Standard precautions: face mask, eye protection, water-impervious gown and gloves

Multiple casualty: number of patients do not exceed facility capabilities

Mass casualties: number of patients exceed facility and staff capabilities

Finding of non-purposeful motor responses strongly suggests need for definitive airway management

Neurological examination alone does NOT exclude diagnosis of C spine injury

Simple pneumothorax can be converted into a tension pneumothorax when a patient is intubated and positive
pressure ventilation is provided before decompressing the pneumothorax with a chest tube

Immediate observation due to blood loss are level of consciousness, skin perfusion and pulse

Improved survival when TXA given within 3 hours of injury. When bloused in the field/ 10mins, follow up
infusion is given over 8 hours span in hospital

The motor score of GCS correlates with outcome

Prevention of secondary brain injury by maintaining adequate oxygenation and perfusion are the main goals of
initial management

Fluid warmers to heat crystalloid fluids to 39 degrees or 102.2F is recommended. Microwave can only warm
fluids, not blood products. Blood preoducts cannot be stored in warmer unlike fluids but heated by passage
through IV fluid warmers

Adjuncts to primary survey: ECG, pulse oximetry, CO2 monitoring, RR, ABG, urinary catheters and gastric
catheters, lactate, X rays, FAST, DPL.

Adjuncts to secondary survey: additional XR of spine and extremities, CT head, chest, abdomen, spine, contrast
urography and angiography, TOE, bronchoscopy, esophagoscopy

Cardiac blunt injury indicated by: dysrhythmias (tachycardia, AF, premature ventricular contractions, ST
changes)

PEA can indicate cardiac tamponade, tension pneumothorax and/or profound hypovolemia. Blunt rupture of
atria and ventricles. Also hypoxia, acidosis, hypo/hyperkalaemia, hypoglycaemia, hypothermia, toxins,
thrombosis.

Hypoxia and hypoperfusion: bradycardia, aberrant conduction, premature beats

End tidal CO2 can be detected by colorimetry, capnometry or capnography (confirm intubation of airway vs
oesophagus) -reflects cardiac output and is used to predict ROSC

When urethral injury suspected, confirm by retrograde urethrogram before catheter inserted

Page 14 – mechanisms of injury

Minimize oedema of face by reverse tredelenburg position

Patients with maxillofacial or head trauma should be presumed to have cervical spine injury

A common sign of potential injury is a seatbelt mark

Injury from a shoulder harness restraint can result in intimal disruption, dissection and thrombosis of cervical
vascular injury.

In adults, UO of 0.5ml/kg/hr, in children over 1 year, 1ml/kg/hr is adequate, under 1 year age 2ml/kg

IM administration of analgesia is avoided. Prefer IV opiates or anxiolytics.

Haemothorax chest drain 28- 32 French. Return of 1500mL indicates urgent thoracotomy. 200mL/hr for 2to
4h. ultimate decision for operative intervention is based on hemodynamic status

Penetrating chest wounds in mediastinal box should alert need for thoracotomy. Medial scapular, nipple line

Trauma team minimally team leader, airway manager, trauma nurse and trauma technician. Also various
residents and medical students.

MIST: mechanism and time, injuries found, signs and symptoms, treatment initiated

Airway compromise can be sudden and complete, or insidious and partial, or progressive and recurrent

Definitive airway: tube placed in the trachea with cuff inflated below the vocal cords, tube connected to a form
of oxygen enriched assisted ventilation, and the airway secured in place with an appropriate stabilising
method.
3 types of definitive airways: orotracheal intubation, nasotracheal tube, surgical airway (cricothyroidotomy
and tracheostomy)

In aspiration of gastric contents, suction and rotate entire patient to lateral position while restricting cervical
spinal motion

Laryngeal fracture: triad of Hoarseness, subcutaneous emphysema, palpable fracture  tracheostomy if

endotracheal intubation unsuccessful. Tracheostomy might be difficult in emergency so surgical
cricothyroidotomy not preferred but can be lifesaving

Agitation suggests hypoxia, obtunded suggests hypercarbia

Hoarseness/ dysphonia implies functional laryngeal obstruction

Injuries below C3 result in normal diaphragmatic function but loss of intercostal and abdominal muscle
respiration – typically see saw breathing

LEMON assessment of potentially difficult intubation page 28

Mallampati classification
Class I: soft palate, uvular fauces, pillars entirely visible
Class II: soft palate, uvula, fauces partially visible
Class III: soft palate, base of uvula visible
Class IV: only hard palate visible

Patients who tolerate OPA are highly likely to require intubation

Extraglottic and supraglottic: LMA and LTA so oesophageal airway – effective if endotracheal intubation has
failed.

