anesthesia for trauma...anesthesia for trauma maribeth m a s s ie, c r n a, m s staff nurse a n...
TRANSCRIPT
Anes
thes
ia f
or T
raum
aM
arib
eth
Mas
sie,
CRN
A, M
S
Staf
f N
urse
Ane
sthe
tist,
The
Joh
ns H
opki
ns H
ospi
tal
Assi
stan
t Pr
ofes
sor/
Assi
stan
t Pr
ogra
m D
irect
orCo
lum
bia
Uni
vers
ity S
choo
l of
Nur
sing
Prog
ram
in N
urse
Ane
sthe
sia
OVE
RVI
EW
•“It
’s n
ot t
he s
peed
whi
ch
kills
, it’s
the
sud
den
stop
”
Epid
emio
logy
of
Trau
ma
•~
8% w
orld
wid
e de
ath
rate
•Le
adin
g ca
use
of d
eath
in A
mer
ican
s fr
om 1
-45
yea
rs o
f ag
e•
MVC
’sle
adin
g ca
use
of d
eath
•Bl
unt
> p
enet
ratin
g•
Oft
en d
rug
abus
ers,
acu
tely
into
xica
ted,
HIV
and
Hep
atiti
s ca
rrie
rs
Epid
emio
logy
of
Trau
ma
•“G
olde
n H
our”
–Fi
rst
hour
aft
er in
jury
–50
% o
f pa
tient
s di
e w
ithin
the
firs
t se
cond
s to
min
utes
exte
nt o
f in
jurie
s–
30%
of
patie
nts
die
in n
ext
few
hou
rsm
ajor
hem
orrh
age
–Res
t m
ay d
ie in
wee
ks
seps
is, M
OSF
Pre-
hosp
ital C
are
•AB
C’S
–In
itial
ass
essm
ent
and
BLS
in t
raum
a–
GO
TEA
M:
rol
e of
CRN
A’s
at M
aryl
and
Shoc
k Tr
aum
a Ce
nter
•Res
usci
tatio
n•
Red
uctio
n of
fra
ctur
es•
Extr
icat
ion
of t
rapp
ed v
ictim
s•
Ampu
tatio
n •
Unc
oope
rativ
e pa
tient
s
Initi
al M
anag
emen
t Pl
an
•Ai
rway
mai
nten
ance
with
cer
vica
l spi
ne
prot
ectio
n•
Brea
thin
g: ve
ntila
tion
and
oxyg
enat
ion
•Ci
rcul
atio
n w
ith h
emor
rhag
e co
ntro
l•
Dis
abili
ty•
Expo
sure
Initi
al A
sses
smen
t
•Pr
imar
y Su
rvey
:–
AIRW
AY•
ALW
AYS
ASSU
ME
A CE
RVI
CAL
SPIN
E IN
JURY
EXIS
TS U
NTI
L PR
OVE
N O
THER
WIS
E•
Prov
ide
MAN
UAL
IN
-LIN
E N
ECK
STAB
ILIZ
ATIO
N•
Jaw
-thr
ust
man
euve
r
Initi
al A
sses
smen
t
•Ai
rway
con
t’d:
–Ce
rvic
al s
pine
eva
luat
ion
•Cr
oss
tabl
e la
tera
l and
sw
imm
er’s
vie
w X
ray
•N
eed
to s
ee a
ll se
ven
cerv
ical
ver
tebr
ae•
Onl
y ne
gativ
e CT
sca
n R/O
inju
ry
Initi
al A
sses
smen
t
•Ce
rvic
al s
pine
con
t’d:
–Fu
nctio
nal a
sses
smen
t of
cer
vica
l lev
el•
C5Bi
ceps
Abdu
ct s
houl
der,
Flex
elb
owC6
Wris
t ex
tens
ors
Cock
wris
tC7
Tric
eps
Exte
nd e
lbow
C8Fi
nger
fle
xors
Gra
sp f
inge
r in
pal
mT1
Fing
er a
bduc
tors
Spre
ad f
inge
rs
Initi
al A
sses
smen
t
ALW
AYS
ASSU
ME
FULL
STO
MAC
H
PREC
AUTI
ON
SRAP
ID S
EQU
ENCE
IN
TUBA
TIO
N•
Indi
catio
ns f
or in
tuba
tion:
–Ai
rway
obs
truc
tion
–Pa
O2
< 8
0 m
mH
g or
SpO
2 <
90%
with
O2
–Sh
ock
with
SBP
< 9
0 m
mH
g–
Seve
re h
ead
inju
ry o
r un
cons
ciou
s (G
CS <
9)–
Antic
ipat
ed s
urge
ry w
ith m
ultis
yste
min
jury
–Co
mba
tiven
ess
Initi
al A
sses
smen
t•
Rap
id s
eque
nce
intu
batio
n (o
r m
odifi
ed)
–Pr
eox
•U
se s
low
insp
irato
ryflo
w r
ates
(1-
1.5
sec
insp
irato
rytim
e)•
Avoi
d st
omac
h di
sten
tion
gast
ric in
flatio
n oc
curs
whe
n in
spira
tory
pres
sure
exc
eeds
EO
P (~
15-1
8 cm
H2O
)–
“Pen
t, S
ux, T
ube”
–M
ay h
ave
to d
ecre
ase
amou
nt o
f se
dativ
e dr
ugs
and
give
app
ropr
iate
dos
e of
RSI
mus
cle
rela
xant
s•
Succ
inyl
chol
ine:
1-
2 m
g/kg
•Ze
mur
on:
1.2
mg/
kg•
Vecu
roni
um:
.2 m
g/kg
Initi
al A
sses
smen
t
•Ai
rway
con
t’d:
–Rem
ove
fron
t of
C-c
olla
r an
d m
aint
ain
in-
line
stab
iliza
tion
–Cr
icoi
dpr
essu
re (
Selli
ck’s
man
euve
r) a
fter
Pe
nt g
iven
•10
# p
ress
ure
requ
ired
to s
eal e
soph
agus
–M
AC v
s. M
iller
deb
ate
Initi
al A
sses
smen
t
•Aw
ake
intu
batio
n: lo
cal,
topi
cal
supe
rior
lary
ngea
l ner
ve b
lock
s•
Awak
e fib
erop
tic:
may
be
too
bloo
dy•
Awak
e cr
icot
hyro
tom
y/tr
ache
osto
my
•G
um e
last
ic b
ougi
e/LM
A•
Know
you
r di
ffic
ult
airw
ay a
lgor
ithm
!
