ATLS 10th Edition Student Manual

Skill Station C CIRCULATION LEARNING OBJECTIVES 1. Diagnose the presence of shock, both compensated indications and contraindications for the use of and uncompensated. traction devices for femur fractures. 2. Determine the type of shock present. 7. Recognize the need for patient reassessment and 3. Choose the appropriate fluid resuscitation. additional resuscitation based on the patient’s response to treatment. 4. Demonstrate on a model the application of a staged 8. Recognize which patients require definitive approach to control external hemorrhage by using hemorrhage control (i.e., operative and/or catheter direct pressure, wound packing, and application of based) and/or transfer to a higher level of care. a tourniquet. 9. Describe and demonstrate (optional) the indications 5. Demonstrate on a model placement of intraosseous and techniques of central intravenous access, access, and discuss other options for vascular peripheral venous cutdown, diagnostic peritoneal access and their indications. lavage (DPL), and pericardiocentesis. 6. Demonstrate the application of a pelvic stabilization device for pelvic fractures and understand the skills included in this • Subclavian Venipuncture: Infraclavicular skill station Approach—Optional Skill • Wound Packing • Venous Cutdown—Optional Skill • Application of Combat Application Tourniquet • Pericardiocentesis Using Ultrasound—Optional • Application of Traction Splint (Demonstration) • Placement of Intraosseous Device, Humeral Skill Insertion wound packing • Placement of Intraosseous Device, Proximal STEP 1. Fully expose the wound and cut clothing, if Tibial Insertion not previously done. • Application of Pelvic Binder or Other Pelvic STEP 2. Use gauze pads to mop bleeding and identify Stabilization Device the general area that is bleeding. • Diagnostic Peritoneal Lavage (DPL) —Optional STEP 3. Place a stack of gauze pads over that Skill area and press down firmly. Hold for 5-10 • Femoral Venipuncture: Seldinger Technique— minutes if using gauze or 3 minutes if using hemostatic gauze. Optional Skill ■ BACK TO TABLE OF CONTENTS 349

350 APPENDIX G ■ Skills STEP 4. If bleeding is controlled, secure the gauze STEP 8. Adhere the remaining self-adhering band pads with roll gauze, an elastic bandage, or over the rod, through the windlass clip, and self-adhering wrap (3M Coban™). Consult continue around the patient’s arm or leg as trauma, vascular, or orthopedic surgeon, far as it will go. based on injury type. STEP 9. Secure the rod and the band with the STEP 5. If bleeding is not controlled and there windlass strap. Grasp the strap, pull it tight, is a cavity, use gloved finger or forceps and adhere it to the opposite hook on the to place gauze into wound, ensuring windlass clip. that the gauze reaches the base of the wound. Place more gauze until the STEP 10. Note the time the tourniquet was applied. wound is tightly packed. Hold pressure If you have a marker, you can write it directly for an additional 3 minutes, and reassess. on the tourniquet. Gauze impregnated with a topical hemostatic agent can be used, if available. STEP 11. If the bleeding is not stopped with one Gauze without a hemostatic agent may tourniquet and it is as tight as you can get be just as effective for wound packing as it, place a second one, if available, just above gauze treated with a hemostatic agent. the first. Tighten it as before. Large wounds may require multiple gauze dressings to fully pack the wound. Pack in application of tr action as much gauze as will fit into the wound, splint and push in even more if you can. If these steps fail to control the bleeding, proceed STEP 1. Consider need for analgesia before applying with placing tourniquet while awaiting a traction splint, and select the appropriate surgical consultation. splint to use. application of combat STEP 2. Measure splint to the patient’s unaffected application tourniquet leg for length. STEP 1. Insert the wounded extremity (arm or STEP 3. Ensure that the upper cushioned ring is leg) through the combat application placed under the buttocks and adjacent tourniquet (CAT). to the ischial tuberosity. The distal end of the splint should extend beyond STEP 2. Place the tourniquet proximal to the bleed- the ankle by approximately 6 inches ing site, as distal as possible. Do not place (15 cm). at a joint. STEP 4. Align the femur by manually applying STEP 3. Pull the self-adhering band tight, and traction though the ankle. securely fasten it back on itself. Be sure to remove all slack. STEP 5. After achieving realignment, gently elevate the leg to allow the assistant to slide the STEP 4. Adhere the band around the extremity. splint under the extremity so that the padded Do not adhere the band past the clip. portion of the splint rests against the ischial tuberosity. STEP 5. Twist the windlass rod until the bleeding has stopped. STEP 6. Reassess the neurovascular status of the injured extremity after applying traction. STEP 6. Ensure arterial bleeding is arrested. Tourniquet should be tight and painful if STEP 7. Ensure that the splint straps are positioned the patient is conscious. to support the thigh and calf. STEP 7. Lock the windlass rod in place in the wind- STEP 8. Position the ankle hitch around the patient’s lass clip. Bleeding is now controlled. ankle and foot while an assistant maintains ■ BACK TO TABLE OF CONTENTS

351 APPENDIX G ■ Skills manual traction on the leg. The bottom Stop when you feel the “pop” or “give” in strap should be slightly shorter than, or infants. (When using a needle not attached to at least the same length as, the two upper a drill, orient the needle perpendicular to the crossing straps. entry site and apply pressure in conjunction STEP 9. Attach the ankle hitch to the traction hook with a twisting motion until a “loss of while an assistant maintains manual traction resistance” is felt as the needle enters the and support. Apply traction in increments, marrow cavity.) using the windlass knob until the extremity STEP 6. Hold the hub in place and pull the driver appears stable or until pain and muscle straight off. Continue to hold the hub spasm are relieved. while twisting the stylet off the hub with STEP 10. Recheck the pulse after applying the counterclockwise rotations. The needle traction splint. If perfusion of the extremity should feel firmly seated in the bone (first distal to the injury appears worse after confirmation of placement). Place the stylet applying traction, gradually release it. in a sharps container. STEP 11. Secure the remaining straps. STEP 7. Place the EZ-Stabilizer dressing over the hub. STEP 12. Frequently reevaluate the neurovascular Attach a primed EZ-Connect™ extension status of the extremity. Document the set to the hub, firmly secure by twisting patient’s neurovascular status after every clockwise. Pull the tabs off the EZ-Stabilizer manipulation of the extremity. dressing to expose the adhesive and apply it to the skin. placement of intraosseous STEP 8. Aspirate for blood/bone marrow (second device, humeral insertion confirmation of placement). STEP 9. Secure the arm in place across the abdomen. STEP 1. Flex the patient’s elbow and internally STEP 10. Attach a syringe with saline to the needle rotate the arm, placing the patient’s hand and flush, looking for swelling locally or on the abdomen with the elbow close to the difficulty flushing. Inject with lidocaine if body and the hand pronated. The insertion the patient is alert and experiences pain site is the most prominent aspect of the with infusion. greater tubercle. placement of intraosseous STEP 2. Use your thumb(s) to slide up the anterior device, proximal tibial shaft of the humerus until you can feel the insertion greater tubercle, about 1 cm (1/3 in.) above the surgical neck. STEP 1. Place the patient in the supine position. Select an uninjured lower extremity, place STEP 3. Prepare the site by using an antiseptic sufficient padding under the knee to effect solution. approximate 30-degree flexion of the knee, and allow the patient’s heel to rest STEP 4. Remove the needle cap and aim the needle comfortably on the gurney or stretcher. tip downward at a 45-degree angle to the horizontal plane. The correct angle will STEP 2. Identify the puncture site—the anteromedial result in the needle hub lying perpendicular surface of the proximal tibia, approximately to the skin. Push the needle tip through the one fingerbreadth (1 to 3 cm) below skin until the tip rests against the bone. The the tubercle. 5-mm mark must be visible above the skin for confirmation of adequate needle length. STEP 3. Cleanse the skin around the puncture site well and drape the area. STEP 5. Gently drill into the humerus 2 cm (3/4 in.) or until the hub reaches the skin in an adult. ■ BACK TO TABLE OF CONTENTS

352 APPENDIX G ■ Skills STEP 4. If the patient is awake, use a local anesthetic medullary canal. Remember, intraosseous at the puncture site. infusion should be limited to emergency resuscitation of the patient and discontinued STEP 5. Initially at a 90-degree angle, introduce a as soon as other venous access has short (threaded or smooth), large-caliber, been obtained. bone-marrow aspiration needle (or a short, 18-gauge spinal needle with stylet) into the application of pelvic skin and periosteum, with the needle bevel binder or other pelvic directed toward the foot and away from the stabilization device epiphyseal plate. STEP 1. Select the appropriate pelvic stabiliza- STEP 6. After gaining purchase in the bone, direct tion device. the needle 45 to 60 degrees away from the epiphyseal plate. Using a gentle twisting STEP 2. Identify the landmarks for application, or boring motion, advance the needle focusing on the greater trochanters. through the bone cortex and into the bone marrow. STEP 3. Internally rotate and oppose the ankles, feet, or great toes using tape or roll gauze. STEP 7. Remove the stylet and attach to the needle a 10-mL syringe with approximately 6 mL of STEP 4. Slide the device from caudal to cephalad, sterile saline. Gently draw on the plunger centering it over the greater trochanters. of the syringe. Aspiration of bone marrow Two people on opposite sides grasp the into the syringe signifies entrance into the device at bottom and top and shimmy it medullary cavity. proximally into position. Alternatively, or place the device under the patient while STEP 8. Inject the saline into the needle to expel restricting spinal motion and with minimal any clot that can occlude the needle. If the manipulation of the pelvis by rotating the saline flushes through the needle easily patient laterally. Place folded device beneath and there is no evidence of swelling, the patient, reaching as far beneath patient as needle is likely located in the appropriate possible. Rotate the other direction and pull place. If bone marrow was not aspirated as the end of the device through. If using a outlined in Step 7, but the needle flushes sheet, cross the limbs of the sheet and secure easily when injecting the saline and there is with clamps or towel clamp. no evidence of swelling, the needle is likely in the appropriate place. In addition, proper STEP 5. Roll the patient back to supine and secure placement of the needle is indicated if the the device anteriorly. Ensure that the device needle remains upright without support and is adequately secured with appropriate intravenous solution flows freely without tension, observing internal rotation of lower evidence of subcutaneous infiltration. limbs, which indicates pelvic closure. STEP 9. Connect the needle to the large-caliber diagnostic peritoneal intravenous tubing and begin fluid infusion. lavage (dpl)—optional Carefully screw the needle further into the skill medullary cavity until the needle hub rests on the patient’s skin and free flow continues. STEP 1. Obtain informed consent, if time permits. If a smooth needle is used, it should be STEP 2. Decompress the stomach and urinary stabilized at a 45- to 60-degree angle to the anteromedial surface of the patient’s leg. bladder by inserting a gastric tube and urinary catheter. STEP 10. Apply sterile dressing. Secure the needle and tubing in place. STEP 11. Routinely reevaluate the placement of the intraosseous needle, ensuring that it remains through the bone cortex and in the ■ BACK TO TABLE OF CONTENTS

353 APPENDIX G ■ Skills STEP 3. After donning a mask, sterile gown, and retroperitoneal injuries such as pancreatic gloves, surgically prepare the abdomen and duodenal injuries. (costal margin to the pubic area and flank to flank, anteriorly). femoral venipuncture: seldinger technique— STEP 4. Inject local anesthetic containing optional skill epinephrine in the midline just below the umbilicus, down to the level of the fascia. Note: Sterile technique should be used when performing Allow time to take affect. this procedure. STEP 1. Place the patient in the supine position. STEP 5. Vertically incise the skin and subcutaneous STEP 2. Cleanse the skin around the venipuncture tissues to the fascia. site well and drape the area. STEP 6. Grasp the fascial edges with clamps, and STEP 3. Locate the femoral vein by palpating elevate and incise the fascia down to the peritoneum. Make a small nick in the the femoral artery. The vein lies directly peritoneum, entering the peritoneal cavity. medial to the femoral artery (remember the mnemonic NAVEL, from lateral to medial: STEP 7. Insert a peritoneal dialysis catheter into the nerve, artery, vein, empty space, lymphatic). peritoneal cavity. Keep a finger on the artery to facilitate anatomical location and avoid insertion of STEP 8. Advance the catheter into the pelvis. the catheter into the artery. Use ultrasound STEP 9. Connect the dialysis catheter to a syringe to identify the femoral artery and visualize placement of needle into the vein. and aspirate. STEP 4. If the patient is awake, use a local anesthetic STEP 10. If gross blood or organic matter is aspirated, at the venipuncture site. STEP 5. Introduce a large-caliber needle attached to the patient should be taken for laparotomy. a 10-mL syringe with 0.5 to 1 mL of saline. If gross blood is not obtained, instill 1 L of Direct the needle toward the patient’s head, warmed isotonic crystalloid solution (10 mL/ entering the skin directly over the femoral kg in a child) into the peritoneum through vein. Hold the needle and syringe parallel the intravenous tubing attached to the to the frontal plane. dialysis catheter. STEP 6. Directing the needle cephalad and poster- STEP 11. Gently agitate the abdomen to distribute the iorly, slowly advance it while gently with- fluid throughout the peritoneal cavity and drawing the plunger of the syringe. increase mixing with the blood. STEP 7. When a free flow of blood appears in the STEP 12. If the patient’s condition is stable, allow syringe, remove the syringe and occlude the the fluid to remain a few minutes before needle with a finger to prevent air embolism. placing the intravenous fluid bag on If the vein is not entered, withdraw the the floor and allowing the peritoneal needle and redirect it. If two attempts are fluid to drain from the abdomen. unsuccessful, a more experienced clinician Adequate fluid return is > 20% of the should attempt the procedure, if available. infused volume. STEP 8. Insert the guidewire and remove the needle. STEP 13. After the fluid returns, send a sample to the STEP 9. Make a small skin incision at the entry point laboratory for Gram stain and erythrocyte of wire, pass the dilator (or dilator introducer and leukocyte counts (unspun). A positive test and thus the need for surgical intervention is indicated by 100,000 red blood cells (RBCs)/mm3 or more, greater than 500 white blood cells (WBCs)/mm3, or a positive Gram stain for food fibers or bacteria. A negative lavage does not exclude ■ BACK TO TABLE OF CONTENTS

