Trauma Practice Guidelines

Trauma Practice Guidelines &
Algorithms
State of Nebraska
Rev. January 2008
Nebraska Department of Health & Human Services

Nebraska State Office Building
301 Centennial Mall South Third Floor
PO Box 95026
Lincoln, NE 68509-5026
Trauma Practice Guidelines & Algorithms

State of Nebraska
Table of Contents
Trauma Team Roles & Responsibilites
4-5
Primary and Secondary Assessment
6-9
Trauma Scoring
10-12
Chest Trauma Evaluation
13-16
Blunt Chest Trauma Algorithm
17
Penetrating Chest Trauma Arrest Algorithm
18
Unstable Blunt Abdominal Injury Algorithm
19
Traumatic Brain Injury
20-24
Widened Mediastinum
25
Blunt Cardiac Injury
26
Blood and Blood Product Transfusion
27
Hypothermia
28
X-rays on Multiple Trauma Patients
29
Pelvic Fractures
30
Open Pelvic Fracture Algorithm
31
Pelvic Fracture (Bony Instability) Algorithm
32
Spine Protocol Algorithm
33
Cervical Spinal Clearance
34
Spinal Cord Injuries
35-38
Cervical, Thoracic and Lumbosacral Spine Injuries
39-40
Abdominal Trauma Assessment
41-43
Stab Wound to Abdomen Algorithm
44
Gunshot Wound to Abdomen Algorithm
45
Eye Injuries
46
Pediatric Trauma
Trauma in Pregnancy
47-48
49
Burned Patients
50-53
Deep Venous Thrombosis Prophylaxis
54
Open Fracture
55
Tetanus Immunization
56
Penetrating Neck Injury
57
Maxillofacial Injuries
58
Dental Algorithm Tooth Avulsion
59
Internet Bibliography
60
Guidelines for the Care of Trauma Patients

The following trauma guidelines, suggestions, are to assist with care and the management of
the trauma patient. Each individual incident will dictate various approaches to the care of the
Trauma patient. The resources of the facility, personnel and needs of the patient may dictate
which guidelines are appropriate to best manage the care of the trauma patient in each
circumstance.
Trauma Team Members Roles and Responsibilities
Team Leader:
Usually an Emergency Medicine attending or Trauma Surgeon. The Team Leader will direct the
course of the Primary Survey and resuscitation and expect a response to his/her questions; all
questions or information should be directed to this person.
1.
Prior to patient arrival:

a) The trauma team assembles with specific role assignments
b) The most senior surgeon informs anesthesia and OR if the patient is to go straight to the
OR
c) Reviews information known regarding patient
2.
Primary assessment and resuscitation:
a) Receives verbal report directly from ambulance personnel
b) Performs the Primary Survey
c) Categorizes the injuries
d) Orders initial X-rays, determines order of priority, orders labs and blood
e) Determines if Trauma Center transfer is to occur
3.
Secondary assessment and definitive care:
a) Performs the Secondary Survey
b) Decides on the need for and priority of further X-rays/additional procedures
c) Contacts consultants as needed
d) Decides on the disposition of the patient & discusses with consultants
e) Talks with family
f) Appropriate documentation
Primary RN:
a) Directs/supervises all non-physician personnel
b) Monitors vital signs (BP, P, RR, pulse oximetry, ongoing neuro signs, etc.)
c) May insert IVs
d) Communicates with/reassures patient
e) Communicates assessments and interventions to the Leader
f) Accepts medical orders from the Leader
g) Administers medications at the direction of the Leader
h) May insert naso/oro-gastric tube, Foley, etc.
i) Delegates duties to nursing and ancillary personnel as appropriate
j) Monitors effects of medications and treatments/communicates patient response to
Leader
k) Anticipates and sets up equipment and procedure trays
l) Assists with blood warming equipment and administration of blood
m) Communicates problems, needs, and current status to ED charge nurse
n) Responsible for proper completion of the Trauma Flow Sheet
Respiratory therapist:
a) Responsible for airway maintenance and oxygenation
b) Assists/performs tracheal intubation
c) Performs manual bag ventilation
d) Monitors patient respiratory and oxygenation status
e) Suctions airway
f) Provides ventilatory set-ups
g) Coordinates ventilator set-ups for other areas where patient is to move
h) Performs arterial puncture for ABG sampling as directed by Team Leader
i) Communicates assessments and interventions to the Leader
Radiology Tech:
a) Performs X-rays as directed by Leader
b) Displays radiologic films or digital images in the resuscitation room
c) May leave when excused by Leader (no further X-rays anticipated)
Laboratory Technologist or Phlebotomist:
a) Performs venous or arterial puncture for blood collection as desired
b) Labels and transports lab specimen to lab for analysis
c) Obtains and transports Type O Negative or Type Specific blood to the resuscitation room
d) Performs Point of Care testing at the direction of the Team Leader
Recorder:
a) This person may be a PCT (patient care technician), pre-hospital emergency care
provider or additional nurse
b) Documents assessments, tests, and interventions on the Trauma Flow sheet
c) Directs necessary questions about findings (for purposes of good documentation) to the
Leader
d) May function as an assistant in obtaining supplies and equipment
e) Performs other duties as directed by the Primary RN
Chaplain or Social Worker:
a) Assists with identifying patient
b) Contacts patients family
c) Keeps appropriate family members informed of patients status
d) Facilitates psychosocial care of patient, family and visitors
e) Coordinates family visits to the bedside with the Leader and Primary Nurse
f) Supports the grieving process
g) May assist with patient/family interviews regarding violence
All trauma patients should be assessed using primary and secondary survey procedures.
Priorities of care are airway with cervical spine control, ventilation with oxygenation, and
circulation. The secondary survey is a head to toe assessment of all injuries and potential
injuries. During the assessment, priority in treatment is given to conditions found in the primary
survey with identification of life-threatening injuries found during the secondary survey.
Primary and Secondary Assessment

Airway with C-spine Control
Assessment:
1. Examine oral pharynx
2. Listen for stridor
3. Ask patient to speak
Management:
1. Chin Lift
2. Clear airway of foreign debris, blood, mucus, teeth, vomitus
3. Oral/nasal airway
4. Bag-valve-mask (BVM) with 100% oxygen-ventilation initiated if the respiratory rate is
<10 or > 24
5. Endotracheal intubation
a. Tracheal intubation if patient is not breathing spontaneously on their own
b. Intubation if the possibility exists of immediate airway compromise
c. Verify Placement
i. Visualize tube passing through vocal cords
ii. Bilateral breath sounds present
iii. Absence of breath sounds over epigastrium
iv. ETCO2
v. Chest x-ray in secondary survey
6. Laryngeal mask airway (LMA) if available
7. Cricothyroidotomy or (rarely) tracheostomy
Breathing:
Supplemental oxygen with appropriate airway adjuncts
Bag-valve-mask with reservoir and 100% oxygen
Chest tube (needle decompression) insertion with pneumothorax.
Ventilator
Assessment:
1. Expose chest
2. Rate and depth of respirations
3. Inspection and palpation for bilateral chest movement
4. Subcutaneous emphysema
5. Auscultation at apex and bases bilaterally
6. Pulse oximetry
7. ETCO2
Management:
1. Oxygen administration
2. Alleviate tension pneumothorax
a. Needle decompression
b. Chest tube insertion
3. Seal open pneumothorax
a. Chest tube insertion
b. Ventilator Support
4. ABGs
Circulation:
Control of obvious bleeding
Vascular access with two large bore IVs
CPR for arrest patients
Pericardiocentesis for cardiac tamponade

Assessment:
1. Pulse
Rate and regularity
Quality and location
2. Color of skin
3. Capillary Refill
4. Blood Pressure
5. Auscultate heart tones
Management:
1. Bleeding control
Direct pressure to bleeding source
2 large bore IVs
Warmed Ringers Lactate or Saline solution
Blood replacement as indicated
Chest x-ray for hemothorax or pneumothorax
o Check placement of chest tube
Lab for trauma panel, Hgb, type and cross (type and hold)
Disability:
Cervical Spine precautions
Check for gross motor movement
Assessment:
1. Level of consciousness
2. Pupils size and reaction
3. Glasgow Coma Score: Best eye-verbal-motor
4. AVPU
5. Motor and sensory function (vertical and horizontal symmetry)
Management:
1. Prevent hypoxia and hypotension
2. Neurosurgery consult for brain and/or spinal cord injury
3. Consider transfer if Neurology/Neurosurgery not available
Expose and Environment:
Remove all clothing
Maintain body warmth

Management:
1. Warm oxygen, warm fluids, blanket, radiant heaters, Bair Hugger as needed
2. Monitor core temperature
Full Set of Vitals:
Blood Pressure, Pulse, Respirations, Core Temperature, Skin vitals
Nasogastic tube, urinary catheter, heart monitor, pulse oximetry

Go from Head to Toe:
Secondary Survey
Half and History:
Turn patient to inspect back
History: AMPLE, history of accident, tetanus

Transfer Criteria
Laboratory:
Full Trauma Labs should be obtained for all unstable trauma patients
1. Full Trauma Labs:
a. ABG- arterial blood gas
b. CBC-Complete blood count (hemogram)
c. Comprehensive metabolic panel (CMET)
d. Coagulation studies (PT, PTT)
e. Type and screen or type and cross
f. Blood alcohol
g. Dipstick urine for blood send urinalysis if positive
h. Urine for drugs of abuse if available locally and if results will alter therapeutic plan
i. Serum pregnancy for females puberty to menopause
2. Simple Trauma Labs:
a. CBC
b. Blood alcohol
c. Dipstick urine for blood send urinalysis if positive
d. Urine for drugs of abuse if results will alter therapeutic plan
3. Consider Blood Type and Match for Patients:
a. Type and cross for minimum of two to six units of packed red blood cells:
i.
obvious source of massive blood loss
ii.
traumatic anemia
iii.
hypotensive from hemorrhagic shock
iv.
going to the operating room for a surgical procedure that
may result in major blood loss
4. Type and Hold:
a. marginal blood loss and no anticipated further blood loss
b. operating room for a procedure with a low likelihood of blood loss
c. hypotensive at the scene but has stabilized with moderate fluid resuscitation
5. CBC:
a. significant injury with evidence of hypo perfusion or bleeding
b. follow-up on patients who had marginally low hematocrit initially or who have had slow
continued blood loss (as in a chest tube)
c. after blood transfusion
6. Renal Panel:
a. preexisting morbidity suggesting an electrolyte abnormality (medications, etc)
b. anesthetized for general anesthesia
c. suspected renal impairment
d. Brain injured patients
7. Renal Panel plus Liver Function Tests:
a. pre-existing illness suggesting abnormalities in liver function/metabolism
8. Clotting Studies (PT/PTT/platelet count):
a. suspected coagulation problems or taking anticoagulants
b. requiring massive transfusions
c. Severely head injured patients (GCS <8 or with cerebral pathology on CT scan)
9. Urinalysis:
a. hematuria on dipstick exam
b. abdominal, flank, or pelvic trauma
10. Lactate:
a. patient with evidence of tissue hypo perfusion
11. Toxicology Screen:
a. evidence of recreational drug intoxication
b. blood alcohol: All non-pediatric trauma patients
12. Arterial Blood Gas:
a. shock or who may potentially be in shock (to assess the degree of metabolic acidosis)
b. severe brain injury
c. SaO2 <90% on pulse oximetry
d. Obvious respiratory compromise baseline
e. Add Co-oximetry if trauma involved fire
TRAUMA SCORING
1.
General
a.
Should be performed on admission and RECORDED on patient with abnormal
levels of consciousness/severe injuries
b.
Assessment of pre-hospital scale should also be estimated for
Glasgow Coma Scale
c.
Neurological/Neurologic consultation should be obtained
2.
Glasgow Coma Scale

a.
Record (see below)
1.
Eye opening response (#)
2.
Verbal response (#)
3.
Motor response (#)
b.
Criteria
The Glasgow Coma Scale (GCS) has received wide usage, but it is only a rough
guide to measure changes in brain function. If a patient does not talk or follow
commands, he can be considered unconscious (but not necessarily in coma). The
three parts of the GCS are eye opening, verbal response, and best upper limb
response (for a 3-15 point spread).
NOTE:
If patient is on a respirator, do eye opening and motor only.

