Royal College Surgical Foundations Objective:

● 2.1.13 - Principles of advanced trauma life support (ATLS) or principles of trauma care
including initial management
● 4.1.1.11 - Trauma/thermal injury (according to ATLS protocols) (Preoperative evaluation
and optimization)

Chapter 1: Initial Assessment and Management

Primary Survey
Airway maintenance with restriction of cervical motion
Establish a definitive airway if there is any doubt about the patient’s ability to maintain
airway integrity.
While assessing and managing a patient’s airway, take great care to prevent excessive
movement of the cervical spine. Based on the mechanism of injury, assume that a spinal
injury exists.
Breathing and ventilation
A simple pneumothorax can be converted to a tension pneumothorax when a patient is
intubated and positive pressure ventilation is provided before decompressing the
pneumothorax with a chest tube.
Circulation and hemorrhage control
Blood volume and cardiac output - once tension pneumothorax has been excluded as a
cause of shock, consider that hypotension is due to blood loss until proven otherwise.
Level of consciousness - altered
Skin perfusion - ashen, gray facial skin, pale extremities
Pulse - rapid, thready; assess central pulse (femoral or carotid)
Bleeding
Definitive bleeding control is essential, along with appropriate replacement of
intravascular volume.
Aggressive and continued volume resuscitation is not a substitute for definitive
control of hemorrhage.
Disability (assessment of neurological status)
Patients with evidence of brain injury should be treated at a facility that has the
personnel and resources to anticipate and manage the needs of these patients. When
resources to care for these patients are not available, arrangements for transfer should
begin as soon as this condition is recognized.
Exposure/Environmental control
Hypothermia can be present with the patient arrives or it may develop quickly in the ED if
the patient is uncovered and undergoes rapid administration of room-temperature fluids
or refrigerated blood. Because hypothermia is a potentially lethal complication in injured
patients, take aggressive measures to prevent the loss of body heat and restore body
temperature to normal.
Clinicians can quickly assess A, B, C, and D in a trauma patient (10-second assessment) by
identifying themselves, asking the patient for his/her name, and asking what happened.
Adjuncts to the Primary Survey with Resuscitation
Physiologic parameters such as pulse rate, blood pressure, pulse pressure, ventilatory rate,
ABG levels, body temperature, and urinary output are assessable measures that reflect the
adequacy of resuscitation. Values for these parameters should be obtained as is practical during
or after completing the primary survey, and reevaluated periodically.
● ECG
● Pulse oximetry
● Ventilatory rate, capnography, and ABG
● Urinary catheters
● Gastric catheters
● Imaging
○ X-rays
○ FAST, eFAST

Consider Need for Patient Transfer

It is important not to delay transfer to perform an in-depth diagnostic evaluation. Only undertake
testing that enhances the ability to resuscitate, stabilize, and ensure the patient’s safe transfer.

Special Populations
Priorities for the care of these patients are the same as for all trauma patients, but these
individuals may have physiologic responses that do not follow expected patterns and anatomic
differences that require special equipment or consideration.

Secondary Survey
Does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are
underway, and improvement of the patient’s vital functions has been demonstrated.
History (AMPLE)
Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury
Blunt Trauma - collisions (frontal, side, rear, ejection, pedestrian), falls,
interpersonal violence
Penetrating Trauma - stabbing, gun shot
Thermal Injury - thermal, electrical, inhalational
Hazardous Environment
Physical Exam - follows this sequence:
Head
Maxillofacial structures
Cervical spine and neck
 Patients with maxillofacial or head trauma should be presumed to have a
cervical spine injury (e.g., fracture and/or ligament injury), and cervical
spine motion must be restricted
Chest
Abdomen and pelvis
Perineum/rectum/vagina
Vaginal examination should be performed in patients who are at risk of
vaginal injury
Musculoskeletal system
Neurological system
Protection of the spinal cord is required at all times until a spine injury is
excluded. Early consultation with a neurosurgeon or orthopedic surgeon
is necessary if a spinal injury is detected.

Adjuncts to the Secondary Survey

X-rays of spine and extremities; CT scans of the head, chest, abdomen, and spine; contrast
urography and angiography; transesophageal ultrasound; bronchoscopy; esophagoscopy.

Reevaluation
Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked
and to discover any deterioration in previously noted findings.

Definitive Care
Whenever the patient’s treatment needs exceed the capability of the receiving institution,
transfer is considered. This decision requires a detailed assessment of the patient’s injuries and
knowledge of the capabilities of the institution, including equipment, resources, and personnel.

Hands-off hand-over: MIST

Mechanism (and time) of injury
Injuries found and suspected
Symptoms and signs
Treatment initiated
 Chapter 2: Airway and Ventilatory Management
Supplementary oxygen must be administered to all severely injured trauma patients.

Airway
Problem Recognition
● A “talking patient” provides momentary reassurance that the airway is patent and not
compromised.
● A definitive airway is defined as a tube placed in the trachea with the cuff inflated below
the vocal cords, the tube connected to a form of oxygen-enriched assisted ventilation,
and the airway secured in place with an appropriate stabilizing method.
Maintaining oxygenation and preventing hypercarbia are critical in managing
trauma patients, especially those who have sustained head injuries.
● Recognize:
Maxillofacial Trauma
Neck Trauma
Laryngeal Trauma - triad of clinical signs:
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture
Objective Signs of Airway Obstruction
1. Observe - agitation suggests hypoxia, and obtunded suggests hypercarbia. Cyanosis
(nail beds, circumoral) indicates hypoxemia from inadequate oxygenation but is a late
finding of hypoxemia and may be difficult to detect in pigmented skin - use pulse
oximetry early. Accessory muscle use, retractions.
2. Listen - noisy breathing is obstructed breathing. Snoring, gurgling, and crowing (stridor)
can be associated with partial occlusion of pharynx or larynx. Hoarseness (dysphonia)
implies functional laryngeal obstruction.
3. Evaluate behaviour: abusive and belligerent patients may in fact be hypoxic; do not
assume intoxication.

Ventilation
Problem recognition
Airway obstruction - clear airway
Altered ventilatory mechanics - rib fractures
CNS depression - intracranial injury, cervical spinal cord injury
Objective Signs of Inadequate Ventilation
1. Observe - symmetrical rise and fall of the chest; asymmetry suggests splinting,
pneumothorax, or flail chest. Labored breathing may indicate imminent threat.
2. Listen - breath sounds on both sides of chest. Beware of tachypnea.
3. Pulse oximetry - to gauge peripheral perfusion; however, SpO2 does not measure the
adequacy of ventilation, and additionally, low SpO2 can be an indication of
hypoperfusion or shock.
 4. Capnography - to assess whether ventilation is adequate and ETT is positioned within
the airway.

Airway Management
Predicting Difficult Airway Management
C-spine injury
Severe arthritis of the c-spine
Significant maxillofacial or mandibular trauma
Limited mouth opening
Obesity
Anatomic variations (e.g., receding chin, overbite, short/muscular neck)
Pediatric patients
Difficult intubation: LEMON
● Look externally (small mouth/jaw, large overbite, facial trauma)
● Evaluate 3-3-2 rule (incisor teeth, hyoid-chin, thyroid notch-mouth floor)
● Mallampati
● Obstruction
● Neck mobility (chin-to-chest, extend to look at ceiling)

Airway Decision Scheme

The first priority of airway management is to ensure continued oxygenation while
restricting cervical spinal motion, which is accomplished by:
● Positioning
○ Chin-Lift - be careful not to extend the neck
○ Jaw-thrust - be careful not to extend the neck
● Preliminary airway techniques
○ Nasopharyngeal airway - do not attempt this in patients with suspected
cribriform plate fracture
○ Oropharyngeal airway - usually inserted upside down until it touches the
soft palate then turned 180 degrees, but do not use this technique in
children. Patients who tolerate OPA are likely to require intubation
A team member then passes an ETT while a second person manually restricts cervical
spinal motion. If an ETT cannot be inserted and the patient’s respiratory status is in
jeopardy, clinicians may attempt ventilation via a laryngeal mask or other extraglottic
airway as a bridge to a definitive airway.
● Laryngeal mask airway (LMA) and intubating LMA
● Laryngeal tube airway (LTA) and intubating LTA
● Multilumen esophageal airway
If this fails, then they should perform a cricothyroidotomy.

Definitive Airways (see definition above)

3 types: orotracheal tube, nasotracheal tube, surgical airway
Criteria for establishing a definitive airway:
 A. Inability to maintain a patent airway by other means, with impending or potential
airway compromise (e.g., following inhalation injury, facial fractures,
retropharyngeal hematoma)
B. Inability to maintain adequate oxygenation by facemask oxygen supplementation,
or the presence of apnea.
C. Obtundation or combativeness resulting from cerebral hypoperfusion.
D. Obtundation indicating the presence of a head injury and requiring assisted
ventilation (GCS≤8), sustained seizure activity, and the need to protect the lower
airway from aspiration of blood of vomitus.
Endotracheal Intubation
Patients with GCS≤8 require prompt intubation. If the patient has apnea,
orotracheal intubation is required.
Drug-Assisted Intubation
Indicated in patients who need airway control but have intact gag reflexes
(especially in patients who have sustained head injuries).
Using etomidate (0.3mg/kg) as an induction drug does not negatively affect blood
pressure or intracranial pressure, but it can depress adrenal function and is not
universally available.
Using succinylcholine, a short-acting paralytic, is advantageous due to fast onset
(<1 minute) and duration of ≤5 minutes. Beware of potential of succinylcholine to
cause severe hyperkalemia in patients with severe crush injuries, major burns,
and electrical injuries.
Surgical airway
Indicated in the presence of edema of glottis, fracture of larynx, severe
oropharyngeal hemorrhage that obstructs the airway, or inability to place ETT
through the vocal cords
Needle cricothyroidotomy
Percutaneous transtracheal oxygenation (PTO) involves placing a
large-calibre plastic cannula through the cricothyroid membrane
into the trachea below the level of obstruction and connecting it to
oxygen at 15L/min (50-60psi) with a Y-connector or a side hole cut
in the tubing so that intermittent insufflation, 1 second on and 4
seconds off, can be achieved by occluding the Y-connector or hole
with the thumb. Beware that PTO can only oxygenate a patient for
30-45 minutes because CO2 accumulates due to inadequate
exhalation. PTO can also cause barotrauma, especially if there is
complete foreign body obstruction of the glottic area.
Surgical cricothyroidotomy
Not recommended for children under 12 years of age.
1. Palpate thyroid notch, cricothyroid interval, and sternal notch.
2. Make skin incision over the cricothyroid membrane and carefully
incise the membrane transversely.
 3. Insert a hemostat or scalpel handle into the incision and rotate it
90 degrees to open the airway.
4. Insert a properly sized, cuffed endotracheal tube or tracheostomy
tube into the cricothyroid membrane incision, directing the tube
distally into the trachea.

