PROBLEM 2 EMERGENCY

Delmy sanjaya
 Learning Issues
1. MM Triage
2. MM chest trauma
3. MM abdominal trauma
4. MM pelvic trauma
5. MM spinal cord trauma
6. MM burn injuries
7. MM musculoskeletal trauma  open & close
fracture
 LI 1 : Triage
• Triage  sorting of patients based on their
needs for th/ and the resources available to
provide that th/ (ABC)
• Sorting ps hospital  ex : trauma to trauma
center
• Other factors that affect triage th/ priority 
– Injury severity
– Salvageability
– Available resources
https://chemm.nlm.nih.gov/salttriage.htm
https://chemm.nlm.nih.gov/salttriage.htm
https://chemm.nlm.nih.gov/salttriage.htm
 Guidelines for Field Triage of Injured
Patients Recommendations of the
National Expert Panelon Field Triage -
January 23, 2009 / Vol. 58 / No. RR-1
 Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panelon Field Triage - January 23,
2009 / Vol. 58 / No. RR-1
 Guidelines for Field Triage of Injured
Patients Recommendations of the National
Expert Panelon Field Triage - January 23,
2009 / Vol. 58 / No. RR-1
Guidelines for Field Triage of
Injured Patients
Recommendations of the
National Expert Panelon
Field Triage - January 23,
2009 / Vol. 58 / No. RR-1
 Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panelon Field Triage - January 23,
2009 / Vol. 58 / No. RR-1
 RATING SCALES FOR INJURY SEVERITY
AIS & ISS
• ISS  derived from AIS & uses
ordinal scale (range 1-75)
• (+) AIS scores to injuries in each part
of the body
• 3 most severe injured parts are
picked and then squared
• Max  75
ISS
• ISS > 15  severe injury  type I & II
prefered
• ISS < 15  non severe injury 
survival rate >94%  type III & IV
prefered

Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panelon Field Triage - January 23,
2009 / Vol. 58 / No. RR-1
 LI 2 : CHEST TRAUMA
• Divided into blunt and penetrating categories
based on the mechanism of injury.
• 80% of cases  blunt thoracic trauma 2nd to
motor vehicle collisions (MVC) & penetrating
trauma due to stab wounds and low-velocity
handgun injuries.
 Blunt thoracic trauma
Injuries that occur after blunt thoracic trauma  fractures
(sternum/ribs) , flail chest, pulmonary contusion, myocardial
injury, and aortic injury.
• Fractures  (X) life threating  except for multiple
fractures. Assests :
– Mediastinum & great vessels  ribs 1-3
– Lungs  ribs 4-8
– Liver/spleen  ribs 9-12
• Flail chest  >/= 3 contiguous ribs fracture in >/= 2 places,
thereby creating a "free floating“ segment of the chest wall
• Pulmonary contusions  focal regions of bruised lung
parenchyma  resulting alveolar hemorrhage & edema
 impair normal respiratory function.
– Several hours post injury
• Blunt myocardial injury (BMI)  E/ direct trauma to
anterior chest wall.
– Can progress to cardiogenic shock  impair pump fx and
dysrhythmia
• Myocardial contusions  regions of "stunned“ tissue 
clinically = to myocardial infarctions.
• Blunt aortic injury (BAI)  rapid ↓ force  significant
sheer strain and 2nd rupture of the aorta.
– 80%  occurs in ligamentum arteriosum distal to the takeoff
of the left subclavian artery
 Penetrating thoracic trauma
Injuries of thoracic trauma  pneumothorax, hemothorax,
cardiac injury, pericardial tamponade, great vessel injury, and
tracheobronchial injury.
• Pneumothoraces (PTX)  divided into :
– Simple PTX  injured lungs tissue  leakage b/w visceral & parietal
pleura
– Open/ communicating PTX  injury of thoracic wall  (+)
communication b/w intrapleural space & environment
– Tension PTX  (+) injury of thoracic wall &/ underlying
bronchopulmonary structures  (+) progressive accumulation of air in
intrapleural space ↑intrathoracic Pa  ⊣ venous return to RA  CV
collapse  pulseless electrical activity arrest
• Intermediate intervension!
• Hemothoraces ( HTX)  develop 2nd to accumulation of blood
into the intrapleural space after thoracal injuries.
– Accommodate up to 40% of a patient's circulating blood volume.
– Massive HTX  acc > 1500 mL, emergent life threatening condition 
induce severe hypoxia & systemic HypoTN
• Penetrating cardiac injury (PCI)  rapidly fatal
– (+) stab wound in anterior heart  survive due to tamponading eff of
intact pericardium
– Acc of fluid in pericardial space  collapse the right side of heart 
cardiac arrest!
• Pericardial tamponade  emergent life threat requiring
immediate intervention.
• Penetrating great vessel injury (PGVI)  (+) w/massive HT Xs +
persistent high-volume bloody chest tube effluent
– Suspect venous air embolism(VAE)  decompenstate into PEA !
• Tracheobronchial injury  mechanism = persistent igh-volume
air leak after chest tube placement / subcutaneous emphysema
 CLINICAL APPROACH TO PATIENTS WITH
THORACAL TRAUMA
History
• lack of seat-belt restraint, dashboard deformity, significant intrusion into the
passenger compartment, pro longed extraction, and ejection from the vehicle
• falls greater than 30 feets  vascular shearing
• Stabbing  penetrating trauma
Physical exams
• Vital signs
– Sinus tachycardia progressive & systemic hipoTN  serious CV derangement
– Significant hypoxia  pulmo contusio, HTX, and PTX
• Venous jugular distension
– Pericardial temponade
– Tension PTX  (+) tracheal deviation
• Chest wall asymmetricity + paradoxical chest movement flail chest
• Large open defect in the chest wall + audible air movement  PTX
 CLINICAL APPROACH TO PATIENTS WITH
THORACAL TRAUMA
Pulmo contusio & laceration
• Sign & symptoms
– Dyspnea, tachypnea, cyanosis, tachycardia,
hypotension, and chest wall bruising
– Hemoptysis
– Moist rales/ (x) sound of breath on auscultation
– Palpation  (+) fractured ribs
– (+) flail chest
• PF/PP
– ↓ pulse oxymetry  hypoxemia
– X-ray  Patchy, irregular, alveolar infiltrate to
frank consolidation & localized to a segment or
a lobe and manifest w/in minutes