Glasgow Coma Scale
4
3
2
1
Eye Opening
Opens Spontaneously
To Voice
To Pain
None
5
4
3
2
1
Verbal Response
What month and year is it?
Any Month and Year
Word
Moan
None
6
5
4
3
2
1
Motor Response
Hold up two fingers.
Localizes
Nail bed pressure withdraws
Flexes
Extends
None ( flaccid )
10
3.
4.
Revised Trauma Score (RTS)

Code Value (0-12)
Glasgow
Coma Scale
(GCS)
13-15
9-12
6-8
4-5
3
Systolic
Blood pressure
mmHg
> 90
70-89
50-69
1-49
0
Respiration
per minute
times/min
10-24
25-35
>36
1-9
0
Code Value
4
3
2
1
0
RTS = Code values [Systolic B/P + Resp. + GCS]

Injury Severity Scale Only assigned after discharge
A.
Record
1.
AIS for each separate body region
a.
Head and face
b.
Neck
c.
Chest
d.
Spine
e.
Abdomen and pelvic contents
f.
Extremities and pelvic girdle
g.
Integument
ISS (Injury Severity Scale) is the sum of squares of highest three categories above. (see
page11)
Criteria
Use the revised Abbreviated Injury Scale (AIS) to grade all injuries for a given
person. (Note that the data codes of the original AIS are not used, but a new
code 6 included Maximum Severity Injuries that are currently untreatable.) Then
assign to each of the six area defined below the AIS code of the most severe
injury in that area. For example, if a person had two chest injuries, codes 1 and
3, the code for chest injury would be 3.
The Injury Severity Score (ISS) is the sum of the squares of the highest AIS code
in each of the three most severely injured areas. In illustration, a person with a
laceration of the aorta (chest AIS + 5), multiple closed long-bone fractures
(extremities AIS = 4), and retroperitoneal hemorrhage (abdomen AIS = 3), would
have an Injury Severity Score of 50 (25+16+9). (An Injury Severity Score should
not be computed for patients with any AIS 6 injuries, such as transection of the
torso. An AIS injury of 6 automatically calculated as an ISS = 75.
Head or neck injuries include injury to the brain or cervical spine, skull or cervical spine fractures,
and whiplash injuries.
Facial injuries include those involving mouth, eyes, ears, nose and facial bones.
Chest injuries and injuries to abdominal or pelvic contents include all lesions to internal organs in
the respective cavities. Chest injuries also include those to the diaphragm, rib cage, and thoracic
spine.
Injuries to the extremities or to the pelvic or shoulder girdle include sprains, fractures,
dislocations, and amputations, except for the spinal column, skull and rib cage.
Integument injuries are external injuries, including lacerations, contusions, abrasions, external
hemorrhage, and burn, independent of their location on the body surface.
The AIS is used in coding only specific individual injuries. Exceptions are made for burns and for
complaint of overall ache, stiffness or tenderness, since by their nature, these types of injuries do
not lend themselves to clear-cut boundaries of a specific body area; also, where an injury to a
single body unit is described collectively, e.g., fractured teeth, multiple fractures in the same
extremity. Refer to the Overall AIS for coding multiple injuries.
11
General -
EXAMPLE
SEVERITY
CODE
_________
0
SEVERITY
CATEGORY
_________
NONE
MINOR
MODERATE
SERIOUS (not life threatening)
SEVERE (life threatening)
CRITICAL (survival uncertain)
MAXIMUM (virtually unsurvivable)
12
Chest Trauma Evaluation

Assessment:
Oxygenation Saturation
Pulse Oximetry
End-Tidal CO2, if available
Chest x-ray-portable
FAST ultrasound, if available
Arterial Blood Gases (ABGs) if available
Primary Survey:
Airway Obstruction
Tension Pneumothorax
Open Pneumothorax
Hemothorax
Flail chest
Cardiac Tamponade
Secondary Survey:
Rib fractures
Pulmonary contusion
Tracheobronchial disruption
Esophageal disruption
Diaphragmatic disruption
Aortic injury
Blunt myocardial injury/contusion
Tension Pneumothorax:
Assessment:
Chest expansion-decreased or fixed
Diminished or absent breath sounds
Respiratory distress
Hyperresonant percussion
Trachea deviation
Management:
Decompression of thorax with needle
Placement of chest tube
Diagnosis made by physical assessment, NOT chest x-ray
Massive Hemothorax:
Assessment:
Chest expansion-decreased
Normal to diminished breath sounds
Dull to percussion, especially posteriorly
Trachea midline
Management:
Insertion of chest tube
1. Observation: < 1000 mL blood after chest tube insertion
2. Consider operative intervention
a. >1500 mL after chest tube insertion
b. >150 mL/hour drainage after chest tube insertion
3. Consider autotransfusion
4. Type and Crossmatch blood
13
Open Pneumothorax:
Assessment:
Chest expansion-decreased
Penetrating wound to chest-sucking chest wound
Chest wall defect
Diminished breath sounds on affected side
Normal to hyperresonant to percussion
Trachea midline
Management:
Closure of defect with occlusive dressing-tape 3 sides
Chest tube insertion
Operative close of chest defect
If patient decompensates, remove occlusive dressing
1. Consider development of tension pneumothorax
Pulmonary contusion:
Assessment:
Chest expansion-normal
Breath sounds-may have crackles
Normal to percussion
Trachea midline
Management:
Observation for limited injury
Mechanical ventilation as indicated for:
1. Respiratory distress
2. Impaired level of consciousness
3. Multi-system disorders
4. Concurrent abdominal injuries
5. Skeletal injuries requiring immobilization
Flail Chest:
Assessment:
Chest expansiondecreased or fixed
Diminished breath sounds
Paradoxical wall motion or asymmetrical wall motion
Poor air exchange, respiratory distress
Normal to hyperresonant to percussion
Trachea midline
Management:
Oxygenation, ensure adequate ventilation
Pain control for rib fractures
1. Analgesics
2. Intercostal block
3. Epidural
Observe for underlying lung injury
Consider operative stabilization for large flail
Cardiac Tamponade:
Assessment:
Becks Triad
1. Elevated venous pressure
2. Decreased arterial pressure
3. Muffled heart tones
Pulse Paradoxus-weakening of pulse during inspiration
Management:
Pericardiocentesis
Thoracotomy
14
Traumatic Aortic Rupture:

Assessment:
Fatal 90% acutely
Wide Mediastium > 8cm
Blurring or obliteration of aortic knob
1st and 2nd rib fractures
Deviation of trachea
Pleural cap on left
Elevation and rightward shift of left mainstream bronchus
Depression of left mainstem bronchus
Deviation of esophagus
Management:
Early cardiothoracic surgery consult
Beta blocker to control blood pressure
Surgical repair
Tracheobronchial Injuries:
Assessment:
Laryngeal trauma
1. Penetrating
2. Blunt- fracture indicated by:
a. Crepitus
b. Subcutaneous emphysema
c. Hoarseness
3. Labored respiration
Bronchial Injury:
1. Hemoptysis
2. Subcutaneous emphysema
3. Pneumothorax with persistent air leak
Management:
Maintenance of Airway
Bronchoscopy for diagnosis
Tracheostomy for laryngeal trauma
Thoracotomy for repair of tears/disruption
Esophageal Trauma:
1. Penetrating:
a. Suspected path of penetrating object
b. Pneumothorax without obvious cause
c. Particulates and food in chest tube
d. Continuous bubbling of chest tube equal on inspiration and
expiration
e. Mediastinal air
f. Blood in mouth or on nasogastric aspiration
Diaphragmatic Rupture/Herniation:
Assessment
Subtle changes on chest x-ray
Elevated left diaphragm
Air-fluid in chest
Check for location of nasograstic tube
Management
Surgical repair
15
Blunt Myocardial Injury:

Assessment:
Abnormalities on ECG
1. Consider MI
2. May mimic myocardial infarction
3. Frequent PVCs
4. Atrial Fibrillation, BBB, S-T changes
Management:
Monitor for dysrhythmia
Oxygen
12 Lead-ECG
Cardiology consult
Consider Echocardiogram
Cardiac enzymes
ACLS protocol for dysrhythmias
Further Diagnostics:
CT scan
Angiography
Bronchoscopy
16
Blunt Chest Trauma

Applies to Level I & Level II Trauma Centers
Stable Vital Signs
Unstable Vital Signs
Primary Survey
ATLS Resuscitation
Secondary Survey
Blood work Chest X-ray
Primary Survey
ATLS Resuscitation
Tube Thoracostomy
Blood work Chest X-ray
Hemothorax / Pneumothorax
Tube Thoracostomy
Observation, if < 1000 mL obtained,

Consider OR.
Stable
Signs of Mediastinal Injury
Unstable
( Hypotensive )
Contrast ( CT or Aortogram )
OR
Negative
If > 1500 mL at insertion or 150 mL for 2 3

hours,
Consider 2nd chest tube if evacuation of
Hemothorax is inadequate or if large air leak.
Observe
Consider Bronchoscopy to Rule Out

Bronchial Injury.
Positive
Cardiothoracic Consult
Operating Room
(if patient has severe head injury and / or elderly,
consider non-operative treatment)
Beta blocker (Esmolol) to Prevent Hypertension
*Note if suspect mediastinal injury is secondary to projection consider upright chest X ray when patient is stable
17
Penetrating Chest Trauma Arrest

Applies to Level I & Level II Trauma Centers
Initial Evaluation
Recent Signs of Life Within 5 -10 Minutes

Cardiac Electric Activity ( PEA Narrow )
No Recent Signs of Life / Asystole
Continue CPR
Intubation Ventilate
IV Access / Administration of Blood
Open Chest in ED Immediately ( if surgeon is available )
Open Pericardium
Internal Massage
Consider Cross Clamp Aorta, Monitoring Clamp Time is ESSENTIAL
Consider Clamp Hilum Air Leak, Bleeding.
DEAD Cease Activity
Second Survey
Response
No Response
Operating Room
DEAD Cease Activity
18
Unstable Blunt Abdominal Injury

Hypotensive Blunt Trauma
Airway Hemothorax
Decide
Massive White Out on Chest

X-ray
Moderate Hemothorax
Thoracotomy
Assess Abdomen (FAST)
Thoracotomy in ED < 70 mmHG
Laparotomy
Consider 2nd Surgical Team

for Chest
Thoracotomy in OR > 70 mmHG
19
Traumatic Brain Injury:

1. Assess Glasgow Coma Scale (for GCS 8, intubate with RSI)
2. Continue resuscitation to maintain euvolemia
3. Maintain oxygenation >95%
4. Mild hyperventilation to achieve pCO2 around 35 mmHg
Assessment:
1. History:
a. Mechanism of injury
b. Response to injury loss of consciousness & length of time
c. Use of alcohol or drug use
2. Head Exam:
a. Check for depressed skull fractures, scalp lacerations, contusions,
abrasions
b. Check for signs of Basilar Skull Fractures (hemotympanum,
Battles sign, and raccoon eyes, CSF drainage from nose or ears)
3. Neurologic Exam:
a. Glasgow Coma Scale / Level of Consciousness. This should be
assessed prior to chemical paralysis and sedation, whenever
possible
GCS 38 severe TBI; 9-12 moderate TBI: 13-15 mild TBI
Note: Because someone has a normal GCS does not
mean that they do not have TBI
b. Test cranial nerves
c. Check pupils; assess size and reactivity to light
d. Test motor/sensory function
Rectal exam
e. Test deep tendon reflexes
f. Test plantar reflexes
4. Medications:
a. Sedate with morphine/fentanyl and/or short acting benzodiazepine to
avoid agitation and protect airway
b. In consultation with Neurosurgery, consider mannitol 0.25 1gm/kg to
prevent herniation. Do not use in hemodynamically unstable patients.
Consider use of hypertonic saline solution (HTS).
c. Ativan 1 -2 mg IV doses to stop seizures
d. Cerebyx ( fosphenytoin ) 20 mg/kg IV no faster than 150 mg/min or
Dilantin ( phenytoin ) 20 mg/kg to be given over 20 minutes if
indicated for phrophylaxis against further seizures
CT scan of head, as indicated
Remove all clothing
Maintain normothermia
Warm blankets
Overhead heating lights
Warm IV fluids
Keep resuscitation room very warm ( 80 F 85 F )
Baer Hugger
Insert naso/oro-gastric tube and Foley catheter, as indicated
Management:
1. Perform primary survey according to ATLS guidelines
20
Treatment of Traumatic Brain Injury (TBI):

1.
Emergency Care:
a. Primary survey and intervention
b. Airway management
c. Cervical immobilization
d. Prevent hypoxia (pO2 < 60 mm Hg)
e. Prevent hypotension (systolic BP < 90 mm Hg). If hypotensive,
identify cause and treat
f. Maintain euvolemia with isotonic crystalloids
g. Normal Ventilation (ETCO2 35-40)
h. Glucocorticoids NOT recommended
i. Head CT: signs of herniation may include; blown pupil, sudden
decrease in GCS, agonal respirations, and a sudden decreased level
of consciousness
j. Prevent hyperthermia
k. Neurosurgery consult
l. Mannitol ( 0.25 1 gm/Kg ) for patients with clinical evidence of
impending herniation.
* DO NOT administer if patient is hypotensive. Manage hypotension
or ongoing blood loss.
* ( Consider short course of hyperventilation to ETCO2 35 )
2. Provide urgent airway for GCS 8. Hypoxia is devastating to the injured

brain.
a. Conduct a rapid, thorough neurologic exam, prior to use of sedation
and paralytics:
i.
Glasgow Coma Scale
ii.
Level of consciousness
iii.
Pupillary response
iv.
Presence of abnormal reflexes
v.
Presence of abnormal posturing
vi.
Presence of rectal tone if unable to move lower extremities
(if feasible)
vii.
Gag reflex
b. Maintain C-spine precautions including semi-rigid collar:
i.
Glasgow Coma Scale
ii.
Level of consciousness
3. Rapid Sequence Induction to Intubate for brain injured patients
a. Pre oxygenate, monitor SaO2
b. Maintain manual in-line cervical immobilization, removing C-collar to
adequately open mouth for intubation
c. Maintain cricoid pressure until tube position confirmed and cuff
inflated
d. Adequate analgesia/sedation with appropriate drugs (see chart)
*The choice of medications utilized should be determined by the
practitioner performing intubation.
He/she should use the medications with which he/she is most
familiar. (The most experienced practitioner in intubation should
be the one performing the procedure under these circumstances)
All drug regimens should have: lidocaine, analgesia, sedation,
short duration neuromuscular blocking agent and perhaps
intermediate duration neuromuscular blocking agent.
21
Sedative and Induction Agents for RSI

Medication
Dosage
Action
Time of Onset
Duration of
Etomidate
Fentanyl
Midazolam
Morphine
60 sec
60 sec
2 minutes
2-5 minutes
3 to 5 minutes
30 to 60 minutes
1-2 hours
2-3 hours
Neuromuscular Blocking Agents

Medication
Dosage
Action
Time of Onset
Duration of
Succinylcholine 1 to 2 mg/kg
Rocuronium
0.6 to 1.2 mg/kg
Vecuronium
0.15 to 0.25mg/kg
30-60 seconds
2 minutes
3 to 5 minutes
4 to 6 minutes
30 minutes
30 to 40 minutes
0.2 to 0.6 mg/kg

2 TO 10 mcg/kg
0.1 to 0.3 mg/kg
0.1 mg/kg
4. Calculate the pre intubation Glasgow Coma Scale. GCS cannot be determined
once patient is chemically altered
5. Obtain a head CT scan:
a. GCS 14
b. Any patient with focal neurologic deficit
c. Any patient with witnessed loss of consciousness >5 minutes
NOTE: CT brain is not necessary prior to transfer if clinical
examination dictates rapid transfer and CT will delay transfer.
6. CT priorities:
a. CT should be abandoned if patient requires emergent operation to
stop hemorrhage or immediately repair life-threatening injury
b. CT should be obtained to determine presence of space-occupying
clot prior to other surgeries
7. Sedation:
a. Uncooperative or thrashing patients should be treated with sedation
i. Morphine 0.1 mg/kg IV if associated with painful injury
ii. Versed 0.1 mg/kg IV for agitation
iii. If intubated, pancuronium or vecuronium 0.1 mg/kg IV or
cisatracurium 0.2 mg/kg IV if sedation is not satisfactory to
allow ventilatory control or cooperation with the diagnostic
studies. Do not give paralyzing agent without associated pain
medications and sedative.
22
8. Hyperventilation:
a. Hyperventilating to pCO2 below 30 mmHg without appropriate
monitoring may result in cerebral ischemia and worsening of
secondary brain injury. This is to be avoided and uncontrolled
hyperventilation (pCO2 < 35 mmHg) is no longer recommended.
9. Seizures:
a. Administer Ativan 0.1 mg/kg boluses repeatedly until seizure
breaks. Be prepared for respiratory depression.
b. Prophylaxis with Dilantin 15 - 20 mg/kg at a rate not to exceed 50
mg/min or fosphenytoin (Cerebyx ) 15 - 20 mg given at rate not to
exceed 150 mg/min.
i. Administer if seizure has occurred
ii. Consider administration if there is a high likelihood of posttraumatic seizure
10. Mannitol: at the discretion of the Neurosurgeon
a. Mannitol bolus of 0.5 - 1 gm/kg can be given for evidence of rising
intracranial pressure
b. Mannitol should not be used in hemodynamically unstable patients
as it will further promote hypovolemia.
11. Hypertonic Saline (HTS)
a. Hypertonic Saline (HTS) has been shown to provide a safer and more
prolonged effect of lowering ICP in traumatic brain injury. It may be used in
hemodynamically unstable patients, as it will not cause a diuresis and
further lowering of plasma volume than mannitol does.
b. Two common forms of HTS are 3% NaCl, and 7.5% NaCl / Na acetate.
3% NaCl can be used as a 250cc bolus over one hour, or 7.5% NaCl / Na
acetate 100cc bolus over one hour for patients whose chloride level is
already above normal secondary to rescuscitation with normal saline.
c. HTS therapy may be preferred as it maintains euvolemia instead of
hypovolemia observed with the osmotic diuresis seen with mannitol.
23
Diagnosis of Brain Injury

1. Concussion:
a. No anatomic brain injury on head CT
b. May have amnesia; retrograde/anterograde
c. Admission suggested if:
Associated organ derangement
History of loss of consciousness
Under age of 5
Persistent vomiting
Skull fracture
Seizure
2. Intracranial Hemorrhages:
Extra-axial hemorrhage
a. Acute epidural hemorrhage (EDH)
i. Usually secondary injury of middle meningeal artery
ii. Associated with linear skull fractures over parietal / temporal
areas ( not always apparent )
iii. Typical Symptoms
a) Loss of consciousness followed by lucid interval,
followed by a secondary decreased level of
consciousness
b) Hemparesis on opposite side of injury
c) Dilated and fixed pupil on same side of injury
iv. Treatment
a) Rapid operative intervention is often required
b) Prognosis good if treated rapidly; Underlying brain
injury usually not significant
b.
Acute subdural hematoma (SDH)

i. Skull fracture may or may not be present
ii. Underlying brain injury usually severe
iii. Typical Symptoms
a) Rapid deterioration after injury
b) Poor level of consciousness secondary to brain injury
and subdural hematoma
iv. Treatment
a) Rapid operative intervention when to treat with
surgery is patient dependent
b) Prognosis is related to the degree of brain injury
3. Subarachnoid hemorrhage (SAH):

a. Traumatic SAH is often cortical in nature
b. If SAH is in basal cisterns, consider ruptured aneurysm.
i. No operative treatment
ii. Signs and Symptoms
a) Meningeal irritation
b) Headache
c) Photophobia
4.
Brain contusion and lacerations:

a. Symptoms depend on location
b. Hemiplegia may occur
c. Visual field defects are common
d. Diagnosis by CT scan
5. Impalement injuries:
a. Do not remove foreign body that is protruding until neurosurgical
assistance is obtained
b. CT Scan
c. Consider Angiogram
24
Widened Mediastinum
Widened Mediastinum:
A mediastinum measurement of 8 cm at the level of the aortic knob on the best film that
can be obtained.
Assessment
1. Suggestive of possible aortic injury
a. Pleural cap
b. Depressed left mainstem bronchus
c. Trachea or esophagus deviated to right
d. First and second rib fracture
e. Obliterated aorto-pulmonary window
2. Assess for symptomatic upper extremity BP differences (> 10 mmHg).
These are suggestive of aortic injury.
3. If the possibility of aortic injury is considered at any point in the resuscitation, avoid
hypertension. High blood pressures (> 120 mmHg) should be treated with a short
acting intravenous beta-blocker (e.g., labetalol or esmolol).
4. Consider:
Upright chest x-ray
CT with cuts through aortic arch
Transesophageal echocardiogram (TEE)
Angiography
25
Blunt Cardiac Injury
Assessment:
1. Consider the possibility of blunt cardiac injury in the following situations:
a. Severe decelerating blunt chest trauma
b. Multiple anterior rib fractures
c. Severe anterior chest pain suggesting rib fractures or chondral fractures
d. Fractured sternum
e. Seatbelt contusion across the anterior chest
f. Severe bilateral pulmonary contusions
2. Treat all chest injuries according to the diagnostic findings, using ABCs.
3. Obtain chest X-ray
Management:
1. Obtain EKG and consider EKG abnormal with the following findings:
a. Unexplained tachycardia (rate >120)
b. New onset ventricular arrhythmias PVCs, bigeminy
c. New onset atrial arrhythmia - multifocal PACs, new atrial fibrillation or flutter
d. New onset right bundle branch block
e. New onset Q-waves
f. New onset ST-T wave abnormality
g. Changes compatible with acute MI or conduction deficit
- For any of the above changes in EKG on a trauma patient,
2. Admit the patient to a monitored bed and get an echocardiogram ( transthoracic or
transesophageal ). If normal, may observe on monitor for 24 hours and may
discharge. If abnormal, obtain a cardiology consultation for further recommendations.
3. Obtain repeat EKG after 24 hours
4. Consider transthoracic (transesophageal) echocardiogram for the following:
a. Unexplained hypotension suggestive of cardiac failure
b. Abnormal EKG at 24 hours
c. Persistent arrhythmias
d. Cardiology consult
e. CPK isoenzymes and possible cardiac troponin levels
NOTE: If aortic disruption is considered, the patient should be immediately transferred to the
Trauma Center for further radiologic investigation where operative intervention can be urgently
initiated if needed.
26
Blood and Blood Product Transfusion

