BEST

BASIC EMERGENCY SKILLS IN TRAUMA

 PREFACE
In the practice of medicine, few situations are as crucial and complex as the initial management of the
multiply injured. Successful outcome is determined by the skills of the resuscitating team, the
promptness with which the resuscitation is carried out, and the precision of diagnosis and treatment.

The Advanced Trauma Life Support (ATLS) Course of the American College of Surgeons Committee on
Trauma was designed to promote quality care and education in the care of the trauma patient. Efforts
by the Philippine College of Surgeons to bring the course to the country were unsuccessful largely due to
prohibitive cost of the ATLS Course. Henceforth, it became necessary for the Philippine College of
Surgeons to come up with its own training course, the Basic Emergency Skills in Trauma (BEST) Course.

This course was developed to accomplish the following goals:

1. To enhance the basic skills of health care provider in the management of the injured patient.
2. To lay the groundwork for the establishment of “standard of care” in trauma management
3. To provide a rapid reference and detailed approach to the treatment of specific injuries.

Although this manual was written, edited, and reviewed by the Technical Working Group of the PCS
Committee on Trauma, most of the guidelines were products of multi- specialty sessions with the
different subspecialties involved in trauma care. Furthermore, diagnostics and treatment algorithms
vary among institutions. Hence, information presented in this course should be tailored to local
reseources and technical capabilities.

This manual was designed to capture the state-of-the-art in trauma care. Health care in general is a
dynamically transforming frontier frequently challenged by new evidence and experiences. In this
regard, the Committee on Trauma invites everyone to bring to its attention any incorrect or outdated
information contained in this manual. Rest assured that this feedback will be highly appreciated.

Technical Working Group

Committee on Trauma
Philippine College of Surgeons
 MESSAGE
from Dr. Alex A. Erasmo
PCS President 2009

I take pride in commending the efforts of the PCS Committee on Trauma for tirelessly spreading the
basic principles in trauma care through the Basic Emergency Skill in Trauma (B.E.S.T.)

The BEST workshop, intended for surgeons, aim to improve the outcome of initial trauma care in the
country. The curriculum, developed by the Committee, teaches the participants basic but life-saving
procedures like tracheostomy and tracheostomy among others.

To the participants, I admire your dedication to your profession. Every knowledge and skill you will learn
will improve patient care in trauma. Rest assured that at the end of this 2-day workshop, you will be a
better physician.

In behalf of the officers and board of regents of the PCS, I wish you a professionally and intellectually
enriching experience through the BEST workshop.

With my warmest personal regards.

Sincerely,

Ales A. Erasmo,MD
President 2009
 SPECIAL THANKS TO:
DR. ART MENDOZA (PSGS PRESIDENT 2006)
AND HIS BOARD OF DIRECTORS

DR. REYNALDO M. BACLIG (PSGS PRESIDENT 2007)

AND HIS BOARD OF DIRECTORS

DR. DANIEL A. DELA PAZ JR

AND TO THE STAFF OF THE DIVISION OF TRAUMA UP-PGH

DR. TEODORO J HERBOSA

CHAIRMAN,DEPARTMENT OF THE EMERGENCY MEDICINE UP-PGH

DR, MA. LUISA AQUINO

PRESIDENT,
PHILIPPINES SOCIETY FOR THE SURGERY OF TRAUMA (2004-2006)
AND HER BOARD OF DIRECTORS

DR. HARRY P.SUPAN

PRESIDENT,
PHILIPPINE ASSOCIATION OF TRAINING OFFICERS IN SURGERY (2006)

DR. MARK MARINAS

SURGICAL RESIDENT, UP-PGH
FOR MAKING THE “BEST” LOGO

PCS SECRETARIAT
MS. ANNETTE TOLENTINO
MS OLIVIA MANZANO
MS EDEN GRACE PAULE
MS. MARAIMA JONEL CABILDO, RN
MR. ERWIN CUDILLA

YOU ARE THE “BEST”;

DR. ORLANDO O OCAMPO
COURSE DIRECTOR
BOARD OG REGENTS 2009
Alex A. Erasmo, MD
President

Stephen Sixto Siguan, MD

Vice President

Maximo H. Simbulan, Jr., MD

Treasurer

Isaac David E. Ampil,II, MD

Secretary

Members
Josefina R. Almonte, MD
Dominador M. Chiong, MD
Alejandro C. Dizon, MD
Esperanza R. Lahoz,MD
Ray B. Malilay, MD
Gabriel L. Martinez, MD
Arturo E. Mendoza, Jr., MD
Maximo B. Nadala, MD
Enrico P. Ragaza, MD
Rodolfo C. Ursua, MD
Jesus V. Valencia, MD
COMMITTEE ON TRAUMA 2009
Orlando O. Ocampo, MD
Chairman

Maximo B. Nadala, MD
Regent-in-Charge

Members
Ma. Luisa d. Aquino,MD
Jorge M. Conception, MD
Joseph T. Juico, MD
Joel U. Macalino, MD
Adrien R. Quidlat, MD
Raymundo F. Resurrection, MD
Emmanuel San Pedro, MD
Ronnie Torres, MD
George Repique, Jr. MD
Raffy Cruz, MD

TECHNICAL WORKING GROUP

Orlando O. Ocampo, MD
Ray B. Malilay, MD
Daniel A. Dela paz, MD
Adrien R. Quidlat, MD
Ray I. Sarmiento, MD
Joel U. Macalino, MD
Jeorge M. Conception, MD
Raymundo F. Resurrection, MD
Leoncio L. Kaw, MD
Joseph T. Juico, MD
Teodoro J. Herbosa, MD
Ma. Luisa d. Aquino,MD
 INITIAL ASSESSMENT OF TRAUMA PATIENT

OBJECTIVES

• To discuss the epidemiology of trauma in the Philippines.

• To provide the correct sequence of priorities in assessing multiply injured patient.

• To provide guidelines and techniques in the initial management of multiply injured patient.

Injury is defined as a bodily lesion resulting from exposure to energy, interacting with the
human body beyond the limits of physiologic tolerance. There are several forms of energy- mechanical,
thermal, radiation, electrical and chemical.

Type of Energy Examples

Mechanical Vehicular crash, projectile injuries, fall
Thermal / Radiation Flame burns, scalds
Electrical Electrocution, lightning
Chemical Industrial exposure, poisoning

Injuries are not accidents. Injuries are very predictable and therefore preventable.
They are not random events but occur in predictable patterns. From now on, instead of vehicular
accident, it is better to say vehicular crash.

Figure 1: Trimodal Pattern of Death in Injury

Deaths dur to injury follow a trimodal pattern, 50% die within minutes after injury and the only
way to decrease from this phase is implementation of good trauma preventive programs. Thirty percent
die within the first 6 hours from the injury often before reaching the hospital and therefore we need a
good trauma system as exemplified by 911 in a North American model. Those 20% that manage to reach
the hospital die of complications and that is where good critical and rehabilitation plays an important
role.
Figure 2: Percentage of Total Deaths by Cause and Age, Philippines, (DOH 1993)

This graph of 1993 date from the Philippines shows the predominance of injuries as the cause of
death for the ages 5-44 who are the working class. In 15-24 years age group, injuries outrank infectious
diseases and malignancies combined. The mortality and morbidity from the injury rank 7 in 1980 rose to
rank 5 by 1998.

Trauma is a disease and the best trauma care is still prevention.

Traditionally, we were taught to extract extensive history and perform meticulous P. E to arrive
at a diagnosis. We have to offer differential diagnosis and rule them out using barrage of diagnostic tests
to come up with a diagnosis before we can institute treatment.

In trauma management, once injury is recognized, an immediate treatment is mandatory.

Trauma concepts:

1. Treat the greatest threat of life

2. Lack of definitive diagnosis should not impede the aaplication of an indicated treatment.
3. Detailed history is not essential to begin the evaluation of an acutely injured patient.

The correct approach to severely injured patient to follow these priorities:

1. Primary survey
2. Resuscitation
3. Secondary survey
4. Definitive management
5. Tertiary survery

The following protocol outlines he priorities for managing seriously injured patients. In actual clinical
situation, many of these activities occur in parallel or simultaneously.

Loop Asessment

Continued reassessment of the patient is absolutely mandatory. Frequent determination of vital signs,
as determined by the severity of injury, should be made. Be sensitive to the trends in physical
examination and vital signs. Deviations will be necessary according to the patient’s status of patient’s re-
evaluation.
Primary Survey

The primary survey is composed of the following in order of priorities

1. Airway AND Cervical Spine Control
2. Breathing
3. Circulation AND Control of Hemorrhage
4. Disability – neurologic exam
5. Exposure / environmental control

A. Airway: guarantee patency (Ask question like “What is your name?”. if the patient is able to
communicate verbally, the airway is not likely to be in immediate jeopardy.)
I Indications for intubation:

i. Decrease mental status (GCS 8 or less).

ii. Obstructed or partially obstructed airway.
iii. Hemorrhagic shock. (all hypotensive trauma patient should be intubated)
iv. Ineffective respiration (flail chest).
v. Combative patients (respiratory distress?).
vi. Potential for airway deterioration (high C- spine injury).
I Assume a C- spine injury until the neck is cleared. Maintain in-line stabilization or C-collar.
II Assume that the patient has a full stomach and is risk of aspiration.

B. Breathing: guarantee adequate oxygenation and ventilation.

• All trauma patients should receive supplemental oxygen irrespective of the severity of injury.
• Airway patency alone does not assured adequate ventilation.
• Ventilation requires adequate function of the lungs,chest wall, and diaphragm.
• Assess respiratory effort, breath sounds, and oxygen saturation (if pulse oximeter is available).

C. Circulation: assure adequacy of tissue perfusion and control bleeding.

I. Assess vital signs.
II. Identify sites of bleeding
i. Chest
ii. Abdomen
iii. Retroperitoneum
iv. Long bones (1.5 liters per 1 cm increase in thigh diameter of patients with
femoral fracture)
v. External blood loss (street and sheets)

III. Control hemorrhage

i. Direct pressure on open wound.
ii. Ligation of bleed
iii. Immediate immobilization/reduction of fractures in long bones and pelvis.
 iv. Surgery

IV. Don’t forget that spinal cord injury can cause hypotension
i. Neurogenic shock possible in patient with paraplegia and quadripledia.
ii. Treat initially with crystalloids.

V. Resuscitate
Place large bore peripheral IV access (minimum of two functioning IV line in hypotensive
patient).

What is the ideal fluid for resuscitation?

i. Any available IV fluid will do, preferably plain LR.
ii. Avoid using D5 containing fluid which can cause diuresis
iii. Consider packed RBC if:
a. The patient loss more than 1 liter of blood (by estimate),
b. There is active ongoing bleeding,
c. More than 2 liters of crystalloid to stabilize the patient.

D. Disability: perform a cursory neurologic exam

I. Assess GCS
II. Assess sensory and motor function of the extremities.

Formula to get the GCS if the patient is intubated or unable to verbalize:

V= M ( 0.5 ) + E ( 0.4 )

E. Exposure: Search for remaining injuries

I Reassess vital signs.
i. is the patient stable?
ii. has the patient’s response to fluid infusion and early stabilization appropriate?
I Look for areas where injuries are often missed, like axilla and perineum
( this means removing the remaining clothing, if any).
II Logroll to visualize the back.
III Keep the patient warm!
Secondary Survey

• Don’t waste precious time extracting the history.

• History: Use the acronym AMPLE
A allergies
M medications
P past illnesses
L last meal
E events preceding the incident/ injury
Detailed head-to-toe-physical examination.
• Insert finger and tubes in all orifices.
• Reassess

Tertiary Survery

Tertiary survery – detailed, meticulous P. E. after definitive management.

CRITERIA FOR ADMITTING INJURED PATIENT:

1. Penetrating injuries to head, neck, toeso, and extremities

Proximal to elbow and knee
2. Flail chest
3. Combination trauma with burns
4. Two or more proximal long – bone fractures
5. Pelvic fractures
6. Open and depressed skull fracture
7. Paralysis
8. Amputation proximal to wrist and ankle
9. Significant underlying medical disease

1. Cardiac disease or respiratory disease

2. Diabetes
3. Cirrhosis
4. Morbid obesity
5. Pregnancy
6. Immunocompromised
7. Bleeding disorders or on anticoagulation

10. Mechanism of injury:

 1. Ejection from automobile
2. Death in the same passenger compartment
3. Falls > 20 feet
4. High speed auto crash > 50 kms/hr
5. Motorcycle crash of >20 kms/hr
6. High impact collision (pedestrian vs train )
7. Separation of rider from motorcycle/bike
8. Pedestrian thrown, rollover, or run-over

11. AGE <5 OR >55

12.

AIRWAY MANAGEMENT IN TRAUMA

OBJECTIVES

At the end of this session, the participant is expected to be able to:

• Discuss the anatomic features which affect airway patency in trauma patient.
• Detect /evaluate for risk factors which threaten airway patency in trauma patient.
• Describe and demonstrate strategies to maintain airway patency.
• Discuss special considerations in airway management in the unconscious patient.
• Discuss indications, contraindications, and complications of different definitive airway
techniques.
• Describe and demonstrate techniques to establish definitive airway control.
• Enumerate the necessary steps involved in rapid sequence intubation.

INTRODUCTION

Airway assessment and management is one of the most fundamental skills learned by medical students
and residents: it should be within the realm of every physician. Loss or alteration of consciousness,
whether due to anesthesia, medications, trauma or disease often times necessitates endotracheal
intubation and mechanical ventilation. Inadequate tissue oxygenation, secondary to loss of airway or
inadequate ventilation can result in permanent brain damage in as quickly as four to six minutes and, if
left untreated, rapidly progresses to death. It is therefore of great importance to know how to rapidly
evaluate and address a patient who may require airway control and ventilator support.

In all injured patients, priority is given in assessing and maintaining airway patency and effective
ventilation. The most immediately life threatening complication of any trauma is loss of airway patency.
Maintaining oxygenation and preventing hypercarbia are critical in managing the trauma patient,
especially if the patient has sustained a head injury. Thus, the first step in evaluating and treating any
trauma patient is to assess airway patency and, if compromised, restore it: the A of A (airway), B
(breathing), C (circulation). Common pitfalls resulting in death due to airway problems include the
following:
 1. Failure to recognize or reassess the need for an airway
2. Inability to estabish an airway
3. Failure to recognize an improperly placed airway
4. Loss of a previously established airway
5. Failure to assess the need for ventilation
6. Failure to prevent aspiration of stomach contents or pharyngeal debris

The loss of airway in a trauma patient can be as precipitous and catastrophic as an aspiration event or as
insidioud as airway edema folloeing massive fluid resuscitation in the burn patient.

ANATOMIC CONSIDERATIONS

The upper airway begins at the oronasal cavities which are lined by richly vascular yet delicate mucosa
overlying wafer-thin bony framework. Trauma to these areas result in simultaneous disruption of
mucosal lining resultant bleeding and edema as well as deformation of the underlying bony structure.
Likewise, the tongue is highly vascular and suspended anteriorly by its attachments to the mandible. In
bilateral jaw fractures, the tongue tend to fall backward and inferiorly, resulting in acute airway
obstruction if the patient is unable sit up.

The larynx and trachea are protected at the back by the cervical vertebrae and at the sides by the
sternocleidomastoid muscles. It is, however, relatively exposed anteriorly where it is susceptible to
direct injury such as deceleration against the steering wheel or dashboard, resulting in laryngeal
fractures. Due to its proximity to major vascular structures, injury and bleeding to these vessels may
result in significant hematoma formation and displacement of the trachea to the contralateral side. Such
a situation may make endotracheal intubation more difficult.

EVALUATING PATIENTS FOR AIRWAY PATENCY

The physical exam will be the most reliable tool for anticipating difficulties in airway management. Start
by reviewing vital signs, particularly oxygen saturation. Then, commence the examination with a general
assessment.

In conscious patients with marginal breathing difficulty, a fairly reliable way to establish the need for
immediate airway management is to ask them if they are getting enough air. If these patients cannot
answer or cannot stick out their tongue fairly easily, they should be intubated.

Breathing is characteristically noisy in a patient with partial airway obstruction. In the unconscious or
intoxicated patient, the tongue falls back against the posterior wall of the pharynx causing snoring.
However, the respiratory efforts of a totally obstructed patient are silent. When inspiratory stridor
occurs, it is assumed that the upper airway is at least 70% occluded. Intercostal muscle retraction,
paradoxic movement of the lower neck and chest, flaring of the nasi, and stridor are also important
signs of upper airway obstruction.

Severe maxillofacial trauma typically seen in the unrestrained frontseat passenger dramatically
demonstrates airway compromise caused by a combination of bleeding, edema, deformation of bony
architecture and accumulation of secretions. A clinical examination of neck and airway may suggest
laryngeal injury or bronchial disruption. Airway compromise may be manifested as stridor, dysphonia,
expanding hematoma causing tracheal compression, or subcutaneous emphysema. A sucking neck
wound and progressive hypoxemia is virtually diagnostic for a major laryngotracheal laceration.

The airway of trauma patients may be at risk even when there is no symptoms specific to the respiratory
system at the onset. Intoxication or unconsciousness and a full stomach make a lethal combination
when these result in aspiration of gastric content.

AIRWAY RISK FACTORS

The need for a definitive airway (i. e. endotracheal intubation) is based upon a number of clinical
findings including:

I nstability, hemodynamic
• Severe pulmonary or multisystem injury associated with respiratory failure or shock
N eck hematoma/trauma
• Laryngeal trauma (with hoarseness or subcutaneous emphysema)
T rauma to the face
• Maxillofacial trauma, facial fractures
U nresponsive (GCS<8)
• Glasgow coma score of 8 or less due to head injury or severe intoxication with the inability to
protect the airway or requiring assisted ventilation
B leeding
• Bleeding from oropharynx or base of the skull fractures
A irway compromise / A pnea
• The presence of apnea
• Inability to maintain a patent airway or oxygenation by less invasive means
T hermal inhalation injury
• Potential or progressive airway edema following inhalation injury
E mesis / epistaxis
• Protection of the respiratory tract from aspiration of blood or gastric contents
• Airway control in patients for transfer/transport
PROVIDING SUPPLEMENTAL OXYGEN

Some patients require oxygen supplementation, despite maintaining a patent airway and normal
ventilatory drive. In such cases devises such a nasal cannula, face tents and simple masks can be used to
deliver oxygen via positive pressure. The nasal cannula (plastic tubing inserted into nares) is the most
commonly employed low-flow oxygen delivery device. It provides supplemental oxygen at flows ranging
0 to 8 L/min, estimated by adding 4% per liter of O2 delivered.
For greater oxygen delivery in a patient with patent airway, a reservoir system such as a simple mask,
which covers the nose and mouth and can provide flow rates of 10L/min and a maximum FiO2 of 55%
to be delivered, and a non-rebreather mask, which uses a series of one way sleeves and can deliver 10-
15 L min and a maximum FiO2 of 80%. High flow systems, such as nebulizers, can also be used for
increased oxygen delivery.
Trauma patient with airway
risk factors

Oxygenate

Airway comromise No airway compromise

Ventilate/intubate with Observe/reassess

cervical in-line stabilization Y
E

Unable to intubate S Airway compromise?

NO
Cricothyroidotomy Continue monitoring
patient’s progress

Reassess adequacy of
ventilation
AIRWAY MAINTENACE MANEUVERS
Trauma patients may come in to the emergency department unresponsive, in severe respiratory distress
or in severe shock. Those patients require immediate intubation after adequate preoxygenation. All
injures patients should be given supplemental oxyxgen soon after entering the emergency room.
Adequate preoxygenation and denitrogenation can prevent hypoxemia for up to 2 to 3 minutes after
patient stops breathing effectively during endotracheal intubation.

In most other trauma victims, initial management consists of clearing the airway of foreign bodies,
broken teeth or dentures, blood clots and secretions. Assessment of the patient should be done while
maintaining the cervical spine in a stable, neutral positions. Patients with unstable mandibular fractures
may fight attempts to have them lie down due acute obstruction caused by the untethered tongue
falling back. Maneuvers sre done to bring the tongue forward and upward.

Finger sweep. Used with utmost caution to void injury from deliberate or unintentional bite in the
uncooperative patient, a bite block I placed at the corner of the mouth while a gloved finger is used to
clear the mouth of vomitus, food particles, broken teeth, blood clots or foreign bodies. Suctioning may
not be able to clear relatively large particles hence making this hazardous maneuver unavoidable in
many situations. All patients with facial trauma should have their mouth carefully examined for blood
clots, foreign bodies, vomitus, and loose teeth or dentures.

Chin lift. The chin entails grasping the mandible along its inferior margin with the thumb either pulling
down the corner of the lower lip or holding the lower incisors. The mandible is then pulled upward and
forward. Care must be taken to avoid excessive traction resulting in hyperextension of the neck.

Jaw thrust. With the fingers of both hands placed behind the angle of the mandible, one hand at each
side, forward traction is placed on the mandible. When using a bag-mask device to ventilate patients,
this maneuver is combined with the thumbs holding down the device on each side to achieve a proper
seal around the face, ensuring effective ventilation.

Face Mask. Delivery of positive pressure ventilation by means of a face mask (or bag-valve-mask device)
is an essential skill to develop. The rim of the mask especially is soft and form-fitting and by pressing it
firmly against the face an airtight seal is made. The mask is attached to a breathing circuit including an
oxygen bag. When pressure in the mask increases by squeezing the inflated oxygen bag, air flows
through the upper airway into the lungs. When the bag is empty or squeezing stops, air will flow out the
lungs through the nose and mouth into the mask.

Successful ventilation requires both an air-tight mask fit and a patent airway. Without an airtight seal
between the skin of the patient’s face and the mask, sufficient pressure to inflate the lungs will not
develop. Leak is the most common problem in delivering face mask ventilation and can be avoided or
resolved by proper technique. With an assistant who can squeeze the ventilation bag, use the two hands
to secure an air-tight seal. The thumbs hold the mask down while the fingertips or knuckles displace the
jaw forward and upward (lift and protrude the jaw to prevent or alleviate airway obstruction by the
tongue). The one handed technique is achieved by using the right hand to generate positive pressure by
squeezing the bag using the left thumb and index finger to secure the mask (by pushing downward). The
middle and ring finger grasp the mandible (and not the soft tissue of the chin) to extend the atlanto-
occipital joint (the neck). The little finger is positioned under the angle of jaw and thrust it anteriorly.

Signs of successful seal and ventilation include:

• A foggy mask
• The rising of the chest with delivery of positive pressure
• Breath sounds on auscultation

Oropharyngeal Airway (OPA). A curved piece inserted over the tongue that creates an air passage
way between the mouth and the posterior pharyngeal wall. Useful when the tongue and/or epiglottis
fall back against the posterior pharynx in anesthetized or unconscious patients obstructing the flow or
air.
After clearing the oral cavity and to keep the tongue from again falling back, an oral airway is placed
with its tip behind the tongue. With one hand depressing the mandible, the oral airway is inserted with
concave surface turned up, running along the palate then rotating it 180 degrees to rest over the
tongue. Be ure not to use the airway to push the tongue backward and block, rather than clear, the
airway. This device should not be used in the awake patient as it may precipitate gagging, vomiting and
aspiration.

