American Academy of Emergency Medicine

Written Board Review 2020

Traumatic Disorders

Michael Silverman, MD FAAEM FACP

Vice Chairman-Director of Operations, Department of Emergency
Medicine-Morristown Medical Center; Clinical Associate Professor of
Emergency Medicine; Sidney Kimmel Medical College of Thomas Jefferson
University (SKMC), Morristown, NJ
American Academy of Emergency Medicine
Written Board Review 2020

TRAUMATIC DISORDERS

General Information

 Trauma topics will be covered in four main sections in this review course
o General Trauma
o Musculoskeletal and Orthopedics
o Neurotrauma
o Environmental (burns, lightning, etc.)
 Core Content format produces non-anatomic organization of topics

Trauma Epidemiology
 #1 cause of death ages 1 – 44
 More deaths in children and adolescents (age 1-19) than all other causes combined
 5th leading cause of death overall in US (all ages)

Trimodal distribution of trauma deaths

 Immediate (within minutes)
o Greatest number of fatalities
o Neurotrauma (head or spinal cord)
o Massive exsanguination (rupture of great vessels)
o Airway compromise
 Early (within hours)
o Remainder of serious trauma
o Origin of the “golden hour” concept
o Target group of EMS and Trauma Systems
o Deaths in this group are caused by
 Hemopneumothorax
 Tension Pneumothorax
 Cardiac Tamponade
 Subdural / Epidural hematoma
 Spleen / Liver hemorrhage
 Pelvic Fracture hemorrhage
 Late (days – weeks)
o Due to sepsis, multi-organ failure

Mechanism of Injury
 Frontal Crash
o Cervical Spine Injuries
o Posterior hip dislocations
 Seat Belts
o Shoulder only – Liver / Spleen
o Lap only – Lumbar Spine / Small Intestine
 T-Bone
o 6 inches of intrusion: 16% significant injury
 Roll –over and Auto-Pedestrian: Higher Risk for Injuries
 Firearms
o All handguns are considered low velocity
 Hunting and military rifles are high velocity

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o Extensive internal damage due to kinetic energy

o Close range shot-gun
 Massive injury, contamination
 Falls
o Average floor is 12 feet
o LD 50% is 4 floors; LD 90% is 7 floors
o Upright impact
 Calcaneal fractures, Thoracic and lumbar spine fractures, pelvic fracture
 Domestic Violence
o Leading cause of injury to women (15-44)
o 30-50% due to partner violence
o Clues
 Cover Story / Evasive
 Ever present, overly concerned / domineering partner
 Defensive wounds / Pregnant with injuries
 Delayed presentation
o Reporting Mandatory if deadly weapon
 Strangulation
o Crushed larynx, fractured hyoid, carotid- intimal injury
 Bicycle Handlebar
o Intramural Duodenal hematoma
o Pancreatic injury

Approach to the Patient with Severe Trauma

 Advanced Trauma Life Support (ATLS) guidelines
 Primary Survey (ABCDE’s) – Assess, resuscitate and stabilize life threatening issues immediately
 Airway (with C-spine precautions)
o Single most important pre-hospital / arrival therapy
o Assessment
 Patency
 Maintainability
 Assume a C-spine injury in any patient with multisystem trauma, especially with
injury above the clavicle or altered mental status
o Intubate trauma patients for
 Inability to oxygenate despite supplemental oxygen
 Inability to ventilate
 Inability to clear secretions or blood
 Head injury with GCS less than 8
 Impending airway compromise (hematoma, swelling)
 Technique
o Orotracheal intubation (with in-line immobilization) is the procedure of choice (even with
suspected C-spine injury)
o Surgical Cricothyroidotomy
 Unsuccessful orotracheal intubation
 Procedure of choice with severe midfacial injuries
o Verify position of the ET tube
 Seeing the tube pass through the cords!
 End tidal CO2

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 Listening over axilla for equal breath sounds

 CXR to confirm its distance into the trachea

 Pediatrics
o Per PALS if cuffed tube go half size lower
o Tube size = Age/4 + 3.5
o Less than 12, needle cricothyroidotomy is preferred over surgical (per ATLS)
 Breathing
o Oxygenation
o Pulse oximeter to determine adequacy
o Administer oxygen (FIO2 >85%) to all trauma patients
 Ventilation
o Assess depth, rate, and pattern to determine adequacy
o ABG/VBG
o Continuous ETCO2
o Correct any injuries that may impede oxygenation or ventilation
o Ventilator setting adjustments in trauma
 Low tidal volumes 5-7cc / kg
 Respiratory rate of 20 or greater
 Circulation with hemorrhage control
o Look beyond blood pressure
o Mental Status
o Capillary Refill / Urine output / Pulses / Heart rate
o Elderly patients, athletes, and those on rate controlling medications may not develop
tachycardia
o Control all obvious external hemorrhage
 Direct pressure or pneumatic splint
 Mast / strap to close open book pelvis
o Access – Two large bore (16 gauge) catheters
o Treatment
 2-3 liters of Ringer’s Lactate (or Normal Saline)
 20cc/kg in children
 Partial responders or non-responders: Blood
 Pericardiocentesis for tamponade
 Consider ED thoracotomy for penetrating thoracic trauma victims who lose vitals
in the ED or arrive recently pulseless with myocardial activity (ATLS states
surgeon must be present)
 Disability
o Pupillary Function: size, reactivity, and symmetry
o GCS or AVPU
o Alert, Responds to Verbal, Responds to Pain, Unresponsive
o Motor function, Rectal tone: Spinal cord function
 Exposure
o Completely undress to assess for injury
o Do not allow the trauma patient to become cold – Coagulopathy
 Initial Resuscitation and Tests - Oxygen, 2 large bore IVs, monitor, pulse ox, screening
 X-rays, labs, fluid resuscitation
 AMPLE history
o Allergies

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o Medicines
 Key on Drugs like beta blockers,
 Oral Anticoagulants: Warfarin, Dabigatran, Rivaroxaban and apixaban
o PMHx
o Last meal
o Events
 Secondary Survey - Head to toe exam, “finger or tube in every orifice,” additional diagnostic studies
(X-rays, CT, Ultrasound, etc.)