Initi
al A
sses
smen
t
•BR
EATH
ING
–Al
way
s ve
rify
corr
ect
posi
tion
of E
TT, e
ven
if ar
rive
intu
bate
d !!
–10
0 %
O2
–M
ay h
ave
Com
bitu
bein
; ch
ange
to
ETT
–N
asal
intu
batio
n:
wat
ch w
ith b
asila
r sk
ull
frac
ture
s
Initi
al A
sses
smen
t
•Ci
rcul
atio
n–
Cont
rol h
emor
rhag
e fir
st!
–Cr
ysta
lloid
s vs
. col
loid
s vs
. blo
od p
rodu
cts?
–Al
otor
alit
tle?
–Ea
rly o
r la
ter?
Seco
ndar
y su
rvey
•Af
ter
prim
ary
surv
ey c
ompl
ete,
att
empt
to
com
plet
e a
head
-to-
toe
asse
ssm
ent
•As
k pe
rtin
ent
ques
tions
if p
atie
nt a
ble
to a
nsw
er–
Alle
rgie
s, P
MH
//PS
H, m
eds,
ETO
H/d
rug
use,
wei
ght,
last
mea
l
Trau
ma/
preo
p as
sess
men
t•
Card
iac:
S/
S sh
ock,
EKG
cha
nges
•Res
pira
tory
: B
reat
h so
unds
, cre
pitu
s,
resp
irato
ry p
atte
rns/
dist
ress
, CXR
•N
euro
logi
c: G
CS, L
OC;
ass
ume
C-sp
ine
inju
ry u
ntil
rule
d ou
tLa
tera
l C-s
pine
Xr
ay, p
alpa
te n
eck
•Ren
al:
mon
itor
urin
e ou
tput
, am
ount
an
d co
lor
Trau
ma/
preo
p as
sess
men
t
•G
astr
oint
estio
nal:
FU
LL S
TOM
ACH
!!!!
–G
astr
ic e
mpt
ying
slo
ws
or s
tops
at
time
of
trau
ma
•En
docr
ine:
re
leas
e of
str
ess
horm
ones
(c
atec
hola
min
esan
d gl
ucos
e)•
Hem
atol
ogic
: h
ypov
olem
icsh
ock;
co
agul
opat
hies
Labo
rato
ry/d
iagn
ostic
tes
ts•
CBC,
ele
ctro
lyte
s, u
rinal
ysis
, PT/
PTT,
la
ctat
e, b
asel
ine
ABG
(as
con
ditio
n pe
rmits
); T
&C
for
at le
ast
4 un
its•
CXR, l
ater
al C
-spi
ne, C
T/M
RI
•12
lead
EKG
•FA
ST:
foc
used
abd
omin
al s
onog
raph
yfo
r t r
aum
a•
DPL
: d
iagn
ostic
per
itone
al la
vage
Anes
thet
ic m
anag
emen
t of
tra
uma
patie
nt
•Pr
eop:
Se
datio
n ra
rely
nec
essa
ry–
Vers
ed in
sm
all d
oses
(.5
-1 m
g IV
)–
Bici
tra
30 c
c pr
eop
Indu
ctio
n
•St
anda
rd m
onito
rs•
Preo
xyge
natio
n•
Basi
c ai
rway
and
diff
icul
t ai
rway
ad
junc
ts•
RSI
with
cric
oid
pres
sure
•In
vasi
ve m
onito
rs a
s in
dica
ted
Indu
ctio
n ag
ents
•Th
iope
ntal
3-4
mg/
kg;
redu
ce d
oses
in
unst
able
pat
ient
s; m
ost
com
mon
ly u
sed
in
trau
ma
•Ke
tam
ine
0.5-
1 m
g/kg
; us
eful
for
bur
n an
d hy
povo
lem
icpa
tient
s; a
void
with
hea
d in
jurie
d•
Etom
idat
e 0.
1-0.
