Advanced Trauma Life Support

Advanced Trauma Life
Support®
Course
Overview
Program Goals
• Rapid and accurate assessment
• Resuscitate and stabilize by priority
• Determine needs and capabilities
• Arrange for transfer to definitive care
• Ensure optimum care

Course Objectives
• Demonstrate concepts and principles of

primary and secondary assessments.
• Establish management priorities.
• Initiate primary and secondary

management.
• Demonstrate the skills necessary to assess

and manage critically injured patients.
The Need
• Trauma is the leading cause of death in the first

four decades of life in developed countries.
• There are more than 5 million trauma-related
deaths each year worldwide.
• Motor vehicle crashes cause over 1 million deaths
per year.
• Injury accounts for 12% of the world’s burden of
disease.
The Need
ATLS
provides a
common
language
The Beginning
The Beginning
“When I can provide better care in the field

with limited resources than what my
children and I received at the primary care
facility  there is something wrong with
the system, and the system has to be
changed.”
James Styner, MD, FACS
1977
Trimodal Death Distribution
ATLS Concept
• ABCDE approach to evaluation and

treatment
• Treat greatest threat to life first
• Definitive diagnosis not immediately
important
• Time is of the essence
• Do no further harm
ATLS Concept
Airway with c-spine protection

Breathing and ventilation
Circulation with hemorrhage control
Disability: Neuro status
Exposure / Environmental control

Initial Assessment / Management
ATLS Educational Format
• Interactive lectures and skills sessions

• Demonstrations
• Group discussions
• Simulated patient scenarios
• Written exams
• Online component
International ATLS Program
• More than 60 countries

• Over 1 million providers trained
Impact of ATLS Program
• Documented improvements in care of

injured patients after implementation of
program
• Organized trauma care reduces injury
mortality
• Retention of organizational and
procedural skills.
Questions?
Summary
• ABCDE approach to trauma care

• Do no further harm
• Treat the greatest threat to life first
• One safe way
• A common language
Initial
Assessment
and
Management
Initial Assessment and Management
Chapter Statement
The primary survey should be

repeated frequently to identify any
deterioration in the patient's status
that indicates the need for
additional intervention.
Case Scenario
● 44-year-old male driver who

crashed head-on into a wall
● Patient found unresponsive
at the scene
● Arrives at hospital via basic
life support with c-collar in
place and strapped to a
backboard; technicians
assisting ventilations with
bag-mask
Case Scenario
What is the sequence of priorities

in assessing this patient?
1. Do you need to identify the specific

injuries before initial management of this
patient?
2. If not, how do you proceed?

Objectives
1. Identify the correct sequence of priorities for assessment

of a multiply injured patient.
2. Apply the principles outlined in the primary and secondary
surveys to the assessment of a multiply injured patient.
3. Explain how a patient’s medical history and the mechanism
of injury contribute to the identification of injuries.
4. Identify the pitfalls associated with the initial assessment
and management of an injured patient and describe steps
to minimize their impact.
5. Recognize patients who will require transfer for definitive
management.
Standard Precautions
● Cap
● Gown
● Gloves
● Mask
● Shoe covers
● Protective eyewear /
face shield
Initial Assessment
Primary survey and

resuscitation of vital
functions are done
simultaneously using
a team approach.
Concepts of Initial Assessment
Quick Assessment
What is a quick, simple way to

assess a patient in 10 seconds?
Quick Assessment
What is a quick, simple way to

assess a patient in 10 seconds?
•Ask the patient his or her name
•Ask the patient what happened

Appropriate Response Confirms
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion
D Clear sensorium
Primary Survey
Airway with c-spine protection

Breathing and ventilation
Circulation with hemorrhage control
Disability: Neuro status
Exposure / Environmental control
Primary Survey
The priorities are the same

for all patients.
Special Populations
● Elderly ● Obese
● Infants and Children ● Athletes
● Pregnant Women
Primary Survey
Airway
● Occult airway injury

Establish patent ● Progressive loss of airway
● Equipment failure
airway and ● Inability to intubate
protect c-spine
Primary Survey
Breathing and Ventilation
● Respiratory rate
Assess and
ensure adequate ● Chest movement
oxygenation and ● Air entry
ventilation
● Oxygen saturation
Primary Survey
Breathing and Ventilation
Airway versus ventilation

problem?
Iatrogenic pneumothorax or
tension pneumothorax?
Primary Survey
Circulation
(including hemorrhage control)
Assess for organ ● Level of consciousness

perfusion ● Skin color and
temperature
● Pulse rate and character
Primary Survey
Circulatory Management
● Control hemorrhage ● Elderly

● Restore volume ● Children
● Athletes
● Reassess patient
● Medications
Primary Survey
Disability
● Baseline neurologic
evaluation
Observe for
● Glasgow Coma neurologic
Scale score deterioration
● Pupillary response
Primary Survey
Exposure / Environment
Completely undress
the patient
Prevent hypothermia
Missed injuries
Resuscitation
• Protect and secure airway
• Ventilate and oxygenate
• Stop the bleeding!
• Crystalloid / blood resuscitation
• Protect from hypothermia

Adjuncts to Primary Survey
Vital signs
ECG ABGs
PRIMARY SURVEY
Pulse
Urinary oximeter
output and CO2
Urinary / gastric catheters
unless contraindicated
Diagnostic Tools
Diagnostic Tools
• FAST
• DPL
Consider Early Transfer
• Use time before

transfer for
resuscitation
• Do not delay
transfer for
diagnostic tests
Secondary Survey
What is the
secondary survey?
The complete
history and
physical
examination
Secondary Survey
When do I start the secondary survey?
After
● Primary survey is completed

● ABCDEs are reassessed
● Vital functions are returning
to normal
Secondary Survey
Components of the secondary survey
• History
• Physical exam: Head to toe
• Complete neurologic exam
• Special diagnostic tests
• Reevaluation
Secondary Survey
History
Allergies
Medications
Past illnesses / Pregnancy
Last meal
Events / Environment / Mechanism
Secondary Survey
Mechanisms of Injury
Secondary Survey
Head
● External exam
● Scalp palpation ● Unconsciousness
● Comprehensive eye ● Periorbital edema
and ear exam ● Occluded auditory

canal
● Include visual acuity
Secondary Survey
Maxillofacial
●Bony crepitus ● Potential airway

obstruction
●Deformity ● Cribriform plate
fracture
●Malocclusion ● Frequently missed
Secondary Survey
Neck (Soft Tissues)

Mechanism: Blunt versus penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor, bruit
●Delayed
signs and
symptoms
●Progressive airway
obstruction
●Occult injuries
Secondary Survey
Chest
● Inspect
● Palpate
● Percuss
● Auscultate
● X-rays
Secondary Survey
Abdomen
● Inspect /
Auscultate
● Palpate / Percuss Hollow viscus injury
Retroperitoneal injury
● Reevaluate
● Special studies
Secondary Survey
Perineum
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture,
rectal wall integrity, blood
Vagina
Blood, lacerations Urethral injury
Pregnancy
Secondary Survey
Pelvis
● Pain on palpation
● Leg length unequal
● Instability
● X-rays as needed
Excessive pelvic manipulation

Underestimating pelvic blood loss
Secondary Survey
Extremities
● Contusion, deformity
● Pain
● Perfusion
● Peripheral
neurovascular status
● X-rays as needed
Secondary Survey
Musculoskeletal System
• Potential blood loss

• Missed fractures
• Soft tissue or ligamentous injury
• Compartment syndrome
Secondary Survey
Neurologic: Brain
● GCS
● Pupil size and reaction
● Lateralizing signs
● Frequent reevaluation
● Prevent secondary
brain injury Early neurological consult
Secondary Survey
Neurologic: Spinal Assessment
● Whole spine
● Tenderness and
swelling
•Altered sensorium
● Complete motor •Inabilityto cooperate with
and sensory exams clinical exam
● Reflexes
● Imaging studies
Secondary Survey
Neurologic: Spine and Spinal Cord
Conduct an in-depth
evaluation of the
patient’s spine and
spinal cord
Early neurological /
orthopedic consult
Secondary Survey
Neurologic
•Incomplete immobilization
•Neurologic deterioration
Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
•Patient deterioration
•Delay of transfer
•Deterioration during
transfer
•Poor communication
How do I minimize missed injuries?
● High index of
suspicion
● Frequent
reevaluation and
monitoring
Pain Management
● Relief of pain /
anxiety as
appropriate
● Administer
intravenously
● Careful monitoring
is essential
Transfer
Which patients do I transfer to a

higher level of care?
Transfer to Definitive Care
Which patients do I transfer to a

higher level of care?
Those whose injuries exceed institutional

capabilities:
●Multisystem or complex injuries

●Patients with comorbidity or age
extremes
When should the transfer occur?

