use full body ct scout as lodox for bullet location
LD90 for fall=7 stories
The median lethal dose (LD50) for falls is 4 stories, or 48
ft, and the lethal does for 90% (LD90) of test subjects is 7 stories, or 84 ft.
Reference: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th
ed. Mosby-Year Book, Inc; 1998:352.
Prognostic factors are height, impact surface, and the body part which first hits the ground (Crit Care Med 2005;33:1239)
Over 50% in autopsy study had cardiac trauma (in half of these, it was the cause of death), consider thoracotomy (J Trauma 2004;57:301)
ABCs in trauma room often stand for Accuse, Blame, and Criticize, Deny, Exaggerate
power vacuum needs to be filled
Airway-Ask patient to take deep breath (Gives A,B, and LOC)
Breathing
Circulation Search For Bleeding
Disability (pupils/moves extremities)
Expose and then cover (Strip, Flip, Touch, and Smell)
Finger (rectal)/FAST Exam/Foley
Glucose/Girl (pregnancy test)
Hang Antibiotics
Inject (tetanus)
Primary Survey
Secondary Survey
Tertiary Exam
The tertiary exam was first introduced in 1993 by Enderson et al to assist with
the diagnosis of any injuries that were not identified during the primary and
secondary survey. The tertiary survey involved repetition of the primary and
secondary surveys, meticulous physical examination, repetition of the history of
the trauma history, and review of all laboratory and radiographic studies. These
authors’ use of this tertiary survey resulting in diagnosis of missed injuries
in 36 of 399 patients (9%). The most common reason for injuries to be missed was
altered level of consciousness. None of the missed injuries resulted in death,
but one missed injury resulted in disability and seven required operative
intervention. In a second large series, a tertiary trauma survey detected 56% of
the injuries missed during the initial assessment within 24 hours of admission.
Military is switching to <C>ABC for catastrophic hemorrhage to urge immediate use of tourniquets, dressings, and hemostatic agents
BATLS
(Emerg Med J 2006;23:745)
Consider an A-line if they need blood or pressors for hypotension
Lactate/Base Deficit probably more useful then serial crits
Study of serial crits (Injury 2006;37:46)
Delta crit @ 4 hours had only 40% sensitivity, specificity of 95%. LR- 0.64 LR+ 7.1
Sodium azide is contained in airbags, shot c spark causing huge gas expansion and releasing talc, if airbag doesn’t properly deploy, then can get NaOH (sodium hydroxide,) which can give contact dermatitis
Use fentanyl 1-2 ug/kg instead of morphine
Consider SQ Ketamine .25 mg/kg then .1 mg/kg/hr. Use 26 gauge cannula in the SubQ space on the
anterior abd wall. Avoid if possibility
of head injury
delayed fluid resuscitation in penetrating torso injuries resulted in shorter hospitalization and less complications (NEJM 331:17; 1105-1109 Oct 1994)
Blood: external chest abd retroperitoneal pelvis long bone
Non-Blood: pneumo tamponade myocardial contusion spinal shock
do not assume aortic injury is the cause of shock
"janitorial injuries"
Best article on traumatic aortic disruption Fabian J Trauma 1997 42:374
new strategy of delayed aortic repair with BP/HR monitoring and control
Brain injury article J Trauma 1993 34:216
Mannitol has to be given by bolus not continuous infusion to be beneficial
pelvis injuries
lateral compression horizontal fracture of the anterior ring look at the sacrum's arcuate lines
vertical shear, tape the feet together
hemoperitoneum goes to the OR first, otherwise to angio suite
put pinky in sternal notch, index finger will be in the cricothyroid
Not true 80/70/60 pulse rule, but they will disappear in the predictable manner (Deakin et al BMJ Sept 2000)
do not need plain films after getting ct abd/pelvis, just reformat (J Trauma 55(4):665, October 2003)
Levels of Trauma Center Shitstorm
SNAFU
FUBAR
AMF YoYo
Farming-manure to vegetables
Scalea TM et al: Central venous
blood oxygen saturation: an early, accurate measurement of volume during
hemorrhage. J Trauma 28:725, 1988;
"Rookies talk tactics, experts discuss logistics"
Tactics/Strategy/Team
General Operative Management
for abd, prep knee to chin
for ext, prep entire ext and 1 unaffect lower ext
neck, prep entire chest
Lethal triad of hypothermia, coagulopathy, and acidosis
always choose the repair option which fails best
figure of eight, first bite to lift the tissue, 2nd bite to get the bleeder
(Peterson J Traum Volume 58(5).May 2005.1078-1 81)
Do not use bovine fibrin glue anymore, it may sensitize to ATIII
The mechanism of coagulopathy in trauma is complex and
multifactorial:
Dilutional coagulopathy results from the dilution of coagulation factors and
platelets caused by the infusion of large volumes of crystalloids, colloids, or
blood products, which are administered to improve oxygen delivery. The severity
of dilutional coagulopathy is determined by both the volume and type of fluids
infused. Whereas permissive hypotension and reduced fluid volume in the
prehospital setting and early in-hospital treatment may decrease the extent of
such coagulopathy, newly developed types of fluids, such as hypertonic saline
(with or without dextran), new colloids, and artificial oxygen carriers, may
exacerbate it [710].
