MULTIDISCIPLINARY TRAINING IN

TRAUMA and EMERGENCY CARE (MTEC)

Basic Trauma Care

Developed by
All India Institute of Medical Sciences Bhopal

with assistance from

Department of Public Health and Family Welfare
Government of Madhya Pradesh
 Multidisciplinary training in
Emergency and Trauma Care (MTEC)

AIIMS Bhopal
Certification in
Basic Trauma care

Developed by
All India Institute of Medical Sciences Bhopal
with assistance from
Department of Public Health and Family Welfare
Government of Madhya Pradesh
AIIMS Bhopal Certification in Basic Trauma Care

A certificate course
developed and conducted by
All India Institute of Medical Sciences Bhopal
2014

Patron: Prof Sandeep Kumar, Director AIIMS Bhopal

Chairperson: Prof Vijaysheel Gautam, AIIMS Patna
Course Director: Dr Saurabh Saigal

Writing team:

Dr Saurabh Saigal Dr Jai Prakash Sharma

Department of Trauma & Emergency Medicine Department of Anesthesiology
AIIMS Bhopal AIIMS Bhopal

Dr Manal M Khan Dr Anshul Rai

Department of Burns and Plastic Surgery Department of Trauma & Emergency Medicine
AIIMS Bhopal AIIMS Bhopal

Dr Vikas Chandra Jha Sr. Resident Department of Anaesthesia

Department of Neurosurgery
AIIMS Bhopal Dr Sanjay Kumar

Dr Adesh Shrivastava
Dr Ritika Dhurwe
Department of Neurosurgery
AIIMS Bhopal
Dr Vigya Goyal
Dr Rajnish Joshi
Dr Jyotsna Kubre
Department of General Medicine
AIIMS Bhopal

Dr Nirendra Rai
Department of Neurology
AIIMS Bhopal
 TABLE OF CONTENTS

Introduction
Chapter 1 : Basic Trauma Life Support 1
Chapter 2 : Airway Management in Trauma 8
Chapter 3 : Shock 17
Chapter 4 : Chest Trauma 23
Chapter 5 : Abdominal Trauma 33
Chapter 6 : Head Injury 38
Chapter 7 : Burns, Thermal and Electrical Injuries 42
Chapter 8 : Maxilofacial Trauma 53
Chapter 9 : Musculoskeletal Trauma 57
Chapter 10 : Spinal Injury 61
Chapter 11 : Trauma Triage 68
 Foreword

Having completed my Masters in Surgery in 1980, I became a Surgical Registrar in an

academic surgical department in Wales, UK. I became a full time surgical teacher in
1984 and started teaching – general surgery and systemic surgery. I have been a fond
student of general surgical principles. We assiduously taught and learnt various types
of wounds and their management. We were given didactic teaching on pre-operative
assessment and post-operative care. There was hardly any concept of electronic
monitoring of vital parameters and the science of critical care was not evolved. There
were no specialist who called themselves as specialist in critical care. We did not
understand the difference between acute care, critical care, long term acute care and
long term critical care. Three decades ago the text book did not describe that critical
care is a common science between all departments be it surgery, medicine, cardiology or nephrology. All of
us compartmentalized our management of critically ill patients with hardly any concept that critical ill
person required a common and perhaps an algorithmic management to support the vital functions of
human body. That brain was to be sustained by an efficient circulatory system maintaining the body’s pH and
electrolytes and getting the body rid of its toxic products. There were no available gadgetry to measure the
discrepancy between ventilation and perfusion. We were heavily dependent upon our clinical judgment and
biochemical estimations done from time to time. The last two decades have turned a corner in clinical
medical practice recognizing that be it major trauma, sepsis, post-operative care or metabolic derangement,
the body required life sustainable efforts which were common to a diverse group of subjects with diverse
systemic affection. This led to an evolution of a science of critical care and emergency medicine. Several types
of paramedics were trained only later to understand that they all coalesce to do almost the same things. And
thus was born the science of critical care and very rightly so a large number of courses and societies have
come up in most countries internationally to take up this onerous task of creating human resource both of
doctor and paramedics in the science of critical care and trauma and emergency medicine. It has somewhat
diversified into acute trauma and life support care, critical care in intensive care units and critical care in
cardiac, respiratory and kidney diseases. Critical care of pediatrics patients and neonates has also evolved as
a new speciality in the past two decades. India was a bit slow initially to take up this emerging branch of
medicine. One reason for this may have been a very high cost of the gadgetry and the invasive monitoring
using gadgets like Swan Ganz Catheter in 1980s. New patho-physiologicalresearches in critically ill subjects,
oscilloscope based non-invasive digital monitoring and discovery of new transducers led to a new genre
gadgets and soon the science of critical care became a common science providing a common consultation
and care to patients from various departments.

There was lot of teaching required in this area. More than teaching a large number of new motor skills were to
be learnt by the providers. There were debates on algorithms. There were ABCD’s, ABCCD’s and CAB and
there were debates as to how much?how to give? andhow much to give? There were disagreements, schools
of thoughts and meetings and conglomerations to bring forth unified thinking. The last decade witnessed
more unison in thinking bridging the gaps of semantics. Yet another gap that was witnessed that life support
required frequent invasive procedures on seriously ill or injured. These procedures included access to
peripheral and central vessels, cardio-pulmonary resuscitation (CPR), ventilatory support, clearing and
creation of new artificial airway for example tracheostomy, removal of helmet and foreign bodies, caring for
destabilized limb and torso, lifting and transport of injured or ill subjects in a critically ill situation. I learnt
these as a boy scout and during my sojourn with St John’s Ambulance Brigade and National Cadet Corps. The
training was simple though very firmly taught me splinting the fractured limbs, use of triangular bandages,
jugaad, and transport and evacuation. It led the classical teaching of “triage”.
A yet another technology that has eminently bridged the gap in providing skilled manpower is availability of
mannequins. These are tremendous innovations. Never in the science of medicine across its 40 odd practiced
disciplines including coronary vessel stenting, there has been availability of simulation equipment.In the last
decade systematic trainers have taken the responsibility of creating a human resource in some of the above
skills. Interestingly this training has not only been given to but the trainers in critical care have been less
partisan in training para-medicals and general public also. This has hoisted the flag of critical care medicine,
the highest and just like computer science. It has evolved a common subject for all medical subjects. Critical
care science in my opinion istruly a trans-disciplinary science with evolved principles of physiology,
medicine, surgical skills, epidemiology, social psychology, primary prevention and tertiary care.

I was very keen to establish skills laboratories at the All India Institute of Medical Sciences Bhopal and we have
proudly done so. Our faculty especially Dr JP Sharma and Dr Saurabh Saigal has taken the lead and
conducted a large number of training programs. The program on ABG (Arterial Blood Gas) and Basic
Mechanical Ventilation were all too popular. These programs were not simplya single shot show off but have
become a feature and have been taken up as regular activity to create human resource in critical care. We
have developed our own modules and have called these multidisciplinary training in trauma and emergency
care (MTEC). The acronym MTEC was given to me by my mentor in Trauma and Emergency Medicine, Dr Vijay
Gautam some three decades ago when he was a consultant in Accident & Emergency in a north London
hospital. I visited him there and we conducted the first MTEC course at King George’s Medical University
(KGMU) Lucknow in 1996. The material we wrote for that workshop was never published and surely needed
total re-writing in the light of new found knowledge of physiology in critical care. When I asked my faculty
members at AIIMS Bhopal, they readily took up the challenge and here is a very well written text in front of
you that I think is first attempt in India to create India specific algorithms and modules in our own hinglish. I
am sure a some of you may frown upon us and say are we trying to show a mirror to ATLS, ACLS modules. But
then the immunity of an author and a creator and the judgment of its reader will only determine the
usefulness of this text. It may see the redundancy of the library shelves or it may soon be the essential referral
module. We will soon translate in vernacular Hindi. Our writers - Dr Rajnish Joshi, Dr Vaibhav Ingle, Dr Sagar
Khadanga, Dr Nirendra Rai, Dr Bhavna Dhingra, Dr Girish Bhatt, Dr Manal M Khan, Dr Vikas Jha, Dr Adesh
Shrivastava, Dr Anshul Rai, Dr Sanjay Kumar, Dr JP Sharma and Dr Saurabh Saigal has worked round-the-clock
to produce this high quality teaching & training module.

Prof Sandeep Kumar

MS (Surgery) FRCS (Edin) PhD (Univ of Wales UK) MMSc (Newcastle)
Director
All India Institute of Medical Sciences Bhopal
Saket Nagar Bhopal – 462 020 MP
 Introduction

Trauma is the fourth leading cause of death in India and accounts for 8.5% of all deaths. India is the world’s
10th most powerful country and ranks 3rd most rapidly growing economy. On a global scale injuries are
responsible for 21.7% of global deaths and 31.1% of DALYs (disease adjusted life years).Injuries most
commonly accrue from road traffic accidents, surface fall (mostly elderly) and fall from height (mostly
children), burns, drowning, natural calamities (floods, earthquakes, landslides, tsunami and tornados),
civilian and industrial accidents, sports, attempted suicide, civilian violence and combats of the armed forces.
In India road traffic accidents are the leading cause of all the injuries. According to the World Health
Organization (WHO), road traffic injuries are the sixth leading cause of death in India with a greater share of
hospitalization, deaths, disabilities and socio-economic losses in the young and middle-aged population.
Road traffic injuries also place a huge burden on the health sector in terms of acute care and rehabilitation.

During 2011, a total of 4,97,686 road accidents were reported by all States/UTs. The proportion of fatal
accidents in the total road accidents has consistently increased since 2002 from 18.1% to 24.4% in 2011. The
severity of road accidents measured in terms of persons killed per 100 accidents has also increased from 20.8
in 2002 to 28.6 in 2011. The state of Madhya Pradesh ranks third (10.3%) in overall list of road accidents in
India and fourth in number of injuries (11%) as per data, published by Ministry of Road Transport & Highway
2012. Census of India published in 2011 reported 53 ‘million-plus’ cities, of these 53 cities, 50 reported road
accident data for 2012. These 50 cities accounted a share of 22.5 per cent in total road accidents in the
country, 12.3 per cent in total persons killed in road accidents and 15.9 per cent in total persons injured.
Among the 53 mega cities, the highest cases of road accidents were reported in Mumbai 24,592 which
resulted in 4543 injuries and 471 deaths. The city of Bhopal ranks 7th in number of total road accidents (3623)
and eighth in total persons injured.

India has lacked behind in providing infrastructure for high profile trauma care to its citizens. Apartfrom the
trauma center at AIIMS Delhi, there is scarcity of dedicated and integrated apex trauma centers in India.
Under Pradhan Mantri Swasthya Seva Yojna (PMSSY) - six new AIIMS have been established. AIIMS Bhopal
being one of them is coming up with first of its kind Level-1 Trauma & Emergency Centre in Central India.

The first hour management i.e. golden hour management of these patients is of prime importance. Around
70% of the population of India resides in villages and small towns. Most of these patients during the first hour
i.e. golden hour reach to their respective District Hospital which are not equipped with essential equipment’s
and manpower. As a result lots of these patients die before reaching the tertiary care hospital.The basic aim of
AIIMS Bhopal is to fill in these gaps in trauma care systems and first step in this process is to train medical
officers of Madhya Pradesh.The Basic Trauma Course will teach and train them in various aspects of trauma
care from initial assessment, airway management, chest trauma, abdominal trauma, head injury, spine
injuries, maxillofacial injuries and burn management. They will also be trained in various skills ranging from
cervical collar placement, spine board placement, manual in line stabilization, log rolling, airway
management, intubation and application of splints. Apart from this most importantly they will be taught
about initial management of trauma patient i.e. Primary Survey in which each patient has to be approached
in systematic way ie ABCDE way.
 AIIMS Bhopal 2014

CHAPTER 1
BASIC TRAUMA LIFE SUPPORT
Definitions : dextrose with normal saline.

1. Injury:Acute exposure to physical agents 5. Universal precautions to be taken like

such as mechanical energy, heat, electricity, wearing caps, masks, gloves and gowns
chemicals and ionizing radiation interacting while handling the patients to protect
with the body in amounts or at rates that against blood borne diseases like-
exceed the threshold of human tolerance. In Hepatitis, AIDS etc.
some cases, injuries result from the sudden
Prerequisites to primary survey : before
lack of essential agents such as oxygen or
initiating primary survey few prerequisites
heat.
are to be followed
2. Trauma : An injury (as a wound) to living
1. Assess consciousness; if consciousness
tissue caused by an extrinsic agent. As per
is intact this means that his airway,
definition we will be dealing in this manual
breathing, circulation and sensorium
variety of trauma ranging from head
are intact.
trauma, airway trauma, chest trauma,
abdominal trauma, musculo skeltal trauma 2. Apply oxygen and attach the monitors
and trauma due to - burns, heat, electricity with monitoring of heart rate pulse
and ionizing radiation. blood pressure and saturation.
Basics steps in Trauma management B. Initial survey and resuscitation

These are the basic steps which are to be Primary survey is basically identification of
followed in each and every case of trauma life threatening injuries; these are injuries
which are immediate danger to life. These
A. Preparation are to be identified immediately and have to
B. Initial survey and resuscitation be corrected immediately. Dictum is to treat
first that kills first. Immediate cause of death
C. Secondary survey in a patient of trauma is hypoxia which
followed by hypotension. The approach to
D. Definitive care the patient has to be done in a systematic
A. Preparation: way.

1. Check oxygen : Availability of oxygen 1. Airway maintenance with cervical spine

cylinders protection

2. S u c t i o n a p p a r a t u s : c h e c k t h e 2. Breathing and ventilation

functionality of the apparatus. 3. Circulation with bleeding control
3. Airway equipment’s are to be kept and 4. Disability (neurological evaluation)
checked like laryngoscopes, facemask,
oropharyngeal airway, nasopharyngeal 5. Exposure/Environmental control:
airway, Endo-tracheal tubes. Undress the patient completely, taking
care of hypothermia.
4. Intravenous cannula 16G, 18G, 20 G;
warm intravenous fluids- including 6. Adjuvants during primary resuscitation
normal saline, ringer lactate and

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Basic Trauma Care

1) Airway maintenance with cervical spine

protection:
Prior handling of the airway the cervical spine
protection is a must. Cervical collar has to be
applied. In airway management following steps

Figure 4: Proper holding of Bag and Mask Ventilation

Figure1 : Jaw-Thrust

Figure 5: Manual in line Stabilisation (MILS)

are to be followed.
i. Suction the airway.
ii. Chin lift, jaw thrust manoeuvres are to be
Figure 2: Proper length of Naso-pharyngeal Airway applied. Head tilt to be avoided in trauma
patients.(Fig 1)
iii. Insert appropriate size oropharyngeal
air way, avoid nasophar yngeal
airway.(Figure 2)
iv. Check for Bag and Mask Ventilation- Proper
mask holding with C&E technique.(Figure 3
& 4)
v. D e fi n i te a i r way : I s d e fi n e d a s t u b e
[Endotracheal tube / Tracheostomy tube] in
the trachea with inflated cuff below the
vocal cords, the tube connected to some
form of oxygen enriched device & airway
Figure 3: Proper holding of Mask; C & E technique
secured with a tape.

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 AIIMS Bhopal 2014

vi. At time of intubation manual in line mediastinum is pushed to opposite side

stabilisation is a must.(Figure 5) with compression of heart and lung to
opposite side. A creation of positive
2) Breathing with ventilation Six life pressure hampers venous return which in
threatening injuries in the chest and turn leads to low cardiac output. Immediate
mediastianum are to be identified and treatment is needle decompression in
treated immediately. Following steps are to second intercostal space in mid clavicular
be followed at the time of examination of line.
the chest.
iii. Flail chest : A flail chest occurs when a
l Inspection : Look for neck veins segment of the chest wall does not have
whether they are distended or collapsed, bony continuity with the rest of the thoracic
injury marks- lacerations etc. cage. This condition usually results from
l Auscultation : Hear for breath sounds trauma associated with multiple rib
fractures— that is, two or more adjacent ribs
l Percussion : Dull note in case of fluid fractured at two or more sites. The presence
and Resonant note in case of air. of a flail chest segment results in disruption
of normal chest wall movement. The
There are six immediate life threatening
definitive treatment is to ensure adequate
injuries which impair ventilation:
oxygenation, administer fluids judiciously
1. Open pneumothorax and provide analgesia to improve
ventilation. The analgesia latter can be
2. Tension pneumothorax. achieved with intravenous narcotics or local
3. Flail chest with pulmonary contusion anesthetic administration. The use of local
anesthetics avoids the potential respiratory
4. Massive hemothorax. depression which is common with systemic
narcotics. The options for administration of
5. Cardiac Tamponade
local anesthetics include intermittent
6. Laryngotracheal injuries intercostal nerve block(s), intrapleural,
extrapleural, or epidural anesthesia. When
i. Open pneumothorax : Open used properly, local anesthetic agents can
pneumothorax is characterized by open provide excellent analgesia and prevent the
wound in chest wall. The open wound in need for intubation.
chest wall leads to an open defect through
which air enters into the pleural cavity and iv. Massive hemothorax : Accumulation of
creates a pneumothorax. The management blood and fluid in a hemi-thorax can
is three sided occlusive dressing of the significantly compromise respiratory efforts
defect, this creates a one way valve by compressing the lung and preventing
mechanism which in turn prevents air entry adequate ventilation. Such massive acute
in inspiration through that defect but accumulations of blood more dramatically
during expiration a positive pressure is present as hypotension and shock. In
created which in turn leads to escape of patients with massive hemothorax, the
gases through that defect. Definite neck veins may be flat as a result of severe
management is chest tube insertion in 4th - hypovolemia, or they may be distended if
5th Intercostal Space just anterior to Mid- there is an associated tension
Axillary Line thereafter closing the defect. pneumothorax. Massive hemothorax is
initially managed by the simultaneous
ii. Tension pneumothorax: As the word restoration of blood volume and
suggests tension, this tension is created in decompression of the chest cavity. Large-
thorax. Air enters the pleural cavity which in caliber intravenous lines and a rapid
turns creates so much pressure that crystalloid infusion are begun, and type-

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Basic Trauma Care

Open Pneumothorax Tension pneumothorax Massive Hemothorax

Flail chest with pulmonary contusion Cardiac Tamponade

Breath sounds

Absent/Diminished Present-Diminished Heart sounds

Percussion Cardiac Tamponade

Dull note Hyper-resonant note

Massive Hemothorax Open Pneumothorax

Flail chest with pulmonary contusion Tension pneumothorax

Figure 6: Identifying Six Life Threatening Injuries including laryngo-tracheal injury

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 AIIMS Bhopal 2014

specific blood is administered as soon as The diagnosis can usually be made with the
possible. A single chest tube (36 or 40 FAST exam. If a qualified surgeon is present,
French) is inserted, usually at the nipple surgery should be performed to relieve the
level, just anterior to the mid-axillary line, tamponade. This is best performed in the
and rapid restoration of volume continues operating room if the patient’s condition
as decompression of the chest cavity is allows. If surgical intervention is not
completed. If 1500 mL of fluid is possible, Pericardiocentesis can be
immediately evacuated, early thoracotomy diagnostic as well as therapeutic, but it is
is almost always required. Patients who not definitive treatment for cardiac
have an initial output of less than 1500 mL of tamponade.
fluid, but continue to bleed, may also
require thoracotomy. This decision is not vi. Laryngotracheal injuries
based solely on the rate of continuing blood This is rare, is characterised by persistent
loss (200 mL/hr for 2 to 4 hours), but also on pneumothorax. Treatment of choices
t h e p a t i e n t ’s p h y s i o l o g i c s t a t u s . surgical repair of the rent.
Thoracotomy is not indicated unless a
s u rg e o n , q u a l i fi e d by t ra i n i n g a n d 3) Circulation with bleeding control
experience, is present.
Main role is stoppage of bleeding along with
v. Cardiac tamponade : Cardiac tamponade replacement with warm intravenous fluids. We
most commonly results from penetrating should not solely rely on blood pressure. Cool
injuries. However, blunt injury also can extremities and tachycardia are the earliest
cause the pericardium to fill with blood signs of impaired hypo perfusion (Figure 7). If
from the heart, great vessels, or pericardial there is blood on floor we should look for four
vessels. The human pericardial sac is a fixed more sites i.e. Chest, Abdomen, Pelvis &
fibrous structure; a relatively small amount E x t re m i t i e s. I f p a t i e n t w i t h t r a u m a i s
of blood can restrict cardiac activity and hypotensive then cause is usually these four
interfere with cardiac filling. Cardiac sites as mentioned above (Figure 8). On the
tamponade may develop slowly, allowing other hand if head injury is present, it leads to
for a less urgent evaluation, or may occur intracranial bleed. The intracranial bleed if
rapidly, requiring rapid diagnosis and present will lead to raised ICP which in turn will
treatment. The diagnosis of cardiac lead to raised BP to maintain cerebral perfusion
tamponade can be difficult in the setting of pressure.
a busy trauma or emergency room. Cardiac
tamponade is indicated by the presence of a) Chest : Massive hemothorax leads to
the classic diagnostic Beck’s triad: venous accumulation of blood in pleural space. This
pressure elevation, decline in arterial in turn leads to hypotension. Immediate
pressure, and muffled heart tones. However, treatment is rapid infusion of crystalloids
muffled heart tones are difficult to assess in followed by blood. The treatment of choice
the noisy exam area, and distended neck is wide bore chest tube insertion preferably
veins may be absent due to hypovolemia. 32-34 Fr in 4-5th ICS just anterior to Mid-
Axillary Line.
FAST is a rapid and accurate method of
imaging the heart and pericardium. It is b) A b d o m e n : F o c u s e d A s s e s s m e n t
90–95% accurate for the presence of Sonography for Trauma is essential in
pericardial fluid for the experienced patients with abdominal trauma. In Fast we
operator. Prompt diagnosis and evacuation have to look for fluid in four abdominal
of pericardial blood is indicated for patients cavities i.e. Hepato-renal, Spleeno-renal,
who do not respond to the usual measures Pelvis and Pericardial spaces. If fluid is
of resuscitation for hemorrhagic shock and present in any of the four cavities then
in whom cardiac tamponade is suspected. surgeon has to be called immediately.

