accomplished in an
hard, cold, white, and numb, the appearance of lhc lesion inpatient setting in a large tank, such as a whirlpool tank.
changes frequently dming the course of treatment. In addi Avoid dry heat, and do not rub or massage the area. Re
tion, the initial 1reatment regimen is applicable for all de warming can be extremely painful, and adequate analgesics
grees of insult, and the initial classification is often not (intravenous narcotics) are essentiaJ. Cardiac monitoring
prognostically accurate. Hence, some authorities simply during rewarming is advised.
classify frostbite as superficial or deep.
Local Wound Care of Frostbite

Nonfreezing Injury The goal of wound care for frostbite is to preserve dam
Nonfreezing injury is due to microvascular endothelial aged tissue by preventing infection, avoiding opening
damage, stasis, and vascular occlusion. Trench foot or cold uninfected vesicles, and elevating the injured area,
immersion fool (or hand) describes a nonfreezing injury which is left open to air. The affected tissue should be
of the hands or feet, typically in soldiers, sailors, and fish protected by a tent or cradle, and pressure spots should
ermen, resulting from long-term exposure to wet condi be avoided.
tions and temperatures just above freezing ( J .6 C to I 0 C, Only rarely is fluid loss massive enough to require re
or 35 F to 50 F). Although the entire foot can appear suscitation with intravenous fluids, although patients may
black, deep-tissue destruction may not be present. Alter be debycLated. Tetanus prophylaxis depends on the patient's
nating arterial vasospasm and vasodilation occur, with the tetanus immtmization status. Systemic antibiotics are re
affected tissue first cold and numb, and then progressing to served for identified infections. The wotmds should be kept
hyperemia in 24 to 48 hours. With hyperemia comes in clean, and uninfected blebs left intact for 7 to 10 days to pro
tense, painful burning and dysesthesia, as well as tissue vide a sterile biologic dressing to protect underlying epithe
damage characterized by edema, blistering, redness, ec lialization. Tobacco, nicoti_ne, and other vasoconStrictive
chymosis, and ulcerations. Complications of local infec agents must be withheld. Weight bearing is prohibited until
tion, cellulitis, lymphangitis, and gangrene can occur. edema is resolved.
Proper attention to foot hygiene can prevent the occur Numerous adjuvants have been attempted in an effort
rence of most such injuries. to restore blood supply to cold-injured tissue. Unfortunately,
Chilblain, or pernio, is primarily a dermatologic most are ineffective. Sympathetic blockade (sympa tbectomy,
manifestation of chronic, repetitive, damp cold exposure, drugs) and vasodilating agents have generally not proven
or long-term, dry cold exposure, as might occur in moun helpful in altering the natural history of the acule cold in
lain climbers. It typically occurs on the face, anterior tib jury. Heparin and hyperbaric oxygen also have failed to
ial muscle surface, and dorsum of the hands and feet, demonstrate substantial treatment benefit. Low-molecular
which arc areas thal are poorly protected or chronically weight dextran has shown some benefit during the re-
COLD INJ URY: SYSTEMIC HYPOTH ERMIA 221
tients, hypotherm ia should be considered to be any core

PITFALLS tempcratme below 36 C (96.8 F), and severe hypother
mia is any core tem p erature below 32 C (89.6 F). Hy
Failure to rapidly rewarm the affected area.
..
pothermia is common in the severely injured, but further
Overzealous debridement of tissue of question- loss of core temperature can be limited wiLh the adminis
able viability. tration of only warmed intravenous Ouids and blood, judi
cious exposure of the patient, an d maintenance of a warm
environ ment .
Because determination of the core tem perature prefer

,
warming phase in animal models. Thrombolytic agents have ably esophageal is essential for the diagnosis of systemic hy
,
also shown some promise. pothermia, special thermometers capable of registering low
With aU cold injuries, estimations of depth of injury temperatures are required.
and extent of tissue damage are not usually accurate until
demarcation is evident. This often requi res several weeks or

months of observation. Earlier surgical debridement or am SIGNS

putation is seldom necessary, unless infection with sepsis In addjtion to a decrease in core temperature, a depressed
occurs. level of consciousness is the most common feature of hy
pothermia. The pa tient is cold to the touch and appears gray
and cyanotic. Vital si gns, including pulse rate, respir a tory
rate, and blood pressure, arc all variable, and the absence of
Cold Injury: Systemic Hypothermia respiratory or cardiac activity is no t uncommon in pat ients
who eventually recover. Because of severe depression of the
respiratory rate and heart rate, signs of respiratory and car
Hypothermia i s defined as a core body t emp era ture below
diac activity are easily missed unless careful assessment is
35 C (95 F). In the absence of concomitant traumatic in
conducted.
jury, hypothermia may be classified as mild (35 C lo 32" C,
or 95 F to 89.6 P), mode rate (32 C to 30 C, or 89.6 F to
86 F), or severe (below 30 C, or 86 F). This drop i n core MANAGEMENT
temperature can be rapid , as in immersion in ncar-freezing
water, or slow, as in exposure to more temperate environ
IJ How do I treat a systemic cold injury?
ments. Immediate attention is devoted to the ABCDEs, i nclud ing
The elderly are particularly susceptible to hypothermia the initiation of cardiopulmona1-y resuscitation (CPR) and
because of their i mpaired ability to increase heat p roduc establishment of intravenous access if the patient is in car
tion and decrease heat loss by vasoconstriction. Children diopulmonary arrest. Care must be taken to identify the
also are more su sceptib le because of thei r relative increased presence of an organized cardiac rhythm; if one exists, suf
BSA and limited energy sources. Trauma patients also are ficient circulation in patients with ma rkedly reduced me
susceptible to hypoth ermia, and any degree of hypoth er
tabolism is likely present, and vigorous chest compressions
mia in trauma patients can be detrimental. In trauma pa- can convert this rhythm to fibrillation. In the absence of an
organized rhyth m, CPR should be instituted and continued
until the patient is rewarmed or there are other indications
to discontinue CPR. However, the exact rol e of CPR as an
adjun ct to rewarming remains controversial.
Prevent heat loss by removing the patient from the cold
environment and replacing wet, cold clothing with warm
blankets. Administer oxygen via a bag reservoir device. The
-
pa ti en t should be treated in a critical care setti ng whenever

possible. Cardiac monitorin g is req uired . A careful search
for associated disorders-such as diabetes, sepsis, and drug
or alcohol ingestion or occult i nju ries should be con
-
ducted, and the disorders should be treated prom p tly.

Blood should be drawn for CBC, el ectrolytes, blood glu
cose, alcohol, toxins screen, creatinine, amylase, and blood
cultures. Abnormalities should be treated accordingly; for
example, hypoglycemia requires intravenous glucose ad
ministration.
Determination of death can be very difficult in patients mon as the temperature falls below 28 C (82.4 F), and at
with hypothermia. Patients who appear to have suffered a temperatllres below 25 C (77 F) asystole can occur. Car
cardiac <lrrest or death as a result of hypothermia should nor diac drugs and defibrillation are not usually effective in the
be pronou nced dead un ti l they have been rewarmed. Re.; presence of acidosis, hypoxia, and hypothermia. I n general,
member the axiom: You are not dead until you are warm and these treatment methods should be postponed until the pa
dead! An exception to this rule is the patient with hy tient is warmed to at least 28 C (R2.4 F). B rctyliu m tosy
po!hermia who has susta ined an anoxic event while still nor late is lhe only dysrhythmia agent known to be effective;
mothermic, who has no puJse or respiration, and who has a lidocaine is ineffective in paticnts wi I h hypo!hermia who
serum potassium level greater than I 0 mmol/L. have ventricular fibrillation. Dop;l mine is the single in
The appropriate rewarming tech nique depends on the otrop1c ttgent that has some degree of action in patients with
patient's temperature and his or her response to simpler hypothermia. Administer 100% oxygen whilethe pa tient i
measures. as well as the presence or absence of concomitant bei ng rewarmed. Arterial blood gases are probably best in
injuries. For example, treat mild and moderate exposure hy terpreted "uncorrected"-that is, the blood warmed to 37 C
pothermia with passive external rewarming i n a warm room (9R.6 F), with the value1. used as guides to administering
using warm blankets and clothi ng and warmed int ravenous sodium bicarbonate and adjusting ventila Lion para meter
fluids. Severe hypothermia may require active core rewarm during rewarming and resuscitation. Attempts to actively
ing methods, which may include invasive su rgical rewarm rewarm tl1e pat ient should not delay transfer to a critical
ing techn iques such as perito neal lavage, thoraci c/pl eural ..:arc set Ling.
lavage, arteriovenous rewarming, and cardiopulmonary
bypass. all of lvhich are best accomplished in a critical care
setting.
PITFALL
Cardiac output falls in proportion to the degree of hy
pothermia, ami cardiac irr itab il ity begins at about 33 C Failure to adequately rewarm patients.
(91 .4 F). Ventricular fibrillation bccomcs increasingly com-

CHAPTER SUMMARY 223
CHAPTER SUMMARY

The Rule of Nines is a useful and practical guide to determine the extent of the burn.
The adult body configuration 1s div1ded into anatom1c regions that represent 9%, or
mu ltiples of 9%, of the total body surface. Body-surface area differs considerably for
children. The infan t's or young child's head represents a larger proportion of the surface
area, and the lower extremities represent a smaller proportion than an adult1S This
guideline helps estimate the extent of burns with irregular outlines or distribution. As
sociated 1njuries can be sustained while the victim attempts to escape the fire, and in
jury from explosions can result in Internal injuries or fractures (eg central nervous system,
,
myocardial pul monary, and abdominal injuries)

, .
f)

tmmed1ate lifesavmg measures for pat1ents with burn injury include the recognition of
1nhalation injury and subsequent endotracheal intubation, and the rapid institution of
mtravenous fluid therapy. All clothing should be removed rapidly. Early stabilization and
treatment of the burn patient i nclude identifying the extent and depth of the burn es .
tablishing fluid guidelines according to the patient's weight, initiating a patient-care

flow sheet, obtaining baseline laboratory and x-ray studies, maintaining peripheral cir
culation in circumferential burns by performing an escharotomy if necessary, and iden
tifyi ng which burn patients require transfer to a burn unit or center.
Diagnose the cause and severity of cold injury by obtaining an adequate history and
noting the physical findings, as well as measuring the core temperature using a low-tem
perature range thermometer (esophageal temperature probe is preferred). The patient

should be removed from the cold environment 1mmediately and vital signs should be
,
monitored and supported continuously. Rewarming techniques should be applied as soon

as possible. The patient with hypothermia should not be considered dead until rewarm
ing has occurred. Early management of cold-injured patients includes: adhering to the
ABCDEs of resuscitation, identifying the type and extent of cold injury, measuring the
patient's core temperature, initiating a patient-care flow sheet, initiati n g rapid rewarm
ing techniques and determining the patient's life or death status after rewarming
, .
e Attention must be paid to special problems unique to thermal injuries. Carbon monox
ide poisoning should be suspected and identifi ed . Circumferential burns may require es
ca otomy.
r Chemical burns require immediate removal of clothing to prevent further injury
and copious irrigation. Electrical burns may be associated with extensive occult myo
necrosis. Patients sustaining thermal injury are at risk for hypothermia. Judicious ana l
gesia should not be overlooked.
The American Burn Association has identified the following types of bu rn injuries that
typically require referral to a burn center: ( 1 ) Partial-thickness and full-thickness burns
on greater than 1 0 % of the total BSA in patients less than 1 0 years or over 50 years of
age, (2) partial-thickness and full-thickness burns on greater than 20% of the BSA In
other age groups; (3) partial thickness and full-thickness burns involving the face, eyes,
-
ears, hands, feet genitalia, and perineum, as well as those lhat involve skin overlying
.
major joi nts; (4) full-thickness burns on greater than 5% of the BSA in any age group;
(5) significant electrical burns, including lightning injury (sigriificant volumes of tissue
beneath the surface can be injured and result in acute renal failure and other compli
cations}; (6) significant chemical burns; (7) inhalation inju ry; (8) burn injury in patients
with preexisting illness that could complicate treatment, prolong recovery, or affect mor
tality; (9) any pat1ent with a burn injury who has concomitant trauma poses an increased
risk of morbidity or mortality, and may be treated initially in a trauma center until sta
ble before transfer to a burn center; ( 1 0) children with burn injuries who are seen i n hos
pitals without q ua lified personnel or equipment to manage their care should be
transferred to a burn center with these capabilities; ( 1 1 ) burn injury in patients who will
require special social and emotional or long-term rehabilitative support, including cases
involving suspected child abuse and neglect.
15. Jurkovich C), Grciser W, Luterman A. et al. Hypothermia in

BIBliOGRAPHY trauma vktims: an ominous predictor of survival . / Trauma
1 987;27: I019 I 024.
I. Amy BW, McManu WI-, (;oodwin CW )r, et aJ. Lightning in
I 6. Lund T, Goodwin C\'V, Mc.:Manu> \\'F, et al. Upper airway se
jury with survival in fiw patients. /AMA 1985;253:243-245.
quelae in burn patients requiring endotracheal intubation or
2. Bntt LIJ, IJascombe WH, Rodriguez A. l':cw horizons in man Lracheotomy. J\mr S11rg 1985;20 I :374-382.
agement of hypothermia and frostbite injury. Surg Clin North
17. Millard LG, Rowell i'JR. Chilblain lupus erythematosus
Am 1991 ;71 (2):.'45-370.
(Hutchin:.on): a clinical and J.1boratory study of 1 7 patienb.
3. Cioffi WG, Grave!. 'IA, McManu> WF, t:t al. High frequ ency Br I Dcrmatol l97R;9R(5 ):497-506.
percussive ventihltion in patients with inhalation i njury. 1
18. Mills WJ Jr. Summary of treatment of the cold injured patient:
Trauma 198':1;29:350-354.
frostbite [ 1 983 classic .lrticl c 1. Ain Mcd 1993;35( I ):61 -66.
4. Danz.l D, Pow R, Auerbach P, et al. Multicenter hypothermi a
19. Mos5 ). Accidental severe hypo thermia. Surg Gynecol Obstet
survey. Arm em erg Ml'd 1987; 16: I 042- 1055.
1986; 162:50 I 513.
5. Demling Hit Burn care in the immediate resuscitation period.
20. Mozi ngo DW, Smith AA, McManus WF, et al. ChemicaJ burns.
Section Ill, Thermal injury. In: Wilmor DW, ed. Scientific
I Trrlllllltr 1988;2S:642-M7.
Americcw 'iurgery. New York: Scientific American; 1998.
21. O'Malley ), Mills W, Kappe B, ct al. Prostbitc: generaJ and spe
6. Edlich R, Ch.mgc 1), Bi rk K, ct al. Cold injuries. Compr Tiler
cific treatment, the Alaskan method. Ala Med 1993;27( L):pull
1989;15(9): 13-21.
out.
7. Gentilello LM, Cobcan RA, Offner PJ, et al. Continuous arte
22. Perry RJ, Moore CA, et .11. Determining the approximate area
riovenous rewarming: rapid reversal of hypothermia in criti
of burn: ,1 n inconsitcncy investigated and reevaluated. BMJ
cally ill patients. / Trauma 19':12;32(3}:316-327.
1996;3 12: 1 338.
8. Gentilello LM, Jurkovich G), Moujacs S. Hypothem1ia and in
23. PrUitt BA )r. The burn patient: I. Initial care. Curr Probl Surg
jury: thermodynamic principles of prevention and treatment.
1979;16(4}:1-55.
In: Levine B, ed. Pcrspectrves 111 Surgery. St. Louis: Quality Med
ical; 1991. 24. PrUitt BA Jr. The burn patient: II. L'\ter care and complications
of thermal intury. Curr Pro/JI Surg 1979;16(5):1-95.
9. Graves TA, Cioffi WG, :'vtct-lanus WF, et al. Huid resuscitation
of mfants and children with massive thermal injury. / Trauma 25. Reed R, Bracey A, !Judson J, et al. llypothermia and blood co
1988;28: 1656 1659. agulation: dissociation between enryme activity and clotting
factor lewis. Urc Shock I ':)':10;.32: 1 4 1 - 152.
10. Gunning K, cd .. B11ms Tnwma Nnruibook. 5th ed. liverpool,
UK: Liverpool I lospital Department of Trauma Services; 1994. 26. Rustin M, Newton ], Smith N, ct al. The treatment of chilblains
with nifcdipinc: the results of a pi lot study, a double-blind
11. Halebian P, Robinson N, Baric P, ct al. Whole body oxygen u ti
plncebo-cont rolled randomized study and a l ong term open
lization during carbon monoxide poisoning and isocapncic
-
trial. Br I /Jemwro/ 19ll9; 120:267-275.

nitrogen hypoxia. j Tmumrr 1986;26: I I0- L 17.
27. Saf'fle JR, Cl\1ndall A, Wmdcn GD. Cataracts: a long-term com
1.2. Hapon ik EF, Munster AM, eds. nespimtory lu]ury: Smoke In
plication uf elect rkal injury. I 'l'mttllm 1985;25: 17-21.
lwlotiort 111111 Bums. Nl!w York: McGraw-Hill; 1990.
28. Schaller M, Hsd1cr A, Perret C. Hyperkalemia: a prognostic
13. Jacob J, Weisman M, Rosenblatt S, er al. Chronic pernio: a his
factor during acute severe hypC>Lhermia. }AMA 1990;264: 1 842-
torical perspective of cold-induced vascular disease. Arch in
1845.
tern Med 1986; 146:1589- 1592.
29. Sheehy TW, Navari RM. Hypothermia. Ala j Med Sci
14. Jurkovich G). l lypothermia in the trauma patient. In: Maull
1984;21 (4}:374-38 1.
Kl, Cleveland HC, Strauch GO, et al., eds. Advances in Tmrmw.
Vol. 4. Chicago: Yearbook; 1989: 1 1 - 140. 30. Slratta RJ, Saffle JR, KravJt7 I, et al. Management of tar and
asphalt injuries. .tim I Surg 1983; 146:766-769.
C H APT E R
CHAPTER OUTLINE Upon completion of this topic the student will demonstrate
,
Objectives the ability to apply the principles of trauma care to treatment

of acutely mjured pediatric patients. Specifically, the doctor will
Introduction
be able Lo:
Types and Patterns of Injury
Unique Characteristics of Pediatric Patients OBJECTIVES
Size and Shape
Skeleton
Identify the unique characteristics of the child as a
Surface Area
trauma patient, including types of injury, patterns of
Psychological Status
injury, anatomic and physiologic differences in chil
long-Term Effects
dren as compared with adults, and long-term effects
Equipment
of injury.
Airway: Evaluation and Management
Anatomy Describe the primary management of critical in
Management juries in children, including related issues uni que
to pediatric patients, emphasizing the anatomic
Breathing: Evaluation and Management
and physiologic differences as compared with
Breath1ng and Ventilation
adults and their impact on resuscitation:
Needle and Tube Thoracostomy
Airway with cervical spine control
Circulation and Shock: Evaluation and Management
Recognition Breathing with recognition and management
Fluid Resuscitation of immediately life-threatening chest injuries
Blood Replacement Circulation with bleeding control and shock
Venous Access recognition a n d ma n age ment
Urine Output Disability with recognition and initial man
Thermoregulation agement of a ltered mental status and in
Chest Trauma tracranial mass lesion s
Abdominal Trauma Exposure with maintenance of body heat
Assessment Central nervous system and cervical spine in
Diagnostic Adjuncts juries
Nonoperative Management
Chest and abdominal injuries
Specific Visceral Injuries
Musculoskeletal injuries
Head Trauma
Assessment Fluid and medication dosages
Management Psychological and family support
Spinal Cord Injury Identify the injury patterns associated with child
Anatomic Differences abuse, and describe the elements that lead to the
Radiologic Considerations suspicion of child abuse.
Musculoskeletal Trauma
History
Blood loss
Special Considerations of the Immature Skeleton Prevention
Principles of Immobilization Chapter Summary
The Battered, Abused Child Bibliography
226 CHAPTER 1 0 Pediatric Trauma
Introduction scending order. Child battering-that is, physical abuse

accounts for the great majority of homicides in infants,
whereas firearm injuries account for the majority of
Injury continues to be the most common cause of cleat homicides in children and :-dolcscents. Falls account for
and disability in childhood. Each year, more than 1 0 mil the majority of all pediatric injuries, but infrequently re
lion children in the United States require emergency de sult in dealh.
partment care for the treatment of injuries, representing Blunt mechanisms of injury and children's physical
nearly 1 of every 6 children. And each year more tha n characteristics result in multisystem injury being the rule
I 0,000 children in the United States die from serious in rather than the exception (Table 10- l ). Penetrating in
jury. Injury morbidity and mortality surpass all major dis juries have increased in childhood and adolescence i n
eases i n children and young adults, making injury the many large cities. Therefore, it should be presumed Lhat all
most serious public health and health care problem in this organ systems may be injured until proven otherwi se Al .
population. Because failure to secure the airway, support though the condition ofthe majority of injured children will
the breathing, and recognize and respond lo intraabdom not deteriorate, and most injured children have no hemo

inal and intracranial hemorrhage are known to be the dynamic abnormalities, the fact remains that some children
leading causes of unsuccessful resuscitation in severe pe with multisystem injuries will have rapid deterioration and
diatric trauma, application of ATLS principles to the care serious complications will develop. Therefore, such patients
of the injured child can have a significant impact on ulti should be transferred early to a facility capable of treating
mate survival. chi ldren with multisystem injuries. The recently revised
Triage Decision Scheme and Pediatric Trauma Score arc
both useful tools for the early identification of pediatric
See Triage Decision
patients with multisystem injuries .
Types and Patterns of Injury Scheme (Pigure 1 - l , page 3) and Pediatric Trauma Score
(Table C-2, page 29 1 ) .
IJ What types of injuries

do children sustain?
Motor vehicle-associated injuries are the most common Unique Characteristics

cause of deaths i n children of all ages, whether lhe child
is an occupant, pedestrian, o r cyclist. Deaths due to
of Pediatric Patients
drowning, house fires, homicides, and falls follow in de-
IJ What aspects of childhood
anatomy do I need to consider?
The priorities of assessment and management of injuries

in children are the same as in the adult. However, the
unique anatomic and physiologic characteristics of pedi
atric palicnts combine with the different mechanisms of
injury to produce distinct patterns of injury. For example,
most serious pediatric trauma is blunt trauma that in
volves the brain. As a result, apnea, hypoventilation, and
hypoxia occur five times more often than hypovolemia
with hyp otensi on in seriously injured children. Therefore,
trealment protocols for pediatric trauma p'atients
emphasize aggressive management of the airway and
breathing.
SIZE AND SHAPE

Because of the smaUer body mass of children, lhe energy
imparted from, {or example, fenders, bumpers, and falls re
sults in a greater force applied per unit of body area. This
more intense energy is transmitted to a body that has less
fat, less connective tissue, and close proximity of multiple
organs. Tllis results in the high frequency of multiple in
j u ries seen in the pediatric population. i n addition, the head
UNIQUE CHARACTERISTICS OF PEDIATRIC PATI ENTS 227
TABLE 10-1 Common Mechanisms of Injury and Associated Patterns of

Injury i n Pediatric Patients

MECHANISM OF INJURY COMMON PATTERNS OF INJURY
Pedestrian struck Low speed Lower extremity fractures

H1gh speed. Multiple trauma, head and neck 1n1uries, lower extremity fractures
Automobile occupant U nrestrained Mult1ple trauma, head and neck lnjunes, scalp and facial lacerations
Restrained. Chest and abdomen 1nJunes. lower spine fractures
Fall from a height Low: l)pper extrem1ty fractures

Medium: Head and neck i nJuries, upper and lower extremity fractures
High Multiple trauma, head and neck Injuries, upper and lower extremity fractures
Fall from a bicycle Without helmet: Head and neck lacerations, scalp and faoal lacerations,
upper extremity fractures
With helmet: Upper extremity fractures
Stnking handlebar Internal abdominal InJuries

. . . . . . ' ..

- - -
. ..-
- - -- - ..... - - N-" --N- -

-
- -----
- -- -
is proportionately larger in young children, resulting in a tion, especially if it is painful, extremely difficult. The doc
higher frequency of blunt brain injuries in this age group. tor who understand these characteristics and is willing to
cajole and soothe an injured child is more likely to establish
a good rapport. Alt hough this rapport facilitates compre
SKELETON
hensive assesrnent of the child's psychological and physical
The child's skeleton is incomplete!) calcified, contains mul injuries, the presence of parents or guardians d uring evalu
ti pl e active growth cen ters, and is more pliable. For these ation .tnd treatment, including resuscitation, does not pres
reasons, internal organ damage is often noted without over ent a hindrance, and may provide the treating doctor with
ly i ng bony fracture. for example, rib fractures in ch ildren even greater help during l.!ar ly care of the pediatric trauma
are uncommon, but pulmonary contusion is not. Other soft patient by minimizing the inj ttred child's natural fears and
tisues of the thorax, the hea rt, and mediasti nal structures anxieties.
also may s us ta i n s ign i fica nt damage without evidence of
bony injury. The i denti ficat ion of skull or rib fractures in a
LONG-TERM EFFECTS
child suggests the transfer of a massive amount of energy,
and underlying organ injuries, such a& traumatic brain in A major consideration i11 t reat i ng injured children is the ef
jury and pulmonary contusion, should be s uspected. fect that injury can have on their subsequent growth and
develop men t . Unlike the adult, the child must uol only re
cover from the effects of the t raumatic event, but also must
SURFACE AREA
continue the normal process of growth and development.
The ratio of a child' body surface area to body volume is The physiologic and psychological effects of injury on this
highest at birth and diminishes as the child matures. As a process should not be underestimated, part icularly in cases
result, thermal energy loss is a significant stress factor in the involving long-term unction,
f growth deformity, or subse
child. Hypothermia may develop quickly and complicate the quent abnormal development. Children who sustain even a
treatment of the pediatric patient with hypotension . minor injury may have prolonged disability in cerebral
function, psychological adjustment, or organ system dis
abil ity
.
PSYCHOLOGICAL STATUS
Some cvidcm:e l!uggests that as many as 60o/o of chil
There may be significant psychological ramifications of in dren who sust,tin severe mult isystem trauma have residual
juries in children. In very young children, emotional insta person ality cha nges at I year after hospi tal discharge, and
bi lity freq uently leads to a regressive psychological behavior 50% :.how ..:ogn i t ive a nd p hysical handicaps. Social, a(fec
when stress, pain, and other perceived threats intervene in tive, ,md learn ing disabilities are present i n half of seriously
the child':. environml.!nt. The child's ability to interact with injured chi l d n.:n. In addi tion, childhood injuries have a sig
unfamiliar individuals in strange and difficult situation::. is n ifi cn n t impact on the fam ily, wit h personali ty and emo
limited, making histo ry taking and cooperative ma nipu la - tional disturbances found in two t h i rds of un i nj u red
-
-
- Airway: Evaluation
,;:_ .. -
and Management
The unique anatomic and physiologic characteris
tics of children occasionally lead to pitfalls in their ..
treatment.
I How do I apply ATLS principles
to the treatment of children?
The small size of the endotracheal tube promotes
obstruction from inspi ssat ed secret ions .
The "A" of the ABCDEs of initial assessment is the same in
Uncuffed tubes may be dislodged, especially dur the child as it is i.n the adult. Establishing a patent airway to
ing patient movement or transportation. provide adequate tissue oxygenation is the tirst objective.
The necessity of frequent reassessment cannot be The inability to establish and/or maintain a patent airway
overemphasized. with the associated lack of oxygenation and ventilation is
The same prudent attention to all tubes and the most common cause of cardiac arrest n i children. There
catheters used for resuscitation and stabilization fore, the child's ain-vay is the first priority.
is essential.
ANATOMY
The smaller Lhe child, the greater is the disproportion be
siblings. Frequently, a child's injuries impose a strain on the tween the size of the cranium and the midface. This leads to
parents' marital relationship, i nc l udi ng financial and some a propensity for the posterior pharynx to buckle anteriorly
times employment hardships. as a result of passive flexion of the cervical spine caused by
Trauma may affect not only the child's survival, but also the large occiput. Avoiding passive flexion of the cervical
the quality of the child's life for years to come. Bony and spine requires that the plane of the midface be kept parallel
solid visceral injuries are cases in point: to the spine board in a neutral position, rather than in the
"sniffing posi ti o n (Figure 1 0- l A). Placement of a l -inch
"
Injuries through growth centers may result in thick layer of padding beneath the infant's or todcUer's en
growth abnormalities of the injured bone. Tf the in lire torso will preserve neutral alignment of the spinal
jured bone is a femur, a leg length discrepancy may column (Figure 10-1 B).
result, causing a lifelong disability in running and The soft tissues in an infant's oropharynx (ie, tongue
walking. If lhe fracture is through the growth center and tonsils) are relatively large compared with those n i the
of one thoracic vertebra (or more), the resull may oral cavity, which may make visualizaLion of the larynx dif
be scoliosis, kyphosis, or even gibbus. ficLtlt. A child's larynx is funnel-shaped, allowing secretions
Massive disruption of a child's spleen may require a to accumulate in the retropharyngeal area. It is also more
splenectomy. The loss of the spleen predisposes the cephalad and anterior in the neck, and the vocal cords have
child to a l ifelong risk of overwhelming post a slightly more anterocaudal angle. The vocal cords are tie
splenectomy sepsis and death. quently more difficult to visualize when the child's head is in
the normal, supine, anatomical position during intubation
Nevertheless, the long-term quality of life for children than when it is in the m:utraJ position required for optimal
with disabilities is surprisingly robust, given the fact that dis cervical spine prolection.The infant's trachea is approxi
abled children in many cases suffer lifelong physical handi mately 5 em long and grows to 7 em by about 1 8 months.
caps. Most such patients report a good to excellent quality of Failure to appreciate this short length may result in intuba
life, and most find gainful employment, justifying aggressive tion of the right mainstem bronchus, inadequate ventila
resuscitation attempts, even for pediatric patients whose ini tion, accidental tube dislodgment, and/or mechanical

tial physiologic status, eg, Glasgow Coma Scale (GCS) score, barotrauma.
might suggest otherwise.
MANAGEMENT
EQUIPMENT
In a spontaneously breathing child with a partially ob
Immediately available equipment of the appropriate sizes is structed airway, the airway should be optimized by keeping
essential for the successful initial treatment of injured chil the plane of the face parallel to the plane of the stretcher or
dren (Table l 0-2). A length-based resuscitation tape, such gurney, while maintaining neutral alignment of the cervical
.
as the Broselow,., Pediatric Emergency Tape, is an ideal ad spine. The jaw-thrust maneuver combined with bimanual
junct for the rapid determination of weight based on length in-line spinal immobilization is used to open the airway.
for appropriate fluid volumes, drug doses, and equipment After the mouth and oropharynx are cleared of secretions
size. .. See Skill Stati.on IV: Shock Assessment and Man or debris, supplemental oxygen is administered. l f the pa
agement, Skill rv-F: BrosclowTM Pediatric Emergency Tape. tient is unconscious, mechanical methods of maintaining
I
.
TABLE 10-2 Pediatric Equipment'
AGE AIRWAY AND BREATHING CIRCUlATION SUPPLEMENTAL EQUIPMENT

AND
WEIGHT 02 ORAL BAG LARYN IV OG/NG CHEST URINARY CERVICAL
MASK AIRWAY VALVE GOSCOPE ETTUBE STYLET SUCTION BP CUFF CATHETER2 TUBE TUBE CATHETER COllAR
Premie Premie, Infant Infant 0 2.5-3.0 6 Fr 6-8 Fr Premie, 22-24 ga 8 Fr HH4Fr 5 Fr -
3 kg newborn straight no cuff newborn feeding
!Hi mos Newborn Infant, Infant 1 3.0-3.5 6 Fr 8 Fr Newborn, 22 ga 10 Fr 12-18 Fr 6 Fror 5 -
3.5 kg small straight no cuff infant Fr feeding
6-12 mos Pediatnc Small Pediatric 1 3.5-4.0 6 Fr B-10 Jnfam, 22 ga 1 2 Fr 14-20 Fr 8 Fr Small
7 kg straigh1 no cuff Fr child
1-3 yr Pedtatnc Small Pediatric 1 4.0-4.5 6 Fr 1 0 Fr Child 20-22 ga 1 2 Fr 14-24 Fr 1 0 Fr Small

10-12 kg straight no cuff
4-7 yr Pediatnc Medium Pedlatrtc 2 5.0-5.5 1 4 Fr 1 4 Fr Child 20ga 1 2 Fr 20-28 Fr 1 0 - 1 2 Fr Small

16-18 kg straight no cuff
)>
-
or curved
.
8-10 yr Adult Medium, Pediatric, 2-3 5.5-6.5 14 Fr 14 Fr Child, 18-20 ga 1 4 Fr 28--38 Fr 1 2 Fr Medtum
24-30 kg large adult straight cuffed adult m
or curved

I
c
'Use of a length-based resusCitation tape, such as a Broselowi M Ped1atnc Emergency Tape, is prefered
r .
'The largest IV catheter that can readily be inserted with reasonable certainty of success is preferred.
-
0
z
-------- ----
)>
z
0

)>
z
)>
C\
m

m
z
-;
N
N
1..0

230 CHAPTER 10 Pediatric Trauma
Plane of face is not

parallel to spine board
- - - - --
--- - -
- .... ...-
.... ...
-
.. ..
.. .. . .. . . . . . . ..
Plane of face is
pa ra l lel to spine board
.. ..
.. . . ..
" .. _ _ _ _ _ -
Figure 1 0-1 (A) Improper positioning of a child to maintain a patent airway. The disproportion between the size
of a child's cranium and the midface leads to a propensity for the posterior pharynx to buckle anteriorly. The large
occiput causes passive flexion of the cervical spine. (B) Proper positioning of a child to maintain a patient airway.
Avoid passive flexion of the cervical spine by keeping the plane of the midface parallel to the spine board in a neu
tral position, rather than in the "sniffing position." Placement of a one-inch-thick layer of padding beneath a child's
entire torso will preserve neutral alignment of the spinal column.
the airway may be necessary. Before attempts are made to Oro tracheal intubation is the most reliable means of es
mechanically establish an airway, the child should be fully pre tablishing an airw<ty and administering ventilation to a
oxygenated. child. UncutTed tubes-of appmpriate size, to avoid sub

gl.ouic edema, ulceration, and disruption of the i n fant':. or
Oral Airway child's fragile airway-should be ucd initially. The smallest
area of the young child'l> airway i at the cricoid ring, which
An oral airway should only be inserted if a child is uncon
forms a natural seal with the endotracheal tube. Therefore,
scious, since vomiting is likely if the gag reflex is intact. The
cuffed endotracheal tubes are uncommonly used in children
practice of inserting the airway backward and rotating it 180
under the age of 9 years who are acutely injured. A simple
degrees ts not recommended for children, as trauma with
technique to gauge the size of the endotracheal tube needed
resultant hemorrhage into soft tissue structures of the
is to approximate the diameter of the child's external nares
oropharynx may occur. The oral airw<y should be gently in
or the tip of the child's sm all linger to the tube diameter.
serted directl y into the oropharynx. The use of a tongue
t\ length-based pediatric resuscitation tape, such as the
blade ro depress the tongue may be hclpfi.1l.
Brosclow M Pediatric Emergency Tape, also lists appropriate
tube izcs fo r endotracheal intubation. l lowever, be sure to
Orotracheal Intubation have tubes readily available that arc one size larger and one
Endotracheal intubation is indicated for injured children in a size smaller than the predicted size. If a stylet is used to fa
variety of situations-for example, a child with severe brain cilitate endotracheal intubation, be ure that the tip does not
injury who requires cont.rolled ventilation, a child in whom an extend beyond the end of the tube.
airway cannot be maintained, a child who exhibits signs of Most tr<tuma centers use a protocol for emergency in
ventilatory failure, and a child who has suffered significant t ubat ion, rcfc1Ted to as drug-assisted intubation (DAI), pre
hypovolemia who has a depressed sensorium or requires op viously known as rapid sequence intubation (RSI). Careful
erative intervention. attention must be paid to the child's weight, vital signs (pulse
AIRWAY: EVALUATION AND MANAGEMENT 231
and blood pressure), and level of consciousness to determine porary chemical paralysis with one of two agents. Ideally, a
which branch of the algorithm to use (Figure 10-2). short-acting, depolarizing, neuromuscular blocking (chemical
Prcoxygcnation should he administered in children paralytic) agent should be used, such as succinylcholine (2
who require an endotracheal tube for airway control. I nfant s mgfkg in children <10 kg; 1 mgfkg in children >10 kg). Suc

nnd child1en have amore pronounced vagal response to en- cinylchol ine has a rapid onset, a short duration of action,
dotracheal intubation than adults. Such responses may be and may be the safest drug of choice (unless the patient has
c.1used by hypoxia, vagal stimulation during laryngoscopy, a previously known spinal cord iojury) . lfa longer period of
or pharmacol ogic agents, and they can be minimized by at paralysis is needed-for example, in a child who needs a com
ropine pretreatment. Atropine also dries oral secretions, per puted tomographic (CT) scan for further evaluation-a longer
mitting easier visualization of landmarks for intubation. The acting, nondepolarizing, neuromuscular blocking agent, such
dose of atropine is 0.1to 0.5 mg given at least 1 to 2 minutes as vecuronium (0.2 mgfkg) or rocuronium (o.6 mgfkg), may
before intubation. Appropriate drugs for intubation include be indicated.
etomiclate (0.3 mg/kg) or midazolam (0.3 mg/kg) in the After the endotracheal tube is inserted, its position must
children with normovolemia or etomidate (0.1 mg/kg) or be a ssessed clinically (see below) and, if correct, the tube
midazolam (0.1 mg/kg) in children with hypovolemia. The carefully secured. Cricoid pressure then may be released. If
specific antidote for midazolnm is lllunazenil, which should it is not possible to place the endotracheal tube after the
be immediately available. child is chemically paralyzed, the child must receive ventila
After sedation, cricoid pressure is maintained to help tion with 1 00% oxygen administered with a self-inflating
avoid aspiration of gastric contents. This is followed by tern- bag-mask device until a definitive airway is secured.
Drug Assisted Intubation (DAI) for Pediatric Patients

I
Preoxygenate
J .....
Atropine sulfate
0.1 0.5 mg
.J. !,.
.....,.
Sedation
J J
Hypovolemic Normovolemic
Etomidate 0. 1 mg/kg, or Etomidate 0.3 mg/kg, or
Midazolam HCl 0.1 mg/kg Midazolam 0.3 mg/kg
J 1,. ,J l
Cricoid pressure
..!. !.
Paralysis*
Succinylcholine chloride Yecuronium or
< 1 0 k.g: 2 mg/kg or Rocuronium
> 1 0 kg: 1 mg/kg (0.6 mg/kg)
..J.],.
Intubate, check tube position
Release cricoid pressure
* Proceed according to clinical judgement and skill/experience level.
Figure 1 0-2 Algorithm for Drug-Assisted Intubation (DAI) in Pediatric Patients.

Orotrachea l intubation under direct vision with ade

quate immobilization and protection of the cervical spine is PITFALL
the preferred method of obtaining initial airway control. Na
sotracheal intubation should not be performed in children Unrecognized inadvertent dislodgment of the en

under the age of 9 years, as it requires blind passage around dotracheal tube-which most often occurs as the pa
tient is transferred from an ambula nce stretcher to a
a rdalivdy acute angle i n the nasopharynx toward the an
hospital gurney in the emergency department, or
terosupcriorly located glottis, making intubation by this
from gurney to gantry, and vice versa, in the CT
route difficult. The potential for penetrating the child's cra s uite-is likely the most common cause of sudden
nial vault or damaging the more prominent nasopharyn deterioration in the intubated pediatric patient, em
geal (adenoidal) soft tissues and causing hemorrhage also phasizing the need for use of transport monitors
makes using the nasotracheal route for airway control ill whenever a child must be transferred from one care
advised. environment to another. Desaturation may also re
Once past the glotl ic opening, the endotracheal tube sult from obstruction of the endotracheal tube by
should be positioned 2 to 3 em below tbe level of the vocal clotted blood or inspissated secretions, worsening of
cords and carefully secured in place. Primary confirmation tension pneumothorax with positive-pressure venti
tcd1niques, such as auscultation of both hemith oraces in the lation (particularly if diagnostic findings were absent
on initial evaluation), and equipment failure-either
axillae, should then be performed to ensure that right main
kinking of the softer, narrower endotracheal tubes
stem bronchial intubation has not occurred and that boLh
used in children or an empty oxygen tank. Use of the
sides of the chest are being adequately ventilated. A second mnemonic, "Don't be a DOPE," (D for dislodgment,
ary confirmation device, such as a real-time capnograph, a 0 for obstruction, P for pneumothorax, E for equip
colorimetric end-tida I carbon dioxide ( ETC02) detector, or ment failure) may help t o remind the treating doc
an esophageal detector dev ice ( EDD), should then be used tor of the most likely calamities when the condition
to document tracheal intubation and a chest x-ray [lim ob of an intubated child begins to deteriorate.
tained to accurately identify the position of the endotracheal
tube.
Because of the short lenglh of the trachea in young
children (5 em in infants, 7 em in toddlers), any movement
or the head may result in displacement of the endotracheal dren i n whom the cricothyroid membrane is easily palpa
tube, inadvertent extubation, right mainstem bronchial in ble (usually by the age of 1 2 years). rl" See Skill Station Ill:
tubation, or vigorous coughing due to irritation of the ca Cricolhyroidotomy, Skill I l 1 -B: Su rgi ca I Cricot hyroido
rina by the tip of the endotracheal tube. These conditions tomy.
may not be recognized clinically until significant deterio
ration has occurred. Thus, breath sounds should be evalu
ated periodically to ensure that the tube remains in the
appropriate position and to identify the possibility of evolv
ing ventilatory dysfunction. If there is any doubt about cor
Breathing: Evaluation
rect placement of the endotracheal tube that cannot be and Management
resolved expeditiously, the tube should be removed and re
placed immediately. _.. See Skill Station fl: Airway and
BREATHING AND VENTILATION
Ventilatory Management, Skill 11-G: Infant Endotracheal
Intubation. The respiratory rate in children decreases with age. An
infant breathes 30 to 40 times per minute, whereas an
older child breathes 1 5 to 20 times per minute. Normal,
Cricothyroidotomy spontaneous tidal volumes vary from 6 to 8 mL/kg'for in
When airway maintenance and control cannot he accom fants and children, although slightly larger tidal volumes
plisheel by bag-mask ventilation or oronacheal intubation, of 7 to 1 0 mL/kg may be required during assisted venti
needle cricothyroidotomy is the preferred method. Needle lation. Although most bag-mask devices used with pedi
jet insufnation via the cricothyroid membrane is an appro atric patients are designed to limit the amount of
priate, temporizing technique for oxygenation, but it does pressure exerted manually on the child's airway, excessive
not provide adequate venlilation, and progressive hypercar volume or pressure during assisted ventilation substan
bia may occur. _.. See Chapter 2: Airway and Ven lilatory tially increases the potential for iatrogenic barotrauma
Management and Skill Stat ion fll: Cricothyroidotomy, Skill because of the fragile nature of the immature tracheo
Il l-A: Needle CricoLhyroidotomy. bronchial tree and alveoli.
Surgical cricothyroidotomy is rarely indicated for in l lypoxia is the most common cause of cardiac arrest
fa nts or small children. lt can be performed in older chil- in the child. However, before cardiac arrest occurs, hy-
CIRCULATION AND SHOCK: EVALUATION AND MANAGEMENT 233
poventilation causes respiratory acidosis, which is the most Circulation and Shock: Evaluation
common acid/base abnormality encountered during the
resuscitation of injured children. With adequate ventila
and Management
tion and perfusion, a child should be able to maLntain a
relatively normal pH. In the absence of adequate ventila IJ What physiologic differences will have
tion and perfusion, attempting to correct an acidosis with an impact on my treatment of pediatric
sodium bicarbonate results in further hypercarbia and wors trauma patients?
ened acidosis.
Key factors in the evaluation and management of circula
tion in pediatric trauma patients include recognilion of
NEEDLE AND TUBE THORACOSTOMY circulatory compromise, fluid resuscita lion, blood re
Injuries that disrupt pleural apposition-for example, he

placement, venous access, urine oulpuL, and thermoregu
lation.
mothorax, pneumothorax, and hemopneumothorax, have
similar physiologic consequences in children and aduJts.

These injuries are managed with p leuraJ decompression, pre

RECOGNITION
ceded in the case of tension pneumothorax by needle de
compression just over the top of the third rib on the Injuries in children may result i_n significant blood loss. A
midclavicu.lar line. Care should be taken during this proce child's increased physiologic reserve allows for mainte
dure to avoid using 14- to 18-gauge over-the-needle catheters nance of systol ic blood pressure in the normal range, even
in and small children, since the longer needle length
infants in the presence of shock (Figure I 0-3 ) . Up to a 30%
may cause, rather than cure, a tension pneumothorax. Chest diminution in circulating blood volume may be required
tubes will need to be small (sec Table 10-3) and arc placed the child's systolic blood pressure.
to manifest a decrease in
into the thoracic cavity by tunneling Lhe tube over the rib This may be misleading to medical professionals who are
above the skin incision site, and directing il superiorly and not familiar with Lhe subtle physiologic changes mani
posteriorly along the inside of the chest waiJ. Tunneling is es fested by children in hypovolemic shock. Tachycardia and
pecially important in children because of t he thinner chest poor skin perfusion often are the only keys to early recog
wall. The site of chest tube insertion is the same in chtldren as nition of hypovolemia and the early initiation of appro
in adults: the fifth intercostal space, just anterior to the mi priate crystalloid fluid resuscitation. Early assessment by
daxillary line. rl' See Chapter 4: Thoracic Trauma, and Skill a surgeon is essential to the appropriate treatment of injured
Station Vll : Chest Trauma Management. children.
- '
-
- I
<0 -
- \
-
E
....
-
- I
- '
-
0 --.. '
z ' '
'
' '
' I

'
'
'
- - - - Heart rate '
-- Blood pressure '
'
- - Cardiac output '
"
15 30 45
% Blood loss
Figure 10-3 Physiological impact of hemodynamic changes on pediatric patients.

Although a child's primary response to hypovolemia FLUID RESUSCITATION

is tachycardia, this sign also may be caused by pain, fear,
and psychological stress. Other more subtle signs of blood The goal of fluid resuscitJtion is to rapidly replace the cir
loss in children include progressive weakening of peripll culating volume. A child's blood volume can be estimated
cral pulses, a narrowing of pulse pressure to less than 20 at 80 mL/kg. When shock is suspected, a bolus of 20
mm Hg, skin mollling ( which substitutes for clammy skin mi./kg of warmed isotonic uystalJoid solution is needed.
in infants and young children), cool extremities compared 11 it were to remain i n the vascular space, Lhis would rep
resent 25o/o of the child's blood volume. The 3-for-1 rule
with the torso skin, and a decrease in the level of con
sciousness with a dulled response to pain. A decrease in applies to the pediatric patient as well as to the adult pa
blood pressure and other indices of inadequate organ per tient. Because the goal is to replace th.e lost intravascular
fusion, such as urinary output, should be monitored volume, it may be necessary to give three boluses of 20
closely, but generally develop later. Changes in vital organ mL/kg, or a total of 60 mL/kg, to achieve a. replacement
of Lhe lost 25% . Sec Chapter 3: Shock. When starting
function arc outlined i n Table 10-3.
The mean normal systolic blood pressure for children the third 20 mL/kg bolus, the use of packed red blood cells

is 90 mm Hg plus twice the child's age in years, and the ( PRBCs) should be considered. PR.BCs are administered
diastolic pressure should be two-thirds of the systolic as a bolus of l 0 mL/kg.
blood pressure. The lower limit of normal systolic blood Pluid resuscitation in the child is based on the child's
pressure in children is 70 rnm Hg plus twice Lh(: age in weigh l . l l is often very difficult for emergency department
years. ( Normal vital functions by age group are listed in
(ED) personnel to estimate the weight of a child, particu
Table 10-4.) Hypotension in a child repre:,enb a stale of larly if these personnel do .not treat many children. The sim
decompensated shock and indicates severe blood loss of plest and quickest method of determ ining the child's weight
greater than 45o/o of Lhe circulating blood volume. Tachy to accmatcly calculate Quid volumes and drug dosages is to
cardia changing to bradycardia often accompanies this hy use a length-based resuscitation tape, such as the Broselow,.,
potension, and this change may occur suddenly in inf<ults. Pedi;ltric Emergency Tape. This tool rapidly provides the
These physiologic changes must be treated by a rapid in child's approximate weight, respiratory rate, lluid resuscita
fusion of both isoronic crystalloid and blood. tion volume, and a variety of drug dosages.
TABLE 10-3 Systemic Responses to Blood loss in Pediatric Patients
MODERATE BLOOD
MILD BLOOD VOLUME LOSS SEVERE BLOOD
SYSTEM VOLUME LOSS (<30%) (30%-45%) VOLUME LOSS (>45%)
Cardiovascular Increased heart rate; Markedly 1ncreased heart Tachycardia followed by

weak, thready peripheral rate, weak, thready bradycardia, very weak or
pulses; r1ormal systoliC central pulses; absent absent central pulses; absent
blood pressure (80-90 + peripheral pulses; low peripheral pulses;
2 x age In years); normal normal systolic blood hypoten$ion (<70 + 2 x age
pu lse pressure pressure (70-80 + 2 x age 111 years), widened pulse
In years). narrowed pulse pressure {or undetectable
pressure diastolic blood pressure)
Central Nervous System Anxious, irritable; Lethargic; dulled response Comatose

confused to pa1n1
Skin Cool, mottled; Cyanotic; markedly Pale and cold

prolonged capillary refill prolonged capillary refill
Urine Output Low lo very low Ml111mal None
'The child's dulled response lo pain with this degree of blood loss (30%-45%) may be IndiCated by a decreased re
sponse to IV catheter insertion.
1After initial decompression by urinary calheter. Low normal is 2 ml/kg/hr (infant), 1 . 5 ml/kg/hr (younger child), 1
ml/kg/hr(older child), and 0 5 ml(hg/hr {adolescent). IV contrast can falsely elevate urinary output.
' . ..
.. . '".. . "" "" ""
..... ... .... ""
.... """' 0 '"' 0 ....H
-
o0 '"'"''""'"-"-' . .........
..
CIRCULATION AND SHOCK: EVALUATION AND MANAGEMENT 235
TABLE 104 Vital Functions
AGE GROUP WEIGHT

BLOOD RESPI RATORY URINARY
RANGE HEART RATE PRESSURE RATE OUTPUT
(IN KG) (BEATS/MIN) (MM HG) (BREATHS/MIN) (ML/KG/HR)
Infant 0-10 <160 >60 <60 2.0

0-12 mo
Toddler 10-14 <150 >70 <40 1 5

1-2 yr
Preschool 14-18 <140 >75 <35 1 0.

3-5 yr
School age 18-36 <120 >80 <30 1.0

6-12 yr
Adolescent 36-70 <100 >90 <30 0.5

1 3 yr
.
....... ... ........ ...... ....... ....
........
........... .. .... .... . ............. ""- .......................
........
. .... . ...............-.........._,..
......... ..-
"" "" "" "" "" ,,_""
''" "' """'"" " "" '"' ""' ' ' "" ....
"'' ,,
,. _,, _,..
.
, .
[njured children should be mo11itored carefuliy for re The resuscitation flow diagram is a useful aid in the ini
sponse to fluid resuscitalion and adequacy of organ perrusion. tial treatment of injured children ( Figure 1 0-4).
A return toward hemodynamic normality is indicated by:
BLOOD REPLACEMENT
Slowing of the heart rate toward normal (with im
provemem of other physiologic signs; this response Failure to improve hemodynamic abnormalities followi ng the
is age-dependent) first bolus of resuscitation fluid raises the suspicion of con
tinuing hemorrhage, prompts the need for administration of
Clearing of the sensorium a second and perhaps a third 2o-mLfkg bolus of isotonic crys
Return of peripheral pulses talloid fluid, and requires the prompt involvement of a sur
geon. When starting the third bolus of isotonic crystalloid
Return of normal skin color tluid or if the child's condition deteriorates, consideration
Increased warmth of extremities must be given to the use of 10 mlfkg of type-specific or Q.
negative warmed PRBCs.
Increased systolic blood pressure (normal is approx
imately 90 mm Hg plus twice the age in years)
VENOUS ACCESS
Increased pLLise pressure (>20 m m Hg)
Severe hypovolemic shock usually occurs as the result of dis
Urinary output of I to 2 mL/kg/hour (age-depen ruption of intrathoracic or intraabdominal organs or blood
dent) vessels. Venous access is preferably established by a periph
er al percutaneous route. I f percutaneous access is uns uc
Children generally have one of four responses to fluid cessful after two atrempls, consideration shoUld be given to
resuscitation. The condition of most children will be stabi int raosscous infusion via a bone marrow needle ( 1 8 gauge
lized bythe use of crystalloid fluid only; blood will not be re in infants, 15 gauge in young children) or insertion of a
quired; this group is considered "responders." Some children femoral venous line using the Seldinger technique or a
respond to crystalloid and blood resuscitation (also "re through-the-needle catheter of appropriate size. l f these
sponders"). l n some children there is an initial response to procedures fail, a doctor with skill and expertise can safely
crystalloid fluid and blood, but then deterioration occurs; perform direct venous cutdown. However, this should be
this group is termed "transient responders." Other children done only as a lasl resort, since venous cutdown can rarely
do not respond at all to crystalloid fluid and blood infusion; be performed in less than I 0 minutes, even in experienced
this group is referred to as "nonresponders." The two latter hands, whereas an intraosseous needle can reliably be placed
groups of children ( transient responders and non respon in the bone marrow cavity in Jess than 1 minute, even by
ders) are candidates for prompt infusion of additional blood providers with limited ::.kiU and expertise. .. See Skill Sta
and consideration for operation. tion fV: Shock Assesment and M<1nagement.
236 CHAPTER 1 0 Pediatr i c Tra um a
Surgical Consultation
20 ml/kg Ringer's lactate solution as bolus
(may repeat 1 or 2 times)*

J
Hemodynamics Hemodynamics
Normal Abnormal
J
J !..

Further 1 0 ml/kg
evaluation PRBC's
..! !..

