ETC Manual 2018 Edite Marques Mendes

Personal copy of Edite Marques Mendes (ID: 338160)
European
Trauma
Course
THE TEAM APPROACH
Edition 4.0
The European Trauma Course Manual
2 | EUROPEAN TRAUMA COURSE

Contents
Introduction 7
Glossary 8
Chapter 1 Human Factors, Non-Technical Skills and

the principles of Crew Resource Management 11
Chapter 2 Reception and resuscitation of the seriously injured patient 21
Chapter 3 Airway management in the trauma patient 35
Chapter 4 Breathing problems and thoracic trauma 51
Chapter 5 Shock 67
Chapter 6 Abdominal trauma 87
Chapter 7 Pelvic trauma 97
Chapter 8 Head trauma 107
Chapter 9 Trauma to the vertebral column and spinal cord 117
Chapter 10 Extremity and soft tissue trauma 131
Chapter 11 Trauma in children 143
Chapter 12 Inter and intra-hospital transfer 153
CONTENTS | 3
The ETC Course Management Committee would like to express their gratitude to the following organisations for
their support in the development of both the ETC and this manual:
European Resuscitation Council (ERC)
European Society for Trauma and Emergency Surgery (ESTES)
European Society for Emergency Medicine (EuSEM)
European Society of Anaesthesiology (ESA)
Editorial team
Karl-Christian Thies, Greifswald, Germany
Al Mountain, Stoke-on-Trent, UK
Peter Goode, Newcastle, UK
Disclaimer
No responsibility is assumed or accepted by the authors or publisher for any injury and/or damage to persons
or property as a matter of product liability, negligence or otherwise, or from use or operation of any methods,
products, instructions or ideas implied or contained in the material herein. Because of the rapid advances in
medical science and practice, the editors recommend that independent verification of diagnosis should be made.
© European Trauma Course Organisation ivzw. All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of the ETCO.

Contributors
Elonka Bergmans Monika Grunfeld Carsten Lott

Consultant in Anaesthesiology and Specialist in Emergency and General Consultant in Anaesthesia, Intensive
Medical Education Medicine Care and Pre-hospital Medicine
Heart Centre Kranj Health Center University Medical Center
Karlsburg Slovenia Johannes Gutenberg University
Germany Mainz
Carl Gwinnutt
Germany
Alistair Billington Emeritus Consultant
Consultant in Emergency Medicine Salford Royal Hospital NHS Foundation David Luke
Musgrove Park Hospital Trust Consultant General Surgeon
Taunton Salford RSUH & UHNM NHS Trust, North
UK UK Midlands MTC
UK
Markus Brucke Stuart Harrisson
Consultant in Anaesthesiology. Consultant, Department of Adam Low
Alb-Donau-Klinikum, Neurosurgery Consultant in Anaesthesia and Pre-

Ehingen Royal Stoke University Hospital hospital Care
Germany UK Queen Elizabeth University Hospital
Birmingham
Walter Busuttil Jochen Hinkelbein
UK
Consultant in Cardiothoracic Surgery Consultant in Anaesthesia
Mater Dei Hospital University Hospital of Cologne Ileana Lulic
Malta Cologne Consultant in Anaesthesiology,
Germany re-animatology and intensive care
Mike Davis
medicine
Consultant in Medical Education Michael Hüpfl
Zagreb
Blackpool Consultant Anaesthesia, Intensive
Croatia
UK Care, Emergency medicine
Landesklinikum Stefan Mattyasovszky
Christopher Day
Neunkirchen Specialist in Orthopaedic and Trauma
Consultant Vascular and Austria Surgery
Interventional Radiologist
University Medical Center
RSUH & UHNM NHS Trust, North Fabian O. Kooij
Johannes Gutenberg University
Midlands MTC Anesthesiologist and HEMS Physician
Mainz
UK Department of Anesthesiology
Germany
Amsterdam UMC
Peter Driscoll Amsterdam Netherlands Carl McQueen ✝
Senior Clinical Teaching Fellow Specialist Registrar in Emergency
University of St Andrews School of Sebastian Kuhn
Medicine
Medicine Consultant in Orthopaedics and
University Hospitals
St Andrews Trauma Surgery
Coventry and Warwickshire NHS
UK University Medical Center
Trust
Johannes Gutenberg-University
Stuart Durham UK
Mainz
Consultant in Emergency Medicine Germany Al Mountain
Royal Preston Hospital Consultant Orthopaedic & Trauma
Preston Caroline Leech
Surgeon
UK Consultant in Emergency Medicine RSUH & UHNM NHS Trust, North
and Pre-hospital Care
Peter Goode Midlands MTC
University Hospitals
Consultant in Emergency Medicine UK
Coventry and Warwickshire NHS
Newcastle upon Tyne and Carlisle. Trust UK Mahmoud Tageldin Mustafa
UK
Consultant in Emergency Medicine
Simon Leigh-Smith
Julie Grice Burjeel Hospital - Abu Dhabi
Consultant in Emergency Medicine
Consultant in Paediatric Emergency United Arab Emirates
Edinburgh Royal Infirmary
Medicine
Edinburgh
Alderhay Children’s Foundation Trust
UK
Liverpool
UK
CONTRIBUTORS | 5
Paola Perfetti Markus Roessler Eshan Senanayake
Consultant in Emergency Medicine Lead Clinician for Prehospital Specialist Registrar in Cardiothoracic
Ospedale Civile Maggiore Emergency Medicine Surgery
University Hospital of Verona Department of Anaesthesia University Hospital Birmingham
Verona University of Goettingen Birmingham
Italy Goettingen UK
Germany
Peter A. Oakley Karl C. Thies
Retired Consultant in Anaesthesia and Simon Scott Consultant in Anaesthesia and
Trauma Consultant Orthopaedic & Trauma Critical Emergency Medicine
Royal Stoke University Hospital Surgeon University Medical Center
Major Trauma Centre Aintree University Hospital & MTC, Greifswald
United Kingdom Liverpool Germany
UK
Marcus Rall Eric Voiglio
Consultant in Human Factors, CRM, Dare Seriki Médecin Inspecteur
Emergency Medicine Consultant in Vascular Radiology Direction de l’Action Sanitaire
InPASS University Hospitals of South Division de Santé
Reutlingen Manchester Monaco

Germany Manchester
UK Hany V. Zaki,
David Robinson Lecturer in Critical Care
Consultant in Anaesthesia Patrick Schramm Core Faculty of Emergency
Warwick Hospital Consultant in Anaesthesia and Medicine
South Warwickshire NHS Intensive Care Medicine Ain Shams University
Foundation Trust University Medical Center Cairo
Warwick Johannes Gutenberg University Egypt
UK Mainz
Germany
Pol M Rommens
Professor of Orthopaedics and Oliver Spelten
Traumatology Consultant in Anaesthesiology,
University Medical Center Schoen-Clinic
Johannes Gutenberg University Düsseldorf
Mainz Germany
Germany

Foreword to the 4th Edition of the ETC Manual:
This edition of the ETC manual, on the 10th anniversary instructors in providing an ever increasing
of the formal introduction of the course, has been an number of courses for candidates. At the time
opportunity to build on the previous good work of of writing, ETC is now being offered in over
a number of contributors and revise the information 20 countries with 120 courses annually.
and guidance in line with up to date practice.
The editors are grateful to their families for their
This would not have been possible without a lot of support over the last few months as they spent
hard work by a number of members of the Course time reviewing submissions, editing, re-editing and
Management Committee of the ETC and the editors discussing the content in numerous conference calls.
are grateful for their contributions. We would also
like to express our thanks to Ingrid Van der Haegen of We hope that the ETC manual and subsequent course
Studio Grid for undertaking the layout and formatting will provide you with the confidence and skills (both
of the manual. Many thanks to Camilla and Bibiana technical and non-technical) to maximise your ability
Metelmann for cross-reading and correcting the to look after trauma patients and provide a strong link
manuscript. Copyright Landesklinikum Neunkirchen. in the chain of survival from serious injury.
We thank YourView (www.yourview.at) and the
emergency team of LK Neunkirchen for the cover This manual is dedicated to the victims of trauma
photographs. and their families who entrust us with their care at a
difficult and stressful point in their lives and to the ETC
This is an opportunity to also thank the ETC instructors who freely give of their time to improve
Course Directors, Course organisers and the trauma care in Europe and beyond.
Peter Goode
Al Mountain
Karl Thies
INTRODUCTION | 7
Glossary
Throughout this manual, the male gender is used generically
ABG Arterial blood gas IV Intravenous

AMPLE A – Allergies, M – Medications, P – Past kPa kilo Pascal
Illnesses, L – Last Oral Intake (also Last LMA Laryngeal mask airway
Menstrual Cycle), E – Events Leading Up LT Laryngeal tube
To Present Illness / Injury
MAP Mean arterial pressure
aPPT Activated partial thromboplastin time
MHP Major haemorrhage protocol
ASIA American Spinal Injury Association
MILS Manual in-line stabilisation
ATMIST A - Age, T - Timing, M - Mechanism,
mmHg Millimeters of mercury
I - Injuries, S - Signs, T - Treatment
mmol/l Millimoles per litre
BM Blood Glucose Level

MRI Magnetic resonance imaging
BP Blood pressure
NEXUS National Emergency X-radiography
CICO can’t intubate, can’t oxygenate situation
Utilisation Study
cmH2O Centimeters of water
NTS Non-technical skills
CO Cardiac output
PaCO2 Arterial partial pressure of carbon dioxide
CO2 Carbon dioxide
PaO2 Arterial partial pressure of oxygen
CPP Cerebral perfusion pressure
PEEP Positive end-expiratory pressure
CPR Cardiopulmonary resuscitation
PRBCs Packed red blood cells
CRT Capillary refill time
REBOA Resuscitative Endovascular Balloon
CSF Cerebrospinal fluid Occlusion of the Aorta
CT Computerised tomography Rh Rhesus
CXR Chest x-ray ROTEM Rotational thromboelastometry
DPL Diagnostic peritoneal lavage RT Resuscitative thoracotomy
ECG Electrocardiogram RTC Road traffic collison
EEG Electroencephalogram SaO2 Arterial oxygen saturation
eFAST Extended focused assessment with SBP Systolic blood pressure
sonography in trauma
SCI Spinal cord injury
ETC European Trauma Course
SGA Supraglottic airway
EVAR Endovascular aneurysm repair
SCIWORA Spinal cord injury without radiological
FAST Focused assessment with abnormality
sonography in trauma
SIRS systemic inflammatory response
FFP Fresh frozen plasma syndrome
FiO2 Fractional inspired oxygen concentration SpO2 Peripheral oxygen saturation
GCS Glasgow coma scale TBI Traumatic brain injury
HR Heart rate % TBSA Percentage of total body surface area
hrs Hours TEG Thromboelastography
ICP Intracranial pressure TTL Trauma team leader
ICU Intensive care unit TTM Trauma team member
IN Intranasal VCI Vertebral column injury
IO Intraosseous

Trauma Care - the Team Approach
The World Health Organisation (WHO) has identified and geography, the spectrum of responses and a
trauma as the major health care challenge of our lack of scientific data. These are addressed by the
century; worldwide, trauma claims more productive course retaining an element of flexibility; where
life years than any other disease. Although prevention effective local variations in management exist, they
is key to tackling this problem, the WHO estimates are acknowledged and recognized as an alternative
that the mortality of major trauma in Europe could approach.
be decreased 30% by improving the chain of care for
major trauma patients. The European Trauma Course On the course, you will be expected to work through
(ETC) has been developed to address this problem a series of trauma cases of varying complexity; in the
and teaches a system of care for managing trauma majority of cases, the patient’s survival is dependent
victims that reflects the reality we experience on a on the trauma team working effectively rather than
daily basis. As a person dealing with these patients, the abilities of any one individual. As in real life, your
you may already have some knowledge and skills, role in the team will change depending on the needs
and experience of working in a team. However, these of the patient. Our goals are that by the end of the
attributes might differ from those of other people course you will have improved your knowledge, skills
that you are working with, and this can impair the and abilities as a team member and team leader. In
efficiency of the team. The ETC aims to address this by turn you will then understand how all of these enhance
enhancing your clinical skills, whilst at the same time team performance and ultimately contribute to
enabling you to become effective both as a trauma improving patient outcome. To maximise the learning
team member and team leader. opportunities available to you as a participant on the
ETC, it is essential that you read this manual; it contains
The contents of the ETC are based upon the working the very essence of what we are trying to achieve. Each
practices of the relevant specialties that treat chapter explains the processes that form the basis of
trauma patients within Europe (European Society of the workshops and the final chapter explains the roles
Anaesthesiology (ESA), European Society for Trauma you will be expected to play. Prior assimilation of this
and Emergency Surgery (ESTES), European Society for information will enable you to gain a great deal more
Emergency Medicine (EuSEM), European Resuscitation from the course than if you arrive unprepared.
Council (ERC)) and, where it exists, evidence of best
practice. In addition, the authors have tried to take Finally, we sincerely hope you enjoy your time as a
a pragmatic approach to improving trauma care by participant on the ETC. If you have, tell your friends and
recognizing that across Europe there are areas of colleagues, if you have not, tell us so we can continue
both commonality and differences in clinical practice. to improve for future participants.
The latter can be a result of variations in resources
INTRODUCTION | 9

1.
Human Factors, Non-Technical Skills and
the principles of Crew Resource Management
Learning outcomes
Following this part of the course you will be able to demonstrate an understanding of:
n T
he various types of non-technical skills
n T
he importance of communication in non-technical skills
n T
he role of non-technical skills in the performance of medical interventions
n T
he use of non-technical skills in the European Trauma Course
n T
he key points of crew resource management in trauma care
Introduction TABLE 1.2

Trauma patients encounter teams all along their Characteristics of an action team
pathway of care; the pre-hospital team, the in-hospital ■ onsist of personnel from varying specialities
C
teams (emergency medicine, anaesthesia, surgery, ■ Frequently train separately
■ Frequent change of personnel
critical care) and finally the rehabilitation teams. The ■ Form shortly before they need to act
performance of all these depends on an individuals’ ■ Deal with critically ill patients
medical knowledge and skills as well as features which ■ Need to provide speedy and precise management
are collectively known as non-technical skills or human
factors (Tab 1.1). These factors are now recognized as
having a major influence on the team’s effectiveness The European Trauma Course aims to recreate these
and the patient’s outcome. action teams and focuses on the processes required
to allow them to assemble and function safely and
effectively in a short period of time. It covers varying
TABLE 1.1
working cultures, different levels of expertise amongst
Definitions the team personnel and dynamic changing medical
Human Factors (HF) is the interrelationship between humans, conditions. The goal is therefore to provide a structured
the tools and equipment they use in the workplace, and the approach to trauma management and training
environment in which they work. The vast of majority of strategies to enable participants to work in a functional
untoward incidents in health care is caused by a breakdown of team. This chapter begins the process by describing
Human Factors.
Non-Technical-Skills (NTS) are social, cognitive and personal
the basic principles underlying effective trauma team
skills that can enhance the way technical skills, tasks and activity. It also provides some tips on managing the
procedures are carried out. By developing these skills, people common problems arising from team interactions.
in safety-critical roles can learn how to deal with a range of
different situations, minimise error and enhance patient safety.
Crew Resource Management is a set of procedures for use
in environments where human error can have devastating
Types of non-technical skills
effects. CRM focuses on interpersonal communication,
leadership, and decision making. Non-technical skills can be divided into four key areas
essential for a team’s effectiveness, all of which are closely
linked and integrated by communication (figure 1.1):
Medical teams often have to assemble on demand; this n teamwork
results in dynamic changes depending on individual n task management
availability. These groups are known as action teams n situational awareness
and a trauma team is a good example of such a team. n decision making
The characteristics of an action team are summarised

in table 1.2.
CHAPTER 1 HUMAN FACTORS, NON-TECHNICAL SKILLS AND THE PRINCIPLES OF CREW RESOURCE MANAGEMENT | 11
TABLE 1.3
Elements of effective communication
■ Structured communication
- SBAR (Table 1.5)
- ATMIST (Table 2.1)
- PACE (Table 1.6)
■ Shared mental model of the situation
■ Minimum distractions
■ Good situational awareness
■ Use of closed loop communication
■ Alertness
■ Respect and understanding amongst all team members
■ Active stress reduction to maximise bandwidth
Figure 1.1 The integration of non-technical skills and communication During the resuscitation
All personnel need to participate in the exchange of
Communication information by communicating effectively, by both
listening and speaking. The team leader facilitates this
Communication is an interpersonal process that by providing informative and complete feedback as

occurs constantly and with differing degrees of the case evolves, sharing information among the team
effectiveness. For the trauma team to be most members and communicating any changes in plans.
effective, all communication must convey the same Factors contributing to effective communication
meaning to the whole team. This is crucial for all between these people are summarised in table 1.3.
non-technical skills; indeed communication can be
considered the glue that holds them all together by To minimise the chance of not passing on key information
ensuring that all team members understand the key ‘closed loop communication’ is recommended. This
priorities and that the team leader immediately picks incorporates the following steps:
up on all relevant information. It is also important to n c
oncentrate on the facts you want to communicate
realise that although there appears to be a great deal n d

irect communication to a specific person – use
of verbal communication, body language also plays names and eye contact
an important role. Therefore care must be taken to n g
ive short focused facts and information (repeat if
ensure that all messages are clear and unambiguous. necessary)

n r
eceiver repeats the instruction
With respect to trauma teams it is useful to consider n r
eceiver reports back, communicating the
three phases of communication: information and the finished action requested
n before the patient arrives (team briefing) n a
voidance of communication not related to the case
n during the resuscitation
n after the patient leaves (team debriefing) There is the potential for communication to fail at a
number of points and it is essential that the loop is
Team briefing closed at all stages. This is summarised in figure 1.2.
For the team to be able to work effectively together the
first aim is to ensure that everyone is introduced by name.
Close the loop
This supports communication throughout immediate and is not said
future encounters, improves situational awareness (see
later) and reduces distractions. Clear legible name tags
help addressing individual team members in a personal Close the loop
is not heard
manner. A key requirement of the briefing is for the team
leader to ensure that all personnel have the same idea of
the patient’s condition and requirements. Achieving this Close the loop
is not understood
common mental model requires two-way communication
so that team members can question and clarify issues.
By doing so a clear initial plan can be developed and
is not done!
appropriate tasks allocated according to individual
competences. However, pre-arrival information is often Figure 1.2 The Stairway of communication. All team members
limited, and the patient may arrive with more severe are responsible for how messages are delivered, understood and
injuries than expected. It is therefore useful to develop acted upon. In a complex situation of a trauma resuscitation where
an alternative strategy (Plan B, C) to cover this eventuality team members constantly exchange information conversations
(chapter 2). How and when this alternative plan will be must be unequivocal and concise in order to facilitate close loop
implemented needs to be clear to all personnel. communication. There is no place for informal conversation,
which only raises the noise level unnecessarily and distracts from
essential tasks.

Team debriefing environment and checking the availability of all the
Debriefing is an effective way of improving future team required resources (material, personnel and time). The
performance and best achieved by running an open team leader then has the responsibility of requesting
discussion at the end of the resuscitation. It must be any additional resources or reallocate team members
non-punitive and led by a member of the team who to more appropriate or less burdensome tasks.
has received appropriate training in the process, using
a structured approach, e.g. the ‘learning conversation’. Prioritisation ensures that key issues are identified
All team members need to have the opportunity and acted upon in the right order. On most occasions,
to contribute at the same hierarchical level and the team will identify and treat immediately life-
receive feedback in order to allow good actions to threatening injuries using the planned primary survey.
be acknowledged, errors corrected, areas of conflict However, on other occasions, priorities change e.g. the
resolved and lessons learned for the next time. After 5-second round revealing exsanguinating external
all critical resuscitations, especially after a death of a haemorrhage that all team members need to address.
patient, a ‘hot debrief’ should be held with the aim to Furthermore if a patient deteriorates unexpectedly,
ensure the emotional wellbeing of all staff involved. priorities may change.
A second debrief addressing the learning points, as
outlined above, should take place at a later stage. Some interventions require a higher level of planning
and preparation. Examples include management of a
Team work difficult airway, tube thoracostomy or application of

A team can be defined as two or more persons with a pelvic binder. In all cases, more than one member
complementary skills working together to achieve of the team will be required and not all members of
a common goal. Typically, it has a leader who the team may have the appropriate skills. Therefore
coordinates the personnel in a way they can maximise these procedures can and should be planned for in
their problem solving capability, such that the sum advance so that tasks are appropriately allocated and
exceeds the parts. This requires mutual respect and implemented. It is essential that all interventions are
flat authority gradients, where all team members feel performed to a standard, which can be facilitated by
safe to share their expertise and to raise concerns. cross-checking or the use of check-lists.
Team members must be committed and competent.
Competence needs to be clarified during the team Situational awareness
brief, and roles allocated accordingly. The roles within Situational awareness can be defined as ‘the
the trauma team are usually predefined by profession perception of elements in the environment within
(anaesthesiologists manage the airway and surgeons time and space, the comprehension of their meaning
operate) and specific skill sets. For example, who and the projection of their status into the future’. More
in the trauma team can perform sonography and simply it is ‘knowing what is going on around you’ and
to what level? This information enables the team applies equally to both the team leader and members.
leader to delegate tasks appropriately and monitor Indispensable prerequisites for situational awareness
performance according to the level of expertise. In are a sound knowledge of the environment and a
doing so team members can work together to the best thorough understanding of the resuscitation process.
of their abilities to reach the desired goal. There are three aspects of situational awareness:
n acquiring information
Leadership is defined as ‘the process whereby n assimilating (i.e. understanding) the information
an individual influences a group of individuals to n anticipating future events
achieve a common goal’. To do this the leader needs

credibility; this comes from experience and being able The team’s collective awareness comes from the
to coordinate, communicate and plan ahead. The team leader gathering information in a structured way
leader must be adaptable so that a range of approaches (e.g. using the ABCDE approach) by observation,
can be used depending on the clinical situation and questioning and listening to feedback. It also depends
the competence of the varying team members. Finally on team members being able to share assertively,
it must be remembered that the label ‘team leader’ is i.e. giving information freely, even if not fitting with
not an indication of superiority, it is an indication of the pre-planned strategy. This prevents errors such
respect and understanding combined with an ability as ‘shared blindness’ (i.e. only seeing what everyone
to focus the team on the task in hand. As a result, the else is seeing) and ‘groupthink’ (i.e. mindlessly going
most senior person is not necessarily the best person along with everyone else in the group). The collected
to take the role of team leader. information then needs to be interpreted by the team
leader to predict impact, both immediately and in the
Task management near future, and provide direction where required.
This is the process of planning, coordination and In this way actions can be taken to avoid or mitigate
prioritisation of the actions of the team. It starts future problems.
before the patient arrives with identification of the
Decision making The ‘STOP’ procedure
This is the process whereby an individual assimilates
information, both from personal observation and (10 seconds for 10 minutes)
other team members, to allow them to carry out Resuscitation of trauma patients can be very busy,
appropriate interventions. The key decision-maker is tense situations with fast rates of activity. This can result
the team leader. in the team leader getting lots of information in a short
time. Processing this information and making focused
Medical decisions are usually not ’black or white’; decisions can be jeopardized by the team leader being
the advantages and disadvantages of a situation ‘hands on’ rather than taking a strategic overview of the
or a treatment need to be calculated. A solution situation. A technique to deal with information over-
is chosen after identifying the advantages and load is by ‘slowing down’ as it gives the team capacity
disadvantages of the options. Once made, the to organise the next steps. This procedure is most
decision has to be communicated clearly to all the beneficial in critical situations such as the beginning of
team members, followed by appropriate checks to the diagnostic process, treatment, planning treatment
confirm understanding and implementation. The priorities with an unexpected deterioration in patients
patient’s physiological response then needs to be condition or if the team feels ‘stuck’. The procedure
evaluated; ‘did what I think would happen, occur?’ is for the team leader to announce a ‘TIME OUT’,
The answer to this question directs the planning of collect again the findings in a structured way (e.g.

the next steps. This cycle then needs to be repeated; going through ABCDE), ask explicitly for additional
a good team leader adapts the frequency of the cycle suggestions from the team members and share
to the situation, each time sharing the information and thoughts. The working diagnosis can then be discussed
the conclusions with the team. This whole process also based on these facts and the next steps defined with
requires the team leader to have a significant amount tasks allocated appropriately. This is referred to as the
of knowledge and experience. ‘STOP’ procedure or ‘10 seconds for 10 minutes’3
(figure 1.3; 1.4). A short pause (10 seconds) can save a
Authority Gradients much longer time of fruitless activity (10 minutes) and is
Clear and visible leadership ensures efficiency and an essential part of all the non-technical skills described
safety of the trauma team’s operations. However, the so far.
qualities of a trauma team leader (TTL) also involve the
ability to follow direction from other team members
when appropriate. In the context of CRM the term
Diagnosis?
‘authority gradient’ is often used to describe this Feel stuck?
aspect of the relationship between team leaders and Decision?
members. Steep authority gradients, where some
team members are afraid to speak up, are identified as
a common source of medical error. One aim of effective
team leadership is to flatten authority gradients
between individuals so that all team members are STOP!
empowered to contribute to decisions and feel safe
to highlight concerns. Leadership roles within teams
should therefore be fluid to ensure the entire team Problems?
remains engaged and understands the strategic Opinions?
direction for the teams’ efforts. Clinicians should Facts?
Plan?
encourage feedback and input from all members Distribute?
of the team. The TTL then becomes a facilitator; an Check!
individual who unites the aims and expectations of
team members into an implementable solution. A Figure 1.3. The ‘STOP’ procedure (10 seconds for 10 minutes)
culture promoting such a leadership style should be
encouraged and supported at an organisational level.
Nevertheless, if the team is very unexperienced or A STOP procedure is useful for bringing the whole
dysfunctional a good team leader must be able to team back together after periods in intense activity
adopt a more authoritative leadership style. where the team members have been task focused, so
can all share the same mental model and understand
prioritisation of continuing intervention. This
procedure can be integrated into all the non-technical
skills outlined above. The processes involved and
actions to achieve these are summarised in table 1.4.

Figure 1.4 A big STOP-sign
with 10-for-10 is laminated
The fifteen key points of Crew Resource
to the floor of the shock Management
room of Zürich University The core aspects of Crew Resource Management are
Hospital as reminder for all explained in the following fifteen key points.
trauma team members
n Know the environment!

CRM begins before patient arrival; one of the
prerequisites for CRM is to know the available resources
and the details of the working environment. Resources are
personnel, equipment infrastructure and supplies. It is
important to have a sound understanding of the trauma
pathways within a hospital and know who can be asked
for help, who is available at different times of the day,
how to call those helpers quickly, and how long it will
take for them to arrive. Regarding the equipment, it is
not only necessary to know what is available and where
TABLE 1.4 to find it but also how to operate it. The trauma team is
responsible for being well versed in the operation of all
Summary of non-technical skills and integration of relevant equipment and should also use manuals and
the STOP procedure other cognitive aids to learn to use the equipment and
as a backup source of information during patient care.
Non-technical skill Key point in healthcare Therefore all members of a trauma team must know
Process Actions their specific roles and responsibilities within the team.
Team working Coordination Effective communication
Exchanging information ‘STOP’ procedure n Anticipate and plan
Authority and assertiveness Exercise leadership and Anticipation is crucial for goal-directed behaviour.
followership Trauma team professionals must consider the
Assessing Anticipate and plan requirements of a case in advance and plan for the
Call for help early key milestones. They must prepare for all eventualities
Supporting others Listening and empathy and plan ahead for possible difficulties. Savvy trauma
Task management Planning and preparing Anticipate and plan professionals expect the unexpected, and when it does
Know your environment strike, they can fall back on an alternative ‘Plans B or C’ if
Prioritising Exercise leadership required. All team members should try and proactively
Set priorities dynamically “stay ahead of the game” instead of passively “falling
Providing and maintaining Use cognitive aids behind”. Using “action cards” with role descriptions
standards helps planning who in the trauma team is doing
Identifying and using Allocate tasks what; no discussion about role allocations and always
resources Distribute the workload everything ready to go.
Mobilize all available
resources n Call for help early
Call for help early Knowing one’s own limitations and calling for help is
‘STOP’ procedure not a sign of weakness. In opposite, trying to handle
Situational Gathering information Use all available information everything alone or ‘toughing’ out a critical situation
awareness Re-evaluate and share is dangerous behaviour. In general, help should be
information called early rather than late. It is important to know in
Recognizing and Allocate attention advance who is available and how to call for help and
understanding ‘STOP’ procedure to plan for how best to use the help when it arrives.
Anticipating Anticipate and plan Typical triggers for calling for help are:
Decision making Identifying options Planning and preparing - when there are too many tasks to do
‘STOP’ procedure - when the situation is already serious (e.g., cardiac
Balancing risks and Prevent and manage errors arrest, difficulty securing the airway)
selecting options ‘STOP’ procedure - when serious problems are getting worse or not
Re-evaluating Re-evaluate repeatedly responding to the usual manoeuvres
Set priorities dynamically
n E xercise leadership and followership with
assertiveness
A team needs a leader. Someone has to direct, distribute
tasks, collect information, and make key decisions.
However, leadership does not mean knowing more
than everybody else, doing everything alone, or putting ambulance service, which ensures that blood products
other people down. Leadership is co-ordination, are available on patient arrival at the hospital. Similar
planning, deciding, and distributing tasks through clear protocols exist for other trauma emergencies e.g. the
communication. Good followership requires excellent need for immediate operating room or airway disasters.
NTS; trauma team members need to be open minded,
know their environment and the care processes involved; n Communicate effectively—speak up
they need very good communication skills to keep up Communication is key in complex team situations. Good
with a dynamic management plan, which can change teamwork depends on everybody being on the same
without warning. To a certain extent team members page. Clear and concise communication helps to ensure
need to ‘go with the flow’ and follow directions. that the team ‘shares the same mental model’ throughout
the resuscitation and consequently works into the
On the other hand this does not mean that team members same direction. This requires a continuous exchange
should shut down their brains. As the team leader, they of information between all team members, which can
also need to stay proactively ahead of the game; they are easily lead to communication overload with essential
the operational element of the trauma team fulfilling their information being lost. Verbal communication during a
allocated tasks and supporting other team members at resuscitation must be concise and to the point. To ensure
the same time. It is not good enough if nothing gets done that a message is understood and acted upon the SBAR
unless it is explicitly ordered. The TTL remains ‘hands format has been introduced in health care (Table 1.5).

off’ and provides the strategy. This does not mean that
a trauma team should be managed solely top down; a TABLE 1.5
good TTL is able to create flat authority gradients to make Safe communication using the SBAR format:
it easy for team members to speak up and is also able to
take advice and change direction if required. S Situation: Team Leader, I need your attention, NOW!
Team members must be assertive if they think that the The patient is bleeding heavily from the groin and
I can’t get it under control
team is making decisions that put patient at risk. It is
their responsibility to make sure that the team is aware B
Background: I know he has been assaulted with a baseball
of their concerns. ‘Speaking up’ is everybody’s duty. A bat, but this looks like stab wound down here.
good team member gets the balance right between
A
A ssessment: I guess the femoral artery is hit and I can’t
‘going with the flow’ and ‘speaking up’. control the bleed with external pressure only; it’s too high
Whenever people work together, conflict can ensue; for a tourniquet and he has lost a lot of blood already; the
anyone on the team may need to disperse conflicts to trolley and the blanket are completely soaked with blood.
focus the team on care of the patient. Get everyone to
R
Recommendation: I need another pair of hands and some
concentrate on what is right, not on who is right. haemostatic gauze. If we can’t control this right now, we
need to go to the operating room without further delay.
n Distribute the workload (“10-seconds-for-10-
minutes principle”)
One of the main tasks of a team leader is distributing Assertiveness contributes to team safety and speaking
the workload; the TTL sets the tasks, ensures that they up in the right way can prevent medical errors,
are fulfilled properly and that all activities match up. particularly fixation errors. Using a format to speak up
The team leader should remain hands off to observe, within a team helps to empower team members to raise
gather information, and delegate tasks. Team members safety concerns. In well trained teams a standardized
should also look actively for things that need to be format, such as the PACE approach, will also alert (tune
done and ‘stay ahead of the game’. However, team in) the TTL early to the perceived seriousness of the
members can be at times task overloaded, which can TM's concerns and usually escalation is not required:
easily result in a disjointing backlog of unfulfilled tasks.
The TTL then needs to step in, call for a stop (10 for 10) TABLE 1.6
and reallocate the tasks to keep up the workflow.
Speaking up using the PACE format
• Probe – e.g. ‘Are you sure about...’
n Mobilise resources • Alert – e.g. ‘Don’t you think this will cause…’
Resources are often difficult to organise on short notice, • Challenge – ‘I am afraid this is going to harm the patient…’
especially out of hours. Mobilising resources early is key • Emergency action – e.g. ‘STOP what you are doing!, I will get
to success if the demands put on the trauma team exceed help...’
their capabilities. It is helpful to have established pathways
that can be activated if such situations arise; an example
for early pathway activation is a massive haemorrhage n Use all available information
protocol that once triggered, delivers a standard Trauma care is particularly complex because
response without the need for lengthy discussions with information must be integrated from many different
the blood transfusion service on the amount of blood sources. Every bit of information can assist in
products required. In modern trauma care systems understanding a patient’s condition better and
massive haemorrhage protocols can be triggered by the arriving at the correct diagnosis. Information sources
include those immediately at hand (the patient, n C rosscheck and double-check—(never assume
monitors, the hand-over record), secondary sources anything)
such as the patient’s chart, and external sources such Crosschecking means to correlate information from
as cognitive aids (see later) or even the Internet. different sources. There are often three independent
sources of information about the patient’s heart rate
nP revent and manage fixation errors (electrocardiogram [ECG], pulse oximetry, and blood
Human actions are based on an instantaneous mental pressure monitor), for example, and two about the
model of the current situation. If the model of the situation rhythm (ECG and pulse oximetry).
is erroneous, the actions will probably be wrong. Another aspect of crosschecking involves reviewing the
status of actions that have been done or are under way.
The term “fixation error” describes a model that is Human memory about actions performed is vulnerable,
persistently faulty despite sufficient evidence to especially when interruptions have occurred. Moreover,
correct it. A fixation error is the persistent failure to although we often attempt to check things “at a glance,”
revise a diagnosis or plan in the face of readily available such fleeting observations are prone to error. Checking
evidence suggesting that a revision is necessary. numbers and settings on equipment by actually
This type of error is extremely common in dynamic touching them and looking carefully may be worth the
situations. There are three main types of fixation errors. effort. In general, it is best to “never assume anything”;
1) One type of fixation error is called “this and only make sure and double-check important information. In
this” -sometimes also called “cognitive tunnel fact, “assumptions” are a very common cause of errors
vision.” In this type of error, attention is focused on and failures in team performance, with catastrophic
only one possibility and other (possibly or actually effects. Example: The team leader assumes that the
correct) alternatives are not taken into account. blood glucose was checked by the ambulance team,
Example: Placing a tourniquet on the thigh to stop and that they would have told if it were low. Or the
bleeding from an open fracture/amputation and not assumption that we all share the same mental model…
considering additional pelvic fracture and not placing Always check your assumptions!
a pelvic sling. Or treating the trauma patient and not
considering underlying heart disease (e.g. myocardial n Use cognitive aids
infarction), which could have triggered the accident. Cognitive aids—such as checklists, handbooks,
2) Another fixation error is “everything but this,” the calculators, online information and smart phone
persistent search for irrelevant information and failure apps—come in different forms but serve similar
to treat a probable cause with serious consequences. functions. They make knowledge “explicit” and
Example: Assuming a bad bronchospasm after “in the world” rather than only being implicit, in
aspiration, and not considering esophageal intubation someone’s brain. Memory and cognitive functioning
as a cause. are vulnerable to error or complete failure, especially
3) Perhaps the most insidious fixation error is the in stressful situations or in phases of low human
persistent claim that “everything is OK,” in which all performance levels (after a long day, in the middle
information is attributed to artifact and possible signs of the night, in emotionally challenging situations).
of a catastrophic situation are otherwise dismissed. Cognitive aids offload memory and safeguard the
Another form of “everything is OK” is the failure to recall of critical items. (e.g. RSI-Checklist, Chapter 3;
transition from “routine mode” to “emergency mode” TRAUMATIC Algorithm, Chapter 5). They also help
when the situation demands it. This leads to a critical ensure the use of current best practices because
loss of precious time at least. Example: Assuming the during a crisis, people sometimes revert to what they
blood pressure readings are low, because the cuff is originally learned as the best, not what is the latest
too large, ignoring hypovolaemic shock as the most recommendation. Sharing the aids helps to share
likely cause of hypotension in trauma. mental models about what to do when.
One principle of managing fixation errors is to get a n Re-evaluate repeatedly (10-for-10)

new view—a second opinion—on the situation from Trauma medicine is dynamic. What is correct now
someone unaware of the faulty previous assumptions. may be wrong in the next minute. Some parameters
Although it is appropriate to brief the new person on change slowly over time, and subtle changes can be
the situation, it is best to avoid biasing the person with hard to perceive. Trend monitoring can be helpful to
the conclusions already drawn. Even when working detect slow, but insidious changes.
alone the professional can deliberately change Furthermore, the dynamic nature of trauma
perspectives (physically or mentally) and look for resuscitation makes it necessary to repeatedly re-
information not fitting the picture of the situation, evaluate the situation and share all relevant information
as though entering the room for the first time or ask with the team to ensure that all members understand
provocative questions to challenge group thinking. the direction (share the same mental model) and are
The 10-for-10 principle might also be helpful in able to contribute to strategic decisions. The 10-for-10
managing fixation errors. is a good tool to implement the principle re-evaluation.
n I mplement principles of good teamwork—coordinate between focusing on details and focusing on the big
with and support others picture and to offload certain responsibilities, tasks, or
Teamwork in multidisciplinary and multi-professional information streams to other qualified team members,
teams is at the heart of trauma care. Coordination provided that they periodically update the team leader
within a team begins before a team gathers. Knowing about the situation.
the members of a team, ideally by name, is critical. If all Multitasking should be avoided; we have to organise
members know their tasks and their roles, coordination ourselves to reduce the demand for multitasking
is easier. Team briefs before the patient arrives should episodes. Team members might “not hear” each other,
be standard. This is described in detail in chapter 2. if they are doing (or thinking) something else. “Hearing”
During the resuscitation, the TTL more or less frequently requires allocation of attention to ensure “listening”!
calls stop procedures to update all team members on
the progress of the resuscitation and to coordinate the n Set priorities dynamically
team’s activities (10-for-10). “Dream teams” support each Dynamic situations demand dynamic measures with
other continuously, with everybody looking after each decisive, purposeful preliminary decisions and actions
other. Professional team members do not need to “like that are constantly re-evaluated and modified as
each other”, to perform as best for the patient as possible. new information becomes available or the results of
treatment are apparent. What was not a right move at
n Allocate attention wisely one time may become the right move at another. In

Human attention is limited and multitasking is very addition, having one solution to an obvious problem
difficult. Attention must be dynamically allocated does not guarantee that it is the best solution, or that
where it is needed. One can develop rhythms and there is only that one problem to deal with. However,
scan patterns to do this. The “ABC” mnemonic is based one priority is always paramount—ensuring adequate
on this principle. Other strategies are to alternate oxygenation and perfusion of critical organs.
InPASS InPASS
CRM Key Points
PATIENTENSICHERHEIT
FOR-DEC
PATIENTENSICHERHEIT
Dynamic Decision Making (Lufthansa CRM-Course) From Rall & Gaba in Miller‘s Anesthesia 7th edition
1. Know the environment.

ontrol Fact
k &C s 2. Anticipate and plan.
¬
c
3. Call for help early.

Execu n ¬ Che
Opt
4. Exercise leadership and followership with

ions ¬ Ris
assertiveness.
tio
5. Distribute the workload. (10-for-10 concept)

6. Mobilize all available resources.
n¬
ks
7. Communicate effectively – speak up.

&B
sio ene
Deci fits
8. Use all available information.
9. Prevent and manage fixation errors.
10. Cross and double check.
10-for-10-concept (Never assume anything)
10 seconds for 10 minutes 11. Use cognitive aids.
Problem? 12. Re-evaluate repeatedly.
STOP
Team? (10-for-10 concept)

Diagnosis! Facts? 13. Use good teamwork, coordinate with and
Plan! Act! support others.
Problem?
Distribute! 14. Allocate attention wisely.
for
10 Sec. Questions? 15. Set priorities dynamically.
www.inpass.de www.inpass.de
Figure 1.5 Pocket cards containing the 15 key points of CRM are helpful to facilitate learning

Summary
Effective trauma care requires efficient multi-
professional, inter-disciplinary co-operation. The
latter depends upon not just technical abilities but
mainly on the non-technical skills of team work, task
management, situational awareness and decision
making, held together by effective communication.
The European Trauma Course focuses on improving
all the team’s non-technical skills in order to
promote safe and effective team work.
Having worked through this chapter you should

now be ready to apply the fifteen key points of
Team Resource Management in the scenarios
working as both a team leader and team member.
These cognitive abilities will be integrated with

the practical skills during the course workshops.
Further information
n A
naesthetists’ Non-Technical Skills (ANTS) System
http://www.abdn.ac.uk/iprc/ants/
n F
lin R, Patey R, Glavin R, Maran N. Anaesthetists’
non-technical skills. British Journal of Anaesthesia

2010;105:38-44.
n K
ohn LT, Corrigan JM, Donaldson MS editors. To
Err Is Human: Building a Safer Health System.

Committee on Quality of Health Care in America,
Institute of Medicine. Washington D.C.The National
Academies Press, 2000.
n R
all M, Howard SK, Dieckmann P. Human
Performance and Patient Safety. In: Miller RD,

Eriksson LI, Fleisher LA, Weiner-Kronish JP, Young
WL. editors. Miller´s Anesthesia. 8th ed. Philadelphia,
Churchill Livingstone: Elsevier; 2015.

2.
Reception and resuscitation of the seriously
injured patient
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
n The briefing process of the trauma team
n Preparation to receive a patient with major trauma

n Receiving and giving a handover
n Performing a primary survey
n Identify the need for and give appropriate analgesia
n How to plan the patient’s subsequent care
n How to perform a secondary survey
Introduction Whatever the pre-hospital system, the subsequent

in-hospital management is a complex process of
Modern trauma care has been reconfigured over the diagnostic and therapeutic procedures, carried out in
past few years into a multi-professional chain of care parallel, within a limited time frame. This clearly needs
organised in regional networks to create a trauma thorough preparation, good organisation, an adequate
system. Within each network are a number of partners; infrastructure and excellent communication between
the pre-hospital emergency medical services (EMS), all staff involved. It is best carried out by a well trained,
the district general hospitals, major trauma centres multi-specialty team. Using such a system has been
(MTC) and rehabilitation services. The main objective shown to result in improved outcomes after major
of these networks is to improve patient outcome by: trauma. This is the principle upon which the European
n facilitating communication and cooperation Trauma Course is based.
between all network partners
n providing overarching clinical governance
Planning and preparation for

Trauma networks result in a strengthening of the
‘Chain of Survival’ by improving the standards of care receiving a trauma patient
at all points, from the pre-hospital phase to definitive
care. Recent figures from the UK confirm that the Hospitals that receive trauma patients usually have
introduction of a network system can decrease early a set of specific guidelines, protocols and standard
mortality of major trauma by 30%. operating procedures describing the pathway for
these patients within their institution.
The level of care that patients receive at scene and
during transport depends on the configuration of the Equipment and facilities:
EMS. In many European systems, pre-hospital care n T rauma admission bays should be close to the
for major trauma patients is delivered by teams of ambulance entrance.
paramedics and doctors with a focus on early triage, n Each patient bay must provide enough space to
rapid transportation and life-saving interventions host a complete trauma team and all standard
carried out at at scene, or en route. These intervention resuscitation and diagnostic equipment required for
include haemorrhage control, advanced airway the initial management of major trauma.
techniques, chest decompression, analgesia, sedation n Immediate availability of additional equipment,
and even transfusion of blood products in some including; difficult airway equipment, surgical
systems.
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 21
instruments, massive transfusion equipment, nursing, but we increasingly see paramedics and
ultrasound machine, x-ray and adequate lighting to operating department (ODP) practitioners in these
carry out life-saving procedures safely. roles. TSP assist the medical staff as circulating
n Immediate access to a supply of packed red blood practitioner or will act as recording practitioner
cells (PRBCs) and further blood products. (scribe). The TSP fulfill the classical supporting roles,
n Ideally the trauma reception bay should be in helping to transfer the patient, removal of clothes,
adjacent to an operating room to allow rapid application of monitoring, obtaining peripheral
transfer for emergency procedures. The vascular access, taking and processing blood
continental concept of Shock-Operating- samples and assisting with invasive procedures; they
Rooms represents a combination of a trauma are key members of the trauma team. It is common
resuscitation bay and an operating room. for the physicians allocated the A,B and C roles to
This allows for immediate life saving surgical work with a dedicated TSP, forming ‘teams within a
interventions without the need to move the team’.
patient. Most advanced Shock-Operating-Rooms All TSP must take part in the team brief as they
have integrated CT facilities. are fully integrated into the task allocation. In
n Ideally a CT scanner should be co-located with addition, the TTL may allocate TSP to carry out
the Emergency Department to allow immediate specific procedures, which are within their scope
imaging. of practice.

n Transfusion services that can respond within TSP are also the first line in liaising with the
minutes according to the hospital’s major patient’s relatives.
haemorrhage protocol.
The process
The trauma team
Emergency Department alert
n ll hospitals that receive major trauma should have
A Emergency Departments usually have some warning
a designated team that can be freed up from their either directly from the pre-hospital team or by central,
routine work to receive the patient. (ambulance) control, that a severely injured patient
n A dedicated ‘trauma alert’ system is required to is about to arrive. Ideally communication should be
inform all team members immediately when a directly between the pre-hospital team and the trauma
trauma patient is expected. team leader (TTL) using a standardised reporting system,
n All team members and team leaders must be e.g. ATMIST in order to minimise the loss of information
competent to fulfil their allocated role within the (table 2.1). The earlier the warning is given, the better
trauma team. because:
n smaller hospitals need more time for preparation
The composition of the trauma team can vary than large centres;
considerably depending on the regional system and n an influx of large number of casualties requires
the resources available. time to mobilise adequate additional resources;

For the purpose of the ETC the core trauma team n specialist equipment or support may be required.
consists of a Trauma Team Leader (TTL) and a variable

number of Trauma Team Members (TTM).
n The TTL coordinates the activities of the trauma
Age, sex and relevant history (e.g. pregnancy, warfarin)
Time of incident
team and ensures effective communication. The Mechanism of incident. This should include:
TTL remains hands off to retain overview and n Gross mechanism of injury (e.g. road traffic accidents,
situational awareness. stabbing)
n The airway practitioner (A-person), who should be n O ther factors known to be associated with major injuries
able to secure a compromised airway and provide (e.g. entrapment, vehicle roll-over, ejection from vehicle,
anaesthesisa, if required. fall from height)
Injuries suspected
n A third clinician, (B-person), who is able to assess
Signs and symptoms
the chest including ventilation and competent to n Respiratory rate, SpO2
insert a chest drain. n Heart rate, blood pressure
n A fourth practitioner (C-person), who is capable of n GCS, focal neurological deficits
assessing the circulatory system, applying a pelvic n Pain

n Trends in vital signs
splint and obtaining vascular access. Ideally the B- or
Treatment given and to be expected on admission (e.g. massive
C-person should also be able to perform sonography transfusion)
e.g. e-FAST (extended Focused Assessment with
Sonography in Trauma) as part of the primary survey. Table 2.1 The ATMIST handover
n On some courses there will be Trauma Support
Practitioners (TSP). Their background is usually

Key decisions that need to be considered at this stage ● e
quipment (e.g. for massive transfusion or difficult
are the requirement for: airway trolley).

n immediate advanced airway intervention n Ensure all TTMs take universal precautions.
n massive transfusion n Ensure that all TTM had the opportunity to take
n other immediate life-saving interventions part in the planning process, ask questions and
raise concerns.
Once this has been determined, the TTL can decide if:
n there is any need to deviate from the standard Once all of the above have been achieved, it is the
cABC response (Table 2.2); individual TTM’s responsibility to prepare for the
n any specialised equipment is required; trauma patient.
n immediate operating room access is required.
Preparation
TABLE 2.2 The equipment in the trauma resuscitation bay must
be checked on a daily basis. In addition, the TTMs,
cABC both doctors and TSP, are responsible for checking the
The cABC approach helps to prioritse and structure resuscitation
of trauma victims towards the most preventable causes of death, availability and functionality of the equipment they
which are require for planned and unplanned interventions:
c= major haemorrhage Airway and cervical spine control:

A=
airway obstruction n a
ll basic and advanced airway equipment
available
B = chest injuries n s
uction to hand and functional
C = circulatory shock n v
entilator tested and ready for immediate use
n s
emi-rigid collars, blocks and tape
n e
scape-plan: supraglottic airway device, surgical
Team Brief airway kit, competent surgical skill availability

Once the trauma team members (TTMs) have
assembled, the TTL should: Breathing:
n Carry out introductions to ensure all members n m
onitors functioning;
know each other. n e

quipment for insertion of intercostal chest drain
n Share the pre-hospital information with the team (ICD)

using an ATMIST format. n e
scape-plan: actions in the event of a traumatic
n Confirm the individual competencies of the TTMs cardiorespiratory arrest

and ensure that there is senior support available
for junior TTM. Circulation:
n Allocate the tasks appropriately n m onitors functioning (including sonography if
n Ensure that the TTMs have: competent)

● a ll the pre-hospital information n d ressings/ haemostatic gauze and tourniquets to
● a complete understanding of their role within the control external haemorrhage

team n p elvic binder
● a mutual awareness of limitations (of both TTL n l arge bore vascular access including large central
and TTMs) venous catheters

● a n understanding to share concerns n m assive transfusion delivery system (Belmont,
● c onfidence to ask for help when required Level-one)

n Alert radiology, operating theatres and the n e scape-plan: alternative vascular access (eg.
Intensive Care Unit (ICU) of possible needs. intraosseous), plan for catastrophic haemorrhage
n Identify if a standard primary survey is to be
followed, and formulate ‘Plan A’ together with the Finally, the TTL must:
team. Check with individual team members to ensure
n
n Ensure that TTMs are aware of an alternative that the equipment is complete and functioning
strategy, ‘Plan ’B’, e.g.: and that TTM know how to summon senior
● n eed for immediate transfer to the operating support if required.
theatre n E
nsure that the room and fluids are pre-warmed.
● m anagement of an unexpected peri-arrest n C

ommunicate with other departments
condition appropriate to the situation:
n Ensure that TTMs are aware of the need for b lood bank
●
additional resources: r adiology

●
● s taffing (e.g. senior colleague, obstetrician in case s urgical specialties

●
of pregnancy, paediatrician) o perating room

●
c ritical care
●

Figure 2.1 Summary of team brief and preparations for the reception of a trauma patient
The primary survey

This starts immediately on the patient’s arrival, its
The Assessment Triangle
purpose is to identify and control any immediate life- and its components
threatening condition.
Social interaction Social interaction
5-Second Round and Handover Calm, collected
Agitated
The priorities on arrival are: Absent
n
The TTL performs a 5-second round, which is a
Respiratory effort
brief initial assessment of the patient, before the Normal
handover commences. The aim of the 5-second Increased
Absent
round is to rule out the following life-threatening
conditions Skin Resp. effort Skin perfusion
Pink
●c omplete airway obstruction perfusion
Pale, mottled
●m assive external haemorrhage Absent
●t raumatic cardiac arrest and to confirm whether
Plan A is still appropriate. Figure 2.2 The assessment triangle is part of the five second round
This can be achieved within seconds using the and helps the team to assess the severity of the patients condition;
‘Assessment Triangle’ (Fig 2.2). This is a basic visual a patient that is calm, collected with normal respiratory effort and
assessment tool that gives an immediate indication good skin perfusion does most likely not require any immediate
of the severity of the patient’s condition. The intervention, whereas an agitated patient in respiratory distress,
‘Assessment Triangle’ looks at three physiological with mottled skin, is likely to require life-saving interventions
aspects. without delay.
●s ocial interaction
●r espiratory effort If the TTL identifies any life-threatening conditions, he
●s kin perfusion must immediately direct the team towards resolution
of the situation rather than proceeding with the
primary survey. For example; directing the team to
apply pressure or tourniquets to stem bleeding, to
relieve airway occlusion or initiate the Traumatic
Cardiac Arrest (TCA) algorithm (See chapter 5c, TCA).
The TTL should call out the findings of the 5-second In most trauma systems this will be the role of the
round clearly to make sure that all team members anaesthesiologist, who can also insert large bore
understand the clinical priorities. In most cases, the vascular access.
team will be able to continue with ‘plan A’.
Then the primary survey commences with all personnel Breathing
working simultaneously and supporting each other Breathing personnel:
where required (figure 2.3). During the primary survey n assess breathing pattern
TTL remains ‘hands-off’. The best position for the TTL n ensure ECG and peripheral oxygen saturation
is at the foot end of the patient’s bed, which gives (SpO2) monitors are attached
him the best overview, helps retaining situational n examine the chest
awareness and maximising bandwith. n perform a lateral thoracostomy and insert ICD as
The TTL should stand next to the recording TSP (scribe) necessary
to allow for optimal communication between the two n inspect and palpate the neck
in a sometimes noisy environment. n support other team members if no chest
intervention is required.
Prior to the Primary Survey the patient must be
exposed to allow a complete examination and access Circulation
to vital structures. Circulation personnel:
n stem any overt haemorrhage
Airway n establish peripheral vascular access, take

Airway personnel establish contact with the patient appropriate blood samples
and check airway patency. Following this, and n start monitoring of heart rate (HR), blood pressure
depending on the response, they will: (BP) and capillary refill time (CRT)
n give oxygen if the SpO is decreased; n start fluid resuscitation or give blood products
2
n provide basic and advanced airway management n examine the abdomen, pelvis and long bones
as necessary; n apply a pelvic binder if indicated
n monitor end-tidal CO n if competent and indicated, perform extended

2
n immobilise the cervical spine focused sonography assessment (e-FAST)
n provide analgesia n insert a urinary catheter.
n carry out a focused neurological assessment (see
Disability) and obtain an AMPLE history; this is Disability (neurological assessment)

essential if the patient is to be anaesthetized This is usually done by the airway personnel and
n use an RSI checklist if general anaesthesia is given consists of:
n support other team members if no airway n assessment/reassessment of the patient’s GCS score;
intervention required n compare pupillary size, symmetry and light response
Figure 2.3 The Team approach to the primary survey

n c heck for any gross difference in motor response in Good documentation is mandatory and needs to be
all four extremities contemporary. The use of standardised trauma charts
(see appendix) ensures that all relevant systems are
Exposure examined. The documentation includes details of all
This will involve all TTMs and consists of: diagnostic and therapeutic steps (both completed and
n Completion of removal of clothes. planned), recorded in such a manner that it is easy to
n Consider a log roll to check the patient’s back and follow for teams that take over the care at a later stage.
remove any debris. Points to note include: Documentation is the task of the scribe. Closed loop
i t has the highest priority in a patient with
● communication between the scribe and the other
penetrating trauma particularly in those with team members ensures that important information is
stab or gunshot wounds not lost. An experienced scribe will also act as auditor
p
● ostpone in cardiovascular unstable blunt trauma of the resuscitation process and prompt the TTL if
patients and those with actual or suspected detects any deviations from standard practice.
pelvic or spinal trauma
i t can be postponed if immediate whole body CT
● It is the TTL’s responsibility to ensure that the
is planned documentation is complete and to decide on
n Active measures must be taken to maintain the immediate future management of the
the patient’s body temperature and prevent patient.

hypothermia. One or more of the team must
therefore ensure that the patient is covered with a
forced-air-warming blanket.
Imaging in the major trauma patient
The key role of the TTL is to supervise and guide
the team whilst the resuscitation is ongoing. This is Sonography
achieved through good team communication: Extended Focused Assessment with Sonography
n all TTMs communicating their findings to the TTL as in Trauma (eFAST) is a standardized ultrasound
and when appropriate examination aimed at identifying immediately life
n the TTL processes these findings and makes threatening conditions and targeting resuscitative
sure that all TTMs have an understanding of the efforts. In many countries it has become part of the
patient’s revised condition and priorities primary survey. It is particularly useful to identify the
n formulation and alteration the treatment plan as source of shock in trauma.
the resuscitation is ongoing
n using the ‘stop procedure’ to ensure that all team The examination consists of three components (Fig 2.4):
members understand the process and the immediate 1) the abdominal examination aims at identifying free
priorities. The ‘stop procedure’ is particularly helpful, fluid in hepatorenal recess, the perisplenic and the
when unexpected problems arise. rectovesical space.
n ensuring that all vital functions are continuously 2) examination of the anterlateral chest wall allows to
reassessed and results recorded reliably identify a pneumo- or haemothorax.
n reallocating tasks of the TTMs if required 3) examination of the heart can identify a cardiac
n ensuring that the relevant diagnostic tests tamponade and help assessing the intravascular
(laboratory and radiology investigations) and fluid status of the patient.
emergency interventions (e.g. major haemorrhage
protocol) are carried out
n the TTL is responsible for organising the patient
pathway (communication with departments or

regional specialist centres
Figure 2.4 The standard views of eFAST (with the kind permission
Dieter von Ow, Kantonsspital St.Gallen, CH)