Management of Oxygenation
● Best provided using tight-fitting oxygen reservoir mask with a flow rate of ≥10L/min
● Approximate PAO2 versus SpO2 levels:

SpO2 PAO2

100% 90 mmHg

90% 60 mmHg

60% 30 mmHg

50% 27 mmHg

● A measured SpO2 of ≥95% is strong corroborated evidence of adequate peripheral

arterial oxygenation (PaO2 > 70 mmHg).
● Pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin or
methemoglobin, which limits its usefulness in patients with severe vasoconstriction or
CO poisoning. Profound anemia (Hgb<50) and hypothermia (<30C) also decrease the
reliability of pulse oximetry.

Management of Ventilation
Two-person bag-mask ventilation is more effective than one-person technique.
Beware of conversion of a simple pneumothorax to a tension pneumothorax or creating
a tension pneumothorax upon positive pressure ventilation.
 Chapter 3: Shock
The first step in managing shock in trauma patients is to recognize its presence. The second
step is to identify the probable cause of shock and adjust treatment accordingly. Hemorrhage is
the most common cause of shock in trauma patients.

Shock Pathophysiology
Basic Cardiac Physiology
CO = HR x SV, where SV is a function of preload, myocardial contractility, and
afterload
Blood Loss Pathophysiology
In most cases, tachycardia is the earliest measurable circulatory sign of shock.
Release of endogenous catecholamines increases PVR, which increases
diastolic blood pressure, narrowing the pulse pressure.
The most effective method of restoring adequate cardiac output, end-organ
perfusion, and tissue oxygenation is to restore venous return to normal by
locating and stopping the source of the bleeding. Volume repletion will allow
recovery from the shock state only when the bleeding has stopped.
The presence of shock in a trauma patient warrants the immediate involvement
of a surgeon.

Initial Assessment
Recognition of Shock
Compensatory mechanism can prevent a fall in sBP until up to 30% of the
patient’s blood volume is lost.
Any injured patient who is cool to the touch and is tachycardic should be
considered to be in shock until proven otherwise.
>160 for infants
>140 for preschool-aged child
>120 for children from school-age to puberty
>100 for adult
Elderly patients may not be able to mount tachycardia and/or may be
beta-blocked.
Massive blood loss may produce only a slight decrease in initial hematocrit or
hemoglobin concentration.
Clinical Differentiation of Cause of Shock
Non-Hemorrhagic
Cardiogenic
● Caused by blunt cardiac injury, cardiac tamponade, air embolus,
myocardial infarction, cocaine.
● Continuous ECG, serial troponins
Cardiac Tamponade
● Penetrating thoracic trauma (most common), blunt injury
 ● Tachycardia, muffled heart sounds, dilated and engorged neck
veins with hypotension and insufficient response to fluid therapy
● FAST
● Requires formal operative intervention; pericardiocentesis is only
temporizing
Tension Pneumothorax
● Spontaneously breathing: extreme tachypnea, air hunger
● Ventilated: hemodynamic collapse
● Subcut emphysema, absent unilateral breath sounds, asymmetric
chest rise, hyperresonance to percussion, tracheal shift
● Immediate thoracic decompression without waiting for x-ray; follow
by chest tube insertion.
Neurogenic
● Isolated intracranial injuries do not cause shock unless the
brainstem is injured.
● Classic presentation is hypotension without tachycardia or
cutaneous vasoconstriction. Narrowed pulse pressure is not seen.
Septic
● Uncommon immediately after an injury. Can occur if arrival to ED
is delayed for several hours.
Hemorrhagic
Most common cause of shock in trauma patients. Identify and stop
hemorrhage. See below.

Hemorrhagic Shock
Definition of Hemorrhage
● Normal adult blood volume = 7% of body weight (70ml/kg)
● Normal child blood volume = 8-9% of body weight (70-80ml/kg)
Physiologic Classification
● Class I - after donation of 1 unit of blood
○ <15% blood volume loss
○ Minimal tachycardia occurs.
● Class II - uncomplicated, crystalloids required
○ 15-30% loss
○ + tachycardia, tachypnea, decreased pulse pressure; subtle CNS
changes (anxiety, fear, hostility); urine output mildly affected (20-30ml/hr)
● Class III - complicated, crystalloid infusion and perhaps blood transfusion
○ 31-40% loss
○ Signs of inadequate perfusion, including marked tachycardia and
tachypnea, significant changes in mental status, and measurable fall in
systolic BP
● Class IV - preterminal event, patient will die within minutes, blood transfusion
required
 ○ >40% loss
○ Marked tachycardia, significant decrease in sBP, very narrow pulse
pressure, unmeasurable dBP, preterminal bradycardia, negligible urine
output, depressed mental status, cold and pale skin

Initial Management of Hemorrhagic Shock

Physical Examination
Airway and Breathing
Maintain SpO2 > 95%
Circulation
Hemorrhage control with direct pressure, tourniquet, pelvic binder,
surgical or angioembolization
Disability
Altered LOC indicates inadequate CNS perfusion
Exposure
Prevent hypothermia, which will exacerbate blood loss by contributing to
coagulopathy and worsening acidosis
Gastric Dilation: Decompression
In unconscious patients, gastric distension increases the risk of aspiration
of gastric contents, a potentially fatal complications
Urinary catheterization
Assess for hematuria and genitourinary system as source of blood loss,
but contraindicated if blood at the urethral meatus or perineal
hematoma/bruising
Vascular Access
● Insert two large-calibre (at least 18G in an adult) peripheral IVs.
● Poiseuille’s Law: the rate of flow is proportional to the fourth power of the radius
of the cannula and inversely related to its length
○ Double the radius multiplies the flow by 16X
○ Double the length cuts the flow in half
● Prefer forearms and antecubital veins
● Challenges: young, old, obese, IV drug users
● Consider IO or central lines if peripheral IV access cannot be obtained.
○ “One person, one try, one minute.”
Initial Fluid Therapy
● Administer an initial, warmed fluid bolus of isotonic fluid:
○ 1L for adults
○ 20ml/kg for children weighing ≤40kg
● Persistent infusion of large volumes of fluid and blood in an attempt to achieve
normal blood pressure is not a substitute for definitive control of bleeding.
● Excessive crystalloid solution can be harmful: increase in BP before hemorrhage
has been definitively controlled can cause more bleeding.
 ○ “Permissive hypotension” refers to balancing the goal of organ perfusion
and tissue oxygenation with the avoidance of rebleeding by accepting
lower-than-normal BP. E.g., penetrating trauma with hemorrhage.
● In traumatic brain injury, it is particularly important to avoid hypotension.
● Measuring Patient Response to Fluid Therapy
○ Prime indicator of resuscitation: volume of urinary output is a reasonably
sensitive indicator of renal perfusion. Normal urine volumes generally
imply adequate renal blood flow, if not modified by underlying kidney
injury, marked hyperglycemia, or the administration of diuretic agents.
■ 0.5mg/kg/h for adults
■ 1mg/kg/h for children
■ 2mg/kg/h for children <1 year of age
○ Can also use serial lactate levels and base deficit
● Patterns of Patient Response
○ The patient’s response to initial fluid resuscitation is the key to
determining subsequent therapy.
1. Rapid response - Surgical consultation and evaluation are necessary
during initial assessment and treatment of rapid responders, as operative
intervention could still be necessary.
2. Transient response - Recognize that they require operative or
angiographic control of hemorrhage. Consider MTP.
3. Minimal or no response - failure to respond to crystalloid and blood
administration in the ED dictates the need for immediate definitive
intervention (i.e., operation or angioembolization) to control
exsanguinating hemorrhage.

Blood Replacement
Crossmatched, Type-Specific, and Type O Blood
● Complete crossmatching takes 1 hour in most blood banks
● If crossmatched blood unavailable, give type O pRBCs and AB plasma
○ Unmatched, type-specific pRBCs is preferred over type O pRBCs
● Give Rh-negative pRBCs for females of childbearing age
Prevent Hypothermia
● Most efficient way to prevent is to heat fluids (crystalloids + blood) to 39C
Autotransfusion
● In patients with massive hemothorax; may still need plasma and platelets
Massive Transfusion
● Defined as >4 units in 1 hour or > 10 units in the first 24 hours.
● Balanced/hemostatic/damage-control resuscitation = administration of pRBCs,
plasma, and platelets in a balanced ratio
Coagulopathy
● Due to consumption of coagulation factors; present in up to 30% of severely
injured patients on admission.
 ● Obtain baseline PT, PTT, platelet count in the first hour; also TEG and ROTEM
● Prehospital TXA improves survival in severely injured patients when
administered within 3 hours of injury
● Reverse anticoagulants
Calcium Administration
● Rarely needed. Guided by measurement of ionized calcium; excessive
supplemental calcium can be harmful.

Special Considerations
Equating Blood Pressure to Cardiac Output
● An increase in blood pressure should not be equated with a concomitant
increase in cardiac output or recovery from shock. E.g., vasopressors will
increase PVR and thus BP, but there is no change in CO and no improvement in
tissue perfusion.
Advanced Age
● Aging process produces a relative decrease in sympathetic activity. Decreased
cardiac compliance. Unable to increase heart rate or efficiency of contractility
when stressed by volume loss.
● Atherosclerotic vascular occlusive disease makes many vital organs extremely
sensitive to even the slightest reduction in blood flow. Pre-existing volume
depletion from diuretic use. Beta blockade can mask tachycardia.
● Reduced pulmonary compliance, decreased diffusion capacity, weakness of
respiratory muscles.
● Glomerular and tubular senescence of kidney.
Athletes
● Blood volume may increase 15-20%, CO can increase by 6X, SV can increase
by 50%, resting pulse can average 50 bpm.
Pregnancy
● Normal hypervolemia means that it takes greater amount of blood loss to
manifest perfusion abnormalities in the mother.
Medications
● Beta blockers, CCB’s, insulin, diuretics, NSAIDs.
Hypothermia
● Coagulopathy may develop or worsen. If under influence of alcohol, may be more
likely to have hypothermia due to inappropriate vasodilation.
Presence of a Pacemaker or Implantable Cardioverter-Defibrillator
● CO is limited by HR, which is limited to device’s set rate.