Normal Abnormal
Transfer as ..!
J
'V
necessary
Further Operati on
evaluation
......
..!. !..
Observe Operation
Transfer as
necessary
J ],.
Observe Operation
Figure 10-4 Resuscitation Flow Diagram for Pediatric Patients with normal and abnormal hemodynamics.
Addttton11 flutd resuscltauon ts gutded l.Jy respone to tntltal bolus
The preferred sites for venous access in children are: peripheral venous cannulation have failed. Complications
of this procedure include cellulitis, osteomyelitis, compart
Percutaneous peripheral (two attcmpts)-Antecu ment syndrome, and iatrogenic fracture. The preferred site
bital fossa( e), saphenous vein(s) at the ankle for intraosseous cannulation is the proximal tibia, below the
level of the tibial tuberosity. If the tibia is fractured, the
lntraosseous placement Anterior tibial bone
needle may be inserted into the distal femur, aJthough the
marrow
contralateral proximal tibia is preferred, if uninjured. fn
Percutaneous placement-Femoral vein(s) lraosseous carumlation should not be performed distal to a
fr<lcture site.
Percutaneous placement-Fxtcrnal jugular vein(s)
(should be reserved for pediatric experts; do not use
if there is airway compromise, or a cervical collar is URINE OUTPUT
applied)
Urine output varies with age. Output for infants up to I year
Venous cutdown-Saphenous vein(s) at the ankle of age is 2 mL/kglhr, for younger children 1.5 mL/kglhr, and
for older children l mL/kg/hr. The lower limit of ruin ary
'
Intravenous access in children with hypovolemia who output does not achieve the normal adult value of 0.5
are younger than 6 years of age is a perplexing and chal mL!kg/hr until the adolescent has stopped growing. (See
lenging problem, even in the most expericnced hands. ln Table 10-4.)
traosseous infusion, cannulating the m.urow cavity of a long Urine output combined with urine specific gravity is
bone in an uninjured extremity, is an appropriate emergency an excellent method of determining the adequacy of volume
access procedure. The intraosseous route is safe and effica resuscitation. Once the circulatmg blood volume has been
cious, and requires far less time than docs venous cutdown. restored, the urinary output should return to normal. In
However, intraosseous infusiOn should be discontinued sertion of a urinary catheter facilitates accurate measure
when uitable peripheral venous access has been established. ment of the child's uri11ary output. A straight catheter, rather
Indications for intraosseous infusion are lim ited to chiJ than one with a balloon, may be ucd in children who weigh
clren for whom venous access is impo!>sible because of cir less Ihan I S kg, although urinary catheters with balloons are
t.:ulatury coiJ<1pse or for whom two attcmpts at percutaneous now available with a diameter as small as 6 French. Catheters
ABDOMINAL TRAUMA 237
alone and are frequently a component of major multisys

PITFALL tem injury. M.ost pediatric thoracic injuries can be success
fully managed using an appropriate combination of
The ability of a child's body to compensate in the supportive care and tube thoracostomy. Thoracotomy is not
early phases of blood loss may create an illusiOn of
gen erall y needed in children.
hemodynamic normal ity, resulting in inadequate
The incidence of penetrating thoracic injury increases
fluid resuscitation and rapid deterioration, which is
after 1 0 years of age. Penetrating Lrauma to the chest n
i chil
often precipitous.
dren is managed the same way as in ad ults rl' Sec Chapter
.
4: Thoracic Trauma, and Skill Station VII: Chest Tra uma

Management.
containing temperature probes are available for children
who need intensive care.
THERMOREGULATION Abdominal Trauma
The high ratio of body surface area to body mass in children

increases heat exchange with the environment and directly Most pediatric abdominal injuries occur as the result of
affects the body's abi lity to regulate core temperature. Thin blunt trauma, primariJy involving motor vehicles and falls.
skin and the lack of substantial subcutaneous tissue con Serious in tra abdom inal inj u ries warrant prompt i nvolve
-
tribute to increased evaporative heat loss and caloric ex ment by a surgeon, and hypotensive children who sustain
penditure. Hypothermia may render the child's injmies penetrating abdominal trauma require prompt operative
refractory to treatment, prolon g coagulation times, and ad intervention.
versely affect central nervous system ( CNS) function. While
the child is exposed during the in i tial survey and resuscita ASSESSMENT
tion phase, overhead heat lamps, heaters, or thermal blan
kets may be necessary to preserve body heat. H is advisable Conscious infants and young children are gen eral ly fright
to warm the room as wel l as the intravenous fl uids, blood ened by t he events preceding adm i ssion to the ED, which
products, and inhaled gases. may affect the abdominal examination. While talking quietly
and calmly to the child, ask questions about the presence of
abdominal pain and gently assess the tone of the abdominal
musculature. Deep, painful palpation of the abdomen
should be avoided at the onset of the examination to pre
Chest Trauma vent voluntary guardi ng that may confuse the abdominal
findings. Almost all infants and young children who are
Eight percent of all injluies in children involve the chest. stressed and crying will swallow large amounts of air. If the
Chest injury also serves as a marker for other organ system upper abdomen is clistended on examination, inserting a
injury, since more than two-thirds of children with chest in gastric tube to decompress the stomach should be a paxt of
jury will have multiple inj uries. The mechanism of injury the resuscitation phase. Orogastric tube decompression is
and the anatomy of the child's chest are directly responsible preferred in infants. Tenseness of the abdominal wall often
for the spectrum of injuries seen. decreases as gastric distention is relieved, allowing for more
The vast majority of chest injuries in childhood arc due c.-.reful Rnd reliable evaluation. The presence of shoulder
to blunt mechanisms, caused principally by mo tor vehicles. or lap bel t marks increases t he likelihood that abdominal
-
The pli abili ty, or compJjance, of a child's chest waU allows injuries are present.
im pac ting forces to be transmitted to the underl yin g pul Abdominal examination in unconscious'patients does
monary parenchyma, causing pulmonary contusion. Rib not vary greatly with age. Decompression of the urinary
fractures and mediastinal injuries are not common, but if bladder also facilitates abdominal evaluation. Since gastric
present, they indicate a severe impacting force. The specific dilation and a distended urinary bladder may bolh cause ab
injuries caused by thoracic trauma in children are similar to dominal tenderness, abdominal tenderness must be inter
those encountered in adults, although the frequencies of preted with caution, unless these organs have been fully
these injuries are somewhat different. decompressed.
Mobility of mediastinal structures makes the child more
susceptible to tension pneumothorax. Diaphragmatic ru.p
DIAGNOSTIC ADJUNCTS
tme, aortic transection, major tracheobronchial tears, flail
chest, and cardiac contusions are rarely encountered in Diagnostic adiuncts for assessment of abdo mi nal trauma
childhood. 'Alben identified, treatment for these inj u ries is include computed tomography, focused assessment sonog
the same as in the adulL. Sign i ficant inj uries r arely occur raphy in trauma, and diagnostic peri toneal lavage.
Computed Tomography malit ies, and with few exceptions, should undergo emer
The advent of helical CT scanning allows for extremely gency laparotomy.
rapid and precise identification of injuries. CT scanning is As in adults, warmed crystalloid solution in volumes
often used to evaluate the abdomen of children who ha\l:e of 10 mLJkg (up to 1000 mL) is used for DPL. Because a
sustained blunt trauma and have no hemodynamic abnor child's abdominal wall is relatively thin compared with that
malities. CT scanning should be immediately available, per or an adult, uncontrolled penetration of the peritoneal cav
formed early, and must not delay further treatment. The ity may produce iatrogenic injury to the abdominal con
identification of intraabdominal injuries by CT scan in pe tents, even when an open technique is used. DPL has utility
diatric patients with no hemodynamic abnormalitie can in diagnosing injuries to intraabdominal viscera only;
allow for nonoperative management by the surgeon. Early retroperitoneal organs cannot be evaluated reliably by this
involvement of the surgeon is essential to establish a baseline technique.
that will allow the surgeon to determine whether, and when, The interpretation of a positive lavage is the same in
operation is indicated. both children and adults. Aspiration of blood on catheter
Injured children who require CT scanning as an ad in:.enion or more than I 00,000 red cells per cubic millime

junct ive study often require sedation to prevent movement ter in the lavage eftluent is considered <1 positive findiJ1g. Al
during the scanning process. Thus, an injured child requir though the defi nition of a positive peritoneal lavage is rhe
ing resuscitation or sedation who undergoes CT scan same for children and adults, the presence of blood in the
should be accompanied by a doctor skilled in pediatric air peritoneum does not in and of itself mandate laparotomy
way management and pediatric vascular access. CT should in a child who responds to resuscitation. The presence of
routinely be performed with contrast agents according to leukocytosis, feces, vegetable fibers, ancllor bile in the lavage
local practice. effluent mandates laparotomy.
Only the surgeon who will care for the child should per
form the DPL, because DPL may interfere with subsequent
Focused Assessment Sonography in Trauma
abdominal examinations upon which the decision to operate
The utility of FAST i n managing pediatric patients remains may in part be based.
uncertain. Although comparatively few studies on the effi
cacy of ultrasound in children with t1bdominal injury have
been reported, its use as an extension of the abdominal ex
amination in injured children is rapidly evolving, and it has NONOPERATIVE MANAGEMENT
the advantage that imaging may be repeated. Focused as Selective, nonoperative management of blunt abdominal in
sessment sonography in trauma (FAST) can identity even juries in children is performed in many trauma centers, es
small amounts of intraabdominal blood in pediatric trauma peciaUy those with pediatric capabilities. The presence of
patients, a finding that is unlikely to be associated with sig intraperitoneal blood on CT, FAST, or DPL does not ncces
nificant injury. If large amounts of intraabdominal blood :.Mily mandate a laparotomy. It has been well demonstrated
arc found, significant injury is more likely to be present. thLtt bleeding from an injured spleen, liver, or kidney gener
However, even in these patients, operative management is ally is self-limited. TI1erefore, a CT, PAST, or DPL that is pos
indicated not by the amount of intraperitoneal blood, but by itive ror blood alone does not mandate a laparotomy in a
hemodynamic abnormality and it& response to treatment. child with initial abnormal hemodynamics that are readily
FAST is not consistently able to identify isolated intra normalized by fluid resuscitation. Ifthe child's condition can
parenchymal injuries, which account for up to one-third of not be normalized hemodynamically and ifthe diagnostic pro
solid organ injuries in children. cedure performed is positive for blood, a prompt laparotomy
to control hemorrhage is indicated.
Diagnostic Peritoneal Lavage \Vhen nonoperative management is selected, these chil
Diagnostic peritoneal lavage ( DPL) may be used to de dren mttst be treated in a facility that offers pediatric inten
tect intraabdominal bleeding in children with hemody sive care capabilities and under the supervision of a qualified
namic abnormalities who cannot be safely transported to surgeon with a special interest in nnd commitment to the
the CT scanner, or when CT and FAST are not readily care of injured children. I rHensivc care must include con
available. However, although DPL continues to be used tinuous pediatric nursing staff coverage, continuous moni
for screening by some experts, CT is now considered the toring of vital signs, and im111ediatc availability of surgical
preferred diagnostic study in most injured children, since personnel and operating room resources.
most such patients have self-limited intraabdominal in The chief indication for operative management in chil
juries and no hemodynamic abnormalities. Moreover, dren who continue to have no hemodynamic abnormalities
FAST is a more rapid and less invasive means of detecting is a transfusion requirement that exceeds one-halfthe child's
significant int raabdominal hemorrhage as compared blood volume , or 40 mLJkg, during the first 24 hours after in
with DPL. In addition, most patients with significant in jury. In most children who require operation for solid organ in
traabdominal bleeding will have hemodynamic abnor- jury, the need presents itself early, within 6 to 12 hours.
HEAD TRAUMA 239
Frequent, repeated examinations by the surgeon are neces a child witb hemodynamic abnormalities to present to the
sary to adequately assess the evolving status of the child. ED and receive rapid crystalloid tluid resuscitation, with re
Nonoperative management of confirmed abdominal turn to hemodynamic normality. 'Vhen a n injury to the
visceral injuries is a surgical decision made by surgons, just liver, spleen, or kidney is suspected, the child should W1-
as is the decision to operate. Therefore, the surgeon must dergo a C T scan. A child with grade n or higher injuries to
supervise the treatment of pediatic trauma patients. these organs is often admitted to the pediatric transitional or
intensive care unit for continuous monitoring. Delayed
hemorrhage from splenic rupture usually does not occur.
SPECIFIC VISCERAL INJURIES The presence of a splenic blush on CT with intravenous con
A number of ab dominal visceral injuries are more common trast does not mandate exploration. The decision to operate
n
i children than in adults. Duodenal hematoma results from continues to be based on the amount of blood lost as well as
a combination of thinner abdominal musculature and a abnormal physiologic parameters.
mechanism of injury such as a bicycle handlebar or an elbow

striking the child in the right upper quadrant. This injury
also may be caused by child abuse. lt is most ofren treated

nonoperatively with nasogastric suction and parenteral Head Trauma
nutrition.
Blunt pancreatic injuries occur from similar mecha
The information provided in Chapter 6: Head Trauma, also
nisms, with their treatment dependent on the extent of in
applies to pediatric patients. This section emphasizes addi
jury. Small bowel perforations at or near the ligament of
tional points specific to children.
Treit"l are more comn10n in children than in adults, as are
Most head injuries n
i the pediatric population are the
mesenteric, small bowel avulsion injuries. These particular
result of motor vehicle crashes, bicycle crashes, and falls.
injuries rue often diagnosed late because of the vague early
Analysis of national pediatric trauma data repositories in
symptoms and the potential for late perforation.
dicate that an understanding of the interaction between the
Bladder rupture is also more common in children than
CNS a11d exuacranial injuries is imperative, because hy
in adults, because of the shallow depth of the child's pelvis.
potension and hypoxia from associated injuries have an ad
Penetrating injuries of the perineum, or straddle injuries,
verse effect on the outcome from intracranial injury. Lack
may occur witl1 falls onto a prominent object, and may re
of attention to the ABCDEs and associated injuries signifi
sult in intraperitoneal injuries because of the proximity of
cantly increases mortality from head injury. As in adults, hy
the peritonemn to the perineum. Rupture of a hollow viscus
potension is infrequently caused by head injury alone, and
requires early operative intervention.
other explanations for this finding should be investigated
Children who are restrained by a lap belt are at partic
aggressively.
ular risk for enteric disruption, especially if they have a
The brain ofthe child is anatomically different from that
lap-belt mark on the abdominal wall or sustain a flexion
of the adulL. It doubles in size in tl1e first 6 montl1s of I ife and
distraction (Chance) fractme of the lumbar spine. Any pa
achieves 80o/o of the adult brain size by 2 years of age. n1ere
tient with this mechanism of injury a n d these findings
is increased water content of the brain up to 2 years of age.
should be preswned to have a high likelihood of injury to
Neuronal plasticity is evident after birth and includes in
the gast rointestinal tract until proven otherwise.
complete neuronal synapse formation and cuborization, in
A child's spleen, liver, and kidneys are frequently dis
complete myelinization, and a vast nmnber of neurochemical
rupted in Lhe face of a blunt force. It is uncommon for these
changes. The subarachnoid space is relatively smaller, and
injuries to require operative repajr. It is not w1common for
hence offers less protection to the brain because there is less
buoyancy. Thus, head momentum is more likely to in1part
pruenchymal structw-al damage. Normal cerebral blood flow

-. increases progressively to nearly twice that of adult levels by
PITFALL , -
..... -
' - . - the age of 5 yerus, and then decreases. This accounts in part
- ....
Delays in the recognition of abdominal hollow vis for children's severe susceptibility to cereb ral hypoxia.
cus injury are possible, especially when the decision
is made to manage solid organ injury nonopera
tively. Such an a pproach to the management of ASSESSMENT
these injuries in children must be accompanied by an
attitude of anticipation, frequent reevaluation, and Children and adults may differ in their response to head
preparation for immediate surgical intervention. trauma, which may inAuence the evaluation of the injured
These children should all be treated by a surgeon in child. The principal differences include:
a fac i lity equipped to handle any contingencies i n an
1 . The outcome i11 children who suffer severe brain in
expeditious manner.
jury is better thru1 that i n adults. However, the out-
come in children younger than 3 years of age is worse modified for childTen younger than 4 years (Table I 0-
Lhan a similar injury in an older child. Children are 5). .. Also see Appendix C: Trauma Scores: Revised
particularly susceptible Lo the effects of the secondary and Pediatric.
brain injury that may be produced by hypovolemia, ..
8 . l3ecause increased intracranial pressure frequently de
with attendant reductions in cerebral perfusion, hy
velops i n children, neurosurgical consultation to con
poxia, seizures. or hyperthermia. The effect of the
sider intracranial pressure monitoring should be
combination of hypovolemia and hypoxia on the in
obtained early i n the course of resuscitation for chil
jured brain is devastating, but hypotension from hy
dren with:
povolemia is the worst single risk factor. Adequate and
rapid restoration of an appropriate circulating blood A GCS score of 8 or less, or motor scores of 1 or 2
volume and avoidance of hypoxia are mandatory.
Multiple injuries associated with brain injury that
2. Although it is an infrequent occurrence, hypotension require major volume resuscitation, immediate life
may occur in small infants as the result of blood loss saving Lhoracic or abdominal surgery, or for which
into either the subgaleal or epidural space. This hypo stabilization and assessment is prolonged
volemia, due to intracranial injury, occurs because of

A CT scan of the brain lhat demonstrates evidence
open cranial sutmes and fontanelles in infants. Treat
of brain hemorrhage, cerebral swelling, or transten
ment is directed toward appropriate volume restora
torial or cerebellar herniation
tion, as is appropriate for blood loss from other body
.
reg tons. 9. Medication dosages must be adjusLed as dictated by
the child's size and in consultation with a neurosur
3. The young child with an open fontanelle and mobile
geon. Drugs often used in children with head injuries
cranial sutures has more tolerance for an e:x.'Panding
include:
intraoanial mass lesion or brain swelling. Signs of
these conditions may be hidden until rapid decom Phenobarbital, lO to 20 mg/kg/dose
pensation occurs. Therefore, an infant who is not in a
Diazepam, 0.1 to 0.2 rng/kg/dose; slow LV bolus
coma but who has bulging fontanelles or suture dia
stases should be treated as having a more severe in Phenytoin or fosphenytoin, 15 to 20 mg/kg, admin
jury. Early neurosurgical consultation is essential. istered at 0.5 to 1.5 mL/kg!min as a loading dose,
then 4 to 7 mg!kg/day for maintenance
4. Vomiting and even amnesia are common after brain
injury i n children and do not necessarily imply in Mannitol, 0.5 to l . O g/kg (rarely required); diuresis
creased intracranial pressure. However, persistent with the use of mannitol or furosemide may worsen
vomiting or vomiting that becomes more frequent is hypovolemia and should be withheld early in the
a concern and mandates CT of rhe head. Gastric resuscitation of children with head injury w1less
decompression is essential, because of the risk of there are incontrovertible signs of Lranstcntorial
aspiration. hemiation
5. Impact seizures-that is, seizures that occur shortly

after brain injmy-are more common in children and
arc usually self-limited. All seizure activity requires
investigation by CT of the head.
6. Children tend to have fewer focal mass lesions than

TABLE 1 0 .. 5 Pediatric Verbal Score
do adults, but elevated intracranial pressme due to
brain swelling is more common. Rapid resLoration of
normal circulating blood volume is necessary. Some VERBAL RESPONSE V-SCORE

practitioners fear that restoratiqn of a child's circulat
Appropriate words or social smile. fixes and follows 5
ing blood volume places the child at greater risk for
worsening of the existing head injury. However, the
opposite is true. lf hypovolemia is not corrected C nes, but consolable 4
promptly, the outcome from head injury is made

worse because of secondary brain injury. Emergency Persistently 1rntable 3
CT is vital to identify children who require emergency

operation. Restless, ag1tated 2
7. The GCS is useful when applied to the pediatric age None 1

group. However, the verbal score component must be
SPINAL CORD INJURY 241
MANAGEMENT RADIOLOGIC CONSIDERATIONS

Management of traumatic brain injury in children involves: Pscudosubluxation frequently com pi icates the radiographic
evaluation of a child's cenrical spine. About 40% of children
1 . Rapid, early assessment and mm1agement of tlie younger than 7 years of age show m1terior displacemenL of
ABCDEs C2 on C3, and 20% of children up to 16 years exhibit this
phenomenon. This radiographic fmding is seen less com
2. Appropriate neurosurgical involvement from the be
monly at C3 to C4. More than 3 mm of movement may be
ginning of treatment
seen when these joints are studied by flexion and extension
3. Appropriate sequential assessment and management of maneuvers.
the brain injury with attention directed toward the pre When subluxation is seen on a lateral cervical spine x
vention of secondmy brain injury-that is, hypoxia ray, the doctor must ascertain whether this is a pseudosub
and hypoperfusion. Early endotracheal intubation with luxation or a true cervical spine injury. Pseudosubluxation
adequate oxygenation and ventilation are indicated to of the cervical vertebrae is made more pronounced by the
avoid progressive CNS damage. Attempts to orally in tlexion of the cervical spine that occurs when a child lies
tubate the trachea in an uncooperative, child with a supine on a hard surface. To correct this radiographic anom
brain injury may be difficult and actuaUy increase in aly, place the child's head i n a neutral position by placing a
tracranial pressure. l n the hands of doctors who have l-inch-thick layer of padding beneath the entire body from
considered the risks and benefits of intubating such shoulders to hips, but not the head, and repeat the x-ray.
children, pharmacologic sedation and neuromuscular (See Figure l0-2.) Cervical spine injury usually can be iden
blockade may be used to facilitate intubation. tified from neurologic examination findings and by detec
tion of an area of soft tissue swelling, muscle spasm, or a
4. Continuous reassessment of all parameters
See
step-off deformity on careful palpation of the posterior cer
Skill Station IX: Head and Neck Trauma: Assessment
vical spine.
and Management.
An increased distance between the dens and the ante
rior arch of Cl occurs in approximately 20% of young chil
dren. Gaps exceeding the upper limit of normal for the adult
population are seen frequently.
Spinal Cord Injury Skeletal growth centers can resemble fractures. Basi
lar odontoid synchondrosis appears as a radiolucent area
The information provided in Chapter 7: Spine and Spinal at the base of the dens, especially in children younger than
Cord Trauma also applies to pediatric patients. This section 5 years. Apical odontoid epiphyses appear as separations
emphasizes points specific to pediatric spinal injwy. on the odontoid x-ray and are usually seen between the
Spinal cord injury in children is fortunately uncom ages of 5 and 1 1 years. The growth center of the spinous
mon-only 5o/o of spinal cord injuries occur in the pediatric process can resemble fractures of the tip of the spinous
age group. For children younger than l 0 years of age, motor process.
vehicle crashes most commonly produce these injuries. For Children may sustain "spinal cord injury without ra
children aged 1 0 to 14 years, motor vehicles m1d sporting diographic abnormalities" (SCIWOR.A) more commonly
activities account for an equal number of spinal injuries. than adults. A normal cervical spine series may be fo und
in up to two-thirds of children who have suffered spinal
cord injury. Thus, i f spinal cord injury is suspected,
ANATOMIC DIFFERENCES based on history or the results of the neurologic exami
The anatomic differences in children to be considered with nation, normal spine x-ray examination does not ex
regard to spinal injury include: clude significant spinal cord injury. When in doubt about
the integrity of the cervical spine or spinal cord, assume
1 . Interspinous ligaments and joint capsules are more that an unstable i njury exists, maintain immobilization of
1lexible. the child's head and neck, and obtain appropriate consul
2. Vertebral bodies are wedged anteriorly and tend to tation.
slide forward with flexion. Spinal cord injury in children is treated in the
same way as spinal cord injuries in adults. Consultation
3. The facet joints are flat. with a neurosurgeon should be obtained early. . See
4. The child has a relatively large head compared with Chapter 7: Spine and Spinal Cord Trauma, Skill Station
the neck. Therefore, the angular momentum forces X: X-Ray Identification of Spine Injuries, and Skill Sta
applied to the upper neck arc relatively greater than in tion XI: Spinal Cord Injury: Assessment and Manage
the adult. ment.
fore the physis has closed may potentially retard the normal
Musculoskeletal Trauma growth or alter the development of the bone in an abnormal
way. Crush injuries to the physis, which are often difficult
The initial priorities in the management of skeletal traum to recognize radiographically, have the worst prognosis.
in the child are similar to those for the adult, with additional The immature, pliable nature ofbones in children may
concerns about potential injury to the growth plate. See lead to a so-called greenstick fracture. Such fractmes are in
Chapter 8: Musculoskeletal Trauma. complete, with angulation maintained by cortical splinters
on the concave surface. The torus, or"buckle," fracture, seen
in small children, involves angulation due to cortical im
HISTORY paction with a radiolucent fracture line. Both types of frac
History is of vital importance. In younger children, x-ray tures may suggest abuse in patients with vague, inconsistent,
diagnosis of fractures and dislocations is difficult because or confl icting histories. Supracondylar fractures at the elbow
of the lack of mineralization around the epiphysis and or knee have a high propensity for vascular injury as well as
the presence of a physis (growth plate). Information injury to the growth plate.

about the magnitude, mechanism, and time of Lhc injury

facilitates better correlation of the physical and x-ray PRINCIPLES Of IMMOBILIZATION
findings. Radiographic evidence of fractures of differing Sin1plc splinting of fractured extremities in children usually is
ages should alert the doctor to possible child abuse, as sufficient until definitive orthopedic evaluation c<m be per
should lower-extremity fractures in children who are too formed. Injured extremities wiLh evidence of vascular com
young to walk. promise require emergency evaluation to prevent the adverse
sequelae of ischemia. A single attempt to reduce the fractme
to restore blood flow is appropriate, followed by simple splint
BLOOD LOSS ing or traction splinting of the femur. ;/' See Skill Station
Blood loss associated with long-bone and pelvic fractures Xri: Musculoskeletal Trauma: Assessment and Management.
is proportionately less in children than in adults. Blood
loss related to an isolated closed femur fracture thal is
treated appropriately is associated with an average fall in
hematocrit of 4 points, which is not enough to cause . The Battered, Abused Child
shock. Hemodynamic instability in the presence of an iso
lated femur fracture should prompt evaluation for other
sources of blood loss, which usually will be found within
IJ How do I recognize abuse injuries?
the abdomen. Any child who sustains an intentional injury as the result
of acts by parents, guardians, or acquaintances is consid
ered to be a battered, abused child. Homicide is the most
SPECIAL CONSIDERATIONS OF
common cause of injury death in the first year of life.
THE IMMATURE SKELETON
Therefore, a his tory and careful evaluation of the child in
Bones lengthen as new bone is laid down by the physis ncar whom abuse is suspected is critically important to
Lhe articular surfaces. Injuries to, or adjacent to, tlus area be- prevent evenlual death, especially in children who arc
younger than 1 year of age. A doctor should suspect
abuse if:
PITFALLS
1. A discrepancy exists betv-Jeen the history and the de
Many orthopedic injuries in children produce only gree of physical injmy-for example, a young hild
subtle symptoms, and positive findings on physi loses consciousness after falling from a bed or sofa,
cal examination are difficult to detect. fractures an extremity during play with siblings or
Any evidence of unusual behavior-for example, a other children, or sustains a lower-extremity fracture
child who refuses to use an arm or bear weight on but is too young to walk.
an extremity, must be carefully evaluated for the
possibility of an occult bony or soft tissue injury. 2. A prolonged interval bas passed betv-Jeen the time of
The parents are often the ones who note behavior the injmy and presentation for medical care.
that is out of the ordinary for their child. 3. The history includes repeated trauma, treated in the
The doctor must remember the potential for child same or different EDs.
abuse. The history of the injury event should be
viewed suspiciously when the findings do not cor 4. The history of injury changes or is different between
roborate the parent's story. parents or guardians.
PREVENTION 243
5. There is a history of hospital or doctor "shopping." In many nations, doctors are bound by law to report in
cidents of child abuse to governmental authorities, even
6. Parents respond inappropriately to or do not comply
cases in which abuse is only suspected. Abused children are
with medical advice-for example, leaving a child un-
.. al increased risk for fatal injmies, and no one is served by
attended in the emergency facility.
failing to report. The system protects doctors from legal li
ability for identifying confirmed or even suspicious cases of
The following findings, on careful physical examina
abuse. Although the reporting procedures may vary, il is
tion, should suggest child abuse and indicate more inten
most commonly handled through l.ocal social service agen
sive investigation:
cies or the state's health and human services department.
The process of reporting child abuse assumes greater im
1 . Multicolored bruises (bruises in different stages of
portance when one realizes that 50% of abused children
healing)
who die or are dead on arrival at the hospital were victims
2. Evidence of frequent previous injuries, typified by old of previous episodes of abuse that went unreported or were
scars or healed fractures on x-ray examination not aken
t seriously.

3. Perioral injuries
4. lnjuries to the genital or perianal area

5. Fractures of long bones in children younget than 3 Prevention
years of age
6. Ruptured inlernal viscera without antecedent major The greatest pitfall related to pediatric trawna is failure to have
blunt trauma prevented the child's injuries in the first place. Up to 80% of
childhood injur.ies could have been prevented by the applica
7. Multiple subdural hematomas, especially without a tion of simple strategies in the home and the community. The
fresh skull fracture ABCOEs of injury prevention have been described, and war
8. Retinal hemorrhages rant special attention in a population among whom the life
time benefits of successful injury prevention are self-evident
9. Bizarre injuries, such as bites, cigarette burns, or rope (Box 10-J ). Not only is the social and familial disruption as
marks sociated with childhood injury avoided, but for every dollar
10. Sharply demarcated second- and third-degree burns invested in injury prevention, four dollars are saved in hospi
in unusual areas tal care.
Box 1 0-1
ABCDEs of Injury Prevention
Analyze injury data Develop prevention activities
-Local i nJ U ry su rvei llance -Create safer environments

Build local coalitions Evaluate the interventions
-Hospital comm un ity partnerships -Ongoing injury surveillance
Communicate the problem

-Inju ries are preven table
Source: Pressley J. Barlow B, Durk1n M. Jacko SA, Roca-Dom1nguez D, Johnson L. A nat1onal program for injury prevent1on 1n
chi ld ren and adolescents: the Injury Free Coalition for Kids. J Urban Health 2005;82:389402
CHAPTER SUMMARY
Unique characteristics of children include important differences In anatomy, body sur

face area, chest wall compliance, and skeletal anatomy. Normal VItal signs vary signifi
cantly wrth age.
f) lnrtial assessment and management of severely injured children is gurded by the ABCDE
approach. Early involvement of a general surgeon or ped iatnc surgeon is imperatrve in
the management of injunes in a child. Nonoperative management of abdomrnal visceral
injuries should be performed only by surgeons m facrlltres equrpped to handle any con
tingency in an expedrtlous manner.
Child abuse should be suspected if suggested by suspicious findings on history or phys

rcal examination. These rnclude discrepant history, delayed presentation, frequent prior
rnjurtes, and perineal inJuries.
Bibliography 10. !Iannan E, Meaker P, Fawell L, ct ,,). Predicting in patient mor

tal i ty for pediatric blunt traum.1 p.ll it n ts: a b..:tter alternative.
J Ptdiatr Surg 2000;35: 155- 1 59.
I. Carncy NA, Chesnut R, Kochanek PM, ct nJ. Guidel in es for the
I I . l larri BH,chwaitz.berg SO, Seman TM, et al. Th e hidden
acute medical managemnt of severe 1 raum atic brain injury
m o rb id i ty of pediatric trauma. / J>ediatr Surg 1989;24:103-
in infants, .:hildren, and adolescent. I TraumJ 2003;54:S235-
1 06.
S310.
12. llemnberg JE, Hensn
i ger RN, Ded nck Dl\ et al. Emergency
2. Chesnut R.\1, Marshall LF. ct al. The role of secondary brain
transport and positionmg of young ch1ldren who have an in
mjury in determining outcome from evere head injury. I
jury of the cervical spi ne. I Bone /oint Surg Am 1989;71: 1 5
fnllllll.l 1993;43:216-222.
--
3. Cloutier DR, Baird TB, Gormley P, McC.1rten KM, Bussey fC,

13. l lolmcs JF, Brant WE, Bond WF, Sokolove PE, Kupperm a n n
l.uks Fl. Pediatric splenic inj uries with a contrast blush: suc
N. r.mcrgency department ultrasonography in the eval uation
ccsfu l nonope rative managemen t witho ut a ngi ography and
of hypotensive and normotensiw ch ildrcn with blunt abdom
cmboliz<llion. I Pediatr Surg 2004;39(6):969-971.
inal I rauma./ Pediatr Surg 200 I ;36(7):968-973.
4. Cooper A, Barlow B, DiScala C, et al. Mortality and truncal in
14. l lolmc Jf, London KL, Brant WE, Kuppc rmann N. lsolated
jury: the pediat ric perspective. / Pcdi<ltr Surg 1994;29:33.
intraperiton eal fluid on abdominal computed tomography in
5. Cooper A, Rarlow B, DiScala C. Vital signs and trauma mor children with blum trauma. Acad Fmerg Med 2000;7( 4): 335-
taltty. the pediatric perspective. Pcdiatr Emcrg Care lll.
:woo; 16:66.
I 5. Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin DR, Win
6. Corbett <;W, Andrews HG, Baker EM. lone WG. ED evalua ston IK. Incidence and clinical significance of abdominal wall
tion of the pediat ric trauma patient by ultrasonography. Am I bruisi ng in restrained children involved in motor'vehide
Emerg Med 2000;1 8(3 ):244-249. mhcs. f Pediatr Surg 2004;39(6):972-975.
7. DiScala C, Sage R, Li G, et al. Child abuse <lllcl unintentional in 16. Mutabagani KH, Col ey BD, Zumbcrgc N, ct al. Preliminary ex
juries. Arch Pediatr Adolesc Mcd 2000; 1 54: 16-22. perience wi th focused abdom inal onography for trauma
(l-AST} in children: is it useful? J Pedi11tr Surg 1999;34:48-54.
8. Pmcry Kll, McAneney CM, R<1cadio JM, Johnson ND, Evora
))K, Garcia VF. Absent peritoneal fluid on screening trauma 17. National Safety Council. Injun L1cH. Itasca, ll: National
ult rasonography in children: a propcctive comparison with Safe!)' Council; 2007.
computed tomography. / Pediatr Surg 2001 ;36(4):565-569.
18. P,1ddock H:-.1, Tepas fl , Ramenofsk) 1'.11.. ManagemeDL of blunt
9. Gerard i MJ, Sacchetl AD, Cantor RM, et .11. Rapid-cquence pcdtat rk hepatic and splemc inJurv: sim i lar process, different
intubation of Lhe pediatril pJtienl. Ann Emcrg Mcd outomc. Am Surg 2004;70: I 068 I 072.
1996;28:55-74.
BIBLIOGRAPHY 245
19. Patel }C, Tepas TJ. The efficacy of focused abdominal S<lnogra 26. Soudack M, Epelman M, Maor R, et al. Experience with fo
ph)' for trauma (FAST) as a screen ing tool in the assessment of cused abdominal sonography for lrauma (FAST) in313 pedi
injured children. j Pediatr Surg 1999;34:44-47. atric patients. I Clin Ultrasound 2004;32(2):53-61 .
20. Pershad ), Gilmore .B. Serial bedside emergency ultrasound in 27. Soundappan SV, Holland A}, Cass DT, Lam A. Diagnostic ac
ncase of pediatric blunt abdominal trauma vvith severe ab curacy of u rgeon-performed focused abdominal sonography
dominal pain. Pediatr Emerg Care 2000;16(5):375-376. (FAST) in blunt paediatric trauma. Injury 2005;36(8):970-
975.
2 1 . Pigula FA, \Vald SL, Shackiord SR, eL at. The eCfect of hy
potension and hypoxia on children with seven: head injuries. 28. Stylianns S. Compliance with evidence-based guidelines in
J Pcdiatr SUJ"g !993;28:31 0-316. children with isolated spleen or liver injury: a prospective
study. I Pediatr Surg 2002;37:453-456.
22. Pres:.ley }, Barlow B, Dwkin M, Jacko SA, Roca-Dominguez D,
Johnson L. A national program for injury prevention in chil 29. Suthers SE, Albred1t R, Foley D, ct al. Surgeon-directed ultra
dren and adolescents: the Injury Free Coalition for Kids. T sound for lraLLma is a predictor of intra-abdominal injury io
Urban Health 2005;82:389-402. children. Am SUJ"g 2004;70(2): 164-167; discussion 167-168.
23. Rathaus V, Zissin R, Werner M, et al. Minimal pelvic fluid in 30. Tepas 1/, DiScala C, Ramenofsky ML, ct al. Mortality and head
bluJll abdominal trauma in children: the significance of this injury: the pediatric perspective. I Pediatr Surg 1990;25:92-96.
sonographic finding. T Pediatr Surg 200 I ;36(9): 1387- 1389.
3 1 . Tepas JJ, Ramenofsky ML, Mollitt DL, et al. The Pediatric
24. Rogers CG, Knight V, MacUra K}. High-grade renal injuries in Trauma Score as a predictor of injury severity: an objective as
children-is conservative management possible? Urology sessmenl. f Trauma 1988;28:425-429.
2004;64:574-9.
32. van der Sluis CK, Kingma T. Eisma \1\Tfl, ten Duis I!). Pedial ric
25. Schwaitzberg SO, .Bergman KS, Harris B\Al. A pediatric trauma polytrauma: short-term and long-term outcomes. I Trauma
model of continuous hemorrhage. J Pediatr Surg 1988;23:605- 1997;43(3):501-506.
609.
-
C H A PT E R
CHAPTER OUTLINE Upon completion of this topic, the stude nt will demonstrate
the ability to apply the principles of trauma care to acutely in
Objectives
jured ge ria tric patients. Spe cifical ly the doctor will be able to:
,
Introduction
Types and Patterns of Injury OBJECTIVES
Airway
Identify the unique characteristics of elderly
Breathing and Ventilation trauma patients, including common types of in
Circulation
jury, patterns of injury, and their anatomic and
Changes with Aging
physiologic differences.
Evaluation and Management
Describe the primary management of critical in
Disability: Brain and Spinal Cord Injury juries in geriatric patients, including related issues
Changes with Aging unique to geriatric patients, emphasizing the
Evaluation and Management anatomic and physiologic differences from
younger patients and their impact on resuscita
Exposure and Environment
tion.
Other Systems Airway management
Breathing and ventilation
Nutrition and Metabolism
Immune System and Infections Shock, fluid, and electrolyte management
Special Circumstances Central nervous system and cervica l spine in-

Medicati ons Junes

Elder Abuse
Identify common causes and signs of elder abuse,
End-of-Life Decisions
and formulate a strategy for managing situations
Chapter Summary of elder abuse.
Bibliography
-
248 CHAPTER 1 1 Geriatric Trauma
Introduction ing level of independent living after aggressive resuscitation

and fol low up care. Despite this, in the United States in 1997
-
more than 36,000 elderly patients died [rom injuries, ac

Globally, human popu l ations continue to age at an i mp res coun Li ng for 25% of all injury fatal ities This high mortal ity
.
sive ra tc. Between 1900 and 1992, the number of i ndividu rate Iikely reflects the decreased physical reserves of lhe el
als aged 65 and above increased from 1 Wo ( J 5 million) to 6o/o der ly due to the changes of aging, the comorbidities that de
{342 milli on) of lhe world's population. By the year 2050, ve lop, and a lack of LU1derstanding of their needs by many
these figures will have risen to 20%, or 2.5 billion. AL that health-care p roviders Figure 1 1-1 illustrates the effects o[
.
Lime, it is projected that the elderly will represent 25o/o or agi n g on organ systems, and Box 1 1-1 outlines the impact of
the populat ion in the United Stales. The rapid grovvth of the p reexisting disease on trauma outcome lv1ilzman et al . re
.
sen ior population has already had a significant econom i c ported that preexisting disease was more common in the
impact because of their un ique med ica l req uirements and older age gro up ( mean age, 49.2) tl1an in the younger age
the fact that sen iors consume more than one third of the
-
group ( mea11 age, 30.0), an d the mo rtal i ty rate was three
country s health care resources. Cur rently, trauma is the sev
'
times greater in the older patients with preexisting disease
enth leading cause of death in the elderly, surpassed only by (9.20fcJ VS 3.2%).
heart disease, cancer, chronic obstructive pulm onary dis The three leading causes of death due to injury among
ease, stroke, diabetes, and pneum oni a. the elderly in the United States are falls, motor vehicle
crashes, and burns. Falls, which are the most common cause
o[ unintentional injury and death among the el der l y, ac
count for 40% of the dea ths in this age group. Both the in
Types and Patterns of Injury cidence of fails and the severity of complications rise with
age, and large numbers or emergency department visits and
IJ Wha t are the unique characteristics of subseq uent hospital admissions occur as a result of falls. Al
though fall-related injury rates are higher in older adults,
geriatric trauma?
the majority do not result in serious injury. Only 5% to 15o/o
Although patients aged 65 and older are less likely to be in of falls in community-dwelling older adults cause serious
jured than are younger individuals, older patients are more injuries, incl uding head trauma, fractures, dislocat ion and
,
likely to have a fatal outcome from their injuries. However, serious soft tissue injury.
more than 80% of lhe n i jmed can return to their preexist - The a ccumul ated effects or the agi ng process and en
vi ronmental hazards most freq uen t l y cau se falls. Changes
in 1he cen t ral nervous and muscu l oskele t al systems make
older people more stiff and less coordinated than younger
adults, and older people may have an unsteady gait. Vi
sual, hearing, and memory i m pairments place older
adults at high risk for hazards that can cause falls . Fall s
res ul ti ng from dizziness or vertigo are extremely com
mon. F i n ally drugs incl uding alcohol-cause or con
, -
tribute to many fa l ls . Seemingly minor mechanisms of

injury can produce serious injury and complications be
cause of the effect of multiple medications, especially an
ticoagulants.
Annually i n the Un i ted States, more than 4000 elderl y
people are killed in motor vehicle crashes, either as dri vers
or p assengers l.n ad dition, 2000 elderly p eople are killed as
.
pedestri ans when struck by motor vehicles. The effects of

th<.: aging process are a major influence on the incidence of
in jury and death. Often, the el derly have dimin i shed visual
and audi tory acuity. Dayli ght acuity, glare resis tance , and
night vision decrease markedl y with age. Medical conditions
and their treatments may alter attention and consciousness.
Because of the onset of senile cha nges in the brain, judg
ment mav' be <ltered. Finally, there often is decreased ability
to implement appropriate actions because of i mpairment
from medical cond itions, including severe arthritis, osteo
porosis, emphysema, heart disease, and decreased muscle
mass.
TYPES AND PATIERNS OF INJURY 249
Brain mass Stroke
Eye disease Diminished hearing
Depth perception Sense of smell and taste

! Discrimination
Saliva production
of colors
Pupillary response Esophageal activity
I Respiratory ! Cardiac stroke

t vital capacity volume and rate
Renal function Heart disease and high

blood pressure
2- to 3-inch loss
in height Kidney disease
Impaired blood flow

to lower leg(s)
Gastric secretions
Degeneration I Number of
of the joints t body cells
Total body water ! Elasticity of skin

Thinning of epidermis
Nerve damage
(peripheral neuropathy) 1 5%-30% body fat
Figure 11-1 The Effects of Aging on Organ Systems.
Box 1 1 -1
Relationship between Age, Preexisting
Disease, and Mortality
Mea n age of pattents with preexisting disease Mortality rate for older pattents wtth preex1sting dis
49.2 ease 9.2%
Mean age of pat1ents w1thout preex1st1ng d1sease; Mortality rate for younger pat1ents w1thout preex
30.6 isting d1sease 3 2%
Source M1lzman DP, Boulanger BR, Rodnguez A, et al. Pre-ex1St1ng d1sease in trauma pat1ents a predictor of fate independent
of age and InJury seventy score. 1 Trauma 1992;31 236-244.
250 CHAPTER 1 1 G eriatric Trauma
Thermal injury is the third leading cause ofdeath due to fhe principles of airway management remain the same,
injury in the elderly, accounting for almost 2000 deaths an with endotracheal intubation as the preferred method for
nually. One-third of these individuab an: fatally injured definitive airway control. l f acute airway obstruction exists
whtlc under the influence of alcohol, while smoking ir1 bed, or the vocal cords cannot be vi:.unlized, surgical cricothy
or when exposed to heat and toxic products of combustion roidotomy should be performed. rl' Sec Chapter 2: Airway
while caught in a building fire. Of the remainder, the ma and Ventilatory Management, and Skill Station Ill:
jority sutain injury and death because of thc.:ir clothing Cricothyroidotomy, Skill lli-B: Surgical Cricothyroidotomy.
being ignited or because of prolonged contact with hot sub
stances. As with falls, factors associated with degenerative
disease and physical impairment appear to contribute sub
stantially to the rate ofthermal injury in the elderly. Elderly Breathing and Ventilation
person!> who come into contact with hot surfaces or liquids
or arc exposed to fire often are not able to remove them
Many of the changes that occw in the airway and lungs of el
selves until after extensive injury occurs. Finally, preexisting
derly patients are difficult to ascribe purely to the process of
cardiovascular, respiratory, and renal diseases often make it

aging and may be the result ofchronic exposure to toxic agents
impossible for the injured person to overcome serious but po
such as tobacco smoke and other environmental toxins
tentially survivable burns.
throughout life. The loss of respiratory reserve, due to the ef.
fects of aging and chronic diseases (eg, chronic bronchitis and
emphysema), makes careful monitoring ofthe geriatric patient's
respiratory system imperative. Administration ofsupplemen
Airway tal a>:ygen is mandatory, although caution should be exercised
with its use because some elderly patients rely on a hypoxic
How do I apply ATLS airway principles drive to maintain ventilation. Oxygen administration can re
to the treatment of elderly patients? sult in loss of this hypoxic drive, causing co retention and
respiratory acidosis. In the acute trauma situation, however,
The "A'' of the ABCDE mnemonic of the primary survey is the
hypoxemia should be corrected by admi.nistering oxygen while
a me in the elderly as for any other trauma patient. Establish
accepting the risk of hypercarbia. In these situations, if respi
ing and then maintaining a patent airway to provide adequate
ratory failure is imminent, intubation and mechanical venti
tissue oxygenation is the first objective. Supplemental oxygen
lation is necessary
hould he administered as soon as possible, even in the pres Chest injuries occur in patients ofall ages with similar fre
ence of chronic pulmonary diseae. Because of the elderly pa
quency, but the mortality rate for elderly patients is higher. Chest
tient\ likely limitation in cardiopulmonary reserve, early
wall injury withrib fractures or pulmonary contusions are com
intubation of the injured elder hould be considered for those
mon and not well tolerated. Simple pneumothorax and he
pre!>enting in hock. Early intubation <llso should be consid
mothorax also arc poorly tolerated. Respiratory failw-e may
ered for those with chest wall injury or alteration in the level
result from the increased work of breathing combined wi Lh a
of conciousness.
decreased energy reserve. Adequate pain control and vigorous
h:atures that a fect
f management of the airvvay in the eld
pulmonary toilet are essential for a satisfactory outcome. Pul
erly include dentition, nasopharyngeal fr.1gility, macroglossia
monary complications-such as atelectasis, pneumonia, and
(enl.lfgemcnt of tonh>ue), microstomia (!imall oral aperture),
pulmonary edema-occur in the elder!)' with great frequency.
and cervical arthritis. A lack of teeth can interfere with achiev
Marginal cardiopulmonary reserve coupled with overtealous
ing a proper seal on a face ma:.k. Consequently, whereas bro
crytalloid infusion increases the potential for pulmonary
ken dentures should be removed, intact well-fitted dentures are
edema and worsening of pulmonary contusions. Admission
often best left in place until after airway control is achieved.
to the hospital usually is necessary even with apparently. minor
Can. must be taken when placing nasogastric and nasotra
injuries.
cheal tubes because of na:.opharyngeal tissue friability, espe
cially around the 1 urbinatcs. Profuse bleeding can ensue,
complicating nn already dangerous situation. The oral cavity
may be compromised by either macroglossia, associated with PITFALLS
amyloH.Iosis or acromegaly, or miLrostomia, such as the con
Failure to recognize indications for early intuba
stricted, birdlike mouth of progressive systemic sclerosis. Fi
tion.
nally, arthritis can affect the temporomandibular joints and the
Undue manipulation of the osteoarthritic cervical
cervical spine, making endotracheal intubation more difficult
spine, leading to cord injury.
and increasing the risk ofspinal cord injury with manipulation
Failure to recognize the serious effects of rib frac
ofthe osteoarthritic spine. Degenerative changes and calcifi tures and lung contusion, which may require me
cation in laryngeal cartilage place the elderly population at chanical ventilation.
increased risk of injury from minor hlows to I he neck.
CIRCULATION 251
Circulation injury. Severely injured elderly patients with hypotension

and metabolic acidosis almost always die, especially ifthey
have sustained brain injury. folu id req uiremen ts-o nee
CHANGES WITH AGING corrected for the lesser, lean body mass-are simihu to
those of younger patients. Elderly patients with hyperten
As the heart ages, there is progressive loss of function. 13y
sion who are on chronic diuretic therapy may have a chron
I he age of 63 years, nearly 50% of the population has coro
ically contracted vascular volume and a serum potassium
nary artery stenosis. The cardial. index falls offlinearly with
deficit; therefore careful monitoring of the administration
age, and the maximal heart rate also begins to decrease from
of crystalloid solutions is important, to prevent electrolyte
about 40 years of age. The formula for maximal heart rate is
disorders.
220 minus the individual's age in years. Although the reaing
Isotonic electrol}1e solutiOn arc used for initial resu
heart rate varies little, the maximum tachycardic reponse
citation. Initially, I or 2 L arc administered rapidly while ob
decreases with age.
serving the parient's physiologic response. Further decisions
The cause of this diminution of function is multifac
with respect to fluid resuscitation are predicated on this ob
eted. With aging, total blood volume decreases and circula
Sec Chapter
served response . 3: Shock.
tion time increases. There is increasing myocardial stiffness,
The optimal hemoglobin level for an injured elderly pa
!>lowed clcctrophysiologic conduction, and loss of myocar
tient is a point of controversy. Many authors suggest that, in
dial cell mass. The response to endogenous catecholamine
people over the age of 65 years, hemoglobin concentration1.
release with stress is also different, which is likely related to
of over 1 0 g!dL should be maintained to maximite oxygen
a reduction in responsiveness of the cellular membrane re
carrying capacity and delivery. However, indiscriminate
ceptor. These changes predispose the aged heart to reentry
blood transfusion should be avoided because of the attendant
dysrhythmias. In addition, diastolic dysfunction makes the
risk ofbloodborne infections, its known impairment ofthe im
heart more dependent on atrial filling to increase cardiac
mune host response and its resulting complications, and the
output.
effect ofthe high hematocrit on blood viscosity, which can ad
In addition, the kidney loses mass rapidly after the age
versely affect myocardial fu nction. Early recognition and cor
or 50 years. This loss involves entire nephron unit's and IS
rection of coagulation defects is crucial, including reversal of
accompanied by a decrement in the glomerular filtration
drug-induced anticoagu lation.
rare and renal blood Ilow. Levels of serum creatinine usu
Because elderly patients may have significant limilation
ally remain within normal limits, presumably because of a
in cardiac reserve, a rapid and complete assessment fo1 all
reduction in creatinine production by muscles. The aged
sources of blood loss i ncceary. The focused assessment
kidney is less able to resorb sodium and excrete potassium
sonography in trauma ( FA')1) examin,ltion is <l rapid mc.tm
or hydrogen ions. The maximum concentration ability of
of determining the presence of abnormal intraabdomin;l)
the kidney of an octogenarian is only 850 mOsm/kg, which
fluid collections. When this i unavailable, diagnostic peri
is 70% of the ability of a 30-year-old kidney. A decrease in
toneal lavage (JJPL) may be of usc. There is at present little
the production of, and responsiveness of the kidney to, renin
role for nonoperative n<nagemcnt of blunt abdominal olid
and angiotensin occurs with age. As a result, creatinine clear
viscus injuries in elderly patients. The risk of nonoperative
ance in the elderly is markedly reduced, and lhe aged kidney
management may be greater than the risk of an early opera
is more susceptible to injury from hypovolemia, medica
tion.
tions, and other nephrotoxim.
The retroperitoneum is an often-unrecogni7ed source
of blood loss. Exsanguinating retroperitoneal hemorrhage
EVALUATION AND MANAGEMENT
may develop in elderly patients after relatively minor pelvic
A common pitfall in the evaluation ofgeriatric trauma patients or hip fractures. A patient with pelvic, hip, or lumbar verte
is the mistaken impression that "normal" blood pressure and bral fractures who demonstrates continuing blood loss with
heart rate indicate normovolemia. Early monitoring ofthe car out a specific source, especially after a negative DPL or FAST
diovascular system must be instituted. Blood pressure gen examination, should have prompt angiography and at
erally increases with age. Thus, a systolic blood pressure of tem pred control v1i th t n1 nscal heter ernbolization.
120 mm Hg can represent hypotension in an elderly patient The process of aging and superimposed disease states
whose normal preinjury systolic blood pressure was 1 70 to make close monitoring mandatory, especially in cases of in
180 mm Hg. A significant loss of blood volume can be jury with acute intravascular volume loss and shock. The
masked by the absence of early tachycardia. The onset of hy mortality rate in patients who on initial assessment appear
potension also may be delayed. In addition, the chronic high to be uninjured or to have only minor injuries can be sig
aftcrload state induced by elevated peripheral vascular re nificant (up to 44%). Approximately 33o/o of elderly patients
sistance can limit cardiac output and ulumately cerebral, do not die from direct consequences of their injury, hut
renal, coronary, and peripheral oxygen delivery. from "inexplicable" sequential organ failure, \:hich may re-
Geriatric patients have a I i 111 i ted physiologic reserve 11ect early, unsuspected states of hypoperfusion. lailme to
and may have clifculty generating an adequate response to recognize inadequate oxygen delivery creates a n oxygen
In the spine, the most dramatic changes occur in the

.--
intervertebral disks. Loss of water and proteins affects tl1e
-:.
:,_ ..:.. shape <md compressibility of the disks. These changes shift
Equating normal blood pressure with normo- the loads on the vertebral column to the facets, ligaments,
..
volemia.
and paraspinal muscles and contribute to degeneration of
Failure to recognize metabolic acidosis as a pre
the facet joints and development of spinal stenosis. Pro
dictor of mortality.
gressively, these alterations place the spine and spinal cord at
Failure to institute early hemodynamic monitor-
. increased risk for injury. This risk is increased in the pres
mg.
ence of osteoporosis, whether or not it is apparent radio
Failure to recognize the effects of indiscriminate
graphically. Finally, osteoarthritis may cause diffuse canal
blood transfusion.
stenosis, segmental immobilily, and kyphotic deformity,
which are most severe in the cervical region (Figure 1 1-2).
deficit from which the geriatric patient is not' able to recover. EVALUATION AND MANAGEMENT
Because of associated coronary artery disease, hypotension

from hypovolemia fTequently results in impaired cardiac Elderly patients witl1 brain injury have fewer severe cerebral
performance from myocardial ischemia. Thus, hypovolemic conLusions than do yOtmger patients. However, the elderly
and cardiogenic shock may coexist. Early anu aggressive in have a higher incidence of subdural and intraparenchymal
vasive monitoring, perhaps with a pulmonary artery hematoma. Subdural hematomas aJe nearly three limes as
catheter, may be beneficial. Hemodynamic resuscitation frequent in elderly as in younger patients, perhaps in part
may require the use ofinotropes after volume restoration in because elderly individuals are more likely to be taking an
these patients. Thus, prompt transfer to a trauma center may ticoagulant medications for cardiac or cerebral disease. Sub
be lifesaving. dural hematomas may produce a rather gradual onset of
neurologic decline, especially in elderly patients. In fact,
chronic subdural hematomas resulting from an earlier fall
may be lhe cause of the fall for which the patient is currently
being examined. CT scans of the head provide rapid, accu
Disability: Brain and rate, and detailed infonmll'ion on structural damage to the
Spinal Cord Injuries brain, skull, and supporting elements. Liberal usc of tllis ex-
CHANGES WITH AGING

Brain weight decreases about I Oo/o by 70 years of age, with
progressive loss of neurons, resulting in cerebral atrophy.
This loss is replaced by cerebrospinal Quid. Concomitantly,
the dura becomes tightly adherent to the skull. Although the
increased space created around the brain may serve to protect
it from contusion, it also causes stretching ofthe parasagittal
bridging veins, making them more prone to rupture on im
pact. This loss of brain volume also allows for more brain
movement in resp011Se to angular acceleration/deceleration.
Significant amounts of blood can collect around the brain
of an elderly individual before overt symptoms become
apparent
Cerebral blood flow is reduced by 20% by the age of70
years. This is further reduced if atheroma to us debris oc
cludes conducting arteries. Peripheral conduction velocity
slows as a result of demyel inization. Reduced acquisition or
retention of information can cause eli nically subtle changes
in mental status. Visual and auditory acuity declines, vibra
tory and position sensation is impaired, and reaction time
increases. In addition to complicating the evnluntion process Figure 1 1 -2 A sagitta I T2-weighted image shows
of injured elderly patients, these changes place the individ severe multilevel degenerative changes affecting disk
ual at greater risk for injury. Finally, preexisLing medical con spaces and posterior elements, associated with severe
ditions or their treatment may be a cause of confusion in central canal stenosis, cord compression and small foci
Lhe elderly. of myelomalacia at the C4-C5 level.
OTHER SYSTEMS 253
amination method is encouraged in elderly patients with population. These disorders are the most likely cause of re
brain injury.
See Chapter 6: Head Trauma. strictions in an mdividual's daily life and arc the key com
Cervical spine injuries appear to be more common in ponents of the lo' of independence. Aging results in the
cldcrlr trauma patients, although they may be mon: occult stiffening of ligaments, cartilage, intervertebral disk!., and
and particularl)' difficult to diagnose ii osteoporosis and os JOint capsule,. Deterioration of tendons, ligaments, and
teoarthrius arc present. Severe osteophytic disease makes joint capsules kads to an increased risk of injury, sponta
diagnolOis of fracture 1.hal1enging. Degeneration of interver neous rupture, and decreased joint stability. The risk of in
tebral ligaments can tncrcase the degree of intervertebral jury increa:;ts not on!} for the musculoskeletal system, but
!>Ubluxation that is physiologic. Preexisting canal stenosis also for the adjacent soft tissues.
due to anterior osteophyte and posterior ligamentous hy Aging l.cHises a general decline i n responsiveness to
pertrophy increases the risk for central and anterior cord many anabolic hormones and an absolute reduction in the
syndromes. These injuries often result from relatively mild levels of growth hormones. After the age of 25 year. mus
extension injuries after falls or rear-end. motor vehicle cle mass decreases by '1% every 10 yearl>. After the age of 50
crashes. Magnetic resonance imaging (MRI) is particularly years, 1he r1te is I ()tlfo per decade unless the levels of growth
useful for diagnosing these injuries. rfJ See Chapter 7: Spine factors are low, in which case the rate of decrease approaches
and Spinal Cord l'n1un1<L 35%J. This is manifested by a reduction in the size and total
number of muscle cells. Th: decrtase in muscle mass is di
rec11y corrcluted to the dccreac;c in strength seen with the
.
.tgmg pro..:es>.
Osteopormis results in a decrease of histologic normal
Exposure and Environment hone with a conequent loss of strength and resistance to
fractures. Thi disorder i endemic in the elderly population,
The skin and connective tissues of elderly individuals un clinically affecting almost 50% of these individuals. The
dergo extensive changes, including a decrease in cell num causes of osteoporosis mclude loss of estrogen hormones,
bers, to's of trength, and impaired function. The epidermal los of body mass, decreas1ng levels of physical activity, and
keratinocytes lose a significant proportion of their prolifer madequate consumpuon and inefficient use of calcium.
ative ability with ,tging. The dermis loses as much as 20o/o of The consequences of these changes on the muscu
its thickness, undergoe a signific<mt loss of vascularity, and loskeletal system are frequently disabling and at times dev
ha a marked decrease in the number of mat ceUs. These ast<lting. InJuries to ligaments :tnd tendons affect joints and
changes result in the loss of thermal regulatory ability, de adjaccnt soft Li'>sues. Osteoporosis contributes to the occur
creased barrier function against bacterial invasion, and sig rence of spontancous vertebra] compression fractures and
nificant impairment to wound healing. to the high incidence of hip fractures in the elderly. The
[njured elderly patients must be protected from hy yearly incidence approaches 1 o/o for men <md 2o/o for women
pothermia. Hypothermia not attributable to shock or expo over the age of 85 years. The case with which fractures occur
sure should alert the physician to the possibility of occult in the elderly patient magnifies the effect of force applied
disease-in particular, sepsis, endocrine disease, or drug during injury in these patients.
ingestion. Elderly individuals are particularly susceptible to frac
The potentitl for invasive bacterial infection through iJ1- tures ofthe long bones, with attendant disability and associ
jured skin must be rccognlzcd. Appropriate care, including as ated pulmonary morbidity and mortality. Early stabilization of
sessing tetanus immunization status to prevent infection, must these fractures may decrease this risk, provided the patient
be instituted early. rfJ Sec Appendi-x: E: Tetanus Immunization. is in an optimal hemodynamic state. Resuscitation should
be t.rgeted at normalizing tissue perfusion as early as pos
sible and before fracture fixation is performed.
The most common locations of fractures in elderly pa
tients are the proximal femur, hip, humerus, and wrist. Pa
Other Systems tients report pain in the area of the greater trochanter or
antenor pclvi\. In general, these individuals are unable to
Other sytems that warrant special attention with regard to walk. Isolated hip fractures do not usually cause dass III or
the treatment of elderly trauma patients include the mus IV shock. Neurovacular integrity should be assessed and
culoskeletal system, nutrition and metabolism, and the im compared with that of the opposite extremity.
mune system. hacturcs of the humerus usually are caused by falls on
an outstretched extremity. The resulting injury is a fracture
of the surg1cal neck of the humerus. Usually, there is pain
MUSCULOSKELETAL SYSTEM
and tcndcrnes!> in the Shoulder or upper humerus area. Of
Disorders of the musculoskeletal system are the most com major importance in the evaluation of tJJese patients b the
mon presenting symptom of the middle-aged and elderly determination of whether the fracture is impacted or non-
impacted. Impacted frac.tures demonstrate no false motion to respond to vaccination, and a lack of reliable response to
of the bumerus when the shoulder is rot<llcd gently from a ski n a nt igen testing. Clinically, elderly individuals are less
llexed elbow. Patients with nonimpacted fractures generally able to tolerate infection and more prone to multiple organ
experience pain on movement of the arm. These latter frac system failure. The ::bsence of fcver, leukoc..ytosis, and other
tures require hospitalization for orthopedic consultation manifestations of the inflammatory reponse may be due to
and often operation. poor immune function.
Calles' fracture results from a fall on the outstretched,
dorsiflexed hand, cnusing a metaphyseal fracture of the dis
tal radius. The classic finding of a fracture at the base of the
uln:: styloid process occurs in 69,1, of cases. Evaluation . Special Circumstances
should include careful testing of the median nerve and J
motor function of the finger flexors. The wrist should be ex

amined radiographically, and all of the ca rpa l bones should What are the special issues to consider
be visualized to exclude a more complex injury .
in treating geriatric trauma patients?