FLAIL CHEST
• (+) disruption of normal chest
wall movement
• Paradoxical motion of the
chest wall during inspiration
and expiration
• Hypoxia
• Restricted chest wall
movement + pain
• Palpation  abN respiratory
motion + crepitation of rib
cartilage fractures
• X-ray  multiple rib fracture
• Th/  Adequate ventilation
+ humidified O2 + fluid
resucitation
• local anesthetics 
intermittent intercostal
nerve block(s) and
intrapleural, extrapleural, or
epidural anesthesia.
• Intubation and ventilation
 PNEUMOTHORAX
• Shortness of breath and chest pain are Chest pain
the most common ■ Air hunger
• Acutely ill with cyanosis and tachypnea ■ Respiratory distress
• ↓ or (x) breath sounds and hyper- ■ Tachycardia
resonance over the involved side as well ■ Hypotension
as subcutaneous emphysema ■ Tracheal deviation away from the side of
• Tension PTX  severe cardiovascular injury
and respiratory distress (dyspneic, ■ Unilateral absence of breath sounds
agitated, restless, cyanotic, tachycardic, ■ Elevated hemithorax without respiratory
and hypotensive and display decreasing movement
mental activity)
■ Neck vein distention
• Signs of tension pneumothorax  ■ Cyanosis (late manifestation)
tachycardia, hypotension,
oxyhemoglobin desaturation, JVD, and
(x) breath sounds on the ipsilateral side.
 HEMOTHORAX
Sign and symptom
• (+) hypovolemic shock
• Respiratory distress and be tachycardic and hypoxemic
• (x) breath sound
• Central line placement
Diagnostic
• upright chest radiograph
• Image  fluid blunting the costophrenic angle and
tracking up the pleural margins
 TRACHEOBRONCHIAL INJURY
Signs and symptoms
• Massive air leak through a chest tube, hemoptysis,
and dramatic or increasing subcutaneous emphysema.
• Auscultation  Hamman’s crunch if air tracks into the
mediastinum
• Open wounded into the pleural space, producing a
large pneumothorax  chest tube fails to evacuate
the space & reexpand the lung  continous bubbling
of air (persistent leak) in the underwater seal device
Cardiac tamponade
• Penetrating > blunt trauma
• (+) beck’s triad  venous pressure
elevation, decline arterial pressure
and muffled heart tones
• ↑JVP, kussmaul’s sign (A rise in
venous pressure with inspiration
when breathing spontaneously)
• PEA  pulseless electrical activity
• FAST / pericardial window  fluid
in pericardial sac
 BLUNT CARDIAC INJURY
• E/  myocardial muscle contusion, cardiac chamber rupture, coronary artery
dissection and/or thrombosis, or valvular disruption.
• SS  Chest discomfort (associated w/ chest wall contusion or fractures of the
sternum and/or ribs)
• True dx  myocardial injury on inspection on myocardial injury
• Sequele  Hypotension, dysrhythmias, and/or wall-motion abnormality on
two-dimensional echocardiography
• ECG  Multiple premature ventricular contractions, unexplained sinus
tachycardia, atrial fibrillation, bundle-branch block (usually right), and ST-
segment changes
• ↑CVP  right ventricular dysfx 2nd to contusio
• Patients with a blunt injury to the heart diagnosed by conduction
abnormalities (an abnormal ECG) are at risk for sudden dysrhythmias and
should be monitored for the first 24 hours
 TRAUMATIC AORTIC DISRUPTION
• Most common cause of sudden death after
automobile collision/falls
• (+) contained hematoma
• Survival = possible if :
– Incomplete laceration near the ligamentum
arteriosum of the aorta.
– Intact adventitial layer or contained mediastinal
hematoma
 TRAUMATIC AORTIC DISRUPTION
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
• Fractures of the first or second rib or scapula
 Traumatic diafragmatic injury
• More common in the left side
• Blunt trauma  (+) large radial tears  herniation
• Penetrating trauma  small perforation  years to
hernia
• Right sided injury  (+) elevated right diafragm on chest
x-ray
• Left sided injury  (+) gastric tube  appears in
thoracic cavity
• Upper GI contrast studies  (+) peritoneal lavage fluid
in chest tube drainage
 LI 2 :
• 15-20 % of all traumas
• Liver  Most frequent injured intraabdominal organ from sport
accident
Blunt trauma
• Direct blow  compression & crushing injuries to abd pelvis &
viscera  deformity  rupture  2nd hemorrhage 
contamination of the viscera content  peritonitis
