Short Notes: Melaka Trauma Life Support

 
SHORT
NOTES
for
Melaka
Trauma Life
Support
1 | M e l a k a Tr a u m a L i f e S u p p o r t
Contents
Chapter 1: Initial Assessment and management…………………………….. 2
Chapter 2: Airway and Ventilatory Management…………………………… 8
Chapter 3: Shock……………………………………………………………………………. 14
Chapter 4: Thoracic Trauma…………………………………………………………… 19
Chapter 5: Abdominal and Pelvic Trauma………………………………………. 29
Chapter 6: Head Trauma………………………………………………………………… 34
Chapter 7: Spine and Spinal Cord Trauma ……………………………………… 40
Chapter 8: Musculoskeletal Trauma………………………………………………. 48
Chapter 9: Thermal Injuries…………………………………………………………… 55
Chapter 10: Pediatric Trauma………………………………………………………… 59
Chapter 11: Geriatric Trauma…………………………………………………………. 73
Chapter 12: Trauma in Pregnancy and Intimate Partner Violence… 76
Chapter 13: Transfer to Definitive Care…………………………………………… 80
Appendices……………………………………………………………………………………. 84
These are the key summaries compiled by the ETDHM MOs. Most are
the excerpts from Malaysian Trauma Life Support and Advance
Trauma Life Support as part of their work project.  
Chapter 1: Initial Assessment and Management
(summarized by Dr Chan Yean Koon)
Initial assessment is the rapid assessment of the seriously injured

patient and the institution of life-preserving therapy that follows a
systematic approach.
Initial assessment includes:
• Preparation
• Triage
• Primary survey (ABCDEs)
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Consider need for patient transfer
• Secondary survey (head-to-toe evaluation and patient history)
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care
Preparation
prehospital phase must be coordinated with the doctors at the receiving hospital allowing
mobilisation of the trauma personnels and resources. During hospital phase, preparations
must be made to rapidly organise and equip resuscitation area to facilitate resuscitation
of the trauma patient.
Triage
This is to sort patients according to their needs for treatment and resources
available.Triage can be performed on a single polytrauma patient or in a mass casualty
situations. Triage can be initiated in the hospital or at field.
Primary survey
The preliminary assessment of a patient conducted in a systematic manner with the

objective of identifying life threatening conditions and managing them as soon as they
are found. Examination, resuscitation and stabilization are carried out simultaneously.
1. Airway maintenance with cervical spine protection
- Rapid assessment for signs of airway obstruction and perform measures to

establish a patent airway
- Inspect the airway: look at nasal opening and mouth for any deformity,
bleeding or obstruction (blood, vomit, tongue, maxillofacial injury)
- Open mouth/airway with jaw thrust or gentle chin lift while immobilizing the
neck. Do not move the patient neck when opening and maintaining the airway.
- Listen and feel for the expired air from mouth and nose.
- Give high oxygen concentration to prevent hypoxia.
Jaw Thrust Gentle Chin Lift
- GCS </= 8 usually require placement of definitive airway
- Assume a cervical spine injury in any patient with multisystem trauma, esp
those with an altered level of consciousness or a blunt injury above the clavicle
- Promptly identify airway compromise and recognize the potential for

progressive airway loss. Frequent reevaluation is important
2. Breathing and ventilation
- Determine the adequacy of ventilation and respiratory function
- Examine the patient by performing Inspection, palpation, percussion,

auscultation
- Injuries that can impair ventilation in the short term: tension pneumothorax,
flail chest with pulmonary contusion, massive haemothorax, open
pneumothorax
- these injuries need to be identified and may need intervention
3. Circulation with haemorrhage control
- hypotensive following injury must be considered to be hypovolaemia until

proven otherwise
- Assess and identify whether shock is present
- Blood volume and cardiac output: observe level of consciousness, skin colour
and pulse
- Bleeding: External haemorrhage is identified and controlled during the primary

survey. Major areas of internal hemorrhage: Chest, pelvis, abdomen,
retroperitoneum and long bones
4. Disability (Neurologic evaluation)
- Rapidly establish patient’s level of consciousness, pupillary size and reaction,

lateralizing signs and spinal cord injury level
- other factors to be considered in a patient with altered level of consciousness 

• Oxygenation (hypoxia) • hypoglycaemia
• Ventilation (hypercarbia) • alcohol
• perfusion (Shock) • narcotics 
5. Exposure/Environment control
- Patient should be completely undressed for thorough examination and

assessment
- Keep patient warm with warm blankets or warming device
Resuscitation
Resuscitation that follows the ABC and management of life-threatening injuries as they are
identified are essential to maximize patient survival.
Airway – A definitive airway (ie intubation) should be established if there is any doubt
about the patient’s ability to maintain airway integrity
Breathing/Ventilation/Oxygenation – Every injured patient should receive supplemental

oxygen; if tension pneumothorax is suspected, chest decompression should be started
immediately
Circulation and bleeding control – definitive bleeding control and intravenous replacement
of intravascular volume; two large bore brannulas should be inserted and blood drawn for
investigations (eg group cross match). Warm fluids should be used. Aggressive and
continued volume resuscitation is not a substitute for definitive control of haemorrhage
Adjuncts to Primary Survey and Resuscitation
- ECG
- Urinary and gastric catheters (However, urinary catheter should not be

inserted before the rectum and genitalia have been examined. Suspect urethral
injury in the following: blood at the urethral meatus, perineal ecchymosis,
blood in the scrotum, high-riding or nonpalpable prostate, pelvic fracture)
- Other monitorings: Ventilatory rate and ABG, colorimetric CO2 detector/

capnograph, Pulse oximetry, BP
- 3 primary Xrays (Chest, Pelvis, Cervical) and diagnostic studies
- FAST scan
Consider need for patient transfer
Transfer process may be initiated immediately while additional evaluation and

resuscitation measures are being performed.
Secondary survey
only begins secondary survey after primary survey is completed, resuscitative efforts are
underway, and the normalization of vital functions has been demonstrated.
History: (from patient, family, prehospital personnel)
A – Allergies
M – Medications currently used
P –Past illnesses/Pregnancy
L – Last meal
E – Events/Environment related to the injury
Blunt trauma
Important information: seat-belt use, steering wheel deformation, direction of impact,
damage to the vehicle, ejection from vehicle.
Penetrating trauma
Determine type and extent of injury: region of body part injured, organs in the path of the
penetrating object, and velocity of the missile.
Thermal injury
Important information: environment in which the burn injury occurred (open or closed
space), the substances consumed by the flames (eg plastics and chemicals) to suggest the
possibility of inhalational injury and carbon monoxide poisoning, possible associated
injuries sustained
Physical Examination (Head to Toe examination)
Head
Scalp and head – examine the entire scalp and head for lacerations, contusions, evidence
of fractures
Eyes – examine visual acuity, pupillary size, haemorrhage of the conjunctiva and/or fundi,
penetrating injury, contact lenses (remove before edema occurs), dislocation of the lens,
ocular entrapment
Maxillofacial structures – Maxillofacial trauma that is not associated with airway

obstruction or major bleeding should be treated only after the pt is stabilized completely
and life-threatening injuries have been managed
C-Spine and Neck – pts with maxillofacial or head trauma should be presumed to have an
unstable cervical spine injury and the neck should be immobilized until all aspects of the
c-spine have been adequately studied and an injury has been excluded; wounds that
extend through the platysma should NOT be explored manually; the finding of active
bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires
operative evaluation
Chest – significant chest injury can manifest with pain, dyspnea and hypoxia. Evaluation:
inspection, palpation, percussion, auscultation and CXR
Abdomen – Close observation and frequent evaluation, esp with pts with unexplained
hypotension, neurologic injury, impaired sensorium secondary to alcohol and/or other
drugs
Perineum/Rectum/Vagina – examine perineum for contusions, hematomas, lacerations and

urethral bleeding; PR before placing urinary catheter and assess for blood within bowel
lumen, a high riding prostate, the presence of pelvic fracture, the integrity of the rectal
wall and the quality of sphincter tone
Musculoskeletal System – inspect for contusions and deformities of the extremities. Look
for evidence of pelvic fracture.
Neurologic – Motor and sensory evaluation, pt’s level of consciousness, pupillary size and
response; pt’s should be frequently monitored for deterioration
Adjuncts to Secondary Survey
Xrays, CT scans, ultrasound, etc – these specialized tests should not be performed until
the patient has been carefully examined and the haemodynamic status has been
normalized.
Minimise missed injuries by maintaining high index of suspicion.
Reevaluation
ensure that new findings are not overlooked and continuous monitoring of vital signs and
urinary output are essential. Provide pain relief and evaluate pain score.
Definitive care
Transfer to facility with higher level of care when indicated.
Records and legal considerations - documentation is very important. Consent is sought

before treatment if possible.
Chapter 2: Airway and Ventilatory Management
(summarised by Dr Nor Atieqah bt Atan)
Airway assessment and management take precedence over all other procedures during
resuscitation. Hypoxia causes irreversible brain damage within 4 minutes if uncorrected hence
airway assessment, and treatment take priority. The likelihood of cervical spine injuries and
maxillofacial deformity in trauma necessitate certain special skills and maneuvres.
Objectives of Airway and Ventilatory Management
1. Assessment of airway patency and ventilatory adequacy
2. Identify the cause of airway obstruction and inadequate ventilation.
3. Immediate management of airway obstruction by performing simple airway maneuvres using

the appropriate airway adjuncts WHILE protecting the endangered cervical spine.
4. Providing effective ventilation WHILE protecting the endangered cervical spine.
5. Providing a definitive airway when indicated
Assessment, Identification and management of Airway and ventilatory compromise.
*A positive, appropriate verbal response indicates that the airway is patent, ventilation is
secured, and brain is adequately perfused.
Supplemental O2 must be administered to all multiple trauma patients.
CLINICAL SITUATION IN WHICH AIRWAY OBSTRUCTION IS LIKELY TO OCCUR
1. Maxillofacial trauma – trauma to midface can produce fracture and dislocations

that compromise nasopharynx and oropharynx. Fracture of mandible could also
cause loss of normal airway support. Haemorrhage, increased secretion and
dislodged teeth can obstruct the airway
2. Neck trauma –
a. Penetrating injury – vascular trauma - haemorrhage —> obstruct airway
b. Blunt injury – disruption of larynx and trachea
3. Laryngeal trauma - triad of clinical sign – hoarseness, subcutaneous emphysema,

palpable fracture. Complete airway obstruction could occur requiring intubation.
SIGNS/SYMPTOMS OF AIRWAY OBSTRUCTIONS
Observe for:
• Agitation – hypoxia
• Obtundation – hypercarbia
• Cyanosis – hypoxemia
• Use of accessory muscle
Listen for:
• Abnormal breath sound – hoarseness/stridor/ snoring / gurgling
Feel for:
• trachea deviation
Evaluate for:
• Patient behaviour (abusive: hypoxia)
SIGNS OF INADEQUATE VENTILATION
• Asymmetrical chest rise- suggests splinting of the rib cage or a flail chest
• Listen for equal breath sounds bilaterally. Decreased or absent breath sounds
suggest the presence of thoracic injury.
• Use pulse oximetry – measure SaO2 (arterial saturation of oxygen), not the partial
pressure PaO2. *relationship between these two is nonlinear as the graph is sigmoid
shape.
HOW TO MAINTAIN AN AIRWAY (while maintaining cervical spine protection at all times)
the main culprit is the tongue (floppy and fall backwards obstructing the hypopharynx
especially in patients with decreased level of consciousness). Perform simple maneuvres to
correct the obstruction
• Chin lift maneuver
▪ Jaw thrust maneuver
• Oropharyngeal/nasopharyngeal airway
• Extraglottic/ Supraglottic Airway devices:
• Laryngeal mask airway
• Laryngeal Tube airway
• Multilumen oesophageal airway
• Definitive airway: Requires a tube inside the trachea, with the cuff inflated below
the vocal cords, while the tube is connected to an oxygen rich ventilatory support
and the airway is secured in place with a tape.
o Orotracheal airway
o Nasotracheal airway
o Surgical airway –
▪ Needle cricothyroidotomy
▪ Surgical cricothyroidotomy
INDICATION FOR DEFINITIVE AIRWAY
NEED FOR AIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATION

Unconscious / GCS < 8 Apnea - neuromuscular paralysis /
unconscious
Severe maxillofacial fractures Inadequate respiratory effort – tachypnea,
hypoxia, hypercarbia, cyanosis
Risk for aspiration – bleeding / vomiting Severe closed head injury
Risk for obstruction - neck hematoma / Massive blood loss and need for volume
laryngeal or tracheal injury / stridor resuscitation
PREDICT DIFFICULT AIRWAY
L – Look externally
E – Evaluate 3-3-2 rule
o Distance between incisor teeth – 3 fingers
o Distance between hyoid bone and chin – 3 fingers
10 | M e l a k a T r a u m a L i f e S u p p o r t
o Distance between thyroid notch and floor of mouth – 2 fingers
M – Mallampati classification – pt sit upright, open mouth fully, protrude tongue -> look for
degree of hypopharynx visibility.
O – Obstruction
N – Neck mobility – able to place chin on chest and extend neck
RAPID SEQUENCE INTUBATION (RSI)
1. Prepare – patient, medication, equipment, proper Plan

(if fail)
2. Preoxygenate
3. Apply cricoid pressure – BURP – backward, upward,

right pressure (Laryngeal manipulation)
4. Paralytic and induction agent
5. Placement of ETT and confirmation
a. Look for symmetrical chest rise
b. Listen for equal breath sound bilaterally and no borborygmi
c. CO2 detector/ end tidal CO2
d. Chest xray
6. Release cricoid pressure
7. Ventilate the patient
Surgical airway
Emergency surgical airway is only indicated when there is an inability to intubate the
trachea in the presence of an unrelieved airway obstruction.
Needle Cricothyroidotomy
Involves insertion of a large bore cannula (12G-14G) through the cricothyroid membrane or
into the trachea in an emergency situation to provide oxygen as a temporary rescue until
definitive airway can be established. Ventilation is achieved using jet insufflation
technique. Bag-valve-mask device can also be used.
Technique
1. Patient in supine position. Prepare patient, prep the neck using antiseptic solution.
2. connect a 12G or 14G over-the-needle plastic cannula to a 10ml syringe
3. Palpate the cricothyroid membrane. Stabilize the trachea with thumb and forefinger of
one hand preventing lateral movement.
4. Puncture the skin in midline through the lower half of the cricothyroid membrane at
45 degree angle pointing the needle caudally, aspirating the needle as while
advancing. Aspiration of air signifies entry into the lumen.
5. Remove the syring and withdraw the needle stylet while gently advancing the cannula.
6. Attach the needle hub to the ventilating device
Needle cricothyroidotomy is only for temporary measure. Adequate oxygenation and

normocarbia can only be sustained for only 30 to 45 minutes.
Complications of needle cricothyroidotomy
1. Asphyxia
2. Bleeding
3. Aspiration
4. Oesophageal laceration/ perforation
5. Hematoma
6. Thyroid perforation
7. Pneumothorax
8. Subcutaneous emphysema
Surgical cricothyroidotomy
1. Patient in supine position. Prepare patient, prep the neck using antiseptic solution.
2. A skin incision is performed through the cricothyroid membrane using a blade.
3. Upon incision, rotate the blade 90 degrees to allow opening.
4. A small endotracheal tube, a minitract tube or a tracheostomy tube is then inserted

into the opening.
5. Ventilation is then provided by a bag-valve mask device
Complications of surgical cricothyroidotomy
1. Hemorrhage and hematoma formation
2. Aspiration (blood)
3. False passage
4. Asphyxia
5. Tracheal laceration
6. Oesophageal laceration
7. Mediastinal emphysema
8. Vocal cord paralysis
9. Subglottic stenosis/ oedema
10.Barotrauma
CHAPTER 3: SHOCK
(summarised by Dr Nurul Huda bt Zakaria)
Shock: A clinical syndrome which occurs in the presence of inadequate tissue perfusion. It is
reversible if identified and treated early.
Objectives:
1. Define shock
2. Identify the presence of shock and recognize the importance of its early identification in
trauma patient
3. Classify shock and describe the various manifestation of the different classes of shock state
4. Describe the Initial management of shock and the role of blood transfusion
5. Evaluate and recognize the importance of regular monitoring of shock patient
The 1st step in initial management of shock is to RECOGNIZE its presence
The 2nd step in initial management of shock is to IDENTIFY the probable cause of the shock state
Hemorrhage is the most common cause of shock in the injured patient.
Recognition of shock.
It is important to be able to recognize the signs and symptoms of shock in a trauma

patient during the initial patient assessment.
Reliance solely on the systolic blood pressure might delay the recognition of the
shock state. Compensatory mechanisms can render a sustained blood pressure until
30% of blood is lost. All trauma patients who are cold and tachycardic are in shock
until proven otherwise.
Physical parameters:
• Pulse rate
• Respiratory rate
• Skin circulation and color
• level of consciousness
• Pulse pressure
Lab parameters:
• Hb&hct (not accurate in acute setting but need serial results)
• Lactate
• Base deficit
Normal heart rate value according to age:
Heart rate value Age

