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Chapter 6 - TRAUMA CARE AND

SURGICAL TREATMENT
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Responding to traumatic events - trauma principles

Every year the statistics of accidents, crime and disasters in the society are on the rise, despite
our best efforts at prevention. Every disaster is a unique challenge, and disaster nurses should
be prepared for anything and everything. A nurse may function as a triage practitioner, a role
that requires that several victims be assessed and prioritized quickly to ensure that resources
are used appropriately. In disaster areas rescue teams must be able to perform under stressful
and often suboptimal conditions. With an understanding of basic trauma nursing skills and
proper planning, nurses can have a significant impact on the outcomes of trauma victims. As
health care professionals, nurses also have a commitment to prevent accidental and
intentional injuries.

Trauma is an injury caused by a physical force. No one is immune to trauma, and traumatic
injuries or disasters can happen at any time. Trauma is the leading cause of death for all age
groups under the age of 44 (CDC - Injury Response, 2008). The elderly and children are
particularly vulnerable to die from injuries. On every continent, regardless of gender, race, or
economic status, injuries remain a leading cause of death worldwide, accounting for more
than 5.8 million deaths each year. Millions of people suffer disabling injuries, and millions
will also be permanently disabled. Annual trauma costs in the United States are estimated to
be between $100 and $200 billion (American Trauma Society).

Disaster nurses are in a unique position to participate in all aspects of disaster response,
including triage, stabilization, definitive care, and evacuation. The nurses goals at a disaster
are to evaluate the scene, set priorities, organize resources, classify victims according to
severity of injury, intervene as indicated, stabilize the victims, and plan transport to the most
appropriate facility. By life-saving techniques and trauma support skills, the rescuers
intervene to if possible prevent deaths, to limit the injuries and promote a return to the best
possible state of wellness.

R Adams Cowley, associated with the renowned Shock Trauma Center section of the
University of Maryland Medical Centers in Baltimore, Maryland developed the concept of
the golden hour. He found that the highest survival rates in trauma victims were influenced
by rescue actions taken in the first hour after the injury. Patients who receive skilled care in
this hour have the best chance to recovery. Quick and the timely help rendered in this crucial
period would ensure that the victim is nearly saved so that appropriate treatment can be made
available from the nearby hospital. To survive injury in combat, every second counts, and
rather than the "golden hour", medical planners in the military now refer to the time
immediately after injury as the "platinum 10 minutes".
The period during which all efforts are made to save a life before irreversible pathological
changes can occur thereby reducing or preventing death may range from the time of injury to
definitive treatment in a hospital. Seconds count in trauma care to make the golden hour
effective and should be distributed as follows to make it fruitful: assessment of the victim and
primary survey 1(-2) minutes, resuscitation and stabilization 5 minutes, immobilization and
transport to nearby hospital. The type of trauma, but also other factors, including the patients
age and medical condition and the estimated time to arrival at the appropriate facility
determine a trauma patients need for transport to a trauma center.

Complications may occur if the patient is not managed appropriately and expeditiously.
Therefore it becomes a priority to transport patients suffering from severe trauma as fast as
possible to specialists, most often found at a Level-I trauma center, for definitive treatment.
Because some injuries can cause a trauma patient to deteriorate extremely rapidly, the lag
time between injury and treatment should ideally be kept to a bare minimum. A trauma center
will often have a helipad for receiving patients that have been airlifted by helicopter to the
hospital. CDC-supported research shows that the overall risk of death was 25 percent lower
when care was provided at a Level-I trauma center than when it was provided at a non-trauma
center. The best prehospital emergency care is doomed to failure if the receiving facilities are
not equipped to carry on a high standard of care after the paramedic has transferred
responsibility for the victim to the emergency department.

Trauma centers vary in their specific capabilities and are identified by designated levels:
Level-I being the highest, to Level-III being the lowest. Level-I trauma centers are
equipped and staffed around the clock to meet the needs of trauma patients. Surgeons,
emergency physicians and anesthesiologists are in the facility 24 hours a day, specially
trained nurses and support staff are ready at all times. These trauma centers serve as outreach
educators and resources for the entire trauma network. Many community hospitals serve as
Level-II trauma centers, where operating facilities and surgeons are immediately or readily
available. A facility classified as Level-III is generally a small rural hospital with limited
staffing and resources. Personnel are generally on call or in house to meet the immediate need
of trauma patients before they are transferred to a Level-II or Level-I facility if the nature of
the injuries so dictate. Some states have five designated levels, in which case Level-V is the
lowest.

The American College of Surgeons (ACS), ("Resources for Optimal Care", 1990) has
identified three phases of death due to trauma: The first peak is within seconds to minutes
to injury. Invariably those deaths are due to lacerations of the brain, brainstem, upper part of
the spinal cord, heart, aorta, or other large vessels. The second peak of deaths occurs within
the first four hours after injury. These deaths are usually due to intracranial hemorrhage,
hemopneumothorax, ruptured spleen, lacerations of the liver, fractured femur, or multiple
injuries associated with significant blood loss. The third peak occurs days or weeks after the
injury and most often is due to sepsis or multiple organ failure.

This scheme with the aspect of time for deaths after accidents indicates the prioritizing of
injured victims (Andrn-Sandberg, 1993):

50% within 30 minutes - extensively injured, impossible to save

30% within 4 hours - significant blood loss, oxygenation problem
20% within weeks - multiple organ failure, sepsis.
The initial medical emergency treatment of seriously injured victims will take place either at
the scene, during transportation or in the emergency department of a hospital (or in a separate
life support facility), in the operating room and the intensive care unit. Emergency Medical
Service (EMS) system is a national network of services coordinated to provide aid and
medical assistance from primary response to definitive care, involving personnel trained in
the rescue, stabilization, transportation, and advanced treatment of traumatic or medical
emergencies. The EMS response system of care, is usually initiated by citizen action in the
form of a telephone call to an emergency phone number (911 available nationwide) after
recognition of serious emergencies. The use of cell phones and sms among the public may
enhance care by improving response time. Subsequent stages include the first medical
responder, ambulance personnel, rescue equipment, and paramedic units, if necessary. In the
hospital service is provided by emergency room nurses, emergency room physicians,
specialists, and critical care nurses and physicians/surgeons.

The National Disaster Medical System (NDMS) works in conjunction with local fire,
police and emergency medical services to provide comprehensive disaster relief. One
component of the NDMS involves civilian, volunteer disaster response teams known as
disaster medical assistance teams (DMATs). DMATs are locally based, federally supported
rapid response teams designed to supplement local medical care when needed, and at times,
even in other states. Teams known as international medical/surgical response teams
(IMSURTs) will make resources available to more areas, even outside the United States and
its territories.

At the scene

The overall approach to the situation of multiple casualties is to maximize use of available
resources and promote optimal outcome for all the trauma victims. When confronted with a
trauma victim the EMS professionals or other rescuers perform an initial rapid assessment
(about 1-2 minutes) of the airway, breathing and circulation and look for injuries that threat
life and limb. Principles of triage are that salvage of life takes precedence over salvage of
limbs. The immediate threats to life are asphyxia and hemorrhage.

Once the primary survey to secure vital functions, according to the basic scheme: Airway,
Breathing, Circulation, and life-threatening conditions affecting the airway, breathing, and
circulation have been adequately managed, a rapid methodical examination (secondary
survey) is required. The rapid secondary survey should begin with an assessment of
consciousness and vital signs and proceed systematically in head-to-toe order
(Disability=response when spoken to/stimulation; Exposure=head-to-toe survey). The head-
to-toe survey should not take more than one to two minutes. If the primary survey elicits any
positive findings, such as an obstructed airway or massive hemorrhage, it will be necessary to
attend those problems, before proceeding further in the assessment of the injured victim. In
the secondary survey the patient will be systemically examined from head to toe, in attempt
to detect any less obvious injuries or signs that may give clues to underlying medical
problems.

Speed is essential in evaluating and managing the multitrauma victim, and every effort must
be made to get the victim to a hospital as quickly as can be safely accomplished. In general,
the victim cannot be stabilized at the scene. Therefore, try to keep the victim alive and
prevent further injury while you ensure prompt arrival at a suitable medical facility (a
regional trauma center). The strategies to "load and go"/"scope and run" or to "stay and play"
must be chosen depending on the situation and hence vary between different accidents and
even between different stages during the course of events of the same accident. The distance
and the estimated time from the scene to arrival at the appropriate facility are also of great
importance. Rules (practical advice) for treatment of seriously injured both prehospital and at
the hospital should be simple and of basic ABC-character. First aid can be trained by lay
public, and also how to call for emergency assistance and how to secure the scene from new
damages.

The management of injured should follow a fixed scheme. This can be divided into four
phases (Andrn-Sandberg, 1993):

1. Primary survey of injuries and the type of trauma.

2. Secure the airway, breathing, circulation and immobilize the spine.
3. Standardized examination.
4. Start of the victims definitive treatment.

Phases 1 and 2 are applicable at the scene. No transport is meaningful if the injured is not
breathing. Severe bleeding can be life threatening, but by applying direct pressure to the
external bleeding you can stop almost any form of bleeding. Shock prophylaxis can also be
given. When a patient is in shock, the secondary priority (after establishing the airway) is to
try to determine the cause of shock so effective interventions can be started.

Knowledge of the type of disaster may help you drew conclusions about the number of
injured, the nature and type of injuries likely to occur in disaster victims.

Expected injuries at different disasters

Type of disaster Type of injury

Motor vehicle
Head injuries
accidents
Fractures
Neck and back injuries
Thoracic and abdominal injuries
Railway accidents Head injuries
Fractures
Neck and back injuries
Thoracic and abdominal injuries
Crush injuries
Ship accidents General cooling (hypothermia)
Fires Burns
Inhalation injuries
Smallpox, antrax, botulism, cholera, plaque, tularemia, and
Bioterrorism agents
hemorrhagic fever
Chemical emergencies Chemical burns
Difficulty breathing
 Irritated eyes, skin, throat
Radiation emergencies Radiation injuries
Natural disasters Varying injuries
Crush injuries
Burns
Drowning
Epidemics Infectious diseases
Pandemic influenza
Resistant microorganisms

In the emergency room

In American literature two letters have been added to the ABC plan of assessment, hence the
beginning of the alphabet then means (Andrn-Sandberg, 1993):

A - airway maintenance with spinal control

B - breathing and ventilation
C - circulation with hemorrhage control
D - disability: neurologic status
E - exposure: completely undress the patient.

The more severe injuries, the more important it gets to follow A-E. Patients must be
reassessed as often as possible, because their condition can deteriorate quickly. For example,
tension pneumothorax and bleedings around the pelvic fractures, can give symptoms first
after a few hours. If you can ask the injured: "What it was that happened?" Youll get
valuable information about injuries, to be expected and at the same time get knowledge about
upper airways, breathing and the patients neurologic status. At the same time the investigator
can palpate the injured patients pulse, look at the skin color, and thereafter the capillary refill
(by pressing on and then releasing the patients skin at the base of the fingernail). The
respiratory rate and depth is also noted as soon as possible. Simultaneously survey of several
aspects will show a reasonable overview of the injuries type and severity. A rapid, accurate
assessment and history are the keys to successful intervention for the trauma patient. The
following texts discuss intervention for specific traumatic injuries.

Assessing the trauma patient

The Field Triage Decision Scheme: The National Trauma Triage Protocol

The Division of Injury Response (DIR) at CDCs Injury Center seeks to improve outcomes
for those who have survived severe injuries and to improve emergency care practices. The
"Field Triage Decision Scheme: The National Trauma Triage Protocol" (Field Triage
Decision Scheme) was developed in 2006 in partnership with the American College of
Surgeons-Committee on Trauma and the National Highway Traffic Safety Administration
(NHTSA) and is grounded in current best practices in trauma triage. The Decision Scheme is
intended to be the foundation for the development, implementation, and evaluation of local
and regional field triage protocols. CDC has developed easy-to-use materials for emergency
medical services professionals (such as a training guide for EMS leaders, guidelines, posters,
pocket card, badge, and protocol) (CDC - Field Triage Decision Scheme, 2010).
The "Field Triage Decision Scheme" provides information that EMS professionals can use to
take an active role in improving the outcomes for the acutely injured.

Field Triage Decision Scheme: The National Trauma Triage Protocol

Step 1: Measure vital signs and level of

consciousness

Glasgow Coma
< 14 or
Scale
Systolic blood
< 90 mmHg or
pressure
< 10 or > 29 breaths/minute
Respiratory rate
(< 20 in infant < one year)

If YES, Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously
injured patients. These patients should be transported preferentially to the highest level of
care within the trauma system.
If NO, Continue to assess anatomy of injury.

Step 2: Assess anatomy of injury

* All penetrating injuries to head, neck, torso,

and extremities proximal to elbow and knee
* Flail chest
* Two or more proximal long-bone fractures
* Crushed, degloved, or mangled extremity
* Amputation proximal to wrist and ankle
* Pelvic fractures
* Open or depressed skull fracture
* Paralysis

If YES, Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously
injured patients. These patients should be transported preferentially to the highest level of
care within the trauma system.
If NO, Continue to assess mechanism of injury and high-energy impact.

Step 3: Assess mechanism of injury and

high-energy impact

* Falls
- Adults: > 20 ft. (one story is equal to 10 ft.)
- Children: > 10 ft. or 2-3 times the height of
the child

* High-Risk Auto Crash

- Intrusion: > 12 in. occupant site; > 18 in. any
site
- Ejection (partial and complete) from
automobile
- Death in same passenger compartment
- Vehicle telemetry data consistent with high
risk of injury

* Auto v. Pedestrian/Bicyclist Thrown, Run

Over, or with Significant (> 20 mph)
Impact

* Motorcycle Crash > 20 mph

If YES, Transport to closest appropriate trauma center, which depending on the trauma
system, need to be highest level trauma center.
If NO, Continue to assess special patient or system consideration.

Step 4: Assess special patient or system

consideration

* Age
- Older Adults: Risk of injury death increases
after age 55 years
- Children: Should be triaged preferentially to
pediatric-capable trauma centers

* Anticoaugulation and Bleeding Disorders

* Burns
- Without other trauma mechanism: Triage to
burn facility
- With trauma mechanism: Triage to trauma
center

* Time Sensitive Extremity Injury

* End-Stage Renal Disease Requiring

Dialysis

* Pregnancy > 20 Weeks

* EMS Provider Judgment

If YES: Contact medical control and consider transport to a trauma center or a specific
resource hospital.
If NO, Transport according to protocol.
When in doubt transport to a trauma center.

By U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

For more information on the Decision Scheme, visit www.cdc.gov/FieldTriage

Airway management, breathing and ventilation

Advanced Trauma Life Support (ATLS) program and courses are designed for doctors
who care for injured patients, but the training program has also been used in a modified form
in the education of nurses and paramedics. The program, developed by the American College
of Surgeons (American College of Surgeons, 2008), has been adopted worldwide in over 40
countries, sometimes under the name of Early Management of Severe Trauma (EMST). Its
goal is to teach a simplified and standardized approach in the initial assessment and
management of acute trauma cases. This modified triage decision scheme for management in
situations of mass casualty/disaster with general principles for primary survey is
characterized by among others the ATLS-education. Assess the patients condition rapidly
and accurately; resuscitate and stabilize the patient according to priority; determine if the
patients needs exceed a facilitys capabilities; arrange appropriately for the patients
definitive care; and ensure that optimum care is provided. The lack of a definitive diagnosis
and detailed history should not slow the application of indicated treatment for life-threatening
injury, with the most time-critical interventions performed early. One of the most widely used
adaptations is the addition of "DR" in front of the basic "ABC", which stands for Danger
and Response. The approach in first aid is to protect yourself before attempting to help
others, and then assure that the victim is unresponsive before attempting to treat them, using
systems such as the AVPU scale or the Glasgow Coma Scale (which are described further
under Disability and Exposure, and Head injury). As the original initials were designed for in
hospital use, this DR ABC was not part of the original protocol.

Airway
Secure vital functions Breathing
Circulation
Disability=Response when spoken to/stimulation

Exposure=Head-to-toe survey
Rapid methodical examination Chest Head
Abdomen Skeleton
Pelvis
DECISION ACTION
Decision/Priority
PRIORITY

Triage of the individual victim with injuries is initiated with the primary survey, according to
the basic ABC-plan of assessment: Airway, Breathing, and Circulation. The first priority
for trauma victims is to establish a patent airway and breathing. Ask all conscious victims
what happened, and where they think they are hurt. A simple appropriate verbal response
reveals that the victim is conscious (cerebral perfusion is adequate) and the airway is open
(ventilation is occurring). In multitrauma as in medical problems, the airway always merits
primary attention and accurate assessment. If the first contact establishes that the victim is
unconscious, immediately further evaluate the airway, breathing, and circulation. Continue to
speak to the victim as though he or she were conscious, as hearing is the last sense to be lost,
and the victim actually may be aware on what is happening. Patients with obstructed airways
must receive immediate efforts to relieve the obstruction. The unconsciousness victim is in
constant jeopardy of mechanical obstruction, and immediate intervention will be required,
otherwise the victim may die within minutes. When dealing with the victim of trauma
remember that any patient with significant head or facial injury is assumed to have cervical
spinal injuries until proved otherwise. Movement of the victims head and neck could
aggravate any spinal injury and cause permanent disability. Efforts to open the airway must
take this into account, and manipulation of the neck must be kept to a minimum. Some
rescuers and protocols use an additional lowercase letter (small) c in between the A and B,
AcBC, standing for cervical spine or consider C-spine, as a reminder to be aware of
potential neck injuries to a victim.

The most common cause of airway obstruction in an unconscious or semiconscious trauma

victim is the tongue falling back into the throat to block air flow through the pharynx. Other
causes include the epiglottis falling back to occlude the trachea; secretions, blood, vomit,
loose or avulsed teeth, broken dentures, or foreign bodies obstructing the airway; mucous
membrane swelling (due to heat or toxic fumes); and trauma to the head and neck.

Look, listen and feel to assess respiratory exchange. Quickly scan the entire victim. Look for
obvious trauma, note skin color and affect. Both sides of the chest should move together with
equal expansion. Victims with inadequate oxygen in their blood will become restless and
agitated. Kneel, lean close to the victims head, peering down at the chest and listen to the
sound of air passing in and out of the victims nose and mouth. Gurgling sounds or snoring
may indicate the upper airway is partially obstructed. If the victim is hoarse, damage to the
laryngeal structures can be suspected. Feel for the flow of air by holding the palm of your
hand near the victims nose and lips. Place your palms lightly on each side of the victims
chest over the ribs to feel if both sides of the chest are rising equally. Evaluate the integrity of
the rib cage, and gently feel for fractures or distorted areas. A pale skin tone indicates that
perfusion is less than adequate. Cyanosis is a late and ominous sign of hypoxia, chiefly
occurring when death is imminent. Cyanosis is difficult to assess if the victim is
simultaneously cold, bleeding out (exsanguinating), or poisoned by carbon monoxide.

Establishing an open or patent airway with adequate air exchange (ventilation) is the first
priority in every trauma patient, because without adequate ventilation, severe brain damage
and death are inevitable. The victims outcome is directly related to the ability to open and
secure the airway. Sometimes simply lifting and holding the victims tongue off the back of
the throat by using the chin lift or forward displacement of the mandible (jaw trust), or both,
with the neck in neutral position and the head stabilized will enhance air flow markedly.
Open the airway, by lifting the victims chin with your index or middle fingers, or place your
thumbs at the angles of the victims jaw to lift the mandible and relieve any obstruction. If the
victim is not breathing take immediate action. Check for a pulse in the carotid artery while
you are evaluating the breathing, and if the patient still does not breathe spontaneously, begin
CPR in accordance with current established guidelines. As of 2010, the American Heart
Association chose to focus CPR on reducing interruptions to compressions, and has changed
the order in its guidelines to Circulation, Airway, Breathing (CAB) (Hazinski, 2010).

A rigid cervical collar should be placed to prevent movement of the head and neck that
might aggravate spinal injury. Examine the mouth for foreign bodies, and carefully sweep
secretions, blood, vomit, and foreign materials from the mouth. Flexion of the head (chin to
chest) is a major mechanism of injury in most spinal trauma. Be careful and avoid especially
bending the neck forward, which is implying the greatest risk to worsen a cervical spine
injury. If suction is available, use a rigid suction. If a skull fracture is present, flexible
suction catheters may enter the cranial vault. The recovery position is for when someone is
unconscious but otherwise unhurt, and breathing normally. Frequent reassessments of the
victim are essential.

An artificial airway may be all that is needed to secure an open airway in the unconscious or
semiconscious victim. Oropharyngeal/oral airways are curved pieces of plastic that are
placed into the mouth to hold the tongue off the back of the throat. The easiest method for an
adult is to insert the airway upside down and then rotate it right side up after its in the proper
position. Alternatively, displace the tongue using the tongue blade and then insert the airway
into the proper position. They are available in a variety of sizes. The correct size will extend
from the victims lip to his earlobe. They are not tolerated by conscious or semiconscious
patients because they may stimulate gagging, vomiting and laryngospasm. Nasal airways are
trumpet-shaped soft, flexible tubes of rubber or plastic that are slid down through a nostril to
keep the tongue off the back of the throat and thus secure flow of air. Nasal airways are better
tolerated by conscious or semiconscious patients because they do not stimulate the gag reflex
as vigorously as oral airways do. They can trigger nose bleeds, and worse the tube may enter
the cranial vault if a skull or mid facial fracture is present.

Artificial ventilation is begun on patients who are apneic. If no spontaneous respiratory

effort occurs after you open the airway, begin artificial respirations and secure the airway.
Give the victim oxygen at the earliest possible moment. If proper technique is used, a
manual resuscitation device with a bag, valve, and mask (bag-valve device, ambu bag)
can be used in conjunction with an oropharyngeal airway and 100% oxygen to provide
adequate ventilation. Ventilations need to be synchronized so that theyre given between
cardiac compressions to allow inflation of the lungs and decrease the risk of aspiration
(before proper intubation by a tube through the mouth, nose, or throat). Endotracheal
intubation is the preferred method of airway management because it isolates the airway,
keeps it patent, and decreases the risk of aspiration. A cuff or balloon near the tip of the
plastic tube is inflated to seal off and protect the lungs from the contents of the stomach and
throat. The tube allows delivery of high concentrations of oxygen, provides easier access for
suctioning and another route for administering potentially lifesaving drugs. Sophisticated
invasive procedures should only skilled professionals attempt to perform. If facial fractures
produce instability of the maxilla and mandible, nasotracheal intubation or cricothyrotomy
(an emergency incision into the larynx) may be urgently required. Prepare to assist with
intubation or establishment of a surgical airway if the victims condition so indicate.