When should the transfer occur?
As soon as possible after stabilizing measures are

completed:
●Airway and ventilatory control

●Hemorrhage control (operation)
Local Facility
Transfer Agreements
Local Resources
Trauma Center Specialty Facility

Case Scenario
● 44-year-old male driver

who crashed head-on into
a wall
● Patient found
unresponsive at the
scene
● Arrives at hospital via
basic life support with c-
collar in place and
strapped to a backboard;
technicians assisting
ventilations with bag-
mask
Questions?
Summary
Airway
and
Ventilatory
Management
Chapter Statement
Prevention of hypoxemia requires a

protected, unobstructed airway and
adequate ventilation, which take
priority over management of all
other conditions.
Case Scenario
● 34-year-old motorcyclist
lost control and crashed
into a fence
● Obvious facial trauma
● No helmet
● Smells of alcohol
● Belligerent at scene; now
not communicating
● Pulse oximeter 85%
Objectives
1. Define definitive airway.

2. Recognize the signs and symptoms of
airway obstruction and ventilatory
compromise.
3. Describe the techniques for
establishing and maintaining a patent
airway.
4. Describe techniques for confirming the
adequacy of ventilation and
oxygenation.
Airway Assessment
How do I know the airway

is adequate?
Airway Assessment
How do I know the airway

is adequate?
• Patient is alert and oriented.
• Patient is talking normally.
• There is no evidence of injury to the

head or neck.
• You have assessed and reassessed for

deterioration.
Airway Assessment
Signs and symptoms of airway

compromise
• High index of suspicion
• Change in voice / sore throat
• Noisy breathing (snoring and stridor)
• Dyspnea and agitation
• Tachypnea
• Abnormal breathing pattern
• Low oxygen saturation (late sign)
Airway Assessment
When to intervene in a
patient with a patent airway
• Impending airway compromise
(Airway problem)
• Need for ventilation

(Breathing problem)
• Inability to protect the airway

(Disability problem)
Airway Management
How do I manage the airway

of a trauma patient?
Airway Management
How do I manage the airway

of a trauma patient?
• Supplemental oxygen
• Basic techniques
• Basic adjuncts
• Definitive airway
• Cuffed tube in the trachea
• Difficult airway adjuncts

• Unexpected difficult airway
• Predicted difficult airway
Airway Management
Protect the cervical spine during airway

management!
Airway Management
Basic Techniques
Chin-lift Maneuver
Airway Management
Basic Techniques
Jaw-thrust Maneuver
Airway Management
Basic Adjuncts
Oropharyngeal airway
● Patients who can tolerate an oral airway will usually need
intubation
Nasopharyngeal airway
● Often well tolerated
Avoid in patients with

mid-face fractures
Airway Management
How do I predict a potentially

difficult airway?
Airway Management
How do I predict a potentially

difficult airway?
• Maxillofacial trauma and deformity
• Mouth opening
• Anatomy
• Beard
• Short, thick neck
• Receding jaw
• Protruding upper teeth
Airway Management
Is this a difficult airway?

How would you manage this patient?
Airway Management
A definitive airway is a tube placed

in the trachea with the cuff inflated
below the vocal cords, the tube
connected to some form of oxygen-
enriched assisted ventilation, and
the airway secured in place with
tape.
Airway Management
Definitive Airway - Easy

• Oral intubation (medication assisted)
• BURP, suction back-up
• Maintain c-spine immobilization
Anticipate difficult airway

Airway Management
Is this a difficult airway?

How would you manage this patient?
Airway Management
Definitive Airway - Difficult
• Get help • Consider use of:

• Be prepared • Gum elastic
bougie
• Rapid sequence vs.
• Combitube
awake intubation
• (Intubating) LMA
• Maintain c-spine
immobilization • Surgical airway
• Other advanced
techniques
Airway Management
Definitive Airway
Surgical airway
● Cricothyroidotomy
Needle Surgical
Airway Confirmation
How do I know the tube is in

the right place?
Airway Confirmation
How do I know the tube is in

the right place?
• Visualize it going through
the cords
• Watch the chest
• Auscultation
• CO2 detector / ETCO2
monitor
• Pulse oximeter
• X-ray
Case Scenario
● 34-year-old motorcyclist
lost control and crashed
into a fence
● Obvious facial trauma
● No helmet
● Smells of alcohol
● Belligerent at scene;
now not communicating
● Pulse oximeter 85%
Questions?
Summary
● Suspect airway compromise in all injured

patients and protect the cervical spine
● Be prepared for easy and difficult airway
● Consider adjuncts for establishing a patent
airway
● Definitive airway is a cuffed tube in the trachea
● Quickly assess the patency and adequacy of
ventilation using a pulse oximeter and end-
tidal CO2
Shock

Chapter Statement
The diagnosis of shock is based on

clinical recognition of the presence
of inadequate tissue perfusion and
oxygenation; the first step in the
initial management of shock is to
recognize its presence.
Case Scenario
● 28-year-old female in
MVC
● Patient was
unrestrained
● Pulse: 126; BP:
96/70; RR: 28
● Confused and
anxious
Objectives
1. Define and recognize shock and correlate a

patient’s acute clinical signs with the degree of
volume deficit.
2. Explain the importance of early identification and
control of the source of hemorrhage.
3. Describe the initial and ongoing management of
hemorrhagic shock.
4. Recognize the physiologic responses to fluid
resuscitation and assess for complications.
5. Explain the role of blood replacement.
6. Describe the special considerations in the
diagnosis and treatment of shock.
Definition of Shock
What is shock?
Definition of Shock
What is shock?
Shock is an abnormality of the circulatory

system that results in inadequate organ
perfusion and tissue oxygenation.
Definition of Shock
Generalized State of Hypoperfusion
• Inadequate oxygen delivery

• Catecholamines and other responses
• Anaerobic metabolism
• Cellular dysfunction
• Cell death
Recognition of Shock
Is the patient in shock?

Recognition of Shock
Is the patient in shock?

• Alteration in level of consciousness, anxiety
• Cold, diaphoretic skin
• Tachycardia
• Tachypnea, shallow respirations
• Hypotension
• Decreased urinary output
Cause of Shock
What is the cause of shock?

Cause of Shock
Hypovolemic vs Nonhemorrhagic
● Blood loss ● Tension
● Fluid loss pneumothorax
● Cardiac tamponade
● Cardiogenic
● Neurogenic
● Septic
Cause of Shock
In the vast majority of trauma

patients, shock is due to
blood loss.
Shock Assessment
Methods of Locating Bleeding
• Physical examination
• Diagnostic adjuncts to
primary survey
• Chest X-ray
• Pelvic X-ray
• FAST / DPL
Interventions
What can I do about shock?

Interventions
Hemostatic Direct
resuscitation pressure/
tourniquet
Angio- Reduce pelvic

embolization volume
Splint fractures Operation
Hemostatic Agents
Interventions

• Fluid resuscitation
• Vascular access?
• Type?
• Volume?
• Balanced
• Monitor response
• Prevent hypothermia!
Interventions
• Balanced resuscitation
• Accepting a lower-than-
normal blood pressure
• Packed red blood cells, FFP,
Too much may be as
platelets bad as too little.
• Not a substitute for
definitive surgical control of
bleeding
Patient Response
What is the patient’s response?

Patient Response
Identify improved organ function

• Skin: warm, capillary refill
• Renal: increased urinary output
• Vital signs
• CNS: improved level of consciousness
Patient Response

Related to volume or persistence
of hemorrhage
• Rapid responder
• Transient
responder
• Nonresponder
Class I Hemorrhage
750 mL Blood Volume Loss (15%)
• Slightly anxious
• Normal blood pressure
Crystalloid
• Heart rate < 100 / min
• Respirations 14-20 / min
• Urinary output 30 mL / hour
Class II Hemorrhage
750-1500 mL Blood Volume Loss (15-30%)
• Anxious
• Normal blood pressure
• Heart rate > 100 / min
Crystalloid
• Decreased pulse pressure
• Urinary output 20-30 mL / hour
Class III Hemorrhage
1500-2000 mL Blood Volume Loss (30-40%)
• Confused, anxious
Crystalloid,
• Decreased blood pressure
blood
• Heart rate > 120 / min components,
• Decreased pulse pressure definitive control
of bleeding
• Urinary output 5-15 mL / hour
Class IV Hemorrhage
> 2000 mL Blood Volume Loss (> 40%)

• Confused, lethargic
• Hypotension
• Heart rate > 140 / min Blood
components,
• Decreased pulse pressure
definitive control
• Respirations > 35 / min of bleeding
• Urinary output negligible
Special Considerations
Complications of Shock – Patient Factors
• Advanced age
• Athletes
• Pregnancy
• Medications
• Pacemaker
Complications of Shock and Shock

Management
• Hypothermia
• Early coagulopathy
• Acidosis
Evaluation and Management of Shock
• Equating BP with cardiac

output
• Misleading hemoglobin and
hematocrit levels
Case Scenario
● 28-year-old female
in MVC
● Patient was
unrestrained
● Pulse: 126; BP:
96/70; RR: 28
● Confused and
anxious
Questions?
Summary
● Shock leads to inadequate organ perfusion and

tissue oxygenation; hypovolemia is the cause in
most trauma patients.
● Diagnosis and treatment of shock must occur
simultaneously.
● Initial assessment requires careful physical
examination; initial management includes rapid
hemostasis and balanced resuscitation with
crystalloids and blood.
● Blood replacement resumes the oxygen-carrying
capacity of the intravascular volume.
Thoracic
Trauma

