Spring 2017

Trauma Special Edition

Spring 2017
IN THIS ISSUE
Lesson 1 n Hand Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Lesson 2 n Blast Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Critical Decisions in Emergency Medicine is the official
Lesson 3 n Traumatic Brain Injury — Concussion. . . . . . . . . . . . 21 CME publication of the American College of Emergency
Lesson 4 n Geriatric Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Physicians. Additional volumes are available to keep
emergency medicine professionals up to date on
Lesson 5 n Trauma in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . 38 relevant clinical issues.
Lesson 6 n Sexual Assualt in the Male Victim. . . . . . . . . . . . . . . 46
Lesson 7 n Traumatic Cardiopulmonary Arrest. . . . . . . . . . . . . 55 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Northeastern Ohio Universities,
EDITOR Rootstown, OH
TRAUMA SPECIAL EDITION
Michael S. Beeson, MD, FACEP SECTION EDITORS
Dr. Beeson is a professor and the director of the Emergency Andrew J. Eyre, MD
Medicine Residency Program at Akron General in Akron, Ohio. Brigham & Women’s Hospital/Harvard Medical School,
Boston, MA
Joshua S. Broder, MD, FACEP
Contributor Disclosures. In accordance with the ACCME Standards for Commercial Duke University, Durham, NC
Support and policy of the American College of Emergency Physicians, all individuals with Frank LoVecchio, DO, MPH, FACEP
control over CME content (including but not limited to staff, planners, reviewers, and Maricopa Medical Center/Banner Phoenix Poison
authors) must disclose whether or not they have any relevant financial relationship(s) to and Drug Information Center, Phoenix, AZ
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perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, University of Maryland, Baltimore, MD
honoraria, or consulting fees), but these individuals do not consider that it will influence the
CME activity. Sharon E. Mace, MD, FACEP; Baxter Healthcare, consulting fees, fees for non- Lynn P. Roppolo, MD, FACEP
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University of California Health Sciences,
Method of Participation. This educational activity consists of seven lessons, a post-test, San Diego, CA
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minimum score of 75% is required) and evaluation questions. Release date June 1, 2017.
Expiration date May 31, 2020. ASSOCIATE EDITORS
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the Accreditation Council for Continuing Medical Education to provide continuing medical University of Texas Southwestern Medical Center,
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Approved by the American College of Emergency Physicians for a maximum of 17.5 hour(s) Sharon E. Mace, MD, FACEP
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OBJECTIVES
On completion of this lesson, you should be able to:
1. Evaluate hand injuries with a thorough understanding of
the anatomy and function.
2. Manage amputation injuries and explain which patients
can be considered for surgical replantation.
3. Describe the red flags that should raise suspicion for
compartment syndrome of the hand.
4. List the cardinal signs of pyogenic flexor tenosynovitis.
5. Explain which injection injuries require emergent
operative management and which can be observed.
6. Discuss how to evaluate and optimally manage
clenched fist injuries.
FROM THE EM MODEL
18.0 Traumatic Disorders
18.1.14 Soft-Tissue Extremity Injuries
The hand, which plays a vital role in our day-to-day livelihood, is comprised of an intricate system of bones,
ligaments, tendons, and neurovascular networks that must function collectively and effortlessly. Therefore, it
is no surprise that hand injuries also carry significant societal costs, heavily contributing to lost wages and workers’
compensation settlements.
Digital
Preservation
Hand Injuries
LESSON 1
By Marisa Hori, MD, Alisheba Hurwitz, MD,
and Nara Shin, MD
Dr. Hori is an attending physician in the Department of Emergency Medicine at
Kona Community Hospital in Kealakekua, Hawaii. Dr. Hurwitz is an instructor in
the Department of Emergency Medicine at Thomas Jefferson University Hospital
in Philadelphia, Pennsylvania. Dr. Shin is the Coordinator of Outpatient Medical
Services at Princeton University in Princeton, New Jersey.
Reviewed by Daniel A. Handel, MD, MPH, FAC
CRITICAL DECISIONS
n How should traumatic hand injuries be evaluated in
the emergency department?
n When is it appropriate to attempt reattachment of an
amputated digit, and what can be done to maximize
successful replantation?
n What red flags should raise suspicion for compart­
ment syndrome?
n How are clenched-fist injuries best managed?
n What clinical examination findings are most
suggestive of pyogenic flexor tenosynovitis?
n Which high-pressure injection injuries require
emergent operative management?
Traumatic Injury Special Edition n Spring 2017 3
 CASE PRESENTATIONS
■ CASE ONE
A 43-year-old woman walks into
the emergency department after
accidentally cutting off the distal tip
of her right index finger. Her husband
states that she injured her finger 20
minutes earlier while using a food
slicer at home. She tells you she is a
surgeon at your hospital and that she
is right-handed. She has no significant
medical problems, but does drink
an average of seven alcoholic
beverages a week and smokes on
occasion. Her husband hands you
a plastic bag containing the severed
fingertip, which is dusky in color. On
examination, the patient’s vital signs
are blood pressure 145/97, pulse rate
94 and regular, respiratory rate of
22, and oxygen saturation 99% on
room air. The examination reveals
an amputation injury of the right
index finger just beyond the distal
interphalangeal joint with non-
pulsatile slow bleeding. The rest of
the evaluation is unremarkable. The
Trauma to the hand accounts for
roughly 10% of all injuries that present
to the emergency department.1 Although
the majority of these cases can be
managed by the emergency physician,
about 10% will be severe enough to
require referral to a hand specialist. 2
Particularly high-risk presentations
include high-pressure injection injuries,
amputations, “fight bites,” pyogenic
flexor tenosynovitis, and compartment
syndrome, in which time from injury to
operative management greatly affects
patient outcomes.
CRITICAL DECISION
How should traumatic hand
injuries be evaluated in the
emergency department?
As with any patient who presents
to the emergency department, the
first priority is the identification and
treatment of potentially life-threatening
injuries. After addressing these issues,
the evaluation of traumatic hand
injuries must begin with a thorough
patient anxiously asks you whether the
amputated finger can be reattached.
■ CASE TWO
A 23-year-old man is brought in
by ambulance. He was found sitting
on the curb outside a bar at 2 am; it is
unknown how long he had been there.
He is well known to the emergency
department for his prior presentations
for alcohol intoxication. On arrival, the
patient is talking incoherently and there
is a smell of alcohol on his breath. His
vital signs are blood pressure 154/96,
pulse rate 74 and regular, respiratory
rate 16, and oxygen saturation 98%
on room air. Blood glucose is 110. You
do not find any signs of head trauma,
and the rest of the examination is
unremarkable. When completing your
chart, you notice a triage note that
mentions an abrasion to the patient’s
left hand. You return to his bedside
and see a 5-mm laceration over his left
dorsal middle metacarpophalangeal
joint, which appears superficial. The
history. Aside from the standard
questions regarding past medical
problems, prior surgeries, medications,
and allergies, the patient should be asked
about the onset, nature, and symptoms
of the injury. The patient’s occupation,
hobbies, and hand dominance also
should be clarified. It also is important
to confirm tetanus immunization status
and, in some cases, hepatitis B and HIV
status.
Next, a complete examination of
the hand should start with its general
appearance, including skin findings,
posture at rest, and any deformities. An
understanding of the anatomy of the
hand is essential for recognizing proper
alignment and range of motion of the
bones and joints (Figure 1). In addition,
neurological function should be tested
(Figure 2). The innervation of the hand
is complex and can vary from person to
person. However, there is a fairly easy
and quick method for testing each of
the nerves, which can be employed by
clinicians who don’t have the luxury of
Traumatic Injury Special Edition
patient admits to drinking 10 beers and
getting in a bar fight earlier that night.
■ CASE THREE
A 37-year-old man is brought in
by his coworker with hand pain. He
works at an auto body shop. About 4
hours ago he was cleaning the tip of
a high-pressure paint sprayer when it
accidentally turned on and injured his
left hand. At first he didn’t think much
of it, but the pain worsened to the point
that he could not continue his work. His
vital signs are blood pressure 135/85,
pulse rate 84 and regular, respiratory
rate 18, and oxygen saturation 97% on
room air. He has a tense and swollen
left hand in “claw hand” position.
You observe a 1-mm puncture wound
on the middle of his palm. The index
and middle fingers have diminished
sensation compared to his right hand,
and capillary refill is prolonged. The
rest of his examination is unremarkable.
time (Table 1). Finally, the hand should
be examined for tendon trauma by
isolating joints around the injured area
and having the patient flex and extend
each part.
CRITICAL DECISION
When is it appropriate to attempt
reattachment of an amputated
digit, and what can be done to
maximize successful replantation?
There are no universally accepted
guidelines for evaluating the viability
of amputated digit replantation in a
particular patient. However, there
have been many studies comparing
factors that contribute to successful
replantation. A meta-analysis of 1,299
patients showed that the mechanism
of injury greatly influenced outcome.
Clean-cut injuries had a 91% rate of
successful replantation; by contrast,
crush and avulsion injuries had a success
rate of 68% and 66% respectively. 3
Success rates also varied depending
n Spring 2017 4

FIGURE 1. Bone Structures of the Hand
on the digit involved: thumb (68%),
2nd (75%), 3rd (83%), 4th (83%),
and 5th (89%). Smokers had a much
lower success rate (61%) compared to
non-smokers (97%). 3 Another study
showed that alcohol consumption and
the patient’s age did not alter rates of
successful replantation.4 Researchers
concluded that age alone should
not be a contraindication to finger
replantation.
One factor remains an area of
significant controversy: whether or not
to replant fingertip amputation injuries.
Many hand surgeons are hesitant to
perform distal tip replantation due
to the technical challenges and the
perceived high cost-to-benefit ratio.
However, recent research suggests
that fingertip replantation has a high
success rate and leads to increased
patient satisfaction and superior
aesthetic and functional outcomes. 5
A meta-analysis of 2,273 distal digit
replantations showed that Zone I (tip of
finger to base of nail) and Zone II (base
of nail to distal interphalangeal joint)
had the same survival rate of 87%.6
Regardless of the specific
circumstances, it is reasonable to
consult a hand surgeon, as it is
ultimately up to the surgeon and the
patient to decide whether to attempt
replantation. To maximize the success
of replantation surgery, take care of the
patient first and foremost. If possible,
assign another health care staff member
to manage the amputated part. The
wound on the residual limb should be
gently irrigated with normal saline;
dressed with petroleum gauze; and
covered with a dry, sterile compression
bandage.7 The amputated part should
be rinsed in normal saline or lactated
Ringer’s solution and wrapped in moist
gauze. It should then be placed in a
plastic bag, which in turn should be
placed in a container of ice and water.8
FIGURE 2. Sensory Nerve Distribution of the Hand
Palmar view
Median Nerve
Radial Nerve
Ulnar Nerve
CRITICAL DECISION
What red flags should raise
suspicion for compartment
syndrome?
Compartment syndrome of the
hand is a rare but serious complication
of traumatic injury. It occurs when
the interstitial pressure rises within
closed fascial compartments,
resulting in vascular compromise
and tissue ischemia. The hand has
10 compartments: hypothenar,
thenar, adductor pollicis, four dorsal
interossei, and three volar interosseous
compartments.7 Patients with intra­
venous injection-related wounds, crush
injuries, gunshot wounds, and arterial
line complications are at greatest risk of
developing this pathology.9
As with compartment syndrome of
other parts of the body, the cardinal
signs for the hand include the “five Ps”:
pain, paresthesia, pallor, paralysis,
and pulselessness. One important
sign is a tense and swollen hand in an
intrinsic minus or “claw hand” position,
where the metacarpophalangeal joints
are in extension and the intercarpal
joints are in flexion.9 Another sign
involves the Bunnel test (positive
stretch test): passively maintain the
metacarpophalangeal joints in extension
and either actively or passively flex the
intercarpal joints. If intercarpal flexion is
Dorsal view

Traumatic Injury Special Edition n Spring 2017 5


TABLE 1. Neurological Examination of the Hand
Motor Function
Ulnar Finger abduction and adduction
Median Flexion of digits 1, 2, and 3 (pinky to thumb)
Thumb opposition (“ok” sign)
Radial Wrist extension
Modified from Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition.
restricted when the metacarpophalangeal
joint is held in extension (but not in
flexion), compartment syndrome should
be suspected.10
In such cases, an emergent
consultation with a hand surgeon
is paramount. If the examination is
equivocal, compartment pressures
must be measured by a surgeon; if the
diagnosis is evident, the patient should
be taken straight to the operating room.
CRITICAL DECISION
How are clenched-fist injuries
best managed?
A human teeth injury to a clenched
fist, or “fight bite,” is a true medical
emergency that requires careful
evaluation and management by the
emergency physician and subsequently
by a hand surgeon. These seemingly
innocuous injuries usually present
with a small laceration overlying the
metacarpophalangeal joint. Even if
the injury appears superficial, there
often is injury to deeper structures. In
one retrospective study of 191 patients
with fight bite, 75% had damage to
deeper structures such as the tendon,
joint capsule, joint, cartilage, and
FIGURE 3. “Fight Bite” Injury
Images courtesy of Eon K. Shin, MD, The Philadelphia Hand Center, P.C.
Sensory Function
Tip of little finger
Tip of index finger
Dorsal first web space
bone.11 Many species of bacteria
have been isolated from human bite
wounds, including Staphylococcus,
Streptococcus, Bacteroides, and
Fusobacterium species.12 To date there
have been five reported cases of HIV
seroconversion and four reported cases of
hepatitis B infections from human bites.14
Despite the potentially serious infectious
agents to which patients with fight bites
are exposed, many are inappropriately
managed. A retrospective study of 421
human bite injuries — of which 25%
involved the hand and fingers — found
that 82% of patients were not referred to
a specialist, 67% did not have hepatitis
B status documented, 20% did not have
tetanus status documented, and 17% did
not receive prophylactic antibiotics.13
Whether every patient with clenched-
fist injury needs admission and emergent
hand surgery consultation remains
controversial. Some experts believe
that all patients require admission
for operating room debridement
and irrigation as well as parenteral
antibiotics.11,14 Others maintain that if
careful exploration of the wound under
ideal conditions (adequate lighting,
hemostasis, and good exposure) through
FIGURE 4. Paint Gun Injury
Traumatic Injury Special Edition
full range of motion of the joint reveals
only a superficial injury, conservative
management (irrigation, wound left
open, prophylactic antibiotics, and
outpatient hand surgery follow up) is
reasonable.15 There is no consensus
regarding a prophylaxis antibiotic
regimen, but recommendations include
amoxicillin/clavulanic acid, as well as
a combination of penicillin and first-
generation cephalosporins.12
The clenched-fist injury is a serious
condition that requires judicious
evaluation in the emergency department
with a high index of suspicion for deep
structure involvement. It is reasonable to
have a discussion with a hand surgeon
to decide whether the patient should be
discharged with prophylaxis antibiotics
and appropriate vaccinations or admitted
for operating room exploration and
parenteral antibiotics.
CRITICAL DECISION
What clinical examination
findings are most suggestive of
pyogenic flexor tenosynovitis?
Pyogenic flexor tenosynovitis (PFT)
is a rare but serious hand infection
involving the flexor tendon sheath.
It occurs most often as a result of
penetrating wounds to the palmar
surface that rapidly spread along the
flexor tendon sheath. Blunt trauma
also has been implicated, but in some
instances there is no recollection of an
injury prior to the diagnosis of PFT.16
Even with prompt antibiotic treatment
and surgical drainage of the infection,
n Spring 2017 6
there can be detrimental effects, including
finger stiffness and worsening of infection
leading to amputation. Therefore, PFT
is considered a true emergency requiring
prompt hand surgery consultation.
PFT is a diagnosis made on clinical
examination. The most common set of n Replantation of fingertip amputations is controversial; the decision should
clinical indicators are Kanavel signs, be determined case by case in consultation with a hand surgeon.
which consist of four physical findings: n To maximize viability, amputated parts should be wrapped in moist gauze
digital fusiform swelling, tenderness and placed in a plastic bag that then should be placed in an ice bath.
to palpation along the flexor sheath, n To avoid further damage, management of high-pressure injection injuries
flexed resting posture, and pain on should include elevating the hand, keeping it at room temperature, and
passive extension of the finger. Not all avoiding digital nerve blocks.
four signs are always present in patients
n Four physical examination findings suggestive of pyogenic flexor
with the disorder. In one retrospective tenosynovitis are digital fusiform swelling, tenderness along the flexor
study of 41 patients with PFT, about sheath, flexed resting posture, and pain on passive extension.
half of the patients had all four signs on
presentation, while all patients exhibited
tenderness along the tendon sheath and the injury can extend well beyond what highest amputation rates (up to ~71%)
pain on passive extension.17 Another is visible on the surface and can cause occurred with organic solvents such
study of 75 patients with PFT found significant tissue damage. Injected as paint thinner, paint, and oil-based
that the most sensitive sign was fusiform material can spread along neurovascular products; injection wounds with air
swelling (97%), followed by pain on bundles and tendon sheaths through and water in this study resulted in no
passive extension (72%), flexed resting amputations regardless of whether
the compartments of the hand.18 Tissue
posture (69%), and tenderness along the they were operatively or nonoperatively
injury occurs as a result of various
flexor sheath (64%).16
processes, including direct impact, managed. Two other factors that increase
CRITICAL DECISION ischemia, chemical inflammation, the likelihood of amputation include
granulomatous formation, and the pressure strength of the injector
Which high-pressure injection equipment (>1,000 psi versus <1,000 psi
secondary infection.19
injuries require emergent Because of the extent of damage had 43% versus 19% amputation rates,
operative management? injection injuries can cause, most require respectively) and time from injury to
Injection injuries occur when various early extensive surgical evaluation, the operating room (>6 hours versus
materials from high-pressure equipment decompression, and debridement. <6 hours had 58% versus 38%
penetrate the skin and are deposited However, there are some cases in which amputation rates, respectively).20
within the tissues. These types of injuries medical management is appropriate, Some injection injuries involve toxic
can be deceptively benign in outward including injection injuries with water substances that can have systemic
appearance, as they often present with or air. One retrospective study of 435 effects; therefore, timely consultation
just a small puncture wound. However, high-pressure injuries showed that the with the poison control center is
important. After stabilizing the patient,
the injured hand should be elevated.
Tetanus prophylaxis and broad-
spectrum empiric antibiotics should be
promptly administered. Analgesics are
best given parentally, keeping in mind
that digital blocks should be avoided
n Failing to adequately assess for deep wounds in fight bite. Even injuries as they can exacerbate swelling and
that appear only superficial need to be explored under adequate lighting,
cause vasospasms, ultimately adversely
hemostasis, and good exposure through full range of motion of the joint.
affecting distal perfusion. Ice also
n Failing to recognize that materials from high-pressure injection injuries should be discouraged in order to
can be systemically toxic. Consider contacting the poison control center optimize perfusion. The wound should
for all injection injuries.
be left open and a hand surgeon should
n Failing to suspect compartment syndrome in obtunded patients who be consulted emergently.21 Steroid
inadvertently may have applied prolonged pressure over their hands. administration for improved anti-
n Failing to consider pyogenic flexor tenosynovitis as a differential diagnosis inflammation effects remains a point of
in patients who don’t have a definitive history of a puncture wound. controversy due to a theoretical increased
risk of infection. Some high-pressure

Traumatic Injury Special Edition n Spring 2017 7

 CASE RESOLUTIONS
■ CASE ONE
The 43-year-old surgeon’s
amputated fingertip was wrapped in
moist gauze and placed in a plastic bag.
The bag then was placed in a bucket
of ice water to maximize viability
for possible reattachment. Although
fingertip amputations often are not
candidates for replantation, the decision
was made to call the hand surgeon
immediately. Since the injury was to
the patient’s dominant hand and the
potential for occupational disability
was high, the surgeon agreed to attempt
replantation in the operating room. The
patient agreed to quit smoking in order
to maximize recovery. Within 3 months
post-operatively, the patient was back at
her job with relatively good function of
her right hand.
■ CASE TWO
The young man with the superficial
laceration on his left hand (Figure 3)
received an updated tetanus shot and his
wound was irrigated with saline. The
injury was explored more thoroughly,
and the underlying anatomical structures
were examined throughout the joint’s
full range of motion. The laceration
was deeper than suspected; a partially
lacerated tendon was visible when the
patient’s joint was in full flexion. Further
questioning revealed that the patient
had punched another person’s face.
Concerned that this may be a clenched-
fist injury, the case was discussed with
the hand surgeon. The patient was given
a dose of IV antibiotics and taken to the
operating room for surgical exploration
and wash out.
■ CASE THREE
The 37-year-old man with the
high-pressure injection injury had
concerning signs for compartment
syndrome. The poison control
center was contacted to ensure there
was no potential systemic toxicity
from the injected material. The
patient received parental analgesic
medications, broad-spectrum
antibiotics, and tetanus prophylaxis.
The hand surgeon was called and the
patient was taken to the operating
room for surgical decompression
and debridement (Figure 4). He
was discharged several weeks later
and, after extensive rehabilitation,
returned to work.

injuries with water or air that have
no signs of compartment syndrome
can be managed nonoperatively at the
discretion of the consulting surgeon.
3. Dec W. A meta-analysis of success rates for digit
replantation. Tech Hand Up Extrem Surg. 2006
Sep;10(3):124-9.
4. Barzin A, Hernandez-Boussard T, Lee GK, et al.
Adverse events following digital replantation in the
elderly. J Hand Surg Am. 2011;36(5):870-4.
5. Jazayeri L, Klausner JQ, Chang J. Distal
18. Bekler H, Gokce A, Beyzadeoglu T, et al. The
surgical treatment and outcomes of high-pressure
injection injuries of the hand. J Hand Surg Eur Vol.
2007;32(4):394-9.
19. Schoo MJ, Scott FA, Boswick JA Jr. High-
pressure injection injuries of the hand. J Trauma.
1980;20(3):229-38.

Summary digital replantation. Plast Reconstr Surg. 2013

Although a majority of traumatic
hand injuries can be managed by the
emergency physician, there are several
high-risk presentations that warrant
a prompt hand surgery consultation.
The time from injury to time of
operative management greatly affects
outcomes, particularly in patients
with high-pressure injection wounds,
amputations, clenched-fist injuries,
pyogenic flexor tenosynovitis, and
compartment syndrome. By performing
a careful history and examination, the
emergency physician plays a critical role
in identifying potentially serious trauma
and reducing the incidence of long-term
sequelae.
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nhamcs_emergency/2010_ed_web_tables.pdf.
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to the upper extremity: a review of the literature. J
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6. Sebastin SJ, Chung KC. A systematic review of
the outcomes of replantation of distal digital 21. Rosenwasser MP, Wei DH. High-pressure injection
amputation. Plast Reconstr Surg. 2011;128(3):723-37. injuries to the hand. J Am Acad Orthop Surg.
2014;22(1):38-45.
7. Daniels JM 2nd, Zook EG, Lynch JM. Hand and
wrist injuries: Part II. Emergent evaluation. Am Fam
Physician. 2004;69(8):1949-56.
8. VanGiesen PJ, Seaber AV, Urbaniak JR. Storage
of amputated parts prior to replantation—an
experimental study with rabbit ears. J Hand Surg
Am. 1983;8(1):60-5.
9. Ouellette EA, Kelly R. Compartment syndromes of
the hand. J Bone Joint Surg Am. 1996;78(10):1515-22.
10. Dolan RT, Al Khudairy A, McKenna P, et al. The
upper hand on compartment syndrome. Am J
Emerg Med. 2012;30(9):2084.e7-10.
11. Patzakis MJ, Wilkins J, Bassett RL. Surgical findings
in clenched-fist injuries. Clin Orthop Relat Res.
1987;(220):237-40.
12. Bunzli WF, Wright DH, Hoang AT, et al. Current
management of human bites. Pharmacotherapy.
1998;18(2):227-34.
13. Harrison M. A 4-year review of human bite injuries
presenting to emergency medicine and proposed
evidence-based guidelines. Injury. 2009;40(8):826-
30.  
14. Kelly IP, Cunney RJ, Smyth EG, et al. The
management of human bite injuries of the hand.
Injury. 1996;27(7):481-4.
15. Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls
in the ED: fight bite. Am J Emerg Med. 2002;20(2):
114-7.
16. Pang HN, Teoh LC, Yam AK, et al. Factors affecting
the prognosis of pyogenic flexor tenosynovitis. J
Bone Joint Surg Am. 2007;89(8):1742-8.
17. Dailiana ZH, Rigopoulos N, Varitimidis S, et al.
Purulent flexor tenosynovitis: factors influencing
the functional outcome. J Hand Surg Eur Vol.
2008;33(3):280-5.

Traumatic Injury Special Edition n Spring 2017 8

CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 Which of the following patients is likely to have a

better outcome in reattachment of amputated digits,
assuming all other factors remain the same?
6 Which of the following should be avoided in the
treatment of a high-pressure injection injury?
A. Administering steroids
A. A patient who does not drink alcohol B. Applying ice to the affected hand
B. A patient who is 58 years old C. Elevating the affected limb
C. A patient with amputation from a crush injury D. Parenteral narcotics
D. A patient with amputation of the fifth digit

2 Which of the following signs is most concerning for

compartment syndrome of the hand?
7 How should the amputated body part be cared
for to optimize chances of replantation?
A. Submerge in an ice bath
A. Diffuse erythema of the hand B. Wrap with petroleum gauze and place on ice
B. Hand held in “claw hand” position C. Wrap with saline-moistened gauze and leave at
C. Inability to flex the distal interphalangeal and proximal room temperature
interphalangeal joints when the metacarpophalangeal D. Wrap with saline-moistened gauze, place in a
joint is in flexion water-tight bag, then place the bag in an ice
D. Purple discoloration bath

3 Which microorganism is of least concern in patients

with “fight bite” injuries?
A. Clostridium tetani
8 Which process is unlikely to cause tissue
destruction from a high-pressure injection injury?
A. Chemical toxicity
B. Fusobacterium nucleatum B. Direct impact trauma
C. Hepatitis C virus C. Ischemia
D. Human immunodeficiency virus D. Thermal burn

4 Which of the following is a Kanavel sign for flexor

tenosynovitis?
A. Clenched fist
9 Approximately what percentage of clenched-fist
injuries include damage to deeper structures
such as tendon, joint capsule, and/or bone?
B. Numbness along the flexor sheath A. 5%
C. Pain on passive extension of the finger B. 25%
D. Tense but localized digital swelling C. 75%
D. 95%

5 Which antibiotic is not an appropriate prophylactic

regimen for a fight bite?
A. Amoxicillin-clavulanate
10 Which of the following is a reliable method for
testing the median nerve?
B. Ciprofloxacin and metronidazole A. Ask patient to make an “ok” sign
C. Penicillin and clindamycin B. Ask patient to make a “peace” sign
D. Trimethoprim-sulfamethoxazole C. Examine hand for diminished sensation on the
dorsal surface
D. Palpate the tip of the pinky

Traumatic Injury Special Edition n Spring 2017 9

 Explosive
Situation
Blast Injuries

LESSON 2

By Liudvikas Jagminas, MD, FACEP

Dr. Jagminas is chief of the Department of Emergency Medicine at Beth
Israel Deaconess Hospital-Plymouth in Plymouth, Massachusetts and a
member of Harvard Medical Faculty Physicians.
Reviewed by Joshua S. Broder, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Define the four categories of blast injuries.
2. Discuss the unique aspects and patterns of blast
injuries.
3. Identify the factors affecting morbidity and
mortality in victims of explosions.
4. Describe the optimal treatment options for
management of blast victims.
CRITICAL DECISIONS
n What steps should be taken to prepare for the arrival
of blast victims?
n What are the key components of managing a patient
injured in an explosion?
n How should diagnostic tests be employed when
determining risk of injury in a blast victim?

FROM THE EM MODEL n Which blast injuries are the most critical to consider,

18.1 Trauma and what are their implications?

18.3 Multisystem Trauma n What factors determine which victims can be safely
18.3.1 Blast injury discharged, and which require ongoing monitoring?

April 15, 2013, Patriot’s Day — The annual Boston Marathon began as it had every other year.
Then suddenly at 2:49 pm, two pressure cooker bombs detonated 13 seconds apart near the finish line — forever
changing the celebratory event and shaking our country’s national security. The explosions killed three spectators
and injured 264 others, who were deployed to 27 local hospitals for treatment.

