ATLS: Advanced Trauma Life Support for Doctors (Student Course Manual), 8th Edition

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Author: American College of Surgeons

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BRIEF C O N T E N T S

1

Initial Assessment and Management

2

Airway and Ventilatory Management

•• SKILL STATION 1: INITIAL ASSESSMENT AND MANAGEMENT

25

Shock

43

51

55

... SKILL STATION IV: SHOCK ASSESSMENT AND MANAGEMENT ._._ SKILL STATION V: VENOUS CUTDOWN (OPTIONAL STATION)

4

19

•• SKILL STATION II: A I RWAY AND VENTILATORY MANAGEMENT ... SKILL STATION Ill: CRICOTHYROIDOTOMY

3

1

73

83

85

Thoracic Trauma

._._ SKILL STATION VI: X-RAY IDENTIFICATION OF THORACIC INJURIES ._. SKILL STATION VII: CHEST TRAUMA MANAGEMENT

5

Abdominal and Pelvic Trauma

6

Head Trauma

1

Spine and Spinal Cord Trauma

103

107

111

•._ SKill STATION VIII: DIAGNOSTIC PERITONEAL LAVAGE

127

131

•._ SKILL STATION IX: HEAD AND NECK TRAUMA: ASSESSMENT AND MANAGEMENT

157

•• SKILL STATION X: X-RAY IDENTIFICATION OF SPINE INJURIES

175

... SKILL STATION XI: SPINAL CORD INJURY: ASSESSMENT AND MANAGEMENT

8

Musculoskeletal Trauma

9

Thermal lnjuries

211

Pediatric Trauma

225

Geriatric Trauma

247

10 11

12 13

187

Trauma in Women

205

•

259

Transfer to Definitive Care

269

277 279

A

Injury Prevention

B

Biomechanics of Injury

C

Trauma Scores: Revised and Pediatric

D

Sample Trauma Flow Sheet

E

Tetanus Immunization

F

Ocular Trauma

G

Austere Environments: Military Casualty Care and Trauma Care in

283 289

293

297

299

Underdeveloped Areas and Following Catastrophes

INDEX

181

... SKill STATION XII: MUSCULOS KELETAL TRAUMA: ASSESSMENT AND MANAGEMENT

APPENDICES

•

153

H

Disaster Management and Emergency Preparedness

I

Triage Scenarios

351

335

305 321


Advanced Trauma Life Support® for Doctors ®

STUDENT COURSE MANUAL EIGHTH EDITION

'

,

American College of Surgeons Committee on Trauma


Chair of COIII/1/tl/ec 011 Trauma: John rildes, MD, l-ACS Medical Director ofTmwnn Program: J. Wayne Meredith, MD, PACS

ATLS Subcommittee Clwmnnn: John Kortbeek, MD, fRCSC, FACS

ATLS Progmm Manager: Will Chapleau, LMT-P, RN, TNS Project Ma11agcr: Claire Merrick

Del'elopmcllt hlllon: Nancy Peterson and fulie Scardiglia ProductiMt

nJI Children's IJ n spi t• ll

Unite d Kin gdo m

Prnli-ssor

David Eduardo Eskena7i, MD, FAC'.S

Univer:.ity of Costa Rlc.1

San lo•c

('htt�t; General and ThorJcic .�urgerr

lltJJ. A. Oiiativia

CoMa Rica

Argentina

Ji/) ComultJnt

Vagn Norgaard Eskcscn MD

Adelaide

Au>tralia uu t ra Lee Demmons, RN, MBA

,

A.,sodJte Profe.»or

U niversity Uinic or l\'curosurgery, Nati ona l

Hospital - Copenhagen Uniw�ity Hospital

Copenhagen

t\l,uwgN

I JcnmJrk

Critical Care Transport, Umvt'rsil}' llospital

Denis Evoy MCH, r:nCSI

nirminghum, Alabama United States

A lejandr o De Gracia , MD, MCS, MAAC ('hid. Gener,1/ Surgery

Agudo' P.trmemo Pu'lcm (,cncral Hospital

Bueno� Alre• Argent i n a

Mauricio Di Silvio· Lopez, MD, FACS

ClinicJi Rc•sidency and Rcst•atdl Ptvp.ram Director

20 de Novicmbre National .McdicJI Ce nt er, ISSSTF Mcxrco City. Districto Federal \-lexreo Frank Doto, M S

Pmlessor ofI Jealth Educlllion

Coun ty Coll e g e of Morris

(.re�>ce

(;rcece

Scott D'Amours MC.CM. FRCS(C), FRACS Royal Adelaide Hospital

Athen>

Michael Gerazou.nis, M0

T3Lrcno> Aires ,

Subnsh Gaut am, MD, M HBil, FRCS, FACS 'Ienior Cansult.Jnt anti Ht•.Jtl ofDepartment of Surger.r

A'/'L'i Co-ordinJtor

Jaime Cortes, MD

llospital Norway

A'tl.S National Coordio.rtor. Ponug.1/

Emergency Surgical Ser\icc>, Ho>pital das C li nica� of the Uni,crsity of S.io Paulo

l!mcrgency Divisiou, Ullcvaal Uni versity o,Jn

Candida Duriio

Francisco Coller e Silva, MD, flAGS, PhD (mcd)

HeJd ofTraumJ Unit, (; Stockport NH� Foundauon TruM Che.�hirc UniteJ Kingdom lena Klarin, RN Former ATLS N .uional C.nordin.uor, Sweden Sahlgreo\ka Universitcts)jukhu�et (;orchorg Sweden

Nur Roehmat Luhis, MD

St.Jff/Jt•partnwnt olSurgery

Skills llcvelopmcnt l.cntcr. Univcr>ity of I long Kung M�>dical Centre Queen Mary l lospiwl, Department of Surgery Hong Kong China

Chiefof Hepatopancre,lcdk. l l Offin·r

Department of Orthop & TraunJ.IIology,

Queen Elizabeth Hospital

...

XIII

M. Hocsin Gcncral llospual, Medical Faculty Sriwijnya Univcrsiry

J.S.K. J.uits�. MD Trawn.JSurgron

Medic11l Director b'nH:rgcncy lkp;lrtmcnt

. Counlinator Traum1 Academic McJical Center Av Tilburg Nethnland.\

Jaime Manzano, MD, flACS c,·na.ll Surgtricto Federal Mexico

Swit7cr1Jnd

lesper Ravn, MD

Om>uiiJnt, Head orr.cncral rhnradc Dcy.Jrtmcnt

Car
Copenhagen University Copenhagen l>cnmJrk

Marcelo Recalde Hidrobo, MD, MCS

Prof..·:.wr orOncologic.ll .md Ccneral Surgerie�

{)).1 University; Internationa l Unh-ers1ty, Ecuador; I

Metropol itan Hospital

Qui to l:coudor Peter Rhee, MD, MPll, FACS, FCCM, OMCC

l'mf..·!>sor ofSurgery

Chid, Set:tion ofTraum,!, Critic.U C _.ue, and

Ariwna Health Sciences Center, Department of

Surgery

'l\1c�nll, Arizona

United States

Cuenca

American British Cowtlr,Jy McuicaJ Center

Renens.Vaud

Jeffrey P. Salomone, M 1), I'ACS th�ocJate Professor of Surgery l.mory Unrversity, Department of Surgery Oeputy Chiefot'Surgu}' ( •rmly Memorial l losp1tal Atlunla, Georgia

Ecuador Mark Sheridan, M BI3S, MMedS c, FRACS

A.mciate � Professor

Dirl'clur uf Surl:\cry �nd Directur of

\lcurosurgery, Liverpool Ho�pital Sydney, �ew South Wales Au.\tralia

Richard K. Simons, M 11, BChir, FRCS, PRCSC. I'ACS

Asq>ciate Professor,Mt•dicol Director. 1i'£1Utll.? Services

United �tares

Dq>Jrtmcnt of Surgery, UBC, Vancouver

Rocio Sanchcz-Aedo, RN

Former ATIS National Omrdmator, Mexico (.ommittee on

Juan Carlos Serrano, MD, h\C'I

I hl\pital Santa Inc,

Argentina

'

San.ixis, SA

�l cuador

Ucparlment ofTraum;l /)inxtcJr

Neuquen

lltad ofTransplant Scntin·.>

Danicllc Poretti, RN

Fmergency Surgery

< MIC Clinic

Octavio Ruix, MD, FACS

Portug� l

Ct•twral Surgeon llospit.tl Lalinoamericano

Norway

C.mliovascular Sw'Bcon

Almada

Consultant General Sttrgt•r.v

Olav R�1ise, MD, PhD

Swl l�crl and

Scrvi�o de Cirurgia. Hosp1tal (iarci.t de Orta

Kuri Schroder Hansen, MD

l lo�pital

Daniel Rui'l., MD, FACS

n. C •neralSurgcoil

Switzerland

Department of Surgt•ry, I l.wkdand Univcrsil y

Pribnurg

Pedro Moniz Pereira, MD, FACS

lkpartment of Anc\thcsinlogy, University

E�uodor

Muoculoskelet.11 Mt-dinnin-ctor .md Jlc.Jd, Consultant G enentl Sugcr)'

Pm(esssor of /)is1ster A lcdicinc & .

11'1'1.� N.Hion;�/ ('mmlin.Jfvr, })ellmark

Philip Truskett , MB BS, FRACS

Br•111SI111j

Sydney, New South Wales

Medicine and TrattmatolOg)', University

1Jem11.1rk

Aust ralia

Hospi1al

Elizabeth de Solczio, MA, PhD

Wolfgang Ummenhofer, MD, DEAA

Professor ofAnesthcsiologr 1111d lmc.•tr:.ivc.· Cart•

S\,rctlcn

Univer>ity Ho�pit.;ll, Ba�cl. l>ep.�rtmcnl ol

Eric Voigtio, MD, PhD, FACS, FRCS

Dan bh Truuma Society

The Prince of Wale; Hospital

Advisor, Ecu,!,oci.llt' Pmfi.·�mr Surgery

Edina V5rkonyi

Cnpcnh.1gen Uni versity, t>cpanmcnt of

Department ofTraum,ttology, University ut

Abdominal Surgery aml Transplanta non

,

Rig�hu;pitaJct

Szcgcd Szeged

Hungary

Copcnh.1gen l>enm.trk

Pantelcimon Vassiliu, MD, PhD

Attending Surgeon

Vasso Tagkalakis

ATLS No�tionJI , PAC�

Jean Peloquin, �ID

)ame' B.uonc, MD, FACS

David M. Heimhach, Ml>, FACS

Philip W.

Perdue, I\ II> , FAC:S

) (Ed), I'I{CS (Eng)

Jo� Maria )over Navalon, MD, FAU;

Richard 1.. Judd, PhD

Rca Brown, \II>, FACS

(;crry Aunting. �ID

Andrew It Burgess, MD, FACS

Sylvia C.lmpbcll, MD, FACS C. lame' C.trrico, MD. FACS

C. Gen.- Cayten, \tiD, FAGS !>avid F.< lark , J\iD, FACS .

Ronald 1>. Cr.ug. M[) .

.

I'ACS

thcthJe '>ol�zio, PhD

Subt·ow ). Deb, M L)

Reed, fl.lD

Bernard Rik•y, I'I·ARCS

Jnhn B. Kortbcck, MD. FACS

Charles Ri IIkcr. M n. FACS

13rcnt Krantz., MD, Ft\CS

Avraham Rivkind, Mil

Inn R. Krohmer, MO, FACEP

Ronald F Rn,enth.tl , MD, FACS

Katherine lane, PhD

Gran� Rt)�ki, MD, FACS

Ann.t \1.

Doug l>.wey, MD

Eli7.

lome� F. Kellam, M 1), FllCS

J. Octavin Ruiz Sp

Chri�toph R. Kaufmann, MD, FAC:S

Howa rd B. Keith, MD, fACS

Richard E. Ourucy, MD, FACS

llerl>crt l'rottnr, M l >. FA< :s

Max I. Ramcnnf,kv, MD, FACS

l�regory ). Jurkovich, MD, FACS

Allen I· Bro"nl', MD. FACS

Pills, Mil FACS

Galen V. l'nnle, M 1>, FACS

Fran�ol\ Bertrand. MD Don E. Boyl e. M 1>. h\CS

Rod ney Peytnn , FRCS (Eel), MRCP

lame;, t-1. Ryan, �ICh, l RCS (Engl. RA..\IC

Lcdgcrwoml, MD, F'ACS

),tmes M. Salandcr, MD. FACS

Dcnni� G. Leland, MD, FACS

Gueidcr Sal.t>, .1\ID

l·r,tnk Lewi s, MD, FACS

Rocin S:inchct-Acdo LinJrc>

Edward B. Lucci, MD. F1\ChP

Thoma�o G. Saul, Mll. IACS

Ronald Dt!ni>. MD

Eduardo Luck, Ml J, 11ACS

)e.,us Dial l'ortoc.trrcro, /Vli), ...ACS

Thoma.' G. Luerssen, M 1), 1'1\CS

Tho rna' E. Swu,

Arnol•J Lutcrman, M l>, J'ACS

Stu.trt R. St·in·, :vJD. FACS

Frank X. Duto,

MS

M.trguc ril, l"t\CS

h•rn,tndn Ma gal lanes Negrete, MD

Steven It Shackford, MD, FACS

l>on,tld W. �·Iarion, MD, F'Al'S

Marc ). Shaptm, \t[), FACS

1\!i,hael R. �laruhn. DO. FACS

Thomas E. Sh,tvcr, 'Ill>. FACS

Barr) D. Martin. Yll>

Richard C. Simmtmd,, DVM, !liS

'>.tlvador Martin YlanduJano, f\.11 ) ...ACS

D:IVid V. Skinna. H�CS (Ed), FRCS (Eng)

William E l·a llun, J r, MD, FACS

Kimball

Arnold Sbdcn, M I>, I'ACS

llavid V. FcliLi.uto, MD, FACS

MMy C. McCarthy, MD. FACS

Ricardo Surmchc>rn, MD. FACS

Fmil.m Fcrmmdcz. MD

G�rald McCull.ough, MD, I;ACS

Gerald 0. Str;luch, MD, I•ACS

C.trlos Fcrnamlc7-Bttcllo, MD

lt•ltll E. McDermou, MD. I·ACS

Luther M. Strayer, i l l , MD

John ). Fikk,, MD, FACS

J,unc; A. McGo.!hee. DVM, MS

)ames K. Styncr, MIl

Ronald P. Hschcr, MD, FACS

William E McMan u,, MD, FAC:S

John E. Sulltln, )r, .\1 [),

Norman 1·. McSwain, )r., MD, FAC'>

joseph ). l'cpa�. lll, MD, I'ACS

PhilipS. Met?, MD. FACS

Stcphanc l .:t raeauh, �fU

Lc�'b M Flint, Jr. M0, FACS

Swvcn'>un l l.migan, MD, FACS

FoiJnini G., MD, FACS

,

L Maull, M 0, FACS

FACS

Cynthia L. Meyer, M D

Gregory 1\. l'imbcriJke, MD. FACS

Rich.ud l'ru�hling. MD

Sid ney F. Miller, MD, FACS

Sylvain G.tgnon, MD

Stanler Troobrn, MD. lACS

l:.me>l E. Moore, MD. I'ACS

Rkh.tr�i G:unclli, MD, FACS

Juh;ulne Morin, MD

Thoma� A. Gcn na rclli, M 0, FACS

h1y Uprrght

D.tvid Mulder,

Antonio Vern 11olc;�

Pclltl Gcbh.tnl

Raj K. Naraya n, MD, I;AC:S

Alan Verdant, Mil

J,tmes 13. Nichols, DVM, MS

1. Leone! Villuviccncio, M 11, FACS

r,tch.tn

Jnrge f l·oianini, MD FACS

IrJnk B. Miller, MD, FACS

.

),tmcs A. c,.:iJing, .MD, FCCP

John I!. (;cnrge, PhD

MD. I'ACS

Marlr n Odrio� ..ola

\ID

, .

,

FACS

Peter r;. Trahon MD. FACS

David Tuggle, M n. Ft\l..S

Franklin C. \\I;Jgncr, MD.

FACS

Roger litlhcrt�on, .1\ID

hankhn COlson, EdD

Robert \\'. Gillespie, MD, FACS

Gon1.alo O>trta P. MD, I'ACS

Clark Wam, !Ill>,

\l.tr< l;irou\, MD

Arthur Page, MD

). Ab ll.tllcr. Jr., MD. FACS

John A. Wctgch, \II>, FACS

)u.se Pa.iz Tejada

John \\-'c.t, Ml>. I·ACS

Steven X. Parks, MD, FACS

Robert ). \Vlutc. Ml>,

Chester (Chet} Paul, Ml>

Frcnwn t P. Wrrth MD, I·AC!'>

Burton I!. ll,tms. MD. I·ACS

M kh.td L l lowki ns, MD, fACS

lon l l tywood, I·RC:S (Eng), MRCS, .

)ll ntcs I>. Ik'kman, MD, FACS

LRCI'

Muk D. Pearlman, M 0

1\ndrcw B. Peizman, t MD, FACS

Raymond 1.. Warpcha, J\.1D. l-i\CS rACS

Fi\CS

,

Bradley D. Wong, MIl, FACS

Peter H. Worluck, DM, ... RCS (Ed), FRCS ( Eng)

•


C 0 U R S E 0 V ERV I E W: The Purpose, History, and Concepts of the ATLS Program

Program Goals The Advanced Trauma Life Support (ATLS) course provides its participants with a safe and reliable method for the im mediate treatment of injured patients and the basic knowl edge necessary to:

1

2

Establi:.h management priorities in a trauma situa tion.

3. Initiate primary and secondary management neces sary within the golden hour for the emergency man

•

agement of acute life-threatening conditions.

4 . In a given simulated clinical and surgical skills practicum, demonstrate the following skills, which are

Assess a patient's condition rapidly and accurately.

2. Resuscitate and stabilize patient� according to prior ity.

3. Determine whether a patient's needs exceed a facility's resources and/or a doctor's cap�1bilitics.

4. Arrange appropriately for a patient's interhospital or intrahospital transfer (what, who, when, and how).

5. Ensure that optimal care is provided and that th� level of care docs not deteriorate at any point during the evaluation, resuscitation, or transfer processes.

often required in the initial a'>sessment and treatment of patients with multiple injuries:

a. Primary and secondary assessment of a patient with simulated, multiple injudes

b. Eswblishment of a patent airway and initiation of one- and two-person ventilation

c. Orotracheal intubation on adult and infant manikins

d. Pulse oximetry and carbon dioxide detection in ex haled gas

e.

Cricothyroidotomy

f. Assessment and treatment or a patient in shock, particularly recognition of life-threatening hemor rhage

Course Objectives

g. Venous and intraosseous access h . Pleural decompression via needle thoracent�sis and chest tube insertion

The content and skills presented in this course aYe designed to assist doctors in providing emergency care for trauma pa tients. The concept of the "golden hour" emphasizes the ur gency necessary for successful treatment of injured patients and

s i

not intended to represent a "fixed" time period of 60

minutes. Rather, it is the window of opportunity during which doctors can have a positive impact on the morbidity

i.

ance of pericardiocentesis)

j.

tify and treat life-threatening and potentially life-threatening injuries w1der the extreme pressures associated with the care of these patienb in the fast-paced environment and anxiety of a trauma room. The ATLS course is applicable to all doctors in a variety of clinical situations. It is just as relevant to doc tors in a large teaching facility in North America or Europe as it is in a developing nation with rudimentary facilities.

Upon completion of the ATLS student course, tbe doc

tor will be able to:

1 . Demonstrate the concepts and principles of the pri mary and secondary patient assessments.

Clinical and radiographic identification of thoracic .

.

.

ll1JUfleS

k. U:.c of peritoneal lavage, ultrasound, and computed tomography (CT) in abdominal evaluation

I. Evaluation and treatment of a patient with brain injury, including use of the Glasgow Coma S�:alc

and mortality associated wilh injury. The ATLS course pro

vides the essential information and skills for doctors to iden

Recognition or cardiac tnmponade (and perform

score and CT of lhe brain

m. Assessment of head and fical examination

n. Protection of the spinal cord, <md radiographic and clinical evaluation of spine injuries

o. Mu�culoskeletal trauma a:.sessment and manage ment

p. Estimation of the size and depth of burn injury and volume resuscitation

q Recognition of the special problems of injuries in infants, the elderly. and pregnant \vomen

r.

Understanding of the principles of disaster man agement

.

.

XVII


•••

COURSE OVERVIEW

XVIII

when it is realized that trauma strikes down a society's

THE NEED Injury deaths worldwide were estimated at more than 5 mil lion in 2000 (Figure

I). The burden of injury is even more

•

significant, accounting tor 12o/o of the world's burden of disC. The greatest growth in recent years has been in the international community, and thii. group currently repre �ents .1pproximatcly more than half of all ATLS activity. The text for the course is revised a pp roximately every 4 years a nd incorpo rates new methods of evaluation and treatment that have becom e accepted parts of the arma mentarium of doctors who treat trauma pati ents Course revisions incorporate suggestion!. from members of the Sub committee on XfLS; members of the ACS COT; members of the international ATLS family; rcpre�entatives to the ATLS Sul)lornmittee from the American College of Emergency Phy:.ici ans and the American College of Anesthesiologists; and course instructors, coordinators, educators, and partic ipants. Changes that are made to the program reflect ac cepted verified practice patterns. not culli ng edge" techn ology or experi ment al methods. The international na ture.' of the program manda tes that the course be adaptable to a var ie ty of geograp hic, economic, social, and medical practice situations. To retain a current status in the ATLS Program, an individual must reverify with the latest edition o f the materials. A parallel course to the ATLS course is the Preho�pital Trauma Life Support (PHTLS) course, which is sponsored by the National Association of Emergency Medical Techni cians (NAEMT). The PHTLS cours e, developed i n cooper ation with the ACS COT, is based on the concepts of the ACS ATLS Progra m for Doctors and is conducted for emcrgem.-y medical technicians, paramedics, and nurses who are providers of prehospital trauma care. Other courses have been developed with sinlllar concepts and philosophies. for example, the Society ofTrauma Nur:.es offers the Advanced Trauma Care for Nurses (ATCN), which is also developed in coop erat ion with the ACS COT. The ATCN and ATLS courses are conducted parallel to each other with the nurses aud i tin g the ATLS lec tures and then partici pati ng in skill stations separate from th e ATLS skill stations conducted for doctors. The benefits of havi ng both prehosp ital and in hospital trauma personnel speaking the same "language" arc app.1rent. ,

.

,

"

INTERNATIONAL DISSEMINATION THE 1980c; AND 1990s The Al LS course was conducted natiom1lly for the first t ime under rhe a uspices of the AmeriGln College of Surgeons in

As a pi lo t project, the ATLS Progr am was exported outside of North America in 1986 to the Rep ubi ic of Tr i nidad and Tobago. The ACS Board of Regen ts gave permission in 1 987

•


COURSE OVERVIEW for promulgation of the ATLS Program in other countries. The ATLS Progrru:n may be requested by a recognized sur gical organization or ACS Chapter in another country by

27. Netherlands, The (Dutch Trauma Society) 28. New Zealand ( Royal Australasian College of Surgeons)

conespondlng with the ATLS Subcommittee Chairperson, care of the ACS ATLS Program Of(icc, Chicago, IL. At Lhc time of publication, 47 cow1tries were actively providing the ATLS course lo their doctors. These countries include:

1 . Argentina (ACS Chapter and Committee on Trauma) 2. Australia { Royal Australasian CoUcgc of Surgeons) 3. Bahrain (Kingdom of Saudj Arabia ACS Chapter and Committee on Trauma)

4. Bolivia ( Bolivian Surgeons Society) 5. Brazil (ACS Chapter and Committee on Trauma) 6. Canada {ACS Chapters and Provi ncial Committees on Trauma)

7. Chile (ACS Chapter and Committee on Trauma)

29. Norway (Norwegian Surgical Society) 30. Pakistan (College of Physicians and Surgeons Pakistan)

31. Panama (ACS Chapter and Committee on Trauma) 32. Papua New Guinea (Royal Australasian College of Surgeons)

33. Peru (ACS Chapter and Committee on Trauma) 34 . Portugal (Portuguese Society of Surgeons) 35. Qatar (Kingdom of Saudi Arabia ACS Chapter and Committee on Trauma)

36. Republic of China, Taiwan (Surgical Association of the Republic of China, Taiwan)

37. Republic of Singapore (Chapter of Surgeons,

8. Colombia (ACS Chapter and Committee on Trauma) 9. Costa Rica (College of Physicians and Surgeons of

Academy of Medicine)

38 . Republic of South Africa (South African Trauma

Costa Rica)

1 0. Cyprus (ACS Chapter and Committee on Trauma, Greece)

1 1 . Denmark (Danish Trauma Society) 1 2 . Ecuador (ACS Chapter and Commillee on Trauma) 13. Fiji and the nations of the Southwest Pacific (Royal Australasian College of Surgeons)

14. Germany (German Society for Trauma Surgery and Task Force for Early Trauma Care)

1 5 . Greece (ACS Chapter and Committee on Trauma) 16. Grenada (Society of Surgeons of Trinidad and 'lbbago)

Society)

39. Spain (Spanish Society of Surgeons) 40. Sweden (Swedish Society of Surgeons) 41 . Switzerland (Swiss Society of Surgeons) 42 . Thailand (Royal College of SllTgeons of Thailand) 43. 11-i.nidad and Tobago (Society of Surgeons of Trinidad and Tobago)

44. United Arab Emirates (Surgical Advisory Committee) 45. United Kingdom { Royal College of Surgeons of England)

46. United States, U.S. territories (ACS Chapters and State

17. Hong Kong (ACS Chapter and Committee on Trauma)

•

XXI

Committees on Tra uma)

47. Venezuela (ACS Chapter and Committee on Trauma)

18. Hungru·y ( Hungarian TraLm1a Society) 1 9. Indonesia ( Indonesian Surgeons Association) 20. Ireland ( Royal College of Surgeons in lrebnd)

·

The Concept

21 . Israel (Israel Sw-gical Society) 22. Italy (ACS Chapter and Committee on Trauma) 23. Jamaica (ACS Chapter and Committee on Twuma) 24. KjJ1gdom of Saudi Arabia (ACS Chapter and Committee on Traw11a)

25. Lithuania (Lithuanian Society of Traumatology and Orthopaedics)

26. Mexico (ACS Chapter and Committee on Trauma)

The concept behind the ATI.S course has remained simple. Historical ly, the approach to treating injured patients, as taught in medical schools, was the same as that for patients with a previously undiagnosed medical conrution: an ex tensive history inclurung past merucaJ history, a physical e...x amination starting at the top of the head ru1d progressing down the body, the development of a differential ruagnosis, and a list of adjuncts to confirm the diagnosis. .AJthough this approach was adequate for a patient with diabetes mellitus


• •

COURSE OVERVIEW

XXII

and many acute surgical illnesses, it did not satisfy the needs of patients suffering life-threatening injuries. The approach required change. Three underlying con cepts of the ATLS Program were. initially difficult to accept:

,

The Impact

ATLS training for doctors i n a developing country has re sulted i n a decrease i n injury mortality. Lower per capita rates of deaths from i nj uries arc observed in areas where doctors have ATLS train ing In one study, a small trauma

1 . Treat the greatest threat to life first.

.

2. The lack of a definitive diagnosis should never im pede the application of an indicated treatment.

3. A detailed history is not essential to begin the evalua tion of a patient with acute injuries.

team led by a doctor with AT LS experience had equivalent

patient survival when compared with a larger team with more doctors in an urba11 setting. l n addition, there were more unexpected survivors than fatalities. There is abun dant evidence tJ1at ATLS training improves the knowledge base, the psychomotor skills and their use in resuscitation,

The result was the development of the ABCDE approach to

and the confidence and performance of doctors who have

the evaluation and treatment of injured patients. These con

taken part in the program. The organization and procedural

cepts are also in keeping with the observation that the care

skills taught in the course are retained by course participants

of injured patients in many circumstances is a team effort,

for a t least 6 years, which may be the most significant impact

allowing medical personnel with special skills and expertise

of all.

to provide care s.imultaneously wi th surgical leadership of the process

.

"n1e ATLS course emphasizes that injury kills i n certain reproducible time frames. For example, the loss of an air way kills more quickly than does lhe loss of the ability to breathe. The latter kills more quic kly than loss of ci_rculating

Acknowledgments

blood volume. The presence of an expanding intracranial

The COT of Lhe ACS and the ATLS Subcommittee gratefully

mass lesion is the next most lethal problem Thus, the

acknowledge tbe following organizations for their time and

mnemonic ABCDE defines the speci fie, ordered evalua Lions

efforts in developing and field testing the Advanced Traw11a

.

and interventions that should be followed in all injured

Life Support concept: The Lincoln Medical Education FoUil

patients:

dation, Southeast Nebraska Emergency Medical Services, the University of Nebraska College of Medicine, and the Ne braska State Committee on Trauma of the ACS. The com

Airl.vay with cervical spine protection

mittee also is indebted to the Nebraska doctors who

Breathing

supported the devel opment of this course and to tl1e Lin

coln Area Mobile Heart Team Nurses who shared their time

Circulation, stop the bleeding

and ideas to help build it. Appreciation is extended to the

Disability or neurologic status

organizations identified previously in this overview for their

Exposure (undress) and Environment (temperature

support of the worldv.ride promulgation of the course. Spe cial recognition is given to tbe spouses, significant others,

control)

children, and practice partners of the ATLS instructors and students. The time that doctors spend away from their homes and practices and effort afforded to this voluntary program are essential components for the existence and suc

Course Overview

cess of the ATLS Program

.

The AILS course emphasizes the rapid initial assessment and primary treatment of in j ured patients, starting at the time of injury and continuing through initial assessment, lifesaving intervention, reevaluation, stabilization, and,

Summary

when needed, transfer to a trauma center. The course consists of precourse and postcourse lests, core content

The ATLS course provides an easily remembered approach

lectures,

to the eva ·luation and treatment of injured patients for any

in teract ive case presentations,

discussions,

development or lifesaving skills, practical laboratory ex periences, and a final performance proficiency evaluation. Upon completion of the course, doctors should feel con

doctor, irrespective of practice specialty, even under the

stress, anxiety, and intensity that accom panies the resusci tation process. In addition, the program provides a common

fident in implementing the skills taught in the ATLS

language for all providers who care for injured patients. The

course.

ATLS course provides a foundation for evaluation, treat-


...

COURSE OVERVIEW ment, education, and quality assurance-i n

short, a system of trauma care that is mea�urable, reproducible, and com prehensive.

The ATLS Program has had a positive i mpad 1997;57:272-273.

25.

ization with regi.Hranl performance in the Advanced Trauma

26. National Safety Council. lniun tional Safety Council.

I 0. Ben Abraham R, Stdn M. Kluger Y, et al. ATLS course in emer

1997; 132:695-697, 743.

R, Stei n M, K luger Y, et al. The impact of Ad vanced Trauma Life Support Cou rse on graduates with non-

J I . Ben Abrah am

t:1cts

(1999). ltasca. IL: :-.Ia

27. 1\ourj ah P. National hospital ambulatory medical care su rvey: 1997 emergency department summary. Adv DatJ 1999;304: 1-24.

GD). Meeuwis ID, Bolhuis HW, et al. Clinical im advanced traun-..1 life �upport. Am I Eme.1g 1\.fcd

2!1. O lden van

2004;22;522-525. 29.

Rutledge R, Fakhry S�l, Baker CC., cl al. A population-based study of the association of mcdkal manpower with count} trauma death rates n i the United State�. Ann Surg 1994;219:547-563.

30.

Walsh DP. Lammert GR, Dl·voll J. The etTectiveness of the ad vanced trauma life support s)'stcm in a mass casualty situation by non-trauma e Kp erienced physicians: Grenada 1983. / Fmct��

Tife Support cour�e. I Emerg Alcd 1984;2: 137- 140.

gency medicine for physician.�. 1/.m:fu.Ih

National Center for l lcalth Statistics: Injury vis its to cmcr gency departments. please state so.

pact of

9. Ap raham ian C. Nelson KT. fho mpson BM, et at. l he rel;t tionsh ip of the level of training and area of medical �pec ial

Life �upport

aboard RFA Argu�. I R Nav Mcd Sen' 1992;78:23-26.

vanced Trau ma Li fe Support program as demonstrated by an

6. Ali

Rll. Advanced Trauma

.

Med 1989;7: 175- 1 80.


•

XXIV 3!.

COURSE OVERVIEW

Williams MJ, Lockey AS, Cutshaw MC. Improved trauma management wilh Advanced Trauma Life Support (ATLS) training. I Accident .Emerg Med 1.997;14:8 1.-83.

32. World Health Organization. The Injury Chart Boo]\: a Graph ical Overview oftl1e Global Burden ofInjuries. Geneva: VVorld Health Organization Department of Injuries and Violence lJre vention. Noncommunicable Di.seascs and Mental T lealth Ch.ls ter; 2002.