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Basic Trauma Care

Chest

5
Abdomen/ Long
Pelvis Bones

Retroperitoneum Floor

Figure 7 : Assessment of circulation Figure 8 : Potential sites of bleed in case of trauma

c) Pelvis : Pelvic binder to be applied if pelvic 6) Adjuvants, during initial assessment.

binder not available then a simple bed sheet
can be wrapped tightly around pelvis l Chest X- ray
l Pelvic X-ray
d) Extremity : Immobilization and splinting is
key to success. If the patient is bleeding then l Focussed Assessment of Sonography in
pressure bandage has to be applied Trauma.
4) Disability assessment l Blood investigations.
It is assessed disability by AVPU score- l Urinary catheter
A-Alert l Gastric catheter
V-Responds to verbal commands l No role of CT scan
P- Responds to pain Don’t attempt urinary catheter if there is blood
at meatus.
U- Unresponsiveness
Better to put OG tubes in patients with nasal
Patients who respond to verbal commands have
bleed, CSF otorrhea, and hemo-tympanum.
mild head injury, one who responds to pain has
moderate head injury and one with Once patient is physiologically stable you
unresponsiveness has severe head injury. proceed to next step.
5) Exposure l Secondary survey
Proper and fast exposure of the patient to find Assessment of anatomical injuries, head to
hidden injuries, on the same hand prevention of toe examination.
hypothermia is the main aim. Log rolling the patient
is an essential skill which in turn looks for injuries in l Definitive care
back region. Once patient is stabilized you send the
patient to nearest trauma cent

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 AIIMS Bhopal 2014

Basic Trauma Life Support Algorithm

ABCDE way

Airway
Circulation
maintenance Breathing
with cervical with Disability Exposure
with
spine Hemorrhage assessment
Ventilation
protection control

Assesment
of Undress
Suctioning Inspection Circulation AVPU the
with
Haemorrhage patient
control

Tachycardia; Pupil
Prevention
Airway cool extremities symmetry
Auscultation of
Manouveres and low U.O & reaction
are earliest signs Hypothermia
to light

Large bore
Airway cannulas Assessment
Percussion Log rolling
Adjuvants along with of GCS
warm iv fluids

One on floor GCS<8

Rule out look for Severe
BMV
Six LTI four more- Head Injury
CAPE

Definite
Airway

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Basic Trauma Care

CHAPTER 2
AIRWAY MANAGEMENT IN TRAUMA
The inadequate delivery of oxygenated blood to the compromise or both. Patient with the altered level
brain and other vital structures is the quickest killer of consciousness are at particular risk for airway
of injured patients. Prevention of hypoxemia compromise and aspiration, so they require definite
requires a protected, unobstructed airway and airway.
adequate ventilation, which take priority over
m a n a g e m e nt o f a l l o t h e r co n d i t i o n s. Fo r Definitive airway : Is defined as a tube placed in the
oxygenation of the patient the airway should be trachea with the cuff inflated below the vocal cords,
patent and be secured, oxygen delivered and the tube connected to some form of oxygen
ventilator support is provided. Supplementary enriched assisted ventilation and airway secured in
oxygen must be administered to the all trauma place with tape. Unconscious Patient with head
patients. injury, alcohol intoxication or other drugs and
thoracic injuries can have ventilator compromise. In
The Early preventable deaths from airway problem these patients the purpose of endotracheal
after trauma often result from: intubation is to provide an airway, deliver
supplementary oxygen, support ventilation and
Ø Failure to identify the need for an airway
prevent aspiration. Maintaining oxygenation and
intervention.
preventing hypercarbia are critical in managing
Ø Inability to establish an airway trauma patient, especially those who have
sustained head injury.
Ø Lack of back up or alternative airway plan in
the setting of failed intubation attempts. It is important to anticipate vomiting in all injured
patient and be prepared to manage the situation.
Ø Failure to recognize an incorrectly placed The presence of gastric contents in the oropharynx
airway. represents a significant risk of aspiration with the
Ø Displacement of a previously established patient’s next breath. Therefore, immediate
airway. suctioning and rotation of the entire patient to the
lateral positions are indicated.
Ø Failure to identify the need for ventilation.
Maxillofacial Trauma : The mechanism for this
Ø Aspiration of gastric contents during injury is exemplified by anunbelted automobile
dealing with airway. passenger who is thrown into the windshield and
dashboard. Trauma to midface can produce
Airway and Ventilation are the first priorities:
fractures and dislocations that compromise the
First step in identifying the airway problems naso-pharynx and oropharynx. Facial fractures can
includes maxillofacial, neck ,laryngeal trauma and be associated with hemorrhage, increased secretion
inhalational burn injuries. and dislodged teeth. Fractures of mandible,
especially bilateral body fractures, can cause loss of
Airway compromise may be sudden and complete, normal airway structural support(Figure 1). Airway
insidious and partial, and or progressive and Obstruction can result if the patient is in supine
recurrent. The early sign of airway or ventilator position.
compromise is Tachypnea or inability to speak
words or sentences. “Talking patient” provides Neck Trauma : Penetrating injury to neck can cause
reassurance for that period of time that the airway is vascular injury with significant hematoma, which
patent and not compromised. Failure to respond or can result in displacement and obstruction of the
an inappropriate response suggests an altered level airway. Emergency placement of a surgical airway
of consciousness, air way and ventilator may be required if this displacement and

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 AIIMS Bhopal 2014

already exists. When fracture of larynx is suspected

computed tomography will help to identify this
injury.
Objective signs of Airway Obstruction:
1. Obser ve the patient for agitation, and
obtundation, suggest hypercarbia, cyanosis
indicates hypoxemia due to inadequate
oxygenation which can be identified by
inspection of nail beds and circum-oral skin.
However, cyanosis is a late finding of hypoxia.
Pulse Oximetry is used early in the airway
assessment to detect inadequate oxygenation
Figure 1. Trauma to face needs expertise but prior to development of cyanosis. Look for
challenging airway management retractions and use of accessary muscles of
ventilation that, when present, provide
obstruction make endotracheal intubation additional evidence of airway compromise.
impossible. Hemorrhage from adjacent vascular
injury can be massive, and operative control may be 2. Listen for abnormal, noisy sound breathing is
required. Blunt or penetrating injury to the neck can usually ,snoring, gurgling and crowing sound
cause disruption of the larynx or trachea, resulting in (stridor) can be associated with partial
airway obstruction and severe bleeding into the obstruction of the pharynx or larynx.
tracheobronchial tree. Hoarseness (dysphonia) implies functional,
laryngeal obstruction.
Disruption of larynx and trachea or compression of
the airway from hematoma into the soft tissue of 3. Feel for location of trachea and quickly
neck can cause partial airway obstruction. determine whether it is in the midline position

Laryngeal trauma : 4. Evaluate patient behavior. Abusive and

belligerent patient may in fact have hypoxia and
Fracture of larynx is a rare injury, but it can present should not be presumed to be intoxicated ( so
with acute airway obstruction. Triad of clinical signs R/o hypoxia, then only presume intoxication.
which are found in the patient of laryngeal injury.
Ventilation :
1. Hoarseness
Sometime it will happen that airway of the patient
2. Subcutaneous emphysema will be patent but ventilation will be inadequate so
look for the objective signs of inadequate
3. Palpate fracture
ventilation. Ventilation may be compromised by
When dealing with the airway issues in laryngeal airway obstruction, altered ventilatory mechanics,
trauma patients endotracheal intubation may be and central nervous system depression. Following
needed if it is not successful then emergency are the conditions where the ventilation may be
tracheostomy may indicated. Tracheostomy in this compromised.
group of patient may be difficult, then
1. Direct trauma to the chest, like rib fractures,
cricothyroidotomy , although not preferred, may be
leading to severe pain during breathing and
life saving. These injuries are often associated with
leads to shallow breathing and hypoxemia.
trauma to the esophageus , carotid artery, or jugular
vein as well as tissue destruction. Noisy breathing 2. Elderly patients and other individual with
indicates partial airway obstruction that can pulmonary dysfunction are at significant risk for
suddenly become complete , where the absence of ventilator failure.
breathing suggests that complete obstruction

09
Basic Trauma Care

3. Intracranial injur y can cause abnormal person provides manual inline stabilization from
breathing patterns and compromise adequacy belwo while the seconds person expands the
of ventilation. helmet laterally and removes it from above. Then
inline stabilization is reestabilized from above. And
4. Cervical spinal cord injury can result in patient,s head and neck are secured during airway
diaphragmatic breathing and interfere with the management. Removal of the helmet using a cast
ability to meet increased oxygen demands. cutter while stabilizing the head and neck can
5. Complete cervical cord transection, which minimize c – spine motion in patients with known c
spares the phrenic and result in abdominal – spine injury .
breathing paralysis of the intercostal muscles,
Predicting difficult airway:
and assisted ventilaton may be required.
It is important to assess the patient’s airway prior to
Objective signs of inadequate ventilation: attempting intubation in order to predict the likely
1. Symmetrical rise and fall of the chest and difficulty of the maneuver. Factors that may predict
adequate chest wall excursion indicate the difficulties with airway maneuvers include C-spine
adequate ventilation but asymmetrical rise and injury, severe arthritis of the c spine, significant
fall suggests splitting of rib cage or flail chest. maxillofacial or mandibular veriations( receding
Labored breathing may indicate an imminent chin, overbite and a short, muscular neck).
threat to the patient’s ventilation. The mnemonic LEMON is helpful as a prompt when
2. Listen for movement of air on both sides of the assessing the potential for a difficult intubation.
chest. Decreased or absent sounds over one or Look for evidence of a difficult airway ( small mouth
both hemi-thoraces should alert examiner to or jaw, large overbite or facual trauma.). LEMON
the presence of thoracic injury. Beware of rapid stands for
respiratory rate-tachypnea can indicate L= Look Externally. Look for characteristics that are
respiratory distress. known to cause difficult intubation or ventilation.
3. Use a pulse oximeter. This device provides E= Evaluate the 3-3-2 Rule: To allow for alignmemt
information regarding patient’s oxygen of the pharyngeal, laryngeal and oral axes and
saturation and peripheral perfusion. therefore simple intubation, following relationships
Airway management : should be observed.

To assess airway patency and adequate ventilation § The distance between the patient’s incisor
quickly ad accurately pulse oximetry and end-tidal teeth should at least 3 finger breadths.
Co2 measurement are essential. There are some § Distance between the hyoid bone and the
measures to improve the oxygenation. Include chin should be at least 3 fingers.
airway maintenance techniques, definitive airway
measures or surgical airways. Because above § Distance between the thyroid notch and
mentioned measures include some movement of floor of the mouth should be at least 2
neck, so it is important to maintain cervical spine fingers.
protection in all patient of trauma.
M=Mallampati : The hypo-pharynx should be
High flow oxygen is required both before and visualized adequately. To assess the Mallampati
immediately after airway management measures grade when possible the patient is asked to sit
are instituted. A rigid suction device is essential and upright. Open the mouth fully and protrude the
should be readily available. Nasal route for tongue as far as possible. The examiner then looks
endotracheal route should not be chosen in patient into the mouth with a light torch to assess the
of patients with facial injury and midface injury. degree of hypo-pharynx visible . In supine condition
Patients who are wearing Helmet and require airway , the Mallampati score can be estimated by asking
management need their head and neck held in a the patient to open the mouth fully and protrude
neutral position. For this two person procedure. One the tongue a laryngoscopy light is shone into the

10
 AIIMS Bhopal 2014

hypo-pharynx from above. ( Figure 2) obstruct the hypopharynx. This form of obstruction
can be correctd readily by the “chin-lift or jaw thrust”
maneuvers. These maneuvers may produce or
aggravate c-spine injury, so inline immobilization of
the c-spine is essential during these proceudres.
The chin lift or jaw thrust maneuvers to be done as
taught in BLS survey.
When jaw thrust is being given with face mask
Class I Class II Class III Class IV
device, a good seal and adequate ventilation can
achieved. Care must be taken to prevent neck
Figure. 2 : Mallampati Classification: Class I: extension.
Soft plate, Uvula, fauces, pillers visible
Oropharynx Airway (OPA) : OPA is always inserted
into the mouth behind the tongue. The preferred
Class II : Soft plate, Uvula, fauces visible Class III:
technique is to use a tongue blade or depressor to
Soft Palate, base of Uvula visible Class IV: Hard palate
depress the tongue and then insert the airway
only visible.
posteriorly, taking care not to push the tongue
Obstruction : backward. This device should not be used in
conscious patient because it can trigger gagging,
Any condition that can cause obstruction of the vomiting and aspiration. Patient who tolerate an
airway will make laryngoscopy and ventilation OPA airway are highly likely require intubation. An
difficult. e.g. epiglottitis, peri-tonsillar abscess and alternate technique is to insert the oral airway
trauma. upside down, so its concavity is directed upward
N= Neck Mobiliity : until the sort palate is encountered. At this point,
with the device rotated 180 degrees, the concavity is
This is a vital requirement for successful intubation. directed inferiorly, and the device is slipped into the
It can be assess easily by asking the patient to place place over tongue. But this alternate method should
his or her chin onto the chest and then extending for not be used in children because rotation of the
nech so that he or she is looking towards the ceiling. device can damage the mouth and pharynx. ( Figure
Patient in hard collar neck immobilization obviously 3)
have no neck movement and are therefore more
difficult to intubate.
Airway Decision Plan :
There is a algorithm to follow when is in acute need
of an immediate airway management and in whom,
a C-spine injury is suspected because of the
mechanism of injury or suggested by the physical
examination. The first priority is to ensure continued
oxygenation with maintenance of C-spine
immobilization. This is done initially by chin lft or jaw
thrust maneuver and the preliminary airway
techniques ( i.e Oro-phar yngeal air way or Figure. 3 : Oro-pharyngeal airway of different sizes.
nasopharyngeal airway). The aim is to avoid
prolonged periods of inadequate or absent Nasopharyngeal Airway (NPA) : NPA is inserted in
ventilation and oxygenation. one nostril and passed gently into the posterior
oropharynx. They should be well lubricated and
Air way Maintenance Techniques : In the inserted into the nostril that appears to be
unconscious patient tongue can fall backward ad unobstructed. If obstruction is encountered during

11
Basic Trauma Care

introduction of the airway, stop and try the other Laryngeal Tube AIrway (LTA) : LTA is an extra glottic
nostril (Figure 4). This procedure should not be device with capabilities similar to those of LMA in
attempted in patient with suspected or potential providing successful patient ventilation. LTA is not a
cribriform plate fracture (Facial trauma specially definite airway and plans to provide a definite
midface and lower face.) airway are necessary. As LTA is placed without direct
visualization of the glottis and does not require
significant manipulation of the head and neck for
placement ( Figure 6).

Figure. 4. Nasopharyngeal airways of different sizes.

Figure. 6 : Showing how does Laryngeal tube
Extra-glottic and Supra-glottic Devices: These airway accommodates in oropharynx
devices (Combi tube, laryngeal tube, Laryngeal and ventilate the victim.
mask airway ) have a role in dealing with airway Multi-luminal Esophageal Airway (COMBI Tube) :
crisis in trauma patient and they are also used to
manage the airway when endotracheal intubation This device is used by some of pre-hospital
fails. personnel to achieve an airway when a definite
airway is not feasible. In this device there are two
l Laryngeal Mask Airway (LMA) : There is an parallel lumen tube, one tube is having a hole at the
established role for the laryngeal mask airway in patient end (esophageal port) which usually lies in
the treatment of difficult airway, particularly if oesophagus or trachea and other tube is having 6-8
attempts at endotracheal tube or bag-mask fenestration (hole) which usually lies in pharynx. The
ventilation have failed. LMA does not provide personnel who use this device are trained to
you a definite airway but it helps in the problem observe which port occludes the esophagus and
of failed intubation to tide over the crisis period. which provides air to trachea. The esophageal port
LMA consists of a elliptical mask and tube. The is then occluded with a balloon, and the other port is
LMA design provides an “oval seal around the ventilated. A CO2 detector improves the accuracy of
laryngeal inlet” once the LMA is inserted and the this apparatus ( Figure 7).
cuff inflated. It lies at the crossroads of the
digestive and respiratory tracts. This device is
easier to insert than endotracheal tube but
there is a need of training to learn how to insert
the LMA ( Figure 5).

Figure. 7 : Illustrating how does Combi tube

Figure. 5 : Laryngeal Mask Airway-Gadget to be accommodates and ventilate the victim
used in difficult intubation scenario. and also showing the balloon’s capacities.

12
 AIIMS Bhopal 2014

Definitive Airway: A definitive airway requires a Table 1 :Indications for a definite airway
tube placed in the trachea with the cuff inflated
Sl Need for Airway Need for
below the vocal cords, the tube connected to some
No. Protection Ventilation or
form of oxygen-enriched assisted ventilation and
airway secured in place with tape. There are three Oxygenation
types of definitive airways, oro-tracheal tubes, naso- 1. Severe Inadequate
tracheal tubes, and surgical airways (crico- maxillofacial respiratory Efforts
thyroidotomy or tracheostomy) (Figure 8). The fractures § Tachypnea
criteria for establishing definitive airway are based § Hypoxia
on clinical findings and include (Table 1) § Hypercapnia
§ Cyanosis
2. Risk for Massive Blood loss
Obstruction and need for
§ Neck volume
hematoma resuscitation
§ Laryngeal or
trachea
§ Stridor
3. Risk for Severe closed
aspiration injury with need
Figure. 8 Endotracheal tube in situ ventilating § Bleeding for bried
the victim. § Vomiting hyperventilation if
acute neurologic
§ Airway problems- Inability to maintain a deterioration
patent air way by other means with occurs
impending or potential compromise of the 4. Unconscious Apnea
airway (e.g following inhalation airway § Neuromuscular
injury, facial fractures or retropharyngeal paralysis
hematoma). § Unconscious
§ Breathing problems- Inability to maintain
adequate oxygenation by face mask indicated. When the need of airway management is
oxygen supplementation and presence not urgent then only the patient can be send for
apnea. Radiological studies.
§ Disability problems- Presence of a closed The most important determinants of whether to
head injury requiring assisted ventilation proceed with oro-tracheal or naso-tracheal
(Glasgow Coma Scale –GCS of 8 or less than intubation are the experience of the clinician and
8) need to protect the lower airway from the presence of a spontaneously breathing patients.
aspiration of blood or vomitus or sustained Both techniques are the safe and effective when
seizure activity. perfomed properly, although orotracheal tube is
more commonly used and has fewer intensive care
Indications for Definitive Airway :
unit complications. If patient is having apnea oro-
Endotracheal Intubation : It is important to tracheal tube is indicated.
establish the presence or absence of C-spine
Blind naso-tracheal intubation requires a patient
fracture , obtaining the radiological studies (CT,
who is spontaneously breathing and is
Cervical X-ray) , it should not delay or impede the
contraindicated in patient with apnea, facial, frontal
placement of a definitive airway whenever
sinus, basilar skull and cribriform plate fractures are

13
Basic Trauma Care

relatively contraindicated. Evidence of nasal to help in confirmation of proper placement of

fractures, raccoon eyes ( bilateral ecchymosis in the endotracheal tube. Proper placement of tube is best
peril-orbital region), Battle’s sign (Post auricular confirmed by chest X-ray, one the possibility of
ecchymosis) and possible cerebrospinal fluid keas ( esophageal intubation is ruled out. To find out the
H/o Rhinorrhoea or Otorrhea) are all signs of these adequacy of ventilation requires arterial blood
injuries. carbon di oxide analysis or end tidal carbon dioxide.
Whenever, patient is moved, tube placement is
If the decision to perform oro-tracheal intubation is reconfirmed.
made, the two person technique withmanual inline
stabilization is necessary. Laryngeal manipulation If the vocal cords are not fully visualized, then one
by backward, upward, and rightward pressure can use GEB to intubate the patient.
(BURP) on the thyroid cartilage can aid in visualizing
the vocal cords. An excellent tool, when faced with Rapid Sequence Intubation : The use of anesthetic,
difficult airway is the Eschmann Tracheal Tube sedative and neuromuscular blocking drugs for
Introducer (ETTI) known as the gum elastic bougie endotracheal intubation in trauma patient is
(GBB). GEB is used when vocal cords cannot be potentially dangerous. In many patient an airway is
visualized on direct laryngoscopy. With the acutely needed, during the primary, the use of
laryngoscope in place, the GBB is passed blindly paralyzing or sedating drugs is not necessary. The
beyond the epiglottis, with the angled tip technique of rapid sequence intubation (RSI) is as
positioned anteriorly. Tracheal position is confirmed follow:
by the feeling clicks as the distal tip rubs along the 1. Always have a plan for failure of intubation or
cartilaginous tracheal rings. ventilation.
Intubation and Confirmation of right placement 2. Ensure that suction and the ability to deliver
of Endotracheal tube : positive pressure ventilation are ready.
To intubate the patient laryngoscope is inserted 3. Pre-oxygenate the patient with 100% oxygen.
through the right corner of mouth and oropharynx
structures are identified. After reaching sufficiently 4. Apply pressure over the cricoid cartilage.
deep in oropharynx epiglottis and glottis are 5. Administer an induction drugs in calculated
visualized and appropriate size endotracheal tube is doses (e.g etomidate 0.3 mg/kg) or sedate
inserted through the glottis under direct vision. according to local protocol.
Cuff of tube is inflated and assisted ventilation is
started. There are clinical method to identify the 6. Administer 1-2 mg/kg Succinylcholine
proper placement of endotracheal tube and rule out intravenously (Usual dose is 50-100 mg).
esophageal intubation. First, auscultate the chest
7. After patient relaxes intubate the patient oro-
bilaterally over five points Epigastrium, Right
tracheally.
infraclavicular area, left infraclavicular area, right
infraaxillary area and left infraaxillary area. In 8. Inflate the cuff and confirm tube placement by
epigastrium area, if gurgling or rumbling sounds( a u s c u l t a t i n g t h e p a t i e n t ’s c h e s t a n d
Borborygmi) are heard then endotracheal tube is in determining the presence of CO2 in exhaled air.
esophagus, tube must be taken out and patient
should pre-oxygenated with bag-mask ventilation 9. Release cricoid pressure.
and re-intubation attempt is made. If endotracheal 10. Ventilate the patient.
tube is in properly in trachea, bilateral breath
sounds are heard and tube is manipulated until Donor use succinylcholine in cases of crush injury,
equal bilateral breath sounds are heard. A CO2 burns, and thermal injury because there is a risk of
detector (ideally a Capnograph nut if that is not hyperkelemia and subsequent cardiac arrest.
available a caloroimetric CO2 monitoring device- Succinylcholine is shor t acting drug, is
this device is not a indicator of physiologic administered. It has a rapid onset of paralysis (<1
monitoring of adequacy of ventilation) is indicated minute) and a duration of 5 minutes or less.