Hypothermia is a common complication of both civilian and combat injuries,
leading to severe coagulation impairment. This is due to the decline in both
platelet and coagulation enzyme activities [1113]. These effects are often
underestimated as most laboratories re-warm blood samples to 37°C before testing
for clotting assays, i.e. PT, PTT. Even if these plasma-clotting assays were
performed at the patient's body temperature, they would still underestimate the
magnitude of the coagulopathy, as these assays do not reflect the in vivo
coagulation process occurring on cell membranes, such as tissue factor (TF)-bearing
cells and activated platelets [14]. Furthermore, platelet functions, which are
significantly impaired by hypothermia [15], are not monitored routinely,
contributing to the underestimation of the hemostatic defect.
Acidosis resulting from decreased perfusion and production of anerobic
metabolism leading to the accumulation of lactic acid is common among trauma
victims. Even a slight decrease in pH compromises the function of both
coagulation enzymes and platelets, particularly in the presence of hypothermia
[11]. A decrease in pH from 7.4 to 7 reduces prothrombin (FII) activation by the
prothrombinase complex (FXa/FVa) by 70% [15].
Hyperfibrinolysis may be more common in trauma patients than was previously
realized. The failure to detect this condition stems from the lack of routine
laboratory tests for fibrinolysis. A recent study using rotational
thromboelastography (roTEG) has shown that approximately 20% of multi-trauma
patients suffering from massive bleeding have marked hyperfibrinolysis (M.
Vorweg and M. Doehn, Personal Communication). The reproduction of these findings
in larger patient series would support the theory that early administration of
antifibrinolytic agents may be beneficial for hemorrhage control in trauma.
Treatment with recombinant activated factor VII (rFVIIa), which reduces clot
susceptibility to fibrinolysis partly by the induction of thrombin-activated
fibrinolytic inhibitor (TAFI), may also be of value in hyperfibrinolysis [16].
Anemia-induced coagulopathy: In addition to their role in oxygen delivery, red
blood cells (RBC) provide important mechanical and biochemical functions in the
coagulation process. Therefore, anemia causes prolongation of the bleeding time,
which can be corrected with a RBC transfusion [1719]. Furthermore, reduction of
the hematocrit (Hct) inhibits platelet adhesion and aggregation, e.g. Hct of 20%
restricts aggregation to a degree similar to that observed with 20 000 platelets
mL1 [20].
Consumption coagulopathy is induced by exposure of TF at the site of injury,
leading to activation of the coagulation cascade at this site. Massive injury
may cause extensive consumption with depletion of platelets and coagulation
factors. This process results in laboratory findings resembling disseminated
intravascular coagulation (DIC), such as prolonged PT and aPTT, low levels of
platelets and fibrinogen, and high levels of D-dimers and other markers of
coagulation and fibrinolysis activation. However, in most cases, these findings
do not reflect DIC, as there is no evidence of microthrombi formation and, thus,
no intravascular clotting [21].
hypothermia is an independent risk factor for trauma mortality (J Trauma 2005;59(5):1081)
hypocalcemia is also a cause of coagulopathy
increased fibrinolysis as well
whole blood is used in iraq
Best Review (Brit J Anaes 2005;95(2):130
Acidosis impairs coagulopathy as well (J Trauma 2006;61:624, J Trauma 2003;55:886)
European Surgical Bleeding Guidelines (Management of bleeding
following major trauma: a European guideline
Critical Care 2007, 11:R17)
Acidosis masively increases risk of coagulopathy, Impairs factor VIIa/tissue factor complex. Clot formation can be normalized with a buffer (J Neurosurg Anesth 2006;18:200)
retrospective prehospital study. DNR if apneic and pulseless on arrival or asystolic or PEA with rate<40 (J AM Coll Surg 2004;198:227)
Another study shows prognosis in traumatic arrest is the same as medical (Crit Care Med 2007;35:2251)
Reasons to Omit Digital Rectal Exam in Trauma Patients: No Fingers, No Rectum, No Useful Additional Information (J Trauma 2005;59(6):1314)
Level I has only limited air elimination abilities (J Clin Anesthesia 1997;9:233)
Study objective: Most injured
patients taken by ambulance to hospital
emergency departments do
not require emergency surgery, yet most US trauma centers require a
surgeon to be present on their
arrival. If a clinical decision rule could be developed to accurately
identify which injured patients
require emergency operative intervention, then such "secondary
triage"
criteria could permit a trauma
center to more efficiently use their surgeons' time.