354 APPENDIX G ■ Skills combination) over the wire and remove the STEP 7. Direct the needle medially, slightly cephalad, dilator holding pressure at the exit site of and posteriorly behind the clavicle toward the wire (or remove dilator if introducer the posterior, superior angle of the sternal combination is used). end of the clavicle (toward the finger placed STEP 10. Insert the catheter over the guidewire in the suprasternal notch). aspirate to assure free blood flow. If using an introducer, aspirate it. STEP 8. Slowly advance the needle while gently STEP 11. Flush the catheter or introducer with saline withdrawing the plunger of the syringe. and cap or begin fluid infusion STEP 12. Affix the catheter in place (with a suture), STEP 9. When a free flow of blood appears in the dress the area according to local protocol. syringe, rotate the bevel of the needle, STEP 13. Tape the intravenous tubing in place. caudally remove the syringe, and occlude the STEP 14. Change the catheter location as soon as it needle with a finger to prevent air embolism. is practical. If the vein is not entered, withdraw the needle and redirect it. If two attempts subclavian venipuncture: are unsuccessful, a more experienced infraclavicular approach— clinician (if available) should attempt optional skill the procedure. Note: Sterile technique should be used when performing STEP 10. Insert the guidewire while monitoring the this procedure. electrocardiogram for rhythm abnormalities. STEP 1. Place the patient in the supine position, STEP 11. Remove the needle while holding the with the head at least 15 degrees down guidewire in place. to distend the neck veins and prevent air embolism. Only if a cervical spine STEP 12. Use an 11 blade to incise the skin around injury has been excluded can the the exit site of the guidewire. Insert patient’s head be turned away from the the dilator over the guidewire to dilate venipuncture site. the area under the clavicle. Remove STEP 2. Cleanse the skin around the venipuncture the dilator, leaving the wire in place. site well, and drape the area. Thread the catheter over the wire to a STEP 3. If the patient is awake, use a local anesthetic predetermined depth (the tip of the catheter at the venipuncture site. should be above the right atrium for STEP 4. Introduce a large-caliber needle, attached to fluid administration). a 10-mL syringe with 0.5 to 1 mL of saline, 1 cm below the junction of the middle and STEP 13. Connect the catheter to the intravenous medial one-third of the clavicle. tubing. STEP 5. After the skin has been punctured, with the bevel of the needle upward, expel the skin STEP 14. Affix the catheter securely to the skin (with plug that can occlude the needle. a suture), dress the area according to local STEP 6. Hold the needle and syringe parallel to the protocol. frontal plane. STEP 15. Tape the intravenous tubing in place. STEP 16. Obtain a chest x-ray film to confirm the position of the intravenous line and identify a possible pneumothorax. venous cutdown optional skill STEP 1. Cleanse the skin around the site chosen for cutdown, and drape the area. ■ BACK TO TABLE OF CONTENTS

355 APPENDIX G ■ Skills STEP 2. If the patient is awake, use a local anesthetic STEP 5. Using a 16- to 18-gauge, 6-in. (15-cm) or at the venipuncture site. longer over-the-needle catheter, attach a 35-mL empty syringe with a three- STEP 3. Make a full-thickness, transverse skin in- way stopcock. cision through the anesthetized area to a length of 1 inch (2.5 cm). STEP 6. Assess the patient for any mediastinal shift that may have caused the heart to shift STEP 4. By blunt dissection, using a curved hemostat, significantly. identify the vein and dissect it free from any accompanying structures. STEP 7. Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a 45-degree STEP 5. Elevate and dissect the vein for a distance angle to the skin. of approximately 3/4 inch (2 cm) to free it from its bed. STEP 8. Carefully advance the needle cephalad and aim toward the tip of the left scapula. Follow STEP 6. Ligate the distal mobilized vein, leaving the the needle with the ultrasound. suture in place for traction. STEP 9. Advance the catheter over the needle. STEP 7. Pass a tie around the vein in a cephalad Remove the needle. direction. STEP 10. When the catheter tip enters the blood- STEP 8. Make a small, transverse venotomy and filled pericardial sac, withdraw as much gently dilate the venotomy with the tip of a nonclotted blood as possible. closed hemostat. STEP 11. After aspiration is completed, remove the STEP 9. Introduce a plastic cannula through the syringe and attach a three-way stopcock, venotomy and secure it in place by tying the leaving the stopcock closed. The plastic upper ligature around the vein and cannula. pericardiocentesis catheter can be sutured To prevent dislodging, insert the cannula an or taped in place and covered with a adequate distance from the venotomy. small dressing to allow for continued decompression en route to surgery or STEP 10. Attach the intravenous tubing to the transfer to another care facility. cannula, and close the incision with interrupted sutures. STEP 12. If cardiac tamponade symptoms persist, the stopcock may be opened and the pericardial STEP 11. Apply a sterile dressing. sac reaspirated. This process may be repeated as the symptoms of tamponade recur, before pericardiocentesis using definitive treatment. ultr asound—optional skill links to future learning STEP 1. Monitor the patient’s vital signs and electro- Shock can develop over time, so frequent reassessment cardiogram (ECG) before, during, and after is necessary. Hemorrhage is the most common cause the procedure. of shock in the trauma patient, but other causes can occur and should be investigated. The MyATLS STEP 2. Use ultrasound to identify the effusion. mobile app provides video demonstrations of most STEP 3. Surgically prepare the xiphoid and procedures. Also visit www.bleedingcontrol.org for more information regarding external hemorrhage subxiphoid areas, if time allows. control. Visit https://www.youtube.com/watch?v=Wu- STEP 4. Locally anesthetize the puncture site, KVibUGNM to view a video demonstrating the humeral intraosseous approach, and https://www.youtube. if necessary. com/watch?v=OwLoAHrdpJA to view video of the ultrasound-guided approach to pericardiocentesis. ■ BACK TO TABLE OF CONTENTS



Skill Station D DISABILITY LEARNING OBJECTIVES 1. Perform a brief neurological examination, including 5. Identify the signs, symptoms, and treatment of calculating the Glasgow Coma Scale (GCS) score, neurogenic shock. performing a pupillary examination, and examining the patient for lateralizing signs. 6. Demonstrate proper helmet removal technique. 2. Identify the utility and limitations of CT head 7. Identify the signs and symptoms of spinal cord decision tools. injury in a simulated patient. 3. Identify the utility and limitations of cervical spine 8. Demonstrate the hand-over of a neurotrauma imaging decision tools. patient to another facility or practitioner. 4. Perform proper evaluation of the spine while restricting spinal motion, including evaluating the spine, logrolling the patient, removing the backboard, and reviewing cervical spine and head CT images. skills included in this STEP 2. Shine light into eyes and note pupillary skill station response. • Brief or Focused Neurological Examination determine new gcs score • Evaluation of Cervical Spine • Transfer Communication STEP 3. Assess eye opening. • Helmet Removal A. Note factors interfering with communi- • Detailed Neurological Exam cation, ability to respond, and other • Removal of Spine Board injuries. • Evaluation of Head CT Scans B. Observe eye opening. • Evaluation of Cervical Spine Images C. If response is not spontaneous, stimulate patient by speaking or shouting. brief or focused D. If no response, apply pressure on fingertip, neurological ex amination trapezius, or supraorbital notch. E. Rate the response on a scale of not testable examine pupils (NT), 1–4. STEP 1. Note size and shape of pupil. STEP 4. Assess verbal response. ■ BACK TO TABLE OF CONTENTS 357

358 APPENDIX G ■ Skills A. Note factors interfering with communica- STEP 2. Inform the patient that you are going to tion, ability to respond, and other injuries. examine him or her. The patient should answer verbally rather than nodding B. Observe content of speech. the head. C. If not spontaneous, stimulate by speaking STEP 3. Palpate the posterior cervical spine for or shouting. deformity, swelling, and tenderness. Note D. If no response, apply pressure on fingertip, the level of any abnormality. Look for any penetrating wounds or contusions. If the trapezius, or supraorbital notch. cervical spine is nontender and the patient E. Rate the response on a scale of NT, 1–5. has no neurological deficits, proceed to Step STEP 5. Assess motor response. 4. If not, stop, replace the cervical collar, and A. Note factors interfering with communication, obtain imaging. ability to respond, and other injuries. STEP 4. Ask the patient to carefully turn his or her B. Observe movements of the right and left head from side to side. Note if there is pain, or any paresthesia develops. If not, proceed sides of body. to Step 5. If yes, stop, reapply the cervical C. If response is not spontaneous, stimulate collar, and obtain imaging. patient by speaking or shouting. STEP 5. Ask the patient to extend and flex his or D. If no response, apply pressure on fingertip, her neck (i.e., say, “Look behind you and then touch your chin to your chest.”). Note trapezius, or supraorbital notch (if not if there is pain or any paresthesia develops. contraindicated by injury). If not, and the patient is not impaired, head E. Rate the response on a scale of NT, 1–6. injured, or in other high-risk category as STEP 6. Calculate total GCS score and record its defined by NEXUS Criteria or the Canadian individual components. C-Spine Rule (CCR), discontinue using the cervical collar. If yes, reapply the cervical evaluate for any evidence of collar and obtain imaging. lateralizing signs tr ansfer communication STEP 7. Assess for movement of upper extremities. STEP 8. Determine upper extremity strength bi- STEP 1. Use the ABC SBAR method of ensuring complete communication. laterally, and compare side to side. STEP 9. Assess for movement of the lower extremities. A. Airway STEP 10. Determine lower extremity strength B. Breathing C. Circulation bilaterally, and compare side to side. D. Situation evaluation of cervical • Patient name spine • Age • Referring facility STEP 1. Remove the front of the cervical collar, if • Referring physician name present, while a second person restricts • Reporting nurse name patient’s cervical spinal motion. • Indication for transfer • IV access site ■ BACK TO TABLE OF CONTENTS

359 APPENDIX G ■ Skills • IV fluid and rate provides full facial coverage, the patient’s • Other interventions completed nose will impede helmet removal. To clear E. Background the nose, tilt the helmet backward and raise it over the patient’s nose. • Event history STEP 5. During this process, the second person must • AMPLE assessment restrict cervical spine motion from below to • Blood products prevent head tilt. • Medications given (date and time) STEP 6. After removing the helmet, continue • Imaging performed restriction of cervical spine motion from • Splinting above, apply a cervical collar. STEP 7. If attempts to remove the helmet result in F. Assessment pain and paresthesia, remove the helmet with a cast cutter. Also use a cast cutter to • Vital signs remove the helmet if there is evidence of • Pertinent physical exam findings a cervical spine injury on x-ray film or by • Patient response to treatment examination. Stabilize the head and neck during this procedure; this is accomplished G. Recommendation by dividing the helmet in the coronal plane through the ears. The outer, rigid layer • Transport mode is removed easily, and the inside layer • Level of transport care is then incised and removed anteriorly. • Meds intervention during transport Maintaining neutral alignment of the head • Needed assessments and interventions and neck, remove the posterior portions of the helmet. helmet removal detailed neurological exam STEP 1. One person stabilizes the patient’s head and neck by placing one hand on either side of STEP 1. Examine the pupils for size, shape, and the helmet with the fingers on the patient’s light reactivity. mandible. This position prevents slippage if the strap is loose. STEP 2. Reassess the new GCS score. STEP 3. Perform a cranial nerve exam by having STEP 2. The second person cuts or loosens the helmet strap at the D-rings. patient open and close eyes; move eyes to the right, left, up, and down; smile STEP 3. The second person then places one hand widely; stick out the tongue; and shrug on the mandible at the angle, positioning the shoulders. the thumb on one side and the fingers on STEP 4. Examine the dermatomes for sensation the other. The other hand applies pressure to light touch, noting areas where there from under the head at the occipital region. is sensory loss. Examine those areas for This maneuver transfers the responsibility sensation to pinprick, noting the lowest for restricting cervical motion to the level where there is sensation. second person. STEP 5. Examine the myotomes for active movement and assess strength (0–5) of movement, STEP 4. The first person then expands the helmet noting if limited by pain. laterally to clear the ears and carefully • Raises elbow to level of shoulder—deltoid, removes the helmet. If the helmet has a face C5 cover, remove this device first. If the helmet ■ BACK TO TABLE OF CONTENTS

360 APPENDIX G ■ Skills • Flexes forearm—biceps, C6 STEP 3. Remove any blocks, tapes, and straps securing • Extends forearm—triceps, C7 the patient to the board, if not already • Flexes wrist and fingers, C8 done. The lower limbs can be temporarily • Spreads fingers, T1 secured together with roll gauze or tape to • Flexes hip—iliopsoas, L2 facilitate movement. • Extends knee—quadriceps, L3–L4 • Flexes knee—hamstrings, L4–L5 to S1 STEP 4. All personnel assume their roles: The • Dorsiflexes big toe—extensor hallucis head and neck manager places his or her hands under the patient’s shoulders, longus, L5 palms up, with elbows and forearms • Plantar flexes ankle—gastrocnemius, S1 parallel to the neck to prevent cervical spinal motion. The torso manager places STEP 6. Ideally, test patient’s reflexes at elbows, his or her hands on the patient’s shoulder knees, and ankles (this step is least and upper pelvis, reaching across the informative in the emergency setting). patient. The third person crosses the second person’s hand, placing one hand at removal of spine board the pelvis and the other at the lower extremities. (Note: If the patient has Note: Properly securing the patient to a long spine board fractures, a fifth person may need to be is the basic technique for splinting the spine. In general, assigned to that limb.) this is done in the prehospital setting; the patient arrives at the hospital with spinal motion already restricted by STEP 5. The head and neck manager ensures the being secured to a long spine board with cervical collar team is ready to move, and then the team in place and head secured to the long spine board. The moves the patient as a single unit onto his long spine board provides an effective splint and permits or her side. safe transfers of the patient with a minimal number of assistants. However, unpadded spine boards can soon STEP 6. Examine the back. become uncomfortable for conscious patients and pose STEP 7. Perform rectal examination, if indicated. a significant risk for pressure sores on posterior bony STEP 8. On the direction of the head and neck prominences (occiput, scapulae, sacrum, and heels). Therefore, the patient should be transferred from the spine manager, return the patient to the supine board to a firm, well-padded gurney or equivalent surface position. If the extremities were tied or as soon as it can be done safely. Continue to restrict spinal taped, remove the ties. motion until appropriate imaging and examination have excluded spinal injury. evaluation of head ct scans STEP 1. Assemble four people and assign roles: one to Note: The steps outlined here for evaluating a head CT manage the patient’s head and neck and lead scan provide one approach to assessing for significant, the movement; one to manage the torso; and life-threatening pathology one to manage the hips and legs. The fourth person will examine the spine, perform STEP 1. Confirm the images are of the correct patient the rectal exam, if indicated, and remove and that the scan was performed without the board. intravenous contrast. STEP 2. Inform the patient that he or she will be turned STEP 2 Assess the scalp component for contusion to the side to remove the board and examine or swelling that can indicate a site of the back. Instruct the patient to place his external trauma. or her hands across the chest if able and to respond verbally if he or she experiences pain STEP 3 Assess for skull fractures. Remember that during examination of the back. suture lines can be mistaken for fractures. Missile tracts may appear as linear areas of low attenuation. ■ BACK TO TABLE OF CONTENTS