Criteria for definitive airway: (3 person technique with C spine restriction)

A – inability to maintain patent airway or potential compromise (retropharyngeal haematoma)
B – inability to maintain adequate oxygenation or apnea
C – obtundation or combativeness from cerebral hypoperfusion
D – Obtundation indication presence of head injury of GCS 8, seizure sustatined and need to protect lower
airway from aspiration

Nasotracheal intubation may be an alternative for spontaneously breathing patients unless apnea is present,
facial or frontus sinus, basilar skull and cribiform plate fractures. (racoon eyes, battles sign, CSF leaks)

Cricoid pressure can reduce aspiration but reduce view of larynx. Backward, Upward and rightward pressure
(BURP) on thyroid cartilage can aid visualising cords.

Confirm position of Gum Elastic Bougie by feeling cliks as the distal tips rubs along with cartilaginous tracheal
rings ( in 65- 90% of placements) – if inserted into oesophagus it will pass without resistance
If endotracheal tube held up at the arytenoids or aryepiglottic folds, turn tube anticlockwise 90 degrees to
advance beyond obstruction

Presence of CO2 in exhaled air confirms airway but not correct position within trachea, then confirm with XR

Drug assisted intubation indiciated in patients who still have intact gag reflexes, especially in those who have
head injuries.
Can use etomidate 0.3ml/kg or sedative as an induction drug
then 1 to 2mg/kg succinylcholine intravenously (usual dose 100mg)

Succinoylcholine must be used cautiously in patients with severe crush injuries, major burns and electrical
injuries due to its potential for severe hyperkalaemia.

Thiopental and sedatives potentially dangerous in trauma patients with hypovolemia.

Surgical airway is indicated in presence of oedema of the glottis, fracture of larynx, severe oropharyngeal
haemorrhage that obstructs the airway or inability to place ETT through vocal cords.

Needle cricothyroidotomy cannula 12- 14 gauge for adults, 16 to 18 gauge in children. Can be done for 30 to
45 minutes, 1 second on 4 seconds off (careful in head trauma as accumulation of CO2)

In surgical cricothyroidotomy, use 5 to 7mm OD- careful not to damage to cricoid cartilage supporting upper
trachea in children – not recommended for those under 12 years of age.

Tracheostomy not recommended as you will need to hyperextend the neck

Pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin or methemoglobin – limiting use in
severe vasoconstriction and carbon monoxide poisoning. Profound anaemia <50 and hypothermia <30 as well.

Shock does not result from isolated brain injury unless brainstem is involved therefore shock in those with HI
indicates a need to search for another cause.

Preload is determined by venous capacitance, volume status, difference between mean venous systemic
pressure and right atrial pressure.

Nearly 70% of the body’s total blood volume is estimated to be in the venous circuit.

Afterload is also known as peripheral vascular resistance. Afterload is the resistance to forward blood flow.

In blood loss, catecholamines increases peripheral vascular resistance, increasing diastolic blood pressure and
reduces pulse pressure.

The most effective method of restoring CO, end organ perfusion and tissue oxygenation is to restore venous
return to normal by locating and stopping source of bleeding.

Vasopressors contraindicated as 1st line treatment of haemorrhagic shock as it worsens tissue perfusion.

Compensatory mechanisms can prevent measurable fall in SBP until up to 30% blood loss.

Tachycardia is >160 in infant, >140 in pre school child, >120 up to puberty and >100 in adults.

A narrowed pulse pressure suggests significant blood loss and involvement of compensatory mechanisms.

Massive blood loss may only slightly decrease initial haematocrit or Hb so if haematocrit is really low, it
suggests either massive blood loss or anaemia. Although normal haematocrit does not exclude blood loss.

Even without blood loss, most non haemorrhagic shock states transiently improves with volume resuscitation.

Suspect cardiac injury when of MOI to the thorax is rapid deceleration. All patients with blunt thoracic trauma
need continuous ECG monitoring.
Cardiogenic shock state may be due to MI in elderly or high risk patients e.g. cocaine intoxication therefore
cardiac enzyme levels may assist as MI may be precipitating event.

Cardiac tamponade most likely in penetrating thoracic trauma but can result from blunt injury as well. ECG
may be useful in diagnosis of tamponade and valve rupture but not practical. Tamponade best managed my
formal operative intervention as pericardiocentesis is only a temporary manoeuvre.

Neurogenic shock causes hypotension without tachycardia or cutaneous vasoconstriction. Narrow pulse
pressure is not seen in neurogenic shock.

Patients with septic shock has tachy, vasoconstriction, decreased UO and narrow pulse pressure. Those with
early septic shock can have normal circulating volume, modest tachycardia, warm skin, normal SBP and wide
pulse pressure.

Trauma patients response to blood loss by fluid shift into extracellular compartment, even in soft tissue injury
– causing oedema due to increased permeability, contributing to depletion of intravascular volume.

Normal blood volume is 7% of body weight. In a child it is 8 to 9% of body weight (70-80ml/kg)

Class 2 haemorrhage causes a decreased pulse pressure as there is a rise in diastolic blood pressure due to
catecholamines, increasing peripheral vascular resistance.

Fractured tibia or humerus can result in 750mL blood loss

Fracture into femur, 1500mL blood loss is common, and several litres of blood can accumulate in
retroperitoneal haematoma due to pelvic fracture.

Pbese pateitsn are at risk for extensive blood loss into soft tissues, even without fractures. Elderly also at risk.