Chapter Statement
Thoracic injury is common in the

poly-trauma patient and can pose
life-threatening problems if not
promptly identified during the
primary survey.
Case Scenario
● 27-year-old male was unrestrained

driver in high-speed, frontal-impact
collision
● Blood pressure: 90/70; heart rate: 110;
respiratory rate: 36
● Initial assessment: GCS score 15,
patent airway
What leads you to suspect thoracic injury in
this patient?
How would you evaluate this patient for
potential thoracic injuries?
Objectives
1. Identify and initiate treatment during the primary

survey of injuries that affect the airway.
• Airway obstruction
• Tension or open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
2. Identify and initiate treatment during the secondary

survey of the eight potentially life-threatening
injuries.
3. Describe the significance and treatment of
subcutaneous emphysema, thoracic crush injuries,
and sternal, rib, and clavicular fractures.
Thoracic Trauma
• Significant cause of mortality

• Blunt: < 10% require operation
• Penetrating: 15-30% require operation
• Majority: Require simple procedures
• Most life-threatening injuries are identified
during the primary survey
Thoracic Trauma
What are the immediately life-

threatening chest injuries?
Thoracic Trauma
What are the immediately life-

threatening chest injuries?
• Laryngeotracheal injury / Airway
obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
Thoracic Trauma
What are the pathophysiologic

consequences of these chest injuries?
Thoracic Trauma
What are the pathophysiologic

consequences of these chest injuries?
• Hypoxia
• Hypoventilation Manage in the
• Acidosis primary survey
• Respiratory as they are
• Metabolic identified
• Inadequate
tissue perfusion
Primary Survey
Identification of Thoracic Injury
• Tachypnea
• Respiratory distress
• Hypoxia
• Tracheal deviation
• Abnormal breath sounds
• Percussion abnormalities
• Chest wall deformity
Laryngeotracheal Injury
Airway Obstruction
• Rare
• Hoarseness
• Subcutaneous
emphysema
• Manage in the
primary survey as
soon as possible
• Intubate cautiously
• Tracheostomy
Tension Pneumothorax
• Respiratory distress Clinical diagnosis

• Shock
• Distended neck veins
• Absent breath sounds
• Hyperresonance
• Elevated hemithorax
• Cyanosis (late sign)
• Immediate decompression
• Needle
• Chest tube NO x-ray
Open Pneumothorax
• Ineffective
ventilation
• 3-sided cover over
defect
• Chest tube
• Definitive operation
Flail Chest and Pulmonary Contusion
• Intubate as indicated
• Oxygen
• Re-expand lung
• Judicious fluids
• Analgesia
Massive Hemothorax
• No breath sounds and

percussion dullness
• Chest decompression
• Flat neck veins
• Shock
• > 1500 mL blood loss
• Volume restoration
• Autotransfusion
• Operative
intervention
Cardiac Tamponade
• Shock
• Distended neck veins
• Muffled heart sounds
• Pulseless electrical
activity
• FAST
• Operation
Resuscitative Thoracotomy
When to Consider Resuscitative

Thoracotomy
• Patients with penetrating thoracic injury
arriving with PEA
• When a surgeon with appropriate skills is
present
• Resuscitative thoracotomy is not indicated
in blunt trauma with PEA
Thoracic Trauma
Secondary Survey: Potentially Life-

threatening Chest Injuries
• Tracheobroncial • Blunt cardiac injury
tree injury
• Traumatic aortic
• Simple disruption
pneumothorax • Blunt esophageal
• Pulmonary rupture
contusion • Traumatic
• Hemothorax diaphragmatic
injury
Thoracic Trauma
What adjunctive tests are used during

the secondary survey to allow complete
evaluation for potentially life-threatening
thoracic injuries?
Thoracic Trauma
What adjunctive tests are used during the

secondary survey to allow complete
evaluation for potentially life-threatening
thoracic injuries?
• Chest x-ray
• FAST
• ABG
• ECG
• Pulse oximetry
Simple Pneumothorax
• Penetrating or
blunt trauma
• Ventilation /
perfusion defect
• Hyperresonance
• Decreased breath
sounds
• Tube
thoracostomy
Tracheobronchial Tree Injury
• Often missed
• Penetrating or blunt trauma
• Persistent pneumothorax or persistent
air leak
• Bronchoscopy
• Treatment
• Airway and ventilation
• Tube thoracostomy
• Operation
Pulmonary Contusion
• Common
• Oxygenate and
ventilate
• Selective intubation
• Delayed x-ray
changes
• Judicious fluid
administration
Hemothorax
• Chest wall injury

• Lung / vessel
laceration
• Tube thoracostomy
Blunt Cardiac Injury
• Spectrum of injury
• Abnormal ECG / monitor changes
• Echocardiography if hemodynamic
consequences
• Treat
• Dysrhythmias
• Perfusion
• Complications
Traumatic Aortic Disruption
• Rapid acceleration /
deceleration
• X-ray signs
• High index of
suspicion
• Surgical consult
Traumatic Aortic Disruption
Diagnosis by Helical CT or Aortography

Diaphragmatic Injury
• Most often left-sided

• Blunt: Large tears
• Penetrating: Small
perforations
• Frequently
misinterpreted x-ray
• Operation
Fractures and Associated Injuries
Sternum, Scapular, and Rib Fractures

Ribs 1-3
• Severe force, high mortality risk
with associated injuries
Ribs 4-9 Pain Control

• Pulmonary contusion and is Key!
pneumothorax
Ribs 10-12
• Suspect intra-abdominal injury
Traumatic Asphyxia
• Signs
• Petechiae
• Swelling
• Plethora
• Cerebral Edema
• Treatment
• Airway control
• Oxygen
Esophageal Injury
• Uncommon and difficult to diagnose

• Mechanism is severe epigastric blow
• Unexplained pain
• Unexplained shock
• Radiographs demonstrate mediastinal air
• Signs and symptoms
• Mediastinal air
• Unexplained shock
• Unexplained left hemothorax / effusion
• Investigations
• Contrast
• Endoscopy
Subcutaneous Emphysema
• Airway injury
• Pneumothorax
• Blast injury
Pitfalls
• Simple pneumothorax converts to tension

pneumothorax
• Retained hemothorax
• Diaphragmatic injury
• Inadequate pain control
• Extremes of age
• Over-resuscitation
• Misplaced chest tube
Case Scenario
● 27-year-old male was unrestrained

driver in high-speed, frontal-impact
collision
● Blood pressure: 90/70; heart rate: 110;
respiratory rate: 36
● Initial assessment: GCS score 15,
patent airway
What leads you to suspect thoracic injury in
this patient?
How would you evaluate this patient for
potential thoracic injuries?
Questions?
Summary
● Chest injuries are common in the multiply

injured patient.
● The ABCDE approach is used to identify life-
threatening and potentially life-threatening
injuries.
● Initial stabilization requires simple maneuvers,
e.g., endotracheal intubation and tube
thoracostomy.
● The goal of treating patients with chest injuries
is to establish normal gas exchange and normal
hemodynamics.
Abdominal
and Pelvic
Trauma
Chapter Statement
Unrecognized abdominal and

pelvic injuries continue to be a
cause of preventable death.
Case Scenario
● 35-year-old male passenger in high-

speed motor vehicle collision
● Blood pressure: 105/80; Pulse: 110;
respiratory rate: 18; GCS Score = 15
● Complaining of pain in chest, abdomen,
and pelvis
What injuries do you suspect,

and how would you manage this patient?
Objectives
1. Identify the key anatomic regions of the

abdomen.
2. Recognize a patient at risk for abdominal and
pelvic injuries based on the mechanism of
injury.
3. Apply the appropriate diagnostic procedures.
4. Identify patients who require surgical
consultation.
5. Describe the acute management of abdominal
and pelvic injuries.
External Landmarks
Mechanism of Injury
When should you suspect abdominal

and pelvic injury?
Blunt
• Speed • Safety devices
• Point of impact • Position
• Intrusion • Ejection
Penetrating
• Weapon
• Distance
• Number, location of wounds
Explosion
• Combined mechanism
Blunt Force Mechanism
Common Injuries
• Spleen
• Liver
• Small bowel
• Pelvis
Penetrating Mechanism
Any Organ at Risk

• Stab
• Low energy, lacerations
• Gunshot
• Ballistics
• Type of weapon
• Shrapnel
• Shotgun
• Distance from target
• Spread of projectiles
• Explosion / blast
Explosions
• ABCDE
• Combination mechanism
• Blunt
• Penetrating fragments
(multiple)
• Blast
Consider proximity, enclosed space,

multiple fragments, and secondary
impacts (thrown or fall from height).
Assessment
How do I determine if there is an

abdominal or pelvic injury?
Assessment
How do I determine if there is an

abdominal or pelvic injury?
Physical Exam Adjuncts of Primary Survey
• Inspection • Pelvic x-ray
• Auscultation • FAST
• Percussion • DPL
• Palpation
• Examination of pelvis
and perineum
Assessment
Factors that Compromise the Exam