<160 bpm Infant
< 140 bpm Preschooler
< 120 bpm Until puberty
<100 bpm Adult
** may not be accurate with those on B-adrenergic blocking agents or pacemaker
Types of shock.
In trauma, shock is largely classified as hemorrhagic and non-hemorrhagic
1. Haemorrhagic shock
The most common cause of shock
Primary focus: to promptly identify and stop the hemorrhage.
CXR, Pelvic Xray, Abdominal assessment (FAST/DPL), CBD may all be necessary to
determine the source of shock.
Class of haemorrhage:
Class I Class II Class III Class IV

Blood loss (ml) Up to 750 750 -1500 1500 – 2000 ➢ 2000
% blood loss Up to 15% 15% - 30% 30% - 40% ➢ 40%
Pulse rate < 100 100-120 120-140 ➢ 140
BP Normal Normal Decreased Decreased
Pulse pressure Normal/increased Decreased Decreased Decreased
RR 14-20 20-30 30-40 >35
Urine output ➢ 30 20-30 5-15 Negligible

(ml/H)
CNS Slightly anxious Mildly anxious Anxious, Confused,
confused lethargic
Fluid Crystalloid Crystalloid Crystalloid & Crystalloid &

replacement blood blood
*for a 70 kg male
Response to initial fluid resuscitation
The patient response to initial fluid resus is key to determine subsequent therapy
** after 2000 ml of isotonic solution in adults , 20 ml/kg bolus Ringer Lactate in children
Rapid Response Transient Response Minimal or No

response
Vital signs Return to normal Transient Remain abnormal
improvement
Estimated blood 10% - 20% 20% - 40% and ongoing >40%

loss
Need for more Low High High
crystalloid
Need for blood Low Moderate to high High
Blood preparation Type &crossmatch Type-specific Emergency blood
Need for operative Possibly Likely Highly likely

intervention
Early presence of Yes Yes Yes
surgeon
2. Non – haemorrhagic shock
➢ Cardiogenic in origin
o Blunt trauma to chest (cardiogenic shock with

myocardial dysfunction)
o Cardiac tamponade
o Air embolism
o Myocardial infarction
➢ Tension pneumothorax
➢ Neurogenic shock (cervical and upper thoracic spinal cord injury can produce
hypotension due to loss of sympathetic tone)
• Isolated intracranial injury does not cause shock

➢ Septic shock (uncommon at the early stage after injury)
Initial management of shock.
1. Airway , C-Spine , Breathing
2. Circulation and haemorrhage control
➢ Find the source of bleeding, stop the bleeding,

immediate replacement of volume loss
3. Disability – brief neurological examination
4. Exposure – complete examination & prevent hypothermia
5. Re-assessment
Monitoring the adequacy of fluid resuscitation.
1. Vital signs monitoring
2. Mental status
3. Urinary output
4. Skin perfusion
5. Acid/base balance
The decision to initiate blood transfusion is based on the patient’s response. Those who
are transient responders and non-responders, in class III or class IV hemorrhage will need
packed red blood cells and blood products at an early part of their resuscitation
** REMEMBER**
1. Virtually all patients with multiple injuries have element of hypovolaemia.

Therefore, initial fluid resuscitation is crucial in all type of shock.
2. One trauma patient may have several contributions of his shock. Think wide.
3. Principle of haemorrhagic shock is to stop the bleeding and replace the volume
loss.
4. Blood on the floor & four more – chest, pelvis, abdomen & long bones
Intraosseous Puncture
Indicated if failed to obtain iv access after 2 attempts of peripheral cannulation when

managing patient in shock.
Use is limited for emergency situation. Should be discontinued when venous access
achieved.
Intraosseous puncture: proximal tibial cannulation
1. Patient in supine. Place the uninjured knee flexed on

a padding at 30 degree.
2. Identify the anteromedial surface of proximal tibia,

approx 1 fingerbreath (1 to 3cm) below the tibial
tubercle.
3. Cleanse and prep the area
4. Apply LA
5. Insert the intraosseous needle at 90 degree angle into

the skin and periosteum with the bevel pointing
towards the foot using twisting motion. Grind down
through the bone cortex and bone marrow
6. Once the needle inside the bone, direct the needle 45

to 60 degree away from the epiphyseal plate
7. Remove the stylet. Try to withdraw blood/marrow using a syringe prefilled with saline.
Aspiration of marrow confirms the placement.
8. Inject/ flush some saline through the cannula and observe for any soft tissue swelling
sorrounding the site. The presence of soft tissue swelling suggests a wrong placement
9. Connect the cannula to a giving set and begin infusion.
10. Secure the cannula with the appropriate dressing.
Complications: 
• Infection • hematoma
• Through and through penetration • Physeal plate injury
• Pressure necrosis • Fracture 
CHAPTER 4: THORACIC TRAUMA
1. Less than 10% of blunt chest injuries and only 15-30 % of penetrating chest injuries
require operative intervention.
2. Hypoxia, hypercarbia, and acidosis often result from chest injuries.
Objectives:
1. Identify and treat Life threatening injuries during the Primary survey
Airway Obstruction
Tension pneumothorax
Open pneumothorax
Massive hemothorax
Flail chest
Cardiac contusion
2. To Identify and treat eight potential life threatening injuries
a. Simple pneumothorax e. Blunt cardiac injury
b. Hemothorax f. Traumatic aortic disruption
c. Pulmonary contusion g. Traumatic diaphragmatic

injury
d. Tracheobronchial tree injury
h. Blunt esophageal rupture 
PRIMARY SURVEY : LIFE THREATENING INJURIES
1. AIRWAY
a. Airway patency and air exchange should be assessed

(look, listen and Feel)
b. Acute airway obstruction can result from:
i. Laryngeal trauma.
ii. Posterior dislocation of clavicular head
2. BREATHING
Severe facial trauma can
a. Major thoracic injuries that affect breathing : lead to acute airway
obstruction
i. Tension pneumothorax
ii. Open pneumothorax
iii.Massive hemothorax
iv. Flail chest and pulmonary contusion
3. CIRCULATION
a. Major thoracic injuries that affect circulation :
i. Massive hemothorax
ii. Cardiac tamponade
TENSION PNEUMOTHORAX
A “ one way valve ” air leak occurs from the lung or through the chest wall; Air is
forced into the thoracic cavity without any means of escape, completely collapsing the
affected lung. Mediastinum displaced to the opposite side causing obstructive shock
due to reduced venous return.
Diagnosis is Clinical
Most common cause : mechanical ventilation

with positive-pressure ventilation in patients
with visceral pleural injury.
Tension pneumothorax is a
clinical diagnosis
Signs and symptoms:
• Chest pain • Unilateral absence of breath sound

• Air hunger • Distended neck veins
• Respiratory distress • Cyanosis (late)
• Tachycardia • Elevated hemithorax without respiratory
• Hypotension movement 
• Tracheal deviation away from site of
injury
Immediate management : Immediate decompression by inserting a large-caliber needle

into the 2nd intercostal space in the midclavicular line (convert to simple
pneumothorax). Do not wait for radiological confirmation before initiating treatment.
Needle Thoracocentesis
1. Assess patient and respiratory status

2. Give High flow Oxygen via Non-rebreather mask
3. Identify 2nd intercostal space,midclavicular line of the affected side
4. Prep the area
5. Give LA (if patient conscious and time permits)
6. Insert the needle (above the rib)
7. Puncture the parietal pleura
8. Listen for the sudden escape of air when parietal pleura is
obliterated (indicating that tension pneumothorax has been
relieved)
9. Remove the needle and apply dressing
10. Prepare and insert chest tube
11. Obtain a CXR film
Location of needle insertion
for Needle Thoracocentesis
Needle thoracocentesis- Complications:
• Local hematoma
• Pneumothorax
• Lung laceration
Definitive management : tube thoracostomy
Chest Tube insertion
1. Determine the insertion site (Safety Triangle)

2. Surgically prepare ansd drape the chest
3. Locally anesthetize the skin and rib periosteum
4. Perform a 2-3cm transverse incision and bluntly dissect through the
subcutaneous tissues
5. Puncture the parietal pleura with the tip of a clamp and put a gloved finger
inside the incision while dividing any soft tissues, adhesions or clots making a
path.
6. Clamp the proximal end of the tube and advance it into the pleural space.
Direct the tube posteriorly alongside the chest wall.
7. Observe the fogging of the chest tube and listen for air movement
8. Connect the end of the tube to an underwater seal
9. Secure the tube
10. Apply occlusive dressing
11. Obtain a check CXR
Complications of Chest Tube insertion
1. Laceration or puncture of intraabdominal or intrathoracic organs

2. Infection (eg empyema)
3. Damage to intercostal nerve, artery or vein
4. Subcutaneous emphysema
5. Hemothorax
OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)
Large defects of the chest wall (opening wound >2/3 of trachea diameter) that remain
open can result in an open pneumothorax. During respirations, air will preferentially
moves through the least resistance route (the large defect in the case of open
pneumothorax)
Initial management: closing the defect with a sterile occlusive dressing, which should
be large enough to overlap the wound’s edges and then taped securely on three sides
in order to provide a flutter-type valve effect. Then a chest tube remote from the
wound should be placed as soon as possible
Definitive management : surgical closure of the defect
Occlusive Dressing
MASSIVE HEMOTHORAX
Results from the rapid accumulation of > 1500 ml of blood or >1/3 of patient’s blood
volume in the chest cavity.
Accumulated blood can compromise respiratory effort by compressing the lung and
prevent effective ventilation.
Diagnosed by finding decreased breath sounds and dullness to percussion on physical

examination.
Initial management requires simultaneous restoration of blood volume and

decompression of the chest cavity with insertion of a large (#36 Fr) chest tube.
A persistent need for blood transfusions is an indication for thoracotomy. The decision
for thoracotomy does not based solely on the rate of continuing blood loss. Patient
physiological factors also take into account.
A qualified surgeon must be involved in the decision for thoracotomy.
FLAIL CHEST
AND PULMONARY CONTUSION
Occurs when segment of the chest wall does not have bony continuity with the rest of
the thoracic cage; ≥2 ribs fractured in ≥2 places
Hypoxia can result from pulmonary contusion, restricted chest wall movement caused
by pain and chest wall instability and paradoxical movements.
Palpation of abnormal respiratory motion and crepitation of ribs or cartilage fractures,

can aid in making the diagnosis.
Initial management: adequate ventilation, administration of humidified O2, fluid

resuscitation
Definitive management: Ensure adequate oxygenation, judicious fluid therapy and

adequate analgesia to improve ventilation
Flail chest
CARDIAC TAMPONADE
Diagnosis by clinical examination, with ultrasound examination to

confirm.
Classic diagnostic Beck’s triad :

• Raised JVP - venous pressure elevation (may be absent with
concomittant hypovolaemia),
• Low BP (decline in arterial pressure)
• Muffled heart sounds (may be difficult in a noisy environment)
Kussmaul’s sign (a rise in venous pressure with inspiration when
breathing spontaneously) is a true paradoxical venous pressure
abnormality associated with tamponade.
Tension pneumothorax (esp on the left) can mimic cardiac tamponade.It is an

important differential diagnosis.
Diagnostic method : ECHO, FAST (pericardial window)
Immediate treatment:
Pericardiocentesis can be diagnostic as well as therapeutic, but not in the case when
the blood in the pericardial sac had clotted, and it is not the definitive treatment for
cardiac tamponade.
Ultrasound can facilitate accurate insertion of the needle into the pericardial space.
Pericardiocentesis
1. Monitor patient’s vital signs (Cardiac monitor, Spo2, PR, BP before, during and after
procedure.
2. Surgically prepare the xiphoid and subxiphoid (if time permits)
3. LA to the puncture site (if time permits)
4. With a 16G to 18G over the needle catheter (or angiocath) attach a 50ml syringe with
a 3-way stopcock
5. Assess for the presence of any mediastinal shift
6. Puncture the skin at 1 to 2 cm inferior to the left of xiphochondral junction, 45 degree
angulation to the skin
7. Carefully advance the needle cephalad (towards the head) and aim towards the tip of
the left scapula
8. Observe the cardiac monitor. If the needle is advanced too far and punctured the
ventricular muscle, the cardiac monitor will show the ‘current of injury’ pattern
(extreme ST-T wave changes or widened and enlarged QRS complexes). Irritation of the
ventricular myocardium could also produce premature ventricular contractions. These
changes indicate that the needle is advanced too far and should be withdrawn.
9. Once the needle punctured the pericardial sac, withraw as much blood as possible.
Remove the needle.
10. Attach a three-way stopcock to the catheter once aspiration is completed. Close the
stopcock and anchor the catheter in place.
11. Repeat the aspiration if tamponade recur.
Pericardiocentesis: Complications:
1. Aspiration of ventricular blood (instead of Pericardial)

2. Laceration of ventricular epicardium/myocardium
3. Laceration to coronary vessels (arteries/ veins)
4. VF
5. Pneumothorax
6. Damage to other structures (eg Oesophagus, peritoneum, great vessels)
Definitive treatment: surgery
All patients with acute tamponade and positive pericardiocentesis will require surgery
for further close examination of the heart and repair of the injury.
SECONDARY SURVEY : POTENTIALLY LIFE THREATENING CHEST INJURIES
8 lethal injuries 
a. Simple pneumothorax e. Blunt cardiac injury
b. Hemothorax f. Traumatic aortic disruption
c. Pulmonary contusion g. Traumatic diaphragmatic
injury
d. Tracheobronchial tree injury
h. Blunt esophageal rupture 
SIMPLE PNEUMOTHORAX
Mainly caused by lung laceration with air leakage. Air in pleural space disrupts the
cohesive forces between the visceral and parietal pleura. Air enters the potential
space between the visceral and parietal pleura.
Can convert to tension pneumothorax if initially unrecognised and Positive Pressure