If the victim is breathing, but respiration is noisy, an airway obstruction may still be present
in the airway or the victim may have serious head, neck or chest injuries. Cut off clothing
from the upper part of the victims body and again look, listen and feel for trauma. Look for
obvious deformities in, or trauma to, neck and chest. Feel for crepitations, escaping air, and
variations in the chest wall, and listen for sounds of breathing. This is an emergency, and the
victim should be transported immediately to the nearest hospital.

If the victim is apneic after a patent airway has been established, or if breathing is very
shallow or slow, artificial ventilation must be initiated preferably with high oxygen
concentrations. Effective respiratory exchange also depends on intact lung-chest wall
dynamics. Thus, the seriously traumatized victim requires further measures to establish useful
breathing. Open wounds of the chest should be sealed immediately. Blunt trauma of force
sufficient to fracture the rib cage often is associated with bruising of the heart and the lungs,
such as pulmonary contusion. It may cause immediate, life-threatening hypoxia or develop
into respiratory distress later. The ribs most commonly broken are the fourth and tenth. If the
end of a fractured rib has penetrated the lung, possible pneumothorax or hemothorax can
occur. Pneumothorax is entry of air into the pleural space with a partial or complete collapse
of the lung. The victim must be reassessed frequently for evidence of developed
pneumothorax, and the seal released periodically if such evidence is found. Massive
hemothorax is the presence of blood in the pleural cavity, and it often accompanies
traumatic pneumothorax. An open or traumatic pneumothorax has a sucking noise at the site
of the chest wall defect. A tension pneumothorax is caused by air entering the pleural space
and getting trapped there, thus increasing tension. Tension pneumothorax is a life-threatening
situation and must be decompressed at the earliest possible opportunity. Flail chest, a thorax
in which multiple rib fractures cause instability in part of the chest wall and paradoxic
breathing, with the lung underlying the injured area contracting on inspiration and bulging on
expiration, and will result in hypoxia if it is uncorrected. Its treatment may be delayed until
life-threatening problems have been dealt with.

Subcutaneous emphysema and tracheal deviation must also be identified if present.

Subcutaneous emphysema is a condition in which trauma to the lung or airway results in the
escape of air into the subcutaneous tissue, especially the chest wall, neck and face, causing a
crackling sensation on palpation of the skin. Bleeding is often perfuse in neck injuries with a
frothy mixture of air and blood blowing through the penetrating wound. The lung and air
passages can be injured by heat, smoke, or toxic fumes. Absent or ineffective breathing also
can be caused by an injury of the respiratory center due to brain injury, hypoxia, or
circulatory shock.

Circulation, hemorrhage and shock

The next priority, after establishing a patent airway and breathing, is to evaluate the
circulation, as apnea and trauma can cause cardiac arrest from loss of circulating blood
volume or hypoxia. Blunt or penetrating trauma to the soft tissue, organs, or bones may result
in shock. Shock is a complex syndrome, developed as the body responds to a disorder thats
causing inadequate circulation or tissue perfusion to support organ function. In the victim of
multiple trauma the heart itself may be damaged by crushing injury to the chest and injury to
the spine can severely comprise the ability of blood vessels to constrict in response to loss of
volume. Blood volume may also be lost through massive external or internal hemorrhage. If
the pulse cannot be felt with properly executed external cardiac compressions, consider the
possibility of cardiac tamponade (significant quantities of blood in the inelastic pericardial
sac (pericardium) surrounding the heart, which limit the ability of the ventricle to fill). The
transport must not be further delayed. Accomplish whatever actions are necessary according
to the primary survey (establish an airway and control external bleeding by direct pressure)
and move swiftly to the hospital. Thus, attempts to restore circulation to the injured must go
beyond mere external cardiac compressions.

Shock occurs in many forms, with signs and symptoms varying according to the cause and
the victim's preexisting conditions. The victims body will respond initially with the same
compensatory mechanisms. The circulatory, neurologic, and endocrine system will all react
to an effort to restore circulating blood volume and increase tissue perfusion. If interventions
are successful, this compensation cycle may successfully reverse the shock process, but the
compensatory mechanisms are effective for only a short time. Then the victim's condition
will deteriorate rapidly in a cycle of decompensation that almost invariably results in death.
Trauma can cause hemorrhagic shock due to significant blood loss. Hemorrhagic or
hypovolemic shock is the most common shock in trauma patients. Hemorrhage is also the
predominant cause of preventable post-injury deaths.

Assume that internal hemorrhage has occurred whenever a traumatized victim has a
distended or tender abdomen, fractured long-bones in extremities proximal to elbow and
knee, pelvic fracture, bleeding from body orifices, penetrating injuries to the head, neck or
torso, or hematemesis. If you can palpate a carotid pulse, the systolic blood pressure is
presumed to be at least 70 mm Hg; the femoral pulse, 80 mm Hg; and the radial pulse, 90 mm
Hg. If there is no palpable pulse commence external cardiac compressions. Start resuscitation
efforts when the victim appears to have a chance for survival. The victim should be
transported immediately to the nearest hospital, preferentially to the highest level of care
within the trauma system.

Cardiogenic shock is an inadequate pumping of the heart, resulting in decreased systemic

blood flow and inadequate tissue perfusion. Cardiogenic shock is not as common as
hypovolemic shock in trauma patients, but it must be considered when no evidence of blood
loss is present, but the victim has signs and symptoms of shock. This shock may originate
with trauma to the heart (did a myocardial infarction cause the accident? or was the heart
injured in the accident or assault? or by a cardiac tamponade?).

When the circulating volume is adequate but the distribution of it is impaired, distributive
shock has developed, identified as neurogenic shock or septic shock. A neurogenic shock,
which results from peripheral vascular dilation, can be caused by a serious injury to the spinal
cord. Suspect neurogenic shock in any injured victim who has paralysis and whose
hypotension is not accompanied by tachycardia. The victim may be severely bradycardic, if
the cardioaccelerator nerves T1-T4 are blocked by spinal injury (Chitwood, 1995).

Septic shock is when massive infection causes vasodilatation and inadequate tissue
perfusion. Unless treatment of the victim was delayed, or injury has caused contamination of
the abdominal cavity from disruption of the gastrointestinal system, septic shock is seldom a
concern in the initial management of injured victims. If the skin is warm, pink, or ruddy, and
the pulse pressure is widened rather than narrowed should septic shock be suspected.

Penetrating chest injuries such as cardiac tamponade can cause a flow obstruction shock
when the ejection of blood from the heart is impeded, and also cardiogenic shock.

Anaphylactic shock, an exaggerated allergic reaction which may be rapidly fatal, is seldom
an issue in injured victims.

The first priority is always to establish or maintain your victim's ABCs. Then concentrate on
replacing body fluids that the victim is losing in a hypovolemic shock. Initially, normal saline
solution or lactated Ringer's solution is usually started to expand blood volume. The only
fluid that replaces lost blood cells is blood itself, a colloid. Researchers are also looking for
artificial blood substitutes that can carry oxygen to tissues. In life-threatening situations,
unmatched type O, Rh- specific blood should be given after 2 to 3 liters of lactated Ringer's
solution until cross matched blood is available (Rh negative blood is given to women of
childbearing age, and Rh positive to men) (The clinical answer book, 1996).

In the United States the size of the blood loss is classified from Class 1 to Class 4. The
symptoms for an adult male (154lb, 70kg) can be outlined like this (Andrn-Sandberg, 1993):

Class
Class 2 Class 3 Class 4
1

Blood loss 1500-

<750 750-1500 >2000
(ml) 2000
Pulse <100 >100 >120 >140
Pulse
normal normal decreased decreased
pressure
Blood
pressure normal decreased decreased decreased
(mmHg)
Capillary
refill after
normal slow slow slow
hard
pressure
Respiratory
14-20 20-30 30-40 >35
rate
Urine
output >30 20-30 5-20 0-5
(ml/hour)
anxious
Brain confused or
normal anxious and
function unconscious.
confused

Adults normally have a total blood volume of 7% to 8% of body weight, or 70 ml/kg of body
weight for men and about 65 ml/kg for women. Pulse pressure, the difference between the
systolic and diastolic pressures is normally 30 to 40 mm Hg.

Lethal blood loss if not replaced (rapid): is 2.0 L for an adult male with a total blood volume
of 5.0-6.6 L; 1.3 L for an adolescent with a total blood volume of 3.3-4.5 L; and 0.5-0.7 L for
a child with a total blood volume of 1.5-2.0 L (Grant, Murray, & Bergeron, 1990). For a
newborn infant within normal weight range with a total blood volume of 300+ ml, a blood
loss of 30-50 ml is lethal if not replaced.

The American College of Surgeons committee on trauma recognizes four types of

hypovolemic shock (Trunkey, 1985; Andrn-Sandberg, 1993):

Blood loss (adult

Class Treatment
male)
(%) (ml)
1 <15 750 Lactated Ringer's
 solution
Lactated Ringer's
solution, Possibly
2 15-30 750-1500 Macrodex
(Dextran) Red
Blood Cells
Lactated Ringer's
solution, Possibly
Macrodex
3 30-40 1500-2000
(Dextran) Red
Blood Cells (but
more rapidly)
Lactated Ringer's
solution Red
4 >40 >2000
Blood Cells
Albumin.

Most patients, can lose about 750 ml (15%) of blood volume without exhibiting signs or
symptoms because of the body's compensatory mechanisms. Signs and symptoms when
someone loses up to 1500 ml (15-30%) of the body's blood volume include increased heart
and respiratory rates, narrowed pulse pressure, anxiety, pale cool skin, and slow capillary
refill. When someone loses up to 2 L (30-40%) of the blood volume signs of inadequate
perfusion appear, including hypotension, tachycardia, tachypnea, and a decline in mental
acuity.

A systolic blood pressure less than 70 mm Hg and a pulse greater than 130 beats per minute
imply at least 40 percent loss of the blood volume. This is a critical situation, and the death
may be imminent. When losing more than 40% of the blood volume (Class IV hemorrhage),
the pulse is rapid and shallow as are the respirations, the skin is cold and clammy, urine
output dwindles and stop, and the patient may lapse into a coma. As death looms, the heart
slows and then finally stops. Note that elderly patients are vulnerable to fluid overload and
that compensatory mechanisms can be compromised by age or cardiovascular diseases.

Clinical signs of shock are:

Skin is pale, clammy and cold, especially peripherally on the extremities.

Veins are collapsed.
Pulse is weak, thready (low pulse pressure), and rapid.
Breathing is shallow and rapid.
Appears apathetic, unresponsive, and frozen. Signs of restlessness and anxiety, an
affect also related to decreased blood flow to the brain.

Shock should be anticipated in every seriously injured patient. Establish shock prophylaxis
within the scope of your license, skills and training:

Apply direct pressure to a bleeding wound to slow the outflow of blood and
encourage clotting. Do not apply direct pressure to bleeding from an injured eye,
because this could cause loss of vision and the eye itself.
 Elevate the injured part to reduce blood flow if the extremity has no fractures and
spinal injury has been ruled out.
If the victim's injuries are severe, raise the level of his feet above his chest and head,
unless there is a head injury, a broken nose, or if he is having trouble breathing.
Trendelenburg position.
Tourniquets should be used only as the last resort and in the cases of massively
traumatized extremities where there has been injury to major blood vessels, such as
traumatic amputation.
For major trauma, involving the lower extremities, abdomen, or both,
Military/Medical Anti-Shock Trousers (MAST) are used to combat shock, stabilize
fractures, promote hemostasis, increase peripheral vascular resistance, and permit
autotransfusion of small amounts of blood. They also are used in emergencies in the
treatment of hemorrhagic shock, as ordered, by a member of the trauma team or
someone specially trained in its application.
Avoid chilling. Cover the victim with a blanket to retain body heat.
Establish and secure open airway and adequate ventilation.
Administer oxygen to reduce the potential for hypoxia, and assisted ventilation as
needed.
Allay anxiety and fear, by using a calm, safe, and friendly approach. Explain what
you are doing and why. Answer the victims question when possible.
Be careful when lifting and moving the victim and immobilize fractures before longer
transports.
If analgesics are given, it must be carefully recorded (time, drug, dose, and route) on a
triage tag.
Do not give the injured victim anything by mouth in case surgery is necessary or in
case the victims level of consciousness decreases.
Start two large-bore intravenous lines and begin fluid resuscitation as ordered with
crystalloids (a clear intravenous fluid, such as normal saline or lactated Ringer's
solution, that can diffuse through a semipermeable membrane), or colloids (a plasma
expander).

Disability and Exposure

In the concept of ATLS has assessment of possible neurologic effect Disability been noted as
the first action after securing vital functions. In situations with many injured, where the
decision scheme must be adjusted to maximum efficiency should this neurologic assessment
only be very rough with the aim to give an early indication of head injury. A basic neurologic
assessment is made, using the AVPU scale (Alert, Voice, Pain, Unresponsive) system by
which a first aider can measure and record a victim's responsiveness, indicating their level of
consciousness (Kelly, Upex, & Bateman, 2005). It is a simplification of the Glascow Coma
Scale, which assesses a patient response in three measures, eyes, voice, and motor skills. The
AVPU scale should be assessed using these three identifiable traits, looking for the best
response of each.

- Response when spoken to (verbal stimuli response) = fully awake, drowsy, no response.
- Response to pain stimuli (pain stimuli response) = adequate, inadequate, no response.
- If fully awake (alert) = finish and continue to Exposure.
- If no response to pain (unresponsive) = consider if you should stop (a head injury with no
response to pain has in these situations a mortality of close to 100% (according to a material
of Victims of War during the Vietnam War) (Lennquist, 2002).
A more detailed and rapid neurologic assessment should be performed after the injuries to the
trunk, which can be directly life-threatening and require immediate interventions and with
that have higher priority. This assessment establishes the state of consciousness, pupil size
and reaction, lateralizing signs, and spinal cord injury level.

The most important clinical sign in head injury is a changing state of consciousness
indicating the need for immediate reevaluation of the victims oxygenation, ventilation and
perfusion status. If the victim is unconscious, consider all potential causes, including
traumatic brain injury, hypoglycemia, alcohol, and drugs, that might account for loss of
consciousness.

The Glasgow Coma Scale is a quick, practical standardized system for assessing the level of
consciousness and for predicting the duration and ultimate outcome of coma, primarily in
patients with head injuries. If not done in the primary survey, it should be performed as part
of the more detailed neurologic assessment in the secondary survey.

Exposure in the concept of the ATLS means a rapid methodical physical examination
systematically in head-to-toe order. To do this properly, one must cut away the victims
clothes, preferably in a shielded area where privacy can be maintained. Cover the victim with
blankets to retain body heat. Victims exposed to major trauma, generally have multiple
injuries (to 2-3 organ systems). Deaths or complications among trauma victims are often due
to airway obstruction, or less obvious but more dangerous injuries, which are overlooked
because of dramatic injuries elsewhere. The multitrauma victim must reach a suitable medical
facility (trauma center) as fast as possible, so do only what you have to do at the scene, and
get moving. Intravenous fluids should be warmed, a necessity especially in cold weather, and
a warm environment maintained (applying warm air-circulating blankets, and increasing the
ambient room temperature). Only after assessing ABC and disability does the responder deal
with environmentally related symptoms or conditions, such as cold (hypothermia), heat
(hyperthermia, heat stroke), or lightning (during thunderstorms, and sometimes during
volcanic eruptions or dust storms).

When the initial ABC survey is complete, the airway is secure, ventilation is monitored or
initiated, and the circulation is adequate, spine immobilized, begin the secondary survey.
Assess state of consciousness, take time to stop any active bleeding and to determine other
signs of trauma. The secondary survey may take place at the scene or during transport. The
rapid methodical examination include assessment of the following areas: chest, abdomen,
pelvis, head (including neurologic assessment), and at the end vertebral column and skeleton.
After securing vital functions and the rapid methodical examination you must in this situation
stop and make decisions about further actions and priorities for treatment and transport to a
trauma center.

Details of the physical examination and treatments are best recorded on a triage tag affixed
to the victim. Priority of treatment, can be indicated by using color-coded tags or affixing a
color-coded sticker to the triage tag during the first round of triage. The triage designation
can be based on a color system with following colors; black/white-deceased, red-immediate,
yellow-delayed, and green-minor. You place a triage tag on each victim and tear off the
colors until the color at the bottom matches the victims classification. The purpose is to
indicate to the rescuers which patients require most urgent or ongoing attention, according to
the judgment of the triage team leader. In the situation in which there are insufficient
numbers of evacuation vehicles, evacuation priorities must also be assigned.
In the emergency room, cut away the patient's clothes, and use the same methodical physical
examination as at the scene. Maintain cervical spine precautions and vertebral alignment with
help of the trauma team; logroll the patient into the lateral position. Inspect also the underside
of the patient, noting any injuries or abnormalities, and blood losses in clothes. From
conscious patients, it will be important to obtain the usual medical history information, such
as name, age, sex, known medical problems, allergies, and current medication. Type of
injury, localization and type of pain, if the patient has been unconscious, nauseous, or have
vomited are noted.

Chest

Inspection (Look): Penetrating injury? Respiratory movements? Note the symmetry of

the chest as it rises and falls with inspiration and expiration. Distended neck veins?
Trachea midline position?
Auscultation (Listen): Unequal breath sounds?
Palpation (Feel): Rib fractures? Instability? Clavicles fractures?
Percussion: Percussion is performed to evaluate resonance, hyper resonance,
tympany, and dull or flat sounds. If pneumothorax is present, the affected side will
have a more hollow, or resonant percussion note; in the presence of hemothorax, the
percussion note over the affected side will be dull with respect to the normal side.

Abdomen

Inspection: Penetrating injury? Fragments? Contusions? Evisceration? Look for

discoloration, distortation, and distention of the abdomen. An abdomen that is
distended often is filled with blood, and shock is imminent.
Palpation: Low rib fractures, tenderness? Rigidity? If gentle pressure elicits pain,
suspect internal injuries.
Percussion: Are bowel sounds - present or absent? Dull? Tympany? Signs of major
intraabdominal bleeding (dullness over the flank)?

Pelvis

Palpation: Pain/tenderness? If gentle pressure applied to each side of the pelvis elicits
pain, suspect a pelvic fracture.
When fracture signs: Stability or instability? (compress iliac wings).

Head

*Neurologic assessment

Verbal stimuli response and pain stimuli response? Note consciousness using the
Glasgow Coma Scale.
Assessing pupillary changes: size, reaction to light, equality?
The ability to move the arms and legs?
Sensation with a pin or touch?
Babinski's sign?

*Inspection/palpation of the head

 Scalp laceration?
Depressed fracture?
Blood or cerebrospinal fluid (CSF) flowing from the ears or nose?
Battle's sign.

*Inspection/palpation of the face

Facial fractures? Fractures of the maxilla (upper jaw) or mandible (lower jaw).
Ocular (eye) injury.
Dental injury.
Bleeding from mouth our throat.

Skeleton

*Vertebral column (assume cervical injury is present).

-Cervical spine

Palpation: Swelling, tenderness, crepitations?

Very gentle movement: Pain or pain reaction in neck, shoulder, arms?
The ability to move the arms and legs?

-Rest of spine

Palpation: Localized tenderness/swelling?

Pain or pain reaction when mowing?
The ability to move the legs?

-Extremities

External bleeding?
Wound or soft tissue injury?
Fracture or any dislocation of a joint? Systematic palpation of joints and long-bones,
gentle control of movement in joints?
Motion pain, tenderness, swelling, crepitations?
Affected vascularity- or nerve function below the injury: Circulation? Sensations?
Ability to move?

Be restrictive with X-ray examinations in these situations. Computed tomography of trunk

injuries could often be replaced by, for example ultrasound, diagnostic laparocentesis,
thoracocentesis or conventional X-ray images (performed in the operating room or unit).

Most hospitals have plans for meeting the needs of disaster victims, and an awareness of a
facilitys disaster plans is essential for nurses employed there. Whenever multiple victims are
present, the rescuers must set priorities, organize resources, and begin interventions.
Hospitals have to get patients out of the emergency room and in to the hospital rooms so they
do not clog up the system.

Trauma management of severely injured in mass casualty situations/disasters must in the

hospital as well as at the scene be followed by decisions:
 Can the injured be saved to a meaningful life with actions that are reasonable
considering the total need of care? If the answer is no: refrain from further
interventions and give only palliative treatment. If the answer is yes (see below).
Is immediate surgery needed? Directly to pre-operative unit for
preparation/prioritizing for surgery.
Is ventilatory support or other advanced monitoring required? To intensive care unit.
The others who need hospital care: Is admission required? To unit for continued
examination.
The others who dont need hospital care? To primary care (psychosocial support).

Take in the scene and continue to gather information while assessing the victim. If possible,
wear gloves, mask, and goggles for protection whenever examining and caring for an injured
victim. Accurate assessment and compilation of an adequate history are crucial to survival
and outcome. Report your findings to the team accepting your patient. Continual recording
(if possible by assistants) should be done during the work in the emergency department. If
possible use routine flow sheets and checklists. In trauma care, documentation is often
delayed until the patient is stabilized.

The Definitive Surgical Trauma Skills Course (DSTS) was originally designed for the
military, but the training structure has now been adopted to accommodate civilian surgical
consultants and teaches vascular, cardiothoracic and general surgery techniques which are
vital in dealing with trauma injuries (Trauma.org, 2011). The Definitive Surgical Trauma
Care (DSTC) course was developed by the International Association for Trauma and
Surgical Intensive Care (IATSIC) of the International Surgical Society, based in Basel in
Switzerland. The IATSIC was founded in 1988 and serves as a forum for Trauma Surgeons
world-wide.

