Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Pathway 8: Adult Trauma

(Secondary Survey for Adults)

The team continues the resuscitation along the pathway suggested by the initial clinical impression. Each pathway includes a complete, thorough, and rapid physical examination with additional history taking. The team leader is wary of conditions that may not be apparent. To obtain additional clinical data or to correct a missed or newly developed condition, the team leader repeats the initial survey if the patient is not responding satisfactorily.

The team leader performs a head-to-toe, rapid but thorough, physical examination. Some possible abnormalities¹ encountered are:

Text Number	Diagnosis/Condition	Related Materials
1	Compromised Airway	Vol I—Airway Skills
2	Abnormal LOC	Vol I—Pathway 1 Altered Level of Consciousness
3	Facial and Skull Fracture/ Scalp Laceration	Vol I—Acute Care Portals; Vol II—Disab Skills 2 Raney Scalp Clips; Vol III—NEU5 Increased Intracranial Pressure
4	Direct Eye Trauma
5	Soft Tissues of the Neck	Vol I—Airway Skills
6	Cervical Spine Injury	Vol II—Xray Skills 1 C-Spine Rules, Xray Skills 2 Cervical Spine Xray Interpretation
7	Chest Wall and Pulmonary Injury	Vol II—Breath Skills 1 Chest Tube Insertion, Breath Skills 2 Chest Suction/Autotransfusion, Breath Skills 5 Needle Thoracostomy
8	Cardiac Tamponade	Vol II—Circ Skills 6 Pericardiocentesis
9	Hypovolemic Shock	Vol I—Acute Care Portals; Vol II—Circ Skills 1 Arterial and Venous Catheter Insertion; Vol III—Trau Care 2 Shock
10	Abdominal Injury	Vol I—Acute Care Portals; Vol III—Trau Care 2 Shock
11	Pelvic Fracture	Vol II—Trau Care 3 Pelvic Fracture Stabilization, Xray Skills 3 Interpretation of Pelvic Xray
12	Trauma in Pregnancy	Vol III—OB9 Trauma in Pregnancy
13	Major Joints, Femurs, and Amputations	Vol I—Acute Care Portals; Vol II—Trauma Skills 1 Compartment Pressure Measurement, Trauma Skills 2 Femur Fracture Splinting; Vol III—Trau Care 2 Shock
14	Burns	Vol I—Acute Care Portals; Vol III—ENV3 Burns Management
15	Heat Stroke	Vol III—ENV2 Hyperthermia
16	Severe Hypothermia	Vol III—ENV1 Hypothermia
17	Near Drowning	Vol III—ENV4 Near Drowning
18	Caustic Substance Ingestion

Obtain the trauma series of x-rays in most trauma patients. The trauma series includes a lateral c-spine, a supine chest x-ray, and an AP pelvis x-ray. Order these immediately and continue the examination as the films are being obtained. If the patient deteriorates during this survey, repeat the initial survey, checking for airway, breathing, circulation, and so on.

Hidden back injury or wound

Carefully log roll the patient, while maintaining c-spine immobilization, just enough to expose the back. Palpate the entire length of the spine checking for deformity, hematoma, lacerations, and pain. Palpate the flanks and the buttocks. Palpate the posterior thorax and scapulae. The log roll maneuver in the presence of an unstable pelvic fracture may stimulate more bleeding. The team should carefully lift the patient straight up instead. If you suspect spine injury, immobilize the patient securely. If there is a question about the spine, order AP views of the thoracic and lumbar spine. Remove glass shards and any other harmful materials before laying the patient back down.

Compromised Airway

During the initial survey, the airway was opened and the patient was ventilated pending this step of the process. If there was failure to ventilate or to open the airway, invasive methods were used to accomplish this. If this has not been done, return to the initial survey and do it now. There is no point in continuing until the patient is breathing or can be ventilated.

If the patient is breathing or being BVM ventilated, a decision regarding the need for emergent or elective intubation is necessary. Before intubation, be sure to obtain a SAMPLE history and perform both mini neurological and rectal exams. (See Abnormal LOC, #2 this portal.)

Reasons to intubate:

Gag reflexes are absent.
The patient is difficult to ventilate as in severe asthma or severe pulmonary contusion.
A burn victim has soot or erythema in the mouth with stridor.
The patient needs to be paralyzed for studies, such as CT scan or angiography.
The patient needs to be paralyzed for safe transport.
There is a flail chest with oxygen desaturation.
A tension pneumothorax was or is present.
The patient is in extreme pain, and analgesia is needed, which could lead to respiratory depression.
The patient is unable to handle secretions because of swelling, bleeding, etc.
The patient is weak or tiring, and respirations are becoming less effective.
Hyperventilation is needed because of CNS deterioration.
There is poor oxygenation because of pulmonary problems.
There is an open chest wound.
An invasive emergency procedure requires anesthesia.
The patient is combative or unable to tolerate needed procedures.

If the patient is deeply obtunded, RSI may not be required, unless airway reflexes and muscle tone are present. If a difficult intubation is anticipated, awake intubation may be preferable. Always have a back-up plan in case intubation fails.

Check to be sure that the needed equipment is at hand. Equip the airway cart (See Vol II—Air Skills Portals) with rescue airways as well as standard orotracheal intubation equipment. Familiarize yourself with its contents.

If physical findings or a mechanism of injury suggest the possibility of a spinal injury, perform orotracheal intubation with in-line immobilization of the head and neck. A surgical airway may be indicated.

Open the cervical collar temporarily: it can limit your ability to lift the chin. An assistant should kneel on the floor at the head of the table toward the left and hold the patient's head between his or her hands. The patient can be intubated over the right shoulder of this individual. This approach enables the application of cricoid pressure^a by another assistant. Alternatively, a team member may provide cervical immobilization by standing at the bedside, resting the forearms on the patient’s clavicles and placing the palms of the hands over the patient’s ears. Fingers and thumbs should be extended so as to provide maximum control of the head while leaving the mandible free. This method works best if the team member performing cricoid pressure stands on the opposite side.

RSI greatly facilitates orotracheal intubation. RSI eliminates laryngospasm. The risk of RSI is greatly reduced if the intubator is prepared to secure the airway with another procedure. A Combitube™ or other airway device, such as the King airway, may often be easily inserted.

An elevated serum potassium level makes the use of succinylcholine risky. (Succinylcholine raises the serum potassium level.) Chronic or acute renal failure, a crush injury or burn more than 24 hours old, muscular dystrophy, muscle wasting, and extreme muscular exertion as in cocaine or amphetamine overdose may elevate the serum potassium level. Vecuronium may be used instead. The disadvantage of vecuronium is that its effects last 30 minutes in comparison with succinylcholine, the effects of which last less than 10 minutes. Succinylcholine also takes effect in less than one minute, while vecuronium may take more than 3 minutes to take effect.

