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Thermal Burn

Burns classification

Burns classification

Stop the burning process

All clothing and any garments and jewelry from the affected areas should be removed to stop the burning process

Synthetic fabrics can ignite, burn rapidly at high temperatures, and melt into hot residue that continues to burn the patient Any clothing that was burned by chemicals should be removed carefully

Dry chemical powders should be brushed from the wound, with the individual caring for the patient avoiding direct contact with the chemical

Burns should be cooled with room temperature water

In patients with large burns careful monitoring of core body temperature is recommended to avoid hypothermia

Most blisters should be left intact however, very large or tense blisters located over joints should probably be ruptured to ease local wound care

The burns should be covered with a clean dressing to minimize further trauma and reduce pain associated with air currents


Larynx protects the subglottic airway from direct thermal injury, but the upper airway is extremely susceptible to obstruction Clinical indications of inhalation injury include:

Face and/or neck burns Singeing of the eyebrows and nasal vibrissae Carbon deposits in the mouth and/or nose and carbonaceous sputum Acute inflammatory changes in the oropharynx, including erythema Hoarseness History of impaired mentation and/or confinement in a burning environment Explosion with burns to head and torso Carboxyhemoglobin level greater than 10% in a patient who was involved in a fire


Breathing concerns arise from three general areas: hypoxia, carbon monoxide poisoning, and smoke inhalation injury

Hypoxia may be related to inhalation injury, inadequate ventilation

due to circumferential chest burns, or traumatic thoracic injury unrelated to the thermal injury -> supplemental oxygen with or

without intubation should be administered

The diagnosis of CO poisoning is made primarily from a history of exposure and direct measurement of carboxyhemoglobin (HbCO) -> receive high-flow oxygen via a non-rebreathing mask

If the patient’s hemodynamic condition permits and spinal injury has been excluded, elevation of the head and chest by 30 degrees helps to reduce neck and chest wall edema

If a full-thickness burn of the anterior and lateral chest wall leads to severe restriction of chest wall motion, chest wall escharotomy may

be required

Intravenous Access

Monitoring of hourly urinary output can reliably assess circulating blood volume -> indwelling urinary catheter

Any patient with burns over more than 20% of the body surface requires fluid resuscitation

Large-caliber (at least 16-gauge) intravenous lines should be introduced immediately in a peripheral vein

The upper extremities are preferable to the lower extremities as a site for venous access Infusion with an isotonic crystalloid solution,

preferably lactated Ringer’s solution

2 to 4 mL of Ringer’s lactate solution per kilogram of body weight per percentage BSA during the first 24 hours to maintain an adequate

circulating blood volume and provide adequate renal perfusion

example a 50 kg man with 80% total BSA burns

2 - 4 * 80 * 50 = 8000 to 16000 mL in 24 hours.

Half of that volume 4000 to 8000 mL should be provided in the first 8 hours, so the patient should be started at a rate of 5001000 mL/hr. The remaining half of the total fluid is administered during the

subsequent 16 hours

After starting at this target rate, the amount of fluids provided should be adjusted based on the urine output target of 0.5 mL/ kg/hr for adults and 1 mL/kg/hr for children

Pharmacologic Therapies

Minor pain :

Oral acetaminophen (1 g in adults or 15 mg/kg in children every 4 to 6 hours) or

an NSAID such as ibuprofen (400-800 mg in adults or 10 mg/kg in children) every 6 to 8 hours.