33. World Health Organization. \liolence and Injury Prevention and Disability ( VIP). http://www.who.int/violence_injur)•_ prevention/publica Lions/other_injuryIchartb/en/index.hLml. Accessed January 9, 2008. 34. World Health Organiz.ation. World Report on Road Tmflic In jury Prevention. Geneva: World Health Organization.

•


CONTENTS -

v

Foreword

..

Preface

VII

xviii

Course Overview

1

Initial Assessment and Management

1

OBJECTIVES

10 10

Introduction Preparation Prehospital Phase Hospital Phase

Triage Multiple Casualties Mass Casualties

Primary Survey Airway Maintenance with Cervical Spine Protection Breathing and Ventilation Circulation with Hemorrhage Control Disability (Neurologic Evaluation) Exposure/Environmental Control

Resuscitation Airway Breathing/Ventilation/Oxygenation Circulation and Bleeding Control

Adjuncts to Primary Survey and Resuscitation Electrocardiographic Monitoring Urinary and Gastric Catheters

2

1

2 2

2 2 4 4 4 4 5

6 7

7

7 8

8 8 8 9

9 9

Other Monitoring X-Ray Examinations and Diagnostic Studies

Consider Need for Patient Transfer Secondary Survey History Physical Examination

25

Introduction Airway

26

Problem Recognition Objective Signs of Airway Obstruction

Ventilation Problem Recognition Objective Signs of Inadequate Ventilation

11

11 12

Adjuncts to the Secondary Survey Reevaluation Definitive Care Disaster Records and Legal Considerations

16

Records Consent for Treatment Forensic Evidence CHAPTER SUMMARY BIBLIOGRAPHY

17 17 17 18 18

�� SKILL STATION 1: Initial Assessment and Management

16 17 17 17

19

Skill I-A: Primary Survey and Resuscitation Skill l-8: Secondary Survey

20

and Management

21

Skiii i-C: Patient Reevaluation Skill t-O: Transfer to Definitive Care

24

Ai�way and Ventilatory Management OBJECTIVES

10

Airway Management

24

25 28

Airway Maintenance Techniques Definitive Airway Airway Decision Scheme

29 32 39 39

28

Management of Oxygenation Management of Ventilation

28 28

CHAPTER SUMMARY BIBLIOGRAPHY

26

26 27

39 40 41 XXV


•

XXVI

CONTENTS Skiii ii-F: Laryngeal Tube Airway (LTA)

�� SKILL STATION II: Airway and Ventilatory Management

43

Skill 11-A: Oropharyngeal Airway Insertion

44

•

Skill ll-8: Nasopharyngeal Airway Insertion

44

Skill 11-C: Bag-Mask Venti lation: Two-Person

Technique

44 45

Skill li-E: Laryngeal Mask Airway (LMA)

Insertion

3

46

Skiii ii-H: Infant Endotracheal Intubation

46

Skill Il-l: Pulse Oximetry Monitoring

47

Skiii ii-J: Carbon Dioxide Detection

48

Scenarios

49

�� SKILL STATION Ill:

Skill ll-0: Adult Orotracheal lntubation (with

and without Gum Elastic Bougie Device)

Insertion

45

Cricothyroidotomy

51

Skill Ill-A: Needle Cricothyroidotomy

52

Skill 111-8: Surgical Cricothyroidotomy

52 •

Shock

55

OBJECTIVES

55

Introduction Shock Pathophysiology

56 56

Basic Cardiac Physiology Blood Loss Pathophysiology

56 56

Initial Patient Assessment

57

Equating Blood Pressure with Cardiac Output Advanced Age Athletes Pregnancy Medications Hypothermia Pacemaker

Recognition of Shock Clinical Differentiation of Cause of Shock

58 58

Hemorrhagic Shock in Injured Patients

59

Reassessing Patient Response and Avoiding Complications

60 60 61

Continued Hemorrhage Fluid Overload and CVP Monitoring Recognition of Other Problems

Definition of Hemorrhage Direct Effects of Hemorrhage Fluid Changes Secondary to Soft Tissue Injury

Initial Management of Hemorrhagic Shock Physical Examination Vascular Access Lines Initial Fluid Therapy

Evaluation of Fluid Resuscitation and Organ Perfusion Urinary Output Acid/Base Balance

Therapeutic Decisions Based on Response to Initial Fluid Resuscitation Rapid Response Transient Response Minimal or No Response

Blood Replacement Crossmatched, Type-Specific, and Type 0 Blood Warming Fluids-Plasma and Crystalloid Autotransfusion Coagulopathy Calcium Administration

Special Considerations in the Diagnosis and Treatment of Shock

62

62 62 63 64

64 64

CHAPTER SUMMARY BI BLI OG RA PHY

and Management

Skill IV-A: Peripheral Venous Access

Technique

73

74 74

Skiii iV-C: Subclavian Venipuncture:

Infraclavicular Approach

65 65 65

Skiii iV-E: lntraosseous Puncture/Infusion:

66

68 68 69 69 69

Skiii iV-8: Femoral Venipuncture: Seldinger

Skiii iV-0: Internal Jugular Venipuncture:

66 66 66 66 66

68

�� SKILL STATION IV: Shock Assessment

64

66

66 67 67 67 67 67 67

Middle or Central Route Proximal Tibial Route

76 76 77

Skill IV-F: Broselow'M Pediatric Emergency

Tape

78

Scenarios

79

�� SKILL STATION V: Venous Cutdown (Optional Station)

Skill V-A: Venous Cutdown

83

84


C O NTENTS

4

85

Thoracic Trauma OBJECTIVES

85

•

Subcutaneous Emphysema 98 Crushing Injury to the Chest (Traumatic Asphyxia) 98 98 Rib, Sternum, and Scapular Fractures

Introduction 86 Primary Survey: life-Threatening Injuries 86 Airway Breathing Circulation

86 86 90

Resuscitative Thoracotomy Secondary Survey: Potentially Life-Threatening Chest Injuries

92

Simple Pneumothorax Hemothorax Pulmonary Contusion Tracheobronchial Tree Injury Blunt Cardiac Injury Traumatic Aortic Disruption Traumatic Diaphragmatic Injury Blunt Esophageal Rupture

93 93 94 94 94 95 96 96

CHAPTER SUMMARY BIBLIOGRAPHY

99 100

�· SKILL STATION VI: X-Ray Identification of Thoracic Injuries

103

Skill VI-A: Process for Initial Review of

Chest X-Rays

1 04

Thorax X-Ray Scenarios

106

�· SKILL STATION VII: Chest Trauma Management

97

107

Skill VIl-A: Needle Thoracentesis

108

Skill VII-B: Chest Tube Insertion

108

Skill VII-C: Pericardiocentesis

109


111

OBJECTIVES

111

Specific Diagnoses

121

Introduction External Anatomy of the Abdomen Internal Anatomy of the Abdomen

112 112 112

Diaphragm Injuries Duodenal Injuries Pancreatic Injuries Genitourinary Injuries Small Bowel Injuries Solid Organ Injuries Pelvic Fractures and Associated Injuries CHAPTER SUMMARY BI BLIOGRAPHY

121 121 121 121 121 121 122

Peritoneal Cavity Retroperitoneal Space Pelvic Cavity

112 113 113

Mechanism of Injury

113

Blunt Trauma Penetrating Trauma

113 113

Assessment History Physical Examination Adjuncts to Physical Examination Evaluation of BluntTrauma Evaluation of Penetrating Trauma

Indications for laparotomy in Adults

6

Other Indications for Chest Tube Insertion 98

92

Other Manifestations of Chest Injuries

5

••

XXVII

115

115 115 116 118 119 120

••

SKILL STATION VIII: Diagnostic

Peritoneal lavage

Skill VIll-A: Diagnostic Peritoneal lavage:

Open Technique

Skill VIII-B: Diagnostic Peritoneal Lavage:

Closed Technique

127

128 128

131

Head Trauma OBJECTIVES

131

Introduction Anatomy

132 132

Scalp Skull

124 124

132 132

Meninges Brain Ventricular System Tentorium

Physiology

133 134 135 135 135


•••

XXVIII

CONTENTS

Intracranial Pressure Monro-Kellie Doctrine Cerebral Blood Flow

Classifications of Head Injuries Mechanism of Injury Severity of Injury Morphology

Management of Minor Brain Injury (GCS Score 13-15) Management of Moderate Brain Injury (GCS Score 9- 1 2) Management of Severe Brain Injury (GCS Score 3-8) Primary Survey and Resuscitation Secondary Survey Diagnostic Procedures

Medical Therapies for Brain Injury Intravenous Fluids Hyperventilation Mannitol Steroids

7

135 135 136 137

137 138 138 140 142 142

142 144 144 146

146 146 146 147

Barbiturates

Anticonvulsants

Surgical Management

1 57

Introduction Anatomy and Physiology

158 158

149

CHAPTER SUMMARY

150

BIBLIOGRAPHY

150

Trauma: Assessment and Management 153 Skill IX-A: Primary Survey

Management Head

154

Skiii iX-D: Helmet Removal

155

Scenarios

156

157 Blunt Carotid and Vertebral Vascular Injuries

X- Ray Evaluation

166 166

Cervical Spine Thoracic and Lumbar Spine

CHAPTER SUMMARY

162 162 163 163

BIBLIOGRAPHY

Atlanto-Occipital Dislocation Atlas Fracture (C1) C1 Rotary Subluxation Axis (C2) Fractures Fractures and Dislocations (C3 through C7) Thoracic Spine Fractures (T1 through T1 0) Thoracolumbar Junction Fractures (T1 1 through L1) Lumbar Fractures Penetrating Injuries

154

Skiii iX-C: Evaluation of CT Scans of the

162

Specific Types of Spinal Injuries

154

Skiii iX-8: Secondary Survey and

Classifications of Spinal Cord Injuries Level Severity of Neurologic Deficit Spinal Cord Syndromes Morphology

149

�� SKILL STATION IX: Head and Neck

160 160 161 162

159

1 48 148 148 148

Prognosis Brain Death

Spinal Column Spinal Cord Anatomy Sensory Examination Myotomes Neurogenic Shock versus Spinal Shock Effects on Other Organ Systems

158

148

Scalp Wounds Depressed Skull Fractures Intracranial Mass Lesions Penetrating Brain Injuries

Spine and Spinal Cord Trauma OBJECTIVES

148 148

General Management

166 168 168

Immobilization Intravenous Fluids Medications Transfer

168 170 170 171 172 172

�� SKILL STATION X: X-Ray

Identification of Spine Injuries

175

163

Skill X-A: Cervical Spine X·Ray Assessment

176

163 164 164 164 165 165

Skill X·B: Atlanto-Occipital Joint Assessment 1 77 Skill X-C: Thoracic and Lumbar X-Ray

Assessment

178

Skill X-D: Review Spine X-Rays

1 78

Spine X-Ray Scenarios

178

�· SKILL STATION XI: Spinal Cord Injury: 166 166 166

Assessment and Management

181

Skill XI·A: Primary Survey and Resuscitation-

Assessing Spine Injuries

182

•


CONTENTS Skill XI·B: Secondary Survey-Neurologic

Assessment

8

182

Patients with Spinal Cord Injuries

..

Immobilization and Logrolling

182

Musculoskeletal Trauma Introduction Primary Survey and Resuscitation Adjuncts to Primary Survey Fracture Immobilization X-Ray Examination

Secondary Survey History Physical Examination

Potentially Life-Threatening Extremity Injuries

limb-Threatening Injuries Open Fractures and Joint Injuries Vascular Injuries, Including Traumatic Amputation Compartment Syndrome Neurologic Injury Secondary to Fracture Dislocation -

Other Extremity Injuries

1 87

Femoral Fractures Knee Injuries Tibia Fractures Ankle Fractures Upper-Extremity and Hand Injuries

188 188 188

188 189 189

189 190

Pain Control Associated Injuries Occult Skeletal Injuries CHAPTER SUMMARY BIBLIOGRAPHY

192

�

SKILL STATION XII: Musculoskeletal Trauma: Assessment and Management 205 Skill XII·B: Principles of Extremity

195 196

Skill XII-C: Realigning a Deformed Extremity 207

Immobilization

Depth of Burn

Primary Survey and Resuscitation of Patients with Burns

207 208

197

Skill XII-E: Compartment Syndrome: Assessment and Management

209

197

Skill XII-F: Identification and

Management of Pelvic Fractures

209

Skill XII-G: Identification of Arterial Injury

210

Scenarios

210

Thermal Injuries

Body-Surface Area

206

Skill XII·D: Application of a Traction Splint

19 9

History

201 201 202 202

194

Principles of Immobilization

Assessment of Patients with Burns

200

Skill XII-A: Physical Examination

197 199 199

Introduction Immediate lifesaving Measures for Burn Injuries

199 200 200 200 200

194

Contusions and Lacerations Joint Injuries Fractures

OBJECTIVES

183

1 87

Major Pelvic Disruption with Hemorrhage 192 Major Arterial Hemorrhage 193 Crush Syndrome (Traumatic Rhabdomyolysis} 194

Airway Stop the Burning Process Intravenous Access

183

Skill XI·E: Principles of Spine

OBJECTIVES

9

XXIX

Skill XI·D: Treatment Principles for

Skill XI·C: Examination for Level of

Spinal Cord Injury

•

21 1 211

212

Airway Breathing Circulating Blood Volume

213 213 216

212

Secondary Survey and Related Adjuncts

217

212 212 212

Physical Examination Documentation Baseline Determinations for Patients with Major Burns Peripheral Circulation in Circumferential Extremity Burns Gastric Tube Insertion Narcotics, Analgesics, and Sedatives Wound Care

217 217

213

213 213 213 213

217 217 217 217 217

•


XXX

CONTE NTS

217 218

Antibiotics Tetanus

Special Burn Requirements Chemical Burns Electrical Burns

Patient Transfer Criteria for Tra nsfer Transfer Procedures

Cold Injury: Local Tissue Effects

10

218 •

218 218

219

219 219

Types of Cold Injury Management of Frostbite and Nonfreezing Cold Injuries

Cold Injury: Systemic Hypothermia Signs Management

219 220 221

221 221

CHAPTER SUMMARY

223

BIBLIOGRAPHY

224

219

Pediatric Trauma

225 •

OBJECTIVES

225

Introduction Types and Patterns of Injury Unique Characteristics of Pediatric Patients

226

Size and Shape Skeleton Surface Area Psychological Status Long-Term Effects Equipment

Airway: Evaluation and Management Anatomy Management

226 226

226 227 227 227 227 228 228

228 228

Breathing: Evaluation and Management 232 Breathing and Ventilation Needle and Tube Thoracostomy

Circulation and Shock: Evaluation and Management Recognition Fluid Resuscitation Blood Replacement Venous Access Urine Output

11

232 233 233

233 234 235 235 236

Thermoregulation

Chest Trauma Abdominal Trauma Assessment Diagnostic Adjuncts Nonoperative Management Specific Visceral Injuries

Head Trauma Assessment Management

Spinal Cord Injury

237 237 237

237 237 238 239 239

239 241 241

Anatomic Differences Radiologic Considerations

241 241


242

History Blood Loss Special Considerations of the Immature Skeleton Principles of Immobilization

242 242 242 242

The Battered, Abused Child Prevention

242

CHAPTER SUMMARY

244 244

BIBLIOGRAPHY

Geriatric Trauma

243

247

OBJECTIVES

247

Introduction Types and Patterns of Injury Airway Breathing and Ventilation Circulation

248

251

Special Circumstances

254

Changes with Aging Evaluation and Management

251 251

Medications Elder Abuse End-of-Life Decisions

254 255 25 5

248 250 250

Disability: Brain and Spinal Cord Injuries 252 Changes with Aging Evaluation and Management

252 252

Exposure and Environment Other Systems Musculoskeletal System Nutrition and Metabolism Immune System and Infections

253 253

253 254 254

CHAPTER SUMMARY

256

BIBLIOGRAPHY

257


.

XXXI

CONTENTS

12

Trauma in Women

25 9. •

OBJECTIVES

Introduction Anatomic and Physiologic Alterations of Pregnancy Anatomic Differences Blood Volume and Composition Hemodynamics Respiratory System Gastrointestinal System Urinary System Endocrine System Musculoskeletal System Neurologic System

13

259 260 260

260 261 261 262 262 262 263 263 263

Mechanisms of Injury Blunt Injury Penetrating Injury

Introduction 270 Determining the Need for Patient Transfer 270

Transfer Responsibilities Referring Doctor Receiving Doctor

Modes of Transportation

Appendices

266

CHAPTER SUMMARY

267 267

BIBLIOGRAPHY

270 270 273

Transfer Protocols Information from Referring Doctor Information to Tra nsferring Personnel Documentation Treatment Prior to Transfer Treatment During Transport

Vehicular Impact Pedestrian Injury Injury to Cyclists Falls 285 Blast Injury

266

274

274 274 274 274 276

273 27 3

Transfer Data

276

CHAPTER SUMMARY

273

BIBLIOGRAPHY

276 276

279 279 279 279

Develop and Test Interventions Implement Injury-Prevention Strategies Evaluate Impact Appendix A Summary

280

BIBLIOGRAPHY

280 280

RESOURCES

Appendix B: Biomechanics of Injury Introduction Blunt Trauma

264 265 265 265

Perimortem Cesarean Section Domestic Violence

Appendix A: Injury Prevention

Define the Problem Define Causes and Risk Factors

264

Primary Survey and Resuscitation Adjuncts to Primary Survey and Resuscitation Secondary Assessment Definitive Care

277

Classification of Injury Prevention Haddon Matrix The Four Es of Injury Prevention Developing an Injury Prevention Program-The Public Approach

264

269 269

Timeliness of Transfer Transfer Factors

263 263

Severity of Injury Assessment and Treatment

Transfer to Definitive Care OBJECTIVES

263

281 281 281 281 282 282

283 283 283

283 285 285

Penetrating Trauma Velocity Bullets Shotgun Wounds Entrance and Exit Wounds BIBLIOGRAPHY

286

286

286 287 287 288 288


• •

XXXII

CONTENTS

Appendix C: Trauma Scores: Revised and Pediatric Introduction Revised Trauma Score Pediatric Trauma Score

289 "'289 289

Level of Consciousness Musculoskeletal Injury Use of the PTS

289 289 289 289

Size 289

Appendix D: Sample Tra uma Flow Sheet

293

Appendix E: Tetanus Immunization

297

Introduction General Principles Surgical Wound Care

297 297

Passive Immunization BIBLIOGRAPHY

297

Appendix F: Ocular Trauma (Optional lecture) OBJECTIVES

299

Introduction Assessment

299

Patient History History of Injury Incident Initial Symptoms Physical Examination

Specific Injuries Eyelid Injury Corneal Injury Anterior Chamber Injury

298 298

299

299 299 300 300 301

301 301 301

299 Injury to the Iris Injury to the Lens Vitreous Injury Injury to the Retina Globe Injury Chemical Injury Fractures Retrobulbar Hematoma Fat Emboli Appendix F Summary BIBLIOGRAPHY

301 301 301 302 302 302 302 303 303 303 303

Appendix G: Austere Environments: Military Casualty Care and Trauma Care in Underdeveloped Areas and Following Catastrophes (Optional lecture) 305 OBJECTIVES

305

Introduction Background Austere and Hostile Environments: Context

305

Personnel and Their Safety Communication and Tra nsportation Equipment and Supplies Military Combat Casualty Care

306 306 306 306

Medical Units Other Challenging Environments

Preparation and Planning

305

Airway Ventilation and Oxygenation Chest Injuries

Management of Circulation 305

307

307 307

Travel to an Austere or Hostile Environment Preparation of a Hospital for Becoming an Austere or Hostile Environment

308

Management of Airway and Breathing

308

307

Hemostasis Resuscitation

Pain Management Management of Specific Injuries Abdominal Injuries Extremity Injuries Burn Injuries

Preparation for Transport Environmental Extremes of Heat and Cold Cold Injury and Hypothermia Heat-Related Illness or Injury

308 309 310 310

310 311 312 312

312 313 314 314 315

315 315

•


CONTENTS

Communications and Signaling Triage

Appendix

316

Appendix G Summary

318

317

BIBLIOGRAPHY

318

H: Disaster Management and Emergency Preparedness 321

(Optional lecture) OBJEGIVES

321

Mitigation

Introduction The Need The Approach Phases of Disaster Management

321 321

Response

Preparation

Recovery

324

33 1 335

324

B I BLIOGRAP H Y

335

335

OBJECTIVES

337

Triage Is Continuous (Retriage)

Introduction Definition of Triage Principles of Triage

33 7 337

Triage Scenario 1: Gas Explosion in

337

Triage Scenario II: Gas Explosion in

Do the Most Good for the Most Patients Using Available Resources Make a Decision Triage Occurs at Multiple Levels Know and Understand the Resources Available Planning and Rehearsal Determine Triage Category Types

•

326 327 330

Pitfalls Appendix H Summary

324

Appendix 1 : Triage Scenarios

Index

...

XXXIII

337 337 337 338 338 338

the Gymnasium

the Gymnasium (continued) Triage Scenario Ill: Tra iler Home Explo sion and Fire Triage Scenario IV: Cold Injury Triage Scenario V: Car Crash Triage Scenario VI: Train Crash Disaster

338 339 342 344 346 348 350

351

•


C H APT E R

CHAPTER OUTLINE Objectives

Upon completion of this topi c the student will demonstrate the ability to a pply the p rinciples of emergency medical care to multiply InJUred pa lients. S pecific ally the doctor will be ,

,

Introduction

able to·

Preparation Prehospital Phase Hospital Phase

OBJECTIVES

Triage Multiple Casualties Mass Casualties Primary Survey Airway Maintenance with Cervical Spine Protection Breathing and Ventilation Circulation with Hemorrhage Control Disability (Neurologic Evaluation) Exposure/Environmental Control Resuscitation Airway BreathingfVentilation/Oxygenation Circulation and Bleeding Control Adjuncts to Primary Survey and Resuscitation Electrocardiographic Monitoring Urinary and Gastric Catheters Other Monitoring X·Ray Examinations and Diagnostic Studies Consider Need for Patient Transfer Secondary Survey H istory Physical Examination Adjuncts to the Secondary Survey Reevaluation Definitive Care Disaster Records and Legal Considerations Records Consent forTreatment Forensic Evidence Chapter Summary Bibliography

Identify the correct sequence of priorities for as sessment of a multiply i njured patient. Apply the principles outlined in the primary and secondary evaluation surveys t o t h e assessment of a multiply injured patient. Apply guidelines and techniques i n the initial re suscitative and definitive-care phases of treatment of a mu ltiply injured p a tient .

Explain how a patient's medical h istory and the mechanism of injury contribute to the identifica tion of injuries. Identify the pitfalls associated with the initial as sessment and management of an injured patient and take steps to minimize their impact. Conduct an initial assessment survey on a simu lated multiply injured patient, using the correct sequence of priorities and explaining manage ment techniques for primary treatment and stabi l ization

.


CHAPTER

2

1

•

Initial Assessment and Management -

Introduction .

The treatment of serio usly inj ured pat ients requires rapid assessment of the inju ries .md

institution of life-preserving therapy. Because time is of the essence, a systematic ap proach that can be easily reviewed and pract iced is most ef fective This process is termed ''initial assessment" and .

includes: •

Preparati on

•

Triage

•

Primary survey (A BCDEs)

• Resu:.cital ion •

Adju nc ts to primary survey and resuscitation

•

Cons i der need

•

Second try survey (head-to-toe evaluation and pa

for patient transfer

,

tient history)

• Adj uncts to the seconda ry survey • Cont in ued post rcsuscita tion mo nitoring and

PREHOSPITAL PHASE

reeval uation

•

•

Coordination with the prehospital agency and perso n nel

Definitive care

can greatly expedite treatment in the field. The prebospi tal

The primary and secondary surveys should be repeated frequently to identify any deterioration in the patient's status and to determine whether it is necessary to institute any treat ment when adverse changes are identified. The assessment sequence presented in this chapter reflects a linear, or long i tudi nal progression of event s Ln an actual clin ical situation many of these activities occur in parallel or si multaneously. The lo ngitudina l progression of the assessment process allows the doctor an opp ortuni ty to m entally review the progress of nn actua l trauma resuscitation. ATLS® principles guide the assessment and resuscita tion of injured patients. Judgment is required to determine which procedures are necessary, because not all patients re quire all ofthese procedures. .

,

,

up to not ify the receiving hos pital be fore personncl tramport the pati ent from the scene. This aJ Iow� for mobili:�ation of the hospital s trauma team members so that houlcl be set

'

'

,

,

.

,

,

.

.

Preparation

The National Asso20 mph) impact •Motorcycle crash >20 mph

• Intrusion: >12 in, occupant site: >18 in, any site Step 3

• Ejection (partial or complete) from automobile · Death in same passenger compartment •

Vehicle telemetry data consistent with high risk of injury

Transport to closest appropriate trauma center which, depending on the trauma system, need not be the highest level trauma center

•Age • Older adults: Risk of injury/death increases after age 55 • Children: Should be triaged preferentially to pediatric-capable trauma centers

Assess special patient or system considerations

•Time-sensitive extremity injury ·Pregnancy >20 weeks •EMS provider judgement •End-stage renal disease requiring dialysis

•Anticoagulation and bleeding disorders Step

4

·Burns • Without other trauma mechanism: Triage to purn facility With trauma mechanism: Triage to trauma center

•

Contact medical control and consider transport to

Transport according

trauma center or a specific resource hospital

to protocol

When in doubt, transport to a trauma center

•

Figure 1 - 1 Field Triage Decision Scheme.

3


4

CHAPTER 1

•

I n itia l Assessment

and Management

trauma patients. Proper airway equipment (eg, laryngo scopes and tubes) should be organized, tested, and placed where it is immediately accessible. Warmed in travenous crystalloid solutions shouJd be available ancL ready to infuse when the patient arrives. Appropriate

Two types of triage situations usually exist: multiple ca sua I ties and mass casualties.

MULTIPLE CASUALTIES

monitoring capabilities should be immediately available.

In mtlltiple-casualty incidents, the 1mmber of patients and

A method to summon additional medical assistance

the severity of their injuries do not exceed the ability of the

should be i n place, as well as a means to ensure prompt

facility to render care. In such situations, patients with life

responses by laboratory and radiology personnel. Trans

threatening problems and those sustaining multiple-system

fer agreements with verified trauma centers sbouJd be

injuries arc treated first. The use of prehospital care proto

established and operational. rl' See American College o f

cols and online medical direction can facilitate and improve

Resource:;

care initiated in the field. Periodic multidisciplinary review

Periodk re

of the care provided through quality improvement activi

Surgeons Committee on Trauma (ACS COT),

for Optimal Care of the lnj11red Patient, 2006.

view of patient care through the quality improvement

ties is essenti chest film and additional films pertinent to the site{s) of suspected injury should be obtained. Essential diagnostic x-rays should be obtained even in pregnant patients. Focused asse:.sment sonography in trauma (FAST) and diagno�tic peritoneal lavage (DPL) are useful tools for the quick dctedion of occult intraabdominal blood. Their u:.e depends on the skill and ex11erience of the doctor. Identifi

cation of the source of occult intraabdominal blood loss may indicate the need for operative control of hemorrhage.

perfusion.

X-RAY EXAMINATIONS AND DIAGNOSTIC STUDIES X-ray examination �hould be used judiciously and should not

Consider Need for Patient Transfer

delay patient resuscitation. Anteroposterior {AP) chest and AP pelvic films often provide information that can guide re

During the prim purpose:

A

-Allergies

M -Medications currently used

The secondary survey i!. a head to-toe evaluation of the

P

-Past illnesses/Pregnvith a drop in systoli c pressure, a 70-

FLUID CHANGES SECONDARY TO SOFT TISSUE INJURY Major soft tissue injw·ies and fractures compromise the he modynamic status of injured patients in n.vo ways. First, blood is lost into the site of injury, particularly in cases of major fractures. For example, a fractured tibia or humerus may be associated with the loss of as much as 1.5 units (750 mL) of blood. Twice that. amount (up to 1500 mL) is com monJy associated with femur fractures, and several liters of blood may accumulate in a retroperitoneal hematoma asso ciated with a pelvic fracture. The second factor to be considered is the edema that occurs in injured soft tissues. The degree of this additional volume loss is related to the magnitude of the soft tissue in jury. Tissue injury results in activation of a systemic in-


62

CHAPTER 3

•

Shock with the rapid reestablishment of intravascular volume by

.

PITFALL

'' -

' ..

·< :_

.

" ..

.. "'

intri� of life-threa ten i ng i nj u rics and includes assess ment of the ABCDEs. Base l i ne recordings nrc important to monitor the patient's response to therapy.

Gastric Dilation-Decompression

Vi ta l sign s uri ,

nary output, and level of consciousnes:. arc essential. A more

detailed examination of the patient follow� as lhe situation

permits. •• Sec Chapter I : Initial A�scssmcnt and Manage ment.

Airway and Breathing E1>tahlishing a patent airway with adequate vcntihllion and oxygenation is the first pri ority. Supplementa ry oxygen is supplied to ma i ntain oxygen saturation at greater than 95o/o.

.• Sec Chapler 2: Airway a nd Vent ilatory Ma 11ageme nt.

Circulation-Hemorrhage Control

stimulation. In unconscious patients, gastric distention i n

creases the risk of aspiration of gastric contents, which is a potentially fatal complication. G,1s1 ric dccom pression is ac complished by intubating the Sll)mach with a tube passed nasally or orally and attaching il to 5l1Ction to evacuate gas I rk contents. However, proper posiI i<m i ng of the tube docs not completely obviate the risk of aspiration.

Urinary Catheterization Bladder catheteri7ation allows for assessment of the urine for hcm,tturia and continuom evaluation of renal perfusion by monitoring urinary output. Blood at the urethral meatus or a hi gh riding, mobile, or non palpable prostate in males is -

contraindication to the insertion of a Ira nsu rethral catheter prior to rad iogra phic confirmation

nn

absolute

of a 11 intact urethra. rl' Sec Chapter 5: Abdominal and Pelvic Trauma.

Priorities for the circulation include controlling obvious hemorrhage, obtaining adequate intravenous access, and as sessing tissue perfusion. Bleeding from external wounds

VASCULAR ACCESS LINES

usually can be controlled by direct pressure to the bleeding

Access to the vascular system must be obtained promptly.

site. A PASG may be used to control bleeding from pelvic or

Thill i� best done by i nsen ing two large caliber (minimum

lower extremity fractures, but its u:.e should J/Ot in terfere

of 16-gauge)

-

peripheral in travenous cathetcrs before placing


I N ITIAL MANAGEMENT OF HEMORRHAGIC SHOCK

a central venous line is considered. The rate of flow is pro portional to the fourth power of the radius of the cannula and inversely related to its length ( Poiseuille's law). Hence, short, large-caliber peripheral int ravenous lines ' re pre � ferred for the rapid infusion of large volumes of fluid. Fluid warmers and rapid infusion pumps are used in the presence of massive hemorrhage and severe hypotension. The most desirable sites for peripheral, percutaneous intravenous lines in adults are the forearms and antecubital veins. If circumstances preven t the use of peripheral veins, large-caliber, central venous (femoral, jugular, or subclavian vein) access using the Seldinger technique or saphenous vein cutdown is indicated, depending on the skill and e}..1'erience of the doctor. •• See Skill Station fV: Shock Assessment and Management, and Skill Station V: Venous Cutdown. Frequently in an emergency situation, central venous access is not accomplished under tightly cont1·olled or com pletely sterile conditiom. These lines should be changed in a more controlled enviro1m1ent as soon as fue patient's con d.ition permits. Consideration also must be given to the po tential for serious complications related to attempted. central venous catheter placement, such as pneumothorax or he mothorax, in patients who may already be unstable. In children younger than 6 yem·s, the placement of m1 intraosseous needle should be attempted before inserting a central line. The important determjnant for selecting a pro cedme or route for establishing vascular access is the expe rience and skill of the doctor. lntraosseous access with specially designed equipment also is possible in adults. As intravenous lines arc started, blood samples arc drawn for type and crossmatch, appropriate laboratory analyses, toxicology studies, and pregnancy testing for all fe males of childbearing age. Arterial blood gas (ABG) analy sis is performed at this time. A chest x-ray must be obtaim�d after attempts at inserting a subclavian or internal jugular CVP monitoring line to document the position of the line and to evaluate for a pneumothorax or hemothorax.

INITIAL FLUID THERAPY Warmed isotonic electrolyte solutions, such as lactated Ringer's and normal saline, are used for initial resuscitation. This type of Ouid provides transient intravasculctr ex1'an sion and further stabilizes the vascular volume by replacing accompanying fluid losses i.nto U1c interstitial and intracel lular spaces. An al tcrnative initial fluid is hrpcrtonic saline, although there is no evidence of survival advantage .i n the current literaturc. An initial, warmed fluid bolus is given as rapidly as pos sible. The usual dose is 1 to 2 L for adults and 20 mlfkg for pediatric patients. This often requires application of pumping

devices (mechanical or manual) to the fluid administration sets. The patient's response is observed during this initial

fluid administration, and further therapeutic and diagnos tic decisions are based on this response.