Additionally, assessment of the diameter of the inferior vena
cava (IVC) for evidence of collapse during inspiration and
an empty urinary bladder after fluid resuscitation suggest
inadequate resuscitation or more seriously ongoing blood
loss. Ultrasound guided central venous cannulation is now
regarded as the ‘gold standard’ and is particularly valuable
in trauma patients where hypovolaemia reduces the
diameter of the central veins.
Sonography has the greatest importance in trauma

patients who are haemodynamically unstable. These
patients require urgent intervention and eFAST can
be used to guide the resuscitation and to establish
the treatment priorities (eg guiding the surgeon to the
correct body cavity). However, CT remains the ‘gold- Figure 2.5 Handover from the pre-hospital to the hospital team;
Shock-Operating-Room with integrated CT-scanner at the Military
standard’ investigation for haemodynamically stable
Hospital Ulm, Germany. (B.Hossfeld)
trauma patients.
A further important role for sonography is in the
investigation of patients who have sustained moderate What type of CT scan?

trauma but do not fit the criteria for major or polytrauma. Whole body, contrast enhanced, multi-detector CT
These patients will not warrant an immediate CT, but scanning is the default imaging of choice in the major
negative sonography and normal haemodynamics trauma patient. Each Radiology Department will acquire
help in planning management. Conversely, if free fluid images in slightly different formats, but as a minimum
is identified then CT scanning should be expedited. the patient needs a CT scan of the head, cervical spine,
thorax, abdomen and pelvis with no ‘skip areas’. The
Finally, sonography can be used as part of the triage images can be acquired in a single block or as separate
system when dealing with multiple patients or in a acquisitions depending on type of CT scanner.
major incident to help identify those who need urgent
intervention. A radiologist, experienced in the interpretation of
trauma scans should provide an initial ‘primary survey
CT scanning report’ within a few minutes so that any immediately
Patients who have sustained major trauma require a life-saving interventions (e.g. insertion of a chest
CT examination from head to mid-femur as soon as drain) can be carried out. Whilst these procedures are
possible. This is to establish a management plan based on-going the radiologist then needs to review all the
upon the appropriateness of surgery, interventional images more completely allowing a ‘secondary survey
radiology or conservative management. report’ to be issued.
Ideally the trauma receiving area and the CT scanner Angiography and interventional radiology
should be co-located as this enables imaging to be All trauma centres should have access to angiography
performed within the first few minutes of arrival, whilst and interventional radiology services 24 hours a
resuscitation continues. When the scanner is remote, day within 30-60 minutes of request. Ideally, an
well-rehearsed procedures need to be in place to ensure interventional radiologist should be immediately
CT imaging is possible within the first hour of admission. available if the CT scan reveals active bleeding as the
Administrative delays should also be minimized by source may be amenable to treatment.
having a standardised request and protocol understood
by all departments. In some advanced systems early
whole body CT scan is carried out as part of the primary Analgesia
survey. This requires the CT scanner to be located in the
trauma bay or the shock room (fig 2.5). From both a humane and therapeutic point of view,
all trauma patients should receive appropriate pain
When scanning occurs shortly after arrival there is relief. This can be achieved using a combination of
no need to perform plain radiographs of the spine, psychological, physical and pharmacological methods.
(particularly cervical) or pelvis. However, if CT scanning
is not immediately available, plain x-rays of the chest Psychological methods
and pelvis remain part of the primary survey. Plain films Stress will make the perception of pain more acute and
of the extremities can be taken as required but again, disturbing and a combination of the following should
should not unduly delay the transfer for scanning. be used to minimise this:
n make eye contact with the patient;
n make physical contact with the patient (e.g. hold hand);

n t alk to the patient – this is best relayed through In some patients with severe, multiple injuries
one person; adequate analgesia is only achieved at the expense
● e xplain what is happening of loss of consciousness, respiratory depression and
● a sk about worries and needs (e.g. message severe hypotension. These cases require general
relayed to relative; wish to urinate) anaesthesia. Endotracheal intubation and general
● w arning before any painful procedure anaesthesia in trauma patient are high risk procedures
n maintain dignity. and require direct supervision by an experienced
anaesthesiologist. Severe cardiovascular depression
Physical methods after induction is a common problem and could be
n F racture stabilization: displaced fractures are due to hypovolaemia or a tension pneumothorax
extremely painful. Early splinting is effective at developing under controlled ventilation.
reducing the severity of pain, fracture-associated Chest decompression, massive transfusion or
bleeding, neurovascular damage, secondary vasopressors are possible treatment options.
tissue damage (e.g. skin necrosis over the medial A selection of the more commonly used analgesic
malleolus in ankle dislocations) and fat emboli. drugs and doses are shown in table 2.3. All are usually
n Covering burns: a sterile dressing will reduce given with an antiemetic.
pain (burns are hypersensitive) and help protect
from contamination. Clear plastic film is cheap, In some European countries metamizole is widely
sterile and non-adherent. It should be placed in used in combination with opioids. The dose is 1g IV.

longitudinal strips to prevent limb constriction. However its use is banned in other countries.
n Early removal of spinal boards or scoop-stretchers:
moving patients to softer surfaces reduces pain TABLE 2.3
and the risk of pressure sores. Commonly used analgesic drugs and their doses
n Prevent and treat hypothermia: many patients
are hypothermic on arrival at hospital. Shivering Drug Route Dose (typical Comments
increases pain intensity and warming using a given bolus)
forced-air warming blanket should be started as Morphine IV 0.03-0.1 mg/kg Titrate to effect, re-
soon as possible. bolus peat bolus every 5-10
(2-8 mg) minutes. Slow onset,
not very effective for
Pharmacological methods musculoskeletal pain.
Parenteral opioids and ketamine are the most Histamine release can
commonly used drugs to provide analgesia in trauma. aggravate hypotension.
Whichever drug is used, the following factors must be Reduce dose in elderly.
taken into consideration: Fentanyl IV 0.5-1 mcg/kg Rapid onset, shorter
n pharmacodynamics of analgesic drugs in shocked bolus duration than
patients (50-100 mcg) morphine.
n route given Titrate to effect;
n age of patient
repeat bolus every
2 minutes
n potential side-effects
n local protocols IN 2mcg/kg

n availability of drugs Alfentanil IV 5-10 mcg/kg Titrate to effect.
n familiarity with the drugs bolus
0.5-1 mg Very short duration.
The side-effects of potent analgesic drugs may be Ketamine IV 0.2-0.5mg/kg
profound in trauma patients. The dose of drug must
(20-40 mg) Titrate to effect.
be titrated in small aliquots to control pain while Doses of >0.5mg/kg
minimising the risk of adverse effects. Circulation may produce general
time is increased in patients in shock and the onset anaesthesia in com-
of analgesia may be significantly delayed. Using promised patients.
combinations of drugs from different analgesic classes Risk of delirium on
increases their efficacy whilst reducing total doses and recovery.
subsequent side effects. IM 2 mg/kg
100-200 mg
Particular care is required in patients with: IN 3 mg/kg Slow onset, prolonged
n a reduced level of consciousness (100 mg) duration.
n respiratory compromise If S-Ketamin is used, reduce dose by 50%
n shock
Paracetamol IV 15 mg/kg Every 4-6 hours.
n hypothermia
(1000 mg) Usually given in
n intoxication (alcohol, drugs)
conjunction with opioid.
n the elderly

Planning the Patient Pathway
Planning Round
Priorities and Investigations/ Communicate Direction of Planning of safe

allocation of Diagnostics with other travel transfer /
outstanding teams patient
tasks movement
Secondary Complete and Operating Operating Transfer

Survey review lab results Room Room team
Blood Complete and Radiology CT ± interventional Equipment

products review imaging radiology
ICU
Talking ITU
to relatives Other specialist

teams Interhospital
transfer
Tertiary referral
centre Ward
Figure 2.6 T he patient pathway. Before the patient leaves the Emergency Department all findings need to be summarised and the priorities
established
Quantifying the intensity of pain is an essential part of The decision making process required to initiate an
initial and ongoing pain assessment. A number of tools are individual patient pathway can be quite complex and
available to assess pain. In the Emergency Department, usually requires senior multispecialty input.
whichever tool is used needs to be quick, accurate and
flexible for varying situations and ages. A commonly used Ultimately, all patients will require transfer out of the
system is the verbal rating scale where patients are asked Trauma Bay regardless of the care pathway planned.
to score their pain on a scale ranging from 0 (no pain) to The transfer should follow the concepts described in
10 (worst pain imaginable). This is repeated to assess the chapter 12.
effectiveness of the analgesia given.
It is the responsibility of the TTL to make contact with
Although regional anaesthesia can be used, it has staff in the immediate receiving unit (e.g. operating
limited applicability during the primary survey. Nerve room, ICU) to ensure that an appropriate handover is
blocks and local anaesthesia can play an important given.
role in preventing pain in invasive procedures, e.g.
chest tube insertion. Time spent by the patient in the Trauma Bay should be
minimised. Those in need of time critical interventions
(e.g. damage control surgery) should be transferred at
Summary and planning round the earliest opportunity. However this need for speed
should not be at the expense of safety. These patients
The primary survey concludes with a summary and must be packaged and moved so that resuscitation
planning round which must take no longer than 5 and monitoring by appropriately trained individuals
minutes. Its purpose is to collate all findings, review all can continue. The TTL should ensure that all relevant
measures taken so far and to establish an individual documentation remains with the patient at all times.
patient pathway (figure 2.6). A number of factors have Handovers of care are crucial moments in the patient’s
a common influence on the pathway. pathway.
They must be carried out in line with hospital guidance
Patient factors: to avoid loss of critical information.
n actual or suspected injuries
n physiological condition When time critical interventions are not necessary,

the patient’s resuscitation phase and secondary
Hospital facilities: survey should be completed before transfer from the
n infrastructure Emergency Department.
n available specialties

The secondary survey there is restricted access to the patient or a brief time
window before embarking on emergency procedures,
The Secondary Survey is a systematic and detailed it is wise to prioritise the subsequent examinations.
examination of all body regions that aims to identify There are pitfalls in carrying out some examinations
all subsequent injuries. It entails a physical top to toe prematurely or in omitting others. For example,
examination (see appendix at the end of the chapter), a turning a patient with severe hypovolaemia can further
reassessment of the vital functions and a review of all de-stabilise their circulation, but a stab wound to the
imaging and laboratory findings. posterior trunk must not be missed. Similarly, log-
In a stable patient, the order of priority is less important rolling a patient with a mechanically unstable pelvic
than in the Primary Survey. The examination may be fracture may cause further damage or displace a clot,
carried out systematically, head-to-toe, front-and- but it is still important to identify any posterior wounds
back, by either a single clinician, which is preferable overlying the fracture at an early stage to minimise the
in a conscious patient (who can only interact with one risk of infection. Adjunct imaging, such as a CT scan
examiner at a time) or in parallel by the full trauma of the pelvis, performed first, will clarify the fracture
team, which is preferable in time critical, unconscious configuration and identify pelvic haematomas before
patients (where it is generally more efficient for committing to a log roll. In compromised patients,
appropriate team members to examine different parts). the team needs a flexible, dynamic approach to the
Secondary Survey.

The secondary findings should be merged together by Body orifices (ears, mouth, urethra, rectum, vagina)
the team leader into a verbal summary. are part of the examination. While some sensitive
As care proceeds, the evolving summary is periodically examinations can be omitted with careful judgement,
shared with the team and then recorded. rectal and vaginal examinations are important in some
Body regions to examine in the Secondary Survey: pelvic fracture configurations: missing internal, open
n Head fractures will increase the morbidity and occasionally
n Face including eyes, mouth, nose and ears increase risk of death.
n Neck The respiratory and circulatory systems are reviewed
n Chest together with monitoring data. The GCS is repeated.
n Abdomen and pelvic contents including the loins, A more detailed neurological examination is
perineum and genitalia incorporated, looking for lateralised, segmental or
n Spine focal deficit. (see chapter 9, neurological examination)
n Limbs including the shoulder and pelvic girdles Pain is assessed and treated.
and buttocks Adjuncts to the Secondary Survey include completion of:
n E xternal burns, wounds and contamination n X-rays
n C T scans
n Other imaging (ultrasound, MRI)

Timing of the Secondary Survey n Arterial and venous blood sampling (acid-
base, blood gases, lactate, glucose, electrolytes;
a) stable patient haemoglobin, clotting profiles including TEG and
Primary Survey Secondary Survey
fibrinogen, liver function tests including amylase,
drug levels; blood group)
n Urinalysis
b) unstable patient
Secondary
Primary Survey Survey Reviewing radiology, laboratory and near-patient
testing reports (e.g. ultrasound, X-ray, CT, blood gases,
time lactate, glucose, clotting profiles) and noting trends
in monitored parameters are also part of the the
Figure 2.7 In stable patients the secondary survey immediately Secondary Survey. Spinal clearance can be achieved
follows the primary survey. In unstable patients the secondary after the Secondary Survey and appropriate imaging,
survey sometimes must be carried out staggered, as resuscitation is in accordance with the local protocol.
ongoing; this does not always allow for the secondary survey to be A detailed history from the patient, witnesses, friends
carried out in one go. Good documentation is necessary to ensure and family should be combined with the Secondary
that no information is lost and the secondary survey gets completed. Survey, as well as clothing checks for drug or allergy
alerts. This should extend beyond the initial ATMIST
In an unstable patient, the Secondary Survey handover and basic AMPLE history. Tetanus status
may require a more prioritised approach. (Fig 2.7). should be confirmed.
Following the Primary Survey, the team may have In complex cases, the team leader and team members
already performed a targeted examination and should be aware of what elements of the Secondary
ordered emergency imaging or near-patient testing Survey have not yet been undertaken and look
in relation to identified or suspected threats to life. If to complete this at the earliest opportunity. It is

inappropriate (a ‘cop-out’) simply to state that the
secondary survey has not been done or is incomplete.
The missing elements should be included in the
summarised diagnostic problem list.
The Tertiary Review is a re-examination of the patient’s
condition, often at the time of admission to the critical
care unit or on the day after admission when reviewed
by the team overseeing continuing acute care. It can
however occur at any stage during the patient’s pathway.
It is not time-critical, but may reveal missed injuries or
subtle physiological instability that warrant prompt
attention to avert deterioration or reduce complications.
At any stage after the Primary Survey, including up to and
beyond the Tertiary Survey, the patient may deteriorate
unexpectedly. An emergency review should then take
place, recapitulating the Primary and Secondary Surveys.
Summary
The initial resuscitation of the trauma patient is
best achieved by a well trained, multidisciplinary
team of Clinicians, and Trauma Support
Practitioners in a shock room environment.
Each member of the team must understand
their responsibilities and role within the team
and work within their competencies. Any
response of a critically injured patient to the
team’s interventions is dynamic and therefore
resuscitation during the primary survey is a
continuous cycle of assessment, intervention
and reassessment.
Having worked through this chapter you are now

ready to apply the knowledge in the scenarios
and demonstrate competence in:
n taking the role of the TTL;
n taking the role of a TTM;
n carry out a primary survey;
n carry out a secondary survey.


APPENDIX:
Secondary Survey Checklist Physical
Examination
Head
n Neuro-status GCS, pupils, eye movements,
lateralising signs
n Scalp: lacerations, bruising, depressions or
irregularities in the skull, Battles sign (bruising
behind the ear indicative of a base of skull fracture)
n Mouth: lacerations, loose, missing or fractured teeth
n Nose: bleeding, nasal septal haematoma, CSF leak
n Ears: bleeding, blood behind tympanic membrane
n Eyes: foreign body, bulbus trauma, contact lenses
n Jaw: pain, malocclusion

Neck
n Cervical spine: pain, tenderness, deformity, neck
movement
n Soft tissues: bruising, pain and tenderness, swelling,
surgical emphysema
n Trachea: deviation
n Neck veins: distension
Chest
n Chest wall: bruising, lacerations, penetrating injury,
tenderness, flail segment

n Lung fields: percussion note, lack of breath sounds,
wheezing, crepitations
n Heart: Apex beat, heart sounds
Abdomen & Pelvis

n Bruising, lacerations, penetrating injury, tenderness
rebound, solid organ or bladder enlargement

n Bowel sounds
n No springing of the pelvis, take pelvic X-ray or
request CT if you suspect a pelvic fracture!
Limbs
n ruising, lacerations, muscle, nerve or tendon
B
damage. tenderness, deformities, open fractures,
n Joint stability/mobility
n Sensory and motor function (muscle strength) of
any nerve roots or peripheral nerves that may have
been injured
Back
n Log roll, inspect the entire length of the back and
buttocks and palpate the spine for tenderness, steps

between vertebrae
n Bruising, lacerations
Buttocks, Genitalia, Perineum

n Soft tissues: bruising, lacerations. Inspect anus,
digital examination is rarely needed

DATE TIME Record of

ATMIST
Narrative GCS EYES (1-4) Drugs and Fluids:
ETC Trauma Chart VERBAL (1-5)
MOTOR (1-6)
Patient IDPatient ID | | | | |
GCS TOTAL (3-15)
R/L SIZE
Team Brief Presumptive | | | | |
PUPILS REACTION
Diagnosis: | | | | |
FiO2
Primary
Plan A D-Disability : for GCS, pupil size and reactivity and blood glucose see VENTILATION ETCO2
Survey
vital function documentation SaO2
lateralising signs: yes no ; central neck pain: yes no ; RESP-RATE

Plan B
Gross motor deficits: yes no ; Sensory deficits: yes no ; 190
other findings 180
Teams informed: Radiology/CT Bloodbank/MHP
170
Anaesthesia Surgery/Theatres 160
Diagnostics: CT-head ; CT-spine ; MRI
150
5 sec catastrophic Haemorrhage: yes no BLOOD
Interventions: Mannitol ; Hypertonic saline ; Neurosurgical referral 140
PRESSURE
Airway obsdtruction: yes no AND 130
E- Exposure & Extremities: hypothermia yes no ; PULSE RATE 120
Breathing problems: yes no long bone fx: yes no ; distal pulses: yes no ;
110
other findings
Shock: yes no 100
90
Alert Verbal Pain Unresponsive 80
ETC Trauma Admission Chart
Change of Plan A: yes no Diagnostics: X-Ray ; 70

Interventions: 60
Handover 50
40
Age Splinting ; forced air warming ;
Mechanism 30
Injuries 20
FLUID LOSS BLOOD LOSS
Signs Planning Injuries
URINE
Treatment Round
CHEST DRAIN
Outstanding tasks TEMP, BM TEMPRATURE

PAIN GLUCOSE
Primary PAIN
Survey A-Airway: clear ; obstructed ; occluded ; blood : vomitus
Patient journey
other findings
Injuries identified:
________________________________________________
Interventions
________________________________________________
Free Text
Oxygen ; Airway support ; Spine immobilisation ; RSI ________________________________________________
B- Chest & Neck: laboured ; > 25 min/ ; < 10 min ; absent ;
Bilateral BS yes no ; Emphysema ; Bruising ;
Chest wall tenderness ; C-spine tenderness ;
other findings
Diagnostics: US ; CXR ;
Interventions:
Chest drain ;
C - Circulation, Abdo & Pelvis: pallor ; mottled ; cold periphery ;

no peripheral pulse ; Tenderness ; Bruising ;
other findings
Diagnostics: US ; Pelvic XR ;
Interventions:
Haemostatic dressing ; Pelvic binder ; TXA ; MHP


3.
Airway management in the trauma patient
Learning outcomes
n A
ssessing a patient’s airway
n B
asic airway management and the use of simple airway adjuncts
n T
he use of supraglottic airway devices
n T
echniques for ventilation of the patient’s lungs
n R
ecognising the potential for a difficult airway
n T
he use of surgical airways in the resuscitation room
Introduction a semi-rigid cervical collar alone or combined with

lateral blocks and tapes or a vacuum mattress,
Establishing a clear airway and ensuring adequate depending on local protocols. Alternatively, manual
oxygenation are essential prerequisites for successful in-line stabilisation (MILS) of the cervical spine can be
resuscitation and are therefore part of the key initial used. Ensure that there is no uncontrolled movement
interventions by the team in the trauma patient. of the spine or loss of airway patency during transfer
Failure to recognize and clear an obstructed airway to, or within, the resuscitation room.
will rapidly result in hypoxemia and ultimately,
cardiopulmonary arrest. Unfortunately, fatalities still
occur in patients because inadequate attention is paid Primary survey
to the principles of basic airway management.
Immediate evaluation of the patient’s airway is carried
Once patent, the airway must be secured to enable out in order to identify and treat current problems
continuous, efficient oxygenation (and ventilation) and to anticipate potential problems. Regular re-
whilst at the same time minimising the risk of evaluation is also mandatory during the primary
aspiration. If the cervical spine is injured, the spinal survey as the situation is dynamic and problems may
cord may be jeopardised if airway interventions are develop over time. The quickest way of evaluating the
not controlled carefully. This chapter will describe how airway is to ask the patient ‘Are you alright?’. A lucid
to assess, clear, and secure the airway and oxygenate reply implies patency, a reasonable vital capacity
the trauma patient, while minimising the risk of breath and a cerebral perfusion sufficient to maintain
injuring the spinal cord. consciousness. If the patient fails to reply or their
response is impaired a more detailed assessment is
made using the look, listen and feel approach:
Standby preparation and transfer n LOOK specifically for chest and abdominal
movement;
Although all equipment must be checked regularly, n LISTEN for any noise associated with breathing.
the airway personnel must complete a final check of Normal breathing should be quiet, noisy breathing
equipment while waiting for the patient to arrive. indicates partial airway obstruction;
n FEEL for airflow at the mouth and nose.
On arrival at hospital, the patient’s airway must be
assessed immediately, as part of the 5-second round. If Patient’s airway is clear
there is evidence of compromise, clear and secure the Breathing should be quiet with no abnormal noises
airway using simple techniques while simultaneously and with good airflow at the mouth and nose. A clear
immobilising the head and neck. This may be with airway is associated with a normal pattern of chest
CHAPTER 3 AIRWAY MANAGEMENT IN THE TRAUMA PATIENT | 35

and abdominal movement, although the respiratory cardiac arrest ensues. While the techniques described
rate may be increased due to hypoxia or hypercarbia. below are implemented to relieve the obstruction,
Therefore oxygen should be given via a facemask and high concentration oxygen should be given via a
a pulse oximeter applied to assess oxygenation. facemask as complete obstruction is relatively rare.
Although the patient may have a clear airway, this Basic techniques for opening the airway
does not guarantee adequate ventilation as there If there is evidence of foreign material in the airway
may be other injuries e.g. to the chest. If ventilation is it should be removed. Small amounts of blood and
inadequate, it must be supported. secretions need to be cleared from the oral cavity by
using a suction catheter. Large amounts of blood or
An obstructed airway vomit are best removed using a rigid, wide bore sucker
Obstruction may be partial or complete and sited at (Yankauer). Solid debris such as food or teeth is best
any level from the upper airway (nose/mouth) down to removed with forceps (Magill) or similar device.
the lower airway (bronchi). Common causes include:
n loss of upper airway muscle tone, usually due to a Initial manoeuvres to relieve obstruction of the airway
reduced conscious level include chin lift and jaw thrust. Assess the effectiveness
n the presence of blood, vomit or foreign bodies of these manoeuvres using the look, listen and
n trauma to the face or neck feel approach described above, whilst at all times

n laryngeal spasm maintaining immobilisation of the cervical spine.
n bronchospasm
Chin lift (see skills section)
Partial obstruction
Look at the patient: KEY POINTS
n t hey are usually tachypnoeic (respiratory rate
Indication: airway obstruction or occlusion
>25/min), agitated, and sweaty due to hypoxia and
Procedure: g rasp the patient’s chin and lift the
hypercarbia;
mandible anteriorly
n t he accessory muscles of respiration are used - the
Complications: failure, loss of the airway on release
neck and the shoulder muscles contract to assist
movement of the thoracic cage. There may also be Common insufficient force used to lift the mandible
suprasternal, intercostal and subcostal recession pitfalls:
and a tracheal tug.
Listen for: Jaw thrust (see skills section)
n inspiratory
stridor - caused by obstruction at the
laryngeal level or above KEY POINTS
n e xpiratory wheeze - suggests obstruction of the
Indication: partial or complete airway obstruction
lower airways, which tend to collapse and obstruct
Procedure: u pwards and forwards pressure at the
during expiration angles of the mandible
n g urgling - suggests the presence of liquid or
Complications: ovement of the cervical spine, loss
m
semisolid foreign material in the upper airways
of the airway on release, may worsen
n s noring - arises when the pharynx is partially
obstruction if the mandible is fractured
occluded by the tongue or palate
Common f ailure to clear the airway, failure to
n b reath sounds - on auscultation, air entry will be
pitfalls: recognize inadequate oxygenation and/
diminished or ventilation
Feel:
n t here will be reduced airflow at the nose and mouth.
Adjuncts to basic airway techniques

Complete obstruction The oropharyngeal (Guedel) airway and the
Look at the patient: nasopharyngeal (Wendl) airway are curved plastic
n s earch for paradoxical movement of thorax and tubes that are designed to overcome airway
abdomen (inward movement of abdominal wall on obstruction caused by the backward displacement
inspiration). This may in some cases be vigorous. of the tongue or by the soft palate. They do not
Listen for: guarantee a secure airway and may need to be used in
n t here will be no sounds due to absence of airflow. conjunction with a jaw thrust. Once inserted, reassess
Feel: airway patency using look, listen, and feel approach. A
n n o airflow is felt at the mouth or nose. patient who tolerates an oropharyngeal airway has an
unprotected airway and is at risk of regurgitation and
Unless airway obstruction is relieved and oxygenation aspiration. The team leader should be informed and
and ventilation restored rapidly, hypoxia will cause plans made to secure the airway using an advanced
injury to the brain and other vital organs. Ultimately a technique.

Insertion of oropharyngeal airway (see skills section) Manual in-line stabilisation (MILS) (see skills section)
KEY POINTS KEY POINTS

Indications: partial or complete airway obstruction Indications: actual or potential risk of injury to the
Procedure: insertion of an oropharyngeal airway cervical vertebrae or spinal cord
Complications: v omiting due to gag reflex if too long, Procedure: stabilisation of the head and neck by a
bleeding do not use if there is a known team member
or suspected base of skull fracture, Complications: difficulties with airway management
laryngeal spasm
Common exacerbation of injury due to use of
Common backward displacement of the tongue pitfalls: excessive force
pitfalls: exacerbating obstruction, assuming a
patent airway means oxygenation
Adequacy of oxygenation
After insertion of either of the above devices, re-check
the patency of the airway using the look, listen and
The nasopharyngeal airway is a soft plastic tube, feel technique. It is usually necessary to maintain a
bevelled at one end with a flange at the other. They jaw thrust. Assuming that these simple manoeuvres
are better tolerated than oropharyngeal devices by allow the patient to breathe spontaneously, give
patients who are not deeply unconscious. It may also oxygen via a good fitting facemask with a reservoir at
be life-saving in patients with maxillofacial injuries or 15 l/min. The reservoir needs to be full before the mask
trismus. is applied and should inflate and deflate with each
breath. If spontaneous ventilation is inadequate, or
Insertion of nasopharyngeal airway (see skills section) the patient remains apnoeic despite a patent airway,
they will need to be ventilated.
KEY POINTS
Bag-mask ventilation
Indications: partial or complete airway obstruction,
particularly when trismus is present This is the simplest and most widely used device to
Procedure: insertion of a nasopharyngeal airway
oxygenate and ventilate a patient whose own efforts
are inadequate or absent. The mask covers the mouth
Complications: vomiting due to gag reflex if too long,
and nose, the bag is squeezed and its contents are
bleeding, do not use if there is a known
or suspected base of skull fracture delivered to the lungs. On release, the expired gas is
diverted to the atmosphere and the bag refills with
Common failure to insert as pushed ‘up’ the
pitfalls: patient’s nose, rather than along the floor air and oxygen if attached. When used alone, the
of the nose lungs are inflated with air (21% oxygen). This can be
increased to a maximum of around 80% if high flow
oxygen and a reservoir are attached.
Cervical spine immobilisation
At all times while managing the airway, consideration The use of a bag-mask apparatus by a single person
must be given to the possibility of injury to the cervical requires considerable skill because it is difficult to
vertebrae and spinal cord. If a patient arrives without achieve a gas-tight seal, and maintain a patent airway
their cervical spine being immobilised, this should with one hand whilst squeezing the bag with the
be achieved initially by a member of the team using other. Any significant leak will cause hypoventilation
MILS. Once the airway has been assessed and any and if the airway is not patent, gas may also be
intervention required completed, MILS should be forced into the stomach. This will reduce ventilation
replaced with a semi-rigid collar, blocks and tapes further and greatly increase the risk of regurgitation
or a well moulded vacuum mattress according to and aspiration. There is a natural tendency to try to
local policy. In patients who arrive with cervical compensate for a leak by excessive compression of the
immobilisation already applied, this will need to be bag, which causes high airway pressures and forces
removed temporarily to allow airway management, more gas into the stomach. Most of these patients will
in particular tracheal intubation or a surgical airway. ultimately need an advanced airway; a supraglottic
In these circumstances, MILS must be applied before device, tracheal tube or surgical airway depending on
any of the immobilising devices are removed and the urgency and the skills available within the team
maintained until they are fully reapplied. Tracheal members. Once an advanced airway device is in place,
intubation should not be attempted with a semi-rigid the bag can be connected to ventilate the patient.
collar in place as the procedure is made much more If there is any possibility of injury to the cervical
difficult and puts the patient at risk of oesophageal vertebrae or spinal cord, all airway interventions
intubation, failed intubation and hypoxia. must be performed while maintaining alignment and
immobilisation of the head and neck.

Bag mask ventilation (see skills section) n It is unreliable when there is severe
vasoconstriction because of the reduced
KEY POINTS pulsatile component of the signal.
n It provides no indication of adequacy of ventilation.
Indications: inadequate spontaneous ventilation,
apnoea Profound hypercapnia (increased PaCO2) is possible
Procedure: bag-mask ventilation
with normal oxygen saturations, particularly when
using a high inspired oxygen concentration.
Complications: leak around the mask, gastric insufflation
n It is unreliable with certain haemoglobins:
Common inadequate ventilation, excessive ● when
carboxyhaemoglobin is present (smoke
pitfalls: ventilation
inhalation), it overestimates SpO2
● w
hen methaemoglobin is present (intoxication
Pulse oximetry with methaemoglobine forming agents), SpO2 is

This is essential in all trauma patients to assess underestimated at values greater than 85%
adequacy of oxygenation which can be impaired n It progressively under-reads the arterial blood
as a result of either ‘A’ or ‘B’ problems as well as saturation as the haemoglobin decreases (but is
‘C’ (e.g. haemorrhagic shock), and ‘D’ problems not affected by polycythaemia)
(e.g. high spinal cord injury). The oximeter probe n It is affected by extraneous light and unreliable
is attached to the tip of a digit or earlobe and the when there is excessive movement of the patient

device displays the SpO2 both as a waveform and
a digital reading. Pulse oximeters are accurate to Advanced airway techniques
± 2%. The heart rate is usually also displayed. The pulse A number of situations may occur when it is
oximeter therefore provides information about both inappropriate or impossible to maintain a patent
the circulatory and respiratory systems. However, there airway and achieve adequate oxygenation and
are several important limitations to pulse oximetry: ventilation using the techniques described above. In
n A saturation of 100% normally equates a PaO of these circumstances an advanced airway technique is
2
12 kPa, whereas a saturation of 90% equates to a indicated. Common indications include:
PaO2 of only 8kPa (60mmHg). That is a 10% drop n inadequate airway with basic techniques, e.g.
in saturation, but a 40% drop in partial pressure. severe facial fractures

Below this, the oxygen content of blood decreases n reduced conscious level, tolerating an
even more rapidly. oropharyngeal airway
Figure 3.1 Difficult Airway Algorithm (with permission of the Difficult Airway Society) http://das.uk.com

n a irway at risk from swelling, e.g. burns, multiple Second is a systematic approach to unexpected
cervical vertebral fractures, massive subcutaneous difficulties in airway management. One such approach
emphysema is the Vortex approach, which describes a mindset,
n compromise of normal respiratory function, e.g. which can be overlaid on any difficult airway algorithm.
chest trauma Conceptually, airway management is described like a
n specific need for ventilation, e.g. traumatic brain injury funnel (figure 3.2). The upper edge of the funnel is the
safe “green zone” in which a patient can oxygenate
Advanced airway management in a patient with and ventilate him- or herself. Once anesthesia is
residual airway patency and/or respiratory effort induced, the green zone is left and oxygenation spirals
usually requires the employment of anesthetic drugs. down the funnel. Once started, there are maximum
This makes it a procedure with a high risk of potentially three attempts at three ways (total of nine attempts)
lethal complications. It should therefore only be carried to restore oxygenation and get back into the green
out by a team of clinicians who are experienced in zone: intubation, supraglottic airway and bag mask
emergency advanced airway management. ventilation. Once a “best effort” for either of these
To reduce the risk of complications, we recommend the three has been done, there is no point in further
implementation of several precautions in your system. pursuing that technique even if it was the first attempt.
First is a difficult airway algorithm. Throughout With each best effort failing, status escalates towards
Europe, the Difficult Airway Society (DAS) guidelines a cannot intubate cannot oxygenate (CICO) situation
have generally been adopted. The main flow diagram and an emergency surgical airway is required.
of the DAS guideline is shown in figure 3.1 Although That said, practice of advanced airway management
ETC recommends the use of the DAS algorithm, it varies considerably, both in the equipment used and
is not the only difficult airway algorithm. ETC also application of the technique. Countries with physician-
recommends to verify which algorithms are in use in based pre-hospital systems will often use drugs-
your own system to assure everyone follows the same assisted tracheal intubation at an early stage, whereas
protocols in an emergency. Independent of which in other systems this will not occur until reaching
exact algorithm the Emergency Department and an anaesthetist is
Figure 3.2 Shaping the mind set; The Vortex Approach (with kind permission of Nicholas Chrimes, www.vortexapproach.org)

in attendance. The European Trauma Course (ETC) skills to perform tracheal intubation; if not anaesthetic
therefore cannot hope to cover all eventualities help must be summoned urgently. To maximise
in this complex area, but supports the concept of the safety and efficacy of tracheal intubation
competency-based training to allow individuals to it must be carried out by those who are trained
follow local protocols in a safe and effective manner. and competent in the use of anaesthetic drugs.
In major trauma Rapid Sequence Induction (RSI) of
Supraglottic airway devices general anaesthesia is the recommended method for
Second-generation SAD are recommended since tracheal intubation. The effect of drugs in patients in
they offer greater protection against aspiration than shock, with low cardiac output, is delayed. Clinicians
first-generation devices. However, the type of device are often wrongly tempted to give a repetition drug
used will depend on local availability, but common doses, which can lead to rapid decompensation and
examples include: cardiovascular collapse. Therefore, implementation of
n l aryngeal mask airway (LMA) and variants simple standardised RSI protocols, clearly defining the
n i -gel choice of an appropriate induction drug, is essential.
n l aryngeal tube (LT) and variants
Furthermore, starting controlled ventilation impedes

These all have a similar function, allowing gas venous return to the heart and can also lead to
flow through the device and into and out of the cardiovascular collapse. This must be taken into

hypopharynx. If there is no obstruction at the level of consideration when anaesthetising a compromised
the larynx, gas passes into the trachea and subsequently major trauma patient.
the lower airways. Air leakage is prevented by sealing
the hypopharynx with a cuff, either air or gel-filled. Tracheal intubation checklists (Fig. 3.3), including data
One of the greatest advantages of these devices is on preparation of the patient, required equipment,
their ease of insertion and lack of need for anaesthetic choice of induction drugs and clear definition of roles
drugs to achieve this; all members of the trauma team within the trauma team, as well as identification of
should therefore be competent in using a supraglottic back-up plans, should be used for all major trauma
airway device. In all patients, once the airway is secure, patients. The only exceptions to this are patients who
a gastric tube should be inserted. are moribund or in cardiorespiratory arrest.
Insertion of a SGA device (see skills section) All patients who require tracheal intubation require
a rapid assessment to try and predict difficulty. If the
KEY POINTS assessment suggests difficulty, tracheal intubation
Indications: need for advanced airway and limited should only be undertaken by those experienced in
skills available, failed tracheal intubation managing difficult airways and with the appropriate
and failed ventilation with bag-mask equipment to deal with the possible problems. The
Procedure: insertion of a SGA device only exception is an immediate threat to life.
Complications: leak, gastric insufflation, trauma to the
airway Recognising a potentially difficult airway
Common unrecognised inadequate ventilation
A difficult airway can be divided into two main types:
pitfalls: when using the device, patient’s level of
consciousness prevents insertion 1. Difficult or impossible to oxygenate the patient with
a mask and simple adjuncts alone, which may be due
to:
Tracheal intubation n facial trauma, e.g. unstable bony injuries, lacerations;
This involves the insertion of a tube into the patient’s n cervical immobilisation
trachea via the mouth (orotracheal intubation). n upper airway obstruction, e.g. blood, vomit
The tube is placed under direct vision using a n abnormal anatomy, e.g. dysmorphic or asymmetrical
laryngoscope and a cuff on the distal end is inflated features, macroglossia

with air to provide a gas-tight seal. This allows n severe cachexia, obesity
ventilation of the lungs using positive pressure and n facial hair
prevents aspiration of regurgitated gastric contents.

To maintain oxygenation during the course of tracheal 2. Difficult laryngoscopy; an inadequate view of the
intubation, pre-oxygenation and apneic techniques larynx prevents insertion of the tube under direct
are recommended in trauma patients. Although vision, which may be due to:
tracheal intubation has many advantages, it is a. Pre-existing anatomical factors; these patients may
technically difficult in a patient with a cervical spine have a medical alert warning giving useful information:
immobilisation in place as this will restrict opening of n reduced neck mobility, e.g. rheumatoid arthritis
their mouth. The team leader should ensure that the n prominent upper incisors
team member tasked with airway management has the n receding mandible

EMERGENCY INDUCTION CHECKLIST
PREPARE PREPARE PREPARE PREPARE FOR
PATIENT EQUIPMENT TEAM DIFFICULTY
Ø  Preoxygenation? Ø  What monitoring is applied? Ø  If the airway is difficult, could

q  Capnography Ø  Alocate roles:
q  Applying 100% O2 we wake the patient up?
q  SPO2 probe q  Team leader
q  Apnoic oxygenation
q  ECG q  First intubator
q  Second intubator Ø  What is the plan for a difficult
Ø  Is the patient’s position q  Blood pressure intubation?
q  Intubator’s assistant
optimal? q  Plan A: RSI
Ø  What equipment is checked q  Drugs
q  Consider sitting up q  Plan B: BMV
and available? q  MILS (if indicated)
q  Rescue airway q  Plan C: Supraglottic airway
Ø  Vascular access? q  Self-inflating bag q  Plan D: “Front of neck access” –
q  Intravenous cannulation q  Working suction FONA
q  Two tracheal tubes Ø  How do we contact further
q  Intraosseous cannulation
q  Two laryngoscopes help if required?
Ø  Where is the relevant
Ø  How will anaesthesia be q  Bougie equipment, including
maintained after induction? q  Supraglottic airway device alternative airway?
q  DO NOT START UNTIL
Ø  Do you have all the drugs AVAILABLE
required?
q  Induction agent Ø  Are any specific complications
anticipated?
q  Muscle relaxant
q  Vasopressor
Reference: NAP4 Report and findings of the 4th National Audit Project of the Royal College of Anaesthetists
Figure 3.3 RSI Checklist
n acroglossia
m Surgical airway
n previous surgery causing scarring This will be required when ventilation has failed using
b. Trauma: the techniques described above and the patient is
n swelling, e.g. burns becoming increasingly hypoxic. This may be the result
n facial trauma, particularly if excessive bleeding of complete airway obstruction e.g. oedema due to
n neck trauma burns or trauma to the larynx. Before proceeding to
n reduced mouth opening, e.g. presence of a cervical a surgical airway it is highly recommended to take a
collar time out (10-for 10) and discuss options with the team
briefly. The decision to create surgical airway should
Insertion of a tracheal tube (see skills section) be clearly communicated and actioned immediately.
The technique used will depend upon the skills of the
KEY POINTS team members. All team members must be trained
Indications: n eed for advanced airway, inadequate to progress to front-of-neck access, and trained
airway with basic techniques, airway at to perform a didactic scalpel technique (surgical
risk, inadequate ventilation with basic airway), by placing a wide-bore tracheal tube (6 mm)
techniques through the cricothyroid membrane into the trachea,
Procedure: insertion of tracheal tube facilitating normal minute ventilation with a standard
Complications: h ypotension (drugs), hypoxia, trauma to breathing system. Those lacking the training and
the airway, failure proposed skills of surgical airway may proceed with
Common u nrecognised oesophageal intubation, needle cricothyroidotomy, by inserting a large bore
pitfalls: bronchial intubation, hyperventilation cannula through the cricothyroid membrane into the
trachea. However, high-pressure oxygenation through
a narrow-bore cannula is associated with serious
Once an advanced airway has been inserted, morbidity. Both are temporising measures that allow
oxygenation and ventilation should commence using oxygenation and ventilation while more skilled airway
a self-inflating bag with high flow oxygen and reservoir personnel are assembled to assist the trauma team,
attached. Whilst the adequacy of oxygenation must e.g. anaesthetist or surgeon.
be checked with a pulse oximeter, ventilation is
confirmed with capnometry and ultimately by arterial
blood gas analysis.

Cricothyroidotomy (see skills section)
Summary
KEY POINTS Airway obstruction is one of the immediately
Indications: c annot intubate or ventilate using any life-threatening conditions in the trauma patient.
other method Most problems can be managed with basic
Procedure: surgical cricothyroidotomy airway manoeuvres, simple adjuncts and oxygen.
If tracheal intubation is required it should only
Complications: bleeding, damage to local structures,
misplaced tube/cannula
be performed by those who are trained and
competent to do so. Supraglottic devices can
Common delay in recognizing need
be used when the team does not have the skills
pitfalls:
to perform tracheal intubation. Ultimately, the
patients who cannot be ventilated or intubated
Team issues in airway management will require surgical airway management.
Although one medical member of the trauma team is
allocated to manage the patient’s airway, it frequently Having worked through this chapter you are now
requires the involvement of other team members; ready to apply the following knowledge in the
e.g. effective bag-mask ventilation uses a two-person airway workshop:
technique and three people will be required if a cervical n how to assess a patient’s airway;

collar has to be opened, in order to maintain MILS. n a pply basic airway management manoeuvres
and use simple airway adjuncts to create and
Whenever the airway person requires assistance maintain a patent airway;
with airway management, the team leader should be n how to insert a supraglottic airway device;
informed, so that he amongst other team members can n be able to support ventilation using a bag-mask
be re-assigned tasks in the most appropriate manner. device with supplementary oxygen;
The most complex reorganisation of the team will be n recognising the potential for a difficult airway;
required if the patient requires tracheal intubation. n recognise the need for, and be able to create a
Once this decision has been reached, team members surgical airway.
will need to be allocated key tasks by the team
leader, appropriate to their skills and knowledge; one These cognitive abilities will be integrated with
person applies MILS, one person removes the collar the practical skills during the course workshops.
and any stabilising devices, e.g. tapes, blocks (and
subsequently applies cricoid pressure if appropriate),
one person draws up and gives the anaesthetic drugs.
These actions will be directed by the person carrying
out tracheal intubation to ensure they are coordinated
to facilitate the procedure; this person is in effect
temporarily taking control with the team leader
standing back and remaining ‘hands-off’ to retain
overview and situational awareness. In addition, prior
to any attempt at intubation, the airway personnel
must also clearly identify an escape plan with the team
leader in case of failed intubation/ventilation, e.g. use
of a supraglottic airway device or a surgical airway,
again clearly identifying the team members’ roles in
these circumstances.
Once the airway has been secured and ventilation is

achieved, the team members can resume their normal
activities.
Mechanical ventilation
A mechanical ventilator is usually used in
conjunction with a tracheal tube to prevent hyper-
or hypoventilation. In addition, their use will free-up
the airway personnel to assist others. However, they
should only be used by those who are trained and
competent to do so. The settings used need to be
tailored to each individual patient and guided by
frequent arterial blood gas analysis.

Insertion of an oropharyngeal airway
Airway and ventilation – skills Indications:
n airway obstruction
Chin lift n airway maintenance
Indication:
n airway obstruction. Procedure:
n Estimate the size required by selecting an airway
Procedure:
with a length corresponding to the vertical distance
n P
lace the fingertips of one hand under the point
between the patient’s incisors and the angle of the
of the patient’s chin, and gently lift to stretch the jaw (figure 3.5).
anterior neck structures. Ensure that the patient’s n O
pen the patient’s mouth and ensure that there is
neck is not hyperextended during the manoeuvre. no foreign material that may be pushed into the
larynx (if there is any, then use suction to remove it).
Complications:
n I nsert the airway into the oral cavity in the ‘upside-
n f ailure to clear the airway
down’ position as far as the junction between the
n l oss of airway on release
hard and soft palate and then rotate it through
180° (figure 3.6).
Jaw thrust
Indications: n A dvance the airway until it lies in the pharynx.
This rotation technique minimises the chance of

n a
irway obstruction, during bag-mask ventilation
pushing the tongue backwards and downwards.

n R emove the airway if the patient gags or strains.
Procedure:
n C orrect placement is indicated by an improvement
n I dentify the angle of the mandible
in airway patency and by the seating of the
n W ith the index and other fingers placed behind the
flattened reinforced section between the patient’s
angle of the mandible, apply steady upwards and teeth or gums (if edentulous).
forward pressure to lift the mandible (figure 3.4)
n The thumbs can be used to open the mouth by Complications:
downward displacement of the chin
n trauma;
Complications: n airway obstruction;
n l aryngeal spasm;
n f ailure
n v omiting.
n e xcessive neck movement
Figure 3.5 Sizing an oropharyngeal airway
Figure 3.6 Insertion of an oropharyngeal airway.

Figure 3.4 Jaw thrust. The mandible is lifted upwards with both
hands and pushed caudally with the thumbs to open
the mouth slightly.

Insertion of a nasopharyngeal airway If there is resistance from the patient when trying
n
Indications: to move the head to a neutral position, do not use
n airway obstruction force to overcome it
n airway maintenance
n f ailure to tolerate an oropharyngeal airway Complications:
n e
xcessive force used endangering the spinal cord;
n d
ifficulty with access to the airway
Procedure:
n C
hoose a tube of the appropriate diameter, 7-8mm Bag-mask ventilation
for adults. Indications:
n C
heck for patency of the right nostril; some designs
n i nadequate or absent ventilation
require a safety pin to be inserted through the
flange to provide an extra precaution against the Procedure:
airway disappearing beyond the nares.
n C hoose a facemask that covers the patient’s nose
n L
ubricate the airway using water-soluble jelly,
and mouth.
insert the airway bevel end first, vertically along
n W ith one hand, apply the mask ensuring a good
the floor of the nose with a slight twisting action
seal with the patient’s face. At the same time, apply
(figure 3.7). The curve of the airway should direct it
a jaw thrust, lifting the patient’s face into the mask.

towards the patient’s feet.
n W ith the other hand, squeeze the bag, watching to
n If any obstruction is met, remove the tube and try ensure that the patient’s chest rises and falls.
the left nostril. n I f not familiar with this device use a two-person
n C
hin lift or jaw thrust may still be required to technique; one applies the mask to the patient’s face
maintain airway patency. using both hands and maintains a jaw thrust (figure
3.8) whilst the other person squeezes the bag.
Complications:
n b leeding Complications:
n a irway obstruction n l ack of adequate seal reducing ventilation
n l aryngeal spasm n g astric inflation
n v omiting n m ovement of the cervical spine
Figure 3.8 Two person technique for using a bag-mask device .

Note the position of the hands of the practitioner holding the
face mask; she performs a jaw-thrust and is pushing the face mask
caudally to open the patient’s mouth.
Figure 3.7 Insertion of a nasopharyngeal airway.
Manual in-line stabilisation (MILS) of Insertion of a supraglottic

the cervical spine
Indication:
airway device
n immobilisation of the cervical spine.
Laryngeal mask airway (LMA)
Procedure: Indications:
n i nadequate airway using basic devices;
n Hold the patient’s head by placing your hands
n i nadequate ventilation;
against their mastoid processes (figure 3.10)
n a
irway at risk and skills of intubation not immediately
n A
void covering the patient’s ears in order to
available;
maintain communication
n f ailed intubation.
n R
estore the head and neck to a neutral, in-line
position without applying traction

Procedure: Laryngeal tube (LT) airway
n Choose a device of the appropriate size (5 for men, Indications:
4 for women), ensure the cuff is intact by inflating n i nadequate airway using basic devices;
and deflating. Leave sufficient air in the cuff to n i nadequate ventilation;
maintain its shape. n a irway at risk and skills of intubation not
n L ubricate cuff with water-soluble gel. immediately available;

n M aintain MILS unless there is no risk of cervical n f ailed intubation.
spine injury – in this case, flex the patient’s neck Procedure:

slightly and extend the head. Release cricoid n S elect a LT of the appropriate size based on the
pressure if it is being applied. patient’s height; size 5 when >180 cm, size 4 when
n H olding the LMA like a pen, insert it into the mouth. 155-180 cm, size 3 when <155 cm.
n A
dvance the tip behind the upper incisors with the n P lace the patient’s head in a neutral position.
upper surface applied to the palate until it reaches n L ubricate the tip of the LT with water-soluble gel.
the posterior pharyngeal wall (figure 3.9). n M aintain MILS unless there is no risk of cervical
n P
ress the mask backwards and downwards around spine injury – in this case, flex the patient’s neck
the corner of the pharynx until a resistance is felt as slightly and extend the head.
it locates in the back of the pharynx. n I ntroduce the LT behind the incisors, and along the
n I f possible, get an assistant to apply a jaw thrust hard palate, down the centre of the mouth until
after the LMA has been inserted into the mouth - resistance is felt or the device is fully inserted.
this increases the space in the posterior pharynx n T he cuffs are then inflated to a pressure of
and makes successful placement easier. approximately 60 cm H2O.

n C onnect the inflating syringe and inflate the cuff n C onfirm a clear airway by listening over the
with air (40 ml for a size 5 LMA and 30 ml for a size chest during inflation and observing bilateral
4 LMA); alternatively, inflate the cuff to a pressure chest movement. A large, audible leak suggests
of 60 cmH2O. malposition of the LT but a small leak is acceptable
n I f insertion is satisfactory, the tube will lift one to two provided chest rise is adequate.
centimetres out of the mouth as the cuff finds its n I nsert a bite block alongside the tube if available and
correct position and the larynx is pushed forward. secure the LT with a bandage or tape.
n I f the LMA has not been inserted successfully after
30 seconds, oxygenate the patient using a bag- Complications:

mask before reattempting LMA insertion. n inadequate seal and lack of ventilation
n C
onfirm a clear airway by listening over the chest during n t rauma
inflation and observing bilateral chest movement. n a spiration
n A large, audible leak suggests malposition of the n a irway obstruction
LMA, but a small leak is acceptable provided chest

rise is adequate. Tracheal intubation
n Insert a bite block alongside the tube if available Indications:
and secure the LMA with a bandage or tape. n a
pnoea
n o
bstruction of the airway, partial or complete, not
Complications: relieved with basic techniques
n i nadequate seal and lack of ventilation; n n
eed for respiratory support to treat hypoxia or
n t rauma; ventilatory failure

n a spiration; n h
igh risk of airway obstruction
n a irway obstruction. n n
eed for targeted pCO management in traumatic
2
brain injury
n c
ardiac arrest
Check presence and function of all equipment (table 3.1)

Once this has been completed, there should be
agreement between the team leader and airway
personnel to decide on allocation of roles for the rest
of the team. Commonly, ED Nurse fills in the airway
checklist, the ‘breathing’ person maintains MILS, the
‘circulation’ personnel remove the collar, any other
immobilising devices and apply cricoid pressure (in
accordance with local practice) and the team leader
gives the drugs on the instruction of the airway person.
In addition, the airway person must inform the team
Figure 3.9 Insertion of a supraglottic airway. of the plan for failed intubation, failed ventilation and
allocate roles accordingly.
Monitoring
expedite drug delivery. An analgesic drug may be
Ensure the following are attached as soon as possible: given prior to both to reduce the cardiovascular
n p ulse oximetry reflexes to laryngoscopy and intubation.
n n on-invasive blood pressure n C
ricoid pressure – use will vary according to local
n c ontinuous ECG practices. In many European countries it is not part of

n i nspired oxygen concentration the RSI protocol anymore, as the risks may outweigh
n c apnometry the perceived benefits.
● A
trained assistant applies cricoid pressure as the
Final checks: patient loses consciousness.
n r
eview the ABCs ● Direct
firm pressure using two or three fingers is
n e
nsure a neurological assessment has been performed; applied to the cricoid ring.
GCS, difference between left and right sides and ● Inadequate
pressure will not occlude the
pupil size and reactivity. Look for the presence of oesophagus; excessive force or incorrect
diaphragmatic breathing, vasodilation, or priapism placement will deform the larynx and make
n r
eview a brief history using the AMPLE approach laryngoscopy and intubation more difficult.
n e
nsure that there are two large-bore intravenous ● Do
not apply cricoid pressure if there is active
cannulae in situ before giving induction drugs vomiting because it may cause oesophageal
rupture.