Reassessing Patient Response and Avoiding Complications

Continued hemorrhage
● An undiagnosed source of bleeding is the most common cause of poor response
to fluid therapy.
Monitoring
 ● Organ perfusion and tissue oxygenation best monitored by urine output, CNS
function, skin color, and return of BP toward normal.
Recognition of Other Problems
● Undiagnosed bleeding, cardiac tamponade, tension pneumothorax, ventilatory
problems, unrecognized fluid loss, acute gastric distension, myocardial infarction,
diabetic acidosis, hypoadrenalism, neurogenic shock.
 Chapter 4: Thoracic Trauma
Most life-threatening thoracic injuries can be treated with airway control or decompression of the
chest with a needle, finger, or tube.

Primary Survey: Life-Threatening Injuries

● Major problems should be corrected as they are identified
Airway Problems
● Airway obstruction - clear blood and vomitus from airway by suction; placement
of a definitive airway is necessary; reduce posterior dislocation or fracture of
clavicle.
● Tracheobronchial tree injury - usually die at the scene; diagnosed by
bronchoscopy; require immediate surgical consultation; may require immediate
definitive airway using advanced techniques (i.e., fiber-optically assisted ETT
placement)
Breathing Problems
● Tension pneumothorax - clinical diagnosis reflecting air under pressure in the
affected pleural space. Do not delay treatment to obtain radiological confirmation.
● Open pneumothorax - “sucking chest wound”; temporize with occlusive dressing
taped on three sides to create “flutter-valve” effect; needs chest tube placed
remote from the wound ASAP.
● Massive hemothorax - accumulation > 1500 ml blood; insert chest tube and
request emergent surgical consultation.
Circulation Problems
● Massive hemothorax - see above; large-calibre IV lines, crystalloid, transfusion
with uncrossmatched or type-specific blood, consider autotransfusion, insert
single chest tube (28-32 French) at the 5th intercostal space, just anterior to the
midaxillary line. Do not perform thoracotomy unless a surgeon, qualified by
training and expertise, is present.
● Cardiac tamponade - FAST is 90-95% accurate in identifying; emergency
thoracotomy or sternotomy should be performed ASAP - if not available,
pericardiocentesis can be therapeutic but is not definitive treatment and, due to
high complication rate, should represent a lifesaving measure of last resort in a
setting where no qualified surgeon is available to perform thoracotomy or
sternotomy.
● Traumatic circulatory arrest - unconscious and no pulse; start closed CPR
immediately with ABC management; definitive airway with orotracheal intubation
without RSI; mechanical ventilation on 100% oxygen; bilateral finger
thoracostomies to alleviate potential tension pneumothoraces; rapid fluid
resuscitation through large-bore IVs or IO; epinephrine 1mg; if VF present, treat
per ACLS; resuscitative thoracotomy may be required if there is no ROSC;
decompressive needle pericardiocentesis (preferably with US-guidance) if
cardiac tamponade is suspected and no surgeon is available to perform
thoracotomy or sternotomy.
Secondary Survey
Potentially Life-Threatening Injuries
● Simple pneumothorax
○ Best treatment of any pneumothorax is with a chest tube connected to an
underwater seal apparatus with or without suction.
● Hemothorax
○ >1500 mL blood drained through chest tube immediately or drainage of
more than 200 mL/hr for 2-4 hours or blood transfusion required =
consider operative intervention
● Flail chest - cautious fluid resuscitation, risk of flash pulmonary edema
● Pulmonary contusion - cautious fluid resuscitation, risk of flash pulmonary edema
● Blunt cardiac injury
○ Myocardial muscle contusion, cardiac chamber rupture, coronary artery
dissection and/or thrombosis, valvular disruption
○ ECG - changes are variable and may even indicate frank MI
● Traumatic aortic disruption
○ Survivors tend to have incomplete laceration near ligamentum arteriosum
○ Radiographic: widened mediastinum, obliterated aortic knob, deviated
trachea right, depression of left mainstem bronchus, elevation of right
mainstem bronchus, obscuration of aortopulmonary window, deviation of
esophagus (NG tube) to right, widened paratracheal stripe, pleural or
apical cap, left hemothorax, fractures of 1st or 2nd rib or scapula
○ If hemodynamically stable, contrast-enhanced CT is accurate screening
method; if equivocal, aortography. TEE also is useful and less invasive.
○ Beta blocker (esmolol) to target HR <80 bpm, BP MAP 60-70 mmHg.
CCB, then add nitroglycerine, then add nitroprusside if esmolol
contraindicated.
○ Requires repair. Endovascular repair is the most common option.
● Traumatic diaphragm injury
○ Most likely on the left. NG tube appears in thoracic cavity. Be careful
inserting chest tube if concomitant thoracic injury as you can damage
abdominal contents that have passed into the thoracic cavity.
● Blunt esophageal rupture
○ Most commonly from penetrating injury. Mediastinal air, presence of
gastric contents in chest tube drain.
Other Manifestations of Chest Injuries
● Subcutaneous emphysema
● Crushing injury to the chest
○ Upper torso, facial, and arm plethora with petechiae secondary to acute,
temporary compression of the SVC. May have cerebral edema.
● Rib, sternum, and scapular fractures
○ Pain, splinting, atelectasis, pneumonia.
○ Fractures of lower ribs should increase suspicion for hepatosplenic injury
 Chapter 5: Abdominal and Pelvic Trauma

● The assessment of circulation during the primary survey includes early evaluation for
possible intra-abdominal and/or pelvic hemorrhage in patients who have sustained blunt
trauma.
● Unrecognised abdominal and pelvic injuries continue to cause preventable death after
truncal trauma.
● Significant blood loss can be present in the abdominal cavity without a dramatic change
in the external appearance of dimensions of the abdomen and without obvious signs of
peritoneal irritation.

Anatomy of the Abdomen

● Injuries to the retroperitoneal visceral structures are difficult to recognize because they
occur deep within the abdomen and may not initially present with signs or symptoms of
peritonitis.
● Significant blood loss can occur from injuries to organs within the pelvis and/or directly
from the bony pelvis.

Mechanism of Injury
Blunt
Spleen, liver, small bowel
Airbag deployment does not preclude abdominal injury.
Penetrating
Stab: Liver, small bowel, diaphragm, colon
GSW: small bowel, colon, liver, abdominal vasculature
Stab wounds and low-energy gunshot wounds cause tissue damage by
lacerating and tearing. High-energy gunshot wounds transfer more kinetic
energy, causing increasing damage surrounding the track of the missile due to
temporary cavitation.
Blast
The potential for overpressure injury following an explosion should not distract
the clinician from a systemic approach to identifying and treating blunt and
penetrating injuries.

Assessment and Management

● Hypotensive patients: goal is to rapidly identify an abdominal or pelvic injury and
determine whether it is the cause of hypotension.
● Hemodynamically normal patients without signs of peritonitis may undergo a more
detailed evaluation to determine the presence of injuries that can cause delayed
morbidity and mortality.