• Shearing injury  improper restraint device wearing
• Deceleration injury  motor vehicle crashes (ex. Buckle handle
injury)
• the organs most frequently injured are the spleen (40% to 55%),
liver (35% to 45%), and small bowel (5% to 10%).
 PENETRATING INJURY
• Stab and gunshot wounds produce injury as the foreign
object passes through tissue.
• gunshot wounds  (+) additional injury from the
transmitted energy of the blast  gunshot wounds create
2nd missiles : fragmented bone that may increase the
traumatic burden.
• Stab wound  liver (40%), small bowel (30%), diaphragm
(20%), and colon (15%).
• Gunshot  small bowel
• (50%), colon (40%), liver (30%), and abdominal vascular
structures (25%).
 Physical Examination
• Inspection
– Inspect for abrasion, contusions
from restraint devices, lacerations,
• Auscultation
penetrating wounds, impaled
– Free intraperitoneal blood / GI
foreign bodies, evisceration of
contents  produce ileus 
omentum / small bowel
loss of bowel sounds
– blood at urethral meatus,
• Percussion & palpation
swelling/bruising, laceration of
– Percussion  slight movement
perioenum, vagina, rectum,
of peritoneum  elicit signs of
buttocks  open pelvic fracture peritoneal irritation
– Cover pt w warmed blankets to – Muscle guarding  sign of
prevent hypothermia  bc can peritoneal irritation
contribute to coagulopathy and – Palpation distinguish
ongoing bleeding superficial & deep tenderness
– Cullen’s sign and Grey Turner’s – High riding prostate gland 
sign (periumbilical and flank significant pelvic fracture
ecchymosis)  represent delayed
findings of intraperitoneal bleeding
 Clinical features
• Abdominal wall injury
– Direct blow / sudden
muscular contraction 
contussion of abd wall
musculature
– Sx: pain with flexion and
rotation of trunk, focal
tenderness to percussion
– Rectus hematoma: from
epigastric trauma / injury to
vessels of abdominal wall. Pt
develop pain and palpable
mass inferior to umbilicus
• Solid organ injuries
– Increase to pulse pressure  loss
of ≤15% of total blood volume.
– Blood loss continue  HR, RR ⬆
– HypoTN occur when there’s 30%
⬇ in circulating volume  urinary
output drops, pt bcm anxious &
confused
– Delayed rupture can occur in
splenic and hepatic injury
– Splenic injury can cause referred
pain to left shoulder / arm
– Liver injury right shoulder pain
• Hollow viscous and mesenteric injuries
– sx from combination of blood loss
and peritoneal contamination by GI
contents
– Hemorrhage from mesenteric injury
may be minimal, and not obvious
on physical exam
– Chemical irritation of peritoneum
from gastric acid content produce
immediate pain
• Diaphragmatic injury
– Diaphragm may spasm 2∘ to direct
blow to epigastrium
– Breathing is difficult, diaphragm
loses its ability to relax & allows
lungs to expand  “ getting the
wind knocked out”. As diaphragm
relax, sx abate
– Left sided phenomenon
– Not treated strangulation of abd
content through the diaphragmatic
defect / herniation
• Retroperitoneal injury
– Pancreatic injury in 4% patient
with abdominal trauma (rapid
deceleration)
• Unrestrained driver who hit
steering column
– Duodenal injuries: small
hematoma of duodenum may go
undiagnosed
• Duodenal hematoma expands,
S/S of gastric outlet
obstruction develop (abd pain,
distention, vomiting)
• Following high-velocity
deceleration events where
intraluminal Pa of pylorus &
prox small bowel ⬆  rupture
• Fever + leukocytosis herald the
development of abscess /
sepsis
 Diagnosis
• Dx in penetrating trauma
• USG
– Locally explore abdominal
– FAST examination : rapid
identification of free intraperitoneal stab wounds
fluid in hypotensive patient – CT, US, DPL
– FAST vs DPL: FAST to evaluate free
pericardial / pleural fluid for
pneumothorax
– US vs CT: US cant identify source of
free intraperitoneal fluid
• CT
– Gold standard: abdominopelvic CT
with IV contrast
• Diagnostic peritoneal lavage
– Can be performed using closed /
open technique
 Treatment
• Laparotomy
– Gold standard th/ • wf
– All pt w persistent hypoTN,
abd wall disruption or
peritonitis need surgical
exploration
• Nonoperative
management
– CT grading: precise
condition of internal
parenchyma, but not
external injury anatomy