Nasopharyngeal Airway (NPA). Also known as nasal trumpets, nasopharyngeal airways are inserted
through one nostril to create an air passage between the nose and the nasopharynx. The NPA is
preferred to the OPA in conscious patients because it is less likely to cause gagging.

The length of the nasal airway can be estimated as the distance from the nares to the meatus of the ears
and is usually 2-4 cm longer than the oral airway. Use a nostril that is unobstructed. It is inserted,
properly lubricated, into one nostril and passed upward and backward, with its tip opening at the
posterior oropharynx. If resistance is encountered during insertion, the device should be pulled out and
the other nostril tried instead. Although better tolerated by awake patients, its smaller lumen increases
work of breathing by increasing airway resistance. It may be used, in combination with a bag mask
device, to ventilate patients.

While nasopharyngeal airways are better tolerated than oropharyngeal airways in awake or lightly
anesthetized patients, they are contraindicated inpatients who are anticoagulant, patients with basilar
skull fractures, patients with nasal infections and deformities as well as in children (because of risk of
epistaxis). It should not be used if a fracture of the central midface is suspected.

Laryngeal mask airway (LMA). The LMA is a cuffed device that provides sufficient seal to allow for
positive pressure ventilation to be delivered. It is particularly useful in maintaining an airway during
emergency situations in which mask ventilation is not possible or intubation and/or ventilation falls.

An LMA is a wide bore tube, with a connector at its proximal end with an elliptical cuff at the distal end.
When inflated, the elliptical cuff forms a low pressure seal around the entrance into the larynx. The LMA
comes in a variety of pediatric and adult sizes and successful insertion requires appropriate size
selection.

Intended as a temporary method of ventilating patients before placement of a definitive airway, this
device is inserted through the mouth and placed over the glottis without the need of laryngoscope.
Unlike standard endotracheal tubes, the LMA is not inserted into the trachea but straddles the glottis
opening. Because it is not a cuffed tube in the trachea, LMA does not protect against aspiration and can
aggravate gastric distention.

Furthermore, it is not recommended as a method of securing the airway because it can be dislodged
during patient transport.

AIRWAY CONTROL

The above maneuvers offer only temporary clearance of the upper airways and do not protect from
aspiration nor eventual airway compromise resulting from deteriorating sensorium, soft tissue edema,
oronasopharyngeal bleeding, or accumulating secretions. The patient’s condition, mental status and
breathing should be continually monitored to determine need for a definitive airway. Patients transport,
sedation, operative management and ventilator support may dictate the need for putting in a definitive
airway despite initial absence of signs of airway compromise.

With any airway or ventilator problem in a severely injured patient, endotracheal intubation is preferred
over mask ventilation or nasal oxygen administration because it:
1. Allows better control of ventilation
2. Helps protect against aspiration of gastric content
3. Provides a means of removal of tracheal secretions.

a definitive airway ca be: an endotracheal tube, a nasotracheal tube, or a surgical airway

(cricothroidotomy). It entails the placement of a cuffed tube into the trachea via the mouth or nose or
directly through a surgically created opening (e.g., cricothroidotomy or tracheostomy). In adults, the cuff
near its distal tip normally seals off the lower airway, thus protecting against aspiration of vomitus,
blood or secretions. In thermal inhalational injury, impending airway obstruction due to progressive
airway edema is treated expectantly by early intubation.

The presence of cervical spine instability and the concominant risk to the spinal cord must always be
assumed to be present until proven otherwise. In this context, placement of an orotracheal tube should
be done while someone stabilizes the patient’s head in the midline. This maneuver is known as in-line
stabilization and should be observed particularly in the following situations:

1. Unconscious patient
2. Patients brought in with the unknown mechanism of injury
3. Patient with gunshot wound to the neck and upper torso
4. Patient with blunt trauma
5. Patient with significant injury to the head
In patient in whom airway compromise is identified, preparations must be made to ensure expeditious
placement of a definitive airway. The following mnemonic may help:

T iming: don’t delay!

E quipment: scopes, suction, supplies
A nesthesia
M onitor
W ear protection: gloves, mask, shield
O xygenate
R einforcement: get help
K eep neck straight: in-line stabilization
Preintubation checklist:

1. Is it safe and possible to extend the head and neck?

2. Does the patient’s mouth open widely?
3. Is the submandibular space large enough and the tissues filling it pliable enough to permit
displacement of the base of the tongue during direct laryngoscopy?

A focused airway exam should be conducted:

1. Examine the mouth and oral cavity (the best combination for easy airway management is a large
oral cavity with a small mobile tongue).
2. Evaluate the extent and symmetry of mouth opening (three finger breadths is optimal)
3. Check for loose, missing or cracked teeth
4. Note any prominent buck teeth or particularly large incisors that may interfere with
laryngoscopy (dental and oral injuries are common complications of laryngoscopy)
5. Note the size of the tongue (large tongues may interfere with use of the laryngoscope)
6. Note the arch of the palate (high arched palates have been known to hamper visualization of
the larynx)
7. Examine the pharynx. The appearance of the posterior pharynx may predict ease of
laryngoscopy and visualization of the larynx. Malampatti has classified patients in class I-IV
based on visualization of structures during preintubation evaluation. The patient is asked to
open the mouth wide, stick out the tongue, and extend the neck to allow for maximal
visualization pharynx.
a. If the whole of the tonsillar pillars are visualized, the airway is rated class I and intubation is
likely to be uncomplicated.
b. If the uvula, but not the tonsillar pillars can be visualized, the airway is rated as class I.
c. Class III is characterized by visualization of part of the uvula and soft palate.
d. An airway is characterized as class IV if the tongue is associated with increased risk of difficult
intubation.
 OROTRACHEAL INTUBATION

Patients who have sustained blunt trauma and require intubation must be regarded as having a
concomitant cervical spine injury until proven otherwise. The urgency of establishing an airway
cannot override the precautions in protecting the patient from cervical cord injury. Timing and
technique are critical. Speedy yet careless intubation with neck extension may cause subluxation of
a previously undisplaced unstable fracture causing spinal cord injury or raising the level of an
existing deficit.

Prior to intubation, always check equipment and make sure everything that be might needed is not
only within reach, but also properly working. If in the emergency room or the hospital wards, make
sure you know where all of your equipment is and, also, that you have the necessary resources to
support the patient once intubated. Prior to positioning the patient:
• Make sure that laryngoscope is locked into position and that the incandescent light on the
blade tip functions. Also make sure that alternate blades are available in case the one
chosen does not allow for visualization of the cords.
• Examine the endotracheal tube. Make sure that the cuff inflates by using a 10-ml syringe to
inflate the cuff and the detach the syringe to ensure that the cuff pressure is maintained. Be
sure to deflate the cuff after testing it.
• Attach the connector to the proximal end of the tube. Push it in as far as possible to lessen
the likelihood of disconnection.
• If using a stylet, it should be inserted into the ET tube and bent to resemble a hockey stick to
facilitate intubation of an anteriorly positioned larynx. Even if not planning on using a stylet,
one should be within easy access in case the intubation proves to be more difficult than
anticipated.
• Ensure a functioning suction unit to clear the airway in case of unexpected blood, emesis or
secretions.
• Ensure that the tape is within reach to secure the tube once it is in place.

Mask Ventilation. If you are able to achieve signs of ventilation using this technique, you are afforded
the knowledge that, if intubation fails, you are able to achieve ventilation using the bag-mask-valve
device. Further, it allows for pre-oxygenation. Preoxygenation provides an extra margin of safety in case
the patient is not easily ventilated after induction.

After preoxygenating the patient and positioning the patient in the Sniff position, with the patient’s
mouth widely open, carefully introduce the blade, held in your LEFT HAND, into the right side of the
mouth. Regardless of which blade is used, IT MUST NEVER PRESS AGAINST THE TEETH or dental trauma
will result. The tongue is then swept to the left and up into the floor of the pharynx by the blade’s
flange.
The curved Macintosh blade is inserted past the tongue into the vallecular (at the base of the tongue).
Providing sufficient lifting force in parallel with the handle, yet avoiding posterior rotation that causes
the blade to press against the teeth, pressure is applied deep in the vallecular space by the tip of the
blade immediately anterior to the epiglottis, which flips out of the visual field to expose the laryngeal
opening.
The straight Miller blade is inserted deep into the oropharynx, PAST the epiglottis. Providing sufficient
lifting force in parallel with the handle, yet avoiding posterior rotation that causes the blade to press
against the teeth, under direct vision, the blade is slowly withdrawn. It will slip over the anterior larynx
and come to a position at which it holds the epiglottis flat against the tongue and anterior pharynx,
exposing a view of the larynx.

With either blade, the handle is raised up and away from the patient in a plane perpendicular to the
patient’s mandible. Avoid trapping a lip between the teeth and the blade and AVOID using the teeth as
leverage and avoid posterior rotation of the blade.

Once a view of the larynx is obtained via laryngoscopy, the ETT is introduced with the RIGHT HAND
through the right side often mouth. Directly observe the tip of the tube passing into the larynx, between
the abducted cords. Pass the tube 1 cm through the cords. The ETT should lie in the upper trachea but
beyond the larynx (3 to 4 cm proximal to the carina). If the patient is going to be repositioned, the cuff
should be closer to 2 cm beyond the cords.

Remove the laryngoscope, careful not to displace the ET tube and not to cause trauma to the teeth, lips
or mucosa. Inflate the cuff with the least amount of air necessary to create a seal duting positive
pressure ventilation (usually 4-8 ml of air).

Remove the mask from the bag-valve device and attach the 15 mm connector on the proximal end of
the ET tube to the bag-valve device (into which oxygen is flowing and to which the carbon dioxide
detector is attached. Provide positive pressure and immediately (and quickly):
• Auscultate the chest for breath sounds
• Check the capnoraphic tracing on the monitor to ensure end tidal CO2
• Check the connector for fog
• Look at the chest for expansion with each breath

If there is any question as to whether the tube is in the esophagus or trachea, remove tube, ventilate
with a mask and try again, this time attempting to adjust anything that may have interfered with your
first attempt. You might reposition the patient, use a different blade, decrease tube size, or add a stylet.

Proceed to tape or tie the tube to secure its position. Do not tape or tie cuff. To prevent the patient
from biting and occluding the ETT, a roll of gauze can be placed between the teeth or an OPA can be
inserted.

Some ways to ensure that the endotracheal tube is placed properly in the trachea include:
1. Visualize the tube going between the vocal cords.
2. Look for breath condentation in the tube.
3. Check the compliance of the ambu bag; esophageal intubation will result in less resistance to
ventilation than the chest.
4. Look for anterior and lateral chest wall motion as the ambu bag is squeezed.
 5. Auscultate both axillas and the epigastrium: if breath sounds in epigastrium is louder than the
those in the lateral chest, the tube is in the esophagus.
6. Measure end-tidal carbon dioxide with a capnograph or disposable ETCO2 detector.

Nasotracheal Intubation: Nasal intubation is smilar to oral intubation except that the ETT is advanced
through the nose into the oropharynx before laryngoscopy. If the patient is awake, local anesthetic
drops and nerve blocks can be used. A lubricated ETT is introduced along the floor of the nose, below
the inferior nasal turbinate, perpendicular to the face. The tube is advanced until it can be visualized in
the oropharynx. Via laryngoscopy, the tube is then advanced in between the abducted vocal cords.

Nasal instrumentation ( with ETT’s, NPOs, or nasal catheters) is contraindicated in all patients with
severe midfacial trauma.

Surgical Cricothyroidotomy: Surgical cricothyroidotomy is performed by making a skin incision that

extends through the cricothyroid membrane. The incision is dilated using a curved hemostat and small
endotracheal tube or tracheostomy tube can be inserted.

Because of potential damage to the cricoid cartilage (the only circumferential support to the upper
trachea), this procedure is not recommended in children under age of 12.

COMPLICATION OF INTUBATION

Complication of laryngoscopy and intubation are most frequently secondary to airway trauma tube
malpositioning , tube malfunction or physiologic responses to airway trauma, tube malpositioning, tube
malfunction or physiologic responses to airway instrumentation. Trauma sucg as tooth damage,
lip/tongue/mucosal laceration, sore throat, dislocated mandible, retropharyngeal dissection can occur
during laryngoscopy and intubation. Mucosal inflammation and ulceration of excoriation of nose can
occur while the tube is in place. Laryngeal malfunction and aspiration, glottis, subglottic, or tracheal
edema and stenosis, vocal cord granuloma or paralysis during extubation. Malpositioning extubation.
Physiologic responses to intubation include hypertention, and laryngospasm.

RAPID SEQUENCE INDUCTION

Rapid sequence inducation helps prevent regurgitation and aspiration of gastri contents, but it requires
preoxygenation and denitrogenation by mask to prevent severe hypoxia during the intubation.
Anesthesia is induced with a appropriate intravenous agent, and succinylcholine is given to relax the
patient’s musculature to facilitate intubation. Alternatively, large doses of nondepolarizing
neuromuscular blocking agents may be substituted for succinylcholine. The trachea is rapidly intubated,
and the cuff is inflated to protect the airway. Proper tube placement is confirmed by auscultation and
appropriate levels of carbon dioxide.

During the induction, an assistant stabilizes the head (to prevent aggravationn of any cervical spine
injuries) while a second assistant presses backward on the cricoid cartilage (Sellick’s maneuver) to
prevent the passage of gastric or esophageal contents in the laryngopharynx. The cricoid pressure is
maintained until the cuff on the endotracheal tube has been inflated and proper placement of the tube
has been confirmed.

The main disadvantage of rapid-sequence induction, is that, when anesthesia has been induced, there is
no turning back. The patient is rendered apneic at a time when oxygenation is difficult to assure without
an endotracheal tube. In addition, if facial injuries do not allow the close application of a face mask,
preoxygenation may be impossible or inadequate. Copious foreign material or blood may obscure the
view even if the patient has no vomited.

The induction of general anesthesia is frequently accompanied by respiratory standstill, and bag-mask
ventilation may be inadequate because of mechanical airway obstruction that caused the respiratory
distress in the first place. This combination of a technically difficult intubation and airway distress often
dictates the need for an emergency cricothyroidotomy.
SEDATING AGENTS USED FOR RAPID SEQUENCE INDUCTION

AGENT TIME TO ONSET DURATION DOSE ADVANTAGES SIDE

OF ACTION EFFECTS

MIDAZOLAM 30-120 SEC. 10-20 MIN 0.1-0.3 MG/KG ADV: Anticonvulsant/

Amnestic
SE: tachycardia
respiratory depression
hypotension
THIOPENTAL 30-60 sec 5-10 min 2.5 mg/kg ADV: anticonvulsant/
ICP, cerebral
metabolism
SE: hypotension
respiratory depression
broncho/laryngospasm
FENTANYL 2 min 30-40 min 3.5 ug/kg ADV: ICP analgesic,
blunts CV response,
hemodynamic stability
reversal w/ naloxone
SE: muscle rigidity,
bradycardia,
respiratory depression
PROPOFOL 30 sec 1-3 min 1.0-2.5 mg/kg ADV: ICP, IOP
SE: hypotension
CO respiratory
depression risk
bacterial
contamination

KETAMINE 30-60 sec 5-15 min 1-2 mg/kg ADV: airway reflexes
intact CO, HR, BP
bronchodilation
SE: emergence
phenomena ICP, IOP
myocardial O2
demand
NEUROMUSCULAR-BLOCKING AGENTS USED FOR RAPID SEQUENCE INDUCTION

AGENTS TIME TO ONSET DURATION DOSE ADVANTAGES SIDE

OF ACTION EFFECTS

SUCCINYL- 60 SEC 3-10 min. 1-1.5 mg/kg Adv: IOP, ICP

CHOLINE hemodynamic stability

SE: muscle fasculations,

ICP/IOP, hypertention,
tachy-/bradycardia,
hyperkalemia
PANCURONUIM 1-5 MIN 40-80 min. Defasciculating Adv:
dose 0.01 mg/kg anticonvulsant/amnestic
SE: tachycardia
Intubating dose respiratory depression
0.1-0.15 mg/kg hypotension
VECURONIUM 2.5 MIN 20-40 min. Defasciculating Adv: little or no CVS
dose 0.01 mg/kg changes

Intubating dose
0.1-0.15mg/kg
ROCURONIUM 1-2 MIN 20-25 min. 0.5-1.0 mg/kg Not used for
defasciculation

Special considerations

1. Maxillofacial injury: patients with severe facial injuries who are hemodynamically stable and
have their spine cleared or immobilized should be allowed to sit up if they can breathe more
effectively and comfortably in that position.
2. Head injury: endotracheal intubation of a patients with severe closed head injury is a major
concern because intracranial pressure (ICP) can increase precipitously during the procedure.
 CERVICAL SPINE

OBJECTIVES

Upon completion of this topic, the student will be able to:

• Define cervical spine instability.

• Identify and recognize patient with cervical spine instability
• Understand proper in- the line stabilization and placement of cervical collar
• Interpret cervical spine films

INTRODUCTION

The incidence of cervical spine (C-spine) injuries among blunt trauma survivors is between 1-3%.
The sequelae are serious, with 7% direct mortality and 10-40% morbidity due to devastating neurologic
injuries. C-spine instability refers to both the bony and ligamentous injuries in the cervical spine, which
can lead or worsen neurologic deficits.

All blunt trauma patients should be presumed to have a spinal injury until complete evaluation
and clearance by clinical examination and/or radiologic tests are performed. Cervical spine
immobilization is a priority in multiply-injured patients, spinal clearance is not . Imaging the C-spine
does not take precedence over life saving diagnostic and therapeutic procedures.

IN-LINE STABILIZATION

Clinical examination is an important part of the evaluation of the C-spine. A C-collar should
never interfere with complete clinical evaluation of the neck. Removal of the C-collar and manual in-line
stabilization is used when patients needs intubation.

The following are the steps in doing in-line stabilization:

1. Position yourself superior to the patient’s head
2. Hold on to the patient’s shoulder’s.
3. To keep the patient’s head and neck steady, gently squeeze the patient’s head between your
forearms.
4. Maintain this position while explaining your actions and offer reassurance while you are ding
these maneuvers.
PROBLEM RECOGNITION

The patients is considered “reliable” if there is no evidenced of:

1. Head injury (patient is alert,awake, GCS=15)
2. Alcohol intoxication
3. Substance abuse
4. Psychiatric problem

The following steps should be done in a reliable patient:

1. The patient is asked for any neck pain. If the patient reports no pain, the cervical collar is
removed and neck stabilization is maintained by the gentle pressure on the forehead of the
patient.
2. Each C-spine vertebra is palpated, and the patient is asked if there is any tenderness during
palpation.
3. In the absence of tenderness, the patient is asked to move his/her forehead (“chin to chest) /
(“chin to shoulder”) and report any neck pain during movement.
4. The examiner should report any pain within the vicinity of the neck that would divert the
patient’s attention away from the neck pain (distracting pain).
5. Assess patient for neurologic deficit by performing the following dimple tasks:
Upper extremity: “touch finger”, “hand wave”, “hand squeeze”
Lower extremity: “touch toe”, “foot wave”, “foot push”
6. In the absence of neck pain, neck tenderness, distracting pain and neurologic deficit, the neck
immobilization device may be removed and may dispense with radiologic evaluation.
7. In the presence of neck pain, neck tenderness, distracting pain and neurologic deficit, placement
of properly fir nrck immobilization device is in order.

In reliable patient with neck pain, tenderness, distracting pain or neurologic deficit:
a. Obtain 3-view C-Spine films:
1. Anteroposterior view (AP)- visualizes anterior view of C3N to C7
2. Lateral view- visualizes lateral view C1 to C7
3. Open mouth view- visualizes the anterior view of C1 and C2
b. If the 3rd-view C-spine films are negative, obtain dynamic views. Dynamic views are plain lateral
films after the patients has extended of flexed his/her neck to the point whre pain or discomfort
is elicited . These views will detect inappropriate spinal movement (subluxation or dislocation0
due to ligamentous injuries.
c. If dynamic views are negative, then the C-spine may be cleared and neck immobilization device
can be removed.
d. If dynamic views show bony or ligamentous injuries or instability, then a neurosurgery or
Orthopedic Surgery consult must be made. A neck immobilization device must be reapplied.
e. If 3-view C-spine films are:
i) Suspicious, equivocal or uninterpretable, a thin cut axial CT should be obtained through the
area of concern
ii) Define for bony abnormalities or obvious fractures, then neurosurgery or Orthopedic
Surgery should be consulted.
 Reliable patients may not undergo 3-view C-spine films if all of he following conditions exist:

a. No neck pain with active range of motion

b. No tenderness to palpation of C-spine or paraspinous area.
c. Patient must be awake and alert (GCS 15).
d. No distracting pain.
e. No neurologic deficits referable to C-spine.

Unreliable patients suspected to have C-spine injuries should have 3 views C-spine x-ray. In intubated
patients and those that cannot follow commands, open-mouth view can be replaced by a thin cut axial
CT scans of C1 and C2.

a. If the view C-spine films (or the 2 view – AP and lateral C-spine x-rat plus thin cut axial CT of
C1 and C2) are negative, then neck immobilization device can be removed.
b. If the 3-view C-spin films (or the 2 views plus CT) revealed bony abnormalities, then
Neurosurgery or Orthopedic Surgery should be consulted.

In multiply injured patients, transportation to CT scan suite is always critical. Efficiency therefore
depends on ordering all the necessary CT scans the first time. If CT scan of C1 and C2 is needed, obtain
first C-spine AP and lateral views x-rays so that any suspicious or questionable C-spine abnormalities can
be included in the CT. Never request for CT scan of the entire C-spine unless indicated.

In summary, reliable patient who is alert, awake with GCS 15 may not need cervical x-rats. However in
the presence of neck pain, neck tenderness, distracting pain and neurologic deficits referable to thr C-
spine will need 3-view films. If these views are normal, dynamic views should be done. In the presence
of abnormal findings in any of the films, orthopedic or neurosurgery should be consulted. If the patients
is unreliable, 3 views c-spine films is preferred, however if the open mouth view cannot be obtain, a thin
cut (1 mm) CT of C1 and C2 should be requested.

