Third Problem

“Destructive Giant Mushroom”

04 October 2021
Group 19-20
• Tutor : ALFRED SUTRISNO SIM dr., SP.BS., Dr
• Ketua : Oktavia Setyaningrum (405170088)– Group 19
• Sekretaris : Angelica Joanna Charity Kamalo (405180088)– Group 20
• Notulen : Moh. Niko Fajrul Yakin (405180051)– Group 19

Group 19
• Oktavia Setyaningrum (405170088)
• Amirah Dea Putri Zahirah (405180007)
• Moh. Niko Fajrul Yakin (405180051)
• Jeffrey Saputra Kawi (405180117)
• Ellyta shafira (405180146)
• Devy Fransiska Susanto (405180160)
• Sylvia regina (405180212)
• Bimayuda (405180213)
Group 20
• Intan Frederika bahari (405180043)
• Billy Oktavian (405180063)
• Angelica Joanna Charity Kamalo (405180088)
• Radhiyya Tsabitah Drajat (405180101)
• Cindy Damara (405180107)
• Mohammad Jofa Rachman Putera
(405180130)
• Belinda Layrenshia (405180204)
• Arryza Fahrita Ikhsani (405180224)
 Destructive Giant Mushroom

A massive explosion rocked a busy harbour in the morning, flattening much of the city’s port, and damaging buildings across the seashore.
More than 100 people were killed and many were injured. You are a part of the emergency response team who gets called to evacuate the
victims. At that moment, you found 6 victims evacuated from the epicentre.
The first patient, a middle-aged female, saved from the rubble. She is coughing and has multiple bruises on her left side of abdomen and left
flank. She looks pale and is complaining of severe abdominal pain. There are visible swellings over her left flank. Her blood pressure is 80/50
mmHg, heart rate is 110 beats per minute and respiratory rate is 28 breaths per minute.
The second patient, a young boy, is conscious. He is crying for help because he cannot move both of his lower extremities and needs to be
carried. There is a hematoma on his back without any apparent bleeding. He says that his legs are numb and cannot feel his lower body parts
starting from his thighs. His blood pressure is 80/50 mmHg, heart rate is 118 beats per minute and respiratory rate is 26 breaths per minute.
The third patient, an elderly female, appears dyspnoeic, breathless and disoriented. A piece of steel stabbed her left chest. Her blood pressure
is 90/60 mmHg, heart rate is 58 beats per minute and respiratory rate is 36 breaths per minute.
The fourth patient, a young female, unconscious, with rapid and shallow breaths, and thick smoke covering her head and upper body. Some
apparent bruise and burn wounds are seen. Her blood pressure is 80/64 mmHg, heart rate is 120 beats per minute and respiratory rate is 40
breaths per minute.
The fifth patient, a young male, conscious and alert. He has a laceration wound at his forehead, just an inch to his right eye. He feels confused,
coughs, breathless, and there is an active bleeding from his head. His initial vital signs examination reveals that his blood pressure is 120/70
mmHg, pulse is 110 beats per minute and respiratory rate is 28 breaths per minute.
The sixth patient, a young male, has burns all over his trunk. His clothes seemed to have caught on fire while he was trapped in the scene. He is
writhing in severe pain. There are also burn injuries on his back and neck. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute
and respiratory rate is 36 breaths per minute.
After initial prehospital care, all of the patients are to be transferred to hospitals with trauma center. The nearest one is one hour away.
However, there are only 2 available ambulances to transport the patients. Discuss the cases, assess the condition of all the patients, make a
priority plan to transfer the patients and plan proper treatment while considering coronavirus pandemic situation and all possible differentials!
MIND MAP Triage

Primary Survey

Secondary
Survey

TRAUMA

Neuro System Chest Injury Abdominal Injury Burn & Inhalation

Injury

Spinal Cord Injury Head Injury Pneumothorax(Tension Blunt Trauma (Liver, Grading, Body
& Simple), Flail Chest, Lien, Small Bowel, Surface Areas
Hemothorax, Pulmonary Retroperitoneal),
Contusion, Cardiac Penetrating Trauma
Anterior Cord, SDH;EDH;SAH;ICH, Tamponade, Rupture (Perforation,
Posterior Cord, Diffuse Axonal Aorta Rupture Abdominal
Central Cord, Cauda Injury, Fracture Aorta)
Equina, Brown Cranium
Saquard,
Transection
LEARNING ISSUE
1. MM. Triage a. Prognosis & Complication
2. MM. Primary Survey & Secondary Survey b. Referral Criteria
3. MM. Physical Examination, Differential Diagnosis & Clinical 1. MM. Abdominal Injury
Diagnosis, Diagnostic Studies (Radiology & Laboratory a. Pathophysiology
Test), b. Signs & Symptoms
4. MM. Neurological Injury ( Spinal Cord & Head Injury) c. Treatment : Pharmacological, Non-Pharmacological
a. Pathophysiology (Surgical), & Emergency
b. Signs & Symptoms d. Prognosis & Complication e. Referral Criteria
c. Treatment : Pharmacological, Non-Pharmacological 2. MM. Burn & Inhalation Injury
(Surgical), & Emergency a. Pathophysiology
d. Prognosis & Complication b. Signs & Symptoms
e. Referral Criteria c. Treatment : Pharmacological, Non-Pharmacological
5. MM. Chest Injury (Surgical), & Emergency
a. Pathophysiology d. Prognosis & Complication
b. Signs & Symptoms e. Referral Criteria
c. Treatment : Pharmacological, Non-Pharmacological
(Surgical), & Emergency
 TRIAGE
• Multiple Casualties
• Number & Capability of Medical
Team > Number of Victims
• Red – Yellow – Green - Black
• Mass Casualties
• Number & Capability of Medical
Team < Number of Victims
• Yellow – Red – Green - Black