361 APPENDIX G ■ Skills STEP 4 Assess the gyri and sulci for symmetry. STEP 3. Assess the cartilage, including examining Look for subdural hematomas and the cartilaginous disk spaces for narrowing epidural hematomas. or widening. STEP 5 Assess the cerebral and cerebellar STEP 4. Assess the dens. hemispheres. Compare side to side for density and symmetry. Look for areas of high A. Examine the outline of the dens. attenuation that may represent contusion or shearing injury. B. Examine the predental space (3 mm). STEP 6 Assess the ventricles. Look for symmetry C. Examine the clivus; it should point to the dens. or distortion. Increased density represents intraventricular hemorrhage. STEP 5. Assess the extraaxial soft tissues. STEP 7 Determine shifts. Hematoma or swelling A. Examine the extraaxial space and soft tissues: can cause midline shift. A shift of more than 5 mm is considered indicative of the need • 7 mm at C3 for surgery. • 3 cm at C7 STEP 8 Assess the maxillofacial structures. Look links to future learning for fractures and fluid in the sinuses. Remember the four things that cause in- “New” Glasgow Coma Scale: www.glasgowcomascale.org creased density: contrast, clot, cellularity (tumor), and calcification. Brain Trauma Foundation Guidelines: Carney M, Totten AM, Reilly C, Ullman JS et al. “Guidelines for evaluation of cervical the Management of Severe Traumatic Brain Injury, spine images 4th Edition” 2016: Brain Trauma Foundation. www. braintrauma.org Note: Before interpreting the x-ray, confirm the patient name and date of examination. “New Orleans Criteria” for CT scanning in minor STEP 1. Assess adequacy and alignment. head injury: Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed A. Identify the presence of all 7 cervical tomography in patients with minor head injury. N Engl vertebrae and the superior aspect J Med. 2000;343:100-105 of T1. “Canadian Head CT rules”: B. Identify the • Anterior vertebral line • Stiell IG, Lesiuk H, Wells GA, et al. The • Anterior spinal line Canadian CT Head Rule Study for patients • Posterior spinal line with minor head injury: rationale, objectives, • Spinous processes and methodology for phase I (derivation). Ann Emerg Med. 2001;38:160-169. 25. Stiell STEP 2. Assess the bone. IG, Lesiuk H, Wells GA, et al. Canadian CT A. Examine all vertebrae for preservation of Head Rule Study for patients with minor head height and integrity of the bony cortex. injury: methodology for phase II (validation B. Examine facets. and economic analysis). Ann Emerg Med. C. Examine spinous processes. 2001;38:317-322. • NEXUS criteria: Hoffman JR, Wolfson AB, Todd K, Mower WR (1998). “Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography ■ BACK TO TABLE OF CONTENTS

362 APPENDIX G ■ Skills Utilization Study (NEXUS).”. Ann Emerg Med. 32 Post-ATLS—Evaluate what procedures exist in your (4): 461–9. practice setting for rapidly evaluating patients for traumatic brain injury (TBI). Does your practice setting Canadian C-spine rules: have a protocol for prevention of secondary brain injury once TBI is diagnosed? Also evaluate what procedures • Stiell IG, Wells GA, Vandemheen KL, Clement exist in your practice setting for spine immobilization. CM, Lesiuk H, De Maio VJ, et al. The Canadian Are all staff members who deal with trauma patients C-spine rule for radiography in alert and adequately educated in these procedures? Evaluate stable trauma patients. JAMA. 2001 Oct 17. your practice setting regarding how the cervical spine 286(15):1841-8. is evaluated and cleared (if appropriate). Are all staff members who evaluate trauma patients adequately • Stiell IG, Clement CM, O’Connor A, Davies educated in the existing, evidence-based criteria for B, Leclair C, Sheehan P, et al. Multicentre evaluation and clearance of the cervical spine? prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. 2010 Aug 10. 182(11):1173-9. ■ BACK TO TABLE OF CONTENTS





Skill Station E ADJUNCTS LEARNING OBJECTIVES 1. Identify the appropriate positioning of an 5. Explain the value of the anteroposterior (AP) pelvic ultrasound probe for FAST and eFAST exams. x-ray examination to identify the potential for massive blood loss, and describe the maneuvers 2. Identify fluid on still images or video of FAST exam. that can be used to reduce pelvic volume and control bleeding. 3. Identify ultrasound evidence of pneumothorax on video images of an eFAST exam. 6. Use a structured approach to interpreting a plain x-ray of the spine or CT (based on course director’s 4. Use a structured approach to interpret a chest x-ray preference). and identify injuries present (see Skill Station B: Breathing). 7. Use a structured approach to evaluating a pelvic x-ray. skills included in this skill station • Perform a FAST Exam and Properly n FIGURE G-1 Position Probes the right (■ FIGURE G-1). The probe angle is shallow, and the liver is used as an • Perform an eFAST Exam and Properly acoustic window. Position Probes STEP 2. Move to the right upper quadrant view. • Identify Abnormal eFAST on Still or Video Place the probe marker toward the head Images in the coronal plane in the anterior axillary line (■ FIGURE G-2). Rotate the • Identify Fluid on FAST Video or Still Images of probe obliquely and scan from cephalad to FAST caudad to visualize the diaphragm, liver, and kidney. • Evaluate Thoracic and Lumbar Spine Images • Interpret a Pelvic X-Ray perform a fast exam and properly position probes STEP 1. Use a low-frequency probe (3.5 mHz). Start with the heart to ensure the gain is set appropriately. Fluid within the heart will appear black. Place the probe in the subxyoid space, with the probe marker to ■ BACK TO TABLE OF CONTENTS 365

366 APPENDIX G ■ Skills n FIGURE G-2 n FIGURE G-3 n FIGURE G-4 n FIGURE G-5 STEP 3. Scan the left upper quadrant. Position a sagittal orientation (■ FIGURE G-6), and slide the probe caudally (■ FIGURE G-7). Examine 2 the probe marker toward the head in the or 3 interspaces. Including more interspaces coronal plane (■ FIGURE G-3). Begin scan increases the sensitivity more cephalad than on the right and more posterior. Begin in the midaxillary line. STEP 2. Evaluate the right and left diaphragms using Rotate the probe obliquely and visualize the same probe position as for evaluation the diaphragm, spleen, and kidney. of the perihepatic and perisplenic space STEP 4: (Ideally, the bladder is full.) Place the probe (■ FIGURE G-8), sliding the probe one rib space above the pubic bone with the probe marker cephalad (■ FIGURE G-9). pointing to the right (■ FIGURE G-4). Scan for fluid, which appears as a dark stripe. identify abnormal efast Rotate the probe 90 degrees so the probe on still or video images marker points to the head (■ FIGURE G-5). Scan for fluid. STEP 1. Look for lung sliding. If you see none, look for lung pulse. perform an efast exam and demonstr ate proper STEP 2. Look for comet tails. probe positioning STEP 3. Look for seashore, bar code, or stratosphere STEP 1. Place the probe in the second or third sign in M mode. Bar code and stratosphere intercostal space in the mid clavicular line in signs indicate pneumothorax. ■ BACK TO TABLE OF CONTENTS

367 APPENDIX G ■ Skills n FIGURE G-6 n FIGURE G-7 n FIGURE G-8 n FIGURE G-9 STEP 4. Look for black or anechoid areas above evaluate thor acic and the diaphragm. lumbar spine images (optional) identify fluid on fast video or still images Note: Before interpreting the x-ray, confirm the patient of fast name and date of examination. STEP 1. Assess for alignment of vertebral bodies/ STEP 1. On the pericardial view, look for a black stripe of fluid separating the hyperechoic angulation of spine. pericardium from the gray myocardium. STEP 2. Assess the contour of the vertebral bodies. This stripe represents fluid. STEP 3. Assess the disk spaces. STEP 4. Assess for encroachment of vertebral body STEP 2. Look at the hepatorenal space. Intraperi- toneal fluid has a black hypoechoic or on the canal. anechoic appearance. interpret a pelvic x-r ay STEP 3. Look at the splenorenal space. Blood will appear as a hypoechoic or anechoic strip in Note: Before interpreting the x-ray, confirm the patient this area. name and date of examination. STEP 1. Check for interruption of the arcuate STEP 4. Look around the bladder for an area of hypoechogenicity. and ilioischial lines, including the pubic symphysis. The pubic symphysis should be STEP 5. Be sure you have thoroughly visualized all spaces before declaring an examina- tion negative. ■ BACK TO TABLE OF CONTENTS

368 APPENDIX G ■ Skills less than 1 cm in pregnancy and less than 0.5 links to future learning cm in nonpregnant adults. STEP 2. Check for widening or displacement of Post ATLS—Review the FAST performance video the sacroiliac joints. Check the transverse on the MyATLS mobile app. After this course, take processes of L-5 because they may fracture the opportunity to perform FAST and eFAST on with sacroiliac disruption. your patients to improve your comfort with use of STEP 3. Check the sacrum for evidence of fracture. this technology. In addition, make an effort to read The arcs of the foramina may be interrupted pelvic x rays on your own before looking at the with sacral fractures. radiologist interpretation. STEP 4. Check the acetabulum bilaterally for interruption and femoral dislocation. Check the femoral head and neck for disruption bilaterally. ■ BACK TO TABLE OF CONTENTS





Skill Station F SECONDARY SURVEY LEARNING OBJECTIVES 1. Assess a simulated multiply injured patient by using 4. Demonstrate splinting a fracture in a simulated the correct sequence of priorities and management trauma patient scenario. techniques for the secondary survey assessment of the patient. 5. Evaluate a simulated trauma patient for evidence of compartment syndrome. 2. Reevaluate a patient who is not responding appropriately to resuscitation and management. 6. Recognize the patient who will require transfer to definitive care. 3. Demonstrate fracture reduction in a simulated trauma patient scenario. 7. Apply a cervical collar. skills included in this • L—last meal skill station • E—environment and exposure STEP 2. Obtain history of injury-producing event • Perform a Secondary Survey in a Simulated Trauma Patient and identify injury mechanisms. • Reduce and Splint a Fracture in a Simulated head and maxillofacial Trauma Patient STEP 3. Assess the head and maxillofacial area. • Apply a Cervical Collar in a Simulated Trauma A. Inspect and palpate entire head and face Patient for lacerations, contusions, fractures, and thermal injury. • Evaluate for the Presence of Compartment B. Reevaluate pupils. Syndrome C. Reevaluate level of consciousness and Glasgow Coma Scale (GCS) score. perform secondary D. Assess eyes for hemorrhage, penetrating survey in a simulated injury, visual acuity, dislocation of lens, and tr auma patient presence of contact lenses. E. Evaluate cranial nerve function. STEP 1. Obtain AMPLE history from patient, family, F. Inspect ears and nose for cerebrospinal or prehospital personnel. fluid leakage. • A—allergies • M—medications • P—past history, illnesses, and pregnancies ■ BACK TO TABLE OF CONTENTS 371

372 APPENDIX G ■ Skills G. Inspect mouth for evidence of bleeding and C. Percuss the abdomen to elicit subtle cerebrospinal fluid, soft-tissue lacerations, rebound tenderness. and loose teeth. D. Palpate the abdomen for tenderness, involun- cervical spine and neck tary muscle guarding, unequivocal rebound tenderness, and a gravid uterus. STEP 4. Assess the cervical spine and neck. A. Inspect for signs of blunt and penetrating perineum/rectum/vagina injury, tracheal deviation, and use of accessory respiratory muscles. STEP 7. Assess the perineum. Look for B. Palpate for tenderness, deformity, swelling, subcutaneous emphysema, tracheal devia- • Contusions and hematomas tion, and symmetry of pulses. • Lacerations C. Auscultate the carotid arteries for bruits. • Urethral bleeding D. Restrict cervical spinal motion when injury is possible. STEP 8. Perform a rectal assessment in selected patients to identify the presence of rectal chest blood. This includes checking for: STEP 5. Assess the chest. • Anal sphincter tone A. Inspect the anterior, lateral, and • Bowel wall integrity posterior chest wall for signs of blunt • Bony fragments and penetrating injury, use of accessory breathing muscles, and bilateral STEP 9. Perform a vaginal assessment in selected respiratory excursions. patients. Look for B. Auscultate the anterior chest wall and pos- terior bases for bilateral breath sounds and • Presence of blood in vaginal vault heart sounds. • Vaginal lacerations C. Palpate the entire chest wall for evidence of blunt and penetrating injury, musculoskeletal subcutaneous emphysema, tenderness, and crepitation. STEP 10. Perform a musculoskeletal assessment. D. Percuss for evidence of hyperresonance or dullness. • Inspect the upper and lower extremities for evidence of blunt and penetrating abdomen injury, including contusions, lacerations, and deformity. STEP 6. Assess the abdomen. A. Inspect the anterior and posterior abdomen • Palpate the upper and lower extremities for signs of blunt and penetrating injury and for tenderness, crepitation, abnormal internal bleeding. movement, and sensation. B. Auscultate for the presence of bowel sounds. • Palpate all peripheral pulses for presence, absence, and equality. • Assess the pelvis for evidence of fracture and associated hemorrhage. • Inspect and palpate the thoracic and lumbar spines for evidence of blunt and penetrating injury, including contusions, ■ BACK TO TABLE OF CONTENTS

373 APPENDIX G ■ Skills lacerations, tenderness, deformity, and apply a cervical collar in a sensation (while restricting spinal motion simulated trauma patient in patients with possible spinal injury). STEP 1. Place the patient in the supine position. neurological STEP 2. Place your extended fingers against the STEP 11. Perform a neurological assessment. patient’s neck. Your little finger should • Reevaluate the pupils and level of almost be touching the patient’s shoulder. consciousness. Count how many of your fingers it takes • Determine the GCS score. to reach the jawline. Remember, sizing a • Evaluate the upper and lower extremities cervical collar is not an exact science; the for motor and sensory functions. available sizes are limited, so make your • Observe for lateralizing signs. best estimate. STEP 3. Find the appropriately sized collar or use an reduce and splint a adjustable one, if available. fr acture in a simulated STEP 4. Have another provider restrict the patient’s tr auma patient cervical spinal motion by standing at head of bed and holding either side of the head. STEP 1. Ensure that the ABCDEs have been assessed STEP 5. Slide the posterior portion of the collar and life-threatening problems have behind the patient’s neck, taking care not been addressed. to move the neck. STEP 6. Place the anterior portion of the collar on STEP 2. Completely expose the extremity and remove while making sure to place the patient’s all clothing. chin in the chin holder. STEP 7. Secure the collar with the hook and loop STEP 3. Clean and cover any open wounds. fasteners, making it snug enough to prevent STEP 4. Perform a neurovascular examination of flexion but allowing the patient to open his or her mouth. the extremity. STEP 5. Provide analgesia. evaluate for presence of STEP 6. Select the appropriate size and type of compartment syndrome splint. Include the joint above and below STEP 1. Assess the degree of pain — is it greater the injury. than expected and out of proportion to the STEP 7. Pad the bony prominences that will be stimulus or injury? covered by the splint. STEP 8. Manually support the fractured area and STEP 2. Determine if there is pain on passive stretch apply distal traction below the fracture and of the affected muscle. counter traction just above the joint. STEP 9. Reevaluate the neurovascular status of STEP 3. Determine if there is altered sensation or the extremity. paresthesiadistal to theaffectedcompartment. STEP 10. Place the extremity in the splint and secure. STEP 11. Obtain orthopedic consultation. STEP 4. Determine if there is tense swelling of the affected compartment. STEP 5. Palpate the muscular compartments of the extremity and compare the tension ■ BACK TO TABLE OF CONTENTS

374 APPENDIX G ■ Skills in the injured extremity with that in the links to future learning noninjured extremity. Asymmetry may be an important finding. Review the secondary survey video on the MyATLS STEP 6. Compartment pressures may be measured, mobile app. but the diagnosis is clinical. Pressure Post ATLS—Recognize that the secondary survey is measurements may be useful in unconscious similar to the comprehensive physical examination or neurologically impaired patients. learned in medical school. It incorporates the AMPLE STEP 7. Frequently reevaluate the patient, because history and takes into account the mechanism compartment syndrome can develop of traumatic injury. It is easy therefore to find over time. opportunities in one’s practice setting to continue STEP 8:. Obtain surgical or orthopedic consultation to practice the skills learned in the secondary survey early. skill station. ■ BACK TO TABLE OF CONTENTS