 Definitive treatment;
o Hemodynamic stability
o Responder, Partial Responder, Non-responder
o Lactic Acid / Base Deficit
o Consult / admit or Transfer
o Don’t forget antibiotics and tetanus

Shock
Definition: inadequate tissue perfusion and organ perfusion
 Hemorrhagic Shock
o Induced hypovolemia secondary to blood loss is the most common cause of shock in the
injured patient
o Early manifestations of shock include tachycardia and cutaneous vasoconstriction
o A narrowed pulse pressure suggests significant blood loss and use of compensatory
mechanisms
o Normal adult blood volume is 7% of body weight, or 5 liters in a 70 kg adult (70cc/kg)
o Amount of hemorrhage can be estimated based on patient’s presentation

Adult Pulse Cap Refill

Class Blood Loss Pulse SBP pressure Mental Treatment
Volume

I < 15% < 750ml <100 -- -- Nl Nl Fluids

II 15 - 30% 750ml - 1.5L >100 -- Narrowed + +/- anxious Fluids

III 30 - 40% 1.5L - 2.0L >120  Narrowed + anxious Fluids/Blood

IV >40% >2.0L >140  Very Narrow +  Fluids/Blood

o Crystalloids (Normal Saline or Lactated Ringer’s) are current resuscitation fluids of

choice. (Warmed)
o 3:1 ratio of crystalloid to blood loss
 Transfuse typed and cross-matched blood when able (Class II), or type specific blood when
needed (Class III)
 Transfuse type O when needed (Class IV)
o Rh Positive for males, Rh Negative for females of childbearing age
 Platelets and FFP (1:1:1) for massive transfusions
 Consider PCC’s if on newer anticoagulants

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 Tranexamic acid
o In adult trauma patients with severe hemorrhagic shock
o SBP <75 mm Hg, with known predictors of fibrinolysis
o Only administer TXA if less than 3 hours from time of injury

Non-Hemorrhagic Shock
 Tension Pneumothorax
o Develops when air enters the pleural space and a ball valve mechanism prevents escape
of air from the pleural cavity
o Pathophysiology: Total lung collapse, increased intrathoracic cavity pressures, impairment
of venous return, and fall in cardiac output
o Hallmarks: Hypotension, absent breath sounds on affected side, deviation of trachea
away from the affected side, and respiratory distress
 Neurogenic Shock
o Shock due to loss of peripheral vasomotor tone after spinal injury
o Pathophysiology: Sympathetic fibers exit spinal cord T1-L2/3. Complete cord lesions can
disrupt sympathetic tone, producing vasodilatation and unopposed vagal stimuli to heart.
o Hallmarks: Hypotension with normal heart rate or bradycardia, lack of vasoconstriction on
exam. (“warm shock”)
 Cardiac Tamponade
o Most commonly identified in penetrating thoracic trauma
o Pathophysiology: Pericardial effusion (blood) that increases intra-pericardial pressures to
the point that filling of the heart is impaired
o Hallmarks: Hypotension, tachycardia, muffled heart sounds, engorged jugular veins, and
resistance to fluid therapy

 Assessment
o Response to fluids (vitals, cap refill, pulses)
o Urine output
 0.5ml/kg/hr in adults
 1.0ml/kg/hr in kids
 2.0ml/kg/hr in infants
o Resolution of Lactic acidosis

Trauma by Body Regions

Abdominal Trauma
General
 Abdominal cavity extends from pubic symphysis to nipple line (4th intercostal space in exhalation)
 Abdominal injuries may be occult initially due to altered mental status and lack of findings on
examination
 All patients with significant mechanism should be evaluated for intra-abdominal injuries. Benign
initial exams in 20% with injury
 Penetrating abdominal trauma with shock or peritoneal signs should go to the OR
 Diaphragm Injuries
o Majority are caused by penetrating trauma
o Injuries are more commonly diagnosed on left (80%), but this may be due to liver blocking
the herniation of bowel contents
o Lung injury associated with penetrating abdominal trauma indicates diaphragmatic injury

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o CXR may show effusion, blurred diaphragm, herniated viscera or NG tube

o CT and MRI helpful in diagnosis
 Hollow Viscus
o May be injured by blunt or penetrating mechanisms
o Involves hemorrhage and peritoneal contamination (irritation, infection)
o Latency of symptoms after rupture

Material Peritoneal Irritation

Blood rapid (maybe)
Gastric (acidic) fluid rapid
Bowel fluids delayed (up to 6-8 hours)
Urine non-irritating

o Parts of duodenum are retroperitoneal. Symptoms after rupture may be delayed

o Antibiotics are mandatory for suspected bowel injuries
Penetrating
 Stab wounds injure along wound track and most commonly involve the liver (40%), small bowel
(30%), diaphragm (20%), and colon (15%)
 Local exploration of the stab wound in patient without peritonitis or hypotension may be indicated
as up to 33% of stab wounds do not penetrate the peritoneum
 Penetration through the anterior fascia increases risk of intra-abdominal injury
 GSW’s may also have concussive injuries, bullet fragments and secondary projectiles (bone
fragments) and most commonly involve the small bowel (50%), colon (40%), liver (30%), and
vascular structures (25%)
 Exploratory laparotomy standard if penetration of abdominal cavity suspected

Retroperitoneum
 Significant hemorrhage (several liters) possible, especially with pelvic fracture
 Signs, symptoms may be slow to develop after injury
 Duodenal injury – commonly retroperitoneal rupture

Solid organs
 Primary problem is hemorrhage. The most commonly injured organs are spleen (40-55%), liver
(35-45%), and retroperitoneal hematoma (15%)
 Pancreatic injuries usually occur from penetrating trauma or direct blow to epigastrium
 Role of non-operative management for solid organ injury has been increasing
 Patient’s condition, not only grade of organ injury, predicts success of non-operative management

Vascular
 Active bleeding – by clinical exam or by extravasation on CT or angiogram – must be addressed
 Angiography and embolization if stable and associated with blunt abdominal trauma
 Operation if unstable or penetrating abdominal trauma

Diagnostic testing
 Plain radiographs
o Blunt Trauma

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 CXR useful to show diaphragmatic rupture or free air

 Pelvic X-rays useful to show pelvic fracture, often associated with abdominal injuries
o Penetrating Trauma
 X-rays may show foreign bodies and imply trajectories

 Diagnostic Peritoneal Lavage (DPL)

o Excellent screening test, now used primarily for unstable pt
o 98% sensitive
o Positive DPL values
 10cc of gross blood immediately or
 >100,000 RBC’s / l (blunt trauma) or
 >10,000-20,000 / l (penetrating trauma)
 >500 WBC’s / l
 Gram stain with bacteria
 Any bile, bowel contents, vegetable matter
 Presence of lavage fluid in chest tube or Foley drainage

Advantages Disadvantages
Sensitivity Nonspecific
Availability Cannot evaluate retroperitoneum
Rapid Invasive
Safe (complication rate ~1%) Non-repeatable, may obscure
Inexpensive subsequent CT

