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Initial Assessment and Management

Preparation
o Prehospital
Coordinate events with clinicians at rec hospital
Airway maintenance
control of external bleeding and shock
immobilization
immediate transport
Triage
o Sorting of patients based on needs for treatment and resourced available
o Treatment rendered based on ABC priorities
o Determine appropriate receiving facility
o Multiple vs Mass casualties
o Page 5. Figure 1-2
Primary Survey
o ABCDE
Quick assessment: ask pt to id self and ask what happened
Appropriate response= no major airway compromise, breathing not
severely impaired, no major decrease in level of consciousness
o Airway
Suction, inspect for FB, look for facial/jaw fractures
Initial chin lift/jaw thrust is recommended to achieve patency
All pts with GCS <8 should be intubated
Finding of non-purposeful motor responses strongly suggest the need for
definitive airway management
Prevent excessive movement of cervical spine
No flexing, extending, rotating
Assume loss of stability of the cervical spine
o Evaluate later
Lateral films only ID 85% of all injuries
o Breathing and ventilation
Evaluate: jugular vein distention, chest rise/symmetry, position of trachea
Auscultate to ensure air flow
Palpation may reveal injuries that may compromise ventilation
Percussion may ID injuries
o Dull vs hyperresonant
o Circulation and hemorrhage control
Hemorrhage is predominant cause of preventable deaths after injury
Evaluate
Level of consciousness
Skin Color
o Pt with pink skin especially in face and extremities rarely has
critical hypovolemia after injury
o Look for ashen/gray facial skin and pale extremities
Pulse
o Easily accessible central pulse (carotid/femoral)
Bilaterally for quality, rate, regularity
Full, slow, regular pulses= relative normovolemia in a pt
not taking BB
Normal pule rate does not neccesarily equal
normovolemia
Irregular pulse warns of cardiac dysfunction
Elderly: impaired compensatory mechanisms rate may
not increase
Children: high physiologic reserve rate may not
increase
Athletes: may have bradycardia
Bleeding
o Determine if internal or external
o Direct manual pressure on wound is best
Tourniquet may be good for extremity but carry risk of
ischemic injury so only use when direct pressure not
effective.
Use of hemostats can result in damage to nerves and
veins
o Disability (Neuro evaluation)
Rapid neuro eval at the end of primary survey
Level of consciousness, pupillary size and reaction, lateralizing signs,
spinal cord injury level
GCS: particularly motor response
Decrease in consciousness: low perfusion or direct brain injury or toxins/drugs
Prevention of secondary brain injury by maintaining oxygenation and perfusion
are the main goals of initial management
o Exposures and environmental controls
Completely undress patient
Cover with warm blankets to prevent hypothermia
IV fluids should be warmed to before infusing
PTs body temperature is more important than healthcare providers comfort!
Resuscitation
o Follows ABCs and occurs simultaneously with evaluation
o Airway
Jaw-thrust or chin lift
Definitive airway if any doubt about pts ability to maintain airway integrity
Establish airway surgically if intubation is contra-indicated
o Breathing, ventilation, oxygenation
EVERY injured patient should get oxygen
Tension pneumothorax suspected decompress chest
Use pulse ox to monitor
o Circulation and hemorrhage control
Definitive bleeding control and appropriate fluid resuscitation
Definitive control includes surgery, angio embolization, and pelvic
stabilization
Fluid resuscitation
Minimum of 2 large bore IV catheters
Max rate of fluid determined by catheter NOT by vein its in
Upper Extremity preferred over lower extremity
Draw blood for type and crossmatch as well as baseline hematological
studies including pregnancy test at time of IV insertion
All IV fluids should be warmed 98.6-104, 37-40)
If patient unresponsive to initial crystalloid therapy, blood transfusion
should be given
Increase temperature of resuscitation area to prevent hypothermia
High flow fluid warmer or microwave to heat crystalloids to 39C
Dont microwave blood products
Adjuncts to primary and secondary survey
o EKG
o Urinary catheter and gastric catheters should be placed during resuscitation phase
Indwelling bladder catheter is best
Contraindications: blood at urethral meatus, perineal ecchymosis, high riding or
nonpalpable prostate
DO NOT PLACE before rectum and genitalia have been examined.