INDEX ABCDEs. See Primary survey FAST for, 201 Acute care, 290b ABC priorities, 6 nonoperative management Acute radiation syndrome (ARS), ABC-SBAR template, 247, 247t Abdomen of, 201–202 298b visceral injuries, 202 Advanced Cardiac Life Support anatomy of, 84–85, 84f pelvic fractures and associated anterior, 84 injuries, 17, 17f, 96f (ACLS), 70, 90, 90t physical examination of, 17 in geriatric patients, 221–222 Advanced Trauma Life Support (ATLS) Abdominal and pelvic trauma hemorrhagic shock and, 98, anatomy of, 84–85, 84f delivering within team, 308–309 assessment and management 98f origins of, 275 management of, 97–98, 97f team members, 307–308 of, 86–98 mechanism of injury and “After Action” sessions, 20 contrast studies for, 92–93 Afterload, 44f, 45 CT for, 90t, 91–92, 93, 94 classification, 96–97 Aging. See also Geriatric patients; diagnostic laparoscopy for, in pregnancy, 228–229 Older adults, effects of, on organ physical examination of, 87–93 systems, 218t 92, 93 adjuncts to, 88–93 AIDS. See Acquired immuno- diaphragm injuries, 95 auscultation, 87 deficiency syndrome DPL for, 90–91, 90t, 91f inspection, 87 Air bag injury, 86t duodenal injuries, 95 palpation, 87 Airway evaluation of, 93–94 pelvic assessment, 87–88 definitive. See Definitive airway percussion, 87 preventable deaths from anterior abdominal wounds, pitfall of, 88 93 urethral, perineal, rectal, problems with, 24 Airway equipment, 6 diaphragm injuries, 95 vaginal, and gluteal Airway loss, progressive, 8f duodenal injuries, 95 examination, 88 Airway management flank and back injuries, pitfalls of, 86, 89, 92, 93, 94, 96 small bowel injuries, 85, 202 airway decision scheme for, 28, 93–94 solid organ injuries, 95–96 29f, 30 genitourinary injuries, 95 teamwork in, 98 hollow viscus injuries, 95 thoracoscopy for, 92 for burn injuries, 170–171, 170f pancreatic injuries, 95 urinary catheters for, 88–89 definitive airways, 32–36 solid organ injuries, 95–96 x-rays for, 89 thoracoabdominal wounds, Abdominal breathing, 26 criteria for establishing, ABG. See Arterial blood gases 32–33 93 ABLS. See American Burn Life Support FAST for, 91f Abruptio placentae, 233, 234f drug-assisted intubation, gastric tubes for, 88–89 Abuse 35–36 genitourinary injuries, 95 burn patterns indicating, 180 history of, 87 child, 207–208 endotracheal intubation, laparotomy for, 94f elder, 222, 222b 33–35, 34f intimate partner, 235, 237, 237b indications for, 94–95 Acidosis, 54, 173 indications for, 33t mechanisms of injury ACLS. See Advanced Cardiac Life needle cricothyroidotomy, Support blast, 85–86 Acquired immunodeficiency 36, 36f blunt, 85, 85f syndrome (AIDS), 6 surgical airway, 36 penetrating, 85 ACS. See American College of surgical cricothyroidotomy, missed injuries, 86 Surgeons other studies, 89 Active shooters, 283–285 36, 37f pancreatic injuries, 95, 202 in geriatric patients, 217, 218f, in pediatric patients, 200–202 assessment of, 200 219 CT scanning in, 200–201 in head trauma, 117–118 DPL for, 201 for hemorrhagic shock, 51 ILMA for, 31 LEMON assessment for, 28, 28b–29b LMA for, 31, 31f, 194 ■ BACK TO TABLE OF CONTENTS 377

378 INDEX LTA for, 31–32, 32f American Burn Life Support (ABLS), Area of operations, 290b Mallampati classification for, 171 ARS. See Acute radiation syndrome Arterial bleeding, management of, 28b American College of Surgeons needle cricothyroidotomy for, (ACS), 4 151 Disaster Management and Arterial blood gases (ABGs), 11 36, 36f Emergency Preparedness Arterial pH, 230t oxygenation management for, (DMEP) course, 275 Arteriography, 151 Trauma Quality Improvement Asphyxia, traumatic, 77 36, 38 Program, 111 Asphyxiants, 297 in pediatric patients, 190, 192– Aspiration, 10, 24, 30 American Spinal Injury Association Assault, 231t 194, 219t (ASIA), 132 Atherosclerotic vascular occlusive anatomy and physiology in, Amnesia, 115 disease, 220 192–193, 192f AMPLE history, 13 shock and, 57 cricothyroidotomy, 194 Amputation, traumatic, 150–151 Athletes oral airway, 193 Analgesia, 19 initial assessment of, 13 orotracheal intubation, Analgesics shock and, 57 Atlanto-occipital dislocation, 136 193–194, 193f brain injury and, 120 Atlas (C1) fracture, 136, 137f predicting difficult, 28 for burn injuries, 178 ATLS. See Advanced Trauma Life problem recognition, 24–26 for pain control, 163 Support Anatomy ATLS in the Operational Envi- laryngeal trauma, 25–26 of abdomen, 84–85, 84f ronment (ATLS-OE), 280–283 maxillofacial trauma, 25, 25f cranial, 105f, 106 Atropine sulfate, 194 neck trauma, 25 of eye, 257–258, 258f Austere environments, 275, 278–279 with restriction of cervical spine of pregnant patients, 228–231 Automobile collisions. See Motor motion, 7–8, 8f Anesthetics, brain injury and, 120 vehicle crashes surgical cricothyroidotomy for, Angioembolization, 201–202 Autotransfusion, 55 36, 37f Ankle Axillary nerve, 161t teamwork in, 38–39 fractures, 163, 164f Axis (C2) fractures, 137 techniques for, 27–28, 30–32 joint dislocation deformities, Baby milestones, 207t chin-lift maneuver, 30, 30f Back, 84 extraglottic devices, 31 155t, 156f Back injuries, 93–94 intubating LMA, 31 Anterior abdomen, 84 Backward, upward, and rightward intubating LTA, 31–32 Anterior abdominal wounds, 93 pressure (BURP), 33 jaw-thrust maneuver, 30, 30f Anterior chamber, of eye, 257, 260 Bag-mask ventilation, 38 laryngeal mask airway, 31, Anterior cord syndrome, 135–136 Balanced resuscitation, 53, 56, 59 Anterior exam, of eye, 259–260 Barbiturates, brain injury and, 122 31f Anterior-posterior (AP) compression BCI. See Blunt cardiac injury laryngeal tube airway, 31–32, BCU. See Body cooling unit fracture, 96, 96f Beta blockers, 222 32f Anterior wedge compression injury, Bilateral femur fractures, 152 multilumen esophageal Bladder injuries, 202 137–138 Blast injuries, 85–86, 278, 296 airway, 32, 32f Antibiotics Bleeding nasopharyngeal airway, 30 arterial, management of, 151 oropharyngeal airway, 31, for burn injuries, 179 control of, 9, 285 intravenous, weight-based Blood loss 31f antiplatelet or anticoagulant supraglottic devices, 31, 32f dosing guidelines, 158t for thoracic trauma, 64–65 Anticoagulation therapy, 56 medications and, 56 by trauma teams, 308 hemorrhagic shock and, 49–50, ventilation in brain injury and, 120–121 management of, 38 geriatric patients and, 222 49t objective signs of inadequate, reversal, 121t pathophysiology, 45 Anticonvulsants, brain injury and, in pediatric patients, 196, 196t 26–27 122 soft-tissue injuries and, 51 problem recognition for, 26 Antiplatelet medications, 56 Airway obstruction brain injury and, 120–121, 121t assessment for, 7 geriatric patients and, 222 objective signs of, 26 Aortic rupture, 75–76, 75f partial, 26 Aqueous humor, 257 in thoracic trauma, 64 Arachnoid mater, 105, 106f, 107 Alcohol abuse, 244 American Burn Association, 172 ■ BACK TO TABLE OF CONTENTS

379 INDEX Blood pressure Brown-Séquard syndrome, 136 end-tidal levels, 11 equating to cardiac output, 56 BSA. See Body-surface area Carbon monoxide (CO) exposure, in pediatric patients, 195–196 Bucket handle injury, 85f in pregnancy, 230 Burns, 170 171–172 Cardiac dysrhythmias, 10–11, 170, Blood transfusion assessment of, 174–176 autotransfusion, 55 body-surface area, 175–176 174 calcium administration and, 56 depth of burn, 176, 177f Cardiac injury, blunt, 10–11, 75 coagulopathy, 55–56 history for, 175 Cardiac output, 9, 44–45, 44f crossmatched blood, 55 pitfalls of, 176 for hemorrhagic shock, 54–56, rule of nines, 175–176, 175f equating blood pressure to, 56 55f in pregnancy, 229–230 hypothermia prevention and, chemical, 179, 179f, 261 Cardiac physiology, 44–45 55 electrical, 14t, 179–180, 179f Cardiac tamponade, 44, 47–48, massive transfusion, 55 in geriatric patients, 217 69–70 in pediatric patients, 198–199 indicating abuse, 180 cause and development of, 69, type O blood, 55 inflammatory response to, 170 inhalational, 14t 70f Blood volume, 9, 45 patient transfer and, 180–181 diagnosis of, 69–70 in pediatric patients, 197 pediatric patients and, 173, 174f management of, 70 in pregnancy, 229 in pregnant patients, 231t vs. tension pneumothorax, 69 primary survey and resuscitation Cardiogenic shock, 47 Blood warmers, 55 Cardiopulmonary resuscitation Blown pupil, 106, 107f for, 170–174 (CPR), 70 Blunt cardiac injury (BCI), 75 airway control, 170–171, 170f in pediatric patients, 199 Blunt carotid and vertebral injuries, circulation management Cardiovascular system, effects of aging on, 218t 140 with burn shock resus- Care Under Fire, 280 Blunt esophageal rupture, 77 citation, 172–174, 173f, Carotid artery injury, 139 Blunt trauma, 15 174t Casualties ensure adequate ventilation, mass, 6–7 to abdomen and pelvis, 85, 85f 171–172 multiple, 6 mechanisms of injury, 14t, 15 pitfalls of, 171, 173, 174 Casualty collection point (CCP), 290b in pregnant patients, 232, 232f, stop burning process, 170 Catheters secondary survey for, 176–178 gastric, 11, 12f 232t baseline determinations for urinary, 11, 52, 88–89 Body-cooling unit (BCU), 271 major burns, 176 CBC. See Complete blood count Body-surface area (BSA), 175–176 documentation in, 176 CBF. See Cerebral blood flow Bone level of injury, 135 gastric tube insertion, 178 CBRNE (Chemical, Biological, Brain, anatomy of, 106 narcotics, analgesics, and Radiological, Nuclear, and Brain death, 124 sedatives, 178 Explosive agents), 290b Brain injury. See also Head trauma; peripheral circulation in CCP. See Casualty collection point circumference extremity Cefazolin, 158t Traumatic brain injuries (TBI) burns, 176–178 Centers for Disease Control and diffuse, 110 pitfalls of, 178 Prevention (CDC), 6 focal, 110–111 wound care, 178 Central cord syndrome, 135 in geriatric patients, 221 tar, 180 Central venous pressure (CVP), 219, mild, 112, 114f, 115, 116f thermal, 14t, 15 230 in pediatric patients, 202–205 BURP. See Backward, upward, and Cerebellum, 106 primary, 10 rightward pressure Cerebral blood flow (CBF), 107–109 secondary, 104 Burr hole craniostomy/craniotomy, Cerebral perfusion pressure (CPP), Brainstem, 106 123–124 108–109 Breathing. See also Ventilation Burst injury, 138 Cerebrum, 106 for geriatric patients, 219, 219t C1 rotary subluxation, 136–137 Cervical collars, 139, 140 in head trauma, 117–118 Calcium, administration of, 56 Cervical spine hemorrhagic shock and, 51 Canadian C-spine rule, 139, 139f anatomy of, 130 for pediatric patients, 195 Capnography, 11, 27 of child, 130 for primary survey, 8 Carbon dioxide fractures, 136–137 in thoracic trauma, 65–68 detection, and intubation, 35 trauma teams and, 308–309 Broselow Pediatric Emergency Tape, 190, 192f ■ BACK TO TABLE OF CONTENTS

380 INDEX atlanto-occipital dislocation, defined, 265 Contusions, 111, 111f, 161–162 136 management of, 267–269 Cornea, 257 physiological effects of, Corneal abrasions, 260 atlas (C1), 136, 137f Corticospinal tract, 132t axis (C2), 137 266–267 Coumadin (warfarin), 121t C1 rotary subluxation, rewarming techniques, 267t, CPP. See Cerebral perfusion pressure Cranial anatomy, 105f, 106 136–137 268f Cranial nerves, 106 C3–C7 fractures and signs of, 266 Craniotomy, 123, 123–124 staging and management of, Cricoid pressure, 33 dislocations, 137 Cricothyroidotomy odontoid, 137, 137f 265, 266t posterior element fractures, local tissue effects, 181–183 needle, 36 management of, 182–183 in pediatric patients, 194 137 surgical, 36, 37f motion restriction technique, frostbite, 182–183 Crossmatched blood, 55 systemic hypothermia, 183 Crush injury to chest, 77–78 7–8, 8f, 308 triage, 325–326 Crush syndrome, 152 physical examination of, 16 types of CT. See Computed tomography radiographic evaluation of, CT cystography, for abdominal and frostbite, 181–182, 182f pelvic trauma, 92 139–141 nonfreezing injury, 182 CVP. See Central venous pressure restriction, with airway Cold zone, 295 Cyanide inhalation, 172 Coma, 109 Cyanosis, 26, 65, 66 maintenance, 7–8 Committee on Trauma (COT), 4 Cystogram, for abdominal and pelvic screening for suspected injuries Communicable diseases, 6 trauma, 92 Communication Cystography, 92 to, 142b in constrained environments, Cytokines, 270 Chance fractures, 138, 138f 278–279 Dabigatran etexilate (Pradaxa), 121t Chemical burns, 179, 179f, 261 in mass-casualty care, 277 DAI. See Drug-assisted intubation Chemical injuries and illnesses, with patient’s family/friends, Deceleration injuries, 85 304–305, 305b, 305f Decompression, of stomach, 52 296–297, 297b in trauma teams, 302, 309–310 Decontamination, 295–296 Chest. See also Thoracic trauma Community preparedness, 292 Decontamination corridor, 290b Compartment syndrome, 17f, 159– Deep peroneal nerve, 161t crush injury to, 77–78 160, 159b, 159f, 161f, 176–178 Definitive airway physical examination of, 16–17 Complete blood count (CBC), 176, criteria for establishing, 32–33 trauma to, 26 268 defined, 24 Complete spinal cord injury, 131 drug-assisted intubation, 35–36 in pediatric patients, 199–200 Computed tomography (CT) endotracheal intubation, 33–35, Children. See also Pediatric patients for abdominal and pelvic trauma, 90t, 91–92, 93, 94 34f cervical spine in, 130 for aortic injury, 76 indications for, 33t cervical spine injuries in, 136 for head trauma, 120, 204f needle cricothyroidotomy, 36, hypothermia in, 266 for mild brain injury, 115, 115t initial assessment of, 13 for pediatric abdominal trauma, 36f maltreatment of, 207–208 200–201 surgical airway, 36 respiratory rate of, 195 for pregnant patients, 235 surgical cricothyroidotomy, 36, Chin-lift maneuver, 30, 30f for retrobulbar hemorrhage, 261 Circulation for spinal cord injury, 206 37f assessment of, 47f of thoracic and lumbar spine, Definitive care. See Patient transfers in geriatric patients, 219, 220t 141 with hemorrhage control, 8–9, Concussion, 110, 112 to definitive care Conflict management, in trauma Deoxyhemoglobin, 11 51, 309 teams, 310–311 Depressed skull fractures, 123 in mass-casualty care, 277 Conjunctiva, 259–260 Dermatomes, 131–132 in pediatric patients, 195–199 Consent for treatment, 19 Diagnostic laparoscopy, for abdom- in severe head trauma, 118–119 Contrast studies, for abdominal and for thoracic trauma, 68–71 pelvic trauma, 92–93 inal and pelvic trauma, 92, 93 Circulatory arrest, traumatic, 70, 71f Controlled resuscitation, 53 Diagnostic peritoneal lavage (DPL), Class I hemorrhage, 49, 49t Class II hemorrhage, 49, 49t, 50 12, 47 Class III hemorrhage, 49, 49t, 50 Class IV hemorrhage, 49, 49t, 50 Clindamycin, 158t Coagulopathy, 9, 55–56 Cold injuries, 15 hypothermia, 265–269 ■ BACK TO TABLE OF CONTENTS