• Special Populations :
• Children
• Pregnant Females
• Elderly People

Rosen’s Emergency Medicine Concepts & Clinical Practice 9th Edition Advanced Trauma Life Support 10th Edition
Rosen’s Emergency Medicine Concepts & Clinical Practice 9th Edition Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011
PRIMARY SURVEY
Indication for Intubation:
• Airway : • Full thickness burns of
• Inspecting for burned nasal, facial and eyebrow hairs the face or perioral
• Looking for burns and edema around the head and neck region
• Determining if there are circumferential burns to the chest which may inhibit ventilation and require
escharotomy.
• Circumferential neck
burns
• Breathing:
• Determine if the patient is moving air or not
• Acute respiratory distress
• Auscultating breath sounds • Progressive hoarseness
• Monitoring rate, depth and work of breathing, and or air hunger
• Monitoring for dyspnea and stridor • Respiratory depression /
• Circulation: Altered mental status
• Monitor circulation and cardiac status with hemorrhage control • Supraglottic edema&
• Obtain appropriate vascular access and use a device to monitor heart rate and blood pressure inflammation on
• Check : Pulse check, capillary refill, urinary output
bronchoscopy
• Exposure:
• Remove any burning agent
• Work toward maintaining a normal temperature by removing wet dressings and covering with dry, sterile
Consider patient’s
dressings anticipated clinical course!
• Begin re-warming the patient with blankets and warmed fluid. Ambient temperature should be from 28°to
32°C (82°to 90°F). The patient’s core temperature must be kept at least above 34°C. Increase the room
temperature if necessary
• Remove all jewelry

Tintinalli's Emergency Medicine -A Comprehensive Study Guide [8th Edition]

 Primary Survey
• Brain injury is affected by 2nd insults (hytotension and hypoxia)  must
cardiopulmonary stabilization
• Airway
• Early ETT must be performed in comatose patient
• Ventilated w/ 100% oxygen  measure FraksiO2 and SaO2 until (> 98% is
desirable), PCO2 ( < 32mmHg in severe brain injury)
• Circulation
• (+) hypotensiontargeted euvolemia  blood products, whole blood, or
isotonic fluids
• Neurologic exams
• GCS score, pupillary light response, and focal neurological deficit
• Presence of drugs, alcohol, intoxicants, and other injuries
• Comatose ps  motoric respons by pinching trapezius muscles or w/ nail
bed or supraorbital ridge pressure  motoric response = prognostic fx
• Doll’s eye (N.III), caloric testing w/ ice (N.VIII) and corneal response

Advanced Trauma Life Support Student Course Manual [chapter 6 page148-170]

®
Secondary survey
• Serial examinations (e.g., GCS score, lateralization, and pupillary
reaction) should be performed to detect neurologic deterioration as
early as possible
• Dx procedure  CT scan
• Significant finding scalp swelling and subgaleal hematomas at the region of
impact
• Crucial findings  intracranial hematoma, contusions, shift of the midline,
and obliteration of basal cisterns (shifts 5 mm/ >  I/ for surgery)

Advanced Trauma Life Support Student Course Manual [chapter 6 page148-170]

®
 PRIMARY SURVEY

Adequate ventilation
Stop the burning process
Direct lower airway injury rare, usually occurs
-Burnt clothes should be renewed immediately, only after exposure to very hot vapours or
except those that stick (synthetic material). inhalation of flammable gases. 
3 common problems : 
-direct contact with the material, Hypoxia: oxygen with or without inhalation
decontaminate the burn area by rinsing with CO poisoning: 100% oxygen,ETT
warm saline irrigation or warm air smoke inhalation injury: supportive

-If the process has stopped🡪 Cover with warm,

clean, dry linen/fiber🡪 avoid hypothermia
Airway 
•Identify if there is obstruction  
• Direct: inhalation injury
• Edema masif 

Advanced Trauma Life Support (ATLS), 10 th

Edition. American College of Surgeon; 2018.
Manage circulation with burn shock resuscitation
• Burn resuscitation is needed to replace capillary leaks due to
the inflammatory process
• Burn resuscitation: deep partial and full thickness > 20% IV
access with 2 large calibers (min 18 G) in peripheral veins
- Try on the upper extremities
- IV access is done on unburned skin Infusion with warm

• isotonic crystalloid solution, possibly with Ringer's lactate.

