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.----- BRIEF C O N T E N T S

1 Initial Assessment and Management 1


2 Airway and Ventilatory Management 25



3 Shock 55

4 Thoracic Trauma 85

5 Abdominal and Pelvic Trauma 111


6 Head Trauma 131


1 Spine and Spinal Cord Trauma 157


8 Musculoskeletal Trauma 187


9 Thermal lnjuries 211

10 Pediatric Trauma 225

11 Geriatric Trauma 247

12 Trauma in Women 259
13 Transfer to Definitive Care 269

A Injury Prevention 279
B Biomechanics of Injury 283

C Trauma Scores: Revised and Pediatric 289

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


Advanced Trauma Life Support

for Doctors




American College of Surgeons


Committee on Trauma

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

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


Copyright(<) 200R American College of Surgeons

n33 N. Saint Clair Street '

Chicago, lL 60611-3211

Previous editions copyrighted 19110, 1982, 1984, 1993, 1997, and 2004 by Lhe
American College t>f Surgeons.

Copyright enforceable internationally under the Bern Convention .md the Unif(Hm
Copyright Conven Lion. All rights reserved. This manual is protected by copyright.
t'\o part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any mean. clec.lmnit, mc<:hanic:al, photocopying, recording, or
otherwie. without wrillcn permission from the American College of Surgeons.

The American College of Surgeon:., its Committee on Trauma, and contributing

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

administration, .md contra indications. It i1> the responsibility of the licensed

practitioner Lobe informed in all aspects of patient care and determine the best
treatment for each individual patient. 'I he American College of Surgeons, its
Committee on lbuma, and contributing auLhors disclaim any liability, loss, or
damage incurred as a consequence, directly or indirectly, of the use and application
of any of the content of this 8'" edition of the ATLS Program.

Advanced Trauma l ife Support ;lnd the acronym ATLS are marks of the
American College of Surgeons.

Printed an the United States of America.

Ad1ranced Trauma Life Support Student Course Manual

Library of Congress Control Number: 2008905266
ISBJ\ 978 I 880696 3 I 6


The 8th Edition of ATLS is dedicated to Jrvene Hughes, RN. Ms. Hughes has
served as a guidi11g light for ATLS fr om its inception in Nebraska, to its adoption
by the American College of Surgeons, through seven editions published from her

desk over 25 years. Trvene's commitment to quality, devotion to the program, and
tireless efforts on behalf of the ATLS family were instrumental to the success of this
international treasure. We, as her ATLS family, wish to thank lrvene for setting
the example we attempt to follow.

. -
........ -


For more th<m a quarter century, the American College of Surgeons Committee on Trauma
has taught the ATLS course to over 1 million doctors in more than SO countries. ATLS has
become the foundation of care for injured patients by teaching a common language and a
common approach. The 8th edition was created using an international, multidisciplinary, and
evidence-based <lpproacb. The result is an ATLS program that is contemporary and mean

in gful in the global commlmity.

-Jo/111 Fildes, MD, FACS





Role of the American College of have participated in the revision process, and the KI'LS Sub
committee apprec iates their outstanding contributions. Na
Surgeons Committee on Trauma tional and internati on a l educators review the educational
materials to en sure that the course is conducted in a man
The American College of Sur geo ns (ACS) was founded to n er tha t facili tate s l earning. All of the course content is
improve the care of su rg ical pat ients and it has long been a
available in other resources, such as textbooks and j omnals.
leader in establishing and mai ntaining lhe high quality of However, theJ\TLS Course is a spec ific entity and the man

surgical practice in North America. ln accordance with that uals, slides, skill procedu res and other resources are used

role, the ACS Com mittee on Trauma (COT) has worked to for the e ntire course on ly and cannot be fragmented in lo
esta blish guideline s for the care of injured pati ents. sepmate, freestan ding l e ct ures or p ractical sessions. Mem
Accordingly, the COT sponsors and contributes to the bers of the ACS COT and the ACS Regional and
continued development of the Advanced Trauma Life Sup State/Provincial Committees, as well as t he ACS ATLS Pro
port (ATLS) Program for Doctors. The ATLS Student gram Office staff members, a re responsible for maintain
Course does not present new concepts in lhe field of trauma ing the high quality of the program. By i nt ro ducing this
care; rather, it teaches established treatment methods. A sys course and maintain ing its hi gh q ua li t y the COT h ope s to

tematic concise approach to the early care of trauma pa

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

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



SKILLS VIDEO terms to facilitate understanding by all students and teach

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

This edition features a new full-color design, along'A-'ith new

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

KEY QUESTIONS: These questions are aligned with the

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


These boxes hig hlight critical pitfalls to Subcommittee on Advanced Trauma

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

Christoph R. K:wfrnann, MD, MPH, FACS

The ACS Committee on Trauma is referred to as the ACS
ATLS Subcommittee, International Course D i rector
COT or the Committee, and the State/Provincial Chair(s) is A.>sociate Mcdiml f)ircctor
referred to as S/P Cha ir(s). Traumn crviccs. Legacy nucl [ lospital
The international nature of this edition of 1 he ATLS Porliand, Ore gon
Student Manual may ncccssil<tle changes in commonly used United States


Janteel Ali, MD, M.Med.Ed, FRCS, FACS Jolm H. McVicker, MD, FACS
Professor ofSurgery Neurosurgeon
University of Toronto Coloratlo Neurological
,. lnslitute, Swedish Medical Center
St. Michael's Hospital, Division of General Surgery/Trauma Engelwood, Colorado

"lbronto, Ontario United States
Cl1arles N. Mock, MD, PhD, MPH
Karen Brasel, MD, FACS
Professor of Surgery, !oim appointment, Pro fessor of
Associate Professor Trauma Surgery & Critical Care
Froedtcr1 Hospital & Medical College nf Wisconsin, Trauma
Department of Surgery, Harborview Medical Center, University
Surgery Division
of Washington
Milwaukee, Wisconsin
Seattle, Washington
United Stales
United States
David G. .Burris, MD, FACS
Professor & Clwirman Frederick Moore, MD, FACS

USl.JHS, Norman M Rich Dep art ment of Surgery Head, Division of Surgical Critical and r1cute Care Surgery
Be[hesda, Maryland Methodist Hospital
United States Houston, 'fex:as
United States
William G. Cioffi, MD, FACS
Steven N. Parks, MD, FACS
Rhode Island Hospital, Department of Surgery Professor ofClinice!l Swgery
Professor and Chairman Unjversit y of California, San Francisco, Department of Surgery,
The Warren Alpert Medical Schnol of Brown University, Community Regional Medical Center
Department of Surgery Fresno, California
Providence, Rhode Island United States
United States

Artbu.r Cooper, MD, MS, FACS, FAAP, FCCM Renato Sergio Poggetti, MD, FACS
Professor ofSurgery Director orEmergency Surgjcal Service

Columbia University Medical Center Hospita.l das Clinicas Un iversidad de Sao Paulo
Affiliation at Harlem Hospital Brazil
New York, New York
United States Thomas M. Scalca, MD, FACS
Physician jn Chief
Michael Hollands, M B BS, FRACS, PAC$ R Adarns Cowley Shock Trauma Center
J-Je:.1d of Hepato!Jjfiary and Gastro-oesophage<ll Surgery Pmncis X Kelly Professor of Trauma Surgeq, Director Program
Westmcad Hospital in 7iauma
Sydney, New South Wales University of Maryland School of Medicine
Australia Baltimore, Maryland
United States
Claus Falck Larsen, MD,, MPA, FACS
Medical Director
R. Stephen Smith MD, RDMS, PACS
The Abdominal Centre, University of Copenhagen, Rigshopit;,lel
Vice Ch<lir and Director of Surgkcal Education
Department of Surgery, The Virginia 1ech- Carillon Medical
Roru1okc, Virginia
United St<Jtes
West livaudais, )r, MD, FACS
Thoracic Surgeon
Southwest Wound Healing Center, Southwest Wahington Richard Bell, MD, PACS (CON)
Medical Center Pro(essor and Chairman, Department ofSurgery
Vancouver, 'vVashington Universill' of South Carolina
United States Columbia, South Carolina
United States
Fred A. Luchette, MD, FACS
Director, Division of Trauma, Critical Care, and Bums Brent E. Krantz, MD, FACS (CON)
Department of Surgery, Stritch School o[Medicine, Loyola Professor orSurgery
University of Chicago University of South Carolim
Maywood, lllinois Columbia, South Carolina
United States United States


Associate Members to the Mary van Wijngaarden-Stephens, MD, FACS

Associate Clinical Professor Department ofSurgery!Dilision
Subcommittee on Advanced Trauma Critical Care

life Support of the American College_ Trauma Director

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

Associate CliJJic<tf Professor ofSurgery

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

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

H artford, Connecticut
United States

Sharon M. Henry, MD, FACS

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

Spartanburg, South Carol ina

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



CONTRIBUTORS Ber ge n Ma ;J.S tri cht

1\orway The 'letherlands
During development of this revision, we re Karim Brohi, MD
Margareta Behrhohm Fallsherg, PhD BSc ,

ceived a great deal of assistance froti1 many Constlil<wt Omsulrnnt in Ttauma, v.scular and Critical
individuals - wh eth er reviewing infonna Co ns ul t ing firm/ small business Cttre Surgery
tion at meetings, submitting images, or eval Linkoping l'be Royal London Hospital
uating research. ATLS" thanks r.he follow ing Sweden London
contributors for their t ime and effort in the United Kingdom
Rcnato Bcssa de Mclo, MD
development of the 8th edition: Assiscmte /-lospicalar Laura Bruna, RN

Melissa V. Abad Scrvi<;o de Cirurgia Geral, llospital dt! S.}oao ltalilltl Nationa] Coordinawr

Regional Program Coordinator, CM Porto Assit ra um a

Coonlin,Jtur (ur Tr.Hifflil Programs Portuga l Torino

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

Office: Erwrgeucy Plrysicillll Jacqueln

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

Bim1ingham Regional EM$ CJinicaJ L ecrmer. Univers ity of Calgary Netherlands

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

Critical Care, Coordinator- ATLS Prvgram M a ri anne Hrandt Buenos Aires British Hospital, Department of
McMaster University Medical Centre Special Educmion /eacher Surger y

H am il ton On tario Diabetes F.ducator Buenos Aires

Canad11 Caracas, Mtrando Argentino

!Jeri Aminuddin, MD June Sau-rllmg Chan
Neurosurg<'On Fred Brenneman, MD, P RCSC FACS , SkiUs Development Center, University of I long
Gatot Soebroto Central Amty Hospital Chid; Trauma Program Kong Medica l Ce nt re
Jakarta Timur, Ja karta Sunnybrook Health Sciences Cent er Queen Mary Hospi tal Department of Surgery

Indonesia AssucitJte Professor !long Kong

Depar tmen t of Surgery, University of Toronto Chi na
John A. And r oulnkis, MD, FACS
lf.mcrillL Professor p(Surgery
'Jbronto, Ontario
Will C ha plea u, EMT-1', RN, TNS
Canad a
wniversity Hospital of Patras ATI.S Program Mamrgcr
Patra > Ase Brinchmann-Hansen, PhD American College of Surgeons ATLS Program Office
Greece ;\!/:waging Educational Consulmnt C hi cago T llinois

Guillermo A rana , MD, PACS The Norwegian Medical Association, United States
General Surgeon Ilepartment of Professional Affairs
Zafarullah Chaudhry, MD, FRCS, FCPS, FACS
1\a tion a l Hos pital o,lo
Professor of Surgl.'l")
Panama Cit)' Norway
National HospiraJ and Medical C enter
Pa nama Peter Brink, MD, PhD President
Ivar Austlid Chic(, Department of Tt"lwnm tology College of Physicians and Sur geons Pakistan
])epamnent of Anaethesia and Intensive Care UnivC'rsity Hospital Maastricht, Department of Labore
Ha ukcland Unive rs ity Ho spital Traumatology Pakis tan


Peggy Chehardy, EdD, CH F.S Rantlolph, 1\"ew Jersey Jorge Esteban Foinnini, MD, FACS
Ai.\t;lllf Professor and Oirtctor of Surgical United States (,enerul Surgeon
Ptlucatiun nirtror
Anne-Michele D rom:
Tulane Univerit)' School of \kdidne, l'oianini Clink
A1LS Na tional Coorduwtor.
D ep artment of Surg ery 'ianta Cruz
1\"cw Orleans, Louisiana
S" i" Society o f Surge on, .

United State.s
Swillerland Knut Fredr iksen , MD, PhD
Robert A. Cherry, MD, FACS Cnmultant & Assoti.ltc: i'role.\oor
Herman us Jacobu:. Christoffel Du P le ssi s M B, .

Tr,wnw Program Medio1l mrcc:tor Dep.ITlment of Erncrgcnq Mcdic,1l Serv ices,

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

llopital uf Crele University of Preloriu Danih Trauma Society

l lcraklion, Crete Pretoria Cnp.m h agen
<.reece South Africa Denmark

Chin Hung Chung, MB BS, FACS Lesley Dunstall Christine Gaarder, MU

ChrdofService FMSTIATLS NaticmJI Coordiuotur, Austr.rli<l HeJd ofTraumJ Unit, (;<'llt'rJi ,md G/ \Urg<'CJil
Department of Accident & Emergency North .
Royal Austr alas i an College of S urge o ns l!mcrgency Divisiou, Ullcvaal Uni versity
l>btricl llosp i tal North Adelaide, South Austr.1lia llospital
llnng Kong AulraJia o,Jn
Chin.r Norway
Candida Duriio

Francisco Coller e Silva, MD, flAGS, PhD (mcd) A'tl.S National Coordio.rtor. Ponug.1/ Subnsh Gaut am, MD, M HBil, FRCS, FACS
Mt'Cfic.ll /)fx.-tor Pmt uguese Society of Su r geon 'Ienior Cansult.Jnt anti Ht.Jtl ofDepartment of

Emergency Surgical Ser\icc>, Ho>pital das Lhbon Surger.r

C li nica of the Uni,crsity of Paulo Portugal haj.1irah HospitJI

Sao Paulo lujairah
Ruth D yson, BA(hons)
Gr.1711 United Arah Emirates
A'/'L'i Co-ordinJtor
The Hoyt I College of Su rgc ons of Engl;md Aggclos Geranios, MD
Jaime Cortes, MD
l.tmdon C:t:m:ral Surgeon, lntctl.,ivi\t
Chid; General SurgerJ
"iatl t>nJI Children's IJ n spi t ll
Unite d Kin gdo m Sur. Clinic of li vad e i<t Ru r.tJ Hospital

Prnli-ssor Athen>
David Eduardo Eskena7i, MD, FAC'.S
Univer:.ity of Costa Rlc.1 ('httt; General and ThorJcic .urgerr
San loc lltJJ. A. Oiiativia Michael Gerazou.nis, M0
CoMa Rica
T3Lrcno> Aires (;rcece
Scott D'Amours MC.CM. FRCS(C), FRACS

Javier Gonzalez-Urinrlc, MD, PhD, EBSQ,

Ji/) ComultJnt Vagn Norgaard Eskcscn MD ,
Royal Adelaide Hospital
A.,sodJte Profe.or Gcncml Surgeon
U niversity Uinic or l\'curosurgery, Nati ona l llopital de Cruces, Bi lbao, l.iver Transplant
Au>tralia Hospital - Copenhagen Uniwity Hospital I;nit
t ra Lee Demmons, RN, MBA Bilbao
I JcnmJrk
t\l,uwgN Sp<tin
Critical Care Transport, Umvt'rsil}' llospital Denis Evoy MCH, r:nCSI
John Greenwood
nirminghum, Alabama C:nnsultnnt Gemn1l Surgt'<lll (Breast Endocrim)
United States Si Vinccmts Pr iv ate l(o,pi t,ll, Con>ultants Cli n ic
Bur ns U ni te Roya l Adel.1ide IJosp itaJ

Il ublin
A lejandr o De Gracia , MD, MCS, MAAC Adelaide, South Australia
('hid. Gener,1/ Surgery Australta
Agudo' P.trmemo Pu'lcm (,cncral Hospital l'roilan A. Fernandc1 MD
Bueno Alre Jl<lttltGll Director Enwrg,nq .Service
Rusell L. Gruen MBB!>, PhD, FRACS

Argent i n a 1\,,wdatt Prolessor

llmpital del Trab<jador
University of Melbourne
Mauricio Di Silvio Lopez, MD, FACS '1hwmu Surgt'Oil
Cll ile
ClinicJi Rcsidency and Rcstatdl Ptvp.ram Director l'llc Ro)al Melbourne 11\)Spitul
20 de Novicmbre National .McdicJI Ce nt er, Cornelia Rita Maria Gctruda Fluit, MD, Melbourne
ISSSTF MEdSd Au,tralm
Mcxrco City. Districto Federal Smior Consultant in FduGJtion
Niels Gudmundsen-Vetrc
\-lexreo University Medical Centre N i)megen, Quality
Frank Doto, M S .1nd Development of Medical Educa tion
D.tnish Armed Force' llc,tllh Service
Pmlessor ofI Jealth Educlllion
Coun ty Coll e g e of Morris
rhe Nether lands



Jeffrey S. <, MD, MSc, I'ACS Peggy Knudson, MD, i"ACS Hong Kong
Die tor Rcgiorwl Hum C
r c , cmer Professor ot'Surycr,v China
A-.ociatc Profe,.or of Surgery Univcrity of California, 'ian Franc1sco General
Helen Livanios, RN
v,1ntlerbih University t-lo)pit.Jl, Dep.mment uf Surgery
IC Unit Staff' Nurse
Nashville, I'N San l'rdncio. California
Meditcrrano llospital
United t.nes UmteJ States
Enrique /\. Gu1.n1nn Cottallnt, MD. FACS Amy Koestner, RN, MSN Greece
i"-1''-urourgc.n fr wm l Progmm ManJger
. .
Chong )eh Lo, MD, fACS
I>iphmlill in PubliC Healc!J 1\orgcss Mcdk.1l Center Assoc i:llc Prvko.\Or ofSurgery
I>ir,ctor. Neuro.wrgtry Service> KalamMOO, Michigon Nntion.1l Chen Kung Universit) Medical
(,uayaquil Hospual Unjted Swo Center
Ftuador Radko Komadim1 , MD, flhD
CenerJI Surgecm, Profe"1" ofSurgc:n; llt'.ld of
Arthur l l ieh, MA, NREMT-P /Jep.ll'lmen! (ar Medic.!l lesmrch Nur Roehmat Luhis, MD
s,,,, Fr.n.:i.:o PMJmeJic Association Gencr.ll .md "fi:<Khing llospital Cclje St.Jff/Jtpartnwnt olSurgery
SJn l'ranlisco, Colifumia Celjc
M. Hocsin Gcncral llospual, Medical Faculty
United States Slovenia Sriwijnya Univcrsiry
Richard llenn, RN, BSN, M.ED Palemhang, South Sum.ura
Digna R. Kool, MD
[)irectnr. fduc.llion [)ep.ll'l men/ Indonesia
. st, /:nH.'I'gCilq /I,JJiology
Northern Arizon.1 1Teallhare
Department ol Rauiology. RadhouJ Univcrsirv J.S.K. J.uits. MD
rlagtafT. Arizona Trawn.JSurgron
"''ijmcgcn Mcdk;u Cntre
United States Medic11l Director b'nH:rgcncy lkp;lrtmcnt
Walter Hcnny, MD The Netherland" Traum1 . Counlinator
Furmerly of Er.1smus Medical Center Academic McJical Center
Rom(1JI Kosir, MD Av Tilburg
Assiswu of Surytry Nethnland.\
Univcr!>ity Chn"al Center Manbur, Department
Grace l lcrrera-llcrnandel of I\'amatology Jaime Manzano, MD, flACS
tiT! C,)()rdin.uor Maribor c,na.ll Surg<on
College nf Phyidan:. and 'ourgeon of Co:.t,t Rica Slovcni.t Hopital Mctmpolitano
SJn jo:.e Quito
)on R. Krohmcr, MD, IACEP Ecuotlnr
Costa Rit.t
f)eputy As;, Secrt't,Jrv or
f Health AfT'air..
Jlcrgal llickey, FRCS, FRCS Ed.(A&E), DA( UK), Patrizio Mao, MD, FACS
Deputv Chid Medic.1f 011icer
I'Cf.M Rtsp<>nsabik UrgcnLe Chirurgithe
Department nf Homcl.1nd Secunt)
Consu/c.wr in emergency Medicine Chirurgia Gcncrale Univcrsitana, A.S.O. San
Washintttoo, DC
Emergency Dep.1rtmen1. Sligo General Hospital Luigi Uonz"!(a eli Orhassano
United States
Sligo Torino
Ireland Ada Lui Yin Kwok Italy
Skills llcvelopmcnt l.cntcr. Univcr>ity of I long
Emily Martem
Scott Holmes Kung M>dical Centre
Duke Umvcrsity Lifefiight
Rcgion.JI Pwgr.1m CoordinJCOr, Surgital Skills
Queen Mary l lospiwl, Department of Surgery
Progmm Coordimllor
Durham, Korth C.m>lin.l Hong Kong
American College nf Surgeom ATLS Program
L'nitcd St.llcs China
Joe Marla }over Navalon, MD, FACS LAM 'luk-Ching, BN. Mll1\1 Chic.1go, IUiwis
Chiefof Hepatopancre<lll<' and Uili.1ry Surgc:r> Admnccd Pra<'lice Nurst' United State'
Htl<pit,tl llnivcrttrio de l
oclfc, Department Queen Mary Hospital Salvijus Mihtius, MD
of General !>urgery Ilong Kong Ch1dof P
Soldier> 11t".1/th G'.Jre C<nter in
Lc:tafe Chin; KJuna;
Military Scnices, Lithuanian Armed
Maria L'tmpi, BSc, RN
Aage W. Karlsen Fore
Narim1.1/ AT/..'i Coordin.110r
ATl.S (
oordin,,rnr Kaunas
Centre ll>r Teaching & Research i 11 Disaster
Norwt>gi.m Air Ambulance Lithuania
Medicine and Traumatology, University Hospit.ll
Drobak Linkopmg Soledad MontOI\1 MD
Norw.ty Sweden Geueml Surgeon
Darren Kilroy, FRCSEd, FCEM, M.Ed Department uf General Surgery, Hospital
LEO Picn Ming MBBS, MRCS (Edin),
Comult.JIJI in m<'rgt'IK,V ,'v(edidnt> Ga roa Orcuyen
Stockport NH Foundauon TruM Estdla
Changi General l lospit.ll, L.cneral
Che.hirc Spain
Orthopaedic, Department of Orthop<tcdics
UniteJ Kingdom New[()n Djin Muri, MD
lena Klarin, RN Republic of Smgaporc Gcntral Sull(con
Former ATLS N .uional C.nordin.uor, Sweden Emergency Surgical Services,
Wilson Li, MD Hospital das Clinicas Universidad de
Sahlgreo\ka Universitcts)jukhuet
l l Offinr
Senior J'>,lcdk.
(;orchorg S.iu Paulo
Department of Orthop<ledic> & TraunJ.IIology,
Sweden Silo Paulo
Queen Elizabeth Hospital Bra1il


Giorgio Olivero, MD, PACS Martin Richardson Adv.111ced Life Support {oi"Olip - NL
JJmfessor orSurgery l'hc Epwonh Centre Hid
Univeri ty of Torino, Department of Medicine Richmond, Victoria 'I he Netherlands
.tnu urgery, St. John thc Baptist Hospital AuMraua
Domenic Scharplatz MD, rACS

haly Uo Richter 1/md Surgeon

MJior Hospit.ll of Thusi
Steve A. Olson, MD, PACS Armed For'<.'li llcalth Scnoiccs Thuis, Grisons
Prnltssor, Dep:mmenr o{Sur!,wr}' Na.:stvcd 'iwllzcrland
ChidOrtlwpa<:dic Tmumu Denmar k
ChidMedical 0117ccr
Inger B. Schipper, MD, PhD
Rosalind Roden, Ft=AF.M Mcdk.JI /Jin'Ctor o( the Snuth West Net}Jcrland
Duke University Hopital
Durham, N orth Carolin.1 in Emergemy Medicine 'Ir.wmacentcr

United States Leeth Tea<hing IIo,pnal, NlIS Trust University Fr,\\mu' MC, Department

Yorkshue ofTrauma Surgery

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

Mark Sheridan, M BI3S, MMedS c, FRACS

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


Peter Skippen, MBBS, FRCPC, FIF'ICM, Wa'cl S. 1aha, MD Eugenia Vns.ilopoulou, MD

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

Br111SI111j Sydney, New South Wales Medicine and TrattmatolOg)', University

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

Righu;pitaJct Szeged
Copcnh.1gen Hungary
l>enm.trk Wai-Key Yuen, MB BS, FRCS, FRACS, FACS
Pantelcimon Vassiliu, MD, PhD
Vasso Tagkalakis Attending Surgeon
Dep.trtmnt of Surgery. Queen Mary
ATLS NotionJI <ll<Jrdin.Jtnr, (;r,'C.:e General Surgical Clinic
Umwr,it)' of l'atra' Attikon linivcrsiL) llospital
I lung Klmg
Patra Athens
(jrc'c Greece

R.1ymund H. Alexander, MD, FACS

HONOR ROll search and lhat our course s i designed to im
prove patient outcome:,. J'he 8lh edition of P.1reed Ali, MD, 1-'RC$ (C l
Over the pal 30 yeasr ATI$ has grown fi-om
ATI,S reflects the elfort of the following m ),tmcel Ali, MD, MMed .Ed, FRCS (C), FACS
a local course training Nebraska doctors to dividuals who contributed to Ihe !irst even Charles Aprahamian, MD, FACS
care for lr<Htmu pa t ient lO a f tm ily of .
cditons, and we honor them here. Guillermo Mana, MIJ, I'ACS
trauma spcciJiists from more th<n 50 coun Ana Lltisa Argomedo Manriq ue
tries who volunteer their lime to ensure that Sabas P. Abuabara, MD, FACS
Gonl..alu Aviles
our materials rdlcct the most cu rrcnt re- Joe E. Acker, Ill, MS, MPII, EMT Hichnrd Bnillot, MD


B.trbara A. ll,trlow, MA, MD, FAC:S lone E. Heilman. 1I>, PAC Jean Peloquin, ID
)ame' B.uonc, MD, FACS David M. Heimhach, Ml>, FACS Philip W. Perdue, I\
)<)hn ll,mcn, MD, IACS D.wid N. Herndon. M 0, fACS J. W. Rod ney Peytnn , FRCS (Eel), MRCP
Pit!rrc Llc,lllmont, MD Lrwin F. Hirsch MD, . Pi\CS Lawrence H. Pills, Mil FACS

Ricltartl M. Bell, MD, FACS J'ra ncisco Holguin. M D Galen V. l'nnle, M 1>, FACS
Fugcne 1.. Berg MD. FACS
, David B. Hoyt, MD, PAC Ernest Prgcnl, M I)
RichorJ Brgcron, MD lrvene K. Hughes, RN Richard R. Price, MD, FACS
Franol\ Bertrand. MD Rkh<trd C. Hunt, MD, FACF.P :s
llerl>crt l'rottnr, M l >. FA<
Emtdto Bianco. t-ID, Jl) Mile> H. Irving, FRC'> (Ed), I'I{CS (Eng) j,1cques Provo.,I, .\t I>
Don E. Boyl e. M 1>. h\CS Jo Maria )over Navalon, MD, FAU; Paul Pudimat, M I>
Rca Brown, \II>, FACS Richard 1.. Judd, PhD Max I. Ramcnnf,kv, MD, FACS
Allen I Bro"nl', MD. FACS lregory ). Jurkovich, MD, FACS Marcelo Rel.tldc, \Jl), FACS
(;crry Aunting. ID Chritoph R. Kaufmann, MD, FAC:S John Reed, fl.lD
Andrew It Burgess, MD, FACS Howa rd B. Keith, MD, fACS Marleta Reynold;, MD, ACS

Richard E. Ourucy, MD, FACS lome F. Kellam, M 1), FllCS . I'ACS Stuar t A. Rcynulds, MD. FACS

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

lon l l tywood, IRC:S (Eng), MRCS,

. LRCI' Muk D. Pearlman, M 0 Bradley D. Wong, MIl, FACS
)ll ntcs I>. Ik'kman, MD, FACS 1\ndrcw B. Peizman,
t MD, FACS Peter H. Worluck, DM, ... RCS (Ed), FRCS ( Eng)

C 0 U R S E 0 V ERV I E W: The Purpose, History, and

Concepts of the ATLS Program

Program Goals 2 Establi:.h management priorities in a trauma situa


3. Initiate primary and secondary management neces

The Advanced Trauma Life Support (ATLS) course provides
sary within the golden hour for the emergency man
its participants with a safe and reliable method for the im
agement of acute life-threatening conditions.
mediate treatment of injured patients and the basic knowl
edge necessary to: 4 . In a given simulated clinical and surgical skills
practicum, demonstrate the following skills, which are
1 Assess a patient's condition rapidly and accurately. often required in the initial a'>sessment and treatment
of patients with multiple injuries:
2. Resuscitate and stabilize patient according to prior
a. Primary and secondary assessment of a patient
with simulated, multiple injudes
3. Determine whether a patient's needs exceed a facility's b. Eswblishment of a patent airway and initiation of
resources and/or a doctor's cap1bilitics. one- and two-person ventilation
c. Orotracheal intubation on adult and infant
4. Arrange appropriately for a patient's interhospital or
intrahospital transfer (what, who, when, and how).
d. Pulse oximetry and carbon dioxide detection in ex
5. Ensure that optimal care is provided and that th level haled gas
of care docs not deteriorate at any point during the e. Cricothyroidotomy
evaluation, resuscitation, or transfer processes. f. Assessment and treatment or a patient in shock,
particularly recognition of life-threatening hemor
g. Venous and intraosseous access
Course Objectives h . Pleural decompression via needle thoracentsis
and chest tube insertion
i. Recognition or cardiac tnmponade (and perform
The content and skills presented in this course aYe designed to
ance of pericardiocentesis)
assist doctors in providing emergency care for trauma pa
j. Clinical and radiographic identification of thoracic
tients. The concept of the "golden hour" emphasizes the ur . . .

gency necessary for successful treatment of injured patients
k. U:.c of peritoneal lavage, ultrasound, and computed
and s
i not intended to represent a "fixed" time period of 60
tomography (CT) in abdominal evaluation
minutes. Rather, it is the window of opportunity during
I. Evaluation and treatment of a patient with brain
which doctors can have a positive impact on the morbidity
injury, including use of the Glasgow Coma S:alc
and mortality associated wilh injury. The ATLS course pro
score and CT of lhe brain
vides the essential information and skills for doctors to iden
m. Assessment of head and f<Kial trauma by phy!>ical
tify and treat life-threatening and potentially life-threatening
injuries w1der the extreme pressures associated with the care
n. Protection of the spinal cord, <md radiographic
of these patienb in the fast-paced environment and anxiety of
and clinical evaluation of spine injuries
a trauma room. The ATLS course is applicable to all doctors
o. Muculoskeletal trauma a:.sessment and manage
in a variety of clinical situations. It is just as relevant to doc
tors in a large teaching facility in North America or Europe as
p. Estimation of the size and depth of burn injury
it is in a developing nation with rudimentary facilities.
and volume resuscitation
Upon completion of the ATLS student course, tbe doc
tor will be able to:
q Recognition of the special problems of injuries in
infants, the elderly. and pregnant \vomen
1 . Demonstrate the concepts and principles of the pri r. Understanding of the principles of disaster man
mary and secondary patient assessments. agement

. .


THE NEED when it is realized that trauma strikes down a society's

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

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

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

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

., .. .

. .

Mortality rate
(per 1 00,000)
\ ,

120.0-1 3 1 . 1 "'

95.0- 1 1 9 . 9


No data

Figure 1 Global Injury-Related Mortality.