63

The amount offluid and blood required for resuscitation is difficult to predict on initial evaluation ofthe patient. Table

3-1 provides general guidelines for establishing the amount of fluid and blood likely required. A rough guideline for the total amount of crystalloid volume required in the short term is to replace each 1 mL of blood loss with 3 mL of crys talloid Quid, thus allowing for restitution of plasma volume lost into the interstitial and intracellular spaces. This is knmvn as fue 3-for-1 rule. It is most important to assess the patient's response to fluid resuscitation and evidence of ade quate end-organ perfusion and oxygenation (ie, via urinary output, level ofconsciousness, and peripheral perfusion). If,

during resuscitation, the amount of fluid required to restore or maintain adequate organ perfusion greatly exceeds these estimates, a careful reassessment of the situation and a search for unrecognized injuries and oilier causes of shock are necessary. The goal of resuscitation is to restore organ perf·usion. This is accomplished by the use of resuscitation fluids to re place lost intravascular volume and guided by the goal of restoring a normal blood pressure. Note, however, that if blood pressure is raised rapidly before the hemorrhage has been definitively controlled, increased bleeding may occur. This can be seen in the small suhset of patients in the tran sient or non responder category. Persistent infusion oflarge volumes of fluids in an attempt to achieve a normal blood pressure is not a substitute for definitive control of bleeding.

Fluid resuscitation and avoidance of hypotension arc important principles in the initial management of blunt trauma patients, particularly those \•:ith traw1mtic brain in jury (TBJ). ln penetrating trauma wilb hemorrhage, delay ing aggressive fluid resuscitation until definitive control may prevent additional bleeding. Although complications asso ciated with resuscitation injury are undesirable, the allerna-


64

CHAPTER 3

•

Shock adequate resuscitation. This situation should stimulate fur ther volume replacement and diagnostic endeavors.

PITFALL Recognize the source of occult hemorrhage. Re member, B lood on the floor x fo ur more." Chest, .. pelvis, retroperitoneum, and thigh. "

Live of exsanguination is even less so. A careful, balanced ap proach with frequent reevaluation is required. Balancing the goal of organ perfusion with Lhe r.isks of rebleeding by accepting a lower-than-normal blood pressure has been termed "controlled resuscitation," "bal anced resuscitation," "hypotensive resuscitation," and "per missive hypotension." The goal is the balance, not t he hypotension. Such a resuscitation strategy may be a bridge to, but is not a substilute for, de fi ni Live surgical con trol of bleeding.

Evaluation of Fluid Resuscitation and Organ Perfusion

I) What is the patient's response? The same signs and symptoms of inadequate perfusion that are used to diagnose shock are useful determinants of pa ti.enl response. The return of normal blood pressure, pulse pressure, and pulse rate are signs that suggest perfusion is returning to normal. However, these observations give no information regarding organ perfusion. Improvements in the CVP status and skin circulation are important evidence of enhanced perfusion, but are difficult to quantitate. The volmne of urinary outpul is a reasonably sensitive indica tor of renal perfusion; normal urine volumes generally imply adequate renal blood flow, if not modified by the ad ministration of diuretic agents. For this reason, urinary out put is one ofthe prime monitors of resuscitation and patient response. Changes in CVP can provide useful information, and the risks incurred in the p lacement of a CVP line arc justified for complex cases. Measurement of CVP is ade quate for most cases.

ACID/BASE BALANCE Patients in early hypovolemic shock have respiratory alkalo sis due to Lachypnea. Resp i ratory alkalosis is frequently fol lowed by mild metabolic acidosis in the early phases of shock and does not require treatmen t. Severe metabolic acidosis may develop from long-standing or severe shock. Metabolic acidosis is caused by anaerobic metabolism, which results from inadequate tissue perfusion and the production of lac tic acid. Persistent acidosis is usually caused by inadequate re t normothermic suscitation or ongoing blood loss, and in he patient in shock it should be treated with fluids, blood, and consideration of operative intervention Lo control hemor rhage. Base deficit and/or lactate can be useful in determining the presence and severily of shock. Serial measurement of Lhese parameters can be used to monitor tl1e response to ther apy. Sodium bicarbonate should 110t be used routinely to treat metabolic acidosis secondary to hn1o-volcmic shock.

Therapeutic Decisions Based on Response to Initial Fluid Resuscitation The patient's response to initial fluid resuscitation is the key to determining subsequent therapy. Having established a preliminary diagnosis and treatment plan based on the ini tial evaluation, the doctor now modifies the plan based on the patient's response. Observing the response to the initial resuscitation identifies palients whose blood loss was greater than estimated and those with ongoing bleeding who re quire operative control of internal hemorrhage Resuscita tion in the operaLing room can accomplish simultaneously the direct control of bleeding by the surgeon and the restoration of intravascular volume.ln addition, it limits the probability of overtransfusion or unnecessary transfusion of blood in patients whose initial status was disproportion ate to the amount of blood loss. It is particularly im port ant to distinguish patients who are "hemodynamically stable" from those who are "hemo dynamically normal A hemodynamically stabl-e p at ient may have persistent tachycardia, tachypnea, and oliguria clearly underresuscitated and stiU in shock. In contrast, a he modynamically normal patient is on e who exhibits no signs of inadequate tissue perfusion. The potential patterns of re sponse to initial fluid administration can be divided into three groups: rapid response, transient response, and mini mal or no response. Vital signs and management guidelines for patients in each of these categories are outlined in Table 3-2. .

."

URINARY OUTPUT \IVithin certain limits, urinary o u tp ut is used Lo monitor renal blood flow. Adequate resuscitation volume replace ment should produce a urinary output of approximately 0.5 mL/kg/hr in adults, whereas 1 mL/kg!hr is an adequate uri nary output for pediatric patients. For children under I year of age, 2 mL/kg/hour should be maintained. The in ability to obtain urinary output at these levels or a decreasi ng uri nary output with an increasing sp ecific grav ity suggests in-


THERAPEUTIC DECISIONS BASED ON RESPONSE TO I N ITIAL FLUID RESUSCITATION

TABLE 3-2

•

Responses to Initial Fluid Resuscitationa RAPID RESPONSE

•

TRANSIENT RESPONSE

MINIMAL OR NO RESPONSE

Vital signs

Return to normal

Transient Improvement, recurrence of decreased blood pressure and increased hean. rate

Remain abnorma l

Estimated blood loss

Minima l (1 0%-20%)

Moderate and ongoing (20%-40%)

Severe (>40%)

Need for more crystalloid

Low

Hrgh

High

Need for blood

Low

Moderate to h•gh

Immediate

Blood preparation

Type and crossmatch

Type-spedtic

Emergency

Need for operative intervention

Possibly

Likely

Hrghly likely

Early presence of surgeon

Yes

Yes

Yes

65

r

blood release

•2000 mL of 1sotomc solution 1n adults; 20 mUkg bolus o1 R•nger's lactate in children.

RAPID RESPONSE Patients in this group, termed "rapid responders," respond rapidly lo Lbe initial fluid bolus and remain hemodynam ic ally normal after the initial fluid bolus has been given and the fluids are slowed to maintenance rates. Such pa tients us ually have lost minimal (less than 20o/o) blood vol ume. No further fluid bolus or immediate blood administration is indicated for this group. Typed and crossmatched blood should be kept available. Surgical con sultation and evaluation are necessary during initial assess ment and treatment, as operative intervention may still be necessary.

TRANSIENT RESPONSE Patients in the second group, termed "transient respon ders" respond to the initial fluid bolus. However. they begin to show deterioration of perfusion indices as the ini tial fluids are slowed to maintenance levels, indicating ei ther an ongoing blood loss or inadequate resuscitation. Most of these patients initially have losl an estimated 20o/o to 40% of their blood volume. Contin ued fluid adminis tration and initiation of blood transfusion are imticated. A transient response to blood administration should iden-

tify patients who are s ti ll bleeding and require rapid sur gical intervention.

MINIMAL OR NO RESPONSE Failure to respond to crystalloid and blood administration in the ED dictates the need for immediate, definitive interven tion (eg, operation or angioembolization) to control exsan guinating hemorrhage. On very rare occasions, fa ilure to respond may be due to pump failure as a result of blunt car diac injury, cardiac tamponade, or tension pneumothorax. Nonhemorrhagic shock always should be considered as a di agnosis in this group of patients. CVP monitoring or car diac ultrasonography helps to di(ferentiate between the various causes of shock. •

PITFALLS • •

Delay in definitive management can be letha l. Do not overlook a source of bleeding.


66

CHAPTER 3

•

Shock

Blood Replacement The decision to initiate blood transfusion is based on the patient's response, as described in the previous section.

CROSSMATCHED, TYPE-SPECIFIC, AND TYPE 0 BlOOD The main purpose of blood transfusion i:.; to restore the m.-ygen-carrying capacity of the intravascular volume. Vol ume re�mcitation itself can be accomplished with crystal loids, with the added advantage that it contributes to interstitial and intracellular volume restitution_ fully crossmatched blood is preferable. However, the complete crossmatching process requires approximately I hour in most blood banks. For patients who stabilize rapidly, crossm.llchcd blood should be obtained and made available for transfusion when indicated. lypc-specific blood can be provided by most blood banks within I 0 minutes. Such blood i� compatible with ABO and Rh blood types, but incompatibilities of other antibodies may exist. Type-specific blood is preferred for patients who are transient responders, as described in the previous seclion. If type-specific blood is required, com plete crossmatching should be pt:rformcd by the blood bank. II" type-specific blood is unavailable, type 0 packed cells arc indicated for patient:. with exl!.mg uinating hem orrhage. lo avoid sensitization and future complications, Rh negative cells are preferred for fem.tle� of childbear ing age. For life-threatening blood loss, the usc o f un matched, type-specific blood is prderrcd over type 0 blood. This is I rue unless multiple, unidcntifiec.J casualties are being treated simultaneously r the potential for occult blood loss exists (eg, head, abdominul, or thoracic injury). However, consideration of early blood component therapy should be given to patients with class IV hemorrhage. Patients with major brain injury are particularly prone to coagulation abnormalities as a result of substances, espe cially tissue thromboplastin, that arc released by damaged neural tissue. Th.:se patients .:o.Jgul.lliPil P•'r1'11c'lers need to h� do.�l'il· munilored.

CAlCIUM ADMINISTRATION Most patients receiving blood transfusions do not need calcium supplements. Excessive, supplemental calcium may be harmful.

Special Considerations in the Diagnosis and Treatment of Shock !:lpecial considerations in the diagnosis and treatment of shock include the mistaken equation of blood pre!.stue with cardiac output; patient age; athletes in shock; pregnancy; patient med ications; hypothermia; and the presence of pacemakers.

AUTOTRANSFUSION

EQUATING BlOOD PRESSURE WITH CARDIAC OUTPUT

Adaptations of standard tube thoracostomy collection de VIces are commercially available; these allow for sterile col-

Trea tment of hypovolemic ( hemorrhagic) shock requires correction of inadequate organ perfusion by increasing

•


SPECIAL CONSIDERATIONS IN THE DIAGNOSIS AND TREATMENT OF SHOCK organ blood flow and tissue oxygenation. Increasing blood flow requires an increase in cardiac output. Ohm's law ( V I x R) applied to cardiovascular physiology states that blood pressure ( V) is proportional to cardiac oulput (l) and systemic vascular resistance (R) (afterload). An in crease in blood pressure should not be equated with a con comitant increase in cardiac output. An increase in peripheral resistance-fo r example, with vasopressor ther apy-with no change i n cardiac output results in increased blood pressure, but no improvement in tissue perfusion or oxygenation. =

ADVANCED AGE Elderly trauma patients require special consideration. The aging process produces a relative decrease i n sympathetic activity with respect to the cardiovascular system. This is thought to result from a deficit in the receptor response to catecholamines, rather than fro m a reduction in cate cholamine production. Cardiac compliance decreases with age, and older patients are unable to increase heart rate or the efficiency of myocardial contraction when stressed by blood volume loss, as are younger patients. Atherosclerotic vascular occlusive disease makes many vital organs ex tremely sensitive to even the slightest reduction in blood flow. Many elderly patients have preexisting volume deple tion resulting from long-term diuretic use or subtle malnu trition. For these reasons, hypotension secondary to blood loss is poorly tolerated by elderly trauma patients. B-adren ergic blockade may mask tachycardia as an early indicator of shock. Other medications may adversely affect the stress re sponse Lo injury or block it completely. Because the thera peutic range for volume resuscitation is relatively narrow i n elderly patients, it is prudent to consider early invasive mon itoring as a means to avoid excessive or inadequate volume restoration. The reduction in pulmonary compliance, decrease in diffusion capacity, and general weakness of the muscles of respiration limit the ability of elderly patients to meet the increased demands for gas exchange imposed by injury. This compounds the cellular hypoxia already produced by a re duction in local oxygen delivery. Glomerular and tubular senescence in the kidney reduces the ability of elderly pa tients to preserve volume in response to the release of stress hormones such as aldosterone, catecholamines, vasopressin, and cortisol. The kidney also is more susceptible to the ef fects of reduced blood flow and nephrotoxic agents such as drugs, contrast agents, and the toxic products of cellular de struction. For all of these reasons, mortality and morbidity rates increase directly with age and .long-term health status for mild and moderately severe injuries. Despite the adverse ef fects of the aging process, comorbidities from preexisting i the "physiologic reserve" disease, and a general reduction n of geriatric patients, the majority of these patients may re cover and return to their preinjury status. Treatment begins

67

with prompt, aggressive resuscitation and careful monitor ing. rl' See Chapter 1 1 : Geriatric Trauma.

ATHLETES Rigorous athletic training routines change the cardiovascu lar dynamics of this group of patients. Blood volume may increase 15o/o to 20%, cardiac output sixfold, and stroke vol ume 50%, and the resting pulse can average 50. The ability of athletes' bodies to compensate for blood loss is truly re markable. The usual responses to hypovolemia may not be manifested in athletes, even when significant blood loss has occurred. •

PREGNANCY Physiologic maternal hypervolemia requires a greater blood loss to manifest perfusion abnormalities in the mother, which also may be reflected in decreased fetal perfusion. rl' See Chapter 12: Trauma in Women.

MEDICATIONS B-adrenergic receptor blockers and calcium-channel block ers can significantly alter a patient's hemodynamic response to hemorrhage. Insulin overdosing may be responsible for hypoglycemia and may have contributed to the injury-pro ducing event. Long-term diuretic therapy may explain un expected hypokalemia, and NSATDs may adversely affect platelet function.

HYPOTHERMIA Patients suffering from bypot.herm ia and hemorrhagic shock do nol respond normally to the administration of blood and fluid resuscitation, m1d coagulopatby often de velops. Body temperature is an important vital sign to mon itor during the initial assessment phase. Esophageal or bladder temperature is an accurate clinical measmement of the core temperature. A trauma victim under the influence of alcohol and exposed to cold temperature extremes is more likely to have hypothermia as a result of vasodilation. Rapid rewarming in a environment witl1 appropriate exter nal warming devices, beat lamps, thermal caps, healed res piratory gases, and warmed intravenous fluids and blood will generally correct hypotension and hyporhermia. Core rewarming (irrigation of the peritoneal Ot' thoracic cavity with crystalloid solutions warmed to 39° C [ 1 02.2° F I or ex tracorporeal bypass) may occasionally be indicated. Hy polhermia is best treated by prevention. rl' See Chapter 9: Thermal Injuries.

PACEMAKER Patients with pacemakers are unable to respond to blood loss in the expected fashion, because cardiac output is di-


68

CHAPTER 3

•

Shock sophisticated techniques are used. Early transfer of the pa tient to an intensive care unit should be considered for el derly patients and patients with nonhemorrhagic causes of shock. CVP monitoring is a relatively simple procedure used as a slandard guide for assessing the ability o f the right side o r the heart to accept a fluid load. Properly inter preted, the response of the CVP to fluid administration helps evaluate volume replacement. Several points to re member are:

1 . The precise measure of cardiac function is the rela

rectly related to heart rate. In tJ1e significant number or pa tients with myocardial conduction Jefects who have such devices in place, CVP monitoring is invaluable to guide J:luid therapy.

Reassessing Patient Response and Avoiding Complications Inadequate volume replacement is the most common com plication of hemor rhagic shock. Immediate, appropriate, and aggressive therapy that restores organ perfusion mini mizes these problematic events.

CONTINUED HEMORRHAGE Obscure hemorrhage is the most common cause of poor re sponse to fiuid therapy. Patients with this condition are gen erally included in the transient response category as defined previously. Immediate surgical intervention may be neces sary.

FLUID OVERLOAD AND CVP MONITORING After a patient's initial assessment and treatment have been completed, the risk of fluid overload is minimized by care ful monitoring. Remember, the goal of Lherapy is restora tion of organ perfusion and adequate tissue o:xygenation, confirmed by appropriate urinary output, Cl'\S function, skin color, and return of pulse and blood pressure toward normal. Monitoring the response to resuscitation is best ac complished for some patients in an environment in which

tionship between ventricular end diastolic volume and stroke volume. Right atrial pressure (CVP) and cardiac output (as reflected by evidence of perfu sion or blood pressure, or even by direct measure ment) are indirect and, at best, insensitive estimates of this relationship. Remembering these facts is im portant to avoid overdependency on CVP monitormg. •

2. The initial CVP level and actual blood volume are

not necessarily related. The initial CVP is some Limes high, even with a significant volume deficit, especially i n patients ,.vith chronic obstructive pul monary disease, generalized vasoconstriction, and rapid fluid replacement. The initial venous pressure also may be high because of the application of PASG or the inappropriate use o f exogenous vasa pressors.

3. A minimal rise in the initially low CVP ·with fluid ther

apy suggests the need for further volw11e expansion (minimal or no response to fluid resuscitation category).

4 . A declining CVP suggests ongoing fluid loss and the

need for additional fluid or blood replacement (tran sient response to lluid resuscitation category).

5. An abrupt or persistent elevation in CVP suggests that volume replacement is adequate or too rapid or that cardiac function is compromised. 6. Pronounced elevations of CVP may be caused by hy pervolemia as a result of overtransfusion, caTdiac dys function, cardiac tamponade, or increased intrathoracic pressure from a tension pneumothorax. Catheter malposition may produce erroneously high . CVP measmements. Aseptic techniques must be used when central venous lines are placed. Multiple sites provide access to the cen tral circulation, and the decision regarding which route to use is determined by the skill and exper.ie.nce of the doc tor. The ideal position for the tip of the catheter is in the superior vena cava, just proximal Lo the right atrium. rl' Techniques for catheter placement are discussed in de-


CHAPTER SUMMARY tail in Skill Station

IV: Shock Assessment and Manage

ment. The placement of central venous l i nes carries the risk of potentially l ife- th reaten i ng com piications. Infections, vas cular injury, nerve i nj u ry, embolization, thrombosis, and pneumothorax may resu I t . CV P m on itor in g ren ec ts righ l heart fun ct ion . It may not be representative of left h ear t function in patient s with pr i mary myocardial dysfunct ion or abnormal pulmonar}' circu lation.

CHAPTER SUMMARY

0

Shock

69

RECOGNITION OF OTHER PROBLEMS When a patient faib to rc:.po nd to therapy, consider cardiac tam pon ade, tension pneum o tho rax ventilatory problems, ,

u n recognized fluid loss, acute gastric distention, myocardial

infarction, diabetic acidosis, hypoadrenalism, and nc u ro genic shock. Constant reevalua tion especial ly when patients' conditions deviate from expected patterns, is the key to rec ogni7ing such problem s as early a� possible. ,

------ -----·

of the circulatory system that results i n inade q uate organ per tissue oxygenation. Shock management, based on sound physiologic pnncl

is an ab norma lity

fusion and ples, 1s usually successful

Hypovolemia is the cause of shock 1n most trauma pat1ents Pat1ents in shock are clas sified as class I, class II, class Ill, or class IV, based on clinical s1gns and estimated blood loss. Treatment of these pat1ents reqwes immed1ate hemorrhage control and flu1d or

blood replacement. In pat 1ents 111 whom these tinuing hemorrhage may be necessary.

measures

fail, operative control of con

The diagnosis and treatment of shock must occ u r al most stm ulta neously. For most trauma pa tie nts, treatment IS Instituted as 1f the pat1ent has hypovolemic shock, unless there is clear evidence that the shock state has a d1fferent cause. The basiC manage ment pnnc1ple is to stop the bleeding and replace the volume loss.

lnit1al assessment of a patient 1n shock reqwes careful phys1cal examination, looktng for signs of tension pneumothorax. card1ac tamponade, and other causes of the shock state

The management of hemorrhag ic shock i nc lu des fluid resuscitation with crystalloids and blood. Early identification and control of the source of hemorrhage is essential.

The classes of hemorrhage serve as an early gu1de to appropriate resuscitation. Careful momtonng of phys1ologic response and the ability to control bleeding will dictate on gomg resuscitatiOn efforts

Bibliography 1 . Abou Khalil B, Scalea TM, Troo:.kin SZ, et al . Hemodynam ic re�ponses to shock in young trauma patients: need for inv� �ivc monitoring. Crit Cnrc Mt•d 1994;22(4):633-639.

P. New developments in fluid resusClliltiOn. Sttrg Clin North Am 2007; 87( I ):55-72, vi.

2. Alam HB, Rhee

3. Alam HB. An tlpdate on fluiJ resuscitation. Scand 1 S11rg 2006; 95(3):136-145.

11. Asensio )A, Berne J 11, Oemclriad�s D, et aL One hundred five

penet rating cardiac injuries: a 2-ye.tr pro&pect ive evaluation. / . Tm11ma 1998; 44(6): 1073- 101!2.

5. Asensio )A, Murray ), Dcmctriades D, et al. Penetrating car

diac injur ies: a prospective �tudy of variables predicting out

comes. 1 Am Coli Surg 1998; 186( 1 ):24-34.

6. Bickell \VH, Wall �IJ, Pcpe PF, ..:t al. lmmcdiat..: versus del ared fluid resusc ita t ion for hypotensive patients with pe netra ti ng t orso 3 3 1 ( 17): 1 l 05- l 1 09.

mi u r ks.

N

Eng/

1

Med

t994;

----

--

----


70

CHAPTER 3

•

Shock

7. Brown M D. Ev idence-based emergen cy medicine. Hypertonic

25.

versus isotonic c rystaUoid for iluid resuscitation in criticaJiy ill patients. Alltt Emerg Med 2002; 40( 1 ) : 1 13 - 1 14.

E. Hypertonic versus nea-r isotonic crystalloid for fluid resuscitation in cr it ically ill pa

1 998; 1 87(2): ll3-122.

8. Bunn F, Roberts l, Tasker R, Akpa

26.

tients. Cochm11e D11tnbnse Syst R.e11 2004; (3):CD002045. Sl. Burris D, Rhee P,

1999;

27. Greaves

46(2):2 16-223.

I 0.

Granger DN. Role of xanthine oxidase and granulocytes ln is cbem ia-reperfusion injmy. Am ] Physiol 1988;255:H 1 269lll 275.

Kau fmann C, et al. Controlled resuscitation

for 11ncontrolled hemorrhagic shock. J Tmunw

Gould SA, Moore EE, Hoyt DB, ct al. The first randomized trial of human polymerized hemogl obin as a blood s ubsti t ute in Col/ S11rg ac ute trauma ami emergent surgery. j Am

I, Porter KM, Revell MP. Fluid resuscitation in pre

hospital trauma care: a consensus view. j R Call Surg Edinb

Carrico C], Canizaro PC, Shires GT. fluid resuscitation fol lowing injury: rationale for Lhe use of balanced saJt solut ions.

2002; 47(2):451 -457. 28. Greco L, Francioso

Ettorre GC. A rterial embolization in the treatment of severe blunt hepatic trauma. Hepatogastroenterology 2003;

Grit Core Med 1976;4(2):46-54. I I . Chernow B, Rainey TG. Lake CR. En dogenous and exogenous

50(5 1 ):746-749.

catecholamines. Crit Care Med 1982;10:409. l2. Cogbil l TH, Blintz M, Johnson JA, et a!. Acute gast ric dilatation

G, Pratichjzzo A, Testini M, l mpedovo G,

29.

after trauma./ Trtlll/1111 1987;27 ( 1 0 ) : 1 1 13-11 1 7 .

'

Guyton AC, Lindsey AW, Kaufman BN. Effect of mean circu latory fi lling pressure and other periph eral circul atory factors

on cardiac output. Ji m ] Physiol 1955; 180:463-468.

13. Cook RE, KeaLing JF, Gil lesp ie 1. The role of angiography in

the management of haemorrhage from major fractures of the pelvis. J Bone joint Surg Br 2002; 84�2): 178- 182.

14. Cooney R, Ku ), Cherry R, et al. Limitations of splen ic an

gioembolization in treating bl un t spl eni c inj ury. j Trauma 2005; 59(4), 926-932; discussion 932.

30. Haan J, Scott l, Boyd-Kranis RL. Ho S, Kramer M, Scalea TM.

Admission angiography for

blunt splen ic inju ry: advantages

an d pitfalls. J Tm111na 200 I; 5 1 (6): 1 1 61-1 165. 3 1 . Hagiwara A, Yukioka T, Ohta S,

Nitarori T, Matsuda H, Shi

15. Cooper DJ, Walley KR. \ decreases beyond tJ1e 10- tool, or 3-meter, ra nge), number of st·ab or gun shot wounds sustained, and the amou nt of external bleedi ng noted at the scene. If possible to obtain it, important addi tional informat ion includes t he magn itude and l ocation of abdom i na l pai n and whet her t his pai n is referred to the shoulder. vVhen i nj ur i es are caused by an exp l osive device, the likel ihood or visceral high pressure i nj ur ies is increased if the explosi on occurred in an enclosed space and with de creas ing distance of the patien t from Lhe ex.-plosion. ,

PHYSICAL EXAMINATION

I How do I determine whether there is an abdominal injury?

The abdominal examination should be conducted in a meticulous, systematic fashion in the standard sequence: i n spect ion , auscu lt a tion , percussion , and palpat i on. This is fol lowed by assess ment of pelvic sta bi l ity ; uretb ral, perineal, and rectal exam; vagina l exarn; and gluteal exam. The find-

Auscultation Auscultation of the abdomen may be difficult in a noisy emergency depa rt men t but il may be used to co11firm the presence or absence or bowel sounds. Free intraperitoneal bl ood or gastrointestinal con tents may prod uce an ileus, re su l ting in the l oss of bowel sounds; however, this finding is nonspecific, as ileus may also be caused by extraabdom inal inj uries These findings are most useful when they are normal ,

.

initially and then change over time.

Percussion and Palpation Percussion causes sl ight movement of the peritoneum and may elicit signs of peritoneal i rri ta tion. When present, no additional evidence ofrebound tenderness need or should be sought as such an examination may cause the patient un necessary further pain .

Volu n t ary guarding by the patient may make the ab dominal examination unreliable. In contrast, in voluntary muscle guarding is a rel i ab le sign of peritoneal irritation. P alpa t ion may also elicit and distinguish super fici al (ab dominal wall) and deep tenderness. The presence of a preg nant uterus as w ell as est imati o n of fetal age al so can be determined. ,

.

Assessment of Pelvic Stability Major hemorrhage may occur from a pelvic fracture in pa tients who sustai_n blum truncal trauma. An ea rly assessment

PITFALL

Repeated man ip u lat ion of a fractured pelvis can ag gravate hemorrhage.


116

CHAPTER 5

•


of the likelihood of hemorrhage from this source can be

suggests an injury to the esophagus or upper gastrointesti

made during the physical exam by evaluating pelvic stabil

nal tract if nasopharyngeal and/or oropharyngeal sources

ity. This begins with manual compression of the anterosu

arc excluded. If severe facial fractures exist or basilar skull

pcrior iliac spines or iliac crests. Abnormal movement or:

fracture is suspected, the gastric tube should be inserted

bony pain suggests fracture, and the exam may stop with

through the mouth to prevent passage of the tube through

this mhcd, also evaluating for bony movement or pain.

Caution should be exercised, as this maneuver can cause or aggravate bleeding. \"/hen rapidly available, some doctors substitute x-ray examination ofthe pelvis to avoid pain and the potential for aggravating hemorrhage.

Urinary Catheter The goals of inserting urinary cathcters early in the resusci tation process are to relieve retention, decompress the blad der before performing

DPL, and allow for monitoring of

urinary output as an index of tissue perfusion. Hematuria is

Urethral, Perineal, and Rectal Examination

a sign of trauma to the genitourinary tract and nonrenal in traabdominal organs. The inability to void, unstable pelvic

The presence of blood at the urethral meatus strongly sug

fracture, blood at the meatus, scrotal hematoma, or perineal

gest:. a urethral tear. Inspection of the scrotum and per

ecchymoses and a high-riding prostate on rectal examination

ineum should be performed to look for ecchymoses or

mandate retrograde urethrography to confirm an intact ure

hematoma, suggestive of the same injury. In patients who

thra before inserting a urinary catheter. A disrupted urethra

have sustained blunt trauma, goals of the rectal examina

detected during the primary or secondary survey may require

tion are to assess sphincter tone, determine the position of

the insertion of a suprapubic tube by an experienced doctor

the prostate (a high-riding pro:.tate indicates urethral dis

and may be performed more safely with ultrasound guidance.

ruption), .md identify any fracture!> of the pelvic bones. In patients with penetrating wounds, the rectal examination is used to assess sphincter tone and look for gross blood from a bowel perforation.

Other Studies With preparation and an organized team approach, the pre ceding evaluation can be performed very quickly. The fol lowing additional studies

Vaginal Examination

t�rc

chosen

based on

the

hemodynamic status of the patient and the suspected in

Laceration of the vagina may occur from bony fragments

juries. When intraabdominal injury is suspected, a number

from pelvic fracture(s) or from penetrating wounds. Vaginal

of studies can provide useful information; however, these

exam should be performed when inju ry is suspected (eg, in

studies should not delay the transfer of a patient to defini

the presence of complex perineal laceration ). ,/' Also sec

tive care.

Chapter I2: Trauma in V\'omen.

X-Ray Examination for Abdominal Trauma An teropo�tcrior (AP) chest and pelvic x-r:Jy examinations are

Gluteal Examination The gluteal region extends from the iliac crests to the gluteal folds. J>enet raling injuries to this �u·c<J tlre associated with an incidence of up to a

50% of significant intraabdominal in

juries, including rectal injuries below the peritoneal reflec tion. Gun:.hot and srab wounds are associated with intraJbdominal injuries; these wound!> mandate a search for �uch injuries.

recommended in the assessment of patients with multisys

tem blunt trauma. Patients with hemodynamic abnormali ties who have penetrating abdominal wounds do not require screening x-ray examination in the emergency department

( I:D). If the patient has no hemodynamic abnormalities and

has penetrating trauma above the umbilicu� or a suspected thoracoabdominal injury, an upright chest x-ray examina tion is useful to exclude an associated hemothorax or pneu

ADJUNCTS TO PHYSICAL EXAMINATION Gastric and urinary catheters are frequcn tly inserted as part or the rcsu:.citation phase, once problem!. with the airway, breathing, .md circulation are diagnosed and treated.

mothorax or to document the presence of intraperitoneal air.

With marker rings or dips applied to all entrance and exit wound sites, a supine abdominal x-ray may be obtained in patients with no hemodynamic abnormalities to determine the track or the missile or presence or retroperitoneal air.

Gastric Tube The therapeutic goals of inserting ga:.tric tubes early in the resuscitation process are to relieve acute gastric dilation, de compress the stomach before performing a move gastric contents, thereby

DPL, and re

reducing the risk of

aspiration. The presence of blood in the gastric secretions

PITFA L L Avoid nasal gastric tube i n midface injury. Use oral gastric

route.


ASSESSMENT

117

Focused Assessment Sonography in Trauma

l�o cused assessment sonography in trauma (FAST) is one of the two most rapid studies for the identification of hemotThagc or the potential for hollow viscus injury. Ln FAST, ul�;rasow1d technology is used by properly trained individuals to detect the presence of hemoperitoneum ( Figure 5-4). With specific equi pment and in experienced hands, ul trasound has a sensi tivity specificity, and accuracy in detecti ng intraabdominal fluid comparable to DPL and abdominal computed tomogra phy. Thus, ultrasound provides a rapid, noninvasive, accurate, and inexpensive m ea ns of diagnosing hemoperitoneum that can be repeated frequently. Ultrasound scanning can be done at the bedside in the resuscitation room while simultaneously performing other diagnostic or therapeutic procedures. The iJ1dicalions for the procedure are tlle same as for D PL. Factors that compromise the utility of ultraso und are obesity the pres ence of subcutaneous air, and previous abdominal operations. Ultrasound scanning to detect hemoperitoneum can be accomplished rapidly. Furthermore, it can detect one of the nonhypovolemic reasons for hypotension: peri can:tial tam ponade. Scans are obtained of the peri cardiaJ sac hepatore nal fossa, sp lenorenal fossa, and pelv is or pouch of Douglas. ,

,

,

After the initial scan is completed, a second or "control" scan

should ideally be performed after an interval of 30 minutes.