3 m
g/kg
; re
duce
dos
es w
ith
hypo
vole
mia
; ?m
yocl
onus
effe
cts
•Pr
opof
ol 1
-2 m
g/kg
in s
tabl
e pa
tient
s; r
educ
e do
ses
in h
ypov
olem
ia
Mus
cle
rela
xant
s
•Su
ccin
ylch
olin
e:1-
2 m
g/kg
; us
eful
for
RSI
/em
erge
ncy;
con
trai
ndic
ated
in
burn
s, s
pina
l cor
d in
jury
and
cru
sh
inju
ries
> 2
4-48
hou
rs a
fter
inju
ry–
May
giv
e no
ndep
olar
izin
gdo
se p
rior
to S
ux
to in
hibi
t fa
scic
ulat
ions
(esp
. w
ith S
CI)
Mus
cle
rela
xant
s
•N
onde
pola
rizer
s–
Vecu
roni
um.2
8 m
g/kg
(25
0-30
0 m
cg/k
g)hi
gh d
ose;
ons
et in
80
secs
; du
ratio
n 75
-90
min
; go
od c
ardi
ovas
cula
r st
abili
ty w
ithou
t hi
stam
ine
rele
ase
–Roc
uron
ium
1.2
mg/
kg h
igh
dose
; on
set
45-6
0 se
cs;
dura
tion
67 m
inut
es
Mai
nten
ance
•O
2/ai
r/Fo
rane
mix
ture
•Av
oid
N2O
if a
ny q
uest
ion
of
pneu
mot
hora
x, p
nuem
ocep
halu
s,
pneu
mom
edia
stin
um, b
owel
inju
ry•
Fent
anyl
1-
10 m
cg/k
g/hr
•M
onito
r flu
ids
and
adm
inis
ter
care
fully
•Pr
epar
e to
giv
e bl
ood
prod
ucts
if
nece
ssar
y
Hyp
othe
rmia
•Co
mm
on w
ith t
raum
atic
inju
ries
and
rela
ted
proc
edur
es•
War
m a
ll IV
flu
ids
–Le
vel 1
: w
arm
s IV
F an
d bl
ood
to 4
2*C
and
deliv
ers
at 7
5-30
,000
ml/h
r–
Rap
id in
fusi
on s
yste
m (
RIS
): w
arm
s to
42*
C an
d ca
n de
liver
pro
duct
s as
bol
us a
nd v
ario
us r
ates
, up
to
3000
ml/m
in;
cell
save
r ca
n be
att
ache
d to
sy
stem
•Fo
rced
air
war
min
g sy
stem
s•
Hea
t m
oist
ure
exch
ange
rs
Emer
genc
e
•N
orm
al e
xtub
atio
n cr
iteria
•H
emod
ynam
ical
lyun
stab
le, e
lder
ly w
ith
rib a
nd lo
ng b
one
frac
ture
s, t
hose
who
ha
ve r
ecei
ved
mas
sive
flu
id a
nd b
lood
re
susc
itatio
n, s
ever
e bu
rns,
and
tho
se
with
coa
gulo
path
ies
shou
ld r
emai
n in
tuba
ted
Post
op
•M
onito
red
and
labs
fol
low
ed c
lose
ly–
Corr
ect
acid
-bas
e im
bala
nces
and
ele
ctro
lyte
di
stur
banc
es
•Lo
ng-a
ctin
g op
ioid
s•
Epid
ural
infu
sion
s•
Inte
rcos
tal b
lock
s•
Com
plic
atio
ns:
–H
ypot
herm
ia, a
tele
ctas
is, V
/Q m
ism
atch
, co
agul
opat
hy
Mec
hani
sm o
f in
jury
•Bl
unt
trau
ma:
ca
used
by
high
-vel
ocity
or
low
-vel
ocity
impa
ct f
rom
gen
eral
ly d
ull
obje
cts
•Pe
netr
atin
g tr
aum
a:
resu
lt of
sha
rp o
bjec
ts
pier
cing
thr
ough
tis
sue,
suc
h as
sta
b w
ound
s pr
oduc
ed b
y kn
ives
or
bulle
t w
ound
s pr
oduc
ed b
y gu
nfire
•Im
pale
men
t in
jurie
s:
com
bina
tion
of b
lunt
an
d pe
netr
atin
g tr
aum
a•
Falls
: v
ertic
al h
igh-
velo
city
inju
ries
•Bu
rns:
th
erm
al, e
lect
rical
or
chem
ical
Mec
hani
sm o
f in
jury
con
t’d
•Ai
rway
bur
ns a
nd s
mok
e in
hala
tion
inju
ries:
as
soci
ated
with
car
bon
diox
ide
pois
onin
g•
Envi
ronm
enta
l inj
urie
s: po
ison
ous
inse
cts
and
snak
es, a
nim
als
or
cons
eque
nces
of
natu
re•
Biol
ogic
al, c
hem
ical
or
nucl
ear
war
fare
Blun
t tr
aum
a•
Res
ult
of d
irect
impa
ct, d
ecel
erat
ion,
co
ntin
uous
pre
ssur
e, s
hear
ing,
and
rot
ary
forc
es•
Asso
ciat
ed w
ith in
jurie
s fr
om h
igh-
spee
d co
llisi
ons
and
falls
fro
m h
eigh
ts•
Mot
or v
ehic
le c
rash
s(M
VC)
are
clas
sifie
d as
he
ad o
n, r
ear
impa
ct, s
ide
impa
ct, r
otat
iona
l im
pact
, and
rol
love
r•
Inju
ries
com
mon
ly m
uch
mor
e se
vere
tha
n pe
netr
atin
g
Pene
trat
ing
trau
ma
•O
ften
req
uire
s su
rgic
al in
terv
entio
n•
Dam
age
depe
nds
on 3
fac
tors
:–
Type
of
wou
ndin
g in
stru
men
t–
Velo
city
of
inst
rum
ent
at t
ime
of im
pact
–
Type
of
tissu
e th
at in
stru
men
t pa
sses
th
roug
h (
orga
ns, v
esse
ls, n
ervo
us t
issu
e,
mus
cle,
fat
, bon
e)
Thor
acic
inju
ries
•Bl
unt
or p
enet
ratin
g tr
aum
a•
Mos
t om
inou
s si
gn:
hyp
oxia
fro
m