History
Physical exam
Inspection, auscultation, percussion, and palpation
● At the conclusion of the rapid physical exam, cover the patient with
warmed blankets to help prevent hypothermia.
● When rebound tenderness is present, do not seek additional evidence of
irritation, as it may cause the patient further unnecessary pain.
Pelvic Assessment
Urethral, perineal, rectal, vaginal, and gluteal examination
Adjuncts to the Physical Exam
Gastric Tubes and Urinary Catheters
● The absence of hematuria does not exclude an injury to the genitourinary
tract. A retrograde urethrogram (“RUG”) is mandatory when the patient is
unable to void, requires a pelvic binder, or had blood at the meatus,
scrotal hematoma, or perineal ecchymosis. To reduce the risk of
increasing the complexity of a urethral injury, confirm an intact urethra
before inserting a urinary catheter.
Other Studies
● In patients with hemodynamic abnormalities, rapid exclusion of
intra-abdominal hemorrhage is necessary and can be accomplished with
either FAST or DPL (the only contraindication to these studies is an
existing indication for laparotomy).
● When intra-abdominal injury is suspected, a number of studies can
provide useful information. However, when indications for patient transfer
already exist, do not perform time-consuming tests, including adbo CT.
● X-rays - upright chest, exclude hemothorax, pneumothorax,
intraperitoneal free air
○ AP chest recommended for assessing patients with multisystem
blunt trauma.
○ An alert, awake patient without pelvic pain or tenderness does not
require a pelvic radiograph.
● FAST
○ Pericardial sac, hepatorenal fossa, splenorenal fossa,
pelvis/pouch of Douglas
● DPL - requires gastric and urinary decompression prior
○ Aspiration of GI contents, vegetable fibers, or bile through the
lavage catheter mandates laparotomy. Aspiration of 10cc or more
of blood in hemodynamically abnormal patients requires
laparotomy.
● CT
○ Should only be used in hemodynamically normal patients in whom
there is no apparent indication for an emergency laparotomy. Do
not perform CT if it delays transfer to a higher level of care.
 ○ CT can miss some GI, diaphragmatic, and pancreatic injuries. In
the absence of hepatic or splenic injuries, the presence of free
fluid in the abdominal cavity suggests an injury to the GI tract
and/or its mesentery, and many trauma surgeons believe this
finding to be an indication for early operative intervention.
● Diagnostic laparoscopy or thorascopy
● Contrast studies
○ Urethrography
○ Cystography
○ Intravenous pyelogram
○ GI contrast studies
Evaluation of Specific Penetrating Injuries
● Most abdominal GSWs are managed by exploratory laparotomy. The incidence of
significant intraperitoneal injury approaches 98% when peritoneal penetration is
present.
Thoracoabdominal wounds
Anterior abdominal wounds: non-operative management
● Consider in hemodynamically normal patients without peritoneal signs or
evisceration.
● Although a positive FAST may be helpful in this situation; a negative
FAST does not exclude the possibility of a visceral injury without a large
volume of intra-abdominal fluid.
Flank and back injuries: non-operative management
Indications For Laparotomy
● Blunt abdominal trauma with hypotension, with a positive FAST or clinical
evidence of intraperitoneal bleeding, or without another source of bleeding.
● Hypotension with an abdominal wound that penetrates the anterior fascia.
● GSW that traverse the peritoneal cavity.
● Evisceration
● Bleeding from the stomach, rectum, or GU tract following penetrating trauma
● Peritonitis
● Free air, retroperitoneal air, or rupture of the hemidiaphragm
● Contrast-enhanced CT that demonstrates ruptured GI tract, intraperitoneal
bladder injury, renal pedicle injury, or severe visceral parenchymal injury after
blunt or penetrating trauma.
● Blunt or penetrating abdominal trauma with aspiration of GI contents, vegetable
fibres, or bile from DPL, or aspiration of 10cc or more blood in hemodynamically
abnormal patients
Evaluation of Other Specific Injuries
Diaphragm
● A common injury is 5-10cm in length and involves the posterolateral left
hemidiaphragm.
 ● Initial CXR may show elevation or “blurring” of the left hemidiaphragm,
hemothorax, and abnormal gas shadow that obscures the
hemidiaphragm, or a gastric tube positioned in the chest.
Duodenal
● Classically encountered in unrestrained drivers involved in frontal-impact
MVC and patients who sustain direct blows to the abdomen, e.g., bicycle
handlebars.
Pancreatic
● Direct epigastric blow that compresses the pancreas against vertebra.
● An early normal serum amylase level does not exclude major pancreatic
trauma. Conversely, the amylase level can be elevated from
non-pancreatic sources.
Genitourinary
● Contusions, hematomas, and ecchymoses of the back or flank are
markers of potential underlying renal injury and warrant an evaluation (CT
or IVP) of the urinary tract.
● Gross hematuria is an indication for imaging the urinary tract.
● Posterior urethral injury usually associated with multisystem injuries and
pelvic fractures.
● Anterior urethral injury results from straddle impact and can be an
isolated injury.
Hollow Viscus
● A transverse, linear ecchymosis on the abdominal wall (seat-belt sign) or
lumbar distraction fracture (i.e., Chance fracture) on x-ray should alert
clinicians to the possibility of intestinal injury.
● Although some patients have early abdominal pain and tenderness, the
diagnosis of hollow viscus injuries can be difficult since they are not
always associated with hemorrhage.
Solid Organ - liver, spleen, kidney
● Solid organ injury in hemodynamically normal patients can often be
managed non-operatively.
● Concomitant hollow viscus injury occurs in less than 5% of patients
initially diagnosed with isolated solid organ injuries.
Pelvic Fractures and Associated Injuries
Mechanism of injury and classification
1. Anterior-posterior compression (open book) = 15-20%
a. Disrupted pelvic ring widens, tearing the posterior venous
complex and branches of the internal iliac arterial system;
hemorrhage can be severe and life-threatening.
2. Lateral compression (closed) = 60-70%
a. Hemipelvis rotates internally, reducing pelvic volume, may
drive pubis into the lower GU system, potentially causing
 bladder/urethral injury; hemorrhage from this type of injury
rarely results in death.
3. Vertical shear = 5-15%
a. Vertical disruption of sacroiliac joint can disrupt the iliac
vasculature and cause severe hemorrhage.
Management
● Rapid hemorrhage control and resuscitation.
● A sheet, pelvic binder, or other device can produce sufficient
temporary fixation for the unstable pelvis when applied at the level
of the greater trochanters of the femur.
 Chapter 6: Head Trauma

The primary goal of treatment for patients with suspected TBI is to prevent secondary brain
injury.
CT scanning should not delay patient transfer to a trauma center that is capable of immediate
and definitive neurosurgical intervention.

Anatomy Review
Scalp
Skull
Meninges
Brain
Ventricular System
Intracranial Compartments
● Ipsilateral pupillary dilation associated with contralateral hemiparesis is the
classic sign of uncal herniation.

Physiology Review
Intracranial Pressure
● Normal ICP for patients in resting state is ~10 mmHg. Pressures >22 mmHg,
particularly if sustained or refractory to treatment, are associated with poor
outcomes.
Monro-Kellie Doctrine
● The total volume of the intracranial contents must remain constant, because the
cranium is a rigid container incapable of expanding. When normal intracranial
volume is exceeded, ICP rises. Venous blood and CSF can be compressed out
of the container providing a degree of pressure buffering, but once this buffer limit
has been reached, the ICP rapidly increases.
Cerebral Blood Flow
● CPP = MAP - ICP
● If MAP is too low, ischemia and infarction result.
● If MAP is too high, marked brain swelling occurs occurs with elevated ICP.
● Make every effort to enhance cerebral perfusion and blood flow by reducing the
elevated ICP, maintaining normal intravascular volume and MAP, and restoring
normal oxygenation and ventilation. Hematomas and other lesions that increase
intracranial volume should be evacuated early.

Classification of Head Injuries

Severity of Injury
● A GCS of ≤8 has become the generally accepted definition of coma or severe
brain injury.
○ 9-12 = moderate
○ 13-15 = mild
 ● In assessing the GCS score, when there is right/left or upper/lower asymmetry,
be sure to use the best motor response to calculate the score, because it is the
most reliable predictor of outcome.
○ Eye opening
■ Spontaneous 4
■ To sound 3
■ To pressure 2
■ None 1
■ Non-testable NT
○ Verbal response
■ Oriented 5
■ Confused 4
■ Words 3
■ Sounds 2
■ None 1
■ Non-testable NT
○ Best motor response
■ Obeys commands 6
■ Localizing 5
■ Normal flexion 4
■ Abnormal flexion 3
■ Extension 2
■ None 1
■ Non-testable NT
Morphology
Skull Fractures
● Basal skull fracture: periorbital ecchymosis, retroauricular ecchymosis
(Battle’s sign), CSF rhinorrhea/otorrhea, dysfunction of CN 7/8 (facial
paralysis, hearing loss)
● Carotid canal disruption: consider cerebral arteriography by CT
angiography
● Do not underestimate the significance of a skull fracture, because it takes
considerable force to fracture the skull.
Intracranial Lesions
Diffuse Brain Injuries - range from concussion to diffuse axonal injury
Focal Brain Injuries
Epidural hematomas
● biconvex, lenticular shape; often from tear of middle
meningeal artery; classically arterial bleed; classic
presentation is lucid interval between time of injury and
neurologic deterioration.
Subdural hematomas
 ● More common than EDH’s; crescent shape; damage
underlying an acute SDH is typically much more severe
than that associated with EDH due to presence of
concomitant parenchymal injury.
Contusion and Intracerebral hematomas
● These patients generally undergo repeat CT scanning to
evaluate for changes in the pattern of injury within 24
hours of the initial scan.

Evidence-Based Treatment Guidelines

Management of Mild Brain Injury
● Concussion = transient loss of neurologic function following a head injury.
● Never ascribe alterations in mental status to confounding factors until brain injury
can be definitively excluded.
● CT scanning is the preferred method of imaging, although obtaining CT scans
should not delay transfer of the patient who requires it.
● Obtain a CT scan in all patients with suspected brain injury who have a clinically
suspected open skull fracture, any sign of basilar skull fracture, and more than
two episodes of vomiting. Also obtain a CT scan in patients who are older than
65 years.
Management of Moderate Brain Injury
● Require admission for observation in unit capable of close nursing observation
and frequent neurological re-assessment for at least the first 12 to 24 hours. A
follow-up CT scan within 24 hours is recommended if the initial CT scan is
abnormal or the patient’s neurological status deteriorates.
Management of Severe Brain Injury
● Do not delay patient transfer in order to obtain a CT scan.
● ABCDEs
○ Perform early endotracheal intubation in comatose patients. Ventilate with
100% oxygen. Maintain PCO2 of approximately 35 mmHg. Prolonged
hyperventilation with PCO2 < 25 mmHg is not recommended.
Hyperventilation is reserved for severe brain injury WITH acute
neurological deterioration or signs of herniation.
○ Hypotension usually is not due to the brain injury itself, except in the
terminal stages when medullary failure supervenes or there is a
concomitant spinal cord injury.
■ Maintain SBP≥100 for patients aged 50-69
■ Maintain SBP≥110 for patients aged 15-49 or older than 70
● Primary survey and resuscitation
○ It is imperative to rapidly achieve cardiopulmonary stabilization in patients
with severe brain injury.
○ Neurologic examination
 ■ When a patient demonstrates variable response to simulation, the
best motor response elicited is a more accurate prognostic
indicator than the worst response.
■ Never attempt doll’s-eyes testing until a cervical spine injury has
been ruled out.
■ It is important to obtain the GCS score and perform a pupillary
exam before sedating or paralyzing the patient, because
knowledge of the patient’s clinical condition is important for
determining subsequent treatment.
■ Although propofol is recommended for the control of ICP, it is not
recommended for improvement in mortality or 6-month outcomes.
Propofol can produce significant morbidity when used in high
dose.
● Secondary survey and AMPLE history
○ A well-known early sign of temporal lobe (uncal) herniation is dilation of
the pupil and loss of the pupillary response to light.
● Diagnostic procedures
○ CT: shift of 5mm or more often indicates the need for surgery to evacuate
the blood clot or contusion causing the shift.
● Admit or transfer to facility capable of definitive neurosurgical care
● Therapeutic agents
○ IV fluids
■ Hypovolemia in patients with TBI is harmful.
○ Correction of anticoagulation
○ Mannitol
■ Do NOT give in patients with hypotension.
■ Acute neurological deterioration (e.g., dilated pupil, hemiparesis,
LOC) is a strong indication for administering mannitol in a
euvolemic patient.
■ Like hypertonic saline, this is used to reduce elevated ICP.
○ Hyperventilation
■ Avoid hyperventilation in the first 24 hours unless signs of
herniation
■ Aggressive and prolonged hyperventilation can result in cerebral
ischemia.
■ On the other hand, hypercarbia (PCO2 > 45 mmHg) will promote
vasodilation and increase ICP, and should therefore be avoided.
○ Hypertonic saline
■ May be preferable agent (over mannitol) for patients with
hypotension because it does not act as a diuretic.
○ Barbiturates
■ Effective for reducing ICP refractory to other measures. Should
NOT be used in hypotension or hypovolemia.
 ○ Anticonvulsants
■ 3 factors linked to a high incidence of late epilepsy:
● Seizures occurring within the first week
● An intracranial hematoma
● A depressed skull fracture
■ Acute seizures can be controlled with anticonvulsants, but early
anticonvulsant use does NOT change long-term traumatic seizure
outcome.
■ Anticonvulsants can inhibit brain recovery, so they should only be
used when absolutely necessary.
● Neurologic re-evaluation:
○ GCS
○ Pupillary light response
○ Focal neurologic exam
● Surgical Management
○ Scalp wounds - blood loss can be extensive, especially in children.
○ Depressed skull fractures
■ CT scan required; generally require operative elevation when
degree of depression is greater than the thickness of the adjacent
skull or when open and grossly contaminated.
○ Intracranial mass lesions
■ Emergency craniotomy in a rapidly deteriorating patient by a
non-neurosurgeon should be considered only in extreme
circumstances; this surgeon should be properly trained in the
procedure and should obtain the advice of a neurosurgeon.
○ Penetrating brain injuries
■ Need CT scan to evaluate; MRI plays a role in evaluating injuries
from penetrating wooden and other nonmagnetic objects.
■ Prophylactic broad spectrum antibiotics for penetrating brain
injury, open skull fracture, and CSF leak.
■ Small bullet entrance wounds to the head can be treated with local
wound care and closure in patients whose scalp is not devitalized
and who have no major intracranial pathology.
■ Disturbing or removing penetrating objects prematurely (before
possible vascular injury has been evaluated and definitive
neurosurgical management is established) can lead to fatal
vascular injury or intracranial hemorrhage.