– Operative grading: excellent
external view of organ but
may underestimate internal
dmg
• Helical CT: identify intraparenchymal vascular
injuries (pseudoaneurysms / arteriovenous
fistulae) & extravasation of contrast
• Pt w/ suspected abdominal trauma who
present in extremis, resuscitative
endovascular balloon occlusion of aorta
* peritonitis, free air,
diaphragmatic injury,
evisceration, gross
blood from
stomach/rectum,
retained stabbing
implement, +ve
diagnostic test, or any
non tangenital GSW
(intraperitoneal
penetration)
TRAUMA TO FLANK
 Penetrating Flank Trauma
• Penetrating wound to flank  intraperitoneal injury +
findings of peritonitis / hemoperitoneum
• Solitary injury to retroperitoneum may not induce
peritoneal sign  late to dx  septic / hemorrhagic
shock
• Path of gunshot / stab wound to flank could track in any
direction
– Inside abd cavity, bullet may ricochet off the bony structure 
produce unique bullet path and injury pattern
– Extent of injury depends on its velocity (higher v, more injury);
greater surface area interface, greater tissue dmg
 Clinical feature
• Ask:
– Mechanism of injury
– How much time has passed since the
event
– Nature of weapon
– Gunshot: nature of gun (shotgun,
handgun, BB gun), distance b/w gun
& pt.
attempt to identify an exit wound
and reconstruct wound path
– Stab wound: size of weapon, est
measure of the depth of penetration
– [!] blood around urinary meatus /
Foley catheter drainage  bladder /
urethral injury
• Dx:
– Emergent laparotomy for pt w
penetrating flank trauma who
are hemodynamically unstable
– Triple contrast CT to detect
trajectory of penetrating
object and evaluate
retroperitoneum, highly
accurate in injuries requiring
laparotomy
– Dxtic peritoneal lavage to
detect intraperitoneal
penetration
• Imaging
• Lab testing
– CT: MOC in hemodynamically
stable with penetrating flank
trauma
– Double (PO and IV) contract
or triple (PO, IV, PR)
• PR if there is any likelihood of
rectal / sigmoid injury
– Free intraperitoneal fluid/air
suggest peritoneal perforation
– Bowel wall thickening w
hematoma near bowel /
contrast extravasation 
suggest bowel injury
 Treatment and disposition
• After pt is stable, find exit wound,
reconstruct bullet path
• Adm broad spectrum IV Ab to
cover gram (-)ve aerobic and
anaerobic organism for peritonitis
• Exploratory laparotomy for pt
who are hemodynamically
unstable / exhibit peritoneal
signs after gunshot to flank
• High velocity gunshot wound
exploratory laparotomy if there’s
concern abt bowel, bladder or
vascular integrity
LI 4 : Assessment of pelvic stability
• Suspect pelvic instability In pt • Motion can be felt if
who have pelvic fractures with
hypotension and no other
iliac crests are grasped
source of blood loss!  unstable hemipelvis
• Suggestive of pelvic fracture: is pushed inward and
– Ruptured urethra (high riding then outward
prostate, scrotal hematoma,
blood at urethral meatus), limb
length discrepancy, rotational
deformity
– Manual manipulation of pelvis:
DETRIMENTAL bc can dislodge
clot and precipitate further
hemorrhage
Reveal laxity or instability
 PELVIC FRACTURES
• Pt w hypoTN & pelvic fractures  high mortality
• Pelvic fractures + hemorrhage:
– Disruption of posterior osseous lig (sacroiliac,
sacrospinous, sacrotuberosus, fibromuscular pelvic
floor) or sacral fracture
– Disruption of pelvic ring tears pelvic venous plexus
 disrupt internal iliac arterial system
– Vertical displacement of sacroiliac joint  disrupt
iliac vasculature  uncontrolled hemorrhage
• Mech of injury / classification
1. AP compression
• Auto-pedestrian collision / motorcycle crash, direct crushing injury, fall from >3.6 meters
• + disruption of symphisis pubis, there’s tearing of posterior osseous lig complex 
represented by sacroiliac fracture / disloc / sacral fracture
• + opening of pelvic ring: there can be hemorrhage from posterior pelvic venous complex
& branch of internal iliac artery
2. Lateral compression
• Motor vehicle crashes  internal rotation of involved hemipelvis
• Pelvic volume is compressed
3. Vertical shear
1. Disrupt sacrospinous & sacrotuberous lig  major pelvic instability.
2. Result from a fall
4. Complex pattern
Management
 KIDNEY INJURIES