Procedure ● There
is no evidence that a second hand applied
n P reoxygenation: behind the neck (two-handed cricoid pressure) in
● Give
100% oxygen for three minutes before an attempt to restrict cervical spine movement is
induction of anaesthesia. A patient who is any safer than the standard technique.
breathing inadequately may not achieve enough
alveolar ventilation to replace nitrogen in the lung n Standard intubation technique:
with oxygen - these patients may require assisted ●hold
the laryngoscope in the left hand
ventilation to achieve adequate preoxygenation ●open
the mouth using the index and thumb of the
before emergency drug-assisted intubation. In a right hand in a scissor action
healthy adult, after effective preoxygenation, the ●insert
the blade of the laryngoscope along the right
time taken for arterial blood to desaturate to 90% side of the tongue, displacing it to the left
may be as long as eight minutes, but is much faster ●advance
the tip of the laryngoscope into the gap
in critically ill, obese, or elderly patients, or those between the base of the tongue and the epiglottis
with respiratory disease. The duration of apnoea (vallecula)
without desaturation can also be prolonged by ●apply
force in the direction the handle is pointing,
passive oxygenation during the apnoeic period thereby lifting the tongue and epiglottis to expose
(apnoeic oxygenation). This can be achieved by the larynx
delivering up to 15 l/min of oxygen through nasal ●use
rigid suction to clear any secretions, blood or
cannulae. Once the pulse oximeter indicates a vomit before attempting to insert the tracheal tube
SpO2 of 92% or less, ventilate the patient’s lungs ●advance
the tube from the right hand corner of the
immediately with 100% oxygen. mouth through the cords
n M anual in-line stabilisation of the cervical spine: ●withdraw
the laryngoscope taking care not to
● An
assistant kneels at the head of the patient dislodge the tube
and to one side to leave room for the person ●inflate the cuff and attempt to ventilate the lungs
intubating. The assistant holds the patient’s head ●confirm

the position of the tube and secure it using
firmly down on the trolley by grasping the mastoid tape or a tie
processes; the tape, lateral blocks, and front of
the collar are removed. The front of a single-piece
collar can be folded under the patient’s shoulder
leaving the posterior portion of the collar in situ
behind the head. Do not attempt laryngoscopy
and intubation with the collar in place – it will
make it very difficult to get an adequate view
of the larynx. MILS can also be provided from
the front of the patient, but it may interfere with
creating a surgical airway, if required..
n I njection of drugs:
● The
induction drug produces unconsciousness,
and is followed immediately by a neuromuscular Figure 3.10 RSI in trauma patients is a complex team task that needs
meticulous preparation, clear role allocations and well rehearsed
blocking drug, using a pre-calculated dose. Both
escape strategies. Up to four persons are required to for a trauma RSI;
drugs are injected rapidly into a functioning 1st as airway operator, 2nd to maintain MILS, 3rd to administer drugs,
intravenous line with an infusion running to 4th to apply cricoid pressure. (Photograph: Grissom TE. Trauma airway

TABLE 3.1
between a tube placed in a main bronchus and
Equipment for emergency drug-assisted intubation one placed in the trachea
Basic resuscitation equipment n look for symmetrical movement of the chest wall
n Tilting trolley / stretcher / Ramping pillow
with ventilation
n Oxygen delivery apparatus including mask with reservoir and n listen in both axillae for breath sounds and over the
oxygen tubing / Transnasal humidified high-flow oxygen nasal stomach for absence of sounds
cannulae
n Sucker
Once tracheal intubation is confirmed, if applied
n Airway adjuncts:
release cricoid pressure, and secure the tube with tape
• Nasopharyngeal airway (sizes 6 and 7) or a ribbon tie. In a patient with raised intracranial
• Oropharyngeal airway (sizes 2, 3 and 4) pressure use of adhesive tape instead of a tie will avoid
n IV access equipment / IO access equipment compression of the jugular veins, which may increase
n M onitors
intracranial pressure. Insertion of an oropharyngeal
airway next to the tracheal tube reduces the risk of
Advanced airway equipment
n Bag-mask apparatus with reservoir bag and oxygen tubing
the patient biting on the tube and occluding the
n
airway. Check the monitors for heart rate, arterial
Drugs – in labelled syringes
n
oxygen saturation, blood pressure, and end-tidal CO2.
Laryngoscope handles and blades (Macintosh sizes 3 and 4 for
Finally, the airway person should formally indicate
adults, McCoy) / Videolaryngoscope

n
that he is handing back leadership of the team to the
Magill forceps
n Intubating bougie and/or stylet
appropriate person.
n Water-soluble jelly
Complications:
n Tracheal tubes in a range of sizes
n d
rug induced hypotension
n 10ml syringe
n h
ypertension due to inadequate sedation/
n Tie and adhesive tape
n
analgesia
Equipment for exhaled CO2 detection
n u
nrecognised oesophageal intubation
n Ventilator
n h
ypoxaemia (prolonged attempt, endobronchial
Failed intubation equipment
n S econd generation Supraglottic airway devices
intubation)
n t
rauma to the airway and bleeding
n S calpel cricothyroidotomy set
n r
egurgitation and aspiration
n Needle cricothyroidotomy kit with high-pressure injector
n t
ension pneumothorax
Drugs
Recent studies demostrated that combined use of fentanyl,
Scalpel cricothyroidotomy (stab – twist –
ketamine and rocuronium effectively attenuates acute hyperten-
bougie – tube technique):
sion during pre-hospital intubation, without causing significant
Indications:
hypotension in patients with major trauma. However, the choice
n l ife-threatening hypoxia and the inability to
should be guided by the operators experience and local practice
but will consist of: oxygenate by any other means
n A naesthetic induction drug/hypnotic
n Neuromuscular blocking drug

TABLE 3.3
n A nalgesic
n Emergency drugs, e.g. atropine, adrenaline

Equipment for scalpel cricothyroidotomy
n Scalpel (number 10 blade)
Ref. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ; Kent, Surrey n Tube (cuffed 6.0mm ID)
& Sussex Air Ambulance Trust. Significant modification of traditional rapid
sequence induction improves safety and effectiveness of pre-hospital trauma
n Gum elastic bougie
anaesthesia. Crit Care 2015;19:134. n Syringe
n Tapes/ties
management. Anesthesiology News. 2017; Airway Management
Supplement 10th Annual Compendium:81-90.)
Procedure:
n C heck all equipment is present and functioning
Use of MILS makes it more difficult to get a good view
of the larynx and use of an intubating bougie or an (table 3.3).
n Continuous oxygenation via upper airway, with
intubating stylet is invaluable. For this reason, some
practitioners prefer to use an intubating bougie or appropriate neuromuscular blockade. In the
stylet routinely when intubating trauma patients. absence of trauma to the cervical spine, extend the
Confirmation of tracheal tube placement; patient’s head.
n Identify the cricothyroid membrane with non-
n etection of carbon dioxide in exhaled gas

d dominant hand.
(waveform capnography or colorimetric carbon n If time permits, prepare the skin with antiseptic
dioxide detector), however, this will not distinguish solution and, if appropriate, infiltrate the skin over

the cricothyroid membrane with 1% lignocaine C. Post-operative care and follow up
with adrenaline (1:100,000). Urgent surgical review of cricothyroidotomy site.
A. Palpable cricothyroid membrane
Stabilise the thyroid cartilage with one hand and Complications:
make transverse stab incision through cricothyroid n damage the posterior tracheal wall by deep
membrane. penetration with the scalpel blade
Turn blade through 90° with sharp edge positioned n haemorrhage
caudally. n m isplaced tube outside the trachea (causing
With the scalpel blade in situ slide coude tip of surgical emphysema)
bougie along blade into trachea. n i ncision too small to admit the tube
Remove the scalpel and railroad well-lubricated
6.0mm cuffed tracheal tube into trachea. Management of massive haemorrhage in
Ventilate, inflate cuff and confirm the correct maxillo-facial trauma
position with capnography and observing chest
movement, listen for breath sounds. Presentation:
Secure the tube and suction any secretions from n o
ngoing haemorrhage into the nasal or oral cavity
the lungs (Fig 3.11)
B. Impalpable cricothyroid membrane Management:

Make an 8-10 cm vertical skin incision, caudad to Follow flow chart as per Fig. 3.12
cephalad.
Use blunt dissection with fingers of both hands to Procedure:
separate tissues. n T
he patients’ airway must be secured by tracheal
Identify and stabilize the larynx with one hand. intubation or surgical airway prior to the procedure.
Proceed with technique for palpable cricothyroid n A
natomically reduce and maintain any boney
membrane as above. displacements or fractures.
Figure 3.11 Scalpel cricothyroidotomy (with permission from the Difficult Airway Society)

Figure 3.13 Anterior
n Mandible should be supported by a cervical collar.
and posterior packing is
If a cervical collar is already applied, continue with usually the first choice
the procedure by leaving the collar in place. If in treatment of severe
cervical collar is not applied, further management bleeding in maxillo-facial
requires its placement to avoid displacement of trauma (with permission
from Ajoy Roychoudhury)
the the lose bony fragements and further increase
in blood loss.
n I nsert the bite block by holding it between the
thumb and the middle finger of one hand, with
the handle bending away from the mouth. Slowly
slide the bite block towards the back of the mouth,
adjusting it firmly between the molars. Repeat
the same on the opposite side of the mouth. The
bite blocks will strut the maxilla against the fixed
mandible.
n O
nce the midface is tabalised through the
combination of biteblocks and mandibular n Make sure to pad the nose tissue with gauze to
support from a c-spine collar, then baloon prevent pressure necrosis.
tamponade of the mid-face is the next priority. n I f haemostasis is not achieved a Vaseline gauze can
This can be achieved with a commercial device if be inserted to pack the anterior nasal cavity.
available or a 12-Fr Foley catheter may be used. n I f there is ongoing haemorrhage from the oral
Insert the catheter into the affected nasal cavity cavity the oral cavity also can be packed with gauze
until the balloon is well into the posterior nasal
cavity. Inflate the balloon with 5 to 7 mL of saline Complications:
(posterior balloon tamponade). Pull the partially n r
isk of pneumocephalus
inflated balloon anteriorly until it is snug against n r

isk of displacement of fragments into the orbita
the posterior turbinates. Finish inflating the or the brain

balloon with another 5 to 7 mL saline. If there is
displacement of the soft palate, remove some
of the saline from the balloon. Secure the Foley
anteriorly by placing an umbilical clamp over the
catheter as it exits the nose.
Management of Massive Haemorrhage in Maxillo Facial Injury
Identify source of bleeding
Nasal Intraoral
Anterior Posterior Bone Soft Tissue
Balloon Pressure Balloon Reduction of Pressure

Tamponade packing Tamponade fracture packing
If Persistent Bleeding
Trans Arterial
Embolization OR
ECA ligation
Figure 3.12 treatment algorithm for severe bleeding in maxillo-facial trauma (with permission from Ajoy Roychoudhury)

References:
n http://vortexapproach.org
n P
avlov I, Medrano S, Weingart S. Apneic oxygenation
reduces the incidence of hypoxemia during

emergency intubation: A systematic review and
meta-analysis. Am J Emerg Med 2017;35:1184-1189.
n F rerk C, Mitchell VS, McNarry AF, Mendonca C,
Bhagrath R, Patel A, O’Sullivan EP, Woodall NM,
Ahmad I. Difficult Airway Society intubation
guidelines working group. BJA 2015;115:827–848.
n N AP4 Report and findings of the 4 National Audit
th
Project of the Royal College of Anaesthetists

n J ose A, Nagori SA, Agarwal B, Bhutia O,
Roychoudhury A Management of maxillofacial
trauma in emergency: An update of challenges and
controversies. J Emerg Trauma Shock. 2016 Apr-
Jun; 9(2): 73–80.

4.
Breathing problems and thoracic trauma
Learning outcomes
n Assessing and managing immediately life-threatening thoracic injuries
n Assessing and managing potentially life-threatening thoracic injuries
n Selecting and interpreting investigations in thoracic injuries

n Inserting a chest tube
n Interpreting a chest x-ray
Introduction n c ardiac tamponade

n airway obstruction/disruption
Thoracic trauma is the cause of about 25% of all
injury related deaths and is a contributory factor in Chest Ultrasound (CUS)
a further 50%, usually as a result of hypoxia and/or Ultrasound has a higher accuracy in detecting a
hypovolaemia. The mortality of isolated penetrating pneumothorax than a chest x-ray. The same is true for
trauma to the lung and pleura is low (<1%), but cardiac detecting a hemothorax or a cardiac tamponade. eFAST
involvement increases the rate 20-fold. In Europe the is particularly helpful in guiding the resuscitative efforts
commonest injuries are to the chest wall, followed by in severely compromised patients. Therefore eFAST
the pulmonary parenchyma and pleural space. The (see chapter 2) has become part of the primary survey
vast majority (approximately 85%) of these conditions in many advanced trauma care systems, especially if
can be treated successfully without the need for computer tomography is not readily available.
surgical intervention. However it is important to
realise that these patients often have other injuries, Tension pneumothorax
particularly to the head, which contributes to the high A pneumothorax is air in the pleural space that occurs
overall mortality. as a result of a breach of the pleural cavity and may be
spontaneous or a result of trauma to the chest wall.
A tension pneumothorax develops when the breach
Assessment and management of the pleural cavity acts as a ‘one-way‘ valve allowing
more gas to enter during inspiration than can escape
This follows the well-defined protocol for all trauma in expiration. As the air accumulates, the pressure in
victims used throughout this course, remembering the pleural cavity increases causing:
that the primary survey and resuscitation are n c
ollapse of the lung
simultaneous events. n d
epression of the diaphragm
n d
istension of the hemithorax
Primary survey and resuscitation n m

ediastinal shift away from the affected side
As described in chapter 2 the aim is to identify and

correct the immediately life-threatening conditions. The pulmonary effects result in hypoxaemia whilst the
The breathing personnel need to eliminate six life- pressure in the thoracic cavity reduces venous return
threatening conditions which can follow thoracic trauma: and cardiac filling. This leads to a fall in cardiac output
n tension pneumothorax with subsequent hypotension. All of these effects are
n open chest wound / open pneumothorax exacerbated by any co-existing hypovolaemia. Note
n massive haemothorax also that these cardiovascular signs are similar to those
n flail chest found with a cardiac tamponade (see later).
CHAPTER 4 BREATHING PROBLEMS AND THORACIC TRAUMA | 51

The main initial compensatory mechanism is respiratory out. Alternatively, if a skilled operator is available,
stimulation leading to tachypnoea and increased sonography can be performed looking for air in either
respiratory effort. Subsequently, in an attempt to maintain or both pleural cavities to exclude the diagnosis of
cardiac output and perfusion of the vital organs, there pneumothorax.
is an increased catecholamine release and adrenergic
discharge, resulting in tachycardia and vasoconstriction.
If the tension is not relieved, the compensatory

mechanisms will fail causing, in turn, decreased
respiratory effort, hypotension, respiratory arrest and
ultimately, cardiac arrest. These symptoms develop
rapidly in patients who are ventilated, because the
positive pressure generated by the ventilator forces
gas into the pleural cavity. In contrast spontaneously
breathing patients have a more gradual onset
of symptoms as the slower gas leak provides the
opportunity for them to compensate by increasing Figure 4.1 Ultrasound of the chest
A: Tension-/pneumothorax: (lack of lung sliding in the moving
their respiratory rate and tidal volume. Therefore

image), lack of comet tail artefacts (B-lines) and distinct
assessment and management of these two types of reverberations (A-lines).
patients are best considered separately (table 4.1). B: Normal findings: (lung sliding, moving image), B-lines.
TABLE 4.1 Any patient who shows signs of cardiorespiratory

Features of a tension pneumothorax in compromise requires rapid decompression of the chest.
a spontaneously breathing or ventilated patient This can occur suddenly and without warning and for
this reason a competent team member should stay with
Tension pneumothorax in Tension pneumothorax in the patient whilst the x-ray is being taken.
spontaneously breathing a ventilated patient
patient TABLE 4.2
n S uspect if there is trauma n S uspect if there is trauma Radiological features of a tension pneumothorax
to thorax, neck or upper to thorax, neck or upper
abdomen abdomen Ipsilateral hyper-expansion Intrathoracic pressure
n Universal findings: n Universal findings: n Lung
collapse n Ipsilateral
flattening of
● chest pain ● rapid
reduction in cardiac n Hemi-diaphragmatic heart border
● initially
a breathless output ± blood pressure depression n Contralateral deviation of
patient, not a shocked one ● rapid
and progressive n Increased separation of ribs the mediastinum / trachea
n Common findings: decrease in PaO2 and SpO2 Increased
n thoracic volume
● i psilateral decreased air entry n Common findings: n Loss of lung markings
● ipsilateral
● tachycardia
and ipsilateral chest
reduced breath sounds hyperexpansion
occur in 50-75% of cases ● ipsilateral
reduced movement
n Inconsistent findings: ● ipsilateral
decreased air entry
● tracheal
deviation ● progressive
increase in
● hypotension
peak airway pressures
● tachycardia
n Decompensation is
preceded by: ● surgical

emphysema
● increasing
hypoxia ● venous
distension if no
● respiratory
arrest, usually co-existing hypovolaemia
over a period of around n Inconsistent finding:
30 minutes ● tracheal
deviation
n Cardiac arrest may follow
respiratory arrest
Making a diagnosis of a tension pneumothorax

in a spontaneously breathing trauma patient
can be difficult particularly in the early stages as
the symptoms can be variable. If the patient is
compensating (normal SpO2 and BP) and it is possible
to obtain x-rays in the resuscitation area without
any delay, a chest x-ray is appropriate. The absence
of specific radiological features (table 4.2; figure 4.2)
Figure 4.2 Plain chest x-ray showing a tension pneumothorax on the
will prevent unnecessary interventions being carried left side in a spontaneously breathing patient

Rarely, bilateral tension pneumothoraces may occur. Open chest wound
This may be revealed by sonography but should be In a spontaneously breathing patient, breaches of the
suspected if there are no localising signs but profound chest wall will always produce a pneumothorax. The
hypoxia, surgical emphysema, cardiovascular collapse larger the wound, the more air enters the pleural cavity
and in a ventilated patient, progressively increasing via the defect rather than entering the lungs during
peak inspiratory pressures. inspiration. This results in collapse of the lung; this rarely
occurs in ventilated patients because the pressure
Immediate chest decompression is required if a within the lungs is positive, which keeps them inflated.
tension pneumothorax is confirmed, or suspected
in a ventilated patient. This will require a lateral Depending on the shape of the wound, or presence of
thoracostomy followed by insertion of a chest tube an overlying dressing, air can enter through the wound
(immediately for a spontaneously breathing patient or but not escape (sometimes referred to as a ‘sucking
after performing airway life-saving procedures for the chest wound’) resulting in the development of a tension
patient in respiratory arrest). Bilateral thoracostomies are pneumothorax. The immediate management consists of
necessary for cases of bilateral tension pneumothoraces removing any occlusive dressing to allow air to escape.
or when the side is in doubt, a situation which can A one-way adhesive chest seal should then be applied
arise in the suddenly decompensating, intubated and to permit gas and blood to escape from the pleural
ventilated patient. Needle decompression (needle cavity whilst preventing air to re-enter. This will provide
thoracocentesis) should be considered a technique of sufficient time for the insertion of a chest drain via a
last resort if there is no competent physician and/or separate route and the wound to be formally redressed.
equipment available.
Massive haemothorax
Tube thoracostomy (see skills section) This condition is defined as greater than 1500 ml
blood in the thoracic cavity. It is usually secondary
KEY POINTS to a laceration of either the intercostal or internal
thoracic arteries. Less commonly it results from injury
Indications: pneumothorax (simple and tension);
haemothorax to a mediastinal great vessel (e.g. pulmonary hilum)
or spillage into the pleural space from a cardiac
Procedure: open procedure; blunt dissection; 5th
intercostal space, 1cm anterior to the
laceration. Accumulation of blood in the pleural cavity
mid-axillary line compresses the lung, impairs ventilation and causes
Complications: haematoma; intercostal neurovascular
hypoxia, while at the same time causing hypovolaemia.
injury; thoracic and abdominal visceral In addition those with ongoing drainage of more
injury; infection than 200ml/hour will require urgent surgical review
Common t ube malposition (i.e. not in pleural regarding the need for thoracotomy. The signs of a
pitfalls: cavity) or slippage massive haemothorax are shown in table 4.3.
TABLE 4.3
Lateral thoracostomy
Signs of a massive haemothorax
This consists of carrying out the initial stages of a
tube thoracostomy procedure, but not inserting
n ypovolaemic shock
H
the chest drain. The technique allows rapid
n Dull to percussion over the affected hemithorax
chest decompression and is diagnostic as well
n Decreased breath sounds over the affected hemithorax
as therapeutic. A repeated finger sweep can be
n Hypoxia
performed to exclude re-accumulation of the tension
n Radiologically, in the supine position, a massive haemothorax
will result in a unilateral whiteout. This will obscure any
should the patient deteriorate again.
underlying, co-existing pneumothorax
Needle thoracocentesis (see skills section)
Diagnosis is confirmed readily by plain x-ray (figure 4.3)
KEY POINTS or sonography (figure 4.4).
Indications: d ecompensating tension pneumothorax
in a non intubated patient
Procedure: 1 4g cannula, 2nd intercostal space,
midclavicular line
Complications: lung injury, pneumothorax, bleeding from
intercostal vessels, cannula blocks or
kinks, failure to reach pleural cavity with
needle
Common misinterpreting the absence of air leak as
pitfalls: a sign that the pneumothorax has been
treated

occur in the young adult where the flail may not be
obvious initially due to muscles splinting the fractured
ribs. In these situations paradoxical movement will
be apparent only if the victim becomes exhausted,
the flail is large (approximately over six ribs) or if it is
central (i.e. involving the sternum).
As lung contusions are usually present with a flail chest

the initial management consists of:
n h igh-flow, warmed, humidified oxygen
n a dequate but cautious fluid resuscitation to prevent
overload/pulmonary oedema
n a nalgesia, usually in the form of intravenous
opioids, to allow maximal thoracic cage movement

with breathing
Figure 4.3 Plain chest x-ray showing a massive haemothorax Intercostal blocks, epidural analgesia and opioid/
ketamine infusions or patient–controlled analgesia

Immediate management consists of oxygen, tube should be considered later during the secondary
thoracostomy, IV access and fluid resuscitation, with survey, depending on the expertise available. Some
the early use of the major haemorrhage protocol patients will require tracheal intubation and controlled
(chapter 5). Beware that insertion of a chest drain and ventilation (table 4.4). In these cases be aware that flail
release of retained blood in the thorax may dislodge chests can co-exist with an underlying pneumothorax
clots and produce further active haemorrhage. It so a chest drain should be inserted if a pneumothorax
is therefore important to ensure adequate venous is present or suspected.
access for volume resuscitation is being achieved
simultaneously. In addition to helping confirm the TABLE 4.4
diagnosis, chest drainage will improve respiratory Indications for tracheal intubation and ventilation
function and where the facilities exist, allow in cases of flail chest
autotransfusion of the blood from the thorax. If the n Falling PaO2 or PaO2 <7kPa (55mmHg) breathing air
diagnosis is correct, most of these patients will need n PaO2 <10kPa (75mmHg) on high flow oxygen
definitive surgery to control the bleeding. n Increasing PaCO2 or >6kPa (45mmHg)
n Exhaustion (respiratory rate <8 breaths/min)
n Respiratory rate >30 breaths/min
n A ssociated injuries compromising ventilation
In all patients arterial blood gases need to be

monitored frequently to assess respiratory function
and an arterial cannula should be inserted by the end
of the primary survey. If intubated these patients need
a lung protective ventilatory strategy with advice from
colleagues in critical care.
Cardiac tamponade
This should be suspected in any victim with a
penetrating wound of the chest, neck or upper
Figure 4.4 Ultrasound of the chest abdomen. A particularly dangerous site is the central
(Massive) haemothorax: Fluid (blood, hypo echoic) between chest area from clavicles to xiphisternum and between
diaphragm and thoracic wall, with an atelectatic lung section (‘half
moon’) ‘swimming’ inside. the right nipple and left lateral chest wall, anteriorly and
posteriorly, (sometimes referred to as ‘the danger box‘,
figure 4.5). Much less commonly cardiac tamponade is
Flail chest seen after blunt trauma particularly in patients who are
A flail occurs when two or more adjacent ribs are taking anticoagulants or antiplatelet drugs.
fractured, at two or more places. If conscious, the
patient will present with severe pain and rapid, shallow
breathing. Examination of the chest wall may reveal
tenderness, crepitus, bruising/abrasions or paradoxical
movement of the flail segment. Diagnostic difficulties

TABLE 4.5
Clinical signs of cardiac tamponade
n Beck‘s triad
● Hypotension
● Raised jugular venous pressure resulting in distended jugular veins
● Decreased heart sounds (difficult to elicit in the noisy

resuscitation room)
n Pulsus paradoxus >10mmHg fall in SBP during inspiration
n Kussmaul‘s sign – raised jugular venous pressure on inspiration
Figure 4.5 Sites of penetrating wounds associated with cardiac

tamponade Initial management consists of augmenting venous
return to maintain cardiac output by elevating the
A penetrating wound to the heart often leads to patient‘s legs (if possible) and rapid IV fluid infusion.
ongoing bleeding into the pericardium, with the Definitive management requires surgical evacuation
sac laceration being sealed with clot. It is important of the clot from the pericardial sac and primary
to realise that only a small amount of accumulated repair of the cardiac laceration. The approach chosen
blood in the pericardial sac is necessary to restrict is dependent on the expertise, environment and
ventricular filling during diastole and therefore reduce equipment available. The commonest approach is
stroke volume. Initially compensatory mechanisms through a median sternotomy ideally performed in
maintain cardiac output (by increasing heart rate) the operating theatre. However this is dependent
and perfusion pressure (by increasing peripheral on the clinical urgency and status of the patient. A
vascular resistance). If the obstructive pressure thoracotomy performed in the Emergency Department
within the pericardial cavity is not released, cardiac can be effective in relieving cardiac tamponade. Only
output falls further and compensatory mechanisms when this expertise is not immediately available, and
will fail. Profound hypotension results, which in turn the patient is dying, should pericardiocentesis be
causes further myocardial injury as a consequence of considered.
reduced coronary perfusion. If not relieved promptly,
the patient will die from grossly inadequate cardiac Emergency Department thoracotomy
function and perfusion. A resuscitative thoracotomy (i.e. one performed as
an integral part of the primary survey) is potentially
The clinical signs of cardiac tamponade are shown in indicated in three groups of patients:
table 4.5, but are only seen in approximately one-third n c
ardiac arrest after penetrating trauma and less
of trauma patients. In the resuscitation room diagnosis than 15 minutes of CPR
is therefore best confirmed by sonography (Figure 4.6). n c
ardiac arrest after blunt trauma and less than 10
minutes of CPR
n r
efractory hypotension (systolic pressure <60mmHg
or signs of life) despite vigorous fluid resuscitation

following penetrating or blunt thoracic injury
Unless an experienced surgeon is immediately

available or where there is any doubt about the
injuries sustained, a bilateral anterior thoracotomy
(clamshell incision) is performed as this allows access
to the entire thoracic contents (figure 4.4). This allows
bleeding to be controlled with direct pressure and
the pericardium opened to evacuate a tamponade.
Internal cardiac compression can be started and if
necessary penetrating cardiac injury can be made
secure with either an occluded Foley catheter or a
Figure 4.6 Ultrasound of the heart, subxyphoid view: Pericardial suture. Aortic cross-clamping can also be used to
effusion: Fluid (blood, hypoechoic) between the pericardial sac and redistribute the limited cardiac output to the brain
the heart suggested compression of the right ventricle (tamponade).
and myocardium, whilst at the same time limit any
abdominal bleeding while resuscitation proceeds.
Resuscitative thoracotomy inevitably results in
significant blood splatter and therefore it is essential
that all the team have appropriate personal protective
equipment (PPE) including eye protection.

The survival rate following Emergency Department ● a false positive aspiration can occur by penetration
thoracotomy is approximately 35% for the patient of the coronary arteries or ventricle
arriving in shock with a penetrating cardiac wound
and 15% overall for patients with penetrating wounds. Airway disruption
However, after blunt trauma, survival is poor, with only Most patients with major airway injuries die
1–2% surviving. As team training for this procedure is at the scene due to asphyxia, intrapulmonary
beyond the scope of this course only those who already haemorrhage, aspiration of blood or air embolism.
have this expertise should carry it out. Otherwise the However, survival is possible if the transection of the
probability of success is negligible and do not counter airway, even a major one, is sealed off by soft tissue.
the high risks of damage to thoracic viscera. These injuries produce severe surgical emphysema,
pneumothorax, pneumomediastinum, haemothorax,
Emergency Department thoracotomy allows: pneumopericardium or even pneumoperitoneum
n p ericardial incision and evacuation of pericardial (table 4.6 and figure 4.7).
clotted blood causing tamponade
n l ocal control of cardiac haemorrhage The diagnosis may be made by the airway personnel
n d irect control of exsanguinating thoracic when trying to clear or secure the patient’s airway,
haemorrhage or if there is a major air leak (e.g. evidence of a large
n o pen cardiac compression pneumothorax or pneumomediastinum). There

n c ross clamping of the descending aorta to maintain should be a high index of suspicion also when there
cardiac and brain perfusion by stopping blood loss is evidence of associated injuries indicative of high
below the diaphragm energy transfer (scapular, clavicular or fractures of 1st-
n d irect repair of exsanguinating pulmonary 3rd ribs). Confirmation comes from airway endoscopy
haemorrhage but this may be limited by free blood or clot in the
n c ross clamping of the pulmonary hila in cases of airway. As any delay in diagnosis increases the risk of
bronchovenous air embolism complications, an urgent chest CT is required where
doubt remains.
Pericardiocentesis (see skills section)
TABLE 4.6
KEY POINTS Chest x-ray features of a ruptured airway
Indications: c ardiac tamponade and no surgical n P neumomediastinum - visualised as linear air density shadows
expertise available tracking along tissue planes of the mediastinum (figure 4.7)
Procedure: subxiphisternal needle aspiration n Surgical emphysema
n Collapse of lung or lobe
Complications: myocardial trauma, coronary artery
laceration, thoracic and abdominal
n Pneumothorax
visceral injury, cardiac arrhythmias, arrest
and tamponade, pneumothorax
Common isinterpreting a negative aspiration as
m
pitfalls: excluding a cardiac tamponade
Pericardiocentesis can be considered if the following

uncommon situation arises:
n no team member is competent to perform a
thoracotomy
n the patient is in extremis (i.e. about to die)
n there is a very high degree of suspicion that
tamponade is present – ideally confirmed by

sonography
In carrying out this procedure be aware that:

n The risks of pericardiocentesis include damage
to organs (myocardium, lung, stomach, bowel, Figure 4.7 Chest x-ray showing a pneumomediastinum
oesophagus, spleen, and kidney) and laceration of
a coronary artery. Treatment of these injuries is almost always surgical
n A formal pericardial exploration will still be so an urgent consultation with a thoracic surgeon is
required irrespective of the perciardiocentesis necessary in all cases. In the short term, with suitable
findings because: expertise and equipment, intubating the patient with
● the
blood clots in the pericardial sac so there is a the tracheal tube extending past the rupture may help
significant chance of having a negative tap even stabilise the patient.
when a tamponade exists

Once these six immediately life-threatening conditions assess the chest x-ray for evidence of progressive lung
have been excluded, or treated, the primary survey contusions. This may occur away from the area of the
should proceed along the lines already discussed. chest wall involved in direct impact and may take
many hours to become obvious on the chest x-ray
Secondary survey (table 4.8 and figure 4.8).
Only when the primary survey is completed and the
patient‘s condition stabilised, a detailed head-to- TABLE 4.8
toe examination is carried out (chapter 2). This aims
Radiological features of pulmonary contusion
to identify the potentially life-threatening thoracic
injuries (table 4.7), other chest injuries and begin
n Parenchymal shadowing:
to plan for definitive care. However, many of these
● Ill defined edges
● Air
injuries will have already been identified and their
bronchogram within this shadowing is characteristic
● Blood
treatment started in the primary survey.
vessels obscured
n Little or no loss in lung volume
May be associated pneumothorax, haemothorax, rib fractures
TABLE 4.7
n
Potentially life-threatening thoracic conditions

P ulmonary contusion/ laceration (parenchymal injuries)
n Blunt cardiac injury

n Ruptured diaphragm
n Traumatic disruption of the aorta
n Ruptured oesophagus
In addition to completing routine investigations

during the secondary survey (e.g. x-rays, ECG and
arterial blood gases), other imaging (e.g. CT scan
or angiography) and invasive monitoring may be
warranted as a result of the findings.
It is important to remember that many of the

conditions sought in the secondary survey may
develop relatively slowly. Consequently, soon after
the injury, signs or symptoms could be minimal or Figure 4.8 Chest x-ray showing extensive right-sided pulmonary
contusion
absent. The chest examination should therefore be
repeated and the findings documented so subsequent
clinicians can identify any changes. Contusions usually resolve over a period of several
days, but normalisation of gas exchange occurs more
Potentially life-threatening thoracic injuries slowly. If there is evidence of clinical deterioration, a
Pulmonary contusions CT thorax may be useful to ascertain the full extent
There is a high incidence (>50%) of pulmonary of the pulmonary damage. Furthermore, serial CTs of
parenchymal injuries with thoracic trauma that the thorax can aid management and assess progress
typically result in impaired oxygenation. In adults, in patients with significant thoracic and other injuries
direct impact causes rib fractures and contusions, requiring ventilator support.
usually but not always, localised to the area of lung
directly adjacent to the rib fractures. There is often an
accompanying pneumothorax or haemothorax. On Blast injuries can give rise to diffuse bilateral infiltrates
examination ventilation is typically rapid and shallow; in the lung field, often with associated pneumothoraces
there may be bruising or abrasions on the chest and/or pneumomediastinum. A similar picture is
wall and tenderness on palpation. Percussion and seen in patients with traumatic asphyxia but here
auscultation of the chest can be normal, particularly the radiographic appearance is due to widespread
early after the insult. interstitial haemorrhage along with pulmonary oedema.
As the pathophysiological effects of contusion Management consists initially of warmed, humidified

progress over 24-48 hours, lung compliance is reduced oxygen, careful fluid resuscitation and observation
and respiratory distress develops. Serial arterial blood preferably in a critical care area. Some cases may be
gas analysis is essential to detect gradual falls in PaO2 managed using non-invasive ventilatory support
as the ventilation/perfusion mismatch increases. In provided adequate oxygenation and effective
such circumstances it is very important to carefully analgesia is possible. Patients with refractory hypoxia

and overt respiratory failure will require intubation Blood troponin levels have improved the specificity
and ventilation using a lung protective strategy. of detecting blunt cardiac injury when compared
with conventional markers. However, it has a low
The criteria followed to determine the need for sensitivity and low predictive values in diagnosing
ventilation varies between units and examples are myocardial contusion and is not good for diagnosing
given in table 4.9. Blast lung injury carries a risk of the condition in haemodynamically stable patients.
systemic air embolism particular in the presence An elevated reading should therefore be considered
of positive pressure ventilation. This needs to be in context with the patient’s injuries and clinical state.
considered when managing patients who are severely
injured following explosions. Current evidence supports the following
recommendations. An admission ECG is required for
TABLE 4.9 all patients if blunt cardiac injury is suspected. If this
is abnormal (e.g. arrhythmia, ST or T wave changes,
Indications for invasive ventilation following
ischemia, heart block, unexplained T wave inversion),
pulmonary contusion
the patient requires admission for continuous ECG
n ecreased level of consciousness
D monitoring for 24-48 hours. Conversely, the pursuit
n Elderly of diagnosis should be terminated if the admission
n Poor analgesia and inability to clear secretions ECG is normal and the risk of having blunt cardiac

n Increasing PaCO2 injury that requires treatment is insignificant. If
n Decreasing PaO2 the patient is hemodynamically unstable imaging
n General anaesthesia required for surgery should be obtained. If an optimal transthoracic
n Transfer required echocardiogram cannot be performed, then the
n Severe pre-existing lung disease patient requires a transoesophageal echocardiogram.
Late complications such as arrhythmia, aneurysm, and
Pulmonary lacerations heart failure have been reported but are rare.
Pulmonary lacerations are usually the consequence
of penetrating thoracic trauma but they can also be Ruptured diaphragm
produced by blunt injuries with a heavy impact. These Both blunt and penetrating trauma can produce
injuries are therefore invariably accompanied by a diaphragmatic rupture. The commonest blunt
pneumothorax, haemothorax or haemopneumothorax mechanism is a road traffic collision; side impacts
and, in the case of blunt trauma, pulmonary contusion. cause three times more diaphragmatic disruption
Consequently a number of features may be seen on than frontal ones. The left hemidiaphragm is more
the chest radiograph (table 4.10). prone to injury than the right, probably because of the
protective effect of the liver. Consequently, right-sided
TABLE 4.10 injuries indicate there has been significant trauma
Chest x-ray features of pulmonary laceration and the liver may be involved. Twenty percent of
n P ulmonary infiltrates from extravasation of blood into the
penetrating thoracic wounds will cross the diaphragm
surrounding tissue and of these 75% are associated with intra-abdominal
n Small opacities denoting lung haemorrhage and/or haematoma injury. Again, the left side is more involved, possibly
n Presence of haemo/pneumothorax because small right-sided ones are missed or perhaps
because most assailants are right handed.
The injury is managed using the principles already Many of these injuries are asymptomatic at
described. About 5% of these patients will require presentation so the most suggestive sign of a
formal thoracotomy, especially if there is persistent diaphragmatic injury is the proximity of the injury.
bleeding, air leakage or haemoptysis. Occasionally there are ipsilateral decreased breath
sounds. Another clue is peritoneal fluid leaking
Blunt cardiac injury through a chest drain. Typically the first suspicion
Blunt cardiac injury represents a spectrum of conditions, comes from the appearance of the chest x-ray (table
which range from minor ECG and/or lab abnormalities 4.11 and figure 4.9). Subsequently a CT of the thorax
to septal, free wall or valvular rupture. It is therefore will be required to identify the extent and site of the
a pathological diagnosis, which lacks an accurate tear.
clinical definition. The key clinical issues are; identifying
patients at risk of clinically significant blunt cardiac TABLE 4.11
injury, detecting the consequences (e.g. arrhythmias,
Chest x-ray features of a ruptured diaphragm
myocardial dysfunction) and management to prevent
adverse outcomes. These patients have usually been
n L oss of the diaphragmatic contour
exposed to major forces (e.g. a road traffic collision) and
n Stomach, naso-gastric tube or bowel gas pattern projected
so often have other injuries. within the chest

Aortic disruption should always be suspected in
cases when there has been rapid deceleration, upper
body hypertension (relative to the lower body) or the
presence of markers of high energy transfer to the
upper thorax (e.g. fractures of the 1st-3rd ribs). Symptoms
in a conscious patient can include severe retrosternal
discomfort, pain between the scapulae, hoarseness
(pressure from haematoma on the recurrent laryngeal
nerve), dysphagia (compression of the oesophagus)
and paraplegia or paraparesis (impairment of the
vessels supplying the spinal cord). There can also be
ischaemia or infarction of other areas (e.g. limbs and
abdominal organs) and accompanying fractures of the
ribs or sternum. The plain chest x-ray may hold clues
(table 4.12 and figure 4.10) but it is important to be aware
that plain x-rays lack both sensitivity and specificity.
If there is clinical suspicion then a CT angiogram (or
angiography depending on local policy) is required.
Figure 4.9 Chest x-ray showing ruptured left hemidiaphragm

TABLE 4.12
Irrespective of the mechanism, subsequent herniation Chest x-ray features suggesting descending
of abdominal viscera into the thoracic cavity can thoracic aorta rupture
lead to respiratory embarrassment and occasionally n ediastinum wider than 8cm (figure 4.10)
M
an acute abdomen due to strangulation of bowel n Pleural cap (apical haematoma) especially on the left
loops through the tear. Consequently diaphragmatic n Compression and downward displacement of left main bronchus
ruptures should always be surgically repaired. n Fractured first or second rib
n Trachea shifted to right
Aortic rupture/great vessel injury n Opacification between the aorta and the left pulmonary artery
In around 85% of cases this occurs in victims subjected n Blunting of the aortic knuckle
to rapid deceleration (e.g. high-speed road traffic n Raised right main bronchus
collisions or falls from a significant height). The remainder n Left haemothorax with no obvious rib fractures or other cause
result from penetrating trauma or crush injury. With n Deviation of the nasogastric tube to the right
deceleration, the aortic injury most commonly occurs
in the region of ligamentum arteriosum, just distal
to the origin of the left subclavian artery. Here the
descending aorta is relatively fixed while the heart
is mobile in the mediastinum, consequently it is the
point of maximal shearing forces. Other sites of relative
immobility (and so sites of damage) are the aortic root
and at the level of diaphragm.
In cases of aortic rupture, the clinical presentation

depends upon the site of injury. Patients with injury
to the intrapericardial portion of the ascending
aorta will usually develop a cardiac tamponade.
Extrapericardial ascending aortic injury produces
a mediastinal haematoma and a haemothorax,
usually on the right side. Injury to the aortic arch may
remain undiagnosed initially if the adventitia remains Figure 4.10 Chest x-ray showing a widened mediastinum
intact and the damage is contained in the form of a
mediastinal haematoma. Consequently patients may With these symptoms and signs, investigations for
show transient hypotension, which initially responds aortic injury and consultation with a cardiothoracic
well to fluid therapy and further clinical signs may be surgeon are mandatory as delay can result in profound
absent. This may delay the diagnosis with catastrophic hypotension and death. If there is enough suspicion
results should the aorta rupture completely. A high patients should be managed as an aortic injury until
index of suspicion and judicious use of appropriate confirmatory diagnosis with a chest CT. In these cases
investigations cannot be overemphasised. blood pressure control is paramount, to prevent
further disruption or rupture of the aorta. Invasive
blood pressure monitoring is required to notice subtle
changes in the haemodynamic condition.
Oesophageal injury pneumothorax should be suspected from bruising or
Injuries to the thoracic oesophagus are uncommon a penetrating wound and decreased movement of the
because it is well protected in the posterior ipsilateral chest wall. Hyper-resonance to percussion
mediastinum. Damage is more likely in the cervical can be present on the affected side and breath sounds
region following penetrating trauma or crush injury. may be decreased or absent. Tachycardia can occur
Distally the oesophagus is at risk of rupture following but if there has been no loss of blood, the patient
a severe blow to the epigastrium. should not be hypotensive.
A leak from an oesophageal injury will give rise to As the clinical signs may not be clear cut, a chest x-ray
mediastinitis. This often presents as shock and severe should be taken when a pneumothorax is suspected
pain out of proportion to the apparent injuries. This (table 4.13). A typical apico-lateral pneumothorax is
is an important diagnostic clue. Pain on swallowing often invisible on the initial supine chest x-ray in up
also suggests oesophageal injury and must be to 30% of cases because the air will be lying anterior
investigated. A left-sided pneumothorax, effusion or to the lung (figure 4.11a). Consequently CT is playing
pneumo-mediastinum in the absence of rib fractures an increasingly important role in the diagnosis of
should also raise suspicions. Depending on the site pneumothorax (figure 4.11b). However its greater
of rupture, surgical emphysema or signs of peritonitis sensitivity needs to be balanced against detecting
may develop with time. small pneumothoraces which may not be clinically

relevant in a non-ventilated patient.
Other injuries in thoracic trauma
Rib and sternal fractures
TABLE 4.13
Rib injuries and fractures are common in thoracic
trauma. Multiple rib fractures are usually associated with Chest x-ray features of a pneumothorax
contusion of the underlying lung to a varying degree. Erect film:
Apart from parenchymal injury, breathing is restricted n H yperlucency of a hemithorax with visualisation of pleural edge
due to pain and the patient cannot adequately cough, and absence of lung markings peripheral to this (figure 4.11a)
n
which increases the risk of pulmonary infection. A rim of about 1 cm on the radiograph corresponds to a pneu-
mothorax of 10% of total lung volume
Fracture of the first three ribs indicates a high-
energy transfer and should prompt a search for Supine film:
n
other underlying trauma e.g. an aortic injury, severe Deep, asymmetrical finger-like costophrenic sulcus on the
affected side
pulmonary contusion or airway rupture. Fractures of n Sharp hemidiaphragmatic border
the lower ribs increase the risk of injury to the liver and n Sharp mediastinal border
spleen. Other fractures (e.g. sternum, clavicle and or
scapula) may suggest the presence of a flail segment
so should prompt a reassessment of the ribs. In doing
this, remember that it is possible that only 50% of rib
fractures are evident on initial chest x-rays.
If a sternal fracture is noted on a chest x-ray, a CT or lateral

chest film should be performed, depending on local
policy, to confirm the presence of displacement. When
there is no evidence of displacement, patients may be
monitored for a period of 24 hours. However if there Figure 4.11a Chest x-ray showing a pneumothorax
is evidence of displacement, troponin levels should be Figure 4.11b CT scan showing an anterior pneumothorax
measured. If the latter are rising the patient needs to be
managed as having a cardiac contusion. Furthermore The treatment of an occult pneumothorax (i.e.
echocardiography should be performed to look for any not seen on a chest x-ray but apparent on CT) in a
evidence of regional wall motion abnormalities. The CT patient being ventilated is by insertion of a chest
of the chest will also be helpful in assessing the presence tube. In spontaneously breathing trauma victims the
of injury to other mediastinal structures. treatment is often the same, however the decision to
insert a chest tube should take into account the state
Simple pneumothorax of the patient, size of the pneumothorax, associated
Patients with a simple pneumothorax may present injuries and planned definitive care. Conservative
with sharp pain in the chest, particularly on inspiration management may be appropriate for an occult
(but beware that rib fractures present in the same pneumothorax if surgery or intubation is not required.
way). Respiratory distress varies in degree, depending If this option is taken then the patient requires ongoing
upon the extent of pneumothorax, accompanying rib close observation so early signs of respiratory distress
fractures and presence or absence of lung contusion. A can be detected.

Haemothorax
A haemothorax in an erect radiograph can be Further information
diagnosed by obliteration of the costophrenic angle
(requiring presence of 300-400ml of blood). In supine n L eigh-Smith S, Harris T. Tension pneumothorax-
patients, this amount of blood may not be immediately time for a re-think? Emerg Med J 2005; 22:8-16.
obvious, often the only clue is a generalised decreased n F itzgerald M, Mackenzie C, Marasco S, Hoyle R,
radiolucent appearance in one hemithorax. A massive Kossman T. Pleural decompression and drainage
haemothorax in contrast will result in a unilateral during trauma reception and resuscitation. Injury
whiteout and a large haemopneumothorax may have 2008;39:9-20.
an air-fluid level on an erect film. n W raight W, Daniel J, Parkin I. Neurovascular
anatomy and the variation in the 4th, 5th and 6th

Treatment of this condition is by chest tube drainage intercostal spaces in the mid axillary line. Clinical
as retention of a significant amount of blood in the anatomy 2005;18:346-349.
pleural cavity can lead to pulmonary contracture and n M oore F, Groslar P, Coimbra R et al. Blunt traumatic
has an increased risk of empyema occult pneumothorax: Is observation safe? Results
of a prospective, AAST multicentre study. J Trauma
Air embolism 2011;70:1019-1025.
This is a rare but potentially life-threatening problem M osquera V, Marinin M, Muniz J et al. Aortic injuries
n
occurring either in blunt or penetrating trauma, in crush trauma patients: Different mechanism,
particularly after a blast injury to the lung. Patients different management. Injury 2013;44:60-65.
with a patent foramen ovale may have paradoxical n B
urlew CC, Moore EE, Moore FA et al. Western Trauma
systemic embolism following right-sided air embolus. Association Critical Decisions in Trauma: resuscitative
Treatment until a thoracotomy can be organised thoracotomy. J Trauma 2012;73:1359-1363.
include nursing the patient head down, expansion n S imms ER, Flaris AN, Franchino X, Thomas MS, Caillot
of the intravascular space by fluid resuscitation, J-L, Voiglio EJ. Bilateral Anterior Thoracotomy
increasing systemic arterial pressure by inotropes (Clamshell Incision) Is the Ideal Emergency
(and/or vasopressors), ventilation with 100% oxygen Thoracotomy Incision: An Anatomic Study. World J
and reduction of tidal volume of the ventilator to Surg 2013 Feb 23 [Epub ahead of print].
reduce intra-thoracic pressures. Even with these n W ise, D et al. Emergency thoracotomy: ‘How to do
interventions mortality remains high, particularly with it’. Emerg Med J 2005;22:22-24.
the neurological consequences of air entering the n A ll ultrasound images courtesy of Dr. Dieter von
cerebral vascular system. Ow, Kantonsspital St. Gallen, Switzerland. First
published in EUROPEAN HOSPITAL Vol. 25, Issue
5/16, www.healthcare-in-europe.com.
Summary
Thoracic trauma is common and contributes directly
to death in about a quarter of all trauma deaths.
Most are due to hypoxaemia and hypovolaemia.
85% of thoracic injuries can be managed with
simple measures of oxygenation, fluid and blood
resuscitation and chest tube placement. Surgical
intervention is only necessary occasionally.

ready to apply the following knowledge in the
thoracic and breathing workshop:
n to understand the pathology of immediately
and potentially life-threatening thoracic injuries;

n to diagnose specific immediately, and
potentially, life-threatening thoracic injuries;
n to manage immediately, and potentially, life-
threatening thoracic injuries.


Skills - Breathing problems and n Confirm correct side for insertion and identify the
5th intercostal space (ICS) or higher, 1cm anterior to
thoracic trauma the mid-axillary line:
● fully
abduct the patient’s arm to allow a clear
Tube thoracostomy (figure 4.12) approach to the axilla and lateral chest wall;
Indications: ● if
trained, use sonography to confirm the correct
n p
neumothorax (simple and tension), haemothorax. site for insertion if immediately available. This
minimises the risk of placing the tube sub-
Procedure: diaphragmatic.
n C
heck presence and function of all equipment ● when
sonography is not available or possible,
(table 4.14). identify the sternal angle and the medial end of
the 2nd costal cartilage. Count down to the correct
TABLE 4.14 level and make a mark 1cm anterior to the mid-
Equipment for tube thoracostomy axillary line.
n L ocal anaesthetic, needle and syringe ● if
it is not possible to identify the ribs, use the width
n Skin cleansing solution of the patient’s hand (i.e. the distance across the
n Artery forceps 2nd–5th metacarpophalangeal joints) below the
inferior anterior axillary border to estimate the 6th

n Surgical drapes
n Scalpel ICS. The skin mark for the incision should therefore
n Chest drain (28-32 Fr gauge) be made at least one intercostal space higher than
n Suture this point. In cases where the patient’s upper limb
n Tape cannot be used due to associated injuries, estimate
n Dressings the correct level by using the operator’s own hand.
n Underwater drainage system, filled and correctly assembled n C lean the area fully and isolate with sterile drapes.
n I f the patient is conscious, infiltrate the area

n If conscious inform patient about the procedure for insertion with local anaesthetic; the skin,
and obtain verbal consent. subcutaneous tissue, down to the pleura and area
n E nsure IV access has been secured. around the skin mark.
Figure 4.12 Sequence for insertion of chest tube

n Ensure local anaesthetic has worked and give
systemic analgesia.
n I f present, remove the metal trocar from the drain.
n A ttach a clamp or artery forcep through the distal
side hole in the drain but ensure no metal projects

distal to the tube – this will enable you to direct the
tip into the pleural cavity.
n M ake a 3-5cm incision along the line of rib.
n U se blunt dissection to deepen the track through
the intercostal muscles down to the pleura. Beware

that the neuro-vascular bundle runs along the
lower border of the rib, therefore make the track
over the superior border of the rib.
n P ierce the pleura using artery forceps.
n I nsert a finger along the track into the pleural

cavity and sweep around the space to detect the
presence of any adhesions or bowel (in case of a Figure 4.13 Check chest x-ray after insertion of chest tube
ruptured diaphragm). Take care in doing this as rib
fractures may be present. n damage to:

n T he tube is then directed through the incision ● lung
parenchyma;
into the pleural cavity and digitally advanced ● mediastinal
contents;
posteriorly and superiorly. This is to ensure it does ● neurovascular
bundle;
not run into the horizontal fissure. ● abdominal
organs.
n F ogging, blood or condensation, caused by warm n b
ronchopleural fistula.
air escaping down the drain, confirms placement in

the pleural cavity. Needle thoracocentesis
n T he proximal end of the drain is then connected to Indications:
the underwater drainage system. n e
mergency decompression of a tension pneumothorax
n T he chest drain is then secured by tape, and/or when no scalpel is available to perform a thoracostomy.
anchoring sutures, and an appropriate dressing.
Knots tend to slip on the plastic tubing so use tape Procedure:
as well as sutures unless you are proficient in this n I f conscious inform the patient about the procedure
technique. and obtain verbal consent.

n R e-examine the chest to ensure the patient has not n E nsure arrangements are being made for a
deteriorated. thoracostomy.
n R epeat the chest radiograph to confirm correct n A ttach a 14 or 16g extra-long thoracocenthesis
tube placement with all the side holes inside the cannula onto a 10ml syringe, with the needle still
pleural cavity, no kinking and resolution of the within the cannula.
pneumothorax (figure 4.13). If required, remove the n F ill the syringe with a few ml of air or saline.
dressing and/or sutures and reposition the drain. n I n view of the urgency of the situation when this
n D o not clamp the drain when there is a massive procedure is carried there will not be time for using
haemothorax; this does not reduce bleeding but local anaesthetic, but the skin should be quickly
does reduce lung expansion. cleaned.
n G ive prophylactic antibiotics (a cephalosporin or n I dentify the mid-clavicular line at the 2 intercostal
nd
clindamycin depending on local policy), at the time space (just above the upper margin of the lower
of insertion and for the first 24 hours afterward. This (3rd) rib).
will reduce the incidence of both empyema and all n A n alternative site is the 5 intercostal space, in the
th
other infectious complications by around 10%. anterior axillary line.

n I nsert the cannula perpendicularly into the chest.
Complications: In most adults, the cannula will have to be inserted
n b leeding (most commonly from injury of an fully to reach the pleural cavity (figure 4.14).
intercostal artery) n O nce in place, inject 1-2ml of air or saline to expel
n m alposition any tissue that may have blocked it on insertion.

n s ide hole in the subcutaneous tissue causing n A ttempt aspiration – if the syringe fills easily with
subcutaneous emphysema air or bubbles are seen, the cannula is likely to be

n i nsertion into the peritoneum, bowel, liver correctly located in the pleural space. Remove the
n s lippage out of the pleural cavity syringe, a significant improvement of the patient‘s
n i nfection cardiovascular and respiratory status confirms the
diagnosis. Occasionally, a jet of air may be felt from
the cannula.
n Extract the inner metal needle and fix the cannula in n While aspirating continuously, advance the needle
place by adhesive tape making sure it does not kink. towards the tip (inferior angle) of the left scapula,
n C
ontinue immediately to a tube thoracostomy; a watching the ECG.
needle thoracocentesis only provides temporary n I f the ECG monitor shows an injury pattern (e.g.
relief. ST depression or elevation) or an arrhythmia (e.g.
n T he inability to aspirate air means either the ventricular ectopics), this indicates that the needle
cannula is blocked, it is not in the pleural cavity or has been advanced too far and is touching the
the diagnosis is incorrect. Definitive chest drainage myocardium.
is therefore urgently required. n R emove the metal needle and re-attach the syringe.
If the injury pattern remains, withdraw the cannula

(whilst aspirating) until a normal ECG is restored.
n O nce in the pericardial sac, as much blood as is
possible should be aspirated.

n A s the pressure on the myocardium decreases, and
its filling increases, the myocardium may move

towards the cannula tip and an injury pattern may
recur.
T he cannula is then taped in place and a three-way

n
tap attached.
n T he pericardial sac can be re-aspirated should the
signs of tamponade recur.
An alternative technique is to insert a Seldinger wire

Figure 4.14 Needle thoracocentesis through the cannula once it is in the pericardial sac.
The cannula is then withdrawn and a larger calibre
Complications: silicone catheter is inserted over the wire. This also
n n eedle too short: in up to 30% of patients, the avoids the need for repeated needle decompression.
length of commonly used IV cannulas (4.5cm) may
not be sufficient to fully penetrate the chest wall; Complications:
n l ife-threatening haemorrhage (due to perforation n o bstruction of the cannula by:
of the internal thoracic and subclavian blood ●blood

vessels or poor location of the landmarks) ●t

issue
n c ardiac tamponade ● kinking

n p neumothorax n d rainage of blood from subcutaneous vessels
n i nfection n d rainage of blood from a cardiac chamber
n i nability to aspirate blood because it has clotted

Needle pericardiocentesis within the pericardium and assuming there is no
Indications: tamponade
n e
mergency decompression of a cardiac tamponade, n i nability to drain a large collection
ideally confirmed by echocardiography, no team n r equirement for repeated needle decompression
member is competent to perform a thoracotomy n b leeding (most commonly from injury of an
and the patient is in extremis (i.e. about to die). intercostal artery)

n d amage to the:
Procedure: ● myocardium

n I f conscious inform patient about the procedure ● coronary

artery laceration
and obtain verbal consent. ● lung

n E
nsure arrangements are being made for a thoracotomy. ● abdominal
viscera
n C onnect a 20ml syringe containing 10ml saline to n c ardiac arrhythmias, arrest and tamponade
a long 14-16g cannula with the needle still in place. n i nfection
n E nsure IV access has been secured and the patient
is connected to an ECG monitor.

n C lean and drape the chest wall and if time permits
infiltrate local anaesthetic into the skin to the left

of the xiphisternum, the subcutaneous tissue and
surrounding area.
n T he skin is punctured 1-2cm below and left of the
xiphoid process, using a long needle and cannula,

at an angle of 45°.