Ventilation is applied.
Typically diagnosed by CXR/CT scan and treated with tube thoracostomy.
HEMOTHORAX
Mostly caused by lung laceration or laceration of intercostal vessels or internal

mammary artery with <1500mls of blood. Bleeding is limited and does not require
operative intervention.
Typically diagnosed by CXY/CT scan and treated with tube thoracostomy.
A simple hemothorax that is not fully evacuated can result in retained clotted
hemothorax and when infected can form empyema
PULMONARY CONTUSION
The most common potentially lethal chest injury resulting in respiratory failure that
develops over time. Can occur without rib fractures or flail chest esp in pediatric
population. May present with wide spectrum of clinical signs that are often not well
correlated with chest Xray findings.
Typically diagnosed by CXR/CT scan.
Management includes judicious fluid resuscitation and selective intubation for

pulmonary support. Those with significant hypoxia (SpO2 <90%) on room air might need
intubation and ventilation within the first hour.
TRACHEOBRONCHIAL TREE INJURY
Majority of injury is within 1 inch from the carina. In severe cases, most patients die
at scene.
Associated with hemoptysis, pneumonediastinum, pneumopericardium, subcutaneous

emphysema, or tension pneumothorax with a mediastinal shift, persistent air leak from
chest tube, persistent pneumothorax after insertion of chest tube.
Intubation migt be difficult due to distortion of airway anatomy and hematoma.
Bronchoscopy confirms the diagnosis.
Treatment: Operative repair
BLUNT CARDIAC INJURY
Resulting in myocardial contusions, cardiac chamber rupture, coronary artery

dissection or thrombosis and valvular rupture.
ECG findings are various include multiple premature ventricular complexes,

unexplained sinus tachycardia, atrial fibrillation, bundke branch block (usually right)
and ST segment changes.
Cardiac troponins can suggest myocardial infarction but its role is limited in blunt
cardiac injury.
Most common complications; cardiac arrhythmias, hypotension and wall motion

abnormality.
patient at risk of cardiac dysrhythmias (ECG changes) should be monitored for the first 24
hours
TRAUMATIC AORTIC DISRUPTION
Common cause of sudden death after MVA and fall from height. Survivors tend to have
incomplete laceration and intact adventitial layer of the aorta.
Specific symptoms and signs are frequently absent

Early diagnosis requires a high index of suspicion.
Features on CXR that can suggest traumatic aortic disruption:
• Widened mediastinum • Deviation of esophagus (NG tube to

• Obliteration of aortic knob the right)
• Deviation of trachea to the right • Widened paratracheal stripe
• Depression of left main stem • Widened paraspinal interfaces
bronchus • Presence of pleural or apical cap
• Elevation of Right mainstem • Left hemothorax
bronchus • Fractures of 2nd rib or scapula 
• Obliteration of space between
pulmonary artery and aorta
Diagnosis is confirmed by dynamic helical CT scanning or aortography.
Treatment: Primary repair or resection and replacement with interposition graft.
TRAUMATIC DIAPHRAGMATIC INJURY
Blunt trauma produces large radial tears that lead to herniation while penetrating
trauma produces small perforations that take time to develop diaphragmatic hernia.
Frequently missed injury.
Early diagnosis requires a high index of suspicion.
Most common radiographic sign is elevation of diaphragm

on involved side. Nasogastric tube will appear in the
thoracic cavity on CXR. More commonly diagnosed on the
left side probably because the liver obliterates the defect
or protect the right hemidiaphragm. If diaphragmatic
injury is suspected, nasogastric tube should be inserted.
An upper GI contrast study should be performed if the

diagnosis is not clear.
Requires early laparatomy for repair and to address associated injuries.
Diaphragmatic injury may be missed during intial evaluation. An undiagnosed

diaphragmatic injury can result in pulmonary compromise or entrapment and
strangulation of peritoneal contents.
BLUNT ESOPHAGEAL RUPTURE
Severe blow to the upper abdomen could cause forceful expulsion of gastric contents
into the esophagus resulting in esophageal rupture. Oesophageal rupture can be ethal
if unrecognized.
Mediastinitis and empyema could result.
Suspect Esophageal rupture in:
• Left pneumothorax or hemothorax without rib fracture.

• Received severe blow to lower sternum or epigastrium.
• Pain or shock out of proportion to injury.
• Presence of particulate matter in the chest tube.
• Presence of mediastinal air.
Treatment: Wide drainage of pleural space and mediastinum with direct repair of injury
via thoracostomy.
OTHER MANIFESTATIONS OF CHEST INJURIES
SUBCUTANEOUS EMPHYSEMA
Can result from airway injury, lung injury, blast injury

does not necessitate treatment, but the treatment of underlying injury must be
addressed. Tube thoracostomy should be inserted if Positive pressure ventilation is
applied in anticipation of development of tension pneumothorax
TRAUMATIC ASPHYXIA (CRUSHING INJURY TO THE CHEST)
Manifested as upper torso, facial and arm plethora with petechiae secondary to acute
temporary compression of the superior vena cava. Massive tissue swelling and cerebral
oedema could result.
RIB, STERNUM, AND SCAPULAR FRACTURES
Fractures of the scapula, 1st or 2nd rib, sternum: look hard for injuries to the head,
neck, spinal cord, lungs and great vessels.
Scapular, sternal fractures: consider pulmonary contusions and blunt cardiac injury
Middle ribs (4 to 9): fractured bones/ribs might injure the thorax, look hard for
pneumothorax and hemothorax
Fractures of the lower ribs (10 to 12) should increase suspicion for hepatosplenic
injury.
CHAPTER 5: ABDOMINAL AND PELVIC TRAUMA
(summarized by Dr Muhammad Fatih Bin Fizal)
- Assessment of Circulation in Primary Survey takes account of the possibility of

hemorrhage in abdomen and pelvis.
- Unrecognised abdominal injury continues to be a cause of preventable death after

truncal trauma
- Retroperitoneum spaces injuries do not initially present with signs and symptoms of
peritonitis
A. ANATOMY OF ABDOMEN
1. EXTERNAL
a. Anterior
-Transnipple line superiorly, the inguinal ligaments and symphysis pubis
inferiorly, and the anterior axillary lines laterally
b. Flank
-Between the anterior and posterior axillary lines from 6th ICS to iliac crest
c. Back
-Posterior to the posterior axillary lines from tip of scapulae to the iliac
crests
2. INTERNAL
a. Peritoneal cavity
i. Upper –diaphragm, liver, spleen, stomach and tranverse colon
ii. Lower-small bowel, parts of ascending and descending colons, the
sigmoid colon and internal female reproductive organs
b. Retroperitoneal cavity
i. IVC
ii. Most of the duodenum
iii.Pancreas
iv. Kideneys and ureters
v. Posterior aspects of ascending and descending colons
vi. Retroperitoneal components of pelvic cavity
c. Pelvic cavity
i. Rectum
ii. Bladder
iii.Iliac vessels
iv. Internal female reproductive organ
B. ASSESSMENT
1. HISTORY
- To ask pertinent historical information. History may predict the presence of abdomen
and pelvic injuries.
- Mechanism of injury predicts the potential injuries and facilitates its early
identification.
a. Blunt trauma b. Penetrating trauma

i. Types of collisions i. Time of injury
ii. Types of restraints ii. Types of weapon
iii.Speed of vehicles iii.Distance from
iv. Patient’s position assailant
v. Passenger’s status iv. Numbers of stabs
vi. Deployment of airbag v. Amount of external
bleeding noted at
scene
c. Explosive devices
i. Distance from
explosion
ii. Open or enclosed
space 
2. PHYSICAL EXAMINATION
- To be conducted in a meticulous systematic in a standard sequence.
a. Inspection
i. Fully undressed
ii. Look for:
1. Any abrasions/contusions/lacreations
2. Penetrating wound
3. Impaled foreign body
iii.Perform logroll cautiously
iv. Cover patient with warmed blanket
b. Auscultation
i. Bowel sound – most useful when they are normal initially and then
change over time. Free intraperitoneal blood and GI contents may
cause ileus.
c. Percussion and palpation

i. Percussion may elicit signs of peritoneal irritation.
ii. Involuntary muscle guarding is a reliable sign of peritoneal irritation.
iii.May elicit superficial and deep tenderness.
iv. May detect the presence of a pregnant uterus.
d. Pelvic stability
i. Manual compression of anterosuperior iliac spines or iliac crests as
abnormal or bony pain suggests fracture
ii. To do cautiously as this maneuver can cause or aggravate bleeding
iii.should not be performed if patient is in shock WITH obvious pelvic
injury
e. Urethral, perineal and rectal examination

i. Urethral injury
1. Blood at urethral meatus
2. Scrotum ecchymoses/hematoma
3. High riding prostate
ii. Sphincter tone
iii.Gross blood in bowel perforation
iv. To identify any fractures of the pelvic bones
(CBD should not be inserted in patient with perineal hematoma or high-riding prostate.
f. Vaginal examination if indicated
g. Gluteal examination
i. Extends from the iliac crests to the gluteal folds
ii. Penetrating injuries to gluteal region is associated with 50% of
significant intraabdominal injuries.
h. Adjunct
i. Gastric tube
1. To relieve acute gastric dilation/remove gastric content to
reduce risk of aspiration
2. Avoid nasal gastric tube in midface/suspected basal skull
fractures (use oral gastric tube instead)
ii. Urinary catheter
1. Monitoring urine output as index of tissue perfusion, relieve
urinary retention and decompress bladder before DPL.
2. Mandatory for retrograde urethrography to confirm intact
urethra if there is inabilty to void or unstable pelvic fracture
or signs of urethral injury during physical examination
3. IMAGING
-To choose based on the hemodynamic status of the patient and suspected injuries.
a. X-ray
i. Recommended for AP CXR and pelvic xray in the assessment of
patients with multisystem blunt trauma
b. FAST
i. To look for hemoperitoneum
ii. Ideally repeated after an interval of 30 minutes
iii.Area of assessment:
1. Pericardial sac
2. Hepatorenal fossa
3. Splenorenal fossa
4. Pelvis/ Pouch of Douglas
c. DPL (Diagnostic peritoneal lavage)

i. Should be performed by surgery team in hemodynamically unstable
patient sustained multiple blunt trauma
ii. Would be performed in hemodynamically stable if ultrasound/ CT are
not available
d. Computed tomography
i. Should be performed in hemodynamically stable patient whom there
is no apparent indication for an emergency laparotomy
4. MANAGEMENT
-Early consultation with primary team is necessary whenever a patient with possible
intrabdominal injuries is brought to the emergency department
a. Laparotomy
i. Surgical judgement is required to determine the timing and need for
laparotomy
ii. Indications:
1. Blunt abdominal trauma with hypotension with a positive
FAST or clinical evidence of intraperitoneal bleeding
2. Blunt abdominal trauma wih positive DPL
3. Hypotension with penetrating abdominal wound
4. Gunshot wound traversing the peritoneal cavity or visceral/
vascular retroperitoneum
5. Evisceration
6. Bleeding from the stomach, rectum, or genitourinary tract
from penetrating trauma
7. Peritonitis
8. Free air, retroperitoneal air, or rupture of the hemidiaphragm
after blunt trauma
9. Ruptured gastrointestinal tract, intraperitoneal bladder
injury, renal pedicle injury, or severe visceral parenchymal
injury after blunt or penetrating trauma, as demonstrated on
contrast-enhanced CT
b. Pelvic fracture
i. Potential sources of blood loss:
1. Fractured bone surfaces
2. Pelvis venous plexus
3. Pelvis arterial artery
4. Extrapelvis sources
ii. Should be temporarily stabilised or closed using an available
commercial compression device or sheet to decrease bleeding
pelvic fracture
pelvic wrap
CHAPTER 6: HEAD TRAUMA
(Summarized by Dr. Avinash Pillay)
- Primary goal of treatment for patients with suspected traumatic brain injury (TBI) is to
prevent secondary brain injury.
o Provide adequate oxygenation
o Maintain blood pressure sufficient for cerebral perfusion
Physiology
- Intracranial pressure
o Increase ICP can reduce cerebral perfusion and can cause/exacerbate ischemia
o normal ICP ~10 mmHg
o Pressures greater than 20mmHg are associated with poor outcomes
- Monroe-Kellie doctrine
o States that the total volume of the intracranial contents must remain constant,
because the cranium is a rigid non expansile container. Venous blood and CSF
provide some degree of buffering.
- Cerebral blood flow(CBF)
o Low levels of CBF are inadequate to meet metabolic demands of the brain early
after injury.
o Cerebral perfusion pressure (CPP) = MAP – ICP
o A MAP of 50 – 150 is autoregulated to maintain a constant CBF
o Secondary injury may occur due to
▪ Hypotension
▪ Hypercapnia ( cerebral blood vessels dilate/constrict due to changes in
partial pressure of Oxygen and carbon dioxide altering the blood flow to
the brain)
Classification of Head Injuries

- Severity
o Minor GCS score 13 – 15
o moderate GCS score 9 – 12
o severe GCS score 3 – 8
- morphology
o skull fractures
▪ vault
• linear vs stellate
• depressed/nondepressed
• open/closed
▪ basilar ( clinical features : raccoon eyes ,Battle sign, rhinorrea /
otorrhea, 7th or 8Th nerve palsy
• with/without CSF leak
• with/without seventh nerve palsy
o intracranial lesions
▪ focal
• epidural
o biconvex or lenticular shaped
o often located at temporal or

temporoparietal region and is often a
result of tear of the middle meningeal
artery. Classically of arterial in origin.
o Watch out for lucid interval.
• Subdural
o Develop from shearing of small surface

or bridging blood vessels of the cerebral
cortex.
o On CT , the clot conforms to contours to

the surface of the brain.
• Intracerebral
▪ diffuse
• concussion
• multiple contusions
• hypoxic/ischemic injury
• axonal injury
Indications for CT Brain ( The Canadian Ct head rule for patients with minor head
injuries)
- Ct brain is required for patients with minor head injuries (i.e witnessed LOC,definite
amnesia,or witnessed disorientation in a patient with GCS 13–15) with any of the
following factors: 
- High risk for neurosurgical intervention - Moderate risk for brain injury on CT
o GCS< 15 at 2 hours after injury o LOC more than 5 minutes
o Suspected open or depressed o Amnesia before impact (more
skull fracture than 30 minutes)
o Any signs of basilar skull injury o Dangerous mechanism of injury
(pedestrian struck by motor
o Vomiting more than 2 episodes vehicle, occupant ejected, fall
from height >3 feet or 5 stairs) 
o Age more than 65 years
Management of Minor Brain Injury (GCS 13-15)
Management of Moderate Brain Injury (GCS 9-12)
Management of Severe Head Injury
Medical therapies for Brain Injuries
- provide optimal milieu for neural tissues to recover
o IV fluids
▪ Maintain normovolemia
▪ Careful, don’t overload the patient
▪ Hypotonic solutions should NEVER be used
▪ Glucose containing solutions result in hyperglycemia
• Shown to be harmful to injured brain
▪ Recommended
• Ringer’s lactate
• Normal saline
▪ Hyponatremia is associated with cerebral edema
o Hyperventilation
▪ Used in moderation and for a limited period as possible
▪ Hyperventilation reduces partial pressure of carbon dioxide causing

cerebral vasoconstriction resulting in reduced cerebral perfusion
▪ In general, its preferable to keep PaCO2 at approx 35mmHg
▪ Hyperventilation will lower ICP in a deteriorating patient with expanding

intracranial hematoma until emergent craniotomy can be performed
o Mannitol
▪ Used to reduce ICP

▪ 20g of mannitol per 100ml solution
▪ Potent osmotic diuretic and should NEVER be used in hypotensive
patient.
▪ Indication in euvolemic patient
• Dilated pupil
• Hemiparesis
• LOC
o Hypertonic solution
▪ Used to reducing ICP refractory to other measures

▪ Should not be used in presence of hypotension or hypovolemia
o Barbiturates
▪ effective in reducing the ICP refractory to other measures.