tens
ion
pneu
mot
hora
x, h
emot
hora
x,
flail
ches
t, h
ypov
olem
ia, c
ardi
ac
tam
pona
de•
Ches
t w
all t
raum
a ca
n re
sult
in a
bove
Pneu
mot
hora
x•
Accu
mul
atio
n of
air
betw
een
parie
tal a
nd
visc
eral
ple
ura
•Res
ults
in s
ever
e V/
Q m
ism
atch
and
hyp
oxia
•S/
S:
–ch
est
wal
l hyp
erre
sona
ntto
per
cuss
ion
–Br
eath
sou
nds
decr
ease
d or
abs
ent
unila
tera
lly–
Subc
utan
eous
em
phys
ema
–CX
R co
nfirm
s•
Trea
tmen
t::
nee
dle
deco
mpr
essi
on s
econ
d in
terc
osta
l sp
ace
mid
clav
icul
arlin
ech
est
tube
4th
or 5
thIC
S,
mid
axill
ary
line
Hem
otho
rax
•Ca
n be
cau
sed
from
ble
edin
g of
hea
rt
and
grea
t ve
ssel
s•
Flui
d lo
ad b
efor
e ch
est
tube
pla
cem
ent
•D
iffer
entia
ted
from
pne
umot
hora
xby
du
llnes
s to
per
cuss
ion
with
abs
ent
brea
th s
ound
s
Tens
ion
pneu
mot
hora
x•
Dev
elop
s fr
om a
ir en
terin
g pl
eura
l cav
ity
thro
ugh
a on
e w
ay v
alve
in lu
ng o
r ch
est
wal
l•
With
eac
h in
spira
tion,
mor
e ai
r be
com
es
trap
ped
in t
hora
x, in
crea
sing
intr
aple
ural
pres
sure
•Ev
entu
ally
the
ipsi
late
rall
ung
collp
ases
and
the
med
iast
inum
and
trac
hea
shift
to
cont
rala
tera
lsid
e
Tens
ion
pneu
mot
hora
xco
nt’d
•S/
S–
Hyp
erre
sona
nce
to p
ercu
ssio
n of
che
st w
all
–Ip
sila
tera
labs
ence
of
brea
th s
ound
s–
Cont
rala
tera
ltra
chea
l shi
ft–
Dis
tend
ed n
eck
vein
s?–
Diff
eren
tiate
d fr
om c
ardi
ac t
ampo
nade
by
hype
rres
onan
ceto
per
cuss
ion
over
ten
sion
pn
eum
o•
Trea
tmen
t–
14 g
auge
cat
hete
r 2n
dIC
S m
idcl
avic
ular
line
ches
t tu
be
Flai
l che
st•
Res
ults
fro
m c
omm
inut
ed f
ract
ures
of
at le
ast
thre
e ad
jace
nt r
ibs
with
ass
ocia
ted
cost
ocho
ndra
lsep
arat
ion
or s
tern
alfr
actu
re•
Acco
mpa
nied
by
hem
otho
rax
or p
ulm
onar
y co
ntus
ion
•Pa
tient
s w
ith 3
or
mor
e rib
fra
ctur
es h
ave
grea
ter
likel
ihoo
d of
hep
atic
or
sple
nic
inju
ry•
S/S
–Pa
rado
xica
l che
st w
all m
ovem
ent
and/
or s
plin
ting
due
to in
tens
e pa
in
Flai
l che
st c
ont’d
•Ch
est
Xray
and
ABG
con
firm
dia
gnos
is•
Trea
tmen
t–
O2
with
hum
idifi
catio
n–
Pain
med
s:
•IV
•th
orac
ic e
pidu
ral
•in
terc
osta
l blo
cks
Pulm
onar
y co
ntus
ion
•In
tra-
alve
olar
hem
orrh
age
and
edem
a re
sulti
ng f
rom
sud
den
incr
ease
in in
tra-
alve
olar
pre
ssur
e an
d ru
ptur
e of
alv
eola
r-ca
pilla
ry in
terf
ace
•D
iffic
ult
to d
iagn
osis
; hi
gh in
dex
ossu
spic
ion
with
tho
raci
c in
jurie
s•
Trea
tmen
t–
If w
orse
ning
res
pira
tory
fai
lure
, int
ubat
ion
with
PE
EP, f
requ
ent
suct
ioni
ng t
o av
oid
bron
chia
l pl
uggi
ng a
nd a
tele
ctas
is, a
nd c
aref
ul v
olum
e re
susc
itatio
n
ARD
S
•La
ter
pulm
onar
y co
mpl
icat
ion
•At
trib
uted
to
dire
ct t
hora
cic
inju
ry,
seps
is, a
spira
tion,
hea
d in
jury
, mas
sive
tr
ansf
usio
n, o
xyge
n to
xici
ty, a
nd f
at
embo
lism
•M
orta
lity
rate
rea
chin
g 50
%
Myo
card
ial c
ontu
sion
•As
soci
ated
with
blu
nt t
raum
a•
Cont
usio
n m
ost
ofte
n rig
ht v
entr
icle
sin
ce li
es
dire
ctly
pos
terio
r to
ste
rnum
•S/
S–
Dys
rhyt
hmia
s:
hear
t bl
ock
to V
fib;
ST s
egm
ent
elev
atio
n–
Elev
ated
CPK
-MB;
? t
ropo
nin
elev
atio
n–
CHF
–An
gina
lpai
n w
hich
may
or
may
not
res
pond
to
nitr
ates
Myo
card
ial c
ontu
sion
con
t’d
•Tr
eatm
ent
–M
anag
emen
t of
dys
rhyt
hmia
s–
Incr
ease
CVP
to
optim
ize
right
ven
tric
ular
ou
tput
Card
iac
tam
pona
de•
Life
-thr
eate
ning
em
erge
ncy
•Bl
eedi
ng in
to p
eric
ardi
al s
pace
, whi
ch
rest
ricts
car
diac
fill
ing
durin
g di
asto
le
and
crea
tes
a lo
w c
ardi
ac o
utpu
t st
ate
•In
itial
sym
ptom
s–
Dys
pnea
–O
rtho
pnea
–ta
chyc
ardi
a
Tam
pona
deco
nt’d
•Cl
assi