A relative contraindication of succinylcholine is the possibility of a globe injury of the eye. The fasciculations produced by succinylcholine may result in loss of vitreous. This can be prevented with a small (defasciculating dose) of vecuronium 0.01 mg/kg, prior to use of succinylcholine.
See Acute Care Portals, Rapid Sequence Intubation Algorithm. Other forms of securing the airway instead of RSI include:

Orotracheal intubation may be accomplished with or without topical anesthesia. Light-guided intubation (LGI) or an intubating laryngeal-mask airway (ILMA) may also be used effectively with topical anesthesia. LGI is relatively contraindicated in obese patients, while an ILMA may be used in such patients. (Vol II—Air Skills 9 Nasotracheal Intubation, Air Skills 8 Intubating Laryngeal Airway)
Nasotracheal intubation is rarely used in trauma resuscitation because it raises ICP and may cause bleeding. A retropharyngeal hematoma is a contraindication. (Vol II—Air Skills 3 Orotracheal Intubation)
A surgical airway may be the best option if anatomic problems are severe. Transtracheal needle ventilation (TTNV) and retrograde intubation may be good options if time is not critical. (Vol II—Air Skills 10 Topical Anesthesia, Air Skills 16 Transtracheal Needle Ventilation) When time is critical, cricothyrotomy is fastest and most easily accomplished. (Vol II—Air Skills 13 Cricothyrotomy) If there has been trauma to the larynx, a tracheotomy is indicated. (Vol II—Air Skills 14 Tracheotomoy)

Unfortunately, the myriad of airway injuries and problems that may arise in trauma occurring in patients of all sizes and configurations make recommendations applicable to all situations impossible. An algorithm quickly becomes a tangle of possibilities. Another way of looking at treatment choices is to consider the tools best suited to a specific problem. Here are some generalities about the tools that may help.

Orotracheal intubation is still the optimal choice for airway management. The disadvantages of causing harmful reflexes and of being painful and difficult in an aware patient are overcome by the use of RSI. The ETI and the EID also make intubation less difficult.

The Combitube™ is probably the most useful rescue airway. The Combitube is very effective if anatomic problems are not severe. Continued sedation is needed because a Combitube is uncomfortable. PEDS: Pediatric sizes are not available. The standard size will function well in almost any adult. The smaller size is available for persons between 4 and 5 feet tall. Many Asian and Hispanic patients may be less than 5 feet tall. The volume of air in the large balloon is reduced to 80 cc in the 4-feet tall model.

The King airway is a supraglottic airway that is inserted blindly. The King airway consists of a curved tube with ventilation apertures located between 2 inflatable cuffs. A single valve/pilot balloon is used to inflate both cuffs. The distal cuff seals the esophagus; the proximal cuff seals the oral pharynx. A 15-mm connector attaches to the proximal end of the tube for attachment to a standard breathing circuit or resuscitation bag. The King airway is intended for airway management in patients over 4 feet tall for controlled or spontaneous ventilations. The King airway is contraindicated for patients who have a gag reflex, known esophageal disease (eg, cancer, varices, stricture), laryngectomy with a stoma, and/or caustic ingestion or airway burns.

Retrograde intubation is a reliable method that may be used when anatomic problems are severe. Retrograde intubation takes about three minutes to accomplish, but if the patient can be BVM ventilated, this is not a problem.

Cricothyrotomy is fast and reliable; however, it requires surgical skill. A tracheal hook and an ETI are helpful.

Tracheotomy is more difficult than a cricothyrotomy; however, it is needed if there has been trauma to the larynx.

Intubating laryngeal mask airway (ILMA) is effective in obese patients and may be used with topical anesthesia. It is possible to remove the ILMA while leaving the patient intubated, but it requires several steps.

Transtracheal needle ventilation (TTNV) is an excellent temporary airway. The patient may be ventilated using this technique, allowing time for more invasive procedures to be accomplished.

Abnormal LOC
If a patient is belligerent, unable to cooperate, or delirious, use RSI to gain control of the patient’s airway, allowing the resuscitation to continue. (Vol II—Air Skills 4 Rapid Sequence Intubation) Before paralyzing the patient, be sure that the SAMPLE history has been obtained, the LOC has been determined (using the AVPU scale), and both mini neuro and rectal exams have been documented. The DONT therapy should have been considered during the initial survey.

A mini neurologic exam may be performed quickly prior to RSI or sedation. It is useful to have a list available for review.

Level of Consciousness
AVPU and Glasgow Coma Scale
Pupils and Vision
Conjugate or disconjugate gaze
Size, equality, and reactivity
Finger counting
Tympanic Membranes
Hemotympanum
Neck
Midline tenderness
Extremities
Movement and strength on command or to pain
Check ankle, patellar, Babinski, brachial reflexes, and clonus
Sensation and position sense
Trunk and Perineum
Priapism, saddle sensation, anal sphincter tone
Sensation level

Level of Consciousness
AVPU Scale	Corresponding GCS
A Awake	14 to 15
V Responds to voice	12 to 13
P Responds to pain	8
U Unresponsive to pain	3 to 4

If uncal herniation is occurring (dilated pupil and weak opposite extremity) or if the patient is posturing (extensor or flexor), perform the following:

Maintain mean arterial pressure (MAP) > 90 mm Hg throughout treatment, which usually maintains the cerebral perfusion pressure >70 mm Hg.
Avoid prophylactic hyperventilation therapy (PCO₂ < 35 mm Hg) during the first 24 hours following injury. However, for impending herniation, hyperventilation therapy (PCO₂ ≤ 30 mm Hg) is appropriate.
Administer mannitol 1 g/kg IV or hypertonic saline. Consult with neurosurgery.
Administer phenytoin (18 mg/kg IV at a rate of no more than 50 mg/min) or fosphenytoin (18 mg/kg IV over 10 min at a rate of no more than 150 mg PE min).

If the patient had an initial lucid interval and continues to herniate despite the measures previously described and transport to a trauma center is delayed, perform the following:

Obtain a head CT to identify an epidural hematoma and location. About 80% of the time, the epidural is located on the side of the dilated pupil. If a CT scan is unavailable, skull trephination should be performed on the side of the dilated pupil. See Vol II—Disab Skills 1 Skull Trephinationfor procedural information. Consult with a neurosurgeon if possible. If the epidural is solid white on CT scan, it is clotted and may not extrude through an emergency trephine. An acute epidural typically looks like a mixture of black and white on CT, indicating continuing bleeding. Emergency trephines for epidural hematomas in areas of the skull other than the typical location are often not practical because of skull thickness and the presence of venous sinuses.

If the patient has a seizure, administer diazepam 8 to 10 mg IV. Repeat this dose in 5 minutes if needed. Lorazepam 1 to 2 mg IV may also be used. If there is suspicion that the patient has cerebral contusion or blood in the cranium, load with phenytoin or fosphenytoin after RSI. (Paralysis will mask seizure activity.) If there is evidence of spinal cord injury, check with your receiving facility or neurosurgical consultant regarding administration of high-dose methylprednisolone.7-9
In the context of multiple trauma, acceptable systemic BP may be variable. For instance, a patient with a ruptured thoracic aorta may be stable and not actively bleeding. Assess carefully the amount of fluid used. It may be advisable to keep the BP low. If the patient has a head injury, a BP of 90 mm Hg systolic is acceptable in terms of cerebral perfusion. Do not use hypotonic solutions.