Urethral integrity should be confirmed by retrograde urethrogram
before the catheter is inserted (page 12)
o Gastric catheter
Indications: reduce gastric distention, decrease risk of aspiration, assess for
upper GI bleed
If cribriform plate injured or suspected to be injured then place gastric tube
through mouth to prevent intracranial passage
o Ventilatory rate
CO
2
detection can confirm that endotracheal tube is placed in airway and not
esophagus but does not confirm its proper placement in the trachea
o ABG
o Pulse ox
Do not place distal to BP cuff
o BP
Should be measured but may be a poor measure and late indicator of actual
tissue perfusion
o Imaging
Should not interrupt resuscitation efforts
Essential diagnostic x-rays should be taken even in pregnant patients
FAST and DPL are good to quickly assess occult intraabdominal blood
Use depends on skill and experience of clinician
Consider need for patient transfer
o Primary survey and initial resuscitation frequently provides enough info to decide on
transfer
Once decision is made communication btw referring and receiving doctors is
essential
Secondary Survey
o Complete physical exam and history
o Begins after primary survey is complete, resuscitation is underway, and normalization of
vital functions has been demonstrated
When additional personnel are available part of the secondary survey can be
conducted while other personnel attend to primary
Secondary shouldnt interfere with primary
o History
Allergies
Medications
Past illnesses/Pregnancy
Last meal
Events/Environments related to injury
Blunt
Seat belt use, steering wheel deformation, direction of impact, damage
to automobile, pt ejected from vehicle
Penetrating
Gunshot
o Velocity, caliber, presumed path, distance from firing
Thermal Injury

Hazardous environment
o Physical Exam
Head
Quick eye exam: ask pt to read printer material
Evaluate ocular mobility
Maxillofacial Structures
Palpate all bony structures, assess for occlusion, intraoral examination,
assessment of soft tissue
Cervical Spine and Neck
Wounds that extend through the platysma should not be explored
manually, probed with instruments, or treated by individuals in the ED
who are not trained to manage such injuries.
Chest
Upper front chest for breath sounds
Lower posterior for hemothorax
Abdomen
Rib or pelvic fractures may elicit pain on abdominal exam.
Perineum, rectum, vagina
Musculoskeletal system
Neurological exam
Adjuncts to secondary survey
o
Re-evaluation
Definitive care
Disaster
Records and Legal Considerations
Teamwork
o Mechanism and time of injury
o Injuries found and suspected
o Symptoms and signs
o Treatment initiated

Airway and Ventilatory Management
Inadequate delivery of oxygenated blood to the brain and other vital structures is the quickest
killer of injured patients
ALL trauma patients should receive oxygen
Airway
o Positive verbal response
o Definitive airway: tube placed in the trachea and cuff inflated below vocal cords, a tube
secured to oxygen-enriched assisted ventilation, and airway secured with tape
o Anticipate vomiting
Gastric contents in the oropharynx represents significant risk of aspiration in
next breath
Immediate suctioning and rotation of the entire patient to the lateral
position
o Laryngeal Trauma
Hoarseness
Subcutaneous emphysema
Palpable fracture
CT for laryngeal injury
Airway obstruction
Noise breath sounds- partial obstruction
Absent breath sounds- full obstruction
Labored respiratory effort
o Objective signs of airway obstruction
Agitation suggest hypoxia
Obtundation suggest hypercarbia
Cyanosis indicates hypoxemia
Inspect nail beds and circumoral skin
Late finding of hypoxia
Pulse ox
Used early in airway assessment prior to development of cyanosis
Look for signs of retractions and use of accessory muscles
Listen for noise breath sounds- obstruction
Snoring, gurgling, crowing sounds (stridor)
Hoarseness implies functional, laryngeal obstruction
Feel for trachea and quickly determine if it is midline position
Evaluate behavior
Abusive and belligerent patients may in fact have hypoxia and should
not be presumed to be intoxicated
Ventilation
o Breathing not improved after clearing airway?
