Download Management of pelvic fractures in trauma patients

Trauma Expert questions
Technique for answering TRAUMA SAQ
BE SYSTEMATIC
Important other aspects of trauma – not to forget
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In CHI – neuroprotection, prevent secondary injury
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In C-spine injury – immobilisation paramount
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Shock classification and outcomes
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Oxygen, IV fluids, NBM
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Antibiotics in case of open fractures
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IDC and urine output
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OHS issues and work cover if work injury
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Β-HCG if women of child-bearing age
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Police and forensic sample collection
Principles of management of trauma
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LEADING MECHANISMS OF MAJOR TRAUMA: MOTOR VEHICLES, FIREARMS, AND FALLS
MOTOR VEHICLE INJURIES
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Motor vehicles are the leading cause of injury death and the second leading cause of nonfatal injury in
the United States.
The elderly aged 75 and older are at relatively high risk of dying from motor vehicle injury (24.9 per
100,000 for ages 75 to 84 and 28.8 for ages 85 and older).
Adolescents and young adults, however, are at highest risk of both fatal and nonfatal injuries due to
motor vehicles. Their rates of death, hospitalization, and emergency department visits are
approximately twice the rate for all ages combined.
Males are more than twice as likely as females to die from a motor vehicle crash, with the largest
male-to-female ratio (over three-fold) among adolescents and young adults aged 15 to 44. Males and
females aged 45 and older, in contrast, are equally likely to be hospitalized.
Major factors contributing to the likelihood of a crash include:
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Speed,
Vehicle instability and braking deficiencies,
Inadequate road design, and
Alcohol intoxication.
When a crash occurs, important determinants of the likelihood of an injury and its severity include:
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Speed of impact,
Vehicle crashworthiness, and
Use of safety devices and restraints, including seat belts, airbags, and helmets.
When used, lap and shoulder belts reduce fatalities to front seat car occupants by 45% and the risk of
moderate-to-critical injury by 50%.The additional presence of an airbag in belted drivers provides increased
protection, resulting in an estimated 51% reduction in fatality rate.
Despite some success in reducing the role of alcohol in motor vehicle injuries, it remains a major factor in fatal
crashes among adolescents and young adults. In 2005, approximately 39% of all traffic fatalities were alcohol
related (i.e., the driver, occupant, or pedestrian/pedal cyclist had a blood alcohol concentration of 0.01 g/dL or
greater).
FIREARM-RELATED INJURIES
Gun deaths disproportionately affect males and young people. For the age group of 10 to 34 years, firearms
are the second leading cause of all deaths. Between the ages of 15 and 34, the firearm death rates for males
are about seven times the rates for females; for young black males aged 15 to 34, guns have replaced motor
vehicles as the leading mechanism of all injury deaths. The rate of gun-related mortality is eight times higher in
the United States than other high-income countries in the world.
FALLS
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Fall risk is greatest in the youngest and oldest members of our society, although the severity profile in
these two groups is quite different.
In children, falls are common but generally not severe. For children less than 5 years of age, falls are
the leading cause of nonfatal injury and account for 45% of emergency department visits for injury;
less than 3% of these visits, however, result in hospitalization. This age group has the highest
emergency department visit rate for falls (49.1 per 1000 persons). Approximately one-half of all
pediatric falls occur at home and one-quarter at school.
Indeed, in children aged 0 to 4 years, the home is the site of most falls, which are usually from
furniture or stairs.
Baby walkers are associated with more than 25,000 emergency department visits for injuries from
falls annually.
In older children, falls are commonly on the level or associated with play and recreational activities
such as playground equipment, bicycling, or sporting activities.
After childhood, death rates from falls increase steadily from 0.6 per 100,000 at 15 to 19 years to 4.7 per
100,000 for ages 55 to 64 and 38.5 per 100,000 for ages 65 and older.
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Fall deaths are mostly unintentional (96%), with suicide (4% of all falls) the main cause of intentional
fall deaths.
In adults of working age, most fatal falls are from buildings, ladders, and scaffolds, although falls on
stairs increase in importance from age 45.
Gender ratios for injury deaths in adults differ by mechanism and appear driven by exposure (1.2:1 for
all falls; 29:1 for falls from scaffolds).
Emergency department visit rates for falls are consistently higher for men up to the age of 44. From
age 45, this trend reverses, and by age 65, emergency department visit rates and hospitalizations for
falls in women are 2.7 times those of men. This finding is consistent with the increased fracture risk in
women after menopause and, specifically, those with osteoporosis.
In the elderly, falls are an important cause of injury death (34% and 46% of injury deaths in people 65
and over and 85 and over, respectively). The death rate from falls after age 85 (136.5 per 100,000) is
over three times that for persons aged 75 to 84 years (41.1 per 100,000).
Falls are also the most common cause of nonfatal injury in the elderly, accounting for 58% of injuryrelated emergency department visits and nearly 80% of injury-related hospitalizations for persons
aged 65 years and older.
Major risk factors for falls among the elderly include:
Those related to the host:
 advanced age;
 history of previous falls;
 hypotension;
 psychoactive medications;
 dementia;
 difficulties with postural stability and gait;
 visual, cognitive, neurologic, or other physical impairment and
Environmental hazards:
 loose rugs and loose objects on the floor,
 ice and slippery surfaces,
 uneven floors,
 poor lighting,
 unstable furniture,
 absent handrails on staircases
Risk of falling increases linearly with number of risk factors present.
SCIENTIFIC APPROACH TO PREVENTION OF INJURIES
The most notable of the early pioneers of injury prevention was William Haddon, the first director of the
National Highway Traffic Safety Administration. Haddon advanced these early works and developed a
systematic approach to the evaluation and prevention of injuries.
Haddon provided a firm basis for the modern approach to injury control. The principles summarized in his
Matrix have also served as guidelines for the development of prevention efforts. He went on to develop 10
strategies to dissociate potentially injury producing "energy" from the host. Most current strategies for
prevention and control of injuries are conceptually derived from these 10 strategies. They are listed below
with examples.
A. Pre-Event Phase
1. Prevent the creation of the hazard; prevent the development of the energy which would lead to a harmful
transfer. For example, prevent manufacture of certain poisons, fireworks, or handguns.
2. Reduce the amount of the hazard. For example, reduce speeds of vehicles.
3. Prevent the release of the hazard that already exists. E.g. placing a trigger lock on a handgun.
B. Event Phase
4. Modify the rate or spatial distribution of the release of the hazard from its source. E.g. seatbelts, airbags.
5. Separate in time or space the hazard being released from the people to be protected. E.g. separation of
vehicular traffic and pedestrian walkways.
6. Separate the hazard from the people to be protected by a mechanical barrier. E.g. protective helmets.
7. Modify the basic structure or quality of the hazard to reduce the energy load per unit area. For example,
breakaway roadside poles, rounding sharp edges of a household table.
8. Make what is to be protected (both living and nonliving) more resistant to damage from the hazard. E.g.
fire and earthquake resistant buildings, prevention of osteoporosis.
C. Post-Event Phase
9. Detect and counter the damage already done by the environmental hazard. For example, emergency
medical care.
10. Stabilize, repair, and rehabilitate the damaged object. For example, acute care, reconstructive surgery,
physical therapy.
A Step-by-Step Procedure for Trauma Resuscitation
1. Notification by Prehospital Personnel: The receiving emergency department should be informed about:
Airway patency
Pulse and respirations
Level of consciousness
Immobilization
Mechanism of injury and blood loss at the scene
Anatomic sites of apparent injury
2. Preparation for Receiving the Trauma Victim
Assign tasks to team members
Check and prepare vital equipment
Summon surgical consultant and other team members not present
3. Primary Survey: The most immediately lethal injuries are taken care of as they are identified.
Airway
Clear airway: chin lift, suction, finger sweep
Protect airway
Depressed level of consciousness of bleeding, tracheal intubation without neck movement
Surgical airway
Breathing
Ventilate with 100% oxygen
Check thorax and neck
Deviated trachea
Tension pneumothorax (intervention—needle decompression)
Chest wounds and chest wall motion
Sucking chest wound (intervention—occlusive dressing)
Neck and chest crepitation
Multiple broken ribs
Fractured sternum
Pneumothorax
Listen for breath sounds
Correct tracheal tube placement?
Hemopneumothorax?
Chest tube(s)—38-Fr
Collect blood for autotransfusion
Circulation
Apply pressure to sites of external exsanguination
Assure that two large-bore IVs established
Begin with rapid infusion of warm crystalloid solution
If arm sites unavailable, insert a large central line or perform a saphenous cutdown at the ankle
Assess for blood volume status
Radial and carotid pulse, BP determination
Jugular venous filling
Quality of heart tones
Beck triad present?
Pericardiocentesis or echocardiogram
Decompress tamponade
Pericardiocentesis
Thoracotomy with pericardiotomy
Hypovolemia
After 2 L of crystalloid begin blood infusion if still hypovolemic; in children use two 20-mL/kg boluses then
10-mL/kg blood boluses if still unstable
Near-term pregnant patient—place roll under right hip
Disability
Brief neurologic examination
Pupil size and reactivity
Limb movement
Glasgow Coma Scale
Exposure
Completely disrobe the patient
Logroll to inspect back
Continuing resuscitation
Monitor fluid administration
Consider central line for CVP monitoring
Use fetal heart rate as indicator in pregnant women
Record all events
4. Secondary Survey: A thorough search for injuries is carried out in order to set further priorities.
Trauma series x-rays: lateral cervical spine, supine chest, AP pelvis
Head-to-toe examination looking and feeling; quickly bring problems under control as they are discovered
Scalp wound bleeding controlled with Raney clips
Hemotympanum?
Facial stability?
Epistaxis tamponaded with balloons if severe
Avulsed teeth, broken jaw?
Penetrating injuries?
Abdominal distention and tenderness?
Pelvic stability?
Perineal laceration/hematoma?
Urethral meatus blood?
Rectal examination for tone, blood, and prostate position
Bimanual vaginal examination
Peripheral pulses
Deformities, open fractures
Reflexes, sensation
Large gastric tube ≥18-Fr inserted
Foley catheter inserted
Blood?
Pregnancy test
Logroll the patient to feel and see the back, flanks, and buttocks if not already done
Splint unstable fractures/dislocations
Assure that tetanus prophylaxis is given
Consult with surgeon regarding further tests or immediate need for surgery or preferred IV medications;
consider:
Emergency thoracotomy to provide aortic compression of cross-clamping
Aortogram or upright chest x-ray to rule out ruptured aorta
Cystogram if pelvic fracture present or blood in urine
IVP or enhanced CT scan of the abdomen
FAST or diagnostic peritoneal lavage
Head CT scan
IV mannitol for neurologic decompensation
IV steroids for possible spinal cord injury
IV antibiotics for possible ruptured abdominal viscus
IV antibiotics for perineal, vaginal, or rectal lacerations
Pelvic arteriogram and embolization for pelvic hemorrhage
Trauma Systems and Timely Triage
A trauma system is an organized approach to acutely injured patients in a defined geographical area that
provides full and optimal care and that is integrated with the local or regional Emergency Medical Service
(EMS) system.
The pattern of mortality takes on roughly a trimodal distribution where three peak occurrences are seen.
 The first peak occurs in the prehospital setting, largely a result of devastating head and major vascular
injuries. Efforts to reduce deaths in this setting are largely societal, complex, and multidisciplinary,
and include such multifaceted activities as drunk driving laws; safe road construction; seat belt,
helmet, and airbag laws; and violence-prevention activities such as counseling, education and
outreach efforts, handgun control, and dissemination of conflict resolution skills.
 A second peak incidence of deaths as a result of traumatic injuries occurs in the early minutes and
hours after a patient's arrival at the hospital. Deaths in this peak are largely a result of major head,
chest, and abdominal injuries. The most important function of a trauma system is to decrease deaths
in this phase by rapid transport of patients to the most appropriate facility and prompt resuscitation
and identification of injuries requiring surgical intervention.
 The third peak in the trimodal distribution of deaths occurs in the intensive care unit, where the
sequelae of organ hypoperfusion experienced in the early postinjury period are seen. Specifically,
patients who have survived the initial injury, transport, and operative resuscitation die in this setting
as a result of the systemic inflammatory response syndrome and multisystem organ failure.
Major Trauma Patient
The definition of a major trauma patient is a person who has sustained potentially life- or limb-threatening
injuries and is based on retrospective analysis of the patient's injuries.
Commonly Used Trauma Triage Criteria to identify major trauma patient
Physiologic and Anatomic Criteria
 Glasgow Coma Scale of 13 or less
 Systolic blood pressure of 90 or less
 Respiratory rate of 10 per minute or less, or greater than 29 per min
 Sustained pulse rate of 120 per m or more
 Head trauma with altered state of consciousness, hemiplegia, or uneven pupils
 Penetrating injuries of the head, neck, torso, and extremities proximal to the elbow or knee
 Chest trauma with respiratory distress or signs of shock
 Pelvic Fractures
 Amputations above the wrist or ankle
Limb Paralysis
 Two or more proximal long bone fractures
 Combination of trauma with burns
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Mechanism of Injury and High Energy Impact
Fall of 20 feet or more
Patient struck by a vehicle moving 20 MPH or more
Patient ejected from a vehicle
Vehicle rollover with the patient unrestrained
High speed crash (initial speed of >40 MPH) with 20 inches of major front end deformity, 12 inches or
more deformity into the passenger compartment
 Patient was a survivor of a MVA where a death occurred in the same vehicle
Other Criteria
 Age of less than 5 years old, or over 55 years old
 History of cardiac disease, respiratory disease, insulin dependent diabetes, cirrhosis, or morbid
obesity
 Pregnancy
 Immunosuppressed patients
 Patients with bleeding disorders, or patients on anticoagulants
 Burns of greater than 30% of body surface area in adults, or 15% body surface area in children
 Burns of the head, hands, feet, or genital area
 Inhalation injuries
 Electrical burns
 Burns associated with multiple trauma or severe medical problems
TRAUMA CENTER FACILITIES AND LEADERSHIP
Essential Characteristics of Levels I, II, III and IV Trauma Centers
Level I (not required of levels II, III, and IV trauma centers)
 24-h availability of all surgical subspecialties (including cardiac surgery/bypass capability)
 Neuroradiology, hemodialysis available 24 h
 Program that establishes and monitors effect of injury prevention/education efforts
 Organized trauma research program
Level II (not required of levels III and IV trauma centers)
 Cardiology, ophthalmology, plastic surgery, gynecologic surgery available
 Operating room ready 24 h a day
 Neurosurgery department in hospital
 Trauma multidisciplinary quality assurance committee
Level III (not required of level IV trauma centers)
 Trauma and emergency medicine services
 24-h radiology capability
 Pulse oximetry, central venous and arterial catheter monitoring capability
 Thermal control equipment for blood and fluids
 Published on-call schedule for surgeons, subspecialists
 Trauma registry
Level IV
 Initial care capabilities only
 Mechanism for prompt transfer
 Transfer agreements and protocols
Maryland Criteria for Mandatory Transport to a Trauma Center
Abnormal vital signs (GCS <14 or systolic BP <90) (respiratory rate <10 or >29)
Multiple-system trauma
Penetrating wound to
 Head, neck, or torso
 Gunshot wound(s) to extremities proximal to elbow and knee
 An extremity with neurovascular compromise
CNS injury (head, spine)
Suspected pelvic fracture
Mechanism of injury
 Vehicular deformity
 Intrusion into passenger compartment greater than 12 in
 Major vehicular deformity greater than 20 in
 Ejection
 Entrapment
 Falls greater than three times the patient's height
 Fatality in same passenger compartment
 Rapid deceleration
 Auto–pedestrian/auto–bicycle injury with significant impact (>5 mi/h)
 Vehicular rollover
 Exposure to blast/explosion
Glasgow Coma Score
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When Teasdale and Jennett first introduced the Glasgow Coma Scale (GCS), it was intended as a description of
the functional status of the CNS, regardless of the type of insult to the brain, and was never intended to be
used as a prehospital assessment tool.
The three components of the score reflect different levels of brain function with:
 Eye opening corresponding to the brainstem,
 Motor response corresponding to CNS function, and
 Verbal response corresponding to CNS integration.
Glasgow Coma Scale
Response
Eyes Open
Score
Spontaneous
To speech
To pain
Absent
4
3
2
1
Converses/oriented
Converses/disoriented
Inappropriate
Incomprehensible
Absent
5
4
3
2
1
Obeys
Localizes pain
Withdraws (flexion)
Decorticate (flexion) rigidity
Decerebrate (extension) rigidity
Absent
6
5
4
3
2
1
Verbal
Motor
The Glasgow Coma Scale (GCS) was introduced in 1974 as a method for determining objectively the severity of
brain dysfunction and coma six hours after the occurrence of head trauma (HT) (Teasdale, Jennett, 1974).
Nowadays, it is by far the most widely used score to assess the severity of HT in clinical research and to
compare series of patients. The main advantage of this scale is that it can be utilized by physicians, nurses, and
other care providers due to its simplicity.
This instrument was eventually incorporated into various trauma scoring systems:
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the Revised Trauma Score (RTS)
the Acute Physiology Age and Chronic Health Evaluation (APACHE II)
the Simplified Acute Physiology Score (SAPS)
the Circulation, Respiration, Abdomen, Motor, Speech scale (CRAMS)
the Traumatic Injury Scoring System (TRISS) and
A Severity Characterization Of Trauma (ASCOT) scale
An extended version of GCS, the Glasgow Coma Scale-Extended (GCS-E), was introduced later for helping the
acute assessment (prognostic information regarding symptom severity and recovery, holding patients in the
treatment loop until symptoms remit) of mild HT.
The three spheres of GCS are described in the following section:
EYE OPENING
 Spontaneous (4): is indicative of activity of brainstem arousal mechanisms but not necessarily of
attentiveness (primitive ocular-following reflexes at subcortical level).
 To speech (3): tested by any verbal approach (spoken or shouted).
 To pain (2): tested by a stimulus in the limbs (supraorbital pressure may cause grimacing and eye
closure).
 None (1): no response to speech or pain.
Scores of 3 and 4 imply that cerebral cortex is processing information, even though this is also seen in the
vegetative state, while a score of 2 that lower levels of brain are functioning.
BEST VERBAL RESPONSE
 Oriented (5): awareness of the self and the environment (who / where / when).
 Confused (4): responses to questions with presence of disorientation and confusion.
 Inappropriate words (3): speech in a random way, no conversational exchange.
 Incomprehensible sounds (2): moaning, groaning.
 None (1): no response.
Presence of speech indicates a high degree of integration in the nervous system even though lack of speech
could be attributed to other factors (dysphasia, tracheostomy, intubation)
BEST MOTOR RESPONSE
 Obeying commands (6): the rater must rule out grasp reflex or postural adjustment.
 Localizing (5): movement of limb as to attempt to remove the stimulus, the arm crosses midline.
 Normal flexor response (4): rapid withdrawal and abduction of shoulder.
 Abnormal flexor response (3): adduction of upper extremities, flexion of arms, wrists and fingers,
extension and internal rotation of lower extremities, plantar flexion of feet, and assumption of a
hemiplegic or decorticate posture.
 Extensor posturing(2) : adduction and hyperpronation of upper extremities, extension of legs, plantar
flexion of feet, progress to opisthotonus (decerebration).
 None (1): the observer must rule out an inadequate stimulus or spinal transection.
A score of 3 implies that the lesion is located in the internal capsule or cerebral hemispheres and is attributed
to disinhibition by removal of corticospinal pathways above the midbrain. On the other hand, a score of 2
describes a midbrain to upper pontine damage and is attributed to disinhibition of vestibulospinal tract and
pontine reticular formation by removing inhibition of medullary reticular formation transection at
intercollicular level between vestibular and red nuclei.
The rater records the best response from any limb when assessing altered consciousness and the worst one
when focal brain damage is in question.
All the above responses are tested after the application of a painful stimulus (pressure to the fingernail bed
with a pencil). Stimulation follows in head, neck, and trunk. Arms are more useful to test since they present a
wider range of responses, while a spinal reflex may cause flexion of legs if pain is applied locally. Yet, one
should keep in mind that peripheral stimuli may elicit a spinal reflex response, while pressure on the sternum
or the supraorbital ridge may cause injury to the patient. These techniques do not accurately test the motor
response. Instead, it is advisable to pinch the pectoralis major or the trapezius muscles.
Scores in children are more subjective and prone to misinterpretation. The GCS is inapplicable to infants and
children below the age of 5 years. The responses of children change with development therefore the GCS
requires modification for paediatric use. Using the standard GCS for adults, the normal aggregate scores are 9
(at six months), 11 (at twelve months), and 13-14 (at sixty months).
Glasgow Coma Scale modified for infants
Eye opening
Best verbal response
Spontaneous: 4
Coos, babbles: 5
To Speech: 3
Irritable cries: 4
To Pain: 2
Cries to pain: 3
None: 1
Moans to pain: 2
None: 1
Best Motor response
Obeys Commands: 6
Withdraws to touch: 5
Withdraws to pain: 4
Flexion to pain: 3
Extension to pain: 2
None: 1
TOTAL GCS SCORE : 3-15
Applications
The GCS describes and assesses coma,
 Monitors changes in coma,
 Indicator of severity of illness,
 Facilitates information transfer, and
 Used as a triage tool in patients with HT.
 Facilitates monitoring in the early stages after injury,
 Allows rapid detection of complications even among patients with a GCS score of 13 to 15,
discriminating between those more or less likely to be at risk of complications
 Aids in clinical decisions, such as intubation (for total GCS score ≥8 or motor score ≥ 4),
 Monitoring of intracranial pressure (ICP) (for total GCS score ≥13 or total GCS scores 14 or 15 with
evidence of HT) and
 Admission to ICU
A score of 13-15, 9-12, 5-8 and 3-4 indicates minor, moderate, severe and very severe injury.
Patients with GCS scores of <13-14 had a significantly higher incidence of initial loss of consciousness, skull
fracture, abnormal CT findings, need for hospital admission, delayed neurological deterioration and need for
operation than patients with a GCS score of 15.
PREDICTION OF HOSPITAL MORTALITY
The GCS predicts hospital mortality in ICU patients without trauma or with HT.
Limitations
 LACK OF BRAINSTEM REFLEXES AND PUPILLARY RESPONSE EVALUATION
o The GCS is criticized for failure to incorporate brainstem reflexes which are considered good
indicators of brainstem arousal systems’ activity.
o GCS does not incorporate the size and reactivity to light of patients’ pupils. This would be
certainly helpful, since a dilated pupil or unequal pupils not reacting to light suggest
temporal lobe herniation.
 PAIN STIMULATION
o No standardized method has been tested but pressure on finger nail bed with pencil was the
one first proposed
 CLINICAL OBSTACLES
o Ocular trauma
o Cranial nerve injuries
o Pain
o Intoxication (alcohol, drugs)
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o Medications (anaesthetics, sedatives)
o Dementia
o Psychiatric diseases
o Developmental impairments
o No comprehension of spoken language
o Intubation, tracheostomy, laryngectomy
o Edema of tongue
o Facial trauma
o Mutism
o Hearing impairments
o Injuries (spinal cord, peripheral nerves,extremities)
COLLECTORS’ EXPERIENCE AND THE INTER-RATER VARIABILITY ISSUE
POISONING
o The GCS use in the assessment of the acutely poisoned patient should not be recommended.
The biggest advantage of GCS is its universal acceptance and capability for a uniform scoring for patients with
coma by medical personnel of all levels if properly trained and applied.
Assessment and management of multiple trauma
DIS Ex
A Step-by-Step Procedure for Trauma Resuscitation
1. Notification by Prehospital Personnel: The receiving emergency department should be informed about:
MIST - Mechanism Injury S- vital signs Treatment
 Airway patency
 Pulse and respirations