The control scan cru1 detect progressive hemoperitoneum in pa tie nts with a low rate of bleedi ng and short i n tervals from injury to the initial scan. Diagnostic Peritoneal

lavage

Diagnostic

peritoneal

lavage (DPL) is the second of tl1e two most rapid studies for the identificat-ion of hcmonhage or the potential for hollow viscus inj ury. DPL is an invasive procedure that significantly a hers subsequent examinations of the patient ru1d is consid ered 98o/o sensitive for intraperitoneal bleeding ( Figu re 5-5). I t should be performed by a surgical team caring tor a patien t with hemodynamic abnormalities and mul tiple blw1t injuries, especially when any of the follmving sit uation s exists:

Figure 5-5 Diagnostic Peritoneal lavage (DPL). DPL is a rapidly performed, invasive procedure that is considered 98% sensitive for intraperitoneal bleeding.

•

• Change

i11 sensori um

brain injury, alcohol intoxi

-

cation, and use of illicit drugs • Ch a nge

in sensation

-

injury to spinal cord

•

Inj ury to adjacent structures-lower ribs, pelvis, lumbar spine

•

Equivoca l results on physical exa m i na tion

•

Prolonged loss of contact with patient an t icipated general anesthesia for ex:traabdominal inj uri es, lengthy x-ray studies ( eg, a ngiog raph y in a patient with or without hemodynamic abn ormalities)

•

La p belt sign ( abdomi nal wall contusion) with sus picion of bowel injury

-

DPL also is indicated in pati en ts with no hemodynam ic abnormalities when the same situations are present, but ul trasound and co mputed tomography (CT) are not avai lable. The only absolute contraindication to DPL is an existing in dication for laparotomy. Relative contraindications include previous abdominal operations, morbid obesity, advru1ced ci rrhosis and preexisting coagulopatlly. Either an open or closed ( Seldi nger) inti·aumbil ical technique is acceptable in the hands of trained doctors. In patients with pelvic frac tures or advanced pregnancy, an open supra umbilical ap proach is preferred to avoid entering a pe lvic hematoma or ,

PITFA L L

Figure 5-4 Focused Assessment Sonography in Trauma (FAST). In FAST, ultrasound technology is used to detect the presence of hemoperitoneum. •

A si ng le p hys i cal exam or adjunct should not allay clinical suspicion based on the mechanism of inj ury. Repeated exams and complementary adjuncts may be necessary.


118

CHAPTER 5

•


damaging the enlarged uterus. Free aspiration ofblood, gas trointestinal contents, vegetable fibers, or bile through the lavage catheter i n patients with hemodynamic abnormalities mandates the use oflaparotomy.

..

If gross blood (> 10 mL) or gastrointestinaJ contents are not aspi rated, lavage is performed with I 000 mL of warmed isotonic crystalloid solution ( 10 ruL/kg in a child). After en suring adequate mixing of peritoncaJ contents with the lavage fluid by compressing the abdomen and moving the patient by logrolling or tilting him or her into head-down and head-up positions, the eftluent is sent to the laboratory for quantitative ana l ysi s if gastrointestinal contents, veg etable fibers, or bile are not obviously present. A positive test for blunt trauma is indicated by> 100,000 red cells per cubic millimeter, 500 white cells per cubic millimeter, or the pres ence of bacteria sho1·vn on Gram staining. _. See Skill Sta tion VITI: Diagnostic Peritoneal Lavage. Computed Tomography

Computed tomography (CT) is a diagnostic procedme that requires transport of the pa

tient to the scanner, administration of contrast, and scan ning of the upper and lower abdomen, as well as the pelvis. It is a time-consuming procedure that should be used only in patients with no hemodynamic abnormalities in whom there is no apparent indication for an emergency laparotomy. The CT scan provides information relative to specitic organ in

jury and its extent, and can diagnose retroperitoneal and pelvic organ injuries that are difficuJt to assess by a physical examination, FAST, and peritoneal lavage. Relative con traindications to the use of CT include delay until the scan ner is available, an uncooperative patient who cannot be safely sedated, and aJiergy to the contrast agent when non ionic contrast is not available. Some gastrointestinal, di aphragmatic, and pancreatic injuries may be missed on CT. In the absence of hepatic or splenic inj uries, the presence of free fluid in the abdominal cavity suggests an injury to the gastrointestinal tract andfor its mesentery, and many trauma surgeons find this to be an indication for early operative in tervention. Contrast Studies

number ofcontrast studies can aid in the diagnosis of specifically suspected inj u ries, but they should not delay the care of patients with hemodynamic ab normalities. These include: •

A

Urethrography

• Cystography •

lntravenOLIS pyelography

teriaJ is instilled with gentle pressure. A radiograph is taken with an oblique projection and with slight stretch ing of the pems. An intraperitoneaJ or extra peritoneal bladder rupture is best diagnosed by a cystogram. A syringe barrel is attached to the indwelling bladder catheter, held 40 em above Lhe pa tient, and 300 mL of water-soluble contrast is allowed to Oow into the bladder or until: ( I ) flow stops, (2) the patient voids spontaneously, or (3) the patient is in discomfort. AP, obi ique, and postdrai nage views are essential to definitively exclude injury. CT evaluation of the bladder and pelvis (CT cystography) is an alternative study Lhat is paTticularly use ful in providing additional information :�bout the kidneys and pelvic bones. Suspected urinary system injuries are best evaluated by contrast-enhanced CT scan. If CT is not available, in travenous pyelography (rVP) provides an alternative. A high-dose, rapid injection of renal contrast ("screening IVP") is best performed using the recommended dosage of 200 mg of iodine/kg body weight. This involves a bolus injection of I 00 mL (standard, 1.5 mL/kg for a 70-kg in dividual) of a 60o/o io di n e solution performed through two 50-mL syringes over 30 to 60 seco nds lf only 30o/o iodine solution is available, the ideal dose is 3.0 ml/kg. The calyces of the kidneys should be visualized on a flat plate x.-ray of the abdomen 2 minutes after the injection is completed. Unilateral nonfunctio.ning i n dica1es an ab sent kidney, 1 hrombosis, avulsion of the renal artery, or massive parenchymal disruption. Nonfunctioning war rants further radiologic evaluation with contrast enhanced CT or renal arteriography, or surgical exp l o ration, depending on the mechanism of injury and local availabiJity or expertise. Isolated injuries Lo retroperitoneal gastrointestinal structures (ie, duodenum, ascending or descending colon, rectum, biliary tract, and pancreas) may not cause peritoni tis and may not be detected on DPL. \1\fhen injury to one of these structures is suspected, CT with contrast, specific upper and lower gastrointestinal contrast studies, and pan creat·icobiliary imaging studies may be useful. These studies .

.

should be guided by the surgeon who will ultimately care for the patient.

EVALUATION OF BLUNT TRAUMA If there is early or obvious evidence that the patient will be transferred to another facility, time-consuming tests, such as contrast urologic and gastrointestinal studies, DPL, and CT,

• GastrointestinaJ contrast studies

Urethrography should be performed before inserting an indwelling urinary catheter when a urethral tear is sus

pected. It is performed with an ,'1.8 French urinary catheter secuTed in the meataJ fossa by balloon inflation to 1.5 to 2 mL. Approximately 15 to 20 mL of tu1diluted contrast ma-

PITFALL Evaluations should not delay the transfer of the pa tient to a more appropriate level of care for severe injuries that have already been identified.

•


ASSESSMENT

rax, and it is not indicated in patients with peritonitis or hy potension from suspected abdominal injury. Because 25o/o to 33o/o of stab wounds to the anterior ab domen do not penetrate the pe1itoncum, laparotomy for such patients is often nonproductive. Under sterile condi tions, local anesthesia is injected, and the wound track is fol lowed through the layers of the abdominal wall or until its termination. Confirmation of penetration through the an terior fascia places the patient at higher risk for intraperi toneal injury, and many trauma surgeons view Lhis as an indication for laparotomy. Any patient in whom the track cannot be followed because of obesity, lack of cooperation, or soft-tissue hemorrhage or distortion should be admitted for continued evaluation or surgical exploration (laparotomy).

Table 5-2 compares the use of DPL, FAST, and CT, including their advantages and disad vantages, in the evaluation or blunt trauma. should not be performed.

•

EVALUATION OF PENETRATING TRAUMA The evaluation of penetrating trauma involves speciaJ con sideration to address penetrating wounds to the abdomen and thoracoabdominal region. Options include local wound exploration and serial phys ical examination. DPL, or CT in anterior abdominal stab 'vounds. Double or triple contrast CT are useful in tlank and back injmies. Smgery may be re quired for immediate diagnosis and treatment.

Penetrating Wounds

Thoracoabdominal Lower Chest Wounds

Most gunshot wounds to the abdomen are managed by ex

Diagnostic options in asymptomatic patients with possible injmies to the diaphragm and upper abdominal structmes include serial physical and chest x-ray examinations, thora coscopy, laparoscopy, and CT (for right thoracoabdominal wounds). Despite all these options, late posttraumatic left sided diaphragmatic hernias continue to occur after thora coabdominal stab wounds; thus early or immediate surgical exploration (laparotomy) for such wounds also is an option. ror left-sided thoracoabdominal gunshot wounds, the safest alternative is laparotomy.

ploratory laparotomy, as the incidence of significant in

Tangential gunshot wounds often are not truly tangential, and concussive and blast injuries can cause intraperitoneal injury without peritoneal penetration. Stab wounds lo the abdomen may be managed more selectively, but approximately 301).. do cause intraperitoneal injury. Thus, indications for laparo tomy in patients with penetrating abdominal wounds in clude:

traperitoneal injury approaches go%.

'1>

•

119

Any patient with hemodynamic abnormalities

Local Wound Exploration and Serial Physical Examinations versus DPL in Anterior Abdom inal Stab Wounds

• Gunshot wound •

Signs of peritoneal irritation

•

Signs of fascial penetration

Approximately SS%1 to 601Vo of patients with stab wounds that penetrate Lhe anterior peritoneum have hypotension, peritonitis. or evisceration of omentum or small bowel. These patients require emergency laparotomy. In the re maining patients, in whom anterior peritoneal penetration can be confirmed or is strongly suspected after local wound exploration, approximately 50% eventually require opera tion. Laparotomy remains a reasonable option for all such

When there is suspicion that a penetrating wound is su perficial and does not appear to travel below the abdominal musculoaponeurotic layer, an experienced surgeon may elect to explore the wound locally to determine the depth of penetration. This procedure is not used with wowJds over lying the ribs because of the risk of causing a pneumotho-

TABLE 5-2

Comparison of DPL, FAST, and CT in Blunt Abdominal Trauma

•

DPL Advantages

Disadvantages

-· ·· · ······--·· -····-···· · ·· · ··· · ··· ··· · · · ·

I

• •

FAST

Early diagnosrs Performed rapidly

• •

CT SCAN •

Early d ragnosrs Noninvasive Performed rapidly Repeatable

•

• 98% sensitive • Detects bowel injury

•

Invasive • Low specificity • Misses injuries to diaphragm and retroperitoneum

• Operator-dependent • Bowel gas and subcutaneous

•

•

air distortion • Misses diaphragm, bowel pancreatic, and solid organ injuries ,

-

··· ·················· · ·····-···· ·· ···· ···-····-····· · ··· ·· ··· -··· ····-· ······ ··

..... ..

.. ·····-···

..

.

. . _,,,

..

... . -

- .. -....

............. .-....... .... _

..

....

.

.......

.. .. .

. . -

......

.

....

.

•

Most speerfie for rnJury

Sensitive 92%-98% accurate

• C ost and time • Mrsses diaphragm, bowel, some pancreatic injuries • Transport required .

.....

. .- .

....... ......-

...

.......

.-

......

....

and

•


120

CHAPTER 5

•


Indications for laparotomy in Adults

-

... :'"��. "' '�-. Oc 'o.

--

� -

...

.

These evaluations are seeking to prove that there is no injury in the patients with no hemodynamic abnormalities. They should not delay laparotomy in pa tients with hemodynamic abnormalities that likely have an abdominal source.

J

•

In which patients is a laparotomy warranted? In individual patients, surgical judgment is required to deter mine the timing and need for laparotomy. The following in

patients. Less invasive diagnostic

options for relatively

asymptom ati c patien Ls (who may have pajn at the site of the stab wound) include serial physical examinations over a 24-

hour period, DPL, or diagnostic laparoscopy. Although a

dications are commonly decision-making process. •

positive FAST may be he l pfu l in this situation, a negative FAST does not exclude the possibility of significant intraab dominal injury producing small volumes of fluid. Serial physical examinations are labor-intensive, but have an over

all accuracy rate of 94%. DPL may allow for earlier iliagno

sis of injury i n relatively asymptomatic patients. The accuracy rate is greater tlum 90% when specific cell cow1ts, rather than gross inspection of the fluid, are used. Use of !.ower thresholds for penetrating trauma increases sensitiv ity and decreases specificity. Diagnostic laparoscopy can confirm or exclude peritoneal penetra t i on , but it is less use ful in iden ti fying specific injuries.

Serial Physical Examinations versus Double- or Triple-Contrast CT in Flank and Back Injuries The thickness of the !lank and back muscles protects th e un derlying viscera from injury from many stab wounds and some gunshot wounds to these areas. Although laparotomy is a reasonable option for all such patients, less invasive di

used to facilitate t11e surgeon's

Blunt abdominal. trauma with hypotension with a positive FAST or clinical evidence of intraperi ton eal

bleedjng •

Blunt abdominal tralm1a with positive DPL

•

Hypotension with penetrating abdominal wound

•

Gunshot wounds traversing the per iton eal cavity or

visceral/vascular ret roperitoneu m

•

Evisceration

•

Bleeding from the stomach, rectum, or genitouri i g trawna nary tract li·om penetratn

•

Peritonitis

•

Free air, retroperitoneal air, or r u pture

of the

h em idi aphrag m after blunt trauma •

Ruptured gastrointesti n a l

tract, intraperitoneal bladder i11jury, ren al pedicl e injury, or severe viscera l parenchymal injury after blunt or penetrating t rauma, as demonst rated on contrast-enhanced CT

agnostic options in patienLs who are initially asymptomatic include serial physical examinations, double- or triple-con

and DPL. Serial physical examination in patients who are in it ial ly asymptomatic and then become sympto matic is ve ry accurate in detec ti ng retrope r ito neal and in trast CT,

traperitoneal injuries with wounds posterior to the anterior

il l ary Ii ne.

ax

Double- (intravenous and oral) or triple- (intravenous, oral, and rectal) contrast-enhanced CT assesses the retroperi

toneal colon on the side of the wound. The accuracy is com

to that of serial physical examinations, but should allow for earlier diagnosis of injury in relatively asympto matic patients when CT is performed properly. On rare occasions, these retropedtoneal. injuries may be missed by serial examinations and contrast CT. Early out patient follow- up is m anda tory after ilie 24-hour period of in-hospital observation because of the subtle presentation par able

of certain colonic injuries.

DPL can also be used as an early screening test in such patients. A positive DPL is an indication for an urgent la parotomy.

Surgica l judgment is required to determine the timing and need for laparotomy.

•


SPECIFIC DIAGNOSES

Specific Diagnoses The liver, spleen, and kidney arc the organs predoJl!inantly involved after blunt trauma, although the relative incidence of hollow visceral perforation, lumbar spinal injuries, and uterine rupture increases with incorrect seat-belt usage (see Table 5- 1 ) . Difficulties in diagnosis may occur with i11juries to the diaphragm, duodenum, pancreas, genitourinary sys tem, or small bowel.

DIAPHRAGM INJURIES Blunt tears may occur i11 any portion of either diaphragm; however, the left hemidiaphragm is more commonly in jured. The most common injury is 5 to 1 0 em in length and involves the posterolateral left hcmidiaphragm. Ab normalities on the initial chest x-ray include elevation or "blurring" of the hemidiaphragm, hemothora,x, an abnor mal gas shadow that obscures the hemidiaphragm, or the gastric tube being positioned in the chest. However, the initial chest x-ray may be normal in a small percentage of patients.

DUODENAL INJURIES Duodenal rupture is classically encountered in unrestrained drivers involved in fron tal-impact motor vehicle collisions and patients who sustain di reel blows to the abdomen, such as from bicycle handlebars. Bloody gastric aspirate or retroperitoneal air seen on a flat-plate x-ray film of the abdomen or abdominal CT shouJd raise suspicion for this injury. An upper gastrointestinal x-ray series or double contrast CT is indicated for high-risk patients.

PANCREATIC INJURIES Pancreatic injuries most often result from a djrect epigas tric blow that compresses the organ against the vertebral column. An early normal serum amylase level does not ex clude major pancreatic trauma. Conversely, lhe amylase level may be elevated from nonpancreatic sources. How ever, persistently elevated or rising serum amylase levels should prompt further evaluation of the pancreas and other abdominal viscera. Double-contrast CT may not iden tify significant pancreatic trauma in the immediate postin jury period (up to 8 hours); it should be repeated later if pancreatic injury is suspected. Should there be concern

after equivocal results on CT, surgical exploration of the pancreas is warranted.

GENITOURINARY INJURIES Direct blows to the back or flank that result in contu sions, hematomas, or ecchymoses are markers of poten-

121

tial underlying renal injury and warrant a n evaluation (CT or fVP) of the urinary tract. Additional indications for evaluating the urinary tract include gross hematuria or microscopic hematuria in patients with: ( 1 ) a pene trating abdominal wound, (2) an episode of hypotension (systolic blood pressure less than 90 m m Hg) i n con junction with blunt abdominal trauma, and (3) in traab dominal injuries associated with blunt trauma. Gross hematuria and microscopic hematuria in patients with an episode of shock indicate that they are at risk for non renal abdominal injmies. A11 abdominal CT scan with fV contrast can document the presence and extent of a blunt renal injury, 95% of which can be treated nonoperatively. Thrornbosis of the renal artery or disruption ol the renal pedicle secondary lo deceleration is a rare upper tract injury in which hematuria may be absent, although the patient may have severe abdominal pain. Wilh either injury, IVP, CT, or renal arteriography may be useful in diagnosis. An anterior pelvic fracture usually is present in patients with urethral injuries. UretluaJ disruptions are divided into those above (posterior) or below (anterior) the urogenital diaphragm. A posterior urethral inJury usually occurs in pa tients with multisystem injuries and pelvic fractures. In con trast, an anterior urethral injury results from a straddle impact and may be an isolated injury.

SMAll BOWEl INJURIES Blunt injury to the intestines generally resuJts f1om sudden deceleration with subsequent tearing near a fixed point of attachment, especially if the patient's seat belt was used in correctly. The appearance of tra11sverse, linear ecchymoses on the abdominal wall (seat-belt sign) or the presence of a lumbar distraction fractme (Chance fracture) on x-ray ex amination should alert the doctor to the possibility of in testinal injury. Although some patients have early abdominal pain and tenderness, diagnosis may be difficult in others, es pecially because only minimal bleeding may result from torn intestinal organs. Early ultrasound and CT are often not di

agnostic for these subtle injuries, and DPL is a better choice when abdominal wall ecchymoses are present.

SOLID ORGAN INJURIES Injuries to the Liver, spleen, and kidney lhal result in shock, hemodynamic instability, or evidence of continuing bleed ing are indications for urgent laparotomy. Solid organ in jury in patients with no hemodynamic abnormalities can often be treated nonoperalively. Such patients must be ad mitted to the hospital for careful observation, and evalua tion by a surgeon is essential. Concomitant hollow viscus injury occurs in less than 5% of patients initially thought to have isolated solid organ injuries.

•


122

CHAPTER 5

•


PELVIC FRACTURES AND ASSOCIATED INJURIES

IJ How do I treat patients with pelvic fractures?

..

The sacrum and innominate bones (ilium, ischium, and pubis), along with many ligamentous complexes, comprise the pelvis. Fractures and ligamentous disruptions of the pelvis suggest that major forces were applied to the patient. Such injuries usually result from auto-pedestrian, motor ve hicle, and motorcycle crashes. Pelvic fractures have a signif icant association with injuries to intraperitoneal and retroperitoneal visceral and vascular structures. The inci dence of tears of the thoracic aorta also appears to be sig nificantly increased in patients with pelvic fractures, especially anteroposterior fractures. Therefore, hypotension may or may not be related to the pelvic fracture itself when blunt trauma is the mechanism of injury. Palients with hemorrhagic shock and unstable pelvic fractures have four potential sources of blood loss: ( 1 ) frac tured bone surfaces, (2) pelvic venous plexus, (3) pelvic ar terial injury, and ( 4) extrapelvic sources. The pelvis should be temporarily stabilized or "closed" using an available com· mercial compression device or sheet to decrease bleeding.

lnlraabdominal sources or hemorrhage must be excluded or treated operatively. Further decisions to control ongoing pelvic bleeding include angiographic emboljzation, surgical stabilization, and direcl sw·gical control (see Figure S-6).

Mechanism of Injury/Classification The four patterns of force learung to pelvic fractures are the foliowi.ng: ( 1) AP compression, (2) lateral compression, (3) vertical shear, and (4) complex (combination) pal rern. An AP compression injury may be caused by an auto-pedestrian collision or motorcycle crash, a direct crushing injury to the pelvis, or a fall from a height greater than 1 2 feet (3.6 meters). With disruption of the symphysis pubis, Lhere often is tearing of the posterior osseous Hga-

Figure 5-7 Closed Fracture.

Intraperitoneal gross blood?

Laparotomy

Angiography

Hemorrhage control fixation device

Figure 5·6 Pelvic Fractures and Hemorrhagic Shock-Management Algorithm.

•

mentous complex (sacroiliac, sacrospinous, sacrotuberous, and fibromuscular pelvic floor) reprcse1itcd by a sacroiJiac fracture and/or dislocation or sacral fracture. Wilh opening of lhe pelvic ring, there may be hemorrhage from the pos terior pelvic venous complex and, occasionally, branches of the internal iliac artery. Figure 5-8 shows an "open book" fracture. Lateral compression injuries often result from motor vehicle crashes and lead to internal rotation of the involved hemipelvis. This rotation drives the pubis into the lower genitourinary system, injuring tJ1e bladder and/or urethra. The pelvic volume is actually compressed in such an injury, so Iife-threatening hemorrhage is not common. Figure 5-7 shows a "closed" fracture. A high-energy shear force applied in a vertical plane across the anterior and posterior aspects of the ring disrupts

Vertical shear 5·15% frequency

Anterior-posterior compression (open book) 1 5-20% frequency

Lateral compression (closed) 60-70% frequency •

Initial Management •Surgical consult •Pelvic wrap

•

Figure 5-8 Open Book Fracture.

•

Figure

5-9

Vertical Shear Fracture.


SPECIFIC DIAGNOSES

123

Management PITFALL

Delay in stabilization of the pelvis al lows continued hemorrhage. •

the sacrospinous and sacrotuberous ligaments and leads to a majox pelvic instability. Fi gu re 5-9 shows a vertical shear fracture. ln some cases of severe injury, combinations of com pression and sh ear forces result in complex combination pallerns. These injuries are associated with major bleeding.

Simple techniques may be used to splint unstable pelvic frac tmes and close the increased pelvic volume prior to patient Lransfcr and during the resuscitation with crystalloid fluids and blood. These techniques include: ( 1 ) a sheet wrapped arom1d Lhe pelvis as a sl ing, causing internal rotation of the lower limbs, (2) commercially available pelvic splints, <md (3) other pelvis-stabilizing devices (Figure 5- 10). Reduction of an acetabular fracture by longi tudi n al traction of the lower extremity also can be useful. Although definitive management of pelvic fractures varies, one treat ment algorithm based on the hemodynamic status for pa tients i n emergency situations in sllown in Figure 5-6: Management of Pelvic fractmes. Since significant resources are required to care for patients with severe pelvic fractures,

Assessment

early consideration of transfer to a trauma center is essential.

The Oank, scrotum, and perianal area should be inspected quickly for blood at the urethral meatus; swelljng or brws ing; or laceration in the perineum, vagina, rectum, or but tocks, which is suggestive of an open pelvic fracture. Palpation of a high-riding prostate gland also i s a sign of a significant pelvic fracture. Mecha.nical instability of the pelvic ring can be quickly ascertained during physical examination of the pelvis. Once instabiliL)' has been verified, a source of hemorrhage has been suggested; no further maneuvers to demonstrate in stability are necessary. A rapidly available x-ray may avoid the pain and potential hemmorrhage associated with ma nipulating the pelvis. The fi rst indication of mechankal iJJStability is seen on inspection for leg-length discrepancy or rotational deform it)' ( usually external) without a fracture of that extremity. Be cause the unstable pelvis is able to rotate extern ally the pelvis can be closed by pushing on the iliac crests at the level of the anterior superior iliac spine. Motion can be felt if the iliac crests are grasped and the unstable hemipelvis is pushed in ward and 1·hen outward (compression Jjstraction maneu ver). With posterior disruption, the involved hemipelvis can be pushed cephalad as well as pulled caudally. This b·ansla Lional motion can be felt by palpating the posterior iliac spine and tubercle while pushing or pulJing the unstable hemipelvis. When appropriate, an AP x-ray film of the pelvis confirms the clinical examination. When time, availability, and patient condition permit, the x-ray may be used in lieu of manipulation to make th e diagnosis. rl' See Chapter 3: Shock; and Skill Station N: Shock Assessment and Manage

A

,

ment.

8

Figure 5- 1 0 Pelvic Stabilization. Pelvic binder (A) and pelvic stabilization using a sheet (B).

•


124

CHAPTER 5

•


CHAPTER SUMMARY

..

The three distinct regions ot the abdomen are the peritoneal cavity, the retroperitoneal space, and the pelvic cavity. The pelvic cavity contains components of both the peri toneal cav1ty and retroperitoneal spaces. Early consultation with a surgeon is necessary whenever a patient with possible in traabdominal inju ries is brought to the emergency department. Once the patient's vital functions have been restored, evaluation and management vary depending on the mechanism of injury as described herein. Patients with hemodynamic abnormalities and multiple blunt injuries should be rapidly assessed for intraabdominal bleeding or contamination from the gastrointestinal tract by performing a FAST or diagnostic peritoneal lavage. Patients with no hemodynamic ab normalities and no peritonitis should be evaluated by contrast-enhanced CT. with the de cision to operate based on the specific organ(s) involved and the magnitude of injury. All patients with penetrating wounds in proximity to the abdomen and associated hy potension, perito nitis, or evisceration require emergency laparotomy. Patients with gun shot wounds that obviously traverse the peritoneal cavity or visceral/vascular area of the retroperitoneum on physical or routine x-ray examination also require emergency la parotomy. Asymptomatic patients with anterior abdominal stab wounds that are shown on local wound exploration to penetrate the fascia or peritoneum are evaluated by se rial physical examinations or DPL. However, laparoscopy or laparotomy remains an ac ceptable option. Asymptomatic patients with flank or back stab wounds that are not obviously superfiCial are evaluated by serial physical examinations or contrast-enhanced CT. Exploratory laparotomy is an acceptable option with these patients as well. It is safer to perform a laparotomy in patients with gunshot wounds to the flank and back. Management of blunt and penetrating trauma to the abdomen and pelvis Includes: •

Reestablishing vital functions and optimizing oxygenation and tissue perfusion

•

Prompt recognition of sources of hemorrhage with efforts at hemorrhage control (such as pelvic stabilization)

•

Delineating the injury mechanism

•

Meticulous initial physical examination, repeated at regular intervals

•

Selecting special diagnostic maneuvers as needed, performed with of time

a

minimal loss

• Maintaining a high index of suspicion related to occult vascular and retroperitoneal

. . lflJUfleS .

•

Early recognition for surgical intervention and prompt laparotomy

.

Bibliography l.

3. Anderson PA, Rivara FP, Maier RV, et al. The epidemiol ogy of seat belt-associated inju ries j Trauma 1991;31:60-67. .

Agol ini SF, Shah K, Jaffe J. et al. Arterial embolization is a rapid

and effeclive 1echniquc for controll ing pel vic fracture hemor

rhage. f Trauma 1 997;43(3):395-399.

2. Almogy G, Mintz Y, Zamir Can external signs

2006;243(4):54 1-546.

G, et al. Suicide bombing attacks: pred ict internal injuries? Ann Surg

4.

Appenzeller GN. Injury paltems in peacekeeping missions: the Kosovo experience. Mil Med 2004; 169(3 ): 187-191.

5. A qu il era

PA, Choi T, Durham Bl-l. Ultrasound-aided supra pubi c cystostomy catheter pl acement in the emergency de partment. 1 Emerg Med 2004;26(3):3 19-321.

6. Ballard

RB, Rozycki GS, Newman PG, et al. An al go rithm to reduce the [ncidencc of false-negative FAST examinations in


B I B LIOGRAPHY patients at high risk for occult injury. I Am Coli Surg

1999; 189(2):145- 150.

7. .Beckley AC. Starnes BW, Sebesta )A. Lessons learned from modern military surgery. Surg Clin North Am 2007;8'Z.( I ):15784, vii. 8. Born CT. Blast trauma: the fourth weapon of mass destruc tion. Scand I Sur� 2005;94( 4):279-285. 9. Boyle EM, Maier RV, Salazar JD, et al: Diagnosis of injuries after stab wounds to the back and flank. j Tra uma. 1997;42(2):260-265. 10. Cook RE, Keating JF, Gillespie T. The role of angiography in

the management of haemorrhage from major li·actures of rhc pelvis. ] Bone loi111 Surg Br 2002;84(2): 1 78-182.

125

24. Gylling SF, Ward RE, Holcroft JW, et al. Immediate external fixation of unstable pelvic fractures. Am ! Surg 1985;150:721724. 25. Hak D). The role of pelvic angiography in evaluntion and man agemen t o[ pelvic trauma. Orthop Clin North Am 2004;35(4):439-443, v. 26. Hare SS, Goddard I, Ward P, Naraghi A, Dick EA. The tadio logical management of bomb blast injury. Clill Radiol 2007; 62(1 ): 1 -9. 27. Heetveld MJ, Harris 1 , Schlaphoff G, Balogh Z, D'Amours SK, Sugrue M. Hemodynamically unstable pelvic fractures: recent care and new guidelines. World I Surg 2004;28(9):904-909.

28. Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamicaUy unstable pelvic frac ture patients. li.NZ J Surg 2004;74(7):520-529.

1 1 . Cryer HM, Miller fB, Evers BM, et al. Pelvic f;acture classifi cation: correlation with hemorrhage. I Trntmlll 1988;28:973980.

29. Holmes JF, Harris D, Battistclla fD. Performance of abdomi

12. Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multi

nal ultrasonography in blunt trauma patients with olll-of hospital or emergency department hypotension. A11n Emerg

ple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. I

Trauma 1989;29:981 - 1 002.

13. De PRG, Burris DG, Champion 1-lR, Hodgson M). Blast in juries. N Eng/ j Med 2005;352(13):1335-1342. 14. Demetriades D, Rabinowitz B, Sofianos C, ct al. The manage ment of penetrating injuries of the back: a prospective study of 230 patients. A1m Surg 1 988;207:72-74. IS. Dischinger PC, Cushing BM, Kerns TJ. Injury patterns associ ated with direction of impact: drivers admitted to traLuna cen ters. / Trauma J 993;35:454-459.

16. Donohue fH, Federle MP, Grif:fiLhs BG, eL al. Computed to mography in the diag11osis of blunt intestinal and mesenteric injuries. } Trauma 1987;27:1 1-17.

l7. Durkin A, Sagi HC, Durham R, Flint L. Contemporary man agement of pelvic fractures. A111 } Surg 2006; 192(2): 21 1-223. I 8. Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage i n pelvic fracture. fll}ttry

2006;37(7):602-613. 19. Fallon \VF fr, Reyna TM, Bmnner RG, ct al. Penetrating trauma to the buttock. South lvled I 1988;81 ( 10):1236- 1238. 20. Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for man agement of Life-threatening hemorrhage from pelvic fracture. } Traumc1 2005;58(5):978-984; discussion 984.

2 1 . Feliciano DV, Bitondo CG, Steed G, et al. Five hundred open taps or lavages in patients with abdominal stab wounds. A m } Surg 1984;146:772-777. 22. Giannoudis PV, Pape HC. Damage control orthopaedics in un stable pelvic ring injuries. Tnjury 2004;35(7):671-677. 23. Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Gi annl�ul>ment of truncal injuries: les

J Trauma

43. Miller KS. l\kAn111ch JW. R.1diographic assessment of renal trauma: our 1 5 ycJrcxpcricnce./ Uro/ 1995;154(2 Pt 1):352-355.

sons

20( I ) : 1 59 170.

trol of severe: hc:mon·h,\gc using C-clamp and arterial .:m bolization in hl•mc1dynamically unstahk pal"icnts with pelvic ring disruption. Arclt Ortlwp

reduces cost and u nnc:ccssMy celiotomies in blunt trau rna.