The aim oftreatment for musculoskeletal injuries should Special circumstances that r equi re consideration in t he
be to undertake the least invasive, most definitive procedure
treatment of elderly trauma patienb include medications,
that will permit early mobilization. Prolonged inactivity and elder abuse, and end-of-life decisiom..
disease often limit the ultimate functional outcome and im
pact survival.
MEDICATIONS
NUTRITION AND METABOLISM Concomitant disc::se may require the use of medications,
and elderly patien ts are often already taking many pharma
Caloric needs dedi ne with age, as lean body mass and meta cologie agents. Drug interactions are frequently encountered,
bolic rate gradually decrease. Protein requirements actually and side effects are much more common because of the very
may increase as a reult of inefficient utilization. There is a narrow therapeutic range in the elderly. Adverse reactions to
widespread occurrence of ch ronically inadequate nutrition some medications may even contribute to thl! injury-pro
among the elderly, and poor nutrition::( :;tatus contributes to ducing event. E-adrenergic blocking agents may limit
a significantly increased complication rnte. Early and ade chronotropic activity, and calcium-channel blockers may pre
quate nutritional support of injured elderly patients is a cor vent peripheral vasoconstriction and contribute to hypoten
nerstone of successful trauma care. sion. Nonsteroidal ::ntii ntlammatory agents may contribute
to blood loss because of their adverse effects on platelet
IMMUNE SYSTEM AND INFECTIONS
Mortality from most diseases increases with age. Wl1y this is
true is uncertain, but the loss of competence of the immune
system with age cenainlr plays a role. Thymic tissue is less
than 15% of its maximum by 50 years of age. Liver and
spleen size also decrease. With aging, cell-mediated and hu
moral immune response to foreign antigens is decreased,
whereas the response to autologous antigens is increased. It
is not clear whether aging alters granulocyte function, but
chronic diseases of the elderly, such as diabetes mellitus, may
do so. As a consequence, elderly persons have an impaired
ability to respond to bacteria and viruses, a reduced ability
PITFALLS
Failure to recognize that minimal trauma may re

sult in fractures and serious disability.
Poor hemodynamic reserve combined with under
estimation of blood loss from fractures may be
lethal.
SPECIAL CIRCUMSTANCES 255
function. Steroids and other drugs may further reduce the underreported. Many cases of abused elderly persons in
inflammatory and. immtme response. Long-term anticoag volve only subtle signs (eg, poor hygiene and dehydration)
ulant use may increase blood loss, and long-term diuretic and have great potential to go undetected. Physical abuse
use may render elderly patients dehydrated, leadin_g to total occurs in up to 14% of elder trauma, resulting in a higher
body deficits of potassium and sodium. Hypoglycemic mortality 1han in younger patients.
agents not only may contribute to the injury event itself but Physical findings suggesting elder abuse include:
also may make control of serum glucose difficult if their use
is unrecognized. Psychotropic medications, commonly pre Contusions affecting the iru1er arms, inner thighs,
scribed for elderly patients, may mask injuries or become palms, soles, scalp, ear (pinna), mastoid area, but
problematic if discontinued abruptly. Changes in central tocks, various planes of Lhe body, or multiple and
nervous system (CNS) function resulting from the use of clustered contusions
these medications also may contribute to the injury. Finallr,
Abrasions to the axillary area (from restraints) or
elderly individuals frequently neglect to keep their tetanus
the wrist <md ankJes (from ligatures)
immunization current.

Pain relief in injured elderly trauma patients should not Nasal bridge and temple injury (eyeglasses)
be neglected after resuscitation. Morphine is safe and effec
Periorbital ecchymoses
tive and should be given in small, titrated (0.5 to 1.0 mg) in
travenous doses. Antiemetic agents should be given with Oral injury
caution to avoid extrapyramidal effects. Finally, nephrotoxic
Unusual alopecia pattern
drugs (eg, antibiotics and radiographic dyes) must be given
in doses that reflect the elderly patient's decreased renal Untreated decubitus ulcers or ulcers in nonlum
fw1Ction, contracted intravascular volume, and other co bar/sacral areas
morbid conditions.
Untreated fractures
Fractures not involving the h.ip, htm1crus, or vertebra

ElDER ABUSE
lnj uries in various stages of evolution
When evaluating an injured elderly patient, consider that
the injury may have been inOicted intentionally. Abuse of Injuries to the eyes or nose
elderly individuals may be as common as child abuse. Abuse
Contact burns and scalds
is defined as any willful infliction of injury, unreasonable
confinement, intimidation, or cruel punishment thai resulls Scalp hemorrhage or hematoma
in physical harm, pain, mental anguish, or other willful dep
rivation by a caretaker. The presence ofthese findings should prompt a detailed
Elder abuse can be classified into six categories: history, which may be at variance with the physical findings
and may uncover a significant delay in seeking treatment.
Physical abuse These findings should prompt reporting and further investi
gation to confirm elder abuse. If present, appropriate action
Sexual abuse
should be taken, including removal ofthe elderly patient from
Neglect the abusive situation . The 2004 report of the National Cen
ter on Elder Abuse stated that 8.3 cases of abuse are reported
Psychological abuse
for every 1000 elder Americans, and several studies have re
Financial and material exploitation ported that only one of 13 or 1 4 cases of elder abuse is ever
reported. This statistic applies even though every state in
Violation of rights
United States mandates reporting of elder abuse. A multi-

disciplinary approach is required.
Often several types of abuse occur sinmllancously. Mul
tifaceted in cause, elder abuse often is not recognized and is
END-OF - LIFE DECISIONS
Many elderly patients return to their preinjury level of func
' tion and independence after recovering (rom injury. Age sig
PITFALLS ..... ...-
....
' ...
nificantly increases mortality from injury, but more aggressive
care, especially early in the evaluation and resuscitation of
Failure to take a drug history or note its impact on
hemodynamics and CNS find ings. elderly trauma patients, has been shown to improve survival.
Failure to titrate drug dosage, leading to in Attempts to identify which elderly trauma patients are at
creased incidence of side effects. greatest risk for mortality have not found much utility i n
clinical practice.
Certain ly there are circumstances in which the doctor The patien t s right to self-determination is para
'
and pa tien t or family member(s), may choose to forgo life

, mount.
saving measures and provide only supportive care. This deci
Medical interveution is appropriate only when it is
sion is particul arly clear in the case of elderly patients who.
i n the patient's best in tcrests.
have sustained extensive burns and when urvivaJ from the
injuries sustained is unprecedented. In other circumstances, it Medical therapy is appropriate only when its likely
can be more difficult to predict patient outcome or to be dog benefits outweigh its likely adverse consequences .
matic about therapy. ll1 many situations the doctor confronts
,
poorly defined probabilities. The trauma team should always The ethical issue of appropriateness of care in an envi
seek the existence of a living will, advance directives, or simi ronment of declining hospital resources and restrictions on
lar legal documents. Although no absol ute ethical guidel ines finances is more challenging.
can be given, the foUowing observations may be helpful:
CHAPTER SUMMARY
The number of elderly persons is increasing global ly Although the elderly are less likely
.
to be mjured than younger people, the mortality rate for the elderly population is higher .
Many geriatric trauma patients can be returned to their preli1JUry medical status and
independence. Knowledge of the changes that occur with aging, an appreciation of
the injury patterns seen m the elderly, and an understanding of the need for aggressive
resuscitation and monitoring of inj u red geriatric patients are necessary for improved
ou tcome.
Increased awareness of elder abuse, including the patterns of injury is necessary so
,
that reporting can be Improved. Th1s should lead to earlier diagnosts and improved treat
ment of elderly injured patients.
Anatomic and physiologic changes in the elderly are associated with increased morbid
ity and mortality following trauma. Comorbidity increases with age. Frequent use of
medications including beta-blockers and a nticoagu lants complicate assessment and
ma nagement.
Treatment of the geriatric trauma patient follows the same pattern as that for younger
patients, but caution and a high index of suspi cion for injuries specific to this age group
are req ui red for optimal treatment Comorbidities and medications may not only cause
but also compl icate injunes 1n the elderly. Careful volume resuscitati on with close he
modynamic monitonng should guide treatment.
0 Consider the possib ility of elder abuse and take appropriate action when assessing the
geriatric trauma patient
'
BIBLIOGRAPHY 257
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30. Mil7man OP. Boulanger BR, Rodriguez A, et al. Pre-exist
I I . DeGncde K1v1, Ashton-Miller I/\, Schultz AB. lall related ing disease in trauma patients: a predictor of fJtC indc
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15. DcMaritt Ll, Merriam MA, Casanov:t LA, et aL Do DRC pay
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258 CHAPTER 11 Geriatric Trauma
39. Scalea TM, Simon HM, Duncan AO, et al. Geriatric blw1t mul 44. van Aalst JA, Morris JA, Yates HI<, et al. Severely injured geri
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40. Schwab CVv, Kauder DR. Trauma in the geriatri c patient. Arcll

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82.
"oldest old" trauma patients. J Trauma 1995;39:254-259.
46. Wardle TO. Co-morbid factors in trauma patients Br Med Bull
42. Smith DP, Enders on BL, Maull Kl. Trauma in the elderly: de
.
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47. Zietlow SP, Capizzi PJ. Banno n M P, et al. Multisystem geriatric
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cimt's Perspecti11e 011 A1edical Law. Park Ridge, IT.: American As
sociation of Neurological Surgeons; 1997.

C HAPTE R
CHAPTER OUTLINE Upon completion of th is topic, the st udent will demonstrate

the ability to i n 1t ia l ly assess and treat a pregnant trauma pa
Objectives
tient and her fetus. Speci fica lly the doctor will be able to:
,
Introduction
Anatomic and Physiologic Alterations of Pregnancy OBJECTIVES
Anatomic Differences
Blood Volume and Composi tion Describe the anatomic and physiologic alterations
Hemodynamics of pregnancy, including their effects on patient
Respiratory System treatment.
Gastrointestinal System
Urinary System Identify common mechanisms of i nj ur y to the
Endocrine System pregnant patient and her fet us.
Neurologic System
Outline the treatment priorities and assessment
methods for both patients (mother and fetus).
Mechanisms of Injury
Blunt Injury Identify the indications for operative intervention
Penetrating Injury that are unique to injured pregnant patients .
Severity of Injury Explain the potential for isoimmunization and the

Assessment and Treatment need for immunoglobulin therapy in pregnant
Primary Survey and Resuscitation trauma patients.
Adjuncts to Primary Survey and Resuscitation
Secondary Assessment Identify patterns of domestic violence.
Definitive Care
Perimortem Cesarean Section
Domestic Violence
Chapter Summary
Bibliography
260 CHAPTER 1 2 Trauma in Women
Introduction Anatomic and Physiologic

Alterations of Pregnancy
Any female patient bctw<.'en the ages of 10 and 50 years can
be pregnant. Pregnancy causes major phys iologic changes
and altered anatom1c relationships involving nearly every
I What changes occur with pregnancy?
organ system of the body. These changes of structure and An undcr!>tclllding of the anatomic and physiologic alter
funct1on can inOuence the evaluation of injured pregnant ations of pregnancy, as weiJ as of the physiologic relationship
patients by altering the sign!> and symptoms of injury, the between a pregnant patient and her fetus, is essential to serve
approach <lnd response!> to resusci tat ion and the results of
,
the best interests of both patients. Such alterations include
diagnostic tests. Pregnancy abo can affect the patterns and differences in anatomy, blood volume and composition, and
severity of injury. The doctor attending a pregnant trauma hemodynamics, as well as changes in the respiratory, gas
patient must remember th<ll there nre two patients: mother trointestinal, urinary, endocrine, musculoskeletal, and neu
and fetus. Nevertheless, initial treatment priorities for an rologic systems.
injured pregnant patient remain the same as for the non
pregnant patient. The best initial treatment for the fetus is ANATOMIC DIFFERENCES
the provision of optimal resuscitation of the mother and
early assessment of the fetus. Monitoring and evaluation The utcru!> rcnhlins an intrapdvic organ until approximately
techniques should allow assessment of the mother and the the 12th week of gestation, when it begins to rise out of the
fetus. I f x-ray cxam111ation is indicated during critical pelvis. By 20 weeks, the uterus is at the umbilicus, and at 34
management, it should not be withheld because of the to 36 weeks, it reaches the costal margin (Figure 12-1 ). Dur
pregnancy. A qualified surgeon and an obstetrician should ing the last 2 weeh of gestation, the fundus frequently de
be consulted early in the evaluation of pregnant trauma scend a!> the fetal head engages the pelvis. As the uterus
patients. enlarges, the bowd i pmhed cephalad, so that tl1e boweJ lies
'
I
\
\I
(1
I
Umbilicus ----f-
\) I
I) t
(maternal )
I
/
'
Symphysis /)
pubis
Figure 12-1 Changes in Fundal
Height in Pregnancy. As the uterus en
t
larges, the bowel is pushed cephalad, so
I \ that it lies mostly in the upper abdomen.
As a result, the bowel is somewhat pro
tected in blunt abdominal trauma,
whereas the uterus and its contents (fetus
and placenta) become more vulnerable.
ANATOMIC AND PHYSIOLOGIC ALTERATIONS OF PREGNANCY 261
mostly Ln the upper abdomen. As a result, the bowel is some

what protected i11 blunt abdominal trauma, whereas the TABLE 12 1 Normal laboratory Values
uterus and its con tents (fetus and placenta) become more during Pregnancy
vulnerable. I fowever, penetrating trauma to the uyper ab
domen during late gestation may result in complex intes Hematocrit 32%-42%
tinal injury because of this cephalad displacement.
During the first trimester, the uterus is a thick-walled WBC count 5000- I 2.000 I L
structure of limited size, confined within the bony pelvis.
During the second trimester, it enlarges beyond its protected Arterial pH 7.40-7.45
int rapelvic location, but the small fetus remains mobile and
cushioned by a generous amount of amniotic fluid. The am Bicarbonate 17-22 mEq/L
nilJtic fluid may cause amniotic fluid embolism and dis
seminated intravascular coagulation following trauma if lhe 25 30 mm Hg (3.3-4 1<Pa)
-
fluid gains access to the maternal intravascular space. By the

third trimester, the uterus is large and thin-walled. In the

vertex presentation, the fetal head is usua l l y within the
pelvis, with the remainder of the fetus exposed above the
pel vic brim (Figure 12-2). Pelvic fracture(s) in late gestation pressure, venous pressure, and electrocardiographic
may result in skuJJ fracture M serious intracranial injury to changes.
the fetus. Unlike lbc clastic myometrium, the placenta ha
little elasticity. This lack of placental elastic t issue results in Cardiac Output
vulnerability to shear forces at the uteroplacental interface,
After lhe lOth week of pregnru1cy, cardiac output .:ru1 be in
which may lead to abruptio placentae. The placental vascu
creased by 1.0 to 1.5 L/min because of tbe increase n
i plasma
lature is maximally dilated throughout gestation, yet it is ex
volume and decrease in vascular resistance of the uterus and
quisitely sensitive to catecholamine stimulation. An abrupt
placenta, which receive 20% of the patient's cardiac output
decrease i n maternal intravascular volume can result in a pro
during the third trimester of pregnancy. This increased out
found increase in uterine vascular resistance, reducing fetal
put may be greatly inlu.enced by the mother's position dw
oxygenation despite reasonably normal maternal vital signs.
ing the second half of pregnancy. In the supine position, vena
cava compression can decrease cardiac output by 30/o be
BLOOD VOLUME AND COMPOSITION cause of decreased venous return from tJ1e lower extremities.
Plasma volume increases steadily throughout pregnancy and

plateaus at 34 weeks of gestation. A smaller increase in red Heart Rate
blood-cell (RBC} volume occurs, resu! Ling i n a decreased Hearl rate increases gradually, by I 0 to 15 beats/min, during
hematocrit (physiologic anemia of pregnancy). l n late preg pregnancy, reaching a maximum rate by the third trimester.
nancy, a hematocrit of 3 I o/o to 35'Jio is normal. Otherwise This change in heart rate must be considered when inter
hcallhy pregnant patients can lose 1 200 to 1500 mL nf their preting the Lachycardic response to hypovolemia.
blood volume before exhibiting signs and symptoms of hypo
volemia. However, this aJ110Wlt ofhemorrhage maybe reflected Blood Pressure
by fetal distress evidenced by an abnormal fetal heart rate.
Pregnancy results in a 5 to 15 mm Hg full in systolic and di
The white-blood-cell (WBC) count increases during
astolic pressures during the second ttimester. Blood pressme
pregnancy. I t is not unusual to see \NBC counts of
returns lo near-normal levels at lerm. Some pregnant women
1 5,000/mm1 during pregnancy or as high as 25,000/mm1
exhibit hypotension when placed in t11e supine position
during labor. Levels of serum fibrinogen and other clotting
(supine hypotensive syndrome), caused by compression of
factors aTe mildly elevated. Prothrombin and pctrtial throm
the inferior vena cava. This hypotension is corrected by re
boplastin limes may be shortened, but bleeding and clotting
lieving uterine pressure on the interior vena cava, as desc.:Tibed
time1. are tmchanged. The serum albumin level falls to 2.2 to
later in his
t chapter. The normal changes in blood pressure,
2.8 g/dL during pregnancy, causing a drop in serum prQtein
pulse, hemoglobin, ru1d hematocrit du.ring pregna11cy must
levels by approximately 1.0 g/dL. Serum osmolarity remains
be iJJterpreted caref
ully in pregnant trauma patients.
at about 280 mOsm/L throughout pregnancy. Table 12-1
outlines normal laboratory values during pregnancy.
Venous Pressure
The resting central venous pressure (CVP) is variable with
HEMODYNAMICS
pregnancy, but the response to volume is the same as in the
Important hemodynamic factors t o consider in pregnant nonpregnant state. Venous hypertension in the lo>ver ex
trauma patients include cardiac output, heart rate, blood tremities is present during the third trimester.
\
Wall of--+-1-!
uterus
Umbilical
cord
Cervix
Vagi Perineum
Figure 1 2-2 Full-Term Fetus in Vertex Presentation. Note the displacement and compression of the abdomi
nal viscera. Most of the viscera would be displaced cephalad. You cannot see them in this picture.
Electrocardiographic Changes vessels seen on chest x-ray examination. Oxygen con

The axis may shift leftward by approximately 15 degrees. sumption is increased during pregnancy. Therefore, it is
important to maintain and ensure adequate arterial oxy
Flattened or inverted T waves in leads III and AVF and the
genation during the resuscitation of the injured pregnant
precordial leads may be normal. Ectopic beats are increased
patient.
during pregnancy.
GASTROINTESTINAL SYSTEM
RESPIRATORY SYSTEM
Gastric emptying Lime is prolonged during pregnancy, and
.
Minute ventilation increases primarily as a result of an in doctors should always assume that the stomach of a preg-
-
crease in tidal vollum: because of increased levels of pro nant patient is fi.lll. Therefore, early gastric tube decom
gesterone dming pregna_ncy. Hypocapnja (Paco2 of 30 mm pression is particuJarly important to avoid the aspiration of
Hg) is therefore common in late pregnancy. A Paco of35
. gastric contents. The intestines are reJocated to the upper
to 40 mm Hg may indicate i m pending respiratory fai lure part of the abdomen and may be shielded by the uterus. The
during pregnancy. Although the forced vital capacity fluc position of the patient's spleen and liver are essentially un
tuates slightly during pregnancy, it is largely maintained changed by pregnancy.
throughout pregnancy by equal and opposite changes in
inspiratory capacity (which increases) and residuaJ volume
URINARY SYSTEM
(which decreases). Anatomic alterations in the thoracic
cavity appear to account for the decreased residuaJ volume The glomerular filtration rate and renal blood flow increase
that is associated with diaphragmatic elevation with in during pregnancy, whereas Jevels of creatinine and serum
creased lung markings and prominence of the pulmonary urea nitrogen fall to approximately half of normal prepreg-
MECHANISMS OF INJURY 263
PITFALLS TABLE 122 Incidence of various Types of

Blunt Trauma in Pregnancy
Not understanding the anatomic changes that
occur during pregnancy
TYPE OF TOTAL
Not recognizing that a normal PaC02 may indicate
BLUNT TRAUMA NUMBER PERCENTAGE
impending respiratory failure during pregnancy
Mistaking eclampsia for head injury
Motor vehicle
accidents/pedestrians 1098 59.6
nancy levels. Glycosuria is common during pregnancy. Falls 41 1 22.3

There is a physiologic dilatation of the renal calices, pelves,
and ureters outside of the pelvis, which may persist for sev Direct assaults 308 16.7
eral weeks following pregnancy. Because of frequent dex
trorotation of the uterus, the right renal collection system Other 24 0.1
is often more clikllcd than the lefL.
Sourc. Shah AJ. Kllchne BA Trauma In nregnancy. Emerg Med Clln N Am
2003,21 61 S-29
ENDOCRINE SYSTEM
The pituitary gland increases in size and weight by 30% to
50% during pregnancy. Shock can cause necrosis of the an jury from blunt trauma. Nonetheless, fetal injuries may
terior pituitary gland, resulting in pituitary insufficiency. occur when the <lhdominal waU strikes an object, such as the
dashboard or steering wheel, or when a pregnant patient is
MUSCULOSKELETAL SYSTEM struc.k by a blunt instrument. indirect injury to the fetus
may occur from rapid compression, deceleration, the con
The symphys1s pubis w1dens to 4 to 8 mm, and the sacroil trecoup effect, or a :.hearing force resulting in abruptio
iac joint spaces increase by the seventh month of gestation. placentae.
These factors must be considered in interpreting x-ray films Compared with restrained pregnant women involved
of the pelvis. in collision:., unrestrained pregnant women have a higher
risk of prcmctturc delivery and fetal death. The type of re
NEUROLOGIC SYSTEM straint system affects the frequency of uterine rupture and
fetal death. The usc of <l lap belt alone allows forward Oex
Eclampsia is a complication of late pregnancy that can ion and uterine compression with possible uterine rupture
mimic head injury. It should be considered if seizures occur or abruptio placentae. A lap belt worn too high over the
with nssociatccl hypertension, hyperrcQexia, proteinuria, and uterus may produce uterine ruptwe because of the trans
peripheral edema. Expert neurologic and obstetric consul mission of direct I:Orce to the uterus on impact. The usc of
tation frequently is helpful in differen tiating between shoulder restraints in conjunction wilh the lap belt reduces
eclampsia n nd other causes of seizures. the likelihood or direct and indirect fetal injury, presumably
because of the greater surface area over which the decelera
tion force is dissipated, as well as the prevention of forward
flexion of the mother over the gravid uterus. Therefore, de
Mechanisms of Injury termination of the type of restraint device wom by the preg
nant patient, if any, is important in the overall assessment.
IJ What are the unique risks There does not appear to be any increase in pregnancy
specific risks from the deployment of airbags in motor
of pregnancy?
vehicle.
Most mechanisms of injury are imilar to those sustained
by nonpregnant patients, but certain differences must be
PENETRATING INJURY
recognized in pregnant patients who sustain blunt or pene
trating injury. As the gravid uterus increases in size, the other viscera are
relatively protected from penetrating injury, whereas the
likelihood of uterine injury increases. The dense uterine
BLUNT INJURY
musculature in early pregnancy can absorb a great amount
The incidence of various types of blunt trauma in pregnancy of energy from penetrating missiles, decreasing missile ve
is outlined in Table 12-2. The abdominal wall, uterine myo locity and lesening the likelihood of injW'y to other viscera.
metrium, and amniotic fluid act as buffers to direct fetal in- The amniotic lluid and conceptus also absorb energy and
264 CHAPTER 12 Trauma in Women
contribute to slowing of the penetrating missile. The result

ing low incidence of associated maternal visceral inju ries ac -
counts for the generally excellent maternal outcome in Lhe

penetrating wounds of the gravid uterus. However, the fetus

generally fares poorly when there is a penetrating injury to

the uterus.
Severity of Injury
The severity of maternal injuries determines maternal and

fetal outcome. Therefore, treatment methods also depend
on the severity of maternal injuries. All pregnant patients
with major injuries require admission to a facility wilh

Figure 12-3 Proper Immobilization of a Preg
trauma and obstetric capabilities, since there is an increased
nant Patient. If the patient requires immobilization in
maternal and fetal mortality rate in this group of patients.
Eighty percent of pregnant women who survive hemor
a supine position, the patient or spine board can be
rhagic shock will experience fetal death. Even the pregnant
logrolled 4 to 6 inches (or 1 5 degrees) to the left and
supported with a bolstering device, thus maintaining
patient with minor in,iuries should be carefully observed,
spinal precautions and decompressing the vena cava.
since occasionally even minor injuries are associated with
abruptio placentae anJ fetal loss. Direct fetal injuries usually
occur in late pregnancy and are typically associated with
serious maternal trauma. tachycardia, hypotension, and other signs of hypovolemia
occur. Thus, the fetus may be i n distress and the placenta de
prived ofvital perfusion while the mother's condition and vital
signs appear stable. Crystalloid fluid resuscitation and early
Assessment and Treatment type-specific blood administration arc indicated to support
the physiologic hypervolemia of pregnancy. Do not admin
;) How do I evaluate and treat two ister vasopressors to restore maternal blood pressure, be
cause these agents further reduce uterine blood flow,
patients? resulting in fetal hypoxia. As intravenous Lines are started,
For optimal outcome of mother and fetus, it is recommended blood samples should be drawn for appropriate laboratory
that doctors assess and resuscitate the mother first, and then analyses, including type and crossmatch, toxicology studies,
assess the fetus before conducting a secondary survey of the and fibrinogen level s.
mother.
Fetus
PRIMARY SURVEY AND RESUSCITATION The abdominal examination during pregnancy is critically
important, as rapid identification of serious maternal in
Mother juries and fetal well-being depend on a thorough evaluation.
Ensure a patent airway, adequate ventilation and oxygena The main cause of fetal death is maternal shock and mater
tion, and effective circulatory volume. If ventilatory support nal death. The second most common cause of fetal death is
is required, intubation is appropriate for the pregnant pa placental abruption. Abruptio placentae is suggested by
tient, and consideration should be given to hyperven tilating vaginal bleeding {70o/o of cases ), uterine tendcmess, frequent
her. See Chapter 2: Air way and Ventilatory Management. uterine contractions, uterine tetany, and uterine irritability
Uterine compression of the vena cava may reduce ve (uterus contracts when touched). rn 300;(> of abruplions tol
nous return to the heart, thereby decreasing cardiac output lovoing trauma, vagina] bleedjng may not occur. Uterine ul
and aggravating the shock slate. The uterus should be dis trasonography may demonstrate the lesion, but t.he test is
placed manually to the left side to relieve pressure on the in not defmitive. Late in pregnancy, abruption may occm fol
ferior vena cava. If the patient requires immobilization in a lowing relatively minor inj uries .
supine position, the patient or spine board can be logrolled Uterine rupture, a rare injury, is suggested by findings
4 to 6 inches (or I S degrees) to the left and supported with of abdominal tenderness, gumding, rigidity, or rebound ten
a bolstering device, thus maintaining spinal precautions and derness, especially if there is profound shock. Frequently,
decompressing the vena cava (Figure 12-3). peritoneal signs are difficult to appreciate in advanced ges
Because of their increased intravascular volume, preg talion because of expansion and attenuation of the abdom
nant patients can lose a significant amount of blood before inal wall musculature. Other abnormaJ findings suggestive
ASSESSMENT AND TREATMENT 265
of uterine rupture include abnormal Ictal lie (eg, oblique or Assessment and f\lanagcmcnt. Indications for abdominal
tranver1>e lie), easy palpation of fetal parts because of their computed tomography, focu>cd assessment sonography in
extrauterine location, and inabil1ty to readily palpate the tr;luma, and diagnostic peritoneal lavage (DPL) arc the
uterine fundus when there i fund.tl rupture. X-ray evidenet: same. However, if DPL is performed, the catheter should be
of rupture includes extended fetal extremities, <lb normal placed above the umbilicus using the open technique. Pay
fetal position, and free intraperitoneal air. Operative explo c.:nreful attention to the presence of uterine contractions sug
ration may be necessary to diagno>e uterine mpturc. gesting early labor or tclank contractions suggcsling pla
In most cases of either abruptio placentae or uterine cental abruption. Evalu.uion of the perineum hould
rupture, the patient reports abdominal pain o r cramping. include a formal pelvic examination, ideally performed by a
\)igns of hypovolemia can accompany each of thee lllJUrtes. doLtor skilled in obstetric care. The presence of amn1otic
Initial fetal heart tones c:an be auscultated with Doppler fluid in the vagina, evidenced by a pH of 7 to 7.5, suggest
ultrasound at 10 weeks of gestation. Continuous fetal moni ruptured chonoamnionic membranes. Cervical effacement
toring should be performed heyond 20 to 24 weeks of gesta and c..Wation, fetal presentation, and the relation.!>hip of the..
tion. Patients with no risk factors for fetal loss should have fetal presenting part to the ischial spines should he noted.
continuous monitoring for 6 hours, whereas patients with risk Because vaginal bleeding in the third trimester may indic.:.llt'
factors for fetal loss or placental abruption should be moni disruption of the placen ta and impending death of tb let us,
tored for 24 hours. The risk factors arc maternal heart rate a vaginal examination is vital. Repeated vaginal examin.1
> I I 0, an Injury Severity Score >9, evidence of placental abrup lions should be avoided. The decision regarding an emer
lion, fetal heart rate > 160 or 120, ejection during a motor gency cesarean section should he made with advice from an
vc:hicle accident, and moton.:ycle nr pedestrian collisions. obstetrician.
Admission to the hopital is mandatory in the pnsenc(
or vaginal bleeding, uterine irritability, abdominal tender
ADJUNCTS TO PRIMARY SURVEY n1.-ss, pain or cramping, evidcm:e of hypovolemia, ch.mges Ill
AND RESUSCITATION or ab:.ence of fetal heart tones, or leakage of amnioti<. lluid
Mother Care should be provided 1. 1 a facility with appropriate fetal
and maternal monitoring and treatment capabilit ies. The
If possible, the patient should be monitored on her left side after
fetus may be in jeopardy even with ap parently minor mater
physical examination. Monitoring of the CVP response to nuid
nal injury.
challenge may be valuable in maintaining the relative hypcrv
olcmia required in pregnancy. Monitoring should include pulse
oximetry and arterial blood ga:. determinations. Remember, DHINITIVE CARE
maternal bicarbonate is norm.11ly low during pregnancy.
Obstetric consultation should he obtained whenever spe
tifk uterine problems e:-.ist or are suspected. \'\1ith extensive
Fetus placental separation or amniotic Ouicl embolization, wide
Obstetric consultation .should be obtained, since fetal distress spread intravascular dotting may develop, causing deple
can occur at any time and without warning. Fetal heart rate is tion of fibrinogen ( <250 mg/dL), other clotting factors, and
,1 :-emit ive indicator of both maternal h.lood volume status platelets. This consumptive coagulopathy can emerge rap
and fetaJ well-being. Fetal heart tones should be monitored idl)'. ln the presence of life threatening amniotic fluid em
in every injured pregnant woman. Lntennillent and repeated bolism and/or disseminated intravascuJar coagulation,
Doppler examination can be used to detect fetal heart tones uterine evacuation should be accomplished on an urgent
after I 0 weeks ofgestation. Continuous fetal monitoring with bais, along with replacement of platelets, fibrinogen, and
a cardiac tocodynamometer b useful after 20 to 24 weeks of other clotting factors if necessar}.
gestation. The normal range for fetal heart rate is 120 to 160 Consequences of fetomaternal hemorrhage include
beats/min. An abnormal fetal heart rate, repetitive decelera not only fetal anemia and death, but also'isoimmuniza
tions, absence of accelerations (1r heat-to-beat variability, and lion if the mother is Rh-negative. Because as little as 0.01
frequent uterine activity can be signs of impending materr1<1l m L of Rh-positivc blood will sensitize 70% of Rh-nega
and/or fetal decompensation (cg, hypoxia and/or acidosi) tive patients, the presence of fetomatcrnal hemorrhage in
.md .should prompt immedial obstetric consultation. an Rb- ncgative mother should warrant Rh im
Indicated radiographic tudies shouJd be performed, be munoglobulin therapy. Although a positive Klcihauer
cauc the benefits certainly outweigh the potential rik to the Betke test (a maternal hlood smear allowing detection of
fetus. However, unncccsary duplication of films should be fetal RBCs in the maternal circulation) indicates fetoma
<Ivoided. ternal hemorrhage, a negati\'e test does not exclude
minor degrees of fetomaternal hemorrhage that .lrl'
c.1pablc of sensitizing the Rh- negative mother. All
SECONDARY ASSESSMENT
pregnant Rh-negative trauma patients should receive
Thc maternal secondary survey should follow the same pa 1- Rh immunoglobulin therapy unless the injury is remote
tern as for nonpregnant patients. _. See Chapter I: Lniti<ll from the uterus (eg, isolated distal extremity inj ury). lm-
266 CHAPTER 12 Trauma in Women
Domestic Violence
PITFALLS
Failure to recognize the need to displace the
uterus to the left side in a hypotensive pregnant
IJ How do I recognize domestic violence?

patient. Domestic violence is a major cause of injury to women during

Fail ure to recog n ize need for Rh imm uno globu l in cohabitation, marriage, and pregnancy regardless of ethnic
therapy in an Rh-negative mother. background, cultural influences, or socioeconomic status. Sev
en teen percent of injured pregnant patients experience tratuna
inflicted by another person, and 60% of these patients ex-peri
ence repeaLed episodes of domestic violence. According lo es
munoglobulin therapy should be instituted within 72
timates from tl1e U.S. Department of Justice, 2 million to 4
hours of injury.
million incidents of domestic violence occm per year and al
The large, engorged pelvic vessels that surround the
most half of all women over their lifetimes are abused in some
gravid uterus can contribute to massive retroperitoneal
manner. As with child abuse, this information must be iden
bleeding after blunt trauma with associated pelvic fractures.
tified and documented. These attacks can result in death and

Initial management is directed at resuscitation and stabiliza
disability. They also represent an increasing number of emer
tion ofthe pregnant patient because the fetal life at this point
gency department (ED) visits.
is totally dependent on the mother's condition. Fetal moni
Indicators that suggest the presence of domestic vio
toring should be maintained after satisfactory resuscitation
lence include:
and stabilization of the mother. The presence oftwo patients
(mother and fetus) and the potential for multiple injuries em Injuries inconsistent with the stated history
phasize the importance of a surgeon working in concert with Diminished self-image, depression, or suicide at-
an obstetric consultant. tempts
Self-abuse
Frequent ED or doctor's office visits
Perimortem Cesarean Section Symptoms suggestive of substance abuse

Self-blame for injuries
There are few data to support peri mortem cesare<m section Partner insists on being present for interview and
in pregnant tratmla patients who experience hypovolemic examination and monopoUzes discussion
cardiac arrest. Remember, fetal distress can be present when These indicators raise the suspicion of the potential fo r
the mother has no hemodynamic abnormalities, and pro domestic violence and should serve to initiate further in
gressive maternal instability compromises fetal survival. At vestigation. The lhree questions in Box 12-1, when asked in
the time of maternal hypovolemic cardiac arrest, the fetus a nonjudgmental manner and without the patient's partner
already has suffered prolonged hypoxia. For other causes of being present, can identify 65o/o to 70% of domestic violence
maternal cardiac arrest, perimortem cesarean section occa victims. Suspected cases of domestic violence should be
sionally may be successful if performed within 4 to 5 min handled through local sociaJ service agencies or the state
utes of the arrest. health and htUllaJ1 services department.
Box 1 2-1
Partner Violence Screen
0 Have you been kicked, hit, punched, or other f) Do you feel safe in your current relationship?
wise hurt by someone within the past year? If
so, by whom?
0 Is there a partner from a previous relationship
who is making you feel unsafe now ?
Reprinted with permission from Feldhaus KM, Kozioi-Mclain J, Amsbury HL, el al. Accuracy of 3 brief screening questions for
detecting pa rtner Violence in the emergency department. lAMA 1997; 277: 13 57-1361 .
CHAPTER SUMMARY 267
CHAPTER SUMMARY

Important and predictable anatomic and physiologic changes occur during pregnancy
that can influence the assessment and treatment of injured pregnant patients Attention
also must be directed towa rd the fetus, the second patient of this unique duo, after its
environment is stabilized. A qualified surgeon and an obstetrician should be consulted
early in the evaluation of pregnant trauma patients.
The abdominal wall, uterine myometrium, and amn1otic fluid act as buffers lo direct
fetal injury from blunt trauma. As the gravid uterus increases in size, the remainder of
the abdominal viscera are relatively protected from penetrating injury, whereas the like

lihood of uterine injury increases.
Vigorous fluid and blood replacement should be given to correct and prevent maternal
and fetal hypovolemic shock. Assess and resuscitate the mother first, and then assess the
fetus before conducting a secondary survey of the mother.
A search should be made for conditions unique to the injured pregnant patient, such as
blunt or penetrating uterine trauma, abruptio placentae, amniotic fluid embolism, iso
immunization, and premature rupture of membranes.
Mmor degrees of fetomaternal hemorrhage are capable of sensitizing the Rh-negative

mother. All pregnant Rh-negative trauma patients should receive Rh immunoglobulin
therapy unless the inJury is remote from the uterus.
Presence of indicato rs that suggest domestic violence should serve to mitiate further in
vestigation and protection of the victim.
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C H A PT E R
CHAPTER OUTLINE Upon completion of this topic, the student will demonstrate
the abi l ity Lo explain and apply general principles for the safe
Objectives
Lransfer of inJured palients to definitiVe care Specifically, the
Introduction doctor w1ll be able to:
Determining the Need for Patient Transfer
Timel1ness ofTransfer OBJECTIVES
Transfer Factors
Transfer Responsibilities Identify injured patients who require transfer
Refernng Doctor from a primary care institution to a facility capa
Rece1ving Doctor ble of providing the necessary level of trauma
care.
Modes of Transportation
Transfer Protocols
Initiate procedures to optimally prepare trauma
Information from Referring Doctor patients for safe transfer to a higher-level trauma
Information to Transferring Personnel care facility via t he appropriate mode of trans
Documentation
portation.
Treatment Prior to Transfer
Treatment During Transport
Transfer Data
Chapter Summary
Bibliography

270 CHAPTER 1 3 Transfer to Definitive Care
Introduction Determining the Need

for Patient Transfer
The Advanced Trauma Life Support course is designed to
train doctors to be more proficient i n assessing, stabilizing, The vast majority of patients receive their total care in a local
and preparing trauma patients for definitive care. Definitive hospital, and movement beyond that point is not necessary.
. .
care, whether support and monitoring n i an intensive care It is essential that doctors assess their own capabilities and
unit (ICU) or operative intervention, requires the presence limitations, as well as those of their institution, to allow for
and active involvement of a surgeon and the traw11a team. early recognition ofpatients who may be safely cared for in the
If definitive care cannot be rendered at a local hospital, the local hospital and those who require transfer for definitive
patient requires transfer to a hospital that has the resources care. Once tl1e need for transfer is recognized, arrangements
and capabilities to care for the patient. Ideally, this facility should be expedited and not delayed for diagnostic proce
should be a verified trauma center, the level of which de dures (eg, diagnostic peritoneal lavage [DPL] or computed
pends on the patient's needs. tomographic [CTl scan) that do not change the immediate
The decision to transfer a patient to another facility plan of care.

depends on the patient's injuries and the local resources.
Decisions as to which patients should be transferred and
when transfer should occur are matters of medical judg TIMELINESS OF TRANSFER
ment. Evidence supports the view that trauma outcome IJ When should I transport the patient?
i s enhanced if critically injured patients are cared for in
trauma centers. Therefore, trauma patients should be trans Patient outcome is directly related to the time elapsed be
ferred to the closest appropriate hospital, preferably a ver tween injury and properly delivered definitive care. ln in sti
ified trauma center. .. See American College of Surgeons tutions in which there is no full-time, in-house emergency
(ACS) Committee on Trauma, Resources for Optimal department (ED) coverage, the timeliness of transfer is
Care of the Injured Pa tien t; Guidelines for Trauma Sys partly dependent on the how quickly the doctor on call can
tem Development and Trauma Center Verification reach lhe ED. Consequently, effective communication with
Processes and Sta11dards. the prehospital system shouJd be developed to identify pa
A major principle of trauma management is to do no tients who require the presence of a doctor i n the ED at the
further harm. [ndced, the level of care of trauma patients time of arrival. In addition, the attending doctor must be
should consistently improve with each step, from the committed to respond to the ED prior to the arrival of crit
scene of the incident t o the facility that can provide the ically injured patients. Identification of patients who require
patient with the necessary, proper treatment. All providers prompt attention can be based on physiologic measure
who care for trauma patients must ensure that the level ments, specific identifiable injuries, and mechanism of

of care never declines f:rom one step to the next. UlJUry.

The liming of interhospitaJ transfer varies based on the
distance of transfer, the available skiU levels for transfer, cir
cumstances of the local institution, and intervention that is
necessary before the patienl can be transferred safely. If the
resources are available and the necessary procedures can be
performed e>..-peditiously, life-threatening injuries should be
treated before patient transport. This treatment may require
operative intervention to ensure that the parient is in the
best possible condition for transfer. Intervention prior to
transfer is a surgical decision.
TRANSFER FACTORS
IJ Whom do I transport?
To assist doctors in determining which patients may require
care at a nigher-level facility, the ACS Conunittee on Trauma
recommends using certain physiologic indices, injury mech
anisms and patlerns, and historical information. These fac
tors also help doctors decide v1hich stable patients might
benefit from transfer. Criteria for interhospital transfer
when a patient's needs exceed available resources are out-
DETERMINING THE NEED FOR PATIENT TRANSFER 271
qualified surgical team. A general or trauma surgeon

....
....
.:.- .
PITFALL should supervise nonoperative management, regardless

:-.,,,,.
of the patient's age. Such patients should not be treated
Patients frequently spend more time than necessary expectantly at facilities that are not prepared for urgent
at the initial hospital after the necessity for transfer operative intervention; they should be transferred to a
has been determined (eg, additiona l diagnostic tests
trauma center.
for "completeness"). Once the decision to transfer
the patient is made, little is gained by performing
Patients with specific injuries, combinations of in
procedures other than those necessary to restore juries ( particularly those involving the brain), or histor
normal hemodynamic function. Delaying the trans ical findings that indicate high-energy-transfer injury
fer to wait for test results is not appropriate. In a pa may be at risk for death and are candidates for early
tient with an obvious brain injury and focal transfer to a trauma center. High-risk criteria suggesting
neurologic findings, waiting for a CT scan of the the necessity for early transfer are also outlined in Table
brain before transferring the patient to the care of 13-1.
a neurosurgeon delays the patient's access to neces Treatment of combative and uncooperative patients
sary specialty care. There are occasions when a pa with an altered level of consciousness is difficult and
tient cannot be hemodynamically normalized prior fraught with hazards. These patienls are often immobi
to transport. Direct consultation with the receiving
lized in lhe supine position with wrist/leg restraints. If se
doctor may be helpful in determ ining the most ap
propriate time to begin the transfer of a patient
dation is required, the patient should be intubated.
with hemodynamic abnormalities. Therefore, before administering any sedation, the treating
doctor must:
1 . Ensure that the patient's ABCDEs are appropriately

managed.
lined in Table 13-l. It is important to note that these crite
ria are O.exihle and must take into account local circum 2. Relieve the patient's pain if possible (eg, apply splint
stances. fractures and administer small doses of narcotics
Certain clinical measurements of physiologic status intravenously).
arc useful in determining the .need for transfer to an in 3. Attempt to calm and reassure the patient.
stitution that provides a higher level of care. Patients who
exhibit evidence of shock, significant physiologic deterio Remember, benzodiazepines, fentanyl. propofol, and
ration, or progressive deterioration in neurologic status ketamine are all hazardous in patients with hypovolemia,
require the highest level of care and will likely benefit patients who are i ntoxicated, and patients with head in
from timely transfer. juries. When in doubt, pain management, sedation, and in
Stable patients wilh blunt abdominal trauma and tubation should be accomplished by the individual most
documented liver or spleen injuries may be candidates skilled in these procedures. See Chapter 2: Airway and
for nonoperative management. Implicit in such practice Ventilatory Management.
is the immediate availability of an operating room and a Abuse of alcohol and/or other drugs is common to all
forms of trauma and is particularly important to identify.
Doctors should recognize that alcohol and drugs can alter
pain perception and mask significant physical findings. Al
terations. in the patient's responsiveness can be related to al-
,-...,---
:"'>.-
.
....
-
PITFALL
::-.

The process of transporting patients to other med
ical facilities is not, in and of itself, a treatment or
cure for any disease or injury. The very process of
transportation holds great potential for the level of
care to deteriorate. The environment into which the
patient is placed can be unpredictable and not well
controlled. Careful planning can minimize the im
pact that these unintentional events may produce.
TABLE 13-1 Criteria for lnterhospital Transfer
CLINICAL CIRCUMSTANCES THAT WARRANT INTERiiPSPITAl TRANSPORT WHEN THE PATIENT'S

NEEDS EXCEED AVAILABLE RESOURCES:
Central Nervous System Head injury:

Penetrating inJury or depes
r sed skull fracture
Open injury with or without CSF leak
GCS score < 1 5 or neurologically a bnormal
La terallzing signs
Spinal cord injury or major vertebral injury
Chest Widened mediastinum or s1gns suggesting great-vessel mjury

Major chest wall injury or pul monary contusion

Cardiac in1ury
Patients who may req uire prolonged ventilation
Pelvis/Abdomen Unstable pelv1c-ring disruption

Pelvic-ring disruption with shock and evidence of continu ing hemorrhage
Open pelvic rnjury
Solid organ injury
Extremities Severe open fra ctures

Traumatrc amputation with potential for replantation
Complex artrcular fractures
Major crush Injury
Ischemia
Multisystem Injuries Head injury with face, chest, abdominal, or pelvic Injury
Injury to moer than two body regions
Major burns or burns with associated injuries
Multiple, proximal long bone fractures
-
Comorbid Factors Age >55 years

Age <5 years
Cardiac or respiratory d1sease
Insulin-dependent diabetes
Morbi d obesity
Pregnancy
Imm unosuppression
Secondary Deterioration Mechanical ventilation requi red

(Late Sequelae) Sepsis
Singleor multiple organ system failure (deterioration in central nervous, cardiac,
,
pul monary hepatic, renal, or coagulation systems)
Major tissue necrosis

Adapted With permission from ACS Committee on Trauma Resources for Optimal Care of the Injured Patient 2006. Chicogo: ACS,
2006.
coho! and/or drugs, but the absence of cerebral injury Death of another individual involved in the incident
should never be assumed in the presence of alcohol or drugs. suggests the possibility of severe, occult injury in survivors.
If the examining doctor is unsure, transfer to a higher-level A thorough and careful evaluation of the patient, even in the
facility may be appropriate. absence ofobvious signs of severe injury, is mandatory.
MODES OF TRANSPORTATION 273
doctor should accompany the patient. All monitoring and

Transfer Responsibilities management rendered en route should be documented.
Specific transfer responsibilities are held by both the refer-

ring doctor and the receiving doctor.

Modes of Transportation
REFERRING DOCTOR
fJ How should I transport the patient?
fJ Where should I send the patient? Do no further harm is the most important principle when
The referring doctor is responsible for initiating transfer of choosing the mode of patient transportation. Ground, water,
the patient to the receiving institution and selecting the ap and air transportation can be safe and effective in fulfilling
propriate mode of transportation and level of care required this principle, and no one form s i intrinsically superior to
for optimal treatment of the patient en route. The referring the others. Local factors such as availability, geo!,rraphy, cost,
doctor should consult with the receiving doctor and should and weather are het main determining factors as to which to
be thoroughly familiar with the transporting agencies, their use ni a given circumstance. Interhospital transfer of criti
capabilities, and the arrangements for patient treatment cally i11jured patients i s potentially hazardous unless the pa
during transport. tient's condition is optimally stabilized before transport,
Stabilizing the patient's condition before transfer to an transfer personnel are properly trained, and provision has
other facility is the responsibility of the referring doctor, been made for managing unexpected crises dmi.ng transport.
within the capabilities of his or her institution. Initiation of To ensure safe transfers, trauma surgeons must be involved
the transfer process should begin while resuscitative efforts in training, continuing education, and quality improvement
.
are m progress. programs designed for transfer personnel and procedures.
Transfer agreements must be established to provide for Smgeons also should be actively involved i n the development
the consistent and efficient movement of patients between and maintenance of systems of trauma care.
institutions. These agreements allow for feedback to the re
ferring hospital and enhance the efficiency and quality of
the patient's treatment during transfer. PITFALL
Moving a patient from one location to another, re

RECEIVING DOCTOR gardless of the distance involved, is hazardous. The
process must be approached with the same atten
The receiving doctor must be consulted with regard to the
tion to detail as the resuscitation of the patient's
transfer of a trauma patient. He or she must ensure that the
vital functions. Problems during transportation must
proposed receiving institution is qualified, able, and willing be anticipated so that their impact may be mini
to accept the patient, and is in agreement wi.tb the intent to mized should they occur. Anticipation of deteriora
transfer. The receiving doctor should assist the referring tion in the patient's neurologic condition or
doctor in making arrangements for the appropriate mode hemodynamic status allows for planning for such a
and level of care during transport. If the proposed receiving contingency if it occurs before the patient arrives at
doctor and facility are unable to accept the patient, they the referral center.
should assist in finding an alternative placement for the
patient.
The quality of care rendered en route is of vital impor
tance to the patient's outcome. OnJy by direct communica
tion between the referring and receiving doctors can the
details of patient transfer be clearly delineated. 1f adequately
trained ambulance personnel are not available, a nurse or
PITFA L L
The prudent doctor must review steps that ensure

the safest possible transfer to another level of care.
Remember, the doctor who begins the care of the
injured patient must be committed to ensuring that
the level of care does not deteriorate. This includes
the care delivered during transfer to definitive care.
Transfer Protocols 2. Breathing

a. Determine rate and administer supplementary
oxygen.
Where protocols for patient transfer do not exist, the fol- ..
b. Provide mechanical ventilation when needed.
lowing guidelines are suggested. c. Insert a chest tube if needed.
3. Circulation
INFORMATION FROM REFERRING DOCTOR a. Control external bleeding.
The local doctor who has determined that patient transfer is b. Establish two large-caliber intravenous tubes and
necessary should speak directly to the surgeon accepting the begin crystalloid solution infusion.
c. Restore blood volume losses with crystalloid fluids
patient at the receiving hospital. The following information
musr be provided: or blood and continue replacement during transfer.
d. insert an indwelling catheter to monitor urinary
Patient identification output.
e. Monitor the patient's cardiac rhythm and rate.
Brief history of the incident, including pertinent
prehospital data 4. Central nervous system
a.Assist respiration in wKonscious patients.
Initial findings i n the ED b. Administer mannitol or diuretics, if needed.
Patient's response to the therapy administered c. Immobilize any head, neck, thoracic, and ltunbar
. .
spme mJunes.
INFORMATION TO TRANSFERRING 5. Diagnostic studies (When indicated, obtaining these

PERSONNEL studies should not delay transfer.)
a. Obtain x-rays of cervical spine, chest, pelvis, and
[nformation regarding the patient's condition and needs extremities.
during transfer should be communicated to the transport b. Sophisticated diagnostic studies, such as CT and
ing personnel. This information includes, but is not lim aortography, are usually not indicated.
ited to: c. Order hemoglobin or hematocrit, type and cross
match, and arterial blood gas determinations for
Airway maintenance al l patients; also order pregnancy tests for females
Fluid volume replacement of childbearing age.
d. Determine cardiac rhythm and hemoglobin satu
Special procedures that may be necessary ration (ECG and pulse oximetry).
Revised Trauma Score, resuscitation procedures,
6. Wounds (Perform ing these procedures should not
and any changes that may occur en route
delay transfer.)
a. Clean and dress wounds after controlling external
DOCUMENTATION hemorrhage.
b. Administer tetanus prophylaxis.
A written record of the problem, treatment given, and pa c. Administer antibiotics, when indicated.
tient status at the Lime of transfer, as well as certain phys
ical items, must accompany the patient (Figure 1 3 - l ) . A 7. Fractures
facsimile transmission may be used to avoid delay i n a. Apply appropriate splinting and traction.
transfer.
The flurry of activity surrounding the initial evaluation,

resuscitation, and preparations for transfer of trauma pa
TREATMENT PRIOR TO TRANSFER tients often takes precedence over other logistic details. This
Patients should be resuscitated and attempts made lo stabi may result in the failure to include certain items in the in
lize their conditions as completely as possible based on the formation that is senL with lhe patient, sucl1 as x-ray films,
following suggested outline: laboratory reports, or narrative descriptions of the evalua
tion process and treatment rendered at the local hospitaL A
1. Airway checklist is helpful in this regard to make sure that all im
a. Insert an airway or endotracheal tube, if needed. portant components of care have been addressed (see Figure
b. Provide suction. 1 3 - 1 ). Checklists can be printed or stamped on an x-ray
c. Insert a gastric tube to reduce the risk of aspira jacket or the patient's medical record to remind the refer
tion. ring doctor to include all pertinent information.
CountY,
TRANSFER FORM General
Hospital
Patient Information
..
.
Name Next of kin
Address Address
City State Zip City State Zip
-
Age Sex Weight Phone # I
-
Phone # I Relationship to patient
Date and Time Ample History
Date I I
Time of injury AM/PM

Time admitted to ED AM/PM
Time admitted to OR AM/PM
Time transferred AM/PM
Condition on Admission Management During Transport
HR Rhythm
BP I RR Temp
Information in transfer materials
Probable diagnoses MIST AMPLE
Checklist
Airway: _ Endotracheal tube _ C-spine protection Circulation: _ Volume _ Blood

_ Drugs
Breathing: _ Oxygen _ SA02 _ EtC02 _ Chest tubes
Diagnostic: _ X-Rays (chest, C-spine, pelvis) _ Laboratory Family notification: _
Equipment: _ ECG _ BP _ SA02 _ IV _ T .