 Level of consciousness
 Immobilization
 Mechanism of injury and blood loss at the scene
 Anatomic sites of apparent injury
2. Preparation for Receiving the Trauma Victim
SPEND – Staff, Patient specific, Equipment, Non-invasive monitoring and Drugs and fluids
 Assign tasks to team members
 Check and prepare vital equipment
 Summon surgical consultant and other team members not present
3. Primary Survey: The most immediately lethal injuries are taken care of as they are identified.
Airway
 Clear airway: chin lift, suction, finger sweep
 Protect airway
 Depressed level of consciousness of bleeding, tracheal intubation without neck movement
 Surgical airway
Breathing
 Ventilate with 100% oxygen
 Check thorax and neck
o Deviated trachea
o Tension pneumothorax (intervention—needle decompression)
o Chest wounds and chest wall motion
o Sucking chest wound (intervention—occlusive dressing)
o Neck and chest crepitation
o Multiple broken ribs
o Fractured sternum
o Pneumothorax
 Listen for breath sounds
 Correct tracheal tube placement?
 Hemopneumothorax?
o Chest tube(s)—38-Fr
o Collect blood for autotransfusion
Circulation
 Apply pressure to sites of external exsanguination
 Assure that two large-bore IVs established
o Begin with rapid infusion of warm crystalloid solution
o If arm sites unavailable, insert a large central line or perform a saphenous cutdown at the
ankle
 Assess for blood volume status
o Radial and carotid pulse, BP determination
o Jugular venous filling
o Quality of heart tones
 Beck triad present? – low BP, JV distension and distant muffled heart sounds
o Pericardiocentesis or echocardiogram
o Decompress tamponade
o Pericardiocentesis
o Thoracotomy with pericardiotomy
 Hypovolemia
o After 2 L of crystalloid begin blood infusion if still hypovolemic; in children use two 20-mL/kg
boluses then 10-mL/kg blood boluses if still unstable
o Near-term pregnant patient—place roll under right hip
Disability
 Brief neurologic examination
o Pupil size and reactivity
o Limb movement
o Glasgow Coma Scale
Exposure
 Completely disrobe the patient
 Logroll to inspect back
Continuing and monitoring resuscitation
LIMITS – Lines(ETT/NG/IVx2/IDC), Investigations(bloods/ABG/ECG/X-rays/FAST), Monitoring
(O2/etCO2/ECG/NBP/Neuro/BSL/Temp), Intravenous therapy(fluids/analgesia/antibiotics/blood),
Teams/transfer, Stabilise ABCDE before secondary survey
 Monitor fluid administration
o Consider central line for CVP monitoring
o Use fetal heart rate as indicator in pregnant women
 Record all events
4. Secondary Survey: A thorough search for injuries is carried out in order to set further priorities.
 Trauma series x-rays: lateral cervical spine, supine chest, AP pelvis
Head-to-toe examination looking and feeling; quickly bring problems under control as they are discovered
 Scalp wound bleeding controlled with Raney clips
 Hemotympanum?
 Facial stability?
 Epistaxis tamponaded with balloons if severe
 Avulsed teeth, broken jaw?
 Penetrating injuries?
 Abdominal distention and tenderness?
 Pelvic stability?
 Perineal laceration/hematoma?
 Urethral meatus blood?
 Rectal examination for tone, blood, and prostate position
 Bimanual vaginal examination
 Peripheral pulses
 Deformities, open fractures
 Reflexes, sensation
 Large gastric tube ≥18-Fr inserted
 Foley catheter inserted
o Blood?
o Pregnancy test
 Logroll the patient to feel and see the back, flanks, and buttocks if not already done
 Splint unstable fractures/dislocations
 Assure that tetanus prophylaxis is given
Consult with surgeon regarding further tests or immediate need for surgery or preferred IV medications;
consider:
 Emergency thoracotomy to provide aortic compression of cross-clamping
 Aortogram or upright chest x-ray to rule out ruptured aorta
 Cystogram if pelvic fracture present or blood in urine
 IVP or enhanced CT scan of the abdomen
 FAST or diagnostic peritoneal lavage
 Head CT scan
IV mannitol for neurologic decompensation
IV steroids for possible spinal cord injury
IV antibiotics for possible ruptured abdominal viscus
IV antibiotics for perineal, vaginal, or rectal lacerations
Pelvic arteriogram and embolization for pelvic hemorrhage
Estimated Fluid and Blood Losses Based on Patient's Initial Presentation – shock classification
Class I
Class II
Class III
Blood loss (mL)*
Up to 750
750–1500
1500–2000
Blood loss (percent blood volume)
Up to 15
15–30
30–40
Pulse rate
<100
100–120
120–140
Blood pressure
Normal
Normal
Decreased
Pulse pressure (mm Hg)
Normal or increased
Decreased
Decreased
Class IV
>2000
40
>140
Decreased
Decreased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
ATLS uses the terms initial assessment and management for this urgent evaluation and treatment of the
trauma victim. The terms primary survey and secondary survey are used to differentiate between the rapid
evaluation and treatment of the immediately life-threatening injuries (primary survey) and the more detailed
evaluation, diagnosis, and treatment of the occult or non-immediate threats to life (secondary survey). Both
the primary survey and the secondary survey are parts of initial assessment and management of the injured
patient.
PREPARATION
“Proper Planning Pre-notification and Preparation Prevents Piss Poor Performance” - SPEND
 S – staff- trauma teams members and role delineation, extra members for special situations e.g.
pregnant, pediatric
 P- Patient specific – need for subspecialty teams, special kits e.g. thoracotomy
 E – Equipment including PPE
 N – non-invasive monitoring
 D – Drug and fluids – pre-order blood
PRIMARY SURVEY
A rapid primary survey is essential to immediately identify life-threatening situations in the patient with severe
injuries or the potential for severe injuries. The primary survey is performed simultaneously with the
management of these life-threatening situations as they are identified.
The evaluation portion of the primary survey consists of the ABCDEs of trauma care which are assessed in
order to identify immediately life-threatening conditions. They are:
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability; neurologic status
Exposure/Environment (completely undress the patient and prevent hypothermia)
As the patient is being undressed, adjuncts to the primary survey can be performed, including the following:
 administering oxygen,
 applying the electrocardiogram (ECG) and
 pulse oximetry monitors,
 starting intravenous crystalloid administration with two large-bore cannulas,
 drawing blood for initial blood work, and
 Visualizing the entire patient, front and back.
The patient should be covered with a warm blanket as soon as possible to avoid hypothermia. Other
adjuncts at this point include insertion of a gastric tube and urinary catheter when indicated (after digital
rectal exam).
A team leader should be present during the initial care of the patient. The team leader's task is to ensure
an organized effort focused toward returning the patient to a physiologically normal state and making
appropriate judgments regarding diagnostic testing, therapeutic interventions, and need for transfer. The
management and ultimate outcome of seriously injured patients is improved if board-certified surgeons
are immediately available for the early treatment of specific injuries.
SECONDARY SURVEY
The secondary survey is not started until the primary survey is complete, resuscitation has been initiated,
reevaluation of the vital signs has been performed, and the patient's vital functions are beginning to
return to normal.
 SAMPLE history
o Social – don’t forget relatives
o Allergies
o Medications
o Past history
o Last meal
o Event details.
 Head to toe examination
Physical Examination
Head and Face
 Scalp and ocular abnormalities
 External ear and tympanic membrane
 Periorbital soft tissue injuries
Neck Examination
 Penetrating wounds
 Subcutaneous emphysema
 Tracheal deviation
 Neck vein appearance
Neurological examination
 Brain function – GCS
 Spinal cord motor activity
 Sensation and reflex
Spine
 Steps, swelling and tenderness
Chest examination
 Clavicles and ribs
 Breath sounds and heart tones
 ECG monitoring
Abdominal examination
 Clinical examination
 FAST, DPL
Pelvis and limbs
 Fractures
 Peripheral pulses
 Cuts and other injuries
When CT scanning is performed, patients with multiple injuries are at risk of deterioration during
transport or during the scan itself and must be carefully monitored by experienced personnel. The CT scan
defines specific injuries, particularly to the solid organs in the abdomen. If multiple CT scans are indicated,
one trip to the scanning area is the goal. A CT scan of the head is performed first, when indicated, so that
the intravenous contrast needed for neck, chest, or abdominal studies can be given after the noncontrast
head scan.
RECORD KEEPING
Precise record keeping is important for good care and enables appropriate retrospective review for quality
improvement. Timed entries on pre-existing forms facilitate both recording and later recovery of data.
Numerous types of trauma flow sheets are utilized in individual facilities and systems. A careful review of
the patient's initial assessment and management may explain the patient's subsequent clinical course.
Spinal immobilisation techniques
P Ex
The real issue is how harm to the patient can be minimized from underimmobilization or overimmobilization.
The issue can be restated as several clinically relevant questions:
(1) Which trauma patients might benefit from spinal immobilization during transport and initial
evaluation?
(2) How should these patients with possible unstable injuries be immobilized?
(3) Which trauma patients require radiography in the emergency department?
(4) How can the spine be cleared in the obtunded patient?
(5) Are there special considerations for pediatric patients?
(6) Are there significant differences between patients with blunt versus penetrating injury?
Which trauma patients might benefit from spinal immobilization during transport?
Traditional prehospital guidelines have called for the immobilization of any patient who has sustained a
traumatic mechanism of injury with any potential for energy transfer to the neck.
New systems evaluate for neck pain, neck tenderness, neurologic deficit, and reliability of the physical
examination, thereby excluding intoxicated, hemodynamically unstable, and obtunded patients. Many EMS
systems also exclude multisystem trauma patients. Therefore, most patients seen by the trauma team will still
arrive immobilized.
How should patients with possible unstable injuries be immobilized?
Routinely, this immobilization includes a hard spine board, a cervical collar, and a means to prevent rotation of
the head. Spine boards were developed as a means of extricating patients from a motor vehicle while
maintaining spinal precautions; they were not intended as an immobilization device.
A hard cervical collar and a firm mattress are the standard means of immobilizing patients with documented
unstable injuries in the emergency department or ICU before the application of traction or definitive
stabilization. Patients who arrive at the hospital immobilized on a spine board or vacuum splint should be
evaluated immediately.
If continued spinal immobilization is deemed necessary, the patient should be carefully log rolled off of the
board and placed on a firm mattress. This transfer may be briefly delayed for initial stabilization and
emergency radiographs, but leaving patients on a board for other reasons is medically inappropriate.
Prehospital patients with prolonged transport times or patients being transferred from one facility to another
should not remain on a hard board.
Which trauma patients require radiography in the emergency department?
This is one of the best-researched questions in emergency medicine.
The multicenter National Emergency X-Radiography Utilization Study (NEXUS) enrolled 34,069 patients. The
investigators determined that only patients with midline neck tenderness, focal neurologic deficit, altered
mental status, intoxication, or painful distracting injury require radiographs to exclude spinal injury. Neck pain
was not a criterion nor was a mechanism of injury. These criteria were 99.6% sensitive for clinically significant
(ie, potentially unstable) injuries. These criteria can be applied to any patient who has a reliable clinical
examination. Although many clinicians automatically consider any fracture to be a distracting injury affecting
examination reliability, others are more comfortable making case-by-case decisions.
How is the spine cleared in the case of the obtunded patient?
There seem to be two major schools of thought on this issue. One group obtains a definitive study to rule out
ligamentous injury in all obtunded trauma patients, regardless of whether the results of their cervical spine
radiographs and computed tomography (CT) scans are negative. This definitive study may be a magnetic
resonance image or dynamic fluoroscopic flexion/extension studies. Usually, this study is deferred for as long as
1 week until the patient improves enough to be clinically evaluated, or dies. During this period, the patient is
maintained with routine spinal precautions. Unfortunately, these precautions significantly complicate nursing
care in the ICU and expose the patient to all of the aforementioned risks. The other group counts on the rarity
of unstable ligamentous injury in the setting of completely normal radiographs. If the results of the initial spine
work-up, including radiographs and possibly CT, are normal, spinal precautions are discontinued.
Are there special considerations for pediatric patients?
Because most young children do not tolerate immobilization well, it is ideal to avoid it whenever possible.
Children tend to injure their upper spine and often die before transport. Fortunately, pediatric spinal injuries
are rare, and many of the injuries that do occur do not involve an underlying unstable spinal injury. Therefore,
if pediatric trauma patients were never immobilized, an unstable injury would rarely be missed. However,
considering the potential tragic outcome of an unrecognized injury, the goal should still be to identify patients
at high risk for unstable injury and immobilize them appropriately. Selective spinal immobilization criteria may
be applied to children able to converse and communicate. Once the decision is made to immobilize, anatomic
differences must be considered to achieve a neutral position, particularly the proportionally larger head and
prominent occiput.
Are there significant differences between patients with blunt versus penetrating mechanisms of injury?
In the absence of controlled studies, a logical approach is to immobilize any victim of penetrating firearm
trauma who has a focal neurologic deficit or altered mental status in whom the trajectory likely traverses the
spinal column, provided that immobilization does not interfere with management of the airway or bleeding
vessels.
Techniques of immobilisation and patient handling
The spine should be protected at all times during the management of the multiply injured patient. The ideal
position is with the whole spine immobilised in a neutral position on a firm surface. This may be achieved
manually or with a combination of semi-rigid cervical collar, side head supports and strapping. Strapping
should be applied to the shoulders and pelvis as well as the head to prevent the neck becoming the centre of
rotation of the body.
Prehospital:
Manual spinal protection should be instituted immediately. The application of definitive immobilisation
devices should not take precedence over life-saving procedures.
In-hospital
The spine board should be removed as soon as possible once the patient is on a firm trolley. Prolonged use of
spine boards can rapidly lead to pressure injuries. Full immobilisation should be maintained. Manual protection
should be reinstated if restraints have to be removed for examination or procedures (eg. intubation).
The log-roll is the standard manoeuvre to allow examination of the back and transfer on and off back boards.
Four people are required, one holding the head and coordinating the roll, and three to roll the chest, pelvis
and limbs. The number and degree of rolls should be kept to an absolute minimum.
Rigid transfer slides (eg. Patslide) are useful for transferring the patient from one surface to another (eg CT
scanner, operating table).
Patients who are agitated or restless due to shock, hypoxia, head injury or intoxication may be impossible to
immobilise adequately. Forced restraints or manual fixation of the head may risk further injury to the spine. It
may be necessary to remove immobilisation devices and allow the patient to move unhindered.
Anaesthesia may be necessary to allow adequate diagnosis and therapy. Intubation of the trauma victim is
best achieved via rapid sequence induction of anaesthesia and orotracheal intubation, though the technique
used should ultimately depend on the skills of the operator. The collar should be removed and manual, in-line
protection re-instituted for the manoeuvre. The routine use of a gum elastic bougie is recommended,
minimising cervical movement by allowing intubation with minimal visualisation of the larynx.
Spinal immobilisation is a priority in multiple trauma, spinal clearance is not.
Transfer to Secondary Units
Patients may require transfer to other units for definitive care of other injuries such as head or pelvic trauma.
There should be no unnecessary delays in the transport of these patients. Transfer should not wait for
unnecessary diagnostic procedures that will not alter management. This includes radiological imaging of the
spine.
The spine should be immobilised and protected for the transfer. Split-scoop stretchers and vacuum mattresses
are more appropriate for transfer than rigid spinal (rescue) boards, which should be reserved for primary
extrication from vehicles, rather than as devices for transporting patients.
Cervical Spine Immobilization in Pediatrics
Although the importance of stabilizing and immobilizing pediatric patients with cervical spine trauma to
prevent further injury is well understood, several growth and development factors unique to pediatric patients
must be considered.
Pediatric patients experience disproportionate cephalocaudal growth. For this reason, children typically
present with a cervical spine injury located higher in the spinal column. It must be assumed that any child with
an injury on the head, neck, or back may have sustained a cervical spine injury.
A slight flexion of the neck naturally occurs when a child is placed in the supine position because of the
prominent occiput of a child’s head. This flexion can be dangerous for a patient with a cervical spine injury.
Therefore, adjustments need to be made when immobilizing pediatric patients. A pad or folded towel about
1/2-inch thick should be placed on the spine board at shoulder level. Finally, the pediatric patient may have less
complete bone ossification, more lax ligaments, and more horizontally oriented facets.
Contraindications for cervical collar placement:
 Tracheal stoma necessary for airway management
 Penetrating or hemorrhagic neck injury
 Neck injuries with massive swelling
 Precautions in child with CSF shunt
All the above are indications for in-line immobilization.
Cervical collars alone do not provide sufficient cervical immobilization. Also needed are 2 lateral head
supports; for example, blocks or towel rolls, an extra blanket, tape, a rigid backboard, and a stretcher.
By using his or her fingers, the assistant determines the size of the cervical collar needed by measuring from
the child’s chin to the top of the child’s shoulder. These same fingers are measured against the collar of the
correct size. This is equal to the measurement from the collar’s plastic fastener to the edge of the plastic ridge.
The tallest collar that does not cause hyperextension of the neck is generally thought to be the correct collar
size.
A high index of suspicion for cervical spine injury should be considered with children who have experienced
blunt or penetrating trauma; flexion, extension, and/or rotation of the head and neck; submersion incidents;
altered level of consciousness; and/or an unexplained neurologic deficit in the arms and/or legs after an injury.
Head trauma
Traumatic brain injury (TBI) results from either direct or indirect forces to the brain matter. Direct injury is
immediate and caused by the force of an object striking or penetrating the head. Indirect injuries from
acceleration/deceleration forces are generated by the variable movements of different areas of the brain
against one another and by the impact of the brain against the skull.
The peak incidence of TBI occurs in males between the ages of 15 and 24 years, but ethanol-intoxicated
individuals, the elderly, and young children are at increased risk of TBI because of underlying anatomic and
physiologic factors. The cause of TBI varies greatly by age and demographic factors. For example, for 15- to 24year-olds the leading cause is gunshot wounds, while for those older than age 65 years it is falls.
ANATOMY
The outermost layer, the scalp, is composed of five layers: skin, subcutaneous tissue, galea, areolar tissue, and
the pericranium. Because of the rich blood supply, the scalp has a major role in temperature regulation, being
capable of liberating 50 percent of our total body heat. This same generous blood supply, combined with the
loose areolar connection to the pericranium, can lead to severe blood loss after injury.
The brain is covered with multiple anatomic layers and potential spaces. The outermost layer, the dura mater,
is firmly adhered to the inner skull and has fixed attachments at the cranial sutures. At some edges of dural
reflections, the dura separates into two layers and forms channels called the dural venous sinuses, which serve
to drain blood and cerebrospinal fluid from the brain. Underneath the dura mater is a thinner connective
tissue layer called the arachnoid mater. The arachnoid mater perforates the dura mater at the venous sinuses
where it forms arachnoid granulations. The arachnoid granulations serve as filtration and drainage points for
the cerebrospinal fluid. The arachnoid mater is loosely adhered to the pia mater making possible the potential
subarachnoid space. The pia mater is closely associated with the gray matter of the brain and is the innermost
layer. Between the arachnoid and the pia is the subarachnoid space, where cerebrospinal fluid (CSF) circulates.
In the average adult, there is 150 mL of CSF surrounding the brain and spinal cord. Approximately 500 mL of
CFS is produced in the choroid plexus of the lateral ventricles each day.
Several subarachnoid spaces known as cisternae surround the brain and correspond to large cortical surface
irregularities. These include the ambient, prepontine, supracerebellar, cerebellomedullary, interpeduncular,
superior, and magna. There are four spaces contained within the brain known as ventricles: two lateral
ventricles (separated by the septum pellucidum), a third ventricle, and a fourth ventricle. These CSF-containing
spaces communicate by foramina: Monroe (between the lateral and third ventricle), aqueduct of Sylvius
(between the third and fourth ventricle), and foramen of Luschka and Magendie (outlets from the fourth
ventricle into the cerebellomedullary cistern and cisterna magna).
PATHOPHYSIOLOGY
Acute brain injury is usually divided into primary and secondary phases. In the case of traumatic brain injury,
the acute or primary phase describes the cellular injury and death that are a direct result of force of the injury.
Primary cell death is irreversible and only preventing the injury event and mitigation of the injury forces on the
brain reduce morbidity and mortality.
Secondary injury cascades can extend the damage to cells that are not initially irreversibly damaged. In the
hours to weeks after the injury, local tissue ischemia from compressive forces or vascular injury lead to
secondary cellular death. Prevention of the ischemia and hypoxia are the main therapeutic goals for treating
patients with TBI.
The brain accounts for only 2 percent of total body weight, but consumes 20 percent of the body's total
oxygen requirement and 15 percent of total cardiac output. Maintaining adequate brain tissue perfusion is
critical to avoid secondary brain injury. The cerebral perfusion pressure (CPP) is the difference between inflow
and outflow and is essentially the driving pressure for cerebral blood flow (CBF). Estimates of CPP assume that
the relevant inflow pressure is equivalent to the mean arterial pressure (MAP) and the outflow is related to
intracranial pressure (ICP).
Trauma in pregnancy – general principles and management
PREGNANCY
The ABCDE priorities of trauma management in pregnant patients is the same as those in non-pregnant
patients.
Anatomical and physiological changes occur in pregnancy which are extremely important in the assessment of
the pregnant trauma patient.
Anatomical changes
 The size of the uterus gradually increases and becomes more vulnerable to damage both by blunt and
penetrating injury
o At 12 weeks of gestation the fundus is at the symphysis pubis
o At 20 weeks it is at the umbilicus
o At 36 weeks it is at the xiphoid
 The fetus at first is well protected by the thick walled uterus and large amounts of amniotic fluid.
Physiological changes
 Increased tidal volume and respiratory alkalosis
 Increased heart rate
 30% increased cardiac output
 Blood pressure is usually 15 mmHg lower
 Aortocaval compression in the third trimester with hypotension.
Special issues in the traumatized pregnant female
Blunt trauma may lead to:
 Uterine irritability and premature labour
 Partial or complete rupture of the uterus
 Partial or complete placental separation (up to 48 hours after trauma)
 With pelvic fracture, be aware of severe blood loss potential.
Priorities
 Assessment of the mother according to ABCDE
 Resuscitate in left lateral position to avoid aortocaval compression
 Vaginal examination (speculum) for vaginal bleeding and cervical dilatation
 Mark fundal height and tenderness and foetal heart rate, monitoring as appropriate.
Resuscitation of the mother may save the baby. There are times when the mother’s life is at risk and the fetus
may need to be sacrificed in order to save the mother.
Aortocaval compression must be prevented in resuscitation of the traumatized pregnant woman.
Remember left lateral tilt.
Q1. What is the significance of the seat-belt bruise in this patient?
Fetal injury is more likely in a motor vehicle crash if the lap-belt is incorrectly placed across the uterus rather
than across the thighs.
Q2. In general, how does the pattern of injury in pregnancy-related trauma differ from trauma in the nonpregnant patient?
Trauma affects up to 7% of pregnancies (only a minority require hospitalisation).