Hypothermia can worsen blood loss in shock due to coagulopathy and worsening acidosis.

Gastric dilation can cause unexplained hypotension or cardiac dysrhythmia, usually bradycardia from excess
vagal stimulation.

Minimal 18 gauge cannula in shock. Rate of flow is proportional to the fourth power of the radius of the
cannula and inversely related to its length – Pouiselle’s law.

Hypovolemic shock – initially 1 litre for adults, 20ml/kg for paediatric patients less than 40kg.

Fluid resuscitation and avoidance of hypotension are important in blunt trauma, especially traumatic brain
injury. In penetrating trauma, permissive hypotension may be beneficial whilst control of haemorrhage.

Early hypovolemic shock has respiratory alkalosis from tachypnoea, followed by metabolic acidosis. Do not use
sodium bicarbonate to treat metabolic acidosis from hypovolemic shock.

AB plasma is given when uncrossmatched plasma is needed

In massive hemothorax, consider collection of tube thoracostomy blood with sodium citrate rather than
heparin for autotransfusion. This blood has low coag factors so plasma and platelets may be needed.

Massive transfusion: >10 units in 24hours or >4units in 1 hour

Balanced/ hemostatic/ damage control resuscitation: blood, platelets and plasma equal ratio.

Coagulopathy present in 30% of admitted patients, especially those with major brain injury.
Thromboelastography TEG and rotational thromboelastometry ROTEM can be used to determine clotting
deficiency and needed products to correct.

Increasing blood flow requires an increase in cardiac output. Ohm’s law (Blood pressure= cardiac output x
systemic vascular resistance = V= Ix R). increase in BP should not presume increase in CO or recovery of shock
Athletes, blood volume may increase 20%, cardiac output increase 6x, stroke volume 50% and HR 50bpm

Oesophageal or bladder temperature is an accurate measurement of core temperature.

Undiagnosed source of bleeding is also classed as transient responders.

Early activation of MTP to avoid lethal triad of hypothermia, coagulopathy and acidosis.

Less than 10% of blunt chest injuries and 15- 30% of penetrating chest injuries require surgery.

Laryngeal injury can accompany major thoracic trauma or from direct blow to the neck or a shoulder restraint
misplaced across the neck.

Posterior dislocation of clavicular head occasionally leads to airway obstruction and SVC obstruction

Reduce a posterior dislocation or a fracture of the clavicle by extending patients shoulders or grasping the
clavicle with a penetrating towel clamp, which may alleviate airway obstruction.

Majority of tracheobronchial tree injuries occur within 1 inch of the carina – majority die at scene. Rapid
deceleration following blunt trauma, blast injuries and penetrating trauma.

For needle decompression of tension pneumothorax, 5cm over the needle catheter will reach pleural space
>50% of the time. 8cm will reach >90% of the time.

When the opening in the chest wall is 2/3rds the diameter of the trachea or greater, air preferentially passes
through chest wall defect with each inspiration

Kussmauls sign (rise in venous pressure with inspiration is a true paradoxical abnormality of tamponade)

Pericardiocentesis is a lifesaving measure of last resort if there is no surgeon available.

Upright expiratory chest XR for diagnosis of simple pneumothorax. Blunt polytrauma not candidates for this
evaluation although those with epentrating chest trauma may be.

A patient with pneumothorax should undergo chest decompression before air ambulance transportation.

In flail chest, patients with significant hypoxia on room air may require I+V within the first hour after injury.

Blunt cardiac injury caused by motor vehicle crash, then pedestrians hit by a car, the falls from height >6m.
common ECG findings are premature ventricular contractions, unexplained sinus tachycardia, atrial fibrillation,
bundle branch block usually right and ST changes. Elevated central venous pressure may indicate RV
dysfunction.

Cardiac troponins offer no additional information beyond ECG in injury. Only for MI prior injury. If there are
ECG changes, should monitor for 24 hours due to sudden dysrhythmias. Patients without ECG abnormalities do
not require further monitoring.

Those patients with the best possibility of surviving traumatic aortic disruption have an incomplete laceration
near the ligamentum arteriosum of the aorta. Maintained by an intact adventitial layer or contained
mediastinal hematoma preventing exsanguination and death. Persistant hypotension is usually due to a
separate, unidentified bleeding site.

TAD – history of decelerating force, obliteration of aortic knob, trachea deviation to the right, depression of
left mainstem bronchus, elevation of right mainstem bronchus, obliteration of space between pulmonary
artery and aorta (airtopulmonary window), deviation of oesophagus/ NGT to the right, widened paratracheal
stripe, widened paraspinal interfaces, presence of pleural or apical cap, left hemothorax, fractures of first or
second rib or scapula.

Best investigated by helical contrast enhanced CT - x ray may be unreliable. If still unreliable, aortography.
Goal heart rate should be less than 80, MAP between 60 to 70.
Blunt injury produces large radial tears with herniation of diaphragm whereas penetrating trauma produces
perforations that may be small and asymptomatic for years. More likely posterolateral of diaphragm

Retrograde urethrogram is mandatory when patient is unable to void, requires pelvic binder or has blood at
the meatus, scrotal hematoma or perineal ecchymosis.