Calculate the Glasgow Coma Score. It is important in terms of estimating prognosis.

Glasgow Coma Scale

Eye Opening
Infant (<1 year)	Pediatric (>1 year)	Adult
Spontaneous	Spontaneous	Spontaneous	4
Voice	Voice	Voice	3
Pain	Pain	Pain	2
None	None	None	1

Verbal Response
Infant (<2 years)	Pediatric (>2 years)	Adult
Coos, babbles	Appropriate word/ phrase	Oriented	5
Irritable but consolable	Disoriented/ converses	Confused	4
Persistent cries/ screams	Inappropriate word	Inappropriate	3
Moans/grunts to pain; restless	Incomprehensible sounds	Incomprehensible	2
None	None	None	1

Motor Response
Infant (<1 year)	Pediatric (>1 year)	Adult
Spontaneous	Obeys	Obeys	6
Localizes pain	Localizes pain	Localizes pain	5
Flexion-withdrawal	Flexion-withdrawal	Withdraws	4
Flexion/decorticate	Flexion/decorticate	Abnormal flexion (decorticate)	3
Extension/decerebrate	Extension/decerebrate	Abnormal extension (decerebrate)	2
None	None	None	1
			_________ 3 to 15

If the primary (initial) assessment is complete, begin the secondary (focused) evaluation.

Facial and Skull Fractures/Scalp Lacerations
Palpate the patient's face and jaw for abnormal step-offs and movement. It is not important to diagnose fracture type; however, Le Fort fractures are frequently mentioned in trauma manuals. See illustration below:

9_p_8_B

Check for loose or missing teeth that the patient may have aspirated in the patient’s mouth and then on the cervical spine and chest x-rays. Tongue injuries with swelling may endanger the airway. Be aware of the possibility of either tongue rings, or other jewelry in the mouth. When facial trauma endangers the airway, cricothyrotomy may be necessary. (Vol II—Air Skills 13 Cricothyrotomy)

Severe nasal hemorrhage may result from facial injuries, especially in hypocoagulable patients. A nasal balloon, Foley catheter, or a Combitube may be used to tamponade bleeding and protect the airway.

If there is a scalp wound, palpate the skull with a gloved finger to identify open or depressed skull fractures. A widely open skull fracture is not necessarily a fatal injury. Cover fractures with a sterile dressing. If the wound edges are bleeding, apply Raney clips to stop the bleeding. These clips do not close the wound. Another technique is to use a large running suture along the wound edges to stop bleeding.

Raney clips are tubular plastic jaws that can grip the full thickness of the scalp,
providing hemostasis. They are applied with a Raney clip applying forces as shown.

9_p_8_C

Posterior access to the scalp is limited. When the patient is lifted or rolled for back inspection, apply the clips. In-line immobilization of the head and neck is necessary. Consider IV antibiotics.

Direct Eye Trauma

CNS injury, direct eye trauma, previous eye surgery as well as nasal decongestants such as phenylephrine may cause dilated or unequal pupils. Topical ophthalmologic anesthetic drops may be used in the initial evaluation and care of any painful eye injury except ruptured globe. Do not remove impaled foreign bodies from eyes.

Remove contact lenses unless there is a possible globe rupture.

Scleral rupture from blunt trauma is accompanied by peripheral scleral hemorrhage. If such is possible, avoid touching the eye. Cover it with a firm plastic or metal shield. Remember to use a defasciculating dose of vecuronium, 0.01 mg/kg, if succinylcholine is to be used in RSI. Fasiculations may cause the muscles of the orbit to squeeze out the vitreous.

If the patient is awake at this time, ask him or her to count fingers as a vision check.

Lid lacerations involving lid margins or tear ducts require repair by an ophthalmologic surgeon.

When there has been eye contamination with acidic or basic chemicals, use copious irrigation with sterile NS using a Morgan lens to prevent continuing injury. Check pH of the tears with a urine dipstick. The resulting pH should be 6 to 8. If there is hyphema of the anterior chambers, try to prevent the patient from struggling as this results in further bleeding.

Bilateral fixed and dilated pupils are ominous for brain death unless secondary to a reversible problem. Hypothermia is an example as well as anticholinergic poisoning.

Disconjugate gaze and nystagmus may be associated with head injury or drug ingestion. Subconjunctival hemorrhage and petechiae of the face occurs with traumatic asphyxia with compression of the superior vena cava.

Soft Tissues of the Neck
Do not explore lacerations and penetrating wounds deeper than the platysma muscle in the ED. Massive hemorrhage can result. Explore these wounds in the operating room, with or without prior angiography. Deep lacerations of the neck may divide the trachea. The trachea may often be directly intubated in such cases.

Laryngeal fracture commonly results from a blow to the neck. A hematoma forms within the larynx, producing airway obstruction. Try gentle orotracheal intubation (if not already performed), but tracheotomy is probably needed. (Vol II—Air Skills 14 Tracheotomy)

The trachea may be displaced to the opposite side of a tension pneumothorax or by a hematoma.

Carotid pulses may be absent secondary to hypotension, direct injury, and aortic injury.

If the external jugular veins can be seen, they provide valuable information regarding the volume status of the trauma patient. Jugular venous distension may indicate tension pneumothorax, cardiac tamponade, volume overload, pulmonary embolism, traumatic asphyxia (compression of the superior vena cava), and heart failure.

Cervical Spine Injury
If cervical spine injury is a possibility, take cervical spine precautions with a hard collar, head blocks, and a long spine board. If the patient has multiple injuries and is likely to be transferred within the hour, maintain immobilization and make no attempt to rule out fracture radiographically. If the patient will be in the emergency department for more than an hour, attempt to get the patient off the spine board. This may involve obtaining a c- spine x ray series as early as possible and/or simply log rolling the cooperative patient off the board and requiring him or her to lie supine with continued cervical immobilization until radiographs are completed. Remember that a non-boarded patient still needs to be log rolled and moved as a unit until radiographs have been confirmed as normal. PEDS: In children and uncooperative patients who require prolonged immobilization, getting the patient off the spine board promptly may not be possible or may require sedation deep enough to necessitate airway control.

Carefully review the lateral c-spine x-ray (Vol II—XraySkills 1 Cervical Spine Rules and Use of Imaging, Xray Skills 2 Cervical Spine Xray Interpretation) for bony or ligamentous injury. Obtain a swimmer’s view if necessary to see the C7-T1 connection. Doing this routinely in large or muscular patients saves time. Look for hematoma formation with airway displacement. Check the sphenoid sinus, if visible, for an air-fluid level signifying a basal skull fracture.

When a patient who is breathing but obtunded needs intubation and the probability of cervical spine injury is high, consider methods that require little neck motion.¹⁰ Light Guided Intubation (LGI) (Vol II—Air Skills 9 Nasotracheal Intubation)and retrograde intubation (Vol II—Air Skills 10 Topical Anesthesia) are two methods that may be used. Standard orotracheal intubation¹¹ with or without RSI has also been shown to be safe and effective in patients with c spine injury when performed with careful manual in-line stabilization of the head and neck.

If not already performed, conduct both mini neuro and rectal exams as described under Abnormal LOC.