Target: urine output is met
Secondary survey

• Documentation 
• Baseline determinations for patiens with major burns
• Peripheral circulation in circumferential extermity burns
• Gastric tube insertion
• Narcotics, analgesics, sedative
• Wound care
• Antibiotics
• Tetanus
Epidural Hematoma
• Epidural hematoma arises under a temporal or parietal fracture and laceration of the middle
meningeal artery or vein
• A few hours later headache of increasing severity develops, with :
o Vomiting
o Drowsiness
o Confusion
o Aphasia
o seizures (which may be one sided)
o hemiparesis with slightly increased tendon reflexes
o Babinski sign.
• As coma develops, the hemiparesis may give way to bilateral spasticity of the limbs and Babinski
signs. The heart rate is often and is bounding as a result of a rise in systolic blood pressure
(Cushing effect). The pupil may dilate on the side of the hematoma.
• The diagnosis can be established rapidly by revealing a lens-shaped clot with a smooth inner
margin with CT and MRI
Adams and Victor’s Principles of Neurology eleventh edition
• Treatment of epidural hematoma The surgical procedure consists of placement of burr
holes in a truly emergency situation in the ED or at the bedside or, preferably a
craniotomy, drainage of the hematoma, and identification and ligation of the bleeding
vessel.
• The operative results are excellent except in cases with extended fractures and laceration
of the dural venous sinuses, in which the epidural hematoma may be bilateral rather
than unilateral. If coma, bilateral Babinski signs, spasticity, or decerebrate rigidity
supervene before operation, it usually means that displacement of central structures and
compression of the midbrain have already occurred.
• Death, which is frequent if an expanding clot is not removed surgically, comes at the end of a
comatose period and is a result of respiratory arrest. The visualization of a fracture line across the
groove of the middle meningeal artery and knowledge of which side of the head was struck (the
clot is on that side) are of aid in diagnosis and lateralization of the lesion.

Adams and Victor’s Principles of Neurology eleventh edition

 SAH

https://www.ncbi.nlm.nih.gov/books/NBK441958/
 Subdural Hematoma
• Tears of the bridging veins that extend from the subarachnoid space to the dural
venous sinuses -> collection of venous blood between the dura matter and the
arachnoid
• SDH occurs most commonly in patients with brain atrophy, such as alcoholic or older
patients, because bridging vessels traverse greater distances than in patients with no
atrophy.
• Acute SDH -> present within 14 days of the injury, and most become symptomatic
within 24 hours of injury.
Headache, altered mental status, or focal deficits
• Chronic SDH -> after 2 weeks
The signs and symptoms may be very subtle or nonspecific, but many patients
demonstrate unilateral weakness or hemiparesis, altered LOC
Tintinalli’s Emergency Medicine Manual
Rosen’s emergency medicine
https://www.ncbi.nlm.nih.gov/books/NBK532970/
Laboratory Tests
• complete blood count (CBC)
• basic metabolic panel (BMP)
• a bedside glucose test in patients with altered mental status
• blood alcohol level in patients suspected of alcohol intoxication chronic SDH -> hypodense acute SDH -> hyperdense
and head trauma.
• Coagulation studies are indicated in patients with
coagulopathies (eg, hemophilia, Von Willebrand disease),
suspected liver disease, and those on anticoagulants.
Neuroimaging
• Cranial computed tomography (CT) -> cornerstone of imaging
for acute head trauma
• acute SDH -> hyperdense, crescent-shaped lesion that crosses
suture lines
• chronic SDH -> isodense or hypodense to brain parenchyma
Treatment
• Indications for surgical evacuation
• acute SDHs with a thickness more than 10 mm or a midline shift of
more than 5 mm on a CT scan, regardless of the patient’s GCS score https://www.researchgate.net/figure/A-Axial-slide-of-a-brain-CT-scan-showing-a-chronic-subdural-h
aematoma-white-arrow-13_fig1_319281561
• worsening GCS score (≥2 points from the time of injury to hospital
admission) in comatose patients
• asymmetric or fixed and dilated pupils
• persistent elevation in ICP.
• Symptomatic chronic SDHs require surgical evacuation
ICH
American College of Surgeon. 2018. ATLS : Advanced Trauma Life Support 10 th Edition.
American College of Surgeon. 2018. ATLS : Advanced Trauma Life Support 10 th Edition.
Macellari F, Paciaroni M, Agnelli G, Caso V. Neuroimaging in intracerebral hemorrhage.. Stroke .2014; 45(3): p.903-8. doi: 10.1161/STROKEAHA.113.003701.
 Medical Therapies
• IV fluid  Ringer’s lactate solution/normal saline.
• O2
• Mannitol  20% solution (20 g of mannitol per
100 ml of solution).
• To reduce elevated ICP
• Bolus mannitol (1g/kg) over 5 minutes
• Hypertonic saline
• Barbiturate (ICP refractory)
• Anticonvulsant
• Phenytoin and fosphenytoin  mainly used
for acute phase (Dose : 1g IV < 50 mg/min,
maintenance dose = 100mg/8 hours)
Surgical management
• Necessary for scalp wounds, depressed skull
fractures, intracranial mass lesions, and
penetrating brain injuries
American College of Surgeon. 2018. ATLS : Advanced Trauma Life Support 10 th Edition.
ATLS 10th ed.
 SPINAL CORD INJURY
• Spine injury, with or without neurologic
deficits, must always be considered in
patients with multiple injuries
• Epid:
• 55%  cervical region
• 15%  thoracic region
• 15%  thoracolumbar junction
• 15%  lumbosacral area
• Complete spinal cord injury  when a
patient has no demonstrable sensory or
motor function below a certain level
• Incomplete spinal cord injury  is one in
which any degree of motor or sensory
function remains; the prognosis for recovery
is significantly better
Rosen’s Emergency Medicine. 2017
Tintinalli’s Emergency Medicine Manual 2018
Rosen’s Emergency Medicine. 2017
Tintinalli’s Emergency Medicine Manual 2018
 • Diagnosis :
• Neurology evaluation : sensory , motor,
spinal reflex
• Radiology : X-Ray, CT-scan, MRI
• Treatment :
• ABC
• Spinal movement restriction: stiff cervical
collar, long spine board
• IV crystalloids: treat hypotension
(neurogenic/hypovolemic shock) → MAP
maintained at 85-90 mmHg for first 7 days
• Urinary catheter: monitors urine output
and prevents VU distension
• Specialty: surgery → stabilization of
severe bone trauma, reducing vertebral
dislocation
• Complications: death, respiratory
distress, sepsis
Rosen’s Emergency Medicine. 2017
Tintinalli’s Emergency Medicine Manual 2018
 Acute Medulla Compression
Happens when pressure on the spinal cord stops the nerves working normally.
Causes • Abnormal spine alignment (scoliosis)
• Injury to the spine
• Spinal tumor
• Certain bone diseases
• Rheumatoid arthritis
• Infection