Urethrography should be performed before inserting a urinary catheter when injury is suspected. With an 8
French urinary catether secured inmeatus by balloon to 2mL. 30mL of undilted contrast material instilled.

A cystogram or CT cystography is most effective in diagnosing intraperitoneal or extraperitoneal bladder

rupture

Suspected urinary system injuries best evaculated bt CT, or if not, intravenous pyelogram.

FAST includes pericardial sac, hepatorenal fossa, splenorenal fossa, pelvic/ pouch of Douglas

FAST and DPL for hemodynamically abnormal with blunt trauma or normal but no CT or USS

DPL contraindications include previous operations, obesity, cirrhosis and coagulopathy (infraumbilical)
In advanced pregnancy or pelvic fractures, go supraumbilically
Aspiration of GI contents, vegetable fibers or bile, or more than 10cc blood mandates laparotomy

Duodenal injuries from unrestrained drivers and a frontal vehicle collision or a direct blow to abdomen e.g.
bicycle handlebars

An anterior pelvic fracture is usually present in patients with urethral injuries.

An anterior urethal injury results from straddle impact and can be isolated whereas a posterior urethral injury
is usually associated with multisystem injuries and pelvic fractures.

Thrombosis of renal artery and disruption of renal pedicle are rare injuries secondary to deceleration.

For penetrating throacoabdomen injuries, diaphragm injuries can be confirmed with laparotomy, thoracoscopy
or laparoscopy.

Lateral compression/ closed book more frequent, then AP compression/ open book then vertical shear.

AP compression due to head on MVC produces external rotation, sepration of symphysis pubic, tearing of
posterior ligamentous complex. Disrupted pelvic ring widens, tearing the posterior venous plexus and
branches of internal iliac arterial system.

Latera compression causes internal rotation and reduces pelvic volume but pushes pubic into lower
genitourinary system, potentially causing bladder and urethral injury. Less severe than anterior mostly but may
need angioembolisation.

Vertical displacement disrupts sacrospinous and sacrotuberous ligaments and longitudinal traction can help

Asymptomatic anterior abdominal stab wounds that penetrate fascia or peritoneum require further evaluation

Head trauma

Prevent secondary brain injury is the primary goal of treatment of TBI – adequate oxygenation and maintain
BP

Dura splits into two leaves enclosing venous sinuses – midline superior sagittal sinus drains into the bilateral
transverse and sigmoid sinuses, larger on the right side.

Uncal herniation is associated with contralateral hemiparesis and ipsilateral pupillary dilatation.

Elevation of ICP can reduce cerebral perfusion/ cerebral blood flow and cause or worsen ischaemia.
Normal ICP is 10mmHg. If over 22, associated with poor outcomes.

Cerebral perfusion pressure= MAP – Intracranial pressure (CPP= MAP – ICP)

A MAP of 50 to 150mmHg is autoregulated to maintain constant CBF

Basilar skull fractures usually require CT scanning with bone window

Basilar skull fracture includes CN VII and VIII dysfunction: facial paralysis and hearing loss

Diffuse brain injuries range from concussions, to hypoxic and ischemic injuries. CT may initially appear normal,
or diffusely swollen and normal grey white distinction absent. Also in high velocity impact or deceleration
injuries, may produce multiple punctate haemorrhages – shearing injuries often seen in border between grey
and white matter= Diffuse axonal Injury.

Subdural hematomas are more common and severe than epidural hematomas due to parenchymal injury

Contusions are as common and are mostly in frontal or temporal lobes. Can develop into hematoma with mass
effect. Therefore contusions undergo repeat CT scanning.

Management of TBI page 112

CT scan for all moderate TBI, consider follow up CT in 12- 18 hours. Frequent neuro assessment for at least 24h

Severe TBI – keep PaCO2 between 35- 40mmHg = 4.7kpa at low end of normal range. Brief periods of
hyperventilation and low PaCO2 may be needed to manage acute neurological deterioration.
paCO2 no less than 25mmHg except with signs of herniation. Avoid hyperventilation in first 24 hours when CBF
can be critically reduced- hyperventilation with PaCO2 <25 not recommended

CT if GCS less than 15 at 2 hours after injury, suspected open or depressed fracture, basilar skull fracture signs,
2x vomiting, >65years of age anticoagulant use, loss of >5mins consciousness, amnesia before impact of
>30mins, dangerous mechanism.

Intracranial haemorrhage alone cannot cause haemorrhagic shock.

Maintain SBP >100mHg if 50- 69 years old. SBP>110mmHg if 15- 49 or >70 years old. All parameters page 119

Testing for dolls eye (oculocephalic) and caloric test with ice water (oculovestibular) and corneal responses are
deferred to neurosurgeon. Don’t do dolls eye until C spine ruled out

CT scan for intracranial haemorrhage with volume >10mL. A midline shift of >5mm indicates need for surgery]

Use isotonic fluids, hypotonic fluids avoid and glucose containing fluids can cause hyperglycemia which can
harm injured brain.