Traumatic Injury Special Edition n Spring 2017 10

 CASE PRESENTATIONS
Your emergency department has just
been notified by EMS of an explosion
on a subway train carrying about 75
passengers. The subway station where
the blast occurred has been secured
and is considered safe. Response teams
have completed initial triage and report
the following injuries: 11 immediate,
37 delayed, 36 minor, and 16 deceased
patients. Numerous injured and
untriaged victims have left the scene
and are presumed to be en route to
your hospital.
■ CASE ONE
As predicted, your first patient
arrives by cab — a 32-year-old woman
who was on the station platform when
the device exploded in the train. Her
vital signs are blood pressure 124/66,
heart rate 102, respiratory rate 20,
and oxygen saturation 96% on room
air. She is complaining of ear pain,
dizziness, and mild shortness of
Until recently, the understanding of blast
wounds has been the exclusive purview
of military physicians; but with the
recent globalization of terrorism, it is
now necessary for emergency physicians
to be cognizant of the spectrum of
injuries and management challenges
these scenarios represent.
Explosions can be physically and
psychologically devastating, and are
capable of inflicting multiple and
catastrophic injuries to a large number
of victims simultaneously — and without
warning. Because of the variety of
factors involved in such an event (eg,
indoor vs. outdoor, size of the explosive
charge, distance of victims from the
explosion, presence of secondary
debris and biological or radiological
contaminants, structural collapse), each
incident is unique.
Although blast injuries can result
from industrial or recreational
accidents, terrorist acts in military and
civilian settings are taking place at an
alarming rate. Bombings, which rose
an estimated 43% worldwide in 2013,
regrettably have become an increasingly
effective and frequent terrorism tool;
breath. Her airway is intact, she is able
to speak, and is breathing spontaneously
with bilateral clear breath sounds with
intact pulses in all four extremities and a
Glasgow Coma Scale (GCS) score of 15.
Intravenous fluids are started, routine lab
tests are ordered, and radiology is called.
Your secondary trauma survey reveals
blood in the external auditory canals
bilaterally; her pupils are equal, round,
and reactive to light. The patient’s chest is
nontender and without crepitus; and her
abdominal examination is normal without
tenderness, rebound, or guarding. Her
neurological, genitourinary, and skeletal
examinations are normal.
■ CASE TWO
EMS arrives with the first immediate
patient, a 56-year-old man found
inside the subway car with a traumatic
amputation of his right leg below the
knee; a tourniquet is in place. His vital
signs are blood pressure 90/60, heart rate
as such, emergency physicians must be
appropriately trained in the management
of these injuries.1
Most blast-related presentations can
be treated in a similar manner to typical
penetrating or blunt traumatic injuries
(as outlined by Advanced Trauma Life
Support [ATLS]); however, wounds
caused by the blast pressure wave itself
cannot. Attributable in part to the
chaotic scene that undoubtedly exists,
poor triage and missed diagnoses are
substantial concerns because wounds
can be subtle or their presentation can be
delayed.
Although it is unnecessary for
medical personnel to possess an
extensive knowledge of bomb design
or explosive compounds, it is critical
to understand the circumstances of the
blast that directly impact the nature
and severity of the expected injuries
(Table 1).2,3 The differences in number,
type, and intensity of injuries produced
are based on factors such as whether
the blast occurred in an open area or a
confined space, the number of potential
victims, and the use or absence of
shrapnel.4-6
Traumatic Injury Special Edition
130, respiratory rate 24, and oxygen
saturation 92% on room air; his GCS
score is 15. A primary survey reveals
an intact airway; he is breathing
spontaneously with bilateral breath
sounds with rhonchi, and is able
to speak. Pulses and sensation are
intact in the patient’s remaining
extremities, but there are multiple
lacerations and contusions to his legs.
Your secondary trauma survey
reveals blood in the patient’s nares
and bilateral external auditory
canals; his pupils are equal, round,
and reactive to light. His chest has
diffuse tenderness without crepitus,
and an abdominal examination
reveals normal bowel sounds with
diffuse tenderness, rebound, and
guarding. The victim’s neurological
and genitourinary examinations are
normal.
Blast Physics
Knowledge of blast-related injury
dates back to the 1914 Balkan Wars,
when three soldiers killed by a military
explosive were observed without any
evidence of external injuries. Franchino
Rusca, a Swiss researcher, went on to
demonstrate that the cause of their
deaths was pulmonary embolism.7 The
term “blast lung” wasn’t coined until
WWII, however, when significant
civilian casualties were found following
bombing raids — all without any
apparent injuries. At autopsy, massive
pulmonary hemorrhage was found from
disruption of the alveolar architecture
and formation of alveolar-venous
fistulas, leading to air embolism and
death.8
Explosives, which are categorized as
either high-order or low-order, cause
the rapid conversion of a solid or liquid
to a gas, resulting in a sudden release of
energy.9,10 High-order explosives, which
produce a supersonic overpressurization
shock wave that expands rapidly
from the detonation point, include
ammonium nitrate (fuel oil), TNT, C-4,
n Spring 2017 11

TABLE 1. Factors Affecting the Severity of Injuries in an Explosive Event20
Magnitude of the blast
Composition of the explosive (eg, presence of shrapnel or other material that can be
propelled; radiological or biological contamination)
Environment of the blast (open space vs. closed space, underwater, urban, existence
of protective barriers)
Distance between the victim and the blast
Structural collapse
Triage accuracy
Availability of medical resources
Triage efficiency
Semtex, nitroglycerin, and dynamite.
Air is rapidly compressed; then, as the
blast wave passes, the air is temporarily
under-pressurized before returning to
the ambient pressure level (Figure 1). 32
These powerful explosives exert
their destruction several different
ways, including fragmentation. This
effect is caused by projectiles, which
can be housed within the bomb
“container,” created by the destruction
of the container itself, or generated by
propelled objects from the surrounding
environment. The extent of these injuries
is directly related to the distance between
the victim and the seat of the explosion;
a person 20 feet away receives 9 times
less force than someone who is 10 feet
from the blast.11
Injury Categories
High-order explosive blast injuries
are categorized as primary, secondary,
tertiary, and quaternary; they can occur
individually or in any combination
(Table 2).12,13
Primary Blast Injury
Primary blast injury (PBI) is caused
by the blast’s direct effect on tissue. Since
air is easily compressible and water is
not, gas-containing organs — especially
or shock from other body injuries.15
Thoracic PBI produces a unique
cardiovascular response, observed
nowhere else in medicine, that is
sufficient to cause death in the absence of
any demonstrable physical injury.
Acute gas embolism (AGE), a form of
pulmonary barotrauma, requires special
attention. Air emboli most commonly
occlude blood vessels in the brain or
spinal cord. Resulting neurological
symptoms must be differentiated from
the direct effect of the incident. Intestinal
barotrauma is most common with
underwater blast injuries. Although the
colon is most commonly affected, any
portion of the gastrointestinal tract can
be damaged.
The ear is the organ most susceptible
to primary blast injury. Acoustic
FIGURE 1. Dynamics of an Explosion32
Peak overpressure
Positive phase
overpressure duration
Pressure
barotrauma commonly consists of
tympanic membrane (TM) rupture;
hemotympanum without perforation
also has been reported. Ossicle fracture
or dislocation may occur with very high-
energy explosions. The long-cherished
belief that an otoscopic examination of
the TM could reliably triage victims for
blast-related lung or bowel injuries has
proved inaccurate. A TM rupture can be
triggered by an increase in atmospheric
pressure as little as 5 psi above normal.
PBI of the brain can be associated
with impaired cerebral vascular function,
including compensatory mechanisms for
traumatic brain injury.
Secondary Blast Injury
Secondary blast injury — the result
of projectiles intentionally included
in the device or propelled during the
explosion — is the most common cause
of death in a blast event. Nails, bolts,
or nuts included in the blast mixture,
military shrapnel, flying glass, and
human parts can cause life-threatening
penetrating injuries.12,16 Secondary is
more common than primary trauma and
represents the leading cause of death in
blast victims, except in the case of major
building collapse.13 The distance over
which these fragments travel is much
greater than the distance of the blast
wave itself; therefore, fragments are
capable of causing injury hundreds of

the lungs, bowel, and middle ear — are Atmospheric pressure

most susceptible to primary wounds,
with pulmonary barotrauma being
the most common fatal injury.14 Other
PBI includes pulmonary contusion,
systemic air embolism, and free radical- Subatmospheric
associated injuries such as thrombosis, pressure phase
lipoxygenation, and disseminated
intravascular coagulation (DIC). Acute
respiratory distress syndrome (ARDS)
Time
can result from direct lung impact

Traumatic Injury Special Edition n Spring 2017 12

yards from the explosion’s epicenter.17
These airborne foreign objects follow
unpredictable paths through the body,
resulting in injuries to the head, neck,
chest, abdomen, and extremities in the
form of penetrating and blunt trauma;
fractures; traumatic amputations; and
soft-tissue injuries.
Secondary trauma often results in
only mild external signs; thus, there
should be a low threshold for imaging
studies in such cases. All wounds should
be considered contaminated and not be
closed primarily.
Tertiary/Quaternary Injuries
Tertiary blast injuries are caused
when the victim’s body is thrown
against another object by the winds
of the explosion. Some victims also
tumble along the ground, resulting in
blunt and penetrating injuries. The
most common tertiary injuries are
fractures and closed head injuries;
others include broken, dislocated, or
even amputated extremities.12-14 The
extent of trauma from this mechanism
also depends on what the victim strikes
in the environment; injuries can range
from simple bruises and abrasions to
impalements.
Quaternary injuries include all
those not due to any of the above
mechanisms and include burns,
inhalation injuries, toxic exposures,
poisoning from carbon monoxide, and
crush injuries. Quaternary trauma also
TABLE 2. Categories of Injuries Associated with Bomb Blasts12,13
Category
Primary injury
Secondary injury
Tertiary injury
Quaternary injury
Crush injury
Closed and open brain injury
Respiratory distress from blast, smoke,
toxic fumes
include exacerbations of chronic medical
conditions such as asthma, obstructive
pulmonary disease, and angina.2,12,14
Morbidity and Mortality
In civilian settings, terrorist attacks
tend to have a bimodal distribution of
mortality — a high number of deaths
followed by low early and late deaths.
The ultimate hospital mortality rate for
initial survivors is an estimated 1.4% for
all victims, and 12.4% for the critically
injured population. Head injury appears
to be the predominant cause of both
early and late deaths. Blast victims, when
compared to nonblast trauma victims,
are more often severely injured (ISS
>25), more frequently require surgical
and intensive care unit (ICU) care, and
require more prolonged hospitalization
and rehabilitation.18,19
CRITICAL DECISION
What steps should be taken to
prepare for the arrival of blast
victims?
It is vital for emergency physicians to
be familiar with their hospital’s disaster
plan and know how to activate it and
secure resources. They should expect
“upside-down” triage, where the most
severely injured arrive after the less
injured, who bypass EMS triage and go
directly to the closest hospitals. A quick
way to estimate the first wave of victims
is to double the first hour’s casualties for
Body Part Affected
Gas-filled structures
Gastrointestinal tract
Ear
Eye
CNS
Any body part
Any body part
Any body part
Traumatic Injury Special Edition
a rough prediction of total injuries.20
If at all possible, obtain and record
details about the nature of the explosion,
potential toxic exposures, environmental
hazards, and casualty location from
police, fire, EMS, health department,
or other reliable news sources. Should
a structural collapse occur, expect
increased severity and a delayed arrival
of patients. Most casualties within the
injury radius of a conventional explosive
detonation or deflagration will present
with common penetrating, blunt, and
burn injuries that are managed no
differently than similar nonblast trauma,
which follows the ATLS algorithm.
Much of this trauma will be soft tissue,
orthopedic, or head injuries.4-6
Large numbers of patients can make
rapid triage impossible and exceed
first responder treatment capabilities,
causing delayed transport to hospitals.
Emergency physicians must be familiar
with the START triage system used
by EMS that divides patients into four
categories:
GREEN — Minor injury (walking
wounded)
YELLOW — Delayed (can wait)
RED — Immediate
BLACK — Deceased
It is important to recognize that any
victim tagged green, yellow, or red can
quickly decompensate during transport
or while awaiting treatment; therefore,
a rapid reassessment is necessary upon
Injury Types
Pulmonary barotrauma
Hemorrhage, perforation
Tympanic membrane rupture and middle
ear damage
Globe rupture
Concussion without physical signs of
external head injury
Penetrating ballistic or blunt injuries
Fracture and traumatic amputation
Closed and open brain injury
Burns of all degrees
n Spring 2017 13
arrival. Faced with a large influx of
patients, expectant management is
appropriate for those unlikely to survive
(eg, patients with 100% body surface
area [BSA] burns and those in cardiac
arrest).21
CRITICAL DECISION
What are the key components of
managing a patient injured in an
explosion?
Arrhythmias (particularly
bradycardia), hypotension, and apnea
are frequently observed after blast injury
to the thorax and have been associated
with primary blast wave effects on the
myocardium and vagal stimulation. A
thorough physical examination should
be performed following standard ATLS
guidelines; the physician should look for
sentinel signs of potentially significant
blast exposure (Table 3).22 Once the
primary and secondary surveys have
been completed, one should acquire
FIGURE 2. Rapid Clinical Assessment of Blast Victims13
No apparent injury present
No
Consider discharge
with abdominal and
pulmonary warnings
an AMPLE history (eg, allergies,
medications, previous medical/surgical
history, last meal time, and events/
environment surrounding the injury).
The following questions also should
be posed to patients during the initial
management any trauma, particularly
explosions:
1. Can you hear me/do you have ear
pain? Tympanic membrane rupture
and temporary hearing loss is
common in blast injury.
2. Are you short of breath/do you get
short of breath with walking? A
pulmonary contusion will inhibit
oxygen diffusion and cause dyspnea.
Pneumothorax and hemothorax can
decrease the volume of inspired air,
with resultant subjective dyspnea.
Shock from a traumatic cause gives
the sensation of dyspnea caused
by lactic acidosis from poor tissue
perfusion.
TM Rupture?
Yes
History:
Symptoms
Deafness
Tinnitus
Earache
Nausea
Retrograde amnesia
Circumstances
Proximity to blast
Closed environment
Entrapment
Crush
Compartment syndrome
Comorbid conditions
Underground/underwater
Yes
Further clinical exam, consideration of x-rays, CT, audiogram, laboratory testing
Normal
3. Do you have pain in your chest?
Chest pain can result from penetra­
ting or blunt trauma; pneumothorax,
pneumomediastinum, or myocardial
ischemia; or infarction due to
coronary AGE.
4. Do you have nausea, abdominal
pain, the urge to defecate, or blood
in your stools? Penetrating or blunt
abdominal trauma can cause pain,
or the patient may have a primary
blast injury to gas-filled abdominal
organs, ruptured colon, or small
bowel.
5. Do you have eye pain or problems
with your vision? Evaluate the
patient for blunt or penetrating eye
trauma.
It is important to keep in mind
causes of early mortality due to blast
injuries (in decreasing order): multiple
trauma, head trauma, thoracic injury,
and abdominal injury.12,14 See Figure 2
for a detailed algorithm for the rapid
assessment of blast victims.
Apparent injuries present
Physical Exam:
Blood in external ear or nose
Cyanosis
Hemoptysis
Cough
Rales
Ronchi
Abdominal tenderness, rigidity,
guarding
6-8 hours of observation,
with O2 monitoring
Abnormal
Admit
Traumatic Injury Special Edition n Spring 2017 14
 TABLE 3. Clinical Signs and Symptoms of Blast-Related Injuries22
System Injury or Condition
Auditory Eardrum hyperemia, hemorrhage, or rupture; deafness, tinnitus, earache
Cardiovascular Tachycardia, bradycardia (can be transient due to blast-induced vasovagal reaction), fall of mean arterial
blood pressure (hemorrhage, AGE, vasovagal reaction), arrhythmia (due to shock or coronary AGE)
Gastrointestinal Nausea, vomiting, abdominal tenderness/rigidity, hematochezia, hematemesis
Neurological Vertigo (usually not due to auditory trauma), coma, altered mental status (due to head trauma, shock, or
cerebral AGE), focal numbness, paresthesia, seizures, retrograde amnesia
Ocular Eye irritation, difficulty focusing, blindness, fundoscopic findings of retinal artery air embolism
Respiratory System Cyanosis, ecchymosis or petechia, hypopharynx, asymmetric breath sounds, cough (often dry), tachypnea
(preceded by a short period of apnea), dyspnea (respiratory difficulty), hemoptysis, rales or moist crepitation
in lung fields, wheezing, chest pain, asymmetric chest movement, subcutaneous emphysema (open wound
or rupture of air-containing internal structure)
Miscellaneous Tongue blanching (may indicate AGE), mottling of non-dependent skin (may indicate AGE or hypotension),
subcutaneous emphysema (open wound), pharyngeal petechiae, abrasions

CRITICAL DECISION
How should diagnostic tests be
employed when determining risk
of injury in a blast victim?
The treatment of blast victims with
major trauma should follow established
ATLS guidelines along with judicious
use of the laboratory or radiology
studies so as not to run tests that are
of little clinical benefit. Most patients
injured by significant explosions
should receive the following tests:
• Complete blood count, including a
platelet count with crossmatching
for potential blood transfusion and
screening for DIC
• Protime
• Activated partial thromboplastin
time (aPTT)
• Thrombin time
• Fibrinogen
• Fibrin split products
• Basic metabolic panel
• If evidence of crush injury,
compartment syndrome, or
severe burns, also screen for
rhabdomyolysis, hyperkalemia, and
myoglobinuric renal failure.
• If the explosion occurred in an
enclosed space or was accompanied
by fire, test for carboxyhemoglobin
(COHb).
• Patients with burns from military
white phosphorous found in military
munitions and hand grenades
are at risk for hypocalcemia and
hyperphosphatemia; follow serial
levels of these ions.
• If there is any evidence of crush
injury, perform urinalysis to check
for myoglobin.
Review for evidence of pulmonary
contusion, pneumothorax, or
barotrauma. The chest x-ray also can
show free air under the diaphragm,
signifying hollow viscus rupture.
Puncture wounds should be presumed
to be due to high-velocity missiles and
examined accordingly. If significant
abdominal pain is present, consider
an immediate abdominal radiographic
series (flat and upright films) or
computed tomography (CT) to detect
pneumoperitoneum from enteric
rupture.
Stable but critically ill patients
can undergo a CT scan before being
transferred to the operating room or
ICU. A scout CT should be performed
to cover the entire body (to look for
shrapnel and undetected fractures) and
be followed by a more definitive CT of
the head and cervical spine, and chest
to pelvis. 23 The focused abdominal
sonography for trauma (FAST)
examination aids in the rapid diagnosis
and prioritization of patients injured
by blunt trauma (including blasts) who
require acute operative intervention.
A positive FAST result in an unstable
patient is an indication for surgical
exploration; in stable patients, it can
facilitate prioritization for CT imaging.
A negative FAST test is unreliable in
the setting of penetrating trauma to the
abdomen, flank, buttocks, or back, or
in patients complaining of abdominal
pain or tenderness, and should be
followed up with a CT scan of the
abdomen and pelvis.
CRITICAL DECISION
Which blast injuries are the most
critical to consider, and what are
their implications?
Pulmonary
Pulmonary blast injury has the
highest mortality of all primary blast
effects (11%); lung tissue is especially
sensitive to barotrauma because of the
extensive tissue-air interfaces involved.
Pulmonary injuries, which include
contusions, pneumothorax, interstitial
emphysema, pneumomediastinum, and
subcutaneous emphysema, increase with
enclosed space events. The most common
lung injury, pulmonary contusion, is
manifested by alveolar hemorrhage
and interstitial edema. Such damage,
which can result in micro-hemorrhages
and perivascular and peribronchial
disruption, may occur as late as 48 hours
after the explosion.
Pulmonary injuries should
be suspected in any patient with
the diagnostic triad of dyspnea,
bradycardia, and hypotension;
wheezing or hemoptysis might also be
evident. Other diagnostic clues include
hypopharyngeal petechiae, hypoxia,
cyanosis, apnea, decreased breath
sounds, and hemodynamic instability.
Chest x-ray evidence of lung trauma
(butterfly pattern) can be seen within
hours of the explosion. Positive-pressure

Traumatic Injury Special Edition n Spring 2017 15

ventilation and positive end-expiratory
pressures should be avoided due to the
risk of pulmonary alveolar rupture and
subsequent formation of air emboli.
Ventilator-associated barotrauma and
systemic air embolism are minimized
by limiting peak inspiratory pressures
(<40 cm H 2 0) through judicious use
of positive-pressure ventilation and
permissive hypercapnia. Extracorporeal
membrane oxygenation has also been
used for severe lung injuries.12
Arterial gas embolism (AGE) is
indicated by sudden blindness, focal
neurological deficit, chest pain, or
sudden loss of consciousness. Physical
examination can reveal retinal arterial
gas bubbles on fundoscopy, mottled
skin, focal neurological deficits, and
dysrhythmias. Such cases require
recompression treatment.
Administer 100% oxygen by tight-
fitting face mask and, if possible, place
patient in the left lateral recumbent
position to minimize the risk of air
embolism. Trendelenburg (head down)
position is no longer recommended.
In the setting of acute mental status,
cerebral AGE should be considered
as well as other causes of symptoms
(eg, central nervous system trauma).
Hyperbaric oxygen treatment is the
definitive procedure for AGE and
cerebral AGE.24 Research suggests
that aspirin is helpful in managing
this complication, and can reduce
inflammation-mediated injury in patients
with pulmonary barotrauma.
Cardiovascular
Cardiovascular hemodynamic
effects caused by blast waves are a less
frequently discussed aspect of primary
blast injury. The heart can be damaged
by contusion from thoracic acceleration
or from air embolization to the coronary
arteries.15 Additionally, the blast wave
can induce other hemodynamic effects,
resulting in direct thoracic injury.
Higher-intensity blasts induce a
more profound bradycardia. The most
common blast-induced arrhythmia, in
addition to bradycardia, is asystole.
Hypotension has been associated with
low cardiac index and stroke volume
in patients with normal systemic
vascular resistance.8 Be aware that
n Standard penetrating and blunt trauma to any body surface is the most
common injury seen among survivors; evaluation and treatment should
follow standard trauma/ACLS guidelines.
n “Blast lung” and “blast abdomen” are associated with high mortality rates.
n Be aware of the many clinical manifestations of air embolism, including
stroke, myocardial infarction, acute abdomen, blindness, deafness, spinal
cord injury, and claudication.
n Do not discount the psychological components of having survived a blast
event. Many victims continue to carry a heavy emotional burden in the form
of post-traumatic stress disorder.
n Always consider the possibility of exposure to inhaled toxins and poisonings
in explosions.
a hemorrhaging explosion-injured mesenteric injury definitively; therefore,
patient might not have the expected symptomatic patients must be observed
compensatory tachycardia and can for 6 to 8 hours and reexamined.26,27 In
become hypotensive without rapid patients who continue to have abdominal
resuscitation. Atropine can be an pain or tenderness, a repeat CT scan
adjunct in patients with blast-induced followed by laparoscopy or DPL is
bradycardia who do not respond to appropriate.24 CT must precede DPL to
resuscitation efforts. prevent the introduction of false-positive
air and fluid.
Gastrointestinal Clinical signs and symptoms of early
Gastrointestinal injuries can cause bowel injury, particularly in children,
hemorrhage, organ perforation and/ can be so subtle as to be easily missed
or lacerations. Blast injury to the in the patient with multiple injuries;
gastrointestinal (GI) tract should be a period of observation and repeat
suspected in any victim with symptoms examination is warranted.28
that include abdominal pain, rebound,
guarding, absent bowel sounds, Central Nervous System
nausea, vomiting, hematemesis, rectal Central nervous system (CNS)
pain, testicular pain, or unexplained injuries can occur even without a direct
hypovolemia.21 The clinical signs of blow to the head. CNS trauma, which
injury might be evident immediately, or can run the gamut from mild to severe,
can be delayed by anywhere from 48 can include concussion, closed or open
hours to 14 days. As in most trauma brain injury, stroke syndrome, spinal
scenerios, FAST ultrasound, plain x-ray, cord injury, and air embolism-induced
CT, and even diagnostic peritoneal injury.
lavage (DPL) are used in managing Mild traumatic brain injury
abdominal blast injury.25 (MTBI) refers to a syndrome caused
Plain films can show penetrating by a seemingly mild brain trauma or a
foreign bodies and free intraperitoneal concussion that usually presents with
air. CT can reveal free air, solid organ minimal or nonobservable symptoms,
injury, hemoperitoneum, retroperitoneal but which can have significant long-
injuries, and mesenteric injury, but the term sequelae. The diagnosis can be
test has poor sensitivity in identifying difficult to confirm since the symptoms
hollow viscus injuries.2 Although CT are nonspecific and similar to many
is specific for solid organ injury and other medical conditions, including
perforation, it lacks the sensitivity post-traumatic stress disorder. Consider
to exclude intestinal contusions and MTBI in patients with the above
Traumatic Injury Special Edition n Spring 2017 16
symptoms and a history of head trauma produce these wounds are associated chloramphenicol, and cephalosporin.
or blast exposure, especially if they have with significant concurrent trauma, and In severely contaminated blast injuries,
amnesia of less than 30 minutes and a the blood loss from disrupted vessels Pseudomonas aeruginosa can be
GCS score above 13.14,29 can result in rapid exsanguination. a problem. Consider giving an IV
Patients with traumatic amputations aminoglycoside or a different drug
Ears and Eyes from a bomb blast have a very high effective against Pseudomonas. Open
Tympanic membrane rupture by
mortality rate and are unlikely to survive fractures, in particular, need coverage
itself does not require specific treatment
long enough to get to the emergency against Gram-positive organisms. A
or hospitalization. Patients should be
department.30 In a lucky few, the penicillinase-resistant penicillin or IV
instructed not to put anything in the
victim is positioned in such a way that cephalosporin is appropriate. Tetanus
affected ear and should be referred to
other body areas are shielded, making is another high-risk complication;
ENT for follow-up care. Remember that
survival possible. Blast amputations administer a tetanus prophylaxis and
neomycin (a component of otic solutions
most often affect the lower extremities.31 consider the need for anti-tetanus
and suspensions) is ototoxic and
The proper use of tourniquets, which immunoglobulin.
theoretically contraindicated in patients
is a key intervention in patients with
with TM perforation. Most cases heal
spontaneously; however, complications
life-threatening hemorrhage, is not CRITICAL DECISION
consistently taught or reinforced in ATLS
such as ossicle disruption, cholesteatoma What factors determine which
or prehospital educational programs
formation, and development of victims can be safely discharged,
perilymphatic fistulae are possible. in the United States, posing a potential
weakness in our trauma preparedness. and which require ongoing
About one-third of these patients suffer
permanent hearing loss. Referral to a monitoring?
Contamination
neurologist and ENT specialist should be There are no definitive guidelines for
Blast wounds are contaminated
considered.48 observation, admission, or discharge;
with bacteria and debris and are
Ocular injuries can be caused by decisions will depend on associated
associated with a high risk of infection.12
flying debris. While the eye represents injuries (Table 3) and the circumstances
Meticulous wound care is essential,
only a tiny amount of total body surface of the blast. Patients who have been
including the removal of nonmetallic
area, these injuries account for 2% exposed to open-space blasts and have
foreign material, excision of nonviable
to 16% of bomb-related wounds.49
tissue, and irrigation with copious no apparent injuries, normal vital signs,
Symptoms of ocular trauma include
amounts of solution (isotonic, if possible) and unremarkable lung and abdominal
foreign body sensation, pain or irritation,
to help remove bacteria and foreign examinations generally can be
change in vision, and periorbital
material. discharged after 4 hours of observation.
swelling.
Gas gangrene by anaerobic They should be instructed to return for
Traumatic Amputation Clostridium is a major threat with blast symptoms of shortness of breath, chest/
Limb amputation is one of the most injuries. Intravenous (IV) penicillin abdominal pain, or vomiting.
dramatic injuries that can occur from helps reduce the risk; alternative Patients exposed to explosions in
a bomb blast. The forces required to antibiotics include erythromycin, water or closed spaces and those with
isolated TM rupture should be observed
for longer periods of time for delayed
complications.
Always admit patients with:
• Significant burns
• Suspected air embolism
• Chemical or radiation exposure
n Assuming that a normal abdominal examination after a blast rules out an
• White phosphorous contamination
intra-abdominal injury. Clinical signs can be initially silent until symptoms of
advanced acute abdomen or sepsis appear. • Abnormal vital signs
• Abnormal lung examination
n Failing to observe a patient who complains of mild shortness of breath who,
findings
on initial examination, has normal oxygen saturation and chest x-ray. Blast
lung is the most common fatal injury among initial survivors and can take • Clinical or radiographic evidence
hours to develop. of pulmonary contusion or
pneumothorax
n Overlooking auditory system injuries and concussions. The symptoms of
mild TBI and post-traumatic stress disorder can be identical. • Abdominal pain or vomiting
• Penetrating injuries to the thorax,
n Failing to treat wounds from blast injury as contaminated; they are at high
risk for infection and must be managed with debridement, delayed primary abdomen, neck, or cranial cavity
closure, antibiotics, and tetanus prophylaxis. • Pregnant women in the second or
third trimester

Traumatic Injury Special Edition n Spring 2017 17

 CASE RESOLUTIONS
■ CASE ONE
The young woman on the
train platform at the time of the
explosion continued to complain
of dizziness, left ear pain, and
persistent mild shortness of breath,
especially when walking. However,
her vital signs normalized,
the laboratory analysis was
unrevealing, and her chest x-ray
was clear without evidence of
free air under the diaphragm or
pneumothorax. Understanding
the delayed presentation of
“blast lung,” she was admitted
for observation and requested an
ENT consultation. Approximately
3 hours later, the patient was
more short of breath, her oxygen
saturation dropped to 92%, and
a repeat chest x-ray revealed the
“batwing” or “butterfly” pattern of
blast lung. Her injury was managed
with judicious fluid use, ensuring
tissue perfusion without volume
overload. Supplemental high-flow
oxygen was provided to prevent
hypoxemia, and she was further
observed for impending airway
compromise, secondary edema,
injury, and massive hemoptysis,
which never occurred. She was
discharged the following day.
■ CASE TWO
The laboratory results for the patient
with the traumatic amputation revealed
a hemoglobin of 8.2, hematocrit of 26, a
chest x-ray with a “butterfly” infiltrate,
and a FAST examination that was positive
for free fluid. He was resuscitated with
crystalloids and transfused with platelets,
3 units of packed red blood cells, and fresh
frozen plasma in a 1:1 ratio. He was sent
for surgery, where a perforated bowel and
splenic laceration were discovered and
repaired; orthopedic surgeons also completed
an above-the-knee amputation. The patient
defied the odds and recovered well after
several weeks in the hospital and many
months of physical therapy.

Pregnant Victims
Direct injury to the fetus is
uncommon due to its protection within
amniotic fluid; however, the blast wave
can cause placental abruption. Spalling
can occur at the interface where
the blast wave and vibrations pass
between tissues of different densities,
causing tissue layers to separate. For
this reason, women in the second
or third trimester should undergo
fetal monitoring and an ultrasound
evaluation to determine the existence
or extent of a placenta abruption. An
empiric immunoglobulin test also is
indicated, and administration of Rh
immunoglobulin might be required.
A positive test requires a mandatory
pelvic ultrasound, fetal non-stress test
monitoring, and obstetrics/gynecology
consultation.14
Children and the Elderly
When children are victims of blast
injury, the history of the event and of
the patient’s complaints can be difficult
to obtain. Pulmonary contusion —
one of the most common pediatric
injuries from blunt thoracic trauma
— may not be apparent initially, but
should be suspected when abrasions,
contusions, or rib fractures are
present.12,14 A chest x-ray is essential in
diagnosis, especially when blast lung
require more ICU resources, have
higher injury severity scores, and have
longer hospital stays than children who
survive traumatic events unrelated to
terrorism. 21
Like children, elderly patients
have an elevated risk of mortality,
and their hospital stays can be longer
and more complicated than those of
other patients.14 Orthopedic injuries
are more prevalent, and blunt chest
trauma is of greater significance.
Furthermore, decontamination methods
sometimes require modification due to
the limited mobility of older patients.
Decontamination of personal medical
equipment (eg, wheelchairs and walkers)
might also be needed.
Summary
As long as the ever-present threat
of terrorism exists, gunpowder and
explosives will be used to “solve”
disagreements between individuals or
nations, and victims of blast injury will
continue to arrive at trauma centers
around the world. Bomb blast injuries
tend to affect air-containing organs, as
the blast wave exerts a shearing force at
air-tissue interfaces.
Three systems are most prone to
injury: the auditory system (damage to
the eardrum in milder cases, and inner-
and occasional perforation of a hollow
viscus); and the respiratory system,
causing barotrauma and “blast lung.”
Expeditious evacuation performed by
EMS personnel results in more victims
arriving at the emergency department
with signs of life. Once there, medical
personnel must perform efficient triage
by separating patients into urgent and
non-urgent groups. During the initial
phase of treatment, only lifesaving
procedures should be performed;
later, medical care can be directed at
patients moved to the ICU. Prompt
evacuation after necessary lifesaving
procedures in the field; proper triage
and distribution; prudent hospital
triage and surgical care; and, last but
not least, expert critical care can help
enable the best possible outcomes in
such circumstances.
REFERENCES
1. Executive Summary: Country Reports on Terrorism
2013. Available at: www.state.gov/j/ct/rls/crt/2013.
Accessed May 16, 2017.
2. Karmy-Jones R, Kissinger D, Golcovsky M, et al.
Bomb-related injuries. Mil Med. 1994;159(7):536-539.
3. Mayorga MA. The pathology of primary blast
overpressure injury. Toxicology. 1997;121(1):17-28.
4. Bombings: Injury Patterns and Care. Available at:
http://www.bt.cdc.gov/masscasualties/bombings_
injurycare.asp. Accessed March 31, 2015.
5. DePalma RG, Burris DG, Champion HR, Hodgson MJ.
Blast Injuries. N Engl J Med. 2005;352(13):1335-1342.
6. Sasser SM, Hunt RC. Clinician Outreach and
Community Activity (COCA) Conference Call. August
3, 2010 Bombings: Injury patterns, context and care.

is suspected. Interestingly, pediatric ear injury in more severe cases); the CDC Training & Continuing Education Online system.
Available at: http://www2a.cdc.gov/TCEOnline/.
victims of terrorism are shown to alimentary tract (contusions, hematoma, Accessed March 31, 2015.