Spinal cord injury syndromes follow:

Complete injury. Total loss of sensation and movement below level of injury.

Level	Function	Sensory Level
C2	Breathing	Occiput
C3	Breathing	Neck
C4	Breathing	Top of shoulders
C5	Arm abduction	Anterior of arm
C6	Elbow flexion	Lateral arm and thumb
C7	Elbow extension	Posterior arm and index finger
C8	Finger flexion	Medial arm and small finger
T1	Finger abduction	Just below shoulders

Dermatomes corresponding to the levels of the spinal cord. From Emergency Management of Skeletal Injuries. Ruiz E, Cicero JJ, editors. Mosby-Yearbook, 1995. Reprinted with permission.¹²

Incomplete injury. This is an important finding. Surgical intervention or aggressive reduction may result in recovery. Variable loss of sensation and movement below the level of injury indicates an incomplete injury. An example is sacral sparing with preserved anal sphincter tone. Another is the presence of an anterior cord syndrome in which there is muscle paralysis but preservation of position sense.
Brown-Sequard syndrome. Occurs with penetrating trauma with hemitransection of the cord. It results in loss of motor function below and on the same side as the lesion. This is coupled with loss of pain and temperature sensation on the opposite side of the lesion.
Central cord syndrome. Damage to the central area of the cord predominantly resulting in marked weakness of the arms relative to the legs. Hand grip is tested by shaking hands with the patient. Flexion-extension injuries result in ischemia and edema of the center of the spinal cord, producing this syndrome even without fracture.
Cauda equina syndrome. Damage to the cauda equina as it descends through the sacrum or lumbar spine. This damage produces anesthesia in a saddle distribution of the perineum with loss of anal sphincter tone.

For All Spinal Cord Injuries:

Spinal shock (hypotension with bradycardia) is a diagnosis of exclusion. Spinal shock responds to volume loading. Vasopressors may be added after volume loading is well under way.

In the past, administering high-dose methylprednisolone (30 mg/kg IV over 15 minutes) to patients with evidence of spinal cord injury had been common practice. This has been controversial and is no longer universally accepted. Check with your receiving facility or neurosurgical consultant regarding administration of high-dose methylprednisolone.^7-9

Consult with a neurosurgeon early to ensure that all treatment options are pursued to preserve neurologic function.

Chest Wall and Pulmonary Injury
Palpate the clavicles and the chest wall again for crepitance and fracture. If there are wounds to the chest, do not explore them. Pneumothorax may result. Wounds that enter the chest should be covered with an occlusive dressing with one corner or edge left free to prevent development of tension pneumothorax.

Do not remove impaled objects because they may be providing tamponade to a pulmonary or cardiac wound. Observe for asymmetrical chest movement that may occur with pneumothorax, flail chest, and spinal cord injury with abdominal breathing.

If a needle thoracostomy has been performed during the initial survey for tension pneumothorax, insert a 36 French chest tube on that side now. (Vol II—Breath Skills 1 Chest Tube Insertion)Connect it to chest suction with preparations made to collect blood for possible autotransfusion. (Vol II—Breath Skills 2 Chest Suction and Autotransfusion) Chest wall crepitation means pneumothorax on that side. Insert a chest tube.

The immediate return of 1500 mL of blood means that emergency surgery is probably needed. The immediate return of < 1500 mL of blood that continues to come out at a rate of about 200 mL/h is also ominous. If the BP falls precipitously with drainage of a large volume of blood from the chest, clamp the chest tube because the blood in the chest may have had a tamponade effect. Using an autotransfuser allows the return of the patient’s own blood, only if there is no possibility of gastric contents contaminating the chest cavity.

If a bronchus rupture has occurred, there may be a massive air leak from the chest tube with inability to inflate the lungs. If this occurs, insert an endobronchial tube to allow ventilation of the functioning lung. (Vol II—Breath Skills 3 Endobronchial Tube)

Use a BVM to ventilate the patient. The ventilatory rate for adults is 10 to 12 breaths per minute (or 1 every 5 to 6 seconds) with a tidal volume of 500 to 600 mL (6 to 7 mL/kg). An orogastric tube will also help prevent gastric distension and subsequent elevation of the diaphragm. Palpate the ribs to detect rib fractures. Multiple rib fractures on the same side may result in paradoxical chest wall motion with breathing signifying a flail chest. Not all patients with flail chest need ET intubation. Monitor the patient carefully and intubate at the first sign of fatigue or hypoventilation.

Chest wall bruising or sternal tenderness—as with steering wheel impact—may indicate that the aorta has been injured. Carefully review the chest x-ray for mediastinal widening or other clues, such as tracheal deviation to the right and an apical cap. If thoracic aortic rupture is being considered, attempt to keep the BP at about 100 mm Hg. A helical CT scan of the chest with IV contrast is now considered to be adequate screening for this condition. However, this is technique dependent. Be certain your radiologist and CT technician understand the purpose of the scan.

Examine the chest x-ray for fractured ribs, pneumothorax, hemothorax, scapular fractures, elevated diaphragm, abnormal cardiac silhouette, lung contusion, position of the ET tube and other tubes, and thoracic spine. With bronchial injury, tracheal injury, and esophageal injury, mediastinal air is visible. If a pneumothorax is present, insert a 36 French chest tube and connect to chest suction.

If the patient has been tracheally intubated, listen carefully for breath sounds. If the tube is in too far, the left lung will be inadequately ventilated. Also check for this on the chest x-ray. When a patient is intubated, obtain a follow-up x-ray to check for correct tube placement.

Pulmonary contusion gets worse as the patient's hemodynamic status improves. Blood oxygen saturation will decrease. Transtracheal pressures increases as the lungs become less compliant. Consider using 5 to 10 cm H₂O PEEP if pulmonary contusion is present and hypoxia develops. This may be problematic for a patient in a helicopter, so consider inserting a prophylactic chest tube so that if a pulmonary bleb ruptures, the lungs will still inflate.

Cardiac Tamponade
Muffled heart sounds associated with shock and distended neck veins (Beck's triad) may indicate cardiac tamponade. Cardiac tamponade with blunt trauma is uncommon, but does occur with atrial rupture. The majority of patients with this injury have suffered penetrating trauma.

Perform echocardiography from the subxiphoid window or along the left sternal border. (Vol II—Ultrasound 2 Emergency Ultrasound Technicques)Hypovolemic shock and spinal shock are associated with a vigorously pumping heart; significant myocardial contusion is associated with a weakly pumping heart. Cardiac tamponade is associated with a ring of hypoechogenic fluid surrounding the heart. A compressed right ventricle with a weak beat may also be detected. Ultrasound is a valuable tool in the management of trauma.

In such a case, insert a guidewire-assisted catheter device from the left subxiphoid position directed at the left scapula. (Vol II—Circ Skills 8 Saphenous Veing Cutdown) Use repeated aspirations to keep the patient stable pending surgical repair.

If this procedure is unsuccessful, consider an emergency thoracotomy if your facility has surgical backup. The blood in the pericardial sac may be clotted. Perform the thoracotomy as described in Vol II—Circ Skills 4 Emergency Thoracotomy. If the heart is beating, make a small incision into the sac creating a "window" through which the clot can extrude. A sterile suction catheter may be used to extract the clot. Use a finger to cover this window pending surgical repair.