Normocarbia preferred. Hyperventilation reduces PaCO2 and can cause vasoconstriction and ischemia. But this
may lower ICP in acute deterioration until craniotomy can be performed.
Hypercarbia will promote vasodilation and increased ICP- avoid.

20%/ 20g mannitol per 100mL solution used to reduce increased ICP. Don’t give if hypotensive. Strong
indication if acute deterioration: dilated pupil, hemiparesis, loses consciousness – bolus 1g/kg over 5 min. Use
with ICP monitor to keep Sosm <320 mOsm.

Can also use hypertonic saline to reduce ICP of 3% to 23.4%. also can use barbiturates

Loading dose of phenytoin is 1g IV no faster than 50mg/min. maintenance is 100mg/ 8 hours

CSF leakage in scalp wounds indicates associated dural tear.

Depressed skull fractures require elevation when degree of depression is greater than thickness of skull or
when open and grossly contaminated
Burr hole craiostomy/ craniotomy involves placing a 10-15mm drill hole. However, bone flap craniotomy is the
definitive lifesaving procedure to decompress the brain.

Brain death: GCS 3, Non reactive pupils, absent brainstem reflexes, no spontaneous ventilation, absence of
confounding factors. Confirm with EEG, CBF studies, Cerebral angiography. Hypothermia or barbiturate can
mimic brain death.

Spinal trauma

Narrow pulse pressure is not seen in neurogenic shock

Below C3, the spinal canal is smaller in diameter relative to cord and spinal cord injuries are more likely

Child’s spine is more flexible until age of 12. More flexible joint capsules, interspinous ligaments, flat facet
joints and vertebral bodies that are wedged anteriorly and tend to slide forward with flexion

Most thoracic spine fractures are wedge compressions, usually not associated with cord injury but when it
does occur it is almost always complete spinal cord injury.

Only 3 tracts can be clinically assessed: lateral corticospinal, dorsal column and spinothalamic

Neurogenic shock= above T6

Spinal shock is rather flaccidity and loss of reflexes occurring immediately after SC injury, then spasticity

Page 132 = dermatomes and tracts

Corticospinal tract – motor power on same side of the body

Spinothalamic tract – pain and temperature from opposite side of the body
Dorsal columns – pripioception, vibration, light teach from same side of the body

Each segmental nerve root innervates more than one muscle, and most muscles aer innervated by more than
one root (usually two)

Paraplegia = thoracic injury. Quadriplegia/ tetraplegia = cervical injury

Central cord syndrome: greater loss of motor strength in upper extremities than lower and varying sensory
loss – typically after hyperextension
Anterior Cord syndrome – paraplegia and bilateral loss of pain and temperature sensation. (dorsal column is
intact however)- poorest prognosis, cord ischemia.
Brown Sequard- ipsilateral motor loss, loss of position sense, contralateral loss of pain and sensation.

Atlanto-Occipital dislocation: most die from brainstem destruction. Shaken baby syndrome.

Jefferson = C1 burst fracture – axial loading- disruption of anterior and posterior rings with lateral
displacement of the lateral masses. Best seen in open mouth. – usually not associated with SC injuries.
C1 rotary subluxation – children – spontaneous, trauma, URTI, RA – torticollis
Type 2 odontoid fractures through base are most common.
Posterior element/ pars interarticularis C2 = Hangman’s fracture – extension injury
C5- C6 most vulnerable to injury – area of greatest flexion and extension.

Thoracic: axial loading with flexion produces an anterior wedge compression injury
Burst injury: vertical axial compression
Change: transverse fractures through vertebral body – restrained by improperly placed lap belt causing flexion
about an axis anterior to vertebral column – associated with retroperitoneal and abdominal visceral injuries.

Thoracolumbar junction fractures – vulnerable to rotational movement, by unrestrained drivers and fall from
height – unstable.

Penetrating injuries of the spine are usually stable unless missle destroys a significant portion of vertebra.
Musculoskeletal trauma

If fracture is open, application of sterile pressure dressing typically controls haemorrhage.

Manual pressure to the wound, a pressure dressing, manual pressure to the artery proximally to the injury,
apply a manual tourniquet or a pneumatic tourniquet.

Pneumatic tourniquet may require pressure as high as 250mmHg in upper and 400mmHg in lower extremity

If time to operative intervention is longer than 1 hour, single attempt to deflate tourniquet considered

If fracture associated with open haemorrhaging wound, realign and splint it while a second person applies
direct pressure to the open wound

In crush syndrome, amber coloured urine in the presence of CPK of 10,000 U/L. urine tests positive for
haemoglobin. Rhabdomyolysis/ myoglobin can lead to acidosis, hyperK, hypoCa, DIC

Myoglobin induced renal failure can be prevented with IVF expansion, alkalinisation of urine by IV bicarbonate,
and osmotic diuresis

Adjuncts to primary survey: Fracture immobilization/ inline traction, X ray

In an open fracture, pull the exposed bone back into the wound, apply splint into anatomical position

The only reason to forgo X ray before treating a dislocation or a fracture is the presence of vascular
compromise or impending skin breakdown. This is seen in fracture- dislocation of the ankle

Ct intraarticular gas or saline or dye leak suggests communication of joint with open wound.