• Alcohol and other drugs
• Injury to brain, spinal cord
• Injury to ribs, spine, pelvis
A missed abdominal Excessive or repeated

injury can cause a testing of pelvic
preventable death. stability can be
detrimental.
Adjuncts
Urinary Catheter
• Monitors urinary output
• Diagnostic
• Decompresses bladder
before DPL
• Pelvic fracture patients are
at high risk of bladder and
urethral injury.
• Hematuria is diagnostic of
injury.
Urethral Injury
A posterior urethral injury usually occurs

in patients with multisystem injuries and
pelvic fractures.
In contrast, an anterior urethral injury

results from a straddle impact and can be
an isolated injury.
Adjuncts
Gastric Tube
• Relieves distention
• Decompresses
stomach before DPL
Basilar skull / facial

fractures can induce
vomiting / aspiration
Adjuncts
Blood and Urine Tests

• No mandatory blood tests before urgent
laparotomy
• Hemodynamically abnormal
• Type and crossmatch
• Coagulation studies
• Pregnancy testing
• Alcohol or other drug testing
• Hematuria (gross versus microscopic)
Adjuncts
X-ray Studies
• Blunt Trauma: AP chest and AP pelvis
• Penetrating Trauma: AP chest and
abdomen with markers (if hemodynamically
normal)
Adjuncts
Contrast Studies
• Abdominal CT
• Urethrogram
• Cystogram
• IVP
• GI studies
Don’t delay
definitive care!
Diagnostic Studies – Blunt Trauma
Diagnostic Studies – Penetrating Trauma
Hemodynamically Normal Patients

Lower chest wounds
• Serial exams, thoracoscopy, laparoscopy,
or CT scan
Anterior abdominal stab wounds

• Wound exploration, DPL, or serial exams
Back and flank stab wounds

• DPL, serial exams, or double- or triple-contrast
CT scan
Laparotomy
Which patients warrant a laparotomy?

Laparotomy

Indications for Laparotomy – Blunt Trauma
• Hemodynamically abnormal with

suspected abdominal injury
• Free air
• Diaphragmatic rupture
• Peritonitis
• Positive FAST, DPL, or CT
Laparotomy

Indications for Laparotomy – Penetrating Trauma
• Hemodynamically abnormal
• Free air
• Peritonitis
• Positive DPL, FAST, or CT
• Evisceration
Early operation is usually the best
strategy for GSW
Pelvic Fractures
• Significant force
• Associated injuries
• Pelvic bleeding
• Venous / arterial
Pelvic Fractures
Assessment of Pelvic Fractures

• Inspection
• Limb-length discrepancy, external rotation
• Open or closed
• Palpation or pelvic ring, stability
• Rectal / GU / vaginal exam
• Open or closed? Palpate prostate
Pelvic Fractures
Management of Pelvic Fractures

• AB, as usual
• C: Control hemorrhage
• Wrap / Binder
• Rule out abdominal
hemorrhage
• Angiography, fixation
• Pelvic packing
Pelvic Fractures
Hemodynamically Abnormal Patients

Pitfalls
• Delayed intervention for abdominal or pelvic

hemorrhage
• Occult intraabdominal / retroperitoneal injuries
• Back and flank wounds
• Repeated manipulation of a fractured pelvis
• Spinal cord injury / altered sensorium
• Improperly applied pelvic wrap
• Skin necrosis from pelvic wrap
Case Scenario
● 35-year-old male passenger in high-

speed motor vehicle collision
respiratory rate: 18; GCS Score = 15
● Complaining of pain in chest, abdomen,
and pelvis
What injuries do you suspect,

and how would you manage this patient?
Questions?
Summary
● Three distinct regions of the abdomen are the

peritoneal cavity, the retroperitoneal space,
and the pelvic cavity.
● Mechanism of injury determines the
management of abdominal and pelvic injuries.
Early surgical consultation is warranted with
possible intraabdominal injuries.
● Appropriate diagnostic procedures are based
on assessment and patient presentation.
Head Trauma

Chapter Statement
The primary goal of treatment for

patients with suspected TBI is to
prevent secondary brain injury.
Case Scenario
● 58-year-old male fell from a second-story

roof in a small rural town
● Initial GCS score = 12
● On admission after 2-hour transfer, GCS
score is 6
What injuries would you suspect?

What are your priorities in
managing this patient?
Objectives
1. Describe basic intracranial physiology.

2. Evaluate and classify head injury patients
based on severity.
3. Explain the importance of adequate
resuscitation in limiting secondary brain
injury.
Anatomy and Physiology
What are the

unique features of
brain anatomy and
physiology, and
how do they affect
patterns of brain
injury?
Anatomy and Physiology
What are the unique features of brain

anatomy and physiology, and how do
they affect patterns of brain injury?
• Rigid, nonexpansile skull filled with brain,
CSF, and blood
• Cerebral blood flow (CBF) usually
autoregulated
• Autoregulatory compensation disrupted by
brain injury
• Mass effect of intracranial hemorrhage
Monro-Kellie Doctrine
Volume-Pressure Curve
Intracranial Pressure (ICP)
10 mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe
• Sustained increased ICP leads to decreased

brain function and poor outcome
• Hypotension and low saturation adversely
affect outcome
Autoregulation
• If autoregulation is intact, CBF is maintained

constant between a mean BP of 50 to 150 mm Hg.
• In moderate or severe brain injury, autoregulation
is impaired so CBF varies with mean BP.
• The injured brain is more vulnerable to episodes
of hypotension, causing secondary brain injury.
CPP ≠ Cerebral Blood Flow

Classifications of Head Injury
By Morphology – Skull Fractures

Vault
• Depressed or nondepressed
• Open / closed
Basilar
• With or without CSF leak
• With or without cranial nerve palsy
By Morphology – Brain Injuries

Focal
• Epidural (extradural)
• Subdural
• Intracerebral
Diffuse
• Concussion
• Multiple contusions
• Hypoxic / ischemic injury
Epidural Hematoma
• Associated with skull

fracture
• Classic: middle
meningeal artery tear
• Lenticular / biconvex
• Lucid interval
• Can be rapidly fatal
• Early evacuation
essential Uncal herniation
Subdural Hematoma
• Venous tear / brain

laceration
• Covers cerebral
surface
• Morbidity / mortality
due to underlying
brain injury
• Rapid surgical
evacuation
recommended,
especially if > 5 mm
shift of midline
Intracerebral Hematoma / Contusion
• Coup / contra coup

injuries
• Most common:
frontal / temporal
lobes
• CT changes usually
progressive
• Most conscious
patients: no
operation
Large Frontal Contusion with Shift
Diffuse Brain Injury
Normal CT Diffuse Injury
Range from mild concussion to severe

ischemic insult
By Severity of Injury Based on

GCS Score
• Mild
• Moderate
• Severe
Mild Brain Injury
• GCS score = 13 – 15
• History
• Exclude systemic injuries
• Neurologic exam
• Radiographic investigation as
indicated
• Alcohol / drug screens as indicated
Observe or discharge based on findings

Moderate Brain Injury
• GCS score = 9 – 12
• Initial evaluation same as for mild injury
• CT scan for all
• Admit and observe
• Frequent neurologic exams
• Repeat CT scan
• Deterioration: Manage as severe head
injury
Severe Brain Injury
• GCS score = 3 – 8
• Evaluate and resuscitate
• Intubate for airway protection
• Neurologic exam prior to intubation
• Focused neurologic exam
• Frequent reevaluation
• Identify associated injuries
Indications for CT Scan
• GCS score still < 15 two

hours after injury
• Neurologic deficit
• Open skull fracture
• Sign of basal skull
fracture
• Vomiting (> 2 episodes)
• Extremes of age
• Retrograde amnesia
• Severe headache
Management
What is the optimal treatment for

patients with brain injuries?
Management
What is the optimal treatment for

patients with brain injuries?
Priorities
• ABCDE
• Minimize secondary brain injury
• Administer oxygen
• Maintain adequate ventilation
• Maintain blood pressure
(systolic > 90 mm Hg)
Management
What is a focused neurological

examination?
Management
What is a focused neurological

examination?
• GCS score
• Pupils
• Lateralizing signs
Consult neurosurgeon early

Management
Medical
• Controlled ventilation
• Goal: PaCO2 at 35 mm Hg
• Intravenous fluids
• Euvolemia
• Isotonic
• Consult with neurosurgeon
Management
Medical
• Mannitol
• Use only with signs of tentorial herniation
• Avoid in patients with hypovolemia
• Dose 1.0 gram / kg IV bolus
• Hypertonic saline
• Anticonvulsants
• Sedation
Neurological examination
• Paralytics before prolonged
sedation/paralysis
Management
Surgical
• Scalp Wounds
• Possible site of major blood loss
• Direct pressure to control bleeding
• Occasional temporary closure
Management
Surgical
• Penetrating Trauma
• ABCs
• X-ray / CT scan
• Early neurosurgical consult
• Prophylactic antibiotics
• Do not remove penetrating object or
probe the wound.
Management
Surgical
• Intracranial Mass Lesion
• Can be life-threatening if expanding
rapidly
• Immediate neurosurgical consult
• Hyperventilation / medical therapy
• Damage control craniotomy: transfer to
neurosurgeon (rural / austere areas)
Brain Death
How do I diagnose brain death?

Brain Death
How do I diagnose brain death?

