COMMITTEE ON TRAUMA

COURSE MANUAL | 11th Edition

Advanced Trauma
Life Support ®

(ATLS )®

Standardized Trauma Care

When Seconds Count
 Chair, Committee on Trauma: Jeffrey D. Kerby, MD, PhD, FACS
Medical Director, Committee on Trauma: Eileen M. Bulger, MD, FACS
ATLS Committee Chair: John P. Sutyak, MD, FACS
ATLS Senior Educator Advisory Board Co-Chair: Gontzal Tamayo, MD, MSc
ATLS Senior Educator Advisory Board Co-Chair: Alicia Ponton-Carss, MD, MSc, PhD
Associate Vice President, Trauma Programs, American College of Surgeons: Jean Clemency
Assistant Director, Trauma Education, American College of Surgeons: Alisa Nagler, JD, MA, EdD
Instructional Design Manager, American College of Surgeons: Julie Cwik, MSEd, MSLIS
Project Manager, American College of Surgeons: Meghan Hogan, DPT
Managing Editor, American College of Surgeons: Tony C. Peregrin

Eleventh Edition

Copyright© 2025 American College of Surgeons 633 N. Saint Clair Street

Chicago, IL 60611-3211
Previous editions copyrighted 1980, 1982, 1984, 1993, 1997, 2004, 2008, 2012, and 2018 by the American College of Surgeons.
Advanced Trauma Life Support® and ATLS® are registered trademarks of the American College of Surgeons.

© 2025 by the American College of Surgeons (ACS), Chicago, IL 60611-3295. All rights reserved. The contents of this publication may
be cited in academic publications, but otherwise may not be reproduced or transmitted in any form by any means without the express
written permission of the ACS. These materials may not be resold nor used to create revenue-generating content by any entity other than
the ACS without the express written permission of the ACS.

RESTRICTED USE: Contents of this publication are strictly prohibited from being uploaded, shared, or incorporated in any third-party
applications, platforms, software, or websites without prior written authorization from the ACS. This restriction explicitly includes, but is
not limited to, the integration of ACS content into tools leveraging artificial intelligence (AI), machine learning, large language models, or
generative AI technologies and infrastructures. Violation of this policy may result in immediate revocation of access, termination of user
accounts, or legal action as deemed appropriate by the ACS.

The American College of Surgeons, its Committee on Trauma, and contributing authors have taken care that the doses of drugs and
recommendations for treatment contained herein are correct and compatible with the standards generally accepted at the time of
publication. However, as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become
necessary or appropriate. Readers and participants of this course are advised to check the most current product information provided
by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and
contraindications. It is the responsibility of the licensed practitioner to be informed in all aspects of patient care and determine the best
treatment for each individual patient. Note that cervical collars and restriction of spine motion remain the current PHTLS standard in
transporting spine injury patients. If the collars and immobilization devices are to be removed in controlled hospital environments they
should be done so when the stability of the injury is assured. Cervical collars and immobilization devices have been removed in some of
the photos and videos to provide clarity for specific skill demonstrations. The American College of Surgeons, its Committee on Trauma,
and contributing authors disclaim any liability, loss, or damage incurred as a consequence, directly or indirectly, of the use and application
of any of the content of this Eleventh Edition of the ATLS Program.

THESE MATERIALS ARE PROVIDED “AS IS” WITH ALL FAULTS, AND ACS DISCLAIMS ANY AND ALL EXPRESS OR IMPLIED
REPRESENTATIONS AND WARRANTIES WITH RESPECT TO THE MATERIALS, INCLUDING ANY EXPRESS OR IMPLIED
WARRANTY OF MERCHANTABILITY, OR FITNESS FOR A PARTICULAR PURPOSE, ACCURACY, OR NON-INFRINGEMENT.

American College of Surgeons.

Printed in the United States of America.

Advanced Trauma Life Support® Course Administration and Faculty Guide Library of Congress Library of Congress Control Number:
2025901684

Last edited: 7/8/2025

ii Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Dedication

DEDICATION
We dedicate this 11th Edition of the Advanced Trauma Life Support (ATLS®) Course to James K.
Styner, MD, FACS, who passed away on January 22, 2024, at his home in Manila, Philippines, at the
age of 89 years. Dr. Styner, the developer (along with Paul E. Collicott, MD, FACS) and pioneer of
the ATLS Course, was born on July 22, 1934, in Los Angeles, California, and attended the University
of California–Irvine Medical School, going on to train in orthopaedic surgery. On February 17,
1976, the tragedy which led directly to the development of the ATLS® Course occurred; Dr. Styner,
his wife Charlene, and their four children were returning home to Lincoln, Nebraska, in a plane
piloted by Dr. Styner that crashed in a field in rural Nebraska. Following the crash, Dr. Styner
struggled to obtain appropriate early injury assessment and care for his family in the rural area. He
discussed with Dr. Ronald Craig, a family physician and friend, his concerns about the lack of initial,
organized trauma care that he and his children received, to which Dr. Craig famously replied, “You
have to train them before you can blame them.” With that, the concept for a course that would teach
the basics of trauma care was born.
After initial development, the course was subsequently brought into the American College
of Surgeons (ACS) as an educational program in 1980 and was quickly promulgated throughout
North America utilizing the regional structure of the Committee on Trauma (COT). ATLS has
now been expanded worldwide, having been translated into more than 10 different languages and
currently being taught to more than 50,000 learners each year in nearly 100 different countries. This
11th Edition of the Advanced Trauma Life Support Course pays tribute to the early focus on the
simultaneous identification and treatment of injuries, while advancing the assessment and skills
training provided through multiple resources and modalities for the ATLS learner. Our thanks to Dr.
Styner for showing the world how to better approach care of the injured patient.
In memory of Dr. Styner and his dedication to trauma education worldwide, the ACS Foundation
is accepting donations to the Trauma Education Fund to help defray the per learner cost of ATLS
and other trauma programs in low-resourced areas, and the further development or translations of
educational components for trauma education courses. Please visit www.facs.org/trauma-education-
fund to make a donation.

James K. Styner, MD, FAC

iii
 FOREWORDS JEFFREY D. KERBY, MD, PHD, FACS
The Advanced Trauma Life Support® (ATLS®) Course remains
PATRICIA L. TURNER, MD, MBA, FACS the gold standard for educating healthcare clinicians devoted to
the care of the injured patient around the world. The Committee
Our commitment to ensuring better outcomes for the injured on Trauma (COT) has been steadfast in its commitment to
patient is universal, but practice settings, available resources, continuously updating and refining ATLS education since the
languages, and mechanisms of injury are not. The combined release of the first ATLS manual 45 years ago. This 11th Edition
efforts of committed leaders from around the world have been of the course provides significant advancement, incorporating
successful in advancing the quality of the Advanced Trauma the latest evidence-based practices and recognizing the varied
Life Support® (ATLS®) Course by ensuring that course content resource environments where ATLS training can be applied to
is relevant in all countries and systems that possess any degree positively impact outcomes from traumatic injury.
of infrastructure to support trauma care. The ATLS Course was Today, more ATLS Courses are taught abroad than in the US,
designed to provide physicians and other healthcare professionals with robust training programs that are active in nearly 100 countries
with a concise and structured approach to assessing and managing around the world. In recognition of the global engagement in
patients with multiple injuries, using a common lexicon to move ATLS education, it was important that this edition of the course be
through the protocols. intentionally inclusive of the international community to influence
Over time, both the course content and modes of delivery its content. I am proud that the COT process for development of
have evolved to meet the varied needs of the learners. In the the ATLS 11th Edition convened contributors from more than 20
11th Edition, significant care and thought have been invested different countries representing the different care and resource
in recommendations that adapt or “flex” care when resources settings where ATLS education is provided. By continuing to
or practice settings differ from the original recommendations. provide a common “language” for multidisciplinary trauma care
This recognition of essential adaptability honors the continued clinicians around the world, ATLS offers a standardized approach
adoption of ATLS in varied settings around the world. The for optimizing the care of the injured patient that has been its core
principle of “Trauma Education for All” is implemented through guiding principle since its inception.
partnerships and promulgation models designed to facilitate Notably, while the care of the trauma patient has evolved over
adoption of the course into nearly any area that seeks to improve the years with new technological advancements, the core tenets of
its approach to the injured patient. ATLS continue to be applicable, such as the prompt identification
A trauma care team integrates many different healthcare of injury and prioritizing and addressing immediate life threats.
professionals, and the ATLS revision team reflects that breadth This 11th Edition is a fitting tribute to Dr. Styner’s original vision
across surgical and practice disciplines. The ACS Committee on and intent for this course. The enduring principles for caring for
Trauma is purposely inclusive to ensure the broadest engagement the injured patient in a course borne from tragedy following a
of interests, abilities, and lived experiences. As a result, more than tragic plane crash involving Dr. Styner and his family has become
200 volunteers from nearly 20 countries and numerous specialties a triumph for the many that have been saved from its teachings.
and disciplines contributed to this 11th Edition revision. Their I would like to thank the many surgeons, trauma care
thoughtful contributions and expertise, combined with innovative clinicians, educators, and ACS staff partners who invested their
delivery and teaching methods have helped ensure that the entire time and energy into this 11th Edition. Through countless hours
trauma care team completes their ATLS experience with critical of in-person meetings, teleconferences across many time zones,
knowledge and skills. We are indebted to the thousands of and individual content development, they have produced a
instructors who have taught this course to more than 1.5 million course that models education innovation, and is both current and
learners in nearly 100 countries to date. translatable to many different practice environments. This course
Collectively, these practitioners of evidence-based trauma care provides the base educational content for caring for the injured
have pursued excellence for nearly 50 years. As you engage with the patient, and when paired with the newly redesigned MyATLS®
newest iteration of ATLS, you too contribute to the advancement app for sustainment training, it will prepare frontline clinicians
of this enduring, vital purpose—ensuring optimal care for injured for the initial evaluation and stabilization of trauma patients. We
patients. Thank you and best wishes for your success. are excited to share this 11th Edition with you.

Patricia L. Turner, MD, MBA, FACS Jeffrey D. Kerby, MD, PhD, FACS
Executive Director & CEO Chair of the ACS Committee on Trauma
American College of Surgeons

iv Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Editorial Notes

Trauma patients often present with a wide range of complex

EDITORIAL NOTES
and variable conditions. The ATLS Course equips clinicians
Advanced Trauma Life Support® and ATLS® are proprietary with comprehensive knowledge and adaptable techniques
trademarks and service marks owned by the American College of that can be applied in diverse clinical environments, whether
Surgeons (ACS). Their use by individuals or entities outside the in a fully resourced urban hospital or an austere setting with
ACS Committee on Trauma (COT) organization for any goods or limited resources. The manual outlines safe and effective ways to
services requires prior approval from the ACS. Any reproduction approach the initial evaluation and management of the injured
of these marks, particularly in connection with the ACS ATLS® patient, ensuring that clinicians can provide competent
Course within the ACS COT, must include the appropriate care in a variety of contexts.
common law trademark symbol (™) to indicate ownership. The ACS acknowledges that there are multiple valid
Given the global reach of the ATLS® Course, this Edition of the approaches to medical care and procedures in this context.
ATLS Course Manual and accompanying materials may require Each clinician must use their own judgment in applying
adjustments in terminology to ensure clarity and comprehension ATLS principles to individual patients, considering their own
across different regions for all learners and instructors. experience and local standards of practice. The knowledge
The objective of the ATLS® Program is to save lives through and skills imparted by the ATLS® Course are designed to be
education. Fostering a safe and productive learning environment applicable and relevant across different clinical settings and a
is central to a successful educational endeavor. Engaging, learner- wide range of environments.
friendly content, such as interactive scenarios and visual aids, To remain current with evolving medical knowledge and
greatly enhances understanding and participation. Global innovations in trauma care, the ATLS® Course is regularly
standardized flexibility of these materials allows customization revised. These revisions incorporate new techniques and
of educational content to a variety of settings while maintaining safer approaches to care. The ACS COT is grateful for the
high-quality standards and best practices. This approach not only invaluable contributions made by ATLS® clinicians, instructors,
empowers healthcare professionals but also serves as a model for coordinators, and educators worldwide, whose outstanding input
delivering patient care with the highest levels of respect, dignity, have been essential to the continual improvement of the course
and excellence. Ultimately, this course provides learners with the and trauma care.
essential knowledge and skills to apply adaptable, best practices in
trauma care, promoting optimal patient outcomes for all.
ATLS is designed as an educational tool and is not intended COT LEADERSHIP
to replace clinical judgment or to serve as a measure of clinical
Jeffrey D. Kerby, MD, PhD, FACS
competence. Determining a clinician’s privileges to provide care
Chair, Committee on Trauma
or perform procedures is the responsibility of local governing
bodies, not the ACS.
Eileen M. Bulger, MD, FACS
Throughout this manual, the ACS Committee on Trauma will
Medical Director, Committee on Trauma
be referred to as the ACS COT or simply the Committee, while
State and Provincial Chairs will be denoted as S/P Chairs.
ATLS ELEVENTH EDITION STEERING
ACS COT AND ATLS ® COMMITTEE

Founded in 1912, the American College of Surgeons (ACS) John P. Sutyak, EdM, MD, FACS, MAMSE
has been committed to improving the care of surgical patients, ATLS Education Program Chair
establishing itself as the foremost professional organization in
North America dedicated to maintaining excellence in surgical Dany Westerband, MD, FACS
practice. In alignment with these goals, the ACS Committee on ATLS International Program Director
Trauma (COT) has continually worked to enhance trauma care
through the development of systems and educational programs. Kimberly T. Joseph, MD, FACS
The ongoing advancement of the Advanced Trauma Life Past-Chair ATLS Education Program
Support® (ATLS®) Course is a cornerstone of these efforts.
The ATLS® Course focuses on established, evidence-based Sharon M. Henry, MD, FACS
methods for the treatment of trauma patients. It provides Past-Chair ATLS Education Program
a systematic, concise approach to trauma care, one that is Past ATLS Global Course Director
easily recalled and applicable in emergent situations. This
methodology, which has become the hallmark of the ATLS®
Course, is invaluable to clinicians responsible for treating injured
patients. The principles outlined in this manual may also benefit
those who care for patients with non-traumatic conditions.

v
 SENIOR EDUCATOR ADVISORY BOARD SPECIAL ACKNOWLEDGEMENT
Co-Chair, Alicia Ponton-Carss, MD, MSc, PhD, Canada The Steering Committee, along with contributors, ATLS®
Co-Chair, Gontzal Tamayo, MD, MSc, Spain friends and family, and the ACS COT staff, expresses our deepest
Past-Chair, Debbie Paltridge, MHSc(Ed), FRACS(Hon), gratitude to Kathryn Bastion Strong. Known affectionately as
Australia Katie, she embodied a relentless passion for trauma education
Wesam Abuznadah, MBChB, FACS, FRCSC, Saudi Arabia and the ATLS® Course. Katie’s vision and commitment extended
Bill Boyer, DHSc, MS, US far beyond the traditional boundaries of education. She was a
Nori Bradley, MD, FACS, Canada bridge-builder, uniting people from diverse backgrounds and
Jeannette Capella, MD, MEd, FACS, US cultures, always seeking to expand the ATLS family
James Colquitt, PhD, RRT-ACCS, US to new frontiers.
Dianne Leverone-Baker, BA, HDE, Hons, South Africa Katie’s energy, warmth, and positive outlook were infectious.
Nisreen Hamza Maghraby, MBBS, FRCPC(EM), Saudi Arabia She approached every challenge with a constructive attitude,
Mayur Narayan, MD, MPH, FACS, US fostering collaboration and innovation among her colleagues.
Jesper Skytt-Kjaergaard, RN, ML, Denmark Her contributions were instrumental in launching the 11th
Elizabeth de Solezio (Liz), PHD, Ecuador Edition revision process, and her unwavering belief in the
Sook Muay Tay, MBBS, FAMS, MEd, Singapore importance of trauma care education continued to inspire all of
us throughout the development of this edition.
Katie’s legacy is felt in every page of this manual. She would
PAST ATLS® CHAIRS be proud to see how the program continues to evolve, expanding
its reach and impact globally. Her spirit lives on in the work
Paul E. Collicott, MD, FACS (1978-1987) we do, and we are profoundly thankful for the energy and
Max L. Ramenofsky, MD, FACS (1987-1992) dedication she brought to this endeavor.
Brent E. Krantz, MD, FACS (1992-1996) Thank you, Katie. Your light continues to guide and inspire.
Richard M. Bell, MD, FACS (1996-1999)
Steven N. Parks, MD, FACS (1999-2003) CONTRIBUTORS
Christoph R. Kaufmann, MD, FACS (2003-2007) George S. Abi Saad, MD, FACS, Beirut, Lebanon
John B. Kortbeek, MD, FACS (2007-2009) Walid AbouGalala, MD, MSc, Doha, Qatar
Karen J. Brasel, MD, FACS (2009-2014) Sasha Adams, MD, FACS, Houston, TX, US
Sharon M. Henry, MD, FACS (2014-2018) Saud Al Turki, MBBS, PhD, FACS, Riyadh, Saudi Arabia
Kimberly T. Joseph, MD, FACS (2018-2022) Adnan A. Alseidi, MD, EdM, FACS, San Francisco, CA, US
Stanley Nnamdi Anyanwu, MBBS, FACS, Ontisha, Anambra,
Nigeria
ACKNOWLEDGMENTS John H. Armstrong, MD, FACS, Ocala, FL, US
Richard A. Bagdonas, MD, FACS, West Islip, NY, US
This Eleventh Edition of the Advanced Trauma Life Support®
Andrew R. Baker, MBChB, FACS, Durban, KwaZulu Natal,
(ATLS®) Manual was developed through the collaborative efforts
South Africa
of dedicated members of the ACS COT, volunteer Fellows of
Liesl Baker, MbChB, FRCA, Durban, KwaZulu Natal,
the ACS, members of the international ATLS community, and
South Africa
various nonsurgical consultants. Each of these individuals
Abdullah Bakhsh, MBBS, FAAEM, Jeddah, Saudi Arabia
generously contributed their time and expertise in trauma care
Samir Ballouz, RN, Msc. IHM, Beirut, Lebanon
and medical education. The global scope of this project, which
Zsolt J. Balogh, MD, PhD, FACS, Newcastle, New South Wales,
brought together individuals from diverse contexts united by a
Australia
shared mission to improve trauma care, is a testament to the ATLS
Robert Barraco, MD, MPH, FACS, Allentown, PA, US
family’s remarkable commitment to the welfare of humanity.
Sabrina Bawa, MD, Los Angeles, CA, US
We extend our heartfelt appreciation to the families, significant
Jonathan Begley, MBBS, MPH, Melbourne, Victoria, Australia
others, children, and practice partners of ATLS instructors and
Andrew C. Bernard, MD, FACS, Lexington, KY, US
participants. Their support has been integral to the program’s
Cherisse D. Berry, MD, FACS, New York, NY, US
success, allowing clinicians to dedicate time away from homes
Tasce Bongiovanni, MD, FACS, San Francisco, CA, US
and practices to enhance their skills in trauma care. Without
Stephanie Bonne, MD, FACS, Hackensack, NJ, US
these sacrifices, the ATLS Course could not exist at the level of
William Boyer, DHSc, MS, Tallahassee, FL, US
excellence it has achieved.
Nori Bradley, MD, FACS, Edmonton, Alberta, Canada
Additionally, the Steering Committee gratefully acknowledges
Karen J. Brasel, MD, MPH, FACS, Lake Oswego, OR, US
the dedicated ACS COT Trauma Education staff, both past and
Miloš Buhavac, MBBS, FACS, Madison, WI, US
present, for their invaluable contributions. Their leadership
Jacqueline Bustraan, MSc, Leiden, Netherlands
and expertise in various areas such as adult learning principles,
Claire Cain Leidy, BA, Baltimore, MD, US
instructional design, graphic design, video production, project
Carlos Julio Calderon Salazar, MD, Bogota, Cundinamarca,
management, learner assessment, and program evaluation are
Colombia
crucial to the continued success and innovation of the ATLS
Scott Cameron, MD, FACEM, FACEP, Cleveland, OH, US
Course.

vi Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Acknowledgments

Lisa Cannada, MD, FACS, Jacksonville, FL, US Cheralyn J. Hendrix, MD, FACS, Baltimore, MD, US
Jeannette M. Capella, MD, MEd, FACS, Des Moines, IA, US Britani R. Hill, MD, FACS, Boise, ID, US
Patricia Caplinger, MD, FACOG, Boise, ID, US Ashley Hink, MD, MPH, Charleston, SC, US
Tatiana C.P. Cardenas, MD, MS, FACS, Austin, TX, US Horacio M. Hojman, MD, FACS, Boston, MA, US
Vicente Cardona-Infante, MD, FACS, Mexico City, Mexico Kyndra Holm, MSN, RN, Augusta, GA, US
Amanda M. Celii, MD, FACS, Oklahoma City, OK, US Roxolana Horbowyj, MD, FACS, Holmes, PA, US
Allyson Chapman, MD, FACS, San Francisco, CA, US Harold Ibagon, MD, Bogota, Colombia
Theresa Chin, MD, FACS, Orange, CA, US Raymond Iezzi, MD, MS, Rochester, MN, US
Ian Civil, MBChB, FACS(Hon), Auckland, New Zealand Eliesa A. Ing, MD, Portland, OR, US
Audra Clark, MD, FACS, Dallas, TX, US David Jacobs, MD, FACS, Charlotte, NC, US
James Colquitt, PhD, RRT-ACCS, Chicago, IL, US Mubeen Jafri, MD, FACS, Portland, OR, US
Mary Condron, MD, FACS, Bend, OR, US Randeep Jawa, MD, FACS, Stonybrook, NY, US
Mackenzie Cook, MD, FACS, Portland, OR, US Aaron R. Jensen, MD, FACS, Oakland, CA, US
Zara Cooper, MD, FACS, Boston, MA, US Maria F. Jimenez, MD, FACS, Bogota, Colombia
Jaime Cortés-Ojeda, MD, FACS, San José, San José, Costa Rica Joey Johnson, MD, FAAOS, FACS, Birmingham, AL, US
Marie Crandall, MD, FACS, Jacksonville, FL, US Laura S. Johnson, MD, FACS, Atlanta, GA, US
Alisa M. Cross, MD, FACS, Oklahoma City, OK, US Joakim Jørgensen, MD, FACS, Oslo, Oslo, Norway
Alfred Croteau, MD, FACS, Hartford, CT, US D'A ndrea Joseph, MD, FACS, FCCM, New York, NY, USA
Rafael Curado, MD, FACS, Campinas, São Paulo, Brazil Catherine Juillard, MD, FACS, Los Angeles, CA, US
Scott D’Amours, MD, FACS, Liverpool (Sydney), NSW, Lillian S. Kao, MD, FACS, Houston, TX, US
Australia Krista L. Kaups, MD, MSc, FACS, Fresno, CA, US
Arman Dagal, MD, FRCA, MHA, Seattle, WA, US Katherine Kelley, MD, FACS, Philadelphia, PA, US
Brian J. Daley, MD, FACS, Knoxville, TN, US David King, MBBS, FRACS, Adelaide, South Australia, Australia
Joao Carlos Das Neves Pereira, MD, PhD, Paris, Ile de France, Denise Klinkner, MD, FACS, Minneapolis, MN, US
France Nelly-Ange Kontchou, MD, MBA, Nashville, TN, US
Airton Leonardo de Oliveira Manoel, MD, PhD, Muscat, Oman Meera Kotagal, MD, FACS, Cincinnati, OH, US
Rochelle A. Dicker, MD, FACS, San Francisco, CA, US Anastasia Kunac, MD, FACS, Tucson, AZ, US
Jody DiGiacomo, MD, FACS, Ocean Grove, NJ, US Andrew Kurmis, MD, FACS, Adelaide, South Australia, Australia
Michael W. Dingeldein, MD, FACS, Cleveland, OH, US Sangeeta Lamba, MD, MS-HPEd, Newark, NJ, US
John Donkersloot, MD, Lansing, MI, US Rachel Landisch, MD, Memphis, TN, US
Alon Duby, MBBCh, West Midlands, United Kingdom Dianne Leverone-Baker, Durban, South Africa
Lauren M. Dudas, MD, FACS, Morgantown, WV, US Carol A. Lin, MD, FACS, Los Angeles, CA, US
Thomas K. Duncan, DO, FACS, Ventura, CA, US Luis E. Llerena, MD, FACS, Tampa, FL, US
Julie A. Dunn, MD, MS, FACS, Loveland, CO, US Sarvesh Logsetty, MD, FRCSC, FACS, Winnipeg, Manitoba,
Richard P. Dutton, MD, MBA, FASA, Dallas, TX, US Canada
Wassim El-Habre, MD, FACS, Wynnewood, PA, US Nisreen Maghraby, MBBS, FRCPC(EM), Al-Khobar,
Paula Ferrada, MD, FACS, Richmond, VA, US Saudi Arabia
Joseph D. Forrester, MD, FACS, Redwood City, CA, US Muhammad A. Majid, FRCS (Edinburgh), FCPS, Dhaka,
Paa Kobina Forson, MD, MPH, Kumasi, Ashanti, Ghana Bangladesh, Bangladesh
Claus-Robin Fritzemeier, Dr. Med, Düsseldorf, North Rhine- Ajai Malhotra, MBBS, FACS, Burlington, VT, US
Westphalia, Germany Samuel P. Mandell, MD, FACS, Dallas, TX, US
Alberto Garcia, MD, MSc, Cali, Valle, Colombia Alicia J. Mangram, MD, FACS, Paradise Valley, AZ, US
Diogo Garcia, MD, FACS, São Paulo, São Paulo, Brazil Courtney Mangus, MD, Ann Arbor, MI, US
Subash Gautam, MBBS, FACS, Fujairah, Fujairah, United Arab Patrizio Mao, MD, FACS, Turin, Italy
Emirates Katherine Martin, MBBS, BMedSci, FRACS, Traumatology,
Jaclyn Ann Gellings, MD, Milwaukee, WI, US Melbourne, Australia
Lawrence M. Gillman, MD, MMedEd, FACS, Winnipeg, M. Travis Maynard, PhD, Fort Collins, CO, US
Manitoba, Canada Robert A. Mazzoli, MD, FACS, Steilacoom, WA, US
Agnieszka Gizzi, MA, England, United Kingdom Joseph McIsaac, MD, MBA, Port St. Lucie, FL, US
James Gould, RN, NRP, Richmond, VA, US Kathryn McKendy, MD, FRCSC, Montreal, Canada
Tristan Griffiths, MBBS, FACEM, Rockhampton, Queensland, Allison McNickle, MD, FACS, Las Vegas, NV, US
Australia Alain Mefire, MD, Buea, Cameroon
Lucas L. Groves, MD, FACS, Nashville, TN, US Christopher Michetti, MD, FACS, Largo, MD, US
Tishia Gunton, MSW, LISW-S, Columbus, OH, US David J. Milia, MD, FACS, Milwaukee, WI, US
Shailvi Gupta, MD, FACS, Baltimore, MD, US Anna N. Miller, MD, FACS, St. Louis, MO, US
Jennifer Gurney, MD, FACS, San Antonio, TX, US Michael Moelmer, MD, Lynge, Denmark
Mark Hamill, MD, FACS, Omaha, NE, US Alexis Moren, MD, FACS, Portland, OR, US
Emily Hathaway, MD, FACS, San Antonio, TX, US Anne C. Mosenthal, MD, FACS, Burlington, MA, US
Kimberly M. Hendershot, MD, FACS, Birmingham, AL, US Angela Muoki, MD, MMed (PRAS), Nairobi, Kenya