All x-rays including CT scan and MRI should be officially read by either a radiologist or a neurosurgeon. In
the presence of positive or questionable findings, a blanket referral to orthopedic, neurosurgery and
rehab med should be done.
 VENTILATION MANAGEMENT

OBJECTIVES

Upon completion of this session, the student will be able to:

• Recognize signs of ventilation problems
• Establish management priorities in ventilation problems
• Confirm the adequacy of ventilation.
• Understand the following:
a. Needle thoracentesis
b. Closed-tube thoracostomy
c. One-rescuer Ventilation

INTRODUCTION

A patient airway and adequate ventilation are the first in al trauma patients, once the airway is
secure, adequate oxygenation and ventilation must be ensured. Adequate delivery of oxygenated blood
to the brain and other vital organ I essential to improve outcome. All trauma patients must receive
supplemental oxygenation. High flow delivery of oxygen blood and normal intrathoracic pressures
provide optimum oxygenation at the cellular level. The ideal oxygen concentration to be delivered is the
best assessed by the use of a pulse oximeter, as the clinical determination of adequate oxygenation is
virtually impossible by any other non-invasive means.

PROBLEM RECOGNITION

Problems with breathing/ventilation are obviously life threatening. Inspection, palpation,

percussion and auscultation are the classic means of physical examination for ventilation. Respiratory
movements and quality if respiration are assessed. If breathing is not improved by clearing the airway,
other causes be sought (CNS depression or altered ventilator mechanics).

Objectives Signs of Ventilation Problems:

A. Inspection- look for symmetrical rise and fall of the chest wall. Asymmetry suggests splinting
or flail chest. Neck vein engorgement may mean tension pneumothorax. Increased
respiratory rate and change in breathing pattern may mean hypoxia. And labored breathing
should be regarded as a threat to the patient’s ventilation.
B. Palpation- feel for any crepitations as this implies subcutaneous emphysema. Tenderness
maybe a sign of rib fractures
C. Percussion- hyperresonnance means pneumothorax and dullness means fluid accumulation
D. Auscultation – listen for air movement on both sides of the chest. Decreased or absent
breath sound alert the examiner of possible thoracic injury.
Oxygenation:

The ultimate goal of resuscitation is adequate tissue oxygen delivery cellular oxygen
consumption. In the multiply injured patient, oxygenated air is best delivered via a tight-fitting facemask
with reservoir at 10-12 L/min.
Pulse oximetry should be considered during resuscitation since changes in oxygenation occur
rapidly and are difficult to detect clinically.

OXYGEN DELIVERY L/MIN APPROX. F1O2

Nasal cannula 1 0.24
2 0.28
4 0.35
6 0.42
Face mask 5-6 0.40
6-7 0.50
7-8 0.60
Face mask w/ reservior 6 0.60
8 0.80
10 1.00
Table 1: Oxygenation achieved using different oxygen-delivery devices.

MANAGEMENT

In the apneic patient, effective ventilation can be achieved by bag-valve-face mask technique.
The 2-person technique, in which both hands are used to assure a good seal, is more effective than the
one-person technique.

Intubation of the apneic patient may not be successful initially. Patient must be ventilated
periodically during each attempt. Doctor must take a deep breath prior to intubation. If he must breath
again, the attempted intubation should be aborted and the patient ventilated.

VENTILATION

a. Mouth to pocket face mask

1. Make sure that patient’s airway is cleared of obstruction or foreign bodies.

2. Apply the mask to the mask assuring a tight seal with both hands
3. Ventilates the patient by blowing through the mouthpiece.
4. Observing the patients chest movement asessess adequacy of ventilation.
5. Patient should be ventilated every 5 seconds.

b. Bag-valve-mask (2 person technique)

1. Select the appropriately sized mask to fit the patient’s face.
 2. Connect the oxygen tubing to the device and adjust the flow to 10-12 l/min.
3. Make sure the patient’s airway is patent.
4. The first person applies the mask to the patient’s face, ascertaining a tight seal with
both hands.
5. The second person ventilates the patient by squeezing the bag with both hands.
6. Observing the patient’s chest movement assesses adequacy of ventilation.
7. Patients should be ventilated every 5 seconds.

PLEURAL DECOMPRESSION

A. Needle Thoracentesis

1. Assess the patient’s chest and respiratory status

2. Administer high flow oxygen and ventilate if necessary.
3. Identify the second intercostal space, in the midclavicular line, on the side of the tension
pneumothorax.
4. Surgically prepare the chest
5. Insert an over-the-needle catheter into the skin and direct the needle above the 3rd rib into the
2nd intercostal space.
6. Puncture the parietal pleura. Sudden escape of air indicates that the tension has been released.
7. Remove the needle, leaving the plastic catheter in place.
8. Stabilize the plastic catheter using a small dressing or bandage.
9. Prepare for closed-tube thoracostomy.

Complications:
- Local hematoma
- Pneumothorax
- Lung laceration

B. Closed-tube thoracostomy
1. On the affected side, determine the site of the tube insertion. Usually the 4th or 5th
intercostal space anterior to the midaxillary line.
2. Surgically prepare the area.
3. Drape the predetermined site of tube insertion.
4. Locally anesthetize the skin, intercostals space and rib periosteum.
5. Make a 2-3 cm horizontal incision on the predetermined site and bluntly dissect the
subcutaneous tissue, just over the top of the inferior rib.
6. Puncture the parietal pleura and place a gloved dinger into the incision to clear any
adhesion
7. Clamp the proximal end of the tube and advance it into the pleural space to the desired
length.
8. Connect the distal end to an underwater-seal apparatus
9. Suture the tube in place.
10. Apply a dressing and tape the tube to the chest
 11. Obtain a chest x-ray.

Complications:
- Laceration and/or puncture of thoracic and/or abdominal organs
- Pleural infections
- Damage to intercostal nerves, artery or vein
- Incorrect tube position
- Chest tube kinking, clogging or dislodging

C. Three- sided dressing

1. Dry the area of a sucking chest wound
2. Place vaselinized gauze over the wound
3. Secure three side of the gauze with Leukoplast tape.
4. Prepare for closed-tube thoracostomy

PULSE OXIMETRY

The pulse oximetry is designed to measure oxygen saturation and pulse rate in peripheral
circulation.
The accuracy of the pulse oximeter is unreliable when there is poor peripheral perfusion. This
may be due to hypothermia, hypotension, vasoconstriction and other causes of poor blood flow such as
an inflated BP cuff above the sensor. Excessive patient movement, other electrical device or intense
ambient light may cause malfunction of the device,
The pulse oximeter works by a low intensity light beamed from a light-emitting diode to a
photodiode that is a light receiver. Two thin beams of light, one red and the other infrared, are
transmitted through blood and body tissue, a portion of which is absorbed. The photodiode measures
that portion of the light that passes through the blood and body tissues. Oxygenated and
nonoxygenated hemoglobin have difference in light absorption. The microprocessor evaluates these
differences and reports the values as calculated oxyhemoglobin saturation.

CIRCULATION

INTRODUCTION

The most important aspect in the assessment of the intraventricular status of an injured patient
is the recognition of shock. Although there are many causes of shock, hemorrhage leading to
hypovolemic is the most common cause. Therefore, the clinical appreciation of the presence of shock,
followed by correct identification of its cause, serves as the main learning objectives for this session.
OBJECTIVES

At the end of this session, the participant is expected to be able to:

1. Define shock
2. Recognize the shock state
3. Know the principal classifications and appropriate treatment of the shock state.
4. Apply treatment principles, with emphasis on recognizing the importance of hemorrhage
control and evaluating the patient’s responses to treatment.

What is shock?

Shock is defined as an abnormality of the circulatory system that results in inadequate organ
perfusion and tissue oxygenation. Initially , when the cells are deprived of essential substrates, they
compensate by shifting to anaerobic metabolism. This results in the formation of lactic acid and the
development of metabolic acidosis. However, if the process is prolonged and the shock state is not
reversed, this can lead to progressive cellular damage and eventually, cell death. Management
therefore, should be directed towards reversing this phenomenon by providing adequate oxygenation,
ventilation, and restoring effective blood flow and tissue perfusion.

The most important aspect in the initial management of an injured patient in shock is
recognition of its presence. There is no laboratory test diagnose shock. The diagnosis is solely based on
the clinical appreciation of the presence of inadequate organ perfusion and tissue oxygenation (acidosis,
oliguria, depressed mental status). Early physiologic responses to volume loss include tachycardia and
cutaneous vasoconstriction, manifesting as pallor and cool extremities. Hypotension is a reliable
indicator of shock although one has to bear in mind that compensatory mechanism may prelude a
measurable fall in systolic pressure until a significant volume of blood is lost. A narrowed pulse pressure,
on the other hand, suggest significant blood loss and involvement of compensatory mechanism.

of shock although one has to bear in mind that compensatory mechanism may prelude a measurable fall
in systolic pressure until a significant volume of blood is lost. A narrowed pulse pressure, on the other
hand, suggest significant blood loss and involvement of compensatory mechanism.

Pitfalls in shock recognition

Although tachycardia is commonly seen in patients in shock, one has to take into consideration
certain physiologic and non-physiologic factors which can alter its interpretation. We know, for instance,
that the normal heart rate varies with age. In an adult, tachycardia is defined as heart rate >100/min but
is present when the heart rate is > 160 in an infant (<1 year), >140 in toddlers (1-3 years), and > 120
from preschool to early childhood (3-7 years). Athletes may have normally low resting heart rates such
that tachycardia may be present despite a heart rate of <100/min. the elderly patient, on the other
hand, may not exhibit tachycardia due to limited cardiac response to catecholamine stimulation from
the stress of injury. Moreover, the ability to increase the heart rate may be limited by presence of a
pacemaker or concomitant intake of medications such as beta blockers. Lastly, hypothermic patients
may be both hypotensive and tachycardic although blood loss is not significant to warrant such
derangement.

ETIOLOGY OF SHOCK
There are several principal classifications of shock. In the trauma setting, these are best grouped
into hemorrhagic and nonhemorrhagic causes. In an injured patient presenting to the Emergency
Department (ED), shock is the most likely due to hemorrhagic and/or cardiac compressive shock.
Ecognition and Hypovolemic or hemorrhagic shock result from acute blood loss whereas cardiac
compressive shock is due to external compression of thin-walled mediastinal venous structures and/or
the chambers of the heart. Cardiac tamponade and tension pneumothorax are the most common causes
of cardiac compressive shock in trauma. These are immediately life threatening and therefore prompt
recognition and management are vital. Cardiogenic shock is an acute pump failure because of intrinsic
cardiac abnormalities such as infarction or arrhythmias. Although rare, this may occur from blunt cardiac
injury and should be suspected when the mechanism of injury may develop neurogenic shock due to an
acute decrease in effective blood volume following symphathetic denervation, with vasodilation and
peripheral pooling of blood. Finally, septic shock results from the release into the circulation of acute
inflammatory mediators that induce microvascular injury with leakage of fluid out of the intravascular
space.this however, occurs infrequently as a presenting feature in trauma but rather as a later
complication.

HEMORRHAGIC SHOCK IN THE INJURED PATIENT

Hemorrhage is defined as an acute loss of circulating blood volume. In a normal adult male, this
blood volume is approximately 7% of body weight. Thus, a 70 kg man will have a circulating blood
volume of approximately 5 liters. The blood volume for a child is calculated as 8% to 9% of the body
weight.

Depending on the amount and aquity of blood volume loss, four classes of hemorrhagic shock
may be apparent, ranging from compensated physiologic response to severe cardiovascular collapse. His
classification system is useful in emphasizing the early signs and pathophysiology of the shock state, as
well as directing therapy. (table 1)

For instance, a 70 kg who arrives at the ED hypotensive would be diagnosed to have a class III
hemorrhage. His estimated blood volume loss would be 1470 ml of blood and therefore fluid
resuscitation should be based, at least initially, on this amount.
 Class I Class II Class III ClassIV

Blood loss (ml) Up to 750 750-1500 1500-2000 >2000

Blood loss (%blood volume) Up to 15% 15-30% 30-40% >40%

Pulse rate <100 >100 >120 >140

Blood pressure normal normal decreased decreased

Pulse pressure normal or decreased decreased decreased

decreased

Respiratory Rate 14-20 20-30 30-40 >35

Urine output >30 20-30 5-15 negligible

CNS/mental status Slightly Midly Anxious Confused,

anxious anxious confused lethargic

Table 1. Classification of Hemorrhage

Initial Management of Hemorrhagic Shock

As emphasized above, the first step in the management of hemorrhagic shock is to recognize in
presence. This is followed by control of bleeding and replacement of volume loss. Note that these are
not mutually exclusive. More often than not, the diagnosis and treatment of shock are performed
simultaneously.

The physical examination is directed at the diagnosis of life-threatening I juries and include
assessment of the ABCs. Under circulation, emphasis is placed on control of obvious hemorrhage,
obtaining adequate intravenous access, and assessing tissue perfusion.
Control of Bleeding

Although frequently, control of bleeding can met only in Or, many techniques can be performed at the
ED.

DIRECT PRESSURE- this is the simplest technique for hemorrhage control. Success is dependent on
having a well localized target that can be compressed against a less-mobile structure.
INFLOW OCCLUSION- this is done by compressing the inflow vessel against an adjacent bony structure.
Each major site of pulse evaluation (e. g. femoral, brachial, radial, ulnar) are excellent areas to apply this
technique.
TORNIQUETS- this technique is best applied in circumstances of major limb injury with concominat
hemorrhagic shock r uncontrolled bleeding that is not manageable with direct pressure or inflow
occlusion attempts.
MANUEVERS TO REDUCE PELVIC VOLUME- These techniques aim to reduce the pelvic volume to
minimize blood loss from injured large pelvic vein plexuses. The “open book” type of pelvic fracture
would be the ideal pattern where these techniques may be beneficial. External fixation and application
of a c-clamp are examples of these techniques. Applications of folded sheets can be readily applied at
the scene or at the ED. The sheet should tightly encircle the pelvis and the wrap must be secured in a
non-slip fashion to prevent loosening and recurrent hemorrhage.
PNEUMATIC ANTI-SHOCK GARMENTS- the concept behind the PASG is to control or prevent shock by
applying external pressure on the extremities and abdomen. This, however, has been largely abandoned
for a number of reasons. Currently, the use of PASG is limited to transfer of unstable trauma patients
with pelvic fractures.

VASCULAR ACCESS

Vascular access should be initiated promptly. This is best done using large-bore (gauge 14 or 16),
short-length peripheral catheters placed in the forearm or antecubital fossa. Should this prove difficult
or inadequate, either central access or a venous cutdown of the saphenous vein is indicated.

The greater saphenous vein lies anterior to the medial malleolus where there are no other
important structures. Therefore, cannulation of this vein using a cut down approach is relatively easy
and safe. A transverse incision over the anticipated course of the vein is created and the vein is lifted
into the wound using hemostat. The vein is accessed using a catheter over a needle device, or a
venotomy is created and a cannula is inserted directly. Either Fr or Fr 8 tubing can be used.

The best location for central venous access is the common femoral vein. This can be readily
accessed using the percutaneous approach and Seldinger technique. The jugular and subclavian veins
are alternative sites although in hypovolemic patients, these should be avoided as they may be
collapsed, making puncture of the adjacent artery and pneumothorax more likely.
 Lastly, in children younger than 6 years, placement of an intraosseous needle into the tibia
should be attempted before central line insertion. Moreover, if the device is available, intrasseous
needle insertion to the sternum in adults may be performed. The most important determinant for
selecting which route for establishing vascular access is the experience and skill level of the doctor.

As intravenous lines are started, blood samples for typing and cross-matching should be drawn.

Fluid Theraphy

There is controversy as to whether crystalloids or colloids should be employed in trauma

resuscitation. Colloids with their high molecular weight compounds remain in the intravascular space
longer where they maintain volume by increasing oncotic pressure, therefore reducing the volume of
infused fluid and third sequestration. However, the microvascular injury characteristic of the shock state
may actually channel the oncotically active particles into the interstitium. This results in exacerbation of
the edema. Although many studies have addressed the efficacy of crystalloids versus colloids, there are
no definite conclusions. There are however, certain principles which may guide the selection of the most
appropriate fluid. First, crystalloid retention in the intravascular space is only 25-30% efficient. Infusion
of large amounts of crystalloids (over 5000ml) will result in marked edema of the interstitial space both
the cellular level and organ level, manifesting as third spacing. Secondly, the chloride load from
crystalloids can cause hyperchloremic metabolic acidosis. This can potentially complicate the lactic
acidosis that accompanies hypovolemic shock, placing an undue metabolic burden on the patient.

Knowing the pros and cons of the each type is therefore critical for the emergency care
provider. Although there is no solid data to demonstrate superiority of one over the other, it seems
administration of colloids is of little value for patients in shock and may even be detrimental. In the
initial resuscitation of the trauma patient, warmed isotonic electrolyte solutions (e.g Ringer’s lactate,
normal saline) are recommended. An initial bolus is given as rapidly as possible. The usual dose is 1 to 2
liters for an adult and 20 ml/kg for pediatric patient. A rough guideline for the total amount of fluid
acutely required is to replace each milliliter of blood loss with 3 ml of crystalloids fluid. This is known as
the “3 for 1 rule” and is based on laboratory observations that isotonic solutions freely cross capillary
membranes and equilibrate within the whole extracellular fluid space. Consequently, the intravascular
retention of these fluids is quite poor such that a large volume (i.e. 3 to 4 times the actual intravascular
volume deficit) has to be infused to achieve normovolemia. However, the patient’s response to fluid
resuscitation should dictate subsequent theraphy.

Therapeutic Decisions Based on Response to Resuscitation

Knowing the response to initial resuscitation identifies those patients whose blood loss was greater than
estimated and those with ongoing bleeding wherein operative control of hemorrhage may be necessary.
There are three potential response patterns (Table 2). The patient’s response to resuscitation should
serve as a guide to subsequent management.
 Rapid response- these patients respond rapidly to the initial fluid bolus and remain
hemodynamically normal when the bolus has been completed and the fluids are placed on maintenance
rates. In these patients, blood loss is generally minimal (<20% of blood volume).
Transient response- these patients respond initially to the fluid bolus but start to
deteriorate thereafter. This pattern is usually indicative of ongoing blood loss or inadequate
resuscitation. Blood transfusion is then indicated.
Transient response to blood transfusion would suggest ongoing bleeding
and will require urgent surgical intervention.
Minimal or no response- failure to respond to crystalloid and blood administration dictates the need
for immediate surgical intervention to control ongoing hemorrhage.

Rapid Response Transient Response No response

Vital signs Return to normal Transient Remain abnormal

improvement
Estimated blood Minimal (10-20%) Moderate and Severe (>40%)
Loss ongoing (20-40%)

Need for more Low High High

Fluids

Need for blood Low Moderate to high Immediate

Blood preparation Type and Type specific Emergency Blood

crossmatch release

Need for surgery Possibly Likely Highly likely

Early presence of Yes Yes Yes

surgeon

Summary

For this session, certain key points are emphasized:

1. Hypovolemia is the most common cause of shock and should be the initial consideration in a
hypovolemic patient.
2. Recognition of the presence of shock is the first step in management
3. Control of bleeding shoule be initiated promptly in the shock patient, followed by aggressive
resuscitation to restore intravascular volume.
 PENETRATING CHEST INJURY

Objectives

• To define guidelines for the management of penetrating injuries to the chest.

• To define an optimal diagnostic strategy and appropriate treatment plans for patients suspected
to have chest injuries

DEFINITION
Penetrating injury to the chest – a penetrating injury of the thorax in area bounded superiorly by the
lower neck and inferiorly by the lower costal margin.

GUIDELINES
1. Any penetrating injury to the chest must be assumed to have caused internal organ damage
which may involve the following:
a. Heart
b. Great vessels
c. Lungs
d. Tracheobronchial tree
e. Spinal cord
f. Esophagus
g. Diaphragm

2. In all patients, assess ABC’s first. Intubate early if the patient is unstable or uncooperative.

3. If the patient has suffered cardiac arrest and has had signs of life (pulse or EKG), at any yime or
is in extremis with extremely low blood pressure, proceed directly with ED thoracotomy while
the patient is being intubated

4. In the non-arrested patient, determine whether the patient is hemodynamically stable

(nonmotensive or SBP of 90 or more) or unstable (hypotensive or tachycardic) and whether the
patient has respiratory distress.
a. If hemodynamically unstable or in respiratory distress consider:
i. Tension pneumothorax
1. Absent breath sounds on affected side.
2. Distented neck veins
3. Shift of trachea or PMI to the contralateral side.
• Consider needle thoracostomy to temporize then insert
large bore chest tube.
ii. Massive hemothorax
1. Absent breath sounds on the affected side.
 2. Dull to percussion on affected side
• Insert larege bore chest tube (consider autotransfusion).
• Stabilize BP with vigorous fluid resuscitation

▪ Take immediately to OR if:

i. Initial drainage is > 1 L, or

ii. Drainage continues at >200 ml/hr for 2-3 hours

iii. Hypotension despite CTT and IVF (consider cardiac

tamponade, intraabdominal bleeding, clogged chest tube, bleeding on
the other chest).

iii. Cardiac tamponade

1. Entry wounds within cardiac box
2. Distented neck veins
3. Distant heart sounds

a. if patient is stable and not in respiratory distress, obtain CXR AP upright.

i. If CXR shows pneumothorax (including minimal pneumothorax) or

hemothorax, place a large bore chest tube.

ii. If CXR is negative and there is no firm indication that the pleural spac or
mediastinum was penetrated, do a 6 hour and 24 hour post- injury film.

1. If 6 hour post-injury film is normal, repeat CXR on the 24th hour post-
injury.
2. If there is pneumothorax or hemothorax, follow above guidelines
(there is an ongoing study showing trends that 3 hour film is as effective
as the 6 hour film in detecting late development of
hemo/pneumothorax).
3. If the patient came in more than 6 hours post-injury and the initial
CXR is negative, do a 24 hour film.

1 If the injury in the chest is located in:

a. Zone I of the neck, consider angiogram, bronchoscopy, and esophagoscopy

b. Between the nipples or between the clavicles, consider possibility of cardiac injury or great
vessel injury. Between the nipples or between the lower costal margins, consider thoracoabdominal
injuries.
 PENETRATING ABBDOMINAL TRAUMA

OBJECTIVES
▪ To define the boundaries of the abdomen.

▪ To define appropriate diagnostic and therapeutic guidelines for patients with penetrating
abdominal injury particularly guidelines what will help determine the presence of an
intraabdominal injury that will require exploratory laparotomy.

DEFINITIONS
Penetrating abdominal injury- any penetrating injury that could have entered the peritoneal or
retroperitoneum inflicting damage on the abdominal contents. In general, the entry wounds for an
abdominal injury extend the fifth intercostal space to the perineum.

Anterior abdomen or anterior thoraco-abdominal-region- area between the trans-nipple lines

superiorly, inguinal ligaments and symphysis pubis inferiorly, and posterior axillary lines laterally. Upper
anterior abdominal wounds could have initially entered the chest and then penetrated the diaphragm to
enter the abdomen.

Posterior abdomen or back – area located posterior to the posterior axillary lines from the tip of the
scapulae to the iliac crest. The thick back and paraspinal muscle act as a barrier to penetrating wounds
but also make the diagnosis of organ injury more difficult.