Moderate to severe burn pain is managed with parenteral opioids;

Morphine sulfate 0.05-0.1 mg/kg

Chemical Burn

Chemical injury can result from exposure to acids, alkalies, and petroleum products

Alkali burns are generally more serious than acid burns, because the alkalies penetrate more deeply

Rapid removal of the chemical is essential -> immediately flush away the chemical with large amounts of water, for at least 20 to 30

minutes, using a shower or hose

If dry powder is still present on the skin, brush it away before irrigating with water

Electrical Burn

Electrical burns result when a source of electrical power makes contact with a patient’s body

The body can serve as a volume conductor of electrical energy, and the heat generated results in thermal injury to tissue

Different rates of heat loss from superficial and deep tissues allow for relatively normal overlying skin to coexist with deepmuscle necrosis

The current travels inside blood vessels and nerves and thus may cause local thrombosis and nerve injury

Immediate treatment of a patient with a significant electrical burn includes attention to the airway and breathing, establishment of an

intravenous line in an uninvolved extremity, ECG monitoring, and placement of an indwelling bladder catheter

Electricity may cause cardiac arrhythmias that may require chest compressions

No arrhythmias within the first few hours of injury, prolonged monitoring is not necessary

Rhabdomyolysis results in myoglobin release, which can cause acute renal failure

Fluid administration should be increased to ensure a urinary output of 100 mL/hr in adults or 2 mL/ kg/hr in children

Criteria transfer to burn center

  • 1. Partial-thickness and full-thickness burns on greater than 10% of the BSA in any patient

  • 2. Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, and perineum, as well as those that involve skin overlying major joints

  • 3. Full-thickness burns of any size in any age group

  • 4. Significant electrical burns, including lightning injury (significant volumes of tissue beneath the surface can be injured and result in acute renal failure and other complications)

  • 5. Significant chemical burns

  • 6. Inhalation injury

  • 7. Burn injury in patients with preexisting illness that could complicate treatment, prolong recovery, or affect mortality

  • 8. Any patient with a burn injury who has concomitant trauma poses an increased risk of morbidity or mortality, and may be treated initially in a trauma center until stable before being transferred to a burn center

  • 9. Children with burn injuries who are seen in hospitals without qualified personnel or equipment to manage their care should be transferred to a burn center with these capabilities

    • 10. Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected child maltreatment and neglect

Spinal Cord Injury

Spine trauma

Trauma to the spine can cause a vertebral spinal column injury, a spinal cord injury or both

Functional anatomy :

Vertebral column Spinal cord

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Pre hospital care :

Recognition of patients at risk Appropriate immobilization Triage to an appropriate facility

Tintinalli’s Emergency Medicine 8 th edition

Initial ED stabilization :

Airway Hypotension Spine immobilization

Tintinalli’s Emergency Medicine 8 th edition

Clinical features :

History pay particular attention to any symptoms indicating present or impending respiratory compromise, including dyspnea, palpitations, abdominal breathing, and anxiety high cervical spine injury

Physical examination :

Presence or absence of midline neck or back tenderness

Test motor function for muscle groups

Sensory loss and investigate proprioception Saddle anesthesia Deep tendon reflexes

Tintinalli’s Emergency Medicine 8 th edition

Tintinalli’s Emergency Medicine 8 edition

Tintinalli’s Emergency Medicine 8 th edition

Guidelines for ScreeningPatients with

Suspected Spine Injury

Suspected Cervical Spine Injury

1. The presence of paraplegia or quadriplegia is presumptive evidence of spinal instability.

2. Patients who are awake, alert, sober, and neurologically normal, and have no neck pain or midline tenderness, or a distracting injury: These patients are extremely unlikely to have an acute c-spine fracture or instability. With the patient in a supine position, remove the c-collar and

palpate the spine. If there is no significant tenderness, ask the patient to

voluntarily move his or her neck from side to side. Never force the patient’s neck. When performed voluntarily by the patient, these maneuvers are generally safe. If there is no pain, have the patient voluntarily flex and extend his or her neck. Again, if there is no pain, c-spine films are not necessary.