vii
 Michael Mwachiro, MBChB, FACS, Nairobi, Kenya Søren Steemann Rudolph, MD, Copenhagen, Denmark
Bindi Naik-Mathuria, MD, FACS, Houston, TX, US Deborah Stein, MD, FACS, Baltimore, MD, US
Mayur Narayan, MD, MPH, FACS, New Brunswick, NJ, US George Tagkalakis, RN, Patras, Achaia, Greece
John Ng, MD, FACS, Portland, OR, US Gontzal Tamayo, MD, MSc, Bilbao, Basque Country, Spain
Peter Nielsen, MD, San Antonio, TX Leah C. Tatebe, MD, FACS, Chicago, IL, US
David M. Notrica, MD, FACS, FAAP, Phoenix, AZ, US Errington C. Thompson, MD, FACS, Huntington, WV, US
Nikiah Nudell, PhD(c), MS, NRP, Loveland, CO, US Areti Tillou, MD, FACS, Los Angeles, CA, US
Kathleen O’Connell, MD, MPH, FACS, Seattle, WA, US D Roxanne Todo, MD, FACS, Bronx, NY, US
Daniel Ojuka, MBBS, FACS, Nairobi, Kenya Julio L. Trostchansky, MD, MBA, FACS, Montevideo, Uruguay
William Oley III, MD, FAAFP, Red Lodge, MT, US Faiz Tuma, MD, MEd, FRCSC, Hamilton, Ontario, Canada
Bryant W. Oliphant, MD, MBA, FACS, Detroit, MI, US Julie Valenzuela, MD, FACS, Miami, FL, US
Debbie Paltridge, MHSc (Ed), FRACS (Hon), Newport, Elizabeth Vallejo de Solezio, PhD, Quito, Ecuador
Queensland, Australia Jesus Alberto Varela, MD, Madrid, Spain
Neil Parry, MD, FACS, London, Ontario, Canada Candice Vasconcelos, MD, FACS, Rio de Janeiro, Brazil
Nirav Patel, MD, FACS, Phoenix, AZ, US Rodrigo Vaz-Ferrara, MD, PhD, FACS, Sao Paulo, Brazil
Maria Paulsen, RN, BSN, Seattle, WA, US Felipe Vega-Rivera, MD, FACS, Mexico City, Mexico
Ruben Peralta, MD, FACS, Doha, Qatar Vishwajit Verma, FRCA, FFCIM, Doha, Qatar
Michael Person, MD, FACS, Sioux Falls, SD, US Derek S. Wakeman, MD, FACS, Rochester, NY, US
Rodney Petersen, FRANZCOG, MBA, Canberra, Australian Jarrod Wall, MBBCh, FACS, Springfield, IL, US
Capital Territory, Australia Jill B. Watras, MD, FACS, Norwalk, CT, US
Tam Pham, MD, FACS, Seattle, WA, US Sonlee D. West, MD, FACS, Albuquerque, NM, US
Renato Poggetti, MD, FACS, Sao Paulo, Brazil Catherine Wilson, MSN, ACNP-BC, Nashville, TN, US
Travis Polk, MD, FACS, Los Angeles, CA, US Mark Wilson, PhD, FRCS (SN), London, England, United
Alicia Ponton-Carss, MD, MSc, PhD, Canada Kingdom
Howard Pryor, MD, FACS, Houston, TX, US Robert J. Winchell, MD, FACS, New York, NY, US
Glen Purcell, RN, BSN, Vancouver, British Columbia, Canada Christoph Woelfel, MD, PhD, Neuwied, Rhieland Palatinate,
Boonkit Purt, MD, Tacoma, WA, US Germany
Tyler Putnam, MD, FACS, Springfield, MA, US Roderick Wouters, MD, FEBS, Eelderwolde, Drenthe,
John Ragheb, MD, FACS, Miami, FL, US Netherlands
Amulya Rattan, MS (Gen Surg), MCh, Liverpool, New South Michael Wyatt, MD, FRACS (Orth), Palmerston North,
Wales, Australia Manawatu, New Zealand
Martin Richardson, MBBS, MS, FRACS, Melbourne, Australia Anna Yang, MD, Memphis, TN, US
Sandro B. Rizoli, MD, PhD, FACS, Doha, Qatar Brad J. Yoo, MD, FACS, New Haven, CT, US
Vicente E. Rodriguez-Maya, MD, FACS, Loja, Loja, Ecuador Ian Young, MD, FRACS, Melbourne, Victoria, Australia
Alan P. Rossi, MD, FACS, Richmond, VA, US Luis Miguel Zamora-Duarte, MD, Mexico City, Ciudad de
Mathieu Rousseau, MD, Stanford, CA, US Mexico, Mexico
Andres Rousselot, MD, Capital Federal, Buenos Aires, Ahmad Zeineddin, MD, Washington, DC, US
Argentina
Daniel Rubaclava, MS, MSPH, Houston, TX, US
Andres M. Rubiano, MD, PhD(c), Cali, Valle del Cauca, ACS TRAUMA STAFF PARTNERS:
Colombia Meghan Baker, Program Manager, Trauma Education
Rosa Aurora Ruiseco, Mexico City, Mexico Jean Clemency, Associate Vice President, Trauma Programs
Babak Sarani, MD, FACS, Washington, DC, US Julie Cwik, MSEd, MSLIS, Instructional Design Manager
Thomas J. Schroeppel, MD, FACS, Aurora, CO, US Jack Daly, MHA, Business Administrator, Trauma Education
Kevin Schuster, MD, MPH, FACS, New Haven, CT, US Programs
Mark F. Scott, MD, FACS, Duluth, MN, USA Olivia Grierson, Program Manager, Trauma Education Projects
Mark W. Siboe, MBChB, FACS, Nairobi, Kenya Rebecca Hill, Visual Designer
Kristen Sihler, MD, FACS, Iowa City, IA, US Meghan Hogan, DPT, Project Manager, Trauma Education
Dionne A. Skeete, MD, FACS, Iowa City, IA, US Programs
Jesper Skytt-Kjærgaard, RN, M.L., Frederiksberg, Alisa Nagler, JD, MA, EdD, Assistant Director, Trauma
Hovedstaden, Denmark Education
Tone Slåke, RN, Drøbak, Akershus, Norway Tony Peregrin, Managing Editor, Special Projects
Guy Slater, MBBS, FRCS, Maidstone, Kent, United Kingdom Brandon Schawel, MA, Instructional Designer
Alison Smith, MD, FACS, New Orleans, LA, US Mark Wieber, Medical Illustrator
Randi N. Smith, MD, FACS, Atlanta, GA, US
Jason A. Snyder, MD, FACS, St. Louis, MO, US

viii Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Overview

and advanced technology. Others are at facilities where access

PREFACE TO THE ELEVENTH EDITION
to diagnostics, specialists, blood products, and medications is
The ATLS® Course establishes an organized and systematic limited or never available. Various local, state, regional, provincial,
approach for evaluation and treatment of patients, promotes and national agencies regulate medical practices. In recognition
standards of care, and recognizes injury as a global healthcare of these variations in practice settings and resources, the concept
challenge. The approach is easily remembered by any clinician, of standardized flexibility was developed to promote adaptability
irrespective of practice specialty and experience, and can be of ATLS Course content. A Flex workgroup was formed. They
rapidly recalled under the stress, anxiety, and intensity of the reviewed all materials through the lens of resource availability
trauma resuscitation process. ATLS provides a common language and ensured that the ATLS Course would be applicable to a wide
for all clinicians that facilitates team and transfer communication. variety of practice environments.
The course offers learners a foundation for evaluation, ATLS learners are members of a multitude of cultures and
treatment, education, and quality assurance, introducing a backgrounds. To be successful, an educational program must
system of trauma care that is measurable, reproducible, and foster an environment conducive to learning that includes safe
comprehensive. The ATLS Program has had a positive impact and impactful terms, wording, and images in all products. For
on the care of injured patients worldwide. This effect is a result effective transfer of the life-saving knowledge, skills, and attitudes
of the improved skills and knowledge of course participants and of ATLS, every learner must be able to visualize themselves as an
promotion of trauma system development. Over an almost half- accepted member of the course. Therefore, another workgroup
century of ATLS instruction and revisions, course content has examined materials for application across varied cultures to
evolved as techniques, technology, and the science of traumatology promote learning and ensure content and delivery are relevant to
have advanced. Moving forward, the ATLS Program will continue all ATLS learners.
to refine its content to meet the needs of the many clinicians
involved in the care of the trauma patient. CHANGES IN COURSE STRUCTURE AND
CONTENT
ELEVENTH EDITION REVISION PROCESS Treat the greatest threat to life first remains the central tenet of
The 11th Edition revision process maintained the global the ATLS mnemonic. This threat is determined by the specifics
participation and positive direction of prior versions. Through of the clinical situation. For certain patients, rapid control of
multiple meetings with ATLS® subcommittee members and exsanguinating external hemorrhage is lifesaving. Military and
surgical education experts, a typical ATLS learner was defined. civilian research has validated application of this approach before
This learner is beginning their journey in emergency trauma initiating airway maneuvers in appropriate clinical contexts.
care, frequently serving as a clinician outside of a level 1 Trauma Therefore, the letter x was added at the beginning of the well-
Center. However, clinicians practicing in an advanced center will known ATLS mnemonic. ABCDE is now xABCDE.
also benefit from the knowledge and skills transmitted in ATLS. Injury and injury care occur within environments that
Every aspect of the course was reviewed and revised, including extend beyond the boundaries of the medical facility and beyond
this manual, interactive discussion materials, skills station the limits of physical interventions. Opportunities for injury
curricula, online modules, video resources, initial assessment prevention and trauma system development may be recognized
stations, multiple-choice test questions, MyATLS® app content, by the events of patient injury. A holistic approach recognizes the
and policies. All aspects were recreated to meet the needs of the dignity and value of every individual and is mandatory to obtain
ATLS learner and to adhere to the best medical and educational optimal outcomes. Effective communication within the care team,
evidence available. As the field of traumatology has expanded to the patient and family members, and during transfer prevent
markedly since the inception of ATLS, the risk of cognitive morbidity and mortality.
overload was recognized and mitigated. Although new content Even an introductory discussion of each topic applicable to
was added, an increase in course length was avoided by attention acute management of the injured patient would overwhelmingly
to objectives, integration of concepts, and provision of pre-course increase ATLS Course length and induce cognitive overload.
materials. Therefore, topics have been integrated like they occur in clinical
Twenty-four content areas were identified. Global trauma practice, wrapped within the context of an injured patient. ATLS®
leaders, representing more than 20 countries, volunteered and refers to this integration of physical, communication, holistic,
were distributed among the content areas to provide a diverse prevention, systems, and other aspects of clinical interaction as
perspective on each topic. A surgical educator was a key member the weave concept.  Figure 1 illustrates the weave concept.
of each team. These workgroups met frequently and developed In the 10th Edition, skills stations were successfully reorganized
new learning objectives for each content area. Product leads into Airway, Breathing, Circulation, and Disability to promote
translated these goals to create each ATLS Course product. practice and retention of the critical ABCDE mnemonic. In this
ATLS® clinicians treat patients in a wide variety of practice 11th Edition, reorganization is extended to the entire course to
environments. Some are at facilities with seemingly unlimited enhance learner cognition and performance of xABCDE during
continuous access to personnel, blood products, specialty care, initial assessment.

ix
 The critical importance of team dynamics and communication
 Figure 1: Content Weave. During interactive discussions,
is recognized with relocation from a 10th Edition appendix to an
online modules, skills station scenario discussions, and
other aspects of the ATLS® Course, the concepts of xABCDE
expanded Section I chapter titled Resuscitation Team Function
(x, control of external exsanguinating hemorrhage; and Communication. Volume resuscitation for burn injury follows
A, Airway; B, Breathing; C, Circulation; D, Disability; E, American Burn Association recommendations. Geriatric Trauma
Exposure and environment) are reinforced and topics is renamed Trauma in the Older Adult and expanded to reflect
of trauma systems, communicating serious news and the increasing importance of injury and frailty in this vulnerable
goals of care, injury prevention, humanization (patient- population. An updated transfer communication mnemonic of
centered care), disaster events, cultural appropriateness, S-xABCDE-BAR is introduced in Transfer to Definitive Care.
teamwork, and flexible options in practice environments Section II covers many of the weave subjects. Trauma Systems
are presented within a clinical story.
is an entirely new chapter that introduces the topic to ATLS®
learners. Concepts related to triage and disaster management
are moved from appendices to an expanded chapter. Three new
chapters, Injury Prevention, Trauma-Informed Care and Social
Determinants of Health, and Communicating Serious News in the
Acute Setting address these critical subjects in trauma care.
Section III includes topics on specific injuries and injury
patterns. Thoracic, Abdominopelvic, and Genitourinary Trauma
reviews specific injuries not previously discussed and updates
on topics that were present in the 10th Edition Abdominal and
Pelvic Trauma chapter. Penetrating Trauma is a new chapter
providing education regarding unique management challenges of
these injuries. Both Ocular Injuries and Injury in Combat Zones
and Austere Environments were updated and moved from the
appendices.

UPDATES TO INTERACTIVE DISCUSSION

SESSIONS AND ONLINE MODULES
Corresponding to the manual rearrangement, the interactive
sessions follow the progression of the Section I titles. All materials
have been rewritten and redesigned with updated cases, images,
and instructor notes. Standardized flexibility permits instruction
that best serves the local practice resources.
This manual is organized into three major sections.
The ATLS Hybrid Course has been extremely successful
Section I is titled Evaluation, Management, and Resuscitation of
since initial release. In many centers it is the primary format for
the Injured Patient. This first section includes subjects related
ATLS instruction. The program provides self-paced interactive
to initial assessment, both primary and secondary surveys.
instruction designed as an educational substitute for many of the
The xABCDE topics are extensively discussed along with team
in-person interactive discussions. Learners complete all designated
function, communication, thermal injury, special populations,
modules before arriving for in-person group discussions, skills
musculoskeletal trauma, and transfer.
training, and course assessments, shortening the in-person
Control of exsanguinating hemorrhage is addressed as
portion of the ATLS Course. The Hybrid ATLS program increases
a separate topic. Airway instruction has added emphasis on
flexibility for the learners and training centers while providing
resuscitation of patients in shock prior to administration of
similar training.
medications for intubation. Most subjects discussed in the 10th
The 11th Edition Hybrid ATLS is a redesign and redevelopment
Edition Thoracic Trauma chapter are included in Breathing and
of the ATLS online modules. An amazing team of instructional
Ventilation Assessment and Management with others transitioned
design professionals developed the modules based on the
to a new Thoracic, Abdominopelvic, and Genitourinary Trauma
interactive discussion materials. Thus, the modules more closely
chapter. The importance of pain management in thoracic injury
mimic an in-person course and provide an educationally equivalent
is emphasized. Content from the 10th Edition Shock chapter is
experience. Learning is enhanced with up-to-date, evidence-
present and expanded in Circulation Assessment and Volume
based interactivity and learning methods. Design is consistent and
Resuscitation. The 10th Edition topics of Head Trauma and Spine
more appealing to the learner. Modules utilize multiple methods
and Spinal Cord Trauma are addressed in a combined Disability:
of interaction, employing current best practices in instructional
Neurological Assessment and Management chapter. Exposure and
design. Following the concept of standardized flexibility, optional
Environmental Threats in the Primary Survey moves the subjects
modules were developed that deliver instruction on material in
of Hypothermia and Heat Injuries from the appendices.
manual Sections II and III.

x Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Course Overview

CHANGES IN SKILLS STATIONS AND VIDEO COURSE OVERVIEW

RESOURCES
Skills Stations in the 11th Edition have a similar organization COURSE GOALS
to those of the 10th Edition. The stations are organized along the
The content and skills presented in this course are designed
xABCDE mnemonic. All materials were re-created and include
to assist clinicians in providing emergency care for trauma
integrated supply lists and instruction slide sets.
patients. Though the concept of the golden hour is not a fixed
Practice is important to the success of ATLS skill instruction.
period of 60 minutes, it emphasizes the urgency necessary for
However, time constraints present challenges to providing quality
successful treatment of injured patients. This concept symbolizes
evidence-based stepwise training. The 11th Edition takes an
the positive impact of rapid assessment and proper management
innovative path to improve skills training. The six steps in technical
on the morbidity and mortality associated with injury. The
skill acquisition are: know (cognition), see (visualization),
ATLS® course provides the essential information and skills for
hear (instructor verbalization), say (learner verbalization), do
clinicians to identify and treat life-threatening and potentially life-
(practice), and review (feedback). The 11th Edition relocates
threatening injuries under the extreme intellectual and emotional
performance of the first three steps (know, see, and hear) from the
pressures associated with the care of these patients. The ATLS
in-person skills stations to pre-course learning. This relocation
Course is applicable to clinicians in a variety of situations. The
was accomplished by creation of new mandatory pre-course video
ATLS Course supplies its learners with a safe and reliable method
resources to clearly introduce specific skills. Thus, in-person skills
for the immediate treatment of injured patients and the basic
stations are primarily devoted to practice and feedback.
knowledge necessary to:
New for the 11th Edition is standardized flexibility in skill
• Assess a patient’s condition rapidly and accurately.
options. The Airway station may focus on intubation or, for
localities when intubation is limited to certain specialty clinicians, • Resuscitate and stabilize patients according to priority.
management prior to intubation. Space is provided in the schedule • Determine whether the specific management needs of a
for optional stations to meet local educational needs such as burn patient exceed the resources of a facility and/or the capability
resuscitation or an enhanced pediatric experience. Management of a clinician.
of prehospital tourniquets and tourniquet conversion has been
added. Triage and disaster management is completely reimagined • Arrange appropriately for a patient’s interhospital or
and follows the principles of the Disaster Management and intrahospital transfer.
Emergency Preparedness course. • Ensure that optimal care is continually provided, and the level
of care does not deteriorate at any point during evaluation,
CHANGES IN LEARNER ASSESSMENT resuscitation, or transfer.
A global workgroup of experts in the construction of multiple-
choice questions was formed. This workgroup developed a
new bank of questions based on this manual and the objectives COURSE OBJECTIVES
developed by the content groups. These questions were vetted Upon completing the ATLS Course, the participant will be
by several groups for appropriateness. Revised initial assessment able to:
patient scenarios with critical treatment decisions were constructed • Practice the concepts and principles of initial assessment
based on the new xABCDE mnemonic and other content changes. through the primary and secondary patient surveys.
MYATLS® APP • Establish management priorities in a simulated trauma
situation.
The MyATLS® mobile app was redesigned and redeveloped
to provide an enhanced user-friendly learning experience. It • Initiate primary and secondary management necessary for the
allows easy access to critical trauma care information in the form emergency management of acute life-threatening conditions
of chapter summaries, videos, step-by-step skill guides, medical in a simulated patient.
calculators, and checklists. New practice features have been • Apply the key principles of effective team function and
added, including quiz questions, flashcards, and interactive case communication in a simulated trauma scenario.
scenarios. The new content management system allows for easy
• Practice primary and secondary initial assessment surveys of
edits to existing content and enables new content to be added on
a patient with simulated injuries.
a regular basis.
ATLS decision-making tools and content can be in the • Perform control of simulated life-threatening external
clinician’s pocket. The MyATLS mobile app can be found in the hemorrhage.
Apple Store and Google Play by searching for “ACS MyATLS.” For • Evaluate and manage airway patency and initiate assisted
additional information visit www.facs.org/myatls. ventilation in a simulated trauma patient.
• Demonstrate the procedure of surgical/incisional airway.
• Identify clinical and radiographic signs of thoracic injuries.
• Describe the steps for a needle or finger thoracostomy and
chest tube insertion for pleural decompression in a simulated
scenario.
xi
 • Assess and treat a simulated patient in shock with recognition • Demonstrate appropriate professional conduct and fulfill any
of life-threatening hemorrhage. other requirements as described in the ATLS policy manual,
• Perform intraosseous access in a simulated patient. other statements, or as determined by ATLS directors and
offices.
• Apply an external pelvic compression device for hemorrhage
due to pelvic fracture in a simulated trauma patient.
NEED FOR ATLS® -THE GLOBAL EPIDEMIC
• Evaluate the abdomen for hemorrhage with either peritoneal OF TRAUMA
lavage or ultrasound (FAST).
• Evaluate and treat a simulated patient with brain injury, The social and economic impact of injury is staggering. Even
including use of the Glasgow Coma Scale score. during the two years of the COVID-19 pandemic, unintentional
injury was the fourth-leading cause of death in the United States
• Demonstrate protection of the spinal cord and radiographic according to data from the CDC. For the most recent year of data,
and clinical evaluation of spine injuries in a simulated trauma 2022, unintentional injury returned to the third-leading cause
scenario. of death, trailing only cardiovascular disease and malignancy.
• Perform musculoskeletal trauma assessment and management Unintentional injury remains the leading cause of death for ages
in a simulated scenario. 1-44, third leading for ages 45-65, and in the top eight beyond age
• Apply the principles of trauma assessment of simulated older 65.
adults, pediatric patients, and pregnant patients. Despite markedly improved prevention and medical care, the
prevalence of death due to injury in the US rose from 2001 to
2022. Injury is frequently viewed as more prevalent in a younger
population. However, injury deaths in those older than 65 have
COURSE STRUCTURE also been rising as illustrated in  Figure 2. The percentage of
The ATLS Course emphasizes application of new knowledge
and skills. Application leads to acquisition. Instruction occurs  Figure 2: US Incidence of Death Due to Injury in Ages
in a variety of venues: self-study, small groups, and larger More Than and Less Than 65. Rates are reported as
deaths per 100,000. Rising incidence of death from all
groups. Didactic material is primarily supplied in this manual.
injury etiologies in both age groupings. Age less than one
Application of didactic knowledge occurs through interactive year excluded.
discussions and online modules. Cognitive and psychomotor
skills are introduced and practiced in the skills stations. A variety
of artificial, inanimate, and animate models may be employed
as determined by the teaching center. Initial patient assessment
stations provide opportunities to practice primary and secondary
survey procedures. Live actors, mannikins, and other simulations
may be used.
For successful ATLS Course completion, at minimum the
learner is required to:
• Complete all pre-course materials including a pretest and
visualization of all videos. Specific centers may have other
pre-course requirements.
• For ATLS Hybrid Courses, complete all modules prior to
the in-person portion of the course. The timeframe for
completion is determined by the center.
Institute for Health Metrics and Evaluation (IHME). GBD Compare Data
• Attend the entire in-person portion of the course per the Visualization. Seattle, WA: IHME, University of Washington, 2024. Available
from http://vizhub.healthdata.org/gbd-compare. (Accessed October 16, 2024).
center’s schedule.
• Actively participate in all interactive discussions. injury deaths due to falls in the older population has increased
from approximately 30% in 2001 to almost 50% in 2022. Overall,
• Successfully perform all core psychomotor and cognitive skills
for all age groups, suicide deaths have doubled, and homicides
as assessed by an ATLS instructor and/or Course Director.
have remained relatively unchanged in the same time period.
• Reach a passing grade on a multiple-choice examination. To place the magnitude of death due to injury in perspective,
• Perform at an adequate level on an evaluation initial during 2020 and 2021 deaths due to injury were 58-fold higher
assessment scenario simulation as determined by an ATLS than deaths due to HIV and equal to approximately 75% of the
instructor and/or Course Director. deaths due to COVID-19. Thus, from a purely mathematical
standpoint, injury mortality in the US is like a COVID-19-severity
• Demonstrate appropriate skills, knowledge, and attitudes epidemic every 16 months. Strikingly, since 2018, firearm injuries
throughout the ATLS Course. surpassed transport-related injuries as a leading cause of death in
ages 1 to 25.  Figure 3 illustrates this change.

xii Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Need for ATLS - The Global Epidemic of Trauma

Injury occurs in younger age groups and the economic impact

 Figure 3: US Injury Death Rates for Ages 1 – 25. Rates
is astounding. For 2019, the U.S. estimated total lifetime costs
are reported as deaths per 100,000 and include intentional
and unintentional injuries. The blue line depicts all
for medical care, lost productivity, lost quality of life, and loss
transport-related deaths excluding drowning-associated of life was $4.2 trillion or 19% of the US GNP. For perspective,
deaths. Red line depicts all firearm-related deaths. the entire US Government budget for 2023 was $7.6 trillion. The
estimated cost for injury is close to the combined amount the US
government budgeted for Medicare, Social Security, Defense, and
Health in 2023.
Multifaceted prevention efforts have decreased the global
rate of road traffic fatalities. These efforts include legislation,
safer vehicles, improved restraint systems, road construction
and design, education, and improved medical care. Although all
economic groups have experienced a reduction in death rates, the
magnitude of improvement is less in lower-income economies. As
illustrated in  Figure 5, more affluent nations have experienced
a nearly 50% reduction in the incidence of road traffic fatalities
while the less-prosperous nations have experienced only a 30%
improvement from 1980 to 2022.

 Figure 5: Road Traffic Deaths. Incidence of road traffic

fatalities globally and distributed into higher and lower
economic groups. Solid line is the global rate. Red line is
Institute for Health Metrics and Evaluation (IHME). GBD Compare Data
Visualization. Seattle, WA: IHME, University of Washington, 2024. Available the rate for low-, low-middle-, and middle-income nations
from http://vizhub.healthdata.org/gbd-compare. (Accessed October 16, 2024). combined and population weighted. Blue line represents
the combined and population-weighted incidence for high-
and high-middle income nations.
According to the World Health Organization (WHO), more
than eight people die every minute from injuries or violence. This
is approximately 4.4 million deaths per year from all ages and
economic groups.  Figure 4 illustrates estimated total injury
death rates by country as of 2021. Road traffic injuries are the
leading cause of death for ages 5–29. According to the WHO,
low- and middle-income countries have about 60% of the world’s
vehicles, yet 93% of deaths occur in these countries.