Types of injuries

The types of injuries that occur in a trauma event depend on the mechanism of trauma. Risk
for trauma, is defined as the accentuated risk of accidental tissue injury, such as a wound,
burn or fracture. Physical injury may be caused by violent or disruptive action or by the
introduction into the body of a toxic substance; psychic injury resulting from a severe
emotional shock (Anderson, Anderson, & Glanze, 1998). Blunt injury is caused by rapid
deceleration, a decrease in the speed, for example when the driver of a car hits a tree. Rapid
forward deceleration can cause blunt trauma in the head, neck, chest, abdomen and
extremities. Rapid vertical deceleration, for example a fall in which the victim slams
against a surface and decelerates, or stops. Impact with the stationary surface will cause blunt
injury and, occasionally, penetrating injury, depending on the surface hit. Potential injuries
are ankle or leg fractures, spinal fractures, or internal injuries.

Most penetrating injuries are caused by projectiles, guns or knives, but any sharp object can
penetrate the body and cause soft-tissue, visceral, or bony injury.

A crush injury occurs when the external surface of the body is exposed to a severe force
applied against the tissues or when the force is sustained for an extended time. The body
structures maybe crushed without signs of external bleeding. Severe earthquakes are a major
cause of crush injuries, but also motor vehicle crushes, construction and industrial accidents,
and terrorist bombings or attacks. Crush injuries are also possible, when a victim remains
lying down for a long time until rescue.
In the following overview injuries to various organ systems, possible or necessary
interventions and principles of management appropriate to each are discussed.

Thoracic injury

Less than 15% of thoracic injuries require the skills of a thoracic surgeon. In many cases,
specially trained nurses and paramedics can perform life-saving procedures at the scene or
during transport. Other patients with chest injuries require prompt skilled interventions,
diagnostic, monitoring and maybe insertion of drainage. Chest injuries can be immediately
life-threatening. They require rapid assessment and intervention because they disrupt the
patients basic life processes. Prepare for basic and advanced life-support measures instantly.
Thoracic trauma is entirely responsible for 25% of all trauma deaths, and injuries to the chest
are the most frequently missed injuries in the first hour of care (Sheehy, & Jimmerson, 1994).

The chest must be assessed by inspection, auscultation, palpation, and percussion. The aim is
to identify and manage six immediately life-threatening, top-priority thoracic injuries at
the scene; airway obstruction, open pneumothorax, tension pneumothorax, massive
hemothorax, flail chest, and cardiac tamponade. Potentially life-threatening thoracic
injuries managed during the secondary survey are pulmonary contusion, aortic disruption,
tracheobronchial disruption, esophageal disruption, traumatic diaphragmatic hernia, and
myocardial contusion. Injured victims must be reassessed as often as possible, because their
condition can deteriorate quickly. Offer quiet and simple explanations and offer frequent
reassurances to the patient as you work even if he or she appears to be unconscious. Hearing
may be present, and high levels of anxiety accompany accidents, assaults, and disasters.
Anxiety accompanies dyspnea and pain and further distresses the patient.

Diagnosis often requires advanced skills and knowledge. Indications for emergency
thoracotomy after chest injuries are: penetrating stab wounds to the heart (entrance wound
over cardiac region, cardiac tamponade); massive or progressive hemothorax (more than
1000 ml initially, more than 800 ml in 4 hours); esophageal injury (odynophagia, mediastinal
or cervical emphysema); and major tracheal or bronchial injury (refractory pmeumothorax,
massive air leak) (Ordog, Wasserberger, Balasubramanium, & Shoemaker, 1994). Make
preparations for an emergency thoracotomy in the emergency department if the patient is
critically injured and his or her condition is unstable.

Assessment of patients with thoracic injuries

Follow the standard ABC-assessment plan: Evaluate the airway, breathing, and circulation.
Take in the scene and continue to gather information while assessing the victim. Be aware
that thoracic trauma is not usually the sole injury. Try to determine the mechanism of injury,
the object that caused the injury, the speed of force, and the area of the thorax hit by the
object. Early detection, intervention, and rapid transportation by the quickest available means
to adequate emergency care are critical to the victims survival. Any victim who has multiple
injuries is presumed to have a spinal injury until proved otherwise. Stabilize the victims head
or apply a Philadelphia collar.

Signs and symptoms of thoracic injury include the following:

Dyspnea.
Shock.
 Hypoxia and cyanosis.
Pain with breathing or at the site of thoracic injury.
Hemoptysis.
Deformity of the neck, chest wall, trachea, or ribcage.
Deviation of trachea from the midline of the body.
Subcutaneous emphysema.
Impalement of an object in the thorax.
Sucking, bubbling, or gurgling sounds from the thorax.
Unequal expansion or excursions of the chest.
Distended or collapsed neck veins.
Muffled heart tones may be indicative of pericardial tamponade.

The absence of overt signs and symptoms of severe injury in patients with blunt thoracic
artery injuries can be misleading, and patients can quickly deteriorate. Thorough and
continuous assessment of patients with blunt chest trauma is important.

Types of thoracic injuries

A closed pneumothorax occurs when air leaks into the pleural space from an opening in the
lung. The chest wall remains intact in this injury, that may be caused by blunt chest trauma.
This type of pneumothorax has a "self-sealing" effect, once the air has leaked into the pleural
space (causing the lung to collapse), the lung tissue seals and the leakage is stopped. Closed
pneumothorax is characterized by decreased or absent breath sounds and hyperresonance on
the side of the collapsed lung.

A sucking chest wound or open pneumothorax, is caused by penetrating trauma to the

chest wall, creating direct access between the pleural cavity and outside air. Air is drawn
through the chest wall opening in to the normally air-tight pleural space by negative
intrapleural pressure during inspiration. The seriousness of the open pneumothorax depends
on the size of the opening. An open pneumothorax has a sucking noise at the site of the chest
wall defect. Because the air doesn't enter the lungs and the blood doesn't exchange gases,
dyspnea and hypoxia occur. Signs and symptoms of open or traumatic pneumothorax include
obvious open defect in the chest wall, dyspnea, tachycardia, shock, and cyanosis.
Management of the sucking chest wound is aimed at sealing off the open defect and
supporting vital functions. Ensure an open airway. Administer oxygen as ordered. An open
pneumothorax wound must be closed immediately by any available means. The wound may
be covered with petrolatum gauze, a rubber glove or plastic wrap. To avoid tension
pneumothorax a special taping method can be used. An occlusive dressing is taped on three
sides. On inspiration, this flutter-valve dressing seals wound, preventing air entry, and during
expiration it allows trapped air to escape through untaped section of dressing. If the patients
condition worsens after application of this dressing, reopen the seal, it may aggravate the
condition. Prepare for needle insertion to relieve tension pneumothorax. A chest tube is
inserted and attached to a water seal drainage system. The tube is not removed until air is no
longer expelled through the underwater drainage system and a radiographic examination
shows that the lung is completely expanded.

A tension pneumothorax is caused by air entering the pleural space and getting trapped
there. If the tear doesn't seal, air enters the pleural space during inspiration, but cannot escape
during expiration, so increasing pressure builds up in the affected pleural cavity, causing a
one-way valve effect. If the tension is not reduced, it puts pressure on the vena cava, causing
a decrease in preload that leads to diminished cardiac output. This positive pressure tends to
push the trachea, heart, esophagus, and great vessels to shift to the unaffected side. A tension
pneumothorax also can be caused by a rescuer who applies excessive positive pressure to a
manual ventilating device and subsequently ruptures the lung, or when the occlusive dressing
applied to seal an open pneumothorax doesn't allow adequate escape of air. Unrelieved
tension pneumothorax can lead to respiratory arrest, and may be fatal within minutes. The
patient will manifest extreme dyspnea, restlessness, and anxiety, the pulse will be weak and
rapid, hypotension, cyanosis may be present, and the neck veins may be distended if the vena
cava is being compressed. Breath sounds will be diminished on the side of the tension
pneumothorax and shock ensues. Ensure an open airway. Administer oxygen as ordered.
Emergency chest decompression of the pleural space with a large bore over-the-needle
catheter and flutter valve (from a rubber glove finger) may be life-saving. If trained and
authorized to do so, insert a large bore needle (14- to 16 gauge) in the affected side of the
chest, in the second to third intercostals space in the midaxillary line. The receiving hospital
should be notified to prepare for chest tube insertion. Any patient with a pneumothorax
whether simple or tension, who needs to be transported by helicopter or plane should have a
chest tube (or catheter) and flutter valve in place to allow for escape of air that may
accumulate in the pleural space with atmospheric pressure changes (Caroline, 1983).

Massive hemothorax is a bleeding into the pleural cavity, and it often accompanies
traumatic pneumothorax. Penetrating thoracic injuries most commonly pierces the organs
contained in the chest, and blunt injury may tear vessels. The accumulation of 1.5 L blood
into the pleural cavity will cause dyspnea due to lung compression. Suspect massive
hemothorax when a patient with thoracic injury is in shock, and has absent or diminished
breath sounds. Proper management of massive hemothorax requires swift and accurate
diagnosis. Ensure an open airway. Administer oxygen as ordered. Assist ventilations as
required. Secure intravenous access with two large-bore intravenous lines and begin volume
replacement as ordered. Administer crystalloids, colloids (plasma volume expander), blood,
and blood products, as ordered, according to the policy. If trained and authorized to do so,
insert a large bore needle or over-the-needle catheter into the affected side of the chest (in the
fifth and sixth intercostal space in the midaxillary line). Use a 50-ml syringe and stopcock to
aspirate as much blood as possible. Move rapidly to the hospital, where a chest tube is
inserted and attached to a water seal drainage system. Massive hemothorax is a serious and
life-threatening emergency that generally requires an emergency thoracotomy. Indications for
emergency thoracotomy are more than 1000 ml blood initially or a continued bleeding of
more than 200 ml/hour during more than 3-4 hours, and also when initial interventions
doesnt reverse the shock process.

Flail chest results from blunt chest trauma, in which multiple adjacent ribs are fractured in
two places, causing a free-floating rib section. The portion of the chest wall that is free-
floating moves in a paradoxical fashion (often palpated during assessment), expanding or
bulging out during expiration and collapsing during inspiration. Additional injuries associated
with flail chest include pulmonary and myocardial contusion, pneumothorax, and hypoxia.
The patient with flail chest injury usually has thoracic bruising, dyspnea, cyanosis,
hypotension, tachycardia, and respiratory acidosis with hypoxemia. Ensure an open airway.
Administer oxygen as ordered. Assist ventilations as required. When ventilatory assistance is
given, the patient must be monitored closely for signs of pneumothorax. Anticipate shock and
establish an intravenous lifeline. Stabilize the flail segment. Respiratory therapy and adequate
analgesia is important. Monitor cardiac rhythm, since chest trauma is liable to involve
myocardial injury as well.
Cardiac tamponade develops when penetrating injury causes blood to leak out of the heart
and into the inelastic sac surrounding the heart (pericardium), which limits the ability of the
ventricle to fill. This condition may be caused by disruption of a coronary artery, rupture of
the myocardium, or severe contusion. Cardiac tamponade is a life-threatening emergency and
will lead to cardiac arrest very quickly if not treated by evacuation of blood from the
pericardial sac. The procedure is best carried out in a hospital, under controlled conditions. A
triad of signs (Beck's triad) aids in the diagnosis of cardiac tamponade: distended neck veins,
hypotension, and muffled (decreased) heart sounds. Noise at the emergency scene may make
it difficult to ascertain any decrease in heart sounds, and the other two signs are also
consistent with tension pneumothorax. Other signs and symptoms of cardiac tamponade
include thready, rapid pulse, and narrow pulse pressure (systolic minus diastolic). If the
patient becomes unconscious and the pulse is not palpable start CPR. Diagnosis and treatment
requires advanced skills and knowledge. Ultrasound is used if available. Aspiration of the
fluid or blood in the pericardial sac (pericardiocentesis) is performed for diagnosis and for
therapy. If emergency thoracotomy is indicated, atropine is administered to increase the heart
rate and shock interventions to increase the hearts filling pressure.

Blunt injury of force sufficient to fracture the rib cage often is associated with bruising of the
chest. Pulmonary contusion, or bruising of the lung, may cause immediate, life-threatening
hypoxia or develop into respiratory distress later.

Tracheobronchial disruption occurs with both blunt and penetrating injury. Blunt injury to
the neck, may cause collapse of the larynx or trachea or consequent airway obstruction.
Penetrating injuries to the neck may sometimes be apparent, if trachea has been disrupted, by
the presence of subcutaneous emphysema in the cervical area and anterior chest wall and by a
frothy mixture of air and blood blowing through the wound. Such penetrating wounds must
be sealed off. Associated injuries of the upper part of the airway may make opening the
airway at the trachea the only option, and even that can be difficult.

Esophageal disruption, mostly caused by penetrating injury is usually diagnosed in the

hospital during post injury assessment and evaluation, and treatment usually takes place in a
hospital.

Myocardial contusion, or bruising of the heart muscle is caused by blunt injury to the
anterior part of the chest. A myocardial contusion behaves in all respects like a myocardial
infarction. Right sided chest trauma frequently results in atrial arrhytmias and heart block,
while left-sided frontal injuries are more apt to cause ventricular fibrillation. This damage to
the heart muscle may cause chest pain, dysrhythmia, and cardiogenic shock. Report changes
in electrocardiogram immediately to physician, and administer antiarrhythmics if ordered.

Aortic rupture (disruption) is a serious condition in which the aorta, the largest artery in the
body, is torn or ruptured as the result of trauma. Blunt injury to the thorax can rupture the
aorta and other great vessels, and objects that penetrate the thorax can also pierce the aorta,
leading to rapidly fatal exsanguination. This can quickly result in shock and death. Most
injured victims have been involved in motor vehicle accidents or falls. Aortic rupture is not
listed as a top-priority thoracic injury because of its high fatality rate. Death occurs
immediately after traumatic rupture of the thoracic aorta 75%-90% of the time since bleeding
is so severe, and 80-85% of patients die before arriving at a hospital (Rousseau, Soula,
Perreault, et al., 1999). Up to 18% of deaths that occur in motor vehicle accidents are related
to the injury. Aortic disruption due to blunt chest trauma is the second leading cause of injury
death (behind traumatic brain injury). Patients who survive the initial injury have a second
chance if you can get them to the trauma center quickly. If conscious, the victim may
complain of pain between the shoulder blades and dyspnea, a minority of patients may be
hoarse. The condition is difficult to detect, chest X-rays are used to diagnose the condition.
The classical findings on a chest X ray are widened mediastinum, apical cap, and
displacement of the trachea, left main bronchus, or nasogastric tube. Aortic rupture is treated
with surgical repair of the aorta. Prepare for surgical procedure. Surgery is associated with a
high rate of paraplegia, because the spinal cord is very sensitive to ischemia, and the nerve
tissue can be damaged or killed by the interruption of the blood supply during surgery (Attar,
Cardarelli, Downing, et al, 1999). Measures to keep the blood pressure low is essential, such
as giving pain medication, keeping the patient calm, and avoiding procedures that could
cause gagging or vomiting.

Both blunt and penetrating trauma can tear the diaphragm, diaphragmatic hernia, and allow
abdominal organs to slip into the thoracic cavity and impair breathing. Any chest injury
below the fifth rib (nipple level) is an abdominal injury as well. Sometimes the injury is not
noted until the thorax is explored surgically, or on the basic of radiographic findings. When
the lung and the heart are displaced by the thoracic organs, breath sounds may be decreased
on one side of the chest, or the heart sounds may be shifted. The patient may complain of
dyspnea, and cyanosis may be evident. Prepare for surgical procedures.

Lacerations and contusions of the thorax cause pain, discoloration, and obvious or occult
bleeding, and potential damage to structures and organs underlying the injury.

Rib fracture is a break in a bone of the thoracic skeleton caused by a blow or crushing
injury. The ribs most commonly fractured in blunt trauma are the fourth to tenth. If the rib is
splinted or the fracture is displaced, sharp fragments may pierce the lung, causing
hemothorax or pneumothorax. Fractures of the upper three ribs indicate a significant blow to
the upper part of the chest and may indicate serious head and neck trauma, facial fractures,
and even the subclavian vessel or the aorta may be injured. Fracture of a simple rib is
significant chiefly because the pain associated with rib fracture tends to impair adequate
respiration. Multiple rib fractures indicate significant blunt trauma and are considered more
serious. Analgesics, rest, and to splint the fracture by hand or by a pillow make deep
breathing easier and may reduce pain.

A foreign object impaled in the thorax should be left in place. The pressure exerted by the
object itself acts to tamponade, or compress, damaged vessels and thus reduce bleeding. Do
not remove an impaled object, as efforts to do so may trigger massive hemorrhage and further
injury to underlying structures. The impeded object should be removed only under controlled
conditions in a hospital. Stabilize the protruding end of the object with bulky dressings, and
bandage them in place. Secure venous access, administer oxygen, monitor the
electrocardiogram, and vital signs, and transport the patient to the hospital.

Traumatic asphyxia (suffocation) refers to a syndrome that results from severe compression
injuries to the chest, such as in a motor vehicle accident. As the sternum is forced inward, it
exerts sudden pressure on the heart beneath, causing the blood in the right heart to back up
into veins of the neck, with associated bleeding into the upper chest and neck. Signs of
traumatic asphyxia are distended neck veins, chest deformity, profound shock, cyanosis of
the head, neck and shoulders, bloodshot and protruding eyes, swollen cyanotic tongue and
lips, and often bloody vomiting (hematemesis). The skin below the level of injury is pink.
Traumatic asphyxia will be rapidly fatal without proper management, and even with adequate
management, the mortality rate is high. Ensure an open airway, and administer oxygen as
ordered. Observe caution and immobilize the spine before moving the victim. Secure
intravenous access with two large-bore lines and begin volume replacement. Check with
physician if shock is profound. Treat tension pneumothorax or sucking chest wound if present
and move rapidly to the hospital.

A fractured sternum (breastbone) causes severe chest pain and sometimes dyspnea. Suspect
a myocardial contusion, and be alert for evidence of hypoxia, hypotension, arrhythmias, or
other indications of further thoracic injury caused by blunt trauma to the anterior part of the
chest. Patients with sternal fracture who are not dypneic, have normal findings on
electrocardiograms, and are hemodynamicically stable can be safely discharged early. The
installation of air bag in motor vehicles has reduced the number of sternal and facial
fractures.

Management of patients with thoracic injuries

Be aware of potential neck injuries to a victim. A rigid cervical collar should be placed to
prevent movement of the head and neck if indicated. It is presumed that the victims airway,
breathing, and circulation have been established and that the injured victim is being
transported to the hospital (trauma center) without delay. Completely expose seriously
injured patients who have multiple trauma, by cutting off clothing. Examine the patient for
injuries.

Ensure an open airway. Begin administration of supplemental oxygen as ordered.

Thoracic injury may cause hypoxia. Assist ventilation as indicated.
Observe and palpate the neck veins as they may become distended in serious chest
trauma. Bulging distended neck veins can indicate obstruction of normal blood flow
into the heart by increasing pressure in the thoracic cavity. Hypovolemia from
bleeding into the chest cavity may collapse neck veins.
Evaluate the trachea for a midline position. Report tracheal deviation, hemoptysis,
distended neck veins, air leaks, and other signs to a physician.
Monitor cardiac rhythm as indicated. Serious arrhythmias may result from myocardial
and vascular damage sustained during thoracic injury. In addition to continuous ECG
monitoring a 12-lead ECG should be performed. Report changes in electrocardiogram
immediately to a physician.
Monitor patient for signs and symptoms of dyspnea, and restlessness and anxiety that
accompany respiratory distress. Monitor breath sounds and respiratory status. Place
the stethoscope in the midaxillary line to compare the bilateral equality of breath
sounds; check for bilateral and equal chest excursions; and palpate for subcutaneous
air. Report any decrease in heart sounds immediately to a physician.
Monitor vital signs closely and as indicated by the patients condition and suspected
injuries. Note and report changes and trends in the patients condition.
Offer explanations and reassurances to the patient as you work, and keep the patient
warm.
Secure intravenous access with two large-bore intravenous lines and begin volume
replacement as ordered, because rapid deterioration may occur. Administer blood
products as ordered.
Have equipment for airway maintenance readily available, and prepare for emergency
intubation and cricothyroidotomy if airway obstruction develops.
 Prepare for emergency thoracotomy if the patient is critically injured and his or her
condition is unstable.
Monitor arterial blood gases as indicated. Routine laboratory testing.
Obtain chest radiographs as ordered.
Help relieve the pressure of tension pneumothorax when necessary. Those with
special training and skills may in this procedure convert the tension pneumothorax to
an open pneumothorax by inserting a large-bore needle into the chest wall to release
the trapped air and decompress the chest. Monitor the patients condition frequently.
The receiving hospital should be notified to prepare for chest tube insertion.
Cover an open pneumothorax wound with any available means, including a rubber
glove or plastic dressing. Many trauma teams use a special taping method (an
occlusive dressing is taped on three sides) that allows air to escape from the chest but
prevents entry of additional air. Watch the patient closely for signs of developing
tension pneumothorax. If this should occur, reopen the seal, and allow the air under
pressure to escape.
Stabilize an object impaled in the chest by putting bandages around it. The impaled
object may be compressing internal structures and preventing hemorrhage. It should
only be removed under controlled circumstances in a hospital.
Splint the simple rib fracture to enable the patient to breathe more comfortable. A
hand or a pillow against the fracture is often sufficient. Analgesics, rest and the
application of heat may also reduce pain.
Do not give the injured patient anything by mouth. Immediate surgical intervention
may be necessary, and oral intake will increase the risk of fatal aspiration during the
perioperative period.
Cover open wounds, apply pressure over sites of direct bleeding to reduce blood loss,
and transport the patient to a nearby hospital without delay.
Palpate gently along the ribs for any structural deformities indicating fractures or
crepitus, which might indicate air collecting under the skin.
Stabilize a flail chest segment of ribs with your hand or by using a bulky dressing
(sandbags or pillow), or having the patient lie with the injured side down, when spinal
injury has been ruled out. Flail chest usually occurs in conjunction with significant
trauma elsewhere, and bleeding may be considerable. Therefore anticipate shock and
hypoxia.