 Ultrasound – Focused Abdominal Sonography in Trauma (FAST)

o Performed at bedside in 1-2 minutes
o Limited risk for pregnant or coagulopathic patients
o Ability to perform serial exams

Advantages Disadvantages
Accurate Nonspecific
Rapid Operator dependent
Noninvasive Cannot evaluate retroperitoneum
Repeatable Does not detect bowel injuries
Also evaluates for without hemoperitoneum
Pericardial and pleural fluid Misses diaphragm, bowel and
some pancreatic injuries

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 CT scanning
o Hemodynamically stable patients only
o Oral contrast optimal, but not mandatory. Do not delay CT to give oral contrast
o Rectal contrast rarely needed for blunt trauma
o Rather high false negative rate (2-25%) – Diaphragm, pancreas, bladder and bowel
injuries. Free fluid in the abdomen without solid organ injury suggests injury to these
structures
o CT has greater specificity than either ultrasound or DPL
o CT in penetrating abdominal trauma is limited

Advantages Disadvantages
Sensitivity Nonspecific
Availability Cannot evaluate retroperitoneum
Rapid Invasive
Safe (complication rate ~1%) Non-repeatable, may obscure
Inexpensive subsequent CT

Chest Trauma
General
 Thoracic trauma accounts for 25% of civilian trauma deaths
 Large majority (85 – 95%) of chest injuries do not require thoracotomy / operative repair
 Hypoxia is the most serious threat of chest trauma
 Penetrating chest injuries frequently produce pneumothorax, and 75% are associated with
hemothorax
 Place subclavian lines on side of thoracic injury, unless vascular injury is suspected

Aortic Disruption
 Associated with blunt trauma, high speed deceleration mechanisms
 Most common site (90%) just distal to left SCA at ligamentum arteriosum
 80-90% die at scene, 50% of remainder die within 24 hours if not repaired
 May have no external evidence of thoracic trauma (1/3 of patients)
 Diagnosis
o Symptoms
 Retrosternal or interscapular pain (25%)
 Dyspnea
o Exam
 Frequently unrevealing
 Pulse deficits
 New harsh systolic murmur over precordium
 Pseudocoarctation – isolated upper extremity hypertension with decreased or
absent femoral pulses
 Voice changes or hoarseness without laryngeal injury
 Paraplegia
o CXR
 Superior mediastinal widening (>8.0 – 8.5cm) on upright PA (most common)
 Rightward deviation of esophagus and/or trachea at T4

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 Obliterated or indistinct aortic knob

 Displaced L main bronchus >40 degrees below horizontal
 Widened paratracheal stripe or deviation to R
 Widening of paraspinous stripes (L or R)
 Left apical pleural cap
 Up to 1/3 have normal initial CXR
o Contrast Enhanced Dynamic CT scan: (New Gold standard)
 Accurate
 Mediastinal hematoma
o Transesophageal Echocardiography (TEE)
 Demonstrates lesion and hematoma
o Angiography
 Old gold standard, demonstrates lesion (rarely used)
 Management
o Operative repair
o Immediate medical management with beta blockers (to reduce shear forces), then
nitroprusside (control BP) to maintain a systolic BP between 100 and 120mmHg while
preparing for OR

Cardiac Injuries
 Penetrating Cardiac Injuries and Pericardial Tamponade
o Stab wounds have higher survival rates than GSW’s
o Iatrogenic perforation of right atrium (most commonly) by catheter placement
o Classic findings of pericardial tamponade (Beck’s triad: JVD, hypotension, muffled heart
tones) are frequently absent
o Kussmaul’s sign: Distended neck veins with inspiration
o CXR unhelpful. Noncompliant pericardium does not distend acutely
o PEA may be the presentation
o Electrical alternans is pathognomonic for tamponade, but is rarely present in the acute
scenario
o Echocardiography (transthoracic or transesophageal) for pericardial effusion
o Treatment
 Stable patients - to OR for repair
 Unstable patients – Pericardiocentesis (10-20cc may be lifesaving)
 Moribund patients – ED Thoracotomy

 Blunt cardiac rupture

o 80 - 90% immediately fatal
o Compression of blood filled chamber, usually right ventricle
o Survivors usually have R atrial tear with pericardial tamponade
o Murmur may imply septal rupture or valve injury (aortic most common)
o CXR unhelpful unless identifying position of CVP line
o Cardiac Ultrasound: presence of pericardial fluid and tamponade
o Treatment same as pericardial tamponade
 Blunt Myocardial Injury (BMI) (previously Myocardial Contusion, other names)
o Usually result from high speed vehicular trauma
o Signs / Sx: Tachycardia, dysrhythmias, conduction delays, cardiogenic shock
o Standard cardiac enzymes nonspecific, not clinically helpful

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o Echocardiography poor as screening test, but helpful if cardiogenic shock or dysrhythmias

are present
o Provide fluid / pressor support, treat dysrhythmias as needed
o If initial ECG is normal, 4 -6 hours of monitoring in hemodynamically stable patient is
recommended

Pulmonary Injuries
 Pulmonary Contusions
o Results from direct chest wall trauma
o Appear as opacifications of lung
 Usually present on arrival, always within 6 hrs of injury
o Predispose to V/Q mismatch, pneumonia, ARDS
 ABG shows hypoxemia and widened A-a gradient
o Analgesics, good pulmonary toilet important to avoid atelectasis and pneumonia
o Pneumonia is most common and most significant complication
o Anticipate mechanical ventilation if
 >28% of lung volume (by CXR)
 More than one lobe involved
 Utilize Intermittent Mandatory Ventilation (IMV)
 Lower tidal volumes (5-7cc/kg)
 PEEP to prevent alveolar collapse
o Normal lung down (improve ventilation perfusion matching to injured lung)
 Lower Tracheobronchial injuries
o Usually caused by blunt deceleration mechanism, shear forces
o Most are within 2cm of carina
o Cervical tracheal injuries caused by direct blows
o High mortality due to associated injuries, complications (mediastinitis)
o Signs / Sx: Dyspnea, hemoptysis, SQ emphysema, Hamman’s sign
o CXR: PTX, pneumomediastinum, non-compressed (round) ETT balloon
o Treatment: diagnostic bronchoscopy, OR repair
 Displaced fractures may be associated with pneumothorax, intrathoracic vascular injuries

Fractures
Clavicle
 5% of fractures
 Most commonly fractured bone during childhood
 Fractures of middle third most common (80%)
 Direct force to lateral aspect of the shoulder
 Fractures of medial third (5%) occur due to direct blow to chest
 Fracture of lateral third (15%) due to blow on top of shoulder