 Figure 4: 2021 Estimated Injury Deaths per 100,000.

Institute for Health Metrics and Evaluation (IHME). GBD Compare Data
Visualization. Seattle, WA: IHME, University of Washington, 2024. Available
from http://vizhub.healthdata.org/gbd-compare. (Accessed October 12, 2024).

Institute for Health Metrics and Evaluation (IHME). GBD Compare Data
Visualization. Seattle, WA: IHME, University of Washington, 2024. Available
from http://vizhub.healthdata.org/gbd-compare. (Accessed October 16, 2024).

xiii
 simplicity, and practicality. The importance and relevance of the
ATLS® HISTORY, DEVELOPMENT, AND
project were recognized by many at Lincoln General Hospital.
GLOBAL DISSEMINATION Soon, a multispecialty panel of private practice physicians, nurses,
and educators joined the group, including Irvene Collicott, RN,
TRAGEDY AND CHALLENGE (née Hughes), Lincoln Area Mobile Heart Team nurses, and the
In February 1976, a tragedy occurred that directly led to LMEF.
improved global trauma care. Dr. James K. Styner, MD, FACS, an
orthopaedic surgeon and pilot, was flying his family home from A NEW WAY TO THINK
California to Lincoln, Nebraska. In poor weather with reduced Prior to ATLS®, medical schools taught the same approach
visibility, the plane struck a row of trees and crash landed in a to be used to treat injured patients and patients with any other
rural Nebraska cornfield.  Figure 6 is a photo of the crash site. undiagnosed medical condition. An extensive history of present
Dr. Styner’s wife, Charlene, was ejected and died instantly. Dr. illness and past medical history was followed by a head-to-toe
Styner sustained serious injuries. Three of their children suffered physical examination. Once a differential list was created, studies
critical injuries, and another sustained minor injuries. were performed to uncover the diagnosis. When all pertinent
laboratory and imaging studies were completed and reported,
 Figure 6: Photograph of 1976 Plane Crash.
treatment was finally initiated. Although this approach was usually
adequate in most situations, it did not satisfy the needs of patients
suffering immediately life-threatening injuries. The approach
required change. Clinicians needed a new way to think.
The group identified three revolutionary underlying concepts
that have stood the tests of time, practical application, and medical
advances:
• Treat the greatest threat to life first.
• Never allow the lack of definitive diagnosis to impede the
application of an indicated treatment.
• A detailed history is not essential to begin the evaluation of a
patient with acute injuries.
Experience from large centers in the late 1970s indicated that
injury mortality occurred in certain reproducible time frames.
For example, the loss of an airway killed more quickly than the
loss of the ability to breathe. The latter caused death more quickly
than internal loss of circulating blood volume. The presence
Despite his own painful injuries, Dr. Styner extricated his
of an expanding intracranial mass lesion may be the next most
children from the plane and walked to a road in search of help.
lethal problem. Based on data and expert opinions at the time,
Eventually, he was able to stop a passing car and obtain assistance.
a simple recall method, ABCDE, was created to remember the
Dr. Styner and his children were driven to the local hospital.
specific ordered evaluations and interventions to be followed:
However, the doors were locked. Although physicians ultimately
arrived and the Styner family was transferred to Lincoln, Dr. • Airway with restriction of cervical spine motion
Styner was dissatisfied with the timeliness and quality of care that • Breathing
he and his family received. It was inadequate by the day’s best
standards. • Circulation, stop bleeding
After taking time to recover from his loss and the physical • Disability or neurologic status
and mental injuries suffered by himself and his children, Dr.
• Exposure (undress) and Environment (temperature control)
Styner repeatedly questioned the inconsistent state of early injury
care in the United States. He is quoted as saying, “When I can Applying principles of adult education, the group set forth to
provide better care in the field with limited resources than what develop a course geared to primary care physicians who do not
my children and I received at the primary care facility, there is manage multiply injured patients on a frequent basis. This new
something wrong with the system, and the system has to be educational program combined didactic sessions, skill practice,
changed.” and simulation. With the help of Southeast Nebraska Emergency
Dr. Ronald Craig, a family medicine specialist who was Medical Services, the first course was delivered in February 1978
a friend and treating physician of the Styners, responded by and a second course shortly after. Both courses were successfully
noting, “You have to train them before you blame them.” Dr. John conducted in rural Nebraska hospitals with positive feedback.
Upright, PhD, EdD, director of the Lincoln Medical Education  Figure 7 illustrates the first ATLS manual.
Fellowship (LMEF), encouraged Drs. Styner and Craig. They
began to develop a trauma care protocol rooted in emerging data,

xiv Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | ATLS History, Development, and Global Dissemination

 Figure 7: Pages from First ATLS® Manual with Course Schedule.

THE TAKE OFF Trauma Education Office, Chicago, Illinois.

Although professional medical educators have been part of
In the fall of 1978, the immediate past Chair of the COT and
ATLS Course design and revision since the beginning, their
the current President of the American College of Emergency
special value was formalized with creation of the Senior Educator
Physicians were both from Nebraska. The new COT Chair was
Advisory Board (SEAB) in 2010. SEAB members come from all
from Oklahoma. During the weekend of the Oklahoma - Nebraska
regions of the COT, creating a group with worldwide knowledge
college football game, these leaders were able to observe an ATLS®
and understanding of cultural impact on learning. Critically
Course. At the next spring COT meeting in Houston, a COT
important to high quality of ATLS Courses are high-quality
member surgeon from Lincoln, Dr. Paul “Skip” Collicott, MD,
instructors. The ATLS Instructor Course provides instructor
FACS, introduced the concept of ATLS® to the COT leadership.
candidates with the opportunity to learn educational theory,
Later that year, a course was conducted in Lincoln for the US
actively apply it within the ATLS Course, and achieve ATLS
COT Region Chiefs. The course was adopted by the ACS Board
instructor status.
of Regents in 1980. With this ACS and COT support, ATLS was
In parallel with the ATLS Course is the Prehospital Trauma
rapidly and enthusiastically disseminated nationally that year
Life Support (PHTLS) Course, sponsored by the National
through the infrastructure of the COT regional committees.
Association of Emergency Medical Technicians (NAEMT). The
PHTLS course, developed in cooperation with the ACS COT, is
GLOBAL ADOPTION
based on the concepts of the ACS ATLS Course and is conducted
In 1981, Toronto and Vancouver hosted ATLS Courses. As a for emergency medical technicians, paramedics, and nurses who
pilot project, the ATLS Course was presented outside of North are clinicians of prehospital trauma care. The Society of Trauma
America in 1986 in the Republic of Trinidad and Tobago. The ACS Nurses offers Advanced Trauma Care for Nurses (ATCN), which
Board of Regents gave permission in 1987 for promulgation of the is also developed in cooperation with the ACS COT. The ATCN
ATLS Course in other countries. Members of the Royal College and ATLS Courses are conducted in parallel. Nurses audit the
of Australasia attended a course in San Diego, CA, in 1987. This ATLS didactic sessions and then participate in separate skills
group and others developed the infrastructure to manage the stations. The benefits of having both prehospital and in-hospital
course. Courses were held in Melbourne and Sydney in 1988, trauma personnel speaking the same language are obvious.
supported by both Australian and US faculty. Also in 1988, ATLS
expanded to Europe through the UK Royal College of Surgeons. ATLS IMPACT
The principles of ATLS were rapidly accepted by the global
ATLS training in a developing country has resulted in a
community. Within 15 years, courses had been delivered on
decrease in injury mortality. Lower-per-capita rates of deaths from
six continents. With growing interest in ATLS outside of North
injuries are observed in areas where clinicians have ATLS training.
America, the COT recognized that to have a more significant
In one study, a small trauma care team led by a doctor with ATLS
impact on trauma care worldwide, global regional leadership
experience had equivalent patient survival when compared with
was necessary. Therefore, new regions were added to the COT
a larger team with more doctors in an urban setting. In addition,
structure.
there were more unexpected survivors than fatalities. There is
These regions promulgated ATLS® within defined areas of
abundant evidence that ATLS training improves knowledge base,
global responsibility, extending the life-saving program into
psychomotor skills, application of skills in resuscitation, and the
regions distant from North America. Currently, more than half
confidence and performance of clinicians. The organizational
of all ATLS® instruction occurs outside North America and these
and procedural skills taught in the course are retained by course
are the fastest-growing ATLS regions. Introduction of the ATLS®
participants for at least 6 years, which may be the most significant
course may be requested by a recognized surgical organization or
impact.
ACS Chapter in another country by corresponding with the COT

xv
 SUMMARY
Starting from a personal tragedy and one death, ATLS has
impacted millions. The course has evolved from a typewritten
manual conceived on a dining room table to a global workforce
delivering and revising high-quality, evidence-based, and
multimedia in-person and hybrid courses. Each year the number
of courses and participants increases and, so far, more than 1.5
million clinicians have been trained around the world. ATLS
materials have been translated into a multitude of languages.
Innovative solutions have allowed transmission of ATLS concepts
to remote, economically disadvantaged, and conflict areas with
the primary goals of saving lives and reducing suffering. Although
originally designed as a course for doctors, the ATLS family now
includes a variety of trauma clinicians.
The ATLS method is accepted as a standard for one safe
way of early trauma care, whether the patient is treated in an
isolated rural area or a state-of-the-art trauma center. The ATLS
Course emphasizes rapid assessment and concurrent treatment
of severely injured patients. Care starts at the time of injury and
continues through initial assessment, lifesaving interventions,
reevaluation, stabilization, and, when needed, transfer. The course
consists of a pre-course test, pre-course videos, online modules
and or interactive discussions, scenario-driven skills stations,
discussions, practice of lifesaving skills, simulations, a post-course
test, and a final proficiency evaluation. Upon completing the
course, participants should feel confident in implementing the
cognitive and psychomotor skills taught in the ATLS Course.

xvi Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Table of Contents

TABLE OF CONTENTS
DEDICATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
FOREWORDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
EDITORIAL NOTES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
ACS COT AND ATLS®. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
COT LEADERSHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
ATLS ELEVENTH EDITION STEERING COMMITTEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
SENIOR EDUCATOR ADVISORY BOARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
PAST ATLS® CHAIRS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
PREFACE TO THE ELEVENTH EDITION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
COURSE OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
NEED FOR ATLS - THE GLOBAL EPIDEMIC OF TRAUMA.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
ATLS® HISTORY, DEVELOPMENT, AND GLOBAL DISSEMINATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

SECTION I: EVALUATION, MANAGEMENT, AND RESUSCITATION OF THE

INJURED PATIENT (xABCDE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: Initial Assessment: Primary Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2: Resuscitation Team Function and Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 3: x: Control of eXsanguinating External Hemorrhage.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Chapter 4: Airway Assessment and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Chapter 5: Breathing and Ventilation Assessment and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Chapter 6: Circulation Assessment and Volume Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter 7: Disability: Neurological Assessment and Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 8: Exposure and Environmental Threats in the Primary Survey.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Chapter 9: Thermal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 10: Musculoskeletal Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Chapter 11: Trauma in the Pediatric Patient.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Chapter 12: Trauma in the Older Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Chapter 13: Trauma in the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Chapter 14: Initial Assessment: Secondary Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Chapter 15: Transfer to Definitive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

SECTION II: TRAUMA SYSTEMS AND PATIENT-CENTERED CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Chapter 16: Trauma Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Chapter 17: Triage and Disaster Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Chapter 18: Injury Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Chapter 19: Trauma-Informed Care and Social Determinants of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Chapter 20: Communicating Serious News in the Acute Trauma Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

SECTION III: SPECIFIC INJURIES AND INJURY PATTERNS – SPECIAL CONSIDERATIONS.. . . . . . . . 287
Chapter 21: Thoracic, Abdominopelvic, and Genitourinary Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Chapter 22: Penetrating Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Chapter 23: Ocular Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Chapter 24: Injury in Combat Zones and Austere Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

xvii
 Chapter 1: Initial Assessment: Primary Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2: Resuscitation Team Function and Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 3: x: Control of eXsanguinating External Hemorrhage.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Chapter 4: Airway Assessment and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Chapter 5: Breathing and Ventilation Assessment and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Chapter 6: Circulation Assessment and Volume Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter 7: Disability: Neurological Assessment and Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 8: Exposure and Environmental Threats in the Primary Survey.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Chapter 9: Thermal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 10: Musculoskeletal Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Chapter 11: Trauma in the Pediatric Patient.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Chapter 12: Trauma in the Older Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Chapter 13: Trauma in the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Chapter 14: Initial Assessment: Secondary Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Chapter 15: Transfer to Definitive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

xviii Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | ATLS 11th Edition

SECTION I

Evaluation, Management,
and Resuscitation of the
Injured Patient (xABCDE)
2 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

Initial Assessment:
Primary Survey

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Identify an appropriate sequence of priorities 6. Recognize patients who would benefit

for the primary survey of injured patients from transfer to another facility for
using a standard algorithm definitive management
2. Describe the options and best practices for 7. Discuss the importance of team dynamics and
resuscitation during the primary survey communication in the initial assessment of
trauma patients
3. Describe the management techniques
employed during the primary survey 8. Explain the importance of using humanistic,
trauma-informed care principles when
4. Identify primary survey adjuncts to the
interacting with patients and families
assessment and management of injured
patients and recognize the contraindications 9. Describe an approach to communicating serious
to their use news in the acute trauma setting
5. Discuss the importance of reevaluating 10. Describe the “3 Es” approach to conceptualizing
a patient frequently during the initial injury prevention
assessment and how that might affect
resuscitation and management

3
 1
 Figure 1-1: Elements of the Initial Assessment. The
initial assessment is a continuum that starts with the Primary
and Secondary Surveys and proceeds through Definitive
Care. Frequent re-evaluation throughout is critical.

CHAPTER STATEMENT
The primary survey in the ATLS® initial assessment allows the
clinician to identify and treat life-threatening traumatic injuries by
applying a systematic approach using the eXsanguination, Airway,
Breathing, Circulation, Disability, and Exposure (xABCDE)
algorithm. In the setting of a critically injured patient, a specific
diagnosis or complete medical history is not necessary prior to the
initiation of treatment and resuscitation.
Proper execution of the primary survey also incorporates
principles of high-level team functioning and communication,
trauma-informed/humanistic care, resource assessment,
empathetic and culturally sensitive patient/family communication,
• Prehospital evaluation and management
and attention to opportunities for injury prevention.
• Triage
INTRODUCTION • Preparation at the healthcare facility,
including resource assessment
The primary goals of the initial assessment and management • Primary survey (xABCDE) with immediate
of an injured patient are to identify life-threatening injuries, resuscitation of patients with life-threatening injuries
establish and implement treatment priorities, reevaluate patient
• Adjuncts to the primary survey and resuscitation
status frequently to adjust treatment plans, and arrange for
definitive care. This is done using principles of effective teamwork • Reevaluation and continued post-resuscitation monitoring
and by treating the patient with dignity and respect. • Secondary survey (head-to-toe evaluation and
This chapter will examine the primary survey. Information patient history) and adjuncts
about the secondary survey is detailed in Chapter 14, Initial • Determination of need for transfer
Assessment: Secondary Survey.
• Definitive care
Three important concepts greatly enhance the ability to
manage injured patients, regardless of the environment where The primary and secondary surveys are repeated frequently
care is provided: to identify any change in the patient’s status that indicates the
1. Treat the greatest threat to life first. need for additional intervention. The assessment sequence
2. The lack of a definitive diagnosis should not delay the presented in this chapter reflects a linear, or longitudinal,
application of urgent treatment. progression of events. In an actual clinical situation, however,
3. An initial, detailed history is not essential to begin the many of these activities occur simultaneously. The longitudinal
evaluation and treatment of a patient with acute injuries. progression of the assessment process allows clinicians
To be applicable in a global environment and assist an opportunity to mentally review the progress of actual
inexperienced clinicians, ATLS follows a defined order of trauma resuscitation. ATLS principles guide the assessment
evaluation, recognizing that experienced trauma clinicians and resuscitation of injured patients. Judgment is required
will frequently use the steps as a mnemonic rather than an to determine which procedures are necessary for individual
unwavering sequence. patients, as not all procedures may be indicated.
When treating injured patients, clinicians rapidly assess injuries
and institute life-preserving therapy. Because timing is crucial, a
systematic approach that can be rapidly and accurately applied is
essential, and in general, life threats should be addressed when
they are identified. This approach, termed the “initial assessment,”
includes the following elements ( Figure 1-1):

4 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

PREHOSPITAL EVALUATION AND ORGANIZING THE TEAM

MANAGEMENT
Preventable adverse events in trauma care may occur during
In settings in which a prehospital infrastructure exists, care the initial resuscitation and are often due to impaired situational
of injured patients is improved when prehospital personnel and awareness and communication failures. This reality reinforces the
institutions work together with healthcare facilities to develop critical need for effective teamwork during the initial assessment.
protocols and expectations. Even when a formal prehospital Regardless of the size and composition of the trauma team, there
network is lacking, healthcare facilities may work with public are five key concepts that can be applied to team function and
health systems, civic entities, or law enforcement to educate communication:
potential field responders on what care can be rendered at the 1. Leadership and followership
scene. 2. Attention and awareness
The Prehospital Trauma Life Support Course, developed by 3. Verbal communication
the National Association of Emergency Medical Technicians in 4. Decision-making
cooperation with the American College of Surgeons (ACS), is a 5. Task management and coordination
well-established course for EMTs, paramedics, nurses, physician
Team members, including the team leader, should have clearly
assistants, physicians, and other prehospital practitioners. ACS’s
assigned roles, and all team members should be able to relate
Stop the Bleed® course trains nonmedical persons who may be
information without fear of judgment.
immediate responders to trauma situations to perform basic
Regularly occurring reevaluations and communication
bleeding control techniques. These educational activities may be
points, such as “huddles” or “time outs,” can assist in this process.
useful in augmenting prehospital capabilities regardless of setting.
Important examples of these include:
The ACS Committee on Trauma (COT)—with the support
of the National Highway Traffic Safety Administration, Health •P  rearrival huddle: In this type of communication, the
Resources and Services Administration’s Maternal and Child known information regarding the patient is discussed and
Health Bureau, and Emergency Medical Services for Children plans are formulated for how to address likely injuries, what
program—led the development of the 2021 National Guidelines equipment and personnel should be available, and what roles
for the Field Triage of Injured Patients. This document uses team members should assume.
physiologic status, mechanism of injury, and EMS judgment to • Systematic handover at the time of patient arrival: In
identify seriously injured patients that might benefit from care at this scenario, information is often communicated via a
a trauma center ( Figure 1-2). standardized process, such as the Mechanism, Injuries,
Symptoms and Signs, and Treatment (MIST) tool ( Figure 1-3).
INITIAL ASSESSMENT AT THE HEALTHCARE When critical care is being delivered or will be
FACILITY—PREPARATION, ASSESSMENT, immediately required (e.g., chest compressions or treatment
AND MANAGEMENT of imminent respiratory failure), the report is delivered in
an abbreviated fashion while care is delivered.
Witnessing the suffering of a trauma victim and facing complex
•H
 uddle/reassessment at a defined point in the
care decisions are stressful and daunting situations. However,
resuscitation: In this scenario, a time out lead by the leader
knowledge, training, and practice instill the skills and confidence
is proven to promote united mental models and team
to manage emotions and save lives.
situational awareness.
Clinicians should also remember that many people have a
•D
 eparture handover: In this scenario, when the patient
history of prior trauma in their lives, and that this trauma may
leaves the resuscitation area to receive definitive care, use
not be physical—it may be emotional, psychological, spiritual,
of a systematic method of communication, such as the
or social. Those previous experiences can affect the way patients
S-xABCDE-BAR ( Figure 1-4) method, is recommended
and families interact with the healthcare system. For example, a
(see Chapter 15, Transfer to Definitive Care for additional
prior unpleasant experience in a hospital may cause anxiety or
information).
other emotions in a patient, which might be misinterpreted as
noncompliance or hostility. In situations in which there is no notification of patient arrival,
Preparation for the arrival of an injured patient requires there will obviously be no opportunity for a prearrival huddle and
organizing the team and assessing hospital resources. In the possibly no arrival handoff. In such situations, it is incumbent
setting of a multiple or mass casualty incident, it will also require upon the team leader to quickly assign roles, verbalize initial plans,
reviewing and implementing the institution’s triage and disaster and request that all team members report clearly what they notice
management procedures. as the resuscitation begins. The team leader should also indicate at
All team members should use appropriate Personal Protective what juncture the first huddle/time out/reassessment will occur.
Equipment (PPE) to reduce the risk of illness or injury from After a resuscitation is completed, the team should make every
exposure to biological, chemical, and other hazards that might effort to conduct a debriefing to acknowledge what went well and
be encountered in the healthcare environment. At minimum, this identify opportunities for improvement. Debriefing also allows
should include eye and face protection, gloves, and gowns; as for peer support after particularly stressful resuscitations.
transpired in the recent pandemic, there may be circumstances in For more detailed information about concepts in team
which more specialized equipment is necessary. functioning in the acute trauma setting, see Chapter 2,
Resuscitation Team Function and Communication.

5
  Figure 1-2: National Guideline for the Field Triage of Injured Patients. Use of the guideline can
ensure that trauma patients are transported to the most appropriate facility for treatment. Source:
Newgard CD, Fischer PE, Gestring M, et al. National guideline for the field triage of injured patients:
Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg. 2022
Aug 1;93(2):e49-e60.

National Guideline for the Field Triage of Injured Patients

RED CRITERIA
High Risk for Serious Injury

Injury Patterns Mental Status & Vital Signs

• Penetrating injuries to head, neck, torso, All Patients

and proximal extremities • Unable to follow commands (motor GCS score <6)
• Skull deformity, suspected skull fracture • RR <10 or >29 breaths/min
• Suspected spinal injury with new motor or sensory loss • Respiratory distress or need for
• Chest wall instability, deformity, or suspected flail chest respiratory support
• Suspected pelvic fracture • Room-air pulse oximetry < 90%
• Suspected fracture of two or more proximal long bones
Ages 0-9 years
• Crushed, degloved, mangled, or pulseless extremity • SBP < 70 mm Hg + (2 x age in years)
• Amputation proximal to wrist or ankle
Ages 10-64 years
• Active bleeding requiring a tourniquet or wound • SBP < 90 mm Hg or
packing with continuous pressure
• HR > SBP

Patients meeting any one of the above RED criteria should be transported to the highest-level
trauma center available within the geographic constraints of the regional trauma system.

YELLOW CRITERIA
Moderate Risk for Serious Injury

Mechanism of Injury EMS Judgment

• High-Risk Auto Crash Consider risk factors, including:

— Partial or complete ejection • Low-level falls in young children (age ≤5 years) or
— Significant intrusion (including roof) older adults (age ≥65 years) with significant head
•> 12 inches occupant site OR impact
•> 18 inches any site OR • Anticoagulant use
•N eed for extrication for entrapped patient • Suspicion of child abuse
— Death in passenger compartment
• Special, high-resource healthcare needs
—C hild (age 0-9 years) unrestrained or in unsecured
child safety seat • Pregnancy >20 weeks
—V ehicle telemetry data consistent with severe injury • Burns in conjunction with trauma
• Rider separated from transport vehicle • Children should be triaged preferentially
with significant impact (e.g., motorcycle, to pediatric capable centers
ATV, horse, etc.) If concerned, take to a trauma center
• Pedestrian/bicycle rider thrown, run over,
or with significant impact
• Fall from height >10 feet (all ages)

Patients meeting any one of the YELLOW CRITERIA WHO DO NOT MEET RED CRITERIA should be
preferentially transported to a trauma center, as available within the geographic constraints of
the regional trauma system (need not be the highest-level trauma center).

6 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

RESOURCE-APPROPRIATE CARE
 Figure 1-3: Mechanism, Injuries, Symptoms and Signs
and Treatment (MIST) Systemic Handover Tool. The MIST ATLS presents one safe way to manage an injured patient.
tool allows for a standardized, systematic way to manage Specific types of injuries, clinician training, resources, practice
handovers from prehospital personnel to the in-hospital environments, geographic location, and a multitude of other
team. Adapted from Iedema R, Ball C, Daly B, et al. Design
factors differ for an individual resuscitation. ATLS recognizes
and trial of a new ambulance-to-emergency department
handover protocol: ‘IMIST-AMBO’. BMJ Quality that modifications of protocols are necessary to meet these
& Safety. 2012;21:627-633. patient- and site-specific variables and provide optimal outcomes.
Facilities should know what their capabilities are before patients
arrive—this includes personnel, equipment, and expertise. This
is particularly important when making decisions about patient
disposition. Prior arrangements with other facilities for the
Mechanism of injury/ transfer of patients with injuries exceeding clinician and/
medical complaint or institutional capabilities allow efficient progress toward
definitive care for patients.
Clinicians should strive to be aware of best practice
Injuries/information recommendations regarding elements of initial trauma care
related to the complaint while acknowledging that protocols and procedures for
management must use existing resources. Issues and gaps that
are identified are opportunities for advocacy, and results of
Signs and symptoms team debriefing may be useful in approaching those responsible
including GCS score and for allocation of resources.
vital signs
TRIAGE AND DISASTER PREPAREDNESS
Treatment given and Hospitals should regularly practice preparing for multiple and
trends noted
mass casualty situations. Detailed information about the process
of triage and disaster preparedness may be found in Chapter 17,
Triage and Disaster Management.

 Figure 1-4: Transfer Communication Using the S-xABCDE-BAR Method. A comprehensive, systematic transfer
communication tool assures that all relevant information is relayed to personnel assuming care of the injured patient.
Adapted from Shahid S, Thomas S. Situation, Background, Assessment, Recommendation (SBAR) communication tool for
handoff in health care—A narrative review. Saf Health. 2018;4(7).