First generation cephalosporins are necessary for all patients with open fractures. Cover with moist sterile
dressing.

Muscle necrosis begins when there is lack of flow for 6 hours

Intracompartmental pressure of >30mmHg suggests decreased capillary lood flow. – can result in
myoglobinuria and muscle necrosis

Sciatic nerve compression from posterior hip dislocation, axillary nerve from anterior shoulder dislocation

Peripheral nerve assessment page 161

If a laceration extends below the fascial level, it may require operative intervention

Colds pack to help contusions

Risk of tetanus increased with wounds more than 6 hours old, more than 1cm deep

Do not apply traction splint in patients with an ipsilateral tibia shaft fracture. Use plaster splint.

Thermal injuries

TBSA > 40-50% indicates early intubation

A carboxyhemoglovin level greater than 10% suggests inhalation injury.

Direct measurement of carboxyhaemoglobin – patients with CO level less than 20% usually asymptomatic

CO shifts curve to the left. HbCO half life can be reduced to 40minutes when breathing 100% O2

Use ETT at least 7.5mm or larger in adult and 4.5mm in child.

Most pulse oximeters cannot distinguish oxyhemoglobin from carboxyhemoglobin.

A sign of potential cyanide toxicity is persistent unexplained metabolic acidosis

There is no role of hyperbaric oxygen therapy in primary resuscitation of a burn patient, only 100% oxygen

Two requirements for the diagnosis of smoke inhalation injury:

Exposure to a combustible agent
signs of exposure to smoke in lower airway, below the vocal cords seen on bronchoscopy

Greater than 20% TBSA in adults and 10% TBSA in <10 or >50 years should be intubated.

Can elevate head and chest by 30 degrees to help reduce neck and chest wall edema.

To provide burn resuscitation fluids for deep partial and full thickness burns larger than 20% TBSA

2ml of lactated Ringers x kg x TBSA for 2nd and 3rd degree burns. First half in 8 hours, rest in remaining 16hrs

Resuscitation of paediatric <14yrs should begin at 3ml/kg/TBSA due to larger surface area to body mass

Children under 30kg should receive maintenance fluids of 5% dextrose in lactated ringer’s on top

But for electric injuries, all ages should receive 4mL LR x kg x TBSA until urine clears.

Palmar suface of a patients hand represents 1% of TBSA

Do not include superficial burns in size estimation – only partial and full thickness burns included

Superficial first degree burns – erythema, no blister, no IV fluid replacement (epidermis intact)
Superficial partial thickness – into dermis. Blanches, more moist
Deep partial thickness – does not blanch, drier, less painfull
Full thickness – leathery, translucent or white, painless, dry

Partial thickness burns should be covered as it is painful when air currents pass over. Do not apply cold water
to a patient with TBSA >10%

Compartment syndrome with circumferential chest burns leading to increased peak inspiratory pressure

Chest and abdominal escharotomies along anterior axillary lines with cross incision at clavicular line and the
junction of thorax and abdomen.

Escharotomies usually are not needed within first 6 hours of a burn injury.

Insert NG tube if >20% TBSA

No indication for antibiotics in a burn patient

Acidic burns cause coagulation necrosis whereas alkali are more penetrating by liquefaction necrosis

Flush away chemical with large amounts of warmed water for 20- 30 minutes. Alkali burns require longer
irrigation. Neutralising agents offer no advantage over water lavage. Alkali burns to the eye require 8 hours

Electrical burns can have deep muscle necrosis with more normal overlying skin – frequently fasciotomies

If urine is dark red, assume hemochromogens are in urine/ myoglobinuria.

Give 4ml/kg/TBSA for UO of 100ml/hr and 1- 1.5ml/kg/hr in children if <30kg until urine is clear

Prolonged ECG monitoring for those who demonstrate burn injury, LoC, and exposureto >1000 volts

Transfer to burn centre if >10% TBSA, 3rd degree, face, hands, genitalia, feet, perineum and major joints,
electrical and chemical burns, inhalation injury...
Frostbite
First degree: hyperemia and edema, no skin necrosis
2nd degree: large clear vesicle with hyperemia dna edema, partial thickness skin necrosis
3rd degree: full thickness and subcutaneous tissue necrosis, haemorrhagic vesicles
4th degree: fill thickness skin necrosis including muscle and bone

Warm blankets, hot fluids, place injured part in circulating water of 40 degrees until pink colour and perfusion
return (usually 30minutes).

Warming of large areas can result in reperfusion syndrome with acidosis, hyperkalemia, and loca swelling.

Sympathetic blockade and vasodilating drugs proven not helpful as well as heparin and hyperbaric oxygen.