Chest x-ray interpretation n Bones (fractures):
X-rays need to be interpreted in a systematic fashion ● ribs

so that all the significant pathological processes ● scapulae

can be detected and mistakes avoided. The system ● vertebrae

recommended on the course is described below. n C

artilages and joints (dislocation; subluxation):
Candidates with their own method review their system ● shoulder

girdle
to ensure it covers all elements described below. ● intervertebral

n S
oft tissues:
Indications: ● central
(mediastinum):
n v ictims of polytrauma or localised thoracic ❍ size and shape
trauma when CT scan not immediately available; ❍ position
n f ollowing invasive procedures on the thorax. ❍ double line (pneumomediastinum)
● lateral
(lungs):
Procedure: ❍ size
n A
h!: ❍ density
● use
the first 10 seconds to simply look at the ❍ edge
image and note any immediately obvious ● peripheral

(diaphragm and chest wall):
abnormalities. Then explore the image in more ❍ position
detail using the AAABCS systematic review. ❍ shape
n A
dequacy and Accuracy: ❍ clarity of the angles
● patient’s
personal details ❍ gas under the diaphragm
● projection
of the x-ray beam (PA or AP) ❍ gas and foreign debris in the lateral chest

● exposure
of the film wall and neck
● area
of the chest on the film ● extrathoracic
soft tissues:
● degree
of inspiration ❍ foreign bodies
n A
lignment: ❍ air
● compare
the distance between the medial
edge of the clavicle and sternum on the left and Complications:
right sides n a
bnormalities missed on inspection, most commonly:
n A
pparatus: at
the apices
●
● location
behind

● the heart
● c
omplications under

● the diaphragms
in
the peripheral soft tissues and breast shadows
●


5.
Shock
Learning outcomes
n Defining shock and knowing its causes in trauma patients
n Assessing, managing and monitoring trauma victims with shock
n Assessing medical factors complicating shock management

n Implementing haemorrhage control
n Haemostatic resuscitation and applying a major haemorrhage protocol
n Assessing, monitoring and managing burned victims
n Vascular access and the use of intraosseous needles
Introduction hypovolaemia. Later, as shock progresses, there is an

increase in oxygen uptake as a result of a response to
Shock is best defined as a generalized, life-threatening, stress, inflammation or sepsis, each of which increase
inadequate oxygen delivery to organs and tissues. oxygen requirements beyond levels seen in health.
It occurs when there is an imbalance between the
processes determining oxygen delivery and oxygen The causes of shock
consumption (figure 5.1). Initially the mismatch is Although hypovolaemia is by far the commonest cause
primarily a result of impaired delivery (hypoperfusion), of shock in the trauma patient, there can be other
which in the trauma patient is usually due to co-existing pathophysiological disorders affecting
ate
Adequ
uate
Inadeq
Reduced Increased oxygen Reduced oxygen Increased oxygen

oxygen delivery consumption consumption delivery
arterial oxygen cardiac output

➞ ➞ ➞
➞
saturation haemoglobin
haemoglobin arterial oxygen
➞ ➞
Adequacy of
cardiac output saturation
oxygen delivery
Figure 5.1 Factors affecting the adequacy of oxygen delivery
CHAPTER 5 SHOCK | 67
TABLE 5.1
Classification of shock
Type of shock Examples of causes Effect on cardiac output
Hypovolaemic Haemorrhage, interstitial (third space) losses, burns, dehydration Decreased
Obstructive Tension pneumothorax, cardiac tamponade, massive pulmonary embolus Decreased
Cardiogenic Myocardial injury or ischaemia Decreased
Distributive:
n Neurogenic Spinal cord injury (usually above T6) Decreased
n Septic Pneumonia, bowel perforation, infection (late complication of trauma), Decreased, normal or
delayed resuscitation increased
n Anaphylactic Acute allergic reaction (type I hypersensitivity) Normal or decreased
oxygen delivery. These are classified in table 5.1. All can On their own, these changes are not accurate enough
eventually lead to cellular hypoxia, microcirculatory to estimate the reduction in blood volume because of

or mitochondrial dysfunction and cell death. If left the presence of confounding factors which affect the
untreated, this causes the release of various mediators trauma victim’s response to hypovolaemia.
initiating a systemic inflammatory response syndrome.
When the patient has multisystem trauma, these Factors affecting estimation of blood loss
changes are cumulative. For example, consider a case The classic presentation of the shock response
of blunt trauma with pulmonary contusions and intra- following trauma is most likely to be seen in the
abdominal haemorrhage. Oxygen delivery will be young, fit adult with an isolated penetrating injury
impaired by reductions in arterial oxygen saturation with little tissue damage (e.g. a stab wound to a major
(SaO2), cardiac output (hypovolaemia reducing artery). More frequently, the patient has significant
preload) and haemoglobin concentration if replaced tissue damage following blunt trauma and is anxious,
with cristalloids. This will be exacerbated by the frightened and in pain. All of these variables will
increase in oxygen consumption from pain, shivering modify the physiological response. The situation may
and, if inadequately treated, the development of an be further complicated by the presence of drugs, or
inflammatory response syndrome. pre-existing comorbidities that modify the patient’s
ability to respond to haemorrhage. These factors may
Recognition of shock lead to a serious risk of over- or underestimation of
The lack of sensitivity with tests used to identify shock in blood loss (table 5.2).
the resuscitation room means its early development can
be difficult to detect. A common mistake is to overlook TABLE 5.2
patients with established tissue hypoperfusion because
their blood pressure is within the normal range for their Patients with a risk of over or under estimation of
age group. Early recognition therefore relies on: blood loss
Blood loss over-estimation Blood loss under-estimation
Clinical examination Pre-existing medical conditions Young children (chapter 11)
n s
igns of external or internal haemorrhage. Drugs/pacemakers Pregnancy (chapter 6b)
Hypothermia Athlete
Estimating the volume of blood lost Penetrating trauma Blunt trauma
n h
eart rate;
n b
lood pressure; Pre-existing medical conditions
n r
espiratory rate; The response to trauma in these patients can vary.
n c
apillary refill time; Those with a reduced cardiorespiratory reserve due to
n s
kin colour and temperature; myocardial ischaemia, valvular disease or sympathetic
n u
rine output; neuropathy (e.g. diabetics) have a restricted ability to
n c
onscious level. compensate for acute hypovolaemia. As a result, blood
pressure can fall when relatively smaller volumes
Metabolic disturbances (blood gases) of blood are lost, leading to an overestimation of
n p H; blood loss. Alternatively, if the patient is normally
n l actate; hypertensive, haemorrhage may only lower the BP
n b ase deficit. into the normal range for that age group, leading to
an underestimation of blood loss.

Drugs and pacemakers In trauma patients, two other factors complicate the
Various medications alter the physiological response situation further; coagulopathy and acidosis. These
to blood loss, (e.g. β-blockers). Illicit drugs (e.g. cocaine) combine with hypothermia to produce an interlinked
can also affect the normal physiological response. The ‘lethal triad’ (figure 5.2). Inadequate tissue oxygenation
effect of a pacemaker will depend upon its complexity; leads to lactic acidosis, whilst environmental exposure
they may pace at a fixed rate (approximately 70-100/ and the use of cold fluids lead to hypothermia. Trauma
min) irrespective of volume loss or arterial blood is associated with the development of coagulopathy
pressure, giving rise to errors in estimation of acute which is exacerbated by acidosis, hypothermia, the
blood loss. A history of therapeutic anticoagulation depletion of clotting factors by clot formation, ongoing
should also be considered, being either sought from haemorrhage and the use of fluids devoid of clotting
the history, medic alert bracelet or early assessment of factors. As a result the cycle of coagulopathy, acidosis
clotting function. Abnormalities should be corrected and hypothermia is established.
when discovered, especially in the actively bleeding or
brain injured patient.
Injury
The athlete
The resting heart rate in an athlete may be less than
50 beats/min and accompanied by an increase in Haemorrhage Exposure
blood volume of 15-20%. Therefore a compensatory

tachycardia indicative of significant acute blood loss
can be less than 100 beats/min. Coagulopathy
The patient with hypothermia

Acidosis Hypothermia
A core temperature below 35⁰C will reduce arterial
blood pressure, heart and respiratory rate in its own
right, irrespective of any blood loss. If this is ignored, Figure 5.2 The lethal triad: hypothermia, acidosis and coagulopathy
hypovolaemia may be overestimated. Hypothermic
patients who are also hypovolaemic are often ‘resistant’ Primary survey and resuscitation
to appropriate fluid replacement. Estimation of the
fluid requirements of these patients may therefore be The initial management of the shocked patient focuses
very difficult and invasive haemodynamic monitoring on eliminating the lethal triad, by:
is often required. n preventing further haemorrhage;
n restoring adequate oxygen delivery;

Penetrating or blunt trauma n minimizing further heat loss and rewarming;
Minimal tissue damage, typically associated with a n recognizing and correcting any coagulopathy.
penetrating wound (e.g. stab wound) will result in
tachycardia, and vasoconstriction. Initially, this may The real challenge of trauma care is to achieve all of
be sufficient to maintain a relatively normal blood this as rapidly as possible and certainly within the
pressure. However continued blood loss will eventually first hour. Consequently these measures need to be
result in a reduction in heart rate, loss of sympathetic implemented while the patient is being transferred
tone (particularly in skeletal muscle and kidneys) and a from the pre-hospital arena to the resuscitation room
profound fall in blood pressure. In contrast, significant and subsequently to either the CT scanner, operating
tissue damage (e.g. blunt trauma with long bone theatre, radiology suite or the intensive care unit.
fractures) results in prolonged progressive sympathetic
stimulation with an increasing tachycardia and marked Before the patient arrives
vasoconstriction in non-essential organs e.g. the gut, Good preparation based on pre-hospital information
skin and kidneys. These patients will continue to is essential, this includes ensuring that:
compensate, despite ongoing blood loss. Eventually n the resuscitation room is warm;
as blood loss continues, no further compensation is n IV fluids are warm;
possible and hypotension ensues. It is therefore a late n the blood warmer is prepared;
sign of impending cardiovascular collapse. n warming blankets are available;
n tranexamic acid is available;

Patients with penetrating or blunt trauma can n the major haemorrhage protocol is activated
appear to have similar signs and symptoms of appropriately;
shock having lost very different volumes of n a team briefing has occurred.
blood.
On arrival
The same plan described in chapter 2 is used with
members of the team carrying out their tasks
Management of shock
Recognise the Vascular access
presence of shock (or IO) Coagulation Consider
Control
assay need for
external
Send trauma (including tranexamic
haemorrhage Identify Identify bloods &
calcium & acid
non-haemorrhagic source(s) of blood gas
causes of shock haemorrhage fibrinogen)
Fluid
resuscitation
Plan and prioritise
Give
Haemostatic/
Control Treat tranexamic
Consider balanced
haemorrhage coagulopathy acid
applying Treat as transfusion
pelvic appropriate appropriately
binder Monitor response to
guide further use of
blood/blood products

Reassess
Plan and prioritise

further management
Figure 5.3 Overview of approach to shock management
simultaneously. Specific features that the circulation there is significant lower limb trauma. The aim should
personnel will have to address are summarised in be that a tourniquet is left on for the shortest time
figure 5.3. Each of these will be considered in turn. possible, (certainly not for more than two hours), until
the source of bleeding has been controlled surgically
Haemorrhage control in the resuscitation room or by interventional radiology.
The techniques available to control haemorrhage in
the resuscitation room include: Splinting a limb is an effective way of limiting further
n direct pressure and elevation at the point of blood loss. A pelvic binder can also be life-saving
haemorrhage; when applied to severe pelvic fractures as it stabilises
n topical haemostatic dressing; the bone fragments, and decreases the pelvic volume
n tourniquets for limb haemorrhage; thereby reducing the risk of major hemorrhage. A
n splints to minimize further blood loss from long number of devices are available to temporarily bind
bone fractures; a fractured pelvis in a haemodynamically unstable
n application of a pelvic binder in a patient until surgical stabilization can be achieved (see
haemodynamically unstable patient with a chapter 7).
suspected pelvic fracture (chapter 7).
Vascular access
Having identified any external haemorrhage, one of the Peripheral venous access
circulation personnel should apply direct pressure over With overt bleeding controlled, vascular access should
the wound with an antiseptic dressing supplemented be obtained by inserting two large bore peripheral
with elevation if practical. When the bleeding stops IV lines (14 or 16g). If peripheral venous access is
or is significantly reduced, a compression bandage unavailable or fails, the alternatives are cannulation of
can be applied. If this fails to control the bleeding, a central vein (subclavian, internal jugular or femoral)
as demonstrated by bleeding through the dressing, or intraosseous (IO) access.
a further one should be applied. The next step is to
consider using a haemostatic dressing and tourniquet. Intraosseous access
Once in place these should be left until there is time to This technique can be used in patients of all ages
gain definitive control of the bleeding source. when it is not possible to cannulate a peripheral vein
and as an alternative when time or expertise limit the
Tourniquets are becoming increasingly used in the use of central access. It is simple to learn and has a low
pre-hospital environment, particularly in areas where incidence of complications.

Insertion of IO needle (see skills section) (FFP), clotting factor concentrate, cryoprecipitate and
platelets. This is best achieved by following a major
haemorrhage protocol (MHP). The use of the MHP
KEY POINTS
has become the cornerstone of fluids resuscitation
Indications: inability to cannulate a peripheral vein, in patients who are physiologically compromised by
lack of time or expertise to insert a
central venous catheter
their blood loss or have ongoing bleeding. In some
areas, blood is also available for use in the pre hospital
Procedure: insertion of intraosseous needle
setting.
Complications: f ailure to enter marrow cavity, infection,
compartment syndrome
All fluids should be warmed before being given to
Common delay in use, inserted distally to fracture prevent iatrogenic hypothermia. This is best achieved
pitfalls: by storing crystalloids in a warming cupboard and
delivering them through a warming device to minimize
heat loss as the fluid passes through the giving set. The
Fluids and blood products for resuscitation use of rapid infusion devices which can deliver large
volumes of warmed blood products or fluid should be
Crystalloids available for the resuscitation of profoundly shocked
patients.
The most commonly used crystalloid solutions

are Hartmann’s, Ringer’s acetate and 0.9% saline.
Hypotonic solutions (e.g. 5% glucose, 4% glucose Identifying the causes of shock
and 0.18% saline) diffuse into both the extracellular The initial assessment aims not only to identify the
and intracellular spaces with little remaining in the presence of shock but also the causes.
intravascular space. Consequently they have no role in
the resuscitation of trauma patients. Sonography (eFAST) can quickly reveal the cause of
shock in the haemodynamically unstable patient.
Hypertonic crystalloid solutions have been advocated eFAST helps to target the resuscitation of the critical
for initial resuscitation of hypovolaemia. The most patient towards the affected cavity (see chapter
widely used is hypertonic saline, consisting of 2,4 and 6). This allows an early decision regarding
between 1.8% and 7.5% saline. The main advantage damage control surgery. In abdominal trauma, free
appears to be in patients with traumatic brain injury fluid indicates intrabdominal haemorrhage. Common
where it may reduce cerebral oedema and intracranial sources of haemorrhage are a splenic rupture or a
pressure (ICP), thereby restoring cerebral perfusion hepatic rupture. Early CT scanning is the investigation
and reducing neuronal injury (chapter 8). of choice and Whole Body scanning has become part
of the primary survey in many advanced trauma care
Blood and blood products systems. There seems to be a survival benefit if carried
Warmed blood products are the fluids of choice out immediately on admission.
for the resuscitation of the unstable hypovolaemic
trauma patient (Fig. 5.5). Stored blood has usually been Damage control resuscitation
processed into a number of products to allow the In cases of ongoing, uncontrollable bleeding, the
most appropriate to be given. Knowledge of the local team leader will also have to assess the need for
provision of blood products is important as different damage control resuscitation; a combined process of
countries may carry this out in different ways. For controlled hypotension, haemostatic resuscitation,
example, fibrinogen concentrate is available in some damage control surgery and interventional radiology
European countries and clotting factor concentrates (figure 5.4). There are three main types of patients who
are becoming more widely used in trauma. may require this approach.
Initially, red cell replacement to restore haemoglobin

concentration is typically given in the form of packed
Damage Control Resuscitation
red blood cells (PRBCs). This is devoid of clotting factors
and platelets. Ideally all blood transfusions should have
undergone a full crossmatch to ensure compatibility,
however, this can take up to an hour. In the urgent Hypotensive Haemostatic Damage Damage
situation the use of uncrossmatched O-negative Resuscitation Resuscitation Control Control
blood may be necessary. Subsequently type-specific Surgery Radiology
blood should be used as soon as it is available, as the
recipient and donor blood are checked for ABO and Figure 5.4 Damage control resuscitation
Rhesus compatibility. When bleeding is ongoing, or
when large volumes of blood have been lost, red cells
need to be supplemented with fresh frozen plasma
1. Penetrating trauma blood pressure is an indication of raised intracranial
Patients with penetrating trauma and minimal tissue pressure and an attempt by the body to maintain
damage may have ongoing haemorrhage into a body cerebral perfusion. No action should be taken to
cavity that cannot be controlled externally. Although lower it. Isotonic fluids should initially be given
aggressive resuscitation with rapid infusion of a large at a normal maintenance rate. Otherwise, the
volume of fluid tends to raise arterial blood pressure, aim should be for a SBP > 110mmHg, a MAP of
there may be adverse effects, such as dislodgement of > 90mmHg, or normotension for the patient if known
an effective thrombus and a dilutional coagulopathy, to be hypertensive. The same targets apply to patients
leading to further haemorrhage. The priority in with isolated spinal cord injury.
these patients is emergency haemostasis either
surgically (damage control surgery) or radiologically, Assessing the patient’s response to fluid
depending on the site of haemorrhage and local resuscitation
facilities. Only essential investigations should be Essentially, there are three possible outcomes:
performed in order to minimize any delay in starting
surgery/interventional radiology, thereby reducing The patient is improving
the period of shock. Providing there is no head injury, This suggests that the combined effect of the body’s
fluid resuscitation prior to any intervention should compensatory mechanisms and the rate of fluid input
be limited to achieving a blood pressure sufficient to are greater than the rate of blood loss. Such patients

maintain organ viability in the short term; a systolic may require PRBCs later but this can wait for a full
blood pressure (SBP) of 80-90mmHg is an appropriate crossmatch. Vital signs should be monitored closely and
target. Hypotensive Resuscitation is only a short term the team leader informed of any sudden deterioration.
measure whilst haemorrhage is controlled. As soon
as it is, the patient should be further resuscitated, The patient initially improves, then deteriorates
aiming to restore normal oxygen delivery and In these cases the rate of bleeding has increased
haemodynamics. either because of a new source of bleeding or loss
of haemostasis at the original site. The latter may be
2. Blunt trauma a result of excessive resuscitation and rise in blood
This typically gives rise to soft tissue and/or bony pressure. These patients require urgent surgical
injuries which requires investigations (x-rays, assessment with the majority needing surgery or
sonography, CT scan). As described previously, the interventional radiology. Blood (usually as PRBCs)
presence of a low BP in this group of patients is an is also required, the choice being between group O,
indication of the need for more active treatment in type specific or fully crossmatched. Blood will need
order to limit cellular damage and prevent the later to be transfused in a balanced manner with FFP and
development of an inflammatory response syndrome platelets and regular checking of clotting. The ongoing
and multi-organ failure. In the absence of a head management decision will depend on the clinical state
injury, these patients may benefit from hypotensive of the patient and results of investigations.
resuscitation using a target SBP of 80-90mmHg.
The patient does not improve
3. The complex patient - Traumatic Brain and Spinal These patients are either bleeding faster than fluids
Cord Injuries and/or blood are being given or they are not suffering
When a patient has both traumatic brain injury from hypovolaemic shock alone but there is a co-
and significant, uncontrollable haemorrhage, it is existing cause e.g. cardiogenic or neurogenic shock.
reasonable to aim for a MAP > 80mmHg (or SBP around Aspects of the history, examination and vital signs are
100mmHg) in the short term, as mortality is significantly essential to distinguish between these possibilities.
increased in patients with traumatic brain injury
who have even brief periods with a SBP < 90mmHg. Those suffering massive ongoing haemorrhage
Surgical/radiological control of the bleeding should will require urgent intervention with ongoing
then be achieved in the shortest time possible. The resuscitation. This is often referred to as ‘damage
resuscitation of the head injury then takes precedence control surgery’. For this group of patients, activation
and most authorities agree that the aim is for a MAP of the major haemorrhage protocol, with early use of
> 90mmHg. When monitoring of intracranial pressure balanced transfusion, correction of coagulopathy and
is in place, blood pressure should be titrated to achieve prevention or treatment of hypothermia is vital. The
an adequate cerebral perfusion pressure. principles are summarised in figure 5.5. If available this
can be informed by the use of thromboelastography
Patients with isolated traumatic brain or spinal cord or thromboelastrometry. The aim is to deliver products
injury represent another group where different in a ratio that approximates whole blood, ensuring
specific goals are now used to guide resuscitation that there are adequate clotting factors and platelets.
efforts. Some patients will present with hypertension Trauma Induced Coagulopathy (TIC) is characterised
and a relative bradycardia. This elevation of the by depletion of fibrinogen and early substitution of
fibrinogen improves survival.
Surgical and radiological management of Major haemorrhage protocols
haemorrhage –‘damage control surgery Most current protocols involve giving PRBCs and FFP
and radiology’ at between a 1:1 and 2:1 ratio, along with appropriate
Damage control surgery seeks to control amounts of platelets. Checking of fibrinogen levels
haemorrhage with minimal intervention whilst there and giving cryoprecipitate or fibrinogen concentrate
is ongoing resuscitation, rewarming and correction is important to provide a substrate for effective clot
of any coagulopathy. It is not in a patient’s immediate strength. This approach ensures that resuscitation with
best interest to undergo prolonged, definitive blood products is haemostatic and contributes as little
general or orthopaedic surgery while they are cold, as possible to the development of coagulopathy. The
coagulopathic and acidotic. Surgery concentrates point at which FFP and platelets are given will depend
on debridement and external fixation of fractures, on local protocol, but most units will have a regime
haemostasis and stapling of perforated bowel, similar to that outlined in (Table 5.3 and figure 5.5).
peritoneal lavage, packing and delayed closure of the
abdomen (laparostomy). The patient is then taken to Tranexamic acid
the ICU where they are stabilized, following which Tranexamic acid should be given to any patients, who
further surgical procedures can be planned. have or are at risk of major haemorrhage, as part of
their resuscitation provided this is within three hours
Interventional radiology in the trauma patient of injury. It can be safely given to patients who also
Once appropriate imaging has located the source have a head injury, but is not indicated if this is the only
of bleeding a decision should be made as to the injury. The adult loading dose of 1g is given over 10
best way to proceed; non-operative management, minutes followed by an infusion of 1g over eight hours.
interventional radiology, damage control surgery, or a
combination (table 5.3). It is essential that the members Coagulopathy in trauma
of the trauma team (including the interventional The significance of coagulopathy in trauma is often
radiologist and surgeon) decide upon the best underestimated with over one-third of civilian and
management for the patient based on all the available military trauma patients having deranged clotting on
information, both clinical and logistical. admission to the resuscitation room. All trauma patients
TABLE 5.3
Comparison of management of the trauma patient

Site of trauma Non-operative Interventional radiology Damage control surgery
Thoracic aorta No role except in small partial Stent graft for suitable lesions Ascending aortic injury or arch
thickness tears injury involving great vessels
Abdominal aorta No role Occlusion balloon, stent graft for Injury requiring visceral revasculari-
suitable lesions sation or untreatable by endovas-
cular aneurysm repair
Kidney Subcapsular or retroperitoneal Active arterial bleeding: Renal injury in association with
haematoma without active arterial embolisation or stent graft multiple other bleeding sites or
bleeding other injuries requiring urgent
surgical repair
Spleen Lacerations, haematoma without Active arterial bleeding or false Packing or splenectomy for active
active bleeding or evidence of false aneurysm: bleeding in association with
aneurysm • f ocal embolisation for local multiple other bleeding sites
lesion,
• p roximal embolisation for diffuse
injury
Liver Subcapsular or intraperitoneal Active arterial bleeding: Packing if emergency laparotomy
haematoma or lacerations without • focal embolisation if possible, needed with subsequent repeat CT
active arterial bleeding • n on selective embolisation if and embolisation if required
multiple bleeding sites as long as
portal vein is patent
Pelvis Minor injury with no active bleeding Focal embolisation for arterial External fixation and
injury (bleeding, false aneurysm or subsequent packing if bleeding
cut-off) from veins or bones
Intestine Focal contusion with no evidence of Focal bleeding with no evidence Ischaemia or perforation requiring
ischaemia, of ischaemia or perforation. Or, to laparotomy ± bowel resection
perforation or haemorrhage stabilise patient, allowing interval
laparotomy pending treatment of
other injuries
Major Trauma?
Major Haemorrhage? Then...
Tranexamic Acid n If not given pre-hospital, administer to the bleeding
T
trauma patient if within 3 hours of injury, or continued
hyperfibrinolysis:
n 1
g bolus, followed by
n 1
g infusion over 8 hours
Resuscitation n A ctivate Major Haemorrhage Protocol
Initial Transfusion Ratio 1:1:1 and consider:
R
n
n R
apid infuser and cell salvage
n T
ime-Limited hypotensive resuscitation
n P
elvic binder / splint fractures / tourniquet
n A void crystalloid use
Avoid Hypothermia n T arget temperature > 36°C
A n R
emove wet clothing and sheets

n W
arm blood products / fluids
n U
se warming blanket / mattress
Unstable? n If unstable, coagulopathic, hypothermic or acidotic,

Damage Control perform damage control surgery of:
U Surgery
n A
n H
aemorrhage control, decompression,
decontamination and splintage
im surgery time < 90 minutes and conduct regular
‘surgical pauses’
Metabolic P erform regular blood gas analysis
M
n
n B ase excess guides resuscitation

n If lactate > 5mmol/L or rising, consider stopping surgery,
splint and transfer to ICU
A
Avoid n Inappropriate use of vasoconstrictors doubles mortality
Vasoconstrictors n H owever, use may be required in cases of spinal cord or
traumatic brain injury
Test Clotting n C
heck clotting regulary and target transfusion:
T
n L aboratory or point of care (TEG/ROTEM)
n A
im platelets > 100x109 /L
n A
im INR & aPTTR ≤ 1.5
n A
im fibrinogen > 2g/L
Imaging C onsider:
I
n
n C T: Most severely injured / haemodynamically unstable

patients gain most from CT
n Interventional radiology
C
Calcium n M
aintain ionised Ca2+ > 1.0 mmol/L
n A
dminister 10mls of 10% Calcium Chloride over 10 mins
as required
Figure 5.5 Major haemorrhage protocol

Copyright: L May, A Kelly, M Wyse
must have their PT, aPTT, platelets and fibrinogen The targets to achieve in the bleeding trauma patient
measured, along with an arterial blood gas, serum include:
lactate and ionised calcium. Increasingly, point of care n Hb 7 – 9g/dl;
coagulation monitoring using thromboelastography n platelets >100 x 10 /l;

9
(TEG) or rotational thromboelastometry (ROTEM) is n fibrinogen >1.5-2.0g/l;
proving useful in guiding rapid identification and n ionised calcium >0.9mmol/l.
correction of coagulopathy in the acute phase. The

cause of coagulopathy is multi-factorial (figure 5.6).
Hypothermia Acidosis Giving fluids Giving PRBCs Clot formation Tissue injury
Decreased Dilution Platelet Clotting factor Release of TPA

calcium consumption consumption
Platelet Impaired Decreased Decreased Increased

dysfunction clotting factor platelet clotting factor fibrinolysis
function concentration concentration
Coagulopathy
Figure 5.6 Trauma Induced Coagulopathy. TPA = Tissue Plasminogen Activator

Patients on anticogulants and The patient’s core temperature also needs to be

Anti-Platelet-Medication (APM) monitored. Throughout the resuscitation efforts
Therapeutically anticoagulated bleeding trauma should be made to avoid heat loss by minimizing the
patients, should have their anticoagulation reversed patient’s exposure and using warmed IV fluids, patient
promptly. The early use of prothrombin complex covers and active warming devices.
concentrate (PCC) is recommended for the emergency
reversal of vitamin K dependent oral anticoagulants. Completion of the primary survey
PCC also mitigates life-threatening post-traumatic By the end of the primary survey, the team leader must
bleeding in patients treated with novel oral ensure that the required tasks have been completed
anticoagulants (NOAC). or are being carried out. Analysis of an arterial blood
Idarucizumab (5 g intravenously) is recommended for gas sample should be available at this stage. Metabolic
the emergency reversal of dabigatran. acidosis is invariably a result of anaerobic metabolism in
Patients on anti-platelet medication are at high risk of poorly perfused tissues. Management consists of oxygen
major haemorrhage after trauma. The effect of these delivery by early use of blood products and, optimising
drugs can only be reversed by platelet transfusion. PaO2, and achieving normothermia. Patients with a
DDAVP can be used additionally at a dose of 0.4 mcg/ persistent acidosis may require intubation and controlled
kg. It is important that the use of such medications is ventilation. Sodium bicarbonate is rarely required
sought when taking an AMPLE history. and is generally reserved for cases of immediately
life-threatening acidosis in the presence of adequate
Monitoring the shocked patient perfusion and ventilation. As described in chapter 2 the
The overview above is aimed at maintaining the primary survey concludes with the planning round and
function of the vital organs whilst haemostasis is the secondary survey if the patient does not require any
achieved. However patients are often complex and further immediate intervention.
may not fit neatly into the categories described. A
further problem is that non-invasive vital signs used Traumatic cardiac arrest
initially become increasingly imprecise and unreliable As described in chapter 2, one objective of the
as the severity of shock increases. This is particularly 5-second round is to confirm that the patient still has
true of non-invasive blood pressure measurement a cardiac output. If not, this triggers a rapid change in
and heart rate. Consequently invasive arterial pressure priorities and team tasks. If the patients presents in
monitoring should be considered at an early stage in traumatic cardiac arrest (TCA) or periarrest the TCA
the resuscitation of patients with significant trauma. algorithm applies as described in chapter 5c.
This allows more accurate and continuous monitoring
of the patient’s blood pressure and repeated sampling
of blood for markers of cellular hypoxia, including
serum lactate, pH and base excess.
Accurate measurement of urine output will obviously

require the insertion of a urinary catheter with the volume
recorded whenever the other vital signs are measured.
the laboratory for routine bloods and used for
Summary bedside glucose estimation.
n Inject a small volume of local anaesthetic to ease
All members of the trauma team must recognize the pain caused by injection.
and initiate treatment in shocked patients as early n F lush the system with 20ml saline to clear any
as possible. In trauma, the cause of the shock is debris or clot.
frequently multifactorial but will invariably have n F luids need to be given in boluses. This is easiest
a hypovolaemic component. Tissue hypoxia to achieve using a syringe and three-way tap.
is minimized by early assessment, constant
monitoring and appropriate interventions. The flow rates under gravity alone are not high enough
Regular reassessment is essential as any for resuscitation.
subsequent deterioration needs to be detected n Intraosseous lines need to be replaced by venous
quickly and treated. In addition as the patient cannulation as soon as possible.

improves, other problems may become apparent.
Complications:
These cognitive abilities will be integrated with n e xtravasation;
the practical skills during the course workshops. n s ubperiosteal infusion;
n f at and bone marrow embolism;

n o steomyelitis;
Further information n d amage to the growth plate and cortex;
n p ain and subcutaneous oedema;
n R
ossaint R, Bouillon B, Cerny V et al. The European
guideline on management of major bleeding and

coagulopathy following trauma: fourth edition. Crit
Care 2016;20:100
n The Royal College of Radiologists. Standards of practice
and guidance for trauma radiology in severely injured

patients, Second edition. London: The Royal College of
Radiologists, 2015.
n G
ruen RL, Reade MC. Administer tranexamic acid early
to injured patients at risk of substantial bleeding. BMJ

2012 Nov 19;345:e7133 doi: 10.1136/bmj.e7133
Skills Figure 5.7 Insertion of an IO needle into the proximal humerus
Insertion of an intraosseous needle Application of a pelvic binder

The greater tubercle of the humerus is the primary This skill is described in detail in chapter 7.
intrasseous access site in adults and older children.
This site allows for the highest flow rates and avoids
the risk of compartment syndrome. Fractured bones
should be avoided
Technique:
n The patient’s hand should rest palm down on the
their abdomen with the elbow adducted

n Slide thumb up the anterior shaft of the humerus
until you feel the greater tubercle, this is the

surgical neck
n ~ 1 cm above the surgical neck is the insertion site.
n The needle is inserted 90° to the skin and
advanced until the bone is reached.

n T he drill is then activated and gentle pressure
applied until a ‘give’ is felt as the cortex is
penetrated.
n R emove the trocar and attach a syringe via a short
extension. Correct placement is confirmed by
aspiration of marrow content and easy infusion
of fluid. The aspirated sample can be sent to

5b.
Injuries due to burns
Learning outcomes
n Carrying out a primary survey and initial resuscitation of a burned patient
n Calculation of percentage of body surface area burned
n Calculation of fluid resuscitation requirements for patients with burns

n Understanding which patients need referral to a specialist burns centre
n Basic principles of transferring burns patients
Introduction Airway, cervical spine control and breathing

Assessment of the airway may reveal early signs of
Significant burns typically result from exposure to inhalational injury.
flames, with scalds being the next most common
cause; electrocution and chemical injuries occur rarely. History:
In the UK, Emergency Departments see an estimated n e
xposure to fire and/or smoke in an enclosed space;
175,000 burn patients per year, around 10% require n e

xposure to a blast;
admission, and approximately 300 die. The incidence n c

ollapse, confusion or restlessness at any time.
is similar in many European countries, are higher in

the United States, with developing countries having Signs and symptoms:
the highest mortality rate. The definitive care of burns n h oarseness or other voice changes;
is complex and requires a multidisciplinary team n h arsh cough;
approach with specialised involvement. Although n s tridor;
all large burns should be cared for in burns centres, n f acial burns;
the management of the patient must start from the n s inged nasal hair;
initial contact because early treatment can have a n s oot in saliva or sputum;
major effect on outcome. It is important to remember n a n inflamed or swollen oropharynx.
that patients may also have other injuries and need

accurate assessment, careful initial resuscitation and Investigations:
rapid transfer to specialist care. Although the latter n r
aised carboxyhaemoglobin levels;
is important, adequate resuscitation and careful n r

espiratory failure.
preparations take precedence.

The signs and symptoms from airway oedema and
pulmonary injury may take from minutes to hours to
Primary survey and resuscitation develop. Therefore the key to diagnosis is having a high
index of suspicion with the frequent re-evaluation of
A full primary survey using the sequence described those considered to be at risk.
in chapter 2 needs to be carried out on arrival. This
will identify any immediately life-threatening injuries. All patients should be given high flow oxygen, preferably
A more thorough assessment of the burns can be humidified. Signs of upper airway obstruction,
undertaken later. particularly stridor, indicate the need for early assessment
CHAPTER 5B INJURIES DUE TO BURNS | 77

by an experienced anaesthetist. The safest option is blood gas analysis and a chest x-ray are also essential.
usually early tracheal intubation as swelling will increase These provide an important baseline as the patient
over the first few hours, making this task progressively may deteriorate from an initially normal state. There is
more difficult. In severe cases a surgical airway may be no evidence that giving steroids is beneficial.
required. Tracheal intubation may also be required in
those patients with significant lung injury to optimise The cutaneous burn
ventilation and, on the rare occasion of circumferential Regardless of the cause of the burn, the severity of the
chest burns restricting inspiration. injury is proportional to the volume of tissue damaged.
Mortality is predicted by the percentage of total body
The cervical spine must not be overlooked, particularly surface area (% TBSA) burned. Functional outcome is
when the mechanism of injury suggests that it may more often dependent on the depth and site of the burn.
be injured. The classic case would be where the burn
victim in a house fire jumps from an upper floor and Calculating the percentage of total body surface
has spinal injuries from the impact of the fall. area burned
There are several techniques for calculating the %
Circulation and haemorrhage control TBSA. Initial assessment can be made with the ‘rule of
Hypovolaemic shock due to burns takes time nines’ or a serial halving technique. The former divides
to develop. Therefore signs of shock in the the body into multiples of nine (figure 5b.1). Serial

resuscitation room will not be due to the burn. The halving assesses burn size on the basis of asking the
team must look for another cause. The mechanism question ‘is half of the body burned?’ If not, ‘is it half of
of injury may give clues as to the possibility of other that?’ and so on until an estimate is achieved.
trauma (e.g. a fall whilst escaping a fire) and the patient
managed as described in chapter 5, irrespective of the
burns. Intravenous access is achieved using two large
bore cannulas. Although it is acceptable to insert a
cannula through burnt skin, this should be avoided
if possible. A preferred option in these circumstances
would be using the central veins or the intraosseous
route. When blood is sent for laboratory baseline
investigations carboxyhaemoglobin levels should be
included where an inhalation injury is suspected.
Disability
Reduced level of consciousness, confusion and
restlessness may occur with hypoxia secondary to an
inhalation injury. However, the possibility of alcohol or
drug ingestion and the presence of other injuries must
also be considered.
Exposure and environmental control

Clothing and any restricting items need to be removed.
However this action and the use of cold water at
the scene, during transfer and in the Emergency
Department often leads to hypothermia. This can be
minimized by covering uninvolved areas and raising Figure 5b.1 The ‘rule of nines’; the body surface is divided into
the ambient temperature to ideally 30°C. regions each equating to approximately 9% of the total surface
area.
Management of thermal burns

Inhalation injury A more accurate method is by using the Lund and
As described already intubation and ventilation are the Browder chart (figure 5b.2). The burnt areas, ignoring
mainstay of early management because the burned erythema, are drawn onto the chart and then the %
airway can become compromised at a rate that is TBSA burnt is calculated. In very large burns it can
difficult to predict. Patients with suspected inhalation be easier to calculate the size of area not affected.
injuries require close observation in an area equipped At this stage differentiating between full and partial
for immediate intubation and should be accompanied thickness burns is not essential. The palmar surface of
by an experienced anaesthetist until arrival at the the patient’s hand including the fingers equates to 1%
receiving burns centre. Pulse oximetry readings TBSA and can be used to estimate small areas of burn.
should be interpreted with caution, especially in the
presence of carboxyhaemoglobinaemia. Arterial

When the patient has additional significant injuries, or
LUND AND BROWDER CHART the % TBSA is greater than 15%, blood in addition to
The numbers represent % TBSA. the calculated volume of crystalloid may be required.
Letters are age dependent: see chart.
Management of the thermal burn wound
Effective burn care aims to achieve maximum
functional and cosmetic outcome. Apart from small
superficial burns, wound management should be
performed in a burns centre. After the affected area is
cooled and dressed there are rarely any indications for
further interventions before transfer.
Initial treatment
Dressing the wound can be achieved by loosely covering
the burn with plastic film. Hands can be placed in plastic
bags. The patient should then be kept warm with dry
blankets. Further accurate assessment of the wound
can take place at the burns centre after transfer. Topical
antiseptic solution and creams should not be applied.
Escharotomy
A circumferential full thickness burn can act like a
tourniquet and compromise the distal circulation.
Surgical division of the constriction is known as
Area Age 0 yr 1 yr 5 yr 10 yr 15 yr Adult escharotomy. There is rarely a need to perform this
A=½ head 9 ½ 8½ 6½ 5½ 4½ 3½
procedure within the first few hours, the exception
being a full thickness burn of the entire trunk that is
B=½ thigh 2 ¾ 3¼ 4 4½ 4½ 4¾
compromising ventilation. If this is carried out, note
C=½ leg 2½ 2½ 2¾ 3 3¼ 3½ that the wounds can bleed excessively as the incision
is down to areas of vascularity. Crossmatching blood
Figure 5b.2 Lund and Browder chart allows accurate calculation of for the patient, if not already done, is essential.
the % TBSA burned adjusted for age
Other initial interventions
Fluid resuscitation Ensure immunity against tetanus. In the absence of any
Any burn greater than 10% TBSA in a child, or 15% TBSA specific indications such as associated contaminated
in an adult, will require intravenous fluids to prevent wounds, there is no requirement for antibiotic
the development of burn shock. There are various prophylaxis at this stage. In contrast a nasogastric
formulae available to calculate fluid requirements, the tube and urinary catheterisation will be needed
Parkland formula is commonly used: in all patients with complex burns. As superficial
and deep dermal burns are painful, adequate pain
2-4ml Hartmann’s solution x % TBSA burned relief is a priority from an early stage. In addition to
x humanitarian reasons, pain leads to catecholamine
body weight (kg) release and may increase peripheral ischaemia and,
potentially, burn depth. Intravenous opiates should be
Use the higher value of 4ml initially. Weigh the patient given until the patient is comfortable.
or ask his/her weight as estimates are often inaccurate.
A child’s weight can be obtained by using a recognized Transfer to definitive care
formula (see chapter 11) or a Broselow tape. Half this In all cases, early contact should be made with a burns
calculated volume is given in the first eight hours from centre so that advice on initial management and
the time of injury and the second half over the next transfer can be given. The team leader needs to be
sixteen hours. Consequently many patients will already aware of the guidelines for referral taking into account
be behind with requirements by the time they arrive in the size of the burn, other indicators of complexity and
the resuscitation area. In addition, allowance has to be local policies. In most countries, all complex burns are
made for deficit due to other injuries and the patient’s managed in specialised burns centres. The following
normal maintenance fluids. A guide to the adequacy of is a guide to the types of complex burns that should
fluid resuscitation is the patient’s urine output (usually receive specialist attention.
requiring urinary catheterisation) which should be:
n 1ml/kg/h in adults
n 2ml/kg/h in children
CHAPTER 5B INJURIES DUE TO BURNS | 79

Complex burn injuries n nsure the patient is being kept warm;
e
A burn is defined as complex if one or more of the n adequate analgesia;
following criteria are met: n a urinary catheter in place;
n a ge: n a free draining nasogastric tube;
● under
5 or over 60 years. n all findings and interventions, including fluid
n a rea: balance, are clearly and accurately documented.
● over
10% TBSA burnt in adults;
● over
5% TBSA burnt in children. If it is likely that a delay in transfer will exceed six
n s ite: hours then the situation needs to be discussed further
● face,
hands, perineum or feet; with the burns centre. In this circumstance it may be
● any flexure, particularly the neck or axilla; deemed necessary for:
● any circumferential dermal or full thickness n escharotomies to be performed;
burn of the limbs, torso or neck. n the burn wound to be cleaned and a specific
n i nhalation injury: dressing applied;

● any significant inhalation injury, excluding pure n the commencement of maintenance intravenous
carbon monoxide poisoning. fluids and/or nasogastric feeding.

n m echanism of injury:
h igh pressure steam injury;

●
● high
voltage electrical injury; Summary
● chemical
injury >5% TBSA burnt; Although burns patients comprise a small
● hydrofluoric
acid injury (>1% TBSA burnt); proportion of trauma patients, they can be
● s uspicion of non-accidental injury, adult or distressing to the inexperienced and distract
paediatric. from other serious underlying injuries. For this
n p re-existing medical conditions: reason, management begins with a full primary
● cardiac
disease; survey to identify and treat life-threatening
● r
espiratory disease; injuries, whether or not caused by the burns.
● diabetes
mellitus; Subsequently a more detailed assessment of
● pregnancy;
the burns can be made along with discussion
● immunosuppression
of any cause; with burns experts. Appropriate management of
● hepatic
impairment, cirrhosis. those requiring transfer can then be organised.
n a ssociated injuries:
● crush
injuries;
● major
long bone fractures;
● head
injury;
● penetrating
injuries.
Associated injuries may sometimes delay referral of

the patient; in these circumstances advice about burns
management should be sought.
Preparations for transfer

Once the decision to transfer a patient to a burns centre
is made, preparations for safe transport should begin.
Distance to the nearest burns bed and method of
transfer will vary both within and between countries.
With some longer distance transfers, rotary or even
fixed wing aircraft may be required. The principles of
safe transfer are covered in chapter 12. Features specific
to the safe transfer of the burned patient include:
n a thorough secondary survey to identify and
manage any other injuries;

n ensure adequate oxygenation and ventilation;
if there is any suspicion of an inhalation injury,

the patient should have been assessed by an
experienced anaesthetist and, if necessary,
intubated;
n ensure adequate, secure IV access and appropriate
fluid resuscitation;
n cover burns;

5c.
Traumatic cardiac arrest
Learning outcomes
Following this part of the course you will be able to:
n Recognise Traumatic Cardiac Arrest
n Recognise Traumatic peri-Arrest states
n Demonstrate an understanding of the treatment options

n Demonstrate an understanding of the indications for Resuscitative Thoracotomy (RT)
Introduction (ALS) algorithm. Cardiac arrest or other causes of

sudden loss of consciousness (e.g. hypoglycaemia,
Traumatic cardiac arrest (TCA) carries a very high stroke, seizures) may cause a secondary traumatic
mortality, but in those where Return of Spontaneous event. Some observational studies have reported
Ciruclation (ROSC) can be achieved, neurological that ~2.5% of non-traumatic out-of-hospital cardiac
outcome in survivors appears to be much better arrests (OHCAs) occur in cars. For a cardiac arrest to be
than in other causes of cardiac arrest. The response traumatic, an adequate mechanism has to be present
to TCA is time critical and success depends on a well- and the secondary trauma usually is not adequate.
established chain of survival, including advanced pre- Shockable rhythms (VF/pVT) are more common in
hospital and specialised trauma centre care. non-traumatic cardiac arrest, whereas PEA or asystole
Immediate resuscitative efforts in TCA focus on are more common in traumatic cardiac arrest. The
simultaneous treatment of reversible causes, which primary cause of the cardiac arrest can sometimes also
take priority over chest compressions. be elucidated from information about past medical
history, events preceding the accident (if possible),
and a systematic post-ROSC assessment, including a
Diagnosis 12-lead ECG.
The diagnosis of traumatic cardiac arrest is made

clinically; the patient presents with agonal or absent Prognostic factors and
spontaneous respiration and absence of a central pulse. withholding resuscitation
A peri-arrest state is characterised by cardiovascular There are no reliable predictors of survival for traumatic
instability, hypotension, loss of peripheral pulses in cardiac arrest. Factors that are associated with survival
uninjured regions and a deteriorating conscious level include the presence of reactive pupils, an organised
without obvious CNS cause. If untreated, this state is ECG rhythm and respiratory activity. Short duration of
likely to progress to cardiac arrest. e-FAST should be CPR and pre-hospital times are also associated with
used in the evaluation of the compromised trauma positive outcomes.
patient to help establishing the course of shock and Current overall survival rate are 3.3% in blunt and
to target life saving interventions. Haemoperitoneum, 3.7% in penetrating trauma, with good neurological
haemo- or pneumothorax and cardiac tamponade outcome in 1.6% of all cases. Outcome is age
can be diagnosed reliably in minutes, even in the pre- dependent, with children having a better prognosis
hospital phase. e-FAST is helpful in the immediate than adults. There is considerable variation in reported
diagnosis and management, but must not delay mortality (range 0-27%) reflecting heterogeneity
resuscitative interventions. in casemix and care in different systems. Pulseless
electrical activity (PEA), which in TCA may initially be a
It is vital that a medical cardiac arrest is not low output state, and asystole are the prevalent heart
misdiagnosed as a traumatic cardiac arrest and must rhythms in TCA. Ventricular fibrillation (VF) is rare but
be treated with the universal advanced life support carries the best prognosis.
CHAPTER 5C TRAUMATIC CARDIAC ARREST | 81

One study reported good neurological outcome in Treatment
36.4% of patients with VF, but only in 7% with PEA
and 2.7% of those in asystole, but other studies of Emphasis on rapid treatment of all potentially reversible
patients in non-shockable rhythms have reported pathology is the basis of treatment guidelines. Figure
100% mortality. 5c.1 shows a traumatic cardiac (peri-) arrest algorithm,
The prognosis is extremely poor in patients presenting which is based on the ERC universal ALS algorithm.
with apnoea, pulselessness and without organised
ECG activity. However, neurologically intact survivors Effectiveness of chest compressions
initially presenting in this state have been reported. In cardiac arrest caused by hypovolaemia, cardiac
We therefore recommend the following approach: tamponade or tension pneumothaorax, chest
compressions are unlikely to be as effective as in
Withholding resuscitation in TCA should be considered normovolaemic cardiac arrest. Therefore, chest
in any of the following conditions: compressions take a lower priority than the immediate
n no signs of life within the preceding 15 minutes treatment of reversible causes, e.g. controlling
n massive trauma incompatible with survival (e.g. haemorrhage, thoracotomy.
decapitation, loss of brain tissue)
Hypovolaemia
Termination of resuscitative efforts should be Uncontrolled haemorrhage is the cause of traumatic

considered if there is: cardiac arrest in 48% of all TCA. The main principle
n no ROSC after reversible causes have been is to achieve ‘haemostasis without delay’, usually with
addressed surgical or radiological intervention. Temporary
n no detectable ultrasonographic cardiac activity haemorrhage control can be lifesaving.
n Compressible external haemorrhage can be treated
Trauma care systems throughout Europe vary with elevation, direct or indirect pressure, pressure
considerably and regional guidelines for treatment dressings, tourniquets and topical haemostatic
of TCA may help tailoring patient pathways to agents.
infrastructure and resources. n Non-compressible haemorrhage is more difficult and
splints (pelvic splint), blood products, intravenous

fluids and tranexamic acid can be used while moving
the patient to surgical haemorrhage control.
Traumatic Cardiac Arrest/Peri-arrest Algorithm
Trauma Patient in Arrest/Peri-Arrest
Non-traumatic Arrest likely? ALS

NO YES
Hypoxemia Address reversible causes

Start CPR
Tension pneumothorax simultaneously:

Tamponade 1. Control external catastrophic haemorrhage
Hypovolemia
2. Secure airway and maximise oxygenation
3. Bilateral chest decompression (thoracostomies) Expertise?
4. Relieve tamponade (penetrating chest injury) Equipment?
5. Proximal vascular control (manual aortic compression) Environment?
Elapsed time since loss
6. Pelvic splint of vital signs <10 min?
7. Blood products / Massive Haemorrhage Protocol

YES
8. REBOA
Resuscitative
ROSC? Thoracotomy
YES NO
Pre-hospital: immediate transport
to appropriate hospital Consider termination
In-hospital: damage control surgery of resuscitation
/ resuscitation
Figure 5c.1 T he TCA algorithm focuses on the simultaneous treatment of reversible causes

Over the past ten years the principle of ‘damage Tension pneumothorax
control resuscitation’ (DCR) has been adopted in trauma Thirteen percent of all cases of TCA are caused by
resuscitation for uncontrolled haemorrhage (see tension pneumothorax.
chapter 5). DCR also is the guiding treatment principle To decompress the chest in TCA, perform bilateral
in trauma patients who are in a peri-arrest state or have thoracostomies in the 4th intercostal space, extending
suffered cardiac arrest. Damage control resuscitation to a clamshell thoracotomy if required. In the presence
combines permissive hypotension and haemostatic of positive pressure ventilation, thoracostomies are
resuscitation with damage control surgery. Permissive likely to be more effective than needle thoracocentesis
hypotension allows intravenous fluid administration and quicker than inserting a chest tube.
to a volume sufficient to maintain a radial pulse.
Haemostatic resuscitation is the very early use of blood Cardiac tamponade and resuscitative
products as primary resuscitation fluid to prevent thoracotomy
exsanguination and trauma-induced coagulopathy. Cardiac tamponade (chapter 4) is the underlying cause
The recommended ratio of Packed Red Cells, Fresh of approximately 10% of cardiac arrest in trauma.
Frozen Plasma and Platelets is 1:1:1. Some services have Where there is traumatic cardiac arrest and penetrating
also started using blood products in the pre-hospital trauma to the chest or epigastrium, immediate
phase of care. resuscitative thoracotomy (RT) (via a clamshell incision,
Fig 5 c2) can be life saving. The chance of survival is
Recent evidence suggests that Resuscitative about 4 times higher in cardiac stab wounds than in
Endovascular Ballon Occlusion (REBOA) improves gunshot wounds.
survival in exsanguinating torso injuries. REBOA as
a temporary damage control procedure is a bridge
to surgical repair. REBOA can be carried out with
an embolectomy catheter advanced into the aorta
through a groin access to the femoral artery. Reduction
in blood flow below the balloon reduces perfusion
to the hemorrhagic focus. Thoracic aortic occlusion
(Zone I) can control bleeding from an abdominal
source, whereas infra-renal occlusion (Zone III) can
help controlling pelvic hemorrhage. REBOA is high-risk
procedure with the potential to cause fatal ischemic
damage to organ systems below the occlusion. Zone I
occlusion should not be longer than 30 minutes whereas
Zone III occlusion can be tolerated up to two hours.
Simultaneous damage control surgery and

haemostatic resuscitation using massive transfusion Figure 5c.2 Resuscitation room emergency clamshell thoracotomy
protocols (MTP) are the principles of damage control
resuscitation in patients with exsanguinating injuries. Resuscitative thoracotomy is also applied for other
life threatening injuries; after arrival in hospital,
Hypoxaemia the decision to proceed with RT should include the
Hypoxaemia due to airway obstruction and traumatic following criteria:
asphyxia has been reported as cause of traumatic TABLE 5C.1
cardiac arrest in 13% of all cases. Effective airway
management and ventilation can reverse hypoxic Indications for Resuscitative Thoracotomy
cardiac arrest and it is essential to establish oxygenation n P enetrating torso trauma patients with less than
15 minutes of CPR
of the severely compromised trauma patient.
P atients with penetrating trauma to the neck or extremity
Tracheal intubation in trauma patients is a difficult n
with less than 5 minutes of pre-hospital CPR
procedure with a high failure rate if carried out by less
n B lunt trauma patients with less than 10 minutes
experienced care providers. Basic airway manoeuvres of pre-hospital CPR
and second-generation supraglottic airways can be n P eri-arrest state in patients with chest injuries refractory
used to maintain oxygenation if tracheal intubation to resuscitation
cannot be accomplished immediately.
Positive pressure ventilation worsens hypotension by
impeding venous return to the heart, particularly in Survival rates for RT are approximately 15% for all
hypovolaemic patients. Low tidal volumes and slow patients with penetrating wounds and 35% for patients
respiratory rates may help optimise cardiac preload. with a penetrating cardiac wound. In contrast, survival
Ventilation should be monitored with continuous from RT following blunt trauma is dismal, with survival
waveform capnography and adjusted to achieve rates of 0 – 2% being reported.
normocapnia.
CHAPTER 5C TRAUMATIC CARDIAC ARREST | 83
The prerequisites for a successful RT can be associated with significant blood loss; it is therefore
summarized as “four Es rule” (4E): essential that blood products are available and all the
n E xpertise: teams that perform RT must be led team have appropriate personal protective equipment
by a highly trained and competent healthcare (PPE) including eye protection.
practitioner. These teams must operate under a
robust governance framework. Resuscitative Thoracotomy allows for:
n Equipment: adequate equipment to carry out RT and n p ericardial incision and evacuation of pericardial
to deal with the intrathoracic findings is mandatory. clotted blood causing tamponade;
n Environment: ideally RT should be carried out in an n local control of cardiac haemorrhage;
operating theatre. RT should not be carried out if n direct control of exsanguinating thoracic
there is inadequate physical access to the patient, haemorrhage; open cardiac compression;
or if the receiving hospital is not easy to reach. n c ross clamping of the descending aorta to maintain
n Elapsed time: the time from loss of vital signs to cardiac and brain perfusion by stopping blood loss
commencing a RT should not be longer than 10 below the diaphragm;
minutes n direct repair of exsanguinating pulmonary
If any of the four criteria is not met, RT is futile and haemorrhage;
exposes the team to risks that outweigh the benefits n c ross clamping of the pulmonary hila in
cases of massive pulmonary haemorrhage or

The procedure bronchovenous air embolism.
A bilateral anterior thoracotomy (clamshell incision)
gives access to the entire thoracic contents (figure
5c.2). This allows bleeding to be controlled with direct Pre-hospital care
pressure and the pericardium opened to evacuate
a tamponade. Internal cardiac compression can be Short pre-hospital times are associated with increased
started and if necessary penetrating cardiac injury can survival rates for major trauma and traumatic cardiac
be made secure with either a stapler or a suture. Aortic arrest. The time elapsed between injury and surgical
compression is used to redistribute the limited cardiac control of bleeding should therefore be minimised
output to the brain and myocardium, whilst at the same and the patient should be immediately transferred to a
time limit any abdominal bleeding while resuscitation Trauma Centre for ongoing damage control resuscitation.
proceeds. The procedural aspects are summarized ‘Scoop and run’ for these patients may be life saving.
in Fig 5c.3. Resuscitative thoracotomy is inevitably
Figure 5c.3 T he ten top tips illustrate procedural key points of resuscitative thoracotomy (with kind permission from the ‘The Secret
Chest Cracker’, Jonathan Carter)

Key Points TCA: Summary
n F ollow ALS guidelines if underlying medical Having worked through this chapter, you are now
cause of TCA is suspected ready to apply the following knowledge in the
n If TCA is confirmed, identify and treat reversible shock workshop:
causes simultaneously without delay n how to assess, manage and monitor trauma
n If indicated Resuscitative Thoracotomy is part victims with shock;

of the primary survey and should be carried out n when to apply the principles of haemostatic
without delay provided the ‘Four E’ criteria are resuscitation;

met. n the indications for activating the major
haemorrhage protocol;
n understand how medical conditions can
Suggested Readings complicate shock management;
n how to assess, manage and monitor burned
n ise D, Davies G , Coats T, Lockey D, Hyde L, Good

W victims.
A Emergency thoracotomy: "how to do it". Emerg n how to assess and mange patients in traumatic
Med J 2005 Jan;22(1):22-4. cardiac arrest

Truhlář A, Deakin CD, Soar J, Khalifa GE, Alfonzo These cognitive abilities will be integrated with
A, Bierens JJ, Brattebø G, Brugger H, Dunning the practical skills during the course workshops.
J, Hunyadi-Antičević S, Koster RW, Lockey DJ,
Lott C, Paal P, Perkins GD, Sandroni C, Thies KC,
Zideman DA, Nolan JP; Cardiac arrest in special
circumstances section Collaborators. European
Resuscitation Council Guidelines for Resuscitation
2015: Section 4 .Cardiac arrest in special
circumstances. Resuscitation. 2015 Oct; 95:148-201.
n Kleber C, Giesecke MT, Lindner T, Haas NP,
Buschmann CT Requirement for a structure
algorithm in cardiac arrest following major
trauma: Epidemiology, management errors,
and preventability of traumatic deaths in Berlin.
Resuscitation. 2014 Mar;85(3):405-10
n Manzano Nunez R, Naranjo MP, Foianini E, Ferrada
P, Rincon E, García-Perdomo HA, Burbano P,
Herrera JP, García AF, Ordoñez CA. A meta-analysis
of resuscitative endovascular balloon occlusion of
the aorta (REBOA) or open aortic cross-clamping
by resuscitative thoracotomy in non-compressible
torso hemorrhage patients. World J Emerg Surg.
2017 Jul 14;12:30

6.
Abdominal trauma
Learning outcomes
n Understanding the differences between blunt and penetrating abdominal trauma
n The principles of assessment and management of abdominal trauma
n Requesting the appropriate investigations in a patient with abdominal trauma

n The role of surgery and interventional radiology in managing patients with abdominal trauma
Introduction localised blows to the renal angle (e.g. assault) or anterior

abdomen (e.g. from bicycle handlebars). The resulting
The commonest causes of death in trauma patients in abdominal damage is a consequence of deceleration
the first 48 hours after injury are traumatic brain injury or compression forces on solid organs, particularly
and major haemorrhage, the latter often the result the spleen, liver and kidneys and hollow viscera such
of trauma directly to the abdomen or indirectly at its as bowel or bladder. Compression of an intestinal loop
boundaries. Furthermore, the outcome from other that has partial proximal and distal obstruction due
unrelated injuries is worsened in the presence of intra- to its folding can lead to a sudden rise in intraluminal
abdominal haemorrhage, by causing poor perfusion, pressure and, occasionally perforation. This is called a
hypoxia, coagulopathy and immuno-suppression, ‘closed-loop phenomenon’ and typically occurs in the
all of which contribute to multi-system organ failure. small intestine. In addition, shear forces may tear the
Finally, perforation of hollow viscera with peritoneal mesentery in a fall, leading to bowel ischaemia.
contamination results in sepsis which is a further
important contributor to late deaths after abdominal Injuries to the chest and pelvis should suggest that a
trauma. Overall, abdominal injury is a contributing significant, co-existing abdominal injury is likely, given
factor in 20% of trauma deaths. that much of the contents of the abdomen are within
either the bony chest or pelvis. Equally wherever there
is evidence of hypovolaemia, or its consequences,
Mechanism of injury abdominal injuries should be suspected and sought.
In cases of blunt injury to the trunk, the abdomen
Understanding the mechanism of injury can be useful must be considered injured until proven otherwise.
in order to predict the potential for abdominal injury
and an estimation of the direction and amount of The clinical diagnosis of abdominal trauma is notoriously
energy involved should be sought from the pre- difficult, as clinical examination of abdomen is unreliable.
hospital care team. Conventional single signs of peritoneal irritation such as
tenderness and guarding often cannot be elicited and
The mechanism of injury is an important the situation is made more complex when coupled with
marker of abdominal trauma. minimal external evidence of injury, painful distracting
injuries or a reduced level of consciousness. In contrast,
false positive examinations may result from injuries to
Blunt abdominal trauma the chest or the pelvis as they can produce abdominal
In Europe, this is the commonest mechanism of injury signs. As a consequence, early imaging has become a
(>90% patients) and usually results from a road traffic standard of care. The wide availability of sonography
collision (RTC) or fall. The blunt force is typically has made its use an extension to the non-specific clinical
distributed over a wide area, with the exception of examination during the primary survey. Bearing these
CHAPTER 6 ABDOMINAL TRAUMA | 87

factors in mind, serial examination by the same clinician co-existing problems such as:
may be of value in patients not requiring immediate n a reduced level of consciousness;
surgery or where imaging is delayed. When abdominal n distracting injuries elsewhere;
injuries are suspected further investigations (mainly CT) n peritoneal irritation caused by blood or intestinal
are usually required. contents leads to vagal stimulation that in turn

inhibits the reflex rise in heart rate expected in
Penetrating abdominal trauma hypovolaemia.
Penetrating trauma in Europe is not common. When it
does occur it is important to remember that weapons do Further confounding factors are:
not respect anatomical boundaries and external signs n solid organ injuries may present initially in a stable
can be minimal. The pattern of injuries can sometimes haemodynamic state and subsequently deteriorate
be predicted from the entry site, but organs can be due to rupture of a subcapsular haematoma;
damaged even though they apparently lie away from n signs of hollow viscus rupture may take a few hours
the site of the entry as a result of the ricochet of a bullet to develop.

or sharpnel within the body, the posture of the patient
at the time of the attack, the use of a long-bladed Up to 20% of initial abdominal examinations are
weapon or cavitation due to high energy transfer. A falsely negative contributing to the toll of undetected
further problem with the latter is that debris is sucked or underestimation of abdominal injury. This rises
into the temporary cavity created as it collapses. As a in younger patients who compensate well even

result, extensive debridement will be required. For after significant blood loss; it is therefore essential
these reasons the incidence of serious internal damage to maintain a high index of suspicion. Finally,
increases with the degree of energy transfer. inexperience may lead to failure to consider injuries
to the boundaries of the abdomen which can result in
Relationships of the peritoneal cavity significant and life-threatening injuries namely:
When considering what underlying structures could n trans-diaphragmatic injury;
be injured, it is helpful to recall the boundaries of the n retro-peritoneal injury;
abdomen (figure 6.1). The anterior abdominal area is n pelvic injury.
bordered by the anterior axillary lines laterally, the

nipple line above and the inguinal ligament below. The In abdominal trauma, a high index of
posterior abdominal area is bordered by the posterior suspicion, an understanding of the
axillary lines laterally and a horizontal line at the level mechanism of injury, reassessment and
of the inferior scapulae angles above. The flanks are the appropriate imaging are essential for a good
areas between the axillary lines. Inferiorly there is the outcome.
pelvic floor which is relatively fixed. In contrast the roof
of the abdominal cavity is formed by the diaphragm.
Therefore depending in the level of ventilation this The primary survey
can lie between the nipple line and the costal margin.
Stab wounds in the anterior areas are more likely to Patients with abdominal trauma are assessed and
penetrate the peritoneum but those in the flank can managed using the same system as described in
enter both thoracic and peritoneal cavities. chapter 2. The circulation team must consider the
abdomen as a source of haemorrhage and ask the
following questions:
n Is the patient bleeding?
n Is the abdomen the likely site?
n How can we achieve haemorrhage control?
Is the patient bleeding?