c sy
mpt
oms
–Be
ck’s
tria
dne
ck v
ein
dist
entio
n, h
ypot
ensi
on,
muf
fled
hear
t so
unds
–Pu
lsus
para
doxu
s:
> 1
0 m
mH
g de
crea
se in
blo
od
pres
sure
dur
ing
spon
tane
ous
insp
iratio
n•
May
not
be
evid
ent
in h
ypov
olem
ia
•Tr
eatm
ent
–Pe
ricar
dioc
ente
sis:
16
g c
athe
ter
inse
rted
at
the
xiph
ocho
ndra
ljun
ctio
n to
war
d le
ft s
capu
la a
t 45
* an
gle
•If
adv
ance
d to
o fa
r, w
ill s
ee e
ctop
y•
Req
uire
s th
orac
otom
y•
Flui
d lo
ad a
nd t
reat
with
pre
ssor
sif
nece
ssar
y•
Avoi
d br
adyc
ardi
a; K
etam
ine
usef
ul a
gent
Asso
ciat
ed t
hora
cic
inju
ries
•Ao
rtic
rup
ture
•Va
lvul
arru
ptur
e•
Sept
alru
ptur
e•
Dia
phra
gmat
ic h
erni
atio
n•
Esop
hage
al r
uptu
re
Abdo
min
al a
nd P
elvi
c tr
aum
a•
Hig
h ris
k fo
r ex
sang
uina
ting
hem
orrh
age
and
perit
oniti
s•
Res
ults
fro
m b
lunt
and
pen
etra
ting
trau
ma
•Ret
rope
riton
eal i
njur
ies
can
dam
age
abdo
min
al a
orta
, IVC
, kid
neys
, pan
crea
s,
duod
enum
•In
trap
erito
neal
inju
ries
can
inju
re s
plee
n,
liver
, sto
mac
h, s
mal
l bow
el, co
lon,
rec
tum
Abdo
min
al a
nd p
elvi
c in
jurie
s co
nt’d
•In
traa
bdom
inal
inju
ries
asso
ciat
ed w
ith
para
lytic
ileu
san
d pe
riton
eal i
rrita
tion
(mus
cle
guar
ding
, ten
dern
ess
to p
ercu
ssio
n,
abdo
min
al d
iste
ntio
n)•
>1-
3 lit
ers
of b
lood
can
seq
uest
er in
ab
dom
en/r
etro
perit
onea
l spa
ce w
ith m
inim
al
sign
s•
Dia
gnos
is c
onfir
med
with
fre
e ai
r on
Xra
yor
FA
ST o
r CT
or
by b
lood
y D
PL
Dia
gnos
tic p
erito
neal
lava
ge(D
PL)
•Pe
rfor
med
whe
n ab
dom
inal
inju
ry
susp
ecte
d fr
om m
echa
nism
of
inju
ry•
Not
per
form
ed r
outin
ely
now
tha
t FA
ST
avai
labl
e•
FAST
and
DPL
can
pre
vent
unn
eces
sary
ex
plor
ator
y la
p•
Can
use
loca
l with
sed
atio
n
DPL
con
t’d•
Perit
oneu
m la
vage
dw
ith f
luid
tha
t is
the
n dr
aine
d by
gra
vity
and
exa
min
ed f
or p
rese
nce
of R
BC’s
, bile
, am
ylas
e, a
nd W
BC’s
–Po
sitiv
e fin
ding
: >
10 c
c gr
oss
bloo
d•
>10
0,00
0 RB
C’s/
ml
•>
500
,000
WBC
’s/m
l•
Amyl
ase
> 2
00 u
nits
•Ba
cter
ia
–Fa
lse
posi
tive
resu
lts <
2%
Sple
nic
lace
ratio
n•
Mos
t co
mm
on in
jury
in b
lunt
abd
omin
al
trau
ma
and
with
pen
etra
ting
wou
nds
of
left
low
er t
hora
x an
d up
per
abdo
men
•Rou
tine
sple
nect
omy
rare
•Sp
leno
rrha
phy
(rep
airin
g th
e sp
leen
) m
ore
com
mon
–D
ecre
ases
inci
denc
e of
sep
sis
–Ca
n ta
ke t
o an
giog
raph
y to
em
boliz
ela
c
Live
r la
cera
tion
•Se
cond
mos
t co
mm
on in
jury
ass
ocia
ted
with
abd
omin
al t
raum
a•
Exsa
ngun
iatin
ghe
mor
rhag
e ca
n oc
cur
•M
ajor
ity o
f liv
er in
jurie
s (8
5-90
%)
heal
sp
onta
neou
sly
and
may
onl
y re
quire
su
rgic
al d
rain
age
Pelv
ic f
ract
ures
•Res
ult
in m
ajor
hem
orrh
age
25%
of
time
•Ex
sang
uina
tion
1% o
f tim
e•
Blee
ding
res
ults
fro
m d
isru
ptio
n of
vei
ns f
rom
bo
ne f
ragm
ents
•Em
erge
nt o
r el
ectiv
e ex
tern
al f
ixat
ion
can
be
follo
wed
by
angi
ogra
phy
–Ar
teria
l ble
edin
g ca
n be
em
boliz
ed–
Blad
der
inju
ries
ofte
n as
soci
ated
with
pel
vic
frac
ture
•U
reth
rogr
amsh
ould
be
perf
orm
ed b
efor
e fo
ley
inse
rted
Abdo
min
al a
nd p
elvi
c tr
aum
a•
Anes
thet
ic c
once
rns
revo
lve
arou
nd
hem
orrh
age,
hyp
othe
rmia
, sep
sis/
perit
oniti
s an
d im
pairm
ent
of v
entil
atio
n•
War
min
g m
easu
re a
re c
ruci
al s
ince
larg
e he
at
loss
fro
m o
pen
mes
ente
ry a
nd s
hock
•Av
oid
N20
to
prev
ent
bow
el d
iste
ntio
n•
Flui
d re
susc
itatio
n im
pera
tive
–Th
e pe
lvis
can
hol
d up
to
3 lit
ers
Extr
emity
tra
uma
•U
sual
ly n
ot im
med
iate
ly li
fe-t
hrea
teni
ng
and
part
of
seco
ndar
y su
rvey
•Ca
n be
ass
ocia