• GCS score = 3
• Nonreactive pupils
• Absent brainstem reflexes (e.g.,
oculocephalic, corneal, and Doll’s
eyes, and no gag reflex)
• No spontaneous ventilatory effort
on formal apnea testing
Organ Donation
• Organ procurement organization

referral for all patients with head
injury and GCS < 5
• Consider organ donation for all
patients with brain death
Case Scenario
● 58-year-old male fell from a second-story

roof in a small rural town
● Initial GCS score = 12
● On admission after 2-hour transfer, GCS
score is 6
What injuries would you suspect?

What are your priorities in
managing this patient?
Questions?
Summary
● Management of head injuries requires an

understanding of basic intracranial physiology.
● Efficient evaluation of head and brain injuries
includes ABCs, a neurologic examination and
searching for associated injuries.
● Adequate resuscitation is important in limiting
secondary brain injury.
Spine and
Spinal Cord
Trauma
Chapter Statement
Spine injury must always be

considered in patients with multiple
injuries. Some patients with spine
injury experience new or worsening
symptoms after treatment in the ED,
which can be caused by inadequate
immobilization.
Case Scenario
● 38-year-old male is pulled from a swimming

pool
● Blood pressure: 80/62; Pulse: 58; Respiratory
rate: 28
● Alert, following commands
● Breathing is shallow
● He is not moving his arms or legs
What injuries would you expect in this patient and

how would you manage him?
Objectives
1. Describe the basic anatomy and physiology of

the spine.
2. Evaluate and appropriately treat a patient with
suspected spinal injury.
3. Identify the common types of spinal injuries
and their x-ray features.
4. Determine the appropriate disposition of
patients with spine trauma.
Spinal Injury
When do I suspect a spine injury?

Spinal Injury
When do I suspect a spine injury?
• Mechanism of injury
• Unconscious patient
• Spine pain or
tenderness
Spinal Injury
How do I protect the spine during

evaluation, management, and
transport?
Spinal Injury
How do I protect the spine during

evaluation, management, and
transport?
• Immobilize entire patient on long spine board
with proper padding.
• Apply semirigid collar.
Protection is priority;
detection is secondary.
Spinal Injury Screening
Clinical
•Normal neurologic exam and
•Absence of spinal pain and tenderness
Drugs, alcohol, and other

injuries can mask spinal
injury.
• If patient is
• Conscious
No further
• Cooperative evaluation or x-ray
• Able to concentrate on c- necessary
spine
• If no neck or spine
pain or tenderness Clear spine and
remove cervical
• If still no pain or collar.
tenderness with
voluntary movement
Altered Consciousness or Symptoms

• Radiographic visualization of entire spine
• Plain films / CT scan
How do I confirm the presence or

absence of a significant spine injury?
How do I confirm the presence or

absence of a significant spine injury?
• Clinical signs of neurological deficit
• Radiological investigations
• Plain X-ray / CT / MRI
• Identify bony fracture / subluxation
• Presume spinal instability
• Early spine service consult
Cervical Spine X-rays
• Cross-table lateral film excludes 85% of

fractures
• Addition of AP and odontoid views excludes
most fractures
• CT scan may be used instead of plain x-rays
• Also may require
• Swimmer’s view
• MRI
Cervical Spine X-rays
• 10% of patients with a c-spine fracture have a

second, associated noncontiguous vertebral
column fracture
• Identify one abnormality? Look for another!
• Radiographic screening of entire spine is
required in this situation
Pitfalls
•Spinalevaluation complicated by altered

sensorium
•Remove spine board as soon as possible
and logroll patient
•Patients at high risk for pressure sores
•unconscious
•paralyzed
•elderly
•shock
Caution
The neurological status of at

least 5% of patients with
spinal cord injuries worsen at
the hospital.
Neurologic Status
How do I assess the patient’s

neurologic status?
Neurologic Status
How do I assess the patient’s

neurologic status?
Neurologic level
• Most caudal level of motor / sensory function
• Motor and sensory may not be the same
• Sensory can vary on each side
Bony level
• Site of vertebral column damage
Neurologic Status
Complete Injury
• No motor or sensory function below injury
level
Incomplete Injury
• Any motor or sensory preservation below
injury level
• Sacral sparing may be only residual function
Effects of Spinal Cord Injury
How do I identify and treat

neurogenic and spinal shock?
Neurogenic Shock – Direct Effects

• Cardiovascular phenomenon due to loss of
sympathetic tone
• Associated with cervical / high thoracic
spine injury
• Hypotension and slow heart rate
• Treatment includes fluid resuscitation,
occasional atropine and vasopressors
Spinal Shock – Direct Effects

• Neurologic, not hemodynamic phenomenon
• Occurs shortly after cord injury
• Variable duration
• Flaccidity and loss of reflexes
Other Consequences
• Inadequate ventilation
• Abdominal evaluation compromised
• Occult compartment syndrome
Management
How do I treat patients with spinal cord

injury and limit secondary injury?
• Ensure adequate ventilation and oxygenation
• Maintain blood pressure
• Maintain perfusion of spinal cord
Management
Management of Hypotension
• Assess for associated bleeding
• Consider neurogenic shock
• Monitor urinary output
Stop
the
bleeding!
Management
Which patients do I transfer?
• Unstable fractures
Avoid transfer delay!

Management
Management of Patients Requiring Transfer
• Provide respiratory
support as needed
• Exclude other life-
threatening injury
• Properly immobilize
entire patient
• Avoid hypothermia
Case Scenario
● 38-year-old male is pulled from a swimming

pool
Respiratory rate: 28
● Alert, following commands
● Breathing is shallow
● He is not moving his arms or legs.
What injuries would you expect in this patient

and how would you manage him?
Questions?
Summary
● The spinal column consists of cervical, thoracic

and lumbar vertebrae. Neurologic shock is
associated with some cervical and high thoracic
injuries.
● Spine injury, with or without neurologic deficits,
must always be considered in patients with
multiple injuries.
● Protect entire spine until injury is excluded.
● Transfer patients with vertebral fractures or
spinal cord injuries to a definitive-care facility.
Musculoskeletal
Trauma

Chapter Statement
Injuries to the musculoskeletal system

occur in many patients who sustain
blunt trauma; they often appear
dramatic, but rarely cause an
immediate threat to life or limb.
However, pelvic fractures and femur
fractures are an important and often
unrecognized source of shock.
Case Scenario
● A wall collapses on a 44-year-old male worker

● Blood pressure: 130/75; Pulse: 110
● GCS score: 15
● Painful, bruised, deformed right leg
What are your priorities?

Is this life- or limb-threatening?
Objectives
1. Explain the significance of musculoskeletal in

patients with multiple injuries.
2. Identify life- and limb-threatening injuries.
3. Explain the initial management of
musculoskeletal injuries.
Primary Survey
What impact do musculoskeletal

injuries have on the primary survey?
Primary Survey
What impact do musculoskeletal

injuries have on the primary survey?
A B C D E
• External bleeding
• Occult blood loss
• Long bone fractures
Primary Survey
What are my priorities and

management principles?
Primary Survey
What are my priorities and

management principles?
During the Primary Survey
• Stop the bleeding!

(pressure - tourniquet)
• Splint the extremity

Primary Survey
Rationale for Splinting
• Prevents further blood

loss and injury
• Can restore or
maintain perfusion
• Relieves pain
• Important during evaluation
• Do not delay
Secondary Survey
Symptoms
•Pain
•Paresthesias
•Numbness
Signs
•Look
•Listen
•Feel
Secondary Survey
Look Listen Feel

• Deformity • Doppler • Crepitus
• Wound(s) signals • Skin flaps
• Bruit • Neurologic
deficit
• Pulses
• Tenderness
Secondary Survey
Key Information
• Preinjury status and predisposing factors

• Mechanism of injury
• Time of injury
• Associated factors (e.g., environment)
• Prehospital observations and care
Secondary Survey
Early Concerns
• Vascular
compromise
• Open fractures
• Compartment
syndrome
Secondary Survey
Assess and Manage Vascular Compromise
• Reduce fracture(s)
• Splint fracture(s)
• Assess by doppler Time is
• Ankle / brachial index
critical!
• Obtain surgical consult
Secondary Survey
Managing Open Fractures

• Apply appropriate splint
• Cleanse/debride (now or later)
• Consider time factor
• Obtain orthopedic consult
• Antibiotic / tetanus status
Secondary Survey
X-Ray Studies
• What x-rays do I need?
• Any suspected area
• One joint above and below
• When do I obtain them?