Symptoms • Pain and stiffness in the neck, back, or lower back

• Burning pain that spreads to the arms, or down into the legs
• Numbness, cramping, or weakness in the arms, hands, or legs
• Loss of sensation in the feet
• Trouble with hand coordination
• "Foot drop," weakness in a foot that causes a limp
• Pressure on nerves in the lumbar region (lower back)  cauda equina syndrome

Treatment • Medicines: NSAIDs

• Physical therapy
• Surgical treatments
*Emergencies (Cauda equina syndrome or a broken back): surgery  the last resort

https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-cord-compression
https://www.cancerresearchuk.org/about-cancer/coping/physically/spinal-cord-compression/about
 Complete Spinal Transection
• These injuries typically demonstrate complete bilateral loss of motor function, pain
sensation, temperature sensation, proprioception, vibratory sensation, and tactile
sensation below the level of injury.
• Lumbosacral injuries will present with paralysis and loss of sensation in the lower
extremities. These injuries may also result in loss of bowel control, loss of bladder
control, and sexual dysfunction.
• Thoracic injuries lead to the same deficits as lumbosacral injuries and, in addition,
may result in loss of function of the muscles of the torso, leading to difficulty
maintaining posture.
• Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in
loss of function of the upper extremities leading to tetraplegia. Injuries above C5
may also cause respiratory compromise due to loss of innervation of the diaphragm.

https://www.ncbi.nlm.nih.gov/books/NBK560721/
 Evaluation
SCI is graded using the American Spinal Injury Association
(ASIA) Impairment Scale. The grading system varies based on
the severity of injury from letters A to E.
• ASIA A: Complete injury with loss of motor and
sensory function.
• ASIA B: Incomplete injury with preserved sensory
function, but complete loss of motor function.
• ASIA C: Incomplete injury with preserved motor
function below the injury level, less than half these
muscles have MRC (Medical Research Council) grade 3
strength.
• ASIA D: Incomplete injury with preserved motor
function below the injury level, at least half these
muscles have MRC (Medical Research Council) grade 3
strength.
• ASIA E: Normal motor and sensory examination.  improvement in patients with SCI.
https://www.ncbi.nlm.nih.gov/books/NBK560721/
Treatment
•Treatment begins at the site of injury
•Immobilization can help prevent the worsening of any existing
injuries. In the case of serious trauma, address any life threats or
concurrent traumatic injuries immediately.
•Hypotension and shock will worsen the impact of any existing SCI
and worsen the likelihood of neurologic recovery. Immediate
measures are necessary to maintain breathing and hemodynamic
stability.
•Surgical decompression may be warranted if feasible to lessen the
extent of the injury. This procedure helps to stabilize the spine, to
prevent pain, reduce deformity, deliver compression from a
herniated disc, blood clot, or foreign body. 
•Several medications have had trials to help with improving
outcomes in SCI, but the results have not shown significant
benefits. Trials with nimodipine, gacyclidine, thyrotropin-releasing
hormone, riluzole, gangliosides, minocycline, magnesium, acidic
fibroblast growth factor have been studied to see their impact on
 BLUNT TRAUMA ABDOMEN
The physical exam
• may reveal marks from a lap belt
• Ecchymosis
• abdominal distention
• absent bowel sounds and tenderness to palpation

https://www.ncbi.nlm.nih.gov/books/NBK431087/
CURRENT Diagnosis and Treatment Emergency Medicine, Seventh Edition (LANGE CURRENT Series)
 Evaluation:
Complication:
• hemodynamically stable: CT scan
• For unstable patients: EFAST &
• Inadequate resuscitation
diagnostic peritoneal lavage • Missed abdominal injuries
Treatment: • Delays in diagnosis and treatment
• ABCs (Airway, Breathing, and Circulation)
• Intraabdominal sepsis
• patients who are hypotensive require
aggressive fluid resuscitation • Delayed splenic rupture
• Laparotomy
• angiography can now help control Prognosis : Overall prognosis for
hemorrhage with the use of
embolization therapy
patients who sustain blunt
abdominal trauma is favorable
• hemodynamic instability persists, blood
should be typed and crossed, but in the
meantime, immediate transfusion

https://www.ncbi.nlm.nih.gov/books/NBK431087/
Penetrating trauma abdomen

etiology
• 80% of gunshot wounds and 20–30% of stab
wounds result in significant intra-abdominal
injury. Commonly injured structures include:
• Liver (37%)
• Small bowel (26%)
• Stomach (19%)
• Colon (17%)
• Major vessel (13%)
• Retroperitoneum (10%)
• Mesentery/omentum (10%)
• Other:
• – Spleen (7%)
– Diaphragm (5%) – Kidney (5%)
– Pancreas (4%)
– Duodenum (2%) – Biliary (1%)

• ATLS Student Course Manual 2018

• Rosen’s Emergency Medicine Concepts and
Clinical Practice
Essensial workup
• Diagnosis of intra-abdominal injury from gunshot wounds
to the abdomen are made by laparotomy in the operating
room.
• Locally explore stab wounds to anterior abdomen: – If the
wound penetrates the anterior fascial layer, the patient
should undergo diagnostic peritoneal lavage or bedside
US.
• Diagnostic laparoscopy is useful in diagnosing
diaphragmatic injury and spleen and liver lacerations: –
May help avoid unnecessary surgery.
• If 10,000 RBC/mm3 or more are found in the diagnostic
peritoneal lavage fluid, the patient should undergo
laparotomy.
• If <10,000 RBC/mm3 are present, the patient should be
observed for 8–24 hr for the development of peritoneal
signs.

