RIOT Nigeria Lectures.pptx

RESUSCITATION
MEDICINE
Riverside International Outreach
Committee on Specialized Training

WELCOME & INTRODUCTION
Stephanie Loe, MD
 Emergency Medicine
 Co-Founder & President,
Riverside International Outreach
Agenda
 Basic Cardiopulmonary
Resuscitation
 Advanced Cardiac Resuscitation
 Advanced Pediatric Resuscitation
 Advanced Trauma Resuscitation
 Stop the Bleed
 Breast Cancer

BASIC
CARDIOPULMONARY
RESUSCITATION
Maria Arvizu, BSN, RN, CEN, MICN
Emergency Medicine

• Describe the importance of high-quality CPR and its
impact on survival.
• Describe all the steps of the Chains of Survival and apply the BLS
concepts of the Chains of Survival.
• Recognize the signs of someone needing CPR.
• Perform high-quality CPR for adults, children, and infants.
• Describe the importance of early use of an AED and demonstrate its
use.
• Recognize the signs of choking in the adult, infant and child
BLS Course Learning Objectives

Despite recent gains, less than
40% of adults receive layperson-
initiated CPR, and fewer than
12% have an AED applied before
EMS arrival. Ninety percent of
these cardiac arrest are fatal
without intervention.

• Recognize life-threatening emergencies in adults and
pediatrics
• Cardiac arrest
• Respiratory arrest
• Provide high-quality CPR
• Utilize and manage an AED
• Relieve choking in a safe, timely, and effective manner.

 Congenital Heart Disease
 Respiratory Failure
 Shock
KEY POINT: Unlike adult cardiac arrest,
which is primarily caused by coronary
artery diseases, the most common
causes of pediatric cardiac arrest are
respiratory failure and shock.
PEDIATRIC
 CAD/MI
 Cardiomyopathy
 Congenital heart disease
 Abnormal Electrical Conduction
ADULTS

 Hypoxemia
 Hypercapnia
 Drowning
 Aspiration
 Congenital or Chronic Airway Disease
 Airway Obstruction
 Airway Infection
 Acute Respiratory Distress Syndrome
 (ARDS)
PEDIATRIC
 Hypoxemia
 Hypercapnia
 Drug/Alcohol-Associated Respiratory
Failure
 Airway obstruction
 Stroke –muscle weakness
 Airway Infection
 Acute Respiratory Distress Syndrome
(ARDS)
ADULTS

• Assess that the scene is safe
• Check for responsiveness
• Shout for help
• Activate the emergency
response system (OHCA) or
emergency response team for
(IHCA)
• Get an AED/CAM with
defibrillator or delegate to
someone.
• Check for breathing-(chest rise
& fall) and pulse (carotid)
simultaneously 5-seconds no
more than 10 seconds.
• Rescue respirations 1 breath
every 6 seconds
• Adult CPR 30:2
• “Hands on only”
• Use AED as soon as available

https://www.youtube.com/watch?v=DUaxt8OlT3o
EFFECTIVE CPR IN ADULTS
• Correct hand placement and technique
• Two hands are placed on the lower half of the sternum
• Compression rate of 100 to 120/min (30 compressions every 15
seconds)
• Compression depth is at least 2 inches and avoid compressing more
than 2.4 inches (decreases effectiveness of compressions)
• Allow for complete recoil after every compression
• MINIMIZE INTERRUPTIONS IN COMPRESSIONS

https://www.youtube.com/watch?v=FSiDT5P0ZlI
AED and DEFIBRILLATION VIDEO
IN ADULT BLS
• Power on the AED
• Place appropriate size pads in correct location
• Clear for analysis of cardiac rhythm
• Clear to safely deliver shock
• Resumes compressions immediately after delivery of shock

https://www.youtube.com/watch?v=wjKH8Cf8IFg
AIRWAY & BREATHING
MANAGEMENT IN BLS
• Open the airway adequately
• Head-tilt chin lift or jaw thrust using appropriate technique (C & E)
• Provide 2 breaths with a barrier mask or Bag Valve Mask (BVM)
• Use appropriate size BVM
• 30:2 ratio or 1 breath every 5-6 seconds with an advanced airway
• Deliver each breath over 1 second
• Deliver breaths that produce visible chest rise and fall
• Avoid excessive ventilation.
• If unable to ventilate consider adjuncts OPA and NPA

 Key point to consider:
Infants and children who experience non-traumatic cardiac
arrest is usually as result of lack of oxygen in nature i.e.
secondary to hypoxia or shock which, if left untreated, leads to
progressive bradycardia and ultimately asystole.

INFANT and CHILD BLS SINGLE/TWO
RESCUER KEY POINTS
• Assess that the scene is safe
• Check for responsiveness
• Shout for help
• Activate the emergency response system (OHCA)
or emergency response team for (IHCA)
• Check for breathing-(chest rise & fall) and pulse
simultaneously 5-seconds no more than 10
seconds.
• Infant-Brachial
• Child- Carotid or Femoral
• Rescue breaths every 2-3 seconds over 1 second
• HR <60 with signs of poor perfusion –
• 1- Rescuer - START CPR with 30:2 ratio
compression/breaths
• 2- Rescuer CPR– 15:2 ratio
• WITNESSED Collapse
• Activate EMS or Emergency Team first
• NOT WITNESSED –
• START CPR
• Check your rhythm

• Place the infant in a firm flat surface
• Place 2 fingers in the center of the infant's chest, just below the nipple
line on the lower half of the breastbone
• Give compressions at a rate of 100-120/min
• Compress at least one third the depth AP of the chest or 1 ½ inches
• Allow for complete recoil
• At every 30 compressions, open the airway with a head tilt-chin lift and
give 2 breaths repeat every 2 minutes.
• Repeat the cycle

Infant CPR / BLS - New 2020 AHA / ILCOR Guidelines | CPR
Certification Institute - YouTube
RATIONALE FOR 2-THUMN ENCIRCLING TECHNIQUE (FOR 2 RESCUER)
• Produces better blood supply to the heart muscle
• Ensure consistent depth
• May generate a higher blood pressure
TECHNIQUE:
• Place the infant on a firm flat surface
• Place both thumbs side by side in the center of the infant’s chest on the lower half of the breastbone
• Encircle the infant’s chest and support the infant’s back
• Use both thumbs for compressions at a rate of 100-120/min
• Compress 1/3 the AP diameter of chest or 1 ½ inches
• Allow for complete recoil
• Compressions 15:2
• Continue compressions until AED arrives or need for defibrillation

6: AED Steps for Children and Infants (2021) OLD - YouTube
AED FOR INFANTS AND
CHILDREN

• Do not check for a pulse start CPR
immediately
• After 2 minutes of CPR activate the EMS or
Team
• Continue CPR
• Open airway and check for any obstructions.
• If visible remove object
• Proceed based on your patient presentation
• Check airway, breathing and pulse
UNCONSCIOUS ADULT & CHILD
What is the universal sign that some one
choking?
• What are some signs and symptoms?
• Weak cough
• Unable to speak
• Adventitious breath sounds
• Decreased air movement
• Periorbital cyanosis
Choking Relief Maneuver is the same for adult and
children 1 year and above
CONSCIOUS ADULT & CHILD
Conscious Adult Choking - YouTube

To relieve choking in a responsive infant:
• Kneel or sit with the infant in your lap
• Hold the infant with head slightly lower than the chest resting on
forearm
• Provide 2 finger chest thrust
• Support the infants head with your hand
• Rest your forearm on your thigh for support
• Use the heel of your hand to deliver up to 5 forceful back slaps
between the infant’s shoulder blades.
Infant Choking (2021) - YouTube

• Stand behind the victim and wrap your hands
around their chest
• Make fist with one hand
• Place the thumb of your fist into the center of the
chest (at the lower half of the breastbone) same
location for compressions
• Begin forceful thrust to the chest repeat until
object is expelled or patient becomes unresponsive

ADVANCED CARDIAC
RESUSCITATION
Charles Lewsadder, DO
Emergency Medicine

OVERVIEW
 Arrythmias
 Identifying Stable vs Unstable
 Identifying Rhythm strips
 TachyArrythmias
 BradyArrythmias
 Treatment options
 Pulseless Electrical Activity (PEA)
 Hs and Ts

TACHYARRHYTHMIA
 Stable vs Unstable?
 Unstable
 Pulseless
 Hypotensive
 Altered Mentation
 Active Chest pain
 Treatment
 SHOCK! SHOCK! SHOCK

STABLE TACHYARRHYTHMIA
 P waves or no P waves?
 Regular or Irregular rhythm?
 Wide or Narrow QRS complex?

SUPRAVENTRICULAR TACHYCARDIA
(SVT)
 No P waves
 Regular rhythm
 Narrow QRS complex

SVT - TREATMENT
Stable
 Vagal maneuvers
 Adenosine (6mg > 12mg) FAST push
 Cardioversion
Unstable
 Cardioversion

ATRIAL FIBRILLATION
 No P waves
 Irregular rhythm
 Narrow QRS complex

ATRIAL FIB - TREATMENT
Stable
 AV Nodal blockade
 Diltiazem or Metoprolol or Verapamil
Unstable
 Cardioversion

VENTRICULAR TACHYCARDIA
 No P waves
 Regular rhythm
 Wide QRS complex

V-TACH - TREATMENT
Stable
 Amiodarone or procainamide
 Synchronized cardioversion
Unstable
 Immediate defibrillation

VENTRICULAR FIBRILLATION
 No P waves

V-FIB - TREATMENT
Stable
 No such thing as “stable” V-Fib
Unstable
 CPR
 Immediate defibrillation
 Amiodarone

TORSADES DE POINTES
 No P waves
 “Ribbon like” aberrancy

TORSADES DE POINTES -
TREATMENT
Always unstable
 CPR
 Magnesium 4mg
 Defibrillation

1ST DEGREE AV-BLOCK
 Prolonged PR interval
Treatment
 Cardiology follow-up

2ND DEGREE AV BLOCK, TYPE I
 Prolonging PR interval with intermittent dropped QRS
Treatment
 Cardiology follow-up

2ND DEGREE AV BLOCK, TYPE II
 Regular PR interval with intermittent dropped QRS
Treatment
 Pacemaker

3RD DEGREE AV-BLOCK
 P-wave & QRS dissociation
Treatment
 Transcutaneous Pacing +/-
Atropine
 Transvenous Pacing
 Pacemaker

WHAT IS THIS RHYTHM IF NO
PULSE?