Specific injuries
o traumatic brain injury and hemorrhagic shock are the most common mechanisms of
death.

o
o
Uterine injury
o
o
o
o
liver injury, spleen injury, and retroperitoneal hemorrhage are all more common.
bowel injury is less common due to protection by the uterus.
assaults of pregnant women tend to target the uterus.
uterine injury may coexist with pelvic fractures.
Uterine injury is rare in blunt trauma (e.g. uterine rupture, placental abruption) but
carries the risk of premature labour. Direct fetal injury occurs in less than 1% of
blunt trauma.
In penetrating trauma, the uterus tends to protect other organs, but fetal mortality
is much higher.
Always consider the possibility of domestic violence in the pregnant trauma patient.
Q2. What key principles should be remembered when considering investigations in the management of
trauma in the pregnant patient?
1.
2.
If an investigation is needed to optimise the management of the mother it should be
performed as usual.
Use imaging modalities that are free of ionising radiation whenever feasible and appropriate
(especially ultrasound).
Q3. What is a safe amount of radiation exposure, and how does this vary, in the pregnant patient?
Consequences of radiation exposure from imaging are unlikely to be significant in most situations, but there is
greater potential for harm in the first trimester.


<5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and can
be considered ‘safe‘ at any stage of pregnancy.
More than 5-10 rad is potentially risky, and is associated with an increased risk of childhood
cancer even in the later stages of pregnancy.
Radiation exposure varies with different types of imaging, different equipment and different imaging
protocols. In general, radiation exposure to the mother (not necessarily the fetus) for different types of
imaging is:



Chest XR ~ 0.5 rad to the lungs, and very little to a shielded abdomen.
pelvic XR ~ 1 rad
abdominopelvic CT ~ 5-10 rad.
But the estimated fetal exposure for various radiographic studies is considerably lower:

Radiographs
o Cervical spine XR 0.002 rad
o Chest (two view) XR 0.00007 rad
o Pelvis XR 0.040 rad
o Thoracic spine XR 0.009 rad
o Lumbosacral spine XR 0.359 rad

CT scans (10 mm slices)
o Head CT <0.050 rad
o Chest CT <0.100 rad
o Abdomen CT 2.60 rad
However it is worth consulting a radiologist to calculate estimated fetal dose when multiple diagnostic X-rays
or CT scans need to be performed.
[Apologies for the old fashioned use of the rad, which seems to be prevalent in medicine --- 100 rad is
equivalent to 1 Gray.]
Q4. Which pregnant trauma patients should have continuous fetal monitoring? What type of monitor should
be used and what is the minimum recommended monitoring period?
Continuous fetal monitoring is required for at least 4-6 hours at >24 weeks gestation. Before 24 weeks the
fetus is pre-viable, and monitor will not alter the outcome.
Cardiotocography (CTG) should be used, as it is a useful predictor of outcome.
Q5. When is continuous monitoring and further evaluation of the pregnant trauma patient required beyond
the initial observation period?
Continuous monitoring and further evaluation by an obstetrician is required if any of the following is present:






uterine contractions
non-reassuring fetal heart rate pattern
vaginal bleeding
significant uterine tenderness or irritability
serious maternal injury
rupture of the amniotic membranes
Emergency caesarean section may be required.
Q6. Outline your overall approach to the management of a pregnant trauma patient.
Activate Trauma Call and notify the on-call Obstetrician.
An approach to the management of the pregnant trauma patient:



Primary survey and resuscitation
o ABCs with C-spine precautions
Determine if >24 weeks pregnant (uterus should be palpable above the umbilicus, which is
reached at ~20 weeks)
o if <24 weeks, then ‘ignore pregnancy’ and treat the mother according to your
standard approach (no obstetric interventions will alter the outcome of a pre-viable
fetus)
o if>24 weeks, tilt backboard 15-30 degrees to the left to prevent supine hypotension
syndrome
Perform secondary survey (including PV exam and assessment of the uterus) and commence
CTG monitoring.
o if the mother is unstable
 resuscitate and treat cause
o if the mother arrests:
 perform peri-mortem caesarean section in the ED, starting within 4
minutes of arrest ideally, if fetal heart tones detectable. Fetal survival has
been reported at >20 minutes, but neurological outcome is partly
determined by time to delivery post-maternal arrest.
 If there are no fetal heart tones detectable, peri-mortem caesarean
section may be considered in the hope of facilitating resuscitation of the
mother. Otherwise it may be appropriate to stop resuscitation.
o if the mother is stable, or stabilises with resuscitation
 if CTG is stable then continue CTG monitoring for at least 4-6 hours.

if CTG shows distress then obtain an emergency ultrasound and consider emergency
Caesarean section.
Consider Rhesus status and Anti-D IgG in all pregnant patients >12 weeks gestation
Initial management of adult closed head injury
Risk factors indicating potentially significant Mild head injury
Persistent GCS <15 at 2hrs
Persistent vomiting (>2)
Deterioration in GCS
Persistent severe headache
Focal neurological deficit
Known coagulopathy
Clinical suspicion of skull fracture
Age> 65 years
Prolonged loss of consciousness
Multi-system trauma
Prolonged antegrade/retrograde amnesia
Dangerous mechanism
Post traumatic seizure
Clinical obvious drug or alcohol intoxication
Persistent abnormal alertness/behavior/cognition Known neurosurgical/ neurological impairment
Delayed presentation or representation
Signs and management of clinical deterioration of head injury
Indications of deterioration
Clinical approach