_ Indwelling catheter _Splints _ Gastric tube

-
r
Referral Information: Receiving Information:
Doctor Doctor
Hospital Hospital
- -
Phone # I Phone If I
Figure 1 3 . 1 Sample Transfer Form. This form includes all of the information that should be sent with the pa
tient to the receiving doctor and facility.
(Adapted w1th permission from Schoettker P, D'Amours S, Nocera N, Caldwel l E, Sugrue M Redudion of time to definitive care in trauma patients: effectiveness
of a nE'w checklist system. Injury 34 (2003), 187-190.)
276 CHAPTER 13 Transfer to Definitive Care
While preparing for transport and while i t is underway,

PITFALL remember that, i f air transport is used, changes in altitude
lead to ch<mges in air pressure, which may result in increases
Endotracheal tubes may become dislodged or mal in the size of pneumothoraces and gastric distention. Hence,
positioned during transport. The necessary equip
placement of a chest tube or gastric tube should be carefully
ment for reintubation must accompany the patient
considered. Similar cautions perlain to any air-filled device.
and the attendants must be capable of performing
For exa mple, during prolonged Oights, it may be necessary
the pro cedure .
to decrease the pressure in air splints, endotracheal tube bal
loons, and pneum atic antishock garments.
TREATMENT DURING TRANSPORT

The appropriate personnel should transfer the patient, based Transfer Data
on the patient's condition and potential problems.
Treatment during transport typically includes:
The n
i formation accompanying the patient should include
both demograph i c and historical information pertinent to
Monitoring vital signs and pulse oximetry
Lhe patient's injury. Uniform transmission of information
Continued support of cardiorespiratory system is enhanced by the use of an established transfer form, such
as the exampl e shown in Figure 13-1. Other data that should
Continued blood-volume repl acem ent
accompany the patient are outlined in Appendix C: Trauma
Use of appropriate medications as ordered by a Scores: Revised and Pediatric. In addition to the informa
doctor or as allowed by written protocol tion already outlined, space shouJd be provided for record
ing data in an organized, sequential fashion-vital signs,
Maintenance of communication with a doctor or
central nervous system (CNS) function, and urinary out
institution during transfer
put-dur ing the initial resuscitation and transport period.
Maintenance of accurate records during transfer rl' See Appendix D: Sample Trauma Flow Sheet.
CHAPTER SUMMARY
Patients whose injuries exceed an institution's capabilities for definitive care should be
identrfied early during assessment and resuscitation Individual capabilities of the treat
.
ing doctor, institutional capabilities, and indications for transfer should be known. Trans
fer agreements and protocols should be in place to support definit ive care .
Opt i mal preparation for transfer includes attention to ATLS principles and clear docu
ment ation The referring doctor and receiving doctor should communicate d irectly. Trans
.
fer personnel should be adequately sk i lled to administer the required patient care en
route.
Scarpio RJ, Wesson DE. Splenic trauma. In: Eichelberger MR,

BIBLIOGRAPHY 4.
ed. Pediatric 11-auma: Prevencion, Acute Care, Rehabilitation.
St. Louis: Mosby Yearbook; 1993:456-463.
1. American College of Surgeons Committee on Trau ma Re .
5. Schoettker P, D'Amours S, Nocera N, Caldwell E, Sugrue M.

sources for Optimal Care of the Injured Patient: 2006.
Reduction of time to definitive care in trawna patients: ef
Chicago: ACS.
fectiveness of a new checklist system. Injury 2003;34: 187-
2. Champion HR, Sacco WJ, Copes WS, et al. A revision of the 190.
trauma score. j 1rauma 1989;29:623-629.
6. Sharar SR, Luna GK, Rice CL, ct al. Air transport following
3. Mullins PJ, Veum-Stone J, Helfand M, et al. Outcome of hos surgical stabilization: an extension of regionalized trauma care.
pitalized injured patients after institution of a trauma system I Trawna 1988;2!1:794798.
in an w-ban ;uea. lAMA 1994;27 1:1919-1924.
APPENDICES
..
Appendix A Injury Prevention
Appendix B Biomechanics of Injury
Appendix C Trauma Scores: Revised and Pediatric

Appendix D Sample Trauma Flow Sheet
Appendix E Tetanus Immunization
Appendix F Ocular Trauma
Appendix G Austere Environments: Military Casualty Care and Trauma

Care in Underdeveloped Areas and Following Catastrophes
Appendix H Disaster Management and Emergency Preparedness
Appendix I Triage Scenarios
277
A P PE N D I X A Injury Prevention

Injury should not be considered an "accident'' which is a services, identification of trauma centers, and the integra
term that implies a random circumstance resulting in tion of rehabilitation services to reduce impairment, con
harm. In fact, injuries occur in patterns that are predictable stitute efforts at tertiary prevention.
and preventable. The expression "an accident waiting to
happen" is both paradoxical and premonitory. There are
Haddon's Matrix

high-risk individuals and high-risk environments. In com

bination, they provide a chain of events that can result in
trauma. With the changing perspective in today's health
care from managing illness to promoting wellness, .injury ln the early 1970s, Haddon described a useful approach to
prevention moves beyond promoting good health to take primary and secondary injury preven tion that is now
on the added dimension of reducing health care costs. known as the Haddon matri.x. According to Haddon's con
Prevention is timely. Doctors who care for injmed in ceptual framework, there are three principal factors in in
dividuals have a unique opportunjty to practice effective, jury occurrence: the injured person {host), the injury
preventive medicine. Although the true risk takers may be mechanism (eg, vehicle, gun), and the environment in
recalcitrant about any and all prevention messages, many which the injury occurs. There are also three phases dur
people who are injured through ignorance, carelessness, ing which injury and its severity can be modified: the pre
or temporary loss of self-control may be receptive to in event phase, the event phase (injury), and the post-event
formation that is likely to reduce their future vulnerability. phase. Table A-1 outlines how the matrix serves to iden
Each doctor-patient encounter is an opportunity to re tify opportunities for injury prevention and can be ex
duce trauma recidivism. This is especially true for surgeons trapolated to address other injury causes. The adoption of
who are ni volved daily during the period immediately after this structured design by the National Highway Traffic
injury, when there may be opportunjties to truly change Safety Administration resulted in a sustained reduction in
behavior. The basic concepts of injury prevention and the fatality rate per vehicle mile driven over the past two
strategies for implementation through traditional public decades.
health methods are included in this appendix.
The Four Es of Injury Prevention

Classification of Injury Prevention
Injmy prevention can be directed at human factors (be
Prevention can be considered as primary, secondary, or havioral issues), vectors of i.njury, and/or environmental
tertiary. Primary preverltion refers to elimination of the factors and implemented according to the four Es of in
trauma incident completely. Examples of primary preven jury prevention:
tion measures include stoplights al intersections, window
Education
guards to prevent toddlers from falling, swimmLng pool
fences to keep out nonswimmers and prevenl drowning, Enforcement

DUI laws, and safety caps on medkines to prevent inges
Engineering
tions.
Secondary prevention accepts the fact that an injury Economics (incentives)
may occur, but serves to reduce the severity of the injury
sustained. Examples of secondary prevention include Education is the cornerstone of injury prevention. Ed
safety belts, airbags, motorcycle and bicycle helmets, and ucationaJ efforts are relatively simple to implement; they
playground safety surfaces. promote the development of constil:l.1encies and serve to
Tertiary preven tion involves reducing the conse bring the issue before the public. Without an informed and
quences of the injury after i t has occurred. Trauma sys activist public, subsequent legislative efforts (enforcement)
tems, including the coordination of emergency medical are likely to fail. Educatjon is based on the premise that
279
280 APPENDIX A Injury Prevention
TABLE A-1 Haddon's Factor-Phase Matrix for Motor Vehicle Crash Prevention
PRE-EVENT EVENT POST-EVENT
Host Avoidance of alcohol use Use of safety belts Care delivered by byst ander
Vehicle Antilock brakes Deployment of air bag Assessment of veh1cle

characteristics that may have
contributed to event
Environment Speed limits Impact-absorbing barriers Access to trauma sysem

" ""'"""' ' .. .. ... -
.
.
.
.,, - - .
.., ............
.......... .,,___,,_, ...........,.._
__,,_
..
.
,
.
.
,_
........ ............... ...._..,,,_,,,....,...... .
......... .....-.......................,..,.,_,___________,,,.........,..
_,_,,
_._
_,,,........ ----- --..----..---.....
knowledge supports a change in behavior. Although attrac and reduced fatalilies confumed the utility of economic in
tive in theory education in injury prevention has been dis
, centives i n injury prevention. Lnsurance companies have
-
appointing in practice. Yet it provides the underpinning for clear data on ri sk tak ing behavior patterns, and the pay
implcmentation of subsequent st rategi es such as that to re , ments from insurance trusts, consequently provide related ,
duce alcohol-related crash deaths. Mothers Against Drunk discount premiums.

Driving is an organizatio n that exemplifies the effective use
of a primary education strategy to reduce alcohol-related
crash deaths. Through their efforts, an informed and Developing an Injury Prevention
aroused public facilitated the enactment of stricter drunk
driving laws, resulting in a decade of reduced alcohol
Program The Public Approach
related vehicle fatalities. For education to work, it must be
directed at the appropriate target group, it must be persist There are five basic steps to developing an injury prevention
ent, and it m ust be linked to other appro aches. program: define the problem, define the causes and risk fac
Enforcement is a useful part of any effective injury tors, develop and test interventions, implement injury
pre,rention strategy because, regardless of the type of prevention s trategies, and evaluate the impact.
trauma, there always arc individuals who resist the changes
needed to improve outcome-even if the improved out
DEFINE THE PROBLEM
come is their own. Where compliance with injury preven
tion efforts lags, legislat ion that mandates certain behavior The first step is a basic one: defme the problem. This may
or declares certain behaviors illegal often results in dramatic appear self-evident, but both the magnitude and commu
differences. For example, safety belt and helmet laws resulted nity impact of trauma can be elusive unless reliable data are
in measurable .increases i n usage when educational pro available. Population-based data on injury incidence are es
grams alone had minimal effect sential to identify the problem and provide a baseline for
Engineering, often more expensive at first., clearly has determining the impact of subsequ ent efforts at injury pre
the greatest long-term benefits. Despite proven effectiveness, vention. Information from death certificates, hospital
engineering advances may require concomitant legislative and/or emergency department discharge statistics, and
and enforcement initiatives, enabling implementation on a traLLma reg istry prin tout s are, collectively, good places to
larger scale. Adoption of air bags is a recent example of the start. Whereas sentinel events in a commtm ity may identify
application of advances in technology combined with fea an individual trauma problem and raise public concern,
tures of enforcement. Other advances in highway design and high-proftle problems do not lend themselves to effective
safety have added tremendously to the margin of safety injury prevention unless th ey are part of a larger docu
-
while driving. mented injury control i ssue.
Economic in centives when used for the correct pur
,
poses, are quite effective. For example, the linking of federal

DEFINE CAUSES AND RISK FACTORS
highway funds to the passage of motorcycle helmet laws mo
tivated lhe states to pass such laws and enforce the wearing After a trauma problem is identified, its causes and risk fac
of helmets. This resulted in a 30o/o reduction in fatali ties tors must be defined. The problem may need to be studied
from head inj uries Although lhis economic incentive is no
. to determine what kinds of injuries are involved and where,
longer in effect, and rates of deaths from head injuries have when, and why they occur. Injury-prevention strategies may
returned to their previous levels in states that have reversed begin to emerge with this additional information. Some
their helmet statutes, the association between helmet laws trauma problems vary from community to community;
APPENDIX A SUMMARY 281
however, there are certain risk factors that are likely to re can be assessed by monitoring the incoming and outgoing
main constant across situations and socioeconomic bound school traffic and showing a difference, whereas the usage
aries. Abuse of alcohol and other drugs is an example of a rates i n the community as a whole may not change.
contributing factor that is likely to be pervasive regardless Nonetheless, the implication is dear-broad implementa
of whether the trauma is blunt or penetrating, the location tion of public educalion regarding safety-belt use can have
is the inner ciry or the suburbs, and whether fatality or dis a beneficial effect within a controlled community popula
ability occurs. Data are most meaningful when the injury tion. Telephone surveys are not reliable measures to confum
problem is compared beuveen populations with and with behavioral change, but they can confirm that the interven
out defined risk factors. In many instances, the injured peo tion reached the target group.
ple may have multiple risk factors, and clearly defined
populations may be difficult to sort out. In such cases, it is
IMPLEMENT INJURY-PREVENTION STRATEGIES
necessary to control for the confounding variables.
With confirmation that a given intervention can effect fa
vorable change, the next step is implementation of injury
DEVElOP AND TEST INTERVENTIONS
prevention strategies. From this point, the possibilities are
The next step is to develop and test interventions. This is the vasl.
time for piJol programs to test intervention effectiveness.
Rarely is an intervention tested without some i11dication that
EVALUATE IMPACT
it will work. lt is important to consider the views and values
of the community if an injury prevention program is to be \1\fith implementation comes the need to monitor the im
accepted. End points must be defined up front, and out pact of the program or evaluation. An effectrve injury
comes reviewed without bias. rt is sometimes not possible to prevention program linked with a11 objective means to de
determine the effectiveness of a test program, especially if it fine its effectiveness can be a powerful message to the pub
is a small-scale trial intervention. For example, a public in Uc, the press, a11d legislators, and ultimately may bring about
formalion program on safety-belt use conducted at a school a perma11ent change in behavior.
APPENDIX A SUMMARY
Injury prevention seems like an immense task, and in many ways it is. Yet, it is important to
remember that a pediatrician in Tennessee was able to validate the need for infant safety
seats that led to the f1rst infant-safety-seat law. A New York orthopedic surgeon gave testi
mony that played an important role in achieving the first safety-belt law i n the United States.
Although not all doctors are destined to make as significant an impact, all doctors can have
an impact on their patients' behaviors. Injury-prevention measures do not have to be imple
mented on a grand scale to make a difference. Although doctors may not be able to prove
a difference In their own patient population, if everyone made 111jury prevention a part of their
practice, the results could be significant. As preparations for hospital or emergency depart
ment discharge are be1ng made, consideration should be given to patient education to pre
vent injury recurrence. Whether it IS alcohol abuse, returning to an unchanged hostile home 0
environment, riding a motorcycle without wearing head protection, or smoking while refu
eli ng the car, there are many opportunities for doctors to make a difference in their patients'
future trauma vulnerability.
282 APPENDIX A Injury Prevention
Bibliography 3. 'Harvard Injury Control Researd1 Center, Harvard School of

Public ITealth, 677 Huntington Ave., 2nd Floor, Boston, MA
021 15; 617-432-3420; www.ltsph.lwrvard.edu/hicrc.
I . American College of Surgeons Conunittee on Trauma. Re
4. Injury Control Research Center, University of Alabama
sourcesfor Optimal Cnre of the lnjurt Pntie11t. Chicago: Amer
BirmiiJgham, CH 1 9 Ui\.8 Station, Birmingham, i\L 35294;
ican College of Surgeons; 2006.
205-934-1643; www.un/J.edu/icrc.
2. Cooper A, .Barlow B. Davidson L, t'l al. Epidemiology of pedi
5 . lnjury Free Coalition for Kids, Columbia University, Mailman
atric lr:JUma: importance of populaLion-hased statistics. I Pe
Scho1.)l of Public Heal lh, 722 W. 168tb St., R.m. 1 7 1 1, New York,
diatr Surg 1992;27: 149-1 54.
NY I 0032; 21 2-342-0517; www.injuryfree.org.
3. Haddon W, Baker SP. Injury COiltrol. lll: Clark DW, MacMahon
6. Injury Prevention and Research Center, University of North
B, eds. Pre'ellt io11 and Conummity Medicine. 2nd ed. Boston:
Carolina, 137 E, Franklin St., CB#7505 CTP, Chapel Hill, NC
Little Brown; 1 981:109-140.
27599-7505; 919-966-1251; W'lVW. iprc.wrc.edu.
L Knudson .MM, Vassar M), Straus EM, et al. Surgeons and in
7. Johns Hopkins Center for Injury Research and Policy, Hamp
jury prevention: what )'Oll don t know can hun you! JAm Col/
'
ton House, 624 N. Broadway, 5th Floor, .Baltimore, MD 21205-

Strg 2001 ; 1 93:l l 9- 1 24.
t996; 41061 4-4026; www.jhsph.edu/Research/Centers/CJRP.
5. Laraque D, .Barlow B. Prevention of pediatric injury. In: Iva
8. National Center for Injury Prevention and Control, Centers
tory R, Caylen G, eds. Tire Text/look ofPenetrating Troumn. Bal
for Disease Control, Program Development and Implementa
timore::: Williams & Wilkins; 1 996.
tion, Mailstop K65, 4770 Buford Hwy. NE, Atlanta, GA 30341 -
6. National Committee for Injury Prevention and Control. In 3724; 770-488-1 506; www.cdc.gov
jury Prevention: Meeti11g the Challeuge. :--lew York: Education
9. San Francisco Center for Injury Re&earch and Prevention, San
Developmelll Center; 1989.
Francisco General Hospital 1001 Potrero Ave., Department of
,
7. Rivera FP. Traumatic deaths of children in United States: cur Surgery, Ward 3A, Box 0807, San Francisco, CA 94110; 415-
rently available prevention strategies. Pediatrics 1985;85:456-4{)2. 206-4623; www.surgery.ucsfedu/sfic.
8. Schermer CR. Alcohol and injury prevention. ! Tmumn 10. Slide Prevention Programs (Alcohol and Injury, Bicycle Hel
2006;60:447-451. met Safety), available from American College of Surgeons,
Customer Service/Publications, 633 N. Saint Clair St., Chicago,
It 60611-3211; 3 12/202-5474; https://secure.facs.orglcommerce/
2003/tmr1mn. html.
Resources I l . State and Local Departments of Health, injury Control Divi-
.
SIOnS.
I. British Columbia Injury Research and Prevention Unit, Cen 12. The Children's Safety Netvvork, National !njury and Violence
tre for Community Heallh and Health Research, L408-4480 Prevention Resource Center, Education Development Center,
Oak St., Vancouver, BC V6H 3V4, Canada; 604-875-3776; Inc., 55 Chapel St., Newton, MA 02458- 1060; 6 1 7/969-7100;
w1vw. injrtryresearclr.bc.ca. www.childrensnfetynetwork. org.
1. Harborview Injury Prevention and Researd1 Center, University 13. flPP Sheets, available from American Academy of Pediatrics ,
of Washington, Box 359960, 325 Ninll1 Ave., SeatUe, WA 98104- 141. Northwest Point Blvd., Elk Grove Village, 1L 60007; 800-
2499; 206-52 I -1 520; http;//depts. wnsltington.edulltiprc. 433-90 16; www.aap.org.
A P P E N D I X B B i omechanics of Injury
Introduction energy is applied, and the clastic properties of the

tissues to which the energy tTansfer is applied.
Biomechanics plays an important role in injury mecha

nisms, especially in motor vehicle crashes. Impact biome
chanics includes four principle areas of study: ( l )
Blunt Trauma
understanding the mechanism of injury; (2) establishing

levels of human tolerance to impact; (3) soliciting the me The common injury patterns and types of injuries identi-
chanical response to injury; and (4) designing more hu 11ed wilh blunt trauma iJlcludc:
manlike test dummies and other smrogates. The details of
the injury event can provide clues to identifying 90o/o of a Vehicular impact when the palient is inside the
patient's injuries. Specific information for doctors to elicit vehicle
regarding the biomechanics and mechanism of injury
Pedestrian injury
includes:
Injury to cyclists
The type of traumatic event (eg, vehicular colli
Assaults (intentional injury)
sion, fall, or penetrating injury)
Falls
An estimate of the amount of energy exchange
that occurred ( eg, speed of the vehicle at impact, Blast injury
distance of the fall, and caliber and size of the
weapon)
VEHICULAR IMPACT
The collision or impact of the patient with the ob
ject (eg, car, tree, knife, baseball bat, or bullet) Vehicular collisions can be subdivided fW"ther into: ( l ) col
lision between the patient and the vehicle, or between pa
Mechanisms of injury can be classified as blunt, pen tient and some stat ionary object outside the vehicle if tbe
etrating, thermal, and blast. In aU cases, there is a transfer patient is ejected (eg, tree, earth), and (2) the collision be
of energy to tissue-or, in the case of freezing, a transfer of tween the patient's organ(s) and the external framework
energy (heat) from tissue. Energy laws help us understand of the body (organ compression).
how tissues sustain injury. These include: The interactions between the patient a11d the vehicle
depend on the type of crash. Five crashes depict the possi
1 . Energy is neither created nor destroyed; however, its ble scenarios-frontal, lateral, rear, angular (front quarter
form can be changed. or rear quarter), and rollover.
2. A body in motion or a body at rest tends to remain
in that state until acted on by an outside force.

Occupant Collision
Types of occupant collisions include frontal impact, lateral
3. Kinetic energy (KE) is equal to the mass (m) of the
impact, rear impact, quarter-panel impact, rollover, and
object in motion multiplied by the square of the ve ejection.
locity (v) and divided by two.
KE = (m)(v2) Frontal Impact A frontal impact is defmcd as a colli
2 sion with an object in front of the vehicle that suddenly re
duces its speed. Consider two identical vehicles traveling at
4. Force (F) is equal to the mass times deceleration ( ac
the same speed. Each veh ide possesses rhe same kinetic en
celeration).
ergy [KE (m)(v2)/2]. One vehicle strikes a concrete bridge
=
5. Injury is dependent on the amount and speed of en abutment, whereas the other brakes to a stop. The braking
ergy transmission, the surface area over which the vehicle loses the same amount of energy as the crashing ve-
283
284 APPENDIX 8 Biomechanics of Injury
h1de, but over a longer time. The Cirst energy law states that vidual hits the ground. The likelihood of serious injury is in
energy cannot be created or destroyed. Therefore, this energy creased by more than 300% if the patient is ejected from the
must be transferred to another form and is absorbed by the vehicle.
crashing vehicle and it& occupants. The individual in the
braking vehicle has the same tow/ arnou nt of energy applied, Organ Collision
hut Lhe energy is distributed over a broad range of surfaces
'T'ypes of organ collision injuries include compression injury
(eg, scat friction, fool to floorboard, tire braking, tire to road
and deceleration injury. Restraint use is a key factor in re
surface, and hand to steering wheel) and over a longer time.
ducing injury.
Lateral Impact A lateral impact is a collision against the Compression Injury Compression injuries occur when
side of a vehicle that accelerates the occupant away from the the anterior portion of the torso ceases to move forward, but
point of impact (acceleration as opposed to deceleration}. the posterior portion and internal organs continue their mo
The driver who is :.truck on the driver's side is at greater risk tion. The organs are eventually compressed from behind by
for left-sided injuries, including left rib fractures, left-sided the advancing posterior tboracoahdominal wall and the ver
pulmonary injury, splenic injury, and left-sided skeletal frac tebral column, and in front hy the impacted anterior struc
tures, including pelvic compression fractures. A passenger tures. Blunt myocardial injury is a typical example of this
struck on the passenger side of the vehicle may experience type of injury mechanism.
similar right-sided skeletal and thoracic injuries, with liver Similar injury may occur in lung parenchyma and ab
injuries being common. dominal organs. In a colli!.ion, it i!> instinctive for the patient
In lateral impact collisions, the head acts as a large mass to take a deep breath and hold it, closing the glottis. Com
that rotates and laterally bends the neck as the torso pression of the thorax produces alveolar rupture with a re
is accelerated a,.,ay from the side of the collision. Injury sultant pneumothorax and/or tension pneumothorax. The
mechanbml>, therefore, involve a variety of specific forces, increase in intraabdominal pressure may produce di
including shear, torque, and lateral compression and aphragmatic rupture and translocation of abdominal or
distrnclion. gam; into the thoracic cavity. Compression injuries to rhe
brain may also occur. Movement of the head associated with
Rear Impact Most commonly, rear impact occurs when a the application of a force through impact can be associated
vehicle IS at a complete stop and is struck liom behind by an with rapid acceleration forces applied to the brain. Com
other vehicle. The stopped vehicle, including its occupants, pression injuries also may occur a a result of depressed skull
accelerated fonvard from the energy transfer from impact. fractures.
Because of the apposition of the seat back and torso, the torso
is accelerated along with the car. In the <lbsence of a func Deceleration Injury Deceleration injuries occur as the
tional headrest, the occupant's head may not be accelerated stabilizing portion of an organ (cg, renal pedicle, ligamen
with the rest of the body. As a result, hyperextension of the tum teres, or decending thoracic aorta} ceases forward mo
neck occurs. Practurcs of the posterior clements of the cer tion with the torso, while the movable body part (eg, spleen,
vical spine-for example, laminar frnctmes, pedicle fractures, kidney, or heart and aortic arch) continues to move forward.
and spinous process fractures, mny result and are equally In the case of the heart, shear force is developed in the aorta
distribtted through the cervical vertebrae. Fract1.1res at mul by the continued fonvard motion of the aortic arch with re
tiple kvcls are common and are usually due to direct bony spect to the stalionary descending aona. The distal aorta,
contact. which is anchored to the spine, decelerates more rapidly
with the torso. The shear forces arc greatest where the arch
Quarter-Panel Impact A quarter panel impact, front or and the stable descending aorta join at the ligamentum
rear, produces a variation of the injury patterns seen in lat a rteriosum.
.
eral and frontal impacts or lateral and rear impacts. This mechanism of injury also may be operative with
the spleen and kidney at their pedicle junctions; with the
Rollover During a rollover, the unrestrained occupant can liver as the right and left lobes decelerate around the liga
impact any part of tbe interior or the passenger compart mentum teres, producing a central hepatic laceration; and in
ment. Injuries may be predicted (rom the impact points on the skull when the posterior part of the brain separates from
the patient's skin. As a general rule, this type of mechanism the skull, tearing vessels and producing pace-occupying le
produces more severe injuries because of the violent, multi siom. The numerous attachments of the dura, arachnoid,
ple motions that occur during the rollover. This is especially and pia inside the cranial vault effectively separate the brain
true for unbelted occupants. into multiple compartments. These compartments are sub
jected to shear stress by both acccler.1tion and deceleration
Ejection The injuries sustained by the occupant during forces. Another example is the flexible cervical spine, which
the process of ejection may be greater than when the indi- is attached to the relatively immobile thoracic spine, ac-
BLUNT TRAUMA 285
counting for the frequent injury identified at the C7-Tl tl1e ground. Lower-extremity injury occurs when the vehi
junction. cle bumper is impacted; the head and torso are injured by
impact with the hood and windshield; and the head, spine,
Restraint Use The value of passenger restraints in re and extremities are injured by impact with the ground.
ducing injury has been so well established that it is no longer
a debatable issue. When used properly, cmTent three-point
INJURY TO CYCliSTS
restraints have been shown to reduce fatalities by 65o/o to
70o/o and to produce a 10-fold reduction in serious injury. At Cyclists and/or their passengers also can sustain compres
present, the greatest failure of the device is Lhe occupant's re sion, acceleration/deceleration, and shearing-type injuries.
fusal to use the system. Cyclists are not protected by the vehicle's structure or re
The value of occupant restraint devices can be illus straining devices, as are the occupants of an automobile. Cy
trated as follows: A restrained driver and the vehicle travel at clists are protected only by clotl1ing and safety devices worn
the same speed and brake to a stop with a deceleration of on their bodies-for example, helmets, boots, and protective
0.5 X g (16 ft/sec\ or 4.8 m/sec2). During the 0.01 second clothing. Only the helmet has the ability to redistribute the
it takes for the inertial mechanism to lock the safety belt energy transmission and reduce its intensity, and even this
and couple tl1e driver to the vehicle, the driver moves an capability is limited. Obviously, the Jess protection worn by
additional 6.1 inches ( 15.25 em) inside the passenger the cyclist, the greater the risk for Lnjury. Tbe concern that
compartment. the use of bicycle and motorcycle helmets increases tl1e risk
The increasing availability of air bags in vehicles may of injury below the head, especially cervical spine injury, has
significantly reduce the injuries sustained in frontal in1pacts. aol been substantjated.
However, air bags are beneficial only in approximately 70o/o
of collisions. These devices are not replacements for the
FALLS
safety belt and must be considered supplemental protective
devices. Occupants in head-on colJjsions may benefit from Similar to motor vehicle crashes, faUs produce injury by
the deployment of an air bag, but only on the first impact. means of a relatively abrupt change in velocity (decelera
If there is a second impact into another object, the bag is al tion). The extent of injury to a falling body is related to the
ready deployed and deflaLed, and is no longer available for ability of tl1e stationary surface to arrest the forward mo-
protection. Air bags provide no protection in rollovers, sec
ond crashes, or lateral or rear impacts. The three-point re
straint system must be used. Side air bag systems offer
promise for safer passenger compartments. Currently, maxi
mum protection is provided only with the simultaneous use
ofboth seat belts and air bags.
When worn correctly, safety belts can reduce injuries.
When worn incorrectly-for example, above the ante
rior/superior iliac spines-the forward motion of the pos
terior abdominal wall and vertebral column traps the
pancreas, liver, spleen, small bowel, duodenum, and kid
ney against the belt in front. Burst injuries and lacerations
of these organs can occur. Hyperflexion over an incor
rectly applied belt can produce anterior compression frac
tures of the lumbar spine (Chance fractures). (See Figure
B-1.}
PEDESTRIAN INJURY
It is estimated that nearly 90% of all pedestrian-auto colli
sions occur at speeds of less than 30 mph (48 kph). Chil
dren constitute an exceptionally high percentage of those
injured by collision with a vehicle. Thoracic, head, and
lower-extremity injuries (in that order) account for the ma Figure B-1 When worn correctly, safety belts can
jority of injuries sustained by pedestrians. reduce injuries. When worn incorrectly burst injuries and
There are three impact phases to the injuries sustained organ lacerations can occur. Hyperflexion over an incor
by a pedestrian: impact with the vehicle bumper, impact rectly applied belt can produce anterior compression
with the vehicle hood and windshield, and final impact with fractures of the lumbar spine.
286 APPENDIX B Biomechanics of Injury
tion of the body. At impact, differential motion of tissues era! atmospheres in magnitude, but it is of extremely short
,'\Tit hi n the organism causes tissue disruption. Decreasing the duration, whereas the negative-pressure phase that follows
rate of the deceleration and enlarging the surface area to is of longer duration. This latter fact accounts for the phe
which the energy is dissipated increase the tolerance to de nomenon of buildings falling inward.
celeration by promoting more uniform motion of the tis Blast injuries may be classified into primary, second
sue. The characteristics of the contact urface that arrests ary, tertiary, and quaternary. Primary blast injuries result
the fall are important as well. Concrete, asphalt, and other from the direct effects of the pressure wave and are most
hard surfaces increase the rate of deceleration and are there injurious to gas-containing organs. The tympanic mem
fore associated with more severe inJ Uries. brane is the most vulnerable to the effects of primary blast
Another factor that should be considered in determin and can rupture if pressures exceed 2 atmospheres. Lung
ing the extent of injury after a fall is the position of the tissue can develop evidence of contusion, edema, and rup
body relative to the impact surface. Consider the fol10\'\fing ture, which may result in pneumothorax caused by pri
examples: mary blast injury. Rupture of the alveoli and pulmonary
veins produces the potential for air embolism and sudden

A ma n falls J S feet (4.5 m) from the roof of a house, death. Intraocular hemorrhage and retinal detachments
landing on his feet arc common ocular manifestations of primary blast in
jury. Intestinal rupture also may occur. Secondary blast
A man falls 15 feet ( 4.5 m) from the roof of a bouse,
injuries result from flying objects striking an individual.
landing on his back
7tmiary blast injuries occur when an individual becomes
A man falls 1 5 feet ( 4.5 m) from the roof of a house, a missile and i s thrown against a solid object or the
landing on the back of his head with his neck in I S ground. Secondary a nd ter tiary blast injuries can cause
degrees of flexion trauma typical of penetrating and blunt mechanisms, re
spectively. Quarternary blast injuries include burn injury,
In the first example, the en Iire energy transfer occurs cru::.h injury, respiratory problems from inhaling dust,
over a surface area equivalent to the area of the man's feet; smoke, or toxic fumes, and exacerbations or complica
energy is transferred via the bones of I he lower extremity to tions of existing conditions such as angina, hypertension,
the pelvis and then the spine. The soft-tissue and visceral and hyperglycemia.
organs decelerate at a slower rate t han that of the skeleton.
In addition, the spine is more likely to flex than to extend
because of the ventral position of the abdominal viscera. In
the second example, the force is distributed over a much Penetrating Trauma
larger surface area. Although tisue damage may indeed
occur, it is less severe. In the final example, the entire energy Pcnetrating trauma refers to injury produced by foreign ob
transfer is directed over a small arc<l and focused on a point jects that penetrate tissue. Weapons are usually classified
in the cervical spine where the apex of the angle of flexion based on the amount of energy produced by the projectiles
occurs. I t is easy to see how the injuries di1Ter in each of these they launch:
examples, even though the mechanism and total energy is
identical. Low energy-kn ife or hand-energized missiles
Medium energy-handguns
81 AST INJURY
High energy-military or hunting rifles
Explosionl! result from the extremely rapid chemical trans
formation of relatively small volumes of solid, semisolid, liq The velocity of a missile is the most significant deter
uid, and gaseous materials into gaseous products that minant of its wounding potential. The importance of ve
rapidly expand to occupy a greater volume than that occu locity i!> demonstrated by the formula relating mass and
pied by the undetonated ex plosive. II' uni mpeded, these rap vcloci I y to kinetic energy.
idly expanding gaseous products assume the shape of a
sphere. Inside this sphere, the pressure greatly exceeds at Kinetic Energy = mass x ( V1 - V/)12
mospheric pressure. The outward expansion of this sphere where V1 is in1pact velocity and V2 is exit
produces a thin, sharply defined shell of compressed gas that or remaining velocity.
acts as a pressure wave at the periphery of the sphere. The
pressure decreases rapidly as this pressure wave travels away
VEL.OCITY
from the site of detonation in proportion to the third power
of the distance. Energy transfer occurs as the pressure wave The wounding capability of a bullet increases markedly
induces oscillation in the media through which it travels. above the critical velocity of 2000 ft/!.ec (600 m/sec). At this
The positive-pressure phase of the oscillation may reach sev- speed a temporary cavity is created by tissue being com-
PENETRATING TRAUMA 287
pressed at the periphery of impact, which is caused by a consequentially a greater transfer of kinetic energy. Some
shock wave initiated by impact of the bullet. bullets are specially designed to fragment on impact or even
Cavitation is the result of energy exchange between the explode, which extends tissue damage. Magnum rounds, or
moving missile and body tissues. The amount of cavitation cartridges with a greater amount of gw1powder than normal
or energy exchange is proportional to the surface area of the rounds, are designed to increase the muzzle velocity of the
point of impact, the density of the tissue, and the velocity missile.
of the projectile at the time of impact. (See Figure B-2.) De The wound at the point of bullet impact is determined
pending on the velocity of the missile, the diameter of lhis by:
cavity can be up to 30 times that of the bullet. The maxi
mwn diameter of this temporary cavity occurs at the area of The shape of the missile ("mushroom")
the greatest resistance to the bullet. This also is where the The position of the missile relative to the impact
greatest degree of deceleration and energy transfer occur. A site (tumble, yaw)
bullet fired from a handgw1 with a standard round can pro
duce a temporary cavity of 5 to 6 times the diameter of the Fragmentation (shotgun, bullet fragments, special
bullet. Knife injuries, on the other hand, result in little or no bullets)
cavitation.
Yaw ( the orientation of the longitudinal axis of the mis
Tissue damage from a high-velocity missile can occur at
some distance from the bullet track itself. Sharp missiles sile to its trajectory) and tumble increase the surface area of
the bullet with respect to the tissue it contacts and, there
with small, cross-sectional fronts slow with tissue impact,
resulting in little injury or cavitation. Missiles with large, fore, increase the amount of energy transferred (Figure B-3).
cross-sectional fronts, such as hollow-point bullets that In general, the later the bullet begins to yaw after penetrat
ing tissue, the deeper the maximum injury. BulJet deforma
spread or mushroom on impact, cause more injury or
cavitation. tion and fragmentation of semijacketed ammw1ition
increase sw-face area relative to the tissue and the dissipa
tion of kinetic energy.
BUllETS
Some bullets are specifically designed to increase the
SHOTGUN WOUNDS
amount of damage they cause. Recall that it is the transfer of
energy to the tissue, the time over which the energy transfer Wounds inflicted by shotguns require special considera
occurs, and the surface area over which the energy exchange tions. The muzzle velocity of most of these weapons is
is distributed that determine the degree of tissue damage. generally 1200 ft/sec (360 m/sec). After firing, tbe shot
Bullets with hollow noses or sernijacketed coverings are de radiates in a conical distribution from the muzzle. With
signed to flatten on impact, thereby increasing their cross a choked or narrowed muzzle, 70o/o of the pellets are de
sectional area and resulting in more rapid deceleration and posited in a 30-inch (75-cm) diameter circle at 40 yards
-
-- ' ------
1
t
I
Figure B-2 Sharp missiles with small cross-sectional fronts slow with tissue impact, resulting in little injury or
cavitation. Missiles with large cross-sectional fronts, such as hollow-point bullets that spread or "mushroom" on
impact, cause more injury and cavitation.
288 APPENDIX B Biomechanics of Injury
trance and exit of one bullet, suggesting the path the missile
may have taken through the body. Missiles usually follow tl1e
path of least resistance once tissue has been entered, and the
clinician should not assume that the trajectory of the bullet
followed a linear path between the entrance and ex.it wound.
The identification of the anatomic structures that may be
damaged and even the type of surgical procedure that needs
to be done may be influenced by such info tmalion.
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axis of the missile to its trajectory) and tumble increase of brain injuries i1wolving bicycles. Am j PubJic f-lealth
the surface area of the bullet with respect to the tissue 1 987;77( I ):76-78.
it contacts and, therefore, increase the amount of en
3. Leads from the MMWR. Bicycle-related injuries: Data from
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idly after firing and further after impact. This weapon
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Helmet L<1w Repeal on Motorcycle Fatalities. DOT Publication
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1987:605.
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ENTRANCE AND EXIT WOUNDS torcyclists? 1 Ttauma 1993;34: 120-122.
For clinical reasons, it may be important to determine 10. Zador PL, Ciccone MA. Automobile driver fatalities in frontal
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A P P E N D I X C Trauma Scores:
Revised and Pediatric
Introduction SIZE
Size is a major consideration for the infant-toddler group,
Correct tdage is essential to the effective functioning of re in which mortality from injury is the highest. Airway is as
gional trauma systems. Overtriage can inundate trauma sessed- not just as a function, but as a descriptor of what
centers with minimally injured patients and delay care for careis required to provide adequate management. Systolic
severely injured patients. On the other hand, undertriage blood pressure assessment primarily identifies those chil
can produce inadequate initial care and cause preventable dren in whom evolving preventable shock may occur (50
morbidity and mortality. Unfortunately, the perfect triage to 90 mm Hg systolic blood pressure l +IJ ). Regardless of
tool does not exist. size, a child whose systolic blood pressure is below 50 mm
Hg (-I) is in obvious jeopardy. On the other hand, a child
whose systolic pressure exceeds 90 mm Hg ( +2) probably
falls into a better outcome category than a child with even
Revised Trauma Score a slight degree of hypotension.
Experience with adult tratu11a scoring systems illustrates

lEVEL OF CONSCIOUSNESS
this problem by the multiplicity of scoring systems that
have been proposed over the past decade. None of these Level of consciousness is Lhe most important faclor in ini
scoring protocols is universally accepted as a completely tially assessing the cenual nervous system. Because chil
effective triage tool. At present, most adult trauma sur dren frequenlly lose consciousness transiently during
geons utilize the Revised Trauma Score (RTS) as a triage injury, the "obtunded" (+I) grade is given to any child who
tool and the weighted variation of this score as a predictor loses consciousness, no matter how fleeting the loss. Tbjs
of potential mortality. This score is based totally on phys grade identifies a patient who may have sustained a head
iologic derangement on initial evalualion and entails a cat injury with potentially fatal-but often treatable-in
egorization of blood pressure, respiratory rate, and the uacranial sequelae.
Glasgow Coma Scale (See Table C-l).
MUSCUlOSKElETAL INJURY
Skeletal injury is a component of the PTS because of its
Pediatric Trauma Score high incidence in the pediatJic population and its poten
tial contribution to mortality. Finally, cutaneous injury,
Application of these three components to the pediatric both as an adjunct to common pediatric injmy patterns
population, however, is difficult and inconsistent. Respi and as an injury category that includes penetrating
ratory rate is often inaccurately measured in the field and wounds, is considered in the computed PTS.
does not necessarily reflect respiratory insufficiency in the
injured child. Although the Glasgow Coma Scale is an ex
USE OF THE PTS
tremely effective neurologic assessment tool, i t requires
some revision for application to the preverbal child. These The PTS serves as a simple checklist, ensuring that all com
problems, in association with the lack of any identification ponents critical to the initial assessment of the injured
of anatomic injury or quanlification of patient size, un child have been considered. It is useful for paramedics in
dermine the applicabiJity of the RTS to effective triage of the field, as well as for doctors in facilities other than pe
injured children. For these reasons, the Pediatric Trauma diatric trauma w-rits. As a predictor of injury, the PTS bas
Score (PTS) was developed. The PTS is the sum of the a statistically significant inverse relationship with the ln
severity grade of each category and has been demonstrated jmy Severity Score (ISS) and mortality. Analysis of this re
to predict potential for death and severe disability reliably lationship has identified a threshold PTS of 8, above which
(Tab.le C-2, page 291.). injured children should have a mortality rate of Oo/tl. All in-
289
290 APPENDIX C Trauma Scores: Revised and Pediatric
TABLE C-1
ASSESSMENT
Revised Trauma Score
START OF END OF
1
COMPONENT VARIABLES SCORE TRANSPORT TRANSPORT
A. Respiratory Rate 1G-29 4

{breathslmmute) >29 3
6-9 2
1-5 1
0 0
B. Systolic Blood >89 4

Pressure 76-89 3
(mm Hg) 50-75 2
1-49 1
0 0
C. Glasgow Coma 13-15 4

Scale Score Conversion 9-12 3
C = D + E' + F (adult) 6-8 2
C = D + E2 + F (pedlatnc) 4-5 1
<4 0
D. Eye Opening Spontaneous 4

To voice 3
To pain 2
None 1
E' Verbal Response, Oriented 5

Adult Confused 4
Inappropriate words 3
Incomprehensible 2
words
None 1
E2Verbal Response, Appropriate 5

Pediatric Cnes, consolable 4
Persistently irritable 3
Restless, agitated 2
None 1
F. Motor Response Obeys commands 6

Localizes pain 5
Withdraws (pain) 4
Flexion (pa1n) 3
Extens1on (pain 2
None 1
Glasgow Coma Scale Score

(Total D + E1 or E2 + F)
=
Revised Trauma Score

(Total =A + B + C)
Adapted w1th permis1on from Champion HR. Sacco WJ, Copes WS, et al A rev1s1on of the Trauma Score. Journal of Trauma. 1989;
29(5) 624
OM ' - - ........
PEDIATRIC TRAUMA SCORE 291
jured children with a PTS ofless than 8 should be triaged to tcntialfor mortality. Unfortunately, the RTS produces un
an appropriate pediatric trauma center, because they have acceptable Levels of undertriage, which is an inadequate
the highest potential for preventable mortality, morbidity, trade-off for its greater simplicity. Perhaps more impor
and disability. According to the National Pediatric Trauma tanlly, however, the PTS's function as an initial assessment
Registry statistics, this group represents approximately 25% checklist requires that each of the factors th a t may con
of all pediatric trauma victims, clearly requiring the most tribute to death or disability is considered during initial
aggressive monitoring and observation. evaluation and becomes a source of concern for those indi
Studies comparing the PTS with the RTS have identi viduals responsible for the initial assessment and manage
fied similar performances of both scores in predicting po- ment of the injured child.
I TABtE c 2 -
Pediatric Trauma Score
1

ASSESSMENT SCORE
COMPONENT +2 +1 -1
Weight > 20 kg (> 44 Ib) 10-20 kg (22-44 lb) <10 kg (<22 1b)
Airway Normal Oral or nasal a1rway, Intubated, cncothyroido-

oxygen tomy, or tracheostomy
Systolic Blood Pressure > 90 mm Hg; good 50-90 mm Hg; carotid/ <50 mm Hg: weak or no
peri phera I pulses and femoral pulses palpable pulses
perfusion
Level of Consciousness Awake Obtunded or any loss Coma, unrespons1ve

of consciousness
Fracture None seen or suspected S1ngle, dosed Open or multiple
Cutaneous None VIS ible Contusion, abras1on, T1ssue loss, any gunshot
laceration <7 em not wound or stab wound
lhrough fascia through fascia
Totals:
Adapted with perm1ss1on from Tepas JJ, Mollllt Dl, Talbert Jl, et a! The ped1atnc trauma score as a pred1ctor of onjury seventy in the in
JUred child Journal of Pediatric Surgery 1987, 22(1 )15.
A P PE N D I X D Sample Trauma Flow Sheet
TRAUMA TEAM
TRAUMA RESUSCITATION RECORD
0 ACTIVATED I
TRAUMA REGISTRY # 0 ACTIVATED II
DATE: ----'--'
' -- TIME ARRIVED: ,., ..-.!..,
. : .>..) 0 MULTIPLES
NAME: ------ 0 UPGRADED
EST. WGT. : --- EST. AGE: --- 0 MALE 0 FEMALE 0 ED ROOM __
TRAUMA I.D. BAND #: WA I OR 0 OR ROOM
TA 8URO SR Al8 JR REB NI.URO ORlHO PI!D8

NAME
CALLED $ $ $ $
RESPOND
ARRIVE
CIRCLE "S' FOR STAT CALL

TIME OF INJURY: LOCATION: -------
XPORT: O AMBU h.'"h""'J O HEUIFI XED O PRIVCAR O WALK-IN OTHER ________
TRAUMA SYSTEM E TRY BY: N

0 FIELD TRIAGE 0 ED 0 TRAUMA CONSULT 0 TRANSFER
-
PRE HOSPITAL EVENTS: ------
MEDICATION PTA:
CHILDREN I A
DU T PUPIL CHART
L
QLASODW COMA SCALE 2 3 < 5
KEY TREATMENT PTA
SPO
NTA
NOE U
S 4 A Abrasion 0 AIRWAY I BVM 0 MAST PANTS (INFLATED)
EYE T ""
""
o:::,:
vO ;:;
IC
E= ""-
- --
'-1
3 B Bum 0 OET I NET I PEAD I CRICO 0 EXTREMIT Y SPLINT I TRACTION
OPENING TO
;.;
:,:,::
::
fi :; ______;"'i
IN:,_ 2 c Contusion o o. ______ 0 HEIMLICH VALVE AIL
NONE 1
_
ORIENTED s 0 Amputation 0 C COLLAR 0 CPR/DEFIBRILLATE

ParalySIS 0 SPINE STABILIZATION OIV
CONFUSED E
VERBAL
RESPONSE
INAPPROP RIATE WORDS 3
F Fracture HEALTH HISTORY: -------
INCOMPREHENSIBLE WOROS 2
NONE I G Gunshot Wound
OBEYS COMMANDS e -.L H Open Fracture PREVIOUS SURGERIES: -------
LOCALIZES PAIN 5 CURRENT MEDS:
WI
THDRAWS P
AIN 4
I Stab Wound -------
MOTOR
RESPONSE FLEXION PAIN 3 J Pain
2
ALLERGIES: ------
EXTENSION (PAIN) K Paresthesia

0 NO
laceration PREGNANT: 0 YES LMP:
NONE _
L
TETANUS STATUS CURRENT 0 YES 0
- NO
0 CHEMICALLY PARALYZED
____
L l R PCP:
ON ARRIVAL R
'I

- -
0 UNCOOPERATIVE O COMSATIVE O SEDATED a RESllWNTS l 0 NON-REACTIVE 0 CONSTRICTED
BEHAVIOR
0 PHARMACOLOGICAL PARALYSIS a DILATED SIZE:
PUPilS
A
IRWAY 0 UNOBSTRUCTED OOTHER R a NOI'IREACTIVE a CONSTRICTED
O LASOREO OPANTING O SPUNT1NG 0 NOT BREATHING 0 DILATED SIZE:
0 ASSISTED BREATHING 0 NECKVEIN DISTENTION
BREATHING 0 PALPABLE fA
CIAL FRACTURES 0 MALOCCWSI
0 CREPITUS 0 DEVIATED TRACH a cYANOSIS FACE
ON
0 HEMOPTYSIS a ABRASIONS a LACERATIONS 0 CONTUSIONS

a oPEN PTX a FLAil CHEST
BREATH L a ABSENT O DECREASED aRALES a WHEEZES OTORRHAGIA OTORRHEA lM.

O RALES a WHEEZES
SOUNDS R O ABSENT O DECREASED
EARS l 0 a l:
A 0 a R
HEMORRHAGE LOCATION:
a ABRASIONS a LACERAT IONS a CONTUSI
ONS
NECK
CARDIAC RHYTHM: a CSPINE CLEARED CUNICALLY .
0 Ul
O RA
DI
l<tlED Oi
a LACERATIO
NS a CONTUSI
ONS a HEMATOMA
L AL O FEMORAl a PEDAL O THREAOY CHEST
0 SEIJ ABRASIONS A
a PENETR TING WOUND
PULSES O THREAD
R a RADIAL OFEMORAL O PEDAL Y
a PREV. SURG 0 PENETRATING WOUNO
CYANOSIS 0 PERIPHERAL OCENTRAL
SKIN ABDOMEN a BELT ABRASIONS a DISTENTION
OCLAMMY a DELAYED CAP. REFILL
OSCAPHOIO
NEURO
.
- O LETHARGY

a STUPOR

0 DECEREBRATE

PELVIS
O UNSABLE
T
0 R ECTALTONE
0 GENITAL INJURY
O GUAJAC +-
a PROST
A TE
O HEMATURIA
CRA
NIAL 0 DECORTIC
A
TE
BACK Q09 roll) R
O DEFO MED a PENETRA
TI
ON
NEURO SPINAL QUAO/PARAPLEGIC LEVEL
CORD UPPER l a LAC OFX O OPEN
MONOPLEGIA EXTREMI'IY:
EXTREMITIES R a LAC OFX a OPEN
0 LACERATIONS:
SCALP LOWER L aLAe OFX a OPEN
a OPEN FRACTURE:
EXTREMITIES A OLAC aFX OOPEN
O HEMATOMA:
, 47029 (2107) WHITE OR IGINAL

YELLOW TRAUMA REGISTRY PINK EO COPY
Used w1th permission from Legacy Trauma Serv1ces, Legacy Emanuel Hospital & Health Care Center, Portland, Oregon. 293
294 APPENDIX D Sample Trauma Flow Sheet
PTA
. . w
IV NO. cc RemaJnlng Crystalloids/Colloids Urine

IV NO. cc RemaJnlng Gastric/Emesis
IV NO. cc Remalnlng
IV NO. oc Remalnlng !
SAMPLE TRAUMA FLOW SHEET 295
H PUS n m mR AB NA+ C K+ WN CR CA+
TO 8LOOO &
HCG :!: CLOT
0 IIAMK CROSS UNITS MTP
AIRWAY I BREATHING FAMILY NOTIFICATION

::J INTUBATED TIME ---- ---- TIME 0 HERE 0 CONTACTED
::1 NASAL 0 ORAL 0 CRICOITRACH ----
L : R _ . _ NEEDLE THORACENTESIS NAME -------

_ _
SIZE ---- DEnH OF TUBE ------ L _ : _ R _ : _ TUBE THDRACOSTOMY(S)

A02 TIDAL VOLUME ------
_ : _ 0 NGT (NO MIDFACE TRAUMA) TELEPHONE
NUMBER
0 OGT (MIOFACE TRAUMA)
-------
MODE RATE
:
-------
0 UNABLE TO REACH
_
END TIDAL C01

_
____________
_
0 FOLEY/SUPRAPUBIC
TIME
_
CIRCULATION _ _ 0 PERITONEAL LAVAGE

TIME _ : _ 0 CERVICAL TRACTION DEVICE
; 0 ORTHO REDUCTION
-- --
- -
0 INT/EXT JUGULAR VEIN L R _ _
-
.
-
0 SUBCLAVIAN VEIN L R _ : _ O SPUNTType: L+R
-

-
0 PERIPHERAL SIZE ___ L R _ : _ OOTHER ------
-
.
-
0 PERIPHERAL SIZE ___ L R
- -
0 FEMORAL SIZE ___ L R BELONGINGS: (SEE ITEMIZED usn
0 INTRAOSSEOUS SITE OHOME OROOM

- -
- -
O&NAHGAHZ SITE 0 POLICE 0 DISCARD
- -
OART UNE SITE

- -
OOTHER SITE
-
.
-
O EKG 12 LEAD
SEQUENCE OF EVENTS DISPOSITION TIME

TIME LEFT RESUSCITATION ROOM ADMIT 0 VP 0 OBSERVATlON ADMIT TIME:
O AMA
- - L
'

.
'
. -

-
. .
-
.
..
.
...

,
.
-
-
.
- .
. .
.

..
..

OHOME
OTRAHSFERRED TO; --------
IN TIM

STUDY XRAYS VIA. 0 GROUND OAIR AGENCY: -------

.. CSP1NE LA
T
ERAL 0 EXPIRED
.
. C-SPINE COMPLETE SERIES REMAINS TO: ------
.. CHEST SUPINE ORGAN DONOR: DYES ONO

.
CHEST ERECT CSPINE CLEARED 0 YES 0 NO BY: ______ M.D.
PELVIS CCOLLAR REMOVED: 0 TIME: __ BY: ------
..
__
EXTREMmES TOORACICJLUMBAR CLEARED 0 YES 0 NO

:
BY: _
______
ABDOMEN
CAT SCAN HEAD
AOMITT1NG DIAGNOSIS; ------
. N SP1NES C T L
CAT SCA
. CAT SCAN CH EST
. CAT SCAN ABD

OME N
. THORACIC SPINE
LUMBAR SPINE
ULTRASOUND ABDOME
N
TRN
ULTRASOUND
IVP/CYSTOGRAM
.. ANGIOGRAM RECORDER
ECHO..CARD
.

CIRCULATOR
;:::
::: :;': TIME RADIOLOGICAL STUDIES COMPLETED
READY FOR DISPOSITION PHYSICIAN SIGNATURE
*NOTE: Th1s flow sheet 1s only a n example ol informa1ion that may be requ1red. All insututions that receive trauma pauents should develop a form
that meets the needs of the institution.
A P P E N D I X E Tetanus I mmunization
Introduction mittee on Trawna recommends contacting the CDC for the

most etu-ent
r information and detailed guidelines related to
tetanus prophylaxis and immunization for injured patients.
Adequate tetanus prophylaxis is important in patients with
multiple injuries, particularly when open-extremity
trauma is present. The average incubation period for General Principles
tetanus is I 0 days; most often it is 4 to 21 days. ln severe
trauma cases, tetanus can appear as cady as l to 2 days
The following general principles for doctors who treat
after injmy. AJl medical professionals must be cognizant
trauma patients concern surgical wotmd care and passive
of this important fact when providing care to injured pa
immunization.
lients. Recent studies conclude that it is not possible to de
termine clinically which wounds are prone to tetanus;
SURGICAl WOUND CARE
tetanus can occur after minor, seemingly innocuous in
juries, yet it is rare after severely contaminated wounds. Regardless of the active immunjzation status of the patienL,
Thus, all traumatic wounds should be considered at risk meticulous swgical care--including removal of all devital
for the development of tetanus infection. ized tissue and foreign bodies-should be provided immedi
Tetanus immunization depends on the patient's previ ately for aJI wounds. If the adequacy of wound debridement
ous immunization status and the tetanus-prone nature of is in question or a puncture injury is present, the wound
the wound. The following guidelines are adapted from the should be left open and not dosed by sutures. Such care is es
literature, and information is available from the Centers for sential as part of the prophylaxis against tetanus. Traditional
Disease Control and Prevention (CDC). Because this infor clinicaJ features that influence the risk for tetanus infection in
mation is continuously reviewed and updated as new data soft tissue wounds are listed in Table E-1. However, all wounds
become available, the American College of Surgeons Com- should be considered at risk for the development of tetanus.
TABLE E-1 Wound Features and Tetanus Risk
CLINICAL FEATURES OF WOUND NON-TETANUS-PRONE WOUNDS TETANUS-PRONE WOUNDS
Age of wound < 6 hours >6 hours
Configuration Linear wound, abrasion Stellate wound, avulsion
Depth s 1 em > 1 em
Mechanism of injury Sharp surface (eg, knife, glass) Missile, crush, burn, frostbtte
Signs of infection Absent Present
Devitalized tissue Absent Present
Contaminants (eg, dirt, feces, soil, saliva) Absent Present
Denervated and/or ischemic tissue Absent Present
Adapted with permtss1on from the Centers for D1sease Control and Prevention. Atlanta, GA,
www.cdc.gov/mmwr/prevtew/mmwrhtmV00041645.h1m. (Las1 updated 2007.)
297
298 APPENDIX E Tetanus Immunization
PASSIVE IMMUNIZATION Bibliography

Passive immunization with 250 units of human tetanus im
mune globulin (TlG) administered intramuscularly must be l. American College of Surgeon s Committee on Trauma. Pro
considered for each patient. TIG provides longer protection pbylaxis against tetanus in wound management. Poster 1995. ,
than antitoxin of animal origin and causes few adverse reac

2. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet )J.
tions. The characteristics of the wound, conditions under Tetanus and 1rauma: a review and recommendation. } Tmuma
which it occurred, wound age, TIG treatment, and the previ 2005;58: 1082- 1088.
ous active immunization status of the patient must all be con
sidered (Table E-2}. When tetanus toxoid and TIG are given 3. U.S. Department of Healtb and Human Services, Centers for
Disease Control and Prevention. Tetanus. http://W>-w.cdc gov/ .
concurrently, separate syringes and separate sites should be

vaccines/pubs/pinkbook!downloads/tetanus.pd Accessed Oc
used. If the patient has ever received a series of three injec
tober 22, 2007.
tions of toxoid, TfG is not indicated, w1less the wound is
judged to be tetanus-prone and is more than 24 hours old.