3. Patients who are awake and alert, neurologically normal, cooperative, and do not have a distracting injury and are able to concentrate on their spine, but do have neck pain or midline

tenderness: The burden of proof is on the clinician to exclude a spinal injury. Where available, all such patients should undergo multi- detector axial CT from the occiput to T1 with sagittal and coronal

reconstructions. Where not available, patients should undergo lateral,

AP, and openmouth odontoid x-ray examinations of the c-spine with axial CT images of suspicious areas or of the lower cervical spine if not adequately visualized on the plain films

Assess the c-spine films for:

bony deformity fracture of the vertebral body or processes loss of alignment of the posterior aspect of the vertebral bodies (anterior extent of the vertebral canal) increased distance between the spinous processes at one level narrowing of the vertebral canal increased prevertebral soft tissue space

If these films are normal, remove the c-collar. Under the care of a knowledgeable clinician, obtain flexion and extension, and lateral cervical spine films with the patient voluntarily flexing and extending his or her neck. If the films show no subluxation, the patient’s c-spine can be cleared and the c-collar removed. However, if any of these films are suspicious or

unclear, replace the collar and obtain consultation from a spine specialist.

4. Patients who have an altered level of consciousness or are too young to describe their symptoms: Where available, all such patients should

undergo multi-detector axial CT from the occiput to T1 with sagittal and

coronal reconstructions. Where not available, all such patients should undergo lateral, AP, and open-mouth odontoid films with CT supplementation through suspicious areas (e.g., C1 and C2, and through

the lower cervical spine if areas are not adequately visualized on the plain

films). In children, CT supplementation is optional. If the entire c-spine can

be visualized and is found to be normal, the collar can be removed after appropriate evaluation by a doctor/consultant skilled in the evaluation/ management of patients with spine injuries. Clearance of the c-spine is particularly important if pulmonary or other care of the patient is

compromised by the inability to mobilize the patient.

5. When in doubt, leave the collar on









evaluation and

management of patients with spine injuries should be consulted in all cases in which a spine injury is detected or suspected.



Patients who have neurologic deficits (e.g.,

quadriplegia or paraplegia) should be evaluated quickly and removed

from the backboard as soon as possible. A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for pressure ulcers.

8. Emergency situations: Trauma patients who require emergency surgery before a complete workup of the spine can be accomplished should be transported carefully, assuming that an unstable spine

injury is present. The c-collar should be left on and the patient logrolled when moved to and from the operating table. The patient should not be left on a rigid backboard during surgery. The surgical

team should take particular care to protect the neck as much as

possible during the operation. The anesthesiologist should be informed of the status of the workup.

Suspected Thoracolumbar Spine Injury

1. The presence of paraplegia or a level of sensory loss on the chest or abdomen is presumptive evidence of spinal instability.

2. Patients who are awake, alert, sober, neurologically normal, and have no midline thoracic or lumbar back pain or tenderness: The

entire extent of the spine should be palpated and inspected. If there

is no tenderness on palpation or ecchymosis over the spinous processes, an unstable spine fracture is unlikely, and thoracolumbar radiographs may not be necessary.

3. Patients who have spine pain or tenderness on palpation, neurologic deficits, an altered level of consciousness, or in whom intoxication is suspected: AP and lateral radiographs of the entire

thoracic and lumbar spine should be obtained. Thin-cut axial CT should be obtained through suspicious areas identified on the plain

films. All images must be of good quality and interpreted as normal

by an experienced doctor before discontinuing spine precautions.

4. Consult a doctor skilled in the evaluation and management of spine injuries if a spine injury is detected or suspected.

Thoracic Trauma

Primary Survey

The principal aim of the primary survey is to identify and treat immediately life-threatening conditions. The life-threatening chest injuries are:

Tension Pneumothorax Massive Haemothorax Open Pneumothorax Cardiac Tamponade Flail chest

Secondary Survey

The secondary survey is a more detailed and complete examination, aimed at identifying all injuries and planning

further investigation and treatment. Chest injuries identified on

secondary survey and its adjuncts are:

Rib Fractures & flail chest Pulmonary contusion Simple pneumothorax Simple haemothorax Blunt aortic injury Blunt myocardial injury

monitoring adjuscts

oxygen Saturation End-tidalCO2(if intubated)

diagnostic adjuscts

Chest X-ray FAST ultrasound Arterial Blood Gas


chest drain Thoracotomy

Chest injuries


Pathophysiology “one-way valve” :