381 INDEX for abdominal and pelvic ECG. See Electrocardiographic (ECG) in pregnant patients, 231t trauma, 84, 90–91, 90t, 91f monitoring Family disaster planning, 293 FAST. See Focused assessment with for pediatric abdominal trauma, Eclampsia, 231 201 eFAST. See Extended FAST (eFAST) sonography for trauma Femoral fractures, 163 for pregnant patients, 234 examination Femoral nerve, 161t Diagnostic studies Elbow, joint dislocation deformities, Fetal heart tones, 234 Fetal monitoring, 234 in primary survey, 12 290b Fetus, 231f in secondary survey, 18, 18f Elderly patients. See Geriatric patients Diaphragmatic breathing, 26 Elder maltreatment, 222, 222b full-term, 229f Diaphragmatic ruptures, traumatic, Electrical burns, 14t, 179–180, 179f primary survey and resuscitation 76–77, 77f Electrocardiographic (ECG) monitor- Diaphragm injuries, 95 for, 233–234 Diffuse brain injuries, 110 ing, 10–11, 230 Fibrinogen, 230t Direct blow, 85 Electromagnetic radiation, 297–298 Field medical triage, 294 Direct thrombin inhibitors, 121t, 222 Emergency medical services (EMS), Field Triage Decision Scheme, 4, 5f, Disability, from brain injury, 104 Disaster, defined, 290b 290b 188 Disaster preparedness and response. Emergency operations center (EOC), Finger decompression, 66f See also Mass-casualty care First-degree burns, 176 approach to, 291 290b Flail chest, 73–75, 74f blast injuries, 296 Emphysema, subcutaneous, 77 Flank, 84 chemical injuries and illnesses, EMS. See Emergency medical services Flank injuries, 93–94 Endocrine system, effects of aging Fluid resuscitation, in pediatric 296–297, 297b communication challenges in, on, 218t patients, 198–199, 199f Endotracheal intubation, 33–35, 34f. Fluid therapy 277 decontamination, 295–296 See also Orotracheal intubation for hemorrhagic shock, 52–54, 53t definitive medical care, 295 End-tidal carbon dioxide levels, 11 measuring patient response to, evacuation, 295 Environmental control, 10, 309 factors affecting trauma care in, EOC. See Emergency operations center 53–54 Epidural hematomas, 111, 111f Focal brain injuries, 110–111 279t Epilepsy, posttraumatic, 122 Focused assessment with sono- mindset for, 275 Equipment failure, 8f need for, 289, 291 Eschmann Tracheal Tube Introducer graphy for trauma (FAST), 12 phases of, 291 for abdominal and pelvic (ETTI), 33, 34f mitigation, 291 Esophageal rupture, 77 trauma, 84, 89, 90, 90t, 91f preparedness, 292–293 Ethical dilemmas, 310 for cardiac tamponade, 69–70 recovery-restoration, 291 Etomidate (Amidate), 35 for pediatric patients, 201 response, 291 ETTI. See Eschmann Tracheal Tube for shock, 46, 46f pitfalls of, 298–299 Forensic evidence, 19 radioactive injuries and ill- Introducer Fracture-dislocations, of spine, 138 nesses, 297–298, 298b Evacuation, 295 Fractures search and rescue, 293–294 Evacuation triage, 294 assessment of, 162 terminology for, 289, 290b Evidence-based treatment guide- bilateral femur, 152 triage, 294–295 cervical spine, 136–137 Documentation lines, for head trauma, 111–117 femoral, 163 of burn injuries, 176 Explosive injuries, 278, 291 immobilization of, 152–153, 152f, during initial assessment, 19 Exposure, 10, 51–52, 220, 221t, 309 in patient transfers, 249, 250f Extended FAST (eFAST) exam- 163 Dorsal columns, 132t lumbar, 138 DPL. See Diagnostic peritoneal ination, 12, 66 management of, 163 lavage Extraglottic devices, 31 neurological injury secondary Drug abuse, 244 Extremity fractures, 17f, 18 Drug-assisted intubation, 35–36 Eyes. See also Ocular trauma to, 161 Duodenal injuries, 95 open, 156–157, 157f, 158t Dura mater, 105, 106f, 107 anatomy of, 257–258, 258f orbit, 260–261 Dysrhythmias, 10–11 physical examination of, 15–16, pelvic, 221–222 ribs, sternum, and scapular, 78, 221 258–260 splinting, in pediatric patients, 206 Facial injuries, 16, 16f thoracic spine, 137–138 Falls thoracolumbar junction, 138 in geriatric patients, 217, 221–222 as mechanism of injury, 14t in pediatric patients, 188t ■ BACK TO TABLE OF CONTENTS

382 INDEX Frostbite, 181–183, 182f Hand-over, 302–304, 304b cerebral blood flow, 107–109 Full-thickness burns, 176, 177f Hangman’s fracture, 138f intracranial pressure, 107 Fundal height, 228f Hartford Consensus, 283–285 Monro-Kellie doctrine, 107, Gastric catheters, 11 Hazardous environment, 15 Hazardous materials (HAZMATs), 108f in abdominal and pelvic trauma, pitfalls of, 117 88–89 290b primary survey for, 117–120 Hazard vulnerability analysis (HVA), prognosis for, 124 insertion, in burn patients, 178 resuscitation for, 117–120 pitfalls of, 12f 290b, 292 secondary brain injury, 104 Gastric dilation, 52 Head, physical examination of, 15–16 secondary survey for, 120 Gastrointestinal system, in preg- Head-to-toe evaluation. See Sec- severe nancy, 231 GEB. See Gum elastic bougie ondary survey anesthetics, analgesics, and Genitourinary injuries, 95 Head trauma. See also Traumatic sedatives and, 120 Gentamicin, 158t Geriatric patients, 216 brain injuries (TBI) circulation and, 118–119 aging and impact of preexisting airway and breathing, 117–118 diagnostic procedures, 120 anatomy of, 104, 105f, 106, neurological examination conditions on, 216–217 airway management, 217, 218f, 106–107 for, 119–120 brain, 106 skull fractures, 109–110, 109t 219, 219t cranial, 105f surgical management breathing and ventilation for, intracranial compartments, depressed skull fractures, 219, 219t 106–107 123 circulation in, 219, 220t meninges, 104, 105f, 106 disability in, 220, 220t scalp, 104 intracranial mass lesions, 123 exposure and environmental skull, 104 penetrating brain injuries, ventricular system, 106 control for, 220, 221t classification of 123–124 goals of care for, 222–223 morphology, 109–111, 109t scalp wounds, 122, 123f hypothermia in, 265–266 severity of injury, 109, 109t teamwork in, 124 injury to CT for, 120, 204f treatment goals, 119t evidence-based treatment guide- triage for, 104 burns, 217 lines, 111–117 Heart rate, 44f falls, 217, 221–222 intracranial lesions, 110–111 in pregnancy, 230 mechanism of, 217 management of Heat exhaustion, 269, 269t motor vehicle crashes, 217 mild brain injury, 112, Heat injuries, 269 penetrating injuries, 217 management of, 270–271 maltreatment of, 222, 222b 112t–113t, 114f, 115 pathophysiology, 270 medications for, 222 moderate brain injury, 116– pharmacology for, 271, 271b pelvic fractures in, 221–222 prognosis for, 271 pitfalls of, 221 117, 117f types of, 269–270 primary survey and resuscitation severe, 118b, 118f Heat stroke, 269–270, 269t for, 217–220 severe brain injury, 117 Helmet removal, 16, 27f, 28 rib fractures in, 221 medical therapies for Hematocrit, 46 risk of mortality-associated com- anticonvulsants, 122 in pregnancy, 229, 230t plications or death in, 216f barbiturates, 122 Hemodynamics, in pregnancy, shock in, 219–220 correction of anticoagu- 229–230 teamwork with, 223 Hemorrhage traumatic brain injury in, 221 lation, 120–121 class I, 49, 49t Glasgow Coma Scale (GCS), 7, 10, hypertonic saline, 122 class II, 49, 49t, 50 32, 109, 110t hyperventilation, 121 class III, 49, 49t, 50 in mild brain injury, 115 intravenous fluids, 120 class IV, 49, 49t, 50 in pediatric patients, 203, 203t mannitol, 121–122 continued, 58 trauma teams and, 309 moderate, 112t–113t, 120 control, circulation with, 8–9, GSW. See Gunshot wounds monitoring patients with, 18 51, 309 Gum elastic bougie (GEB), 33, 34, 34f mortality from, 104 definition of, 48–49 Gunshot wounds (GSW), 14t, 85, 93, in pediatric patients, 202–205 internal, 9 231t, 232t assessment of, 202–203 major arterial, 150–151 Hand injuries, 163 causes of, 202 retrobulbar, 260–261 management of, 203–205 physiological concepts ■ BACK TO TABLE OF CONTENTS

383 INDEX Hemorrhagic shock, 45 staging and management of, International Standards for Neuro- blood replacement for, 54–56, 265, 266t logical Classification of Spinal 55f Cord Injury, 132, 133f confounding factors, 50–51 systemic, 183 definition of, 48–49 Hypovolemia Intimate partner violence, 235, 237, fluid changes secondary to soft- 237b tissue injury, 51 in burn patients, 178 hypothermia and, 57 in pediatric patients, 196 Intracerebral hematomas, 111, 111f initial management of, 51–54 Hypovolemic shock, 9, 44, 196 Intracranial compartments, 106–107 initial fluid therapy for, Hypoxemia, 178 Intracranial hematomas, 111, 111f 52–54, 53t Hypoxia, 195 Intracranial lesions, 110–111 patient response to, 53–54 IC. See Incident command/com- Intracranial mass lesions, 123 physical examination for, mander Intracranial pressure (ICP), 107 51–52 ICS. See Incident Command System Intraocular pressure, 259 vascular access, 52 IED. See Improvised explosive devices Intraosseous puncture, 52 overview of, 46–47 I-gel supraglottic airway, 32f Intravenous access, in pediatric pelvic fractures and, 98, 98f ILMA. See Intubating laryngeal physiological classification of, mask airway patients, 197–198, 197f 49–50, 49t ILTA. See Intubating laryngeal tube Intravenous antibiotics, weight- airway Hemothorax, 73 Implantable cardioverter-defibril- based dosing guidelines, 158t Heparin, 121t lator, shock and, 58 Intravenous fluids Hepatitis, 6 Improvised explosive devices (IEDs), HICS. See Hospital Incident Com- 278 for brain injury, 120 Incident command/commander for spine injury, 144 mand System (IC), 290b Intravenous pyelogram (IVP), for Hip, joint dislocation deformities, Incident command post, 290b abdominal and pelvic trauma, 92 Incident Command System (ICS), Intubating laryngeal mask airway 155t 276, 290b, 291–292, 292b (ILMA), 31 History, of mechanism of injury, Incomplete spinal cord injury, 131 Intubating laryngeal tube airway Inferior gluteal nerve, 161t (ILTA), 31–32 13, 15 Inhalational burns, 14t Intubation Hollow viscus injuries, 95 Initial assessment drug-assisted, 35–36 Homicide, of child, 207 of airway, 24–26 endotracheal, 33–35, 34f Hospital Incident Command System consent for treatment in, 19 LEMON assessment for difficult, definitive care and, 19 (HICS), 290b, 291–292 determining need for patient 28, 28b–29b Hospital phase, 6 orotracheal, 33, 193–194, 193f Hospital preparedness, 292–293 transfer during, 12, 19 pitfalls of, 35 Hot zone, 295 elements of, 4 unsuccessful, 8f HVA. See Hazard vulnerability analysis forensic evidence in, 19 Ionizing radiation, pediatric patients Hypertonic saline, brain injury preparation for, 4, 4f and, 190 Iris, 257, 260 and, 122 hospital phase, 6 IV fluid therapy, for hypovolemic Hyperventilation, brain injury prehospital phase, 4 shock, 9 primary survey for, 7–12 IVP. See Intravenous pyelogram and, 121 records during, 19 Jaw-thrust maneuver, 30, 30f Hypocapnia, 230 reevaluation in, 19 Jefferson fracture, 136, 137f Hypotensive resuscitation, 53 secondary survey for, 13–18 Joint dislocation deformities, 155t, Hypothermia, 10f, 265–269 of special populations, 13 156f teamwork in, 19–20, 20f Joints in children, 266 triage, 5f, 6–7 dislocations, neurological injury defined, 265 Insidious respiratory compromise, management of, 267–269 24, 24f secondary to, 161 in older patients, 265–266 Interhospital transfer guidelines, injuries to, 162 in pediatric patients, 199 19. See also Patient transfers to open injuries, 156–157 physiological effects of, 266–267 definitive care Joint stability, 156 prevalence of, 265, 266 Jugular venous distention, 8 prevention of, 10, 51–52, 55 Kleihauer-Betke test, 235 rewarming techniques, 267t, Knee, joint dislocation deformities, 155t 268f Knee injuries, 163 shock and, 57 signs of, 266 ■ BACK TO TABLE OF CONTENTS