Presumptive antibiotics – are antibiotics theraphy started after the injury on the presumption that
contamination already occurred. It is different from prophylactic antibiotics that are given before the
contamination and from therapeutic antibiotics that are given after the infection sets in.

GUIDELINES
1. Follow the ABC’s and resuscitate patient according to findings of the primary survey.

2. Assess the abdomen looking for entry wounds, bleeding and peritoneal signs. Make sure that
good chest exam is performed since chest injuries can be associated with penetrating abdominal
injuries.

3. Determine if there are signs and symptoms suggestive of immediate need for surgery:

a. Signs of hemodynamic instability associated with the abdominal injury

b. Herninated abdominal contents
c. Obvious peritoneal signs consistent with intraabdominal injuries or
hemoperitoneum
d. Any gunshot wound with a path or other evidence of intra peritoneal
penetration
 e. Signs of lower extremity ischemia suggestive of vascular injury
f. Pneumoperitoneum on x-ray
g. Impaled foreign body
h. Blood in orifice (NGT, foley catheter, rectal exam). Beware! Minimal blood from
NGT or Foley catheter may be iatrogenic in nature.

4. If any of the above signs are present then take the patient to the Operating Room
immediately for exploratory laparotomy. Once the decision is made, don’t delay!!!

5. if the physical exam of the abdomen is equivocal and the patient is stable, the following
options can be consider:

1. Perform serial physical examination of the abdomen – ‘serial’ means doing the
PE of the abdomen every 30 minutes for 2-3 times preferably by one examiner.

i. Perform exploratory laparotomy if positive:

1. Increase in the area of tenderness

2. The tenderness involve area away from the entry wound
3. Abdomen becomes diffusely tender
ii. If negative – can perform any of the options below (DPL, ultrasound, etc.)
iii. Disadvantages:
1. Need to admit patients for definite period of time
2. Subjective

b. Perform DPL for single or multiple anterior abdominal wounds

i. Perform exploratory laparotomy if positive:

1. RBC count of >100,000
2. Gross feces, bile, urine, food particles
ii. If negative – patient can be discharge otherwise admit for any other injuries.
iii. Disadvantages:
1. High false positive results
2. Increase non- therapeutic laparotomy rate
c. Wound exploration for single anterior abdominal wound
i. Perform DPL and follow guideline for DPL if positive:
1. Penetration of the fascia or anterior rectus sheath.
ii. If negative – admit the patient for 24 hours and perform abdominal physical
exam every 3 hours.
iii. Disadvantages: not a practical option for:
1. Multiple abdominal wounds
2. Upper abdominal wounds – may inadvertently enter the chest
3. Ice pick wounds!
d. Ultrasound (focused Abdominal Sonography for Trauma – FAST ) –
i. Perform laparotomy if positive:
1. Free intraperitoneal fluid or presence of solid organ injury.
ii. If negative – consider patient discharge in the absence of other injuries
 iii. Disadvantages:
1. Operator dependent
2. Hollow viscus injury may be missed
3. Needs at least 50 ml of free intraperitoneal fluid to be
sonographically visible (DPL can be positive with 5 ml)

e. CT scan – to assess both the anterior, lateral and posterior abdominal wounds
i. Exploratory Laparotomy is in order if positive:
1. Presence of free intraabdominal or retroperitoneal fluid.
2. Presence of solid organ injury
3. Presence of hollow viscus injury
ii. If negative – consider discharge
iii. Disadvantages:
1. Expensive
2. Need at least 50 ml of free fluid to have positive result

f. laparoscopy
i. Consider open laparotomy if positive:
1. Penetration of abdominal wall
2. Presence of bowel or vascular injuries
3. Isolated diaphragmatic injury can be repair laparoscopically.
ii. If negative – may admit patients for at least 24 hours
iii. Disadvantages:
1. Expensive
2. Laborious preparation
1 For all patients taken to the OR for exploratory laparotomy.
a. Administer presumptive antibiotics.
b. Pre widely for all contingencies i.e. chin to knees, table to table
c. Generous midline incision from xiphoid to pubis.
 BLUNT ABDOMINAL TRAUMA

OBJECTIVES
▪ To define the patients at risk for intra- abdominal injury after blunt trauma.

▪ To provide appropriate diagnostic approaches to intra- abdominal injury.

▪ To discuss non-operative management

DEFINITIONS

Triple contrast abdominal CT- SCAN- abdominal CT scan with intravenous, oral and rectal
contrast

FAST- focused Assessment using Sonography in Trauma patient

GUIDELINES

▪ Treat the ABC’s first. The diagnosis of abdominal trauma is part if the secondary survey.

▪ Perform physical examination of the abdomen including rectal exam.

▪ Consider the possibility of abdominal injury in the following situations

a. Obvious abdominal pain with or without peritoneal signs.

b. Significant external findings on the abdominal wall such as abrasions, lacerations and
avulsions

c. Pelvic fractures

d. Lower rib fractures

e. Lumbar or thoracic spine fractures

f. Unexplained hemorrhagic shock or blood loss

g. History of abdominal impact (i.e. deformed steering wheel, passenger compartment

damage)

h. Patients with altered sensorium after blunt trauma

i. Prolonged acute non-abdominal surgery requiring anesthesia

j. Quadriplegia or Paraplegia

k. Death in the same passenger compartment

 l. Falls > 20 feet (6 meters)

m. Ejection from auto or roll over

n. Pedestrian thrown or run over

o. High speed auto crash >60 km/hr

p. Motorcycle crash with separation of rider and bike

▪ Bring the patient immediately to the operating room for laparotomy in the following situations:

a. Findings of diffuse/generalized peritoneal irritation

b. Hemorrhage shock (unstable BP) with an indication that blood loss is in the abdomen
(distending abdomen)

c. Ruptured diaphragm on chest x-ray or pneumoperitoneum

▪ If the patient gas possibility of abdominal injury and has stable vital signs a Do FAST
i. FAST positive for intra-abdominal fluid:
1. If non-operative management for blunt abdominal trauma does not sound
familiar to you, it will be safe to perform laparotomy.
2. If contemplating on non-opearative management, perform DPL looking for
signs of hollow viscus injury i.e. presence of fecal material, bile, succus, urine, and
bacteria (positive lavage) disregarding the values of lavage RBC and WBC counts.
a. Positive lavage – perform laparotomy
b. Negative lavage – perform non- operative management
3. If not capable of performing non-operative management
a. Positive DPL (indication for laparotomy)
i. Gross
1. 10 ml of blood
2. Feces
3. Bile
4. Urine
5. Food particles

ii. Microscopic

1. RBC count - >100,000

2. WBC count - >500

▪ The following are the criteria to terminate non-operative management:

a. Hypotension attributed to abdominal injury (femoral fracture and blunt chest injuries
can also present with hypotention!)
b. Signs of hollow viscus injury
 c. Development of septic syndrome despite normal abdominal findings
d. Deterioration in vital signs despite adequate resuscitation (TRENDING)

BLUNT ABDOMINAL INJURY

ABC

P.E

(-) EQUIVOCAL (+)

ALTS CRITERIA FAST

(-) (+) (-) (+)

Discharge or admit for DPL

Treat other 24 hours (look for signs
Injuries of hollow viscus
Injury)

(-) (+)

NON- OPERATIVE EXPLORE LAP

MANAGEMENT

***if the facilities for non-operative management is not available.

 IMMOBILIZATION OF THE MUSCULO-SKELETAL INJURIES
OF THE EXTREMITIES

OBJECTIVES
▪ To provide basic knowledge in the immobilization of the musculo-skeletal injuries of the
extremities
▪ To know the principles and complications of splinting the extremities in trauma patients.

INTRODUCTION
▪ Any suspected fracture or dislocation should be splinted, immobilized or both.
▪ All injuries of the upper and lower extremities should be splinted before the person is moved to
minimize furher injury.
▪ Emergency care for all painful, swollen, or deformed extremities is splinting.
▪ Effective splinting minimizes the movement of distrupted joints and broken bone ends.

SIGNS AND SYMPTOMS OF SERIOUS INJURY TO THE EXTREMITIES

▪ Pain or tenderness
▪ Swelling
▪ Discoloration at the injured site
▪ Deformity of limb
▪ Inability to move/use limb
▪ Protruding bone
▪ Severe bleeding
▪ Loss of feeling or sensation

PURPOSE OF SPLINTING
▪ Reduce the patient’s pain
▪ Decrease muscle spasm
▪ Can help minimize blood loss
▪ Helps prevent additional injury soft tissues and neurovascular structures
▪ Can prevent a closed fracture from becoming an open fracture

PRINCIPLES ON SPLINTING
▪ Splint them “where they lie” before movement or transportation of any kind is attempted
▪ Apply splint to area
▪ If bone, splint the joints above & below the bone
▪ If joint, splint the bones above & below the joint
▪ Traction splint is required for most fracture of long bones to overcome muscle contraction and
associated shortening
 ▪ Traction splint overcomes muscle contraction and lessens shortening and thus regains or
maintains normal length of the bone.

MATERIALS
▪ Splints
▪ Splints may be improvised from such items as boards, poles, sticks, tree limbs, or
cardboard
▪ If nothing is available for splint, the chest wall can be used to immobilize a fractured arm
and the uninjured leg can be used to immobilize (to some extent) the fractured leg
▪ Padding
▪ Padding may be improvised from ff items:
▪ Jacket
▪ Blanket
▪ Poncho
▪ Shelter half
▪ Leafy vegetation
▪ Bandages
▪ Bandages may be improvised from belts, kerchiefs, or strips torn from clothing or
blankets

CAUTION
▪ Narrow materials such as wire or cord should not be used to secure a splint in
place
▪ The application of wire and/ or narrow materials to an extremity could cause
tissue damage and a tourniquet effect
▪ Slings
▪ Bandage suspected from the neck to support an upper extremity
▪ If a bandage is not available, improvise by using the tail of a coat or shirt or
pieces of cloth torn from such items as clothing and blankets
▪ The triangular bandage is ideal for this purpose
▪ Swathes
▪ Swatches are any bands (pieces of cloth or load bearing equipment) that are
used to further immobilize a splinted fracture
▪ Triangular and cravat bandages are often used and are called swathe bandages

RULES IN SPLINTING
1. Evaluate the Casualty

▪ Be prepared to perform any necessary lifesaving measures

▪ Monitor the casualty for development of conditions that may require you to
perform necessary lifesaving measures

2. Prepare the patient before splinting the fractures

 A. Locate the site of the suspected fracture
▪ Ask the patient for the location of the injury
o Does he have any pain?
o Where is it tender?
o Can he move the extremity?
▪ Look for an unnatural position of the extremity
▪ Look for a bone sticking out (protruding)

B. Expose the injury – get a good look at the fracture site & evaluate associated injuries

C. dress any wounds BEFORE splinting – cover the exposed bones w/ moist sterile dressing

D. Assess the distal neurovascular status – as a baseline for future evaluation

E. Loosen any tight & binding clothing

F. Remove jewelry from the finger

G. Straight SEVERELY angulated fractures

• Relieve pain
• Restore blood flow (if compromised)
• Allow for a fairly straightforward splinting

CAUTION:
• If you encounter resistance while attempting realignment- STOP – you may cause
more damage
• Never attempt to realign fractures associated with a joint

3. Gather the materials

• If standard splinting materials are not available, gather improvised materials

• Fracture of arm/leg, parts of the px’s body may be used
Ex. Chest wall splint an arm
Uninjured leg splint injured leg

4. Pad the splints

- padding prevents excessive pressures to the areas where splints have direct contact like:

-elbow -knee -wrist -ankle

5. Check the circulation

• Below site of injury

• (+) capillary refill test
• Indicator of poor blood circulation:
• Pale to blue skim
• Numbness
• Tingling sensation
 • Cold to touch

6. Apply and tie splint in place

a. Splint the fracture(s) in the position found

in open fracture – stop the bleeding and protect the wound

CAUTION:
DO NOT attempt to reposition the injury
DO NOT push back protruding bone under the skin
b. Tie the splints

• Tied away from the body of the patient

• Ties should be square not / non- slip knots
• Distal pulses of the affected extremity checked after the application of the splint

CAUTION:
DO NOT tie cravats directly over suspected fracture/dislocated site

7. Check the splint for tightness

a. Bandages tight enough to hold splint

-should be able to slip 2 fingers under the tied bandage

b. Recheck the circulation after application of the splint

8. Apply sling if applicable

a. Improvised sling may be made from non- stretching piece of cloth or showing at all times
b. Hand should be higher than patient’s elbow and fingers should be showing at all times
c. Should be applied so that the supporting pressure is on the uninjured side

CAUTION:
Never apply a sling to an unsplinted fracture
 DISASTER PREPAREDNESS
Disaster- are natural or man-made events wherein communities experiences severe danger and incur
loss of lives and properties causing disruption in its social structure and prevention of the fulfillment of
all or some of the affected community’s essential functions…

‘Any occurrences that causes damage, economic disruption, loss of human life and
deterioration in health and health services on a scale sufficient to warrant an extraordinary response
from outside the affected area or community.’ (WHO)

The most important aspects to remember about a disaster are:

Disasters interrupt the normal functioning of a community

Disasters exceed the coping mechanism (capacity) of the community
Disasters assistance is needed to return to normal functioning of a community

HAZARD
A source of danger, an extreme event; possibility of incurring loss or misfortune

Natural Hazards

• Nuclear, biological or chemical incidents

• Explosion
• Aircraft crash
• Hazardous chemicals incidents
• Conventional warfare
• Building collapse
• Civil disturbance

Hazard + Community = DISASTER

Multiple Casualty Incident (MCI)

Any event resulting in a number of victims large enough to disrupts the normal course of
emergency health care services.

If your daily emergency management is bad Don’t Expect To Be Able to Manage Disasters properly

Disaster Management Is an Escalation of the daily Emergency Response

But if a hospital is unable to handle day to day emergencies in the ED, it will not be able to cope with
demands of multiple casualty incidents

MCI RESPONSES:
LEVEL I – LOCAL EMERGENCY RESPONSE PERSONNEL AND ORGANIZATION ARE ABLE TO
CONTAIN THE DISASTER
LEVEL II – REGIONAL EFFORTS AND MUTUAL AID FROM SURROUNDING COMMUNITIES
LEVEL III- REQUIRING NATIONAL OR INTERNATIONAL ASSISTANCE

The Philippine Disaster Management system

PD 1566
June 11,1978
Stregthening the Philippine Disaster Control Capability and Establishing the national program on
Community Disaster Preparedness

RESPONSIBILITY FOR LEADERSHIP RESTS ON THE PROVINCIAL GOVERNOR. CITY MAYORS, MUNICIPAL
MAYORS, (AND BARANGAY CHAIRMAN).EACH ACCORDING TO HIS AREA OF RESPONSIBILITY.

IT IS THE RESPONSIBILITY OF ALL GOVERNMENT DEPARTMENTS, BUREAUS, AGENCIES AND

INSTRUMENTALITIES TO HAVE DOCUMENTED PLANS OF THEIR EMERGENCY FUNCTIONS AND
ACTIVITIES.

Hospital Roles in a Disaster

• Provision of Disaster Medical Teams
• Acting as the receiving Hospital for casualties from a disaster
• Triage in multiple/mass casualty incidents
• Receiving hospital for patients transferred from other disaster affected health-care facilities

Disaster Management
HEICS (Hospital Emergency Incident Command System) USA

MIMMS (Major Incident Medical Management Support)

 FLUID AND BLOOD THERAPHY IN TRAUMA

Currently there three main with regard to resuscitation in the trauma patient. First the choice of fluids:
not just the continuing debate of crystalloid versus colloid but also the potential benefits of new types of
fluid. Second, the potential for improved outcomes with so called restricted/restrained fluid
resuscitation versus conventional resuscitation. Third, the role of prophylactic administration of blood
component during massive transfusion.

Fluid for resuscitation are divided into four main types: conventional cystalloids, hypertonic saline
solutions, colloids and colloid-hypertonic saline mixtures.

Conventional crystalloids. Otherwise known as balanced salt solutions, most commonly used are
Ringer’s lactate solution and normal sodium chloride solution. Ideally these fluids should not contain
dextrose due to the large volumes infused within a short period, potentially aggravating stress- induced
hyperglycemia. These have been the standard fluids for resuscitation for over 50 years now.

The problem with conventional crystalloids is these do not remain in the intravascular compartment.
Being isotonic, these fluids are able to reconstitute the intravascular volume rapidly. After infusion,
however, being true solutions, crystalloids equilibrate with the interstitial and intracellular
compartments. As a result, for every 1 liter infused, only 250cc remains in the intravascular space. The
rest diffuses into the interstitial spaces promotes cellular edema. In massively resuscitated patients, this
is manifest as peripheral edema. Although this edema may not be clinically significant in most cases,
patients who sustain combined torso and cranial injuries are at higher risk of developing UK & Europe.

HOPE (Hospital Preparedness for Emergencies & Disasters)

Asia & Developing Countries Specific

Components EMS System

• Triage
• On- site care
• Initial resuscitation and treatment
• Medical transport
• Definitive care or trauma center

Triage
• Assess victims’ vital signs and condition
• Assess their likely medical needs
• Assess their probability of survival
• Assess medical care available
• Priorities the definitive management
• Color tag
Triage categories are:
a) Immediate – RED
b) Delayed – YELLOW
c) Walking wounded – GREEN
d) Dead and dying – BLACK

Aim of triage
To achieve the greatest good for the greatest number of casualties

The key to Disaster is Preparedness

Increased intracranial pressures. Furthermore, as the severity hemorrhage worsens, the ratio of 2
volume remaining intravascularly to 3 volumes diffusing interstitially does not remain throughout the
resuscitation phase. As blood is continually shed, say, from one blood volume to twice the blood
volume, the amount of crystalloid needed to maintain the same volume effect rises sharply, (figure from
Cervera, AL, et al. J trauma,1974;14:506-520) in hemorrhage, more and more crystalloids are needed to
maintain perfusion

And if that weren’t bad enough: as more research has gone into the resuscitation it has been found that
the use of these fluids result in neutrophil activation along with release of inflammatory cytokines.
There result in what is now recognized as the systematic inflammatory response syndrome (SIRS)
And if left unchecked, progresses to such clinical entities as acute lung injury (ALI) and ARDS, abdominal
compartment syndrome (ACS), multi-organ dysfunction syndrome (MODS). Currently, researchers are
trying to improve on the hundred- year old Ringers lactate, testing new buffering compounds such as
ketones and L-lactate in an attempt to minimize the inflammatory consequences of reperfusion.
Colloids. A colloid solution exerts its volume effect by attracting free water molecules (oncotic effect).
Unable to freely diffuse through the endothelial lining, it expands intravascular volume much greater
than the actual amount of colloid infused. Colloids are of four different types: albumin, dextran
(polysaccharide-derived), gelatin (collagen-derived) and starch solutions. Under elective surgical
conditions, colloids remain in most part within the intravascular space, hence their effectiveness in
replacing intraoperative remote from the site of injury. Despite the larger molecules, there is significant
amount of colloidal dispersal into the interstitium. The colloid molecules continue to exert their oncotic
effect, drawing fluid from and further depleting the intravascular volume.

For a quick run down of the different types of colloids. Dextrans are the earliest and cheapest type
available. They have the biggest molecules, the greatest and longest-lasting volume effect. However, it
increases risk of bleeding and renal failure. Gelatins, available in 3-4% solutions, have the shortest
volume effect but are best for patients with renal disease. The starches (HES for hydroxylethyl starch)
presently available as 6% & 10% penstarch and 6% tetrastarch solutions locally. Made of amylopectin, it
has high water binding capacity and plateau effect due to osmotically-active intermediate molecules
during its breakdown by amylase.

Hypertonic saline solutions: developed in the 1990s driven requirements of the US military to
develop a more compact solution for battlefield resuscitation. By drawing free water to develop a more
compact solution for battlefield resuscitation. By drawing free water from the interstitium due to its
hypertonicity, it restores cardiac output and mean arterial pressure, it has direct intropic and direct
vasodilating effect, increasing renal and coronary blood flow. It is also meant for was intended to be use
in patients with traumatic brain injury to limit cerebral edema. The initial apprehension of rapid
increases in sodium levels leading to central pontine myelinosis have not been substantiated in clinical
trials. Presently, it is already a recommendation by the US Institute of Medicine Committee on Fluid
Resuscitation for Combat Casualties of giving 250cc of 7.5% saline solution.

Colloid- Hypertonic Saline. To combine the benefits of colloids and hypertonic saline, with small
volumes and lasting volume effects. The hypertonic saline draws the fluid and the colloid keeps it
intravascularly. This fluid is meant for the prehospital and transfort settings. It is meant for resuscitation
in the definitive care setting.

But even as the rest of medical world advances, we remain stuck or stocked with lactated Ringer’s and
isotonic sodium chloride. From the real world point of view, given limited resources, for initial
resuscitation the precise fluid used is probably not important as long as an appropriate volume is given.
Next, anemia is better tolerated than hypovolemia.

With regard to restrained resuscitation, conventional wisdom has it that the hypovolemic patient should
resuscitated to normotensive levels. This is the ATLS 3-for-1 rule. This means infusing 3 cc of crystalloid
per 1 cc of blood loss. Having been given this volume of fluid, 3 patterns of patient response are
described. First, are the rapid responders: they rapidly improve and remain hemodynamically stable.
Second, the transient responders: those who improve but start deteriorating as soon as fluid infusion is
slowed down.
Lastly, the nonresponders: those who do not respond with even with infusion of blood products. These
different patterns or response correlate with the different stages of shock. The duration and magnitude
of oxygen debt. (a.k.a shock), largely determines who will and won’t survive and who of the survivors
will either go on with uneventful recovery or manifest multi-organ failure later. Based on controlled-
hemorrhage shock models, data have shown that the longer period of shock, the greater the risk of
developing multiple organ system failure in survivors. Non-survivors do not recover from the initial
insult even with resuscitation. These patients remain hypotensive, acidotic and hypothermic and later
coagulopathic despite resuscitation. Of those who survive, prolonged hypoperfusion correlates with the
incidence of subsequent multi-organ failure. These trauma patients previously did not survive albeit
with varying degrees of organ dysfunction.