Rib Fractures and Flail chest

 Fractures of 1st / 2nd ribs may be markers of other serious intrathoracic injuries; lower rib fractures
may be associated with abdominal injuries
 Displaced fractures can produce pneumothorax (PTX) and/or hemothorax (HTX), or damage
nearby organs
 Analgesics and, good pulmonary toilet are important to avoid atelectasis and pneumonia
 Flail Chest 3 or more adjacent ribs with segmental fractures
o Segment shows paradoxical motion during respiration

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o Increases work of breathing

o Treatment: Pain control, Intubation, positive pressure ventilation

Sternum
 Due to anterior blunt trauma, usually when chest strikes steering wheel
 Rate of sternal fracture is more likely if restrained than unrestrained
 Increased 3 fold since use of across the shoulder belts
 Isolated sternal fractures are benign with low mortality (0.7%)
 Myocardial contusion in 1.5-6%
 No association with aortic rupture
 Mediastinal Hematoma
o Acute blood loss
o Compression of adjacent structures
 Lateral radiographic view of sternum is diagnostic
 CT shows associated mediastinal hematomas and injuries

Hemothorax
 Decreased breath sounds, dullness to percussion
 Upright CXR shows as little as 200 – 300cc as blunting of costophrenic angles
 Supine CXR shows diffuse haziness
 25% have concomitant pneumothoraces
 73% have extra-thoracic injuries
 Most are self-limited
 Treatment
o Large bore (36+ fr) chest tube
 Indications for OR
o Initial drainage of 1500cc
o Bleeding or ongoing bleeding >200cc per hour for 2-4 hrs
o Persistent hypotension
o Persistent air leak or failure of lung to re-expand
 Auto-transfusion of shed blood is possible with appropriate equipment

Penetrating Chest Trauma

Pneumothorax (PTX)
 Simple PTX – collection of air in pleural space
o Clinical exam poor for small PTX. CXR (with expiratory view?) best test
o CT scan may pick additional small pneumothoraces
o SQ Emphysema is commonly due to PTX
o Small PTX may be followed with serial CXR’s
o Treatment: Chest tube. Use large (36+ Fr) tube due to likely associated HTX
 Tension PTX
o Large PTX under pressure compresses mediastinum & contralateral lung
o Clinical diagnosis: (Do not wait for CXR to confirm)
 Dyspnea
 Hypotension
 Tachycardia (late: PEA)
 Tracheal deviation away from affected side (Check at sternal notch!)
 Jugular venous distention

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 Ipsilateral hyper-resonance
 Ipsilateral absent breath sounds
o Treatment: immediate decompression via needle thoracostomy or chest tube
 Open PTX (Sucking Chest Wound)
o Wound is usually apparent
o Large defects (2/3rds the diameter of the trachea) will allow air to move preferentially
through the chest wall defect, causing ineffective ventilation and hypoxia
o Cover with occlusive dressing sealed on three sides
o Watch for Tension PTX – open dressing to relieve
o Place chest tube at separate site

Cutaneous injuries
General
 General wound care principles apply to cutaneous injuries, wounds, and lacerations
 X-rays are indicated if any suspicion of a foreign body (Wood, plastic, and most organic materials
are radiolucent)
 Always consider possible underlying injuries and don’t forget to address tetanus

Bite wounds
 High risk for contamination: Use careful wound care and closure debated
 Prophylactic antibiotics generally used for human bites and bites on hand
 Staphylococcus and Streptococcus is common
 Human Bite – Eikenella corrodens
 Cat Bite – Pasteurella multocida
o 50-80% of infected wounds
o Often develops within 24 hours
 Dog Bite – Capnocytophaga canimorsus
 X-rays appropriate to evaluate for foreign bodies (esp. broken teeth) as well as fractures
 Consider rabies prophylaxis in high risk animals (raccoons, dogs, bats), check current CDC
recommendations

Thermal Burns <See Section 14 Environmental >

Electrical Injuries <See Section 14 Environmental >

Puncture wounds
 High risk for infection, usually skin flora. (Rubber sole shoes may harbor pseudomonas species)
 Difficult to assess depth
 X-ray / Ultrasound for foreign body

Facial Trauma
General
 Maxillofacial trauma is associated with elder / child abuse and domestic violence
 Most common facial fracture is nasal, then mandible

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Dental 1
 Ellis classification of dental fractures 2
o Class I – enamel only 3
 No hot / cold sensitivity
o Class II – enamel and dentin
 Hot / cold sensitivity
 Needs to be covered / F/U in 24 hours
o Class III – enamel, dentin, and pulp
 Pink tinge or drop of blood at fracture site
 Immediate dental referral
 Isolated dental fractures – outpatient treatment with antibiotics, analgesics

Le Fort classification of facial fractures

 Le Fort I: palate-facial disjunction
o Horizontal fracture of the maxilla
 Upper alveolar ridge / maxilla is mobile
 Le Fort II: Pyramidal disjunction
o Fractures through nasal bones and infraorbital rim
o Nose, hard palate, and upper teeth mobile as a unit
 Le Fort III: Craniofacial disjunction
o Fractures through zygomatic frontal suture and frontal
bone
o Entire midface, including zygomas, mobile
o Non-symmetrical Le Fort fractures are common

Zygomaticomaxillary complex fractures

 Depressed malar eminence
 Flattening of the cheekbone
 Pain upon palpation of the zygomatic eminence
 Lateral subconjunctival hemorrhage may be present
 Paresthesia of the lateral side of the nose and upper lip
 Diplopia upon upward gaze (entrapment of the inferior rectus muscle)
 Rarely, trismus occurs
 X-rays or CT for diagnosis
 Consult for definitive repair

Mandibular
 Malocclusion of teeth, inability to bite down imply mandible fractures
 Mandible is a ring structure, frequently fractures in 2 places
 Most common sites: condyle, body, and angle
 Plain X-rays or panorex films are usually adequate for diagnosis
 Open mandible fractures need antibiotics directed toward oral flora (penicillin or clindamycin
common)

Orbital Fractures
 Orbital floor fracture (most common)

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o Pain and diplopia on upward gaze

o Enophthalmos
o Hypoesthesia of infraorbital nerve (ipsilateral cheek and lip)
o Limitation of upward gaze (entrapment of inferior rectus muscle and fat)
o Radiograph
 Air fluid level in maxillary sinus
 Tear drop (soft tissue into maxillary sinus)
 Disruption of floor
 Orbital emphysema
 Medial wall fracture
o Epistaxis
o Emphysema of lids or conjunctiva
o Limitation of lateral gaze (rare, entrapment of medial rectus)
o Radiograph
 Unilateral clouding of ethmoid sinus
 Orbital emphysema
 Treatment
o 30% of these fractures have associated ocular injuries
o Decongestants and antibiotics
o NO blowing their nose
o Refer to ophthalmology (Surgery is infrequently needed)