▪ May cause hypotension therefore not indicated in acute resuscitative
phase
o Anticonvulsants
▪ Used for post traumatic epilepsy

▪ Should be used only when necessary as it may inhibit brain recovery.
▪ Phenytoin and fosphenytoin
• 1g IV at rate no faster than 50mg/min
• Usual maintenance dose 100mg/8hours
Brain death
- Diagnosis
o GCS = 3
o Nonreactive pupils
o Absent brainstem reflexes
▪ Oculocephalic
▪ Corneal
▪ Doll’s eyes
▪ No gag reflex
- Hypothermia and barbiturate coma may mimic brain death and diagnosis should only
be made once all physiologic parameters are normalised and CNS function is not
affected by medications.
Chapter 7: Spine and Spinal Cord Trauma
(summarized by Dr Liew Xiao Ching)
Introduction
-about 5% of patients with brain injury have an associated spinal injury
-25% patients with spinal injury have at least a mild brain injury.
-55% of spinal injury in cervical region, 15% in thoracic, 15% at thoracolumbar junction and
15% in lumbosacral
-about 10% of cervical spine # patients have a 2nd, non-contiguous vertebral column #.
-at least 5% of patients have the onset of neurologic symptoms or worsening of pre-
existing symptoms after reaching ED, usually due to
1) ischemia
2) progression of spinal cord edema
3) no adequate immobilization
-Evaluation of spine can be deferred as long as spine is protected (especially in the

presence of systemic instability)
-Prolonged immobilization of patients on a hard surface like a backboard can cause serious
decubitus ulcers in patients with spinal cord injuries.
-If patient could not be removed from the spine board within 2 hrs, then patient should be
logrolled every 2 hrs.
Anatomy and physiology
Spinal column:
-consists of 7 cervical, 12 thoracic, 5 lumbar vertebrae, sacrum and the coccyx.
-cervical spine is most vulnerable to injury due to its mobility and exposure.
-cervical canal is wide from foramen magnum to lower part of C2. The diameter of the
cervical canal is much smaller below C3 and spinal cord injuries are more likely to occur.
-1/3rd of patients with upper cervical injuries die at injury scene due to phrenic nerve
involvement caused by spinal cord injury at C1.
-Incidence of thoracic spine # is much lower due to restricted mobility and additional
support from rib cage.
-most thoracic spine #: wedge compression # without spinal cord injury
-fracture-dislocation of thoracic spine: almost always results in complete spinal cord

injury due to relatively narrow spinal canal.
-15% spinal injury occur in thoracolumbar junction.
Spinal cord:
-originates at the caudal end of medulla oblongata at the foramen magnum
-ends around L1 bony level as conus medullaris, below this level is the cauda equina
-3 tracts can be assessed clinically: corticospinal tract, spinothalamic tract and posterior
columns.
-corticospinal tract controls motor power on the same side of the body and is tested by
voluntary muscle contractions or involuntary response to painful stimuli.
-spinothalamic tract transmits pain and temperature sensation from the opposite side of
the body, and is tested by pin prick and light touch.
-posterior columns carry position sense (proprioception), vibration sense and some light
touch sensation from the same side of the body.
-complete spinal cord injury: state of no demonstrable sensory or motor function below a
certain level.
-incomplete injury: any motor or sensory functions remains, eg. Sacral sparing.
Dermatomes:
-area of skin innervated by sensory axons within a particular segmental nerve root.
-key sensory points: 

• C5: area over deltoid • T12: symphysis pubis
• C6: thumb • L4: medial aspect of calf
• C7: middle finger • L5: web space between the
• C8: little finger 1st and 2nd toe
• T4: nipple • S1: lateral border of foot
• T8: xiphisternum • S3: ischial tuberosity
• T10: umbilicus • S4 & S5: perianal region 
Myotomes:
-Each root innervates more than one muscle, most muscles are innervated by more than
one root(usually 2)
-key muscles: 
• C5: deltoid • L3,L4: knee extensors
• C6: wrist extensors (quadriceps, patellar
(biceps,extensor carpi reflexes)
radialis longus and brevis) • L4,L5,S1: Knee flexion
• C7: elbows extensors (hamstrings)
(triceps) • L5: ankle and big toe
• C8: finger flexors to the dorsiflexors (tibialis
middle finger (flexor anterior, extensor hallucis
digitorum profundus) longus)
• T1: small finger abductor • S1: Ankle plantar flexors
(abductor digiti minimi) (gastrocnemius, soleus) 
• L2: hip flexors (iliopsoas)
Neurogenic shock VS Spinal shock:
-Neurogenic shock:
• impairment of descending sympathetic pathways in the cervical or upper

thoracic spinal cord
• causes loss of vasomotor tone, leading to vasodilatation of visceral and
lower extremity blood vessels, pooling of blood and consequently
hypotension
• loss of sympathetic innervations to the heart, causing bradycardia.
• BP maybe restored by judicious use of vasopressors after moderate volume
replacement.
• Atropine maybe used for hemodynamically unstable bradycardia.
-Spinal shock:
• Flaccidity (loss of muscle tone) and loss of reflexes after spinal cord injury.
Classification of spinal cord injury
-can be classified according to
1. Level
2. Severity of neurological deficit
3. Spinal cord syndrome
4. Morphology
1. Level:
-Sensory level:
• The most caudal segment of the spinal cord with normal sensory function.
-Motor level:
• The lowest key muscle that has a muscle strength grading of ≥ 3/5
-Injuries of 1st 8 cervical segments result in quadriplegia
-Lesions below T1 level result in paraplegia.
-The bony level of injury is the vertebra at which the bones are damaged.
-Neurological level of injury is determined primarily by clinical examination.
2. Severity of neurological injury:
• Incomplete paraplegia (incomplete thoracic)

• Complete paraplegia (complete thoracic)
• Incomplete quadriplegia (incomplete cervical)
• Complete quadriplegia (complete cervival)
-signs of incomplete injury:
• Any sensation, including position sense

• Voluntary movements in lower extremities
• Voluntary anal sphincter contraction
• Voluntary toe flexion
-Sacral reflexes, for eg. Bulbocavernous reflexes or anal wink, do not qualify as sacral
sparing
3. Spinal cord syndromes:
-Central cord syndrome
• Vascular compromise of the cord in the distribution of spinal cord artery

• Greater loss of motor power in upper extremities than in lower extremities,
with varying degree of sensory loss.
• Usually seen after a hyperextension injury in a patient with pre-existing
spinal canal stenosis
• History of forward fall that resulted in a facial impact
• Recovery: lower extremities recovering 1st, bladder function next, proximal
upper extremities and hands last.
• Prognosis: better than other incomplete injuries.
-Anterior cord syndrome
• Usually due to infarction of the cord in the distribution of anterior spinal

artery.
• Paraplegia and a dissociated sensory loss with loss of pain and temperature
sensation
• Posterior column function is preserved
• Has the poorest prognosis of incomplete injuries
-Brown-Sequard Syndrome
• Results from hemisection of the cord, usually due to penetrating trauma

• Ipsilateral motor loss and loss of position sense, associated with
contralateral loss of pain and temperature sensation beginning 1 or 2 levels
below the level of injury
4. Morphology:
-spinal injuries:
• Fractures
• Fracture-dislocation
• Spinal cord injury without radiographic abnormalities (SCIWORA)
-Stable or unstable.
-All patients with radiographic evidence of injury and neurological deficits should be
considered to have an unstable spinal injury.
Specific Types of Spinal Injuries
-Mechanisms of injury of cervical spine:
• Axial loading
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
Atlanto-occipital dislocation:
-due to severe traumatic flexion and distraction
-patients die of brainstem destruction, apnoea or profound neurological impairments
-common cause of death in Shaken Baby Syndrome
-cervical traction is not used
-spinal immobilization is recommended initially.
Atlas fracture (C1)
-5% of acute cervical fracture
-40% associated with fracture of axis
-most common C1 fracture is burst fracture (Jefferson fracture)
• Mechanism of injury: axial loading

• Disruption of both anterior and posterior rings of C1 with lateral
displacement of lateral masses.
• Best seen on open mouth view of C1,C2 and axial CT scan
• Unstable #, need cervical collar
• Unilateral ring or lateral mass #: stable #
C1 rotary subluxation
-most often in children
-may occur spontaneously, after major/minor trauma, with URTI, or with rheumatoid
arthritis
-presents with torticollis
-open mouth odontoid view: odontoid not equal distant from 2 lateral masses of C1.
-patient should be immobilized in rotated position
Axis (C2) Fractures
-18% of all cervical spine injuries
Odontoid fractures
-60% of C2 fracture involves odontoid process
-type 1: involve tip of odontoid, relatively uncommon
-type 2: occur through base of dens, are the most common odontoid fractures
-type3: occur at the base of dens and extend obliquely into the body of axis
Posterior element fracture of C2
-Hangman’s fracture:
• involves pars interarticularis

• 20% of all axis #
• Extension type injury
Fractures and dislocations of C3-C7
-in adults, most common level of cervical # is C5, and most common level of subluxation is
C5 on C6
-most common injuries patterns:
• Vertebral body # with or without subluxation

• Subluxation of articular process
• Fractures of laminae/ spinous process/ pedicles/ lateral masses
-Neurologic injuries increase with facets dislocations.
Thoracic spine fractures (T1-T10)
-4 categories:
• Anterior wedge compression injuries

• Burst injuries
• Chance fractures
• Fracture – dislocations
-Anterior wedge fractures:
• Axial loading with flexion

• Anterior vertebral body rarely more than
25% shorter than the posterior body
• Stable #
-Burst injury:
• Vertical- axial compression, unstable #
-Chance fracture:
• Transverse # through vertebral body, unstable #

• Caused by flexion about an axis anterior to vertebral column
• Commonly seen after MVA in which the passenger was restrained by a lap
belt
• May be associated with retroperitoneal and abdominal visceral injuries
-Fracture-dislocations:
• Due to extreme flexion and severe blunt trauma to the spine, causing
disruption to the posterior elements
• Unstable #
• Uncommon due to orientation of facets joints
• Commonly cause complete neurologic deficits due to narrow spinal canal
Thoracolumbar junction fracture (T11-L1)
-combination of acute hyperflexion and rotation, unstable #
-for eg.fall from height and restrained drivers
-may cause injury to conusmedullaris, resulting in bladder & bowel dysfunction, decrease
sensation and strength of lower extremities
Blunt carotid and vertebral vascular injuries (BCVI)
-blunt trauma to the head and neck
-suggested criteria for screening:
• C1-C3 #
• Cervical spine # with subluxation
• # involving foramen transversarium
-1/3 of these will have BCVI on CT angiography of neck
rd
General Management
Immobilisation
• Protection is Primary, Detection is Seconday: Any patient who is suspected to have spinal
injury should be immobilised above and below the suspected injury until a fracture is
excluded by radiological investigation.
• The presence of paraplegia, quadriplegia or neurological abnormality is presumptive

evidence of spinal instability
• When in doubt, leave the collar on.
Cervical spine injury requires continuous immobilization of the entire patient with a
semirigid cervical collar, head immobilisation, backboard, tape and straps before and
during transfer toa definitive care facility. Once arrived in ED, every effort must be made
to remove the rigid spine board ASAP to reduce the risk of pressure ulcers. It should not be
delayed for the purpose of radiological investigations.
A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at risk
for pressure sores
Four Person Log-roll

Chapter 8: Musculoskeletal Trauma
(summarized by Dr. Khairul Annisah bt Ibrahim)
Primary survey and resuscitation

Aim: Identify exsanguining haemorrhage and control bleeding.
Musculoskeletal injuries are potential areas of blood loss. Long bone fractures such as
femur fracture and extensive soft tissue damage are the common sources of blood loss
causing shock. Every effort must be put to arrest the ongoing bleeding.
Adjuncts to primary survey
1)Fracture immobilisation
-realign limbs as close to its anatomical

position by applying traction or splint
-splints can reduce blood loss, reduce pain,
prevent further soft tissue damage
2)xray examination
Secondary Survey
a) History
-mechanism of injury-may give clues to extent of injury
Examples:
Side impact vehicle coalition- pelvis fracture
Patient ejected from vehicle- more severe injuries and
unpredictable injury patterns
Head on collision-hip dislocation
Wearing seatbelt – chance fracture, intra abdominal injury
Chest hit steering wheel- intrathoracic injury, sternal /rib fracture
b) Environment
Examples:
does the patient sustained open fracture in a dirty environment?
c) Preinjury status and predisposing factors

-determine patient baseline condition prior to injury because this information may alter
the understanding of patient’s condition, treatment regime and outcome
-AMPLE history (A:Allergy,M:medication, P: Previous medical/ surgical history,L: last
meal,E:event/environment prior to incident)
d) Prehospital Observations and care

Examples:
-what was the position patient was found?
-Bleeding or pooling of blood at the scene? How much?
-Does dressing or splint applied?
-any delay in extrication or transport?
PHYSICAL EXAMINATION
Patient must be completely undressed
Aim of physical examination is to identify

1) life threatening condition
2) limb threatening condition
3) any other musculoskeletal injury
components must be assessed: skin, neuromuscular, circulatory, skeletal and ligament

integrity
a) Look and Ask

-Colour, perfusion, wounds(laceration or abrasion), deformity(angulation or shortening),
swelling, discoloration or bruising
-remember to Logroll patient
-ask patient to move major joints
b) Feel
Check sensation
Palpate areas of tenderness
Common joint Dislocation Deformities
Joint direction deformity
Shoulder Anterior Squared Off
Posterior Locked in internal rotation
Elbow Posterior Olecranon became prominent posteriorly
Hip Anterior Flexed, Abducted, externally rotated
Posterior Flexed Adducted , Internally rotated
Knee Anteroposterior Loss of normal contour, extended
ankle Lateral is most common Externally rotated, prominent medial
malealus
Subtalar Lateral is most common Laterally displaced os calcis
c) Circulatory evaluation
Palpate distal pulses, capillary refill
Doppler and measure ABSI(less than 0.9 is considered ischaemia)
XRAY
-Should be ordered in patient with NO haemodynamic instability
-one joint below and one joint above the injury
-standard 2 views, AP and lateral
POTENTIALLY LIFE THREATENING EXTREMITY INJURIES
a) Major arterial haemorrhage

- Application of direct pressure to open wound
- It is not advisable to apply vascular clamps unless superficial vessel identified
- Fluid resuscitation
- Fracture realigned and splinted
- Consult surgeon
b) Crush Syndrome
Crush injury of significant muscle mass that causes rhabdomyolysis which can lead to
acute renal failure and DIC
Patient presented with:- 

• Dark coloured urine • Hypocalaemia
• Metabolic acidosis • DIVC 
• Hyperkalaemia
Management:-
Aggressive fluid resuscitation
May use Diuretics
Keep urine output 100ml/hr until myoglobin is cleared
LIMB THREATENING iNJURIES
1) open fracture and joint injuries
Definition of fracture: a break in the continuity of bone

cortex
Open fracture: communication of fracture to the external
environment
-prone to infection, poor healing
-Diagnosis is based on history of the incident, physical
examination that demonstrates evidence of open wound on
the same limb segment with or without significant muscle
damage, contamination and associated fracture
-An open wound near a joint should be assumed
communicating with the joint
• the only safe way to determine communication of
open wound and joint is to surgically explore and
debride the wound
• Consult surgeon immediately
-Apply traction or splints
-Control haemorrhage
-Fluid resuscitation
-Tetanus
-Cover with antibiotics-1st generation cephalosporins and aminoglycoside(or other gram
negative coverage antibiotics)
2) Traumatic amputation
Amputated part should be rinsed in isotonic solution(eg ringers lactate) and wrapped in
sterile gauze that is soaked with aqueous Penicillin (100 000 units in 50cc of ringers
lactate) and wrapped in moistened sterile towel, then put in a plastic bag and transported
in a cooling chest with crushed ice
3) Compartment syndrome
• Occurs when pressure in osteofacial compartment causes muscle ischaemia and
subsequent necrosis
• Common areas:lower leg,forearm, hands, foot, gluteal region and thigh
Higher risk in: tibial and forearm fracture, burns, severe crush injury, prolonged external
pressure to muscle, excessive exercise, and when immobilised in tight dressing or cast
Signs and symptoms:-