Penetrating / blunt chest injury Parenchymal lung injury fails to seal Inspiration: air pleural Expiration: air stucked in pleural

Signs :

Chest pain, Tachycardia, Hypotension Tracheal deviation away from the affected side Lack of/decreased breath sound on affected side Subcutaneous emphysema on the effected side

Chest injuries


Management :

Immediate decompression

14-gauge angiocatheter in the 2nd ICS in the midclavicular line of the affected side

Repeated reassessment is necessary Definitive treatment : insertion of a chest tube

Tension pneumothorax

Needle decompression

Chest injuries

Open Pneumothorax :

Large defects


the chest wall




results in an open pneumothorax ( sucking chest wound )

Pathophysiology :

If wound is 2/3 of the tracheal chest wall defect with each respiratory effort effective ventilation is impaired

Signs : Hypoxia, Hypercabia

Open Pneumothorax :

Management :

Closing the deffect Sterile oclusive dressing Large, overlap the wound Taped securely on 3 side Inspiration: prevented air entering Expiration: air escape from pleural Definitive treatment: surgical closure

Open pneumothorax

Dressing for treatment

Dressing for treatment

Massive Hemothorax

Accumulation of blood >1500 mL or 1/3 or more of the patient’s blood volume in chest cavity

Sign and symptoms:

Neck veins may be flat or distended Dullness Hypotension Absence of breath sounds

Massive Hemothorax • Accumulation of blood >1500 mL or 1/3 or more of the patient’s blood


Large caliber IV line and crystalloid Type specific blood is adminiestered Chest tube (at the nipple level, just anterior to the midaxillary line)

Flail Chest and Pulmonary Contusion

Occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage.

This condition results from trauma associated with multiple rib fractures.

Diagnosis :

Inspection :Flail chest may not be apparent initially if patient’s chest wall

has been splinted move air poorly, movement of the thorax will be asymmetrical and uncoordinated.

Palpation : abnormal respiratory motion and crepitation of rib or cartilage

fractures Chest x-ray multiple rib fractures

Initial treatment of flail chest includes adequate ventilation, administration of humidified oxygen, and fluid resuscitation.

Definitive treatment is to ensure adequate oxygenation, administer fluids judiciously, and provide analgesia to improve ventilation.

Cardiovascular trauma

Blunt cardiac trauma

Myocardial concussion Myocardial rupture Miscellaneous cardiac injury Penetrating cardiac injury Acute pericardial tamponade Blunt aortic injury

Blunt cardiac trauma

Usually results from high speed MCV in which the chest wall strikes the steering wheel.

Myocardial concussion

The term myocardial concussion or commotio cordis is used to describe an acute form of blunt cardiac trauma that is usually produced by a sharp, direct blow to the midanterior chest that stuns the myocardium and results in brief dysrhythmia, hypotension, and loss of consciousness

There is no histopatologic change, if the patient can’t survive the initial dysrhythmiasudden death with no histopatologic change demonstrated in autopsy

Myocardial contusion

Several mechanism

Compressed heart between sternum and vertebrae, or elevated diaphragm

Compression of the abdomen and pelvis may displace abdominal viscera upward

Histologically characterized by intramyocardial hemorrhage, edema, and necrosis of myocardial muscle cells (similar finding in acute MI)

  • decrease in ventricular compliance cardiac dysfunction

Most myocardial contusions heal spontaneously, with resolution of cellular infiltrate and hemorrhage leading to scar formation. (50%

leads to small pericardial effusion that require no therapy)

the majority of patients with myocardial contusion have external signs of thoracic trauma (e.g., contusions, abrasions, palpable crepitus, rib fractures, or visible flail segments)

The most sensitive but least specific sign of myocardial contusion is sinus tachycardia (70%)

Diagnostic strategies

ECG (no significant changes)

Laboratory finding ( first screening tools for detecting myocardial injury): cardiac troponin serum, CK-MB level??