Genitourinary Trauma
General
 Approximately 80% of GU injuries involve kidney, 10% involve bladder
 Majority of GU injuries are from blunt trauma
 ~80% of patients with renal injuries have other serious injuries
 CT scan is imaging study of choice for upper GU system, perform for
o Gross hematuria
o Microhematuria plus hypotension or associated injuries
o Rapid deceleration mechanism
o Penetrating trauma with proximity to kidney

Bladder
 Bladder injuries often associated with pelvic fractures
 Bladder rupture may produce intraperitoneal or retroperitoneal extravasation of urine
 Imaging may be by contrast urethrogram / cystogram or CT

Urethral injury
 Posterior injuries (membranous prostate) occur with pelvic fractures
 Blood at meatus, scrotal hematoma, perineal ecchymosis, or high-riding prostate imply urethral
injury
 Do retrograde urethrogram (RUG) before placing foley
 Delay RUG and foley if pelvic angiography is required as it may obstruct views

External Genitalia
 Standard management of lacerations
 Testicular ultrasound will help identify extent of injury
 Testicular contusions = analgesics

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 Testicular rupture = OR

Renal
 90% of renal injuries are contusions
 Injuries usually produce hematuria, but not always (ureteral transactions and major hilar injuries
may prevent hematuria)
 Non-operative management is common, unless uncontrolled bleeding or other major injuries
 CT with IV contrast is study of choice if stable. If unstable, one shot IVP in OR

Ureter
 Rarely injured in blunt trauma
 IVP is study of choice to look for extravasation

Head Trauma
General
 Traumatic brain injury accounts for ~30% of all trauma related deaths in patients less than 45 years
 Uncontrolled intracranial hypertension is most frequent cause of death in patients sustaining
severe head injury
 Altered level of consciousness is hallmark of injury
 CT scan is study of choice for intracranial injury
 Intoxicated patients have higher incidence of head injury
 Patients with head injuries from non-vehicular collisions are more likely to need surgical
intervention, particularly if comatose or lateralizing
 Head injuries are seldom the cause of hypotension, except as terminal event
 ACEP clinical Policy ”A head CT scan is not indicated in those patients with MTBI who do not
have”
o Headache
o Vomiting
o Age greater than 60 years
o Drug or alcohol intoxication
o Deficits in short-term memory
o Physical evidence of trauma above the clavicle
o Seizure

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Glasgow Coma Score

 Quantitative assessment of level of consciousness
 Mild 14-15
 Moderate 9-13
 Severe 3-8

Eye Opening
Spontaneous 4
To verbal command 3
To pain 2
None 1
Verbal Response
Oriented - converses 5 Aware of self and environment; oriented to person, place and time
Disoriented - converses 4 Organized and well-articulated, but disoriented to person, place or time
Inappropriate words 3 Random exclamatory recognizable words
Incomprehensible 2 Moaning, no recognizable words
No response 1
Motor Response Assess for the best extremity score
Obeys verbal commands 6
Localizes to painful stimuli 5 Moves limb toward painful stimulus
Flexion withdrawal 4 Pulls away from pain in flexion (utilize extremity)
Abnormal flexion 3 Decorticate posturing
Extension 2 Decerebrate posturing
No response 1
(Remember Mike’s Memory technique: 3-4-5-6 and go down from your Head)

 Cushing’s Response to elevated ICP

 Hypertension, bradycardia, and abnormal respiration
 Treatment
 Prevent hypoxia, ischemia, hypercarbia, and increased ICP

Intracranial injuries <See Section 1 Neurotrauma >

Scalp lacerations / Avulsions

 Scalp has rich blood supply, can bleed profusely
 Carefully palpate lacerations for possible underlying fractures
 Shaving hair prior to repair is not necessary (increases infection rate)
 Close wide galeal defects if possible with buried sutures to prevent subgaleal hematoma and scar
retraction
 Sutures or staples to close skin

Skull fractures
 CT scan is imaging study of choice. Skull films have limited (no) utility
 Non-depressed linear skull fractures – no specific treatment
 Depressed and open fractures need operation
 Basilar skull fractures
o CSF rhinorrhea / otorrhea (Ring sign or halo on filter paper)

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o Hemotympanum
o Battle’s sign: retroauricular ecchymosis
o Raccoon’s eyes: infraorbital or periorbital ecchymosis
 Up to ~20% may develop meningitis

Injuries of the spine < See Section 5 Musculoskeletal >

Lower extremity bony trauma < See Section 5 Musculoskeletal >

Neck Trauma
 Multiple injuries are common in the neck – numerous vital structures in exposed area
 Promptly address airway management. Distorted anatomy may produce airway challenges
 Presume cervical spine injury until ruled out
 Nexus Criteria: No C-spine radiography if all of the following
o No posterior or midline cervical spine tenderness
o No evidence of intoxication
o Normal level of alertness
o No focal neurologic deficit
o No painful distracting injuries

Laryngotracheal injuries
 Commonly due to direct blow to anterior neck
 Signs / Sx: dysphonia, hoarseness, stridor, dyspnea, SQ air, tracheal deviation
 Tracheal disruption commonly occurs at cricoid area – difficult airway situation
 Options include intubation over bronchoscope with immediate laryngoscopy / bronchoscopy or
immediate tracheostomy
 Plain X-rays plus CT scan appropriate in stable patients

Penetrating Neck Trauma

 5-10% of all traumatic injuries
 If platysma muscle is violated, injury to deep structures should be suspected
 Soft Signs
o Hemoptysis / Hematemesis
o Dyspnea
o Dysphonia / Dysphagia
o Subcutaneous air
o Non-expanding hematoma
o Focal Neurologic deficits
 Hard Signs
o Expanding hematoma
o Severe active bleeding
o Shock, unresponsive to fluids
o Decreased radial pulse
o Vascular bruit or thrill
o Cerebral ischemia
o Airway obstruction
 Bleeding should be controlled by direct pressure or operative exploration
 Blind clamping is discouraged – risk of damage to other structures
 Obvious aerodigestive injuries or hemodynamic instability go to OR
 Classically 3 anatomic zones

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 Diagnostic approach in stable patients

o Zone 1
 Sternal notch to cricoid cartilage
 Angiography, bronchoscopy, endoscopy
o Zone 2
 Cricoid cartilage to angle of mandible
 Surgical exploration
 OR Angiography, bronchoscopy, endoscopy
 OR ultrasound
 OR serial examinations (some centers)
o Zone 3
 Angle of mandible to base of skull
 Angiography