• Most injuries are associated with

other intra-abdominal injuries.
• Consider renal injury in flank
contusions/ecchymosis, palpable
mass, lower rib fracture,
penetrating wound in flank
• Urinalysis to detect Hburia, but
renal pedicle injuries &
segmental arterial thrombosis
may be present w/o hematuria
– Patient w SBP <90 mmHg and
microscopic hematuria hv higher
likelihood of significant injury
Grading Treatment
• Renal exploration & intervention
in life threatening hemorrhage,
expanding, pulsatile /
noncontained retroperitoneal
hematoma; and renal avulsion
injury (grade V vascular injury)
demonstrated on imaging studies
• Grade I-III can be handled non-
operatively
• CT indication: if pt is
hemodynamically stable /
suspicion for renal injury
• Renal vascular injury: optimal
time for revascularization in 4-20
hr
• Narrow arrow = renal
laceration. Thick arrow
= perinephric
hematoma.
 Ureteral injuries
• 80% occur from intraoperative,
iatrogenic dmg
• Of the 20% of injuries due to
external trauma, 90% occur from
penetrating trauma
• In stable patient w suspicion of
ureteral injury  obtain CT pf
abdomen and pelvis w/ IV
contrast (delayed phase)
• IV pyelography / retrograde
pyelography if CT remains
nondiagnostic
• Th/: operative procedures
 Bladder injuries
• Direct blow to distended bladder
 rupture
– Suspect bladder injury in alcohol-
intoxicated patients (distended
bladder) or motor vehicle crash
• Findings: lower abd pain +
tenderness, gross hematuria
– Lower abdominal bruising,
abdominal swelling from urinary
ascites, perineal or scrotal edema
from urinary extravasation, and
inability to void
• Gold standard: retrograde
cystogram
– Contrast spills out of the bladder to
peritoneal cavity (intraperitoneal
rupture) or to retroperitoneal area
surrounding the bladder
(extraperitoneal rupture)
 Treatment
• Extraperitoneal (55%)
– Managed by bladder
catheter drainage alone
– 85-90% geal within 10
days
• Intraperitoneal (38%)
– Surgical exploration
• Combined (5%-8%)
 Urethral injuries
Posterior urethral injuries
– Consists of prostatic and
membranous portion
– Result of major blunt force
trauma (motor vehicle
collisions, falls from heights)
 shearing forces applied to
prostatic-membranous
urethral junction
• Anterior urethral injuries
– Bulbar segment & penile
segment
– Bc direct perineal trauma
– Trauma may be missed
initially, pt present with
urethral stricture years later.
– Bulbar segment is typically
affected
 Clinical features
• Hematuria, dysuria,
inability to void
• Rectal & perineal exam:
perineal hematoma / high
riding prostate
• Posterior urethra injury:
triad of urinary retention,
blood at the meatus, high-
riding prostate
• In female: vaginal bleeding
(blood at introitus)
• Dx: by retrograde urethrogram,
performed before catheterization
to prevent further urethral injury
• Do not insert Foley catheter if
there’s any signs of possible
urethral injury (high-riding
prostate, meatal blood, perineal
ecchymosis, scrotal hematoma,
pelvic fracture, gross hematuria)
• Complete anterior urethral
laceration: retrograde urethrogram
reveals contrast extravasation at
site of injury w/o contrast proximal
to the site of injury
 SPINAL CORD INJURY
• 55% cervical region, 15% thoracic region, 15% at the thoracolumbar
junction, and 15% in the lumbosacral area.
• 10% Ps w/ cervical spine fracture hv 2nd vertebral column fracture
• Excessive manipulation and inadequate immobilization 
worsening the ps outcome
• (x) Neurological deficit, pain or tenderness along the spine, evidence
of intoxication, or distracting injury exclude spinal cord injury
• Comatose ps  obtain x-ray to exclude spinal cord injury  (x) find
anyth?  remain protected
• Inadeq Immobilization  prolonged  decubitus ulcer formation 
transport using longboard w/in 2 hours  (x) feasible?  remove
from board & logrolled every 2 hours to reduce the ulcer formation
 ANATOMICAL CORRELATION
• Cervical spine injury  most vunerable to injury
– (+) cervical canal wide in the upper cervical region from the
foramen magnum to C2  1/3 ps die from apnea anfd loss of
central innervation of the phrenic nerves caused by SCI at C1
– Below the C3  foramen diameter smaller
• Thoracic spine  stronger than cervical  (+) support from
ribcage
– Incidence of thoracic fractures are low ,and are wedge compression
fractures (x) associated w/ SCI
– When fracture-dislocation occurs  result in complete SCI due to
narrow thoracic canal
– Most common site  thoracolumbar junction
SPINAL CORD ANATOMY
The spinal cord originates at the
Tracts of spinal cords caudal end of the medulla oblongata
at the foramen magnum. In adults,
it usually ends near the L1 bony
level as the conus medullaris

(x) sensory or motor function below

certain level?
• Complete spinal cord injury  dx
(x) made until 2st weeks injury
(possibility of spinal shock)
How to assest • Incomplete spinal cord injury
• degree of motor or sensory
function remains
• Better prognosis
• (+) sacral sparing 
preservation of sensory
perception in perianal
region
ASSEST NEUROLOGICAL
STATUS
IDENTIFY AND TH/ NEUROGENIC SHOCK
Neurogenic shock  impairment of the descending sympathetic
pathways in the cervical or upper thoracic spinal cord, resulting :
– Lose of vasomotor tone  vasodilatation visceral & lower extremity
blood vessels pooling of blood  hipoTN
– Sympathetic innervation to the heart  bradycardia in response to
hypovolemia  th/ atropine
• Rare below T6
• (x) response to fluid resucitation  if (+) fluid  pulmo edema
and fluid overload
• Restored by vasopressore
Spinal shock refers to the flaccidity (loss of muscle tone) and loss
of reflexes seen after spinal cord injury.
CLASSIFICATIONS OF SPINAL CORD INJURIES