Definitions:
1. Packed red blood cells: A blood product that contains red blood cells with most of the plasma
removed. Each unit PRBCs (220 ml) will raise the hematocrit by about 3%.
2. Fresh frozen plasma: A blood product that contains fresh components of plasma, including
colloid proteins and clotting factors.
3. Platelets: A blood product that contains primarily platelets suspended in a small amount of
plasma. Each unit of plasma will raise the platelet count by about 10,000.
4. Cryoprecipitate: A blood product component of plasma that primarily contains Factor VIII,
Factor V and fibrinogen. This is the best blood product for treatment of low fibrinogen (<150
mg/dL).
Management:
1. Initial resuscitation with warmed LR/NS solution infused through two, large-bore IV catheters.
2. Upon initiating resuscitation, send blood sample to the Blood Bank for immediate type and
cross.
3. LR/NS may be administered until type and cross-matched blood is available. O-negative or
type-specific blood may be necessary.
4. Due to limited supply of O-negative blood, consider O, positive blood for males and sterile or
post-menopausal females.
5. Type Specific Blood (Uncross-matched, ABO, Rh compatible blood): available in 10 minutes
after sample received in the Blood Bank.
6. Consider:
Autotransfusion
Anticoagulated patient
Fresh frozen plasma
Massive transfusion (six units of PRBCs)
Cryoprecipitate
o Coagulopathy
o Elevated PT/PTT
o Platelets
7. Massive Transfusion: Coagulopathy
1.
Temperature Control Common Cause of Coagulopathy
a. Radiant Heater ED
b. Maintain high ambient temperature in operating room
c. Warm IV fluids and blood
d. Patient wrap-around heating device (Baer Hugger ) or warmed blankets
2.
Usually dilutional problem
a. Treat with fresh whole blood or fresh frozen plasma and platelets
b. Platelet problems usually do not occur until after 10 units of banked blood
1)
If coagulopathy after 10 units of banked blood, treat with 6-10
platelet packs every 10 units of banked blood
2)
Majority of subjects DO NOT need calcium replacement
a)
If Q-T interval of EKG is prolonged and/or patient
receiving transfusion at greater than 100 mL/min, patient
should receive 0.2 gram CaCl2 for every 500 mL
transfused
b)
Total dose of CaCl2 should not exceed 2 grams unless
hypocalcemia is documented by laboratory
3)
Consider cryoprecipitate if fibrinogen levels are decreased
and/or above treatment is not effective
8. NovoSeven (Factor VIIa) Guidelines
NovoSeven is an adjunct to appropriate surgical procedure and adequate blood product
replacements in trauma patients suffering massive uncontrolled bleeding or in trauma
that is not amenable to surgical repair.
NOTE: Consideration for using NovoSeven should include a reasonable expectation of survival
for the patient.
27
Hypothermia
Definitions:
Clinical hypothermia: A core temperature below 35 C in any victim of trauma, classified as
follows:
a. Mild hypothermia: 32 to 35 C
b. Moderate hypothermia: 30 to 32 C
c. Severe hypothermia: <30 C
Assessment:
Patients at Risk for Hypothermia:
History of prolonged, cold environmental exposure
Massive blood and fluid loss with large fluid requirements
Severe head and spinal cord injury
Infants and children
Geriatric patients
Burns
Drowning victims
Management:
a. All victims of major trauma are considered at risk for hypothermia
b. Core temperature should be obtained on all patients
c. Avoid prolonged patient exposure
Cover with warm blankets
Radiant heaters
Baer hugger
Ambient room temperature
Warmed fluids
Warmed oxygen
d. Fluids going into patient should be warm
e. For major transfusion requirements, use the Level I fluid infuser with warmer
f. Consider:
Bypass for severe hypothermia
Gastric lavage with warm fluids
Warm water enemas
Peritoneal lavage with warm fluids
28
X-rays on Multiple Trauma Patients:

1. Usual order of X-rays:
a. Supine chest X-ray:
In general, almost all multiply injured patients require a supine chest
X-ray
On all patients with suggestion of chest injury
Obtain as soon as possible in intubated patients
b. AP pelvis:
Obtain on all obtunded patients with a possible mechanism
suggesting a pelvic injury
If the patient is alert and cooperative, obtain portable pelvis X-ray
when there are signs and symptoms of pelvic injury
c. C-spine (cross table lateral):
Patients with an altered level of consciousness, and patients with a
mechanism or pain suggestive of a possible C-spine injury
Pull shoulders down to visualize T1
NOTE: The cervical spine cannot be cleared for manipulation based solely on the
results of a lateral cervical spine film.
Other films should be obtained only if the information from them is
urgently needed (e.g., foreign body identification in GSW, etc.) or if
the patient is unstable
2. Other X-rays:
Obtained in the main X-ray Department whenever possible
Thoracic arteriogram
Carotid angiogram (four-vessel preferred): Obtain on patients with a neurologic
deficit unexplained by findings on head CT. MRA or CT-angiogram may be considered instead
Retrograde cystogram: Should be considered for cases of gross hematuria,
penetrating abdominal trauma and pelvic fractures where bladder disruption is
suspected
Retrograde urethrogram: should be considered for all cases of gross hematuria,
penetrating abdominal trauma and pelvic fractures where disruption of the
urethra is suspected
o Blood at the urethral meatus
o High riding prostate
o Obvious perineal injury (perineal hematoma or open perineal injury or
scrotal hematoma)
3. NOTE: IN TRAUMA PATIENTS, CT SCANS TO EVALUATE FOR ABDOMINAL
TRAUMA MUST ALWAYS INCLUDE THE PELVIS AND MUST ALWAYS (IN THE
ABSENCE OF CONTRAINDICATIONS) BE DONE WITH IV CONTRAST. CT SCANS
FOR ABDOMINAL TRAUMA WITHOUT CONTRAST WILL MISS SIGNIFICANT
INJURIES.
29
Pelvic Fractures
Assessment:
1. Evaluate for urethral injury prior to Foley insertion:
a. High riding prostate
b. Blood at urethral meatus
c. Scrotal hematoma
2. Fracture stabilization:
a. Reduce fracture dislocation
b. T-POD is available in the ED for use with unstable pelvic fractures
c. Evaluate neurovascular compromise
d. Stop bleeding use direct pressure
e. Antibiotics for open fractures
3. Spine:
a. Assess for sensory and motor deficits, sphincter tone, and bulbocavernosus
reflex
b. Log roll patient with in-line cervical stabilization
Management:
1. Prioritize injuries:
a. Life-threatening
b. Stable but potentially life-threatening
c. Limb-threatening
d. Not life or limb-threatening
e. Determine sequence: X-ray, OR, angiography, ICU
f. Determine radiologic sequence
g. Determine need for tetanus toxoid and antibiotic coverage
2. Continued reassessment is ABSOLUTELY mandatory:
a. Vital signs: frequent determinations of vital signs, as determined by the severity
of injury, should be made
b. Outputs: should be checked frequently during the resuscitation phase and then
hourly when stable urine, naso/oro-gastric
c. Remain alert to trends in physical examination and vital signs in response to
interventions. Continue to re-evaluate
30
Open Pelvic Fracture

Soft Tissue Injury with Exposed Bone
Initial Evaluation
Early wrapping of pelvis with sheet/pelvic binder to close volume
Stable Vital Signs

Non-Tender Abdomen
Life Line & Tubes

Secondary Survey
Blood Work
Foley after Rectal Exam
Consider Urethrogram
Vaginal Exam
X-ray of Pelvis
CT of Pelvis & Abdomen
OR for Debridement of Pelvis

Orthopedic Management of Pelvic Fracture
Consider Colostomy (Diverting)

and / or Tender Abdomen
X-ray Pelvis
Abdominal Ultrasound
(+)
(-)
OR Exploratory Laparotomy
Debride Pelvis
Vaginal / Rectal Exam
Orthopedic Management of Pelvic
Fracture
External Fixation
Stable Vital
Signs
OR Debride Pelvis
Definitive Management of Fracture
when Medically Stable
31
Unstable Vital
Signs
Angiography Embolization
OR - Debride Pelvis
Definitive Management of
Fracture when Medically Stable
Pelvic Fracture (Bony Instability)

Initial Evaluation
Early wrapping of pelvis with sheet/pelvic binder (T-pod) to close volume (+)
Definitive management when medically stable
Stable Vital Signs

Non-Tender Abdomen

and / or Tender Abdomen
Life Line & Tubes

Secondary Survey
Blood Work
Vaginal Exam
X-ray of Pelvis
Life Line & Tubes

Secondary Survey
Blood Work
Vaginal Exam
X-ray of Pelvis
CT of Pelvis & Abdomen
Ultrasound of Abdomen
(+)
(-)
Exploratory Laparotomy
Orthopedic Management of
Pelvic Fracture
External Fixation of Pelvis
Stable Vital Signs
Definitive Management
when Medically Stable
32
Unstable Vital
Signs
Angiography
and Embolization
Spine Protocol
Alert
No neck pain
No neuro deficits
No distracting injury
No significant head /facial injury
Clear by physical exam (AROM)

No pain at rest
No pain palpation
No pain with flexion, extension, lateral
rotation/bending.
Children no pain or tenderness,
full ROM
Document cervical spine clearance in chart
All other trauma patients
3 view C-spine series

(AP, Lateral, Odontoid)
Single attempt of odontoid or optional in
pediatrics
Lateral view in ED portable
GCS<= 8
Neuro deficits
Emergent to OR
Penetrating neck wounds
Requested by Neurosurgery
All other laterals done in Radiology
If 3 views normal, but patient continues to have

neck pain, continue C-collar
flexion / extension by the patient (optional)
Children should be able to follow directions and
verbalize complaints. (may need to be done at
a later time, due to muscle spasms)
Cervical collar until mental status improves, and

then clear by physical exam.
Change to Aspen Cervical Collar ASAP, if unable
to clear within 24 hours
Spine consult (neurosurgery or orthopedics)

Fractures, dislocations, subluxations,
SCI or neruo deficits
Persistent abnormal exam
Unable to clear C-spine
Document cervical spine clearance in chart
33
Thoracic Lumbar Spine

X-rays if
Lateral impact
Rollover
Ejection
Other spine fracture
Auto pedestrian
Fall > 20ft.
Pain
Multiply injured patients
who cannot communicate
(head injury or chemical paralysis)
Cervical Spinal Clearance

NOTE: There is no current standard, universally accepted, evidence based
protocol for the clearance of the cervical spine.
Assessment:
1. C-Spine: Includes C1 to the upper border of T1.
Patients will arrive to the trauma room with a cervical collar in place.
a. Make sure the collar has been applied correctly
b. Check under the collar (with manual immobilization) for the presence of
lacerations, swelling, penetrating injuries, tracheal deviation, subcutaneous
emphysema or distended neck veins
c. Make sure that the collar is appropriately padded around lacerations or other
open wounds
2. Proceed with C-spine clearance protocol.
3. Clearance of C-Spine: A clinical decision confirming the absence of acute bony,
ligamentous and neurologic abnormalities of the cervical spine based on history,
physical exam and/or negative radiologic studies.
Management:
1. Patients should be considered to have a cervical spine injury if they present with
any of the following conditions:
a. A history of blow to the head or neck
b. Pain in the cervical spine or paraspinous muscles
c. Pain to palpation of the cervical spine
d. Traumatic brain injury and/or skull fracture
e. Facial injuries such as fractures, tooth loss or severe lacerations
f. Neurologic deficits in torso, legs or arms not explained by peripheral nerve
Injuries
2. Awake patient without cervical tenderness:
a. A patient with possible C-spine injury may have their cervical spine cleared
without further radiologic evaluation if all of the following conditions exist
i.
No neck pain
ii.
No pain to palpation of cervical spine or paraspinous area
iii.
Awake and alert
iv.
No significant distracting pain
v.
No associated injuries suggesting serious C-spine injury
vi.
No pain with active range of motion of the neck
vii.
Absence of intoxicating agents alcohol or drugs
b. If the cervical spine is cleared under these conditions, there must be
appropriate documentation in the chart
3. Awake patient with tenderness:
a. A patient with possible cervical spine injury associated with cervical
tenderness should be evaluated as follows:
i.
Obtain a full cervical spine series: AP, lateral, swimmers view, open
mouth odontoid. Trauma oblique views can be added.
ii.
If the above films are negative, it will be the decision of the evaluating
physician to clear the spine, obtain consultation or proceed with
flexion/extension views, CT scan of the cervical spine or MRI. There is
no evidence-based literature to support one approach over another.
4. Patients who require radiologic clearance will follow these guidelines:
a. The spine remains immobilized in neutral position at all times
b. The cervical collar is briefly removed in the Emergency Department with manual
stabilization of the head to inspect and palpate the neck and then is reapplied
c. The patient is promptly log rolled off the long spine board and laid onto a Smooth
Mover type device. THE PATIENT WILL SPEND LIMITED TIME ON A RIGID
SPINE BOARD TO PREVENT PRESSURE WOUNDS.
34
Spinal Cord Injuries