Vascular injuries
 Carotid Artery
o Most commonly injured artery in the neck (22%)
 Vertebral artery (1.3%)
 Significant vascular injuries may be clinically occult, but signs include
o Expanding or pulsatile hematoma
o Bruit
o Pulse deficit
o Hemothorax
o Neurologic deficits
o Horner’s syndrome has been associated with vascular injury
 Ptosis
 Miosis
 Enophthalmos ( +/-)
 Anhydrosis
 Injuries may present as neurologic deficits similar to stroke, symptoms may develop weeks later
 Diagnosis by angiography or MRI/MRA
 Medical management (anticoagulation, platelet inhibition) usually adequate
 Jugular Vein
o Most frequently injured vessel in the neck

Ophthalmologic Trauma

Corneal Abrasions < See Section 11 HEENT >

Corneal Lacerations
 Signs of corneal perforation (full thickness)
o Loss of anterior chamber depth
o Tear-drop shaped pupil
o Blood in anterior chamber
o Seidel’s sign (washing away of fluorescein by leaking aqueous humor)
 Full thickness lacerations require operative repair
 Superficial partial thickness
o Cycloplegic

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o Topical antibiotic

Corneal burns
 Topical anesthetic and immediate copious irrigation (until pH is 6-8) are the initial treatment for any
chemical burn
 Acids = coagulation necrosis, shallower burns
 Alkalis = liquefaction necrosis, deeper burns

Ultraviolet = UV keratitis
 Pain, photophobia, foreign body sensation 6-12 hours after exposure
 Fluorescein staining shows numerous punctate corneal “microdots”
 Use analgesics, cycloplegic, erythromycin ointment, patch overnight

Eyelid lacerations
 Simple lacerations may be repaired in the ED
 Full thickness lacerations, those involving the lid margins, and those with possible lacrimal duct
involvement need an ophthalmologist

Orbital and Intraocular Foreign Body

 Suspect with any ocular injury associated with metal on metal contact
 Grinding, sanding, drilling, and hammering
 Organic compounds have higher propensity to cause infection
 Admit, protective eye shield, antibiotics

Hyphema <See Section 11 HEENT >

Lacrimal Duct Injuries

 Most frequently occur with naso-orbital fractures and soft tissue lacerations
 Injury medial to the punctum suggests injury to lacrimal duct
 Repair prevents epiphora and dacryocystitis

Penetrating globe injuries

 Penetrating mechanism, foreign bodies, flat anterior chamber, hyphema, pupil defect, new vision
loss, difficult fundoscopy suggest penetration of globe
 Fluorescein staining may show “waterfall” of unstained aqueous fluid from wound (Seidel test)
 Any penetration of globe = OR for repair

Traumatic iritis
 Pain upon pupillary motion after blunt trauma
 Cell and flare on slit lamp
 Treat with topical cycloplegics, analgesics, outpatient referral

Otologic Trauma
General
 Cartilage of ear is poorly vascularized
 Use careful wound care and closure to avoid infection
 Avoid buried sutures if possible, use 5-0 or 6-0 absorbable if needed

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Hematoma
 Auricular hematomas can result in necrosis of the underlying cartilage and “cauliflower ear”
deformity
 Hematomas should be incised and evacuated, with dressings secured for 24 hours then recheck

Perforated tympanic membrane

 Occurs secondary to lightning strike, blast injury, and basilar skull fracture
 Most recover without sequelae unless
 Disruption of ossicles or mastoid injury
 Look for cerebrospinal fluid otorrhea

Pediatric fractures < See Section 5 Musculoskeletal >

Pelvic fractures
 Associated with major bleeding, vascular, rectal, and genitourinary injuries
 Standard X-rays vs CT, CT scans often used to evaluate fully in stable patients
 Massive bleeding into retroperitoneum (up to 4L) possible, from venous or arterial sources
 Angiography / embolization frequently useful in stable patients with ongoing bleeding
 Temporary stabilization / splinting: MAST or sheet splint until orthopedic stabilization

Soft-tissue extremity injuries < See Section 5 Musculoskeletal >

Amputations / Re-implantation
Amputations of digits are most common
 Thumb and index finger of dominant hand are most important for function
 Amputations proximal to the nail bed may be candidates for re-implantation
 Indications
o Multiple digits
o Thumb
o Wrist / Forearm
o Sharp amputations proximal to elbow
o Single digits between PIP and DIP joint (distal to flexor digitorum superficialis insertion)
o All pediatric amputations
 Preservation of recovered tissue (by EMS or ED personnel) should include
o Wrap in sterile gauze, damp with normal saline
o Place in a waterproof bag
o Cool over ice for possible replacement
 Consult plastic or hand surgeon as appropriate
 Warm ischemia is tolerated for 6-8 hours, cooling to 4 degrees C allows for 12-24 hours for distal
amputations

Compartment syndromes < See Section 5 Musculoskeletal >

High-pressure injection injuries

 Industrial sprayers and other high pressure equipment may cause serious injuries with minimal
exam findings
 Usually the index finger of the non-dominant hand

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 Single most important factor is type of material injected

o Paint and paint thinner produce inflammatory response
o Grease has lower incidence of amputation
 Hours after injury: painful, swollen, pale digit
 X-rays may show air / other material dissecting along tissue planes
 Treatment: analgesics, tetanus, antibiotics, elevate affected area, consult specialist for possible OR
debridement
 Avoid digital nerve blocks – concerns of increasing edema and neurovascular damage

Injuries to joints < See Section 5 Musculoskeletal >

Penetrating Trauma to the Extremities

 20-40% of gunshot wounds have extremity involvement
 Penetrating trauma causes about 80% of all extremity vascular injury
 Hard signs of arterial injury include: (OR)
o Absent or diminished distal pulses
o Arterial bleeding
o Expanding hematoma
o Audible bruit
o Palpable thrill
o Distal ischemia
 Soft Signs of arterial injury include
o Small, stable hematoma
o Injury to related nerve
o Unexplained hypotension
o History of arterial bleeding
o Complex fracture
 An ankle brachial pressure index (ABI) of greater than 1.0 is normal. An ABI of less than 0.9 is
indicative of EVALUATION arterial injury. It cannot detect intimal flaps
 Duplex ultrasonography, CTA and arteriography can delineate the injury