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


hematomas, hemopneumothorax, ruptured spleen, lac

Road traffic erations of the liver, pelvic fractures, and/or multiple
injuries other injuries associated with significant blood loss. The
golden hour of care after injury is characterized by the
need for rapid assessment and resuscitation, which are
the fundamental principles of Advanced Trauma Life
Self-inflicted Su ppo r t .
violence Fires The third peak, which occurs several days to weeks
16% 5% after the initial i njury, is most often due to sepsis and mul
tiple organ system dysfunction. Care provided during
Poisoning each of the preceding periods impacts on outcomes dur
ing this stage. The first and every sub sequen t person to
violence care for the injured patient has a direct effect on long
10% Drowning War term outcome.
9% 6% The temp oral distribution of deaths reflects local ad
vances and capabilities of trauma systems. The development
Figure 2 Distribution of Global Injury Mortality of standardized trauma training for doctors, beller prehos
by Cause. pital care, and the development of trauma centers with ded
Reproduced w1th perm1ss1on from The InJury Chart Book. A Graphtcal
icated trauma teams and established protocols to care for
Overvrew of the Global Burden of InJurieS Geneva World Health Orgamzation injured patients has altered the picture. A recent study in
Department of lnJunes and V1olence Prevention. Noncommunicable D1seases
and Mental Health Cluster, 2002.
California demonstrated that approximately 50% of pat ients
died at the scene or wi thin the first hour, supporting con
tinued emphasis on injury-prevention programs. Both the
aorta, or other large blood vessels. Very few of these pa mechanism of i njury and the body area injured were im
l ien ts can be saved b eca use of the severity of their injuries. portant determinants of the subsequent clinical course and
Only prevention can significan tly reduce this peak of the temporal risk of death. Eighty percent of deaths due to
trauma-related deaths. severe chest trauma occurred within the first 6 hours,
The second peak occurs within minutes to several whereas 90% of deaths from head injury occurred during
hours following injury. Deaths that occur during this the fust week. The incidence of late deaths was m uch lower
period are usuaJly due to subdural and epidural in this series (8%).


300 J
f'O 250
0 200
Immediate Early Late
] deaths deaths deths
E 150




1 2 J 4 2 3 4 5
Hours Weeks
Tlme after Jnjury Figure 3 Trimodal Death


)anUJr}' 1980. Canada became an active participant in the

History ATLS Program in 1981. Cou nt ri es in I.atin and South Amer
ica joined the ACS COT in 1 986 and implemented the ATLS
The delivery of tra um a care by doctors in the United States .. Prog ram. Under the auspices of the ACS Military Commit
bcltlre 191:!0 was at best inconsistent. A tragedy occurred in tee on Trauma, the p rogra m has bee n conducted for U.S.
Febnw ry 1976 t hat changed trauma care in the "first hour" military doctors in other cou ntrics.
for injured patien ts in the Un ited Stall'S and in much of the The program has grown each year in the number of
rest of the world. An orthopedic l>Urgeon Wall piloting his both courses and pa rt icipants. By 2007, the course had
plane and crashed in a rural Nebrallka cornfield. The sur trained approximately 1 miUion doctors in more than
geon sustained serious injurie!>, three of his children sus 60,000 courses around the world. Cu rrently an average of

tained critical i njuries, and one child sustained minor 40,000 d octors arc trained each year in approximately 2600
injuries. His wife was kil led in sta nt ly. The care that he and course!>. The greatest growth in recent years has been in the
his family subsequently received was inadequate by the day s ' international community, and thii. group currently repre
standards. The surgeon, recognizing how inadequate their ents .1pproximatcly more than half of all ATLS activity.

treatment was, stated: "vVhen I can pmvide better care in The text for the course is revised a pp roximately every 4
the field with limited resource!> than what my chi ldren and years a nd incorpo rates new methods of evaluation and
1 received a t the pri mary care facili ty there is something
, treatment that have becom e accepted parts of the arma
wrong with the system, and the system has to be changed." mentarium of doctors who treat trauma pati ents Course .

A group of private-practice surgeons and doctors in revisions incorporate suggestion!. from members of the Sub
t'ebraska, the Lincoln Medical Education Foundation, and committee on XfLS; members of the ACS COT; members of
the Lincoln-area Mobile Heart Team Nurses, with the help the international ATLS family; rcpreentatives to the ATLS
of the University of Nebraska Medical Center, the Nebraska Sul)lornmittee from the American College of Emergency
State Committee on Trauma (COT) of t he American Col Phy:.ici ans and the American College of Anesthesiologists;
lege of Surgeon s (ACS), <md the Southeast Nebraska Emer and course instructors, coordinators, educators, and partic
gency Medical S:rvice identified the need for t rain i ng in ipants. Changes that are made to the program reflect ac
advanced trauma life support. A combin ed educational for cepted verified practice patterns. not culli ng edge"
, "

mat of lectures, lifesaving skiU dcmon!ltration, and pr acti techn ology or experi ment al methods. The international na
cal laboratory experiences formed the first prototype ATLS ture.' of the program manda tes that the course be adaptable
course for doctors. to a var ie ty of geograp hic, economic, social, and medical
A new approach to the provision of care for individu practice situations. To retain a current status in the ATLS
als who suffer major, life-threatening injury premiered in Program, an individual must reverify with the latest edition
1978, the year of the first ATLS coure. This prototype ATLS o f the materials.
course was field-tested in conju ncti o n with the Southeast A parallel course to the ATLS course is the Prehopital
Nebraska Emergency Medical Services. One year later, the Trauma Life Support (PHTLS) course, which is sponsored
ACS COT, recog nizi ng trauma as a su rg ica l disease, ent h u by the National Association of Emergency Medical Techni
sias tica lly adopted the course under the im primat ur of the cians (NAEMT). The PHTLS cours e, developed i n cooper
Col lege and incorporated it as an educational program. ation with the ACS COT, is based on the concepts of the ACS
This course was based on the as1.umption that appropri ATLS Progra m for Doctors and is conducted for emcrgem.-y
ate and timely care could significantly improve the outcome medical technicians, paramedics, and nurses who are
of injured patients. Tbe original intent of the ATLS Program providers of prehospital trauma care. Other courses have
was to train doctors who do not manage major trauma on a been developed with sinlllar concepts and philosophies. for
daily basis, and the primary audiem:e for the course has not example, the Society ofTrauma offers the Advanced

changed However, today the ATLS method is accepted a<; a

. Trauma Care for Nurses (ATCN), which is also developed
Mandan.! fcw the "first hour" of trauma care by many who pro in coop erat ion with the ACS COT. The ATCN and ATLS
vide care for the injured, whether the patient is treated in an courses are conducted parallel to each other with the nurses
is ola ted rural area or a state-of the-art trau ma cen ter. aud i tin g the ATLS lec tures and then partici pati ng in skill
stations separate from th e ATLS skill stations conducted for
doctors. The benefits of havi ng both prehosp ital and in
hospital trauma personnel speaking the same "language" arc
Course Development app.1rent.
and Dissemination
THE 1980c; AND 1990s As a pi lo t project, the ATLS Progr am was exported outside
The Al LS course was conducted natiom1lly for the first t ime of North America in 1986 to the Rep ubi ic of Tr i nidad and
under rhe a uspices of the AmeriGln College of Surgeons in Tobago. The ACS Board of Regen ts gave permission in 1 987


for promulgation of the ATLS Program in other countries. 27. Netherlands, The (Dutch Trauma Society)
The ATLS Progrru:n may be requested by a recognized sur
28. New Zealand ( Royal Australasian College of
gical organization or ACS Chapter in another country by
conespondlng with the ATLS Subcommittee Chairperson,
care of the ACS ATLS Program Of(icc, Chicago, IL. At Lhc 29. Norway (Norwegian Surgical Society)
time of publication, 47 cow1tries were actively providing the
30. Pakistan (College of Physicians and Surgeons
ATLS course lo their doctors. These countries include:

31. Panama (ACS Chapter and Committee on Trauma)

1 . Argentina (ACS Chapter and Committee on Trauma)
32. Papua New Guinea (Royal Australasian College of
2. Australia { Royal Australasian CoUcgc of Surgeons)
3. Bahrain (Kingdom of Saudj Arabia ACS Chapter and
33. Peru (ACS Chapter and Committee on Trauma)
Committee on Trauma)
34 . Portugal (Portuguese Society of Surgeons)
4. Bolivia ( Bolivian Surgeons Society)
35. Qatar (Kingdom of Saudi Arabia ACS Chapter and
5. Brazil (ACS Chapter and Committee on Trauma)
Committee on Trauma)
6. Canada {ACS Chapters and Provi ncial Committees
36. Republic of China, Taiwan (Surgical Association of
on Trauma)
the Republic of China, Taiwan)
7. Chile (ACS Chapter and Committee on Trauma)
37. Republic of Singapore (Chapter of Surgeons,
8. Colombia (ACS Chapter and Committee on Trauma) Academy of Medicine)

9. Costa Rica (College of Physicians and Surgeons of 38 . Republic of South Africa (South African Trauma
Costa Rica) Society)

1 0. Cyprus (ACS Chapter and Committee on Trauma, 39. Spain (Spanish Society of Surgeons)
40. Sweden (Swedish Society of Surgeons)
1 1 . Denmark (Danish Trauma Society)
41 . Switzerland (Swiss Society of Surgeons)
1 2 . Ecuador (ACS Chapter and Commillee on Trauma)
42 . Thailand (Royal College of SllTgeons of Thailand)
13. Fiji and the nations of the Southwest Pacific (Royal
43. 11-i.nidad and Tobago (Society of Surgeons of Trinidad
Australasian College of Surgeons)
and Tobago)
14. Germany (German Society for Trauma Surgery and
44. United Arab Emirates (Surgical Advisory Committee)
Task Force for Early Trauma Care)
45. United Kingdom { Royal College of Surgeons of
1 5 . Greece (ACS Chapter and Committee on Trauma)
16. Grenada (Society of Surgeons of Trinidad and 'lbbago)
46. United States, U.S. territories (ACS Chapters and State
17. Hong Kong (ACS Chapter and Committee on Committees on Tra uma)
47. Venezuela (ACS Chapter and Committee on Trauma)
18. Hungruy ( Hungarian TraLm1a Society)

1 9. Indonesia ( Indonesian Surgeons Association)

20. Ireland ( Royal College of Surgeons in lrebnd)

The Concept
21 . Israel (Israel Sw-gical Society)

22. Italy (ACS Chapter and Committee on Trauma) The concept behind the ATI.S course has remained simple.
Historical ly, the approach to treating injured patients, as
23. Jamaica (ACS Chapter and Committee on Twuma)
taught in medical schools, was the same as that for patients
24. KjJ1gdom of Saudi Arabia (ACS Chapter and with a previously undiagnosed medical conrution: an ex
Committee on Traw11a) tensive history inclurung past merucaJ history, a physical e...x
amination starting at the top of the head ru1d progressing
25. Lithuania (Lithuanian Society of Traumatology and
down the body, the development of a differential ruagnosis,
and a list of adjuncts to confirm the diagnosis. .AJthough this
26. Mexico (ACS Chapter and Committee on Trauma) approach was adequate for a patient with diabetes mellitus


and many acute surgical illnesses, it did not satisfy the needs
The Impact
of patients suffering life-threatening injuries. The approach ,
required change.
Three underlying con cepts of the ATLS Program were. ATLS training for doctors i n a developing country has re
initially difficult to accept: sulted i n a decrease i n injury mortality. Lower per capita
rates of deaths from i nj uries arc observed in areas where
1 . Treat the greatest threat to life first. doctors have ATLS train ing In one study, a small trauma

team led by a doctor with AT LS experience had equivalent

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

"n1e ATLS course emphasizes that injury kills i n certain

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

The AILS course emphasizes the rapid initial assessment

and primary treatment of in j ured patients, starting at the
time of injury and continuing through initial assessment,
lifesaving intervention, reevaluation, stabilization, and,
when needed, transfer to a trauma center. The course
consists of precourse and postcourse lests, core content The ATLS course provides an easily remembered approach
lectures, in teract ive case presentations, discussions, to the eva luation and treatment of injured patients for any
development or lifesaving skills, practical laboratory ex doctor, irrespective of practice specialty, even under the
periences, and a final performance proficiency evaluation. stress, anxiety, and intensity that accom panies the resusci
Upon completion of the course, doctors should feel con tation process. In addition, the program provides a common
fident in implementing the skills taught in the ATLS language for all providers who care for injured patients. The
course. ATLS course provides a foundation for evaluation, treat-



ment, education, and quality assurance-i nshort, a system surgical medical background. Eur I Emcrg Mcd 1997;4:1 1
of trauma care that is meaurable, reproducible, and com 14.
prehensive. 12. B erger LR, MoiMn ]): Injury Control: A Global View. Delhi,
The ATLS Program has had a positive i mpa<;_t on the India: Oxford Un iversity Press; 1996.
care prov ided to injured pa t ients worldwide. This has re
13. Blumenrield A, Ben Abn1ham R, Stei n M, et al. Cogn itivt
sulted from the improved skills and knowledge of the doc
knowledge decline ,, fter Ad voneed Trauma Life Support
tors a nd ot her health ca re p rov iders who have been course
courses. I Trauma 1998;44:5 13-516.
participants. The AILS course establishes an organized and
systematic approach for the evaluation and treatment of pa 14. Burt CW. Injuryrelated visits to hospita l emergenq depart
ments: United St<lles, 1 992. tldv<l 1995;26 1 : 1 20.
tients. promotes minimum standards of care, and recognizes -

injury as a world health care issue. Morbidity and mortali ty 15. Demetriades 0, I<imbrell B, SJiim A, et al. Trauma deaths in ,,
have been reduced , but the need to eradicate injury remains. mature urban trau ma system: "trimodaJ" cllitribution a valid
The ATLS Program has changed and will continue to change concept? JAm Coil Sw-g 2005;201 :343-348.
as advances occur in medici n e and the needs and ex pect a -
16. lJeo SD, Knottenht'lt JD, Peden MM. Evaluation of a small
1 ions of our societies ch a nge. 1 rauma team for mLtjn r resuscitation. Tnjury 1997;28:633-637.

17. Di reccao Geral de Vic.1o, Lisboa, Portugal, data p rovided by

Pedro Ferreira Muniz Perdra, MD, FACS.

18. Fingerhut LA, Cox

Bibliography CS, Warner M, et al. l.nternation,\1 com
paratiw analysis of injury mortality: findings from t he !Ct. on
injury statistics. tld1 1),,,,, 1998;303: 1 20.-

I . Ali J, Adam R, Butler AK, et at, Trauma o utcome improves fol

19. firdley FM,Cohen D J, Bicnhaum tlfl, etal. Advanced Trauma
lowing the Advanced Trauma Life Supp ort program in a de
Life Support : Assessment of cognitive achievement. Milit Akd
velop i ng country. I Tmuma 1993;34:890-899.
1993;1 58:623-627.
Adam R, Josa D, et ol. Comparison of interns complt.'l ing
2. l\li J,
20. Gautam V, l le}'\vorth ) . A met hod to measure the value of fnr
the old ( 1993) and new intenttive ( 1997) Advanced Traumo
mal train i ng in trauma m<lnagcmcnt: comparison between
Life Support courses. f Tril uma 1999;46:80-86.
ATlS and induction courses. lniury 1995;26:253-255.
3. Al i J, Adam R, Stedmm M. et <I. Advanced Trauma Life Sup
2 1 . Greenslade GL, Taylor Rll. Advanced Trauma Life upport
port program increases emergency room application of
aboard RFA Argu. I R Nav Mcd Sen' 1992;78:23-26.
t rauma resuscitative proced ures in a develo ping country. I
1rJuma 1994;36:391-394. 22. Ldbo,ci D, FedmJn Il, Gofrit ON, et at. Prehospital cricothy
roidotomy by pbyic1ans. Am I Emerg Med 1997; 15:91 -93.
4. Ali J, Adam R, Stedman l\1, et al. Cognitive and attitudinal im
pact of the Advanced Trauma Life Support Course 1n a devel 23. Mock CJ. JnternatiOihll ,1pproachcs to trauma care. Tri!u/ll,J Q
oping coun try. f Trauma 1994;36:695-702. 1998; 14: 191-341!.

5. Ali J, Co he n R, Adam R, et ,1!. Te(lch i ng effeclivenes of the Ad 24. Murray C}, Lope7, A. The gk1bal burden of disease: I. A com
vanced Trau ma Li fe Support program as demonstrated by an prehensive assessment of monal i t} and disability from dis

objective structured clinical exami nation for practicing physi ases, and inju ries and risk factors in 1990 and projected lo

cians. World I Swg 1996;20: I 121-1 125. 2020. Cambridge, MA: Harvard Umversity Press; 1 996 .

6. Ali J, Cohen R, Adams R, et ,\I. At trition of cognitive and 25. National Center for l lcalth Statistics: Injury vis its to cmcr
trauma skills after the Adv.mced Trau ma Life Support (ATLS) gency departments. please state so.
course. I Trauma 1996;40:860 866.
26. National Safety Council. lniun t:1cts (1999). ltasca. IL: :-.Ia
7. l\li ), Howard M. The Advanced Trauma Life Support Program tional Safety Council.
in Manitoba: a 5 year review. C111 J Swg 1993;36:1 8 1 - 1 83.

27. 1\ourj ah P. National hospital ambulatory medical care su rvey:

8. Anderson JD, Anderson IW, Cli fford P, et at. Advanced Trauma 1997 emergency department summary. Adv DatJ 1999;304: 1-24.
Life Su pport in the UK: 8 year. on. Br I Ho.sp 1\ft>d
2!1. O lden van GD). Meeuwis ID, Bolhuis HW, et al. Clinical im
pact of advanced traun-..1 life upport. Am I Eme.1g 1\.fcd
9. Ap raham ian C. Nelson KT. fho mpson BM, et at. l he rel;t 2004;22;522-525.
tionsh ip of the level of training and area of medical pec ial
29. Rutledge R, Fakhry Sl, Baker CC., cl al. A population-based study
ization with regi.Hranl performance in the Advanced Trauma
of the association of mcdkal manpower with count} trauma
Tife Support coure. I Emerg Alcd 1984;2: 137- 140.
death rates n
i the United State. Ann Surg 1994;219:547-563.
I 0. Ben Abraham R, Stdn M. Kluger Y, et al. ATLS course in emer
30. Walsh DP. Lammert GR, Dlvoll J. The etTectiveness of the ad
gency medicine for physician.. 1/.m:fu.Ih 1997; 132:695-697, 743.
vanced trauma life support s)'stcm in a mass casualty situation
R, Stei n M, K luger Y, et al. The impact of Ad
J I . Ben Abrah am by non-trauma e Kp erienced physicians: Grenada 1983. / Fmct

vanced Trauma Life Support Cou rse on graduates with non- Med 1989;7: 175- 1 80.


3!. Williams MJ, Lockey AS, Cutshaw MC. Improved trauma 33. World Health Organization. \liolence and Injury Prevention
management wilh Advanced Trauma Life Support (ATLS) and Disability ( VIP).
training. I Accident .Emerg Med 1.997;14:8 1.-83. prevention/publica Lions/other_injuryIchartb/en/index.hLml.
Accessed January 9, 2008.
32. World Health Organization. The Injury Chart Boo]\: a Graph
ical Overview oftl1e Global Burden ofInjuries. Geneva: VVorld 34. World Health Organiz.ation. World Report on Road Tmflic In
Health Organization Department of Injuries and Violence lJre jury Prevention. Geneva: World Health Organization.
vention. Noncommunicable Di.seascs and Mental T lealth
ter; 2002.


Foreword v

Preface VII

Course Overview xviii

1 Initial Assessment and Management 1

OBJECTIVES 1 Other Monitoring 10

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

2 Aiway and Ventilatory Management 25

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




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

Skill Il-l: Pulse Oximetry Monitoring 47
Skill ll-8: Nasopharyngeal Airway Insertion 44
Skiii ii-J: Carbon Dioxide Detection 48
Skill 11-C: Bag-Mask Venti lation: Two-Person
Scenarios 49
Technique 44
Skill ll-0: Adult Orotracheal lntubation (with SKILL STATION Ill:
and without Gum Elastic Bougie Device) 45 Cricothyroidotomy 51

Skill li-E: Laryngeal Mask Airway (LMA) Skill Ill-A: Needle Cricothyroidotomy 52
Insertion 45 Skill 111-8: Surgical Cricothyroidotomy 52

3 Shock 55
OBJECTIVES 55 Equating Blood Pressure with Cardiac Output 66
Introduction 56 Advanced Age 67
Shock Pathophysiology 56 Athletes 67
Basic Cardiac Physiology 56 Pregnancy 67
Blood Loss Pathophysiology 56 Medications 67
Initial Patient Assessment 57 Hypothermia 67
Recognition of Shock 58 Pacemaker 67
Clinical Differentiation of Cause of Shock 58 Reassessing Patient Response and
Hemorrhagic Shock in Injured Patients 59 Avoiding Complications 68
Definition of Hemorrhage 60 Continued Hemorrhage 68
Direct Effects of Hemorrhage 60 Fluid Overload and CVP Monitoring 68
Fluid Changes Secondary to Soft Tissue Injury 61 Recognition of Other Problems 69
Initial Management of Hemorrhagic CHAPTER SUMMARY 69
Shock 62 BI BLI OG RA PHY 69
Physical Examination 62
SKILL STATION IV: Shock Assessment
Vascular Access Lines 62 and Management 73
Initial Fluid Therapy 63
Skill IV-A: Peripheral Venous Access 74
Evaluation of Fluid Resuscitation
and Organ Perfusion 64 Skiii iV-8: Femoral Venipuncture: Seldinger
Technique 74
Urinary Output 64
Acid/Base Balance 64 Skiii iV-C: Subclavian Venipuncture:
Infraclavicular Approach 76
Therapeutic Decisions Based on
Response to Initial Fluid Resuscitation 64 Skiii iV-0: Internal Jugular Venipuncture:
Middle or Central Route 76
Rapid Response 65
Transient Response 65 Skiii iV-E: lntraosseous Puncture/Infusion:
Proximal Tibial Route 77
Minimal or No Response 65
Blood Replacement 66 Skill IV-F: Broselow'M Pediatric Emergency
Tape 78
Crossmatched, Type-Specific, and Type 0 Blood 66
Warming Fluids-Plasma and Crystalloid 66 Scenarios 79

Autotransfusion 66
SKILL STATION V: Venous Cutdown
Coagulopathy 66
(Optional Station) 83
Calcium Administration 66
Special Considerations in the Diagnosis Skill V-A: Venous Cutdown 84
and Treatment of Shock 66



4 Thoracic Trauma 85

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

5 Abdominal and Pelvic Trauma 111

OBJECTIVES 111 Specific Diagnoses 121

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

6 Head Trauma 131

OBJECTIVES 131 Meninges 133

Introduction 132 Brain 134
Anatomy 132 Ventricular System 135
Scalp 132 Tentorium 135
Skull 132 Physiology 135


Intracranial Pressure 135 Barbiturates 148

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

Primary Survey and Resuscitation 142

Skill IX-A: Primary Survey 154
Secondary Survey 144
Diagnostic Procedures 144 Skiii iX-8: Secondary Survey and
Medical Therapies for Brain Injury Management 154
Intravenous Fluids 146 Skiii iX-C: Evaluation of CT Scans of the
Head 154
Hyperventilation 146
Mannitol 146 Skiii iX-D: Helmet Removal 155
Steroids 147 Scenarios 156

7 Spine and Spinal Cord Trauma 157

OBJECTIVES 1 57 Blunt Carotid and Vertebral Vascular Injuries 166

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


Skill XIB: Secondary Survey-Neurologic Skill XID: Treatment Principles for

Assessment 182 Patients with Spinal Cord Injuries 183
Skill XIC: Examination for Level of Skill XIE: Principles of Spine
Spinal Cord Injury ..
182 Immobilization and Logrolling 183

8 Musculoskeletal Trauma 1 87

OBJECTIVES 1 87 Femoral Fractures 199

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

X-Ray Examination 189 Pain Control 200

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

9 Thermal Injuries 21 1

OBJECTIVES 211 Airway 213

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


Antibiotics 217 Types of Cold Injury 219

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

10 Pediatric Trauma 225

OBJECTIVES 225 Thermoregulation 237

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

11 Geriatric Trauma 247

OBJECTIVES 247 Exposure and Environment 253

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


12 Trauma in Women 25 9.

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

13 Transfer to Definitive Care 269

OBJECTIVES 269 Transfer Protocols 274

Introduction 270 Information from Referring Doctor 274
Determining the Need for Patient Transfer 270 Information to Tra nsferring Personnel 274
Timeliness of Transfer 270 Documentation 274
Transfer Factors 270 Treatment Prior to Transfer 274
Transfer Responsibilities 273 Treatment During Transport 276
Referring Doctor 273 Transfer Data 276
Receiving Doctor 27 3 CHAPTER SUMMARY 276
Modes of Transportation 273 BIBLIOGRAPHY 276

Appendices 277
Appendix A: Injury Prevention 279

Classification of Injury Prevention 279 Develop and Test Interventions 281

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

Appendix B: Biomechanics of Injury 283

Introduction 283 Penetrating Trauma 286

Blunt Trauma 283 Velocity 286
Vehicular Impact 283 Bullets 287
Pedestrian Injury 285 Shotgun Wounds 287
Injury to Cyclists 285 Entrance and Exit Wounds 288
Falls 285 BIBLIOGRAPHY 288
Blast Injury 286


Appendix C: Trauma Scores: Revised and Pediatric 289

Introduction 289 Level of Consciousness 289

Revised Trauma Score "'289 Musculoskeletal Injury 289
Pediatric Trauma Score 289 Use of the PTS 289
Size 289

Appendix D: Sample Tra uma Flow Sheet 293

Appendix E: Tetanus Immunization 297

Introduction 297 Passive Immunization 298

General Principles 297 BIBLIOGRAPHY 298

Surgical Wound Care 297

Appendix F: Ocular Trauma (Optional lecture) 299

OBJECTIVES 299 Injury to the Iris 301

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

Appendix G: Austere Environments: Military Casualty Care and Trauma

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

OBJECTIVES 305 Airway 308

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



Communications and Signaling 316 Appendix G Summary 318

Triage 317 BIBLIOGRAPHY 318

Appendix H: Disaster Management and Emergency Preparedness

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

Preparation 324 B I BLIOGRAP H Y 335

Appendix 1 : Triage Scenarios 335

OBJECTIVES 337 Triage Is Continuous (Retriage) 338

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

Index 351


CHAPTER OUTLINE Upon completion of this topi c the student will demonstrate

the ability to a pply the p rinciples of emergency medical care

to multiply InJUred pa lients. S pecific ally the doctor will be

Introduction able to
Prehospital Phase OBJECTIVES
Hospital Phase
Triage Identify the correct sequence of priorities for as
Multiple Casualties sessment of a multiply i njured patient.
Mass Casualties
Apply the principles outlined in the primary and
Primary Survey
secondary evaluation surveys t o t h e assessment of
Airway Maintenance with Cervical Spine Protection
a multiply injured patient.
Breathing and Ventilation
Circulation with Hemorrhage Control Apply guidelines and techniques i n the initial re
Disability (Neurologic Evaluation) suscitative and definitive-care phases of treatment
Exposure/Environmental Control of a mu ltiply injured p a tient.

Explain how a patient's medical h istory and the
mechanism of injury contribute to the identifica
Circulation and Bleeding Control tion of injuries.

Adjuncts to Primary Survey and Resuscitation Identify the pitfalls associated with the initial as
Electrocardiographic Monitoring sessment and management of an injured patient
Urinary and Gastric Catheters and take steps to minimize their impact.
Other Monitoring
XRay Examinations and Diagnostic Studies Conduct an initial assessment survey on a simu
lated multiply injured patient, using the correct
Consider Need for Patient Transfer
sequence of priorities and explaining manage
Secondary Survey ment techniques for primary treatment and stabi

H istory l ization

Physical Examination
Adjuncts to the Secondary Survey
Definitive Care
Records and Legal Considerations
Consent forTreatment
Forensic Evidence
Chapter Summary

2 CHAPTER 1 Initial Assessment and Management


The treatment of serio usly inj ured pat ients requires rapid
assessment of the inju ries .md institution of life-preserving
therapy. Because time is of the essence, a systematic ap
proach that can be easily reviewed and pract iced is most ef
fective This process is termed ''initial assessment" and


Preparati on


Primary survey (A BCDEs)

Resu:.cital ion

Adju nc ts to primary survey and resuscitation

Cons i der need for patient transfer

Second try survey (head-to-toe evaluation and pa


tient history)

Adj uncts to the seconda ry survey

Cont in ued post rcsuscita tion mo nitoring and

reeval uation

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

and to determine whether it is necessary to institute any treat

members so that <Ill necc!.sary personnel and resources are
ment when adverse changes are identified.
presen t in the em ergen cy depa rt ment (ED) at the time of
The assessment sequence presented in this chapter reflects
the pati en t s a rrival .

a linear, or long i tudi nal progression of event s Ln an actual clin

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

process allows the doctor an opp ortuni ty to m entally review

diate tranoport to the cl osest a ppropri a te fa ci l i ty ,

the progress of nn actua l trauma resuscitation.

preferabl y n verified trau ma center. Every effort should be
ATLS principles guide the assessment and resuscita
made to minimize scene time (see Figure 1 - 1 ) Emphasis .

tion of injured patients. Judgment is required to determine

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

quire all ofthese procedures.

jury, events related to the i njury and pat ien t histo ry) The
, .

mechanisms of i njury Clll suggest the d egree of inj ury as

well as s pecific i nj uries for which the patient must be eval
uated .

Preparation The National Asso<..iation of Emergency Medical Tech

nicians' Prehmpital Trauma Life Suppo rt Committee, in co

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

made to rapidly faci litate the trauma pat ien t s resuscitation.

' sential. I dea l l y, a resuscitation area is available for


Measure Vital Signs and Level of Consciousness

Glasgow Coma Scale < 1 4 or Systolic blood pressure, mm Hg <90 or

Respiratory rate, /min <10 or >29 (<20 in infant less than 1 year)

Step 1

Take to trauma center. Steps 1 and 2 triage attempts to identify the most Assess anatomy of injury
seriously injured patients in the field. These patients would be transported
preferentially to the highest level of care within the trauma system.

All penetrating injuries to head, neck, torso and Amputation proximal to wrist and ankle
extremities proximal to elbow and knee Pelvic fracture
Flail chest Open and depressed skull fracture
lWo or more proximal longbone fractures Paralysis
Crush, degloved, or mangled extremity
Step 2

Take to trauma center. Steps 1 and 2 triage attempts to identify the most Assess mechanism of
seriously injured patients in the field. These patients would be transported injury and evidence
preferentially to the highest level of care within the trauma system. of high-energy impact

Falls Auto v pedestrian/bicyclist thrown, run over,

Adults: >20 ft (1 story 10 ft)
= or with significant (>20 mph) impact
Children: > 1 0 ft or 2 to 3 times the height of the child Motorcycle crash >20 mph
High-risk auto crash
Intrusion: >12 in, occupant site: >18 in, any site
Ejection (partial or complete) from automobile
Step 3 Death in same passenger compartment
Vehicle telemetry data consistent with high risk of injury

Transport to closest appropriate trauma center which, depending on Assess special patient or
the trauma system, need not be the highest level trauma center system considerations

Age Time-sensitive extremity injury

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

Contact medical control and consider transport to Transport according

trauma center or a specific resource hospital to protocol

When in doubt, transport to a trauma center

Figure 1 - 1 Field Triage Decision Scheme.