TABLE E-2 Summary of Tetanus Prophylaxis for Injured Patients '
I
HISTORY OF ADSORBED TETANUS NON-TETANUS-PRONE TETANUS-PRONE
TOXOID (DOSES) WOUNDS WOUNDS
TO TIG TO TIG
Unknown or < 3 Yes No Yes Yes
> 3b No< No Nod No
Adapted wrth permissron from the Centers for Disease Control and Prevention, Atlanta, GA.
www.cdc.gov/mmwr/preview/mmwrhtmi/00041645.htm. (Last updated 2007.)
For chrldren younger 1han 7 years old, diphtheria-tetanus-perlu$Sis (DI'T) vaccine (OT. if pertussis vaccine is contraindicated) is pre
ferred to Ltanus Loxoid alone. For patients 7 years old and older, Letanus and diphtheria toxolds are preferred to tetanus toxoid alone.
" I f only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an odsorbed toxoid, should be given
' Yes, If more than 10 years since last dose.
Yes, If more than 5 years since lasl dose. (More frequent boosters are not needed and can accentuate side effects.)
A P P E N D I X F Ocular Trauma
(Optional Lecture)
Upon completion of this topic the student will be able to

Introduction ,
assess and manage sight-threatening eye inju ries. Specifi

cally, the doctor will be able to:
The initial assessment of a patien t with an ocular in
jury r equires a system atic approach . The physical OBJECTIVES
examination should proceed in an organized, step-by

step manner. It does not require ex-tensive, compli Obtain patient and event histories.
cated instrumentation in the multiple-trauma setting.
Rather, simple therapeutic measures often can save the
Perform a systematic examination of the orbit
and its contents.
patient's vision and prevent serious sequelae before an
oph th al mologist is available. This appendix prov i des Identify eyelid injuries that can be treated by
pertinent information regarding the early identifica the primary care doctor, as well as those that
tion and treatment of ocular inj u ri es that wiJI enhance must be referred to an ophthalmologist for
doctors' basic knowledge and may save their pati ents' treatment.
VlSlOn.
Explain how to examine the eye for a foreign
body, and how to remove superficial foreign
bodies to prevent further injury.
Assessment
Identify corneal abrasion and describe its
proper management.
Key factors in the assessment of patie nts with ocular
trauma include patient history, hi story of the injury Identify hyphema and describe its initial man
incident,initial symptoms, and results of physicaJ ex agement and the necessity for referral to an
ami nation . ophthalmologist.
Identify eye injuries that require referral to an

PATIENT HISTORY ophthalmologist.
Obtain a his tory of any preexisti ng ocular disease. Key Identify ruptured-globe injury and describe its
questions incl ude: initial management prior to referral to an oph
thalmologist.
1. Does the patient wear corrective lenses?
Evaluate and treat eye injuries that result from
2. 1s there a history of glaucoma or previous eye chemicals.
surgery?
Evaluate a patient with an orbital fracture and
3. \A/hat medications does the patient use (eg, describe its initial management and the neces-

pilocarpine)? sity for referral.
Identify retrobulbar hematoma and explain

HISTORY OF INJURY INCIDENT the necessity for immediate referral.
Obtain a detailed descri ptio n of the circumstances
surrounding the injury. This information often raises
the index of susp icion for ce r tain potential i nj uries
and their sequelae, such as the higher risk of infection from
certain foreign bodies (eg, wood vs. metallic). Key ques
tions include:
299
300 APPENDIX F Ocular Trauma
1 . Was there bl unt trauma? eyelids to be rolled open. Then assess the globe anteriorly
tor any displacement from a retrobulbar hematoma and for
2. Was there penetrating injury? (In motor vehicular
any posterior or inferior displacement due to an orbit frac
crashes there is potential for g lass and metallic foreign
ture. Also assess the globes for normal ocular movement,
bodies.)
diplopia, and evidence of entrapment.
3. Was there a missile injury?
4. Was there a possible thermal, chemical, or flash burn? Pupil

Assess the pupils for roundness, with regular shape, equal
ity, and reaction to Light stimulus. It is important to test for
INITIAL SYMPTOMS
an afferent pupil defect. Optic nerve trawna usually results
Key questions regarding the patient's initial symptoms in in the failure of both pupils to constrict when a light is dj
clude: rected at lbe affected eye.
1. What were the initial symptoms? Cornea
2. Did the patient report pain or photophobia? Assess the cornea for opacity, ulceration, and foreign bodies.
Fluorescein and a blue light can facilitate this assessment.
3. Was there an immediate decrease in vision that has
remained stable, or is it progressive?
Conjunctiva
Assess the conjunctivae for chemosis, subconjunctival em
physema (indicating probable fracture of the orbit into Lhe
The physical examination must be systematic so that func ethmoid or maxillary sinus), subconjunctival hemor rhage ,
tion and anatomic structures are evaluated. As with injuJies and foreign bodjes.
to other organ systems, the pathology also may evolve with
time, and the patient must be reevaluated periodically. A d i
Anterior Chamber
rected approach to the ocular examination, beginning with
the most external structures in an "outside-to-inside" man Examine the anterior chamber for hyphema (blood u1 the
ner, ensures that injuries are not missed.
ru1terior chamber). The depth of the anterior chamber can
be assessed by shining a light u1to the eye from the lateral
aspect of the eye. If the light does not illuminate the entire
Visual Acuity surface of the iris, a shallow anterior chamber should he sus
Visual acui tyis evaluated first by any means possible and pected. This condition can result from an anterior pene
recorded (eg, patient counting fingers at 3 ft [0.9 m ] ) . trating wound. A deep anterior chamber can result from a
posterior penetrating wound of the globe.
Eyelids
The most external structures to be examined are the eyelids. Iris
The eyelids should be assessed for: ( l ) edema; (2) ecchy The iris should be reactive and regulru in shape. Assess the
mosis; (3) evidence of burns or chemical injury; ( 4) lacera iris for iridodialysis (a tear of the iris) or iridodonesis (a
tion(s)-medial, lateral, l id margin, canaliculi; (5) ptosis; floppy or tremulous iris).
(6) foreign bodies that contact the globe; and (7) avulsion of
the canthal tendon.
Lens
The lens should be transparent. Assess the lens for possible
Orbital Rim anterior displacement into the anter.ior chamber, partial dis
Gently palpate the orbital rim for any step-off deformity or location with displacement into the posterior chamber, ru1d
crepitus. Subcutaneous emphysema can result from a frac djslocation into the vitreous.
ture of the medial orbit into the ethmoids or a fracture of
the orbital floor into the maxillary antrum. Vitreous
The vitreous should be transparent, allowing for easy visu
Globe alization of the fundus. Visualization may be djfficult if vit
The eyelids should be retracted to examine the globe with reous hemorrhage has occurred. In this situation, a black
out applying pressure to the globe. Specially designed re rather than red reflex is seen on ophthalmoscopy. Vitreous
tractors are available for this pur pose Cotton-tipped
. bleeding usually indicates a significant Lmderlying ocular in
applicators can also be used; they should be placed gently jury. The vitreous also should be assessed for an intraocular
against the superior and inferior orbital rims, enabling the foreign body.
SPECIFIC INJURIES 301
Retina CORNEAL INJURY

The retina is examined for hemorrhage, possible tears, or Corneal abrasions result i n pain, foreign-body sensation,
detachment. A detached reti.na is opalescent, and the blood photophobia, decreased visual acuity, and chemosis. The in
columns are darker. jured epithelium stains with fluorescein.
Comealforeign bodies sometin1es can be removed with
irrigation. However, if the foreign body is embedded, the
patient should be rcfetTed to an ophthalmologist Corneal
Specific Injuries abrasions are treated with antibiotic drops or ointment to
prevent ulcers. Clinical studies have demonstrated no ad
Common traumatic ocular injuries include eyelid injury, vantage to patching in terms of patient comfort or time re
corneal injury, anterior chamber injury, injury to the iris, quired for the abrasion to heal. The patient should be
injury to the lens, vitreous injuries, injury to the retina, globe instructed to instill the drops or ointment and should be fol
injury, chemical injury, fractures, retrobulbar hematoma, lowed up within 24 to 48 hours.
and fat emboli.
ANTERIOR CHAMBER INJURY

EYEliD INJURY Hypherna is blood in the anterior chamber, which may be
Eyelid injuries often result in marked ecchymosis, making difficult to see if there is only a small amount. In extreme
examination of injuries to the globe and lid difficult. How cases, the entire anterior chamber is filled. The hyphcrna can
ever, a more serious injury to the underlying structures must often be seen with a penlight. Hyphema usually indicates se
be excluded. Look beneath the lid as well to exclude damage vere intraocular trauma.
to the globe. Lid retractors or cotton-tipped applicators can Glaucoma develops in 7o/o of patients with hyphema.
be used if necessary to forcibly open the eye to inspect the Comeal staining also may occur. Remember, hyphema can
globe. Ptosis may result from edema, damage to the levator be the result of serious m1derlying ocular injury. Even i n the
palpebrae, or oculomotor nerve injury. case of a small bleed, spontaneous rebleeding often occurs
Lacerations of the upper and Lower lids that arc hori within the first 5 days, which may lead to total hyphema.
zontal, superficial, and do not involve the levator in the Therefore, the patient must be referred to an ophthalmolo
upper lid may be closed by the examining doctor using in gist. The affected eye will be patched, and the patient usually
terrupted 6-0 (silk, nylon) skin sutures. The doctor also is hospitalized, placed on bed rest, and reevaluated fre
should examine the eye beneath the lid to rule out damage quently. Pain after hyphema usually indicates rebleeding
and/or acute glaucoma.
to the globe.
Lid injuries that require treatment by a11 ophthalmologist
include: ( 1 ) wounds involving the medial canthus that may INJURY TO THE IRIS
have damaged the medial canaliculus; (2) injuries to the
lacrimal sac and nasal lacrimal duct, which can lead to ob Contusion injuries of the iris can cause traumatic mydria
struction if not properly repaired; (3) deep horizontal lac sis or miosis. There may be disruption of the iris from the
erations of the upper lid that may involve the Levator and ciliary body, causing an irregular pupil and hyphema.
result in ptosis if not repaired correctly; and (4) lacerations
of the lid margin that are d j fficult to close and can lead to
INJURY TO THE LENS
notching, entropion, or ectropion. These wounds may be
covered with a saline dressing pending emergency ophthal Contusion of the lens can lead to later opacification or
mologic consultation. cataract formation. Blunt trauma can cause a break of the
Foreign bodies of the lid result in profuse teming, pain, zonular tibers that encircle the lens and anchor it to the cil
and a foreign-body sensation lhat increases with lid move iary body. This results in subluxation of the lens, possibly
ment. The conjunctiva should be inspected, and the upper into the anterior d1amber, causing shallowing of the cham
and lower lids should be everted to examine the inner sur ber. In cases of posterior subluxation, tl1e anterior chamber
face. Topical anesthetic drops may be used, but only for deepens. Patients witl1 these injuries should be referred to
initial examination and removal of the foreign body. an ophthalmologist.
Penetrating foreign bodies should not be disturbed and
arc removed only in the operating room by an ophthalmol
VITREOUS INJURY
ogist or appropriate specialist. l 'f the patient requires trans
port to another facility for treatment of this injury or otl1ers, Bllmt tralm1a may also lead to vitreous hemorrhage. This
consult an ophthalmologist regarding management of the usually is secondary to retinal vessel damage and bleeding
eye during transport. into the vitreous, resulting in sudden, profolmd loss of vi
sion. Funduscopic examination may be impossible, and the
302 APPENDIX F Ocular Trauma
red reflex, seen with an ophthalmoscope light, is lost. A pa CHEMICAL INJURY

tient with this injury should be placed on bed rest vvith the
Chemical injuries require immediate intervention in order
eye shielded and referred to an ophthalmologist.
to preserve sight. Acid precipitates proteins in the tissue and
sets up somewhat of a natural barrier against extensive tis
INJURY TO THE RETINA sue penetration. However, alkali combines with lipids in the
cell membrane, leading to disruption of the cell membranes,
Blunt trauma also can cause retinal hemorrhage. The pa
rapid penetration of the caustic agent, and extensive tissue
tient may or may not have decreased visual acuity, depend
destruction. Chemical injury to the cornea causes disrup
ing on involvement of the macula. Superficial retinal
tion of stromal mucopo.lysaccharides, leading to opacifica
hemorrhages appear cherry red in color, whereas deeper le
tion.
sions appear gray.
The treatment for chemical injuries lo the eyes in
Retinal edema and detachment can occur with head
volves copious and continuous irrigation. Attempts
trauma. In such cases, a white, cloudy discoloration is ob
should not be made to neutralize the agent. Intravenous
served. Retinal detachments appear "curtain-like." If the
solutions (eg, crystalloid solution) and tubing can be
macula is involved, visual acuity is affected. An acute retinal

used lo improvise continuous irrigation. Blepharospasm
tear usually occurs in conjunction with blunt trauma to an
is extensive, and the lids must be manually opened dur
eye with preexisting vitreoretinal pathology. Retinal detach
ing irrigation. Analgesics and sedation should be used, if
ment most often occurs as a late sequela of blunt trauma,
not contraindicated by coexisting injuries. Thermal in
with the patient describing light flashes and a curtain-like
juries usually occur to the lids only and rarely involve the
defect in peripheral vision.
cornea. However, burns of the globe occasionally occur.
A rupture of the choroid initially appears as a beige area
A sterile dressing should be applied and the patient re
at the posterior pole. Later it becomes a yellow-white scar. If
ferred to an ophthalmologist. Exposure of the cornea
it transects the macula, vision is seriously and permanently
must be prevented or it may perforate, and the eye may
impaired.
be lost.
GLOBE INJURY
FRACTURES
A patient with a ruptured globe has marked visual impair
ment. The eye is soft because of decreased intraocular pres Blunt trauma to the orbit may cause rapid compression of
sure, and the anterior chamber may be flattened or shallow. the tissues and increased. pressure within the orbit. One of
I f the rupture is anterior, ocular contents may be seen ex the weakest points is the orbital floor, which may fracture,
truding from the eye. allowing orbital contents to herniate into the antrum-lead
The goal of initial management of the ruptured globe ing to the use of the term "blowout."
is to protect the eye from any addilional damage. As soon Clinically, the patient presents with pain, swelling, and
as a ruptured globe is suspected, the eye should not be ma ecchymosis of the lids and periorbital tissues. There may be
nipulated any further. A sterile dressing and eye shield subconjunctival hemorrhage. Facial asymmetry and possi
should be applied carefully to prevent any pressttre to the ble enophthalmos can be evidenl or masked by surrounding
eye that may cause further extrusion of the ocular con edema. Limitation of ocular motion and diplopia second
tents. The patient should be instructed not to squeeze the ary to edema or entrapment of the orbital contents may be
injured eye shut. If not contraindicated by other injuries, noted. Palpation of the rims may reveal a fracture step-off
the patient may be sedated while awaiting transport or deformity.
treatment. Do not remove foreign objects, tissue, or clots Subcutaneous and/or subconjunctival emphysema may
before placing the dressing. Do not use topical analge occur when the fracture is into the ethmoid or ma.xil!ary si
sics-only oral or parenteral, if not contraindicated by any nuses. Hypesthesia of the cheek occurs secondary to injury
other injuries. of the infraorbital nerve. The Waters view and Caldwell view
An intraocular foreign body should be suspected if the (straight on) are useful for evaluating orbital fractures. Ex
patient reports sudden, sharp pain with a decrease in visual amine the orbital floor and look for soft-tissue density in
acuity, particularly if the eye might have been struck by a the maxillary sinus or an air fluid level (blood). Computed
small fragment of metal, glass, or wood. Inspect the surface tomographic scans also are helpful, and may be considered
of the globe carefully for any small lacerations and possible mandatory.
sites of entry. These may be difficult to find. In the anterior Treatment of fractures may be delayed up to 2 weeks.
chamber, tiny foreign bodies may be hidden by blood or in Watchful waiting may help to avoid unnecessary surgery by
the crypt of the iris. A tiny iris perforation may be impossi allowing the edema to decrease. Indications for orbital
ble to see directly, but with a pen light the red reflex may be blowout repair include persistent diplopia in a fi.mctional
detected through the defect (if the lens and vitreous are not field of gaze, enophthalmos greater than 2 mm, and fracture
opaque). involving more than 50% of the orbital floor.
BIBLIOGRAPHY 303
RETROBULBAR HEMATOMA FAT EMBOLI

A retJobulbar hematoma requires immediate treatment by an Patients with long-bone fractures are at risk for fat. em
ophth alm ologist. The resulting increased pressure within the boli. Remember, this is a possible cause of a sudden
orbit compromises the blood supply to the retina and optic change in vision for a patient who has sustained multiple
.
nerve, resulting in blindness if not treated. Ifpossible, the head 111JUrieS.
should be elevated, with no direct pressure placed on the eye.
APPENDIX F SUMMARY

Thorough, systematic evaluation of the inJured eye results in few significant i nju ries being
missed. Once the injuries have been identified, treat the eye injury using simple, systematic
measures; prevent further damage; and help preserve sight until the patient IS in the oph
thalmologist's care.
5. Palt erson ), Fetzer D, Kral l ), et al. Eye patch treatment for the
Bibliography pain of corneal abrasion. South Med J 1996;89:227-229.
6. Pooo A, JvlcCiuskey PJ, HiJJ DA. Eye i J1juries in pa tienLs with
L Arbour JD, Bru nette I, Boisjoly HM, et al. Should we patch
major trauma. I Trau111a 1999;46:494-499.
corneal erosions? Arch Ophthalmo/ 1997; 115:313-317.
7. Sastry SM, Paul BK, Bain L, Champion HR: Oculr trau ma
2. Cam panile TM, St Clair DA, Bcnaim M. The evalu.alion of e)re
among major Lrauma victims in a regional trauma center. !
patching in the treatment of traumatic corneal epithelial de
Tmumn 1993;34:223-226.
fects. I Emerg Med 1997;1 5:769-77<1.
8. Tasman WS. Posterior vitreous detachment and peripheral
3. Flynn CA, D'Amico F, Sm ilh G. Should we patch corneal abra
retinal breaks. Tmns Am Acnd Ophtfmlmol Oro/(lryngol
sions? A meta-analysis. I Pam Pract. 1998;47:264-270.
1968;72:217.
4. Hart A, White S, Conboy P, et al. The management of corneal
abrasions in accidenl and emergency. l11jury 1997;28:527-529.

Austere Environments:
A P P E N D I X G Military Casualty Care and Trauma Care
in Underdeveloped Areas and Following
Catastrophes (Optional Lecture)
Upon completion of this topic, the doctor will be able to:

Introduction
OBJECTIVES
'
Even the largest hospital or medical center can become
an austere environment after a natural or human-made Define austere and hostile environments.
disaster. During a war or after a terrorist attack with ex
plosives, and chemical, biologic, or nuclear weapons, the
In a given situation, describe patient treatment
priorities in the context of environment and
environment may be both austere a11d hostile. In a hos
relative risk.
tile environment, the safety of the patients, medical care
provi.ders, and even the medical facility is threatened, In a given situation, identify available re
and provisions must be made to protect them. How do sources and treatment options.
doctors support the ABCDEs of patient care in such sit
uations? The goal of this chapter is to explain how to I n a given situation, adapt available resources
apply the principles of Advanced Trauma Life Support
to meet the ABCDE goals of Advanced Trauma
Life Support.
(ATLS) when standard equipment and supplies are not
available or advisable in a n austere or hostile environ
ment.
practices. rl' Further description of such wounds is in

Background cluded in Appendix B: Biomechanics of lnjury.
Some areas are thrust into austerity or become hos
Many cow1tries of the world are able to commit signifi tile environments because of the destruction of their in
cant resources to health care, including the care of injured frastructu.res by disasters, either natural or human-made
patients. The ATLS course is written with such well (eg, terrorist actions or war). These situations are particu
equipped and well-staffed hospital facilities in mind. How larly challenging because of their unpredictability. Citizens
ever, not all the equipment and supplies for diagnostic of large countries with strong militaries should not fail to
testing and treatment mentioned within the course are prepare, believing themselves to be immune.
available to all doctors. Some countries and regions have Doctors in disaster situations will be more prepared to
few resources to devote to health care. The doctms who care for injured patients when they recognize that ATLS is
practice in these countries include local nationals, mjs not comprised of the equipment and supplies that can be
sionaries, tnilitary personnel, and members of charitable used for patient care. Rather, ATLS is an organized ap
and relief orgaruzations, such as Lhe International Red proach to the care of injured patients with the goal of treat
Cross and Red Crescent Societies. Remote and wilderness ing the most life-threatening conditions first to decrease
areas in any country are austere medical environments. morbidity and mortality. This appendix is not an exhaus
Hostile environments are defined by ongoing risks to tive manual for care in these environments. It describes
the patients and rescuers. These risks may be from lhings some substitutions or adaptations to meet the goals of
such as climate, collapsing buildings, explosions, and tox ATLS in this context.
ins, but are most conunonly associated with enemy action
in some advanced police situations and the military. Those
who know that they will practice in such environments or
Austere and Hostile
who wish to be prepared for such events should seek ad
ditional training in the care of massive wow1ds from ex
Environments: Context
plosive weapons. Although the number of survivors with
such wotmds is small, they offer challenges in hemorrhage The AILS course focuses on treatment priorities for
control and management that are not seen in most civilian trauma patients in a robust hospital environment. Austere
305
306 APPENDIX G Austere Environments
and hostile environments arc different for several reasons, Pharmacologic support may be minimal or nonexis
including personnel and their safety, communication and tent, so clinicians must know how to make optimal use of a
transportation, and equipment and supplies. limited m.1mber of medications. Some treatments should
nol be started unless they can be completed appropriately
or treatment regimens may need t o be delayed or tempo
PERSONNEL AND THEIR SAFETY
rized until resomces and definitive care are available. For ex
Personnel limitations are a key factor in austere and hostile ample, frostbite should not be rewarmed if the individual
environments. Available care providers may not have been cannot subsequently be kept warm, because the risk of re
trained to deal with injured patients, and specialty and sur freezing can cause more injury than simply leaving the part
gical care may not be available. In addition, there may be frozen for a longer period.
blurring of specialty boundaries; a surgeon or nonsurgeon
may be called upon to perform procedures that are typically
pcrformecl by other specialists. There may be too few or no MILITARY COMBAT CASUALTY CARE
doctors or other health care providers. The abilities of the To son1e, Lhe term military combat casuafty care implies a
most highJy trained specialist can be neutralized by the lack single homogeneous entity. In fact, military combat casu
of equipment in a hostile environment, such as an environ alty care is conducled over a continuum of that can progress
ment under enemy fire. Such providers must evaluate what from austere <tnd hostile to robust and protected. Large mil
should be done, balancing what lhey are capable of doing itary field hospitals may offer more resources than are avail
with \vhat can be done with the available resources. able lo the sunounding populace. Some have enough
resources to use the tools described i n the ATLS course, such
COMMUNICATION AND TRANSPORTATION as specialty care, CT scanners and interventional radiology.

However, the various sized hospitals at sequential echelons
Di srupted or nonexistent communication can prevent spe of care may all become austere environments, depending on
cialt)' consultation, p rov i sio n of supplies, and arrangement the number of casualties received within a certain period or
for removal of casualties. Disrupted communication is the on enemy action.
most commonly cited "lesson learned" i n disasters. Plans Military combat casualty care occurs in phases Lhat are
must be in place for alternative means of communication best described in Tactical Combat Casualty Care (TCCC or
prior to an event. Transportation to bring in resources and TO), a program that was developed by the U.S. military and
persmmel or to transport patients to definitive care may be has been adopted by a number of other countries. The ear
infrequent or nonexistent. lier phases of TCCC are the most austere and hostile and
overlap greatly with prehospital care; i n fact, tl1e earliest lev
EQUIPMENT AND SUPPliES els of care arc provided primarily by medics or fellow sol
diers. This recognition has lead to the inclusion of the TCCC
An austere environment is defined by limited equipment concepts in a military version of the Prehospital Trauma Life
and supply resources. A typical community hospital emer Support Course (PHTLS), which is a useful reference for

gency department is very well supplied when compared with doctors who are likely to practice in this environment. Re
most out-of-hospital settings. Doctors need to understand view of TCCC and PHTLS is key for the doctors at tl1e
that even equipment that is outdated, suboptimal, or in higher echelons who will receive the patients so tl1ey un
tended for other uses can be used to save lives. Triage deci derstand what the medics have done and why.
sions Lhat change the treatment of ABC prioriLies may be
necessary to balance the needs of the patients with the avail
able resources. For exampie, a paucity of suppi ies relative to Care Under Fire
the number of casualties may make i t inadvisable to start an Care Under Fire, the first phase ofTCCC, is the most austere
intravenous line on many injured patients. Lim i t i ng tluid and hostile. At this Level, Lhe main obligation of Lhe provider
use to patients who are sufficiently hypovolemic to sustain is to prevent further injury by removing the casualty from
cellular damage helps to extend fluid resources. the area of danger or by suppressing enemy fire. This con
Definitive care is not usually possible i n austere and cept also applies to some advanced special weapons police
hostile environments. Diagnostic challenges include man units n
i larger cities. Only a small percent of these casualties
agement of possible fractures without radiology support have ajrway or breathing injuries as their primary life
and blood pressure determination in the absence ofblood threatening injury; rather, the casualty frequently demon
pressure cuffs. Operative considerations in these environ strates a patent ainvay by requesting aid. In addition, the
ments include deciding which operating room procedures medic does not have the safety, lime, or equipment for ad
can be performed outside the operating room under less vanced airway management.
than ideal circumstances versus which operative proce The most common life-threatening injury is extemal
dures should never be performed outside the operating hemorrhage, usually from the extremities. In this context
room. (risk of a specific injury and the de facto clearing of airway
PREPARATION AND PLANNING 307
and breathing by use of the voice), the concept of "CAB" thus the care provided may also need to balance the context
(circulation or hemorrhage control, followed by airway and of the tactical situation with d1e medical needs.
breathing) has been proposed. This mantra, the inversion
of the "ABC" ofATLS is proposed to be different from ATLS.
OTHER CHAllENGING ENVIRONMENTS
l n fac t, CAB does not deny the importance of ai rway and
breath ing but addresses the most Likely danger and the only
, Remote areas have p ro blem s that are unique, such as iden
one that can be addressed rap idly in the sit uat ion. This sug tification of the occurrence of i11jury, which is a significan t
gests that ABC is not a linear mandate, but is i nstead problem in remote areas. For this reason, highway call boxes
important life saving priorities in a circle; i n many research
- are in place in many developed countries, and some vehi
rich environments, they are addressed simu.llaneously. The cles have been fi tted with emergency locator t ra nsmit ters
context will decide which of the three may take treatment similar to those in airplanes. Ln addition, the burden of rural
priority in a resource-constrained environment when o nly and remote areas includes the problems generated by time
one can be addressed at a time. ln Care Under Fire, hemor and distance.
rhage control assumes the highest priority. Tourniquets are vVi lderness acti\rities such as hiking/biking, spelunking,
useful to sav e I ives during Lh is phase, as the medic cannot and water sports create a special chall enge for the medical
maintain pressure while under fire. Advanced hemostatic care provider, as the bulk a nd weight of medical supplies be
dressings may also be used, but they require some period of comes a tremendous issue. When supplies must be carried
pressure to achieve benefit. by backpack, rneclications and provisions must be thought
fully selected. These also are the activities that can result in
Tactical Field Care the most chaUengi ng evacuation because of the difficuhy of
contacting help.
After tbe casualty is removed from under fire to a relatively
Natural disasters (cg, hurricanes, tornados, and floods)
safe place, a more thorough evaluation of ABC is accom
and human-made disasters (cg, terrorism, war/armed con
plished and treated if need be wih
t the lools and skills avail
llicts, and industrial accidents/chemical spi lls) can rapidly
able. This phase is tem1ed Tactical Field Care.
turn a no naustere environment into an austere one. Even
doctors work ing in tertiary-care cen ters sho uld h ave t rai n
Care During Evacuation ing and knowledge of trauma care under these circum
The evacuat ion phase may invol ve very austere vehicles and stances. The hospi tHI and the com mu nity should devel op
helicopters implying basi.c care, and is often called
, an d practice plans for such situations.
''CASEVAC" for Casualty Evacuation care. Evacu a tion from
larger hospitals may also involve worldwide air transport
with ICU level care. This may also be referred to as Air Evac.
Preparation and Planning
Successful trauma care in austere and hostile enviro11mcnts

Medical Units comes from careful preparation and planning.
Along the way, depending on the countries involved and the

TRAVEL TO AN AUSTERE OR
situation, the casualty may be treated in medical units with
HOSTILE ENVIRONMENT
various levels of capability from aid stations with doctors
-
and no surgeons to small surgical teams with limited post Doctors traveling to austere or hoslile environments must
operative care performing hemorrhage control with "dam first prepare for self-protection and survival; otherwise, they
age control" procedures to very robust field hospitals. C<ue can become a burden rather than a help in lhe situation

.
in each setting is applied according to the context. Good physical health and fitness are prerequisites. Appro-
Most tactical care must be accomplished with the re piate shel ter, cloth ing, food, and ,.vater must be planned for,
sources that soldiers can cauy with them. There is a pre and in many cases, brought with the individual. lt cannot
mium for lightweight items that can perform more than one be assumed that such supplies are available. Before travel
use, as well as items that are likely enough to be used as to ing, careful communication with the local authorities and
justify the weig ht Since resuscitation fluids are beavy, deci an advance party must be accomplished.
sions on fluid types, volumes, and use are strongly impacted Communication between members of the party, with
by their weight local and international authorities, and with the home base
Some special military units funct ion covertly in hostile must be planned . Planning for the care of loved ones and
areas, complicating trauma care, with prolonged times to the medical practice left behind includes wills, powers of at
defmitivc care and the need to avoid detection. Such units torney, and access to funds to pay bills.
bring inlo sharp relief the understan di ng that a successful Adminislrative preparations include passports, visas,
mission is likely to save more lives than any medical care, local currency, and transportation. It is important ro have
an invitation by local authorities to enter either the country rily on the environment itself, the limited equipment that is
or austere/hostile environment-unwanted and unprepared usually available, and the evacuation constraints. If the pa
volunteers only place a burden on the local system. tient is threatened with further injury because of environ
Personal health protection includes vaccinations, ap mental concerns (eg, rough terrain), preventing fu rther
propriate personal prescriptions, and over-the-cotmter injury to the patient and to the health care provider takes
medications. priority. Once the site is secure or the patient is moved to a
Further preparation for military physicians varies by safe location, then tlle doctor can attempt to aid the victim.
country. .. See Chapter 2: Airway and Ventilatory Management.
PREPARATION OF A HOSPITAL FOR BECOMING AIRWAY

AN AUSTERE OR HOSTILE ENVIRONMENT
Discerning the patient's true airway status may be difficult
Preparalion of a hospital for disaster requires a city- or in an austere or hostile environment. The "look, listen, and
region-wide plan that includes communications with fire feel" approach remains impor"lanl. However, under condi
and rescue personnel, police, and civil and military author tions of low Jjght, high noise levels, etc., the recognition of
ities. Such a plan includes how and when to involve each of airway problems may be challenging. It requires close at
these authorities and clearly delineates a chain of command, tention, patience, and ingenuity to fully evaluate the patient.
including who is in charge. These plans determine how pa Feeling chest or abdominal movements may become the
tients are sorted and routed to the appropriate hospital to primary means of assessing airway patency and breathing
avoid overwhelming any one institution. efforts.
An assessment of the tllJ"eats is in1portant. Health care
providers in the tropics may need to consider typhoons and
volcanoes, whereas those in other regions may need to pre Airway Maintenance Techniques
pare for earthquakes. Terrorist threats are not predictable. Management of a compromised ainvay is usually performed
Hospitals need to have a pla_n to recall key personnel and a in a standard fashion in the austere environment. However,
personnel rotation plan to allow those personnel to rest if because of limited equipment or personnel, other issues or
the situation is prolonged. mechanisms may become important. Foremost is the deci
Spare equipment and supplies need to be stored in pro sion to initiate treatment. If a patient with a compromised
tected areas in the event regular equipment and supplies are airway can be treated rapidly and maintaining that airway
destroyed or contaminated. Plans must include options for does not risk the safety of others in the group, hen
t the stan
loss of electric power, water, steam sterilization ventilators, dard tecl1_niques remain unchanged.
intensive care unit(s), etc. Associated with initial airway management is protec
Terrorist activities, industrial accidents, and war can tion of the cervical spine. Cervical collars and other devices
contaminate the patients and facilities with toxic chemical normally used Lo protect the cervical spine during transport
or biologic agents. Although a detailed discussion of these and evaluation are sometimes not available, so ingenuity is
agents and specific protections and treatments is outside essential to protecting the neck. Common examples of
the scope of this chapter, the doctor must become familiar equipment used in stabilizing Lhe neck include blankets, pil
with the symptoms, signs, and treatment of these condi lows, shoes, sa11dbags, malleable splints, and padded hip
tions. belts. Cervical spine injuries are uncommon in penetrating
Plans must include decontamination of patients prior trauma, particularly in the military, so complex methods to
to their being brought into the health care facility so that protect the C-spine in this situation are rarely necessary.
the health care workers do not become secondary casualties During care under fire, such efforts are unlikely to be
who are unable to help. Protective clothing and respiratory needed, and put the rescuer and victim at increased risk. If
protection must be available. Detection equipment for var there is evidence of a fall, blunt injury, or motor vehicle
ious threat agents must be available, and caregivers must be crash associated with the penetrating injury, then C-spine
familiar with the use of these items. Fi naJJy, the plan must be protection should be considered. Even with these other
exercised as a ''full-dress" rehearsal on a regular basis. mechanisms, efforts at cervical spine protection should not
delay removing the victim from the line of fue.
Management of Airway Chin Lift/Jaw Thrust Performance of chin-lift/jaw

thrust maneuvers remains unchanged in the austere envi
and Breathing ronment. Placing the patient on his or her side in the "rescue
position" may also be helpful. A temporary means of lifting
The procedures needed to treat problems in "A" and "B" may the tongue off the posterior pharynx can be perfonned by
vary substantially in an austere environment. The problems attaching the anterior tongue to the lower lip or chin with
facing treatment in this type of environment center prima- safety pins or sutures. Alternatively, the pins can be held for-
MANAGEMENT OF AIRWAY AND BREATHING 309
ward with slring attached to the patient's clothing. Placing by the presence of blood or secretions, is performed blindly,
the pins transversely through the tongue wiU keep them from and does not require manipulation of the cervical spine.
pulling through. Once learned, it can be performed rapidly to obtain a secure,
definitive airway. However, it does not provide visualization
Oropharyngeal and Nasopharyngeal Airways The of the laryngeal cords and exposes the doctor to bodily flu
use of oropharyngeal and nasopharyngeal airways remains ids. ln addition, precautions must be taken to protect the op
important. If placement of one of these ainvays relieves Lhe erator's hand from the patient's teelh. To perform this
airway obstruction, then it must be well secured prior to procedure, the patient must be wKonscious. Facing the pa
evacuation. lf ventilation must be assisted wilh a face mask, tient from the front, hook the first and second fingers of one
then the patient ties up additional valuable personnel re hand over the tongue and inlo lhe vallecula or grasp the
sources prior to and during evacuation. When the proper epiglottis with the fingertips. The ET is guided along the
equipment is not available, a nasal airway can be made with groove between the fingers into the trachea.
a urinary catheter, radiator hose, or other small tube.
Surgical Airway
laryngeal Mask Airway The laryngeal mask airway The inability to obtain an airway using any of the previously
(LMA) is designed to be placed blindly into the posterior mentioned techniques is the main indication for a surgical
pharynx, with its final position resting over the epiglottis. It airway. Lack of training in performing the procedure and
should be viewed as an interim airway between the oropha unavailability of necessary equipment may preclude tllis
ryngeal and nasopharyngeal airways and Lhe endotracheal technique from being performed rapidly and safely.
tube (ET). In addition, the modified LMA can be used as a
conduit through which an ET can be placed.
Needle Cricothyroidotomy Entering the cricothyroid
The LMA is viewed as an alternative to the face mask
membrane with a large-caliber intravenous catheter and .i n
to establish and maintain control of the patient's airway, but
sufflating the lung with pressurized oxygen is quick and easy.
it is not a substitute for an ET. It establishes an airway in un
However, it requires an oxygen source. If the equipment is
conscious patients without a gag reflex, but because it does
available, this technique can provide up to 45 minutes of oxy
not completely occlude the tracheal inlet, it cannot reliably
genation until a more stable airway can be established. .. See
prevent aspiration. It can be inserted from virtually any po
Chapter 2: Airway and Ventilatory Management, and Skill
sition using one hand. As it is inserted blindl}', the patient's
III-A: Needle Cricothyroidotomy.
head and neck are maintained in a neutral position.
Surgical Cricothyroidotomy .. Surgical cricothy
Multilumen Esophageal Airway Devices Multilu
roidotomy and its advantages and disadvantages are outlined
men esophageal airway devices contain two cuffs and two
in Chapter 2: Airway and Venlilatory Management, and Skill
airway ports. The}' differ from the esophageal obturator air
UI-B: Surgical Cricothyroidotomy. In the absence of an ET
way in that lung insufflation does not require the use of a
tube, an airway can be made from a syringe barrel, a flash
face mask, with all of its inherent problems and difficulties.
light or pen casing, or another small-diaineter tube.
Use of these tubes requires minimal skill and equipment; as
with the LMA, they can be inserted rapidly and blindly with
Percutaneous Puncture/Dilation Techniques Per
minimal cervical spine manipulation. Ventilation does not
cutaneous puncture/dilation uses one of several products on
require the face mask to be sealed. Their design allows ade
the market to penetrate the cricothyroid membrane. The
quate ventilation regardless of whether the distal tube and
opening in the cricothyroid membrane is dilated in a man
cuff are in the esophagus or the trachea.
ner similar to that of the Seldinger technique to allow place
ment of the ET tube. Performance of the technique is similar
Definitive Airway to that of needle cricothyroidotomy for jel insufflation, yet
The definition of a defin itive airway remains unchanged permits a standard cuffed tube to be placed in the trachea. rt
in the austere environment-a cuffed tube in the trachea. does require special equipment and more time to perform,
Endotracheal intubation with an ET and laryngoscope and has all of the inherent complications of other surgical
.
remain the standard against which all other airways' ef rurways.
fectiveness is compared. However, under austere condi
tions, the environment or lack of required equipment
VENTILATION AND OXYGENATION
may prevent the performance of standard endotracheal
intubation. After an airway is established, sufficient oxygenation ru1d
ventilation must be supported. The challenges in the aus
Tactile/Digital Orotracheal Intubation Tactile/digi tere environment focus on the equipment needed to sup
tal orotracheal intubation is potentially useful in a difficult port the failing respiratory system and the number of
environment; it requires minimal equipment, is not hindered personnel required to assist the patient. Because supple-
mental oxygen usually is not available, the ability to support distention can easily occur, gastric tube placement should
a patient with oxygen remains very difficult in an austere be considered.
environment.
When oxygen is available in only limited amounts, it
should be reserved for patients with evidence of hypoxia on
physical examination (cyanosis), by pulse oximetry read
Management of Circulation
ings, or by blood gas analysis. The patients most Wcely to re
quire the additional oxygen in the short term are those with The tools and supplies used to treat injured patients become
chest injuries associated with lung contusion. less plentiful as the environment becomes more austere.
Initiating ventilation in the austere environment com Nowhere is this more obvious than in management of hy
mits personnel and resources to the patient. Maintaining the povolemic shock. Fluids (crystalloid, colloid, and blood)
ain-vay in these environments and during transport requires that are the mainstay of restoring circulating volume are
close vigilance because of the risk of the airway device be very bulky and heavy. They are usually fo und in only mini
corning dislodged. Monitoring includes ensuring a secure, mal amounts in most field kits, and are quickly used up in
patent ainvay and adequate ventilation. Ideally, monitoring disasters.
also includes pulse oximetry and end-tidal COz monitoring, Althougl1 the presence of shock in an injured patient
if available. demands the immediate involvement of a surgeon, one may
not be available, or the surgeon's skills may be negated with
out appropriate surgical equipment, anesthesia, and support
CHEST INJURIES
personnel. The goal under such circumstances is to maintai n
Chest injury in an austere environment should be handled l ie
f until a higher level of care can be delivered.
as discussed in . Chapter 4: Thoracic Trauma. However, Successful treatment of hypovolemic shock under these
not all materials necessary to manage a chest wow1d may be conditions reqttires a thorough understanding of the com
available. Open chest wounds must be covered, but in the pensatory mechanisms of the body. . See Chapter 3:
absence of a chest tube, an occlusive dressing using plastic Shock. Although the goals of resuscitation are unchanged,
bags, IV lluid bags, or something similar can be used. Such the emphasis may shift in the austere environment. Less
ancillary devices arc taped on three sides to prevent a tension than ideal organ perfusion may have to be accepted. "Life
pneumothorax; however, three-sided taping may not be ef over-! imb" and triage decisions assume a central role in sav
fective in dirty, sweaty casualties. I n this case, complete oc ing as many lives as possible.
clusion with petroletun jelly gauze is used. The patient is
then monitored for or prophylactically treated for a tension
HEMOSTASIS
pneumothorax.
Needle decompression of a tension pneumothorax is Control of bleeding is of utmost importance when there is
performed as described previously. See Chapter 4: Tho minimal or no fluid with which lo replace the lost blood.
racic Trauma, and Skill VlJ-A: Needle Thoracentesis. How Direct pressure remains important and may be augmented
ever, a tube other than a large-caliber IV catheter may have with the compression of the artery above the bleeding site at
to be improvised. The decompression ideally is performed a pressure point-points where arteries pass superficially
with an over-the-needle catheter with the catheter left in and are felt as pulses. These pressure points are the radial,
place to prevent recurrence. A Heimlich valve can be at brachial, and axillary arteries in the arm, and Lhe femoral,
tached to the catheter. If a Heimlich valve is not available, popliteal, and ankle arteries in the leg. Compression of the
one can be improvised with a finger from a rubber glove at artery for 20 minutes can stop or decrease the bleeding suf
tached lo the tube ""rith a hole at the fingertip. This simu ficiently to allow a dressing to be placed,
lates the flutter valve of a Heimlich valve. Of course a simple Elevation of the bleeding area above the level !)f the
small stab wound, such as would precede the placement of heart reduces the pressure to the bleeding area and aids he
a chest tube, will decompress a tension pneumothorax and mostasis for arterial bleeding. Elevation and a dressing may
should be considered when other options are unavailable. be all that are necessary for venous bleeding. The patient or
If air evacuation is planned, the effects of altitude, tem another individual may be enlisted to hold pressure, while
perature, and other factors associated vvith flight must be the doctor treats someone else.
considered. For airway management, endotracheal cuff pres In the worst cases, tourniquets are used. Although there
sures increase. If a manometer is not available for the flight, is a real risk of limb loss with a tourniquet, blood loss must
then lhe cuffs are filled with a nonexpanding liquid (water be stopped to save the life of the patient. Commercially
or saline) rather than air. Similarly, a pnetm1othorax also available simple small windlass tourniquets that can be ap
expands at high altitudes, with the potential for unexpected plied with one hand are used by many military services.
respiratory compromise. Ideally, supplemental oxygen Those venturing into austere environments of combat
should be made available because of the decreased partial should ensure their availability. Any flexible material of
pressure of oxygen at high altitudes. Finally, because gastric enough length (rope, wire, cloth strips) can be used to en-
MANAGEMENT OF CIRCULATION 311
circle the limb and be tied in place. A rigid device (eg, a rod tion tubing, with the connectors cut off, nasogastric tubes,
or stick) is placed through the loop and twisted to tighten il and urinary catheters may be used for venous access with a
until bleeding ceases. Arterial flow to, as well as venous flow cutdovvn. rl' See Chapter 3: Shock, and SkU! V-A: Venous
from, lhe extremity must be stopped to prevent paradoxi Cutdown.
cally increased bleeding from venous injuries. The lime of
tourniquet application should be recorded, and tlus wriltcn Alternative Fluid Routes
record should accompany the patient. When the time to care
Although oral fluids are avoided in the usual clinical arena
is short, there is little dsk to the limb, and a li fe can be saved.
because of the possibilit}' of aspi ration, fluids may be ad
The risk to the limb increases with the duration of use of
ministered orally to the awake patient, or via a gastric tube
the tourniquet. Life over limb is a time-honored choice that
in the unconscious patient. Absorption may be decreased
should not be made lightly. Especially i n combat, the re
after injury, but il docs occur. Similarly, rectal clysis allows
ceiving doctor should remember that the decision was made
excellent fluid absorption, as demonstrated during World
under fire.
War I. Only about 250 mL/hr can be absorbed safely by ei
A technique that stops vigorous scalp bleeding Tom f a
ther of these routes, so they arc most useful as substitutes
large flap is to fold the flap outward onto itself. This crimps
for massive resuscitation in dehydrated patients and those
the vessels and stops the bleeding. After 20 minutes the
wbo have had mild lo moderate hemorrhage that is now
bleeding should be stopped or slowed enough to return the
con trolled.
flap to its normal position and apply direct pressure and
Patients who do not have partial stabilization on their
dressings. Prior to surgical management, endogenous he
own or who do not respond to some fluid using these alter
mostatic mcchatusms must be relied on to control unseen
native metl1ods are unlikely to respond to large amounts of
bleeding.
fluiJ. This might be used as a triage consideration, placing
With the possibility of ongoing or barely clotted bleed
such patients in the expectant category
ing sites, rapid restoration of normal blood pressure with a
vigorous fluid bolus should be avoided. Smaller amounts of
fluid given more slowly and stopped when the blood pres Fluid Choices
sure rises lo an acceptable, yet Jess than normal, level may The fluids used are those that are available. Usually this is
allow the clot to be maintained and still provide adequate crystalloid or co!Joid fluid. In military situations, fluid
organ perfusion. choices are usually based on weight considerations; colloids
Advanced topical hemostatic d1essings are increasingly and hypertonic fluids weigh less for equivalent intravascu
available. All function as "pressure adjuncts" and require lar volume than do crystalloids. The initial effect of in
some period of pressure over them with a bandage after ap creased blood pressure may dissipate over time as the body
plication to affect hemorrhage control. Some have Lhe side water equilibrates w:ilh the osmotic load. Blood transfusion
effect of exolherrnia, which can damage normal tissue. A from noninjured members of the group can be considered.
stepwise algorithm has been proposed i n military care in Typing can be done by the patient's report of his or her own
several countries. JL emphasizes the usc of normal pressme blood type. Quick "crossing" of drops of blood from the pa
techniques or tourniquets to control hemorrhage first. If tient and the donor on a smooth white surface, which was
these fail or an analysis of a large wound suggests tl1at they the method used in the earliest days of blood transfusion,
will not be effective because of the wound's location, then may reveal major incompatibilities by clumping. Of course,
the hemostatic agents that have no side effects should this is an unusual choice for difficult circumstances, and
be used first. If ineffective, they can be followed by those it carries some risk. Such fresh whole blood does bear
with potential side effects if needed. This balances the the additional benefit of clotting factors useful in severe
potential risk of the exothermic reaction with Lhe benefit of hemorrhage.
hemostasis. Careful consideration of the goals of f1i-!id therapy is
necessary in planning the use of a limited quantity of flu
ids. Patients who appear to be compensating for their fluid
RESUSCITATION losses and maintaining organ perfusion may require no t1u
Fluid resuscitation i n the austere environment may be chal ids. This can be judged by level of consciousness. The con
lenging. Both difficulties in establishing access and having scious cooperative paLient can be observed. Units of Uuid
sufficient fluids are likely obstacles. (bags, bottles, etc.) can be split among several patients, giv
ing each only the amount absolutely necessary to maintain
life. Plujds such as commercial beverages ma)' be used as oral
Venous Access rehydration fluids. When balancing rebleeding \'\lith organ
Central venous access kits, intravenous needles, and in perfusion, careful reevaluation is key to determining
traosseous needles may be unavailable i n an austere or hos whether further small amounts of fluid should be given to
tile environment, so performing venous cutdown assw11es a maintain tl1e low level of perfusion necessary to maintain
more important role in these situations. Fluid administra- life until definitive care is possible. A less than normal blood
prcl>sun. 1s acceptable with this tech nique. [f the patient is sorption and thereby decrease the likelihood of toxicity. A
unconsliou, fluid is titrated on and off a ccord in g to the caveat is to not add epinephrine if the injection is used in
presenct or absence of the radial pulse. Care must be taken fingers, toes, penis, or nose because of the risk of ischemia
when ti 1rating hyperton ic or colloid lluids in this manner, as in these areas with arteriolae. Another point to remember
they may overshoot the target blood pressure as they recruit is that the nonsteroidal antiin 0<1mmatory medications may
extravascular fluid. inhibit platelet function. so they must be avoided if there
is hemorrhage or an injury with significant risk of severe
h emorr h age.
Ketamine, a dissociative anesthe t ic, can be used safely
Pain Management e1thcr intramuscularly or intravenously. It has an effect sim
ilar to that of general anesthetics in that the patient is un
Control of pain and alleviation of suffering is a primary aware of his or her surroundings. Allenlion must be directed
goal of all doctors. This is important not only as a kind to keeping the airway free of secretions. Although ketamine
ness, hut

also to minimize the adverse physiologic conse is useful for sutme repair of laccrtltion and setting of frac
quences of pain, such as incrcG\Sl'S in levels of tures with angulation or arteria] compromise, the individual
catecholamines and cortisol, metabolic rate, and total body will not be able to function without assistance for 1 to 2
oxygtn consumption. Management of pain in hosp i tals is hours, making it necessary to carry the patient if evacuation
fatilitated not only hy the availability of many different is imminent. Other agents allow the patient to assist n
i his or
analgeic agents and cardiovascular monitoring, but aho her own transportation, if his or her injuries allow.
by the a\ailability of anes thesiolo gists who are knowl
edgeable and helpful regarding pain management. Austere
circumM<Inces require alternatives to hospital- based pain
management protocol s. Management of Specific Injuries
Pain management is a challenge in austere military cir
cumstances because oflimitations in the numbers and types
ABDOMINAL INJURIES
of personnel and equipment and drugs and the potential for
even a few casualties to overwhelm existing resources. The The evaluation and management of abdominal in.iuries in
doctors in these locations should be familiar vv-ilh all uses of austere sellings is very different from what is practiced in
the agent they have available. Civilian remote and wilder well-equipped modern ho!>pitals . See Chapter 5: Ab
ness situations provide similar challenges to relieving a pa dominal and Pelvic Trauma. Mortality from untreated in
tient' pain. A wi de spectrum of thera peu tic agents is not traabdominal injury is high: patients either die quickly from
a lways available to the doctor in these venues. Agents must uncontroUed hemorrhage or they die later from intraab
be carefully selected, not only for their ability to relieve pain domin.tl sepsis. For this reason, a high index of suspicion
but also with consideration for safety. must be maintained in these patients. Those with suspected
Principles of pain management in the austere environ injury must be referred early for surgical consultation or
ment include: (I) type of environment; (2) available op evacuation. Sophisticated diagnostic techniques such as ul
tions; (3) anatomic location and severity of injury; (4) trasound and computed tomography (CT) are not available
posibil ity of complications; ( 5) allergies; ( 6) ass ocia ted in in the austere setting. Diagnostic peritoneal lavage (DPL),
juries; .111d (7) ava i labili ty of, t iming of, and plan for evacu while potentially available, has very different indications and
ation. The choice of a drug or multiple drugs depends on im pl ications in this setting.
many factors. Many agents are available to relieve pain or The actual mechanism of injury becomes paramount
act as adjunct. in establishing priorities in settings with limited resources.
Patients in a low-flow state secondary to hypovolemic Gunshot wounds to the abdomen, unless clearly tangential,
<;hm:k should not be given intramuscular injections of nar are associated with visceral injury in 90% of patients. These
cotics, as these drugs can remain in the muscle until flow is patients all require rapid su rg ical rctcrral and celio tomy. fn
restored. With restoration of lJow, a bolus of drug is rel.eased, the civ il i<1 n settin g stab wounds to the abdomen are associ
,
pulling the patient at risk for re!.piralory depression. How ated with visceral injury in only 30% to 40% of patients. Un
ever, in the austere environment, with an inadequate sup less there is clear evidence of intraabdominal injury
ply of I V catheters, it may be necessary to consider the (eg, evisceration, pneun1operitoneum, peritonea] findings,
intramuscular use of narcotics. Oral use is reasonable in the shock, or blood in the nasogast ric tube or rectum), these pa
absence of abdominal and head injury. tients are treated based on symptoms and wound explo
Local anesthetics are considered for hematoma blocks ra tion . Stab wounds usually can be explored under local
associated \"'ith fractures and regional blocks if the doctor is anesthesia without much difficulty to determine whether
knowledgeable about the sites of injection and allowable the abdominal wall fascia is penetrated. If no fascial pene
doses. Remember, local anesthetics can cause seizures if too trations or abdominal symptoms are present, the wound can
high a dosage is used. Epinephrine can be added to slow ab- be managed primarily.
MANAGEMENT OF SPECIFIC INJURIES 313
Blunt [njury to the abdomen is associated with a vari cular injuries, if the patient does not exsanguinate, must be
ety of solid and hollow organ injuries and may be less dra definitively repaired early, within 6 hours of injury, to pre
matic in appearance than penetrating injury. Abdominal serve limb function. Likewise, because of the risk of arterial
pain, Lenderness, distention, shock, or blood in the nasa injury and osteonecrosis, major dislocations should be re
gastric tube or urinary catheter are all suggestive of blunt duced early. FinaJiy, traumatic ampulations usually require
intraabdominal injury. Although CT and ultrasotmd are not early surgical debridement.
available in the austere setting, DPL can serve as a expedient The immediate treatment of extremity injury should
substitute in the field. include, a l a minimum, control of active bleeding by apply
DPL is accomplished with a minimwn of resources and ing direct pressure, cleaning grossly contami11ated wounds,
lime, and is a reliable means to determine whether a signif and immobilizing the injured extremity until the patient is
icant hemoperitonewn exists. If gross blood is not encoun evacuated. Use tourniquets sparingly, if ever, since they place
tered and newsprint-sized writing can be read through JV the entire limb at risk. Dislocations and major angulation
lubing containing the lavage fluid, the DPL is negative for deformities should be carefully reduced, while monitoring
significant intraperitoneal bleeding. DPL is limited in that it tl1e limb's neurovascular status before and after reduction.
provides no information about extraperitoneal organs and If definitive treatment is delayed, administer antibi
structures. It is contraindicated in patients with obvious in otics, perform limited irrigation and debridement of open
traabdominal injury and is indicated only in patients with a wounds, and keep the extremity immobilized with some
high probability of intraabdominal injury. Many of these type of splint or cast. The use of antibiotics in poorly de
patients eventually require celiotomy because of continued brided or nondebrided wounds does not prevent infec
bleeding or peritonitis. DPL might help to identify these pa tions; rather, the goal is to shift the spectrum of infection
tients earlier and assist in triage if evacuation is possible. from gram-positive synergistic gangrene or clostridial in
. See Chapter 5: Abdominal and Pelvic Trauma, and Skill fections that can be fatal in a few hours to more indolenl
Station VIII: Diagnostic Peritoneal Lavage. infections. However, the doctor must consider the risk of
In situations in which evacuation is impossible or sig encouraging resistant organisms when choosing too broad
nificantly delayed, DPL has no role. If a major intraabdom a coverage. Patients with femur fractures should be put
inal injury exists, it becomes quite apparent with time. In into some sort of traction to minimize further blood loss
tl1is setting, DPL adds nothing to physical examination or n
i to the th..igh.
treatment. Splints and traction devices can be improvised from
Patients with a defmite abdominal injury (as demon equipment and resources at the scene. Any rigid item, if
strated by evisceration, shock, peritoneal findings, and properly padded, can be used as a splint. Likewise, a
pneumoperitoneum) are expeditiously referred for surgical makeshift frame can be constructed to provide traction for
treatment. They should receive a broad-spectrum antibiotic femur fractures, sometimes using the patient's own boot or
and intravenous fluids sufficient to maintain urinary out shoe as the ankle hitch. These patients also should receive
put. Open wounds should be cleaned of gross contamina analgesics and sufficient hydration to prevent shock, if avail
tion and dressed. E
viscerations should be covered with moist able. .. See Chapter 8: Musculoskeletal Trauma, and Skill
gauze or dressings, and the patient must be kept warm. If Station XU: Musculoskeletal Trauma: Assessment and
wounds are massive, resources are minimal, and evacuation Management.
unlikely, these patients are given comfort measures only and Compartment syndrome, a late complication of ex
treated expectantly. tremity injury, can present insidiously in injured patients,
Every patient with a significant history of injury should especially after a crush injury in which no fracture is pres
be considered to have an in traabdom..i11al iujury until ent. If compartment pressures cannot be measured, early
clinical examination, diagnostic test, or celiotomy proves fasciotomy may be indicated, especially in the presence of
otherwise. any vascular injury. .
Other late complications of extremity injuries include
fat embolus syndrome, deep venous thrombosis, and os
EXTREMITY INJURIES
teomyelitis. These complications must be considered if
Extremity injuries are common in trauma patients. See transfer to definitive care is markedly delayed.
Chapter 8: Musculoskeletal Tratuna. Although these injuries The management of pelvic fractures n
i the austere set
are not usually immediately life-threatening, they are often ting deserves some comment. Since tJ1c force required to
dramatic in appearance and can divert attention from other fracture the pelvic ring is so great, pelvic fractures usually
injuries. Elicitation of a brief history of the injury and a per occur in association with intraabdominal or other injuries.
tinenl medical hislory should be followed by a complete Patients with these injuries may go into shock because of
examination of the extremity. bleeding from the pelvic fracture itself and fmm both arte
The management of extremity injuries depends to a rial and venous vessels in the pelvis. Patients aJso may have
great extent on the available resources and the length of time significant neurologic injury, as well as genitourinary or
it takes to transfer the patient to a definitive care facility. Vas- rectaJ injuries.
Very little can he done for suth paucnts in austere en ile dressings. If circumferential hurns are present, distal
vironments, with the exception of immobilization of the circulation nnd the need for escharotomy should be al>
lower extremities and pelvis. The patient should be kept im sessed. If local resources are II m i ted but evacuation is pos
mobil i'lcd .llld Lhe pelvis stabilized as well as possible with sible, even if delayed, the patient with a significant burn
sheet:, sandbags, etc. If available, external [ixal ion can be should be stabilized as much as possible prior to transport.
'
performed to reduce open-book pelvic fractures and help lf possible, the airway should he secured and fluid resusci-
minimize bleeding. Although it is out of 1:wor for use in tation begun. lf resources are limited and evacuation is dif
trauma, a pneumatic antishock garment, if available, can liwlt or impossible, small (<5% of body-surface area)
function as an "air splint" for the pelvis or lower extremi burns o 1en
f heal with nonoperativc care, although some
ties. Care must be taken to prevent compartment syndromes times with significant scarring or loss of fu nction, espe
by overinflation and prolonged use. ci<llly over joints.
Patients with musculoskeletal injuries are classified ac
cording to the severity of their injury and the need for or
thopedic evaluation and trea tmenl . Pa I ien t with vascular
injury nnd dislocations require urgent referral or evacua-
Preparation for Transport
1 ion, as do patients with significant pelvic rractures or sus
pecteu cervical or thoracolumbar spinal injuries. Patients The following discussion highlights the major principles of
with table open or closed fractures also require referral or preparing injured patients for evacuation from isolated cir
evacuation, though less urgently. I f referral or evacuation lUI1l'>tances in which resources arc limited, including mili
i dcl.tyed for more than 6 hours, these patients should ttlf}' operations, wilderness environments, and civil disasters
receive antibiotics, analgesia, hydration, immobilization, with delayed rescue. It may be necessary to provide care for
and wound management as rcsoun:c allow. Patients with hour:. to days in proximity to dangers-for example, fire
:.prains and minor injurie:. can either be treated primarily from ho:.tile weapons, persistently threatening weather, and
or referred to an orthopedist in a more routine fashion. imminent nood.
Under 1hese circumstances, the II rst priori ly is to pro
led the caregivers and tl1e patients from further injury. In
BURN INJURIES
general, a minimum of medical care is attempted while the
The mortality from major burn injuric is significant, even injured patients and caregivers arc exposed to danger. Once
with unlimited resources. Patients with bum injuries often the danger has been mitigated, care of injured patients may
require airway support, mechankal ventilation, and massive commence to the fullest extent possible, given limitations
fluid resuscitation, in addition to management oftheir bmn inherent in the circumstances, " hilc applying ATLS princi
wounds. . See Chapter 9: Thermal Injuries. The initial ple:. with some modifications. The skilb required are simi
evaluation and treatment of these patient:. follows closely lar to those used by a military medic or corpsman in the
the ARCDE algorithm. Remember, these patients often have field once the caregiver and the p.llient are no longer under
other injuries in addition to their burn injury (eg, blast in hostile tire.
jury or injury from jumping in an attempt to get away from The odds of successful rescue/evacuation, if needed, in
the fire). crease dramatically when plans are made in advance for such
Inhalation injury, either from breathing heated air or contingencies. Initiating rescue and communicating with
breathing toxic gases emitted during combustion, essentially rescuers is beyond the scope of this appendix; however, it is
double the mo11ality from burn injury. Patients with sig essential that provisions be considered for establishing com
nificant facial burns and smoke or team inhalation, well munications with or signaling rescuers. This requires a plan
as those with toxic gas inhalation from burning plastics, re for rescue, which includes notification of individuals not in
quire a definitive ainvay (ie, endotracheal intubation or tra volved 111 the movement or plan of action. A flight, fi_oat, or
cheostomy) and mechanical ventilation. expedition plan should be filed with individuals who can
Pmhably the most significant aspect of the care of burn initiate rescue, automatically and nutonomously under cer
patients is the massive Auid replacement they require. These tain cond ilions. It is easy Lo understand why emergency ex
patients also require urgent evacuation to <1 burn center; traction and rescue plans are an essential part of any military
otherwise, the care necessitated by their injuries can quickly operation.
overwhelm even a well-equipped hospital. Under austere llexibility and improvisation while waiting for evacu
conditions, patients with e,erc burns may need to be ation from isolation are important to a successful outcome.
treated expectantly. Seeking appropriate shelter until evacuation is possible is an
The 1nitial treatment of patients with smaller burns early priority. Shelter should be sought as soon as the pa
can be imt1ated i n the austere setting by preventing fur tients and caregivers are out of immediate danger. High
ther injury, limiting debridement to ruptured blisters only, ground is generally preferable if the patient can be moved.
initiating 11uitl resuscitation (orally if necessary), prevent Simple shelters of various types can be constructed from
ing hypothermia, and applying topical antibiotics and ster- available male rials with a minimum number of simple tools.
ENVIRONMENTAL EXTREMES OF HEAT AND COLD 315
Use the following principles while waiting to transporL because of radiation. In contrast, convection is the major
patients: source of heat loss in a cold environment, particula"rly wilh
Move patients as little as possible after sheller is strong winds. Conduction is a major route of heat loss dur
obtained. ing cold-water immersion. Heat losses from convection and
conduction can be effectively reduced with whatever cloth
iniLiate appropriate medical .interventions as soon ing materials arc available. Evaporative heat loss occurs
as feasible, based on the available resources and the through both respiration and perspiration. This route is
.
mJunes. most important during exposure to cool dry environments.
Arrange for a stretcher or litter for severely injured Also, keep in mind that:

or unconscious patients while providing extra Clothing musl provide adequate insulation.
padding to pressure points.
Adequate shelter must be sought for adequate pro
ln general, place patients in a supine position. tection from the environment.
Place patients with thoracic injuries in a lateral de Food consumption must be adequate for the in
cubitus position with the injured side down or in a creased caloric energy requirements.
semi-elevated position (head and chesl elevated at
approximately 45 degrees). Activity must be at an adequate level to produce the
heat required to keep warm.
Splint fractmes with available materials or splint
them to another extremity. The amount of heat lost by convection is determined
by the temperature difference between the air and the body
Keep patients as dry as possible and preven t surface with which il is in contact and by the speed with
hypothermia. which the air is moving. A wind of 8 mph (12.8 kph) re
Shield patients from prolonged exposure to intense, moves four times as much heat as a wind of 4 mph (6.4
direct sunlight. kph). Wind-chill charts detail the relationship between the
ambient temperatmc and the effective temperature based
Do not leave unattended patients close to campfires. on the prevailing wind speed.
1f helicopter evacuation is a possibility, seoul a Iandi ng Many different materials an used for cold weather
site to facilitate rescue. The landing site should ideally be on clothing. The oldest is wool, which is still one of the best be
level, flat terrain Lhal is clear of obstructions. It may be nec cause it contains innumerable small air pockets that provide
essary to mark the site with smoke, reflectors, or other de excellent insulation. One of the greatest values of wool is its
vices that can be seen from the air (branch or stone pointer). ability to provide insulation even when wet. lts major dis
Helicopter extraction (while hovering) is also a possibility, advantage is its weight. Down provides excellent insulation
but it is much more difficult and riskier to the patient. when dry, but provides little protection when it is wet.
Heat production by the body can be increased signifi
cantly only by muscular exercise, either by shivering or per
forming voluntary work. Large muscle:. (eg, leg muscles)
Environmental Extremes produce more heat than smaU muscles. Vigorous exercising
of Heat and Cold can produce more heal Lhan shivering. if a threatening sit
uation cannot be avoided, deliberate exercise that uses large
muscles, such as repeatedly stepping on and off rocks or
Preventing heat and cold injuries is preferable to treating
logs, produces more heat than just standing and shivering.
them. Understanding the effects of environmental extremes
No drugs or other behavior can substitute for exercise as a
on the human body helps to avoid these injuries. Unfortu
means of generating body heat.
nately, accidental heat and cold injuries still occur despite
\.hen cold injury does occur in the austere environ
adequate precautions.
ment, an important principle is to avoid rewarming until a
sustained warm environment can be ensured. Clearly, as
COLD INJURY AND HYPOTHERMIA vvith systemic cold injury, the best management of local cold
injury is prevention.
A high index of suspicion is essential to making the diagno
sis of hypothermia. Patients suffering overwhelming envi
ronmental exposures (eg, cold-water drowning and cold
HEAT-RELATED IllNESS OR INJURY
exposure) are readily identifiecL Preventing hypothermia in
volves two strategies: reducing heat loss and increasing heat Heat illness is due to exposure to increased ambient tem
production. Heat is losl from the skin i n four ways: radia perature under conditions in which the body is unable to
tion, convection, conduction, and evaporation. ln a normal maintain appropriate homeostasis. The milder syndromes
environment, an individual loses so<vo to 60% of body heat are exer tional; Lhe most severe may occur without exercise.
The three common heat-related conditions are heat cramps, Resuscitation with approximately 20 mL/kg of balanced salt
heat exhtlustion, and heat stroke. solution is often required within the first 4 hours. Vigorous
cooling :.houJd be stopped when the patient's temperature
reaches 38.9 C ( 102 F). If myoglobinuria is present, hy
Heat Cramps
dration must be maintained to ensure a good urine output.
Painful muscles after exertion in a hot environment arc Intravenous mannitol (25 g, or 300-400 mg!Kg) may be
often attributed to a salt deficit. However, it is likely that given after ensuring adequate intravascular volume.
many cases represent excrtional rhabdomyolysis. Acute Poor prognostic signs are body temperatures of 42.2 C
muscle injury due to severe exertional effort beyond the lim ( I 08 F) or more, coma lasting longer than 2 hours, shock,
its for which lhe individual is trained can result in myoglo and hyperkalemia. Mortality rates are about 10%.
binuria, but this rarely affects kidney function unless heat As with all thermal environmental injuries, the best
stroke b present. Treatment includes rest in a cool environ treatment for heat stress is prevention. Acclimation to ex
ment and salt replacement with a 650-mg sodium chloride treme heat requires about 3 to 5 days. Best strategies for ac
tablet in 500 ml of water or a commercially available bal tivity involve alternating work and rest cycles and
anced electrolyte replacement solution. emphasizing fluid intake. Work in a desert environment at
49 C ( 120 F) requires 2 1iters of water per hour. Availabil
Heat Exhaustion ity of shelter with shading from the sun is important.
Fatigue, muscular weakness, tachycardia, postural syncope,
nausea, vomiting, and an urge to defecate can result from
dehydration and heat stress. This occurs in unacclimatized Communications and Signaling
individuals who exercise in the heat and results from loss of
both salt and water. Body temperature is normal. There may
be a continuum from heal exhnustion to heat stroke. Treat The principles of effective communications in the austere
ment consists of rest in a cool environment, acceleration of environment include:
heat loss by fan evaporation, and Ouid repletion with salt
containing solutions. After the patient recovers, exercise in Having a working plan in place beforehand.
a hot environment should be avoided for 2 to 3 days to avoid Knowing what your communications system can
recurrcnce. and cannot do.
Having a backup communications plan.
Heat Stroke
Core body temperature exceeds 40 C ( I 04 F) with heat Doctor-to-doctor contact with at least a minimtun of
stroke and severe central nervous system dysfunction and patient information or f referral is the safest way to coordi
anhidrosis occur. The two types of heat stroke are classic and nate patient transfers. Unfortunately, the austere environ
exertional. ment may not afford either a doctor or a reliable means of
Classic heat stroke occurs after several days of extreme communication. Effective communications rely on a
heat expo:.urc in individuals who are not acclimated. Risk preestablished and tested means of communication, with
factors include chronic illness, advanced age, high humidity, contingencies for a backup system when lhe primary means
obesity, chronic cardiovascular disease, poverty, alcohol of communication fail. Available technologies include hand
abuse, dehydration, and use of sedatives. Sedentary heat held radios, cellular phones, and newer technologies, such as
stroke is a disease of the elderly or infirm whose cardiovas tclemcdicine.
cular !.}'stems are unable to adapt to the hot environmental Limitations of a telephone system in a disaster setting
stress. include destruction of the phone lines, power lqss, in
Excrtio11al heat stroke occurs rapidly in unacclimatized clement weather, and an increase in phone calls that fre
individuals who exercise in conditions of high ambient tem quent!)' result in system saturation and overload. Cellular
pera ture and humidity. ln the United States each year, about phones should ideally serve as a backup to a VHF radio
4000 people die from heat stroke. Exercise-induced heal com mun ica tion system, which emits a directional signal
stroke most often affects young people (cg, athletes, military that could be pinpointed. In addition, Global positioning
recruits, and laborers). Individuals with this type of heat systems (GPS) are becoming relatively inexpensive and
stroke arc more likely to have disseminated intravascular co afford the medical care provider the opportunity to iden
agulopathy, lactic acidosis, and rhabdomyolysis. tify his or her location in the austere setting "vith extreme
The treatment for heat stroke is rapid cooling. The most accuracy.
efficient method is to induce evaporative heat loss by llllst Oral reporting should be efficient and clear, particu
ing <1nd fan cooling. Immersion in an icc-water bath or the larly in disaster settings in which radio traffic is high. I nfor
use of icc packs also is effective but can cause vasoconstric mation relayed should include scene snfety, number of
tion and shivering, which limits cooling and monitoring. patients, and the patients' conditions. Use of a standardized
TRIAGE 317
phonetic alphabet and phonetic numerals is preferred. cru1 wait for care, and which are so severely injured that at
When no direct contact is made with the receiving facility or tempts at care are futile given the e.xisring circumstances.
medical care providers, every effort must be made to provide The philosophy behind triage is to do the greatest good for
an accurate record that survives with at least a minimum the greatest number. Triage in the austere environment may
amount of transfer data, including patient identification, be required when there are as few as two injured patients,
medical problem, treatmem provided, and patient status at which may easily overwhelm the resources available to a sin
transfer. Online medical care protocols for nondoctor gle doctor. A decision must be made regaJ"ding which pa
providers are critically important when direct medical con tient should first receive the benefit of the doctor's full
trol is not available. attention and application of available resources.
Communications at a disaster site are frequently and Even large, well-orgru1izcd medical teams, such as dis
severely disrupted. Effective means of communication in aster-response teams or military hospitals, may face over
this setting may include handheld radios, messengers, and whelming numbers of casualties. Preplannu1g and practice
megaphones. Disaster management is a multidisciplinary must occur prior to team deployment Typically, the most
community activity, and effective communication among experienced surgeon acts as the triage officer. In the event
disaster responders is best addressed through the Incident the surgeons are all needed to perform operations, another
Command System (ICS). Military organizations can bring experienced doctor can act as the triage officer. This indi
to these sites well-developed communication systems with vidmll should have prior training in triage.
the ability to communicate worldwide through a secure net In ''Vilderness austere environments, the doctor may not
work. Hospitals are expected to report to their local emer have the benefits of preplanning and must rely on experi
gency conununications center about their bed availability, ence. In these circumstances, it is particularly important for
number of casualties they have received and are prepared to care providers lo be ver)' familiar with their equipment and
accept, and items in short supply. In a disaster situation, supplies in order to do the most good for the largest num
most patients are not likely to have accessed the emergency ber of patients. Only with knowledge of available resources
medical services (EMS) system prior to arrival at medical and the possible ways to make the best use of them can a
facilities. Communication backup systems may address doctor save the most Jjves.
unique situations sud1 as communication by medical staff Remember, the en tire concept of triage is predicated on
while operating i n hazardous material suits or a chemical or the fact that not every patient gets immediate attention for
biologic "protective postme." See also Appendix H. his or her most significant injury. [n order to do the most
In the austere environment, available communications good for the Largest number of patients, it is critically im
equipment is frequently limited to that which is carried into portan l to have a basic understanding of triage methods and
the field by Lhe participants. In the event that electronic categories. The first step in a mass casualty event is to "sift"
equipment is unavailable, the best signaling devices are ei the patients rapidly. This may consist of an order for all pa
ther audio or visual. A universally recognized distress signal Licnts who a1e able to move to gather at a single, clearly vis
is essentially considered three of anything-for example, ible site in Lhe immediate area-for example, "Everyone who
three whistle blasts, three gun shots, or three columns of can, please move to the base of the large tree." This enables
smoke. An effective ground-to-air device is a mirror reflect the medical care providers to pay immediate attention to
ing sunlight, which may be seen up to 1 0 miles ( 16 km} the remaining patients.
away. Ground signals should be ::s large as possible and con Next, a careful "sieve" of the more severely injured pa
tain straight lines and square corners. An "X" on the ground tients occurs. Patients with life-threatening injuries are
is the symbol internationally recognized as needing medical treated tirst, using the ABCDEs. The ne.xt priority is patients
assistance. Both day-and night-signaling devices are readily with limb-threatening or other injuries that are not imme
avai !able; these include mirrors, smoke, dyes, flashlights, diately life-threatening-for example, abdominal injuries
flares, search and rescue transponders (SARTs), and other without hypotension.
pyrotechnic and non pyrotechnic devices. In order to do the most good using existing supplies in
an austere environment, it may be necessary to categorize
some pntients as expectant (expected to die). Patients in
this category arc given pain medication, if available, so they
Triage do not suffer. Supplies in limited quantity, such as intra
venous fluids, should not be used in the care of expectant
Mass-casualty triage is the process of sorting or prioritizing patients.
patienLs into specific care categories depending on the num Many mass casualty triage classification schemes exist.
ber and severity of casualties and the resources available at A simple and useful method of triage involves four
that tune. By defmition, triage means there are inadequate categories:
resources to care for this number of patients in the usual
manner. Triage is the process of priorilizing injwed patients 1 . Immediate ( needs treatment of life-threatening
to determine which need medical care immediately, which injuries)
2 Delayed (can wait l to 2 hours or more before Triage of mass-casualty victims is not a one-time exe r
treatment) cise. Triage can occur at several levels, and needs to be both
accura tc and repetitive. Disaster-scene triage may be per
3. M i n i mal or ambulatory (can wail many hours for
formed by experienced pa ramedics initially and then later by
trcatm<.:nt)
an on-site doctor if evacuation of victi ms is prolonged be
4 Expectant or expected to die (given currenr patient caue of the sheer number of victims or difficulties in extri
load and resources) cation or transport to definitive care. It is extremely
important to understand the ncld for repeated triage. Pa
The nam and number of triage categories are not as im ti ents who are placed into the expel.tant category because of
portant as the fact that all care providers have an understand lack of resources in a mass-casualty scenario may become
ing ofthe sy:.tem being used. Color-coded triage tags are useful immediate-category patients once operating room resources
n
i identifying the category into which a patient is placed (cg, become available and no additional patients are expected to
red for immediate, yellow for delayed, green for minimal, and arriw. This is only one of many possible scenarios that
gray for expectan t). Patients who a rc dead should be trans serves to underscore the need for triage to be continuous
po rted to the morgue or another desig na ted area. rather than discrete.
APPENDIX G SUMMARY
ATLS prov ides an organized approach to the care of injured pat ients and is taught in the
context of a resource-rich environment. However, there are many circu mstances that can
result in a doctor needing to work outside the normal environment. These include both
military and civilian austere and/or host1le environments. These may be either planned
(wilderness or mi lita ry) or unplanned ( natura l disaster or terrorist attack) austere and hos
tile environments. Preparation and fam1ilanty with the pnnoples of the care of InJured
patients under austere and hostile circumstances optimize the care provided us10g lim1ted
resources.
7. Bellamy RP. The causes of death in conventional land warfare:

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Disaster Management and

A P P E N D I X H Emergency Preparedness
(Optional Lecture)
U pon com pletion of this topic, the student will be able to

Introduction explain the app li cation of ATLS principles to patients In
jured in natural or human-made disasters. Specifically, the
Disasters may be defi11ed, from a medical perspective, as doctor will be able to:
i nc idents or evenrs in which Lhe needs of patients overex
tend or overwhel m the resources needed to care for them. OBJECTIVES
Although d isasters usual ly st ri ke with o ut warning, emer
gency preparedness-the rea d iness for and anticipation Define the terms multiple casualty incident
of the contingencies that fo llow in the aftermath of disas (MCI) and mass casualty event (MCE) and de
ters-enhances the ability of the health care system to re scribe the differences between them.
spond to Lhe challenges imposed. Such preparedness is the
Describe the "all ha za rds approach to disaster
"
institutional and personal responsibility of every health
management and emergency preparedness, in
care facility and professional. Adherence to the h ighes t clud ing Its application to acute injury care.
stru1dards of quality medical practice that are consistent
with the available medical resources serves as the best Identify the four phases of disaster manage
guidel ine for developing disaster plans. Commonly, the ment and describe the key elements of each
ability to respond to disaster situations is compromised by phase with respect to acute injury care.
the excessive demands p laced on resources, capabilities,
and organizational structures. 0 Describe the incident command system that
has been adopted in his or her specific practice
Multi p l e casualty incidents (MCis), or disasters in
area.
which patient care resources are overextended but are not
overwhelmed, such as automobile crashes that involve 5
or more patients, can stress local resources such that triage
focuses on identifying the patients with the most life
threatening injuries.
Mass casualty events (MCEs) are disasters in which
patient care resources are overwhelmed and cannot be
supplemented, such as nalural or human -ma de disa.slers own thresholds, recognizi ng that the hospital disaster plan
that involve 20 or more patients, can exhausL local re must address both MCis and MCEs.
sources such that triage focuses on identifying those pa Lilte mosl disciplines, disaster management ru1d emer
tients with the greatest probability of su rvival .
gency preparedness experts have developed a nomencla
Note that MCis and MCEs are both called MCis by ture unique to their tield. J3ox 1-1-1 is a glossary of all key
many experts. The ATLS course distinguishes between the terms ( ie, those appearing in boldace
f type) in this appen
terms because their different circumstances mandate al dix.
ternative strategies for triage and treatment, based on ill
ness and injury acuity and severity, versus availability and
accessibil i t y of existing and s up pl emc11Lal resources. It
must also be emp hasi zed that the numerical gttidelines
The Need
ci ted ( eg 5 or more pat ients for an MCI, and 20 or more
,
for an MCE) are arbitrary and based o.n the capab il ities of Disaster management and emergency preparedJ1ess con
trauma hospilals and trauma systems that routinely care stitute key knowledge areas that prepare ATLS provi ders
for trauma patients. Many hospitals would be over to apply ATLS principles during natural and. human-made
whelmed by 5 or more disaster patients, whereas some disasters. Successful application of these principles dming
could manage 20 or more without a si gni ficant disrupti on the chaos that typically comes in the aftermath of sud1 ca
of daiJy routines. Thus, each hospital must determine its tastrophes requires both familiarity with the disaster
321
322 APPENDIX H Disaster Management and Emergency Preparedness
Box H-1
Key Disaster Management and
Emergency Preparedness Terminology
Acute Ca re-The early care of v1ctims of disasters that Emergency Medical Services (EMS)-Emergency
IS prov1ded in the field and 1n the hosp1tal (ie. emer med1cal responders (EMRs). 1nclud1ng emergency med
gency department, operating room. tntens1ve care ical techmcians (EMTs) and paramedics who provide
,
unit, acute care untt inpat1ent untts) prior to recovery prehosp1tal care under med1cal d1rect10n as part of an
and rehabilitation organtzed response to medical emergen Cies
Acute Care Speci al ists-Physicians who provide Eme rgency Operations Center (EOC)-The head
acute care to victims of disas ters . 1ncludtng, but not quarters of Umfied Incident Command (UIC) for a re
limited lo, emergency medicine physicians, trauma gion or system, established in a safe location outside
surgeons. cntical care medicine physicians. anesthesi the area of operatio ns ("warm zone"), usually at a
ologists, and hosp1talists-both adult and pediatric. fixed s1te. and staffed by emergency ma nage rs.
Area of Operations ("Warm Zone")-The geo Emergency Preparedness The readiness for and
graphic subdiviSIOn established around a disaster site ant1c1pat1on of the contmgenoes that can follow 1n the
into which only qualified personnel-for example, haz aftermath of natural or human-made dtsasters. Pre
ardous material (HAZMAn technicians and emergency paredness 1s the institutional and personal responsibil
medteal services (EMS) prov1ders are permitted
- ity of every health care facil ity and professional.
Casualty Collection Point (CCP)-A sector within Emergo Train System (ETS)-An organizational
the external perimeter of an area of operations structure used chiefly in Europe and Australasia to help
("warm zone") where casualties who exit the Search coordinate an in-field or in-hospital disaster response.
and Rescue (SAR) area (" hot zone") v1a a decontami (Note: Nations and hospitals typica l ly adopt their own
natiOn chute are gathered pnor to transport off site. vers1ons of this system )
Chemical, Biological, Radiological, Nuclear, and External Perimeter-The outer boundary of an Area
Explosive (CBRNE). Including incendiary, agents of Operations ("warm zone") that 1s established
human-made hazardous matenals (HAZMATs) that around a d1saster site to separate geographic subdivi
may be the cause of human-made disasters, whether SIOns that are safe for the general public ("cold
unintentional or intentional. zones" ) from those that are safe only for qualified per
sonnel .
Decontamination Chute-A fixed or deployable fa
cility where hazardous materials (H AZMATs) are re Hazardous Materials (HAZMATs)-C hemical, bio
moved from a patient, and through which the pa t1 ent logical, radiological, nuclear. and explos ive (CBRNE).
must pass before transport, e1ther out of a Search and including incendiary, agents that pose potential risks
Rescue (SAR) area ("hot zone"). or 1nto a hospital to human ltfe, health, welfare, and safety
Disaster-A natural or human-made tnodent or Hospital Incident Command System (HICS}-An

event, whether internal (ong1nating 1nside the hospi orgamzat1onal structure used chiefly in the Americas
tal) or external (ongmat1ng outs1de the hospital) i n to help coordinate an i n-hosp 1tal d1saster response.
which the needs of pat1ents overextend or overwhelm (Note. NatiOns and hospitals typically adopt their own
the resources needed to care for them. versions of th is system . )
THE NEED 323
Hazard Vulnerability Analysis (HVA)-An analysts Multiple Casualty Incident (MCI)-A disaster 111
of the probability and severity of the risks of vanous which patient care resources are overextended but not
hazardous matenals (HAZMATs), industrial mishaps, overwhelmed
natural disasters, and weather systems that pose po
Personal Protective Equipment (PPE )-S pec ial
tential risks to community health and safety.
cloth ing worn by disaster response personnel to
Incident Command or Incident Commander (IC) avoid self-contammation by hazardous mate n a ls

The final authority and overall coordinator or supervi ( H AZ MATs) .
sor for the management of any disaster response.
Preparation-Activ it ies that health care facilities and
Incident Command Post (ICP)-The headq uarters prov iders underta ke to build capacity and identify re
for Incident Command (IC), established in a safe loca sources that may be used if a disaster occurs.
tion wtthin the area of operations ("warm zone"), but
Recovery-Activiti es that are designed to assist health
at a safe distance from the Search and Rescue (SAR)
care facilities and professionals resume normal opera
a rea ("hot zone"), for any disaster.
tions after a disaster situatton is resolved
Incident Command System (ICS)-An organiza
Response-Activ tties that health care faci l ities and
tional structure that provides overall direction for the
professionals undertake in evaluating and treating vic
management of the disaster response.
tims of a n actual disaster.
Internal Perimeter-The outer boundary of a Search
Search and Rescue (SAR) Area ("Hot Zone")-A
and Rescue (SAR) area ("hot zone") that isolates this
sector within the internal perimeter of an area of op
area from the surrounding Area of Operattons ("warm
erations for a disaster in which humans are directly af
zone").
fected by the hazard.
Mass Casualty Event (MCE) -A d isaster in which
Surge Capability-The extra assets that can actually
paltent care resources are overwhelmed and cannot
be de ployed-for example beds that can actua lly be
,
immediately be supplemented.
staffed and ventilators and monitors that can actually
M itigation-Activities that health care facilities and be used-in a disaster.
professionals undertake in an attempt to lessen the
Unified Incident Command (UIC}-The locus of in
severity and i mpact of a potential disast er.
cident command for an entire region or system, where
Medical Response Team-A team of 1 to 4 health incident commanders from all involved publ ic safety
care professionals, led by an acute care spec ialist that , and public health disciplines meet to direct the overall
provid es emergency medical care to an ind iv idual strategy of the incident response to mass casua lty
patient. events (MC Es)
Minimal Acceptable Care-The lowest appropriate Weapons of Mass Destruction (WMDs)-Haz

level of medical and surg ical treatment req u i red to ardous materials (HAZMATs) used, or intend.ed to be
sustain l ife and limb unti l addit ion a l assets can be used, for the explicit purpose of harming or destroying
mobilized . human life.
respon se and knowledge of t.hc medical conditions likely to agement. Plans that are too complex or cumbersome to re
be encoLmtercd. Terror events constitute a minority of a l l member or implement are destined to fail. All p lan s must
disasters, but nearly all tenor events cause physical inj ury , include training in disaster management and emergency
three-fourths of which ar e due to blast trauma and m os t of preparedness appropriate to the educational preparation of
the rest to gunshot wounds. As such, Lhe unde rsta nding and the in d ividuals being t rai ned.
application of ATLS principles are essential in the evalua
tion and treatment of all disa ster v icti ms. Community P la nning Disaster p lanni ng, whether at the
local, region al , or national level, involves a wide range of in
di vi dual s and resources. All plans:
The Approach Should involve acute cal e specia l ists ( eg, emer
'
gency medicine p hysici an s trauma surgeons, criti

,
Disasters are unpredictable because of their na tun.>, loca l ion , cal care medicine phys icia ns, anesthesiologists, and
and timing. An "alJ hazards" approach is used in contempo hospitalists, both adLllt an d pediatric) and local hos
rary disaster manage ment. This approach is based on a sin pitals, as well as officials of the local p oljce, fire,
glc, common, initial emergency response protocol with , emergency medical senrices (EMS), homeland se
branch points that lead to specific actions depending on the curity, emergency managemen t, public health, and
type of disaster encountered. The fu ndamental principle of governmen tal a gencies charged with hazardous
disaster management is to do the greatest good for the great m ater ial (HAZMAT) management and disaster
est number. prepa ra lion.
Should be frequently tested and reevaluated.

1vlu st
provide for a means of commun ication con
Phases of Disaster Management sidering all contingencies, such as loss of telephone
land lines and cellular c i rcujts.
The public health approach to d isas ter and mass casualty
Must provi.de for storage of equi pm en t supplies,,
management consists of four distinct p hases:

and any special resources that may be necessary
based on local hazard v ulnerability analysis
1. Prep a rati on
(HVA).
2. M iti gatio n
Must provide for all of assislance-rrom
levels First
3. Response aid through clelinitive care to rehabilitation.
4. Recovery Mu st prepare for the Lransporta Lion of casual ties to

other facilities by prior ag ree ment should the local
ln most nations, local and region al disaster response facility become saturated or unusable.
p lans are developed in accordance with national response
Must consider the urgent needs of pa t ien ts a lread y
p lan s. Emergency medicine, trauma care, public health, and
hospitalized for conditions unrelated to the
disaster medicine experts must be involved in all four phases
disaster.
of m an agement with respect to the medical components of
the operat ional p lan The clements that must be addressed
.
durin g each of these four phases are described below.

Hospital Plann i ng a regional ap proach to
Although
planning is ideal for the management of mass casualtis. cir
PREPARATION cumstances may require each hosp ita l to function with little
or no outside support. Earthquakes, floods. riots, or nuclear
Preparation involves the activities a hospi tal undertakes to
contamination may require the individual hospital to oper
build capacity and identify resources that may be used if a
ate in isolation. The crisis may be instantaneous or it may
disaster occurs. These activities include the development of
develop slowly SiLuations may cxisL Lhnt disrupt the in fra
.
a simpl e, yet flcx.iblc, disaster plan that is regularly reviewed

structure of society and prevent access to the medical facil
and revised as n ecessary and provision of disaster training
,
ity. For Lhis reason, it is vital that each hospital develop a

that is necessary to allow these plans to be i m plemented
disaster plan that accurately reflects its HVA. Once a state of
when indicated.
di5aster has been declared, the hospital disast er plan should
be put into effect. Specific procedures should be autom ati c
Simple Disaster Plans and include:
A basicand readil y understood approach to MCTs and
MCEs is the key to effective disaster and emergency man- Establishment of an in cident command post (ICP).
PHASES OF DISASTER MANAGEMENT 325
Notification of on-duty and off-duty personnel. anesthesiology and nursing; mobilizing needed ad
ditional staff; retrieving and deploying appropriate
Preparation of decontamination, triage, and Lreat
equipment; and identifying additional resources,
ment areas.
such as obstetric operating rooms and nursing staff,
Classification of in-hospital patients to determine that are not typically used to care for injured
whether additional resources cm1 be acquired to patients.
care for them or whether they must be discharged
Critical care plans must identify who will be re
or transferred.
sponsible for organizing critical care unit staff, both
Checking of supplies (eg, blood, fluids, medication) medical and nursing; mobilizing needed additional
and other materials ( eg, food, water, power, commu staff; retrieving and deploying additional venLiJators
nications) essential to sustain hospital operations. and monitors; and preparing additional isolation
rooms, suites, or w1its that are not typically used to
Activation of decontamination facilities and staff
care for contaminated or contagious patients.
and application of decontamination procedures if
necessary.
Institution of securiry precautions, including hospi Personal Planning Since the hospital disaster response,
tal lockdown if necessary, to avoid potential con of necessity, is bullt on the personal and fanuly disaster re
tamination and subsequent hospital closure. sponse, personal and family disaster pl;:tnning constitutes a
vital part of pre-event hospital disaster preparation for both
Establishment of a public i_nformalion center and
the hospital and its employees. Most health care providers
provision of regular briefings to inform family,
have tamily responsibilities, and will be at best uncomfort
friends, the media, and the government.
able, and at worst unable, to meet their employment re
sponsibilities in tbe event of a disaster if the health and safety
Departmental Planning Effective disaster planning
of their tarn ilies is uncertain. Hospitals can assist health care
builds on existing strengths to address identified weaknesses.
providers in meeting their responsibilities to the hospital and
Since patient care can best be delivered to individual patients
to their famiHes in a number of ways, and it is obviously to
by providers working in small teams, every hospital depart
the advantage of both for hospitals to ensure that employ
ment with responsibility for the care of injured patients must
ees' family needs are met. Among these needs are assistance
identify its medicaJ response teams in advance. These teams
in identifying alternative resources for the care of dependent
must be provided with specific instructions as to where to go
children and adults and ensuring tbal aJI employees develop
and what to do in the event of an intcmal or external disas
family disaster plans, since all hospital-specific response plans
ter. Such instructions should not he overly complex. They
depend on mobilization of additional staff, whose first duty
should also be readily accessible in the event of a disaster
in any disaster \'Ifill be to ensure their own and their families'
for example, printed on the back of hospital identification
health and safety.
cards or posted on wall charts. They should also be very spe
cific in terms of the job action Lo be performed, as follows:
Hospital Disaster Training
Emergency department plans must identify who All health care providers must be trained in the principles of
will be responsible for notifying the incident com disaster management and emergency preparedness com
mander; deploying the decontamination team; or mensurate with their level of patient contact. Training in
ganizing the available physicians, nurses, allied disaster managernent includes both operational and med
health personnel, patient care technicians, orderlies, ical components. The ATLS provider should be well versed
and housekeepers into individual teams to care for in the fundamental elements of the local, regjonal, and na
individual patients; directing emergency depart tional disaster plans, as appropriale, and understand the role
ment triage of disaster victims; and mobilizing ad of medical care i.n the overall management plan. Lt is essen
ditional staff as needed. tial to realize that, although the purpose of all disaster rnml
agement is to ensure the safety and security of the maximum
Surgical department plans must identify who wiU
number of human lives and the greatest mass of public and
be responsible for org<mizing he t available surgeons
private property, the medical component is but one element
into resuscitation and operating teams and where
of the operational plan, at both the hospital and the com
these teams will assemble, or "muster"; identifying
munity level. Tllis is because the provision of medical care
the leaders of such teams; and determining which
requires a complex infrastructure of logistical support be
patients will receive priority if operating rooms or
fore medical professionals can safely and securely apply their
perioperative staff are i.n short supply.
skills.
Operating room plans must identify who will be re Beyond this basic understanding, it is also vital that the
sponsible for organizing perioperative staff, both ATLS provider have a working understanding of the appli-

cation of ATLS principles i n disaster situations. I t is impor be made \\'ilhout the need for prior confirmation by inci
tant to recognize that the approach lo the palienl injured in dent commanders, whi.ch consumes valuable Lime. J n MCEs
a disaster is no different from the approach to the patient that affect an entire region or system, the effective res must
injured i n the cowse of everyday activities: Airway, Breath be fully i ntegrated with the unified incident command
ing, CircuJation, Disability, and Exposure. Rather, it is the ( U I C ) serving the entire region or system, which is com
application of this basic approach that may he altered, which prised of aU involved public ht'<tlth and safety agencies.
is best summarized by the phrase, "Care ordin ary, circum A hierarchical approach lo incident command, such as
stances extraordinary." For example, the fact that the AILS the Hospital Incident Command System (HICS) developed
provider may need to care for muJtiple victims more or Ies under the auspices of the California EMS Authority
simultaneously, and may not have suffi<.icnt equipment or (hllp://ww;.v.emsa.ca.gov/hics/hics.asp), is favored in the
assistance to carry out all needed tasks i n a timely manner, A111ericas. A more collaborative and medicaJly centered ap
requires that routine standards of care may need to be al proach to incident command, such as the Emergo Train
tered such that disaster medicine must focus o n the mini System (ETS) promulgated by the Linkoping University
mLml acceptable standard of care required for salvage of life Trauma Center in Sweden ( h ltp://ww\v.cmergotrain.com), is
and limb, not lhc highest possible standard of care normally favored i n Europe and AusLTalasia. Most nations adopt one
offered to severely injured patients. of the two approaches for incident conunand (IC) in de
As such, it is vital thai the ATLS provider obtain suffi veloping their response plans, adapting them l o fi t local
cient basic education to initiate the medicaJ care of multiple needs and resources. The models used by these two systems
victims not only of natural disasters, but also of human are shown in Table H - 1 .
made disasters, including those caused bv
'
HAZMATS-in- Regardless of the TCS system used, incident command
eluding weapons of mass destruction (WMDs) such as (!C) is responsible for all aspects o f the disaster response
CBRNE (chemical, biological, ra di ol ogical, nuclear, and under its jurisdiction-operational, medical, or both. The
explosive) and incendiary agents-in the potentially aus initial responsibility of IC is to declare an in tern aI disaster or
tere environment of an emergency department over an external disaslcr. All opera! ional a n d medicaJ section
whelmed by panicked patients and staff shortages. Although heads reporl directly to, and must be in constant commu
brief outlines of such treatment are provided in this appen nication with, the IC, either i n person or by telecommuni
dix, additional training in disaster medical care is currently cations, for unified incident conm1a11d to be effective and
beyond the scope of the ATLS provider course, but can be efficient.
obtained tluough participation in the appropriate national As soon as possible after an internal or external disaster
disaster management courses. i cident command post (ICP), previ
is declared by IC, a n n
ously known as the incident command center, must be es
tablished. with reliable communication links to all
MITIGATION functional units-operationaJ/Iogistic or medical. The !CP
Mitigation involves the activities a hospital u11dertakes in

attempting to lessen the scvcrily and impact of a poLenliaJ
disaster. These include adoption of an i nciden I command
system for managing internal (originating inside the hospi TABLE H-1 Commonly Used Models
tal) and external (originating outside the hospitaJ) disasters, for Incident Command Systemsa
and the exercises and drills necessary to successfully imple
ment, test, and refine the hospital disaster plan.
HICS FUNCTIONAL ETS FUNCTIONAL
JOB ACTIONSb JOB ACTIONS'
Incident Command System
Incident command (hospital) Field
An i.ocident command system (lCS) is vital to operaliomtl Command slaff Ambulance Incident
success during disasters and must be known to all personnel Public information command
within every health care facility and agency. The ICS estab Lia1son Medical Incident com mand
lishes dear lines of responsibility, authority, reporting, and Safety Hospital

Med1cal/tech nical Log 1stics com mand
communication for all heaJth care personnel, thereby maxi
Fina nce and administration Medical command
mizing collaboration and minimizing conilicts during the dis

Logistics
aster response. It is also i mporran l that the hospital ICS follow Operations
normal Jines or hospital authority as closely as possible to Planning and intelligence
avoid confusion about who is i n charge, provided that all hos

pital officials within the chain of conu11and undcrstand the Regardless of Ihe system being used, like stnJCtures ;Jre used 1n-field and
in-hospital
res and their roles and responsibilities within the res bh11J.l://www.erna .ca.gov/h!cslh1cs.asp
The effective ICS includes both vertical and horizontal ' 11ttp://www.emergotra1n.com
reporting relationships, lo ensure that urgent decisions can
must be established .in a secure location, distant from, but RESPONSE

with ready access to, Lhe site of primary patient care activity,
whether field or hospital. ln the field, it should be located Response involves activities a hospital undertakes in treating
within Lhe area of operations, or "warm zone," uphill and victims of an actual disaster. These include activation of the
upwind of lhc search and rescue (SAR) area, or "hot zone;' hospital disaster plan, including the JCS, and management
decontamination chutes, and casualty collection points
of the disaster as it unfolds, implementing schemes for pa
(CCPs). In the hospital, it should be located al a safe dis
tient decontamination, disaster triage, surge capacity (mo
Lance from decontamination areas, pa Lien l care areas, bilization and deployment of the necessary staff, equipment,
resources, and filcilities to treat increased numbers of pa
family support areas, and potential hazards, such as con
taminated ventilation and drainage, but dose enough to pa tients, better termed surge capability) , and alternative care
tient care and family supporl areas so that messages can be (provision of the minimal acceptable care needed to save
lransmilled in person if electronic communications fail. life and limb). Given the increased level of activitv in d.isas-
'
ter events, traffic control is needed lo ensure an uninter-

rupted forward flow of communications, patients, supplies,
Frequent Disaster Drills and personnel. The medicaJ disaster response must also ad
As in trauma resuscitation, medical management of mass dress the needs of special populalions, including children,
casualties can be provided to individual patients only by in elders, the disabled, and the dispossessed.
dividual providers, working in small medical response
teams, led by a senior acute care specialist. It is cruciaJ to an
Prehospital Care
effective disaster medical response that such teams have
been drilled, not simply trained, in disaster medical care, Tbe prehospital (EMS) response to natural and human
under circumstances that are as reali1>tic ll!> possible. Disas made disaster:. typically occurs in four stages:
ter drills should always emphasize the disasters expected on
1 . Chaos phase, I ypically lasting IS to 20 minutes
the basis of the hospital's HYA. The purpose of disaster
drills and exercises is not only to train emergency medical 2. Organizational phase, usually lasting I to 2 hours
responders to provide care to disaster victims, but also lo
3. Site-clearing and cvacui.ltion :,tage of variable length,
identify gaps in the hospital disaster plan so lbey can be
depending on disaster type, complexity of SA R ef
closed prior to the occurrence of an actuaJ internaJ or cx
forts, and number of evacuees
Lcmal disaster. In 3ddition, they should involve scenarios
that emphasize the needs of special populations, such as 4. Gradual recoverv '
burn patients, pediatric patients, geriatric patients, and dis

abled patients, which may require the mobilization and de All SAR efforls at the scene should be the responsibil
ployment of population-specific resources. The types of ity of HAZMAT technicians speciflcaJly trained for this pur
disaster drills and exercises hospitals should hold <lre de pose, and musl proceed as rapidly and safely as possible, due
scribed in Box ll-2. lt is wise to proceed from simple drills to the potential for a "second hit" designed to injure first re
to complex exercises as staff members gain familiarity with sponding personnel, including volunteers. Since tJ1e first re
the ICS and experience with the problems likely to arise sponsibility of field providers is to protect themselves,
during a disaster. first-response personnel, including EMS professionals,
Box H -2
Types of Disaster Drills and Exercises
Disaster Drill Supervised activity with a limited Functional Exercise Simu lat ion of a disaster in the
focus to test a procedure that is a limited compo most realistic ma nner poss1ble without moving real
nent of a facility's overall disaster p la n . people or real equipment to a real sile.
Tabletop Exercise Wntten and verbal scenanos Field Exercise Culmination of previous drills and
that evaluate the effectiveness of a facility's overall exerc1ses Lhat tests the mobilization of as many of
disaster p la n and coordination. the response components as possible 1n real time,
using real people and real equipment.
should not enter the disaster scene until it has been declared sible for HAZMAT teams or fi.rst responders to perform de
sa.fe and secure by the appropriate authorities. Appropriate contamination under all circumstances. Moreover, many pa
personal protective equipm en t (PPE) is mandatory for all tients are likely to transport themsehres to the closest hospital,
health care personnel in direct contact with patients. and will arrive at the emergency department before being
decontaminated, demanding urgent care.
In-Hospital Care For this reason, hospitals must rapidly and conscien
tiously determine the l ikelihood of contamination and pro
Once the hospital disaster plan is activated, the first priority
ceed accordi ngly AJthougb the safest course might be to
.
of IC is to ensure sufficient resources to mount an effective

consider alJ disaster patients contaminated until public
disaster response. This includes mobilization and deploy
safety officials determine otherwise, this approach slows pa
ment of adequate patient care staff, facilities, and equipment
tient throughput and can result in further deterioration of
to meet anticipated needs, as weU as early discharge of eligi
high-risk patients. Anotl1er approach is to segregate patients
ble patients from hospital inpatient and fast track units; can
who transport themselves to the hospital in a holding area
cellation of elective operations and outpatient clinics;
outside the hospital until HAZMAT teams deLermine the
selective withholding of "elective" blood component ther
nature of the event, recognizing that such patients are far
apy; and accurate determination of each unit's surge capa
less likely to deteriorate than patients transported by am
bility, not merely its capacity, including identification and
bulance. Either way, hospitals must plan for decontamina
mobilization of alternative care sites. The next priority is to
tion of potentially contaminated patients before they can
sustain the disaster response, through adjustment of shifts
enter the emergency department. Failure to do so can result
and schedules, provision of room and board for in-house
in contamination and subsequent quarantine of the entire
hospital staff, and assistance in activating family disaster
facility. Involvement of hospital security, and local police,
plans, including child and elder care as needed. Prep1inted
may be necessary if lockdown is required to prevent pre
job action sheets should be made available to appropriate
sumptively contaminated patients fiom entering the emer
facility staff for each functional job description within the
gency department or hospital before they can be effectively
res, to serve as a tangible reminder of the tasks each staff
decontaminated.
member is expected to undertake.
Patient Decontamination Hospital disaster care begins Disaster Triage Scheme Whether the disaster is an MCI
with decontanunation, the principles and methods for which that overextends or an MCE that overwhelms the resources
are shown in Box H-3. Ninety percent of hazardous materi of an institution, a metl10d for rapid identification of vic
als to which disasLer victims may have been exposed can be tims requiring priority treatment is essential. Most triage
eliminated simply by removal of outer garments contami schemes use color-coded tags to indicate acuity and severity
nated with hazardous materials. However, it may not be pos- of needed treatment (red = immediate, yellow = delayed,
Box H-3
Principles and Methods of Decontamination
Gross (primary) deconta mination OR
Performed in the field or outside t he hospita l after Assisted decontamination with soap and water
removal of clot h ing via a warm sponge bath
Patient is hosed with a fine mist spray under mod-
Eradicates almost all residual contam1nants, suffices
erat e p ressu re
for radioactive agents
Washes away most remain ing contaminants
Additional cleansing with dilute chlorine bleach may
Technical (secondary) decontamination be recommended if susceptible biologic agents or
Self-decontamination with soap and water under a chemical agents are suspected
warm shower bath
Remember, "Dilution is the solution to pollution."

green = minor, blue = expectant, black = dead). The goal of tain life and limb until additional assets can be mobilized.
treatment in MCis is to treat the sickest patients first, whereas Since each disaster response presents health care providers
the goal in MCEs is to save the greatest number of lives. As with a different mix of patient needs and available resources,
such, triage schemes in MCEs should adopt an approach that no single description of a minimum acceptable standard of
separates patients with minor i.njmies from those with more care is applicable to every facility or every disaster circum
serious injuries, before proceeding v.1th evaluation and sus stance. However, because the selection of patients to receive
tentative treatment of patients with major i11juries. Unsal scarce or intensive resources will present the traw11a spe
vageablc patients receive terminal or comfort care only after cialist with an ethical dilemma and poten tia!Jy a later legal
other patients have been treated. problem, generaJ criteria should be developed before the dis
Overtriage and undert riage can substantially affect the aster event, based on demographic and geographic circum
medical disaster response in the emergency department and stances as well as the community HVA. I t is wise to develop
after admission to the hospital. Overtriage slows system such criteria in collaboration with the hospital's legal coun
throughput, and undertriage delays medically necessary sel, bioethics committee, and pastoral care department to
care. I3oth increase the fatality rate among potentially sal ensure consistency with the community standard of legal,
vageable patients. Therefore, triage should be performed by ethical, and moral values. They should then be included as
an experienced eli nician with speciJic knowledge of the con part of Lhc facility's disaster plan.
ditions affecting most patients. ln addition, all injured pa
tients should be continunlly reevaluated and reassessed. Traffic Control System Controlling the flow of infor
mation (communications), equipmenr (supplies), patients
Effective Surge Capability The initial disaster response ( rransport ), and personnel (providers, relatives, the public,
is invariably a local response, as regional or national assets and the press) is of paramount importance in a meclicaJ dis
can not typically be mobilized for 24 to 72 hours. Thus, loccll, aster response. These arc the issues most often cited in after
regional, and national disaster plans must presume that hos action reports as causes of disaster mismanagemenl. The
pitals will be able to deploy sufficient stafl cquipmcnl, and unidirectional flow of patients from the emergency depart
resources to care for an increase, or ''surge," in patient vol ment to inpatient units must be ensured, since emergency
ume that is approximately 20% higher than its baseline, an department beds will be made available for later-arrivi.ng
estimate that reflects recen t worldwide experience with lim patients as tJ1ey are emptied.
ited MCEs. Redundant communications systems, reliable supply
The term surge capacity is more often used in disaster chains, and redoubtable security measures arc also vital
plans than surge capa/Jility, but the ATLS course uses the lat components of an effective disaster medical and operalional
ter term, as it is more inclusive than the fom1er term. This response. These assets must be tested on a regular basis
is because su1ge capacity too often is used to refer only to Lhe through drills and exercises that realistically reflect the dis
nw11ber of additional beds or assets, such as ventilators or aster scenarios that are most likely to be encountered by a
monitors, that might be pressed into service on the occasion particular facility, whatever its location.
of ru1 MCE. By contrast, Sl/rge cnpability refers to the mun
ber of additionaJ beds that can actually be staffed or venti Special Needs Populations Special needs populations
lators and monitors that can actually be operated. In large include tribal nations; children, especially those who are
urban areas, many staff may work multiple jobs, and may technology-dependent; elders, especially those who are
unknowingly be pari of more than one hospital's disaster bedridden, including the nursing home population; the dis
plan. In addition, most hospital staiT are working parents, abled, both physically and emotionally, for whom assistance
who must consider the needs of their families and relatives, will be illness- or injury-specific; and the dispossessed, in
in addition to those of their workplaces. cluding tbe poor and Lhe homeless, who will be difficult to
reach by traditional means for purposes of disaster educa
Alternative Care Standards In MCEs, it can be ex tion and treatment. Specific response plans are needed to
pected that during the first 24 to 72 hours of the disaster ensure that their special needs are met.
there wiU be insufficient local assets to provide a level of care
comparable to that routinely provided in locaJ hospital emer
gency departments or intensive care units. Lf scarce resources, Pathophysiology and Patterns of Injury
particularly intensive resources, arc devoted to the [rrsl sev As with all rrauma, natural and human-made disasters re
eral critically i.ll or injured patients who require them, it will sult in recognizable patterns of injury that are based on the
be difficult, if not impossible, to later redirect them to others properties o[ the particular wounding agent and the unique
in greater need. pathophysiology that results from each such agent. Although
To achieve this goal, hospital disaster plans must strive detailed descriptions of the pathophysiology and patterns of
to provide the largest possible number of patients with the injury encountered in the acute disaster response are beyond
minimum acceptable care, defined as the lowest appropri the scope of this appendix, l 00% of all natural disasters and
ate level of medical and surgical treatment required to sus- 98% of all terror events worldwide involve physical trauma.
Thus, the principles of AILS arc ideally suited to the early agent used, or may be added as adulterants to eA'Piosivc de
care of patients with blunt and penetrating injuries observed vices to construct a "dirty bomb." lf present, \1\TNlDs can
in natural or human-made disasters, provided that the mech complicate lhe care of individuals who have suffered blasl
anisms and patterns of physical injury that are typically ob trauma, alth ough their effectiveness in such scenarios may
served in natmal and human-made disasters are distinclly be I imited by the effects of the blast. Descriptions o( W1v1D
understood. However, certain additional factors must also be agents and care ofWMD injmies oll1er than con tagious ill
considered in the early and later care of seriously injured dis nesses are summarized in Boxes H-4 through H -10. Re
aster patients, including the very real possibility that chemi member, the emergency care of these patients becomes even
cal, radiologic, and biologic injuries may coexist with blast more complex in the face of MCEs, with their associated
injuries-specifically, that the blast device may be a "dirty needs for disaster triage, additional staff, and adequate sup
bomb" that is contaminated wi.th deadly agents. plies. The treatment of contagious illnesses, which typi cal ly
WMDs arc HAZMATs-particularly CBRNE agents present days after exposure with fever and rash, or in
that are used, or intended to be used, for Lhc express pur fluenza-like symptoms is microbe-dependent
pose of harming or dc:.troying human l_ife, or causing earf of
tbe same. Members of the medical team should be familiar
RECOVERY
with the basics of decontamination and initial treatment of
all patients injured by WMDs, not only those injured by Recovery involves activities designed to help facilities re
bomb blasts and gunshot wounds. WMDs may be the sole sume operations after an emergency. The local publ ic
Box H-4
Special Considerations in the Care of Blast Injury
Early Care Active and passive rewarming (to avoid hypother

mic coagulopathies)
Airway
Preferential use of fresh whole blood, if available
Lat eral recovery position (field care of facial trauma (for treatment of coagulopathies)
withou L cervical spine injury) Administration of recombinant factor VIla (rVIIa) (for
Modified HAINES* posit ion (field care of fac1al treatment of coagulopathies)
trauma with cervical spine injury) Jud1cious crystalloid fluid resuscitation (for combined
blast lung and blast burn)
B reath i ng *High Arm IN Endangered Spine (lateral recovery po
Supplemental oxygen (blast lung) sition + head on outstretched arm)
Needle decompressio n (tension p neumothorax)
later Care
Circulation
Compartment syndrome despite fasciotomy (espe
Tourniquets (field care of bleed111g from traumatic cially d un ng aeromedical transport)
amputations) E arly recognition and repa1r of vascular injury (inti-

HemCon (chitosan), QuikCiot (zeolite) (field care of mal tears caused by shock wave)
bleeding from soh tissues) Wound management (reopening, irrigation de
,
Hypot ensive resuscitation (field care of patients in bridement, reclosure of dirty wounds)
shock) Tertiary survey (should be performed by different
Damage control laparotomy/thoracotomy team of examiners)

Completion amputations for unsa lvage able man Docu mentation (essential for p rov iders in subse
gled extremities quent echelons of care)
Liberal use of fasciotornies and escharotomies (to Feedback (a ll p rovide rs must lea rn of outcome for
avoid compartment syndromes) care to improve)
Box H-5
Chemical Agents Commonly Associated
with Human-Made Disasters
Nerve (cholinergic) agents Diphosgene (DP)

Ammonia
Ta bu n (GA)
Sarin (GB)
Blister (vesicant) agents
Soma n (GO)
VX (an oily, brown li q ui d ; all other nerve agents are Mustards (HD, HN HT)
,
gases) Lewisite (L)

Phosgene oxime (CX)
Blood (asphyxiant and hemolytic) agents
Incapacitating (psychogenic) agents
Hydrogen cyan1de (AC)
Cyanogen chloride (CK) Agent 1 5
Arsine (SA) BZ
Choking (pulmonary) agents