14
 AIIMS Bhopal 2014

Surgical Airway : surgical airway established when rates (5-7 L/min) should be used when persistent
edema of glottis, fracture of larynx or severe oro- glottis obstruction is present.
pharyngeal haemorrhage obstruct the airway or
endotracheal tube can not be place through the Surgical Cricothyroidotomy : Surgical
vocal cords. A surgical crico-thyroidotomy is Cricothyroidotomy is performed by making a skin
preferred to a tracheostomy to most patient who incision that extends through the cricothyroid
require establishment of an emergency airway, membrane. A curved hemostat may be inserted to
because it is easier to perform, associated with less dilate the opening and a small endotracheal tube or
bleeding and require less time to perform than an tracheostomy tube (preferably 5-7mm). When an
emergency tracheostomly. endotracheal tube is used, the cervical collar can be
reapplied. It is possible for endotracheal tube to
Needle Cricothyroidotomy: Needle become malpositioned and therefore, advanced
cricothyroidotomy involves insertion of needle into a bronchus. Care must be taken, especially with
through the crico-thyroid membrane or into the children, to avoid damage to the cricoid cartilage
trachea in the an emergency situation to provide which is only circumferetial support for the upper
the oxygen on a short term basis until a definitive trachea. Therefore, surgical cricothyroidotomy is not
airway can be placed. This procedure can provide recommended for children under 12 years of age.
temporary, supplemental oxygenation so that
In the recent years, percutaneous tracheostomy has
intubation can be accomplished on an urgent rather
been reported as an alternative open
than an emergent basis.
trachesostomy. This is not a safe procedure in the
The jet insufflation technique is performed by acute trauma situation. Because the patient’s neck
placing a large catheter plastic cannula 12-14 gauge must be hyperextended to properly position the
for adults, and 16-18 gauge in children, through the head to perform the procedure safely. Percutaneous
crico-thyroid membrane into the trachea below the tracheostomy requires use of a heavy guuidewire
level of the obstruction. The cannula is then and sharp dilator, or a guidewire and multiple or
connected to oxygen as 15L/Min (40-50 psi) with a Y single large bore dilators. This procedure could be
connector or a side hole cut in the tuning between dangerous and time consuming, depending on the
the oxygen source and the plastic cannula, type of equipment used. (Figure 10)
intermittent insufflation, 1 second on and 4 seconds
off can then be achieved by placing the thumb over
open end of the Y connector or the side hole.
The patient can be adequately oxygenated for 30-40
min using this technique, and only patients with
normal pulmonary function who donot have a
significant chest injury may be oxygenate in this
manner. During the 4 seconds that the oxygen is not
being delivered under pressure, some exhalation
occurs. Because of the inadequate exhalation, CO2
slowly accumulate limiting the use of this
technique, especially in patients with head injuries. Figure.10 Crico-thyroidotmy using dilators and
Jet insulation must be used with caution when guidewire technique.
complete foreign body obstruction of the glottis
area is suspected. Although high pressure can expel Monitoring of adequacy of oxygenation:
the impacted material into the hypopharnx where it Oxygenatyed inspired air is best provided a via tight
can be removed readily, significant barotrauma can fitting oxygen reservoir face mask with a flow rate of
occur, including pulmonary rupture with tension at least 11L/min. Other methods (e.g Nasal catheter
penumo-thorax Therefore, particular attention and non-breather mask) can improve the inspired
must be paid to effectivwe airflow and low flow oxygen concentration. Pulse oximetry is a non-
invasive method of continuously measuring the

15
Basic Trauma Care

oxygen saturation (O2 sat) of arterial blood. It does poisoning. Profound anemaia (Hb >5g/dl) and
not measure the partial pressure of oxygen (PaO2) hypothermia (<30oC) decrease the reliability of the
and depending upon the position of oxy- technique. However, in most patient pulse oximetry
hemoglobin dissociation curve, the PaO2 can vary is useful as the continuous monitoring of oxygen
widely. However a measured saturation of 95% or saturation provides an immediate assessment of
greater by pulse oximetry is strongly suggests therapeutic intervention.
adequate peripheral artery oxygenation (PaO2 >
70mmHg). The simple formula for deducting PaO2 from the
value of SpO2 is = % saturation of Hb - 30. But
thus formula is valid only upto % saturation of
Hemo-globin upto70.
Monitoring adequacy of Ventilation : Effective
ventilation can be achieved by the bag-mask
ventilation techniques. However, one person
ventilation techniques using bag-mask are less
effective than two person techniques in which both
hands can be used to ensure a good seal.
Figure.11 : Pulse Oximeter. (a) Pulse oximetry shows
oxygen saturation, heart rate Adequacy of ventilation can be checked clinically by
ensuring the B/L equal chest air entry and seeing the
Pulse oximetry requires intact peripheral perfusion color of the patient. Though, End-tidal CO2 is the
and can not distinguish oxy-hemoglobin from gold standard for seeing the adequacy of
carboxy- hemoglobin or methemoglobin, which ventilation but it may not be present in periphery
limits its usefulness in patients with severe hospitals so one has to rely on clinical monitoring
vasoconstriction and those with carbon monoxide and SPO2 .

Be Prepared Equipment : Suction, O2, oropharyngeal and nasopharyngeal airways, bag-mask,

laryngoscope, gum elastic bougie (GEB), supra-glottic devices, surgical or needle Crico- throidotomy
kit, endendotracheal tube, pulse oximetry, CO2 detection device, drugs.

Able to oxygenate No Definitive airway / surgical airway.

Assess airway anatomy, predict

Difficult
ease of intubation (LEMON)

Easy Call for assistance, if available

Intubation +/- Drug assisted

intubation, cricoid pressure

Unsuccessful

Consider adjunct
(e.g GEB, LMA, LTA) Consider awake intubation

Definitive airway / Surgical airway.

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 AIIMS Bhopal 2014

CHAPTER 3
SHOCK
The definition of shock—an abnormality of the The reliance solely on systolic blood pressure as an
circulatory system that results in inadequate organ indicator of shock can result in delayed recognition
perfusion and tissue oxygenation—globly. Basically of the shock state. Compensatory mechanisms can
when managing a patient with shock there are 9 preclude a measurable fall in systolic pressure until
queries or questions which are to be answered in a up to 30% of the patient’s blood volume is lost.
systematic way. Specific attention should be directed to pulse rate,
pulse character, respiratory rate, skin circulation,
The first step in the initial management of shock and pulse pressure (i.e., the difference between
is to recognize its presence. The shock is a clinical systolic and diastolic pressure).
diagnosis which is characterised by group of
science/ symptoms. No vital sign or symptom Tachycardia and cutaneous vasoconstriction are the
neither any laboratory test can diagnose shock . typical early physiologic responses to volume loss in
Shock is characterised by decreased blood flow to most adults. Any injured patient who is cool and has
vital organs such as CNS, CVS, Kidney and hence tachycardia is considered to be in shock until proven
characterised by following S/S (Figure 1). otherwise. In addition, most non hemorrhagic
shock states respond partially or briefly to volume
1. Altered sensorium (CNS) resuscitation. Therefore, if signs of shock are
2. Tachycardia (CVS) present, treatment usually is instituted as if the
patient is hypovolemic. However treatment is
3. Cool Extremities are found in all types of instituted, it is important to identify the small
shock except vasodilatory shock (CVS) number of patients whose shock has a different
cause (e.g., a secondary condition such as cardiac
4. Capillary refilling time>10 seconds (Skin)
tamponade, tension pneumothorax, and spinal
5. Low urine output (Kidney) cord injur y, or blunt cardiac injur y, which
complicates hypovolemic/ hemorrhagic shock).
6. Low blood pressure (CVS)
The second step in the initial management of
shockis to identify the probable cause of the
Signs of tissue hypoperfusion shock state. The common varieties of shock are:
Brain 1. Hypovolemic
Altered mental
state
2. Vasodilatory shock: which includes septic,
Neurogenic shock
Tachycardia
3. Cardiogenic shock
Skin Elevated
blood
Mottled.
lactate
4. Obstructive shock: includes
clammy
a. Tension pneumothorax
Kidney b. Cardiac tamponade
Oliguria
For all practical purposes, shock does not result from
isolated brain injuries. Patients with spinal cord
Figure 1: Signs of Tissue Hypo-perfusion injury may initially present in shock resulting from
both vasodilation and relative hypovolemia. Patient
m a n a g e m e n t re s p o n s i b i l i t i e s b e g i n w i t h

17
Basic Trauma Care

Table 1 : Classification of Hypovolemic Shock based on blood loss1

CLASS I CLASS II CLASS III CLASS IV

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 (BPM) <100 100-120 120-140 >140

Systolic b pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased

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

Urine output (mL/hr) >30 20-30 5-15 Negligible

CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic

Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood
1
For a 70-kg man.

recognizing the presence of shock, and treatment peritoneum, extremities, and external
should be initiated simultaneously with the bleeding—must be quickly assessed by physical
identification of a probable cause. The response to examination and appropriate adjunctive studies.
initial treatment, coupled with the findings during
the primary and secondary patient surveys, usually 2. Septic Shock : The Septic shock occurs due
provides sufficient information to determine the to an infection is an example of Vasodilatory
cause of shock (Figure 2). shock. The diagnosis is made by the
following criteria SIRS+ INFEC TION+
1. Hypovolemic shock: Hemorrhage is the SHOCK. The shock is defined as SBP<90 mm
most common cause of shock in Hg despite adequate fluid resuscitation of 1
theinjured patient. (Table 1) Hemorrhage liter. Patients with sepsis who also have
is the most common cause of shock after hypotension and are afebrile are clinically
injury, and virtually all patients with difficult to distinguish from those in
multiple injuries have an element of hypovolemic shock, as both groups can
hypovolemia. manifest tachycardia, cutaneous vaso
onstriction, impaired urinary output,
The primary focus in hemorrhagic shock is to decreased systolic pressure, and narrow
promptly identify and stop hemorrhage. Sources of pulse pressure. However patients with early
potential blood loss—chest, abdomen, pelvis, retro-

Distributive shock Hypovolemic shock Cardiogenic shock Obstructive shock

Loss of Obstruction
Vasodilation plasma or
blood
volume

Ventricular Pericardial
failure temponade

Figure 2: Different varieties of shock

18
 AIIMS Bhopal 2014

septic shock can have a normal circulating condition. Tension pneumothorax can
volume, modest tachycardia, warm skin, mimic cardiac tamponade, but it is
systolic pressure near normal, and a wide differentiated from the latter condition
pulse pressure. by the findings of absent breath sounds,
tracheal deviation, and a hyper-
3. C a r d i o g e n i c S h o c k : M y o c a r d i a l resonant percussion note over the
dysfunction is commonly as a result of affected hemi-thorax.
myocardial infarction or rarely, by blunt
cardiac injury, cardiac tamponade, an air 5. Neurogenic Shock : Isolated intracranial
embolus. All patients with cardiogenic injuries do notcause shock. The presence of
shock need constant electro cardiographic shock in a patient with ahead injury
(ECG)monitoring to detect injury patterns necessitates the search for a cause other
and dysrhythmias. The blood creatine than an intracranial injury. Cervical or upper
k inase (C K ; formerly, creatine thoracicspinal cord injury can produce
phosphokinase [CPK] iso-enzymes and hypotension dueto loss of sympathetic
specific isotope studies of the myocardium tone. Loss of sympathetic tone compounds
rarely assist in diagnosing or treating the physiologic effects of hypovolemia, and
i n j u re d p at i e nt s i n t h e e m e rg e n c y hypovolemia compounds the physiologic
department(ED). effects of sympathetic denervation. The
classic picture of neurogenic shock is
4. Obstructive shock: includes hypotension without tachycardia or
a) Tension pneumothorax : Tension cutaneous vaso constriction. A narrowed
pneumothorax is a true surgical pulse pressure is not seen in neurogenic
emergency that requires immediate shock. Patients who have sustained a spinal
diagnosis and treatment. It develops injury often have concurrent torso trauma;
when air enters the pleural space, but a t h e re fo re, p a t i e n t s w i t h k n o w n o r
flap-valve mechanism prevents its suspected neurogenic shock should be
escape. Intra-pleural pressure rises, treated initially for hypovolemia. The failure
causing total lung collapse and a shift of of fluid resuscitation to restore organ
the mediastianum to the opposite side perfusion suggests either continuing
with the subsequent impairment of hemorrhage or neurogenic shock. CVP
venous return and fall in cardiac output. monitoring may be helpful in managing this
The presence of acute respiratory complex problem
distress, subcutaneous emphysema, Third Step is to differentiate various types of
absent breath sounds, hyper-resonance shock : Initial determination of the cause of shock
to percussion, and tracheal shift depends on taking an appropriate patient history
supports the diagnosis and warrants and performing an expeditious, careful physical
immediate thoracic decompression examination. Selected additional tests, such as
without waiting for x-ray confirmation monitoring centralvenous pressure (CVP), chest
of the diagnosis. and/or pelvic x-ray examinations, and
b) Cardiac tamponade : Blood in the ultrasonography, can provide confirmatory
pericardial sac inhibits cardiac evidence for the cause of the shock state, but should
contractility and cardiac output. not delay appropriate resuscitation (Figure 3).
Tachycardia, muffled heart sounds, and Fourth step is: What is the Management of shock:
dilated, engorged neck veins with Patient management responsibilities begin with
hypotension resistant to fluid therapy recognizing the presence of shock, and treatment
suggest cardiac tamponade. However, should be initiated simultaneously with the
the absence of these classic findings identification of a probable cause (Table 2).
does not exclude the presence of this

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Basic Trauma Care

Extremities

Hypovolemic Early
Cardiogenic Septic
Obstructive Cold Warm Shock
Late Septic
Shock
Hypovolemic
Vs
DBP High Cardiogenic
Vs
Obstructive
Low

Clinicalfeatures
Late And
Septic Shock CVP
Figure 3: Recognition of shock at bed side.

1. H y p o v o l e m i c s h o c k : T h e b a s i c response. It is most important to assess the

management principle is to stop the patient’s response to fluid resuscitation and
bleeding in hemorrhagic shock and replace identify evidence of adequate end-
the volume loss Similarly in hypovolemic organperfusion and oxygenation (i.e., via
shock due to other causes basic rule is to urinary output, level of consciousness, and
replace with intravenous fluids. Warmed peripheral perfusion). Persistent infusion of
isotonic electrolyte solutions, such as large volumes of fluid and blood in an
lactated Ringer’s and normal saline, are attempt to achieve a normal blood pressure
used for initial resuscitation. This type of is not a substitute for definitive control of
fluid provides transient intravascular bleeding. Excessive fluid administration can
expansion and further stabilizes the exacerbate the lethal triad of coagulopathy,
vascular volume by replacing acidosis, and hypothermia with activation
accompanying fluid losses into the of the inflammatory cascade.
interstitial and intracellular spaces. An
initial, warmed fluid bolus is given. The usual 2. Septic shock: I n Septic Shock it is
dose is 1 to 2 L for adults and 20 mL/kg for recommended that within 1 hour of
pediatric patients. Absolute volumes of patient’s admission into the hospital, he has
resuscitation fluids should be based on to be given antibiotics post blood cultures
patient response. It is impor tant to along with at least 1 liter (20 ml/kg) of i.v.
remember that this initial fluid amount fluids. The most impor tant thing in
includes any fluid given in the pre - management of septic shock issource
hospitalsetting. The patient’s response is control i.e. source of infection has to be
observed during this initial fluid removed.
administration, and further the rapeutic and 3. C a r d i a c t a m p o n a d e : N e e d l e
diagnostic decisions are based on this Pericardiocentesis using subxiphoid

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 AIIMS Bhopal 2014

approach may be used as a temporizing resuscitation volume replacement should produce

maneuver when thoracotomy is not an a urinary output of approximately0.5 mL/kg/hr in
available option. adults, whereas 1 mL/kg/hr is an adequate urinary
output for pediatric patients.
4. Tension pneumothorax : Appropriate
placement of a needle into the pleural space For children under 1 year of age, 2 mL/kg/hour
in a case of tension pneumothorax should be maintained.
temporarily relieves this life-threatening
condition. The Needle – 14 G or 16 G has to Sixth step :What type of iv access?
be inserted into second intercostal space in The important determinant for selecting a
mid-clavicular line and the following is procedure or route for establishing vascular access
connected to i.v. drip set attached to an is the clinician’s experience and skill. Access to the
underwater drainage set. The definite vascular system must be obtained promptly (Figure
management is insertion of chest tube in 4- 4). This is best accomplished by inserting two large-
5 th intercostal space just anterior to Mid caliber (minimum of 16-gauge in an adult)
Axillary line. peripheral intravenous catheters before placement
of a central venous line is considered. The rate of
5. Neurogenic shock : It is best managed by
flow is proportional to the fourth power of the
judicious fluid administration and
radius of the cannula and inversely related to its
vasopressors. It is a vasodilatory shock and is
length (Poiseuille’s law). Hence, short, large-caliber
best managed by use of vasopressors.
peripheral intravenous lines are preferred for the
Fifth step: Is my management adequate? rapid infusion of large volumes of fluid. The most
desirable sites for peripheral, percutaneous
The same signs and symptoms of inadequate intravenous lines in adults are the fore arms and
perfusion that are used to diagnose shock are useful ante-cubital veins. If circumstances prevent the use
of peripheral veins, large-caliber, central venous(i.e.,
Table 2 : Brief management of different
types of shock
Type of shock Management Special mention

Hypovolemic Shock IV Fluids-NS/RL

Angled
Septic Shock Vasopressors Norepinephrine, needle

Adrenaline Catheter
entering
subclavian
Cardiogenic Shock Inotropes Dobutamine, Dopamine vein

Obstructive shock
Tension Pneumothorax Needle decompression
Cardiac Tamponade Pericardiocentesis Implanted port
in subcutaneous
pocket
determinants of patient response. The return of
C
normal blood pressure, pulse pressure, and pulse A

rate are signs that suggest perfusion is returning to

normal. However, these observations give no Internal jugular vein

information regarding organ per fusion. Subclavian vein

Improvements in the CVP status and skin circulation Median basilic vein
Cephalic vein
are important evidence of enhanced perfusion, but Median cephalic vein

are difficult to quantitate. The volume of urinary

output is a reasonably sensitive indicator of renal PICC
perfusion; normal urine volumes generally imply Basilic vein
Axillary vein
adequate renal blood flow, if not modified by the Brachiocephalic vein
Superior vena cava
administration of diuretic agents. For this reason, B

urinary output is one of the prime monitors of

resuscitation and patient response. Adequate Figure 4 : Types of IV access

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Basic Trauma Care

Femoral, Jugular, or Subclavian vein) access using patients who stabilize rapidly, cross matched blood
the Seldinger technique or saphenous vein cut should be obtained and made available for
down is indicated, depending on the clinician’s skill transfusion when indicated.
and experience.
Type-specific blood can be provided by most blood
Frequently in an emergency situation, central banks within 10 minutes. Such blood is compatible
venous access is not accomplished under tightly with ABO and Rh blood types, but incompatibilities
controlled or completely sterile conditions. of other antibodies may exist. If type-specific blood
Therefore, these lines should be changed in a more is unavailable, type O packed cells are indicated for
controlled environment as soon as the patient’s patients with exsanguinating hemorrhage. To avoid
condition permits. Consideration also must be sensitization and future complications, Rh-negative
given to the potential for serious complications cells are preferred for females of child bearing age.
related to attempted central venous catheter As soon as it is available, the use of unmatched,
placement, such as pneumothorax orhemothorax, type-specific blood is preferred over type O blood.
in patients who may already be unstable.
Eigthstep : Fluids warm/cold?
As intravenous lines are started, blood samples are
drawn for type and cross-match, appropriate Hypothermia must be prevented and reversed if a
laboratory analyses, toxicology studies, and patient has hypothermia on arrival at the
pregnancy testing for all females of childbearing hospital.The use of blood warmers in the ED is
age. Arterial blood gas (ABG) analysis is performed critical, even if cumbersome. The most efficient way
at this time. A chestx-ray must be obtained after to prevent hypothermia in any patient receiving
attempts at inserting a Subclavian or Internal massive volumes of crystalloid is to heat the fluid to
jugular CVP monitoring line todocument the 39°C (102.2° F) be foreinfusing it. This can be
position of the line and evaluate for apneumothorax accomplished by storing crystalloids in a warmer or
or hemothorax. with the use of a microwave oven. Blood products
cannot be warmed in a microwave oven, but they
Seventh step : When to give blood? can be heated by passage through intravenous fluid
warmers.
The main purpose of blood transfusion is to restore
the oxygen-carrying capacity of the intra vascular Ninth step : Current role of Calcium?
volume. Patients who are in Class III or Class IV
hemorrhagic shock—will need pRBCs and blood Most patients receiving blood transfusions do not
products as a nearly part of their resuscitation. Fully need calcium supplements. When necessary,
crossmatched blood is preferable. However, the administration should be guided by measurement
complete cross matching process requires of ionized calcium. Excessive, supplemental calcium
approximately1 hour in most blood banks. For may be harmful.