Brain Death
Diagnosis requires meeting these criteria:
● GCS = 3
● Non-reactive pupils
● Absent brainstem reflexes (e.g., oculocephalic, corneal, and doll’s eyes; no gag reflex)
 ● No spontaneous ventilatory effort on formal apnea testing
● Absence of confounding factors such as alcohol or drug intoxication or hypothermia

Ancillary studies that may be used to confirm the diagnosis if brain death include:
● EEG
● CBF
● Cerebral angiography
 Chapter 7: Spine and Spinal Common Trauma

● Up to 10% of patients with a cervical spine fracture have a second, non-contiguous

vertebral column fracture.
● If the patient’s spine is protected, evaluation of the spine and exclusion of spinal injury
can be safely deferred, especially in the presence of systemic instability, such as
hypotension and respiratory inadequacy.
● Long backboards should be used only during patient transportation, and every effort
should be made to remove patients from spine boards as quickly as possible.

Anatomy and Physiology

Spinal Column
● Cervical spine, because of its mobility and exposure, is the most vulnerable part
of the spine to injury.
● Most thoracic spine fractures are wedge compression fractures and not
associated with SCI; however, when fracture-dislocation in the thoracic spine
does occur, it almost always results in a complete SCI.
Spinal Cord Anatomy
● Cord usually ends at L1 as the conus medullaris, then cauda equina.
● Complete SCI: no sensor and motor function below a certain level
● Incomplete SCI: some degree of motor or sensory function remains
Dermatomes
● C5 = area over deltoid
● C6 = thumb
● C7 = middle finger
● C8 = little finger
● T4 = nipple
● T8 = xiphisternum
● T10 = umbilicus
● T12 = symphysis pubis
● L4 = medial aspect of calf
● L5 = webspace between the 1st and 2nd toes
● S1 = lateral border of foot
● S3 = Ischial tuberosity
● S4 and S5 = perianal region
Myotomes
● C5 = elbow flexors
● C6 = wrist extensors
● C7 = elbow extensors
● C8 = finger flexors
● T1 = finger abductors
● L2 = hip flexors
● L3 = knee extensors
 ● L4 = ankle dorsiflexion
● L5 = long toe extensors
● S1 = ankle plantar flexors
Neurogenic Shock versus Spinal Shock
● Neurogenic shock results in loss of vasomotor tone and sympathetic innervation
to the heart; injury at T6 and above can cause impairment of the descending
sympathetic pathways
○ Fluid resuscitation, vasopressors, atropine
● Spinal shock refers to the flaccidity (loss of muscle tone) and loss of reflexes that
occur immediately after SCI.
Effects of Spine Injury on Other Organ Systems
● The inability to perceive pain can mask a potentially serious injury elsewhere in
the body, such as the usual signs of acute abdominal or pelvic pain associated
with pelvic fracture.

Documentation of Spinal Cord Injuries

Level
Bony level, neurologic level, sensory level, motor level (MRC ≥3/6)
Severity of Neurological Deficit
Incomplete/complete, para/quadriplegia
Spinal Cord Syndromes
● Central cord - weaker in upper extremities; typically after hyperextension
● Anterior cord - paraplegia and bilateral loss of pain/temp sensation; from cord
ischemia
● Hemicord (Brown-Sequard) - ipsilateral motor and proprioception loss,
contralateral pain and temperature loss; usually from penetrating trauma to cord
Morphology
Particularly during the initial treatment, all patients with radiographic evidence of
injury and all those with neurological deficits should be considered to have an
unstable spinal injury.

Specific Types of Spinal Injuries

Cervical Spine Fractures
Atlanto-occipital dislocation
● extreme flexion and distraction; often die of brainstem destruction and
apnea; cause of death in shaken baby syndrome
Atlas (C1) fracture
● Axial loading; best seen on open mouth view of C1 to C2 and axial CT
C1 rotary subluxation
● Most often seen in children; present with torticollis
Axis (C2) fractures
Odontoid fractures
● Type 1 = tip
 ● Type 2 = base of dens, most common
● Type 3 = base of dens extending to body of axis
Posterior element fractures
● Hangman’s fracture; pars interarticularis; extension-type injury
Fractures and dislocations (C3-C7) - most common level of fracture is C5
Thoracic Spine Fractures
1. Anterior wedge compression injuries
2. Burst injuries
3. Chance fractures - associated with retroperitoneal and abdominal visceral injury
4. Fracture-dislocations = the thoracic spinal canal is narrow in relation to the spinal
cord, so fracture subluxations in the thoracic spine commonly result in complete
neurological deficits.
Thoracolumbar Junction Fractures (T11-L1)
Patients with thoracolumbar fractures are particularly vulnerable to rotational
movement, so be extremely careful when log-rolling them
Lumbar Fractures - cauda equina only, so less chance of complete neurological injury
Penetrating Injuries - usually stable, but often result in a complete neurological deficit
Blunt Carotid and Vertebral Artery Injuries - risk of stroke

Radiographic Evaluation
Cervical Spine
● Use Canadian C-Spine Rule or NEXUS to determine need for imaging
● AP view of c-spine: sensitivity of up to 97%, a doctor qualified to interpret these
films must review the complete series of cervical spine radiographs before the
spine is considered normal. Do not remove the cervical collar until a neurologic
assessment and evaluation of the c-spine, including palpation of the spine with
voluntary movement in all planes, have been performed and found to be
unconcerning or without injury.
● MDCT scans may be used instead of plain images to evaluate the cervical spine
● Under no circumstances should clinicians force the patient’s neck into a position
that elicits pain. All movements must be voluntary.
● Approximately 10% of patients with a cervical spine fracture have a second,
non-contiguous vertebral column fracture.
Thoracic and Lumbar Spine
● As with cervical spine, a complete series of high-quality radiographs must be
properly interpreted as without injury by a qualified doctor before spine
precautions are discontinued. However, due to the possibility of pressure ulcers,
do not wait for final radiographic interpretation before removing the patient from a
long board (>2 hours on board makes high risk for pressure ulcers).

General Management
Spinal Motion Restriction
 ● Attempts to align the spine to aid restriction of motion on the backboard are not
recommended if they cause pain.
● Log-roll maneuver.
Intravenous Fluids
● Be careful not to cause pulmonary edema; insert a urinary catheter to monitor
urine output. If BP not improving with fluid challenge, consider neurogenic shock
and vasopressors.
Medications
● Insufficient evidence to support use of steroids.
Transfer
● Remember, cervical spine injuries above C6 can result in partial or total loss of
respiratory function. If concerned about this, intubate before transfer.
 Chapter 8: Musculoskeletal Trauma

Continued reevaluation of the patient is necessary to identify all injuries.

Primary Survey and Resuscitation of Patients with Potentially Life-Threatening Extremity

Injuries
● Hemorrhage from long-bone fractures can be significant, and femoral fractures in
particular often result in significant blood loss into the thigh.

Major Arterial Hemorrhage and Traumatic Amputation

Assessment
● Assess for external bleeding, loss of a previously palpable pulse, changes in
pulse quality, Doppler tone, and ankle/brachial index.
Management
● Manual pressure
● Pressure dressing
● Manual pressure to artery proximal to injury
● Manual/pneumatic tourniquet
○ Up to 250 mmHg required for upper extremity
○ 400 mmHg for lower extremity
○ Document time applied
■ If time to operative intervention is more than 1 hour, consider a
single attempt to deflate the tourniquet in an otherwise stable pt
● If a fracture is associated with an open hemorrhaging wound, realign and splint it.
Reduce joint dislocations.
● Traumatic amputation: a pt with multiple injuries who requires intensive
resuscitation and/or emergency surgery for extremity or other injuries is not a
candidate for replantation.
○ In replantation cases: thoroughly wash the amputated part in isotonic
solution (e.g., Ringer’s lactate) and wrap it in most sterile gauze, then in a
moistened sterile towel, place in a plastic bag, transport it in an insulated
cooling chest with crushed ice and be careful not to freeze it.

Bilateral Femur Fractures

Higher risk for significant blood loss, severe associated injuries, pulmonary
complications, multiple organ failure, and death.

Crush Syndrome (traumatic rhabdomyolysis)

● Can lead to acute renal failure and shock - huge release of myoglobin from muscle cell
death.
Assessment
 ● Myoglobin produces dark amber urine that tests positive for hemoglobin. CK will
also be high. Rhabdomyolysis can lead to metabolic acidosis, hyperK, hypoCa,
and DIC.
Management
● Early and aggressive IVF is critical to preventing renal failure in pts with rhabdo.
● Can also alkalinize urine via IV bicarbonate and osmotic diuresis.