Recently the use of the controlled-hemorrhage model to justify aggressive fluid resuscitation in the
trauma patient has become into question. Clinically, trauma patients continue to blee throughout
resuscitation phase. This implies that without control the bleeding source, fluid resuscitation to restore
normal blood pressure levels may actually undo the body’s protective mechanism in limiting blood loss.
Reversal of vasoconstriction due to the restoration of blood volume results in hydraulic acceleration of
the hemorrhage. Animal studies have shown that the highest mortality is found in those subjects. But
surprisingly, the second highest mortality is found in those subjects who received the most fluid;
mortality decreasing with decreasing magnitude of fluid resuscitation. Suggested mechanism of these
findings is that an early increase in the pulse pressure may be enough to dislodge a soft clot and thus
promote further bleeding. Does aggressive fluid resuscitation prejudice outcome? Hence the hypothesis
that some degree of permissive hypotension may improve outcomes compared to resuscitating to
normotensive levels. Despite methodological shortcomings in human studies (e.g, the delayed
resuscitation group being brought to the OR earlier than the immediate resuscitation group), outcomes
of groups with delayed or less fluid resuscitation were comparable to standard resuscitation regimens.
Clinical trials are currently addressing the issue of restricted fluid resuscitation end points (lower systolic
or mean arterial pressures), determining a safe duration for delaying fluid resuscitation and the
composition of fluids used.

The available evidence, though thought-provoking, remains insufficient to mandate a change in

resuscitation strategy. Permissive hypotension with the intent of minimizing further bleeding in humans
does remain speculative and the safety limits have not been established. Aggressive pre-operative fluid
infusion is still considered standard management for the unconscious patient without a palpable blood
pressure and those with controllable hemorrhage such as in extremity injuries or isolated head injuries.
In areas where there are problems in terms of transport times and operative capabilities, under-
resuscitated patient may actually exsanguinate. The one principle that remains unchallenged is need for
prompt surgical hemostasis by whatever means possible.

The restrained resuscitation controversy does succeed in making the trauma surgeon more circumspect
in giving fluids until the patient is in the operating room. Also, distinction should be made with regard to
mechanism and anatomic involvement of trauma: combined head and torso injuries require balancing
the need to resuscitate versus the risk of exacerbating cerebral edema.

The third and last issue to discuss is the role of prophylactic blood component theraphy. In the massively
transfused patient coagulopathy remains a significant problem. Usually it is clinically evident in patients
who have undergone replacement equivalent to more than 1 ½ times the blood volume. However, the
development of coagulopathy is not as predictable as it may seem. Despite similar volume of blood loss,
some patients develop coagulopathy while others do not. The reason being coagulopathy is a multi-
factorial phenomenon and not simply a consequence of hemodilution. For instance, it may be due to the
entry if brain matter into the circulation as evidenced by its higher incidence in patients with combined
brain injury and torso trauma compared to patients with torso trauma alone. Then there is shock itself.
Shock is the best predictor of coagulopathy and implies that resuscitation remains adequate.

Precisely because coagulopathy is not simply a mechanical process of wash-out or dilution of

coagulation factors or platelets, the prophylactic administration of blood components in the massively
transfused trauma patient has been questioned.

Fresh Frozen Plasma. There is no evidence that prophylactic administration of fresh frozen plasma
decreases transfusion requirements in patients receiving multiple transfusion. Prolongation of PT and
PTT in the absence
of clinical bleeding should not be an indication for the administration of FFP. Fresh Frozen Plasma should
be reserved for patients demonstrating abnormal bleeding and in whom platelet concentrates have
failed to reverse the bleeding. If FFP is indicated, 4-8 units (600-2000ml) are given rapidly to increase
serum levels of coagulation factors.
Platelet Concentration. Both dilutional thrombocytopenia and platelet function defects have been
demonstrated to occur in massively transfused trauma patients. However, platelet counts cannot be
predicted on the basis of the volume of blood transfused. Prolonged bleeding time (>10 minutes) is a
very sensitive predictor of increased bleeding, but has poor specificity. Platelets should not be
administered in setting of massive transfusion unless there is documented bleeding going on. How much
to give? Around 6 to 8 units of platelet transfusion. In patients with abnormal bleeding think of giving
platelet transfusion as the initial intervention rather than fresh frozen plasma.

In summary, crystalloids remain the mainstay of trauma resuscitation. Alternatively colloids and
hypertonic saline solutions may be more effective in restoring hemodynamic stability, especially if the
time available for administration is limited. Interestingly, there are data suggesting a more restrained
approach to resuscitation achieves outcomes similar to standard resuscitation protocols. Lastly
coagulopathy after traumatic injury is the end result of multiple pathological events and not due to
dilution alone. Therefore, no data supports the routine administration of blood components for
prophylaxis against coagulopathy after massive transfusion.

GUIDELINES FOR MANAGEMENT OF ACUTE BURN INJURIES

INTRODUCTION

Burn injuries are among the worst problems which can befall man. A burn is injury resulting from
exposure to an open flame, hot liquids, contact with hot objects, exposure to caustic chemicals or
radiation, or contact with an electric current. A review of the following topics will help in formulation an
initial management plan for all types of burn.
• Definitions related to extent and depth of burn injuries
• Classification of burn injuries
• Initial assessment and stabilization

I. Determining Severity of the Burn Injury

A. Depth of a Burn

The depth of tissue damage due to burn is dependent on the temperature and duration of contact with
the tissue (skin). Skin contact with heat, chemicals, or electricity results in tissue destruction of variable
degrees. Due to the thinner skin in the very young and the very old, special considerations are given to
patients of these age groups. Burns in these age groups may be deeper and more severe than they
initially appear.

• First Degree Burns (Superficial thickness burns)

Injury involves only the epidermis and is rarely clinically significant other than being painful. The
involved skin is red and hypertensive. Erythema is due to vasodilation, desquamation eventually
ensues and usually heals without a scar in 7-10 days. The most common example of this type of
burn injury is “sunburn”.
• Second Degree Burns (Partial Thickness Burns)
Injury involves the epidermis and part of the dermis. These are further categorized into
superficial and deep. In superficial injuries, all of the epidermis is destroyed as well as varying
superficial portions of the dermis. These lesions are usually pink to cherry red, painful and
blistering is often present. Healing will generally occur within 2 weeks with minimal scarring.
Therapy is directed at preventing infection.

In deep partial thickness burns all the epidermis and most of the deep dermis is destroyed.
There will be less blistering formation and is usually mottled white to red which blances on
pressure with rapid capillary refill. Re-epithelialization is greatly retarded in these wounds.
Healing may occur in 21 to 35 days with some degree of scarring.
• Third Degree Burns (Full Thickness Burns)
Burns of this degree involve necrosis of the entire thickness of skin, leaving no chance for
healing except for very small wounds which may heal by contraction and epithelialization from
the wound edges. Involve skin is white and leathery with a charred appearance. Sensory nerves
are destroyed therefore all sensation to pinprick is lost in the burned area. Third degree wounds
routinely are treated with excision and grafting.

B. Extent of Burn Injury

Many decisions regarding care of the burn patient are based on “estimate” of extent of burn
injuries and therefore should be recorded as accurately as possible using a body diagram. Extent
of burn is commonly estimated using the “Rule of Nines” because it is easy to remember. The
body surface of an adult is divided into 11 segments of 9 percent with 1 percent reserved for the
perineum.

An alternative method is the use of the palm of the patient’s hand which represents
approximately 1 percent of the patient’s body surface. This is useful in estimating scattered
burns of limited extent anywhere in the body.

Frequently, a modified chart, devised by lund and browder is used to estimate burn size in
children because this chart may be more accurate. It is also allows estimating burn size for
adults. Either method of estimating burn extent is acceptable to most clinicians. Superficial
areas of burn are not used in the estimate. Only partial and full thickness areas of burn are used
in estimating the extent of burn.

II. Initial Assessment, Management and Stabilization of Moderate and Major Burns

A. Assessment

1. Primary survey – the initial assessment of the burn patient is like that of a trauma patient. A
convenient approach to the primary survey is through the methodology of ABCDEF:
A – Airway
 B – Breathing
C – Circulation
C – spine immobilization
C ardiac status
D – Disability
(Neurologic) Deficit
E – Expose and Examine
F – Fluid Resuscitation

a. Airway

b. Breathing

The patient’s airway and breathing must be assessed immediately. The compromised airway must be
controlled by simple measures, including:
• Chin thrust
• Jaw lift
• Oral pharyngeal airway in the unconscious patient
• Auscultate for breath sounds in both lungfields
• Assess adequacy of rate and depth of respiration
• High flow oxygen is started on each patient at 15 L (100%) using a rebreathing mask
• Circumferential full thickness burns of upper trunk may impair ventilation and must be closely
monitored

c. Circulation
Assessment includes evaluation of skin color, sensation, peripheral pulses, and capillary refilling.
Remember that limb circulation may be impaired in a circumferential full thickness burns as result of
edema formation so maintain a high index of suspicion and careful observation

C- spine Injuries
Remember to stabilize the spine before doing anything that will flex or extend the spine.

d. Disability/Neurologic Deficits. This should be checked and treated to prevent aggravating

condition.
e. Expose and examine. Be sure to make quick full body survey so as not to miss any other
contaminant injury
f. Fluid resuscitation. The goal of successful resuscitation is to replace intravascular volume and
maintain adequate tissue perfusion.

Calculation of Fluids for the first 24 hours

A. Adults: Plain Lactated Ringer’s solution at 2-4 mL x kilogram body weight x TBSA percent burn

B. Children: Plain Lactated Ringer’s solution at 3-4 mL x kilogram body weight x TBSA percent burn

The infusion rate is regulated such that ½ of the calculated volume is given in the first 8 hours from the
time of the burn. The second half of the estimated fluid is given within the subsequent 16 hours. The
rationale for such a schedule is that the time of greatest capillary permeability and intravascular volume
.meant to act as guides in the institution of fluid therapy. Fluid resuscitation is thus adjusted according
to the individual patient’s response to the burn and the treatment regimen

Resuscitation Fluid Composition

• The First 24 Hours

Crystalloid fluid is the fluid of choice in the initial 24 hours of fluid resuscitation. in fact, it has
been mentioned that crystalloid fluid is the keystone of initial resuscitation of burn patients.
With increased capillary permeability, colloids have no significant influence on maintaining
intravascular volume during the initial hours post burn. Due to the leakage of large molecules of
proteins through open capillary membranes, colloids have little role in resuscitation. Between
18-24 hours the capillary leak begins to seal sufficiently so that colloid may remain within the
intravascular space. Colloid replacement at this time may be estimated at 0.5cc/kg/% burn.
Either Albumin or Fresh Frozen Plasma is used and calculated amount is replaced over one to
two hours.

• The Second 24 hours

Capillary permeability approaches normal during the latter half of the first post burn day with
restoration of functional capillary integrity by 2nd post burn day. The amount and composition of
the fluids required thus changes after the first 24 hours because of these pathophysiologic
changes. 5% dextrose in water at rate of 1 cc/kg/% burn. The serum sodium should be
maintained between 133 and 135 mEq/dl/

Monitor of Resuscitation
Fluid resuscitation in each patient must be individualized, because each person has varied
reactions and responses to burn injury and fluid resuscitation. The actual volume of fluids
infused must be adjusted according to the individual’s physiologic responses. One must also
keep in mind that it is more difficult to remove excess fluid than to infuse additional fluid
The optimal resuscitation regimen is that which decreases volume and salt loading, prevents
acute renal failure and has low incidence of pulmonary and cerebral edema.

A. Hourly Urine Output

Hourly urine output monitoring utilizing an indwelling urethral catheter is the most readily
available and reliable guide to adequacy of fluid resuscitation.

Adults: 30-50 cc/hour or 0.5 to 1 cc/kg/hour

Children: (weighing less than 30 kg) 1 cc/kg/hour

If urine output falls below or exceeds these limits by more than 1/3 for two to three
hours, fluid infusion may be increased or decreased by one third accordingly.

1. Management of Oliguria
a. Alteration of Fluid Infusion Rate
Oliguria, in conjunction with increased systemic vascular resistance and decreased cardiac
output is most commonly due to inadequate fluid resuscitation. The use of diuretics at this
point is contraindicated. Rapid fluid infusion is the measure to be instituted in these cases.

b. Use of Diuretics
A diuretics may be administered to prevent the development of acute renal failure in patients
with extensive burns who remain oliguric despite fluid therapy, that is assuming that they
have received their calculated fluid needs and have no other evidence of a significant
persistent blood volume deficit.
2. Management of Myoglobinuria and Hemoglobinuria

In cases if high voltage electrical burns and those with extensive soft tissue damage which may
also due to mechanical trauma, patients may present with significant amounts of myoglobulin in
their urine. Increased fluid administration is needed to address the problem. Maintaining urine
output of 75-100 cc/kg/hr (or 1.5 to 2 cc/kg/hr.) is necessary to clear the body of heme
pigments. This situation eliminates the need for diuretics.

If with increase in fluid infusion, the patient’s urine does not clear up, mannitol may be given at
12.5 g per liter of resuscitation fluid. This may help in clearing the heme pigments.\

Once adequate urinary output has been achieved and pigment density decreases, fluid therapy
is continued without the need for the use of diuretic agents.
 Alkalinization of urine with Sodium Bicarbonate is instituted as needed. Heme pigments are
more soluble in an alkaline medium. This would thereby facilitate clearance of the pigments.

With the administration of diuretics, the use of the hourly urine output as guide to fluid therapy
is no longer reliable as a parameter for assessment of the adequacy of volume
replacement.other parameters must then be monitored and relied upon.

Monitoring of patient response should include the following parameters:

• Hourly urine output monitoring
• Frequent assessement of the patient’s general condition
• Baseline laboratory examination of hematocrit, hemoglobin, serum chemistries and arterial
blood gases. Subsequent studies needed as indicated by the patient’s clinical course.
• Chest X-rays
• ECG as needed/indicated

Fluid Resuscitation in Pediatric Patients

Children need special attention because the burned child is more susceptible to fluid overload and
hemodilution owing to a lesser intravascular volume per unit surface area burned in the child.
Children have greater amount of resuscitation fluid needed.

Hypoglycemia is also another pediatric problem. Chidren have limited liver glycogen stores available.
This, in turn, is rapidly exhausted by elevated levels of circulating steroids and catecholamines
during the early post burn period. As such, vigilant monitoring of the pediatric patient’s blood
glucose levels should be done and if hypoglycemia develops, a glucose containing electrolyte
solution (e.g. D5LR) may be used for resuscitation.

In the young child, electrolyte free fluids in the second 24 hours post-burn should be avoided. This is
beacause of the high incidence of hyponatremia. Half normal saline solution should be utilized
instead.
Initial Procedures Specific to the Type of Burn

A. Thermal Burns – cover the burn area with a clean, dry, and warm sheet. Covering all burn
wounds prevents air currents from causing pain in partial thickness burns. Ice should never be
directly applied to the burn due to the possibility of frostbite. Cold application, if used, should be
brief so that body temperature is not needed.

B. Electric Burns – an electric current passing through an individual may cause extensive internal
damage. A major concern is the effect the electric current has on normal cardiac electrical activity.
Serious dysrhythmias may occur even after stable cardiac rhythm has been obtained. Continuous
 cardiac monitoring may be necessary during the first 24 hours post injury. Note that even if the
visible surface injury does not appear serious, there may be inapparent severe, deep tissue injury.

C. Chemical Burns – chemical agents should immediately be flushed from the body surface with
copious amounts of water. Powdered chemicals should be brushed from the skin prior to flushing
the body surface area. Remove all contaminated clothing. Chemical eye injuries require continuous
irrigation until its discontinuation is instructed by a burn physician.

D. Initial Laboratory Studies – burn injuries can cause dysfunction of any organ system. Baseline
laboratory studies are necessary to evaluate the patient’s subsequent progress. Upon admission,
obtain baseline studies:
• Hematocrit
• Electrolytes
• Blood urea nitrogen
• Urinalysis
• Chest X-ray
Special Consideration
• Arterial blood gases (if indicated)
• ECG – with all electric burns or pre-existing cardiac problems
• Carboxyhemoglobin (if indicated)
• Glucose (in children) and diabetics

Inhalation Injury:

In essence, three distinguishable types of inhalation injury have been identified:

1. carbon monoxide poisoning

2. inhalation injury above the glottis
3. inhalation injury below the glottis

Initial Management

A. Oxygen Therapy and Airway Management

The simplest and probably the best treatment for carbon monoxide poisoning is administration of 100
percent oxygen. This would decrease the half- life of carboxyhemoglobin from 4 ¼ hours to about 50
minutes. A face mask with a non-rebreather bag could appropriately administer oxygen with an fi02 of
100%. Care, however, should be exerxised in patients with chronic lung disease in whom hypoxia
provides the primary respiratory drive.

If signs of laryngeal edema appear – hoarseness, brassy cough, stridor or noisy breath sounds –
indications of impending upper airway obstruction, immediate endotracheal intubation is indicated. The
transnasal route is the preferred method, if facilities and staff are available for such practice; however,
be practiced in the case of potential cervical spine injury. A cross table lateral x-ray may be performed
prior to airway intubation.

The integrity and proper positioning of the endotracheal tube must be ascertained by (1 auscultation
and 2) chest roentgenogram. The tube must then be properly and safely secured with particular
consideration of the inherent difficulties in securing a tube in the burned face. This is best done using an
umbilical tape passed around the head. Newer devices have been constructed for proper securing of the
tube. These, however, are not currently available in our setting.

If endotracheal intubation is not successful or not possible owing to various factors such as marked
edema of the upper airway, immediate cricothyroidotomy should be performed to secure a patent
airway.

B.Specific Laboratory Tests

After initial airway management is instituted, an arterial blood gas, chest xray, and carboxyhemoglobin
levels (where possible) should be obtained.

Assessment and Management

A. General Assessment Findings

The following are considered to be important considerations in the initial assessment of patients with
probable inhalation injury.

1. History –
a. Is there a history of unconsciousness?
b. Were noxious chemicals involved?
c. Did the burn injury occur in a closed space?
It is important to note a high percentage of patients with documented inhalation injury were in an
enclosed space at the time of the burn. However, there is a subset of patients with inhalation injury who
were in an open area at the time of the burn.

Physical findings suggestive of respiratory tract injury are the following:

a. Carbonaceous sputum
b. Facial burns, singed nasal hairs
c. Agitation, tachypnea, anxiety, stupor, cyanosis
d. Rapid respiratory rate, flaring nostrils, intercostal retractions, especially of the lower rib cage
e. Hoarse voice, brassy cough, grunting, guttural respiratory sounds
f. Rales, rhonchi, distant breath sounds
g. Erythema, swelling of the oro – or nasopharynx
h. Mucosal slough/burns of the oro – or nasopharynx
B. Treatment for each Type of Inhalation Injury

1. Carbon Monoxide Poisoning

There is actually no specific theraphy for carbon monoxide poisoning except to displace it from
hemoglobin by mass action. This is accomplished by the administration of 100% oxygen until levels of
less than 15% are achieved. The administration of 100% oxygen reduces the half-life of CO in the blood
from about 4 ¼ hours down at around 50 minutes. Hyperbaric oxygen for these patient is currently still
of unproven value. Efforts to institute hyperbaric oxygen therapy should not hamper efforts to transfer
the patient to a burn center. In our setting, hyperbaric oxygen facilitates are unavailable.

2. Inhalation Injury Above the Glottis

The development of upper airway obstruction can occur very rapidly when the condition arises. Patients
with pharyngeal burns, hoarseness, stridor, a brassy cough or noisy breath sounds have a high likelihood
of developing upper airway obstruction, and thus should be intubated prior to transfer to the burn
center. Monitoring of arterial blood gases would not be of primary import in this setting. One should
give careful consideration to the physical findings of airway obstruction in such a situation.

3. Inhalation Injury Below the Glottis

Patients with inhalation injury sometimes manifest primarily with symptoms of bronchial and
bronchiolar injury – bronchorrhea and/or expiratory wheezing. In this situation, intubation is indicated
prior to transferring the patient for purposes of clearing secretions, relieving dyspnea and/or
establishing safe levels of arterial blood gases.
Inhalation injury may, however, occur chiefly at the level of respiratory gas exchange. This form of injury
is often times delayed in onset. The earliest manifestation of such type of injury is impaired arterial
oxygenation rather than an abnormal chest roetgenogram.

It is mandatory that this subset of patients be transferred to a burn center as soon as possible. If,
however, transfer would be delayed, respiratory management and ventilation should be coordinated
with the burn center. It is essential that vigilant monitoring of the patient’s respiratory status and overall
condition in order to identify the possible need for ventilation with a volume ventilator if the need
arises.

The existence of circumferential burns of the chest may require escharotomies to improve the overall
ventilation of the patient. The use of steroids in patients with inhalation injury should not be practiced.

4. Inhalation Injury in Pediatric Patients

The development of upper airway obstruction in the pediatric age group may be particularly more rapid
in onset owing to the relatively smaller caliber of the pediatric patient’s upper airway. If, indeed,
endotracheal intubation is required, a tube of proper size should be utilized. Proper positioning of the
tube should be confirmed by auscultation and by a chest roetgenogram. The use of small uncuffed tubes
in the pediatric age group makes it particularly easier to displace, and therefore, greater care must be
exercised in securing the tube.
Chest wall escahrotomies in pediatric patients should be performed promptly with the first evidence of
ventilator impairment. This is due to the fact that the development of respiratory failure secondary to
the decrease in chest wall compliance associated with constrictive circumferential chest burns is more
rapid in children.

Burn Center Referral

A. Burn Center Characteristics

A burn is a service capability based in a hospital that is dedicated to care for the burn patient. The burn
center is staffed by a team of professional with expertise in the burn patient. Care includes both acute
care and early rehabilitation. The burn team provides educational programs regarding burn care to all
health care providers and involves itself In research related to burn injury. A burn unit is specified area
within the hospital, which has a specialized nursing unit dedicated to burn patient care.

B. Referral Criteria

The American Burn Association has identified the following injuries as those requiring a referral to a
burn center. Patients with these burns should be treated in a specialized burn facility after assessment
and treatment at an emergency department.

• 2nd and 3rd degree burns of more than 10% BSA in patients under 10 and over 50 years old.
• 2nd and 3rd degree burns of more than 20% BSA in other age groups.
• 2nd and 3rd degree burns in serious threat of functional or cosmetic impairment that involve face,
hand, feet, genitalia, perineum and joints.
• 3rd degree burns greater than 5% BSA in any age group
• Significant electric burn injuries including lightning injury.
chemical burns with serious threat of functional or cosmetic impairment
• Inhalation injury with burn injury
• Circumferential burns of an extremity or chest
• Burn Injury in patients with with pre-existing medical disorders which could complicate
management, prolong recovery or affect mortality
• Any burn patient with concominant trauma (i.e. fractures) in which the burn injury pose the
greater risk of morbidity or mortality.
• Burned children should b transferred to a hospital with qualified personnel and equipment.
Initial Management of the Burn Wound

After the initial patient assessment and institution of measures to life threatening problems, attention is
turned to local care of the wounds. Loose, devitalized tissue is generally trimmed away. Pain and
bleeding are kept to a minimum.
Blisters of a medium size are preferably left intact and allowing underlying wounds to heal
spontaneously. Arguments, based on several studies, advocate puncturing the blister at one end with a
needle and evacuating the fluid but leaving the blister over the wound as a protective biologic covering.
The wound with intact blister covering is dressed protectively with a light topical antimicrobial cream.