S-xABCDE-BAR Communication Tool

Acronym Intent Information

S-xABCDE Situation-x-Airway-Breathing-Circulation- •R  eferring clinician and facility

• Name, age, gender, mechanism of injury
Disability-Exposure/Environment
• Indication for transfer
• x-emergency hemorrhage control interventions
(e.g. pressure, packing, or tourniquet)
•A  irway: assessment, intervention
•B  reathing: assessment, intervention
•C  irculation: assessment, intervention
•D  isability: assessment, intervention
•E  nvironment/Exposure: assessment, intervention

B Background • AMPLE history

• Fluid/blood administered
• Medications (date and time)
• Images
• Reduction/splints

A Assessment Current Status:

• Physiology
• Response to interventions
• Likely injuries

R Recommendation • Transport mode and capability

• Transport interventions
• Other necessary interventions

7
 mirror those used in the field: direct pressure, wound packing,
PRIMARY SURVEY WITH SIMULTANEOUS
and application of a tourniquet where appropriate. Clinicians
RESUSCITATION should become familiar with when tourniquet application is
most helpful. Small soft-tissue wounds with superficial arterial
The initial assessment, starting with the primary survey,
bleeding may often be managed with direct pressure alone. In
uses a systematic approach that identifies, prioritizes, and treats
contrast, extremity wounds with rapid bleeding from large vessels
life-threatening conditions. The sequence of care, known as the
or with multiple sites of bleeding (e.g., “mangled” extremities)
xABCDE algorithm, is described in  Table 1-1.
can often only be controlled with application of a tourniquet.
CONTROL OF EXSANGUINATING EXTERNAL Hemorrhage from any extremity wound that does not respond
to direct pressure or wound packing should have a tourniquet
HEMORRHAGE applied. Early placement of tourniquets in the setting of massive
External hemorrhage is often associated with extremity wounds extremity wound hemorrhage is associated with improved
and fractures. However, soft-tissue injuries anywhere on the outcomes.
body may result in significant external blood loss. One frequently Not all exsanguinating external hemorrhage can be addressed
overlooked site of ongoing external blood loss is the scalp. The with a tourniquet. Significant blood loss from injuries to the neck,
mainstays of external hemorrhage management in the hospital pharynx, and mouth must initially be treated with direct pressure

 Table 1-1: The Primary Survey and Simultaneous Resuscitation. The xABCDE algorithm
provides clinicians with a systematic approach to identifying, prioritizing, and treating life-
threatening conditions. Following the sequence lessens the chance of missed injuries and
encourages efficient evaluation.

Key Causes and Issues

x exsanguinating Massive bleeding from open extremity

and other wounds
external hemorrhage

A Airway Inability to maintain the airway patency

due to direct injury, altered mental
status, shock

B Breathing Compromise of oxygenation and/or

ventilation due to direct injury, shock

C Circulation 1. P
 resence of shock from hemorrhagic,
neurogenic, cardiogenic, or other
sources

2. Hemorrhage control

3. R
 estoration and maintenance
of end-organ perfusion

D Disability Injury to the central nervous system

• Traumatic brain injury

• Spinal cord injury

E Exposure/ 1. E
 xposure to prevent missed injuries
while maintaining patient dignity
Environment
2. M
 aneuvers to prevent hypothermia

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 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

and wound packing and often require rapid definitive control via should prepare accordingly. Equipment for surgical airway (also
angiography or operation. Significant bleeding from scalp wounds known as “Equipment for incisional airway should be available,
may be managed with direct pressure but may also require control along with appropriate adjuncts”) should be available, along
with sutures or clips. Complex scalp wounds should be carefully with appropriate adjuncts (e.g., gum-elastic bougie introducer).
monitored even after bleeding is controlled and may require more Clinicians should be open to soliciting assistance from more
comprehensive debridement and cleansing. experienced personnel when appropriate. See Chapter 4, Airway
Recently, “junctional tourniquets” have been recommended as Assessment and Management, for additional information.
a method of controlling bleeding from the groin/iliac area and the
proximal axillary area. These have been tested mostly in combat BREATHING AND VENTILATION
situations and are not widely available in civilian centers. In the Airway patency alone does not ensure adequate ventilation.
absence of such devices, junctional bleeding in the groin or axilla Adequate gas exchange is required to maximize oxygenation
is managed with direct pressure. and elimination of carbon dioxide. Ventilation requires adequate
function of the lungs, chest wall, and diaphragm; therefore,
AIRWAY MAINTENANCE WITH CERVICAL clinicians must rapidly examine and evaluate each component.
SPINE MOTION RESTRICTION Injuries that significantly impair ventilation and result in
Initial evaluation of the airway in a trauma patient focuses on immediate life threats include tension pneumothorax, massive
determination of patency. Rapid assessment for airway obstruction hemothorax, open pneumothorax, pulmonary contusion, and
involves identifying foreign bodies; facial, mandibular, and/or tracheal or bronchial injuries. These injuries should be identified
tracheal fractures; and other injuries that may cause obstruction. during the primary survey and often require immediate attention
The clinician should suction or clear the airway of accumulated to ensure effective ventilation. Some injuries affect both breathing
blood, debris, and secretions. Assessment for signs of airway and circulation in the primary survey. A tension pneumothorax, for
edema or smoke inhalation is also important in certain patients example, acutely compromises ventilation and impairs venous return
with thermal injury. All airway maneuvers in a patient at to the right heart; this results in hypotension as well as respiratory
risk for spinal injury are performed with cervical spine distress and decreased breath sounds on the side of injury. Chest
motion restriction. For additional information, see Chapter 4, decompression in this situation is an emergency procedure needed to
Airway Assessment and Management, and Chapter 7, Disability: restore both ventilatory and circulatory function.
Neurological Assessment and Management. Every injured patient should initially receive supplemental
If a patient is able to phonate and communicate verbally, the oxygen. Oxygen may be delivered by a mask-reservoir device to
airway is unlikely to be in immediate jeopardy. However, frequent achieve optimal oxygenation. A pulse oximeter is used to monitor
reassessment of airway status is critical. adequacy of hemoglobin oxygen saturation. Frequent reassessment
A patient with head injuries resulting in an altered level of and monitoring are necessary. A simple pneumothorax, for
consciousness and/or a GCS score of 8 or lower will usually example, can convert to a tension pneumothorax when a patient
require a definitive airway, which ATLS defines as an airway is intubated and positive pressure ventilation is applied.
device in the trachea with an inflated cuff distal to the vocal cords. Continuous end-tidal CO2 (ETCO2) monitoring, when
Several maneuvers may be performed to maintain airway available, can also be used for control of ventilation to avoid
patency while other elements of the primary survey are being hypoventilation and hyperventilation when correlated with
performed or in preparation for a definitive airway. Techniques the arterial partial pressure of CO2 (PaCO2). It is important to
such as the jaw thrust can lift the tongue away from the back of recognize that ETCO2 reflects both ventilation and perfusion;
the throat, ameliorating upper airway obstruction and allowing thus, low ETCO2 may be an early sign of hypovolemic shock or
for effective oxygenation and ventilation with a bag-valve mask poor cardiac output. An arterial blood gas (ABG) analysis should
apparatus. Devices such as the laryngeal mask airway and other be obtained to ensure the ETCO2 correlates with the PaCO2 prior
supraglottic airways may be employed to temporarily maintain to using ETCO2 to adjust ventilation. In the setting of cardiac arrest,
airway patency. ETCO2 can be used to evaluate the quality of cardiopulmonary
Recent literature has emphasized the importance adequate resuscitation (CPR) and predict return of spontaneous circulation
resuscitation plays in patients undergoing definitive airway (ROSC). See Chapter 5, Breathing and Ventilation Assessment and
placement, particularly when medications are administered for Management, for additional information.
rapid-sequence intubation. In addition to volume administration,
some studies have suggested vasopressor administration for CIRCULATION, HEMORRHAGE CONTROL,
temporary adjunctive management of hypotension during AND MANAGEMENT OF SHOCK
intubation. While vasopressor administration may be useful in Among the more complex aspects of the primary survey
these select situations, clinicians should not use vasopressors as are those associated with the diagnosis and management of
first-line therapy for shock or as a replacement for diagnosing shock in the injured patient. Shock is defined as insufficient
and treating the cause of the shock state. tissue perfusion and oxygenation. The failure to diagnose and
When a definitive airway is required, the responsibility for effectively manage shock in the prehospital setting and during the
that task varies depending on clinician experience and practice initial assessment can result in fatality in the acute setting; it also
environment. Clinicians should be aware of standard procedures has implications for the patient later in their course by potentially
for their practice setting. Any airway may be considered as contributing to organ failure and late mortality.
potentially complex or “difficult” in a trauma patient, and clinicians

9
 DIAGNOSIS OF SHOCK When large-volume hemorrhage is suspected, it is useful to have a
massive transfusion (or hemorrhage) protocol (MTP or MHP) in
Early signs of shock can include tachycardia, tachypnea, place that can be activated expeditiously. Resuscitation endpoints
sequalae of compensatory vasoconstriction (shivering, decreased vary according to mechanism and suspected injuries. In a patient
capillary refill), and anxiety. Most laboratory studies are not with isolated penetrating trauma to the torso, clinicians might use
helpful in the diagnosis of shock; the exceptions are blood gases permissive hypotension during resuscitation, aiming for a lower-
and lactate levels, which may be abnormal before other findings than-normal systolic blood pressure that will maintain tissue
manifest. When compensatory mechanisms begin to fail, signs perfusion but not exacerbate bleeding. Conversely, the Brain
of end-organ dysfunction appear: a patient may have decreased/ Trauma Foundation recommends age-dependent systolic blood
altered mental status, decreased urine output, and hemodynamic pressure goals for patients with suspected traumatic brain injury
abnormality as manifested by narrowed pulse pressure and/or (TBI) that are somewhat higher to prevent secondary brain injury.
hypotension. Clinicians should remember that low systolic Recent literature has suggested that whole blood is preferable
blood pressure is a relatively late sign of shock; compensatory to fractionated blood components. However, not all prehospital
mechanisms can prevent a measurable fall in systolic pressure organizations or hospital facilities have immediate access to
until up to 30% of the patient’s blood volume is lost. whole blood or even blood component products. Even in centers
Shock in trauma patients can be broadly classified as that are well supplied, a multiple or mass casualty event may
hemorrhagic or nonhemorrhagic. Nonhemorrhagic causes of overwhelm blood product administration capacity, and alternative
shock may be further classified as obstructive causes (e.g., tension resuscitation strategies will be needed. Clinicians in such situations
pneumothorax, cardiac tamponade), distributive causes (e.g., must analyze how to use their resources to optimize outcomes.
neurogenic, septic), and primary cardiogenic causes (e.g., blunt See Chapter 6, Circulation Assessment and Volume Resuscitation,
cardiac injury). Obstructive causes of shock such as tension for additional details on resuscitation strategies for shock.
pneumothorax and cardiac tamponade are addressed prior
to (or simultaneously with) investigation of hemorrhage. The DISABILITY
initial resuscitation of neurogenic and cardiogenic shock mirrors
that of hemorrhagic shock; thus, sources of hemorrhage should A rapid neurologic evaluation establishes the patient’s level of
be excluded prior to investigation of these issues. Septic and consciousness, determines pupillary size and reaction, identifies
anaphylactic shock are unusual in the setting of acute injury but the presence of lateralizing signs, and determines if there is gross
can be considered if the clinical findings are suggestive. motor evidence of a spinal cord injury.
Hemorrhage remains the most common etiology of shock in The GCS is a quick, simple, and objective method of
the injured patient and should thus be excluded before considering determining level of consciousness. The motor score of the GCS
other causes in most cases. As discussed earlier in this chapter, correlates with outcome. A decrease in level of consciousness
immediate attention should be given to controlling exsanguinating may indicate progression of direct cerebral injury or decreased
external bleeding. Should a patient remain in shock once external cerebral oxygenation and/or perfusion due to a shock state.
bleeding has been addressed, consideration should be given to Although hypoglycemia, alcohol, narcotics, and other drugs can
internal, or cavitary, bleeding sources. These include the pleural alter a patient’s level of consciousness, clinicians should assume
cavities bilaterally, the peritoneal cavity, the retroperitoneum and that changes in level of consciousness are due to traumatic injury
pelvis, and the muscle or subcutaneous tissue. Bleeding in any until proven otherwise.
of these cavities can result in enough blood loss to lead to shock Primary brain injury results from the structural effect of an
( Figure 1-5). injury to the brain. Prevention of secondary brain injury—by
See Chapter 6, Circulation Assessment and Volume Resuscitation, maintaining adequate oxygenation and perfusion—is the main
for information on how to diagnose and address blood loss in goal of management during the primary survey. Because evidence
these areas. of brain injury can be absent or minimal at the time of initial
The MOST effective method of restoring adequate cardiac evaluation, frequent reexamination is critical. Patients with
output, end-organ perfusion, and tissue oxygenation in the evidence of brain injury or spinal cord injury should be treated
setting of hemorrhage is to restore venous return to normal by at a facility that has the personnel and resources to anticipate
locating and stopping the source of bleeding. Volume repletion and manage the needs of these patients. When resources to care
will allow recovery from the shock state only when the bleeding for these patients are not available, arrangements for transfer
is controlled. should begin as soon as this condition is recognized. Optimally,
neurosurgical, spine, or other appropriate specialty consultation
RESUSCITATION STRATEGIES FOR SHOCK should be obtained once brain or spinal cord injuries are identified.
In a hemodynamically abnormal patient with clinical
As stated above, control of the source of shock is the most
findings of a spinal cord injury, the clinician should still exclude
effective element in the treatment of shock. However, maintenance
hemorrhagic shock before assuming hypotension is due only
of perfusion while this is being accomplished remains a challenge
to the spinal cord injury. Patients may have both hemorrhagic
for the clinician.
and neurogenic shock present, depending on the mechanism.
In the setting of hemorrhage, replacement of blood loss with
See Chapter 7, Disability: Neurological A ssessment and
blood component therapy or whole blood is preferred over the use
Management, for additional information.
of crystalloid. There are data documenting the disadvantages of
crystalloid use in this setting, including immunologic alterations,
coagulation issues, and pulmonary and cardiac complications.

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 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

 Figure 1-5: Potential Anatomic Locations for Blood Loss, “One on the Floor and
Four More” or “Four and the Floor”. A. Thoracic cavity. B. Peritoneal cavity. C. Pelvic
and Retroperitoneal Space. D. Long bone fracture sites, muscle compartments, and
subcutaneous tissue. E. External hemorrhage (“the floor”).

EXPOSURE AND ENVIRONMENTAL urine output) and can be therapeutic as well (decompression of
CONTROL the urinary bladder and stomach). Interventions such as spinal
motion restriction, extremity splinting, and pelvic stabilization (in
All patients who present with injury should be examined the setting of suspected or confirmed pelvic fracture) can provide
carefully to prevent missing an injury. This requires that all preventive and therapeutic benefits for the trauma patient. Serial
clothing and jewelry be removed. Maintaining patient dignity and physical examination can alert clinicians to significant changes in
modesty is a priority during this process. Patient belongings are patient status ( Figure 1-6).
collected and secured per institution policy. Some novice trauma clinicians can become confused about
Hypothermia will aggravate shock and coagulopathy. when certain adjuncts are utilized and whether they are part
Therefore, warmed blankets, convection warming systems, of the primary or the secondary survey. As a general rule, if a
elevated room temperature, and warmed resuscitative fluids are of monitoring device, diagnostic test, or procedure assists the
critical importance. Information about recognition and treatment clinician in managing immediate life threats, it can be included
of systemic hypothermia can be found in Chapter 8, Exposure and as part of the primary survey. For example, in a hemodynamically
Environmental Threats in the Primary Survey. abnormal patient with suspected abdominal trauma, it is
appropriate to use FAST or DPL as part of the primary survey.
ADJUNCTS TO THE PRIMARY SURVEY WITH Similarly, splinting a femur fracture or stabilizing the pelvis to
RESUSCITATION mitigate blood loss that may be causing a shock state can also be
considered primary survey procedures.
Adjuncts employed during the primary survey can be used
to monitor, diagnose, treat, and prevent harm. Continuous MONITORING
electrocardiography (ECG), pulse oximetry, and capnography
can allow the clinician to monitor real-time changes in a patient’s Physiologic parameters such as pulse rate, blood pressure,
status. Diagnostic studies such as chest and pelvis x-rays, focused pulse pressure, ventilatory rate, pulse oximetry, capnography,
assessment with sonography for trauma (FAST) and extended and body temperature are measurable assessments that can
FAST (eFAST), and diagnostic peritoneal lavage (DPL) provide reflect the adequacy of resuscitation. Values for these parameters
the clinician with information about life-threatening injuries should be obtained as soon as is practical and should be evaluated
that should be diagnosed during the primary survey. Urinary at regular intervals.
and gastric catheters can provide diagnostic information (e.g.,
the presence of blood) and monitoring information (hourly
11
 Hemoglobin saturation from the pulse oximeter should be
 Figure 1-6: Adjuncts to the Primary Survey with
compared with the value obtained from ABG analysis. Inconsistency
Resuscitation. Any monitoring tool, diagnostic test,
intervention, or procedure that can assist the clinician
indicates that one of the two determinations is in error.
in the diagnosis and management of immediate life-
threatening conditions is appropriate to use as part of the VENTILATORY RATE, CAPNOGRAPHY, AND
Primary Survey. Note the importance of serial physical ARTERIAL BLOOD GASES
examination as part of the re-evaluation process in many
trauma patients. Ventilation can be monitored using ETCO2 levels. ETCO2 can
be detected using colorimetry, capnometry, or capnography—a
noninvasive monitoring technique that provides insight into
the patient’s ventilation, circulation, and metabolism. Because
Pulse Oximetry, endotracheal tubes can be dislodged whenever a patient is
Respiratory Rate,
Electrocardiographic
Capnography, and moved, capnography can be used to confirm intubation of the
Monitoring
Arterial Blood Gases airway (versus the esophagus) but does not confirm the precise
position of the endotracheal tube within the airway. Continuous
ETCO2 monitoring, when available, can also be used for control
of ventilation to avoid hypoventilation and hyperventilation. As
Urinary
and Gastric Serial Physical
mentioned previously, it may be used as an early indicator of
Catheters Examination hypovolemic shock and poor cardiac output, as well as to predict
ADJUNCTS return of spontaneous circulation (ROSC) during CPR.
to the
Primary Survey ABG is a particularly versatile test that can be obtained in the
trauma bay. It provides specific information about oxygenation
(PaO2 and O2 saturation) as well as ventilation (PaCO2). It also
Chest and Diagnostic
provides information about the patient’s acid-base status (pH and
Pelvis X-Rays Studies: FAST, base excess/deficit); this can alert the clinician to the presence of
eFAST, DPL
shock before other measurements (like blood pressure) become
Interventions: IV/
IO access; Pelvic
indicative. Trends in pH and base excess levels can also reflect the
Stabilization; Selected progress of resuscitation. Lactate levels can also be obtained and
Extremity Splinting;
Spinal Motion trended to accomplish the same goal. Depending on the practice
Restriction
setting, ABG may be used in place of technological devices to
monitor oxygenation, ventilation, and acid-base status.

ELECTROCARDIOGRAPHIC MONITORING OTHER INTERVENTIONS IN THE PRIMARY

ECG monitoring of all trauma patients is important. SURVEY
Dysrhythmias—including unexplained tachycardia, atrial Some interventions are performed during the primary
fibrillation, premature ventricular contractions, and ST segment survey to protect the patient from potential harm or to treat life-
changes—can indicate blunt cardiac injury. Pulseless electrical threatening injuries.
activity can indicate cardiac tamponade, tension pneumothorax, or
profound hypovolemia. When bradycardia, aberrant conduction, INTRAVENOUS/INTRAOSSEOUS ACCESS
and premature beats are present, hypoxia and hypoperfusion Even if a patient does not require immediate volume
should be suspected immediately. Extreme hypothermia also resuscitation, it is important in most cases to obtain intravenous
produces dysrhythmias. or intraosseous access. Having access will allow for the rapid
administration of medications or fluids should the patient’s status
PULSE OXIMETRY change. Short-length, large-caliber intravenous catheters remain
Pulse oximetry is a valuable adjunct for monitoring the ideal for resuscitation of trauma patients. Intraosseous access
oxygenation in injured patients. A small sensor is placed on the is commonly obtained via the humeral or tibial route.
finger, toe, earlobe, or another convenient place. Most devices
display pulse rate and oxygen saturation continuously. The relative SPINAL MOTION RESTRICTION
absorption of light by oxyhemoglobin and deoxyhemoglobin In any patient at risk for spinal cord injury, spinal motion
is assessed by measuring the amount of red and infrared light restriction measures should be applied. This usually includes
emerging from tissues traversed by light rays and processed by the placement of a cervical collar or similar device and maintaining
device, producing an oxygen saturation level. Pulse oximetry does logroll precautions when the patient is moved or turned.
not measure the partial pressure of oxygen or carbon dioxide. Maintaining cervical motion restriction is an important
Note that pulse oximetry can be inaccurate in patients exposed to component of the intubation process in at-risk patients. Patients
carbon monoxide. Quantitative measurement of these parameters should not be left on long spine boards for extended periods, as
occurs as soon as is practical and is repeated periodically to they do not inherently provide immobilization of the spine and
establish trends. patients left on them can sustain significant pressure injuries.

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 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

PELVIC STABILIZATION patient in shock has no evidence of external hemorrhage, has a clear
chest exam/x-ray, and has no evidence of pelvic or femur fractures,
In hemodynamically abnormal patients with suspected intra-abdominal bleeding must be a primary consideration as the
pelvic fractures, stabilization of the pelvic girdle with a sheet source of shock, even if it cannot be specifically diagnosed.
or commercial device should be performed during the primary
survey. See Chapter 6, Circulation Assessment and Volume URINARY AND GASTRIC CATHETERS
Resuscitation; Chapter 10, Musculoskeletal Trauma; and Chapter
21, Thoracic, Abdominopelvic, and Genitourinary Trauma, for The placement of urinary and gastric catheters may occur
additional details. during or following the primary survey.

EXTREMITY SPLINTING URINARY CATHETERS

Although extremity splinting is usually part of the secondary Urinary output is a sensitive indicator of a patient’s volume
survey, there are situations in which it is appropriate to perform status and reflects renal perfusion. Monitoring of urinary output
during the primary survey. Femur fractures can cause significant is best accomplished by insertion of an indwelling bladder
blood loss that may be mitigated with appropriate splinting. catheter. In addition, a urine specimen should be submitted for
routine laboratory analysis. Transurethral bladder catheterization
X-RAY EXAMINATIONS AND OTHER is contraindicated for patients who have suspected urethral injury.
Suspect a urethral injury in the presence of either blood at the
DIAGNOSTIC STUDIES
urethral meatus or perineal ecchymosis on exam of the genitalia
and perineum. If a urethral injury is suspected, placement
PLAIN X-RAYS of a transurethral catheter must be delayed until a retrograde
Use x-ray examination judiciously, and do not delay patient urethrogram is performed to rule out injury.
resuscitation or transfer to definitive care in patients who require At times, anatomic abnormalities (e.g., urethral stricture or
a higher level of care. Anteroposterior (AP) chest and AP pelvic prostatic hypertrophy) preclude placement of indwelling bladder
x-rays often provide information to guide resuscitation efforts catheters, even with appropriate technique. Nonspecialists should
of patients with blunt trauma and can also be helpful to locate avoid excessive manipulation of the urethra and use of specialized
retained missiles in penetrating trauma. Chest x-rays can show instrumentation. Consult a urologist early in such situations.
potentially life-threatening injuries that require treatment or
further investigation and can document placement of devices GASTRIC CATHETERS
such as endotracheal and chest tubes. Pelvic x-rays can show A gastric catheter is indicated to decompress stomach
fractures of the pelvis that may indicate the need for early blood distention, decrease the risk of aspiration, and check for upper
transfusion. These studies can be obtained in the resuscitation gastrointestinal hemorrhage from trauma. It is considered an
area with a portable/bedside x-ray unit, but not when doing so important adjunct to employ following endotracheal intubation.
will interrupt the resuscitation. Do obtain essential diagnostic Decompression of the stomach may reduce the risk of aspiration
x-rays, even in pregnant patients. but does not prevent it entirely. Thick and semisolid gastric
contents will not return through the tube, and placing the tube
FAST, eFAST, AND DPL itself can induce vomiting. The tube is effective only if it is properly
In the setting of suspected abdominal trauma, FAST and DPL positioned and attached to appropriate suction.
are adjuncts that can be used to detect peritoneal blood as part of Blood in the gastric aspirate may indicate oropharyngeal (i.e.,
the primary survey. Many sites employ FAST, as it is noninvasive, swallowed) blood, traumatic insertion, or injury to the upper
but DPL is still used in sites that have a large burden of penetrating digestive tract. If a fracture of the cribriform plate is known or
trauma or less access to ultrasound technology. Both can be suspected, insert the gastric tube orally to prevent intracranial
challenging to perform in obese patients and pregnant patients. passage. In this situation, any nasopharyngeal instrumentation
While the indications for its use do not vary, DPL technique is potentially dangerous, and an oral route is recommended.
must be altered in patients who are pregnant, obese, or have
had prior laparotomies. Obesity and intraluminal bowel gas can SERIAL PHYSICAL EXAMINATION
interfere with images obtained on FAST. In a hemodynamically With the availability of technology, it can become easy to neglect
abnormal patient, the presence of intraperitoneal blood with the value of physical examination. Serial physical examination
either FAST or DPL indicates the need for surgical intervention. can be critical to ensuring that changes in patient status (and by
In hemodynamically normal patients, a surgeon should still be extension, evolving injuries) are not missed. Examples include
consulted to direct care when blood is detected. Note that neither repeating GCS assessments, reassessing the girth of an injured
of these studies can effectively evaluate the retroperitoneum. The extremity, examining for expansion of a soft-tissue hematoma,
eFAST procedure can be used to detect pneumothoraces and reevaluating pulses, and repeating exams in patients with
hemothoraces. Success when performing any of these procedures abdominal trauma. Changes in the acuity or character of pain
depends on the clinician’s experience and level of skill. after injury may signal worsening of a physiologic process.
In the absence of the recommended technology, a clinician
should rely on patient presentation and a high level of suspicion
to avoid missing injuries. For example, diagnosis of a tension
pneumothorax is primarily clinical. Similarly, if a polytrauma

13
 The other important communication element in this process
SECONDARY SURVEY IN THE INITIAL
is that which occurs between the healthcare team and the patient/
ASSESSMENT family. Particularly when a patient is being transferred to another
facility, the family may need additional information and support
In a trauma patient, the secondary survey begins after the
beyond the medical data.
primary survey is completed (in hemodynamically normal
See Chapter 15, Transfer to Definitive Care, for more
patients) or after the patient is responding to resuscitation (in
information.
hemodynamically abnormal patients).
For some patients, a complete secondary survey cannot be
accomplished before the patient must be transferred to definitive
SPECIAL POPULATIONS
care, be it an operating room or another hospital facility. However, More detailed information on these topics can be found in
clinicians should make every effort to obtain secondary survey Chapter 11, Trauma in the Pediatric Patient; Chapter 12, Trauma in
information when possible. the Older Adult; and Chapter 13, Trauma in the Pregnant Patient.
As with the primary survey, frequent reassessment is Injury presentation in pediatric, older adult, and pregnant
critical during the secondary survey. Any deterioration in populations, as well as in obese patients, athletes, and other
patient status should prompt repeating the primary survey. populations, may include some distinct characteristics. The
For additional information, see Chapter 14, Initial Assessment: following sections discuss some initial assessment considerations
Secondary Survey. specific to these populations; however, the priorities for the care
of these patients are the same as for all trauma patients.
REEVALUATION
Trauma patients must be reevaluated frequently to ensure
TRAUMA IN PEDIATRIC PATIENTS
that new findings are not overlooked and to discover any Pediatric patients have distinct physiology and anatomy. The
deterioration in previously noted findings. As initial life- dose requirements for blood, fluids, and medications vary with
threatening injuries are managed, other equally life-threatening the size of the child. Children typically have abundant physiologic
problems or less severe injuries may become apparent, which can reserve and often have few signs of hypovolemia, even after
significantly affect the ultimate prognosis of the patient. A high severe volume depletion. When deterioration does occur, it can
index of suspicion facilitates early diagnosis and management. be precipitous and catastrophic. A child’s increased metabolic
As noted in “Adjuncts to the Primary Survey with Resuscitation” rate, thin skin, and lack of substantial subcutaneous tissue
section, serial physical examination must be employed in addition also contribute to increased evaporative heat loss and caloric
to frequent technological monitoring. The team leader should expenditure. Hypothermia can significantly compromise a child’s
ensure that all team members feel comfortable in communicating response to treatment, prolong coagulation times, and adversely
any changes in patient status to the entire group. affect central nervous system function.