Echocardiography (direct visualization of cardiac structures and chambers)

If patient have painfull wall injury (transesophageal echocardiography)


Out of hospital evaluation: vital signs, level of consciousness, cardiac rhythm, presence of chest wall trauma


Minor injuries and asymptomatic: elevated troponin level and minor ECG abnormalities (no carefully monitoring needed)

On admission, treatment of a suspected myocardial contusion should be similar to that of an MI: intravenous line, cardiac monitoring, and

administration of oxygen and analgesic agents.

Thrombolytic agents and aspirin are contraindicated in the setting of acute trauma. In rare instances there may be an acute MI associated with

trauma, which can arise from lacerations or blunt injury to the coronary

arteries. (manage using PCI and surgery)

Depressed CO: fluid administrationdobutamine (after optimal preload ensued)

Myocardial Rupture

Acute traumatic perforation of ventricle or atria, but may also include othe part of heart

Delayed rupture may occur as a result of necrosis or infarcted myocardium

A rupture occurs during closure of the outflow track when there is ventricular compression of blood-filled chambers by a pressure sufficient to rupture the chamber wall, septum, or valve. (occurs in diastole or early


The atria are most susceptible to rupture by sudden compression in late systole when these chambers are maximally distended with venous blood

and the atrial ventricular valves are closed

The immediate ability of the patient to survive cardiac rupture depends on the integrity of the pericardium. Two thirds of patients with cardiac rupture have an intact pericardium and are protected from immediate


In a review of survivors of myocardial rupture, common symptoms and signs included hypotension (100%); elevated CVP (95%); tachycardia (89%); distended neck veins (80%); cyanosis of the head,

neck, arms, and upper chest (76%); unresponsiveness (74%); distant heart sounds (61%); and associated chest injuries (50%).

The following findings are suggestive of pericardial rupture:

  • 1. Hypotension disproportionate to the suspected injury

  • 2. Hypotension unresponsive to rapid fluid resuscitation

  • 3. Massive hemothorax unresponsive to thoracostomy and fluid


  • 4. Persistent metabolic acidosis

  • 5. The presence of pericardial effusion on echocardiography or

elevation of CVP and neck veins with continuing hypotension despite

fluid resuscitation

Tracheobronchial tree injury

If tracheobronchial injury is suspected, immediate surgical consultation is warranted.

*Such patients typically present with hemoptysis, subcutaneous emphysema, or tension pneumothorax.

Incomplete expansion of the lung after placement of a chest tube suggests a tracheobronchial injury, and placement of more than one chest tube often is necessary to overcome a significant air leak.

Bronchoscopy confirms the diagnosis.

Temporary intubation of the opposite mainstem bronchus may be required to provide adequate oxygenation.

Advanced Trauma Life Support, 9th Edition

Traumatic aortic disruption

A high index of suspicion prompted by a history of decelerating force and characteristic findings on chest x-ray films should be maintained, and the patient should be further evaluated.

Adjunctive radiologic signs on chest x-ray, which may or may not be present, indicate the likelihood of major vascular injury in the chest and include:

  • - Widened mediastinum

  • - Obliteration of the aortic knob

  • - Deviation of the trachea to the right

  • - Depression of the left mainstem bronchus

  • - Elevation of the right mainstem bronchus

  • - Obliteration of the space between the pulmonary artery and the aorta (obscuration of the aortopulmonary window)

  • - Deviation of the esophagus (nasogastric tube) to the right

  • - Widened paratracheal stripe

  • - Widened paraspinal interfaces

  • - Presence of a pleural or apical cap

  • - Left hemothorax

Advanced Trauma Life Support, 9th Edition

Helical contrast-enhanced computed tomography (CT) of the chest has been shown to be an accurate

screening method for patients with suspected blunt

aortic injury.

A qualified surgeon should treat patients with blunt traumatic aortic injury and assist in the diagnosis.

The treatment is either primary repair or resection of the torn segment and replacement with an interposition graft. Endovascular repair is now an acceptable alternative approach.