Abdominal- and genitourinary injury

Abdominal injuries are often not evident on physical examination. Injuries to the abdomen
may result in damage to any of the several organs and blood vessels within the abdominal
cavity that extends from the diaphragm down to the pelvis. They can be overlooked because
of more dramatic injuries elsewhere. What looks like a chest injury from the outside may in
fact be an abdominal injury inside. Abdominal injuries can go undetected because the injuries
and bleeding are often internal rather than external.

Penetrating injuries to the abdomen may be caused by knives or bullets, and a variety of other
instruments and may lead to impalement, laceration, or rupture and puncture of the
abdominal organs. Like blunt trauma injuries, open injuries may be much more serious than
they appear. Bullets shatter organs and spill intestinal contents into the abdominal cavity. The
length and size of the weapon effect how deep the stab wound is and how much damage is
inflicted, and immediate treatment is usually based on the patients signs and symptoms.
Blunt trauma to the abdomen is especially deceptive, for it may cause devastating injury with
few external signs, such as steering wheel injuries of the liver and the spleen. Blunt injury
with force sufficient to fracture the pelvis is often associated with damage to the urinary
bladder or urethra. Severe blunt trauma to the back and flanks can fracture the kidney.

Because the genitourinary organs are protected by their location in the body, genitourinary
trauma, with a few exceptions, is seldom life threatening. Penetrating injury may result in
impalement, laceration, rupture, or puncture of the genitourinary organs. Penetrating injury in
the urinary system is extremely common in gunshot wounds of the upper part of the abdomen
and stab wounds of the flank. Burns may result in severe disfigurement and loss of function
of the genitalia. Genitourinary trauma may occur from rapid deceleration in a motor vehicle
accident, during fall, or when an object such as a fist or a bat strikes the abdomen or flank or
external genitalia. Blunt trauma often is associated with damage to the bladder and urethra.
Severe blunt trauma may fracture the kidney.

Assessment of patients with abdominal injuries

Rapid assessment, identification and control of bleeding, and prompt intervention are the
keys to the patients survival. Seriously injured patients with penetrating injuries to the
abdomen, abdominal trauma associated with pain or tenderness, and abdominal trauma with
affected circulation need immediate intervention at a trauma center. A victim with severe
damage to an organ inside the abdomen requires emergency surgery to repair the injury.

Signs and symptoms of abdominal injury include the following:

Abdominal pain and nausea.

Abdomen tender, sometimes rigid and board like.
Guarding by the patient to protect tender abdominal areas.
Abdominal distension.
Bruising, crepitus.
Bowel sounds will be absent.
Signs of bruising and swelling diagonally across the chest and across the pelvis by a
seat belt and shoulder harness as a result of deceleration indicate a blunt injury.

There are signs and symptoms indicating possible internal hemorrhage in a patient with
abdominal trauma including: hypotension, tachycardia, and pallor; rigid or distended
abdomen; hematemesis; hematuria, blood, or semen (from ruption of the prostate) at the
meatus; and inability to void. Impalement of the abdomen or evisceration of the abdominal
contents is obviously a serious emergency. Bruising and discoloration around the umbilicus
(Cullens sign), may indicate hemoperitoneum, or blood in the peritoneal cavity; and bruising
over the flank (Grey Turners sign) may indicate blood in the retroperitoneal space.

Genitourinary injuries may go undetected until radiologic studies are done. A rectal
examination and palpation of the prostate in male patients are often the first step, or a pelvic
examination in female patients to confirming genitourinary injury. A ruptured bladder is a
serious injury, and internal hemorrhage from a fractured kidney can be substantial.
Genitourinary injury is likely if any of the following occurs: Pain in the pelvic or suprapubic
region; the external genitalia have an obvious deformity; the urine is bloody; the patient
cannot void; blood is present at the meatus, or semen (from ruption of the prostate); swelling
or bruising of the scrotum or over the flank is present; and the patient sustained penetrating or
blunt injury.
Diagnostic tests for abdominal trauma may be used to evaluate the injuries and determine the
need for surgery. Diagnostic peritoneal lavage is frequently done in the emergency
department to help determine the presence of blood or intestinal contents in the peritoneal
cavity. Computed tomography (CT) is useful in examining the abdomen for defects and
collections of fluid or air, but patients whose condition is critical and unstable may not
tolerate to be transported to the CT scanner. Obtaining sonograms when assessing patients
with abdominal injury is a procedure that can be performed with portable equipment in the
emergency department. Radiographs can also help detect free air or foreign objects in the
abdomen. After infiltration with local anesthesia, the wound may be explored (laparocentesis)
in the emergency room, by a physician to assess the nature of the abdominal injury and
determine if the patient should have surgery.

Common abdominal injuries

Common abdominal injuries include lacerations and contusions of the abdomen. Blunt and
penetrating trauma to the abdomen cause pain, sometimes bruising and discoloration, and
obvious or occult bleeding. Marked damage to abdominal organ is possible.

The liver, with its rich blood supply, may be shattered or lacerated by either penetrating or
blunt trauma. It can hemorrhage massively, causing death from internal bleeding within
minutes. Hepatic injuries should be suspected in patients who have rib fractures down the
right side of the chest or who complain of abdominal pain and tenderness, especially in the
right upper quadrant. The conscious patient may guard the abdomen against touch and
complain of nausea. The treatment of liver injuries depends on the type and severity of
injuries. Minor bruises and lacerations to the liver heal without surgery, while severe injuries
require surgery.

The spleen, located in the left upper quadrant, is the most commonly injured organ in the
blunt abdominal trauma. The spleen is also vulnerable to rupture whenever there is a fracture
of the lower left ribs, and pain in the upper left quadrant, and pain referred to the left shoulder
may indicate injury to the spleen. Life-threatening exsanguinating hemorrhage can occur
from rupture of the spleen. Although tamponade may reduce the flow of blood, hemorrhaging
may recur hours or even a few days after the abdominal injury. Treatment of spleen injury
may include bed rest, intravenous fluids, or pain medication. Severe spleen injury may
require surgery to repair the spleen or surgery to remove the spleen (splenectomy).

The aorta can be injured by either blunt or penetrating trauma. Rapid deceleration in a motor
vehicle accident may tear the aorta, and compression against spine or impact with the steering
wheel sometimes ruptures the aorta. Exsanguination occurs within minutes after aortic
rupture. About 80-90% of traumatic ruptures of the great vessels are fatal at the accident
scene, and 10-15% of traffic fatalities are due to aortic rupture (Strange, 1987).

The diaphragm is a dome that ascends up in the chest. Blunt or penetrating trauma may
disrupt the diaphragm, allowing abdominal contents to enter the chest cavity, which generally
impairs breathing. The patient may complain of dyspnea, and cyanosis may be evident. Signs
of diaphragmatic injury include breath sounds that are decreased on one side of the chest and
shift in heart sounds. More often a diaphragmatic injury is diagnosed on the basis of
radiographic findings or explored surgically at the hospital. Prepare for surgical procedure.
Ensure an open airway. Administer oxygen as ordered. Assist ventilation as required.
Diaphragmatic injuries are to 95% left sided, the right sided 5% of injuries, are often
combined with liver injury and death occurs immediately (Lennquist, 2002).

Hollow abdominal organs, such as the stomach and gut, are also subject to rupture. An
empty stomach is compressible, and not as likely as a full stomach to be injured. Patients with
gastrointestinal trauma often complain of abdominal pain, tenderness, and maybe nausea.
Hematemesis may occur. Damage to the pancreas, tucked away behind the stomach and
liver, will result in spillage of digestive enzymes and consequent peritonitis. Rupture of the
intestines can also cause peritonitis, because intestinal contents are spilled in the abdominal
cavity.

If there is objects impaled in the abdomen, leave them there, as they often compress and
tamponade affected vessels and organs and therefore reduce or stop bleeding. The damage
depends on the type of instrument lodged in the body and the structures affected.

Severe penetrating injury of the abdominal wall may leave the abdominal contents exposed
outside the abdominal cavity. Cover eviscerated organs with a wet sterile occlusive dressing
until the injury can be evaluated by a physician, and notify the surgical team of impending
case. Administer antibiotics as ordered. Determine the date of the patients last tetanus
prophylaxis and report it to the physician for consideration of tetanus booster injection.

The genitourinary system comprises the kidneys, ureters, bladder, urethra, and the male or
female organs of reproduction, and any of these organs may be injured by trauma. Pelvic
fracture is a serious injury that may result in hypovolemia and death. If gentle pressure
applied to each side of the pelvis elicits pain, or there is abdominal distension from internal
bleeding, evidence of hypovolemic shock, and bloody urine, suspect a pelvic fracture. The
patient with multiple trauma involving the pelvis should be suspected of possible renal
trauma. Traumatic emergencies most frequently involve damage to the kidneys and bladder.
Bladder injuries are more likely to occur when the bladder is distended with urine, and the
result is often rupture of the bladder. Do not attempt to catheterize a patient who has a pelvic
fracture. The urethra may be damaged, and attempts to insert a catheter may make the injury
worse. Blunt trauma of sufficient force to fracture the maternal pelvis often damages the
fetus, too.

The kidneys may be traumatized by any blow to the flanks. Major renal trauma as fractured
or lacerated kidneys and injuries to the renal pelvis can produce life-threatening internal
hemorrhage whenever a patient has serious blunt or penetrating abdominal trauma. Although
the injury may not be obvious, anticipate hypovolemic shock from hemorrhage. The
treatment of kidney injuries depends on the type and severity of injuries. Minor bruises and
lacerations to the kidney may heal without surgery, while severe injuries require surgery.
Surgical repair of the ureters is completed after more serious injuries are dealt with.

Urethral injury most often is caused by missile or foreign object that penetrates the
abdominal cavity, and seldom a blunt injury. When blunt trauma forces the pubic bone
backward into the urethra, pelvic fractures will sometime interrupt or tear the urethra from
the bladder. Urethral injuries are more common in males because of the increased length of
the urethra and its anatomic position in males. Suspect a ruptured bladder if a patient has
evidence of penetrating injury in the suprapubic region or indications of a fractured pelvis.
An empty bladder is less likely than a full bladder to be injured by blunt trauma. A full
bladder is often ruptured when the patient is thrown forward against a restraining seat belt, or
a blow from the steering wheel.

Management of patients with abdominal injuries

Nursing strategies for any patient with abdominal trauma, are to establish the airway,
breathing, and circulation. Your interventions should be within the scope of your professional
license, skills and training, and when performed in a health care setting, adherent to the
facilitys standard of practice. Assess and reassess the patient regularly. Ideally, the patients
condition is stabilized and injuries evaluated under controlled circumstances. As with acute
abdomen, the treatment in the field of genitourinary problems is nonspecific and is
determined by the patients overall condition. Associated shock is managed as outlined.

Ensure an open airway (prevent movement of the head and neck). Administer oxygen
as ordered. Assist ventilation as indicated.
Secure intravenous access with two large-bore intravenous lines, and begin volume
replacement as ordered.
The MAST garment to enhance venous return and support the blood pressure is often
used.
Watch for indications of internal hemorrhaging, and report changes. Signs and
symptoms include hypovolemic shock, abdominal pain, abdominal tautness or
distension, and increasing girth. Reassess frequently.
Type and cross-match abdominal trauma patients for at least four units of blood,
according to the facilitys policy.
Do not remove any object that has been pierced and lodged in the abdomen.
Do not attempt to replace the protruding (eviscerated) organs into the abdomen.
Cover gently the exposed viscera with sterile dressing soaked in sterile saline, and
then place an occlusive dry dressing over that.
Do not give the injured patient anything by mouth. Immediate surgical intervention
may be necessary, and oral intake will increase the risk of fatal aspiration during the
perioperative period.
Insert nasogasric tube as ordered. The use of nasogastric intubation is contraindicated
in patients with base of skull fractures, severe facial fractures especially to the nose
and obstructed esophagus or obstructed airway.
Insert a Foley catheter cautiously if ordered, but only after other injuries are ruled out,
such as urethral injury.
Pain is often intense; administer analgesics as ordered, after the patient has been
examined by a physician, because the medications can mask symptoms.
Offer quiet and simple explanations to the patient (close ones), and frequent
reassurances, because trauma increases anxiety and anxiety increases pain.
If the condition of a critically injured patient with abdominal trauma is unstable and
rapidly deteriorating, urgent surgery will be required.
Management of blunt renal trauma requires recognition of injury, by observation of
minor injuries, and close observation of major injuries that may need surgical repair
or nephrectomi.

Pelvic injury

Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone,
sacrum, and coccyx. Fractures of the pelvic girdle may result from direct trauma to the pelvic
bones during a motor vehicle accident, motor cycle crash, cycling accident, motor vehicles
striking pedestrians, a fall from significant height, or be caused by forces transmitted to these
bones from the lower extremities. The most common cause in elderly is a fall. Pelvic
fractures may be associated with injury to pelvic soft tissues, blood vessels, nerves, and
organs. They may produce significant internal bleeding, loss of more than 2-3 L blood, which
is invisible to the eye. The patient with multiple trauma involving the pelvis should be
suspected of possible renal injury and neurovascular injuries.

The pelvis is the lower part of the trunk of the body and the area of transition from the trunk
to the lower extremities. The pelvis is enclosed by bony, ligamentous, and muscular walls. It
is composed of four bones, the two innominate hip bones laterally and ventrally, and the
sacrum and coccyx posteriorly. The hip bones are joined anteriorly at the pubic-symphysis to
form a pelvic girdle that is firmly attached to the sacrum for support of the lower extremities.
Pelvis is divided into the pelvis major (greater or false pelvis) and the pelvis minor (lesser or
true pelvis) by an oblique plane passing through the sacrum and the pubic symphysis. The
major pelvis is the expanded part of the cavity situated cranially and ventral to the pelvic
brim. The minor pelvis is situated distal to the pelvic brim, and its bony walls are more
complete than those of the major pelvis.

The pelvis of a woman is usually less massive but wider and the shape more circular than that
of a man. These differences are related mainly to the heavier build and larger muscles of men
and to the adaptation of the pelves of women for child bearing. The pelvic cavity contains the
urinary bladder, terminal parts of the ureters, pelvic genital organs, rectum, blood vessels,
lymphatics, and nerves. The pelvis minor is important in obstetrics because it is the bony
canal through which the fetus passes during birth. Blunt trauma can fracture the pelvis of the
mother and the skull or other bones of the fetus too. Blood loss in pelvic fracture is generally
significant and may affect oxygen delivery to the fetus.

Pelvic fractures may be stable or unstable. Unstable pelvic fractures typically occur as a
result of high-energy injuries. Head, chest, and abdominal injuries frequently occur in
association with pelvic fractures. When excessively distended, the bladder rises to the level of
the umbilicus. Because of this position of the distended bladder, it may be ruptured by
injuries to the inferior part of the anterior abdominal wall or by fractures of the pelvis. The
rupture may result in the escape of urine intraperitoneally, extraperitoneally, or both.
Fractures of the extremities and spinal column also can occur in patients with pelvic
fractures. Pediatric pelvic fractures may be associated with visceral, genito-urinary and
neurological injury.

Anterior displacement of pelvic ring has the highest incidence of associated injuries and
mortality of all pelvic fractures. Bucket-handle fractures, double vertical fractures of pelvis
on same side, resulting in pelvic dislocation, are caused by blow or anterior compression
force, with or without sacral torsion. Most hemorrhage associated with pelvic fractures occurs
as a result of bleeding from exposed fractures, soft-tissue injury, and local venous bleeding.

Diagnosis is made on the basis of history, clinical signs and symptoms, and special
investigations usually including X-ray and CT scan.

Assessment of patients with pelvic injury

A careful assessment of the patient must begin with an examination of immediately life-
threatening injuries. Then the examination for pelvic stability is an important part of the
trauma assessment. Anterior/posterior and vertical stability is tested. Lateral displacement of
the pelvic wings suggests instability. Palpation must be undertaken carefully to avoid
harming the patient. Suspect a pelvic fracture if gentle pressure to each side of the pelvis
elicits pain. Indications of pelvic fracture include local swelling and tenderness at the site of
fracture, abdominal distension from internal bleeding, evidence of hypovolemic shock and
bloody urine (suspect bladder disruption). Associated organ system injuries, such as
neurovascular injuries, bladder disruptions, urethral injuries, rectal injuries and neurologic
injuries to the L5 or S1 rotes may be present.

Management of patients with pelvic injury

Emergency interventions and treatment consists of advanced trauma life support

management. The MAST is also suited for the treatment of pelvic fractures. Any signs of
instability should have prompt urgent consultation with an orthopedic surgeon. After
stabilisation, the pelvis may be surgically reconstructed to prevent significant pelvic
deformities. Undisplaced fracture may be painful but requires no specific treatment other than
having careful lifts and movements. Pediatric pelvic fractures rarely require operative
fixation, and are only occasionally life-threatening, but there may be associated with visceral,
genito-urinary and neurological injury. Unstable and displaced pelvic ring disruptions cause
significant deformity, pain, and disability. Significant permanent pelvic deformities have
been identified in patient outcomes and also decreased activity levels.

Ensure an open airway (prevent movement of the head and neck). Administer oxygen
as ordered. Assist ventilation as indicated.
Secure intravenous access with two large-bore intravenous lines, and begin volume
replacement as ordered.
The MAST garment to enhance venous return and support the blood pressure is often
used.
Watch for indications of internal hemorrhaging, and report changes. Signs and
symptoms include hypovolemic shock, abdominal pain, abdominal tautness or
distension, and increasing girth. Reassess frequently.
Type and cross-match abdominal trauma patients when fracture of the pelvis is
suspected, at least four units of blood, according to the facilitys policy.
Do not remove any object that has been pierced and lodged in the abdomen or pelvic
area.
Do not give the injured patient anything by mouth. Immediate surgical intervention
may be necessary, and oral intake will increase the risk of fatal aspiration during the
perioperative period.
Insert nasogastric tube as ordered. The use of nasogastric intubation is contraindicated
in patients with base of skull fractures, severe facial fractures especially to the nose
and obstructed esophagus or obstructed airway.
Insert a Foley catheter cautiously if ordered, but only after other injuries are ruled out,
such as urethral injury. Urgent consultation if any sign of instability.
Pain is often intense; administer analgesics as ordered, after the patient has been
examined by a physician, because the medications can mask symptoms.
Offer quiet and simple explanations to the patient (close ones), and frequent
reassurances, because trauma increases anxiety and anxiety increases pain.
 If the condition of a critically injured patient with abdominal trauma and pelvic
fracture is unstable and rapidly deteriorating, urgent surgery will be required.

Head injury

Each year, traumatic brain injuries (TBI) contribute to a substantial number of deaths and
cases of permanent disability. Recent data shows that, on average, approximately 1.7 million
people in the United States sustain a traumatic brain injury annually (Faul, Xu, Wald, &
Coronado, 2010). Head injuries occur in more than two-thirds of motor vehicle accidents and
are a major factor in mortality in most of them (Caroline, 1983). Patients with head injuries
have a death rate twice as high (35% vs. 17%) as the victims without central nervous system
injuries (Campbell, 1988).

Head trauma is any sudden impact, blow, or physical injury to the head that damage the brain
tissue. Blood vessels, nerves, and meninges can be torn, which may result in bleeding, edema,
and ischemia. Head injuries are categorized as open, or penetrating (the brain is exposed),
and closed, or blunt (the skull is intact, although the scalp may be disrupted). Types of
injuries include scalp injuries (lacerations, abrasions, hematomas). Skull fractures (linear,
depressed, basilar), concussions (temporary loss of consciousness after the brain strikes the
skull), and cerebral contusion (bruising of the brain tissue, disrupting neural function). Severe
head and brain injuries can result in death or disability, body and functional changes, residual
deficits, mental and emotional sequele, and difficult quality-of-life issues.

A head injury may be the result of blunt or penetrating trauma. Because the brain is protected
by the skull, most brain injuries are caused by blunt trauma to the head. The first collision of
the brain with the skull is the coup, and the second collision, with the opposite side, is the
contrecoup. Coup and contrecoup injury is associated with cerebral contusion, a type of
traumatic brain injury in which the brain is bruised. This movement of the brain in the skull
can tear blood vessel and damage others structures, leading to collections of blood that
occupy space or to swelling of the brain. Bullets and knives may also enter the brain through
the skull, thus bone fragments may be driven into the wound along with the foreign object,
causing additional injury to the brain, such as intracranial bleeding and structural damage.
Penetrating injury usually fractures the skull, and projectile may be retained in the brain.

Blunt or penetrating trauma can cause the brain to swell, or cause bleeding in the cranium,
and the blood from the hemorrhage must occupy space. The intracranial pressure (ICP) will
increase, a serious event, because the skull is rigid and inelastic. The blood pressure also
rises, as the body attempts to continue to perfuse the brain. In later stages, the heart rates
slow, the body decompensates, and death results. Another grave event is when increased ICP
force the brain down through the foramen magnum and herniate the brainstem.

Assessment of the patient with head injuries

One of the most important tasks in assessing and managing patients with head injuries is
continual monitoring of the patients condition, which can change radically within minutes.
Follow the standard ABC assessment plan, and immobilize the head and neck (cervical
collar). Do not move the patient's head. Determine a baseline of the patient's condition, and
act on any deviation. In all head injuries, the most important aspect of neurologic assessment
is whether the patients findings are changing and in what direction. A neurosurgeon will
attend in the hospital if there is a serious head injury.
It will be necessary to make repeated evaluations, and each time recording the time and the
findings, so that emergency department staff can rapidly determine whether the patient's
condition is improving or deteriorating. The level of consciousness and any change in it are
the most important indicators of head injury. The patient who shows deterioration, such as in
the level of consciousness or any slurred or inappropriate speech, is of great concern and may
require urgent surgery.