4 CHAPTER 1 I n itia l Assessment and Management

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

What is a quick, simple way to assess

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

Patients are assessed, and their treatment priorities are

established, bas<.:d on their injuries, vital signs, and the

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

fying severely injured patients who should be

transported to a trauma center. . See Appendix l: Triage
Scenarios and Appendix: C: Trnuma Scores: Revised and


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

6 CHAPTER 1 Initial Assessment and Management

Despite the efforts of even the most prudent and

attentive doctor, there are circumstances in which
airway management is exceptionally difficult and
occasionally even impossible to achieve. Equip
ment failure often cannot be anticipated, for ex
ample, the light on the laryngoscope burns out or
the cuff on the endotracheal tube that was placed
with exceptional difficulty leaks because it was
torn on the patient's teeth during intubation.
Tragic pitfalls include patients in whom intubation
cannot be performed after paralysis and patients
i n whom a surgical airway cannot be established
expediently because of their obesity.
Endotracheal intubation of a patient with an un
known laryngeal fracture or incomplete upper air
Figure 1 -2 If immobilization devices must be way transection can precipitate total airway
removed temporarily, one member of the trauma occlusion or complete airway transection. This may
team should manually stabilize the patient's occur in the absence of clinical findings that sug
head and neck using inline immobilization gest the potential for an airway problem, or when
techniques. the urgency of the situation dictates the immedi
ate need for a secure airway or ventilation.
These pitfalls cannot always be prevented. However,
they should be anticipated, and preparations should
be made to minimize their im pact.
The stabilization equ i p ment used 10 protect the pa
l ienl's sp i na l cord should be left in pl ace u nt i l c ervi cal sp in e
i nju ry has been exc l u ded. Protection of the spine and spinal
cord is a critically important management princi pl e Cervi .
thora' du ri n g a noisy resuscitation may be d i ffi cu l t or
produce unreliable results.
cal spine radiographs may be obtained to confirm or ex
clude injury once immediate or poten t ial ly l ife-threatening Injuries that can impair ventilation in the short term in

conditions have been addressed. Assume a cervical spine in clude tension pneumothorax, flail che:.t with pulmonary con
jury in any patient with multisystem trauma, especially those tusion, massive hemothora,x, and open pneumothorax. These

with an altered level ofconsciousness or a blunt i njury above injuries should be identified during the primary sur vey. Sim
the clavicle. rl' See Ch apte r 7: Spine nnd Sp i nal Co rd ple pneumothorax or hemothorax, fractured ribs, and pul

Tr auma. monary contusion can compromise ventilation to a lesser

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

portant is the necessity to recogni;e the potcntiaJ for

progressive airway loss. frequent reevaluation of airway pa ..
. .
.. .
tency is esscntiaJ to identify and treat pa tients who are los
ing the abil ity to maintain an adequate airway. Differentiating between ventilation problems and
airway compromise can be difficult:

BREATHING AND VENTILATION A patient who has profound dyspnea and tachy
pnea gives the impression that his or her primary
Ai rway patency alone d ocs n o t ensu re a deq uat e ventila problem is related to an inadequate airway. How
tion. Adequate gas exchange i s requ i red to maxim i ze oxy ever, if the ventilation problem is caused by a
genation and carbon dioxide elimination. Ventilation pneumothorax or tension pneumothorax, intuba
requires adequate function of the lu ng chest waU, and di
tion with vigorous bag-valve ventilation can rap
idly lead to further deterioration of the patient.
aphr agm Lach component must he examined and evaJu

ared r api dly.

When mtubation and ventilation are necessary in
an unconscious patient, the procedure itself can
The pa t ien t s chest shou ld b e exp()sed to adequately

unmask o r aggravate a pneumothorax, and the

assess che:;t wall excursion. and a uscu l ta t i on should be
patient's chest must be reevaluated. Chest x-rays
perfo rm e d t() ensure gas flow in the lungs. Visual inspec
should be obtained as soon after intubation and
tion and palpation can detect injuries to the chest wall initiation of ventilation as is practical.
that mi gh t compromise ventilation. Percussion of th e



' ,14jH
: -
Circulation issues to consider include blood volume and
cardiac output, and bleeding. Trauma respects no patient population barrier. The

elderly, children, athletes, and individuals with

chronic medical conditions do not respond to vol
Blood Volume and Cardiac Output
ume loss in a similar or even in a " normal" manner.
Hemorrhage is 1 he predominant cause of preventable deaths
Elderly patients have a limited ability to increase
after inju ry. Hypotension following injury must be consid
their heart rate in response to blood loss, which
ered to be hypovolemic in origin until proved otherwise;
obscures one of the earliest signs of volume de
therefore, rapid and accurate assessment of an injured pa
pletion-tachycardia. Blood pressure has little cor
tient's hemodynamic status is essential. The clements of relation with cardiac output in older patients.
clinical observation that yield important iJlformation within Anticoagulation therapy for medical conditions
seconds are level of consciousness, skin color, <1nd pulse. such as atrial fibrillation, coronary artery disease,
and transient ischemic attacks can increase blood
Level of Consciousness When circulating blood volwne loss.
is reduced, cerebral perfusion may be critically impaired, re Children usua ll y have abundant physiologic re

sulting in altered levels of consciousness. However, a conscious serve and often have few signs of hypovolemia,
patient also may have lost a significant amount of blood. even after severe volume depletion. When deteri
oration does occur, it is precipitous and cata
Skin Color Skin color can be helpful in evaluating lhe in
Well-trained athletes have similar compensatory
jured patient who has hypovolemia. A patient with pink skin,
mechanisms, may have bradycardia, and may not
especially in the face and extremities, rarely has critical hypo
have the usual level of tachycardia with blood
volemia after injury. Conversely, the patient with hypovolemia
may have ashen, gray facial skin and white extremities.
Often, the AMPLE history, described later in this
chapter, is not available, so the health-care team is
Pulse The pulse, rypically an easily accessible central pulse
not aware of the patient's use of medications for
(femoral or carotid artery), should be assessed bilateraUy for chronic conditions.
quality, rate, and regularity. Pull, slow, and regular peripheral
Anticipation and an attitude of skepticism regard
pulses are usually signs of relative normovolemia in a patient ing the patient's "normal" hemodynamic status are
who is not taking B-adrcnergic blocking medications. A rapid, appropriate.
thready pulse is typically a sign of hypovolemia, but the con
dition may have other causes. A normal pulse rate does not
ensure Lhat a patient has normovolemia, bul an irregular
The GCS is a qui ck, simple method for determining tl1e
pulse does warn of potential c<1rdiac dysfunction. Absent cen
level of consciousness that is predictive of patient outcome-
tral pulses that are not attributable to local factors signify lhe
particularly the best motor response. [f it was not performed
need for inm1ediate resuscitative action to restore depleted
during the primary survey, the GCS should be performed as
blood volL1me and effective cardiac output.
part ofthe more detailed, quantitative neurologic examination
during the secondary smvey. ,. See Chapter 6: Head Trauma
Bleeding and Appendix C: 'frauma Scores: Revised and Pediatric.
External hemorrhage is identified and controlled during the A decrease in the level of consciousness may indicate
primary survey. Rapid, external blood loss is managed by di decreased cerebral oxygenation and/or perfusion, or it may
rect manual pressure on the wound. Pneumatic splinting be caused by direct cerebral iJljuty An altered level of con
devices aJso can help to control hemorrhage. These devices sciousness indica tcs the need for immediate reevaluation of
should be transparent lo allow for rnon.iloring of underlying the patient's OX')'genation, ventilation, and perfusion status.
bleeding. To urniquets are infrequently used to control se Hypoglycemia and alcohol, narcotics, and other ru-ugs also
vere bleeding. The use of hemostats can damage nerves and can alter the patient's level of consciousness. However, if
veins. The major areas of occult blood loss are the chest, ab these factors are excluded, changes i n the level of con
domen, retroperitoneum, pelvis, and long bones. sciousness should be considered to be of traumatic central
nervous system origin until proven otherwise.


A rapid neurologic evaluation is performed at the end of the
primary survey. This neurologic evaluation establishes the The patient should be completely undressed, usuaUy by cut
patient's level of consciousness, pupillary size a11d reaction, ting off his or her garments to facilitate a thorough exami
lateralizing signs, and spinal cord injury level. nation and assessment. After the patient's clothing has been

8 CHAPTER 1 Initial Assessment and Management

injured patient should receive supplemental oxygen. lf not

' ..
intubated, the patient should have mrygen delivered by a
. , .

mask-reservoir device to achieve optimal oxygenation. The

Despite proper attention to all aspects of treating a use of the pulse oximeter is valuable in ensuring adequate
patient with a closed head injury, neurologic deteri-
hemoglobin saturation. .. See Chapter 2: Airway and Ven
oration can occur-often rapidly. The lucid interval
tilatory Management.
classically associated with acute epidural hematoma
is an example of a situation in which the patient will
"talk and die." Frequent neurologic reevaluation CIRCUlATION AND BlEEDING CONTROl
can minimize this problem by allowing for early de
tection of changes. It may be necessary to return to Definitive bleeding control is essential, and intravenous re

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

BREATHING/VENTilATION/OXYGENATION Injured patients can arrive i n the ED with hypother

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


sures should be taken to prevent the loss of body heat and re

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

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

Adjuncts to Primary Survey

found hypovolemia. vVhen bradycardia, aberrant conduc
and Resuscitation tion, and premature beals are p.resent, hypoxia and hypo
perfusion should be suspected immediately. Extreme
Adjuncts that are used during the primary survey and re hypothermia also produces these dysrhythmias. .. See
suscitation phases include electrocardiographic monitoring; Chapter 3: Shock.
urinary and gastric catheters; other monitoring, such as of
ventilatory rate, arterial blood gas (ABG) levels, pulse URINARY AND GASTRIC CATHETERS
oximetry, and blood pressure; and x-ray examination and
diagnostic studies. The placement of urinary and gastric catheters should be
considered as part of the resuscital ion phase. A urine spec
imen should be submitted for routine laboratory analysis.
Electrocardiographic (ECG) monitoring of all trauma pa Urinary Catheters
tients is important. Dysrhythmias-including unexplained Urinruy oul-pul is a sensitive indicator of the patient's vol
tachycardia, atrial fibrillation, premature ventricular con ume status and rcllects renal perfusion. Monitoring of uri
tractions, and ST segment changes-can indicate blunt car nary output is best accomplished by the insertion of an
diac injury. PuJseless electrical activity (PEA) can indicate indwelling bladder catheter. Trru1surethral bladder caLheter
cardiac tamponade, tension pneumothorax, and/or pro- ization is contraindicated in patients in whom urethral tran
section is suspected. Urethral injury should be suspected in
the presence of one of the following:

Blood at the uretJ1 ral meatus

Perineal ecchymosis

Blood i n tJ1 e scrotum

High-riding or nonpalpable prostate

Pelvic fracture

Accordingly, a urinary catheter should not be lilSerted be

fore the rectum and genitalia have been e.xrunined. If urethral
injury is suspected, urethral integrity should be confirmed by
a retrograde urethrogram before the catheter is inserted.

Gastric Catheters
A gastric lube is indicated to reduce stomach clislcnLion and
decrease the risk of aspiration. Decompression of the stom
ach reduces the risk of aspiration, but does nol prevent it
entirely. Thick or semisolid gastTic con len Is will not return
through the tube, and actual passage of Lhe tube can induce
vomiting. For the tube to be effective, it must be positioned
properly, be altachcd lo appropriate suction, and be func
tional. Blood i n the gastric aspirate can be indicative of
oropharyngeal (swaJlowed) blood, traumatic insertion, or

10 CHAPTER 1 Initial Assessment and Management

actual injury to the upper digestive tract. If the cribriform

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


X-ray examination hould be used judiciously and should not
Patient Transfer
delay patient resuscitation. Anteroposterior {AP) chest and
AP pelvic films often provide information that can guide re During the prim<try survey and resuscitation phase, the eval
suscitation eiTorts of pat icnts with blunt trauma. Chest x-rays uating doctor frequently has obtained enough information
cru1 show potentially life- threatening injuries that require to indicate the need Lo transfer the patient to another facil-


. *'
Technical problems may be encountered when per
forming any diagnostic procedure, including fhose
necessary t o identify intraabdominal hemorrhage. id =- --

Obesity and intraluminal bowel gas can com promise

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

ity. This transfer proces:. may be initiated immediately by

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

tained from a patient who has sustained lrauma, and prc

Secondary Survey hopital personnel and family must be consulted to obtain
information that can enhance the understanding of the pa
I Wha t is the secondary survey, and tient':. physiologic state. The AMPLE history is a useful
when does it start? mnemonic for thi!> purpose:

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

12 CHAPTER 1 Initial Assessment and Management

debris, Lhe patient's attempt to escape a fire. lnhalation in

jury and carbon monoxide poisoning often complicate burn
injuries. Therefore, it is in1portant to know the ci.rClU11-
slances of the burn injury. Specifically, knowledge of the en
vironment in which the burn injury occurred (open or
dosed space), the substances consumed by the names (eg,
plastics and chemicals), and any possible associated injmies
sustained, is critical for patient treatment.
Acute or chronic hypothermia vvithout adequate pro
tection against heal loss produces either local or generalized
cold injuries. Significant heat loss can occur at moderate
temperatures ( lS"C to 20"C or 59"F lo 68F) if wet clothes,
decreased activity, and/or vasodilation caused by alcohol or
drugs compromise tbe patient's ability to conserve heaL
Such historical informalion can be obtained from prehos
pital personneL

Hazardous Environment
A history of exposure to chemicals, toxins, and radiation is
important to obtain for two main reasons: first, these agents
can produce a variety of pulmonary, cardiac, and internal
organ dysfunctions in injured patients. Second, these same
agents may also present a hazard to hcalthcare providers.
t=requentJy, the doctor's only means of preparation is to un
derstand the gencraJ principles of management of such con
ditions and establish immediate contact with a Regional
Poison Control Center.

direction of impact, damage to the automobile in terms of

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

Penetra ti ng injury
Thermal Injury
Contact lenses ( remove before edema occurs)
Burns are a significant type of trauma that can occur alone
Dislocation of the lens
or be coupled with blunt and penetrating trauma resulting
from, for example, a bur ning automobile, explosion, fall ing Ocular entrapment


TABLE 1-1 Mechanisms of Injury and Related Suspected Injury Patterns


Cervical spine fractu re

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

Posterior fracture/dislocation of hip and/or knee

Side impact automobile collision Contralateral neck sprain

Cerv1cal spine fraclure

Lateral flail chest

Traumatic aort1c d1srupt1on
Diaphragmatic rupture

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

Cervical spine Injury

Rear impact automobile collision

Soft tissue injury to neck

Ejection from vehicle Ejection from the vehicle precludes meaningful prediction of
injury patterns. but places patient at greater risk from virtually
all Injury mechanisms

Pedestrian struck by motor vehicle Head injury

Traumallc aortic d
isrup lion

Abdominal VIsceral inJuries
Fractured lower extremities/pelvis
,___ _
__ _, ..
_,,,_ .............._,,_.,,. ..... ..... ..... ..... .........................-.........,_,,....
------ -
" '
_ ,,
,_ ...
, ,_...,.

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

Maxil lofacial Structures . I.


Maxillofacial trauma that is not associated \vith airway ob

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

m en t.

14 CH APTER 1 Initial Assessment and Management

and such injury should be presumed until a complete cervical


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

. -

perienced in detecting cervical spine fractures radiographi

cally. Blunt injury to the neck can produce injuries in

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


ations. l n addition, pregnancy tests should be performed on




! ,,._, ._
all females of c h i ldbea ring age.

Elderly patients may not tolerate even relatively

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

Perineum/Rectum/Vagina peri pheral pulses can identify vaM.ular injuries.

Si gn i fica nI ex trem i ty injuries can exist without frac
The peri neu m should be exa mined [or contusi o ns ,

tures being evident on exami nn ti on or x-rays. Ligament rup

hematomas lacerations a nd u rcl hr<l b l eeding. .. Sec Chap
, ,

tures produce joint instability. Muscle-tendon unit injuries

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

i njuries must be considered based on physical findings and

Vaginal examination should be performed in patients
mechanism of i n ju ry. Other injuries can mask the phys i cal
who are at risk ofvaginal injury. T he doctor should assess for
fi nd i ngs ol sp i nal injuries, and they <:an remain undetected
the presence of blood in the vaginal vault and vagi nal Iacer
unless the doctor obtains t he tppropriae x-rays.

The m usculoskeletal examination is not com plete with

out an exam i nation of the pati ent s back. Unl ess the patient s
' '

........: back is examined, significant injuries may be missed. rl' See
Ch a p ter 7: S pi ne and Spi n al Cord Tra uma, and Cha pter 8:
Excessive manipulation of the pelvis should be Musculoskeletal Tra u ma.
avoided, because it may precipitate additional
hemorrhage. The AP pelvic x-ray examination, per
formed as an adjunct to the primary survey and re Neurologic
suscitation, can provide valuable information A com prehensive neu ro logic exam ination i n cludes not on l y
regarding the presence of pelvic fractures, which motor and sensory evaluation of the extrem i tiLs but reeval

are potentially associated with significant blood uation or the patient's lt:vd of co n sc i ousness and pupi l la ry
size and response. The GCS score facilitates detection of
Injury to the retroperitoneal organs may be diffi
early changes <tnd trends i n the neurol ogic status. .. Sec Ap
cult to identify, even with the use of CT. Classic ex
pendix C: Trauma Scores: Revised and Pediatric.
amples include duodenal and pancreatic injuries.
Early consultation with a neurosurgeon is required for
Knowledge of injury mechanism, identification of
patients with neurol ogic in j u ry. Patients should be fre
associated injuries, and a high index of suspicion
are required. Despite the doctor's appro priate dili quently monitored for deterioration in level of conscious
gence, some of these injuries are not diagnosed ness a nd c h an ges in Lhe neu rol og ic examination, as these
initially. find i ngs can reflect progression of the intracranial i nju ry. If
a pati ent wi th u head injury deterior<J lcs neurologically ox-y
Female urethral injury, while uncommon, does

occur in association with pelvic fractures and genation and perfusion of the brain and adequacy of venti
straddle injuries. When present, such injuries are lation (ie, the ABCDEs) must be reassessed . Int rac ra n ial
difficult to detect. su rgical intervention or measures for reducing intracranial
pressure may be necessary. The neurosurgeon will deci de

16 CHAPTER 1 Initial Assessment and Management

rioration in previously noted tindtng:.. As initial life-threat

PITFALLS ening injuries arc managed other equally life-threatening

problem1> and less severe injuries can become apparent. Un

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

Adjuncts to the PITFALL

Secondary Survey Any increase in intracranial pressure (ICP) can reduce

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


developed, reevaluated, and rehearsed frequently to en

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

Records and legal

Specific legal considerations, i n cl uding records, consent for
treatment, and forensic evidence, are relevan t to ATLS

Meticulous record keeping, incl udi ng do cum en t in g the
t ime for all events, is very important. Often more than one
doctor cares for an individual pa tien t. Precise records are
essential to evaluate t he patient s needs and clinical status.

Accurate record keeping du rin g resuscitation can be facili

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

18 CHAPTER 1 Initial Assessment and Management


The correct sequence of priorities for assessment of a multiply injured patient is prepa
ration; triage; primary survey; resuscitation; adjuncts to primary survy and resuscita
tion; consider need for patient transfer; secondary survey, adjuncts to secondary survey;
reevaluation; and definitive care.

The principles of the primary and secondary surveys are appropriate for the assessment
of all multiply injured patients.

e The guidelines and techniques included in the initial resuscitative and definitive-care
phases of treatment should be applied to all multiply injured patients.

A patient's medical history and the mechanism of injury are critical to identifying in

Pitfalls associated with the initial assessment and management of injured patients must
be anticipated and managed to minimize their impact.

The initial assessment of a multiply injured patient follows a sequence of pnorities, as

do the management techniques for primary treatment and stabilization.

e.'l:pcrimental evidence to clinical routine. Advantages and dis

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


Performance at this skill station will allow the partici pant to practice and
Interactive Skill
demonstrate the following activities 1n a simulated clinical situation:


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

0 Establish resuscitation (management) priorities in a multiply injured

patient based on findings from the primary survey.

Integrate appropriate history taking as an invaluable aid in patient


Identify the injury-producing mechanism and describe the injuries

that may exist and/or may be anticipated as a result of the mechanism
of injury.

Using secondary survey techniques, assess the patient from head to


0 Using the primary and secondary survey techniques, reeva luate the
patient's status and response to therapy instituted.

Given a series of x-rays:

Diagnose fractures.
Differentiate associated injuries.

Outline the definitive care necessary to stabilize each patient in

preparation for possible transport to a trauma center or to the closest
appropriate facility.

As referring doctor, communicate with the receiving doctor (instruc

tor) in a logical, sequential manner:
Patient's history, including mechanism of injury
Physical findings
Treatment instituted
Patient's response to therapy
Diagnostic tests performed and results
Need for transport
Method of transportation
Anticipated time of arrival

20 SKILL STATION I Initial Assessment and Management

Skill 1-A: Primary Survey and Resuscitation

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

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

SKILL STATION I Initial Assessment and Management 21

STEP 4. Insert minary and gastric catheters Lmless STEP 6. Consider the need for and perform FAST or
contraindicated, and monitor tJ1e patient's DPL.
hourly output of urine.
STEP 5. Consider tJ1e need for and obtain AP chest and REASSESS PATIENT'S ABCDEs AND

Skill l-8: Secondary Survey and Management

(Also See Table 1-1: Secondary Survey)

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

STEP 9. Assessment
STEP 5. Assessment
A. Inspect for signs of blunt and penetrating A. Inspect the anterior and posterior abdomen
injury, tracheal deviation, and use of for signs of blunt and penetrating injury and
accessory respilatory muscles. internal bleeding.
B. Palpate for tenderness, deformity, swelling, B. Auscultate for Lhe presence of bowel sounds.
subcu taneo us emphysema, tracheal deviaU.on, C. Percuss the abdomen to elicit subtle rebound
and symmetry of pulses. tenderness.

22 SKILL STATION I Initial Assessment and Management

TABLE 1-1 Secondary Survey



level of Seventy of GCS score B. Severe head inJury CT scan

Consciousness head InJury 9-1 2, Moderate Repeat without
head InJUry paralyzmg agents
1 3-15, Minor head injury

Pupils Type of head InJury Stze Mass effect CT scan

Presence of eye injltry Shape Diffuse bram 1njury
Reactivity Ophthalmrc Injury

Head Sealp injury Inspect for lacerations Scalp laceration CT scan

Skull Injury and skull fractures Depressed skull fracture
palpable deretts Basilar skull fracture

Maxillofacial Soft-tissue injury Visual deformity Facial fracture Factal-bone x-ray

Bone injury Maloccluston Soft-tissue InJury CT scan of faoal bones
Nerve Injury Palpation for crepttatlon
Teeth/mouth injury

Neck Laryngeal injury Visual Inspection Laryngeal deform1ty C-sptne x-ray

C-spi ne injury Paipalton Subcutaneous Angtography/duptex
Vascular inJury Auscultation emphysema exam
Esophageal injury Hematoma Csophagoscopy
Neurologtc deficit Bruit Laryngoscopy
Platysma! penetration
Pa1n, tenderness

of c-sptne

Thorax Thoraoc-wail InJury Visual inspectton BrUJStng, deformity, or Chest x-ray

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

Pulmonary contusion MufHed heart tones TF tJilrasound

Thoracic aortic Med1ast1nal crepttation
disruption Severe back pain

AbdomenfFiank Abdominal-wall tnjury V1sual inspecton Abdominal-wall DPUultrasound

lntrapentoneal mJury PalpatiOn pau'l!tendemess CT scan
Retropentoneal tnJury Auscultation Pentoneal trntatton Laparotomy
Determine path Visceral injury Contrast Gl x-ray
of penetratton Retropentoneal organ stud1es
InjUry Angtography

Pelvis GU tract lnJu nes Palpate symphysis GU tract InJury Peiv1c x-ray
Pelvic fracture(s) pu bis for widening (hematuria) GU contrast studies
Palpate bony pelvis Pelvtc fracture Urethrogram
for tenderness Rectal, vaginal, and/or Cystogram
Determine pelvic perineal injury IVP
stability only once Contrast-enh anced CT
Inspect penneum
Rectallvagtnal exam

SKILL STATION I Initial Assessment and Management 23



Spinal Cord Cranial 1n1ury Mototresponse U nilateral cranial Pla1n spine x-rays
Cord injury Pain response mass effect CT Scan
Peripheral nerve(s) Quadriplegia MRI
InJUry Parap legia
Nerve root injury

Vertebral Column Column injury Verbal response to Fracture versus Plain x-rays
Vertebral 1nstab1hty pain, laterahzmg s1gns diSlocation CT scan
Nerve Injury Palpate for tenderness MRI

Extremities Soft-tissue tnJury Visual tnspection Swelling, bruisl ng, Speofic x-rays
Bony deformities Palpation pallor Doppler examination
J01nt abnormalities Malalign ment Compartment pressures
Neurovascular Pain, tenderness , Angiography
defeds crepitation
Tense muscular
Neurologtc defiCitS

- -
--- --

D. Palpate the nbdomcn for tenderness, STEP 13. Vaginal assessment in selected patients. Assess
involuntary muscle guarding, unequivocal for:
rebound tendcrncs. and a gravid uterus. A. Presence of blood in vaginal vault
E. Obtain a pelvic. x-ray film. B. Vaginal lacerations
F. Perform DP!Jabdominal ultrasound, if
G. Obtain cr of Ihe abdomen if the patient is
hemodynamically normal. STEP 14. Assessment
A. lnspect the upper and lower extremities for
STEP 10. Management
evidence of blunt and penetrating injury,
A. Transfer the patient to the operating room,
including contusions, lacerations, and
if indicated.
B. Wrap a sheet around the pelvis or apply a
B. Palpate tht: upper and lower extremities for
pelvic compression hinder as indicated to
tenderness, crepitation, abnormal
reduce pelvic volume and control
movement, and cnsation.
hemorrhage from a pelvic fracture.
C. Palpate all peripheral pulses for presence,
absence, nnd equality.
PERINEUM/RECTUM/VAGINA D. Assess the pelvis for evidence of fracture
and associated hemorrhage.
STEP 11 . Perineal assessment. Assess for:
E. Inspect ami palpnte the tl1oracic and lumbar
A. Contusions and hematomas
spines for evidence of blunt and penetrating
B. Lacerations
i njur)', including contusions, lacerations,
C. Urethral bleeding
tenderness, tkformity, and sensation.
STEP 12. Rectal assessment in selected patients. Assess F. Evaluate the pelvic x-ray film for evidence of
for: a fracture.
A. Rectal blood G. Obtain x-ray films of suspected fracture
B. Anal sphincter tone sites as indicated.
C. Bowel wall integrity
STEP 15. Management
D. Bony fragment!>
A. Apply and/or readjust appropriate splinting
E. Pros tate position
devices for extremity fractures as indica ted.

24 SKILL STATION I Initial Assessment and Management

B. Maintain immobilization of the patient's C. Evaluate the upper and lower e>..'tremities for
thoracic and lumbar spines. motor and sensory functions.
C. Wrap a sheet around the pelvis or apply a D. Observe for lateralizing signs.
pelvic compression binder as indicated to
STEP 17. Mrumgement
reduce pelvic volume and control hemorrhage
A. Continue ventilation and oxygenation.
associated with a pelvic fractme.
B. Maintain adequate immobilization of the
D. Apply a splint to immobilize an e.Ktremity
entire palienl.
E. Administer tetanus i mrnun ization.
F. Administer medications as indicated or as ADJUNCTS TO SECONDARY SURVEY
directed by specialist.
STEP 18. Consider the need for and obtain these
G. Consider the possibility of compartment
diagnostic tests as the patient's condition
permits and warrants:
H. Perfonn a complete nemovascular
Spinal x-rays
examination of the extremities.
CT of the head, chest, abdomen, and/or spine
Contrast urography
NEUROLOGIC Angiography
Extrem i L-y x- rays
STEP 16. Assessment
Transesophageal ultrasound
A . Reevaluate the pupils and level of
. Bronchoscopy
B. Detenninc the GCS score.

-- - --- - ---- - - - - - -.---:.

..,;:---- =-

Skiii i-C: Patient Reevaluation

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

Skill l-0: Transfer to Definitive Care

Outline rationale for palient transfer, transfer procedures,
and patient's needs during transfer, and state the need for
direct doctor-to-doctor conununication.


CHAPTER OUTLINE Upon completion of this topic the student will identify actual

or impending airway obstruction, explain the techniques of es

tablishing a nd maintainin g a patent airway, and confirm the
Introduction adequacy of ventilation Specifica l ly the doctor will be able to:

Problem Recogn1t1on OBJECTIVES
Objective Signs of Airway Obstruction
Ventilation Identify the cl inica l situations in which airway
Problem Recognition compromise is like ly to occur.
Obje<t1ve Stgns of Inadequate Ventilation
Recognize the signs and symptoms of acute airway
Airway Management obstruction.
Airway Maintenance Techniques
Definitive Airway Describe the techniques for establishing and ma in
Airway Decision Scheme ta i n i ng a patent airway.

Management of Oxygenation Describe the tech ni q ues for confirming the ade
Management of Ventilation quacy of ventilation and oxygenation, including
pulse ox i metry and end-tidal C02 monitoring .

Chapter Summary
Bibliography Define the term definitive airway.

Outline the steps necessary for maintaining oxy

genation before, during, and after establishing a
defi nitive airway.

26 CHAPTER 2 Airway and Ventilatory Management


The inadequate delivery of oxygenated blood Lo the brain ..

and other vital structures is the quickest killer of injured pa-

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

Failure to recognize the need for an airway inter

lnabili ty to establish an airway.
Failure to recognize an incorrectly placed airw<l)'

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

The first steps toward identifying and managing potentially

Maxillofacial Trauma
life-threatening ai rway compromise are to recognize prob
lems involving maxillofacial, neck, and laryngeal trauma and Trauma to the face demands aggressive airvvay management.
to identify objective signs of airway obstruction. The mechanism for this injury is exemplified by an unbelted
automobile passenger who is thrown into the windshield
and dashboard. Trauma to the midtace can produce frac
PROBLEM RECOGNITION tures and dislocations that compromise the nasopharynx
Airway compromise can be sudden and complete, insidi and oropha rynx. Facial fractures can be associated vvith
ous and partial, and/or progressive and recurrent. Al hemorrh age, increased secretions, and dislodged teeth,
though it is often related to pain or anxiety or both, wbich cause additional difficulties in maintaini_ng a patent
tachypnea can be a subrle but early sign of airway or ven airway. Fractures of the mandible, especially bilateral body
tilatory compromise. Therefore, assessment and frequent fractures, can cause loss of normal airway support Airway
reassessment of airway patency and adequacy of ventila
tion are critical.
Patients with an altered level of consciousness are at
particular risk for airway compromise and often require a PITFALL -....:-:
:;:. '

Ufll!l "
defmitive airway (a tube placed i n the trachea with the cuff
Trauma patients can vomit and aspirate. Functional
inflated, the tube connected to some form of oxygen-en
suction equipment must be immediate ly available to
riched assisted ventilation, and the airway secured in place aid doctors in ensuring a secure, patent airway in all
with tape). Unconscious patients with head injuries, pa trauma patients.
tients who are obtunded because of the use of alcohol


obstruction can result if the patient is in a supine position. 1 . Hoarseness

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


Several objective signs of airway obstruction can be identi
fied by laking Lhe following steps:

1 . Observe the patient to detetmu1e whether he or she is

agitated or obtuncled. Agitation suggests hypoxia, and
obtundation suggests hypercarbia. Cyanosis indicates
hypoxemia due to inadequate oxygenation; it is iden
tified by inspection of the nail beds and circumoral
skin. Cyanosis is a late finding of hypoxia, and pulse
oximetry is used early in the assessment of airway ob
Figure 2-1 Traumatic Disruption of Trachea, as struction. Look for retractions and the use of acces
seen on radiograph. A definitive airway is urgently re sory muscles of ventilation that, when present,
quired in this situation. provide additional evidence of airway compromise.