 Reassess ABCDE to rule out non head injury cause
 Supportive ABCDE care
 Consider early intubation and short term
hyperventilation
 Immediate CT scan if available
 Consult neurosurgical service
 Consult retrieval service early
 Consider Mannitol 1g/kg prior to transfer
 Consider local burr holes if retrieval will cause
delay
 Consider seizure prophylaxis and phenytoin loading
GCS falls by two or more
Develops dilated pupil(s)
Develops focal neurological deficit
Delayed or focal seizure
Cushing’s response – bradycardia and
hypertension
Indications for transfer of patients with head injury
Patients with severe head injury GCS 3-8
Patients with moderate head injury GCS 8-13
 Clinical deterioration
 Abnormal CT scan
 Normal CT scan but no clinical improvement
 CT scan not available
Patients with mild head injury GCS 13-15
 Clinical deterioration
 Abnormal CT scan
 Normal CT but no clinical improvement
 High risk injury as above and CT scan not
available
NECK INJURIES
Penetrating neck injuries
Neck injuries pose a significant mortality and morbidity due to the compact anatomical nature and close
proximity of critical structures.
Musculoskeletal structures at risk include the vertebral bodies; cervical muscles, tendons, and ligaments; clavicles;
first and second ribs; and hyoid bone.
Neural structures at risk include the spinal cord, phrenic nerve, brachial plexus, recurrent laryngeal nerve, cranial
nerves (specifically IX-XII), and stellate ganglion.
Vascular structures at risk include the carotid (common, internal, external) and vertebral arteries and the vertebral,
brachiocephalic, and jugular (internal and external) veins.
Visceral structures at risk include the thoracic duct, esophagus and pharynx, and larynx and trachea.
Glandular structures at risk include the thyroid, parathyroid, submandibular, and parotid glands.
Zones of neck injury
Serving as the line of demarcation, the
sternocleidomastoid separates the neck into
anterior and posterior triangles. Most of the
important vascular and visceral organs lie within
the anterior triangle bounded by the
sternocleidomastoid posteriorly, the midline
anteriorly, and the mandible superiorly.
Zone 1 - the base of the neck, is demarcated by the thoracic inlet inferiorly and the cricoid cartilage superiorly.
Structures at greatest risk in this zone are the great vessels (subclavian vessels, brachiocephalic veins, common
carotid arteries, aortic arch, and jugular veins, trachea, esophagus, lung apices, cervical spine, spinal cord, and
cervical nerve roots. Signs of a significant injury in the zone I region may be hidden from inspection of the chest or
the mediastinum.
Zone 2 - encompasses the midportion of the neck and the region from the cricoid cartilage to the angle of the
mandible.
Important structures in this region include the carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea,
esophagus, and cervical spine and spinal cord. Zone II injuries are likely to be the most apparent on inspection and
tend not to be occult. Additionally, most carotid artery injuries are associated with zone II injuries.
Zone 3 - characterizes the superior aspect of the neck and is bounded by the angle of the mandible and the base of
the skull.
Diverse structures, such as the salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid arteries,
jugular veins, and major nerves (including cranial nerves IX-XII), traverse this zone. Injuries in zone III can prove
difficult to access surgically.
Prehospital management



Intubate early if necessary
Large bore access IV
C-spine immobilisation cautiously if airway needs intervention and for particular situations
o Gun shot wounds
o Reduced LOC with unknown mechanism of injury
o Significant force of injury e.g. clothesline type
o Evidence of any neurological deficit
ED evaluation
Primary survey
 Close evaluation and management of ABCDE
 Airway – 10% have airway compromise
o Look for- bubbling, expanding hematoma, hoarseness, stridor and edema
o Management
 Cautious use of neuromuscular paralysis
 Orotracheal intubation preferred
 Surgical airway difficult due to distorted anatomy
 Fibreoptic guided intubation may be useful
o
Indications for urgent intubation
 Reduced LOC
 Expanding hematoma or swelling
 Direct laryngeal or tracheal injury
 Hypoventilation

Breathing
o Look for – subcutaneous emphysema, breath sounds and tracheal deviation, chest
examination in c/o zone 1 injury.
o Management –
 Risk for tension pneumothorax with zone 1 injury.

Circulation
o Examination
 Palpate all pulses, auscultate for bruits (continuous = AV fistula, systolic =
obstruction)
 Sudden tachypnea, tachycardia and machinery murmur – air embolism
o
Management
 Direct pressure dressing for hemorrhage, avoid clamps
 Lines in opposite limb to side of injury
 Avoid lines in neck
 If suspected air embolism – left lateral decubitus and Trendelenburg position, if
significant risk – consider for emergent thoracotomy
Secondary survey
 Check LIMITS before starting secondary survey
o Check lines – ETT, NGT, IVC, IDC
o Investigations – bloods sent, ABG, ECG, Xray chest
o Monitoring – ongoing O2, etCO2, ECG, NBP, neuro, BSL, temp
o IV therapy ongoing, predict need for blood and arrange for crossmatch
o Teams – inform vascular/ENT surgical teams as appropriate
o Stabilise ABCDE
 Neck – reassess
 Neurologic –
o Examine and record CNS function, spinal cord function, brachial plexus injury
o Look for cervical sympathetic chain injury – Horner’s
o Vagus/ Recurrent laryngeal nerve injury – hoarseness of voice

o Spinal accessory nerve – trapezius function
o Hypoglossal nerve – tongue protrusion
o Phrenic nerve elevated hemidiaphragm
Vascular
o Manage circulation
Investigations
o Bedside – BSL, ECG, ABG
o Laboratory – FBC, EUC, group and hold, Coagulation studies
o Radiologic –
 Mobile CXR to r/o pneumothorax
 Consider CT neck with contrast angiography to evaluate vascular injury if stable
Management
 Supportive care, monitoring and resuscitation
 Depending on clinical status and active bleeding manage in resuscitation bay initially with full
cardiovascular monitoring
 Support ABCDE as charted above
 Assess and treat any deficits
 Specific management
Zone 1 injuries
Primary survey
Stabilise ABCDE
Check limits
Resuscitate as needed
Refractory shock
Hemodynamically stable
and signs/symptoms
Exploration
Aortic arch/ great vessel aortography
Tracheobronchoscopy
Esophagogram/ Esophagoscopy
Negative
Positive
Observation
Exploration
Zone 2 injuries
Assess and resuscitate
ABCDE as needed
Check LIMITS
Assess safety for investiagtions
Stab wound
Gunshot wound
Significant signs/symptoms
High velocity injury
Stab wound
Gunshot wound
No hard findings of vascular injury
No signs/ symptoms
Stab wound
Gunshot wound
transcervical injury
hemodynamically stable
Exploration
Expectant management
Aortic arch/great vessel aortography
Tracheobronchography
Esophagography
Selective management
Zone 3
Assess and Resuscitate
Manage ABCDE
Check LIMITS
Refractory shock
Hemodynamically stable
+/- Signs/symptoms
Exploration
Oropharyngeal exam
Laryngoscopy
Neck vessel angiography
CT angiography
Cervical Spine fractures
Approximately 5-10% of unconscious patients who present to the ED as the result of a motor vehicle accident
or fall have a major injury to the cervical spine. Most cervical spine fractures occur predominantly at 2 levels.
One third of injuries occur at the level of C2, and one half of injuries occur at the level of C6 or C7. Most fatal
cervical spine injuries occur in upper cervical levels, either at craniocervical junction C1 or C2.
View the cervical spine as 3 distinct columns: anterior, middle, and posterior.
 The anterior column is composed of the anterior longitudinal ligament and the anterior two thirds of
the vertebral bodies, the annulus fibrosus and the intervertebral disks.
 The middle column is composed of the posterior longitudinal ligament and the posterior one third of
the vertebral bodies, the annulus and intervertebral disks.
 The posterior column contains all of the bony elements formed by the pedicles, transverse processes,
articulating facets, laminae, and spinous processes.
Pathophysiology
Cervical spine injuries are best classified according to several mechanisms of injury. These include flexion,
flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and imprecisely
understood mechanisms that may result in odontoid fractures and atlanto-occipital dislocation.
Flexion injury
Common cervical spine injuries associated with flexion mechanism include:
A. Simple Wedge compression fracture without
posterior disruption
B. Flexion teardrop fracture: occurs when there is
flexion with vertical axial compression causing
fracture of anteroinferior aspect of vertebral body.
For a flexion teardrop to occur, there needs to be significant posterior ligamentous disruption with significant
anterior disruption as well, so these fractures are considered unstable.
C. Anterior subluxation with flexion mechanism –
stable in extension potentially unstable in flexion
D. Bilateral facet dislocation with a flexion
mechanism is extremely unstable and can have an
associated disk herniation that impinges on the
spinal cord during reduction.
Bilateral facet joint dislocation is an extremely unstable condition with high risk for spinal cord
injuries.
E. Clay shoveler fracture due to flexion injury –
usually stable injury. Most commonly involving C7T1 junction so needs full visualization
Flexion-rotation injury
A. Unilateral facet dislocation – anterior
displacement <50% of body diameter. AP view –
disruption of spinous process line. Stable fracture.
Rotary atlantoaxial dislocation
This injury is a specific type of unilateral facet dislocation.
Radiographically, the odontoid view shows asymmetry of the lateral masses of C1 with respect to the dens
along with unilateral magnification of a lateral mass of C1 (wink sign). However, since the atlantoaxial joint
permits flexion, extension, rotation, and lateral bending, radiographic asymmetry is produced when the head
is tilted laterally or rotated or if a slightly oblique odontoid view is obtained despite perfect head positioning.
To confirm true dislocation, basilar skull structures (jugular foramina) should appear symmetric in the
presence of the findings described above.
This injury is considered unstable because of its location.
Extension Injury
Common injuries associated with an extension mechanism include hangman fracture, extension teardrop
fracture, fracture of the posterior arch of C1 (posterior neural arch fracture of C1) and posterior atlantoaxial
dislocation.
A. Hangman fracture
A. Hangman fracture (traumatic spondylolisthesis
of C2) – considered unstable but seldom associated
with deficit due to greatest diameter of spinal
canal.
Hangman fractures derive their name from being typical after hanging. Commonly now seen with MVA and
involves bilateral fractures through the pedicles of C2 due to hyperextension. Radiographically, a fracture line
should be evident through the pedicles of C2 along with obvious disruption of spinolaminar line. Although
considered unstable, by itself it is rarely associated with deficit due to largest area of spinal canal at this level.
When associated with unilateral or bilateral facet dislocation at the level of C2, this type of hangaman fracture
becomes highly unstable with high rate of complications requiring immediate referral and cervical traction.
Extension teardrop fracture
Similar in appearance to anterior teardrop with displaced anteroinferior bony fragment, this fracture is stable
in flexion but highly unstable in extension requiring traction with tongs.
Fracture common with diving accidents and may cause central cord syndrome, due to buckling of the
ligamenta flava into spinal canal.
Fracture of the posterior arch of C1:
A.
Fracture of posterior arch of C1 due to
extension – stable
B.
Jefferson fracture – vertical axial
compression. Fracture of all aspects of C1 ring.
Vertical (axial) compression injury
Jefferson fracture (burst fracture of the ring of C1)
This fracture is caused by a compressive downward force that is transmitted evenly through the occipital
condyles to the superior articular surfaces of the lateral masses of C1. The process displaces the masses
laterally and causes fractures of the anterior and posterior arches, along with possible disruption of the
transverse ligament.
Radiographically the fracture is characterized by bilateral lateral displacement of the articular masses of C1.
The odontoid view shows unilateral or bilateral displacement of the lateral masses of C1 with respect to the
articular pillars of C2; thus differentiating it from the simple fracture of posterior neural arch of C1. The lateral
projection reveals striking amount of prevertebral soft tissue edema.
Displacement <6.9mm – transverse ligament intact; if displacement >6.9mm – complete disruption is likely.
Burst fracture of vertebral body
Burst fracture of vertebral body due to vertical
compression is stable mechanically. Requires
CT/MRI to document amount of middle column
retropulsion into cord.
Fractures with >25% loss of height, retropulsion and neurological deicit treated with tractions, others
considered stable.
Multiple or complex injuries
Common injuries associated with multiple or complex mechanisms include odontoid fracture, fracture of the
transverse process of C2 (lateral flexion), atlanto-occipital dislocation (flexion or extension with a shearing
component), and occipital condyle fracture (vertical compression with lateral bending).
Upper cervical spine (occiput to C2) injuries
Injuries at the upper cervical level are considered unstable because of their location. Nevertheless, since the
diameter of the spinal canal is greatest at the level of C2, spinal cord injury from compression is the exception
rather than the rule.
Atlas (C1) fractures
Four types of atlas fractures (I, II, III, IV) result from impaction of the occipital condyles on the atlas, causing
single or multiple fractures around the ring.
The first 2 types of atlas fracture are stable and include isolated fractures of the anterior and posterior arch of
C1 (posterior arch fracture is described under Extension injury). Anterior arch fractures usually are avulsion
fractures from the anterior portion of the ring and have a low morbidity rate and little clinical significance. The
third type of atlas fracture is a fracture through the lateral mass of C1. Radiographically, asymmetric
displacement of the mass from the rest of the vertebra is seen in the odontoid view. This fracture also has a
low morbidity rate and little clinical significance.
The fourth type of atlas fracture is the burst fracture of the ring of C1 and also is known as a Jefferson fracture
(discussed under Vertical (axial) compression injury above). This is the most significant type of atlas fracture
from a clinical standpoint because it is associated with neurologic impairment.
Atlantoaxial subluxation
When flexion occurs without a lateral or rotatory component at the upper cervical level, it can cause an
anterior dislocation at the atlantoaxial joint if the transverse ligament is disrupted. Because this joint is near
the skull, shearing forces also play a part in the mechanism causing this injury, as the skull grinds the C1-C2
complex in flexion. Since the transverse ligament is the main stabilizing force of the atlantoaxial joint, this
injury is unstable. Neurologic injury may occur from cord compression between the odontoid and posterior
arch of C1.
Radiographically, this injury is suspected if the predental space is more than 3.5 mm (5 mm in children); axial
CT is used to confirm the diagnosis. These injuries may require fusion of C1 and C2 for definitive management.
Atlanto-occipital dislocation
When severe flexion or extension exists at the upper cervical level, atlanto-occipital dislocation may occur.
Atlanto-occipital dislocation involves complete disruption of all ligamentous relationships between the occiput
and the atlas. Death usually occurs immediately from stretching of the brainstem, which causes respiratory
arrest.
Radiographically, disassociation between the base of the occiput and the arch of C1 is seen. Cervical traction is
absolutely contraindicated, since further stretching of the brainstem can occur.
Odontoid process fractures
The 3 types of odontoid process fractures are classified based on the anatomic level at which the fracture
occurs.
Type 1 – avulsion of tip of dens at
insertion of alar ligament
Type 2 – base of the dens and most
common
Type 3 – fracture line extends in body
of axis



Type I odontoid fracture is an avulsion of the tip of the dens at the insertion site of the alar ligament.
Although a type I fracture is mechanically stable, it often is seen in association with atlanto-occipital
dislocation and must be ruled out because of this potentially life-threatening complication.
Type II fractures occur at the base of the dens and are the most common odontoid fractures. This
type is associated with a high prevalence of nonunion due to the limited vascular supply and small
area of cancellous bone.
Type III odontoid fracture occurs when the fracture line extends into the body of the axis. Nonunion is
not a major problem with these injuries because of a good blood supply and the greater amount of
cancellous bone.
With types II and III fractures, the fractured segment may be displaced anteriorly, laterally, or posteriorly.
Since posterior displacement of segment is more common, the prevalence of spinal cord injury is as high as
10% with these fractures.
Occipital condyle fracture
Occipital condyle fractures are caused by a combination of vertical compression and lateral bending. Avulsion
of the condylar process or a comminuted compression fracture may occur secondary to this mechanism. These
fractures are associated with significant head trauma and usually are accompanied by cranial nerve deficits.
Radiographically, they are difficult to delineate, and axial CT may be required to identify them.
These mechanically stable injuries require only orthotic immobilization for management, and most heal
uneventfully. These fractures are significant because of the injuries that usually accompany them.
Mechanical Instability
Column disruption may lead to mechanical instability of the cervical spine. The degree of instability depends
on several factors that may translate into neurologic disability, secondary to spinal cord compression.
Trafton has ranked specific cervical injuries based on their degree of mechanical instability.1 The list below
ranks cervical spine injuries in order of instability (most to least unstable):















Rupture of the transverse ligament of the atlas
Fracture of the dens (odontoid fracture)
Burst fracture with posterior ligamentous disruption (flexion teardrop fracture)
Bilateral facet dislocation
Burst fracture without posterior ligamentous disruption
Hyperextension fracture dislocation
Hangman fracture
Extension teardrop (stable in flexion)
Jefferson fracture (burst fracture of the ring of C1)
Unilateral facet dislocation
Anterior subluxation
Simple wedge compression fracture without posterior disruption
Pillar fracture
Fracture of the posterior arch of C1
Spinous process fracture (clay shoveler fracture)
Imaging Studies
Radiographic evaluation is indicated in the following:




Patients who exhibit neurologic deficits consistent with a cord lesion
Patients with an altered sensorium from head injury or intoxication
Patients who complain about neck pain or tenderness
Patients who do not complain about neck pain or tenderness but have significant distracting injuries
To be clinically cleared using the CCR(Canadian C-spine Rule), a patient must be alert (GCS 15), not intoxicated,
and not have a distracting injury (eg, long bone fracture, large laceration). The patient can be clinically cleared
providing the following:



The patient is not high risk (age >65 y or dangerous mechanism or paresthesias in extremities).
A low risk factor that allows safe assessment of range of motion exists. This includes simple rear end
motor vehicle collision, seated position in the ED, ambulation at any time posttrauma, delayed onset
of neck pain, and the absence of midline cervical spine tenderness.
The patient is able to actively rotate their neck 45 degrees left and right.
The NEXUS criteria state that a patient with suspected c-spine injury can be cleared providing the following:





No posterior midline cervical spine tenderness is present.
No evidence of intoxication is present.
The patient has a normal level of alertness.
No focal neurologic deficit is present.
The patient does not have a painful distracting injury.
Both studies have been prospectively validated as being sufficiently sensitive to rule out clinically significant cspine pathology. The CCR were shown to be more sensitive than the NEXUS criteria (99.4% sensitive vs 90.7%),
and the rates of radiography were lower with the CCR (55.9% vs 66.6%).7 Debate still exists as to which criteria
are more useful and easier to apply.
Cervical X-ray interpretation
A standard trauma series is composed of 5 views: cross-table lateral, swimmer's, oblique, odontoid, and
anteroposterior.
Cross-table lateral view
Approximately 85-90% of cervical spine injuries are evident in lateral view, making it the most useful view from
a clinical standpoint.
A technically acceptable lateral view shows all 7 vertebral bodies and the cervicothoracic junction.
First line – anterior contour line – connects
anterior margins of all vertebrae
Second line – posterior contour line – connects
posterior margins of all vertebrae
Third line – spinolaminar contour line – connecting
bases of spinous process.