Thrombolytic agents only helpful if administered within 23 hours

Core hypothermia under 26, severe hypothermia 32

Paediatric trauma

Apnea, hypoventilation and hypoxia occur fie times more often than hypovolemia with hypotension in children

Most serious is blunt trauma that involves the brain

They have less fat, less connective tissue and closer proximity of multiple organs, smaller body mass

Ratio of body surface area to body is highest at birth – at risk for thermal energy loss

Breslow paediatric emergency tape – to rapidly etermine weight based on length. For fluid volumes, drug
doses and equipment size.

Passive flexion due to large occiput causes posterior pharynx to buckle anteriorly. Use 1 inch board under

Soft tissue of oropharynx are relatively large compared to oral cavity which may obstruct view.

Larynx is funnel shaped, allowing secretions to accumulate

Larynx and vocal cords are more cephald and anterior in the neck – more difficult to visualise

Trache is short, 5cm and grows to 7cm in 18 months.

Appropriate ETT depth is 3x tube size. Which is measured as diameter of the nares or tip of small finger

The smallest area is at the cricoid ring which forms a natural seal around an uncuffed ETT in infants but do use
a cuffed tube in toddlers and small children – cuff pressure should be <30mmHg

Infants have a more pronounced vagal response to endotracheal intubation than do children and adults and
may experience bradycardia with direct laryngeal stimulation

Atropine sulfate pretreatment should be considered for infants requiring DAI but is not required for children. It
dries oral secretions, enabling visualization of landmarks for intubation

Do not perform nasotracheal intubation in children as it requires blind passage around acute angle of
nasopharynx toward the anterosuperior glottis – potential of penetrating cranial vault or adenoid soft tissues

When airway cannot be done by bag mask, or orotrachel intubation, rescue airways such as LMA or needle
cricothyroidotomy is necessary.

Surgical cricothyroidotomy is rarely indicated unless over 12 years.

DOPE: common causes of deterioration- dislodgement, obstruction, pneumothorax, equipment failure

A paediatric bag mask is recommended in those under 30kg due to barotrauma

Respiratory acidosis is the most common acid bas abnormality encountered children resuscitation

Attempting to correct acidosis with sodium bicarbonate can result in hypercarbia and worsened acidosis

Use 14- 18G needle in tension pneumothorax to avoid causing a tension

Tunnelling a chest tube is especially important in children due to thinner chest wall

Up to 30% of blood volume may be required to manifest a decrease in SBP- usually only tachycardia and
decreased skin perfusion are the only keys to early recognition, narrowing of pulse pressure to less than 20

Hypotension represents decompensated shock and a blood loss of over 45%, and bradycardia starts instead

Mean SBP is 90mmHg plus 2x age

An weight estimate is 2x age, plus 10

Infants blood volume is 80ml/kg

18G intraosseous in infants, 15G in children

Fluid resuscitation: 20ml/kg bolus followed by one to two additional boluses pending physiological response
MTP: after 20ml/kg bolus give 10- 20ml/kg blood, 10-20mL/kg FFP and Plts.

Urine output goal for infants is 1-2 mL/kg/hr, for children over 1 up to adolescence is 1- 1/5, and for teenagers
it is 0/5ml/kg/hr

Those with ROSC in the field have 50% of neurologically intact survivcal. Those still in arrest or had CPR
>15minutes before arrival to ED and fixed pupils are unformly non survivors

The mobility of mediastinal structures makes them more suspectible to tension pneumothorax, the most
common life threatening injury in children

Orogastric tube decompression is preferred in infants

Presence of shoulder and or lap belt marks increased likelihood that intraabdominal injuries are present

Small bowel perforations near the ligament of treitz are more common in children as are mesenteric and small
bowel avulsion. Bladder rupture is also more common

Children restrained by a lap belt only are at risk for enteric disruption, especially if they have a lap belt mark or
Chance fracture of lumbar spine

A child’s subarachnid space is smaller, oferring less protection to the brain.

Normal cerebral blood flow is 2x as much as an adults by age 5 then decreases- susceptibility to hypoxia and
hypercarbia

The outcome in children who suffer severe brain injury is better than adults but worse than an older child if
less than 3 years old.

Hypotension can occur following significant blood loss into subgaleal, intraventricular or epidural spaces due
to open cranial sutures and frontanelles

Modified GCS for those under 4 years

Imcreased intracranial pressure frequently develops in children due to brain swelling, consider intracranial
pressure monitoring in GCS < 8 or motor score 1or 2

3% hypertonic saline and mannitol are often used to reduce intracranial pressure. (hyperosmolality and inc Na)
Attempts in oral intubation in an uncooperative child with brain injury may increase intracranial pressure

Interspinous ligaments and joint capsules are more flexible, vertebral bodies are wedged anteriorly and slife
forward with flexion, facet joints are flat. Angular momentum of heads are greater and fulcrum exists higher in
c spine so more injuries at the level of the occiput to C3.

40% of children have pseudosubluxation, under the age of 7 show anterior displacement of C2 on C3. Can be
normal and can be exaggerated by forward flexion due to large occiput. – true subluxation will not disappear
after placing a 1inch board underneath.