Traumatic Injury Special Edition n Spring 2017 18

7. Irwin RJ, Lerner MR, Bealer JF, et al. Cardiopulmonary
physiology of primary blast injury. J Trauma.
1997;43(4):650-655.
8. Explosions and blast injuries: a primer for physicians.
CDC.gov web site. Available at: http://www.bt.cdc.
gov /masstrauma/explosions.asp. Accessed March
31, 2015.
9. Bailey A, Murray SG. The chemistry and physics
of explosions. In: Bailey A, Murray SG. Explosives,
Propellants, and Pyrotechnics (Land Warfare, Vol 2).
2nd ed. London, UK: Brassey’s UK Ltd; 1989:1-19.
10. Dewey JM. The air velocity in blast waves from T.N.T.
explosions. Proc R Soc Lond A. 1964;279:366e85.
11. Cullis IG. Blast waves and how they interact with
structures. J R Army Med Corps. 2001;147(1):16-26.
12. Katz E, Ofek B, Adler J, et al. Primary blast injury
after a bomb explosion on a civilian bus. Ann Surg.
1989;209(4):484-488.
13. Stewart, C. Blast Injuries: preparing for the inevitable.
Emerg Med Pract. 2006;(8)4:1-28.
14. Lemonick, DM. Bombings and blast injuries: a primer
for physicians. Am J Clin Med. 2011;8(3):134-140.
15. Gutierrez de Ceballos JP, Turégano Fuentes F,
Perez Diaz D, et al. Casualties treated at the closest
hospital in the Madrid, March 11, terrorist bombings.
Crit Care Med. 2005;33(1 Suppl):S107-S112.
16. Aharonson-Daniel L, Waisman Y, Dannon YL, et al.
Epidemiology of terror related versus non-terror-
related traumatic injury in children. Pediatrics.
2003;112(4):e280.
17. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty
survival with emergency tourniquet use to stop limb
bleeding. J Emerg Med. 2011;41(6):590-597.
18. Hiss J, Kahana T. Suicide bombers in Israel. Am J
Forensic Med Pathol. 1998;19(1):63-66.
19. Propper BW, Rasmussen TE, Davidson SB, et al.
Surgical response to multiple casualty incidents
following single explosive events. Ann Surg.
2009;250(2):311-315.
20. Mellor SG. The pathogenesis of blast injury and its
management. Br J Hosp Med. 1988;39(6):536-539.
21. Ohnishi M, Kirkman E, Guy RJ, et al. Reflex nature of
the cardiorespiratory response to primary thoracic
blast injury in the anaesthetized rat. Exp Physiol.
2001;86(3):357-364.
22. Shackford SR, Rogers FB, Osler TM, et al. Focused
abdominal sonogram for trauma: the learning
curve of nonradiologist clinicians in detecting
hemoperitoneum. J Trauma. 1999;46(4):553-562.
23. Taber KH, Warden DL, Hurley RA. Blast-
related traumatic brain injury: what is known? J
Neuropsychiatry Clin Neurosci. 2006;18(2):141-145.
24. Maxson R. Management of pediatric trauma: blast
victims in a mass casualty incident. Clin Pediatr
Emerg Med. 2002;3:256-261.
25. Warden D. Military TBI during the Iraq and
Afghanistan wars. J Head Trauma Rehabil.
2006;21(5):398-402.
26. Jones E, Fear NT, Wessely S. Shell shock and mild
traumatic brain injury: a historical review. Am J
Psychiatry. 2007;164(11):1641-1645.
27. Hoffer ME, Balaban C, Gottshall K, et al. Blast
exposure: vestibular consequences and associated
characteristics. Otol Neurotol. 2010;31(2):232-236.
28. Mines M, Thach A, Mallonee S, et al. Ocular injuries
sustained by survivors of the Oklahoma City
bombing. Ophthalmology. 2000;107(5):837-843.
29. Wolf DG, Polacheck I, Block C, et al. High rate of
candidemia in patients sustaining injuries at a bomb
blast at a marketplace: a possible environmental
source. Clin Infect Dis. 2000;31(3):712-716.
30. Hirshberg B, Oppenheim-Eden A, Pizov R, et al.
Recovery from blast lung injury: one-year follow-up.
Chest. 1999;116(6):1683-1688.
31. Aharonson-Daniel L, Klein Y, Peleg K; ITG. Suicide
bombers form a new injury profile. Ann Surg.
2006;244(6):1018-1023.
32. Friedlander FG. The diffraction of sound pulses. I.
Diffraction by a semi-infinite plane. Proc R Soc Lond
A 1946; 186: 322e44.

Traumatic Injury Special Edition n Spring 2017 19

CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
Which factor impacts the resulting injuries following a
blast?
A. General physical health and comorbidities of the
6 Which category encompasses injuries caused by burns,
crush trauma, smoke inhalation, and exposure to toxic
fumes?
patient A. Primary blast injury
B. Orientation of the victim to the blast and whether it B. Quaternary blast injury
was in an enclosed or open space C. Secondary blast injury
C. The amount and type of clothing worn by the victim D. Tertiary blast injury
D. Whether the victim was standing or seated

2 Primary blast injuries primarily affect which organ

system(s)?
7 A patient suffering from “blast lung” caused by a
primary blast injury might exhibit which symptom?
A. Concomitant injury to visceral structures (eg, the liver)
A. Brain and central nervous system B. High peak inspiratory pressure requirements when
B. Eyes ventilated
C. Lung, ear, and hollow viscus C. Normal oxygen saturation and no respiratory
D. Musculoskeletal system symptoms
D. Pulmonary “butterfly” pattern on chest x-ray

3 Which of the following can cause secondary blast

injuries?
A. Flying debris and bomb fragments
B. High explosives only
C. Inhaled gases or toxins secondarily produced by the
chemical reaction of the explosion
D. Movement of the victim’s body by the blast wave
8 Ringing in the ears can be a symptom of which injury?
A. Air gas embolus to the brain
B. Barotrauma and possible disruption of the ossicles
C. Concussion from the blast wave
D. Post-traumatic stress disorder

4 Which organ is most sensitive to the effects of an

explosion blast wave?
9 Which treatment is appropriate for a blast-injury victim
who develops sudden blindness, a focal neurological
deficit, and chest pain?
A. Ear A. Intubate and place on a ventilator
B. Eye B. Order a CT scan of the head
C. Large intestine C. Shield the patient’s eyes and schedule an
D. Liver ophthalmology consultation
D. Treat with 100% oxygen and place in the left lateral

5 Which category includes trauma caused by a victim’s

body being thrown against another object by blast
decubitus position

winds?
A. Primary blast injury
B. Quaternary blast injury
10 A pregnant patient in her second trimester was in close
proximity to a blast, but has no apparent abdominal
complaints. Which is a reasonable first step in her
C. Secondary blast injury management?
D. Tertiary blast injury A. Discharge home with obstetrical follow up within
24 hours
B. Initiate fetal monitoring and an ultrasound
examination
C. Observe in the emergency department for 4-6 hours
D. Provide a sterile speculum examination; if normal,
discharge home with obstetrical follow up within
24 hours

Traumatic Injury Special Edition n Spring 2017 20


OBJECTIVES
On completion of this lesson, you should be able to:
1. Describe the physical examination findings that
should raise concern for concussion.
2. Identify the most common complications of acute
concussion and second impact syndrome.
3. Explain the options for treating concussion in the
emergency department.
4. Explain the underlying pathophysiology of
concussion.
5. Detail when and how patients can be cleared to
resume physical activities following head injury.
FROM THE EM MODEL
18.0 Traumatic Disorders
18.1.6 Head Trauma
Defined by a complex constellation of physical, cognitive, and emotional symptoms, concussion is among the
most common injuries seen in the emergency department. Although it falls on the mild end of the traumatic
brain injury (TBI) continuum, this seemingly benign diagnosis can have life-altering — even deadly — consequences
if not properly identified and managed.1,2
Head Games
Traumatic Brain
Injury – Concussion
LESSON 3
By Rachel R. Bengtzen, MD; Melissa A. Novak, DO;
and James C. Chesnutt, MD
Dr. Bengtzen is an assistant professor in the Departments of Emergency
Medicine, Family Medicine, and Sports Medicine, and an assistant program
director of the Emergency Medicine Residency; Dr. Novak is an assistant
professor in the Departments of Family Medicine and Sports Medicine; and
Dr. Chesnutt is a clinical associate professor and the associate fellowship
director of the Primary Care Sports Medicine Fellowship in the Departments
of Orthopedics and Rehabilitation and Family Medicine at Oregon Health
& Science University in Portland.
Reviewed by Daniel A. Handel, MD, MPH, FACEP
CRITICAL DECISIONS
n What is a concussion, and what presentations should
raise suspicion for this diagnosis?
n What role does the pathophysiology of concussion
play in patient management?
n What diagnostic tools are most valuable for the
evaluation of concussion?
n What are the best options for treating acute
concussion in the emergency department?
n How should prolonged symptoms be managed?
n What critical information should be included in a
concussive patient’s discharge instructions, and how
should return to play be approached?
Traumatic Injury Special Edition n Spring 2017 21
 CASE PRESENTATIONS
■ CASE ONE
A 17-year-old athlete “got her bell
rung” by taking an elbow to the head
during a soccer match; she presents to
the emergency department at her coach’s
insistence. The patient denies loss of
consciousness, but reports experiencing
pain, dizziness, and a “dazed” feeling
before being removed from the field. Her
symptoms (which lasted less than 10
minutes) now have resolved completely,
and she insists being “back to normal.”
Her vital signs are normal; she
appears alert and shows no signs of
head trauma. The patient’s trauma
and neurologic examinations are
unremarkable (eg, mental status, cranial
nerves, cerebellar signs, motor and
sensory testing, reflexes, and gait). Her
Glasgow Coma Scale (GCS) score is
Because no single test or biomarker
currently is capable of confirming
concussion, physicians must rely solely
on clinical judgement and patient history
when managing such cases. These
diagnostic pressures may be further
compounded when providers feel rushed
to determine the presence or absence of
injury to clear an athlete for return to play.
There is a growing body of research
to suggest concussions may last longer,
occur more often, and pose a greater risk
of long-term sequelae than previously
recognized. In response, diagnostic
definitions and guidelines continue to
evolve as more becomes understood
about the complex metabolic crisis
brewing below the brain’s surface.
CRITICAL DECISION
What is a concussion, and what
presentations should raise
suspicion for this diagnosis?
The diagnosis and evaluation of
concussion can be complicated by the
ambiguous nature of its symptoms. A
patient may present with an isolated
head injury, multiple traumatic injuries,
or a constellation of post-concussive
symptoms manifesting after the initial
normal. The girl and her father are
eager for her to be discharged so she
can return to play out the rest of the
game, which is being attended by
college scouts.
■ CASE TWO
A 54-year-old woman returns
to the emergency department with
a headache, nausea, and difficulty
concentrating 9 days after being
involved in a motor vehicle collision
in which she was the restrained
driver. She was traveling 45 miles per
hour when she hit an oncoming car
head on; the airbags deployed, and
she did not lose consciousness.
Her previous evaluation included
computed tomography (CT) scans
of the head and neck, which were
negative; and a radiograph of her
trauma. Concussion, as defined in
a recently published evidence-based
systematic literature review, is:
1. A change in brain function;
2. Following a force to the head (a
potentially concussive event);
3. May (or may not) be accompanied by
temporary loss of consciousness;
4. Identified in awake individuals; and
5. Includes measures of neurologic and
cognitive dysfunction.3
The injury can result from acceleration
or deceleration with or without an actual
impact to the head. Loss of consciousness
occurs in less than 10% of patients, but is
found in about 40% of those who present
to the emergency department.4
The systematic review also identified a
set of “consistent and prevalent diagnostic
indicators,” including:
1. Observed and documented
disorientation or confusion
immediately after the event;
2. Impaired balance within 1 day after
injury;
3. Slower reaction time within 2 days
after injury; and /or
4. Impaired verbal learning and memory
within 2 days after injury.
Symptoms of concussion generally
Traumatic Injury Special Edition
forearm, which showed no signs
of fracture or dislocation. She
was placed in a wrist brace and
instructed to follow up with a
primary care provider. Since then,
she says she has struggled with
work and reports sleeping longer
than usual. She complains of
continued headaches, photophobia,
phonophobia, and neck pain.
Her vital signs are normal. A
trauma examination reveals left
wrist bruising and paraspinal
cervical neck tenderness to
palpation, but no midline pain with
range of motion. The GCS score and
neurologic examination are normal,
including assessments of mental
status, cranial nerves, cerebellar
signs, motor and sensory testing,
reflexes, and gait.
are divided into four main categories:
physical, cognitive/thinking, emotional/
mood, and sleep. The most frequent signs
are headache (75%), dizziness (60%),
blurred vision (75%), nausea (54%),
double vision (11%), noise sensitivity
(4%), and light sensitivity (4%).3
Symptoms are variable for each individual
and can become more prominent with
an increased cognitive or physical load,
especially with return to school or work.
Patients with suspected concussion
can be assessed with the symptom log in
the Sport Concussion Assessment Tool
(SCAT3), which is available online and
can be incorporated into an electronic
medical record flowsheet for use in the
emergency department.5
Risk Factors
Certain risk factors may increase
a patient’s susceptibility to injury or
complicate recovery. A prior history of
head trauma increases the likelihood of
subsequent injury. Concussions clustered
together within a short period of time
or sustained before the full resolution
of a prior injury may alter a patient’s
prognosis significantly.
Younger athletes, who are at an
increased risk of injury, may experience
n Spring 2017 22
longer recovery times than adults, as
are female patients and those with
learning disabilities or ADHD.1,6 Those
who suffer from migraines are more
susceptible to concussion-associated
headaches.
Approximately 1 in 220 pediatric
patients seen in the emergency
department is diagnosed with a
concussion; 30% to 50% of these cases
are sports-related.6 American football
is the leading culprit of sports-related
concussion in the US, followed by
soccer, which is the number-one cause
of concussion in female high school
athletes. Interestingly, female soccer
players are approximately 1.8 times more
likely to sustain a concussion than their
male counterparts.7 The reason for this
variation is unknown; however, studies
point to possible gender differences in
cervical muscle strength and hormone
variations.
Despite significant advancements
in helmet technology, helmeted sports
continue to result in the greatest number
of concussions. Beyond football, the
most common culprits of sports-related
concussion are (in order of frequency),
hockey, girls’ soccer, wrestling, boys’
soccer, girls’ basketball, boys’ basketball,
and girls’ softball. Lacrosse also is a
high-risk sport, but often is excluded
from study data.7
Bicycle- and playground-related
injuries each account for about 10%
of recreational- and sports-related
head trauma — more than any specific
organized sport. The most common
non-sports injuries involve falls (38.5%),
vehicles (31.3%), and intentional injury
(11.4%).4,8
Second Impact Syndrome
Concussions also appear to make
patients vulnerable to second impact
syndrome, which occurs when a patient
sustains additional head trauma before
recovering from the initial injury or
concussion. Secondary injuries also may
increase the risk of malignant cerebral
edema and herniation, in which the
mortality rate would approach 100%.6
However, this theory is widely contested
and lacks systematic evidence.
Multiple concussions or a high level
of subconcussive blows can contribute
to significant changes in the brain and
potentially lead to chronic traumatic
encephalopathy (CTE), which has effects
similar to other neurodegenerative
disorders such as Alzheimer and
Parkinson diseases.9
CRITICAL DECISION
What role does the
pathophysiology of concussion
play in patient management?
Concussion represents a functional
metabolic crisis in the brain, rather than
a structural injury.6 These forces result in
shearing of axons — a stretch that spurs
a pathologic release of neurotransmitters
that can trigger short- or long-term
functional disturbances in the brain.
The symptoms of head injury result
from derangements in the subsequent
neurometabolic cascade.10 This
disruption of neuronal cell membranes
leads to fluctuations in ion levels,
including an efflux of potassium and
glutamate release; in turn, the ion
gradient is altered across the membrane.2
In an attempt to restore ionic balance
and normalize membrane gradients,
sodium-potassium ion pump activity is
enhanced, resulting in a greater demand
for energy in the form of adenosine
triphosphate (ATP).
Regional changes in cerebral
blood flow, however, fail to match
this increased need — a mismatch
between energy needs and the delivery
of glucose that can exacerbate the
metabolic crisis. The increased cellular
ATP metabolism leads to a relative
energy deficit and resultant intracellular
calcium accumulation, mitochondrial
dysfunction, free radical production,
impaired glucose metabolism,
cytoskeletal injury, abnormal
axonal transport, and alterations in
neurotransmission.1,2
These physiological perturbations
correlate with concussion symptoms
and a period of further metabolic
vulnerability. In time, however,
ionic balance is restored and neuron
metabolism and blood flow normalize.2
Metabolic derangements long have
been thought to resolve in 1 to 2
weeks; however, magnetic resonance
spectroscopy and neuropsychological
Traumatic Injury Special Edition
assessments suggest a longer road to
recovery (up to 45 days).
Additionally, young developing
brains may be even slower to heal; and
children are at increased risk for long-
term functional impairments — factors
attributed to immature myelination,
brain/water volume, and neuronal
plasticity.2
CRITICAL DECISION
What diagnostic tools are most
valuable for the evaluation of
concussion?
Historically, the ability of emergency
medicine providers to accurately diagnose
concussion has varied widely.11,12 In recent
years, however, significant efforts have
been made to elucidate clinicians and
standardize the assessment and treatment
of brain injuries, particularly in young
athletes, who frequently are encouraged
to return to play prematurely.
Furthermore, previous grading systems
for diagnosing concussion, which focused
on the timing of symptoms and presence
of loss of consciousness, have been
outmoded in light of evidence that even
“mild” concussions can cause significant
problems.1,10
Trauma and Neurologic
Examinations
The initial stages of concussion
assessment should focus on ruling
out more serious problems such as
intracranial hemorrhage (ICH) or cervical
spine injury. Depending on a patient’s
presentation, the examination may
start with a typical trauma assessment,
including a primary survey (with GCS)
and a secondary survey to rule out signs
of head trauma, neck injury, or gross
neurologic deficits. A trauma survey may
be unwarranted unless other injuries are
noted or a patient presents at the time of
acute head injury.
The next step in neurologic screening
includes assessments of the cranial nerves,
reflexes, balance, sensation, motor
strength, and coordination (including
gait). If a structural brain injury (eg,
ICH) is not suspected and the clinical
evaluation suggests a concussion, there
are a number of assessment tools that
can be used in conjunction with medical
n Spring 2017 23
judgment to confirm the diagnosis. No
single test can be used in isolation to
diagnose concussion or medically clear an
athlete for return to play.
Clinicians should remember that
symptom scores, physical examinations
with sideline concussion tests, and
neuropsychological assessments describe
and measure cognitive, physical, and
neurobehavioral changes associated
with an injury; however, they cannot
confirm or rule out the presence of
a concussion. Additionally, due to
the pathophysiological nature of the
diagnosis, symptoms and deficits on
testing can evolve in the hours and days
following injury. Because of this, the
diagnosis may remain uncertain during
the acute phase.
Concussion Examinations
Among the most commonly used
concussion assessment tools is the SCAT3.
Developed in 2012 by the Concussion
in Sport Group,1 the guidelines feature a
symptom scale and physical examination
protocol that can be used on the sidelines,
in the emergency department, or in
outpatient follow up to assess and track
the symptoms of athletes 13 years and
above. (A Child-SCAT3 is available for
younger patients.)13
The SCAT3 physical examination
goes beyond the standard neurologic
evaluation to evaluate cognition,
motor control, balance, immediate
memory, concentration, and delayed
recall (including Maddocks questions
and the Standardized Assessment of
TABLE 1. Canadian CT Head Rule
A minor head injury is defined as a witnessed loss of consciousness, definite
amnesia, or witnessed disorientation in a patient with a GCS score of 13 to 15.17-19
A minor head injury is indicated by any one of the following symptoms.
High Risk (for neurological intervention)
GCS score <15 at 2 hours after injury
Suspected open or depressed skull
fracture
Any sign of basal skull fracture (eg,
haemotympanum, “raccoon” eyes,
cerebrospinal fluid otorrhoea/rhinorrhea,
Battle sign)
Vomiting (two episodes)
Age >65 years
Concussion).14 A balance test (modified
balance error scoring system) is used
to assess static postural stability with
a sensitivity of 34% to 60%. Newer,
more sensitive (about 80%) balance tests
incorporate wearable wireless inertial
sensors to digitally record and compare a
patient’s balance to normative values.15
Oculomotor Testing
Vestibular and oculomotor deficits,
including nystagmus, saccades,
trochlear nerve palsy, convergence, and
anisocoria all have been documented
after concussion. Visual function testing
can be a sensitive means for assessing
minor head injury, and may aid in the
diagnosis of concussion. Although there
is no rapid clinical tool specifically
designed to evaluate for these deficits, the
King-Devick Test shows promise with its
ability to assess saccadic eye movements
by measuring a patient’s speed and
accuracy while reading aloud a series of
numbers on test cards.16
Computer-Based
Neuropsychologic Testing
It has become increasingly common
for athletes to undergo computerized
assessments when asymptomatic to
obtain data about their baseline levels
of neurocognitive functioning. These
tools, including the ImPACT test, can
help clinicians track a patient’s progress
following concussion and guide decisions
about return to play by comparing pre-
and post-injury scores.
Medium Risk (for brain injury on CT)
Amnesia before impact >30 min
Dangerous mechanism (pedestrian struck by
motor vehicle, occupant ejected from motor
vehicle, fall from height >3 feet or five stairs)
Traumatic Injury Special Edition
Neuroimaging
Because concussions are due to
functional rather than structural
brain injuries, clinically available
neuroimaging with CT and MRI is
non-diagnostic and not recommended.
Furthermore, CT poses a measureable
risk of radiation exposure, and may be
an impractical use of resources in such
cases.
Diagnostic imaging should be
considered, however, when structural
injuries (eg, intracranial hemorrhage) are
suspected. It also is indicated for patients
older than 60 years or those taking
anticoagulants, and in cases of multiple
or severe traumatic injuries, possible
skull fracture, or dangerous mechanism.
The Canadian CT Head Rule
(Table 1) has 100% sensitivity for
injuries requiring neurosurgical
intervention, and is more specific than
the New Orleans Criteria.17,18 It remains
the most accurate and cost-effective
decision instrument for safely reducing
unnecessary neuroimaging in cases
of minor head trauma (defined as a
witnessed loss of consciousness, definite
amnesia, or witnessed disorientation
in a patient with a GCS score of 13
to 15).19 This rule does not apply to
patients with GCS scores below 13,
those taking blood thinners, or children
younger than 16 (additional criteria are
available for pediatric patients).17,19
CRITICAL DECISION
What are the best options for
treating acute concussion in the
emergency department?
Return-to-Play Restrictions
Since 2014, all 50 states and the
District of Columbia have enforced
concussion laws to protect youth
athletes. 20 The first such regulation to
be developed was Washington State’s
Zackery Lystedt Law, named for a
middle school athlete who prematurely
— and catastrophically — returned to
play after suffering a seemingly minor
head injury during a football game.
The boy’s near-fatal case inspired a
2009 law mandating that any athlete
who has sustained a suspected head
injury (including concussion) must be
n Spring 2017 24
removed from play, and may only return
after receiving written clearance from a
licensed health care provider. 21
Some states, including Oregon, also
require yearly concussion education for
coaches and espouse the motto, “when in
doubt, stay out,” emphasizing the elusive
nature of head injury symptoms (which
may take hours or days to evolve) and
the potentially devastating consequences
of an overlooked diagnosis.22
For patients participating in exercise
or sports, a gradual return-to-play
protocol is indicated once symptoms
have resolved. However, even athletes
with short-lived complaints exhibit
deficits on formal neuropsychological
testing several days after reporting
symptom resolution. This finding
suggests that the absence of symptoms
may be a poor indicator of full
recovery.23
Although between 80% and 90% of
athletes will report symptom resolution
within 7 days of injury, neuropsychologic
and functional deficits (ie, balance and
eye tracking) may still be present, and
symptoms often return with exertion.24
Cognitive and Physical Rest
In the past 10 years, concussion
recommendations have appeared at
opposite ends of the spectrum —
some allowing same-day return to
play if symptoms resolve in less than
15 minutes, while others suggesting
confinement in a dark room for several
days of complete rest (ie, “cocoon”
therapy). Current guidelines are not
nearly as extreme; however, they caution
against relative overexertion, which can
worsen symptoms and prolong recovery
times. Importantly, a repeat head injury
prior to the resolution of a previous
concussion can lead to severe or long-
term neuropsychologic consequences,
including learning and memory
problems, depression, and even death.
The mainstay of acute concussion
management is physical and cognitive
rest in the 24 to 48-hour symptomatic
period after injury.1,2,6 Following
the acute phase, patients may begin
a gradual return to academic and
social activities at a pace that doesn’t
exacerbate symptoms.1 An early
transition back to school and noncontact
TABLE 2. Gradual Return-to-Play Protocol1
Step 1. No same-day return to play; physical and cognitive rest. Objective is recovery.
Step 2. Light aerobic exercise (eg, walking, swimming or stationary cycling), while
keeping intensity <70% maximum heart rate. Objective is to increase heart rate.*
Step 3. Sport-specific exercise (eg, skating drills in ice hockey, running drills in soccer);
no head impact activities. Objective is to add some movement.
Step 4. Non-contact training → progressing to more complex drills (eg, passing in
football and ice hockey) → progressing to resistance training. Objective is to gradually
add exercise, coordination, and cognitive load.*
Step 5. Full-contact practice (following medical clearance, participates in normal
training activities). Objective is to restore confidence and allow coaching staff to assess
functional skills.
Step 6. Return to gameplay.
Patient must be symptom-free for 24 hours before progressing to the next step. Emergency providers
should direct patients to follow up with a concussion specialist or primary care physician prior to
advancing to Steps 2 and 5.
*Patients should consider seeing a primary care provider or concussion specialist prior to advancing
to the next step in the protocol.
physical activity appears to benefit Medications
recovery, although further research is In the acute setting, medications
needed to gauge the safety and efficacy for concussion management should
of active rehabilitation in the acute post- be limited and carefully considered.
injury period.1,25 Agents that can alter mental status
For asymptomatic pediatric (eg, benzodiazepines and narcotics)
patients, many clinicians recommend generally should be avoided; therapy
a longer period of relative rest before should be aimed at specific symptom
resuming activities (eg, 2 weeks at control, with a focus on minimizing risk.
Step 1, according to the protocol in Acetaminophen, for example, may be
Table 2). However, there is a paucity the first-line treatment for headache, the
of evidence about the value of rest and most common symptom of concussion
the optimal amount and type required. (occurring acutely in more than 90%
When compared to usual care (ie, of patients). No controlled trials have
demonstrated increased bleeding
recommendations at the physician’s
with post-injury anticoagulation with
discretion), strict rest for 5 days appears
NSAIDs; however, due to its theoretical
to provide no added benefit in adolescent
risk, patients often are counseled to
patients, and may — in fact — increase
avoid the drug in the 24 to 48 hours
psychosocial symptoms.6,25-26
following injury.28
Sleep Hygiene Narcotics also should be avoided
Approximately half of concussion in concussive patients. The side effect
profiles of these drugs often overlap
patients will experience some sleep
symptoms of the diagnosis and can
dysfunction, including persistent
magnify fogginess, nausea, and
sleepiness, even with adequate rest;
confusion; they also are commonly
latency in sleep initiation; and frequent
associated with rebound headaches.
waking.27 In the acute setting, these
Alternative treatments for pain include
issues can be treated conservatively with
environmental modifications such as the
sleep hygiene techniques and behavioral reduction of stimulation (eg, avoidance
modifications such as establishing of loud and bright places), and physical
regular bedtime and wake time routines, modalities such as massage and the
allowing more time for sleep, and application of ice.
avoiding naps. Sleep aids are reserved for A concomitant migraine induced
persistent sleep disturbances, and should by a traumatic head injury may be
be managed by a clinician who can alleviated by abortive treatments for
provide close follow up. overlying migraine components in
Traumatic Injury Special Edition n Spring 2017 25