The wound is gently irrigated or washed with warm water and a mild bland soap. Chlorhexidine soap is
desirable for its antimicrobial activity. After through rinsing with water, the involved area is gently dried
and topical antimictobial cream is applied.

Closed wound dressings on burns are used to serve three main purposes:
Provide protection and isolation of wound from the environment
Absorb drainage
Decrease wound pain

These closed dressings are preferred for extensive burns specially of the deep partial thickness injuries.
Likewise it is ideal in a setting where the patient is confined in a ward with other patients to prevent
cross infection between patients.

After cleansing, a mild topical antibiotic is placed and wound is covered with mesh gauze (Xeroform or
Adaptic) or absorbent gauze dressing held in place by elastic gauze bandage (Kling or Kerlix) or
stockinette. Joints are dressed to facilitate range of motion. Fingers are dressed individually.

The frequency with which dressings are changed is arbitrary. Recommendations range from twice daily
to as infrequent as once a week. The author prefers once daily dressing changes in order to permit daily
inspection of the wound.

One of the most effective ways to reduce incidence of infection in burns is to eliminate edema from a
burned part. More often, there is also a tendency for the patient to hold an injured part immobile in a
dependent position. To eliminate edema, an injured part should be exercised regularly and maintained
slightly above the level of the heart.

Topical Antimicrobial Agents

Burn injury not only damages the normal skin barrier, but also disrupts host immunological defenses.
Systematically administered antimicrobial agents may not achieve reliable therapeutic levels in the
avascular eschar. Topically applied antimicrobials will provide higher concentration of the agent on the
wound surface where microbial numbers are usually highest. Topical agents penetrate eschar to a
variable extent, which should be considered in the selection of the topical antimicrobial to be used.
The normal cutaneous bacterial flora are sparse but after burn injuries the bacterial count become
significantly increased. The usual burn wound will have Staph aureus as the predominant flora.
Subsequently, gram negative opportunistic species appear. These include Proteus, Klebsiella and
coliform species as well as Pseudomonas. Anaerobes are infrequently isolated, although Clostridial
myositis may be encountered particularly in high voltage electrical injuries.

The goal of topical antimicrobial therapy is to initially delay and minimize wound microbial colonization.
These agents need not penetrate the eschar too deeply. They should have activity against common
pathogens, they should not retard wound healing, and should have acceptable toxicity.

Specific Agents:

A. 1% Silver Sulfadiazine]
The white cream is relatively painless to apply and does not stain bed linens. It has in vitro activity
against a wide range of organisms including S. aureus, E. coli, Pseudomonas, Proteus, Enterobacter,
and Candida. The drug penetrates the eschar poorly but softens it. Its toxic effect is a transient
leukopenia which is reversed on discontinuation of the cream.

B. Mafenide
It is a water soluble cream which has excellent antibacterial activity most gram positive and gram
negative organisms with good eschar penetrate. The downside is that it is painful on application.
The drug is rapidly absorbed and thus ideally applied twice a day. A toxic effect of Mafenide is that it
is a potent carbonic anhydrase inhibitor. As a result, hyperchloremic metabolic acidosis is frequently
seen. Moderate to severe hyperventilation as a respiratory compensation for the acidosis is
characteristic. The risk of systemic toxicity increases in proportion to the wound area being treated
and the duration of treatment. It is ideal as a short term treatment, however, it is no longer
available commercially in the local market.

C. 0.5% Silver Nitrate solution

The agent is effective against most strains of Staphylococcus and also has activity against
Pseudomonas as well as common gram negative organisms. Solutions greater than 0.5% are
histotoxic. The bolus gauze dressing has to be wet every several hours leaving messy, stained bed
linen. It leaches electrolytes especially sodium from the wound surface so hypernatremia occurs
rapidly especially in infants or children with major burns.

D. Cerium nitrate with silver sulfadiazine

Studies have shown that the improved bacteriostasis in burn wounds with this combination is due to
improved cell mediated immune response from cerium nitrate. It retains the usual efficacyof silver
sulfadiazine.

E. Nitrofurazone
A water-soluble cream has good activity against burn wound pathogens such as Staphylococcus, but
has no significant activity against Pseudomonas.
Surgical Wound Debridement and Closure

Superficial partial thickness burns usually heal with minimal scarring in about 2 weeks time. If well
taken cared for with regular dressings and application of topical antibiotics, no surgical debridement
is needed except for removal of loose blister covering.

Deep dermal (partial thickness) burns extend into the reticular dermis and generally takes 3 or more
weeks to heal by re-epithelialization. Hypertrophic scar and contracture which limit function are
common sequelae of burn of this type. Full thickness burns have devitalized soft tissue (eschar)
which encompass the full thickness of the skin and even the subcutaneous fat (or even the
periosteum). Wound closure cannot occur while eschar remains in situ. Often too, eschar also may
not spontaneously separate as expected (around 2 weeks). Studies have shown that although
metabolically inactive, eschar produces toxins which may cause distant organ dysfunction. Eschar
also serves as a good medium for bacterial growth, and so the earlier eschar is removed, the better.
A more aggressive, earlier and more frequent use of surgical therapy is the common practice today.
Often “tangential” excision of eschar is done early (5-7 days) after burn therapy. Tangential excision
entails sequentially shaving the eschar from the burn surface until a viable tissue plane is reached.

Small but deeps burns on lax skin areas as the buttock, the female breast or the limbs and torso in
the elderly can on occasion be excised and closed primarily by suturing or by staples, particularly if
cosmesis is not a major issue. Soft tissue defects after debridement are usually closed with
autologous split thickness skin grafts. This is supposing that there is adequate, non injured
autologous donor skin. In cases where there is a large burn area with inadequate donor skin, the
option available is staged debridement and autologous skin graft closure. It is advisable in cases of
large burn areas (greater than 30% TSBA) to do staged debridement wherein no more than 20% of
TBSA burned is debrided and skin grafted per session. The next session will then debride another
20% of the TBSA burned and closed with skin grafts. The usual time interval between the staged
debridement is 10 days or until sufficient donor skin becomes available. Progressive wound closure
is thus achieved in a series of planned operative procedures. The unexcised burned area is still
cleansed daily and applied with silver sulfadiazine. Silver sulfadiazine with the addition of cerium
nitrate has been found to be useful, because this topical antimicrobial preparation is resistant to
bacterial colonization and can be safely left in place until it can be excised and closed with
autologous skin graft.
 PEDIATRIC TRAUMA

Planning treatment
The 3 most common causes of death are: airway obstruction
Blood loss
CNS injury

Critical Issues in Pediatric Trauma

√ Beware of hypothermia
• Children lose body heat rapidly
• Room anD IVF should be warmed
√ Multisystem injury is common
• Check all regions
√ Head injury is frequent
• Observe closely for altered consciousness
Determine Pediatric Trauma Score

The Pediatric Trauma Score

An anatomic and physiologic scoring system useful for triage and prediction of severity of injury
• Components predictive of death and disability
 PEDIATRIC TRAUMA SCORE

COMPONENT +2 +1 -1

SIZE >20 KG 10-20 kg <10 kg

AIRWAY STATUS NORMAL Maintainable Unmaintainable

CNS STATUS AWAKE Obtunded Comatose

SYSTOLIC BP >90 mm Hg 50-90 Hg <50 mm Hg

OPEN WOUNDS None Minor Major or penetrating

SKELETAL None Single closed fracture Open or multiple

fractures

Interpretation:

• Range is 12 to -6
• The lower the PTS the more severe the injury
• An inverse linear relationship exists between PTS and mortality. The higher mortality rate
equate with a lower pediatric trauma scores.
• PTS is used as a simple yet effective triage tool
• No deaths for PTS of 9 or greater
• A PTS of 8 has been defines as the critical triage point

Airway & Breathing

• A child’s airway is special:

• The upper airway may be occluded
• The tonsils and tongue are large
• The larynx is anterior and high in the neck
• The trachea is short- avoid inadvertent extubation or endobronchial intubation

Suggestions for airway access:

• “Sniffing“ position
• Chin lift or jaw thrust (for obstruction by tongue or foreign material)
• Use oral airway with bag and mask
• OROTRACHEAL INTUBATION PREFERRED – following preoxygenation, sedation, paralysis
• Needle cricothyrotomy is preferable to tracheostomy

Circulation
• Hypovolemia causes tachycardia and peripheral vasoconstriction BEFORE hypotension
 • Hemorrhage or hypovolemia makes SURGICAL CONSULTATION ESSENTIAL
• Be alert for shock caused by gradual or internal blood loss
• Physiologic guidelines
o Normal blood volume= 80 ml/kg
o Hypotension: loss of 24% of bood volume
o Blood pressure and heart rates are age-related

Resuscitation for Hypovolemia

• 20 ml/kg Ringer’s lactate as bolus (may repeat 2-3x)
• Hemodynamics Unstable 10ml /kg P-RBCs

SPECIAL CONSIDERATIONS

• Administer oxygen to ALL injured children

• Hyperventilate for CNS injury
• Consider NG tube to relieve gastric distention
• Maintain adequate urine output
Infant……………………………………… 2ml/kg/hr
Child………………………………………..1-1.5 ml/kg/hr
Adolescent……………………………….0.5-1ml/kg/hr

DIFFERENCES IN PEDIATRIC ANATOMY AND PHYSIOLOGY

Small body size Greater force applied per unit body area à incr. multiple organ
injuries

Body portion Particular risk of head injury from falls and motor vehicular
• Large head accidents
• Short extremities
• Midpoint in height is the umbilicus Suffer abd’l, thoracic, or head trauma in MVA
Large body surface area/mass ratio Incr. heat loss- at risk of hypothermia
Incr. water loss- predisposed to dehydration

Large head Obvious target for injury

Skull is thin and cranial bones are compliant Less protection- more impact transmitted to brain; acute
diffuse brain swelling more common

Fontanelles and sutures remain open until an average of 16 Infants initially may be more tolerant of an increase in ICP and
months can have delayed signs

Cervical Spine • Provides incr. momentum in acceleration

• Larger relative mass of the head deceleration injuries (seen in MVA, shaken baby
• Lack of muscle strength syndrome) that results in greater stress to the
• Fulcrum of cervical cervical spine
• Mobility at C2-C3 level (adult C5-7) cervical ligaments • 60-70% of pediatric fractures occur in C1 and C2
more elastic
 • Cervical spine fractures less common in infants and
young children

Compliant, elastic pediatric skeleton
Airway characteristics
Smaller tracheal diameter
• Large tongue, small mouth
• Epiglottis less stiff
• Larynx more cephalad
• Trachea shorter and anterior
• Larger volume of lymphoid tissue
Circulatory system
• Child’s heart has limited functional capacity; stroke
volume reaches a plateau at low filling pressure
• Blood volume in an infant and child is approximately
100 ml/kg and 80 ml/kg
• Physiological response of the child to hypovolemia is
in the form of hHr vasoconstriction and narrowed
pulse pressure
Abdominal characteristics
• Thin abdominal wall with poorly developed
abdominal muscles, subcutaneous tissue
• Pliant skeleton
Permits significant energy transmission, injuries to internal
organs are commonly seen without external signs of trauma or
fracture (e.g. pulmonary contusions w/o rib fracture)
• Easily obstructed by mucosal edema, blood, vomitus,
and foreign body
DIFFICULT
INTUBATION
• Cardiac output in very young children is almost
entirely dependent on heart rate
• The loss of a small amount of blood (50-100 ml) can
cause a significant reduction of th total blood volume
of the chid
• The mean arterial and systolic blood pressure remain
in the normal range until approximately 20% of the
blood volume is lost
• Provides little protection to abdominal organs and
make them vulnerable to major abdominal injuries
with very minor forces

ANATOMIC AND PHYSIOLOGIC CHARACTERISTICS THAT MAKE CHILDREN

UNIQUE

SYSTEM CHARACTERISTIC PITFALLS

Head and neck Large head, weak cervical
muscles, short neck, small and
anterior larynx, floppy
epiglottis, short trachea, large
tongue
Thorax Compliant chest wall, mobile
mediastinum, propensity for
aerophagia
Abdomen Begins at the level of the nipple,
rib cage is pliable and small,
underdeveloped abdominal
Prone to head injuries, spinal
cord injury without radiographic
abnormality (SCIWORA),
difficult to intubate, larynx and
trachea easily obstructed.
Rib fractures are rare,
intrathoracic injury presents
without external signs,
traumatic asphyxia, decreased
functional residual capacity
Solid organs vulnerable to
injury, bladder intra abdominal
organ
 muscles, pelvis smaller,
congenital anomalies

Metabolic Greater surface area-to-mass Greater insensible water loss,

ratio, greater heat loss, potential for hypothermia
increased oxygen demand
Physiologic Respiratory arrest, inability to Cause of cardiac arrest, watch
alter stroke volume in response for signs of shock
to blood loss, compensatory
response: tachycardia and
increase in systemic vascular
resistance

Normal Pediatric Vital Signs

AGE C RATE BP R RATE

1 MONTH 110-170 >70 <50

1 YEAR 100-160 >80 <40

5 YEARS 80-130 >90 <30

TEENS <90 >90 <20

Organs System Responses to Blood Loss in the Child

 Early Prehypotensive Hypotensive
(<25% loss) (25% loss) (40% loss)

CARDIAC Weak thread pulse, HR HR, positive tilt test Hypotension, tachy-
brady

CNS Lethargic, irritable, Level of consc, dulled Comatose

confused response to pain

SKIN Cool, clammy Cyanotic, cap. Refill,

cold ext.

KIDNEYS Decreased urinary Increased BUN No urinary output

output

FLUID RESUSC. LR 20 ml/kg LR 20 ml/kg x 3 PRBC LR 20 ml/kg x 3 PRCBC

and to OR

ANIMAL BITES: PRINCIPLES OF TREATMENT

OBJECTIVES:

Upon completion of this topic, the participant will be able to assess, categorize and manage the patient
with animal bite. Specifically, the student will be able to:
• Apply the principles of local wound treatment
• Identify the classifications of animal bite exposures and wounds.
• Identify the indications for antibiotic prophylaxis and coverage
• Identify the indications for tetanus prophylaxis.
• Ascertain the indications for rabies prophylaxis.

INTRODUCTION

Animal bites rarely cause lethal bleeding. Bites, however, can devitalize tissues, cause significant
damage, and introduce microorganisms.
Fifty percent of animal bite victims are children. Only 20% of the cases required medical attention.
Eighty percent of the bites that needed medical intervention were inflicted by dogs.

The most dreaded complication of aminal bites is the development of infections- soft tissue infections,
tetanus, and rabies.

I.LOCAL WOUND TREATMENT

Local wound treatment should be applied in all types of bite exposure.

A. Wounds should be immediately and thoroughly washed with soap and water, preferably for 10
minutes. Liberal cleansing and irrigation may, likewise, be done using sterile normal saline or
lactated Ringer’s solution. Do not use antibiotic solution for irrigation, as this may aggravate
tissue injury.

A. Devitalized tissues should be debrided.

A. Apply alcohol, tincture or aqueous solution of iodone or povidone iodine to the wound surface.

A. Generally, wounds should be left open. If suturing id necessary, it should be done loosely. If
rabies prophylaxis is warranted, anti-rabies immunoglobulin should be infiltrated around and
into the wound before suturing.

A. Avoid applying ointment, cream, or occlusive dressing to the bite site.

II. CLASSIFICATION OF ANIMAL BITES

The categorization and classification of animal bite exposures and wounds guide the clinician on the
appropriate interventions needed – antibiotics, tetanus and rabies prophylaxis.

A. CATEGORY I

Exposures that involve touching and feeding of the animal, and licking alone of the
patient’s healthy skin, with no open wound and no mucous membrane contact, and
with good reliability of the patient history.

B. CATEGORY II

Category I exposures that are associated with an unreliable history from the patient.
 Wounds that are minor scratches or abrasions without bleeding, or hematoma alone, or
are the result of an animal’s nibbling of uncovered skin or licking of broken skin or
healing wounds.

Wounds that are induced to bleed.

Head and neck exposures are classified as Category III.

C. CATEGORY III

Wounds that are the result of single or multiple transdermal bites, or licking of mucous
membranes.

Exposures to a rabies patient through bites, contamination of mucous membranes with

saliva/ fluids through splattering, through mouth-to-mouth resuscitation, licks of eyes,
lips and vulva.

Handling of infected carcasses or ingestion of infected raw meat.

III. ANTIBIOTIC COVERAGE AND PROPHYLAXIS

Antibiotics should be started for grossly infected wounds. The empirical antimicrobial agent to be used
much be guided by the knowledge of the prototypical organisms isolated from the most common
vectors of bites, as listed in table 1.

Table 1. Prototypical organisms isolated from bites.

Bacteria DOG CAT HUMAN

Anaerobe 38-78% 50%

Prototype A hemolytic Pasteurella Eikenella
streptococcus Multocida Corrodens

30% 50-74% 10-20%

P. multocida, is resistant to cephalexin, clindamycin, dicloxacillin, and erythromycin. Infection usually

develops within 24 hours after infliction of the bite. Some studies cite that dog bites, P. multocida is also
the most commonly isolated organism.
E. corrodens is a B- lactamase producing bacterium.
Cat bites become infected in more than 50% of cases, while less than 5% of dog bites develop an
infection.

For non- infected wounds, antibiotic prophylaxis is reserved for CATEGORY III bites.
Table 2 lsits the wound type and corresponding recommended antimicrobial agents.

Table 2. Category III wounds and recommended antibiotics.

WOUND VECTOR ANTIBIOTICS
Simple Cat Amoxicillin 500 mg q8 hrs
Deep, multiple extensive Cat Amoxicillin/Clavulanic 875/125
mg q12 hrs
Amoxicillin/Clavulanic 500/125
TID
Located on the hand Cefuroxime axetil 500 mg q12 hrs
Doxycycline 100 q12 hrs
Deep, multiple extensive DOG Amoxicillin/Clavulanic 875/125
mg BID
Amoxicillin/Clavulanic 500/125
TID

Located on the hand Clindamycin 300 mg QID plus:

Flouroquinolone (adults)
TMP- Sulfamethoxazole (children)

IV. TETANUS PROPHYLAXIS

Bite wound may be contaminated with spores of Clostridium tetani and predispose victims to develop
tetanus. Proper management of animal bites requires consideration for passive immunization with
tetanus immune globulin and active immunization with vaccination.
The features of tetanus-prone wounds are summarized in Table 3. It can be surmised that tetanus
prophylaxis should be considered for Category II and III wounds.

Table 3. Clinical features of tetanus-prone and non- tetanus prone wounds.

FEATURE TETANUS PRONE NON-TETANUS PRONE
Age of wound >6 hrs <6 hrs
Configuration Stellate, avulsion Linear
Depth >1 cm <1cm
Mechanism of Injury Missile, Burn Sharp
Crush, Frostbite Surface (glass,knife)
Devitalized tissue Present Absent
Contaminants (saliva, dirt, etc.) Present Absent
It is recommended that tetanus prophylaxis be administered in accordance with the schedule provided
in Table 4.

Table 4. Tetanus Immunization Schedule

History of Tetanus Immunization Tetanus-Prone Non-Tetanus Prone
Td A,B TIG Td TIG
Unknown or <3 doses Yes Yes Yes Yes
3 or more doses No C No No No

A. Td = Tetanus and Diphteria toxoids adsorbed (adult)

TIG = Tetanus Immune Globulin (human)
B. Yes if wound > 24 hours old
For children < 7 years, DPT (DT if pertussis vaccine is contraindicated)
For persons ≥ 7 years, TD preferred to tetanus toxoid alone
C. Yes, if < 5 years since last booster
D. Yes if > years since last booster

V. RABIES PROPHYLAXIS

An estimated million people receive post- exposure treatments each year after being exposed to rabies
suspect animals. Worldwide, the number of human rabies deaths is estimated to be between 35,000
and 60,000 annually. Almost all human deaths due to rabies are caused by dog bites and approximately
90% of human deaths from rabies occur in Asia. The case fatality rate of rabies remains at around 100%.

In 1999,69,373 Filipinos were treated for exposure due to domestic animal bites. The Philippines
reported the highest number of human deaths (401) in South East Asia that same year. Dogs inflicted
96% of the bites.

In the Philippines, rabies in animals has been documented in domestic dogs and cats and two unknown
species of wild animals. The vaccination rate of dogs and cats in the Philippines is only around 10%.
Large populations of domestic animals remain susceptible to rabies and are potential transmitters of the
disease. Rabies is a vaccine preventable disease and most of the people who die of disease do not
receive appropriate post-exposure treatment.

The objective of post-exposure prophylaxis is neutralization/removal of the rabies virus from the surface
of the wound and within the human body. The algorithm for post exposure rabies prophylaxis is shown
in figure 1.

Category I bites require no rabies prophylaxis. In a patient who is likely to have repeated exposure, pre-
exposure prophylaxis may be considered.

Category II require rabies prophylaxis. Full course vaccination is given if the animal is rabid or sick, or
when the animal is unavailable for evaluation. A healthy animal that inflicts a bite must be observed for
14 days for the development of signs and symptoms of rabies. If the animal remains healthy, vaccination
 may be discounted, or continued as pre- exposure prophylaxis. If the animal gets sick or dies, its head is
sent to a qualified laboratory for rabies testing. If the test is negative, vaccination is given for a positive
test.

Category III bites require not only vaccination, but also the administration of Rabies Immune Globulin,
as post- exposure prophylaxis. The algorithm follows that for Category II bites.

Vaccines and vaccination schedules are available in animal bite treatment centers designated by the
local government unit. Published vaccination schedules are available locally.

SUMMARY: all bite exposures and wounds require local wound treatment. Antibiotics should be
given for Category III wounds that are grossly infected. Prophylaxis for tetanus and rabies are warranted
for Category II and III wounds.

Fig.1.ALGORITHM for Rabies Prophylaxis

CATEGORY II CATEGORY III

Unknown, escaped,
Unknown, escaped, Healthy Animal* Healthy Animal*
sick, proven rabid
sick, proven rabid
animal
animal

Full course vaccine Vaccines RIG# + Vaccine RIG# + Full course

vaccine
# RIG = Rabies Immune Globulin *Vaccinated or Unvaccinated

REFERENCES

1. Centers for disease Control and Prevention MMWR Recommendations and Reports (1999).
Human rabies prevention –United States 1999: recommendations of the Advisory Committee on
Immunization Practices (ACIP). Available from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056176.htmhe production.