Spinal cord and nervous system trauma < See Section 1 Neurotrauma >

Upper extremity bony trauma < See Section 5 Musculoskeletal >

Trauma in Pregnancy
 Blunt abdominal trauma in pregnant patients is most commonly caused by motor vehicle crashes,
then falls, then direct assault
 Significant trauma complicates up to 8% of all pregnancies
 Physiologic changes in pregnancy
o 1st trimester – physiologic anemia, blood volume increases 45%, but red cell mass does
not increase as much
o 2nd trimester – increased HR, decreased BP is normal (mimic hemorrhagic shock)
o Pulmonary changes include decreased residual volume and increased tidal volume,
resulting in hyperventilation with respiratory alkalosis
 12+ weeks – uterus is intra-abdominal, more prone to injury
 20+ weeks – uterus can compress IVC, dec. venous return, dec. BP
o Position patient on left side to avoid compression of IVC
 Best treatment for fetus is optimal resuscitation and treatment of the mother

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 Indications for trauma related X-rays, medications, tetanus, and operations are unchanged
 In addition to maternal and fetal injuries, trauma may induce
o Uterine irritability
o Preterm labor
o Placental abruption (most common cause of fetal death after maternal death)
o Fetal-maternal hemorrhage (up to 30% of severe trauma cases)
 Assess fetal heart tones during secondary survey: 120 – 160 bpm is normal
 Remember to check mother’s Rh blood type, give RhoGAM if Rh negative
 Consult OB/GYN for fetal monitoring after significant injuries to mother

Abruption Placentae < See Section 17 OB/GYN >

Perimortem C-section
 Consider in cases of fatal injuries to mother, 23+ weeks gestation
 Perform within 5 minutes of maternal death
 Continue resuscitation of mother during procedure

Rupture of Uterus
Rare
Fetal mortality rate is close to 100%

Blast injuries
 Explosives are a unique injury mechanism with complex, multi-system effects
 Distance from source, position in relation to buildings (which can reflect blast waves) are critical
 Four classes of blast injuries
o Primary (direct) blast injury
 Initial positive pressure shock wave, followed by negative pressure wave
produce tympanic membrane rupture (common), pulmonary contusions and
hemorrhage, GI and CNS injuries
o Secondary blast injury
 Blunt and penetrating injuries from projectiles, flying debris, shrapnel, etc.
o Tertiary blast injury
 Patient’s body falls or is propelled by blast
o Miscellaneous
 Dust inhalation, toxic gasses, thermal burns, radiation, etc.

Lung injury
 Pulmonary edema and hemorrhage
 ARDS can occur up to 48 hours post blast

GI tract
 Air containing organs may rupture
 CNS injuries leading cause of mortality

Pediatric Trauma
 Trauma is leading cause of death, ages 1-19 years
 Motor vehicle accident is the most common mechanism
 Homicide accounts for up to 25% of pediatric deaths due to trauma

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 Head injury is the most common cause of death

 General approach to pediatric trauma is same as adult, but must consider differences in pediatric
anatomy and physiology
 Infants are obligate nose breathers, have early tachypnea and accessory muscle use if respiratory
distress
 Infants and young children may have enough blood loss from scalp to cause shock
 Normal blood volume is 8-9% of body weight (80-90ml/kg)
 Tachycardia is the most sensitive and earliest sign of volume loss
 Hypotension is a late and ominous sign
 Infants and young children have pelvic organs that are intra-abdominal and therefore more
exposed to injury
 Children are prone to hypothermia – ratio of body surface area to mass is high
 Flexible, non-ossified bony structures make SCIWORA more likely (2/3 of spinal injuries)
 Blunt chest trauma may transmit more force to internal chest structures making pulmonary
contusions more likely with little external evidence
 Non-accidental trauma should be considered if mechanism of injury is inconsistent, or with retinal
hemorrhages, multiple stages of healing fractures, or specific injury patterns (stocking burns)
 If IV access is difficult, an intraosseous line should be placed
 Resuscitation in hemorrhagic shock
o Boluses of 20cc/kg crystalloid, 10cc/kg of blood
 Transfer children with significant injuries to a specialized pediatric trauma center

Geriatric Trauma
 Falls are the most common cause of injury in patients over 65 years old
 28% of deaths due to accidental causes occur in patients >65 years old
 MVC is the most common mechanism for fatal incidents between ages 65 and 80 years
 Inter-trochanteric fractures are the most common hip fracture
 Incidence of cervical spine injury is 2X that of younger trauma victims
 Odontoid fractures account for 20% of geriatric C-spine fractures
 The elderly suffer a higher incidence of subdural hematomas due to brain atrophy that stretches
the bridging veins, but a lower incidence of epidural hematomas
 Elderly are more likely to die from a given traumatic injury
o Less physiologic reserve
o Comorbid medical conditions can interfere with recovery
 Medications and underlying conditions may interfere with evaluation of trauma
o Example: beta blockers, heart disease may prevent tachycardic response to shock
o Example: dementia may prevent cooperation with neurologic examination
 More likely to develop pneumonias, other complications after trauma
 The IV contrast load may exacerbate underlying renal pathology due to
o Poor baseline renal function
o Volume depletion secondary to diuretics, trauma
 Markers for poor outcome in the elderly population
o Age >75
o Severe head injury, GCS <7
o Presence of shock upon arrival
o Development of sepsis

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Trauma Procedures

Thoracostomy
 Indications
o Pneumothorax
 Large (>3cm from apex to cupula)
o Hemothorax
o Effusions
o Empyema
 Contraindications
o In an unstable injured patient: NONE
o In stable patient
 Anatomic abnormalities such as scarring / adhesions
 Coagulopathic patients should be corrected
 Physical Examination
o Decreased breath sounds
o Diagnostic accuracy of 89% for hemo/pneumothorax
o Asymmetric chest expansion
o Subcutaneous emphysema
o Examination will miss
 Pneumothorax of 10-20%
 Pleural fluid collection of less than 500cc
 Radiography
o Upright inspiratory film
o 300-500cc to blunt CPA
o Plain supine radiograph
o Up to 1000cc may only demonstrate slight differences in density of lung field
o Decubitus films with injured side up
o CT scan picks up in 10% with normal CXR
 Procedure
o Locate the fourth or fifth intercostal space at the anterior axillary line
o Measure distance to apex and assure last hole is in chest
o Elevate the arm on the affected side
o Anesthetize with lidocaine with epinephrine
o Infiltrate all the way to the pleura
o Make a 3-4cm incision through skin and subcutaneous tissue one rib below the rib over
which the tube will pass
o Blunt dissect with Kelly clamp up over superior surface of rib
o Push closed clamp through the pleura
o Spread clamp wide and withdraw
o Insert a gloved finger and sweep
o Place tube along finger to prevent subcutaneous placement
o Direct tube posteriorly and superiorly
 Confirmation
o Fogging of tube
o Movement of fluid or air during respiration
o Chest radiograph