384 INDEX Kussmaul’s sign, 69 Maxillofacial structures, physical Multiple-casualty incidents (MCIs), Lacerations, 161–162 examination of, 16 289 Lacrimators, 297 Laparotomy, 94–95, 94f Maxillofacial trauma, 25, 25f Multidetector CT (MDCT) Lap-belt injury, 85f, 86t, 202 MCEs. See Mass-casualty events of cervical spine, 140–141 Laryngeal mask airway (LMA), 31, MDCT. See Multidetector CT of thoracic and lumbar spine, Mean arterial blood pressure (MAP), 141 31f, 34f, 194 Laryngeal trauma, 25–26 108 Multidimensional injuries, 278 Laryngeal tube airway (LTA), 31–32, Median, anterior interosseous nerve, Multilumen esophageal airway, 32, 32f 161t 32f Lateral compression injury, 96, 96f Median distal nerve, 161t Multiple casualties, 6 LEMON assessment, 28, 28b–29b Medical evacuation (MEDEVAC) Multiple-casualty incident (MCI), Level of consciousness, 9, 10 platform, 280 290b altered, 24 Medical triage, 294 Musculocutaneous nerve, 161t Ligament injuries, 162 Medications. See also specific Musculoskeletal system, 17–18 LMA. See Laryngeal mask airway Logrolling, 143–144, 143f medications effects of aging on, 218t Lower extremities, peripheral nerve geriatric patients and, 222 in pregnancy, 231 for heat injuries, 271, 271b Musculoskeletal trauma assessment of, 161t shock and, 57 associated injuries, 164–165, 164t Low molecular weight heparin, 121t for spine injury, 144 contusions, 161–162 LTA. See Laryngeal tube airway Medulla, 106 fracture immobilization for, Lumbar spine Meningeal arteries, 106 Meninges, 104, 105f, 106, 106f 152–153, 152f fractures of, 138 Metabolic acidosis, 54, 173 fractures, 162–163 radiographic evaluation of, 141 Midbrain, 106 immobilization for screening for suspected injuries Midline shifts, 111f Mild brain injury ankle fractures, 163, 164f to, 142b CT for, 115, 115t femoral fractures, 163 Magnetic resonance imaging (MRI) discharge instructions, 116f knee injuries, 163 management of, 112, 112t–113t, tibial fractures, 163 of cervical spine, 141 upper extremity and hand for spinal cord injury, 206 114f, 115 Major arterial hemorrhage, 150–151 Military trauma care, 279–283 injuries, 163 Malignant hyperthermia, 271 joint and ligament injuries, 162 Mallampati classification, 28b ATLS in the operational joint dislocation deformities, Mannitol (Osmitrol), 121–122 environment, 280–283 MAP. See Mean arterial blood 155t pressure Care Under Fire, 280 lacerations, 161–162 Mass-casualty care, 275–276 tactical combat casualty care, life-threatening challenges of, 277–278 management priorities in, 277 279–280 bilateral femur fractures, 152 pitfalls of, 276 tactical evacuation care, 280 crush syndrome, 152 resource considerations in, 276 tactical field care, 280 major arterial hemorrhage, tools for effective, 276–278 Minimally acceptable care, 290b triage in, 276–277, 276b Minimal or no response, to fluid 150–151 Mass-casualty events (MCEs), 6–7, therapy, 54 traumatic amputation, 289, 290b MIST mnemonic, 303–304 improving survival from, 283–285 Mitigation, 290b 150–151 Massive hemothorax, 67–69, 68t Moderate brain injury, 112t–113t, 120 limb-threatening cause and development of, 68, Monro-Kellie doctrine, 107, 108f Morel-Lavallée lesion, 162 compartment syndrome, 69f Motor level of injury, 135 159–160, 159b, 159f, 161f differentiating from tension Motor vehicle crashes (MVCs), 75, 188, 188t neurological injury second- pneumothorax, 68t in geriatric patients, 217 ary to fracture or dis- management of, 68–69 as mechanism of injury, 14t location, 161 Massive transfusion protocol (MTP), in pregnant patients, 231t 54, 55 MRI. See Magnetic resonance imaging open fractures and open Mass volunteerism, 277–278 MTP. See Massive transfusion protocol joint injuries, 156–157, 157f vascular injuries, 157–159 occult skeletal injuries, 165 pain control for, 163–164 patient history for environment information in, 154 ■ BACK TO TABLE OF CONTENTS

385 INDEX mechanism of injury in, Neurological injury, secondary to Osteopenia, 78 153–154 fractures or dislocations, 161 Osteoporosis, 222 Oxygen mechanisms of injury, 154f Neurological level of injury, 135 prehospital observations Neurological system high-flow, 27 supplemental, 8 and care in, 154 physical examination of, 18 Oxygenation, management of, 36, 38 preinjury status and predis- in pregnancy, 231 Oxygen saturation, 38, 38t Neurosurgical consultation, for Oxyhemoglobin (HbO), 11 posing factors in, 154 patients with TBI, 104t, 106 Pacemaker, shock and, 58 in pediatric patients NEXUS. See National Emergency PPaaiCnOc2o, 2n3tr0otl, 19 X-Radiography Utilization Study for burn injuries, 178 blood loss in, 206 Nonfreezing injury, 182 for musculoskeletal trauma, fracture splinting, 206 Nonhemorrhagic shock, 47, 54 patient history for, 206 Obese patients 163–164 special considerations for initial assessment of, 13 Pancreatic injuries, 95, 202 transfer of, 244 Paraplegia, 135 immature skeleton, 206 Obturator nerve, 161t Parietal lobe, 106 peripheral nerve assessment, Occult skeletal injuries, 165 Parkland formula, 173 Occupational Safety and Health Partial airway obstruction, 26 161t Administration (OSHA), 6 Partial pressure of oxygen, 38, 38t, physical examination for Ocular trauma anatomy of, 257–258, 258f 121, 230t circulatory evaluation, 156 assessment of Partial-thickness burns, 176, 177f, feel, 155–156 goals of, 155 patient history for, 258 178 look and ask, 155 physical examination of, Particle radiation, 298 pitfalls of, 150, 152, 157, 161, 165 Patient arrival, 308 primary survey and resuscitation 258–260 Patient reevaluation, 19 for, 150–152 chemical burns, 261 Patient transfers to definitive care, adjuncts to, 152–153 open globes, 261–262 secondary survey for, 153–156 orbit fractures, 260–261 242 teamwork in, 165 retrobulbar hemorrhages, ABC-SBAR template for, 247, x-ray examination, 153, 156, 162f MVCs. See Motor vehicle crashes 260–261 247t Myocardial contractility, 44f, 45 Oculomotor nerve, 106 burn injuries and, 180–181 Myotomes, 132, 134, 134f Odontoid fractures, 137, 137f data for, 251 Narcotics Ohm’s law, 56 determining need for, 12, 19 for burn injuries, 178 Older adults. See also Geriatric patients documentation in, 249, 250f for pain control, 164 factors in, 242, 242f, 244 Nasopharyngeal airway, 30 hypothermia in, 265–266 information to transferring National Association of Emergency initial assessment of, 13 Medical Technicians’ Pre- osteopenia in, 78 personnel for, 249 hospital Trauma Life Support population growth of, 216 modes of transportation, 248– Committee, 4 shock and, 56–57 National Emergency X-Radiography ventilatory failure in, 26 249, 248b Utilization Study (NEXUS), 139, Online medical direction, 4 of pediatric patients, 247–248 140f Open fractures, 156–157, 157f, 158t pitfalls of, 245, 246, 248, 249 Neck, physical examination of, 16 Open globes, 261–262 rapid triage and transport Neck trauma, 25 Open pneumothorax, 66–67, 67f Needle cricothyroidotomy, 36, 36f Operational environments guidelines, 243t–244t Needle decompression, for tension ATLS in, 280–283 receiving doctor in, 248 pneumothorax, 66 challenges of, 278–279 referring doctor in, 246–248 Needle thoracostomy, 195 Oral airway, in pediatric patients, Nerve agents, 296–297, 297b 193 information from, 249 Nerve blocks, for pain control, 164 Orbit fractures, 260–261 spine injuries and, 144 Neurogenic shock, 44, 48, 134–135 Oropharyngeal airway, 31, 31f teamwork in, 251 Neurological examination Orotracheal intubation, 33, 193–194, timeliness of, 244–245 in hemorrhagic shock, 51 193f transfer protocols, 249–251 for primary survey, 10 OSHA. See Occupational Safety and transfer responsibilities, 246–248 in severe head trauma, 119–120 Health Administration treatment before transfer, 245–246 treatment during transport, 249, 251 ■ BACK TO TABLE OF CONTENTS

386 INDEX PEA. See Pulseless electrical activity hypothermia in, 266 Personal protective equipment PECARN. See Pediatric Emergency initial assessment of, 13 (PPE), 290b injury to Care Applied Research Network Physical examination (PECARN) criteria long-term effects of, 190 of abdomen, 17 PECs. See Preexisting conditions prevalence of, 188 for abdominal and pelvic Pediatric Emergency Care Applied prevention of, 208, 208b trauma, 87–88 Research Network (PECARN) types and patterns of, 188 of cervical spine, 16 criteria, 204f maltreatment of, 207–208 of chest, 16–17, 17 Pediatric patients musculoskeletal trauma in of eye, 258–260 abdominal trauma in, 200–202 blood loss in, 206 of head, 15–16 fracture splinting, 206 for hemorrhagic shock, 51 assessment of, 200 patient history for, 206 of maxillofacial structures, 16 CT scanning in, 200–201 special considerations for of musculoskeletal system, DPL for, 201 17–18 FAST for, 201 immature skeleton, 206 of neck, 16 nonoperative management needle and tube thoracostomy of neurological system, 18 of perineum, 17 of, 201–202 in, 195 of rectum, 17 visceral injuries, 202 normal vital functions in, 197t in secondary survey, 15–18 airway management, 190, pitfalls of, 190 of vagina, 17 192–194 spine injuries in, 136 anatomy and positioning Pia mater, 105, 106f, 107 anatomical differences, 205 Piperacillin, 158t for, 192–193, 192f radiological considerations Placenta, 228–229 cricothyroidotomy, 194 Placental abruption, 233, 234f oral airway, 193 for, 205–206 Pneumothorax orotracheal intubation, teamwork with, 208–209 transfer to definitive care for, open, 66–67 193–194, 193f simple, 72–73, 72f blood loss in, 196, 196t 247–248 tension, 48, 65–66, 65f, 67, 68t breathing and ventilation for, Pediatric Trauma Score, 188, 189t treatment of, 73 Pelvic cavity, 84–85 Poiseuille’s law, 52 195 Pelvic fractures, 17, 17f, 96f Pons, 106 burn injuries in, 173, 174f Posterior element fractures, 137 cardiopulmonary resuscitation in geriatric patients, 221–222 Posterior exam, of eye, 260 hemorrhagic shock and, 98, 98f Posterior tibial nerve, 161t in, 199 management of, 97–98, 97f PPE. See Personal protective characteristics of, 188–190 mechanism of injury and equipment Preexisting conditions (PECs), in psychological status, 189–190 classification, 96–97 geriatric patients, 216–217 size, shape, and surface area, pitfalls of, 98 Pregnant patients in pregnancy, 228–229 anatomical and physiological 189 Pelvic trauma. See Abdominal and skeleton, 189 pelvic trauma changes in, 228–231 chest trauma in, 199–200 Pelvis, physical examination of, 17 blood volume and compo- circulation and shock in, 195–199 Penetrating injuries fluid resuscitation and blood to abdomen and pelvis, 85 sition, 229 brain, 123–124 hemodynamics, 229–230 replacement for, 198– in geriatric patients, 217 assessment and treatment of, 199, 199f mechanisms of injury, 14t, 15 233–235 recognition of circulatory to neck, 16 blood pressure in, 230 compromise in, 195–196, in pregnant patients, 232, 232t blunt injury in, 232, 232f 195f to spine, 139 cardiac output in, 229–230 thermoregulation for, 199 Pericardiocentesis, 70 definitive care for, 235 urine output, 199 Perimortem cesarean section, 235 electrocardiographic changes venous access, 197–198, 197f Perineum, physical examination in, 230 weight and blood volume of, 17 gastrointestinal system changes determination, 197 Peripheral circulation, in circum- in, 231 equipment used for, 190, 191t ference extremity burns, 176–178 heart rate in, 230 head trauma in, 202–205 Permissive hypotension, 53 assessment of, 202–203 Personal disaster planning, 293 causes of, 202 management of, 203–205 hemodynamic changes in, 195f ■ BACK TO TABLE OF CONTENTS

387 INDEX immobilization for, 233f for fetus, 233–234 security and communication, initial assessment of, 13 in geriatric patients, 217–220 278–279 intimate partner violence and, for head trauma, 117–120 for musculoskeletal trauma, war wounds, 279 235 Respiratory rate, of children, 195 mechanisms of injury in, 231– 150–152 Respiratory system, in pregnancy, in pregnant patients, 233–234 232, 231t rapid triage and transport 230–231 musculoskeletal system changes Response, 290b guidelines, 243t Restraint devices, injuries from, 85f, in, 231 with simultaneous resuscitation, neurological system changes in, 86t 7–12 Resuscitation. See also Primary survey 231 for thoracic trauma, 64–71 penetrating injury in, 232 Pseudosubluxation, 205 area, 6 perimortem cesarean section in, Psychological status, of pediatric cardiopulmonary, in pediatric patients, 189–190 235 Psychosocial issues, in mass- patients, 199 primary survey and resuscitation casualty care, 278 in head trauma, 117–120 Pulmonary agents, 297 in musculoskeletal trauma, for, 233–234 Pulmonary contusion, 73–75 respiratory system changes in, Pulmonary system, effects of aging 150–152 on, 218t tape, for pediatric patients, 190, 230–231 Pulse, 9 Rh-negative, 235 Pulseless electrical activity (PEA), 192f secondary survey for, 234–235 11, 68 Retina, 257 severity of injury in, 232 Pulse oximetry, 11, 27, 38 Retrobulbar hemorrhages, 260–261 shock and, 57 carbon monoxide poisoning Retroperitoneal space, 84 teamwork with, 237–238 Rhabdomyolysis, 170 trauma in, 236t–237t and, 172 Rh immunoglobulin therapy, 235 urinary system changes in, 231 in head trauma, 117–118 Rib fractures, 78, 221 venous pressure in, 230 pitfalls of, 12f Riot control agents, 297 Prehospital phase, 4, 4f Pupils, 258–259 Rivaroxaban, 121t Prehospital Trauma Life Support Quadriplegia, 135 Rotational thromboelastometry (PHTLS), 4, 279–280 Quaternary survey, 281, 281f, Prehospital trauma scoring, 6 282–283 (ROTEM), 56 Preload, 44f, 45 Radial nerve, 161t Rule of nines, 175–176, 175f Preparedness, 290b Radiation threat scenarios, 298b SAR. See Search and rescue Pressure dressing, 151 Radioactive injuries and illnesses, Scalp Primary brain injury, 10 297–298, 298b Primary survey (ABCDEs), 4 Radiographic evaluation anatomy of, 104 adjuncts to, 10–12 of cervical spine, 139–141 wounds, 122, 123f of thoracic and lumbar spine, Scapular fractures, 78 arterial blood gases, 11 Sciatic nerve, 161t capnography, 11 141 SCIWORA. See Spinal cord injury diagnostic studies, 12 Rapid response, to fluid therapy, 54 without radiographic abnor- ECG monitoring, 10–11 Record keeping. See Documentation malities gastric catheters, 11, 12f Recovery, 290b Sclera, 257 pulse oximetry, 11 Rectum, physical examination of, 17 Screening IVP, 92 urinary catheters, 11 Red blood cells (RBCs), in pregnancy, Search and rescue (SAR), 290b, ventilatory rate, 11 293–294 x-ray examination, 12, 12f 229 Secondary brain injury, 104 airway maintenance with Reevaluation, in initial assessment, Secondary survey, 4 restriction of cervical spine adjuncts to, 18, 18f motion, 7–8, 8f 19 definition and process of, 13, 15 breathing and ventilation, 8 Regional nerve blocks, for pain for head trauma, 120 for burn injuries, 170–174 history in, 13, 15 circulation with hemorrhage control, 164 mechanisms of injury control, 8–9 Renal system, effects of aging on, disability (neurological evaluation), blunt injury, 14t, 15 10 218t hazardous environment, 15 exposure and environmental Resource-constrained environments, penetrating injury, 14t, 15 control, 10 thermal injury, 14f, 15 275 for mild brain injury, 115 challenges of, 278–279 ■ BACK TO TABLE OF CONTENTS