• Spinal cord injuries can be classified according

to (1) level, (2) severity of neurologic deficit,
(3) spinal cord syndromes, and (4)
morphology.
• The neurologic level  Most LEVELS
caudal segment of the spinal
cord that has (N) sensory and
motor function on both sides of
the body.
• The motor level  similar to
motor function as the lowest key
muscle that has a grade of at
least 3/5
• In complete injuries, when some Lesion above/ below T1
impaired sensory and/or motor • Above  quadriplegia
function is found just below the
• Below paraplegia
lowest normal segment, this is
referred to as the zone of partial
preservation.
 SEVERITY OF NEUROLOGIC DEFICITS
• Motor or sensory function
Spinal cord injury may be below the level of the
categorized as: injury constitutes an
• Incomplete paraplegia incomplete injury
(incomplete thoracic injury) Signs :
• Complete paraplegia • Sensation (includingposition
(complete thoracic injury) sense) or voluntary
movement in the lower
• Incomplete quadriplegia
extremities
(incomplete cervical injury) • Sacral sparing
• Complete quadriplegia • Voluntary anal sphincter
(complete cervical injury) contraction
• Voluntary toe flexion
o
e SPINAL CORD SYNDROME
t
• Central cord syndrome  disproportionately greater loss of motor
strength (upper > lower extremities) w/ vary sensory loss
– Occurs after hyperextension injury (preexisting cervical canal stenosis due
to degenerative osteoartritic changes)
– History of forward fall  Result facial impact
or
– Due to vascular compromise of the cord in distribution of ant spinal artery
– Recovery  (+) classic pattern  lower extremities recovering strength
first, bladder function next, and the proximal upper extremities and hands
last.
• Anterior cord syndrome  paraplegia and a dissociated sensory
g loss with a loss of pain and temperature sensation.
– Dorsal column function (position, vibration, and deep pressure sense) is
preserved
– E/  infact of ant spinal artery
– Poorest prognosis
 SPINAL CORD SYNDROME
• Brown-Séquard syndrome results from
hemisection of the cord, usually as a result of
a penetrating trauma.
– ipsilateral motor loss (corticospinal tract) and loss
of position sense (dorsal column), associated with
contralateral loss of pain and temperature
sensation beginning one to two levels below the
level of injury (spinothalamic tract)
 MORPHOLOGY
• Spinal injuries can be described as fractures,
fracturedislocations, spinal cord injury without radiographic
abnormalities (SCIWORA), and penetrating injuries.
• Each of these categories may be further described as stable or
unstable.
• Therefore, especially in the initial treatment, all patients with
radiographic evidence of injury and all those with neurologic
deficits should be considered to have an unstable spinal injury.
• These patients should be immobilized until after consultation
with an appropriately qualified doctor, usually a neurosurgeon
or orthopedic surgeon.
 SPECIFIC TYPE OF SPINAL CORD INJURIES
Cervical spine injuries can result from one or a combination of the following
mechanisms of injury:
• Axial loading
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
The injuries involve the spinal column.
They are listed in anatomic sequence (not in order of frequency), progressing
from the cranial to the caudal end of the spine.
Of note, upper cervical spine injuries in children (C1–C4) are almost
twice as common as lower cervical spine injuries.
 Atlantooccipital dislocation
• Craniocervical disruption injuries are uncommon and result
from severe traumatic flexion and distraction.
• Mechanism  injury  die of brainstem destruction and
apnea or have profound neurologic impairments (e.g., are
ventilator-dependent and quadriplegic).
• Patients may survive if prompt resuscitation is available at the
injury scene.
• Atlanto-occipital dislocation may be identified in up to 19% of
patients with fatal cervical spine injuries and is a common
cause of death in cases of shaken baby syndrome
• Spinal immobilization is recommended initially.
 ATLAS / C1 FRACTURE
• Fractures of the atlas represent
approximately 5% of acute cervical spine
fractures.
• 40%  associated with fractures of the
axis (C2).
• The most common C1 fracture is a burst
fracture (Jefferson fracture).
• Mechanism  axial loading
• The Jefferson fracture involves
disruption of both the anterior and
posterior rings of C1 with lateral
displacement of the lateral masses.
• Radiology  open-mouth view of the C1
to C2 region and axial computed
tomography (CT) scans
• Th/  cervical collar,
C1 ROTARY SUBLUXATION
• Most often seen in children
• E/  post major or minor trauma, w/ URTI /
RA
• SS  The patient presents with a persistent
rotation of the head (torticollis).
• Dx  open-mouth odontoid view, although
the x-ray findings may be confusing.
• In this injury, the odontoid is not equidistant
from the two lateral masses of C1.
• The patient should not be forced to overcome
the rotation, but should be immobilized in the
rotated position and referred for further
specialized treatment.
 C2 FRACTURE