n Remind patients and their families to limit screen time, rest from vigorous
activity, and avoid drugs and alcohol.
n Cognitive and physical rest should involve a decrease in stimulation. It does
not, however, mean that a patient should lie all day in a dark room.
n Expect a concussed patient to have difficulty remembering the emergency
department encounter, including the diagnosis and treatment plan.
Whenever possible, this information also should be shared with family
members and/or coaches, and provided in a written form for later
reference.
the acute setting.24 The vast majority
of headaches resolve spontaneously;
however, patients should be encouraged
to discuss additional treatments with an
outpatient physician if their pain persists
or returns.28
CRITICAL DECISION
How should prolonged
symptoms be managed?
A solid awareness of long-term
concussion treatments can help clinicians
counsel patients and set expectations,
despite the fact that these therapies are
unlikely to be initiated in the emergency
department. The majority of concussion
symptoms resolve within 7 to 10 days
(perhaps longer in younger children);
however, they may persist for months —
possibly even years — in a small portion
of patients.6
During outpatient follow up, some
patients benefit from shortened work/
school days, rest breaks, extended
assignment deadlines, and restrictions on
exercise or physically demanding work
environments.6 For the minority whose
concussion symptoms linger, there are a
number of interdisciplinary rehabilitation
protocols may aid in recovery.30
While there is no clear data on
the best time to initiate the following
therapies, current guidelines endorse
starting individual treatment plans for
persistent symptoms approximately 3 to
4 weeks post-injury.
• Physical therapy: Vestibular/
balance therapy, gaze stabilization,
neck rehabilitation, and exercise
prescription
• Occupational therapy: Concentrates
on visual and functional therapy
• Speech therapy: Directed at
cognitive and executive function,
memory, speed of processing,
attention, planning, problem solving,
organization, social cognition, and
school interventions
• Neuropsychology: Cognitive
testing to determine brain function,
assessment to determine other mental
illness (eg, anxiety, depression,
ADHD)
• Psychology: Cognitive behavioral
therapy; cognitive restructuring;
biofeedback; and strategies to address
emotional and psychological effects to
improve coping skills, resiliency, and
function
The pharmaceutical management
of protracted symptoms can include
different medications than those initiated
in the emergency department, where
patient monitoring often is limited.
Headache and sleep derangements can
be treated with tricyclic antidepressants,
beta-blockers, topiramate, or triptans.
Longtime treatment with NSAIDs
or acetaminophen may cause rebound
headaches that can be relieved with
ceasing daily use of the medication.
Narcotics also should be avoided for
the treatment of headaches; these agents
typically worsen symptoms of concussion
such as fatigue, memory loss, and mental
fogginess. Dizziness and disequilibrium
may be treated with meclizine,
scopolamine, and dimenhydrinate.
Melatonin and diphenhydramine
commonly are recommended as first-
Traumatic Injury Special Edition
line treatments for sleep disturbances,
in the event that sleep hygiene
recommendations fail; amitriptyline
or trazodone also may be considered.
Concussive patients commonly
experience increased irritability,
depression, anxiety, post-traumatic
stress disorder, personality changes,
and apathy. Selective serotonin reuptake
inhibitors (SSRIs) have become the
primary treatment for TBI-associated
depression because of their perceived
clinical efficacy and relatively few side
effects.28
CRITICAL DECISIONS
What critical information should
be included in a concussive
patient’s discharge instructions,
and how should return to play be
approached?
Diagnosis
When appropriate, patients should
receive an explicit diagnosis of
concussion. If the diagnosis is uncertain
at the time of discharge, providing a
list of closed head injury and “at-risk”
concussion precautions can trigger earlier
follow up for patients who become aware
of concussive symptoms after they’ve left
the emergency department.
Treatment
Patients should be advised to adhere
to the following guidelines in the days
following discharge.
Cognitive rest
• Consider taking a day or two off from
school/work to maximize rest acutely;
return gradually to prevent worsening
symptoms (eg, work partial days).
• Avoid screen time by limiting the use
of televisions, computers, cell phones/
texting, and video games.
• Avoid areas of significant visual/
auditory stimulation (eg, movie
theaters, sports arenas)
• As you feel better, introduce these
activities back into your everyday
routine at a level that doesn’t worsen
symptoms or cause them to return.
Physical rest
• Avoid sports, physical education
classes, and recreational activities (eg,
n Spring 2017 26
 riding skateboards or playing pickup
games in the park).
• As you begin to feel better, light
aerobic exercise can be helpful in
recovery (eg, walking for 10 to 20
minutes).
• Before you return to sports or
exercise, follow up with a primary
care physician or concussion specialist
to develop a gradual, stepwise return-
to-play protocol.
Reintroduction of Exercise
Information about return to play can
temper expectations and help patients
avoid resuming physical activity too
quickly. The 2012 Zurich consensus
statement recommends no same-day
return to play and an initial period of
rest, followed by six-step return protocol
that can be followed once the concussion
symptoms have abated (Table 1).
If symptoms return at any point,
the athlete should regress to the last
step in which they were asymptomatic.
Theoretically, the gradual reintroduction
of metabolic demand on the brain may
help patients identify the return of
symptoms and discourage maximum
exertion, thereby reducing the risk of
repeat head injuries. Additionally, early
intervention seems to impact recovery,
as adolescents who rest for several days
before resuming a modified schedule
appear to recover faster.25
Return to Driving
Safe driving is a complicated endeavor
under any circumstances. In concussed
patients, attention and reaction time
can be impaired and worsen in the
few days following injury. In addition,
n Allowing an asymptomatic athlete with a concussion to return to play the
same day, or without a graduated return-to-play protocol.
n Recommending “cocoon therapy,” or advising an athlete to refrain from
play for any set period of time.
n Failing to provide concussion activity restrictions to a patient with a non-
sports-related head injury.
n Neglecting to educate patients and their family members about
concerning symptoms that may develop 48 to 72 hours after a head injury.
common concussion symptoms include
dizziness and blurred vision, which can
significantly impact safety. Despite these
overt risks, 52% of patients report no
intention of altering their driving habits
following a traumatic head injury.29
There is evidence to support driving
restrictions in the 24-hour period
following injury; however, there is
limited research to support any specific
timeframe or measurement of fitness.
This clearance is best made in a
follow-up visit to assess balance, vision,
and cognitive function. In general, any
patient with a diagnosed concussion
should avoid driving acutely, and be
warned that the ability to do so safely
may be diminished.
Sleep
Sleep is therapeutic and constitutes
a treatment for concussion. If level of
consciousness and neurologic serial
examinations are warranted, the
patient should undergo head imaging
and/or observation in a hospital
setting. Previous advice to periodically
wake patients from sleep is no longer
recommended; after discharge, a patient
may sleep without interruption.30 Return
precautions should include a sudden
change in mental status, severe headache,
vomiting two or more times, and seizure
activity.
Precautions
Patients with closed head injuries
should be advised to return to the
emergency department for neurologic
changes indicative of intracranial
bleeding. Additionally, patients with
Traumatic Injury Special Edition
head trauma or acceleration-deceleration
injuries who may have sustained upper-
extremity or neck injuries may be at risk
for concussion, even in the absence of
acute concussion symptoms. Patients and
their families should be educated about
the potential for delayed signs, advised
about what to watch for, and directed to
seek primary care follow up in the event
they occur.
Concussion Precautions
Patients and their families should be
advised to watch for the following signs
after discharge and, if indicated, seek
advice from a provider who cares for
patients with concussions.
Physical
• Dizziness, headaches, balance
problems, nausea, vision changes,
hearing changes, sensitivity to light,
excessive fatigue or sleepiness, sleep
problems
Cognitive
• Difficulty remembering
things;
confusion; difficulty
concentrating; slower to answer
questions, think of words, or solve
problems; feeling “foggy” or “funny”
Emotional
• Restless, angry, cranky, tearful,
frustrated
Sleep
• Increased amount of sleep (longer
night sleep, or naps), difficulty falling
or staying asleep, or decreased sleep
Common symptoms
in infants/toddlers
• Headache or rubbing of the head,
inability to carry out newly learned
skills (eg, toilet training, speech),
disinterest in favorite toys,
crankiness,
irritability, difficult to comfort,
changes in eating and/or sleeping
patterns, tiring easily, or listlessness,
bothered by light or noise
Summary
Concussion is a functional metabolic
crisis in the brain that manifests in a
wide variety of physical, cognitive, and
emotional symptoms. Clinical findings
include a normal traditional neurologic
screening examination; however, patients
often fail to remember the traumatic
n Spring 2017 27
 CASE RESOLUTIONS
■ CASE ONE
Because the young soccer player’s
symptoms extended beyond pain
at the site of contact, a concussion
was suspected. The clinician advised
against same-day return to play; and
the patient was told to follow up with a
concussion health care provider. While
the player and her father were unhappy
with the restrictions, they understood
the increased risk of further injury.
The patient did, in fact, develop
more symptoms the following day,
including fogginess, fatigue, headache,
nausea, difficulty concentrating,
and irritability. She continued with
cognitive and physical rest, and
embarked on a successful gradual
return to play.
■ CASE TWO
During her repeat visit to the emer­
gency department more than a week
after a major car accident, the patient
received a diagnosis of concussion. She
did not require repeat head imaging or
a lumbar puncture, and was prescribed
cognitive and physical rest. She began
to feel considerably better over the
next week, and the intensity and
number of her complaints improved.
However, several symptoms
persisted for nearly 4 months during
follow-up treatment, which entailed
physical, occupational, and speech/
cognition therapies. The patient
was given strategies to modify her
screen time and prevent eye strain,
and a temporary change in her
glasses prescription helped relieve her
headaches.

event, and may have difficulties with
recent memory and attention, and
balance.
The underlying pathophysiology of the
diagnosis is precipitated by a mismatch
in the amount of energy the brain
demands, and the amount it can process
in the setting of relative regional cerebral
hypoperfusion.
Patients with diagnosed or suspected
concussions should be restricted from
same-day return to play, and advised to
follow up with a primary care provider
or concussion specialist before resuming
sports or vigorous exercise. Instituting
cognitive and physical rest treatment in
a timely way can help ameliorate both
short- and long-term consequences of
these common injuries.
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25. 29. Preece MH, Geffen GM, Horswill MS. Return-to-
driving expectations following mild traumatic brain
13. Concussion in Sport Group. Child - Sport Concussion injury. Brain Inj. 2013;27(1):83-91.
Assessment Tool – 3 rd edition [online text]. Br J
Sports Med. 2013;47:263. Available at: http://bjsm. 30. Broglio SP, Cantu RC, Gioia GA, et al. National
Athletic Trainers’ Association position statement:
bmj.com/content/47/5/263.full.pdf. Accessed January
management of sport concussion. J Athl Train.
8, 2016.
14. Maddocks DL, Dicker GD, Saling MM. The
2014;49(2):245-265.
assessment of orientation following concussion in
athletes. Clin J Sport Med. 1995;5(1):32-35.
15. King LA, Horak FB, Mancini M, et al. Instrumented
Balance Error Scoring System (iBESS) for detecting
abnormalities after sports-related concussion. Arch
Phys Med Rehabil. 201419.
16. Ventura RE, Balcer LJ, Galetta SL. The neuro-
ophthalmology of head trauma. Lancet Neurol.
2014;13(10):1006-1016.;13:01111-8.
17. Cooper DD, Seupaul RA. Does this patient with minor
head trauma need neuroimaging? Ann Emerg Med.
2012;60(3):368-369.
18. Melnick ER, Shafer K, Rodulfo N, et al. Understanding
overuse of computed tomography for minor head
injury in the emergency department: a triangulated
qualitative study. Acad Emerg Med. 2015;22(12):1474-
1483.
19. Li J, Brown J, Levine M. Mild head injury,
anticoagulants, and risk of intracranial injury. Lancet.
2001;10;357(9258):771-772.
20. National Conference of State Legislatures. Traumatic
Brain Injury Legislation; 2014. Available at: http://
www.ncsl.org/research/ health/traumatic-brain-
injury-legislation.aspx. Accessed January 19, 2015.
21. Zackery Lystedt Law, Washington State House Bill
1824, Rodne, Quall, Anderson et al.; 2009. Available
at: http://www.cdc.gov/media/subtopic/matte/
pdf/031210-Zack-story.pdf. Accessed January 8, 2016.
22. Max’s law, Oregon State Senate Bill OAR 581-022-
0421; 2010. Available at: http://www.ode.state.or.us/
teachlearn/subjects/pe/ocampguide.pdf. Accessed
January 8, 2016.

Traumatic Injury Special Edition n Spring 2017 28

CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
A 16-year-old football player was tackled and hit in
the head during a game. The boy was slow to get
up, but responsive to his name. His initial complaints
5 According to current concussion guidelines, which
statement is true?
A. Grade 1 concussions resolve in less than 15 minutes
of headache, visual blurriness, and dizziness resolved B. If there was no loss of consciousness, the injury is
within 10 minutes. What should be the next step in graded as “mild”
managing this patient while on the sideline? C. Relative overexertion in the acute phase should be
A. Contact EMS for transfer to the nearest emergency avoided
department D. Strict rest for 5 days can improve psychosocial
B. Initiate ImPACT testing symptoms in adolescents
C. Perform sideline neurocognitive testing and a
focused neurological examination
D. Refer the patient to an ambulatory clinic for head
6 Which medication is appropriate for the treatment of
acute concussion?
A. Acetaminophen
imaging within 24 hours
B. Aspirin

2 While on the sideline, the patient in Question #1

asks when he can to return to play. What is the
most appropriate response?
C. Diazepam
D. Oxycodone

A. After a 1-week period of complete rest

B. Immediately (same-day play)
7 What process is most likely to be involved in
the pathophysiology of a concussion injury?
A. Axonal shearing
C. In 1 week if symptoms have resolved and he has
B. Cerebral contusion
completed a structured, graded exertion protocol
C. Cerebral edema
over 5 to 7 days without symptoms
D. Global ischemia
D. In 30 days, following a normal CT scan and

8
complete neuropsychological testing Which of the following is the leading cause of sports-
related concussions in girls?
3 What percentage of concussions involve loss of
consciousness?
A. Less than 10%
A. Basketball
B. Lacrosse
B. 20% C. Soccer
C. 30% D. Softball

9
D. 50% Over what period of time do most (>80%) concussions
resolve in athletes?
4 Which criterion is most useful for determining the
need to perform brain imaging in an adult patient
with head trauma?
A. 24 hours
B. 3 to 5 days
A. American Head CT Rule C. 7 to 10 days
B. Canadian Head CT Rule D. 5 to 6 weeks

10

C. GCS <14 When is the best time to reintroduce light physical
D. Loss of consciousness activity (eg, walks) in concussed athletes?
A. After 24 to 48 hours, when the patient feels better
B. Following a few weeks of rest, even if symptoms
persist
C. On the sidelines (to test if activity worsens symptoms)
D. Only after all symptoms resolve

Traumatic Injury Special Edition n Spring 2017 29

 Insult to Injury
Geriatric Trauma

LESSON 4

By A. Travis Manasco, MD; Casper Reske-Nielsen, MD;

and Ron Medzon, MD
Dr. Manasco is a chief resident in the Department of Emergency Medicine at
Boston Medical Center, Boston University School of Medicine in Massachusetts. Dr.
Reske-Nielsen is an attending physician in the Department of Emergency Medicine
at Lahey Medical Center in Burlington, Massachusetts. Dr. Medzon is an associate
professor of emergency medicine and the director of the Solomont Center for
Simulation and Nursing Education at Boston Medical Center, Boston University
School of Medicine.
Reviewed by George Sternbach, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Describe the most common risk factors and mechanisms
n How can frailty be used to predict the outcome
of injury in elderly trauma patients.
2. Apply the concept of frailty to the workup of the geriatric of a geriatric trauma patient?
trauma patient. n What age-related physiological changes should
3. Differentiate the need for liberal diagnostic and laboratory
be considered when managing elderly patients?
testing for geriatric trauma patients compared to the
general population. n What mechanisms of trauma pose the greatest
4. Explain the seriousness of falls in the elderly, particularly risk to elderly patients?
ground-level falls.
n How should resuscitation be approached?
5. Apply clinical decision rules and guidelines to the elderly
patient population. n Which injuries are most concerning in the

FROM THE EM MODEL geriatric population, and how should they be

18.0 Traumatic Disorders managed?
18.1 Trauma

The US population is aging in spades. By the year 2030, more than 20% of Americans will be 65 years
or older; by 2050, an estimated 40% of trauma patients will fall within the geriatric age group.1,2 In 2014
unintentional injury was the seventh leading cause of death in elderly patients, who comprise 10% of trauma cases yet
account for 25% of total costs related to hospital trauma care.3,4 Poor physiological reserves, unique injury characteristics,
frailty, medical comorbidities, and in-hospital complications such as pneumonia, venous thromboembolism, and/or organ
failure all contribute to the complexity of care.5-7

Traumatic Injury Special Edition n Spring 2017 30

 CASE PRESENTATIONS
■ CASE ONE
A 75-year-old woman with a
history of osteoporosis, coronary
artery disease, and insulin-
dependent diabetes mellitus presents
after a fall. She reports tripping on a
rug, but did not hit her head or neck
and denies loss of consciousness.
She is unable to walk or bear weight
on her right hip and complains of
diffuse right knee pain.
■ CASE TWO
An 80-year-old woman
arrives via ambulance after
being struck by a vehicle while
crossing the street. The car was
going an estimated 35 miles
per hour, and the patient flew
onto the hood and windshield
after being struck. She is
tachycardic, normotensive, and
moaning in pain.
■ CASE THREE
An 84-year-old man with a past medical
history of atrial fibrillation, diabetes, and
hypertension presents after a witnessed fall. He
reports suddenly collapsing while walking away
from the dinner table. He does not remember
any presyncopal symptoms such as chest pain,
shortness of breath, palpitations, sweats, or
headache. His neurological examination is
normal; however, he has a large abrasion to his
forehead and complains of a headache.

Advancing age correlates with
increased mortality in trauma victims,
in whom the odds of dying increase by
6.8% for every year they are over the
age of 65. Research indicates that elderly
patients frequently are undertriaged
because their underlying comorbidities
and low physiological reserves go
unappreciated.8 All told, geriatric trauma
patients often are much sicker than meets
the eye, and it is incumbent upon the
emergency physician to recognize and
manage their life-threatening injuries.
CRITICAL DECISION
How can frailty be used to
predict the outcome of a
geriatric trauma patient?
Frailty, defined as a decreased
physiological reserve and resistance to
stressors, is a significant predictor for
complications in the geriatric trauma
population.9,10 Simply put, frail patients
get sicker faster and remain sick longer.
Although frailty may be more
definitively gauged using a 50-point
index that measures the proportion
of deficits against the total number of
age-related health variables considered,
this complex system is impractical in
the emergency department.11 There are a
variety of simplified clinical assessment
tools that may be more useful for
assessing patients in the acute setting
(Figure 1).
In addition, surrogate markers such as
sarcopenia and baseline functional status
can help pinpoint frailty.12 Of note,
geriatric trauma patients with sarcopenia
admitted to the intensive care unit (ICU)
spend more days on the ventilator and
demonstrate an increased need for post-
hospital medical care and rehabilitation.13
CRITICAL DECISION
What age-related physiological
changes should be considered
when managing elderly patients?
A progressive loss of functional reserve
in each organ system combined with the
likelihood of concomitant disease (eg,
hypertension, hyperlipidemia, coronary
artery disease, arthritis, and vision and
hearing impairments), can reduce the
elderly patient’s ability to withstand and
recover from a physical insult (Table
1). Cardiac output decreases and blood
pressure increases with age, often leading
to the development of arteriosclerosis. Gas
exchange in the lungs is impaired, which
diminishes vital capacity and expiratory
flow rates. Functional changes in the
gastrointestinal system often result in
senescence, atrophic gastritis, and altered
hepatic drug metabolism.
Elderly patients frequently experience
a progressive elevation of blood glucose;
and osteoporosis, which results from a
linear decline in bone mass, can increase
the risk of fractures. Lean body mass
also dwindles, muscle cells atrophy, and
joints degenerate. In addition, decreased
water in the cartilage of the intervertebral
discs, tendons, and ligaments can reduce
compressibility and flexibility. These
changes can hinder mobility, further
increasing the risk of traumatic injury,
particularly from falls. In addition,
changes in metabolism can alter a
geriatric patient’s response to commonly
used drugs, necessitating dosage
adjustments.
CRITICAL DECISION
What mechanisms of trauma
pose the greatest risk to elderly
patients?
When evaluating a geriatric patient,
it is important to remember that a
medical event may have precipitated the
trauma, or vice versa. In addition, the
mechanisms of injury often are different
in the elderly than in younger patients,
as is their response to trauma. Suspicion
should remain high for serious injury,
even with seemingly minor or low-
mechanism trauma.
Falls
It is not surprising that falls are the
most common mechanism of injury and
the leading cause of traumatic death in
this fragile population (between 7% to
11%).14 Forty-four percent of geriatric
patients are readmitted to the hospital
after a ground-level fall, a clinical
course that carries a staggering one-year
mortality rate of 33%.15
Falls also are the most common cause
of traumatic brain injuries (TBI) in the
elderly.16 As patients age, the dura adheres
more firmly to the skull and becomes
more susceptible to tearing, increasing
the risk of mortality. The increased use of
anticoagulants and/or antiplatelet agents
in these patients further complicates the
risk of significant sequelae.17
The incidence of fall-related injuries,
which continues to rise, is highest in
white women.18,19 Roughly 25% of
these incidents, most of which occur at
home, can be attributed to underlying
medical problems, including stroke,

Traumatic Injury Special Edition n Spring 2017 31

syncope or near-syncope, elder abuse,
and hypovolemia (often related to
gastrointestinal bleeding, ruptured
abdominal aortic aneurysm, sepsis,
or dehydration). Other risk factors
include arthritis and other mobility-
restricting conditions, cognitive or
visual impairment, stroke, and the use
of sedatives (Table 2).
Vehicular Accidents
Approximately 12% of geriatric
trauma patients present after being
struck by a motor vehicle, the second
most common mechanism of injury in
this population. 20 Elderly pedestrians
are at greater risk of being struck due
to frailty, decreased reaction time,
lack of depth perception, physical
instability, and poor hearing. 20,21
Motor vehicle collisions (MVCs) are
the largest traumatic contributor to the
number of ICU days in patients 65 years
or older. Older adults in MVCs are more
likely to require admission and receive
more diagnostic imaging than their
younger counterparts. 22 An underlying
medical problem should be suspected

TABLE 1. Age-Related Changes

Organ System Anatomical Changes
General Decreased organ and muscle
mass
Cardiovascular Fibrosis and thickening of
arteries, sclerosis of cardiac
valves, elongation and
tortuosity of aorta
Lungs Decreased lung elasticity,
decreased activity of cilia,
reduced cough reflex
Kidneys Increased number of abnormal
glomeruli
Genitourinary Prostatic enlargement, vaginal/
urethral mucosal atrophy
Gastrointestinal Atrophic mucosa, atrophic taste
buds, anorectal incompetence
Hematological/ Bone marrow fibrosis,
Immunological metaplasia
Musculoskeletal Decreased height, weight,
muscle mass, and bone density
Endocrine Osteoporosis, vertebral
collapse, changes in fluid
volumes
Nervous Reduced brain mass, decreased
cortical cell count
Eyes Decreased translucency of lens,
decreased size of pupil, increased for increased illumination,
intraocular pressure, macular
degeneration, arcus senilis
Ears Loss of auditory neurons,
atrophy of cochlear hair cells
Skin Flattening, atrophy, and
attenuation in dermal collagen,
rete pegs, and cytoplasm of
basal keratinocytes
Physiological Changes
Decreased organ function,
decreased oxygen consumption
Decreased maximal heart rate each
decade of life, decreased β-adrenergic
responses, decreased arterial
compliance
Decreased vital capacity,
microaspiration
Decreased glomerular filtration
rate, decreased renal blood flow,
decreased urine concentration,
proteinuria
Increased urine residual volume,
bacteriuria, atrophic vaginitis
Decreased salivary flow, decreased
gastric acid production, decreased
hepatic function, decreased motility incontinence, modified appetite, food
Decreased bone marrow reserve,
decreased T-cell function, antibody
dysfunction
Loss of skeletal calcium, reduced
elasticity in connective tissue,
decreased viscosity of synovial
fluid
Altered glucose homeostasis;
decreases in thyroid and testosterone diabetes mellitus, hyponatremia,
hormones, renin and aldosterone
production, and vitamin D absorption; osteoporosis, impotence
increased antidiuretic hormone
Decreased brain catechol and
dopamine synthesis, impaired
thermal regulation
Decreased accommodation, need
susceptibility to glare
Decreased hearing, especially
higher frequency tones; decreased
directional discrimination;
vestibular dysfunction
Decreased skin thickness, risk for
dermo-epidermal separation, loss
of elasticity
Functional Consequences
Decreased flexibility, endurance,
and maximal performance
Decreased cardiac output, decreased
physical work capacity, orthostatic
hypotension, decreased endurance,
syncope, shortness of breath
Shortness of breath, cough, aspiration
pneumonia
Delayed response to salt or fluid
restriction, nocturia
Nocturia, tenesmus, incontinence,
urinary tract infection
Regurgitation with aspiration,
food intolerances, constipation,
intake, and gut motility
False-negative immunological skin
tests, false-positive laboratory
immunological tests
Loss of cartilaginous surfaces,
hypertrophic changes in joints,
increased ratio of fat to muscle mass,
osteoporosis, failure to thrive, loss of
muscle strength
Hyperglycemic response to stress,
hyperkalemia, osteopenia,
Decreased nerve conduction, impaired
cerebral and cognitive functions,
dementia, depression, sleep changes,
hypothermia, hyperthermia, global
sensory impairment
Decreased vision, including color and
night vision; impaired accommodation,
presbyopia
Loss of hearing, balance impairment
with falls
Decreased resistance to tearing

Traumatic Injury Special Edition n Spring 2017 32

in any patient who presents following a
single-vehicle accident.
Abuse
An estimated 5% to 10% of elderly
patients report abuse; and perhaps even
more concerning, 5% of caregivers and
family members admit to physically
abusing their care recipients (Figure 2).23
It is imperative to consider the possibility
of intentionally inflicted trauma when
assessing a patient’s history, especially when
there are signs of neglect or injuries that are
inconsistent with the reported mechanism.
While one sign does not necessarily
indicate abuse, red flags include the
following.24
• Bruises around the breasts or genital
area can be signs of sexual abuse.
• Bruises, pressure marks, broken
bones, abrasions, and burns may be an
indication of physical abuse, neglect, or
mistreatment.
• Bedsores, unattended medical needs,
poor hygiene, and unusual weight loss
are indicators of possible neglect.
• An obviously strained or tense
relationship between the caregiver
and elderly person may be cause for
concern.
TABLE 2. Risk Factors Associated With Falls
Category Examples
Intrinsic factors Acute illness, cardiovascular impairment, confusion,
deconditioning, dehydration, difficulty rising from a chair,
dizziness, fatigue, impaired balance, impaired hearing,
medications (especially use of four or more prescription
drugs), muscle weakness, postural instability, seizures,
syncope, vestibular disease, deficits, fear of falling
Extrinsic factors Dim lighting or glare, slippery surfaces, steep stairways,
unstable furnishings, obstructed pathways, missing handrails,
misuse of assistive devices, or tripping hazards
Situational factors Rushing to the bathroom in the middle of the night, walking
in high heels on uneven pavement
Adapted from the Centers for Disease Control
CRITICAL DECISION can be approached by using clinical
end points of resuscitation (eg, heart
How should resuscitation be
rate, blood pressure, and urine
approached? output). However, these parameters
The adequate resuscitation of can be complicated by factors such as
geriatric trauma patients begins with the use of beta-blockers, hypertension,
prioritizing care based on the severity and preexisting organ dysfunction.8
of injuries; a timely diagnosis and Anatomical changes in the elderly
treatment are key.8 Hypovolemic can complicate endotracheal intubation;
shock is the most common type of a decreased mouth opening secondary
shock in trauma patients, and goal- to temporomandibular joint disease
directed fluid resuscitation can reverse and poor dentition warrant careful
hypoperfusion while minimizing the laryngoscope placement. When
risk of fluid overload. This strategy considering intubation medications,

FIGURE 1. Clinical Frailty Scale

1. Very Fit — Patients who are robust, active, energetic and
motivated. These people exercise regularly and are among
the fittest for their age.
2. Well — Patients who have no active disease symptoms,
but are less fit than those in category 1. They may exercise or
are occasionally very active (eg, seasonally).
3. Managing Well — Patients whose medical problems are
well controlled, but are not regularly active beyond routine
walking.
4. Vulnerable — While not dependent on others for daily
help, these patients have symptoms that may limit activities.
They commonly complain of being “slowed down” and/or
tired during the day.
5. Mildly Frail — Slowing is more evident. These
patients require help with daily activities such as finances,
transportation, heavy housework, medications. Typically, mild
frailty progressively impairs shopping and walking outside
alone, meal preparation, and housework.
6. Moderately Frail — Require help with household chores
and all outside activities. Inside, these patients often have
difficulty navigating stairs and need minimal assistance with
dressing (cuing, standby) and bathing.
7. Severely Frail — Completely dependent on
caregivers for cognitive and physical help with personal
care. Even so, these patients seem stable and are not
at high risk of dying (within ~6 months).
8. Very Severely Frail — Completely dependent and
approaching the end of life. Recovery, even from a
minor illness, is unlikely.
9. Terminally Ill — Approaching the end of life. This
category applies to patients with a life expectancy less
than 6 months, who are not otherwise evidently frail.
Scoring frailty in people with dementia
The degree of frailty corresponds to the degree of dementia.
Common symptoms in mild dementia include forgetting the
details of a recent event (though still remembering the event
itself), repeating the same question/story, and social withdrawal.
Patients with moderate dementia can complete personal care
tasks with prompting. Although their recent memory is very
impaired, they seemingly can remember past life events. Patients
with severe dementia cannot handle personal care without help.
Adapted from Geriatric Medicine Research, Dalhousie University, Halifax, Canada.