LOOK FOR OTHER PROBLEM
Direct chest trauma, intracranial injury, cervical spinal cord injury
(phrenic/diaphragm)
Complete cervical cord transection spares phrenic nerves (C3,C4)
o Results in abdominal breathing and paralysis of intercostal
muscles; assisted ventilation may be required
o How do you know if breathing is adequate? Objective signs:
Symmetrical rise/fall of chest and adequate chest excursion
Assymetry suggests splinting of rib cage or a flail chest
o Labored breathing imminent threat to ventilation
Auscultate for air movement bilaterally
Pulse ox: measures saturation and perfusion but no info on ventilation
Management of Airway
o Pulse ox and ETCO
2
are essential
o High flow oxygen before and after airway management techniques instituted
o Cribriform plate= no tube through nose
o 2 person removal of helmet; 1 person provides inline stabilization; 2
nd
person expands
helmet laterally and pulls off helmet; once removed first person supports the weight of
pt head; 2
nd
person takes over inline stabilization
o How do I predict a potentially difficult airway?
C-spine injury
Severe arthritis of the c-spine
Significant maxillofacial/mandibular trauma
Limited mouth opening
Obesity
Receding chin, overbite, short/muscular neck
LEMON
L: LOOK for external signs
E: EVALUATE the 3-3-2 rule
o Distance btw incisors 3 finger breadths
o Distance btw hyoid bone and chin 3 finger breadths
o Distance btw thyroid notch and floor of mouth 2 finger breadths
M: MALLAPATI
o 1: soft palate, uvula, fauces, pillars
o 2: soft palate, uvula, fauces
o 3: soft palate, base of uvula
o 4: hard palate only
O: OBSTRUCTION
o Epiglottitis. Peritonsillar abscess trauma
N: NECK MOBILITY
o Ask pt to place chin on chest then extend neck to look towards
ceiling
o Page 38; figure 2-3
o Pts with decreased consciousness tongue can fall backward and obstruct the
hypopharynx
Readily corrected by chin lift or jaw thrust
Then airway can be maintained with oro or nasopharyngeal airway
o LMA (laryngeal mask airway) (intubated LMA)
Does not provide definitive airway
ILMA: allows for intubation through LMA
o LTA (laryngeal tube airway)
Not a definitive airway device
Placed without visualization of the glottis and does not require significant
manipulation of the head or neck
o Page 41; table 2-1
o Endotracheal intubation
All patients with GCS of 8 or less should be intubated
Orotracheal route has fewer ICU related complications than nasotracheal
If pt has apnea, orotracheal intubation is indicated
Blind nasotracheal intubation requires a patient who is spontaneously
breathing and is contraindicated in patients with apnea
Facial, frontal sinus, basilar skull, and cribriform plate fractures are all relative
contraindications to nasotracheal intubation
Bilateral ecchymosis in periorbital region, postauricular ecchymosis,
possible CSF leaks (rhinorrhea or otorrhea)
Gum elastic bougie
Use if first attempt is unsuccessful or when vocal cords cant be
visualized
Stick in blindly; position in tracheal position is confirmed by feeling
clicks as the distal tip rubs along cartilaginous tracheal rings
Once in place an endotracheal tube over it pass it through and then
remove the GEB
o Correct positioning?
Check BL breath sounds to suggest (not confirm) proper placement
Borborygmi (rumbling/gurgling noises) in epigastrium Suggest esophageal
intubation
ETCO
2

If CO
2
is not detected then esophageal intubation has occurred
Best confirmed by X-ray
Re-assess if patient is moved by auscultating BL
o Rapid sequence intubation
Make sure everything is ready
Apply cricothyroid pressure
Etomidate .3 mg/Kg
1-2 mg/kg succinylcholine (usual dose is 100mg)
Risk of hyperkalemia use with caution with crush injuries, major burns,
electrical injuries
Once relaxed intubate
Release cricothyroid pressure
Ventilate pt
**when using sedation and neuromuscular blockade if intubation is not
successful then provide bag mask ventilation
o Surgical airway
Indications
Intubation unsuccessful, edema of glottis, fracture of larynx, severe
oropharyngeal hemorrhage obstructs the airway
Surgical cricothyroidotomy preferred over tracheostomy bc
Easier, less bleeding, less time
Needle cricothyroidotomy
Short term oxygen until definitive airway can be placed
Can be adequately oxygenated for 30-45 minutes
Only pts with normal pulmonary function who do not have significant
chest injury
Surgical cricothyroidotomy
Not recommended for children under 12
Percutaneous tracheostomy not safe in acute trauma situation
Management of oxygenation
o Pulse ox
Cannot distinguish between hemoglobin, carboxyhemoglobin, and
methemoglobin
Limits usefulness in pts with severe vasoconstriction and CO poisoning
Profound anemia and hypothermia decrease reliability
Management of ventilation

Spine and Spinal Cord Trauma

As long as the spine is protected, evaluation of the spine and exclusion of spinal injury may be
safely deferred, especially in the presence of systemic instability, such as hypotension and
respiratory inadequacy.