388 INDEX for musculoskeletal trauma, initial management of, 51–54 Soft-tissue injuries, fluid changes 153–156 overview of, 46–47 secondary to, 51 patient response, 53–54 physical examination physical examination for, Solid organ injuries, 95–96 abdomen, 17 Special populations, initial cervical spine, 16 51–52 chest, 16–17, 17 physiological classification assessment of, 13 head, 15–16 Spinal column, 130–131, 131f maxillofacial structures, 16 of, 49–50, 49t Spinal cord musculoskeletal system, hypothermia and, 57 17–18 hypovolemic, 9, 44 anatomy of, 131 neck, 16 initial assessment of injury classifications for neurological system, 18 perineum, 17 clinical differentiation of level, 135 rectum, 17 cause of, 46–48, 47f morphology, 136 vagina, 17 neurological deficit severity, recognition of, 45–46 in pregnant patients, 234–235 initial management of, 52 135 rapid triage and transport management of syndromes, 135–136 tracts, clinical assessment of, guidelines, 243t–244t first step in, 44 132t for thoracic trauma, 72–78 second step in, 44 Spinal cord injury without Security, in constrained environ- medications and, 57 radiographic abnormalities ments, 278–279 monitoring and, 58 (SCIWORA), 136, 205 Sedatives neurogenic, 44, 48, 134–135 Spinal nerve segments, 132, 132t brain injury and, 120 nonhemorrhagic, 54 Spinal shock, 134–135 for burn injuries, 178 overview of, 47 Spine injury for pain control, 164 pacemaker or implantable anatomy and physiology in, 131f Seidel test, 261 cardioverter-defibrillator dermatomes, 131–132 Seizures, posttraumatic, 122 and, 58 myotomes, 132, 134, 134f Seldinger technique, 36f, 70, 198 pathophysiology, 44–45 neurogenic shock vs. spinal Self-deployment, 277–278 blood loss pathophysiology, Sensory level of injury, 135 shock, 134–135 Septic shock, 48 45 spinal column, 130–131 Severe brain injury. See Traumatic cardiac physiology, 44–45 spinal cord, 131 brain injuries in pediatric patients, 195–199 blunt carotid and vertebral Shearing injuries, 85, 110 pregnancy and, 57 artery injuries, 139 Shock reassessment of patient cervical spine fractures, 136–137 advanced age and, 56–57 response, 58 atlanto-occipital dislocation, athletes and, 57 recognition of other problems avoiding complications, 58 and, 58 136 blood pressure considerations septic, 48 atlas (C1), 136, 137f special considerations for, 56–58 axis (C2), 137 for, 56 spinal, 134–135 C1 rotary subluxation, burn, 172–174 teamwork in, 58 cardiac tamponade, 47–48 tension pneumothorax, 48 136–137 cardiogenic, 47 vascular access in, 52 C3–C7 fractures and definition of, 44 Shoulder, joint dislocation diagnosis of, 50 deformities, 155t dislocations, 137 in geriatric patients, 219–220 Shoulder harness injury, 86t odontoid, 137, 137f hemorrhagic, 45 Simple pneumothorax, 72–73, 72f posterior element fractures, Skeletal injuries. See Musculoskeletal blood replacement for, 54– trauma 137 56, 55f Skin, effects of aging on, 218t classification of, 133f Skin perfusion, 9 complete, 131 confounding factors, 50–51 Skull, anatomy of, 104 effects on other organ systems continued, 58 Skull fractures, 109–110, 109t definition of, 48–49 depressed, 123 of, 135 hypothermia and, 57 Small bowel injuries, 85, 202 evaluation of, 130 initial fluid therapy for, Smoke inhalation injury, 172 guidelines for screening patients 52–54, 53t with suspected, 142b immobilization for, 130, 136, 139 incomplete, 131 level of, 135 lumbar fractures, 138 management of ■ BACK TO TABLE OF CONTENTS

389 INDEX intravenous fluids, 144 TBI. See Traumatic brain injuries screening for suspected injuries logrolling in, 143–144, 143f TCCC. See Tactical combat casualty to, 142b medications and, 144 patient transfer and, 144 care Thoracic trauma spinal motion restriction, Team leader, 20 airway problems, 64–65 blunt cardiac injury, 75 141, 143–144 briefing of trauma team by, 303t blunt esophageal rupture, 77 in pediatric patients, 136 checklist for, 303t breathing problems, 65–68 penetrating, 139 communication with patient’s cardiac tamponade, 69–70 pitfalls of, 134, 141 cause and development of, radiographic evaluation of family/friends by, 304–305, 69, 70f 305b, 305f diagnosis of, 69–70 cervical spine, 139–141 effective leadership by, 305–306, management of, 70 thoracic and lumbar spine, 141 306b circulation problems, 68–71 severity of neurological deficit roles and responsibilities of, crush injury to chest, 77–78 in, 135 302–305 flail chest, 73–75, 74f spinal cord team debriefing by, 304 hemothorax, 73 documentation of, 135–136 team direction and responding initial assessment of, 64 in pediatric patients, to information by, 304 life-threatening injuries, 64, Team members, roles and 64–77 205–206 responsibilities of, 306–308 massive hemothorax, 67–68, syndromes, 135–136 Teamwork, 20f 68–69 teamwork in, 144 in abdominal and pelvic trauma, cause and development of, thoracic spine fractures, 137–138 98 68, 69f thoracolumbar junction in airway management, 38–39 management of, 68–69 fractures, 138 with geriatric patients, 223 open pneumothorax, 66–67, 67f Spinothalamic tract, 132t in head trauma, 124 in pediatric patients, 200 Splints, 163, 164f, 206 in initial assessment, 19–20 primary survey for, 64–71 Stab wounds, 14t, 85, 86f, 93, 232t in musculoskeletal trauma, 165 rib fractures, 78 Standard precautions, 6, 6f in patient transfers, 251 scapular fractures, 78 Starling’s law, 45 with pediatric patients, 208–209 secondary survey for, 72–78 Sternum fractures, 78 with pregnant patients, 237–238 simple pneumothorax, 72–73, Stomach, decompression of, 52 shock and, 58 72f Stop the Bleed campaign, 283, 284f, in spine injury, 144 sternum fractures, 78 285 in thermal injuries, 183 subcutaneous emphysema, 77 Stroke volume, 44, 44f in thoracic trauma, 78 teamwork in, 78 Subcutaneous emphysema, 77 Tear gas, 297 tension pneumothorax, 65–66, Subdural hematomas, 111, 111f TEE. See Transesophageal echo- 65f Subtalar joint, joint dislocation cardiography tracheobronchial tree injury, deformities, 155t Tension pneumothorax, 48, 65–66, 64–65 Sucking chest wound. See Open 65f traumatic aortic disruption, pneumothorax vs. cardiac tamponade, 69 75–76 Superficial (first-degree) burns, 176 decompression for, 66, 66f traumatic circulatory arrest Superficial peroneal nerve, 161t differentiating from massive diagnosis of, 70 Superior gluteal nerve, 161t hemothorax, 68t management of, 70, 71f Supraglottic devices, 31, 32f pitfall of, 67 traumatic diaphragmatic injury, Surge capability, 290b signs and symptoms of, 66 76–77, 77f Surge capacity, 290b Tentorial hiatus, 106 Surgical airway, 36 Tetanus, 162 Thoracoabdomen, 84 Surgical cricothyroidotomy, 36, 37f Thermal burns, 14t, 15 Thoracolumbar junction fractures, Systemic hypothermia, 183, 265–269 Thermal injuries. See Burns; Cold Tachycardia, in shock, 46 injuries; Heat injuries 138 Tactical combat casualty care Thermoregulation, in pediatric Thoracoscopy, for abdominal and (TCCC), 279–280 patients, 199 Tactical evacuation care, 280 Thoracic spine, 130–131 pelvic trauma, 92 Tactical field care, 280 fractures, 137–138 Thoracoabdominal wounds, 93 Tar burns, 180 radiographic evaluation of, 141 Thoracostomy, 195 Tazobactam, 158t Thromboelastography (TEG), 56 Thromboembolic complications, 56 ■ BACK TO TABLE OF CONTENTS

390 INDEX Tibial fractures, 163 correction of anticoagu- earthquake and tsunami, Tourniquet, 151, 151f lation, 120–121 329–330 Toxidromes, 297b Tracheobronchial tree injury, 64–65 hypertonic saline, 122 mass shooting at shopping Tranexamic acid, 9 hyperventilation, 121 mall, 319–322 Transesophageal echocardiography intravenous fluids, 120 mannitol, 121–122 suicide bomber blast at (TEE), 76 mild, 112, 112t–113t, 114f, 115 political rally, 331–333 Transfer agreements, 6, 247 moderate, 112t–113t, 120 Transfers. See Patient transfers to neurological examination for, trailer home explosion and 119–120 fire, 323–324 definitive care neurosurgical consultation for, Transient response, to fluid therapy, 104t, 106 Tube thoracostomy, 195 in pediatric patients, 202–205 Type O blood, 55 54 pitfalls of, 115, 117, 119 UC. See Unified Command Transportation, in mass-casualty prognosis for, 124 Ulnar nerve, 161t secondary survey for, 120 Uncal herniation, 106–107, 107f care, 277 severe, 112t–113t Uncus, 106 Trauma centers, 6 surgical management Unified Command (UC), 290b Trauma Quality Improvement depressed skull fractures, Upper extremities Program (TQIP), 111 123 immobilization of injuries to, Trauma teams, 19–20, 20f intracranial mass lesions, 163 briefing of, 303t 123 peripheral nerve assessment of, characteristics of successful penetrating brain injuries, 161t ATLS, 302 123–124 Urethrography, for abdominal and configuration of, 301–302 scalp wounds, 122, 123f pelvic trauma, 92 conflict management in, 310–311 survivor impairments from, 104 criteria for activation of, 308t team member roles and respon- Urinary catheters, 11 culture and climate of, 306 sibilities, 306–308 in abdominal and pelvic trauma, debriefing of, 304 Traumatic circulatory arrest 88–89 delivering ATLS within, diagnosis of, 70 in hemorrhagic shock, 52 management of, 70, 71f 308–309 Traumatic diaphragmatic injury, Urinary system, in pregnancy, 231 effective communication by, 76–77, 77f Uterine rupture, 233 Treatment, consent for, 19 Uterus, in pregnancy, 228–229, 228f 309–310 Triage, 6 Vagina, physical examination of, 17 effective leadership of, 305–306, for brain injury, 104 Vaginal bleeding, 233, 235 definition of, 317 Vascular access 306b of disaster victims, 294–295 hand-over processes, 302–304 errors in, 294–295 establishment of, 9 leaders of, 302–305 evacuation, 294 in hemorrhagic shock, 52 record keeping by, 309 field medical, 294 Vascular clamps, 151 Traumatic amputation, 150–151 medical, 294 Vasopressors, 45 Traumatic aortic disruption, 75–76 pitfalls of, 295 Venous access, in pediatric patients, Traumatic asphyxia, 77 Field Triage Decision Scheme, 197–198, 197f Traumatic brain injuries (TBI) 4, 5f Venous pressure, in pregnancy, 230 anesthetics, analgesics, and in mass-casualty care, 6–7, 276– Ventilation 277, 276b bag-mask, 38 sedatives and, 120 for multiple casualties, 6 for burn injuries, 171–172 circulation and, 118–119 prehospital, 6 for geriatric patients, 219 diagnostic procedures, 120 principles of, 317–319 in head trauma, 117–118 evidence-based treatment rapid, and transport guidelines, management of, 38 243t–244t objective signs of inadequate, guidelines, 111–112 scenarios in geriatric patients, 220, 221 bus crash, 327–328 26–27 hand-over processes, 304b cold injury, 325–326 for pediatric patients, 195 management of, 112t–113t for primary survey, 8 problem recognition, 26 moderate injuries, 116–117, trauma teams and, 308–309 117f Ventilatory rate, 11 Ventricular system, 106 severe injuries, 117, 118b, 118f Verbal responses, 24 medical therapies for Vertebral artery injury, 139 anticonvulsants, 122 barbiturates, 122 ■ BACK TO TABLE OF CONTENTS

391 INDEX Vertical displacement, of sacroiliac Warm zone, 295 gunshot, 14t, 85, 93, 231t, 232t joint, 96–97, 96f War wounds, 279 scalp, 122, 123f WBC. See White blood cell (WBC) stab, 14t, 85, 86f, 93, 232t Vertical shearing, 96–97, 96f tetanus risk and, 162 Vesicant agents, 297 count war, 279 Vision exam, 258 Weapons of mass destruction X-ray examinations, 12, 12f Visual acuity tests, 15–16 for abdominal trauma, 89 Vital functions, assessment of, 7 (WMDs), 290b, 291 for musculoskeletal trauma, 153, Vitreous humor, 257 White blood cell (WBC) count, in Volume–pressure curve, 107f 156, 162f Vomiting pregnancy, 229, 230t Zero survey, 281–282, 281f WMDs. See Weapons of mass aspiration after, 25 management of, 25 destruction Wound care, in burn injuries, 178 Wounds ■ BACK TO TABLE OF CONTENTS

TRAUMA SCORES Correct triage is essential to the effective functioning six measures including the child’s weight, SBP, level of of regional trauma systems. Over-triage can consciousness, presence of fracture, presence of open inundate trauma centers with minimally injured wound, and state of the airway. The score correlates patients and delay care for severely injured patients, and with injury severity, mortality, resource utilization, under-triage can produce inadequate initial care and and need for transport to a pediatric trauma center. cause preventable morbidity and mortality. In fact the The PTS serves as a simple checklist, ensuring that all National Study on the Costs and Outcomes of Trauma components critical to initial assessment of the injured (NSCOT) found a relative risk reduction of 25% when child have been considered. It is useful for paramedics severely injured adult patients received their care at a in the field as well as doctors in facilities other than Level I trauma center rather than a nontrauma center. pediatric trauma units. All injured children with a PTS of less than 8 should be triaged to an appropriate pediatric Unfortunately, the perfect triage tool does not exist. trauma center because they have the highest potential For this reason, most experts now advocate using for preventable mortality, morbidity, and disability. the “Guidelines for Field Triage of Injured Patients: According to National Pediatric Trauma Registry Recommendations of the National Expert Panel on statistics, this group represents approximately 25% Field Triage, 2011” in lieu of trauma scores per se. A of all pediatric trauma victims and clearly requires the recent review of the sensitivity and specificity of these most aggressive monitoring and observation. Studies guidelines found the sensitivity to be 66.2% and the comparing the PTS with the RTS have identified similar specificity to be 87.3% for an injury severity score of performances of both scores in predicting potential greater than 16; sensitivity was 80.1% and specificity for mortality. Unfortunately, the RTS produces what was 87.3% for early critical resource use. The sensitivity most experts believe to be unacceptable levels of decreased as a function of age. under-triage, which is an inadequate trade-off for its greater simplicity. However, because many emergency medical services (EMS) systems still rely on trauma scores and scales Traumatic injuries can be classified using an as tools for field triage, some of the most commonly Abbreviated Injury Severity (AIS) score. The scale was used are described here. None of these are universally first published in 1971 and graded the severity of tissue accepted as completely effective triage tools. The injury associated with automotive trauma. It is now Glasgow Coma Score (GCS) is used worldwide to rapidly widely used to grade injuries related to all types of assess the level of consciousness of the trauma patient blunt and penetrating trauma. The scale ranges from (see Table 6-2 in Student Manual Chapter 6). Many 1 (minor) to 6 (unsurvivable). It is the basis of Injury studies have demonstrated a good correlation between Severity Score (ISS). This score was first proposed in GCS and neurological outcome. The motor response 1974 and is derived from the sum of the squares of contributes the greatest to the discriminatory power highest three scores in six body regions (head and of the score. neck, face, chest, abdomen, limbs, and external). Scores range from a minimum of 1 to a maximum of 75 (when The Trauma Score (TS) calculation is based on five a score of 6 is given in any area, a score of 75 is assigned variables: GCS, respiratory rate (RR), respiratory effort, regardless of other injuries). Mortality increases systolic blood pressure (SBP), and capillary refill. Values with injury severity. A score of less than 15 generally range from 16 to 1 and are derived by adding the scores indicates mild injury. ISS tends to underestimate injury assigned to each value. This system was revised in in penetrating trauma because injuries in the same body 1989 based on the analysis of 2000 cases. The Revised region are not accounted for. The New Injury Severity Trauma Score (RTS) is calculated based on values (0–4) Score (NISS) was developed to address this issue. assigned to three variables: GCS, SBP, and RR. These The sum of the squares of the most severely injured values are assigned a weight and then the score is areas, disregarding body region, is used to improve calculated; it varies between 0 and 7.8408. Higher score sensitivity. scores are associated with higher probability of survival. Similarly to pediatrics, previously described tools The Pediatric Trauma Score (PTS) was developed to may not accurately predict the impact of injury in the address concerns that RTS may not apply directly to the pediatric population. This score is based on the sum of ■ BACK TO TABLE OF CONTENTS 392