DEFINITIVE CARE TRAUMA IN PREGNANCY

The anatomic and physiologic changes of pregnancy affect
Whenever the patient’s treatment needs exceed the
how the pregnant patient responds to injury. Pregnant patients
capability of the initial treating clinician or institution, transfer
can lose more volume/blood before they develop hypotension. As
is considered. This decision requires a detailed assessment of the
the pregnancy progresses, uterine compression of the inferior vena
patient’s injuries and knowledge of the institution’s capabilities,
cava can decrease venous return; lateral uterine displacement/
including equipment, resources, and personnel.
tilting can be an important maneuver to perform during the
Interhospital transfer guidelines will help determine which
primary survey to restore hemodynamic normality. It is important
patients require the highest level of trauma care; see ACS COT’s
to keep in mind that even relatively minor injury mechanisms
Resources for Optimal Care of the Injured Patient (2022 Standards).
may result in poor outcomes for the mother and the fetus, and
These guidelines take into account the patient’s physiologic status,
careful monitoring is key.
diagnosed anatomic injury, mechanisms of injury, concurrent
diseases, and other factors that can alter the patient’s prognosis.
TRAUMA IN OLDER ADULTS
Emergency department and surgical personnel may use these
guidelines to determine whether the patient requires transfer to Older adults may have a limited ability to adapt and
a trauma center or the closest appropriate hospital capable of maintain homeostasis when subjected to traumatic injury. This
providing more specialized care. The closest appropriate facility can be influenced by the aging process itself, medication use,
is chosen based on its overall capabilities to care for the injured and frailty. Anatomic and physiological changes associated with
patient. aging can present the clinician with challenges in managing
Communication between those who provide initial care for all aspects of the xABCDE algorithm. Airway anatomy can
the patient and those who will provide definitive care is critical be affected by arthritis and degenerative changes; pulmonary
to optimal patient safety and outcomes. This communication is compliance and reserve may be diminished; and patients with
not only useful for interfacility transfers but may be used even if essential hypertension may require a higher mean pressure
definitive care takes place in the same institution that provided to maintain perfusion, meaning “normal” blood pressure
emergency care. The S-xABCDE-BAR acronym is a useful method is inadequate. Susceptibility to TBI may be enhanced by the
for structuring this communication (see  Figure 1-4). presence of cerebral atrophy and the use of anticoagulant
medications, and even low-energy falls may result in spinal

14 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

cord and other injuries. Finally, loss of subcutaneous fat, Having clinicians with expertise in patient and family support,
nutritional deficiency, and other issues may increase the risk such as social workers and spiritual care professionals, can greatly
of hypothermia. assist with the process. Determine if an interpreter (professionally
trained, not a family member or friend) is necessary. It is
TRAUMA IN OBESE PATIENTS also important to consider local cultural, religious, and
The anatomy of obese patients may make procedures such other traditions when engaged in these often sensitive and
as intubation challenging. Diagnostic tests such as FAST, disquieting conversations. Different cultures may have specific
DPL, and CT may also be more difficult. Many obese patients expectations about how and to whom such information is
have cardiopulmonary conditions, which limit their ability to conveyed. Cultural sensitivity and preparation by the individual
compensate for injury and stress. Volume resuscitation should be clinician and the team are key.
based on ideal body weight and take into consideration that rapid For additional information, see Chapter 20, Communicating
fluid administration may exacerbate underlying comorbidities. Serious News in the Acute Trauma Setting.

TRAUMA IN ATHLETES INJURY PREVENTION AND INTERVENTION

The enhanced conditioning of athletes may mean that they will The trauma community recognizes that most traumatic
not manifest early signs of shock, such as tachycardia and tachypnea. incidents are not “accidents” and are subject to principles of
Their resting blood pressure may be lower than expected. injury prevention and intervention. There are many approaches
to injury prevention; ATLS recommends that clinicians consider
COMMUNICATING SERIOUS NEWS IN THE the “3 Es”:
ACUTE TRAUMA SETTING • E ducation: What opportunities for individual, family,
community, or societal education may have an impact on
Just as having an organized, systematic approach to the
reducing injury?
medical management of a critically injured patient is critical,
• Engineering/Environment: How could altering the physical
communicating serious news to a patient or family should
environment (e.g., road intersection structure) or engineering
also consist of preparation and a well-formulated process.
(e.g., seatbelts and airbags in vehicles) reduce injury?
Misunderstandings and subsequent mistrust can often be avoided
• Enforcement: How could changes in legislation or policy
by taking a few minutes to create a clear, understandable message
reduce injury?
(that everyone on the healthcare team is aware of and agrees on)
and communicating that message in a professional, compassionate, While it may not seem clear why this concept should be
and empathetic manner. One approach to this process is outlined included in the initial assessment, it is often during this time that
in  Figure 1-7. the most indelible impressions are made on clinicians regarding

 Figure 1-7: Communicating Serious News in the Acute Trauma Setting. It is a necessary part of the work of trauma
clinicians to communicate serious news to patients and families. The approach must be deliberate, with time taken to
consider what should be said, who should be involved in the communication, and where and how the communication
should take place. Finally, a debrief with the team assures that everyone is informed and knows the treatment plan.

Think about a “warning.” Determine which team Ask what the family has Ensure all team members
(I have serious news to members will be present. been told. know the details of the
share with you.) WIll an interpreter meeting and plans
Begin with the warning. for next steps.
Follow with a “Headline” be needed?
statement. What are the Concise summary. Try to arrange for
Be aware of
most serious injuries your appearance.  o allow for silence.
D opportunities for team
and what is their Don’t speak too much. members to explore and
Select a comfortable,
expected impact? Listen! manage their own emotions.
private setting.
Make sure there is enough Encourage and validate
space so that all can sit and Emotions. Elicit questions.
be at “eye level.” End Encounter with a
plan for next steps.

15
 the nature of an injury. Spending even a few minutes to take note If criminal activity is suspected in conjunction with a patient’s
of injuries at your institution that occur repeatedly can lead to injury, the personnel caring for the patient must preserve the
opportunities for education and advocacy. Similarly, opportunities evidence. All items, such as clothing and bullets, may need to be
to provide screening and referral for abuse or neglect, substance saved for law enforcement personnel. In such cases, it is important
misuse, PTSD, and other mental health and social health concerns to explain to the patient/family why the patient’s belongings may
may become evident during the initial assessment, particularly not be accessible to them. Laboratory determinations of blood
during the secondary survey. Even if actual action on these issues alcohol concentrations and presence of other drugs may be
takes place at a later time, clinicians should include injury required, depending on local protocols.
prevention principles as part of their approach to the initial
care of injured patients and make sure that their concerns are CHAPTER SUMMARY
included in communications with definitive care clinicians and
in the medical record. The initial assessment and primary survey should follow a
For additional information, see Chapter 18, Injury Prevention. standardized sequence that includes the following:
• Triage (if applicable)
RECORDS AND LEGAL CONSIDERATIONS • Team preparation and assessment of hospital resources
Preparing and maintaining detailed and meticulous records is • Identifying, prioritizing, and addressing life-threatening
crucial to the process of caring for the critically injured patient. injuries using the xABCDE algorithm
Detailed records help promote continuity of care and allow
• Initiating appropriate resuscitation
clinicians engaged in the next phases (or future phases) of care
to better understand what was done during the initial assessment • Using appropriate primary survey adjuncts
and primary survey. This process can be facilitated by designating • Frequent reevaluation of patient status
a team member as a scribe or recorder, if resources permit.
Whenever possible, consent for treatment should be obtained • Secondary survey with adjuncts
from either the patient or their surrogate. If consent cannot be • Consideration of the need for transfer to definitive care
obtained due to the emergent nature of the treatment, make every The priorities for treatment of critically injured patients are
effort to explain the indications and nature of the treatment to the the same, even when they possess special characteristics (e.g.,
patient/family afterward. pediatric, older adult, pregnant patients). Using a standardized
If the patient is being transferred, all relevant documentation approach lessens the chance that a clinician will allow bias to
should travel with them; this includes any test results and relevant interfere with the treatment process.
clinician notes. If possible, diagnostic studies should be placed on When a patient’s condition changes, clinicians should repeat
digital storage or other media and sent with the patient; the patient/ the primary survey and address any new findings.
family may also request copies of these studies. Documents such as Any patient with treatment needs that exceed the clinician’s or
advanced directives and living wills should also be included. The institution’s capabilities should be considered for transfer. Having
team should ensure that the family has the appropriate contact prearranged transfer agreements facilitates this process and
information if they have questions after the patient is transferred. using a standard communication transfer tool can ensure that an
In the US, the Health Insurance Portability and Accountability effective handoff is achieved.
Act (HIPAA) features several regulations that organizations The initial assessment should be accomplished using effective
and individuals must follow to ensure compliance. The purpose team dynamics principles and communication. While the trauma
of these rules is to safeguard protected health information and setting can be chaotic, clinicians should ensure that the patient is
privacy. In the trauma setting, clinicians are often asked to share treated with dignity and respect, recognizing that they may have
information with associates of the patient, relying on others to be had prior trauma (physical, emotional, social, psychological, or
truthful in their description of their relationship to the patient. spiritual) in their lives, which may affect their interactions with
When possible, the patient should be asked what information the healthcare team.
they want shared and with whom. If the patient is not able to Clinicians in the trauma setting should anticipate having
make such decisions, US-based clinicians should be familiar with to communicate serious, life-altering news to a patient and/or
the Department of Health and Human Services guidelines for family and should spend time in preparation to make sure that the
Disclosures to Family and Friends and use their best judgment to discussion is most beneficial for them.
act on the patient’s behalf. Clinicians caring for trauma patients are in a unique position
Although these guidelines are specific to the US, many to recognize and catalog injury patterns and advocate for changes
countries and supranational entities have similar guidelines: the that may lead to more effective prevention of these injuries.
General Data Protection Regulation (GDPR) in the European
Union; the Lei Geral de Proteção de Dados Pessoais (LGPD) in
Brazil; and the Privacy Act in Australia. Similar personal data/
protection guidelines are used in Malaysia, Singapore, South
Korea, and Vietnam, among other countries. Protected personal
health information is a concept as much as a policy, and clinicians
should look to local protocols for its application.

16 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 1 | Initial Assessment: Primary Survey

factors of preventable death in a mature trauma center: A

KEY LEARNING POINTS
propensity-score analysis. Eur J Trauma Emerg Surg. 2024
•  he Primary Survey in the Initial Assessment
T Apr;50(2):477–487. DOI: 10.1007/s00068-023-02367-w.
requires the clinician to identify, prioritize, and Epub 2023 Sep 25. PMID: 37749282.
address immediate life threats; it is not necessary 5. Evans JA, van Wessem KJ, McDougall D, Lee KA,
to have a definitive diagnosis to begin urgent Lyons T, Balogh ZJ. Epidemiology of traumatic deaths:
treatment. Using the xABCDE algorithm allows Comprehensive population-based assessment. World J
both novice and expert trauma clinicians to Surg. 2010;34(1):158–163. DOI: 10.1007/s00268-009-
organize their approach to the Primary Survey, and 0266-1. PMID: 19882185.
this sequence can be applied to all trauma patients.
6. Teixeira PG, Brown CV, Emigh B, et al. Civilian
• Application of the Primary Survey requires prehospital tourniquet use is associated with improved
efficient team functioning and clear, respectful survival in patients with peripheral vascular injury. J
communication, including among team members Am Coll Surg. 2018;226(5):769–776.e1. doi: 10.1016/j.
and between the team and other clinicians, jamcollsurg.2018.01.047. Epub 2018 Mar 29. PMID:
patients, and families. 29605726.
7. Eilertsen KA, Winberg M, Jeppesen E, Hval G, Wisborg T.
• Clinicians should make use of appropriate adjuncts
Prehospital tourniquets in civilians: A systematic review.
to optimize completion of the Primary Survey
depending on what resources are available to them. Prehosp Disaster Med. 2021;36(1):86–94. DOI: 10.1017/
S1049023X20001284. Epub 2020 Nov 3. PMID: 33138876;
• Frequent reevaluation is critical to the performance PMCID: PMC7844612.
of the Primary Survey; a trauma patient’s status 8. Newgard CD, Fischer PE, Gestring M, et al. National
may change quickly. guideline for the field triage of injured patients:
Recommendations of the National Expert Panel on Field
• The Secondary Survey should begin when the
Primary Survey is completed and vital functions Triage, 2021. J Trauma Acute Care Surg. 2022;93(2):e49–
are returning to normal; in some cases, a complete e60. DOI: 10.1097/TA.0000000000003627.
Secondary Survey cannot be completed in the initial 9. Murphy M, McCloughen A, Curtis K. The impact of
evaluation. simulated multidisciplinary trauma team training on team
performance: A qualitative study. Australas Emerg Care.
• Determining what definitive care the patient 2019;22(1):1–7. DOI: 10.1016/j.auec.2018.11.003. Epub
requires is also crucial; clinicians should decide as
2018 Dec 10. PMID: 30998866.
early as possible if all care can be delivered at the
emergency treating facility or if the patient
10. Pellegrini CA. Time-outs and their role in improving safety
requires transfer. and quality in surgery. Bull Am Coll Surg. 2017;102(6):54–
56. PMID: 28885812.
• All patients should be treated with dignity— 11. Appelbaum RD, Puzio TJ, Bauman Z, et al. Handoffs
with consideration for preserving patient modesty and Transitions of Care: A systematic review, meta-
and privacy, respecting cultural heritage, and analysis, and practice management guideline from the
recognizing that many patients have experienced Eastern Association for the Surgery of Trauma. J Trauma
prior trauma.
Acute Care Surg. 2024;97(2):305–314. DOI: 10.1097/
• Clinicians should remember their role in Injury TA.0000000000004285. PMID: 38407300.
Prevention, even in the acute setting. Recognizing 12. Appelbaum R, Martin S, Tinkoff G, Pascual JL, Gandhi
injury patterns and patient risk factors can begin RR. Eastern Association for the Surgery of Trauma—
in the emergency department. Quality, Patient Safety, and Outcomes Committee—
Transitions of care: Healthcare handoffs in trauma.
Am J Surg. 2021;222(3):521–528. DOI: 10.1016/j.
amjsurg.2021.01.034. Epub 2021 Feb 1. PMID: 33558061.
13. Iedema R, Ball C, Daly B, et al. Design and trial of a new
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18 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

Resuscitation Team Function

and Communication

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explore the science of team dynamics

2. Learn behaviors of high-performing, ad hoc teams
3. Acquire tools and strategies that can be rapidly deployed in this complex environment

19
 To optimize care, it is crucial to educate resuscitation team

2
members (regardless of team size) on these essential trauma
teamwork skills and to have these topics included as core training
principles across disciplines. It is important that all members of
the trauma resuscitation team (e.g., physicians, nurses, respiratory
therapists, medical assistants, radiology technicians, laboratory
and blood bank participants) are included in such training
programs, as a working knowledge of CRM principles serves to
optimize team dynamics and ultimately improve patient outcomes.
Resuscitation Team Function KEY CONCEPTS
and Communication
LEADERSHIP AND FOLLOWERSHIP
Both leaders and followers are needed to care for patients,
CHAPTER STATEMENT
and effective interaction between these roles is required for high-
Trauma resuscitation is one of the most challenging processes in functioning teams. Resuscitation is a complex endeavor that relies
healthcare and requires team situation awareness and exceptional on a myriad of inputs from multiple sources. As noted in Team
communication to prevent adverse events. Nontechnical skills Strategies and Tools to Enhance Performance and Patient Safety
must be embraced and trained to create exceptional teams and (TeamSTEPPS), effective leadership is required to direct team
improved outcomes. This chapter promotes effective behaviors actions.
and provides strategies and tools to build enduring high- Being a successful leader is a learned skill; however, little
functioning ad hoc teams. formal instruction in leadership occurs during medical training,
Despite immense advances in trauma resuscitation, as many as and attitudes regarding these topics are likely established
29,000 patients needlessly die each year. The fast-paced, complex, early in training. To have a team, there must be followers with
and information-rich trauma environment, where teams are complementary skills. There are times when the roles of leader and
typically comprised of ad hoc members, is a setup for cognitive follower are fluid, and high-functioning teams enable members to
overload, impaired situational awareness, and communication move seamlessly between these roles. Effective leaders promote
failure. The initial resuscitation phase has been identified as the a shared vision and collective ownership to coproduce better
stage in which most preventable adverse events in trauma care outcomes. These team skills must be regularly practiced and
occur. To change the status quo and improve patient safety, it modeled. Evidence suggests that leadership skills can be honed as
is imperative that we create environments in which it is easy to part of a broader teamwork training initiative. While the topic of
do the right thing. To improve outcomes, we must embrace leadership is quite popular, less attention is given to the important
nontechnical skills that boost effective communication, lessen role of followership. Great followers, like great leaders, take
cognitive overload, promote situational awareness, and foster ownership of team decisions, which promotes team effectiveness.
shared mental models to create enduring, exceptional trauma
resuscitation teams. ATTENTION AND AWARENESS
Trauma resuscitation requires both focused attention and the
INTRODUCTION ability to scan and receive numerous and disparate data. Focused
attention comes with a risk of fixation, while scanning risks
Trauma resuscitation is one of the most challenging processes
cognitive overload. This is summarized in  Table 2-1. Trauma
in healthcare. There is an abundance of scientific and technical
events are information-rich, subject to abrupt changes, and
research to optimize care, but only recently have nontechnical skills
nonlinear. Within such dynamic events, situational awareness—
been emphasized within training programs. There is an extensive
an individual’s ability to maintain sight of the “big picture”—is
body of literature around nonmedical crisis resource management
critical. Additionally, while not all data are relevant, they must still
(CRM) and a growing body of exceptional monographs specific
be processed.
to medicine and trauma. Building exceptional trauma teams of
Taking a structured approach to information processing, such
all sizes and compositions begins with an understanding of these
as that offered by ATLS®, improves the ability of team members
principles. While there are many factors that shape effective
to determine what is immediately relevant versus what can be
teamwork across domains, there are five key concepts that
reserved for later investigation. A leadership style that promotes
deserve special attention within the area of trauma teamwork:
open communication should be encouraged and taught, and
1. Leadership and followership
defined communication strategies between members (leaders and
2. Attention and awareness
followers) are key to this endeavor. Strategies may include time
3. Verbal communication
outs; Situation, Background, Assessment, and Recommendation
4. Decision-making
(SBAR) reassessment; probing for additional perspectives;
5. Task management and coordination
and allowing team members to safely challenge assumptions.
Promoting collective situational awareness is a skill that can be
developed with education and practice and should be part of
training and simulation.

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 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

 Table 2-1: The Three Levels of Situational Awareness.

Level Benefits Risks

I - Perception

Scanning Attention • Sample many stimuli • Stimulus overload

• Avoid fixing on one stimulus • Lack of prioritization

Focused Attention • Prioritize • Fixation error

• Eliminate ‘unimportant’ cues • Miss ‘important’ cues

II - Synthesis

Cognitive Modeling • Recognize patterns (heuristics) • See patterns where they do not exist
• Reduce workload • Premature closure/confirmation bias
• Predictable response • Resistant to new ideas

III - Projection

Anticipation Predict future events Incorrect assumptions

Sharing Increased resources (cognitive/physical) Need to coordinate a team

Adapted from Endsley MR. Toward a theory of situation awareness in dynamic systems. Hum Factors. 1995;37(1):32–64.

VERBAL COMMUNICATION TASK MANAGEMENT AND COORDINATION

Effective communication should be a two-way channel An accurate shared mental model is crucial for efficient task
and must be both heard and understood. This is highlighted management and coordination. Both scarce and excessive resources
in TeamSTEPPS as the three Cs of communication: (1) Cite present challenges when managing tasks and coordinating teams.
names; (2) Clear and concise; and (3) Close the loop. Tested Even in the most austere environments, the smallest team is
communication tools help standardize and clarify intent, direct composed of at least two individuals who work interdependently
team members toward common ideas and purpose, and allow for (and often simultaneously) on task activities toward a common
a safe communication approach during emergencies. Appropriate goal. As teams become larger, there is more simultaneous task
design of tools is useful to coordinate activities and achieve a work, which increases the need for active information-sharing to
shared mental model. create an accurate shared mental model and efficient coordination.
Task coordination can be either explicit or implicit, but implicit
DECISION-MAKING understanding is typically established prior to an event and is the
Critical decision-making, akin to problem-solving, is not hallmark of high-functioning teams.
innate and should not be left to chance. Humans can only manage An ideal teamwork environment can be encouraged through
about seven pieces of discrete information—less if information standardization, continuing education, and regularly scheduled
processing is required. This is called working memory. As training. Standardization is achieved through institution-specific
expertise improves, cues can be grouped, creating larger effective protocols or guidelines informed by evidence-based best practices.
working memory. Often referred to as intuition, it is simply pattern For example, given the ad hoc nature of resuscitation teams, using
recognition born of knowledge acquisition and experience. a standardized and consistent prearrival huddle script provides
Carefully designed training and simulation to enhance cue information about team member capabilities and experience,
recognition and appropriate decision-making can be applied as well as resource challenges and data specific to the arriving
patient. This allows for judicious initial task assignment and
across many situations and is paramount to improving outcomes.
care coordination. Similarly, as resuscitation proceeds, certain
tasks such as vascular access (circulation) may be performed by
the nursing staff, which allows other members of the team, like
the physician staff, to take on higher-priority duties (airway,
breathing). Likewise, when a team faces a challenge (e.g., access

21
 is unsuccessful), effective teamwork requires team adaptation, Within each phase, specific tools are provided that, if used
which may include task switching and choosing an alternative effectively, can enhance resuscitation team dynamics and
method. This approach can be applied to a multitude of tasks and effectiveness.
institutional protocols developed for more effective task switching.
Continuing education, such as that offered by ATLS and PREPLANNING AND ADMINISTRATION
Advanced Trauma Care for Nurses (ATCN®), share didactics Effective trauma teams do not occur by happenstance but are
essential to building shared understanding. Both courses offer built intentionally from the top down. Hospital leadership must
skills stations, although as currently taught, these are offered commit to support trauma care by ensuring adequate resources,
separately. Benefit would be derived from combining skills station processes, and systems. At non-trauma-center hospitals,
activities from both ATLS and ATCN courses. Trial combinations administrative support ensures the presence of appropriate transfer
of ATLS and ATCN skills stations prompted sharing of role- agreements and the ability to care for all patient age ranges (e.g.,
specific knowledge, promoted healthy interdisciplinary dialogue, pediatric readiness). Within trauma centers, surgical leadership,
and engendered support for safe communication. Courses trauma program leadership, and collaborative relationships
specific to team training focus solely on these crucial team skills: throughout the institution help ensure that adequate training,
Simulated Trauma and Resuscitation Team Training (STARTT), guidelines/protocols, and process improvement measures are in
Trauma Team Dynamics: A Trauma Crisis Resource Management place.
Manual, and TeamSTEPPS. Finally, regularly conducted, Though administrative and leadership support are important
institution-specific, multidisciplinary team simulations boost team foundations for the trauma team, effective teamwork develops
coordination and competency. As teams mature through practice through shared vision and collaborative respect. It is not enough
and experience, explicit coordination becomes increasingly to have the equipment, staff, resources, and trauma care guidelines
implicit through a shared understanding of roles, enhancing team in place; mutual training must also be provided to develop and
performance. maintain shared vision and trust. Teams need to drill to ensure skill
maintenance and efficiency, as well as promote staff development
SUMMARY using an evidence-based program, such as TeamSTEPPS, to
Inadequate teamwork is among the most common reasons optimize team performance.
for preventable medical error. Refining team dynamics, much Practical aspects of preplanning include awareness of facility-
like trauma process improvement, requires continuous effort specific resource availability. Other factors to consider include the
over time. Indeed, these leadership deficiencies, while sometimes following:
difficult to assess after the fact, should be part of all process • Who declares a trauma activation, and what are the criteria?
improvement endeavors and be assessed during team debriefings. • Is there a checklist or report form to document and share the
A scorecard should be developed to help structure such debrief patient prehospital report?
or after-action review discussions. These steps are essential, as
focus on nontechnical skills has trailed the tremendous technical • What is the contingency plan for trauma patients who arrive
advances of the last several decades. Ad hoc resuscitation teams without prenotification?
form rapidly, may not know one another, have unknown prior • How many staff could be expected to attend a trauma
experience, and operate under great uncertainty over compressed resuscitation?
time frames. The concepts outlined above can be incorporated
• Is there blood readily available? Does the facility have a
into trauma training. This involves preplanning to establish an
massive transfusion / hemorrhage protocol (MTP MHP)?
institutional culture, emphasis on appropriate behaviors that
promote effective and safe communication, structured debriefing, • Is radiology available around the clock?
and mentored training and simulation. The tools discussed in • Is the operating room (OR) staffed continuously and ready
this chapter provide opportunities to enhance team dynamics for emergent cases?
and overall effectiveness. With practice, high-performance
teamwork becomes reflexive. • What are the internal resources for emergent obstetrics,
pediatric, burn care, or other specialty care?
PHASES OF CARE OVERVIEW • How does the facility initiate transfer to specialty care and
aeromedical or ground transport?
Trauma evaluation and management can be organized into
discrete phases of care:
1. Preplanning and administration PREARRIVAL TEAM HUDDLE
2. Prearrival team huddle Once the team is notified that a trauma patient is en route to
3. Arrival handover the facility, they should do a prearrival huddle. Although brief,
4. Initial Assessment team function the prearrival huddle is a critical part of preparing for the
5. Departure handover trauma patient. As such, leaders of trauma teams should make
6. Event debrief sure that such a huddle occurs and that all team members give
their undivided attention. One way to do this is for the leader to
call for quiet during the huddle. Key components of the huddle
include the following:

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 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

• Emergency medical services (EMS) report—what is currently Prehospital providers, including emergency medical
known about the patient technicians (EMTs), paramedics, or other providers responsible
• Staff introductions—who is present, and what are their roles for the treatment and transport of injured persons, are the first
team members to encounter the patient at the injury scene. These
• Staff preparation—key staff present, appropriate personal providers have a unique role in reporting initial assessment
protective equipment (PPE), security presence, etc. information about the patient and the environment where the
• Clear expectations and goals injury occurred. They also provide hemorrhage control and
important resuscitative measures (e.g., airway, breathing, and
• Review of the expected plan for the patient, including possible
circulation) during transport. Various handover protocols and
resuscitation endpoints
local practices may influence how clinicians collaborate and
• Room preparation—warm room, warm fluids, equipment communicate during the arrival handover. There are generally
available and working three time points for information relay from prehospital providers.
Whether an injured patient arrives to the facility without Prenotification: Whether by radio, mobile phone, text message,
prenotification or is upgraded to trauma status in the triage area, or communication app, prenotification is often provided while
it remains critically important to perform a quick team huddle the paramedics are on the scene or during transport. During this
to confirm key team members’ assignments and ensure the best period, the prehospital provider may be task-saturated managing
possible coordination of resuscitative care ( Table 2-2). a critical patient with few resources and unable to provide all the
desired information. The hospital team may need to prepare for
 Table 2-2: The Key Components of the Team Huddle. the arrival with limited details; however, basic details such as the
mechanism of injury, airway status, mentation, and systolic blood
pressure can be essential.
Initial arrival handover: One popular handover protocol,
the Introduction, Mechanism of Injury, Information related to
the complaint, Signs and Symptoms, Treatment given, Allergies,
Medications, Background History, Other information, (IMIST-
AMBO,  Table 2-3), provides prehospital providers and hospital
clinicians with a standardized process for conducting handovers
for all types of patients. Standardized processes must include
behaviors that minimize interruptions, reduce the need to repeat
information, and allow communication of patient interventions
and status to actively listening team leaders while maintaining
eye contact. Trauma team leaders (TTLs) should be easily
identifiable and may wear differently colored attire than the rest
of the team. A brief 20–30-second observation period is reserved,
like a presurgical time out, as “hands off, eyes on” when the
patient remains on the ambulance stretcher and the paramedic
delivers the IMIST-AMBO information. After delivering this
information to team leaders, the prehospital provider asks if there
are any questions about the information delivered. At completion,
the patient is transferred from the ambulance stretcher to the
trauma resuscitation bed. An exception is made for patients in
critical condition, receiving chest compressions, or those that
require manual restraint. In these cases, it may be appropriate to
move the patient without delay. When this occurs, TTLs should
coordinate the prehospital providers’ IMIST-AMBO report
as soon as possible after the patient has been transferred to the
trauma resuscitation bed.