Adjuncts to the Primary Survey

Fracture Immobilization
● Inline traction to realign the extremity + maintaining traction with an
immobilization device. Helps control blood loss, reduce pain, prevents further
neurovascular compromise and soft-tissue injury. Assess neurovascular status
BEFORE and AFTER splint application.
● However, resuscitation efforts must take priority over splint application.

X-Ray Examination
● Usually secondary survey, but may be undertaken in primary survey when
fracture is suspected as cause of shock.

Secondary Survey

History
Mechanism of injury, environment, pre-injury status, predisposing factors, prehospital
observations and care.

Physical Exam
For a complete examination, completely undress the patient, taking care to prevent
hypothermia.
1. Identify life-threatening injuries (primary survey)
2. Identify limb-threatening injuries (secondary survey)
3. Conduct a systematic review to avoid missing any other MSK injury.
● Look and ask
○ Color, perfusion, wounds, deformity, swelling, bruising
● Feel
○ Sensation, tenderness, joint ROM, swelling
● Circulatory evaluation
○ Distal pulses, capillary refill, Doppler
○ Knee dislocations can reduce spontaneously and may not present with any gross
external or radiographic anomalies until a physical exam of the joint is performed
and instability is detected clinically. An ankle/brachial index of less than 0.9
indicates abnormal arterial flow secondary to injury or PVD.
● X-ray examination
 ○ The only reason to forgo x-ray examination before treating a dislocation or a
fracture is the presence of vascular compromise or impending skin breakdown -
commonly seen with the ankle.

Limb-Threatening Injuries

Open Fractures and Open Joint Injuries

● Prone to problems with infection, healing, and function.
Assessment
● Open wound on the same limb segment as an associated fracture. Do not probe
wound!
● If an open wound exists over or near a joint, it should be assumed to
communicate with the joint.
● Intra-articular gas on CT is highly sensitive and specific.
Management
● Treat all pts with open fractures as soon as possible with intravenous antibiotics
using weight-based dosing.
● First-generation cephalosporins are necessary for all pts with open fractures.
○ If penicillin allergic, use clindamycin (My comment: there is no evidence
for this - in fact, ancef shares no side chain in common with any other
beta lactam; therefore, the only people who should not receive ancef are
people with a specific ancef allergy. Give ancef to a penicillin-allergic
patient all day long… they won’t react to it.)
○ Severe soft-tissue damage and substantial contamination: Gentamycin
(an aminoglycoside = GN coverage)
○ Farmyard, soil, or standing water: Pip-tazo (broad spectrum GP and GN)
● Delay beyond 3 hours is associated with increased risk of infection.
● Remove gross contamination, cover with moist sterile dressing, immobilize,
operative debridement, tetanus prophylaxis.

Vascular Injuries
Assessment
● May appear viable because of collateral circulation, or may appear cold, pale,
and pulseless.
Management
● It is crucial to promptly recognize and emergently treat an acutely avascular
extremity.
● Muscle necrosis begins when there is a lack of blood flow for more than 6 hours.
● Splinting a fracture deformity or reducing a joint dislocation may help re-establish
blood flow to an ischemic extremity, but always perform and document a
neurovascular exam before and after application of a splint.

Compartment Syndrome
 ● Compartment syndrome can occur wherever muscle is contained within a closed fascial
space. Remember, the skin acts as a restricting layer in certain circumstances.
● Common areas: lower leg, forearm, foot, hand, gluteal region, thigh
Assessment
● High risk injuries
○ Injuries immobilized in tight dressings or casts
○ Severe crush injury to muscle
○ Localized, prolonged external pressure to an extremity
○ Increased capillary permeability secondary to reperfusion of ischemic
muscle
○ Burns
○ Excessive exercise
● The absence of a palpable distal pulse is an uncommon or late finding and is not
necessary to diagnose compartment syndrome.
● Clinical diagnosis… pressure measurements are only an adjunct to aid in Dx.
● Signs and symptoms:
○ Pain greater than expected and out of proportion to the stimulus or injury
○ Pain on passive stretch of the affected muscle
○ Tense swelling of the affected compartment
○ Paresthesias or altered sensation distal to the affected compartment
Management
● Fasciotomy

Neurological Injury Secondary to Fracture or Dislocation

Assessment
● Voluntary motor function and sensation for each significant peripheral nerve.
Management
● Reduce and splint

Other Extremity Injuries

Contusions and Lacerations

Joint and Ligament Injuries
Fractures
Assessment
● To exclude occult dislocation and concomitant injury, x-ray films must include the
joints above and below the suspected fracture site.
Management
● Immobilization must include the joint above and below the fracture

Principles of Immobilization

Femoral Fractures
 ● Do not apply traction in patients with an ipsilateral tibia shaft fracture.
● A simple method of splinting is to bind the injured leg to the opposite leg.

Knee Injuries
● Do not immobilize the knee in complete extension, but with approximately 10 degrees of
flexion to reduce tension on neurovascular structures.

Tibial Fractures
● Plaster splints immobilizing the lower thigh, knee, and ankle are preferred.

Ankle Fractures
● Use a well-padded splint.

Upper Extremity and Hand Injuries

● Hand: splint in anatomic, functional position with the wrist slightly dorsiflexed and the
fingers gently flexed at 45 degrees at the MCP joints.

Pain Control
● Narcotics (have narcan available to reverse in the event of respiratory depression) and
regional nerve blocks; however, it is essential to assess and document any peripheral
nerve injury before administering a nerve block and keeping in mind the risk/possibility of
compartment syndrome since a nerve block will mask it.
 Chapter 9: Thermal Injuries

The most significant difference between burns and other injuries is that the consequences of
burn injury are directly linked to the extent of the inflammatory response to the injury. The larger
and deeper the burn, the worse the inflammation.

Primary Survey and Resuscitation of Patients with Burns

Stopping the Burning Process

● Completely remove pts clothing. Do not peel off adherent clothing. Prevent
overexposure and hypothermia.

Establish Airway Control

● Airway can become obstructed not only from direct injury (e.g., inhalational) but also
from the massive edema resulting from the burn injury.
● Indications for early intubation:
○ Signs of airway obstruction (hoarseness, stridor, retractions)
○ Extent of burn >40-50% of total body surface area
○ Extensive and deep facial burns
○ Burns inside the mouth
○ Significant edema or risk for edema
○ Difficulty swallowing
○ Signs of respiratory compromise: inability to clear secretions, respiratory fatigue,
poor oxygenation or ventilation
○ Decreased LOC where airway protective reflexes are impaired
○ Full thickness circumferential neck burns
● A carboxyhemoglobin level greater than 10% in a patient who was involved in a fire also
suggests inhalational injury.

Ensure Adequate Ventilation

● Direct thermal injury to the lower airway is very rare and essentially occurs only after
exposure to superheated steam or ignition of inhaled flammable gases. Breathing
concerns arise from three general causes:
○ Hypoxia
■ administer O2 +/- intubate
○ Carbon monoxide poisoning
■ always assume in pts burned in enclosed area
■ high CO level may result in headache (HbCO 20-30%), nausea,
confusion (30-40%), coma (40-60%), death (> 60%).
■ Half life of CO is 4 hours on room air; can reduce it to 40 minutes by
administering 100% O2 - administer it for 4-6 hours but be careful in
COPD patients
○ Smoke inhalation injury - mortality is doubled compared with other burn pts
 ■ 2 requirements for diagnosis:
● Exposure to a combustible agent
● Signs of exposure to smoke in the lower airway below the vocal
cords seen on bronchoscopy
■ Get a CXR and ABG at baseline
■ Treatment is supportive; elevate head and chest by 30 degrees to reduce
neck and chest wall edema.
○ A sign of cyanide poisoning is a persistent profound unexplained metabolic
acidosis.

Manage Circulation with Burn Shock Resuscitation

● In contrast to resuscitation for other types of trauma in which fluid deficit is typically
secondary to hemorrhagic losses, burn resuscitation is required to replace the ongoing
losses from capillary leak due to inflammation.
● Should provide burn resuscitation for deep partial and full-thickness burns > 20% TBSA
● Warmed Ringer’s lactate
● Indwelling urinary catheter to monitor urine output to assess perfusion
● Parkland formula can lead to over-resuscitation
● Current guideline for the initial rate:
○ 2ml of RL x pts body weight in kg X %TBSA for 2nd and 3rd degree burns
○ One-half of the total fluid provided in the first 8 hours, and remainder in the next
16 hours.
○ E.g., 100kg man, 80% TBSA burn
■ 2ml x 100 x 80 = 16,000ml
■ Give half (8,000ml) in the first 8 hours = 1L per hour for 8 hours
■ Give the other half over the next 16 hours = 500ml per hour for 16 hours
● After the initial resuscitation, adjust to make urine output:
○ 0.5ml/kg/hr urine adults
○ 1ml/kg/hr for children weighing less than 30kg
● In pediatrics, begin at 3ml/kg/%TBSA
○ Very small children (<30kg) should receive D5RL at a maintenance rate in
addition to the resuscitation with RL at 3ml/kg/%TBSA
● For electrical injury, all ages:
○ 4ml RL x kg x %TBSA until urine clears and target 1-1.5ml/kg/hr

Patient Assessment

History

Body Surface Area

● Rule of nines
○ The palmar surface (including the fingers) of the pts hand represents
approximately 1% of the patient’s body surface.
 ○ Adult
■ Google diagram
○ Children
■ Google diagram; and note that, in comparison to adults, you take 9% from
the legs and add it on the head/face because kids have relatively larger
heads and smaller lower extremities.

Depth of Burn
● Superficial (1st degree) - e.g., sunburn - erythema and pain, do not blister
● Partial-thickness burns
○ Superficial partial - moist, painfully hypersensitive (even to air current), potentially
blistered, homogeneously pink, blanch to touch
○ Deep partial - drier, less painful, potentially blistered, red or mottled, do not
blanch to touch
● Full-thickness burns - appear leathery, translucent, waxy white, painless to light touch or
pinprick, dry, does not blanch with pressure

Secondary Survey and Related Adjuncts

Baseline Determinations for Patients with Major Burns

● CBC, type and crossmatch/screen, ABG with HbCO, serum glucose, lytes, HCG
(females); CXR in intubated pts or those suspected to have inhalational injury

Peripheral Circulation in Circumferential Extremity Burns

● Goal: r/o compartment syndrome
● Pressure > 30 mmHg in compartment will cause muscle necrosis
● If circumferential chest and abdominal burn, may see increases peak inspiratory
pressures in ventilated patients or abdominal compartment syndrome
○ Chest and abdominal escharotomy
● Always attempt to incise the skin through the burned, not the unburned, skin

Gastric Tube Insertion

● If pt experiences N/V, abdominal distention, or burns >20%TBSA.
● Attach to suction.