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 AIIMS Bhopal 2014

CHAPTER 4
CHEST TRAUMA
A Clinical Case : to address major injuries as they are identified.
An adult male has been brought to casualty Classification of chest trauma:
department following road traffic accident. He was
Injury to the Airways:
driving a jeep and had hit a parked truck on road
side. At arrival he is conscious but seems short of 1. Airway obstruction
breath and holding on to his left side of chest. The
pulse is feeble with tachycardia and tachypnoea. 2. Tracheobronchial tree injury

Objectives 3. Simple pneumothorax

1. Suspecting chest trauma 4. Tension pneumothorax

2. Identifying life threatening injuries on 5. Open pneumothorax

primary survey and initiating management. 6. Haemothorax
3. Secondary survey for potentially life 7. Flail chest and pulmonary contusion
threatening injuries and their management.
8. Massive haemothorax
4. Decision making for further management.
Injury to Viscera
Introduction :
1. Blunt cardiac injury
Very often medical officers at PHC/CHC or district
hospitals are faced with such clinical scenarios and 2. Cardiac tamponade
prompt action is needed to save life. Less than 10%
3. Traumatic aortic disruption
of blunt
4. Traumatic diaphragmatic injury
chest injuries and only 15% to 30% of penetrating
chest injuries require operative intervention 5. Blunt esophageal rupture
(typically thoracoscopy or thoracotomy). In fact,
most patients who sustain thoracic trauma can be Immediately Life threatening chest injuries – to be
treated by technical procedures within the identified and treated during primary survey
capabilities of clinicians who take this course. 1. Airway obstruction
The major physiologic adverse effects of thoracic 2. Tension pneumothorax
trauma are hypoxia, hyper-carbia and acidosis. The
primary damage causes derangement of blood 3. Open pneumothorax
oxygenation leading to anaerobic metabolism and
4. Flail chest and pulmonary contusion
development of metabolic acidosis. Retention of
carbon dioxide leads to respiratory acidosis. 5. Massive haemothorax
Suspecting Thoracic Trauma and its type 6. Cardiac tamponade
Any patient with trauma due to impact over the Potentially Life threatening chest injuries – to be
torso (blunt or penetrating) should be suspected of addressed during secondary survey
sustaining chest trauma. A quick primary survey
checking on the airway, followed by breathing and 1. Simple pneumothorax
then circulation should be performed. It is prudent 2. Haemothorax

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Basic Trauma Care

3. Pulmonary contusion and manually reducing the fracture. Once reduced,

this injury is usually stable if the patient remains in
4. Tracheobronchial tree injury the supine position.
5. Blunt cardiac injury
BREATHING :
6. Traumatic aortic disruption
The patient’s chest and neck should be completely
7. Traumatic diaphragmatic injury exposed to allow for assessment of breathing and
the neck veins. This may require temporarily
8. Blunt esophageal rupture releasing the front of the cervical collar following
Following manifestations of thoracic trauma are blunt trauma. I n this case, cer vical spine
indicative of a greater risk of associated injuries: immobilization should always be ac tively
maintained by holding the patient’s head while the
1. Subcutaneous emphysema collar is loose. Respiratory movement and quality of
respirations are assessed by observing, palpating,
2. Crush injuries of the chest
and listening. Important, yet often subtle, signs of
3. Injuries to the upper ribs (1–3), scapula, and chest injury or hypoxia include an increased
sternum respiratory rate and change in the breathing
pattern, which is often manifested by progressively
Managing Chest Trauma – Primary survey and shallower respirations. Cyanosis is a late sign of
life threatening injuries hypoxia in trauma patients. However, the absence of
cyanosis does not necessarily indicate adequate
The basic principles of management remain the
tissue oxygenation or an adequate airway. The
same with the universal sequence of airway,
major thoracic injuries that affect breathing and
breathing and circulation to be treated in that
that must be recognized and addressed during the
sequence.
primary survey include tension pneumothorax,
AIRWAY: open pneumothorax (sucking chest wound), flail
chest and pulmonary contusion, and massive
It is necessary to recognize and address major haemothorax.
injuries affecting the airway during the primary
survey. Airway patency and air exchange should be IMPORTANT : After intubation, one of the common
assessed by listening for air movement at the reasons for loss of breath sounds in the left thorax is
patient’s nose, mouth, and lung fields; inspecting a r i g ht m a i n s te m i nt u b at i o n . D u r i n g t h e
the oropharynx for foreign-body obstruction; and reassessment, be sure to check the position of the
observing for intercostal and supraclavicular muscle endotracheal tube before assuming that the change
retractions. Laryngeal injury can accompany major in physical examination is due to a pneumothorax or
thoracic trauma. Although the clinical presentation haemothorax.
is occasionally delayed, acute airway obstruction
from laryngeal trauma is a life-threatening injury. Tension Pneumothorax

Injury to the upper chest can create a palpable A tension pneumothorax develops when a “one-
defect in the region of the sternoclavicular joint, way valve” air leak occurs from the lung or through
with posterior dislocation of the clavicular head, the chest wall. Air is forced into the pleural space
which causes upper air way obstruction. without any means of escape, eventually
Identification of this injury is made by listening for completely collapsing the affected lung. The
upper airway obstruction (stridor) or a marked mediastinum is displaced to the opposite side,
change in the expected voice quality, if the patient is decreasing venous return and compressing the
able to talk. Management consists of a closed opposite lung. Shock results from the marked
reduction of the injury, which can be performed by decrease in venous return causing a reduction in
extending the shoulders or grasping the clavicle cardiac output and is often classified as obstructive
with a pointed instrument, such as a towel clamp, shock (Figure 1). The most common cause of tension
pneumothorax is mechanical ventilation with

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 AIIMS Bhopal 2014

positive-pressure ventilation in patients with kinking of the catheter and other technical or
visceral pleural injur y. However, a tension anatomic complications, this maneuver may not be
pneumothorax can complicate a simple successful. When successful, this maneuver
pneumothorax following penetrating or blunt chest converts the injury to a simple pneumothorax;
trauma in which a parenchymal lung injury fails to h o w e v e r, t h e p o s s i b i l i t y o f s u b s e q u e n t
seal, or after a misguided attempt at subclavian or pneumothorax as a result of the needle stick now
internal jugular venous catheter insertion. exists, so repeated reassessment of the patient is
Occasionally, traumatic defects in the chest wall also necessary. Chest wall thickness influences the
can cause a tension pneumothorax if incorrectly likelihood ofsuccess with needle decompression.
covered with occlusive dressings or if the defect Recent evidence suggests that a 5 cm needle will
itself constitutes a flap-valve mechanism. Tension reach the pleural space >50% of the time, whereas
pneumothorax rarely occurs from markedly an 8 cm needle will reach the pleural space >90% of
displaced thoracic spine fractures. Tension the time. Even with a needle of the appropriate size,
pneumothorax is a clinical diagnosis reflecting air the maneuver will not always be successful.
under pressure in the affected pleural Definitive treatment requires the insertion of a chest
space.Treatment should not be delayed to wait for tube into the fifth intercostal space (usually at the
radiologicconfirmation. Tension pneumothorax is nipple level), just anterior to the midaxillary line.
characterized by some or all of the following signs
and symptoms:
■ Chest pain Decrease in
vonous return

■ Air hunger Left

Air Lung
Compression of Compression of
■ Respiratory distress reptured right lung opposite lung

Air Mediastinal shift

Pleural
■ Tachycardia membrane
Heart
Air
■ Hypotension

■ Tracheal deviation away from the side of injury

In a tension pneumothorax, air from a ruptured lung enters the pleural
■ Unilateral absence of breath sounds cavity without a means of escape. As air pressure builds up, the affected
lung is compressed and all of the mediastinal tissues are displaced to
the opposite side of the chest.
■ Elevated hemithorax without respiratory
movement Figure 1 : Tension Pneumothorax, in this condition
air from a ruptured lung enters the pleural cavity
■ Neck vein distention without a route of escape so it works as one way
■ Cyanosis (late manifestation) valve allowing air movement during inspiration
only. As air pressure builds up, the affected lung is
Because of the similarity in their signs, tension compressed and all of the mediastinal tissues are
pneumothorax can be confused initially with displaced to the opposite side of the chest.
cardiac tamponade. Differentiation is made by a
hyperresonant note on percussion, deviated Open Pneumothorax (Sucking Chest Wound)
trachea, and absent breath sounds over the affected
hemithorax, which are signs of tension Large defects of the chest wall that remain open can
pneumothorax. Tension pneumothorax requires result in an open pneumothorax, which is also
immediate decompression and may be managed known as a sucking chest wound. Equilibration
initially by rapidly inserting a large-caliber needle between intrathoracic pressure and atmospheric
i n t o t h e s e c o n d i n t e rc o s t a l s p a c e i n t h e pressure is immediate. Air tends to follow the path of
midclavicular line of the affected hemithorax. least resistance; as such, if the opening in the chest
However, due to variable thickness of the chest wall, wall is approximately two-thirds of the diameter of

25
Basic Trauma Care

the trachea or greater, air passes preferentially Flail Chest and Pulmonary Contusion
through the chest wall defect with each respiratory
effort (Figure 2). Effective ventilation is thereby A flail chest occurs when a segment of the chest wall
impaired, leading to hypoxia and hypercarbia. Initial does not have bony continuity with the rest of the
management of an open pneumothorax is thoracic cage. This condition usually results from
accomplished by promptly closing the defect with a trauma associated with multiple rib fractures— that
sterile occlusive dressing. The dressing should be is, two or more adjacent ribs fractured in two or
large enough to overlap the wound’s edges and more places (Figure 3). The presence of a flail chest
then taped securely on three sides in order to segment results in disruption of normal chest wall
provide a flutter-type valve effect. As the patient movement. Although chest wall instability can lead
breathes in, the dressing occludes the wound, to paradoxical motion of the chest wall during
preventing air from entering. During exhalation, the inspiration and expiration, this defect alone does
open end of the dressing allows air to escape from not cause hypoxia. The major difficulty in flail chest
the pleural space. A chest tube remote from the stems from the injury to the underlying lung
wound should be placed as soon as possible. (pulmonary contusion). If the injury to the
Securely taping all edges of the dressing can cause underlying lung is significant, serious hypoxia can
air to accumulate in the thoracic cavity, resulting in a result. Restricted chest wall movement associated
tension pneumothorax unless a chest tube is in with pain and underlying lung injury are major
place. Any occlusive dressing (e.g., plastic wrap or causes of hypoxia. Flail chest may not be apparent
petrolatum gauze) may be used as a temporary initially if a patient’s chest wall has been splinted, in
measure so that rapid assessment can continue. which case he or she will move air poorly, and
Subsequent definitive surgical closure of the defect movement of the thorax will be asymmetrical and
is frequently required. uncoordinated. Palpation of abnormal respiratory
motion and crepitation of rib or cartilage fractures
can aid the diagnosis. A satisfactory chest x-ray may
suggest multiple rib fractures, but may not show
costochondral separation. Initial treatment of flail
chest includes adequate ventilation, administration
of humidified oxygen, and fluid resuscitation. In the
absence of systemic hypotension, the
administration of crystalloid intravenous solutions
should be carefully controlled to prevent volume
overload, which can further compromise the
patient’s respiratory status. The definitive treatment
is to ensure adequate oxygenation, administer
fluids judiciously, and provide analgesia to improve
ventilation. The latter can be achieved with
intravenous narcotics or local anesthetic
administration, which avoids the potential
respiratory depression common with systemic
narcotics. The options for administration of local
anesthetics include intermittent intercostal nerve
block(s) and intrapleural, extrapleural, or epidural
anesthesia. When used properly, local anesthetic
agents can provide excellent analgesia and prevent
the need for intubation. However, prevention of
hypoxia is of paramount importance for trauma
patients, and a short period of intubation and
Figure 2 : Open sucking wound -suspect open
ventilation may be necessary until diagnosis of the
pneumo-thorax and treatment is three sided
entire injury pattern is complete. A careful
bandage of open sucking wound.

26
 AIIMS Bhopal 2014

assessment of the respiratory rate, arterial oxygen

tension, and work of breathing will indicate
appropriate timing for intubation and ventilation.

Figure 4 : In Massive hemo-thorax - chest X-rays

Figure 3 : Flail chest- where two or more subsequent showing whitening out of effected lung side.
chest ribs are broken at two or more sites give flail
chest, which could be associated with pulmonary
contusion specially in elderly age group. because of volume depletion. Blood pressure and
pulse pressure are measured and the peripheral
circulation is assessed by observing and palpating
Massive Haemothorax the skin for color and temperature. Neck veins
should be assessed for distention, however, keep in
Accumulation of blood and fluid in a hemithorax mind that neck veins may not be distended in
can significantly compromise respiratory efforts by patients with concomitant hypovolemia and either
compressing the lung and preventing adequate cardiac tamponade, tension pneumothorax, or a
ventilation (Figure 4). Such massive acute traumatic diaphragmatic injury. A cardiac monitor
accumulations of blood more dramatically present and pulse oximeter should be attached to the
as hypotension and shock. patient. Patients who sustain thoracic trauma
IMPORTANT: Both tension pneumothorax and especially in the area of the sternum or from arapid
massive haemothorax are associated with deceleration injury, are also susceptible to
decreased breath sounds on auscultation. myocardial injury, which can lead to dysrrhythmias.
Differentiation on physical examination can be Hypoxia and acidosis enhance this possibility.
made by percussion; hyperresonance supports a Dysrrhythmias should be managed according to
pneumothorax, whereas dullness suggests a standard protocols. Pulseless electric activity (PEA)
massive haemothorax. The trachea is often deviated is manifested by an electrocardiogram (ECG) that
in a tension pneumothorax, and the affected shows a rhythm while the patient has no identifiable
hemithorax can appear elevated without pulse. PEA can be present in cardiac tamponade,
respiratory movement. tension pneumothorax, profound hypovolemia,
and cardiac rupture. The major thoracic injuries that
CIRCULATION : affect circulation and should be recognized and
addressed during the primary survey are tension
The patient’s pulse should be assessed for quality, pneumothorax, massive haemothorax, and cardiac
rate, and regularity. In patients with hypovolemia, tamponade.
the radial and dorsalis pedis pulses may be absent

27
Basic Trauma Care

Massive Haemothorax thoracotomy because of potential damage to the

great vessels, hilar structures, and the heart, with the
Massive haemothorax results from the rapid associated potential for cardiac tamponade.
accumulation of more than 1500 mL of blood or Thoracotomy is not indicated unless a surgeon,
one-third or more of the patient’s blood volume in qualified by training and experience, is present.
the chest cavity. It is most commonly caused by a
penetrating wound that disrupts the systemic or Cardiac Tamponade
hilar vessels. However, massive haemothorax can
also result from blunt trauma. In patients with Cardiac tamponade most commonly results from
massive haemothorax, the neck veins may be flat as penetrating injuries. However, blunt injury also can
a result of severe hypovolemia, or they may be cause the pericardium to fill with blood from the
distended if there is an associated tension heart, greatvessels, or pericardial vessel. The human
pneumothorax. Rarely will the mechanical effects of pericardial sac is a fixed fibrous structure; a relatively
massive intrathoracic blood shift the mediastinum small amount of blood can restrict cardiac activity
enough to cause distended neck veins. A massive and inter fere with cardiac filling. Cardiac
haemothorax is suggested when shock is associated tamponade may develop slowly, allowing for a less
with the absence of breath sounds or dullness to urgent evaluation, or may occur rapidly, requiring
percussion on one side of the chest. This blood loss is rapid diagnosis and treatment. The diagnosis of
complicated by hypoxia. Massive haemothorax is cardiac tamponade can be difficult in the setting of a
initially managed by the simultaneous restoration busy trauma or emergenc y room. Cardiac
of blood volume and decompression of the chest tamponade is indicated by the presence of the
cavity. Large-caliber intravenous lines and a rapid classic diagnostic Beck’s triad: venous pressure
crystalloid infusion are begun, and type-specific elevation (distended neck veins), decline in arterial
blood is administered as soon as possible. Blood blood pressure, and muffled heart sounds. However,
from the chest tube should be collected in a device muffled heart tones are difficult to assess in the
suitable for autotransfusion. A single chest tube (36 noisy examination area, and distended neck veins
or 40 French) is inserted, usually at the nipple level, may be absent due to hypovolemia. Additionally,
just anterior to the midaxillary line, and rapid tension pneumothorax, particularly on the left side,
restoration of volume continues as decompression can mimic cardiac tamponade. Kussmaul’s sign (a
of the chest cavity is completed. When massive rise in venous pressure with inspiration when
haemothorax is suspected, prepare for breathing spontaneously) is a true paradoxical
autotransfusion. If 1500 mL of fluid is immediately venous pressure abnormality associated with
evacuated, early thoracotomy is almost always tamponade. P E A is suggestive of cardiac
required. Patients who have an initial output of less tamponade, but can have other causes, as listed
than 1500 mL of fluid, but continue to bleed, may above. Insertion of a central venous line with
also require thoracotomy. This decision is not based measurement of central venous pressure (CVP) may
solely on the rate of continuing blood loss (200 aid diagnosis, but CVP can be elevated for a variety
mL/hr for 2 to 4 hours), but also on the patient’s of reasons. Additional diagnostic methods include
physiologic status. The persistent need for blood echocardiogram, focused assessment sonography
transfusions is an indication for thoracotomy. in trauma (FAST ), or pericardial window. In
During patient resuscitation, the volume of blood hemodynamically abnormal patients with blunt or
initially drained from the chest tube and the rate of penetrating trauma and suspected cardiac
continuing blood loss must be factored into the tamponade an examination of the pericardial sac for
amount of intravenous fluid required for the presence of fluid should be obtained as part of a
replacement. The color of the blood (indicating an focused ultrasound examination performed by a
arterial or venous source) is a poor indicator of the properly trained provider in the emergency
necessity for thoracotomy. Penetrating anterior department (ED). FAST is a rapid and accurate
chest wounds medial to the nipple line and method of imaging the heart and pericardium. It is
posterior wounds medial to the scapula should alert 90–95% accurate for the presence of pericardial
the prac titioner to the possible need for fluid for the experienced operator. Concomitant
haemothorax may account for both false positive

28
 AIIMS Bhopal 2014

and false negative ultrasound exams. Prompt because the blood that perfuses the nonventilated
diagnosis and evacuation of pericardial blood is alveoli is not oxygenated. When a pneumothorax is
indicated for patients who do not respond to the present, breath sounds are often decreased on the
usual measures of resuscitation for hemorrhagic affected side, and percussion may demonstrate
shock and in whom cardiac tamponade is hyperresonance. The finding of hyperresonance is
suspected. The diagnosis can usually be made with extremely difficult to determine in a busy
the FAST exam. If a qualified surgeon is present, resuscitation bay. An upright, expiratory x-ray of the
surgery should be performed to relieve the chest aids in the diagnosis. Any pneumothorax is
tamponade. This is best performed in the operating best treated with a chest tube placed in the fourth or
room if the patient’s condition allows. If surgical fifth intercostal space, just anterior to the
intervention is not possible, pericardiocentesis can midaxillary line. Observation and aspiration of a
be diagnostic as well as therapeutic, but it is not small, asymptomatic pneumothorax may be
definitive treatment for cardiac tamponade. appropriate, but the choice should be made by a
Although cardiac tamponade may be strongly qualified doctor; otherwise, placement of a chest
suspected, the initial administration of intravenous tube should be performed. Once a chest tube is
fluid will raise the venous pressure and improve inserted and connected to an underwater seal
cardiac output transiently while preparations are apparatus with or without suction, a chest x-ray
made for surgery. If subxyphoid pericardiocentesis examination is necessary to confirm reexpansion of
is used as a temporizing maneuver, the use of a the lung. Neither general anesthesia nor positive-
plastic-sheathed needle or the Seldinger technique pressure ventilation should be administered in a
for insertion of a flexible catheter is ideal, but the patient who has sustained a traumatic
urgent priority is to aspirate blood from the pneumothorax or who is at risk for unexpected
pericardial sac. If ultrasound imaging is available, it intraoperative tension pneumothorax until a chest
can facilitate accurate insertion of the needle into tube has been inserted. A simple pneumothorax can
the pericardial space. Because of the propensity of readily convert to a life-threatening tension
injured myocardium to self-seal, aspiration of pneumothorax, par ticularly if it is initially
pericardial blood alone may temporarily relieve unrecognized and positivepressure ventilation is
symptoms. However all patients with acute applied. The patient with a pneumothorax should
tamponade and a positive pericardiocentesis will also undergo chest decompression before transport
require surgery to examine the heart and repair the via air ambulance due to the expansion of the
injury. Pericardiocentesis may not be diagnostic or pneumothorax at higher altitude, even in a
therapeutic when the blood in the pericardial sac pressurized cabin.
has clotted. Preparation to transfer such a patient to
an appropriate facility for definitive care is always HAEMOTHORAX
necessary. Pericardiotomy via thoracotomy is The primary cause of haemothorax (<1500 mL
indicated only when a qualified surgeon is available. blood) is lung laceration or laceration of an
SIMPLE PNEUMOTHORAX intercostal vessel or internal mammary artery due to
either penetrating or blunt trauma. Thoracic spine
Pneumothorax results from air entering the fractures may also be associated with a
potential space between the visceral and parietal haemothorax. Bleeding is usually selflimited and
pleura. Both penetrating and nonpenetrating does not require operative intervention. An acute
trauma can cause this injury. Lung laceration with air haemothorax large enough to appear on a chest x-
leakage is the most common cause of ray film is best treated with a large-caliber (36 or 40
pneumothorax resulting from blunt trauma. The French) chest tube. The chest tube evacuates blood,
thorax is normally completely filled by the lung, reduces the risk of a clotted haemothorax, and,
being held to the chest wall by surface tension importantly, provides a method for continuous
between the pleural surfaces. Air in the pleural monitoring of blood loss. Evacuation of blood and
space disrupts the cohesive forces between the fluid also facilitates a more complete assessment of
visceral and parietal pleura, which allows the lung to potential diaphragmatic injury. Although many
collapse. A ventilation/perfusion defect occurs factors are involved in the decision to operate on a

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Basic Trauma Care

patient with a haemothorax, the patient ’s haemoptysis, subcutaneous emphysema, or

physiologic status and the volume of blood tension pneumothorax. Incomplete expansion of
drainage from the chest tube are major factors. As a the lung after placement of a chest tube suggests a
guideline, if 1500 mL of blood is obtained tracheobronchial injury, and placement of more
immediately through the chest tube, if drainage of than one chest tube often is necessary to overcome
more than 200 mL/hr for 2 to 4 hours occurs,or if a significant air leak. Bronchoscopy confirms the
blood transfusion is required, operative exploration diagnosis. Temporary intubation of the opposite
should be considered. The ultimate decision for mainstem bronchus may be required to provide
operative intervention is based on the patient’s adequate oxygenation. However, intubation of
hemodynamic status. patients with tracheobronchial injuries is frequently
difficult because of anatomic distortion from
PULMONARY CONTUSION paratracheal hematoma, associated oropharyngeal
Pulmonary contusion can occur without rib injuries, and/orthe tracheobronchial injury itself. For
fractures or flail chest, particularly in young patients such patients, immediate operative intervention is
in whom ribs are not completely ossified. However, indicated. In more stable patients, operative
i n a d u l t s i t i s m o s t co m m o n l y s e e n w i t h treatment of tracheobronchial injuries may be
concomitant rib fractures, and it is the most delayed until the acute inflammation and edema
common potentially lethal chest injury. The resolve.
resultant respiratory failure can be subtle, BLUNT CARDIAC INJURY
developing over time rather than occurring
i n s t a n t a n e o u s l y. T h e p l a n f o r d e fi n i t i v e Blunt cardiac injury can result in myocardial muscle
management may change with time and patient contusion, cardiac chamber rupture, coronary
response, warranting careful monitoring and artery dissection and/or thrombosis, or valvular
reevaluation of the patient. Patients with significant disruption. Cardiac rupture typically presents with
hypoxia (i.e., PaO2 <65 mm Hg [8.6 kPa] or SaO2 cardiac tamponade and should be recognized
<90%) on room air may require intubation and during the primary survey. However, occasionally
ventilation within the first hour after injury. the signs and symptoms of tamponade are slow to
Associated medical conditions, such as chronic develop with an atrial rupture. Early use of FAST can
obstructive pulmonary disease and renal failure, facilitate diagnosis. Patients with blunt myocardial
increase the likelihood of needing early intubation injury may report chest discomfort, but this
and mechanical ventilation. Pulse oximetry symptom is often attributed to chest wall contusion
monitoring, ABG determinations, ECG monitoring, or fractures of the sternum and/or ribs. The true
and appropriate ventilatory equipment are diagnosis of blunt myocardial injury can be
necessary for optimal treatment. Any patient with established only by direct inspection of the injured
the aforementioned preexisting conditions who myocardium. Clinically important sequelae are
needs to be transferred should undergo intubation hypotension, dysrrhythmias, and/or wall-motion
and ventilation. abnormality on two-dimensional
echocardiography. The electrocardiographic
TRACHEOBRONCHIAL TREE INJURY changes are variable and may even indicate frank
Injury to the trachea or major bronchus is an myocardial infarction. Multiple premature
unusual and potentially fatal condition that is often ventricular contractions, unexplained sinus
overlooked on initial assessment. In blunt trauma tachycardia, atrial fibrillation, bundle-branch block
the majority of such injuries occur within 1 inch (2.54 (usually right), and ST-segment changes are the
cm) of the carina. Most patients with this injury die at most common ECG findings. Elevated central
the scene. Those who reach the hospital alive have a venous pressure in the absence of an obvious cause
high mortality rate from associated injuries or delay may indicate right ventricular dysfunction
in diagnosis of the airway injury. If tracheobronchial secondary to contusion. It also is important to
injury is suspected, immediate surgical consultation remember that the traumatic event may have been
is warranted. Such patients typically present with precipitated by a myocardial ischemic episode. The
presence of cardiac troponins can be diagnostic of