28 CHAPTER 2 Airway and Ve ntil ato ry Management

2. Liste n for abnormal sounds. Noisy breath ing is ob 1 . Look for symmetrical rise and [ali of the chesl and ad
structed breathing. Snori ng, gurgl i ng, and crowing equate chest wall excursion. Asymmetry suggests
sounds (stridor) can be associated with pa rtial occlu splinting of the rib cage or a flail d1est. Labored
sion of the pharynx or larynx. Hoarseness (dyspho breathing may iJ)(Iicate <m imminent threat to the pa
nia) implies functional, la ryngeal obstruction. tient's ventilation.
Abusive and belligeren t patients may in fact have hy
2. Liste n for movement of air on both sides of tJ1e chest.
poxia and should not be presumed to be in toxicated.
Decreased or absent breath sounds over o ne or both
3. Peel for the location of the I rac hea and quickly deter hemithoracc:.. should alert the examiner to the pres
mine whether it is in t he midline posit io n. ence of thoracic injury. rl' See Chap ter 4: Th oracic
Trauma. Beware of a rapid respiratory rate-tachy
pnea can indicate respiratory d istres s.

Ventilation 3. Use a pulse oximeter. This device provides informa

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

structed airway is n ot likely to benefit the patien t unless

there is also adequate ventilation. The doctor must recog
nize problems with ventilation and look for objective signs
of inadequate venti lat ion . Airway Management
airway of a trauma patient?
Ventilation can be compromised by airway obstruction, al
tered ventilatory mechanics, or central nervous system (CNS) Airway patency and a dequacy of ventilation must be as
depression. if a patient's breathing is not improved by clear sessed quickly and accu rately. Pulse oximetry and end-tidal
ing the airway, other causes of the problem must be identi C02 measurement are essential. lf problents arc identified
fied and managed Direct trauma to the chest, especially with
or suspected measmes should be instituted immedi a tely to

rib fractures, causes pain with breathing and leads to rapid, improve oxygenation and reduce the risk of furlher ventila
shallow ventilation and hypoxemia. Elderly patients and those tory compromise. These measures include airway mainte
,., pree.xisting pulmonary dysfunction are at significa nt risk nance tech n iq ues, definitive airway measures (including
for ventilatory failure under U1ese circumstances. Intracranial s urgica l ainvay), and methods of providing s upplemental
injury can cause abnoJmal breath ing patterns and compro ventilation. Because all of these actions can require some
mise adequacy of ventilation. Cervical spinal cord injury can neck motion, it is important to maintain cervical spine pro
result in diap hragmat ic breathing and interfere with U1e abil tection in all patien ts esp ecially those who are known to

ity to meet increased oxygen demands. Complete cervical have an unstable cervical sp ine injury and those who have
cord transection, which spares the phrenic nerves (C3 an d been incompletely evaluated and are at risk. The spinal cord
Ol), results in abdominal breathing and paralysis of the in must be pro lected until the possibility of a spinal injury has
tercostal muscles; assisted ventilation may be required. been excluded by clinical assessment and appropriate radi
ographic studies.
Patients who are wearing a helmet and require airway
OBJECTIVE SIGNS OF INADEQUATE VENTILATION management need their head and neck held in a neutral po
I How do I know ventilation sition while the helmet is removed. This is a two-person pro
is adequate ? cedure: One person provides in-line manual immobiUzation
from below, while the second person expands the helmet lat
Several objective signs of inadequate ventilation can be iden
eraUy and removes il liom above (Figure 2-2). Then, in-line
tified by taking the following steps:
manual immo bilizatio n is reestablished from above, and t he
patient s head and neck are secured during airway manage

ment. Removal of the helmet using a cast cutter while sta

PITFA LL bilizing the head and neck can minimi.ze cervical spine
motion in patients with known cervical spine injm y.
Patients who are breathing high concentrations of
High-flow oxygen is required both before and imme
oxygen can maintain their oxygen saturation al
diately after airway management mea.smes are instituted. A
though breathing inadequately. Measure a rteri al or
end-tidal carbon dioxide. rigid suction device is essential and should be readi ly avail
able. Patients with facial injuries can have associated cribri -


A c

Figure 2-2 Helmet Removal. Removing a helmet properly is a two-person pro
cedure. While one person provides manual in-line stabilization of the head and neck
(A), the second person expands the helmet laterally. The second person then removes
the helmet (B), with attention paid to the helmet clearing the nose and the occiput.
Once removed, the first person supports the weight of the patient's head (C), and the
second person takes over inline stabilization (D).

form plate fractures, and Lhe insertion of any rube through bring the chin anterior. The thumb of the same hand lightly
the nose can result in passage into the cranial vault. depresses U1e lower lip to open the mouth (Figure 2-3 ). The
thumb also may be placed behind the lower incisors and, si
multaneously, the chin is gently Hfted. The chin-lift maneu
ver should not hyperextend the neck. This maneuver is
l n patients who have a decreased level of consciousness, the useful for trawna victims because it can prevent converting
longue can fall backward and obstrud the hypopharynx. a cervical fracture \Vithout cord injury into one with cord
This form of obstruction can be corrected readily by the lnJ ury.
chin-lift or jaw-thrust maneuver. The ainvay can then be
maintained with an oropharyngeal or nasopharyngeal air
way. Maneuvers used to establish an airway ca11 produce or Jaw-Thrust Maneuver
aggravate cervical spine injury, so in-line immobilizati.on of
The jaw-thrust maneuver is performed by grasping lhc an
the cervical spine is essential during these procedures.
gles o[ the lower jaw, one hand on each side, and displacing
Lhe mandible forward (Figure 2-4). When Lbis method is
Chin-Lift Maneuver used with the face mask of a bag-mask device, a good seal
In the chin-lift maneuver, the fingers of one hand are placed and adequate ventilation can be achieved. Care must be
under the mandible, which is then gently Hfted upward to taken to prevent neck extension.

30 CHAPTER 2 Airway and Ventilatory Management


Figure 2-3 Chin-lift Maneuver to Establish an

Airway. This maneuver is useful for trauma victims be
cause it can prevent converting a cervical fracture with B
out cord injury into one with cord injury.

Figure 2-5 In this alternative technique, the oral

irway is inserted upside down (A) until the soft palate
2-4 Jaw-Thrust Maneuver to Estab lish an 1s encountered, at which point the device is rotated 180
Fig u re
Airway. Care must be taken to prevent neck extension. degrees and slipped into place over the tongue. (B) This
method should not be used in children.

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


be weU lubricated and inserted into the nostril that ap

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

Laryngeal Mask Ai rway

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

Multilumen Esophageal Airway

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

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

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

Gum Elastic Bougie

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

32 CHAPTER 2 Airway and Ventilatory Management

GEB-aided intubation was successful i n 100% of cases in

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


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

Presence of apnea

Inability to maintain a patent airway by other


Need to protect the lower airway from aspiration of

blood or vomitus

lmpenc..ling or potential compromise of the air

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


TABLE 2-1 Indications for Definitive Airway


Unconscious Apnea
Neuromuscular paralysis


Severe maxillofacial fractures Inadequa te respira tory efforts


1-iyperca rbia


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

Bleeding acute neurologic deterioration occurs
Vom it1ng

Risk for obstruction Mass1ve blood loss and need for volume resuscitation

Neck hematoma
La ryngea I or trachea I injury

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

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

34 CHAPTER 2 Airway and Ventilatory Management

Be Prepared

Suction, 021 bag-mask, laryngoscope, gum elastic bougie
(GEB), laryngeal mask airway (LMA), laryngeal tube airway
(LTA), surgical or needle cricothyroidotomy kit,
endotracheal tube, pulse oximetry, col detection device,
Protect C-Spine!


02 +/- bag-mask +/- oral airway +/- nasal airway

Able to oxygenate?
Definitive airway Surgical airway

Assess airway anatomy

Predict ease of intubation (eg, LEMON)

Call for assistance, if available
Cricoid pressure

Consider adjunct
Consider awake intubation

Definitive airway Surgical airway

The ATl.S airway algorithm provides a general approach to airway management In trauma, MJJny centers
have developed detailed airway management algorithms. lt ls Important to review and learn the standard
used by teams In your trauma system.

Figure 2-10 Airway Decision Scheme. Used for deciding the appropriate route of airway management.


Figure 2- 1 1 Orotracheal
intubation using two-person
technique with inline cervical
spine immobilization.

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

B How do I predict a potentially 4. Apply pressure over the cricoid cartilage.

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

36 CHAPTER 2 Airway and Ventilatory Management

BOX 2-1
LEMON Assessment for Difficult Intubation

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

struction of the airway will make laryngoscopy and

The distance between the patient's incisor teeth
ventilation difficult Such conditions include epiglotti
should be at least 3 finger breadths (3)

tis, peritonsillar abscess, and trauma.

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

The distance between the thyroid notch and cessful intubation. It can be assessed easily by asking
floor of the mouth should be at least 2 finger the patient to place his or her chin onto the chest and
breadths (2) then exte nding the neck so that he or she is looking
toward the ceiling. Patients in a hard collar neck im
M = Mallampati (see below): The hypopharynx mobilizer obviously have no neck movement and are
should be visualized adequately. This has been done therefore more difficult to intubate.
traditionally by assessing the Mallampati classification. Modif1ed w1th permiSSIOn from Reed, MJ, Dunn MJG,
When poss1ble. the patient is asked to sit upright, McKeown DW. Can an airway assessment score pred ict dif
open the mouth fully, and protrude the tongue as far ficuiLy at Intubation 1n the emergency department? Emerg

as possible. The examiner then looks into the mouth Med J 2005;22:99-1 02.

Class 1: soft palate, uvula, Class II: soft palate, Class Ill: soft palate, Class IV: hard palate
fauces, pillars visible uvula, fauces visible base of uvula visible only visible

Mallampati Classifications. Used to visualize the hypopharynx. Class 1: soft palate, uvula, fauces,
pillars visible. Class II: soft palate, uvula, fauces visible. Class Ill: soft palate, base of uvula visible.
Class IV: hard palate only visible.




A c

The 3-3-2 Rule. To allow for alignment of the pharyngeal, laryngeal, and oral axes
and therefore simple intubation, the following relationships should be observed: The
distance between the patient's incisor teeth should be at least 3 finger breadths (A);
the distance between the hyoid bone and the chin should be at least 3 finger breadths
(B); and the distance between the thyroid notch and floor of the mouth should be at
least 2 finger breadths (C).

Etomidate does not have a significant effect on blood the potential for severe hyperkalemia, succinylcholine is not
pressure or intracranial pressure, btlt it can depress adrenal used in patients with severe crush injmies, major burns and
ftmction and is not universally available. This drug does pro electrical injuries, preexisting chronic renal failure, chronic
vide adequate sedation, which is advantageous in these pa paralysis, and chronic neuromuscular disease.
tients. Etomidate and other sedatives must be used with induction agents, such as Lhiopental and sedatives, are
great care 1.0 avoid loss of the airway as the patient becomes potentially dangerous in trauma patients with hypovolemia.
sedated. Then, succinylcholine, which is a short-acting drug, Small doses of diazepam or midazolam are <ppropriate to
is administered. I t has a rapid onset of paralysis (< 1 minute) reduce anxiety in paralyzed patients. .Flurnazenil must be
and a duration of 5 minutes or less. The most dangerous available lo reverse the sedative effects after benzod.iazepines
complication of using sedation and neuromuscular blocking have been admin istered. Practice patterns, drug preferences,
agents is the inability to establish an airway. If endotracheal <md specific procedures for airway management vary among
intubation is unsuccessful, the patient must be ventilated institutions. The principle that the individual using these
with a bag-mask device until the paralysis resolves; long-act techniques needs to be skilled in their usc, knowledgeable
ing drugs arc not routinely used for this reason. Because of of the inherent pitfalls associated with rapid sequence intu-

38 CHAPTER 2 Airway and Ventilatory Management

' 1'
. .
.. _

Equipment failure can occur at the most inoppor

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

hation, and capable of managing the potential complica

tions cannot be overst:lted.

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

Needle Cricothyroidotomy. Insertion of a needle

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


onds that the oxygen is not being delivered under pressure,

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


avoid damage to the cricoid cartilage, which is the only cir

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

gical cricothyroidotomy is not recommended for children Hemoglobin Saturation levels
under 12 years of age. rl' See Chapter
10: Pediatric Trauma.

ln recent years, percutaneous tracheostomy has been re- Pa02 LEVElS 02 HEMOGLOBIN SATURATION LEVELS
ported as an alternative to open tracheostomy. This is not a safe
procedure in the acute trauma situation, because the patient's 90 mm Hg 100%
neck must be hyperex:tended to properly position the head to
perform the procedure safely. Percutaneous tracheostomy re 60 mm Hg 90%
quires the use of a heavy guidewire and sharp dilator, or a
guidewire and multiple or single large-bore dilators. This pro 30 mm Hg 60%
cedure can be dangerous and time-consuming, depending on
See Skill Station ill: Cricothy
the type of equipment used. 27 mm Hg 50%
roidotomy, Skill In-B: Surgical Cricothyroidotomy.

AIRWAY DECISION SCHEME measure the oxygen saturation (02 sat) of arterial blood. It
The airway decision scheme shown in Figure 2-l 0 applies does not measure the partial pressure of oxygen (Pa02) and,
only to patients who are in acute respiratory distress (or who depending on the position of the oxyhemoglobin dissocia
have apnea), who are in need of an immediate airway, and tion curve, the Pa02 can vary widely (see Table 2-2). How
in whom a cervical spine injury is suspected because of the ever, a measured saturation of 95o/o or greater by pulse
mechanism of injury or suggested by the physical examina oximetry is strong corroborating evidence of adequate pe
tion. The first priority is to ensure continued oxygenation ripheral arterial oxygenation (Pa02 >70 mm Hg, or 9.3 kPa).
with maintenance of cervical spine m
i mobilization. This is Pulse oximetry requires intact peripheral perfusion and
accomplished initially by position (ie, chin-lift or jaw-thrust cam1ot distinguish oxyhrmoglobin from carboxyhemoglobin
mru1euver) and the preliminary airway techniques (ie, or methemoglobin, which limits its usefulness in patients with
oropharyngeal airway or nasopharyngeal airway) previously severe vasoconstriction and those with carbon monoxide poi
described. An endotracheal tube is then passed whil.e a sec soning. Profound anemia (hemoglobin <5 g/dL) and hy
ond person provides in-line immobilization. If ru1 endotra pothermia ( <30 C, or <86 F) decrease the reliability of the
cheaJ tube cannot be inserted and the patient's respiratory technique. However, in most trauma patients pulse oximetry
status is in jeopardy, ventilation via a laryngeal mask airway is useful, as the continuous monitoring of oxygen saturation
or other e.xtraglottic airway device may be attempted as a provides an irnmediate assessment of therapeutic interventions.
bridge to a deftnitive airway. If this fails, a cricothyroido
tomy should be performed.
Oxygenation and ventilation must be maintained be
fore, during, and immediately upon completion of insertion , Management of Ventilation
of the definitive airway. Prolonged periods of inadequate or
absent ventilation and oxygenation should be avoided.
a How do I know ventilation is adequate?
Effective ventilation can be achieved by bag-mask techniques.
However, one-person ventilation techniques using a bag-mask
. Management of Oxygenation are less effective than two-person techniques in which both
hands can be used to ensure a good seal. Bag-mask ventilation

a How do I know oxygenation is should be performed by two people whenever possible. rl' See
Skill Station 11: Ainvay and Ventilatory Mcmagement, Skill 11-
C: Bag-Mask Ventilation: Two-Person Technique.
Oxygenated inspired air is best provided via a tight-fitting
oxygen reservoir face mask with a flow rate of at least I I
l!min. Other methods ( eg, nasal catheter, nasal cannula, and ..
";,..... -
nonrebreather mask) can improve inspired oxygen concen -

Gastric distention can occur when ventilating the pa
Because changes in oxygenalion occm rapidly ru1d are
tient with a bag-mask device, which can result in the
impossible to detect clinically, pulse oximetry should be used
patient vomiting and aspi rating. It also can cause dis
when difficulties are anticipated in intubation or ventilation,
tention of the stomach against the vena cava, re
including during transport of criticaliy injured patients. sulting in hypotension and bradycardia.
Pulse oximetry is a noninvasive method to continuously

40 CHAPTER 2 Airway and Ventilatory Management

Intubation of patients with hypo ven ti lat i on and/or With intubation of the trachea accomplished, assisted
apnea patients may not be successful initially and may re ventilation follows, using positive-pressure breathing tech
quire multiple attempts. The pati.enl must be ventilated pe niques. A volume- or pressure-regulated respirator can be
riodically during prolonged efforts to intubate. The doctor used, depending on availability of the equipment. The doc
. ..
should practice taking a deep breath a nd holding it when tor should be alert to the complications of changes in in
intubalion is first anempted. When the doctor must breatl1e, trathoracic pressure, which can convert a simple
the allempted i n t uba tio n is aborted, nnd the patient venti pneumothorax to a tension pnewnothorax, or even create a
lated. pneumothorax secondary to barotrauma.


Clinical situations in which airway compromise is likely to occur include maxillofacial

trauma, neck trauma, laryngeal trauma, and airway obstruction.

Actual or impending airway obstruction should be suspected in all injured patients. Ob

jective signs of airway obstruction include agitation, presentation with obtundation,
cyanosis, abnormal sounds, and a displaced trachea.

f) Techniques for establishing and maintaining a patent airway 1nclude the chin-lift and
jaw-thrust maneuvers, oropharyngeal and nasopharyngeal airways, laryngeal mask air
way, multilumen esophageal airway, and the gum elastic bougie device. With all airway
maneuvers. the cervical spine must be protected by in-line immobilization. The selection
of orotracheal or nasotracheal routes for intubation is based on the experience and skill
level of the doctor.
A surgical airway is indicated whenever an airway IS needed and intubation is un
successfu I.

The assessment of airway patency and adequacy of ventilation must be performed

quickly and accurately. Pulse oximetry and end-tidal C02 measurement are essential.

A definitive airway requires a tube placed In the trachea with the cuff inflated, the tube
connected to some form of oxygen-enriched assisted ventilation, and the airway se
cured in place with tape. A definitive airway should be established if there is any doubt
on the part of the doctor as to the integrity of the patient's airway. A definitive airway
should be placed early after the patient has been ventilated with oxygen-enriched air,
to prevent prolonged periods of apnea.

Oxygenated inspired air is best provided via a tight-fitting oxygen reservoir face mask
with a flow rate of greater than 1 1 Umin. Other methods (eg, nasal catheter, nasal can
nula, and nonrebreather mask) can improve inspired oxygen concentration.


Bibliography taneously breathing anesthet ized adults. Anesthesjo/ogy J 99R;

88(4 ):970-977.

17. Grein AJ, \!\Ieiner GM. Laryngea.l mask airway versus bag-mask
l. Alexander R, Hodgson P, Lomax D, Bullen C. A comparison
ventilation or endotracheal intubation for neonatal resuscita
of the laryngeal mask airway and Gucdel airway, bag'nnd face
tion. Cochrane Database Syst Rev 2005;(2):CD003314.
mask tor manual ventilatjon following formal training. Arwe.s
thesia 1993; 48(3):231-234. 18. Grmec S, Mally S. Prehospital determination of tracheal tube
placement in severe head injury. Emerg Med /2004; 2 1 (4):5 1 8-
2. Aprahamian C, Thompson HM, Finger WA, et al. Experimen
tal cervical spine injury model: evaluation of airway manage
ment and splinting techniques. Ann Emerg Med 1984; 19. GuLldner CV. Resuscit:ltion-opning the airwa)': a compara
13(11):584-587. tive study of techniques for opening an airway obstructed by
the tongue. ! Am Coli Emcrg Physicians 1 976;5:588-590.
3. Asai T, Shingu K. The laryngeal tube. l3r I Annesth 2005;
95(6 ):729-736. 20. Hagberg C, Bogomolny Y, Gilmore C, Gibson V, Kaitner M,
Khurana S. An evaluation of the insert ion and function of a
4. Bergen JM, Smith DC. A review or etomiclate for rapid e
new supraglottic airway device, the !(jng LT, during sponta
quence intubation in the emergency department. } Emerg Med
neous ventilation. Ancsth A1wlg 2006; I 02 (2 ):62 1 - 625.
1 997; 1 5(2):22 1-230.
2 1 . .lserson .KV. Blind nasotracheal intubation. An11 Emcrg Med
5. Brantigan CO, Grow )13 Sr. Cricothyroidotomy: elective use in
1 9 8 1 ; 1 0:468.
respiratory probl ems requiring tracheotomy. I Th oniC C;u
diovasc Surg I 976;71 :72-81. 22. Jabre P, Combes X, Leroux B, Aaron E, Auger 11, Margenct A,
Dhonneur G. Usc of the gum clastic bougie for prehospital dif
6. Combes X. Dumerat. M, Dhonneur G. EmergenC)' gum elas
ficult intubation. A m } .Hmerg Med 2005;23( 4):552-555.
tic bougie-assisted tracheal intubation i n four patients with
upper airway distortion. Can / AnaestlJ 2004; 5 1 ( 1 0):1022- 23. Jorden RC, Moore EE, Marx JA, ct al. A comparison of PTV
1 024. anJ endotracheal ventilation i n an acute trauma model. I
1hwma 1985;25( 10):978-983.
7. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated
difficult airwa)' with recommendations for management. C;m 24. Kidtl JF, Dyson A, Latto JP. Successful difficult intubation. Use
I i\.naestb 1998; 45(8):757-776. of the gum clastic bougie. Anaesth esia 1988;43:437-438.

8 . Dal171 DF, Thomas DM. Nasotracheal intubation in the emer 25. Kress TD, et al. Cricothyroidotomy. Ann Emcrg Mcd
gency department. Grit Cart Med 1980;8( L l ):667-682. 1982; ll:l97.

9. Davies PR, Tighe SQ, Greenslade GL, Evans GH. LaryngeaJ 26. Latto IP, Stacey M, Mecklenburgh J, Vaughan RS. Survey of the
rnask airway and trachea l tube insertion by unskilled pe rson use or the gum elastic bougie in clinical pracl ice. Arwesthesia
nel. Lancet l990; 336(8721 ):977-979. 2002;57(4):379-384.

10. lJogra S, falconer Jt Latto JP. Succtssful difticult intubation. 27. .Levinson MM. Scuderi PE, Gibson RL. et al. Emergency per
Tracheal tube placement over a gum-elastic bougie. Anaesthe cutaneous and transtracheal ventilation. I Am Coli Bmerg
sia 1990; 45(9):774-776. Physicians 1979;8( 10):396-400.
1 1 . Dorges V, Ocker J-1, Wenzel V. Sauer C, Schmucker P. Emer 28. Levitan R, Ochroch EA. Airway management and direct laryn
gency airway management by non-anaesthesia house offi goscopy. A review and update. Grit Care Clin 2000; 16(3):373-
cers-a comparison of three strategies. Emerg Nf ed J 200 I ; 88, v.
29. Macintosh RR. An nid to oral intubation. BM/1949; I :28.
l2. EI-Orbany Ml, Salem MR. Joseph NJ. The Eschmann tracheal
30. Majernick TG, Bieniek R, Houston i e
JB, et aJ: Cervical spn
tube introducer is not gum, clastic, or a bougie. Anesthesiology
movement during orotracheal intubation. Ann Emerg Med
2004; I 0 I ( 5); 1240; author reply 1242- 1240; author reply 1244.
1986;15{4):41 7-420.
13. l:rame S13, Simon JM, Kerstein MD, ct al. Percutaneous
3 1 . Morton T, Brady S, Clancy M. Difficult airwoy equipment in
transtracheal catheter ventilation (PTCV) in com plete ainvay
English emergency departments. Anaesthesia 2000;55(5):485-
obstructions canine model. J '/}auma 1989;29(6):774-781.
14. Fremstad )D, Martin SH. Lethal complia1tion from insertion
32. Nocera A. A flexible solution for emergency intubation diffi
of nasogastric tube after severe basilar skull fracture. J
c ulties. Ann Emerg Med 1996;27(5):665-667.
Trauma 1978; 1 8:820-822.
33. Noguchi T, Koga K, Shiga Y, Shigen"Latsu i\. The gum elastic
15. Gataure PS, Vaughan RS, Latto I P. Simulated difficult intuba
bougie eases tracheal intubation v,rhile applying cricoid pres
tion: comparison of the gum elastic bougie and the stylet.
sure compared to a stylet. Can J Anaesth 2003;50(7):71 2-71 7.
Anaesthesia 1996; 1:935-938.
34. Nolan )P, Wilson ME. A11 evaluation of the gum elastic bougie.
16. Greenberg RS, Brimacombe J, Berry A, Gouzc V,
Piantad<JSi S,
Intubation times and incidence of sore throat. Anaesthesia
Dake EM. A randomjzed controlled trial comp<trLng the cuffed
1992;47( 10):878-88 1.
orophar)'ngeal airwa)' and the laryngeal mask airway in spon-

42 CHAPTER 2 Airway and Ventilatory Management

35. Nolan JP, Wilson ME. Orotracheal intubation in patients with Cornbitube in a Simulated Difficult Airwav Patient Encounter

potential cervical spine injuries. A n indication for the gum ( I n Process Citation ! . Acad Emerg Med 2007;14(5 Suppl
clastic bougie. Anaestlwsia 1993;48(7}:630-633. I ):S22.

36. Oczenski W, Krenn H, Dahaba AA, et al. Complications fol;;;. 42. Seshul MB Sr, SiJ1n DP, Gerlock AJ Jr. The Andy Gump fracture
lowing the use of the Combitube, tracheal tube and laryngeal of the mandible: a cause of respiratory obstruction or distress.
mask airway. Anaesthesia 1999;54 ( 12): 1 1 6 1 - 1 165. j Tiauma 1978;18:61 1-612.

37. Pennant JH, Pace NA, Gajraj NM. Role t)f the laryngeal mask 43. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out
airway in the immobile cervical spine. 1 Clin Anesth of-hospital usc of continuous end-tidal carbon dioxide mon
1993;5(3 }:226-230. itoring on the rate of unrecognized misplaced intubation
within a regional emergency medical services system. Ann
38. Phelan MP. Use of the endotracheal bougie introducer for dil:.
Emerg Med 2005;45( 5) :497-503.
ficuh intubations. Am 1 Emerg Med2004;22(6):479-482.
44. Smith CE, Dejoy $}. New equipment and techniques for air
39. Reed MJ, Dunn M), McKeown DW. Can an ainvay assessment
way management in trauma [ I n Process Citation]. Curr
score predict difficult-y at intubation Ln the emergency depart
Anaeschesiol 2001;14(2}:197-209.
ment? F.mcrg Med /2005;22(2):99- 102.
45. Walter J, Doris PE, Shaffer MA. Clinical presentation of pa
40. Reed MJ, Rennie LM, Dunn MJ, Gray AJ, Robertson CE, McK
tients with acute cervical spine injury. Ann 11merg Med
eown D\V. ls the 'LEMON' method an easily applied emer
1 984; 1 3(7):5 12-5 15.
gency ainvay assessment tool? Eur f Emerg Med
2004;1 1 (3);154- 157. 46. Yeston NS. Noninvasive measurement of blood gases. Infect
Swg 1990;90: 18-24.
4 I . Russi C, Miller L An Out-of-hospital Comparison of the King
LT to Endotracheal Intubation and the Esophageal-Tracheal


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

station is a series of scenarios,

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

Skill II-A: Oropharyngeal

0 Intubate the trachea of an infant intubation manikin with an endo
tracheal tube (within the guidelines listed} and provide effective ven
Airway Insertion
Skill li-B: Nasopharyngeal
Airway Insertion
Describe how trauma affects airway management when performing
oral endotracheal intubation and nasotracheal intubation.

Skiii ii-C:Bag-Mask
Ventilation: Two Person
Using a pulse oximeter:
State the purpose of pulse oximetry monitoring.
Technique Demonstrate the proper use of the device .

Skill 11-D: Adult Orotracheal Describe the indications for its use, its functional limits of accuracy,
Intubation (with and without and possible reasons for malfunction or inaccuracy.
G urn Elastic Bougie Device} Interpret accurately the pulse oximeter monitor readings and re
late their significance to the care of trauma patients.
Laryngeal Mask
Skill 11-E:
Airway (LMA} Insertion Discuss the indications for and use of end-tidal C02 detector devices.
laryngeal Tube
Skiii ii-F:
Airway (LTA) Insertion
Skill 11-G: Infant Endotracheal

SkillIIH: Pulse Oximetry

Skill 11-1: Carbon Dioxide
Detecti on


44 SKILL STATION II Airway and Ventilatory Management

... ' 0" L- --

" T- - "
-" "" -
- - '

Skill II-A: Oropharyngeal Airway Insertion

Note: Thi:. proccdwe is for temporary ventilation while adequately. Be careful not <.:ausc the patient to
preparing to intubate an unconscious pnlienl. gag.

STEP 1. Select the proper-size airway. A correctly sized STEP 4. I nsen Lhe airway posteriorly, gently sliding the
airway over the curvature or the tongue until the
airway extends from the corner of the patient's
device's flange rests on top of the patient's lips.
mouth to the external auditory canal.
The airway must not push the tongue backward
STEP 2. Open the patient's mouth with either the chin and block the airwa)'
lift maneuver or the crosloed finger technique
STEPS. Remove the tont,rue blade.
(scissors technique).
STEP 6. Ventilate the patient with a bag-mask device.
STEP 3 . Insert tongue blade on top of the patient's
tongue f;r enough back to depress the tonj,rue

- - --
- --
---- - -- - - - - .-. - ,

Skill li -B: Nasopharyngeal Airway Insertion

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

STEP 3. Lubricate the Rasopharyng:al airway with a

water-soluble lubricant or tap water.

- - - -
- --- -
- -
---- - -- -
- --- - -- -- -

Skill 11-C: Bag-Mask Ventilation: Two-Person Technique

STEP 1. Select the proper-size mask to lit the patient's face. STEP 4. The first person applies the mask to the patient's
race, ascertaining a Ligh 1 seal with both hands.
STEP 2. Connect the oxygen tubing to the bag-mask
device and adjust I he llow of oxygen lo STEP 5. The second person applies v:ntilation by
12 L/min. queezi ngthe bag with both hands.

STEP 3. Ensure that the patient's airway is patent and STEP 6. Assess the adequacy of ventilntion by observing
secured according to preYiously described the patient's chest movement.
techniques. STEP 7. Apply ventilation in this manner every 5 seconds.

SKILL STATION I I Airway and Ventilatory Management 45

Skill l i-D: Adult Orotracheal lntubation

(with and without Gum Elastic Bougie Device)

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

Ski ii i.I.- E : Laryngeal Mask Airway (LMA) Insertion

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

finger pointing toward the intubator.

STEP 4. Be fore attempting insertion, compl e tely deflate
the LMA cuff by p ress ing it firmly onto a flat STEP 8. Push U1c lllbricated LMA into position along the
surface and lubricate it. palatopharyngeal curve, wilh lhc index finger
maintaining pressure on the tube and guiding

46 SKILL STATION II Airway and Ventilatory Management

the LMA into the final position. STEP 10. Check the placement of the endotracheal tube
by bag-mask-to-tube ventilation.
STEP 9. Inflate the cuff with the correct volume of air
(indicated on the shaft of the LMA). STEP 11. Visually observe chest excursions with


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

STEP 1 . Ensure proper sterilization. behind the base of the tongue.

STEP 2. Inspect all components for visible damage. STEP 12. Rotate the tube back to the midline as the tip
reaches the posterior wall of the pharynx.

STEP 3. Examine the interior of the airway tube to

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

Skiii ii-G: Infant Endotracheal Intubation

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

are 10 progress. of the mouth, moving I he longue to the left .