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 Securing tube
o Simple stay suture to close wound
o Horizontal mattress suture around tube
o Wind ends around tube
 Complications
o Infection
o Prophylactic antibiotics are controversial
o Laceration
o Intra-abdominal placement
o Re-expansion pulmonary edema
 Rare and unpredictable
 Of concern when condition is >3- 4 days duration

Open Thoracotomy
 Indications
o Patients with vital signs following penetrating trauma
 Vital signs lost in ED or < 5 min prior to arrival
o Suspected Pericardial Tamponade
o Penetrating chest injury with (Done in OR)
 Initial chest tube drainage of >20cc/kg
 Persistent drainage of >7cc/kg/hr
 Persistent hypotension
 Air embolism
o Blunt trauma with arrest in ED (controversial)
 Contraindications
o Patients with blunt trauma who arrest prior to ED arrival
o CPR for more than 10 minutes with intubation, 5 minutes without intubation
 Statistics for ED Thoracotomies
o Stab wounds: 16.8%
o Gunshot wounds: 4.3%
o Blunt Trauma: 1.4%
 Procedure
o Intubate patient and place nasogastric tube
o Prep chest, put left arm overhead, and prop up on towels
o Incise down to intercostals with scalpel at nipple line (men) or inframammary line (women)
from sternum to posterior axillary line
o Use metzenbaum scissors to cut through intercostals to prevent lung injury
o Place rib spreader and open chest (crank side down)
o Pericardiotomy
 Incise starting at diaphragm anterior and parallel to phrenic nerve using scissors
and forceps
 Deliver heart and inspect for
 Volume depletion
 Laceration
 Start Cardiac massage
o Inspect great vessels and pulmonary vessels for hemorrhage
 Clamp as necessary
o Cross clamp the aorta

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 Complications
o Serious infection is uncommon
o Disease transmission
 HIV + rate in trauma victims is 2 to 9%
 Hepatitis B + rate is 3.1%

Pericardiocentesis
 Indication
o Relieve pericardial tamponade
 Contraindications
o No absolute
 Procedure
o Ultrasound guided if possible
o Anesthetize the route with lidocaine (without epinephrine)
o Elevate patient to 45 degrees if possible
o 3-5 inch 18g spinal needle
o Introduce needle under skin with obturator in place
o Attach syringe and apply suction
o Approaches
 Parasternal approach
 Left 5th intercostal space lateral to the sternal border
 Subxiphoid approach
 Insert needle between xiphoid process and left costal margin
 Angle at less than 45 degrees
 Aim for the heart (left scapular tip??)
o Attach alligator clip wire to V lead
 If myocardium is touched, current of injury pattern
 Aspirate when blood / fluid is achieved
 Right space?
o Check that hematocrit is lower than venous blood
o pH is 0.10 less than arterial blood
o Blood may clot
o Removal of as little as 30-50cc may be clinically significant
 Complications
o Dry tap
o Laceration / Puncture
o Dysrhythmia

Diagnostic Peritoneal Lavage

 Indications
o Blunt trauma with unexplained hemodynamic instability
o Unreliable exam
 ETOH, spinal cord lesion, AMS
o Concern over hollow viscus injury
o Fluid on CT without solid organ damage
o Stab wound with suspected peritoneal penetration
o Diaphragmatic injury
o GSW
 Wound track is most likely superficial

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 Penetration is low chest

 Contraindication
o Absolute
 Clear indication for laparotomy
o Relative
 Previous abdominal surgery
 Advanced cirrhosis or ascites
 Severe coagulopathy
 Gravid uterus
 Morbid obesity
 Procedure
o NG and Foley should be placed
o Infiltrate with Lidocaine with Epi
o Techniques
 Open (Semi or Fully) vs Closed
o Location: Infraumbilical Ring
o Pregnancy and pelvic fracture: fully open supraumbilical
o Previous surgery: Left lateral rectus border
o Direct catheter into L/R pelvic recess
o Aspirate for blood (10cc)
o Instill 1 Liter NS (warm) or 15cc/kg in kids
o Shift the patient side to side
o Drop bag to floor
o 700cc return is considered adequate
 Diagnostic Criteria
o Positive Tap for blunt trauma
 >10cc gross blood on aspiration
 Obvious enteric contents
 Appearance of fluid in Foley or Chest tube
 100,000 RBC/ml
 500 WBC/ml
o For penetrating trauma in low chest
 5,000 RBC/ml (diaphragm)
o For penetrating trauma in abdomen
 10,000 -20,000 RBC/ml
Retrograde Urethrogram
 Indications
o Uncertainty about the integrity of the urethra
 Technique
o Full Strength Hypaque (50%) or Renografin 60
o Toomey syringe or 60cc with Christmas tree adaptor
o Retract Foreskin
o Prep penis
o Grasp penis between long and ring fingers to allow thumb and index finger to maintain a
snug fit between catheter and urethra
o Advance catheter until snug fit
o Stretch penis across thigh to unfold urethra
o 50-60cc of contrast is injected slowly under constant pressure
o Take radiograph (KUB) during last 10cc

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o Collect contrast material. Spillage will obviate ability to repeat the procedure

Retrograde Cystogram
 Indications
o Suspected bladder injury
o Assumes normal urethra
 Technique
o Place foley catheter
o Dilute to <10% solution of dye
o Do not spill contrast
o Instill bladder with contrast by gravity only
o Endpoints
 100ml with gross extravasation (optional)
 400cc in an adult (age >11)
 Bladder capacity (age + 2) x 30cc
 To the point of bladder contraction and then 50cc more
o Obtain AP and oblique views
o Obtain a post evacuation film for posterior perforation

Cricothyroidotomy
 Indications
o Massive midface trauma
o Inability to control airway via other means
o Failed RSI
o Upper airway obstruction
 Contraindications
o Absolute
 Endotracheal intubation can be accomplished
 Transection of trachea
 Fracture of larynx / cricoid cartilage
o Relative Contraindications
 Acute laryngeal disease
 Trauma to area
 Infection
 Tumor
 Age less than 6 years old
 Massive neck edema
 Bleeding diathesis
 Procedure
o Hyperextend the neck if possible
o Palpate Cricothyroid membrane
o Vertical 3-4cm incision with 11 blade
o Re-palpate membrane
o Horizontal incision 1-2cm
o Hook trachea superiorly
o Advance dilator or No. 4 Tracheostomy tube
o Secure in place

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