Initial signs may be subtle and it is important to have
a high index of suspicion and remain vigilant. LATE
indicators of circulatory compromise include poor
capillary refill, cold clammy skin, tachycardia, systolic
hypotension, anxiety or reduced level of consciousness
Figure 6.1 The boundaries of the abdomen. A-A: anterior axillary (chapter 5). Therefore once the symptoms and signs of
line, B-B: internipple line, C-C: inguinal ligament, D-D: pelvic floor, shock are identified, it is essential that resuscitation is
E-E: posterior axillary line, F-F: inferior scapular line
started and the next question quickly answered with:
Assessment and management Is the abdomen (or its boundaries) the likely
Having accepted that clinical examination of the cause?
abdomen in trauma is unreliable, it is not surprising The abdomen must be considered as a cause of
that it can become very insensitive in the presence of haemorrhage if the mechanism of injury is appropriate or

Focused Assessment with Sonography in Trauma (eFAST)
examination of the abdomen reveals the following clues:
n abdominal bruises (seatbelt or tyre marks); A positive abdominal eFAST in a trauma patient is
n lacerations; characterized by finding a dark, anechoic strip in the
n scrotal or labial haematoma; respective areas of the peritoneum, suggesting a
n flank haematoma; haemoperitoneum (figure 6.2). Unfortunately FAST does
n tenderness; not reliably determine the source of any fluid identified
n guarding. and may miss visceral damage, especially in solid organs
without rupture of the capsule and retroperitoneal
In addition: injuries. Therefore it is useful as a ‘rule in’ rather than a
n shoulder-tip pain can be an indicator of subphrenic ‘rule-out’ investigation for free intra abdominal fluid.
irritation from intraperitoneal blood;
n consider the back of the patient; a log-roll should There are five views that are used in FAST:
be performed as soon as possible, particularly n subxiphoid transverse view: assess for pericardial
when dealing with penetrating injuries. effusion and left lobe liver injuries
n longitudinal view of the right upper quadrant:
A rectal examination may be required to detect rectal assess for right liver injuries, right kidney injury,
or anal blood, displaced pelvic bony fragments, anal and Morison pouch
sphincter tone, perianal sensation and in males, the n longitudinal view of the left upper quadrant: assess
position of the prostate. This can be done supine or for splenic injury and left kidney injury
during the log roll. Vaginal examination is indicated in n transverse and longitudinal views of the suprapubic
the presence of perineal blood and when the source is region: assess the bladder and pouch of Douglas
unknown. Where there is frank blood loss per vagina,
examination should be deferred until the patient is
in the operating room. If examination of the rectum
and external genitalia does not suggest urethral
injury a catheter should be passed to measure urine
output, decompress bladder and detect haematuria. A
nasogastric tube helps decompress the stomach since
most patients will have some degree of gastroparesis
after trauma.
Good clinical acumen and a high index of suspicion will

point towards the likeliest source of haemorrhage and
investigations planned to assist with the confirmation.
However it is essential that management occurs
simultaneously with investigations.
How can haemorrhage be controlled? Figure 6.2 a Haematoperitoneum: Fluid (blood, hypoechoic) in
It is safest to consider intra-abdominal haemorrhage the lesser pelvis, with the uterus and full bladder, separated by the
as uncontrollable and requiring urgent surgical bladder wall (on the right in image) ‘swimming’ inside.
assessment. Haemodynamically unstable patients
will require immediate surgical intervention and as
a result, the primary survey may not be completed
due to need for surgery. In the meantime controlled
resuscitation should commence using blood
products and tranexamic acid according to the local
major haemorrhage protocol and prevention of
hypothermia. In those in whom there is no immediate
indication for laparotomy, but a high degree of
suspicion, early CT scanning should be carried out. This
can also act as a precursor to interventional radiology.
In more advanced trauma systems it is possible to
simultaneously resuscitate and perform a CT scan with
very early access to haemorrhage control surgery.
Investigations Figure 6.2 b Haematoperitoneum: Fluid (blood, hypoechoic)

In addition to routine blood tests, a number of other between kidney and liver, i.e. in the Morison’s pouch
investigations are available, so local expertise and
protocols must guide their use. The commonly used
ones in Europe are:

CT scanning compartment syndrome. Where facilities are available,
CT allows imaging of both the viscera and musculo- an endovascular approach by an interventional
skeletal structures, making it ideal for most abdominal radiologist can be used to identify any arterial
trauma. It has superseded many other investigations, bleeding and control it by temporary or permanent
e.g. intravenous urography for renal trauma. However embolization. This can lead to either complete
it is less reliable for injuries to the diaphragm, bowel haemostasis or reduce it sufficiently to allow a limited
or pancreas. Clinical suspicion regarding the need surgical intervention.
for surgical intervention remains very important
in considering the CT findings and may overule Phase 2: Resuscitation in the Intensive Care Unit
a negative CT result. The involvement of a senior This aims to optimize tissue oxygenation and
experienced surgeon is important in these situations. remove the ‘lethal triad’ by correcting any acidosis,
coagulopathy and hypothermia. In appropriate cases
Plain x-rays interventional radiology should again be considered
A chest x-ray may have been taken in cases of doubt as it can reduce blood loss before any further surgical
about the presence or side of a pneumothorax. This intervention.
may also reveal lower rib fractures or evidence of
diaphragmatic injury (chapter 4) but subphrenic gas is Phase 3: Second look or definitive surgery
unlikely to be visible on a supine film. Plain abdominal The objective at this stage is to carry out corrective and

x-rays are rarely required, except to show the position restorative surgery in a patient who is normothermic,
of a residual foreign body such as a bullet or shrapnel. not acidotic or coagulopathic and receiving adequate
nutrition. Where the abdomen is open, closure begins
Diagnostic peritoneal lavage but this may require more than one operation.
Sonography and greater accessibility to early CT has led to
diagnostic peritoneal lavage virtually disappearing from Interventional radiology
clinical practice. The only indication for its use is if other (angiography and embolisation)
imaging modalities are not available. Like sonography it It is increasingly recognized that many intra-abdominal
is sensitive for haemoperitoneum but has low specificity. injuries causing haemorrhage can be managed with
angiography and embolisation, either alone or in
Immediate management conjunction with surgery.
Some hypotensive patients will respond to fluid
resuscitation. However immediate intervention Advantages:
should be the rule when the shocked patient has a n minimally invasive;
positive FAST scan or fails to have a sustained response n accurate localisation of arterial bleed;
to appropriate treatment and the mechanism of n ability to control bleeding by embolisation.
injury suggests an intraperitoneal haemorrhage. It is

crucial to understand that resuscitation may include Disadvantages:
laparotomy and that correction of hypovolaemia may n competences may not be present in all centres
not be possible before surgical control of bleeding receiving trauma;

is achieved. Nevertheless, in severely compromised n can take time (1–5 hours depending on complexity);
patients, damage control resuscitation (chapter 5) n technically difficult in cases of obesity, hypotension,
should be started before surgery commences; opening degloving injury, atherosclerotic disease;
the abdominal wall will cause significant hypotension n complications reported: haematoma, thrombosis,
as the tamponade effect is lost. subintimal dissection, pseudoaneurysm;

n radiation dose;
Damage control surgery n adverse reaction to the contrast material.
This is the type of operative intervention commonly

carried out on shocked patients with abdominal A summary of the emergency management options
trauma. It consists of three phases: for intra-abdominal injuries is given in table 5.3.
Phase 1: Abbreviated laparotomy to control Blood transfusion

haemorrhage and contamination The same system should be used as described in
The entire focus is to identify and control life- chapter 5.
threatening haemorrhage. Vessels vital for survival
are repaired, expendable organs (e.g. spleen) are
removed, non-expendable organs are packed, gut
perforations are stapled, haemorrhage from other
areas is controlled with packs and haemostatic agents.
Finally, the abdomen is closed with a ‘Bogota Bag’
or left open (laparostomy) to avoid intra-abdominal

Secondary survey Pitfalls
The greatest risk is the underestimation of the
Once the patient is haemodynamically normal and the severity of abdominal injury and the over-reliance
primary survey completed, the abdomen must be re- upon clinical examinations. This is particularly
evaluated as part of secondary survey as described in true when the latter is complicated by a reduced
chapter 2. level of consciousness, distracting injuries or good
physiological compensation. Both blunt and
Patients in whom there is a high index of suspicion penetrating diaphragmatic injuries are diagnosed,
of intra-abdominal trauma, but no specific focus as are hollow viscous and retroperitoneal trauma.
found, should undergo serial physical examination, Potential pregnancy must be considered on any
repeated blood tests and abdominal sonography. presentation of injury in women of child-bearing age.
Diaphragmatic, pancreatic, duodenal and small bowel
trauma may all be missed during the initial assessment
and may require further CT examination or surgical Summary
exploration. Abdominal trauma can vary immensely in
magnitude. The presence of significant injury
If the secondary survey reveals the signs of may not always be obvious on presentation and
an acute abdomen, urgent surgical referral is the clinical signs can add to the confusion. The
required. trauma team must therefore be suspicious of

abdominal trauma in all patients with multiple
injuries and must have a clear understanding
Local wound exploration of the mechanism of injury. It is best to assume
A stab wound may be explored in the operating room that abdominal trauma exists unless proven
to determine whether there is a peritoneal breach. otherwise. All the investigations available to
Penetration of the transversalis fascia or inability to find establish a diagnosis have their roles and must be
the end of the tract constitutes a positive exploration used liberally according to the index of suspicion.
and the need for further diagnostic evaluation. If all These cognitive abilities will be integrated with
such patients are subjected to laparotomy, up to half the practical skills during the course workshops.
will not show any significant injury. Laproscopy may
be useful in looking for peritoneal breach and reduce
the need for laparotomy. Wounds in the posterior n ll ultrasound images courtesy of Dr. Dieter von
A
abdomen and flank are particularly difficult to explore Ow, Kantonsspital St. Gallen, Switzerland. First
due to the thickness of the muscles. Be very cautious published in EUROPEAN HOSPITAL Vol. 25, Issue
when dealing with penetrating trauma between the 5/16, www.healthcare-in-europe.com.
nipple and the costal margins because these could
have entered the thorax, abdomen or both depending
upon the position of the diaphragm at the time of
impact. These require exploration by a surgeon and, if
there is doubt, double contrast CT may help.
Definitive care
Definitive care is provided after complete resuscitation
of the patient. It will be based upon the response to
treatment, the results of all the investigations, the
extent of all the abdominal injuries identified and the
surgical resources available. Most haemodynamically
stable patients with solid organ injury from blunt
and penetrating trauma may be managed without
operation. This is only possible if there is high
quality CT available to accurately assess and stage
the injuries. Once a non-operative approach is
decided upon, observation of vital parameters in a
ward with continuous monitoring and assessment
by an experienced team is mandatory. Frequent
measurement of the haemoglobin and haematocrit
is necessary as well as repeated imaging. Surgical
intervention must be possible at any time.


6b.
Trauma in pregnancy or as a result of domestic violence
Learning outcomes
n Understanding the anatomical and physiological changes associated with pregnancy
n How these changes affect the management of the pregnant trauma patient
n How to recognise injuries due to domestic violence

Introduction Although the uterus has elastic properties, these are

not shared by the placenta. Thus, shear forces applied
Trauma in pregnancy is not common, but it is the most to the utero-placental interface can result in cleavage.
frequent cause of non-obstetric death. It also presents This explains the incidence of placental abruption
the resuscitation team with a number of logistical (abruptio placentae) in otherwise minor trauma.
problems; two patients are involved, both of whom This possibility must always be considered in the
require resuscitation, the anatomical and physiological management of the pregnant patient.
changes induced by pregnancy influence the patterns of
injuries seen and the patient’s response to those injuries When faced with a patient with penetrating injuries
and therapeutic interventions. Domestic violence is the clinician should remember that in late pregnancy,
unfortunately remarkably common, under-diagnosed, lower thoracic and upper abdominal injuries may
and without effective intervention, is often fatal. result in complex combinations of gastrointestinal
involvement. On the other hand, the uterus is quite
effective in protecting the mother, both in terms of
Anatomical implications its size (increasing the probability that it will be the
on the mechanism of injury ‘target’) and its capacity to absorb energy. Maternal
outcome, therefore, tends to be favourable after
For the first 12 weeks of pregnancy, the gravid uterus penetrating injury. The fetus, on the other hand, tends
is relatively safe within the bony pelvis. During the not to fare as well. For example, gunshot wounds
second trimester it ascends, but its thick, muscular involving the uterus are associated with a 7-10%
walls, the contained amniotic fluid, and the relatively maternal mortality, but with a fetal death rate of
small size of the fetus, all help to diminish the direct around 70%.
consequences of trauma. As the third trimester
progresses and the uterus continues to enlarge, its Pre-hospital care
wall thins, affording progressively less mechanical This follows the procedures described in chapter 2.
protection to the fetus. At the same time, the bowel Local triage protocols should ensure that pregnant
and diaphragm are elevated to within the boundaries trauma victims are transported to centres where
of the thorax, making the uterus the most vulnerable obstetric and, for near-term pregnancies, neonatal
intra-abdominal organ. As the woman approaches facilities are available. The ability to adequately
term, descent of the fetal head into the pelvis may monitor the fetus is crucial for decision-making
be associated with a slight decrease in fundal height. during clinical management. It is also important that
However engagement of the fetal head means that the pre-hospital team warn the receiving hospital so
maternal pelvic fractures may be associated with that appropriate obstetric personnel can be available
serious intracranial injury to the fetus, with or without when the patient arrives.
fetal skull fracture.
CHAPTER 6B TRAUMA IN PREGNANCY OR THE RESULT OF DOMESTIC VIOLENCE | 93

Primary survey and resuscitation As in any other young trauma patient, the pregnant
female will compensate for blood loss and only develop
The same system as described in chapter 2 is used signs of hypovolaemia after the loss of a significant
but requires some adaptations to take account of the volume. As her blood pressure falls, this will trigger
anatomical and physiological changes induced by placental vasoconstriction and a fall in fetal oxygenation.
pregnancy. However, the priorities remain the same. Furthermore, uterine vessels are exquisitely sensitive to
The important changes are summarised below. catecholamines which cause profound vasoconstriction.
For these reasons, hypovolaemia in the mother will gravely
Airway and cervical spine control compromise the fetus. The presence of physiological
The risk of inhalation of gastric contents is a constant changes in the mother should alert the trauma team to
threat in pregnancy, particularly from the second the potential for compromise of the fetus.
trimester onwards. Therefore early consideration should
be given to preventing its occurrence by securing the In Rhesus negative women with obvious uterine
airway with a cuffed tracheal tube. However, there is bleeding, an early prophylactic dose of anti-D
an increased incidence of difficult and failed intubation immunoglobulin should be given.
in this group of patients. Due to the reduction in the
volume of the functional residual capacity (the reserve In addition to the usual causes of shock, uterine rupture
from which oxygen is drawn during apnoea) and the must also be considered. Symptoms and signs suggestive

increase in oxygen consumption, careful attention must of this condition are abdominal tenderness, guarding,
be paid to ensure adequate pre-oxygenation before the rigidity, an abnormal fetal lie and the easy palpation of
use of hypnotics and neuromuscular blocking drugs to fetal parts. Fetal survival in these cases is rare.
facilitate tracheal intubation. This intervention therefore
is best performed by those with appropriate training. Disability (neurological assessment)
It should be remembered that the trauma may have
Alternative airway devices must also be available to been secondary to a seizure as a result of hypertensive
allow the safe management of the airway in cases of disease of pregnancy and a reduced level of
difficult or failed intubation. However these devices consciousness after a seizure could be confused with
do not guarantee protection against aspiration and the presence of a head injury. Dipstick analysis of urine
should be replaced with a tracheal tube as soon as should be performed as soon as a specimen can be
skilled assistance is available. obtained. The concomitant presence of proteinuria,
hypertension and peripheral oedema usually allow
Breathing and ventilation the diagnosis to be made, but skilled obstetric help
Maternal hyperventilation is normal as a result of will be indispensable under these circumstances.
an increase in tidal volume and results in a PaCO2
value of 4.0-4.5kPa (30-34mmHg). However, the Exposure
pregnant patient will desaturate and become hypoxic As with all trauma patients, a full examination must be
significantly more rapidly than an age-matched, carried out taking care to avoid hypothermia. Bleeding
non-pregnant woman. Supplemental oxygen must from the urogenital tract may first be seen at this point.
therefore be provided to ALL pregnant trauma patients.
Investigations
Circulation and control of haemorrhage The indications and relative advantages of sonography
Maternal cardiovascular adaptation to pregnancy is and CT scanning are the same in the pregnant patient
extensive, and complicates management of the victim as in other patients (chapter 2).
of trauma. Heart rate increases gradually throughout
pregnancy, reaching a maximum during the third
trimester, at 10-15 beats/min over baseline. Blood Secondary survey
pressure decreases by 5-15mmHg during the second
trimester, with a return to normal values by term. The After initial evaluation and resuscitation, the systematic
blood volume increases by 40-50%, with the increase secondary survey is undertaken using the principles
in plasma volume exceeding that of red cell mass. This described in chapter 2. In addition, obstetric consultation
causes the ‘physiologic anaemia of pregnancy’ and in must be obtained as a priority along with assessment of
late pregnancy a haematocrit of 30-35% is normal. fetal heart sounds. The latter can be done using Doppler
as early as 10 weeks gestation and cardiotocographic
As trauma patients are cared for supine, aortocaval monitoring can be instituted between 20-24 weeks
compression will occur in any visibly pregnant gestation. The normal fetal heart rate is 120-160 beats/
woman. This will result in reduced venous return to min; tachycardia or bradycardia, recurrent decelerations,
the mother compromising her cardiac output and lack of accelerations, or the loss of beat-to-beat heart
blood flow to the fetus. It is therefore essential that rate variability are markers of possible fetal distress.
manual displacement of the uterus or left lateral tilt of
15 degrees is used to prevent this.
Careful examination of the patient’s abdomen Feto-maternal haemorrhage
is essential. Signs of peritoneal irritation may be This occurs when there is blood transfer loss from the
difficult to elicit because of thinning of the abdominal fetus to the maternal circulation and occurs in 8-30% of
wall musculature, and stretching of the peritoneal pregnant trauma cases. This results in the risk of a Rh-
membrane itself. Areas of tenderness and guarding are negative mother being sensitised by her Rh-positive
important to note. Fetal movements may be palpated, as fetus. To avoid this complication, a prophylactic dose
well as the presence or absence of uterine contractions. (300 micrograms) of anti-D immunoglobulin should
The height of the uterus is also useful to corroborate be given to all pregnant Rh negative women, within
estimates of gestational age with the gestational age in 72 hours of the injury. The only possible exception
weeks being approximately equal to the height (in cm) being those with trauma limited to sites far from the
above the pubic symphysis (figure 6b.1). abdomen.
The obstetrician who will care for the patient should Peri-mortem caesarean section
perform a vaginal examination. In addition to Data in trauma are lacking. In the context of ‘medical’
assessment of fetal position, the presence of vaginal cardiac arrests, it is relatively well documented that if
bleeding, amniotic fluid and any dilatation and/or resuscitation is not effective after 5 minutes, delivery
effacement of the cervix are important elements to of the fetus if over 20 weeks, is the only management
evaluate. Vaginal bleeding is present in up to 70% that will allow adequate CPR in the mother and
of cases of placental abruption. Additional signs are possible restoration of her circulation. A decision to
uterine tenderness, contractions, and uterine irritability perform a peri-mortem caesarian section must be
(contractions induced by palpation of the uterus). made in close collaboration with the obstetrician.
There is some controversy as to the optimal duration Domestic violence

of electronic fetal monitoring in the pregnant patient The incidence of domestic violence is enormous. A
after trauma. If the initial assessment reveals more Swiss survey of 1500 women showed an incidence
than six contractions per hour, abdominal or uterine of 20%, and a similar study in the UK concluded
tenderness, ruptured membranes, hypotension that 25% of women were victims of some form of
or vaginal bleeding, monitoring must continue domestic violence. Other data reveal that up to one
for at least 24 hours. Without any of these signs or third of women are beaten, coerced into having sexual
symptoms, and with normal abdominal sonography intercourse or otherwise abused in their lifetimes.
and no abnormalities on monitoring, an otherwise
normal patient can be discharged after four hours. Diagnosis and management
Conversely signs of placental abruption and fetal Given the incidence of this problem, trauma team
distress in a patient with a viable fetus should prompt members will meet with it in their day-to-day practice.
immediate operative delivery. However the associated shame and guilt means that
under-diagnosis is the rule rather than the exception.
For this reason, a high clinical index of suspicion is
necessary. Presence of the following suggests a non-
accidental origin of the injuries:
n injuries inconsistent with the explanation given of
their cause;
n frequent attendance at the Emergency
Department;
n self-blame for the cause of the injuries;
n delayed presentation;
n low self-esteem, features of depression and self
harm;
n a partner insisting being present at all times;
n substance abuse;
n inappropriate concern about the injuries.
Although it is important to identify victims of domestic

violence when they present, this is secondary to their
immediate care. Clearly after the patient’s injuries
have been dealt with, a member of the team should
be tasked with screening for evidence of violence and
Figure 6b.1 Diagram of fundal height with gestation in weeks ensuring referral to the appropriate local authorities
according to local protocols.
CHAPTER 6B TRAUMA IN PREGNANCY OR THE RESULT OF DOMESTIC VIOLENCE | 95

Summary
The anatomical and physiological changes that
occur in pregnancy are sufficient to require
members of the trauma team to have an
understanding of how to adapt the primary
survey and resuscitation in this group of patients
to maximise the chances for the outcome of both
the mother and child after major trauma. There
should be early involvement of obstetricians in
all pregnant trauma patients and neonatologists
or paediatricians where a viable pregnancy is
involved.

abdominal trauma:
n the differences in presentation and

management between blunt and penetrating
abdominal trauma;
n the principles of assessment and management
of abdominal trauma;
n what investigations to request in a patient with
abdominal trauma;
n the role of surgery and interventional radiology
in managing patients with abdominal trauma;

n the anatomical and physiological changes
associated with pregnancy;
n how these changes impact on management of
the pregnant trauma patient.


7.
Pelvic trauma
Learning outcomes
n Assessing pelvic injuries
n The clinical examination of patients with suspected pelvic injury
n Initial life-saving management in severe pelvic bleeding

n Interpretation of pelvic imaging
n Understand the principles of further management of patients with pelvic fractures
Introduction sacroiliac ligaments, the strong sacrotuberal and

sacrospinal ligaments and the thin ligaments of the
The pelvis is the largest and strongest osteo- symphysis pubis.
ligamentous structure in the human body and
disruption is usually the result of high energy injuries. The space contained by this ring of bones and
These occur in high velocity road traffic collisions, falls ligaments is divided in two:
from a great height, or crush injury. Patients with pelvic 1. The large or false pelvis is the volume above the
ring injuries therefore have to be considered severely pelvic brim and between the iliac wings. It contains
injured even if it is an isolated pelvic injury. It should the organs of the lower abdomen.
be remembered that, when the pelvic ring is injured, it 2. The small or true pelvis lies between the sacrum,
is almost always disrupted in 2 or more places. both acetabula and the symphysis pubis and
It is important, however, to be aware that lower energy contains the infraperitoneal organs such as the
mechanisms, such as falls from < 2m, can result in bladder, prostate, urethra, rectum, uterus, and
pelvic ring injuries in the elderly, more osteoporotic vagina. In addition large vessels and nerves run
population. from the retroperitoneal space through this space
Pelvic ring injuries occur in 8-9% of all blunt force towards the lower extremities. The vessels also form
trauma. The mortality rates for pelvic ring injuries multiple anastomoses within the small pelvis, which
range from 10 – 50%, depending on haemorrhage and supply the above mentioned organs with blood.
associated injuries to the head, spine, chest, abdomen
and limbs. 5 – 10 % of pelvic fractures will have a major Types of pelvic fractures
urological injury. Due to the vascular anatomy within The pelvic ring may suffer a number of different types
the pelvis, pelvic ring fractures should be treated as a of fractures. They are usually classified by the direction
type of vascular emergency. of the force applied.
Anteroposterior force (e.g. frontal collision)

Pelvic applied anatomy This drives the left and right sides of the pelvic ring
apart causing external rotation and instability of the
The pelvis can be divided into the dorsal hemipelvis two hemipelvises. This is likened to the pages when
consisting of the sacrum, sacroiliac ligaments and a book is opened, hence the injury is often described
iliac bones and the ventral pelvis consisting of the as an ‘open book’ fracture (figure 7.1a,b). To permit this
symphisis pubis and pubic and ischial bones with their rotation either the symphysis pubis dislocates or the
rami. The intrinsic stability of the pelvic ring is due to a pubic and ischial rami are fractured. In contrast the
combination of the bony structures and the ligaments dorsal hemipelvis is incompletely broken because the
which connect the sacrum and two innominate bones large posterior sacroiliac ligaments remain intact while
with each other; the thin anterior and large posterior the thin anterior sacroiliac ligaments are torn. This
CHAPTER 7 PELVIC TRAUMA | 97

injury is associated with massive blood loss because
the volume of the small pelvis increases and multiple
vascular anastomoses are torn filling this expanded
infraperitoneal space with blood. In addition structures
connected to the pelvic floor (e.g. urethra) may be
ruptured. These injuries are rotationally unstable, but
vertically stable.

Figure 7.2a,b X-ray and diagrammatic representation of lateral
compression fracture
Vertical force (e.g. fall from great height)

With this mechanism of injury the left and right
hemipelvis are completely separated from each
other as the affected side is displaced upwards. It is
therefore described as ‘vertical shear’ injury (figure
Figure 7.1a,b X
-ray and diagrammatic interpretation of open book 7.3a,b). Such a displacement means there is complete
type fracture rupture of the anterior and posterior hemipelvis and
floor of the pelvis. As a result there is vertical instability
Lateral force (e.g. lateral collision) and massive damage to the structures surrounding
With this force the two sides are driven together with and inside the pelvic ring. There are no anatomical
one hemipelvis being internally rotated. Typically borders anymore, allowing blood to leak from the
there is also a crush injury of the lateral mass of the infraperitoneal into the retroperitoneal space, as high
sacrum on the same side (lateral compression injury, as the diaphragm. These are highly unstable injuries
figure 7.2a,b). Rotational instability results, but in the and in many cases, larger vascular structures also are
opposite (internal) direction when compared to the damaged resulting in life-threatening haemorrhage.
open book lesion. Unless there is massive displacement These injuries are both rotationally and vertically
(e.g. rollover trauma), lateral compression injuries are unstable.
not as mechanically unstable as open book lesions
and are less often associated with massive blood
loss. Nevertheless, organs inside the true or small
pelvis may be damaged by the increase in pressure at
the moment of trauma (e.g. bladder rupture). These
injuries are rotationally unstable, but vertically stable.

When the pelvic ring is disrupted, bony structures will
be broken and ligaments torn. Soft tissue structures
surrounding the pelvic ring such as skin, subcutaneous
tissue and muscles may be damaged as well.
Retroperitoneal organs inside the pelvic ring may also
be disrupted, with immediate and important blood loss
and late functional deficits as consequences. Pelvic ring
disruptions must therefore be considered as a specific
combination of injuries rather than a solitary lesion.
Pelvic ring lesions are combined with intraperitoneal
lesions in more than 10% of cases. Both have to be seen
as separate entities and treated separately. That is why it
is vital to perform a thorough neurovascular and pelvic
examination in the primary, secondary and tertiary
surveys in these patients. An open pelvic fracture
with the risk of faecal contamination will require an
urgent defunctioning colostomy to prevent any further
contamination.
Standby preparation and transfer

Although all equipment must be checked regularly,
for the team members responsible for managing the
circulation this includes equipment for stabilizing the
pelvis.
Pelvic lesions relevant to the 5-second round will include

those associated with massive haemorrhage e.g. open
fractures, which can cause hypovolaemic cardiac arrest.
The MHP should be activated and Tranexamic acid (1g
Figure 7.3a,b X
-ray and diagrammatic representation of vertical over 10 min + 1g over 8h i.v.) applied.
shear injury
Combination of forces Primary survey

These are a variable mixture of any of the above forces
that can result in combinations of types of pelvic The same plan as described in chapter 2 is used
fractures. They are usually due to high energy transfer, with members of the team carrying out their tasks
e.g. an unrestrained passenger in rollover accident. simultaneously. The circulation personnel will need to
look specifically for indications of actual or potential
Open pelvic fractures, degloving and impalement pelvic injury. Although there may be obvious clues,
injuries (figure 7.4) and traumatic amputations are if these are not apparent, diagnosis may be initially
specific pelvic ring injuries with a poor outcome. Besides based on the mechanism of injury and evidence of
the above mentioned damage, there is contamination, hypovolaemia with no other obvious cause. If a trauma
continuous blood loss through open traumatic wounds or orthopedic surgeon is not primarily part of the trauma
and/or irreversible damage to large vessels and nerves. team, it is essential to involve him/her at the earliest
possible opportunity as part of the clinical examination
should be performed by an expert to identify if the
injury is unstable and to distinguish between rotational
and vertical unstable pelvic ring lesions.
Clinical examination of pelvic fractures

Look for possible lesions of soft tissues and internal
organs outside and inside the pelvic ring: skin
lacerations around the iliac crests, degloving injuries
(Morelle-Lavallée lesions, figure 7.5a,b) at the greater
trochanter and the upper thigh or at the lumbosacral
junction in the back. The perineal region needs a
special inspection: a large haematoma in the scrotum
(figure 7.6) or in the labiae is an indirect sign of a lesion
Figure 7.4 I mpalement injury of the pelvic floor. Spontaneous blood loss at the

external urethral meatus is a hint of a lesion in the The examination of the pelvis should be performed by
lower urogenital tract (bladder rupture or urethral one of the circulation personnel who is both trained
tear). Skin lacerations around the anus or vagina or to do so and capable of interpreting the findings. For
impalement injuries are possible sources of major the first stage, the examiner should stand beside the
bleeding and contamination. All patients suffering supine patient at the level of the pelvis. It is no longer
high energy trauma must have an examination of recommended to rock or spring the pelvis to assess for
the perineum and genitalia plus a rectal examination pelvic instability, as this is likely to aggravate bleeding
and the findings recorded in the notes (BOAST 14: see by disruption of any early clot. Palpation for tenderness
appendix to chapter 7). If visual inspection suspects a over the iliac crests and pubis gently can be performed
vaginal injury eg blood coming from the vagina, then to assess for tenderness (Fig 7.7). This assessment must
a vaginal examination should also be performed. only be performed once.
Usually this is carried out in the operating room.

Figure 7.5a D
egloving injury
Figure 7.7 E xamination for pelvic instability – stage 1
The second stage of the pelvic examination must be

conducted by a trained trauma or orthopaedic surgeon.
This is normally only performed in the haemodynamically
stable patient. In the correct hands it gives additional
information that will aid surgical planning. It has no role in
the hyper-acute situation. The examiner stands beside the
lower leg of the supine patient. One hand is used to lift the
patient’s leg carefully off the table, while the other hand
is placed on the ipsilateral iliac crest to control movement.
When the examiner is able to pull down or up one
hemipelvis while the opposite hemipelvis does not move
Figure 7.5b D
egloving injury nor rotate, a vertical instability exists (figure 7.8). A vertical
instability never exists without rotational instability. With
two simple tests, the examiner is able to differentiate
between different forms of pelvic ring lesions, which
correspond with different severities of trauma.
Figure 7.6 Scrotal haematoma
Figure 7.8 Examination for pelvic instability – stage 2

reduce the volume of the small pelvis and hinder
The examination for pelvic stability should large movements during manipulation or transport.
only be performed once, since repeated A further advantage of using a pelvic binder is the
manipulations can aggravate bleeding. region of the pelvis and abdomen remains free and
accessible for interventions. In the absence of a pelvic
binder at scene, a sheet may be used instead.
Imaging Pelvic sheet and pelvic binder (see skills section)

If CT is not immediately available and part of the
primary survey process, an antero-posterior x-ray of KEY POINTS
the pelvis is compulsory in every polytrauma patient. Indication: u nstable pelvic fracture, haemodynamic
Large disruptions and displacements will be detected instability
immediately. Analysis of the posterior hemipelvis Procedure: immobilization of the pelvis using sheets
is difficult and fractures or dislocations may be or binder
overlooked due to overlying soft tissue structures, Complications: increased blood loss
bowel content and intrapelvic haematoma. For a
definitive diagnosis, CT imaging is indispensable. Common insufficient immobilization
pitfalls:
Total body multislice CT with contrast is performed
with high speed CT scanners in patients who are

haemodynamically stable or compensated. In cases, A pelvic binder should be applied as soon as an unstable
when the CT is adjacent to the Emergency Department pelvic ring with hypotension is suspected, before
and resuscitation can be maintained, this examination transport or immediately after arrival in the hospital.
can be carried out immediately, and conventional In these situations imaging is not a prerequisite for
x-rays can be omitted. immobilization. A pelvic binder can be left in place
for several hours and should only be taken off in the
Pelvic x-ray (see skills section) presence of a resuscitation team, as recurrent bleeding
with hypovolaemia can occur. However application
KEY POINTS must be done carefully; the broken pelvic ring must be
tilted for only a short time. The binder should be left
Indication: every polytrauma patient, unless CT
immediately available in situ until the risk of pelvic bleeding has stopped.
It should then be removed AFTER consultation with
Procedure: plain x-ray
the appropriate specialist and should be removed
Complications: none ideallywithin 6 hours of injury and certainly by 24 hours.
Common failure to recognize a fracture or its If an unstable, bleeding pelvic ring fracture is excluded
pitfalls: significance, particularly posterior ones following CT scan then the binder can be removed in
the resuscitation room in the presence of the trauma
Management team. A post-binder removal plain pelvic radiograph
Pelvic ring disruptions are the result of high energy should be taken in resuscitation room in all cases.
transfer and so need to be considered a life-threatening
injury. The immediate threat to life is haemorrhage. Urinary catheter
This has three main origins: the large bone fragments A single, gentle attempt at urinary catheterisation, by
of the dorsal pelvic ring; multiple small vessels of the an experienced doctor, is permissible, even if the clinical
plexus anterior to the sacrum and around the organs or CT findings suggest a urethral or bladder injury. The
of the small pelvis; and bleeding from arteries in and procedure and the presence of clear or blood-stained
around the small pelvis. Active arterial bleeding is urine must be recorded. The finding of blood-stained
present in less than 10% of patients with pelvic trauma. urine mandates a retrograde urethrogram via the
catheter. If the catheter will not pass, or passes and
Initial management therefore focuses on the only drains blood, do not inflate the balloon, withdraw
haemodynamic situation of the patient, rather than the catheter and perform a retrograde urethrogram.
on the stabilization of the fractures. The standard The presence of a urethral or bladder injury mandates
approach described in chapter 2 is followed. Different informing the on call urologist. If a catheter cannot
methods are available to diminish or minimize blood be passed, then a suprapubic catheter will be
loss, they are not competitive, but complementary, required. This can be performed percutaneously in
and their working mechanism is indirect or direct. the resuscitation bay or via open technique in theatre.
Placement of the suprapubic catheter can affect the
Pelvic immobilization timing of any pelvic surgery and so the pelvic team
A pelvic binder or sheet have the same working should be involved at an early stage.
mechanism; when applied around the pelvic ring to
create direct pressure on the disrupted elements,

Further management Surgical packing (see skills section)
The following interventions are undertaken when Used in transient responders who continue to bleed
the patient has left the Emergency Department. following pelvic clamping or external fixation and who
Nevertheless, the decision to perform them must need more aggressive management. It is important to
be taken as early as possible based on the clinical recognize that surgical packing is useless and dangerous
findings and the response to resuscitation measures. when no pelvic clamping or external fixation has been
The trauma team leader must be aware of which is performed as lack of stabilization of the bone fragments
the most appropriate intervention for their patient in will drive them further apart and increase blood loss.
order to plan further treatment.
Selective angiography and embolization
Pelvic clamp (see skills section) Interventional radiology is being increasingly used
This is a surgical procedure which must only be carried in the management of bleeding pelvic fractures. It is
out by those trained to do so. The device consists of indicated when there is a blush identified on the Trauma
two large K-wires and a large C-shaped clamp. It is CT with contrast indicating continuous arterial bleeding,
used to restore stability of the dorsal hemipelvis and a patient requiring ongoing transfusion of more than
its application is part of the resuscitation of a patient in 0.5 units of blood per hour, or patients with repeated
extremis or with borderline haemodynamics. Although episodes of hypotension despite resuscitation. Often
not taught on the ETC, trauma team members must be it is used after pelvic packing if there is still evidence

familiar with the indications for its use and application. of an ongoing small arterial bleed. As it is rather time-
consuming, it is not indicated in the presence of large
External fixator (see skills section) vessel active bleeding.
To provide provisional management in resuscitated A commonly used algorithm is shown in figure 7.9.
patients until definitive reduction and fixation is possible.
Most appropriate in those patients who are, or rapidly
become, haemodynamically stable with resuscitation.
Unstable Patient
Apply Pelvic Binder
YES
Haemodynamics Stabilize?
NO
NO Intra-peritoneal or external YES
haemorrhage
Operating Room
Angio available < 30 mins?
NO
Extra-Peritoneal Pack
YES Damage Control Laparotomy
Angio-embolization
ICU
Definitive Imaging
Definitive Fixation
Figure 7.9. Aintree MTC Pelvic fracture management algorithim

Summary Further information
Pelvic ring disruptions are the result of high n O
rthopaedic Trauma Association committee
energy transfer and patients with this trauma for coding and classification. Fracture and
must be considered as severely injured. Simple dislocation compendium. J Orthop Trauma 1996;
examination techniques can be applied, x-ray 10 Suppl.1:1-154.
and CT scan are used to confirm the diagnosis. n R
ommens PM, Hofmann A, Hessmann MH.
Pelvic binders reduce the pelvic volume and Management of acute hemorrhage in pelvic
reduce mechanical instability. trauma: an overview. Europ J Trauma Emerg Surg
2010;36:91-99.
Having worked through this chapter you are now n B
ottlang M, Krieg JC, Mohr M, Simpsom TS, Madey
ready to apply the following knowledge in the SM. Emergent management of pelvic ring fractures
abdominal and pelvic trauma workshop: with use of circumferential compression. J Bone
n understanding the different types of pelvic Joint Surg Am 2002;84A Suppl 2:43-47.
fractures; n G
anz R, Krushell RJ, Jakob RP, Küffer J. The antishock
n the signs of pelvic injury; pelvic clamp. Clin Orthop Rel Res 1991;267:71-78.
n the principles of examining the pelvis; O
sborn PM, Smith WR, Moore EE, Cothren
n interpretation of pelvic imaging; CC, Morgan SJ, Williams AE, Stahel PF. Direct
n plan further treatment that may be required. retroperitoneal pelvic packing versus pelvic
angiography: a comparison of two management
These cognitive abilities will be integrated with protocols for haemodynamic unstable pelvic
the practical skills during the course workshops. fractures. Injury 2009;40:54-60.
n T ile M. Acute pelvic fractures: 1. Causation and
Classification. J Am Acad Orthop Surg 1996;4:143-151.
n H aemorrhage in fragility fractures of the pelvis.
n D ietz SO, Hofmann A, Rommens PM.
n E ur J Trauma Emerg Surg. 2015 Aug;41(4):363-7. doi:

10.1007/s00068-014-0452-1. Epub 2014 Sep 23.
n R ommens, PM Kuhn, S Hofmann, A
n C hapter 16 “Becken” in Management des

Schwerverletzten
n H erausgeber: Pape, Hans-Christoph, Hildebrand,
Frank, Ruchholtz, Steffen, Springer, 2018 DOI:

10.1007/978-3-662-54980-3
n BOAST 14:THE MANAGEMENT OF UROLOGICAL TRAUMA
ASSOCIATED WITH PELVIC FRACTURES Aug 2016

Pelvic trauma – skills In Type A, the pelvic ring remains stable. There are
marginal lesions such as fractures of the iliac wing,
Interpretation of the pelvic x-ray avulsion fractures of the ischial tuberosities or the
Indication: spines; or minimally displaced fractures of the pubic
n polytrauma patients. and ischial rami. There is no threat to the general
condition of the patient.
Procedure:
n A
h!: In Type B, there is rotational instability. Open book
●use the first 10 seconds to simply look at the lesions, lateral compression injuries or combinations
image and note any immediately obvious of both are part of this group (figures 7.1a,b. 7.2a,b).
abnormalities. Then explore the image in more When larger displacement exists, type B lesions may
detail using the AAABCS systematic review. be dangerous because of major blood loss.
n A
ccuracy and Adequacy:
●check
the name and the date of the x-ray for In Type C, (figure 7.3a,b) there is rotational and vertical
accuracy, to ensure it is the correct x-ray of the instability. Vertical shear injuries belong to this group.
patient; They can be unilateral, combined with a contralateral
an adequate pelvic x-ray should include the rotational instability or bilateral. These represent

●
whole pelvis and the proximal 1/3 of femurs with major trauma, which are a threat to life if not managed
an overall exposure that allows for interpretation. early and aggressively.
n A
lignment:
●t here are three rings to be checked. The sacrum Application of a pelvic binder (figure 7.9):
and the pelvic brim form the main pelvic inlet Indication:
(large ring). The two small ones are the obturator n p
atients with rotational or vertically unstable
foramina. If one of these circles is broken a search pelvic fractures.

should be made for fractures or joint separation
elsewhere in the ring; Procedure:
● in correctly aligned images the pubic symphysis n U
ndress patients completely or if impossible
is in line with the spinous processes. Deviation remove all objects from patient’s pockets and
from this alters the relative shape of the right and pelvic area.
left hemipelvises; n r
emember to check for the 5 p’s
● t he last check of alignment is a smooth curved Pulses

line continuous with the obturator foramen Pockets
and the inner surface of the neck of femur Phones
(Shenton’s line). Penis (genitalia)
n B
ones (fractures): Pulses
● trace
along the cortical margins to detect a n S
lide binder underneath the patient’s knees and
fracture, which may show up as a lucency, slide upwards to the level of trochanters.
density or trabecular disruption; n W
ith the legs in slight flexion and internal rotation
● interruptions
of the ilioischial and iliopubic line close binder. The closing mechanism depends on
are hallmarks for an acetabular fracture; the various models.
● check
the acetabular margin for fractures.
n C
artilage and joints: Complications:
● the
sacroiliac joints and the symphysis pubis n increased blood loss;
should be checked for widening. Normal values n misplaced binder.
are 2-4 mm for the sacroiliac joints and 5mm

(10 in adolescents) for symphysis pubis.
n S
oft tissues:
● a haematoma inside the small pelvis may be

detected by bladder displacement.
Complications:
n f ailure to recognize injury to the posterior pelvis.
Classification of pelvic fractures

The Tile system, adapted by the Association for the
Study of Internal Fixation (ASIF), is used worldwide. It
distinguishes between three groups of lesions, which
significantly differ in morbidity and outcome.
Figure 7.9 A
pplication of pelvic binder

Application of an external fixator Surgical packing
This is a procedure that is rarely undertaken in the Indications:
resuscitation room. It is not a skill that is practiced n p
atients who continue to bleed despite
on the course and the information is provided as an application of a pelvic clamp or external fixation.
insight into potential treatment of an unstable pelvic
injury. Procedure:
This involves opening of the small (true) pelvis and
Indications: filling it with sterile gauze bandages to create local
n p
atients who arrive and are initially pressure against the soft tissues and stop bleeding.
haemodynamically unstable but respond well n A
n incision is made from the umbilicus to the
to resuscitation. External fixation is not used symphysis pubis. Through this incision, lesions of
as a definitive treatment, but a provisional the abdomen can also be treated, when needed.
one and is performed in the operating theatre Alternatively, a Pfannenstiel incision can be used.
under sterile conditions by an experienced n A
fter incision of the linea alba, the infero- and
trauma surgeon. retroperitoneal space is opened while the

abdomen remains closed.
Procedure: n F
rank bleeding will occur as the pelvic haematoma
n S
everal pins are inserted percutaneously into is released and the patient’s blood pressure can
the iliac wing or in the iliac bone above the fall dramatically.
acetabulum (figure 7.10). n T
he void, which has been created by the
n T
he pelvic ring is reduced carefully. disrupted soft tissues and the haematoma, is
n T
he pins are connected to each other with bars, packed with sterile gauze bandages. The counter
which bridge the pelvic ring anteriorly. pressure provided by the stabilized pelvis on the
n T
his creates good anterior stability, additional traumatized soft tissues and torn small vessels
stabilization of the posterior pelvic ring is needed arrests bleeding.
in vertically unstable pelvic ring lesions. n T
he abdominal wall is closed over the gauzes. A
second look, in which the gauzes will be removed

Complications: or replaced, is scheduled within 48 hours (figure
n m
isplaced pins; 7.11 a,b).
n a
septic pin loosening;
n p
in tract infection. Complications:
n d amage to organs within the true pelvis;
n m assive haemorrhage, cardiac arrest;
n i nfection.
Figure 7.10 Application of an external pelvic fixator Figure 7.11a,b Pelvic packing

BRITISH ORTHOPAEDIC ASSOCIATION
AUDIT STANDARDS for TRAUMA
August 2016
BOAST 14: THE MANAGEMENT OF UROLOGICAL TRAUMA

ASSOCIATED WITH PELVIC FRACTURES
Background and Justification:
Urological trauma is rare and the incidence of severe urethral trauma is 1/million population/year. The majority of cases are
due to blunt high-energy trauma with associated multi-system injuries and 80% of these cases are associated with pelvic
fractures. Urological injuries are potentially fatal and can result in severe long-term disability.
Inclusions: Patients of all ages with potential bladder or urethral trauma.
Standards for practice audit:

1. All Major Trauma Centres and Trauma Units should have agreed written guidelines for the management of suspected urological
trauma and these must be easily available within the Emergency Department.
2. All patients suffering high-energy trauma must have examination of the perineum and genitalia plus a rectal examination and
the findings recorded in the medical records.
3. A single, gentle attempt at catheterization, by an experienced doctor, is permissible, even if the clinical or CT findings suggest
urethral injury. In adults a 16F soft, silicone catheter should be used. The procedure and the presence of clear or blood stained
urine must be recorded in the medical records.
4. The finding of blood stained urine mandates a retrograde cystogram via the catheter.
5. If the catheter will not pass or passes and drains only blood, do NOT inflate balloon. Withdraw catheter and perform a
retrograde urethrogram.
6. If there is a urethral or bladder injury, the on-call urologist should be informed immediately so that a treatment plan can be
formulated and recorded in the notes.
7. If a urethral catheter cannot be passed, a suprapubic catheter is required. This can be inserted during emergency laparotomy
but otherwise a percutaneous suprapubic catheter should be placed.
8. A percutaneous, suprapubic catheter should be placed using a Seldinger technique under ultrasound control by a doctor
experienced in this technique. The skin insertion point MUST be in the midline and should be 3 to 4 fingers-breadths above
the symphysis. A 16F silicone catheter should be used.
9. The placement of a suprapubic catheter may alter the timing of pelvic fracture surgery and so the pelvic fracture service
should be involved at an early stage.
10. If there is a urine leak from either the bladder or urethra, the pelvic fracture should be treated like an open long-bone fracture
with appropriate antibiotics for 72 hours and early fracture fixation if the patient’s physiology allows.
11. Intraperitoneal bladder rupture requires emergency laparotomy and direct repair.
12. Extraperitoneal rupture of the bladder may be treated by catheter drainage alone. However, in the presence of an unstable
pelvic fracture, it is recommended that fracture reduction and fixation is performed along with primary repair of the bladder.
13. Extraperitoneal rupture of the bladder neck continues to leak even in the presence of a catheter and requires primary repair.
14. Bladder injuries identified during pelvic fracture surgery should be repaired at the same time and bladder drainage (via urethral
or suprapubic catheter, as appropriate) ensured.
15. Bladder injury in children is rare but often more complex than adults. A paediatric urologist should always be involved early in
the care of these injuries.
16. All urethral injuries in females and children must be discussed at a very early stage with the appropriate supra-regional
specialist in urology.
17. The indications for primary (within 48 hours) urethral repair are: associated ano-rectal injury, perineal degloving, bladder neck
injury, massive bladder displacement and penetrating trauma to the anterior urethra.
18. The recommended definitive treatment for urethral rupture in adult males is delayed repair at 3 months post injury. Each MTC
should have a clear referral pathway to a recognised centre for reconstructive urethral surgery with a named urological lead
consultant.
19. Primary re-alignment of the urethra during fracture surgery is not recommended as, in the hands of an inexperienced (urethral)
surgeon, the risk of additional damage probably out-weighs the benefits. Accurate reduction of the bony pelvic ring indirectly
re-aligns the urethra and facilitates delayed repair.
20. Male and female patients suffering displaced anterior pelvic fractures or urethral injury have a high incidence of urinary and
sexual dysfunction. All patients should be provided with a written information sheet on this issue.
21. All Major Trauma Centres must have a linked Andrological service and all patients with displaced anterior pelvic fractures
should be offered access to this service.
22. Hospitals receiving patients with these severe injuries must be part of the Trauma Audit and Research Network (TARN) and all
centres performing delayed urethral reconstruction should participate in the national audit of this procedure.
Evidence base: Consensus meeting BOA and BAUS 2015. www.nice.org.uk/guidance/ng37 PTO

8.
Head trauma
Learning outcomes
n Assessing and managing a patient with a head injury
n Neurological assessment of a patient with a head injury
n Recognising when and how to communicate with a neurosurgeon

n Use of the correct terms when describing the severity of head injury
n Interpreting a head CT scan
Introduction haematoma, or diffuse injury as the brain is subjected to

rapid deceleration. The incidence and severity of these
The incidence of moderate and severe head injury injuries may only be reduced by preventative measures
in Europe is between 200 and 300 per 100,000 of the e.g. wearing seatbelts and crash helmets.
population. These occur during leisure time (35%), at
home (30%) and at work (15%). About 28% of victims are Secondary brain injury
under the age of 15 and an increasing number of patients This is damage that occurs after the primary brain
above 65 years of age particularly on some form of injury as a result of:
anticoagulation therapy. Alcohol is a contributory factor n h
ypoxia: PaO2 <10kPa (75mmHg);
in 25% of cases of head injury and road traffic collisions n h
ypotension: systolic blood pressure <110mmHg,
are responsible for 26% of cases. The majority of head mean arterial pressure (MAP) <90mmHg;
injured patients are seen initially in a non-specialist n r
aised intracranial pressure (ICP) >20mmHg.
centre and subsequently more than half may require
transfer to a neurosurgical unit. The development of The latter two factors are important determinants of
trauma systems can reduce the number of patients the cerebral perfusion pressure, (CPP):
requiring secondary transfer , particularly with time
critical brain injuries, by taking the patient directly to the CPP = MAP – ICP
MTC from the scene. After severe head injury outcome
is poor with a mortality of 31%; 3% in a vegetative state, Clearly a reduction in mean arterial pressure, increase
16% severely disabled and 20% moderately disabled. in intracranial pressure, or at worse both, will reduce
Only 30% have a good recovery six months after injury. cerebral perfusion causing ischaemia and secondary
As the majority of head injuries occur in younger male brain injury.
age groups, the economic and social consequences of
delayed or inadequate treatment can be devastating. Secondary brain injury is therefore a result of problems
with the patient’s airway, breathing and circulation, hence
these are the priorities when assessing and managing
Types of brain injury a patient with a head injury. Even short periods (<5
minutes) of hypoxia and hypotension significantly worsen
Primary brain injury the outcome after head injury; prevention is therefore
All head injuries are unique and can be a combination of essential. Secondary brain injury can also be a result of:
primary and secondary injury each of which can progress n d elay in diagnosis;
at a different pace. The cornerstone of management is to n d elay in definitive treatment;
optimise initial management and prevent deterioration. n s uboptimal management of other injuries.
This is the damage sustained at the moment of injury
as a result of the energy transferred to the brain. It All causes of secondary brain injury have a tendency
may cause a focal injury, e.g. a skull fracture driving to be compounding and cause further deterioration.
bone into the brain substance, the development of a This can be reduced by following the same primary
survey priorities as for all trauma victims.
CHAPTER 8 HEAD TRAUMA | 107
Assessment and management TABLE 8.1
Indications for intubation and ventilation
Primary survey and resuscitation following a head injury
Patients with traumatic brain injury are assessed n Inability to maintain an adequate airway
and managed using the same system as described n Risk of aspiration from loss of laryngeal reflexes
in chapter 2. The airway, breathing and circulation n Inadequate ventilation:
personnel must identify and correct any immediately
• Hypoxia: PaO2 <9kPa (70mmHg) breathing air
life-threatening conditions; these may be extracranial PaO2 <13kPa (100mmHg) breathing oxygen
even if the head injury is thought to be significant. • Hypercarbia: PaCO2 >6kPa (45mmHg)
Resuscitation should be carried out on a tilting trolley n To assist in acute reduction of ICP by hyperventilation
in order that, where appropriate, a 15° head-up tilt can n Spontaneous hyperventilation causing PaCO2 <3.5kPa
be used to reduce ICP, providing blood pressure is not (25mmHg)
compromised. n Rapidly deteriorating GCS regardless of initial level
n Initial GCS <9
Airway and cervical spine control n Continuous or recurrent seizures
n e
nsure adequate oxygenation at all times; n Development of complications e.g. neurogenic pulmonary
n m aintain continuous verbal communication with oedema, hyperthermia
the patient wherever possible;

n monitor and report to the team leader any changes
When urgent surgical treatment is planned, perform early
in the ability to communicate with the patient; tracheal intubation
n w here indicated, perform tracheal intubation
and mechanical control of ventilation (table 8.1).
Breathing
Attempting tracheal intubation may cause or worsen In the spontaneously breathing patient, the respiratory
secondary brain injury if not performed in a controlled pattern and rate gives vital information and must be
manner as a result of hypoxia and hypertension continually monitored. Adequacy of ventilation is best
increasing the ICP. Furthermore, the cervical spinal assessed by arterial blood gas (ABG) analysis. Thoracic
cord may also be injured. injuries should be rapidly identified and appropriate
action performed to ensure adequate oxygenation;
In a head injured patient, tracheal intubation this may include mechanical ventilation and the use
must be carried out by an individual of positive end-expiratory pressure (PEEP). In such
experienced in the use of anaesthetic and patients, neuromuscular blocking drugs and adequate
neuromuscular blocking drugs. sedation is required to prevent the patient struggling
against the ventilator in an attempt to breathe; expert
The risk of an associated cervical spine injury in an help is also essential. The ventilator should be set
unconscious patient following a road traffic collision to minimise intrathoracic pressure; high pressures
or fall is 5-10%. If tracheal intubation is required, the impede venous return from the brain and increase ICP.
presence of a semi-rigid collar limits mouth opening Adequacy of ventilation is again best determined by
and makes laryngoscopy much more difficult (chapter regular ABG analysis.
3). Manual in-line stabilisation (MILS) is therefore the
preferred technique to maintain stability and once Where ventilation is inadequate, it must be
applied the collar should be opened to facilitate supported. Hypercapnia is an important
intubation. Consequently, an additional person will be cause of raised ICP and must be prevented.
required to maintain MILS.
Once intubation is achieved, aim for normoventilation
Once intubation has been completed, immobilization initially (PaCO2 4.6-5.0kPa, 35-40mmHg) , but be aware
of the cervical spine has to be reapplied. It is vital that etCO2 is usually at least 0,5 kPa / 4 mm Hg lower
to ensure the collar fits adequately and the head is than PaCO2. Hyper-ventilation will reduce intracranial
maintained in a neutral position, as constriction of pressure by causing vasoconstriction of cerebral
the neck veins from too tight a collar or tube tie, or arterioles, and reducing the volume of arterial blood
poor positioning can elevate the ICP from venous in the brain. However if excessive (PaCO2 <4.0kPa,
congestion. 30mmHg) it will severely reduce blood flow to already
compromised areas, worsening ischaemia and may
exacerbate any injury. Hyperventilation is generally
reserved for those patients in danger of imminent
coning, after discussion with a neurosurgeon, or with
the aid of close monitoring in a neurosurgical unit.
Regular monitoring of arterial blood gases is required
to control the degree of ventilation accurately.