STEP 2. Select the proper-size uncuffed tube, which should STEP 6. Observe the epiglottis and then the vocal cords.
be the same size as the infanl's nostril or little
STEP 7. Insert the endotracheal tube not more than 2 em
past the cords.
STEP 3. Connect the laryngoscope blade and handle;
STEP 8. Check the placement of the tube by bag-mask
check the light bulb for brill ianee.
to-tube ventilation.
STEP 4. Hold the laryngoscope in the left hand.

SKILL STATION I I Airway and Ventilatory Management 47

STEP 9. Check the placement of the endotracheal tube by helpfulto assess the position of the tube, but it
observing lw1g inflations and auscultating the crumot exdude esophageal i nt ubat i on .

chest and abdomen with a stethoscope.

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

Skiii ii-H: Pulse Oximery Monitoring

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

48 SKILL STATION I I Airway and Ventilatory Management

100 !.,eft Shift

t pH ... -- - - - - - - - - - - - - - - - - - - - - - - - - - - -
-- -
90 l. Temperature -
J Paco2 ;;
; - - - - - - -- - - - -
- -- - - - - -
-- --
! 2,3-dpg , ;. --

, -
, -
c , -
0 ,
I , ,, Right Shift
ov ,
.._ 60 , ,,
, , l pH
' ,
I , T Temperature
' ,
"' 50 ' ,
0 ' '
, t Paco2
' ,
' I t 2,3-dpg
' ,

I ,
I ,
I ,
, ,
, ,,
27 30 50 60 90 100
Pao2 (mm Hg/kPa)

Figure 11 -1 Relationship between partial pressure of oxygen in arterial blood (Pa02} and %Sa02

Skill Il- l : Carbon Dioxide Detection

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

SKILL STATION I I Airway and Ventilatory Management 49



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

mask. Shortly after his arrival in the ED, he begins to vomit.

A 35-year-old male sustains blunt chest trauma during a
single-motor-vehicle collision. [ n the ED, he is alert and
The patient described i n the first Scenario II- I is now W1fe has evidence of a right-chest-wall contusion. He has
sponsivc and has un dergon e endotracheal intubation. Ven point tenderness and fracture crepitation of several right
tilation with 100% oxygen is being applied. Part of his ribs. His GCS score is 14. He is immobilized with a semi
evaluation includes a CT scan ofhis brain. After he is trans rigid cervical spine collar and secured to a long back
ported to radiology for the scan, the pulse oxjmeter reveals board. High-ilm-v oxygen is being administered via a face
82% Sa01 mask.


Performance at th 1s skill station will allow the student to pract1ce and demon
Interactive Skill
strate the techniques of needle cricothyroidotomy and surgical cricothyroido
tomy on a live anesthetized animal, a fresh human cadaver, or an anatomic

Note: Standard precautions are human body maniki n Specifically, the student will be able to:

required whenever caring for

trauma patients.

Identify the surface markings and stru ctures t o be noted when per
forming needle and surgical cricothyroidotomies.

Skill lil-A: Needle State the indications and complications of needle and surgica l
Cricothyroidotomy cricothyroidotomies.

Skill 111-B: Surgical Perform needle and surgical cricothyroidotomies on a live, anes
Cricothyroidotomy thetized animal, a fresh human cadaver, or an anatomic human body
manikin, as outlined in this skil l station.


52 SKILL STATION Ill Cricothyroidotomy

Skill 111-A: NeedJe Cricothyroidotomy

STEP 1. Assemble and prepare oxygen tubing by cutting a STEP 10. Remove the syringe and withdraw the stylet,
hole toward one end of the tubing. Connect the \vhile gently advancing the catheter downward
other end of the oxygen tubing to an oxygen into position, Laking care not to perforate the
source capable of delivering 50 psi or greater at posterior wall of the trachea.
Lhe nipple, and ensure the free flow of oxygen
STEP 11. Attach Lhe oxygen tubing over the catheter
through the tubing.
needle hub, and secure the catheter to the
STEP 2. Place Lhe pa ti en t in a supine position. patien t s neck.

STEP 3. Assemble a 12- or 14-gauge, 8.5-crn, over-the STEP 12. Intermittent ventilation can be achieved bv '

needle catheter to a 6- to 12-mL syringe. occluding the open hole cut into the oxygen
tubu1g \.vith your thumb for 1 second and

STEP 4. Surgically prepare the neck using antiseptic

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

Skill lll -8: Surgical Cricothyroidotomy

(See Figure 1/1- 1)

STEP 1. Place tl1e patient in a supine position with the STEP 6. Make a transverse skin incision over the
neck in a neutral position. cricothyroid membrane, and carefully incise
through the membrane transversely.
STEP 2. Palpate the thyroid notch, cricothyroid interval,
and the sternal notch for orienlaLion. STEP 7. Insert hemostat or tracheal spreader into the
incision and rota te it 90 degrees to open the
STEP 3. Assemble Lhe necessary equipment. .

STEP 4. Snrgically prepaTe and anesthetize the area
STEP 8. insert a proper-size, cuffed endotracheal tube or
locally, if the patient i s conscious.
tracheostomy tube (usually a number 5 or 6) into
STEP 5. Stabilize the thyroid cartilage with the left hand the cricoLhyroid membrane incision, directing
and maintain stabilization until Lhe hachea is the tube distally into the trachea.

SKILL STATION Ill Cricothyroidotomy 53

Step 2

Thyroid notch

[_-- Thyroid cartilage

Step 6 Step 7 Step 8

Figure 111- 1 Surgical Cricothyroidotomy. (Illustrations correlate with selected steps in Skill Ill-B.)

STEP 9. lnflale the cuff and apply ventilation. COMPLICATIONS OF SURGICAL

STEP 10. Observe lung inflations and auscultate the chest
for adequate ventilation. Aspiration (eg, blood)
Creation of a false passage into the tissues
STEP 11. Secure the endotracheal or tTacheoslomy tube to
Subglottic stenosis/edema
the patient to prevent dislodging.
Laryngeal stenosis
STEP 12. Caution: Do not cut or remove the cricoid Hemorrhage or hematoma formation
and/or thyroid cartilages. Laceration of the esophagus
Laceration of the trachea
Mediastinal emphysema
Vocal cord paralysis, hoarseness


CHAPTER OUTLINE Upon completion of this topic, the student will ident1fy and
apply princ1ples of management related to the in it ia l dia g no
sis and t reatmenL of shock in injured patients. Specifically, the
Introduction doctor will be able to:
Shock Pathophysiology
Basic Cardiac Physiology OBJECTIVES
Blood Loss Pathophysiology
Initial Patient Assessment
Define shock and apply this definition to clinical
Recognition of Shock practice.
Clinical Different1at1on of Cause of Shock
Recognize the clinical shock syndrome and corre
Hemorrhagic Shock in Injured Patients late a patient's a cute clinical signs with the degree
Definition of Hemorrhage of volume deficit.
Direct Effects of Hemorrhage
FlUid Changes Secondary to Soft Tissue Injury Explain the importance of early identification a nd
control of the source of he morrhage i n trauma pa
Initial Management of Hemorrhagic Shock ti ents

Phys1cal Examination
Vascular Access Lmes Compare and contrast the clinical presentation of
Initial Fluid Therapy patients with various causes of the shock state.
Evaluation of Fluid Resuscitation and Organ
Describe the ma n agem ent a nd on goi n g evalua
tion of he mor rhag ic shock.
Uri nary Output
Acid/Base Balance Recog n ize t h e p hysi ol og ic responses to resuscita
Therapeutic Decisions Based on Response to tion in order to continually reassess patient re
Initial Fluid Resuscitation sponse and avo id com pl ications .

Rapid Response
Transient Response
Minimal or No Response
Blood Replacement
Crossmatched, Type-Specific, and Type 0 Blood Medications
Warming Fluids-Plasma and Crystalloid Hypothermia
Autotransfusion Pacemaker
Reassessing Patient Response and Avoiding
Calcium Administration
Special Considerations in the Diagnosis and Treatment Continued Hemorrhage
of Shock Fluid Overload and CVP Monitoring
Equatmg Blood Pressure w1th Cardiac Output Recogn i tion of Other Problems
Advanced Age
Chapter Summary
Ath letes
Pregnancy Bibliography

56 CHAPTER 3 Shock

Myocardial contractility

The initial step in managing shock in injured patients is to Afterload

recognize its presence. No laboratory test diagnoses shock;

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

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


Heart rate Stroke volume -

Cardiac output
X -

(beats /min) (eelbeat) (LI mm)

Preload Myocardial Afterload


Systemic arteries

Figure 3-1 Cardiac Output.

does not contribute to mean systemic venous pressure. marked increac m i ntersti t ial edema, which is caused by
However, this compensatory mechanism is limited. The "reperfusion injury" to the capillary interstitial membrane.
most effective method of restoring adequate cardiac output As a result, larger volumes of fluid may be required for re
and end organ perfusion i11 to restore venous return to nor suscitation than initially anticipated.
mal by volume repletion. The initial treatment of shock is directed toward restor
At the cellular level, inadequately perfused and m.:y ing cellular and organ perfusion wilh adequately m.')'genated
ge nated cells arc deprived of essential substrates for normal blood. Control of hemorrhage and restoration of adequate
aerobic metnbolism and enc.:rgy production. Initially, com circulating volume are the goals of treatment of hemor
pensation QCl.U rs by shifting to anaerobic metabolism, rhagic shock. With the possible exception of' penetrating
which rcsuhs in the formation of lactic acid and. the devel t nwma Lo the torso without bead injury, euvolemia should
opment of metabolic acidosi1.. l f shock is prolonged and be maintained. Vasopressors are contraindicated for the
substrate delivery for the generation of adenosine triphos trealment of hemorrhagic shock because they worsen tissue
phate (ATP) is inadequate, the ce!Jular membrane loses the perfusion. Frequent monitoring of the patient's indices of
ability to maintain its integrity, and the normal electrical perfusion is necessary to evaluate the response to therapy
gradient is lost. and detect deterioration in the patient's condition as early as
Swelling of the endoplasmic reticulum is the first ul possible.
trastructural evidence of cellular hypoxia. Mitochondrial Most injured patients who are in hypovolemic shock
da mage soon follows. Lysosomes rupture and release en- require early surgical intcrvcnlton to reverse the shock state.
7ymes that digest ot her intracellular structural elements. The presence ofshock in an injured patient warrants the im
Sodium and water enter the cel l and cellular swelling oc
, mediate involvement of a surgeon.
curs. Intracellular calcium deposition also occurs. I f the
process is not reversed, progressive cellular damage, addi
tional tissue swelling, and cellular death occur. This
process compound:. the impact of blood loss and hypo
Initial Patient Assessment
The administration l>f a sufficient quantity of isotonic
electrolyte solutions helps combat this process. Patient treat Optimally, doctors will recognize the shock state during the
ment is directed toward reversing the shock state by pro in it i<ll patient nlisessmen t. To do so, it is important to be fa
viding adequate oxygenation, ventilation, and appropriate miliar with the clinical differentiation of the causes of
lluid resuscitation. Resuscitation may be accompanied by a shock-chiefly, hemorrhagic and nonhemorrhagic.

58 CHAPTER 3 Shock

RECOGNITION OF SHOCK of the body to increase the heart rate also may he limited hy
the presence of a pacemaker. A narrowed pulse pressure sug
I Is the patient in shock? gests significant blood loss and involvement of compensa
Profound circulatory shock-evidenced by hemody; tory mechanisms.
namic collape with inad(!quate per fusion of the skin, Labor<tory values for hematocrit or hemoglobin con
kidney, and central nervou> system-is simple to recog centration are unreliable for estimating acute blood loss
ni;e. However, after the airway and adequate ventilation and inappropriate for diagnosing shock. Massive blood loss
have been ensured, careful evaluation of the patient's cir may produce only a minimal acute decrease in the hemat
culatory status is necessary to identify early man ifesta ocrit or hemoglobin concentration. Thus, a very low hcma
tions of shock, including tachycardia and cutaneous t<)Lrit value obtained shortly after injur)' suggests massive
vasoconstriction. blood loss or a preexisting anemia, whereas a nonnal hcma
Reliance solely on systolic blood pressure as an indi toCJit does not exclude significant blood loss. Base deficit
cator ol shock may result in delayed recognition of the and/or lactate levels may be useful in determining the pres
shock state. Compensatory mechanisms may preclude a ence and severity of shock. Serial measurement of these pa

measurable fall in systolic pressure until up to 30% of the rameters may be used to monitor a patient's response to
pa lien I':. blood vol is lost. Spcci fie allen tion should therapy.
be directed to pulse rate, respiratory rate, skin circulation,
and pulse pressure (the difference between systolic and di CLINICAL D I FFERENTIATION
astolic pressure). Tachycardia and cutaneous vasocon OF CAUSE OF SHOCK
striction are the typical early physiologic responses to
volume loss in most adults. Any injured patient who is cool I What is the cause of the shock state?
and has tachycardia is considered to be in shock until Shock in a trauma patient is clasified as hemorrhagic or
proven otherwise. Occasionally, a normal heart rate or nonhemorrhagic. A patient with injuries above the di
even bradycardia is associated with an acute reduction of aphragm mil)' have evidence of inadequate organ perfusion
blood volume. Other indice> of perfusion must be moni due ro poor cardiac performance from blunt myocardial in
tored in these situations. jury, cardiac tamponade, or a tension pneumothorax Lhat
The normal heart rate varies with age. Tachycardia is produces inadequate venous return ( preload). A high index
present when the heart rate is greater than 160 in an infant, of suspicion and careful observation of the patient's re
140 in a preschool-age child, 120 in children from school l.ponsc to initial treatment will enable the doctor to recog
age to puberty, and 100 in an adult. Elderly patients may not nize and manage all forms of shock.
exhibit tachycardia because of their limited cardiac response Initial determination of the cause of shock depends on
to catecholamine stimulation or the concurrent usc of med taking an appropriate history and performing a careful
ications, such as B-adrenergic blocking agents. The ability physical examination. Selected additional tests, such as
monitoring central venous pressure (CVP) and obtaining
data from a pulmonary artery catJ1etcr, chest and/or pelvic
x-ray examinations, and ultrasonogrnphy, may provide con
li rma tory evidence for the cause of the shock state, but
should not delay aggressive volume restoration.

Hemorrhagic Shock
Hemorrhage is the most common cause of shock after in
jury, and virtually all patients with multiple injuries have an
dement of hypovolemia. ln addition, most non hemorrhagic
shock states respond partially or brieOy to volume resusci
tation. Therefore, iJ signs of shock arc present, treatment
usually is instituted as i f the pa ticnt is hypovolemic. How
ever, as treatment is instituted, it is important to identify the
small number of patients whoe >hock has a different cause
(eg, a secondary condition such all cardiac tamponade, ten
sion pneumothorax, spinal cord injury, or blunt cardiac in
jury, which complicates hypovolemic/hemorrhagic shock).
Specific information about the treatment of hemorrhagic
shock is provided in the next section of this chapter. The
primary focus in hemorrhagic shock is to identify and stop
hemorrhage promptly.


Nonhemorrhagic Shock
Nonhemorrhagic shock includes cardiogenic shock, cardiac PITFA LLS
tamponade, tension pnetunothorax, neurogenic shock, and Missing tension pneumothorax.
septic shock.
Assuming there is only one cause for shock.
Young, healthy patients may have compensation
Cardiogenic Shock Myocardial dysfunction may be for an extended period and then crash quickly.
caused by blunt cardiac injury, cardiac tamponade, an nir
embolus, or, rarely, a myocardial infarction associated with
the patient's injury. l3lunl cardiac injury should be suspected
when the mecha nism of injury to the thor<L'< is rapid decel
eration. All patients with blunt thoracic trauma need con Neurogenic Shock Isolated intracranial i njuries do not
stan t electrocardiographic (ECG) monitoring to detect cause shock. The presence of shock in a patient with a
injury patterns and dysrhytJ1mias. Blood creatine kinase (CK; head. injury necessitates a search for a cause other than a n
fo rmerly, creatine phosphokinase I CPKJ) i soenzymes and intracranial injury. Spinal cord injury may produce hy
specific isotope studies of the myocardium rarely assist the potension due to loss of sympathetic tone. Loss of sympa
doctor in diagnosing or treating patients in the emergency thetic tone compounds the physiologic effects of
department (ED). Echocardiography may be useful in the di hypovolemia, and hypo vo lemi a compounds the physio
agnosis of tamponade and valvular rupture, but it is often logic effects of sympalhetic denervation. The classic pic
not pradical or immediately available in the ED. Focused as ture of neurogenic shock is hypotension without
sessment sonography in trauma (FAST) in the ED can iden tachycardia or cutaneous vasoconstriction. A narrowed
tify pericardia! fluid and the likelihood of cardiac tamponade pulse pressure is not seen in neurogenic shock. Pa ticn ts
as the cause of shock. Blunt cardiac injury may be an indica who have sustained a spinal injury often have concurrent
tion for early CVP monitoring to guide fluid resuscitation i n torso trauma; therefore, patients with lUlown or suspected
this situation. neurogenic shock should be treated initially for hypov
Cardiac tamponade is most commonly identified in olemia. The failure of Auid resuscitation to restore organ
penetrating thoracic trauma, but it may occur as the result perfusion suggests either conti n u ing hemorrh age or neu
of blunt injury to the thorax. Tachycardia muffled heart
rogenic shock. CVP monitoring may he helpful in manag
sounds, and dilated, engorged neck veins with hypotension ing this sometimes complex problem . .. See Chapter 7:
resistant to lluid therapy suggest cardiac tamponade. How Spine and Spinal Cord Trauma.
ever, the absence o r these classic findings does not exclude
the presence of this condition. Tension pnew11othorax may Septic Shock Shock due to infection i m med ia tely after
mimic cardiac tamponade, but i t is differentiated from the injury is uncommon; however, if a patient's arrival at an
latter condition by the findings of absent breath sounds and emergency facility is delayed for several h ours, i t could
a hyperresonant percussion note over the affected hem i tho occur. Septic shock may occur in patients with penetrat
rax. Approp ri ate placement of a needle into the pleural ing abdominal injuries and contamination of the peri
space i n a case of tension pneumothorax tempo rar i ly re toneal cavity by intestinal contents. Patients \ sepsis
lieves this li fe-th reatening condition. Cardiac tamponade who also have hypotension and are afebrile arc clinically
is best managed by thoracotomy. Pericardiocentesis may be difficult to d is tinguish from those in hypovolemic shock,
used as a temporizing maneuver when tho racotomy is not as both groups may manifest tachycardia, cutaneous vaso
an available option. .. See Skill Station VII: Chest Trauma constriction, impaired urinary output, decreased systolic
Management, Skill V 11-C: Pericardiocentesis. pressure, and narrow pulse pressure. Patients with early
septic shock may have a normal circulating volume, mod
Tension Pneumothorax Tension pneumothorax is a est tachycardia, warm, pink skin, systolic pressure near
true surgical emergency that requires immediate diagnosis normal, and a wide pulse pressure.
and treatment. I t develops when air enters the pleural space,
but a flap-valve mechanism prevents its escape. LntrapleuraJ
pressure rises, causing total lung collapse and a shift of the
mediastimtm to the opposite side with a subsequent impair Hemorrhagic Shock
ment of venous return and fall i n cardiac output. The pres
ence of acute respiratory distress, subcutaneous emphysema,
in Injured Patients
absent breath souJ1ds, hyperresonance to percussion, and tra
cheal shift supports the diagnosis and warrants immediate Hemorrhage is the most common cause ofshock in trauma pa
thoracic decompression without waiting for x-ray confir tients. The trawna patient's response to blood loss is made
mation of the diagnosis . See Skill Station Vli: Chest more complex by shifts of fluids among the fluid compart
Trauma Management, Skill VI l-A: Needle Tho racentesis. ments in lhe body-particularly in the extracellular fluid com-

60 CHAPTER 3 Shock

partment. The classic response to blood loss must be consid It is dangerous to wait until the trauma patient fits a pre
ered in the context of fluid shifts associated with soft tissue in cise physiologic classification of shock before initiating ag
jwy. ln addition, the changes associated with severe, prolonged gressive volume restoration. Fluid resuscitation must be
shock and the pathophysiologic results of resuscitation and initiated when early signs and symptoms of blood loss are ap
rcpcrfusion must also be considered, as previously discussed. parent or suspected, not when the blood pressure is falling
or absent.

Class I Hemorrhage-Up to 1 5 %
Hemorrhage is defined as an acute loss o f circulating blood
Blood Volume loss
volume. Although there is considerable variability, the nor
mal adult blood volume is approximately 7% of body The clinical symptoms of volume loss with class I hemor
rhage arc minimal. In uncomplicated situations, minimal
weight For example, a 70-kg male has a ciTcnlating blood
tachycardia occurs. No measurable changes occur in blood
volume of approximately 5 L. The blood volume of obese
pressure, pulse pressure, or respiratory rate. For otherwise
adults is estimated based on their ideal body weight, because

healthy patients, this amount of blood loss does not require

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


TABLE 31 Estimated Blood lossa Based on Patient's Initial Presentationb


Blood loss (ml) Up to 7 50 750-1500 1 500-2000 >2000

Blood loss (% blood volume) Upto 1 5 % 1 5%-30% 30%-40% >40%

Pulse rate <100 100-120 1 20-140 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased

Respiratory rate 14-20 20-30 30-40 >35

Urine output (mLJhr) >30 20-30 5-15 Negl igi ble

CNSimental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic

Fluid replacement Crystalloid crystalloi d crystalloid and blood Crystalloid and blood

For a 70-kg male.

"The gu1delines 1n th1s table are based on the 3-for-1 (3: 1) rule, which derives irom the emp1nc observation that most pat1ents m hem
orrhagiC shock requ1re as much as 300 ml of electrolyte solut1on for each 100 ml of blood loss. Applied blindly, these guidelines may
result in excessive or Inadequate fluid admimstration For example, a patient with a crush Injury to an extrem1ty may have hypotension
that is mrt of proportiOn lo his or her blood loss and may require fluids in excess of the 3:1 guidelines. In contrast, a pati ent whose on
going blood loss is being replaced by blood transfusion reqwes less than 3 I. The use of bolus therapy With careful monitoring of the
patient's response may moderate these extremes.

agement is to stop the hemorrhage, by emergency operation kg patient with hypotension who arrives at an ED or trauma
if necessary, in order to decrease the need for transfusion. center has lost an estimated 1470 mL of blood (70 kg x 7%
The decision to transfuse blood is based on the patient's re x 30% = 1.47 L, or 1470 mL). Nonresponse to admin
sponse to initial fluid resuscitation and the adequacy of end istration indicates persiste nt blood loss. unrecognized fluid
organ perfusion and oxygenation, as described later in this losses, or nonhemorrhagic shock.

Class IV Hemorrhage-More than 40%

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

62 CHAPTER 3 Shock

with the rapid reestablishment of intravascular volume by

PITFALL '' .. - intr<lvenous fluid infusion. The adequacy of tissue perfusion
' "'
- <:_ . "

dictate:. the amount of 11uid resuscitation required. Surgery

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


Find the source of bleeding.

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

nasally or orally and attaching il to 5l1Ction to evacuate gas

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

supplied to ma i ntain oxygen saturation at greater than 95o/o.

nn absolutecontraindication to the insertion of a
. Sec Chapler 2: Airway a nd Vent ilatory Ma 11ageme nt.
Ira nsu rethral catheter prior to rad iogra phic confirmation
of a 11 intact urethra. rl' Sec Chapter 5: Abdominal and Pelvic
Circulation-Hemorrhage Control Trauma.
Priorities for the circulation include controlling obvious
hemorrhage, obtaining adequate intravenous access, and as
sessing tissue perfusion. Bleeding from external wounds
usually can be controlled by direct pressure to the bleeding Access to the vascular system must be obtained promptly.
site. A PASG may be used to control bleeding from pelvic or Thill i best done by i nsen ing two large caliber (minimum

lower extremity fractures, but its u:.e should J/Ot in terfere of 16-gauge) peripheral in travenous cathetcrs before placing


a central venous line is considered. The rate of flow is pro

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

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

64 CHAPTER 3 Shock

adequate resuscitation. This situation should stimulate fur

PITFALL ther volume replacement and diagnostic endeavors.

Recognize the source of occult hemorrhage. Re

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

Evaluation of Fluid Resuscitation

and Organ Perfusion
Therapeutic Decisions Based
I) What is the patient's response? on Response to Initial Fluid
The same signs and symptoms of inadequate perfusion that Resuscitation
are used to diagnose shock are useful determinants of pa
ti.enl response. The return of normal blood pressure, pulse The patient's response to initial fluid resuscitation is the key
pressure, and pulse rate are signs that suggest perfusion is to determining subsequent therapy. Having established a
returning to normal. However, these observations give no preliminary diagnosis and treatment plan based on the ini
information regarding organ perfusion. Improvements in tial evaluation, the doctor now modifies the plan based on
the CVP status and skin circulation are important evidence the patient's response. Observing the response to the initial
of enhanced perfusion, but are difficult to quantitate. The resuscitation identifies palients whose blood loss was greater
volmne of urinary outpul is a reasonably sensitive indica than estimated and those with ongoing bleeding who re
tor of renal perfusion; normal urine volumes generally quire operative control of internal hemorrhage Resuscita

imply adequate renal blood flow, if not modified by the ad tion in the operaLing room can accomplish simultaneously
ministration of diuretic agents. For this reason, urinary out the direct control of bleeding by the surgeon and the
put is one ofthe prime monitors of resuscitation and patient restoration of intravascular volume.ln addition, it limits the
response. Changes in CVP can provide useful information, probability of overtransfusion or unnecessary transfusion
and the risks incurred in the p lacement of a CVP line arc of blood in patients whose initial status was disproportion
justified for complex cases. Measurement of CVP is ade ate to the amount of blood loss.
quate for most cases. It is particularly im port ant to distinguish patients who
are "hemodynamically stable" from those who are "hemo
dynamically normal A hemodynamically stabl-e p at ient

may have persistent tachycardia, tachypnea, and oliguria
\IVithin certain limits, urinary o u tp ut is used Lo monitor clearly underresuscitated and stiU in shock. In contrast, a he
renal blood flow. Adequate resuscitation volume replace modynamically normal patient is on e who exhibits no signs
ment should produce a urinary output of approximately 0.5 of inadequate tissue perfusion. The potential patterns of re
mL/kg/hr in adults, whereas 1 mL/kg!hr is an adequate uri sponse to initial fluid administration can be divided into
nary output for pediatric patients. For children under I year three groups: rapid response, transient response, and mini
of age, 2 mL/kg/hour should be maintained. The in ability mal or no response. Vital signs and management guidelines
to obtain urinary output at these levels or a decreasi ng uri for patients in each of these categories are outlined in Table
nary output with an increasing sp ecific grav ity suggests in-
- 3-2.


TABLE 3-2 Responses to Initial Fluid Resuscitationa



Vital signs Return to normal Transient Improvement, Remain

recurrence of decreased abnorma l
blood pressure and
increased hean. rate

Estimated blood loss Minima l Moderate and Severe

(1 0%-20%) ongoing (>40%)

Need for more crystalloid Low Hrgh High

Need for blood Low Moderate to hgh Immediate

Blood preparation Type and Type-spedtic Emergency

crossmatch blood release

Need for operative Possibly Likely Hrghly likely


Early presence of Yes Yes Yes


2000 mL of 1sotomc solution 1n adults; 20 mUkg bolus o1 Rnger's lactate in children.

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

Patients in the second group, termed "transient respon

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

66 CHAPTER 3 Shock

lection, anticoagulation (generally with sodium citrate so

Blood Replacement lutions, not heparin), and retransfusion of shed blood. Col
lection of shed blood for autotransfusion should be
The decision to initiate blood transfusion is based on the considered for any patient with n major hemothorax.
patient's response, as described in the previous section.

Severe injury and hemorrhage result in the consumption ofco
agulation factors and early coagulopathy. Massive transfusion
The main purpose of blood transfusion i:.; to restore the with the resultant dilution of platelets and dotting factors,
m.-ygen-carrying capacity of the intravascular volume. Vol along with the adverse effect of hypothermia on platelet aggre
ume remcitation itself can be accomplished with crystal gation and he t clotting cascade, all contribute to coagulopathy
loids, with the added advantage that it contributes to in injured patients. Prothrombin time, partial thromboplastin
interstitial and intracellular volume restitution_ time, and platelet count are valuable baseline studies to obtain

fully crossmatched blood is preferable. However, the in the first hour, especially if the patient has a history of coag
complete crossmatching process requires approximately I ulation disorders, takes medications that alter coagulation (cg,
hour in most blood banks. For patients who stabilize rapidly, warfarin, aspirin, and nonsteroidal antiinflan1matory agents
crossm.llchcd blood should be obtained and made available [NSATDs]}, or a reliable bleeding history cannot be obtained.
for transfusion when indicated. Transfusion of platelets, cryoprecipitate, and fresh-frozen
lypc-specific blood can be provided by most blood plasma should be guided by these coagulation parameters, in
banks within I 0 minutes. Such blood i compatible with cluding fibrinogen levels. Routine Ul>C ofsuch products s i gen

ABO and Rh blood types, but incompatibilities of other erally not warranted unless the patient has a known coagulation
antibodies may exist. Type-specific blood is preferred for disorder or has undergone anticoagulation pharmacologically
patients who are transient responders, as described in the for management of a specific medical problem. Tn such cases,
previous seclion. If type-specific blood is required, com spcciflc f:1ctor replacement Lher<"py is immediately indicated
plete crossmatching should be pt:rformcd by the blood when there is evidence of bleeding, l>r the potential for occult
bank. blood loss exists (eg, head, abdominul, or thoracic injury).
II" type-specific blood is unavailable, type 0 packed However, consideration of early blood component therapy
cells arc indicated for patient:. with exl!.mg uinating hem should be given to patients with class IV hemorrhage.
orrhage. lo avoid sensitization and future complications, Patients with major brain injury are particularly prone
Rh negative cells are preferred for fem.tle of childbear to coagulation abnormalities as a result of substances, espe
ing age. For life-threatening blood loss, the usc o f un cially tissue thromboplastin, that arc released by damaged
matched, type-specific blood is prderrcd over type 0 neural tissue. Th.:se patients .:o.Jgul.lliPil P'r1'11c'lers need to
blood. This is I rue unless multiple, unidcntifiec.J casualties h do.l'il munilored.
are being treated simultaneously <nd the risk of inadver
l:ntly <HJministcring the wrong llllil or bJood tO a patient
is great.
Most patients receiving blood transfusions do not need calcium
supplements. Excessive, supplemental calcium may be harmful.
Hypothermia must be prevented and reversed if a patient
has hypothermia on arrival at the hospital. The use of blood Special Considerations in the
warmer!> in the ED is desirable, even if cumbersome. The
mot efficient way to prevent hypothermia in any patient re
Diagnosis and Treatment of Shock
ceiving massive volumes of crystalloid is to hcnt Lhe fluid to
39 C: ( I 02.2" F) before using it. This can be accomplished by !:lpecial considerations in the diagnosis and treatment of shock
storing crystalloids in a warmer or with the usc of a mi include the mistaken equation of blood pre!.stue with cardiac
crowave oven. Blood products cannot be warmed in a mi output; patient age; athletes in shock; pregnancy; patient med
crowave oven, but they can be heated by passage through ications; hypothermia; and the presence of pacemakers.
intravenous fluid warmers.