,\rch Sur.'! 1996; 13: 951-959.

in the managc:mc:nl of pl'nc:trating wounds to the abdomen:

63. Shackford SR, Rogers FB, Osler TM, ct al. roo.::used abdominal sonography for tr;tuma: the learning curve of nonradiologist

�xp�riencc: with 2.212 patienh. r\1111 Surg 1974; 179(5 ):639-646.

dinici.tm

Bohman HR. Pred1ctur� of mort.tlit) in dose proximity blast

injuries during Operation I r.1qi I recdom. I Am Coli Surg 2006;

6·1. Sh30% of the infused volume.

STEP 13. After the fluid returns, send a sample to the laboratory for Gram staining and eryth rocyte and leukocyte cow1ts ( tmspun). Positive test results and the need for surgical intervention are indicated by I 00,000 red cells per cubic mi.llimeter or more, more than 500 white cells per cubic millimeter, or a positi ve Gram stain for food tibers or bacteria. A nega ti ve lavage does not exclude retroperitoneal injuries, such as pancreatic and duodenal injuries or diaphragmatic tears.

STEP 7. Insert a peritoneal dialysis catheter into the peritoneal cavity.

STEP 8. Advance the catheter into the pelvis. STEP 9. Connect the dialysis catheter to a syringe, and aspirate. STEP 10. lf gross blood is not obtained, instill I L of wam1ed isotonic crystalJoid solution/normal saline ( 1 0 mL/kg in a chi ld) into the peritoneum through the intravenous tubing attached to the d ialysis catheter.

STEP 1 1 . Gently agitate the abdomen to distribute the Quid throughout the peritoneal cavity and increase mixing with the blood.

�� COMPLICATIONS OF PERITONEAL LAVAGE • Hemorrhage, secondary to injection oflocal anesth etic or incision of the skin or

subcutaneous tissues, which produces false positive results • Peritonitis due to intestinal perforation from the catheter • L acerati on of u rinary bladder (if bladder not evacuated prior to procedure) • lnjury to other abdominal and retroperitoneal struc tu res requirin g operative care • Wound infection at the lavage site (late com pl i ca tion )

� Skill VIII-:�� Diagnostic Peritoneal Lavage: Closed TecHnjque STEP 1 . Decompress the urinary bladder by inserting a tu·i nary catheter.

STEP 2. Decompress the stomach by inserting a gastric tube.

STEP 3. Surgically prepare the abdomen ( costal margin to the pubic area and flank to flank, a nteriorly). STEP 4. Inject local 3Jlesthctic at the midline, just below the umbilicus. Use lidocaine \Vith ep inep hri ne to avoid blood contamination from skin and subculaJleous Lissue.

STEP 5. Elevate the skin on either side of the proposed need le insertion site wilh the fmgers or (creeps. STEP 6. Lnsert an IS-gauge beveled needle attached· to a syringe through the skin and subcutaneous tissue. Resistance is encOlmtered when traversing the fascia and again when penetrating the peritoneum. STEP 7. Pass the flexible end of the guidewire through the 18-gauge needle until resistance l.s met or 3 em is still showing outside the needle. Remove the needle from the abdominal cavity so that only the guidev.rire remains.

•


SKILL STATION VIII STEP 8. Make a small skin incision at the entrance site of

•

Diagnostic Peritoneal Lavage

STEP 1 3. After the fluid has returned, send a sample to

the catheter, and inl>ert the peritoneal lavage catheter over the guidewirc and into the peritoneal cavity. Remove the guidewire f�om the abdominal cavity so that only the lavage catheter . remams.

the laboratory for Gram staining and erythrocyte and leukocyte counts ( unspu n). A positive test and the need for surgical interveMion arc indicated by 100,000 red cells per cubic millimeter or more, more than 500 white cells per cubic millimeter, or a positive Gram stain for food fibers or bacteria. A negative lavage does not exclude retroperitoneal injurie1., such as pancreatic and duodenal injurie1. or diaphragmatic tears.

STEP 9. Connect the dialysis catheter to a syringe. and

aspirate. STEP 10. If gross blood is not obtained, instill I L of warmed isotonic crystalloid solution ( 10 mL/kg

in a child) into the peritoneum through the intravenous tubing attached to the dialysis catheter.

STEP 1 1 . Gently agitate the abdomen to distribute the

the peritoneal cavity and increase mixing with the blood.

fluid throughout

STEP 12. If the patient's condition is stable, let the fluid

remain a few minutes before placing the crystalloid container on the floor and allowing the peritoneal fluid to drain from the abdomen. Make sure the container is vented to promote now of the Ouiu from the abdomen; adequate fluid return is >30%> of the infused volume.

129

�� COMPLICATIONS OF PERITONEAL LAVAGE Hemorrhage, secondary to injection of local ancsthet ic or incision of the skin or subcutaneous tissues, which produces fabe positive results • Peritonitis due to intestinal perforation from the catheter • Laceration of urinary bladder (if bladder not evacuated prior to procedure) • Injury to other abdominal and retroperitoneal structures requiring operative care • Wound infection ot thc lavage site (late complication) •


C H A PT E R

•

CHAPTER OUTLINE Objectives Introduction Anatomy Scalp Skull Meninges Brain Ventricular System Tentorium Physiology Intracranial Pressure Monro-Kellie Doctrine Cerebral Blood Flow Classifications of Head Injuries Mechanism of Injury Severity of Injury Morphology

Upon completion of this topic, the student will demonstrate the a bil ity to apply the techniques of assessment and explain the emergency management of head trauma. S pecifically the doctor will be able to ,

OBJECTIVES

Describe basic intracranial physiology. Evaluate patients with head and brain injuries. Perform a focused neurologic examination. Explain the importance of adequate resuscitation in limiting secondary brain injury. Determine the need for pati ent transfer, admis sion. consultation, or discha rge .

Management of Minor Brain Injury (GCS Score 13-15) Management of Moderate Brain Injury (GCS Score 9-12) Management of Severe Brain Injury (GCS Score 3-8) Primary Survey and Resuscitation Secondary Survey Diagnostic Procedures Medical Therapies for Brain Injury Intravenous Fluids Hyperventilation Mannitol Steroids Barbiturates Ant1convulsants

Surgical Management Scalp Wounds Depressed Skull Fractures Intracranial Mass Lesions Penetrating Brain Injuries Prognosis Brain Death Chapter Summary Bibliography


132

CHAPTER 6

•

Head Trauma

Introduction Head inj uries are among the most common types of traum� seen in N orth American em ergency d epartments (EDs), with an estimated l million cases seen an nual ly. Many pa tients with severe bra in inj uries die before reaching a hos pital, and almost 90°;b of prehospital trauma-related deatl1s involve brain inju ry. About 70% of patients with brain in juries who receive medical attention can be categorized as having minor i njuries, 15% as moderate, and 15% as severe. In 2003 there were an estimated 1,565,000 traumatic brain injuries (TB!s) in the United Stales, i ncluding I ,224,000 ED visits, 290,000 hospi talizations, and 51,000 deaths. Survivors of TBI are often left with ncuropsychologic impai rmen ts that result in disabilities affecti ng work and soci al activ ity. Every year, an estimated 80,000 to 90,000 people in Lhe United States exp erience Lhe on&el of long-term disability from brain injury. In an average European country (Den mark), 363 per million inhabitants suffer mode rate to se vere head inj uri es yearly, with more than one-third of these requi ri ng brain inj ury rehabilitalion. Therefore, even a small reduct ion in the mortality and morbidity resu l ting from brain inju ry should have a major impact on publ ic heaiLh. The primary focus o f treatment for patients in whom a severe brain injury is suspected should be to prevent sec ondary brain injury. P roviding adeq uate oxygem1tion and maintaining a blood pressure that is sufficient to perfuse the brain arc the most importa nt ways to limit secondary brain damage and thereby improve the patient's outcome. Subse quent to managing the ABCDEs, identification of a mass le sion requiring surgical evacuation is critical , and t his is best achieved by in1mcdia tely obtaining a computed tomo graphic (CT) scan of the head. However, obtaini ng a CT scan should n ol delay patient transfer to a trauma center ca pabl e of immediate and definitive neurosu rgicaJ interven tion. The triage of a patient with brain injury depends on the sever ity of the i nj ury and the facilities available within a par ticular commu nity. For facilities without neurosurgical cov erage, prear ra nged transfer agreements wiLh higher-level facilities should be in place. Consultation with a neu rosur geon ea rl y in the course or treatmen t is stron gly recom m ended, especial ly if the pati en t is comatose or brain inj u ry is othenvise su spected. In consul.ting a neurosurgeon about a patient with a brain injlll·y, tl1e following information is relayed : • Age of pati en t and mechanism and time of injury •

Resp iratory and cardiovascular s tat us ( parL icu larl y

blood pressure and oxygen sat uration )

• The neurologic examination, consist ing of the Glas gow Coma Scale (GCS) score (with particular em

phasis on th e motor response ) a nd p upil size and reaction to Eght

•

• Presence and type of associated injuries • Resul ts of d iagnostic stud ies, part icLtl arl y CT scan

(if available)

•

Treatmen t or hypoten sion or hypoxia

Do not delay patient transfer to obtain a CT scan or other diagnostic tests.

Anatomy

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

t\ review of craniaJ anatomy includes th e scaJp, skull, m eni nges, brain, ventricular system, cerebrospinal lluid, and ten torium (Figure 6-1 ).

SCALP The scal p is made up of five layers of tissue ( mnemonic: SCALP) that cover lhe skull: ( 1 ) skin, (2) connective tiss ue, (3) aponeurosis or gaJea aponeurotica, ( 4) loose areolar tis sue, and (5) pericran i tun . Loose areolar tissue separates the ga l ea from the pericra n i u m and is the site of subgal eal hematomas. Because of the scalp's gene rous b l ooc.! supply, scalp lacerations may result in majo r bl ood l oss, especi ally in infants and c hil d re n.

SKUll The sku ll is composed of the cran iaJ vault (calvaria) and the base. The calvaria is es pec ially thin in the temporal regions, bu t is cu sh ioned here by the temporal i s muscle. The base of the skull is irregular, whi.ch may contribute to injtu·y as the brain moves within the skull during acce l eration an d decel -


ANATOMY Subarachnoid space

Third

ventricle

133

Superior sagittal sinus

Choroid plexus

..H'l� Straight sinus

Midb rain

4-'-T--Subarachnoid ,'i.,'·� :r�� space

)

Fourth

\11f=-----y{__

Spinal cord

� Central canal

_ _:

Choroid plexus ' •

'

of cord

' '

'

I

.. .. - � '

•

Figure 6-1 Overview of Cranial Anatomy.

l eration. The tloor of the cranial cavity is divided into hree distinct regions: the anterior, middle, and posterior cranial fossae. Simply put, the anterior fossa houses the frontal lobes, the middle fossa the temporal lobes, and Lhe poste rior fossa the lower brainstem and the cerebellum.

MENINGES The meninges cover Lhe brain, and consist of th ree layers: tbe dura mater, arachnoid, and pia mater (Figure 6-2). The dura mater is a tough, fibrous membrane that adheres firmly to Lhe internal surface of the skull. At specific sites the dura splits inlo Lwo leaves that enclose the large venous sin uses that provide the major venous drainage from the brain. The midline superior sagirtal sinus drains into the bilateral trans verse and sigm oid sinuses, which are usually larger on the right side. Laceration of these venous sinuses may result in massive hemorrhage.

Meningeal arteries lie between Lhe dura and the inter nal surface of the skuJJ ( the epidural space). Overlying skull fractures may lacerate these arteries and cause an epidural hematoma. The most commonly injured meningeal vessel i:. the middle meningeal artery, which is located over the temporal fossa. An expanding hematoma from arterial in jury in this location may lead to rapid deterioration and death. Epidural hematomas may also result from injury to dural sinuses and from skull fractures, which tend to expand more slowly and to put less pressure on the underlying brain. However, most epidural hematomas represent a life threatening emergency, and must be evaluated hy a neuro surgeon as soon as possible. Beneath the dura is a second meningeal layer, the thin transparent arachnoid membrane. Because the dura is not attached to the w1derlying arachnoid, a potential space be tween these layers exists (the subdural space), into which hemorrhage may occur. In brain injury, bridging veins that

•


134

CHAPTER 6

•

Head Trauma

•

Dura mater:

Periosteal layer

•

Meningeal layer Arachnoid mater

------=:; -----�

Blood vessel Pia mater

SinUS

Brain:

Gray matter -!� White matter__

-1-

="� � - - Falx cerebri

(in longitudinal fissure only)

Figure 6-2 The Meninges. The meninges cover the brain and consist of three layers: the dura mater. arachnoid, and pia mater. •

travel from the surface of the brain t·o the venous sinuses within the dura may tear, leading lo the formation of a sub dural hematoma. The third layer, 1 he pia mater, is firmly attached to the surface of the brain. Cerebrospinal Ouid (CSF) tills the space between the watertight arachnoid and the pia mater (the subarachnoid space), cushioning the brain and spinal cord. Hemorrhage into this tlu.id-fiJled space (subarachnoid hem orrhage) is frequently seen i n brain contusion or injury to major blood vessels at the base of the brain.

BRAIN The brain consists or Lhc cerebrum, cerebellum, and brain stem (see Figure 6 - l ) . The cerebrum is composed of right and left hemispheres that arc sep who open their eyes sponta neously. obey commands, and are oriented score a total of 1 5 points on the CCS. whereas flaccid patients who do not open their eyes or vocalize sounds score the minimum (3 points) (Table 6-2). A GCS score of8 or less has become the generally accepted definition ofcoma or severe brain injury. Patients with a brain injury who have a GCS score of9 to 1 2 are categorized as "moderate," and t ho�c with a GCS �core of 13 to 15 are des ignated as "minor." In assessing the GCS score, when there is right/left asymmetry, it is important to use the best motor re sponse in calculating the score because this is the most reliable predictor ofoutcome. l lowever, one must record the actual re

sponse on both sides.

MORPHOLOGY Head trauma may include fractures, conlusions, hema

tomas, and diffuse injuries.

Skull fracture!> m.ty be seen in the cranial vault or skull base. They may be linear or stellate, and open or closed. Basal skull fractures usua lly require CT scanning with bone-window set tings for identification. The presence of clinical signs of a ba�al skull fracture should increase the index of suspicion

•

Glasgow Coma Scale (GCS) SCORE

ASSESSMENT AREA Eye opening (E) • Spontaneous

4

• To speech

3

• To pain • None

2 1

Best motor response (M) • Obeys commands

6

• Localizes pam

5 4 3 2

• Normal flexion (withdrawal) • Abnormal flex1on (decortiCate) • Extens1on {decerebrate) • None {flacod)

1

Verbal response (V) • Onented • Confused conversat1on • Inappropriate words • Incomprehensible sounds • None GCS score

=

5 4 3 2 1

(E + M + V); best possible score

possible score = 3.

....

'

'"""

ately or a few days after the initial injury. In general, the prognosis for the recovery of seventh-nerve function is bet ter in the delayed-onset variety, but the prognosis for recov ery of eight h-nerve function i� poor. Basal skull fractures that traverse the carotid canals may damage the carotid arteries (dissection, pseudo.1ncurysm, or t hrombosis ) , and consider ation should be given to cerebral arteriography. Open or compound skull fractures may provide a di rect communication between the scalp laceration and the cerebral surface, because I he dura may be torn. The signifi· cance of a skull fracture should not be underestimated, since It takes considerable force to fracture the skull. A linear vault fracture in conscious pa tients increases the likelihood of an intracranial hematoma by 1hout 400 times. ,

Intracranial Lesions

Skull Fractures

TABLE 6·2

and help in itl> idt•ntification. These signs include periorbital ecchymo�i� (r 100 mm Hg despite aggressive fluid re suscitation, the priority is to establish the cause of the hypotension, with the neurosur gical evaluation taking second priority. In such cases, the patient undergoes a DPL or ultra sound in the ED and may need to go directly to the operating room (OR) for a laparotomy. CT scans of the head are obtained after the la parotomy. If there is clinical evidence of an in-

resuscitation and the patient has clinical evi dence of a possible intracranial mass (unequal pupils, asymmetric results on motor exam), the first priority is to obtain a CT head scan. A DPL or FAST exam may be performed in the ED, CT area, or OR, but the patient's neurologic eval uation or treatment should not be delayed.

g In borderline cases-i.e., when the systolic

BP

can be temporarily corrected but tends to slowly decrease every effort should be made to get a head CT prior to taking the patient to the OR for a laparotomy or thoracotomy. Such cases call for sound clinical judgment and cooperation be tween the trauma surgeon and neurosurgeon.


146

CHAPTER 6

•

Head Trauma

also should be repeated whenever there is a change in the patient's clinical status and routinely at 1 2 to 24 hours after injury for patients with a contusion or hematoma on the initial scan . • • See Skill Station IX: Head and Neck Traum(\; Assessment and Management, Skill IX-C: Evaluation of CT Scans of the Head. Findings of significance on the CT images include scalp swelling or subgaleal hematomas at the region of impact. Skull fractures may be seen better with bone windows, but are often apparent even on the soft-tissue windows. The cru cial findings on the CT scan are intracranial hematoma, contusions, and shift of the midline (mass effect) (see Fig ure 6-5: CT Scans ofintracranial Hematomas). The septum pellucidum, which lies between the two lateral ventricles, should be located in the midline. The midline can be deter mined by drawing a line from the crista gal li anteriorly to the insertion of the falx at the internal occipital protuber ance posteriorly. The degree of displacement of the septw11 pellucidum away from the side of the hemat·oma should be noted, and rhe actual degree of shift should be determined by using the scale lhat is printed on the side of the scan. A sh ift of 5 mm or greater is often indicative ofthe need for sur

gery to evacuate the blood clot or contusion causing tile shift.

There is some evidence thai the addjtion of CT aJJgiogra phy (CT-A) or cerebral arteriography may uncover unsus pected vascular injury to the skull base that could place the patient at risk for stroke. These studjes should be consid ered when a high-energy mechanism of injury is present. rl' See Chapter 7: Spine and Spinal Cord Trauma for specific criteria. In patients whose blood pressure can be normalized, every effort should be made to obtain a head CT se<m prior to taking the patient to the operating room. Such cases re quire sound clinical judgment and cooperation between the trauma surgeon and the neurosurgeon (see Figure 6-9). Table 6-4 provides an overview of the management of traumatic brain injury.

Hypovolemia in these patients is harmful. Care should also be taken not to overload the patient with fluids. Hypotonic flu ids should not be used. Furthermore, the use of glucose containing fluids may re sult in hyperglycemia, which has been shown to be harmful Lo the injured brain. Therefore, it is recommended Ringer's lactate solution or normal saline be used for resuscitation. Serum sodium levels need to be very carefully monitored in patients with head i njuries. Hy ponatremia is associated with brain edema and should be prevented.

HYPERVENTILATION In most patients, normocarbia is preferred. Hyperventila tion acts by red ucing Paco2 and causing cerebral vasocon striction. Aggressive and prolonged hyperventilation may actuall y produce cerebral ischemia by causing severe cere bral vasoconstriction and thus impaired cerebral perfusion. This is particularly true if the Paco2 is allowed to fall below 30 nun Hg (4.0 kPa).

Hyperventilation should be used only in moderation and for as limited a period as possible. ln general, it is preferable to keep the Paco2 at 35 mm Hg or above. Brief periods of hy perventilation (Paco2 25 to 30 mm Hg) are acceptable if necessary fo r acute neurologic deterioration while other treatments are initiated.

MANNITOL Mannitol is used to reduce elevated ICP. The preparation most commonly used is a 20o/o solution. The most widely accepted regimen is 0.25 to 1 g/kg administered intra venously as a bolus. Large doses of mannitol should not be

•

Medical Therapies for Brain Injury The primary aim of inlensive care protocols is to prevent sec ondary dqutted

given to patients with hypotension, because mannitol

is a

potent osmotic diuretic. Acute neurologic deterioration.

the CT scanner or directly to the operating room if the causative lesion already has been identified.

�uch as the development of a dilated pupil, hemiparesis, or loss or consciousness while the patient is being observed, is a strong indic• potension or hypovolemia. Furthermore, hypotension often result� from their use. Therefore, barbiturates are not indi cated in the acute resuscitative phase.

ANTICONVULSANT$ Posttraumatic epilepsy occurs in about So/o of patients ad mitted to the hmpital with closed head injuries and in 15% of those with severe head injuries. Three main factors are linked to a high incidence of late epilepsy: ( I ) seizures oc curring within the first week, (2) an intracranial hematoma, and (3) a depressed skull fracture. A double blind study found that prophylactic phenytoin reduced the incidence of seizures in the tirst week of injury, but not thereafter. Currently, phenytoin or fosphenyLoin is the agent usually used i n the acute phase. For adults, the usual loading dose is 1 g of phenytoin given intravenously at a rate no faster than 50 mg/min. The usual maintenance dose is 1 0 0 mg/8 hours, with the dose titrated to achieve therapeutic serum levels. For patients with prolonged seizure!., diazepam or lorazepam arc used in addition to phenytoin until the seizure stops. Control of continuous seizures may require general anesthesia. I t is imperative that the seizure be controlled as soon as possible because prolonged seizures (30 to 60 minutes) may cause second ary brnin injury.

Surgical Management Surgical management may be necessary for scalp wotmds, depressed skull fractures, intracranial mass lesions, and pen etrating brain injuries.

fracture or foreign material. CSF leakage indicates that there i� an associated dural tear. A neurosurgeon should be con sulted in all cases of open or depressed skull fractures. Not infrequently, a subgaleal collection of blood can feel like a skull fracture. I n sud1 cases, the presence of a fracture can be confirmed or excluded by plain x-ray cxaminaUon of the re gion Jnd/or a CT scan.

DEPRESSED SKUll FRACTURES Generally, a depressed skull fractu n.' needs operative eleva tion if the degree of depression is greater than the thickness of the adjacent skull, or if it is open and grossly contami nated. Less significant depressed fractures can often be man aged with closme of the overlying scalp laceration, if present. A CT scan is valuable in identifying the degree of depres sion, but more importantly in excluding the presence of an intracranial hematoma or contusion.

INTRACRANIAL MASS LESIONS Intracranial mass lesions typically are evacuated or treated by a neurosurgeon. If a neurosurgeon is not available in the facility initially receiving the patient with an intracranial mass lesion, early transfer to a hospital with a neurosurgeon is essential. ln very exceptional circumstances, a rapidly ex panding intracranial hematoma may be imminently life threatening and may not allow time for transfer if neurosurgical care is some di:.tancc away. Although this cir cumstance is rare in urban settings, it may occur in rural ucas. Under such conditions, emergency craniotomy may be considered if a surgeon properly trained in the procedure is available. This procedure is especially important in a pa tient whose neurologic status b rapidly deteriorating and docs not respond to nonsurgical measures. Emergency cran iotomy by a non-neurosurgeon should be considered only in extreme circumstances, and the procedure should be done only with the advice of a neurosurgeon. The indications for a craniotomy performed by a non neurosurgeon are few, and widespread use as a desperation maneuver is neither recommended nor supported by the Committee on Trauma. This procedure is justified only when definitive neurosurgical care is unavailable. The Com mittee on Trauma strongly recommends that those who an ticipate the need for this procedure receive proper training from a neurosurgeon.

SCALP WOUNDS It is important to clean the wound thoroughly before su turing. The most common cause of infected scalp wounds is inadequate cleansing and debridement. Blood loss from scalp wounds may be extensive, espel..ially in children. Scalp hemorrhage usually can be controlled by applying direct pressure and cauterizjng or ligating large vessels. Appropri ate sutures, clips, or staples may then be applied. Carefully inspect the wound under di reel vision for signs of a skull

PENETRATING BRAIN INJURIES CT :.canning of the head ic; strongly recommended to eval uate patients with penetrating brain injury. Plajn radi ographs of the head can be helpful in assessing bullet trOry funct ion. The 1/lotor level is defined similarly with re spect lo motor function as the lowest key musde that has a grade of at least 3/5 (see Table 7-1 ). I n complete injuries, when some impaired sensory and/or motor function is found just below the lowest nom1al segment, this is referred to as t he zone of partial preservation. As described previously, the de termination of the level of injury on both sides is important. A broad distinction may be made between lesions above and below T l . lnjuries of the tirst eight cervical segments of the spinal cord result i11 quadriplegia, and lesions below the T I level result in paraplegia. The bo11y lntcf of injury is the vertebra at which the bones arc damaged, causing inju ry to the spinal cord. The neurologic level of i11jury is determined primarily by clinical examination. Frequently, there is a dis crepancy between the bony and the neurologic levels be cause t he spinal nerves enter the !>pinal canal through the foramina and ascend or descend inside the spinal canal be fore actually entering the spinal cord. The further caudal the injury is, the more pronounced thi� discrepancy becomes. Apart from the initial management to stabilize the bony in jury, all subsequent descriptions of the level of injury arc based on the neurologic level. .

SEVERITY OF NEUROLOGIC DEFICIT Spinal cord injury may be catcgori L.cd as; •

Incomplete paraplegia ( incomplete thoracic)

•

Complete paraplegia

•

lm:omplete quadriplegia (incomplete cervical)

(complete thoracic )

• Complete quadriplegia (complete cervical injury)


SPECIFIC TYPES OF SPINAL INJURIES It is important to assess for any sign of preservation of function of the long tracts of the spinal cord. Any motor or sensory function below the level of the injury consti tutes an incomplete injury. Signs of a11 incomplel: injury include any sensation (including position sense) or volun tary movement in the lower extremities, sacral spa1·ing (ie, perianal sensation), voluntary anal sphincter contraction, and volunta1·y toe flexion. Sacral reflexes, such as the bul bocavernosus reflex or anal wink, do not qualify as sacral spanng.

SPINAl CORD SYNDROMES Certain characteristic patterns of neurologic injury are fre quently seen in patients with spinal cord injuries. These pat terns should be recognized so they do not confuse the . exam mer. Central cord synd1'ome is characterized by a dispropor tionately greater loss of motor power in the upper extremi ties than u1 the lower extremities, with varying degrees of sensory loss. Usually this syndJ'Ome is seen after a hyperex tension injury in a patient with preexisting cervical canal stenosis (often due to degenerative osteoarthritic cha11ges). The history is commonly that of a forward fall that resulted ill a facial impact. Lt may occur with or without cervical spine fracture or dislocation. Recovery usually follows a characteristic pattern, with the lower extremities .recovering strength first, bladder function next, and the proximal upper extremities and hands last. The prognosis for recovery in central cord injuries is sornewhat better than with other in complete injuries. Central cord syndrome is hought t to be due to vascular compromise of the cord in the distribulion of the anterior spinal artery. This artery supplies the central portions of the cord. Because the motor fibers to the cervi cal segments are topographically arranged toward the cen ter of the cord, the arms and hands are the most severely affected. Anterior cord syndrome is characterized by paraplegia and a dissociated sensory loss with a loss of pain a11d tem perature sensation. Posterior column flmction (position, vibration, and deep pressure sense) is preserved. Usua!Jy, anterior cord syndrome is due to infarction of the cord in the territory supplied by the anterior spinal artery. This syndrome has the poorest prognosis of the incomplete ill. . Junes. Brown-Sequard syndrome results from hemisection of the cord, usually as a result of a penetrating trauma; it is rarely seen. Nevertheless, variations on the classic picture are not uncommon. l n its pure form, the syndrome con sists of ipsilateral motor Joss (corticospinal tract) and loss of position sense (posterior column), associated with con tralateral loss of pain and temperature sensation begin ning one to two Levels below the level of injury (spinothalamic tract). Even if the syndrome is caused by a direct penetrating injury to the cord, some recovery is usually seen.

163

MORPHOlOGY Spinal injuries can be described as fractures, fracture-dislo cations, spinal cord injury without radiographic abnormal ities (SCIWORA), a11d penetrating injuries. Each of these categories may be further described as stable or unstable. However, determining the stability of a particular type of injury is nol always simple and, indeed, even experts may disagree. Hence, especially in the initial treatment, all patients with radiographic evidence of injury and all those with neu rologic deficits should be considered to have an unstable spinal injury. These patients should be immobilized until after consultation with an appropriately qualified doctor, usually a neurosurgeon or orthopedic smgeon.

Specific Types of Spinal Injuries Cervical spine injuries can result from one or a combina tion of the following mechanisms of injury: •

Axial loading

•

flexion

• Extension •

Rotation

• Lateral bending • Distraction

The injuries identified in this chapter all involve the spinal column. They are listed in �matomic sequence (not in order of frequency), progressing from the cranial to the caudal end of the spine.

ATlANTO-OCCIPITAl DISlOCATION Craniocervical disruption injuries are uncommon and re sult from severe traumatic flexion and distraction. Most of these patients die of brainstem destruction and apnea or have profound neurologic impairments (are ventilator-de pendent and quadriplegic). An occasional patient may sur vive if prompt resuscitation is available at the injury scene. This injury may be identified u1 up to 19o/o of patients with fatal cervical spine mjurics and is a common cause of death in cases of shaken baby syndrome in which the infant dies immediately after shaking. Cervical traction is not used in patients with craniocervical dislocation. Spinal immobi lization is recommended initially. rl' Aids to the identifica tion of atlanto-occipital dislocation on spine films, including Power's ratio, are included in Skill Station X: X Ray Identification of Spine Injuries.

•


164

CHAPTER 7

•

Spine and Spinal Cord Trauma

ATLAS FRACTURE (C1 ) The atla1> is a thin, bony ring with broad articular surfaces. Fractures of the atlas represent approximately SOlo of acute cervical spine fral.lures. Approximately 40% of atlas frac:" tures arc assoctated with fractures of the axis (C:!). The most common C l fracture is a burst fracture ( Jefferson fracture).

may be conlu�ing. ln tim injury, the odontoid is not equi

distant from the two lateral mas�cs of C l . The patient should not be forted to overcome the rotation, but should be immobilized in thl' rotated position and referred for fur ther specialized treatment.

The usual mechanism of injuq' is axial loading, which oc

AXIS (C2) FRACTURES

curs when a large load falls vertically on the head or a patient

The axis is the largest cervie on the top of his or her head in a relatively neutral po sition. The Jefferson fn�eture involves disruption of both the anterior and posterior rings of C I wilh Ia teral displacement of the lateral masses. The fracture is best seen on an open mouth view of the C I to C2 region and axial CT scans ( Fig ure 7-S). In patients who survive, these fractures usually are not associated with spinal cnrd injuries. However, they arc unstable and :.houiJ he initially treatcu with a cervical col lar. Unil,llcral ring or latcr,ll mass fracture� are not uncom mon and Lend ro be stable injuries. However, they are treated

as unstable until the patient is examined by an appropriately qualified doctor, u�ually a ncu ro�urgeon or orthopedic sur geon.

usual in shape. Therefore, it i.s susceptible to various frac tun.�s depending on the force nnd direction of the impact. Acute frnctures of C2 represent approximately 18% of all

ccrvic'ith a persistent rotation of the head (torticolli�). Thb injury is also best diagnosed with an open-mouth odontoid view, although the x-ray ftndings

Figure 7-5 Jefferson Fracture. Open-mouth view radiograph showing a Jefferson fracture.

•

dens and are the most common odontoid fracture (Figure 7-

6). In children rounger than 6 years of age, the epiphysis may be prominent and may look like a fracture at tJ1is level.

·y ypc I I I odontoid frncturcs occur at the base of the dens and

extend obliquely into the body of the axis.

• Fig ure 7-6 Odontoid II odontoid fracture.

Fracture. CT view of a Type


SPECIFIC TYPES OF SPINAL INJURIES Posterior Element Fractures of C2 A hangman's fracture involves the posterior elements of C2-that is, the pars interarticu\aris (Figure 7-7). This type of fracture represents approximately 20% or all a�is frac tures and usually is caused by an extension-type injury. Pa tients with this fracture should be maintained in external immobilization until specialized care is available. Variations of a hangman's fracture include bilateral li·acl u res through the la Lcral masses or pedides. Approxi mately 20% of all axis fractures arc nonodontoid and non hangman's. These include fractures through the body, pedicle, lateral mass, laminae, and spinous process.

FRACTURES AND DISLOCATIONS (C3 THROUGH C7) A fracture of C3 is very uncommon, possibly because it is positioned between the more vulnerable axis and the more mobile "relative fulcrum" of the cervical spine that is, CS and C6-where the greatest tlexion and ex tension o r the cervical spine occur. In adults, Lhe most common level of cervical vertebral fracture is CS, and the most common level of subluxation is C5 on C6. The most common injury patterns identified at these levels are ver tebral body fractures with or without subluxation, sub luxation of the articular processes (including unilateral or bilateral locked facets), and fractures of the laminae, spinous processes, peclicles, or lateral masses. Rarely, lig arncntous disruption occurs without fractures or facet dislocations. The incidence of neurologic injury increases dramat ically with facet dislocations. [n the presence of unilateral facet dislocation, 80% of patients have a neurologic in jury-approx.imately 30% have root injuries only, 40o/o in complete spinal cord injuries, and 30o/o complete spinal cord injuries. r n the presence of bila teral locked facets, the

A

8

165

morbidity is much worse, with l 6o/o incomplete and 84% complete spinal cord injuries.