Assessment:
Manipulation or movement of a suspected spine injury can cause additional injurySTABILIZE SPINE
1. Follow the ABCs
2. Perform a complete neurologic exam looking for the presence and level of
neurologic deficit
3. Maintain spine precautions
4. Spinal column injuries can be present without spinal cord or other systemic symptoms
5. Full length of the spine should be immobilized as there is a 12% incidence on
noncontiguous spine fracture
6. Obtain X-rays
Motor Strengths and Sensory Testing

The extent of injury is defined by the American Spinal Injury Association (ASIA)
Impairment Scale (modified from the Frankel classification), using the following
categories:
1. Complete: No sensory or motor function is preserved in sacral segments
S4-S5
2. Incomplete: Sensory, but not motor, function is preserved below the
neurologic level and extends through sacral segments S4-S5
3. Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have muscle grade less
than 3
4. Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have muscle grade greater
than or equal to 3
5. E - Normal: Sensory and motor functions are normal
Perform rectal examination to check motor function or sensation at the anal
mucocutaneous junction. The presence of either is considered sacral-sparing.
Definitions of complete and incomplete SCI are based on the above ASIA definition with
sacral-sparing.
1. Complete - Absence of sensory and motor functions in the lowest sacral
segments
2. Incomplete - Preservation of sensory or motor function below the level
of injury, including the lowest sacral segments
Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers
with the sacral fibers located more at the periphery of the cord. Indication of the presence
of sacral fibers is of significance in defining the completeness of the injury and the
potential for some motor recovery. This finding tends to be repeated and better defined
after the period of spinal shock.
With the ASIA classification system, the terms paraparesis and quadriparesis now have
become obsolete. The ASIA classification using the description of the neurologic level of
injury is used in defining the type of SCI (eg, C8 ASIA A with zone of partial preservation
of pinprick to T2), with tetraplegiaused to describe injuries involving the cervical region,
and paraplegia for those involving T1 and lower.
35
Other classifications of SCI include the following:

1. Central cord syndrome often is associated with a cervical region injury
leading to greater weakness in the upper limbs than in the lower limbs
with sacral sensory sparing.
2. Brown-Squard syndrome often is associated with a hemisection
lesion of the cord, causing a relatively greater ipsilateral proprioceptive
and motor loss with contralateral loss of sensitivity to pain and
temperature.
3. Anterior cord syndrome often is associated with a lesion causing
variable loss of motor function and sensitivity to pain and temperature,
while proprioception is preserved.
4. Conus medullaris syndrome is associated with injury to the sacral cord
and lumbar nerve roots leading to areflexic bladder, bowel, and lower
limbs, while the sacral segments occasionally may show preserved
reflexes (eg, bulbocavernosus and micturition reflexes).
5. Cauda equina syndrome is due to injury to the lumbosacral nerve roots
in the spinal canal leading to areflexic bladder, bowel, and lower limbs.
Muscle strengths are graded using the following Medical Research Council (MRC) scale
of 0-5:
5 - Normal power
4 - Moderate movement against resistance
3 - Movement against gravity but not against resistance
2 - Movement with gravity eliminated
1 - Flicker of movement
0 - No movement
Muscle strength always should be graded according to maximum strength attained, no

matter how briefly that strength is maintained during the examination. The muscles are
tested with the patient supine, unless contraindicated.
The following key muscles are tested in patients with SCI, and the corresponding level of
injury is indicated:
1. C5 - Elbow flexors (biceps, brachialis)
2. C6 - Wrist extensors (extensor carpi radialis longus and brevis)
3. C7 - Elbow extensors (triceps)
4. C8 - Finger flexors (flexor digitorum profundus) to the middle finger
5. T1 - Small finger abductors (abductor digiti minimi)
6. L2 - Hip flexors (iliopsoas)
7. L3 - Knee extensors (quadriceps)
8. L4 - Ankle dorsiflexors (tibialis anterior)
9. L5 - Long toe extensors (extensors hallucis longus)
10. S1 - Ankle plantar flexors (gastrocnemius, soleus)
36
Sensory testing is performed at the following levels:

1.
C2 - Occipital protuberance
2.
C3 - Supraclavicular fossa
3.
C4 - Top of the acromioclavicular joint
4.
C5 - Lateral side of antecubital fossa
5.
C6 - Thumb (dorsal surface of the proximal phalanx)
6.
C7 - Middle finger
7.
C8 - Little finger
8.
T1 - Medial side of antecubital fossa
9.
T2 - Apex of axilla
10.
T3 - Third intercostal space (IS)
11.
T4 - 4th IS at nipple line
12.
T5 - 5th IS (midway between T4 and T6)
13.
T6 - 6th IS at the level of the xiphisternum
14.
15.
16.
17.
T10 - 10th IS or umbilicus
18.
19.
T12 - Midpoint of inguinal ligament
20.
L1 - Half the distance between T12 and L2
21.
L2 - Mid-anterior thigh
22.
L3 - Medial femoral condyle
23.
L4 - Medial malleolus
24.
L5 - Dorsum of the foot at third metatarsophalangeal joint
25.
S1 - Lateral heel
26.
S2 - Popliteal fossa in the midline
27.
S3 - Ischial tuberosity
28.
S4-5 - Perianal area (taken as one level)
Sensory scoring is for both light touch and pinprick, as follows:

0 - Absent
1 - Impaired or hyperesthesia
2 - Intact
A score of zero is given if the patient cannot differentiate between the point of a sharp pin and
the dull edge.
37
Management:
1. With any spinal cord injury, start the steroid protocol:
a. SoluMedrol 30 mg/kg, IV over 15 minutes (begin as early as possible) within
eight hours of injury
b. SoluMedrol 5.4 mg/kg/hr for the next 23 hours
c. Continue the protocol even if there is complete neurologic improvement
2. Arrange for immediate transfer to the Trauma Center
3. Neurogenic shock may occur with injuries down to T4-6
a. Place Foley and monitor urine output
b. Follow frequent blood pressures
c. If patient has SBP <90 mmHg or MAP <65 mmHg and hemorrhagic shock has
been ruled out (by CXR, DPL, FAST or CT scan of the abdomen/pelvis):
i. Place in Trendelenburg, if not contraindicated
ii. Administer 2000 ml IV fluid
iii. Start dopamine at 5 mcg/kg/min; continue fluid resuscitation as
necessary
iv. If no response, increase dopamine to 10 mcg/kg/min
v. Insert pulmonary artery catheter or central venous line to assess filling
pressures and cardiac index
vi. Consider phenylephrine starting at 30 mcg/min if filling pressures and
cardiac index are satisfactory
4. Provide DVT prophylaxis: mechanical sequential compression device (if not
contraindicated) and anticoagulation with prophylactic dose of unfractionated or low
molecular weight (LMW) heparin (if no contraindication).
5. Keep the patient warm and prevent hypothermia
6. Request Physical Therapy and Occupational Therapy services, and PM&R consultation
upon admission
7. Neurologic Exam
a. Glasgow Coma Scale/Level of Consciousness. This should be assessed prior to
chemical paralysis and sedation, whenever possible
GCS: 3-8 severe TBI; 9-12 moderate TBI; 13-15 mild TBI
Note: Just because someone has a normal GCS does not mean they do
not have TBI
b. Test cranial nerves
c. Check pupils; assess size and reactivity to light
d. Test motor/sensory function
e. Rectal exam
f. Test deep tendon reflexes and monitor for any pathologic reflexes
38
Cervical, Thoracic and Lumbosacral Spine Injuries

Assessment:
If transfer is not imminent, remove long spine board and roll patient back onto
Smooth Mover type device.
Types of Spinal Injuries:
A. Radiologic evaluation
1. Contour and alignment of vertebral bodies
2. Displacement of bone fragments into spinal canal
3. Linear or commuted fractures of laminae, pedicles, or neural arch
4. Soft tissue swelling
B.
Mechanism of injury: one or a combination of the following forces
1. Axial loading
2. Flexion
3. Extension
4. Rotation
5. Lateral bending
6. Distraction
C.
Cervical spine-fracture/dislocations
1. C1 (Atlas)
a.
Jefferson fracture
1)
Burst of ring
2)
Axial load
3)
1/3 associated with fracture of C2
4)
Not associated (usually) with cord injury
5)
Unstable: Treat with rigid collar, halo or surgery
2. C2 (Axis)
a.
Odontoid fractures
1)
Evaluate with axial and sagittal CT scan
2)
Posterior displacement may not result in injury to cord
3)
Types of odontoid fractures
a)
Type I: above base of odontoid-usually stable
b)
Type II: at base of odontoid-usually unstable (in
children-epiphysis in this area) Treat with halo or
surgery
c)
Type III: through vertebral body-treat with halo or
C-collar
b.
Hangmans Fracture (C2)
1)
Involves pars of C2
2)
Extension/Distraction or Extension/Axial Compression injury
(more common)
3)
Immobilize injury acutely rigid collar/halo/or traction
3. C3 through C7
a.
Usual mechanism of injury in stable fractures
1)
Flexion
2)
Extension
3)
Lateral bending
4)
Axial loading
b.
Mechanism of injury in unstable fractures
1)
Flexion axial loading
2)
Extension axial loading
3)
Flexion rotation
c.
Rule for soft tissue C-spine swelling is 6mm at C2 and 22mm at
C6.
39
Management:
a.
b.
c.
d.
D.
Immobilize all fractures/dislocations rigid collar

Maintain in-line spinal traction
Obtain Neurosurgery Consult when spinal cord injury diagnosed or
suspected, consider MRI
Methylprednisolone protocol [within 3 hours]
30mg/kg in 15 min, 5.4 mg/kg/hr x 23 hours, for spinal cord injury
Check with Neurosurgery before starting administration
This protocol should be used for BLUNT INJURY ONLY
If less then 3 hours then infuse x 24 hours
Between 3-8 hours infuse x 47 hours
Spinal Cord Injury Without Fracture