• Rosen’s Emergency Medicine Concepts and

Clinical Practice
 Lab
• Hemoglobin or hematocrit:
– Repeated measurements to assess for
ongoing
• hemorrhage
Urinalysis for blood to assess for possible
genitourinary tract damage
• ABG:
• Base deficit may be helpful in assessing
hypovolemia and guide volume resuscitation. • CT with IV contrast in experienced facilities
• Type and cross-match for all patients with
significant intra-abdominal injuries.
Imaging
•
Plain films:
• Obtain after placement of markers for localization
of foreign bodies, missiles, associated fractures,
and free air.
• IV pyelogram:
• For possible renal injury
• Bedside abdominal US (FAST: Focused
abdominal sonography for trauma):
• May reveal intraperitoneal blood or fluid
and with stable patients:
• For possible retroperitoneal and solid organ
injuries
• Rosen’s Emergency Medicine Concepts and
Clinical Practice
treatment
• 2 large-bore IV lines with crystalloid
infusion
• If no response to 2 L of crystalloid,
infuse 2–4 units ;packed red blood
cells:
– May use O negative blood initially if
patient is unstable
– Type-specific and cross-matched
blood when it becomes available
• 100% oxygen by nonrebreather face
mask
pediatric
• Children in hypovolemic shock
should receive 20 mL/kg
boluses of crystalloid.
• Children in severe hypovolemic
shock should receiver 1 mL/kg
of packed red blood cells.
• Age <8 yr is a relative
contraindication for diagnostic
peritoneal lavage.
• Rosen’s Emergency Medicine Concepts and
Clinical Practice
• Nasogastric tube placement
• Foley catheter placement
• Tetanus if appropriate
Rosen’s Emergency Medicine Concepts and Clinical Practice
DIFFERENTIAL DIAGNOSIS
• In cases of upper abdominal wounds, consider the possibility of
intrathoracic injury.
• In cases of wounds to the lower thoracic area, consider the possibility
of intra-abdominal injury.

• Rosen’s Emergency Medicine Concepts and

Clinical Practice
 Pelvic Trauma
Pelvic injuries are the result of high energy trauma; they frequently have associated
injuries. The injuries can be life-threatening and lead to life-long disability.

Clinical features:
• Local pain and tenderness to pelvic instability and severe shock
• Examine the patient for pain, pelvic instability, deformities, lacerations, ecchymoses,
and hematomas
• Avoid excessive movements of unstable fractures as this could produce further injury
and cause additional blood loss
• Rectal examination may reveal displacement of prostate or rectal injury
• Blood at the urethral meatus suggest urethral injury

Tintinalli’s Emergency Medicine Manual 2018

 Diagnosis:
• In patients with a suspected pelvic fracture, obtain a standard anteroposterior
(AP) pelvis radiograph to evaluate for bony injury.
• In an unstable blunt trauma patient, use an AP pelvic radiograph to identify a
pelvic fracture quickly, allowing for emergent stabilization maneuvers.
• Pelvic fractures include those that involve a break in the pelvic ring, fractures
of a single bone without a break in the pelvic ring, and acetabular fractures
• Acetabular fractures are commonly associated with hip dislocations and can be
diagnosed with pelvis radiographs and Judet views. CT is more sensitive than
radiography in detecting acetabular injury and is helpful in preoperative
planning.

Tintinalli’s Emergency Medicine Manual 2018

Tintinalli’s Emergency Medicine Manual 2018
Pneumothorax
Diagnostic testing
Pneumothorax, which is the • Radiography (CT or Xray)
accumulation of air in the • Ultrasound
pleural
space, is a common
complication of chest trauma.
Pneumothorax type :
• simple
• communicating
• tension
clinical features: The cardinal sign of Tension Pneumothorax
• shortness breath and chest pain (most common • tachycardia
pneumothorax complain) • hypotension
• Cyanosis • oxyhemoglobin desaturation
• tachypnea • Jugular Vein Distention (JVD)[maynot reliably
On Tension Pneumothorax: present in massive blood loss]
• acutely ill within minute • absent breath sound on ipsilateral side
• severe cardiovascular and Respiratory
distress(dyspneic, agitated, restless, cyanotic, Suspicion of tension pneumothorax
tachycardic, and hypotensive and display on the basis of clinical findings is indication for
decreasing mental activity. ) immediate tube thoracostomy.
The preferred site for insertion is the fourth
or fifth intercostal space at the midaxillary line. Rosen Emergency Medicien 9th Edition
Treatment

Simple Pneumothorax Communication Pneumothorax

• just observed - formal tube thoracostomy in ED
• performed chest tube if there are any - prepared for definitive surgical
sign of deterioratation repair.
• If there is significant air leak or a large
Tension Pneumothorax
hemothorax, the tube may be
When the diagnosis of tension
connected to a source of constant
pneumothorax is suspected
vacuum at 20 to 30 cm H2O for more
clinically
rapid reexpansion.
• immediately performed
• routine intravenous antibiotic
needle thoracostomy
administration in these patients
• cefazolin 1 to 2 g(prior to-or within
1 hour of—chest tube insertion)
• Vancomycin (1 g) or clindamycin
(600 mg) if patient have KI with
cephalosphorin.