If the heart is not beating, the sac needs to be widely opened to facilitate internal massage and staple repair of the wound. Open the sac widely by using two fingers to tear it horizontally. If possible, repair the cardiac wound using a skin stapler. Do this before restarting the heart. (Vol II—Circ Skills 4 Emergency Thoracotomy) The staples will be removed and replaced with sutures in the operating room.

If myocardial contusion is possible, observe for ECG changes and evidence of heart failure. Lidocaine 1 mg/kg IV followed by an infusion of 1 to 4 mg IV/min may be indicated for significant ventricular arrhythmias. Amiodarone 150 mg infused over 10 minutes may also be used. Ventricular arrhythmias in this situation are rare.

Hypovolemic Shock
CPR is probably not effective when hypovolemia is involved. Volume replacement is the most important aspect of resuscitation from traumatic cardiac arrest. However, if cardiac arrest occurs, apply CPR while volume is restored.

If IVs have not been established, insert two large bore IVs or a large lumen central venous catheter. Intraosseous methods, including the Bone Injection Gun (BIG)™ and EZ-IO may be used. A lower extremity IV may not be effective if there is a vena cava laceration. Number the IV bags to keep track of the amount of fluid being infused.

Always be careful to avoid air embolism. Track vital signs and review the physical examination for continuing evidence of hypoperfusion (prolonged capillary refill, pallor, coolness, absent or decreased pulses). BP readings alone are not enough. Check the accuracy of your automatic BP machine by comparing it to manual auscultation measurements. These machines are not always reliable in shocky patients. Observe the ECG monitor. Head injuries in and of themselves do not cause hypotension.

Warm NS solution (1 to 2 L) is the preferred fluid during the initial few minutes of resuscitation. To avoid hemodilution, switch to blood transfusion after 2 liter NS if patient remains in shock. Blood is usually administered as packed RBCs. While typed and crossmatched blood is preferred, type-specific blood may also be used. If blood is required immediately, Type O blood is also acceptable. Use Type O Rh-negative for any female with current or future childbearing potential; for all others, use O Rh-positive.

Another common cause of hypocoagulation is hypothermia. Immediately take measures to keep the patient warm. An overhead warming light is useful. Use blood and fluid warmers to warm the IV fluids. Keep the patient covered whenever appropriate.

If blood is not available and continuing fluid infusion is necessary, switch from NS to Ringer's lactate to avoid hyperchloremic acidosis.

Geriatric patients are at great risk of volume overload and pulmonary edema. If the jugular veins are not clearly visible, insert a central venous line (Vol II—CircSkills 1 Arterial andVenous CatheterInsertion) in such patients so that central venous pressure (Vol II—Circ Skills 2 Central Venous Access) can be monitored to titrate volume resuscitation. Head-injured patients and spinal cord-injured patients also benefit from this titration. To rule out the complication of pneumothorax as well as to check placement, always obtain a chest x-ray after insertion of a central line.

To tamponade abdominal or pelvic bleeding, use commercially available pelvic wraps or a sheet and towel clips.

Consider other causes of hypocoagulopathy.

Patients on aspirin or Plavix have poorly functioning platelets. An average-size adult who takes aspirin needs about 4 platelet packs to restore adequate platelet function.
Measure INR in patients on Coumadin. Give fresh frozen plasma units to correct. Under most circumstances, administer Vitamin K.
Draw a fibrinogen level in patients with poor liver function, as in chronic alcoholism. Cryoprecipitate units may be needed.

Inform the referral center of these concerns. Even though your facility may not have these blood products in the laboratory, considerable time can be saved by alerting the referral hospital about your concerns.

Abdominal Injury
If the stomach is filled with air, blood, or food, insert a large orogastric tube and connect to suction. If the patient is intubated, an 18-gauge nasogastric tube may be inserted orally. Pregnant women are especially prone to gastric distension and should almost always have a gastric tube placed when traumatized.

Abdominal tenderness may mean peritoneal irritation secondary to free blood from bowel injuries, splenic rupture, liver laceration or disruption, vena caval or aortic laceration, mesenteric laceration, penetrating wounds, and renal injuries. Patients may minimize abdominal tenderness when distracted by other painful injuries, such as pelvic or femur fractures. Examine for linear bruising caused by seat belts. These are associated with devascularizing injuries to the bowel. Retroperitoneal organs may be injured without signs of peritoneal irritation. Duodenal rupture (or hematoma) and pancreatic lacerations are examples that may be difficult to detect on physical examination.

Lower rib cage injuries may produce abdominal tenderness, but this is a diagnosis of exclusion. Penetrating abdominal knife wounds may be explored down to the first layer of fascia to detect peritoneal penetration. Beyond the first fascial layer, exploration is unreliable.

Flank wounds may involve the colon, kidneys, vena cava, and aorta. When intra-abdominal wounds are suspected, administer a broad-spectrum antibiotic, such as cefoxitin 2 g IV. Penicillin-allergic patients (anaphylactic reaction) may be treated with gentamicin 2 mg/kg IV and clindamycin 600 mg IV.

In most instances, CT scans and/or ultrasound have replaced peritoneal lavage in abdominal trauma. Peritoneal lavage may not be appropriate in the rural setting unless (1) immediate surgical intervention is available and (2) the surgeon must choose between embolization of pelvic bleeding in the radiology suite or surgery in the operating room.

Rapid bedside ultrasound examination (FAST-Focused Assessment Sonography in Trauma) performed by the clinician has become routine at many institutions. Sensitivity and specificity are variable, but identification of intraperitoneal fluid/blood greater than 700 cc, and detection of pericardial tamponade are quite reliable and may guide subsequent management in selected cases. Morrison’s pouch view, subxiphoid view of the heart, and trans-vesical views are the easiest to perform.

Pelvic Fracture
Compress the pelvis in a horizontal and AP plane. Movement or pain with this test signifies pelvic fracture. Movement signifies an unstable pelvic fracture. Review the supine AP view of the pelvis. (Vol II—Xray Skills 3 Interpretation of Pelvic Xray) Pelvic fractures may be difficult to see, but some clue is almost always present. Consider any pelvic fracture dangerous. The major danger is occult hemorrhage.