Cervical spine injury in children is relatively rare ~1%
In a neurologically intact patient, the absence of pain or tenderness along the spine virtually
excludes the presence of a significant spinal injury
o More difficult in comatose or pt with depressed consciousness
Only use long backboard to transport patient dont use for longer than 2 hours
Cervical spine more vunerable due to mobility and exposure
Most thoracic spine fractures are wedge compression fractures that are not associated with
spinal cord injury
When fracture dislocation does occur in thoracic spine it almost always results in a complete
spinal cord injury bc of relatively narrow thoracic canal.
Thoracolumbar junction is a fulcrum btw the inflexible thoracic region and the stronger lumbar
levels
o This makes it more vunerable to injury
o 15% of all spinal injuries occur in this region
Complete spinal cord injury
o No demonstrable sensory or motor function below a certain level
o DX cannot be made during first weeks after injury bc possibility of spinal shock
Incomplete spinal cord injury
o Any degree of motor or sensory function remains
Page 178; table 7.1
Page 179; dermatomes
C1-C4 are somewhat variable and are not commonly used for localization
Page 180; figure 7-4; table 7-3
Neurogenic shock
o Loss of vasomotor tone and sympathetic innervation to the heart
Rare if injury below T6 look for other cause
Hypotension and bradycardia
Vasopressors and atropine may work
o Fluid resuscitation may not help hypotension and too much fluid may result in fluid
overload and pulmonary edema
Spinal shock
o Loss of muscle tone and loss of reflexes seen after spinal cord injury
o Variable duration
Injury to C3-C5 could damage phrenic nerve
Inability to perceive pain may mask serious injury elsewhere
Spinal level
o Sensory level
Most caudal segment of the spinal cord with normal sensory function
o Motor level
Most caudal segment that has a grade of at least 3/5
o When some impaired sensory or motion function is found below the lowest normal
segment it is referred to as the zone of partial preservation
o Lesions above T1 cause quadriplegia
o Below T1 cause paraplegia
o Sacral reflexes such as bulbocavernosus reflex or anal wink do not qualify as sacral
sparing
Central cord syndrome
o Greater loss of motor strength in the upper vs lower extremities with varying degrees of
sensory loss
o Usually after hyperextension injury in pt with pre-existing cervical canal stenosis and
usually dt forward fall and face trauma
o Anterior spinal artery compromise
o Lower extremities recover first, then bladder function, then proximal upper extremities,
hands last
o Prognosis for recover is somewhat better than with other incomplete injuries
Anterior cord syndrome
o Paraplegia and a dissociated sensory loss with a loss of pain and temperature sensation
o Dorsal column function (position, vibration, and deep pressure sense) is usually
preserved
o Poorest prognosis of incomplete injury
Brown-Sequard syndrome
o Hemisection of the cord; usually dt penetrating trauma
o Ipsilateral motor loss (corticospinal tract) and loss of position sense (dorsal column) and
contralateral loss of pain and temperature 1-2 levels below injury (spinothalamaic tract)
o Some recovery is usually seen
Page 188; Box 7-1
Cervical spine injury (or suspected) requires continuous immobilization of the entire patient
with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and
during transfer to a definitive-care facility.
o Once in ED, every effort should be made to remove the rigid spine board as early as
possible to reduce risk of pressure ulcer formation.