The observations in the field, if precise, detailed, and recorded, will be of enormous value to
those who must render definitive care to the patient. Ask bystanders about the patient's
actions and level of consciousness before the injury occurred to get clues about the nature of
the injury. Important information in the history of the patient with head injury includes the
following:

How was the injury sustained (mechanism of injury)? A blow to the head, caused by
trauma: motor vehicle accident, falls; or assaults: gunshot and stab wounds.
Did the patient lose consciousness? When did this occur (immediately or after some
delay)? How long was the patient unconscious?
Did the patient vomit? Children will often vomit after head injuries. Vomiting in
adults after a head injury, may indicate serious intracranial pathology.
Current symptoms? Complains of headache? Dizziness? Double vision? Nausea?
Weakness (if so, where)? Does the patient have pain elsewhere, particularly in the
neck or over any other part of the spine? Does the patient have any, numbness,
tingling, or "pins and needles" sensations (paresthesias) anywhere in the body?
Has the patient ingested any drugs or alcohol, during the past several hours? Sniff the
patient's breath for clues about the patient's history, such as the odor of ethanol from
ingestion of alcohol, the fruity odor of ketoacidosis, or the odor of petroleum
ingestion of poison.

The physical examination, repeated several times, will be of enormous importance. Do not
move the patient until it has been ascertained that there is no associated spinal cord injury. Be
sure the airway is clear and the patient is breathing adequately. Check for presence and
quality of the pulse. Stop active bleeding by pressure and investigate other parts of the body
for life-threatening injuries. Although scalp lacerations are not always a serious injury, blood
loss may exceed 0.5 L. Hold a sterile gauze pad over any lacerations. Do not attempt to
remove a helmet, or an artificial hairpiece, and do not attempt to force open swollen or
lacerated eyelids, or apply pressure to lacerations of the eyelids, as further damage may
result. Take the initial vital signs, and repeat these (at 5- to 10- minute intervals). Note the
rate and quality of respirations, and note any changes in the blood pressure.

Hypertension and bradycardia means rising intracranial pressure, while shock means injury
elsewhere. A slowing of pulse will usually accompany the rise in blood pressure observed in
a patient with rising intracranial pressure. A rising pulse may signal impending shock from
hemorrhage elsewhere in the body. If the blood pressure is elevated, but the pulse rate is low
(this is an ominous and late sign of increased ICP):

Increasing Shock
Intracranial (hemorrhage
Pressure (ICP) elsewhere)
Blood
Rising. Falling
pressure
Pulse Falling Rising.

Carefully examine the patient's head. Look and feel over the head and scalp for lacerations,
fractures, or depressed fracture in the skull; deformity or fracture of the face and jaw; and ask
the patient to report any tenderness or pain. Is there blood or spinal fluid leaking from the
patient's ears or nose? Are there ecchymoses over the mastoid process behind the ears
(Battle's sign) or bilateral, symmetric periorbital ecchymoses (raccoon eyes)? All of these are
evidence for basal skull fracture, but it may take several hours for this discoloration to
appear. Any leakage or fluid from the nose, suggests fracture of the cribriform plate of the
skull. If there is leakage of clear fluid from the ears or nose, place a sterile gauze lightly over
the nose or external ear, allowing free flow to continue.

Assess the patient's neck, and when in doubt, maintain traction, and apply a cervical collar or
other means of immobilization. There is a very high incidence of associated injuries in
patients with head injuries. The head injury may not be the most serious of the patient's
problems. Complete the standard physical examination in head-to-toe order, and take care of
bleedings, fractures, and so forth, before proceeding to a thorough neurologic examination.

The most important single sign in the evaluation of a patient with head injury is a changing
state of consciousness (record the findings accurately). At each assessment the professionals
should determine the following:

Is the patient alert?

Is the patient oriented to person, place and time?
Does the patient remember what happened?
If the patient is less than fully alert, what kind of stimuli are required to make him/her
respond? Verbal stimuli response? Pain stimuli response? Is the patient totally
unresponsive to any stimuli? Head injury can cause confusion, slurred speech and
problems with comprehension. Do not assume that the obviously intoxicated patients
slurred speech or staggering gait is the result of alcohol ingestion or substance abuse
rather than a head injury.
If the patient moves, is the movement purposeful? Or is the movement restricted to
flexion or extension of the arms and legs? Head injury is highly likely if the patient
has paralysis or motor weakness, especially on just one side of the body, or has
abnormal posturing and rigidity of the extremities.
Has the patient had a seizure?

In the conscious patient, test modalities of position sense, pain, and movement. Observe
pupillary signs and extra ocular motions. Head injury is highly likely if the pupils are
unequal, dilated, or unresponsive to light, or the conscious patient reports visual disturbances
or a reduction in visual equity. Be aware that some drugs, such as narcotics, can alter the size
and reactivity of the pupils. The difference also could be physiologic (congenital), or due to a
direct eye injury (with a passing pupil dilation during 15-30 minutes after the accident).

The Trauma Score is used to give each injured patient a numerical score that can be used to
estimate the severity of head injury. This is a system combining cardiopulmonary assessment
with the Glasgow Coma Scale in estimating the degree of injury and the prognosis in a
patient who has suffered a head injury (Anderson, Anderson, & Glanze, 1998).
Cardiopulmonary factors include respiratory rate and chest expansion, systolic blood
pressure, and capillary refill. The neurologic factors are eye opening, verbal response, and
motor response. The Champion Sacco Trauma Score: Total Trauma Score =
Cardiopulmonary Assessment + Neurologic Assessment (Champion, Sacco, Carnasso, et al.,
1981).

Trauma Score

10-24/min 4
24-35/min 3
Respiratory Rate 36/min or greater 2
1-9/min 1
None 0
Normal 1
Respiratory Expansion
Retractive 0
90 mm Hg or greater 4
70-89 mm Hg 3
Systolic Blood Pressure 50-69 mm Hg 2
0-49 mm Hg 1
No Pulse 0
Normal 2
Capillary Refill Delayed 1
None 0

(Cardiopulmonary assessment 0-11)

Capillary refill is determined by pressing a nail bed, the skin of the forehead, or the lining of
the mouth (oral mucosa) until there is a loss of normal color (blanching or turning white).
Normal return of color after pressure release will take place in approximately two seconds.

There are four elements to the cardiopulmonary assessment. The numerical values are added
together to produce a cardiopulmonary score. Each category of the Glasgow Coma Scale is
given a numerical value (Total Glasgow Coma Scale points: 14-15=5, 11-13=4, 8-10=3, 5-
7=2, 5-4=1). This number is then reduced by approximately one-third its value to produce the
neurologic assessment score. The cardiopulmonary assessment and the neurologic assessment
scores are added together to give the Trauma Score. For example, a patient's total score for
cardiopulmonary function is 7, and for neurologic assessment is 4 (approximately one-third
of this number is 1). The cardiopulmonary and neurologic scores are added together (7+1) to
give a Trauma score of 8.

The Glasgow Coma Score system involves three determinants, eye opening, verbal response,
and motor response, all of which are evaluated independently according to the rank and the
order that indicates the level of consciousness and degree of dysfunction. The results are
plotted on a graph to provide a visual representation of the improvement, stability, or
deterioration of the patient's level of consciousness. The sum of the numeric values for each
parameter can also be used as an overall objective measurement, with 15 indicative of no
impairment, 7 usually accepted as a state of coma, and 3 compatible with brain death. The
GSC score can also function as an indicator of certain diagnostic tests or treatments such as
the need for intubation, intracranial pressure monitoring, and computed tomography
(Anderson, Anderson, & Glanze, 1998).
Glasgow Coma Scale (GCS)

Best Eye Response (4)

Eyes open spontaneously 4
Eye opening to verbal command 3
Eye opening to pain (supraorbital or digital) 2
No eye opening 1

Best verbal Response (5)

Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1

Best Motor response (6)

Obeys commands 6
Localizing pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1

Glasgow Coma Score Total 3-15

(Neurologic assessment 1-5, conversion=approximately one-third total value)

The eye opening test is valid only if there is no injury or swelling that prevents the patient
from opening the eyes. For a total GSC score of 15: the patient opens his or her eyes without
any stimulation; an aroused patient should be able to tell you his or her name, where he or she
is, and the date in terms of the year and month; and perform a simple task such as moving a
specific finger or holding up two fingers. It is important to break the figure down to
components, such as E3V3M5 = GCS 11, instead of GSC of 11. A coma score of 13 or
higher correlates with a mild brain injury; 9 to 12 is a moderate brain injury, and 8 or less a
severe brain injury.

The third motor response is that the patients start to flex their whole body to pain. They pull
the finger you're pinching into towards the midline, but they also pull the other hand towards
the midline. They also straighten their legs right out and turn their toes in towards each other.
This abnormal flexion (decorticate rigidity) is due to damage to the corticospinal tracts (the
pathways of the brain and spinal cord). The next worse response is when a patient extending
all their limbs in response to pain. The toes are pointed down, and they often arch their head
backwards. This extension posturing is called decerebrate rigidity. Decerebrate rigidity is
caused by an injury at the level of the brainstem, and basically it means that your brain isn't
working anymore. Although both postures are extremely serious, decerebrate posturing
indicates greater cerebral damage than decorticate posturing. If you cause pain to a patient
and they don't respond at all (unresponsive), that is as bad as it can get.

Classical signs of a progressive brain injury, besides changed consciousness are decreased
heart rate, increased blood pressure, and decreased respiratory rate. These signs (Cushings
triad - bradycardia, hypertension, and bradypnea) usually occur late or not at all. The
patients level of consciousness is the best early indicator of increasing intracranial pressure.

In the initial period the efforts are to find focal injuries which could be actively attended,
respectively the injured that have complications to the injuries. An understanding of the risk
after trauma can be estimated (Andrn-Sandberg, 1993):

Low risk Medium risk High risk

no symptoms affected consciousness unconscious
headache increasing headache focal neurology
dizziness alcohol/drug intoxication deteriorating consciousness
scalp lump indistinct history of injury penetrating injury
scalp wound < age of 2 palpable, depressed fracture
seizure
repeated vomiting
multiple trauma
serious facial injury
basilar skull fracture
child abuse

Suspect a serious head injury if the injured patient:

is unconscious.
has unequal pupils.
move extremities that are not injured differently.
has an open head injury.
has leakage of cerebrospinal fluid (clear fluid drainage from nose or ears).
has a depressed skull fracture.
has deteriorating status.

Common head injuries

Scalp lacerations are not always a serious injury, but the scalp is vascular and bleeds freely.
Blood loss may exceed 0.5-1 L and appear quite dramatic. In children, it may be sufficiently
profuse to cause hypovolemic shock, because they have a lower blood volume than adults.
Apply gentle pressure with a sterile dressing to reduce blood flow. Palpate the skull in the
area of the scalp wound to be sure there isn't a depressed skull fracture beneath the wound, as
pressure on it could injure the brain further. Scalp lacerations are the most common type of
head injury requiring surgical care.

Skull fracture can occur with or without brain damage. The hard and inflexible box of skull
protects the brain, covered by the thin membranous meninges. A skull fracture may be
obvious because it deforms the skull, or it may not be diagnosed until a CT scan of the head
is performed. Suspect a skull fracture in any patient who is unconscious or who has a
penetrating head injury, unequal or unreactive pupils, blood or CSF drainage from ears and
nose, or bilateral periorbital ecchymoses or ecchymoses behind the ears. The base of the skull
is a common fracture site, and basilar skull fractures can provide an opening between the
nasal air passages and the brain. Do not insert a nasal airway, endotracheal tube, suction
catheters, or a nasogastric tube through the nose of a patient with a head injury until the
possibility of a basilar skull fracture has been ruled out, as the tube can entering the brain.
Patients with an open or depressed skull fracture should be transported preferentially to the
highest level of care within the trauma center.

A concussion is a mild closed head injury caused by a blow to the head that results in no
significant brain injury. Blunt trauma to the head, violent jarring or shaking, as in a fall or a
sports accident, can cause a concussion. Temporary loss of consciousness after the brain
strikes the skull, and some amnesia is common. The patient often complains of headache,
nausea and dizziness. If the loss of consciousness exceeds 5 minutes, the patient may be
hospitalized for further observation.

A cerebral contusion is another closed head injury also caused by blunt force to the head. A
contusion results in a bruise to the brain tissue. This can cause increased ICP from severe
edema and bleeding associated with the injury. Loss of consciousness occurs, usually for a
prolonged period, and proportionate to the severity and location of the injury. The victim
should be transported to a hospital for examination of the degree of cerebral contusion, and
any deterioration or change in the victim's condition.

Subdural hematoma, an accumulation of blood in the subdural space, usually caused by an

injury. It may develop over a period of hours or days or weeks after the injury, because
bleeding is often from a venous source. The patient may complain of headache and have
alterations in neurologic status, such as changes in the level of consciousness or slurred
speech. This is a serious injury; the outcome is improved by early recognition and swift
intervention. Subdural hematoma may be fatal without surgery.

Epidural hematoma is an arterial bleeding that produces a collection of blood above the
dura mater of the brain or spinal cord. It usually results from tearing of the middle meningeal
artery, so the signs and symptoms appear sooner than those of subdural hematoma.
Immediate loss of consciousness occurs, followed by a brief period when the patient is
conscious and lucid, but then the patient again lapses into unconsciousness. Evidence of
neurologic injury becomes apparent, especially paralysis on one side of the body. Dilated,
unreactive pupil on the injured side. Immediate neurosurgery is required to evacuate the
hematoma, otherwise the prognosis may be poor. These patients with paralysis should be
transported preferentially to the highest level of care within the trauma center.

Penetrating head injury, and sometimes blunt injury, can cause bleeding into the brain,
intracerebral hemorrhage, similar to that associated with a stroke. The ICP increases, and
death may occur.

A transtentorial herniation, a bulge of brain tissue out of the cranium through the tentorial
notch, is caused by increased intracranial pressure. It is important to identify signs of
impending transtentorial herniation as this will affect the course of the immediate
management of these patients. Pupils may be initially normal and then dilate as intracranial
pressure rises and the brain starts to herniate. This condition is identified by unilateral
abnormal posturing and/or the presence of a unilateral dilated pupil.

Impaled objects protruding from the skull should be left, and stabilized in place. Removing
it could make the injury worse. The patient should be transported to a hospital (trauma center)
immediately.
Management of the patient with head injuries

In the management of head-injured patients, priority always goes to the airway and breathing.
Management of head injury focuses on stabilization of the patient and prevention of
secondary neuronal injury. Hypoxia and hypotension are the greatest threat to functional
outcome in traumatic brain injury. Oxygenation and cerebral perfusion must be maintained.
Normal blood pressure and pCO2 under 28 mm Hg (3.73 kPa) is enough to maintain
adequate perfusion to the brain (Andrn-Sandberg, 1993). If pCO2 increases over 28 mm Hg
is the risk high, that the ICP increases. Cerebral anoxia is the most common cause of death in
head-injured patients, and cerebral anoxia should be entirely preventable. Significant
neurological damage can occur between the time of injury and computed tomography
scanning, accurate management of ICP and other interventions. Interventions for patients
with severe head injuries are:

Maintain a patent airway and supply oxygen (prevent movement of the head and
neck). Be alert for vomiting, and have suction handy. Be careful when you put your
fingers into an injured patient's mouth, because a seizure may develop quickly. A
patient with significant head injury has a cervical spine injury until proved otherwise.
Assist ventilation as needed. Follow physician's order about hyperventilation
(increased rate and depth of breathing). Increases in pCO2 in the blood due to
ineffective breathing will dilate the blood vessels and increase intracranial pressure.
Hyperventilation lowers the arterial pCO2, which in turn causes cerebral
vasoconstriction and thereby helps minimize cerebral edema.
Correct hypovolemia and hypotension. Hypotension is most likely caused by
hemorrhage in another area of the body.
Control bleeding from the scalp, especially in children, it may be sufficiently profuse
to cause hypovolemic shock. If the skull is unstable, apply pressure to the scalp close
to the wound, but beyond the depressed fracture.
Secure intravenous access. Unless shock is present, fluids should be severely
restricted in head-injured patients, for excessive fluids may worsen cerebral edema.
Slight dehydration reduces extracellular fluid thereby reducing cerebral edema. Do
not give the injured victim anything by mouth.
Do not allow the patient to become overheated, as patients with head injury, tend to
develop a high temperature, which in turn may worsen the condition of the brain.
Cover wounds as needed, if leakage of blood or CSF apply loose sterile dressings, just
to keep the area clean
Impaled objects protruding from the skull should be stabilized in place. Transport
directly to a hospital with neurological facilities; the unconscious patient semiprone
(on backboard).
Monitor the cardiac rhythm; bradycardia should raise the suspicion of increasing
intracranial pressure. Keep rechecking neurologic and vital signs, and record each
finding accurately.
A CT scan of the head injury should be obtained when appropriate. This will delineate
the brain injury and determine whether surgery is indicated to remove a mass
(subdural or epidural hematoma) and the degree of diffuse injury or swelling present.
When there are signs of increasing intracranial pressure, the physician may order
hyperventilation (20-24 breaths/min) and Mannitol before the surgery. (The patient
should have a Foley catheter in place).
Neurosurgery if indicated.
 Intensive care for further monitoring and management. Monitor artery blood gases as
ordered and notify if abnormal values. In patients with severe head injuries who are
intubated and undergoing ICP monitoring, pain medications can be administered
without fear of causing hypoventilation or masking clinical signs of increased ICP.
Patients should be kept sedated to prevent coughing or valsalva maneuvers from
fighting the ventilator as these increase intracranial pressure.
Reassure patients and their close ones that everything is being done to return the
patient to his or her pretrauma stage of functioning if possible, or otherwise to help
the patient achieve the best possible outcome with minimal limitations.

Possible surgical procedures for patients with head injuries are: Suturing to repair superficial
lacerations; craniotomy to evacuate hematomas, control hemorrhage, remove bone fragments
or foreign impaled objects, debride tissues, or elevate depressed fractures; and trephination
(burr holes) to evacuate hematoma or insert intracranial monitoring devices. Cranioplasty to
repair traumatic defects in the skull; ventriculostomy to remove excess cerebrospinal fluid; or
ventricular shunting procedures to drain cerebral fluid and reduce intracranial pressure may
also be performed.

Maxillofacial and neck injury

Maxillofacial injury is not usually life-threatening unless the airway is compromised, but
patients with injury to the neck are at high risk. The airway, the carotid arteries, the jugular
veins, the cervical spine, and the spinal cord are all contained in the neck. Blunt and
penetrating injury to the neck can cause death within minutes from hemorrhage and airway
obstruction or permanent paralysis can be the outcome.

Projectiles (knives and bullets) are responsible for most penetrating maxillofacial or neck
injuries and may lead to lacerations, impalement, or puncture of the eye or cheek. Disruption
of the major blood vessels in the neck, can result in brain damage or exsanguination. Blunt
maxillofacial or neck injury often occur in motor vehicle accidents, sport accidents, or falls or
when the face or jaw is struck in an assault with an object such as a bat or fist. Unrestricted
occupants (especially front-seat passengers) in motor vehicle accidents may crash through the
wind shield and then be pulled back through the shattered glass as the car decelerates. The
result can be severe facial and scalp lacerations (bleeding is often profuse); soft tissue trauma;
and facial, neck, or skull fractures. The installation of air bag in motor vehicles has reduced
the number of sternal and facial fractures.

Assessment of patients with maxillofacial and neck injuries

Follow the standard ABC assessment plan, and evaluate the airway, breathing, and
circulation. Start with serious injuries that threat life and limb. Once the airway and
circulation are established, and bleeding is controlled, head or cervical spine injuries have
been stabilized, turn your attention to assessment of the maxillofacial trauma. Observe the
scene and elicit a history of the injury while assessing the patient. Patients who sustain
significant injury to the face may have fractures of the jaws and damage to or loss of teeth.
Massive trauma to the face is likely to be associated with cervical spine injury, and extreme
care must be taken with these patients to avoid aggravating their injury. It is necessary to
examine the entire face and mouth carefully to ascertain the extent of injury.

Suspect maxillofacial and neck injury in any patient who has any of the following:
 Obvious deformities, fractures, or distortions of the face or neck.
Asymmetry of the face and neck.
Pain and a noticeable edema.
Swelling and discoloration; especially under the eyes (Raccoon eyes) or of the sclera,
or bruising behind the ears at the base of the skull (Battles sign). Raccoon eyes and
Battles sign are indications of a fracture in the base of the skull (basilar skull
fracture).
Dislocation of eye, deformity, facial bruises, loose or missing teeth, and swollen jaw
are signs of facial fractures.
Misalignment of the upper and lower teeth.
Damage to the teeth, loose or missing teeth, bleeding from the mouth.
Blood or fluid (possible CSF fluid) draining from the nose, and hemorrhage from the
major vessels in the neck.
Difficulty in speaking or moving the jaw.

Common maxillofacial and neck injuries

Maxillofacial injury causes distortion of the facial structures and copious bleeding. Broken
teeth and blood may obstruct the airway, and it may be difficult to ensure an open airway
because of fracture of the mandible. The injury may make endotracheal intubation
impossible. When a cricothyroidotomy (the airway is opened below the level of the
epiglottis) is needed, the technique should be performed only by those who are skilled in the
execution.

Le Fort Fractures are three different types of mid facial fractures that are common after
blunt facial injury. They include a fracture of the maxilla above the teeth, a triangular fracture
from the upper teeth to an area between the eyes, and a serious fracture involving separation
of the facial bones from the cranium.

Fracture of the maxilla (upper jaw) is often accompanied by a black eye. The face appears
elongated, the patients bite is no longer even, and there will usually be noticeable edema.

Mandibular fractures are caused by significant force from blunt injury in motor vehicle
accidents, assaults, falls and sport injuries. When the mandible (lower jaw) is fractured, it is
likely to be broken in at least two places and will therefore show instability on palpation, and
there will be evident ecchymosis and swelling. Unless the mandible is shattered and the
airway is obstructed, no immediate intervention is indicated.

A zygomatic arch fracture by blunt trauma to the cheekbones is not a critical injury unless
the orbits or eyes are damaged by the blow. An impaled foreign object in the cheek
associated with massive bleeding may obstruct the airway. The inside of the cheek should be
gently palpated to determine whether the impaled object has penetrated all the way through.