ted
with
vas
cula
r in
jurie
s ca
usin
g he
mor
rhag
e, s
hock
, sep
sis,
fat
em
boli,
and
thr
ombo
embo
lichy
poxi
c re
spira
tory
fai
lure
Ope
n fr
actu
res
•Id
eal t
o re
pair
in f
irst
few
hou
rs p
ost
inju
ry s
o fu
ll st
omac
h pr
ecau
tions
•Sh
ould
rep
air
with
in 6
hou
rs t
o le
ssen
in
cide
nce
of s
epsi
s•
If o
bvio
us h
emor
rhag
e, h
old
pres
sure
m
anua
lly;
can
have
MAS
T pa
nts
appl
ied
whi
le in
fie
ld
Vasc
ular
tra
uma
•S/
S–
Pain
–Pu
lsel
essn
ess
–Pa
llor
–Pa
rest
hesi
as–
Pare
sis
–Co
nfirm
ed w
ith a
ngio
grap
hy
Com
part
men
t sy
ndro
me
•Ch
arac
teriz
ed b
y se
vere
pai
n in
aff
ecte
d ex
trem
ity–
Calf
pain
on
dors
iflex
ion
of f
oot
•Em
erge
ncy
fasc
ioto
my
mus
t be
don
e to
pr
even
t irr
ever
sibl
e m
uscl
e an
d ne
rve
dam
age
•D
iagn
osis
con
firm
ed b
y co
mpa
rtm
ent
pres
sure
s >
40
cm H
20
Long
bon
e fr
actu
res
•Co
mm
only
lead
to
thro
mbo
embo
lichy
poxi
c re
spira
tory
fai
lure
due
to
fat
glob
ules
or
frac
ture
deb
ris r
each
ing
pulm
onar
y va
scul
ar
bed
•Fa
t em
bolis
m s
yndr
ome:
–Fe
ver
–Pe
tech
aie
–D
ysrh
ythm
ias
–Fa
t gl
obul
es in
urin
e, p
lasm
a, r
etin
al v
esse
ls–
Men
tal d
eter
iora
tion
1-3
days
pos
t tr
aum
a
Fat
embo
lism
syn
drom
e co
nt’d
•D
iagn
osis
: e
leva
ted
seru
m li
pase
, fat
in
urin
e, a
nd t
hrom
bocy
tope
nia
•Tr
eatm
ent:
ea
rly f
ract
ure
stab
iliza
tion
is k
ey t
o pr
even
tion
–Ag
gres
sive
car
diov
ascu
lar
and
pulm
onar
y su
ppor
t
Anes
thet
ic c
once
rns
with
ext
rem
ity
trau
ma
•Po
sitio
ning
•As
soci
ated
inju
ries
•To
urni
quet
s
Crus
h in
jurie
s•
Can
occu
r w
ith b
lunt
and
pen
etra
ting
trau
ma
•In
crea
sed
risk
of m
yogl
obin
uria
, lea
ding
to
rhab
dom
yolis
is•
Alw
ays
chec
k ur
ine
and
docu
men
t co
lor
with
tr
aum
a pa
tient
s; in
form
sur
geon
imm
edia
tely
if
beco
min
g bl
oody
–N
eed
to h
ydra
te, o
smot
ic d
iure
tics,
alk
alin
ize
urin
e to
pro
tect
kid
neys
–Fo
llow
lact
ate;
> 2
can
be
sign
of
unde
r re
susc
itatio
n
Hea
d in
jury
•G
oal i
s pr
even
tion
of s
econ
dary
bra
in d
amag
e re
sulti
ng f
rom
intr
acra
nial
ble
edin
g, in
crea
sed
ICP,
ede
ma
•M
anag
emen
t sh
ould
incl
ude
early
con
trol
of
airw
ay, c
ardi
ovas
cula
r st
abili
ty, a
nd
avoi
danc
e of
incr
ease
d IC
P•
Patie
nts
with
sus
pect
ed h
ead
inju
ry s
houl
d be
pl
aced
hea
d up
pos
ition
to
prom
ote
veno
us
drai
nage
and
dec
reas
e IC
P; m
oder
ate
hype
rven
tilat
ion
to 3
0 m
mH
g
Spin
al c
ord
inju
ry
•H
igh
inde
x of
sus
pici
on r
elat
ed t
o m
echa
nism
of
inju
ry•
Alw
ays
trea
t as
sus
pect
ed C
-spi
ne
inju
ry u
nles
s pr
oven
oth
erw
ise
–C
colla
r–
Inlin
e st
abili
zatio
n w
ith in
tuba
tion
–RSI
/airw
ay a
djun
cts
Sign
s an
d sy
mpt
oms
rela
ted
to S
CI•
Para
lysi
s•
Pain
•Po
sitio
n:
patie
nt h
oldi
ng h
ead
uprig
ht w
ith
both
han
ds m
ay in
dica
te J
effe
rson
(ha
ng
man
) fr
actu
re C
1; “
hold
-up”
pos
ition
with
ar
ms
abov
e he
ad m
ay in
dica
te C
4-5
frac
ture
; “p
raye
r po
sitio
n” w
ith a
rms
fold
ed a
cros
s ch
est
poss
ible
C5-
6 fr
actu
re
S/S
of S
CI c
ont’d
•Pa
rest
hesi
as•
Ptos
is•
Pria
pism
SCI
•Le
adin
g ca
use
of d
eath
at
scen
e:
aspi
ratio
n•
Mos
t in
jurie
s oc
cur
in m
ales
in 2
0’s-
30’s
•O
ccur
fro
m f
alls
, MVC
’s, d
ivin
g in
jurie
s,
pene
trat
ing
mis
sile
s, s
port
s in
jurie
s•
Mus
t ob
tain
late
ral C
-spi
ne X
ray
–C7
mos
t co
mm
on s
ite o
f in
jury
Anes
thet
ic m
anag
emen
t w
ith S
CI•
Nas
al in
tuba
tion
met
hod
of c
hoic
e if
patie
nt
does
not
hav
e as
soci
ated
bas
ilar
skul
l fr
actu
re/L
eFor
t2-
3 fr
actu
res
–To
pica
l ane
sthe
sia
–Av
oid
tran
stra
chea
lblo
ck d
ue t
o in