• Largest & (+) unusual shape 

susceptible to various type
• Odontoid fracture
– Peg-shaped bony protuberance that projects
upward and is normally positioned in contact
with the anterior arch of C1
– Dx  lateral cervical spine film or open-
mouth odontoid views
• Type 1  involve the tip of odontoid
• Type 2  fracture occurs through the base of
dens and most common type of fracture
• Type 3  bases of dens extend obliquely into the
body of axis
 Posterior Element Fractures (C2)
Posterior Element Fractures/ A hangman’s fracture
• Involves the posterior elements of C2—that is, the pars
interarticularis
• This type of fracture represents approximately 20% of all axis
fractures and usually is caused by an extension- type injury.
• Patients with this fracture should be maintained in external
immobilization until specialized care is available.
• Variations of a hangman’s fracture include bilateral fractures
through the lateral masses or pedicles.
 FRACTURE & DISLOCATION (C3-7)
n
• Very uncommon (+) unilateral facet dislocation,
• 80% of patients have a neurologic
• E/  positioned between
injury
the more vulnerable axis • 30% have root injuries
and the more mobile • 40% incomplete spinal cord
“relative fulcrum” of the injuries
cervical spine, C5-6 has • 30% complete spinal cord injuries.
the greatest extension & In the presence of bilateral locked
flexion facets
• the morbidity is much worse, with
• Most common in adult  16% incomplete
fracture C5 and • 84% complete spinal cord injuries
subluxation C6
Thoracic spine fractures 
classified into four broad
categories:
• Anterior wedge
compression injuries
• Burst injuries
• Chance fractures
• Fracture-dislocations
E/  flexion an axis ant to
vertebral collumn  motor
vehicle crashes
THORACIC FRACTURE
(T1-10)
Type
• Axial loading with flexion 
anterior wedge compression
injury
• Burst injury is caused by
vertical-axial compression
• Chance fractures are transverse
fractures through the vertebral
body  retroperitoneal and
abdominal visceral injuries
Th/  rigid brace, internal fixation
 THORACOLUMBAR JUNCTION FRACTURE
(T11-L1)
• Due to relative immobility • Ss  bladder n bowel
of the thoracic spine as dysfx, decrease sensation
compared with the and strenght of lower
lumbar spine. extremities
• Result of acute • Vulnerable to rotational
hyperflexion and rotation movement  (+)
 unstable logrolling
• RF  falls, restrained
drivers  (+) severe
energy transfer
 PENETRATING INJURIES
PENETRATING INJURIES
• The most common types of penetrating injuries are those
caused by gunshot wounds or stabbings.
• It is important to determine the path of the bullet or knife.
• If the path of injury passes directly through the vertebral canal,
a complete neurologic deficit usually results.
• Complete deficits also may result from energy transfer
associated with a high-velocity missile (e.g., bullet) passing
close to the spinal cord rather than through it.
• Penetrating injuries of the spine usually are stable injuries
unless the missile destroys a large portion of the vertebra.
Blunt carotid and veterbral vascular injuries

• RF  Blunt trauma to the head and neck

• Early recognition  prevention stroke
• I/ for screening 
– C1-3 fracture
– Cervical spine fracture w/ subluxation
– Fracture involving foramen transversarium
• CT angiography  blunt carotid and vertebral vascular injury
• Th/  anticoagulant/antiplatelets
THERMAL INJURIES
LIVESAVING MEASURES FOR BURN INJURIES

• AIRWAY
– Burn  massive edema
 obstruction of upper
airway
– RF for upper airway
obstruction: ⬆ burn size
& depth, burns to head
and face, inhalation
injury, burns inside the
mouth
• Identify inhalation injury: • NEEDS INTUBATION
– Face and/or neck burn
– Singeing of eyebrow & nasal – Stridor occurs late and is
vibrissae an indication for
– Carbon deposits in mouth/nose and immediate ETT
carbonaceous sputum
– Acute infl changes in oropharynx, – Circumferential burns of
incl erythema neck  swelling of
– Hoarseness tissue around the airway
– History of impaired mentation /
confinement in burning
environment
– Explosion with burns to head &
torso
– carboxyHb lv >10%
 STOP THE BURNING PROCESS
• Remove all clothing, but do
not peel adherent clothing
• Synthetic fabrics can melt
into hot residue that
continues to burn the patient
• Dry chemical powders should
be brushed from the wound
• Rinse with copious amt of
tap water
• Cover pt to prevent
hypothermia
 INTRAVENOUS
ACCESS
• Pt w/ burn >20% of body
surface requires fluid
resuscitation
• Establish airway patency 
treat life threatening injury 
establish IV line
• Large caliber (16G) IV line in
peripheral vein
• Upper extremities more
preferable bc when saphenous
vein are used for venous access,
risk of phlebitis & septic
phlebitis ⬆
BODY-SURFACE
AREA
• Rule of Nines to determine
extent of a burn
– Differs for children
– Infant’s / young child’s head
represent larger proportion
of surface area, and lower
extremities represent smaller
proportion than an adult’s
– Palmar surface of pt’s hand
represents appx 1% of the
patient’s body surface
 DEPTH OF BURN
• 1st degree burn (sunburn)
 erythema, pain, (-)
blisters
– Not life threatening, do not
require IV fluid replacement
bc epidermis remains intact
• Partial thickness burns
red / mottled appearance
+ swelling, blister (+)
– Surface can have weeping,
wet appearance
– Painfully hypersensitive
DEPTH OF BURN