Traumatic Injury Special Edition n Spring 2017 33

 be unreliable because of decreased pain
FIGURE 2. Reporters of Elder Abuse perception, dementia, or minimization by
the geriatric patient.27,28

3% 5% Head Injury
Head injuries are the leading cause
15%
of death in geriatric trauma patients.
15% Compared to younger adults, individuals
65 years or older with TBI are admitted
more frequently, have longer hospital
stays, and require more post-hospital
6% 23% medical care.29 Cortical atrophy
(common in the elderly) can delay the
clinical signs of serious intracranial
hemorrhage, which may be clinically
16% occult.
5% American College of Emergency
4% Physicians (ACEP) clinical practice
8%
Adapted from the National Center on guidelines recommend a non-contrast
Elder Abuse CT scan for patients older than 60 years
with loss of consciousness (LOC) or in
patients 65 years or older without LOC.30
FIGURE 3. Pedestrians Injured by Automobiles: Injuries by Age Group45 Magnetic resonance imaging (MRI) may
be warranted if the injury is subacute
and an isodense subdural hematoma is
suspected.
In patients not taking anticoagulation
medications, repeat CT scans may be
reserved for those with neurological
changes and/or unreliable examination
findings.31 One study of head trauma
patients taking warfarin or clopidogrel
showed that out of the 930 individuals
with an initial normal head CT scan, four
6.3% 15.5% 15% 0.4% had a delayed intracranial hemorrhage
71 / 1136 1761 1136 170 / 1136 5 / 1136 (ICH), two of whom died.32 Another
13% 8.3% 27.3% 5.7% evaluation of a 24-hour observation
487 / 3741 309 / 3741 1023 / 3741 214 / 3741
protocol for patients on warfarin with
16 .2% 8.3% 34.8% 7.1% minor head trauma found five out of 97
681420 35/ 420 146 / 420 30 / 420
patients suffered a delayed ICH within
22.6% 9.8% 32% 8.5%
122/541 53/541 173 / 541 46 / 541
the 24-hour window, and another two
had an ICH the following week. All
benzodiazepine and etomidate doses CRITICAL DECISION patients with delayed ICH were older
should be reduced by 20% to 40% to than 65 years.33
Which injuries are most concern­ Although controversy exists, it seems
decrease their hemodynamic effects.25
ing in the geriatric population, and reasonable — given the low incidence of
Ketamine may be used as an alternative
sedative; however, due to the agent’s how should they be managed? delayed ICH in anticoagulated geriatric
effect of increasing myocardial oxygen patients — to discharge those with
When assessing any elderly patient
a normal CT scan with clear return
demand, it should not be used in for trauma, the emergency clinician
precautions.
patients with ischemic heart disease.26 should remain suspicious of “normal”
Older patients may require oxygen vital signs and physical examination Cervical Spine
supplementation and aggressive findings and maintain a low threshold Geriatric trauma patients suffer a high
blood and fluid resuscitation with for diagnostic imaging. For example, rate of cervical spine injuries (CSIs), most
frequent reevaluation. A lower beta- or calcium-channel blockers frequently involving the C1 and C2 ver-
threshold for advanced airway control may blunt compensatory tachycardia tebrae — a serious risk that likely arises
(endotracheal intubation) also should secondary to hemorrhage or volume loss, from degenerative changes that decrease
be maintained. and the abdominal examination may mobility of the lower cervical spine.34,35

Traumatic Injury Special Edition n Spring 2017 34


n Maintain a high clinical suspicion for serious injury in geriatric patients with
seemingly low-risk trauma.
n Any patient older than years 65 with a suspected TBI should be evaluated with
a CT scan of the head and neck.
n Consider frailty as a significant predictor for complications in the geriatric
trauma population.
n If intubation is required, reduce the dose of benzodiazepine and etomidate by
20% to 40% to decrease the drugs’ hemodynamic effects.
If a brain CT is ordered, imaging of the
cervical spine also is recommended.
Because elderly patients are
susceptible to CSIs with lower-risk
mechanisms of injury, there is debate
about using the National Emergency
X-Radiography Utilization Study
(NEXUS) Low-Risk Criteria to clear
the cervical spine in this population;
however, the tool has demonstrated equal
reliability in assessing older patients.35 It
is important to note that the Canadian
C-Spine Rule excludes patients 65 years
and older and/or taking anticoagulant
medications because of the elevated risk
of injury in these patients.36,37
Thorax
Thoracic trauma is the second leading
cause of death in elderly trauma victims.
Ventilatory failure, respiratory arrest,
and blunt aortic injury can be triggered
by chest or abdominal trauma, despite
the absence of conventional symptoms. It
is important to maintain a low threshold
for CT imaging in any elderly patient
who has sustained a blow to the thorax.
Rib fractures are the most common
injury in blunt chest trauma. Each
additional broken rib raises mortality by
19% and the likelihood of pneumonia
by 27%; however, this danger extends
beyond the immediate thoracic injury.38
Adverse events (most commonly pneu­
monia) are reported to complicate 16%
of hospitalizations in geriatric patients
with isolated blunt thoracic injury.39
Fractures
Musculoskeletal injuries are very
common in the elderly, particularly
upper-extremity fractures, including
distal radius, proximal humeral, and
of significant complications, are best
managed by an inpatient care team
consisting of a geriatrician or medical
physician and orthopedic surgeon.44
Summary
Frailty, a decreased physiological
reserve, and medical comorbidities all
complicate the clinical course of geriatric
trauma patients, who are at greater risk
of morbidity and mortality than their
younger counterparts. Seemingly benign
mechanisms such as ground-level falls
can lead to repeat emergency department
elbow injuries. Among the most common visits and potentially catastrophic
lower-extremity injuries are fractures outcomes. Clinicians must maintain a
of the tibial plateau, patella, and ankle high index of suspicion for low-impact
(most commonly the lateral malleolus). traumas and abuse, and use laboratory
Osteoporosis is a leading risk factor and diagnostic imaging studies liberally.
for hip fractures, the most common
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pelvis is a reasonable alternative. 2006; Chicago, Ill: American College of Surgeons;
2006.
Pain management is a significant 7. Hildebrand F, Pape HC, Horst K, et al. Impact of
concern in patients with fractures, age on the clinical outcomes of major trauma. Eur J
Trauma Emerg Surg. 2016;42(3):317-332.
particularly of the hip. Femoral nerve 8. Rushing AM, Scalea TM, eds, et al. Trauma
resuscitation of the elderly patient. http://www.
blockade can provide rapid comfort, consultant360.com/articles/trauma-resuscitation-
elderly-patient. Accessed November 22, 2016.
reduce the need for opioids, and cause 9. Joseph B, Pandit V, Rhee P, et al. Predicting hospital
less sedation.43 Geriatric patients with discharge disposition in geriatric trauma patients:
is frailty the answer? J Trauma Acute Care Surg.
hip fractures, which pose a variety 2014;76(1):196-200.
n Overlooking a hip fracture by relying on x-rays to confirm the diagnosis. Patients
with persistent hip pain and tenderness should be evaluated with CT or MRI.
n Failing to consider signs of elder abuse or neglect, including bruises around the
breasts or genital area, pressure marks, broken bones, abrasions, and burns.
n Relying on the abdominal examination when evaluating for trauma. Decreased
pain perception, dementia, or minimization by the elderly patient can mask life-
threatening complications.
n Failing to consider underlying medical conditions that may have precipitated the
trauma.
Traumatic Injury Special Edition n Spring 2017 35
 CASE RESOLUTIONS
■ CASE ONE
Despite the woman’s right hip
pain and inability to walk, x-rays
of her chest, hip, pelvis, and knee
were negative; basic laboratory
tests were normal. A pelvic CT
without contrast was performed,
which revealed an intertrochanteric
neck fracture. Orthopedics was
consulted, and the patient was
admitted to a co-management hip
fracture service.
■ CASE TWO
The pedestrian hit by a vehicle
was triaged immediately into a
resuscitation room. Her airway
was intact, and she demonstrated
bilateral breath sounds and strong
10. Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Hashmi
A, Green DJ, O’Keeffe T, Tang A, Vercruysse G, Fain
MJ, Friese RS, Rhee P. Superiority of frailty over age
in predicting outcomes among geriatric trauma
patients: a prospective analysis. JAMA Surg. 2014
Aug;149(8):766-72. doi: 10.1001/jamasurg.2014.296.
PubMed PMID:
11. Searle SD,Mitnitski A, Gahbauer EA, Gill TM,
Rockwood K. A standard procedure for creating afrailty
index. BMC Geriatr. 2008;8:24. doi:10.1186: 1471-2318-
8-24.
12. Dodds R, Sayer AA. Sarcopenia and frailty: new
challenges for clinical practice. Clin Med (Lond). 2015
Dec;15 Suppl 6:s88-91. doi: 10.7861/clinmedicine.15-
6-s88. PubMed PMID: 26634689.
13. Moisey LL, Mourtzakis M, Cotton BA, Premji T,
Heyland DK,Wade CE, Bulger E, Kozar RA. Skeletal
muscle predicts ventilator-free days, ICU-free days,
and mortality in elderly ICU patients. Crit Care.
2013;17(5):R206.
14. Tinetti  ME, Speechley  M, Ginter  SF. Risk factors for
falls among elderly persons living in the community. N
Engl J Med. 1988;319(26):1701-1707.
15. Ayoung-Chee P, McIntyre L, Ebel BE, Mack CD,
McCormick W, Maier RV. Long-term outcomes of
ground-level falls in the elderly. J Trauma Acute Care
Surg 2014;76:498–503.
16. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic
Brain Injury in the United States: Emergency
Department Visits, Hospitalizations, and Deaths.
Atlanta, GA: National Center for Injury Prevention and
Control, 2004.
17. Thompson HJ, McCormick WC, Kagan SH. Traumatic
brain injury in older adults: epidemiology, outcomes,
and future implications. J Am Geriatr Soc. 2006
Oct;54(10):1590-5.
18. Cigolle CT, Ha J, Min LC, Lee PG, Gure TR, Alexander
NB, Blaum CS. The epidemiologic data on falls,
1998-2010: more older Americans report falling.
JAMA Intern Med. 2015 Mar;175(3):443-5. doi: 10.1001/
jamainternmed.2014.7533. PubMed PMID: 25599461.
19. Nordell E, Jarnlo GB, Jetsén C, Nordström L,
Thorngren KG. Accidental falls and related fractures in
65-74 year olds: a retrospective study of 332 patients.
Acta Orthop Scand. 2000 Apr;71(2):175-9. PubMed
PMID: 10852324.
20. Reith G, Lefering R, Wafaisade A, Hensel KO, Paffrath
T, Bouillon B, Probst C; TraumaRegister DGU. Injury
pattern, outcome and characteristics of severely
injured pedestrian. Scand J Trauma Resusc Emerg
Med. 2015 Aug 5;23:56. doi: 10.1186/s13049-015-0137-8.
PubMed PMID: 26242394; PubMed Central PMCID:
PMC4524010.
21. O’Hern S, Oxley J, Logan D. Older Adults at
Increased Risk as Pedestrians in Victoria, Australia:
An Examination of Crash Characteristics and Injury
Outcomes. Traffic Inj Prev. 2015;16 Suppl 2:S161-7. doi:
2+ distal pulses in all extremities.
A full body examination revealed
diffuse back and abdominal pain. A
CT scan of the head/neck revealed
multiple cervical and thoracic spinous
process fractures, a right renal
laceration, and a minimally displaced
left femoral neck facture without
active extravasation. Trauma surgery,
orthopedics, and neurosurgery
were consulted. After a neurologic
examination, the patient received
an ultrasound-guided femoral nerve
block for pain and was admitted to
the surgical ICU.
■ CASE THREE
The fall victim’s ECG showed
stable atrial fibrillation, and
10.1080/15389588.2015.1061662. PubMed PMID:
26436227.
22. MacKenzie EJ, Morris JA, Smith GS. Acute hospital
costs of traumain the United States: Implications
for regionalized systems of care. J Trauma.
1990;30:1096-1101.
23. National Center on Elder Abuse. Administration on
aging. Available at: http://www.ncea.aoa.gov/librar/
data. Accessed August, 2016.
24. What is Elder Abuse? Administration for
Community Living Web site. http://www.aoa.acl.
gov/AoA_Programs/Elder_Rights/EA_Prevention/
whatIsEA.aspx. Accessed November 22, 2016.
25. Narang AT, Sikka R. Resuscitation of the elderly.
Emerg Med Clin North Am. 2006 May;24(2):261-72,
v. Review. PubMed PMID: 16584957.
26. Craven R. Ketamine. Anaesthesia. 2007 Dec;62
Suppl 1:48-53. Review. PubMed PMID: 17937714.
27. Aschkenasy MT, Rothenhaus TC. Trauma and falls
in the elderly. Emerg Med Clin North Am. 2006
May;24(2):413-32, vii. Review.
28. Marco CA, Schoenfeld CN, Keyl PM, Menkes
ED, Doehring MC. Abdominal pain in geriatric
emergency patients: variables associated with
adverse outcomes. Acad Emerg Med. 1998
Dec;5(12):1163-8. PubMed PMID: 9864129.
29. Dams-O’Connor K, Cuthbert JP, Whyte J, Corrigan
JD, Faul M, Harrison-Felix C. Traumatic brain injury
among older adults at level I and II trauma centers.
J Neurotrauma. 2013 Dec 15;30(24):2001-13. doi:
10.1089/neu.2013.3047. Epub 2013 Nov 26. PubMed
PMID: 23962046; PubMed Central.
30. Jagoda A, Bazarian J, Bruns J, Cantrill S, et al.
Clinical Policy: Neuroimaging and Decisionmaking
in Adult Mild Traumatic Brain Injury in the Acute
Setting. Ann Emerg Med. 2008;52:714-748.]
31. Haider AA, Rhee P, Orouji T, Kulvatunyou N,
Hassanzadeh T, Tang A, Farman A, O’Keeffe T,
Latifi R, Joseph B. A second look at the utility
of serial routine repeat computed tomographic
scans in patients with traumatic brain injury. Am
J Surg. 2015 Dec;210(6):1088-94. doi: 10.1016/j.
amjsurg.2015.07.004. Epub 2015 Sep 18. PubMed
PMID: 26482515.
32. Nishijima DK, Offerman SR, Ballard DW, Vinson
DR, Chettipally UK, Rauchwerger AS, Reed ME,
Holmes JF; Clinical Research in Emergency
Services and Treatment (CREST) Network.
Immediate and delayed traumatic intracranial
hemorrhage in patients with head trauma and
preinjury warfarin or clopidogrel use. Ann Emerg
Med. 2012 Jun;59(6):460-8.e1-7. doi: 10.1016/j.
annemergmed.2012.04.007. PubMed PMID:
22626015.
33. Menditto VG, Lucci M, Polonara S. et al.
Management of minor head injury in patients
receiving oral antiocoagulant therapy: a
Traumatic Injury Special Edition
laboratory data revelaed an
international normalized ratio of
4.5. A head and cervical spine CT
scan demonstrated a large subdural
hematoma with midline shift. The
monitor showed an 8-round run
of ventricular tachycardia (VT).
The man spontaneously reverted
back to atrial fibrillation and was
loaded with amiodarone. His mental
status decompensated and he again
devolved into VT.
No pulse could be detected, and
advanced cardiac life support was
initiated. After three subsequent
shocks, the family was consulted;
given the patient’s grave prognosis,
resuscitation was terminated.
prospective study of a 24-hour observation protocol.
Ann Emerg Med 2012;59:451-455. 
34. Touger M, Gennis P, Nathanson N, Lowery DW,
Pollack CV Jr, Hoffman JR, Mower WR. Validity of a
decision rule to reduce cervical spine radiography in
elderly patients with blunt trauma. Ann Emerg Med.
2002 Sep;40(3):287-93. PubMed PMID: 12192352
35. Wang H, Coppola M, Robinson RD, Scribner JT,
Vithalani V, de Moor CE, Gandhi RR, Burton M,
Delaney KA. Geriatric Trauma Patients With Cervical
Spine Fractures due to Ground Level Fall: Five Years
Experience in a Level One Trauma Center. J Clin Med
Res. 2013 Apr;5(2):75-83. doi: 10.4021/jocmr1227w.
Epub 2013 Feb 25. PubMed PMID: 23519239
36. Stiell, IG, Wells G, Vandemheen KL, et al.The
Canadian C-Spine Rule for Radiography in Alert and
Stable Trauma Patients.JAMA. 2001;286(15):1841-
1848. doi:10.1001/jama.286.15.1841.
37. Stiell IG, Wells GA, Vandemheen K, Clement C,
Lesiuk H, Laupacis A, McKnight RD, Verbeek R,
Brison R, Cass D, Eisenhauer ME, Greenberg G,
Worthington J. The Canadian CT Head Rule for
patients with minor head injury. Lancet. 2001 May
5;357(9266):1391-6.
38. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib
fractures in the elderly. J Trauma. 2000;48:1040-104
39. Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL,
Ahmed SS, Menchine MD. Factors associated with
complications in older adults with isolated blunt
chest trauma. West J Emerg Med. 2009 May;10(2):79-
84. PubMed PMID: 19561823; PubMed Central.
40. Johnell O, Kanis JA. An estimate of the worldwide
prevalence and disability associated with
osteoporotic fractures. Osteoporos Int. 2006
Dec;17(12):1726-33. Epub 2006 Sep 16. PubMed
PMID: 16983459.
41. Switzer JA, Gammon SR. High-energy skeletal
trauma in the elderly. J Bone Joint Surg
Am. 2012;94(23):2195-2204.
42. Ward R, Weissman B, Kransforf M, et al. Acute
Hip Pain – Suspected Fracture Appropriateness
Criteria® Acute Trauma to the Foot. Available
at https://acsearch.acr.org/docs/70546/Narrative.
American College of Radiology. Accessed 9/1.
43. Fletcher AK, Rigby AS, Heyes FL (2003) Three-in-one
femoral nerve block as analgesia for fractured neck of
femur in the emergency department: a randomized,
controlled trial. Ann Emerg Med 41(2):227–233
44. Friedman SM et al (2008) Geriatric co-management
of proximal femur fractures: total quality
management and protocol-driven care result in
better outcomes for a frail patient population. J Am
Geriatr Soc 56(7):1349–1356
45. Switzer JA, Gammon SR. High-energy skeletal
trauma in the elderly. J Bone Joint Surg
Am. 2012;94(23):2195-2204.
n Spring 2017 36
CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
Which physiological parameters most closely correlate
with frailty?
A. Baseline functional status
6 What percentage of caregivers has reported physically
abusing their care recipients?
A. 2%
B. Ejection fraction on a recent (≤6 months) B. 5%
echocardiogram C. 10%
C. Oxygen saturation D. 20%
D. Resting heart rate

2 What is the most common cause of death in elderly

trauma patients?
7 Which factor can contribute to an unreliable abdominal
examination in an elderly trauma patient?
A. Decreased pain perception
A. Cervical spine injuries B. Distrust of medical providers
B. Compound fractures C. Frailty
C. Head injuries D. Use of anticoagulants
D. Thoracic trauma

3 Bruises, pressure marks, broken bones, and abrasions

should raise clinical suspicion for what?
8 What is the most common injury in blunt chest trauma?
A. Hemothorax
B. Pneumothorax
A. Abuse C. Pulmonary contusion
B. Frailty D. Rib fracture
C. Osteoporosis
D. Use of antiplatelet medications
9 Which test is the most sensitive in diagnosing hip
fractures in the elderly?

4 Which mechanism of injury contributes to the greatest

number of ICU days in patients 65 years or older?
A. Assault
A. CT scan
B. MRI
C. Ultrasound
B. Falls D. X-ray
C. Motor vehicle collisions
D. Pedestrian accident (struck by a car)
10
What is the one-year mortality rate in geriatric patients
who are readmitted after ground-level falls?
5 Which sedative medication should not be used in
elderly patients with preexisting ischemic heart
disease?
A. 17%
B. 23%
C. 28%
A. Etomidate
D. 33%
B. Dexmetomedine
C. Diazepam
D. Ketamine

Traumatic Injury Special Edition n Spring 2017 37

 Double Bind
Trauma in Pregnancy

LESSON 5

By Eva Tovar Hirashima, MD, MPH, and Heidi Kimberly, MD

Dr. Tovar Hirashima is a clinical instructor of emergency medicine and an
ultrasound fellow at the University of Maryland School of Medicine in Baltimore.
Dr. Kimberly is Chief of the Division of Emergency Ultrasound at Brigham and
Women’s Hospital in Boston, Massachusetts.
Reviewed by Kathleen Wittels, MD

OBJECTIVES
On completion of this lesson, you should be able to:
1. Describe the most frequent causes of trauma in pregnant
patients.
2. Describe the physiological effects of trauma to the mother
and fetus.
3. Discuss the initial evaluation and treatment of pregnant
trauma victims.
4. Explain the unique complications of trauma during
pregnancy.
5. Describe the indications for a perimortem cesarean
delivery.
CRITICAL DECISIONS
n What anatomical and physiological changes
affect resuscitation in the pregnant trauma
patient?
n When and how should a fetus be assessed in
the emergency department?
n Which imaging modalities are safe or pregnant
trauma victims?
n When should Rho(D) immune globulin be given
to a pregnant trauma victim?

FROM THE EM MODEL n When should a perimortem cesarean delivery be

18.0 Traumatic Disorders performed?
18.2 Trauma in Pregnancy n What traumatic complications are unique to
pregnant trauma victims?
n What emergency department interventions can
help reduce trauma in pregnancy?

Traumatic Injury Special Edition n Spring 2017 38

 CASE PRESENTATIONS
■ CASE ONE
A 24-year-old woman (gravida
2, para 1) at 32 weeks’ gestation is
brought in by ambulance after falling
1 hour earlier. The patient states
that she tripped and fell down two
steps, landing on her right shoulder
and abdomen. She is unsure if she
sustained a head strike but denies
loss of consciousness. Her husband,
who witnessed the event, told her to
lie flat on the ground and not move
while he called EMS. She denies
abdominal pain or vaginal bleeding
but does notice a decrease in the
fetal movements. The remainder of
the review of systems is negative.
She is not on any medications except
prenatal vitamins.
Her vital signs are blood pressure
90/60, pulse rate 110, respiratory
rate 12, temperature 36.7°C (98.1°F),
oxygen saturation 100% on room air,
and Glasgow Coma Scale score 15.
On physical examination, the patient
has good eye contact and is in no
acute distress. Her head is atraumatic
and normocephalic, the pupils are
equal, round, and reactive to light,
and the tympanic membranes are
intact bilaterally. Midline tenderness
is absent on palpation of the cervical
spine. Her chest is nontender, and
on auscultation her heart and lung
sounds are normal. The abdomen is
nontender and notable for a gravid
uterus with the fundal height at
Pregnancy is a recognized risk factor
for trauma, and trauma during
pregnancy is one of the leading
causes of nonobstetrical death. In the
United States, unintentional traumatic
injuries complicate 7% of pregnancies,
with the leading mechanism being motor
vehicle collisions.1,2 Falls are the second
leading cause of nonintentional injury,
with most of them occurring during the
third trimester. The most frequent cause
of intentional trauma is intimate partner
violence (IPV). 3 In fact, pregnancy is an
independent risk factor for IPV, with
12 cm above the umbilicus. There are
no gross deformities of her extremities;
she has mild tenderness on palpation
of the right shoulder but has full
range of motion of the joint. The skin
examination reveals a 4-cm abrasion
over the right forehead and minor
bruising of the right shoulder, right
flank, and right buttock in the same
stages of healing. The fetal heart rate,
assessed with bedside ultrasonography,
is 120, and fetal movement is present.
An eFAST is performed and is negative
for intraabdominal or pericardial fluid,
and pleural sliding is noticed bilaterally.
A complete blood count reveals a
hematocrit of 32; her blood type is O
Rh-negative. The patient is placed in a
left lateral decubitus position and the
obstetrics team is consulted.
■ CASE TWO
EMS reports that paramedics are
en route with a pregnant stab wound
victim. They are 2 minutes away.
The patient is a 21-year-old pregnant
woman; her last menstrual period is
unknown. The patient’s intoxicated
boyfriend called EMS after stabbing
her in the chest and abdomen with a
kitchen knife. The history is unclear,
but the neighbors report that both
of them had been drinking alcohol
heavily. The patient’s vital signs in the
field were blood pressure 90/60, pulse
rate of 140, and oxygen saturation 98%
on 15 liters per minute of oxygen by
nonrebreathing mask. Two large-bore
higher prevalence reported during the
third trimester.4 Such situations can
manifest as gunshot wounds, stabbings,
and attacks aimed at the gravid uterus. 5
When treating pregnant trauma
victims, the initial focus should be on
maternal stability and the evaluation
should follow the basic advanced trauma
life support (ATLS) algorithm.6 Fetal
survival is dependent on the mother’s
condition, so ensuring maternal
hemodynamic stability is imperative for
both. Once maternal stability is ensured,
focus can be directed to the fetus.
Traumatic Injury Special Edition
intravenous lines were established.
The emergency physician prepares
the trauma bay, crash cart, and
airway cart, including gathering the
equipment for a difficult airway. The
trauma team is activated, and the blood
bank is alerted. The obstetrical team
and neonatologist are notified. On
arrival, vital signs are blood pressure
80/50, pulse rate 165, and oxygen
saturation 96% on nonrebreathing
mask. The patient is obtunded, with a
Glasgow Coma Scale score of 6, and
the decision to intubate is made. She is
preoxygenated with the nonrebreathing
mask. After rapid sequence intubation
(RSI), apneic oxygenation is continued
with the use of a nasal cannula at
6 L/min. On direct laryngoscopy, the
epiglottis cannot be visualized. The
intubation is successful on the second
attempt using the videoscope and a 7.0
endotracheal tube.
No breath sounds can be heard on
the left; a chest tube is placed in the 4th
intercostal space, and 500 mL of gross
blood is drained. The patient’s carotid
pulse is weak but palpable, the uterus
is displaced to the left manually, and 2
units of packed red blood cells (RBCs)
are transfused. The injury consists of
two stab wounds to the left anterior
hemithorax and three stab wounds to
the upper abdomen. Before a secondary
survey can be started, the patient
loses pulses, and cardiopulmonary
resuscitation is initiated.
CRITICAL DECISION
What anatomical and
physiological changes affect
resuscitation in the pregnant
trauma patient?
Maternal adaptation to pregnancy
involves several organ systems.
Emergency physicians should be
especially cognizant of the changes that
affect the initial resuscitation efforts.
Airway
Physiological changes in pregnancy
can result in weight gain, airway edema,
n Spring 2017 39
and gastric aspiration.7 Additionally,
reduced functional residual capacity
and an increased metabolic rate during
pregnancy cause more rapid progression
to hypoxia. Of note, airway edema in
pregnancy causes a decreased tracheal
luminal size and therefore a smaller than
expected endotracheal tube should be
used (6.5-7 mm internal diameter).8
The incidence of airway management
failure in patients at term is up to 8
times greater than in the nonpregnant
population. The expected incidence of
failed tracheal intubation during general
anesthesia may be as high as 1 in 224.9
Furthermore, older age and higher body
mass index appear to be significant
predictors of failed tracheal intubation in
pregnant patients.9 Airway management
can be even more challenging in
potentially unstable patients fitted with
cervical collars; a difficult airway should
be anticipated in all pregnant trauma
victims.
Breathing
In addition to decreased functional
residual capacity, oxygen consumption
increases by almost 20% to meet the
maternal and fetal metabolic demands.
Both of these changes predispose
the pregnant trauma victim to rapid
desaturation when rendered apneic,
and supplemental oxygen should
be used liberally whether or not
intubation is imminent. If intubation
becomes necessary, patients should be
preoxygenated using at least 8 vital
capacity breaths or 3 minutes of breathing
100% oxygen.7 Apneic oxygenation,
which is the diffusion of oxygen to alveoli
in the absence of ventilation, can be
achieved by placing patients on high-
flow oxygen during the apneic period
of RSI. This has been shown to extend
the duration of safe apnea and should be
considered in the airway management of
pregnant patients.10
If a tube thoracostomy is required, it
should be placed higher, at the 4th to 5th
intercostal space, given that pregnancy
leads to an elevation of the diaphragm.
Ultrasonography can be used to diagnose
pneumothorax as well as aid tube
thoracostomy placement by helping the
clinician to visualize the location of the
diaphragm in exhalation.11
Circulation
The most pronounced changes in the
cardiovascular system during pregnancy
are:
• 40% increase in maternal cardiac
output by 10 weeks
• Decrease in mean blood pressure of 10
to 15 mm Hg by the 2nd trimester
• Increase in pulse of 5 to 15 beats per
minute by the 2nd trimester
• 20% to 30% increase in RBC volume
• 50% increase in plasma volume
Because of the rise in plasma volume,
pregnant women can lose 10% to
20% of blood volume acutely without
exhibiting changes in vital signs. In
addition, one of the first compensatory
mechanisms during maternal hemorrhage
is decreasing uterine blood flow. Fetal
distress, therefore, is one of the initial
manifestations of maternal instability.
Maternal tachycardia and hypotension
are late signs of maternal acute blood loss,
and should never be initially attributed to
“physiological” changes of pregnancy.6
After 20 weeks’ gestation, the uterus
compresses the inferior vena cava when
a pregnant woman lies supine, leading
to a 30% decrease in cardiac output.
The former is known as the “supine
hypotension syndrome” and is prevented
by leftward tilt to a 30-degree angle of the
backboard or by manual displacement of
the uterus to the left.
If a blood transfusion is needed
emergently, Rh-negative blood should be
used to prevent sensitization to Rho(D)
factors; in cases of massive transfusion,
general trauma protocols should be
followed.12 Of note, the randomized,
placebo-controlled CRASH2 trial
revealed that tranexamic acid (TXA), an
antifibrinolytic, reduces the risk of death
in bleeding trauma patients if given within
3 hours of injury. Although nearly 85% of
the subgroup who received the medication
(n=10,096) were men, pregnancy wasn’t
an exclusion criteria. Thus, TXA may be
considered as an adjunct of treatment in
the pregnant, bleeding trauma victim who
presents within this timeframe.13
Disability
In general, the brief evaluation of
disability is similar in nonpregnant and
pregnant trauma victims. Although
unlikely in a trauma patient, eclampsia
Traumatic Injury Special Edition
should be considered as a cause of
altered mental status in the appropriate
clinical scenario.
Exposure
Given the association between
trauma in pregnancy and IPV, these
patients should be fully exposed to
search for signs of intentional trauma.
CRITICAL DECISION
When and how should a fetus
be assessed in the emergency
department?
The identification of injuries and
stabilization of the mother are clearly
the first priorities; however, fetal
heart rate should be assessed once
the primary survey of the mother is
complete.11 Ultrasonography detects
cardiac activity by 6 to 7 weeks’
gestation and Doppler by 10 to 14
weeks. A fetal heartbeat is audible
by stethoscope by 18 to 20 weeks’
gestation. A more thorough assessment
of the fetus depends on its gestational
age; if the pregnancy is viable (20 to
24 weeks’ gestation) then a period of
continuous fetal and uterine monitoring
with an external Doppler and tocometer
is indicated.6
External fetal monitoring is the
most sensitive test for diagnosing
placental abruption, preterm labor,
and fetal distress.14 The monitoring
should be performed by an obstetrical
team in an area conducive to rapid
cesarean delivery in the event that
a nonreassuring fetal heart rate is
identified.11 The optimal length of
time for electronic monitoring is not
well established. For instance, the
American College of Obstetricians
and Gynecologists recommends 4
hours of monitoring post trauma,while
the American College of Surgeons
recommends a minimum of 6 hours.6,15
Regardless, the monitoring time should
be extended to 24 hours if contractions,
vaginal bleeding, abdominal pain, or a
nonreassuring fetal heart rate variability
is detected.
In the absence of concerning signs,
discharge may be appropriate in most
cases of minor maternal trauma.
However, pregnant trauma victims
n Spring 2017 40
who require fetal monitoring should be
transferred to a facility equipped to do
so. Of note, using pregnancy as a sole
criterion for trauma team activation
has recently been challenged by a study
indicating that patients in their first and
second trimesters can be managed safely
without such measures if they do not
meet other criteria. Despite this, many
trauma centers use pregnancy as a sole
criterion for activation; institutional
practices should be followed.
CRITICAL DECISION
Which imaging modalities are
safe for pregnant trauma victims?
Diagnostic imaging procedures can
be divided into two groups, those using
nonionizing radiation (ultrasonography
and magnetic resonance imaging [MRI])
and those using ionizing radiation
(radiography, computed tomography
[CT], and fluoroscopy).
Ionizing Radiation
Fetal exposure to ionizing radiation
should be minimized during pregnancy.
However, in cases of maternal instability,
the risks of missing a serious injury far
outweigh the potential harm of radiation
to the fetus.16 As noted previously,
uterine hypoperfusion is one of the
first compensatory mechanisms that
comes into play in cases of maternal
hemodynamic instability. CT or
TABLE 1. Radiation Risks to the Fetus Based on Gestational Age and Radiation Dose17-19
Gestational Age
3-4 weeks
5-10 weeks
11-17 weeks
Entire pregnancy
a
Refers to cumulative exposure during pregnancy
b
Estimated childhood cancer incidence from prenatal radiation exposure
radiography should not be delayed
or abandoned because it can lead to
prompt identification and treatment of
the underlying cause.
Radiation poses three main risks to
the fetus, loss of viability, teratogenesis,
and carcinogesis (Table 1).11 Loss of
viability is possible—but unlikely—
early in pregnancy with exposures
greater than 50 mGy. A rise in the risk
of fetal death is observed at doses above
100 mGy. Teratogenic effects exhibit
a similar pattern, with no significant
risks at doses of 50 to 100 mGy.16,17
The Centers for Disease Control and
Prevention classify a child’s risk for
cancer after in utero radiation exposure
as minimal when cumulative exposure
during pregnancy is less than 50 mGy;
however, the incidence increases to
more than 6% with exposures above
500 mGy.18
If the patient’s clinical status
permits, the clinician must discuss
the risks, benefits, and alternatives
of the diagnostic procedures with the
patient and answer any questions the
patient may have. When neither life
nor limb is in imminent jeopardy, the
decision regarding what to image and
how should be based on a thoughtful
assessment of the clinical scenario and
patient preference (Table 2).
Major Effect Radiation Dose (mGy)
Loss of viability <50
50 to 100
>100
Teratogenesis <50
50 to 100
>100
Teratogenesis <50
50 to 100
>100
Carcinogenesis None
<50 a
50 to 500a
>500 a
Traumatic Injury Special Edition
Nonionizing Radiation
Ultrasonography
Although ultrasonography is
less sensitive for the detection of
intraabdominal injury in pregnant
patients than in nonpregnant patients,
it is a rapid and safe way to evaluate
a pregnant trauma victim. The test’s
reported sensitivity and specificity
for evaluating blunt trauma range
from 61% to 83% and 94% to 100%,
respectively.20-22 Of note, sensitivity
is highest in the first trimester of
pregnancy. Fetal cardiac activity
and gestational age may be assessed
at the bedside using sonography. As
mentioned previously, cardiac activity
can be seen as early as 6 weeks’
gestation. It is important to note that
M-mode, which theoretically transmits
less acoustic energy to the fetus, should
be used instead of Doppler to examine
cardiac motion.
A recent study showed that
emergency physicians can accurately
estimate gestational age in stable
second- and third-trimester pregnant
patients using biparietal diameter (BPD)
and femur length (FL).23 Importantly,
the accuracy of determining fetal
viability (age >24 weeks) was 96% using
ultrasonography compared to 80%
using fundal height, and the average
time to complete the measurements
Risk
None
Likely none
Spontaneous abortion
None
Unclear, likely minimal
Possible malformations
None
Unclear, likely minimal
IQ deficit
0.3%b
0.3% to 1%b
1% to 6%b
>6%b
n Spring 2017 41