Methods: We analyzed 7.5 years of data (8,289 consecutive trauma
activations) in our prospectively
maintained Level I trauma center registry. We used classification and
regression tree analyses to
generate clinical decision rules using standard out-of-hospital
variables to identify emergency
operative intervention (within 1 hour) by a general surgeon (for
adults) or a pediatric surgeon (if _14
years).
Results: Emergency operative intervention occurred in 3.0% of adults
and 0.35% of children. For
adults, summoning a surgeon for any one of 3 criteria (penetrating
mechanism, systolic blood
pressure _96 mm Hg, pulse rate _104 beats/min) could reduce surgeon
calls by 51.2% while
failing to identify emergency operative intervention in only 0.08%
(rule sensitivity 97.2% and
specificity 48.6%). For children, no rule at all (ie, never
automatically summoning a surgeon) would
fail to identify emergency operative intervention in only 0.35% of
patients, and use of a single
criterion (penetrating mechanism) would reduce surgeon calls by 96.2%
while failing to identify
emergency operative intervention in only 0.09% (rule sensitivity 75.0%
and specificity 96.5%).
Conclusion: We have derived simple decision rules for trauma centers
that, if validated, could
substantially reduce the need for routine surgeon presence on trauma
patient arrival. These rules
demonstrate low false-negative rates. [Ann Emerg Med.
2006;47:135-145.]
article discussing the evidence (Annals of EM 2006;47(5):405)
Damage Control
Scalea [19] has condensed the principles of damage control: only blood loss kills early; gastrointestinal injury causes problems later; everything takes longer than you think; an injury may be missed during hurried laparotomy in an unstable patient; hypothermia, acidosis, and coagulopathy lead to more of the same; the best setting for a critically ill patient is the intensive care unit.
Low iCal at arrival is associated with bad outcome (J Trauma Volume 61(4), October 2006, pp 774-779)
Cochrane Database Syst Rev.
2004;(3):CD004173. Links
Advanced trauma life support training for hospital staff.Shakiba H, Dinesh S,
Anne MK.
BACKGROUND: Injury is responsible for an increasing global burden of death and
disability. As a result, new models of trauma care have been developed. Many of
these, though initially developed in high-income countries, are now being
adopted in low and middle-income countries (LMICs). One such trauma care model
is advanced trauma life support (ATLS) training in hospitals, which is being
promoted in LMICs as a strategy for improving outcomes for victims of trauma.
However, the evidence of effectiveness for this health service intervention, in
either HIC or LMIC settings, has not been rigorously tested using methodology
such as a systematic review. OBJECTIVES: To quantify the effectiveness of
hospitals with an ATLS-trained trauma response system versus hospitals without
such a response system in reducing mortality and morbidity following trauma.
SEARCH STRATEGY: We searched the Cochrane Injuries Group Specialised Register (CIGSR),
the Cochrane Controlled Trials Register (CCTR), MEDLINE & PubMed, EMBASE, CINAHL,
Science Citation Index, National Research Register, and web-based trials
databases such as Current Controlled Trials. We checked references of background
papers and contacted authors to identify additional published or unpublished
data. SELECTION CRITERIA: Randomised controlled trials, controlled trials,
controlled before- and- after studies comparing effectiveness of hospitals with
an ATLS-trained trauma response system versus hospitals without such a response
system in reducing mortality and morbidity following trauma. DATA COLLECTION AND
ANALYSIS: Two reviewers independently applied eligibility criteria to trial
reports for inclusion and to extract data. MAIN RESULTS: There is a limited
literature relating to this topic but none of the studies identified met the
inclusion criteria for this review. REVIEWERS' CONCLUSIONS: There is no clear
evidence that ATLS training (or similar) impacts on the outcome for victims of
trauma, although there is some evidence that educational initiatives improve
knowledge of what to do in emergency situations. Further, there is no evidence
that trauma management systems incorporating ATLS training impact positively on
outcome. Future research should concentrate on the evaluation of trauma systems
incorporating ATLS, both within hospitals and at the health system level, by
using rigorous research designs.
Resus from Severe Hemorrhage (Crit Care Med 1996;24(2):12S)
mention the Bickell Study (NEJM 1994;331:1105) delayed till operating room vs. immediate.
give fluids when inducing or pericode
Hypertonic Saline (Trauma Resus update Lancet 2004;363:1988)
Management of Bleeding Following Major Trauma: a European Guideline
Donat R. Spahn; Vladimir Cerny; Timothy J. Coats; Jacques Duranteau; Enrique
Fernández-Mondéjar; Giovanni Gordini; Philip F. Stahel; Beverley J. Hunt; Radko
Komadina; Edmund Neugebauer; Yves Ozier; Louis Riddez; Arthur Schultz;
Jean-Louis Vincent; Rolf Rossaint
Crit Care. 2007;11(1) ©2007
J Trauma, Volume 62(5).May 2007.1310-1312
Trauma & Motorcyclists (Injury 2007;38:1131)
Pull helmet edges in the lateral direction
Journal of Emergency Medicine
Volume 34, Issue 3, April 2008, Pages 319-320
how to properly apply direct pressure