Nasal fracture (broken nose) most commonly is caused by motor vehicle accidents, assaults,
falls, and sport injuries. Blunt trauma at the front of the face may cause posterior
displacement of the bones; and from the side it may cause lateral displacement. The nose may
be bleeding, and some swelling and deformities often occurs. Be aware of the possibility of
orbital fracture or other significant head trauma in the patient with obvious nasal fracture.
Perforation of the tympanic membrane may result from foreign bodies in the external
acoustic meatus, trauma or excessive pressure (during detonations or scuba diving). Severe
bleeding or escape of CSF through a ruptured tympanic membrane and the external acoustic
meatus may occur after a severe blow to the head.

Avulsion is the separation, by tearing, of any part of the body from the whole, such as the
scalp, lower eye lid, and teeth. The scalp most frequently is torn from the skull; profuse
bleeding results. When a patients head sustains trauma that causes an avulsion, a skull
fracture and neck injury can be suspected.

The first three layers of the scalp, the scalp proper, remain together when the scalp is torn off
during accidents (Moore, & Agur, 1996). The loose connective tissue layer (fourth layer) is
the dangerous area of the scalp because blood or infection spreads easily in it, and can also
pass into the cranial cavity and infect the brain. These wounds bleed profusely, and
unconscious patients may bleed to death from scalp lacerations if bleeding is not controlled
(by sutures).

Ocular (eye) injury. Trauma to the face may result in fracture of one or several of the bones
of the skull that form the orbits (eye sockets). Orbital fractures require hospitalization and
possible surgery.

The impaled foreign object in the globe should be left and stabilized in place.

Suspect corneal abrasion if the cornea does not appear smooth and shiny, can cause intense
pain.

Chemical burns when alkali or caustic substances contact the eyes cause intense pain in
most cases, the eye often is reddened, and some tissue destruction may be evident. This is a
serious emergency, immediate, continuous irrigation is required.

Lacerations, cuts to the eyelids may affect the movement of the eyelids and disrupt the
lacrimal system and require suturing. The eyes may also be swollen from blunt facial injury
and from tissue edema in response to the injury. Any bruises or contusions of the orbit or
globe should be evaluated by an ophthalmologist.

Hyphema (intraocular hemorrhage) may occur when the orbit or globe sustains blunt trauma.
Patients with hyphema often complain of pain and a decrease in their visual aquity; the sclera
may appear bloody.

Retinal detachment may occur when blunt trauma to the head tears or separates the retina
from the choroid in the back of the eye. The patient may complain of a decrease in visual
aquity or odd perceptions of flashing lights or dark spots in front of his or her eyes; blindness
often results. Gentle transport is crucial.

Perforation of the globe, when penetrating injury perforates the eye or ruptures the globe,
loss of the eye often results. Seepage of blood, vitreous humor, or intraocular contents from
the eye may be noted.

Tracheal injury may be caused by blunt or penetrating trauma that close the airway; hypoxia
and death follow within minutes. Blunt injury to the neck, signaled by swelling, ecchymosis,
and pain, may cause collapse of the larynx or trachea or consequent airway obstruction.
Penetrating trauma of the neck with injury to major vessels is a serious emergency. Severe
life-threatening hemorrhage or air embolism may occur. The bleeding is difficult to stop
because of the pressure within the vessels. The carotid arteries supply the blood for
perfusion and oxygenation of the brain. When bright red blood spurts in a pulsating flow
from the neck wound, the carotid artery may be damaged, a life-threatening situation. Dark
red blood streaming from the open jugular vein is a serious emergency because of potential
blood loss and potential air entrainment into the venous system. If the trachea has been
disrupted, subcutaneous emphysema in the cervical area and the anterior chest and a fruity
mixture of air and blood blowing through the penetrating wound may be present.

Laryngeal fractures may result from blows or from compression (by a shoulder strap during
a vehicular accident). They produce submuccous hemorrhage and edema, respiratory
obstruction, hoarseness, and sometimes an inability to speak because of injury to the
laryngeal nerves.

Dental injury is common in facial trauma. Loose teeth can obstruct the airway, and dentures
may be knocked out or swallowed. Any patient with dental injury should be evaluated by a
dentist or an oral surgeon.

Management of patients with maxillofacial and neck injuries

Treatment at the scene is aimed at ensuring an airway and trying to promote the best possible
cosmetic and dental outcomes. Your interventions should be within the scope of your
professional license, skills and training, and when performed in a health care setting, adherent
to the facilitys standard of practice. Wear protective eyewear and a mask in case the patient
coughs and spray blood.

Ensure airway, breathing and circulation. Have suction equipment available when
possible. Monitor respiratory status frequently, because blood or foreign material can
quickly obstruct the airway. Assist ventilation as indicated. Suction any blood from
the mouth and throat.
Immobilize the head and neck and assume that injuries to the cervical spine exist in
any patient with maxillofacial trauma who lost consciousness from the blow. A
cervical collar and a backboard are also desirable.
Apply firm pressure over a bleeding site in the neck to reduce severe blood loss but do
not occlude the airway, administer oxygen, prepare for the onset of shock if bleeding
is severe and transport the patient immediately to the hospital. Keep the site covered
when possible.
Air can be sucked into the open jugular vein and circulated to the heart (air
entrainment); could result in a fatal air embolism, causing arrhythmias and death.
When there is a significant bleeding from the neck, seal the wound quickly with
gauze, apply a bulky dressing, and maintain pressure manually over the bleeding site.
Promptly position the patient on his left side in Trendelenburg (head down, feet
elevated). This positioning helps to trap air in the apex of the ventricle and prevent it
from reaching the lung circulation.
Apply direct pressure with a sterile dressing over bleeding sites, except for: where
cerebrospinal fluid is flowing or brain tissue is exposed, or ruptured or penetrated
eyes, and where obvious deformity indicates fractures. Then apply loose sterile
dressing, just to keep the area clean.
 Do not attempt to remove object impaled in the patients head, neck, brain or eye,
unless it is obstructing the airway. Stabilize the object on each side of it, and transport
the patient immediately to the hospital.
Lay a dressing moistened in saline over avulsed tissue to reduce contamination and
drying of the tissues, if available.
Offer the patient with nasal fractures gauze bandages to catch any drainage, and
transport him or her to a hospital. Do not obstruct the bleeding, due to possible airway
obstruction or increased intracranial pressure in the event that a skull fracture exists.
Elevate the head of the bed of the conscious patient to reduce swelling, bleeding,
congestion and facilitate respiration, if it is not contraindicated by other injuries and a
physician has ruled out spinal injury.
Do not allow the patient to eat or drink until seen by a physician.
Never insert a nasal airway or nasogastric tube in a patient with suspected mid facial
or skull fractures. The airway or tube could penetrate the cranium and enter the brain.
Retrieve and preserve avulsed tissue, such as an ear from the scene, cover it with
sterile moist dressing, wrap it in plastic, label it, make a note of the time, and transport
it to the hospital with the patient. The surgeons may be able to reattach the part.
Save loose and dislodged teeth if possible. Make a note of the time, wrap the loose
teeth in moist dressings, label the container, and transport it to the hospital with the
patient. Dislodged teeth can sometimes be reimplanted successfully.
Bring any dentures or pieces of dentures to the emergency department with the
patient, as they will be needed to establish proper alignment in wiring a fractured jaw.
Surgical treatment of ear injuries should only be performed by a specialist.
All but the most minor ocular injuries should be evaluated by a specialist in eye care
(ophthalmologist). The goal of care is to preserve both vision and the eyes. Unless the
globe has been ruptured or penetrated, outcome and maintenance of the sight are often
good.
Do not attempt to force injured eyelids open to check pupils. Lay a cool moist
compress over the contusion.
Do not shave the eyebrows of a patient, as they provide a landmark for repair, and
they may not grow back (Sheehy, & Jimmerson, 1994).
Flush the eyes immediately with running water (from the inner to the outer aspect of
the eye) in any patient who has experienced a chemical burn to the eyes. Contact
lenses must be removed or flushed out. The affected eye should be continuously
irrigated with saline or water, while gently holding the lid up; flush without ceasing,
the time is important.
Sterile eye patches lightly applied to both eyes can help reduce discomfort until the
patient can be seen by a physician. Patching both eyes may help limit movement of
both eyes and reduce pain.
Offer strong emotional support to patient who have maxillofacial trauma. Use
communication aids when possible for any patient who cannot speak. Facial and eye
injuries frighten patients, who are concerned about loss of vision and alterations in
appearance. It is important to maintain a calm, reassuring attitude and explain to the
patient what is happening.

Spinal injury

A spinal cord injury refers to any injury to the spinal cord that is caused by trauma. Spinal
injuries can be devastating and deadly. It is estimated that approximately 11.000 people
sustain spinal cord injury in the United States each year, about one-third of these victims die
before reaching a hospital. Traumatic injury occurs most often in young adult men (the 16- to
30- year age group). The average age at the time of injury has slowly increased from a
reported 29 years of age in the mid-1970s to a current average of around 40. In the United
States there are around 250.000 individuals living with spinal cord injuries.

Rapid forward deceleration during a motor vehicle accident and rapid vertical deceleration
from a fall are two leading causes of spinal injury. Acts of violence have overtaken fall as the
second most common source of spinal cord injury. Motor vehicle accidents account for 44%
of spinal cord injuries; acts of violence, for 24%; falls, for 22%; sport accidents, for 8% (two-
thirds of these sport-related injuries are from diving), and other causes, for 2%. Falls overtake
motor vehicles as the leading cause after age 45. Acts of violence and sports cause less
injuries as age increases.

The mechanism of injury is important in determining the type of injury. Flexion of the head
(chin to chest) is a major mechanism of injury in most spinal trauma. Head-on collisions
cause hyperflexion, and rear-end collisions usually cause hyperextension. Direct injuries
involve compression or transection of the cord by the causal agent. Compression and
rotational injuries can shatter vertebrae and force bone fragments into the spinal cord. Indirect
injury involves compression, overstretching, rotation, wedging, or misalignment of the cord,
which results in edema, swelling, and localized hemorrhage. It can also be involved in minor
injuries, such as whiplash.

The spinal cord, the major reflex center and conduction pathway of sensory and motor
impulses between the body and the brain, is a cylindrical structure that is slightly flattened
anteriorly and posteriorly, and about 1 cm in diameter. The spinal cord is lodged in the
vertebral canal, extending from the foramen magnum at the occipital base of the skull (begins
as a continuation of the medulla oblongata, the inferior part of the brainstem) to the upper
part of the lumbar region (intervertebral disc between L1 and L2 vertebrae). It is protected by
the vertebrae, their associated ligaments and muscles, the three spinal meninges (the dura
mater, arachnoid, and pia mater), and the cerebrospinal fluid (CSF). Nerve tissue in the spinal
cord is bundled together in two regions. The brachial plexus of nerves (extending from C4 to
T1 segments) innervate the upper limbs, and the lumbar and sacral plexus of nerves
(extending from L2 to S3 segments) innervate the lower limbs. Thirty-one pairs of spinal
nerves originate from the cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.

The spinal cord connects the brain to all of the other organs in the body. If the cord is
interrupted by trauma, all connections between the brain and muscle groups or organ below
the level of cord damage are severed. The initial care, starting at the scene and early
interventions has profound influence on the outcome of the injury. The mechanisms of the
primary spinal injury cannot be undone, but the rescuers can alter the effect of hemorrhage,
hypotension, and hypoxia that cause secondary injury to the spinal cord and thus limit and
prevent further damage.

One must maintain a high index of suspicion in any case where the mechanisms of injury
suggest the possibility of spinal cord injury. Common spinal cord injuries are vertebral
fractures and dislocations, such as those commonly suffered by individuals involved in motor
vehicle accidents, airplane crashes, or other violent impacts. Compression injuries, such as
those that may be sustained in diving, falling from a height, or in jumping from a height and
landing on ones feet, are also a likely source of spinal injury. The majority of cerebral spine
injuries are associated with head injury. Foreign bodies may lodge in the cord and directly
disrupt its structure and function. Bullets or knives are the most frequent objects involved in
penetrating spinal cord injury. Dont forget gunshot wounds, especially to the chest, back and
abdomen. Bleeding or hematoma at the trauma site can compress the cord, and loss of blood
supply to the cord can cause irreversible damage. Crushing injuries, such as those that occur
in a cave-in, and injuries to lightning (which cause violent muscle contractions), are apt to
produce spinal injuries. Any victim found unconscious after trauma should be assumed to
have a spinal injury and treated accordingly.

The most common site of spinal cord injury is between the cervical vertebrae C5 and C6, and
the second most common site is between T12 and L1. Spinal cord injuries are classified as
complete when the loss of sensation and function is total and as incomplete when the loss is
partial. The loss begins at the site of the lesion or injury and continues downward. About 55%
of all spinal cord injuries result in quadriplegia or loss of sensation and function from the
shoulder down, and the remaining 45% are paraplegic. Patients with paraplegia are affected
from about the waist down, the lower extremities. If the spinal cord is disrupted, the body
cannot signal vital organs. Breathing may stop, the pulse rate may become dangerously slow,
blood pressure can fall, and death may occur if interventions are not swift.

Assessment of patients with spinal injury

Whenever a victim has a spinal injury evaluate and ensure the airway, breathing and
circulation. Act as if all trauma patients have spinal cord injury until proved otherwise.
Assume that a spinal injury exists if the patient has any of the following:

Unconsciousness.
Trauma to the head, neck or upper part of the chest.
Difficulty breathing despite no obvious thoracic trauma. Head injury may produce
several types of abnormal respiratory patterns. Shallow, diaphragmatic breathing;
indicates a need to assist ventilation?
Signs of spinal shock: hypotension with a normal or slow pulse and warm skin (this is
very suggestive of neurogenic shock).
Paralysis or loss of sensation in any part of the body.
Involuntary loss of the control of bowel or bladder.
Priapism.

Try to determine as precisely as possible the circumstances of the accident. Ask bystanders
about the accident or assault. Find out the exact time of the injury if possible. If it has been
more than 6 hours since the accident, the chances of restoring lost function are greatly
reduced. If the patient is conscious, instruct him or her to not move. Ask patients to wiggle
their toes and then fingers, squeeze your hand, and determine which of their toes or fingers
you are touching.

Suspect spinal cord injury in:

Motor vehicle accidents (higher prevalence, when the occupants are unrestrained).
Falls from a height.
Diving accidents.
Cave-ins.
Patients with head or facial injuries.
Lightning injuries.
 Any unconscious victim of trauma.

If the patient is unconscious or the mechanism of injury indicates possible spinal injury,
assume that spine injury is present. Assessment of a conscious patient who has spinal injury
also requires a brief neurologic examination during the secondary survey to evaluate the
patients motor and sensory function. If patients can squeeze your hand, wiggle their fingers
and toes, their motor function may be intact. If they can feel your touch, sensory function
may be intact.

A patient who has any demonstrable motion whatsoever after spinal injury has a 75 percent
chance of recovering functional ambulation at a later data (Caroline, 1983). It I s important
for the physician to be able to identify which patients fall into this category. Occasionally,
swelling from injury around the spinal cord can cause temporary compression of the cord,
resulting in paralysis. As the swelling subsides, function may return. In most instances
damage to the spinal cord is permanent.

Signs and symptoms of spinal cord injury:

Pain and tenderness over the spine.

Numbness and paresthesias.
Weakness or heaviness of the limbs.
Position: arms folded across chest. A patient with an injury around C6, will often lie
with his forearms flexed across his chest and his hands half-closed. Another position
seen in some cervical spine injuries is the "stick em up" position in which the patient
holds his hands above his head.
Hypotension without other signs of shock.
Cuts and bruises over the head, face, neck and back.
Note also any signs of loss of bowel or bladder control.
Diaphragmatic breathing.
Signs of loss of bowel and bladder control.
Priapism.
Deformity of the spine.
Loss of sensation.
Weakness, paralysis, or flaccidity.
There may be no signs and symptoms at all!

Loss of sensation. Can the patient tell when someone is moving his finger or toe up or down?
Does he/she feel pain in response to pinprick (starting with the toes)? Mark the level at which
sensation is first elicited on the patients body. Recheck periodically. The umbilicus is at
approximately the level of the tenth (T10), the nipple around T4, and the clavicles around C3
(third cervical nerve).

Motor function. In an unconscious patient, test for paralysis by applying a noxious stimulus
first to each foot, then to each hand, and observing for withdrawal. A normal neurologic
examination does not rule out the possibility of spinal cord injury. Victims of a motor vehicle
injury have been known to walk from the accident only to become paralyzed hours later.

Common spinal injuries

Common spinal cord injuries are vertebral fractures and dislocations such trauma may cause
varying degrees of paraplegia and quadriplegia. Sheehy, & Jimmerson (1994) classify the
three major types of spinal injuries as injury to the spinal cord itself, fracture of the vertebrae,
and injury to the spinal nerves. Traumatic spinal cord injury is also classified into five
categories (A, B, C, D, and E) by the American Spinal Injury Association (ASIA) and the
International Spinal Cord Injury Classification System. Fracture and dislocations may also
interfere with the blood supply to the spinal cord from the radicular arteries (segmental
vessels), causing weakness and paralysis of the muscles.

Cervical injury. If the injury is at the sixth cervical vertebrae (C6) the hands will be affected
in addition to the legs, and intercostals muscles will be paralyzed, severely compromising
respiration. A hit higher on the spinal cord, C4 or above, the spinal injury will paralyze the
diaphragm as well as making respiration virtually impossible. In such an injury, the patients,
if they survive, become for the rest of their life totally dependent on machines (artificial
ventilator), and on other people for every need. Also, 27% of patients with cervical spine
injuries have concomitant head injuries (Sheehy & Jimmerson, 1994). Severe hyperextension
of the neck may pinch the superior arch of C1 between the occipital bone and C2, and the
spinal cord is usually severed. Victims with this injury seldom survive. If the transverse
ligament of C1 vertebrae, the atlas ruptures as the result of trauma the C2 vertebrae, dens of
axis is set free and may be driven into the cervical region of the spinal cord, causing
quadriplegia, or into the medulla of the brain stem causing death (Moore, & Agur, 1996).

Thoracic injury. Because of its stability (even from the attached ribs), the thoracic spine is
not injured as often as other parts of the spine. The neck of any victim who has a suspected
injury of the thoracic spine should be immobilized, and the injured victim should be
transported to the nearby hospital on a long backboard. Thoracic injury can impair ventilation
and circulation. Complete injuries at or below the thoracic spinal levels result in paraplegia.
Functions of the hands, arms, neck, and breathing are usually not affected. The lower the
level of injury, the less severe the effects.

Lumbar and sacral injury. Because of its flexibility, where the lumbar vertebrae join the
thoracic vertebrae at a flexible joint, the lumbar spine in the T12-L1 area is the second most
common site of spinal injury. Lumbar injury is common in patients who cannot move their
legs. The effects of injuries to the lumbar and sacral regions of the spinal cord are decreased
control of the legs and hips, urinary system, and anus. Bowel and bladder function, and also
sexual function are regulated by the sacral region of the spine.

Impalement. Any object that lodges in the spinal column should be left in place, as removing
it could make the injury worse. Most spinal injuries due to penetrating trauma are caused by
guns or knives.

Spinal shock, or neurogenic shock is a complex phenomenon in which the nerve pathways
controlling the diameter of the vessels are interrupted and peripheral vascular dilation,
hypotension results. Pooling of blood may make the skin feel warm and pink. The
sympathetic system generally stimulates an increase in pulse to compensate for any decrease
in blood pressure, but as this impulse is impaired in spinal cord injury, the pulse may be
normal, slow or severely bradycardic. The emergency team may apply MAST to help support
blood pressure by compressing the lower extremities, intravenous fluids may help somewhat,
but inotropic agents are often necessary to sustain life.
Central cord syndrome accounts for approximately 9% of traumatic spinal cord injuries
(McKinley, Santos, Meade, & Brooke, 2007). It is a form of incomplete spinal cord injury
characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is
also referred to as inverse paraplegia, because the hands and arms are paralyzed while the
legs and lower extremities work correctly.

Management of patients with spinal injury

After a patent airway, breathing, and circulation have been established, the goal of
prehospital care is to limit any further damage to the spinal cord. Immobilize the patient and
maintain perfusion and oxygenation of the nervous system. Your interventions should be
within the scope of your professional license, skills and training, consistent with your states
nurse practice act, and adherent the facilitys standards of practice. Treatment of the patient
with possible spinal injury is aimed at supporting vital functions and preventing further spinal
cord damage (note patients position and general appearance):

Ensure an open airway. For the unconscious patient, use jaw trust without backward
tilt of the head, and insert an oropharyngeal airway. Keep suction readily available.
Assist breathing as required. Evaluate the patients breathing, if it is shallow, you will
need to assist ventilations. Administer oxygen to all patients who have sustained a
suspected spinal injury to increase oxygen supply to the spinal cord. Administer
oxygen, either by nasal cannula to the patient who is breathing adequately or via bag-
valve-mask when assisted ventilation is required.
Support the circulation:
- Control bleeding.
- Secure venous access. Administer intravenous fluids, plasma expanders, and
inotropic agents as ordered (to support the blood pressure).
- Anticipate possible application of MAST for severe hypotension.
Specialists may recommend intravenous administration of methylprednisolone (within
a few hours of the trauma) to reduce the severity of a spinal cord injury or enhance
recovery.
Treat other injuries. Evaluate the chest, abdomen, and lower extremities repeatedly, as
the patient with a spinal cord injury often can no longer perceive pain from other
injuries because of the disruption of spinal cords messenger function.
Do your best to keep the victims head, neck, and spine in alignment, and never drag
or pull the victim by the head or neck. Try to stabilize the victims head and neck with
your hands. Move the patient by yourself only if the patient or you are in immediate
danger (e.g. explosion or fire at the trauma scene seems imminent).
Immobilize the patient on a long backboard. Patients who have a spinal injury are
always placed and transported on a long spineboard/backboard to immobilize the
whole body and with a rigid Philadelphia collar in place. The emergency team often
adds additional support with rolled towels placed on each side of the patients head.
The head is then taped in place to the backboard to further restrict movement. Logroll
the patient as a unit (four or more trained professionals); keep the head in alignment
with the body. This series of steps is called packaging the victim. Quickly scan the
patients back for injuries before the patient is rolled onto the spinal board.
Once wounds have been dressed, and fractures splinted. Keep the patient covered with
a blanket. Loss of sympathetic tone means loss of vasoconstriction, which in turn
means that the patient can no longer conserve body heat effectively.
 Transport the unconscious patient in a lateral recumbent position. This position will
assist drainage of secretions out of the mouth.
Make frequent checks of vital signs and neurologic status on route; record your
findings.
Do not attempt to remove a helmet from the victim of a motorcycle or sports accident
(unless necessary to access the airway, sustain breathing, or control life-threatening
hemorrhage). Use careful appropriate rescue techniques for victims injured in a water
accident.
Do not allow the patient to eat or drink until he or she is seen by a surgeon. Immediate
surgery may be indicated, and the patients condition may also deteriorate, and
vomiting or aspiration may occur.
A full bladder may burst so catheterization is often indicated, but not until the
potential for urethral damage due to pelvic fracture has been ruled out.
Be prepared for seizures.
Monitor the condition and placement of extremities and body parts. Patients with
spinal cord injury may not be able to tell you when something hurts.
Reassure the patient frequently, and offer calm simple explanations.