THE 5 OR 6 HS
 Hyper/HypoKalemia
 Hypothermia
 Hypoxia
 Hypovolemia
 High Proton concentration (Acidemia)
 Hypoglycemia

THE 5 TS
 Tamponade
 Tension Pneumothorax
 Thrombus (MI)
 Thrombus (PE)
 Toxins (Drugs)

ADVANCED PEDIATRIC
RESUSCITATION
Kelly Smith, RN, MICN, CEN
Emergency Medicine

PEDIATRIC
BRADYCARDI
A WITH
PULSE

PEDIATRIC
TACHYCARDI
A WITH
PULSE

PEDIATRIC
TACHYCARDI
A WITH
PULSE
- STABLE

PEDIATRIC
TACHYCARDI
A WITH
PULSE
- UNSTABLE

OBJECTIVES
• Understand basic physiology unique to pediatric respiratory system
• Assess signs and symptoms of respiratory distress and failure
• Determine and plan appropriate inventions for respiratory distress and failure
• Understand different respiratory emergencies commonly seen in the ED
• Promote health education and prevention techniques to the patient and family to prevent
reoccurrences
• Gain the knowledge and confidence to ultimately save a child’s life

INTRODUCTION
 Respiratory issues are the major causes of illness and
hospitalization in children
 Children have unique respiratory responses and anatomy that
require early inventions
 Children can compensate for while until they have used all
their reserves and crash very quickly
 Respiratory distress respiratory failure
Cardiopulmonary arrest DEATH

WHAT KIND OF RESPIRATORY ISSUES/PROBLEMS
DO YOU SEE KNOWING THE DIFFERENCES IN
THE PEDIATRIC ANATOMY?

SIGHTS OF ABNORMAL BREATHING
• Nasal flaring & retractions- https://youtu.be/iiX6vQ2F6ao
• Head bobbing- https://youtu.be/q0bHwMayCJY
• Global retractions- https://youtu.be/sJLHiTaXrtc
• Respiratory failure- https://youtu.be/oGwCfZW9Xiw

SOUNDS OF RESPIRATORY DISTRESS
• Wheezing- https://youtu.be/QNrsjDzD0QM
• Grunting- https://youtu.be/KQTEu1mpRY8
• Stridor- https://youtu.be/oeoAze-CHng

THE SMELLS OF RESPIRATORY DISTRESS?!

RESPIRATORY FAILURE
Change in level of consciousness
Decreasing PO2 and/or increasing PCO2
Can exist with:
Slow respiratory rate
Normal respiratory rate
Fast respiratory rate

Uh- oh, sick kiddo.
Now what?
Interventions???

INTERVENTIONS
 PHONE A FRIEND
 CALL RT- 66650
 TELL THE DOCTOR, SENIOR NURSE, CHARGE NURSE, CNE
 LEAST INVASIVE FIRST
 FOLLOW THE ABCs of RESCUTATION
 RE-ASSESS AFTER EACH INTERVENTION AND
WITH ANY CHANGE IN PATIENT CONDITION
 LISTEN TO YOUR PARENTS/CAREGIVERS

AIRWAY
 REMOVE FORGIEN BODY
 POSITION HEAD IN NEUTRAL SNIFFING POSITION
 SUCTION SECRETIONS, BLOOD, VOMIT FROM
MOUTH
 USE BULB SUCTION FOR NARES
 ESPECIALLY FOR INFANTS <6 MONTHS
 TEACH CAREGIVERS HOW TO USE
 Prepare for intubation

BREATHING
o Positioning the patient
o Bear hug caregiver
o Semi-fowlers, hugging a pillow
o Provide calm, safe environment
o Provide oxygen
o Bronchodilating breathing treatments
o Steroids
o Assist ventalations using bag valve mask (BMV)
o Infant size up to 10 kgs
o Pediatric size 10-30 kgs
o Adult size > 30 kgs
o Ensure proper fit
o Enough squeeze to produce chest rise and fall

Circulation
 Increased work of breathing leads to dehydration
 Provide warmed isotonic crystalloid solution fluid bolus
 20 ml/kg
 Rapid infusion
 Offer oral hydration as appropiate
 Fever control
 Tylenol10-15 mg/kg/dose q 4-6 hrs
 Not recommended for infants <6 wks
 Ibuprofen 10 mg/kg/dose q 6-8 hrs
 Don’t use in infants < 6 months
 Teach parents on the medications

 Anticipate the need for intubation
 Assess the stuttle changes in patient going into
respiratory failure
 Pre-oxygenate and ventilate with OPA/NPA & BVM
 Select and prepare equipment
 Use browslow bag for appropriate sized ET/NG tubes
 C-MAC or Glidescope to bedside
 Set up suction
 Premedicate/ medicate
 Consider lidocaine
 Atropine may be used for patients less
than 8 years of age
 Use sedation and induction medications
 Confirm placement
 Once ETT tube in place, remember to place gastric tube to
decompress the stomach

UPPER VS. LOWER RESPIRATORY
EMERGENCIES
Upper Airway
 Croup
 Epiglottitis
 Bacterial tracheitis
 Foreign bodies
 Sleep apnea
 Tracheomalacia
Lower Airway
 Asthma
 Bronchiolitis
 Pertussis
 Pneumonia
 Foreign bodies
 Bronchomalacia
 Failure secondary to neurological
disorder (muscular dystrophy) or
anatomical issues (scoliosis/kyphosis)

CROUP
• Upper respiratory disorder-
Commonly viral lasting up to 14 days
• Barky, seal-like cough – worse at night
• “steeple sign” on xray
• Concurrent resting stridor
• Observe for rebound effect
• https://youtu.be/fGP0vKQO4CY
Signs and symptoms
• Treatment is symptomatic/supportive
• Cool mist/oxygen, as indicate
• Teach caregivers to take pt outside into
cold air
• Sit in steamy bathroom
• Consider corticosteroids to reduce
inflammation
• Consider racemic epinephrine
(typically 2 hours relief)
Treatment

EPIGLOTTITIS
 Symptoms
 Acutely high fever
 Muffled voice
 Severe sore throat − difficulty
swallowing
 Drooling
 Stridor
 “Thumb sign” on xray
 Keep pt calm
 Secure an airway
 Antibiotics
 Ampillicin or cephalosporin
 To cover Haemophilus influenzae type
B
 Streptococcus pneumoniae and
Staphylococcus

 MOST IMPORTANT INTERVENTION IS …
• NASAL SUCTIONING USING A
BULB SYRINGE
• OBTAIN SPECIMEN FOR RSV
• PLACE IN CONTACT ISOLATION
BRONCHIOLITIS INTERVENTIONS

 “Whooping Cough”
• Bacterial infection – contagious
• Incubation period 7-10 days
• Signs/Symptoms- usually occur at night
• Paroxysmal spasms of coughing with vomiting and
fatigue after each episode
• Ill and distressed appearance when coughing
• Appears normal when not coughing
• Infants younger than six months may not exhibit the
whoop, but paroxysms of coughing are present
Pertussis “whooping cough”
TREATMENT:
 Droplet isolation
 O2 and fluids
 Zofran
 Erythromycin
PREVENT

SIGNS AND SYMPTOMS
 COUGH
 RETRACTIONS
 FEVER
 TACHYPNEA
 GRUNTING
 WHEEZING
 CRACKLES
 ABDOMINAL PAIN
 SICK AND LETHARGIC

HEALTH PROMOTION AND EDUCATION
 CHILD PROOF THE HOUSE
 ENCOURAGE
IMMUNIZATIONS
 EDUCATE ON ASTHMA
 ENSURE THEY FOLLOW-UP
WITH PCP
 INSTRUCT ON MEDICATION
ADMINISTRATION
 REMIND THEM OF S/S OF
WORSENING CONDTION
 PROVIDE RESOURCES
 ENCOURAGE TAKING BLS
CLASSES

The emergency department nurse is caring
for a child diagnosed with epiglottitis. In
assessing the child, the nurse should
monitor for which indication that the child
may be experiencing airway obstruction?
1. The child exhibits nasal flaring and
bradycardia.
2. The child is leaning forward, with the chin
thrust out.
3. The child has a low-grade fever and
complains of a sore throat.
4. The child is leaning backward, supporting
himself or herself with the hands and arms.

A 10 year old child with asthma is treated for acute
exacerbation in the emergency department. The nurse
caring for the child should monitor for which sign,
knowing that it indicates a worsening of the condition?
1. Warm, dry skin
2. Decreased wheezing
3. Pulse rate of 90 beats/minute
4. Respirations of 18 breaths/minute

ADVANCED TRAUMA
RESUSCITATION -
OVERVIEW
Stephanie Loe, MD
Emergency Medicine

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Course Overview Tenth Edition

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Course Overview
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Welcome and Introductions
• Course Director
• Faculty
• Course Coordinator

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Course Overview
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Welcome and Introductions
We would like you to introduce yourselves now:
Who are you?
What is your professional background?
What is your experience with trauma?
What do you hope to gain from this course?