Follow a protocol when evaluating pelvic trauma:

Examine for perineal lacerations. Do not explore perineal lacerations because external hemorrhage may result. Check for blood in the underwear.
Perform a rectal exam to feel for the position and consistency of the prostate gland in males (including adolescent males) and to detect frank blood in the rectum as well as to determine sphincter tone. Perform this exam before attempting to insert a Foley catheter because a boggy or high-riding prostate indicates urethral transection. Blood in the rectum means rectal penetration or laceration. Begin antibiotics, such as cefoxitin 2 g IV. Treat penicillin-allergic patients (anaphylactic reaction) with gentamicin 2 mg/kg IV and clindamycin 600 mg IV.
Blood at the urinary meatus in males also indicates urethral injury. Insertion of a Foley catheter is contraindicated at this time. However, a urologist may elect to use a Foley to treat a partial dissection of a urethra. In females, gentle insertion may still be performed.
Pelvic fractures, with or without instability, can be associated with massive internal hemorrhage. An alternative method is pelvic sheeting. (Vol II—Trau Skills 3 Pelvic Fracture Stabilization) Commercially made binders are also available.
If the bladder is distended to palpation or ultrasound examination and a urethral disruption or injury has occurred (blood at the meatus), perform a percutaneous suprapubic cystostomy using guidewire technique. (Vol II—Trau Skills 4 Suprapubic Cystostomy) This is especially important for head-injured patients because bladder distension can raise ICP. If the patient is in shock, do not perform this procedure.
Check for femoral pulses because some pelvic fractures are associated with iliac artery injury.
Perform a bimanual vaginal examination feeling for laceration and bone spicules. If positive, begin antibiotics, such as cefoxitin 2 g IV. Treat penicillin-allergic patients (anaphylactic reaction) with gentamicin 2 mg/kg IV and clindamycin 600 mg IV.

If the patient has an unstable pelvic fracture, take care not to move the pelvis, causing more hemorrhage. Instead of log rolling the patient to view his or her back, lift the patient straight up. If the patient is large, simply slide one's hands under the patient to feel the back.

Trauma in Pregnancy
Palpate the abdomen for the presence of a pregnant uterus. If the uterus is palpable above the umbilicus, turn the patient 30º toward the left lateral decubitus position to take the weight of the uterus off of the inferior vena cava. In a spine-boarded patient, towels or blanket s can be placed under the right edge of the board to achieve this. In the non-boarded patient, blankets or pillows can be placed under the right thigh, buttock, flank and shoulder. Central venous pressure (Vol II—Circ Skills 3 Central Venous Pressure Measurement) monitoring may be useful when the cause of hypotension is not clear. Do not forgo essential x-ray studies in pregnant patients. Be aware of the blood volume changes of pregnancy and the placental sensitivity to circulating catecholamines when the mother's blood volume is decreased. Evaluate fetal heart rate with a Doppler stethoscope or ultrasound. Fetal heart rate (FHR) is a sensitive indicator of the mother's volume status.

Placental abruption is common with significant abdominal trauma and may not be accompanied by physical findings. Even small abruptions can result in fetomaternal hemorrhage with isoimmunization. If the mother is Rh-negative, administer Rh-immune globulin for abdominal trauma: 50 μg in the first trimester and 300 μg during the second and third trimesters of pregnancy. Placental abruption may or may not result in external vaginal bleeding. Ultrasound should be preformed to assess for possible placenta abruption or other causes of vaginal bleeding but frequently will not reveal small abruptions. If bleeding is present sterile speculum exam of the cervix is permissible, but digital exam should not be preformed until the possibility of placental previa has been ruled out. (Vol III—OB7 Bleeding in the Second Half of Pregnancy)

If no serious injuries are detected in a pregnant patient but abdominal trauma has been sustained, monitor the patient for at least 4 hours for signs of abruption using FHT tracings, contractions, uterine tenderness, and vaginal bleeding. (Vol III—OB9 Trauma in Pregnancy) Obtain obstetric consultation.

If the patient has soaked fewer than 3 pads and has no positive findings after 4 hours of monitoring, she may be discharged with instructions to contact her physician or return to the ED should any of the following symptoms occur: vaginal bleeding, abdominal pain, contractions, fainting or dizziness, rupture of membranes, and decrease in fetal movement.

Amniotic fluid embolism resulting from abruption results in respiratory failure and disseminated intravascular clotting (DIC) consuming fibrinogen. Treat according to the results of blood clotting tests and clot lysis. Consider perimortem cesarean section if fetal heart beats are present on ultrasound and the level of the uterus is well above the umbilicus. (Vol III—OB10 Emergency Cesarean Section)

See Vol III—OB1 Physiology of Pregnancy for more information about the physiology of the pregnant patient and the emergency management of labor.

Major Joints, Femurs, and Amputations
Reduce major joint dislocations (such as hips, knees, and ankles) using sedation, relaxation, and traction with counter-traction. Short-acting sedatives such as etomidate and propofol work well for this purpose. Reduce the etomidate dose to 0.2 mg/kg to avoid respiratory depression. Add an opioid for pain relief. (Vol II—Air Skills 4 Rapid Sequence Intubation) Take airway precautions. Before the reduction, check for pulses and motion. Absent or decreased pulses can result from the deformity or direct trauma to arteries as well as systemic hypotension. Reduction often results in the return of pulses. Remove all jewelry from extremities prior to manipulation.

When a bone end or fragment is protruding from a wound, rinse off any gross contaminant (such as pebbles or dirt) with saline-soaked sponges then apply traction to reduce the fracture.

If there is a penetrating wound in proximity to a major vessel or nerve, special imaging and/or surgical exploration may be indicated, even in the presence of an apparently good pulse.

Check the legs, thighs, and arms for tense swelling of the muscle compartments. Alert your surgeon about any area suspicious for a compartment syndrome. A decreased pulse is not a necessary component of the syndrome. Fasciotomy may be needed if the patient's transfer is delayed.

If life-threatening problems are ongoing, simply splint the limb in its current position, deferring reduction until the clinical situation permits. Reduce dislocated shoulders and elbows and splint when time permits. Avoid taking x-rays of the extremities for injuries that you will not have to definitively manage.

Fractured femurs. Significant blood loss (as much as 1500 mL) can occur into the soft tissues of the thighs. Traction splints may reduce this loss. Apply traction splints (Sager or Hare) to reduce femur fractures. (Vol II—Trau Skills 1 Compartment Pressure Measurement) The helicopter service may prefer one type of splint because of space issues.

If amputation has occurred and the body part is available, rinse in NS solution and place in a plastic bag (in case it can be implanted later or serve as a source for skin grafting). Place the bag on ice, but do not freeze.

Burns

Perform orotracheal intubation (Vol II—Air Skills 3 Orotracheal Intubation)with in-line immobilization for the following indications: stridor, soot in the pharynx, edema of the uvula, significant burns of the neck, and depressed LOC. If an explosion or closed space fire has occurred, be especially alert to the need to intubate. Also consider possible cyanide exposure. The RSI protocol may be advisable if the patient has muscle tone and reflexes. (Vol II—Air Skills 4 Rapid Sequence Intubation) Ventilate with oxygen.

Completely undress the patient. Be careful of smoldering clothing. Remove jewelry and contact lenses. Immediately cool all burns with NS if <10% of TBSA is burned. (If NS is not available, use water.) If >20% TBSA is burned, cover patient with dry gauze dressings. Patients with burns >20% TBSA are at greater risk for developing hypothermia if wrapped in wet gauze. If <20% TBSA is burned, keep burns moist, but cover patient with blankets to prevent hypothermia.

Start 2 IVs in unburned skin, but use burned skin sites if other sites are not available. Obtain pain relief with morphine IV. Do not administer IM. Titrate from 4 mg to whatever dose provides relief. (Note that you may need much higher doses than normal.) Ventilatory support may be needed.