• Patient is hemodynamically
normal
Secondary Survey
X-Ray Studies
• When should I delay
getting x-rays?
• If life-threatening injuries take
priority
• If patient transfer will be
delayed
Compartment Syndrome
What injuries can cause compartment

syndrome?
• Tibia, forearm fractures
• Vascular and bony
injuries
• Injuries immobilized in
tight dressings or casts
• Severe crush injuries
• Burns
Compartment Syndrome
How do I recognize compartment

syndrome?
• Pain
• Disproportionate
• Passive stretch
• Tense compartments
• Asymmetry
• Paresthesia
• Tissue pressures >
35 to 45 mm Hg
Pitfalls
• Altered sensation
• Compartment syndrome
• Vascular injury
• Crush injuries / myoglobinuria
• Occult fractures / soft tissue injuries
• Coagulation disorders
Case Scenario
● A wall collapses on a 44-year-old male worker

● Blood pressure: 130/75; Pulse: 110
● GCS score: 15
● Painful, bruised, deformed right leg

Is this life- or limb-threatening?
Questions?
Summary
● Musculoskeletal injuries may pose delayed

threats to life and limb.
● Stop the bleeding!
● Reduce and immobilize fractures and
dislocations
● Recognize vascular compromise
● Consider compartment syndrome
Thermal
Injuries

Chapter Statement
All thermal injuries require the

identification and management of
associated mechanical injuries and the
maintenance of hemodynamic
normality with volume resuscitation.
Case Scenario
● A 54-year-old male is rescued from a smoke-

filled room in a burning house.
● Patient is conscious, agitated, and coughing
carbonaceous sputum.
● His head and upper body appear to be
extensively burned.
What are your priorities in managing this patient?

Objectives
• Demonstrate the initial assessment and

treatment of thermal injuries and associated
injuries.
• Estimate burn size using the Rule of Nines.
• Anticipate the special problems unique to
thermal injuries.
• List the criteria for transferring patients with
burn injuries to burn centers.
Types of Thermal Injuries
Burn Injuries Cold Injuries

Burn Injuries
Priorities
What is my first priority?

Priorities
What is my first priority?
A B C D E
C
Stop the burning!
Assess the patient’s ABCs
Priorities
Manage Airway and Breathing
• Consider inhalation injury.

• Establish and maintain patent airway early
and consider early ET intubation.
• Oxygenate and ventilate.
• Obtain ABGs and CO levels.
Assessment and Management
How do I identify inhalation injury?

How do I identify inhalation injury?

• Hoarseness and stridor
• Hypoxia
• Inflamed oropharynx
• History of closed space
• Carbonaceous sputum
• Carboxyhemoglobin (HbCO) > 10%
• Singeing of hair, eyebrows, eyelashes
Maintain Organ Perfusion
• Adequate venous access

• Monitor vital signs
• Hourly urine output Beware of edema
causing IVs to pull
• Adult: 0.5 – 1.0 mL / kg / hour
out of vein
• Child: 1.0 mL / kg / hour
How do I estimate burn size and depth?

How do I estimate burn size and depth?

Partial-thickness Burn
Full-thickness Burn
What is the rate and type of fluids

administered to patients with burns?
What is the rate and type of fluids

administered to patients with burns?
• 2-4 mL warmed Ringer’s lactate / wt (kg) x total BSA
(whole number, e.g., 40 not 0.4) in first 24 hours
• Administer ½ calculated fluids volume in first 8
hours
• Administer the remainder during next 16 hours
• Monitor urinary output
Calculated fluid rate is

only an estimate.
Other Information
• AMPLE history
• Tetanus status
Other Management
• Baseline blood analyses and chest x-ray
• Gastric tube insertion
• Analgesia – intravenous narcotics
• Wound care
• Documentation
Management of Chemical Burns
• Flush with copious

amounts of water for
20 – 30 minutes
• Brush off powder
before flushing
Management of Electrical Burns

• Fascia and muscle
damage; may spare
overlying skin
• Myoglobinuria:
Increase fluids
• Maintain adequate
perfusion
Transfer Criteria
Who do I transfer to a burn center?

Transfer Criteria

Partial-thickness and Full-thickness Burns
• > 10% BSA

• Any size burn affecting:
• Face • Hands • Perineum
• Eyes • Feet • Skin over
• Ears • Genitalia major joints
• All full-thickness burns (all ages)

Transfer Criteria

Partial-thickness and Full-thickness Burns
• Significant electrical burns, including lightening
injuries
• Significant chemical burns
• Inhalation injury
• Patients with preexisting illnesses that could
complicate treatment or recovery
• Associated injuries may need care in a trauma
center before transfer to a burn center
Transfer Procedures
• Coordinate with burn

center physician
• Transfer with:
• Documentation /
information
• Laboratory results
Case Scenario
● A 54-year-old male is rescued from a smoke-

filled room in a burning house.
● Patient is conscious, agitated, and coughing
carbonaceous sputum.
● His head and upper body appear to be
extensively burned.
What are your priorities in managing this patient?

Cold Injuries
Case Scenario
● A 72-year-old female is found lying in the

garden outside her back door.
● It is winter, and the outside temperature is just
above freezing.
● The patient’s right leg is shortened and
externally rotated.
● Her fingers and toes are white and cold.
What factors should you consider

in her early management?
Cold Injuries
How does cold affect my patient?

Local Tissue Effects
How does cold affect my patient?

• Temperature • Immobilization
• Duration of exposure • Moisture
• Environmental • Vascular disease
conditions
• Open wound
Recognition
How do I recognize a local cold injury?

Recognition
How do I recognize a local cold injury?
• Frostnip
• Frostbite
• Nonfreezing injury
Management
How do I treat local cold injuries?

Management
How do I treat local cold injuries?

• Decrease duration of
tissue freezing
• Replace constricting,
damp clothing with warm • Avoid dry heat
blankets
• Do not rub or massage
• Place injured body part in the area
circulating water at a • Rewarming can be
constant 40°C (104°F) extremely painful –
until pink color and provide adequate
perfusion returns analgesics (IV narcotics)
Systemic Hypothermia
Mild
• 35°C to 32°C, or 95°F to 89.6°F
Moderate
• 32°C to 30°C, or 89.6°F to 86°F
Severe
• Below 30°C, or 86°F
• Recognition
• Depressed level of consciousness
• Gray, cyanotic
• Absence of respiratory or cardiac activity is not
uncommon in patients who eventually recover.
• Laboratory evaluation
• ABG
• Potassium
• Treatment
• Mild, moderate: passive rewarming
• Severe: active rewarming
• Futility
• Potassium >10.0
• pH < 7.0
Case Scenario
● A 72-year-old female is found lying in the

garden outside her back door.
● It is winter, and the outside temperature is just
above freezing.
● The patient’s right leg is shortened and
externally rotated.
● Her fingers and toes are white and cold.
What factors should you consider

in her early management?
Questions?
Summary
Burn Injuries
● Recognize and treat inhalation injury
● Appropriate fluid resuscitation
● Early identification of burn injuries requiring
transfer
Cold Injuries
● Local cold injuries should be treated with
moist heat and systemic analgesia
Pediatric
Trauma
Chapter Statement
Injury continues to be the most

common cause of death and disability
in childhood.
Case Scenario
● A 7-year-old boy is struck by a moving car while

riding his bicycle.
● He was not wearing a helmet.
● He is unresponsive on arrival, breathing rapidly,
and pale with mottled extremities.
● Vital signs on admission: HR 144, RR 38, BP
80/57, GCS score 5 (E = 1, V = 2, M = 2)
What is your initial assessment?

What are your priorities for initial resuscitation?
Objectives
• Identify unique anatomic and physiologic

characteristics that affect injured children.
• Describe common patterns and responses to
injury.
• Explain how the ATLS® management principles
apply to pediatric trauma patients.
• List the ABCDEs of injury prevention.
Injury in Children
• Injury mortality surpasses deaths from all other

childhood illnesses combined.
• Anatomy, physiology, and mechanisms produce
patterns of injury distinct from adults.
• Mechanisms of injury are related both to age and
stage of development.
• Neurologic and respiratory derangements far
exceed hemodynamic derangements.
Injury in Children
What types of injuries do children

sustain?
Injury in Children
What types of injuries do children

sustain?
• Motor vehicle-associated injuries
• Drowning
• House fires
Multisystem
• Homicides
injury is
• Falls common
Anatomic Considerations and Implications
What aspects of childhood anatomy do

I need to consider?
What aspects of childhood anatomy do

I need to consider?
Larger tongue,
smaller jaw and
shorter, narrower,
funnel-shaped
airway with
anterior larynx
Prominent
occiput in
younger child
1” pad under
torso for neutral
position
Larger head, softer

cranium, open
fontanelles
Open physeal spaces,

flexible cartilagenous
skeleton
Cervical Spine
• Flexible spinal ligaments
• Anteriorly wedged
vertebrae
• Flat facet joints
• Angular momentum
• Pseudosubluxation
• SCIWORA
Chest
• Soft, pliable chest wall –
pulmonary contusion
• Horizontally aligned ribs,
weak intercostal muscles
• Rib fractures indicate
significant force
• Tension pneumothorax
more likely due to mobile
mediastinum
Abdomen
• Softer, thinner, muscular wall
• Lower-riding liver, spleen
• Bladder is an intra-abdominal
organ in young children
Physiology
What physiologic differences will

impact my management of pediatric
trauma patients?
Physiology
What physiologic differences will

impact on my management of pediatric
trauma patients?
• Age-specific vital signs
• Smaller blood volume (70 – 80 mL / kg)
• Decreased functional residual capacity
• Vigorous compensatory response
• Sudden deterioration
• Increased vagal tone
Vital Signs
Age Group
Sign 0–2 3–5 6 – 12
years years years
< 150 - < 100 -
Heart Rate < 140
160 120
Blood
> 60 - 70 > 75 > 80 - 90
Pressure
Respiratory
< 40 - 60 < 35 < 30
Rate
Adequate 1.5 – 2 0.5 – 1