ARRIVAL HANDOVER INITIAL ASSESSMENT TEAM FUNCTION

Clinical handover involves transfer of information, professional In larger centers, trauma teams consist of a minimum of two
responsibility, and accountability between individuals and teams. physicians and three nurses. One physician serves as the TTL,
An effective arrival handover is one that is delivered succinctly standing at the foot of the bed. The TTL oversees and directs the
and in a structured manner and that contains only vital data rest of the team but does not actively participate in procedures
necessary to direct immediate treatment. or handover care in order to maintain situational awareness
and avoid fixation errors. The second physician performs the
primary survey and verbally relays results to the team, ensuring
that findings and cues are identified and explicitly declared for the
entire team to hear.

23
  Table 2-3: The IMIST-AMBO Handover Tool. A popular standardized process for conducting the initial handover of all types
of patients between the prehospital providers and the receiving medical facility team members.

Adapted with permission of BMJ Publishing Group Ltd, from Design and trial of a new ambulance-to-emergency department handover protocol: ‘IMIST-AMBO’, Iedema
R, Ball C, Daly B, et al., 21, 2012; permission conveyed through Copyright Clearance Center, Inc.

The three nurses function as a team overseen by the charting Any instructions to team members should avoid vague
nurse, who generally takes up position next to the TTL and helps language such as “Let’s give more fluid,” or “Let’s give some
with task assignment and nursing management. The other nurses sedation,” but instead should be directed at a particular team
fill the roles of medication nurse and procedure nurse, though member (Cite names), be Clear, and utilize Closed-loop
there may be some overlap in roles depending on the needs of the communication ( Table 2-4). For example, an instruction would
immediate situation. Many centers add additional team members, be given as, “David, could you please transfuse one unit of packed
which may include but are not limited to an airway physician, RBCs under pressure and let me know when the transfusion is
a respiratory therapist, and representatives from other surgical complete,” and David should confirm by responding with, “I will
specialties and critical care. With this approach, team members transfuse one unit of packed RBCs under pressure and let you
can perform concurrent management rather than following a rigid know when it's complete.”
sequential pathway. However, the TTL should use the xABCDE A purposeful, “tactical” pause and summary, or time out,
mnemonic to organizing the primary survey. is an excellent way to maintain a shared mental model or
collective situational awareness among team members and to
elicit input from the team in difficult cases. These pauses are

 Table 2-4: The Three Cs of Communication. Giving direct, specific instructions in a high-pressure
clinical environment, helps avoid misunderstandings and reduce medical errors.

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 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

best called for by the TTL in times of transition, such as at the When faced with a complicated, multiply injured trauma
end of the primary survey or following intubation. This helps patient, even the most experienced practitioner can be
reorient the team, ensure details are not missed, and establish overwhelmed. ATLS algorithms help simplify and prioritize
next priorities. A good summary should include (1) a review of management. Similarly, the TTL should consider that there are
the xABCDEs; (2) an assessment of the current situation; and a finite number of destinations for the trauma patient when they
(3) a plan. For example, “The airway is now secure, and we have leave the trauma/resuscitation bay. At smaller centers where
decompressed the tension pneumothorax. The patient remains capabilities to manage the patient do not exist, the only destination
hypotensive despite two units being transfused with a positive is transfer to a regional referral center, and the transfer process
abdominal FAST. I believe the patient is in hemorrhagic shock. should be initiated as soon as this lack of capability is recognized
The MTP has been activated, and we need to prepare the patient (sometimes even prior to or concurrent with patient arrival).
for transfer to the OR.” For larger trauma centers, destinations for unstable patients are
While the TTL maintains overall team leadership, team limited to the OR and angiography.
members should be empowered to speak up if they notice For stable patients, computed tomography (CT) scan is
discordant findings or have opinions regarding diagnosis or an additional option that may help determine the ultimate
management. While this is best done during tactical pauses, team destination: ward, intensive care unit (ICU), OR, or angiography.
members may need to speak up sooner depending on the urgency Time spent in the trauma bay should be limited and focused on
of the findings. Resuscitations are stressful, and many tools exist completing the primary and secondary surveys and any lifesaving
to guide team members in avoiding confrontational language bedside procedures, with the ultimate goal of determining which
( Table 2-5). These communication skills apply equally to all destination is most appropriate for the patient.
sizes of teams but may need to be adapted to fit local trauma team Prior to leaving the trauma bay, a final time out should be
models. initiated to review patient status and ensure that all appropriate
personnel and equipment are prepared. A standardized
checklist can help ensure important details are not missed and
 Table 2-5: Graded Assertiveness for Speaking Up in
Times of Crisis (CUS). In times of crisis, the CUS approach can be adapted to one’s own center ( Table 2-6).
allows team members to speak up while avoiding
confrontational language.
AIRWAY
Trauma victims often require the individual attention of a
person whose role is to manage the airway. During the team
briefing before patient arrival, the TTL should identify a clinician
Graded assertiveness for speaking with practical expertise to take responsibility for assessing and
up in times of crisis (CUS).
managing the airway. For example, some doctors in training,
such as junior residents, may not have the experience and training
Concerned (e.g., I am concerned we are in managing difficult airways, such as those associated with
missing a tension pneumothorax.) inhalation burns or extensive facial trauma. If a person with this
expertise does not routinely respond to trauma calls, the TTL
should be able to identify someone who can quickly be contacted
to assist the team.
Uncomfortable (e.g., I am uncomfortable that
the patient is still hypotensive and we don’t
If the prehospital information suggests that the patient may
know why.) require a definitive airway, it may be wise to prepare appropriate
drugs for sedation and drug-assisted intubation (DAI) before the
patient arrives. Equipment for managing a difficult airway should
also be easily accessible from the resuscitation room.
Safety Issue (e.g., We need to stop, taking this It is important that the airway manager promptly communicate
hypotensive patient to CT scan is unsafe.) any concerns regarding the airway to the TTL. These may include
anticipation of a difficult airway on assessment or changes in
From Pocket Guide:TeamSTEPPS 2.0 airway status. The TTL should ask the airway manager to secure
a definitive airway when the need becomes apparent during the
primary survey. The timing of definitive airway management may
require a discussion between the consultants and the trauma team
if there is no urgency to secure a definitive airway. For example,
in patients with head injuries who are not in obvious distress,
discussion between the neurosurgical member of the team and the
TTL may be helpful.

25
  Table 2-6: Pre-Departure Checklist. Useful for time out before leaving the trauma bay.

Pre-Departure Checklist

Is there potential for further airway compromise?

If yes, has the airway been secured prior to departure?

Have we reviewed chest and pelvis x-rays?

Is the patient in shock? If yes, have we notified the trauma surgeon?

Are blood products required or activation of the MTP MHP indicated?

Indicators: > 4U blood products in 1 hour OR ABC Score >2 OR evidence of shock

Have we controlled external bleeding?

Is Tranexamic Acid indicated?

If yes, administer 2 grams IV

Have we recorded temperature and treated hypothermia (T <35°C)?

Have we considered analgesia, antibiotics and tetanus?

Have we documented the neurovascular status of all 4 limbs?

Is vascular access adequate and functional?

Do we have all medications necessary for transport?

Do we have the transport monitor connected and functioning?

Have we updated the family?

Have we contacted the receiving unit?

Are there any concerns or issues from any team member?

Communication among team members is vital when a definitive confirmation of medication names and dosages, confirmation of
airway is placed. The team leader assigns roles in conjunction drug administration, and confirmation that the airway has been
with the airway manager, depending on the skills and experience secured or otherwise. Patients may require transfer to the CT scan
of other team members. The airway plan, along with backup plans suite, OR, or ICU. Therefore, the TTL should clarify who will
for any failed attempts, should be communicated to the team. The be responsible for managing the airway and ventilation during
use of checklists ( Figure 2-1) may aid in communication and transfer. This is especially important if the patient is mechanically
ensure the team shares the same mental model. While securing ventilated through a definitive airway.
a definitive airway, closed-loop communication between team Any concerns regarding the airway should be documented and
members is important to ensure that any orders or requests communicated while transferring the patient to other teams. This
have been completed. Examples of closed-loop communications should include the anesthetist if the patient is being transferred to
include confirming with the TTL that the airway person is ready, the OR or ICU.

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 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

 Figure 2-1: TQEH ICU Intubation Checklist. One example of a checklist that ensures adequate preparation and closed-loop
communication between all team members prior to endotracheal intubation.

ADD PATIENT LABEL HERE

TQEH ICU INTUBATION CHECKLIST

V3, 14 Nov 2019 Date_____________________ Time In___________________ Time Out_______________

TEAM PATIENT EQUIPMENT DRUGS PLAN

Intubation  x patent IVC - large

2 Monitoring:
 ECG, Induction Verbalize plan
Leader Position optimised SpO2, BP, ETCO2 Paralysis
Consultant Aspirate NGT Check
 suction Vasopressors
Aware Oxygen - bag-valve
Optimise
 space Flush IV running
Anaesthetist around bed and mask Bag mask
Fluids
aware ventilator Oropharyngeal
Airway
 doctor Pre-oxygenate, 2 A  working direct and
Airway nurse sources of oxygen video laryngoscope
Drugs Runner Checked
 allergies Bougie (Ventilating) Bag mask
Scribe/ 2  sizes, ETT, cuff
monitor checked
Laryngeal mask
PEEP valve “Does anyone
Ventilator circuit have any
checked and test questions or
lung connected concerns?”

Post-procedure Tube
 secured N
 G inserted ABG CXR Debrief
 Family Notified Documention

The Queen Elizabeth Hospital (TQEH) ICU, Adelaide South Australia. Reproduced with permission.

thoracotomy.

CIRCULATION
BREATHING
Hemodynamic instability related to blood loss from
Prior to patient arrival, the TTL must quickly establish
penetrating injury mandates rapid intervention focused on the
the competencies of team members in performing needle
anatomic location of external wounds. In patients with blunt
decompression and chest drainage techniques. The status of
injury, swiftly narrowing the injury possibilities is crucial for
airway and breathing, including respiratory rate, auscultation
timely and appropriate intervention. As findings are identified,
findings, and saturation, should be conveyed to the team as
they should be shared with the team to promote a shared mental
part of the arrival handover. Any interventions such as needle
model of patient status ( Table 2-7). The process of promptly
decompression or finger thoracostomy should also be conveyed
identifying and addressing injuries can be divided into two key
to the team. Any changes in the respiratory status should be
areas: physiological response and diagnostics.
conveyed to the TTL by the person performing the primary
survey to facilitate appropriate action by the team. Physiological response has three actionable categories:
The TTL should recognize which thoracic injuries can or
cannot be managed by the receiving institution. Where the injuries Responders: Often, 1 L of crystalloid and/or 1 unit of blood/
exceed the institution’s capacity to manage them, arrangements blood components will stabilize this group. These are often patients
should be made to transfer the patient to the appropriate facility with long bone injuries contained in a closed compartment or
as soon as reasonably possible. These injuries may include major patients with solid organ or soft-tissue injuries that are not actively
vascular or tracheobronchial injuries or injuries requiring open bleeding. In this situation, the team usually has enough time to

27
  Table 2-7: Sites of Blood Loss in Trauma. A stepwise approach to the identification of possible sources of hemorrhage in
the trauma patient.

SITE DIAGNOSTIC TIMING FINDINGS Comments/Caveats

Abdomen FAST Can be performed as Positive in any window A negative FAST is nondiagnostic
a part of the primary and should be repeated at intervals
survey (xABCDE — in the persistently unstable patient
FAST)

Diagnostic Usually after excluding Grossly positive Used when other sources of
peritoneal hemorrhage in other bleeding have not been clearly
aspiration sites identified
(aspiration or
lavage) Should only be performed by an
available surgeon

Chest Chest radiograph As soon as possible ‘White-out’ of A wide mediastinum is a danger

after arrival, either hemithorax sign, but not likely active bleeding
during or immediately
after primary survey Pneumonectomy may mimic
hemothorax

Pelvis Pelvis radiograph As soon as possible Pelvis fracture patterns

after arrival, either associated with
during or immediately bleeding: open book,
after primary survey vertical shear, lateral
compression

Retroperitoneum By elimination Moving to the CT There are no current This is a closed space and often
scanner should only bedside diagnostics to these patients will be transient
occur when there evaluate this area responders, allowing time for CT
is a modicum of scanning
stability and reserved
for responders and
transient responders

Floor Observation/History At time of arrival and Gross blood on the If patient is a transient or non-
from field during primary survey gurney at patient responder and no gross bleeding is
arrival; report from observed, look for other sources
transporting providers

Muscular and Rapid TEG, INR, low Discuss TEG This can stem from multiple injuries
subcutaneous hematocrit, skeletal that are nonsurgical in nature (e.g.,
x-rays INR may not scalp laceration, multiple bony and
tissues; Fracture change early
sites soft tissue injuries), resulting in
trauma-induced coagulopathy
Low hematocrit is a
late sign, but any low Low hematocrit may be chronic but
hematocrit detected could be determined by looking at
at first lab draw RBC indices
should raise suspicion
for bleeding

complete further diagnostic testing. definitive care areas (the OR or interventional radiology suite).
In facilities that lack these capabilities, teams must work rapidly
Transient responders: These are patients likely to have ongoing to attempt stabilization, promote timely transfer, and inform
bleeding from solid organ or soft-tissue injuries and who need accepting facilities/clinicians of the greatest potential injuries of
timely diagnostics to confirm or exclude injuries in need of urgent concern.
appropriate interventions. Using a stepwise approach to identify the likely source of
Nonresponders: Despite active resuscitation and interventions, bleeding can be very effective. With practice, logical stepwise
these patients mandate rapid, directed diagnostic approaches to decision-making can be completed quickly, usually within the first
facilitate appropriate, emergent interventions and movement to 10–15 minutes after arrival. Pertinent negatives are as valuable as

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 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

positive findings, allowing teams to eliminate sources of bleeding and team can plan for likely patient needs and supplies. These
and focus on the next area of concern to intervene accordingly. include:

DISABILITY Airway—need for emergent airway control/cricothyroidotomy

Traumatic Brain Injury (TBI): In the case of an agitated patient, for airway edema; need for warmed ventilator circuit
rapid sequence intubation (RSI) may be required to facilitate safe Breathing—need for escharotomies with circumferential
and efficient evaluation and resuscitation, and the need for RSI chest burns
may itself be a sign of deteriorating brain injury. This can make Circulation—warmed IV fluids, warmed blood, resuscitation
subsequent neurological evaluations more challenging. It is volume needs for burn patients
important that the team continue to reassess and report on patient Disability—Glasgow Coma Scale (GCS) alterations
status to avoid delayed recognition of neurologic deterioration. from toxins, hypothermia/hyperthermia, need for fracture
A common pitfall in patients with head injuries is managing management, fasciotomies/escharotomies
scalp lacerations. While these are a seemingly minor concern Environment/Exposure—quick removal from cold spine
in the setting of a severe brain injury, they can be a source of boards, removal of wet clothes, active warming measures, time-
exsanguinating hemorrhage and can be controlled with simple limited exposure, and quick replacement of warm blankets after
measures. The first step is recognition. Well-functioning teams patient assessment
should empower members to speak up to ensure that injuries like Early decision and preparation for transfer to definitive care
this are recognized and addressed. remain a priority if patient needs exceed center capabilities,
Spinal cord injury (SCI): In multiply injured patients, keen especially for burns, pediatrics, obstetrics, and specialty care.
observation is warranted to detect upper and lower extremity
motor issues. Findings must be voiced audibly to ensure team TRAUMA TEAM AND CHILDREN
awareness of the potential for impending physiologic deterioration. In nonpediatric-designated centers, the impending arrival of
The need for airway management can be obvious in patients with a pediatric trauma patient may trigger levels of team anxiety and
a high cervical cord injury due to respiratory distress. Patients stress that are profound. The perceived weakness of an injured
with lower cervical (C5–C7) or high thoracic (T1–T6) injuries are child impacts the entire team. Because very young trauma patients
more challenging, since they often present with little to no obvious comprise a small percentage of the trauma population at most
respiratory distress and are able to maintain shallow breathing centers, trauma teams may have a confidence gap and thus feel
despite their injury. However, up to 30% of these patients will challenged by young trauma victim care.
need intubation due to progressive volume loss and atelectasis, The adage “Good things come in small packages” may
which can lead to acute hypoxemic respiratory failure or even predictably mutate to “scary things” in the absence of good
death. Team members should be observant of these changes and preparation and training. There is no substitute for robust
be encouraged to verbalize their concerns. prearrival preparation and planning. Trauma triage and treatment
Shock in the patient with SCI is hemorrhagic until that cause simulation (with video review if possible) of pediatric trauma
is excluded. Patients with SCI may not be able to report subjective scenarios measurably strengthen skills, as well as the physical and
complaints such as pain; thus, the team must rely on their powers psychological preparation of the trauma team. Simulation, when
of observation during the Initial Assessment. Reevaluating the followed by critical debriefing to embed efficiencies and best
patient at scheduled intervals and providing verbal reports may practice models for the team, is an ideal model for practicing skills
reveal changes pointing to a source of internal hemorrhage. and understanding team roles and responsibilities.
In the unconscious seriously injured child, the psychological
EXPOSURE AND ENVIRONMENT and emotional health of the child may be superseded by that of
All team members should consider environmental concerns the trauma team. Strong team leadership, clear communication
that may impact trauma patient care and take the needed steps to of priorities, and delegation of critical clinical responsibilities will
protect patients from the impact of exposure and environmental have the greatest salient effects on the psychological and emotional
extremes. Understanding potential impacts of exposure and responses of the trauma team.
extreme temperatures allows teams to address those needs early In the conscious, more physiologically stable child, basic
(e.g., warm room, warm blankets, heat exchangers, potential for understanding of childhood response to injury and environment
airway compromise). is essential. The concept of the “distracting injury” is well
The EMS prehospital report can provide critical information anchored in trauma language and practice. In the injured child,
that assists the trauma team as they prepare to receive the patient. being restrained with a cervical collar, on an immobilizing device,
In addition to information about the patient’s mechanism of and away from parents and family in prehospital or trauma room
injury, treatments provided, and vital signs, critical information locations are all enormously “distracting.”
about whether a patient was exposed to extreme conditions or Additionally, it is important to remember that there are
temperatures can be gathered as well, including submersion, substantial numbers of injured children who may have special
prolonged extrication in extreme weather, “found down” status, needs, including learning or neurodevelopmental disability.
burns related to specific environments (blast, enclosed space), Information obtained during the initial arrival handover can be
potential for nonintentional trauma, or exposure to hazardous particularly important if there is history of one of these conditions.
materials. Based on the exposure information gathered, the TTL If possible, talk to the child as calmly and clearly as the situation
will allow, and judge responses with these potential variants

29
 in mind. The emotional environment of the conscious child is skills is increasingly recognized, and the use of simulation to help
important during Initial Assessment. Overly emotional or strident improve the performance of obstetrical teams in such situations
communication is counterproductive and is best minimized. has been demonstrated to be effective.
Tachycardia is an important physiologic sign in injured Initial evaluation of a reproductive-age woman should include
children. Knowledge of normal ranges of common vital signs for a concise and focused obstetric and gynecologic history and
different age groups is important clinical information. Anxiety ensuring that universal pregnancy testing is performed. In some
and the child’s emotional response may play a role but should instances, early pregnancy may be diagnosed using point-of-
not preclude careful assessment of other causes of sustained care ultrasound. Approach to the female trauma patient can be
tachycardia. stratified as follows: (1) potentially pregnant; (2) pregnant at less
Accurate prehospital information is helpful in preparation than 20 weeks' gestation (or local standards for viability); and (3)
for pediatric trauma patients. Accurate weight estimates and vital pregnant at greater than 20 weeks' gestation (or local standards for
signs may be challenging in the prehospital setting. The use of viability) ( Table 2-8).
adjuncts such as a weight- or height-based pediatric emergency Verbal confirmation by the TTL will help focus team efforts.
tape are indispensable when there is uncertainty regarding Fetal viability is achieved at approximately 23 weeks’ gestation,
therapeutic options in small children. There are posters available at which time maternal resuscitation and fetal assessment should
that describe pediatric and infant GCS scoring, formulae for take place concurrently. Perimortem delivery is recommended
computation of age-appropriate systolic blood pressure, and within 4 minutes of arrest with the goal of fetal delivery within
guidelines for optimal imaging; these are helpful if available in the 5 minutes of arrest, while resuscitation is continued. The need
resuscitation areas. There are also effective algorithms to help with for early delivery (not perimortem C-section) should be based
recognition of common patterns of nonaccidental trauma, which upon mutual decision-making between obstetric and trauma
is especially prevalent in the infant age range. The age-adjusted specialists and should include patient input to ensure appropriate
pediatric shock index (SIPA) is an effective tool to help triage the consideration is given regarding implications related to mode of
severity of injury. Familiarity with this tool is a tested method to birth, outcomes related to prematurity, and other relevant points
assess severity of hypovolemia from injury. based on individual circumstances.
Family members in the pediatric trauma resuscitation room Minor injuries in pregnant patients can pose a risk to the
may be of huge benefit to the injured and anxious child. If the fetus. These typically manifest within 4–6 hours of presentation
family or caretakers do not materially interfere with the care being and require monitoring with cardiotocography by a team member
provided by the trauma team, they may help with communication, with experience in recognition of uterine contractions and fetal
historical information, or support. Injured and emotionally fragile heart rate interpretation.
children will typically mimic the level of the most emotional
family member present. It is important to assess a family advocate’s DEPARTURE HANDOVER
ability to maintain a calm and supportive demeanor. Displays of The departure handover occurs when the patient is transferred
volatile or stressful emotional response will often be mirrored by to a different location/department within the hospital (e.g., OR,
the child. Conversely, parental detachment or disinterest may be ICU, ward) or to an outside facility when in-house resources are
warning signs of child maltreatment or neglect. not available to meet the patient’s needs. Developing a standard
reporting format is central to consistent and reliable information
TRAUMA TEAM AND THE PREGNANT PATIENT
sharing. The foundation of this report is to communicate the most
Treating a pregnant trauma patient can amplify the stress of relevant information in a concise yet comprehensive manner.
the Initial Assessment and generate powerful emotional responses The handover includes both written documentation and
from team members. Successful assessment and management of verbal communication and should include the circumstances of
the pregnant trauma patient requires knowledge of and attention the injury, details of the resuscitation, relevant physical findings,
to pregnancy-specific physiologic changes, knowledge of the pertinent imaging and laboratory data, specific treatments,
spectrum of potential injuries, and appropriate early integration current clinical condition, anticipated areas of concern, and
of obstetrical services into the trauma team, with preparation for pertinent medical history. Several structured, standardized
extreme cases that may require rapid obstetrical intervention. handover tools exist to achieve this objective, such as S-xABCDE-
Maternal trauma can result in significant and sometimes occult or BAR, as outlined in Chapter 1, Initial Assessment: Primary Survey,
delayed consequences to the fetus ( Table 2-8). in Chapter 15, Transfer to Definitive Care.
Care of the pregnant trauma patient requires coordination of Closed-loop communication is important to ensure that the
a multidisciplinary team. To ensure optimal management, care receiver understands the information, and the reporter should
must be coordinated between the TTL and the obstetrical service. provide the opportunity for questions and leave a callback number
Strategies to achieve this include the use of clear activation to ensure optimal patient care. Centers should monitor adherence
criteria, institutional obstetric emergency teams that can respond and embed this process into routine educational offerings to
to the trauma venue, or, in the absence of an available obstetrical ensure acceptance.
service, practice guidelines appropriate to location. The
importance of interprofessional team function and use of CRM

30 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

 Table 2-8: Trauma in Pregnancy Toolkit. Evaluation of the female trauma patient of reproductive age.