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Course Overview
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Safe Learning Environment
• Interactive, unfolding case discussions, stimulus questions
• Participation required
• Respect for each other
• Try answering the questions – it’s ok if you get it wrong

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Course Overview
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M
43 year old male, driver MVC,
involved in head on collision
with truck
I
Right sided bruising and
abrasions on Chest, deformed
right leg,
S
Non responsive, RR 30, HR 130,
BP 80/60
T
On spine board with C spine
collar
Discussion Question:
What are your concerns with this
patient?

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Course Overview
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The ATLS course provides one
acceptable method for the safe,
immediate management of
trauma patients.

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Course Overview
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Program Goals
ATLS course provides participants with a safe and reliable method to:
1. Assess a patient’s condition rapidly and accurately.
2. Resuscitate and stabilize patients according to priority.
3. Determine whether a patient’s needs exceed a facility’s resources and/or provider’s
capabilities.
4. Arrange transfer when indicated

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Course Overview
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Course Objectives
Upon completion of the ATLS student course, you will be able to:
1. Demonstrate the concepts and principles of the primary and secondary
patient assessments.
2. Establish management priorities in the initial management of a trauma
patient.
3. Initiate the primary and secondary management of a simulated trauma
patient in a timely manner.
4. In a given trauma simulation, demonstrate the skills that are often required
in the initial assessment and treatment of patients with multiple injuries.

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Course Overview
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The Need
• 5.8 million people die every year
from unintentional injury and
violence -- more than nine people
every minute.
• Injury accounts for 18% of the
world’s burden of disease.
• Motor vehicle crashes alone cause
more than 1 million deaths annually
and 20 to 50 million significant
injuries.
Self-inflicted
violence
16%
Interpersonal
violence
10%
Other
17%
Road traffic
injuries
25%
Fires 5%
Poisoning 6%
Falls 6%
War
6%
Drowning
9%

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Course Overview
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ATLS provides a
common language

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Course Overview
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The Beginning

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Course Overview
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“When I can provide better
care in the field with
limited resources than what
my children and I received
at the primary care facility,
there is something wrong
with the system, and the
system has to be changed.”
James Styner, MD, FACS
1977

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Course Overview
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Trimodal to Bimodal Distribution

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Course Overview
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ATLS Concept
• Follow ABCDE approach to evaluation and treatment.
• Treat the greatest threat to life first.
• Recognize the definitive diagnosis is not immediately important.
• Understand that time is of the essence.
• Do no further harm.

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Course Overview
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ATLS Concept
Airway with restriction of cervical spine motion
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurological status
Exposure / Environmental control

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Course Overview
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Initial Assessment and Management

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Course Overview
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ATLS Educational Format
• Introductory lecture
• Interactive group discussions
• Interactive skill sessions
• Simulated patient scenarios
• Written examinations
• mATLS online learning modules
• MyATLS mobile app

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Course Overview
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International ATLS Program
• 83 countries
• 3,380 courses
• 68,000 students
• MyATLS mobile app 181 countries,
216,000 downloads

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Course Overview
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Impact of ATLS Program
• Documented improvement in the care of injured patients after
implementation of program
• Organized trauma care resulting in reduced injury mortality
• Retention of organizational and procedural skills

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Course Overview
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Any Questions?

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Course Overview
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Summary
• ABCDE approach to trauma care
• Do no further harm
• Treat the greatest threat to life first
• One safe way
• A common language

https://m.youtube.com/watch?v=9RlPGjBtHZk

TRAUMA – INITIAL
ASSESSMENT &
MANAGEMENT
Greg Harriman, BSN, RN
Trauma/Emergency Medicine

1 Initial Assessment and Management Tenth Edition

1 Initial Assessment and Management
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The primary survey (ABCD) is the cornerstone of the initial
assessment of the trauma patient. Repeat the primary survey
frequently to identify any deterioration in the patient’s
status that indicates the need for additional intervention.

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Objectives
By the end of this interactive discussion, you will be able to:
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.

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1
Case Scenario
18-year-old male , unrestrained
driver in MVC vs. tree
None reported
Vitals not reported
Prolonged extrication; transported
to ED by ambulance; O2 by mask;
fluids via single IV; spinal motion
restricted on long spine board
M
I
S
T

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1
Discussion Questions:
1. How would you prepare for the arrival
of this patient?
2. What other information would be
helpful to know in order to prepare?
3. From the history, what are the
potential injuries this patient may have
suffered?
Case Details
M
18-year-old male ,
unrestrained driver in
MVC vs. tree
None reported
Vitals not reported
Prolonged extrication;
transported to ED by
ambulance; O2 by mask;
fluids via single IV; spinal
motion restricted on long
spine board
I
S
T

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1
Case Scenario Progression
• EMS report: patient is
lethargic, mumbling
unintelligibly
• Patient has facial injuries
• Vital signs: HR 120; BP 90/40;
RR 24, O2 sat 89%, temp 36°C

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1
1. Based on this information, what
interventions can be done in the
prehospital setting?
2. Which patients should be immediately
transported to the trauma center
based on their field presentation?
Case Details
• EMS report:
patient is
lethargic,
mumbling
unintelligibly
• Patient has facial
injuries
• Vital signs: HR
120; BP 90/40; RR
24, O2 sat 89%,
temp 36°C

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1
• Patient arrives at hospital
• Vital signs: HR 120; BP 90/palp;
RR 20; O2 sat 82%, temp 35.5°C.

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1
1. What are your clinical concerns?
2. What are your management priorities?
Case Details
• Patient arrives at
hospital
• Vital signs: HR
120; BP 90/palp;
RR 20; O2 sat
82%, temp
35.5°C.

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1
Primary survey reveals:
A: Obvious facial trauma and mumbling incoherently.
B: Decreased breath sounds, L chest; no visible neck veins
C: Minimal bleeding; open L femur fracture; L chest bruising;
possible pelvic fracture
D: Localizes to pain with upper extremities; moans to painful
stimuli; does not open eyes

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1
1. What are your clinical concerns?
2. What are your management priorities?
Case Details
A: Obvious facial trauma and
mumbling incoherently.
B: Decreased breath
sounds, L chest; no
visible neck veins
C: Minimal bleeding; open L
femur fracture; L chest
bruising; possible pelvic
fracture
D: Localizes to pain with
upper extremities; moans
to painful stimuli; does
not open eyes

148 of 23
1
• Patient intubated
• Femur fracture reduced and immobilized; pelvic stabilizing
device applied
• 500 mL warmed crystalloid and 1 unit unmatched pRBCs IV
• Vital signs: HR 97; BP 110/64; RR 24; O2 sat 96%
• Patient begins to respond to verbal stimuli, opens eyes, and tries
to brush away your hands

149 of 23
1
1. What additional adjuncts and
treatments would you order at this
time?
2. When should the transfer occur and
what tests are necessary before
transferring the patient?
Case Details
• Femur fracture reduced
and immobilized; pelvic
stabilizing device applied
• 500 mL warmed
crystalloid and 1 unit
unmatched pRBCs IV
• Vital signs: HR 97; BP
110/64; RR 24; O2 sat 96%
• Patient begins to respond
to verbal stimuli, opens
eyes, and tries to brush
away your hands

150 of 23
1
• Patient’s LOC decreases
• Patient opens his eyes to
pressure and moves away from
stimulus (normal flexion)
RR 20
• Good breath sounds bilaterally

151 of 23
Secondary survey:
• Pupils: 5 mm, minimally reactive, L; 6
mm, reactive, R
• Laceration and soft tissue injury, L
temporal-frontal region; no active
bleeding
• L hemotympanum
• Large ecchymosis, L anterior chest
• Abdomen soft, nondistended

152 of 23
1
What is your first step when a patient’s condition changes?

153 of 23
1
When does the secondary survey occur, and how is it conducted?

154 of 23
1
• No neurosurgery on site
• Decision: transfer patient to
another facility for definitive care
• Contact the family to give update
and obtain consent for transfer

155 of 23
1
1. The family insists on obtaining a CT of
the head, even though this will
significantly delay transport (the team
is ready). Do you agree and why?
2. What information should you provide
to the receiving facility?
Case Details
• Femur fracture reduced
and immobilized; pelvic
stabilizing device applied
• 500 mL warmed crystalloid
and 1 unit unmatched
pRBCs IV
• Vital signs: HR 97; BP
110/64; RR 24; O2 sat 96%
• Patient begins to respond
to verbal stimuli, opens
eyes, and tries to brush
away your hands

156 of 23
1
Case Scenario Conclusion
The patient is transferred to a
trauma center via air, and goes to
surgery for evacuation of an
intracranial hematoma.

157 of 23
1
Any Questions?

158 of 23
1
Review Objectives
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.

159 of 23
Key Learning Points
1. The initial management of the injured patient requires:
• coordination with prehospital providers
• preparation for receiving the patient
• anticipation of injuries based on the mechanism of injury
2. The evaluation of all trauma patients follows a precise algorithm.
3. Patients who exceed the capability of the institution should be
identified rapidly and process for transfer begun.
4. Evaluate the patient according to priority using the ABCDEs.

TRAUMA – AIRWAY &
VENTILATORY
MANAGEMENT
Charles Lewsadder, DO
Emergency Medicine

2 Airway and Ventilatory Management Tenth Edition

163 of 20
Airway and Ventilatory Management
2
2 Airway and Ventilatory Management
The earliest priorities in managing the injured patient are to
ensure an intact airway and recognize a compromised airway.

164 of 20
2
Objectives
1. Identify different clinical situations in which airway compromise is likely to occur.
2. Recognize the signs and symptoms of acute airway compromise in a trauma case
scenario.
3. Determine factors that may lead to a difficult airway.
4. Apply the ATLS airway algorithm to a case scenario involving a patient with a difficult
airway.
5. Define the term definitive airway.