Administer Ringer’s lactate (or normal saline) solution IV to restore normal BP if possible. Insert a Foley catheter and monitor urine output to provide a guide to the adequacy of fluid administration. A urine output of 50 to 70 mL/h is the goal. (The gold standard for fluid resuscitation in burn victim is to maintain urine output at 50 to 70 mL/hour.)

Don’t treat tachycardia as all burn patients are prone tachycardic.

For any patient with a body surface burn of 20% or greater, administer IV fluids. The Parkland Formula is used to calculate the estimated fluid requirements of burn patients:

Percentage of Body Surface Area burned X weight in kg X 4 mL Ringer's Lactate solution = 24 hour fluid requirement.
Half will be needed during the first 8 hours.
Half will be needed during the following 16 hours.

Administer cimetidine IV, 300 mg. Insert an NG tube if the burn is significant. Using the Rule of Nines, grossly estimate the percentage of body surface burned: the head is 9%, each arm is 9%, the front of the torso is 18%, the back of the torso is 18%, each whole leg is 18%, and the perineum is 1%.

9_p_8_E

The Rule of Nines is used to estimate percentage of body burned. Monitor the patient’s core temperature with a rectal probe. Do not use cool NS soaks for pain relief. A dry occlusive dressing will suffice. Do not apply antiseptic creams. Do not break intact blisters. Do not administer antibiotics. Consider tetanus status.

Circumferential third-degree burns of the extremities or the chest (torso) can produce a tough eschar that can compromise blood flow or chest wall movement. Escharotomies may be necessary. Contact a burn consultant emergently regarding how and where to perform these escharotomies. Fortunately, these areas will be anesthetic as the nerve endings have been destroyed.

Treat patients with the following indications at a burn center:

Burns > 10% of body surface in patients < 10 or > 50 years
Burns > 20% of body surface in all age groups
Full thickness (third-degree) burns > 5% of body surface - all ages
Burns involving the hands, feet, eyes, perineum
Inhalation, electrical, or chemical burns
Burns associated with major trauma or preexisting disease

Electrical burns

The extent of electrical burns may be difficult to ascertain immediately. The injury is typically to the deeper structures of the body, such as muscle and vascular (not superficial or cutaneous) tissue. Thus, the damage is not easily observable to the naked eye on physical exam. For this reason, cardiac dysrhythmias may result from electrical burns. ECG monitoring is important. When dysrhythmias occur, see Vol I—Pathway 2 Cardiovascular Emergencies for treatment options. Another common finding is muscle necrosis resulting in myoglobinuria. Clinically, this is observed as a reddish hue to the urine. Increase the infusion of fluids to result in a urine output of 100 mL/h. If this does not rapidly clear the urine, add 25 g mannitol IV and add 12.5 g to each subsequent liter bag of Ringer’s solution.

Many patients with electrical injury have suffered injuries from seizures and falls, including cervical spine injuries and head trauma. Carefully evaluate the whole patient.

Lightning strike

Cardiac arrest with VF or asystole is the most serious effect of lightning strike. Treat any dysrrhythmia as described in Vol I—Pathway 2 Cardiovascular Emergencies. Burns from lightning strike are often inconsequential. Wet clothing may protect the patient by causing the current to flow over the patient rather than through him or her. This is referred to as flashover phenomenon.¹³ Under unusual conditions, an explosive or implosive effect from a lightning bolt can cause blunt injury. Initial management is as with all trauma patients.

Heat Stroke

Heat exhaustion is accompanied by weakness, faintness, and diaphoresis. Core body temperature does not reach dangerous levels. Cool liquids and rest usually suffice.

Heat stroke is accompanied by weakness, faintness, or coma and (classically) dry skin, with dangerous core temperatures of 40.5ºC (105ºF) or higher. In athletes and others well accommodated to heat, the skin may be diaphoretic.

A patient usually presents with prostration and a depressed LOC. Seizures may occur. Orotracheal intubation may need to be performed. (Vol II—Air Skills 3 Orotracheal Intubation)

When vital signs reveal severe hyperthermia, immediately begin cooling the body to reduce core temperature before permanent CNS damage occurs. An effective method is to undress the patient and spray tepid water on the body while fans blow air over the body. The resulting evaporation lowers body temperature without causing shivering that can slow the cool-down. Ice packs may be placed in the axillae and groin. If the core temperature fails to respond, gastric and bladder irrigation with cool NS may also be used. Lower the body temperature to about 40ºC (104ºF) then remove the water and fans because the core temperature will continue to decrease.

Geriatric patients taking psychotropic medications and/or living in settings without air conditioning are especially prone to heat stroke. Monitor such patients carefully.

Many complications may ensue including cerebral edema, heart failure, myonecrosis, and pulmonary edema. The patient may be severely dehydrated on arrival. Hydrate vigorously but monitor carefully so as not to overshoot the mark. Central venous access (Vol II—Circ Skills 3 Central Venous Pressure Measurement) may be advisable, especially in geriatric patients. Most patients will require monitoring in an intensive care unit post resuscitation.

Severe Hypothermia
Many patients with hypothermia have also suffered trauma. Evaluate hypothermia patients as trauma patients.¹³

Definition According to Core Temperature

Mild hypothermia	34ºC to 36ºC (93ºF to 96ºF)
Moderate hypothermia	30ºC to 34ºC (86ºF to 93ºF)
Severe hypothermia	< 30ºC

Mildly hypothermic patients may be rewarmed with the external application of warmth and warm fluids. Moderately hypothermic patients must be closely monitored because of cardiac irritability at this temperature. However, external warmth and warm IV fluids will suffice as rewarming methods.

Core temperature is best measured with an esophageal probe with a monitor capable of reading very low temperatures, but this is invalid if gastric lavage is used. Rectal temperature is the most practical method.

The severely hypothermic patient may appear to be clinically dead. In the absence of other factors incompatible with life, aggressively attempt resuscitation until the core temperature is above 34ºC (93ºF). Asystole above this temperature should not be attributed to hypothermia and other causes should be considered. (Vol I—Acute Care Portals, Asystole)

Patients have survived total immersion in very cold water for 30 to 45 minutes and core temperatures of about 15ºC to 16ºC (60ºF). Use clinical judgment. The American Heart Association recommends not completely rewarming every patient before pronouncing death, but astounding cases of survival from apparent death do occur.

Aggressive airway management is necessary. RSI is usually not needed. Cold bronchorhea occurs and demands good tracheal toilet. Heated humidified oxygen ventilation is also needed. Gross movement—as in moving from an upright to supine position—can precipitate VF. Perform CPR. If the patient is in VF, attempt defibrillation one time, but do not persist.

The natural history of VF arrest in hypothermia in a patient with a normal heart is as follows:

At a core temp of about 21ºC (75ºF), the rhythm spontaneously converts to atrial fibrillation with a slow ventricular response. At a core temp of about 27ºC (80ºF) the ventricular response becomes faster. At a core temp of about 30ºC (86ºF) the rhythm spontaneously converts to normal sinus rhythm.