THORACIC SPINE FRACTURES (T1 THROUGH T1 0) Thoracic spinal fractures may be classified into four broad ca tegorics: •

Anterior wedge compression injuries

•

Burst injuries

•

Chance fractures (Figure 7-8)

•

Fracture-djslocations

Axial loading with llexion produces an anterior wedge compression injury. The amount of wedging usually is quite small, and the anterior portion o[ the vertebral body rarely is more than 25o/o shorter Lhan the posterior body. Because of the rigidity of the rib cage, most or these fractures are sta ble. The second type of thoracic fracture is the burst injury, which is caused by vertical-axial compression. Chance frac tures arc transverse fractures through the vertebral body. They are caused by Aex.ion about an axis anterior to the ver tebral column and are most frequently seen following motor vehicle crashes in which the patient was restrained b)' only a lap bell. Chance fractures may be associated with retroperitoneal and abdominal visceral injuries. Fracture dislocations are relatively uncommon in the thoracic and I umbar spine because of the orientation of the facet joints. These injuries almost always are due to extreme flexion or severe blunt trauma to the spine, which causes disruption of the posterior elements (pedicles, fa cets, and lamina) of the vertebra. The thoracic spinal canal is narrow in relation to the spinal cord, so fracture subluxations in the thoracic spine commonly result in complete neurologic deficits.

c

Figure 7-7 Hangman's Fracture (arrows) demonstrated in axial (A), sagittal paramedian (B), and sagittal mid line (C) CT reconstructions. Note the anterior angulation and excessive distance between the spinous processes of C1 and C2 (double arrows).

•

•


166

CHAPTER 7

•

Spine and Spinal Cord Trauma PITFALLS • An inadequate secondary assessment may result in

the failure to recognize a spinal cord injury, par ticularly an incomplete spinal cord injury. • Patients with a diminished level of consciousness and those who arrive in shock are often difficult to assess for the presence of spinal cord injury. These patients require careful repeat assessment once initial life-threatening injuries have been man aged.

Figure 7-8 Chance Fracture. Radiograph showing the Chance fracture.

•

Sim pic com pression fractures are usual ly stable and often treated with a rigid brace. Burst fi·actures, Chance frac tures, and fracture-dislocations are extremely UJJstable and almost always require internal fixation.

THORACOLUMBAR JUNCTION FRACTURES (T1 1 THROUGH L1) Fractures at the level of the thoracolumbar junction are due to the relative immobility of the thoracic spine as compared with the lumbar spine. They most often result from a com bination of acute hyperflexion and rotation, and, conse quently, they are usually unstable. People who fall f1-om a height and restrained drivers who sustain severe flexion en ergy transfer are at particular risk for this type of injury. The spinaJ cord terminates as the conus medullaris at approximately the level of Ll, and injury 1.0 this part of the cord commonly results in bladder and bowel dysfuncl'ion, as well as in decreased sensation and strength in the lo"''er extremities. Patients with thoracolumbar fractures are par ticul arly vulnerable to rotational movement. Therefore, logrolling should be performed with extreme care.

LUMBAR FRACTURES The radiographic signs associated with a lumbar fracture arc similar to those of thoracic and thoracolumbar fractures. How ever, because only the cauda equina is involved, lhe probability ofa complete neurologic deficit is much less with these injuries.

PENETRATING INJURIES The most common types of penetrating injuries are Lhose caused by gunshot wounds or stabbings. It is important to determine the path of the buUet or knife. This can be done

by combining information from the history, clinical exam ination (entry and exit sites), plain x-ray films, and CT scans. lf the path of injury passes directly through the ver tebral canal, a complete neurologic deficit usually results. Complete deficits also may result from energy transfer as sociated l·vith a high-velocity missile (eg, bullet) passing close Lo the spi nal cord rather than through it. Penetrating injuries of the spine usually are stable injuries unless Lhe missile destroys a large portion of the vertebra.

BLUNT CAROTID AND VERTEBRAL VASCULAR INJURIES 131unt trawna to the head and neck has been recognized as a risk factor for carotid and vertebral arterial injuries. Early recognition and treatment of these injuries may reduce the risk of stroke. Indications for screening are evolving, but suggested criteria for screening include: • Cl-C3 fracture • Cervical spine fracture with subluxation •

Fractures involving the foramen transversarium

Approximately one-third of these patients will be shown to have blunt carotid and vertebral vascular injury (BCVl ) on CT angiography of the neck ( Figure 7-9). The treatment of these injuries is evolving, and the impact of treatment is not well defined.

X-Ray Evaluation

I) How do I confirm the presence o;

absence of a significant spine injury?

Both careful clinical examination and thorough radi ographic assessment are critical in identifying significant spine injury. rl' See Skill Station X: X- Ray Tdentification of Spine Injuries.

CERVICAL SPINE Cervical spine radiography is indicated for all trauma pa tients who have midline neck pain, tenderness on palpation,

•


X-RAY EVALUATION

167

Figure 7-9 Blunt Vertebral Artery Injury. CT and angiogram of blunt ver tebral artery injury.

•

neurologic deficits referable to the cervical spine, or an al

be obtained in injured patients without an altered level of

tered level of consciousness or in whom intoxication is sus

consciousness, or in those who report neck pain, to detect

pected. Lateral, anteroposterior (AP) and open-mouth

occult instability or determine the stability of a knovm frac

odontoid views should be obtained.

ture, such

as

a laminar or compression fracture. It is possi

On the lateral view, the base of the skull, all seven cer

ble for patients to have a purely ligamentous spine injury

vical vertebrae, and the tirst thoractc vertebra must be visu

that results in instability without associated fracture, al

alil'ed. The patient's shoulders may need to be pulJed down

though some studies suggest that if plain three-view cervi

when obtaining the lateral cervical spine x-ray film, to avoid

cal spine radiographs with CT supplementation are truly

missing fractures or fracture-dislocations in the lower cer

normal ( ie, no anterior soft-tissue swelling, no abnormal

vical spine. If all seven cervical vertebrae are not visualized

C1ngulation), then significant instabiJily is unlikely.

on the lateral x-ray film, a swim mer's view of the lower cer vical and upper thoracic area should be obtained.

In some patients with significant soft-tissue injury, paraspinal muscle spasm may severely limit the degree of

The open-mouth odontoid view should include tl1e entire

flexion and extension that the patient allows. In such cases,

odontoid process and the right and left Cl, C2 articulations.

the patient is treated with a semirigid cervical collar for 2

The AP view of ilie c-spine assists in the identification ofa uni

to 3 weeks before another allempt is made to obtain flcx

l.tteral facet dislocation in casl'S in which little or no dislocation

ion-ex'tension views. Under no circumstances should rhe

i:. identified on the lateral film. Axial CT scans at 3-mm inter

patient's neck be forced into a position that elicits pain. All

vab also should be obtained through suspicious areas identi

movements must be volunt'gement of acute spinal cord injury. Spine 2006;31 ( 1 L Suppl):S 16-S2l; discussion $36. 26. l lurlbert RJ. The role of steroids in acute spinal cord injury: an evidence-based analysis. Spine 200 I ;26(24 Suppi):S39-S46. 27. ltrt.ernotiallnl Standards for Neurological t.�llrl Punctional Classi jicatioll ofSpinnl Cord Injury. Atlanta, GA: American Spinal In jury Association and l nternal.ionaJ Medical Society of Paraplegia (ASIA/TMSOP); 1996.

286. 4. 1 .

Tator CH, Fehlings MG. Review of the second;1ry injury theory of acute spinal cord trauma with special emphasis on vascular mechanisms. } Neuros11rg 1 9 9 1 ;75: 15-26.

42. Widder S, Doig C, Burrowes P, Larsen G, I Jurlhert RJ. Kort beek ]B. Prospective evaluation of computed tomographic �canning for the spinal clearance uf ohtunded trauma patients: preliminary results. f Tra11nw 2004;56(6): 1 179- 1 184.


S K I L L S TAT I O N •

�� Interactive Skill Procedure THE FOLLOWING PROCEDURES ARE INCLUDED IN THIS SKILL STATION: •• Skill X·A: Cervlcal Spine

X-Ray Assessment �� Skill X-8: Atlanto-Ocdpital

Joint Assessment �� Skill X·C: Thoracic and

lumbar X·Ray Assessment

Performance at t his skill station will allow the participant to:

OBJECTIVES Identi fy various spine injuries by using specific anatomic guidelines

for examining a se ri es of spine x-rays. Given a series of spine x-rays and scenarios, Define limitations of examination. Diagnose fractures. Delineate associated injuries. Define other areas of possible injury.

•� Skill X-0: Review Spine

X·Rays

17 5

•


176

�

SKILL STATION X

•

X-Ray Identification of Spine Injuries

Skill X-A: Cervical Spine X-Ray Assessment (See Figures X-1, X-2, and X-3)

STEP 1 . Assess adequacy and alignment ( Figure X-1 ).

A.

Identify the presence of aU

7 cervical

vertebrae and the superior aspect ofTL

B. Identify the:

• • • •

Anterior vertebral line (Fig. X-1, line A) Anterior spinal line (Fig. X-1, line B)

Posterior spinal line (Fig. X-1, line C) Spinous processes (Fig. X-1, line D)

STEP 2. Assess the bone ( Figure X-2).

A.

•

Examine all vertebrae for preservation of

height and integrity of the bony cortex.

B. Examine facets. C. Examine spinous processes.

STEP 3. Assess the cartilage, including examining the cartilaginous disk spaces for narrowing or widening (see Figure X-2).

STEP 4. Assess the dens (Figure X-3 ) .

A.

Examine the outline of the dens.

B. Examine t.he predental space (3 mm). C. Examine the clivus; it should point to the dens.

•

Figure X-1

•

Figure X-2

•

Figure X-3


SKILL STATION X STEP 5. Assess the extraaxial l.oft tissues.

A. Examine the extraaxial lopace and soft tissues • 7 mm at C3 • 3 em at C7

•

17 7


B. Examine the dtstances between the spinous

processes.

•

� Skill X-8: Atlanta-Occipital Joint Assessment (See Figures X-4 and X-5) Detection of an atlanta-occipital dislocation can be chal lcnging. Two useful findings include a Power's ratio > I ( BC/OA, where BC is the dist•1ncc from the basion I B I to the posterior arch [C] ofCI .1 nd OA is the clistance from the anterior arch of CJ [A] to the opisthion [ 0-the posterior

NORMAL

Wackenheim

margin of the foramen magnum I). Wackenheim's line runs along the posterior clivus nnd passes t·angentially to the pos terior tip of the dens. If an atlanto-occipital injury is sus pected, spinal immobilization should be preserved, and expert racliologic interpretation should be obtained.

CO-C1 INSTABILITY I •

•

•

.... . � � -� �·.

BC/AO (Power's ratio) .s 1 •

Figure X-4

BC/ AO (Power's ratio) >

1


SKILL STATION X

178

•


>3mm

-.'1 to the torso. STEP 4. Carefully straighten the patient's legs and place

them in neutral alignment with the palient's spine. Tie tl1e ankles together with a roller-type dressing or cravat. ·

STEP 5. While mai11taining alignment of tbe patient's

head and neck, another person reaches across and grasps the patient at tl1e shoulder and vvrist. A third person reaches across and grasps the patient's hip just distal to the wrist with one hand and with the other hand firmly grasps the roller bandage or cravat that is securing the ankles together.


184

SKILL STATION XI

•

Spinal Cord Injury: Assessment and Management

STEP 6. At the direction of the person who is maintaining immobilization of the patient's head and neck, cautiously logroll the patient as a unit toward the two assistants at the patient's side, but only to the. least degree necessary to position the board under the patient. Maintain neutral alignment of the entire body during this procedure.

STEP 1 . As previously described, properly secure the

patient to a long spine board, which is the basic technique for splinting the spine. In general, this is done in the prehospital setting, and the patient arrives at the hospital already immobilized. The long spine board provides an effective splint and permits safe transfers of the patient with a minimal number of assistants. However, unpadded spine boards can soon become uncomfortable for conscious patients and pose a significant risk for pressure sores on posterior bony prominences (occiput, scapulae, sam1m, and heels). Therefore, the patient should be transferred from the spine board to a firm, well padded gurney or equivalent surface as soon as it can be done safely. Before removing the patient from the spine board, c-spine, chest, and pelvis x-ray films should be obtained as indicated, because the patient can be easily lifted and tl1e x-ray plates placed beneath the spine board. \Vhile the patient is immobilized on tl1e spine board, it is very important to maintain inm10bilization of the head and the body continuously. The straps used to immobilize the patient on the board should nol be removed from the body whjJe the head remains taped to the upper portion of the spine board.

STEP 7. Place the spine board beneath the patient and carefully logroll the patient in one smooth movement onto the spine board. The spine board is used only for transferring the patient and should not be left under the patient for any length of time.

STEP 8. Consider padding under the patient's head to avoid hyperextension of the neck and for patient comfort.

STEP 9.

Place padd.ing,

rolled blankets, or similar bolstering devices on both sides of the patient's head and neck, and firmly secure the patient's head to the board. Tape the cervical collar, further securing the patient's head and neck to the long board.

�� PEDIATRIC PATIENT A pediatric-sized long spine board is preferable when im mobilizing a small child. If only an adult-sized board is available, place blanket rolls along the entire sides of the child to prevent lateral movement. A child's head is propor tionately larger than an adult's. Therefore, padding should be pl aced under the shoulders to elevate the torso so that the large occiput of the child's head does not produce flex ion of the cervical spine; tllis maintains neutral alignment of the child's spine. Such padding extends from the chlld's ltm1bar spine to the top of the shoulders and laterally to the edges of the board.

STEP 2.

Movement of a patient wiU1 an w1stable vertebral spine in jury can cause or worsen a spinal cord injury. To reduce the risk of spinal cord damage, mechanical protection is necessary for all patients at risk. Such protection should be maintained until an unstable spine injury has been excluded.

unstable or

potentially unstable spine requires continuous maintenance of anatomic alignment of the vertebral colwm1. Rotation, flexion, extension, lateral bending, and shearing-type movements in any direction must be avoided. Manual, in-line immobilization best controls the head and neck. No part of the patient's body should be allowed to sag as the patient is lifted off the supporting surface. The transfer options listed below may be used, depending on available personnel and equipment resources.

,

�� REMOVAL FROM A LONG SPINE BOARD

the patient from the spine board as early as possible. Preplanning is required. A good time to remove the board from under the patient is when the patient is logrolled to evaluate the back.

STEP 3. Safe movement of a patient vv:ith an

�� COMPLICATIONS If left immobilized for any length of time (approximately 2 hours or longer) on tl1e long spine board, pressure sores may develop at the occipu t scapulae, sacrum, and heels. There fore, padding should be applied under these areas as soon as possible, and the patient should be removed from the long spine board as soon as his or her condition permits.

Remove

STEP 4.

Modified Logroll Technique: The modified

logroll technique, previously outlined, is reversed to remove the patient from the long spine board. Four assistants are required: one to maintain manual, in-line immobilization of the patient's head and neck; one for the torso (including the pelvis and hips); one for the pelvis and legs; and one to direct the procedure and remove the spine board.

STEP 5. Scoop Stretcher: The scoop stretcher is an alternative to using the modified logrolling

•


SKILL STATION XI

•


techniques for patient transfer. The proper use of this device can provide rapid, safe transfer of the patient from the long spine board onto a firm, padded patient gurney. For example, this�evice can be used to transfer the patient li·om one transport device to another or to a designated place, eg, x-ray table. The patient must remain securely immobilized until a spine injury is excluded. After the patient is transferred from the backboard to the gurney (stretcher) and the scoop stretcher is removed, the patient must again be immobilized securely on the gurney (stretcher). The scoop stretcher is not a device on '"'hich the patient is immobilized. In addition, the scoop stretcher is not used to transport the patient, nor should the patient be transferred to the gurney by picking up only the foot and bead ends of tbe scoop stretcher. With out firm support under the stretcher, it can sag in the mid dle and result in loss of neutral alignment of the spine.

�� IMMOBILIZATION OF THE PATIENT WITH POSSIBLE SPINE I NJURY

185

to suspect that a c-spine and/or thoracolumbar spine in jury may exist, based on mechanism of injury. In patients witb multiple injuries with a diminished level of con sciousness, protecUvc devices should be lefl in place until a spine injury is excluded by clinical and x-ray examina tions. .. See Chapter 7: Spine and Spinal Cord Trauma. If a patient i s immobil ized on a spine board and is para plegic, spinal instability should be presumed and all ap propriate x-ray films obtained to determine the site o f spinal injury. However, if the patient is awake, alert, sober, neurologically normal; is not experiencing neck or back pain; and does not have tenderness to spine palpation, spine x-ray examination and immobilization devices are not needed. Patients who sustain multiple injuries and arc coma tose should be kept immobilized on a padded gurney (stretcher) and logrolled to obtain the necessary x-ray films to exclude a fTacture. Then, using one of the aforementioned procedures, they can be transferred carefully to a bed for better ventilatory support.

Patients frequently arrive in the ED with spinal protective devices i n place. These devices should cause the examiner

� SCENARIOS SCENARIO Xl- 1

SCENARIO Xl-3

A IS-year-old boy is riding his bicycle through a parking lot.

A 25-year-old male passenger sustains mulliple injuries in

He is distracted and hits a car at low speed when it backs out of a parking space. He is Lhrown from his bicycle across the trunk of the car and sustajns a mild abrasion and an ru1gled deformity of the left wrist. He is brought to the ED im mobilized on a long spine board and with a semirigid cervical collar in place. He is alert and cooperative and has no hemodynamic abnormalities.

a car collision. The driver died at the scene of the injury. The patient is transported to the ED imn1obilized on a long spine board with a semirigid cervical collar applied. Oxygen is being administered, and admin istration of warmed crystalloid fluids with two large-caliber intra venous l i nes is initiated. His blood pressure is 85/40 mm Hg, his heart rate 130 beats/min, and his respiratory rate 40 breaths/min. His respirations are shallow, and there is a contusion over the chest wall. His eyes are open, and his verbal response is appropriate. He is able to shrug his shoulders, b u t is unable to raise his elbow t0 Lhe shoulder level or move his legs.

SCENARIO Xl- 2 A 75-year-old male is walking to the store when he trips

and falls forward, striking his chin on a parked car. He is transported to the ED immobilized o n a long spine board with a semirigid cervical collar applied. He has ctn abra sion on his chin and is alert and appropriately responsive. Physical examination reveals paralysis o[ his hands, with very little finger motion. He has some upper-extremity movement (grade 2/5), but is clearly weak bilaterally. Ex amination of the lower extremities reveals weakness, but he is able t o !lex and extend both his legs at the hip and knee. He has various areas of hypesthesia over his body.

SCENARIO Xl-4 This scenario is essentially the same as Scenario Xl-3, but the instructor will make changes in the patient's neurologic status as rhe student examines the patient. A 25-year-old passenger sustains multiple injuries i n a car collision. The driver died at the scene of the injury. The passenger is transported to the ED immobilized on a


186

SKILL STATION XI

•


long spine hoard with a semirigid cervical collar applied. Oxygen is being administered, administration of warmed crystalloid fluids with two large-caliber intravenous lines is initiated.

•

SCENARIO Xl-5 A 6-year-old boy fell off his bicycle and hit the back of his head. In the ED, his head and neck are in a flexed position, and he reports pain in his neck. He is immobilized on an unpadded long !>pine board without a cervical collar.

I


C H A PT E R

CHAPTER OUTLINE

Introduction Primary Survey and Resuscitation Adjuncts to Primary Survey Fracture Immobi lization X Ray Examination

Upon completion of th1s top ic the stu dent will be able to i n i tially assess and manage pati en ts with life-threatening and limb-threatening musculoskeletal Injuries. Specifically, the doc tor will be able to: ,

OBJECTIVES

-

Secondary Survey History Physical Examination Potentially Life-Threatening Extremity Injuries Major Pelvic Disruption with Hemorrhage Major Arterial Hemorrhage Crush Syndrome (Traumatic Rhabdomyolysis) Limb-Threatening Injuries Open Fractures and Joint Injuries Vascular Injuries, Incl ud i ng Traumatic Amputation Compartment Synd rome Neurologic Injury Secondary to Fracture-Dislocation

E xplai n the signi ficance

of musculoskeletal injuries in patients with multiple i njuri es .

Outline priorities in the assessment of muscu loskeletal trauma to identify life-threatening and limb threateni ng i njur ies -

.

Explain the proper principl es of initial manage ment for musculoskeletal injuries.

Other Extremity Injuries Contusions and Lacerations Joint Injuries Fractures Principles of Immobilization Femoral Fractures Knee Injuries Tibia Fractures Ankle Fractures Upper-Extremity and Hand I njuries Pain Control Associated Injuries Occult Skeletal Injuries Chapter Summary Bibliography

•


188

CHAPTER 8

•


Introduction Injuries to the musculoskelkcletal trauma docs pose a challenge to the treating doctor. Musculoskeletal injuries cannot be ignored and treated at a later time. The doctor must treat the whole patient, including musculoskeletal in juries, to ensure an optimal outcome. Despite careful as sessment and management of mul tipl e injuries, fractures and soft tissue injuries may not be initi al ly recognized. Con· tinued reevaluation of the patient is necessary to identifY all injuries.

PITFA L L

Musculoskeletal injuries are a potential source of oc cult blood loss i n patients with hemodynamic ab normalities. Occult sites of hemorrhage are the retroperitoneum from unstable pelvic ring injuries, the thigh from femoral fractures, and any open frac ture with major soft tissue involvement in which blood loss may be serious and occurs before the pa tient reaches the hospital.

applic,llion of a sterile pre!>:..ure dressing us ually controls hemorrhage. Aggressive lluid resuscitation is an i mp ortan t

supplement· to these mechanical measures.

Adjuncts to Primary Survey Adjuncts to the primary survey of patients with muscu loskeletal trauma include fracture immobilization and x-rav' exa mina tion .

FRACTURE IMMOBILIZATION The goal of initial fracture immobilization is to realign the inj ured extremity in as close to anatomic position a5 possi ble and to prevent excessive fracture-site motion. Thi� re alignment is accomplished by the application of in-line traction to realign the extremity and maintained by an Im mobilization device. The proper application of a splint help!> control blood loss, reduce pain, and prevent further soft tis sue injury. Tf an open fracture is present, the doctor need not be concerned about pulling exposed bone back into the wound because all open fractures require su rg ica l debride ment. .• See Skill Station XII: Muscul oskeletal Tra uma: As-

Primary Survey and Resuscitation

n What impact do musculoskeletal

injuries have on the primary survey?

During the primary survey, it is imperative to recognize and control hemorrhage from musculoskeletal injuries. Deep soh tissue lacerations may involve major vessels and lead to ex:.anguinating hemorrhage. l lemorrbage control is best ef fected by direct pressure. Hemorrhage from long-hone fractures may be signifi cant, and certain femoral fractures may result in up to 4 units of blood loss into the thigh. producing class I l l shock. 1\ppropriatc splinting of the fracture may significantly de crease bleeding hy reducing motion and enhancing a tam ponade ciTed of the muscle. I( the fracture is open,

Major musculoskeletal injuries indicate that significant forces were sustained by the body.


SECONDARY SURVEY sessment and Management, Skill XH-C: Realigning a De formed Extremity. Joint dislocations usually require splinting in the posi tion in which they are found. Tf a closed reduction has suecessfully relocated the joint, immobilization in an anatomic position may be accomplished in a number of ways: pre fabricated splints, pillows, or plaster. These devices will maintain the extremity in its umeduced position. Splints should be applied as soon as possible, but they must nol take precedence over resuscitation. However, splints may be very helpful during this phase to control hemorrhage and pain.

example, lateral compression fracture of the pelvis re sulting fTom a side impact in a vehicle colllsion. 2. What was the postcrash location of the patient-in

•

side the vehicle or ejected? Was a seal belt or airbag in use? This information may indicate patterns of injury. If the patient was ejected, determine the distance the patient was throvvn and the landing conditions. Ejec tion generally results in increased injury severity and unpredictable patterns of injury.

3.

X-RAY EXAMINATION X-ray examination of most skeletal injuries occurs as the part of the secondary survey. Which x-ray films to obtain and when to obtain them are determined by the patient's initial and obvious clinical findings, the patient's hemody namic status, and the mechanism of injury. An anteropos terior (AP) view of the pelvis should be obtained early for all patients with multiple injuries for whom a source of bleeding has not been identified.

Secondary Survey Elements of the secondary survey of patients with muscu loskeletal injuries are the history and physical examination.

HISTORY Key aspects of the patient history are mechanism of injury, environment, preinjury status and predisposing factors, and prehospital observations and care.

Mechanism

of Injury

Information obtained from the transport personnel, the patient, relatives, and bystanders at the scene of the injury should be documented and included as a part of the pa tient's medical record. It is particularly important lo de termine the mechanism of inju ry, which may arouse suspicion of injuries that may not be immediately appar ent. rl" See Appendix B: Biomechanics of Injury. The doc tor shottld mentally reconstruct the injury scene, identify other potential injuries that the patienl may have sus tained, and determine as much of the following informa tion as possible:

\.Yas there eJo..'ternal damage to the vehicle-for exam ple, deformation to the front of the vehicle from a head-on collision? This information raises the suspi cion of a hip dislocation.

4. Was there internal damage to the vehicle-for exam ple, bent steering wheel, deformation to the dash board, or damage to the windscreen? These findings indicate a greater likelihood of sternal, clavicular, or spinal fnctures or hip dislocation. 5. Was the patient wearing a restraint? I f so, what type (lap or three-point safety belt)? Was the restraint applied properly? Faulty application of safety re straints may cause spinal fra'ctures and associated intraabdomina1 visceral injuries. Was an air bag de ployed?

6. Did the patient fall? If so, what was the distance of the fall, and how did the patient land? This information helps identify the spectrum of injuries. Landing on the feet may cause foot and ankle injuries with associ ated spinal fractures. 7. Was the patient crushed by an object? If so, identify the weight of the crushing object, the site of the in jury, and duration of weight applied to the site. De pending on whether a subcutaneous bony surface or a muscular area was crushed, different degrees of soft tissue damage may occur, ranging from a simple con tusion to a severe degloving extremity injury V\>'llh compartment syndrome and tissue loss. 8. Did an explosion occur? lf so, what was the magni

tude of the blast and what was lhe patient's distance from the blast? An individual dose to the explosion may sustain primary blast injury from the force of the blast wave. A secondary blast injury may.occur from debris and other objects accelerated by the blast effect (eg, fragments), leading to penetrating wounds, lacer ations, and contusions. The patient also may be vio lently throW11 to Lhe ground or against other objects by the blast effect, leading to blunt musculoskeletal a11d other in,iuries (tertiary blast effect).

9. 1 . In a motor vehicle crash, what was the precrash loca tion of the patient in the vehicle-driver or passen ger? This fact can indicate the type of fracture-for

189

Was the patient involved in a vehicle-pedestrian colli sion? Musculoskeletal injuries may follow predicted patterns (eg, bumper injury to leg) based on the size and age of the patient.

•


190

CHAPTER 8

•


Environment Ask prehospital care personnel for information about the environment, including: •

• Patient exposure to temperature extremes • Patient exposure to toxk fumes or agents

• Broken glass fragments (which may also injme the examiner)

• Sources of bacterial contamination (eg, dirt, animal feces, fresh or sail water)

This information can help the doctor anticipate poten •

tial problems and determine the initial antibiotic treatment.

Preinjury Status and Predisposing Factors lt is important to determine the patient's baseline condition

The patient must be completely exposed for adequate assessment.

prior to injury, because this information may alter the un derstanding of the patient's condition, treatment regimen,

pi tal. All prehospital observations and care must be reported

and outcome. The AMPLE history also should include in

and documented.

formation about the patient's exercise tolerance and activity level, ingestion of alcohol and/or olber drugs, emotional problems or illnesses, and prev ious musculoskeletal injuries.

PHYSICAL EXAMINATION The patient must be completely undressed for adequate ex

Prehospital Observations and Care Findings at the incident site that may help the doctor iden tify potential injuries include: •

Position in which the patient was found

•

Bleeding or pooling of blood at the scene, indu ding the estimated amount

•

amination. Obvious extremity injuries are often splinted. prior to the patient's arrival in the emergency department (ED). There are three goals for tl1e assessment of trauma pa. tLents' extrem1tJes: .

1 . Identification of life-threatening injury (primary sur vey)

2.

fractures

• Obvious deformity or dislocation

• Presence or absence of motor and/or sensory func tion in each extremity

• Delays in extrication procedures or transport • Changes in limb function, perfusion, or nemologic state, especially after immobilization or during transfer to the hospital • Reduction of fractures or dislocations during extri

cation or splinting at the scene

• Dressings and splints applied, with special attention to excessive pressure over bony prominences that

may result i n peripheral nerve compression injuries, compartment syndromes, or crush syndromes.

Identification oflimb-threatening injmies (secondary survey)

Bone or fracture ends thai may have been exposed

• Open wounds in proximity to obvious or suspected

.

3.

Systematic review to avoid missing any otl1er muscu loskeletal injury (continuous reevaluation) Assessment of musculoskeletal trauma may be achieved

by looking at and talking to the patient, as well as by palpa tion of the patient's extrem ities and performance of a logical, systematic review of each extremity. The four com ponents that must be assessed are: ( I ) skin, which protects the patient from excessive fluid loss and infection;

(2) neu

romuscular function; ( 3) circulatory status; and ( 4 ) skeletal and ligamentous integrity. Using this evaluation prqccss re duces the risk of missing an injury. ,JI See Skili Station XU:

Musculoskeletal Trauma: Assessment and Management,

Skill XII-A: Physical Examination.

Look and Ask Visually assess the eA.'tremities for color and perfusion, wot.mds, deformity (angulation, shortening), swelling, and discoloration or bruising.

The time of the injury also should be noted, especially

A rapid visual inspection of the entire patient is neces

if there is ongoing bleeding and delay in reaching the hos-

sary to identify sites of major external bleeding. A pale or


SECONDARY SURVEY white dist,JI e>.tremi ty is indicative of ,1 lack of arterial in flow. l xtrem ities that arc swollen in the region of major muscle groups may indicate a crush injury with an im pending compartment S}'ndromc. �welling or ecchyJ110sis in or around a .Jolllt and/or over the subcutaneow; surface of ,1 bone is a s1gn of a musculoskeletal injury. Extremity defor mity is an obvious sign of major ext remit}' injury (sec Table 8- I ). l nl>pcct the pat ien t's entire body for lacerations and abrasiom. O pen wounds arc obvious unless they are located on the dorsum of the body. The patient must be carefu lly logml led to asses� for an injury or skin laceration. If a bone prot rudes or is vi�ualized in the wo und an open fracture exist�. Any open wound to a limb with an associated fracture also is considered an open fracture until proven otherwise by a su rgco n. Observe till· patient s spon ta neous ex trem i ty motor fun...t ion to help identify any neuro log ic and/or muscular im pa irmen t. If the pa t ient is unconscious, absent sponta neous ex tremit y movement may be the only sign of im pa ired fUnction. With a coopemtive pat ient active voluntary muscle ,1nd peripheral nerve function may be assessed by asking the patient to contract major muscle groups. The ability to move all m<Jjor joints through a full range of mo tion usually mdilate\ that the nerve-muscle unit is intact and the joint i� stable. ,

'

,

Feel Palpate' the extremities to determine sensation to the ski n ( neurologic func ti on) and identify areas of tenderness ( frac ture or deep muscle injury). Loss of sensation to pain and touch demonstrates the pre�ence of a spinal or peripheral nerw injury. Areas of tenderness or pain over muscles may indicate a musde coni us ion or fracture. Pai n tenderness, swe ll ing �mel deformity over penicillin ( 100,000 units in 50 mL of Ringer's lactate solution). The amputated part i� then wrapped in a similarly moistened sterile toweT, placed in a plastic bag and trnnsported with the patient in an insulated cooling chest with crushed ice. Care must be taken not to freeze the amputated part.

Assessment Any i nj ury to an ext remi ty ha�> the poten tia l to cause a com partment syndrome. However, certain injuries are consid ered high risk, including:

,

•

• Injuries

COMPARTMENT SYNDROME

con tamed within a dosed fascial space. (Remember, the skin

a lso may act as a restricting membrnne in cer tai n circum stances.) Common areas for compartment syndrome in dude the lower leg, forearm, foot, hand, glu tea l region, and thigh ( rigu re 8-4 ). The end results of unchecked compartment syndrome arc ca tastropb ic. Tbey include neurologic deficit, muscle nccrosi�, ischemjc contracture, infection, delayed healjng of a fracture, and pos:..iblc amputation.

immobil jzed in tight dressings or casts

•

i jury to m usde Severe crush n

•

Localized, prolonged external pressure to an ex trem it y

•

Increased capillary permeability secondary to rcper fusion of ischemic muscle

Injury Compartment syndrome develops when the pressure within nn osteol:tscial compartment of muscle causes ischemia ami subsequent necrosis. This ischemia may be caused by an in crease in compartment size (eg, swelling secondary to revas cularizntion of an ischemic extremity) or by decreasing the compartment l>ize (eg, a constrkt iVl' dressing}. Compart ment syndrome may occur in any site in which muscle is

Tibial and forearm fractures

•

Burns

•

Excessive exercise

The key to the successful treatment of acute com putment synd rome is earl)' diagn osi1-.. A high degree o f awa re ness is important, C.'>peciall} if the patient has an altered mental sensorium and is un,tblc to respond ap propriately to pain. .• See Skill Station XII: Muscu loskeletal Trauma: Assessment and Management, Skill Xll-E: Compartment Syndrome: Assessment and Man agement. The signs and symptoms of compartment syndrome indudc:

B

A

Superficial posterior compartment .._.... Nerves and

blood vessels

l-==:::::J�.!