165 of 20
2
Case Scenario
43-year-old obese- restrained driver lost
control of his small vehicle while traveling at
a high speed on an icy road; crashed driver’s
side into a large tree.
None reported
Patient combative during extrication
Spinal motion restricted on long spine
board; C collar; bag-mask ventilation
M
I
S
T

166 of 20
2
1. What aspects of the reported mechanism
of injury present a risk of airway
compromise?
2. Which clinical findings suggest(s) potential
airway compromise?
Case Details
M
43-year-old obese- restrained
driver lost control of his small
vehicle while traveling at high
speed on an icy road;
crashed driver’s side into a
large tree.
None reported
Patient combative during
extrication
Spinal motion restricted on
long spine board; C collar;
bag- mask ventilation
I
S
T

167 of 20
2
3. How do you know if the patient’s airway is
patent?
4. What are some patient factors that may
contribute to a difficult airway in this
patient?
Case Details
M
large tree.
None reported
extrication
Spinal motion restrictedon
I
S
T

168 of 20
2
5. Are there additional factors that may be
present in other trauma patients?
6. How might we predict a difficult airway?
Case Details
M
large tree.
None reported
extrication
Spinal motion restricted on
I
S
T

169 of 20
2
On arrival:
• Patient lethargic
• Asymmetric chest expansion
• Shallow breathing, O2 sat 82%
• Significant facial injuries, L chest bruising
You are attempting to assist his ventilation with bag-mask ventilation.

170 of 20
2
1. What are the symptoms of inadequate
ventilation?
2. What are the signs of inadequate
ventilation?
• Significant facial injuries, L chest
bruising
• You are attempting to assist his
ventilation with bag-mask
ventilation.
Case Details

171 of 20
2
3. What are your next steps in management?
4. What equipment is required?
Case Details
• Significant facial injuries, L chest
bruising
• You are attempting to assist his
ventilation with bag-mask
ventilation.

172 of 20
2
• Patient now unconscious
• Vital signs: systolic BP 100; HR 120
• Upper airway suctioned, some bloody sputum cleared
• Teeth and facial bones intact
• Oral airway inserted and bag-mask ventilation continued with 100%
oxygen. O2 sat improves to 93%
• You decide to intubate the patient

173 of 20
2
1. What constitutes a definitive airway?
2. How do you prepare for this
intubation?
3. What adjuncts might be used during
intubation?
Case Details
• Patient now unconscious
• Vital signs: systolic BP 100; HR 120
• Upper airway suctioned, some bloody
sputum cleared
• Teeth and facial bones intact
• Oral airway inserted and bag-mask
ventilation continued with 100%
oxygen. O2 sat improves to 93%
• You decide to intubate the patient

174 of 20
2
• You have difficulty intubating the patient.
• LMA is inserted, but it is difficult to get an adequate seal.
• An attempt with a gum elastic bougie is successful.
• The patient oxygenation improves.

175 of 20
2
1. When is a surgical airway indicated? Should
one have been performed now
2. Is there anything that may have been
considered for intubation prior to the
patient’s decompensation?
Case Details
• You have difficulty intubating
the patient.
• LMA is inserted, but it is
difficult to get an adequate
seal.
• Successful drug-assisted
intubation performed using a
gum elastic bougie.
• The patient oxygenation
improves.

176 of 20
2
• Following successful drug-assisted intubation:
• Vital signs a few minutes following intubation: HR 130; BP 90/30; O2
sat 70%.
• Breath sounds are diminished on the L side.

177 of 20
2
1. What are the possible causes of this
patient’s deterioration?
2. How can you diagnose and treat these
possible causes?
Case Details
• Successful drug-assisted
intubation performed
• Vital signs a few minutes
following intubation: HR 130;
BP 90/30; O2 sat 70%.
• Breath sounds are diminished
on the L side.

178 of 20
2
• Right mainstem intubation is discovered and readjusted.
• Patient’s vital signs return to normal.
• Primary survey is completed.

179 of 20
2
Any Questions?

180 of 20
2
Objectives
1. Identify different clinical situations in which airway compromise is likely to occur.
2. Recognize the signs and symptoms of acute airway compromise in a trauma case
scenario.
3. Determine factors that may lead to a difficult airway.
4. Apply the ATLS airway algorithm to a case scenario involving a patient with a difficult
airway.
5. Define the term definitive airway.

181 of 20
2
Key Learning Points
1. One of earliest priorities is recognizing a compromised airway.
2. All trauma patients should receive supplemental oxygen.
3. Risk of airway compromise and difficult airway management can be
predicted.
4. Alterations in mental status (agitation, combativeness, confusion, or
obtundation) may indicate the need for airway management.
5. A definitive airway (cuffed tube in trachea below vocal cords) should be
obtained in cases of airway compromise.

TRAUMA – AIRWAY &
VENTILATORY
MANAGEMENT
Raj Patel, DO
Emergency Medicine

184 of 17
Shock
3
The first step in the initial management of shock is to recognize its
presence. The diagnosis of shock is based on clinical recognition of
the presence of inadequate tissue perfusion and oxygenation.

185 of 17
Shock
3
Objectives
1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient
with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.

186 of 17
Shock
3
Case Scenario
80-year-old male, unrestrained
passenger in a low-speed MVC
None reported
Patient confused
Brought to ED by paramedics
M
I
S
T

187 of 17
Shock
3
1. What are the possible reasons for the
patient’s confusion?
2. What additional scene information
would be helpful to obtain from the
prehospital providers that could help
you differentiate the causes of his
confusion?
Case Details
M
80-year-old male,
unrestrained
passenger in a low-
speed MVC
None reported
Patient confused
Brought to ED by
paramedics
I
S
T

188 of 17
Shock
3
• Vital signs: BP 100/70; HR 100; RR 20
• Patient on a stretcher, receiving IV fluids

189 of 17
Shock
3
1. Based on the information given, is
this patient in shock? What
additional information is needed to
help determine this?
2. What vital signs and laboratory
studies support the diagnosis of
shock?
3. Can a single vital sign or laboratory
result diagnose shock?
• Vital signs: BP
100/70; HR 100; RR 20
• Patient on a stretcher,
receiving IV fluids
Case Details

190 of 17
Shock
3
4. What is the most common
cause of shock in a trauma
patient?
5. What types of soft tissue or
bony injuries might result in
shock?
• Vital signs: BP
100/70; HR 100; RR 20
• Patient on a stretcher,
receiving IV fluids
Case Details

191 of 17
Shock
3
• Two large-bore IVs placed, 1 L crystalloid bolus given
• Vital signs post treatment: BP 98/77; HR 80
• The patient remains confused and unable to give his medical
history

192 of 17
Shock
3
1. What adjuncts should be
considered to determine the cause
of shock (if not already done)?
2. How should further resuscitation
proceed?
Case Details
• Two large-bore IVs
placed, 1 L crystalloid
bolus given
• Vital signs post
treatment: BP 98/77;
HR 80
• The patient remains
confused and unable to
give his medical history

193 of 17
Shock
3
3. How will you continue to monitor
this patient’s ongoing response to
fluid resuscitation?
Case Details
• Two large-bore IVs
placed, 1 L crystalloid
bolus given
• Vital signs post
treatment: BP 98/77;
HR 80
• The patient remains
confused and unable to
give his medical history

194 of 17
Shock
3
• Chest x-ray shows multiple rib fractures, large R hemothorax
• The patient’s family arrives and provides history:
o coronary artery disease
o coronary artery stenting 1 year ago
o Meds: beta blocker, clopidogrel (Plavix), and aspirin

195 of 17
Shock
3
1. How do the beta blockers affect this
patient’s presentation and response to
interventions?
2. What management concerns are
presented by the antiplatelet agents
the patient is taking?
3. What medical condition could further
impact the patient’s response to shock?
Case Details
• Chest x-ray shows multiple
rib fractures, large R
hemothorax
• Patient history:
o coronary artery
disease
o coronary artery
stenting 1 year ago
o Meds: beta blocker,
clopidogrel (Plavix),
and aspirin

196 of 17
Shock
3
• Platelet transfusion initiated.
• R chest tube is placed 750 mL of blood obtained
• Subsequent chest tube output is 50 mL/2 hours

197 of 17
Shock
3
Any Questions?

198 of 17
Shock
3
Review Objectives
1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of a trauma patient in shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient
with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.

199 of 17
Shock
3
Key Learning Points
1. Hemorrhage is the most common cause of shock after injury.
2. No single laboratory test and no single vital sign on its own can diagnose shock.
3. Massive blood loss may produce only minimal acute decrease in hemoglobin or
hematocrit.
4. Major soft tissue injuries and fractures can be associated with significant
hemorrhage.
5. The patient’s response to initial fluid therapy will help guide subsequent
therapy.
6. A variety of special conditions may affect the patient’s response to shock and
the management of it (e.g., age, medication use).

STOP THE BLEED
Kelly Smith, RN & Missy Blenkarn, RN
Emergency Medicine

STOP THE BLEED® COURSE
AMERICAN COLLEGE OF
SURGEONS
Copyright © 2019 American College of Surgeons
STOPTHEBLEED.ORG
Version 2
STOP THE BLEED® is a registered trademark of the U.S. Department of
SAVE A LIFE

The American
College of Surgeons
Committee on
Trauma
The Committee
on Tactical
Combat
Casualty Care
The National
Association of
Emergency Medical
Technicians
The American
College of
Emergency
Physicians

Some of the images shown
during this presentation may be
disturbing to some people.

Why Do I Need This Training?
Introduction | A-Alert | B-Bleeding | C-Compression |
Stop the Bleed Course v. 2.0
The #1 cause of preventable
death
after injury is bleeding.

WHERE CAN I USE THIS
TRAINING?