Rosen Emergency Medicien 9th Edition

 Thoracic Trauma
PRIMARY SURVEY

AIRWAY BREATHING CIRCULATION

• Airway patency : listen air • Respiratory movement & • Heart rate: Frequency, quality
movement; Stridor : upper quality : observe, palpating & & regularity
airway obstruction, |Gurgle : listening • Blood pressure
water/semisolid obstruction| • Hypoxia sign: tachypnea, • Peripheral Circulation :
Wheezing : | Snoring : breathing pattern temperature, color
• Inspecting oropharynx (shallower), Cyanosis (late • JVP
• retraction sign) • Cardiac monitor & Pulse
• Trauma that affect breathing Oxymetri
-> Tension pneumothorax,
Open pneumothorax, Flail
chest, Pulmonary contusion,
Massive hemothorax

ATLS - Advanced Trauma Life Support - Student Course Manual (10th edition)
 Primary Survey - Hemothorax
• Accumulation of blood and fluid in a hemithorax can significantly compromise respiratory efforts by compressing the lung
and preventing adequate ventilation.
• Results from  rapid accumulation of >1500 ml of blood or 1/3 or > of the patient’s blood volume in the chest cavity
• Present as  hypotension, hypovolemic shock & dyspnea
• Physical Examination  tactile fremitus is decreased & breath sounds is diminished

Etiology Penetrating wound blunt trauma

Th/ Initially 
•Simultaneous restoration of blood volume and decompression of the chest cavity
•Large-caliber intravenous lines and a rapid crystalloid infusion
•Type-specific blood is administered

Blood from the chest tube should be collected in a device suitable for autotransfusion
If 1500 mL of fluid is immediately evacuated  early thoracotomy
output of <1500 mL of fluid, but continue to bleed  thoracotomy.

ATLS - Advanced Trauma Life Support - Student Course Manual (10th edition)
 Secondary Survey - Hemothorax
Hemothorax
• Chest x-ray with the patient in the supine HTX
position
• Acute hemothorax that is large enough to appear
on a chest x-ray treat w/ 28-32 French chest
tube.
• >1500 mL of blood obtained immediately
through the chest tube: a massive
hemothoraxmay require operative
intervention
• If drainage of >200 mL/hr for 2 to 4 hours occurs,
or if blood transfusion is requiredshould
consider operative exploration.

ATLS - Advanced Trauma Life Support - Student Course Manual (10th edition)

Sheran SC. Clinical Emergency Medicine - LANGE

https://www.resmedjournal.com/article/S0954-6111%2810%2900351-3/fulltext
Pericardial Tamponade • Physical Exam:
• Signs of shock/right heart failure
• Accumulation of pericardial fluid  elevation (tachycardia, hypotension, JVD)
of pressure in the pericardial • Pericardial friction rub
spaceimpairment of ventricular filling and
decreased CO • Pulsus paradoxus
• Low grade fever
• Etiology: Medical causes
(pericarditis,malignancy,postmyocardial • Lungs should be clear
infarction, ESRD, autoimmune, RF, radiation, • Essential Workup:
myexedema,CHF, drugs, idiopathis) and • EKG
surgical causes. • Chest X-ray
• Signs and symptoms: • USG
• Beck’s Triad (JVD, hypotension, muffled
heart sounds)
• Dressler syndrome

Rosen & Barkin’s 5 Minute Emergency Medicine Consult 5th edition

• Diagnostic tests: • Differential Diagnosis
• Lab: • Noncardiogenic shock
• CBC • Cardiac conditions: MI, pericardial
• ESR,CRP constriction, CHF
• Cardiac enzymes • Pulmonary conditions: pulmonary
• Electrolytes embolus, tension pneumothorax,
• Coagulation profile hemothorax
• Blood cultures • Others: air embolism, aortic dissection,
• Imaging: ruptured abdominal aortic aneurysm
• Chest Radiograph
• Echocardiography
• Chest CT
• Transesophageal echocardiography
• MRI with gadolinium
• Diagnostic procedures/ Surgery:
• EKG
• Pericardiocentesis
• CVP determination
Rosen & Barkin’s 5 Minute Emergency Medicine Consult 5th edition
 Algorithm of management