-pain out of proportion to stimulus
-Palpable tenseness of compartment
-Pain on passive stretch of muscle
-Altered sensation
-Absent of pulse(late sign)
-Weakness/paralysis(late sign)
Management:-
-All cast, dressing and splints should be released
-Consult surgeon
-Fasciotomy
NEUROLOGIC INJURY SECONDARY TO FRACTURE/ DISLOCATION

Peripheral Nerve Asessment of upper extremities
NERVE MOTOR SENSATION INJURY
Index and little finger

Ulnar Little inger Elbow injury
abduction
Thenar contraction with

Median Index finger Wrist fracture or dislocation
opposition
Median, anterior Supracondylar fracture of

Index tip flexion none
interosseous humerus
Musculocutaneous Elbow flexion Radial forearm Anterior shoulder dislocation
Thumb finger
Distral humeral shaft,anterior
Radial metacarpophalangeal First dorsal web space
shoulder dislocation
extension
Anterior shoulder
axillary deltoid Lateral shoulder dislocation,proximal humerus
fracture
Peripheral nerve Assessment of Lower Extremities
Nerve Motor Sensation Injury
Femoral Knee extension Anterior knee Pubic rami fracture
Obturator Hip abduction Medial thigh Obturator ring fracture
Posterior tibial Toe flexion Sole of foot Knee dislocation
Fibular neck fracture,knee

Superficial Peroneal Ankle eversion Lateral dorsum of foot
dislocation
Fibular neck
Dorsal first to second
Deep Peroneal Ankle/toe dorsiflexion fracture,compartment
webspace
syndrome
Sciatic Nerve Plantar dorsiflexion Foot Posterior hip dislocation
Superior Gluteal Hip Abduction Upper buttocks Acetabular fracture
Gluteus maximus hip

Inferior Gluteal Lower buttocks Acetabular fracture
extension
ASSOCIATED INJURIES
INJURY Missed/ ASSOCIATED INJURY
Clavicular fracture
Major thoracic injury esp pulmonary contusion and
Scapular Fracture
rib fracture
Fracture/ dislocation of shoulder
Displaced thoracic spine fracture Thoracic aortic rupture
Spine fracture Intrabdominal injury
Brachial artery injury

Fracture/dislocation of elbow
Median ulnar and radial nerve injury
Femoral neck fracture

Femur fracture
Posterior hip dislocation
Femoral fracture
Posterior knee dislocation
Posterior hip dislocation
Knee dislocation or displaced tibial plateu fracture Popliteal artery and nerve injuries
Spine injury or fracture

Calcaneal fracture Fracture dislocation of hind foot
Tibial plateu fracture
Open fracture 70% incidence of associated nonskeletal injury
PAIN CONTROL
Analgesia is required for joint injuries and fractures

Usually narcotics are used which should be given in small amount
Titrate analgesia using Pain Score
Watch out for respiratory depressant effects
Summary
-Musculoskeletal injury although not life threatening may pose delayed threats to life and
limb
-Goals of assessment is to identify life threatening and limb threatening injuries
-Early splinting of fractures and dislocations may prevent serious copmplications and late
sequelea
-it is very important to detect and manage arterial injuries, compartment syndrome, open
fractures, crush injuries, and fracture-dislocations
-it is essential to take thorough history and be able to anticipate other injuries involved
with associated condition.
CHAPTER 9: THERMAL INJURIES
(summarized by Dr. Yeo Suat Ching)
Immediate life saving measures for burn injuries:
AIRWAY: because burn can result in massive edema, the upper airway is at risk for
obstruction.
Clinical indications of inhalation injury include:
− face and/or neck burns

− singeing of the eyebrows and nasal vibrissae
− carbon deposits in the mouth/or nose and carbnaceous sputum
− acute inflammatory changes in the oropharynx, including erythema
− hoarseness
− history of impaired mentation/ confinement in a burning environment
− explosion with burns to head and torso
− carboxyhemoglobin level > 10% in a patient who was involved in a fire
any of the above suggests an inhalation injury and the need for intubation
STOP THE BURNING PROCESS:
all clothing should be removed to stop the burning process (warm tap water)
INTRAVENOUS ACCESS: large caliber branulas (at least 16G)
Assessment of burn patients:
The Rule of Nines is a useful and practical guide to determine the extent of burn. BSA
differs in children. The infant's head represents a larger surface area and the extremities
represent a smaller proportion than an adult’s.
Depth of burn:
first degree burn: erythema, pain and absense of blisters
partial thickness burn: red or mottled appearance with swelling and blister formation.
Can have a weeping, wet appearance and is painfully hypersensitive
full thickness burn: dark, leathery, painless. May be red but does not blanch with
pressure.
Primary Survey and Resus:
Airway: Pharyngeal thermal injuries can produce marked upper airway edema and early
protection of airway is important
Breathing: breathing concern arise from 3 general areas: hypoxia, CO poisoning and smoke
inhalation. Always assume CO poisoning in patients who were in enclosed area
IX: baseline ABG and CXR
The treatment of inhalation injury is supportive. Patient with high likelihood of inhalation
injury and significant burn should be intubated. If no spinal injury can elevate the head
and chest by 30 degree to reduce neck and chest wall edema. Escharotomy may be
required in a full thickness burn of anterior and lateral chest wall.
Circulation-burn shock resus:
the initial fluid rate is based on Parkland formula:
total fluid requirements in the first 24h= 2-4ml/kg/% total BSA
-divide total vol into 2
-infuse first ½ within the first 8 hr
-infuse the rest within the next 16hr
start time = time of burn injury
fluid of choice=Hartmann's solution
after starting, the amout of fluids should be adjusted based on Urine Output target:
0.5ml/kg/hr in adult;1ml/kg/hr in children <30kg
Secondary Survey and related adjuncts:
-physical examination
-documentation
-baseline ix: abg, related xrays, fbc, electrolytes
-peripheral circulation: need to rule out compartment syndrome
-gastric tube insertion
-analgesics and sedatives. Use pain score and titrate with the appropriate analgesia
-wound care
-antibiotic: no indication for prophylactic antibiotics in early postburn period.
-tetanus immunization
Chemical Burns:
-result from contact with acid, alkali or petroleum products
-influenced by duration of contact, concentration and amount of the agent
-alkali burn requires longer irrigation
-alkali burn to the eyes require continuous irrigation during the first 8hrs
Electrical Burns:
-immediate treatment: airway, breathing, iv line, ECG,
-examine for associated musculoskeletal damage and spinal injury.
-Rhabdomyolysis can cause acute renal failure
-fluid administration should be increased to ensure a urinary output of 100ml/kg/hr in

adult or 2ml/kg/hr in children <30kg
-metabolic acidosis should be corrected
Cold injury:
frostnip: mildest form of cold injury
characterized by pain, pallor and numbness of the affected part and is reversible with
rewarming
frostbite: freezing of tissue with intracellular ice crystal formation, microvascular

occlusion and subsequent tissue anoxia
non freezing injury: trench foot or cold immersion foot or hand
due to microvascular endothelial damage, stasis and vascular occlusion
Management of cold injuries:
-warm blankets
-hot fluids
-place the injured part in circulating water at a constant 40 degree C until pink and
perfusion return
-avoid dry heat and do not rub or massage
-rewarming can be painful therefore require adequate analgesia
Local wound care of frostbite:
goal: to prevent infection, avoid opening uninfected vesicles and elevating the injured
part, which is left open to air
Systemic hypothermia: in trauma patients, core temperature <36 C and severe

hypothermia <32 C
Administer warmed iv fluids and blood
avoid iatrogenic hypothermia as hypothermia may worsen coagulopathy
Chapter 10: Pediatric Trauma
(summarized by Dr Lau CH)
Unique Characteristics of Pediatric Patients
Size and shape
-more intense energy is transmitted to a smaller body mass of children that has less fat,
less connective tissue , and close proximity of multiple organs.
-higher frequency of blunt brain injuries because of the head is proportionately larger in
young children.
Skeleton
-child’s skeleton is incompletely calcified, contains multiple active growth centers, and is
more pliable. For these reasons, internal organ damage is often noted without overlying
bony fracture.
-The identification of skull or rib fractures in a child suggests the transfer of a massive
amount of energy, and underlying organ injuries, therefore, traumatic brain injury and
pulmonary contusion, should be suspected.
Surface area
-the ratio of a child’s body surface area (BSA) to body volume is highest at birth and
diminishes as the child matures.
-hypothermia may develop quickly because of thermal energy loss
Psychological Status
- in very young children, emotional instability frequently leads to a regressive
psychological behaviour when stress, pain and other perceived threats intervene in the
child’s environment.
Equipment
-immediately available equipment of the appropriate sizes is essential for the successful
initial treatment of injured children.
-A length-base resuscitation tape ,eg Broselow ™ Pediatric Emergency Tape ,is an ideal
adjunct for rapid determination of weight based on length for appropriate fluid volumes,
drug doses, and equipment sizes.
Broselow Tape
Airway: Evaluation and Management
The child’s airway is the first priority because the inability to establish and/or maintain a
patent airway with the associated lack of oxygenation and ventilation is the most common
cause of cardiac arrest in children.
Anatomy
The smaller the child, the greater is the disproportion between the size of the cranium
and the midface. This leads to a propensity for the posterior pharynx to buckle anteriorly
as a result of passive flexion of the cervical spine caused by large occiput.
Avoid passive flexion of the cervical spine by keeping the plane of the midface parallel to
the spine board in a neutral position, rather than in the “sniffing position”.
Placement of a 1-inch-thick layer of padding beneath a

child’s entire torso will preserve neutral alignment of
the spinal column.
Management
In a spontaneously breathing child with a partially

obstructed airway, the airway should be optimized by
keeping the plane of the face parallel to the plane of
the stretcher or gurney, while maintaining neutral
alignment of the cervical spine.
Jaw-thrust maneuver combined with bimanual in-line spinal immobilization is used to open
the airway.
If patient is unconscious, mechanical methods of maintaining the airway may be necessary.
The practice of inserting the oral airway backward and rotating it 180˚ is not
recommended for children, as trauma with resultant hemorrhage into soft tissue
structures of the oropharynx may occur.
The smallest area of the young child’s airway is at the cricoid ring, which forms a natural
seal with the endotracheal tube. Therefore, cuffed ETT are uncommonly used in children
under the age of 9 years who are acutely injured.
Uncuffed ETT should be used to avoid subglottic edema, ulceration and disruption of the
infant’s or child’s fragile airway.
Most trauma centers use a protocol for emergency intubation , referred to as drug-assisted
intubation (DAI), previously known as rapid sequence intubation (RSI)
Infants and children have a more pronounced vagal respone to endotracheal intubation
than adults. Such response may be caused by hypoxia, vagal stimulation during
laryngoscopy ,and can be minimized by atropine pretreatment.
Atopine (0.1-0.5mg) given at least 1-2 minutes before intubation
Etomidate (0.3 mg/kg ) or Midazolam (0.3 mg/kg) in children with normovolemia
Etomidate (0.1 mg/kg ) or Midazolam (0.1 mg/kg) in children with hypovolemia
After sedation, cricoid pressure is maintained to help avoid aspiration of gastric contents.
A short-acting ,depolarizing, neuromuscular blocking agent should be used , eg,
Succinylcholine ( 2 mg / kg in children , 10 kg ; 1 mg / kg in children > 10 kg)
A longer-acting, nondepolarixing ,neuromuscular blocking agents , eg,
Vecuronium (0.2 mg/kg) or Rocuronium (0.6 mg/kg) may be indicated for longer period
in a child who needs a CT scan .
Nasotracheal intubation should not be performed in children under the age of 9 years.
ETT should be positioned 2 to 3 cm below the level of the vocal cords .
Primary confirmation techniques, such as auscultation of both hemithoraces in the axillae,

should then be performed to ensure that right mainstem bronchial intubation has not
occurred and chest rise are equally both sides.
Secondary confirmation device, such as real-time capnograph, a colorimetric end-tidal

carbon dioxide(ETCO2)detector, or an esophageal detector devide( EDD) should be used to
document tracheal intubation and a chest x-ray film obtained to identify the position of
the ETT.
Because of the short length of the trachea in young children (5cm in infants, 7cm in
toddlers), any movement of the head may result in displacement of the ETT ,inadvertent
extubation, right mainstem bronchial intubation, or vigorous coughing due to irritation of
the carina by the tip of the ETT.
Breath sounds should be evaluated periodically to ensure that the tube remains in the
appropriate position
Cricothyroidotomy
-Surgical Cricothyroidotomy is rarely indicated for infants or small children.
- it can be performed in older children in whom the cricothyroid membrane is easily
palpable.
Breathing : Evaluation and management
Breathing and ventilation
-Respiratory rate in children decreases with age.
-Normal, spontaneous tidal volumes is from 6-8 mL /kg for infants and children, larger
tidal volumes of 7- 10 mL/kg may be required during assisted ventilation.
-Excessive volume or pressure during assisted ventilation substantially increase the
potential for iatrogenic barotraumas because of the fragile nature of the immature
tracheobronchial tree and aveoli.
-Hypoxia is the most common cause of cardiac arrest in the child
-Hypoventilation —>respiratory acidosis —> cardiac arrest.
-A child should be able to maintain a relatively normal pH with adequate ventilation and
perfusion.
- In the absence of adequate ventilation and perfusion, attempting to correct an acidosis
with sodium bicarbonate results in further hypercarbia and worsened acidosis
Needle and tube thoracostomy
Injuries like hemothorax, pneumothorax, and hemopneumothorax are managed with

pleural decompression.
Care should be taken during this procedure to avoid using 14- to 18- gauge over–the –
needle catheters in infants and small children, since the longer needle length may cause a
tension pneumothorax.
Chest tube will need to be small and placed into the thoracic cavity by tunneling the tube
over the rib above the skin incision site and directing it superiorly and posteriorly along
the inside of the chest wall.
Tunneling is especially important in children because of the thinner chest wall.
Circulation and shock : Evaluation and management
Recognition
-Injuries in children may result in significant blood loss.
- Up to 30 % diminution in circulating blood volume may be required to manifest drop in

systolic BP
-Tachycardia and poor skin perfusion often are the only keys to early recognition of
hypovolemia and early initiation of appropriate crystalloid fluid resuscitation.
Fluid Resuscitation
-the goal is to rapidly replace the circulating volume
-a child’s blood volume can be estimated at 80 mL /kg.
- A bolus of 20m L/ kg of warmed isotonic crystalloid solution is needed when shock is

suspected.
-The 3-for-1 rule applies to pediatric patient as well as to the adult patient.
-it may be necessary to give 3 boluses of 20mL/kg or a total 60 mL/kg, to achieve a

replacement of the lost 25 %
- simplest and quickest method of determining the child’s weight is to use the Broselow™
Pediatric Emergency Tape.
-A return towards hemodynamic normality is indicated by:
• Slowing of the heart rate to normal

• Clearing of the sensorium
• Return of peripheral pulses
• Return of normal skin colour
• Increased warmth of extremities
• Increased systolic BP
• Increased pulse pressure (>20 mmHg)
• Urinary output of 1 to 2 mL/kg/hour (age-dependent)
- 4 responses to fluid resuscitation
• Responders - respond to crystalloid fluid only