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 AIIMS Bhopal 2014

myocardial infarction. However, their use in although very rare, can be lethal if unrecognized.
diagnosing blunt cardiac injury is inconclusive and Blunt injury of the esophagus is caused by the
offers no additional information beyond that forceful expulsion of gastric contents into the
available from ECG. Patients with a blunt injury to esophagus from a severe blow to the upper
the heart diagnosed by conduction abnormalities abdomen. This forceful ejection produces a linear
(an abnormal E CG) are at risk for sudden tear in the lower esophagus, allowing leakage into
dysrrhythmias and should be monitored for the first the mediastinum. The resulting mediastinitis and
24 hours. After this inter val, the risk of a immediate or delayed rupture into the pleural space
dysrrhythmia appears to decrease substantially. cause emphysema. The clinical picture of patients
Those without ECG abnormalities do not require with blunt esophageal rupture is identical to that of
further monitoring. postemetic esophageal rupture. Esophageal injury
should be considered in any patient who has a left
TRAUMATIC DIAPHRAGMATIC INJURY pneumothorax or haemothorax without a rib
Traumatic diaphragmatic ruptures are more fracture; received a severe blow to the lower
commonly diagnosed on the left side, perhaps sternum or epigastrium and is in pain or shock out of
because the liver obliterates the defect or protects it proportion to the apparent injury; and has
on the right side of the diaphragm, whereas the particulate matter in the chest tube after the blood
presence of displaced bowel, stomach, and begins to clear. The presence of mediastinal air also
nasogastric (NG)tube is more easily detected in the suggests the diagnosis, which often can be
left chest radiographically . Blunt trauma produces confirmed by contrast studies and/or
large radial tears that lead to herniation, whereas esophagoscopy. Treatment consists of wide
penetrating trauma produces small perforations drainage of the pleural space and mediastinum with
that can take time, sometimes even years, to direct repair of the injury via thoracotomy, if
develop into diaphragmatic hernias. Diaphragmatic feasible. Repairs performed within a few hours of
injuries are frequently missed initially when the injury lead to a much better prognosis.
chest film is misinterpreted as showing an elevated Other Manifestations of Chest Injuries
diaphragm, acute gastric dilatation, loculated
hemopneumothorax, or subpulmonary hematoma. Other significant thoracic injuries, including
The appearance of an elevated right diaphragm on subcutaneous emphysema; crush injury (traumatic
chest x-ray may be the only finding of a right-sided asphyxia); and rib, sternum, and scapular fractures,
injury. If a laceration of the left diaphragm is should be detected during the secondary survey.
suspected, a gastric tube should be inserted. When Although these injuries may not be immediately
the gastric tube appears in the thoracic cavity on the life-threatening, they have the potential to do
chest film, the need for special contrast studies is significant harm.
eliminated. Occasionally, the condition is not
identified on the initial x-ray film or subsequent CT SUBCUTANEOUS EMPHYSEMA
scan. An upper gastrointestinal contrast study Subcutaneous emphysema can result from airway
should be performed if the diagnosis is not clear. The injury, lung injury, or, rarely, blast injury. Although it
appearance of peritoneal lavage fluid in the chest does not require treatment, the underlying injury
tube drainage also confirms the diagnosis. must be addressed. If positive-pressure ventilation
Minimally invasive endoscopic procedures (e.g., is required, tube thoracostomy should be
laparoscopy or thoracoscopy) may be helpful in considered on the side of the subcutaneous
evaluating the diaphragm in indeterminate cases. e m p hy s e m a i n a n t i c i p a t i o n o f a t e n s i o n
Operation for other abdominal injuries often reveals pneumothorax developing.
a diaphragmatic tear. Treatment is by direct repair.
CRUSH INJURY TO THE CHEST
BLUNT ESOPHAGEAL RUPTURE
(TRAUMATIC ASPHYXIA)
Esophageal trauma most commonly results from
penetrating injury. Blunt esophageal trauma, Findings associated with a crush injury to the chest
include upper torso, facial, and arm plethora with

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Basic Trauma Care

petechiae secondar y to acute, temporar y haemothorax. As a general rule, a young patient

compression of the superior vena cava. Massive with a more flexible chest wall is less likely to sustain
swelling and even cerebral edema may be present. rib fractures. Therefore, the presence of multiple rib
Associated injuries must be treated. fractures in young patients implies a greater transfer
of force than in older patients. Fractures of the lower
RIB, STERNUM, AND SCAPULAR FRACTURES ribs (10 to 12) should increase suspicion for
The ribs are the most commonly injured component hepatosplenic injury. Localized pain, tenderness on
of the thoracic cage, and injuries to the ribs are often palpation, and crepitation are present in patients
significant. Pain on motion typically results in with rib injury. A palpable or visible deformity
splinting of the thorax, which impairs ventilation, suggests rib fractures. A chest x-ray film should be
oxygenation, and effective coughing. The incidence obtained primarily to exclude other intrathoracic
of atelectasis and pneumonia rises significantly with injuries and not just to identify ribfractures.
preexisting lung disease. The upper ribs (1 to 3) are Fractures of anterior cartilages or separation of
protected by the bony framework of the upper limb. costochondral junctions have the same significance
The scapula, humerus, and clavicle, along with their as rib fractures, but will not be seen on the x-ray
muscular attachments, provide a barrier to rib examinations. Special rib-technique x-rays are not
injury. Fractures of the scapula, first or second rib, or considered useful because they may not detect all
the sternum suggest a magnitude of injury that rib injuries and add nothing to treatment decisions,
places the head, neck, spinal cord, lungs, and great whereas they are expensive and require painful
vessels at risk for serious associated injury. Because positioning of the patient. The presence of rib
of the severity of the associated injuries, mortality fractures in the elderly should raise significant
may be as high as 35%. Sternal and scapular concern, as the incidence of pneumonia and
fractures are generally the result of a direct blow. mortality is double that in younger patients. Taping,
Pulmonary contusion may accompany sternal rib belts, and external splints are contraindicated.
fractures, and blunt cardiac injury should be Relief of pain is important to enable adequate
considered with all such fractures. Operative repair ventilation. Intercostal block, epidural anesthesia,
of sternal and scapular fractures occasionally is and systemic analgesics are effective and may be
indicated. Rarely, posterior sternoclavicular necessary. Early and aggressive pain control,
dislocation results in mediastinal displacement of including the use of systemic narcotics and local or
the clavicular heads with accompanying superior regional anesthesia, improves outcome in this
vena caval obstruction. Immediate reduction is population. Increased use of CT has resulted in the
required. The middle ribs (4 to 9) sustain the majority identification of injuries not previously known or
of blunt trauma. Anteroposterior compression of diagnosed, such as minimal aortic injuries and
the thoracic cage will bow the ribs outward with a occult pneumothoraces and haemothoraces.
fracture in the midshaft. Direct force applied to the Appropriate treatment of these occult injuries
ribs tends to fracture them and drive the ends of the should be discussed with the relative specialty
bones into the thorax, increasing the potential for consultant.
intrathoracic injury, such as a pneumothorax or

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 AIIMS Bhopal 2014

CHAPTER 5
ABDOMINAL TRAUMA
Introduction
Accidents are a counter product of modernization
and hasty life and are considered as a modern day
epidemic. The statistical profile reflects a global
estimate of 5.1 million deaths in 2000.Road Traffic
Accident (RTA) is one among the top five causes of
morbidity and mortality in South-East Asian
countries. The fatality rate in road traffic accident in
India is one of the highest in the world and reported
to be 20 times more than that reported in developed
countries. Blunt abdominal trauma (BAT) is one of
the leading causes of mortality among trauma
victims. It is the main cause of death in people under
35 years of age worldwide. Most common cause of
blunt abdominal trauma in India is road traffic
accident followed by pedestrian accidents,
abdominal blows, and fall from heights. This ever-
expanding epidemic targeting the young and
productive generations is likely to take a heavy
burden on the quality of life and socio-economic
growth of the region. Figure 1: Anatomy of Abdominal quadrants

I. Anatomy of Abdomen: various quadrants 4. Vasculature

The abdomen is divided into nine quadrants C. Based on severity of injury of abdominal viscera:
which are described in Figure 1 below. The Injury scales have been devised that classify organ
knowledge of quadrant is important as it leads injury severity from grade 1 (minimal) to grades 5 or
to identification of the organ injured, if that 6 (massive). The mortality and need for operative
particular quadrant is involved. repair increase as grade increases. Scales exist for
II. Classifications of abdominal injury the liver, spleen and kidneys.

A. Based on aetiology abdominal trauma is III. Mechanisms of injury

divided into blunt and penetrating types. Intra-abdominal injuries secondary to blunt force
Penetrating trauma is further subdivided into stab are attributed to collisions between the injured
wounds and gunshot wounds, which require person and the external environment and to
different methods of treatment. acceleration or deceleration forces acting on the
B. Injuries are often categorized by type of person’s internal organs. Blunt force injuries to the
structure that is damaged: abdomen can generally be explained by three
mechanisms.
1. Abdominal wall.
1. The first mechanism is rapid deceleration.
2. Solid organ (liver, spleen, pancreas, kidneys). Rapid deceleration causes differential
3. Hollow Viscus (Stomach, Small intestine, Colon, movement among adjacent structures. As a
Ureters, and Bladder) result, shear forces are created and cause

33
Basic Trauma Care

hollow, solid, visceral organs and vascular sequence of inspection, auscultation

pedicles to tear, especially at relatively fixed palpation, percussion and Inspection-
points of attachment. For example, the Undress the patient fully and look for
distal aorta is attached to the thoracic spine abrasion,laceration,foreign bodies,and any
and decelerates much more quickly than penetrating wound over anterior or
the relatively mobile aortic arch. As a result, posterior aspect of abdomen lower part of
shear forces in the aorta may cause it to chest,pelvis,if log roll needed it can be done
rupture. to complete examination. Quick look over
flank,scrotum, vagina,buttock, blood at
2. The second mechanism involves crushing: urethral meatus should be inspected.
Intra-abdominal contents are crushed Remember to prevent from hypothermia
between the anterior abdominal wall and during whole procedure.
the vertebral column or posterior thoracic
cage. This produces a crushing effect, to c. Auscultation-
which solid viscera (eg, spleen, liver,
kidneys) are especially vulnerable. Auscultate for bowel sounds as free
intraperitoneal blood or gastrointestinal
3. T h e t h i r d m e c h a n i s m i s e x t e r n a l content or extra abdominal injury can cause
compression-Whether from direct blows or ileus and loss of bowel sound.
from external compression against a fixed
object (eg, lap belt, spinal column). The liver d. Palpation and Percussion-
and spleen seem to be the most frequently Percussion can be useful to elicit sign of
injured organs, though reports vary. The peritoneal irritation, when present we
small and large intestines are the next most should avoid rebound tenderness
frequently injured organs. otherwise it may cause unnecessary pain.
IV. Assessment: e. Assessment of pelvic stability
If the patient is hypotensive our goal should be to Unexplained hypotension may be the only
rapidly determine whether any abdominal or pelvic indication for pelvic assessment as pelvic
injury is present and whether hypotension is due to hemorrhage occurs rapidlyand early
that injury. This may need repeated examination to recognition is must for appropriate
determine whether signs of bleeding or peritonitis resuscitative treatment. This procedure
develop over time. should be done only once during physical
a. History- examination, as its repeated testing may
further increase bleeding.
Can be provided by patient, passengers,
police or medical emergency personnel. In f. Urethral, perineal and rectal examination:-
motor vehicle accident speed of The presence of blood at meatus strongly
vehicle,type of collision, vehicle intrusion in suggests a urethral injury; Foley’s catheters
passenger’s compartment type of restraints, should not be placed in patients with
deployment of airbags becomes perineal hematoma or high riding prostate.
important.When assessing a patient with g. Adjunct to physical examination
penetrating trauma time of injury, type of
injury,type of weapon,distance from GastricTube-Therapeutic goals of inserting
assailant becomes important. gastric tube is to relieve acute gastric
dilatation.In case of severe facial fracture or
b. Physical examination:- suspected basilar fracture gastric tube
To determine whether abdominal or pelvic should be inserted through the mouth to
injury physical examination should be done prevent accidental passage of the tube
meticulously and systematically in standard through cribriform plate into the brain.

34
 AIIMS Bhopal 2014

Urinary catheter-The goals of inserting urinary

catheter in resuscitation process is to relieve
distension, allow for urinary output as an index for
tissue perfusion. The inability to void,blood at
meatus,high lying prostate,scrotal hematoma
mandate urethrogram and a disrupted urethra
needs supra pubic cystostomy.
V. Investigations:
a) Comparison of FAST,DPL AND CT in Blunt
abdominal trauma
1. Hepatorenal
2. Lienorenal
3. Pelvis
4. Pericardial
b) Contrast studies-A number of contrast studies
can be done to aid diagnosis but should not delay
the care of patients who are hemodynamically Figure 2 : Focussed Abdominal Sonography in
unstable viz Trauma: Four quadrants which have to be visualized

a. Urethrography
VI. Treatment
b. Cystography
a) Prehospital care :
c. Intravenous pyelogram
Focuses on rapidly evaluating life-threatening
d. Gastrointestinal contrast studies problems, initiating resuscitative measures and

DPL FAST (Figure 2) CT SCAN

Advantages Early diagnosis. Early diagnosis. Non invasive
Performed rapidly Performed rapidly 86-96% sensitivity
No transportation No transportation Most specific
required. required
Detects bowel injury 86-96% sensitivity
98% sensitivity Non invasive
Disadvantages Invasive Depends on operator Costly
Misses injury to Misses bowel Misses
diaphragm and retro diaphragm, and boweldiaphragm,
peritoneum pancreatic injuries and pancreatic
Low specificity injuries.
Transportation
required
Indications Unstable blunt trauma Unstable blunt Stable blunt trauma
Penetrating trauma trauma Penetrating trauma
of back and flank

35
Basic Trauma Care

initiating prompt transport to a definitive care site. v. Evisceration

Hence, securing the airway, placing large-bore
intravenous (IV) lines, and administering i.v. fluid vi. Peritonitis
must take place en route, unless transport is vii. Bleeding from the stomach,rectum,or
delayed. genitourinary tract from penetrating
trauma.
b) In-hospital management :
The approach should be as a general dictum for d) Angiographic embolization : Ongoing
each and every trauma case. Our approach should bleeding can sometimes be stopped
be ABCDE approach. In case of abdominal trauma without surger y by embolizing the
special emphasis should be placed on circulation. bleeding vessel using a percutaneous
External haemorrhage rarely is associated with angiographic procedure (angiographic
blunt abdominal trauma. If external bleeding is embolization). Haemostasis is obtained by
present, control it with direct pressure. Titrate injecting a thrombogenic substance (e.g.,
Intravenous fluid therapy to the patient’s clinical powdered gelatin) or metallic coils into the
response Intravenous fluids should be titrated to a bleeding vessel.
systolic blood pressure of 90-100 mm Hg. Ongoing PELVIC FRACTURES AND ASSESSMENT: Patients
haemorrhageis suggested by worsening with hypotension and pelvic fractures have a high
hemodynamic status, significant ongoing mortality so sound and quick decision is very
transfusion needs (e.g. more than 2 to 4 units over a important. Disruption of pelvic ring tears the pelvic
12-h period) significant decrease in Hct (e.g. by > 10 venous plexus and occasionally disrupts the internal
to 12%), patients suspected of significant ongoing iliac arterial system. Mortality varies from 5-50%
haemorrhage should be considered for depends upon type of fracture and association of
angiography with embolization or immediate hypotension.
laparotomy.Prophylactic antibiotics are not
indicated when patients are managed without Management of pelvic frac ture : Initial
surgery. However, antibiotics are often given before management of pelvic disruption with hypotension
surgical exploration when patients develop an is haemorrhage control and fluid resuscitation.
indication for surgery. Haemorrhage control is achieved through
mechanical stabilisation of pelvic ring and external
c) Laparotomy counter pressure (Figure 3). Pelvic binder or sheet or
Indications for laparotomy in a patient with blunt any other device can apply sufficient stability for
abdominal injury include the following: unstable pelvis at the level of greater trochanters of
the femur (Figure 4). Definitive care of patients with
i. Blunt abdominal trauma with hypotension hemodynamic abnormalities demands the
with a positive FAST cooperative efforts of a team.A treatment algorithm
based on the hemodynamic status for emergency
ii. Blunt or penetrating abdominal trauma
patient is shown below.
with a positive DPL
SUMMARY
iii. Hypotension with penetrating abdominal
trauma 1. Once the patient’s vital functions have been
restored, early consultation with surgeon is
iv. Gunshot injury traversing the peritoneal
necessary.
cavity

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 AIIMS Bhopal 2014

Ini al management 2. Hemodynamically unstable patients with

multiple blunt injuries should be rapidly
Surgical consult Pelvic wrap assessed for intra-abdominal bleed by
performing FAST or DPL.
3. Management of blunt and penetrating trauma
Intra-peritoneal gross blood? to the abdomen and pelvis includesprompt
recognition of sources of hemorrhage with
effort to control either with laparotomy, pelvic
stabilizations and angiographic embolization
4. Re-establish ABCDE: Meticulous initial physical
Laprotomy Angiography
examination at regular intervals & selecting
special diagnostic maneuvers as needed.

Hemorrhage control fixa on device

Figure 3: Pelvic fractures and hemorrhagic shock

management algorithm.

Whenever in doubt that pelvic injury is there or not,

it is always better to apply pelvic binder because it
will not harm the patient

Figure 4: Pelvic binder

37
Basic Trauma Care

CHAPTER 6
HEAD INJURY
A Clinical Case : practice. In the setting of acute head injury, give
priority to the immediate assessment and
A 25 year old man has been brought to your casualty stabilization of the airway and circulation. Following
in a tractor trolly. He was driving a motorcycle stabilization, direct attention to prevention of
without wearing a helmet and was speeding up secondary injury.
when he had a head on collision with a jeep. He was
thrown off the highway. When you receive him he is The basic management of head injury rests on the
unconscious and breating heavily. There is active ATLS principles where the sequence of steps remain
bleeding from a scalp wound and the pulse is as ABCDE. There may be a confusion with ACLS
thready with tachycardia. The CT scan shows large guidelines that the sequence should be CAB. It is to
extra dural haematoma (Figure 1) be noted here that in ACLS it is presumed that the
patient already has a cardiac arrest and hence
requires cardiac massage first. Whereas in trauma
cases it is not known whether the patient has
cardiac or a respirator y ar rest. I n such a
circumstance the dictum is to treat that pathology
first which kills first. And of course a lack of oxygen
for four minutes can cause similar irreversible
d a m a g e t h at c a n b e c a u s e d by a 2 0 m i n
hypotension (SBP<90mmHg). So always remember
that whenever you are dealing with a case of trauma
follow the ATLS principle of ABCDE.
Overview of cranial anatomy: as shown in figure 2

The Major Portions of the Brain include the Cerebrum,

Cerebelium and Brain Stem

Meninges Convolution
Skull Sulcus
Figure 1 : CT Scan showing extra dural haematoma Cerebrum
Corpus
Diencephalon callosum
Objectives :
Brain Midbrain
stem Pons Transverse
1. Deciding whether patient has head injury Fissure
Medulla
oblongata Cerebullum
2. Evaluating the severity of injury
Spinal Cord
3. Initial basic management of head injured
patients
Figure 2 : Cranial anatomy
4. Prevention of secondary damage
What constitutes head Injury :
5. Planning of transfer
Not every injury to the head and neck region
Introduction constitute head injury. Only certain types of head
Every medical officer has to invariably face this and neck injuries qualify for this category.
sensitive situation very frequently during their • Skull fractures

38
 AIIMS Bhopal 2014

– Vault shown in the figure.

– Base of skull Accordingly the pressure volume cure follows a
parabolic curve with sudden decompensation after
• Meningeal injuries a certain level as shown in the graph. In clinical
• Vascular injuries setting this leads to sudden deterioration in the
patient condition which if goes unchecked
• Parenchymal Brain injury b e co m e s l i fe t h re a te n i n g d u e to ce re b ra l
– Microscopic herniations.