TABLE 2. Estimated Fetal Radiation Dose from Common
Imaging Examinations17,18
Imaging Modality
Chest radiograph
Anteroposterior pelvic radiograph
Extremities radiograph
CT head
CT chest or PECT
CT abdomen
CT abdomen and pelvis
Fluoroscopy of abdomen and pelvis
was less than 1 minute. Although not
conclusive, the study supports the use
of emergency physician-performed fetal
dating to assess gestational age and
viability at the bedside.
A pitfall of ultrasonography in the
assessment of the pregnant trauma
patient is its poor sensitivity for detecting
placental abruption, with 50% to 80% of
cases being missed.14,24 Therefore, when
placental abruption is being considered,
the fetus should be monitored despite a
seemingly negative sonogram.
MRI
Magnetic resonance imaging does not
expose the fetus to ionized radiation,
and there are no reports of adverse
outcomes to either fetus or mother with
its use. However, gadolinium during
pregnancy is not recommended because
of its association with nephrogenic
systemic fibrosis. Despite its safety, MRI
is not recommended in the immediate
evaluation of a pregnant trauma victim
because of its long acquisition time and
the suboptimal monitoring of the critical
patient during the performance of the
study.
Estimated Fetal Dose (mGy)
<1
1.4
<1
<1
<1
4 consequences for the fetus such as
25
<100
a beta-human chorionic gonadotropin
test performed and be shielded for
radiographs whenever possible.
• Concern about possible effects of
high-dose ionizing radiation exposure
should not prevent medically indicated
maternal diagnostic radiograph
procedures from being performed.
During pregnancy, other imaging
procedures not associated with ionizing
radiation should be considered instead
of radiographs when possible.
• Exposure to less than 5 rads (<50 mGy)
has not been associated with an increase
in fetal anomalies or pregnancy loss and
is deemed to be safe at any point during
the entirety of gestation.
• Consultation with a radiologist
should be considered for purposes of
calculating estimated fetal dose when
multiple diagnostic radiographs are
performed.
CRITICAL DECISION
When should Rho(D) immune
globulin be given to a pregnant
trauma victim?
Fetomaternal hemorrhage (FMH)
refers to the entry of fetal blood into the
maternal circulation before or during
delivery. Secondary to the resultant
anemia, FMH may have devastating
neurological injury, stillbirth, or death.
Not surprisingly, FMH is four times
more common in trauma-exposed
pregnancies than in controls.26 In the
fetus, the Rh antigen will develop by 6
weeks’ gestation and as little as 0.1 mL
of fetal blood is needed to sensitize an
Rh-negative mother.27
Rh alloimmunization in pregnancy,
caused by FMH, can lead to hemolytic
disease of the newborn, fetal anemia,
and fetal death. Because of this, all
Rh-negative pregnant patients who
have sustained abdominal trauma
should receive empiric intramuscular
Rho(D) immune globulin (IG) to prevent
sensitization even in the absence of overt
hemorrhage. A 50-mcg dose of Rho(D)
IG is used during the first trimester; after
12 weeks’ gestation, a 300-mcg dose is
recommended.11
The Kleihauer-Betke (KB) test
measures the percentage of fetal RBCs
in a maternal blood sample. The test is
sensitive to detect more than 5 mL of
FMH and therefore cannot serve as a

Current Guidelines
The most recent recommendations
by the Eastern Association for the
Surgery of Trauma for the management
of pregnant patients are divided into
levels, which are stratified by the strength
of evidence.25 Those pertaining to
diagnostic procedures are level III, based
on retrospectively collected data, large
case reviews, and expert opinion. These
include the following:
• All female patients of childbearing age
with significant trauma should have
n The initial evaluation of a pregnant trauma victim should focus on maternal
stability; tachycardia and hypotension are ominous signs in these patients.
n Expect and prepare for a difficult airway, preoxygenate and use apneic
oxygenation to extend the period of safe apnea, and use a smaller than
usual endotracheal tube.
n Fundal height and bedside ultrasonography can be used to estimate
gestational age in the trauma bay.
n If a chest tube is required, place it higher up in the 4th to 5th intercostal
space.
n Fetal monitoring is indicated for pregnant women with trauma even if
ultrasonography is negative; the imaging modality has poor sensitivity for
detecting placental abruption.

Traumatic Injury Special Edition n Spring 2017 42

screening tool to determine which cases
warrant the administration of Rho(D)
IG. However, the KB test does become
useful when more than 30 mL of FMH
is present; in such cases, a higher dose of
Rho(D) IG is indicated.
CRITICAL DECISION
When should a perimortem
cesarean delivery be performed?
Perimortem cesarean delivery is a
time-critical emergency procedure.
According to the American Heart
Association (AHA), it should be started
4 minutes after the onset of maternal
cardiac arrest if resuscitation has failed
to restore circulation in a patient with a
fundal height at the level of the umbilicus
(20 weeks).28 The procedure is thought
to relieve aortocaval compression exerted
by the gravid uterus and thus improve
preload as well as cardiac output,
increasing the likelihood of maternal
return of spontaneous circulation.3,11,26
In addition, perinatal outcomes are
optimized when delivery is performed
within minutes, thereby decreasing the
fetal exposure to anoxic brain injury.25,29
During the procedure, CPR should be
continued and broad-spectrum antibiotics
should be administered to decrease any
risk of postpartum infection.
CRITICAL DECISION
What traumatic complications
are unique to pregnant trauma
victims?
Placental Abruption
Placental abruption is the leading
cause of fetal death after trauma. It
occurs in as many as 5% of patients
with seemingly minor injuries and in up
to 50% of patients with severe injuries.
Symptoms include abdominal pain,
uterine tenderness, and vaginal bleeding.
Hemorrhage can be occult even when
significant and can lead to coagulopathy
and hemodynamic instability. Neither
clinical examination nor imaging
studies are sensitive enough to rule out
placental abruption, emphasizing the
need for electronic fetal monitoring in the
presence of a viable pregnancy despite
seemingly minor injuries in the mother.27
n Neglecting to consider IPV as a cause of trauma during pregnancy.
n Failing to provide continuous monitoring of fetal heart rate and uterine
contractions for at least 4 hours in cases of minor maternal injury.
n Neglecting to initiate necessary imaging tests based on misplaced
concerns about radiation exposure to the fetus.
n Failing to perform a perimortem cesarean delivery 4 minutes into maternal
cardiac arrest when a viable pregnancy is present.
Uterine Rupture
Uterine laceration and rupture occur
in fewer than 1% of severe trauma cases;
however, this complication is one of the
most life-threatening emergencies in
obstetrics, leading to near 100% fetal
mortality and 10% maternal mortality.19
Prior cesarean delivery, previous
uterine surgery, or congenital uterine
anomalies increase the risk for uterine
rupture in women with blunt trauma.
Penetrating trauma is an independent
risk factor. Symptoms include
maternal hemodynamic instability
and absent fetal heart rate. Diagnosis
is better accomplished with CT than
ultrasonography.19 Early recognition
of uterine rupture and appropriate
intervention can contribute to maternal
survival.
CRITICAL DECISION
What emergency department
interventions can help reduce
trauma in pregnancy?
Inadequate seat belt usage is a
recognized risk factor for worse
outcomes in patients involved in motor
vehicle collisions.1,30 It is imperative to
counsel pregnant patients about the
appropriate use of automobile restraints
regardless of their chief complaint.
Similarly, it is imperative to screen for
abuse when managing pregnant trauma
victims, who are at increased right of
IPV, and provide referrals if needed.30
Summary
Trauma is the most common cause
of nonobstetrical death among pregnant
women in the United States. Motor
Traumatic Injury Special Edition
vehicle collisions, falls, and IPV are
the most common causes. The initial
evaluation and management should focus
on maternal stability. When clinically
indicated, imaging studies should not be
withheld because of the risk of missing
serious maternal injury. Placental
abruption is the leading cause of fetal
distress and cannot be ruled out by
ultrasonography. Therefore, after initial
maternal stabilization, the fetus should
be monitored electronically for at least 4
hours, even in cases of seemingly minor
maternal trauma. In order to prevent
alloimmunization, O Rh-negative blood
should be used when blood products
are indicated and Rho(D) IG should be
administered intramuscularly within 72
hours post trauma.
REFERENCES
1. Brookfield KF, Gonzalez-Quintero VH, Davis JS,
Schulman CI. Maternal death in the emergency
department from trauma. Arch Gynecol Obstet.
2013;288(3):507-512.
2. Mirza FG, Devine PC, Gaddipati S. Trauma in
pregnancy: a systematic approach. Am J Perinatol.
2010;27(7):579-586.
3. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ.
Trauma in pregnancy: an updated systematic review.
Am J Obstet Gynecol. 2013;209(1):1-10.
4. Chambliss LR. Intimate partner violence and its
implication for pregnancy. Clin Obstet Gynecol.
2008;51(2):385-397.
5. Ribe JK, Teggatz JR, Harvey CM. Blows to the
maternal abdomen causing fetal demise: report of
three cases and a review of the literature. J Forensic
Sci. 1993;38(5):1092-1096.
6. American College of Surgeons. Trauma in Women. In:
Advanced Trauma Life Support for Doctors, Student
Course Manual. Chicago, IL: American College of
Surgeons; 2008.
7. Dobiesz VA, Zane RD. The pregnant patient. In: Walls
RM, Murphy MF, eds. Emergency Airway Management.
Philadelphia, PA: Lippincott Williams & Wilkins;
2012:392-397.
8. Einav S, Sela HY, Weiniger CF. Management and
outcomes of trauma during pregnancy. Anesthesiol
Clin. 2013;31(1):141-156.
9. Quinn AC, Milne D, Columb M, et al. Failed tracheal
intubation in obstetric anaesthesia: 2 yr national case-
control study in the UK. Br J Anaesth. 2013;110(1):74-80.
10. Weingart SD, Levitan RM. Preoxygenation and
prevention of desaturation during emergency airway
management. Ann Emerg Med. 2012;59(3):165-175.
n Spring 2017 43
 CASE RESOLUTIONS
■ CASE ONE
Following the 24-year-old fall
victim’s initial evaluation, the
obstetrical team initiated external
fetal monitoring. The patient’s vital
signs were consistent with third-
trimester pregnancy rather than
hemodynamic instability. Radiographs
of the chest and right shoulder were
unremarkable. The cervical spine was
cleared clinically in accordance with
the Canadian C-spine rule.31 Similarly,
the decision not to image the head was
based on the Canadian CT head rule.32
In order to prevent alloimmunization
and neonatal complications in future
pregnancies, Rho(D) IG, 300 mcg, was
given intramuscularly.
The patient was questioned without
her husband’s presence about feeling
safe at home and the circumstances
of the fall. Because the pattern of
the injuries was consistent with the
woman’s history and she denied abuse,
IPV was deemed unlikely. Four hours
of monitoring continued to show a
reassuring fetal heart rate and no
uterine contractions or other concerning
signs, so discharge was considered
safe. The patient was instructed to
return to the emergency department if
she experienced any vaginal bleeding,
decreased fetal movement, loss of
fluid vaginally, repetitive uterine
contractions, abdominal pain, or
tenderness.
■ CASE TWO
An immediate anterolateral
thoracotomy was performed in the
pulseless stabbing victim, which
revealed a large pericardial effusion. An
incision was made in the pericardium
to relieve the tamponade. On further
examination, one stab wound to the
anterior wall of the left ventricle was
identified and controlled with direct
finger pressure. A right subclavian
catheter was placed, and massive
transfusion protocol was initiated.
The fundal height was 5 cm above
the umbilicus, indicating a viable
pregnancy. Four minutes into the
arrest, given the lack of return of
spontaneous circulation, a perimortem
cesarean delivery was performed. ‘
After delivery, the patient regained
pulses and was taken to the operating
room for definitive repair of the cardiac
defect and exploratory laparotomy.
Multiple large bowel injuries and a
tear to the anterior gastric wall were
repaired. The patient was admitted to
the ICU in stable condition. She was
discharged to a rehabilitation center
3 weeks later after a prolonged stay.
She made a full recovery and was
discharged home 3 months after the
assault. Unfortunately, the baby died
on day 12 from complications related
to prematurity.

11. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med
Clin North Am. 2012;30(4):937-948.
12. Elmer J, Wilcox SR, Raja AS. Massive transfusion in
traumatic shock. J Emerg Med. 2013;44(4):829-838.
13. CRASH-2 trial collaborators, Shakur H, Roberts I,
et al. Effects of tranexamic acid on death, vascular
occlusive events, and blood transfusion in trauma
patients with significant haemorrhage (CRASH-2):
a randomised, placebo-controlled trial. Lancet.
2010;376(9734):23-32.
14. Grossman NB. Blunt trauma in pregnancy. Am Fam
Physician. 2004;70(7):1303-1310.
15. ACOG educational bulletin. Obstetric aspects of
trauma management. Number 251, September 1998
(replaces Number 151, January 1991, and Number 161,
November 1991). American College of Obstetricians
and Gynecologists. Int J Gynaecol Obstet.
1999;64(1):87-94.
16. Chen MM, Coakley FV, Kaimal A, Laros RK Jr.
Guidelines for computed tomography and magnetic
resonance imaging use during pregnancy and
lactation. Obstet Gynecol. 2008;112(2 Pt 1):333-340.
17. Puri A, Khadem P, Ahmed S, et al. Imaging of trauma
in a pregnant patient. Semin Ultrasound CT MR.
2012;33(1):37-45.
18. Centers for Disease Control and Prevention.
Radiation and pregnancy: A fact sheet for clinicians.
Available at: http://www.bt.cdc.gov/radiation/
prenatalphysician.asp. Accessed June 15, 2013. (Risks
of different imaging modalities based on theoretical
radiation doses.)
19. Sadro C, Bernstein MP, Kanal KM. Imaging of
trauma: Part 2, abdominal trauma and pregnancy—a
radiologist’s guide to doing what is best for
the mother and baby. AJR Am J Roentgenol.
2012;199(6):1207-1219.
20. Richards JR, Ormsby EL, Romo MV, et al. Blunt
abdominal injury in the pregnant patient: detection
with US. Radiology. 2004;233(2):463-470.
21. Brown MA, Sirlin CB, Farahmand N, et al. Screening
sonography in pregnant patients with blunt
abdominal trauma. J Ultrasound Med. 2005;24(2):175-
181; quiz 183-184.
22. Goodwin H, Holmes JF, Wisner DH. Abdominal
ultrasound examination in pregnant blunt trauma
patients. J Trauma. 2001;50(4):689-693; discussion 694.
23. Shah S, Teismann N, Zaia B, et al. Accuracy of
emergency physicians using ultrasound to determine
gestational age in pregnant women. Am J Emerg
Med. 2010;28(7):834-838.
24. Glantz C, Purnell L. Clinical utility of sonography in
the diagnosis and treatment of placental abruption. J
Ultrasound Med. 2002;21(8):837-840.
25. Barraco RD, Chiu WC, Clancy TV, et al. Practice
management guidelines for the diagnosis and
management of injury in the pregnant patient: The
EAST Practice Management Guidelines Work Group. J
Trauma. 2010;69(1):211-214.
26. Brown S, Mozurkewich E. Trauma during pregnancy.
Obstet Gynecol Clin North Am. 2013;40(1):47-57.
27. Tsuei BJ. Assessment of the pregnant trauma patient.
Injury. 2006;37(5):367-373.
28. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part
12: Cardiac arrest in special situations: 2010 American
Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122(18 Suppl 3):S829-S861.
29. Katz VL, Dotters DJ, Droegemueller W. Perimortem
cesarean delivery. Obstet Gynecol. 1986;68(4):571-576.
30. Brown HL. Trauma in pregnancy. Obstet Gynecol.
2009;114(1):147-160.
31. Stiell IG, Wells GA, Vandemheen KL, et al. The
Canadian C-spine rule for radiography in alert and
stable trauma patients. JAMA. 2001;286(15):1841-1848.
32. Stiell IG, Wells GA, Vandemheen K, et al. The
Canadian CT Head Rule for patient with minor head
injury. Lancet. 2001;357(9266):1391-1396.

Traumatic Injury Special Edition n Spring 2017 44

CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
A 27-year-old woman at 14 weeks’ gestation
presents after a high-speed motor vehicle collision
(MVC). A fetal heart rate cannot be detected with
Doppler ultrasound. What is the most appropriate
next step?
A. Continue maternal resuscitation
B. Place the patient on electronic fetal monitoring
and notify obstetrics
C. Prepare for an emergent cesarean delivery
D. Transport the patient to radiology for an
emergent formal fetal ultrasound
2 What is the leading cause of trauma-related fetal
death?
A. Placental abruption
B. Premature birth
C. Splenic rupture
D. Uterine rupture
3 What is the most likely cause of hypotension in
a pregnant woman at 34 weeks’ gestation who
presents after a fall?
A. Compression of the inferior vena cava from the
gravid uterus
B. Massive maternal hemorrhage
C. Normal physiological changes of pregnancy
D. Septic shock
6 A 22-year-old woman at 38 weeks’ gestation involved in a
low-speed MVC is placed on electronic fetal monitoring.
Although she has no significant maternal injuries, persistent
late decelerations with loss of variability are noted after 2
hours. What is the next best step?
A. Continue to monitor the fetus and consult obstetrics if the
patient develops early decelerations
B. Immediately call the obstetrical specialist; the patient likely
requires an emergent cesarean delivery
C. Immediately perform a bedside ultrasound
D. Immediately transfuse 2 units of RBCs; the most likely cause
of fetal distress is maternal hemorrhage
7 Why is airway management more difficult in late pregnancy?
A. It is impossible to adequately preoxygenate pregnant
patients
B. Paralytics are contraindicated
C. Preinduction agents are contraindicated
D. There are anatomical distortions of the airway, and increased
oxygen risk of aspiration
8 Which describes the prevalence of intimate partner violence
during pregnancy?
A. It decreases
B. It increases
C. It is not associated with pregnancy
D. It stays the same

4 A 26-year-old woman at 24 weeks’ gestation

presents after being assaulted with a baseball bat.
Her blood pressure is 70/50, and an eFAST reveals
9 A clinically unstable pregnant patient presents following an
free fluid in all abdominal views. In addition to
manually displacing the uterus to the left, what
other measure should be considered for blood
pressure management?
A. Administer a 2-liter bolus of IV normal saline
B. After an initial fluid bolus, start norepinephrine if
the patient remains hypotensive
C. Transfuse O Rh-negative blood, and consider
tranexamic acid
D. Wait until the mother’s blood type is known
before transfusing in order to prevent
alloimmunization
MVC; she is at 36 weeks’ gestation. You recommend a CT of
the abdomen and pelvis, but she expresses concerns about
the risks of radiation. Which response is most appropriate?
A. Delay the test until the radiologist is able to discuss the risks
of radiation with the patient
B. Explain that at her stage in pregnancy the radiation slightly
increases the fetus’s risk of childhood cancer; however, the
danger of missing a serious fetal or maternal injury outweighs
this theoretical risk
C. Order an MRI instead to prevent exposing the fetus to
ionizing radiation
D. Repeat the eFAST in 4 hours and reconsider the need for CT
if intraabdominal fluid increases

5 Which of the following is a pitfall of

ultrasonography in the evaluation of pregnant
10
trauma victims?
A. Poor sensitivity for detecting fetal cardiac activity
B. Poor sensitivity for detecting placental abruption
C. Poor sensitivity for estimating gestational age
D. Long acquisition time
What is the best course of action when resuscitating a
pregnant patient who shows no return of circulation after 4
minutes of CPR?
A. Call the code; the patient and fetus are unsalvageable
B. Continue CPR and consider performing a perimortem
cesarean delivery
C. Continue CPR and wait until a health proxy arrives in order to
obtain consent for a cesarean delivery
D. Stop CPR and perform a perimortem cesarean delivery

Traumatic Injury Special Edition n Spring 2017 45

 Brutal Force
Sexual Assault
in the Male Victim

LESSON 6

By Ralph J. Riviello, MD, MS, FACEP

Dr. Riviello is professor and vice chair of clinical operations in the Department of
Emergency Medicine at Drexel University in Philadelphia, Pennsylvania.
Reviewed by George Sternbach, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Describe the risk factors and unique characteristics of n What unique characteristics should be considered
male sexual assault victims.
when managing a male victim of sexual assault?
2. Perform a complete sexual assault evaluation and
describe key findings that suggest serious injury. n How should the physical examination be

3. Discuss the role of the sexual assault nurse examiner and
evidence collection process in male victims.
4. Describe the optimal prophylaxis for male victims
following a sexual assault.
5. Explain the long-term psychological consequences of
sexual violence.
FROM THE EM MODEL
14.0 Psychobehavioral Disorders
14.6 Patterns of Violence/Abuse/Neglect
approached in a male victim of sexual assault?
n What is the role of the Sexual Assault Nurse
Examiner, and how should forensic evidence be
collected?
n What prophylaxis should be provided to male
victims of sexual assault?
n What are the long-term psychological
consequences of sexual violence?

Research estimates that 1 in 6 men will experience unwanted sexual attention or abuse by the age of 18,
and an estimated 2 million have been the victim of rape.1-3 The majority of male patients who seek medical
attention following a sexual assault choose to do so in the emergency department. Although serious injury is rare,
clinicians must be prepared to address the unique needs of this patient population, provide time-sensitive prophylaxis against
infection, rule out potentially life-threatening trauma, and provide appropriate follow-up referrals to mitigate the significant
psychological consequences of sexual violence.

Traumatic Injury Special Edition n Spring 2017 46

 CASE PRESENTATIONS
■ CASE ONE
A 10-year-old boy is brought in
by his grandmother after disclosing
that his coach has been sexually
abusing him for the past several
months. His last contact with the
coach was one month ago, prior
to traveling to the grandmother’s
home for summer vacation. The
child reports digital penetration of
his anus, and describes being forced
to both receive and perform oral
sex. He is clinically asymptomatic
and does not appear to have any
physical abnormalities.
■ CASE TWO
A 30-year-old man presents
after being sexually assaulted at
a party. He remembers having a
few drinks and then waking up
to several strangers penetrating
him with unknown objects. The
physical examination reveals a sore
throat, rectal pain and noticeable
bleeding, and lower abdominal
tenderness with guarding. He has
no significant medical history and
his vital signs are stable. He is
visibly shaken and emotional.
■ CASE THREE
A 40-year-old man presents after being
raped by an ex-boyfriend. The assault involved
oral and anal penetration; the assailant
ejaculated and did not use protection.
The patient denies any specific physical
complaints, but is concerned because the
ex-partner has a history of IV drug abuse and
multiple sexual partners, and thinks he may
have recently become HIV positive. Their last
consensual intercourse with each other was
about a year ago. The patient’s last HIV test
was 1 month ago and was negative. Although
he does not want the police to be called, he
does agree to the collection of a rape kit.

CRITICAL DECISION
What unique characteristics
should be considered when
managing a male victim of sexual
assault?
Barriers to Reporting
Males are far less likely to report
sexual assault than their female counter­
parts for a number of reasons, including
cultural resistance to the idea that men
can indeed be “legitimate” victims of
these often-violent crimes. In addition,
there are significant social and emotional
barriers that discourage rape victims
from coming forward, including shame,
guilt, embarrassment, desire to keep the
incident secret from family and friends,
concerns about confidentiality, and fear
of not being believed.4 Although the
trepidation of being perceived as gay is
another significant deterrent to reporting,
particularly for men, sexual violence is
nondiscriminatory; every adult and child
is a potential victim.
Interestingly, males are far more
likely to report assaults committed by
strangers; they are 5 times more likely to
come forward when injuries are sustained,
and 8 times more likely when medical
treatment is required.5
Victim Characteristics
The mean age of male victims is
between 20 and 30 years, a statistic
that is comparable to that of female
victims.6 More than 47% of males
were first victimized before the age
of 25 years, often during childhood
and adolescence.2,3 More than 71% of
those who were forced to penetrate a
perpetrator were victimized before age
25, 21.3% before age 18 years, and
18.6% between age 11 to 17 years.7
An estimated 1 out of 59 (1.6%) non-
Hispanic white males will be a victim
of rape, which is defined as unwanted
oral or anal penetration.2 Sexual assault,
defined as any unwanted sexual contact,
including fondling and molestation, will
be experienced by 39.5% of multiracial
men, 26.6% of Hispanic men, 24.5%
of American Indian/Alaska Native men;
24.4% of non-Hispanic black men,
22.2% of non-Hispanic white men, and
15.8% of Asian or Pacific Islander men
during their lifetimes.3
Contrary to common stereotypes,
homosexuality does not appear to
increase the risk of assault; in fact, one
recent study reported that 68% of male
victims self-identified as heterosexual.8
Analysis of the 2010 National Intimate
Partner and Sexual Violence Survey
(NISVS) found that while the lifetime
prevalence of rape was 0.7% in
heterosexual males, it was too small to
calculate in gay and bisexual men.9 The
same study found the lifetime prevalence
for sexual violence, other than rape, was
40.2% for gay males, 47.4% for bisexual
males, and 20.8% for heterosexual
males.9 Interestingly, lesbian women
and gay men are significantly more likely
to report sexual and intimate partner
violence than heterosexuals.
Perpetrator Characteristics
Perpetrators of sexual assault can be
either male or female, although women
are far less common.3 Nearly 80% of male
rape victims report male-only assailants;
however, females appear to be the
predominate perpetrators of other sexual
violence (made to penetrate [82.6%],
sexual coercion [80%], and unwanted
sexual contact [54.7%]). In cases of
noncontact unwanted sexual experiences,
an estimated 46% of male victims report
male perpetrators, and approximately
43.6% had female perpetrators.
As with female victims, male victims
often know their assailant (Figure 1).
An estimated 52.4% are raped by an
acquaintance, 29% by an intimate
partner, and 15.1% by a stranger.2
Interestingly, other studies show a wide
range of stranger rapes among male
victims — some describing them as rarity,
and others attributing nearly all (95%)
to strangers.6,8,10-12 The marked disparity
in these statistics can be ascribed to how
each study defined “acquaintance” and
“stranger.”10
Males are twice as likely to be attacked
by multiple assailants than female
victims.6,11-14 This reality has important
implications in evidence collection and
analysis, and can help determine the need
for HIV prophylaxis.