crea
sed
risk
of
aspi
ratio
n an
d m
ovem
ent
of n
eck
with
cou
ghin
g
•O
ral i
ntub
atio
n:
indu
ce p
atie
nt t
hen
rem
ove
fron
t of
C c
olla
r an
d ho
ld in
-line
st
abili
zatio
n/RSI
Mus
cle
rela
xant
s w
ith S
CI
•Su
ccin
ylch
olin
e: d
o no
t gi
ve t
o pa
tient
s >
24
hour
s po
st m
assi
ve m
uscl
e or
de
nerv
atio
nin
jurie
s, S
CI’s
, cru
sh
inju
ries
or b
urns
–Ac
utel
y m
ay w
ant
to a
void
sec
onda
ry t
o fa
scic
ulat
ions
that
may
exa
cerb
ate
SCI
–\C
an g
ive
cura
rizin
gdo
se o
f N
DM
R–
Hig
h do
se V
ecor
Roc
goo
d al
tern
ativ
e
Spin
al s
hock
•H
ypot
ensi
on•
Brad
ycar
dia
•H
ypot
herm
ia/p
oiki
loth
erm
ia(b
ody
tem
pera
ture
mig
rate
s to
war
d en
viro
nmen
tal l
evel
)•
Res
ults
fro
m s
ympa
thec
tom
yin
SCI
pa
tient
s•
Mor
e in
tens
ified
at
T6 le
vel a
nd h
ighe
r
Spin
al s
hock
•Pa
tient
s pr
esen
t w
ith h
ypot
ensi
on,
brad
ycar
dia
and
war
m, p
ink
extr
emiti
es–
Hem
mor
rhag
icsh
ock
tend
to
be
hypo
tens
ive,
tac
hyca
rdia
cw
ith c
old,
cl
amm
y sk
in–
Trea
tmen
t:•
Care
ful v
olum
e re
susc
itatio
n–
Una
ble
to m
aint
ain
adeq
uate
car
diac
fill
ing
pres
sure
s bu
t ov
erag
gres
sive
flu
id a
dmin
istr
atio
n ca
n pr
ecip
itate
pul
mon
ary
edem
a (n
euro
geni
c)
Spin
al s
hock
con
t’d
•M
ay r
equi
re p
ress
ors
Dop
amin
e 4-
5 m
cg/k
g/m
in•
Avoi
d us
ing
radi
al a
rter
ies
for
arte
rial
line
if p
arap
legi
c–
If a
rm e
mbo
lizes
, pat
ient
at
seve
re
disa
dvan
tage
Auto
nom
ic h
yper
efle
xia
•Se
en in
85%
of
patie
nts
with
inju
ries
abov
e T5
•S/
S–
Hyp
erte
nsio
n–
Brad
ycar
dia
–D
ysrh
ythm
ias
–Cu
tane
ous
vaso
dila
tion
abov
e an
d va
soco
nstr
ictio
n be
low
inju
ry–
Seve
re h
eada
ches
–Se
izur
es
–Lo
ss o
f co
nsci
ousn
ess
Auto
nom
ic h
yper
efle
xia
•O
ccur
s af
ter
spin
al s
hock
pas
sed
•U
sual
ly s
een
>24
hou
rs p
ost
inju
ry a
nd
whe
n pa
tient
s re
turn
to
OR f
or
subs
eque
nt o
pera
tions
•Ca
used
by
stim
ulat
ion
belo
w le
vel o
f le
sion
•Tr
eatm
ent:
st
op s
timul
us;
deep
en
anes
thes
ia;
card
iova
scul
ar s
uppo
rt
Ther
mal
inju
ry•
> 2
mill
ion
patie
nts
will
be
brou
ght
to t
raum
a ce
nter
s fo
r bu
rns
and
asso
ciat
ed in
jurie
s•
Maj
ority
are
the
rmal
inju
ries
in c
hild
ren
< 5
ye
ars
•El
ectr
ical
bur
ns c
ause
tis
sue
dam
age
by
ther
mal
inju
ry a
nd in
jury
to
unde
rlyin
g st
ruct
ures
and
hea
rt•
Chem
ical
bur
ns d
epen
d on
che
mic
al,
conc
entr
atio
n, a
nd d
urat
ion
of e
xpos
ure
Deg
ree
of b
urn
•Fi
rst-
degr
ee b
urn:
su
perf
icia
l inv
olvi
ng
uppe
r la
yers
of
epid
erm
is;
skin
red
and
ed
emat
ous
and
pain
ful l
ike
sunb
urn
•Se
cond
-deg
ree
burn
: p
artia
l thi
ckne
ss
burn
s ex
tend
dam
age
thro
ugh
derm
is;
rege
nera
tion
can
occu
r; b
liste
rs d
evel
op
and
have
whi
te o
r re
d ar
eas
that
are
pa
infu
l
Deg
ree
of b
urn
cont
’d•
Third
-deg
ree
burn
: f
ull t
hick
ness
bur
n ch
arac
teriz
ed b
y de
stru
ctio
n of
all
laye
rs o
f sk
in, i
nclu
ding
ner
ve e
ndin
gs;
skin
will
not
re
gene
rate
and
hea
ling
does
not
occ
ur u
nles
s de
ad t
issu
e de
brid
edan
d sk
in g
raft
s pl
aced
; sk
in c
harr
ed a
nd n
ot p
ainf
ul•
Four
th-d
egre
e bu
rn:
invo
lve
dest
ruct
ion
of
all l
ayer
s of
ski
n an
d ex
tend
into
su
bcut
aneo
us t
issu
e, f
asci
a, m
uscl
e, a
nd
bone
Seco
nd d
egre
e bu
rn (
supe
rfic
ial d
erm
al
burn
)
Third
deg
ree
burn
(su
b-de
rmal
bur
n)
Rul
e of
Nin
es•
Size
of
burn
est
imat
ion
to a
sses
s to
tal B
SA
burn
ed•
Body
div
ided
into
reg
ions
tha
t re
pres
ent
9%
or m
ultip
les
of 9
% o
f to
tal B
SA•
Adul
ts:
hea
d/ne
ck 9
%;
arm
s/ha
nds
9% e
ach
extr
emity
; th
ighs
/legs
18%
eac
h ex
trem
ity;
ante
rior/