Often done as part of secondary survey when pt is logrolled for inspection and
palpation of back
Do not delay removal for definitive spine for radiographs

Chest Trauma

1. Thoracic Trauma
a. Case Scenario: 27 y.o head on collision: mechanism of injury,
b. Primary Survey: Life-Threatening Injuries
i. Airway- look and see if they are talking
ii. Breathing-Listen to breath sounds
iii. Circulation- Check pulses and have IV access,
iv. Call Chest X-ray technician and be ready for when D and E are done.
v. Must recognize during primary survey
1. Tension pneumo/Open pneumo
2. Flail chest
3. Pulmonary contusion
4. Massive hemothorax
c. Urgent Chest Injuries
i. Signs of thoracic injury
1. Tachypnea
2. Respiratory distress
3. Hypoxia
4. Hypoventilation
ii. Airway obstruction/Laryngeal tracheal injury
1. Look at mouth, have a surgical airway ready to go, Pre-oxygenate him
(oxygenation mask), See if you can bag them, call team. Do not do a
blind intubation because can make injury worse.
2. Consequences: Hypoxia, hypoventilation, acidosis, inadequate tissue
perfusion.
3. Signs: rare, hoarseness, subcutaneous emphysema, manage in the
primary survey ASAP, intubate cautiously, tracheostomy
iii. Tension Pneumo
1. Signs: tracheal deviation to opposite side, neck vein distention,
decreased breath sounds, respiratory distress, shock (decreased venous
return because of the pressure on the vena cava; avg venous pressure
low teen number, hyperressonance, elevated hemithorax, cyanosis (late
sign)
2. Tests:
a. Chest X-ray
3. Treatment: Needle decompression ASAP (2
nd
IC in mid-clavicular line)
and follow up with chest tube (5
th
IC space; usually at nipple level just
anterior to mid-axillary line).
a. Once done can immediately turn around patient otherwise to
head to arrest.
b. 5cm reaches >50%
c. 8cm reaches >90%
4. Complications: if intubate prior to decompressing, you make the tension
worse.
iv. Open Pneumo- cant breath because they are not able to get negative pressure,
when breath in air goes through the hole. Ineffective ventilation but not
affecting CO. Cant move air in
a. Signs: will not have the signs of tension pneumo. No JVD.
b. Treatment:
i. 3-sided cover over defect. DO NOT cover it all. IF they
have a hole you can create a tension pneumo. Put a
chest tube
1. if have multiple holes, intubate them and give
positive pressure but still cover hole ASAP.
ii. Definitive treatment: surgical
c. Complications
v. Flail chest/ pulmonary contusion
1. Signs: unilateral chest, chest suck in when they breath
2. Treatment:
a. Initial tx includes adequate ventilation, administration of
humidified oxygen, and fluid resuscitation
b. supportive care, intubate as indicated; judicious fluids if
hemodynamically stable be careful with fluids as the may
likely have pulmonary contusion
c. Analgesia can improve ventilation and prevent need for
intubation

vi. Massive hemorrhage/Hemothorax-
1. Signs
a. No breath sounds and percussion dullness, flat neck veins,
hemithorax may be elevated without inspiration, >1500mL
blood loss
b. Hemithorax: dull percussion
c. Tension pneum: hyperresonant percussion
2. Treatment:
a. chest decompression
b. put chest tube
c. Auto-transfuser
d. OR if >1500mL initially or putting out at a rate of 200ml 2-4 hrs.
e. If 1500ml of fluid is immediately evacuated, early thoracotomy
is almost always required
i. Or if less than 1500 but continue to bleed
f. Indications for thoracotomy:
i. Persistent need for blood; rate of blood loss and pt
physiological status
ii. Color of blood (arterial vs venous) is POOR indicator of
necessity for thoracotomy
iii. Penetrating wounds medial to nipple or scapula should
alert to possible damage to major vessels
iv. Only indicated if qualified surgeon is present
vii. Circulation
1. PEA
a. Cardiac tamponade
b. Cardiac rupture
c. Tension pneumothorax
d. Profound hypovolemia
2. Major thoracic injuries that affect circulation that should be recognized
during primary survey
a. Tension pneumothorax
b. Cardiac tamponade
c. Massive hemothorax
viii. Cardiac tamponade
1. Signs: Shock, distended neck veins, muffled heart sounds, tachycardia,
low voltage EKG, late signs: pulseless electrical activity.