Traumatic Injury Special Edition n Spring 2017 47

Assault Characteristics
Male patients are more likely to
sustain injuries to the anus than to any
other region of the body. They also are
at greater risk of suffering digital or
object (rather than penile) penetration, a
factor that may explain why male victims
sustain higher rates of injury to the
anal area than females.9,10,15 While male
victims experience more fondling, they
also may experience more violence during
sexual assault, including the use of a
weapon, verbal threats, physical restraint,
and forced alcohol consumption.7,10,12,13
When the assailant is female, forced
vaginal penetration often is a component
of the assault.
Special Populations
There are several populations
that appear to be at greater risk of
sexual assault, including men who
are incarcerated or institutionalized,
homeless, transgendered, and physically
or cognitively disabled; college students,
military personnel, gang members, and
mental health patients also are at greater
risk.12 Between 1 in 5 and 1 in 11 of male
college students report being sexually
victimized in some way.7 The Association
of American Universities reports an
incidence of 5% to 8%.16
Between 0.9% and 1.8% of active
duty male military personnel report
sexual victimization.17 Because of the
overwhelming volume of men in the
military, males are almost twice as
likely to be victimized than their female
counterparts; however, they are far less
likely to report the crime (Figure 2).
A reported 2% to 5% of male prison
inmates are sexually assaulted, and the
odds are even greater for prisoners with
other risk factors, including mental
health issues.18,19 Approximately, 60% of
these assaults are perpetrated by jail or
prison staff.
CRITICAL DECISION
How should the physical
require a victim-centered, trauma-
informed approach. The initial
goals are to ensure patient safety
and rule out any serious injuries or
complications. At a minimum, all
victims should undergo a medical
screening examination. Based on
those results, a sexual assault nurse
examiner (SANE) should be called
to complete the medical forensic
examination. If a SANE specialist is
not available, the American College
of Emergency Physician guidelines
support the transfer of medically stable
sexual assault victims to a designated
examination facility. 20
Upon arrival to the emergency
department, the patient should be
rapidly triaged and other members of
the Sexual Assault Response Team
(eg, social services, SANE, and rape
crisis center advocate) should be
notified. Depending on jurisdictional
protocols and patient preference, law
enforcement also should be contacted.
The clinician should perform a brief
history to rule out potentially serious
injury, determine which prophylactic
medications are needed, and assess
whether the patient has presented
within the time window required for
evidence collection.
Because of the risk of bodily injury
FIGURE 1. Intimate Partner Violence
tims?
are men vic
How often
U ni te d St ates have
n in the
1 in 10 me and/or stal
p hy si ca l violence,
rap e, th at th e y
d repo rt
par tner an
th e in ci dent.
by
e United S
e ly 1 in 4 men in th
at r shoved b
Approxim u sh e d o
been slap
ped, p
his lifetime.
par tner in
and complications from forced anal
intercourse, a thorough head-to-toe
assessment should be performed. An
estimated 43% of male victims sustain
oral penetration, and 66.7% sustain anal
assault.21 The rate of non-anogenital
injury in male victims appears to range
between 17% and 38%; approximately
66% suffer bodily injury.8,14,21
During the examination, caution
should be taken to avoid destroying
or altering physical evidence (Table 1).
Radiographic studies should be obtained
if indicated, and standard wound and/
or fracture care should be provided.
In the vast majority of cases, these
injuries are minor and rarely require
emergent intervention. The treatment of
life-threatening injuries should follow
advanced trauma/cardiac life support
(ATLS/ACLS) protocols and take
precedence over evidence collection.
The final documented diagnosis
should avoid the use of loaded terms
such as “alleged” and “rule out” when
referring to sexual assault. Better
alternatives include descriptions such as
“evaluation following sexual assault,”
“sexual assault,” and “reported sexual
assault.” Specific injury diagnoses or
physical findings also should be included
in the final patient record.
d
experience
a
king b y
ed
h av e b een af fect
tates has
y an in timate

examination be approached in a
States has
male victim of sexual assault? 7 m e n in the United by an
Nearly 1 in al violence
ce d se vere physic
The emergency department expe ri e n
is lifetim e.
ar tner in h
management of a male patient who has intimate p
been sexually assaulted is no different
ADAPTED FROM THE PEDIATRIC VICTIMS NATIONAL COALITION AGAINST DOMESTIC VIOLENCE
than that of a female patient; both

Traumatic Injury Special Edition n Spring 2017 48


FIGURE 2. Victims in the Military
COURTESY OF NATIONAL SEXUAL VIOLENCE RESOURCE CENTER
CRITICAL DECISION
What is the role of the Sexual
Assault Nurse Examiner, and
how should forensic evidence be
collected?
The role of the Sexual Assault Nurse
Examiner (SANE) is no different for
male victims than for female victims.
These specialists should be consulted to
perform a medical forensic examination
in any patient who reports a sexual
assault. Although the evaluation can be
conducted up to 7 days following the
incident, most hospital policies indicate
5 days as a cutoff.22 Evidence, which
should be collected in a jurisdictionally
specific sexual assault evidence kit (rape
kit), usually is not gathered more than 24
to 36 hours after an oral or anal assault.
In pediatric cases, it is particularly
important to follow jurisdictional
protocols. In such cases, a 72-hour
window typically is utilized; however,
this should be determined on a case-by-
case basis.23 Any prepubescent patient
should be assessed by a specialized
pediatric examiner. If the window for
acute evidence collection has expired,
the patient should be referred to the local
child advocacy center for a specialized
forensic interview and examination. The
use of a multidisciplinary response team
is best practice for pediatric victims.
Each state has mandated reporting
standards regarding children that must
be followed.
All victims should consent to
the examination, photography, and
evidence collection, and agree for
the information to be turned over to
law enforcement. The patient has the
Traumatic Injury Special Edition
right to decline any or all parts of the
evaluation and can revoke or change that
consent at any time during the process.
Documentation of the medical
forensic examination should occur on
jurisdiction-specific forms that include
preprinted questions. The process begins
by taking a forensic history detailing
the assault. The physical examination
should include a head-to-toe assessment;
the more intrusive components of the
examination should be performed last.
Next, injuries must be documented and
evidence (including photographs) should
be collected.
In victims who were unconscious or
cannot remember specifics about the
assault, it is important to collect swabs
from the mouth, neck, breast, nipple,
penis, scrotum, perineum, and rectum,
as these areas have a high likelihood of
DNA recovery. Two swabs moistened
with sterile or distilled water can be
used for the entire penis, and two
additional swabs can be used for the
base of the penis and anterior scrotum. 22
Alternatively, swabs of the glans/prepuce,
shaft, base of penis, and anterior scrotum
can be taken separately (8 swabs total).
Swabs should be air dried, packaged, and
then placed into the rape kit.
Ultraviolet light can be used to
scan the body for potential biological
evidence. Saliva, semen, and urine
all fluoresce under ultraviolet light.
Areas that glow should be documented
and wiped with moistened swabs for
submission to the crime lab. It should be
noted that not all items that fluoresce are
biological; soaps and lotions also may be
visualized — but this potential confusion
should not deter specimen collection.
Although multiple studies describe the
incidence of male anogenital injuries, the
data is inconsistent; some report a rate
as low as 3.1%, while others estimate
it to be as high as 72%. 10,21,23-27 This
discrepancy may be due in part to studies
that do not differentiate bodily injury
from anogenital injury. While some
researchers claim that female victims
sustain anogenital injuries more often
than males (52.7% vs 35.5%), others
assert the opposite is true (32.4% vs
43.9%). 21,24 Regardless, if the gap exists
between these two patient populations, it
is unlikely to be wide.12
n Spring 2017 49
 Common anal findings in male
victims include erythema, tears,
bleeding, hematoma, tenderness, fissures,
traumatic proctitis, non-perforating
mucosal lacerations, anal sphincter
disruption, transmural perforation of
the rectosigmoid colon, foreign bodies
(eg, dirt, foreign bodies, hair), friability,
and engorgement. The diagnosis of
deeper, transmural lacerations may be
delayed; these patients may present with
peritonitis. Males who have sustained
digital penetration and/or fisting may
present with higher rates of severe
injuries, some of which will require
examination under anesthesia or surgical
repair.
Anoscopic Evaluation
An anoscopic examination can be
enhanced with the use of toluidine blue
dye, a nuclear stain that can be applied
around the anal sphincter to highlight
lacerations, abrasions, and tears. The dye
can be removed with lubricating jelly,
baby wipes, or 1% acetic acid solution.
TABLE 1. Evidence Collection in Male Victims
Medical Forensic Examination
• Pertinent past medical history
and allergies
• Forensic history
• Vital signs
• Physical appearance
• Demeanor
• Behavior and sexual orientation
• Identification of injuries or trauma
• Anogenital examination
— External and perineal area for injury
identification and physical evidence
— Abdomen
— Buttocks
— Thighs
— Foreskin
— Glans
— Urethral meatus
— Penile shaft
— Scrotum
— Testes
— Perineum
— Anal examination
— Rectal examination with anoscope
— Oral examination
— Documentation (eg, written,
diagrammatic, and photographic)
Anoscopy, which is capable of detecting
additional injuries not noted on gross
examination, may perform better than
colposcopy in detecting injuries. The
diagnostic tool, which can be gently
inserted to observe rectal-sigmoid
mucosal damage, appears to increase
the detection of anal findings by 32%. 27
The anoscope also facilitates forensic
evidence collection without external
surface contamination and allows better
visualization of swab insertion. The
tool should be inserted after perineum
and perianal areas have been swabbed
and toluidine blue has been applied.
Anal swabbing can be accomplished
by inserting swabs about 2 cm into
the rectum. If anoscopy is not used,
gentle, steady anal traction can be
used to allow dilatation and facilitate
visualization.
Patients with moderate to severe
pain, rectal bleeding without visible
injury, anal sphincter disruption,
rectosigmoid injury, a retained foreign
Evidence Collection
• Clothing
• Debris
— From patient’s body
— From under fingernails
• Foreign materials and swabs from
body
• Pubic hair combings
• Oral and genital swabs (as indicated)
— Penile swab
— Anal swab
— Oral swab
— Perioral swab
Traumatic Injury Special Edition
body, or peritoneal signs require surgical
consultation and probable examination
under anesthesia.
Substance Abuse
Alcohol and drug-facilitated sexual
assault (ADFSA) is not uncommon.
Most studies report high rates of alcohol
consumption among male victims,
although it is not clear if this action is
voluntary or involuntary. Other drugs
commonly used in ADFSA include
benzodiazepines, diphenhydramine,
sleeping pills, and rarely Gamma-
Hydroxybutyrate acid (GHB) and
rohypnol.
Alcohol and drug-facilitated sexual
assault should be considered in patients
who present with amnesia of events,
severe nausea and vomiting, drowsiness,
fatigue, dizziness, memory loss, impaired
motor skills, severe intoxication, or
in those whose level of intoxication
is disproportionate to the amount
of alcohol consumed.27 If ADFSA is
suspected, urine and blood drug testing
should be performed, preferably using
the first available urine specimen, per
jurisdictional policy. These specimens
should be sent to specialized forensic
laboratories, not analyzed by the in-
hospital laboratory. Specimen collection
for ADFSA can be performed up to 96
hours post assault; however, the chance
of recovery is better when the evidence
is collected closer to the time of the
incident.
CRITICAL DECISION
What prophylaxis should be
provided to male victims of
sexual assault?
The Centers for Disease Control
and Prevention recommend offering
prophylaxis against certain infectious
agents to any victim of sexual assault
(Table 4).28 Males are at particular risk
for contracting sexually transmitted
infections (STIs) following such an
attack. While older studies assert that
only a small proportion of victims
actually develop these diseases, no
recent studies have been performed. Of
particular concern is the transmission
of Neisseria gonorrhoeae, Chlamydia
trachomatis, syphilis, hepatitis B virus
(HBV), and human immunodeficiency
n Spring 2017 50

TABLE 2. Risk of HIV Acquisition from an Infected Source
Exposure Type
Receptive anal intercourse
Insertive anal intercourse
Insertive penile-vaginal intercourse
Receptive penile-vaginal intercourse
Oral intercourse (insertive or receptive)
virus (HIV). Effective prophylactic
treatment is available for all of these STIs,
with the exception of syphilis.
Hospitals should have a protocol in
place for STI testing in sexual assault
victims prior to offering prophylaxis.
One approach is to forgo testing in lieu
of offering prophylaxis to all victims.
Another option is to test patients and
offer prophylaxis only to victims who
are deemed high risk, including those in
whom a preexisting infection has been
identified (provided the victim presents
prior to the infectious agent’s incubation
period). If testing is warranted, specimens
should be taken from all areas of
potential penetration. Nucleic acid
amplification tests (NAATs) are adequate
for pharyngeal and anal sites.
Pediatric Victims
In the prepubescent and sexually
inexperienced population, the presence
of an STI beyond the neonatal period
is a strong indicator that a sexual
assault has occurred. Therefore,
testing is recommended; however, only
children with confirmed STIs should
be treated. Because the data on NAAT
use in children is limited, culture is the
preferred method of detection. Pediatric
victims should undergo anal cultures for
gonorrhea and chlamydia and pharyngeal
cultures for gonorrhea only, as the
likelihood for pharyngeal chlamydia
recovery is very low. Urethral sampling
is not recommended unless discharge is
present. Some clinicians opt to use a urine
NAAT, confirming positive results with a
cultured urethral swab.28
Hepatitis B and HIV
The risk of hepatitis B transmission
is another serious concern. Most
children have been vaccinated against
the disease and do not usually require
Rate Per 10,000 Exposures
138
11
4 Patients should undergo rapid
8
Low
additional doses. The hepatitis B
series should be initiated in any
unimmunized adult; hepatitis B
immunoglobulin is not recommended.
If the adult has been vaccinated but has
not received post-vaccination testing,
a single booster dose is appropriate.
A patient with an unknown post-
vaccination status can undergo testing
or be given a booster dose.
The biggest concern among male
sexual assault victims is HIV. HIV
seroconversion has occurred in patients
whose only risk factor was sexual assault
or abuse. Although the exact risk of
transmission is unknown, it is dependent
upon the type of exposure and may be
higher in sexual assault due to genital
injuries sustained through the use of
force (Table 2).29 If the assailant is HIV
negative, the risk of infection clearly
is zero; however, the HIV status of the
assailant frequently is unknown.
Nonoccupational Post-
Exposure Prophylaxis
Occupational post-exposure
prophylaxis has been extrapolated
to use in patients following sexual
assault. During the initial examination,
the risk of HIV exposure should be
assessed, and high-risk victims should
be informed about the possible benefits
of nonoccupational post-exposure
prophylaxis (nPEP). The sooner nPEP is
initiated, the more effective it is. Ideally,
the treatment should be administered
within 72 hours of the assault and
continued for a total of 28 days.
There are several factors that
influence the medical recommendation
for nPEP (Table 3).28,29 If the treatment
is offered, the victim must be informed
of the necessity of early initiation, close
follow up, adherence to regimen, and
Traumatic Injury Special Edition
potential medication side effects. Even
with the fear of HIV acquisition, regimen
ease, and minimal complications, the
number of patients who accept the
treatment remains low, and the rate of
regimen compliance is even lower.
HIV testing prior to the initiation of
nPEP to exclude preexisting infection;
however, the treatment should not be
withheld even if testing is unavailable.
In addition, a complete blood count
and chemistry panel should be
evaluated. Patients should be given a
starter pack upon discharge from the
emergency department to bridge them
to follow up care (eg, a 3- to 7-day
dose), or the patient may be provided
a prescription for the entire course
of treatment. Most prescription drug
plans will cover medications for HIV
nPEP. A consultation with an HIV
medical specialist should be obtained
for pediatric patients or patients with
preexisting renal disease, liver disease, or
a complex medical history.
The key to a successful nPEP program
is follow up and access to care. It is
important for emergency departments
to develop a predetermined follow-up
plan for victims of sexual violence.
Patients should be referred to a clinician
knowledgeable in HIV disease and nPEP.
TABLE 3. Considerations for
HIV Post-Exposure Prophylaxis
• Assailant Factors
— HIV Status
— Characteristics and HIV risk
behaviors in assailant (injection
drug abuse, men who have sex
with
— Presence of mucosal lesions
• Local epidemiology/prevalence of
HIV/AIDS
• Time elapsed since assault
• Risk and benefits of treatment
• Assault Characteristics
— Multiple assailants
— Vaginal and/or anal penetration
— Condom use
— Ejaculation onto mucosal
membranes
— Presence of mucosal lesions on
victim
— Genital injury/trauma
n Spring 2017 51
 Additional information can be
obtained from the CDC website
(www.cdc.gov). Additional HIV nPEP
information and help can be obtained
from the Clinician Consultation Center
PEP Helpline at 1-888-448-4911.
CRITICAL DECISION
What are the long-term
psychological consequences
of sexual violence?
Victims of sexual violence cope
with their trauma in a variety of ways;
there is no universal strategy. Common
psychological consequences of these
events include anxiety, depression,
irritability, somatic complaints,
insomnia, and behavioral changes.7 In
the immediate aftermath of an assault,
patients may experience extreme
disorganization and chaos in their lives.
Interestingly, fewer than 50% of male
victims will seek counseling services.13
The trauma may manifest as
emotional lability and physical symptoms
such as skeletal muscle tension/pain,
gastrointestinal irritability, genitourinary
disturbances, and impotence. Long-term
effects can include avoidance/withdrawal
behaviors, nightmares/flashbacks, fear of
places that remind them of where assault
occurred, fear of crowds, and avoidance
of consensual sexual activity.
Although males suffer from higher
rates of alcohol abuse than female
victims, the increased risk does not
extend to drug abuse. Males who
have been sexually assaulted also
report a disproportionately higher
rate of depression and anxiety. Sexual
dysfunction and posttraumatic stress
n Male sexual assault victims should receive the same services offered to female
victims, including a comprehensive forensic evaluation by a SANE specialist.
n The biggest concern among male sexual assault victims is HIV. During the initial
examination, the risk of HIV exposure should be assessed, and high-risk patients
should be informed about the possible benefits of nPEP.
n Anoscopy should be performed to identify rectal injury.
n Male victims should be referred to rape crisis centers to assist in their healing
process.
TABLE 4. Prophylactic Post-Sexual Assault Regimens
Gonorrhea Ceftriaxone 250 mg IM once
Chlamydia Azithromycin 1 g PO once
HBV Hepatitis B vaccine 1 mL IM once; repeat at 1 month
and 6 months
HIV Emtricitabine-tenofovir (Truvada) 200 mg/300 mg PO
daily x 28 days
PLUS
Raltegravir (Isentress) 400 mg PO 2x/day x 28 days
OR
Dolutegravir (Tivicay) 50 mg PO daily x 28 days
disorder, which has been linked to rape element that can exacerbate the sense
trauma syndrome (a cluster of emotional of guilt or shame. It is not uncommon
and physical symptoms), also are for a victim to experience an erection
commonly reported.7 and even ejaculate during such an event.
Pediatric male sexual assault These complex physiological responses
survivors are more likely than adults to often are erroneously perceived to imply
report mental health symptoms. Boys consent or suggest that the victim may
also experience higher rates of anxiety, have even “enjoyed” the experience. On
depression, substance abuse, and health the contrary, these involuntary responses
problems in later life. In addition, are beyond a victim’s complete control
sexually victimized children have a high and can be provoked by high anxiety,
rate of subsequent sexual victimization.1 intense pain, panic/fear, or genital or
One of the most common anal stimulation.
ramifications of sexual violence its
Summary
ability to cause male victims to doubt
Male sexual assault survivors have
their masculinity or “true” sexual
unique medical forensic needs and
orientation.7,6 The victims often question
often feel marginalized by responders,
whether the rape “makes” them gay or
including law enforcement, health
wonder if others perceive them as such.
care, and advocacy groups. Emergency
One study found that 70% reported
departments who treat sexual assault
long-term crises with their sexual
victims should develop protocols
orientation, and 68% felt their sense of specifically for managing male patients.
masculinity had been compromised by These victims should be offered a
the assault.30 medical forensic examination by a
These concerns can be especially SANE, and also should receive STI
acute if the victim experienced any and HIV prophylaxis and be referred
form of arousal during the assault, an for rape crisis counseling services.
In addition, past sexual assault
experiences may negatively affect the
physical and psychological wellbeing of
survivors, portending future emergency
department visits.
REFERENCES
1. Dube SR, Anda RF, Whitfield CL, et al. Long-term
consequences of child sexual assault by gender of
victim. Am J Prev Med. 2005;28(5):430-438.
2. Black MC, Basile KC, Breiding MJ, et al. The national
intimate partner and sexual violence survey (NISVS):
2010 Survey Report. Atlanta, GA: National Center
for Injury Prevention and Control, Centers for
Disease Control and Prevention. 2011. Available
at: http://www.cdc.gov/violenceprevention/pdf/
nisvs_executive_summary-a.pdf.
3. Breiding MJ, Smith SG, Basile KC, et al. Prevalence and
characteristics of sexual violence, stalking, and inti­
mate partner violence victimization: national intimate
Traumatic Injury Special Edition n Spring 2017 52
 CASE RESOLUTIONS
■ CASE ONE
After ensuring the child’s
safety, the clinician notified
the police and Child Protective
Services. Because the patient’s last
contact with his perpetrator was
more than 72 hours ago, it was
determined that a rape kit was not
needed. The physical examination
revealed a healed anal laceration
(scar) at the 4 o’clock position.
The boy also underwent a forensic
interview and examination at the
local children’s advocacy center.
partner and sexual violence survey, United States,
2011. MMWR Surveill Summ. 2014;63(SS08):1-18.
4. Sable MR, Danis F, Mauzy DL, Gallagher SK. Barriers
to reporting sexual assault for women and men:
perspectives of college students. J Amer Coll
Health. 2006;55(3):157-162.
5. Pino NW, Meier RF. Gender differences in rape
reporting. Sex Roles. 1999;11(12):979-990.
6. McLean IA. The male victim of sexual assault. Best
Pract Res Clin Obstet Gynaecol. 2013;27(1):39-46.
7. Tewksberry R. Effects of sexual assaults on men:
physical, mental, and sexual consequences. Intl J
Men’s Health. 2007;6(1):22-35.
8. Larsen ML, Hilden M. Male victims of sexual assault:
10 years’ experience from a Danish assault center. J
Forensic Leg Med. 2016;43:8-11.
9. Walters ML, Chen J, Breiding MJ. The national
intimate partner and sexual violence survey
(NISVS): 2010 findings on victimization by sexual
orientation. Atlanta, GA: National Center for
Injury Prevention and Control, Centers for Disease
Control and Prevention. 2013. https://www.cdc.gov/
violenceprevention/pdf/nisvs_sofindings.pdf.
10. Pesola GR, Westfal RE, Kuffner CA. Emergency
department characteristics of male sexual assault.
Acad Emerg Med. 1999;6(8):792-798.
11. Hiquet J, Gromb-Monnoyeur S. Men victim of sexual
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unit for victims of assaults in France. J Forensic Leg
Med. 2013;20(7):836-841.
12. Stermac L, Del Bove G, Addison M. Stranger and
acquaintance sexual assault of adult males. J
Interpers Violence. 2004;19(8):901-915.
13. McLean IA, Balding V, White C. Further aspects of
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Manchester. Med Sci Law. 2005;45(3):225-232.
n Failing to provide adequate post-assault services to male victims.
n Failing to provide a comprehensive medical forensic examination to male
victims.
n Neglecting to provide STI and/or HIV prophylaxis following a reported assault.
n Dismissing the psychological sequelae of sexual violence in male victims.
■ CASE TWO
Anoscopy revealed a large laceration
to the lateral rectal wall of the man
who had been attacked by multiple
assailants. His white blood cell count
was elevated to 18,000. General surgery
was consulted and the patient was taken
to the operating room, where a 10-cm
rectal wall laceration was found with
contamination of the peritoneal cavity.
While the he was in the operating room,
the Sexual Assault Nurse Examiner
obtained evidence using rectal swabs.
The patient underwent a diverting
colostomy, and did well postoperatively.
14. Nesvold H, Worm AM, Vala U, Agnarsdóttir G.
Different Nordic facilities for vicitms of sexual
assault: a comparative study. Acta Obst Gynecol
Scand. 2005;84(2):177-183.
15. Stermac L, Sheriden PM, Davidson A, Dunn S.
Sexual assault of adult males. J Interpers Violence.
1996;11:52-64.
16. Cantor D, Fisher B, Chibnall S, Townsend R, et al.
Report on the AAU campus climate survey on on
sexual assault and sexual misconduct. Rockville, MD:
Westat, 2015. Available at: https://www.aau.edu/
uploadedFiles/AAU_Publications/AAU_Reports/
Sexual_Assault_Campus_Survey/Report%20on%20
the%20AAU%20Campus%20Climate%20Survey%20
on%20Sexual%20Assault%20and%20Sexual%20
Misconduct.pdf.
17. US Department of Defense Sexual Assault
Prevention and Response. Department of Defense
annual report on sexual assault in the military, fiscal
year 2014. Washington, DC: Department of Defense,
2015. Available at: http://sapr.mil/public/docs/
reports/FY14_Annual/FY14_DoD_SAPRO_Annual_
Report_on_Sexual_Assault.pdf.
18. Wolff N, Jing Shi. Contextualization of physical and
sexual assault in male prisons: incidents and their
aftermath. J Corr Health Care. 2009;15(1):58-82.
19. Beck AJ, Berzofsky M, Caspar R, Krebs C. Sexual
victimization in prisons and jails, reported by
inmates, 2011-12: national inmate survey 2011-12.
Washington, DC: U.S. Department of Justice, Office
of Justice Programs Bureau of Justice Statistics,
2013. Available at: https://www.bjs.gov/content/
pub/pdf/svpjri1112.pdf.
20. American College of Emergency Physicians.
Selective triage for victims of sexual assault victims
to designated exam facilities. Available at: https://
www.acep.org/clinical---practice-management/
Traumatic Injury Special Edition
■ CASE THREE
The patient who had been
raped by an ex-partner underwent
a medical forensic examination,
which revealed bruising to the soft
palate and oropharynx as well as
edema and ecchymosis of the anal
sphincter. The anoscopic examination
was unremarkable. Standard STI
prophylaxis was administered;
HIV prophylaxis (ie, Truvada and
Isentress) also was initiated and
continued for 28 days. The patient
remained HIV negative at his 3- and
6-month follow-up visits.
selective-triage-for-victims-of-sexual-assault-to-
designated-exam-facilities.
21. Riggs N, Houry D, Long G, et al. Analysis of
1,076 cases of sexual assault. Ann Emerg Med.
2000;35(4):358-362.
22. U.S. Department of Justice Office of Violence
Against Women. A national protocol for sexual
assault medical forensic examinations: adults/
adolescents. 2nd ed. Washington, DC: 2013.
Available at: https://www.ncjrs.gov/pdffiles1/
ovw/241903.pdf.
23. U.S. Department of Justice Office of Violence
Against Women. A national protocol for sexual
assault medical forensic examination: pediatrics.
Washington, DC: 2016. Available at: https://www.
justice.gov/ovw/file/846856/download.
24. Lammers K, Martin L, Andrews D, Seedat S. Reported
rapes at a hospital rape centre: demographic and
clinical profiles. SAMJ. 2010;100(6):362-363.
25. Grossin C, Sibille I, Lorin de la Grandmaison G, et al.
Analysis of 418 cases of sexual assault. Forensic Sci
Int. 2003;131(2-3):125-130.
26. Ernst AA, Green E, Ferguson MT, et al. The utility
of anoscopy and colposcopy in the evaluation
of male sexual assault victims. Ann Emerg Med.
2000;36(5):432-437.
27. International Association of Forensic Nurses.
Examination process-alcohol and drug facilitated
sexual assault. Elridge, MD: Sexual Assault Forensic
Examination Technical Assistance. Available at:
http://www.safeta.org/?page=ExamProcessADFSA.
28. Workowski KA, Bolan GA. Sexually transmitted
disease treatment guidelines, 2015. MMWR Recomm
Rep. 2015;64(No. RR-3):1-137.
29. Centers for Disease Control and Prevention.
Updated guidelines for antiretroviral post exposure
prophylaxis after sexual, injection drug use, or other
nonoccupational exposure to HIV—United States,
2016. Atlanta, GA:2016. Available at: https://stacks.
cdc.gov/view/cdc/38856.
30. Walker J, Archer J, Davies M. Effects of rape on
men: a descriptive analysis. Arch Sex Behavior.
2005;34(1):69-80.
ADDITIONAL READING
American College of Emergency Physicians. Evaluation
and Management of the Sexually Assaulted or
Sexually Abused Patient. 2013. Available at: https://
www.acep.org/sexualassaultebook.
U.S. Department of Justice Office of Violence Against
Women. A national protocol for sexual assault
medical forensic examinations: adults/adolescents.
2nd ed. Washington, DC: 2013. Available at: https://
www.ncjrs.gov/pdffiles1/ovw/241903.pdf.
n Spring 2017 53
CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
Which of the following describes an important
difference between male and female victims of
sexual assault?
6 Which of the following should be considered when evaluating a
A. Males are more likely to be victimized by
multiple assailants
B. Male victims are 3 times more likely report
the assault to the police
C. Male victims tend to be older than female
victims
D. Most male victims experience their first
assault after the age of 25
suspected victim of alcohol and drug-facilitated sexual assault?
A. Urine and blood specimens are of no forensic value if collected
more than 24 hours after the assault
B. Urine and blood specimens should be gathered and
immediately sent to the in-hospital laboratory for expedient
testing
C. Urine and blood tests are warranted in any victim with amnesia,
dizziness, impaired motor skills, or other signs of acute
intoxication
D. Urine tests are likely to be contaminated and will be of little
utility in such cases

2 Which patient population is most at risk of

sexual assault?
A. Gay men 7 Routine prophylaxis against which of the following infections is
not recommended for male victims of sexual assault?
B. High school boys A. Chlamydia
C. Male athletes B. Gonorrhea
D. Male military personnel C. HIV
D. Trichomonas

3 Which of the following is a characteristic of

sexual violence against males?
A. Gay men are at greater risk than
heterosexuals
B. In male victims, sexual assault is defined as
unwanted penetration
C. It can cause significant shame and lead
victims to question their masculinity and/or
sexual orientation
D. It frequently results in significant bodily injury
8 Which of the following factors should be considered when
providing HIV prophylaxis after an assault?
A. It has many side effects and often is poorly tolerated
B. It should only be offered if the assailant is known to be HIV-
positive
C. The patient should be well informed about the risks and benefits
of the treatment
D. The treatment is only effective if initiated within 24 hours of the
assault

4 Which of the following is commonly seen in

male victims post-sexual assault?
A. Anxiety, depression, and sexual dysfunction
9 What factor should be considered when evaluating for
anogenital injuries in male sexual assault victims?
A. Bleeding is the only reliable sign of injury
B. Promiscuity B. Colposcopy is more sensitive than anoscopy for detecting injury
C. Psychosis and aggression C. These injuries are best detected using anoscopy and toluidine
D. Suicide blue dye
D. These injuries often are serious enough to require surgical

5 Which of the following steps is appropriate

when discharging a victim of sexual violence?
intervention

A. The diagnosis should be documented as

“alleged sexual assault” to avoid legal
liability
B. The patient must be required to report the
assault to law enforcement
C. The patient should be provided with a
referral to a local rape crisis center
D. The patient should receive a formal
psychiatric evaluation prior to discharge
10
How should the forensic examination be approached in a male
patient?
A. Evidence must be collected within 24 hours of an assault
B. Evidence must be collected within 48 hours of an assault
C. Evidence should be collected from all areas of potential contact
or penetration
D. Evidence should be collected in a male-specific kit that differs
from the kits used for females