• Full thickness burns 

dark and leathery
– May also appear
translucent / waxy white
– Painless, generally dry
– Red but doesn’t blanch
with pressure
– Little swelling of the full
thickness burned tissue,
although surrounding
tissue may swell a
significant amt
 PRIMARY SURVEY & RESUSCITATION OF PT
WITH BURN
• Airway
– Pharyngeal thermal injury 
marked upper airway edema
– Inhalation injury  clinical
manifestation is subtle and do
not appear in the first 24h
– Do not wait for evidence of
pulmonary injury / change in
blood gas determination !
• Airway edema can preclude
intubation & require surgical
airway
• Breathing
– Direct thermal injury to
lower airway is
extremely rare & only
occur after exposure to
superheated steam /
inhaled flammable gases
– Breathing concerns:
hypoxia, carbon
monoxide poisoning,
smoke inhalation injury
 Inhalation injury
• Hypoxia
– Bc inhalation injury, inadeq
ventilation bc circumferential
chest burns, traumatic thoracic
injury unrelated to thermal injury
– Administer supplemental O2, with
/ w/o intubation
• Carbon monoxide (CO) exposure in pt
who were burned in enclosed areas
– Dx: history of exposure, direct
measurement of
carboxyhemoglobin (HbCO)
– Pt w/ CO lv <20% have no physical
sx
– Higher CO lv can result in
• headache and nausea
(20%–30%)
• confusion (30%–40%)
• coma (40%–60%)
• death (>60%)
– Cherry red skin color only
seen in moribund patient
• Management of inhalation injury
 ETT + mechanical ventilation
• ABG determination to eval
patient’s pulmonary status
• Baseline HbCO lv should be
obtained, 100% O2 should be
administered
• Inhalation of products of
combustion, incl carbon particles &Inhalation injury
toxic fumes can double the
mortality
• Smoke particle settling into distal
bronchioles  dmg and death of
mucosal cells  ⬆ inflammatory
response  ⬆ capillary leakage 
O2 diffusion defect  necrotic cells
obstruct the airways
• Plugging of airways & impaired
ability to fight infx  ⬆risk of
pneumonia
• Must meet the requirement:
1. Exposure to a combustible
agent
2. Signs of exposure to smoke in
lower airway, below the vocal
chords, by bronchoscopy
• Assess pulmonary status: initial
CXR & ABG determination 
those can deteroriate overtime
• Treatment: supportive
• Smoke inhalation injury +
significant burn  intubate !
• If pt is hemodynamically stable &
spinal injury has been excluded 
elevate head and chest by 30∘ to
reduce neck&chest wall edema
• Full thickness burn of anterior &
lateral chest wall  restriction of
chest wall motion 
escharotomy
Circulation – Burn Shock Resuscitation

• Monitor hourly urinary output to

assess circulating blood volume in
absence of osmotic diuresis (insert
indwelling urinary catheter)
• Formulas are only for providing
starting target rate. After this target
rate, amt of fluid should be adjusted
based on urine output target:
– 0.5 mL/kg/hr for adults
– 1 mL/kg/hr for children <30 kg
• If urine output is above target, IV The remaining one-half of total fluid is
rate should be decreased administered during the subsequent
• IV rate should not be decreased by 16h
one half at 8hr; reduction in IV fluid
rate should be based on urine
output
• In very small children (<10 kg), add
glucose to IV fluid  avoid
hypoglycemia
• Cardiac dsyrhythmias  first sign of
hypoxia & electrolyte / acid-base
abN
• ECG should be performed for
cardiac rhythm disturbances
• Persistent acidemia may be caused
by cyanide poisoning
 SECONDARY SURVEY
• Physical examination
• Documentation
• Baseline determinations for pt w
major burns
– CBC, type and crossmatch,
ABC with HbCO, serum
glucose, electrolytes,
pregnancy test in all females
of childbearing age
– CXR for those who are
intubated / suspected smoke
inhalation injury , w/ repeat
films as necessary
• Peripheral circulation in circumferential
extremity burns
– To rule out compartment syndrome
• Result from ⬆in Pa inside a
compartment that interfere w/
perfusion to the structure
within that compartment
– For an extremity, perfusion to
muscle within the compartment is
the main concern. Pressure >30
mmHg within a compartment 
muscle necrosis
• Signs of compartment syndr:
– ⬆pain with passive motion,
tightness, numbness, ⬇distal Pa
• (cont) compartment syndrome
– Measure by inserting needle
connected to pressure tubing (arterial
or central pressure monitor) into
compartment
– Pa >30 mmHg  indication of
escharotomy
– Circumferential chest & abdomina
burns  ⬆peak inspiratory pressure.
• Chest & abdominal escharotomies
performed down the anterior
axillary lines w corss incision at the
junction of the thorax & abdomen
– Aggressive fluid resuscitation 
abdominal compartment syndr occur
• Gastric tube insertion
– If pt experiences nausea,
vomiting, abdominal distention,
burns involve >20% total BSA
• Narcotics, analgesics, sedatives
– Hypoxemia, hypovolemia  pt
restless and anxious
– Manage hypoxemia &
hypovolemia before adm of
narcotics
• Wound care
– Don’t apply cold water to pt w
extensive burns (>10% total
BSA)
 CHEMICAL BURNS
• Bc exposure to acids, alkalies, petroleum products
• Alkali burns are more serious than acid burns, bc
alkalies penetrate deeper
• Chemical burns are influenced by duration of contact,
[] of chemical, amt of agent
• Immediately flush away the chemical w large amt of
water at least 20-30 mins, using shower/hose.
– Alkaline burns require longer irrigation
– Alkali burns to the eye require continuous irrigation during
1st 8h after the burn
 ELECTRICAL BURNS
• When source of electrical power contacts pt’s body
• Body can serve as volume conductor of electrical energy, and the heat
generated results in thermal injury to tissue
• Diff rates of heat loss from superficial and deep tissue  normal
overlying skin can coexist with deep muscle necrosis
• Current travels inside blood vessels & nerves  local thrombosis, nerve
injury
• Management: ABCs, IV line, ECG monitoring (bc electricity can cause
cardiac arrhythmias that may require cheat compression)
• Rhabdomyolisis  myoglobin release  acute renal failure
– Do not wait for laboratory confirmation before instituting th/ for
myoglobinuria
– If pt’s urine is dark, assume that hemochromogens are in the urine
• Fluid administration should be increased to ensure urinary output of
100mL/hr in adults / 2ml/kg/hr in children <30 kg