2. Kussmauls sign
a. Rise in JVP with inspiration
3. Tests
a. FAST
b. Chest X-ray- see big heart
c. Elevated CVP
4. Treatment:
a. With a pulse: Fluids and rush to OR.
b. Pulseless: Pericardiocentesis and left thoracotomy and stick
foley cathereter in the hole and take to OR.
c. If surgeon present OR
d. If no surgeon pericardiocentesis (not curative)
e. Pulses Paradoxus- breath in overcome tamponade and have
pulse and on expiration decrease in pulse will likely go into PEA.
d. Resuscitation Thoracotomy
i. DO not do them in blunt trauma.
ii. Patient with penetrating trauma injury arriving in PEA
iii. When a surgeon with appropriate skills is present
iv. Closed heart massage for cardiac arrest or PEA is ineffective in pts with
hypovolemia
v. No signs of life (reactive pupils, spont movements, organized ECG activity) and
no electrical cardiac activity no further resuscitative efforts needed
e. Secondary Survey: Potentially Life-Threatening Injuries
i. Adjunctive test; Chest X-ray, ABG, pulse oX, CT, FAST
ii. Tracheobronchial tree injury
1. Often missed
2. Penetrating or blunt trauma
3. Persistent pneumo or persistent air leak
4. Bronchoscopy
5. Treatment: Decompress. Get chest tube in, if still have air leak, put in
a second chest tube and make diameter as great as possible (find
biggest one, 36-40) may put in a third one. airway and ventilation,
tube thoracostomy, OR.
iii. Simple Pneumothorax
1. Penetration or blunt trauma, if dont treat can go into tension especially
if on positive pressure ventilation, if will be on pp intubation put chest
tube.
iv. Hemothorax
1. Chest wall
2. Lung vessel
3. Chest tube
v. Pulmonary Contusion
1. Common, will not look as bad in the initial X-ray as it will later.
2. Dont give them more fluid than what they need.
vi. Tracheobronchial Tree Injury
vii. Blunt Cardiac Injury
1. Spectrum of injury
2. Abnormal EKG/monitor changes
3. Echocardiography if hemodynamic consequence. Have them on monitor
in case of arrhythmia.
4. Treat: dysrhythmias
viii. Traumatic Aortic Disruption
1. Rapid acceleration/deceleration
a. X-ray signs: wide mediastinum, loss of aortic notch, loss of
apical pleural cap, deviation of trachea to right. Deviation of
esophagus with NG tube. Scapular fractures etc.
b. High index of suspicion
c. Treatment: Control BP if stable, control with a drip that is short
acting.
d. With definitive diagnosis get Surgical consult.
e. Gold standard for diagnosis is CT or angiography.
f. Most do not make it alive and those that do 50% die in the
hospital
ix. Traumatic Diaphragmatic Injury
1. Most often left-sided
2. Blunt: large tear
3. Penetrating: small perforation
4. Frequently misinterpreted X-ray
5. Treatment is surgery
x. Blunt-Esophageal Rupture
1. Uncommon and difficult to diagnose
a. Mechanism is severe epigastric blow
b. Unexplained pain and shock
c. Radiographs show mediastinal aire
d. Treatment: OR
xi. Fractures and Associated Injuries- Rib, Sternum and Scapular fractures
1. Ribs 1-3 sever force, high mortality, aortic
2. Rib 4-9 pulmonary contusion, pneumo
3. Rib 10-13 intrabdominal; spleen and liver
xii. Traumatic Asphyxia
1. Signs: petechial, swelling, plethora, cerebral edema
2. Treatment: airway control and O2
xiii. Subcutaneous Emphysema.
1. Can result from airway injury, lung injury or rarely blast injury. Does not
require treatment.
2. If positive-pressure ventilation is required, tube thoracostomy should
be considered on the side of the subcutaneous emphysema in
anticipation of tension pneumothorax developing.
xiv. Pittfalls
1. Simple pneumo converts to tension pnemo
2. Retained hemothorax- complication is empyema . IF not working called
a thoracic surgeon and have it cleaned.
3. Diaphragmatic injury- missed early on, persistent pain and things dont
look right reassess.
4. Inadequate pain control- big issue in patient with pulmonary contusion.
And rib fractures. Consider NSAIDs and local anesthetics.
5. Extremes of age- more potential for chest injury
6. Over-resuscitation in patients with pulmonary contusion.
7. Misplaced chest tube