Restrepo, Carlos & Lemos, Diego & Lemos, Julio & Velasquez, Enrique & Diethelm,
Lisa & Ovella, Ty & Martinez-Jimenez, Santiago & Carrillo Bayona, Jorge Alberto &
Moncada, Rogelio & Klein, Jeffrey. (2007). Imaging Findings in Cardiac Tamponade
with Emphasis on CT1. Radiographics : a review publication of the Radiological
Society of North America, Inc. 27. 1595-610. 10.1148/rg.276065002.
Flail Chest
Flail chest describes a situation in which a portion of the rib cage is
separated from the rest of the chest wall, usually due to a severe blunt
trauma, such as a serious fall or a car accident.
SIGNS AND SYMPTOMS
History Physical Exam
• Blunt thoracic trauma by any • Flail chest paradoxically moves
mechanism inward during inspiration and
outward during expiration
• Localized chest wall pain
• Multiple rib fractures
• Pleuritic chest pain
• Cyanosis, tachycardia, hypotension
• Dyspnea
• Auscultation with initially normal
• Hemoptysis breath sounds progressing to wet
rales or absent breath sounds
DIAGNOSIS TESTS & INTERPRETATION
Lab
• Arterial blood gas analysis:
-May reveal hypoxemia
-Elevated alveolar–arterial gradient
Imaging
• Chest radiograph aids diagnosis
and prognosis:
– May reveal associated
intrathoracic pathology
• Thoracic CT is useful in detecting
associated intrathoracic injuries
not identified on chest
radiograph
DIFFERENTIAL DIAGNOSIS
• Chest wall contusion or intercostal muscle
strain
• Costochondral separation
• Sternal fracture and dislocation
• Radiographic differential diagnosis includes:
– ARDS
– Pulmonary laceration, infarction, or embolism
– CHF
– Pneumonia, abscess, other infectious
processes
– Noncardiogenic causes of pulmonary edema
TREATMENT
PRE-HOSPITAL
• Positioning the patient with the injured side
down can stabilize the involved chest wall
• Thoracic trauma with significant mechanism or
combined with pre-existing pulmonary disease
should be routed to the nearest trauma
center.
INITIAL STABILIZATION/THERAPY
• Manage airway and resuscitate as indicated.
• IV line, O2, continuous cardiac monitoring,
and pulse oximetry
• Control airway
ED TREATMENT/PROCEDURES
• Maintain adequate oxygenation and ventilation.
• Monitor O2 saturation and respiratory rate.
• In conscious and alert patients, O2 administration via face mask is first-line therapy.
• If patient cannot maintain a PaO2 >80 mm Hg on high-flow oxygen, consider continuous
positive airway pressure via mask or nasal bilevel positive airway pressure.
• Consider early endotracheal intubation and mechanical ventilation
• External fixation or stabilization of the flail segment is not indicated.
• Adequate pain control is critical to maintaining adequate pulmonary function
• Search for associated injuries and treat exacerbation of underlying lung disease.
• Intercostal nerve blocks with 0.5% bupivacaine are safe and effective when performed
properly
  Pulmonary contusion

Journal of Surgical Research

A Novel CT Volume Index Score Correlates with Outcomes in Polytrauma Patients with Pulmonary Contusion -
Journal of Surgical Research
Rosen's Emergency Medicine 9 th edition
Journal of Surgical Research
A Novel CT Volume Index Score Correlates with Outcomes in Polytrauma Patients with Pulmonary Contusion - Journal of
Surgical Research
 Treatment
• Treatment for pulmonary contusion is essentially the same as that for flail chest. When only one
lung has been severely contused and has caused significant hypoxemia, consideration should be
given to intubating and ventilating each lung separately using a dual-lumen endotracheal tube
and two ventilators. This allows for the difference in compliance between the injured and the
normal lung and prevents hyperexpansion of one lung and gradual collapse of the other.
• Certain patients may benefit from a trial of noninvasive positive pressure ventilation with CPAP
in order to avoid intubation and mechanical ventilation.
• Certain procedures may ameliorate the pulmonary contusion, including the restriction of
intravenous fluids to maintain intravascular volume within strict limits and aggressive
supportive care consisting of vigorous tracheobronchial toilet, suctioning, and pain relief.

Rosen's Emergency Medicine 9 th edition

 BURNS

Scalds Contact Thermal Radiation Chemical Electrical Friction

SIGNS & SYMPTOMS HISTORY

• Most burns will have external signs of trauma to the skin • AMPLE history, source of fire, the location and surroundings, any
• Inhalation injury explosion
 Facial burns, pharyngeal injection • Medical/surgical/social history, medication, allergies, tetanus
 Singed nasal hair/eyelashes immunization status
 Carbonaceous sputum • CO poisoning from exposure to wood based fire/combustion (pulse
 Change in respiratory mechanics (wheezing, coughing, tachypnea) oximetry unreliable in CO poisoning)
• Electrical and chemical burns may have minimal external finding • Cyanide poisoning from burning wool, silk, nylon, and polyurethane found
(entry/exit wounds) in furniture/paper

Physical Exam
• Focus on airway 1st, the secondary survey for concurrent injuries
• Evaluate the face, oropharynx, and nares for signs of inhalation injury
• Assess need for mobilization of cervical spine (explosion or falls)
• Eye exam for corneal burns
• Estimate severity of partial and full thickness burns by assessing size/depth of burn

ESSENTIAL WORKUP
1. Rule of nines (applies only to adults)
2. Lund and Browder chart; divided body into areas and assigns percentage of BSA based on age, produce more reliable results than rule of 9s
3. Palm surface area; patient’s palm and fingers represent – 1% of TBSA
4. 1st degree, 2nd degree, 3rd degree, and 4th degree
 DIAGNOSIS TEST & INTERPRETATION
• Lab
o Severe burns: CBC, serum electrolytes, glucose, BUN, creatinine, PT/PTT, type and crossmatch, and pregnancy test (if indicated)
o Blood gas with CO level for closed space or suspected inhalation exposures
o Cyanide level (if indicated)
• Imaging  CXR
• Diagnostic procedures/Surgery
o Bronchoscopy to assess for inhalation injury
o ECG, especially in electrical burns, elderly patients