Adaptations of standard tube thoracostomy collection de Trea tment of hypovolemic ( hemorrhagic) shock requires
VIces are commercially available; these allow for sterile col- correction of inadequate organ perfusion by increasing


organ blood flow and tissue oxygenation. Increasing blood with prompt, aggressive resuscitation and careful monitor
flow requires an increase in cardiac output. Ohm's law ( V ing. rl' See Chapter 1 1 : Geriatric Trauma.
= I x R) applied to cardiovascular physiology states that
blood pressure ( V) is proportional to cardiac oulput (l)
and systemic vascular resistance (R) (afterload). An in
crease in blood pressure should not be equated with a con Rigorous athletic training routines change the cardiovascu
comitant increase in cardiac output. An increase in lar dynamics of this group of patients. Blood volume may
peripheral resistance-fo r example, with vasopressor ther increase 15o/o to 20%, cardiac output sixfold, and stroke vol
apy-with no change i n cardiac output results in increased ume 50%, and the resting pulse can average 50. The ability
blood pressure, but no improvement in tissue perfusion or of athletes' bodies to compensate for blood loss is truly re
oxygenation. markable. The usual responses to hypovolemia may not be
manifested in athletes, even when significant blood loss has

Elderly trauma patients require special consideration. The

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

68 CHAPTER 3 Shock

sophisticated techniques are used. Early transfer of the pa

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

1 . The precise measure of cardiac function is the rela

tionship between ventricular end diastolic volume
and stroke volume. Right atrial pressure (CVP) and
cardiac output (as reflected by evidence of perfu
sion or blood pressure, or even by direct measure
ment) are indirect and, at best, insensitive estimates
of this relationship. Remembering these facts is im
portant to avoid overdependency on CVP monitor-
rectly related to heart rate. In tJ1e significant number or pa

tients with myocardial conduction Jefects who have such
devices in place, CVP monitoring is invaluable to guide J:luid 2. The initial CVP level and actual blood volume are
therapy. not necessarily related. The initial CVP is some
Limes high, even with a significant volume deficit,
especially i n patients ,.vith chronic obstructive pul
monary disease, generalized vasoconstriction, and
rapid fluid replacement. The initial venous pressure
Reassessing Patient Response and also may be high because of the application of
Avoiding Complications PASG or the inappropriate use o f exogenous vasa
Inadequate volume replacement is the most common com 3. A minimal rise in the initially low CVP with fluid ther
plication of hemor rhagic shock. Immediate, appropriate, apy suggests the need for further volw11e expansion
and aggressive therapy that restores organ perfusion mini (minimal or no response to fluid resuscitation category).
mizes these problematic events.
4 . A declining CVP suggests ongoing fluid loss and the
need for additional fluid or blood replacement (tran
CONTINUED HEMORRHAGE sient response to lluid resuscitation category).

Obscure hemorrhage is the most common cause of poor re 5. An abrupt or persistent elevation in CVP suggests that
sponse to fiuid therapy. Patients with this condition are gen volume replacement is adequate or too rapid or that
erally included in the transient response category as defined cardiac function is compromised.
previously. Immediate surgical intervention may be neces 6. Pronounced elevations of CVP may be caused by hy
sary. pervolemia as a result of overtransfusion, caTdiac dys
function, cardiac tamponade, or increased
intrathoracic pressure from a tension pneumothorax.
FLUID OVERLOAD AND CVP MONITORING Catheter malposition may produce erroneously high
After a patient's initial assessment and treatment have been CVP measmements. .
completed, the risk of fluid overload is minimized by care
ful monitoring. Remember, the goal of Lherapy is restora Aseptic techniques must be used when central venous
tion of organ perfusion and adequate tissue o:xygenation, lines are placed. Multiple sites provide access to the cen
confirmed by appropriate urinary output, Cl'\S function, tral circulation, and the decision regarding which route to
skin color, and return of pulse and blood pressure toward use is determined by the skill and of the doc
normal. tor. The ideal position for the tip of the catheter is in the
Monitoring the response to resuscitation is best ac superior vena cava, just proximal Lo the right atrium.
complished for some patients in an environment in which rl' Techniques for catheter placement are discussed in de-


tail in Skill Station IV: Shock Assessment and Manage RECOGNITION OF OTHER PROBLEMS
The placement of central venous l i nes carries the risk of When a patient faib to rc:.po nd to therapy, consider cardiac
potentially l ife- th reaten i ng com piications. Infections, vas tam pon ade, tension pneum o tho rax ventilatory problems,

u n recognized fluid loss, acute gastric distention, myocardial

cular injury, nerve i nj u ry, embolization, thrombosis, and
pneumothorax may resu I t . CV P m on itor in g ren ec ts righ l infarction, diabetic acidosis, hypoadrenalism, and nc u ro
heart fun ct ion . It may not be representative of left h ear t
genic shock. Constant reevalua tion especial ly when patients'

function in patient s with pr i mary myocardial dysfunct ion conditions deviate from expected patterns, is the key to rec
or abnormal pulmonar}' circu lation. ogni7ing such problem s as early a possible.

CHAPTER SUMMARY ------ -----

0 Shock
fusion and
of the circulatory system that results i n inade q uate organ per
is an ab norma lity
tissue oxygenation. Shock management, based on sound physiologic pnncl
ples, 1s usually successful

Hypovolemia is the cause of shock 1n most trauma pat1ents Pat1ents in shock are clas
sified as class I, class II, class Ill, or class IV, based on clinical s1gns and estimated blood
loss. Treatment of these pat1ents reqwes immed1ate hemorrhage control and flu1d or
blood replacement. In pat 1ents 111 whom these measures fail, operative control of con
tinuing hemorrhage may be necessary.

The diagnosis and treatment of shock must occ u r al most stm ulta neously. For most
trauma pa tie nts, treatment IS Instituted as 1f the pat1ent has hypovolemic shock, unless
there is clear evidence that the shock state has a d1fferent cause. The basiC manage
ment pnnc1ple is to stop the bleeding and replace the volume loss.

lnit1al assessment of a patient 1n shock reqwes careful phys1cal examination, looktng for
signs of tension pneumothorax. card1ac tamponade, and other causes of the shock state

The management of hemorrhag ic shock i nc lu des fluid resuscitation with crystalloids and
blood. Early identification and control of the source of hemorrhage is essential.

The classes of hemorrhage serve as an early gu1de to appropriate resuscitation. Careful

momtonng of phys1ologic response and the ability to control bleeding will dictate on
gomg resuscitatiOn efforts

11. Asensio )A, Berne J 11, Oemclriads D, et aL One hundred five

Bibliography penet rating cardiac injuries: a pro&pect ive evaluation. /
Tm11ma 1998; 44(6): 1073- 101!2.
1 . Abou Khalil B, Scalea TM, Troo:.kin SZ, et al . Hemodynam ic
5. Asensio )A, Murray ), Dcmctriades D, et al. Penetrating car
reponses to shock in young trauma patients: need for inv
diac injur ies: a prospective tudy of variables predicting out
ivc monitoring. Crit Cnrc Mtd 1994;22(4):633-639.
comes. 1 Am Coli Surg 1998; 186( 1 ):24-34.
2. Alam HB, Rhee P. New developments in fluid resusClliltiOn.
6. Bickell \VH, Wall IJ, Pcpe PF, ..:t al. lmmcdiat..: versus
Sttrg Clin North Am 2007; 87( I ):55-72, vi.
del ared fluid resusc ita t ion for hypotensive patients with
3. Alam HB. An tlpdate on fluiJ resuscitation. Scand 1 S11rg 2006; pe netra ti ng t orso mi u r ks. N Eng/ 1 Med t994;
95(3):136-145. 3 3 1 ( 17): 1 l 05- l 1 09.
---- -- ----

70 CHAPTER 3 Shock

7. Brown M D. Ev idence-based emergen cy medicine. Hypertonic 25. Gould SA, Moore EE, Hoyt DB, ct al. The first randomized trial
versus isotonic c rystaUoid for iluid resuscitation in criticaJiy of human polymerized hemogl obin as a blood s ubsti t ute in
ill patients. Alltt Emerg Med 2002; 40( 1 ) : 1 13 - 1 14. ac ute trauma ami emergent surgery. j Am Col/ S11rg
1 998; 1 87(2): ll3-122.
8. Bunn F, Roberts l, Tasker R, Akpa E. Hypertonic versus nea-r
isotonic crystalloid for fluid resuscitation in cr it ically ill pa 26. Granger DN. Role of xanthine oxidase and granulocytes ln is
tients. Cochm11e D11tnbnse Syst R.e11 2004; (3):CD002045. cbem ia-reperfusion injmy. Am ] Physiol 1988;255:H 1 269-
lll 275.
Sl. Burris D, Rhee P, Kau fmann C, et al. Controlled resuscitation
for 11ncontrolled hemorrhagic shock. J Tmunw 1999; 27. Greaves I, Porter KM, Revell MP. Fluid resuscitation in pre
46(2):2 16-223. hospital trauma care: a consensus view. j R Call Surg Edinb
2002; 47(2):451 -457.
I 0. Carrico C], Canizaro PC, Shires GT. fluid resuscitation fol
lowing injury: rationale for Lhe use of balanced saJt solut ions. 28. Greco L, Francioso G, Pratichjzzo A, Testini M, l mpedovo G,
Grit Core Med 1976;4(2):46-54. Ettorre GC. A rterial embolization in the treatment of severe
blunt hepatic trauma. Hepatogastroenterology 2003;
I I . Chernow B, Rainey TG. Lake CR. En dogenous and exogenous
50(5 1 ):746-749. '

catecholamines. Crit Care Med 1982;10:409.

29. Guyton AC, Lindsey AW, Kaufman BN. Effect of mean circu
l2. Cogbil l TH, Blintz M, Johnson JA, et a!. Acute gast ric dilatation
latory fi lling pressure and other periph eral circul atory factors
after trauma./ Trtlll/1111 1987;27 ( 1 0 ) : 1 1 13-11 1 7 .
on cardiac output. Ji m ] Physiol 1955; 180:463-468.
13. Cook RE, KeaLing JF, Gil lesp ie 1. The role of angiography in
30. Haan J, Scott l, Boyd-Kranis RL. Ho S, Kramer M, Scalea TM.
the management of haemorrhage from major fractures of the
Admission angiography for blunt splen ic inju ry: advantages
pelvis. J Bone joint Surg Br 2002; 842): 178- 182.
an d pitfalls. J Tm111na 200 I; 5 1 (6): 1 1 61-1 165.
14. Cooney R, Ku ), Cherry R, et al. Limitations of splen ic an
gioembolization in treating bl un t spl eni c inj ury. j Trauma
3 1 . Hagiwara A, Yukioka T, Ohta S, Nitarori T, Matsuda H, Shi
mazaki S. Non surgica l management of patients with blun t
2005; 59(4), 926-932; discussion 932.
sp leni c injury: efficacy of transcathcter arterial embolization.
15. Cooper DJ, Walley KR. \<\Tiggs RB. et al. Bicarbonate does not AIR A111 J loentgeno/ 1996; 167( I ):159-166.
improve hemodynamics in criticaUy ill palients wbo have lac
32. Hak D). The role of pelvic angiography in evaluation and man
tic acidosis. A1111 /litem Med 1 990;1 12:492.
agement of pelvic trauma. Orthop Cli11 Nortlt Am 2004;
16. Counts RB, Haisch C, Simon fL, et al. Hemostasis in massively 35(4):4J9-443, v.
transfused trauma patients. Ann Surg 1979;190( 1):91-99.
33. Harrigan C, Lucas CE, Ledgerwood AM, el al. Serial ch anges in
17. Davis JW, Kaups KL, Parks SN. Base deficit is superior to pH primaq' hemostasis after massive transfusion. Surgery
i n evaluating clearance of acidosis after traumatic shock. j 1985;98:836-840.
Tmumn 1998 jan ;44( I ) : 1 14-1 18.
34. Hoyt DB. Fluid resuscitation: the target from an analysis of
18. Davi s JW, Parks SN, !{a ups KL et al. I Trauma Admission base trauma systems and patienL survival. J Thwmtt 2003; 54(5
deficit predicts transfusion requirements and risk of compli Suppl }:S3 .1-35.
cations. 1997 Mar;42(3):571-573.
35. Jurkovich QJ. Hypothermia in the trauma patient. ln: MauJI
I 9. Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injur ies: Kl, ed. Advn11ces in Trauma. Chicago: Yearbook; 1989:1 1 1 - 140.
high nonoperative managemenL rate caJl be achieved with se
36. Ka pl a11 LJ, KelJum JA. Initial pH, base deficit, lactate, anion
lective emboization.
l j Trauma 2004; 56(5): 1063-1067.
gap, strong ion difference, and slrong ion gap prcd jct outcome
20. Dutton I, Mackenzie GF, Scalea TM. H ypotensive resuscita from major vascular injury. Grit Care Metf 2004;32(5}:1 120-
tion d urn
i g active hemorrhage: impact on in-hospital mortal 1 124.
i ty. j Trnumo 2002; 52(6):1 141-1 146.
37. Karmy-J ones R, athens A, J u rkovich G), et al. Urgent and
2 l . Fru1gio P, Asehnoune K, Edou ard A, Sma iJ N, Benha mou D. emergent thoracotomy for penetrating chest trauma. ] Tmuma
Early embolization and vasopressor administration for man 2004; 56(3), 664-668; discussion 668669.
agement of life-threatening bemorrhage from pelvic fracture.
38. Knudson MM, Ma ull K1. :-.lonoperalive management of solid
] Trauma 2005; 58(5), 978-984; discussion 984.
organ injuries. Past. present, and future. Surg Cli11 North A111
22. Ferrara A, MacArth ur JD, Wright HK, et al Hypoth ermi a and 1999;79(6):1357-1371.
acidosis worsen coagulopathy in patients requiri ng massive
39. Krausz NIM. Fluid resuscitation strategies in the Israeli army.
transfusion. Am J Surg 1990;160:515.
J Tmu111n 2003; 54( 5 Suppl ) :S39-42.
23. Gaarder C, Dorn1agen JB, Eken T, et al. Nonoperative man
40. Kruse )A, Vyskocil JJ, Haupt MT. Intraosseous: a tlexible option
agement of splenic injuries: improved results with angioem
for the adult or child with del ayed, difficul t , or impossible con
bolization. I Tmuma 2006; 6 1 ( 1 } : 192-1 98.
ventional vascular access. Cril Care Med 1994;22:728-735.
24. Glover JL. Broadie TA. Intraoperative autotransfusion. World
41. Lowry Sl;, Po ng Y. Cytokines and the celJulru response to inju ry
] Surg 1987; I I :60-64.
and infection. In: Wilmore DW, Bren nan tvt.F, Harken AH, et


al., eds. Cnre ofthe Surgical Patient. New York: Scientific Amer 58. Sarnoff S). Myocardia] contractil ity as described by ventricu
ican; 1990. lar function curves: observalions on Starling's law of the heart.
Plrysiol Rev 1988;35: 107- 122.
42. Lucas CE, Ledgerwood AM. Cardiovascular and renal response
to hemorrhagic and septic shock. In: Clowes Gli.A j r, ed. 59. Sawyer RW, Bodai BT. The cu rrent status ofi ntraosseous infu
Tmumn, Sepsis and Shock: The Physiological Basis of Therapy. sion. 1 Am Coli Surg 1 994; 179:353-361.
New York: Marcel Dekker; 1988:87-215.
60. Scalea TM, Hartnett RvV, Duncan AO, et al. Central venous
43. Mandal A K, anusi M. Penetrating chest wounds: 24 years ex oxygen saturation: a useful clinical tool in trauma patients. j
p erience. VVorld 1 Surg 2001;25(9):.1 145-1 149. Trawnn l990;30( 12): 1539-1543.

44. Mansour MA, Moore EE, Moore rA, Read RR. Exigent postin 6 I . Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt mul
jury thoracotomy analysis ofblunt versus penetrating trauma. tiple trauma: improved survival with early invasive monitor
Surg Gynecol Obsret 1992;175(2):97- 101. ing. j Trau111n 1990;30: 129-136.

45. Martin D), Lucas CE, Ledgerwood AM, et al. Fresh frozen 62. Schierhout G, Roberts I. Fluid resuscitation with colloid or
plasma supplement lo massive red blood cell transli.tsion. Ann crys talloi d solutions in cri tical ly ill patients: a systematic re
Surg 1985;202:505. view of randomised trials. Br j Med 1998;316:961 -964.

46. Martin, MJ, Fitz, Sullivan E, Sali m, A, et al. Discordance be 63. Shapiro M, McDonald AA, Knight D, Joh annigman JA,
tween lactate and base deficit in the smgical intensive care unit: Cuschieri ). The role of repeat angiography in tl1e management
which one do you Lrust? Am ] Surg 2006;191 (5): 625-630. of pelvic fractures. I Trnun1n 2005;58(2):227-231.

47. Mizushima Y, Tohira H, Mizobata Y, Matsuoka T, Yokota f. 64. Smith 1-lE, Biffl WL, Ma_iercik SD, Tcd.nacz J, Lambiase R, Cioffi
Fluid resuscitation of trauma pat ients: how fast is the optimal 'vVG. Splenic a1tery embolization: Have we gone too far? J
rate? Am J Emerg Med 2005;23(7):833-837. Trnuma 2006; 61 (3 ) :54 1 -544; discussion 545-546.

48. Novak L, Shackford SR, Bourguignon P, et al. Comparison of 65. Thourani VH, Feliciano DV, Cooper WA, et aJ. Penetrating car
standard and al ternative prehospita l resusci tal ion in uncon diac rauma at an urban trauma center: n 22-rear perspective.
trolled hemorr hagic shock and head injury. J Trqrmw Am S11rg 1999; 65(9 ) :8 1 1 8 1 6; discussion 817-8 18.

I 999;47( 5 }:834-844.
66. T)rburski )G,Astra L, Wilson R.F, Dente C, Steffes C. Factors af
49. O'Neill PA, Riina ), Sclafani S, Tornetta P. Angiographk 5nd fect i ng prognosis with penet rating wounds of the heart. ]
ings in pelvic fractures. Gli11 Orrhop Relnt Res 1 996;(329) :60 - Trauma 2000;48(4):587-590; discussion 590-591.
67. Velanovich V. Crystalloid versus colloid fluid resuscitation: a
50. Pappas P, Brathwaite CE, Ross SE. Emergency central venous meta-analysis of mortalily. Surgery .1990;105:65-71.
catheterization during resuscitation of trauma patien ts. Am
68. Velmahos GC, Toutouzas KG, Vassiliu P, et al . A p rospective
Surg 1992;58:1 08- J 1 1.
study on the safety and efficacy of angio graphic embolization
51. Peck KR, Altieri M. lntraosseous inli.tsions: an old technique for pelvic and visceral injuries. J 7iawnn 2002;53(2):303-308;
with modern appli cations. Pedintr Nrm 1988;14(4):296-298. discussion 308.

52. Poole GV, Meredith JW, Pennell T, et al. Comparison of col 69. Virgilio RW, Rice CL, Smith DE, et al. Crystalloid vs colloid re
loids and crystalloids in resuscitation from hemorrhagic shock. suscitation: is one better? A randomized clinical study. Surgery
Surg Gynecol Obstet 1982;.154:577-586. 1 979;85(2) : 129-139.

53. Revell M, Greaves l, Porter K. Endpoints for fluid resucitation

s 70. von OUO, Bautz P, De GM. Penetrati11g thoracic injuries: what
in hemorrhagic shock. J Traumn 2003;54(5 Suppl):$63-$67. we have learnt. Thome Cardiovasc Surg 2000;48 ( I ):55 -6 1 .

54. Rhodes M, Brader A, Lucke J, et al. A direct transport to the 71. WaJ1l WL, Ahrns KS, Chen S, Hemmila MR, Rowe SA, Arbabi
operating room for resuscitation of trauma p atien ts. J Trauma S. Blunt splenic injury: operat ion versus angiograp hi c em
1989;29:907 -915. bolization. Surgery 2004; 1.36(4 ):89 1 -899.
55. Rohrer MJ, Natale AM. Effect of hypothermia on the coagula 72. Vl'erwath DL, Schwab CW, Scholtcr JR, et al. Microwave oven:
Lion cascade. Grit Care Med 1992;20:490. a safe ne>>: method of warming crystaJJoi ds. Alii ] Surg
1984; 12:656-659.
56. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage "

control": an approach for improved survival in exsanguinating 73. Williams JF, Seneff MG, Friedman BC. et al. Use of femoral ve
penetrating abdominaJ injmy. I Trnu111a 1993;35:375-382. nous catheters in crit i cally ill adults: prospective study. Grit
Care Med 1991;1 9:550-553.
57. Sadri H, Nguyen-Tang T, Stern R. Hoffmeyer P, Peter R. Con
trol of severe hemorrhage using C clamp and arterial em 74. York J, Arrilaga A, Graham R. et al. fluid resuscitation of pa
bolization in hemodyn amically unstab le patients with pelvic tients with multiple injuries and severe dosed head injury: ex
ring disruption . Arch Ortlwp Trauma Surg 2005;125(7):443- peri ence with an aggressive fluid resuscitation strategy. ]
447. -
Trauma 2000;48(3 ):376 379.


Performance at this skill station will allow the participant to practice the as
Interactive Skill
sessment of a patient in shock. determine the cause of the shock state, insti
tute the initia l management of shock. and evaluate the patient's response to
Note: Accompanying some of treatment. Specifically the student will be able to:

the skills procedures for th1s

station is a senes of scenarios,
which are provided at the OBJECTIVES
conclus1on of the procedures for
you to rev1ew and prepare for this Recognize the shock state.
station. Tables pertaining to the
inilial assessment and Evaluate a patient to determine the extent of organ perfusion, in
management of the patient in cluding performing a physical examination and the relevant adjuncts
shock also are prov1ded for your to the primary survey.
rev1ew after the scenanos. Note:
Standard precautions are
Identify the causes of the shock state.
req u i red when caring for
Initiate the resuscitation of a patient in shock by identifying and con
trauma patients.
trolling hemorrhage and promptly initiating volume replacement.

THE FOLLOWING Identify the surface markings and demonstrate the techniques of vas
PROCEDURES ARE INCLUDED cular access for the following:
IN THIS SKILL STATION: Peripheral venous system
Femoral vein
Skill IV-A: Peripheral Venous
Internal jugular vein
Subclavian vein
Skill IV-8: Femoral lntraosseous infusion i n children
Venipuncture: Seldinger
Technique Use adjuncts in the assessment and management of the shock state,
Skiii iV-C: Subclavian
X-ray examination (chest and pelvic film)
Venipuncture: Infraclavicular
Diagnostic peritoneal lavage (DPL)
Abdominal ultrasound
Skiii iVD: Internal Jugular Computed tomography (CT)
Venipuncture: Middle or BroselowrM Pediatric Emergency Tape
Central Route
Identify patients who require definitive hemorrhage control or trans
Skiii iV-E: lntraosseous fer to the intensive care unit, where extended monitoring capabilities
Puncture/Infusion: Proximal are available.
Tibial Route
Identify which additional therapeutic measures are necessary based
Skill IVF: Broselow
on the patient's response to treatment and the clinical significance of
Pediatric Emergency Tape
the responses of patients as classified by:
Rapid response
Transient response


74 SKILL STATION IV Shock Assessment and Management

Skill IV-A: Peripheral Venous Access

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

STEP 5 . Thread the catheter into the vein over the needle. STEP 10. Secure the catheter and tubing to the skin of the


Skiii iV-8: Femoral Venipuncture: Seldinger Technique

(See Figure /V-1)

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

SKILL STATION IV Shock Assessment and Management 75

Step 5 Step 8

NeNe ------
Femoral artery --=
Femoral vein

creater Guidewire
saphenous and
vein introducer

Step 9

Guidewire -"'"'

Figure IV-1 Femoral Venipuncture: Seldinger Technique.

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

76 SKILL STATION IV Shock Assessment and Management

-- . - -- .
. -. - . - -- -- .
-- -
'. .- -
-. .
- .

Skiii iV-C: Subclavian Venipuncture: Infraclavicular Approach

Note: Sterile technique should be used when perfonning hi&
t clavicle (toward the finger placed in the
procedure. suprasternal notch).

STEP 8. Slowly advance the needle while gently

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

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

Skill IV-D: Internal J:gular Venipuncture: Middle or Central Route

Note: Internal jugular catheterization is freq uently difficult center of the triangle formed by the two lower
in injured patients because of the immobilization necessary heads of the sternomastoid and the clavicle.
to protect the patient's cervical spinal cord. Sterile technique Ultrasound can be used as an adjunct for the
should be used when performing this procedure. placement of central venous lines.
STEP 5. After the skin bas been punctured, with the bevel
STEP 1 . Place the patient in Lhe supine position, with the
of the needle upward, expel the skin plug that
head at least 15 degrees down to distend the neck
can occlude tbe needle.
veins <md prevent an air embolism. Only if the
cervical spine has been cleared radiographically STEP 6. Direct the needle caudally, parallel to the sagittal

can the patient's head be turned away from the plane, at an angle 30 degrees posterior to the
venipuncture site. frontal plane.
STEP 7. Slowly advance the needle while gently
STEP 2. Cleanse the skin around the venipuncture site
withdrawing the plunger of the syringe.
1.vell and drape the area.
STEP 8. When a free Aow of blood appears in the syringe,
STEP 3. If Lhe p atien t is awake, use a local anesthetic at remove the syringe and occlude t.he needle with a
the venipuncture site. finger to prevent air embolism. If the vein is not
STEP 4. Introduce a large-caliber needle, attached to a 12- entered, withdraw the needle and redirect it 5 to
ml syringe with 0.5 to I mL of saline, into the I 0 degrees laterally.

SKILL STATION IV Shock Assessment and Management 77

STEP 9. Insert the guidewire while monitoring the ECG COMPLICATIONS OF CENTRAL
for rhythm abnormalities.
STEP 10. Remove the needle while securing the guidewire Pneumothorax or hemothorax

and advance the catheter over the wire. e:onnect
Venous thrombosis
the catheter to the intravenous t ubing
Arterial or neurologic injury
STEP 1 1. AfflX the catheter in place to the skin (with suture}, Arteriovenous fistula
apply antibiotic ointment, and dress the area. Chylothorax
STEP 1 2. Tape the intravenous tubing in place. Air embolism

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

the intravenous line a11d identify a possible

(See Figure /V-2)

. . Tibial Route
Skiii iV- E: lntraosseous Puncture/Infusion: Proximal .. ... . .

Note: Sterile technique should be used when performing this seep:. from the upper end of the chicken or turkey bone
procedure. when the solution is injected (see Step 8).
The procedure described here is appropriate for chil
STEP 1 . Place the patient in the supine position. Select an
dren 6 years of age or younger for whom venous access is
uninjured lower extremity, place sufficient padding
impossible because of circulatory collapse or for whom per
under the knee to effect an approximate 30-degree
cutaneous peripheral venous cannulation has failed on two
flexion of the knee, and allow the patient's heel to
allempts. lntraosseous infusions should be limited to emer
rest comfortably on the gurney (stretcher}.
gency resuscitation of the child and discontinued as soon as
other venous access has been obtained. (Techniques for in STEP 2. Identify the puncture site-the anteromcdial
traoscous infusion in adults are not discussed here. See ref surface of the proxi m al tibia, approximately one
erence:. in the bi bliogra phy for Chapter 3: Shock for further fingerbrcadth ( I to 3 em) below the tubercle.
STEP 3. Cleanse the skin around the puncture site well
Methylene blue dye can be mixed with the saline or
and drape the area.
water for demons! ration purposes on chicken or turkey
bones only. When the needle is properly placed within the STEP 4. Lf the patient is awake, use a local anesthetic at
medu l lary canal, the methylene blue dye/saJjne solution th e puncture site.

Patella 1 finger

) J
Figure IV-2 lntraosseous Puncture/Infusion: Proximal Tibial Route.

78 SKILL STATION IV Shock Assessment and Management

STEP 5. Initially at a 90-degree angle, introduce a short STEP 9. Connect the needle to the large-caliber
(threaded or smooth), large-caliber, bone intravenous tubing and begin fluid infusion.
marrow aspiration needle (or a short, 18-gauge Carefully screw the needle further into the
spinal needle with stylet) into the skin and medullary cavity until the needle hub rests on
periosteum with the needle bevel directed toward the patient's skin and free flow continues. [fa
the foot and away from the epiphyseal plate. smooth needle is used, it should be stabilized at a
45- to 60-degree angle to the anteromedial
STEP 6. After gaining purchase in the bone, direct the
surface of the child's leg.
needle 45 to 60 degrees away from the epiphyseal
plate. Using a gentle twisting or boring motion, STEP 10. Apply antibiotic ointment and a 3-x-3 sterile
advance the needle through the bone cortex and dressing. Secure the needle and tubing in place.
tnto the bone marrow.
STEP 1 1 . Routinely reevaluate the placement of the
STEP 7. Remove the stylet and attach to the needle a 12- intraosseous needle, ensuring that it remains
mL syringe with approximately 6 mL of sterile through the bone cortex and in the medullary

saline. Gently draw on the plunger of the syringe. canal. Remember, intraosscous infusion should
Aspiration of bone marrow into the syringe be limited to emergency resuscitation of the
signifies entrance into the medullary cavity. child and discontinued as oon as other venous
access has been obtained.
STEP 8. Inject the saline into the needle to expel any clot
that can occlude the needle. [f the saline flushes
through the needle easily and there is no
evidence of swelling, the needle IS likely in the
appropriate place. If bone marrow was not
aspirated as outlined in Step 7, but the needle Infection
Oushes easily when injecting the saline and there Through-and-through penetration of the bone
is no evidence of swelling, the needle is likely in Subcutaneous or subperiosteal infiltration
the appropriate place. In addition, proper Pressure necrosis or the skin
placement of the needle is indicated if the needle Physeal plate injury
remains upright \.vithout support and Hematoma
intravenous solution flows freely without
evidence of subcutaneous infiltration.

Skill IV-F: Broselow Pediatric Emergency Tape

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

SKILL STATION IV Shock Assessment and Management 79

' . - - --
- --
- ---
. --.. .. .. .. - .
. ...... - - . ... . . .


SCENARIO IV- 1 SCENARIO IV-3 (continuation of

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

80/46 mm Hg, and the respiratory rate is 30 breaths/min. and peripheral perfusion. Fluid infusion is slowed to main
Her k111 1s pale, cool, and moi st to touch. She moans when tenance levels. Five minutes later, the assistant reports a de
stimulated. ()ee Table JV-2.) terioration in the blood pressure to 88/60 mm Hg, an

TABLE IV-1 Initial Assessment and Shock Management


Tension pneumothorax Tracheal deviation Needle decompressiOn

Distended neck vein Tube thoracostomy
Absenl breath sounds

Massive hemothorax Tracheal deviation Venous access

Flat neck veins Volume replacement
Percuss1on dullness Surg1cal consultation/thoracotomy
Absent brealh sounds Tube thoracos1omy

Cardiac tamponade Distended neck ve1ns Venous acces

Muffled heart tones Volume replacement
Ultrasound Peocard1otomy

lntraabdominal Distended abdomen Venous access

hemorrhage Utenne hft, if pregnant Volume replacement
DPUultrasonography SurgiCal consultation
Vag1nal examination Displace uterus from vena cava

Obvious external Identify source of D1rect pressure

bleeding obv1ous external bleedtng Splints
Closure of actively bleeding
scalp wounds
... " ....
. .... ..
.. ' ...... ... .... '-......
.. --- ._..,
.. .....
, ..
_.. ---
.............. ....... ' .. ' ......... I--""'" , .
. . " " '
... .... " "" ....
.... .....
. ...
. --.
. ...
,_ , . .____,_,,_

80 SKILL STATI ON IV Shock Assessment and Management

TABLE IV-2 Pelvic Fractures


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

Visceral organ CTscan

injury Jnlraabdominal hemorrhage Potential for conti nuing blood loss VoiJme replacement
Performed on1y in hemodynamically Poss1ble tr<;nsfusion
normal patients Surgical consultation

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

TABLE IV-3 Transient Responder


Underestimation of Abdom1nal distention DPL or ultrasonography Surgical consultation

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

Cardiac tamponade Distended neck veins Ec;hocardlogram Thoracotomy
Decreased heart sounds FAST
Normal breath sounds Pericardiocentesls

Rewrrentlpersistent Distended neck veins Clinical diagnosis Reevaluate chest

tension pneumothorax Tracheal shift Needle decompression
Absent breath sounds Tube thoracostomy
Hyperresonant chest percussion

SKILL STATION IV Shock Assessment and Management 81

TABLE IV-4 Nonresponder


Massive blood loss

(Class Ill or IV)
lntraabdom1nal bleed1ng Abdominal distention DPL or ultrasonography lmmed1ate 1ntervenron
by surgeon
Volume restorauon
Operatrve resusotat1on

Tensron pneumothorax Drstended neck veins Chmcal diagnos1s Reevaluate chest
Tracheal shift Needle decompression
Absent breath sounds Tube thoracotomy
Hyperresonant chest perCllssron
Card1ac tamponade Ditended neck veins Echocard iograrn Thoracotomy
Decreased heart sounds FAST
Normal breath sounds Pericardrocentesrs
Blunt cardrac injury Irregular heart rate lschem1c ECG changes Prepare for OR
Inadequate perfusion Echocardiogram 1nvas1ve momtoring
InotropiC support
Consrder operative intervention
lnvasrvEC> monitoring may be


Performance at this skill station will allow the participant to practice and
Interactive Skill
demonstrate on a live, anesthetized animal or a fresh, human cadaver the tech
nique of peripheral venous cutdown. Specifically, the student will be able to:
Note: Standard precautions
are required when caring for

trauma patients.
Identify and describe the surface markings and structures to be noted
in performing a peripheral venous cutdown.