Traumatic Injury Special Edition n Spring 2017 54


OBJECTIVES
On completion of this lesson, you should be able to:
1. Describe the initial diagnostic and therapeutic
approach to the trauma patient in, or at immediate
risk for, cardiopulmonary arrest.
2. Discuss the common causes of cardiopulmonary
arrest in cases of blunt and penetrating trauma.
3. Identify the indications for the emergency
department thoracotomy.
4. Manage the patient in cardiopulmonary arrest due
to pericardial tamponade.
5. Describe the predictors of survival in patients with
traumatic cardiopulmonary arrest.
6. Explain the indications to terminate resuscitation of
the patient in traumatic cardiopulmonary arrest.
FROM THE EM MODEL
3.0 Cardiovascular Disorders
3.1
Cardiopulmonary Arrest
Broken Hearted
Traumatic
Cardiopulmonary Arrest
LESSON 7
Mandy M. Pascual, MD, and John Pease, MD, FACEP (not pictured)
Dr. Pascual is an assistant professor in the Department of Emergency Medicine at
UT Southwestern Medical Center in Dallas, Texas. Dr. Pease is an attending
emergency physician at Baylor Emergency Medical Center in Rockwall, Texas.
Reviewed by Lynn Roppolo, MD, FACEP
CRITICAL DECISIONS
n What essential steps should be taken when diagnosing
and treating the trauma patient in cardiopulmonary
arrest?
n What are the common causes of cardiopulmonary arrest
in patients with blunt trauma, and how should these
injuries be managed?
n What are the common causes of cardiopulmonary arrest
in patients with penetrating trauma, and how should
these injuries be managed?
n When should emergency department thoracotomy be
performed?
n What factors should be considered when predicting
patient survival?
n When should resuscitation be terminated?
Traumatic Injury Special Edition n Spring 2017 55
 CASE PRESENTATIONS
■ CASE ONE
A 24-year-old man involved in
a gang-related shooting arrives by
ambulance after sustaining a single
gunshot wound to the left chest.
EMS reports finding the diaphoretic,
pale-appearing patient at the scene,
clutching a blood-soaked handkerchief
to his chest; he was minimally
responsive to voice and complained
only of pain at the site of bullet entry.
The EMS crew performed rapid
primary and secondary surveys and
placed two large-bore IVs during
transport to the hospital. The patient’s
initial vital signs were blood pressure
80/40, pulse 140, and respiratory
rate 30. As the patient is rushed
through the doors of the emergency
Major trauma is the leading cause
of death in young adults worldwide,
and accidents are the leading cause
of death of Americans from 1 to
44 years old.1 Trauma victims can
arrest immediately at the scene, during
transport by prehospital personnel, in
the emergency department, or after
disposition to the operating room
or intensive care unit. Recognizing
pending arrest is critical in the
management and treatment of these
critically ill patients.
The trimodal distribution of
trauma deaths includes 1) death in the
prehospital stage, 2) minutes to hours
after emergency department arrival,
and 3) in the intensive care setting after
admission. 2 Emergency physicians, who
deal most frequently with patients in the
second peak, must concentrate on the
prompt identification and treatment of
potentially lethal injuries that require
emergent intervention.
Causes of death from blunt and
penetrating trauma differ, as each
injury mechanism predisposes patients
to specific injury patterns. Death
typically results from severe injuries
to the head, torso, or extremities (in
cases of major vascular trauma). 2 The
department, one of the paramedics
yells, “He just lost his pulse!”
■ CASE TWO
A middle-age man is rushed to the
emergency department by ambulance
following a motor vehicle accident
on a major interstate. Emergency
personnel report that he was traveling
75 miles per hour when he lost
control and crossed over three lanes
of traffic, slamming head on into
a concrete divider and rolling his
sedan several times. The driver was
unrestrained and partially ejected; his
legs were pinned, slowing extrication.
His vital signs on scene were heart
rate 132, blood pressure 92/60, and
oxygen saturation 80% with shallow
respirations. EMS placed two large-
emergency physician must be able
to recognize and treat these life-
threatening conditions while minim­
izing further insults to the patient.
CRITICAL DECISION
What essential steps should
be taken when diagnosing and
treating the trauma patient in
cardiopulmonary arrest?
Every trauma patient should be
approached according to the Advanced
Traumatic Life Support (ATLS)
algorithm developed by the American
College of Surgeons Committee on
Trauma. The universal guidelines,
which provide a systematic framework
for managing trauma victims, were
developed to help healthcare providers
recognize and simultaneously initiate
treatment of life-threatening injuries.
The “ABCDE” approach delineates
the evaluation of airway, breathing,
circulation, disability, and exposure.
Specific life-threatening injuries that
can be immediately recognized during
the primary survey include airway
obstruction, tension pneumothorax,
and massive hemorrhage (Table 1). 3
Traumatic Injury Special Edition
bore IVs and intubated the patient
before transport. He loses his pulse
just as the ambulance arrives at the
hospital.
■ CASE THREE
A pulseless 18-year-old student
arrives by ambulance after being
struck by a car while attempting
to cross a busy thoroughfare; she
has sustained significant injury to
her upper abdomen and thorax.
At the scene, the patient’s vital
signs were blood pressure 90/45
with a heart rate of 130, but
EMS reports that she became
progressively hypotensive during
transport. Despite aggressive fluid
resuscitation, she continued to
decline until arrival at the hospital.
Airway
The airway assessment determines
patency and injury. Obstruction of
the airway can result from direct
maxillofacial trauma or profound
decreased alertness, which can
predispose the patient to aspiration.
Complete or partial obstruction can
quickly result in hypercapnic or hypoxic
respiratory arrest and subsequent
cardiopulmonary arrest; any airway
obstruction must be identified and
addressed immediately. Evaluating the
patient’s ability to speak with their
normal voice typically assesses if the
airway is patent; if it is not, a definitive
airway must be established.
A delay in intubation is associated
with increased mortality.4 A definitive
airway is defined as a cuffed
endotracheal tube secured in the glottis
opening. Rapid-sequence induction
(RSI) with direct laryngoscopy and
orotracheal intubation, which is used
to produce expeditious sedation and
paralysis, is the most commonly used
technique. An RSI drug regimen should
be used to achieve adequate sedation,
neuromuscular blockade, maintenance
of hemodynamic stability and
oxygenation, prevention of increased
n Spring 2017 56
intracranial pressure (ICP), and
prevention of vomiting and aspiration.
An obtunded patient might require
lower dosages of the induction agent to
achieve adequate sedation. Furthermore,
higher doses of paralytic agents should
be used when a patient is in shock due to
inadequate tissue perfusion.
Although direct laryngoscopy
is the most common technique for
endotracheal intubation, airway
adjuncts such as supraglottic devices,
gum-elastic bougie, video-assisted
laryngoscopes, or flexible fiberoptic
laryngoscopy also can be used. It is
essential to maintain in-line cervical
stabilization during intubation, as these
patients are at high risk for cervical
spine injury.
Supraglottic devices, including
laryngeal mask airway (LMA), are used
in many EMS systems and emergency
departments for establishing primary
and rescue airways. If a patient is
adequately ventilated by a supraglottic
device and is in cardiopulmonary arrest,
the clinician can consider leaving it
in place until the patient is stabilized.
When an intubation-type LMA has
been used in the field, an endotracheal
tube can be inserted through the device
to improve control of the airway.
Video laryngoscopy can provide
an indirect view of the larynx while
minimizing cervical spine motion
during intubation. The tool also can
be used as an adjunct in patients
with anatomically difficult airways;
however, this approach presents its
own set of of obstacles. It can be
challenging to pass a tube despite
adequate visualization of the larynx,
and complications such as distorted
anatomy or blood obscuring the
camera lens can hinder the procedure.
If endotracheal intubation cannot be
performed successfully, cricothyrotomy
might become necessary. Although
the difficult and failed airway
algorithms are well described,
there are other clear indications
for immediate cricothyrotomy. For
example, a foreign body or traumatic
injury that completely obstructs
the oropharynx and larynx makes
orotracheal intubation impossible. In
such circumstances, it is reasonable
to proceed directly to cricothyrotomy
to avoid imminent cardiopulmonary
arrest.
Breathing
Absent or decreased breath
sounds and chest wall ecchymosis are
indicative of significant chest trauma.
Identifiable injuries that can result in
cardiorespiratory arrest include tension
pneumothorax, massive hemothorax,
and chest injuries (eg, stab or gunshot
wounds). Crepitus can signify the
presence of a tension pneumothorax,
as can tracheal deviation, which is a
late finding. Open pneumothoraces can
result in a one-way valve phenomenon
and tension pneumothorax. Alleviation
of a tension pneumothorax via needle
thoracostomy or finger thoracostomy
can prompt immediate resolution of
cardiopulmonary arrest.
Needle thoracostomy should be
performed with a 14-gauge catheter (at
least 5 cm in length), placed at the second
intercostal space anteriorly or the fourth
or fifth intercostal space laterally on the
affected side.3,4 Finger thoracostomy is
performed by making a scalpel incision at
the anterior axillary or midaxillary line
at the fourth or fifth intercostal space,
and inserting a gloved finger through the
parietal pleura. Both procedures only
serve as a bridge to stabilize the patient
until chest tube placement.
Circulation
Circulation must be assessed by first
addressing the patient’s hemodynamic
status, which also entails initiating
hemorrhage control. Next, the patient’s
central and peripheral pulses should be
addressed. Per ATLS guidelines, radial
pulse correlates to a systolic blood
pressure greater than 80 mm Hg, while
femoral and carotid pulses only correlate
to a systolic pressure less than 80 mm Hg.
Loss of peripheral pulses indicates
hypoperfusion, which puts patients at
high risk for cardiopulmonary arrest.
Hemorrhage control and intravascular

TABLE 1. Primary Survey — Identifiable Injuries and Lifesaving Interventions

Survey Injury Intervention

Airway Unable to protect airway Oral intubation
Obstruction by foreign object or trauma Cricothyrotomy
Breathing Tension pneumothorax Needle decompression or tube thoracostomy, and
then tube thoracostomy
Massive hemothorax Tube thoracostomy
Open chest wounds (stab wound or gun shot wound) Autotransfusion of blood from chest tubes
Operative repair if blood loss exceeds 1500 mL
initially or 200 mL/hr for 3 hours or more
Occlusive dressing and tube thoracostomy
Circulation Massive hemorrhage Direct pressure if external
Exsanguination from extremities Direct pressure
Tourniquet application
Volume replacement with crystalloids and blood
products, including red blood cells, plasma, and
platelets

Traumatic Injury Special Edition n Spring 2017 57


TABLE 2. Contraindications for Emergency Department Thoracotomy
Blunt Trauma No signs of life in the field
Signs of life with loss of vital signs >5 minutes
Asystole
Penetrating Trauma No signs of life in the field
Signs of life with loss of vital signs >15 minutes
Asystole without the possibility of cardiac tamponade
volume replacement must occur
simultaneously. Aggressive management
of traumatic hemorrhage includes
application of direct pressure or a
tourniquet, when appropriate, which can
minimize ischemic injury. The tourniquet
should be applied proximally to the
wound and only tight enough to control
bleeding; it should be left in place for
no more than 2 hours to prevent further
neurovascular injury to the extremity.
Two large-bore IVs (>16 gauge)
are essential tools in the initiation of
intravascular volume replacement. If
peripheral access cannot be established,
intraosseous (IO) or central access
should be pursued. IO access can be
obtained much faster, and can be
used as a bridge until central venous
access is established. Any medication
or fluid resuscitation that can be
given intravenously can be given
intraosseously. Although the proximal
tibia is the most commonly used access
site, the proximal humerus can provide
flow rates of 4 to 6 liters per hour.
The rate at which fluid can be infused
is proportional to catheter diameter
and inversely proportional to catheter
length; central venous access with a
large catheter introducer (8F–9F) is
preferred over multilumen varieties.
Another option is saphenous venous
cutdown at the ankle or the proximal
anteromedial thigh.
Massive blood transfusion (eg, 4
units of red blood cells over 1 hour)
in the emergency department should
be started as soon as the hemorrhage
is identified. If the patient becomes
hypotensive, un-crossmatched blood
should be used until crossmatched blood
is available. Women of childbearing age
should be given type O-negative blood.
Massive blood transfusion can lead to
complications, including hypothermia,
acidosis, electrolyte abnormalities, and
coagulopathy. A fluid warmer should
be used with massive transfusions to
prevent hypothermia. Acidosis and
electrolyte abnormalities should be
monitored and corrected. Hypocalcemia
and hyperkalemia are the most
commonly detected abnormalities.
Coagulopathy after trauma is
multifactorial and can be caused by
hypothermia, consumption of clotting
factors and platelets, and dilution with
crystalloid infusions. Developments in
military trauma care have prompted
changes in the civilian massive
transfusion protocol, as well. These new
recommendations indicate replacing
clotting factors and platelets much
earlier in the resuscitation. Massive
transfusion of blood products should
start in a 1:1 ratio of packed red blood
cells (PRBC), fresh frozen plasma (FFP),
and platelets to increase survival. 5-7
A patient in traumatic cardio­
pulmonary arrest is unlikely to gain
spontaneous circulation without
both hemorrhage control and volume
replacement. Emergency bedside
ultrasound has become a useful
diagnostic tool to identify the source of
bleeding in the trauma patient.
Disability
The level of disability should be
estimated quickly. This is determined
by evaluating the patient’s level of
alertness, pupil size and reactivity, and
ability to move all four extremities. The
Glasgow Coma Scale (GCS) score is
the most common and reliable tool for
rapidly assessing neurological status.
Exposure
The final phase of the primary
survey is exposure. The patient should
be completely undressed to allow
Traumatic Injury Special Edition
for a thorough examination and the
identification of all possible injuries.
The skin should be carefully examined
for occult damage in any patient with
a penetrating wound. (For example,
a gunshot entry wound in the right
axilla can be missed when the patient
is rolled only to the right side during
examination of the spine.)
Agonal, abnormal, or absent
respirations and a weak or absent pulse
are ominous signs in a trauma patient
and should be addressed immediately.
The initial primary survey assessment
must take place promptly upon arrival
to the emergency department, and
should be completed within a few
minutes.
CRITICAL DECISION
What are the common causes
of cardiopulmonary arrest in
patients with blunt trauma, and
how should these injuries be
managed?
The term “mechanism of injury”
is used to describe the type and
directionality of force applied to
a given patient. When recognized,
these common injury patterns can
alert emergency physicians to the
likelihood of life-threatening injuries.
The most common mechanism of
blunt trauma by far is motor vehicle
accidents, which can cause deceleration
injuries, subsequent cardiopulmonary
arrest (often attributable to injuries
of the head, neck, torso, and pelvis),
and occasionally exsanguination via
extremity trauma.1
Traumatic brain injuries (TBI)
account for more than 50,000 deaths
in the US each year; falls and motor
vehicle accidents result in the majority
of these deaths due to blunt traumatic
injury.8 TBI-related deaths are most
common in adolescents, young adults,
and the elderly.8 They most frequently
are triggered by epidural and subdural
hematomas, subarachnoid hemorrhage,
intraparenchymal hemorrhage,
intraventricular hemorrhage, cerebral
contusion, and/or focal or diffuse
patterns of axonal injury with cerebral
edema.
The autoregulation of cerebral
n Spring 2017 58
perfusion is disrupted in many traumatic somnolence, seizures, and finally often is immediately fatal. An intact
brain injuries. The skull is a rigid respiratory depression, brady­cardia, pericardium can prevent sudden death,
container for the brain and blood and hypertension due to herniation.9 but typically will lead to cardiac
vessels; as a result, any changes in Definitive treatment for epidural tamponade. Thoracotomy is indicated
volume due to hemorrhage or edema can hematomas includes decompression; in specific circumstances when the
increase intracranial cerebral pressure however, many insti­tu­tions do not have proximate cause of cardiopulmonary
(ICP) and decrease cerebral perfusion neurosurgery capabilities. In such cases, arrest is pericardial tamponade.
pressure (CPP) (normal ICP is 15 mm a burr hole procedure can be considered Blunt cardiac injury can result in
Hg; normal CPP is >60 mm Hg). As ICP in select patients prior to transfer for significant myocardial injury, resulting
increases, the brainstem is compressed, definitive care. in decreased contractility or commotio
resulting in loss of brainstem reflexes, If a patient is awake and talking and cordis, both of which are usually fatal.
irregular respirations or apnea, then suddenly has a change in mental Commotio cordis can be treated if
bradycardia, and ultimately death. status, an isolated epidural without witnessed and the patient is defibrillated
Emergent treatment of patients associated parenchymal injury should quickly. This scenario is extraordinarily
showing signs of brainstem compression be suspected. Neurological outcome rare and is most often applicable in the
and herniation include hyperventilation after decompression for isolated setting of sports-related trauma via a
and intravenous hyperosmolar therapy. epidural hematomas is significantly
direct blow to the chest.11
Hyperventilation can be performed higher than for deterioration caused
Cardiopulmonary arrest in patients
initially as a temporizing course with an by other intracranial injuries.
with blunt trauma also can be the result
end-tidal carbon dioxide level goal of Trephination should be performed
of pulmonary injuries, including tension
30 to 35 mm Hg. Intravenous therapies quickly with an instrument such as a
pneumothorax, open pneumothorax or
include intravenous mannitol (0.5-1 g/kg Galt trephinator on the side of injury
“sucking chest wound,” and massive
bolus), intravenous 3% hypertonic to reduce intracranial pressure, relieve
hemothorax. Patients with tension
saline through peripheral catheters, herniation, and prevent impending
pneumothorax can become acutely
and 23.4% hypertonic saline through cardiopulmonary arrest.10
hypoxic, agitated, and hypotensive; the
central venous catheters.9 Many causes of cardiopulmonary
cardinal signs are diminished breath
Epidural hematomas, in particular, arrest in the blunt trauma patient
sounds on the affected side, jugular
can cause rapid neurological deteriora­ also result from injuries to the torso,
tion. Rupture of the middle meningeal including traumatic aortic rupture, venous distension, tachycardia, and
artery causes the accumulation of myocardial rupture, blunt cardiac hypotension. The condition mandates
blood, which does not cross suture injury, pericardial tamponade, and immediate decompression treatment
lines and rapidly increases intracranial dysrhythmias. Traumatic aortic rupture via needle or finger thoracostomy
pressure. Patients traditionally have a typically occurs at the left subclavian or (needle decompression must be followed
“lucid interval” during which they are proximal aorta, where the ligamentum by chest tube placement to prevent
awake, but then suddenly deteriorate. arteriosum fixes the aorta in the chest the reaccumulation of pressure and
Symptoms include anisocoria, wall. Myocardial rupture refers to tamponade physiology in the chest).
unilateral weakness, agitation, rupture of the atria or ventricles and For simple pneumothorax, chest tubes
should be attached to underwater seal
drainage and be connected to suction
initially. An open pneumothorax should
be treated with an occlusive dressing
taped on three sides, immediately
followed by chest tube placement.13
Massive hemothorax causes impair­
n A systematic approach to a trauma victim in cardiopulmonary arrest should ed ventilation by drastically reducing
be used to identify and treat potentially fatal injuries. vital capacity and can be alleviated by
n If a patient’s airway is completely obstructed by a foreign body, prompt the placement of a large-bore chest tube
cricothyrotomy might be the only way to establish a definitive airway and (preferably >36F).13 Defined as output
prevent cardiopulmonary arrest.
greater than 1,500 mL initially or
n The most common cause of cardiopulmonary arrest in patients with blunt above 200 mL/hr for 3 or more hours,
trauma is injury to the torso, including traumatic aortic rupture, myocardial
massive hemothorax is an indication
rupture, blunt cardiac injury, pericardial tamponade, and dysrhythmias, as
well as tension pneumothorax and massive hemothorax. for operative repair. It also can cause
hypovolemic shock, requiring a blood
n Emergency department thoracotomy is indicated for blunt trauma patients
within 5 minutes of arrest, and penetrating trauma patients within 15 transfusion. Autotransfusion of blood
minutes of arrest. collected from hemothorax is the
preferred option whenever possible.

Traumatic Injury Special Edition n Spring 2017 59

CRITICAL DECISION
What are the common causes
of cardiopulmonary arrest
in patients with penetrating
trauma, and how should these
injuries be managed? tamponade ongoing hemorrhage. To
Unlike blunt trauma, penetrating
trauma is marked by injuries focal
to the site of impact and the path of
high-velocity projectiles. Penetrating
trauma to the chest can quickly cause
cardiopulmonary arrest triggered
by myocardial rupture, pericardial
tamponade, and damage to major
vascular structures. Penetrating cardiac
injuries most often affect the right
ventricle due to the anterior anatomical
location in the chest. The left ventricle
is the next commonly affected cardiac
structure, followed by the atria.13
As in cases of blunt cardiac rupture,
cardiopulmonary arrest can result
from exsanguination or pericardial
tamponade, which often can be
diagnosed with ultrasound.
Pericardiocentesis can be used as
a bridge to definitive repair in cases
of traumatic pericardial tamponade;
however, the emergency physician
should be aware that hemopericardium
is likely to rapidly reaccumulate.13 If
pericardiocentesis is unsuccessful,
emergency department thoracotomy
should be initiated. A left lateral incision
from the sternum to the bed should be
made to allow maximum exposure of
the heart and left hilum; a pericardial
incision should be made anterior to the
phrenic nerve. Release of the pericardium
n Neglecting to use a systematic approach as outlined by ATLS guidelines to
evaluate patients with traumatic injuries.
n Failing to identify potentially life-threatening traumatic injuries and initiate
timely treatment.
n Performing a thoracotomy in with traumatic injuries in whom resuscitation
is futile.
n Removing a foreign body from a heart laceration, rather than stabilizing
the patient until the object can be removed under more controlled
circumstances in the operating room.
can restore cardiac output and the return
of vital signs. The heart must be further
exposed to identify myocardial injuries.
Penetrating myocardial injuries can
be controlled by direct digital pressure
or insertion of a Foley balloon to
suture the myocardium laceration, use
4-0 nonabsorbable monofilament suture
in a figure-8 stitch. Teflon pledgets
can be used to reinforce the suture
line. Myocardial muscle tears easily;
care must be taken, especially when
tying the sutures. An impaled foreign
object should not be removed in the
emergency department, but instead
under more controlled circumstances
in the operating room. In cases of
multiple trauma or trauma to the right
chest, it might be necessary to extend a
“clamshell” incision across the chest for
increased exposure and identification of
injuries. If the patient is hemorrhaging
and unresponsive to intravenous fluid
replacement, the aorta can be cross-
clamped to increase cardiac output to the
brain and heart.13
In addition to injuries to the heart and
pericardium, patients with penetrating
trauma can suffer from tension
pneumothorax and tension hemothorax.
As in the management of blunt trauma,
as previously described, these patients
should be treated with needle or finger
thoracostomy and subsequent chest tube
placement. Furthermore, patients can
suffer from injuries due to both blunt
and penetrating etiologies. For example,
a patient might sustain injuries from a
motor vehicle collision in which a foreign
Traumatic Injury Special Edition
body penetrates the torso. Etiologies
of cardiopulmonary arrest from both
penetrating and blunt trauma must be
considered in these situations.
CRITICAL DECISION
When should emergency
department thoracotomy be
performed?
As one might expect, patients who
show vital signs prior to arrival are
significantly more likely to survive
than those who do not.12,14 The
overall survival of patients receiving
emergency department thoracotomy
is 1.9% to 11%, with 3.9% surviving
functionally intact.12,15-17 As discussed
earlier, thoracotomy allows evacuation
of pericardial tamponade, direct
control of intrathoracic hemorrhage,
and open cardiac massage; however,
there remains much debate about when
the procedure is warranted in the acute
setting.
For both penetrating and blunt
mechanisms of injury, numerous
studies have shown that emergency
department thoracotomy is futile
after prolonged cardiopulmonary
resuscitation. Furthermore, traumatic
cardiopulmonary arrest patients who
receive the procedure are less likely
to die in cases of penetrating trauma
(versus blunt trauma).10,16-19 The survival
rates of patients with blunt trauma and
cardiopulmonary arrest average less
than 2%; as a result, some researchers
argue that emergency thoracotomy plays
no role in the management of blunt
trauma.22 However, many case reports
indicate there are specific situations in
which patients with blunt traumatic
injuries and a loss of vital signs after, or
just prior to, arrival in the emergency
department survive neurologically
intact.20,23 Due to low survival rates,
there is little evidence detailing the
maximum length of time CPR can be
performed in the blunt trauma patient
before an emergency thoracotomy is
contraindicated.
In summary, contraindications for
emergency department thoracotomy after
CPR prior to arrival are different for
patients who suffer from blunt trauma
versus penetrating trauma (Table 2). In
n Spring 2017 60
patients with blunt trauma and signs of
life prior to arrival, emergency department
thoracotomy can be lifesaving; but those
who show no signs of life prior to arrival
and who have sustained CPR for longer
than 5 minutes should not undergo the
procedure.
Emergency department thoracotomy is
not indicated in patients with penetrating
traumatic injuries requiring CPR for 15
minutes or more and in asystole without
the possibility of pericardial tamponade.
However, if a patient arrives in asystole
and pericardial tamponade is suspected
as the causative event, the procedure can
relieve tamponade physiology and restore
perfusion.18,24-25 Ultrasound can be used
in this situation to assess for cardiac
activity; if none is detected, the likelihood
of survival approaches zero and no
thoracotomy should be performed.23
CRITICAL DECISION
What factors should be
considered when predicting
patient survival?
Predictors of survival vary widely
and include initial cardiac rhythm, signs
of life, pupillary response, a GCS score
greater than 3, and cardiac motion on
ultrasound.16,27 Research estimates an
11.5% survival rate in patients with signs
of life upon hospital arrival, and a 2.6%
CASE RESOLUTIONS
■ CASE ONE
It was clear that the gunshot victim
suffered traumatic arrest secondary to
a penetrating injury. CPR continued
and further resuscitative measures were
performed, including the adminis­
tration of normal saline boluses
followed by the rapid transfusion of
un-crossmatched packed red blood
cells. An emergency department
thoracotomy was performed, which
revealed a pericardium full of clotted
blood and a small pericardial defect
that appeared clotted off, but was
oozing blood. The trauma team quickly
relieved this hemopericadium and
found a small atrial defect caused by a
bullet fragment that had ricocheted off
survival rate in those with no signs of
life on arrival.15 Reactive pupils appear
to be particularly predictive of hospital
survival.16
A recent study of patients in traumatic
cardiopulmonary arrest found that those
with ventricular fibrillation (by initial
cardiac rhythm) had the best chance of
survival (as high as 90%). Patients with
pulseless electrical activity (PEA) showed
an estimated 60% survival rate; and the
survival rates of patients in asystole were
invariably poor.27
Ultrasound is used regularly as an
adjunct in medical cardiopulmonary
arrests; this principle can be extended to
traumatic injury. The overall survival of
patients in traumatic cardiopulmonary
arrest is low, and the absence of both
cardiac motion and electrical activity
is highly predictive of death.28 Patients
who are asystolic with no cardiac motion
on ultrasound might not require further
resuscitative efforts if found to have
a reversible condition such as cardiac
tamponade.
CRITICAL DECISION
When should resuscitation be
terminated?
The decision to terminate resuscitation
of a patient in cardiopulmonary arrest
can be exceedingly difficult. The National
a nearby rib. Following the application
of digital pressure to the atrial defect,
spontaneous circulation returned and the
patient’s heartbeat became visibly active.
He was rushed to the operating room
for definitive (and ultimately successful)
therapy, and discharged 15 days later.
■ CASE TWO
The emergency physician directed
continual resuscitative efforts of the
high-speed accident victim; however,
the patient remained asystolic without
a detectable pulse or obtainable blood
pressure. A bedside ultrasound was
performed and no cardiac activity was
found. The patient was pronounced dead.
Traumatic Injury Special Edition
Association of EMS Physicians and
the American College of Surgeons
Committee on Trauma published
guidelines on withholding or terminating
resuscitation of patients with traumatic
injuries. Resuscitation should not be
initiated on victims of blunt trauma
who are apneic, pulseless, and without
organized ECG activity on the scene.
Patients with penetrating trauma who
are apneic and pulseless should be
transported rapidly if they show signs of
life such as pupillary reflex, spontaneous
movement, or organized ECG activity.22
If a patient with blunt trauma
is transported to the emergency
department and loses vital signs en
route, thoracotomy might be indicated.
However, resuscitation efforts should
cease if the patient has had no signs of
life (absence of pulse, pupillary reactivity,
or cardiac motion by ultrasound) for 10
minutes.20-25,28
Further resuscitative efforts,
including emergency thoracotomy, are
warranted in patients with penetrating
trauma if the initial cardiac rhythm is
asystole and pericardial tamponade is
the suspected proximal cause. If there
are no signs of life, including pupillary
reactivity, organized activity on ECG,
or cardiac motion on ultrasound for 15
minutes, resuscitative efforts should be
terminated.18,22-25,28
■ CASE THREE
On arrival, the cardiac monitor
of the young pedestrian struck by
a motor vehicle showed ventricular
fibrillation and cardiac motion
on ultrasound. The clinician
immediately directed resuscitation
and performed an emergency
department thoracotomy, which
was reasonable in this case because
the woman’s blunt traumatic arrest
occurred immediately upon arrival
to the hospital. Despite maximal
exposure and cross-clamping the
thoracic aorta, the patient died from
catastrophic major vasculature
injuries.
n Spring 2017 61
Summary
Traumatic cardiopulmonary arrest is
the number one cause of death in young
adults. Emergency physicians should
use a systematic approach according
to ATLS to evaluate and treat patients
with traumatic injuries, and should be
aware of the unique injury patterns for
both blunt and penetrating trauma.
Emergency department thoracotomy is
indicated in select patients and can be
lifesaving.
References
18. Powell DW, Moore EE, Cothren CC, et al. Is
emergency department resuscitative thoracotomy
futile care for the critically injured patient requiring
prehospital cardiopulmonary resuscitation? J Am
Coll Surg. 2004;199(2):211-215.
19. Hunt PA, Greaves I, Owens WA. Emergency
thoracotomy in thoracic trauma – a review. Injury.
2006;37(1):1-19.
20. Lockey D, Crewdson K, Davies G. Traumatic cardiac
arrest: who are the survivors? Ann Emerg Med.
2006;48(3):240-244.
21. Huber-Wagner S, Lefering R, Qvick M, et al.
Outcome in 757 severely injured patients with
traumatic cardiorespiratory arrest. Resuscitation.
2007;75(2):276-285.
22. Hopson LR, Hirsh E, Delgado J, et al. Guidelines
for withholding or termination of resuscitation in
prehospital traumatic cardiopulmonary arrest: joint
position statement of the National Association
of EMS Physicians and the American College of
Surgeons Committee on Trauma. J Am Coll Surg.
2003;196(1):106-112.

1. Heron M. Deaths: leading causes for 2009. Natl Vital
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2. Brunett PH, Cameron PA. Chapter 250. Trauma in
Adults. In: Tintinalli JE, Stapczynski JS, Cline DM,
Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s
Emergency Medicine: A Comprehensive Study Guide.
7th ed. New York, NY: McGraw-Hill; 2011.
23. Cook TM, Gupta K. Emergency thoracotomy after
cardiac arrest from blunt trauma is not always futile.
Resuscitation. 2007;74(1):187-190.
24. Gross E, Martel M. Multiple Trauma. In: Marx J, et
al, eds. Rosen’s Emergency Medicine: Concepts and
Clinical Practice, 7th ed. Philadelphia, PA: Mosby/
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3. American College of Surgeons. Advanced Trauma
Life Support, 9th ed. Chicago, IL: American College
of Surgeons; 2012.
4. Mayglothing J, Duane TM, Gibbs M, et al. Emergency
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injury: An Eastern Association for the Surgery of
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Acute Care Surg. 2012;73(5):S333-S340.
25. Moore EE, Knudson MM, Burlew CC, et al. Defining
the limits of resuscitative emergency department
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339.
26. Pickens JJ, Copass MK, Bulger EM. Trauma patients
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5. Zink KA, Sambasivan CN, Holcomb JB, et al. A high 27. Leis CC, Hernández CC, Blanco MJ, et al. Traumatic
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Traumatic Injury Special Edition n Spring 2017 62

CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1
A 24-year-old man sustains a rapid-deceleration injury
and is found without signs of life immediately following
his accident. What is his likely cause of death?
6 Which of the following patients should receive an
emergency department thoracotomy as a lifesaving
intervention?
A. Mildly displaced pelvic fracture A. A 16-year-old with prolonged CPR in the field
B. Multiple extremity fractures B. A 22-year-old in pulseless electrical activity following
C. Ruptured aorta a cold-water drowing
D. Spinal injury C. A 23-year-old who loses a pulse after a gunshot
wound to the head

2 What is the anatomical cause of the devastating

vascular injury described in the case in Question #1?
A. Exposed carotid bulb makes it prone to injury
D. A 26-year-old with blunt trauma to the chest and loss
of pulse on arrival

B. Multiple branches off the superior vena cava

C. Rigid fixation of the aorta by the ligamentum
arteriosum
7 An 8-year-old boy presents with traumatic arrest after
a 40-foot fall. Even after 35 minutes of CPR by the
EMS crew, the patient shows no signs of life (fixed
D. Weak, thin-walled left ventricle pupils, asystole on ECG, and no cardiac motion). What
is the next best course of action?

3 Why is it important for every trauma patient to be

approached systematically using ATLS guidelines?
A. Accurate record keeping requires guidelines
A. Continue CPR until the boy’s parents arrive
B. Initiate a massive transfusion protocol
C. Perform emergency department thoracotomy based
B. Billing and compliance regulates how the trauma
on the child’s age
patient is approached
D. Terminate efforts; this is an unsurvivable injury
C. The secondary survey is often not needed
D. To prevent life-threatening emergencies from being
overlooked 8 When should resuscitation for traumatic arrest be
terminated?
A. Immediately upon arrival of any patient over age 75

4 A 19-year-old man with a penetrating injury to the

chest from a small-caliber handgun loses his pulse
and blood pressure upon entrance to the trauma
B. The patient has known comorbidities
C. The patient shows no signs of life for 15 minutes with
ongoing CPR
resuscitation room. What should be the emergency
D. The trauma surgeon is busy in the operating room
physician’s next course of action?
A. Call code and pronounce time of death on arrival
B. Perform an emergency department thoracotomy
C. Place a pelvic binder to improve circulation
9 During an emergency department thoracotomy,
the physician identifies a pericardium full of blood.
Where should a pericardial incision be made to allow
D. Place bilateral chest tubes drainage?
A. Anterior to the phrenic nerve

5 What is the reported survival rate of emergency

department thoracotomy?
A. Approximately 3.9%
B. Anywhere on the lateral pericardium
C. Parallel to the eighth rib
D. Provider preference
B. Between 1.9% and 11%
C. Less than 1%
D. The rate is dependent on each clinician’s skill and
cannot be calculated

10 Which injury should be identified and treated during
the primary survey?
A. Avulsion injury of left lower extremity
B. Obstruction of the airway
C. Open ankle fracture
D. Scalp laceration with massive hemorrhage

Traumatic Injury Special Edition n Spring 2017 63