393 TRAUMA SCORES geriatric patient. The Geriatric Trauma Outcome Score table x-1 tash score calculation (GTOS) was developed to address this concern. It is based on three a priori variables: age, ISS, and 24-hour VARIABLE RESULT SCORE transfusion requirement. GTO = Age + (2.5 × ISS) + 22 (if any pRBCs are transfused in the first 24 hours after Gender Male 1 injury). A nomogram correlating GTOS to probability of mortality was created. Female 0 Timely initiation of massive transfusion protocols Hemoglobin < 7 g/dL 8 has been shown to impact survival and decrease waste of blood products. Precise approaches to implement < 9 g/dL 6 this strategy have, however, not been defined. Several scoring systems have been developed to aid the clinician < 10 g/dL 4 in making this difficult decision. To be useful, the score must be easily calculated and based on data available < 11 g/dL 3 either immediately or shortly after patient admission to the emergency department. The simplest is the ABC < 12 g/dL 2 score. It requires four data points: penetrating trauma mechanism, SBP < 90 mm Hg, HR > 120 bpm, and ≥ 12 g/dL 0 positive FAST. Each variable receives a score of 1 if present, for a maximum score of 4. The need for massive Base excess < –10 mmol/L 4 transfusion is defined by a score of 2 or greater. < –6 mmol/L 3 The Trauma Associated Severe Hemorrhage (TASH) Score is more complex. It is calculated from < –3 mmol/L 1 seven variables: SBP, hemoglobin, FAST, presence of long-bone or pelvic fracture, HR, base excess ≥ –2 mmol/L 0 (BE), and gender. The variables are weighted and the score is calculated by adding the components. Systolic blood < 100 mm Hg 4 (■ TABLE X-1) A 50% probability of need for massive pressure < 120 mm Hg 1 transfusion was predicted by a score of 16, and a score of greater than 27 was 100% predictive of the need for ≥ 120 mm Hg 0 massive transfusion. Heart rate > 120 2 The McLaughlin score uses four variables to predict the need for massive transfusion: HR > 105, SBP ≤ 120 0 >110 mm Hg, PH < 7.25, and hematocrit < 32%. Each variable present indicates a 20% incidence of massive Positive FAST Yes 3 transfusion. When all four variables are present, an 80% likelihood of the need for massive transfusion No 0 was present. bibliography 1. Centers for Disease Control and Prevention. Unstable pelvis Yes 6 Guidelines for Field Triage of Injured Patients: fracture No 0 Recommendations of the National Expert Yes 3 Panel on Field Triage, 2011. http://www.cdc. Open or dislocated No 0 gov/mmwr/preview/mmwrhtml/rr6101a1.htm. femur fracture Accessed April 18, 2017. Data from: Holcomb JB, Tilley BC, Baraniuk S, Fox EE, et al. Transfusion 2. Cotton BA, Dossett LA, Haut ER, et al. Multicenter validation of a simplified score to predict of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and massive transfusion in trauma. J Trauma 2010 July;69(1):S33–S39. mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015 Feb 3;313(5):471-482. 3. Guidelines for field triage of injured patients: recommendations of the National Expert Panel ■ BACK TO TABLE OF CONTENTS

394 TRAUMA SCORES in combat casualty patients. J Trauma on Field Triage, 2011. Morbidity and Mortality 2008;64:S57–S63. Weekly Report 2012;61:1–21. 7. Newgard CD, Zive D, Holmes JF, et al. Prospective Validation of the National Field Triage Guidelines 4. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, et al. for Identifying Seriously Injured Persons. J Am Transfusion of plasma, platelets, and red blood Coll Surg 2016 Feb;222(2):146–158. cells in a 1:1:1 vs a 1:1:2 ratio and mortality in 8. Yücel N, Lefering R, Maegele M, et al. Polytrauma patients with severe trauma: the PROPPR Study Group of the German Trauma Society. randomized clinical trial. JAMA 2015 Feb Trauma Associated Severe Hemorrhage 3;313(5):471–482. (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage 5. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. after multiple trauma. J Trauma 2006 A national evaluation of the effect of trauma- Jun;60(6):1228–1236; discussion 1236-7. PubMed center care on mortality. N Engl J Med 2006 Jan PID: 16766965. 26; 354(4):366–378. 6. McLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion ■ BACK TO TABLE OF CONTENTS

INJURY PREVENTION Injury should not be considered an accident, because the trauma incident completely. Examples of primary that term implies a random circumstance resulting prevention measures include stoplights at intersections, in harm. In fact, injuries occur in patterns that window guards to prevent toddlers from falling, fences are predictable and preventable. The expression “an around swimming pools that keep out nonswimmers accident waiting to happen” is both paradoxical and to prevent drowning, DUI laws, and safety caps on premonitory. There are high-risk behaviors, individuals, medicines to prevent ingestion. and environments. In combination, they provide a chain of events that can result in traumatic injury. Secondary prevention recognizes that an injury may With the changing perspective in today’s health care occur but serves to reduce the severity of the injury from managing illness to promoting wellness, injury sustained. Examples of secondary prevention include prevention moves beyond promoting good health to take safety belts, air bags, motorcycle and bicycle helmets, on the added dimension of reducing healthcare costs. and playground safety surfaces. Prevention is timely. Doctors who care for injured Tertiary prevention involves reducing the individuals have a unique opportunity to practice effect- consequences of the injury after it has occurred. Trauma ive, preventive medicine. Although the true risk takers systems, including the coordination of emergency may be recalcitrant about considering any and all prevent- medical services, identification of trauma centers, ion messages, many people who are injured through and integration of rehabilitation services to reduce ignorance, carelessness, or temporary loss of self-control impairment, are efforts to achieve tertiary prevention. may be receptive to information that is likely to reduce their future vulnerability. Each doctor–patient encounter haddon matrix is an opportunity to reduce traumatic injury or recidivism. This is especially true for surgeons and physicians who In the early 1970s, William Haddon described a useful are involved daily during the period immediately after approach to primary and secondary injury prevention injury, when there may be opportunities to truly change that is now known as the Haddon matrix. According behavior. This document covers basic concepts of to Haddon’s conceptual framework, injury occurrence injury prevention and strategies for implementing them involves three principal factors: the injured person through traditional public health methods. (host), the injury mechanism (e.g., vehicle, gun), and the environment where the injury occurs. There are classification of also three phases during which injury and its severity injury prevention can be modified: the pre-event phase, the event phase (injury), and the post-event phase. ■ TABLE 1 outlines Prevention can be considered as primary, secondary, how the matrix serves to identify opportunities for or tertiary. Primary prevention refers to elimination of injury prevention and can be extrapolated to address other injury causes. The National Highway Traffic table 1 haddon’s factor-phase matrix for motor vehicle crash prevention Host PRE-EVENT EVENT POST-EVENT Avoidance of alcohol use Use of safety belts Care delivered by bystander Vehicle Antilock brakes Deployment of air bag Assessment of vehicle characteristics that may have contributed to event Environment Speed limits Impact-absorbing barriers Access to trauma system ■ BACK TO TABLE OF CONTENTS 395

396 INJURY PREVENTION Safety Administration adopted this design, which Engineering, often more expensive at first, clearly resulted in a sustained reduction in the fatality rate has the greatest long-term benefits. Despite proven per vehicle mile driven over the past several decades. effectiveness, engineering advances may require concomitant legislative and enforcement initiatives, the four es of enabling implementation on a larger scale. Adoption injury prevention of air bags is a recent example of using advances in technology and combining them with features of Injury prevention can be directed at human factors enforcement. Other advances in highway design and (behavioral issues), vectors of injury, and/or safety have added tremendously to the margin of safety environmental factors and implemented according while driving. to the four Es of injury prevention Economic incentives, when used for the correct • Education purposes, are quite effective. For example, the linking • Enforcement of federal highway funds to the passage of motorcycle • Engineering helmet laws motivated the states to pass such laws • Economics (incentives) and enforce the wearing of helmets. This resulted Education is the cornerstone of injury prevention. in a 30% reduction in fatalities from head injuries. Educational efforts are relatively simple to implement; Although this economic incentive is no longer in effect, they promote the development of constituencies and rates of deaths from head injuries have returned and help bring issues before the public. Without an to their previous levels in states that have reversed informed and activist public, subsequent legislative their helmet statutes, the association between helmet efforts (enforcement) are likely to fail. Education laws and reduced fatalities confirmed the utility of is based on the premise that knowledge supports a economic incentives in injury prevention. Insurance change in behavior. Although attractive in theory, companies have clear data on risk-taking behavior education in injury prevention has been disappointing patterns, and the payments from insurance trusts; in practice. Yet it provides the underpinning for discount premiums are available to those who avoid implementation of subsequent strategies, such risk-taking behavior. as that to reduce alcohol-related crash deaths. Mothers Against Drunk Driving is an organization developing an injury that effectively uses a primary education strategy to prevention program—the reduce alcohol-related crash deaths. Through their public he alth approach efforts, an informed and aroused public facilitated the enactment of stricter drunk-driving laws, resulting in Developing an injury prevention program involves a decade of reduced alcohol-related vehicle fatalities. five basic steps: Analyze the data, Build local coali- For education to work, it must be directed at the tions, Communicate the problem, Develop and appropriate target group, it must be persistent, and implement injury prevention activities, and Evaluate it must be linked to other approaches. More recent the intervention. examples are campaigns to prevent distracted driving through legislation outlawing the use of smartphones analyze the data while driving. Enforcement is a useful part of any effective injury- The first step is a basic one: define the problem. This prevention strategy because, regardless of the type of may appear self-evident, but both the magnitude and trauma, some individuals always resist the changes community impact of trauma can be elusive unless needed to improve outcome—even if the improved reliable data are available. Population-based data on outcome is their own. Where compliance with injury injury incidence are essential to identify the problem prevention efforts is lacking, legislation that mandates and form a baseline for determining the impact of certain behavior or declares certain behaviors illegal subsequent efforts at injury prevention. Information often results in marked differences. For example, from death certificates, hospital and/or emergency safety-belt and helmet laws resulted in measurable department discharge statistics, and trauma registry increases in usage when educational programs alone data and dashboards are, collectively, good places had minimal effect. to start. After identifying a trauma problem, researchers must define its causes and risk factors. The problem may need ■ BACK TO TABLE OF CONTENTS

397 INJURY PREVENTION to be studied to determine what kinds of injuries are accepted. End points must be defined up front, and involved and where, when, and why they occur. Injury- outcomes reviewed without bias. Sometimes it is not prevention strategies may begin to emerge with this possible to determine the effectiveness of a test program, additional information. Some trauma problems vary especially if it is a small-scale trial intervention. For from community to community; however, certain risk example, a public information program on safety-belt factors are likely to remain constant across situations use conducted at a school can be assessed by monitoring and socioeconomic boundaries. Abuse of alcohol and the incoming and outgoing school traffic and showing other drugs is an example of a contributing factor a difference, even when safety-belt usage rates in the that is likely to be pervasive regardless of whether the community as a whole may not change. Nonetheless, trauma is blunt or penetrating, whether the location is the implication is clear—broad implementation of the inner city or the suburbs, and whether fatality or public education regarding safety-belt use can have a disability occurs. Data are most meaningful when the beneficial effect in a controlled community population. injury problem is compared between populations with Telephone surveys are not reliable measures to confirm and without defined risk factors. In many instances, behavioral change, but they can confirm that the the injured people may have multiple risk factors, and intervention reached the target group. clearly defined populations may be difficult to sort out. In such cases, it is necessary to control for the With confirmation that a given intervention can effect confounding variables. favorable change, the next step is to implement injury- prevention strategies. From this point, the possibilities build local coalitions are vast. Strong community coalitions are required to change the evaluate the impact of an perception of a problem and to design strategies that intervention are likely to succeed in an individual community. What works in one community may not work in another, and With implementation comes the need to monitor the the most effective strategy will fail if the community impact of the program or evaluation. An effective targeted for intervention does not perceive the problem injury-prevention program linked with an objective as important. means to define its effectiveness can be a powerful message to the public, the press, and legislators. It communicate the problem ultimately may bring about a change in injury rates or a permanent change in behavior. Although sentinel events in a community may identify an individual trauma problem and raise Injury prevention seems like an immense task, and public concern, high-profile problems do not lend in many ways it is. Yet, it is important to remember themselves to effective injury prevention unless they that a pediatrician in Tennessee was able to validate are part of a larger documented injury-control issue/ the need for infant safety seats, and that work led to injury-prevention strategy. Local coalitions are an the first law requiring use of infant safety seats. A New essential part of any communication strategy—not only York orthopedic surgeon gave testimony that played in getting the word out, but in designing the message an important role in achieving the first safety-belt that is most likely to be effective. Members of the media law in the United States. Although not all healthcare are also key partners in any communication plan. providers are destined to make as significant an impact, they can influence their patients’ behaviors. Injury- develop and implement prevention prevention measures do not have to be implemented activities on a grand scale to make a difference. Individual healthcare providers may not be able to statistically The next step is to develop and test interventions. This is prove a difference in their own patient population, but if the time to review best practices, and if there are none, all doctors and other healthcare providers make injury it may be appropriate to develop pilot programs to test prevention a part of their practice, the results will be intervention effectiveness. Rarely is an intervention significant. As preparations for hospital or emergency tested without some indication that it will work. It department discharge are being made, consideration is important to consider the views and values of the should be given to patient education and community community if an injury prevention program is to be partner referral to prevent injury recurrence. Whether it is alcohol abuse, returning to an unchanged hostile home environment, riding a motorcycle without wearing head protection, or smoking while refueling the car, there are many opportunities for healthcare ■ BACK TO TABLE OF CONTENTS