Skill V-A: Venous Cutdown Describe the indications and contraindications for a peripheral venous

The primary site for a peripheral venous cutdown is the greater
saphenous vein at the ankle, which is located at a point approxi
mately 2 em anterior and superior to the medial malleolus. (See Fig
ure V-1.)

A secondary site is the antecubital medial basilic vein, located 2.5 em

lateral to the medial epicondyle of the humerus at the flexion crease
of the elbow.



84 SKILL STATION V Venous Cutdown

Skill V-A: Venous Cutdown

(See Figure V- 1)

STEP 1 . Prepare the skin or the ankle with antiseptic STEP 9. Introduce a plastic cannula through lhe
solution and drape the area. venotomy and secure i t i n place by tying the
upper ligature around the vein and cannula. The
STEP 2. Infi.Jlrate the skin over the vein with O.s<Yo
cannula should be inserted an adequate distance
to prevent dislodging.
STEP 3. Make a full-thickness, transverse skin incision
STEP 10. Attach tl1e in travenous tubing to the cannula
through the anesthetized area to a length of 2.5
and close the incision witb interrupted sutures.
STEP 1 1 . Apply a sterile dressing with a topical antibiotic
STEP 4. By blunt dissection, using a curved hemostat,

identify the vein and dissect i t free from any
accompanying structures.

STEP 5. Elevate and dissect the vein for a distance of COMPLICATIONS OF PERIPHERAl VENOUS
appro:>rima.tely 2 ern to free it from its bed. CUTDOWN
STEP 6. Ligate the distal mobilized vein, leaving the Cellulitis
suture in place for traction. Hematoma
STEP 7. Pass a tie arOlmd the vein in a cephalad direction.
Perforatjon of the posterior wall of the vein
STEP 8. Make a small, transverse venotomy and gently Venous thrombosis
dilate the venotomy with the tip of a closed Nerve transaction
hemostat. Arterial transaction

.,_ Saphenous vein


----- Saphenous nerve nerve

Incision ::;.;..;
Vein ;;

Figure V-1 Venous Cutdown


CHAPTER OUTLINE Upon completion of this topic the student will identify and

initiate treatment of common and life-threatening thoracic in

Juries. Specincally the doctor will be able to:

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

Describe the significance and treatment of subcu

taneous emphysema, thoracic crush injuries and,

sternal, rib, and clavicular fractures:

86 CHAPTER 4 Thoracic Trauma

It is necessary to recognize and address major injuries af

IJ What life-threatening chest injuries ..

fc.:L Ling the a ir way during the primary survey. Airway pa
tency and air exchange should be assesseJ by listening for
should I recognize as causing major
.tir mnvement at the patient's nose, mouth, and lung fields;
pathophysiologic events?
inspecting the oropharynx for foreign-body obstruction;
Thoracic tnlUma is a significant L<lUM of mortality. Many and observing for intercostal and !>upraclavicular muscle rc
patients with thoracic trauma die after reaching the hos tr<ICtions.
pital, yet many of these deaths could be prevented with Laryngeal injury can accompany major thoracic
prompt diagnosis and treatment. Les than 10% of blunt trauma. Although the clinical presentation is occasionally
chest injuries and only 15% to 30% of penetrating chest subtle, acute airvvay obstruction from laryngeal trauma is a
injuries require thoracotomy. Most patients who sustain life- threatening injury. rJI Sec Chapter 2: Airway and Venti
thoracic tr<tuma can be treated by technical procedures lator }' Management .
within the capabili t ies of doctor who take this course. It is Injury to the upper che:.t can crcalt: a palpable defect in

i mp or ta nt Lo remember that i<l lrogen ic thoracic inj urics the region of the sternodavi.ular joint with posterior dis
Me cummon (eg, hemothorax or pneumothorax \-vilh cen lol.<ll it>n or the clavicular head, causing upper airway ob
tral line placement and esophage.d inju ry during en slruttion. Identification of thil> injury is made by
doscopy). observation of upper airway obstruction (stridor) or a
Hypoxi<l, hypercarbia, and acidosis often result from marked change i n the expected voice quality (if the patient
chest injurie. Tissue hypoxia results from inadequate de is ;tblc to talk). l\lanagement consists of a clo1.ed reduction
livery of oxygen to the tissues beLausc of hypovolemia of the inJury, which can he performed by extending the
(blood loss), pulmonary ventilation/perfusion mismatch shoulders or grasping the clavicle with a pointed clamp, such
(cg, contusion, hematoma, and :tlveolar collapse), and .1!-. a towel clip, and manually reducing the fracture. This in
1.h,tngcs in in Ira I hontcic pressu rc relat ionshi ps ( eg, ten sion jury, once reduced, usually is stable if the patient is in the
pneumothor<1X and open pneumothorax). H ype rca rbia supine pt>sition.
mot often results from inadequ,tl ventilation caused by rJI Other injuries affecting the ai rway are addressed in
chJngcs in intrathoracic pressun: rcl.ttionships and de Chapter 2: Airway and Ventilatory Management.
pres!>ed level of consciousness. Mel<tbolic acidosil> is caused
bv hypoperfusion of the tissues (shock).
Initial assessment and treatment of patients with tho
racic trauma comists of the primary survey, resuscitation of The patient's chest and neck should he completely exposed
vital functions, detailed secondary survey, and definitive to allow for assessment of breathing and the neck veins. Res
care. Because hypoxia is the most seriou feature of chest in pi ratory movement and quality of respirations are assessed
jury, the goaJ of early intervention is to prevent or correct by observing, palpating, and listening.
hypoxia. Injuries that are an im rmd i11 te threat to life are I mporta n t, yet often subtle, signs of chest injury or hy
1 rea ted a.s quickly and simply as is possible. Most I ife-threat poxia include an incn:ased respi ratory rate and change in the
ening thoracic injuries are treated by airway control or an breathing pattern, especially progressively more shallow res
appropriately placed chest tube or needle. The secondary pirations. Cya nosis is a late sign of hypo>.ia in trauma pa
survey is influenced by the history of thc mjury and a high trents. l lowcver, the absence of cyanosis does not necessarily
index of suspicion for specific inJuries. tmhcate adequate tissue oxygenation or an adequate airway.
The major thoracic injuries that affect breathing and that
must be recognized and addressed during the primary sur
vey include tension pneumothorax, open pneumothorax
(sucking chest wound), flail chest and pulmonary contu
Primary Survey: sion, and massive hemothorax.
Life-Threatening Injuries

IJ What are the significant patho PITFALL

- ..;

physiologic effects of chest injury that I After intubation, one of the common reasons for loss
should identify in the primary survey, of breath sounds i n the left thorax is a right main
and when and how do I correct them? stem intubation. During the reassessment, be sure to
check the position of the endotracheal tube before
The primary survey of patients with 1horaLic injuries begins assuming that the change in physical examination re
with the airway. Major problems should be corrected as they sults is due to a pneumothorax or hemothorax.
are identified.


Tension Pneumothorax large-caliber needle into the second intercostal space in

A tension pneumothorax dcvdop when a "one-way valw" the middavicular line of the ,1 ffected hemithorax ( f igure
air h:ak occurs from the lung or through the chest wall (Fig 4-2) . See Skill Station Vll: Chest Trauma Man age
ure 4-J ) . Air is forced into the thorac ic cavity without any ment, Skill VIl-A: Needle Thoracentesis. This mancuwr
means or escape, complercly collapsing the affected lung. converts the injury to a simple pneumothorax; however,
The mediastinum is displa ced 10 th( opposite side, decreas the possibility of subsequent ]Jncu.mothorax as a result
ing venous return and compresing the opposite lung. of the needle stick now exists. Repeated reassessment ol
!'he most common cause of tension pneumothorax is the patien t is neces sa ry. Definitive treatment usually re
mechanical ventilation with po1>itive-pressure ventilation in quires only the insertion o f a chest tube into the fifth In
patients with ''i!>ceral pleural injury. However, a tension tercostal space (usually the ni pple level), just anterior to
pneumothorax m:.r compl icate a simple pneumothorax fol the midaxillary line.
lowlllg penetrating o r h lun t chest trauma in which a
parenchymal lung injury fails to seal, or after a misguided
attempt at subclavian or internal jugular venous catheter in Open Pneumothorax (Sucking Chest Wound)
sertion. Occasionally, traumatic ddi.cts in the chesr wall also Large defects of the chest wall that remain open may result
may cause a tension pneumothorax if incorrectly covered in an open pneumothorax, or :-ucking chest wound (figure
with occlusive dressings or ir the defect itself constitutes a 4-3l. Equilibration between intrathoracic pressure and <ll
nap-valve mechani:..m . Tension pneumothorax also may mopheric pressure is immediate. If the opening in the chest
occur from marked!) displaced thoracic spine fracture). wall is approximately two-thirds the diameter of the trachea,
Tension pneumothorax is a clinical diagnosis reflecting tir passes preferentia lly through the chest wall defect with

air under pressure in the pleural space. Treatment should not each respiratorr effort, because air tends to follow the path
be delayed to wait for radiologic confirmation. Tension pneu of leas t resistance. Effective ventilation is thereby imp,1ircd,
mothorax is characterized by some or all of the following leading to hypoxia and hypercarbiu.
:.igns and symptoms: chest pain, air hunger, respiratory dis Initial management or an open pneumothorax is ac
t re1.s, tachycardia, hypotension, tracheal deviation, unilat cnrnplished by promptly closing the defect with a sterile oc
er;ll absence of breath ound, neck vein distention, and clusive dressing. The dressing should be large enough 10
cyanois (late manifest.1 tion). Because of the similarity in owrlap the wound's edges and then taped securely on three
their signs. tension pneumothorax may be confused initially sides in order to provide a llutter-type valve effect ( ligure
with cardiac tamponade. Differentiation can be made by .t 4-4). As the patient breathes in, the dressing occlude the
hyperresonant note on percussion and absent breath :.ounds wound, preventing air from entering. During exhal,uion,
over the affected hemithorax. the open end or the dressi ng ;lllows air to escape from the
Tension pneumothorax requires immediate decom pleural space. A chest tube remote from the wound :.hould
pression and is managtd inittally by rapidly inserting a be placed as soon as posiblc. Securely taping all edges of



Figure 4-1 Tension Pneumothorax. A

tension pneumothorax develops when a
"one-way valve" air leak occurs from the
lung or through the chest wall. Air is forced
into the thoracic cavity, completely collaps
ing the affected lung.

88 CHAPTER 4 Thoracic Trauma

sme of the defect is frequently required. .,. See Skill Sta

tion VLI: Chest Trauma Management, Skill Vll-B: Chest
Tube Insertion.

Flail Chest and Pulmonary Contusion

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

Collapsed lu


chest wound


Figure 4-3 Open Pneumothorax.

Large defects of the chest wall that re
main open may result in an open pneu
mothorax, or sucking chest wound.


achieved by using intravenous narcotics or various methods

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

Figure 4-4 Dressing for Treatment of Open Massive Hemothorax

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

lnitial therapy includes adequate ventilation, admin

istration of humidified oxygen, and fluid resuscitation. In
the absence of systemic hypotension, the administration Both tension pneumothorax and massive hemotho
rax are associated with decreased breath sounds on
of crystalloid intravenous solutions should be carefully
auscultation. Differentiation on physical examina
controlled to prevent overhydration.
tion is made by percussion; hyperresonance confirms
The definitive treatment is to ensure oxygenation as a pneumothorax, whereas dullness confirms a mas
completely as possible, administer fluids judiciously, and sive hemothorax.
provide analgesia to improve veutilation. This can be

Inspiration Expiration

Figure 4-5 Flail Chest. The presence of a flail chest segment results in severe disruption of normal chest wall
movement. If the injury to the underlying lung is significant, serious hypoxia may result.

90 CHAPTER 4 Tho rac ic Tra u m a

acute acwmulations of blood more dramatical ly present as patient's blood volume in the chest cavil}' (hgure 4-6). 11 is
hyp otensi on and shock, and arc discussed rurthcr below. most commonlr caued by J penet rat in g wound that dis
rupts the system ic or hilru vessels. Massive hemothorax nlso

may result from blunt traw11a .

Blood l oss i com plicated by hypoxia. The neck veins

The patient\ pulse hould be ascs:-.ed for qu alit y, rate, and may be flat as a result of severe hypovolemia, or they may be
regul<rity. In palie nts with hypovolemia, the radial and dor distended if there is an associated tension pncumothomx.
salis ped is pulses may he ab1>ent because of volume depletion. However, ra rel y will the mechanical effects of massive in
Blood pressure and pulse pressure is measured and the pc trathoracic blooJ shift the media:;tinum enough to C<IUse
ripheral drculation a:>essed by observing a nd palpating the d istend ed neck veins. A mass iv e hemothorax is discovered
skin for color and temperature. Neck veins shoultl be assessnl when shock is associated with the absence of breath sounds
for di::.tention, remembering that neck veins rn.ty not be dis or dullnc!.s to percussion on one side of the ches t .

tended in patients wtth hypovolemia and cardia: tamponade, Massive hemothora..x is init ially managed by the simul
ten::.ion pneumo thorax, or traum llic diaphragmatic injury.
taneou restoration of blood volume and decompression of
A cardi ac mon1tor and puh.c oximeter hould be at the chest cavity. Large-caliber intravenous lines and a rapid
tached to the p.tlicnl. Patients who sutain thoracic crystalloid infusion arc begun, and type-l>pec ific blood is ad
trauma-especially in the are.1 of the sternum or from ,1 ministered as soon as possible. Blood from the chest tube
rapid deceleration injury-are susceptible to myocardial in should be collected in a device suitable for autotr an sfusi on.
ju ry which may lead to dysrhythmias. Hypoxia and acido
A single chest tube (#38 French) is inserted, us ually at the
sis enhance this possibility. Oysrhythmia:. should be ni pple level, ju s t anterior to the rnidaxillary line, and rapid
managed accordi ng to standard protocols. Pulsdess elect ril: restor;ltion of volume contin ues as decomp res::.ion of the
activity (Pl.:.:\) is manifested b) an ECG that hows a rhythm chest cavity is completed. When massive hemothorax is sus
while the patient has no identifiable pulse. PEi\ may be pre:. pected prepare for autotransfusion. If 1500 mL is immedi

ent in cardiac tam pon u dc tension pneu moth orax profou nd

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

Partially collapsed lung

Parietal pleura

Visceral pleura

Blood in
pleural space -r"""-=---=,:;

Figure 4-6 Massive Hemoth

orax. This condition results from
the rapid accumulation of more
than 1500 ml of blood or one-third
or more of the patient's blood vol
ume in the chest cavity.


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

Cardiac tampom1de most commonly results from penetrat cardium, bul reports suggest it has a significant false-nega
i ng injuries. However, blunt injury also may cause the peri tive rate of about 5% to I Oo/o. fn hemodynamically
cardium to fill with blood from the hearl, greal vessels., or abnormal patients with blunt trauma, provided it does not
pericardia! vessels (Figure 4-7). The human pericardia] sac delay patient resuscitalion, an examination of lhe pericardial
is a fixed fibrous structure; only a relatively small amoun 1 sac for the presence of Ouid may be obtained as part of a fo
or blood is required to restrict cardiac activity and interfere cused abdominal ultrasound examination performed by
with cardiac filling. Cardiac tamponade may develop slowly, properly trained and credentialed SllJ'gical team in the emer
allowing for a more lcisUJ"cly evaluation, or may occur rap gency department. h\ST is a rapid and accurate method of
idly, requiring rapiJ diagnosis and treatment. The diagno imaging the heart and pericardium. It may be 90% accurate
sis of cardiac tamponade can be difficult. for Lhe presence of pericardia] tluid for tl1e experienced op
The classic diagnostic Beck's triad consists of venous erator. See Chapter 5: Abdominal and Pelvic Trauma.
pressure elevation, decline in arterial pressure, and muft1ed Prompt diagnosis and evacuation of pericardia! blood
heart tones. However, muffled heart tones are diff1cult to as- is indicated for patients who do not respond to the usual

Normal Pericardia! tamponade

Pericardia! sac

Figure 4-7 Cardiac Tamponade. Cardiac tamponade results from penetrating or blunt injuries that cause the
pericardium to fill with blood from the heart, great vessels, or pericardia! vessels.

92 CHAPTER 4 Thoracic Tra uma

measures of resuscitation for hemorrhagic shock and have evacuation of pericardial blood causu1g tamponade
the potential for ca1diac tamponade. ff a qualified surgeon
direct control of exsanguiJ1ating intrathoracic hem
is present, surgery should be performed to relieve the tam
ponade. Tlris is best performed in the operating room if th
patient's condition allows. Ifsurgical intervention is not avail open cardiac massage
able, pericardiocentesis can be diagnostic as well as thera
cross-clamping of the descending aorta to slow
peutic, but is not definitive treatment for cardiac tamponade.
blood loss below the diaphragm and increase perfu
_. For further information regarding FAST, see Chapter 5:
sion to the brain and heart
Abdominal and Pelvic Trauma.
Although cardiac tamponade may be strongly sus
Despite the value of these maneuvers, multiple reports con
pected, the initial administralion of intravenous n uid raises
firm that thoracotomy in the ED for patients with blunt
the venous pressme and improves cardiac output transiently
trauma and cardiac arrest is rarely effective.
while preparations are made for surgery. H subxyphoid peri
Once these and other immediately life-threatening in
cardiocentesis is used as a temporizing maneuver the use of
juries have been treated, attention may be directed to the

a plastic-sheathed needle or the Seldinger technique for in

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


usc of adjunctive studies. These injuries are more often the midaxillary line. Observation and aspiration ofan asymp
missed than diagnosed during the initial posttraumatic pe tomatic pneumothorax may be appropriate, but the choice
riod; however, if overlooked, lives can be lost. should be made by a qualified doctor; otherwise, placement of

a chest tube should be performed. Once a chest tube is in
serted and connected to an under.'latcr seal apparatus with
or without suction, a chest x-ray examination is necessary to
Pneumothorax results from air entering the potential space confirm rcexpansion of the lung. Neither general anesthesia
between the visceral and parietal pleura (Figure 4-8). Both nor poit ive pressure ventilation should be administered in
penetrating and nonpenetrating trauma can cause this in a patient who has sustained a traumatic pneumothorax or
jury. Thoracic spine fracture dislocations also can be asso who is at risk Cor unexpected intraoperative pneumothorax
ciated with a pneumothorax. Lung laceration with air until a chest tube has been inserted. A simple pneumotho
leakage is the most common cause of pneumothorax re rax can readily convert to a life-threatening tension pneu
suJLing from blunt trauma. mothorax, particularly if it is initia!Jy unrecognized and
The thorax is normally completely filled by the lung, positive-pressure ventilation is applied. The patient with a
being held to the chest wall by surface tension betl.veen the pncumOI'horax should also undergo chest decompression
pleural surfaces. Air in the pleural space disrupts the cohe before he or she is transported via air ambuJance.
sive forces between the visceral and parietal pleura, which
allows the lung to collapse. A ventilation/perfusion defect
occurs because the blood that perfuses the nonventilated
area is not oxygenated. The primary cause of hemothorax (<1 500 mL blood) is
When a pneumothorax is present, breath sounds are lung laceration or laceration of an Lntercostal vessel or in
decreased on the affected side, and percussion demonstrates ternal mammary artery due to either penetrating or blunt
hyperresonance. An upright, expiratory x-ray film of the trauma. Thoracic spine fracture dislocations also may be as
chest aids in the diagnosis. sociated with a hemothorax. Bleeding is usually self-imited
Any pneumothorax is best treated with a chest tube and doc nor require operative intervention.
placed in the fourth or fifth intercostal space, just anterior to

Muscle layers
r- ....

- \ 1
- .....



pleura pleura

Figure 4-8 Simple Pneumothorax. Pneumothorax results from air entering the potential space between the
visceral and parietal pleura.

94 CHAPTER 4 Thoracic Trauma


A simple pneumothorax in a trauma patient should A simple hemothorax, not fully evacuated, may re
not be ignored or overlooked. It may progress to a sult in a retained, clotted hemothorax With lung en
tension pneumothorax. trapment or, if infected, develop into an empyema.

An acute hemothorax large enough to appear on a chest If lracheobronch ia 1 injury is suspected, immediate sur
x-ray film is best rreated with a large-caliber (36 French) gical consultation is warranted. Such patients typically pres
chest lube. The chest tube evacuates blood, reduces the risk ent with hemoptysis, subcutaneous emphysema, or tension
of a clotted hemothorax, and, importantly, provides a pneumothorax wilh a mediastinal shift. A pneumothorax
method fo r continuous monitoring of blood loss. Evacua associated with a persistent lcuge air leak after tube U1ora
tion of bluod and fluid also facilitates a more complete as costomy suggests a tracheobronchial injury. Bronchoscopy
sessment of potential diaphragmatic injury. Although many confirms the diagnosis of Lhe injury. Placement of more
factors are involved in the decision to operate on a patient than one chest tube often is necessary to overcome a very
with a hemothorax, the patient's physiologic slat us and the large leak and expand the lung. Tem pora ry intubation of the
volume of blood drainage from the chest tube are major fac opposite mainstcm bronchus may be required to provide
tors. As a guideline, if 1500 mL of blood is obtained imme adequate oxygenation.
diately through I he chest tube, if drainage of more than 200 Intubation of patients with tracheobronchial injuries is
m L/h r for 2 to 4 h r occurs, or if blood tJansfusion is re freq uenlly difficult because of anatomic distortion from
quired, operative exploration should be considered. paratracheal hematoma, associated oropharyngeal injuries,
and/or the tracheobronchial injury itself. For such patients,
immediate operative i11lcrvention is indicated. Tn more sta
ble patients, operative treatment of tracheobronchial in
Pulmonary contusion may occur without rib fractures or juries may be delayed until the acute inflammation and
flail chest, particularly in young patients without completely edema resolve.
ossified ribs. However, pulmonary contusion is the most
common potentially lethal chest injury. The resultant respi
ratory failure can be subtle, and it develops over time, rathcr
than occurring instantaneously. The plan for definitive man Blunt cardiac injury can result in myocardial muscle contu
agement may change \viU1 Lime, wananting careful moni sion, cardiac chamber rupture, coronary artery dissection
toring and reevaluation of the patient. and/or thrombosis, or valvular disruption. Can..liac rupture
Patients with significant hypoxia { ie, PaO: <65 m m Hg typically presents with cardiac injury tamponade and should
[8.6 k.Pal or SaO, <90;h) on room air may require intuba- be recognized during the primary survey. However, occa
tion and ventilation within the first hour after injwy. Asso- sionally tbe signs and symptoms of tamponade arc slow to
ciated medical conditions, such as chronic pulmonary develop with an atrial rupture. Early use of FAST can facil
disease and renal failure, increase tbe necessity o[ early in itate diagnosis.
LUbation and mechanical ventilation. Some patients with Patients ,.vith myocardial contusion may report chest
stable conditions may be treated selectively without endo discomfort, but this symptom is often attributed lo chest
tracheal intubation or mechanical ventilation. wall contusion or fractures of the sternum and/or ribs. The
Pulse oximetry monitoring,ABG determinations, ECG true diagnosis of myocardial contusion can be established
moniloring, and appropriate ventilatory equipment are nec only by direct inspection of the injured myocardium. The
essary for optimal treatment. Any patient with the afore clinically important sequelae of myocardial contusion are
mentioned preexisting conditions who is to be transferred
should Lmdergo intubation and ventilation.

Injury to the trachea or major bronchus is an unusual and Avoid underestimating the severity of blunt pul
monary injury. Pulmonary contusion may present as a
potentially fatal condition that is often overlooked on ini
wide spectrum of clinical signs that are often not well
tial assessment. In blunt trauma the majority of such in
correlated with chest x-ray find ings. Carefu I mon itor
juries occur within I in. (2.54 em) of the carina. Most ing of ventilation, oxygenation, and fluid status
patients wiLb this injury die at the scene. Those who reach is required, often for several days. With proper man
the hospital alive have a high mortality rate from associated agement, mechanical ventilation can be avoided .
lnJ unes.


hypotension, dysrhythmias, or wall-motion abnormality on

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

changes are the most common ECG fi ndings. Elevated cen

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

blunt carcliac in.iury is inconclusive and offers no additional

information beyond that available from ECG. Therefore,
they have no role in the evaluation and treatment of patients
wiU1 blunt cardiac injury.
Patients with n blunt injury to the heart diagnosed by
conduction abnormalities are at risk for sudden dysrhyth
mias and should be monitored for the tlrst 24 hours. After
this interval, the risk of a dysrhythmia appears to decrease
Figure 4-9 Aortic Rupture. Traumatic aortic rup
ture is a common cause of sudden death after an auto
TRAUMATIC AORTIC DISRUPTION mobile collision or fall from a great height.
Traumatic aortic rupture is a common cause of sudden
death after an automobile collision or fall from a great
s.istent or recurrent hypotension is usually due to a separate,
height (Figure 4-9). For survivors, recovery is freq uenUy
unidentified bleeding site. Although free rupture o( a tran
possible if aortic rupture is identified and treated immedi
secled aorta into the left chest does occur and may cause hy
potension, it usually is fatal unless lhe patient is operated
Patients vvith aortic mpturc, who may potentially sur
on within a few minutes.
vive, lend to have an incomplete laceration near the liga
Specific signs and symptoms of traumatic aortic dis
mentum nrleriosum of the aorta. Continuity maintained
ruption are frequently absent. A high index of suspicion
by an in tact adventitial layer or contained mediastinal
prompted by a history of decelerating force and character
hematoma prevents immediate dealh. Many surviving pa
istic findings on chest x-ray films should be maintained, and
tients die in the hospital if left untreated. Some blood can es
t.he patient should be further evaluated. Adjunctive radio
cape into the mediastinum, but one characteristic shared by
logic signs on chest x-ray films, which may or may not be
all survivors is that they have a contained hematoma. Per-
present, indicate the likelihood of major vascular i njury in
tl1e chest They include:

Widened mediastinum
Obi it.era tion of the aortic knob
Penetrating objects that traverse the mediastinum Deviation of the trachea to tl1e right
may injure the major mediastinal structures, such as
the heart, great vessels, tracheobronchial tree, and Depression of the left mainstem brohchus
esophagus. The diagnosis is made when careful ex
ami nation and a chest x-ray film reveal an entrance Elevation of the right mainstem bronchus
wound in one hemithorax and an exit wound or a Obliteration of the space between the pulmonary
missile lodged in the contralateral hemithorax. arte11 and the aorta (obscuration of the aortopul
Wounds in which metallic fragments from the missile
monary window)
are in proximity to mediastinal structures also should
raise suspicion of a mediastinal traversing injury. Deviation of the esophagus (nasogastric tube) to
Such wounds warrant careful consideration, and sur the right
gical consultation is man datory.
Widened paratracheal sttipe

96 CHAPTER 4 Thoracic Trauma

Widened paraspinal interfaces "lechniques of endovascular repair are rapidly evolving as an

alternative approach for surgical repair of blunt traumatic
Presence of a pleural or apical cap
aortic injury.
Left hemothorax

Fractures of the first or second rib or scapula TRAUMATIC DIAPHRAGMATIC INJURY

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

.. . -
caused by the forceful expulsion of gastric con tents i nto the

Delayed or extensive evaluation of the wide medi

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



1- Abdominal

Figure 4-1 0 Diaphragmatic

:-- Hernia Rupture. Blunt trauma produces
large radial tears that lead to herni
Diaphragm ation, whereas penetrating trauma
produces small perforations that
often take some time to develop
into diaphragmatic hernias.

esophagus from a severe blow to the upper abdomen. This

forcefuJ ejection produces a linenr tear in the lower eso pha
gus, leakage into t he mediastinum (Figure 4-1 1 ) .

The resul ting mediastinitis and immediate or delayed rup

ture into the pleural space cause em pyema .

The clinical picture of patients with blunt esophageal

rupture is identical to that of posternetic esophageal rup
ture. Esophageal injury should be considered i n any pa
tient who: ( 1) has a left pneumothorax or hemothorax
without a rib fracture; (2) has received a severe blow to the
lower stern u m or epigastrium and is in patn or shock out
of proportion to the apparent mjury; aml (3) has particu
late matter in the chest tube after the blood begins to clear.
Presence of mediastinal air also suggests the diagnosis,
which often can be confirmed by contrast studies and/or
Treatment consists of wide drainage of the pleural space
and mediastinum with direct repair of the injury via thora
cotomy, iffeasible. Repairs performed wit.hin a few hours of
injury lead to a much better prognosis.

Other Manifestations
of Chest Injuries Figure 4-1 1 Radiograph showing rib fractures.
Fractures of the scapula, first or second rib, or the ster
Other significant thoracic injuries-including subcutaneous num suggest a magnitude of injury that places the
emphysema; crushing injury (traumatic asphyxia); and rib, head, neck, spinal cord, lungs, and great vessels at risk
sternum, and scapular fractures-should be detected dming for serious associated injury.
the secondary survey. Although these injuries may not be
immediately life-threatening, they have the potential to do
significant hann.

98 CHAPTER 4 Thoracic Trauma

Subcutaneous emphysema can result from airway injury,

' '
. .

lung injury, or, rarely, blast i nj Ul'Y- Although it does not re Unde restimating the severe pathophysiology of rib
quire treatment, the underlying injury must be addressed': fractures is a common pitfall, pa rticu larly in patients
l f positive-pressure ventilation is required, tube thoracos at the extremes of age. Aggressive pain control with
tomy should he considered on the side of the subcutaneous out res pi ratory depression is the key management
emphysema ill <Jnticipation or a tension pneumothorx de p ri n cip le .

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

Direct force applieJ to the ribs tends to fracture them and

drive the ends or tbe bones into the thorax, raising the po Individuals requiring positive-pressure ventilation
tential for more intrathoracic injury, such as a pneumotho- in whom substantial chest injury is suspected



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

Mass1ve hemothorax-D1agnosed by find 1ng decreased breath sounds and dullness
to percussion on physical examination. Initial management requires evacuation with
insertion of a large (#36 French) chest tube. A qualified surgeon must be involved ,
1n the dec1S1on for thoracotomy.
Card1ac tamponade-D1agnos1s by clinical examination, w1th ultrasound examina
tiOn to confirm. lnit1al management mcludes flUid resuscitation and surgery. Peri
cardiocentesis may be used as a temporizmg maneuver if surgical intervention is not
Immediately available.
The secondary survey includes 1dentif1cation and 1nitial treatment of the following po
tentially life-threatemng lnJunes, ut11izmg adJunctive stud1es (x-rays. laboratory test, ECG):
Simple pneumothorax-Typically diagnosed by chest x-ray or CT scan and treated
with Lube t horacostomy.
Hemothorax-Typical ly d 1agnosed by chest x-ray or CT scan and treated with tube
Pulmonary cont us io n Ty pica lly di a gnosed by chest x-ray or CT scan. Management

includes j u dic ious fluid resuscitation and select1ve Intubation for pu l m on ary sup
Tracheobronchial tree injury-Associated with hemoptysi s pn eu momediastin um
, ,

pneumope rica rdi u m persistent a1r leak from chest tube, or pers1stent pneumo

thorax afte1 insertion of a chest tube. Req u ires operative repair.