Latera compartment

Deep posterior compartment

compartment

Figure 8-4 Compartment Syndrome. Develops when the pressure within an osteofascial compartment of muscle causes ischemia and subsequent necrosis. (A) Normal calf. (B) Calf with compartment syndrome.

•

•


OTHER EXTREMITY INJURIES •

Increasing pain greater lhan expected and oul of proportion to the stimulus

NEUROLOGIC INJURY SECONDARY TO FRACTURE-DISLOCATION

•

Palpable tenseness of the compartment

Injury

..

•

Asymmetry of the muscle compa rtmenls

•

Pain on passive stretch of the affected muscle

•

Altered sensation

Absence of a palpable distal pulse usually is an uncom mon finding and shou ld not be rel ied upon to diagnose com partment syndrome. Weakness or paralysis of involved muscles and loss of pulses (because the compartment pres sure exceeds the systolic pressure) in the affected limb arc lalc signs of compartment syndrome. Remember, changes in distal pulses or capillary refill limes are not reliable i n diagnosing compartment syn drome. Clinical diagnosis is based on the history of in jury and physical signs, coupled wiLll a high index of susp1c1o n. IntracompartmentaJ pressure measurements may be helpful in diagnosing suspected compartment syndrome. Tissue pressw-es that are greater than 30 to 45 111111 Hg sug gest decreased capillary blood tlow, which may result in in creased muscle and nerve damage caused by anoxia. Systemic blood. pressure is imporla nt: the lower the systemic pressure, the lower the compartment pressure rhat causes a compartment syndrome. Pressure measuremen L is indicated in all patients who have an aJtered response to pain.

Management All constrictive dressings, casts, and splints applied over the affected extremity must be released. The patient must be carefully monitored and reassessed clinically for the ne>..i 30 to 60 minutes. If no significant changes occur, fasciotomy is required. Compartment syndrome is a time-dependent con dition. 111e l1igher the compartment pressure and the longer i t remains elevated, the greater the degree of resulting neu romuscular damage and functional deficit. Delay in per forming a fasciotomy may result in myoglobinuria, which may cause decreased renal function. Surgical consultation

19 7

Fractures and particularly dislocations may cause significant neurologic injury because of lhe anatomic relationship and proximity of the nerve to the joint-for example, sciatic nerve compression from posterior hip dislocation or axil lary nerve injury from anterior shoulder dislocation. Opti mal functional outcome is jeopardized unless this injury is recognized and treated early.

Assessment A thorough examination of the neurologic system is essen tiaJ in patients with nmswloskeletnl injury. Determination of nemologic impai1·ment is important, and progressive changes must be documented. Assessment usually demonstrates a deformity of the extremity. Assessment of nerve function usually requires a coopera�ivc patient. For each significant peripheral nerve, voluntary motor function and sensation must be confirmed systematically (Tables 8-2 and 8-3). Muscle testing must include palpation of the contracring muscle. In most patients with multiple injmies, it is difficuJt to in itially assess nerve function. However, assessment must be repeated on an ongoing basis, especially after the patient is stabilized. Progression of neurologic findings is indicative of continued nerve compression. The most important as pect of any neurologic assessment is the documentation of progression of neurologic findings. It also is an important aspect of surgical decision making.

Management The injured extremity should be immobilized in the dis .located position, and surgical consultation obtained im mediately. If indicated and if the treating doctor is knowledgeable, a careful reduction of Lbe dislocation ma)' be attempted. After reducing a dislocation, neurologic function should be reevaluated and the limb splinted.

for diagnosed or suspected compartment syndrome must be obtained early.

Other Extremity Injuries PITFALL

Compartment syndrome is l imb-threateni ng. Clinical findings must be recognized and surgical consulta tion obtained early. Remember that in unconscious patients or those with severe hypovolemia, the clas sic findings of acute compartment syndrome may be masked.

•

Other significru1t ex·tremity injuries include contusions and lacerations, joint injuries, and fractures.

CONTUSIONS AND LACERATIONS Simple contusions and/or lacerations should be assessed to rule out vascular and/or neurologic injury. In generaJ, lac erations require debridement and closure. If a laceration extends below the fasciaJ level, it requires operative


198

CHAPTER 8


•

TABLE 8-2

Peripheral Nerve Assessment of Upper Extremities

•

NERVE

MOTOR

SENSATION

INJURY

Ulnar

Index finger abduction

L1ttle finger

Elbow injury

Median distal

Thenar contraction w1th opposrtion

Index f1nger

Wnst dislocation

Median, anterior interosseous

Index Up rlexion

Musculocutaneous

Elbow flexion

S u pra condylar fracture of humerus (Children) Antenor shoulder d1slocation

Lateral iorearm

•

...

Radial

Thumb, finger metocarpO· phalangeal extension

First dorsal web space

Distal humeral shaft, ante nor shoulder dislocation

Axillary

Deltoid

Lateral shoulder

Antenor shoulder dislocation, proximal humerus fractur

.... -

........ ....... --···

O.'tremity may suggest to the examiner other obvious or occult injuries. /\n example is a patient with a brain injury who does not follow commands and has no spontaneous lower-extremity movement; this patient coukl have a thoracic or lumbar li·act ure. STEP 5. Note gender and age, which are important dues

to potential injuries. Children may sustain growth plate injuries and fractures that may not manifest themselves (eg, buckle fractLlre}. Females are less likely to have urethral injuries than vaginal injuries with a pelvic fracture. STEP 6. Observe drainage from the urinary catheter.

If

the urine is bloody or catheter insertion is difficult, the patient may have a pelvic fracture and a urologic injury.

�� FEEl Life- and limh-Lhreatening injuries are excluded first. STEP 1 . Palpate the pelvis an tcriorly and posteriorly to as�ess fo r deformi ty, motion, and/or a gap that

indicates a potentially unstable pelvis. The

compression-distraction and push-pull tests should be done only once. These tests are d<mgcrous because they can dislodge clots and cause rebleed in g. STEP 2. Palpate pulses in all ex-tremities and document

the findings. Any perceived abnormality or difference must be explained. Normal capillary refill (

r �I I

.,.. 4.5%�

I

t ..

�

13%

9% -

/'?

18 %

2.5�.12.5% •

Adult

_....4.5%. .. .

(

.. -

....

-

18%

18% '

1% 9%

9%

9%

9%

Figure 9-1 Rule of Nines. This practical guide is used to evaluate the severity of burns and determine fluid management. The adult body is generally divided into surface areas of 9% each and/or fractions or multiples of 9%.

•


PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS

215

A Partial thickness second

Epidermis

,

•

degree

Dermis Subcutaneous layer • • •

Blistering Painful

' ' ' ' ' ' ' ' ' '

' ' ' '

Glistening

wound bed

' ' '

'

' ' ' ' ' ' ' ' ' ' ' ' ' ' •

B Epidermis

Full thickness ,

third

Dermis

degree

Subcutaneous layer

• • • •

Leathery White to charred Dead tissue Surface is painless

' ' ' ' '

'

'

' ' ' '

' ' ' ' '

' ' , ' ' ' ' I ' ' I ' '

Figure 9-2 Depth of Burns. (A) Shallow partial-thickness or second-degree burn injury. (B) Deep partial, full thickness or third-degree burn injury. •

made primarily from a history of exposure and direct meas urement of carbo:>.:yhemoglobin

( HbCO). Patients with CO

levels of less than

20o/o usually have no physicaJ symptoms. Higher CO levels can result in: ( 1 ) headache and nausea (20o/o-30o/o), (2) confusion (30%-40%), (3) coma (40%-60%), and (4) death (>60%). Cherry-red skin color

i� rare. Because of the increa:;ed affinity of CO for hemo globin (240 times thi.lt of oxygen), it displaces oxygen from the hemoglobi n molecule and shi ts f the oxyhemoglobin dis-

sociation curve to t he left. CO dissociates very slowly, und its half-life is 250 minutes

(4 hours) while the patient is breath ing room air, compared with 40 minutes while breathing LOO% o.>rygen. Therefore, patients in whom CO exposure is

suspected should receive high-flow oxygen via a nome breathing mask. Early management of inhaJation injury may require en

dotracheaJ intubation and mechnnical ventilation. Prior to intubation, the patient should be preoxygenated with con


216

CHAPTER 9

•

Thermal

Injuries

tinuous admini stration

of oxygen. Intubation should be performed early in patients with suspected airway injury. Because there is a high probability of tl1e need for bron choscopy in burn patients wiili airway injury, an endot ra cheal tube of sufficient size should be chosen for a defin itive

airway. Arterial blood gas determinations should be ob tained as a baseline for the

evaluation of the patient's pul monary status. However, measurements of arterial Pa0 do 2 not reliably predict CO poisoning, because a CO partial pressure of only 1 mm Hg results in a carboxyhemoglobin level of 40o/o or greater. Therefore, baseline carboxyhemo globin levels should be obtained, and l OOo/o oxygen should be administered. lf the patient's hemodynamic condition p ermi ts and spinal injury has been

excluded, elevation of the head and chest by 30 degrees helps to reduce neck and chest wall edema. If a full-thickness burn of the anterior and late ral chest wall leads to severe restriction of the chest wall mo tion, even in the absence of a circumferential burn, chest wall escharotomy may be required.

CIRCULATING BLOOD VOLUME

IJ Wha t is the rate and type of fluids

administered to patients with burns?

Evaluation of circ ulati ng blood volume

is often difficult in severely burned patients. ln add i tion these patients may have accompanying injuries tllat cause hypovolemic shock. Shock should be treated according to resuscitation princi ples as previously outlined. rl' See Chapter 3: Sh ock Burn resuscitation fluids also should be provided. Blood pressure measurements can be difficult to obtain and may be unreliable in patients with severe burn i njuries, but monito ring of hourly urinary outputs can reliably as sess circulating blood volume in the absence of osmotic di,

.

uresis (eg, gl ycosuria) . Therefore, an indwelling urinary catheter should be inserted. A good rule to follow is to in fuse flu ids at a rate sufficient to produce 1.0 mL of urine per kilo gram of body weight per hour for children who weigh 30 kg or less, and 0.5 to 1.0 mL of urine per kilogram of body weight per hour in adults. Patients with burns require 2 to 4 mL of Ringer's lactate solution per kilogram of body weight per percent of second degree and third-degree body-surface bums in the first 24 hours to maintain an adequate circulating blood volume and provide adequate renal pe rfusio n. The calculated fluid volume is then proportioned in the following manner: half the total fluid is provided in the first 8 hours after the burn injury has occurred, and the remaining half is administered in the nexl l 6 hours. In children who weigh 30 kg or less, the goal is to maintain an average uri nary output of 1 mlfkgfhr. In these patients, it is necessary to administer maintenance intravenous fluids containing glucose in addition to the burn formula. Resuscitation formulas provide only an estimate of fluid need. Fluid requirement calcu lations for infusion rates are based on the time from injury, not urinary output from the time fluid resuscitation is in itiated. The amount of fluid given should be adjusted according to the individual pa tient's response-ie, urinary output, vi tal

signs, and general condition. Cardiac dysrhythmias may be ilie first sign of hy poxia and electrolyte or acid-base abnom1alilies. Electro cardiography (ECG) should be performed for cardiac rhythm disturbances. Persistent acidemia may be caused by cyanide poisoning. Consultation with a burn center or poison conLrol center should occur if this diagnosis is

suspected.


SECONDARY SURVEY AND RELATED ADJUNCTS

217

1 . Remove all jewelry on the patient's extremities.

Failure to recognize the increased fluid req uire ment for patients with inhalation injury and those with concomitant blunt or crush trauma and for pediatric burn patients. • Fail ure to adjust the fluid administration rate based on a patient's physiologic response. •

Secondary Survey and Related Adjuncts Key aspects of the secondary su rvey and its related ad juncts include physical examination; documentation; base line determinations, including blood levels and x-rays; maintenance of peripheral circulation in circumferential extremity burns; gastric tube insertion; narcotics, anal gesics, and sedatives; wound care; antibiotics; and tetanus immunization.

PHYSICAL EXAMINATION l n order to plan and direct patient treatment, the doctor must estimate the extent and depth of the burn, assess for associated injuries, and weigh the patient.

DOCUME NTATION A Aow sheet or other report that outlines the patient's treat ment should be initiated when the patient is admitted to the ED. This flow sheet should accompany the patient when transferred to the burn unit.

BASELINE DETERMINATIONS FOR PATIENTS WITH MAJOR BURNS Obtain samples for a complete blood count (CBC), type and crossmatch/screen, carboxyhemoglobin, serum glucose, electrolytes, and pregnancy test in aU females of childbear ing age. Arterial blood samples also should be obtained for blood gas determinations to include measurement of HbCO. A chest film also should be obtained, with repeat ftlms as necessary. Other x-rays may be indicated for appraisal of associated injuries.

PERIPHERAL CIRCULATION IN CIRCUMFEREN TIAL EXTREMITY BURNS In order lo maintain peripheral circulation in patients with circumferential extremity burns, the doctor should:

2. Assess the status of distal circulation, checking for cyanosis, impaired capiUary refilling, and progressive neurologic signs, such as paresthesia and deep-tissue pain. Assessment of peripheral pulses in patients with bums is best performed with a Doppler ultrasonic tlow meter.

3. Reli eve circulatory compromise in a circumferentially burned limb by escharotomy, always with surgical consultation. Escbarotomies usual ly are not needed within the first 6 hours after a burn i nj ury. 4. Although fasciotomy is seldom required, it may be

necessary to restore circulation for patients with associated skeletal trauma, crush injury, high-voltage elec trical injury, and burns involving tissue beneath the investing fascia.

GASTRIC TUBE INSERTION Insert a gastric tube and attach it to a suction setup if the patient experiences nausea, vomiting, or abdominal disten tion, or if burns involve more than 20% of the total BSA. Prior lo transfer, it is essential that a gastric tube be inserted and functioning in patients with these symptoms.

NARCOTICS, ANALGESICS, AND SEDATIVES Severely burned patients may be restless and anxious from hypoxemia or hypovolemia rather than pain. Consequently, hypoxemia and inadequate Ou.id resuscitation should be managed before administration of narcotic analgesics o.r sedatives, which can mask the signs of hypoxemia and hy povolemia. Narcotics, analgesics, and sedatives should be administered in smaU, frequent doses by the inLTavenottS route only.

WOUND CARE Partial-thickness burns are painful when air currents pass over the burned surface. Gently covering the burn with clean linen relieves the pain and deflects air currents. Do not break blisters or apply ru1 antiseptic agent. Any applied medica tion must be removed before appropriate antibacterial top ical agents can be applied. Appli.cation of cold compresses can cause hypothermia. Do not apply cold water to a patient with e>..1:ensive burns (> 10% total BSA).

ANTIBIOTICS Prophylactic antibiotics are not indicated in the early post burn period. Antibiotics should be reserved for the treat ment of infection.

·


218

CHAPTER 9

•

Thermal Injuries more serious than acid burns, because the alkalies pene trate more deeply. Removal of the chemical and immedi ate attention to wound care are essential. Chemical burns arc influenced by the duration of contact, concentration of the chemical, and amount o f the agent. Immediately flush away the chemical with large amounts of water, for at least 20 to 30 minutes, using a shower or hose if avail able (Figure 9-3). Alkali burns require longer irrigation. If dry powder is still present on the skin, brush i.t away be fore irrigating with water. Neutralizing agents offer no ad vantage over water lavage, because reaction with the neutralizing agent can itself produce heat and cause fur ther tissue damage. Alkali burns to the eye require con tinuous irrigal ion during the first 8 hours after the burn. A small-caliber cannula can be fixed in I he palpebral sui CUi> for irrigation.

ELECTRICAL BURNS

TI=TANUS Oelermination oft he patient's tetanus immunization stalus is very important. rl' See Appendix E: Tetanus Immuniza tion.

Special Burn Requirements

Electrical burns result when a source of electrical power makes contact with a patient's body. Electrical burns fre quently are more serious than they appear on the body sur face. The body can serve as a volume conductor of electrical energy, and the heat generated results i n thermal injury to tissue. Different rates of heat loss from superficial and deep tissues allow for relatively normal overlying skin to coexist with deep-muscle necrosis. Rhabdomyolysis re sults in myoglobin release, which can cause acute renal fail ure. Immediate trc airway i� at the cricoid ring, which

forms a natural seal with the endotracheal tube. Therefore, cuffed endotracheal tubes are uncommonly used in children under the age of 9 years who are acutely injured. A simple technique to gauge the size of the endotracheal tube needed is to approximate the diameter of the child's external nares or

the

tip of the child's

sm all linger

to the tube diameter.

t\ length-based pediatric resuscitation tape, such as the

Brosclow� M Pediatric Emergency Tape, also lists appropriate tube �izcs fo r endotracheal intubation. l lowever, be sure to have tubes readily available that arc one size larger and one size smaller than the predicted size. If a stylet is used to fa cilitate endotracheal intubation, be �ure that the tip does not extend beyond the end of the tube. Most trenting in �hock. Early intubation ue), microstomia (!imall oral aperture), and cervical arthritis. A lack of teeth can interfere with achiev ing a proper seal on a face ma:.k. Consequently, whereas bro

ken dentures should be removed, intact well-fitted dentures are often best left in place until after airway control is achieved.

Can.• must be taken when placing nasogastric and nasotra cheal tubes because of na:.opharyngeal tissue friability, espe

drive to maintain ventilation. Oxygen administration can re

sult in loss of this hypoxic drive, causing co� retention and

respiratory acidosis. In the acute trauma situation, however,

hypoxemia should be corrected by admi.nistering oxygen while accepting the risk of hypercarbia. In these situations, if respi ratory failure is imminent, intubation and mechanical venti lation is necessary

Chest injuries occur in patients ofall ages with similar fre

quency, but the mortality rate for elderly patients is higher. Chest wall injury withrib fractures or pulmonary contusions are com mon and not well tolerated. Simple pneumothorax and he mothorax also arc poorly tolerated. Respiratory failw-e may result from the increased work of breathing combined wi Lh a decreased energy reserve. Adequate pain control and vigorous pulmonary toilet are essential for a satisfactory outcome. Pul monary complications-such as atelectasis, pneumonia, and pulmonary edema-occur in the elder!)' with great frequency.

Marginal cardiopulmonary reserve coupled with overtealous cry�talloid infusion increases the potential for pulmonary

edema and worsening of pulmonary contusions. Admission to the hospital usually is necessary even with apparently. minor injuries.

cially around the 1 urbinatcs. Profuse bleeding can ensue, complicating nn already dangerous situation. The oral cavity may be compromised by either macroglossia, associated with amyloH.Iosis or acromegaly, or miLrostomia, such as the con stricted, birdlike mouth of progressive systemic sclerosis. Fi nally, arthritis can affect the temporomandibular joints and the cervical spine, making endotracheal intubation more difficult and increasing the risk ofspinal cord injury with manipulation

ofthe osteoarthritic spine. Degenerative changes and calcifi

cation in laryngeal cartilage place the elderly population at increased risk of injury from minor hlows to I he neck.

PITFALLS • Failure to recognize indications for early intuba

tion. • Undue manipulation of the osteoarthritic cervical spine, leading to cord injury. • Failure to recognize the serious effects of rib frac tures and lung contusion, which may require me chanical ventilation.

•


CIRCULATION

Circulation

injury. Severely injured elderly patients with hypotension and metabolic acidosis almost always die, especially ifthey have sustained brain injury. folu id req uiremen ts-o nee

CHANGES WITH AGING

corrected for the lesser, lean body mass-are simihu to

As the heart ages, there is progressive loss of function. 13y

I he age of 63 years, nearly 50% of the population has coro nary artery stenosis. The cardial. index falls offlinearly with age, and the maximal heart rate also begins to decrease from about 40 years of age. The formula for maximal heart rate is 220 minus the individual's age in years. Although the re�aing

heart rate varies little, the maximum tachycardic re�ponse decreases with age. The cause of this diminution of function is multifac eted. With aging, total blood volume decreases and circula tion time increases. There is increasing myocardial stiffness, !>lowed clcctrophysiologic conduction, and loss of myocar dial cell mass. The response to endogenous catecholamine release with stress is also different, which is likely related to a reduction

in responsiveness of the cellular membrane re

ceptor. These changes predispose the aged heart to reentry dysrhythmias. In addition, diastolic dysfunction makes the heart more dependent on atrial filling to increase cardiac output. In addition, the kidney loses mass rapidly after the age or 50 years. This loss involves entire nephron unit's and

251

IS

accompanied by a decrement in the glomerular filtration

rare and renal blood Ilow. Levels of serum creatinine usu ally remain within normal limits, presumably because of a reduction in creatinine production by muscles. The aged kidney is less able to resorb sodium and excrete potassium or hydrogen ions. The maximum concentration ability of the kidney of an octogenarian is only 850 mOsm/kg, which is 70% of the ability of a 30-year-old kidney. A decrease in the production of, and responsiveness of the kidney to, renin and angiotensin occurs with age. As a result, creatinine clear ance in the elderly is markedly reduced, and lhe aged kidney is more susceptible to injury from hypovolemia, medica

tions, and other nephrotoxim.

EVALUATION AND MANAGEMENT

those of younger patients. Elderly patients with hyperten sion who are on chronic diuretic therapy may have a chron ically contracted vascular volume and a serum potassium deficit; therefore careful monitoring of the administration of crystalloid solutions is important, to prevent electrolyte disorders. Isotonic electrol}1e solutiOn� arc used for initial resu� citation. Initially,

I

or 2 L arc administered rapidly while ob

serving the parient's physiologic response. Further decisions with respect to fluid resuscitation are predicated on this ob

served response . • • Sec Chapter

3: Shock.

The optimal hemoglobin level for an injured elderly pa

tient is a point of controversy. Many authors suggest that, in people over the age of 65 years, hemoglobin concentration1. of over 1 0 g!dL should be maintained to maximite oxygen carrying capacity and delivery. However, indiscriminate blood transfusion should be avoided because of the attendant risk ofbloodborne infections, its known impairment ofthe im mune host response and its resulting complications, and the effect ofthe high hematocrit on blood viscosity, which can ad versely affect myocardial fu nction. Early recognition and cor

rection of coagulation defects is crucial, including reversal of drug-induced anticoagu lation. Because elderly patients may have significant limilation in cardiac reserve, a rapid and complete assessment fo1 all sources of blood loss i� ncce��ary. The focused assessment sonography in trauma ( FA')1) examin,ltion is . After the age of 50

crashes. Magnetic resonance imaging (MRI) is particularly

years, 1he r�1te is I ()tlfo per decade unless the levels of growth

useful for diagnosing these injuries. rfJ See Chapter 7: Spine

and Spinal Cord l'n1un1.

Exposure and Environment

Osteopormis results in a decrease of histologic normal hone with a con�equent loss of strength and resistance to fractures. Thi� disorder i� endemic in the elderly population,

The skin and connective tissues of elderly individuals un

clinically affecting almost 50% of these individuals. The

dergo extensive changes, including a decrease in cell num

causes of osteoporosis mclude loss of estrogen hormones,

bers, to's of �trength, and impaired function. The epidermal

los� of body mass, decreas1ng levels of physical activity, and

keratinocytes lose a significant proportion of their prolifer

madequate consumpuon and inefficient use of calcium.

ative ability with ,tging. The dermis loses as much as 20o/o of

The consequences of these changes on the muscu

its thickness, undergoe� a signific<mt loss of vascularity, and

loskeletal system are frequently disabling and at times dev

ha� a marked decrease in the number of ma�t ceUs. These

ast. Crit Care A1ed 2004;32:39.

9. Coun..:il Report. Decisions ncar the end of life. lAMA 1992;267:2229-2233.

i\,

Braun DW J r, ct

aL Brain injury:

analysis uf survtval and hospit:tlrt..ttton lime for 937 patients.

Ann Surg 19 l:lO; l 92:472-47!\.

upper body injuries in the older adult: a review of the bio chemical tssuc�. / Bromeclr 2003;36: I 043-1053.

Lact CF. Pols liA. Fractures in

and demography.

Lachs MS, Pillcmcr K. Abu�e and neglect of elderly persons. N E11gl J Mt•t/ 1995;332:437-443.

26. Mackcn1ie F.), Morris )A, Eddstcin SL. Effect

of pre· existing

disease on length of star in trauma patients. I ·l muma

1989;29:757 764.

of traum,t in the United Stales: implicatiom syslerm of care. J

for rcgiorhllizcd

Trauma 1990;30: I 096-110 I .

28. Manton OK, Vaupel JW. Survival after the age of 80 in the United States, Sweden, Fran.:e, England, and Japan. N E11gl 1

IVlt•tl 199');333: 1232-L235.

29. Mdvl.1hon OJ. Schwab CW, I--auder DR. Comorbidity llt'>t Pmct Res Clirr Emlocrurol

Metnb 2004; 1 4 : 1 7 1 - 1 79.

ing disease in trauma patients: a predictor of fJtC indc

penden1 of age and injury severity score. I Trau ma

1992;� I :236-244.

31. Morris )A, Auerbach P�. Marshall GA. et al. The Traum55 years Age , therefore, involve a variety of specific forces, including shear, torque, and lateral compression and distrnclion.

Organ Collision 'T'ypes of organ collision injuries include compression injury and deceleration injury. Restraint use is a key factor in re ducing injury.

Compression Injury

Compression injuries occur when

the anterior portion of the torso ceases to move forward, but the posterior portion and internal organs continue their mo tion. The organs are eventually compressed from behind by the advancing posterior tboracoahdominal wall and the ver tebral column, and in front hy the impacted anterior struc tures. Blunt myocardial injury is a typical example of this type of injury mechanism. Similar injury may occur in lung parenchyma and ab dominal organs. In a colli!.ion, it i!> instinctive for the patient to take a deep breath and hold it, closing the glottis. Com pression of the thorax produces alveolar rupture with a re sultant pneumothorax and/or tension pneumothorax. The increase in intraabdominal pressure may produce di aphragmatic rupture and translocation of abdominal or gam; into the thoracic cavity. Compression injuries to rhe

Rear Impact

Most commonly, rear impact occurs when a

vehicle IS at a complete stop and is struck li·om behind by an other vehicle. The stopped vehicle, including its occupants, � accelerated fonvard from the energy transfer from impact. Because of the apposition of the seat back and torso, the torso

brain may also occur. Movement of the head associated with the application of a force through impact can be associated with rapid acceleration forces applied to the brain. Com pression injuries also may occur a� a result of depressed skull fractures.

is accelerated along with the car. In the demonstrated by the formula relating mass and vcloci I y to kinetic energy. Kinetic Energy = mass x ( V1� - V/)12 where V1 is in1pact velocity and V2 is exit or remaining velocity.

VEL.OCITY The wounding capability of a bullet increases markedly above the critical velocity of 2000 ft/!.ec (600 m/sec). At this speed a temporary cavity is created by tissue being com-

•


PENETRATING TRAUMA pressed at the periphery of impact, which is caused by a shock wave initiated by impact of the bullet. Cavitation is the result of energy exchange between the moving missile and body tissues. The amount of cavitation or energy exchange is proportional to the surface area of the point of impact, the density of the tissue, and the velocity of the projectile at the time of impact. (See Figure B-2.) De pending on the velocity of the missile, the diameter of lhis cavity can be up to 30 times that of the bullet. The maxi mwn diameter of this temporary cavity occurs at the area of the greatest resistance to the bullet. This also is where the greatest degree of deceleration and energy transfer occur. A bullet fired from a handgw1 with a standard round can pro duce a temporary cavity of 5 to 6 times the diameter of the bullet. Knife injuries, on the other hand, result in little or no cavitation. Tissue damage from a high-velocity missile can occur at some distance from the bullet track itself. Sharp missiles with small, cross-sectional fronts slow with tissue impact, resulting in little injury or cavitation. Missiles with large, cross-sectional fronts, such as hollow-point bullets that spread or mushroom on impact, cause more injury or cavitation.

BUllETS Some bullets are specifically designed to increase the amount of damage they cause. Recall that it is the transfer of energy to the tissue, the time over which the energy transfer occurs, and the surface area over which the energy exchange is distributed that determine the degree of tissue damage. Bullets with hollow noses or sernijacketed coverings are de signed to flatten on impact, thereby increasing their cross sectional area and resulting in more rapid deceleration and

--

t

'

287

consequentially a greater transfer of kinetic energy. Some bullets are specially designed to fragment on impact or even explode, which extends tissue damage. Magnum rounds, or cartridges with a greater amount of gw1powder than normal rounds, are designed to increase the muzzle velocity of the missile. The wound at the point of bullet impact is determined by: •

The shape of the missile ("mushroom")

•

The position of the missile relative to the impact site (tumble, yaw)

•

Fragmentation (shotgun, bullet fragments, special bullets)

Yaw ( the orientation of the longitudinal axis of the mis

sile to its trajectory) and tumble increase the surface area of the bullet with respect to the tissue it contacts and, there fore, increase the amount of energy transferred (Figure B-3). In general, the later the bullet begins to yaw after penetrat ing tissue, the deeper the maximum injury. BulJet deforma tion and fragmentation of semijacketed ammw1ition increase sw-face area relative to the tissue and the dissipa tion of kinetic energy.

SHOTGUN WOUNDS Wounds inflicted by shotguns require special considera tions. The muzzle velocity of most of these weapons is generally 1200 ft/sec (360 m/sec). After firing, tbe shot radiates in a conical distribution from the muzzle. With a choked or narrowed muzzle, 70o/o of the pellets are de posited in a 30-inch (75-cm) diameter circle at 40 yards

------

�

-

1

I

Figure B-2 Sharp missiles with small cross-sectional fronts slow with tissue impact, resulting in little injury or cavitation. Missiles with large cross-sectional fronts, such as hollow-point bullets that spread or "mushroom" on impact, cause more injury and cavitation. •

•


APPENDIX B

288

•

Biomechanics of Injury trance and exit of one bullet, suggesting the path the missile may have taken through the body. Missiles usually follow tl1e path of least resistance once tissue has been entered, and the clinician should not assume that the trajectory of the bullet followed a linear path between the entrance and ex.it wound. The identification of the anatomic structures that may be damaged and even the type of surgical procedure that needs to be done may be influenced by such info tmalion.

Bibliography l . Grcensher J. Non-automotive vehicle injuries in the adolescenL. Pediatr Ann 1988; 1 7(2): 114, 117-121.

Figure B-3 Yaw (the orientation of the longitudinal axis of the missile to its trajectory) and tumble increase the surface area of the bullet with respect to the tissue it contacts and, therefore, increase the amount of en ergy transferred. In general, the later the bullet begins to yaw after penetrating tissue, the deeper the maximum InJUry. •

•

•

2. Kraus JF, Fife D, Coruoy C. Incidence, severity and outcomes

of brain injuries i1wolving bicycles. Am j PubJic f-lealth 1 987;77( I ):76-78. 3. Leads from the MMWR. Bicycle-related injuries: Data from the National Electronic lnjuq' Surveillance System. lAMA 1987;257:3334, 3337. 4. Mackay M. Kinetics ofvehicle cra�hcs. In: Maull KT, Cleveland

(36 m ) . However, the "shor>' is spherical, and the coeffi cient of drag through air and tissue is quite high. As a result, the velocity of the spherical pellets declines rap idly after firing and further after impact. This weapon can be lethal at close range, but i ts destructive potential rapidly dissipates as distance increases. The area of max imal inj u ry to tissue is relat ively superficial unless the weapon is fired at close range. Shotgun blasts can carqr clothing and deposit wadding (the paper or plastic that separates the powder and pellets i n the shell) into the depths of the wound and become a source of infection if not removed.

ENTRANCE AND EXIT WOUNDS For clinical reasons, it may be important to determine whether the wound is an entrance or ex.it wound. 1\vo holes may indicate either two separate gunshot wounds or the en-

HC, Strauch GO, et aJ., eds. Advances in 1i"auma, vol. 2. Chicago: Yearbook; 1987:21-24. 5.

Mau ll Kl, Wh itley RE, Cardea )A. Vertical deceleration iJ1juries. Surg Gyneco/ Obstet 1981; 153:233-236.