Laminectomy is the surgical procedure used to expose the spinal cord to relieve compression
on neural structures from hematomas, and to remove bone fragments, or penetrating objects.
Spinal fusion is used to stabilize spine. Cervical tongs or halo traction are used to immobilize
the cervical spine, and body cast or Harrington rods are used to immobilize the thoracic
spine. Tracheostomy may be performed to provide long-term ventilatory support.

Research into treatments for spinal cord injuries includes controlled hypothermia and stem
cells. Aside from methylprednisolone, many treatments have not been studied thoroughly and
very little new research has been implemented in standard clinical care.

Orthopedic injury

In the multiple-injury victim, fractures may be the most obvious and dramatic injuries, but
they are rarely the most serious. A simple fracture is generally not life-threatening, but some
musculoskeletal injuries, such as pelvic fractures/crush injuries, traumatic proximal
amputations, and multiple open or closed fractures may be life-threatening, due to loss of
blood or spinal cord injury. Other injuries, such as hip or knee disclocations, can result in loss
of the limb from arterial occlusion or in permanent disability.

The musculoskeletal system comprises the bones, cartilages, muscles, tendons and ligaments
of the body. The skeleton, the supporting framework for the body is composed of 206 bones
in the adult that protect structures, provide attachments for muscle, allow body movement,
serve as major reservoir for blood, and also produce red blood cells, platelets, and most white
blood cells. The four types of bones composing the skeleton are the long bones (bones of the
extremities), short bones (bones of the wrist, ankle), flat bones (ribs, shoulder blades), or
irregular (vertebrae, mandible). Bones are living organs that hurt when injured, bleed when
fractured, and change with age.

The skeleton changes throughout life as bone formation and bone destruction proceed
concurrently. The age of a person can be determined by studying ossification centers.
Fractures are more common in children than in adults because of their slender growing bones
and care-free activities. Many of these breaks are greenstick fractures (incomplete breaks
caused by bending of the bone), and fractures in growing bones heal faster than those in adult
bones. During old age, there is a reduction in the quantity of bone; hence the bones lose their
elasticity and fracture easily.

Loss of the arterial supply to a bone results in death of bone tissue (avascular necrosis). After
every fracture, small areas of adjacent bone undergo necrosis. Veins accompany the arteries,
and nerves accompany the blood vessels supplying bones. Periosteral nerves are especially
sensitive to tearing or tension, which explains why pain from broken bones is severe. Within
bones, vasomotor nerves cause constriction or dilation of blood vessels.

Orthopedic trauma may result from a variety of mechanisms. The direct or indirect force of
blunt trauma can fracture or dislocate bones, and also cause trauma to the surrounding tissues,
nerves and vessels near the bone. In some instances, the bone are sheared or torn from
surrounding structures, resulting in amputation. Sometimes the bone does not break, but
tendons, ligaments, and muscles are strained, sprained, or torn by the force to site. Twisting
injuries, such as commonly occur in football or skiing, result in fractures, sprains, and
dislocations. Powerful muscle contractions in seizures may tear muscle from bone. The
elderly (and patients with bone metastasis) have weaker, more brittle bones and are thus more
prone to fractures.

Penetrating trauma is caused by bullets, knives or other instruments that shatter bones and
lacerate muscles, tendons, and ligaments. The ends of fractured bone may protrude through
the skin and may become an open pathway for infectious organisms.

Assessment of patients with orthopedic injuries

Evaluate the airway, breathing and circulation and intervene in life-threatening injuries first,
limb-threatening injuries second, and then less serious injuries. Surrounding nerves and
vessels may be injured during orthopedic trauma, and these additional injuries could cause
permanent disability and deformity, especially in children, so injuries must be carefully
managed. The evaluation of patients with possible musculoskeletal injuries requires
observation of the scene to determine mechanism of injury, followed by a history of the
injury while examining the patient. It is not always easy at the scene to distinguish between a
dislocation and a fracture.

Assessment includes the following steps:

Cut clothing away from the extremities. Do not compromise stabilization of the head
and cervical spine. Look carefully, and compare the injured extremity with the
opposite limb; note color and skin temperature; and look for obvious injuries,
deformities or bleeding that may require immediate interventions.
Feel gently down each extremity. Note uneven surfaces, swelling and ecchymosis,
changes in skin temperature, grinding sensations, deformity or shortening, tenderness
to palpation, guarding and disability, and complaints of pain from the patient.
A careful assessment must be made of pulses, sensation, and movement distal to the
fracture site. Palpate the distal pulses in each extremity to determine if circulation is
impaired. Distal pulses should be equal. Mark the point where the maximal impulse is
felt, so that you can locate it later.
Ask the patient if he or she can feel you touching the extremity, and if there is any
numbness or tingling. If no obvious deformity is present, ask the patient to wiggle the
 fingers or toes of the affected extremity. This test provides information about damage
to the nerves in the area.
Ask the patient about previous musculoskeletal system injuries, diseases or surgical
operations. When in doubt treat the injury as a fracture and immobilize the injured
area.

Signs and symptoms of fracture:

The primary symptom is moderate to severe pain, usually well localized to the
fracture site. The patient may also report that he or she heard something snap or felt
the bone break.
Tenderness to palpation will usually be well localized to the area over the injury and
is elicited by pressing gently along the length of the bone or each side of the pelvis.
Deforming and shortening of an extremity. Deformity: difference in size and shape?;
does any portion (the skull or rib cage) appear caved in?; unnatural position?; or, false
or unnatural motion?
Guarding and disability; the patient with a fracture will attempt to find a comfortable
position and avoid moving it; the patient with a dislocation will be unable to move the
dislocated extremity at all.
Swelling and ecchymosis. Swelling and bruising are caused by leakage of
extracellular fluid and blood from vessels that have been ruptured in and about the
fractured end of break.
Grating and crepitus may be noted during splinting attempts, when broken fragments
of bone grind against one another. Testing for crepitation can produce further tissue
damage.
Exposed bone ends present (in open or compound fracture).

Signs and symptoms of dislocation:

Pain or a feeling of pressure over the involved joint.

Loss of motion of the joint.
Sign of deformity. If the dislocated bone end is pressing on nerves or blood vessels,
corresponding functions also may be compromised. Numbness or paralysis below the
dislocation if nerve is depressed, loss of pulse below the dislocation if blood vessel is
compressed. The absence of pulses means that extremity is in a grave danger. An
orthopedic surgeon should be alerted to be standing by when the patient arrives.

The possibility of associated damage to nerves and blood vessels must always be considered
in cases of fracture, and a careful assessment must be made of pulses, sensation, and
movement distal to the fracture site.

Estimated blood loss in fractures:

Fracture of Blood Loss (L)

Pelvis 2.0-3.0
Hip 1.5-2.5
Femur 1.0-2.0
Humerus 1.0-2.0
Knee 1.0-1.5
Fracture of elbow, tibia and ankle, can each lose 0.5-1.5 L, and fracture of forearm 0.5-1.0 L.

Common orthopedic injuries

Fracture is a traumatic injury to a bone in which the continuity of the bone tissue is broken.
A fracture is classified by the bone involved, the part of that bone, and the nature of the
break, such as a comminuted fracture of the head of the tibia. Fracture may be open
(compound, the skin is broken over the fracture site), or closed (simple, the skin remains
intact). Open fractures are considered more serious, as they may become an open pathway for
infectious organisms and foreign bodies.

Pelvic fractures may be stable or unstable. Unstable pelvic fractures typically occur as a
result of high-energy injuries, such as motor vehicle crashes. If gentle pressure applied to
each side of the pelvis elicits pain, or there is abdominal distension from internal bleeding,
evidence of hypovolemic shock, and bloody urine, suspect a pelvic fracture. Blood loss can
be more than 2-3 L. Any signs of instability should have prompt urgent consultation with an
orthopedic surgeon.

Femur fracture is an injury to the longest and strongest bone in the lower extremity. The
fractured leg may appear to be shorter than the other leg and usually is rotated externally.
Sometimes a MAST is applied to patients who have a fractured femur because of significant
blood loss and because compression applied by the garment helps splint the fracture. A
Thomas half-ring leg splint is also often used to realign the bone and promote circulation
when a femur is fractured. Concurrent fracture of both femurs can cause life-threatening
hemorrhage and death.

Hip fractures are most common in elderly women and usually caused by simple falls.
Fractures of the hip bone also often occur in serious vehicular accidents, and other sudden
deceleration accidents. Blood loss can be 1.5-2.5 L. The affected extremity may appear to be
shorter than the other extremity. Dislocation and swelling may be present over the fracture
site. This is a serious injury that requires evaluation by an orthopedic surgeon.

Humerus fracture is an injury to the longest and strongest bone in the upper extremity.
Substantial force is required to fracture it; blood loss may be heavy, and neuromuscular
compromise may develop. Fractures of the surgical neck of the humerus mostly occur from
falls in which the outstretched arm strikes the ground (impacted fracture). Humerus fracture
is a serious injury that requires evaluation by an orthopedic surgeon.

Wrist fractures often occur when individuals fall on their outstretched hands (with elbow
extension), or when they throw up their hands against the interior of the vehicle in a motor
vehicle accident.

Ankle fractures often occur in sports accidents, motor vehicle accidents, and falls. If the
injury was caused by a fall, suspect spinal and head injuries as well, because the energy
would have been directed up the body on impact. Swelling and pain, and sometimes obvious
deformity may be present.

Any dislocation, the displacement of a bone from its normal articulation with a joint can be
serious. Tearing of the ligaments, disruption of the blood supply and nerves in the area can
result in loss of limb or permanent disability. The shoulder, elbow, fingers, hips, knee, and
ankles are the joints most frequently affected. Even if the dislocated joint slips back in the
place, the patient still must be evaluated by an orthopedic surgeon. Joint dislocations should
be reduced and splinted as soon as possible, especially knees, hip, and ankle.

Hip dislocations. The ball-and-socket joint of the hip, formed by the articulation of the head
of the femur into the cup-shaped cavity of the acetabulum involves seven ligaments and
permits very extensive movements. Hip dislocation often occurs in motor vehicle accidents
when a person's knees strike the dashboard, and the energy is directed back to the hip. A hip
dislocation is a serious injury as the blood supply to the head or top of the hip may be
impaired, causing necrosis and necessitating replacement with an artificial joint in the future.
Pressure on the sciatic nerve can result in permanent disability. Pain is often severe, and the
leg may rest in an unnatural position.

Knee dislocations or fractures may cause serious injury to the popliteal artery. Therefore,
arteriograms are obtained in the hospital whenever a patient has a dislocated knee. In a
patient with a dislocated knee and absence of distal pulses, reduction must be accomplished
within 1 to 2 hours of injury. Dislocations of the wrist, elbow, shoulder, hip, and ankle can be
tolerated for 2 to 3 hours without much danger of permanent damage (Caroline, 1983).
Serious knee injuries may necessitate amputation of the leg (Campbell, 1988).

Tibia fracture. The tibia is the most common long bone to be fractured and also the most
frequent site of an open (compound) fracture. Fracture of the fibula is often associated with
fracture-dislocations of the ankle joint. It is also a common source of bone for grafting.

Shoulder dislocations are most often sustained in athletic activities. The shoulder is the most
commonly dislocated joint and this dislocation may become chronic and require surgical
interventions. Like shoulder dislocations, elbow dislocations are often associated with
athletic activities or when children fall on their hands with their elbows flexed. Serious
damage to nerve and vessels may occur.

Wrist fractures, commonly occurs when the person slips or trips and, in an attempting to
break the fall lands on the outstretched hand with the forearm pronated.

Sprains are injuries in which the ligaments that connect one bone to the other are partially
torn, usually caused by sudden twisting forces. They most commonly affect the knees and
ankles and are characterized by pain, swelling, and discoloration of the skin over the injured
joint. Sprains usually do not manifest deformity but it is generally best to treat the sprain as if
it were a fracture and immobilize it accordingly. Keep the sprained joint elevated, and apply
ice compresses if available.

Strains are soft tissue injuries or muscle spasms around a joint due to overstretching or
overexerting a muscle, as in sports activities. The strain is generally in the area of a tendon,
where the muscle attaches to the bone, and is characterized by pain on active movement.
Strains are best treated by avoiding weight-bearing on the injured area. The extremity may be
immobilized pending evaluation in the emergency department.

Simple lacerations often heal with only simple suturing. Lacerations that penetrate the
ligaments and tendon in the hands and feet may result in permanent disability if not
thoroughly irrigated and repaired. Penetrating injury may also result in foreign bodies or
objects impaling bones, muscles, or tendons. Due to the impalement disability or loss of the
extremity may occur.

Traumatic amputations, when a limb or part of a limb is severed from the body are serious
emergencies, often sustained in industrial accidents, recreation accidents, traffic accidents,
amputation from weapons, explosives, bombs, terrorist attacks or natural disasters. Blood loss
may be significant. The most important is to save the life of the victim by ensuring airway,
breathing and circulation (control of bleeding, shock), and so forth. Depending on the
circumstances the amputated parts can sometimes be reinplanted, so the parts should be
preserved and always accompany the patient to the hospital. Bleeding from a stump is usually
not a problem, since the severed blood vessels tend to restrict into the stump and be squeezed
shut. Control the bleeding by applying an appropriate sterile dressing moistened in sterile
saline directly on the wound. Cover the dressed stump with a dry bandage, and elevate the
stump above the level of the patients heart, but only if doing so does not compromise
stabilization of the head and cervical spine. If bleeding cannot be controlled, apply pressure
on the appropriate pressure points. Do not use a tourniquet except as a very last resort, as it
will reduce the viability of the distal stump and thus lessen chances of successfully
reinplanting the amputated stump. The amputated part should be wrapped loosely in wet
gauze or other material, placed and sealed in a plastic bag. Place the plastic bag or waterproof
container on ice. The goal is to keep the amputated part cool but not to cause more damage
from the cold ice. Do not cover the part with ice or put it directly into ice water, it will only
harm the tissues and nerve endings further possibly hindering reattachment of the limb. The
patient and the preserved amputated part should be taken as expeditious as possible to the
hospital. Notify the emergency surgical team in advance about the estimated time for arrival.
If the part cannot be found right away, transport the injured person to the hospital and bring
the amputated part to the hospital when it is found.

Compartment syndrome is a pathologic condition caused by a progressive development of

arterial compression and reduction of blood supply; an increase in pressure within a facial
compartment. This leads to tissue death from lack of oxygenation. It develops most often
with blunt trauma or crush injuries (such as earth quakes). Compartment syndrome most
often involves the forearm and lower leg. There are classically five "Ps" associated with
compartment syndrome: pain out of proportion to what is expected, paresthesias, pallor,
paralysis, and pulselessness. Tense and swollen shiny skin, restriction of movement,
sometimes with obvious bruising of the skin and an increase in intracompartmental pressure
are other signs and symptoms. These may develop a few hours to a few days after the injury.
Treatment includes removal of restrictive dressing or cast, and surgical compression to
relieve increased intracompartmental pressure. Acute compartment syndrome is a medical
emergency requiring immediate surgical treatment, known as fasciotomy to allow the
pressure to return to normal (Salcido, & Lepre, 2007). Otherwise, loss of the extremity may
occur because vascular compression causes tissue necrosis.

Management of patients with orthopedic injuries

Interventions and treatments of fractures should be deferred until life-threatening conditions

have been adequately managed. When life-threatening conditions have been dealt with, it is
appropriate to identify and immobilize all fractures in preparation for transport.
Musculoskeletal injuries, such as: all penetrating injuries to extremities proximal to elbow
and knee; two or more proximal long-bone fractures; crushed, degloved, or mangled
extremity; amputation proximal to wrist and ankle; pelvic fractures; and also flail chest; open
or depressed skull fracture; and paralysis should be taken to a trauma center. The most
seriously injured patients should be transported preferentially to the highest level of care
within the trauma system.

Treat the life-threatening injuries first, after that the patients airway, breathing, and
circulation have been established, orthopedic injuries should be carefully examined and
stabilized if present. The goals are to limit further damage, preserve the structure and function
of the extremity, ensure perfusion and oxygenation, and transport the patient to a hospital
(trauma center) for examination by an orthopedic surgeon. Some orthopedic injuries are
associated with significant morbidity and mortality and may affect the patients quality of
life. Immobilize the head and the neck and assume that injuries to the cervical spine exist
until proved otherwise.,/p>

Assess and stabilize the airway, breathing and circulation before evaluating other
orthopedic injuries.
Administer oxygen to any patient who has multiple fractures or a fracture of a long
bone.
Secure intravenous access with two large-bore intravenous lines, and begin volume
replacement as ordered to any patient who has a fractured long bone or a suspected
pelvic fracture, because shock may follow. Be aware that a pelvic fracture or bilateral
femoral fractures can cause life-threatening hemorrhage and death. Type and cross-
match orthopedic trauma patients when fracture of the pelvis or long bones is
suspected.
The MAST garment to enhance venous return and support the blood pressure is often
used. For massive trauma to the lower extremities or pelvic fractures MAST can be
used as a splint.
Do not allow the patient to eat and drink anything until he or she is examined by an
orthopedic surgeon.
Do not remove an object stuck in bone or muscle unless the object is interfering with
the airway. Stabilize the impaled object, and transport the patient to a hospital
immediately.
In open fractures, do not attempt to push exposed bone ends back into the wound.
Cover with sterile dressing. Immobilize all fractures before moving the patient. Splint
the extremity as you find it, and transport the patient to a hospital for emergency care.
A dislocated hip or knee is a serious orthopedic emergency. The blood and nerve
supply to the extremity may be impaired; permanent disability can result, or
amputation of the extremity may be necessary.
Splint an extremity to prevent possible injury if you are uncertain whether orthopedic
injury exists. Immobilize and splint any injury as you find it. Move the patient
carefully to avoid making the injury worse.
If the condition of a critically injured patient with pelvic fracture is unstable and
rapidly deteriorating, urgent surgery will be required.
Apply gentle pressure to any orthopedic injury that is bleeding. Await the arrival of an
emergency team who can properly splint the fracture. If the patient must be moved,
splint the fracture as you find it. Move the patients carefully to avoid making the
injury worse.
Do not attempt to straighten fractures involving the spine, shoulder, elbow, wrist or
knee. Fractures involving joints should be splinted in the position which they are
found.
 Severely angulated fractures of long bones should be straightened before splinting
(exert longitudinal traction). Specially trained trauma professional sometimes realign
extremities at the scene, but unless you have this skills and special training, do not
attempt this. Pillows, newspapers, broomsticks, and cardboard are a few of the items
that can be used as splints.
Do not attempt to straighten a dislocated or fractured knee, hip, shoulder, or elbow.
Splint the extremity as you find it and transport the patient to a hospital for emergency
care.
Splint dislocations in the position in which they are found. Splint above and below the
dislocated joint to maintain stability during the transport.
Immobilize a dislocated hip in the position you find it. Transport the patient
immediately to the hospital for evaluation.
Splint one leg with the other and transport the patient to the hospital if you suspect a
hip fracture. The pain may be referred to the knee or pelvis.
Immobilize the joints above and below the fracture. For example, elbow and wrist for
fractures of the radius and ulna.
Splint firmly but not so tightly as to occlude circulation. Check distal pulse after
splinting. Leave fingers and toes visible. Check and recheck air splints. Pad board
splints well. Be sure that it is not applied to tightly, or pressing against areas of
contact.
For fractures above the knee, the half-ring traction splint is often used.
Lay a fractured wrist on a firm surface to splint and immobilize the fracture. Splint it
in the position found, and if the wrist fracture is an isolated injury, apply a cool pack,
and transport the patient to the hospital.
Pillow splint or an air splint can be used for suspected ankle fractures. If no other
pathologic changes or indication of spinal injury is present, elevate the ankle slightly
and apply a cool pack to reduce swelling. Take care not to change the position of the
ankle if there is a distal pulse.
Elevate a sprained or strained extremity if spinal injury has been ruled out. Apply a
cool pack and recheck at intervals to make certain the injured site has not changed and
the pack is not to cool.
Assess and record the neurovascular status of the extremity. Palpate distal pulses, note
skin temperature, and check sensations frequently in an injured extremity, and
reassess each time the patient is moved or the extremity is repositioned. Report
changes or trends to a physician immediately. Orthopedic injury can result in
neurovascular compromise and can cause subsequent loss of the extremity or normal
function of the extremity.
Check cast and splints at regular intervals to ensure that swelling has not occurred, for
tightness can precipitate development of compartment syndrome; record abnormal
findings and report them to a physician. Compartment syndrome and necrosis of the
extremity can develop in a constricting cast or splint.
Cover the dressed stump with a dry bandage, and elevate the stump above the level of
the patients heart, but if doing so do not compromise stabilization of the head and
cervical spine. If bleeding cannot be controlled, apply pressure on the appropriate
pressure points.
The amputated part should be wrapped loosely in wet gauze or other material, placed
and sealed in a plastic bag. Place the plastic bag or waterproof container on ice. The
goal is to keep the amputated part cool but not to cause more damage from the cold
ice. Do not cover the part with ice or put it directly into ice water, it will only harm
the tissues and nerve endings further possibly hindering reattachment of the limb.
 The patient and the preserved amputated part should be taken as expeditious as
possible to the hospital. Notify the emergency surgical team in advance about the
estimated time for arrival. If the part cannot be found right away, transport the injured
person to the hospital and bring the amputated part to the hospital when it is found.
Notify the surgical team of a patient for possible reinplantation. Follow protocols for
preserving all amputated parts. Reinplantation may be possible, and the parts may be
used for grafts. Mark the time the parts were amputated and the time they were placed
on ice on the container, because this information will help the transplantation team
plan the care.
In traumatic finger amputations, reinplantation of the thumb is generally a priority
because of the function of this digit.
X-ray all suspected fractures, including joints above and below. A computed
tomography scan is often used to obtain more detail about a fracture or bone problem
that was found with plain X-rays.
Prepare for surgery or vascular studies and assist with the measurement of
intracompartmental pressure as indicated.
Provide adequate analgesia as ordered. Immobilizing in a position of relative
alignment can achieve significant analgesia, and also improvements in skin/limb
perfusion to the limb.
Use strict aseptic technique, and administer antibiotics as ordered. Monitor
temperature and white blood cell count. Determine the data of the patients last
tetanus prophylaxis and report it to a physician for consideration of a tetanus booster
injection.
Offer explanations and reassurances to the patient as you work, and reassure the
patient that everything possible is being done.