GOALS
1. Identify
Recognize
life-threatening
bleeding
2. Stop the Bleed
Take steps to
STOP THE BLEEDING
✓ Pressure
✓ Packing
✓ Tourniquets

PERSONAL SAFETY
YOUR safety is YOUR first priority
• If you are injured, you cannot help others
• Help others only when it’s safe to do so
• If the situation changes or becomes
unsafe:
✓ Stop
✓ Move to safety
✓ If you can, take the victim with you

PERSONAL SAFETY
YOUR safety is YOUR first priority
• Wear gloves if you can
• If you get blood on you, be sure to clean any
part of your body that the blood has touched
• Tell a health care provider that you got blood
on you, and follow his or her direction

ABCs of Bleeding Control
A Alert 911
B Bleeding
C Compress
Introduction | A-Alert | B-Bleeding | C-Compression |
Stop the Bleed Course v. 2.0

ABCS OF BLEEDING
CONTROL
A Alert 911
• Call 911
• Know your location
• Follow instructions provided by
911 operator

ABCS OF BLEEDING
CONTROL
B Bleeding
• Find source of bleeding
• Look for:
✓ Continuous bleeding
✓ Large-volume bleeding
✓ Pooling of blood

ABCS OF BLEEDING
CONTROL
B Bleeding
• There may be multiple places the
victim is bleeding
• Clothing may also hide
life-threatening bleeding

ABCS OF BLEEDING
CONTROL
B Bleeding
• Arms and legs
• Neck, armpits,
and groin
• Body

ABCS OF BLEEDING
CONTROL
A Alert 911
B Bleeding
C Compress - Pressure

C Compress - Pressure
• Apply direct pressure to wound
• Focus on the location of the bleeding
• Use just enough gauze or cloth to
cover injury
• If pressure stops the bleeding, keep
pressure on wound until help arrives
ABCS OF BLEEDING
CONTROL

ABCS OF BLEEDING
CONTROL
C Compress - Packing
• For large wounds, superficial
pressure is not effective
• If bleeding is from a deep
wound, pack gauze tightly
into the wound until it stops
the bleeding; hold pressure
until help arrives

ABCS OF BLEEDING
CONTROL
C Compress -
Packing
• Arms and legs
• Neck, armpits,
and groin
• Body

C Compress - T
ourniquet
• Apply 2 to 3 inches above wound
• Do not place over the elbow or knee
• Tighten tourniquet until bleeding stops
• Do NOT remove the tourniquet
ABCS OF BLEEDING
CONTROL

C Compress - Tourniquet
• Can apply to others or on yourself
• Can be applied over clothes
• Tourniquets HURT
• A second tourniquet may be required to stop
the bleeding
ABCS OF BLEEDING
CONTROL

ABCS OF BLEEDING
CONTROL
CAT
RMT
TX3
SAM-XT
TMT
CAT
SOFT-
TT

 Recommended Non-Pneumatic Limb Tourniquets
• Combat Application Tourniquet Gen 6 (CAT-6)
• Combat Application Tourniquet Gen 7 (CAT-7)
• Ratcheting Medical Tourniquet (RMT) Tactical
• SAM Extremity Tourniquet (SAM-XT)
• SOF Tactical Tourniquet–Wide (SOFTT-Wide)
• Tactical Mechanical Tourniquet (TMT)
• TX2 Tourniquet (TX2)
• TX3 Tourniquet (TX3)

 Recommended Pneumatic Limb Tourniquets
• Delphi EMT (EMT)
• Tactical Pneumatic Tourniquet 2” (TPT2)

 In all but the extremely young child, the same tourniquet used
for adults can be used in children.
 For the infant or very small child (tourniquet too big), direct
pressure on the wound as described previously will work in
virtually all cases.
• For large, deep wounds, wound packing can be performed in children
just as in adults using the same technique as described previously.

FAQS
• Impaled objects?
• Improvised tourniquets?
• Loss of arm or leg?
• Pain?
• Other questions?

SUMMA
RY
✓Personal safety
A Alert 911
B Find bleeding
C Compress with
pressure and/or packing
C Compress with a
tourniquet
✓ Wait for help to arrive

TRAUMA – THORACIC
INJURIES
Raj Patel, DO
Emergency Medicine

4 Thoracic Trauma Tenth Edition

235 of 27
Thoracic Trauma
4
Thoracic injury is common in polytrauma patients and can be life-
threatening, especially if not promptly identified and treated during
the primary survey.

236 of 27
Thoracic Trauma
4
Objectives
1. Apply the ATLS principles to the management of a patient with thoracic
trauma.
2. Recognize the important life-threatening injuries in a patient with thoracic
trauma.
3. Evaluate the case scenario of a patient with thoracic trauma to identify
immediate life-threatening injuries.
4. Discuss the clinical findings and adjunctive studies that may be useful during
the secondary survey in a patient with thoracic trauma.

237 of 27
Thoracic Trauma
4
Case Scenario
27-year-old male unrestrained driver
in high-speed, frontal-impact MVC
Airway patent, obvious respiratory
distress
BP 90/50; HR 110; RR 36; and
GCS 14
None reported
M
I
S
T

238 of 27
Thoracic Trauma
4
1. What life-threatening injuries might
one discover in the primary survey that
could account for the patient’s clinical
status?
2. What are the next steps in the
evaluation and treatment of this
patient?
Case Details
M
27-year-old male
high-speed, frontal-
impact MVC
Airway patent, obvious
respiratory distress
BP 90/50; HR 110; RR
36; and GCS 14
None reported
I
S
T

239 of 27
Thoracic Trauma
4
1. What are the immediately life-
threatening thoracic injuries involving:
• Airway
• Breathing
• Circulation
Case Details
M
27-year-old male
high-speed, frontal-
impact MVC
Airway patent, obvious
respiratory distress
BP 90/50; HR 110; RR
36; and GCS 14
None reported
I
S
T

240 of 27
Thoracic Trauma
4
On arrival to ED:
• Patient complains of profound shortness of breath, asking to sit up
• O2 sat 89%.
• Cervical collar in place
• Trachea deviated to right
• Breath sounds absent on left
• Heart sounds normal
• Left chest wall crepitus

241 of 27
Thoracic Trauma
4
1. What is this patient’s most
likely diagnosis?
2. What is the appropriate
technique to alleviate this
patient’s condition?
• Patient complains of
profound shortness of
breath, asking to sit up
• O2 sat 89%.
• Cervical collar in place
• Trachea deviated to right
• Breath sounds absent on left
• Heart sounds normal
• Left chest wall crepitus
Case Details

242 of 27
Thoracic Trauma
4
• Needle decompression performed, no rush of air
• Vital signs unchanged

243 of 27
Thoracic Trauma
4
What alternative management
strategy can you use?
Case Details
• Needle decompression
performed, no rush of
air
• Vital signs unchanged

244 of 27
Thoracic Trauma
4
What are the differences in clinical
presentation between a tension
pneumothorax and an open
pneumothorax?

245 of 27
Thoracic Trauma
4
• Finger thoracostomy performed
• Vital signs: RR 28; HR 110; BP 100/60
• Thoracostomy tube placed, 600 mL dark blood drained
• Two large-bore IV lines established, isotonic fluid given
• Type and crossmatch requested
• Chest x-ray shows:
o obscured L diaphragm
o multiple L rib fractures
o wide mediastinum
o pulmonary contusion

246 of 27
Thoracic Trauma
4
1. What are the indications for
operation in a patient with
traumatic hemothorax?
2. What resuscitative measures should
be undertaken in a patient with
massive hemothorax?

247 of 27
Thoracic Trauma
4
3. What other potential life threats
might exist in a patient with this
mechanism? For each, what
would the clinical
presentation/findings and the
appropriate treatment be?
4. What test would you perform to
make the diagnosis during the
secondary survey?
• Finger thoracostomy performed
• Vital signs: RR 28; HR 110; BP 100/60
• Thoracostomy tube placed, 600 mL
dark blood drained
• Two large-bore IV lines established,
isotonic fluid given
• Type and crossmatch requested
• Chest x-ray shows:
• obscured L diaphragm
• multiple L rib fractures
• wide mediastinum
• pulmonary contusion
Case Details

248 of 27
Thoracic Trauma
4
Potential Life Threat Clinical
Presentation/Findings
Treatment Pitfalls
Simple Pneumothorax +/- shortness of breath No
hypotension
Diagnosis by chest x-ray
Chest tube drainage Could become tension
pneumothorax if untreated
Hemothorax Dullness to percussion
Diagnosis by chest x-ray
Chest tube drainage Could become massive
hemothorax
Flail Chest and Pulmonary
Contusion
May see paradoxical movement
of chest wall More commonly
presents with pain and poor
respiratory excursions
Oxygen
Analgesia
Intubation if necessary
Progressive respiratory failure
Blunt Cardiac Injury ECG changes Cardiac monitoring
Therapy based on clinical
status
At risk for clinically significant
dysrhythmias
Traumatic Aortic Disruption May be asymptomatic
Multiple possible radiographic
findings
Endovascular or open surgical
repair
Blood pressure control
important prior to definitive
therapy
Traumatic Diaphragm Injury Respiratory distress
Obscured left diaphragm
border
Evidence of abdominal viscera
in chest
Operative repair Concomitant pulmonary
contusion may mask diaphragm
injury
Esophageal injury Chest pain; mediastinal air on
imaging; crepitus
delayed fever
Operative repair Delayed diagnosis

249 of 27
Thoracic Trauma
4
• 250 mL of IV fluids given
• Vital signs: BP 110/70; HR 110; RR 18
• O2 sat 91% on nonrebreather mask

250 of 27
Thoracic Trauma
4
Which of the following treatments is best for pulmonary
contusion/flail chest?
A. Beta blockers
B. Massive fluid resuscitation
C. Immediate nebulizer treatment
D. Supplemental oxygen, pain control, and recognition of
the potential for respiratory failure

251 of 27
Thoracic Trauma
4
Your institution has the capability to care for this patient, and
you order a CT scan for further evaluation.