These are estimates only, and individual cases vary. Continue CPR until the pulse is palpable. If the patient has not converted at a temp of about 32ºC (90ºF), administer appropriate cardiac medications to restore sinus rhythm. (Vol I—
Pathway 2 Cardiovascular Emergencies) Cardiac medications are not effective in severely hypothermic patients and may accumulate with adverse effects when the patient is warm. Hypothermic patients will have abnormal electrolytes, acid/base components, and glucose. Measure these frequently during the rewarming process.

Hypothermic patients are hypovolemic because of cold diuresis produced when the cold kidneys fail to concentrate urine. Establish large bore IVs for administering a bolus of warm NS.

Cold causes a shift of the oxyhemoglobin dissociation curve to the left. Some degree of acidosis (which causes a shift to the right) is protective. A low PCO₂ can cause alkalosis; do not hyperventilate these patients.

Blood gases may be corrected for temperature or not. One line of reasoning is that the whole body is cold, not just the blood, so measuring blood gases at 37ºC is appropriate because the cold body temperature changes the body's enzyme systems and chemistries in the same way as it does the blood gases. Normal blood gases, under these circumstances, indicate that a physiologic balance of oxygen, hydrogen ions, and carbon dioxide are present in a hypothermic patient.

To rewarm severely hypothermic patients, avoid using external methods because increasing the oxygen demands of the periphery before the central circulation is capable of delivery is counter-productive. Peripheral vasodilation may return cold blood to the core with a resulting paradoxical drop in core temperature. Use internal methods if the patient's core temperature is less than 30ºC (86ºF). Expect a rate of rewarming of about 4ºC (7ºF) per hour.

Internal Rewarming Methods That May Be Used:

Heated, humidified oxygen ventilation at 42ºC to 46ºC [108ºF to 115ºF].
Warm IV (or IO) fluids at 40ºC to 43ºC [104ºF to 109ºF]
Warm gastric lavage using tap water at 40ºC to 43ºC [104ºF to 109ºF]. Use a standard gastric lavage set up
Warm urinary bladder lavage using sterile NS at 40ºC to 43ºC (104ºF to 109ºF). Connect the Foley catheter to a standard gastric lavage set up that has been sterilized. Use a volume of about 5 mL/kg.
Closed peritoneal lavage if the patient does not have a surgical incision on the abdomen. Use NS at 40ºC to 43ºC (104ºF to 109ºF).
Closed left chest lavage using a chest tube connected to chest suction (Vol II—Breath Skills 1 Chest Tube Intubation)and a large needle thoracostomy catheter inserted over the 3rd rib in the midclavicular line (Vol II—Breath Skills 5 Needle Thoracostomy). Warm NS at 40ºC to 43ºC (104ºF to 109ºF) is infused into the chest through the needle thoracostomy catheter and allowed to bathe the heart and left lung before evacuation through the chest tube.
Cardiopulmonary bypass is the quickest and most effective way of rewarming severely hypothermic patients. Trauma centers are prepared to do this. Patients who have solidly frozen extremities or are in cardiac arrest are most likely to benefit with this form of rewarming. Consult freely about these cases.

Near Drowning

Some near-drowning patients are actually diving accident victims. Always work up patients with possible trauma in mind.¹⁵ Patients should be immobilized. In the ED, evaluation and treatment follows the usual trauma patient protocol.

Patients rarely inhale much fluid into the lungs because of laryngeal spasm and breath holding. The occurrence of hemolysis in fresh water drowning and hemoconcentration in salt water drowning is largely theoretical. A significant admonition, however, is that patients may develop acute pulmonary edema hours after the event. All near-drowning patients require a period of observation, even if asymptomatic upon presentation. If the patient remains entirely asymptomatic with normal respiratory function at 6 to 8 hours, he or she may be safely discharged. Any abnormality that occurs during the observation period such as cough, difficulty breathing, abnormal lung sounds, oximetry, or blood gasses in an indication for further observation and intervention as needed. (Vol III—ENV4 Near Drowning) Recognize that hypothermia may be present. Measure rectal temperature.

If hypothermia, trauma, and significant aspiration are not present, hypoxic brain injury is probably the cause of continuing coma. (Vol I—Pathway 1 Altered Level of Consciousness)

Caustic Substance Ingestion
Caustic ingestions usually involve the intentional ingestion of drain cleaners containing concentrated alkaline powders or solutions. These strongly basic substances, usually sodium or potassium hydroxide, produce liquefaction necrosis. In powder form, they likely result in more proximal tissue destruction and more airway compromise. In liquid form, they likely destroy tissue in the distal esophagus and stomach.

The potential for airway compromise is great. If there is any question about swelling, stridor, edema, or burning about the posterior pharynx, orotracheally intubate the patient. (Vol II—Air Skills 3 Orotracheal Intubation) Perform RSI to ensure the gentlest intubation. (Vol I—Air Skills 4 Rapid Sequence Intubation) Nasotracheal intubation is contraindicated because it may result in more injury. If orotracheal intubation is not successful, perform emergency cricothyrotomy. (Vol II—Air Skills 13 Cricothyrotomy) Administer oxygen and establish IVs. Pain control may be needed. Support the patient's vital signs.

Beyond airway control and general support, little can be done in the rural setting. Gastric lavage and dilution may do more harm than good. Consult the otolaryngologist and prepare to transfer as quickly as possible. The consultant may favor steroid therapy and antibiotics. Subsequent gastric and esophageal perforation may occur a week or two after the ingestion.

References

American College of Surgeons. Advanced Trauma Life Support for Doctors: Student Course Manual, 7th ed. Chicago, Ill: American College of Surgeons, 2004.
Miller, RD, editor. Miller’s Anesthesia, 6th ed. Philadelphia, Pa: Churchill Livingstone, 2005.
Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50:653-665.
Shirley P. Cricoid pressure for emergency airway management. Emerg Med Australas. 2006;18:99.
Morris J, Cook TM. Rapid sequence intubation: a national survey of practice. Anaesthesia. 2001;56:1090-1097.
Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia. 2000;55:208-211.
Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine. 2006;31(11 suppl):S16-S21.
Sayer FT, Kronvall E, Nilsson OG. Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature. Spine J. 2006;6:335-343.
Bracken MB. Steroids for acute spinal cord injury. Cochrane Database of Systematic Reviews 2002. Issue 2. Art No: CD001046.DOI: 10.1002/14651858.CD001046.
Holley J, Jorden R. Airway management in patients with unstable cervical spine fractures. Ann Emerg Med. 1989;18:1237-1239.
Shatney CH, Brunner RD, Nguyen TQ. The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg. 1995;170:676-679.
Ruiz E, Cicero JJ, editors. Emergency Management of Skeletal Injuries. Mosby-Yearbook, 1995.
Cwinn AA, Cantrill SV. Lightning injuries. J Emerg Med. 1985; 2:379-388
McCullough L, Arora S. Diagnosis and treatment of hypothermia. Am Fam Physician. 2004;70:2325-2332.
Golden FS, Tipton MJ, Scott RC. Immersion, near-drowning and drowning. Br J Anaesth. 1997;79:214-225.

Pathway 8: Adult Trauma

(Secondary Survey for Adults)

References

Edition 13-October 2011