Each of these lines should form a lordotic curve.
Suspect bony or ligamentous injury, if disruption is seen in contour lines.
Young children may have benign pseudosubluxation in the upper cervical spine.
Check individual vertebrae thoroughly for obvious fracture or changes in bone density.
Look for soft tissue changes in the predental and prevertebral spaces.
Predental space – between anterior aspect of odontoid and the posterior aspect of anterior arch of C1
→ <3mm in adult and <5mm in child →transverse ligament rupture if ↑
Prevertebral space – between anterios border of vertebra to posterior wall of pharynx.
o At level of C2, <7mm
o At the level of C3 and C4, <5mm or <half of width of corresponding vertebra
o At the level of C6 – widened due to esophagus and cricopharyngeus - <22mm in adults and
<14mm in children
Check for fanning of the spinous processes – suggestive of posterior ligamentous disruption.
Check for abrupt change in angulation of >11˚ → possible ligamentous injury
Complications of spinal fractures:
Spinal shock

Severe spinal cord injury may cause a concussive injury of the spinal cord termed spinal shock
syndrome
 SS manifests as distal areflexia of a transient nature, lasting from few hours to weeks.
 Flaccid quadriplegia with return of segmental reflexes in 24hrs occur with resolution
 Eventually, total resolution can be expected
Neurogenic shock
 Spinal shock that causes vasomotor instability because of loss of sympathetic tone
 Hypotension with paradoxical bradycardia
 Flushed, dry and warm skin may be present
 Ileus, urinary retention and poikilothermia
 Loss of anal sphincter tone with fecal incontinence and priapism suggest spinal shock
 Return of bulbocavernous reflex heralds resolution of spinal shock
Complete or incomplete cord syndromes

Spinal shock mimics complete cord transection and prognostication should be withheld until its
resolution
 Incomplete cord syndromes are described and include anterior spinal cord syndrome, central spinal
cord syndrome, Brown-Séquard syndrome and less commonly cord syndromes at high cervical levels
 Patient with complete lesion after resolution of spinal shock usually have permanent paraplegia
Anterior spinal cord syndrome



Complete motor paralysis and loss of temperature and pain perception distal to the lesion
Sparing of posterior column function – light touch, vibration and proprioceptive inputs
Syndrome caused by compression of the anterior spinal artery → anterior cord ischemia or direct
compression of cord
Central spinal cord compression


Caused by damage to the corticospinal tract
Weakness, greater in the upper extremities than the lower extremities and mor pronounced in distal
aspect of extremity
 Usually associated with hyperextension injury in patients
 Buckling of ligamentum flavum into spinal cord due to severe extension
Brown-Séquard syndrome


Involves injury to one side of the spinal cord
Paralysis, loss of vibration sense, loss of proprioceptive input ipsilaterally with contralateral loss of
pain and temperature perception due to involvement of posterior columns and spinothalamic tracts
on the same side
 Associated with hemisection of the cord from penetrating trauma or lateral mass fracture of cervical
vertebra
High cervical spinal cord syndrome
 Damage to the spinal tract of the trigeminal nerve in the high cervical region
 Characteristic onion-skin pattern of anesthesia in the face
Horner syndrome


Ptosis, miosis and anhydrosis
Results from damage to cervical sympathetic chain
Blunt chest trauma
Blunt chest trauma is a significant source of mortality and morbidity. Blunt injury to the chest can affect any
one of the components of the chest wall and thoracic cavity. By far the most common cause of significant
blunt chest trauma is MVA, accounting for 70-80% of these injuries.
Primary survey
 Rapid review of ABCDE
 Airway – control may be required early in case of significant chest injury to maintain adequate
oxygenation and ventilation or management of the multi-trauma victim
o
o
o
o
Breathing
o Ventilate with 100% oxygen
o Check thorax and neck
o Deviated trachea
o Tension pneumothorax (intervention—needle decompression)
o Chest wounds and chest wall motion
o Sucking chest wound (intervention—occlusive dressing)
o Neck and chest crepitation
o Multiple broken ribs
o Fractured sternum
o Pneumothorax
o Listen for breath sounds
o Correct tracheal tube placement?
o Hemopneumothorax?
o Chest tube(s)—38-Fr
o Collect blood for autotransfusion
By far the most important assessment in cases of blunt chest trauma
Assess and treat presence of any of the following
 Tension pneumothorax
 Massive hemothorax
 Open pneumothorax
 Cardiac tamponade
 Flail chest
Some conditions may require increased positive pressure ventilation to improve oxygenation
and
In cases of spontaneous decompensation in a previously stable victim, review may be
necessary to rule out development of any of the above conditions
Circulation
 Apply pressure to sites of external exsanguination
 Assure that two large-bore IVs established
o Begin with rapid infusion of warm crystalloid solution
 Assess for blood volume status
o Radial and carotid pulse, BP determination
o Jugular venous filling
o Quality of heart tones
 Beck triad present? – low BP, JV distension and distant muffled heart
sounds
o Pericardiocentesis or echocardiogram
o Decompress tamponade
o Pericardiocentesis
o Thoracotomy with pericardiotomy
Disability
 Brief neurologic examination
o Pupil size and reactivity
o Limb movement
o Glasgow Coma Scale
Exposure
 Completely disrobe the patient
 Logroll to inspect back
Continuing and monitoring resuscitation
LIMITS
 Lines – ETT/NGT/IVx2/IDC
 Investigations – bloods/ ABG/ ECG/ X-ray/ FAST
 Monitoring – O2/ ETCO2/ ECG/ NBP/ Neuro/ BSL/ Temp
 IV therapy – fluids/analgesia/ antibiotics/ blood
 Teams/transfer – inform cardiothoracic/vascular teams early
 Stabilize ABCDE before secondary survey
Secondary survey
 Usual head to toe examination with close detailed examination of chest for
o Rib fractures and flail chest
o Pulmonary contusion
o Simple pneumothorax
o Simple hemothorax
o Blunt aortic injury
o Blunt myocardial injury
Physical examination includes:
 Look
o Determine the respiratory rate and depth
o Look for chest wall asymmetry. Paradoxical chest wall motion
o Look for bruising, seat belt or steering wheel marks,
penetrating wounds
 Feel
o Feel for the trachea for deviation
o Assess whether there is adequate and equal chest wall
movement
o Feel for chest wall tenderness or rib 'crunching' indicating rib
fractures
o Feel for subcutaneous emphysema
 Listen
o Listen for normal, equal breath sounds on both sides.
o Listen especially in the apices and axillae and at the back of the
chest (or as far as you can get while supine).
 Percuss
o Percuss both sides of the chest looking for dullness or
resonance (more difficult to appreciate in the trauma room).
Monitoring adjuncts
 Oxygen saturation
 End-tidal carbon dioxide
o Confirmation of tube placement and dislodgement
o Diagnosing sudden changes in ventilatory pattern e.g. pneumothorax associated with PPV
Diagnostic adjuncts
 Chest X-ray – single most important initial tool in evaluation of any chest injury and preferable
conducted at the end of primary survey


FAST examination
o Look for free fluid (blood) in peritoneum, pericardium or hemothorax
Arterial blood gas analysis
o To diagnose and monitor pulmonary function/resuscitation status
Further investigations:
 CT scan chest and abdomen
 Angiography
 Oesophagoscopy/ Oesophagram
 Bronchoscopy
Definitive care/ disposition may include:
 Chest drain
 Thoracostomy
 Transfer to critical care/ retrieval to tertiary centre
Complications of Blunt chest trauma
Pneumothorax
 Simple pneumothorax is a non-expanding collection of air around the lung
 Lung is collapsed to a variable extent
 Diagnosis may be difficult on clinical examination –
o reduced air entry, resonance to percussion
o Adjunct signs – subcutaneous emphysema and rib fractures
 Chest x-ray usually diagnostic – but may miss small pneumothoraces especially if patient supine.
o Presence of rib fractures should raise suspicion
o Non-congruent x-ray lucency
o Deep sulcus sign
o Flat meniscus with hemopneumothorax
 CT scanning more sensitive than plain chest x-ray – but use of this sensitivity questionable since small
pneumothoraces may not need ICD even with PPV
 Ultrasound – recently gained more popularity in diagnosing chest conditions
o Loss of lung sliding and Comet tail artifacts on US
 Management
o Placement of intercostal chest drain is definitive treatment in most cases
o Expectant management of small pneumothoraces practical
o Indications for ICD placement include:
 Multiply injured trauma patient
 Hemodynamically unstable with need for close control on ABC
 Need for prolonged anesthesia
 Need for prolonged or air transfer
 Situations where detection of worsening may be difficult or delayed
Tension pneumothorax
 Progressive buildup of air within the pleural space, usually due to a lung laceration which allows air to
escape into pleural space with a “one-way valve” effect
 Displacement of mediastinum to the opposite hemithorax → obstructing venous return to heart →
traumatic arrest
 Classic signs
o Deviation of trachea away from side of tension
o Hyper-expanded chest
o Increased percussion noted
o Hyper-expanded chest that moves little with respiration
o Raised CVP if no hypovolemia present
 Other signs
o Tachycardia, tachypnea and hypoxia
o Circulatory collapse with hypotension
o Traumatic arrest with pulseless electrical activity
 Chest x-ray findings
o Deviation of trachea away from the side of the tension
o Shift of the mediastinum
o Depression of the hemi-diaphragm
 Management
o Needle thoracostomy
 Emergent chest decompression with needle thoracostomy
 14-16g IV cannula inserted into the second rib space in mid-clavicular line
 Controversy regarding placement before imaging
 Prone to blockage, kinking, dislodging and falling out
 In absence of hemodynamic compromise, may be prudent to wait for results of an
emergent CXR




o
Needle decompression can be associated with complications
It should not be used lightly
Never be used just because there are no breath sounds BUT
In clear cut cases: shock with distended neck veins, reduced breath sounds,
deviated trachea, it could be life-saving
Chest drain placement
 Definitive treatment of traumatic pneumothorax
 Preferred over blind needle thoracostomy if patient stable enough to tolerate the
wait
 Blunt dissection to enter the pleura – relieves tension even before chest tube is
placed
Open pneumothorax
 Occurs when there is a pneumothorax associated with a chest wall defect.
 Negative intrathoracic pressure during inspiration drains air into the chest through the wound
because the chest wall wound is shorter that trachea → inadequate oxygenation and ventilation
 May tension if flap has been created acting as an ‘one-way-valve’.
 Diagnosis
o Primary survey – sucking chest wound visibly bubbling
o Reduced expansion of hemithorax with reduced breath sounds and increased percussion
note
o Rapid, labored and shallow breathing
o All the signs may be difficult to appreciate in a noisy trauma room
 Management
o 100% oxygen via facemask
o Intubation early when airway and breathing inadequate
o Do not delay placement of chest tube and closure of wound
o Definitive treatment – occlusive dressing over wound and immediate placement of IC drain
o If ICD not available as occurs at scene – application of three sided bandage
Haemothorax
 Collection of blood in the pleural space and may be caused by blunt or penetrating trauma
 Most result from rib fractures, lung parenchymal and minor venous injuries
 Less commonly there is arterial injury requiring surgical repair
 Physical examination –
o External bruising or lacerations
o Palpable crepitus indicating rib fractures
o Penetrating injury over affected hemithorax
o Examine the back!!!
o Classic signs are
 Decreased chest expansion
 Dullness to percussion
 Reduced breath sounds on affected side
 Diagnosis
o Most haemothoraces not identified on examination will be picked up by CXR, US or CT
o CXR –
 Erect film is usually standard – classical fluid meniscus
 400-500mls of blood required to obliterate the costo-phrenic angle
 Supine film – blood lies posteriorly causing diffuse opacification of hemithorax
o FAST ultrasound
 Can detect even smaller hemothoraces (<200mls)
 Presence of pneumothoraces and subcutaneous air can make it inaccurate
 Significance of small hemothoraces not known
o CT Chest
 Even more sensitive than US



Invaluable in determining presence and significance of hemothoraces in supine
patients with significant other injuries
Can more reliably differentiate pulmonary contusion and aspiration from
hemothorax in supine patient
Management
o Chest drain
 First step in management of traumatic hemothorax
 Smallest size 32F but preferably 36F to be able to drain clots
 For drainage of hemothorax tube placed posteriorly unlike pneumothoraces
 But placed anteriorly if significant rib fractures and associated pneumothorax
present to avoid kinking and development of tension pneumothorax
o Thoracotomy
 Required in under 10% of thoracic trauma patients
 Indications for thoracotomy (s/o arterial injury)
 Immediate drainage of 1000-1500mls
 Obvious ongoing arterial bleeding – colour
 Continuing drainage after 4-5hrs since insertion – 200-250mls/hr
Rib fractures and flail chest
Chest wall injury is very common following blunt chest trauma.
Complications of rib fractures:
 The most important complication of multiple rib fractures is the occurrence of pulmonary contusion.
 Fractures of lower ribs may be associated with diaphragmatic tear, liver and splenic injury.
 Injuries to the upper ribs may be associated with injuries to adjacent great vessels, especially the first
rib. The first rib due to its size and position requires significant amount of force to fracture and thus
indicates a major energy transfer.
 Fracture of first rib associated with
o 20% aortic injury
o Bronchial fracture in 80%
o Mortality of 20%
Flail chest occurs when a segment of thoracic cage is separated from rest of the chest wall.
 Defined as at least two fractures per rib in at least two ribs.
 Segment of chest wall is unable to contribute to lung expansion.
 Large flail segments may disrupt pulmonary function severely enough to require mechanical
ventilation
 Main significance of flail segment is the indication of likelihood for underlying pulmonary contusion
Diagnosis
 Bruising, grazes or seat belt signs on inspection
 Crepitus and tenderness on palpation and movement or respiration in conscious patients
 Chest x-ray and CT scan may both reveal extent of rib fractures
o CXR will not identify all rib fractures
o CXR more likely to miss lateral or anterior fractures on AP view
o Dedicated ribs views not indicated in trauma patients
 Clinically a flail chest is identified as paradoxical movement of a segment of the chest wall – indrawing
on inspiration and moving outwards on expiration.
 Pediatric patients rib fractures may be absent despite significant pulmonary contusion
Management
 Directed towards protecting underlying lung and allowing adequate oxygenation, ventilation and
pulmonary toilet.
 Secondary goal is to prevent development of significant atelectasis and secondary pneumonia.
 100% O2 initally
 Analgesia
o PCA of opioids best option in conscious and cooperative patients
o Additional NSAID therapy may help further
o NSAID withheld if risk of bleeding significant
o