Heat cramps, heat exhaustion, and heat stroke

Body temperature is usually maintained near a constant level of 98-100F (36.5-37.5C).

Fever is defined as a rectal temperature of 100-101F (>37.5-38.3C), hyperthermia 101-
104F (>38.4-39.3C), and hyperpyrexia 104-107F (>40.0-41.5C). If heat production
exceeds heat loss, the temperature will rise. When core temperature rises, peripheral
vasodilation occurs, and the blood brings increased amounts of heat to the skin, where it is
dissipated, unless the ouside temperature approaches or exceeds the skin surface temperature,
and as long as metabolism does not produce an overwhelming heat load. Then the
physiologic effects of exposure to high environmental temperatures and humidity is that the
heart must increase the output (tachycardia); blood is shunted away from the brain; as
sweating increases, excessive amounts of sodium, chloride, and other electrolytes are lost
through the skin, resulting in cramps and dehydration.

Heat cramps are painful muscle cramps, usually in the lower extremities, the abdomen, or
both, resulting from excessive loss of salt and water through sweating. It often occurs after
vigorous physical activity in an extremely hot and humid environment. The patient may
become somewhat hypotensive and nauseated, with rapid pulse, pale and most skin, the
temperature is normal, and the patient remains alert. Heat cramps may progress to heat
exhaustion, if untreated. Treatment is aimed at eliminating the exposure and restoring lost salt
and water. The victim should be moved to a cooler place and given salt-containing fluids. If
the victim is too nauseated, start an IV. Do not massage the cramping muscles. As salt and
water are replenished, the patients symptoms will abate. The patient should avoid strenuous
activities for at least 12 hours, to avoid heat exhaustion or heat stroke (Caroline, 1983).
Heat exhaustion, prostration caused by excessive loss of salt and water through sweating, as
well as to peripheral blood pooling, that results from the exposure to intense heat or inability
to acclimatize to heat. It is especially likely in dehydrated, elderly patients and in persons
with hypertension; the elderly are more prone because of diminished thirst mechanisms.
Syncope, headache, weakness, vertigo, nausea, and sometimes abdominal cramping
characterize this condition. The patient is usually perspiring profusely, the pulse is rapid and
weak, skin is pale and clammy, the blood pressure may be decreased, the respirations are
usually fast and shallow, the temperature is either normal or decreased, the pupils may be
dilated, and the patient may be somewhat disorientated. Untreated heat exhaustion may
progress to heat stroke. The patient usually recovers with rest and replacement of water and
electrolytes. Move the patient to a cool environment, remove clothing as much as possible,
and place him or her in a supine position with elevated legs. Make the patient comfortably
cool; sponge with cool water, and fan him or her if the humidity is not excessively high. Start
an IV with normal saline or Ringers solution and run the fluids rapidly.

Heat stroke (sunstroke, heat hyperpyrexia) is a life-threatening condition caused by severe

disturbance in the bodys heat-regulating mechanism that may occur at any age in persons
having too much sun exposure or prolonged confinement in a hot atmosphere. The victims
temperature control system, which produces sweating to cool the body, stops working.
Elderly patients and those with a history of cardiac disease are at increased risk for heat
stroke when taking an anticholinergic, such as dicyclomine (The clinical answer book, 1996).
This adverse effect is especially common with strenuous activity and high environment
temperatures. Body temperature may rise as high as 106F (41C) or higher within 10 to 15
minutes; the skin appears flushed, and is hot and dry. The patient may experience throbbing
headache, dizziness, and dryness of the mouth; the pulse is strong, bounding. Coma and
seizures often follow rapidly. The patient may vomit, lose consciousness, and suffer cardiac
arrhythmias. Immediate and aggressive therapy (aimed at maintaining vital functions and
inducing as rapid a temperature fall as possible) must be initiated to avert cardiac arrest.
Establish an airway, and administer oxygen. Move the patient to a cool environment, remove
as much clothes as possible, and cool the patient rapidly. Use a bathtub filled with cold water
and ice cubes, an ice-cold shower, crushed ice rubbed over the patients head and body
(massaging increases peripheral circulation, which accelerates heat loss), a garden hose, cold
packs, or continued washings with rubbing alcohol and wet sheet wrapped around the patient
with a fan blowing; speed is essential. Delay may result in permanent brain damage.
Vigorous efforts to cool the patient must continue until the body temperature is below 102F
(38.9C) (Caroline, 1983). Secure venous access, monitor cardiac rhythm; and monitor for
respiratory alkalosis at the hospital. Fluid replacement, as needed; administration of cool
fluids also helps to bring down the patients core temperature. Treat seizures, as indicated.
Avoid shivering as it generates heat and increases the metabolic rate and oxygen demand in
the body; administer diazepam, lorazepam, or meperidine, as ordered.

Populations can acclimatize to hot weather, but mortality and morbidity rise when the
daytime temperature remains unusually high for several days in a row and nighttime
temperatures do not drop significantly. Heat waves result in adverse health effects in cities
more often than in rural areas (American Public Health Association, 2005, 1). The elderly
people (65 years and older), infants, people with chronic medical conditions, those with a
prior heatstroke, and those who are obese, are more prone to heat stress and adverse
outcomes. Infants and young children are sensitive to the effects of high temperatures and
rely on others to regulate their environments and provide adequate liquids. Air-conditioning
is an excellent protective factor against heat-related illness and deaths.
Pediatric injury

Injury is the leading cause of death in children. The injured infant or child present unique
challenges in assessment and management, depending on the age, they may not be able to
report what is bothering them. Anatomic and physiologic differences also exist between the
bodies of infants and children and adults.

Special differences between adults and children when injured include (Andrn-Sandberg,
1993):

Smaller size often gives multiple injuries.

Less ability to absorb a blow to the skin or subcutaneous tissue.
Softer skeleton (can give underlying injury without fracture).
Higher heat loss.
Higher frequency of paralytic ileus.
First appearance of symptoms due to congenital defects (for example, cardiac failure).
Other psychological conditions.

In general, the injured child is frightened, by pain, discomfort, the presence of strangers, the
possibility of separation from parents or caretakers, and an atmosphere of panic or distress. It
is important to be aware of all these fears; and to be calm, patient, and gentle. Smaller sizes
of emergency equipment are also required, such as airways and catheters.

A childs heart is generally healthy and strong, unless he or she was born with a congenital
heart defect. Because of the lower blood volume and smaller size of a child, an injury can
cause shock and hypotension easier and also reduce the margin of error when fluids and
medications are administered. The heart rate decreases as the child grows older, and the blood
pressure generally increases as the child grows older.

Because the nostrils are narrower, nasal airways are not usually appropriate for a child. It is
more difficult to intubate children tracheally than adults. The respiratory rate is higher in the
younger children. The chest wall of children is compliant and quite flexible; but the organs
and structure protected by the rib cage are also more vulnerable. The lungs are still immature
the first three months of their lives.

Children have an elevated basal metabolic rate, and thus higher oxygen requirements. The
kidneys have less ability to correct serious disturbances in the water and electrolyte balance.
The thermoregulatory mechanisms in infants and children are not so well developed yet and
they are prone to hypothermia. With the large surface-to-mass ratio, children are less able to
maintain their body temperature.

A large percentage of pediatric injuries result from motor vehicle accidents in which the child
is a pedestrian, bicyclist, or passenger. Head injury is the most common type of trauma. Falls,
especially from high-rise buildings, are also a common cause of injury in infants and
children. Blunt trauma is most common. Penetrating injuries are usually due to assault
(gunshot wounds) or accidents (impalement). Children are particularly vulnerable to die from
injuries or suffer disabling injuries. Many deaths are due to an obstructed airway, blood loss,
or central nervous system injury.

Assessment of injuries in infants and children

Follow the standard ABC plan, and evaluate the airway, breathing, and circulation. Take in
the scene and continue to gather information while assessing the injured infant and child.
Assessment may be hampered because the victim may be unable to communicate with you,
and parents and caretakers may be injured, or lose control of their own stress at seeing the
infant or child injured. Try to obtain information from the parent or bystanders, if possible.
Knowledge about the nature of the injury, the patients age and any preexisting medical
conditions will be helpful.

Signs and symptoms of injury to look for include the following:

Newborn may make grunting sounds on expiration. In infants sternal retraction occurs
with only a slight increase in respiratory effort; the result of the pliability of their
chest wall. Flaring of the nostrils may be another sign of respiratory distress.
In children, a scalp laceration may be sufficiently profuse to cause hypovolemic
shock, because they have lower blood volume than adults.
Any loss of consciousness can be serious, and the patient should be transported to a
medical facility immediately.
Any obvious injuries such as abrasions, lacerations, avulsions, contusions,
deformities, fractures, and burns should be evaluated by a pediatrician.

Glasgow Coma Scale (GCS) for children is the same as for adults except that verbal
response has been modified:

Best verbal Response (5)

Oriented 5 - respond adequately, provide social smiles, fixes and follows with his/her eyes
Confused 4 - crying, but can be consoled
Inappropriate words 3 - constantly irritated
Incomprehensible sounds 2 - anxious, agitated
No verbal response 1 - does not react at all when spoken to.

Common injuries in infants and children

Children are most frequently injured in the summer months, often in a motor vehicle
accident. Multiple injuries in children are common when a car in a motor vehicle accident
strikes a child. Waddells triad; fracture of the femur coupled with blunt injury to the spleen
and head; is a classic set of injuries in this situation. Because the head is disproportionately
large in a child, skull fractures and head injuries are common. Blunt injury from a motor
vehicle accident or a blow to the abdomen can cause compression and subsequent rupture of
the internal organs; the liver and spleen are most vulnerable, and kidneys. The ribs and chest
wall are more flexible in children, but a blunt chest injury may cause a pneumothorax or flail
chest. Chest injuries by blunt-force impact are a common cause of death in children subjected
to an explosive blast.

Disability and deformity can result from improper management of fractures, and a pediatric
orthopedic surgeon should examine any suspected fracture or fracture. Burns in infants and
small children (especially under the age of 5) pose a special problem because the surface area
in children is much larger in proportion to the total body mass than in adults. Potential fluid
loss through extensive burns can be massive. Scald injuries are more common in children,
from hot drinks or hot bath water. An immersion scald is created when an extremity is held
under the surface of hot water, and is a common form of burn seen in child abuse. Burns in an
infant or a child can be serious and should be evaluated by a physician.

Management of injuries in infants and children

The primary goals are to preserve the injured infants and childrens lives and transfer them to
a pediatric trauma facility for the best possible outcomes; and to provide emotional support
for the parents or caretakers. In general, time is not spent at the scene to intubate or securing
intravenous access, unless it is deemed essential. Your interventions should be within the
scope of your professional license, skills and training, and when performed in a health care
setting, adherent to the facilitys standard of practice. Assess and reassess the patient
regularly.

Ensure airway, breathing, and circulation. Administer oxygen.

Use the car seat of a child for transportation, if possible, and immobilize the childs
head by taping it to the seat; in case the cervical spine is injured.
Do not move a child who has fallen from a structure unless it is necessary. Stay with
the child and call for assistance. Apply pressure to sites of bleeding as indicated;
administer oxygen.
Bradycardia is a warning sign of serious hypoxia, and immediate intervention is
required to prevent imminent brain damage and death. A child cannot respond if
circulation and perfusion of the brain is inadequate.
When you encounter a seriously burned infant try to start an IV if possible; otherwise
wrap the baby in a moist, sterile sheet and enough blankets to keep the baby warm,
and transport rapidly to the hospital.
Guard against hypothermia by covering the infant or child and protect against heat
loss.
Improper management of fractures in a growing child can lead to permanent
deformity and disability.
Intraosseous infusion by boring a sturdy needle through the skin and into the bone
marrow to administer fluids, medications, and blood may be used, when securing
intravenous access is difficult.
Transport the patients to a pediatric facility whenever possible.
Do not allow the patient to eat or drink until a pediatrician sees him or her.
Secure tubes and lines adequately; in case the infant or child becomes restless and
agitated, and will pull them out. Control the endotracheal tube for proper position in
trachea.
Keep pediatric emergency equipment available if your work in an emergency
department.
Transport any child with blunt abdominal injury to the hospital immediately, as shock
may ensue. Fluid resuscitation may be necessary; pediatric pneumatic antishock
trousers may be used. Determine the patients weight. Monitor intake and output
meticulously. Use an intravenous fluid pump or a volume chamber to prevent fluid
overload.
Be calm, patient, and gentle. Do not tell the child that something will not hurt if it will
hurt. Try not to separate the child from his parents, even if they are injured. The
manner in which one approach the injured child depends on the childs age. Where
possible, let parents hold and comfort the infant and small children. Do not overlook
the needs of the parent at the time of the injury.
 Identify yourself, and explain that you are there to help. Tell the child what you are
going to do. Pain, fright, discomfort, and hypoxia can prevent an injured child from
cooperating with you. Allow open expression of feelings in a nonjudgmental
atmosphere. Offer explanations and reassurances to the patient and his guardians as
you work, and tell them that everything possible is being done.
Acknowledge the childs fear. Get down on the childs eye level when possible so you
will be perceived as less threatening. Allow the child to take a favorite toy or blanket
to the hospital and encourage parents or caretakers to be with the child as much as
possible.

Postoperative care and intensive care

First aid and assessment of the injured at the scene and transportation with advanced life
support (resuscitation); ABCDEs and interventions in the emergency department
(assessment); and continued interventions and treatments in the operating room or the
intensive care unit (further care); planning, education, evaluation, and research are integrated
parts of disaster management.

In a mass casualty situation or disasters should an effectively managed zon for postoperative
recovery be prepared as soon as possible. Only the patients who need ventilatory support or
intensive care/monitoring of other reasons can stay for postoperative intensive care.

Intensive care, constant complex care is provided in various life-threatening conditions such
as multiple injuries, severe burns, myocardial infarction or after certain kinds of surgery, by
specially trained staff to give critical care as needed. Care is most frequently given in an
intensive care unit (ICU) equipped with various highly technical and sophisticated machines
and devices for treating and monitoring the condition of the patient. A large care facility
usually has separate units specially designed for the intensive (critical) care of adults,
children or newborns or for other groups of patients requiring close monitoring, intensive
care and certain kind of treatment.

Monitoring

The patient is continuously monitored; airway, breathing, and circulation, consciousness,

vital signs, intake and output, arterial blood gases, water- and electrolyte balance, etc.
Electrocardiogram is monitored in any patient who has thoracic injury. Nursing care includes
monitoring the patients condition and vital signs, offering explanations to the conscious
patient, keeping the patient warm, and ensuring the flow of oxygen and intravenous fluids.

Airway and breathing

The risk for postoperative complications is common. A trauma patient who is unconscious
should have the airway secured by an endotrachel tube as soon as possible. Common
indications are head injury (Glasgow Coma Scale 9, or less), airway obstruction, shock, chest
injury with hypoventilation, cardiac arrest, or combative patient requiring sedation. Severe
head and maxillofacial injury may make it impossible to secure the airway via the mouth or
nose. Tracheostomy and cricothyroidotomy are alternative surgical airways.

A complication that may increase at multiple casualties, disasters is noncardiogenic

pulmonary edema, and it causes acute respiratory distress (Adult Respiratory Distress
Syndrome, ARDS). ARDS result from increased permeability of the alveolar capillary
membrane; fluid accumulates in the lung interstitium, alveolar spaces, and small airways,
impaired gas exchange, and ventilation perfusion abnormalities, causing the lung to stiffen
(clinical symptoms of the process seen after 12-48 hours). Effective ventilation is impaired,
prohibiting adequate oxygenation of pulmonary capillary blood (decreased lung compliance
and expansion). ARDS can be caused by an acute lung injury; this injury may be direct (as in
a stab wound, a pulmonary contusion from chest injury, cardiac surgery, or mistake in
surgical procedure; or indirect (as in shock, sepsis, hypothermia, near drowning or multiple
fractures). The impaired gas exchange caused by ARDS causes problems in all mayor body
systems, and prophylactic treatment and monitoring is required.

Signs and symptoms of ARDS:

Tachycardia, normal blood pressure, tachypnea, or dyspnea, cyanosis.

Crackles, wheezes, gurgles (decreased breath sounds possible), thin frothy sputum.
Restlessness, agitation or confusion.
Use of accessory muscles, but no jugular vein distension.
Increased PaCO2, pulmonary hypotension.

Prophylactic measures are effective ventilation and adequate shock treatment of all severely
traumatized patients. Intensive monitoring with repeated control of arterial blood gases and
platelets is essential. The patients with ARDS usually require mechanical ventilation, with
positive end-expiratory pressure (PEEP). Treatment includes establishing an airway,
administer oxygen, improving the underlying condition (immobilization of fractures and
extremity injuries), removing the cause, suctioning the respiratory passages as necessary and
reducing oxygen consumption. When ventilation cannot be maintained, mechanical
ventilation is necessary. Supportive PEEP (at the lowest effective level) is widely used in the
treatment of ARDS. The patient with ARDS requires constant and meticulous care,
reassurance, and ventilation is carefully monitored using arterial blood gases and pulse
oximetry.

Circulation

The planning of continued intravenous fluid administration to postoperative patients and/or

severely injured patients is based on the following requirements (Lennquist, 2002):

Compensation of blood loss.

Volume and electrolyte replacement according to the metabolic need.

In hypovolemic shock, the therapy is to replace volume. Initially, lactated Ringers solution
or normal saline solution is usually started to expand blood volume. These isotonic
crystalloids are readily available to increase preload (improve CO and tissue perfusion) until
the patients blood can be typed and cross-matched. The only fluid that replaces lost blood
cells is blood itself, a colloid. In life-threatening situations, unmatched type O, Rh-specific
blood should be given after 2 to 3 liters of lactated Ringers solution until cross-matched
blood is available. A blood warming coil is used for the warming of blood before massive
transfusions, such as those often required for patients who experience extensive abdominal
hemorrhage. Administration of cold blood in such transfusions may cause the patient to go in
to a state of shock. Massive replacement may cause hyperkalemia, thrombocytopenia,
ammonia, and citrate toxicity. Sometimes autotransfusion may be used.
The first 24 hours after the injury the daily need of water and electrolytes; the extra renal
losses of water from surfaces of wounds, hyperventilation and losses in connection with
surgical procedures; as well as the fluid shifts from extracellular to intracellular vascular
space in connection with severe shock, should be considered. Careful control of the patients
circulation, kidney function, and reaction to all volume replacement is essential. After 2-3
days calories and essential nutrients are needed; parenteral nutrition or enteral nutrition.

Compartment syndrome is a pathologic condition caused by a progressive development of

arterial compression and reduction of blood supply; an increase in pressure within a facial
compartment. This leads to tissue death from lack of oxygenation. It develops most often
with blunt trauma or crush injuries (such as earth quakes). Compartment syndrome most
often involves the forearm and lower leg. Acute compartment syndrome is a medical
emergency requiring immediate surgical treatment, known as fasciotomy to allow the
pressure to return to normal (Salcido, & Lepre, 2007). Otherwise, loss of the extremity may
occur because vascular compression causes tissue necrosis.

Disseminated intravascular coagulation (DIC), is a grave coagulopathy resulting from the

overstimulation of clotting and anticlotting processes in response to disease and injury, such
as septicemia, acute hypotension, poisonous snakebites, obstetric emergencies, severe
injuries, extensive surgery, and hemorrhage. The major problem is uncontrolled bleeding
caused by a lack of available clotting factors to repair large vascular damage; most of the
clotting factors are active in the microcirculation. It may participate in the development of
multiple organ failure, which may lead to death.

Extracorporeal membrane oxygenation (ECMO), is a device that oxygenates the blood of

a patient outside the body and returns the blood to the patients circulatory system. An
ECMO machine is similar to a heart-lung machine, and may be used to support an impaired
respiratory system, such as in acute respiratory failure secondary to infection with H1N1
influenza virus, diseased lungs, drowning accidents, and sepsis. In veno-arterial (VA) ECMO,
this blood is returned to the arterial system and in veno-venous (VV) ECMO the blood is
returned to the venous system. Management of the ECMO circuit is done by a team of
ECMO specialists.

A study showed that severe traumatic brain injury was independently associated with a
failure to return to work or school after surgical ICU admission. Patient age, initial injury
severity score, and the number of days receiving mechanical ventilation failed to alter this
outcome. Another study suggests that ICU admissions for vascular surgery and trauma are
particularly associated with worse long-term quality of life outcomes (Barclay, & Vega,
2011).