– Macroscopic Suspecting Head Injury:

What does not constitute head Injury: The most important question which comes to mind
in such situation is how do we suspect that the
• Scalp injury patient might have sustained head injury during the
accident or assault. The dictum here is that any
– Lacerations and abrasions
patient involved in an accident or fight and had one
– Edema and subgaleal hematomas of the following features qualifies as a case of head
injury:
• Facial injuries
– Having any signs of head or neck injury
• Purely orbital injuries without skull base #
– Bleeding from Ear, Nose and Throat
Uniqueness of Head Injury:
– Altered sensorium – confused,
Monro-Kellie Doctrine & Volume-Pressure delerious, comatose....
Curve:
– Had a seizure or episode of LOC
The cranium is a fixed volume cavity which is shared
by three physiological components namely – brain, – Having symptoms or signs of
blood and cerebrospinal fluid (Figure 3). Any lesion neurological deficit
which is caused by head injury displaces these All these patients should be treated as having head
normal components to accommodate itself, as

Lateral Choroid Subarachnoid

A ventricle Plexus Space
Bone B ICP
Arachnoid Dura mater 60 mmHg
Villi
CSF
Choroid
plexus
50

40 I II III

30
Third
ventricle
Tentorial Tentorium
20
hiatus Cerebellum
Aqueductus Foramen megnum
sylvii 10
Fourth
ventricle DV(cm3)
0 20 40

Figure 3: Monro Kellie Doctrine and Volume- Pressure Curve

39
Basic Trauma Care

injury unless proven otherwise and should be Table 1 : Glasgow Coma Scale (GCS)
managed accordingly. Eye Opening Sponteneous –open with blinking 4 points
Response at baseline
Pathology of head injury : Open to verbal command, speech, 3 points
or shout
Before coming to the management of head injury in Open to pain, not applied to face 2 points
particular, the treating clinician should know what None 1 point
does it mean when we say that the patient had head Verbal Oriented 5 points
Response Confused conversa on, but able 4 points
injury. There are two aspects. The first is the primary
to answer ques ons
injury which occurs at the time of impact. This injury Inappropriate responses, words 3 points
caused by the direct physical force transmitted to discemible
the head and neck region and is present immediate Incomprehensible speech 2 points
after the event. This primary damage can be focal None 1 points
(Fracture ,Contusion, Hematoma (EDH/SDH)) or Motor Obeys commands for movement 6 points
Response Purposeful movement to painful 5 points
diffuse (DAI (Diffuse Axonal Injury), DVI (Diffuse
s mulus
Vascular Injury), Diffuse brain swelling) . Withdraws from pain 4 points
Abnormal (spas c) flexion, 3 points
Managing head injury patients at primary health decor cate posture
care centers: Extensor (rigit) response, 2 points
decerebrate posture
REMEMBER WHO IS YOUR PATIENT: Mostly a None 1 points
healthy child or a working adult with no or minimal
co-morbidities. These patient will respond best to reduced thus increasing chances of survival (more
your targeted treatment as their physiology has importantly meaningful survival).
maximum compensatory capacity. They can fight
b a c k t h e i n s u l t b e s t i f gi ve n t h e co r re c t Initial Examination and ABC:
management .
• History
IMPORTANT: The primary injury needs specialist
investigative, operative and neurointensive care • Vitals – pulse , BP, Temp., Resp.
procedures for management which are not • External Signs of Injury
available at primary care centers.
• Consciousness- GCS
What we are concerned here is the secondary injury,
which is caused by other factors that compound the • Pupils
effects or primary injury and lead to further damage. • Vision
These compounding factors include those
conditions which can be managed by you at your • Limbs Watch the moments of all limbs
primary care center, thus preventing further brain
damage. These include the six – H: U/L paralysis -- Injury to Brachial Plx or Cx. Spine

– BP -Hypotension L/L paresis – Injury to spine

– Temp -Hyperthermia/Hypothermia Repeat Examinations:

– Electrolytes -Hyponatremia • GCS Every 4 -6 Hrs

– B Sugar -Hyperglycemia/Hypoglycemia • Pupil Size / Reaction – every 30minutes to 2

hours.
– ABG -Hypoxia
• Neurological Sign
-Hypercarbia
• Vitals
If these factors are managed successfully the
chances of developing secondary injury are

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 AIIMS Bhopal 2014

Glasgow coma scale Fluid management

The Glasgow Coma Scale or GCS is a neurological In a case of head injury patient the blood brain
scale that aims to give a reliable, objective way of barrier is physically as well as chemically disrupted.
recording the conscious state of a person for initial Thus the brain’s capacity to keep out edema fluid is
as well as subsequent assessment (Table 1). A lost. In such situations any hypotonic fluid like 5%
patient is assessed against the criteria of the scale, dextrose IV will lead to increased cerebral edema
and the resulting points give a patient score and accentuated secondary brain damage. The best
between 3 (indicating deep unconsciousness) and fluid for any head injury patient in the primary
either 14 (original scale) or 15 (the more widely used setting is normal saline. In case if patient is also
modified or revised scale). hypoglycaemic, calculated amounts of DNS can be
g i ve n . A l l o t h e r hy p o t o n i c s o l u t i o n s a re
Clinically grading head injury and decision contraindicated. Even when treating shock use NS
making: rather than RL.
Minimal Head injury: GCS 15 at the time of Role of mannitol, steroids and antiepileptics
examining the patient. H/o loss of consciousness
(LOC) for less than 5 min. No deficits. Observe for 24 Mannitol
hours with repeated checks. In case of any
deterioration, refer to higher center after In a patient with suspected head injuty, the nature
stabilization. of pathology can be defined only after a CT scan
brain has been done. Unless an extradural
Mild head injury : GCS 15 with LOC > 5 min. hemorrahage has been ruled out, mannitol should
Obser ve for 48 hours. I n case of any not be administered as it may lead to expansion of
deterioration, refer to higher center after the EDH. Additionally in a patient who has been
stabilization. received with shock, mannitol infusion without
bringing back systolic blood pressure to normal
GCS 14 +/- LOC. Observe, if GCS not improving range can leas to sudden hypotension and further
within 6 hours, stabilize and refer. secondary damage.
Moderate head injury : GCS 9 to 13. Stabilize Steriod
and early referral to higher center.
No scientific study has proven that there is any role
Severe head injury : GCS <9. Stabilize and early of steroids in the management of head injury
referral to higher center. patients. These are more harmful than beneficial to
Special circumstances the head injured patients. Hence for any patient
with head injury, use of steroids is contraindicated.
Children : Even small scalp lacerations or even
subgaleal hematomas can lead to shock in case of Antiepileptics
small children. They may not be able to give specific When suspecting head injury:
complaints and neurological examination is not
always easy. Thus always keep a low threshold to Minimal – Do not start AEDs till need arises
respond and refer early. But remember that promary
Mild – One week course of AEDs
management remains the same
Moderate to severe – Start AEDs early and
Elderly: Due to blunting of autonomic reflexes and
give adequate coverage during transfer.
existing chronic diseases, elderly patients also need
to be given special attention with a low response The best AED which is easily available is phenytoin
threshold for response and early referral. sodium which has a loading dose of 20mg/kg and
maintenance dose of 3-5 mg/kg.

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Basic Trauma Care

CHAPTER 7 BURNS, THERMAL AND

ELECTRICAL INJURIES
Contents: There are three commonly used methods of
estimating burn area, and each has a role in different
l Introduction scenarios. When calculating burn area, erythema
l Assessment of a Burn Patient (Burn Surface should not be included.
Area & Classification of Burns Depth) Wallace Rule of Nines (Figure 1) — The “rule of nines”
l Fluid Resuscitation of Burn Patient is a simple, quick and relatively accurate method of
estimating TBSA burned in adults. The body is
l Management of A Patient with Burns divided into areas of 9%, and the total burn area can
(Immediate & Primary Survey) be calculated. It is not accurate in children.
l Secondary Survey Palmar Surface— The surface area of a patient’s
palm (including fingers) is roughly 1% of total body
l Chemical Injuries
surface area. Palmar surface can be used to estimate
l Electrical Injuries relatively small burns (< 15% of total surface area) or
very large burns (> 85%, when unburnt skin is
l Cold Injuries counted). For medium sized burns, it is inaccurate.
INTRODUCTION : Lund and Browder Chart (Figure 2)—This chart, if
Burns are one of the most devastating conditions used correctly, is the most accurate method. It
encountered in medicine. The injury represents an compensates for the variation in body shape with
assault on all aspects of the patient, from the age and therefore can give an accurate assessment
physical to the psychological. It affects all ages, from of burns area in children.
babies to elderly people, and is a problem in both It is important that all of the burn is exposed and
the developed and developing world. Thermal assessed. During assessment, the environment
injuries are responsible for high morbidity and should be kept warm, and small segments of skin
mortality. To decrease the high morbidity and exposed sequentially to reduce heat loss.
mortality associated with burns, it is necessary to
apply the principles of initial trauma resuscitation Head = 9% (Front & Basic)
and the timely application of simple emergency Head=9%
measures. (front and back)
Back
=18%

Burns are also a major problem in the developing Chest=18%

world. Over two million burn injuries are thought to Right arm
=9%
Left arm
=9%
occur each year in India, but this may be a Head=18%
(front and back)
substantial underestimate. Mortality in the Back
=18%
developing world is much higher than in the Perineum
Chest=18%
Right arm Left arm
developed world. =1%
=9% =9%

This chapter provides an overview of the most Right leg Left leg Perineum
important aspects of burn injuries for hospital and =18% =18% =1%

non-hospital healthcare workers. Right leg Left leg

=13.5% =13.5%

ASSESSMENT OF BURN PATIENT

TOTAL BURN SURFACE AREA (TBSA) Adult Child

Figure 1 : Wallace Rule of Nines

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 AIIMS Bhopal 2014

Epidermis

Dermis

Fat

First degree burn

Figure 2 : Lund & Browder Chart

CLASSIFICATION OF BURNS DEPTH

In order to classify burn depth, it is imperative to
have the knowledge of normal anatomy of the skin.
(Figure 3) the burn affects the healing of the wound,
making assessment of burn depth important for
appropriate wound management and, ultimately,
the decision for operative intervention.
1. Superficial burns(First Degree) (Figure 4 & 5)
involve the epidermis only and are Second degree burn
erythematous and painful, but no blisters. These

Epidermis

Dermis

Hair Follicle
Hypodermis

Sweat Glant

Fat

Blood
Connective Tissue Vessels

Third degree burn

Figure 3 : Anatomy of the Skin Figure 4 : Classification of Burns depth

43
Basic Trauma Care

Figure 7 : Deep Partial-thickness burns

(Second Degree- Deep)
Figure 5 : Superficial burns(First Degree)
bullae, clear serous fluid is present.
Epidermis and papillary region of dermis is
involved. These burns typically heal within 2
weeks and generally do not result in
scarring, but could result in alteration of
pigmentation. E.g. Water scald burns, flame,
flash & contact burns (Figure 6).
b) Deep partial-thickness burns (Second
Degree- Deep)involve the entirety of the
epidermis and extend into the reticular
portion of the dermis. These burns are
typically dry and mottled pink and white in
appearance and have variable sensation. If
protected from infection, deep partial-
thickness burns will heal within 3 to 8 weeks.
They will typically heal with contraction,
scarring, and possible contractures (Fig. 7).

Figure 6 : Superficial Partial-thickness burns

(Second Degree- Superficial)
burns typically heal within 3 to 5 days. These
burns are not included in burn assessment. E.g.
Sunburn.
2. Partial-thickness burns (Second Degree) involve
the entirety of the epidermis and a portion of
the dermis.
a) Superficial partial-thickness burns (Second
Degree- Superficial) are typically pink,
moist, and painful to the touch. Blisters,
Figure 8 : Full-thickness burns (Third Degree)

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 AIIMS Bhopal 2014

hours.}
It is important to keep in mind that the volume
calculated is to be given from the time of injury and
not from the time of initial evaluation of the patient.
Also, these formulas are merely a starting point and
that precise monitoring of the patient’s status
should be used to fine-tune fluid replacement. Urine
output remains an excellent guideline for the
adequacy of fluid replacement. An output of 0.5
ml/kg/hour for adults and greater than 1.0
ml/kg/hour for children is used as a guideline for
adequate fluid resuscitation. Decrease or increase in
IV fluid rate should be based on urine output.
Figure 9 : Types of burns.
MANAGEMENT OF A PATIENT WITH BURNS
(Figure 10):
3. Full-thickness burns (Third Degree) involve the
epidermis and the entirety of the dermis. These IMMEDIATE: (by rescue workers, at site of accident/
wounds are brown-black, leather y, and burn injury)
insensate. Occasionally, full-thickness burn
wounds have a cherry-red color from fixed STOP the BURNING PROCESS - The heat source
carboxyhemoglobin in the wound. These should be removed. Flames should be doused with
wounds can be differentiated from more water or smothered with a blanket or by rolling the
superficial burns because they are usually victim on the ground. Rescuers should take care to
insensate and do not blanch (Figure 8). avoid burn injury to them. Clothing can retain heat,
even in a scald burn, and should be removed as soon
The anatomical and clinical features of all the as possible. Adherent material, such as nylon
three major types of burn are summarised in clothing, should be left on. Tar burns should be
figure 9. cooled with water, but the tar itself should not be
removed. In the case of electrical burns the victim
FLUID RESUSCITATION/ THERAPY OF BURN
should be disconnected from the source of
PATIENT electricity before first aid is attempted.In the case of
Fluid losses from the injury must be replaced to chemical burns, remove clothing, dry chemical
maintain homoeostasis. There is no ideal powder dusted off if any, and then irrigate with
resuscitation regimen, and many are in use. All the copious amount of water.
fluid formulas are only guidelines, and their success COOLING THE BURN - Active cooling removes heat
relies on adjusting the amount of resuscitation fluid and prevents progression of the burn. This is
against monitored physiological parameters. effective if performed within 20 minutes of the
Simple, safe and inexpensive formula for calculating injury.
resuscitation volume is 2 - 4 mL/kg/% TBSA of
Initial assessment of a major burn
Lactated Ringer’s solution over the first 24 hours of
injury. Half of this volume is given over the first 8 Perform an ABCDEF primary survey:
hours and half over the next 16 hours after injury.
A – Airway with cervical spine control
{Example: A 50 kg man with 80% total BSA burns
requires (2 to 4 X 50 X 80 = 8000 to 16000 ml in 24 B – Breathing
hours) One-half of that volume, 4000 to 8000 ml C – Circulation
should be provided in the first 8 hours, so the patient
should be started at a rate of 500–1000 ml/hr. D – Neurological disability
Another half of the fluid volume is given in next 16

45
Basic Trauma Care

Airway Yes
Compromised or at Intubate
risk of compromise?
No

Breathing Yes
Cause :
Compromised? Mechanical Escharotomies
Carboxyhaemoglobin Intubate and ventilate
No
Smoke inhalation Nebulisers
Circulation Non-invasive ventilation
Compromised perfusion Invasive ventilation
to an extremity? Blast injury Invasive ventilation
Chest drains
No Yes

Escharotomies

Neurological disability Yes Consider :

Impaired score on Hypoxia (carboxyhaemoglobin level?)
Glasgow coma scale? Hypovolaemia

No
Exposure
Fully assess burn area and depth
Full examination for concomitant injuries
Keep warm

Fluids
Calculate resuscitation formula based on Go back and re-evaluate
surface are and time since burn

Figure 10 : Stepwise management burn patient.

E – Exposure with environmental control • Catheterize patient or establish fluid

balance monitoring
F – Fluid resuscitation
• Ta k e b a s e l i n e b l o o d s a m p l e s f o r
• Assess burn size and depth investigation (full blood count; urea and
• Establish good intravenous access and give electrolyte concentration; clotting screen;
fluids (in children, the interosseous route blood group; and save or cross-match
can be used for fluid administration if serum)
intravenous access cannot be obtained) Electrical injuries
• Give analgesia • 12-lead electrocardiography

46
 AIIMS Bhopal 2014

• Cardiac enzymes (for high tension injuries) the “ABCDEFs” (Airway, Breathing, Circulation,
Disability, Exposure &Fluid resuscitation).A
Inhalational injuries
modified “advanced trauma life support” primary
• Chest X-ray survey is performed, with particular emphasis on
assessment of the airway and breathing. The burn
• Arterial blood gas analysis injury must not distract from this sequential
Dressing of wound assessment, otherwise serious associated injuries
may be missed.
• After completion of the primary survey, a
secondary survey should assess the depth A—Airway with cervical spine control
and TBSA burned, reassess, and exclude or An assessment must be made as to whether the
treat associated injuries airway is compromised or is at risk of compromise.
• Arrange safe transfer to specialist burns The cervical spine should always be protected
facility unless it is definitely not injured. The airway is
commonly compromised in cases of inhalational
PRIMARY SURVEY and MANAGEMENT of a burn injury which is described below.
patient:
Inhalational injury : Currently, inhalation injury is a
History taking : more common acute cause of death from a burn
injury than the surface burns themselves. The
The history of a burn injury can give valuable
mechanisms of injur y may involve carbon
information about the nature and extent of the
monoxide inhalation, thermal injury to the upper
burn, the likelihood of inhalational injury, the depth
airway and digestive tract, and inhalation of the
of burn, and probability of other injuries. The exact
products of combustion (Figure 11).
mechanism of injur y and any pre -hospital
treatment must be established. The upper airway is at risk for obstruction because
burns can result in massive oedema, especially
Primary survey :
when there are closed-space fire, burns of the head
On admission and initial evaluation, the burn victim
is treated as any trauma patient and is evaluated for
Airway Injuries
Table 1 : Signs of inhalational injury and its
management
Carbon Monoxide
Signs of inhalational Indications for Poisoning
Signs and symptoms
injury intubation may vary

· History of flame burns · Erythema or Inhalation Injury

or burns in an enclosed swelling of Above The Glottis
Singed nasal hair,
space oropharynx facial burn,
· Full thickness or deep on direct carbonaceous sputum
dermal burns to face, visualisation Glottis
neck, or upper torso · Change in
· Singed nasal hair, voice, with
Inhalation Injury
eyebrows, and hoarseness Below The Glottis
eyelashes or harsh Signs and Symptoms
· Carbonaceous sputum cough may not be immediate
or carbon particles in · Stridor,
oropharynx tachypnoea,
· Carboxyhemoglobin or dyspnoea
level greater than 10%
in a patient who was
involved in a fire Figure 11 : Airway injuries in case of burn

47
Basic Trauma Care

and face, inhalation injury, and burns inside the exacerbating the situation. The inflammatory
mouth. This burn will become oedematous over the exudate created is not cleared, and atelectasis or
following hours, especially after fluid resuscitation pneumonia follows.
has begun.Symptoms of inhalational injury can take
24 hours to 5 days to develop. If there is any concern Carboxyhaemoglobin—Most devastating effect of
about the patency of the airway then intubation is inhalation injury in burns is Carbon Monoxide
the safest policy as the signs of obstruction may Poisoning. Carbon monoxide binds to
initially be subtle until the patient is in crisis. deoxyhaemoglobin with 40 times the affinity of
Children are at more risk owing to their smaller oxygen. It also binds to intracellular proteins,
airways.Securing the airway prior to transport is particularly the cytochrome oxidase pathway. These
recommended (Table 1). two effects lead to intracellular and extracellular
hypoxia. The clinical features include progressive
If inhalational injury is suspected, early increase in respiratory effort and rate. Pulse
intubation is necessary to prevent respiratory oximetr y cannot differentiate between
distress, especially if the patient is being oxyhaemoglobin and carboxyhaemoglobin, and
transferred to a burn centre. The physician must may therefore give normal results. However, blood
maintain a high degree of suspicion for the gas analysis will reveal metabolic acidosis and raised
presence of inhalational injury. If it is suspected, carboxyhaemoglobin levels but may not show
arterial blood gases and carboxyhemoglobin hypoxia. Treatment is with 100% oxygen, which
(HbCO) levels should be obtained. If HbCO levels displaces carbon monoxide from bound proteins six
are elevated (>10%), 100 percent oxygen must times faster than does the atmospheric oxygen.
be administered. C—Circulation
B—Breathing Intravenous access - Intravenous access should be
All burn patients should receive 100% oxygen established with two large bore cannulas (16 or 18
through a humidified non-rebreathing mask on gauge) preferably placed through unburned tissue
presentation. Breathing problems are considered to in upper limbs. This is an opportunity to take blood
be those that affect the respiratory system below for checking full blood count, urea and electrolytes,
the vocal cords. There are several ways that a burn blood group, and clotting screen. Peripheral
injury can compromise respiration. circulation must be checked. Any patient with burns
over more than 20% of the body surface requires
Mechanical restriction of breathing— Deep dermal fluid resuscitation. Infusion with an isotonic
or full thickness circumferential burns of the chest crystalloid solution, preferably Lactated Ringer’s
can limit chest excursion and prevent adequate Solution should be started.
ventilation. This may require Escharotomies
(R elease of thick , leather y eschar from a Peripheral circulation must be checked. Any deep or
circumferential burn to the trunk or upper and lower full thickness circumferential extremity burn can act
extremities, which can be life or limb threatening.). as a tourniquet, especially once oedema develops
after fluid resuscitation. This may not occur until
Blast injury—If there has been an explosion, blast some hours after the burn. If there is any suspicion of
lung can complicate ventilation. Penetrating decreased perfusion due to circumferential burn,
injuries can cause tension pneumothoraces, and the the tissue must be released with Escharotomies.
blast itself can cause lung contusions and alveolar Once airway, ventilation and systemic perfusion
trauma and lead to adult respiratory distress have been established, the next priority is diagnosis
syndrome. and treatment of concomitant life-threatening
injuries.
Smoke inhalation—The products of combustion,
though cooled by the time they reach the lungs, act D—Neurological disability
as direct irritants to the lungs, leading to
bronchospasm, inflammation, and bronchorrhoea. All patients should be assessed for responsiveness
The ciliary action of pneumocytes is impaired, with the Glasgow coma scale; they may be confused

48
 AIIMS Bhopal 2014

because of hypoxia or hypovolaemia. Baseline determinations for patients with major

burns : Obtain samples for a complete blood count
E—Exposure with environment control (CBC), type and crossmatch /screen, an arterial
The whole of a patient should be examined blood gas with HbCO, serum glucose, electrolytes,
(including the back) to get an accurate estimate of and pregnancy test in all females of childbearing
the burn area (as described above) and to check for age. A chest x-ray should be obtained for those
any concomitant injuries. Burn patients, especially patients who are intubated or have a suspected
children, easily become hypothermic. This will lead smoke inhalation injury, with repeat films as
to hypoperfusion and deepening of burn wounds. necessary. Other x-rays may be indicated for
Patients should be covered and warmed as soon as appraisal of associated injuries.
possible.
Peripheral circulation in circumferential
F—Fluid resuscitation extremity burns : The goal for assessing peripheral
circulation in a patient with burns is to rule out
The resuscitation regimen should be determined (as Compartment Syndrome. Compartment syndrome
described above) and begun based on the results from an increase in the pressure inside a
estimation of the burn area. A urinary catheter is compartment that interferes with perfusion to the
mandatory in all adults with injuries covering > 20% structures within that compartment. For an
of total body surface area to monitor urine output. extremity, perfusion to the muscle within the
Children’s urine output can be monitored with compartment is the main concern. Although a
external catchment devices or by weighing nappies compartment pressure greater than systolic blood
provided the injury is < 20% of total body area. In pressure is required to lose a pulse distal to the burn,
children the interosseous route can be used for fluid a pressure of >30 mm Hg within the compartment
administration if intravenous access cannot be may lead to muscle necrosis. Once the pulse is gone,
obtained, but should be replaced by intravenous it may be too late to save the muscle. Thus, clinicians
lines as soon as possible. must be aware of the signs of a compartment
SECONDARY SURVEY syndrome: increased pain with passive motion,
tightness, numbness, and, eventually, decreased
At the end of the primary survey and the start of distal pulses. If there are concerns about a
emergency management, a secondary survey compartment syndrome, the compartment
should be performed. This is a head to toe pressure is easily measured by inserting a needle
examination to look for any concomitant injuries. connected to pressure tubing (arterial or central
This includes include physical examination, pressure monitor) into the compartment. If the
documentation, baseline blood levels and x-rays, pressure is >30 mm Hg, escharotomy is indicated
m a i nte n a n ce o f p e r i p h e ra l c i rc u l at i o n i n (Figure 12).
circumferential extremity burns, gastric tube
insertion, narcotic analgesics and sedatives, wound Compartment syndromes may also present with
care, and tetanus immunization. circumferential chest and abdominal burns, leading
to increased peak inspiratory pressures. Chest and
Physical examination : In order to plan and direct abdominal escharotomies performed down the
patient treatment, the provider must estimate the anterior axillary lines with a cross-incision at the
extent and depth of the burn, assess for associated junction of the thorax and abdomen usually relieve
injuries, and weigh the patient. the problem. With aggressive fluid resuscitation,
abdominal compartment syndrome may occur, so
Documentation : A flow sheet or other report that the clinicians should watch for this potential
outlines the patient’s treatment should be initiated problem. In order to maintain peripheral circulation
when the patient is admitted to the ED. This flow in patients with circumferential extremity burns, the
sheet should accompany the patient when clinician should:
transferred to the burn unit.
• R e m ove a l l j e we l l e r y o n t h e p at i e nt ’s
extremities.