C h lo n ne (CL)
Phosgene (CG)
health system plays a major role i n this phase of disaster the disaster event, the word disaster being derived from the
management, although health professionals will provide Latin words for evil and star. Falling stars are seldom seen,
routine heahh care Lo the affected community consistent and when they are, they vanish from view almost immedi
with available resources, in terms of uperable facilities, us ately, and do not reenter the collective consciousness until
able equipment, and credentialed petsonnel. Acute care Lhe next star faJ.ls. While the exact dates, times, and places of
physicians who provide care for neglected injuries and future disasters are unknown, the lessons learned from pre
chronic illnesses may find both Lhe medical and organiza vious disasters are invaluable in teachi11g us how to better
tional skills required for the early care of the t-rauma pa prepare for them.
tient useful in the days after the response phase subsides. It can be expected, not merely anticipated, that land
The principles of ATLS-that is, treatment of the greatest and mobile telecommunications systems will be over
threat to life first, without wailing for a definitive diagno whelmed. Communications systems must b fully interop
sis, and causing the patient no hann, are no less useful in erable and overly redundant, both in terms of duplicate
the austere environments that may follow natural or equipment and disparate modes. Capabilily for bolh verti
human-made disasters. cal and horizontal communications must be ensured. Sup
plies needed for disasters must be sequestered and stored
in high, dry, safe, and secure areas. Security must be en
sured for providers, patients, supplies, and systems needed
Pitfalls for disaster care, such as communications and transport.
Volunteers, well meaning as they may be, must be properly
The four common pitfalls in the disaster medical response trained and credentialed to participate in a disaster re
are always the same-communications, supplies, security, sponse, and must participate only as part of a properly
and volunteers-leading many disaster experts to ask why planned and organized disaster response, since they other
humans seem incapable of learning from the mi.stal<es made \Vise place both themselves, and the intended recipients of
i11 past disaster events. The ans-.-ver lies in the very nature of ll1eir aid, in danger.
Box H-6
Special Considerations in the Care
of Chemical Injuries
Nerve (cholinergic) agents (GA, GB, GO, VX) Sx: telltale odor in association with shortness of
breath
Pathophysiology: form complexes with AChE i
- CL: bleach
ACh; victim drowns 1n secretions
- CG, DP: green corn, mown hay
Sx. cholinergic crisis (both muscarinic and nicotimc
- NH3: ammonia
effects; see Box H-7)
Rx: supportive
Rx: atropine (dries secretions); pralidoxime* (2-PAM]
Note: Dry oxygen in CL exposure avoids HCI dam
(inactiva les complexes)
age to tracheobronchial tree.
Note: A bendodiazapene should also be given if
seizure activity s
i evident. Blister (vesicant) agents
Blood (asphyxiant and hemolytic) agents Pathophysiology: severe/painfu l/blistering cuta
(AC, CK and SA) neous/pulmonary/mucous burns
Sx: telltale odor in association with epithelial dam
Pathophystology:
age
- AC, CK: CN- replaces 02 in Cya
, - HD,HN,HT: garlic, mustard, omons
- SA: acute hemolysis renal failure
- L: geraniums
Sx: telltale odor in association with cardinal signs
- CX: pepper
- AC, CK: almonds, in association with LOC
Rx: aggressive decontamination, wound care
- SA. garlic, in association with hematuria, jaundice
Note: Administer British anti-Lewisite (BAL) in L ex
Rx:
posure.
- AC, CK: OHCbl (CNCbl) [or NaN02
(HbMetHb)] + Na2SP3
Incapacitating (psychogenic) agents
- SA: supportive
(Agent 1 5, BZ)
Note: OHCbl has largely replaced NaN02 in treat
ment of A C. CK exposure. Pathophysiology: agent specific
Sx: bizarre behavior
Choking (pulmonary) agents Rx: await recovery
Pathophysiology: chemical pneumonia, severe tra

cheobronchitis and alveolitist
GDAChE complexes age rapidly; pralidoxime must be g1ven as oon as posstble

rPhosgene is tatal lf pu lmonay
r edema develops 1n 24 hr
Box H-7
Classic Toxidromes Associated with
Cholingeric Crisis due to Nerve Agents
SLUDGEM. DUMBELs MTW(t)HP

Sa livation Diarrhea, Dyspnea, Diaphoresis Mydriasis
Lacrimation Urination Tachycardia
Urination Miosis Weakness
Defecation Bradycardia, Bronchorrhea, Bronchospasm (t)Hypertension
Gastro1 ntesti na I Emesis Fasciculations
Emesis Lacrimation
Miosis Sa livation, Secretions, Sweating
*Muscannic eHeds (treated W1th atropine)

tN1cotimc effects
Box H-8
Radioactive Agents Commonly Associated
with Human-Made Disasters
Ionizing radiation - Graphite reactor: '331, 3'1, 132Te, 1 37Cs, "0Sr (based
on Chernobyl experience)
Particles:
- Note: Pressure water reactors are most common;
- Alpha (u) [He>+ nucleus]
graphite reactors are now obsolete.
- Beta ((3) !energized e]
Rays:
Radiation dosimetry
- x [high energy photon waves]
- Gamma (-y) [high energy photon waves] For (3, x. and 'Y emitters. 1 R (Roentgen)= 1 rad (ra
diation absorbed dose) [or 0.01 Gy)
likely agents For ex or n em itters
. 1 rad x Q* = # rem- (Roentgen
equivalent man) [or 0.01 Sv)
"Dirty bomb":
Note: In most' circumstances, 7 R 7 rad {OR 0.07
=
- Low level radioactive waste (1 37Cs, '921r) of medical Gy] 7 rem [OR 0.07 Sv}.
=
or industrial origin
Note: "Rad" and "rem" are preferred in the Ameri
Nuclear accident:
cas, "Gy" and "Sv" elsewhere.
- Pressure water reactor: 133Xe, 135Xe, 88Kr (based on
Three Mile Island experience)
o = qual1ty factor (13. x, -y emitters: 1; Inhaled/ingested u emttters: 20; n emlt1ers: 3-20)

'Il ls this unit that denotes extent of biolog1cal damage (background dose = 360 mSvtyr)
Box H-9
Special Considerations in the Care of
Radiation and Nuclear Injuries
Ionizing radiation - Note: The more rapid the symptom onset, the
higher the dose, patients who develop gastroin
Pat hophysiology:
testinal symptoms within 4 hours of exposure rarely
- Strips electrons from atomic nuclei, damaging cel survive.
lular DNA; rap1dly dividing tissues (gastrointestinal, Rx:
hematopoietic, epidermal) are most susceptible to and 13: external [ internal] decon + supportive
- 01
1onizing radia Lion care; x and -y: supportive care (treat external con
- Note: Radioactive atoms emit particles (or rays) dur
tamination as dirt; no risk to provider from patient
ing decay, risk of exposure depends upon energy of
x or "Y exposure)
emissions ("dirty bomb": low; nuclear accident: high).
- Note: Do NOT delay resuscitation for decontami
Sx: nation, as risk to provider is nil; perform opera
- Specific to dose and type, distance to source, den tions by day 3 to avoid wound complications r
sity of shieldmg; asymptomatiC <50 rad (0.5 Sv), 13
RES failure.
burns > 1 0 0 rad ( 1 Sv), acute radiat1on syndrome
>200 rad (2 Sv)
Box H-1 0
Classic Toxidromes Associated
with Acute Radiation Syndrome
Stage 1: (chiefly gastrointestinal) Stage Ill (multisystem involvement)

Onset. minutes to hours*; duration 48-72 hr Onset: 3-5 weeks; duration: variable
Presentation nausea, vomiting; also diarrhea, Presentation;: CNS/CVS (> 1 5 Sv); CRS/GIT (>5 Sv);
cramps RES (> 1 Sv)
Stage II (chiefly hematopoietict) Stage IV (gradual recovery)

Onset: hours to days; duration 1 1h-2 wk Onset: weeks; durat1on: weeks to months
Presentation: asymptomatic bone marrow sup Presentation: leading cause of death before recovery
pression IS sepSiS
. .
Acute radiation syndrome Is fatal t gastrointestinal symptoms develop w1th1n 2-4 hours
'HematopoietiC (RES) derangements nterferf:' w1th healing, may last weeks to months
'CNS = central nervous svstem, CVS = cardiovascular system, CRS = cardiorespiratory system, GIT = gastromtesllnal lract, RES = reticuloen
dothelial system
BIBLIOGRAPHY 335
APPENDIX H SUMMARY
The medical disaster response occurs within the context of the pub li c health disaster re
sponse-preparation, mitigation, response, and recovery.
Preparation requires both the convicti on that a disaster will occur, and the commit
ment to be ready when it happens, and must ensure both that a simple plan is devel
oped and that all are edu cated in its i m plementation .
Mitigation is thekey to the success of the disaster response since it provides the frame
,
work within which medical care must be rendered-for exa m p le, incident command
systems and effective disaster drills and exercises .
Response 1s the essence of disaster management. It comprises both prehospita l and

in -pat ient care, and must embrace the minimal acceptable standard of ca re needed to
provide the greatest good for the greatest number. It requires a sound understan ding
of pathophysiology and patterns of injury for care to be delivered expeditiously and de
terioration anticipated and avoided.
Recovery is mainly the province of publi c health personnel, but it depends on su pport
from acute care physicians for treatment of untreated injuries and chronic illnesses that
may develop or become exacerbated in the aftermath of the acute response.
However, it is not enough to be competent in the medical aspects of disaster man
agement, whether acute or chronic. Pitfalls must be foreseen a nd foresta l led th rough
redundant communication systems, reliable su pply chains, situational awa reness and ,
professiona l self-discip line.
Bibliography 7. Gutierrez de Ceballos JP, Thregano-Fuentes F, Perez-Diaz D,

Sanz-Sanchez M, Martin-Liorente C, Guerrero-Sanz )E. l l
March 2004: the terrorist bomb explosions in Madrid, Spain
1. American Academy of Pediatrics (Foltin GL, Schonfeld OJ,
an aoalysis of the logistics, i11juries sustajned and clinical man
Shannon MW, eds.). Pediatric Terrorism and Disaster Pre
agement of casualties treated at the closest hospital. Crit Care
paredness: A Resourcefor Pedintricinns. AHRQ Publication No.
2005;9: I 04- 1 1 1 .
06-0056-EF. Rockville, MD: Agency for Healthcare Research
and Quality; 2006. http://w>vw.ahrq.org/research/pedprep/re 8. Hirshberg A, Scott BG, Granchi T, Wall MJ, Mattox Kl, Stein
source.htm. Accessed February 26, 2008. M . How does casually load affect trauma care in urban bomb
ing incidents? A quantilative analysis. J Trauma
2. auf der Heide . Disaster Response: Principles of Prepnrntion
2005 ;58( 4) :686-693; discussion 694-695.
aud Coordination. Chicago, IL: CY Mosby; 1.989.
9. Holden PJ. The London attacks-a chronicle: Improvising in
3. Committee on Trauma, American CoUege of Surgeons. Dis
an emergency. N E11gl } Med 2005;353(6):541-543.
aster Management and Emergency Preparedness Course Stu
dent Manual. Chicago: American College of Surgeons, 2007. 10. Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health
threat with a trauma system response. J Tmumn
4. DiPalma RG, Burris DC, Champion HR, Hodgson Mj. Blast
2003;55(6): 1014-1021.
injuries. N Engf } Med 2005;352: 133 5- 1 342.
1 1 . Kales SN, Christiani DC. Acute chemical emergencies. N Eng/
5. Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned
1 Med 2004;350(8):800-808.
from Belfast to Beirut. Ann Surg 1988;208:569-576.
12. Klein )S, Weigelt )A. Disaster ma nagerneot: lessons learned.
6. Gutierrez de Ceballos JP, Turegano-Fuentes F, Perez-Diaz D,
SurgClin North Arn 1991;71 :257-266.
Sanz-Sa nchez M, Martin-Llorente C, Guerrero-Sanz }E. Casu
alties treated at the closest hospital in the Madrid, March 1 1, 13. Mettler FA, Voelz GL. Major radjalion exposure-what to ex
terrorist bombings. Crit Care Med 2005;33(1 Suppi);SJ 07- peel and how to respond. N Eng/ J Med 2002;346(20):1554-
S l l2 . 1561.
14. Muhtplc authors. Perspective: The London atracks-a chronicle. J lrgiene (Arquilla B, Foltin G. Uraneck K, eds.). Pediatric Dis
N Eng// A1ed 2005;353:541 -550. astl!r Toolkit: Hospital Guidelines for Pt:dratrics in Disasters. 2nd
ed. New York: New York City Department of Health and Men
15. Musolino SV, Tla rper FT. Emergency n:sponsc guidance for the tal Hygiene, 2006. hllp://www.nyc.gov/html!doh/
first 48 hours after the outdoor detonation of an explosive ra ht mllbhpp/bhpp-focus-ped-toolkit.ht mi. Accessed Novem
diological dispersal device. Health Phys 2006;90(4):377-385. ber 17, 2007.
16. :-.latiom1l Disaster Life Support Executive Committee, National I!:\. Roccaforte JD, Cushman )G. Disaster prepararion and man
Disaster Life Support Founu,\lion <lllU American Medical A:. agement for the intensive care uni1. C11rr Opin Crit Care
suciation. Advtmcecl, Basic, Core, and Decoutnmuwtion L1je 2002;8(6):607-615.
Support Provider Mauuals. Chicago, IL.: American Medical tu
socaauon, 2007. 19. Sever I\
IS, Vanholder R, Lameire '\1. Management of crush-re
lated injuries after disasters. N Eng/ } AJctl 2006;354(lO): 1052-
17. Pediatric Task I-oree, Centers for Bioterrorism Preparedness 1063.
Planning, ew York City Department of Health and Mental
A P P E N D I X I Triage Scenarios
Introduction Upon completion of this session, the doctor will be able

to:
This is a self-assessment exercise, to be completed before OBJECTIVES

you arrive for the course. Please read through the intro
ductory in formation on the following pages before reading Define triage.
Lhe individual scenarios and answering the related ques
tions. This skill station is conducted in a group discussion Exp lain the principles involved and the factors
format in which your participation is expected. Upon that must be considered during the triage
completion of this session, your instructor will review the process.
answers. Apply the principles of triage t o act ua l
The goal of this station is to apply trauma triage prin .
scenanos.
ciples in multiple patient scenarios.
Definition of Triage
complete data. The triage decision maker (or triage offi
Triage is tl1e process of prioritizing patient treatment dur cer) must be able to rapidly assess the scene and the num
ing mass-casualty events. bers of casualties, focus on individuaJ patients for short
periods, and make immediate triage determinations for
each patient. Triage decisions are typically made by de
Principles of Triage ciding which patients' injuries constitute the greatest lin
mediate threat to life. As such, the airway, breathing,
circulation, and disability priorities of ATLS are the same
DO THE MOST GOOD FOR THE MOST
priorities used to make triage decisions. That is, in gen
PATIENTS USING AVAILABLE RESOURCES
eral, airway problems are more rapidly lethal than breath
This is tl1e central guiding principle that underlies all other ing problems, which are moe rapidly lethal Lhan
triage principles, rules, and strategies. Multiple-casuaJty circulation problems, which are more rapidly lethal than
events, by definition, do not exceed the resources available. neurologic injuries. All available information, including
Mass-casualty events, however, do exceed available med vital signs, when available, should be used to make each
ical resources and require triage; the care provider, site, sys triage decision.
tem, and/or faciJjty is unable to manage the number of
casualties using standard methods. Standard of care inter
TRIAGE OCCURS AT MULTIPLE lEVElS
ventions, evacuations, and procedures cannot be com
pleted (for each injury) for every patient withill the usual Triage is not a one-time, one-place event or decision.
time frame. The principles of triage are applied when the Triage first occurs at the scene or site of the event as deci
number of casualties exceeds the medical capabilities that sions are made regarding which patients to treat first and
are immediately available to provide usual and customary the sequence in which patients will be evacuated. Next,
care. triage typically occurs just outside the hospital to deter
mine where patients wiJI be transported within the facility
(emergency department, operating room, intensive care
MAKE A DECISION
unit, ward, or clinic). Triage then occurs in the preopera
Time is of the essence during triage. The most difficult as tive area as decisions are made regarding the sequence in
pect of this process is making medical decisions without which patients are taken for operation.
337
338 APPENDIX I Triage Scenarios
KNOW AND UNDERSTAND are the walking wounded who have suffered o nly minor in
THE RESOURCES AVAILABLE juries. These patients can sometimes be used to assist with
their own care and the care o f others. Black is frequently
Optimal triage decisions are made with knowledge and un
used to mark dead patients. Many systems add another
derstanding of the available resources at each level or stage
color, such as blue, for "expectant" patients-tl10se who are
of patient care. The triage officer must also be immediately
so severely injured that, given the current number of casu
aware of changes in resources, whether additional or fewer.
alties requiring care, the decision is made to simply give pal
A surgeon is the ideal triage officer for hospital triage liative treatment while first caring for red (and perhaps
pos iti ons be<:ause he or she understands all components of
some yellow) patients. Patients who are classified as expec
hospital function, i ncl udi ng the operating rooms. This
tant because of the :;everity of their injuries would typica lly
arrangement will not work in situations with limited num
be the lirst priority in situations in which there are only two
bers of surgeons and docs not apply to the incident site. The or three casualties requiring immediate care. However, the
medical incident commander (who may or may not elect to rules, pro tocob and standards of care change in lhe face of
,
serve as the triage officer) should be the highes t ran king

-
a mass-casual ty event. Remember: "Do the most good for

medical pro fess iona l on th<.: scene who is trai ned in disaster the mos t patients using available resources."
management.
PlANNING AND REHEARSAL TRIAGE IS CONTINUOUS (RETRIAGE}

Triage must be planned and rehearsed as possible. Events
, Triage should be continuous and repetitive at each level or
that arc likely to occur in the local area are a good starting site where it is requ ired. Constant vigilance and reassess
point for mass-casualty planning and rehearsal. For exam ment will ident i fy pat i en ts whose circumstances have
ple, simulate a mass-casualty event from an airplane crash if changed-either because of a change in physiologic :;latus or
the facility is near a major airport, a chemical spill if near a because of a change in resource availability. As the mass-ca
busy railroad, or an earthquake if in an earthquake zone. sualty event conti nuesto unfold, the need for retriage be
Specific rehearsal for each type of possible disaster is not comes apparent. The physio logy of injured patients is not
possible, but broad planning and fine tuning of facility re constant or predictable, especiaJJy considering the limited
sponses based on practice drills is possible and necessary. rapid assessment required during triage. Some patients will
unex-pectedly deteriorate and require an "upgrade" in their
triage category, perhaps from yellow to red. In others, an
DETERMINE TRIAGE CATEGORY TYPES
open fracture may bediscovered after initial triage has been
The title and color markings for each triage category should com p leted mandating an "u pgrade" in triage category from
,
be determined at a systemwide level as part of planning and green to yellow. An important group requiring retriage is
rehearsa l. Many options are used around the world. One the expectant category. Altho ugh an initial triage catego
common, simple method is to use tags the colors of a stop rization decision may label a pati en t as hav ing nonsurviv
li ght : red, yellow, and green. Red implies life threaten ing i n
- able injuries, this may change after all red (or perhaps red
jury that requires immediate intervention and/or operation. and some yellow) patien ts have been cared for or evacuated
Yellow implies injuries that may become life- or L imb threat
- ( eg, a young patien t with 90% burns may su rvive if burn
ening if care is delayed beyond several hours. Green patients center care becomes available).
Triage Scenario I
Gas Explosion in the Gymnasium
SCENAR IO: You are summoned to a tnage area at a construction site where 5 workers are injured in a gas ex
plosion during the renovation of a gymnasium ceiling. You quickly survey the situation and determine that the
patients conditions are as follows:
'
PATIENT A-A young man is screaming, "Please help me my leg is killin g me l "
,
PATIENT 8-A young woman has cyanosis and tachypnea and is breathing very noisily.
PATIENT C-A 50 year old man is lying in a pool of blood with his left trouser leg soaked in blood.
- -
PATIENT 0-A young man is lying face down on a stretcher and not moving .
PATIENT E-A young man is swearing and shouting that someone should help him or he will call his lawyer.
Questions for Response

0 For each patient, what is the primary problem requiring treatment?
PATIENT A-is a young man screaming, "Please help me, my leg is k illing me l "
---
Possible Injury/Problem: --
PATIENT 8-appears to have cyanosis and tachypnea and is breathing very noisily.
Possi ble I njury/Probl em : ------
PATIENT C-is a 50 year old man lying in a pool of blood with his left trouser leg soaked in blood.
- -
Possible Injury/Problem: -------
PATIENT D-is lying face down on a stretcher and not moving.

Possible Injury/Problem: -------
PATIENT E-is swearing and sh o uting that someone should help him or he will call his lawyer.
Possible Inju ry/Problem: ____________________________
f) Establish your patient priorities for further evaluation by placing a number (1 through 5, with 1
being the highest priority and 5 being the lowest) in the space next to each patient letter.
____ Patient A
____ Patient B
____ Patie nt C
____ Patient D
____ Patient E
8 Briefly outline your rationale for prioritizing these patients in this manner.
Priority 1-Patient ___

_
Rationale: ------
(Continued)
Triage Scenario I (Continued)
Priority 2-Patient ---

.
Rationale: ------
Priority 3-Patient ____ :
Rationale: ------
Priority 4-Patient ____
Rationale: ------
Rationale: --
--
9 Briefly, describe the basic life support maneuvers or additional assessment techniques you
would use to further evaluate the problem(s).
Basic life support maneuvers or additional assessment techniques: -------

TRIAGE SCENARIO I 341
Basic life support maneuvers or additional assessment techniques: ____ ________
Basic life support maneuvers or additional assessment techniques: ------

Triage Scenario I I
Gas Explosion in the Gymnasium
......
.
Conti nuation of Scenario 1:
1-%.
D Characterize the patients according to who receives basic life support (BLS) or advanced life
support (ALS) care and describe what that care would be. (Patients are listed in priority order as
identified in Scenario 1.)
.
;: ' PATIENT BLS ALS DESCRIPTION OF CARE
.: ..
D 0
0 0
D D
D D
fJ Prioritize patient transfers and identify destinations. Provide a brief rationale for your destina
tion choice.
PRI ORITY PATIENT DESTINATION RATIONALE
1 0 Trauma cen ter 0 Nearest hos pital
2 0 Trauma center C Nearest hospital
3 0 Trauma center 0 Nearest hospital
'
- -- --- --..:,:___ I-- - -- - ...2-- o
- -=--- ,
--

-- ---
---

"" - - ---=- -
- ..__."'
TRIAGE SCENARIO II 343
D In situations involving multiple patients, what criteria would you use to identify and prioritize
the treatment of these patients?
9 What cues can you elicit from any patient that could be of assi
stance in triage?
I) Which patient injuries or symptoms should receive treatment at the scene before prehospital
personnel arrive ?
l'lJ After prehospital personnel arrive, what treatment should be instituted, and what principles
govern the order of initiation of such treatment?
D In multiple-patient situations, which patients should be transported? Which should be trans

ported early?
li.J Which patients may have treatment delayed and be transported later?
Triage Scenario Ill

Trailer Home Explosion and Fire
SCENARIO: An explosion and fire, due to a faulty gas line, has involved one trailer home in a nearby trailer park.
Because of the close proximity of the incident to the hospital, the prehosp1tal personnel transport the patients
direclly to the hospital without prior notification. The five patients. a l l members of the same family, are immo
bilized on long sp1ne boards when they arrive at your small hospital emergency department. The injured pa
tients are:
PATIENT A-A 45-year-old man 1s cough1ng and expectorating carbonaceous material. Hairs on his face
and head are singed. His voice is clear, and he reports pain in his hands, which have erythema and
early blister formation. Vital signs are blood pressure, 1 2 0 mm Hg systolic; heart rate, 100 beats per
minute. and respiratory rate, 30 breaths per minute.
PATIENT B-A 6-year-old g irl appears frightened and is crying. She reports pain from burns
(erythema/blisters) over her back, buttocks, and both legs posteriorly. Vital signs are blood pressure,
1 10/70 mm Hg; heart rate, 100 beats per minute. and respiratory rate, 25 breaths per minute.
PATIENT C-A 70-year-old man is coughing, wheezing, and expectorating carbonaceous material. His
voice is hoarse, and he responds only to painful stimuli. There are erythema, blisters, and charred
skin on the anterior chest and abdominal walls, and circumferential burns of both thighs. Vital signs
are blood pressure, 80/40 mm Hg; heart rate, 140 beats per minute, and respiratory rate, 35 breaths
per minute.
PATIENT D-A 19-year-old woman is obtunded but responds to pain when her right humerus and leg
are moved. There is no obvious deformity of the arm, and the thigh is swollen while in a traction
splint. Vital signs are blood pressure, 140/90 mm Hg; heart rate, 1 1 0 beats per mmute. and respira
tory rate, 32 breaths per minute.
PATIENT E-A 45-year-old man IS pale and reports pain in his pelvis. There is clinical evidence of fracture
with abdominal distention and tenderness to palpation. There is erythema and blistering of the ante
rior chest and abdominal walls and thighs. He also has a laceration to the forehead. Vital s1gns are
blood pressure, 1 30/90 mm Hg; heart rate, 90 beats per minute, and respiratory rate, 25 breaths per
minute.
Management priorities 1n this scenario can be based on information obtained by surveying the injured patients
at a distance. Although there may be doubt as to which patient 1s more severely injured, based on the available
information, a decision must be made to proceed with the best information available at the time.
TRIAGE SCENARIO Ill 345
0 Identify which patient(s) has associated trauma and/or inhalation injury in addition to body
surface burns.
0 Patient A 0 Patient B 0 Patient C 0 Patient D Cl Patient E
f) Using the table provided below:

a. Establish priorities of care in your hospital emergency department by placing a number (1 through 5, with
1 being the highest priority and 5 being the lowest) in the space next to each patient letter in the col
umn "Treatment Priority."
b. Identify which patient has associated trauma and/or an airway injury and place a mark in the appropri
ate column under "Associated.''
c. Estimate the percent of body-surface-area (BSA) burn for each patient and enter the percent for each pa
tient letter in the column " % BSA."
d . Identify which patient(s) should be transferred to a burn center and/or a trauma center and place a mark
in the appropriate column under "Transfer. "
e. Establish your priorities for transfer and enter the priority number under "Transfer Priority."
E
Triage Scenario IV
Cold Injury
,......
SCENARIO: You are in you r hospital when you receive a call that five members of a doctor's family were snow
mobil in g on a lake when the ice broke. Four family members fell into the lake water. The doctor was able to stop
in time and left to seek help. The response time of basic and advanced life support assistance was 1 5 minutes.
By the time prehospital care providers arrived, one individual had crawled out of the lake and removed another
i -::-: . victim from the water. Two individuals remained submerged; they were found by rescue divers and removed
:1:\:: from the lake. Rescuers from the scene provided the following information:
'.
:
PATIENT A-The doctor's 10-year-old grandson was removed from the lake by rescuers. The ECG mon
itor shows asystole.
PATIENT 8-The doctor's 65-year-old wife was removed from the lake by rescuers. The ECG monitor
shows asystole.
PATIE NT C-The doctor's 35-year-old daughter, who was removed from the water by he r stster-in-law,
has bruises to her anterior chest wall. Her blood pressure is 90 mm Hg systolic.
PATIENT 0-The doctor's 35-yea r-old daughter-in-law, who had been submerged and crawled out of
the lake, has no obvious signs of trau ma. Her blood pressure is 1 10 mm Hg systolic.
PATIENT E-The 76-year-ol d retired doctor, who never went Into the water, reports only cold hands and feet.
0 Es tab/ish the priorities for transport from the scene to your emergency department, and
explain your rationale.
TRANSPORT PRIORITY PATIENT (IDENTIFY BY lETIER) RATIONALE
5
TRIAGE SCENARIO IV 347
fl In the emergency department, all patients should have their core temperature measured. Core
temperatures for these patients are:
PATIENT A: 29 C (84.2 F)
PATIENT B: 34 C (93.2 F)
PATIENT C: 33 C (91 .4 F)
PATIENT 0: 35 C (95 F)
PATIENT E: 36 C (96.8 F)
Briefly outline your rationale for the remainder of the primary assessment, resuscitation, and secondary survey.
PATIENT A: Priority ____
PATIENT 8: Priority ----
PATIENT C: Priority ____
PATIENT 0: Priority ____
PATIENT E: Priority ____

Triage Scenario V
Car Crash
SCENARIO: You are the only dodor available in a 1 00-bed community emergency department. One nurse and a
nurse assistant are available to assist you. Ten minutes ago you were notified by radio that ambulances would
be arriving with patients from a single motor vehicle crash. No further report is received. Two ambulances arrive
with five patients who were occupants in an automobile traveling at 60 mph (96 kph) before it crashed. The in
jured patients are:
PATIENT A-A 45-year-old man was the dnver of the car. He apparently was not wearing a seat belt.
Upon impad, he was thrown against the windshield. On admission, he is notably in severe respira
tory distress. The prehospital personnel provide the following information to you after preliminary as
sessment: Injuries include ( 1 ) severe maxillofacial trauma with bleeding from the nose and mouth, (2)
an angulated deformity of the left forearm, and (3) multiple abrasions over the anterior chest wall.
The vital signs are blood pressure, 1 50/80 mm Hg; heart rate, 120 beats per minute; respiratory rate,
40 breaths per minute; and Glasgow Coma Scale (GCS) score, 8.
PATIENT 8-A 38-year-old female passenger was apparently thrown from the front seat and found 30
feet (9 meters) from the car. On admission she is awake, alert, and reports abdominal and chest
pain. The report you are given indicates that, on palpating her hips, she reports pain, and fradure
related crepitus is felt. The vital signs are blood pressure, 1 10/90 mm Hg; heart rate, 140 beats per
m1nute; and respiratory rate, 25 breaths per minute.
PATIENT C-A 48-year-old male passenger was found under the car. You are told that on admission he
was confused and responded slowly to verbal stimuli. Injuries include multiple abrasions to his face,
chest, and abdomen. Breath sounds are absent on the left, and his abdomen is tender to palpation.
The vital s1gns are blood pressure. 90/50 mm Hg; heart rate, 140 beats per mmute; respiratory rate,
35 breaths per minute; and GCS score, 1 0 .
PATIENT D-A 25-year-old woman was extricated from the back seat of the vehicle. She is 8 months
pregnant, behaving hysterically, and reporting abdominal pain. Injuries include multiple abrasions to
her face and anterior abdominal wall. You are told that her abdomen is tender to palpation. She is in
adive labor. The vital signs are blood pressure, 120/80 mm Hg; heart rate, 1 00 beats per minute;
and respiratory rate, 25 breaths per minute
PATIENT E-A 6-year-old boy was extricated from the floor of the rear seat. At the scene, he was alert
and talking. He now responds to painful stimuli only by crying out. Injuries include multiple abrasions
and an ang ulated deformity of the right lower leg. There is dried blood around his nose and mouth.
The vital signs are blood pressure, 1 1 0/70 mm Hg; heart rate, 180 beats per m1nute; respiratory rate,
35 breaths per minute.
Questions and Response Key for Students' Response

0 Outline the steps you would take to triage these five patients.
-
- . - -. - -
--- - -- . . - - . ---

TRIAGE SCENARIO V 349
f) Establish your patient priorities by placing a number (1 through 5, with 1 being the highest
priority and 5 being the lowest) in the space next to each lettered patient. Then, in the space
provided, briefly outline your rationale for prioritizing these patients in this manner.
Priority Patient A : -------
Rationale: _
__________________________________
Priority __
__
_ Patient B : __
_ __ __
__ __
____
____
____
____
____
____
____
__ __
__ __
___
Rationale: ------
Priority _
_
__
Patient C: __
____
__ __
__
__
__ ___
____
____
____
____
____
____
__ __
__
_
__
Rationale: __
____
____
____
____
____
__ __
__ __
_____
____
____
____
____
____
____
____
___
Priority __
__ Patient D: __
____
__
__
_____
____
____
____
____
____
____
__
__
__
__
___
__
Rationale: ------
Priority _
_
__ Patient E:
Rationale: -------
Triage Scenario VI
Train Crash Disaster
SCENARIO: Two trains collide head-on at 1800 hours. One train is a commercial tanker carrying eight tanker cars
and is driven by an engineer and fireman. No other personnel are on board. The tanks are filled with a highly
flammable l1quid. The other tram is a passenger train traveling on the same track. Weather conditions are mild,
and the ambient temperature is 20 C (72 F). Upon arrival at the scene, EMTs and paramedics find:
DECEASED-Two engineers and one fireman
Five passengers, including one infant with a fatal head injury
INJURED-The fireman from the commercial train, ejected 30 feet, with 40% BSA second- and third-de
gree burns
Forty-seven passengers from the passenger train
1 2 category Red pat1ents, 8 with extensive (20-50% BSA) second- and third-degree burns
8 category Yellow patients, 3 with focal (< 1 0% BSA) second-degree burns
22 category Green patients, 1 0 with painful hand and forearm deformities
5 category Blue patients, 3 with catastrophic (>75% BSA) second- and third-degree burns
Two f1re companies and two additional ambulances have been called. The local commumty hospital has 26 beds,
5 primary care providers, and 2 surgeons, 1 of whom IS on vacation. The nearest trauma center is 75 miles (120
kilometers) away, and the nearest designated burn center is over 200 miles (320 kilometers) away.
0 Should community disaster plans be invoked? Why, or why not?
fJ If a mass-casualty event is declared, who should be the medical incident commander?
B What s
i the first consideration of the medical incident commander at the scene?
B What considerations should be taken into account in medical operations at the scene?
- - -= - What is the second consideration of the medical incident commander at the scene?
m What is the meaning of the red, yellow, green, blue, and black triage categories?
D Given the categories in Question 6, which patients should be evacuated to the hospital, by
what transport methods, and in what order?
llJ What efforts should be taken by the medical incident commander to assist with response andre
covery?
I N DEX
ABCDE, 5 Penetrating, evaluation of, 1 19 Maintenance

Brain injury,145 Pitfalls in pediatric, 239 Assessment, 5
Cold injury, 221 X ray examination of, 1 16
- in Austere and hostile environments,
Geriatric, 250 Visceral injuries, 239 308-309
Tnjury prevention, 243 ABG (See Arterial blood gas) Cervical spine protection with, 5-6,
Reassessing, 21 Abruptio placentae, 264 20
Abdomen Abuse Chin-lift maneuver, 29, 30, 308-309
Anatomy Domestic violence, 266 GEB and, 31-33
External, 1 12 Geriatric, 255 Jaw-thrust maneuver, 29, 30, 308-
internal, 1 12-113 Pediatri c, 226, 242-243 309
Assessmenr, 1 1 2, 1 15-126 Injuries, 2 42 L\IJA and, 3 1
Auscultation, 1 15 Law regarding, 243 LTA and, 3 1 , 32
Contrast stuclies, 1 1 8 Acid/base balance, 64 Mu lti lu m en esoph ageal airway and,
CT, 1 1 8 Acidosis, 233 31
Diagnoses, specific, 121-123 Acute care, 322 Nasopharyngeal airway, 30-3 1
DPL, 117-l H ! Adenosine triphosphate (ATP), 57 Oropharynge<ll airway, 30
Injuries 14-15
, Agi ng Pitfalls, 6
Austere and hostile environment Blood volume and, 251 Preparation , prch ospita l phase, 2
management of, 312-313 Brai n changes with, 252 Techniques, 29-39,308-309
Determini ng, 1 15 Circulation and, 251 M an agement 25-40, 2 1 5-2 16, 228-
,
Gunshot, 1 14 Organ systems and effects of, 248, 249 232

Hidden, 1 1 3 Populations, 248 in Austere and hostile environments,
M an agement, 21-23 Spni al changes with, 252 308-309
M ech anism of, 1 13-114, 1 1 7 Air b ags 285
, Deciding appropriate route for, 34
Missed, 1 14 Airway Helmet s and, 28-29, 155-156
Multiple, 1 1 2 Assessment 5 , Pitfalls, 26
Recogn izi ng, 1 1 2 Brain injury, 142-143 Skills/procedttres, 43-49
Shock a.nd, 1 15 Burn injury, 2 1 2 Trauma and, 26-29
Inspection, l l5 Assessmen l, 213 Multilumeo esophageal, 3 1
Laparoscopy, 1 19, 120 Chest injuries and, 86 in Austere and hostile environments,
Percussion, 1 15 Compromise, 6 309
Peritoneal cavity, 1 12-1 13 Definitive, 32-33 Nasopharyngeal, 30-31
Physical examination, 14-15, 1 1 5 in Austere and hostile environments, in Austere and hostile environments,
Adjun cts to, 1 16 - 1 1 8 309 309
P alpation, l l 5 Criteria for establishing, 32 insertion, 44
Retroperitoneal spaces, 1 12-113 Indications, 33 Neck trauma, 27
Injuries to, 1 13 Difficult Obstruction, 5, 27
Secondary survey, 21-23 Endotracheal intubation and, 35-38 Burn injuries causing, 213
Stab wou nds, 1 19-120 Intubation of, 35-38 Object ive signs of, 27-28
Thoracoa bdomi nal component, J 13 LEMON mnemonic and, 36 Oral, 230
Trauma, 1 1 1-124 Edema, 2 1 3 Oropharyngeal, 30
Bltmt, L l 3 G eriatric, 250 in Austere and hostile environments,
Blunt, evaluation of, 1 18-119 H emorrhagic shock, 62 309
CT, 238 Inhalation injury Insert ion, 44
DPL, 238 Burn, 212, 2 1 3 Oxygenation, 26
PAST, 1 17, 23!\ Management of, 215-2 1 6 Pediatric, 228-232
Nonoperative management of Intubation, 27 Anatomy of, 228, 230
pediatric, 238-239 Endotracheal, 6, 35-38 M an agement, 228-232
Pediatric, 237-239 Paralys is, 6 Problem recognition, 26 27
-
Penetrating, 1 13-114 Laryngeal trauma, 27 Resuscitation, 8
351
352 INDEX
";urgical, 38-39 Preparation, hospit;ll phase of. 2-4 Resuscitation, 31 1-:112

in Austere and h<lstill: environments, Preparatio n , prehospital phase of, Risb. 305
309 2.3 pecific injury management in,
Cricothvr
.
oidotonw, 311-39 Pr imary urvey, 1-8 312-314
.
Obesity and, 6 Reevalua tion, 1 6 fhermal in jurie,, .l l 5-3 1 6
Pitfall .3R Resuscitat ion, II 9 Cold-related, 3 1 5
"T,tlking patient," 27 )econdarr survcv, I I 1 6
fleat-rclated, 3 1 5-316
rransfer of patient illld, 274 Shock, 5 7-59, 79 '1 ransport.ttion in
l'ra u ma and Skills/procedurt'S, 19-24 PrepMatio n for, 06, 3 1 4-3 15
Maxillofacial structurt, 26-27 Transfer, 2, I 0-1 I 'travel to, 307 OH
:-.leek. 27 triage, 4 Triage, 3 1 7-311!
Vcmilation problem. 6 Joint injury, 199 Ventilation, 309-3 10
Vomiting a nd, 26 Pelvic, 1 15-126 Automobile crash ( St't: lotor veha cle
Aimay decision scheme, 39 Spinal cord inj ury , I I! I 186 crash)
Alcohol abuse, 271 Trauma Axis fractures, 164-165
Alkali burns, 2 1 H Head, 153-156, 239-240 Odontoid, 164
Alkalosis, 64 M usculoskeletal, 190-19 J , 205-2 1 () Posterior denwnl f"nlcture of C2, 165
AMPLE history, I I, 21 Neck, 1 53-I 56
Blood los:., 7 Ocular, 299-30 I Backboards, 162
Amputation Vacular injury. 195
Replant<llion, 195 \ 1\U,ll, 190- 1 9 1 , 206 Backward, upward, and rightward
lb um;Hic, I 95-19o Vital fun ctwn , I pressu re (HURP), .B
Aneurysm, 149 Athletes
Angiography (See CT angiogmphy) Blood loss. 7 Bag-mask ven l ila tio n, W
Ankle f:ractures, 200 Shuck i n . t:o7 PiU.a.Us, 39--40
Anlerior chamber, 300 Atlanto-occipital joint assessment, Two-perwn tcth nique , 44
Injury, :\01 177-17R Barbi tu rates
Anterior cord synd rome, I 63 ATP (Scc Adenoant traphmphatc) Brain injurv, 141!
Antibiotics (See also SfJI'njic 1/llti/nollcs) Atropine, 231 Coma, 149-150
13ram injury. 1 19 Auscultation BCVI (See Bl u nt carotitl ami vertebr-.11
Hurn injury, 2 1 7 1\bdominal, 1 15 vascuiJr injury)
Anticonvulsanls, 1411 (Sec olso specific Nto.k, l.J Ben zodiazcpincs, 271
filii iCOIII'rtfStl/1/$) Austere and host ilc envi ron ments , Biomechanics
Aortic rupture/disrupt ion, 95-96 305-318 lmpact,283
Arachnoid, 13.3 Abdominal injury managemenr in, fn t urr, 283- 288

f>.kmbrane, 1.'.3-134 3 1 2-313 Blast injuries, 286
Area of Operations (Warm Zone), 322 Airway managrrnclll in, 01!-JOY Care of, 330
Arterial blood gas ( AllG ), 9 Hrca th ing ml n.1gcmcnt in, 308-3 10 Blood borne infections, .2:'i l
Reuscitation monitoring tlf, I 0 Burn i11jury management in, 314 Blood composi tion, in Pregnancy, 261
Shock,63 Ch ltll enging cnvironmrnls, 307 Blood loss (Sec olso H emorrhage)
Art cric Chet i nju ries in, 3 1 0 Athlete, 7
Hemorrhage, maJor, 19.-1 94 Circulation managl'ment in, 310-312 Blood product w arming and, 9
InJUT} r
l emostasis, 3 1 0-3 1 1 Circulation, 7
1\ssessment, 193 Communication and ' ignaling in, 3 1 6 Respom.e of, 56
Identifying, 2 1 0 3l7 Externa l bleeding. 2
Managemcn L, 193-194 Communication and transportation .
Cer iatric 7
Musculo:.kdetal tra u ma, 1 93 in, 306 H emorrh age ci.1S'. a nd , 60-61
Mc:ningeal,133 Context, 305-307 Massive hemothorax. 90

Arteriography, 146 Fnvironmcntal extremes in, 315-31 n J\!usculoskelctal lraum,l. 242
AltseSment Equipment and supplies in, 306 Pathophysiolof!y, 56-57
Abdominal, 1 15-11o Evacuation in, 3 1 1-315 PedJatric,7, 233,234, 242
A irway, 5 l::.xtremit)' injury management in, 3 1 3- Pelvit fracture, 2 1 0
Approach to inj ury, 2 314 Pitfalls, R
A rteria l injury, 193 Health .:are resou rce.. :05 Resuscitation, 8-<J
Burn injury, 2 1 3 l Jospital preparation for becomi ng, Shock and, 56-57. (l0-6 l
Compartment syndrome. 196-197,109 308 Blood pressure ( Sl'c al>cJ Mean arterial
Cruh sv nd rome, 1 94 \ledacal units, 307 blood pre\Ure)

btremitv fracture. I 99

M ilitary combat tasualty care, 306-307 Hrain .injurr. 1-15
Initial, l-18 Oxygenation, 309-] I 0 Burn injury, 2 1 6
Hrain injury, 142, 145 Personnel and their .,fety in, 306 Cardiac output equa ted with, 66-67
Components, 2 Preparalion and pla n n in g for, 307-308 Luwer-Lhan-nllrnull, 64
INDEX 353
P.:diJtric, 234 Minor, 1 32 Ae....ment, 113

Rc:,uscilat ion monitoring of, 10 M anagc:mcnt of, I.JO An t ibiotic, 2 1 7
Bl<od replacement/transfusion Muder.llc, 132 t\sst:s\lllL'nt, 213-216
Auwtransf'usilm, 66 Management of, I 12, 144 Atcst.:rc ;md huLile environment
(.alt:tum auministration, 66 Pitfalb, I 12 m,H1<1gement of, 3 1 4
< uagulopalhy, 66 Pediatric, 23':1-2,10 Baseline dctcrmimuion for patien t
( 'ross-m.1tched, 66 !'vlanagement or. 2<1 l wit h major, 2 1 7
( r}'>lal lu id, 66 Penetrating, I .'7 Blood p rc.,su re, 116
t ;.:ri.Hric 251
, Antihiotks for. 149 llody-Mirfacc <lrea, 2 U
P.:diJtriL, :!35 cr. H8-l 19 Breath ing
l'l<hl1lil, 66 ;\.1an.lgement of, 14!1-149 A"essmcnt, 2 1 3-216
Shot.:k, oo Secondary. 1 6 ( hcmK.II, 1 1 8
Type 0 blood, o6 Severe. 1 3 2 Ocular, 302
Typ.:->pccific, 66 ABCI1F.. I..J" Circulat ing blood volume, 2 1 6
,
W mning 11 uid. 6Cl A irw.1y/hre01 1 hing, 142-143 l'in:ulation, 2 1 7
13 1oud sampl es, 6.' Blood prest1re, 145 Dept h. 2 1 3
Hlood volume Circulatio n, I <13 I 14 Dl.li..Umcntation, 2 1 7
Aging and, 251 CT. 144-146 Fk.:Lrkal, 2 1 8-219
1\urn in j ury ctrculating, 2 1 6 Diagnostic prtKt:Ullrr;, 144 n x t rem it v , 1 1 7
,1 nd (..Hdiac output, 7 ,
l ly po tensin n ll3-l14 Firt degree, 213
in Pregn.mcy, 16 1 I nitial cvalu.Hion. 142, 145 lluid resuscitation, 2 1 2-213, :! 16
Blood warming, 9, 66 !-.lanagement
' of, 142 1-16 Pit l tlf.., 217

Blunt carotid and vertebral va\culnr "eurologcc examination, 144 < a'tr " tube i nsertion, 217
.
inj ury (BCVI), I M, 167 Patient outcome, f.l-1 (erialm, 248, 250
.
Bl u nt trauma (Sec Met.:h.ml'll1 of' Primary survey 1 12-144 . H I' tory, I ' ' I .:>
_, _
injury/injury p.Hll'rns) Rcsubcitation, 142 144 lmmcuiatc lifesaving measun:s for,

Body-surface area (burn injury), 2 1 j St'cundMy surwy. I <14 212-213
Brachial pl exu s, 14 Trea tmcnl ltll:t'> for, 132 I nt mvenous access, 2.12-21 3
Brain Tri age, 142. ll5 M,111:1gement, 223, 314
t\gmg .1nd changes in, 152 Sp i n 1l injury .lsKiutl!d
, c with, 158 Pain. 2 1 !1
'\n,llmny, 134-135 Steroids, 147-1 4!\ Nart.:otks, analgesics, and sed,l!ivc-.,
Aneurysm, 149 Treatment, l.\2, 110 217
Death, 149-150 Tnage, 1 32. 142, 145 l'a111 ITI<IIl.lgement, 218
Lobe.,, 134 Brainstem, 131 Paticnt tra nsfer, 2 1 9
Brain injuries (Ste lll$c> :'1-hnor t raumatic Reflexes, absent, 149 Pedia tr ic, :! 14
brain injury} Breath sounds, 9 Circulating blood vo lu me, 216
Anticonvulsantlt, 14!\ AbnormJI, 2!\ Physil'll l'Xaminalion, 2 1 7
Barbiturates, 148 Breath ing Pctf:1lb,11!\, 2 1 9
Blood llow, 137 Austere and hostile envi ronmen t Primary survey, 2 1 3-216
Blunt, 137 man.1 gc mcn l ol. 30!1-3 1 0 Priorit ccs. 2 1 2
ur. 136 Brain 1niu ry. 142-IIU Resuscitation, 1 1 3-216
(.ontw.ions. l39-l40 Burn injury, U 2 1 6 Rul.: of Nines. 214. 223
niffme. 138 Che>t iniu r)', 8o Secondary \urvey, 2 17-11 !\
fpilepw, 148 Geriatric, 250 econd-degree, 1l3, 2 1 5
( . --
. llrtC, 75') - .>
--75' Ped.1atr." p_,} 1 l)
oert, -, _ ___ _ Scventy, 2 1 3, 114
E\'aluatton and m.magement of, PitIiliis, 6 Si;.:, 2 1 3
252-153 Primary >urvey, b, 10 pecial rLqui rements, 218-119
Iil'matomas Respi ratOf)' .1rrc.,t, I 12 Stop burni ng process in. 2 1 2
rpidurnl, 138-139 Resuscitation, !\, 20 'Jltnnu. 2 1 !\
lntracerebral, l 39-1 10 Transfer of pat icnt .1nd, 27'1 Third-degree, 213, 2 1 5
1\ubdural, 139 B retyl iw11 tosylatc, 222 Types, 223
1-lyperventii.Hion, 14o Bronchi, I O<L Wound ill'.:, 2 1 7
I lypovokmia, 146 Bronchial tree, 9'1 BURP (SL'<' Backward, upward, ;1nd
ICU .1dmission for, 142 Bronchoscopy, 21 h rightward pressure)
l ntravenom fluids. 146 Broselow(tm) Pediatric Emergency Burr hole craniotomy, 149
hul.lgcment, 140, I 42-1-16. I 1!1-149, Tape, 7!\
_..., ., _.)_
11( 11-....
73
Brown S quard syndrome, 163 CL rotary ubluxation, 164
5urgteal, 148-149 Bullets, 287
t-.1annitol, 146-1-17 Burn centers, 219, 22J Calcium administration, 66
tviAP. 137 Burn injuries (Sec nlso Thermal injuries)
,
Medical therapies 146 11!! Airway, 2 1 2 Carbon dioxide detection, '19
354 INDEX
Carbon monoxide (CO) poisoning Radiography, J 67-168 Blood pressure, 234

Burn injury, 2 1 3 Secondary survey , 21 Blood replacem ent 235 ,
Diagnosis, 2 1 3-2 1 5 Chance fractures, J 65, 166 Brain injury 239-240

,
Cardiac arrest, 232-233 Chemical, biologkal, radiological, Management of, 24l

Cardiac injury, 94-95 nuclear, and explosive (CBRNE), Verbal score and, 240
Cardiac output 322 Breathing, 232-233
Blood pressure equated with, 66--67 Chemical buros , 2 1 8 Cardiac arresl in, 232-233
Blood volume and, 7 Ocular, 302 Cause of death in, 226
in Pregnancy, 261 Chemical injuries, 322, 331-333 Circulation, 233-237
Cardiac physiology, 56, 57 Chest Organ perfusion, 235
Cardiac tamponade, 9 1-92 Crushing injury, 98 PitfaUs, 237
Diagnosis, 91 Flail, 88-89 Cricothyroidotomy, 232
Pcricard iocentesis, 92 Diagnosing, 88 DAl, 230 23 1
,
Tension pneumothorax. m imicki ng, 9 1 lnj uries, 14 Flu id (esuscitation, 234-235

Cardiopulmonary resuscitation (CPR), Airway a nd, 86 Head trawna, 239-241
221 i n Austere and hostile environments, Assessmenl of, 239-240
Care standards, alternative, 329 310 Hemorrhage, 238
Casualty collection point (CCP}, 322 Breathing and, 86 Hypovolemia, 234
Catheters Geriatric, 15, 250 Hypovolemic shock, 235
Gastric, 9-1 0 lntubalion, 86 Immobilization, 241 , 242
Pitfalls, 9 Life-threatening, 86, 92-93 Spinal, 1 8 4
Urinary, 9, 1 1 6 Man ifestatio ns of, 97-98 Injuries
Cause of Death Pathophysiologic effects of, 86 Brain, 239-241
Geriatric, 248 Pediatric, J 5, 237 Burn, 2 1 4 , 2 1 6
Homicide, 242 anagernent , 2 1 , 107-109 Chest, 1 5
Pediatric, 226, 242 Physical examination, 14 Equipment for, 228, 229
CBF (See Cerebral blood flow) Pitfalls, 1 5 Long-term ef
fects of, 227-228
CBRNE (See Chemical, biological, Secondary survey, 2 1 Patterns, 226
radiological, nuclear, and Trauma Psychological starus and, 227
ex-plosive) Management, 1 07-1 09 Recognizing, 233
CCP (See Casualty collection point) Pediatric, 23 7 Spinal , 241
Central cord syndrome, 163 Wounds, thoracoabdominal lower, 1 1 9 Types, 226
Central nervous system, 274 X ray, 1 04- 105
- Intracranial injuries, 240
Central venous pressure (CVP) Chest tube insertion, 98, 108 Tntubation
Mon itorin g Complicati ons, 108-109 Endotracheal, 47, 230-231
Line placemem for, 69 Ch ilblain, 220 Orotracheal, 230-232
Shock, 68 Child abuse, 226, 242-243 Pitfalls 232
,
i n Pregnancy, 2 6 1 lnjuries, recognizing, 242 Medications, 231

Cerebellum, 134-135 Law, 243 Musculoskeletal trauma, 242
Cerebral blood flow (CBF), 136-137 Children Oropharyngeal air.vay in, 30
Cerebral perfusion pressure (CPP), 136 Abdominal traum a, 237-239 as Patients, 226-228
Cerebrospinallluid, 134 Assessment, 237 Preox.ygenation, 23 I
Cerebrum, 134 CT, 238 Primary survey in, 5
Arteriography, 146 Diagnostic adjuncts, 237 PTS, 289
Blood flow, 252 DPL, 238 RSI, 230
Hematomas, 139-140 FAST, 238 Skeleton, 227, 242
Hem ispheres, 134 1\onoperative management, 238- Spinal cord injury, 24 1
Cervical spine 239 Tachycardia, 234
Anatomy, 158, 159 Pit falls 239
, Tension pneumothorax, 237
Dislocarions, 165 Airway, 228-232 Thermoregulation, 237
Fractu res 165, Anatomy of, 228, 230 Thoracoscopy, 233
Inju ry, 158 Managing, 228-232 Trauma, 225-244
Neurological deficit and, J3 Oral, 230 Abdominal, 237-239
Screening patients for, 169-170 Anatomy, 226 Ainvay and, 228-232
X-ray evaluation, 167-168, 1 76-177 Tntubation and, 232 Blunt, 226
Management, 2 1 Multiple inj ur ies and, 226 Chest, 237
Nerve root inju ry, 1 4 Size and shape, 226-227 Head, 239-241
Physical examination, 13-14 Skeleton, 227 usculoskelelal, 242
Protection ( See also Immobilization) Spinal cord injury and, 241 Penetrating, 226
Airway maintenance with, 5-6, 20 Surface area, 227 Preventing, 243
Pitfalls, 6 Blood loss, 7, 233, 234, 242 Scores, 289
INDEX 355
Spinal, 241 Acute, 197 DAJ (See Drug-assisted intubation)

freatmenl of, 233 Assessment, 196-197,209
Treatment, 22!1 Diagnosis, 197 Death
Urine output, 236-237 Distal pulse, 197 Brain, 149-150
Vascular access lines, 63 InJury, 196 Dagnosmg, 149-150
Venous access, 77, 235-236 Management, 197, 209 Cause of
Preferred sites for, 236 Pitfalls, 197 Geriatric, 248
Ventilation, 230, 232 233 Signs and symptom. 196- I 97 Homicide, 242
Viceral injuries, 239 Compression injury 284 , Pediatric, 226, 242
Chin-lift maneuver, 29, 30 Compu ted tomography (CT}, 10 Determination of, 222
in Austere and hostile environments, Abdominal, I I 8 Deceleration injury, 284-285
30!1 309 Pediatnc, 238 Decompression
Circulation (Sec also Cerebral blood Back injury, 120 Gastric, 62
now} Brain injury Needle, 88
Aging and, 251 Penetrating, 148-149 Decontamination, 328
Blood now Severe, 144-146 Chute, 322
Rrain injury, 137 Flank injury, 120 Dcfmitive care, 1 7
Extremity, 1 9 1 - 1 9 2 Head, 154-155 Initial assessment, 2
Brain inJury, 143-144 MTBI, 140 Pregnancy, 265-266
Burn injury, 2 1 6 Pelvic, 1 1 8 Transfer, 17, 269-276
Extremity, 2 1 7 Concussions, 140 Skills/procedures, 24
Frotbite, 220 Conjunctiva, 300 Dentures, 250
Geriatric, 25 1-252 Consent for treatment, 1 7 Determinat ion of death, 222
Evaluatton of, 251 252 Contrast studies Dextran, 220-221
Management of, 251-252 Abdominal. I I 8 Diagnostic peritoneal lavage (DPL), I 0,
Pitfalls. 252 Pelvic, 1 18 127-129
Hemorrhage control with, 20 Contusions Abdominal, 1 1 7-1 1 8
Hemorrhagic 'hock and, 62 Brain, 139-140 Pediatric, 238
Management, 251-252 Extremity, 197-199 Closed technique, 128-129
111 Austere and hostile envtronmems, ntraccrebral hematomas and, Open technique, 128
3103 12 139-140 Pelvic, 117-118
lasstve hemothorax, 90-91 Pulmonary, 88-89 Diagnostic studies, 10 (See also
Musculoskeletal trauma, 191-192 Thoracic trauma and, 94 Radiology; X-rays; specific tests)
Pediatric, 233-237 Recognizing, 198 Brain death, 149
Pitfalls, 237 Cornea, 300 Brain injury, 144-146
Pitfalb, 7 Injury, 301 Pitfalls, 1 1
Primary survey, 7 CPP (See Cerebral perfusion pressure) Resuscitation, 1 0
Resuscitation, !I -9 CPR (See Cardiopulmonary Technical problems, 1 1
Shock, 58 resuscitation) Transfer of parient and, 274
Thoracic trauma, 90-92 Craniotomy, 149 Diaphragm injury, 121
Transfer of patient and, 274 Cricothyroidotomy Diagnosis, 96
CO poisoning (See Carbon monoxide Needle, 38, 52 Traumatic, 96, 97
poisoning) in Austere and hostile environments, X-ray, 104-105
Coccyx, 158, 159 309 Diazepam
Cold immersion injuries, 220 Pediatric, 232 Brain injury, 148
Cold injury Skills/procedures, 51-53 Paralysis and, 37
in Austere and hostile envtronments, Surgical, 38-39, 52 Pediatric head injury, 240
315 in Austere and hotilc envnonments, DisabiUty
Frostbite, 220 309 Geriatric, 252-253
Frostn ip, 219 Complications, 52 Hemorrhagic shock and, 62
l.ocal. 220 Crush syndrome, 194 Pitfall. 8
T1ssue effects of, 2 1 9-221 Crushing injury Primary survey, 7, 20
1\onfreezing, 220 Chest, 97, 98 Resuscitation, 20
Recognizing, 219 Extremity, 198 Disasters
RewarmiJ1g, 222 Musculoskeletal, 189 Communication during, 317
Systemi<:, 221-222 CT (See Computed tomography) Drills, 327
Systemic hypothermia, 221-222 CT angiography (CT-A), 146 Injury patterns and pathophysiology
Treatment, 220, 221-222 CT-A (See CT angiography) in, 329-330
Triage scenario, 346 - 347 CVP (See CentTal venous pressure) Management, 17,321-333
Types, 21 9-220 Cyanosis, 27 Approach to, 324
Compartment syndrome, 196-197 Cyclist mjuries, 285 Community plruming for, 324
356 INDEX
Dcp<rtment<11 planning for, 325 D1sJbllitv, .25 .2-25 3