2. Gilbert DN, Moellering RC, and Sande MA (eds.). the Sanford Guide to Antimicrobial Therapy
33rd edition. VT USA.

3. ACS Bull. No. 10.1984.69:22-23. (as cited in reference 1)

 4. MMWR 1990.39:37, MMWR 1997. 46 (SS-2):15 (as cited in reference 1)

5. World Organization. (1999). World Survey of Rabies for the Year 1999. . Available from:
http://www.who.int/emc-documents/rabies/whocdscreph200210.html

6. World Health Organization. (1998). World Survey of Rabies No. 34 for the year 1998. Available
from: http://www.who.int/emc-documents/rabies/docs/wsr98/wsr98.pdf

7. Gibbons R and Rupprecht C. Twelve common questions about human rabies and its prevention.
Infectious Disease in Clinical Practice 2000; 9:202-207

8. World Health Organization. (1999). World Survey of Rabies for the Year 1999. Available from:
http://www.who.int/emc-documents/rabies/whocdscreph200210.html

9. Meslin F. (2001). The programme on human rabies surveillance and control. Rabies Control and
Prevention 2001. Available from: http://www.who.int/emc/diseases/zoo/rabies/html

10. World Health Organization Interregional Consultation Report (July 2001). Strategies for the
Control and Elimination of Rabies in Asia. Available from:
http://www.who.int/rabies/en/strategiesforthecontrolandeliminationofrabiesinAsia.pdf

11. Handbook on Rabies and Dog bites. UP- Philippine General Hospital Anti-rabies Unit.

TRAUMA IN PREGNANCY
OBJECTIVES
To know the guiding principle in the management of a pregnant trauma patient.

To discuss relevant physical examination findings in relation to physiologic changes of pregnancy.

To discuss the issues on the systematic approach in the clinical assessment of a pregnant trauma
patient.

The pregnant trauma patient presents a unique challenge to emergency medical care provides because
care must be provided for two patients- the mother and the fetus. Anatomic and physiologic changes in
pregnancy can mask or mimic injury, making diagnosis of trauma related problems difficult. Care of
pregnant trauma patients with severe injuries often requires a multidisciplinary approach involving
emergency physician, trauma surgeon, obstetrician and neonatologist.

The guiding principle in treatment of a pregnant trauma patient is to treat the mother first. The best
what you help the baby is to help the mother first. The treatment priorities for the pregnant patient are
the same as for the nonpregnant patient.

EMERGENCY DEPARTMENT CARE

Patients who have minor trauma and who are at less than 20 weeks do not require specific intervention
or monitoring. All patients beyond 20 weeks’ gestation who have direct or indirect abdominal trauma
should undergo at least 4 hours cardiotocographic monitoring. Resuscitation of the more serious
pregnant trauma patient must focus on the mother because the most common cause of fetal death is
maternal shock or death. It is important to remember that the mother will maintain her vital signs at the
expense of the fetus. Because plasma volume is increased by 50%, maternal shock may not manifest
itself until maternal blood loss exceeds 30%.

During the initial ABC assessment, the fetus is addressed only after primary survey.

If patients is more than 25 week’ pregnant, the mother should be tilted 15 degrees to the left.
Alternately, one person may be designated to manually displace the uterus to the left. If the patient
does not require spinal immobilization, then she can be asked to assume a left lateral decubitus
position.

PRIMARY SURVEY

Airway

Be sure that the airway is patent and unobstructed.

All pregnant trauma patients should receive supplemental oxygen, because the fetus is extremely
sensitive to hypoxia and because the oxygen reserve is significally diminished in the pregnant patient.
High flow oxygen through a non-rebreather mask is adequate for spontaneously breathing patients.

In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is
increased (lower esophageal sphincter pressure, decreased gastric tone, delayed gastric emptying,
increased gastric acidity and cephalad displacement of intraabdominal organs). Cricoid pressure must be
maintained during inhalation. The use of medications for rapid-sequence intubation is not well studied;
however, no absolute contraindication exist.

BREATHING

Auscultate at the axilla and apex of both lungs. The diaphragm is push higher as pregnancy advances.
This is particularly true in the supine position. Breath sounds may not be present in lower chest as they
are in a nonpregnant patient. If a chest tube is placed, enter the chest 1 or 2 interspaces higher than
usual so that the diaphragm is not desaturation can be very rapid.

Physiologic changes in advanced pregnancy include increased tidal volume, and minute ventilation but
not tachypnea. This should be interpreted as a sign of respiratory distress. Functional residual capacity is
decreased which alters pulmonary reserve. Oxygen desaturation can be very rapid.

CIRCULATION

Resuscitate the patient with warmed crystalloid (and blood as appropriate) administered through large-
bore catheters placed for intravenous sites above the diaphragm, because as the relative hypervolemia
of pregnancy allows for a 30—35% loss of volume before hypotension develops. During hemorrhagic
shock maternal blood volume is supported by uterine vasoconstriction at the expense of fetal blood flow
and may result in fetal distress. Therefore, tachycardia and hypotension are late signs of maternal
hemorrhage. It is prudent to resuscitate these patients until their circulatory status is more precisely
assessed. The supine hypotensive syndrome can occur in women in the second half of pregnancy due to
the large uterus that compresses the inferior vena cava and the bifurcation of the iliac veins. This
reduces the return of preload to the heart. As earlier mentioned in the emergency department care,
rotating the patient’s right side upward 15-20 degrees and manually displacing the uterus to the left can
reverse the supine hypertensive syndrome. Patients who are in spinal immobilization can be left on the
backboard with the cervical collar in the entire contraption can be elevated on the right side.
Disability

A quick neurological examination includes Glascow coma scale, papillary reactivity and the presence or
absence of movement in all four extremities. Glascow coma scale determines the mental status, injuries
to the brain can be lateralized by the papillary examinations. The level of spinal cord injury is
determined by the combination of motor and sensory findings on physical exam. Spinal cord injuries at
any level will mask important physical finding in the abdominal and obstetrical examination.

EXPOSURE

The patient must be completely exposed so that all injuries can be identified. Prevention of hypothermia
is through the use of droplights, blankets and warned intravenous fluids.

SECONDARY SURVEY
A detailed, meticulous physical examination of the mother is performed during the secondary survey.
This is also the start the fetus is assessed. Laboratory and imaging studies are ordered at this particular
time. The patient usually receives medications as required. Perform a complete examination of
neurologic, cardiac and pulmonary systems.

ABDOMEN

In examining the abdomen, inspect for eechymoses, especially across the lower abdomen which may
indicate a possible seatbelt injury, palpate for uterine contractions or tenderness. Gestational age can
be estimated by the size of the gravid uterus. In general, when the fundal height reaches the umbilicus,
gestational age can be estimated at 20 weeks. Once above the umbilicus, the fundal height in
centimeters measured from the symphysis pubis correlates well with gestational age. This is a crucial
information in clinical decision making.

FETAL DISTRESS

Maternal injuries must be rapidly identified and surgically addresses. If the pregnancy is 24 weeks or
more (age of viability), simultaneous emergency caesarian section must be performed. If the pregnancy
is less than 24 weeks, intensifying resuscitation and addressing maternal injuries treats fetal distress.
Caesarian section is not recommended on such an immature fetus because. The survival is poor.

PELVIS AND VAGINAL EXAMINATION

Evidence of pelvic fracture or instability must be identified. The pelvic ligaments soften as the pregnancy
progresses. Pelvic relaxation can result in widening of the pubis that mimics diastasis. Identify point
tenderness in this area as a marker for acute injury. Do not perform pelvic rock (preferably OB should
this procedure)

The presence of blood or amniotic fluid in the vagina, cervical tenderness and uterine contractions are
serious findings that must be communicated to the obstetrical team immediately.

STERILE SPECULUM EXAMINATION BEFORE BIMANUAL EXAMINATION

-perform these in the absence of vaginal bleeding
-test the fluid for and ph and ferming. A ph of 7 indicates amniotic fluid. Vaginal secretions are more
acidic, with a ph around 5.
-examine for vaginal lacerations and fragments in the vagina, which signify an open pelvis fracture.

EVALUATION FOR POSSIBLE DOMESTIC VIOLENCE

-ecchymoses of breast, abdomen, and upper extremities may be present
-injuries at more than one site in varying stages of healing may be observed.

LABORATORIES
CBC, blood chemistry, PT/PTT and blood type are commonly ordered for trauma patients, CBC may show
a reduced hemoglobin and hematocrit. This “anemia of pregnancy” is seen in the second and third
trimesters. It is caused by a disproportional expansion of the plasma volume compared to the red blood
cells. Hemoglobin less than 11g/dl is abnormal. Pregnancy-induced leukocytosis peaks to level of 12,000-
18,000/cuml. during the third trimester. During labor, levels as high as 25,000/cuml may occur. PT/PTT
should be normal.

Rhesus (Rh) blood group determination (administer RhoGAM if the mother is Rh negative).

All injured female patient of child-bearing age should have a routine pregnancy test.

IMAGING STUDIES

-radiologic examinations must be interpreted in the context of pregnancy-related changes. In chest x-

rays- increased AP diameter, mild pulmonary vascular cephalization, cardiomegaly, and a slightly
widened mediastinum are seen in normal pregnancy. Similarly, pelvic radiographs show normal
widening of the sacroiliac joints and symphasis pubis.

-all necessary x-rays should be obtained. Radiologic examinations should not be deferred because of the
presence of the fetus. A missed maternal injury is more likely to have a negative effect on the fetus than
the judicious use of diagnostic x-rays. Data about injury to the fetus secondary to diagnostic radiology
are only suggestive. The 3 primary concerns are the following:
• Radiations-induced cancer
• Loss of viability
• Radiation-induced malformation

-Usually, the adverse effects are not expected until the dose is in the 50-100 mGy (mGy= 0.1 rad). The
table below shows the estimated fetal exposure for various radiographic studies.

Examination type Estimated fetal dose per exam (rad)

Plain film
Cervical spine 0.002
Chest (2 view) 0.00007
Pelvis 0.040
Thoracic spine 0.009
Lumbosacral spine 0.359
CT scan (10 mm slices)
Head <0.050
Chest <0.100
Abdomen 2.60
 - Abdominal trauma should be initially evaluated by ultrasound. If CT scan is required the spacing
of cuts passing through the uterus should be increased to 1 cm.

TOXICOLOGY SCREENING

D- dimer testing helps in determining the course of action for placental abruption.

CARDIOTOCOGRAPHIC MONITORING

- Monitoring begins at 20-24 weeks of gestation

- Fetal distress maybe the first sign of maternal hemodynamic compromise because the mother
will maintain her vital signs by shunting blood away from the relatively low-resistance uterus.
- A minimum of 4-6 hours of monitoring is suggested, even after minor abdominal, to identify
patients that might experience placental abruption. This is because clinical signs and symptoms
of abruption such as vaginal bleeding, abdominal pain and tenderness, and uterine tenderness,
are often absent.

ELECTROCARDIOGRAPHY

- The ECG may change as the diaphragm elevates

- It may show a left-axis deviation with flattened T- waves and possibility a Q wave in leads III and
a VF
- Do not mistake these changes for the ischemic or traumatic changes in blunt chest trauma.

MEDICATIONS

• Medication safety is a common issue in the treatment of patients who are pregnant. The most
common medications administered to trauma patients are analgesics, antibiotic and tetanus
toxoid.
• Analgesics like morphin and meperidine have been used for many years and possess a good
safety profile. If necessary they can be reversed with naloxone.
• Second and third generation cephalosporins are safe and effective against the most common
organisms encountered in a trauma situation.
• Tetanus toxoid and tetanus immune globulin are safe and should also be administered when
required.

MANAGEMENT IN THE OPERATING ROOM

• Prepare the operating room as you would for a major trauma case
• The abdomen should be entered through a midline incision. This will allow the uterus to be
moved from side to side and all quadrants to be exposed.
 • If a caesarian sections needs to be performed, a transverse uterine incision can be made using
the exposure provided by the midline abdominal incision.
• If the pregnancy is less than 24 weeks gestational age, uterine injuries should be directly
repaired and expectant management exercised. There is no need to evacuate the uterus when
fetal death is present. Spontaneous delivery will usually occur within 24-48 hours.
• Hysterectomy is indicated only when the pelvic and uterine vascular structures are beyond
repair.
• If the pregnancy has advanced beyond 24 weeks, obstetrical and neonatal support should be
immediately available. The development of fetal distress may require caesarian section and
resuscitation of the infant.
• Occasionally the fetus is injured too. A second surgical should be assembled to manage the
newborn’s injuries.

OTHER PROCEDURES

- Perimortem caesarian section

• Perform this within 4 minutes to facilitate rapid developing of the fetus
• Use of large incisions to facilitate rapid developing of the fetus
• Perform a midline incision
• Open the uterus using a midline vertical incision thru the upper uterine segment

NEUROTRUMA EMERGENCY MANAGEMENT

Basic Care and Interventions

HEAD TRAUMA PATIENT

HISTORY TAKING VITAL SIGNS AND PHYSICAL EXAMS ABC’s of Resuscitation

(Note: If above maneuvers can be done almost simultaneously by the ER Surgeon on duty together with
the ER Staff (Interns/Nurses), then it would be beneficial to patient on such an urgent and emergent
situation).

HISTORY: T ime/ Date of Injury

Manner of Injury
Place of Injury

Others: + / - loss of consciousness, vomiting, nausea, dizziness

+ /- hx of alcohol intake esp in vehicular accident (va) patients
Accompanying medical conditions (esp if elderly)
If patient is transferred from another institution, interview particular manner how he was
Handled and managed.

VITAL SIGNS AND PHSICAL EXAMINATIONS:

I General Physical Condition

A. Visual Inspection of the cranium-----? Basal Skull Fracture

* Raccoon’s eyes or periorbital ecchymoses
* Battle’s sign or post auricular eccymoses
* CSF rhino / otorrhea
* hemotympanum / laceration of external auditory canal

---? Facial Fractures

*Lefort, orbital rim------palpate for instability
--? Periorbital edema, proptosis
--? Lacerations of the scalp----close
Temporarily heavy bleeders, may need to
debride later inside the OR

A Cranio-cervical auscultation
Bruit over carotids – carotid dissection
Bruit over globe of eye – traumatic carotid caverneous fistula
B Physical signs of spine trauma – cervical, thoraco lumbar
C Presence or absence of seizure episodes

II. Neurologic Exam

A. Cranial Nerves
Pupils – check size ambient light/reaction to light
+/- anisocoria (rule out afferent papillary defect by doing swinging flashlight test, can be
possible optic nerve injury)
Optic Nerve – if conscious – can test vision with a Rosenbaum near vision card or printed
material, if not then counting fingers or hand motion or lastly light perception

Facial Nerve_ facial asymmetry

Funduscopic exam – check for papilledema, preretinal hemorrhages

B. level of Consciousness
- Glasgow Coma Score (see table I)
- Orientation (place/time/person) if patient able to communicate

C. Motor Exam
- If cooperative, check motor strength of all extremities (nail beds)
*differentiate withdrawal of extremities from posturing

D. Sensory Exam
Cooperative Patient- pinprick on trunk, 4 extremities
-touch-C4,C6,C7,C8,T4,T6,T10,L2,L4
L5,S1, sacrococcygeal
-joint position sense of lower extremities
Uncooperative - central response (vocalization or grimace) to noxious
Stimuli (apply to supraorbital ridge or nipple)
Vs peripheral response- flexion/withdraw

E. Reflexes - deep tendon reflexes-if patient is not restless

(if + DTRs then flaccid limb indicates CNS injury and not nerve root injury)
-Babinski/Clonus
Anal wink and Bulbocavernosus reflex

QUICK SUMMARY (Categorization of head Injury)

Mild- CGS 14-15- Recommndation:

CTScan if
- + LOC History
 - + Skull Fracture
- + deficits
- + History of Alcohol or drug in take
- Elderly

Moderate GCS 9-13 CTScan (plain)

Severe GCS less than or equal to 8

Detailed Clinical Categorization of Risk for I.C. Injury

Low Risk for I.C Injury can be:

➢ Asymptomatic or headache, dizziness, scalp hematoma, laceration, contusion or scalp/ patient

abrasion, no moderate nor high risk criteria present.
➢ Excludes patient with loss of conciousness
➢ Recommendation
- Observes at home with written head injury instruction (see Table II)
- CTScan at this point not usually indicated unless requested or medico legal
- Skull X-Ray may be done to see if it +/- fracture
- Linear non-displaced skull fractures may require overnight in hospital observation and CTscan
especially if readily available

Moderate Risk for Intracranial Injury

Finfings: -history of : change in or loss of consciousness on or after injury

: progressive headache
: alcohol or drug intoxication
: vomiting
: post-traumatic amnesia
: suspected child abuse
: less than two years of age
: post-traumatic seizure
: unreliable/ inadequate history

- PE : signs of basilar skull fracture

: multiple trauma
: serious facial injury
: possible skull penetration
: depressed fracture
: significant subgaleal swelling

➢ Recommendations:
 A. Brain CTScan (plain)
B. Skull X- Ray not recommended unless CTScan not available. Usefull normal, if positive fracture,
refer to neurosurgery
C. Observation
1 At home
- Criteria
- Normal CTScan
- Initial GCS more than equal to 14
- No high risk criteria
- No moderate risk criteria except loss of consciousness
- Patient is now neurologically intact (amnesia for event acceptable)
- A responsible, sober adult is availab;e to monitor patient
- Patient has ready access to hospital/ ER if needed
- No “complicating” circumstances (child abuse history, domestic violence)
NOTE: give discharge instructions (see Table II)
1. In Hospital
- To monitor for neurodeterioration especially if CTScan not available

High Risk for I.C Injury

➢ Findings:
- History of depressed level of consciousness not clearly due to alcohol, drugs, metabolic
abnormalities, post-ictal, etc.
- P.E
• Focal Neuro Findings
• Decreasing level of consciousness
• Penetrating skull injury or depressed fracture
➢ Recommendations:
A. CTSCAN- admit and refer to neurosurgeon or neuro specialist if available
B. Medical decompression
I Mannitol in ER
- Indications
i. evidence of intracaranial hypertension (unilateral or bilateral papillary dilatation, asymmetric
pupillary reaction to light, decelebrate or decorticate posturing, progressive neuro
deterioration)
ii. evidence of mass effect (ex. Hemiperesis)
iii. Sudden deterioration prior to CT /9including papillary dilatation)
iv. After CT, if a lesion is present that is associated with increased ICP (Intracranial pressure)
v. After CT, if going to OR
vi. To assess “ Salvageability” in patients with no brainstem function, watch out for possible
return of brainstem reflexes
- Contraindications of Mannitol:
vii. Hypotension/hypovolemia
 viii. Prophylactic use NOT recommended – (see indications)
ix. Relative contraindication- may impede coagualtion’
x. Congestive heart failure patients/use with cautions
- Dosage: 0.25- 1 gram per kilo over less than 20 minutes (per average adult = 350 m.l. of 20%
solution). Peak effect = 20 minutes

II. Clinical supportive measures:

- normovolemia, normotensive patient
• Fluids – usually .9 NSS
• Concept of “running patient drt” is obsolete
- Head elevation -30 degrees
- Oxygen support
- Dexamethasone in head injury not indicated at this point unless for spinal chord trauma
- Anti – epileptic drugs
• In patients with seizure within first 24 hours after injury
• GCS less than 10
• Penetrating brain injury
• Open depressed skull fracture with parenchymal injury
• History of significant alcohol abuse
• On CTScan –positive acute subdural, epidural, or intracerebral hematoma
- Positive cortical contusion
C. Intubation and hyperventilation
Indications in Trauma:
I. Depressed Level of consciousness, GCS less than or equal to 7
II. Need for hyperventilation- brief use only (do not use when pCO2 <30 mmHg, can reduce
cerebral blood flow)
III. Severe maxillofacial trauma, may consider
Cricothyroidotomy if can not do nasotrachial or orotracheal intubation.
IV. For pharmacologic paralysis/ controlled breathing/ assisted verntilation

Cautions:
- If patient has possible basal skull fracture
- Prevents assessment of patient’s ability to verbalize
TABLE I: GLASGOW COMA SCALE (recommended for age more than or equal to 4
years)

Points Best Eye Opening Best Verbal Best Motor

6 (-) (-) Obeys commands
5 (-) Oriented Localiz pain
4 Spontaneous Confused Withraw to pain
3 To speech Inappropriate Decorticate (fexion)
 2 To pain Incomprehensible Decerebrate
(extension)
1 none none none

TABLE II: DISCHARGE INSTRUCTIONS FOR PATIENTS for observation (subdural precautions)

Seek medical attention if:

- Change in level of consciousness, increased sleeping time
- Abnormal behavior
- Increased headache
- Slurred speech
- Weakness/ numbness in arm/leg
- Persistent vomiting
- Enlargement of one or both pupils which does not get smaller even when a bright light
shone on it
- Seizures/ convulsions
- Increase in swelling at sight of injury

Note: do not take sedatives, pain medicines stronger than paracetamol for 24 hours. Do not
take aspirin or anti- inflammatory medications

Preparations
1. Explain the procedure, if patient is conscious
2. Assure patent airway
3. Assure optimal oxygenation and ventilation
4. Assure IV access
5. Apply pulse oximeter, ECG and blood pressure device
6. Assemble all equipment and ensure proper working order
7. Prepare the endotracheal tube
a. Check cuff integrity by inflating and fully deflating
b. Insert lightly lubricated stylet into endotracheal tube, bend to configuration
predicted to assist glottis entry
c. Apply water-soluble lubricant to the cuff end of the tube

8. Connect laryngoscope blade to handle

a. Blade selection
1.) Straight blade- used to elevate epiglottis anteriorly
2.) Curved blade –inserted into the vallecular
b. Select blade length -#3 blade is proper unless patient’s neck is very long
 c. Assure that the light from the bulb is light
9. Don gloves, mask, eye protection
10. Place pad or tower under occiput if cervical injury not suspected
11. Topically aneesthesize the patient
12. As necessary, proceed with sedation and neuromuscular blockade

Technique for Orotracheal Intubation

1. The operator stands at the head of the bed or stretcher. The bed or stretcher is raised to
a position of comfort for the operator. The head of the bed may be flat or raised slightly
per operator preference.

2. When no cervical injury is suspected, a small pad is placed under the occiput (the
“sniffing” position) and the neck is gently extended. When cervical spine injury is
possible, these steps are omitted and the neck is stabilized by an assistant and the
anterior portion of the cervical collar is removed.

3. Regardless of the operator’s dominant hand in other contexts, the laryngoscope is

always held in the left hand.

4. Cricoid pressure should be gently but firmly applied by an assistant and sustained until
the endotracheal tube is positioned and its cuff inflated.

5. Mouth opening in the sedated/relaxed patient may be assisted by a “cross-finger”

technique wherein the thumb of the right hand is placed on the front lower teeth of the
mandible and the first finger on the front upper teeth (maxilla). The mouth is gently
opened by a “reverse-scissor”movement of the fingers and the laryngoscope is
introduced into the mouth.

6. Insert tip of laryngoscope blade into the right side of the patient’s mouth; advanced the
blade to the base of the tongue.

7. Sweep the tongue to the left proper tongue control is key to laryngeal visualization.

8. Gently advance the blade further to its proper position. A straight blade is placed
beneath the epiglottis; curved blade is placed into the vallecular above the epiglottis.