1. No bony abnormalities on CT or X-ray with neurological deficit
2. Spinal immobilization and Neurosurgery Consult
3. Emergent MRI to rule out disc, hem
4. Methylprednisolone protocol [within 3 hours]
30mg/kg in 15 min, 5.4 mg/kg/hr x 23 hours, for spinal cord injury
Check with Neurosurgery before starting administration
This protocol should be used for BLUNT INJURY ONLY
If less then 3 hours then infuse x 24 hours
Between 3-8 hours infuse x 47 hours
40
Abdominal Trauma
Initial Assessment
Look Listen - Feel
1. Follow the ABCs, and resuscitate patient according to findings of the primary survey
2. Assess the chest and abdomen looking for entry wounds, bleeding and peritoneal
findings
3. Determine the presence of symptoms/signs suggestive of immediate need for
operative intervention:
a. Herniated abdominal contents
b. Massive bleeding from the wound
c. Obvious peritoneal signs consistent with hollow viscous injury or
hemoperitoneum
d. Signs of hemodynamic instability associated with the abdominal injury
e. Signs of lower extremity ischemia suggestive of vascular injury
f. All gunshot wounds with path or other evidence of intraperitoneal penetration
or retroperitoneal organ injury
g. Blood per NG/OG tube, rectum, Foley
4. If any of the above signs are present, then take patient to the operating room
immediately for exploratory laparotomy
5. For stab wounds, if none of the above signs are present, determine the location of
the wound and classify as:
a. Anterior
b. Thoracoabdominal
c. Posterior or flank
6. Intra-abdominal injury suspected:
a. Type of accident
b. Location and/or presence of bruises
c. Areas where abdomen has been penetrated
d. Local or referred pain if patient is awake
Penetrating Wounds:
1.
Gunshot wounds to abdomen:
a. Bleeding is usually manifested by abdominal pain, a quiet abdomen
or shock
b. Bowel perforation is slower to manifest itself; local peritoneal signs
are usually the best indicator
c. Abdominal exploration is mandatory in all but trivial injuries
2.
Stab wound to abdomen:
a. Superficial abdomen wound (i.e. obviously not penetrating
peritoneum)
1) Primary repair of slash
2) Leave open if stab
b. Violation of peritoneum
1) Obvious peritoneal irritation requires exploration
2) Serial physical examination is suitable to rule out abdominal
injury. Need urgent exploration if peritoneal irritation develops or
shock is present
c. Questionable abdominal injury do nothing; follow physical exam
DO NOT PROBE WOUND Serial physical exam q 2 hours.
This is done by surgeon
1) If peritoneal signs develop, explore patient or perform a DPL
2) 24 hours observation, then discharge if patient remains normal
41
Blunt Trauma:
1.
Mechanism of action
a. Compression of hollow or solid viscus against vertebral column
b. Direct transfer of energy to an organ
c. Rapid deceleration with tear of organ
d. Most common injury Blunt trauma
1) Liver
2) Spleen
3) Pancreas
4) Duodenum
5) Bladder
6) Small bowel/large bowel
Management:
o Obtain chest X-ray
o Laparotomy
o Thoracoscopy to inspect the diaphragm
o Insert Foley catheter to determine the presence of hematuria
o Obtain a triple-contrast CT scan to determine injury by retroperitoneal organs
o The CT scan to detect the path of injury
o Perform anoscopy and sigmoidoscopy to determine the presence of a
mucosaldefect
o Obtain a rapid one-shot IVP to determine the presence of bilateral kidneys if
hematuria is present.
o ABCDE
Intubation
Nasogastric Tube
a. To relieve gastric dilation
b. To decrease chance of aspiration of gastric and bowel contents
c. To rule out presence of blood in the stomach (weak)
d. CONTRAINDICATIONS:
1) Cribriform plate fracture
2) Penetrating neck wounds
e. If cribriform plate fracture is present, insert orally
Genitourinary Catheter
a. To monitor urinary output
b. To evaluate presence of hematuria
c. CONTRAINDICATIONS:
1) Meatal blood
2) Scrotal hematoma
3) High riding prostate
d. If any contraindication present, do urethrogram first in
emergency department
42
FAST/CT
o Peritoneal Lavage (see procedure section)-rarely utilized
1. Physical exam most important parameter
2. Insert genitourinary catheter
3. Insert nasogastric tube
4. Contraindications for peritoneal lavage
a. Absolute
Multiple abdominal operations
Obvious indications for exploratory celiotomy
b. Relative
Gravid uterus
5. Peritoneal lavage does not rule out retroperitoneal injury
6. Reserved for patients usually in OR and cannot perform ultrasound
or diagnosis of small bowel injury when abdominal CT not diagnostic
All patients undergoing exploration for blunt or penetrating trauma should have
preoperative broad spectrum antibiotic(s). They should cover aerobes anaerobes.
T-POD is available in the ED for use with unstable pelvic fractures
If a patient arrives in the ED with Pneumatic Anti-shock Garments in place, it is
important to deflate trousers appropriately
1. Deflate trousers slowly while monitoring blood pressure/never
rapidly
2. Stop deflation if the blood pressure falls 5 mm Hg and return and
maintain patients blood pressure
3. Always begin with deflation of the abdominal segment first
4. Deflate 1 segment at a time and check BP between each segment.
5. Should the patient experience a sudden fall in blood pressure, the
trousers should be re-inflated until more fluid can be given and/or
operation for control of the hemorrhage can be carried out
REMEMBER: Deflation of the trousers without the reestablishment of blood volume
will result in profound shock, cardiac arrest and death of the patient. The greatest
danger in the use of these garments is inappropriate removal
Contraindications to Use of the Trousers:
1. The only absolute contraindications to their use is pulmonary edema
2. Recent information questions their use, and probably they will be
phased out
43
Stab Wound to Abdomen

Initial Evaluation
Stable Vital Signs

Negative Peritoneal Signs

Positive Peritoneal Signs
Operating Room
Antibiotics to Cover
Aerobic / Anaerobic
Secondary Survey
Blood Work
Lines & Tubes
Ultrasound
(+)
Exploratory Laparotomy
Orthopedic Management of
Pelvic Fracture
(-)
Consider Observation
[ frequent abdominal exams ]
Consider Abd CT
Consider Local Wound Exploration
( Talk with Trauma Attending )
Consider Peritoneal Lavage
( Talk with Trauma Attending )
44
Gunshot Wound to Abdomen

Initial Assessment
Trivial or Tangential
Wounds to Back / Flank
Peritoneal Penetration
Positive Peritoneal Signs
Gross Blood per NG / Rectum / Foley
Secondary Survey
Blood Work
Lines & Tubes
Life Lines & Tubes

Antibiotics to Cover Aerobic / Anaerobic
OR (if unstable vital signs-emergent to OR)
Consider Bypass of Emergency Department
Observe by Surgeon
Vitals
Abdominal Exam
Consider CT
45
Eye Injuries
Assessment
1. Follow the ABCs.
2. During the secondary survey obtain history of the injury as it relates to the eye:
a. Pain (consider corneal injury)
b. Photophobia
c. History of thermal injury
d. History of corrective lens use
e. History of blunt or penetrating trauma
f. Previous visual acuity
g. Medications (e.g., pilocarpine, etc.)
3. Perform a physical exam:
a. Eye:
i.
Gross visual acuity (e.g., count fingers, read label, see light, etc)
ii.
Pupils: shape, size, reactivity, consensual reactivity
iii.
Range of motion
iv.
Anterior chamber (clear, hyphema, cloudy)
v.
Conjunctiva (scleral hemorrhage, edema, etc.)
vi.
Globe (anterior displacement, shape, symmetry)
vii.
Retina (tears, hemorrhage, detachment)
viii.
Papilledema
b. Lids:
i.
Laceration
ii.
Ecchymosis
iii.
Edema
iv.
Ptosis
v.
Foreign body
c. Orbits:
i.
Symmetry
ii.
Crepitus or instability
iii.
Obtain CT scan with 2 mm cuts through orbits and facial bones
d. Cornea:
i.
Apply fluorescein after topical anesthetic
ii.
Examine with blue light
iii.
Assess for opacity, ulceration, and foreign bodies
Management:
a. Chemical burns:
i.
Apply topical anesthetic
ii.
Systemic analgesics and sedation as needed
iii.
Copiously irrigate with 1000 ml or more of warm saline placed into
the eye
b. Corneal injury:
i.
Apply topical anesthetic
ii.
Apply antibiotic ointment ( no steroids )
iii.
Apply eye patch
c. Eyelid injury:
i.
If superficial, suture with fine non-absorbable nylon
ii.
Eyelid wounds best treated by Ophthalmology: medical canthus,
lacrimal sac or duct, deep horizontal lacerations that may involve the
levator muscle, lid margin lacerations
d. Foreign body or material on the surface of eye:
i.
Irrigate the eye gently with normal saline to see if it floats away
ii.
If the material is over sclera, gently try to capture it with cotton-tipped
applicator
e. Hyphema, retrobulbar hematoma, retinal injury and penetrating globe injuries
should be referred immediately to Ophthalmology
46
Pediatric Trauma
Unique Anatomic & Physiologic Considerations:

1. Head and Neck
a. Disproportionately large head size especially occiput
b. Poorly developed cervical musculature
c. Flat cervical facet joint surface
d. Larger tongue in relation to the oropharynx
e. Trachea is short, more anterior and narrowest below vocal cords
i.
Propensity to intubate right mainstem
ii.
Use size appropriate for child by referencing Broselow tape or by
estimating the size: little finger of the child
2. Thorax
a. Absorbs greater amount of energy without associated rib fractures
Relative elasticity of rib cage affords less protection to underlying organs
b. Great vessel and mediastinum less well fixed. Children more susceptible to
cardiovascular compromise from tension pneumothorax
3. Abdomen
a. Smaller size abdominal cavity
b. Children swallow large amounts of air leads to distension and potential for
compromised ventilation. Exam may be misleading. Place gastric tube
c. High index of suspicion for bowel injury from lap-belt with lumbar spine fracture,
duodenum at risk
d. Diagnostic peritoneal lavage not used in children
e. Abdominal Ultrasound (when available)
f. Abdominal CT
4. Other
a. Greater surface area/body mass ratio equal greater heat loss. Keep child warm.
Rectal probe for critical patients.
b. Marked ability to increase SVR and maintain normal BP even with greater than
25% blood volume loss. Will then decompensate rapidly. Signs and symptoms of
decompensated shock are altered level of consciousness, hypotonia,
tachycardia, weak central pulses with absent peripheral pulses. Bradycardia,
hypotension and irregular respiration are late, ominous signs of shock.
5. Spinal Cord Injuries
a. Children have looser ligamentous attachments and larger head by proportion
b. Children may have spinal cord injury without fracture. Must protect C-spine until
assessed thoroughly.
c. Spine Steroid Protocol is helpful with Spinal Cord Injury (SCI), as in adults
Management
Primary Survey: Goal is to identify and immediately treat life-threatening injuries:
1.
Airway
a. Maintain spinal immobilization
b. Bag-mask with oxygen and oral airway
c. When in doubt, intubate
d. Choose right size tube
ETT size: childs small finger or 16 + age / 4
Cuffed endotracheal tube for 2 years and older
Consider LMA if unable to intubate
e. Trachea is short. Be aware of tendency to intubate right mainstem
bronchus
f. End-tidal CO2 monitoring
g. Suction to clear secretions
47
2.
3.
4.
5.
6.
Breathing
a. Use appropriate size bag-valve-mask. Respiratory Rate:
Up to 1 year 40bpm
1-6 years 20bpm
above 6 years 15bpm
b. Pulse oximetry, ETCO2 if intubated
c. Place OG or NG early to keep stomach decompressed.
Circulation
a. Two large bore IVs antecubital and/or femoral veins. Intraosseous
if IV access unobtainable, (may be used on ages up to 18 year of
age).
b. Initial bolus is 20 mL/kg of warmed crystalloid
c. Repeat bolus if vital signs abnormal
d. If still unstable, prepare for OR and start O Negative
uncrossmatched PRBCs at 10mL/kg
Disability
a. Assess pupillary size and response
b. Glasgow Coma Score use appropriate scale for childs age
c. Neurological status vertical/horizontal motor symmetry (hemiplegia,
paraplegia, quadriplegia)
Exposure
a. Completely undress and examine
b. Rectal exam
c. Cover quickly to prevent hypothermia use warming lights, blankets,
etc. Rectal temperature for critical patients.
Tubes and Drains
a. NG/Foley/chest tube appropriate for age (Broselow tape)
b. NG tube (oral gastric tube with significant mid-face injury or CSF in
nose or ears)
c. Foley insertion for critical patients. Always check for blood at urethral
meatus, hematoma at scrotum and perineum.
48
Trauma in Pregnancy
Follow the ATLS protocols including initial assessment, resuscitation and secondary
survey. (See Initial Assessment Protocol.) Remember that the mothers welfare comes first
so that all of the initial assessment should be directed to the mother while keeping the fetus
welfare in mind. This includes X-rays and CT scanning.
Assessment:
1. Assess for pregnancy and gestational age by one or more of the following:
a. History and last menstrual period
b. Beta-HCG
c. Prior or immediate sonogram
d. Discussion with primary care obstetrician
e. Fundal height
2. Notify patients primary obstetrician of the trauma event.
3. If 24 weeks or greater by any indicator, including physical exam, contact Labor and
Delivery immediately for external fetal monitor to be brought to the trauma room:
a. Non-stress test strip to be reviewed by L&D monitoring nurse
b. Any non-reassuring strip is to be reviewed by the primary obstetrician (or
resident on-call) and perinatologist
4. Keep patient (>20 weeks pregnant) on the left side to take uterine pressure off vena
cava.
5. Obtain standard trauma labs dependent on injuries and Kleihauer Betke test and
D-dimer.
6. Determine maternal Rh status. If Rh negative, then:
a. Rhogam 300 mcg for 2nd and 3rd trimester or 50 mcg for 1st trimester
7. Obtain ultrasound examination.
8. If this is major trauma requiring transfer to trauma ICU or trauma specialty unit, then:
a. Obtain obstetrics consult
b. Continuous fetal monitoring by L&D nurse for at least 24 hours or longer at the
discretion of obstetrics
9. If this is minor trauma not requiring transfer to trauma specialty unit, then consider 24
hours of continuous fetal monitoring at the discretion of obstetrics.
10. If the gestational age is less than 24 weeks, then continuous fetal monitoring is usually
not necessary unless ordered by obstetrics.
11. Perimortem Cesarian Section should be a consideration in extreme cases involving
impending fetal demise or fetal death and undertaken in conjunction with Perinatology to
resuscitate the fetus and Obstetrics.
49
Burn Patients
Derived from the classification of burns and guidelines proposed by the American Burn Association
Severely burned patient:
This is a patient with a severe burn injury who should be transferred for specialized care to a burn
center.
Partial thickness burns that involve >10% total body surface area (TBSA)
Burns involving the face, eyes, ears, hands, feet, perineum or that involves the skin over
major joints
Full thickness burns in any age group
Burns associated with significant fractures or other major injury.
High-voltage electrical burns including lightening
Chemical burns.
Inhalation injury.
Lesser burns in patients with significant pre-existing disease that might increase
morbidity or mortality
Burns associated with trauma in which the burn injury poses the greater risk of morbidity
or mortality, if the traumatic injury poses a greater risk it should be dealt with initially for
later transfer to a burn facility
Pediatric burns in a setting lacking the personnel or equipment to care for children
Patients requiring special social, emotional, or rehabilitative interventions unique to a
burn facility
Assessment of Burn Patients: ABC`s
Do not allow your attention to be diverted by the thermal cutaneous burn. Look for life
threatening injuries first.
1. Airway: A clear airway is priority number one
Airway Distress Secondary to Burn Injury: Clinical signs
a. Facial burns
b. Singeing of eyebrows and nasal hair
c. Carbon deposits and acute inflammatory changes on oropharynx
d. Carbonaceous sputum
e. History of confinement in a burning environment
f. Respiratory distress
g. Hoarseness or voice changes.
h. Treatment of airway injury in burns:
i.
Respiratory support with supplemental oxygen.
ii.
Endo tracheal intubation
iii.
Surgical airway
-tracheostomy
-cricothyrotomy
2. Breathing:
a. Supplemental Oxygen
b. Full thickness circumferential burns of the chest (see below)
c. Carbon Monoxide poisoning (see below)
50
3. Circulation: I.V. fluid resuscitation necessary in most burns greater than 10-15 %
a. Assess for shock and treat accordingly if present
b. Obtain large bore IV access. Two lines desirable in large burns (#16
gauge preferred). These may be placed peripherally or centrally. It is
acceptable to place the IVs through eschar if it is the only available
access site.
c. Begin administration of lactated Ringers solution, warmed if possible.
(See fluid calculations below.)
Disability: Look for obvious signs of impairment such as

intoxication unresponsiveness, paralysis, paresis, etc.
Expose: Remove all clothing and constricting bands or jewelry.

Edema formation may create a tourniquet effect.
Place patient on clean sheet. Sterile sheets are not required.

Do not immerse burn into cold water or apply ice.
Hypothermia on arrival at the burn center is common. Keep
the patient warm.
Assessment of the Burn Injury:

1. History of injury: closed space injury, possible inhalation injury.
2. Calculating Burn Size:
a. RULE of NINES - The body is divided into areas representing
multiples of nine (the RULE of NINES) to calculate total
body surface area burned (TBSA).
i.
Head
9% (adult)
18% (child)
ii.
Torso
18% (front)
14% (child)
18% (back)
14% (child)
iii.
Leg
18% (adult)
9% (child)
iv.
Arm
9%
v.
Perineum 1%
b. RULE of PALM: The size of a patients palm (not counting the fingers)
is roughly equivalent to 1% of TBSA and can be used as a guide to
calculate burn size.
51
3. Assessing Depth of Burn:

a. Partial thickness Burns-Superficial (or First Degree)
i. Classic Sun Burn
ii. Reddened skin
iii. Hair intact
iv. Painful/Hypersensitive
b. Partial Thickness Burns-Deep (or Second degree burn)
i. Red or mottled appearance
ii. Swelling/Blister formation
iii. Painful/Hypersensitive
iv. Blistering and or loose skin.
v. Raw surfaces often present
c. Full Thickness Burns (or Third degree burns)
i. Appearance can vary from dark red, waxy white, dark
leathery, to frank charring.
ii. Hair easily removed by wiping with 4x4 and is often missing
iii. Surface is painless and generally dry.
Steps In Management Of The Acute Burn Patient: ABC`s Always first

.
1. Airway Management.
a. Acute problems: Assess airway including the possibility of
intubation manage per ATLS/ABLS protocols as above.
2. Breathing: Supplemental Oxygen.
a. Respiratory distress may result from Eschar of chest wall in
circumferential burns limiting respiratory motion.
b. May require acute surgical release of eschar to allow chest expansion
(escharotomies), Contact burn center.
c. Carbon Monoxide: elevated levels in closed space fires. life of CO
<30 minutes on 100 % non-rebreather mask. Hyperbaric chambers may help
if neurological symptoms present. Length of transfer time to facility is
critical.
3. Circulating blood volume
a. Requires I.V. support in burns > 10-15 % burn:
Initiate lactated Ringers at 3 ml/kg body wt./percent body
surface burn.
Or, consider 500 cc`s/Hr. in adults, 250 cc`s/Hr in Adolescents,
maintenance fluid rates in children in consultation with a burn
center.
50% of total fluid volume estimated for the first 24 hours

should be infused over the First 8 hours.
The remainder should be administered over the next 16 hours.
b. Monitor Vital signs: Urine output is an excellent monitor of the adequacy of
volume replacement in burned patients
maintain urine out put of 1 ml/kg body wt. per Hr. in children
maintain urine output of 30-50 cc`s/Hr or cc per Kg in adults.
Fluid volume requirements may be massive in large burns, this
may require both central line access and foley catheter
52
c. REMEMBER: fluid resuscitation formulas are guides only, adequacy

of response suggesting increases or decreases in infusion rates
are based on urine output, vital signs, and patient response.
NOTE: calculate first 8 hours from time of burn, not time of
presentation to ED.
4. EKG monitoring
5. Arterial oxygen saturation monitoring.
6. Base line determinations:
CBC, Chem. profile, ABC`s and carboxyhemoglobin as
indicated
Chest X-ray
Consider drug/alcohol screen
7. Additional measures:
nasogastric tube in large burns for prevention of ileus and/or
early tube feedings
Pain medication and sedation: these should be given
frequently I.V. in small doses to keep your patient as
comfortable as possible.
Tetanus immunization per protocol.
Peripheral perfusion: edema in burns can lead to acute
compartment syndromes. Distal pulses should be monitored in
extremity burns
Initial Care of the Burn wound:
1.
If the patient is being transferred to a burn facility do not apply goop de jour
as it will only need to be painfully removed on admission.
2.
Cover wounds with clean linens, they do not need to be sterile.
3.
Do not peel off tar, it takes skin with it. If necessary remove with an organic
solvent such as Crisco, mineral oil, vegetable oil, or non-toxic commercial
products (i.e. Go-Joe, etc.)
4.
Loose or hanging skin may be trimmed or removed gently; blisters can be
left intact for transfer. If removed they expose a painful raw surface.
Transferring the Burn Patient:
1.
Contact the burn center early, physician to physician communication when
possible.
2.
Direct transport to a burn center often appropriate if the injury scene is
< 30 miles from a burn center.
3.
<30 miles ground transport appropriate.
4.
> 30-50 miles (+/-) consider helicopter transport.
5.
> 150 miles consider fixed wing transport
53
Deep Venous Thrombosis Prophylaxis

Assessment:
1. The following patients should be considered candidates for DVT prophylaxis:
a.
Patients with traumatic brain injury in coma (GCS <8)
b.
Patients with spinal cord injury
c.
Patients with prior history of DVT or pulmonary embolism
d.
Patients with fractures or crush injuries of the pelvis and lower extremities
e.
Patients requiring bed rest for >72 hours
f.
Patients with hypercoagulable states
2. Routine assessment for DVT with duplex scanning is not indicated; however, in high
risk patients, duplex scanning for DVT should be considered on a weekly basis as
long as they are hospitalized. Duplex scanning should also be performed if any
evidence of DVT is found.
Management:
1. The following prophylaxis should be considered:
a.
Mobilization: all patients should be mobilized out of bed as soon as
possible and when feasible
b.
Leg compression devices should be used in all patients for who
anticoagulation is contraindicated
i.
Traumatic brain injury (first 2-3 days)
ii.
Spinal cord injury (first 2-3 days)
iii.
Bleeding diathesis (until resolved)
c.
If leg compression devices cannot be placed on both lower extremities, foot
pumps should be applied
2. Medications
o DVT Prophylaxis Standing Orders (choose ones that apply):
Sequential Compression Devices/Foot Pumps
Heparin 5000 Units SubQ every 12 hours
Fragmin 2500 International Units SubQ daily
Lovenox 40 mg SubQ daily
No DVT prophylaxis required (ambulating normally without risk factors)
3. If a venous thrombosis is detected, systemic heparin should be implemented unless
anticoagulation is contraindicated.
4. Vena cava filters are indicated in the following circumstances:
a.
Recurrent pulmonary embolus (PE) despite full anticoagulation
b.
Proximal DVT and major bleeding while on full anticoagulation
c.
Progression of femoral clot despite anticoagulation
d.
Large free-floating thrombus in the iliac vein or inferior vena cava
e.
After massive PE in which recurrent emboli would prove fatal
f.
High risk patients in whom anticoagulation is contraindicated or frequently
interrupted for operative procedures
54
Open Fracture
Assessment:
1.
Follow ABCs.
Extremity fractures assume low priority in the multiply injured patient
unless there is significant bleeding or impending loss of skin integrity by
dislocation or displaced fracture.
2.
When patient is stable, examine the fracture and document distal neurovascular
status of limb.
3.
Frequent reassessment of neurovascular status of limb.
Management:
1.
Remove all gross contamination using sterile saline and cover all wounds with
moist saline sterile dressing.
2.
Grossly align limb or reduce dislocation.
a. Splint femur fractures with Hare traction or similar splint
b. Splint other fractures with aluminum or plaster splints, including joint
above and below the fracture
3.
Radiographs in two planes.
a. includes joints above and below fracture
b. If the patient is to be transferred to the Trauma Center, extremity
radiographs are not necessary prior to transfer if the transfer will be
delayed obtaining those films
4.
Prophylactic antibiotics.
a. Ancef 1 gm every 8 hours and aminoglycoside (gentamicin or
tobramycin) 5-7 mg/kg every day and cefazolin 1 gm every 8 hours
b. Soil contamination or barnyard wounds: add penicillin G 4-5 million
units every 4 hours
5.
Tetanus prophylaxis if indicated
6.
Consult orthopedics
55
Tetanus Immunization
Attention must be directed toward adequate tetanus prophylaxis in the multiply injured patient,
especially if open extremity trauma is present.
Assessment Use diphtheria tetanus for adults.
1.
The physical exam must determine for each patient with a wound what is
required or adequate prophylaxis against tetanus
2.
Regardless of the active immunization status of the patient, meticulous surgical

care, including removal of all devitalized tissue and foreign bodies, should be
provided immediately for all wounds. Such care is essential as part of the
prophylaxis against tetanus
3.
Passive immunization with Tetanus Immune Globulin-Human (human T.A.T.)