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

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

100 CHAPTER 4 Thoracic Trauma

Several manifestations of thorac1c trauma are indicative of a greater risk of associated


Sub cutaneous emphysema is associated with airway or lung injury. Tube thoracos-
tomy should be considered for patients (e q u i ri ng positive pressure ventilation.
Crush inJunes of t he chest present with petech1ae and plethora of the head, neck,
and upper torso. Brain injury with progressive cerebral edema should be suspected.
Injuries to the upper ribs ( 1 -3), scapula, and sternum are associated with si g nifica nt
mechanisms of injury. Underlying head, spine, and cardiothoracic injury should be sus

Bibliography 12. Fabian TC, Richardson JO, Croce MA, cr al. Prospective study
ofbJunl aortic injury: multicenter trial of the American Asso
ciation for rhe Surgery of Trauma. J Trauma 1997;42:374-383.
1. Ball CG, Kirkpatrick AW, Laupland KB, ct al. Incidence, risk
13. Flagel R, Luchette FA, Reed RL et al. Half a dozen ribs: the
factors, and outcomes for occult pneumothoraces in victims
breakpoint for mortality. Surgety 2005; 138:7 17-725.
of major trauma. j 'fmuma 2005; 59(4), 917-924; discussion
924-925. 14. Gavant ML, Menke PG, Fabian TC, ei al. Blunt traumatic aor
tic rupture: detection lvith helical CT of the chest. Radiology
2. Berlinchant JP, Robert E, Polge A, et al. Rele<Jse kinetics of car
1995; 1 97: 125- 133.
diac troponin 1 and cardiac troponin T in eff luents from iso
lated perfused rabbit hearts after graded experimental 15. Goldberg SP, Karalis DC, Ross J], et al. Severe right ventricu
myocardial contusion. / Trntl/1111 1999;47(3):474-480. lar contusion mimicking cardiac taJnpoMde: the value of
transesophageal echocardiography i n blunt chest tr au ma. Arm
3. Boyd M, Vanek VW, Bourguet CC. Emergency mom resusci
Emerg Med 1993;22(4):74.5-717.
tative thoracotomy: when is it indicated? j Tm11111a
1992;33 (5):714-721. I 6. Graham )C, Mattox KL, Beall J\C Jr. Penetrating trauma of Lhe
lung. / Trmmtn 1979; 19:665.
4. Brasel K), Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC.
Treatment of occulL pneumothoraces from blunt trauma. I 17. J-lcnitord BT, Carrillo EG, Spain DA, et al. The role of thora
Trauma 1999; 46(6), 987-990; discussion 990-991 . coscop)' in the;: management of retained thoracic collections
after tratlma. Ann Thome S11rg 1997;63(4):940-943.
5. Brooks f\P, Olson LK, Shackford SR. Computed tornography in
the diagnosis of traumatic rupture of the thoracic aorta. Clin 18. Hopson LR, Hirsh E, Delgado J, Domeier IUvl, McSwain NE,
Radiol 1989;40: 133-138. Krohmcr ]. Guidelines for withholding or termination of re
suscitation in prehospita.l traumatic cardiopulmonary arrest: a
6. Bulger EM, Edwards T, Klotz P, Jurkovich G). Epidural analge
joint position paper From the National Association of EMS
sia improves outcome after mu lt i p le rib fractures. S11rgcry
Physicia11S Standards and Clinical Practice Committee and lhe
2004; 136(2):426-430.
American College of Surgeons Committee on Tnmma. Preltosp
7. Callaham M. Pcricardiocentesis in traumatic and nontrau Emerg Cnrc 2003; 7( I ) , 1 4 1 - 146.
l)latic cardiac tamponade. A1111 Emerg Med 1984; 13( I 0):924-
19. Hopson LR, Hirsh , Delgado ), et aJ. (uidelines for with
holding or termination of resuscitation i n prehospital trau
8. Cook J, Salerno C, Krishndasan B. l\icholls S, Meissner M, matic cardiopulmonary arrest j Am Cull Surg 2003; J 96(3),
Karmy-Jones R. The effect of changing presentation and man 475-481.
agement on U1e outcome of blunt rupture of the thoracic
20. Hunt PA, Greaves
1 , Owens WA. Emergency thoracotomy in
aorta. j Tho me Cnrdiovasc Surg 2006; 1 3 1 (3 ), 594-600.
thoracic Lrawua-a review. Injury 2006; 37( 1 ) , 1 - 1 9.
9. Dunham CM, Barraco RD, Clark D, et al. Guidelines for
2 1 . Karalis DG, Victor MF, Davis GA, et al. The role of echocar
emergency tracheal inLLJbation immediately following trau
diography i n blunt chest trauma: a transthoracic and trans
matic injury: an EAST Practi ce Management Guidelines
eophageaJ echocardiography study. I Tm11mr1 1994;36
\<\1o rkgroup. / Tm1111U1 lllfect Cril Cnre Bums 2003;55: 162-1 79.
I 0. Dyer DS, Moore E, Mestek M F, et al. Can chest CT be used to
22. Lang-Lazdunski L, Mourox J, Pons F, et al. Role of videotho
exclude aortic injury? Rarliology 1999;2 13( I ) : 1 95-202.
racoscopy in chest trauma. .t\1111 Tirorae S11rg 1997; 63(2):327-
I I . Esposito T), Jurkovich GJ, Rice CL, et al. Reappraisal of emer 333.
gency room thoracotomy in a changing environmen L. }
23. Lee JT, White RA. CurrcnL status of thoracic aortic endograft
Tmrmw 1991;3 I (7):88 1-887.
repair. Surg Clin North Am 2004;84(5):.1295- 1318.


24. Lockey D, Crewdson K, Davies G. Trmum1tic cardiac arrest: 40. Richardson JD, Flint LM, Snow N), et al. Management of trans
who are the survivors? Ann Emerg Med 2006; 48(3), 240-244. mediastinal gunshot wounds. '\urgery 1981 ;90( 4 ):67J -676.

25. Marnocha KE, Magiinte DDT, Woods J, et al. Blunt chest 41. Rosato R.\-1, Shapiro MJ, Keegan MJ. et al. Cardiac in jury com
trauma and suspected aortic rupture: reliability of cbest radi plicating traumatic asphyxia. I Traumll 1991;31 ( LO): l387-
ograph findings. A1111 Emerg 1\tfed 1985;14(7):644-649. l389.

26. Mattox KL, Flint LM, Carrico CJ, et ol. Blunt .:ardiac injury.} 42. Rozycki GS, Feliciano DV, Oschner MG, et al. The role of ul
Tm111110 1994;33(5):64':1-650. trasound in patients with possible penetrating carcliac wounds:
a prospective mull icenter study. J Trauma 1999;46(4):542-551.
27. Mattox KL. Wall M). Newer diagnostic measures and emer
gency management. Chest Surg Cli11 North A111 1.997;2:2 1.3-226. 43. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeon
performed ult rosound in patients with possible cardiac
28. McPhee JT, Asham Ell, Rohrer MJ, et al. The midterm results
wound. Atilt Surg 1 996;223(6):737-74-!.
of stent graft treatment of thoracic aortic injuries. I S11rg Re
2007; 138(2): 1 8 1 - 188. 44. Simeone A, Freitas M, Frankel HL. lvlanagcmenl options in
blunt aortic injury: a case series and literature review. A111 Surg
29. Me)er DM, )essen ME, Wait MA. Early evacuation of trau
2006; 72( I), 25-30.
matic retained hemothoraces using thoracoscopy: t\ prospec
tive randomized triai.An11 TltomcSurg 1997;64(5):1396-1400. 45. Simon B, Cushman J. Barraco R, et al. Pain management in
blunt thoracic trauma: an EAST Practice Management Guide
30. Mirvis SE, Shanmugantham K, Buell ), et al. Use of piral com
lines Workgroup. ] Trallma infect Crit Care Bums
puted tomography for the assessment of blunt trauma patients
2005;59: 1 256- L267.
with potenLial aortic inj ury. 1 Tnwma 1999;45:922-930.
46. Smith MD, C1ssidy j!vl, Souther S, et al. Trnnsesophageal
3 1 . Moon M R, l.uchette FA, Gibson SW, et a I. Propective, ran
echocardiography in the diagnosis of traumatic rupture of the
domized comparison of epidural versus parenteral opiQid
aorta. N Eng/ } Med 1995;332:356-362.
analgesia in U1oracic trauma. Ann Surg 1 999;229:684-692.
47. S0reide K, S0iland II, l.ossius JIM, et al. Resuscitative emer
32. Peterson BG, fVlatsumura JS, Morasch MD, \Vest i'vlA, Eskan
gency U1oracotomy in a Scandinavian trawna hospital-Is it
dari MK. Percutaneous endovascular repair of blunt thoracic
justilied.? Injwy 2007;38( J ):34-42.
aortic transection. / Trmmw 2005 Nov;59(5): 1 062- l 065.
48. S0reide K, S0iland l f, Lossius HM, Vet rhus M, Soreide )A, Sor
33. Pezzella AT, Silva WE, Lancey RA. Cardiothoracic trauma. C11rr
cide E. Resuscitative emergency thoracotomy in a Scandina
Probl Surg 1998;35( 8):649-650.
vian trauma hospital-is it justified? ln:fiiT)' 1007; 38.( 1 ), 34-42.
34. Poole G, Myers RT. Morbidity and monalit)' rates in major
49. Stafford RE, LiJlll J, Washinglon L. lncidence and management
hlunt trauma to the upper chest. Ann Surg 1 9110; 193( I ):70-75.
of occult hemothoraces. Am 1 Su rg 2006; 192(6), 722-726.
35. Powell 0\tV, Moore EE, Cothren CC, et al. Ts emergency de
50. Swaaenburg JC, Klaase JM, De)ongste MJ, et al. Troponin l,
partment resuscitative t.horacotomy futile care for the critically
troponin T, CKMB-aclivity a.nd CKN!G-mas as marken for
injured patient requiring prehospital cardiopulmonary resus
the detection of myocardial cont usion in patients who experi
citation? I Am Col/ Surg 2004;199(2):21 1-21 5.
enced blunt trauma. Clir1 Chi111 Acta 1998;272(2): 1 7 1 - 1 8 1 .
36. Ramzy AJ, Rodriguez A, Turney SZ. Ma11agcment of major tra
5 1 . Symbas PK CardiotJ1oracic trauma. Curr Probl Srtrg
cheobronchial ruptures in patients witJ1 multiple system
1991;28( 1 1 ):741 -797.
trauma. f Traumll 1988;28:91 4-920.
52. Tehrani H Y, Peterson BG, Katariya K, et al. .Endovascular repair
37. Reed Al3, Thompson JK, Crafton C), el al. Timing,,,. cndovas
of Lhoracic aortic tears. Ann Thome Surg 2006;82(3 ):873-877.
cular repair of bluJlt traumatic thoracic aortic transections. /
Vase Surg 2006;43( 4):684-688. 53. Weiss RL, Brier JA, O'Connor W, et aJ. Tbe usefulness of trans
esophageal echocardiography in diagnosing cardiac contu
38. Rhcc PM, A<:osta ), Bridgeman A, Wang D, Jordan M, Rich N.
sions. Chest 1 996; 1.09( I ):73-77.
Survival after emergency department LhoracotQm}r: review of
published data fxom the past 25 )'ears. JAm Colt Sur-g 2000; 54. Woodring D. Radiographic manifestations of mediastinal
190(3 ), 288-298. hemorrhage from blunt chest trauma. Am1 Thome Surg
1984;37(2): 1 7 1 - 1 78.
39. Richardson JD, Adams L, Flint LJ.\1. Selective management of
flail chest and pulmonaJy contusion. Ann Surg 55. Woodring JH. A normal mediastinum in blunt trauma rup
1 982; 1 96( 4):481.-487. ture of the thoracic aorta and brachiocephalic arteries. J Emerg
Met/ 1990;8:467-476.


Performance at this skill station will allow the part icip a n t to:
Interactive Skill
Note: This Skill Station includes a
systemati c method for evaluating
chest x-ray fil ms A senes of x
Describe the process for viewing a chest x-ray film for the purpose of

rays with related scenarios is then

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

Given a series of x-rays:

Diagnose fractures.
Diagnose a pneumothorax and a hemothorax.
Identify a widened mediastinum.
Delineate associated injuries.
Identify other areas of possible injury.


104 SKILL STATION VI X-Ray Identification of Thoracic Injuries

skiii VI-A: Process for Initial Review of Chest X-Rays

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

II. TRACHEA AND BRONCHI A widened mediastinum-most reliable tlnding

Fractures of the first and second ribs
STEP 1. Assess the position of the tube i n cases of Obliteration of the aortic knob
endotracheal in Lubation. Deviation of the trachea to the right

STEP 2. Assess for the presence of interstitial or pleural Presence of a pleural cap

air that can represent tracheobronchial injury. Elevation and rightward shift of the right
mainstem bronchus
STEP 3. Assess for tracheal lacerations that can present as Depression of the left mainstem bronchus
pneumomectiastinum, pnewnothorax, Obliteration of the space between the
subcutaneous and interstitial emphysema of the pulmonary artery and aorta
neck, or pneumoperitoneum. Deviation of the esophagus (NG tube} to

STEP 4. Assess for bronchial disruption that can present the right
as a free pleural communication and produce a
massive pneumothorax with a persistent air leak V. DIAPHRAGM
that is unresponsive to tube thoracostomy.
Note: Diaphragmatic rupture requires a high index of sus
picion, based on the mechanism of injury, signs and symp
Ill. PLEURAL SPACES AND LUNG toms, and x-ray findings. Initial chest x-ray examination
may not clearly identify a diaphragmatic injury. Sequential
films or additional studies may be required.
STEP 1 . Assess the pleural space for abnormal collections
of Ouid thai can represent a hemothorax. STEP 1 . Carefully evaluate the diaphragm for:
STEP 2. Assess the pleural space for abnormal coUections a. Elevation (may rise to fourth intercostal space
of air tbat can represent a pneumothorax with full expiration)
usuaUy seen as an apical lucent area without b. Disruption (stomach, bowel gas, or NG tube
bronchial or vascular markings. above the diaphragm}
c. Poor identification ( irregular or obscure} due
STEP 3. Assess the lung fields for infiltrates that can to overlying fluid or soft-tissue masses
suggest puhnonary contusion, hematoma,
aspiration, etc. Pulmonary contusion appears as STEP 2. X-ray changes suggesting injury include:
air-space consolidation that can be irregular and a. Elevation, irrcgularil'y, or obliteration o[ the
patchy, homogeneous, diffuse, or extensive. diaphragm-segmental or total
b. A mass-like density above the diaphragm that
STEP 4. Assess the parenchyma for evidence of laceration.
can be due to a fluid-filled bowel, omentum,
Lacerations appear as a hematoma, vary
liver, kidney, spleen, or pancreas (may appear
according to the magnitude of injury, and appear
as a "loculated pneumothorax")
as areas of consolidation.
c. Air or contrast-containing stomach or bowel
above the diaphragm
d. Contralateral mediastinal shift
e. Widening of the cardiac silhouette if the peri
STEP 1 . Assess for air or blood that can ctisplace toneal contents herniate into tbe pericardia] sac
mecliastinal structures or blur the demarcation f. Pleural effusion

SKILL STATION VI X-Ray Identification of Thoracic Injuries 105

STEP 3. Assess for associated injuries, such as splenic, a. Fracture, especially in two or more places (flail
pancreatic, renal, and liver. chest)
b. Associated injury, such as pneumothorax,

pulmonary contusion, spleen, liver, and/or
STEP 1 . Assess the clavicle for evidence of:
STEP 6. Assess the stcrnomanubrial junction and sternal
a. Fracture body for evidence of fracture or dislocation.
b. Associated inju.ry, such as great-vessel injury (Sternal fractures can be mistaken on Lhe AP film
STEP 2. Assess Lhe scapula for evidence of: for a mediastinal hematoma. After Lhe patient is
stabilized, a coned-down view, overpenetrated
a. Fracture
film, lateral view, or CT may be obtained to
b. Associated injury, such as airway or great
better identify suspected sternal fracture.)
vessel injury, pulmonary contusion
STEP 7. Assess the sternum for associated injuries, such
STEP 3. Assess ribs I through 3 for evidence of:
as myocardial contusion and great-vessel injury
a. Fracture (widened mediastinum), alt.hough these
b. Associated injury, such as pneumothorax:, combinations are relatively irrfrequent.
major airway, or great-vessel injury
STEP 4. Assess ribs 4 through 9 for evidence of:
a. Fracture, especially in lwo or more contiguous
ribs in two places (flail chest) STEP 1 . Assess for:
b. Associated injury, such as pneumothorax, a. Displacement or disruption of tissue planes
hemothorax, pulmonary contusion b. Evidence of subcutaneous air
STEP 5. Assess ribs 9 through 1 2 for evidence of:

TABLE Vl-1 Chest X-Ray Suggestions


Respiratory distress Without x-ray findings CNS 1njury, aspiratJon, traum atic asphyxia

Any rib fracture Pneumothorax, pulmonary contuSIOn

Fracture of first three nbs or sternoclavicular Airway or great-vessel Injury

fractu re-d islocat ion

Fracture of lowei ribs 9 to 12 Abdominal Injury

Two or more rib fractures in two or more places Flail chest, pulmonary contusion

Scapular fracu re t Great-vessel InJury, pulmonary
conwsion, brachial plexus Injury

Mediastinal wtdemng Great-vessel injury, sternal fracture, thoracic spine 1n1ury

r large pneumothorax or a1r leak B ronchtal tear
after chesttube lnsert1on ;

Mediastlna I air Esophageal disruption, lracheal injury, pneumoperitoneum

Gl gas pattern In the chest (loculate(! air) Diaphragmti<: rupture

N G tube In the chesl Diaphragmatic rupture or ruptured esophagus

Air fluid level tn the chest Hemopneumothorax or diaphragmatiC rupture i

Disrupted diaphragm Abdominal visceral injury

Free atr \J nder the dia hr p agm Ruptured hollow abdominal v1scus
.. -..
...... ..
. .
.; ...
; ,
_ .. .
. ...a..

. ..
. ...
... ..
, ..
. ..
.. ...
- ..
. .....
.. .-.
- ..
.*-" ''-"" ..
. .. .....
-. . ...
, ,
_ _ ,, "
, "'
.. - -........
... ,,..
. ..... -OOOL

106 SKILL STATION VI X-Ray Identification of Thoracic Injuries

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



X-ray ftlm of a 33-year-old bicyclist who was hit by a car. X-ray Ctlm of a 36-year-old male after treatment of an obvi
ous pneumothorax on the right side, still desaturated.
X-ray lilm of a young female with a small stab wound above PATIENT Vl-8
the nipple on the right side with ipsilateral dinunishcd
X-ray film of a 45-year-old male motorcyclist who hit a tree
breath sow1ds.
at high speed. He was intubated by EMS and presents as he
mod)'11amically normal.
X-ray film of a 56-year-old truck driver who hit an abut
ment and reported left-sided chest pain and respiratory dis
tress. X-ray film of a 56-year-old motorcyclist who sustained a
collision with a truck. He was intubated and received a tho
PATIENT Vl-4 rax drain in the prehospital setting.

i a
X-ray film of a 22-year-old male in distress after a figbl n
bar (stab wound in the back, fourth intercostal tpace on left). PATIENT Vl- 1 0
X-ray film of an 18-year-old gang leader who was assaulted.
PATIENT Vl-5 He has multiple contusions, an altered level of conscious
X-ray film of a 42-year-old male in respiratory illstress after ness, and a small entrance wound on the right hemithorax.
sustaining a gunshot wound in a jewelry shop robbery. He has received initial resuscitation.


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

111ISS!On. with severe head injury.


Performance at lhis skill station will allow the student to practice and demon
Interactive Skill
strate on a live, anesthetized animal; a fresh, human cadaver; or an anatomic
human body manikin the techniques of needle thoracic decompression of a
Note: Standard precautions tension pneumothorax, chest tube insertion for the emergency management
are required when caring for of hemopneumothorax, and pericardiocentesis. Specifically, the student also

trauma patients. will be able to:

IN THIS SKILL STATION: Identify the surface markings and techniques for pleural decompres
sion with needle thoracentesis, chest tube insertion, and needle peri
Skill VIl-A: Needle cardiocentesis.
Describe the underlying pathophysiology of tension pn eu mothorax
Skill VII-B: Chest Tube and cardiac tamponade as a result of trauma.

Skill VII-C: Pericard1ocentesis

Describe the complications of needle thoracentesis, chest tube inser
tion, and pericardiocentesis.


108 SKILL STATION VII Chest Trauma Management

Skill VIl -A : Needle Thoracentesis

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

STEP 1 . A:,e:,s the patient's chest and re::.piratory status.

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

nlidclavicLJaI' line 011 the side of the tension affected hemithorax.

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

Skill Vll-8: Chest Tube Insertion

STEP 1 . Determine the insertion site, usuaUy at the desired length. The tube should be directed
nipple level (fifth intercostal :.pace), just anterior posteriori)' along the inside of the chest wall.
to the midaxillary line on the affected side. A
STEP 7. Look for "fogging" of the chest tube with
:,econd chest tube may be used for a
expiration or listen for air movement.
STEP 8. Connect the end of the thoracostomy tube to an
STEP 2 Surgically prepare and drape the chest at the
underwater-seal apparatus.
predetermined site of the tube insertion.
STEP 9. Suture the tube in place.
STEP 3. Locally anesthetize the skin and rib periosteum.
STEP 10. Apply a dressing, and Lap Lh Lube to the chest.
STEP 4. Make a 2- to 3-cm transverse (horizontal)

incision at the predetermined site and blunlly STEP 1 1 . Obtain a chest x-rny tilm.
dissect through the subcutaneous tissues, just
STEP 1 2. Obtain arterial blood gas values and/or institute
over the top of the rib.
pulse oximetry monitoring as necessary.
STEP 5. Puncture the parietal pleura with the tip of a
clamp and put a gloved finger into the incision to
avoid injury to other organs and to clear any COMPLICATIONS OF CHEST TUBE INSERTION
adhesions, clots, etc.
Laceration or puncture of intrathoracic and/or ab
STEP 6. Clamp the proximal end of the thoracostomy dominal organs, which can be prevented by using
tube and advance it into the pleural space to the the finger technique before inserting the chest tube

SKILL STATION VII Chest Trauma Management 109

Introduction of pleural infcction-eg, Large primary leak

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

Skill VII-C: Pericardiocentesis

STEP 1 . Monitor the patient's vital signs and ECG before, injury pattern persist, withdraw the needle
during, and after the procedme. completely.
STEP 2. Surgically prepare Lhe xiphoid and subxiphoid STEP 11. After aspiration is completed, remove the
areas, if time allows. syringe, and attach a three-way stopcock, leaving
STEP 3. Locally anesthetize the puncture site, if necessary.
the stopcock closed. Seaure the catheter in place.

STEP 4. Using a 16- to 18-gauge, 6-in. ( 15-cm) or longer STEP 12. Option: Applying the Seldinger technique, pass a
over-the-needle catheter, attach a 35-mL empty flexible guidewire through the needle into the
syringe with a three-way stopcock. pericardia! sac, remove the needle, and pass a 14-
gauge tlex:ible catheter over Lhe guidewire. Remove
STEP 5. Assess the patien t for any mediastinal shift that the guidewire and attach a three-way stopcock.
may have caused the heart to shift significantly.
STEP 13. Should the cardiac Lamponade symptoms
STEP 6. Puncture the skin I to 2 em inferior to the left of persist, the stopcock may be opened and the
lhe xiphochondraJ junction, at a 45-degree a-11gle pericardia! sac reaspirated. The plastic
to Lhe skin. pericardiocentesis catheter can be sutured or
STEP 7. Carefully advance the needJe cephalad and aim taped in place and covered with a smaU dressi11g
toward the tip of the left scapula. to allow for continued decompression en route
to surgery or transfer to another care facility.
STEP 8. ff the needle is advanced too far (ie, into the
ventricular muscle), an injury pattern known as
the "current of inju1y" appears on the ECG
monitor (eg, ex'treme ST-T wave changes or
widened and enlarged QRS complex). This Aspiration of ventricular blood instead of
pattern indicates that the pericardiocentesis pericardial blood
needJe shouJd be withdrawn until the previous Laceration of ventricular
baseline ECG tracing reappears. Premature cpicardium/myocardium
ventricular contractions also can occur, secondary Laceration of coronary artery or vein
to irritation of tl1e ventricular myocardium. New hemopericardium, secondaxy to
lacerations of lhe coronary artery or vein,
STEP 9. \Vhen the needle tip enters the blood-filled
and/or ventricular cpicardium/myocardiWil
pericardia! sac, withdraw as much nonclotted
Ventricular fibrillation
blood as possible.
Pneumothora.x, secondary to lung puncture
STEP 10. During the aspiJation, the epicardium Puncture of great vessels with worsening of
approaches the inner pericardiaJ surface again, pericardia! tamponade
as does the needle Li.p. Subsequently, an ECG Puncture of esophagus wilh subsequent
current of injury paltcrn may reappear. This mediastinitis
indicates that the pericardiocentesis needle Puncture of peritoneum with subsequent
should be withchawn slightly. Should this peritonitis or false positive aspirate


CHAPTER OUTLINE Upon completion or this topic. the student will identify com
mon patterns of abdominal trauma based on mechanism of
injury and establish management priorities accordingly. Specif
Introduction ically, the doctor will be able to:
External Anatomy of the Abdomen
Internal Anatomy of the Abdomen OBJECTIVES
Peritonea l Cavity
Retroperitoneal Space Identify the key anatomic regions of the ab
Pelvic Cavity domen.

Mechanism of Injury Identify the patient at risk for abdominal and

Blunt Trauma pelvic injuries based on the mechanism of injury.
Penetrating Trauma
Apply the appropriate diagnostic procedures to
i dent i fy ongoing hemorrhage and injuries that
can cause delayed morbidity and mortality
Physical Exammation
Adjuncts to Physical Examination Describe the short-term management of abdomi
Evaluation of Blunt Trauma nal and pelvic injuries.
Evaluation of Penetrating Trauma
Indications for Laparotomy in Adults
Specific Diagnoses
Diaphragm Injuries
Duodenal I njuries
Pancreatic lnjunes
Genitourinary Injuri es
Small Bowel lnjunes
Solid Organ I njuries
Pelvic Fractures and Associated Injuri es
Chapter Summary

112 CHAPTER 5 Abdominal and Pelvic Tra u ma

of the anterior abdomen, acts as a partial barrier to pene

Introduction trating wounds, particularly stab wounds.
The back is the area located posterior to the posterior
When should the abdomen be assessed axillary lines from the tip of the scapulae to the iliac crests.
in the treatment of multiply injured Similar to the abdominal-wall muscles i n the Aank, the thick
patients? back and parasp inal muscles act as a partial barrier to pen
etrating wounds.
Evaluation of the abdomen is a ch allengi ng component of
the initial assessment of i nj ured patients. The assessment of
circulation during the primary survey includes early evalua
tion of the possibility of occult hemorrhage in the abdomen
and pelvis in any patient who has sustained blunt trauma. Internal Anatomy of the Abdomen
Penetrating torso wounds between the nipple and perineum
also m ust be considered as potential causes of intraabdom The three distinct regions of the abdomen are the peritoneal
inal injury. The mechanism of injury, the force with which cavily, the retro peri toneal space, and the pelvic cavity. The
the injury was sustained, the location of inj ury and the he
pelvic cavi ty in fact, contains components of both the peri

modynamic status of the patient determine the best method toneal cavity and re troperitoneal spaces (F igure 5-l ).
of abdominal assessment.
Unrecognized abdominal injury continues to be a cause
of preventable death after truncal trauma. Rupture of a hol PERITONEAL CAVITY
low viscus and bleeding from a solid organ are not easily I t is convenient to divide the peritoneal cavity into two
recognized, and patient assessment is often comprom ised .
parts-upper and lower The upper p eri to neal cavity which ,

by alcohol intoxication, use of illicit drugs, injury to the is covered by the lower aspect of the bony thorax, includes
brain or spinal cord, and injury to adjacent structures such
as the ribs, spine, or pelvis. Significant am ounts of blood
the di ap h ragm l iver, spleen stomach, and transverse colon
, , .
may be present i n the abdominal cavity with no drarn<ltic
chru1ge in appearance or dimensions and with no obvious
signs ofperitoneal irritation. Any patient who has sustained
significant blunt torso injury from a direct blow, decelera
tion, or a penet rating torso injwy must be considered to
have an abdominal visceral or vascular injury until proven

External Anatomy of the Abdomen -r----4-- Retroperitoneal

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


Delay in recognizing intraabdominal or pelvic injury

leads to early death from hemorrhage or delayed Figure 5-1 Regions of Abdomen. The three dis
death from visceral injury. tinct regions of the abdomen are the peritoneal cavity,
retroperitoneal space, and pelvic cavity.


as the result of a motor vehicle crash, can cause compres

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

retroperitoneum must be suspected and evaluated.

tents, and peritonitis. Shearing inj uries are a form of aush
ing injury that may result when a reslraint device, such as a
lap-type seat bell or shoulder harness component, is worn
This area is also referred to as the "thoracoabdominal com improperly (Figure S-2). Patients injured in motor vehicle
ponent" of the abdomen. As the diaphragm rises to the crashes also may sustain deceleration injuries, in which there
fourth intercostal space during fuJI expiration, fractures of is a differential movement of fixed and non fixed parts of the
the lower ribs or penetrating wounds below the nippl e line body. Examples include the frequent lacerations of the I iver
may inj ure abdominal viscera. The lower peritoneal cavity and spleen, both movable organs, at the sites of their fixed
contains the small bowel, parts of the ascending and de supporting ligaments.
scending colons, the sigmoid colon, and, in (emales, the in Air-bag deployment does not preclude abdominal in
ternal reproductive organs. jury. ln patients who sustain blunt trauma, the organs
most frequently injured include the spleen (40%-55%),
RETROPERITONEAL SPACE liver (351Yo-4So/o) , and small bowel (So/o-10%). In addi
tion, there is a 15% incidence of retroperitoneal hema
This po ten tial space is the area posterior to the p eritoneal toma in patients ,.vho undergo laparotomy for blunl lrauma.
lining of the abdomen. Tt contains the abdominal aorta; the Although restraint devices prevent more major inj ur ies ,

inferior vena cava; most of the duodenum, pancreas, kid they may produce specific patterns of i njury as shown in

neys and ureters; the posterior aspects of Lhe ascending and Table 5 - l .
descending colons; and the retroperitoneal components of
the pelvic cavity. Injuries to the retroperitoneal visceral struc
tures are difficult to recognize because the area is remote PENETRATING TRAUMA
from physical examination, and injuries do not initially pre Stab wounds and Jowvelocity gunshot wounds cause tis
sent with signs or symptoms of peritonitis. Ln addition, this sue damage by lacerating and cutting. High-velocity gun
space is not sampled by diagnost ic peritoneal lavage (D PL). shot wounds transfer more kinetic energy to abdominal
rl' See Skill Station VIII: Diagnostic Peritoneal Lavage. viscera. High-velocity wounds may cause increased dam
age lateral to the track of the missile due Lo temporary cav