Circulation Disability (neurological assessment)
A closed intracranial injury is never a cause of Hypoxia and hypotension can both contribute to
hypovolaemic shock in an adult patient. Children a lowered conscious level. Once they have been
under 18 months (with open fontanelles) or adults corrected, an assessment of the patient’s neurological
with massive scalp injury may lose sufficient blood to status should be performed assessing the:
cause shock, but other life-threatening injuries must n G lasgow Coma Scale (table 8.2);
always be considered and excluded. n p upillary size, symmetry and light response;
n d ifference in motor response between the left and
In the head injured patient, aim for a mean arterial right sides.
pressure >90mmHg (SBP >110mmHg), in order to
maintain a cerebral perfusion pressure >50-70mmHg The Glasgow Coma Scale (GCS) assesses three responses;
and prevent cerebral hypoperfusion and ischaemia. the patient’s ability to open their eyes, vocalise and
move their limbs. Each of the three responses is given
Patients not in shock. a numerical value, the sum of which is the GCS score.
In normotensive patients, IV fluid needs to be confined At best, a patient will open their eyes spontaneously
to maintenance volumes of isotonic solutions (e.g. (4), vocalise demonstrating orientation in time and
0.9% saline, compound sodium lactate). Isolated place (5) and obey commands (6), giving a total of 15.
hypertension should not initially be treated as this As the patient’s conscious level falls, their response will
represents the body’s attempt to maintain cerebral deteriorate and may require a painful stimulus to elicit a
perfusion in the face of raised ICP. response. It is important to recognize that the minimum
total score is 3; no eye opening (1), no verbal response
Patient in shock. (1) and no motor response (1). Both sides of the patient
IV fluid should be used to restore blood pressure to an should always be assessed and the best response
appropriate level for the patient until haemorrhage recorded along with a note of the difference.
is controlled (chapter 5). Following this, aim for a
MAP >90mmHg to prevent the adverse effects of TABLE 8.2
hypotension on cerebral perfusion. Initially a bolus
Glasgow Coma Scale
of warmed isotonic crystalloid or colloid is given,
according to local protocols, with further fluid type Eye opening:
dictated by the patient’s response. Spontaneously 4
To speech 3
It is vital that all fluids given are recorded accurately;
To pain 2
consideration should be given to early monitoring of
the status of the circulation (e.g. CVP) to guide fluid None 1
management. Motor response:
Obeys commands 6
In head trauma, glucose-containing fluids (5% glucose, Localises to pain 5
4% glucose plus 0.18% saline) are avoided because they:
Flexion (withdraws) to pain 4
n reduce plasma sodium, thereby lowering the plasma
osmolality and exacerbating cerebral oedema; Abnormal flexion to pain (decorticate) 3

n c
ause hyperglycaemia, which is associated with a Extension to pain (decerebrate) 2
worse neurological outcome. None 1
Verbal response:
Hypertonic solutions
Orientated 5
These are solutions of saline (e.g. 7.5%). Although
Confused 4
no benefit has been demonstrated compared with
isotonic solutions in patients with extracranial Inappropriate words 3
trauma, they appear to be beneficial for resuscitation Incomprehensible sounds 2
of patients with traumatic brain injury, possibly as a None 1
result of:
n s maller volumes given more rapidly to restore the
circulating volume and cerebral perfusion; A poor neurological response or deterioration
n a reduction in cerebral oedema and intracranial pressure; should never be attributed solely to alcohol
n m odulation of the inflammatory response helping ingestion. The presence of intracranial
reduce subsequent neuronal injury. pathology or secondary brain damage from
hypoxia, hypotension, hypovolaemia or
They are usually given as a bolus, but be aware that hypoglycaemia must always be considered.
repeated use can cause a hyperchloraemic acidosis.
The role of mannitol is discussed below.

Common pitfalls when assessing the GCS: the cardiovascular and respiratory systems, blood
n Inability to open the eyes due to swelling does not pressure and respiration should be closely monitored.
automatically mean ‘no eye-opening’. Record that
the assessment cannot be made. In cases of uncontrolled fitting an intravenous
n The response to pain is elicited by applying pressure barbiturate, (commonly thiopental), will be required.
on the supra-orbital nerve in the supra-orbital ridge. An expert (often an anaesthetist) must give this, as it will
A peripheral stimulus may not be sensed in the also necessitate intubation and controlled ventilation
presence of a cervical spinal cord injury. ‘Localising to of the patient. Neuromuscular blocking drugs must
pain’ (5) occurs when the patient raises a hand above never be given alone, as muscle paralysis does not
the level of the clavicle. If the hand fails to reach the terminate convulsions. This is usually performed in
clavicle, this is ‘flexion (withdraws) to pain’(4). a critical care setting along with EEG monitoring to
n S plints and painful fractures limit limb movement. ensure burst-suppression. Expert advice is essential.
This may cause differences between sides. Record
the best side and indicate there is disparity and why. Exposure and environment
n A verbal response cannot be assessed in an Hypothermia is common in trauma patients. However,
intubated patient. Record ‘patient intubated’. When there is no evidence that mild hypothermia is
tracheal intubation is planned, the GCS must always beneficial in the early stages of managing a head
be assessed and recorded before drugs are given. injury in the Emergency Department. Hyperthermia

may develop at a later stage in response to particular
The size of the patient’s pupils and their reaction to types of brain injury. If detected it should be treated
light, both directly and indirectly, should be assessed by active cooling measures e.g. ice-bags, fans and IV
and recorded. Congenital unilateral pupillary dilatation paracetamol or metamizol.
may be present in 10% of the population, but the
pupils on both sides should have normal light reflexes. Team leader
If not recognised diring the primary survey, an ocular Upon completion of the primary survey, the team
prosthesis can misleading as they as it will show as a leader should confirm that appropriate resuscitation is
fixed and dilated pupil. under way and all factors that contribute to secondary
brain injury have been eliminated, in particular
Unilateral brain injury may result in a difference in the hypoxia, hypotension, hyperglycaemia and raised ICP.
response between the patient’s left and right sides, In addition, the patient must be adequately monitored
most often a unilateral weakness, asymmetry of motor to ensure that any change in the neurological status is
response or difference in pupillary size or response detected early. Continual re-assessment of heart rate,
to light. These signs strongly suggest the presence blood pressure, respiratory rate, ABG, GCS and pupils
of focal brain injury. A classical example of an injury is therefore mandatory. If time permits, an arterial line
causing such signs would be an extradural (epidural) will allow continuous blood pressure monitoring and
haematoma giving rise to an ipsilateral dilated, frequent arterial blood sampling.
unreactive pupil and contralateral deterioration in
motor function. In a conscious patient, upper-arm drift Do not forget that extracranial injuries may
is a sensitive test of partial hemiplegia. The patient is be the cause of a neurological deterioration.
asked to close their eyes and hold their arms out in
front of them, palms facing upwards. Rotation of the
arm so the palm faces downwards is an early and Investigations
sensitive sign of cause for concern. Polytrauma patients have a CT scan of their head as
part of a whole body scan on arrival at the trauma
Convulsions centre; this will provide useful information about any
These may occur spontaneously in patients with brain injury. However, where this is not possible or
epilepsy or may indicate primary or secondary brain where the patient has an isolated head injury, a CT
damage. Further brain damage can occur if the fits are is increasingly performed at the end of the primary
left untreated due to the hypoxia and hypercapnia that survey. Thie should be combined with a c-spine CT,
can develop. Convulsions need treating according to if a c-spine injury cannot be ruled out clinically. The
local protocol; a typical regime might be to use a slow only exception to this is when there is uncontrolled
intravenous bolus of lorazepam (maximum 0.1mg/kg). haemorrhage requiring urgent surgical intervention.
If this fails or the fitting recurs, an intravenous infusion Indications for performing a head CT are shown in
of phenytoin can be used (15mg/kg given over table 8.3.
approximately one hour). As this drug can precipitate
cardiac arrhythmias, ECG monitoring is required during
the infusion and the infusion rate must not exceed
50mg/min. As all anticonvulsants can depress both

TABLE 8.3 TABLE 8.4
Indications for immediate CT after cranial trauma Signs of a fracture to the base of the skull
n GCS ≤13 at any time since injury Early:
n Haemotympanum
n GCS <15 at 2 hours after injury
n
n Suspected open or depressed skull fracture Bloody cerebrospinal fluid from the ear or nose
n S cleral haemorrhages with no posterior margin
n Any sign of a basal skull fracture
n Subhyaloid haemorrhages
n Post-traumatic seizure
n Focal neurological deficit
n More than one episode of vomiting (use clinical judgement if Late (occurring up to 12-24 hours after injury):
n
less than 12 years of age) Bruising over the mastoid (Battle’s sign)
n
n Amnesia for >30 minutes of events before impact (not pos- Orbital bruising (‘panda’ or ‘racoon’ eyes)
sible to detect in very young children)
Blood dripping from the nose or ear can be tested for

Also in patients with the following risk factors providing they
cerebrospinal fluid (CSF) bwith the beta-transferrin
have experienced some loss of consciousness or amnesia:
n Age ≥65 years
test, which detects as little as 2% contaminatin of
n
booy fluds with CSF. If CSF is mixed with the blood, a
Coagulopathy (history of bleeding, known clotting disorder,
double ring pattern will develop. The presence of CSF
anticoagulant, antiplatelet drugs)

n
also delays clotting of any blood discharge, although
Dangerous mechanism of injury (e.g. pedestrian hit by car, fall
this is not such a reliable sign.
more than 1m or down five steps). Use a lower threshold for
height of fall in young children.
Giving antibiotics routinely is not of proven value
in a base of skull fracture, even if there is a CSF leak
Additional treatment indicating the presence of a compound fracture.
Therapeutically anticoagulated bleeding trauma Antibiotics are generally reserved for those patients
patients, or those with intracerebral haemorrhage, with a depressed compound fracture to prevent
should have their anticoagulation reversed promptly meningitis and abscess formation. The antibiotics
(see chapter 5). It is important that if not already done, chosen will depend on local policy, and should be
the use of such medications is sought when taking an known by the team leaders.
AMPLE history.
A nasogastric tube should not be used if there is a
Secondary survey fractured base of skull, as the tube may be pushed
A detailed head to toe examination needs to be carried up into the skull vault. As a general rule, it is therefore
out as described in chapter 2 along with those features safer to use the orogastric route for gastric drainage in
specific to head trauma described below. The team an unconscious head injured patient.
leader is responsible for ensuring that all findings, and
any gaps in the examination are recorded. Eyes
Penetrating injuries may occur through the orbits
Scalp into the anterior cranial fossa. Therefore the eyes
Examine the scalp for lacerations, bruising or swelling and should always be inspected for obvious trauma or
gently digitally explore all cuts for a linear or depressed haemorrhage and the pupils regularly compared for
skull fracture in the base. Occasionally a haematoma in size and reactivity.
the loose areolar layer can imitate a fracture. Any open
fractures exposing brain tissue must not be explored, GCS
but covered with a clean dressing and left for expert Repeated assessments of the patient’s level of
assessment. Foreign matter protruding from the skull consciousness are required to detect any trends. A
should also be left for removal by the neurosurgeons. deterioration of one point is significant and prompts
Significant scalp bleeding must be controlled either by an immediate reassessment of the patient using the
direct pressure on the edges or using haemostats to grip ABCDE system to identify the cause.
the aponeurosis and fold the scalp back on itself. Deep
sutures or a skin stapler can be used for wound closure. Other injuries
Cardiovascular instability in an unconscious trauma
Base of skull patient must always be investigated and treated prior
Examine the patient to elicit any clinical signs of a basal to moving the patient for further investigation, e.g.
skull fracture. This structure lies along a line joining CT scanning. Depending on local facilities, abdominal
the landmarks of the mastoid process, tympanic sonography may need to be carried out in the
membrane and orbits, and a fracture is suggested by resuscitation room to exclude occult abdominal injury.
any of the findings in table 8.4. In the acute situation,
the later signs of fracture may not be present.

Severity of head injuries Completion of secondary survey
At this point, the trauma team leader should ensure
To aid further assessment and management, it is the following:
helpful for the team leader to collate the information n t he neurological state of the patient immediately
gathered so that the severity of the head injury can be following injury, on arrival and any subsequent
grouped into one of three general categories. changes have been recorded;
n they have identified and wherever possible,
Minor head injuries eliminated any factors causing secondary brain

These constitute the majority of those that attend the damage;
Emergency Department. This category of patients have n they have assessed and treated any associated injuries;
a minimal disturbance of conscious level (GCS 14–15). n a ny cervical injuries have been detected;
n t here is on-going monitoring of all the vital signs.
In addition, to be in this category, they must not have
any of the following:
n a mnesia >10 minutes duration; Referral to a neurosurgeon
n n eurological signs or symptoms at the time of
examination; Any patient with potential or actual need for neurosurgical
n s kull fractures, clinically or radiologically; intervention should be referred to a neurosurgeon. This

n any abnormalities on a CT scan. will include all of those patients in the category ‘severe
head injury’ and those in whom a CT scan is indicated
These patients can be discharged, providing they (table 8.3) but cannot be arranged within 2-4 hours.
have a GCS of 15, but need appropriate written
instructions on when to return. Ideally they should Communication with a neurosurgeon
also be supervised by a sensible adult for 24 hours. Not every patient discussed with a neurosurgeon
The relative risk of a haematoma is directly related to a will need to be admitted under their care, but advice
reduced conscious level. about investigation and treatment will often be useful.
Neurosurgeons require a detailed referral as indicated
Moderate head injuries in table 8.5.
This category of patients all have a definite reduced
level of consciousness (GCS 9–13), irrespective of other TABLE 8.5
findings and require admission for observation and Patient information needed by a neurosurgeon
investigation. Wherever possible it is recommended n ho you are and what do you want
W
they remain under the care of a local admitting team n Name, age and sex of the patient
with experience of caring for head injuries. All of these n Time and mechanism of injury
patients must be discussed with a neurosurgeon, with n Neurological state at the scene (description)
further contact if there is any deterioration in their n Any change in neurological status during transfer to hospital
condition during admission. n Initial assessment (ABCDE)
Other patients who require admission, even if they n Signs of neurological injury or convulsions
have a GCS of 14–15 are: n Treatment administered and any response
n t hose who are difficult to assess, e.g. due to alcohol, n Other injuries
drug intoxication, epilepsy; n Results of any investigations
n those with relevant co-existent medical disorders or n Relevant past medical history and medication
treatment e.g. blood clotting disorders, anticoagulants;
n those with a skull fracture, on CT scan, x-ray or clinically.
Treatment strategies
Severe head injuries The following are recognized treatments for head
These patients are in coma (GCS <9) even after full injuries, but should not be used routinely and ideally
resuscitation. All require urgent neurosurgical referral, only after neurosurgical referral.
along with patients who have any of the following:
n a skull fracture and neurological signs; Mannitol
n a compound or depressed skull fracture; This is an osmotic diuretic agent that has a dual
n b asal skull fracture; effect in reducing ICP. Its early effect is due to an
n p ost traumatic epilepsy; improvement in cerebral blood flow by altering red
n drop of GCS >2 points regardless of initial cell deformability and size. It also reduces interstitial
presentation; brain volume by establishing an osmotic gradient and
n neurological disturbance lasting more than six hours; movement of water between brain tissue and blood.
n a mnesia >10 minutes; In areas where the blood brain barrier is damaged it
n a ny abnormality on their head CT scan. can however leak into the brain tissue and increase
the local water content. Initially, 0.5g/kg, of mannitol

(2.5ml of 20% per kg = 175ml Mannitol 20% in 70kg
adult), is given and the patient reassessed, e.g. for a Summary
reduction in pupil size. A urinary catheter is always
required if not already in place. Repeated doses can Head trauma management in the Emergency
cause hypovolaemia or electrolyte disturbances. Department should be directed at identifying
and treating the factors that cause secondary
Hypertonic Saline (HTS) brain injury. Life-threatening injuries to other
HTS is increasingly used to treat increased ICP after TBI. systems need to be treated prior to transfer for
HTS also is an osmotic agent that extracts fluid from further neurosurgical investigation or treatment.
swollen cerebral tissue to both control intracranial Co-ordination of the resuscitation team is vital in
pressure and lessen the deleterious effects of secondary order to detect these injuries and prioritise their
brain injury. Standard preparation vary from 1,8% to treatment. Fortunately the majority of head injuries
10% solutions. 100 mg/kg hypertonic NaCl (e.g. 1 ml/ seen in the Emergency Department do not require
kg of a 10% solution or 1,25 ml/kg of a 7,5% solution) admission or neurosurgical input but the team
given over 10 minutes is a standard dose. Mannitol must be able to confidently detect those that do.
and HTS are both effective in treating increased ICP
while HTS has the added advantage of also increasing Having worked through this chapter you are now
intravascular volume and not causing osmotic diuresis. ready to apply the following knowledge in the
head trauma workshop:

Furosemide n assessing and managing a patient with a head
This is a potent diuretic that also lowers ICP by reducing injury;

brain water and the rate of CSF production. It can be n recognizing when and how to communicate
used instead of mannitol at a dose of 0.5mg/kg. The with a neurosurgeon;

effect of furosemide on the ICP can be potentiated if n use of the correct terms when describing the
used in conjunction with mannitol or hypertonic saline. severity of head injury;

However care must be taken to avoid hypovolaemia, n identifying neurological disorders caused by
hypotension and biochemical derangement. common medical problems.
Hyperventilation These cognitive abilities will be integrated with

This has been discussed above. Its use should be the practical skills during the course workshops.
confined to cases of imminent coning in conjunction
with other treatments e.g. mannitol.
Currently no neuroprotective drugs exist. The use of Further information

steroids should be avoided; they have no beneficial
effects and are associated with a worse outcome. n N
ational Institute for Health and Care Excellence
(UK. Head Injury: assessment and early

management. Update guidance June 2017, www.
Neurological disorders caused by braintrauma.org.
medical problems
It is essential to try and obtain details of any pre-existing
medical and neurological problems as these can be
the cause of trauma (due to a loss of consciousness)
or they may mimic signs and symptoms suggesting
underlying traumatic brain injury. The common causes
are listed in table 8.6.
TABLE 8.6
Medical and neurological disorders complicating
trauma
n ypoglycaemia, hyperglycaemia
H
n Non-traumatic subarachnoid haemorrhage
n Seizures
n Acute coronary syndromes
n Cardiac arrhythmia
n Cerebrovascular accident (stroke)
n Vasovagal attack
n Medications (in particular anticoagulant and antiplatelet drugs)
n Alcohol, recreational drugs
Head trauma – skills Indication:
The indications for performing a head CT are given in
How to read a head CT scan table 8.3.
A head CT needs to be interpreted in a systematic
fashion in order that any significant abnormalities Procedure:
can be detected and mistakes avoided. The system n A
h!:
recommended on the course is described below. ● use

the first 10 seconds to simply look at the
However it is appreciated that some ETC participants image and note any immediately obvious
will already have developed their own method for abnormalities, particularly asymmetry. Then
interpreting head CTs; in these circumstances it is best explore the image in more detail using the
for the candidate to review their system to ensure it AAABCS systematic review.
covers all the elements of the course’s recommended
method. Before interpreting CTs, there are four key
points that must be remembered: When considering if a particular feature is
1. The CT image is taken ‘looking from the patient’s normal or not, check if it is symmetrical. If
feet’. Consequently, the left side of the image is the there is a similar finding on the other side
right side of the head and vice versa. it has a high probability of being normal.
2. The image plain is diagonal and parallel to the base Conversely an asymmetrical finding has a

of the skull. high chance of being abnormal.
3. The age of the patient affects the structure of
the image. In babies and young children, there is
proportionally more grey and white matter and Accuracy, Adequacy and Alignment:
n
the CSF spaces and ventricles are relatively small. ●the
correct patient;
With age, there is atrophy of the brain matter with ●the
whole head is in the image;
expansion of the CSF spaces (figure 8.1a,b). ●technically
acceptable or better;
4. The image density is expressed in Hounsfield Units ●all
the slices can be viewed;
(HU) and varies from bright white (+1000 HU) to ●no
rotation (in three axes).
deep black (-1000 HU), with soft tissues being shades
of grey (table 8.7). Bones (fractures):
n
●start
with the scout view, this may give you a
TABLE 8.7 clue that there is a fracture. Look for breaks in
the continuity of the bone;
Different tissues and appearance on CT ●check
for soft tissue swelling, this is an indicator
Tissue Hounsfield Units Colour of a high risk of a fracture;
Bone 1000 Bright white ●base
of skull fractures are most common in the
Grey matter 37 – 45 Grey petrous ridges, look for blood in the mastoid
air cells. Intracranial air (appears black) is also
Blood 40 Grey
an indication of possible base of skull fracture;
White matter 20-30 Grey ●check
the ethmoid, sphenoid and maxillary
CSF 15 Black sinuses are all aerated. Remember, the patient
Water 0 Black will have been lying supine during the CT so a
Fat -10 Black fluid level is therefore dependent (i.e. parallel
with the floor). If you see blood check for other
Air -1000 Very black
indications of base of skull fracture.
Blood:
n
●the
appearance of blood will be determined by
its age; an acute blood clot appears hyperdense
(white), becoming isodense between 4-14 days
and finally hypodense (darker than brain tissue)
after two weeks;
●where
there is active bleeding (no clot, as
may be seen in an acute extradural) the blood
appears black, only turning white as the iron in
haemoglobin is reduced as a clot forms.
Figure 8.1 (a) CT showing normal brain matter and CSF spaces in a After trauma, blood tends to be either extradural,
n
40 year old; (b) CT showing atrophy of brain matter and expansion subdural, intracerebral, subarachnoid or a
of CSF spaces in an 80 year old.
combination. Look for signs of an:

● extradural
haematoma, usually caused by Symmetry. Check:
n
bleeding from an artery, typically the middle ●pattern

of sulci;
meningeal. It is ‘lens’ shaped (biconvex), and ●grey
and white matter;
does not cross suture lines (Fig 8.2); ●l ateral ventricles;
● acute
subdural haematoma (Fig 8.3), usually ● the
position of the falx cerebri;
caused by venous bleeding, crescentic in ● any
unilateral discrepancies.
shape over the surface of the cortex and
crosses suture lines. It may also extend along Soft tissues:
n
the tentorium. The presence of dark areas in ●look

at the extracranial soft tissues for swelling
hyperdense (white) areas may indicate active and the presence of foreign bodies.
bleeding;
● c
hronic subdural haematoma, often isodense Surfaces. Look at :
n
and difficult to identify. The clue to distinguish ●external

surface of skull;
it from the underlying brain is there are no sulci ●internal
surface of skull;
over the rim of the haematoma; ●identify
cortical sulcal pattern;
● intracerebral
haematoma. Bleeding within ●check
for clarity of the cortical – subcortical
the brain, either into the brain tissue interface. Intracerebral bleeding or oedema are
(intraparenchymal) or into the ventricles common causes for this to be lost after head
(intraventricular); trauma;
● subarachnoid
haemorrhage. This presents as ●signs
of a fracture necessitate a review of the
hyperdense areas outlining the CSF spaces, underlying brain images.
typically into the sulci and basal cisterns. It is
often associated with hydrocephalus;
● look
for mass effect of the haematoma; midline
shift away from the haematoma, compression
(effacement) of the ipsilateral lateral ventricle
and dilatation of the contralateral ventricle;
● look
for evidence of oedema of the adjacent brain;
this appears as a darker (hypodense) region.
Brain. Look for:

n
●definition
and symmetry of the sulci;
●differentiation
between grey and white matter;
●hyperdensity;
from blood, contrast leak,
calcification;
●hypodensity;
from air, fat, ischaemia, active
bleeding; Figure 8.2 Extradural haematoma
●presence
of the third ventricle and basal cisterns;
●compare
the cerebellar and cerebral
hemispheres, the former is usually darker
(hypodense) than the cerebral hemisphere. If
this is reversed, (the ‘reverse cerebellar sign’)
it may indicate cerebral oedema, usually as
a result of generalised hypoxia. The cerebral
hemispheres are more sensitive and develop
oedema more than cerebellum.
Cisterns and ventricles. Look for:

n
●third
ventricle;
●lateral
ventricles;
●fourth
ventricle;
●basal
cisterns;
●midline
shift and presence of blood; Figure 8.3 Subdural haematoma
●symmetry
of the lateral ventricles and presence
of calcified choroid plexus.


9.
Trauma to the vertebral column and spinal cord
Learning outcomes
n Assessing and managing vertebral column and spinal cord injuries
n Assessing and managing neurogenic shock
n Neurological examination in patients with suspected spinal injury

n Clinical clearance of the cervical spine
n Safe log rolling and removal from a long spinal board
n Interpretation of spinal imaging
Introduction head trauma will have a spinal cord injury. Moreover,

SCI occur in 20-35% of patients with multiple injuries.
In all major trauma patients, there should be a high Of particular concern is the combination with
index of suspicion of vertebral column injury (VCI) abdominal and thoracic trauma. When associated
and spinal cord injury (SCI). Recent studies are not with severe haemorrhage, the fatality rate is greater
consistent and suggest that 2-15% of polytrauma than either injury alone. Therefore, the pre-hospital
patients may sustain SCI with a corresponding high and early in-hospital management of patients with
chance of life-long morbidity. Many victims are young severe injuries should always be conducted bearing in
individuals and these injuries have a major impact on mind the possibility of, and need for, management of
society as a whole. vertebral column and spinal cord injuries.
Epidemiology of vertebral Assessment and management

column and spinal cord injury
Pre-hospital principles
The aetiology of vertebral column and spinal cord The following principles are applied to reduce morbidity
injury varies worldwide, but overall, the most frequent and mortality in trauma patients with VCI or SCI:
cause in all age groups is road traffic collisions (RTCs), n a
wareness of the mechanism of injury;
accounting for approximately 40-50% of all victims. In n t
riage to facilities with SCI expertise;
an RTC, the exact nature of the injury varies according n p
re-warning to the receiving hospital of a patient
to a number of factors including driver or pedestrian, with either a spinal, head or multiple injuries;
type of vehicle, the direction and the speed of the n full spinal immobilization, including semi-rigid
vehicle at impact, the victim’s position and the collars, spinal boards and vacuum mattresses have
presence or absence of seat belts and airbags. The been the standard of care for decades. However,
next most common causes are falls, acts of violence, there is no evidence to support this practice, and
and sports-related injuries. Children have a higher procedures around immobilisation have become
percentage of spinal cord injury compared to adults less rigid as explained below.
due to sports and water recreational activities.
Initial reception
Up to 60% of patients suffering from spinal cord trauma The goal of in-hospital management of VCI and SCI is
will have other injuries; 25-50% will have an associated to preserve neurological function while maximising the
head injury and conversely, 5-10% of patients with chances of recovery. This requires:
CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 117

n a primary survey and resuscitation with appropriate Once the team leader has completed the 5-second
patient immobilization and a minimal handling round and the team have initiated the primary survey,
strategy. information about the mechanism of the incident
n a secondary survey, including physical evaluation should be sought from the patient and/or the pre-
of the patient and radiological examination. hospital team to identify the potential for spinal trauma
n t reatment of hypotension to maintain spinal cord and cord injury.
perfusion.
n e arly surgical decompression particularly in
TABLE 9.1
incomplete SCI Mechanism of Injury
n fall from height
Subsequently, the patient will require definitive care n high speed RTC (motorbike)
e.g. ICU, surgery.
Signs and symptoms
unconsciousness
Transfer of the patient on arrival in hospital
n
n intoxication
Most patients in whom VCI or SCI is suspected will n neck and/or back pain
arrive at hospital fully immobilised. However, for those n neurological deficit
patients who are not, there are two ways of transferring n severe facial injury
the patient onto an Emergency Department trolley:

n polytrauma
n A n ambulance scoop-stretcher can be inserted n distracting injuries
beneath the patient, the head and neck immobilised
manually and then the patient lifted over. Pre-existing medical conditions
n M anual transfer of the patient. This requires a team n cervical spondylosis (old age!)
of five people, all fully trained in the procedure. n previous vertebral column surgery
One person stabilizes the patient’s head and n dementia
cervical spine using his hands and forearms and
also controls the transfer, three other members In all these groups, the presence of an underlying vertebral
position themselves for lifting; one for the thoracic and/or spinal cord injury should be assumed until positively
excluded by both clinical and radiological examination.
spine, one for the lumbar spine and pelvis and one Moreover, it is vital for the team leader to ensure that these
for the legs (figure 9.1). On the controller’s command patients are moved in a manner such that secondary injury
all four gently lift the patient and the fifth member to the spinal cord is prevented.
removes the trolley. At no time during the course of
this manoeuvre should the patient be subjected to
a bending or twisting force. The team leader must ensure that all team
members are aware of the potential for spinal
injury.
Airway and cervical spine control

If the airway needs to be secured, the neck should be
stabilised in a neutral position, without any distracting
force being applied.
No patient should have their head or neck

forced into a neutral spine position. No
deformity should be reduced.
If the spine has not been stabilised, this is best achieved

Figure 9.1 Manual transfer of a trauma patient initially by asking the patient to keep his head in neutral
position. In the unconscious patient manual in-line
Primary survey and resuscitation stabilisation (MILS) should be applied. If the victim is
still wearing a motorcycle crash helmet, two skilled
Spinal cord injury is frequently suspected early, operators should remove it; one expands the helmet
often before arrival in the Emergency Department. laterally and gradually ‘rocks’ the helmet off the head
Acknowledging this information, the team should until it can be rotated free, while the other person
not be distracted from the routine of the primary immobilises the cervical spine from below. As soon
survey and the team leader must ensure that the same as appropriate, MILS should be replaced with head
system of assessment and resuscitation is followed as blocks and tapes or a vacuum mattress according to
described in chapter 2 to prevent deterioration due to local policy. If, for whatever reason, the patient cannot
other trauma. tolerate this, MILS should be continued. If at any time it
becomes necessary to remove the collar and blocks then a fibreoptic laryngoscope. The use of hypnotics and
im MILS should be reapplied. Although immobilization neuromuscular blocking drugs to facilitate intubation
devices as semi rigid collars are generally effective in of the trachea in these patients by trained staff is
limiting motion they can be associated with significant the technique of choice. The specific neuromuscular
morbidity including patient discomfort, pressure sores, blocking drug used will depend on local policy
raised intracranial pressure, risk of aspiration and and individual preferences; however the use of
restriction of ventilation. Therefore, immobilization succinylcholine in patients with spinal cord injury
devices should be removed as soon as any lesion of soon after injury may cause a profound bradycardia,
the vertebral column and/or the spinal cord is excluded and after 48 hours it may also cause profound
with certainty. hyperkalaemia and cardiac arrest.
The effect of spinal immobilisation on Emergency drug assisted tracheal intubation should
mortality, neurological injury, spinal stability be performed with the semi-rigid collar released and
and adverse effects in trauma patients remains replaced with MILS; this requires a team approach,
uncertain. Airway obstruction is a major cause usually under the direction of the airway doctor. After
of preventable death in trauma patients, and successful intubation of the trachea, the cervical collar
immobilisation, particularly of the cervical should be re-fastened. Supraglottic airway devices are
spine, can cause airway compromise, the useful alternatives for airway management, particularly
possibility that immobilisation may increase in the case of difficulty with intubation. Therefore these
mortality and morbidity cannot be excluded devices, according to local protocol, should always be
available when intubation is attempted.
Conscious patients suspected of having spinal injury Breathing and ventilation

but who are confused, restless, and agitated and refuse Immediately life-threatening thoracic injuries need
to lie down can present a problem. On no account to be identified and treated as described in chapter
should such patients be forcibly restrained, but rather 4. Depending on the level of spinal cord injury the
reassured and allowed the freedom to move. The accessory muscles of respiration, intercostals and
muscle spasms associated with spinal injury result in abdominal muscles may be paralysed; a lesion in the
the conscious person instinctively holding the head upper cervical region (C3-C5) will result in loss of most
and neck still and avoiding movement. It is therefore respiratory muscle activity causing acute respiratory
unusual for these patients to worsen spinal injury by failure and hypoxia due to hypoventilation. Injuries
their own voluntary movement. The team must try to below this level, sparing the diaphragm but paralysing
identify and to treat the cause of the restlessness; this the intercostals and abdominal muscles will result
is commonly due to pain, fear, a full bladder, or not in diaphragmatic breathing (paradoxical chest and
understanding the language. abdominal movement on spontaneous ventilation);
this may be the first clue to a significant injury of the
Three groups of patients with spinal injuries require cervical spinal cord. In addition there will be:
urgent tracheal intubation. n inadequate coughing;
1. Unconscious patients. These develop a paralytic n a decrease in vital capacity;
ileus rapidly and an incompetent gastroesophageal n r educed functional residual capacity;
sphincter. This combination, with a potentially full n loss of active expiration.
stomach, puts them at a high risk of regurgitation

and aspiration. Frequent re-evaluation of breathing and ventilation
2. Patients with signs of a high cervical cord injury. is necessary since it might deteriorate over time. Early
Complete injury above the C3 level leads to apnoeic considerations must be given to arterial blood gas analysis
respiratory arrest and death unless immediate to assess the adequacy of oxygenation and ventilation.
ventilatory assistance is provided.
3. Patients with associated major injuries. This will Circulation and control of haemorrhage
include head, chest and abdominal injuries. Assessment and management are as described in
chapter 5; external haemorrhage should be controlled
Intubation in these individuals is more difficult by direct pressure, IV access obtained and bloods taken
because of the need to maintain absolute neck for crossmatching and appropriate investigations.
immobilization. Uncontrolled attempts at intubation Hypotension may be the result of neurogenic shock,
resulting in hyperflexion and/or hyperextension of however haemorrhagic shock needs to be excluded.
the cervical spine can cause or exacerbate vertebral It may be possible to distinguish between the two but
column or spinal cord injuries and even lead to the remember they may co-exist and severe haemorrhage
death of the patient. To reduce these risks intubation from co-existing injuries can complicate and
must be carried out by an experienced anaesthetist exacerbate the degree of hypotension. Furthermore,
proficient in using specialized equipment for example the inability to perceive pain can mask potentially

life-threatening injuries e.g. pelvic or intra-peritoneal For fluid resuscitation, crystalloids or colloids can be
trauma as they are unnoticed by the patient. Whatever given according to local protocols. Furthermore, it
the cause, resuscitation will be required using is not yet clear whether hypertonic solutions as part
the principles already described; hypotension is a of a ‘small volume resuscitation’ technique provide
potential cause of secondary neurological injury of a clinical benefit in the management of patients
the spinal cord and therefore, it is essential that it is suffering from spinal cord injury. Extrapolating from
identified and treated rapidly. the findings in patients with traumatic brain injury
implies these solutions may be justified in patients in
Neurogenic shock whom hypotension or multiple trauma is combined
This is defined as vascular hypotension associated with spinal cord injury. However, controlled clinical
with a bradycardia as a result of spinal cord injury. It trials are still lacking. Whichever regimen is used, fluids
occurs following injury to the spinal cord above T6 and containing glucose should not be given for two reasons:
results in a progressive loss of sympathetic outflow n r
apid metabolism of glucose results in ‘free water’
and vasomotor tone with ascending level of the lesion. which supports oedema formation;
This leads to hypotension secondary to arteriolar and n t
he risk of hyperglycaemia with an increase in
venous vasodilatation of the peripheral vasculature lactate and decrease in pH is associated with a
and the splanchnic vascular beds. The higher the worse outcome.
lesion, the greater will be the loss of vasomotor tone

and peripheral vasodilatation. When the lesion is Dysfunction of the CNS
above T2, there will also be a bradycardia and a reduced During the primary survey it may become apparent
stroke volume secondary to loss of the sympathetic that there is a symmetrical weakness. This should be
innervation of the heart. These pathophysiological noted, but the full definitive neurological assessment
changes cause pooling of blood in the extremities and must wait until the secondary survey.
reduction of central venous return. Thus, neurogenic
shock may be associated with a SBP below 70mmHg Exposure and environmental control
and a bradycardia below 60 beats/min in the presence The patient needs to be completely divested of all
of normovolaemia. Moreover, such a patient cannot remaining clothes to allow a full examination, while
mount a normal response to hypovolaemia caused not forgetting their dignity. All patients cool rapidly
by other injuries Neurogenic Shock is not be confused once exposed, but particularly those with spinal
with Spinal Shock, which is a reversible combination cord injury due their inability to control and maintain
of areflexia/hyporeflexia and autonomic dysfunction body temperature and the associated vasodilatation.
that accompanies spinal cord injury. Every effort must be made to minimise heat loss
using blankets, warm air blowers or overhead heaters
In an unconscious patient these findings may be the whilst avoiding hyperthermia as it is associated with
only indication of a significant SCI. Furthermore the increased neurological injury. The overall aim should
lack of any sympathetic activity may be unmasked be for normothermia.
as profound parasympathetic reflexes such as severe
bradycardia during laryngoscopy. Atropine should In the conscious patient it is essential that there
be reserved for patients with severe symptomatic is minimal handling and that all manouveres and
bradycardia due to the profound effect on heart rate procedures are fully explained on beforehand. At all
and widespread side effects. times it is also essential to ensure there is no twisting
of the spine. This means using a co-ordinated log roll
These patients may require intravenous vasopressors when examining the patient’s back and removing
and/or positive chronotropic agents; a central venous them from a spinal board.
line should be inserted early to help monitor and guide
the response to fluid challenges. Although elevation of
the patient’s legs can be used to counteract peripheral Secondary survey
venous pooling, it will not be possible in the presence
of pelvic, lower limb or lumbar spine injuries. As already described, this consists of a head-to-toe
examination of the patient to detect any injuries that
In patients suffering from spinal cord injury, care is were not immediately apparent during the primary
required to ensure optimal fluid resuscitation. Too little survey. It may only be at this phase of the patient’s care
and tissue ischaemia will increase whereas too much that a VCI or SCI becomes apparent. Therefore should
may precipitate pulmonary oedema. The aim should the secondary survey be delayed for any reason (e.g.
be to maintain a MAP of >90mmHg and any episode of the need for emergency surgery) spinal immobilization
hypotension avoided. Neurogenic shock needs to be should be maintained. The requirement for a spinal
considered in those patients who respond inadequately examination must also be clearly documented in the
to fluid resuscitation and remain bradycardic. patient’s notes and relayed to the clinician responsible
for the in-patient care at handover.

The remainder of this section will concentrate on Neurological function
those aspects of the secondary survey that relate to Assessment of the neurological function is complex
the management of patients with spinal injuries. In the and should therefore be done systematically to ensure
conscious patient, a number of signs and symptoms that subtle signs are not overlooked. The ASIA Chart
are associated with the presence of spinal injury: (figure 9.2.) is a neurological assessment tool for patients
n p ain in the spine at the level of the injury worsened with suspected SCI. It looks at all aspects of motor and
with movement; sensory function and guides the clinician through the
n a reas of abnormal or absent sensation; examination in a structured way. Additionally tendon
n ignorance of other injuries, particularly fractures, in reflexes and a rectal examination should be performed.
the absence of intoxicants;
n p
resence of weakness or inability to move a limb Dermatomes
or limbs. Sensory function is evaluated according to segmental
organization in dermatomes of the human body. A
Log rolling the patient dermatome is an area of the skin supplied predominantly
If Whole Body CT scanning is part of the primary by the sensory axons within a particular segmental
survey, log rolling is not a priority in blunt trauma. nerve root (figure 9.2). In order to determine the level
It may cause fracture dislocation, pain, distress or of spinal cord injury the lowest dermatome level with
clot disruption in patients with pelvic fractures or normal sensory function is taken as the sensory level.
other injuries. The classical log roll is performed if no Do not forget to test for perianal sensation, its
immediate imaging is available and meant to detect presence may be the first indication of an incomplete
superficial lacerations, wounds, bruising, swelling spinal cord injury (see spinal cord injury below).
and deformity as external signs of vertebral column
injury. Palpation of the entire spine from occiput Myotomes
to coccyx is performed to identify any tenderness, Although strictly speaking most muscles are innervated
steps, deformations and gaps between the spinous by more than one nerve root, the functions that can
processes. Finally, if indicated, a rectal examination is be regarded as being performed predominantly by
carried out to rule out sacral sparing. Any indication muscles with one spinal root value are shown in figure
of the potential presence of vertebral column injury 9.2. The power of the muscle supplied by the spinal
mandates appropriate radiological investigation, nerves is evaluated using either the MRC (UK) scale or
according to local protocols. the ASIA scale.
Removal of the spinal board Reflexes

Prolonged immobilization on a spinal board can be The following reflexes with their approximate nerve
of danger to the patient. If not done so already, a root values should be evaluated (the order presented
long spinal board must now be removed in the ED is simply to act as an aide memoire):
to minimize the risk of the development of pressure n a
nkle (S1, S2);
sores and at the same time a note must be made of the n k
nee (L3, L4);
state of the pressure areas. The spinal board serves the n b
iceps (C5, C6);
primary purpose as an extrication and transportation n t
riceps (C7, C8).
device. The patient should be transferred to a trauma
stretcher as soon as possible. Rectal tone
The external anal sphincter muscle needs to be
Log Roll (see page 124) tested by digital examination and asking the patient
to voluntary contract. Perianal sensation may be
assessed at the same time.
KEY POINTS
Indication: in every stable blunt trauma patient once
imaging is completed.
Procedure: safe, coordinated turning of the patient
to allow examination of their back,
removal of the spinal board and if
indicated, rectal examination
Complications: unsafe movement of the spine, with the
risk of secondary injury, displacement of
lines and tubes, clot dislodgement
Common uncoordinated team effort
pitfalls:

(ISNCSCI)
C4 C2 C4
SENSORY SENSORY
C5 Elbow flexors
Elbow flexors C5
RIGHT MOTOR
LEFT
C3
KEY SENSORYC4POINTS
MOTOR
UER Wrist extensors C6 KEY MUSCLES
Light Touch Personal copy
(LTR) Pin Prick (PPR) of Edite Marques Mendes (ID:
KEY SENSORY POINTS
338160) C6 Wrist extensors Date/Time
Patient Name_____________________________________
Light Touch (LTL) Pin Prick (PPL)
KEY MUSCLES
of UEL
Exam _____________________________
Extremity Right) INTERNATIONAL STANDARDS FOR NEUROLOGICAL T2 (Upper Extremity Left)
Elbow extensors C7 T3 C7 Elbow extensors
CLASSIFICATION OF SPINAL CORD C2 INJURY
C2 C8 Finger flexorsC2Signature _____________________________________
C5
Finger flexors C8 0 = absent T4
Examiner Name ___________________________________
(ISNCSCI)C3 T5 C3
Finger abductors (little finger) T1 1 = altered T6 T1 Finger abductors (little finger)
2 = normal
C4 SENSORY SENSORY C4
RIGHT LEFT
T7 C2
T2
NT = not testable
MOTOR T2 MOTOR
KEY SENSORY POINTSMOTOR
C3
ments (Non-key Muscle? Reason for NT? Pain?): C5 KEY SENSORYT8 C5 Elbow flexors
T3 Elbow flexors
POINTS C3
KEY MUSCLES 0 = absent T9 T1 T3 (SCORING ON KEY MUSCLES
REVERSE SIDE)
UER Wrist extensors C6 Light Touch (LTR) Pin Prick (PPR)
1 = altered
C4
C4 Light Touch (LTL) Pin Prick (PPL) C6 Wrist extensors UEL
(Upper Extremity Right) T4 2 = normal T10 C6
T2 T4 0 = total paralysis (Upper Extremity Left)
Elbow extensors C7 C2 NT = not testable T11 T3 C2 C7 Elbow extensors
T5 C2
T4 C5 T5 1 = palpable or visible contraction
Finger flexors C8 0 = absentC3 T12 2 = active movement, C3 eliminated
gravity C8 Finger flexors
T6 T5 T6 3 = active movement, against gravity
0 = absent Finger abductors (little finger) T1 1 = alteredC4 L1
Palm T6
C2 4 = active movement, C4
against some T1 Finger abductors (little finger)
resistance
1 = altered
T7 2 = normal
T7 T7
2 = normal
Elbow flexors C5 NT = not T2 testable C3
T2 full resistance
5 = active movement, against
C5 Elbow flexors
NT = not testable Comments (Non-key Muscle? Reason for NT? Pain?):
T8
C3 T8
T8 5* = normal corrected for pain/disuse MOTOR
UER Wrist extensors C6 T3 S3 0 = absent C4
T9 T1 NT = not testable T3 C6 (SCORING ON REVERSE SIDE) UEL
Wrist extensors
(Upper Extremity Right) T9 Elbow extensors
C7 T4 L2 • Key Sensory
1 = altered
C4
2 = normal
C2
T10
T3
T2 C6 T9 T4 C7 Elbow
0 = total extensors
paralysis (Upper Extremity Left)
T10
S4-5 NT Points T11
= not testable T4 C5 T10 SENSORY 1 = palpable or visible contraction
T5
Finger flexors C8 0 = absentT5 (SCORING ON REVERSEC8 Finger flexorsgravity eliminated
T11 T6
T12
T5 T11 T6 2 = normal
2SIDE)
= active movement,
Finger 0 abductors (little finger) T1 1 = altered T6 L1 T1 Finger
3 = active abductors
movement, against(little
gravity
finger)
T12
= absent 2 = normal
NT = not T7
T7 Palm T12 0 = absent
T7 NT = not 4 = active movement, against some resistance
1 = altered
T2
testable
S2 L3
C3 8 8 1= altered T2 5 = testable
active movement, against full resistance
2 = normal
L1= not testable
Comments (Non-key Muscle? Reason for NT? Pain?): C6
C
C6
C T8
L1 T8 MOTOR
NT
T8
T3 C7 C7 T9 T1 T3 5* = normal corrected
(SCORING
for pain/disuse
testable ON REVERSE SIDE)
0 = absent
1 S3 NT = not
Hip flexors L2 T9
T4 Dorsum =DorsumC4
altered
2 = normal T10 L2 • KeyC6Sensory L2 Hip flexors T4 T9 0 = total paralysis
Knee extensors L3
T11
T10
T5
S4-5
NT = not testable Points L3 Knee extensors T10
T5 1 = palpable or SENSORY
LER L4 T12 2 = activeLEL visible contraction
movement, gravity eliminated
Extremity Right) Ankle dorsiflexors L4 T11
T6 L1 L4 Ankle dorsiflexors T11
T6 (Lower
3 =
(SCORING
Extremity
active
ON
movement,Left)
REVERSE
against gravity
SIDE)
0 = absent L5
Long toe extensors L5 1 = altered T12
T7 L3
Palm
L5 Long toe T12
T7
extensors 40 =
= absent
active movement, against some 2 = normal
resistance
NT resistance
= not testable
2 = normal S2 C8 C8 51==altered
active movement, against full
Ankle plantar flexors S1 NT = not testable L1 S1
T8 L5
C6 C6
C7 C7 S1 Ankle plantar L1
T8
flexors 5* = normal corrected for pain/disuse
S2 Hip flexors L2 T9
S3
L2 • Key
Dorsum Sensory
Dorsum S2 T9
NT = not testable
L2 Hip flexors
Points
S3 Knee extensors L3 T10 S4-5
S3 T10 L3 Knee extensors SENSORY
oluntary anal contraction LER L4 (DAP) Deep anal pressure LEL
S4-5 Ankle dorsiflexors
(Yes/No) (Lower Extremity Right) L4 T11 S4-5 T11 L4 (SCORING ON
Ankle dorsiflexors
REVERSE SIDE)
(Lower Extremity Left)
L5 (Yes/No)
Long toe extensors L5 T12 S2 L3 T12 L5
0 = absent 2 = normal
Long toe extensors NT = not testable
1= altered
RIGHT TOTALS S1 C8 6 C8 LEFT TOTALS L1
Ankle plantar flexors S1 L1 L5 C6 C
C7 C7 S1 Ankle plantar flexors
(MAXIMUM) (MAXIMUM)
Hip flexors L2 S2 Dorsum Dorsum S2 L2 Hip flexors
OR SUBSCORES SENSORY SUBSCORES
LER anal contraction
(VAC) Voluntary Knee extensors L3 S3 S3 L3 Knee extensors LEL
(DAP) Deep anal pressure
+ UEL = UEMS TOTAL LER + LEL = LEMS TOTAL
S4-5 L4
S4-5
Ankle dorsiflexors L4
(Lower Extremity Right) (Yes/No)
LTR + LTL = LT TOTAL PPR + PPL = PP
L4 TOTAL
Ankle dorsiflexors
(Yes/No) (Lower Extremity Left)
(25) (25) (50) MAX (25) (25) (50) L5
Long toe extensors L5 MAX (56) (56) (112) MAX (56) (56)
L5 Long toe (112)
LEFT TOTALS extensors
RIGHT TOTALS S1
UROLOGICAL R L Ankle plantar flexors S1 L5
4. COMPLETE OR INCOMPLETE? (In complete injuries only) S1(MAXIMUM)
Ankle
R plantar
L flexors
(MAXIMUM)
3. NEUROLOGICAL
LEVELS 1. SENSORY
MOTOR SUBSCORES S2 Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL S2
SENSORY
LEVEL OF INJURY SENSORY SUBSCORES
s 1-5 for classification
2. MOTOR (NLI) S3 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION S3MOTOR
as on reverse UER + UEL =
(VAC) Voluntary Anal ContractionUEMS TOTAL LER + LEL = LEMS TOTAL Most caudal level with any innervation (DAP) Deep Anal Pressure
S4-5 LTR + LTL = LT TOTAL S4-5 PPR + PPL = PP TOTAL
MAX (25) (25)
This (Yes/No)
form (50)but should
may be copied freely MAXnot(25) (25) permission from the (50)
be altered without American Spinal MAXInjury
(56) Association. (56) (112) MAX (56) REV (Yes/No)
02/13(56) (112)

RIGHT TOTALS LEFT TOTALS
NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L
LEVELS (MAXIMUM) (MAXIMUM)
ZONE OF PARTIAL
1. SENSORY LEVEL OF INJURY Incomplete = Any sensory or motor function in S4-5 SENSORY
MOTOR
Steps 1-5SUBSCORES
for classification PRESERVATION
as on reverse 2. MOTOR (NLI) 5. ASIA SENSORY
IMPAIRMENTSUBSCORES
SCALE (AIS) Most caudal level with any innervation
MOTOR
UER + UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL REV 02/13
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)
NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L
LEVELS 1. SENSORY ZONE OF PARTIAL SENSORY
Figure 9.2
Incomplete = Any sensory or motor function in S4-5
LEVEL OF INJURY
Steps 1-5 for classification
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal level with any innervation
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 11/15
Unconscious patients ● type
III through the vertebral body of the axis.
The key to recognizing the presence of a spinal cord n Mechanism: combination of flexion/extension
injury in unconscious patients is a continued high index and rotation. In elderly patients often due to a
of suspicion and checking for features listed in table 9.1. ground level fall.
When there is spontaneous movement it is important to n S ymptoms: variable, from isolated neck pain to
note if it was voluntary or a response to pain and whether high cervical paralysis.
there is any difference between limbs. Unconscious
patients will require a detailed reassessment. Posterior element fracture of C2
n D
efinition: bilateral fractures of the posterior
TABLE 9.1 elements (pars interarticularis or pedicles) are
referred to as a hangman`s fracture.
Features suggesting spinal cord injury in an
n M
echanism: forced extension with distraction.
unconscious patient
Despite their eponym, common in deceleration
n ypotension with a bradycardia
H
injuries in which the patient’s face hits an object
n Flaccid areflexia
leading to forced cervical spine extension.
n Diaphragmatic breathing
n S
ymptoms: dependent on the degree of
n Loss of response to pain below an identified dermatomal level
dislocation. Spectrum ranges from death due
n Absence of reflexes below an identified level
to medullary compression, stroke symptoms in
n Priapism
cases of dissection of either or both vertebral
arteries and isolated neck pain.
Types of vertebral column injuries Injuries to the lower cervical spine (C3-C7)
In spinal trauma the following injuries may be encountered: n D
efinition: vertebral fractures, subluxation and
ligamentous injuries to C3-C7.