9. Traction should be applied only along the long axis of the laryngoscope handle as the
laryngoscope lifts the tongue upward away from the larynx, revealing the glottis
opening. A rocking or rotating motion of the laryngoscope blade should never contact
the upper teeth.
 10. Visualize the vocal cords and glottis opening

11. Gently insert the endotracheal tube through the vocal cords, holding the tube/stylet
with the right hand. The stylet, if angled, may interfere with passage of the tube into the
trachea. If resistance is encountered as the tube is advanced, consider having an
assistant remove the stylet while the operator holds the endotracheal tube firmly in the
glottis opening.

12. Carefully remove stylet and laryngoscope. The operator must continue to firmly hold the
endotracheal tube; position the tube such that the external centimeter length msrkers
on the tube show 21 to 22cm adjacent to the front teeth.

13. Inflate cuff.

14. To ensure proper position of the tube:

a. Inspect and auscultate chest to assure equal bilateral air entry

b. Use CO2 detector
c. Observe for consideration in the endotracheal tube during exhalation
d. Listen for breath sounds through the endotracheal tube as the patient is breathing
spontaneously
e. Obtain chest x-ray (tube tip should be 2-3 cm above carina)

15. Secure endotracheal tube with tape

Pediatric Considerations

A. Anatomic differences between adults and children

1. Larynx is more anterior and cephalad in infants than in adults, making visualization during
laryngoscopy more difficult
2. Cricoid pressure is valuable during laryngoscopy because of the position of the larynx, and
assists in preventing aspiration
3. In young children, the narrowest part of the airway is at the level of the cricoid cartilage, not
at the larynx, making an anatomic “cuff” below the vocal cords
4. In general, the diameter of a small finger approximates the properly sized endotracheal
tube. A full- term neonate can accept a 3.5mm inner-diameter tube.
 5. Cuffed tubes are therefore usually limited to use in children >8 yrs old v (endotracheal tube
size >6.0 –mm internal diameter), uncuffed tubes are generally used in younger children

B. technique differences between adults and children

1. Head position: a towel roll under the head is often needed in adults to achieve the “sniffing”
position; a shoulder roll in usually needed to achieve this position in infants.
2. Laryngoscope blade selection: choice of straight or curved blade is indivisual; however, most
clinicians do not use curved blades in infants. A common mistake in intubating a child is
choosing a blade that is too small. The blade must be long enough to reach the epiglottis.
3. Proper depth of insertion in centimeters can be estimated by multiplying the internal diameter
of the endotracheal tube by 3, e.g., internal diameter = 4.0, depth of insertion = 4.0 x 3 = 12.0
cm
4. Appropriately sized equipment (e.g. face mask, laryngoscope, endotracheal tubes, suction
catheter) should be used

C. Precautions/complications
1. Hypoxia, hypercapnia during procedure
2. Cardiovascular compromise during procedure
3. Damaged teeth, lips, gingiva
4. Malpositioned tube (esophagus, right mainstream bronchus)
5. Pharyngeal, laryngeal and aspiration of gastric contents

INSERTION OF PERIPHERAL INTRAVENEOUS LINE

PROCEDURE

1. Gather all equipment needed.

2. Explain procedure to patient/parent.
3. Wash hands with antiseptic soap. Don gloves
4. Apply the tourniquet above insertion site
5. Disinfect the selected site eith skin prep and allow to dry
6. Inspect the cannula before insertion to ensure that the needle is fully inserted into the plastic
cannula and that the cannula tip is not damage.
 7. Ensure the bevel of the cannula is facing upwards. This will facilitate piercing of the skin by
the bevel
8. Insert the needle and the cannula into the vein. Gentle traction on skin may stabilize the vein
under the skin.
9. Partially withdraw the needle and advance the cannula
10. Release the tourniquet
11. Secure the hub of the cannula with clean adhesive tape. Do not cover the puncture site.
12. Flush the cannula with normal saline. This will ensure the line is patent and accessible.
13. Cover the intravenous and surrounding area with a sterile transparent dressing. This will
ensure that the insertion site are visible for inspection purposes.
14. Prime the line end and connect the intravenous set to the cannula.
15. If the site needs to be immobilized, used a well padded splint and strapping if necessary.
16. Dispose of equipment safely.

SURGICAL CRICOTHYROIDOTOMY

What are the indications for a cricothyroidotomy?

• Inability to intubate the trachea is a clear indication for creating a surgical airway
This may be due to:
o Edema of the glottis
o Fracture of the larynx
o Severe oropharyngeal hemorrhage
• Creating an emergency airway where equipment is lacking.

1.1 Needle Cricothyroidotomy

How is this procedure performed?

1. Ensure a free flow tubing of oxygen. Cut a hole toward the end of the tubing
2. Place patient in a supine position
3. Assemble a 12 or 14 gauge over the needle catheter to a 5 ml syringe
4. Surgically prepare the neck using antiseptic swabs
5. Identify the cricothyroid membrane, between the cricoid cartilage and the thyroid cartilage.
Stabilize the trachea with the thumb and forefinger of one hand to prevent lateral movement of
the trachea during performance of the procedure.
6. Puncture the skin in the midline with the needle attached to the syringe, directly over the
cricothyroid membrane. A small incision with a no 11 blade may facilitate passage of the needle
through the skin.
7. Direct the needle at a 45- degree angle inferiorly, while applying negative pressure to the
syringe and carefully insert the needle through the lower half of the cricothyroid membrane.
8. Aspiration of air signifies entry into the tracheal lumen.
9. Remove the syringe and withdraw the needle while advancing the catheter downward into
position, being careful not to perforate the posterior wall of the trachea.
 10. Attach the oxygen tubing over the catheter needle hub.
11. Intermittent ventilation can be achieved by occluding the open hole cut into the oxygen tubing
with your thumb for one second and releasing it for four seconds. After releasing your thumb
from the hole in the tubing, passive exhalation occurs.

Identify the following structures on the wet specimen

A= Thyroid cartilage B=Cricoid cartilage C=Cricothyroid membrane

Make sure you can identify the entry site of the needle through the cricothyroid membrane. Identify this
on yourself and on your colleague.

It is highly unlikely to injure the thyroid gland due to the position of the isthmus over the second and
third tracheal cartilages. Be careful in the case in the case of an enlarged thyroid gland. However, in 40%
patients a pyramidal lobe is found running up the arterior midline of the neck, which may be injured.

Note that these structures may be perforated when advancing the needle too far posteriorly.

1.2 Surgical cricothyroidotomy

How is this procedure performed?

1. Place the patient in a supine position with the neck in a neutral position. Palpate the thyroid notch,
cricothyroid interval, and the sternal notch for orientation. Assemble the necessary equipment.
2. Surgically prepare and anaesthesize (if there is time) the area, id the patient is conscious.
3. Stabilize the thyroid with the left hand.
4. Make a transverse skin incision over the cricothyroid membrane. Carefully incise through the
membrane.
5. Insert the scalpel handle into the incision and rotate it 90 degrees to open the airway.
6. Insert an appropriately sized, cuffed endotracheal tube or tracheostomy tube into the cricothyroid
membrane incision, directing the tube distally into the trachea.
7. Inflate the cuff and ventilate the patient.
8. Observe lung inflation and auscultate the chest for adequate ventilation
9. Secure the endotracheal tube to the patient to prevent dislodging.
10. Caution: Do not cut or remove the cricothyroid cartilage.

Identify the following structures

A=Vocal cords B=Cricothyroid membrane C=Cricoid cartilage

Identify A and B

Note the relationship of the entry site of the endotracheal tube and the vocal cords.
Advancing the tube superiorly may injure the vocal cords.
A subglottic stenosis is mentioned to be a complication of this procedure. This is understood when
realizing that the entry site is inferior to the glottis.

Cellulitis of the area may spread rapidly across the neck. Mediastinal emphysema is also mentioned as
complication of the procedure. Try to explain this anatomically by referring to the pretracheal fascia.

Identify C

Care must be taken especially with children to avoid damage to this structure. Why?

It is the only circumferential support to the upper trachea.

MAXILLO FACIAL TRAUMA

The British Association of Oral and Maxillofacial Surgeons carried out recently the first prospective
national accident and emergency based survey of facial soft tissue injuries and structures population of
40 million. From these data it was estimated that about 500 000 people suffer facial injuries annually, in
the UK, 125 00of them in assaults. Many of these assaults affect teenagers and young adults and are
associated with alcohol consumption by either the victim or the assailant (61% of cases in the survey).
Among 15-25 year olds almost half the facial injuries were sustained in assaults, usually I bars or nearby
streets, and 40% of these resulted in injury that necessitated specialist maxillofacial treatment.

In the US there is a higher incidence of blunt and penetrating trauma from motor vehicle accidents; and
very much higher incidence of penetrating gunshot wounds to the head and neck; however; any busy
trauma center will see a high volume of facial trauma cause by an extraordinarily wide variety of
mechanisms.

In the Philippines, no published prospective study has been undertaken. At the Western Visayas Medical
Center and other hospitals in Iloilo City, we see a rising trend of facial fractures in the last five years.

ASSESSING THE PATIENT

Patients who figure in high impact velocity collision sustain multiple facial – head & neck injuries aside
from bodily injuries. The quick assessment of these patients should be through so as not to leave any
fracture untreated within the golden period of surgical intervention.

The basic tenets of trauma management of ABC hold true for maxillofacial trauma.
FIRST: You must secure the AIRWAY. Evaluate the usual ABC’s get reports from initial care providers
than exercise your own judgment about the state of the patient.

The following are the important questions we need to answer before any intervention is applied:
• Is the victim awake, alert and cooperative or unconscious/obtunded?
 • Are there extensive injuries requiring immediate resuscitation?
• How about the need for elective and corrective surgery or isolated facial injury for elective
patient?
• Is there a possibility of C-spine injury or close head injury (mechanism of trauma)?
• Is the victim scheduled for ‘STAT” or ‘elective” surgery? What procedures? Is general anesthesia
required? If regional technique are planned, is airway security an issue?

The rapid development of facial edema obscures the pupils and obstructs the upper airway. There is a
need for early airway control and neurologic assessment of the head injured trauma patient, because –
eyes and lips are the “shock organs” of the face and develop edema rapidly after blunt facial trauma.

Evaluate the pupils, look for lateralizing neurologic abnormalities and accurately assess the level of
consciousness of the patient while securing the airway of the trauma patient with facial injuries.
Changes in the level of consciousness, pupil size and development of clinical signs of intracranial
hypertension, i.e., hypertension, bradycardia, and irregular breathing patterns, must be documented,
“assume the worst until proven otherwise.”
Ask yourself:
• Is the victim cyanotic, apneic, dyspneic, dysphoric, or agitated?
• Are accessory muscle being recruited?
• Is the victim leaning forward, drooling blood, gagging, wheezing, gasping, or choking?
• Is the victim supine and likely to aspirate blood or vomitus at any moment?
• Can the mouth be opened, the neck extended, the tongue and uvula visualized?
• Are there lacerations to the larynx, dislodged teeth, clots of blood in the mouth?
• Is direct laryngoscopy feasible or do you anticipate need for fiberoptic?
• Are there relative contraindications to an awake intubation? (victim already asleep, intoxicated,
irrational or psychotic?
• Do you have to act immediately?

EVALUATE THE INJURIES: Soft Tissue vs. Bone Fractures

Significant bone trauma can co- exist with only modest soft tissue injury, similarly, dramatic soft tissue
injury may occur in the absence of facial fractures. Mandible fractures will typically involve the ramus; a
bilateral fracture may mobilize a bone segment and result in impaction or the upper airway. The force of
impact may be transmitted to the condyle or directly to the TMJ, making the mouth difficult to open.
Zygomatic arch fractures may similarly affect jaw opening thus complicating tracheal intubation.
Chemical, electrical or flame burns can cause extensive tissue damage to the face and also to the airway;
edema and tissue sloughing can result in difficult spontaneous breathing and can also greatly complicate
airway management.

Facial fractures ( LeFort classification)

LeFort ONE: Maxilla (Guerin); LeFort TWO (pyramidal): Midface; LeFort THREE (Craniofacial
Dysfunction): Separation of midface from cranial skeleton (which may lead to shear injury of the base of
the brain, and will generally represent an absolute contraindication for nasal intubation, naso- gastric
tube placement or even for aggressive mask ventilation until evaluation by radiology or Maxillofacial
Surgery service).

MANDIBULAR FRACTURES

The mandible is reportedly the most commonly fractured bone in facial trauma. The injury is found
predominantly in males in the 20 to 30 year old age group and occurs with highest frequency in the
summer months. The mandible is composed of a thick outer plate of bone and a compact inner plate of
cortical bone separated by trabeculated medullary bone. The mandible is divided into the alveolar tooth
– bearing process, the symphysis, the body, the angle or gonion, the ramus, the coronoid, and the
condylar processes. The inferior alveolar nerve enters at the mandibular foramen and exits at the adult
teeth which are numbered according to the ADA universal classification system. The upper right third
molar is #1, the upper left #16, lower left third molar #17, lower right third molar is #32.

Occlusion is classified according to angle’s system, which is based on the relationship of the retrobuccal
cusp of the upper first molar to the buccal groove of the lower first molar. In normal class I occlusion,
the mesiobuccal cusp of the maxillary first molar occludes exactly with the mandibular first molar buccal
groove. In class II occlusion the mesiobuccal cusp is mesial or anterior to the mandibular first molar
buccal groove. An overjet of more than 4mm creates a “buck tooth appearance. In class III occlusion,
the mesiobuccal cusp is distal to the buccal groove. The incisors are either edge to edge or with a
negative overjet. The anatomic distribution of fractures varies with etiology. Condylar and subcondylar
fractures make up 26% to 36%; angle fractures 20% to 26%; symphyseal and parasymphyseal fractures,
14% to 23%, 11% to 21% ramus, 25 to 3% and coronoid fractures,1 to 2%.

Fractures are often termed favorable or unfavorable depending on their tendency towards distraction
by masticatory musculature. A horizontally unfavorable fracture is one directed anterior superior to
posterior inferior. The posterior fragment of the mandible will be pulled cephalad by the musculature
causing distraction of the fracture segments. If the fracture was directed anterior inferior to posterior
superior, the cephalad pull the musculature will squeeze the fragments together making this favorable
fracture. A vertically unfavorable fracture is one directed anterior medial to posterior lateral. The
mylohyoid pills the posterior segment medially causing distraction.

A fracture running anterior lateral to posterior medial is squeezed together by the medial pull of the
mylohyoid. The treatment of mandible fractures can be divided into open and closed techniques.
Referral to the ENT specialist is mandatory as soon as the patient is assessed at the emergency room.

EVALUATE THE INJURIES – BLUNT vs PENETRATING TRAUMA

Blunt trauma is commonly seen in cases of assault, falls, traffic accidents and work-place injury,The
classic penetrating injury of the face is the gun-shot wound, but also often results from motor vehicle
accidents. Penetrating injuries will frequently involve bleeding, loss of skeletal support fragmentation of
teeth and bone, and extensive tissue swelling; ability to ventilate may be seriously affected and normal
anatomical ladmarks may be obliterated, making airway assessment and definition very problematic.
Blunt trauma may appear to involve less facial rearrangement but airway definition may be even more
difficult in cases of severe mid-face trauma.

Blunt trauma causing extensive facial injury should alert you to the possibility of concomitant cervical
spine injury and closed head injury. There may be spinal fractures or dislocation; there may be cerebral
contusions or intracranial hemorrhage; it is difficult to assess sensory and motor deficits in unconscious
patients. Until the spine is cleared formally exercise appropriate caution and avoid all manipulation of
the neck; consider the necessity for head CT or placement of intracranial pressure monitors prior to
surgery under anesthesia.

ESTABLISH A PLAN OF ACTION

Do you need to define the airway now, if so how are you going to proceed? What resources will you
need? If the airway is patent and the patient is ventilated effectively, then you can move on the
establish a plan for surgical anesthesia; most maxillofacial surgery will necessitate tracheal intubation.

MANAGE THE AIRWAY

Conscious patients are usually able to control their own airway; make a very careful analysis of the
situation before inducing unconsciousness. If the upper airway is closed or obliterated and you feel that
intubation is likely to be difficult and time-consuming you probably have to move immediately to a
surgical airway. Even cricothyrotomy or laryngeal jet ventilation can be very difficult with a struggling
patient. Don’t attempt emergent tracheostomy unless you are highly skilled in the maneuver. It may be
possible to open the airway simply be applying a jaw thrust, or applying traction to the mandible but
unless this attempt is immediately successful proceed to surgical airway. If the circumstances are not so
dire then establish a rational plan for securing the airway transorally. Consider the feasibility of direct
laryngoscopy and the need for fiberoptic devices and associated airway anesthesia.

The need to consult the ENT/otolaryngologist and Anesthesiologist are of paramount importance at this
stage! Call for skilled assistance, make sure you have adequate equipment (suction, oxygen, ventilation
device etc.) Emergencies are not good opportunities for trying out novel techniques, stick to what you
know. If the airway is lost, all other resuscitative intervention are futile.

Mask ventilation has only limited use in facial trauma; there are constant problems attaining
appropriate seal and adequate airway opening without applying pressure to fracture sites or extending
the cervical spine. There is always the risk of forcing blood or bile into the lungs, air into the stomach (or
even into the subdural space). It is far better to define and protect the airway definitively. The
anesthesiologist follows the ASA algorithm for airway definition – it’s there to help and will stop you
from inadvertently burning bridges!
DIRECT LARYNGOSCOPY can be impossible, or unwise in certain circumstances, but generally offers
the most rapid route to the establishment of a secure, protected airway. Consider this approach first,
then think of relative or absolute contraindications before proceeding. DL invariable involves muscle
relaxation (induced or intrinsic), hypnotic induction and re-alignment of the airway; these can all be
profoundly dangerous in cases of extensive maxillofacial trauma. Again burn no bridges and plan your
escape routes in the event of trouble.

FLEXIBLE FIBEROPTIC BRONCHOSCOPE [FFB]

The FFB is probably the most useful instrument in skillful hands. It allows awake intubation with minimal
distress in the appropriately reassured and medicated patient. Copious blood, bile or oral secretions can
make life difficult, as can extensive pharyngeal edema or tissue rearrangement. Even if there is a
partially occluded airway, the fiberoptic can frequently be advanced into the trachea if the patient is
spontaneously breathing, and thereby “blowing bubbles”, identifying the route from the trachea.
Consider simultaneous mask ventilation during fiberoptic evaluation of the oropharynx; and note that
Venturi oxygenation (and a degree of CO2 clearance can be attained by intermittent insufflation via the
aspiration channel. Success with the technique is often dependent on the quality of airway topical
anesthesia.

RETROGRADE WIRE

Blind technique so there is a risk to using this approach in traumatized airways and in cases of extensive
midface fracture; however use of retrograde wire placement can be life-saving when going hemorrhage
makes direct visualization of airway structures impossible.

PERCUTANEOUS (TRANS-TRACHEAL) JET VETILATION

Consider this route if the airway is completely obstructed and other approaches have failed or seem
doomed a priori. Puncture the cricothyroid membrane with a 14 gauge catheter (or central line
introducer), secure the catheter confidently; connect a source of moderate-pressure oxygen (50 psi) and
institute jet ventilation by intermittently injecting oxygen for 1 second and allowing passive exhalation
for 2-3 seconds. The airway is not protected, the oxygenation source is tenuous and complications such
as barotraumas and subcutaneous emphysema are common, so this is a technique for urgent,
temporary oxygenation/ventilation, not a definitive airway.

CRICO-THYROIDOTOMY

Emergent lifesaver! Palpate thyroid notch and prominence of cricoid below it, cricothyroid membrane is
the depression above the cricoid cartilage. Make a vertical skin incision. Push into membrane scissors,
hemostat, etc. and dilate the airway opening. Endotracheal or tracheostomy tube may be placed. Once
patient is stabilized, cricothyrotomy is revised to formal tracheostomy in the operating room to avoid
the development of subglottic stenosis. Tracheostomy is an elective procedure and requires skill,
sterility and surgical equipment.

(Reference: John Bramhall PhD MD Anesthesia For Maxillofacial Trauma University Of Washington,
Seattle)

FRONTAL FRACTURES

Fractures of the frontal sinus pose certain treatment dilemmas to the facial trauma surgeon. Their
mismanagement may lead to potentially life-threatening complications, including osteomyelitis,
cerebrospinal fluid (CSF) leak, mucopyocele, meningitis, brain abscess, and cavernous sinus thrombosis.

Traditionally, these injuries were managed by a variety of medical specialists, including

otolaryngologist/head and neck surgeons, maxillofacial surgeons, plastic surgeons, and neurosurgeons,
leading to controversies in treatment protocols and decision-making and treatment modality of these
injuries.

The few series reported in the literature have relatively small numbers of subjects and, as might be
expected, mostly limited follow-up periods. Fractures of the frontal sinus pose certain treatment
dilemmas to the facial trauma surgeon. Their mismanagement may lead to potentially life-threatening
complications, including osteomyelitis, CSF leak, mucopyocele, meningitis, brain abscess, and cavernous
sinus thrombosis, traditionally, these injuries were managed by a variety of medical specialists, including
otolaryngologist/head and neck surgeons, maxillofacial surgeons, plastic surgeons, and neurosurgeons
leading to controversies in treatment protocols and decision-making algorithms. Consensus does not
exist among surgeons regarding the timing, indications, and treatment modality of these injuries. The
few series reported in the literature have relatively small numbers of subjects and, as might be
expected, mostly limited follow- up periods.

Evaluation. For purposes of initial evaluation, frontal sinus fractures should be regarded as head
injuries. The majority of these patients are victims of automobile accidents with multiple injuries
requiring a multispecialty team approach and complete evaluation.

The standard trauma protocol must be followed with emphasis on ensuring an adequate airway,
breathing, circulation, CNS status, and C-spine. Any other life-threatening injuries take precedence over
the sinus fracture. Injuries to the thorax, abdomen, and extremities are not uncommonly associated
with injury to the head and face and must not be overlooked. Appropriate consultations must be
obtained and treatment must be prioritized appropriately.

In any patient sustaining significant maxillofacial injury, the cervical spine should be suspect and should
be evaluated both radiographically as well as clinically prior to other studies or examinations requiring
hyperflexion or other manipulation in the head and neck. The c-spine should be stabilized in a cervical
collar until a cross-table lateral radiograph is obtained and demonstrates that all seven cervical
vertebrae are normal.
A thorough neurologic examination is extremely important as well as a referral to an
ENT/Otolaryngologist, significant intracranial injury occurs more commonly with injury to the frontal
sinus (12-17% of the time) than with injury to the mandible or midface due to the proximity of the
frontal sinus to the brain and the great forces required to cause a frontal sinus fracture. Neurological
consultation should be obtained promptly if abnormal neurologic studies or brain CT changes are
observed.