post
erio
r tr
unk
18%
eac
h si
de;
perin
eum
1%
•Ch
ildre
n ca
lcul
ated
slig
htly
diff
eren
t du
e to
la
rge
head
•Si
ze o
f ha
nd r
ough
ly e
qual
to
1% B
SA
Thre
e ph
ases
of
burn
inur
y
•Res
usci
tativ
e ph
ase
–Fi
rst
24 h
ours
–In
clud
es a
irway
man
agem
ent
and
trea
ting
any
circ
ulat
ory
and
asso
ciat
ed in
jurie
s–
Susp
icio
n of
upp
er a
nd lo
wer
airw
ay in
jury
is
incr
ease
d w
ith s
inge
d ey
ebro
ws/
eyel
ashe
s an
d bl
ack
soot
aro
und
nose
and
mou
th
Anes
thet
ic m
anag
emen
t of
bur
n pa
tient
•Ea
rly in
tuba
tion
•M
ultip
le la
rge
bore
IV
acce
ss•
Aggr
essi
ve f
luid
res
usci
tatio
n•
Stan
dard
and
inva
sive
mon
itors
pla
ced
early
–N
eedl
e el
ectr
odes
•Te
mpe
ratu
re r
egul
atio
n
Man
agem
ent
cont
’d•
Varie
d dr
ug r
espo
nses
–Al
bum
in c
once
ntra
tion
decr
ease
d af
ter
48 h
ours
albu
min
-bou
nd d
rugs
(su
ch a
s be
nzos
and
antic
onvu
lsan
ts)
have
an
incr
ease
d fr
ee f
ract
ion
and
prol
onge
d ef
fect
–Ca
rdio
vasc
ular
sup
port
–Req
uire
hig
her
than
nor
mal
dos
es o
f N
DM
R (
2-5
times
nor
mal
dos
e)–
Keta
min
efo
r dr
essi
ng c
hang
es a
nd e
scha
roto
mie
s
Airw
ay in
jury
•H
igh
inde
x of
sus
pici
on if
loss
of
cons
ciou
snes
s at
sce
ne a
nd if
fire
occ
urre
d in
cl
osed
spa
ce•
S/S
of in
hala
tion
inju
ry–
Res
pira
tory
irrit
atio
n (c
ough
ing)
–So
re t
hroa
t–
Dys
phag
ia–
Hem
opty
sis
–Ca
rbon
-col
ored
spu
tum
–Ta
chyp
nea,
use
of
acce
ssor
y m
uscl
es, w
heez
ing
–Cr
epitu
s
Inha
latio
n in
jury
•H
oars
enes
s de
man
ds im
med
iate
at
tent
ion
mea
ns a
irway
bec
omin
g ed
emat
ous
and
can
quic
kly
obst
ruct
gl
ottis
•D
iagn
osis
mad
e w
ith
carb
oxyh
embo
glob
inle
vels
•Sh
ould
be
intu
bate
d im
med
iate
ly if
any
su
spic
ion
of in
jury
Carb
on m
onox
ide
(CO
) po
ison
ing
•Res
ults
fro
m in
hala
tion
of C
O p
rodu
ced
by
fires
, exh
aust
fro
m in
tern
al c
ombu
stio
n en
gine
s an
d co
okin
g an
d ch
arco
al s
tove
s•
Prod
uces
tis
sue
hypo
xia
by it
s 20
0 tim
es
affin
ity f
or H
gbco
mpa
red
to o
xyge
n•
COH
gBfo
rmed
puls
e ox
imet
erm
ay d
ispl
ay
high
er t
han
actu
al O
2 sa
tura
tion
•S/
S–
Tach
ypne
a–
Cher
ry r
ed c
olor
of
bloo
d (o
nly
whe
n CO
HgB
>40
%)
Clin
ical
man
ifest
atio
n of
CO
exp
osur
eC
O H
gBle
vel (
%)
Man
ifes
tati
ons
0-5
Non
e
5-10
Mild
H/A
, co
nfus
ion
11-2
0Se
vere
H/A
, blu
rred
vis
ion
21-4
0D
isor
ient
atio
n, N
/V,
irrita
bilit
y, s
ynco
pe41
-60
Tach
ycar
dia,
tac
hypn
ea,
agita
tion
>60
Dea
th
CO p
oiso
ning
•Tr
eatm
ent:
10
0% O
2 im
med
iate
ly•
Hyp
erba
ric o
xyge
n th
erap
y (H
BO)
may
be
initi
ated
if s
ympt
oms
not
abat
ing
Flui
d re
susc
itatio
n•
Park
land
for
mul
a–
4ml/k
g LR
per
per
cent
BSA
bur
ned
–½
giv
en o
ver
first
8 h
ours
–Re
st o
ver
next
16
hour
s–
In a
dditi
on t
o m
aint
enan
ce
•Br
ooke
for
mul
a–
3ml/k
g pe
r pe
rcen
t BS
A bu
rned
–½
ove
r fir
st 8
hou
rs–
Rest
ove
r ne
xt 1
6 ho
urs
Myo
glob
inur
ia•
Occ
urs
follo
win
g rh
abdo
myo
lisis
and
hem
oglo
binu
riadu
e to
hem
olys
is;
affe
cts
rena
l blo
od f
low
via
dam
age
to r
enal
pa
renc
hym
a•
FFP
may
pro
tect
ren
al f
unct
ion
sinc
e it
cont
ains
hap
togl
obin
, whi
ch b
inds
fre
e he
mog
lobi
n•
Aggr
essi
ve f
luid
res
usci
tatio
n•
Mai
nten
ance
of
urin
e ou
tput
with
osm
otic
di
uret
ics
and
sodi
um b
icar
bto
pro
tect
kid
neys
Deb
ridem
ent
and
graf
ting
phas
e•
Mul
tiple
ski
n de
brid
emen
ts•
Esch
arot
omie
s•
Ampu
tatio
ns•
Gra
fts
•Tr
ache
otom
ies
May
stil
l be
hem
odyn
amic
ally
unst
able
in
this
pha
se
Rec
onst
ruct
ive
phas
e
•M
ay c
ontin
ue f
or r
est
of li
fe•
Rel
ease
of
cont
ract
ures
•M
ultip
le p
last
ic s
urge
ry