PREHOSPITAL
• Stop the burning process, remove
smoldering/contaminated clothes/jewelry
• Keep patient warm, cool affected areas
• Establish patent airway
• Early IV fluid therapy (>20 TBSA)
• Institute pain relief, with narcotic if possible
• Protect the wound with clean sheets
• Transport to burn center if transport time <30 min
• Spinal immobilization if mechanism is concerning
INITIAL
STABILITATION/THERAPY
• Airway control is paramount
• IV access, supplemental 100% oxygen, monitor,
pulse oximetry
• Evaluation for concurrent injuries
• Provide adequate analgesia
• Early fluid resuscitation is essential
ED TREATMENT/PROCEDURES
• Fluid resuscitation
• Escharotomy
• Wound care
• Out patient of minor burns
TREATMENT
PEDIATRIC CONSIDERATIONS
• Parkland formula underestimates fluid requirement in children; the Galveston formula is more
accurate
• Use 5% dextrose in lactated ringer solution IV over the 1 st 24 hour; give ½ in 1st 8 hour and the other
½ over the next 16 hour
• Consider nonaccidental trauma, particularly with burns on the back of hand or feet, buttocks,
perineum, or legs
• Avoid hypothermia and hypoglycemia
PREGNANCY CONSIDERATIONS
• Significant morbidity to mother and child
• Fluid requirements may exceed estimations
• Fetal monitoring and early obstetric consultation recommended
MEDICATION
• Bacitracin ointment  apply 1-4 times per day
• Mafenide (Sulfamylon) acetate cream: apply 1 or 2 times per day
• Narcotic, especially for debridement of blisters and larger, severe burns
• Silverlon and Acticoat  cut sheet to size of burn; moisten the sterile water
• Silver sulfadiazine cream: apply 1-2 times per day
• Tetanus toxoid or immunoglobulin: 0,5 mL IM; 250 U IM once along with toxoid
o Santyl: apply to eschar/wound bed once daily
Admission Criteria
• Injuries requiring admission
• Injuries requiring transfer/admission to a burn center
 Inhalation Injury
Inhalation injury is a broad term that includes pulmonary exposure to a wide range
of chemicals in various forms including smoke, gases, vapors, or fumes.

Toxic compounds in smoke Diagnose Evaluation

• carbon monoxide • Anamneses • Chest imaging
• ammonia • Symptoms : burning sensation • CBC, CMP, Lactate
• carbon dioxide in the nose or throat, • Pulse Oximetry
• hydrogen cyanide odynophagia, cough with • ABG
• aldehydes increased sputum production, • Carboxyhemoglobin level
• sulfur dioxides stridor, and dyspnea with • Cyanide level
• nitrogen dioxide rhonchi or wheezing. Systemic • Pulmonary function test
symptoms • Bronchoscopy and direct
laryngoscopy

https://www.ncbi.nlm.nih.gov/books/NBK513261/
 Management
• Removing the patient from the exposure area
• Intubation, tracheostomy if necessary
• aggressive pulmonary hygiene
• N-acetylcysteine (NAC)
• Bronchodilators (Beta-2-adrenergic agonists & muscarinic receptor
antagonists)
• Steroids
• Antibiotics
• Anticoagulation (Nebulized heparin)
• Hyperbaric oxygen treatment (HBO)
• Hydroxocobalamin

https://www.ncbi.nlm.nih.gov/books/NBK513261/
 DD
• Acute respiratory distress
syndrome (ARDS)
• Asthma
• Aspiration
pneumonitis/pneumonia
• Chronic obstructive lung disease
(COPD)
• Congestive heart failure
• Interstitial lung diseases
• Pulmonary embolism
• Pneumonia: viral or bacterial
• Pneumothorax
https://www.ncbi.nlm.nih.gov/books/NBK513261/
Prognosis
• Patients with smoke inhalation injury are at
high risk for complications. Severe injuries
often will lead to long-term complications
Complication
Short-term complications
• Pneumonia
• Acute respiratory distress syndrome
• Pulmonary edema
Long-term complications
• Subglottic stenosis
• Bronchiectasis
• Bronchiolitis obliterans.
• Neurological complications
 Patient Patient Triage Pre-Hospital Emergency Department
1st Red IV Fluid, Oxygenation IV Fluid, Oxygenation, FAST/CT-Scan,
Laparotomy
Triage
2nd Yellow Collar Neck (Restriction),Neutral IV Fluid, Analgesia, Urinary Catheter,
Primary Survey Position, IV Fluids VTE Prophylaxis, CT Scan, Surgery if
needed
Secondary Survey
3rd Red IV Fluid, Oxygenation, 3 side plaster, IV Fluid, Oxygenation,POCUS/X-
Don’t pull the steel, Chest tube ray/CT-scan, Surgery (Thoracotomy)
Pre-Hospital
placement if needed
Management
4th Red Stop burning process, secure the IV Fluid, Wound Care, Escharotomy if
airway, intubation, high flow oxygen, needed,
IV Fluid Access Oxygen IV Fluid, protect the burn wound

Stable Hemodynamic 5th Green Bandage wound, Oxygenation CT-scan , Surgery if needed
6th Red Stop burning process, secure the IV Fluid, Wound Care, Escharotomy if
Transfer airway, intubation, high flow oxygen, needed.
IV Fluid, topical moisturizer,
analgesic, protect the burn wound,
Emergency Department Management

Diagnostic Studies
Priority Transfer : 1st and 3rd Patient
Second Transfer : 4th and 6th Patient
Confirmed Diagnosis Treatment
Third Transfer : 2nd and 5th Patient