Prostaglandin and Angiotensin increase the filtration of blood.

In the kidney you prostaglandin

(inhibited by NSAIDs) vasodilate the afferent, and Angiotensin vasoconstrictor the efferent (inhibited by
ACEi). For kidney injury always hold NSAIDs, ACEi/ARBs, and Metformain (increased accumulation
increased in anaerobic respiration and formation of lactic acid).

NSAIDs (3Ps)” Aspirin, Naproxen, ibuprofen

Acetaminophen is not an NSAIDs

http://tmedweb.tulane.edu/pharmwiki/doku.php/acetaminophen
LR (Lactated Ringers) requires less fluid to restore intra vascular volume, causes less urine output, less
hyper chloremic acidosis and less dilutional coagulopathy compared to N/S. Ringers Lactate is the fluid
of choice for hemorrhagic shock.

When staging with GCS intubated patient (t) can’ give verbal response. Thus they are reported as
GSC=#t

Strict adherence to the order of priorities is paramount. There are many distracting issues occurring
during the management of a trauma case and it is easy to be diverted by obvious injuries. Keep to:

 A-Airway with C-spine control and burn assessment

(OIL=Oxygen, IV, and Leads/monitoring)

 B-Breathing

 C-Circulation (vitals, peripheral status,…

 D-Disability

 E-expose the patient

Remember that two concepts:

1-For intubation you need to administer (Etemodate/Propofol/Ketamine and )
2- For chest tube insertion you will need to administer lidocaine
3-For fluid ringers lactate is the best for loss of fluid with a bolus of 1000cc.
4-rule of 9 to assess fluids
5- We need TIG = Tetanus Immune Globulin for burned noncofirmed complete vaccination
6- Remember that for lost peripheral pulse due to burn an escharotomy is needed. It is a surgical
procedure used to treat full-thickness (third-degree) circumferential burns.

Take an AMPLE history from the patient, from first responders, urgence sante, etc, family and friends as
available.

A = Allergies

M = Medications

P = Past illness/current pregnancy status

L = Last meal

E = Events/environment related to the injury (look for patterns of injury)

Classification of shock:
Classification of Shock:

 Usually the classification is according to pulse rate

 Blood loss is basically <10%, 20%, 30%, >40%
 First step for up to class III is to give crystalloids and if no adequate response give blood with 1:3
ratio
Splenic injury:
After a blunt abdominal trauma a patient with a splenic injury may need surgical repair or
observation
1. Non-operative management
a. NPO and on best rest * 24h + hemoglobin levels every 6 hours
b. Observation for > 5 days identifies > 95% of patients who require further Intervention
c. Consider if the patient is:
i. Hemodynamically stable
ii. without peritonitis
iii. with an isolated splenic injury
iv. If there is adequate monitoring and an OR available
d. Angiography is an adjunct non-operative management for patients with high risk for
delayed bleeding or to identify vascular abnormalities
2. Surgical exploration is:
a. Hemodynamic instability = absolute indication
b. Diffuse peritonitis = absolute indication
c. Patients who fail non-operative management
d. In hemodynamically patients with patient's age (>55), grade of injury (III and above),
presence of other intra-abdominal injury, large volume hemoperitoneum, active
contrast extravasation, and neurological status are strong indicators for surgical
exploration
e. Due to limited resources, patients cannot be adequately observed.

Splenectomy Complications:

1. Thrombosis most often affecting the portal, mesenteric or splenic veins

2. Over-whelming post-splenectomy infection (OPSI):

a. Post splenectomy (ideally 14 days) should be vaccinated against:

i. encapsulated bacteria including S. pneumoniae

ii. H. influenzae

iii. N. Meningitdis

Learning the Nuances of the Primary Survey:

A: B:

C: hemorrhagic Shock and Volume Resuscitation

a. Signs and symptoms of shock are tachycardia, hypotension, tachypnea, mental status changes,
diaphoresis and pallor

b. Use vitals to grade the class of hemorrhagic shock. The class will answer > what fluid and what
volume
 c. Bolus fluid initially and then re-assess vitals. If the response remains muted consider other
potential causes of shock

d. Blood should be considered in Class 3 and used in Class 4 hemorrhage

e. Use blood with crystalloid in a 3:1 ratio

Class 2

1. patients present with a decrease in pulse pressure and mild tachypnea

2. Give 1 L bolus of crystalloid initially

3. No blood is needed during acute resuscitation

Class 3

1. Give 2 L bolus of crystalloid initially

2. Consider giving blood when the response to the initial bolus of crystalloid is less than
expected.Giving blood alone is an unnecessary use of a valuable resource.

Class 4

1. Patients present in extremis

2. Patients need blood and crystalloid

3. Fluid resuscitation begins with an IV bolus of isotonic crystalloid based on the patient's size. For
persistent hypotension, the bolus is repeated once before PRBCs are transfused.

D: Anxiousness and confusion increase with increased blood loss, until the patient become lethargic.
Lethargy is a sign of massive (Class 4) hemorrhage

E: A patient with blunt thoraco-abdominal trauma when:

1. Hemodynamically stable - CT scan

2. Hemodynamically unstable - CXR, FAST, and Pelvic E-ray

In a hemodynamically unstable patient with negative FAST results and no other obvious sourse of
hypotension, consider diagnostic peritoneal aspiration.
28-year-old male motorcyclist:

 Collision with a car 80/km/hr

 Patient transported on backboard, breathing is labored, patient has blue lips and has priapism

 Patient is speaking incoherently

 No obvious arm or leg movements

 BP 70/50, pulse 45

 Saturation 80%