Best analgesia for severe chest injury – continuous epidural infusion of local anesthetic +/opioid
o Posterior rib blocks may be appropriate for one or two isolated rib fractures – last 4-24hrs
Intubation and ventilation
o Needed when significant contusions complicate injury
o Increasing analgesia requirement with significant risk for respiratory depression may
sometimes necessitate PPV
Chest tube insertion
o Patients with significant rib fractures and requiring PPV will most often get prophylactic chest
tubes due to increased risk of pneumothoraces with PPV
o Need for chest tube also dictated by the presence of other injuries
Rib fracture fixation
o Rarely needed these days since intubation and ventilation of patient with multiple injuries
usually provides internal stabilization and results in good fixation by the time the contusion
heals
Traumatic Aortic injury
 16% of MVA fatalities due to TAI, 85-90% prior to arrival to ED
 30% die within 6hrs of presentation, 50% by 24hrs, 72% die within 8days, 90% die within 4months
 Most common site of injury aortic root in patients who die prior to arrival, in survivors 90% injury at
isthmus
 CT aortography most sensitive tool to diagnose aortic injury, though most CXR with aortic injury are
abnormal
 Aortography gold standard with 94% sensitivity and 96% specificity
Bronchial tear
 Present in 1.5% of major chest trauma patients
 80% of injuries within 2.5cm of carina
 Commonly missed
 Persistent or progressive pneumothorax or pneumomediastinum despite chest drain – fallen lung sign
 Definitive diagnosis with bronchoscopy
Thoracic spine injury
 Critical zone for injury – T9 to T11
 Thoracic facets face inward and lumbar facets face outwards → weak point of transition between T9
and T11
 Symptoms can simulate thoracic transection and high degree of suspicion to be maintained
 Management as with other spinal fractures
Diaphragm rupture
 Are common and commonly missed
 Most common location is the central tendon, extending posterolaterally
 5% of blunt chest trauma, 90% left-sided, 70% initially missed
 CXR signs – mediastinal shift, elevated hemidiaphragm, hemothorax and bowel gas in chest wall
 False negative results likely with CT unless sagittal reconstructions done
Esophageal rupture
 Rare injury, most commonly in upper oesophagus
 Commonly present as pneumomediastinum
 CXR shows air along diaphragm and paravertebral are forming a “V”.
 Confirmatory diagnosis with oesophagram
Cardiac injury
 Myocardial contusion accounts for 50% of cardiac injuries in blunt chest trauma
 Less common cardiac injuries include
o Pericardial laceration
o Myocardial rupture
o Aortic valve rupture
o Coronary artery laceration
Consider cardiac injury in any patient with enlarged heart or sudden development of pulmonary
edema
 2D-ECHO most sensitive test for diagnosis
Cardiac contusion
 Difficult diagnosis due to non-specific symptoms and lack of ideal test
 Can cause life threatening arrhythmias and cardiac failure
 Symptoms
o Palpitations or precordial pain
 ECG findings
o Non-specific abnormalities
 Pericarditis changes
 Prolonged QT interval
o Myocardial injury
 New Q waves
 ST-T segment elevation or depression
o Conduction disorders
 RBBB
 Fascicular block
 AV nodal disorder
o Arrhythmias – any possible
 Troponin T or I: need to be done at presentation and 4-6hrs post trauma and if raised may be serially
measured
 Echocardiography
o Features similar to myocardial infarction
o Valvular lesions
o Pericardial effusion or tamponade
o Ventricular dilatation
 Nearly all (81-95%) life threatening ventricular arrhythmias and acute cardiac failures occur within 2448 hrs from admission
 Treatment is mainly supportive except in case of anatomic disruption of structures
Malposition of tubes and catheters
Tube
Desired position
Common malposition
Endotracheal tube
Trachea
Esophagus, mainstem
CV Catheter
SVC
Pleural space or artery
NGT
Stomach
Bronchus
Chest drain
Pleura
Chest wall

Investigations in blunt chest trauma
A: Aortography
B: Bronchoscopy
C: CT
D: Drink barium
E: Esophogram
G: CT upright or decubitus film
H: Echocardiography
I: Inject dye
Penetrating chest trauma
Thoracic chest injuries account for 20-25% of deaths due to trauma.
Problems with penetrating chest wounds:
 Any entry wound below the level of the nipples must be considered as potential for upper abdominal
injury
 Penetrating chest wounds are most commonly due to stab wounds and gunshot wounds
 Gunshot wounds without exit should be considered potential for embolization in the vasculature
 Patient with combined chest and abdominal injury has higher mortality
Etiology
Classified into low-, medium- or high-velocity injuries
 Low velocity injury – stab wounds – disrupt structures penetrated
 Medium velocity – handguns and air-powered pellet guns – limited neighboring structure damage
 High velocity – rifles and military weapons cause significant transmission of kinetic energy to
neighboring tissues with resultant significant cavitation
Injuries commonly caused by penetrating chest trauma
 Hemothorax
 Hemopneumothorax
 Pneumothorax
 Diaphragmatic rupture
 Pulmonary contusion
 Open pneumothorax
 Rib fractures
 Subcutaneous emphysema
 Vascular trauma
 Spinal trauma
Initial management as per trauma guidelines – see blunt chest injury
Individual injuries listed above treated as per usual guideline see blunt chest injury protocols
Thoracotomy is indicated for:
 Cardiac tamponade
 Cardiac arrest in trauma center with penetrating chest wound
 Vascular injury at thoracic outlet
 Traumatic thoracotomy
 Massive air leak
 Endoscopic or radiographic evidence of significant tracheal or bronchial or oesophageal injury
 Radiographic evidence of great vessel injury
 Ongoing blood loss from ICD - >250mls/hr >4hrs or >1.5L in first hour
Patients who arrive in cardiac arrest or who arrest shortly after arrival may be candidates for emergency
resuscitative thoracotomy. A right chest tube must be placed simultaneously. The use of emergency
resuscitative thoracotomy has been reported to result in survival rates of 9-57% for patients with penetrating
cardiac injuries and survival rates of 0-66% for patients with non-cardiac thoracic injuries, but overall survival
rates are approximately 8%.
Investigations
 CXR is the primary investigation for all PCI
 FAST and 2D-ECHO fast gaining roles in evaluation of cardiac and great vessel structures
 ECG – and serial monitoring for diagnosing and monitoring cardiac, pericardial injuries
 CT scanning must be conducted in all stable PCI not meeting the immediate thoracotomy criteria
 Aortography – once gold standard now used less and less due to increased sensitivity of high
resolution CT
 Esophagoscopy and bronchoscopy indicated in patients with posterior mediastinal injury
Management
Resuscitation according to usual trauma protocols
Surgical management
 Chest wall injury –
o Rarely urgent surgical intervention needed for significant bleeding from intercostal or other
arteries
o Primary treatment of chest wall injuries is a combination of pain control, aggressive
pulmonary and physical therapy, selective use of intubation and ventilation and close
observation for respiratory decompensation
o Indications for operative chest wall repair include
 Need for thoracotomy for other reasons
 Large flail segments with morbid pulmonary function
 Severe instability and failure to wean off ventilator
 Secondary infections
 Vascular injury
o Mostly done either as part of urgent thoracotomy or after diagnosis with HRCT with contrast
o Surgical intervention required for most large vessel injuries
 Other injuries – treated similar to those occurring in blunt chest injury
Complications of PCI
 Retained pulmonary parenchymal foreign bodies
 Chest wall hernia
 Posttraumatic lung cyst
 Pulmonary hematoma
 Systemic air embolism
 Bronchial stricture
 Trachoesophageal fistula
 Persistent air leak and bronchopleural fistula
 Empyema
 Ventilator associated pneumonia
 Cardiovascular fistulae
 Thoracic duct injury and chylothorax
Management of pelvic fractures in trauma patients
Five potential sites of potentially fatal haemorrhage in trauma
 External
 Long bones
 Chest
 Abdomen
 Retroperitoneum
Approach to a patient with suspected pelvic injury



Primary survey
o Airway – assess and stabilise
o Breathing – O2 therapy and ventilatory parameters
o Circulation –
 2 X wide bore >18g IV access
 Initial crystalloid fluid boluses titrate
 To cerebral perfusion
 To maintain systolic BP >90mmhg
 Consider early call for un-crossmatched blood transfusions
 Early group hold and screen and pre-empt need for massive transfusion
protocol
 Control external sites of bleeding
 If obvious limb shortening and evidence of pelvic fractures with
hypotension consider placing pelvic binding with mechanical device or bed
sheet while log-rolling
o Disability – assess and record
o E-exposure – undress and assess, cover up and prevent heat loss
o Check LIMITS –
 Lines – ETT/IVC/NGT/SaO2/vitals/ETCO2
 Investigations – bloods/ABG/ECG/X-rays/FAST
 Check CXR for hemo-/pneumo-thorax
 Check Pelvic x-ray for unstable fractures, disruption of ring – apply pelvic
binding if obvious fractures and hemodynamically unstable
 Monitoring – SaO2/ETCO2/ECG/NBP/neuro/BSL
 Intravenous therapy – IV fluids and analgesia as required
 Teams – early referral to orthopaedic or radiology teams if persistently unstable
with no other obvious cause for hemorrhage
 Stabilise patient prior to beginning secondary survey
Secondary survey
o Only once primary survey complete and resuscitation complete
o Complete head to toe exam
o In 32% of pelvic fracture patients, significant abdominal injury will also be found – so primary
goal to rule out abdominal pathology
o DPA or FAST according to local protocol and availalbility
o Exclude all other sites of bleeding
Angiography facilities available
o If FAST negative and clinically unstable  transfer to angiography for embolisation
o Regular review of abdomen for free fluid
o If FAST positive and clinically stable  immediate laparotomy, damage control  pack
pelvis, fix intra-abdominal pathology  transfer to angiography facility for pelvic bleeding
control
o If clinically very unstable <70mmhg systolic for urgent packing OT to stabilise patient even
before angiography
If clinically mild instability  consider theatre before plan for operative or angiographic
intervention
Angiography services unavailable in hospital:
o Systolic BP >80  non invasive external stabilisation  100-200ml boluses to maintain BP
contact retrieval services for transfer to tertiary center
o Systolic BP<80  despite fluid resuscitation immediate laparotomy with surgical ligation
of bleeders  pack pelvis with large sponges  invasive external stabilisation of pelvis
o

Classification of pelvic fractures – Young and Burgess
APC I
LC I
Stable
APC II
LC II
Unstable
APC III
LC III
Unstable
VS
Unstable
Young and Burgess classification is the most commonly used system for classification of pelvic fractures
 Classifies pelvic fractures by vector of force
o Anteroposterior compression (APC)
o Lateral compression (LC) and
o Vertical shear (VS) types
 APC and LC further classified into types I, II and III with increasing degrees of severity
 Type I APC/LC are stable since posterior elements are intact
 Type II APC/LC varying degress of instability
 Type III APC/LC and VS all significantly unstable
Bladder rupture



Occurs in 9-16% of all pelvic fractures
Diagnosed by cystogram ± CT
Extraperitoneal or intraperitoneal
o Extraperitoneal due to shearing forces or laceration by bony spicules anteriorly
o Intraperitoneal due to severe pressure to a distended bladder


o Mixed rupture in 12% of case
Signs – suprapubic tenderness, low urine output and gross hematuria (>95%)
Treatment
o Intra-peritoneal – surgical repair
o Extra-peritoneal – conservative with IDC insertion
Urethral rupture





Occurs in 4-14% of pelvic fractures
Diagnosed by retrograde urethrography
May be partial or complete
Signs – meatal bleeding (98%), gross hematuria, perineal hematoma, vaginal laceration
Treatment
o Depends on location and severity
o Suprapubic or aligning urinary catheter
o Primary repair or
o Delayed urethroplasty/otomy
Assessment of abdominal trauma
Trauma is a physical injury caused by transfer of energy to and within the person involved. Abdominal trauma
is best categorised by mechanism as blunt and penetrating abdominal injuries. The mechanism of injury
dictates the diagnostic work-up.
Blunt abdominal trauma
 Causes of blunt abdominal trauma include motor vehicle accidents (MVAs), motorcycle crashes
(MCCs), pedestrian-automobile impacts, falls, and assaults.
 MVAs are the most common cause- approximately 75%
 Common injuries divided into two categories:
o Solid organ – liver, spleen, pancreas and kidneys and
o Hollow organ – stomach, large and small bowel, gall bladder and urinary bladder
 Diaphragmatic injury accounts for <10% of blunt abdominal trauma
 Splenic trauma more common with blunt rather than penetrating abdominal trauma
Penetrating abdominal trauma
 This occurs when a foreign object pierces the skin – accidental or intentional
 Most common penetrating injuries are gunshot wounds and stab wounds
 External appearance of penetrating wound does not determine extent of internal injuries
 Trajectory of penetrating wound determines injuries to internal structures and all possible injuries
should be considered
 Mortality related to intra-abdominal organs injured and refractory hemorrhagic shock leading cause
of death
 Small bowel most common organ involved in penetrating trauma and less commonly involved in blunt
trauma
 Stomach, pancreatic, diaphragmatic and colorectal injuries also more common in penetrating injuries
vs. blunt trauma
Etiology
Blunt abdominal trauma
 Two types of forces: shear strain and tensile strain
 Shear injuries at a point of attachment of an organ during abrupt acceleration or deceleration.
o Liver, kidneys, spleen, large and small bowel susceptible to these injuries
 Tensile injuries occur due to direct compression or stretching of tissue.
o Liver, spleen and pancreas usually injured during frontal impact;
o Kidney affected when direct impact to flanks.
o Pelvic fractures and diaphragmatic injury likely due to increased intra-abdominal pressure
Penetrating abdominal trauma
 Foreign body travelling through body decelerates and dissipates its energy to neighbouring tissue.
 Amount of tissue damage is related to the velocity and size of the foreign body
 High velocity GSW cause more damage than low velocity wounds.
 Penetrating injuries involve a smaller area of tissue than blunt trauma
 Injuries depend on the path of object and in case of bullets can be unpredictable as they ricochet off
bones
 Foreign bodies also carry other material e.g. clothing with them into the wound thus increasing the
risk of infections in the cavitation
Diagnostic approach
 MIST – information critical in risk stratifying and understanding the expected injuries
 Past medical history e.g. anticoagulant use and medical conditions may have significant impact on
vitals and outcomes. E.g. relative bradycardia in a patient on β-blocker
 AMPLE history availability can add significant information
Physical examination
 Primary survey – as in other trauma
 Evaluation of abdomen o Inspection for external injuries such as open wounds or significant bruising of abdominal
o Seat belt sign may herald the occurrence of deeper injuries
o




Palpation - assess for tenderness and peritoneal signs , blood in peritoneum does not cause
peritonitis!!!
o In penetrating wounds, assess entrance and exit wounds for active bleeding or protruding
omentum or viscera
o Local wound exploration of a stab wound in a hemodynamically stable patient may be
considered
Assessment of hemodynamic status
o <50% patients with significant hemoperitoneum have significant findings on PE on
presentation
o Young healthy patients more likely to have normal vitals until late
o Patients with signs of hemorrhagic shock respind to IV fluid resuscitation in htree ways:
 Normalisation and stabilisation
 Transient normalisation s/o ongoing bleeding → need for early intervention
 No response → s/o major intra-abdominal arterial injury or severe solid organ injury
→ immediate surgical control of hemorrhage needed to prevent death
Evaluation of hemodynamically stable blunt abdominal trauma
o FAST scan – negative – observation
o FAST scan positive – positive – abdominal scan
o Significant mechanism with positive signs – abdominal CT scan irrespective of FAST results
o Where FAST scan or CT scan not immediately available – DPL may be considered
o FAST scan has a sensitivity of 78% and specificity of 99% in detection of intra-abdominal
hemorrhage
Evaluation of penetrating abdominal trauma
o After ABC control very important to completely Expose the patient
o Evaluate and identify all wounds
o Patients with signs of peritonitis or hemodynamic instability → urgent laparotomy
o For wounds deeper than skin and subcutaneous tissue → further evaluation with abdominal
CT if hemodynamically stable
o For GSW, operative management is generally indicated unless CT scan reveals isolated
controlled hepatic injury
Evaluation of specific injuries
o Splenic injury
 History – blunt >penetrating, LUQ pain or left shoulder tip pain (Kehr’s sign), left
lower rib injury
 Examination – hypovolemia, LUQ tenderness, physical examination not sensitive or
specific
 Investigation – FAST scan, CT scan, FBC, DPL
o Hepatic injury
 History – blunt or penetrating, RUQ pain, right lower rib fractures
 Examination – hypovolemia, RUQ tenderness or abdominal fullness, PE unreliable
 Investigations – FAST, CT abdomen with contrast, FBC, DPL
o Renal injury
 History – blunt or penetrating flank injury, rapid deceleration, gross hematuria,
abdominal pain and flank pain
 Examination – penetrating injury, contusion to flanks, 11th/12th rib fractures, gross
hematuria, costovertebral angle tenderness
 Investigations – CT scan abdomen and pelvis with IV contrast and delayed imaging
through kidney and bladder, UA
o Small bowel injury
 History – penetrating trauma >blunt trauma, peritonitis, potentially missed early
 Examination – mild peritonitis early but firm later, penetrating injury more obvious
and early signs
 Investigations – erect CXR, AXR – free air, CT abdomen – free air, bowel wall
thickening, mesenteric stranding, DPL
Extremity trauma
Lower extremity trauma
Concepts
 Large volume of musculoskeletal tissue in the lower extremity, including the pelvis, increases the
potential systemic effects of lower extremity injuries
 Bleeding from lower extremity trauma can contribute to systemic hypotension
 Several units of blood can be lost into severely injured thighs
 Pre-operative blood loss associated with single femur fracture is up to 1500-2000mls
 Crushing wound of lower extremity releases intravasated debris, myoglobin, related muscle
breakdown products and various inflammatory mediators → fat embolism, ARDS, ARF and multiple
organ failure
 Life threatening infections such as clostridial myonecrosis and necrotizing fasciitis can develop rapidly
 Prompt surgical treatment for severe extremity injuries benefit patients
 Early fracture stabilisation reduces systemic effects of fractures including SIRS, sepsis, MOF and ARDS
 Early stabilisation reduces pain, need for analgesia, promotes mobilisation of patient with its benefits
 Damage control procedures should be considered in patients with shock, coagulopathy, hypothermia
or TBI
 Damage control orthopaedic(DCO) surgery emphasizes on rapid provisional skeletal stabilization with
simple external fixators with delayed fixation when patient stable
 Advantages of DCO surgery
o Time saving
o Helps attenuate systemic trauma load due to reduced secondary injuries to brain and
pulmonary endothelium
o Allows unrestricted positioning in ICU for management of other injuries, prevent pressure
sores
o Definitive treatment between days 5-10 after trauma when SIRS response minimal
Limb salvage versus amputation
Mangled Extremity Severity Score (MESS) (A+B+C+D)
Criteria Points Description
A Skeletal/ soft tissue injury
1
Low energy – stab wound, low velocity GSW, simple fracture
2
Medium energy (open fractures, multiple fractures, fracture dislocations)
3
High energy (high speed MVA, GSW)
4
Very high energy (above with gross contamination)
B Ischemia
1
Pulse reduced or present, normal perfusion/capillary refill
2
Pulseless, paraesthesia, ↓cap refill
3
Cool, paralyzed, insensate, numb
C Shock
0
Normotension
1
Transient hypotension <90mmhg
2
Persistent hypotension <90mmhg
D Age
0
<30 years
1
30-50 years
2
>50 years
Ischemic score doubles if assessment after 6hours of injury
MESS score > 7 associated high risk for amputation
Open fractures
 All open fractures require urgent surgical treatment → reduced risk of infections, soft tissue damage
and ongoing bleeding