Advanced Trauma Life Support, 9th Edition

Traumatic diaphragmatic injury

The appearance of an elevated right diaphragm on chest x-ray may be the only finding of a right-sided injury.

If a laceration of the left diaphragm is suspected, a gastric tube should

be inserted. The appearance of peritoneal lavage

fluid in the chest tube drainage also

confirms the diagnosis.

Operation for other abdominal injuries often reveals a diaphragmatic tear. Treatment is by direct repair.

Traumatic diaphragmatic injury • The appearance of an elevated right diaphragm on chest x-ray may be
Traumatic diaphragmatic injury • The appearance of an elevated right diaphragm on chest x-ray may be

Advanced Trauma Life Support, 9th Edition

Blunt esophageal rupture

The clinical picture of patients with blunt esophageal rupture is identical to that of postemetic esophageal rupture. Treatment consists of wide drainage of the pleural space and

mediastinum with direct repair of the injury via thoracotomy, if feasible. Repairs performed within a few hours of injury lead to a

much better prognosis.

Advanced Trauma Life Support, 9th Edition

Other Manifestations of

Chest Injuries

Several manifestations of thoracic trauma are indicative of a greater

risk of associated injuries:

  • - Subcutaneous emphysema

  • - Crush injuries of the chest

  • - Injuries to the upper ribs (13), scapula,

and sternum

Advanced Trauma Life Support, 9th Edition

Abdominal Trauma

Abdominal trauma

Abdominal trauma accounts for 15% to 20% of all trauma deaths The most common mechanism for blunt abdominal trauma is a motor vehicle collision

Patient who survive the initial traumatic insult are at risk for infection and suffer mortality or morbidity secondary to sepsis

Tintinalli’s Emergency Medicine 8 th edition

Blunt abdominal trauma :

Motor vehicle collision compressive, shearing or stretching, and acceleration/deceleration forces impact the abdominal cavity differently abdominal wall, solid organ or hollow viscous injuries

Tintinalli’s Emergency Medicine 8 th edition

Penetrating abdominal trauma :

Stab and gunshot wounds and the transmitted energy of the blast; secondary missiles as fragmented bone traumatic burden

Tintinalli’s Emergency Medicine 8 th edition

Clinical features :

Physical examination :

Inspect the abdomen for external signs of trauma Palpate the abdomen in all quadrants tenderness, tympany, or rigidity

Abdominal wall injuries :

Direct blow or indirectly via a sudden muscular contraction contusions of the abdominal wall musculature

Tintinalli’s Emergency Medicine 8 th edition

Solid organ injuries :

Due to blood loss increase pulse pressure, tachycardia, hypotension Splenic injuries referred pain into the left shoulder or arm

Hollow viscous and mesenteric injuries :

Combination of blood loss and peritoneal contanmination by Gi contents

Tintinalli’s Emergency Medicine 8 th edition

Retroperitoneal injuries :

Pancreatic injuries from rapid deceleration

Duodenal injuries asymptomatic on presentation and a small hematoma of the duodenum may go undiagnosed gastric outlet obstruction develop

Diaphragmatic injuries :

Spasm secondary or direct blow to the epigastrium Rupture penetrating injury or blunt trauma

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Diagnosis :

USG (FAST) accurate, rapid, noninvasive, repeatable, and portable and involves no nephrotoxic contrast material or ionizing radiation exposure to

the patient CT scan with IV contrast gold standard

Tintinalli’s Emergency Medicine 8 th edition

Treatment :

Laparotomy gold standard therapy

• Treatment : • Laparotomy  gold standard therapy Tintinalli’s Emergency Medicine 8 edition

Tintinalli’s Emergency Medicine 8 th edition

Pelvic Trauma


What Type Of Fracture(s) Is It? Lateral Compression Injuries The most common type of pelvic fracture The causative force is delivered laterally, as might occur in a “Tbone

motor vehicle crash or when a pedestrian is struck from the side.

Laterally directed forces cause inward displacement of the ipsilateral

hemipelvis, hinging on the sacroiliac joint.