Atlanto–occipital dislocation n M
echanism: variable.
n D
efinition: internal decapitation in which the n S
ymptoms: neurological impairment is dependent
skull becomes separated from the spinal column. on the degree of fracture displacement and has a
n M
echanism: usually results of high energy trauma high incidence in uni- or bilateral facet dislocation.
with severe flexion and distraction.
n S
ymptoms: mostly fatal due to brain stem Fractures of the thoracic and lumbar spine
destruction, apnoea or severe neurological n D
efinition: fractures are divided into the following
compromise. Survivors usually arrive at hospital entities; compression fractures, burst fractures,
intubated and ventilated. transverse fractures (Chance fractures) and
fracture-dislocations.
Atlas fracture (C1 fracture) n M
echanism: compression and burst fractures are
n D
efinition: isolated fracture of the bony ring or mainly caused by axial loading. Chance fractures
a burst fracture of C1 (Jefferson fracture) with are a result of violent forward flexion. Fracture-
involvement of the anterior and posterior arches dislocations are due to severe flexion or multi-
of the vertebra. directional forces.
n M
echanism: axial loading of the spine due to a n S
ymptoms: in thoracic fractures (apart from pure
fall onto the top or back of the head e.g. diving compression fractures) there is a high incidence
in shallow water. of neurological impairment due to the narrow
n S
ymptoms: variable from isolated neck pain to fatal. vertebral canal. In adults fractures below L2 have
n A
ssociated injuries: high incidence of a low incidence of complete neurological deficit
combination injuries with fracture of the axis and since they can only involve the cauda equina.
lower cervical spine injuries. n A
ssociated injuries: Chance fractures have a high
incidence of associated intra-abdominal injuries

Atlas subluxation (>50%).
n D
efinition: rotatory subluxation of C1.
n M
echanism: variable (atraumatic, minor or major Spinal cord injury
trauma to head). Spinal cord injuries can be classified as either complete
n S
ymptoms: torticollis (rotation of the head). or incomplete according to ASIA. The former should
be suspected when there has not been any recovery of
Axis fractures (C2 fractures) sensory or motor function within 48 hours. However,
Odontoid fractures during the first few weeks, this diagnosis cannot be
n D
efinition: fractures of the odontoid process of made with certainty due to the presence of spinal
C2 are subdivided into: shock. This is a condition where there is a complete
type

● I extends through the tip of the dens; but transient loss of sensation, muscle tone (including
type

● II through the base of the dens; rectal tone), muscle power and reflex activity (flaccid

areflexia) below the level of the cord injury. It can extremities because they are transmitted in the
last for a variable length of time (days or weeks), but intact posterior columns in the cord.
there is a potential for full recovery. Due to this delay, n C
arries a poor prognosis, only a 10% chance of
an accurate prognosis for the patient cannot be given functional motor recovery.
in the first days and statements as such should not be
issued in the Emergency Department. Brown-Séquard syndrome
n A
rare injury resulting from a hemi-transection of the
Incomplete spinal cord injury has a much better spinal cord and associated unilateral spinal tracts.
prognosis for some functional motor recovery. The n T
he mechanism of injury is most commonly
presence of sacral nerve root function may be a more the result of a penetrating wound from either a
stable and reliable indicator of the incompleteness gunshot or stabbing.
of an injury as it represents at least partial structural n O
n examination:
integrity of the corticospinal and spinothalamic tracts. loss

● of power and proprioception, vibration and
Sacral sparing can be confirmed by finding intact deep pressure sensation on the side of the injury
perianal sensation and anal sphincter tone. from the level of the lesion;
on

● the opposite side of the body there is a loss of
Spinal cord syndromes in incomplete spinal cord injury pain and temperature sensation below the level
Central cord syndrome of the lesion.

n M
ost common pattern of incomplete spinal cord n A
lmost all of these patients show a partial
injury. recovery, and most regain bowel and bladder

n O
ften follows hyperextension to the neck, such function and the ability to ambulate.
as from a fall on to the face. Typically seen in older
patients who have pre-existing degenerative Nerve root injury
changes (e.g. cervical spondylosis) in their spine n S
pinal nerve root may be injured with the cord at
with associated narrowing of the spinal canal. that level or in isolation.

n U
sually results in a vascular event, compromising n P
rognosis is favourable for motor recovery, with
blood flow to the centre of the cord. about 75% of those with complete spinal cord
n R
esults in damage to the corticospinal and injury showing no root deficit at the level of
spinothalamic tracts, with preservation of injury or having a functional return.
the sacral spino-thalamic and peripheral n T
hose with higher cervical injuries have a 30%
corticospinal tracts. chance of recovery of one nerve root level, those

n O
n examination: with midcervical injuries have a 60% chance, and
● weakness
of the limbs, arms worse than legs; almost all patients with low cervical fractures
● flaccid
paralysis of arms, worse distally; have recovery of at least one nerve root level.
● intact
perianal sensation and an early return of
bowel and bladder function; Further management of patients
● there
may be disturbance of sensation with Interventions
hyperaesthesia, more pronounced in the arms After the primary and secondary survey, the patient’s
than the legs. condition dictates further management (e.g. surgery,
n R
eturn of motor function usually begins with the ICU). The following interventions complete the
sacral elements followed by the lumbar elements management in suspected cases of spinal cord injury:
of the ankle, knee and hip. Upper limb functional n i nsertion of a urinary catheter;
return is usually minimal. n p ass a naso/orogastric tube, ileus and aspiration
n T
he chance of some functional motor recovery pneumonitis are common complications;
has been reported to be about 75%. n t ake measures to prevent hypothermia and
hyperthermia;
Anterior cord syndrome n i nstitute measures to prevent respiratory
n D
ue to the loss of function of the anterior two- complications (e.g. atelectasis, muscle fatigue,
thirds of the spinal cord. increased breathing effort and ventilation-
n U
sually the result of a flexion injury or an axial perfusion mismatch);
loading leading to a burst fracture and damage n c onsider antiemetics and analgesics;
to the anterior spinal artery. n r epeated neurological evaluation;
n M
ay also be seen after a period of profound n r emoval of immobilization devices at the earliest
hypotension. opportunity to prevent pressure sores;

n O
n examination: n g lucose levels should be measured to aim for
● loss
of motor function (flaccid paralysis), sharp a target blood glucose level within the normal
pain and temperature sensation below the lesion; range (4.0–7.0mmol/l);
● proprioception,
vibration and deep pressure n e arly contact with a specialist/spinal
sensation are all retained in the trunk and lower rehabilitation unit.

1. Any high-risk factor which mandates Rule not applicable if:
radiography? - Non-trauma case
■ Age >65 years - GCS <15
or - Unstable vital signs
■ Dangerous mechanism* - Age <16 years
or - Acute paralysis
■ Paraesthesiae in extremities - Known vertebral disease
- Previous injury to the cervical spine
NO YES
2. Any low-risk factor which allows safe

assessment of range of motion?
■ Simple rear-end RTC**
or
■ Sitting position in the ED
or NO RADIOGRAPHY
■ Ambulatory at any time
or
■ Delayed onset of neck pain***
or
■ Absence of midline cervical spine
tenderness
UNABLE
YES
* Dangerous mechanism:
- Fall from elevation >1m (5 stairs)
- Axial load to the head
3. Able to actively rotate neck? - RTC high speed (>100km/hr, 60 mph),
450 left and right rollover, ejection
- Motorized recreational vehicle
- Bicycle collision
** Simple rear-end RTC excludes:
ABLE - Pushed into oncoming traffic
- Hit by bus/large truck
- Rollover
- Hit by high speed vehicle
*** Delayed onset of neck pain
NO RADIOGRAPHY - i.e. not immediate onset of neck pain
Figure 9.3 Canadian C-Spine Rule. For use with alert (GCS 15) and stable trauma patients where cervical spine injury is a concern.
ED=Emergency Department
Clinical clearance of the cervical spine

Patient meets all low-risk criteria?
Based solely upon the mechanism of injury many
patients have the potential for a vertebral column 1. No posterior midline cervical spine tenderness
injury, particularly to their cervical spine. In practice 2. No evidence of intoxication
however many will turn out to be uninjured. The 3. A normal level of consciousness
Canadian C-Spine Rule (figure 9.3) and the National 4. No focal neurological deficit
Emergency X-radiography Utilization Study (NEXUS) 5. No painful distracting injuries
Low-Risk Criteria (figure 9.4) are well established
systems to determine which patients need YES NO
radiological investigation of their cervical spine
and who can be cleared on the basis of history and
clinical examination. In these patients cervical spine NO RADIOGRAPHY RADIOGRAPHY
immobilization is no longer required and it is safe to
remove the collar. This is commonly referred to as Figure 9.4 National Emergency X-radiography Utilization Study
(NEXUS) criteria

‘clearing the cervical spine’. If any criteria are positive,
full immobilization is maintained and appropriate Summary
radiological investigations (antero-posterior, lateral The management of the patient with a spinal
and open mouth view) are obtained. injury starts at the scene and continues through
to rehabilitation in order to minimise the risk of
Pharmacological intervention with secondary injury and maximise the potential
corticosteroids for recovery. The management of vertebral
Some experimental studies have suggested that column and spinal cord injuries requires an
treatment with methylprednisolone may be beneficial interdisciplinary team approach and is crucial for
in spinal cord injury. However, from a scientific point of the long-term quality of life for these patients.
view, even after the National Acute Spinal Cord Injury
Studies (NASCIS), it is still questionable as to whether Having worked through this chapter you are now
treatment with methylprednisolone is beneficial. ready to apply the following knowledge in the
Moreover, patients treated with it have an increase in spine trauma workshop:
clinically important side effects e.g. severe pneumonia n a ssessing and managing spinal injuries including
and wound infections. Currently the evidence in use neurogenic shock;

of high-dose steroids for spinal cord injury remains n n eurological examination in patients with
inconclusive and routine use of steroids is not supported. suspected spinal injury;

n s pinal immobilization and clearing the cervical
Investigations spine;
In patients suffering from major trauma and/or multiple n i nterpretation of spinal imaging.
injuries, multi-slice CT of the whole spine is the preferred

initial imaging modality. It is more accurate in diagnosing These cognitive abilities will be integrated with
vertebral column injury than plain x-rays and the total the practical skills during the course workshops.
imaging time and patient manipulation are reduced.
Magnetic resonance imaging (MRI) is the investigation Further information

of choice to identify soft tissue (non-osseous) injuries
of the vertebral column and spinal cord. However the n A
merican Spinal Injury Association:
environmental restrictions and procedure time mean http://www.asia-spinalinjury.org/

MRI scans are at present limited in their application. It is n A
O Spine: http://www.aospine.org
generally reserved for patients in whom life-threatening n Connor D, Greaves I, Porter K et al on behalf of the
injuries have been excluded and/or treated. consensus group, Faculty of Pre-Hospital Care. Pre-
hospital spinal immobilisation: an initial consensus
Plain x-rays statement. Emerg Med J 2013;30:1067-1069.
A lateral cervical spine x-ray is the most common type n Moss R, Porter K, Greaves I on behalf of the
of vertebral column x-ray. A number of errors can be consensus group. Minimal patient handling: a
made when evaluating these films that can result in faculty of prehospital care consensus statement.
injuries being missed. These include: Emerg Med J 2013;30:1065-1066.
n an inadequate x-ray; n Kornhall DK, Jørgensen JJ, Brommeland T et al.
n a ssuming that a ‘normal x-ray’ rules out spinal The Norwegian guidelines for the prehospital
injury. A good quality lateral cervical spine x-ray management of adult trauma patients with
is only 85% sensitive; potential spinal injury. Scand J Trauma Resusc
n S CI due to a vascular event with no bony Emerg Med 2017;25:2.
injury. (spinal cord injury without radiological
abnormality - SCIWORA);
n f ailure to appreciate the severity of the abnormality;
n f ailure to systematically evaluate the x-ray.
CT
CT is indicated in the following situations:
n G CS ≤13 on initial assessment;
n p atient anaesthetised;
n i nadequacy or abnormality (even suspicion) on
spinal x-rays;
n o ther requirement for CT scan;
n d ementia;
n n ew neurological signs or symptoms;
n n eck pain: described as severe neck pain (> 7/10) or
in conjunction with pre-existing vertebral disease.

Trauma to the vertebral column
and spinal cord - skills
Interpretation of the lateral cervical spine
x-ray
X-rays need to be interpreted in a systematic fashion
so that all the significant pathological processes
can be detected and mistakes avoided. The system
recommended on the course is described below.
Candidates with their own method review their system
to ensure it covers all elements described below.
Indication:
n p
atients identified by either the Canadian C-Spine
Rule or the National Emergency X-radiography

Utilization Study (NEXUS) as needing radiological
investigation of their cervical spine.
Procedure:
n A
h!:
●use
the first 10 seconds to simply look at the
image and note any immediately obvious
abnormalities. Then explore the image in more
detail using the AAABCS systematic review.
n A
ccuracy and Adequacy: Figure 9.5 Lateral cervical spine film showing the four longitudinal
curves
●correct
film for the patient and personal details
correct;
●are
all 7 cervical vertebrae, the occipito-cervical n Bones:
junction and the C7-T1 junction visible? ● check
the cortical surfaces of all vertebrae for
n A
lignment: steps, breaks, or angulation;
●check
the contours of the four longitudinal ● check
C1: the laminae and pedicles, think about
curves (figure 9.5): a Jefferson fracture;
❍ anterior
– along the anterior aspect of the ● c
heck C2: the outline of the odontoid and
vertebral bodies from the skull base to T1; pars interarticularis, think about a hangman’s
❍ posterior
– along the posterior aspect of the fracture.
vertebral bodies from the skull base to T1; ● C3–T1
start at the anterior inferior corner of
❍ the
spinolaminar line – this should be the vertebral body and proceed clockwise,
smooth except at C2 where there can be checking body, pedicles, transverse process,
slight posterior displacement (2mm); laminae and spinous process. The height of the
❍ the
tips of the spinous processes – these anterior and posterior bodies should be the
should trace out a tighter curve and same. More than 2mm difference suggests a
projection of the tips should converge to a compression fracture.
point behind the neck. n C
artilages and joints:
● Check
the disc spaces, facet joints and
A break in any of these lines indicates a fractured interspinous gaps.
vertebra or facet dislocation until proven Disc spaces should be of uniform height and
otherwise. Divergence of the spinous processes similar in size to those between adjacent
is also abnormal. In some patients there is a vertebrae. Facet joints have parallel articular
pronounced loss of the normal curve of the cervical surfaces, with a gap less than 2mm. Widening
spine (lordosis). This may be due to muscle spasm, of the gap and visibility of both facets suggests
age, previous injury, radiographic positioning or unifacetal dislocation. There will also be
the presence of a hard collar. Its presence therefore anterior displacement of less than half the
only indicates that the patient may have sustained width of the vertebral body and associated soft
a cervical spinal injury. tissue swelling. If there is displacement greater
than 50%, both facets are dislocated. There will
If the film is not adequate, it must be repeated also be narrowing of the disc space, widening
with the patient´s arms pulled down to remove the (fanning) of the spinous processes and soft
shoulders from the field of view or take a ‘swimmer´s tissue swelling.
view’. If these fail, then perform CT scan.
● Check
the gap between C1 and the front of the Log roll
odontoid peg. Indications:
The distance between the posterior surface of n t o allow examination of the patient’s back;
the anterior arch of C1 and the anterior surface of n r emoval of the spine board;
the odontoid should be less than 3mm in adults, n i f indicated, rectal examination.
greater than this suggests rupture of the transverse

ligament. This may occur without there being Procedure:
bony injury or cord damage (Steele’s rule of three: n A minimum of five people is involved in the
‘One third of the spinal canal within C1 is occupied procedure.
by the odontoid, one third by an intervening space n O ne person, standing at the head, should be
and one third by the spinal cord’). assigned as in charge and it is essential that all
n S
oft tissues: the others follow his/her orders.
●Check
the soft tissue shadow anterior to the n I f conscious, the patient should be warned what
cervical vertebrae. is about to happen.

Fractures of the cervical vertebrae or ligamentous n T he person at the head will maintain manual
injury will result in a haematoma that is seen as control of the patient’s head, either with the
an increase in the width of the soft tissue shadow cervical collar in place or by MILS.
adjacent to the injury. In some subtle injuries this n T hree assistants stand to the side of the patient

may be the only evidence. As a ‘rule of thumb’ the onto which the patient is to be turned:
soft tissue shadow between the anterior border ● the
one nearest the patient’s head grasps the
of C1–C3 and the air in the oro and nasopharynx patient’s far shoulder and pelvis;
should be less than 7mm wide. From C5 ● t
he second grasps the patient’s chest/arm with
downwards this increases to about 21mm, or one hand and places their second hand under
the width of the vertebral body. Occasionally, the patient’s knee;
this may be seen as anterior displacement of a ● the
third places one hand under the patient’s
tracheal tube. thigh and the other under the patient’s lower leg.
It must be remembered that the stability of the As a result, the assistants’ hands are placed such
cervical spine is dependent on the ligaments that are that the three hands on the torso will be facing
not revealed on a plain x-ray. Therefore, the lateral palms down, whereas the three hands supporting
cervical film must be examined not only for signs of the leg will be palms up.
bony trauma but also clues of ligamentous damage as n T he person at the head will then identify the
this may indicate the presence of an unstable injury. command to be given that indicates the team
Markers include facet joint widening, facet joint should turn the patient towards them e.g. “I will
overriding, widening of the spinous processes, >25% count to three and we will turn the patient on three”.
compression of a vertebral body, >10° angulation n E nsure that the whole team understands and is
between vertebral bodies, >3.5mm vertebral body ready.

overriding with fracture, Jefferson fracture, hangman’s n T he count is made and the patient turned on
fracture and a tear-drop fracture. ‘three’ (figure 9.6).

n T he 5 assistant then carries out the examination.
th
Complications: This will include an inspection of the back for

n a
bnormalities missed on inspection, most any signs of injury, palpation of the spine for
commonly: tenderness and in case of suspected or actual
at
the craniocervical junction;
● neurological deficit, a rectal exam. It is also a
at

● the cervicothoracic junction due to an good opportunity to listen to the back of the
inadequate film; chest and to remove the spinal board if indicated.
unifacetal

● dislocations; n U pon completion of the examination the person
signs

● of ligamentous injury. at the head will control the turn of the patient
supine. The same command structure is used as
for the initial turn; “I will count to three and we
will return the patient supine on three”.
n T he count is made and the patient returned
supine on ‘three’.
n I f the cervical collar has been removed for the
roll, it is now reapplied and spinal immobilization

completed. If at any time during the log roll
any of the assistants has a problem, they must
immediately alert the leader to allow a controlled
return of the patient supine.

Figure 9.6 L og roll of a patient. Note the position of the team
members’ hands
Complications:
n lack of coordination and risk of injury;
n tubes and lines being displaced;
n f atigue of team members.


10.
Extremity and soft tissue trauma
Learning outcomes
n Identifying musculoskeletal injuries
n Prioritizing the treatment principles of extremity injuries in the primary and secondary survey
n Assessing common fractures and soft tissue injuries by the ‘Look - Feel - Move’ approach
n Management of common fractures and soft tissue injuries in the resuscitation room
Introduction Examples of when musculoskeletal injuries may be

identified during the primary survey are given in table
Extremity trauma is very common in polytrauma 10.1. It is important to note however that though
patients and may range from minor injuries to limb- or fractures of the extremities (especially open fractures)
life-threatening ones. Whatever the severity, proper frequently look impressive they are rarely immediately
initial management is essential to prevent early mortality life-threatening unless associated with a vascular injury.
as well as morbidity at a later stage. During the primary It is essential that the team avoids being distracted by
survey, the aim is to identify and treat immediately such injuries during the primary survey.
life-threatening problems with the secondary survey
detecting all limb-threatening injuries. It is now TABLE 10.1
recognized that patients with significant trauma
Detection of musculoskeletal injuries in
should also routinely undergo a tertiary survey, the aim
the primary survey
being to find all injuries not apparent during previous
examinations, often described as function-threatening Airway Complaints of pain
injuries. This is particularly important in those patients Circulation Blood loss associated with open fractures
on the ICU who may be sedated, ventilated and unable Penetrating injuries involving major limb vessels
to indicate the presence of minor injuries. In other Multiple limb fractures
patients, it may take place when clinically stable or
Large soft tissue injuries
after surgery. Whatever the circumstances, it should be
completed within 24 hours of first admission although Traumatic amputation
it may be several days before all injuries are identified. Disability Reduced limb movement
Exposure Fractures and dislocations
(deformity, angulation, wounds)
Primary Survey
In the presence of life-threatening haemorrhage
Patients with extremity trauma are assessed and associated with limb trauma the team leader should
managed using the same system as described in direct the circulation team during the 5-second round
chapter 2. The focus in relation to extremity trauma to immediately control the haemorrhage using a
is to recognize and control catastrophic haemorrhage stepwise process:
that results from traumatic amputation, long bone n d
irect pressure;
injuries and deep soft tissue lacerations which if n e
levation of affected limb;
untreated can lead to exsanguination. While large n w
ound packing with novel pro-coagulant,
wounds and open fractures are readily apparent to the haemostatic dressings if available. Otherwise
trauma team, other extremity injuries such, as multiple gauze dressings are sufficient.
closed fractures, can cause significant occult bleeding n c
orrect application of a tourniquet.
if a systematic assessment is not performed. Femoral
fracture can account for 1L-1.5L blood loss
CHAPTER 10 EXTREMITY AND SOFT TISSUE TRAUMA | 131

As a result of the military experience in both Iraq and Soft tissue and bony injuries may lead to important
Afghanistan, appropriately applied tourniquets have functional, cosmetic issues and long term psychiatric
been shown to be life-saving for patients suffering problems, including persistent pain, numbness, joint
from both blast and ballistic injuries. Recent terrorist stiffness, weakness and deformity. Depending on
atrocities have reinforced these lessons within a their location they may compromise hand function
civilian environment. or walking, and therefore produce difficulties with
mobility, rehabilitation, work and recreation.
Ideally a tourniquet should be applied before the
onset of shock in the presence of catastrophic Assessment of extremity injuries during the
haemorrhage to reduce morbidity associated with secondary survey
their use. Once applied, the tourniquet is tightened History
until haemorrhage ceases. The time of application Further details of the mechanism of the accident
must be documented, included in the handover to must be obtained, including the time since injury.
the trauma team. The time the tourniquet is applied For all patients vital information can be obtained
should be kept to a minimum but only be removed from the pre-hospital personnel (which may include
when either the patient condition allows or when initial photographs from the accident scene and allow for
surgery is commenced. Recent advances in tourniquet assessment of the damage to any vehicles, “reading
technology have improved tourniquet safety and the wreckage”). Examples where the history is

lead to a decrease in complications including pain, important include:
transient or permanent nerve damage, skin changes n A
limb run over by the wheel of a vehicle has
(blistering, necrosis) and compartment syndrome. a risk of degloving injuries. This can result in a
limb threatening injury due to internal shearing
Towards the end of the primary survey, additional forces.
fracture treatment that is carried out includes n T
he position of the patient at the time of injury
realignment and immobilization to decrease further may give clues as to where to look for injuries,
bleeding and reduce pain. This coincides with the particularly after penetrating trauma.
concept of “socially aligned” which does not need to n T
he cause of the injury: lacerations associated
be anatomically or definitive. It also has the advantage with contamination, e.g. wounds sustained
of reducing the risk of secondary trauma particularly with a garden implement or gross aquatic
to neurovascular structures. contamination.
The confirmation of corraborative information using

Secondary Survey the AMPLE history as this will influence possible
treatment options to minimise risks to the patient:
During the secondary survey, all patients n s
teroid usage;
must be assessed for the presence of other n d
iabetes mellitus;
possible injuries on the basis of the history n s
moking;
and mechanism of injury. n p
eripheral vascular disease;
n m
alnutrition;
By the end of the secondary survey all limb-threatening n u
se of immunosuppressant drugs.
trauma must be recognized and a management plan
be in place. Typical problems include: Clinical examination
n m ajor soft tissue injuries; It is easy to miss both soft tissue and bony injuries,
n c ompound fractures (delayed infection); particularly if the patient has a reduced level of
n v ascular limb injuries; consciousness. These can be minimised by ensuring
n c ompartment syndrome; the patient is appropriately exposed to facilitate a full
n n eurological injuries; clinical examination of their musculoskeletal system
n joint dislocations. and performed in the following systematic fashion:
n L OOK: compare with the other side looking
The majority of soft tissue injuries and fractures do not for swelling, deformity and wounds. The key is
fall into these categories. Nevertheless they still need symmetry.
to be carefully assessed because they are: n F EEL: for tenderness, crepitus, swelling, skin
n a significant part of the Emergency Department temperature, peripheral pulses, sensation and
workload; compare with the uninjured side.
n a frequent cause of prolonged and sometimes n MOVE: both actively and passively and compare sides.
significant morbidity;
n a relatively common source of litigation. Care should be taken however to reduce any pain
caused by clinical examination to a minimum. Many
patients with limb injuries will require x-rays but these

and other investigations are NEVER a substitute for anatomical knowledge. Motor power is recorded using
adequate clinical examination. the Medical Research Council scale (chapter 9). If the
history, clinical symptoms and clinical findings suggest
Soft tissue trauma can be limb-threatening (table 10.2) the presence of a nerve injury, the patient must be
and may occur in isolation. It is important not to miss referred for exploration and if necessary nerve repair.
these in patients with multiple injuries involving the This should be undertaken in the operating room.
torso or head.
Vessels
TABLE 10.2
Assessment of vascular damage should include
Limb-threatening soft tissue injuries examination of skin pallor, capillary refill time, skin
n ascular injury at, or proximal to, the elbow or knee
V temperature, skin turgor and peripheral pulses. The
n Major joint dislocation, especially the knee latter may be undertaken by palpation; however if
n Crush injury there is any doubt a Doppler device can be used to
n Compartment syndrome locate the pulse, estimate pressures and compare
n Open fracture with the normal side. Remember, vascular injuries
n Fracture with neurovascular injury may be present even in the presence of distal pulses
and muscle is increasingly vulnerable with ischemia
exceeding 120 minutes. Therefore, if suspected, re-
Wound Management assessment is crucial.
Assessment of soft tissue injuries requires an adequate If an injury to a major limb artery is suspected, urgent
understanding of the anatomy of the injured area. In all vascular opinion is necessary. With direct vascular
cases of penetrating trauma, clinical assessment must trauma in penetrating injuries the need for referral
be made of all structures underlying the area of the is usually obvious, however following blunt trauma
wound. When making the assessment of the damage, the clinician must maintain a high index of suspicion
consider the patient’s posture at the time of injury. and seek expert opinion if there is any doubt. The
aim is to minimise warm ischaemic time to reduce
If it is not possible to exclude underlying tissue damage, ideally to less than five hours. These
damage the patient should be referred for a patients are likely to require angiography, pre- or
specialist opinion and a formal exploration of intraoperatively.
the wound.
Tendons
Details of the wound should be quantified and Tendon injuries occur frequently in lacerations
documented. This includes: to the limbs, in particular the wrist and hand. An
n s
ite and dimensions of the wound and depth if this understanding of the anatomy is vital along with
is apparent; a systematic way of examining each body area.
n t
he state of the wound edges, e.g. ragged or Simple inspection of wounds is often misleading, as
contused; the tendon ends may retract out of sight. If there is
n p
resence of any obvious contamination; any suspicion of tendon injury, referral for a formal
n p
resence of devitalised tissue. exploration is required.
In the presence of high energy trauma, all wounds

should be considered as significant and may require Analgesia after extremity trauma
formal exploration. Foreign bodies do not always
need to be removed unless they are intra-articular, Analgesia should be provided at the earliest
near neuro-vascular structures or causing significant opportunity following an injury and may already
symptoms. have been given by pre-hospital personnel. Non-
pharmacological interventions include elevation
Nerves of the injured limb, immobilization using plaster
Assessment of sensation early after injury may be very backslab in a neutral position. There is no indication
difficult. Patients may report the presence of sensation for the application of a full cast in trauma patients
even when subsequent exploration shows the relevant due to the significant risk of swelling and subsequent
nerve has been divided. Assess simple touch and compartment syndrome. Additionally oral or IV
two-point discrimination using an appropriate blunt analgesics are a standard of care, while peripheral
device, e.g. a contoured paperclip. Compare sensation nerve blocks may be indicated in specific injuries
with the opposite side, rather than ask if sensation is (chapter 2). In major trauma the oral, subcuteanous
present or normal. The area of abnormal sensation and intra-muscular routes should be avoided due to
should be mapped out and recorded. Motor function poor efficacy.
can be assessed more precisely but again requires

Management of injuries the patient should be referred to the plastic or
reconstructive surgery service at the time of initial
No matter what the cause of extensive wounds, the presentation. Management options include split skin
principles of management remain the same and are grafts, full thickness skin grafts, rotation flaps (skin or
summarised in table 10.3. myofascial) or free flaps.
TABLE 10.3 Specialised wounds

Principles of wound management Gun shot wounds
n rrest of external haemorrhage
A
All gun shot wounds require special consideration
n Adequate analgesia
because of the associated pathophysiology, the
n Photograph
features of which are summarised in table 10.4. Tissue
n Removal of gross contamination
destruction occurs as a result of the direct path of the
n Reduction of any extruding bone, particularly if risk of skin necrosis
bullet producing a permanent cavity. In injury due to
n Application of a sterile “Betadine” soaked dressing, covered
high-energy transfer, temporary cavitation also occurs
with transparent, self-adhesive dressing (e.g. Opsite)
in which a large cavity, (30-40 times the volume of the
n Realignment of the limb (angulation, rotation and length)
permanent one) is created. This results in extensive
n Splintage of the limb, without compression if possible
soft tissue damage over a much wider area and as the

n Antibiotic therapy
cavity collapses, debris is sucked into the wound. The
n Anti-tetanus protection
principles of treatment are as illustrated above, taking
n
Early referral for specialist opinion (if not already a part of the
into consideration the specific features of this type of
resuscitation team)
injury.
Simple wound closure TABLE 10.4

All simple lacerations, particularly if superficial
Specific characteristics of gun shot wounds
(affecting only the skin and subcutaneous fat), may n Kinetic energy of the missile
be treated under local anaesthesia in the resuscitation n Presenting area of the missile
room. Prior to closure the wound must be thoroughly n The missile’s tendency to deform and fragment
cleaned, washed out and inspected to ensure there n The tissue density
is no deeper extension. Any contamination that is n Tissue mechanical characteristics
obviously present would mean that the would should n Cavitation (permanent and temporary)
be explored formally in theatre and closure is often a n Wound contamination
delayed procedure.
Tissues which are severely contused or significantly Blast injuries

contaminated, should be left open at the initial Extremities may be injured by blast injuries. Such
exploration and be reviewed at 48-72 hours. If clean trauma is typically associated with penetrating
at that time the wound can be closed, (a technique injuries due to shrapnel, which can act as high or
called ‘delayed primary closure’) giving results very low velocity projectiles. As well as penetration, the
similar to those of primary closure. Wounds that blast may lead to a closed injury arising from the
cannot be closed at 72-96hrs often contain retained shock wave. This in itself results in injuries to vascular
dirt. Closure of wounds should only be undertaken structures in soft tissues causing gross swelling and
when complications are minimised (ICRC surgical ischemia. Consequently, exploration may be required
guidelines). to decompress fascial compartments (fasciotomies)
and assess the viability of tissue. Primary closure in
All traumatic wounds that cannot be closed such injuries is contraindicated. These are complicated
with simple methods should be referred to the wounds and should be dealt with by the relevant
surgical speciality that can provide advanced experienced specialities.
wound management.
It is essential to maintain adequate records. If

wounds or lacerations are present, a diagram and
description or photograph should be included in the
documentation.
Extensive wounds
If a wound cannot be closed, and it is not suitable
to be left to heal by second intention (e.g. extensive
area, cosmetically important, risk of contracture),

Assessment of fractures Imaging
History Plain radiographs are the first line of imaging in
The energy sufficient to break a bone varies between musculoskeletal trauma. To be acceptable and
patients. Older patients with osteoporosis suffer adequate these should:
fractures with minimal trauma (fragility fractures), n b
e clearly labelled and identified including the
while young patients can withstand high-energy side (left or right);
forces with no skeletal damage. Such mechanisms n b
e bi-planar (usually antero-posterior and lateral);
may be direct (e.g. assault with a blunt weapon) or n demonstrate the joint above and the joint below
indirect (e.g. twisting injury to planted foot causing any bony injury. However, in the poly-traumatised
a tibial fracture). Generally, a fall over a distance patient, CT is often more timely and efficient.
greater than body height is described as a high- If there is time then simple AP radiographs can
energy transfer injury. A further factor determining help to identify significant boney abnormality at
the degree of damage is the direction of the force. little risk to patient.
A fall onto the tip of the shoulder is likely to be
associated with a fractured clavicle, while a fall on to The exception to above is a fracture at the extreme end
the outstretched hand may lead wrist fractures. of a bone, e.g. a distal radial or malleolar fracture where
it is acceptable to obtain radiographs of the affected
Examination part only. However it is essential that an adequate
The classical signs and symptoms of a fracture are: examination of the whole affected bone is undertaken
n p ain; to determine any tenderness or other features that
n d eformity; suggests damage. In doing this the clinician should be
n s welling; mindful of common fracture patterns such as:
n t enderness; n injury of the medial malleollus and/or diastasis
n c repitus; of the distal tibio-fibular joint that may be

n loss of function. associated with fracture of the proximal fibula
(e.g. Maisoneuve fracture);
Fractures are painful. In the upper limb they result in n f racture of the mid-radius that can be associated
restricted use and in the lower limb weight bearing is with a dislocation of the distal radio-ulna joint
impaired. Some fractures, e.g. femoral shaft fractures, (e.g. Galeazzi fracture).
may be associated with significant blood loss,
requiring appropriate resuscitation and stabilisation of Interpretation of radiographs
the fracture during the primary survey. Gross fracture Increasingly, radiographs are digitalised and made
displacement can compromise surrounding soft available for viewing electronically. These images
tissues including skin and neurovascular structures. should be viewed on a screen with appropriate
For this reason, following the primary survey and resolution. Hard copy films should always be examined
provision of analgesia, the fracture should be realigned on a light box. Fractures are identified by:
by manual in-line traction to restore congruity with n a
break in the cortex of the bone on one or more
the uninjured limb without awaiting radiographs of the views;
of the injury. Only when the diagnosis is uncertain, n a
ngulation of bone, especially in children;
e.g. in fractures near joints (which can be difficult to n a radiolucent line (in the case of a distracted fracture)
differentiate from fracture- dislocations), should x-rays or a radiodense line (in an impacted fracture) across
be undertaken prior to limb realignment. However part or all of the bone at the injury site;
when the diagnosis is certain, e.g. fracture-dislocation n s
oft tissue swelling adjacent to the suspected site
of the ankle, reduction should preceed x-rays. of the fracture;
n s
oft tissue evidence of fractures (e.g. the fat pad
Fracture realignment achieves reduction of: sign in radial head fractures or a lipohaemarthrosis
n p
ain; in intra-articular knee injuries).
n b
lood loss;
n p
ressure on the soft tissues; Once a fracture is spotted on the x-ray and correlated
n r
isk of neurovascular compromise; to clinical symptoms there are a number of important
n r
isk of fat emboli. features which need to be noted:
n L
ocation: is it in the diaphysis, metaphysis or
Before obtaining x-rays, temporary splintage or support epiphysis? This predicts the healing potential and
should be applied. In the upper limb the use of a sling is important for planning what sort of fixation to
may be sufficient or it may be necessary to use a plaster use, if any.
back slab, box or vacuum splint. In the lower limb a back n Pattern: is the fracture transverse, oblique or
slab, box splint, vacuum splint or traction splint may be spiral? This indicates the stability of the fracture
appropriate depending on the site of injury. Such simple to axial loading after splinting/reduction and may
measures will help minimise pain from the fracture and determine whether operative treatment is required.
during any movement, while the x-ray is taken. n I nvolvement of a joint surface: if so, is there

displacement of the subchondral bone (and Early complications after a fracture
hence articular cartilage)? Is the fracture actually a Impairment of circulation to the limb beyond the fracture
fracture-dislocation or fracture-subluxation? It is vital to check for the presence of pulses distal to
n I nvolvement of a growth plate in children. If the the fracture, while keeping in mind the possibility
fracture line actually crosses it, this is associated that, even with palpable pulses, arterial damage
with risk of growth disturbance. may have occurred. Pulses may be present initially
n Segmental fracture (more than one fracture in the and then disappear, for instance with intimal flap
same long bone) increases the risk of compartment tears of the arterial wall. The only adequate guard
syndrome, vascular injury, non-union. against ischaemia due to arterial injuries is repeated
examination of temperature, sensation and pulses of
Further information may be required to determine limbs (table 10.6). If a vascular injury has occurred, an
fracture configuration, particularly in complex joint emergency vascular surgical assessment is needed.
fractures. This is usually obtained following specialist
opinion. Although additional plain x-rays may be TABLE 10.6
helpful, CT scanning is often required to elucidate more Signs of vascular impairment
details and allow planning of operative treatment. n Pain
n Pallor
Sometimes it is not possible to identify a fracture on

n Perishing cold
an initial radiographs. If careful clinical examination n Pulselessness
indicates the presence of signs of fracture (bony n Paraesthesia
tenderness and swelling), there are a number of n Paralysis
management options:
n d
ecide that it is clinically insignificant (undisplaced
Compartment syndrome
fracture in an unimportant site, e.g. 5th toe);
n splint the limb and repeat the radiographs usually Compartment syndrome most commonly follows
after a week or two. If the fracture is not visible blunt trauma to the leg resulting in a closed tibial
on the original radiograph, it may become visible fracture. However it also occurs after injuries to
due to bone resorption at the fracture line (e.g. the forearm, foot, buttock or any other muscle
scaphoid fractures); compartment. Progressive swelling within the fascial
n C
T scan; compartments results in ischaemia of muscles and
n M
RI scan. nerves. The classical features are:
n p
rogressive pain;
Initial management of fractures n p
ain of inappropriate severity to the background
The principles of initial fracture immobilization are injury;
summarised in table 10.5. The majority should be n extreme tenderness over the affected muscle
immobilised in the first instance as this will reduce group;

pain and then appropriate referrals can be made. In n p
ain with passive movements/stretching of the
open fractures it is important to resist the temptation affected muscle group.
to repeatedly inspect the wound. This should not
occur again until the patient is in the operating room Beware, this condition can occur even when there
for wound exploration, debridement and lavage. are open fractures. This is because limbs have several
Management of open fractures should comply with compartments (e.g. the lower leg has four) and it
national guidelines and clinicians should refer to their is possible that some of the compartments remain
local hospital protocols. unopened even though there are overlying skin wounds.
TABLE 10.5 If unrecognized, the late features include

paraesthesiae, pulselessness and eventually necrosis
Treatment of skeletal injuries of muscle and nerves. The diagnosis may not be
Site of fracture: Preliminary stabilisation: apparent in unconscious patients, where based on
Clavicle, humeral neck Sling the history and clinical findings (e.g. marked limb
Humeral shaft U slab, collar and cuff
swelling), the clinician should have a low incidence for
suspecting an acute compartment syndrome and seek
Forearm Full arm back slab
urgent orthopaedic opinion for surgical management.
Distal radius, metacarpus Short arm back slab The common sites of compartment syndrome are
Femoral shaft Traction splint summarised in table 10.7.
Around the knee, tibia Full leg back slab
Ankle, foot Short leg back slab
Remember: severe pain after a fracture,
persisting after immobilization is due
to compartment syndrome until proven
otherwise.
TABLE 10.7
Common sites of compartment syndrome Summary
Soft tissue injuries and fractures are frequently
n L ower leg n Foot
challenging, potentially disabling and occasionally
n Forearm n Thigh
life-threatening. Careful assessment of the anatomical
n Hand n Buttock
extent of these injuries, and appropriate treatment is
essential and can make an enormous difference to
Causes of compartment syndrome: the initial symptoms and the degree of long-term
n f ractures; disability experienced by patients after trauma.
n c rush injury;
n r eperfusion injury (post correction of any Having worked through this chapter you are now
displacement causing vascular impairment); ready to apply the following knowledge in the
n p harmacological, e.g. anticoagulants; extremity trauma workshop:
n injection (e.g. misplaced intraosseous needle). n identifying musculoskeletal injuries;
n prioritizing the treatment principles of

Patients with acute compartment syndrome require extremity injuries during the primary and
immediate surgical decompression. secondary survey;
n a ssessing common fractures and soft tissue
Dislocations injuries by the ‘Look-Feel-Move’ approach;

A dislocation is an injury to a joint which results in the n m anagement of common fractures and soft
two joint surfaces no longer being in contact. A partial tissue injuries in the resuscitation room.
dislocation (subluxation) may also occur. These are
often difficult to distinguish from periarticular fractures These cognitive abilities will be integrated with
and it is important to obtain adequate imaging. the practical skills during the course workshops.
However, if there is gross deformity, neurovascular
compromise or a problem with overlying skin, it is
appropriate to reduce the deformity prior to obtaining Further information
x-rays. Experience will help, as there are a limited
number of characteristic deformities with dislocations. n A
O Foundation Trauma:
https://aotrauma.aofoundation.org
Dislocations are painful and are an orthopaedic n B
OAST 4 The Management of severe open lower
emergency. They are often dealt with in the emergency limb fractures (BOA & BAPRAS consenscus 2009)
department. In any dislocation, the neurovascular n B
OAST 10 Diagnosis and management of
status of the dislocated limb should be documented compartment syndrome of the limbs (BOA &
pre & post manipulation. A typical dislocation is BAPRAS 2016)
anterior dislocation of the shoulder. It usually follows n K
ey Clinical Topics in Trauma 2016 Porter, Greaves
a fall on to the outstretched hand. This is frequently & Burke

recurrent, occurs in young patients and is associated
with a typical deformity of the shoulder (empty
glenoid). Neurovascular injuries occasionally occur
but are uncommon. Reduction has to be performed
by a doctor with experience in joint reduction. Gleno-
humeral (shoulder) dislocations are usually anterior.
Hip dislocations are usually posterior.
Other common joints that dislocate are:
n P atello-femoral
n e lbow
n a nkle (usually associated with a fracture)
n w rist
n k nee (high incidence of occult vascular injury

BRITISH ORTHOPAEDIC ASSOCIATION and
BRITISH ASSOCIATION OF PLASTIC, RECONSTRUCTIVE
AND AESTHETIC SURGEONS
STANDARD for TRAUMA – 2009
BOAST 4: THE MANAGEMENT OF SEVERE

OPEN LOWER LIMB FRACTURES
Background and Justification:
The British Orthopaedic Association and the British Association of Plastic, Reconstructive and Aesthetic
Surgeons have reviewed their 1997 guidance and now publish a review of all aspects of the acute man-
agement of these injuries using an evidence-based approach, leading to the “Standards for the
Management of Open Lower Limb Fractures,” which are free to download from www.boa.ac.uk and
www.bapras.org.uk. This BOAST is derived from these standards. Contrary to traditional teaching, best
outcomes are achieved by timely, specialist surgery rather than emergency surgery by less experienced
teams.

Included Patients:
All patients with high energy open fractures as manifest by the following injury patterns:
Fracture Pattern: - Multifragmentary (comminuted) tibial fracture with fibular fracture at same level
- Segmental fractures
- Fractures with bone loss, either from extrusion or after debridement
Soft tissue injury: - Swelling or skin loss, such that direct, tension-free wound closure is not possible
- Degloving
- Muscle injury that requires excision of devitalised muscle via wound extensions
- Injury to one or more major arteries of the leg
- Wound contamination with marine, agricultural or sewage material
Standards for Practice Audit:

1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav
(1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6
hourly if penicillin allergy
2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, par-
ticularly after reduction of fractures or the application of splints
3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within
3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia
4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions
(see overleaf)
5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heav-
ily contaminated by marine, agricultural or sewage matter.
6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and
orthopaedic surgical teams and clearly documented
7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-
soaked gauze and an impermeable film to prevent desiccation
8. The limb, including the knee and ankle, is splinted
9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures
have protocols in place for the early transfer of the patient to an appropriate specialist centre
10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only
takes place in a non-specialist centre if the patient cannot be transferred safely
11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic sur-
geons working together on scheduled trauma operating lists within normal working hours and within 24 hours
of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for
solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision
and continued for 72 hours or definitive wound closure, which ever is sooner
12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum
foam dressing or an antibiotic bead pouch is applied until definitive surgery.
13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days.
14. Vacuum foam dressings are not used for definitive wound management in open fractures.
15. The wound in open tibial fractures in children is treated in the same way as adults

Evidence Base:
Derived from the 2009 BOA/BAPRAS Standards for the Management of Open Lower Limb Fractures.
This is based upon case series, case-controlled studies and reviews together with an evolved, multi-
national, professional consensus over 15 years.
Limitations:
There is inconclusive evidence to the best method of skeletal stabilisation.
Recommended incisions for fasciotomy and wound extensions. (a) Margins of subcutaneous bor-
der of tibia marked in green, fasciotomy incisions in blue and the perforators on the medial side arising
from the posterior tibial vessels in red. (b) line drawing depicting the location of the perforators. (c) mon-
tage of an arteriogram. The 10cm perforator on the medial side is usually the largest and most reliable
for distally-based fasciocutaneous flaps. In this patient, the anterior tibial artery had been disrupted fol-
lowing an open dislocation of the ankle; hence the poor flow evident in this vessel in the distal 1/3 of the
leg. The distances of the perforators from the tip of the medial malleolus are approximate and vary
between patients. It is essential to preserve the perforators and avoid incisions crossing the line between
them.
Cross-section through the leg showing incisions to decompress all four compartments

Extremity and soft tissue trauma - Skills
How to apply a Thomas Splint n elect the correct sized Thomas splint and take
S
all the equipment to the patient. If the splint is a
A Thomas splint can be applied as a temporary measure half ring construct, ensure that the medial side is
prior to definitive fixation of a femoral fracture or for shorter than the lateral.
transport of patients abroad (as seen in evacuation of n After the analgesia has been given, ensure patient
UK military patients from Iraq and Afghanistan) is comfortable.
n Apply skin traction taking care to protect the
Procedure malleoli and head of fibula with padding.
n Inform patient about fitting of the splint and n Apply the bandage snugly but do not make it too
traction tight.
n Provide adequate analgesia
n Prepare the equipment:

You will need the following:
1. Correct size splint
2. Skin traction kit
3. 2 crepe bandages
4. 3-5 calico-type slings
5. safety pins or bull dog clips
6. Gamgee dressing (length of cotton wool
enclosed in gauze to serve as cushion)
7. Tape
8. 2 wooden spatulas
9. Scissors
n Measure the uninjured leg and make allowance
for present and anticipated swelling
Measure also the length of the leg from inner thigh to

the heel and add 20-30 cm

n pply traction with one hand on the spreader bar
A
of the skin traction.
n The selected splint is pushed up the leg. It should
reach the ischial tuberosity or perineum and it
should be possible to pass one finger beneath the
ring around its complete circumference.
n Gamgee dressing can be applied above the

A
slings as a protective cushion underneath the leg.
A cotton pad can also be applied below the knee to
flex it by about 10-15˚ and another cotton pad can
be applied along the head of the fibula to protect
the common peroneal nerve from pressure against

the outer rod of the splint.
n hen fully pushed in, the splint must have 30 cms

W
projecting beyond the foot. There should also be
space enough between the inner ring and thigh
for one finger to go round.
n Strips of 6 inch Calico bandage can be used to
make slings
n Chinese windlass using 2 spatulas may be used

A
to take up the slack. The 2 spatulas are inserted
between the two chords and then rotated to
create further traction and tightening.
After care:
n ne of the slings should be placed directly under
O n Check for tightness of the ring from swelling.
the fracture. n Look for any developing pressure sores.
n The slings should be sagging and not tight. n Check Achilles tendon and malleoli for pressure
areas.
n Check for new weakness of ankle dorsiflexion
(common peroneal Nerve pressure) and repad as

necessary around fibula head.

How to apply the Kendrick traction device.
lace upper thigh strap high into groin with the poles
P
on the outside of the leg. Measure pole against leg.
The bottom of the pole should extend 1 section below
the foot. The pole can be shortened or lengthened.
NB maintain inline traction of limb
rior to attachment of the ankle strap, the yellow

P
Velcro strap can be placed just above the knee.
pply the ankle strap with the padded bit behind the
A
ankle. Tighten using the green strap. The yellow strap
fits over the pole and traction applied with the red

strap. (a small amount of counter-traction needs to be
applied at this point)
Apply the other two Velcro straps: the red strap at

the top of the thigh, the green strap on the lower leg.
Manual traction is now released.

11.
Trauma in children
Learning outcomes
n How to prepare to receive a paediatric patient with major trauma
n How to assess a paediatric patient with major trauma
n Understanding the differences between adult and paediatric trauma victims

n Recognizing the common injuries that children sustain
n Recognizing the signs of non-accidental injury in children
Introduction n U ncontrolled haemorrhage is the leading cause of

preventable death from trauma in children;
Although major trauma is relatively rare in children, it n s olid abdominal organs in small children are less
is a leading cause of death above the age of one year protected by the ribcage than in bigger children
and 10% of all trauma fatalities occur in children of and are more prone to injury;
less than 16 years. Given the low frequency of major n t he elasticity of bones makes organ injuries possible
trauma, a methodical approach to the management of without overlying fractures;
the injured child is essential and trauma teams should n p elvic fractures are rare in children and cause less
receive continuous training and rehearse regularly to blood loss than in adults;
enable all team members to fulfill their roles. n 9 0% of all solid organ injuries in children are treated
conservatively;
s pinal immobilization should only be applied in
Planning and preparation n
cooperative or unconscious patients; enforcing it

for receiving a paediatric could cause further damage;
children have a greater reserve to compensate
trauma patient
n
initially for blood loss, followed by sudden

decompensation. Hypotension is a late sign in
Hospitals that receive paediatric trauma should have shock and precedes decompensation, hypotensive
a set of specific guidelines, protocols and standard resuscitation should therefore not be applied in
operating procedures describing the pathway for children;
seriously injured children within their institution. As a n c hildren have a high body surface area/volume
minimum there must be: ratio causing small children to be very prone to
n immediate availability of staff with paediatric hypothermia;
expertise; n t hose aged 10 years or older should be assessed
n p aediatric airway and vascular access equipment; and resuscitated as small adults.
n p aediatric monitoring;
n v isual aids or approved phone apps for all paediatric The trauma alert and team briefing
calculations and drug preparation in order to avoid The alert and briefing follow the same principles
drug errors. as discussed in chapter 2 (figure 2.1) with only a few
differences for the paediatric patient:
Injury patterns are age dependent, however the n Follow the ATMIST communication between the
following points apply to all children: team leader and pre-hospital team. If the child’s age
n t
raumatic brain injury is the leading cause of death is known, their weight can then be approximated
and disability in all age groups followed by chest to enable the relevant equipment, drugs and fluids
injuries; to be prepared in advance (table 11.1).
CHAPTER 11 TRAUMA IN CHILDREN | 143

n E nsure that the room is as warm as possible and oropharyngeal airway of the appropriate size
avoid further heat loss after arrival by having can help to maintain a patent airway. It must be
appropriate equipment readily available e.g. inserted carefully to avoid damage to palate and
forced air warming, warm fluids and blankets. subsequent bleeding.
n D uring the briefing, acknowledge the fact that n If indicated, suction should be performed with
some team members may be anxious but use a large bore soft catheter to avoid mucosal
reassurance emphasising that the system is lacerations. Care is required to avoid too deep
exactly the same as for an adult patient. insertion with stimulation of the gag reflex and
n B rief a team member to remain with the family vomiting.
at all times to explain what is happening in the n In children who arrive with a tracheal tube in
resuscitation room and provide a conduit for an place, confirm correct tube position and size
AMPLE history. This person can be a doctor or a immediately by auscultation and capnography.
Trauma Support Practitioner (TSP).
n B rief the airway person to communicate with TABLE 11.2
and reassure the child. Keeping children as calm
as possible enables procedures to be carried out Structural characteristics of the paediatric airway
with minimal distress and allows assessment of Anatomical feature: Effect:
their neurological status.