252 of 27
Thoracic Trauma
4
Case Scenario #2
25-year-old male, high-speed MVC
Awake and responds to questions, complaining of chest
pain and shortness of breath, gurgling sounds L lung base.
BP 102/76; HR 134; O2 sat 93% on oxygen by face mask
Chest x-ray
M
I
S
T

253 of 27
Thoracic Trauma
4
1. What abnormalities do you
note on the chest film?

254 of 27
Thoracic Trauma
4
2. What is the treatment for a
traumatic diaphragm injury?
3. Aside from the tracheal
deviation to the right seen on
the chest film, what other signs
and x-ray findings might one see
in a patient with traumatic
aortic disruption?
Case Details
M
25-year-old male, high-speed
MVC
Awake and responds to
questions, complaining of
chest pain and shortness of
breath, gurgling sounds L lung
base.
BP 102/76; HR 134; O2 sat 93%
on oxygen by face mask
Chest x-ray
I
S
T

255 of 27
Thoracic Trauma
4
CT scan shows blunt aortic injury

256 of 27
Thoracic Trauma
4
1. What is the expected hemodynamic
impact of a contained aortic disruption
from blunt trauma?
2. If a patient with a known contained
aortic disruption from blunt trauma
becomes hypotensive, what should you
consider?
3. What therapeutic steps should a clinician
consider when managing a traumatic
aortic disruption?
Case Details
• CT scan shows blunt
aortic injury

257 of 27
Thoracic Trauma
4
• Discussion with anesthesiology re: management of the
patient’s aortic injury
• Patient undergoes repair of his diaphragmatic injury via
laparotomy
• The following day, he undergoes endovascular repair of his
aortic injury
• He does well after 2 weeks in the ICU and is discharged home

258 of 27
Thoracic Trauma
4
Any Questions?

259 of 27
Thoracic Trauma
4
Review Objectives
1. Apply the ATLS principles to the management of a patient with thoracic
trauma.
2. Recognize the important life-threatening injuries in a patient with thoracic
trauma.
3. Evaluate the case scenario of a patient with thoracic trauma to identify
immediate life-threatening injuries.
4. Discuss the clinical findings and adjunctive studies that may be useful during
the secondary survey in a patient with thoracic trauma.

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Thoracic Trauma
4
Key Learning Points
1. It is important to recognize thoracic life-threatening problems in
polytrauma patients.
2. Most immediate thoracic life-threatening problems can be recognized
without special testing and may be treated with:
• airway control
• decompression and/or
• fluid resuscitation
3. Potential life-threatening problems can become immediate life-
threatening problems if untreated (e.g., a simple pneumothorax can
become a tension pneumothorax).

TRAUMA – ABDOMINAL &
PELVIC INJURIES
Kelly Smith, RN, MICN, CEN
Emergency Medicine

5 Abdominal and Pelvic Trauma Tenth Edition

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Abdominal and Pelvic Trauma
5
When uncontrolled or unrecognized, blood loss from
abdominal and pelvic injuries can result in preventable
death.

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5
Objectives
1. Identify the anatomic regions of the abdomen that are critical in assessing and managing
trauma patients.
2. Discuss the risk for abdominal and pelvic injuries based on the mechanism of injury.
3. Identify patients who require surgical consultation and possible surgical and/or catheter-
based intervention.
4. Determine appropriate diagnostic procedures to ascertain if a patient has ongoing
hemorrhage and/or other injuries that can cause delayed morbidity and mortality.
5. Formulate an acute management plan for abdominal and pelvic injuries utilizing a case
scenario.
6. Discuss the importance of early identification and emergent management of pelvic
hemorrhage.

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5
Case Scenario
28-year-old male, helmeted
motorcyclist, high-speed collision,
head-on into the side of a vehicle that
pulled out in front of him
Patient reports brief loss of
consciousness, complains of pain in
chest, abdomen, and pelvis
BP 100/75; HR 115; RR 20, and GCS 15
Backboard and c-collar
M
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1. What are your priorities for
management of this patient?
2. What is your interpretation
of the vital signs?
Case Details
M
head-on into the side of a vehicle
that pulled out in front of him
consciousness, complains of pain
in chest, abdomen, and pelvis
BP 100/75; HR 115; RR 20, and
GCS 15
I
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5
3. What is your initial therapy
for this patient?
Case Details
M
head-on into the side of a vehicle
that pulled out in front of him
consciousness, complains of pain
in chest, abdomen, and pelvis
BP 100/75; HR 115; RR 20, and
GCS 15
I
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5
• EMS reports:
o Patient found 10 feet (3 meters) from his motorcycle
o Patient lying on R side, wearing a helmet
o Had been travelling at 45 mph (70 kph)
• Patient reports:
o Hard R sided landing, brief LOC
o No allergies, no previous medical history or current
medications

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5
1. Based on the reported
mechanism of injury, what
intra-abdominal and/or pelvic
injury is the patient likely to
have sustained?
• Patient found 10 feet (3 meters)
from his motorcycle
• Patient lying on R side, wearing a
helmet
• Had been travelling at 45 mph (70
kph)
• Hard R sided landing, brief LOC
• No allergies, no previous medical
history or current medications
Case Details

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5
1. How would the risk of intra-
abdominal injury change if the
patient described striking the
handlebar into the
epigastrium?
2. How would the risk of intra-
abdominal injury change if a
penetrating injury was
observed?
• Patient found 10 feet (3 meters)
from his motorcycle
• Patient lying on R side, wearing a
helmet
• Had been travelling at 45 mph (70
kph)
• Hard R sided landing, brief LOC
• No allergies, no previous medical
history or current medications
Case Details

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On examination:
• Right-sided lower chest tenderness
• Contusions, R chest, abdomen, and flank
• Tender R upper quadrant, R flank, and suprapubic region
• Pain on palpation of the anterior pelvis
• No blood at the urethral meatus
• Rectal examination is normal.
• Vital signs following 500 ml of crystalloid solution: BP 110/75; HR 100;
RR 20; GCS 15

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5
1. How should you assess the abdomen
and pelvis for injury and as
potential sources of bleeding?
2. Based on your knowledge of
anatomy, the mechanism of injury,
and this patient’s physical
examination, what abdominal
and/or pelvic injuries are most
likely?
3. Is a FAST exam indicated at this
stage?
• Contusions, R chest, abdomen, and
flank
• Tender R upper quadrant, R flank, and
suprapubic region
• Vital signs following 500 ml of
crystalloid solution: BP 110/75; HR
100; RR 20; GCS 15
Case Details

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5
4. If this patient were female, what
other examination would be
relevant?
flank
suprapubic region
100; RR 20; GCS 15
Case Details

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5
5. What radiological investigations
would be appropriate to arrange
now?
flank
suprapubic region
100; RR 20; GCS 15
Case Details

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5
• Your institution has full surgical and radiological capabilities
• Abdominal CT: grade III liver injury, R rib fractures, bilateral
pelvic rami fractures
• Surgical consultation obtained
• Vital signs: BP normal; HR 100
• A total of 1.0 L of crystalloid solution given

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5
1. Is emergent laparotomy warranted
in this patient?
• Your institution has full surgical
and radiological capabilities
• Abdominal CT: grade III liver
injury, R rib fractures, bilateral
• A total of 1.0 L of crystalloid
solution given
Case Details

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5
2. What clinical changes in this
patient would indicate the need for
operation, other therapies, or
additional investigations regarding
the abdominal and pelvic injuries?
solution given
Case Details

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5
3. How would your management
change if the CT scan identified
contrast extravasation suggesting
bleeding in the pelvis?
solution given
Case Details

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5
• Emergent laparotomy not required; nonoperative management
undertaken
• Patient admitted to ICU for monitoring, pain control, and
respiratory care
• Hemodynamics normal over 24 hours, transferred to the ward
• Physical therapy for the pelvic fractures
• Patient discharged home on day 6

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Any Questions?

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5
Review Objectives
1. Identify the anatomic regions of the abdomen that are critical in assessing and managing
trauma patients.
2. Discuss the risk for abdominal and pelvic injuries based on the mechanism of injury.
3. Identify patients who require surgical consultation and possible surgical and/or catheter-
based intervention.
4. Determine appropriate diagnostic procedures to ascertain if a patient has ongoing
hemorrhage and/or other injuries that can cause delayed morbidity and mortality.
5. Formulate an acute management plan for abdominal and pelvic injuries utilizing a case
scenario.
6. Discuss the importance of early identification and emergent management of pelvic
hemorrhage.

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5
Key Learning Points
1. Mechanism of injury is critical when considering abdominal and/or pelvic
injury.
2. Thorough examinations of the chest, abdomen, and pelvis (anterior, lateral,
posterior, and perineum) are required to avoid missing significant injuries.
3. Appropriate diagnostic procedures should be employed.
4. Surgical intervention is assessed via clinical findings and the patient’s
response to management.
5. Early identification and emergent management of pelvic hemorrhage can be
lifesaving.

TRAUMA – HEAD
INJURIES
Louis Tran, MD, FACEP
Emergency Medicine

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Head Trauma
6
The primary goal of treatment for patients with suspected
traumatic brain injury is to prevent secondary brain injury.

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Head Trauma
6
Objectives
1. Recognize the GCS score that corresponds to a severe head injury and indicates a
comatose patient.
2. Identify the different types of intracranial bleeding seen on CT that are associated
with traumatic brain injury.
3. Discuss the role of supplemental oxygen and systolic blood pressure maintenance in
limiting secondary brain injury.
4. Describe the management of intracranial hypertension associated with the mass
effect of blood or brain swelling.
5. Discuss the indications for early, rapid transfer to a center equipped to manage a
patient with brain injury.