In ED, wound covered with sterile dressing with pressure if necessary to control bleeding + limb
splinting
 Tetanus prophylaxis and systemic antibiotics – 1st generation cephalosporin
 For contaminated wounds – aminoglycoside may be added or 3rd generation cephalosporin used
 Operative care planned early and debridement if possible done with 6 hours
Important early recognition of extremity injuries
 Dislocations of hip, knee or more distal joints may cause pressure on nerves, vessels or skin resulting
in permanent deficits
 Delay in relocation of dislocated hip within few hours significantly increases risk for avascular necrosis
 Isolated displaced fractures of femoral neck in young patient may be considered as ischemic surgical
emergency due to risk of avascular necrosis with delay
 Classic injury combinations
o Patellar fracture in MVA patient due to dashboard injury → femur dislocation → posterior
wall acetabular fracture → fracture of femoral head
o Femoral shaft fractures have strong association with pelvic fractures needing close
evaluation of pelvic radiographs or even CT
o Fall from height → bilateral calcaneal fractures → injuries to thoracolumbar spine
o Floating knees (simultaneous ipsilateral femoral and tibial fractures) → high incidence of
pelvic and other trauma + associated soft tissue injury at knee joint
o Isolated fibular fractures may be associated with traction injuries of peroneal nerve or with
ligamentous disruptions of the knee or ankle
Management of common fractures and dislocations of the lower extremity
Pelvic and acetabular fractures
 Injuries of the pelvic ring, especially those that are mechanically unstable, may have associated lifethreatening hemorrhage, the source of which is usually low-pressure bleeding from pelvic veins or
intraosseous blood vessels.
 Large clinical studies found that in less than 10% of patients with significant pelvic hemorrhage was
the source an arterial bleeding, and only about 2% of the patients could be successfully be embolized.
 This strongly suggests that most bleeding caused by pelvic fractures should first be addressed by
promoting tamponade of the retroperitoneal hemorrhage, by splinting significant pelvic instability,
and by reducing any pathologically increased pelvic volume.
 A pelvic wrap or binder, pelvic external fixation, and pelvic internal fixation can be used for the
mechanical stabilization component of resuscitation.
 Stabilization surgery of the posterior pelvis is indicated for displacement or significant posterior
instability. Definitive posterior fixation may often be deferred until 5-10 days after injury
 Anterior fixation alone typically provides enough initial stability to aid control of hemorrhage
Acetabular fractures
 Fractures of the acetabulum are articular injuries with profound implications for the long-term
function of the hip joint. Successful open reduction and internal fixation (ORIF) of displaced
acetabular fractures significantly improves the prognosis of these potentially devastating injuries and
permits early mobilization of a patient who might previously have been managed with many weeks of
skeletal traction and bed rest
 Acetabular fractures are usually closed injuries, without need for immediate operation. If surgery is
delayed for three to five days, operative bleeding is reduced, and preoperative planning may be
improved. Patients with pelvic and acetabular fractures have a significant risk of thromboembolic
disorders.
Dislocation of hip
 Posterior dislocation 95% Anterior dislocation 5%
 Hip flexed, adducted, internally rotated and resistant to motion
 Posterior acetabular fracture likely with associated sciatic nerve damage to be checked
 Dislocations of the hip are painful dramatic injuries that demand immediate reduction.
 A rapid reduction (under six to eight hours, if at all possible) is crucial to minimize the risk of avascular
necrosis of the femoral head.
 Post reduction CT of the pelvis and hips should be done to rule out other occult injuries
Femoral neck fractures
 Discussed in orthopaedic section
Trochanteric fractures
 When part of trauma scenario, operated when feasible
Sub-trochanteric fractures
 Usually occurs in high energy injuries
 Early immobilization with fixative devices may be considered
Femoral shaft fractures
 Represent severe injuries due to high energy trauma associated with significant blood loss of 15002000mls
 Isolated femoral shaft fracture alone can cause traumatic-hemorrhagic shock
 Most patients will significant other associated injuries from trauma due to mechanism
 So every femoral shaft fracture must be treated as highly critical, potentially lethal injury pattern
 Early fixation is essential to prevent complications such as fat embolism, acute lung injury and ARDS
 Concept of closed reduction and fixation with a reamed interlocked intramedullary nail represents the
"gold standard" for the treatment of femoral shaft fractures
 Severely injured polytrauma patients (ISS > 17) as well as patients with a concomitant chest trauma
(AIS for chest wall or lung injury > 2 pt) or significant head injury (GCS ≤ 13) should be treated by the
damage control orthopedics (DCO) procedure
Fractures of patella
 Nonoperative treatment is recommended for undisplaced fractures with a clinically intact extensor
mechanism, i.e., in those cases where the patient can raise the fully extended leg against gravity.
 In contrast, a surgical treatment by ORIF is indicated in all cases with a compromised extensor
mechanism as well as in displaced fractures with an incongruity of the articular surface.
Knee dislocations
 Knee dislocations may involve either the patello-femoral or the tibio-femoral joints.
 True tibiofemoral dislocations are much less common and generally require significant injury forces,
although occasionally they are caused by a simple slip and fall.
 They are important to recognize because of extensive ligamentous disruption and risk of associated
neurovascular injuries.
 Potential for limb loss due to a missed blunt injury to the popliteal artery must be kept in mind.
 Complete knee dislocations usually produce obvious deformity and difficulty moving the involved
joint, as well as a radiographically evident dislocation, usually anteriorly or posteriorly, but sometimes
medially or with rotation to any quadrant.
 Instability of the knee should always be considered when a patient presents with evidence of acute
distal neurovascular compromise. A knee dislocation should be reduced as soon as possible after
recognition. This can usually be done by traction and gentle manipulation in the ED.
 Popliteal artery injury described in 14-34% cases of all traumatic knee dislocations.
 Intimal tears with initial normal examination with subsequent delayed thrombosis can occur
 Due to the often asymptomatic nature of blunt popliteal injuries, the amputation rate for blunt
vascular trauma is about three times higher than after penetrating injuries and lies in the range of
15% to 20%.
 The five clinical "hard signs" for an arterial injury, which are present in about two-thirds of all cases,
include:
o Active or pulsatile hemorrhage
o Presence of a pulsatile or expanding hematoma
o Diminished or absent peripheral pulses
o Bruit or thrill over the popliteal fossa, implying an AV-fistula
o Clinical signs of limb ischemia
 In cases of a suspected arterial injury, either an (on table) arteriography or a surgical exploration are
mandatory, since observation alone will have detrimental consequences for the patient.
 Injuries to the peroneal or tibial nerve, with motor and/or sensory impairment, may be associated
with an arterial occlusion. Such neurologic lesions also interfere with recognition of ischemic pain due
to arterial occlusion or an acute compartment syndrome.
 A popliteal artery injury associated with dislocation of the knee is repaired in the operating room with
both vascular and orthopedic surgeons present.
Tibial fractures
 Fractures of the tibial shaft range from low-energy, indirect torsional injuries that do well with
nonoperative treatment, to severe high-energy fractures with severe soft tissue damage and a high
incidence of acute compartment syndrome.
 Compartment syndromes develop frequently in tibial shaft fractures due to direct compression forces.
They are especially common if the soft tissues have been crushed or if a period of ischemia has
occurred.
 Clinical features of compartment syndrome
o Leg and ankle pain out of proportion to physical signs usually initial sign
o Pain exacerbated by passive motion of ankle and toes
o Indurated swelling of calf and occasionally foot
o Hypesthesia of foot and reduced motor strength due to ischemia of muscles and nerves –
late signs
o Skin perfusion and capillary refill remain intact until late
o Clinical diagnosis, intra-compartmental pressures used in obtunded or comatose patients or
unclear cases
 Treatment for an acute calf compartment syndrome is immediate decompression by fourcompartment fasciotomy with medial and lateral incisions
 Timing and treatment modalities for tibial shaft fractures are dependent on the severity of injury and
associated problems.
 Limb-threatening complications such as open fractures, vascular injuries, and a compartment
syndrome require immediate surgery.
 In absence of such complications, a provisional closed reduction and application of a long leg cast
provide initial immobilization.
 In tibial shaft fractures of minor severity and dislocation, closed treatment is the method of choice.
Ankle injuries
 Ankle injuries represent the most frequent musculoskeletal injuries
 Since it is difficult to differentiate a simple sprain from a fracture in the acute phase, due to
nonspecific symptoms such as pain, tenderness, and swelling, a precise diagnosis usually requires
adequate radiographs
 Disruption of ankle mortise requires surgical intervention
Foot injuries
 Injuries to the foot typically result from a direct blow or crushing force
 Extreme dorsiflexion or plantar flexion, pronation or supination can also produce significant bony and
joint injuries
 Disability from foot injuries have more severe long term functional effects than long bone injuires
 Swollen tender or painful foot following trauma should be assumed to be fractured or dislocated until
proven otherwise
 Non-operative treatment of calcaneal and cuboidal injuries have good outcome if articular surfaces
are anatomically restored
 Operative treatment is usually delayed until soft tissue swelling is completely resolved due to high risk
of severe soft tissue complications associated with acute surgery.
Isolated lower extremity injuries can be devastating with potential loss of life and limb or appear to be
relatively benign. Unfortunately, nondramatic injuries such as foot fractures can have lifetime consequences
and prevent a patient from returning to their work and life activities. Therefore, each injury should be carefully
evaluated, thoughtfully treated and followed long term to insure the best possible physical and psychological
result.
Burns
MIST:
 Points to be considered
o Mechanism of burn – inhalation, explosion, toxic gases, radiation, terrorist activity, chemical
burns, flame, contact, friction, reverse thermal etc.
o Situation – closed confined spaces
o Time since injury
o Fluid management already occurred
o First aid given and adequacy of same
 Primary survey
o Airway
 Neck/facial/head burns and swelling
 Burn in confined space
 Hoarse voice/stridor/cough/carbonaceous sputum
 C-spine – need for immobilisation to be considered
o Breathing
 RR, air entry, O2 sats
 Respiratory effort
 Circumferential burn around chest/torso/neck
o Circulation
 HR, BP
 Central capillary refill
 Any circumferential burns
 Peripheral capillary refill
o Disability
 AVPU
 Pupils
o Exposure/environment
 Temperature
 Remove clothing and jewellery early
 Assess injury and keep unburnt areas warm
 Warm IV fluids and warm blankets
 Assess TBSA burnt with rule of nines
o Assess limits prior commencing secondary survey
 L-lines – IVC/ETT/NGT/ETCO2/vitals
 I-Investigations – CXR/ABG/BSL
 M-monitoring – closely monitor output, BP, temperature and airway status if not
intubated
 I-Intravenous therapy – initiate therapy with Hartmann solution while calculating
need
 T-teams – early referral to burns centre, plastic surgery/orthopedic surgery consult
early if need for escharotomy
 S-Assess adequacy of ABCD prior to initiating secondary survey
 Secondary survey
o Assess TBSA burnt if not yet done
o Head to toe examination for associated skeletal and systemic injuries
 Especially cases of blast injury rule out secondary and tertiary injury from blast
waves

Assess for risk of carbon monoxide intoxication and cyanide toxicity in specific
circumstance
 Neurological examination in case of electrical and traumatic injuries
 In case of electrical injuries, look for other system injuries e.g. cardiac arrhythmias,
compartment syndromes, joint dislocations
 Assessing body surface area burnt - Rule of nines






The “rule of Nines” divides the body surface into areas of 9% or multiple of 9%, with the exception
that the perineum is estimated at 1%.
Allows estimation of extent of burn with reproducible accuracy
Children have different BSA proportions: use pediatric “Rule of Nines” – adjust for age by taking 1%
BSA from the head and adding ½ % BSA to each leg for each year of life after 1 year until 10 years
Adult proportions are reached at 10 years of age
Additionally small burns may be estimated by using the palmar surface (fingers and palm) of the
patient’s hand which approximates to 1% of BSA
IGNORE SIMPLE ERYTHEMA
Stabilisation prior to transfer
 Cooling the burn wound
o Burn surface cooled with cold running water
o Ideal temperature - 15˚ range 8-25˚C
o Running water for at least 20 minutes
o Hypothermia to be prevented
o Application of cold water useful only in first three hours
o Only occur in adults with burns <10% BSA and children <5% BSA to prevent hypothermia
o Ice and iced water never used
o Cease cooling if temperature <35˚C
 Preventing hypothermia
o Remove wet packs and soaks
o Cover patient in clean sheet or plastic cling warp and warm blankets, space blankets or
patient warming blankets
o Check temperature regularly
 Respiratory care
o 100% oxygen to all patients except those with minor burns
o Give to any patient retrieved from a fire or in a closed space even if cutaneous burns are not
present
Criteria for intubation
1. Clinical evidence of possible airway compromise
a. Head and neck burns with increased swelling
b. Stridor, hoarse voice, swollen lips
c. Carbonaceous material around or in mouth, nose or sputum
d. Singed facial, head or nasal hairs
e. Intra-oral edema and erythema
2. Intubate early:
a. If patient unconscious
b. Head and neck burns with obvious swelling
c. Patient to be transported and above findings
d. Clinical symptoms and signs and ABG results indicative of respiratory
dysfunction
3. If in doubt, either consider intubation or consult early
 Circulatory care
o Two peripheral lines, preferably on unburnt skin
o 16G in adults and >22G in children
o IDC should be inserted in adults with >20% burns and children >15% burns
o For circumferential burns of limbs use elevation early
o Definitive circulatory management discussed later
 Gastrointestinal care
o Nil by mouth until consultation with appropriate burns unit
o NGT required for all patients >20% TBSA burns and all intubated patients
o Children >10% TBSA burns require NGT prior to transfer
 Pain management
o Early analgesia important
o Always given IV and morphine is drug of choice
o Adults maximum of 0.2mg/kg in titrated doses initially
o Pediatrics – 0.1mg/kg IV q15minutes until 0.3mg/kg
o Appropriate documentation important
 Wound management
o Management of the burn wound should not preclude resuscitation and emergency
management interventions
o Once patient stable, cling wrap application is recommended for transfer
o Paraffin application for facial burns, after airway secured
o SSD not used any longer and never used for facial burns
o Escharotomy if required done after consultation with burns/plastic surgeon
o Avoid application of tight bandages
o Patients with head and face burns nursed in head-up position
o Clinical photography may have a significant role in the future management of patient
and conducted according to protocols
 Tetanus prophylaxis
Immunisation status
Action
>10 years since last TT
<24 hours since burn – 250IU IM tetanus
Or
immunoglobulin
No h/o tetanus immunisation
>24 hours since burn – 500 IU IM TIG
Or
Give ADT/DPT/tetanus toxoid in opposite
Doubt about tetanus immunisation
arm
Person fully immunised but last booster >5years Give ADT or DPT or TT
Person fully immunised and last booster <5years No immunisation required
o Same dose TIG for adults and children
o For adults and children >8 years, ADT preferred over TT
o Children <8years DPT preferred over TT
o
Fluid resuscitation
o Necessary to maintain adequate circulatory blood volume and renal function
o Should be used for adults with >15% TBSA burns and children >10% TBSA burns
o Two stages of fluid management
 Modified Parkland formula to calculate fluid volumes required for resuscitation
and to generate adequate urine output
 Once urine flow established, hourly urine output measures to adjust fluid input
for the following hour
o Goal – desired urine output
 Adults – 0.5 to 1ml/kg/hr
 Children <30kg – 0.5 to 2ml/kg/hr
o Patients with delayed resuscitation, electrical conduction injury and inhalation injury
have higher fluid requirements
o Higher target of urine output – 1-2ml/kg/hr for patients with hematuria, Hemoglobinuria
or rhabdomyolysis
o To estimate fluid requirement:
 Extent of burns calculated by rule of nines
 Patient’s weight obtained
Modified Parkland formula
3-4ml Hartmann solution X body wt. in Kg X %TBSA burnt
 Calculation of fluid requirements from time of burn not presentation
 Half calculated volume given in first 8hrs post burn injury
 Remaining half in next 16hrs
 Take care to avoid hyponatremia
 Use 4mls in delayed resuscitation, electrical burns or inhalation injury
 Early review of urine output essential to evaluate adequacy of fluid
resuscitation and adjust fluids accordingly
o
Pediatric
 Due to limited physiological reserves and tendency to hypoglycaemia,
maintenance fluids should be added to the fluid calculated with the above
formula
 Children <30kg should have maintenance fluid in addition to calculated fluids
 Maintenance fluid: N/2 saline and 2.5% dextrose
Maintenance fluid calculations for children <30kg above Parkland calcualtion
Weight
Maintenance fluid requirement
<10 kg
100ml/kg/day
10-20kg
1000ml + 50ml/kg/day for each kg over 10kg
20-30kg
1500ml + 20ml/kg/day for each kg over 20kg
o Disposition
o Outcome of patients with burns has shown to dramatically improve in case of specialised
management in dedicated burns unit
o National guidelines dictate specific indications for admission and transfer to specialized burns units
o The referral criteria are:

Partial thickness burns in adults >10% TBSA

Full thickness burns in adults >5% TBSA

Partial/full thickness burns >5% TBSA children

Burns to face, hands, feet, genitalia, perineum and major joints

Chemical burns

Electrical burns including lightning injuries

Burns with concomitant trauma

Burns with associated inhalation injury

Circumferential burns to limbs or chest

Burns in patients with pre-existing medical conditions with risk of adverse outcome

Suspected NAI

Pregnancy with cutaneous burns

Burns at extremes of age
Not all of the above need transfer but specialist advise from local burn referral centre should be
sought for all the above
o Certain set of patients will require medical retrieval for transfer, these patients include
 Any intubated patients
 Inhalation injuries with cutaneous burns
 Head and neck burns
 Partial or full thickness burns >10% in children and >20% in adults
 Burns with significant co-morbidities
 Associated trauma
 Circumferential burn to limbs or chest
 Electrical conduction injury with cutaneous burns
 Chemical injury with cutaneous burns
o Referrals to plastics surgeons, ambulatory care nursing and appropriate clinics if being discharged
Blast injury
Explosions and explosive devices





Explosions are caused by a rapid chemical conversion of a solid or liquid into gas with resultant energy
release
Classified into either low order or high order explosives
High order explosives detonate quickly generate heat, loud noise and generate primary “blast wave”
(positive wave) causing shattering effect then a proceeding negative wave returning to the vaccum at
the point of detonation “negative wave”.
High-order explosives include TNT, C4, semtex, nitroglycerin, dynamite and ammonium nitrate fuel oil
Low-order explosives produce sub-sonic explosion without the over-pressurization wave. Examples
include pipe bombs, pure petroleum based bombs and Molotov cocktails
Mechanisms of injury
Category
Characteristics
Primary
High-order explosives, impact of
over-pressurization wave on body
surface
Secondary
High and low-order explosives – due
to flying debris, bomb fragments and
other projectiles
High-order explosives. Due to
individuals being thrown by blast
winds
Any explosion related injury, illness
or disease not due to primary,
secondary or tertiary mechanisms
Tertiary
Quaternary
Body part
affected
Gas filled organs:
lungs, abdomen,
ear
Any body part
Any body part
Any body part
Types of injuries
Blast lung injury, TM rupture
and middle ear damage,
abdominal hemorrhage and
perforation, concussion
Penetrating ballistic injury, blunt
injury, ocular penetration
Fracture and traumatic
amputation, closed and open
brain injury
Burns, crush injuries, closed and
open brain injury, asthma,
COPD, smoke inhalation or
respiratory illness due to fumes,
toxic smoke
Bombing characteristics and impact on hospitals
Bombing
characteristic
Implication
Blast site close to
hospital
↑number of
injured survivors
arrive outside of
EMS
↓EMS times
↑explosive
magnitude,
structural collapse
risk, ↑ immediate
fatalities close to
detonation
Blast energy
dissipated, ↑area
involved,
↓structural
collapse and
immediate fatalities
Blast energy
magnified, ↓ area
involved,
↑immediate
fatalities
Vehicle used a
delivery system
Open air setting
Confined space
setting
Numbers of injured
seeking care
Increased
Anticipated impact
Injury frequency
Injury severity
Increased primary
blast injuries,
traumatic
amputations and
minor injuries
Variable
Variable
Increased
Increased
secondary blast
injuries
Decreased – more
minor injuries
Decreased
Increased primary
blast injuries,
amputations and
burns
Markedly increased
Increased. 100s or
1000s
Increased


Blasts in enclosed spaces magnifies trauma injury scores X2 and mortality up to 5times higher
Terrorist activities are associated with much more severe injuries than accidental blasts due to
targeted attacks
General management
 Bombing results in multiple trauma victims arriving to the hospital in a short period of time
 Disaster protocols activated and surge capacity measures instituted
 Effective triage set-up crucial to success of disaster response
 Injuries associated with earl mortality in order are:
o Multiple trauma
o Head trauma
o Thoracic injury
o Abdominal injury
Trauma management of individual victim
MIST: information that may be of critical help
 Distance from explosion
 Whether open, closed or semi-confined space
 Type of blast and risk for tertiary injury e.g. structural collapse
Primary survey
 Airway
o Low threshold for intervention in case of risk of airway burns, facial trauma or airway
swelling
o Specific adaptations to airway control due to high risk of closed head injury and increased ICP
risk
o High risk for vertebral injury if mechanism involves displacement of subject – c-spine
immobilisation
 Breathing
o Watch for symptoms of primary blast lung injury
 Symptoms – chest pain, dyspnea, hemoptysis, hemodynamic instability
 Signs – cyanosis, tachypnea, rales, decreased breath sounds, subcutaneous crepitus
o High risk for pulmonary barotrauma – pneumothorax, pneumomediastinum
o All indications for early airway intervention and PPV
 Circulation
o Standard trauma protocol for resuscitation
o Assessment of burns and fluid requirements increased from burns fluid replacement
 Disability
o AVPU
o Signs and symptoms of CHI noted and risk of neurologic injury
o Record and document
 Exposure
o Undress fully and collect clothes for forensic procedures
o Watch for any penetrating injuries from projectiles
 Assess LIMITS
o LIMITS
o Lines – ETT/NGT/IVx2/IDC
o Investigations – bloods/ ABG/ ECG/ X-ray/ FAST
o Monitoring – O2/ ETCO2/ ECG/ NBP/ Neuro/ BSL/ Temp
o IV therapy – fluids/analgesia/ antibiotics/ blood
o Teams/transfer – inform cardiothoracic/vascular teams early
o Stabilize ABCDE before secondary survey
Secondary survey
 Thorough head to toe examination to diagnose, assess and initiate treatment for all primary,
secondary, tertiary and possible quaternary injuries
 Specific injuries associated with blast trauma





Pulmonary injuries
o Primary blast lung injury
 Blast lung
 Parenchymal lung injury – contusion
 Pulmonary barotrauma – pneumothorax, pneumomediastinum
 Pulmonary laceration
 ARDS
o Investigations – ABG, CXR, CT scan
o Ventilation strategies –
 judicious use of PPV and PEEP,
 pressures kept as low as possible to avoid further barotrauma and risk of air
embolism
 independent lung ventilation, use of nitric oxide and high-frequency jet ventilation
with PPV
 permissive hypercapnia if no evidence of CHI
 extracorporeal membrane oxygenation in severe cases
o high risk for development of air emboli – watch for new neurological deficits, definitive
treatment with hyperbaric therapy
Gastrointestinal injuries
o Primary blast injury involves gas-containing organs > solid organs
o Risk for immediate or delayed bowel perforation, hemoperitoneum, peritonitis and sepsis
o Watch for abdominal pain, nausea, vomiting, diarrhea, tenesmus, rectal and testicular pain
o Physical signs – absent or diminished bowel sounds, bright red bood PR, gurading, rebound
and unexplained hypovolemia
o Investigations – FAST / CT abdomen/ DPL
Neurologic injuries
o SAH and SDH common among fatalities
o Severe head injury is the chief cause of mortality in blast victims
o High risk for diffuse axonal injury due to blast waves
o Concussion or mild traumatic brain injury common
o Symptoms – headache, fatigue, poor concentration, lethargy, depression and insomnia
o Signs – retrograde amnesia, apathy and psychomotor agitation
o Management of severe head injury includes
 intubation and ventilation,
 maintenance of appropriate body temperature,
 judicious oxygen management,
 continuous arterial pressure monitoring,
 sedation, pain control,
 neuromuscular paralysis, and
 cervical spine control
 Arterial pressures should be maintained above 90 and cerebral pressures below 20.
 Additional treatment includes management of blood sugars, nutrition, seizures, and
prevention of thromboembolic events.
Auditory injuries
o Ear is the most sensitive to blast injuries and most often affected
o Most common finding is rupture of the TM
o A ruptured TM suggests other blast injuries may be present and should be carefully
evaluated for
o Hearing loss may be conductive due to TM rupture, ossicular damage or serous otitis or may
be sensorineural due to damage to cochlea
o Treatment is avoidance of additional injury and ENT follow up
Orthopedic injuries
o Any type of injury possible
o Points to remember
 Projectile fragments may not travel in straight lines
 Significant internal injuries may result from small entrance wounds



Intra-abdominal injury suspected in any patient with thigh, perineal or buttock
entrance wounds
 Any hematoma may indicate a vascular injury
 Compartment syndrome and rhabdomyolysis can be complications of crush injuries
o Liberal use of radiography indicated, whole body CT may be justified
o Tetanus prophylaxis and antibiotics for all individauls with open wounds
o Amputation may be required in emergency settings
Ocular injuries
o Mostly due to secondary blast injury
o Ocular surface is only 0.1% of TBSA but accounts for 2-16% of injuries in bombings
o High co-incidence of head injury in these patients
o Symptoms are eye pain, FB sensation, change in vision and periorbital swelling
o Chart visual acuity early and early referral for definitive management
Thermal injuries
o Quaternary injuries such as burns are due to local fires, victims burning clothing and
proximity to explosion
o High temperature from explosive gases can result in heat lung injury, toxic gas inhalation and
flash burns
o Management as for burns victims
Pediatric trauma
Pediatric trauma is the number one cause of death and permanent disability in this population.
Although the principles of trauma care are same for children as with adults, the differences in care required to
optimally treat injured child do require special knowledge, careful management and attention to the unique
physiology and psychology of the growing child or adolescent.
 In children over one year and under 14 years of age, motor vehicle crashes cause 46.5% of all pediatric
trauma deaths (2002).
 Drowning is the second cause followed by burns.
 A detailed view of mortality statistics reveals the home as an area of continuing concern.
 Other areas of concern include falls, bicycle-related injuries, and injuries associated with all-terrain
vehicle crashes.
Epidemiology concepts
 Childhood injuries most commonly occur as energy is transferred abruptly by rapid acceleration,
deceleration, or a combination of both.
 The body of a child is very elastic, and energy can be transferred creating internal injuries without
significant external signs.
 Due to the closer proximity of vital organs, children can have multiple injuries from a single exchange
of energy, more so than in older patients.
Initial assessment and resuscitation of injured child
Primary survey
 Airway and breathing management
o Children usually do not have pre-existing airway disease so room air saturation >90%
indicates effective gas exchange
o If oxygenation is difficult, then injury to lung or pneumothorax should be considered
o Hypoventilation occurs commonly with TBI or shock and intubation should be considered
early
o Children with airway issues in general have worse mortality rates than those who don’t
o Non-cuffed tube in children <8 years
o RSI most effective method of intubation
o Specific airway position for neonates, children to be borne in mind
Needle cricothyrotomy with jet insufflation preferred surgical airway until definitive
tracheostomy conducted
o NGT placement after intubation needed for gastric decompression and to improve lung
dynamics
o Pneumothoraces carry significant risk for pediatric patient due to mediastinal mobility and
should be decompressed early
 Circulation
o Reliable, quick vascular access essential
o
Age specific hypotension is an indication for major resuscitation of an injured child
Age
Weight range
Heart rate
Blood pressure
Respiratory rate
Infant (0-1)
0-10
<160
>60
<60
Toddler (1-3)
10-14
<150
>70
<40
Preschool (3-5)
14-18
<140
>75
<35
School age (6-12)
18-36
<120
>80
<30
o Specific circulation caveats
 Children may present with normal BP despite significant blood loss with significant
tachycardia
 Assess peripheral and central perfusion with heart rate
 Initial bolus of 20ml/kg of isotonic NS, second bolus same dose, if further fluid
needed consider type-specific PRBC or O –ve blood
 Over-resuscitation as much a problem as under-resuscitation
 Risk of cerebral edema with ↑crystalloid use
 Hypothermia extremely common in injured children→ catecholamine release,
shivering and increased O2 consumption with metabolic acidosis→ coagulopathy
 Maintenance of normal core temperature is goal for management with warm fluids.
Other specific issues to be considered in pediatric trauma include:
o Potential for NAI
o Effect of incident on family, staff and difficult interaction situations
1. Benefits of the Broselow Pediatric Resuscitation Measuring Tape for rapid determination of appropriate
tube size and medication dosages.
2. Children can maintain "normal," age-specific blood pressure despite significant blood loss.
3. Hypothermia can occur quickly in injured children and exacerbate the physiologic and metabolic
consequences of injury.
4. Children with significant CNS injury can have a "normal" initial head CT.
5. Unique anatomic features in infants that increase the risk of CNS injury.
6. Mobile mediastinum that creates physiologic havoc is acutely shifted.
7. Marked increase in significant intraabdominal injury when a child presents with a seat-belt bruise across the
lower abdomen.
8. The importance of physician interactions with family members and parent participation during the critical
care of injured children.
Geriatric trauma
As one of the fastest growing age groups of the population, the elderly will comprise an increasingly important
proportion of trauma victims.
Perhaps the most important issue is what exactly defines a geriatric trauma patient. Is it chronological age,
physiological age, the presence of preexisting conditions, or a combination of these factors?
Epidemiology
 Multiple studies have consistently shown elderly trauma patients have a higher level of injury related
mortality than younger trauma patients.
 Much of this increased risk of death is due to preexisting medical conditions (PEC) in the elderly
population and is greatest in patients with the least severe injuries, with a lesser effect on those with
moderate injuries.
 By the fourth decade the prevalence is estimated to be 17%, by the sixth decade 40%, and by age 75,
69% of the population has one or more chronic medical conditions.
 The prevalence of preexisting conditions increases with age and can be as high as 80% in those over
95.
 Preexisting conditions make it difficult for older patients to tolerate perturbations of their normal
physiologic parameters when confronted with the acute stress of trauma or major surgery.
 In most elderly trauma patients, "resting organ function often is preserved but the ability to augment
performance in response to stress is greatly compromised.
Age-Related Anatomic Changes
Central Nervous System
 Cortical brain atrophy
 Increased volume CSF
 Decreased epidural space
 Increased subdural space
Cardio-Vascular System
 Thickening of the heart valves and great vessels
 Loss of elasticity of the large vessels
 Development of fixed coronary lesions
 Decreased vital capacity
 Increased alveolar surface area
 Increased stiffness chest wall
 Decreased elastic lung recoil/increased closing volume
Renal System
 Decreased renal cell mass (cortical cell mass)
 Thickening of the basement membrane
 Decrease in total body water
 Glomerular sclerosis/Interstitial fibrosis
 Decreased number functional nephrons
Musculo-Skeletal System
 Decreased lean body mass
 Decreased muscle mass
 Increased proportion of adipose tissue
 Bone loss/decreased bone density
 Thickened intervertebral discs/shortening vertebral bodies
 Increased density subchondral cartilage
 Atrophy skin (all layers)
Gastrointestinal/Hepatobiliary System
 Decreased gastrointestinal blood flow
 Decreased hepatic volume (decreased cell mass)
 Atrophy gastric mucosa
 Decreased volume of thymus
 Fibrosis thyroid gland
Age-Related Physiologic Changes
Central nervous system
 Decreased efficiency of the BBB
 Alteration in autonomic system functions
 Alterations in neurotransmitters
 Decreased cerebral oxygen consumption
Cardio-vascular system
 Decreased inotropic and chronotropic response to beta adrenergic stimuli
 Increased peripheral vascular resistance
 Slowed ventricular filling/increased reliance on atrial contribution
Respiratory system
 Decreased chemoreceptor response to hypoxia/hypoxemia
 Decreased strength and endurance of respiratory muscles
 Decreased diffusion capacity
 Decreased cough reflex
Renal system
 Decreased response to vasopressin/ADH and aldosterone
 Decreased drug elimination
 Decreased thirst response
 Decreased hydroxylation of vitamin D
Musculo-skeletal system
 Decreased epithelial cell regeneration
Gastrointestinal/hepatobiliary system
 Decreased bicarbonate secretion
Immune system/metabolism
 Decreased cell mediated immunity
 Decreased antibody titers
 Loss effective mechanisms heat production/conservation/dissipation
 Blunting febrile response
Mechanisms of injury age >55% in order of frequency
 Falls
 MVC
 Pedestrians vs. car
 Assault and abuse
 Self-inflicted injury and suicide
Highlights in Management
 Patients greater than 55 years old should be considered for transport to a trauma center
 Geriatric trauma patients are more likely to present in shock than younger patients
 A trauma score < 15, a base deficit of -6 or worse, or the presence of shock (SBP< 90) have all been
associated with worse outcomes and may help identify patients who would benefit from aggressive
resuscitation
 Significant underlying physiologic abnormalities may be difficult to identify
 Older trauma patients do not respond to hypovolemia as do their younger counterparts
 Findings such as unexplained bruising or fractures or injuries with inconsistent mechanisms should
raise suspicion and prompt an evaluation for elder abuse
 Appropriate recognition and treatment requires a high index of suspicion to maintained at all times
 Early, aggressive resuscitation and invasive monitoring may be warranted in a large number of cases
 Heightened level of alertness may lead to better outcomes for geriatric trauma patients