1 cc/kg
Urine Output cc/kg cc/kg
Fluid Management
Resuscitation
• With an isotonic solution at 20 mL / kg
• Blood should be given if resuscitation is
needed following two boluses of crystalloid
• Early use of plasma and platelets
• Bleeding of more than half the child’s blood
volume in the first four hours should be
resuscitated with PRBCs, and early use of
plasma and platelets
Fluid Management
Resuscitation
• Permissive hypotension is an option in
patients without traumatic brain injury
• Maintenance fluid after resuscitation follows
the 4:2:1 rule
• 4 mL / kg for the first 10 kg
• 2 mL / kg for the second 10 kg
• 1 mL / kg for every kg beyond 20 kg
Physiologic Impact
Physiologic Impact
Thermoregulation
• Higher body surface area to mass ratio

• Thinner skin
• Less insulation by subcutaneous tissue
Prevent hypothermia!
Management
How do I apply ATLS principles to the

treatment of children?
Management
How do I apply ATLS principles to the

treatment of children?
A ABCDE priorities
are the same!
B
C D E
Management Issues: ABCDEs
Obstructs easily
A
Tension pneumothorax; avoid barotrauma
B
Vascular access; fluid and blood
C
D Pediatric GCS score; diffuse swelling
E Avoid heat loss

Pitfalls
•Shorttrachea: main stem bronchial

intubation
•ETT depth is 3 x ETT size
•Endotracheal tube easily obstructed

•Deceptive presentation of hypovolemic
shock
Pitfalls
•Gastric dilation can increase risk of

aspiration and cause hypotension
•Difficult intravenous access in children < 6
years
•Missed hollow viscus injury
•Subtle musculoskeletal injury findings
Pitfalls
•Radiation Exposure - ALARA

As Low As Reasonably Achievable
•Scan only when medically necessary
•Scan if the results will change management
•Scan only the area of interest
•Scan at the lowest dosage possible
Management Issues: Adjuncts
• CT
• FAST
• Tubes
Child Maltreatment Injuries
How do I recognize injuries from child

maltreatment?

maltreatment?
Clues from History
• Discrepancies
• Delay in care
• Repetitive injuries
• Inappropriate responses
• Medical neglect
• Developmentally improbable mechanism

maltreatment?
Clues from Physical Exam
• Multicolored bruises
• Bilateral subdural hematomas
Evaluate
• Retinal hemorrhages completely
• Femur fracture(s) for injuries
• Rib fracture(s)
• Unusual scald / contact burns
Injury Prevention
Prevention ABCDEs
Analyze injury data

Build local coalitions
Communicate the problem
Develop prevention activities
Evaluate program interventions
Case Scenario
● A 7-year-old boy is struck by a moving car while

riding his bicycle.
● He was not wearing a helmet.
● He is unresponsive on arrival, breathing rapidly,
and pale with mottled extremities.
● Vital signs on admission: HR 144, RR 38, BP
80/57, GCS score 5 (E = 1, V = 2, M = 2)
What is your initial assessment?

What are your priorities for initial resuscitation?
Questions?
Summary
● Unique anatomic, physiologic, and mechanistic

differences modify the application of ATLS®
principles.
● ABCDE approach
● Involve appropriate surgeon early!
● High index of suspicion for child maltreatment
● Injury prevention
Geriatric
Trauma

Chapter Statement
Special considerations in caring for

elderly patients include the effects of
age on physiologic functions,
comorbidities, and concomitant
medications. However, the priorities in
evaluation and resuscitation remain
the same.
Case Scenario
● A 79-year-old male is brought to the ED after he

was found at the base of the stairs by his wife.
● Initial vital signs: RR 32, Pulse 64, BP 110/60,
GCS score 12
What issues should you consider

in managing this patient?
Objectives
1. Describe characteristics of the elderly patient

that affect trauma management.
2. Discuss the relevance of comorbidity and
medication.
3. Explore the potential for elder maltreatment.
Unique Characteristics
What are the unique characteristics of

geriatric trauma?
What are the unique characteristics of

geriatric trauma?
• Age-related changes in anatomy and
physiology
• Preexisting diseases and comorbidities
• Medications
• Possibility of elder maltreatment
The Problem of Elder Trauma
● Increase in proportion of world population

aged 65 and older by 2050 will be 20 percent, or
2.5 billion
● Increased mortality and morbidity
Many will return to preinjury status with

appropriate management
Decline in Function with Age
↓ Brain mass Stroke

Eye disease Diminished hearing
↓ Depth of perception ↓Sense of smell and taste
↓ Discrimination of colors ↓Saliva production
↓ Pupillary response ↓Esophageal activity
↓ Respiratory vital capacity ↓Cardiac stroke volume and rate
↓ Renal function Heart disease and high blood
pressure
2- to 3-inch loss in height
Kidney disease
Impaired blood flow to lower
leg(s) ↓Gastric secretions
↓ Degeneration of the joints ↓Number of body cells
Total body water ↓Elasticity of skin, thinning of
epidermis
Nerve damage (peripheral
neuropathy) 15 – 30% body fat
• Fall
• Alcohol
Leading • Burns
Causes
• Pedestrian vs.
of vehicle
Injury
• Motor vehicle
crash
Unique Airway Problems
• ABCDE
• Priorities are the same
• Decreased cardiopulmonary reserve may
require early intubation
• Factors affecting airway management

• Dentition (including dentures)
• Nasopharyngeal mucosal fragility
• Cervical arthritis
Unique Breathing Problems
• Diminished respiratory reserve
• Use of supplemental oxygen

• COPD
• Chest injuries poorly tolerated
• “Minor” chest injuries with major effects

Unique Circulatory Problems
• Decreased cardiovascular function and reserve
• Cautious fluid administration

• Increased BP, decreased HR, and loss of renal
function with age
• Anticoagulants and other medications
• Pharmacologic effects
• Catecholamine effects and dysrhythmias
Unique Neurologic Problems
• Acute and chronic

subdural hematomas
• Altered sensorium
secondary to cerebral
atrophy, hypoperfusion,
and medications
• Spinal osteoarthritis,
leading to frequent spinal
column and cord injuries
Unique Exposure Problems
• Abnormal thermoregulatory mechanism
• Increased sensitivity to hypothermia
• Increased risk of infection
• Lack of tetanus protection

Unique Musculoskeletal Problems
• Most frequent cause of morbidity
• Susceptible to certain fractures
• Osteoporosis
• Preexisting deformities complicate evaluation
• Immobility can lead to complications

Special Issues
What are the special issues to consider

in treating geriatric trauma patients?
Special Issues
What are the special issues to consider

in treating geriatric trauma patients?
• Medications
• Elder maltreatment
• End-of-life decisions
Drugs That Affect Resuscitation
• Beta blockers • Corticosteroids
• Antihypertensives • Diuretics
• NSAIDS • Hypoglycemics
• Anticoagulants • Psychotropics
Recognizing Elder Maltreatment
• High index of suspicion

• Patterns of injury
• Multiple types
• Physical maltreatment
• Sexual maltreatment
• Neglect
• Psychological maltreatment
• Financial and material exploitation
• Violation of rights
Strategy For Elder Maltreatment
• Don’t query in presence of possible abuser.

• If maltreatment is suspected, remove patient
from abusive environment.
Failure to recognize and report

End-of-Life Decisions
• “When is enough, enough?”

• Advance directives?
• Right to self-determination is paramount
• Treatment only in patient’s best interest
• Benefits of treatment outweigh adverse
consequences
Case Scenario
● A 79-year-old male is brought to the ED after he

was found at the base of the stairs by his wife.
● Initial vital signs: RR 32, Pulse 64, BP 110/60,
GCS score 12
What issues should you consider

in managing this patient?
Questions?
Summary
● Trauma in the elderly is increasing globally

● Treatment priorities are the same
● Anatomic and physiologic changes are
associated with comorbid conditions and
medications
● Consider elder maltreatment
Trauma in
Pregnancy
and Intimate
Partner
Violence
Chapter Statement
Changes in structure and function can

influence the evaluation of injured
pregnant patients by altering the signs
and symptoms of injury, the approach
and responses to resuscitation, and
the results of diagnostic tests.
Case Scenario
● A 25-year-old woman who appears to be in

the third trimester of pregnancy is brought to
the ED following a motor vehicle collision.
● She is unconscious and immobilized on a
long spine board.