49
Basic Trauma Care

avoid vomiting and possible aspiration, insert a

gastric tube and attach it to a suction setup if the
patient experiences nausea, vomiting, or abdominal
distention, or if burns involve more than 20% total
BSA.
Narcotics, analgesics, and sedatives: Severely
burned patients may be restless and anxious from
hypoxemia or hypovolemia rather than pain.
Consequently, hypoxemia and inadequate fluid
re s u s c i t a t i o n s h o u l d b e m a n a g e d b e fo re
administration of narcotic analgesics or sedatives,
which can mask the signs of hypoxemia and
hypovolemia. Narcotic analgesics and sedatives
should be administered in small, frequent doses by
the intravenous route only. Remember that simply
covering the wound will improve the pain.
Wound care: Partial-thickness burns are painful
when air currents pass over the burned surface.
Gently covering the burn with clean sheets relieves
the pain and deflects air currents. Do not break
blisters or apply an antiseptic agent. Any applied
medication must be removed before appropriate
antibacterial topical agents (Silver Sulfadiazine) can
be applied. Application of cold compresses can
cause hypothermia. Do not apply cold water to a
patient with extensive burns (>10% total BSA).
Antibiotics: There is NO indication for prophylactic
Figure 12 : The commonly used Escharotomy sites
antibiotics in the early post-burn period. Antibiotics
should be reserved for the treatment of infection.
• Assess the status of distal circulation, checking
for cyanosis, impaired capillary refill, and Tetanus: Determination of the patient’s tetanus
p ro gre s s i ve n e u ro l o gi c s i gn s, s u c h a s immunization status is very important. Tetanus
paresthesia and deep-tissue pain. Assessment immune-prophylaxis should be done.
of peripheral pulses in patients with burns is
best performed with a Doppler ultrasonic CHEMICAL INJURIES
flowmeter. Traditionally, chemical injuries are classified as
• Relieve circulatory compromise in a either acid burns or alkali (base) burns. The severity
circumferentially burned limb by escharotomy, of chemical injuries depends on the composition of
always with surgical consultation. the agent, concentration of the agent, and duration
Escharotomies usually are not needed within of contact with the agent. In general, alkaline burns
the first 6 hours after a burn injury. cause more severe injury than acid burns because
alkaline agents cause a liquefaction necrosis that
• Although fasciotomy is seldom required, it may allows the alkali to penetrate deeper, extending the
be necessary to restore circulation for patients area of injury. The first step in managing a chemical
with associated skeletal trauma, crush injury, injury is removal of the inciting agent. Clothes,
high-voltage electrical injury, and burns including shoes that have been contaminated
involving tissue beneath the investing fascia. should be removed. The powder, if present should
first be dusted off and then irrigation can take place.
Gastric tube insertion: Prior to transfer, in order to

50
 AIIMS Bhopal 2014

Areas of affected skin should be copiously irrigated urinary output of 100 mL/hr in adults or 2 mL/ kg/hr
with water immediately for at least 20 to 30 minutes in children <30 kg. Metabolic acidosis should be
up to 2 hrs. Adequate irrigation can be verified by corrected by maintaining adequate perfusion.
checking the skin pH. Neutralization of the inciting
agent should never be attempted because because Burn injuries that should be referred to a burn
reaction with the neutralizing agent can itself unit (BURN TRIAGE)
produce heat and cause further tissue damage. If The American Burn Association has defined the
ocular injury has occurred, the eyes should also be criteria used in triaging burns to be admitted and
copiously irrigated. An ophthalmologist should be treated in a specialized burn unit:
consulted to assist in the management of these
patients. 1. Partial- and full-thickness burns >10% TBSA in
patients under 10 or over 50 years of age
ELECTRICAL INJURIES
2. Partial- and full-thickness burns > 20% TBSA in
Electrical injuries are potentially devastating events other age groups
that result in damage to the skin as well as other
tissues, including nerve, tendons, and bone. 3. Full-thickness burns >5% TBSA in any age group
Electrical burns can take several forms, including 4. Partial- and full-thickness burns involving the
injury from the electrical current itself, flash burns, face, hands, feet, genitalia, perineum, or major
flame burns, contact burns, or a combination joints
thereof.Electrical burns result when a source of
electrical power makes contact with a patient’s 5. Electric burns, including lightning injury
body. The body can serve as a volume conductor of 6. Chemical burns with serious threat of functional
electrical energy, and the heat generated results in or cosmetic impairment
thermal injury to tissue. Different rates of heat loss
from superficial and deep tissues allow for relatively 7. Inhalation injuries
normal overlying skin to coexist with deep muscle 8. Any burn patient with concomitant trauma
necrosis.
9. Lesser burns in patients with pre-existing
Patients with electrical injuries frequently need medical problems that could complicate
fasciotomies and should be transferred to burn management
centers early in their course of treatment.
10. Combined mechanical and thermal injury in
Immediate treatment of a patient with a significant
which the burn wound poses the greater risk
electrical burn includes attention to the airway and
breathing, establishment of an intravenous line in 11. Any case in which abuse or neglect is suspected
an uninvolved extremity, ECG monitoring, and
placement of an indwelling bladder catheter. COLD INJURIES
Electricity may cause cardiac arrhythmias that may Three types of cold injury are seen in trauma
require chest compressions. If there are no patients: frostnip, frostbite, and nonfreezing injury.
arrhythmias within the first few hours of injury,
prolonged monitoring is not necessary. Since Frostnip : It is the mildest form of peripheral cold
electricity causes forced contraction of muscles, injury, which tends to occur in apical structures
clinicians need to examine the patient for (nose, ears, hands, feet), where blood flow is most
associated skeletal and muscular damage, including variable because of the richly inner vated
the possibility of spinal injuries. Rhabdomyolysis arteriovenous anastomoses. It is characterized by
results in myoglobin release, which can cause acute initial pain, pallor, and numbness of the affected
renal failure. Do not wait for laboratory confirmation body part. It is reversible with rewarming and does
before instituting therapy for myoglobinuria. If the not result in tissue loss, unless the injury is repeated
p a t i e n t ’s u r i n e i s d a r k , a s s u m e t h a t over many years, which causes fat pad loss or
h e m o c h ro m o g e n s a re i n t h e u r i n e. Fl u i d atrophy.
administration should be increased to ensure a
Frostbite: Exposure to extremes of cold (and wet)

51
Basic Trauma Care

conditions can lead to cellular injury and death. Cell inflammatory medications and anticoagulants has
death and tissue necrosis occur from the formation also been described.
of ice crystals within the cells and extracellular space
from ice crystal formation during the period of cold Nonfreezing Injury: Nonfreezing injury is due to
exposure, whereas microvascular thrombosis is microvascular endothelial damage, stasis, and
thought to occur during reperfusion when the vascular occlusion. Trench foot or cold immersion
affected limb is rewarmed. Similar to burn injury, foot (or hand) describes a non-freezing injury of the
frostbite injury is classified according to the depth of hands or feet, typically in soldiers, sailors, and
injury. fishermen, resulting from long-term exposure to
wet conditions and temperatures just above
• First-degree frostbite is similar to a superficial freezing (1.6°C to 10°C, or 35°F to 50°F). Although
burn injury, with tissue erythema, pain, and the entire foot can appear black, deep-tissue
edema. destruction may not be present. Alternating arterial
vasospasm andvasodilation occur, with the affected
• Second-degree frostbite is marked by blistering tissue first cold and numb, then progressing to
and partial-thickness skin injury. hyperemia in 24 to 48 hours. With hyperemia comes
• Third-degree frostbite occurs when there is full- intense, painful burning and dysesthesia, as well as
thickness necrosis of the skin, and tissue damage characterized by edema, blistering,
redness, ecchymosis, and ulcerations.
• Fourth-degree frostbite occurs when there is Complications of local infection, cellulitis,
full-thickness skin necrosis as well as necrosis of lymphangitis, and gangrene can occur. Proper
the underlying muscle and/or bone with attention to foot hygiene can prevent the
gangrene. occurrence of most such injuries. Management of
Although the affected body part is typically initially this injury entails careful washing and air-drying of
hard, cold, white, and numb, the appearance of the the feet, gentle rewarming, bed rest, and slight
lesion changes frequently during the course of elevation of the extremity. Improvement occurs
treatment. Again, it is important to note that within 24-48 hours, while the injury completely
determination of the full depth of tissue injury is not resolves in 1-2 weeks. Early physical therapy is
possible until several weeks following injury. essential. The patient should be warned that
subsequent chilling will preferentially affect the
The first step in management of frostbite is removal previously injured area. Key to prevention of
of all wet clothes, gloves, socks, and shoes. Patients immersion foot injury is keeping the feet dry for at
should then be wrapped in warm blankets. Frostbite least 8 h/d.
can also be associated with hypothermia. In these
cases, care must be taken to rewarm the entire body. Systemic Hyperthermia: Trauma patients also are
susceptible to hypothermia, and any degree of
In cases of extreme hypothermia (less than 32◦C)
hypothermia in trauma patients can be detrimental.
warming can be achieved with use of warm
In trauma patients, hypothermia should be
intravenous fluids, bladder irrigation with warm
considered to be any core temperature below 36°C
solutions, placement of peritoneal catheters and
(96.8°F), and severe hypothermia is any core
chest tubes through which warm fluids can be
temperature below 32°C (89.6°F). Hypothermia is
administered, and even, if available,
common in the severely injured, but further loss of
cardiopulmonary bypass. Frostbitten extremities
core temperature can be limited with the
should be rapidly rewarmed inwater that is 104◦F administration of only warmed intravenous fluids
(40◦C). Typically, rewarming can be completed in and blood, judicious exposure of the patient, and
20 to 30 minutes. Adjunctive use of anti- maintenance of a warm environment.

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CHAPTER 8 ORAL AND MAXILOFACIAL

TRAUMA
The fracture of the maxillofacial bones including the The mandibular bone can be fractured from
mandible, maxillae, zygoma, nasal, orbital, frontal, symphysis, parasymphysis, body, angle, ramus,
ethmoidal, lacrimal, vomer, paired palatine bones coronoid and the condyle which is the common site
and the sphenoid bone are treated by the of mandibular fracture (Figure 2 & 3). Mandibular
maxillofacial surgeon. condyle commonly fractured from the indirect
trauma. Bilateral fracture of the mandibular bone is
also very common, but it makes the management
difficult.

Fig1: Representing Fracture of the

maxillofacial bones
The mandible is largest, heaviest, strongest and the
only movable bone of the facial skeleton with the
incidence of injury and fracture being most
Fig 4: The percentage wise distribution of
common of all facial bones [61%] by virtue of its
mandibular fracture
position and prominence followed by maxilla [46%],
zygoma [27%] and nasal bone [19.5%] (Figure 1). The clinical features on inspection including
swelling [tumor], rubor, ecchymosis/bleeding,
haematoma [sublingual], lacerations
[mucosal/skin], facial asymmetry, step deformity,
decreased interincisal distance, change in occlusal
plane, empty sockets or fracture/loose teeth. On
palpation tenderness, inter fragmentary mobility,
deranged occlusion, crepitation & abnormal
mandibular movements.
The Malar or the Zygomatic bone represents a
strong bone on fragile supports and it is for this
reason that, though the body of the bone is rarely
broken, the four processes frontal, orbital, maxillary
and zygomatic are the frequent sites of fracture
(Figure 4-6).

Fig 2&3: Showing the common fracture sites

over the mandible

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Basic Trauma Care

Fig 5 : 3D scan showing fractured zygomatic bone

Maxillary fracture
Rene Le Fort described the classic patterns of
fracture in his 1901 work. Le Fort's experiments
consisted of using 32 cadavers that were either
intact or decapitated. Cadaver skulls were dropped
from several stories or were struck with a wooden
club. He found 3 distinct fracture patterns, which he
termed the lineaminorosresistentiae (Figure 7-8).
Orbit fracture occurs isolated or in association i.e
blow out or blow in fracture, orbital roof or floor
fracture, medial or lateral wall fracture 5 (Figure 9).
Due to its prominent position on the face the nasal
bone fractured commonly, although a very little
force is required to fracture the nasal bone. The
clinical features including the edema, depression of
the nasal bridge,epistaxis,septal dislocation or
deviation, edema and ecchymosis6 (Figure 10-11).
Fig 6 : Showing clinical features of zygomatic bone
Management of Maxillofacial fractures:
fracture i.e flattening of the malar prominence,
1. ABCDE : Life saving treatment first subconjunctival haemoorhage, circumorbital
ecchymosis, diplopia, V-in fracture of zygomatic
2. Initial management : Temporary stabiliztion of arch, ptosis, enophthalmos, hypoglobus.
the fractured bone can be achieved with the help of
barrol bandage, barton bandage or a simple
application of bandage from forehead to chin (Fig
12). t h e h e l p o f m i n i p l ate s, m i c ro p l ate s,
3. Closed reduction :Intermaxillary fixation (IMF) reconstruction plates, lag screws, 3D plates or
with the help of arch bars , IMF screws (fig 13), with bio resorbable plates. The fixation of the
eyelet wiring, direct interdental wiring. fracture fragment done from outer to inner
surface and lower to upper fracture fragments
4. Open reduction and rigid internal fixation : with of bone (Fig 14).

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Fig 10: Nasal bone fracture due to injury from

Fig 7 : Showing Le fort I,II,III fracture lines, when skull lateral aspect
base is involved along with le fort fracture it is called
as Le fort IV fracture.

Fig 11: Nasal bone fracture due to injury from

anterior aspect

Fig 8 : Showing clinical features Le fort fracture

i.eguriens sign 4, dish face deformity, lengthening of
the face, telecanthus, floating maxilla.

Fig 9 : Showing cause and CT scan of blow out

fracture Fig 12: Showing application of bandages

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Basic Trauma Care

Fig 13 : Representing IMF with arch bars and screws

Fig 14: Showing internal fixation of

maxillofacial fractures.

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CHAPTER 9
MUSCULOSKELETAL TRAUMA
The structure of the skeletal system is composed of musculoskeletal trauma. The hemorrhage
bones, cartilages, tendons, ligaments, muscle and from long bone fracture like femur, pelvic
synovial fluid. Bones provides structural support, bone fracture may cause significant blood
protection for soft tissue and leverage for mobility. loss and can be fatal. In such cases proper
Bones meet at joints and are held together by splinting may reduce bleeding significantly
ligaments. Cartilage provides the smooth surface by reducing movement and tamponade
and padding for bones to slide or pivot against each effect. If fracture is open, application of a
other. The synovial fluid contained inside the sterile pressure dressing is helpful in
ligamentous joint capsule lubricates the surface. hemorrhage control. If the fracture is
Tendon are cord like connective tissue that joint consider as a cause of shock immobilization
muscle to bone, crossing joints in the cable and and x-ray can be used as a adjunct during
pulley system that effect movement. The muscle primary survey.
itself is encased in connective tissue compartment
b. Immobilization
called fascia (Figure 1). Our primary concern is
whether an injured bone or joint can still safely The goal of immobilization is to realign the
perform its function, or must be stabilized and injured extremity in anatomical position as much as
protected. Musculoskeletal trauma dose not ignore possible by application of inline traction to realign
the priorities of ABCDEs. the extremity and keep it in place by immobilization
devices. This reduces further blood loss, pain and
Stretched soft tissue injury. The dislocated joint may be
tendon splinted in normal anatomic position and in case of
Torn Stretched
open fracture opposing the bone may not be crucial
ligament muscle as they may need debridement.
Steps to follow during immobilization
l Expose the patient completely and remove
potentially constricting devices such as
bracelets, watches, and rings etc. This has to be
done fast as hypothermia has to be prevented.
Misaligned l Cover any open wound with sterile dressings
joint
l Assess for pulse, external hemorrhage,
neurovascular status and perform motor and
Figure 1 : Different structure of Musculo-skeleton sensory examination.
injury in trauma
l Select appropriate size and type of splint. In the
I. Primary survey and resuscitation case of Thomas Splint the upper cushioned ring
should be placed under the buttock, adjacent to
Assess ABCDE and treat life threatening events first.
ischial tuberosity and distal end should extend
After taking care of airway with cervical spine
beyond ankle about 15 cm.
protection (A), breathing (B)with ventilation, it
becomes imperative to recognize and control l Immobilize one joint above and below the
hemorrhage after musculoskeletal injury. injury site.
a. Circulation : The circulation is the most l Apply padding over bony prominences
component of ABCDE which is affected in l No forced realignment of a deformed extremity

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Basic Trauma Care

with normal pulse FEEL

l Obtain orthopedic consultation 1. Palpate for tenderness, swelling, deformity,
sensation. Loss of sensation may indicate
l Document neurovascular status before and
peripheral nerve or spinal cord injury.
after every manipulation
2. Palpation at the time of logrolling the
l Administer appropriate tetanus prophylaxis.
patient is important to identify soft tissue
Once an injury is stabilized, the most important injury, hematoma and gaps between
anticipated problem becomes distal ischemia spinous process etc.
caused by compression of neurovascular bundle as
3. Palpate the distal pulses in each limb
swelling develops inside splints or bandages.
Treatment should include medication, rest and LISTEN
elevation of to reduce swelling and pressure.
1. Doppler Signals : To look for signs of vascular
II. Secondary survey sufficiency
Elements of the secondary survey are history 2. Bruits
and physical examination. c. Pain control: Pain control is one of the
a. History important aspects in management of
trauma patient and ways to achieve pain
The history includes the mechanism of injury,
controls are done by
predisposing factors, pre -injur y status,
prehospital care received, patient relatives and 1. Appropriate immobilization
bystanders at the scene of the injury should be 2. Use of analgesics
documented and included as a part of the
patients medical record. The AMPLE history 3. Regional nerves block, but remember to
(allergies, medications, past history, last meal, document any peripheral nerve injury
events/environment related injury) also should before giving any regional nerve block.
include information about the patients exercise MUSCULOSKELTAL TRAUMA: IMPORTANT
tolerance, ingestion of alcohol, other drugs and INJURIES
emotional problem.
I. LIFE THREATENING INJURIES
b. Physical examination
a. Crush injury
The patient should be completely undressed
avoiding hypothermia keeping in mind three b. Major arterial injury
important goals a. Crush injury : The crush injury of a muscle
i. Identification of life threatening events leads to direct muscle injury, muscle
ischemia and cell death releasing large
ii. Identification of limb threatening events amount of myoglobin. The clinical features
iii. Systemic review to avoid any missing injury. include the dark amber color urine (which is
due to myoglobin), metabolic acidosis,
The dictum is look, listen and feel
hypocalcemia, hyperkalemia, disseminated
LOOK: intravascular coagulation and acute kidney
injury. The treatment of choice is early and
1. Color and perfusion of the injured extremity
aggressive fluid therapy along with osmotic
2. Swelling, deformity of the injured limb diuresis in order to maintain urine output of
3. Discoloration, anybruising atleast 100ml/hour. This is done in order to
reverse myoglobin induced acute kidney
4. Patient’s spontaneous extremity movement injury.
to rule out muscular and neurological
injury. b. Major arterial injury : Any penetrating &
blunt trauma leading to fracture,

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dislocation, in close proximity to artery In case of ongoing hemorrhage even

leads to major arterial injury. This is after direct pressure application if
manifested as external bleeding, feeble bleeding doesn’t stop, the use of
pulse or loss of pulse and pallor. Direct tourniquet sometimes may be life-
application of pressure to control bleeding saving. When using a tourniquet care
along with vascular and or thopedic should be paid regarding risk of
consultation is of prime importance. development of ischemia. If arterial
injury with joint dislocation is present, a
II. LIMB THREATENING INJURIES
skilled clinician may attempt once to
a. Open fracture with joint dislocation : reduce joint.
Open fracture is communication between
iv. Care of amputated part: The amputated
the bone and external environment, the
part should be washed thoroughly with
damage along with bacterial contamination
isotonic solution and thereafter wrap it
makes the situation prone for infection and
with sterile gauge which has been
delayed healing.
already soaked in aqueous penicillin
i. Assessment : This is based on history of (1,00,000 unit in 50 ml of R/L). The
the incident and physical examination amputated part is then wrapped in a
of the open wound. If open wound sterile moistened towel and placed in a
exists close to joint it is assumed that p l a s t i c b a g, a n d t ra n s p o r te d i n
wound is extending to joint and surgical insulated cooling chest with crushed
opinion is must. ice. The amputated part should not be
allowed to freeze.
ii. Management : First and foremost we
should try to achieve hemodynamic c. Compartment Syndrome
stability by hemorrhage control and
It develops when pressure within a
adequate fluid resuscitation. The
osteofascial compartment of muscle causes
wound has to be immobilized.
ischemia and subsequent necrosis. The
Currently, first generation
osteo-fascial compartment comprises of
cephalosporin should be given in all
artery, vein, and nerve (Figure 2). The
cases with open fractures and gram
compression of artery leads to loss of pulse,
negative antibiotics should be given in
pallor and pain (which is due to
cases of severe infection. Tetanus
a cc u m u l a t i o n o f tox i c p ro d u c t s o f
prophylaxis is a must in such cases.
metabolism).The compression of nerve
b. Va s c u l a r i n j u r i e s a n d t r a u m a t i c leads to paresthesia and the compression of
amputation vein leads to swelling. These five common
sign and symptoms comprises of ‘6 P’s of
i. Injury: History of blunt, penetrating
compartment syndrome
trauma, crushing and twisting injury is
there. l Pain (out of proportion of clinical
condition)
ii. Assessment: On examination patient
has cold extremities, prolong capillary l Pressure (One of the earliest sign is the
refill time and diminished peripheral extreme pain which is there on passive
pulses. They have on Doppler stretching too)
examination abnormal ankle brachial l Pallor
pressure index (ABPI).
l Paresthesia
iii. Management: First and foremost step in
management is hemorrhage control l Pulse - absent or diminished
along with adequate fluid resuscitation. l Palpable tenderness

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Basic Trauma Care

It can occur in any site in which muscle is contained compartment syndrome

within a closed fascial space, However certain
iii. Management:-
injuries are considered high risk such as tibial and
forearm fracture ,tight dressing and casting, severe Remove all constrictive dressing, casts and
crush injury, increase capillary permeability splints applied over the affected extremity.
secondary to re perfusion of ischemic muscle, burns Thereafter monitor the patient, reassess in
etc. 3 0 - 6 0 m i n a n d i f n o c h a n g e o cc u r
fasciotomy should be done (Figure 3). So
i. Assessment : The key to success of acute
the definitive management of
compartment syndrome is early diagnosis;
compartment syndrome is fasciotomy.
pain out of proportion to injury is the
earliest recognizable sign of compartment D. Neurological injury secondary to dislocation
syndrome. O ther common sign and and fracture:-
symptons are pallor, paresthesia, loss of
Anatomical proximity of nerve to joints makes them
prone to injury particularly after dislocation and
Compartment fracture.
syndrome :
Leg swollen, i. Assessment : Sensory function, motor function
tight, pale, must be carried out for each significant
and shiny
Swollen muscle
peripheral nerve. In case of multiple injuries
compresses stabilization of the patient is first and for most
blood vessels
and nerves in priority, then one has to assess for nerve injury.
the leg The sensory & motor function should be
documented properly.