• Responders - respond to crystalloid and blood resuscitation
• Transient responders -initial response to crystalloid and blood, but then
deterioration occurs
• Non responders -Do not respond at all to crystalloid and blood
-The transient responders and nonresponders are candidates for prompt infusion of
additional blood and consideration for operation.
Blood replacement
-failure to improve hemodynamic abnormalities after 1st bolus of fluid, should prompt the
need for 2nd bolus and perhaps a 3rd bolus and requires the prompt involvement of a
surgeon.
-when starting the 3rd bolus of isotonic crystalloid fluid or the child’s condition
deteriorates, the use of 10mL/kg of type–specific or negative warmed PRBCs should
considered.
Venous access
-venous access is preferably by a peripheral percutaneous route.
-intraosseous (IO) infusion via a bone marrow needle (18 gauge in infants, 15 gauge in
young children) or insertion of a femoral venous line by Seldinger technique if 2 attempts
of peripheral line unsuccessful.
-if these procedures fail, a doctor with skill and expertise can safely perform direct
venous cutdown.
-IO route is safe and efficacious, and should be discontinued when suitable peripheral line
has been established.
-complications of IO route include cellulitis, osteomyelitis, compartment syndrome, and

iatrogenic fractures.
-Preferred site for IO cannulation is proximal tibia, below the level of the tibial tuberosity.
-if the tibia is fractured, the needle may be inserted into the distal femur
-the IO cannulation should not be performed distal to the fracture site.
Urine output (UO)
-UO for infants up to 1 year is 2 mL/kg/hr

for younger children is 1.5 mL/kg/hr
for older children is 1.0 mL/kg/hr
-UO combined with urine specific gravity = the adequacy of volume resuscitation
-insert a urinary catheter for accurate measurement of the child’s UO
Thermoregulation
-High ration of BSA to body mass in children increases heat exchange with the environment
and directly affect the body’s ability to regulate core temperature.
- Thin skin and the lack of subcutaneous tissue —> increased evaporative heat loss and
caloric expenditure.
-Hypothermia may prolong the coagulation times, and adversely affect CNS function
-overhead heat lamps, heaters, or thermal blankets can be used to preserve body heat
Chest trauma
-8 % of all injuries in children involve the chest
-serve as a marker for other organ system injury.
-the compliance of a child’s chest wall allows impacting forces to be transmitted to the
underlying pulmonary parenchyma, causing pulmonary contusion.
-Rib fractures and mediastinal injuries are not common.
-Mobility of mediastinal structures makes the child more susceptible to tension

pneumothorax
-Diaphragmatic rupture, aortic transection, major tracheobronchial tear, flail chest and
cardiac contusion are rarely encountered in childhood.
Abdominal Trauma
-serious intra-abdominal injuries warrant prompt involvement by a surgeon.
-hypotension with penetrating abdominal trauma requires prompt operative intervention.
Assessment
-Deep, painful palpation of the abdomen should be avoided at the onset of the
examination to prevent voluntary guarding that may confuse the abdominal findings.
-a stressed and crying child will swallow large amounts of air.
-insert a gastric tube to decompress the stomach if upper abdomen is distended.
-Orogastric tube decompression is preferred in infants.
-the shoulder or lap-belt marks —> more likely abdominal injuries are present.
-Decompression of the urinary bladder also helps in abdominal evaluation.
Diagnostic Adjuncts
1. CT 2. FAST 3.DPL
Computed Tomography
CT scanning is often used to evaluate the abdomen of children who have sustained blunt
trauma and have no hemodynamic abnormalities which can allow for nonoperative
management by the surgeon.
An injured child requiring resuscitation and sedation who undergoes CT scan should be
accompanied by a doctor skilled in pediatric airway management
Focused Assessment Sonography in Trauma
• modest sensitivity
-can identify even small amounts of intraabdominal blood.
-Large amounts of intraabdominal blood, significant injury is more likely
Diagnostic Peritoneal Lavage
-DPL may be used when patient is not safely transported to the CT scanner, or when CT
and FAST are not available
-Only the surgeon who will care for the child should perform DPL, because DPL may
interfere with subsequent abdominal examinations upon which the decision to operate
may in part be based
Nonoperative Management
-The presence of intraperitoneal blood on CT, FAST and DPL does not necessarily mandate
a laparotomy.
- it has been well demonstrated that bleeding from an injured spleen, liver, or kidney
generally is self-limited.
- if the child’s condition cannot be normalized hemodynamically and if the diagnostic

procedure performed is +ve for blood, a prompt laparotomy to control hemorrhage is
indicated.
-When nonoperative management is selected, these children must be treated in pediatric

intensive care and under supervision of a qualified surgeon.
- Nonoperative management of confirmed abdominal visceral injuries is a surgical decision

made by surgeons. Therefore, the surgeon must supervise the treatment of pediatric
trauma patients.
Specific Visceral Injuries
• Duodenal hematoma results from a combination of thinner abdominal musculature.

it is most often treated nonoperatively with nasogastric suction and parenteral
nutrition.
• Small bowel perforations at or near the ligament of Treitz are more common in
children than in adults.
• Bladder rupture is common in children because of the shallow depth of the child’s
pelvis
• Rupture of a hollow viscus requires early operative intervention.
• Children who are restrained by a lap belt are at particular risk for enteric
disruption, especially if they have a lap-belt mark on the abdominal wall, should
be presumed to have a high likelihood of injury to the GIT until proven otherwise.
• When an injury to the liver, spleen, or kidney is suspected, the child should
undergo a CT scan.
• A child with grade II or higher injuries to these organs is often admitted to the
peadiatric ICU for continuous monitoring.
Head Trauma
The brain of the child is anatomically different from that of the adult.
It doubles in size in the first 6 months of life and achieves 80% of the adult brain size by 2
years of age.
Neuronal plasticity is evident after birth and includes incomplete neuronal synapse
formation and arborization, incomplete myelinization, and a vast number of
neurochemical changes.
Subarachnoid space is relatively smaller —> less protection to the brain because there is
less buoyancy
Assessment
Children and adults may differ in their response to head trauma, principal differences
include:
1. The outcome in children who suffer severe brain injury is better that in adults
however, outcome in children younger than 3 years of age is worse than a similar injury
in an older child.
2. Hypotension may occur in small infants as the result of blood loss into either subgaleal
or epidural space. Hypovolemia, due to intracranial injury, occurs because of open
cranial sutures and fontanelles in infants.
3. The young child with an open fontanelle and mobile cranial sutures has more tolerance
for an expanding intracranial mass lesion or brain swelling. Therefore, an infant who is
not in coma but who has bulging fontanelles or suture diastase should be treated as
having a more severe injury.
4. Vomiting and amnesia are common after brain injury in children and do not necessarily
imply increased intracranial pressure (ICP). However, persistent vomiting or vomiting
more frequently mandates CT of the head.
5. Impact seizures are common in children and are usually self-limited. All seizure
activity requires CT of the head
6. Children tend to have fewer focal mass lesions than do adults, but elevated ICP due to
brain swelling is more common.
7. Verbal score component of GCS must be modified for children younger than 4 years.
8. Neurosurgical consultation to consider intracranial pressure monitoring should be
obtained early in the course of resuscitation for children with:
• A GCS score of 8 or less, or motor scores of 1 or 2

• Multiple injuries associated with brain injury that require major volume
resuscitation , immediate life saving thoracic or abdominal surgery, or which
stabilization and assessment is prolonged
• A CT scan of the brain that demonstrates evidence of brain hemorrhage, cerebral
swelling, or transtentorial or cerebellar herniation.
8. Medication dosages must be adjusted and in consultation with a neurosurgeon.
Drugs often used in children with head injuries include:
• Phenobarbital 10-20mg/kg/dose
• Diazepam 0.1-0.2 mg/kg/dose ;slow IV bolus
• Phenytoin or fosphenytoin 15-20mg/kg , administered at 0.5-1.5 mL/kg/min as a
loading dose, then 4-7 mg/kg/day for maintenance
• Mannitol 0.5-1.0 g/kg (rarely required) diuresis with the use of mannitol or
frusemide may worsen hypovolemia and should be withheld early in the
resuscitation of children with head injury there are incontrovertible signs of
transtentorial herniation.
Management
1) Rapid , early assessment and management of the ABCDEs

2) Appropriate neurosurgical involvement from the beginning og the treatment
3) Appropriate sequential assessment and management of the brain injury with
attention directed toward the prevention of 2nd brain injury , hypoxia and
hypoperfusion. Early endotracheal intubation with adequate oxygenation and
ventilation are indicated to avoid progressive CNS damage. Pharmacologic sedation
and neuromuscular blockage may be used to facilitate intibation.
4) Continuous reassessment of all parameters
Spinal Cord Injury
- uncommon in children –only 5% of total incidents of spinal cord injuries
Anatomic Differences
1) Interspinous ligaments and joint capsules are more flexible.

2) Vertebral bodies are wedged anteriorly and tend to slide forward with flexion
3) The facet joint are flat.
4) The child has a large head compared to the neck. Therefore, the angular
momentum forces applied to the upper neck are relatively greater than in the
adult.
Radiologic considerations
Pseudosubluxation frequently complicates the radiographic evaluation of a child’s cervical

spine.
-seen less commonly at C3 to C4.
-to correct this radiographic anomaly, place the child’s head in a neutral position by
placing a 1-inch-thick layer of padding beneath the entire body from shoulders to hips, but
not the head, and repeat the x-ray.
-an increased distance between the dens and the anterior arch of C1 occurs approximately
20% of young children.
-Skeletal growth centers can resemble fractures.eg
1) Basilar odontoid synchondrosis appears as a radiolucent area at the base of the

dens, especially in children younger than 5 years.
2) Apical odotoid epiphyses appear as separations on the odontoid x-ray and are
usually seen between the age 0f 5 and 11 years
3) The growth center of the spinous process can resemble fractures of the tip of the
spinous process.
-Children may sustain “spinal cord injury without radiographic abnormalities” (SCIWORA)
more commonly than adults.
-normal spine x-ray does not exclude significant spinal cord injury.
-When in doubt about the integrity of the cervical spine or spinal cord, assume than an
unstable injury exists, maintain immobilization of the child’s head and neck, and obtain
appropriate consultation.
Musculoskeletal Trauma
History
-History is vital importance
-X-ray diagnosis of fractures and dislocations is difficult because of the lack of

mineralization around the epiphysis and the presence of a physis (growth plate)
-X-ray of fractures of differing ages should alert that possible child abuse; as should lower-
extremity fractures in children who are too young to walk.
Blood Loss
-blood loss a/w long-bone and pelvic fractures is proportionately less in children than in
adults.
-blood loss related to an isolated closed femur fracture that is treated appropriately is
associated with an average to cause hematocrit drop of 4 points (not enough to cause
shock).
Special considerations of the immature skeleton
Injuries to or adjacent to the area before the physis has closed may potentially retard the
abnormal growth or alter the development of the bone in an abnormal way.
Immature, pliable nature of bones in children may lead to greenstick fracture where
fractures are incomplete, with angulation maintained by cortical splinters on the concave
surfaces.
Supracondylar fractures at the elbow or knee have a high propensity for vascular injury as
well as injury to the growth plate.
Principles of immobilization
A single attempt to reduce the fracture to restore blood flow is appropriate ,followed by
simple splinting or traction splinting of the femur.
The Battered, Abused Child
How do recognize abuse injuries?
1) A discrepancy exists between the history and the degree of physical injury
2) A prolonged interval has passed between the time of the injury and presentation
for medical care
3) The history includes repeated trauma, treated in the same or different EDs.
4) The history of injury changes or is different between parents or guardians
5) There is a history of hospital or doctor “shopping”
6) Parents respond inappropriately to or do not comply with medical advice. Eg,
leaving a child unattended in the emergency facility.
The following findings, on careful physical examination, should suggest child abuse and
indicate more intensive investigation:
1) Multicolored bruises( bruises in different stages of healing)

2) Evidence of frequent previous injuries, typified by old scars or healed fractures on
x-ray
3) Perioral injuries
4) Injuries to the genital and perianal area
5) Fractures of long bones in children less than 3 years of age
6) Ruptures internal viscera without antecedent major blunt trauma
7) Multiple subdural hematomas, especially without a fresh skull fracture
8) Retinal hemorrhages
9) Bizarre injuries, such as bites, cigarette burns, or rope marks
10) Sharply demarcated second- and third- degree burns in unusual areas
Chapter Summary
1. Unique characteristics of children include important differences in anatomy, body

surface area, chest wall compliance, and skeletal anatomy. Normal vital signs vary
significantly with age.
2. Initial assessment and management of severely injured children is guided by the

ABCDE approach. Early involvement of a general surgeon or pediatric surgeon is
imperative in the management of injuries in a child. Nonoperative management of
abdominal visceral injuries should be performed only by surgeons in facilities
equipped to handle any contingency in an expeditious manner.
3. Child abuse should be suspected if suggested by suspicious findings on history or

physical examination. These include discrepant history, delayed presentation,
frequent prior injuries, and perineal injuries.
CHAPTER 11 : Geriatric Trauma
(summarized by Dr. Zahanah binti Ariffin)
TYPES AND PATTERNS OF INJURY
• Fall
- effect of aging process and environmental hazards
• MVA
- diminished visual and auditory acuity
-decreased ability to avoid injury because of impairment from conditions: arthritis,

osteoporosis, emphysema, heart disease and decrease muscle mass
• Thermal injury
AIRWAY
• Features that affect management of airway
-dentition -microstomia (small oral aperture)
-nasopharyngeal fragility -cervical arthritis
-macroglossia (large tongue)
BREATHING AND VENTILATION
• Loss of respiratory reserve due to effect of aging and chronic disease

• Supplemental oxygen is mandatory but caution in patient whom rely on hypoxic
drive to maintain ventilation
• Respiratory failure may result from increased work of breathing combined with
decreased energy reserve
• Pulmonary complications are common; atelectasis, pneumonia, and pulmonary
oedema
CIRCULATION
• Blood pressure generally increase with aging

• Early stages of shock can be masked by the absence of early tachycardia
• More sensitive to volume overload due to higher incidence of cardiac disease
• The retroperitoneum is an often unrecognised source of blood loss
• Hypovolemic and cardiogenic shock may coexist
DISABILITY: BRAIN AND SPINAL CORD INJURY

• Higher incidence of subdural and intraparenchymal haematomas
• Rapid screening of anticoagulant use and correction with blood component therapy
may improve outcome
• Severe oesteophytic disease makes the diagnosis of cervical injury challenging
• Central and anterior cord syndrome- preexisting spinal canal stenosis due to
anterior osteophytes and posterior ligament hyperthophy
EXPOSURE AND ENVIRONMENT
• The skin and connective tissues of elderly undergo extensive changes

• These results in the loss of thermal regulatory ability, decrease barrier function
against bacteria invasion and impairment of wound healing
OTHER SYSTEMS
MUSCULOSKELETAL SYSTEM
• Most common locations of fractures are the ribs, proximal femur, hip, humerus and
wrist
NUTRITION AND METABOLISM
• Caloric need decline and protein requirement increase

• Poor nutritional status contributes to an increase complication rate
IMMUNE SYSTEM AND INFECTION
• Elderly are less able to tolerate infection and more prone to multiple organ failure
• Absence of fever and leucocytosis may be due to poor immune function
SPECIAL CIRCUMSTANCES
MEDICATIONS
• Drug interaction and side effects are common

• Beta adrenergic blocking agent may limit chronotropic activity
• CCB (calcium channel blocker) may prevent periphery vasoconstriction and
contribute to hypotension
ELDER MALTREATMENT
• Classified into 6 categories 

1) Physical maltreatment 4) Psychological maltreatment
2) Sexual maltreatment 5) Financial and material
exploitation
3) Neglect
6) Violation of right 
END-OF -LIFE DECISION
• The patients right to self -determination is paramount

• Medical intervention is appropriate only when it is in the patient best interest
• Medical therapy is appropriate only when its likely benefits outweigh its adverse
consequences
• The ethical issue of appropriateness of care in an environment of declining hospital
resources and restriction on financial
Chapter 12: Trauma in Pregnancy and Intimate Partner Violence
(summarized by Dr. Nurul Hana binti Jaafar)
Pregnant trauma patients – two patients; mother and fetus (priority for the injured
pregnant mother)
Anatomic and Physiological Changes in Pregnancy
1) Uterus level – 12 weeks; intrapelvic, 20 weeks ;

umbillical region, 34-36 weeks ; costal margin
2) Blood volume – Increasing plasma volume,

decreasing HCT, Increasing WBC
3) Cardiac output – Increase in cardiac output by 1 to

1.5 litre/min due to increase in plasma volume. In
supine position, gravid uterus compression on the vena
cava can decrease cardiac output by 30 %
4) Heart rate – increases gradually by 10 to 15 beats per min – maximum rate by 3rd
trimester
5) Blood pressure – Fall in blood pressure by 5 to 15 mmHg in systolic and diastolic

pressure during 2nd trimester. Blood pressure turns back to normal at term. In supine
position – vena cava compression can cause hypotension.
6) Respiratory system – Decrease in residual volume because of diaphragmatic elevation,

increasing oxygen consumption. Hypocapnia (PaCO2 of 30 mm Hg) is common in late
pregnancy (PaCO2 35 to 40 mmHg may indicate impending respiratory failure)
7) Gastrointestinal system – Delayed gastric emptying, intestine in the upper abdomen and
shielded by uterus.
8) Musculoskeletal system – Widening of symphysis pubis by 4 to 8 mm and increasing

sacroilliac joint space.
Mechanism of Injuries
Blunt Injury
Types; MVA, falls, direct assaults
The abdominal wall, uterine myometrium and amniotic fluid act as buffers to direct fetal
injury from blunt trauma.
Injury to the abdominal wall causes indirect injury to the fetus due to rapid compression,
deceleration, contrecoup effect or shearing force resulting in abruptio placentae.
Type of restraint system affects frequency of uterine rupture and fetal death.
Penetrating injury
As gravid uterus increase in size, other viscera are protected from penetrating injury.
Due to dense uterine musculature, and the fact that amniotic fluid and the fetus can
absorb energy from penetrating missile it causes low incidences of maternal visceral
injuries and generally good maternal outcome. However fetus fares poorly in cases of
penetrating injuries.
Assessment and Treatment
For optimal outcome of mother and fetus – assess and resuscitate mother first – and
then assess fetus before conducting secondary survey of mother
Mother
Ensure patent airway, adequate ventilation and oxygenation, effective circulatory volume.
*Uterine compression to the vena cava can decreases cardiac output – aggravates shock –
manually displace the uterus to left side to relieve pressure.
*Immobilizing a pregnant lady – the patient, or

spinal board logrolled 4 to 6 inches to the left and
support with bolstering device.
 