6. National Highway Traffic Safety Administration. The Effect of Helmet L29 6-9 1-5 0

4 3 2 1 0

B. Systolic Blood

>89

Pressure

4

76-89

(mm Hg)

50-75 1-49 0

3 2 1 0

C. Glasgow Coma Scale Score Conversion

13-15

4

9-12 6-8

3 2

4-5

Airway

Systolic Blood Pressure

20 kg (> 44 Ib)

+1

-1

10-20 kg (22-44 lb)

lower extremities and pelvis. The patient should be kept im

sessed. If local resources are II m i ted but evacuation is pos

mobil i'lcd .llld Lhe pelvis stabilized as well as possible with

sible, even if delayed, the patient with a significant burn

sheet:�, sandbags, etc. If available, external [ixal ion can be

should be stabilized as much as possible prior to transport.

performed to reduce open-book pelvic fractures and help

lf possible, the airway should he secured and fluid resusci-

minimize bleeding. Although it is out of 1:wor for use in

tation begun. lf resources are limited and evacuation is dif

trauma, a pneumatic antishock garment, if available, can

liwlt or impossible, small

function as an "air splint" for the pelvis or lower extremi

f heal with nonoperativc care, although some burns o 1en

ties. Care must be taken to prevent compartment syndromes

times with significant scarring or loss of fu nction, espe

by overinflation and prolonged use.

citances in which resources arc limited, including mili

i� dcl.tyed for more than

hours, these patients should

ttlf}' operations, wilderness environments, and civil disasters

receive antibiotics, analgesia, hydration, immobilization,

with delayed rescue. It may be necessary to provide care for

and wound management as rcsoun:c� allow. Patients with

hour:. to days in proximity to dangers-for example, fire

:.prains and minor injurie:. can either be treated primarily

from ho:.tile weapons, persistently threatening weather, and

or referred to an orthopedist in a more routine fashion.

imminent nood.

6

Under 1hese circumstances, the II rst priori ly is to pro

BURN INJURIES

led the caregivers and tl1e patients from further injury. In

general, a minimum of medical care is attempted while the

The mortality from major burn injuric� is significant, even

injured patients and caregivers arc exposed to danger. Once

with unlimited resources. Patients with bum injuries often

the danger has been mitigated, care of injured patients may

require airway support, mechankal ventilation, and massive

commence to the fullest extent possible, given limitations

fluid resuscitation, in addition to management oftheir bm·n

inherent in the circumstances, " hilc applying ATLS princi

wounds.

ple:. with some modifications. The skilb required are simi

.• See Chapter 9: Thermal Injuries. The initial

evaluation and treatment of these patient:. follows closely

lar to those used by a military medic or corpsman in the

the ARCDE algorithm. Remember, these patients often have

field once the caregiver and the p.llient are no longer under

other injuries in addition to their burn injury (eg, blast in

hostile tire.

jury or injury from jumping in an attempt to get away from the fire).

The odds of successful rescue/evacuation, if needed, in crease dramatically when plans are made in advance for such

Inhalation injury, either from breathing heated air or

contingencies. Initiating rescue and communicating with

breathing toxic gases emitted during combustion, essentially

rescuers is beyond the scope of this appendix; however, it is

double� the mo11ality from burn injury. Patients with sig

essential that provisions be considered for establishing com

nificant facial burns and smoke or �team inhalation, � well

munications with or signaling rescuers. This requires a plan

as those with toxic gas inhalation from burning plastics, re

for rescue, which includes notification of individuals not in

quire a definitive ainvay (ie, endotracheal intubation or tra

volved 111 the movement or plan of action. A flight, fi_oat, or

cheostomy) and mechanical ventilation.

expedition plan should be filed with individuals who can

Pmhably the most significant aspect of the care of burn

initiate rescue, automatically and nutonomously under cer

patients is the massive Auid replacement they require. These

tain cond ilions. It is easy Lo understand why emergency ex

patients also require urgent evacuation to pital TrtlliiiJn LUi• S11pport

(PHT!.S), 1\Iilitary Fditiun. 'it. Louis, MO: �1osby; 2006. 20. Kauva r DS, Hokumb

J H, '\urns Lers. E111erg Mrcl Cliu Nart!l Am 1996; 14:429-438.

-

-

.

....... ..

...

...


Disaster Management and A P P E N D I X H Emergency Preparedness (Optional Lecture)

U pon com pletion

Introduction

explain the

of this topic,

the student will be able to app li cation of ATLS principles to patients In

jured in natural or human-made disasters. Specifically, the

Disasters may be defi11ed, from a medical perspective, as i nc idents or evenrs in which Lhe needs of patients overex tend or overwhel m the resources needed to care for them. Although d isasters usual ly st ri ke with o ut warning, emer gency preparedness-the rea d iness for and anticipation of the contingencies that fo llow in the aftermath of disas ters-enhances the ability of the health care system to re spond to Lhe challenges imposed. Such preparedness is the institutional and personal responsibility of every health care facility and professional. Adherence to the h ighes t stru1dards of quality medical practice that are consistent with the available medical resources serves as the best guidel ine for developing disaster plans. Commonly, the ability to respond to disaster situations is compromised by the excessive demands p laced on resources, capabilities, and organizational structures. Multi p l e casualty incidents (MCis), or disasters in which patient care resources are overextended but are not

doctor will be able to:

OBJECTIVES

Define the terms multiple casualty incident (MCI) and mass casualty event (MCE) and de scribe the differences between them. Describe the "all ha za rds approach to disaster management and emergency preparedness, in clud ing Its application to acute injury care. "

Identify the four phases of disaster manage ment and describe the key elements of each phase with respect to acute injury care.

0

Describe the incident command system that has been adopted in his or her specific practice area.

overwhelmed, such as automobile crashes that involve 5 or more patients, can stress local resources such that triage focuses on identifying the patients with the most life threatening injuries. Mass casualty events (MCEs) are disasters in which patient care resources are overwhelmed and cannot be supplemented, such as nalural or human -ma de disa.slers that involve 20 or more patients, can exhausL local re sources such that triage focuses on identifying those pa tients with the greatest probability of su rvival .

Note that MCis and MCEs are both called MCis by many experts. The ATLS course distinguishes between the

terms because their different circumstances mandate al ternative strategies for triage and treatment, based on ill ness and injury acuity and severity, versus availability and accessibil i t y of existing and s up pl emc11Lal resources. It must also be emp hasi zed that the numerical gttidelines ci ted ( eg 5 or more pat ients for an MCI, and 20 or more for an MCE) are arbitrary and based o.n the capab il ities of trauma hospilals and trauma systems that routinely care for trauma patients. Many hospitals would be over whelmed by 5 or more disaster patients, whereas some could manage 20 or more without a si gni ficant disrupti on of daiJy routines. Thus, each hospital must determine its

own thresholds, recognizi ng that the hospital disaster plan must address both MCis and MCEs. Lilte mosl disciplines, disaster management ru1d emer

gency preparedness experts have developed a nomencla ture unique to their tield. J3ox 1-1-1 is a glossary of all key terms ( ie, those appearing in boldace f type) in this appen dix.

The Need

,

Disaster management and emergency preparedJ1ess con stitute key knowledge areas that prepare ATLS provi ders to apply ATLS principles during natural and. human-made disasters. Successful application of these principles dming the chaos that typically comes in the aftermath of sud1 ca tastrophes requires both familiarity with the disaster

321


322

APPENDIX H

•


Box H-1 Key Disaster Management and Emergency Preparedness Terminology Acute Ca re-The early care of v1ctims of disasters that IS prov1ded in the field and 1n the hosp1tal (ie. emer gency department, operating room. tntens1ve care unit, acute care untt inpat1ent untts) prior to recovery

Emergency Medical Services (EMS)-Emergency med1cal responders (EMRs). 1nclud1ng emergency med ical techmcians (EMTs) and paramedics who provide ,

prehosp1tal care under med1cal d1rect10n as part of an

and rehabilitation

organtzed response to medical emergen Cies

Acute Care Speci al ists-Physicians who provide

Eme rgency Operations Center (EOC)-The head

acute care to victims of disas ters . 1ncludtng, but not

quarters of Umfied Incident Command (UIC) for a re

limited lo, emergency medicine physicians, trauma

gion or system, established in a safe location outside

surgeons. cntical care medicine physicians. anesthesi

the area of operatio ns ("warm zone"), usually at a

ologists, and hosp1talists-both adult and pediatric.

fixed s1te. and staffed by emergency ma nage rs.

Area of Operations ("Warm Zone")-The geo

Emergency Preparedness The readiness for and

graphic subdiviSIOn established around a disaster site

ant1c1pat1on of the contmgenoes that can follow 1n the

into which only qualified personnel-for example, haz

aftermath of natural or human-made dtsasters. Pre

ardous material (HAZMAn technicians and emergency

paredness 1s the institutional and personal responsibil

medteal services (EMS) prov1ders

ity of every health care facil ity and professional.

are permitted

-

Casualty Collection Point (CCP)-A sector within the external perimeter of an area of operations

Emergo Train System (ETS)-An organizational structure used chiefly in Europe and Australasia to help

("warm zone") where casualties who exit the Search

coordinate an in-field or in-hospital disaster response.

and Rescue (SAR) area (" hot zone") v1a a decontami

(Note: Nations and hospitals typica l ly adopt their own

natiOn chute are gathered pnor to transport off site.

vers1ons of this system )

Chemical, Biological, Radiological, Nuclear, and

External Perimeter-The outer boundary of an Area of Operations ("warm zone") that 1s established

Explosive (CBRNE). Including incendiary, agents human-made hazardous matenals (HAZMATs) that

around a d1saster site to separate geographic subdivi

may be the cause of human-made disasters, whether

SIOns that are safe for the general public ("cold

unintentional or intentional.

zones" ) from those that are safe only for qualified per

Decontamination Chute-A fixed or deployable fa

sonnel .

cility where hazardous materials (H AZMATs) are re

Hazardous Materials (HAZMATs)-C hemical, bio

moved from a patient, and through which the pa t1 ent

logical, radiological, nuclear. and explos ive (CBRNE).

must pass before transport, e1ther out of a Search and

including incendiary, agents that pose potential risks

Rescue (SAR) area ("hot zone"). or 1nto a hospital

to human ltfe, health, welfare, and safety

Disaster-A natural or human-made tnodent or event, whether internal (ong1nating 1nside the hospi tal) or external (ongmat1ng outs1de the hospital) i n

Hospital Incident Command System (HICS}-An orgamzat1onal structure used chiefly in the Americas to help coordinate an i n-hosp 1tal d1saster response.

which the needs of pat1ents overextend or overwhelm the resources needed to care for them.

(Note. NatiOns and hospitals typically adopt their own

versions of th is system . )


THE NEED

Hazard Vulnerability Analysis (HVA)-An analysts of the probability and severity of the risks of vanous hazardous matenals (HAZMATs), industrial mishaps, natural disasters, and weather systems that pose po tential risks to community health and safety. Incident Command or Incident Commander (IC) The final authority and overall coordinator or supervi sor for the management of any disaster response.

Incident Command Post (ICP)-The headq uarters for Incident Command (IC), established in a safe loca tion wtthin the area of operations ("warm zone"), but at a safe distance from the Search and Rescue (SAR) a rea ("hot zone"), for any disaster.

Incident Command System (ICS)-An organiza tional structure that provides overall direction for the management of the disaster response.

Multiple Casualty Incident (MCI)-A disaster 111 which patient care resources are overextended but not overwhelmed

Personal Protective Equipment (PPE )-S pec ial cloth ing worn by disaster response personnel to avoid self-contammation by hazardous mate n a ls ( H AZ MATs) . Preparation-Activ it ies that health care facilities and prov iders underta ke to build capacity and identify re

sources that may be used if a disaster occurs.

Recovery-Activiti es that are designed to assist health care facilities and professionals resume normal opera tions after a disaster situatton is resolved Response-Activ tties that health care faci l ities and professionals undertake in evaluating and treating vic

tims of a n actual disaster.

Internal Perimeter-The outer boundary of a Search and Rescue (SAR) area ("hot zone") that isolates this area from the surrounding Area of Operattons ("warm

zone").

Search and Rescue (SAR) Area ("Hot Zone")-A sector within the internal perimeter of an area of op erations for a disaster in which humans are directly af fected by the hazard.

Mass Casualty Event (MCE) -A d isaster in which

immediately be supplemented.

Surge Capability-The extra assets that can actually be de ployed-for example beds that can actua lly be

M itigation-Activities that health care facilities and

be used-in a disaster.

paltent care resources are overwhelmed and cannot

,

staffed and ventilators and monitors that can actually

professionals undertake in an attempt to lessen the severity and i mpact of a potential disast er.

Unified Incident Command (UIC}-The locus of in cident command for an entire region or system, where

Medical Response Team-A team of 1 to 4 health care professionals, led by an acute care spec ialist that provid es emergency medical care to an ind iv idual

incident commanders from all involved publ ic safety

patient.

events (MC Es)

Minimal Acceptable Care-The lowest appropriate level of medical and surg ical treatment req u i red to sustain l ife and limb unti l addit ion a l assets can be mobilized .

Weapons of Mass Destruction (WMDs)-Haz

,

and public health disciplines meet to direct the overall

strategy of the incident response to mass casua lty

ardous materials (HAZMATs) used, or intend.ed to be used, for the explicit purpose of harming or destroying human life.

323


324

APPENDIX H

•


respon se and knowledge of t.hc medical conditions likely to be encoLmtercd. Terror events constitute a minority of a l l disasters, but nearly all tenor events cause physical inj ury three-fourths of which ar e due to blast trauma and m os t of the rest to gunshot wounds. As such, Lhe unde rsta nding and application of ATLS principles are essential in the evalua tion and treatment of all disa ster v icti ms. ,

agement. Plans that are too complex or cumbersome to re member or implement are destined to fail. All p lan s must include training in disaster management and emergency preparedness appropriate to the educational preparation of the in d ividuals being t rai ned. Community P la nning local, region al , or national

Disaster p lanni ng, whether at the level, involves a wide range of in

di vi dual s and resources. All plans:

The Approach

•

Should involve acute cal e specia l ists ( eg, emer '

medicine p hysici an s trauma surgeons, criti cal care medicine phys icia ns, anesthesiologists, and hospitalists, both adLllt an d pediatric) and local hos pitals, as well as officials of the local p oljce, fire, emergency medical senrices (EMS), homeland se curity, emergency managemen t, public health, and governmen tal a gencies charged with hazardous m ater ial (HAZMAT) management and disaster gency

Disasters are unpredictable because of their na tun.>, loca l ion and timing. An "alJ hazards" approach is used in contempo rary disaster manage ment. This approach is based on a sin glc, common, initial emergency response protocol with branch points that lead to specific actions depending on the ,

,

type of disaster encountered. The fu ndamental principle of disaster management is to do the greatest good for the great

,

prepa ra lion.

est number. •

Should

Phases of Disaster Management

•

1vlu st

The public health approach to d isas ter and mass casualty management consists of four distinct p hases:

• Must provi.de for storage of equi pm en t supplies,

1.

provide for a means of commun ication con sidering all contingencies, such as loss of telephone land lines and cellular c i rcujts. ,

and any special

resources that may be necessary

based on local hazard v ulnerability analysis

Prep a rati on

(HVA).

2. M iti gatio n

•

3. Response 4.

be frequently tested and reevaluated.

Must aid

Recovery

most nations, local and region al disaster response p lans are developed in accordance with national response p lan s. Emergency medicine, trauma care, public health, and disaster medicine experts must be involved in all four phases of m an agement with respect to the medical components of the operat ional p lan The clements that must be addressed durin g each of these four phases are described below.

provide for all

of assislance-rrom through clelinitive care to rehabilitation. levels

First

•

prepare for the Lransporta Lion of casual ties to other facilities by prior ag ree ment should the local facility become saturated or unusable.

•

Must

ln

Mu st

consider the urgent needs of pa t ien ts a lread y hospitalized for conditions unrelated to the

disaster.

.

PREPARATION Preparation involves the activities a hospi tal undertakes to build capacity and identify resources that may be used if a disaster occurs. These activities include the development of

a simpl e, yet flcx.iblc, disaster plan that is regularly reviewed and revised as n ecessary and provision of disaster training that is necessary to allow these plans to be i m plemented ,

when indicated.

Simple Disaster Plans and readil y understood approach to MCTs and MCEs is the key to effective disaster and emergency man-

Hospital

Plann i ng

a regional ap proach to planning is ideal for the management of mass casualti�s. cir cumstances may require each hosp ita l to function with little Although

or no outside support. Earthquakes, floods. riots, or nuclear contamination may require

the individual hospital to oper ate in isolation. The crisis may be instantaneous or it may develop slowly SiLuations may cxisL Lhnt disrupt the in fra structure of society and prevent access to the medical facil ity. For Lhis reason, it is vital that each hospital develop a disaster plan that accurately reflects its HVA. Once a state of di5aster has been declared, the hospital disast er plan should be put into effect. Specific procedures should be autom ati c .

and include:

A basic

•

Establishment of an in cident command post (ICP).


PHASES OF DISASTER MANAGEMENT •

Notification of on-duty and off-duty personnel.

•

Preparation of decontamination, triage, and Lreat ment areas.

•

Classification of in-hospital patients to determine whether additional resources cm1 be acquired to care for them or whether they must be discharged or transferred.

• Checking of supplies (eg, blood, fluids, medication)

and other materials ( eg, food, water, power, commu nications) essential to sustain hospital operations.

• Activation of decontamination facilities and staff

and application of decontamination procedures if necessary.

•

•

Institution of securiry precautions, including hospi tal lockdown if necessary, to avoid potential con tamination and subsequent hospital closure. Establishment of a public i_nformalion center and provision of regular briefings to inform family, friends, the media, and the government.

Departmental Planning Effective disaster planning builds on existing strengths to address identified weaknesses. Since patient care can best be delivered to individual patients by providers working in small teams, every hospital depart ment with responsibility for the care of injured patients must identify its medicaJ response teams in advance. These teams must be provided with specific instructions as to where to go and what to do in the event of an intcmal or external disas ter. Such instructions should not he overly complex. They should also be readily accessible in the event of a disaster for example, printed on the back of hospital identification cards or posted on wall charts. They should also be very spe cific in terms of the job action Lo be performed, as follows: • Emergency department plans must identify who

will be responsible for notifying the incident com mander; deploying the decontamination team; or ganizing the available physicians, nurses, allied health personnel, patient care technicians, orderlies, and housekeepers into individual teams to care for individual patients; directing emergency depart ment triage of disaster victims; and mobilizing ad ditional staff as needed.

• Surgical department plans must identify who wiU

t available surgeons be responsible for org<mizing he into resuscitation and operating teams and where these teams will assemble, or "muster"; identifying the leaders of such teams; and determining which patients will receive priority if operating rooms or perioperative staff are i.n short supply.

•

Operating room plans must identify who will be re sponsible for organizing perioperative staff, both

325

anesthesiology and nursing; mobilizing needed ad ditional staff; retrieving and deploying appropriate equipment; and identifying additional resources, such as obstetric operating rooms and nursing staff, that are not typically used to care for injured patients. •

Critical care plans must identify who will be re sponsible for organizing critical care unit staff, both medical and nursing; mobilizing needed additional staff; retrieving and deploying additional venLiJators and monitors; and preparing additional isolation rooms, suites, or w1its that are not typically used to care for contaminated or contagious patients.

Personal Planning Since the hospital disaster response, of necessity, is bullt on the personal and fanuly disaster re sponse, personal and family disaster pl;:tnning constitutes a vital part of pre-event hospital disaster preparation for both the hospital and its employees. Most health care providers have tamily responsibilities, and will be at best uncomfort able, and at worst unable, to meet their employment re sponsibilities in tbe event of a disaster if the health and safety of their tarn ilies is uncertain. Hospitals can assist health care providers in meeting their responsibilities to the hospital and to their famiHes in a number of ways, and it is obviously to the advantage of both for hospitals to ensure that employ ees' family needs are met. Among these needs are assistance in identifying alternative resources for the care of dependent children and adults and ensuring tbal aJI employees develop family disaster plans, since all hospital-specific response plans depend on mobilization of additional staff, whose first duty in any disaster \'Ifill be to ensure their own and their families' health and safety.

Hospital Disaster Training All health care providers must be trained in the principles of disaster management and emergency preparedness com mensurate with their level of patient contact. Training in disaster managernent includes both operational and med ical components. The ATLS provider should be well versed in the fundamental elements of the local, regjonal, and na tional disaster plans, as appropriale, and understand the role of medical care i.n the overall management plan. Lt is essen tial to realize that, although the purpose of all disaster rnml agement is to ensure the safety and security of the maximum number of human lives and the greatest mass of public and private property, the medical component is but one element of the operational plan, at both the hospital and the com munity level. Tllis is because the provision of medical care requires a complex infrastructure of logistical support be fore medical professionals can safely and securely apply their skills. Beyond this basic understanding, it is also vital that the ATLS provider have a working understanding of the appli-


•

326

APPENDIX H

•


cation of ATLS principles i n disaster situations. I t is impor

be made \\'ilhout the need for prior confirmation by inci

tant to recognize that the approach lo the palienl injured in

dent commanders, whi.ch consumes valuable Lime. J n MCEs

a disaster is no different from the approach to the patient

that affect an entire region or system, the effective res must

injured i n the cow·se of everyday activities: Airway, Breath ing, CircuJation, Disability, and Exposure. Rather, it is the

application of this basic approach that may he altered, which

be fully i ntegrated with the unified incident command

( U I C ) serving the entire region or system, which is com prised of aU involved public ht'tic ll!> possible. Disas ter drills should always emphasize the disasters expected on the basis of the hospital's HYA. The purpose of disaster drills and exercises is not only to train emergency medical responders to provide care to disaster victims, but also lo identify gaps in the hospital disaster plan so lbey can be closed prior to the occurrence of an actuaJ internaJ or cx Lcmal disaster. In 3ddition, they should involve scenarios that emphasize the needs of special populations, such as burn patients, pediatric patients, geriatric patients, and dis abled patients, which may require the mobilization and de ployment of population-specific resources. The types of disaster drills and exercises hospitals should hold vw.ahrq.org/research/pedprep/re source.htm. Accessed February 26, 2008.

2.

auf der Heide £. Disaster Response: Principles of Prepnrntion aud Coordination. Chicago, IL: CY Mosby; 1.989.

3.

Committee on Trauma, American CoUege of Surgeons. Dis aster Management and Emergency Preparedness Course Stu dent Manual. Chicago: American College of Surgeons, 2007.

4.

DiPalma RG, Burris DC, Champion HR, Hodgson Mj. Blast injuries. N Engf } Med 2005;352: 133 5- 1 342.

5.

Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned from Belfast to Beirut. Ann Surg 1988;208:569-576.

6.

Gutierrez de Ceballos JP, Turegano-Fuentes F, Perez-Diaz D, Sanz-Sa nchez M, Martin-Llorente C, Guerrero-Sanz }E. Casu alties treated at the closest hospital in the Madrid, March 1 1, terrorist bombings. Crit Care Med 2005;33(1 Suppi);SJ 07S l l2 .

7.

Gutierrez de Ceballos JP, Thregano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M, Martin-Liorente C, Guerrero-Sanz )E. l l March 2004: the terrorist bomb explosions in Madrid, Spain an aoalysis of the logistics, i11juries sustajned and clinical man agement of casualties treated at the closest hospital. Crit Care 2005;9: I 04- 1 1 1 .

8.

Hirshberg A, Scott BG, Granchi T, Wall MJ, Mattox Kl, Stein M . How does casually load affect trauma care in urban bomb ing incidents? A quantilative analysis. J Trauma 2005 ;58( 4) :686-693; discussion 694-695.

9.

Holden PJ. The London attacks-a chronicle: Improvising in an emergency. N E11gl } Med 2005;353(6):541-543.

10. Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health threat with a trauma system response. J Tmumn 2003;55(6): 1014-1021. 1 1 . Kales SN, Christiani DC. Acute chemical emergencies. N Eng/ 1 Med 200·4;350(8):800-808. 12. Klein )S, Weigelt )A. Disaster ma nagerneot: lessons learned. SurgClin North Arn 1991;71 :257-266. 13. Mettler FA, Voelz GL. Major radjalion exposure-what to ex peel and how to respond. N Eng/ J Med 2002;346(20):15541561.


336

APPENDIX H

•


14. Muhtplc authors. Perspective: The London atracks-a chronicle.

N Eng// A1ed 2005;353:541 -550.

15. Musolino SV, Tla rper FT. Emergency n:sponsc guidance for the first 48 hours after the outdoor detonation of an explosive ra

diological

dispersal device. Health Phys 2006;90(4):377-385.

16. :-.latiom1l Disaster Life Support Executive Committee, National Disaster Life Support Founu,\lion 75% BSA) second- and third-degree burns

Two f1re companies and two additional ambulances have been called. The local commumty hospital has 26 beds, 5 primary care providers, and 2 surgeons, 1 of whom IS on vacation. The nearest trauma center is 75 miles (120 kilometers) away, and the nearest designated burn center is over 200 miles (320 kilometers) away.

- - � -= ·

-

0

Should community disaster plans be invoked? Why, or why not?

fJ

If a mass-casualty event is declared, who should be the medical incident commander?

B

What s i the first consideration of the medical incident commander at the scene?

B

What considerations should be taken into account in medical operations at the scene?

�

What is the second consideration of the medical incident commander at the scene?

m

What is the meaning of the red, yellow, green, blue, and black triage categories?

D

Given the categories in Question

llJ

What efforts should be taken by the medical incident commander to assist with response andre

6,

which patients should be evacuated to the hospital, by

what transport methods, and in what order?

covery?


I N DEX

ABCDE, 5

Penetrating, evaluation

145 Cold injury, 221 Geriatric, 250 Brain injury,

Tnjury prevention, 243 Reassessing,

21

Abdomen Anatomy

External, 1 12 internal, 1 12-113 Assessmenr, 1 1 2, 1 15-126 Auscultation, 1 15 Contrast stuclies, 1 1 8 CT, 1 1 8 Diagnoses, specific, 121-123 DPL, 117-l H !

Injuries 14-15 Austere and hostile environment management of, 312-313 Determini ng, 1 15 Gunshot, 1 14 Hidden, 1 1 3 M an agement, 21-23 M ech anism of, 1 13-114, 1 1 7 Missed, 1 14 Multiple, 1 1 2 Recogn izi ng, 1 1 2 Shock a.nd, 1 15 Inspection, l l5 Laparoscopy, 1 19, 120 Percussion, 1 15 Peritoneal cavity, 1 12-1 13 Physical examination, 14-15, 1 1 5 Adjun cts to, 1 16 - 1 1 8 P alpation, l l 5 Retroperitoneal spaces, 1 12-113 Injuries to, 1 13 Secondary survey, 21-23 Stab wou nds, 1 19-120 Thoracoa bdomi nal component, J 13 Trauma, 1 1 1-124 Bltmt, L l 3 Blunt, evaluation of, 1 18-119 CT, 238 DPL, 238 PAST, 1 17, 23!\ Nonoperative management of pediatric, 238-239 Pediatric, 237-239 Penetrating, 1 13-114 ,

of, 1 19 Pitfalls in pediatric, 239 X ray examination of, 1 16 Visceral injuries, 239 ABG (See Arterial blood gas) Abruptio placentae, 264 Abuse Domestic violence, 266 Geriatric, 255 Pediatri c, 226, 242-243 Injuries, 2 42 Law regarding, 243 Acid/base balance, 64 Acidosis, 233 Acute care, 322 Adenosine triphosphate (ATP), 57 Agi ng Blood volume and, 251 Brai n changes with, 252 Circulation and, 251 Organ systems and effects of, 248, 249 Populations, 248 Spn i al changes with, 252 Air b ags 285 Airway Assessment 5 Brain injury, 142-143 Burn injury, 2 1 2 Assessmen l, 213 Chest injuries and, 86 -

,

,

Compromise, 6 Definitive, 32-33 in Austere and hostile environments,

309 Criteria for establishing, 32

Indications, 33 Difficult

Endotracheal intubation and, 35-38 Intubation of, 35-38 LEMON mnemonic and, 36 Edema, 2 1 3 G eriatric, 250 H emorrhagic shock, 62 Inhalation injury

Maintenance Assessment, 5 in Austere and hostile environments,

308-309 Cervical spine protection with, 5-6, 20 Chin-lift maneuver, 29, 30, 308-309 GEB and, 31-33 Jaw-thrust maneuver, 29, 30, 308309 L\IJA and, 3 1 LTA and, 3 1 , 32 Mu lti lu m en esoph ageal airway and, 31 Nasopharyngeal airway, 30-3 1 Oropharyngelal lu id, 66 t ;.:ri.Hric 251 l'lpccific, 66 W mning 11 uid�. 6Cl 13 1oud sampl es, 6.' Hlood volume Aging and, 251 1\urn in j ury ctrculating, 2 1 6 ,1 nd (..Hdiac output, 7 in Pregn.mcy, 16 1 Blood warming, 9, 66 ,

injury/injury p.Hll'rns) Body-surface area (burn injury), 2 1 j Brachial pl exu s, 14 Brain t\gmg .1nd

changes in, 152 '\n,llmny, 134-135 Aneurysm, 149 Death, 149-150 Lobe.,, 134 Brain injuries (St•e lll$c> :'1-hnor t raumatic brain injury} Anticonvulsantlt, 14!\ Barbiturates, 148 Blood llow, 137 Blunt, 137 u�r. 136 (.ontw.ions. l39-l40 niffme. 138 fpilepw, 148 . llrtC, (� . -75') - .> oert, --75' E\'aluatton and m.magement of, 252-153

Iil'matomas

,

or. 2urvey, b, 10 Respi ratOf)' .1rrc.,t, I ·12 Resuscitation, !\, 20 Transfer of pat icnt .1nd, 27'1 B retyl iw11 tosylatc, 222 Bronchi, I O· 322

'I ri.1ge su?n

.

Exposure/environmental control, 7-!!

in Auster•• .llld hmtile l'nvironmcnts, -' 1 5 _, 16

_

Exposu re and envi ron ment, 253

rio, '\:!H-329

.l

1 1•1

Musculol>kcletal svstem, 2"i3-25i.J •

(� .e n at n.c tr cen ter (EOC),

OOJlJ)Ier probe, 191-192

(Sec Di.1gnostic peritoneal lovage) Drug abuse, 27 1 Drug-assisted i nt ubation (DAI), 230, DPL

21 1 Duodenal i njuries, 1 2 1 Dura mater, Ln

322 Emergency prepared.ness, -�2 1-33_,

Austere ,1 11d hostile environment

Emergo train system

(E.TS), J22, 32(>

Emphysema, 9 7, 98 EMS (Sec Emergency 1\kdi-,1! �crYiCl'S) 25';-.2';6

man:1gcmcnt uf. 3 1 3-314 Burn, 2 1 7 Circulation, 2 1 7

Contusions, 197-199 Crush, 198 Fractures, 199

Endotracheal intubation, 33 3H

Assessment, 199

Difficult airway, 35JH

1\tln;Jgcmcnt, 199

rac1.1l, 13

l.I:: B m , d, 35

�ufl tis� uc, 6 1--{)2

Open, 194 195

Infant, 47

Edema

Elderly

I

Abuse, 255

Pt!diatric, 230-2J

AirWJ)'· 250

Tube pl��cemenL, 33-35

Breathing,

250

Burn�, 248, 2"iO

Cause o( death, 248 Chest anJuncs, I S Circulation, 2 51-2 52 Blood transfusaons, .251

F.valuJ tion of, 251-252 M.--posure/cnvirunmc:nt.ll wntrol)

EOC !See E mergency operations cen ter )

Prindpb

uL 207

Joint, l9•l- 19S Limh-thrt.'att:uing, I ':14- 1 ':17 Managellll'11l, I \.J2 , 199

Phvsical cxilmination, 1 9 0 '

Porenua llr

Iife-th reatening. 19 2-1 9-1

Epidural hematomas, 138-139

Upper. 200

Epilepsy, 148

Vascular, 195-196

Seizure managemcnt, 1 16 · Equipment (See nLU'• 132-135 ("I st,lm of, 154-155 F;h .ioll edema, 1 3 lnjuric�, 132 Classification of, 137-140 Mcch:111ism of, 137 !vlorphology, 138 Scvcrit) of, l38 M,w,Jgt:mcnt, 2 1 Mcning,·�. 133-134 l'h).,KJI e\ammatioo, 12-13 Ph)'�tology. 135-137 Sccond.lf)' survey, ll lhwma, U, 1 31- 1 50 A�sc�'ment and management ,

Transler of" p1l icnl and, 274 Vertical sh ecund .t rY vev, 1 8 2 ' sur . Sensory examination, 160 n.,, 170

ResusLi t.1t1vc thoracotomy. 92

Thoracoscopy

Surge capability, 323

16.:!

Prim,t rr �uncy, 86-'n, 99

Thoracol u mba r junct ion fracture�>, 166

Pediatric, 231

Incomplete paraplegia/quadriplo:gi.t,

Trauma. !\5-1 no

OiagmN ng, 92 q3

Steroi

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