Narcotics, Analgesics, Sedatives

● May be restless and anxious from hypoxemia or hypovolemia rather than pain.
● Remember that simply covering the wound will decrease pain.

Wound Care
● A fresh burn is a clean area that must be protected from contamination. When
necessary, clean a dirty wound with sterile saline. Ensure that all individuals who come
 in contact with the wound wear gloves and gown, and minimize the number of caregivers
within the patient’s environment without protective gear.

Antibiotics
● No indication in early post-burn period.

Tetanus
● Determine status.
○ >3 doses (complete Vx) w/ no tetanus booster in past 5 yrs and burn is ≥2nd
degree: give tetanus booster
○ <3 doses (incomplete Vx): immunize and give immune globulin

Unique Burn Injury

Chemical
● Alkali burns are generally more serious than acid burns.
● Rapid removal of the chemical and immediate attention to wound care are essential.
● Flush with large amounts of warmed water for at least 20 to 30 minutes. Neutralizing
agents can produce heat and cause further tissue damage.
● Alkali burns to eye require continuous irrigation for the first 8 hours after the burn.

Electrical
● Severe electrical injuries usually result in contracture of the affected extremity. A
clenched hand with a small electrical entrance wound should alert the clinician that a
deep soft tissue injury is likely much more extensive than is visible to the naked eye.
● Airway, oxygenation, ventilation, IV, ECG (arrhythmias), indwelling bladder catheter.
● 4ml/kg/%TBSA to ensure urinary output of 100ml/hr adults and 1-1.5ml/kg/hr in children
weighing less than 30kg. When urine is clear, titrate down to achieve 0.5ml/kg/hr urine
output.

Tar Burns
● Rapidly cool tar, then mineral oil to dissolve the tar.

Burn Patterns Indicating Abuse

● It is important for clinicians to maintain awareness that intentional burn injury can occur
in both children and adults.
● Circular burns, burns with clear edges and unique patterns, soles of a child’s feet,
posterior aspect of the lower extremities and buttocks (hot bathtub).
● Above all, the mechanism and pattern of injury should match the history of the injury.

Cold Injury: Local Tissue Effects

Types of Cold Injury

 ● Frostbite
○ Freezing, crystal formation
○ Reperfusion injury
○ Classification: 1st, 2nd, 3rd, and 4th degree
■ Initial treatment applies to all degrees.
● Non-freezing injury
○ Trenchfoot
○ Complications: local infection, cellulitis, lymphangitis, gangrene - proper attention
to foot hygiene can prevent these

Management of Frostbite and Non-freezing Cold Injuries

● Warming of large areas can result in reperfusion syndrome, with acidosis, hyperkalemia,
and local swelling; therefore, monitor the pts cardiac status and peripheral perfusion
during warming.
● Local wound care
○ Prevent infection - systemic antibiotics are not indicated prophylactically
○ Avoid opening uninfected vesicles - need 7-10 days
○ Elevate injured area
○ Protect tissue and avoid pressure - minimize weight bearing

Cold Injury: Systemic Hypothermia

● Trauma pts are susceptible to hypothermia, and any degree of hypothermia in them can
be detrimental.
● Definition:
○ Hypothermia = any core temperature below 36C
○ Severe hypothermia = below 32C
● Can worsen coagulopathy and affect organ function.
● Passive rewarming: place pt in environment that reduces heat loss (e.g., dry clothing,
blankets) is used for mild hypothermia
● Active warming: supply additional sources of heat energy to pt (e.g., warmed IV solution,
warm packs to areas of high vascular flow such as the groin and axilla, initiating
circulatory bypass) is used for moderate and severe hypothermia
 Chapter 10: Pediatric Trauma

The condition of the majority of injured children will not deteriorate during treatment, and most
injured children have no hemodynamic abnormalities. Nevertheless, the condition of some
children with multisystem injuries will rapidly deteriorate, and serious complications will develop;
therefore, early transfer of pediatric patients to a facility capable of treating children with
multisystem injuries is optimal.

Unique Characteristics of Pediatric Patients

Size, Shape, and Surface Area

● A child’s head is proportionally larger than an adult’s, which results in a higher frequency
of blunt brain injuries in this age group.
● The ratio of a child’s body surface area to body mass is highest at birth. As a result,
thermal energy loss is a significant stress factor in children. Hypothermia may develop
quickly.

Skeleton
● Rib fractures are uncommon, whereas pulmonary contusion is not.
● The presence of skull and/or rib fractures in a child suggest the transfer of a massive
amount of energy; in this case, underlying organ injuries, such as traumatic brain injury
and pulmonary contusion, should be suspected.

Psychological status

Long-term Effects of Injury

Equipment
● Broselow Pediatric Emergency Tape

Airway

Anatomy
● Large occiput results in passive flexion of the c-spine; avoid by placing a 1-inch layer of
padding beneath the infant or toddler’s entire torso.
● Larynx and vocal cords are more cephalad and anterior in the neck.
● Short trachea (be careful not to intubate the right mainstem bronchus)
○ Optimal ETT depth (cm) = 3 x appropriate tube size
○ E.g., 12cm at gums = 3 x size 4.0 ETT
Management
● Before attempting to mechanically establish an airway, full preoxygenate the child.
 ● The practice of inserting an OPA backwards and rotating it 180 degrees is not
recommended for children, since trauma and hemorrhage into soft-tissue structures of
the oropharynx may occur.
● RSII:
○ Preoxygenate
○ Sedation
■ Hypovolemic: etomidate (lower dose) or midazolam
■ Normovolemic: etomidate or midazolam
○ Paralysis
■ Succinylcholine or vecuronium or rocuronium
● Orotracheal intubation under direct vision with restriction of cervical motion is the
preferred method of obtaining definitive airway control
○ Deterioration after intubation:
■ “Don’t be a DOPE”
● Dislodgment
● Obstruction
● Pneumothorax
● Equipment failure
● Cricothyroidotomy
○ Surgical cricothyroidotomy is rarely indicated for infants or small children. It can
be performed in older children in whom the cricothyroid membrane is easily
palpable.

Breathing
● Infant RR: 30-40 breaths/min
● Older child: 15-20
● Hypoxia is the most common cause of pediatric arrest; however, before cardiac arrest
occurs, hypoventilation causes respiratory acidosis.
● In the absence of adequate ventilation and perfusion, attempting to correct an acidosis
with sodium bicarbonate can result in further hypercarbia and worsened acidosis.

Circulation and Shock

● Recognition of Circulatory Compromise
○ Up to a 30% decrease in circulating blood volume may be required to manifest a
decrease in the child’s systolic blood pressure.
○ Tachycardia and poor skin perfusion often are the only keys to early recognition
of hypovolemia.
○ Mean normal sBP for children = 90 + 2 x (age in years)
○ Lower limit for sBP for children = 70 + 2 x (age in years)
● Determination of weight and circulating volume
○ Weight in kg = 2 x (age in years) + 10
○ Infant blood volume: 80mL/kg
○ Child age 1-3 years blood volume: 75mL/kg
 ○ Children over 3 years: 70mL/kg
● Venous Access
○ Start IO if percutaneous access unsuccessful after 2 attempts
● Fluid Resuscitation and Blood Replacement
○ Warmed isotonic crystalloid solution as an initial 20mL/kg bolus, followed by one
or two additional 20mL/kg boluses pending the physiologic response.
■ This practice is changing currently in favor of a move towards “damage
control resuscitation” consisting of the restrictive use of crystalloids and
early administration of balances ratios of pRBCs, FFP, and platelets.
● Urine Output
○ Infants goal: 1-2 mL/kg/hr
○ Children aged 1 to adolescence: 1-1.5 mL/kg/hr
○ Teenagers: 0.5 mL/kg/hr
● Thermoregulation
○ Avoid hypothermia

Cardiopulmonary Resuscitation
● Predictors of non-survival
○ CPR in the field
○ Received CPR for more than 15 minutes before arrival to ED
○ Fixed pupils on arrival to ED

Chest Trauma
● The mobility of mediastinal structures makes children more susceptible to tension
pneumothorax, the most common immediately life-threatening injury in children.

Abdominal Trauma
● Assessment
○ Orogastric tube decompression is preferred in infants.
○ Decompress bladder as well.
● Diagnostic Adjuncts
○ CT
■ Fatal cancers are predicted to occur in as many as 1 in 1000 patients who
undergo CT as children.
■ To achieve lowest dose of radiation possible, perform CT scans only
when medically necessary, scan only when the results will change
management, scan only the areas of interest, and use the lowest
radiation dose possible.
○ FAST
○ DPL
● Nonoperative Management
 ○ If the child’s hemodynamic condition cannot be normalized and the diagnostic
procedure performed is positive for blood, perform a prompt laparotomy to
control hemorrhage.

Head Trauma
● Children have significant susceptibility to cerebral hypoxia and hypercarbia.
● Assessment
○ It is critical to ensure adequate and rapid restoration of an appropriate circulating
blood volume and avoid hypoxia.
○ An infant who is not in a coma but who has bulging frontanelles or suture
diastases should be assumed to have a more severe injury, and early
neurosurgical consultation is essential.
○ CT head for persistent vomiting or vomiting that becomes more frequent, seizure
activity
○ Common meds: 3% hypertonic saline and mannitol to reduce intracranial
pressure, and levetiracetam and phenytoin for seizures
● Management
○ Similar to adults. Key is to prevent secondary brain injury - that is, hypoxia and
hypoperfusion. Note that attempts to orally intubate the trachea in an
uncooperative child with a brain injury may be difficult and actually increase
intracranial pressure - pharmacologic sedation and neuromuscular blockade may
be needed.
○ Hypertonic saline and mannitol create hyperosmolality and increased sodium
levels in the brain, decreasing edema and ICP. They also are rheostatic agents
that improve blood flow and downregulate the inflammatory response.