Anterior-Posterior Compression Injuries

Anterior-posterior compression fractures account for 20% to 30% of pelvic ring injuries. 51 The force vector is delivered directly to the front of the patient, as might occur during a head-on motor vehicle crash or when a pedestrian is struck in the same manner.

A force vector delivered to the anterior elements of the

pelvic ring causes diastasis of the symphysial ligaments and/or fracture of the pubic rami. With progressive disruption of the anterior elements of the pelvis, the posterior ring is pulled apart, usually through the sacroiliac joint. These injuries are often referred to as

“open book” pelvic fractures.

Vertical Shear Injuries

Vertical shear injuries may result from a fall on the

extended extremity or from a headon motor

vehicle crash in which the occupant has the leg braced against the brake pedal or the floorboard.

Significant vertically oriented forces cause

disruption of both the anterior and posterior

pelvic rings, forcing one hemipelvis up relative to the other. Severe ligamentous injury is the rule.

Pelvic injuries

Clinical presentations :

Tenderness, laxity, or instability on palpation of the bony pelvis Hematuria

A hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum

Neurovascular deficits in the lower extremities Rectal bleeding

Pelvic injuries

Complications :

The incidence of deep venous thrombosis ↑ Continued bleeding from fracture or injury to pelvic vasculature

GU problems from bladder, urethral, prostate, or vaginal injuries : the incidence of urethral injuries varies by the type of pelvic fracture

Sexual dysfunction, infections from disruption of bowel or urinary system, chronic pelvic pain ( more so if the sacroiliac joints are involved )



By using triage, patients are sorted based on objective criteria on how

they present. The severity of injury and therefore treatment and/or

transport priority in triage is sorted by color code. Triage tags contain these colors so treatment and transport crews can see at a glance

which patients have been triaged to which level

COLOR CODES GREEN - Minor injury (walking wounded) YELLOW - Delayed- can wait RED - Immediate! BLACK - Deceased


1. Conduct a scene size up.

a. Assure well being of responders

b. Determine if (or render as possible) the scene safe prior to entering

2. Take BSI

3. Determine the number of patients. If there are multiple or mass casualties, communicate that fact through the proper channels, establish command,

and establish a medical officer and triage officer

Now its time to start triage.

You may encounter people self evacuating the scene as you arrive. Direct these people to an appropriate area of refuge so they can be monitored and evaluated.

These people would be considered non-injured or “walking wounded”

As you approach the actual scene, you may encounter people with a variety of injuries from superficial to life threatening.

Your first step is to clear out the remaining “walking wounded”. Do this by simply announcing “if any of you are well enough to stand up and walk out of here, do so now”

Do not let then wander aimlessly These victims shall be categorized GREEN. If you believe some of the uninjured victims are capable of assisting you, keep them near you to help if needed.

Now all you should be left with are those victims who are injured severely enough to not be able to get up and walk out on their own. But where do you start? Who do you go to first? The loudest? The bloodiest? The youngest? None of the above

START WHERE YOU STAND. R. P. M. R = Respiratory P = Perfusion

M = Mental Status


The first thing we check for is presence of respiration.


NONE? Open the airway Still none?

Tag BLACK, deceased

Were respirations restored?

Tag RED, immediate



Assess respiratory rate

RATE ABOVE 30 breaths per minute?

Tag RED, immediate

RATE BELOW 30 breaths per minute?

Move on to assess perfusion criteria PERFUSION Radial Pulse Absent or Capillary Refill > 2 secs Tag RED, immediate Radial Pulse Present or Capillary Refill < 2 secs Move on to assess mental status


Cannot follow simple commands? (unconscious or altered mental status)

Tag RED, immediate CAN follow simple commands. Tag YELLOW delayed

Now that the patients have been triaged, more focused treatment can


Moving victims to treatment areas may be needed. Those tagged RED or immediate are trated (or moved to treatment areas) first, followed by those tagged YELLOW or delayed.

Patients tagged BLACK can be left in place