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Head Trauma
6
Case Scenario
23-year-old male, fell from bicycle, hitting head on curb; no helmet
10 cm laceration to the L temporal-parietal region
Initially able to say his name. HR 115; BP 100/60; O2 sat 88%; GCS 12
(E3V3M6)
Two hours after transport to local hospital, patient has sonorous respirations;
HR 120; BP 100/70; GCS 6 (E2V1M3)
IV cannulas in situ, O2 via nasal prongs, 200mLs crystalloid infused
M
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Head Trauma
6
1. What are the initial
priorities in the
management of this
patient?
Case Details
M
23-year-old male, fell from bicycle, hitting
head on curb; no helmet
10 cm laceration to the L temporal-parietal
region
Initially able to say his name. HR 115; BP
100/60; O2 sat 88%; GCS 12 (E3V3M6)
Two hours after transport to local hospital,
patient has sonorous respirations; HR 120; BP
100/70; GCS 6 (E2V1M3)
IV cannulas in situ, O2 via nasal prongs,
200mLs crystalloid infused
I
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T

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Head Trauma
6
2. What are the signs
that the patient’s
injury is progressing?
Case Details
M
23-year-old male, fell from bicycle, hitting
head on curb; no helmet
10 cm laceration to the L temporal-parietal
region
Initially able to say his name. HR 115; BP
100/60; O2 sat 88%; GCS 12 (E3V3M6)
Two hours after transport to local hospital,
patient has sonorous respirations; HR 120; BP
100/70; GCS 6 (E2V1M3)
IV cannulas in situ, O2 via nasal prongs,
200mLs crystalloid infused
I
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Head Trauma
6
• Given 1 L normal saline
O2 Sat 94%

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Head Trauma
6
1. How do you monitor this patient’s
neurological status?
• Vital signs: HR 100;
BP 100/70; O2 Sat 94%
Case Details

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Head Trauma
6
2. What other injuries and physical
exam findings may suggest cranial
and intracranial injury?
• Vital signs: HR 100;
BP 100/70; O2 Sat 94%
Case Details

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Head Trauma
6
• Head, c-spine and abdominal CTs performed.
• Head CT: temporal bone fracture, epidural hematoma, 1 cm of
midline shift
• C-spine normal

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Head Trauma
6
1. What types of intracranial
hemorrhage can be identified
on CT scan?

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Head Trauma
6
2. What CT scan findings are
indicative of severe head injury
that may require intervention?
• Head, c-spine and
abdominal CTs performed.
• Head CT: temporal bone
fracture, epidural
hematoma, 1 cm of
midline shift
• C-spine normal
Case Details

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Head Trauma
6
• Thoracoabdominal CT scan normal
• Initial management includes:
o elevating the head of bed
o sedation with short-acting medications
o frequent neurological examinations

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Head Trauma
6
1. What are the initial
management options for this
patient with severe brain
injury and how do these differ
from mild and moderate brain
injury?
• Thoracoabdominal CT scan
normal
• elevating the head of bed
• sedation with short-acting
medications
• frequent neurological
examinations
Case Details

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Head Trauma
6
2. What are the indications for
transferring a patient with a
head injury to a center with a
higher level of care?
• Thoracoabdominal CT scan
normal
• elevating the head of bed
• sedation with short-acting
medications
• frequent neurological
examinations
Case Details

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Head Trauma
6
• Neuro exam shows progression to extensor
posturing.
• Repeat CT scan shows new subdural
hematoma with associated mass effect and
midline shift.
• Herniation appears imminent without
treatment.
• Patient requires a higher level of care and
rapid transfer to neurosurgeon.

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Head Trauma
6
What are the initial
treatment options that may
protect the brain from
ongoing swelling?
• Neuro exam shows progression to
extensor posturing.
• Repeat CT scan shows new subdural
hematoma with associated mass
effect and midline shift.
• Herniation appears imminent
without treatment.
• Patient requires a higher level of
care and rapid transfer to
neurosurgeon.
Case Details

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Head Trauma
6
• Neurosurgeon recommends 0.5 g/kg mannitol and adjusting
PaCO2 to 30 to 35 mm Hg.
• Patient is immediately transported for emergency craniotomy.
• Patient underwent successful evacuation of his intracranial
hematoma.
• He was discharged to a rehabilitation center for ongoing therapy.

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Head Trauma
6
Any Questions?

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Head Trauma
6
Review Objectives
1. Recognize the GCS score that corresponds to a severe head injury and indicates a
comatose patient.
2. Identify the different types of intracranial bleeding seen on CT that are associated
with traumatic brain injury.
3. Discuss the role of supplemental oxygen and systolic blood pressure maintenance in
limiting secondary brain injury.
4. Describe the management of intracranial hypertension associated with the mass
effect of blood or brain swelling.
5. Discuss the indications for early, rapid transfer to a center equipped to manage a
patient with brain injury.

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Head Trauma
6
Key Learning Points
• GCS score is an objective, reproducible measurement of brain injury severity.
• GCS of 8 or less is considered severe and indicative of a comatose patient.
• Consider a CT scan of the head for any trauma patient with suspected traumatic
brain injury.
• Initial management of intracranial hypertension includes:
• elevation of the head of bed
• sedation
• selective administration of mannitol and hypertonic saline

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Head Trauma
6
Key Learning Points
• Minimize secondary brain injury by:
• adequate oxygenation (supplemental oxygen)
• ensuring brain perfusion: SBP > 100 mm Hg (age 50-69) or > 110 mm Hg (15 –
49 and older than 70)
• If no neurosurgical capability, consider early, rapid transfer

TRAUMA – SPINE &
SPINAL CORD INJURIES
Louis Tran, MD, FACEP
Emergency Medicine

7 Spine and Spinal Cord Trauma Tenth Edition

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Spine and Spinal Cord Trauma
7
Because spine injury can occur with both blunt and penetrating
trauma, and with or without neurological deficits, it must be
considered in all patients with multiple injuries. These patients
require restriction of spinal motion to protect the spine from
further damage until spine injury has been ruled out.

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7
Objectives
1. Apply the ABC principles of ATLS when assessing a patient for spine injury.
2. Identify a common mechanism and type of spinal injury.
3. Describe the typical signs and symptoms of a patient with a spinal cord
injury.
4. Describe the technique and importance of documentation of a potential
spinal injury.
5. Describe the appropriate initial treatment of patients with spinal injuries.
6. Determine the appropriate disposition of patients with spine trauma.

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7
Case Scenario
28-year-old male fell 5 meters (16
feet) from scaffolding, wearing hard
hat; bystander reports patient landed
head-first, with neck hyperextended
None reported
Skin warm; breathing shallow; not
moving arms or legs; Vital signs: BP
80/62; HR 58; RR 28; GCS 15
None Reported
M
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7
1. What injuries has the patient
likely sustained?
2. What other mechanisms of
injury are associated with
spinal cord trauma?
3. What types of shock are
potentially present in this
patient?
Case Details
M
feet) from scaffolding, wearing
hard hat; bystander reports patient
landed head-first, with neck
hyperextended
None reported
moving arms or legs; Vital signs:
BP 80/62; HR 58; RR 28; GCS 15
None Reported
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7
4. How should you initially
manage this patient?
5. What would you do if the
patient was not breathing?
Case Details
M
hyperextended
None reported
BP 80/62; HR 58; RR 28; GCS 15
None Reported
I
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7
6. Which signs and symptoms
are concerning for a spinal
injury in this patient?
7. What other signs and
symptoms not previously
mentioned may be
associated with the presence
of a spinal cord injury?
Case Details
M
hyperextended
None reported
BP 80/62; HR 58; RR 28; GCS 15
None Reported
I
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7
Peripheral neurologic exam:
• Patient unable to move or feel legs
• Patient can move fingers and wrists bilaterally
• Weak L triceps extension
• Patient unable to move R elbow
• Patient able to feel fingers and thumbs
bilaterally
• Patient unable to feel inner arms above the
elbows

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7
1. At what level is the suspected
spinal lesion?
2. What resources are available to
assist with determining the level
of spinal injury?
3. Why is the exam different
between the right and left upper
extremities?
• Patient unable to move or feel
legs
• Patient can move fingers and
wrists bilaterally
• Weak L triceps extension
• Patient unable to move R
elbow
• Patient able to feel fingers and
thumbs bilaterally
• Patient unable to feel inner
arms above the elbows
Case Details

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7
4. What are important aspects of
documenting the neurologic
examination?
5. Why is it important to accurately
and thoroughly document the
neurologic examination findings?

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7
• Patient is spinal motion restricted
• 1 L of crystalloid fluid is given
• Vital signs: BP 100/64; HR 62; RR 28; GCS 15

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7
1. What imaging would you request
for this patient?
2. What tools are available to assist
with decisions regarding spine
imaging?
• Patient is spinal motion
restricted
• 1 L of crystalloid fluid is
given
• Vital signs: BP 100/64; HR
62; RR 28; GCS 15
Case Details

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7
• Negative chest x-ray, pelvic x-ray, and FAST exam
• CT scan unavailable.
• Lateral c-spine x-ray: C6 fracture with anterior displacement.
• Patient placed in c-collar with mobility restrictions
• Vital signs: BP 80/62; HR 58; RR 28; GCS 15

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7
How do you manage the
patient’s ABCs at this point?
• Negative chest x-ray, pelvic
x-ray, and FAST exam
• CT scan unavailable.
• Lateral c-spine x-ray: C6
fracture with anterior
displacement.
• Patient placed in c-collar
with mobility restrictions
• Vital signs: BP 80/62; HR 58;
RR 28; GCS 15
Case Details

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7
• Following additional 1 L of IV crystalloid, BP remains 80/50, HR
45
• RR increased to 30
• Patient complains of shortness of breath
• ABGs: PCO2 50 mm Hg

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7
1. What interventions are
indicated at this facility?
2. Does this patient require
transfer? What is the rationale
for this decision?
• Following additional 1 L
of IV crystalloid, BP
remains 80/50, HR 45
• RR increased to 30
• Patient complains of
shortness of breath
• ABGs: PCO2 50 mm Hg
Case Details

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7
• Systolic BP improves to 110/65 with vasopressor support
• O2 sat 98% on 30% oxygen
• Repeat FAST negative
• Transferred to definitive care, where C6 and T6 fractures identified
• Admitted to ICU
• Surgery for C6 fracture, nonoperative management of T6 fracture
• Transferred to a spinal cord rehabilitation center

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7
Any Questions?