How does this patient’s pregnancy
impact on her treatment?
Objectives
1. Discuss anatomic and physiologic alterations

of pregnancy and effects on patient
management.
2. Establish assessment and treatment priorities
for the mother and the fetus.
3. Identify elements of intimate partner violence.
Assessment
Is she pregnant?
• Ask her!
• Enlarged uterus?
• Pregnancy test
Changes and Risks
What changes to anatomy and

physiology occur with pregnancy, and
what are the unique risks?
Changes and Risks
What changes to anatomy and

physiology occur with pregnancy, and
what are the unique risks?
12th week
Uterus becomes an
abdominal organ
20th week
At umbilicus
34 – 36 weeks
At costal margin
38 – 40 weeks
Head engages pelvis
Changes and Risks
First Trimester
•Uterus is intrapelvic and
thick-walled
•Fetus is protected from
direct injury
•Risks
•Abortion
•Isoimmunization
Changes and Risks
Second Trimester
•Uterus is extrapelvic
•Large volume of
amniotic fluid
•Risks
•Abruptio placenta
•Amniotic fluid embolism
•Isoimmunization
Changes and Risks
Third Trimester
•Uterus is thin-walled
•Maternal abdominal
viscera displaced
•Inferior vena cava
compression
•Risks
•Pelvic fractures with
maternal hemorrhage and
direct fetal injury
•Abruptio placentae
•Amniotic fluid embolism
•Isoimmunization
Physiologic Changes
Increased Decreased
•Minute ventilation •pCO2
•Heart rate and cardiac •Hematocrit
output
•Blood volume
•Glomerular filtration
rate
•Gastric emptying time
Primary Survey and Risks
A Aspiration risk With maternal

blood loss,
fetal distress
B Difficult ventilation
precedes
C changes in
C Failure to recognize maternal vital
blood loss early
signs.
D Eclampsia
Evaluation and Management
How do I evaluate and treat two

patients?
How do I evaluate and treat two

patients?
• Primary survey / resuscitation of mother
• Fetal assessment
• Secondary survey of mother
• Definitive care of mother and fetus
• Rh-negative mothers receive immunoglobulin
therapy (unless injury remote from uterus)
• Early OB consult
The Mother
A Same as nonpregnant
Same as nonpregnant
B Caution – chest tube placement
C
C
Displace uterus and volume infusion
Caution – fetal shock
D Eclampsia vs. brain injury
E Same as nonpregnant
The Fetus
•Resuscitate the mother
•Monitor fetal heart tones
•Consider fetal injury with
•Vaginal bleeding
•Abruptio placentae
•Uterine tenderness
•Uterine rupture
•Labor
Intimate Partner Violence
How do I recognize intimate partner

violence?
How do I recognize intimate partner

violence?
• A major cause of injury, regardless of ethnic
background, cultural influences, or
socioeconomic background
• May result in death and disability
• Patterns and clues similar to child maltreatment
• Not just women at risk
• High risk in pregnancy
Indicators
•Injuries inconsistent with stated history
•Diminished self-image, depression
•Self-abuse, suicide attempts
•Frequent emergency department visits
•Symptoms suggestive of substance abuse
•Self-blame for injuries
•Partner insists on being present for interview
Screening Questions
•Have you ever been kicked, hit, punched or
otherwise hurt by someone within the past year? If
so, by whom?
•Do you feel safe in your current relationship?
•Is there a partner from a previous relationship who
is making you feel unsafe now?
How do I respond to intimate partner

violence?
How do I respond to intimate partner

violence?
• Confidential discussion with victim
• Recommend place of safety
• Explain concerns for children in the home
• Refer to social / adult protective services once
the victim is safe and with consent
Case Scenario
● A 25-year-old woman who appears to be in

the third trimester of pregnancy is brought to
the ED following a motor vehicle collision.
● She is unconscious and immobilized on a
long spine board.

How does this patient’s pregnancy
impact on her treatment?
Questions?
Summary
● Anatomic and physiologic changes of

pregnancy influence patient management.
● Assessment and treatment priorities must be

established for the mother and fetus.
● Indicators suggesting intimate partner

violence should trigger action.
Transfer
to
Definitive
Care
Chapter Statement
If definitive care cannot be provided at

a local hospital, the patient requires
transfer to a hospital that has the
resources and capabilities to care for
him or her.
Case Scenario
● A 27-year-old male is brought to an 80-bed

rural hospital following an MVC.
● The hospital has a CT scanner and ultrasound
capability, but no neurosurgical capability.
● Vital signs: Systolic BP 80; shallow
breathing; and GCS score 6.
What are your concerns and priorities in

organizing transfer of this patient?
Objectives
1. Identify injured patients who require transfer to

a higher level of care.
2. Discuss optimal preparation for safe patient
transfer.
Transfer Principles
• Know institutional capabilities

• Be prepared and anticipate patient needs.
• Do no further harm.
• Identify patients whose needs exceed local
resources
Transfer Principles
• Perform only essential procedures.

• Establish direct communication between
referring and receiving doctors.
• Transport to closest, appropriate facility.
• Use most appropriate mode of transport.
Transfer Decisions
Whom do I transport?
Transfer Decisions
Whom do I transport?
● Patients with multiple injuries
● Patients whose needs exceed institutional
capabilities
● Patients with comorbidities
● Extremes of age
● Preexisting disease
Transfer Decisions
Where should I send the patient?

Transfer Decisions
Where should I send the patient?

● Transfer to an institution capable of providing
equipment and resources
● Transfer to an appropriate, qualified physician
who can:
● Make the diagnosis
● Treat the patient’s injuries
● Provide commitment and resources
Transfer Decisions
When should I transport the patient?

Transfer Decisions
When should I transport the patient?

● Transfer after life-threatening problems are
managed.
● Transfer after disabling injuries are stabilized.
● Transfer after arrangements are made.
● Transfer before performing unnecessary tests
and procedures.
Avoid delay!
Transfer Decisions
How should I transport the patient?

Transfer Decisions
How should I transport the patient?

Determine by:
●Care required en route
●Patient destination
●Available resources
●Existing
transfer
agreements
Case Scenario
● A 27-year-old male is brought to an 80-bed

rural hospital following an MVC.
● The hospital has a CT scanner and ultrasound
capability, but no neurosurgical facility.
● Vital signs: Systolic BP 80; shallow
breathing; and GCS score 6.
What are your concerns and priorities in

organizing transfer of this patient?
Questions?
Summary
● Patients with injuries exceeding an institution’s

capabilities should be transferred.
● Provide optimal preparation for safe transfer.

Committee on Trauma Presents
Triage
Scenarios
Focused Discussion
Triage Scenarios
GOAL :
To apply trauma triage principles in multiple
patient scenarios
OBJECTIVES :
 Define triage
 Understand and identify factors
 Apply principles of triage with scenarios
What is Triage ?
TRIAGE :
Process of management prioritization of
multiple patient casualties
WHAT factors are considered in the triage
process ?
1. Degree of life threat (ABCD)
2. Injury severity
3. Salvageability
4. Resources
5. Time, ect
Other Triage Factors
6. Information may be incomplete
7. Decisions may differ
8. Use all cues possible—Frequently
requires survey from a distance
9. Avoid indecision
*All Walking Wounded START Triage
MINOR RESPIRATIONS
YES NO
Under 30/min Over 30/min
PERFUSION
Radial Pulse Absent Radial Pulse Present
Position Airway
Immediate
Cap refill Cap refill
> 2 sec < 2 sec
Control NO YES
Bleeding STATUS
MENTAL
Immediate Non- Immediate
salvageable
Failure to follow Can follow
simple commands Simple commands
Immediate Delayed
Questions?
Summary
 Detailed assessment is not always possible, but Detailed assessment is

not always possible, but decision must be made.
 Act on decision promptly.
 Priorities are initially based on ABCDEs wherever possible.
 Consider other factors–Resources, etc.
 After immediate life threat is managed, then initiate secondary survey and
decide if transport and/or transfer are required.
 decision must be made.
 Act on decision promptly. ttt
 Priorities are initially based on ABCDEs wherever possible.
 Consider other factors–Resources, etc.
 After immediate life threat is managed, then initiate secondary survey and
decide if transport and/or transfer are required.

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Advanced Trauma Life

• Rapid and accurate assessment

• Resuscitate and stabilize by priority

• Determine needs and capabilities

• Arrange for transfer to definitive care

• Ensure optimum care

• Demonstrate concepts and principles of

• Establish management priorities.

• Initiate primary and secondary

• Demonstrate the skills necessary to assess

• Trauma is the leading cause of death in the first

“When I can provide better care in the field

• ABCDE approach to evaluation and

Airway with c-spine protection

Exposure / Environmental control

• Interactive lectures and skills sessions

• More than 60 countries

• Documented improvements in care of

• ABCDE approach to trauma care

The primary survey should be

● 44-year-old male driver who

What is the sequence of priorities

1. Do you need to identify the specific

2. If not, how do you proceed?

1. Identify the correct sequence of priorities for assessment

Primary survey and

What is a quick, simple way to

What is a quick, simple way to

•Ask the patient his or her name

•Ask the patient what happened

B Sufficient air reserve to permit speech

Airway with c-spine protection

The priorities are the same

● Occult airway injury

Breathing and Ventilation

Breathing and Ventilation

Airway versus ventilation

Assess for organ ● Level of consciousness

● Control hemorrhage ● Elderly

• Protect and secure airway

• Ventilate and oxygenate

• Stop the bleeding!

• Crystalloid / blood resuscitation

• Protect from hypothermia

Consider Early Transfer

• Use time before

When do I start the secondary survey?

● Primary survey is completed

Components of the secondary survey

and ear exam ● Occluded auditory

●Bony crepitus ● Potential airway

Neck (Soft Tissues)

Excessive pelvic manipulation

• Potential blood loss

Neurologic: Spinal Assessment

Neurologic: Spine and Spinal Cord

Special Diagnostic Tests as Indicated

Which patients do I transfer to a

Which patients do I transfer to a

Those whose injuries exceed institutional