Large occiput (<3 years), Head and neck flex
n Recognize the potential for difficulties with short neck
immobilising the cervical spine in distressed and Infants (<6 months) breath Complete airway obstruction
uncooperative patients. A more pragmatic approach via the nose may occur if blocked by blood,
is required to optimise cervical immobilization. oedema, tubes
n E nsure early access to analgesia, don’t forget the Relatively large tongue, Obscures view of glottis
intranasal route (IN). This will improve the child’s floppy epiglottis
cooperation and reassure distressed parents. Relatively short trachea Risk of right main bronchus
n E nsure there is senior support available. intubation
Smallest diameter below Pass glottis but cannot pass
TABLE 11.1 glottic level subglottis with ET
Calculation of child’s weight

1-12 months (0.5 x age in months) + 4 n C
hildren are at greater risk of regurgitation and
1-5 years (2 x age in years) + 8 aspiration from swallowing air (aerophagy); a naso-
6-12 years (3 x age in years) + 7 or oro-gastric tube should be used to decompress
the stomach if the distension is excessive. An
unconscious child requiring ventilatory support
should also have a gastric tube inserted to vent the
The primary survey stomach and reduce the risk of aspiration.
n If a child requires intubation, it should be
Paediatric trauma patients are assessed (figure 2.2) undertaken by an anaesthetist. General
and managed (figure 2.3) using the same system as anaesthesia is required to avoid increases
described in chapter 2 and follows the cABC principle. in intracranial pressure and trauma during
Factors relevant to the primary survey in children are: attempted intubation from coughing, gagging
and vomiting. The team leader needs to allocate
Airway personnel tasks as described in chapter 2. Indications
Start by talking to the child, introduce themselves, for intubation and ventilation are outlined in
explain what is happening and, if appropriate, table 11.3. Equipment and planning for failed
comfort them. This allows airway patency and level intubation must be in place e.g. supraglottic
of consciousness to be assessed. Following this, and airway devices. Remember, almost all children
depending on the response: can be oxygenated adequately using a good
n G ive high flow oxygen if the SpO2 is below 95% in technique with a bag-mask while expert help
rest (ensure the mask is the right size and place it is obtained. Surgical airways in children are
so the child receives maximum oxygen without technically difficult and should only be attempted
unnecessary distress). by appropriately trained clinicians.
n If there is any sign of airway obstruction, provide
basic airway management bearing in mind the

specific characteristics of a child’s airway (table 11.2).
Whilst carrying out simple airway manoeuvres in
a young child, ensure that the soft tissues are not
compressed resulting in airway compromise. An

TABLE 11.3 provide rapid analgesia and sedation if there is no
Indications for intubation and ventilation IV access in place. The choice of drug will depend
n Inability to provide adequate oxygenation on local protocols; examples are given in table 11.4.
n Obvious need for prolonged control of the airway e.g. multiple
injuries
n Decreased level of consciousness e.g. head injury
TABLE 11.4
n Inadequate ventilation e.g. flail chest, exhaustion Analgesic drugs and doses used in children
n Persisting circulatory failure
Drug Dose Comments
n Potential airway compromise e.g. burns, inhalational injury
Morphine 0.03-0.1 mg/kg Must be diluted (usu-
n Each child that needs sustained airway support requires ETI
IV/kg IV ally to 1mg in 10ml,
100microgram/ml)
Fentanyl 0.5-1microgram/kg IV Must be diluted
n If a surgical airway is required, needle
(usually to 100mi-
cricothyroidotomy using a 14-18g cannula is an crogram in 10ml,
option if the landmarks can be identified. This is 10microgram/ml)
described in chapter 3. However, in children a surgical 2microgram/kg
airway or needle cricothyroidotomy is hardly ever intranasal
required; the practitioner should concentrate on
Ketamine 0.2-0.5mg/kg IV Excessive doses

optimising his basic airway technique, maintain PEEP, will cause loss of
use a supraglottic airway and call for an anaesthetist consciousness
before proceeding to a surgical airway. During
3mg/kg intranasal
ventilation through a face mask or a supraglottic
2mg/kg
airway air can escape into the stomach and inflate
intramuscular
the stomach (diaphragmatic splinting), which makes
ventilation more difficult and can cause hypoxaemia. Reduce doses by 50% when using S-Ketamine
To treat diaphragmatic splinting, a large bore suction Paracetamol 15mg/kg IV Opiate sparing
catheter can be inserted into the stomach and can
be left in place; a modern face mask usually seals well
around a suction catheter. Using this method high Whichever drug is used, the dose must be checked to
ventilation pressures can be delivered; air insufflated ensure an accurate and safe dose is given. In order to
into the stomach escapes easily through the suction avoid dosing errors we recommend the use of local
catheter, which prevents gastric distention. guidelines, visual aids and approved smart-phone
n Monitoring should be attached. Oxygen saturation apps. The child’s pain should be re-assessed at regular
is the most important parameter to be monitored intervals using a suitable tool and further doses
and a pulse oximeter should be applied immediately. given as required. Other methods such as distraction
In the haemodynamically compromised child the techniques, regional nerve blocks, splintage and
signal can be weak and the readings unreliable. immobilization will be applicable to some patients.
Capnography is essential in the intubated patient. n Check the AMPLE.
n Ensure adequate immobilization of the cervical n The airwary personnel carries out the neurological
spine until a spinal injury is ruled out. Up to 75% assessment, which is mainly based on the social
of cervical spinal cord lesions are incomplete at interaction of the child with its environment and
presentation with the potential for deterioration the child's response to external stimuli. This can be
if handled incorrectly. If in doubt, assume cervical difficult at times, especially in autistic children or
spinal injury. There is no evidence to support the children with a low pain threshold. The presence
use of cervical collars for immobilisation in children. of a parent is helpful to calm the child and to help
Immobilisation of the cervical spine should be interpreting the child's behavior. The neurological
maintained with manual in-line stabilisation. assessment consists of: the paediatric GCS (table
Alternatively, children a vacuum splint can be used 11.6), pupillary response to light, and assessment
to immobilise the whole child, including head and of the motor response between all four quadrants.
neck. Involving the parents or carers may enable This is of particular importance if the child is
better immobilization. Forced immobilisation is to be anaesthetised, which makes a through
likely to cause harm and should not be applied. If neurological assessment impossible.
a C-spine injury is suspected MILS or head-blocks
should be applied if tolerated by the child. Breathing personnel
n P
rovide analgesia after discussion with the n ssess breathing pattern. This can be difficult if the
A
team leader. This should be given at the earliest child is crying but with reassurance and analgesia
opportunity to allow a more effective assessment a more accurate assessment is possible. It is
of the child. The IV route is the most appropriate important to assess the respiratory rate, symmetry
in major trauma, but if this fails, the intranasal of movement, work of breathing (whether there is
route can be used. Intranasal Fentany is ideal to any accessory muscle use) and if it is effective.
n Ensure ECG and SpO2 monitors are attached, if haemorrhage protocol (MHP). The use of crystalloids
not already done so. It can be difficult at times to and colloids should be limited to avoid dilution of
assess pulse oximetry if the child is unsettled or clotting factors and aggravation of trauma induced
upset but usually with persistence and reassurance coagulopathy (TIC). As in adults, PRBC, platelets and
an accurate reading is possible. The ECG leads are FFP should be transfused in a ratio of 1:1:1. in 1-10 ml/kg
usually tolerated well. aliquots depending on the severity of hemodynamic
n Inspect, palpate, percuss and auscultate the chest. instability. TXA and factor concentrates should be
Despite minimal external evidence of injury, there given according to local protocol.
can still be significant internal injury. Pulmonary n Aim for normal blood pressure. The compensatory
contusions are the commonest thoracic injury in mechanisms for blood loss in children are different
children, and can be present even in the absence from adults. Children respond with tachycardia and
of hypoxia and hypoventilation. Most significant massive vasoconstriction, allowing them to keep
contusions will be seen on the initial chest x-ray their bloodpressure relativley stable until abrupt
but may be delayed and only seen after 48 hours. circulatory collapse ensues (Fig 11.1). Hypotensive
n Inspect and palpate the neck. Resuscitation is therefore not applicable in children.
n Perform lateral thoracostomy and chest tube The principles of damage control resuscitation in
insertion as necessary. The indications are the children are outlined in Fig. 11.2.
same as in adults. n Examine the abdomen, pelvis and long bones
n Support other team members if no chest even if there is little external evidence of injury.
intervention is required. The pelvis needs assessing only once to determine
pain or instability. The perineum should also be

Circulation personnel inspected but rectal and vaginal examinations are
n S tem any overt haemorrhage. In infants scalp not indicated in children at this point.
lacerations can occasionally cause significant n Apply the correct sized pelvic binder if indicated
blood loss. by the history/mechanism/findings. Children
n Establish IV access, take appropriate blood samples. are less likely to suffer major haemorrhage from
Venous access is a high priority in the child with pelvic fractures; in children that have not reached
severe injury and should be delegated to the puberty the haematoma remains contained within
most appropriate person. The optimal sites are the the strong periostum. Again there can be minimal
veins on the dorsum of the hand or foot and the evidence of the damage externally.
saphenous vein anterior to the medial malleolus. n If competent and indicated, perform sonography
Two short, wide bore IV cannulas are the ideal, the (eFAST). As in adults, ultrasound is an extemely
size dictated by the size of the child. If vascular valuable tool to guide resuscitation in children. Due
access is difficult the intraosseous route is preferred to the relatively higher resolution and penetration
using an electrical powered drill, e.g. EZ-iO®. of ultrasound, image quality is usually better
Consider the use of IN analgesia before IO insertion. in children than in adults. However, negative
n Start monitoring, if not already done attach ECG, sonography does not rule out significant abdominal
measure pulse rate, capillary refill time and blood injury. A CT scan of the abdomen is or sometimes a
pressure. Children are often tachycardic because diagnostic laparoscopy (in stable patients) are the
of anxiety or pain and not just fluid loss. As they preferred investigations if intrabdominal injuries are
have a lower absolute circulating blood volume suspected. An uncooperative child may need to be
than adults, the loss of relatively small volumes can anaesthetised for a scan.
result in a significant haemodynamic compromise. n Insert a urinary catheter if clinically indicated and
However, they compensate very effectively by no signs of urethral injury.
increasing their peripheral resistance and heart rate
until they suddenly decompensate. Bradycardia in
a shocked child usually heralds cardiac arrest. It can
be difficult to get an accurate blood pressure in a
restless and conscious child. If it is easy, this may
be an indicator as to how unwell the child is. Non-
invasive blood pressure monitoring in shock can
give false readings of both systolic and diastolic
pressures, whereas the mean pressure better
reflects invasive BP readings. It is important to use
an adequately sized cuff to avoid over- or under-
estimation of the BP. Early consideration should be
given to inserting an arterial line as this will also
provide information on volume status and repeated
arterial blood gas sampling. The normal ranges of
vital signs in children vary with age (table 11.5). Figure 11.1 The cardiovascular response to blood loss in children
is different to the adult response; a significant decreases in blood
n Start fluid resuscitation. If there are signs of ongoing
pressure occurs only immediately before decompensation. The
and uncontrolled blood loss activate the massive vertical red lines indicate the decompensation threshold. (HR
Heart-Rate; BP Blood-Pressure)

Paediatric Major Trauma?
Paediatric Major Haemorrhage? Then...
Tranexamic Acid If not administered already:
T
n
n 1 5 mg/kg bolus (max 1g), followed by

n 2 mg/kg/hr over 8 hours (max 125mg/hr)
Resuscitation n A ctivate MHP & consider:

R apid infuser
R
n
n C ell salvage
n N o hypotensive resuscitation (unless post-pubertal)
n P elvic binder / splint #s / tourniquet
n L imit crystalloid and colloid use
Avoid Hypothermia n T arget temperature > 36°C
A n
n
R
W
W
emove wet clothing and sheets
arm fluids
arming blanket / mattress
Unstable? n If unstable, coagulopathic, hypothermic or acidotic,
U
perform damage control surgery
Damage Control
A im surgery time < 90 minutes
Surgery
n
n H aemorrhage control, decompression, decontamination

and splintage
Metabolic n A void acidosis
M
n B ase excess guides resuscitation
n If lactate > 5mmol/L or rising, consider stopping surgery,
splint and transfer to ICU
n M onitor blood glucose
A
Avoid n Inappropriate use of vasoconstrictors doubles mortality
Vasoconstrictors n H owever, use may be required in cases of spinal cord or
traumatic brain injury
Test Clotting n C
onsider TEG
T
n C
heck clotting every 15ml PRBC / kg BW
n A
im platelets > 75x109/L
n A
im INR & aPTTR ≤ 1.5
n A
im fibrinogen > 1.5g/L
Imaging n C onsider:
I
n S upine CXR and e-FAST
n C T: Most severely injured / haemodynamically unstable
patients gain most from CT
n Interventional radiology
Calcium M
aintain ionised Ca2+ > 1.0 mmol/L
C
n
n A
dminister 0.2ml/kg 10% Calcium Chloride over 10 mins
as required
n G
ive routinely after MHP Pack One
Figure 11.2 Massive Haemorrhage Protocol for children

Copyright: L May, A Kelly, M Wyse, K Thies, T Newton. Contact: lauraflower@doctors.org.uk

3-6 months 5-7 100-160 30-40 70-90
3-6 months 5-7 100-160 30-40 70-90
3-6 months 5-7
10 100-160 30-40 70-90
1 year 10 100-160 30-40 70-90
1 year 10 100-160 30-40 70-90
21 years
year 12 100-160
95-140
30-40
25-30
70-90
80-100
2 years 12 95-140 25-30 80-100
2 years 12 95-140 25-30 80-100
3-4 years 14-16 95-140 25-30 80-100
3-4 years 14-16 95-140 25-30 80-100
3-4 years 14-16 95-140 25-30 80-100
5-8 years 18-24 80-120 20-25 90-110
5-8 years 18-24 80-120 20-25 90-110
5-8 years 18-24 80-120 20-25 90-110
10 years 30 80-100 15-20 90-110
10 years 30 80-100 15-20 90-110
10 years 30 80-100 15-20 90-110
TABLE 11.5
TABLE 11.5
12 years
12 years
40
40
60-100
60-100
12-20
12-20
100-120
100-120
12 years
TABLE 11.5 40 60-100 12-20 100-120
TABLE
Normal11.5
vital signs in children
Normal vital signs in children
Normal vital
Age signs in children Weight Pulse Respiratory rate Systolic BP
Normal vital
Age signs in children Weight Pulse Respiratory rate Systolic BP
Intraosseous
Intraosseous page Weight
Ageneedle (see skills
skills 125)
section)
(kg) Trauma Support
(beats/min)
Pulse Practitioner
(breaths/min)
Respiratory rate (mmHg)
Systolic BP
Ageneedle (see page section)
125)
(kg)
Weight Trauma
Pulse
(beats/min) Support Practitioner
Respiratory rate
(breaths/min) Systolic
(mmHg)BP
3-6 months (kg)
5-7
(kg)
Trauma
(beats/min)
n The Support
TSP have
100-160n The TSP have a Practitioner
crucial
(breaths/min)
30-40 role in the resuscitation
(mmHg)
70-90 of
KEY POINTS
POINTS
3-6 months 5-7 (beats/min)
100-160n The
children.
TSP have
They a30-40
a crucial
(breaths/min)
are
crucial
oftenroleable
role in the
in the
to resuscitation
(mmHg)
70-90
resuscitation
establish of
good
of
KEY 3-61months
year 5-7
10 100-160
100-160 30-40
30-40 70-90
70-90
3-611months
Indications:
year
year 5-7
10 a peripheral vein,
inability to cannulate 100-160 children.
100-160 contact They
children.with
Theytheare
30-40
are often
child
30-40 often able
andable to
to support establish
70-90
to establish good
relatives
70-90 good
at
Indications:
21 years
year inability to cannulate
12 a peripheral
10 vein, 100-160 contact with the childthe
30-40 andmedical
to support
support relatives
70-90 at
21years
year lack of
of time
time or
or expertise
expertise
10
12 to insert
insert aa 95-140 the
100-160 contact
same with
time, 25-30
thewhilst
child
30-40 and to team80-100
relatives
70-90members at
lack to 95-140 25-30 80-100
2 years
3-4 years central venous cannula
12
14-16
central venous cannula 95-140 the
95-140 are same
the same
focused time,
time, whilst
25-30
on25-30
whilst the medical
the resuscitation.
25-30 the medical teamteam
Engagingmembers
80-100
members
80-100 with
2 years
3-4 years 12
14-16 95-140
95-140 25-30 80-100
80-100
Procedure:
3-4 years insertion of intraosseous
14-16 needle 95-140
are awake
are
the focusedchild
focused on25-30
on theimportant;
is
the resuscitation.
resuscitation.
it Engaging
helps
Engaging
to
80-100
with
establish
with
5-8
Procedure: years
3-4 years
years 18-24
insertion of intraosseous
14-16 needle 80-120
95-140 the awake child20-25 20-25
25-30 90-110
80-100
5-8 18-24 80-120 is important; it helps to
90-110 establish
Complications:
5-8 years
10 years
Complications:
5-8 years
failure to enter marrow
18-24
30 cavity,
failure to enter marrow
18-24 infection, 80-100 confidence
cavity, infection, 80-120
80-120
the awake child
confidence
and20-25
can
is important;
15-20
and20-25
secure cooperation,
can and
secure
it helps
cooperation,
to establish
90-110
90-110
90-110
which in
which inin
10 years compartment syndrome 30 80-100 confidence
turn facilitates
and 15-20
fast
can securegoal
cooperation,
directed 90-110
treatment.
which
10 years
years compartment syndrome 30 80-100 15-20 90-110
12
12 years
10 years 40
30 distally to fracture
40
60-100 turn
80-100 Children
60-100 facilitates
turn facilitates
develop fast
12-20
15-20 and goal
fasthypothermia
12-20 directed
and goal directedmuch treatment.
100-120
90-110
faster
treatment.
100-120 than
Common delay in use, inserted
Common delay in use, inserted distally to fracture 60-100 Children develop hypothermia much faster than
pitfalls:12
12
years
years clogged cannula 40 40 60-100 Children
adults. 12-20
Forced-air-warming
develop12-20hypothermia or 100-120
warmed
much faster
100-120 blankets
than
pitfalls: clogged cannula adults. Forced-air-warming or warmed blankets
adults. be Forced-air-warming or treat warmed blankets
should
adults. Forced-air-warming
applied to prevent and or warmed hypothermia.
blankets
should
should
The be
further applied
be appliedtasks of to
totheprevent
preventTSP are and
andlargelytreat hypothermia.
treat hypothermia.
the same as
Intraosseous needle (see page skills 125)
section)
TABLE
TABLE 11.6
Intraosseous
11.6
Intraosseous needle
needle (see
(see page
skills 125)
section) Trauma The further
The
outlinedfurther
Support
in tasksPractitioner
chapter
tasks of 2.
of the TSP
the TSP are are largely
largely the the samesame as as
Intraosseous
TABLE 11.611.6 needle (see page skills 125)
section) Trauma outlined Support
in chapter Practitioner
2.
TABLE Trauma The TSP TSP have
Support aa crucial
crucial
Practitioner role in in the the resuscitation
resuscitation of of

KEY POINTS
Glasgow Coma Scale
Scale -- Age
Age <4 <4 years
years n The
outlined have
in chapter 2. role
n The TSP have a crucial role in the resuscitation of
n
KEY POINTS
Glasgow Coma children. Theyathe are often able to resuscitation
establish good good
Glasgow
KEY Coma
POINTS
Indications:
Glasgow Scale
i
- Age
nability
inability
Coma Scale to
- Age <4 years
cannulate
<4 yearsa peripheral vein, The
children.
nEnsure TSP
children. that have
They
that
They the are
crucial
are often often role
child’s able in the
to establish
temperature
abletemperature
to establish good is of
Eye opening:
Indications: inability to cannulate a peripheral vein, Ensure child’s is at
Eye opening: lack of time or expertise to insert a contact with
children.
contact
Ensure
maintained with
They
that the
the
and are
the child
childoften
hypothermia andable
and
child’s totemperature
to support
support
tois establish relatives
relatives
prevented. good
is at Trauma Sup
Eye opening:
Indications:
Spontaneously
Eye opening:
Spontaneously inability
lack of timeto cannulate
or expertisea peripheral
to insert a4vein, contact
maintained with the
and child
hypothermiaand to support
is relatives
prevented. at
Spontaneously central
lack of venous
time or cannula to insert a44
expertise the same
contact
the
maintained
This sameis with time,
time, the
achieved
and whilst
whilst
child the
the
hypothermiaand
by medical
medical
to
having support
is team
team
prevented.
a members
relatives
members
warm at n The TSP hav
Spontaneously
To central venous cannula 34 the same
This is time, achieved whilst the by medical
having team a tomembers
warm
To speech
speech
Procedure: central
insertion
insertion venous cannula needle 3
of intraosseous are same
the
are
This focused
focused
resuscitation is time, on
on
achievedarea theand
whilst
the resuscitation.
resuscitation.
the
by medical
tasking having Engaging
team
Engaging
a TSP a members
warm
keep with
with often able to
To speech
Procedure: insertion of intraosseous needle 233 are focused
resuscitation onarea the andresuscitation.
tasking a Engaging
TSP to keep with
To
To speech
To pain
Procedure: insertion 2 thepatient
are
the awake child
awake
focused
resuscitation
the child
on
covered
area is important;
is
the important;
andresuscitation.
with tasking
a it helps
it
blanket helps
a Engaging
TSP or to
to tohotestablish
establish
keep with
air relatives at
pain
Complications: failure to of intraosseous
enter needleinfection,
marrow cavity, the patient
awake child is important; it helpsor tohot establish
Complications:
To pain
No response failure to enter marrow cavity, infection, 12
2 the
theconfidence
the
confidence
warming awakedevice
patient covered
and can
child
and
covered can with
secure
isatimportant;
secure
all
with times acooperation,
a blanket
cooperation,
it helps
blanket
and toor tohot
warm whichair
establish
whichair
all in in
in the same time
To pain
No response
Complications: compartment syndrome
failure to entersyndrome
marrow cavity, infection, 1 confidence and can secure cooperation, which
No response compartment 1 warming
turn facilitates
confidence
turn
warming
fluids given. device
facilitates and
device fast
fast at
can
at all
and
and
secure
all times
goal
goal
times and
directed
cooperation,
directed
and to
to warm
warm all in
treatment.
treatment.
which all are focused o
No response
Common
Verbal compartment
delay syndrome
in use, inserted 1
distally to fracture turn facilitates fast and goal directed treatment.
Verbal response:
Common response: delay in use, inserted distally to fracture fluids
Children given. develop hypothermia much faster faster than
pitfalls:response: delay
Verbal clogged cannula turn
Children
fluids
Children facilitates
given. develop
develop fasthypothermia
hypothermia
and goal directed much
much treatment.
faster than
than the awake chi
Common
Alert, babbles,
babbles, words in use,
to usual
usual inserted distally to fracture
ability
Verbal
pitfalls:
Alert, response: wordsclogged
to cannula
ability 55 adults. Forced-air-warming
Children
adults. Forced-air-warming
develop hypothermia or warmed
much fasterblankets
than confidence an
pitfalls:
Alert, babbles, wordsclogged to usualcannula
ability 5 adults. Forced-air-warming or warmed blankets
Alert,
Less
Less thanbabbles,
than usualwords
usual words,tospontaneous
words, usual abilityirritable
spontaneous irritable cry
cry 454 One should
adults.
should
of thebe be
be applied
Forced-air-warming
key applied
roles of toprevent
to prevent
the teamand and
and
or
leader treat
treat
warmed hypothermia.
hypothermia.
blankets
ishypothermia.
to supervise turn facilitate
Less than usual words, spontaneous irritable cry 4 One should
of further
the key applied
roles of to
of prevent
the TSPteam leader treat ishypothermia.
to supervise
Less
Criesthan
Cries only usual
only to
to painwords, spontaneous irritable cry 343 One
and The
should
Theof
guide further
the be key
the tasks
applied
tasks
roles
team to the
prevent
the
members TSP
team are
are
andleader
whilst largely
largely
treat
the is the
the
to same as
same
supervise
resuscitation as Children deve
TABLE 11.6 pain The
andongoing.guidefurtherthe tasks
team of the TSP whilst
members are largely the same
theit resuscitation
resuscitation as
Cries only
TABLE
Cries 11.6 to pain 3 and
is outlined
The
outlined
guidefurthertheinInchapter
in chapter
tasks
teama of 2.
2.
the
members
paediatric TSP are
whilst
trauma largely
the the
is same
essential as adults. Forced
Moansonly
Moans to to pain
to pain
pain 232 outlined inInchapter 2.
TABLE 11.6
Moans to pain
Glasgow Coma Scale -- Age Age <4 <4 years
years 2 is ongoing.
is
that ongoing.
outlined
the child is aakept
inInchapter paediatric
2. peaceful
paediatric
as trauma
trauma it is
it
as possible is essential
essential
so they should be app
Glasgow
Moans
No
No response
Glasgowresponse Coma
to pain
Comato Scale
to pain
Scale
pain - Age <4 years 121 that the child is kept as peaceful as possible so they
No response to pain 1 that Ensure
Ensure
understand the childthat
that
whatis the
the
kept
is as child’s
child’s
peaceful
happening temperature
temperature
butas possible
without so is
is
they
scaring The further ta
Glasgow
Eye
Motor
No
Eye opening:
response
opening:
Coma
response: Scale - Age <4 years
to pain 1 Ensure that
understand what the
is child’s temperature
happening but without is
scaring
Motor
Eye response:
opening: maintained
Ensure
maintained
understand
them. This that
can what beand
and the
is
done hypothermia
child’s
hypothermia
happening
by having but
a iswithout
temperature
is
calm prevented.
prevented. is
scaring
resuscitation Trauma
outlined in Supch
Motor response:
Spontaneously 4 them.maintained
This can and
be done hypothermia
byby having is prevented.
aa calm
calm resuscitation
Eye
Motor
Obeys opening:
Spontaneously
response: 4466 ThisThis iscan achieved by having a warm
Obeys verbal
Spontaneously
verbal command
command them.
room,maintained
This
This is
distracting
is beand
achieved
achieved thehypothermia
done by
child byhaving having
in having
a variety is prevented.
aresuscitation
aof ways warm
warm and nEnsure
The TSP thathavth
Spontaneously
Obeys
To speechverbal command 346 room, distracting the child in a variety ofto ways and
To speech
Obeys
Localises
To speechverbal
to command
to pain 33565 room,
havingresuscitation
This
resuscitation is
distracting
the achieved
parent/carer area
area
the and
and
child by
close tasking
tasking
in having
by. a varietya TSP
a TSP aof towayskeep
warm
keep and often able to
maintained an
Localises pain resuscitation
having the parent/carerarea and close tasking
by. a TSP to keep
To
To speech
Localises to pain
pain (withdraws)
Localises
Flexion to pain to
325
22454 havingthe patient
patient
resuscitation
the the parent/carercovered
area and
covered with
with
close aa blanket
tasking
by. blanket
blanket a TSP orto
or hot
hotkeep air
air relatives at
This is achieve
To pain
Flexion
To pain (withdraws) to pain
pain the patient covered with a or hot air
Flexion
No
To (withdraws) to pain
response
pain 214 There warming
the
warming patient
is the device
covered
device
misconception at all
at all
with times
times a
that and
blanket
and
sometimes toor
to warm
warm hot all
air
all
keeping the same time
resuscitation
No
No response
Flexion
Abnormal (withdraws)
response
Abnormal flexion to to
flexion to pain
painpain
(decorticate)
(decorticate) 11343 Therewarming is given.
the device
misconception at all times that and to warm
sometimes all
keeping
No response
Abnormal flexion to pain (decorticate) 13 There
the fluids
warming
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having the pa
Imaging in the paediatric trauma patient
Imagingtoinradiation
Exposure the paediatric
should betrauma patient
minimised in children. Specific injuries in children
Exposure
There must to radiation
be a clear should be minimised
indication for each in children.
imaging
There must
request and be a clear indication
therefore the standard for each C-spine,imaging
CXR Traumatic brain injury
request
and pelvicand XR therefore
as part of the standardsurvey,
the primary C-spine, are CXR
not Over half of all severely injured children suffer isolated
and pelvic XROnly
appropriate. as part
if theof the primary
injuries cannot survey,
be are not
cleared head injuries. This is the leading cause of death and
appropriate.
clinically Only aif the
should, cervicalinjuries spinecan XR notand be cleared
a CXR permanent disability in paediatric trauma. Survivors
clinically,
be a cervical
obtained. A negative spine chestXR X-ray
and avirtually
CXR shouldrules outbe of traumatic brain injury exhibit functional difficulties
obtained.
any majorAthoracic
negativeinjury
chestin X-ray virtually
a child withrules out any
no obvious persisting beyond childhood. Common findings
major thoracic
clinical signs ofinjury in a child
a chest injury.with Theno use obviousof clinical
whole include poor school performance, employment
signs of CT-scan
body a chest injury. iscontroversial because of the difficulties, poor quality of life, and increased mental
The use ofexposure
significant whole to body CT-scanA is
radiation. controversial
CT-scan should health problems. The best outcome after head
because
only beofrequested
the significant if the exposure to radiation.
mechanism andA CT-the injury is achieved by rapid access to definitive care
Specific injuries in children
scan should
physical only be requested
examination suggests if the
an mechanism
injury, andanda and minimisation of ‘secondary injury’, including
the physical
change of examination
managementsuggests is to anbeinjury, and a
expected. avoidance of hypoxaemia, hypotension, and hypo-
Traumatic
changethyroid
The brain
of managementglandinjury is toparticularly
be expected. susceptible or hypercapnia. Twenty percent of all children with
The radiation
Over
to half
thyroid
of all and
gland
severely isinjured
given particularly
the children susceptible
low incidence suffer isolated
of to
C- traumatic brain injuries require emergency craniotomy
radiation
head
spine injuries.
and This
injuries givenis the
theleading
conventional low incidence
cause
X-ray of of deathC-spine
diagnosticand for evacuation of sub- or extradural haematoma.
injuries conventional
permanent
should priorityinX-ray
takedisability over diagnostic
paediatric trauma.
CT-scanning. should Onlytakeif
Survivors This should be undertaken as fast possible, with a
priority
of
there is over
traumatic CT-scanning.
brain
a strong injury
suggestion Onlyoffunctional
exhibit ifathere
C-spine isdifficulties
ainjury
stronga maximum acceptable time target of 4 hours from the
suggestionshould
persisting
CT-scan of a C-spine
beyond injury a Common
bechildhood.
considered. CT-scan should
Consideration be
findings injury.
considered.
include
should poor
be Consideration
school
given to should
as performance,whether be itemployment
given as to
is justified
whether it is
difficulties,
depending onjustified
poor quality
the depending
of life, and
mechanism onincreased
of the mechanism
injury andmental
the Thoracic trauma
of injuryclinical
health
child’s and thecondition
problems. child’s
The best clinical condition
or outcome
can be focused or can
after be
head
on Serious chest injuries in children are rare, but can present
focused
injury
specific on
isbody specific
achieved
regions. body
by rapidregions.
access to definitive care without visible external signs and are associated with
and minimisation of ‘secondary injury’, including significant morbidity and mortality. The high flexibility
Planning
avoidance Round of hypoxaemia, hypotension, and hypo- of the paediatric ribcage explains why even fatal chest
or hypercapnia.
The primary survey Twenty percent of
concludes withall the
children
planning
with injuries can occur without any bony lesions. Rib fractures
traumatic
round, the brain
the purposeinjuries
purpose of require
which
of which isemergency
to collate
is to all craniotomy
findings,
collate all occur only if exceptional force is involved and if present
review
for evacuation
findings, allreview
measuresofallsub-
taken
measuresor soextradural
far, and so
taken haematoma.
establish
far, andan should raise suspicion regarding further underlying
individual
This should
establish patient
an be undertaken
pathway
individual (figure
patient as fast 2.5).possible,
pathway Depending
(figurewith ona
2.6). serious injuries. A chest x-ray is the first imaging
the local infrastructure
maximum
Depending acceptable
on the local timethe target
majority of 4 of
infrastructure hours
the from
the severely
the
majority modality for thoracic trauma in children, but if there is
injury.
injured
of children injured
the severely will need to be will
children transferred
need totobea suspicion of an intra-thoracic injury a chest CT should be
children’s trauma
transferred to a centre.
children’s trauma centre. obtained. As in adults, the majority of thoracic injuries in
Thoracic trauma children rarely require surgical intervention, apart from
Serious chest injuries in children are rare, but can present placing a chest tube for a pneumothorax.
Secondary survey
without visible external signs and are associated with
significant morbidity and mortality. The high flexibility Abdominal injury and pelvic fracture
A
secondary
ofn the survey is
paediatric ribcage performed
explains in anfatal
why even identical
chest Abdominal injuries are the third most frequent injuries
waycan
injuries to an
occuradult with any
without a detailed ‘headRib
bony lesions. to fractures
toe’ and after head and extremity trauma in children and are
occur‘front onlytoif back’ examination.
exceptional force is involved and if present the primary cause of circulatory shock. The history and
n Whilst
Whilst
should raisecarrying
suspicion out regarding
the examination,
further remember,
underlying understanding the mechanism of injury are both key
eveninjuries.
serious minimalA external
chest x-ray marking
is the may indicate
first imaging in diagnosing abdominal injuries. The solid organs are
significant
modality injury internally.
for thoracic trauma in Make a detailed
children, record
but if there is proportionally larger and the abdominal wall is thin,
including
suspicion of andiagrams and photographs.
intra-thoracic injury a chest CT should be offering relatively little protection. The diaphragm is
n ItIt is extremely
obtained. rarethe
As in adults, to perform
majorityaofrectal examination
thoracic injuries in more horizontal than in adults, causing the liver and
in a child.
children rarely Ifrequire
it is indicated, it must be done
surgical intervention, by a
apart from spleen to lie lower and more anteriorly. In addition the
paediatric
placing a chestsurgeon
tube forand not repeated.
a pneumothorax. ribs, being very elastic, offer less protection to these
n During
During the examination, although complete organs. This exposure leads to a higher incidence of
Abdominal
exposure is injury and pelvic
necessary, fracture
it is essential to keep the spleen and liver injuries than in adults. Fortunately,
child as injuries
Abdominal warm as arepossible. Children
the third most cool injuries
frequent quickly 90% of these injuries can be managed conservatively
afterand infants
head andeven more rapidly.
extremity trauma in children and are or with interventional radiology alone. The bladder is
n Request
the Rprimary
equest cause
any further investigations
of circulatory shock.or Theinterventions
history and intra-abdominal, rather than pelvic, and is therefore
as needed. the mechanism of injury are both key
understanding more exposed when full. Respiratory compromise
Review
Review all abdominal
inndiagnosing patient documentation;
injuries. The solid it isorgans
essential
are can complicate abdominal injury as a result of
to be as accurate
proportionally larger and as possible.
the abdominalThis is wall
evenismore
thin, diaphragmatic splinting/irritation.
significant
offering in child
relatively littleprotection
protection. cases.
The diaphragm is
n Maintain
more Maintain
horizontal ongoing
than indialogue with the
adults, causing parents/
the liver and
carers,
spleen to lielisten
lowertoand their
more concerns
anteriorly.and information
In addition the
ribs,they canvery
being provide.
elastic, offer less protection to these
organs. This exposure leads to a higher incidence of
spleen and liver injuries than in adults. Fortunately,
149
90% of these injuries can be managed conservatively
or with interventional radiology alone. The bladder is
Road traffic collisions often involve rapid decelerations present with absent pulses and pallor of the affected
which cause abdominal compression. This can result in limb. They are easily overlooked in the polytrauma
damage to the liver, spleen and kidneys and rupture of patient and they must be actively searched for in order
the duodenum at the duodenojejunal flexure; direct to save the limb.
blows can readily injure the same solid organs. Injuries
to the pancreas or duodenum are a classic sequel of Non-accidental injuries
bicycle handlebar trauma. It is important when dealing with any child to have an
awareness of non-accidental injury. There are clues
Fractures of the elastic immature pelvis are relatively in the history; an unexplained delay in presentation,
rare in children, and generally have a good prognosis. injury incompatible with history or a change in the
However, if they are associated with other serious story over time. In the resuscitation room there are
injuries (head injury, long bone fractures, intra- sometimes indicators of possible concern revealed
abdominal injuries), mortality can increase to 15%. by watching the interaction of the parents with the
Most pelvic fractures in children can be treated child and the parents’ behaviour. Occasionally the
conservatively. In adolescents, fractures of the pelvic appearance of the child can be cause for concern
ring can lead to severe life-threatening retroperitoneal or the child may disclose physical abuse if given the
haemorrhage, which requires external splinting in the opportunity.
Emergency Department.

During the examination, certain injuries should raise
Vertebral column and spinal cord injuries suspicion; rib fractures in an infant, long bone fractures
In children under eight years, the upper three cervical in a non-mobile child, or metaphyseal or epiphyseal
vertebrae are most often injured, compared with injuries, which are often multiple. Sometimes suspicion
adults when it is usually lower cervical vertebrae. is only raised following imaging, when old fractures are
The low incidence of bony injury is explained by identified or there is evidence of healing. It is important
the greater mobility of the cervical spine in children when examining burns or scalds to ensure that the
which dissipates applied forces over more segments. injury distribution is compatible with the mechanism.
Remember that on plain cervical spine x-rays, 9% of Non-Accidental Injuries often show a typical pattern
children can have pseudosubluxation of C2 on C3 and (figure 11.3).
of C3 on C4. Injuries to the thoracic and lumbar spine
are rare but are most common in the multiply injured Non–accidental injuries must be considered but it is
child. In the 2nd decade of life, 44% of reported injuries important to put all the factors together carefully to
to the vertebral column and/or spinal cord result from avoid any unnecessary distress for the family with
sporting and other recreational activities. When an an inappropriate accusation. However, if there are
injury does occur, multiple levels are often involved as concerns, it is vital that they are explored, to ensure
the force is dissipated; the most common mechanism the well-being and safety of the child that is being
of injury is hyperflexion. treated, and any siblings still at home. Please familiarise
yourself with your local safeguarding protocols.
Spinal cord injury without radiographic abnormality
(SCIWORA) is said to have occurred if the spinal cord
has been injured without an obvious injury to the Injury Pattern
vertebral column. The cervical spine is more frequently
affected because it has the greatest mobility.
Limb injuries
The mortality of isolated limb injuries in children and
adolescents is low. If associated with trauma to other
organ systems, the mortality seems to depend on these
injuries rather than on the extremity. In the context
of damage control resuscitation, definitive repair is
postponed until the patient is fully stabilised. However,
temporary stabilisation of long bone fractures is part of
the resuscitative efforts because it reduces blood loss, Non-Accidental Injury Accidental Injury
pain and the incidence of multiple organ dysfunction
syndrome. Temporary measures include external
Figure 11.3 Non-Accidental Injuries often exhibit a typical pattern.
fixation or casting for more distal fractures.
Crush injuries need early debridement. Reconstructive

surgery is often staged and tailored to the patient’s
condition. Vascular injuries are relatively rare and

Summary
The paediatric trauma patient can be managed
effectively and competently following the
system outlined above and need not be feared.
It is essential to focus on communication with the
child and the family, to enable the most accurate
assessment and treatment. The mechanism will
give an indication of the likely injury, particularly
if the child is unable to localise it and the external
evidence is minimal. Preparation of equipment,
drugs, and fluids before arrival alleviates some
of the stress when faced with a distressed child
and helps to prevent mistakes and ensure timely
assessment and management. Early analgesia
is imperative and improves the assessment and
experience for the child. It is important when
dealing with any child to have an awareness of
non-accidental injury. Certain injuries should

raise suspicion such as rib fractures in an infant,
long bone fractures in a non-mobile child, or an
injury inconsistent with the history.

paediatric trauma workshop:
n how to prepare to receive a paediatric patient
with major trauma;

n understand the differences between adult and
paediatric trauma victims;

n how to conduct a primary survey in a paediatric
patient with major trauma;

n recognize the common injuries that children
sustain;
n recognize the signs of non-accidental injury in
children.


Trauma in children – skills
Insertion of intraosseous needle
Indications:
n inability to obtain vascular access;
n lack of time or expertise to insert a central venous
cannula.
Procedure:
n The most common sites used for intraosseous
access in children is 2-3cm below the tibial

tuberosity on the flattened medial aspect of
the tibia, alternatively the anterolateral surface
of the femur (figure 11.4), 3cm above the lateral Figure 11.4 Insertion of an IO needle into the proximal tibia
condyle, the proximal humerus (figure 5.7), or
the medial malleolus. The major tubercle of
the humerus can also be used as in adults but

it can be difficult to identify in infants. Fractured
bones should be avoided particularly those with
fractures proximal to the site of entry.
n If a tibial IO is inserted, a pillow should support
the knee and proximal lower leg. The skin should

be cleaned.
n In a conscious child, infiltrate the area and
underlying periosteum with 3–5ml 1%

lignocaine.
n The needle is inserted 90° to the skin and
advanced until the bone is reached.

n The drill is then activated and gentle pressure
applied until a ‘give’ is felt as the cortex is

penetrated.
n Remove the trocar and attach a syringe via a short
extension. Correct placement is confirmed by

aspiration of marrow content and easy infusion
of fluid. The aspirated sample can be sent to
the laboratory for routine bloods and used for
bedside glucose estimation.
n Inject a small volume of local anaesthetic to ease
the pain caused by injection.

n Flush the system with 20ml saline to clear any
debris or clot.
n Fluids need to be given in boluses. This is easiest
to achieve using a syringe and three-way tap.

The flow rates under gravity alone are not high
enough for resuscitation.
n Intraosseous lines need to be replaced by venous
cannulation as soon as possible.
Complications:
n extravasation;
n subperiosteal infusion;
n fat and bone marrow embolism;
n osteomyelitis;
n damage to the growth plate and cortex;
n pain and subcutaneous oedema;
n compartment syndrome.

12.
Inter and intra-hospital transfer
of the trauma patient
Learning outcomes
Following this part of the course you will be able to demonstrate an understanding of:
n Managing complex transfer situations
n Leadership and followership in complex transfer situations

n Difficult decision making in transfer
n Different levels of communication
Introduction (MTC, large city hospitals or university hospitals). Within

this system Trauma Units have the capability to assess
The focus of this manual and the ETC is on the and stabilise patients with injuries but their resources
immediate resuscitation and stabilisation of trauma are limited for ongoing care particularly for those with
patients. This requires a team who are focussed and head injuries or with multiple injuries requiring ITU
working together to achieve this goal. There will always care. Major Trauma Centres provide all the resources
come a time in this process where complex decisions to receive seriously injured patients around the clock.
have to be made about what will happen to this patient Pre-hospital triage is based on a pre-defined triage
next; they cannot remain indefinitely in the Emergency tool (Fig. 12.1), which helps to direct trauma patients
Department. They will have to be transferred to another to the appropriate level of care; the right patient to the
department either within the hospital (intra-hospital) right facility the first time. Seriously injured patients
or another hospital (inter - hospital) for their ongoing should be transferred directly from scene to the MTC,
care needs. Transfer of these injured patients is a more bypassing local hospitals and trauma units. There are
serious and potentially complicated process than many however a number of situations related to time of day,
people realise and the potential for adverse incidents weather and the distance to the nearest MTC where
during transfer is well documented. These adverse patients needs to be taken to the nearest Trauma
incidents relate to important technical and non- Unit for stabilisation ± imaging ± surgery to control
technical skills before and during transfer. This chapter ongoing haemorrhage and then facilitation of an inter
considers the challenges that planning and safely hospital transfer to a MTC for definitive care.
transferring a trauma patient pose to the trauma team
and proposes some strategies to mitigate the risks. The More mature networks will have a point of contact
technical aspects of performing a transfer safely are between the ambulance service and the hospitals
well documented in both textbooks and papers, and within the network, such that conference call facilities
therefore will not be considered in detail in this chapter. exist and advice can be sought from the MTC for major
trauma patients in trauma units. To complement these
trauma networks there has been the development
Trauma Networks of enhanced care pre hospital teams, that include
physicians and critical care capabilities. These teams
As outlined in chapter 2, there are a number of links in will deliver critical interventions such as general
the chain of Trauma care with well-defined roles and anaesthesia and blood transfusions on scene to
responsibilities of all partners involved in the chain. stabilise the patients and make these extended
Ideally all chain partners are organised within a Trauma primary retrievals safer. Depending on the network,
Network. These networks are configured as hub and these teams may also facilitate inter hospital transfers
spoke systems with peripheral Trauma Units (TU, of trauma patients.
District Hospitals) feeding into Major Trauma Centres
CHAPTER 12 INTER AND INTRA-HOSPITAL TRANSFER OF THE TRAUMA PATIENT | 153

Figure 12.1 Ambulance Service Trauma Triage Tool (EOC = Emergency Operation Centre)
Your place of work will dictate how you interact distraction from parameter changes on the monitor
with your trauma network. If you work in a smaller and loss of situational awareness can and commonly
Trauma Unit, you may have cases that warrant care do occur. Movement between departments means
in a MTC self present to you, or brought in due to life that access to emergency drugs and equipment is
threatening injuries that require stabilisation. You will limited to what the team can carry in grab bags or on
need to resuscitate this patient and then plan where the transport platform.
the most appropriate destination is. If you work in a
MTC as a trauma team leader, you may be contacted by Inter hospital transfers will involve decisions about
a trauma unit to discuss patient transfers, or potentially the most appropriate transport modality (Table 12.1)
asking for advice and assistance with complex decision and the make-up of the accompanying transfer team.
making. If the patient arrives in your facility direct from Logistical considerations may require attention to
scene (a primary transfer), they will need resuscitating prevent it the transfer being to the detriment of the
by your team before you agree where the next most ongoing resuscitation, and the team must consider
appropriate destination for the patient is: imaging, strategies to mitigate this risk. Pre planning of as many
interventional radiology, theatres, intensive care or aspects of personnel and equipment as possible is
a trauma ward? What are the risks associated with essential. The requirements to arrange a transfer,
moving them to these departments and how might potentially arrange for a transfer team, who have not
these risks be mitigated? Might the plan have to been involved in the patients care so far, and decide on
change and if so is your team aware of the alternatives? the transport modality carries risks of distraction and
loss of situational awareness. Good communication
The risks and benefits of transfer is essential at all times. The team must consider how
Alongside the technical risks of physiological best to tackle all these elements of the transfer based
deterioration, equipment malfunction, failure and on the resources available to them.
dislodgement of drips, drains or tubes, physically
moving the patient adds a significant dynamic for The mechanism and pattern of injury should be
the team. Communication loops are easily broken, considered to advise precautions that should be

taken when packaging patients for transfer, for Trauma Team Leadership
example, minimal movement log-rolls in patients
with polytrauma where there is suspected pelvic
Considerations
and spinal injuries. Long bones should be splinted
to reduce the risk of hypovolaemia during transfer The Environment
and reduce analgesic requirements. The potential for The resuscitation of seriously injured patients can
deterioration during transfer should be anticipated exceed the resources of local hospitals and trauma
and planned for: for example if the patient has a units and leading a trauma call under these conditions
significant traumatic brain injury confirmed on scan therefore means managing limited resources: Planning
with a borderline GCS, it is safer to electively intubate ahead will help to mitigate the risk ensuring that the
pre departure. Hypothermia is a real risk in all trauma required help and senior clinician input is available. Good
patients; easily overlooked and preventable. working knowledge of your department and hospital
will help with planning and decision making; staffing
It is easy for important information to be lost between levels during different times of the day (operating
teams when a patient is transferred. Case notes may room staff, radiology staff, specialty staff available and
become lost or displaced and important information their corresponding skills set), availability of technical
forgotten. The scribe during the initial resuscitation resources (Lab, CT, angiography), local protocols
plays an integral role in capturing a lot of the information (massive haemorrhage etc) can vary significantly and
that can be referred back to at a later date, but this affect the hospitals response to major trauma.
relies on clear “closed loop” communication from team
members and not being overloaded with too much Human Factors
information at the same time. A trauma booklet for The sicker and more unstable the patient, the more
recording all the information from observations, the focus will be required by yourself to immediate
team leader and team members, radiologist and other active decisions. Your capacity to forward plan will
specialists is very useful in ensuring all the information therefore at best be limited, and at worse risks you
is in one place and events are properly recorded. becoming distracted and missing important clinical
These structured proformas and handover tools, (e.g. considerations, with risk of patient harm and poor
ATMIST) help to ensure that important information overall team performance. Predicting injury pattern
is not forgotten, is clearly documented and can be based on pre-alert information and mechanism of
referred back to at a later date. If the patient is being injury can help to ensure that you have the correct
transferred to a different hospital it is important that a people attending or en route to you and minimising
copy of this documentation accompanies the patient. the number of calls that need to be made in the midst
It is increasingly common that radiology images can of managing the resuscitation.
be electronically transferred between hospitals – it is
important to confirm that this has occurred. In complex polytrauma cases this may not always be
possible and so calling in a senior colleague as co-
Many polytrauma patients are likely to exceed the ordinator will help to offload some of these tasks. This
resouces available in the Trauma Unit to provide will mean you can focus on what is going on in the
definitive care and transfer to a Major Trauma Centre immediate resuscitation whilst the coordinator liaises
is therefore inevitable. This transfer should take with other specialties/the MTC or Ambulance service
place as soon as possible. At the local hospital only and retains the ability to plan ahead and to make
immediately life saving procedures should be carried critical decisions (Fig. 12.2)
out; diagnostics should be deferred unless they
can be completed without delaying the transfer
process. Within a trauma network, there should be clear
transfer arrangements and guidelines that describe the
indications and procedures for safe and fast transfer.
TABLE 12.1
Mode of Transport
Road Ambulance available, relatively cheap, quick to
activate, can cope with most weather
conditions, reasonable access to patient
Helicopter quicker, expensive, may require a
secondary transfer by land ambulance,
limited space, limited patient access,
limited communication in flight, limited
by weather/ light

your team leader in making some of these difficult
Multiple Levels of Communication decisions, or discuss alternatives based on your own
experience or expertise. It is really important that if
you recognise deterioration or potential risk, that you
convey this information in a timely manner to the team
leader to achieve the best outcome for the patient. In a
busy resuscitation bay this may be difficult, and timing
of interjections and communication loops is a skill in its
own right. This will become easier the more individuals
work together as a team.
Table 12.2 summarises some of the strategies that can

be considered to improve performance and mitigate
risks associated with transfer.
There will be tasks required in preparing to move or
transfer the patient that are outside of your initial
brief or remit, such as packaging or preparing drug
infusions. These tasks are vital but may require forward

planning and actions within your clinical competence.
If given a task that you cannot do, say and suggest
switching with a colleague to do a task that you can
do without the processes stagnating. This is especially
important in time critical transfer (e.g. patient with an
acute extradural haematoma requiring emergency
Figure 12.2 The TTL concentrates on the resuscitation, whereas neurosurgery). Use your experience to inform how you
the Trauma Coordinator assumes an overarching managerial manage each patient, for example if you have noticed
role communicating internally with other staff and departments previous trauma patients are very hypothermic by the
within the hospital and leads the external communication with the time they get to theatre, remember to instigate early
receiving hospital and the transfer team. warming and heat loss prevention strategies early in
the resuscitation and continue these during transfer.
If you are transferring the patient out to a different
hospital, the initial handover and clinical information Effective packaging for transfer is a skill that requires
will need to be passed by you or the coordinator and engagement from the whole team, and probably
then updates given to the receiving unit of when warrants practice in its own right. Consider how you
the patient has left and anticipated arrival time. You will achieve this slickly and effectively, maintaining
should ensure that there is a named point of contact access to IV lines, ensuring there is minimal risk
in the receiving hospital (ideally accepting clinician) of pressure sores and neuropraxia, maintaining
and established the destination for the patient (ED, spinal immobilisation where necessary and without
theatre number or intensive care unit). dislodging anything.
Trauma Team Membership

Considerations
Physiological deteriorations can occur “rapidly”
necessitating changing prior plans. It is essential that the
team are all working towards a shared goal, feel able to
voice concerns and suggest alternatives. While the most
unstable patients potentially have the most to gain from
imaging to plan surgery/interventional radiology, in
cases of ongoing haemorrhage, stopping the bleeding
surgically may have to take priority, or the plan changed
to direct transfer to the operating theatres in refractory
hypotension despite aggressive resuscitation.
Lines of communication between the team and

imaging/operating theatre departments must be
kept open with systems in place to allow for these
unforeseen plan changes. You may have to support

TABLE 12.2
Team Leader Challenges Potential Solutions Team Member Challenges Potential Solutions
Maintaining overview of the • Deputising leadership to team Feedback to team leader and • Addressing colleagues by
ongoing resuscitation, members when coordinating other members of findings and name
alongside forward planning or use a trauma coordinator concerns • Closed loop communication
(fig 12.2)
• If resources allow ask senior
colleague to take over
coordination
• Summary from scribe
• 10 for 10 moment
Telephone conversations with • Discuss options with team Task fixation when given • Clarify missed information
other hospitals/specialties • Peer review decisions procedure to complete with scribe, other team mem-
• Debrief bers or team leader 10 for 10
moment
Difficult decisions: e.g. CT scan • Personal clinical acumen and Disagreeing with proposed • A sk the team leader to clarify
versus direct to theatre that of team course of action rationale for the decision.
• Utilising suitable investiga- Highlight concerns based on
tions and point of care testing your experience. Debrief

• Experience
Anticipating clinical course and • Ensure team has correct equip- Anticipating clinical course and • Utilise personal experience –
interventions warranted ment, monitoring and drugs. interventions warranted e.g. dedicated IV access point
Foresee potential complica- for contrast in CT,
tions and have plans in place • Easily accessible cannula
to manage these – e.g. taking when positioned in road am-
blood with the patient when bulance etc.
moving between departments
if active bleeding ongoing.
Forward planning • Prompt the team to use a Forward planning for •A
nticipate what you would
challenge/ response checklist equipment, monitoring, need in the worse case
and allocate roles point of care testing and drugs scenario, have a plan B – does
this need to be shared with
the team/leader or will this
overload them? If you have to
use the plan B discuss this in
the debrief
Not missing anything • Use a checklist Not missing anything •U
se a challenge response
checklist developed for local
need.
Unfamiliarity with destination • Arrange
for a porter or
hospital clinician to meet the team on
arrival at pre-agreed place –
e.g. ED
Table 12.2 a summary of some of the key considerations of the team leader and team members, and some solutions to improve team
performance. Note the overlap between the considerations for team leader and the team members.
Debrief and improving and non-technical skills further in the future. Feedback
from the MTC to the TU that first dealt with the patient
performance is essential to inform good trauma audit.
You will become accustomed throughout the European There should be a governance system in place for all
Trauma Course to debriefing scenarios and discussing inter-hospital transfers to be reviewed and any learning
some of the issues that the team has encountered. points disseminated back to the teams involved, and
In clinical practice this is something that we can all practitioners who may be involved in subsequent
improve on: the clinical workload in your respective transfers. Enhanced Care teams will have a separate
departments does not pause and time pressures are governance structure but there should be positive
ever present within healthcare. The only way that you interaction between these teams and the hospital
will develop and improve as a team however is if you teams they handover and/or receive patients from.
re-group and discuss how a resuscitation and transfer These feedback loops will draw out positive practice
went. This will not only improve the overall team points and areas for future development. For this
dynamic, but will give individuals reflections points system to work effectively leadership and positive team
that they can take forward to develop their technical membership are required from everyone involved.
Summary
This chapter summarises the complex Human
Factor aspects related to the acute transfer of
major trauma patients; there are multiple levels of
communication, which need to be coordinated to
ensure that no information is lost and all members
of the wider team work into the same direction.
Further information
n Fanara B et al. Recommendations for the intra-hospital
transport of critically ill patients. Critical Care. 2010; 14:
R87
n Brown JB et al: Helicopters improve survival in seriously

injured patients requiring interfacility transfer for
definitive care. J Trauma 2011; 70(2): 310-314.
n Van Lieshout EJ, Stricker K. ESICM PACT: Patient
Transportation. Skills and Techniques. Updated

2011. At: http://pact.esicm.org/media/Patient%20
transportation%201Feb2011%20final.pdf
n AAGBI Safety Guideline: Interhospital Transfer.
February 2009. At: https://www.aagbi.org/sites/
default/files/interhospital09.pdf
n Low A, Hulme J. ABC of transfer and retrieval medicine.
Wiley Blackwell BMJ Books. October 2014

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Chapter 1 Human Factors, Non-Technical Skills and

Chapter 2 Reception and resuscitation of the seriously injured patient 21

Chapter 3 Airway management in the trauma patient 35

Chapter 4 Breathing problems and thoracic trauma 51

Chapter 6 Abdominal trauma 87

Chapter 7 Pelvic trauma 97

Chapter 8 Head trauma 107

Chapter 9 Trauma to the vertebral column and spinal cord 117

Chapter 10 Extremity and soft tissue trauma 131

Chapter 11 Trauma in children 143

Chapter 12 Inter and intra-hospital transfer 153

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Elonka Bergmans Monika Grunfeld Carsten Lott

Alb-Donau-Klinikum, Neurosurgery Consultant in Anaesthesia and Pre-

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Throughout this manual, the male gender is used generically

ABG Arterial blood gas IV Intravenous

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Introduction TABLE 1.2

results in dynamic changes depending on individual n task management

availability. These groups are known as action teams n situational awareness

and a trauma team is a good example of such a team. n decision making

The characteristics of an action team are summarised

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realise that although there appears to be a great deal n d

ensure that all messages are clear and unambiguous. necessary)

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Team work difficult airway, tube thoracostomy or application of

an individual influences a group of individuals to n anticipating future events

achieve a common goal’. To do this the leader needs

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n Know the environment!

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One principle of managing fixation errors is to get a n Re-evaluate repeatedly (10-for-10)

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1. Know the environment.

3. Call for help early.

4. Exercise leadership and followership with

5. Distribute the workload. (10-for-10 concept)

7. Communicate effectively – speak up.

Team? (10-for-10 concept)

18 | EUROPEAN TRAUMA COURSE

Having worked through this chapter you should

These cognitive abilities will be integrated with

the practical skills during the course workshops.

non-technical skills. British Journal of Anaesthesia

Err Is Human: Building a Safer Health System.

Performance and Patient Safety. In: Miller RD,

20 | EUROPEAN TRAUMA COURSE

n Preparation to receive a patient with major trauma

n Receiving and giving a handover

n Performing a primary survey

n Identify the need for and give appropriate analgesia

n How to plan the patient’s subsequent care

n How to perform a secondary survey

Introduction Whatever the pre-hospital system, the subsequent

Planning and preparation for

One principle of managing fixation errors is to get a n Re-evaluate repeatedly (10-for-10)

assessing the circulatory system, applying a pelvic n Pain

n Share the pre-hospital information with the team (ICD)

n Confirm the individual competencies of the TTMs cardiorespiratory arrest

n Ensure that the TTMs have: competent)

● a complete understanding of their role within the control external haemorrhage

● c onfidence to ask for help when required Level-one)

● m anagement of an unexpected peri-arrest n C

additional resources: r adiology

● s taffing (e.g. senior colleague, obstetrician in case s urgical specialties

of pregnancy, paediatrician) o perating room

in a sometimes noisy environment. n support other team members if no chest

n stem any overt haemorrhage

Airway n establish peripheral vascular access, take

as necessary; n apply a pelvic binder if indicated

n monitor end-tidal CO n if competent and indicated, perform extended

n carry out a focused neurological assessment (see

intervention required n compare pupillary size, symmetry and light response

n make physical contact with the patient (e.g. hold hand);

n local protocols IN 2mcg/kg

n physiological condition When time critical interventions are not necessary,

n Other imaging (ultrasound, MRI)

n taking the role of a TTM;

n carry out a primary survey;

n carry out a secondary survey.

n Nose: bleeding, nasal septal haematoma, CSF leak

n Ears: bleeding, blood behind tympanic membrane

n Eyes: foreign body, bulbus trauma, contact lenses

n Jaw: pain, malocclusion

n Neck veins: distension

n No springing of the pelvis, take pelvic X-ray or