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7
Review Objectives
1. Apply the ABC principles of ATLS when assessing a patient for spine injury.
2. Identify a common mechanism and type of spinal injury.
3. Describe the typical signs and symptoms of a patient with a spinal cord
injury.
4. Describe the technique and importance of documentation of a potential
spinal injury.
5. Describe the appropriate initial treatment of patients with spinal injuries.
6. Determine the appropriate disposition of patients with spine trauma.

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7
Key Learning Points
1. Attend to the life-threatening injuries identified in the primary survey while
minimizing movement of the spine.
2. Assume possible spinal injury until clinical and/or radiographic evaluation can be
completed (decision tools such as Canadian C-Spine Rules or NEXUS may be used).
3. Be as specific and accurate as possible when describing and documenting the level of
neurologic injury (ASIA tool is extremely useful).
4. High spinal cord injuries may be associated with respiratory failure and/or neurogenic
shock, which must be addressed prior to transfer.
5. Consider obtaining early consultation with a spine surgeon when a spinal injury is
suspected and/or detected.

TRAUMA –
MUSCULOSKELETAL
INJURIES
Stephanie Loe, MD
Emergency Medicine

8 Musculoskeletal Trauma Tenth Edition

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Musculoskeletal Trauma
8
Injuries to the musculoskeletal system are common in trauma
patients. The delayed recognition and treatment of these
injuries can result in life-threatening hemorrhage or limb loss.

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8
Objectives
1. Explain the significance of musculoskeletal injuries in patients with multiple
injuries.
2. Outline the priorities of the primary survey, resuscitation and secondary
survey of patients with extremity injuries.
3. Identify the adjuncts needed in the immediate treatment of life-threatening
extremity hemorrhage.
4. Explain the principles of the initial management of limb-threatening
musculoskeletal injuries.

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8
Case Scenario
38-year-old female (102 kg), restrained
driver, high-speed, head-on collision with
large truck
Prolonged extrication, marked deformity
R thigh, open fracture R lower leg.
Awake and alert, in severe pain;
Vital signs: HR 120; BP 90/50; RR 22;
GCS 15
Two large-bore IVs in upper extremities,
resuscitation with isotonic fluids
M
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8
• Airway and breathing are OK
• Lower limb actively bleeding,
dressing applied
• Vital signs after fluids: HR
130; BP 80/40; RR 24; GCS 14
• Chest x-ray, pelvic x-ray, and
FAST exam negative

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8
1. What are the priorities for
this patient during the
primary survey and
resuscitation?
2. How will you assess the
injured extremities at this
point?
Case Details
• Lower limb bleeding,
dressing applied
130; BP 80/40; RR 24; GCS
14
FAST exam negative

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8
3. How much blood loss would
you expect from this
patient’s extremity injuries,
and what is the best way to
control it?
4. How should femur and tibial
shaft fractures be stabilized?
Case Details
• Lower limb bleeding,
dressing applied
130; BP 80/40; RR 24; GCS
14
FAST exam negative

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8
• Right dorsalis pedis and posterior tibial pulses absent
• Pulses remain absent after splinting.
• Blood soaking through dressings, R lower leg
• Dressing taken down, pulsatile bleeding noted
• Direct pressure applied to wound, followed by gauze packing
• Dressing quickly becomes saturated with blood again

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8
What is the next step in the
management of this patient’s
uncontrolled extremity
hemorrhage?
Case Details
• Right dorsalis pedis and posterior
tibial pulses absent
• Pulses remain absent after splinting.
• Blood soaking through dressings, R
lower leg
• Dressing taken down, pulsatile
bleeding noted
• Direct pressure applied to wound,
followed by gauze packing
• Dressing quickly becomes saturated
with blood again

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8
• Tourniquet applied and time of placement documented
• Bleeding controlled
• Distal pulses not palpable

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8
How would you manage the patient
now?
• Tourniquet applied
and time of placement
documented
• Bleeding controlled
• Distal pulses not
palpable
Case Details

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8
• Patient’s hemodynamics improve with IV fluids
• Secondary survey begins
• Awaiting transfer due to no surgical capabilities at this facility

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8
1. How would you identify any limb-
threatening injuries or other
extremity injuries during the
secondary survey?
2. What x-rays should be ordered for
this patient prior to transfer?
• Patient’s
hemodynamics
improve
• Secondary survey
begins
• Awaiting transfer due
to no surgical
capabilities at this
facility
Case Details

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8
• X-rays of the patient’s extremities are obtained.
• Radiographs do not cause a delay in transfer.

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8
• Vital signs: HR 105; BP 110/70; RR 24; GCS 15.
• Bleeding is controlled with tourniquet.
• Urgent transfer already initiated.
• No known drug allergies.

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8
1. What else should be done
prior to transfer
2. What antibiotics would you
give and at what dose?
3. How can you decrease the
patient’s discomfort and
pain?
Case Details
RR 24; GCS 15.
• Bleeding is controlled with
tourniquet.
• Your facility does not have the
resources to manage the
patient’s injuries, so urgent
transfer initiated.

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8
• The patient is transferred to the nearest trauma center, where a
trauma surgeon and an orthopedic surgeon are available to take
the patient to the operating room immediately
• Vital signs: HR 105; BP 110/70; RR 24; GCS 15
• Bleeding is controlled with tourniquet
• Patient received antibiotics prior to transfer

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8
1. What measures need to be
taken at the receiving
hospital?
Case Details
• Patient is transferred to the nearest
trauma center, where a trauma
surgeon and an orthopedic surgeon
are available to take the patient to
the operating room immediately.
• Vital signs: HR 105; BP 110/70; RR
24; GCS 15.
• Bleeding is controlled with
tourniquet.
• Patient received antibiotics prior to
transfer.

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8
2. How can you make an early
diagnosis of compartment
syndrome?
3. What is the treatment for
compartment syndrome?
• Patient’s
hemodynamics
improve
• Secondary survey
begins
• Awaiting transfer due
to no surgical
capabilities at this
facility
Case Details

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8
Patient taken to the operating room for urgent evaluation of
vascular injury, wound washout and external fixation of
fracture.

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8
Any Questions?

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8
Review Objectives
1. Explain the significance of musculoskeletal injuries in patients with multiple
injuries.
2. Outline the priorities of the primary survey and resuscitation of patients with
extremity injuries.
3. Identify the adjuncts needed in the immediate treatment of life-threatening
extremity hemorrhage.
4. Describe key elements of the secondary survey of patients with
musculoskeletal trauma.
5. Explain the principles of the initial management of limb-threatening
musculoskeletal injuries.

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8
Key Learning Points
• Hemorrhage from long bone fractures can be significant
• Early splinting helps to control blood loss, reduce pain, and prevent
further neurovascular compromise and soft tissue injury
• Early weight-based dosing of antibiotics for patients with open
fractures
• Compartment syndrome is a clinical diagnosis, and the treatment is
fasciotomy.

TRAUMA – BURN
INJURIES
Emeka Anyanwu, MD
UC San Diego Health

+
Objectives
 Review epidemiology and mechanisms of burn to include inhalation injury
 Review depths of burns and how to calculate TBSA
 Understand the principles of fluid resuscitation and how to calculate Parkland Formula
 Review ABA Referral Criteria
 Know how to prepare the burned patient for transfer
 Case studies

+
Epidemiology of Burns
 Burns and fires are the 3rd leading cause of accidental death in all age groups
 2 million people a year are burned
 80% of these are less than 20% TBSA
 3,400 fire/burn/smoke inhalation deaths/year
 About 50,000-75,000 patients require hospitalization
 450+ admissions at UCSD per year
 Children 5 years old or younger account for ½ of all burn admissions
 100,000’s - Outpatients per year
 3,000+ outpatient visits per year at UCSD

+
Etiologic Types of Burns and Wounds
 Scalds
 Non-burn (SJS, Nec. Fasciitis,
chronic wound)
 Electrical
 Flame
 Structural/Car Fire
 Welding
 Propane/Gas explosion
 Open flame
 Friction/road rash
 Chemical
 Lightning strike
 Self Inflicted/Suicide
 Assault
 Smoking
 **E-cig burns **

+
Scalds-Water Heater Temperature

+
Smoke Inhalation Injury
 Smoke consists of combustible products, asphyxiates and
carbonaceous debris
 Greater effect on mortality than either patient age or surface area
burned
 Inhalation injuries present in 25-50 % of burn
patients
 Identified in 60-70% of
patients who die in burn
centers

+
Clinical Signs of Inhalation Injury
 Upper airway edema is the earliest consequence of
inhalation injury
 High index of suspicion, (ie. fire in a closed space)
 Concurrent oral pharyngeal or facial burns
 Carbonaceous deposits/soot in
oropharynx or nares
 Patient with an impaired
sensorial or agitation
 Hoarsenes, tachypnea, dysphagia

+
Diagnosis of Inhalation Injury Bronchoscopy

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