*Take note that because pregnant ladies have increased intravascular volume, they can
lose significant amount of blood before tachycardia, hypotension and other signs of
hypovolemia. Fetus may be in distress because of decrease perfusion to the placenta while
mother's condition appear stable – Crystalloid fluid resuscitation and early type-specific
blood administration are indicated to support the physiologic hypervolemia of pregnancy.
Fetus
Main cause of fetal death is maternal shock and maternal death.
2nd most common – placenta abruption (suggestive by PV bleed, uterine tenderness,

frequent uterine contractions, uterine tetany, uterine irritability)
Uterine rupture – rare – abdominal tenderness, guarding, rigidity, rebound tenderness,

mother in shock, easily palpable fetal parts, abnormal fetal lie, unable to palpate uterine
fundus.
Assessment of fetus viability – doppler ultrasound – by 10 weeks, tocodynamometer by 20

to 24 weeks – get obstetric consultation.
Secondary assessment
FAST, CT abdomen, DPL
Pay attention to uterine contractions and formal pelvic examinations; amniotic fluid in the
vagina, cervical effacement and dilatation.
A qualified surgeon and an obstetrician should be consulted early in the evaluation of

pregnant trauma patients.
Intimate Partner Violence
Indicators that may suggest presence of intimate partner violence;
− injuries inconsistent with history

− diminished self image, depression, suicidal attempts
− self abuse
− frequent ED or doctor's office visit
− symptoms suggestive of substance abuse
− self blame for injuries
− partner insists of being present for interview and examination and monopolizes
conversation.
3 questions can be asked in a non judgmental manner without presence of patient's

partner as a screening (can identify 65 to 70% victims);
1) Have you been kicked, hit, punched or otherwise hurt by someone within the past
year? If so, by whom?
2) Do you feel safe in your current relationship?
3) Is there a partner from a previous relationship who is making you feel unsafe now?
3 indicators should raise suspicion of possible intimate partner violence and further
investigation should be initiated.
Suspected cases of intimate partner violence should be handled through local social
service agencies, state health or human service department.
Chapter 13: Transfer to definitive care
(summarized by Dr Nursaleha binti Mohammad Pala)
• Patients whose injuries exceed an institution’s capabilities for definitive care

should be identified early during assessment and resuscitation and arranged
transfer to a hospital that has resources and capibilities to care for the patient.
• Decision to transfer depends on medical judgments (patients’ injuries and the local
resources)
Who should u transfer??
-based on physiologic measurements, specific identifiable injuries and mechanism of

injury
Transfer responsibilities
Referring doctors
• Select appropriate mode of transportation and level of care required for optimal
treatment of the patient en route
• Should consult with the receiving doctor and established transfer agreement
• Stabilize patient before transfer to another facility
Receiving doctor
• Ensure that the receiving institution is qualified, able, and willing to accept
patient
• Assist the referring doctor in making arrangements for the appropriate mode of
transportation and level of care during transport
• Should assist in finding an alternative placement for patient if they are unable to
accept the patient
Transferring Protocols
Information from receiving doctor
✓ Should speak directly to the surgeon accepting the patient

-patient identification
-brief history of the incident, including pertinent prehospital data
-initial findings in ED
-patient’s response to the therapy administered
Information to transferring personnel
✓ Inform regarding patient’s condition and needs during transfer

-airway maintenance
-fluid volume replacement
-special procedures that may be necessary
-revised trauma score, resuscitation procedures, and any changes that may occur en route
Documentation
✓ Written record of the problem, treatment given, patient status at time of transfer
and certain physical items
Treatment prior to transfer
✓ Patient should be resuscitated and stabilized

1) Airway
• Insert an airway or endotracheal tube if needed
• Provide suction
• Insert gastric tube to reduce risk of aspiration
2) Breathing
• Determine rate and administer supplementary oxygen
• Provide mechanical ventilation when needed
• Insert chest tube if needed
3) Circulation
• Control external bleeding
• Establish 2 large calibre intravenous tubes and begin crystalloid solution
infusion
• Restore blood volume losses with crystalloid or blood
• Insert an indwelling catheter to monitor urine output
• Monitor patient’s cardiac rhythm and rate
4) Central nervous system
• Assist respiration in unconscious patient
• Administer mannitol/diuretics if needed
• Immobilize head/neck/thoracic/and lumbar spine injuries
5) Diagnostic studies (when indicated, obtaining these studies should not delay
transfer)
• Obtain xrays of cervical spine, chest, pelvis and extremities
• Sophisticated diagnostic studies such as CT usually not indicated
• Order haemoglobin/haematocrit , cross match blood and arterial blood
gases for all patients, also order UPT for females of childbearing age
• Determine cardiac rhythm/haemoglobin/ecg/pulse oximetry
6) Wounds
• Clean and dress wounds after controlling external haemorrhage
• Administer tetanus prophylaxis
• Administer antibiotics when indicated
7) Fractures
• Apply appropriate splinting and traction
Treatment during transport
-monitor vital signs and pulse oximetry
-continued support of cardiorespiratory system
-continued blood volume replacement
-use appropriate medications as ordered
-maintenance of communication with a doctor or institution during transfer
-maintenance of accurate records during transfer
APPENDIX A : OCULAR TRAUMA
(summarized by Dr Farhana)
Early identification and treatment of ocular injuries may save the patients’ vision
ASSESSMENT
History :
1. Was there blunt trauma?

2. Was there penetrating injury?
3. Was there missile injury?
4. Was there a possible thermal, chemical or flash burn?
Physical examination:  
1. Visual acuity 7. Conjunctiva
2. Eyelid 8. Anterior chamber
3. Orbital rim 9. Iris
4. Globe 10. Lens
5. Pupil 11. Vitreous
6. Cornea 12. Retina 
Specific injuries :
1. Eyelid injury
• Result in marked ecchymoses, making examination difficult, use retractors

to check underlying structures
• Lacerations of lids that might need treatment by ophthalmologist include
- Wounds involve medial canthus that may damage medial canaliculus
- Injuries to lacrimal sac and duct may lead to obstruction if not repaired
properly
- Deep horizontal lacaration of upper lid may involve levator, may result
in ptosis
- Lacerations of lid margin can lead to notching, entropion, ectropion
• Fereign bodies of lid may lead to tearing
• Penetrating foreign bodies should not be removed or disturbed.
2. Corneal injury
• Corneal abrasion can lead to pain, FB sensation, photophobia, reduced

visual acuity, and chemosis.
• Corneal foreign body can be removed with irrigation, refer to
ophthalmologist if embedded
3. Anterior chamber injury
• Hyphema indicates severe intraocular trauma, must be referred
• Glaucoma develops in 7% of patient with hyphema
4. Injury to iris
• Can cause traumatic mydriasis or miosis
• Look for irregular pupil or hyphema
5. Injury to lens
• Lens contusion can later lead to cataract
• Anterior subluxation cause shallow chamber
• Posterior subluxation cause deepens anterior chamber
6. Vitreous injury
• Blunt trauma may cause vitreous vessels damage and bleeding into vitreous
result in sudden severe loss of vision.
• Red reflex absent
• Put eye shield, refer immediately
7. Retinal injury
• Blunt trauma may cause retinal hemorrhage, superficial hemorrhage is
cherry red in colour and deeper lesion appear grey
• Visual acuity may be affected if macula is involved
• Acute retinal tear may also occur in blunt trauma
• Retinal detachment most often occurs as late seguelae of blunt traumawith
patient describing light flashes, an curtain-like defect in peripheral vision
• Rupture of choroid appear as a beige area at posterior pole, but if transect
the macula, vision may permanently impaired
8. Globe injury
• Patient may have marked visual impairment, ocular contents may extruding
out
• The goal in to protect the eye from further damage
• Eye should not be manipulated any further
• Do not remove foreign bodies or clots, and do not use topical analgesics,
apply sterile dressing.
• An intraocular foreign body should be suspected if patient have sudden

sharp pain with reduced visual acuity. Inspect for the entry wound.
9. Chemical injury
• Acid precipitates proteins in tissues, and set sup natural barrier against
extensive tissues perforation
• Alkali combines with lipids in cell membrane, disrupts the cell membrane,
and cause rapid penetration of caustic agents, and extensive tissue
destruction.
• Chemical injury to cornea causes disruption of stroma mucopolysaccharide,

leading to opacification.
• Treatment is copious and continuous irrigation
• Do not neutralize the agent
• Thermal injury usually occurs to lid only, however burns of globe

occasionally occur
• Apply dressing and refer to ophthalmologist.
10.Fractures
• Blunt trauma to orbit may cause rapid compression of tissues and increase
pressure within orbit. The weakest point is orbital floor, which may
fractures, allowing orbital contents to herniate into antrum. ‘blowout
fracture’
• Subcutaneous emphysema may occur when fracture is into ethmoid or

maxillary sinus. Examine orbital floor and look for soft tissue density in
maxillary sinus
11.Retrobulbar hematoma
• This cause increased pressure within orbit compromise the blood supply to
retina and optic nerve, resulting in blindness
• Head should be elevated with no direct pressure placed on eye
APPENDIX B: HYPOTHERMIA AND HEAT INJURIES
(summarized by Dr. Marina bt Abdul Rahman)
COLD INJURY: SYTEMIC HYPOTHERMIA
Hypothermia- a core temperature below 35°C
• Mild (35°C to 32°C);

• moderate (32°C to 30°C);
• severe (below 30°C)
Older adults and children are more susceptible:
Older adults - impaired ability to increase heat production and decrease heat loss
by vasoconstriction
Children - relative increased body surface area (BSA) and limited energy sources
Signs :
• decrese in core temperature

• depressed level of consciousness
• cold to touch
• appear gray and cyanotic
• vital signs (HR, RR, BP) are all variable
Management:
• ABCDEs including the initiation of CPR and establishment of intravenous access if

the patient is in cardiopulmonary arrest.
• Prevent heat loss by removing the patient from the cold environment and replacing
wet, cold clothing with warm blankets.
• Administer oxygen.
• Patient should be treated in a critical care setting and cardiac monitoring is
required.
• Search for associated disorders (eg diabetes, sepsis, and drug or alcohol ingestion)
or occult injuries and treat promptly.
• Send blood for FBC, electrolytes, blood glucose, alcohol, toxins, creatinine,
amylase, and blood cultures.
• Treat mild and moderate exposure hypothermia with passive external rewarming in
a warm room using warm blankets, ambient overhead heaters, warmed forced-air
blankets, and warmed intravenous fluids.
• Severe hypothermia may require active core rewarming methods, starting with
bladder irrigation with a three-way foley, adding warmed humidification to
ventilation, and proceeding to invasive surgical rewarming techniques such as
peritoneal lavage, thoracic/pleural lavage, arteriovenous rewarming, and
cardiopulmonary bypass.
Physiologic Effects of Hypothermia:
• Cardiac output falls in proportion to the degree of hypothermia; cardiac irritability

begins at approximately 33°C.
• Ventricular fibrillation becomes incresingly common as the temperature falls below
28°C.
• Asystole can occur at temperature below 25°C.
• Cardiac drugs and defibrillation are not usually effective in the presence of
acidosis, hypoxia, and hypothermia. These treatment methods should be postponed
until patient is warmed to at least 28°C.
• It is inadvisable to insert a subclavian or internal jugular line in hypothermic
patients due to risk of triggering an uncontrollable cardiac arryhtmia.
• Lidocaine is ineffective in patients with hypothermia who has VF.
• Dopamine is the single inotropic agent that has some degree of action in patients
with hypothermia.
• Administer 100% O2 while the patient is being rewarmed.
HEAT INJURIES
Types
− Heat exhaustion(HE)
− Heat stroke(HS)
Heat exhaustion:
• caused by excessive loss of body water, electrolyte depletion, or both

• symptoms including headache, nausea, vomiting, light-headedness, malaise, and
myalgia
• it is distinguished from HS by having mental function that is essentially intact and
a core temperature usually less than 39°C
Heat stroke:
• a life threatening disease

• defined as hyperthermia ≥ 40°C with associated dehydration, hot flushed ,dry skin,
and central nervous system dysfunction, resulting in delirium, convulsions, and
coma.
• Associated with systemic inflammatory response which may lead to multiple organ
dysfunction and DIVC
• Two forms 1) classic/ non-exertional 2) exertional
◦ Classic- occurs during environmental heat waves and primarily affects elderly
and/or ill patients
◦ Exertional-occurs in healthy, young, and physically active people who are
engaged in strenuous exercise in a hot and humid environment
• HS occurs when the core body temperature rises and the thermoregulatory system
fails to respond adequately
• Signs:
4) tachycardia
5) tachypnea
6) may be hypotensive or normotensive with wide pulse pressure
7) core body temperature ≥40°C
8) Usually warm skin and dry or clammy and diaphoretic
9) liver and muscle enzymes level will be elevated
Pathophysiology:
• Human body able to maintain a core body temperature at about 37°C, despite
being exposed to a wide range of environmental conditions through multiple
physiological responses.
• Heat is both generated by metabolic processes and gained from the environment.
• The first response to elevated core temperature is peripheral vasodilatation,
increasing loss through radiation.
• If the ambient air temperature is greater than that of body temperature
hyperthermia will be exacerbated.
• To dissipate heat when the ambient temperature exceed 37°C, sweating is
required.
• Thermoregulatory response includes autonomic changes( increase in skin blood
flow, sweating) and behavioral changes( removing clothing, moving to a cooler
area).
• At the cellular level, exposure to excessive heat can lead to denaturation of
proteins, phospholipids, and lipoprotein, and liquefaction of membrane lipids that
results in cardiovascular collapse, multi-organ failure, and death.
• Endothelial cell injury and diffuse microvascular thrombosis are prominent features
of HS, leading to DIVC.
• HS and its progression to multi-organ dysfunction are due to a complex interplay
among the acute physiological alterations associated with hyperthermia (e.g.
circulatory failure, hypoxia, and increased metabolic demand), the direct
cytotoxicity of heat, and the inflammatory and coagulation responses of the host.
Management:
• Airway protection, adequate ventilation, and fluid resuscitation are essential.