TRAUMA IN PREGNANCY TOOLKIT

Team Awareness Concerns Team Actions/Shared Knowledge

Stages of Pregnancy Potentially Pregnant •C

 onfirm pregnancy test obtained, report results aloud
ACTIONS

•O
 bstetrical and gynecologic history: include GTPAL (total
gestations, term gestations, preterm gestations, abortions, and
living children); prior surgery; obstetrical care to date; knowledge
of Rh status
•A
 ssess uterus during primary survey
•U
 terine fundus above umbilicus correlates
with > 20 week gestation

Suspected or known: <20 weeks •M aternal resuscitation per nonpregnant patent
(or local standard for viability) •O bstetrical consult and fetal ultrasound if available
• Fetal maternal hemorrhage test (Kleihauer Betke, flow cytometry)
• Electronic fetal monitoring if available and recommended by
Obstetrical Team
• Focused obstetric history (ideally obtained with obstetrical team)
using “CODE” mnemonic: Complications of Pregnancy; Obstetric
history and prenatal care; Dating method/Estimated Due Date;
Event details, including leaking, bleeding, contractions, fetal
movement

Suspected or known: >20 weeks •C

 oncurrent assessment of mother & fetus
•L
 ateral lift tilt or manual uterine displacement
•P
 oint-of-care ultrasound where available may be used
to confirm the presence of fetal heart activity
•B
 e ready for emergency C-section
•E
 lectronic fetal monitoring (if available)

Team Awareness Concerns Team Actions/Shared Knowledge

Psychological Increased team anxiety •C

 all for additional assistance
FOR TEAM AWARENESS

•G
 uidelines for obstetrical activation

Two teams/Two patients • Develop roles/responsibilities checklist with obstetrical team

• Stratify approach by gestation
• Systematic collaborative resuscitation
• Multidisciplinary simulation-based training

Physiological Shock less evident •H

 ypervolemic, hyperdynamic at baseline
•D
 ilutional anemia
•N
 ormocapnea is an early sign of ventilatory compromise

Fetal distress •E
 arly fetal heart rate monitoring as an additional vital sign
•E
 arly indication of maternal distress

Rh status •F  etal maternal hemorrhage test on all pregnant patients

•R  h immune globulin on all Rh-negative patients
• I f unable to obtain Rh status, administer immune globulin

Radiation exposure Protect fetus when able • Prioritize optimal resuscitation of mother
• Obtain imaging as clinically indicated

Emergency C-section Time matters • I nitiated within minutes of arrest and fetal delivery
delivery within 5 minutes
•D  o not waste time for fetal heart tones or ultrasound
•V  ertical incision in abdomen and uterus
•M  ay improve maternal survival even if fetus <20 weeks
• Notify neonatal ICU team if available
•M  ultidisciplinary simulation-based training

Minor maternal Occult fetal consequences •M

 inimum of 4-6 hours of cardiotocographic monitoring/electrical
injury/Obstetrical fetal monitoring, ultrasound, consider:
complications/Other •P
 remature rupture of membranes
•P
 reterm labor
•P
 lacental abruption
•U
 terine rupture
• S creen all women of childbearing age
for intimate partner violence

31
 EVENT DEBRIEF  Table 2-10: TAKE STOCK Debrief Tool.
Debriefing is defined as a reflective conversation about One example of a structured debrief tool that
performance. Allocating time for a debrief following trauma can be used by the trauma team following
resuscitations can be beneficial to (1) address team member stress; a resuscitation.
(2) identify strengths in management; (3) identify areas in need of
improvement; and (4) improve team functioning while building
TAKE STOCK Debrief Tool
mutual respect and empathy.
To be most effective, debriefs should be structured and
constructive. Having a guided debrief is more effective than T Take an instruction sheet
unguided ones; thus, facilities should develop specific features
to be included in the debriefs and build a structure where those A Ask “Is everyone OK?”
facets are discussed. The Promoting Excellence and Reflective
Learning in Simulation (PEARLS) framework presents a simple,
easy-to-learn technique that can be helpful to structure debriefs.
K Know if anyone needs a break

This framework consists of setting the scene and creating a safe

context to facilitate learning. The facilitator then obtains reactions E Equipment issues?

from participants, exploring their feelings. At this stage, facts are

clarified before analyzing the performance. This type of approach
may be useful for longer debriefs, but when time is limited, even a
quick reactions phase (“How did that feel?”) followed by a simple
S Summarize the event

plus/delta (“What went well? What would you do differently

next time?”) is probably adequate, though this is an area in need
T Things that went well?

of further study. Debriefs should never be seen as punitive or

place fault on an individual but should instead be focused on
O Opportunities to learn?

identifying gaps that could improve team function and, ultimately,

patient care. As such, it is important that a psychologically safe
C Cold debrief necessary?

environment be built when rolling out a debriefing process.

Debriefing can occur immediately following a resuscitation K Know who is present

( a “hot” debrief ) or in a delayed fashion ( Table 2-10). While Adapted with permission of BMJ Publishing Group Ltd,
delayed debriefs may be required for critical incidents and very from Implementation of the ‘TAKE STOCK’ Hot Debrief Tool
traumatic events, immediate debriefs are more practical for in the ED: A quality improvement project, Sugarman, Max;
Graham, Blair; Langston, Sarah; Nelmes, Pam; Matthews,
most situations. It is important to set aside time for the debrief; John, 38, 2021; permission conveyed through Copyright
otherwise it is unlikely to happen. The TTL is an obvious choice Clearance Center, Inc.
to facilitate the debrief, but any team member could be assigned
this role. Having an accepted process and role clarity is more GOALS OF CARE AND COMMUNICATION OF
important than the background of the facilitator. Training is SERIOUS NEWS
helpful for facilitating a multidisciplinary group debrief in order
to ensure that the conversation isn’t dominated by one or two An unfortunate reality is that not all patients with trauma
individuals and that all priorities are addressed. Such training will survive their injuries. Data suggest that about 1%–2% of all
should demonstrate to leaders the merits of conducting such transfers to a trauma center either die or are palliated without
debriefs and provide them the tools and techniques they will need any operative, endoscopic, or radiological intervention. This may
to conduct effective debrief sessions. increase the burden on referring and receiving centers, medical
transfer services, and families and loved ones, especially if the
receiving center is a long distance away.
However, predicting trauma outcomes is an inexact science.
In patients with injuries thought to be potentially nonsurvivable,
communication between the healthcare team, the family, and the
accepting transfer facility is critical. Goals of care discussions
should include the patient’s preexisting wishes (if known) and
should be initiated once there is enough information regarding the
nature, likely impact, and expected course of the patient’s injuries.
In many cases there will not be enough information about this at
the initial receiving facility, and clinicians should be honest with
the patient and family about what they do and do not know. This
is particularly true when prognostic determinations will require
specialist input not available at the initial receiving facility.
Discussions around limitations of care and palliation are
difficult. There are a variety of models to guide this communication;
one approach is outlined in Chapter 20, Communicating Serious
News in the Acute Trauma Setting.
32 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 2 | Resuscitation Team Function and Communication

8. Kean S, Haycock-Stuart E, Baggaley S, Carson M. Followers

CHAPTER SUMMARY
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injury.2022.07.045.

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36 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 3 | x: Control of eXsanguinating Hemorrhage

x: Control of eXsanguinating
External Hemorrhage

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course manual, you will have the ability to do the following:

1. Identify life-threatening compressible external hemorrhage

2. Initiate tiered emergent external bleeding control
3. Evaluate indications for, and describe application of, an extremity tourniquet

37
 for massive (i.e., active, large-volume, and continuous) external

3
blood loss. When present, massive external compressible
hemorrhage is immediately controlled upon patient arrival.
Bleeding control interventions are lifesaving, take seconds
to initiate, and may be provided while other team members
simultaneously proceed to initial basic airway management.
An xABCDE protocol has recently been associated with improved
survival over an ABCDE protocol in one prehospital study.

ASSESSMENT
Control of eXsanguinating
External Hemorrhage Traumatic hemorrhage can be divided into compressible
and noncompressible types. Compressible hemorrhage may be
defined as bleeding that is visible and potentially controllable
without making an incision, employing methods such as
CHAPTER STATEMENT pressure, packing, and tourniquet application. Compressible
hemorrhage may be due to an extremity injury or a massively
Massive external hemorrhage represents an immediate threat
bleeding nonextremity wound. The clinician visually inspects
to life. Stopping exsanguinating external bleeding through direct
the patient, clothing, and stretcher, searching for continuous
pressure, wound packing, and/or tourniquet application is the
large-volume bleeding, pooling of blood, and spurting arterial
first step in the primary survey of the trauma patient.
hemorrhage. In many trauma scenarios, external visible bleeding
INTRODUCTION is not large in volume, is not spurting from a larger artery, or
was adequately controlled during prehospital management. In
Treat the greatest threat to life first. Rapid trauma primary situations of non-life-threatening external hemorrhage, the
survey consists of a systematic approach to identify and mitigate clinician proceeds to the airway assessment and management
life-threatening conditions. In some scenarios, massive external step of the primary survey.
hemorrhage, such as occurs with extremity and other open
wounds, may represent the greatest threat to life. A focus on MANAGEMENT
stopping compressible, life-threatening external bleeding is
The area of exsanguination is completely exposed. All
supported by data reporting improved outcomes.
clothing is removed around and proximal to the injury. Direct
Tourniquet use was recognized as an effective method to
pressure is applied with a gauze dressing as precisely as possible
control hemorrhage during the World Wars. However, prolonged
over the site of bleeding. Larger and deeper wounds are packed
tourniquet application led to amputations of potentially viable
with gauze while pressure is applied. If bleeding control is
limbs, rhabdomyolysis, and neuropathies. Thus, through the latter
accomplished, a pressure dressing is applied and the wound is
half of the 20th century, tourniquet use almost disappeared from
observed for resumption of hemorrhage while other steps of the
military and civilian practice. During the 1990s and the early 21st
primary survey are completed. Most trunk wounds and scalp
century, tourniquets were reassessed and adopted throughout
lacerations are temporarily controlled with gauze, packing, and
the US military, with an 85% decrease in deaths due to extremity
pressure. If extremity bleeding control is not rapidly achieved
hemorrhage.
with direct pressure and wound packing, a tourniquet is
Civilian prehospital tourniquet use lagged military adoption.
applied. Blind clamp placement into wounds is not performed.
The Sandy Hook tragedy and the Hartford consensus occurred at
the same time the success of military tourniquets was confirmed.
The Bleeding Control Basic (B-Con) course for the public
TOURNIQUET APPLICATION
was released in 2014. B-Con was successful beyond expectations A tourniquet is applied if extremity bleeding is not rapidly
and transitioned into the Stop the Bleed® program. Subsequently, controlled with pressure, if “spurting” arterial hemorrhage
tourniquets became a standard component of trained first is visualized, or if a complete or near-complete amputation
responder, bystander, and emergency medical service (EMS) has occurred. The tourniquet is applied 2–3 inches (5–8
equipment. Bleeding control kits are frequently located next cm) proximal to the bleeding site and not over a joint. At a
to automatic defibrillators in public areas. Several studies have healthcare facility, preferably all clothing surrounding the injury
documented a lower rate of mortality, blood transfusion, and has been removed, and the tourniquet is applied directly on skin,
complications following tourniquet application. If tourniquet not over clothing ( Figure 3-1). The tourniquet is tightened
duration is less than 2 hours, there does not appear to be an sufficiently to overcome systolic blood pressure. A pulse should
increased rate of amputations or other tourniquet-related adverse not be palpable distal to the tourniquet following application,
events. and bleeding should cease. The tourniquet is painful when
The “x” step of xABCDE does not diminish the importance tightened adequately. If bleeding continues, a second tourniquet
of airway assessment and maintenance, nor does it represent a is placed 2–3 inches proximal to the first device. Importantly,
full assessment of circulation. The “x” step is a quick evaluation time of application is recorded, preferably on the device itself.

38 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 3 | x: Control of eXsanguinating Hemorrhage

 Figure 3-1: Extremity Tourniquet and Application. An extremity tourniquet

applied 2-3 inches (5-8 cm) proximal to the bleeding site, on skin, not over
clothing, and not over a joint. The tourniquet is tightened sufficiently to
overcome systolic blood pressure.

Following completion of the primary survey and adequate continuous, compressible external hemorrhage is immediately
resuscitation, assessment for tourniquet conversion is performed. controlled upon patient arrival through tiered application of direct
Tourniquet conversion is the deliberate process of exchanging pressure, packing, and tourniquet application. A distal pulse is not
a tourniquet for another method of hemorrhage control. Please present following proper application of an extremity tourniquet.
see Chapter 14, Initial Assessment: Secondary Survey, for the Bleeding control is lifesaving, takes seconds to perform, and is
procedure of tourniquet conversion. provided while other team members simultaneously provide
initial basic airway management.
NONCOMPRESSIBLE HEMORRHAGE
Hemorrhage within the chest, abdomen, and pelvis cavities, as
KEY LEARNING POINTS
well as at junctional locations (i.e., too proximal on an extremity • Uncontrolled massive external hemorrhage
for tourniquet application), is considered noncompressible. represents a great and rapid threat to life.
Junctional tourniquets are being evaluated for efficacy. At
present, inadequate clinical experience and data exist. Control • Immediate identification and control of
of pelvic hemorrhage by application of external pelvic devices exsanguinating external hemorrhage is the “x”
will be covered in Chapter 6, Circulation Assessment and Volume step of the xABCDE primary trauma survey.
Resuscitation. Data and indications for catheter-based vascular • A tiered application of direct pressure, wound
occlusion devices (e.g., resuscitative endovascular balloon packing, and tourniquet application is performed
occlusion of the aorta, REBOA) are evolving. These advanced to manage exsanguinating external hemorrhage.
techniques are beyond the scope of ATLS®.
• A tourniquet is tightened until bleeding stops.
CHAPTER SUMMARY A distal pulse is not palpable when a tourniquet
is adequately tightened.
Treat the greatest threat to life first. Massive external
• The time of tourniquet application is recorded,
hemorrhage may represent the greatest threat to life. A quick preferably on the device.
evaluation and stopping of compressible exsanguinating external
bleeding comprise the “x” step of xABCDE. Active, large-volume,

39
 REFERENCES
1. Prehospital hemorrhage control and treatment by
clinicians: A joint position statement. Ann Emerg Med.
2023;82(1):E1–E8. https://www.annemergmed.com/
article/S0196-0644(23)00209-3/fulltext.
2. Kragh JF Jr, Dubick MA. Battlefield tourniquets: Lessons
learned in moving current care toward best care in an
army medical department at war. US Army Med Dep J.
2016;(2–16):29–36. PMID: 27215863.
3. Schroll R, Smith A, Alabaster K, et al. AAST
multicenter prospective analysis of prehospital
tourniquet use for extremity trauma. J Trauma Acute
Care Surg. 2022;92(6):997–1004. DOI: 10.1097/
TA.0000000000003555. Epub 2022 Jan 18. PMID:
35609289.
4. Smith AA, Ochoa JE, Wong S, et al. Prehospital tourniquet
use in penetrating extremity trauma: Decreased blood
transfusions and limb complications. J Trauma Acute
Care Surg. 2019 Jan;86(1):43–51. DOI: 10.1097/
TA.0000000000002095. PMID: 30358768.
5. Teixeira PG, Brown CV, Emigh B, et al. Civilian
prehospital tourniquet use is associated with improved
survival in patients with peripheral vascular injury. J
Am Coll Surg. 2018;226(5):769–776.e1. DOI: 10.1016/j.
jamcollsurg.2018.01.047. Epub 2018 Mar 29. PMID:
29605726.
6. Ritondale J, Piehl M, Caputo S, et al. Impact of prehospital
exsanguinating airway-breathing-circulation resuscitation
sequence on patients with severe hemorrhage. J Am Coll
Surg. 2024;238(4):p 367–373.
7. Butler FK Jr, Hagmann J, Butler EG. Tactical combat
casualty care in special operations. Mil Med. 1996:161
Suppl:3–16.
8. Eastridge BJ, Mabry RL, Seguin P, et al. Death on
the battlefield (2001–2011): Implications for the
future of combat casualty care. J Trauma Acute Care
Surg. 2012;73(6 Suppl 5):S431–S437. DOI: 10.1097/
TA.0b013e3182755dcc. Erratum in: J Trauma Acute Care
Surg. 2013;74(2):706. Kotwal, Russell S [corrected to
Kotwal, Russ S]. PMID: 23192066.
9. Eilertsen KA, Winberg M, Jeppesen E, Hval G, Wisborg T.
Prehospital tourniquets in civilians: A systematic review.
Prehosp Disaster Med. 2021;36(1):86–94. DOI: 10.1017/
S1049023X20001284.
10. Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby
JD, Holcomb JB. Characteristics and outcomes of
prehospital tourniquet use for trauma in the United
States. Prehosp Emerg Care. 2023;27(1):31–37. DOI:
10.1080/10903127.2021.2025283.
11. Joarder M, El Moussaoui HN, Das A, Williamson F,
Wullschleger M. Impact of time and distance on outcomes
following tourniquet use in civilian and military settings:
A scoping review. Injury. 2023;54(5):1236–1245.
12. Schroll R, Smith A, Alabaster K, et al. AAST
multicenter prospective analysis of prehospital
tourniquet use for extremity trauma. J Trauma Acute
Care Surg. 2022;92(6):997–1004. DOI: 10.1097/
TA.0000000000003555.

40 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

Airway Assessment
and Management

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe the critical role of airway management 4. Describe an approach to anticipate, identify,
in trauma care and the importance of ensuring and manage potential complications in airway
adequate oxygenation and ventilation in trauma management including an inability to intubate
patients 5. Explain application of the principles of safe
2. Explain the indications for various airway airway management including use of continuous
management techniques as a range of airway monitoring, planning, and cognitive aids.
interventions, from basic maneuvers to advanced 6. Describe adaptation of airway management
procedures and explain when each is appropriate techniques to specific patient populations
3. Describe the concept of an individualized and including pediatric, obstetric, and larger
context-based approach to airway management patients
and explain modifications of airway management 7. Explain management principles of airway
strategies by considering the patient’s specific injuries and burns
injuries, airway anatomy, and physiology; the
expertise and training of the ATLS clinician 8. Discuss development and implementation of
and team; and the management environment, team-based approaches to airway management
including available equipment and human
resources
41
 Safe airway management is achieved through individual and

4
team training, continuous physiological monitoring, proactive
planning for potential failures, early problem recognition, and
excellent teamwork and communication. Less-invasive upper
airway techniques may provide adequate airway management
until appropriate expertise is available to perform endotracheal
intubation or other advanced maneuvers.
This chapter promotes an individualized and context-based
approach to airway management, considering the following:
• The presenting injuries, airway anatomy, and physiology
Airway Assessment
• The ATLS® clinician and team level of expertise, experience,
and Management and training
• The management environment, available equipment, human
resources, and access to specialized assistance
CHAPTER STATEMENT
Managing injuries or burns to the airway can be very
Airway management is a fundamental aspect of trauma care. challenging, even for experienced clinicians. In such instances,
Meticulous planning and flawless execution are important to early consultation with specialist surgeons and/or critical care
ensure patient safety. Ensuring adequate oxygenation is a primary physicians is important.
goal, understanding that not all patients benefit from immediate This chapter serves as an introduction to airway management
intubation. in trauma. It is not intended to replace clinical training, expertise,
Airway management interventions may be considered on a and judgment, nor does it seek to limit the practice of airway
spectrum, ranging from basic airway maneuvers and upper airway management specialists who apply their expertise in a different
devices to subglottic airways (tracheal intubation and surgical/ fashion than described in this chapter.
incisional airways). A modified rapid-sequence intubation
(RSI) technique is recommended for tracheal intubation in ANATOMY AND PHYSIOLOGY
trauma scenarios, with preoxygenation, apneic oxygenation,
and confirmation of successful tracheal intubation as critical The airway includes the nasopharynx and oropharynx, the
components. Checklists, cognitive aids, and well-organized laryngeal structures, the trachea, and the progressively smaller
equipment enhance team performance in high-stress airway divisions of the airways in the lungs. Airway management focuses
management situations. on ensuring patency to the level of the trachea. Injuries can occur
to the more distal airways, especially the main bronchi.
INTRODUCTION The primary physiological functions of the airway are, in order
of importance in trauma management:
Trauma patients may present with injuries or burns affecting • To provide oxygenated air to the lungs (oxygenation)
the airway or adjacent structures. Airway assessment and • To remove carbon dioxide (CO2) from the lungs (ventilation)
management are important due to the systemic effects of trauma,
particularly in neurological and respiratory injuries. Managing • To protect the lungs from foreign material, including
the airway involves a balance between a swift intervention and a food, fluids, secretions, and regurgitated gastric contents
thoughtful approach. While compromised airways can result in (protection against pulmonary aspiration)
significant morbidity and mortality, interventions can sometimes In airway management, maintenance of oxygenation has
exacerbate a partially obstructed airway, leading to complete the highest priority, as permanent systemic injury can occur
blockage. Airway management failures account for 8% to 15% of within minutes of inadequate oxygen. In normal physiology,
potentially preventable trauma deaths. reduced CO2 clearance is frequently well tolerated, but this
A 2011 audit in the United Kingdom revealed that even tolerance may decrease in critical illness, particularly in traumatic
among specialist clinicians within advanced healthcare systems, brain injury (TBI). Pulmonary aspiration can impair oxygenation
catastrophic complications related to airway management can and ventilation and lead to pneumonitis or pneumonia in a more
occur. These complications may be prevented through training delayed fashion.
and following protocols. The 2021 INTUBE study provided
additional insights into global airway management complications. PATHOPHYSIOLOGY
Cardiovascular instability was common, and the study highlighted
areas for improvement, including equipment selection and AIRWAY INJURIES AND PATHOLOGIES
guideline adherence. Sentinel cases of death under anesthesia
due to airway complications serve as stark reminders that even Direct injuries to the airway, while infrequent, present
experienced airway clinicians in elective scenarios must remain significant management challenges. Laryngeal, tracheal, or
vigilant and be prepared. maxillofacial fractures can distort normal airway anatomy and
severely impact management. Positive-pressure ventilation,

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 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

passage of endotracheal tubes, and surgical intubation may

AIRWAY BURNS
complicate airway injuries (e.g., lacerations or transections) or
create false passages. A multidisciplinary approach involving The patient with airway burns may present with a patent
surgeons with maxillofacial expertise is beneficial. Intracranial airway. However, progressive edema can cause airway
injuries are commonly associated with facial trauma and are often obstruction. Airway management will be significantly more
an indication for early airway management. difficult in the presence of impending obstruction. Early intubation
Clinical findings suggestive of significant laryngotracheal is sometimes warranted. The clinician continuously evaluates and
airway injury include dysphagia, hoarseness, stridor, reevaluates if the patient is best treated with early intubation or
subcutaneous or mediastinal emphysema, loss of laryngeal is better managed with frequent monitoring and reassessment.
prominence, laryngeal tenderness (with pain disproportionate The decision to intubate the airway may be complex. When time
to examination findings), crepitus, cartilaginous asymmetry, allows and resources are available, burn center consultation may
ecchymosis, expanding hematoma, or open penetrating be beneficial.
injuries. Continuous air leakage into the subcutaneous tissue may Urgent intubation is generally indicated in the presence of
occur with trachea-bronchial injury. This leakage is exacerbated these signs of potentially imminent airway obstruction:
by positive-pressure ventilation and may extend to the pleura, • Decreased level of consciousness
mediastinum, neck, chest/abdominal wall, and throughout the • Dyspnea
body.
Multiple maxillofacial and/or mandibular fractures may • Decreased oxygen saturation (SpO2)
disrupt structural bony integrity with resultant soft-tissue • Stridor
collapse and airway obstruction. This obstruction may be more • Suprasternal, substernal, or subcostal retraction
pronounced when the patient is in a supine position. Condylar
fractures may cause mechanical obstruction and trismus (limited • Full-thickness facial burns
mouth opening), creating challenging or near-impossible oral • Edema of oral structures and/or the tongue
airway management. Airway bleeding can accompany any injury,
Clinical factors that raise the potential for airway challenges
further complicating treatment. Depending on location and
in burn trauma include a history of confinement in a burning
severity, airway bleeding may represent an existing or potential
environment; inhalation of smoke, heated gasses, and/or
emergency. Management focuses on obtaining an open airway
toxic chemicals (e.g., burning foam in furniture, industrial
and controlling or stopping the bleeding.
locations); singed facial or nasal hairs; carbonaceous deposits
Assessment of airway injuries includes a history (mechanism
in the mouth; hoarseness; dysphagia; drooling; carbonaceous
of injury and symptoms), examination (searching for the signs
sputum; wheezing; and large body surface area burns, which
of airway compromise mentioned earlier), and possibly more
will be complicated by the development of edema during
advanced investigations of the airway. Flexible endoscopy
resuscitation. However, these signs are neither sensitive nor
(nasoendoscopy), if available, may visualize the larynx and be
specific indications for urgent intubation. They are indications
valuable in assessment of suspected laryngeal injury or airway
for frequent monitoring and reassessment. When expertise
burns. Various potential imaging modalities are discussed later in
and equipment are available, nasoendoscopy may be useful in
this chapter (see Adjuncts to Assessment).
assessing airway burns. Toxicity from carbon monoxide (CO) or
Management of each patient with airway injuries is unique,
cyanide (produced by plastic combustion) is relatively common.
making global recommendations challenging. Administration of
Specific therapy is further outlined in Chapter 9, Thermal Injuries.
supplemental oxygen, if available, while awaiting expert advice
may be appropriate. Patients with multiple facial and airway
ASSESSMENT
injuries often assume the most comfortable and efficient airway
position, frequently sitting upright. These patients are allowed
to maintain this spontaneous effective position, even if other PERSONAL PROTECTIVE EQUIPMENT (PPE)
injuries are suspected. Cervical spine collars, when indicated, The PPE for airway management is identical to that for other
are adjusted to avoid airway obstruction. Airway edema from trauma management (see Chapter 1, Initial Assessment: Primary
multiple injuries may progress and lead to obstruction over Survey). Eye protection and a mask are important due to the
time. Continuous observation and reassessment are crucial, potential for direct exposure to exhaled secretions.
with the trauma clinician prepared to immediately intervene
to maintain airway patency. INDICATIONS FOR AIRWAY INTERVENTION
Tracheal intubation may be indicated. To prevent further
General indications for airway management during the
injury, invasive maneuvers are performed as gently as possible,
primary survey are summarized in  Table 4-1.
with surgical/incisional airway equipment prepared. The safest
airway may be an awake tracheostomy performed by a qualified
surgeon. However, this resource may not be available in the ATLS
context.