must be considered individually for each patient. The characteristics of the
wound, conditions under which it was incurred, its treatment, age, and previous
active immunization status of the patient must be considered. Passive
immunization is not indicated if the patient has ever received three or more
injections of toxoid in the past.
4.
For precise tetanus prophylaxis, an accurate and immediately available history

regarding previous active immunization against tetanus is required.
5.
Immunization in adults requires at least three injections of toxoid. A routine

booster of adsorbed toxoid is indicated every ten years thereafter. In children
under seven, immunization required four vaccines. A fifth dose may be
administered at four to six years of age. Thereafter a routine booster of tetanus
and diphtheria toxoid is indicated at ten-year intervals.
Management - Previously Immunized Individuals

When the physician has determined that the patient has been previously fully
immunized and the last dose of toxoid was given within ten years: For tetanusprone wounds (i.e., deep penetrating, dirty wounds with extensive tissue injury,
burns) and if more than five years have elapsed since the last dose, give 0.5 ml
adsorbed toxoid.
1.
Individuals NOT Adequately Immunized

When the patient has received only two or less prior injection of toxoid, or the
immunization history is unknown.
a.
For non-tetanus-prone wounds, give 0.5 ml adsorbed toxoid
b.
For tetanus-prone wounds:
i.
Give 0.5 ml adsorbed toxoid
ii.
Give 250 units (or more) of human T.A.T.
iii.
Consider providing antibiotics, although the effectiveness of
antibiotics for prophylaxis of tetanus remains unproved
iv.
Administer, using different syringes and sites of injection
v.
Will require tetanus toxoid boosters at 2 and 6 months to be fully
immunized
56
Penetrating Neck Injury
Definition of Zones
Zone I
Zone II
Zone III
Below cricoid cartilage [base of the neck]

Between cricoid cartilage and angle of mandible
Above the angle of the mandible
Assessment:
1. Immediate Exploration of Neck/Chest hard signs of injury
a.
Airway ETT or surgical airway
b.
Expanding hematoma
c.
Active hemorrhage
d.
Shock
e.
Obvious major vascular, esophageal, or tracheal injury, SQ air or
crepitus
f.
Air bubbling from the wound
g.
Dysphonia
Management:
2. Treat based on findings
a.
Oropharyngeal Examination
b.
Arteriography
c.
Ultrasonography
d.
Bronchoscopy
e.
Esophagoscopy
f.
Barium/Gastrografin swallow
g.
CT scanning
3. Antibiotics
Consider antibiotics if any violation of oral or esophageal mucosa [48 hours]
57
Maxillofacial Injuries
Assessment:
1. Manage the ABCs. Fractures of the facial bones are frequently associated with
severe traumatic brain injury and cervical spine fractures.
a. Airway:
Avoid nasotracheal intubation. If an airway is needed, consider
orotracheal intubation with in-line stabilization
Cricothyrotomy should be considered with severe mouth and
mandible trauma
b. Breathing:
Be aware of the possibility of aspirated blood. Any suggestion of
aspiration would indicate the immediate need for a secured airway.
c. Circulation:
Bleeding from facial trauma can be significant and sometimes very
occult. Any hypotension should indicate the need for a vigorous
resuscitation.
d. Disability:
Perform a good neuro exam. In the conscious patient, unequal pupils
will most likely be associated with direct globe trauma or damage to
the oculomotor nerve.
e. Expose:
Make sure that the back of the scalp is examined for any lacerations
that might result in severe bleeding. Control obvious vigorous
bleeding before proceeding.
Management:
Treat based on findings.
2. Once the patient has stabilized, perform thorough secondary survey looking for:
a. Scalp lacerations
b. Depressed skull fractures
c. Depressed frontal sinus fractures
d. Orbital fractures
e. Eye injury, loss of eye motion, and foreign body in eye
f. Zygomatic arch fractures
g. Unstable nasal fractures
h. Maxillary alveolar ridge fractures
i. Missing teeth. View CXR carefully for aspirated teeth
j. Mandible fractures
k. Sensory deficits
l. Hemotympanum
m. Malocclusion
3. If patient is stable and is getting a head CT, consider obtaining facial cuts to include
mandible. Do not delay transfer for CT scanning when transfer necessary.
58
Teeth splinted with

fishing line and
composite resin if
available
Dental Algorithm / Tooth Avulsion

Extruded luxation
Tooth Avulsion
Teeth repositioned
Establish if tooth is primary or permanent
Primary
Permanent with closed apex
Avulsion No treatment
Subluxation/Luxation monitor, if grossly mobile extract
Intrusion allow to passively erupt
Establish length of time tooth has been out of mouth

< 60 minutes (Prognosis Fair)
Take steps to replant as soon as possible
All such cases should be

referred to a pediatric dentist for
radiographic exam and follow-up
to assess damage to underlying permanent tooth
> 60 minutes (Prognosis Poor/guarded)

Re-hydrate via immersion of tooth in Hanks Balanced Salt Solution
or sodium fluoride solution or doxycycline (100mg/20ml saline)
Clean oral wound with saline or Chlorhexidine rinse

Remove coagulum and debris from socket and examine
for bony integrity. Reposition bone with suitable instrument
Reposition any teeth that have been luxated out of position
Transfer Mediums for Avulsed

Teeth
Clean root surfaces of the avulsed tooth, removing gross debris with
saline stream (not under tap) Do not touch the root surface.
Hanks Balanced Salt Solution
Replant slowly with slight digital pressure.
Skim Milk
Suture gingival lacerations and splint luxated and avulsed teeth with
fishing line and composite resin if available.
Patients own saliva
Types of Tooth
Displacements
Concussion injury to tooth and
supporting tissue without abnormal
loosening.
Subluxation injury to tooth with
abnormal loosing but not displaced.
Luxation injury to tooth with
abnormal loosening and
displacement; intrusion, extrusion,
lateral
Avulsion complete displacement
(buccal vestibule)
Additional Treatment
Check occlusion of teeth adjust if possible
Take dental radiograph if available to confirm replanting
Antibiotics Options
Doxycycline BID for 7 days (dose/age dependent)
Penicillin QID for 7 days (dose/age dependent)
Tetanus booster if tooth was contaminated with soil
or uncertain tetanus coverage history
Chlorhexidine rinse oz , 30-60 seconds
rinse/expectorate BID for 2 weeks
59
Instructions
Splint for 1 2 weeks with referral to DDS
Teeth >60 have poor long term prognosis with increased
risk of ankylosis, root resorption and loss of tooth/bone
Soft Diet x 2 weeks
Soft bristled brush
Internet Bibliography
Eastern Association for the Surgery of Trauma

http://www.east.org/tpg.asp
The Brain Trauma Foundation
http://www.braintrauma.org/
The Academy of Medicine of Cincinnati
http://www.academyofmedicine.org/webpages/ems/traumaguid.asp
Trauma.org
http://www.trauma.org/spine/cspine-eval.html
World Health Organization
http://www.who.int/violence_injury_prevention/publications/services/guidelines_traumac
are/en/
Guidelines for Essential Trauma Care
World Health Organization
http://whqlibdoc.who.int/publications/2004/9241546409.pdf#search=%22trauma%20gui
delines%22
The Internet Journal of Rescue and Disaster Medicine
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijrdm/vol2n2/pmg.xml
American Association for the Surgery of Trauma
http://www.aast.org/
The National Foundation for Trauma Care
http://www.traumafoundation.org/public/links.php
Mountain Area Trauma Regional Advisory Committee
http://missionhospitals.org/pdfs/guidelin.pdf#search=%22trauma%20guidelines%22
Patient Plus
http://www.patient.co.uk/showdoc/40001987/
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov/guidelines
Trauma Practice Guidelines & Algorithms State of Nebraska
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Trauma Practice Guidelines &

Nebraska Department of Health & Human Services

Trauma Practice Guidelines & Algorithms

Primary and Secondary Assessment

Chest Trauma Evaluation

Blunt Chest Trauma Algorithm

Penetrating Chest Trauma Arrest Algorithm

Unstable Blunt Abdominal Injury Algorithm

Traumatic Brain Injury

Blunt Cardiac Injury

Blood and Blood Product Transfusion

X-rays on Multiple Trauma Patients

Open Pelvic Fracture Algorithm

Pelvic Fracture (Bony Instability) Algorithm

Spine Protocol Algorithm

Cervical Spinal Clearance

Spinal Cord Injuries

Cervical, Thoracic and Lumbosacral Spine Injuries

Abdominal Trauma Assessment

Stab Wound to Abdomen Algorithm

Gunshot Wound to Abdomen Algorithm

Deep Venous Thrombosis Prophylaxis

Penetrating Neck Injury

Dental Algorithm Tooth Avulsion

Guidelines for the Care of Trauma Patients

Prior to patient arrival:

Primary and Secondary Assessment

Pericardiocentesis for cardiac tamponade

Remove all clothing

Maintain body warmth

Blood Pressure, Pulse, Respirations, Core Temperature, Skin vitals

Nasogastic tube, urinary catheter, heart monitor, pulse oximetry

Turn patient to inspect back

History: AMPLE, history of accident, tetanus

Glasgow Coma Scale

If patient is on a respirator, do eye opening and motor only.

Revised Trauma Score (RTS)

RTS = Code values [Systolic B/P + Resp. + GCS]

SERIOUS (not life threatening)

SEVERE (life threatening)

CRITICAL (survival uncertain)

MAXIMUM (virtually unsurvivable)

Chest Trauma Evaluation

Traumatic Aortic Rupture:

Blunt Myocardial Injury:

Blunt Chest Trauma

Stable Vital Signs

Unstable Vital Signs

Observation, if < 1000 mL obtained,

If > 1500 mL at insertion or 150 mL for 2 3

Consider Bronchoscopy to Rule Out

Penetrating Chest Trauma Arrest

Recent Signs of Life Within 5 -10 Minutes

No Recent Signs of Life / Asystole

DEAD Cease Activity

DEAD Cease Activity

Unstable Blunt Abdominal Injury

Massive White Out on Chest

Assess Abdomen (FAST)

Thoracotomy in ED < 70 mmHG

Consider 2nd Surgical Team

Thoracotomy in OR > 70 mmHG

Traumatic Brain Injury:

Treatment of Traumatic Brain Injury (TBI):