Figure 2 : Mechanism of Compartment syndrome

pulse and palpable tenderness.

ii. Diagnosis : This is based on history of injury,
physical signs with high index of suspicion.
Severe hypovolemia can mask findings of
acute compar tment syndrome. The
absence of palpable distal pulse is
uncommon and late finding and should not
be relied upon. The pressure measurement
is indicated in all patients who have altered
response to pain, unconscious or intubated Figure 3 : Plane of fasciotomy
patients can not complain of pain even in
extreme ischemia so needs extra vigilance. ii. Management Immobilize the injured limb in
Intra-compartmental pressure dislocated position and ask for surgical
measurement may be helpful in diagnosis. consultation. Careful reduction may be
Intra-compartmental pressure ≥30-45 attempted if treating doctor is competent.
mmHg is suggestive of decreased capillary Reevaluate neurologic function after reduction.
blood flow.
Delta-P method: -Diastolic blood
pressure−intra compartmental pressure. If it
is ≤ 30mmHg, patient may have

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CHAPTER 10
SPINAL INJURY
INTRODUCTION : course of management. It is important to note that
prolonged immobilization is not free from danger.
According to World Health Organization (WHO), the Along with discomfort, it may be associated with
term ‘spinal cord injury’ (SCI) is defined as damage to pressure ulcers. A patient with SCI should be
the spinal cord from trauma (traumatic spinal cord evaluated by experts to remove him from spinal
injury i.e. TSCI) or from disease or degeneration (e.g. board as early as possible, preferably within two
cancer). In this chapter, we will discuss traumatic hours; otherwise he should be “logrolled” every two
spinal cord injury (TSCI) in details. The majority of hours.
spinal cord injuries (up to 90%) are due to traumatic
causes (e.g. road traffic accidents, falls or violence). It NEUROANATOMY AND NEUROPHYSIOLOGY:
may be associated with polytrauma or brain injury.
TSCI should always be suspected in any patient with Spinal cord starts at foramen magnum and ends at
multiple traumas until proven other wise. L1 in adults. Below L1, there are only nerve roots in
Approximately 2-4 % of patients with blunt trauma the canal, collectively known as cauda equina,
and 5 % of patients with brain injury have SCI. which comes out from canal from the lower side of
corresponding vertebral body (Figure 1). These
There is no reliable estimate of global prevalence of roots supply to various muscles (myotomes) and
SCI. According to estimation of WHO, globally about specific part of skin (dermatomes) through plexus
250 000 to 500 000 people suffer a spinal cord injury and/or nerves. Each root has it localization to the
(SCI) every year. An estimated global-incident rate corresponding spinal cord level, hence knowledge
is about 23 TSCI cases per million. In South-Asia its of myotomes and dermatomes is very essential for
incidence is about 21 cases per million. TSCI has localization of level of spinal cord injury. The key
bimodal age of distribution. It primarily affects dermatomes and myotomes are shown in Table 1. It
males aged 18–32 years in both developed (high is well known that spinal cord is consists of various
income) and developing countries (low income). In tracts, but in trauma patients three tracts viz.
developed countries, it affects both male and corticospinal tracts, spinothalamic tracts and
female over the age of 65 years due to an ageing posterior column are clinically important. Selective
population.
Vertebral Column
An accurate, properly recorded account of Anterior Left lateral view Posterior view
View
neurological status of a patient with SCI/trauma is
Atlas (C1) Atlas (C1)
most often missing. It should be recorded as soon as Cervical
Axis (C2) Axis (C2)
possible within minutes following the injury. C7 C7
vertebrae

Limiting factors for proper assessment may be T1 T1

altered level of consciousness, intoxication, multiple
injuries, and lack of experienced health care Thoracic
Vertebrae
provider. A health care provider must be aware of
spinal injury, transportation and manipulation of T12 T12
such patients with spinal cord injuries, multiple L1 L1

traumas and brain injuries should be done with Lumbar

vertebrae
utmost care. Inappropriate immobilization may L5 L5
results into appearance of newer neurological Sacrum
Sacrum
deficit or worsening pre-existing deficit. About 3% (S1-5)
Sacrum
(S1-5)
(S1-5)

to 25% of spinal cord injuries occur after the initial Cocoyx Cocoyx Cocoyx

trauma, either during transportation or early in the

Figure 1: Anatomy of vertebral column

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Basic Trauma Care

involvement of any of these tracts with sparing II. Various sites of spinal injuries:
other is suggestive of incomplete cord injury.
1. Atlanto-occipital dislocation
It has to be noted that severe pain or altered level of
consciousness may be the limiting factor for 2. Atlas fracture
accurate neurological evaluation. 3. Atlas subluxation
SPINAL CORD INJURY 4. Axis (C2) fracture
Types of Spinal Cord Injury 5. Fractures and dislocations of C3-C7
Traumatic SCI can be classified according to 6. Thoracic spine fracture (T1-T10)
(I) Mechanism of injury, 7. Thoracolumbar junction fracture (T11-L1)
(II) Severity & anatomical level, 8. Lumbar fractures
(III) Neurological deficit and 9. Penetrating injuries
(IV) Morphology 10. Vascular injuries
I. Mechanism of SCI III. Severity of SCI :
Spinal cord injury can be due to one or combination Severity of deficit depends on complete or
of various mechanical injuries. These injuries may be incomplete injury to the cord (Figure1). Incomplete
(1) Axial loading, (2) Flexion, (3) Extension, (4) lesion means preservation of any sensory or motor
Rotation, (5) Lateral bending and (6) Distraction. function below the level of lesion. It includes

C4 Injury
Quadriplegia/
Tetraplegia, results in complete
paralysis below the neck 7 Cervical Vertebrae

C6 Injury
12 Thoracic Vertebrae
Results in partial paralysis of
hands and arms as well as
lower body

T6 Injury 5 Lumbar Vertebrae

Paraplegia, results in paralysis
below the chest

5 Sacral Vertebrae

L1 Injury 4 Coccyx (fused together)

Paraplegia, results in paralysis
below the waist

Figure 2: Level of spinal cord injury and its neurologic effects

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preservation of partial or complete sensation (pain, nerve deficit and spinal cord injury level. It is
temperature, joint position or vibration) or important to note that other than trauma, altered
voluntar y movement (i.e. limb movement, level of consciousness may be due to
voluntary bladder or bowel control or sacral hypoglycaemia, alcohol, narcotics and other drugs.
sparing). Reflexes may be preserved or lost in These causes must be explored during evaluation.
complete SCI. Injury to cervical spine leads (Please see Chapter on Head injury for details)
tetraplegia/tetraparesis and lesion to thoracic spine
leads to paraplegia/paraparesis. For localization of level of spinal injury, sensory and
motor examination has important role as each
Due to high mobility and anatomical position, nerve root supplies particular segment of skin
cervical spine is most vulnerable to trauma in adults. (dermatome) and particular muscle (myotome).
However, it is less commonly involved in paediatric Hence knowledge of normal dermatome and
age groups (less than 12 years). Among children, myotome is prerequisite to determine the level of
upper cervical cord injury is more common than spinal injury. (Table 1)
lower cervical cord. The cervical canal is quite wide
till lower C2 vertebra, hence majority of patients i. Dermatome level: Lowest normal sensory level
with upper cervical region injury may not have is considered as sensory level which can be different
neurological deficit if they are immobilized on other side, hence bilateral sensory examination is
properly. However, about 1/3rd patients may die mandatory in all patients with suspected spinal
due to phrenic nerve involvement. Below C3, level. Upper cervical dermatomes are variable. It
cervical canal is relatively narrow; hence spinal cord should be remembered that skin over
is liable to injury with vertebral column trauma. supraclavicular area and pectoralis muscle (upper
chest) is supplied by C2,3,4 nerve roots followed by
Thoracic spine has different anatomical structure as T2 nerve root. The remaining nerve roots i.e. C5 to T1
it has limited mobility and support of rib cages supplies dermatomes of upper limb. (Figure 3)
along with relatively narrow canal. Due to these
differences, most thoracic spine fractures are wedge ii. Myotome : Myotome is not as simple as
compression without cord injury. Thoracic cord dermatome, as one root may supply multiple
injury is seen with fracture-dislocation of spine muscles and one muscle may be supplied by
leading to complete injury, hence paraplegia. multiple roots (Figure 3). However, major
contributory nerve root to a clinically important
Lumbar vertebrae are relatively stronger, except muscle is used for localization of spinal level (Table
thoraco-lumbar junction (T11 to L1). This thoraco- 1). Strength of these muscles on both sides should
lumbar junction is next common site of injury after be evaluated on a six- point (0 through 6) scale from
cervical region. As spinal cord terminates at L1, complete paralysis to normal strength (Table 2).
injury to thoraco-lumbar region commonly results
in bowel/bladder abnormality or cauda equina iii. Evaluation of various spinal cord tracts : The
syndrome. This region is very vulnerable to three important spinal cord tracts should be
rotational movements, hence extreme care is evaluated in all patients with spinal injury (Figure 4)
needed during logroll or transfer of the patient. a. Co r t i co s p i n a l t ra c t : I t i s s i t u ate d at
IV. Clinical Evaluation: posterolateral segment of cord and controls
ipsilateral motor strength. In conscious patients, it
Like other patients with trauma, ABC i.e. Airway can be evaluated by voluntary muscle contraction
maintenance & cervical spine protection; Breathing and in patients with impaired consciousness, it can
& ventilation; and Circulation and hemorrhagic be evaluated by involuntary response to painful
control has to be followed in all patients with spinal stimuli.
injury. After securing ABC, disability i.e. quick
neurological evaluation has to be performed. It b. Spinothalamic tract : It is situated at
includes patient’s level of consciousness, papillary anterolateral segment of cord. It carries pain and
size and reaction, any lateralizing or localizing sign temperature sensation from contralateral side of
for example, hemiparesis, paraparesis, or cranial body to thalamus. Pinprick and light touch of

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Basic Trauma Care

C1 Cervical spinal nerve roots C1-C7

correspond with upper aspects of
vertebral bodies.

Sensation of C7 nerve is for

Bone notch at the base C8 the middle finger.
of the neck is C7. T1
C8 and lower spinal nerve roots
leave below the correspoding
vertebral body.
T4 Sensation of T4 spinal nefve is
approximately level with the
nipple line.
T6 Sensation of T6 spinal nerve root is
approximately level with the bottom
of the sternum.

T10 Sensation of T10 spinal nerve root is

approximately level with the abdomen.

T12 Sensation of T12 spinal nerve root is

The spinal cord ends approximately level with the
approximately L1 pubic bone.
between L1 & L2.
Sacral cord segments The sensations of lumbar nerves
(S1-S5 'Cauda Equina') are over the legs.
are level with T12-L1
Vertebrae.
L5 The sensations of lumbar nerves
S1 are over the legs.
The sacral vertebrae
are fused to make up S3 Sensation of S3, S4 & S5 nerves is the
the sacrum. perineal (gonital) area.
S5
The coccygeal vertebrae
are fused to make the
coccyx or "tail bone".

Figure 3: Key Myotomes

selected dermatome should be evaluated for iv Neurogenic vs Spinal shock :

localization.
Neurogenic shock result from cervical and upper
c. Posterior (or dorsal) column : It is situated at thoracic spinal cord injury due to impaired
posteromedial segment of spinal cord. It transmits descending sympathetic tract. Impaired
ipsilateral position sense, and vibration sense to sympathetic tone results vasodilatation followed by
brain. It can be evaluated by position sense of toes blood pooling and relative hypovolemia. In spite of
and fingers or vibration sense at bony prominence hy p o te n s i o n , t h e re i s b ra d yc a rd i a ( o r n o
by using a tuning fork. compensatory tachycardia) due to impaired

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 AIIMS Bhopal 2014

ASCENDING TRACTS DESCENDING TRACTS

Medial longitudinal
Fasciculus gracilis
fasciculis
Fasciculus cuneatus Lissauer's tract

Lateral
cortco-spinal tract

Dorsal spino
cerebellar Rubrospinal tract
tract
Fasciculus Pontine
propius reticulospinal
tract
Ventral
Medullary
spino cerebellal
reticulospinal tract
Tract
L:ateral
vestibulospinal
tract

Tectospinal tract
Spinothalamic tract
Ventral corticospinal tract

Figure 4: Various Spinal Cord Tracts

sympathetic innervations to heart. Hence a patient with head, entire spine and limb immobilization
with upper spinal cord injury, hypotension without with backboard, tapes and straps. However, more
compensatory tachycardia (or bradycardia) is than 2 hours immobilization may predispose them
clinical clue for neurogenic shock. for pressure sore. In the violent, agitated patients, a
short acting sedative or paralytic agent may be used
Spinal shock :I t is a neurologic but not a after ensuring proper airway protection and
hemodynamic phenomenon. It occurs shortly after ventilation. Use of these drugs requires clinical skill,
cord injury. It is of variable duration and is experience and proper judgement.
characterized by flaccidity and loss of reflexes.
In emergency department, patients should be
GENERAL MANAGEMENT: removed from backboard as early as possible,
After securing ABCs, general management of acute preferably after spine radiograph. If radiographic
spinal injury includes immobilization, intravenous evaluation is not possible for several hours, patient
fluids, medications and transfer to appropriate should be removed from board. Removal from
centre. board is a careful act and atleast 4 or more trained
persons are required. During removal, patient is
Immobilization : It is most important pre-hospital often “logrolled” for secondary survey to inspect and
care before transportation. All patients with spinal palpate spinal injury.
injury should be immobilized above and below the
suspected injury site in the neutral position. The Four-Person Logroll : Aim of logroll is to maintain
spinal immobilization should be maintained spinal neutral anatomic alignment of unstable spine
injury is excluded by appropriate investigation. Any during rolling or lifting the patient. One person
deformity should not be reduced before proper stands on head end of patient to control cervical
evaluation and expert’s opinion. If alignment of spine and head. Two persons stands along the side
spine is painful, it may be transferred in least painful of patient to which he has to be turned to control
position with proper immobilization. Patients with body and limbs. One of them manually prevents
cer vical spine injur y requires complete segmental movement of spine and second one
immobilization with semirigid cervical collar, along prevents leg movement with respect to body. The

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fourth person removes board (on which patient was stocking may be used.
transferred from accident site to ED) and same time
examines back. After removing board, patient is Definite Treatment : Definite treatment depends
again returned to supine position. Alignment of on type of injury at specialized centre. Early surgical
spine must be maintained through-out the decompression is safe with better results.
manoeuvre. Discussing definite treatment is beyond the scope
of this chapter.
Radiographic Evaluation : A three view cervical
spine series (AP, lateral, and odontoid views) is KEY POINTS:
recommended for radiographic evaluation of the 1. Clinical finding may not be very reliable if
cervical spine in patients who are symptomatic patient has altered level of consciousness or
following traumatic injur y. This should be sever pain.
supplemented with computed tomography to
further define areas that are suspicious or not well 2. All patients with neurological deficit or with
visualized on the plain cervical x-rays. However radiographic evidence of injury should be
special imaging should be tailored according to site considered as patient with unstable spinal
and type of injury. X-ray of whole spine should be injury.
performed to screen non contagious spinal injury.
3. An suspected cervical spine injury patient
Intravenous Fluid: A spinal injury patient with who is alert and awake, without any clinical
hypotension without active haemorrhage may have deficit or radiographic evidence of spine
neurogenic shock or occult bleeding (hypovolemic injury or spinal tenderness is less likely to
shock). Neurogenic shock result from cervical and have spinal cord injury. He should be asked
upper thoracic spinal cord injury due to impaired for voluntary movement. If there is no pain
descending sympathetic tract. Impaired on movement, no need of fur ther
sympathetic tone results vasodilatation followed by investigation. If he has pain on voluntary
blood pooling and relative hypovolemia. In spite of movement or mild tenderness, he should be
hy p o te n s i o n , t h e re i s b ra d yc a rd i a ( o r n o evaluated radiographically in details to rule
compensatory tachycardia) due to impaired out spinal injury.
sympathetic innervations to heart. Hence a patient
4. If there is doubt of injury, cervical collar
with upper spinal cord injury, hypotension without
should be continued.
compensatory tachycardia (or bradycardia) is
clinical clue for neurogenic shock. Although 5. I m m o b i l i z at i o n i s o n e o f t h e m o s t
intravenous fluids should be administered in all important steps for transferring patients
patients with suspected spinal injury as early as with suspected spinal injury.
possible, only fluid may not be able to restore blood
pressure. Excess intravenous fluid may lead to fluid 6. Injured thoraco-lumbar spines are very
overload and pulmonar y edema. Invasive vulnerable to rotational injury. Hence
monitoring for hydration monitoring and urinary logrolling should be performed in these
bladder catheter for urinary output may be used if patients with extreme care.
fluid status in not known. 7. About 10 % of cervical spine facture have
Medications : Phenylephrine, norepinephrine or noncontiguos vertebral column fracture.
dopamine may be used for hypovolemia after Hence whole spine screening is very
moderate intravenous fluid and atropine for important.
bradycardia. At present evidences are not sufficient 8. A patient on hard backboard for more than
to support use of steroid in patients with acute SCI. 2 hours is predisposed to pressure ulcers.
Prophylactic treatment of deep venous thrombosis
to prevent thromboembolism in patients with 9. All radiographic images must be of good
severe motor deficits due to spinal cord injury is quality and must be interpreted as normal
recommended. Low molecular weight heparin, by a expert before discontinuing spinal
conventional heparin or dynamic compression precautions.

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 AIIMS Bhopal 2014

Table 1 Clinically Important Myotomes and Dermatomes

Spinal Root Dermatome Myotome

C5 Area over deltoid muscle Deltoid
C6 Thumb Forearm Flexor (Biceps)
C7 Middle finger Forearm extensor (Triceps)
C8 Little finger Finger flexors (hand grip)
T1 Inner side of forearm Small finger abductor (Abductor
digitiminimi)
T4 Nipple -
T8 Xiphisternum -
T10 Umbilicus -
T12 Symphysis pubis -
L2 Inner aspect of thigh Hip flexor (iliopsoas)
L3,4 L3- Knee Knee extensor (quadriceps)
L4- Medial aspect of calf & ankle
L5 Web space between 1 st& 2nd toe Ankle & big toe dorsiflexior (Tibialis
ant. & Extensor hallusislongus )
S1 Heel & lateral aspect of foot Ankle planter flexor (gastrocnemius-
soleus)
S3 Ischial tuberosity area -
S4,5 Perianal area

Table 2 Muscle strength grading

Score Strength of muscle

0 Complete paralysis
1 Palpable or visible contractions
2 Full range of movement when gravity eliminated
3 Full range of movement against gravity
4 Full range of movement which is less than normal
5 Normal strength

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Basic Trauma Care

CHAPTER 11
TRAUMA TRIAGE
Trauma triage is the use of trauma assessment for B. Priority 2 (P2) or Triage (T2): Intermediate or
prioritizing of patients for treatment or transport urgent care needed - requires significant
according to their severity of injury. Primary triage is intervention within two to four hours. The color
carried out at the scene of an accident and code is yellow.
secondary triage at the casualty clearing station at
the site of a major incident. C. Priority 3 (P3) or Triage 3 (T3): Delayed care -
needs medical treatment, but this can safely be
Triage is repeated prior to transport away from the delayed. The color code is green.
scene and again at the receiving hospital. The
primary survey aims to identify and immediately D. Dead is a fourth classification and is important
treat life-threatening injuries and is based on the to prevent the expenditure of limited resources on
'ABCDE' resuscitation system: those who are beyond help. The color code is black.

Airway control with stabilization of the cervical The simplest way of triaging patients is to classify
spine. the patients arriving into the Emergency Area or
Trauma Centre into five types
Breathing
a) Walking
Circulation (including the control of external
hemorrhage) b) Talking

Disability or neurological status c) Broken

Exposure or undressing of the patient while also d) Bleeding

protecting the patient from hypothermia e) Dying
Priority is then given to patients most likely to Walking & Talking patients would have airway,
deteriorate clinically and triage takes account of breathing &circulation intact hence are taken into
vital signs, prehospital clinical course, mechanism of green resuscitation area.
injury and other medical conditions. Triage is a
dynamic process and the patients should be Broken patients are one with fractures; hence these
reassessed frequently, the following is one example patients can bleed& are taken into yellow area.
of triage sieve which is used in the UK:
Bleeding and dying patients are on one with
A. Priority 1 (P1) or Triage 1 (T1): Immediate immediate life-threatening injuries and can die if
care needed - requires immediate life - not adequately resuscitated, hence are taken into
savingintervention. The color code is red. red area.
The following is described in Figure 1

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 AIIMS Bhopal 2014

FURTHER TRIAGE OF PATIENTS

Yes
Can the patient walk? DELAYED : PRIORITY 3

No
No No
Is the patient breathig? NO-even after NO RESPONSE:DEAD
opening airway

Yes

YES YES
Yes
Without After IMMEDIATE :
resuscitation opening PRIORITY 1
airway

What is the
respiratory rate? >30/min OR <10/min

<40 or > 120 (or

capillary rell > 2 secs)
>30/minute
10-30/minute or
<10/minute

<40 or >120
What is the pulse rate (or capillary
(or capillary rell time)? rell time
> secs)

Between 40 and 120

(or capillary rell time URGENT : PRIORITY 2
>2 secs)

Figure 1: Triaging of patients as arriving into emergency area or trauma area.

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Basic Trauma Care

Notes

70
 Anupam Mudran # 9425025574

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All India Institute of Medical Sciences Bhopal
Saket Nagar, Bhopal
www.aiimsbhopal.edu.in