• 100% oxygen should be administered initially and further oxygen delivery should be
guided by ABG results.
• Intubation and mechanical ventilation for patients with altered level of
conciousness, significant hypercapnia, or persistent hypoxia.
• Investigations: ABG, electrolytes, creatinine, BUN, CXR.
• Treat hypoglycemia, hyperkaelemia, and acidosis by standard methods.
• Seizures may be treated with BDZ.
• Prompt correction of hyperthermia by immediate cooling and support organ-system
function.
• Prehospital: water spray and airflow over the patient, ice packs to areas of high
blood flow (groin, neck, axilla).
• Survival and outcomes in HS are directly related to the time required to initiate
therapy and cool patients to ≤ 39°C.
Appendix C : Austere and Armed Conflict Environment
(summarized by Dr. Ahmad Fadhly bin Abu Bakar)
Introduction
Effective disaster management requires a different mindset that recognizes the need for
casualty population management and explicit healthcare worker safety.
“Adapt and overcome” is the model slogan for readiness.
Mass Casualty Care

A mass casualty event exists when casualties exceed the resources to provide complete
individual care, such as in situation of incomplete information and uncertainty regarding
event evolution.
The care paradigm shifts from the greatest good for the individual to the greatest good for
the greatest number of casualties, because of resource limitation and the situation.
Casualty disposition in disaster will intersect between casualty, resource and situation
consideration.
Casualty characteristic include immediately life threatening injuries, simplicity of

intervention to manage threats to life, injury severity and survivability.
Resource considerations include what is available for care such as space, staff, supplies,
systems and evacuation such as transportation and roads as well as the timeline for
resupply and casualty evacuation.
Situation involves event progression, secondary event and environmental conditions such
as time of day, weather and geography.
Tools for effective mass casualty care.

Incident command and triage are essential tools for effective mass casualty care
Incident command is a system management tool that transforms planning, operations,

logistics, and finance/administration to function for integrated and coordinated response.
The incident commander is responsible for the overall response to ensure the safety of
responders, save lives, stabilize the incident and preserve property and the environment .
Casualty clinical care falls under operations element of incident command.
Triage is a system decision tool used to sort casualties for treatment priority, given
casualty needs, resources and the situation.
The goal is to do “the best for most rather “everything for everyone”.
At each setting, an experienced acute care professional should serve as the triage officer.
The first triage decision is to define who is living and move these casualty to casualty
collection point.
The next triage decision determined who is critically injured for example who has
immediately life threatening injuries.
Triage system that uses motor response is helpful in finding these critically injured.
Triage decisions differentiate casualties to a greater degree when move to other setting
and health care facilities.
Each casualty category should have a defined area for collection and management.
The primary survey provides the framework for initial casualty assessment and
intervention.
Creative solutions involve improvisation of materials to address life threatening

physiology.
Initial airway intervention might stop at the side positioning and oral airway in
unconscious patient when equipment and resources are not vailable.
Circulation is addressed first by stopping the bleeding using tourniquets, scalp laceration
with rapid whip stitch and long bone extremity fractures can be reduced and splint.
Tactical combat casualty care
When under fire the priorities are return of fire and casualty safety.
When under fire stopping the bleeding with direct pressure, hemostatic gauze and
tourniquets provides effective temporary hemostasis.
ATLS principle are applied in this context as CAB intervention (circulation, airway,
breathing), note that assessment moves quickly through ABC to get to C with reevaluation
of A and B in safer environment.
War wounds
War injuries result from high velocity guns and high energy explosives.
High velocity gunshot wounds result from linear and cavitating (radial) energy of the round
and cause tissue devitalization and destruction beyond the path of the round.
High energy explosion causes multi dimensional blast injuries across four mechanism.
• Primary blast from supersonic pressure wave,

• Secondary blast from fragments,
• Tertiary blast from blunt or penetrating impact in the environment and
• Quaternary blast as burn or crush.
Wound management includes hemorrhage control and debridement of devitalized tissue.
Challenges in austere and armed conflict

environment
Communication remains a dominant challenge in disaster response across all

environments. Application of incident command improves communication. Duplicate and
rehearsed communication plans should be routinely practiced for disaster preparation.
Normal transportation are limited. Any vehicle can be used to move casualties.
Safety and security should be emphasized, planned and practiced in drills. For example
prevention of heat casualties includes acclimation for 3 to 5 days, alternating work and
rest cycles, and emphasis on regular fluid and electrolyte replacement.
Psychosocial issues predominate the long term recovery. Organizational practice, positive
behaviour, awareness and debriefing of the healthcare personnel can promote resilience
and prevent psychosocial stress disorders.
Appendix D: Disaster Management and Emergency Preparedness
(summarized by Dr. Nur Atikah bt Arifin)
Disasters
Incidents or events in which the needs of patients overextend or overwhelm the

resources needed to care for them
Multiple casualty incidents (MCIs)
• Patient care resources are overextended but are not overwhelmed
• It can stress local resources on identifying the patients with the most life
threatening injuries
Mass casualty events (MCES)
• Patient care resources are overwhelmed and cannot be immediately

supplemented
• Need to focus on identifying the patients with the greatest probability of
survival
Phases of disaster management
1. Preparation
2. Mitigation
3. Response
4. Recovery
1. Preparation
• The activities a hospital undertakes to identify risks, build capacity, and

identifying resources that may be used if a disaster occurs
o Simple disaster plans
▪ Training in disaster management
▪ Emergency preparedness appropriate to educational

preparation of the individuals being trained and to the specific
function they will be asked to perform
o Community planning
▪ Involve acute care specialists, local hospitals, local police,

public health, governmental agencies charged with HAZMAT
management and disaster preparation
• Frequently tested and reevaluated
• Provide for storage equipment, supplies and any special

resources based on HVA & all level of assistance, transportation
• Consider the urgent needs of patients already hospitalized for

conditions unrelated to the disaster
o Hospital planning
▪ Each hospital need to develop a disaster plan that reflects its

HVA
▪ Establish incident command post (ICP)
▪ Notification on duty and off duty personnel
▪ Preparation of decontamination, triage and treatment

areas
▪ Classification of in-hospital patient
▪ Checking of supplies and other materials (food, water,

power, communication)
▪ Activation of decontamination facilities and staff and

application of decontamination procedures
▪ Security precaution
▪ Public information centre and provision of regular

briefing to inform family, friends, the media and to the
government
o Departmental planning
▪ Every department must identify its medical response team in

advance, with specific instructions
o Personal planning
▪ Hospital can assist health care providers in meeting their

responsibilities to the hospital and to their families
o Hospital disaster planning
▪ All personnel must be trained in the principal of disaster

management, in both operational and medical components
2. Mitigation
• To lessen the severity and the impact of a potential disaster
o Incident command system (ICS)
▪ Establish clear lines of responsibility, authority, reporting and

communication for all personal
▪ Incident command (IC) responsible for all aspects of disaster
response
• Disaster is declared -> incident command post (ICP)

must be established in a secured location, distant from,
but with ready access to, the site of the primary care
activity (in warm zone) : bounded by external
perimeter, and must be sited uphill, upwind and
upstream of the search and rescue (SAR) area (hot
zone) bounded by internal perimeter, from which
decontamination corridors lead to casualty collection
point (CCP)
o Frequent disaster drill
3. Response
• Activities in treating victims of an actual disaster
o Activation of hospital disaster plan : ICS, management of disaster,

patient decontamination, triage, surge capacity and surge capability
▪ Pre hospital care : EMS response to disaster in 4 stages

• Chaos phase : 15-20 minutes
• Organizational phase : 1-2 hours
• Site clearing and evacuation stage
• Gradual recovery
▪ In-hospital care : IC need to ensure sufficient resources

• Mobilization and deployment of adequate staff, facilities
and equipment to meet anticipated needs
▪ Patient decontamination
▪ Disaster triage scheme : rapid identification of victims require
priority treatment
▪ Effective surge capability
▪ Alternative care standards : hospital needs to provide for the

largest possible number of patients with the maximum
acceptable care
▪ Traffic control system
▪ Specific needs population (children, elders, the disabled, the

dispossessed) : need specific response plans
4. Recovery
• The activities to help facilities resume operations after an emergency
• Involve the local public health system and acute care physicians
EXTRA TOPICS FROM OLDER EDITION (ATLS 8TH EDITION)
APPENDIX A: Injury Prevention * ATLS 8TH EDITION

(summarized by Dr Chin Wei Horng)
Prevention can be consider as
• Primary
Elimination of trauma incident completely.
Eg: stoplight at intersection, window guards to prevent falling, swimming pool fences.
• Secondary
Accept the fact that injury may occur, but serve to reduce the severity of the injury
sustained.
Eg: Safety belt, motorcycle helmet, playground safety surfaces.
• Tertiary
Reduces the consequences of injury after it has occurred.
Haddon’s matrix
Is an approach for primary and secondary prevention, consists of
- 3 principal factors (host, mechanism, environment)

- Prevent phase ( pre-event phase, event phase, post event phase)
Examples
Pre-event Event Post event

Host Avoidance of Use of safety belt Care delivered by
alcohol bystander
Vehicles Antilock brakes Deployment of Assessment of
airbag vehicles
characteristic that
may have
contributed to
event
Environment Speed limits Impact absorbing Access to trauma
barriers system
Four Es of injury prevention
- Education
Must direct to appropriate target group, persistent and linked to other approaches.
- Enforcement
Where compliances to injury prevention lags, legislation that mandates certain
behaviors and declares certain behavior illegal results in dramatic difference.
- Engineering
Advances in technologies and combination of enforcement give greatest long term
effect but more expensive. E.g.: Air bags, highway safety design.
- Economics
The association between laws and reduced facilities confirmed the utility of economic
incentives in injury prevention.
Developing an injury prevention program
1. Define the problem

2. Define causes and risk factor
3. Develop and test intervention.
4. Implement injury-prevention strategies
5. Evaluate impact
APPENDIX E : Tetanus Immunization * ATLS 8TH EDITION
(summarized by Dr Calyn Tan)
• Incubation period for tetanus : 4-21 days (average 10 days), in severe trauma 1-2
days
• All traumatic wounds should be considered at risk of development of tetanus

infection
• General principle for prophylaxis against tetanus :
1) Surgical wound care – prompt removal of devitalized tissue and foreign body
(* if puncture injury is present/ unable to perform proper wound debridement,

wound should be left open and not closed by sutures)
2) Passive immunization - 250 units of human tetanus immunoglobulin (TIG)
WOUND FEATURES AND TETANUS RISK
CLINICAL FEATURES OF NON-TETANUS PRONE TETANUS PRONE WOUND

WOUND WOUND
Age of wound < 6 hours >6 hours

Configuration Linear wound, abrasion Stellate wound, avulsion
Depth ≤ 1cm > 1cm
Mechanism of injury Sharp surface ( eg knife, Missile, crush, burn, frostbite
glass)
Signs of infection Absent Present

Devitalised tissue Absent Present
Contaminants ( eg dirt, Absent Present
feces, saliva, soil)
Denervated and/or Absent Present
ischemic tissue
TETANUS PROPHYLAXIS FOR INJURED PATIENTS
• History of administration of adsorbed tetanus toxoid unknown or < 3
Non-Tetanus-prone wound: ATT only
Tetanus- Prone wound: ATT and TIG
• History of administration of adsorbed tetanus toxoid ≥ 3
Non-Tetanus-prone wound: none ( if more than 10 years from last dose, ATT
indicated)
Tetanus-prone wound: none ( if more than 5 years from last dose, ATT indicated)
* For children < 7 years old, DPT (Diphteria-Pertusis-Tetanus) Vaccine preferred to Tetanus
toxoid alone
* For patients 7 years and older, Tetanus and Diphteria toxoids preferred to Tetanus toxoid
alone

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Chapter 1: Initial Assessment and management…………………………….. 2

Chapter 2: Airway and Ventilatory Management…………………………… 8

Chapter 4: Thoracic Trauma…………………………………………………………… 19

Chapter 5: Abdominal and Pelvic Trauma………………………………………. 29

Chapter 6: Head Trauma………………………………………………………………… 34

Chapter 7: Spine and Spinal Cord Trauma ……………………………………… 40

Chapter 8: Musculoskeletal Trauma………………………………………………. 48

Chapter 9: Thermal Injuries…………………………………………………………… 55

Chapter 10: Pediatric Trauma………………………………………………………… 59

Chapter 11: Geriatric Trauma…………………………………………………………. 73

Chapter 12: Trauma in Pregnancy and Intimate Partner Violence… 76

Chapter 13: Transfer to Definitive Care…………………………………………… 80

Initial assessment is the rapid assessment of the seriously injured

Initial assessment includes:

• Primary survey (ABCDEs)

• Adjuncts to primary survey and resuscitation

• Consider need for patient transfer

• Secondary survey (head-to-toe evaluation and patient history)

• Adjuncts to the secondary survey

• Continued postresuscitation monitoring and reevaluation

The preliminary assessment of a patient conducted in a systematic manner with the

- Rapid assessment for signs of airway obstruction and perform measures to

- Give high oxygen concentration to prevent hypoxia.

Jaw Thrust Gentle Chin Lift

- GCS </= 8 usually require placement of definitive airway

- Promptly identify airway compromise and recognize the potential for

2. Breathing and ventilation

- Determine the adequacy of ventilation and respiratory function

- Examine the patient by performing Inspection, palpation, percussion,

- these injuries need to be identified and may need intervention

3. Circulation with haemorrhage control

- hypotensive following injury must be considered to be hypovolaemia until

- Assess and identify whether shock is present

- Bleeding: External haemorrhage is identified and controlled during the primary

4. Disability (Neurologic evaluation)

- Rapidly establish patient’s level of consciousness, pupillary size and reaction,

- other factors to be considered in a patient with altered level of consciousness

• Ventilation (hypercarbia) • alcohol

• perfusion (Shock) • narcotics

- Patient should be completely undressed for thorough examination and

- Keep patient warm with warm blankets or warming device

Breathing/Ventilation/Oxygenation – Every injured patient should receive supplemental

Adjuncts to Primary Survey and Resuscitation

- Urinary and gastric catheters (However, urinary catheter should not be

- Other monitorings: Ventilatory rate and ABG, colorimetric CO2 detector/

- 3 primary Xrays (Chest, Pelvis, Cervical) and diagnostic studies

Consider need for patient transfer

Transfer process may be initiated immediately while additional evaluation and

History: (from patient, family, prehospital personnel)

M – Medications currently used

E – Events/Environment related to the injury

Physical Examination (Head to Toe examination)

Maxillofacial structures – Maxillofacial trauma that is not associated with airway

Perineum/Rectum/Vagina – examine perineum for contusions, hematomas, lacerations and

Minimise missed injuries by maintaining high index of suspicion.

Transfer to facility with higher level of care when indicated.

Records and legal considerations - documentation is very important. Consent is sought

Objectives of Airway and Ventilatory Management

1. Assessment of airway patency and ventilatory adequacy

2. Identify the cause of airway obstruction and inadequate ventilation.

3. Immediate management of airway obstruction by performing simple airway maneuvres using

4. Providing effective ventilation WHILE protecting the endangered cervical spine.

5. Providing a definitive airway when indicated

- other factors to be considered in a patient with altered level of consciousness 

• perfusion (Shock) • narcotics 