SCIWORA – spinal cord injury without radiographic abnormalities more commonly than adults

Blood loss in long bone and pelvic fractures are less in children than in adults. Blood loss due to an isolated
femur fracture should not cause shock and other sources of blood loss should be considered.

Supracondylar fracutres at elbow or knee have high chance of vascular injury and injury to growth plate

Geriatric trauama

5 PEC (pre- existing conditions): cirrhosis, COPD, IHD, coagulopathy, DM

Loss of protective airway refelexes, arthritis jaw and c spine

No teeth makes intubating easier but bag mask ventilation harder.

Decreased sensitivity to catecholaminesm fixed CO and HR, increased afterload, decreased sensitivity to ADH,
decreased production and response to thyroxin, decreased DPEA

With RSI, reduce doses of barbiturates, BZD to between 20- 40%

Aging causes a suppressed heart rate response to hypoxia so resp failure may be insidious

Since they may have a fixed HR and CO, response to hypovolemia will involve increasing systemic vascular
resistance.

Aging causes dura to become more adherent to the skulls, increasing risk of epidural hematoma.

Moderate cerebral atrophy may permit intracranial pathology to initially have normal neurology exam

Trauma in pregnancy

Uterus is intrapelvic until week 12. At 20 weeks it is at the umbilical and 34-36 week at costal margin

It pushes intestines into upper abdomen so it is somewhat protected in blunt trauma

Clinical signs of peritoneal irritation are less evident

Amniotic fluid entering the maternal intravascular space can cause embolism and DIC

Pelvic fractures in late pregnancy can result in skull fracture or intracranial injury.

Unlike the myometrium, the placenta is less elastic and more vulnerable to shear forces at uteroplacental
interface – leading to abruptio placentae

Placental vasculature more sensitive to catecholamine stimulation

An abrupt decrease in maternal intravascular volume can result in profound increase in uterine vascular
resistance, reducing foetal oxygenation despite reasonably normal maternal vital signs.
Plasma volume increases through pregnancy and RBC volume only increases a little bit so haematocrit level is
decreased (physiological anemia of pregnancy)- 31- 35% is normal at late pregnancy

WBC count increases, serum fibrinogen and clotting factors increases

Prothrombin and partial thromboplastin times shortened but bleeding and clotting times unchanged

By 10th week, CO can increase by 1- 1.5L due to increase in plasma volume and decrease in vascular resistance
of the uterus and placenta, receiving 20% of CO

In supine position, IVC compression can decrease CO by 30%

HR gradually increases to 10-15bpm over normal

Blood pressure falls 5- 15mmHg but returns to normal at term

Haematocrit decreases, WBC increases, pH more alkalotic, bicarb decreases, PaCP2 decreases – resp alkalosis
in pregnancy with bicarb compensation. PaO2 increases – page 230

ECG axic may shift left by 15 degrees, flat or inverted T waves in leads 3 and avF and precordial leads. Ectopics

Minute ventilation increases due to increase in tidal volume causing hypocapnia so normal Co2 levels may be
impending respiratory failure.

Decreased residual volume due to diaphragmatic elevation. Increased lung markings and pulmonary vessels

Fetus is very sensitive to hypoxia so maternal basal oxygen consumption is elevated at baseline

GFR and renal blood flow increase and creatinine decreases. Glycosuria is common

Symphysis pubis widens to 4-8 mm and sacroiliac joint spaces increase by month 7

Indirect injury such as rapid compression, deceleration, contrecoup effect or shearing force may result in
abruptio placentae

Using a lap belt alone allows forward flexion and uterine compression with rupture and abruptio placentae

Lap belt worn too high over the uterus may cause uterine rupture due to transmitting direct force on impact

Airbags do not increase risks of injury

Assess and resuscitate mother first, then asses fetus before secondary survey

Log roll to the left 15- 30 degrees

Vasopressors should be last resort as they reduce uterine blood flow.

A normal fibrinogen may indicate early DIC as it should be raised

Abruptio placentae suggested by vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine
tetany and uterine irritability.

Late in pregnancy, abruption may occur following relatively minor injuries

Perform continuous fetal monitoring with tocodynamometer beyond 20- 24 weeks gestation

No risk factors for fetal loss- monitoring for 6 hours

Risk for fetal loss or placental abruption – monitor for 24 hours

Abnormal fetal heart rate, repititve decelerations, absemce of accelerations or beat to beat variability and
frequent uterine activity can be signs of impending maternal or fetal decompensation

In DPL, place cather above the umbilicus

Presence of amniotic fluid in the vagine, ph >4.5 suggests ruptured chorioamniotic membranes

CT scan is 25mGY and fetal doses less than 50mGy are not associated with risks

In presence of life threatening amniotic embolism, DIC – immediate perform uterine evacuation and replace
platelets, fibrinogen and clotting factors

Rh immunoglobulin therapy should be given within 72 hours of injury unless isolated away from uterus

If other causes of arrest apart from hypovolemia, perimortem CS within 4-5 minutes