Failure, b
' . .
Hopit<ll disaster training and, 32S- r:nd-oi-life deLi'>iom, 255-256 . 1 tatfl
P Cu ' JJU --
lll)llr> --o. J9

32o F,11ls, 248 Eschmann Tracheal Tube Introducer

l los p iLal plann ing for, 324-.25 Fractures, 253 (ETTI), 31
Mitigating, 326--330 I Typothermia in, 2:! 1 Esop hagus
;-..Iced, 32 1-324 Immune S)'Stcm,254 , 3 1
Multilu llll'll, .1 irwav
Personal plan nin g lor, 325 Infections, 251 Rupture
Ph.1cs of, 324-33 1 Injury Blunt. 96 97
I'it fi11ls, 33 1 -, 148 1"(}
P.at te ms. ot _.., __ Postcmetit, 97
Prcparat ton and, 324-325 Type-" of, 248-250 Etomidate, 37
n,sp<ll"c.' and, 32 7-330 Intubation, 250 Pediatril, HI
l,im plc plam for, 324-325 ll.tedkation us;gc in, l4ll, 254-255 ETS ( St Fmergo tr.un system)
n:rm t nolog)' 322-323 Pitfalls. 255 ETTT ( 'IC<' Eschm,tnn I racheal Tube
Rccow rv. 330-331 Metabolism, 254 lntrndu..:er)

Rcpnnsc, 327-330 Monitoring, 25 1-252 Euvolem ia, I IJ
Altcrnutiw care standard. 32') t\-1otor vehicle crashe, 241! Evacuation care, '07
In hosp ita l mre and, 328-329 Nutrition, 254 Expl osi on
Patient d.:contamination .111d, 32H Pain rdief, 255 Abdominal i n iu rieo, 1 11
Prchospital 'are Jnd 327-.2!! , Prc(;xbli11g di sease, 250 lnjuric-., '22
S p,cial need populations and, 329 Resuscitarinn, 5 l\1usculoskdct,1 l t rauma, 189
Surge ,,,pability, 329 hock, 67 Triage scenario. 339-3-1.5
fr.1ftic control svstcm, 329 S pmaJ
. -
, cord/spme .ln)llr),
. 1e 1-1'
-:>-- -' -' Exposure/environmental control, 7-!!
Situ.lltons, 305 Thermal injuq, 250 in Auster .llld hmtile l'nvironmcnts,
'lc:rminolu> 322 ,.,_
'I"r,lunlitl 5, '47--\
1 -' 1 5 _, 16
-
_
. . ,.,.
, r,ulllng, -'-r31"
-" Exposu re and envi ron ment, 253 (
.e n at n.c tr<lllma anJ, -
. ,-
-'-'
'I ri.1ge su?n . rio, '\:!H-329

.l Musculol>kcletal svstem, 2"i3-25i.J Ilazardou'> .:nvironmcnt, history ot, 12

Dblocation:. Prex.isting dieac and, 21!! .'vlusculosk<:ll'lnl trauma, 189
Cervical spine, 1b5 Spt:cia l circumslances in, 254-256 Shock and, 62
Neurologic in ju r y econdJ ry to, 1 9 7 S)1tems and, :!5 -254 Ex ternal per imeter, .\22
Distal pube J 97, Unique charactcristks of, 248 Extremity deformity, 191
Do no fu rth er harm, 270 Ventilation, 250 Fo rearm , 208
Documentation Electrical burns, 218-219 Humeral, 207
Burn inJu n, 2 1 7 Electrocardiograph, 2b) Realigning, 107-20!!
Transkr, 271 Electrolyte disorders, 251 l'ibi.ll, 208
Domestic violence, 266 Emergency medical service:. (EMS), 322 Extremity injurie/trauma, 197-199 (S<'t'
DO PI:. m nemonic, 232 Emergency operation> cen ter (EOC), c/so Musnaloskelet<11 sytem)
OOJlJ)Ier probe, 191-192 322 Arterial hcnH>nh.tg. major, 193
DPL (Sec Di.1gnostic peritoneal lovage) Emergency prepared.ness, -2 1-33_, Austere ,1 11d hostile environment
Drug abuse, 27 1 'Jimninolog)', 321 32: man:1gcmcnt uf. 3 1 3-314
Drug-assisted i nt ubation (DAI), 230, Emergo train system (E.TS), J22, 32(> Burn, 2 1 7
21 1 Emphysema, 9 7, 98 Circulation, 2 1 7
Duodenal i njuries, 1 2 1 EMS (Sec Emergency 1\kdi-,1! crYiCl'S) Contusions, 197-199
Dura mater, Ln Endocrine system, in pregnancy, 263 Crush, 198
End-of-Life decisions, 25';-.2';6 Fractures, 199
ECG monitoring (See Monitoring) Endotracheal intubation, 33 3H Assessment, 199
Edema Difficult airway, 35JH 1\tln;Jgcmcnt, 199
rac1.1l, 13 l.I:: B m
, d, 35 Open, 194 195
ufl tis uc, 6 1--{)2 Infant, 47 lmmohiJaz,1tion, 199-200

Elderly I nha!ation iniury, 2 1 5-2 I 6 Prindpb uL 207
Abuse, 255 Pt!diatric, 230-2J I Joint, l9l- 19S
AirWJ)' 250 Tube plcemenL, 33-35 Limh-thrt.'att:uing, I ':14- 1 ':17
13rain inj my, 252-253 Environment (See Managellll'11l, I \.J2 , 199
Breathing, 250 E>.--posure/cnvirunmc:nt.ll wntrol) Phvsical cxilmination, 1 9 0
'
Burn, 248, 2"iO EOC !See E mergency operations cen ter ) Porenua llr Iife-th reatening. 19 2-1 9-1
Cause o( death, 248 Epidural hematomas, 138-139 Upper. 200
Chest anJuncs, I S Epilepsy, 148 Vascular, 195-196
Circulation, 2 51-2 52 Seizure managemcnt, 1 16
Eye1ids,300
Blood transfusaons, .251 Equipment (See nL<o Pt:r'>on.ll prntcctive lnjuf1, 301
F.valuJ tion of, 251-252 equipment) Eyes
M<111,1gemcnt of, 251-252 in Austere and host ile environments, Nonreactiw pupib, 149
Pitfalls, 252 306 Ocul.H tmu ma, 2.\.J<J-303
INDEX 357
Assessment. 299-30 I Ankle, 200 Gastric catheters, 9-10

Chemical injuqr, 302 Atla. 164 Burn tnjury, 2 1 7
rractures, 302 Ax is 1 64- I 65
, Pitralh,9, 10
Initial symptoms, 300 Ch,cd, 122 Placement, 1 o
.
Physical exam i nati o n 300-JO I Extremity, I ':19 Gastric decompression, 62
pccific iniuric$, JO I 303 Assesmcn t, I 99 Gastric dilation, 6 2
Physical cxarnination, 1 2 13, 300.J() I Management, 199 Gastric tubes, 1 16
Vi'>U<ll-acuily e.xamination. U Femoml, 199-200 Gllstrointestina1 system, 262
Geriatric, 25J GCS (<;<'L' Gl.lSgow Coma Sc.1le)
Falls Humeral, 25. 254 GEB (.\et Cum clastic bougie)
Biomechanics. 285 286 lmmobihlilt10n, 199 200 Genitourinary injuries, 1 2 1
Gcnatric. 248 Laryngeal, 27 Geriat ric (Set' Elderly)
Mu.:uloskeletal trauma, 189 L umbar spine, 15. lo6 Glasgow Coma Scale (GCS), 7
PAST ( S('(' Focused asemnt Maxillofacial tl"lL(t urc, 1 3 Brain death, 149
sonography m ll\IUilHl) Musculokclet<11 Brain iniuq
Pat emboli, 303 l m mobili7ation nt, I RH-189, Min or, 140
Femur 199-200 Moderate, 142
Deformed, realigning, 208 Sp li nti ng, 11lH I lead injury severity, 1 3 R
l'r.Ktures, immobilization nl. 199 200 Neurologic i njury cco ndary to, 197 Pedialri<.. head injury, 240
Venipun.:ture, 74, 7h Ocular traum.1, 302 Globe, 100
\'lnous access, 74 Odontoid, I Cvl lntury, 02
,
Fentanyl 271 Open Gluteus, 1 16
Fetus Asse,ment of, 194-195 Gum elastic bougie (GEB), 31-33
Primary survey of trauma and, [xtremit). I1H-195 Endotradle;l) intubation ami, 35
264-265 Injury, 194 lntubauon with, 32
Management of, 195 . .
POSlliOil, -
3'"'
Resuscitation and, 264-265
Fistula, 149 Muculoskl'lclll. Jill! Gunshot wounds, 1 1 3- 1 1 4
Piail chest, 81!-89 Open book, 122
rhlllk injuries Pelvit, J 5, 80, 192 Haddon matrix, 279, 280
cr. 120 t\)essmenl of. 123 I land injuries, 200
Physical examination, 120 Blood los lmm. 21 0 Hazard vulnerability analysis (HVA), 323
rluid resuscitation/therapy Causes of, 122 Hazardous materials ( HAZMATs), 322
in Austere and hostik en\'ironmcnh, Classification of, 1.!2 123 HAZMATs (See Hazardous material)
' 1 1-312 ldentilic.llion .md management, Head ( Sec 11/so specific stntctllrts)
Burn inJ ury, 2 1 2-213, 2 1 6 209-2 1 0 Anatom>' 132-135
Pitfalls, 2 1 7 Managing, 1 2\, 209-2 1 0 ("I st,lm of, 154-155
InitJal, 64-65 Mechanbm of injury, 122-123 F;h.ioll edema, 1 3
Minimal or no response.:, 65 Pallerns ol force k.1ding to, 1 2 2 lnjuric, 132
Musculoskeletal injury. 188 Rib, sternum, and c:puJar, 98 Classification of, 137-140
Organ perfusion a nd, 64 Skull, IJ8, 148 Mcch:111ism of, 137
Overload or IJuid,, 68 Spinal !vlorphology, 138
Pediatric, 234 Cervic,ll, l6.'i Scvcrit) of, l38
Pelvi.: disruption with hemorrhage, Lumbar, 15, 166 M,w,Jgt:mcnt, 2 1
193 Thoracic, 15, 97 98, 165-166 Mcning,. 133-134
Rapid response, oS Thoracolumbar Junction, 166. l'h).,KJI e\ammatioo, 12-13
Shock, 64 Splintmg, 188 Ph)'tology. 135-137
Hemorrhagic, 63-64 Thoracic spine, 15, 97-98, 165-166 Sccond.lf)' survey, ll
Overload or fluids t. nd, 68 hemothorax and, 93 lhwma, U, 1 31- 1 50
Transient respon5e, 65 Tibial, 200 Asc'ment and management ,
Jbuma, 63-64 Transler of" p1l icnl and, 274

. 153-156
Flumazcnil, 37 Vertical sh<.'<ll\ I 22-123 Pediatric, 239-24 1
Pedi.ttric, 231 Frostbite, 220 Pnmary survey, 15'1
focused assessment sonography in Circulation, 220 Prognosis, 149
trauma (FAST), 10 Depth, 221 !->cconda r v , 154
survey
Abdominal, 1 17 Local, 220-22 1 Vcntrkular wstem, 135

Pediatric., 238 1anagemcnt,

' 2:!0-2 2 1 Head Injury Warning Discharge
Pelvic, 1 1 7 Pitfalls, 221 Instructions, 140, 143
Forearm deformity, 208 1.etanus, --
1 "0 Hea1th care reources, 305
Forensic evidence, 1 7 Tissue damage 221 , Heart rate, 261
Four Es of injury prevention, 279 280 Treatment, 220-221 Heat-related illness/injwy, 94-95 ,
flractures Frost nip, 2 1 9 3 1 5-316 (See olso Burn i njuries)

358 INDEX
Cnrdiac arrest, 232-233 Penetrating, 1 2 Preparation prehospital phase, 2

,
Ileal cramps, 3 1 6 Hospital incident command system P rinciples, 199-200

lleat exhaustion, 3 1 6 (HlCS), 322, 326 Spinal, 168, 1 83 1 84
!Jeat stroke, 3 16 Humerus Complications, 184
Helmet removal, 28-29, 155-156 Deformed, realign mg. 207 Injury and, 185
Hematomas Fractures, 253-254 Pediatric, 1 84
Burr hole craniotomy, 149 HVA (See Hazard vulnerability anai}'Sis) Immune system, 254
Epidurul 1 38- 139
. lfypercarbia, 26 lmmunoglobulin therapy, 265-266
I ntracerebra.l, 139-140 Hyperventilation, 146 lnc.ident command (IC), 323
Retrobulbar, 303 Hypotension Incident command post (ICP), 323
Subdural, 139 Brain injury, 143 144 Incident command system (ICS), 323,
Hemodynamics Causes, 143 326-327
'lormal, 64 Permissive, 64 Models for, 326
in Pregnancy, 261-262 Volume replacement, 143 Infections (See t1l.o specific 111[emo11s)
Stable, 64 Hypothermia Blood borne, 251
llemorrhage in Austere and host ilc environments, Geriatric traum,l and, 254
Arterial, 193-194 ' 1 ::>
- Injur ies
Clas I, 60 Brain death mimicked by, 149-150 Assessment approach to. 2
Class 11, 60 Determmation of death and, 222 Biomechanics, 283-288
Class Ill, 60-61 <.eriatric, 221 Classification, 1 1
Class IV, 6 1 Management, 221 Prevention, 243, 279-281
Classification, 60 Resuscitation and, 8-9 Causes, 280-281
Control Shock and, 67 Classificatitm of, 279
Circulation wirh, 20 Signs, 221 Economic incentives, 280
Pitfalls of, 7 Systemic, 221-222 Education, 279 280
Primary survey for, 7 Pitfalls, 222 Enforcement, 280
Definition of, 60 Treating, 221-222 Engin eering, 280
Direct effects of, 60-6 1 Hypovolemia Four Es of, 279-280
Fxtcrnal, 7 Brain injury, 146 Haddon matrix, 279, 280
Fctomaternal, 265 Burn injury, 2 1 7 Implementing strategies for, 2 8 1
Musculoskeletal inj ury, 18R Pediatric, 234 Interventions, 281
Occult, 64 Shock, 56 Problem, 280
Pediatric, 238 Hypoxemia, 26 Prograrn, 280-28l
Pelvic, 15, 193 Burn injury, 2 I 7 Program, impact of, 281
Pelvk disruption with, 192- 1 94 Hypoxia Risk factors. 280-28 1
lanagcmento 193 Brain injury, 142 Injury, disability, and mortality
Pelvic manipulation and, I I S Cellular, 57 statistics
Resuscitation, 8-9 Massive hemothorax, 90 Aging, 248
Shock, 56-57, 59,62 Pediatric, 232-233 Domestic violence, 266
Continued, 68 Geriatric, 249
Volume replacement, 60 IC (See Incident command) Injury Severity Score {ISS), 5
Hemorrhagic shock (Set Shock) JCP (See Incident command post; INR (See International normalized ratio)
Hemostasis, 310-31 1 Intracranial pressure ) Intensive care unit (ICU), 142
Hemothorax,93-94 ICS(See Incident command system) Internal perimeter, 323
Cause, 93-94 ICU (See I ntensive care unit) Lnternational normalized ratio (JNR),
Massive, 89-90 mmobilization 140
Circulation and, 90-91 Airway maintenance ,md, 5, 6 ln lracran iaJ inj uries
Initial management of, 90 Extremity, 199-200 Pediatric, 240
Pitfalls in diagnosing, 89 Principles of, 207 Shock and, 59
Treatment, 94 Upper, 200 Intracranial lesions, 138-140
HICS (See Hospital inCident command Fracture Diffuse, 1 3 8
system) Ank1e, 200 Focal, 138
History Musculoskeletal, 1 88- 1 89 , 199-200 Management, 148
AMPLE, I I , 2 l Tibial, 200 Mas, 148
Blood loss and, 7 Hand injury, 200 lntracranial pressure (ICP), 135
llazardous environment, 1 2 Knee injury, 200 Jncrease, 16
Ocular trauma, 299-300 Long spine board, 184-185 lonitoring, 146
Secondary survey, I 1-12 Musculoskeletal, 188-189, 199-200 Pediatric, 240
Thermal injury, I 2, 2 1 3 Neck, 168 lntraosseous puncture/infusion , 77-78
Trauma Pediatric, 241 , 242 Intravenous fluids
Blunt, 1 1-12 Spinal, 184 Brain injury, 146
INDEX 359
Burn injury Trauma, 2 7 Terminology, 322-323

Access for, 211-213 Laws/legal issues Extremity injuries/trauma, 192, 199
Spinal injury, 170 Child abuse, 243 in Austere and hostile environments,
Intubation (See also Drug-assisted End-of-life decisions, 256 3 1 3-314
intubation; Rapid sequence Records, 17 Fractures
intubation) Seat belt, 281 Extremity, 199
Airway LEMON mnemonic, 36 Pelvic, 209-21 0
Difficult, 35-38 Lens, 300 Frostbite, 220-221, 221
Management, 27 injury, 301 Head, 2 1
Chest injury, 86 Level of consciousness (WC), 7 Hemothorax, 90
Endotracheal, 33-38 Altered, 162 1nitial, 1-18, 19-24
lnfant, 47 Spinal cord/spine injury, 160 Hemorrhagic shock, 62-64
Pediatric, 230-231 Trauma scores, 289 Massive hemothorax, 90
Tube placement for, 33-35 Living will, 256 Open pneumothorax, 87, 89
GEB, 32 LMA (See Laryngeal mask airway) Intracranial lesions, 148
Geriatric, 250 LOC (See Level of consciousness) Joint injury, 199
LEMON mnemonic for, 36 Logrolling Maxillofacial structures, 2 1
Nasotracheal, 45-46 MusculoskeletaJ lrauma, 1 91. MTBT, 140, 1 4 1
Complications, 46 Spinal injury, 168, 1.71, 1 83-184 Musculoskeletal S)'Stem, 23-24
Orotracheal Lorazepam, 148 Neck, 21
Adult, 44-45 LTA (See Laryngeal tube airway) Neurologic evaluation, 24 '
in Austere and hostile environments, Lucid interval, 8 Nonfreezing injury, 220-221

309 Lumbar spine Oxygenatlon, 39
Complications, 46 Anatomy, 158, 159 Pelvic, 193, 209-2l0
Pediatric, 230-232 Practures, 1 5 Perineum, 23
Pediatric, 230-232 Thoracolumbar junction, 166 Records, legal issues, 1 7
Pitfalls, 232 Injuries Rectum, 23
Pitfalls, 38, 232 Screening patients for, 170 Shock,62-64,73-81
Positioning for, 37 X-ray evaluation, 168, 1 7 8 Scenarios, 79-81
Rapid sequence, 35 tung lacerat ion , 93 Skills/procedures, 2 1-24
Sedatives for, 37 Lung parenchyma, 104 Spinal cord injury, 181-186
Successful, 40 Cervical, 2 1
Tracheal, 38, 94 Magnetic resonance imaging (MRI), 167 TBI, 146, 147
X-rays, I 06 Mrutagement (See also Pain Trauma
lris, 300 mru1agement) Chest, 107-109
Injury, 301 Abdominal injUJy/trauma, 21-23 Head, 153-156
ISS (See Injury Severity Score) Pediatric, 238-239 Maxi l lofacial structure, 26-27
Airway, 25-40, 2L5-216, 228-232 Musculoskeletal, 205-2 10
Jaw-thn1st maneuver, 29, 30 in Austere and hostile environments, Neck, 21, 27, 153-156
in Austere and hostile environments, 308-309 Vagina, 23
308-309 Deciding appropriate route for, 34 VascuJru il1jmy, 195-196
Joints Helmets and, 28-29, 1 55-1 56 VentilaLion, 25-40
Injuries, 194-195 Pit falls, 26 Pitfalls, 39-40
Assessment/management of, 199 Skills/procedures, 43-49 Skills/procedures, 43-49
Stability, 191 Trauma and, 26-29 Trauma and, 28
Arterial injury, 193-194 Manni tol
Ketamine, 271 Brain injury, 140, 1 42-146, 1 48-149, Brain injury, 1 46-147 .
Knee inj uries, 200 241, 252-253 Pediatric head injury, 240
Burn injury, 223, 3 I 4 MAP (See Mean arterial blood pressure)
Laparotomy, 1 1 9 , 120 Chest, 2 1 , 107-L09 Mass casualty events (MCEs), 321, 323
Pediatric, 238 Circulation, 251-252, 3 1 0-312 1!-iage, 33 7
Laryngeal mask airway (LMA), 3 1 in Austere and hostile environments, Mass casualty triage, 4, 3 1 7-318
in Austere and hostile environments, 310-3L2 Maxillofacial st ructures
309 Compartment syndrome, L97, 209 Fractures, 13
Insertion, 46 Cmsh syndrome, 194 Management, 2 1 , 26-27
Laryngeal tube airway (LTA), 3 1 , 32 Oefinilive care, 1 7 Physical examination, 1 3
Insertion, 46-47 Disaster, 17, 321-333 Secondruy survey, 2 1
Larynx Approach to, 324 Trauma, 26-27
BURP manipulation of, 33 Need, 321-324 MCEs (See Mass casualty events}
Endotracheal intubation and, 33 Phases of, 324-331 MCis (See Multiple casualty incidents
Injury, 86 Pitfalls, 3 3 1 (MCis))
360 INDEX
Mean arterial blood llressure (MAP), 137 Side effects, 254 Trillge, 337
Mechru1ism of injury/injury patterns, Spinal injury, 170 Musculoskeletal system (See also specUic
12, 1 3 Meninges structures)
Abdominal, I 13-1 14, 1 1 7 Anatom)', 133-134 Amputation, 195-196
Evaluation of, I J 8- J 1 9 Arteries, 133 Compartment syndrome, 196-197
Biomechanics, 283 Layers, 133 Contusions, 197-199
Blast, 283, 286 Metabolism, 254 Extremil)' deform.il)'. 1 9 1
Blunt, I I , 283-286 Midazolam Ext rem i ly injuries/trauma
Abdominal, I J 3, J I S-J J 9 Paralysis and, 37 Phys ical examination, J 90
Brain, 137 Pet!iatric, 231 POLenLially !He-threatening, 192-194
Causes of, l l-.l2 Midline tenderness, 162 hactun:s
Fluid resuscitation, 63-64 Mi l itary casualty care, 305-3 1 8 Extremity, 199
History ot 1 1- 1 2 Care under fire, 306-307 lmmobili7alion o f, 1 88-189, 199-
Motor vehicle crash, 1 1- 1 2 Combat, 306-307 2 00
MuscuJoskeleta!, I 8!\ during Evacuation, 307 Open, 18S, 1 94-1 <J:i
Pediatric, 226 Tactical field care, 307 Splinting, 188
Pelvic, 1 13, l l 8- 1 1 9 Minimal acceptable care, 323 Immobilization, 188-189, I 99-200
in Pregnancy, 263 Minor traumatic brain injury (MTBI), Injury
Spinal, 166 140 Hemorrhage and, 188
Vehicular impact, 283-285 CT, 1 40 PTS and, 289-291
Classifications, 283 TNR, 140 Joint injuries, 194-195, 199
Disaster, 329-330 Management, 140, 141 Management, 23-?4, 205-210
Geriatric, 248-250 Pil fall, 140 Occult skeletal injuries, 20 I
Head, 137, 148-149 Secondary survey, 140 Physical examination, IS, 1 90- 19 2, 20b
Musculoskeletal trauma, 189 Missile injury, 287 Palpation, 1 9 1 , 206-207
PecUatric, 226 Tumble, 288 Pitfalls, 16
Pelvic, 1 13-1 11, l l8-ll9 Yaw, 288 Visual assessmen t, 190- 1 9 1 , 206
Pelvic [racture, 122-123 Mitigation, 323, 326-330 in Pregnancy, 263
Penetmting, I I , 283, 286-288 LCS, 326-327 Primary survey, 1 8 8
Abdominal, 1 1 3-1 1 4, 1 1 9-120 Monitoring, 1 0 Adjuncts to, I 88-189
Brain, 137, 148-149 ABC, 1 0 Resuscitation, 18!!
Bullets, 287 Blood pressure, 10 Secondary survey, 23 2 4, J 89-190
-
Entrance and ex.it wounds, 288 CVP His tory, 189-190

History of, 12 line placement r()r, 69 Pitfalls, 192
Missile, 287 shock, 68 X-ray examination, 192
Neck, 14 Electrocardiographic, 9 Trauma, 187-202
Pedialric, 226 Geriatric, 251-252 Assessment, 205-2 1 0
Pelvic, 1 13-114, 1 1 9 Pediatric, 235 Associated injuries, 201
in Pregnancy, 263 Postresuscitation, 2 Blunt, 1 8 8
Shotgun wounds, 287-288 Pregnancy, 260 Circulatory evaluation, 191- I 92
Spinal, 166 Pulse oximetry, I 0, 48 Closed soft tissue injuries, 1 9 1
Velocity, 286-287 Resuscitation, I 0 Cmsh syndrome, 194
in Pregnancy, 263 Ventilatoq' rate, 10 CrushLng injury, 189
Skills/proceelures, 2 1 Monro-Kcllie Doctrine, 135 Environment and, 190
Thermal, 283 Morphine, 255 Explosion, I 89
Med.iastinal structures Motor vehicle crash (See nlso Vehicular Fall, 189
Injury, 95 impact) Geriatric, 253-254 .
Pitfalls in, 96 Biomechanics, 283 Hemorrhage, major arterial, 193-
X-ray, I 04 Geriatric, 248 194
Medical response team, 323 Musculoskeletal rr<1llma, 189 Limb-threatening injuries, 194-197
Medical units, 307 Pelvic injuries, 192 Management, 205-2 1 0
Medications Trauma, 1 1-12 Mechanisms of injtlry, 189
Geriatric, 248 Triage scenario, 348 - 349 Neurnlogic evalLtalion, J 97, 198
Pitfalls, 255 MRI (See Magnetic resonance imaging) Observations and care, prehospital,
Geriatric trauma and, 254-255 MTBI (See .'vlinor traumatic brain 190
Interactions, 254, 255 injury) Open wounds, 1 9 1
Intubation, 23 1 MuiWumen esophageal airway, J I Pain conLrol, 200
Multiple, 248 i n Austere and hostile environments, Pediatric, 242 '
Pain, 200 309 Pitfalls, 242

Pediatric head injury, 240 Multiple casualty incidents (MCJs), 3 2 1 , Preiniury status and predisposing
Shock and, 67 323 factor:., 190
INDEX 361
Vehicle-pedestrian collision, I R9 Occult association injuries, 20 I Complete/incompldc, 162

X-ray examination, 189 Occult skeletaJ injuries, 201 PASG (Sec Pneumatic antishock
Vascular injuries, 1':15-1 ':16 Ocular trauma, 299-303 garment)
Myocardial contractility, 56 i\sessmen t, 299-30 l Pathophysiology
Myocardial infarction, 95 Injury incident history and, 299-300 Blood loss, 56-57
Myotomes, 160 Pa1ient history, 299 Chest i nju r ies and, 86
Chemical injury, 302 Disaster, 329-330
Narcotics, 21 7 (See also specific IIIJrcotics) Fractures, 302 PEA (See Puhclcss electrical activity )
Nasophar)'llgeal airway, 30-31 Initial symptoms, 300 Pedestrian injury, 285
in Austere and hostile environments, Ph ysical examination, 300-30 I Pediatric (See Children)
309 Specific i nju ries, 301-303 Pediatric trauma scores (J>TS), 289
Insertion , 44 Odontoid fractures, 1 6 4 LOC and, 289
NasotracheaJ intubation, 45-46 OrbitaJ rim, 300 Musculoskeletal injury, 289
Neck Organ perfusion Size and, 289
l rnmobUization, 1 61! Fluid resuscitation m1d, 64 Usc or, 289-29 1
Injury Pediatric, 235 Pediatric verbal score, 240
Blunt, 1 4 Shock, 64 Pelvic ring
Penetrating, 14 Organ systems Injuries, 192
Managem en t, 2 1 Aging effects on, 248, .249 Instability, 193
Pain, 1 62 Inj ur ies, 1 2 1 PelvL. 1 1 3 (Sec rrlso specific stmcturcs)
Physical examination, 13-14 Spinal injury and, 162 Assessment, I 15-126
Pi tfalis, 1 4 VehicuJar impact, 284-285 Contrast stud ies, 1 18
Secondary s urvC)', 2 1 O ropha ryngeal airway, 30 CT, 1 1 8
Trauma in Austere and hostile environments, Diagnoses, specifie, 1 2 1-1 23
Airway managemen 1 and, 27 309 Disruption with hemorrhage, J 92-194
Assessm en t and management, Insertion, 44 IV!anagement uf, 193
153-156 Orotracheal in tubation DPL. 1 1 7-J 1 8
Primary survey, 154 Adult, 44-45 Fractures, 15, 80, 122-123, 192
Secon dary u rW)' 1 54 in Austere and hostile environments. Assessme nt of, 123
Needle decompression, 88 309 Associated injuries, 1 22-123
Needle thoracentesis, I OS Complications, 46 Causes ol 122
Nervous system (Sec Central nervous Pediatric, 230-232 Classit1cat.ion of, 122-123
system; Peri pheral nerv<1us Osteoporosis, 253 ldentificalion of, 209-2 1 0
yslem) Oxygenation, 8 rv!anaging, 123, 209-210
Neurologic deficit Adequate, 39 Mechanism of injury, 122-123
Spinal cord i nj LLry, 162-163 in Austere and hostile environments, Pa11erns of Ioree leading 10, I 22
Neurologic deterioration, 8 309-310 l lemorrhage, 1 5, l 1 5
Neurologic evaluation, 15-16, 10 rvlanagcmcnt, 39 Injuries, 192
Brain injury, 144 Primary survey, 20 Ascssm cn L of, 193
Foe used, 144 Resuscitation, 8, 20 Hemorrhag aJ1d, 193
GCS, i Tiauma, 26 Mechanism of, J l 3- l l 4, I 1 7
LOC, 7 Missed, 1 1 4
Management, 24 Pacemakers, 67-68 Recognizing, 1 1 2
Musculoskeletal trauma, J 97, 1 % Pain Management, 123, 209-2 1 0
Pitfalls, 8, 1 6 Neck, 169 Penetrating wounds, I 1 9
Primary Survey, 7 Spinal, 169 Physical cxam il1ation, J 5, l iS
Seconda ry su rvey, 24 Pain management Adjuncts 10, l H i-1 1 8 .
Shock and, 62 in Austere and hostile environment, Stabili ty, 1 1 5 - l l fi
Spinal injury, J fiO, 1 82 312 Trauma, 1 1 1 - 1 24
Neurologic inju ry, 197 Burn injury, 2 1 8 Blunt, 1 1 3, 1 18- 1 1 9
Neurologic system, 263 Gcrial"ric, 255 FAST, I I?
Neurological deficit/injury, 15-16 Musculoskeletal system, 200
Penetrati ng, 1 1 3-1 1 <1, J 1 9
Cervical spine injury and , l3 Palpation Penetrating trauma (See Mechanism of
Nonfreezing injury, 220 Abdominal, 1 15 injury/injury pal lerns)
Management, 220-22 1 Musculoskeletal trauma, 1 9 1 , 206-207 Percussion, I 1 5
Nonhemorrhagic shock (See Shock) Neck, 1 4 Percutaneous puncture/dilation
Nuclear injuries, 322, 333-334 Pancrea1ic inju ries, 1 2 l tech n iques, 309
Nutrition, 254 Paralysi s Pericardia! blood, 9 1 -92
lnlubntion, 6 Pericardiocentesis, I 09
Obesity, 6 Medications for, 37 Cardiac tamponade, 92
Obt u ndat ion , 27 Paraplegia, 169, 170 Perimortcm cesarean section, 266
362 INDEX
Perineum Treatment, 87, 88, 93 Pregnant female, 5

Examination, 1 16 Postresuscitation monitoring, 2 Adjuncts to, 265
J'vlanagement, 23 PPE (See Personal protective equipment) Fetus and, 264-265
Physical examination, 15 Preexisting disease, 248 249 , Mother and, 264
Secondary survey, 23 Geriatric, 250 Skills/procedures, 20-2.1
Peripheral nervous system, 1 6 Pregnancy Spinal cord injury, 182
Peritoneal cavity, 1 12-J I 3 Anatomic changes during, 260-261 Traum::
Per nio, 220 Blood volume/composition during, Head, 154
Personal protective equ.ipment (PPE), 261 Neck, 154
323 Definitive care, 265-266 Thoracic, 86-92, 99
Personnel Hemodynamics, 261-262 Propofol, 271
in Austere and hostile environments, BIood pressure, 26 J Psychological status, 227
306 Carruac output, 261 PTS (See Pediatric trauma scores)
Communicable disease protection, 4 Heart rate, 261 Pul mon ary contusion, 88-89
Safety, 306 Venous pressure, 261 Thoracic trauma and, 94
Phenobarbital, 240 Hemorrhage during, 265 Pulmonary injury, 94
Pheny toin Mechanisms of injury, 263-264 Pulse, 7
Brain injury, 148 Blunt, 263 Distal, .197
Petlintrit:: head injury, 240 Penetrating, 263-264 Oximetry
Physical examination Monitoring, 260 Monitoring, 48
Abdominal, 14-15, 1 1 5 Perimortem cesarean section, 266 Oxygenation adequacy and, 39
Adjuncts to, I 16- 1 1 8 Physiologic changes during, 260-263 Pitfalls, I 0
Back injury, 120 Endocrine system in, 263 Resuscitation, 10
Rurn injury, 217 Gastrointestinal system in, 262 Sensor placement for, I 0
Cervical spine, 13-14 Musculoskeletal system in, 263 Pulseless electrica.l activity (PEA), 9
Chest. 14 Neurologic system in, 263 Pupils
Extremity trauma, 190 Respiratory system in, 262 Nonreactive, 149
Flank injury, 120 Urinary system in, 262-263 Ocular trauma, 300
Head, 12-13 Primary survey of, 264-265
Maxillofacial structures, 13 Adjuncts to, 265 Quadriplegia, 169
Musculoskeletal system, 15, 190-192. Resuscitation ot: 264-265 Complete, 162
206 Adjuncts to, 265
Neck, 13-14 Seat belt use during, 263 Radiation inju ries, 322, 333 - 334
Neurologic, 15-16 Secondary survey, 265 Radiography (See also Spinal cord injmy
Ocular trauma, 300-301 Shock in, 67 without radiographic
Pelvic, J 5, 1 1 5 Trauma during, 260 abnom1alities)
Adjuncts to, I 1 6-l 18 Assessment and treatment of, 264- Cervical spinal, 167-168
Perineum, 15 265 Lumbar spinal, 1 61!
Rectum, 1 5 1njur)' severity in, 264 Thoracic spinal, 168
Secondary survey, 12-16 Unique risks of, 263
Radiology, 24 1
Shock,62 Preinjury status, 190 Rapid sequence intubation (RSI), 35
Spinal, 120 Preload, 56 Pediatric, 230
Vaginal, 1 5 Preoxygenation, 231 Records, legal issues, 17
Pia mate.r, 133 Preparation, 2-4, 323 Recovery, 323
Placental abruption, 264 Initial assessment, 2 Rectum
Pleural spaces, l 04 Trauma patient, 2 Examination, l l 6
Pneumatic antishock garment (PASG), Primary survey, 4-8 Management, 23
199 Adjuncts to, 9-10 Physical examination, 15
Pneumothorax Skills/procedures, 20-21 Secondary survey, 23
Causes, 93 Airway maintenance with cervical Reevaluation, 16, 24
Open, 87-88 spine protection, 5-6 Replantat ion, J 95
Initial management of, 87, 89 Brain injury, 142-144 Respirators, 40
Ventilation for, 87 Breathing and Ventilation, 6 Respiratory arrest, 142
Simple, 93 Burn injury, 213-2 16 Respiratory system, 262
Pitl'alls. 94 Circulation with hemorrhage control, Response, 323
Tension, 87 7 Restraints
Cardjac tamponade mimicked by, 9 1 Disability, 7 Combative/uncooperative patient, 271
Causes, 87 Exposure/environmental control, 7-8 Laws, 281
PeruatTic, 237 Initial assessment, 2 Musculoskeletal trauma and use of ,
Pitfalls in diagnosing, 89 Musculoskeletal, 188 189

Treatment, 87, 88 Pediatric patient, 5 Use of. 285
INDEX 363
Resuscitation, 8-9 (See also Initial Assessment, 2 Surgical intervention, 57

Cardiopulmonary resuscitation ) t\IITBr, 140 Treatment, 66--67
Adjuncts to, 9-10 Musculoskeletal system, 189-190 h1anagen1ent, 56, 62-64, 73-81
Skills/procedure, 20-2 1 Pitfalls, 192 Scenarios, 79-8 1
Airway, 8 Physical examination, 12-16 Medications and, 67
in Austere and hostile environments, Pregnancy, 265 Neurogenic, 56
311 Skills/procedures, 2 1 -24 Cause of, 59
Blood loss, 8-9 Spinal cord injury, .182 Spinal shock , , 1 6 1
Brain injury, 142-144 Thoracic trauma, 92-97 Treating, 1 6 1
Breathing, 8 Trauma Nonhemorrhagic, 57
Burn injury, 2 1 3-216 Head, 154 Cause of, 59
Circulation, 8-9 Neck, 154 Nonresponder, 8 1
Geriatric, 5 Tl1oracic, 99 Organ perfusion, 64
Initial assessment, 2 Sedatives, 2 1 7 (See also specific sedatives) Pacemakers and, 67-68
Musculoskeletal, 188 Seizures, 146 Pathophysiology, 56-57
Oxygenation, 8 Senses Patient response, reassessing, 68
Pregnant lemale Examination of, 160 in Pregnant women, 67
AdjtLncts to, 265 Loss of, 170 Preparation, prehospital phase control
Fetus and, 264-265 Septic shock, 59 of, 2
Mother and, 264 Shock, 55-64 Recognition of other problems, 69
Shock,63 Abdominal injury, 1 1 5 Recognizing, 56, 57, 58
Skills/procedures, 20-2 1 ABG, 63 Septic, 59
Spinal cord injury, 182 Assessment, 73-8 1 Spinal
Tapc,234 r nitiaJ, 57-59, 79 Neurogen ic v., 1 6 1
Ventilation, 8 Scenarios, 79-81 Treating, 161
Retina, 301 in ALhletes, 67 Stale, 58
Injury, 302 Blood Joss and, 60, 61 Tachycardia and, 58
Retrobulbar hematomas, 303 PaLhophysiology of, 56--57 Tension pneumothorax and, 59
Retroperitoneal spaces, 1 1 2-L 1 3 Blood replacement, 66 Transient responder, 80
Revised trauma scores (RTS), 289, 290 Blood samples, 63 Trauma and, 58
Rewarming, 222 Cardiac physiology, basic, 56, 57 Treatment, 62
Rhabdomyolysis, 194 Carcliogenic, 56 Initial, 57
Rh-negative pati ents, 265-266 Cause of, 59 Special consideralions in, 66--68
Rib fractures, 98 Cause, 56, 57-58 Vlhat is, 56
Ringer's lactate solntion, 2 1 6 Clinical differentiation of, 58-59 Shotgun wounds, 287-288
RSl (See Rapid sequence intubation) Determining, 58 Skeleton, 227, 242
RTS (See Revised trauma scores) Pitfalls in determining, 59 Skin color, 7
Rnle of Nines, 214, 223 Cen u<l venous pressure monitoring, SJ..-utl
68 Anatomy, 132-133
Sacrum Circulatory, 58 Fractures, 138
Anatomy, 158, 159 Complications, avoiding, 68 Depressed, 148
Decubitus ulcers over, 1 4 Diagnosis, 58, 62 Managemem, 148
SAR (See Search and rescue) Initial, 56 Small bowel injuries, 121
Scalp Special <.:onsiderations in, 66--68 Snellen chart, 1 3
Anatomy, 132 Fluid resuscitation Soft tissue injuries
Wounds, 148 Jnitial, 64-65 Closed, 191
Scapular fractures, 98 Overload of Ouids and, 68 Edema and, 6l-62
SCIWORA (See Spinal cord injnry GeriatTic, 67 Fluid changes secondary to, 61-62
without radiographic Hemorrhage and, 59 X-ray, 105
abnormalities) Continued, 68 Sonography, I 0
Search and rescue (SAR), 323 Hcmorrhagic, 56--57 Spinal column, 158, 159
Seat-belt i nju ries 1 2 1 (See also
, Cause of, 58 Posterior, 1 58-160
Restrai11ts) Fluid therapy, initial for, 63-64 Spinal cord injury without radiographic
Pregnam women, 263 Initial management of, 62--64 abnormalities (SCIWORA), 1 63
Restraint usc, 285 in Injured patients, 59-62 C l rotary subluxation, 164
Secondary survey, 1 1-16 Physical examination, 62 Pediatric, 241
Adjw1cts, 1 6 Resuscitation, 63 Spinal cord/spine (See nlso Lumbar
Skills/procedures, 24 Vascular access I ines, 62-63 spine; Thoracic spi11e)
Brain injury, 144 HypoU1ermia and, 67 Aging and changes in, 252
Burn injury, 2 1 7-218 Hypovolemic Anatomy, 158-162
History, 1 1- 1 2 Pediatric, 235 Atlanto-Occipital dislocation, 163
364 INDEX
Arias lracture, I M <,hock Ilemothnra\ .md, 93

Axts fracture. 164-165 curogcnic ho..k 1'., I 61 Thora.:olumb.tr juncti on , 166
Dislnc.ll ions, I o5 Treating, 1 6 1 lnj uri c,, 97 ':li!
fv.tlu.llion and Tra nport, p rohd ing Syndrome. 16.3 Scree ni ng pat icnt for, 1 70
.pin: during, 168 Tracts, 158-160 X 1'<1)' a l u 1l ion, 168, 178
(v ,
Tr,tdurcs, 165 Corticospina l, 158-1 hO X ra)' idcntiliLation of. 103-JU6

ImmobiliL.iltion, 168, 183-IH4 Posterior column, 1511 I 60 Mobil i1y, 158
Complications, I H4 pinotluJJ mic, 1 5 H 160 Trauma. !\5-1 no
lon g pin e hoard. 184-18.5 Spl int i ng Card i<ll lampmude and, 9 1 -92
Pedi.ll ric, I R-1 Ext remity, 199 Circul<llton and, 90-92
ln i urr
/ trauma, 16, 157-1 T2 f-racture OiagmN ng, 92 q3
t\\SCS'>J11Cilt, )81-186 MuscuJuskddal, 188 Lethal, 9.:! 93
llht nt c.1mud, 166 Pelvic, 123 Prim,t rr uncy, 86-'n, 99
Brain injurv associated with, ISH Traction, app lica tion nt, 20!\ ResusLi t.1t1vc thoracotomy. 92
U.1ssifiuttions, 162-163 Stab wounds, I 1 3 econtlaq ....urvey, 92-n, 99
Co mplete, 160 Abdominal, I I <J-120 Thoracol u mba r junct ion fracture>, 166
(
Jn 111 plctc paraplcgi;l/quad ri plcgia, Standard precaution, I Thoracoscopy
1 62 Stern wn , 98 Needle. 2JJ
Co n firmin g 166-167
, Steroi<b, 1-!7-148 Pcdiat nc, lJ.I
Cl, 120 Subluxation, 24 1 Tube, 23J
1.\'itlu.ltion, 158, 252-253 Succinyl choline, 37, 14h Thoracotomy
Ceriatnc, 252-253 Pediatric, 231 ,\las,i n hemnl hor.r\, 90 9 1
lmmnhilizatton, 185 Surge capability, 323 Rcsu\cit.llin-,92
Incomplete paraplegia/quadriplo:gi.t, E ffect ive. 329 Thorax, I 05, I 06
16.:! Tibia
lt\l r,IVCI10US tluids, 170 Tachyca rdia Ueforntcd, tl.'.tltgmng, 20!\
!.eve:I. I o2, 182-183 Pediatric, 234 Fract u rcs, 200
L(1grolling .tnd, I 68, 1 7 1 . I H3 I H4 Shock and, 58 Tida l vol umes, 232
M.uugcment, 158, 168- 1 7 1 . 1 8 1 Tactical Combat Casual t y Care (TCCC), TIG ('Icc Tcwnw. immune: globul i n )
186.252-253 306 Tissue damage, 220. ::!21
.1\kdl(at il>n.,, 170 Car w1der fire, 306-)07 Tourniquet
1\lorplwlogy, 163 Tactical Field Care, .l07 Pncunl.lt ic, 1 93-19-l
1\.lvotomcs, 160 TBI (.Set' Traumatic hr.1in inJun) \ ilSLUJ.tr 111JIIr\'Ue of, 195
NeurologiC.. asessment, 182 TCCC (St!c Tactical Comb,lt ( ,tsualh Trachea
Ncu rologtc deticit seventy. 162-163 Care) t\irwa\ ob,tru<.tion, 27
Neurologic evaluation, 160 1cntorium, 135 Injury, <;).!
Org.t n systems and effed of, 162 letanus lntub;1lion, I.J.J
Pc:d iatric, 2<1 1 Bum i nj ury, 2 1 8 ln ahili t v lor. 38
P:nctrating, 166 Ex t remi ty i n jury, 19X-199 Position, 28
Phy..icaJ exa m ination 120, Prostbite. 22.0 Trau ma, 27
Pr i m;t l'} survey, 182 Immunization, 297-2911 X-r<ty, 104
lksuscit.ttion, 181 General pri nc iple s, l9t 29!! Transfer
"tectt.tri o. 185-186 P.t!>Sive, 298 Che..kltt, 274, 275
"tcreen mg pat ients for, 169 Incubation, 297 Consider tlc:l'd for. I 0-1 I , "> I
Secondary, li mitin g, 1 68 Tetanus imm une globulin (TIG), 298 Diltil, 27'i
'> ecund .t rY
' sur
vev, 1 8 2 Thermal inju r ies, 2 1 1-223 Definttive c;tre, 17, 269-27fo
.
Sensory examination, 160 in Austere and hostile etwtrotuncnb, SkiII/proccdurc'>. 24
<.;hok and, 1 6 1 31 5-3 1 6 Detcrm i ning need lor, 270-272
Specilk tn)es ot, 163-166 l:lurn. 212-2 1 1.J Dowmcntatinn, 271
supecting, 162 Cold i n j u ry, 2 1 9-121 h1Cl01', 270-272
Tran\fcr for, 1 7 1 i n Auslere and hnstilc: nvironmcnb, Pitfitlls. 2 7 1
Treatment, 183,241 115 l l igh-1 bk Cl'ltl.'ria, 271, 272
L;nrcw!{ntLed, 1 7 0 <;ctiatric , 250 !mt ial JS\CSslllClll, 2, 10-J J
t;nstahle, 163 Heat-related illness or mjury, J 15-116 lntcrhospital, l72
\'ertt>bral va,cular, 166 History, 1 2 Proces.,, I I
'\-r.l)' eV,J)lJ,ltlOn, 166-161! Thermoregulation, 237 Protocol;,, 271
X-ra) identification of. 175-179 Thiopen tal, 37 Receiving do<.to r, 272
1\
ludcs, 160, 1 62 Th oracentesi s, I 08 Referring dottm. 272
Pain, 170 Thoracic spine lntorm,ltton Irom, 274
Phyiu logy, 1 38- I 62 Antomy, 158, 159 Responsihilittcs, 272
Protect i ng, 6 rractures, 15, 97-98, 165-1 (16 Timcli nc, 270
INDEX 365
'Ii-anportat ion Initial assessmnt, 2 Q uarter panel i mpact, 284

-
i\'lodes or, 273 Mass casualrr. 4, 3 1 7-3 1 8 Rear i mp<lct, 284

Pitfalls, 273, 275 Mu ltipl e casualties, 4 Ro llover, 284
Process of, 2 7 1 Multiple levels of, 337 Organ collision, 284-285
Tre.Jtment duri ng, 275 Planning and rehearsal, 338 VcnipLmcture
Treatment p rior to, 274 Principles, 337-338 Central, 77
Transportation Resources available, 337, 338 remora!, 74, 76
in Austere and hostile environmt!nt. So.:enarios, 337-350 Inte rnal j ugula r, 76-i7
306 Car cmsh, 348 - 349 Subclavi an, 7o
P rep<l ration Cor, 3 14-3 1 5 Cold i n.i ury, 346 - 347 Venous access
Tra nsfe r Gas expl osion, 3 39-34 3 in Austere and hostile environments, 3 1 1
.VI odes ot 273 Trailer home explosi on and fire, Pemoral, 74
P itfalls, 273,275 341!-345 Pediatric. 77, 235-236
Process of, 2 7 1 Train crash, 350 P refer red sites for, 236
Treatment Juring, 275 Timing, 337 Per ipheral , 74
Trauma (Set lllsv S{lo:Cific urg11ns 11nd Trimesters, 261 Venous cutdown, R3-R4
systems) Anatomic c.onsiderations for, 83
Alcohol/ d rug abuse in, 271 UIC (See Unified incident comman d) Peri pheral, H4
Care Ulcers, 1 4 Skills/procedures, 84
following Catastrophes, 305-3 18 Unified incident command (UIC), 323 Venous voluJne
in Underdeveloped areas, 305-3 18 Urethra Aftcrl oad, 56
Combative, l 0 Cathet<."r Cardiac physiology in shock and, 56
Do no further harm, 270 PitfaUs, 9 Preload, 56
FAST, I 0 P lacement and, 9 Ventilation
Flow heel, 293-296 Examination, 1 16 Adequate, 39-40
Geriatric. 5, 2.J7-256 Female, 15 i n Austere and hosti le environ ments,
l?.xpou re ;md envi ronment, 253 Urinary catheters, 9, 1 1 6 309-3 1 0
.'vledications and, 254-255 Pediatric, 236-237 Bag mask, 39-40
-
Musculoskeletal sy tem , 253-254 P i t falls, 9 Two-person tech niq ue, 44

P reexi sting disease and, 2'18 Shuck, 62 lrain dtat h, 1 4 9
Special ci rrumstance. in, 254-256 Urinary o u tpu t, 64 lrain i nj u rr. 1 42
Systems aml, 253-254 Burn i nju r y, 2 16 Geriatri c, 250
Unique characteristics of, 248 Ped i atric, 236-237 I nadequate, 28
PeJi<llric, 225-24-1 Urinary system, 262-263 Management, 25-40
Airway and, 228-232 Uterus, 260-261 Pitt'all5, 39-40
Treatm ent of, 233 Pregna n cy <lnd, 264-265 Skills/proc.:dures, 43-49
Juri ng, Pregnanq , 260r Rupr ure, 264-265 1rauma and, 2R
Assessment and treatment of, 264- Mechanical
2115 Vagina In halation inj ury, 2 1 5-216
Injury sever i ty in, 264 Exam i nation, 1 16 Ten sion pn eumo thorax caused by, 87
Preparation, 2 Pregnancy and, 265 Pediatri c, 230. 232-233
Reevalua t ion, 1 6 Management , 23 Pitfalls, 6
Scores, 289-291 P hysi cal examination, 1 5 Pncumothora.x, 87
LOC, 289 Secon dary su rvey, 23 Primary survey, 6, 20
l iiage Decision Scbeme, 3 Vascular access lines Problem recogn i tion, 28
in \Nomen, 259-267 Pediatric , 63 Rate, I 0, 20
Traumatic brain injury (TB.!), 63-64 Shock, 62-63 Resusci ta tion, 8, 10, 20
Anticoagul ation, 1 40 Vascular compromise, 1 9 5 Ventricular system, 135

Manag
e ment, 146, 147
Vascular injuries, 1 95-J 96 Vertebral column injury, 158
Treatment in the field, 2 Assessmen t, 195 Radiography, 167
Trench foot, 220 Ma nageme n l, 195-196 Visceral injuries, 239
Triage, 4 Vecuronium, 146 Visual acuity, 300
in Austere and hostile environ ments, Vehicle-pedestrian collisions, 285 Exam ina tion, 1 3
3 1 7-3 1 8 Musculoskdetal trauma, I f\9 Vital functions, 4
Brain injury, 132 Vehicular impact, 283-285 Vitreous, 300
severe, 142, 145 Com pression i nj u ry, 284 Injury, 301-302
Categor y t)'PC-'>, 338 Deceleration imp<lCl, 284-285 Volwne, 8-9
Continuous, 338 Occupant collision, 283-284 Volwne replacement
Decision cheme, 3 Ejection, 284 H emorrhage, 60
Defi n ition, 337 rron tal impact, 283-284 I lypotension, 143
Disaster, scheme, 328-329 La tera l i m pact, 284 Vomjting, 26
366 INDEX
Warm Zone (See Area ol Operations) Primary survey of, 264-265 Reaessment, I 06
Weapons of mass destruction (WMDs), Resuscitation of, 264 265 Reuscitation, I 0
323 Secondary su rvcy, 265 Spinal, 166-168
WMDs (See Weapons of mas Shock in.67 Cervical, 167-168, 176-177
destruction) Trauma in, 259-267 Clues, 178-179
Women Domestic violcm:c, 266 lnju ries identified by, 175-179
Domestic violence, 266 Wound care Lumbar, J68, 178
Pregnant Burn injurv. 2 1 7 'iccnarius, 178-179
Anatomic changes m, 260-261 Surgical, 297 1 horac.:sc, I 03-106, 168, 178
Definitive care, 265-266 Transfer of patu:nt and, 274 Thorax, I 05, I 06
InJury severity in, 264 Tubes and lines, 106
Mechanisms of injury, 263-264 X-rays, 10
Perimortem cesarean section, 266 Chest, 1 04-1 05
Physiologic changes in, 260-263 Musculoskeletal tr;Juma, 189, 192

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1 Initial Assessment and Management 1

2 Airway and Ventilatory Management 25

... SKILL STATION Ill: CRICOTHYROIDOTOMY 51

5 Abdominal and Pelvic Trauma 111

6 Head Trauma 131

1 Spine and Spinal Cord Trauma 157

8 Musculoskeletal Trauma 187

9 Thermal lnjuries 211

11 Geriatric Trauma 247

C Trauma Scores: Revised and Pediatric 289

Advanced Trauma Life Support

STUDENT COURSE MANUAL

American College of Surgeons

Chair of COIII/1/tl/ec 011 Trauma: John rildes, MD, l-ACS

Copyright(<) 200R American College of Surgeons

The American College of Surgeon:., its Committee on Trauma, and contributing

administration, .md contra indications. It i1> the responsibility of the licensed

Printed an the United States of America.

Ad1ranced Trauma Life Support Student Course Manual

-Jo/111 Fildes, MD, FACS

tematic concise approach to the early care of trauma pa

SKILLS VIDEO terms to facilitate understanding by all students and teach

This edition features a new full-color design, along'A-'ith new

KEY QUESTIONS: These questions are aligned with the

These boxes hig hlight critical pitfalls to Subcommittee on Advanced Trauma

Christoph R. K:wfrnann, MD, MPH, FACS

Associate Members to the Mary van Wijngaarden-Stephens, MD, FACS

life Support of the American College_ Trauma Director

Associate CliJJic<tf Professor ofSurgery

Depa rtment of Eme rgency Medicin e/Tra um a, Hartford Hospital

Sharon M. Henry, MD, FACS

Spartanburg, South Carol ina

CONTRIBUTORS Ber ge n Ma ;J.S tri cht

Regional Program Coordinator, CM Porto Assit ra um a

Coonlin,Jtur (ur Tr.Hifflil Programs Portuga l Torino

Office: Erwrgeucy Plrysicillll Jacqueln

Bim1ingham Regional EM$ CJinicaJ L ecrmer. Univers ity of Calgary Netherlands

Canad11 Caracas, Mtrando Argentino

Indonesia AssucitJte Professor !long Kong

Tr,wnw Program Medio1l mrcc:tor Dep.ITlment of Erncrgcnq Mcdic,1l Serv ices,

llopital uf Crele University of Preloriu Danih Trauma Society

Chin Hung Chung, MB BS, FACS Lesley Dunstall Christine Gaarder, MU

Emergency Surgical Ser\icc>, Ho>pital das Lhbon Surger.r

C li nica of the Uni,crsity of S.io Paulo Portugal haj.1irah HospitJI

Javier Gonzalez-Urinrlc, MD, PhD, EBSQ,

Argent i n a 1\,,wdatt Prolessor

haly Uo Richter 1/md Surgeon

Yorkshue ofTrauma Surgery

Mark Sheridan, M BI3S, MMedS c, FRACS

Peter Skippen, MBBS, FRCPC, FIF'ICM, Wa'cl S. 1aha, MD Eugenia Vns.ilopoulou, MD

Br111SI111j Sydney, New South Wales Medicine and TrattmatolOg)', University

R.1ymund H. Alexander, MD, FACS

lon l l tywood, IRC:S (Eng), MRCS,

C 0 U R S E 0 V ERV I E W: The Purpose, History, and

Program Goals 2 Establi:.h management priorities in a trauma situa

3. Initiate primary and secondary management neces

XVIII COURSE OVERVIEW

THE NEED when it is realized that trauma strikes down a society's

significant, accounting tor 12o/o of the world's burden of dis-

Figure 1 Global Injury-Related Mortality.

COURSE OVERVIEW XIX

hematomas, hemopneumothorax, ruptured spleen, lac