Spinal Cord Injury

● Anatomical Differences
○ Children have relatively large heads, which leads to more injuries at the level of
the occiput to C3.
● Radiological Considerations
○ Children sustain SCIWORA (SCI without radiographic abnormalities) more
commonly than adults.
○ When in doubt about the integrity of the cervical spine or spinal cord, assume
that an unstable injury exists, limit spinal motion, and obtain appropriate
consultation.
○ CT and MRI should not be used as routine screening modalities for evaluation of
the pediatric cervical spine; rather, plain radiographs should be performed as the
initial imaging tool.

Musculoskeletal Trauma
● Blood loss
 ○ Blood loss associated with long bone and pelvic fractures is proportionately less
in children than in adults.
● Special Considerations of the Immature Skeleton
○ Greenstick fractures and buckle fractures may suggest maltreatment in pts w/
vague, inconsistent, or conflicting histories.
○ Supracondylar fractures at the elbow or knee have a high propensity for vascular
injuries as well as injury to the growth plate.

Child Maltreatment
● Children who suffer from non-accidental trauma have significantly higher injury severity
and a six-fold higher mortality rate than children who sustain accidental injuries.
● Suspicious physical exam findings:
○ Multicolored bruises (different stages of healing)
○ Evidence of frequent previous injuries, typified by old scars or healed fractures
on x-ray examination
○ Perioral injuries
○ Injuries to genital or perianal area
○ Fractures of long bones in children younger than 3 years of age
○ Ruptured internal viscera without antecedent major blunt trauma
○ Multiple subdural hematomas, especially without a fresh skull fracture
○ Retinal hemorrhages
○ Bizarre injuries such as bites, cigarette burns, and rope marks
○ Sharply demarcated 2nd and 3rd degree burns
○ Skull fractures or rib fractures seen in children less than 24 months of age
● Physicians are legally bound to report child maltreatment even if it is only suspected.
 Chapter 11: Geriatric Trauma

Mechanism of Injury
● Falls
○ TBI, fractures
● Motor Vehicle Crashes
● Burns
○ High mortality, inability to escape burning structures
● Penetrating Injuries
○ Many GSW’s are related to intentional self-harm or suicide

Primary Survey with Resuscitation

● Follows ABCDE methodology, taking into account the effects of aging on organ systems.
● Airway
○ When performing rapid sequence intubation, reduce the doses of sedatives to
between 20 and 40% to minimize the risk of cardiovascular depression.
● Breathing
○ Reduced compliance and stiffer chest wall = increase work of breathing
○ Aging causes a suppressed HR response to hypoxia, so respiratory failure may
present insidiously
● Circulation
○ sBP of 110 should be used as threshold for identifying hypotension in >65yo
○ It is critical to identify pts w/ significant tissue hypoperfusion
■ Base deficit, serum lactate
○ The elderly trauma pt w/ evidence of circulatory failure should be assumed to be
bleeding. Consider the early use of advanced monitoring (CVP, echo, U/S) to
guide optimal resuscitation, given the potential for preexisting CV disease.
● Disability
○ Identify and correct therapeutic anticoagulation early
○ Neuro exam may be normal because cerebral atrophy gives space for them to
bleed compression/shift/herniation
● Exposure and Environment
○ At higher risk for hypothermia and delirium
○ Rapid evaluation, removal from spine board and c-spine collar will minimize
complications

Specific Injuries
● Rib Fractures
○ Primary complication is pneumonia - incidence can be up to 30%
○ Pain control and pulmonary hygiene (be careful with narcotics and delirium)
● Traumatic Brain Injury
○ Confounded by delirium, dementia, depression
○ Reverse anticoagulants: PCC, plasma, vitamin K, idarucizumab (for dabigatran)
 ● Pelvic Fractures
○ Most are due to ground level falls (superimposed on osteoporosis)

Special Circumstances
● Medications
○ Beta blockers
○ Anticoagulation, antiplatelet, direct thrombin inhibitors
● Elder Maltreatment
○ Physical, sexual, neglect, psychological, financial, rights
○ Signs may be subtle: poor hygiene and dehydration
○ If suspected or confirmed, report.
● Establishing Goals of Care
○ Early discussion with patient and family
 Chapter 12: Trauma in Pregnancy and Intimate Partner Violence

The best initial treatment for the fetus is to provide optimal resuscitation of the mother.

Anatomical Differences
● 12wks = uterus intrapelvic
● 20wks = fundus of uterus at umbilicus
● 34-36wks = fundus at costal margin
● Cephalad displacement of bowel
● 2nd trimester: fetus protected by amniotic fluid
○ Amniotic fluid embolism and DIC occur if amniotic fluid enters maternal
intravascular space
● 3rd trimester:
○ Placenta has little elasticity, vulnerable to shear forces at uteroplacental interface
and abruption
● An abrupt decrease in maternal intravascular volume can result in profound increase in
uterine vascular resistance, reducing fetal oxygenation despite reasonably normal
maternal vital signs

Blood Volume and Composition

● Physiologic anemia of pregnancy = increase in plasma volume with a smaller increase in
RBCs; Hct of 31-35% is normal
● Pregnant women can lose 1200-1500mL of blood before exhibiting signs and symptoms
of hypovolemia; however, this amount of blood loss may be reflected by fetal distress

Hemodynamics
● Cardiac Output
○ Uterus and placenta receive 20% of CO in 3rd trimester
○ When supine, IVC compression can decrease CO by 30%
● Heart Rate
○ Usually 10-15bpm above baseline
● Blood Pressure
○ Nadir (fall by 5-15mmHg) during 2nd trimester; then BP returns to normal by term
● Venous Pressure
● ECG Changes
○ Axis may shift leftward by 15 degrees.
○ Flattened or inverted T waves in leads III and AVF and precordial leads may be
normal

Respiratory System
● Increase in minute ventilation; hypocapnea (PaCO2 of 30mmHg) is common in late
pregnancy
● A PaCO2 of 35 to 40 mmHg may indicate impending respiratory failure during pregnancy
 ● Administer supplemental oxygen to maintain SpO2 ≥ 95%
● Place chest tube higher to avoid intraabdominal placement

Gastrointestinal System
● Gastric emptying delayed; insert nasogastric tube early.

Urinary System
● Serum Cr and BUN fall to approx half pre-pregnancy levels.

Musculoskeletal System
● Large, engorged pelvic vessels surrounding the gravid uterus can contribute to massive
retroperitoneal bleeding after blunt trauma with associated pelvic fractures

Neurological System
● Seizure from head trauma or eclampsia?
● Eclampsia may be present if seizures occur w/ associated hypertension, hyperreflexia,
proteinuria, peripheral and pulmonary edema.

Mechanism of Injury
Most are MVCs and most are blunt injury.

Blunt Injury
● Using shoulder restraints in conjunction with a lap belt reduces the likelihood of direct
and indirect fetal injury, presumably because the shoulder belt dissipates deceleration
force over a greater surface area and helps prevent the mother from flexing forward over
the gravid uterus.
● Unrestrained pregnant women have a higher incidence of premature delivery and fetal
death compared with restrained pregnant women in MVCs.

Penetrating Injury
● Likelihood of uterine injury increases with increasing uterus size.

Severity of Injury

Assessment and Treatment

To optimize outcomes for the mother and fetus, clinicians must assess and resuscitate the
mother first and then assess the fetus before conducting a secondary survey of the mother.

Primary Survey with Resuscitation

● Mother
○ Manually displace the uterus to the left side to relieve pressure on the IVC.
 ○ The fetus may be in distress and the placenta deprived of vital perfusion while
the mother’s condition and vital signs appear stable… this is due to increased
intravascular volume in pregnancy.
○ Fibrinogen level may double in late pregnancy, so a normal fibrinogen level may
indicate early DIC.
● Fetus
○ Main cause of fetal death = maternal shock and maternal death
○ 2nd most common cause of fetal death = placental abruption
■ Vaginal bleeding
■ Uterine tenderness
■ Frequent uterine tenderness
■ Uterine tetany
■ Uterine irritability (contracts when touched)
○ Uterine rupture
■ Abdominal tenderness, rigidity, guarding, rebound, shock, hematuria.
■ Abnormal fetal lie, easy palpation of fetal parts because of extrauterine
location, inability to palpate uterine fundus.
■ X-ray: extended fetal extremities, abnormal fetal position, free air
○ Perform continuous fetal monitoring with toco beyond 20-24 weeks
■ No risk factors or fetal loss: continuous fetal monitoring for 6 hours
■ Risk factors for fetal loss: 24 hours
● RFs
○ Maternal HR > 110
○ ISS > 9
○ Evidence of placental abruption
○ FHR > 160 or < 120
○ Ejection during a MVC
○ Motorcycle or pedestrian collision

Adjuncts to Primary Survey with Resuscitation

● Mother
○ Left side, monitor fluid status, ABG
● Fetus
○ Obstetrics consult, FHR should be 120-160, reflects both maternal blood volume
status and fetal well-being

Secondary Survey
● CT abdo, FAST, DPL as needed - if DPL is performed, place catheter above umbilicus
● Uterine contractions suggest early labor; tetanic contractions suggest abruptio.
● Abdo/pelvis CT radiation dose is 25mGy, and fetal radiation doses less than 50 are not
associated with fetal anomalies or higher risk for fetal loss.
 ● Admit to hospital if: PV bleeding, uterine irritability, abdo tenderness, pain, cramping,
evidence of hypovolemia, changes in or absence of FHR, and/or leakage of amniotic
fluid

Definitive Care
● Amniotic fluid embolus: widespread intravascular clotting, depletion of fibrinogen, other
clotting factors, and platelets
○ Tx: immediate uterine evacuation and replace platelets, fibrinogen, and other
clotting factors if necessary
● All pregnant Rh-negative trauma patients should receive Rh immunoglobulin therapy
unless the injury is remote from the uterus

Perimortem Cesarean Section

● At the time of maternal hypovolemic cardiac arrest, the fetus has already suffered
prolonged hypoxia.
● For other causes of maternal cardiac arrest, perimortem cesarean section occasionally
may be successful if performed within 4-5 minutes of the arrest.

Intimate Partner Violence

● IPV is a major cause of injury to women during cohabitation, marriage, and pregnancy,
regardless of ethnic background, cultural influences, or socioeconomic class.