43
  Table 4-1: Indications for Airway Management During the Primary Survey.

ASSESSMENT OF THE AIRWAY IN TRAUMA  Figure 4-1: Factors Contributing to Airway Managament
PATIENTS in Trauma. The confluence of these factors illustrates
that the potential for difficulty with emergency airway
A thorough, rapid, and accurate airway assessment is management is always present.
important. As illustrated in  Figure 4-1, several factors can create
challenging airway management in trauma patients, including the
following:
• Anatomy—individual variation
• Physiology—derangements
• Environment—practice factors (equipment availability, team
training and dynamics, cognitive load, individual experience)
• Injury—direct airway trauma
Airway interventions exist on a spectrum starting at basic
airway maneuvers, proceeding through upper airway devices,
and culminating at subglottic airways (tracheal intubation
and surgical/incisional airways). A subglottic device is not
mandatory for all patients. An anatomical airway assessment
aims to predict difficulty in performing any of these techniques.
Assessment of physiology is also important in formulating an Assessment of airway anatomy includes a history,
airway management strategy. A reassuring assessment does not examination, and investigations. Historical factors predictive of
exclude the possibility of a difficult airway. difficulty include previous difficult airway management (strongly
Preparation involves planning for procedural failure predictive), pregnancy, obstructive sleep apnea, and previous
and complications. Nonpatient factors, including practice radiotherapy or surgery to the airway or neck. Predictive features
environmental conditions (ergonomics, noise, lighting), on examination include obesity, large or abnormal neck anatomy,
equipment, the level of individual and team familiarity and a short thyromental distance, retrognathia, limited neck mobility
training, and other human factors can also challenge airway (including spinal motion restriction), the presence of a beard
management. Therefore, airway management in trauma patients (during mask ventilation), restricted jaw movement (mouth
always has the potential to be difficult. opening and jaw protrusion), and limited space inside the mouth.

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 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

 Figure 4-2: The Mallampati score. Employed in less emergent situations, this scoring system predicts airway
management difficulty based on the structures visible. The patient is asked to open the mouth and protrude the
tongue without phonating. Class I: soft palate, uvula, fauces, pillars entirely visible; Class II: soft palate, uvula, fauces
partially visible; Class III: soft palate, base of uvula visible; Class IV: hard palate only visible.

In less emergent scenarios, the Mallampati score is commonly oximetry readings may result from either severe hypoxia or
used to assess jaw movement and mouth space.  Figure 4-2 hypoperfusion (e.g., shock or hypothermia states). The absence
illustrates the Mallampati score. This assessment is performed of a reading indicates the need for investigation and treatment of
with a cooperative patient in the sitting position. Therefore, the both possibilities. Most pulse oximeters will read falsely high in
Mallampati score is of limited utility in trauma. Several other cases of CO poisoning. Special CO pulse oximeters are available
scoring systems have been used to predict difficult airways (e.g., in some treatment areas.
the MACOCHA score), but none have been specifically validated
in trauma patients. CAPNOGRAPHY
Hypoxemic and hypotensive physiology are associated Capnography measures the presence of exhaled CO2 and
with rapid development of apnea and inability to maintain provides valuable information regarding airway patency.
an open airway. In these situations, a high risk of precipitous Waveform capnography, if available, is also useful for nonintubated
cardiorespiratory deterioration is present during airway patients (e.g., during face mask and laryngeal mask ventilation, as
management and positive-pressure ventilation. Pre-intubation well as spontaneous ventilation with supplemental oxygen). The
fluid resuscitation, oxygenation, monitoring, and preparation absence of exhaled CO2 indicates lack of ventilation and airway
of vasopressors are important to reduce the risk of lethal obstruction unless proven otherwise (including in cardiac arrest).
complications. Capnographic detection of sustained exhaled CO2 is the best
practical indicator to confirm successful intubation. Sustained
ADJUNCTS TO ASSESSMENT detection is defined as CO2 present on at least seven breaths.
Physiological monitoring by pulse oximetry and end-tidal An alternative method of ventilation is employed if exhaled CO2
capnography is of critical importance in airway management. confirmation is not achieved.
If appropriate equipment is available, end-tidal CO2 (ETCO2)
PULSE OXIMETRY numerical values may be useful for assessing minute ventilation.
Pulse oximetry provides near-real-time information. However, However, this assessment is accurate only in a sealed airway (e.g.,
it has important limitations. There is a 30- to 60-second delay laryngeal mask or subglottic airway) with a normal waveform
(potentially longer in shock) between a change in alveolar as illustrated in  Figure 4-3A. ETCO2 values may assist in
oxygen levels and a change at the oximeter. Residual oxygen in management of elevated intracranial pressure (ICP; discussed
the lungs may maintain blood oxygenation for several minutes in Special Population Considerations later in this chapter).
even if complete airway obstruction is present. Thus, a decrease A low ETCO2 may be an indication of low cardiac output with
in SpO2 is a late sign of airway obstruction, especially when paradoxically elevated PaCO2 potentially present.  Figure 4-3
supplemental oxygen has been administered. Inability to obtain illustrates several ETCO2 waveforms.

45
  Figure 4-3: Common Capnography Waveforms. END-TIDAL OXIMETRY
A. Normal capnograph where ETCO2 can accurately Measurement of exhaled end-tidal oxygen (ETO2) is utilized in
estimate PaCO2. B. Partial upper airway obstruction or some emergency departments. Reaching an ETO2 of > 85% may
hypoventilation. Smaller, rounded waves are seen if
be an indication of adequate preoxygenation prior to attempted
tidal volume is low. Measured ETCO2 will underestimate
PaCO2. C. Bronchospasm. ‘Shark-fin’ waves are seen in intubation.
bronchospasm and some other situations. The measured
ETCO2 will underestimate the PaCO2. D. Esophageal
IMAGING
intubation. CO2 may be returned from the stomach initially Due to the urgent need for airway management in trauma,
but will diminish over time. In successful endotracheal imaging modalities have limited application. A lateral soft-tissue
intubation, exhaled CO2 is sustained. This is defined as neck radiograph may be useful to assess edema and airway
CO2 being adequately detected on a minimum of seven disruption, although sensitivity is limited. CT provides useful
breaths. This example shows a higher level of CO2 than is
information on anatomy and airway injury. However, the time
often seen in esophageal intubation.
invested to obtain images, the need to lie flat, risks of transport,
and loss of access to the airway limits the utility of CT. Ultrasound
has been described for airway assessment. However, images are
often degraded by air. Specialized training is recommended to
obtain useful images and perform accurate interpretation.

INTERVENTIONS/TREATMENTS
Following control of massive hemorrhage, the clinician opens
and maintains the airway. Several injury presentations (e.g.,
transportation crashes, falls from height, injuries in frail patients,
neck gunshot wounds) have the potential of unstable spine
injury. Providing simultaneous spinal motion restriction during
airway maintenance is important in these clinical scenarios. If
hemorrhagic shock is present, airway maneuvers are performed
concurrently with initiation of resuscitation, as previously
mentioned above in the Assessment section (preferentially
with blood products; see Chapter 6, Circulation Assessment and
Volume Resuscitation). Clinicians consider the available resources
and scope of practice to select the best intervention to maintain
oxygenation and ventilation. Oxygen delivery devices are
important adjuncts.

OXYGEN DELIVERY DEVICES

Prolonged hypoxia may lead to arrhythmias, hemodynamic
decompensation, hypoxic brain injury, and death. Therefore,
preventing hypoxia is crucial. When available, oxygen is
administered to trauma patients with abnormal oxygen
saturations (i.e., <94%), those with airway obstruction, or
those in whom oxygenation cannot be measured (due to a lack
of equipment or poor perfusion). A target SpO2 of 94%–98% is
generally appropriate. Initiating treatment with a reservoir mask
(nonrebreather mask) at a flow rate of 15 L/min is reasonable.
Other oxygen delivery devices include standard oxygen masks
and nasal cannula, which deliver a lower fraction of inspired oxygen
(FiO2) than reservoir masks. High-flow nasal oxygen (HFNO)
can deliver up to 100% O2.  Figure 4-4 illustrates HFNO. HFNO
is contraindicated in severe facial trauma or basal skull fracture.
A self-inflating bag-valve mask (BVM) with a one-way positive
end-expiratory pressure (PEEP) valve (to prevent room air being
inspired through the expiratory port) can provide close to 100%
O2. Noninvasive ventilation may occasionally be useful and can
deliver high FiO2. However, noninvasive techniques increase the
risk of aspiration through gastric distension. Invasive definitive
airway methods may be more appropriate for severely hypoxemic
trauma patients.

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 Figure 4-4: High-Flow Nasal Oxygen (HFNO) SUCTION AND REMOVAL OF FOREIGN
Equipment. HFNO delivers humidified and warmed MATERIAL
oxygen at flow rates that exceed peak inspiratory flow
(e.g., 60 L/min). The warmth, humification, and wider nasal A rigid suction catheter can clear liquid from the pharynx.
cannula allow these flow rates to be tolerated. However, larger material may block the catheter. Specialized,
larger-bore rigid suction catheters have been designed for airway
management. These can aspirate larger particulate material.
Suction catheters are used under direct vision to avoid causing
oropharyngeal injury. Narrow, flexible suction catheters are ideal
for aspiration of the lumen of airway devices. However, these are
less suitable for massive amounts of material.
Massive amounts of oropharyngeal matter can be managed
by placing the patient in the left lateral position (as mentioned
earlier), suctioning, and manual/digital removal of the
material. Visualization with a laryngoscope and placement of a
suction catheter in the upper esophagus can be useful in managing
vomitus. Angled forceps (e.g., Magill or Boedeker) can be used
with direct visualization to remove solid objects and material.

JAW THRUST
Jaw thrust involves moving the mandible anteriorly to
displace oropharyngeal soft tissues and create an air passage.
When combined with clearance of oropharyngeal material and
mask ventilation, the jaw thrust may maintain an open airway
until further expertise and equipment arrive to the bedside.
The maneuver may be uncomfortable for the patient and may
not be tolerated by semiconscious patients. Reduced force may
provide adequate airway patency in such situations. The vise grip
technique is effective and can be applied with or without mask
BASIC AIRWAY MANEUVERS ventilation.  Figure 4-5 illustrates the jaw thrust maneuver and
vise grip. An isolated chin lift is less effective and may produce
These interventions have relatively rapid application. Airway more spinal movement. Hand position may be altered to avoid
patency is continuously assessed. Continuous capnography is facial fractures and other injuries while maintaining anterior
useful when available. mandible displacement.
LATERAL POSITIONING MASK VENTILATION
Placing the patient in a left-side-down position is a highly Positive pressure ventilation can be applied with a mask
effective and noninvasive technique in airway management. It connected to a self-inflating bag (i.e., BVM), anesthesia circuit, or
may be particularly useful in mass casualty scenarios or resource- mechanical ventilator. However, positive pressure alone does not
limited settings where clinical resources are overwhelmed. In overcome airway obstruction. A jaw thrust with an oropharyngeal
these settings, unconscious patients may be placed in the left or nasopharyngeal airway (see below) is often employed. The
lateral position if continuous one-to-one monitoring is not mask can be secured with one or two hands. A two-handed vise
feasible. Lateral positioning can assist with management of airway grip, as illustrated in  Figure 4-5, is most effective when adequate
obstruction by blood, vomitus, or other foreign material. In these personnel are present. Jaw thrust, oropharyngeal airways, and
overwhelming clinical scenarios, spinal movement is minimized nasopharyngeal airways are very effective in combination with
as much as possible (maintaining alignment with collars, boards, mask ventilation.
log roll technique), while airway management takes precedence.

47
  Figure 4-5: Jaw Thrust and “Vise Grip”. (Oxygen mask and oropharyngeal airway have been removed for illustrative
purposes) A and B, Jaw Thrust: The clinician’s thenar eminences rest on the patient’s maxilla. The fingers are placed
behind the angle of the mandible bilaterally. The mandible is pulled anteriorly. The thumbs can be used to open the
mouth. C and D, Vise Grip and Mask Ventilation: The mask is held with the thenar eminences and the mandible pulled
anteriorly into the mask. Wrist movements are used to optimize the seal of the mask. A second clinician ventilates. It is
helpful for the clinician’s elbow to be extended either by lowering the bed or providing a step for the clinician.

A. B.

C. D.

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 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

UPPER AIRWAY DEVICES  Figure 4-6: Laryngeal Mask Airway. A. The LMA is
Various devices are available that are intended to maintain inserted without visualization of the vocal cords. Oriented
airway patency above the vocal cords. They are relatively quick to anteriorly, it creates a seal at the origin of the trachea and
insert and are less invasive compared to subglottic devices. is proximal to the vocal cords. The esophagus is posterior.
B. An LMA. The green area represents the cuff of the LMA
OROPHARYNGEAL AIRWAYS which rests at the origin of the trachea.

These minimally invasive devices extend to behind the A.

tongue and are sized from the incisors to the angle of the jaw.
Oropharyngeal airways stimulate a gag response. To prevent
emesis, they are removed if gagging occurs.

NASOPHARYNGEAL AIRWAYS
These devices are inserted into the nose and extend into
the oropharynx at the base of the tongue. They are sized by
measuring from the nose to the tragus of the ear. There is a risk
of bleeding during insertion, so lubrication and gentle placement
are important. A nasopharyngeal airway is not advanced against
significant resistance. They are less stimulating of a gag response
than oropharyngeal airways. Nasopharyngeal airways are
contraindicated in facial and basilar skull fractures.
.
SUPRAGLOTTIC AIRWAYS B.
Supraglottic airways are designed to maintain airway patency
without passing through the larynx. Thus, they are less invasive
than endotracheal tubes. The term supraglottic airway may
sometimes include oropharyngeal and nasopharyngeal airways
but more commonly refers to devices that can be directly
connected to a ventilator, such as laryngeal masks, laryngeal
tubes, and esophageal-tracheal double-lumen devices. Of these,
only the laryngeal mask is discussed in ATLS. Prehospital services indication for intubation is life-threatening hypoxia due to
in some regions may employ other devices. Familiarization with airway obstruction that is not relieved by basic or upper airway
local prehospital airway techniques is beneficial. maneuvers.
Large studies show that intubation has higher rates of serious
LARYNGEAL MASKS complications than noninvasive airway maneuvers. Therefore,
intubation is performed when other measures are, or are likely
Laryngeal mask airways (LMAs) are inserted without
to be, ineffective. Except during cardiac arrest, drug-facilitated
laryngoscopy. Many different devices exist, and the clinician is
intubation is performed in trauma scenarios. Laryngoscopy
encouraged to be familiar with local equipment. LMAs generally
and intubation without premedication stimulate gag reactions and
provide improved airway patency, more effective positive pressure
may cause physiologic responses that increase technical difficulty
ventilation, and some protection against regurgitation and
(e.g., vocal cord spasm), even in profoundly obtunded patients.
aspiration in comparison to oropharyngeal and nasopharyngeal
Drug-facilitated intubation is performed as a modified RSI
airways with mask ventilation.  Figure 4-6 illustrates an LMA. As
technique. In this manual, the terms RSI and modified RSI are
with oropharyngeal airways, laryngeal masks are only tolerated
used interchangeably. The word rapid describes the relatively
by obtunded or anesthetized patients. Insertion is abandoned
short time between drug administration and securing the
if a gag reflex is elicited.
airway; it does not imply a hurried or rushed process. Even
well-rehearsed teams may take 5–10 minutes to prepare and
RAPID-SEQUENCE TRACHEAL INTUBATION
perform a safe RSI.
An airway device in the trachea with an inflated cuff distal
to the vocal cords is termed a definitive airway. This is usually RISKS OF RSI
an oral endotracheal tube but can be a surgical/incisional airway. RSI involves the administration of drugs which abate
Despite the term definitive, continuous reassessment is performed respiratory effort. Therefore, the most significant risk during RSI
to maintain the airway. Tubes can dislodge, obstruct, or leak. is loss of the airway and/or respiratory drive. Once medications
Constant vigilance is critically important. Tracheal intubation are administered, the clinician is committed to providing airway
establishes a definitive airway. However, the procedure is associated and ventilation, which may be accomplished via successful
with significant risks. Adequate training, time, and resources are intubation, rescue laryngeal mask, rescue mask ventilation, or
imperative to safe performance. Intubation generally provides surgical/incisional airway.
improved ventilation and protection against aspiration as A catastrophic complication of attempted intubation is
compared to less invasive options. The absolute and immediate

49
 unrecognized misplacement of the endotracheal tube into the be continued with replacement temporarily deferred until
esophagus. Esophageal intubation is fatal unless recognized optimal personnel and equipment are available for more
immediately. Identification of this complication is made controlled intubation.
rapidly and accurately by lack of sustained exhaled CO2. Upon
diagnosis of failed tracheal intubation, the tube is immediately EQUIPMENT FOR RSI
removed, and ventilation and oxygenation are provided Successful RSI utilizes specialized equipment for safe
via laryngeal mask or facial mask ventilation. Improvement performance of the procedure and for airway rescue maneuvers.
in oximetry is critical prior to further intubation attempts. If
oxygenation and ventilation cannot be adequately provided, a Endotracheal Tubes
surgical/incisional airway may be indicated. Various sizes of endotracheal tubes are available for both adult
Laryngoscopy and intubation can injure the airway. Injury and pediatric use (e.g., 7-9 mm internal diameter for adults). For
is more common with repeated attempts and can make effective trauma intubations, cuffed tubes are appropriate in all age groups
mask or laryngeal mask ventilation impossible. Hence, most including small children.
guidelines limit the number of attempts at intubation. All sedative
medications used for RSI may induce or worsen hemodynamic Laryngoscopes
derangement. Doses are reduced compared to elective Immediate availability of least two functional laryngoscopes
intubation. The transition from spontaneous ventilation to (i.e., one used and one as backup) is optimal. There are two
positive-pressure ventilation significantly alters hemodynamic types in common use. Direct laryngoscopes (DLs) are intended
physiology with a risk of resultant cardiovascular collapse in for visualizing the larynx with the unaided eye. The Macintosh
hypovolemic patients. Hypovolemic patients are administered (curved blade) is the most common. Straight blades (e.g., Miller)
fluid resuscitation prior to RSI. Vasopressors are commonly are sometimes beneficial for intubation of small children with
administered presumptively during RSI to offset vasodilation a slightly modified technique. Several specialized DLs exist for
induced by sedative agents. various purposes and techniques.
DECISION TO PERFORM AND TIMING OF RSI Video laryngoscopes (VLs) have a camera and screen (or, less
commonly, an eyepiece) and improve intubation success rates.
RSI utilizes time and resources, which may detract from VLs are optimal for trauma intubations. It is helpful for the screen
other treatment priorities. RSI is often deferred until further to be visible to the team.  Figure 4-7 illustrates intubation via
resuscitation is performed and/or more resources are available. VL. Clinicians less experienced at intubation may find VL easier
 Table 4-2 lists several factors to consider regarding RSI. with a blade similar in shape to a Macintosh direct laryngoscope
Some patients arrive with a functioning supraglottic airway blade.  Figure 4-8 illustrates different laryngoscope blades and
inserted by prehospital clinicians. The decision to remove an endotracheal tube with stylet. Extended-angle VL blades
the prehospital device and perform intubation follows the are effective but are difficult to use for those without additional
same principals listed above. If oxygenation or ventilation training.
are inadequate, assessment and revision or provision of an
alternate airway device is a priority. However, if oxygenation
and ventilation are adequate, the prehospital airway may

 Table 4-2: Factors to Consider in Timing of RSI.

Factors toward immediate RSI Factors toward delaying or deferring RSI

Inability to oxygenate via mask or supraglottic Well-functioning upper airway device or patient
airway (absolute indication), or difficulty maintaining airway spontaneously
maintaining ventilation with these methods Hypotension or hemodynamic abnormality
Appropriate resuscitation and adequate Inadequate intubation experience
hemodynamic status
Potential or suspected difficult airway and
Inability to maintain airway patency due to airway anticipated rapid arrival of expert assistance
bleeding, regurgitation, or emesis More urgent clinical priorities

Lack of or prolonged delay until availability of Inadequate staff available to assist

airway specialist Rapid availability of airway specialist
Definitive airway indicated for safe transfer Multi-casualty scenario

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 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

 Figure 4-7: Video Laryngoscope Screens. A. Larynx and  Figure 4-8: Laryngoscope Blades and Stylet in
vocal cords before intubation. B. Endotracheal tube (ETT) Endotracheal Tube. The shape of the direct laryngoscope
passing through vocal cords after intubation. (DL) with Macintosh blade (A) and video laryngoscope (VL)
standard-geometry blade (B) are very similar. The same
A. intubation technique is used with both devices. The VL may
be used as a direct laryngoscope in the event of camera
failure. The extended-angle VL blade (C) uses a different
technique with additional training. The VL blades are
connected via a cable to the screen. D. A stylet inserted into
a shaped endotracheal tube with a bend at the cuff.

B.

 Figure 4-9: Bougie and Malleable Stylet. A. Malleable

stylet (also illustrated in  Figure 4-8D). B. Bougie. The
arrow points at the angulated tip, an important feature
of the device. (The bend in the middle of the bougie is the
result of packaging. It is not an intended feature.) When
using a bougie, a 90-degree anticlockwise rotation of the
endotracheal tube can help the tip slide over the arytenoids
if the tube becomes wedged at the larynx.

Eschmann Endotracheal Tube Introducer/Gum-Elastic

Bougie
Commonly called a bougie, this device may assist challenging
intubations. It is placed either blindly or via laryngoscopy. An
angled tip facilitates anterior passage through the oropharynx and
larynx.  Figure 4-9B illustrates a bougie. An endotracheal tube is
inserted over the bougie into the trachea.

Malleable Stylet
This device assists intubation by maintaining the flexible
endotracheal tube in a desired shape, typically straight with a
bend at the cuff.  Figures 4-8D and 4-9A illustrate stylets.

51
 Mechanical Ventilator MEDICATIONS FOR RSI
While it is possible to ventilate and oxygenate an intubated Medications for RSI can be organized into three broad
patient manually with a self-inflating bag or anesthetic circuit, a categories:
mechanical ventilator is helpful. The ventilator protects against • Sedative and anesthetic agents
hypo- and hyperventilation and against clinician fatigue and loss
of focus. Examples of initial ventilator settings are discussed later. • Neuromuscular blockers
• Vasopressor and inotropic agents
Common medications and doses are listed in  Table 4-3,
although other agents may be reasonable based on clinician
experience.

 Table 4-3: RSI Medications and Potential Dosing.

Medication Dose Comments

Sedative and anesthetic agents

Ketamine (sedation) 0.5 mg/kg, repeat if necessary May induce airway/respiratory
collapse

Ketamine (RSI) 0.5-2 mg/kg Can cause or exacerbate

hypotension and shock–dose
reduction in shock

Etomidate (RSI) 0.2-0.3 mg/kg

Propofol (RSI) Dose determined by an Can cause or exacerbate

experienced clinician hypotension and shock–dose
Thiopentone (RSI) reductions in shock, sometimes
up to 90%
Midazolam (RSI)

Fentanyl (sedation RSI) 0.5 - 1 mcg/kg

Medication Dose Comments

Neuromuscular blocking drugs

Rocuronium 0.6-1.2 mg/kg Will prevent patient from

maintaining spontaneous,
unassisted open airway
Suxamethonium 1 mg/kg
(succinylcholine)

Medication Dose Comments

Vasopressors and inotropes

Metaraminol 0.5-1 mg (or 10 mcg/kg) boluses

Phenylephrine 50 mcg (or 1 mcg/kg) boluses

Ephedrine 6 mg (or 0.5 mg/kg) boluses

Epinephrine (adrenaline) 10-50 mcg (or 1-5 mcg/kg) boluses Depending on severity of
hypotension; use higher doses
0.05 - 2 mcg/kg/min infusion with caution

Norepinephrine (noradrenaline) 0.1-1 mcg/kg/min infusion Titrated to target blood pressure.

For peripheral administration,
a dilute solution (e.g., 20 mcg/ml)
is used through a reliable
access point

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Sedatives and Anesthetic Agents Vasopressor and Inotropic Agents

These agents render the patient sedated or unconscious. Vasopressors are included in discussion of RSI, as they are
Opioids are included in this category. Due to altered pharmacology, used to counteract hypotension induced by RSI medications
adverse hemodynamic effects can be magnified in a patient with and positive-pressure ventilation. Agents include metaraminol,
hypovolemia despite using doses considered safe in nonemergent phenylephrine, ephedrine, and epinephrine (adrenaline). The
scenarios. Thus, all agents have the potential to produce specific medications and their availability vary by region. Although
significant hypotension. fluid and blood are the first treatment for hypotension in the
Several medication options are reasonable. Ketamine and injured patient, vasopressors are useful in treating vasodilation
etomidate are selected by many clinicians and are recommended produced by sedatives and anesthetics.
in authoritative guidelines. These drugs produce relatively fewer
hemodynamic alterations. Ketamine results in dissociation such PREPARATION FOR RSI
that patients often retain spontaneous eye-opening but lose
awareness and purposeful response. While ketamine can cause Checklists and Other Cognitive Aids
or exacerbate hypotension, it is more commonly associated with
Checklists enhance performance and outcomes in medicine
tachycardia with mild hypertension. Potential raised intracranial
and other high-demand industries. Pre- and post-intubation
and pulmonary arterial pressures are likely of less clinical
checklists help ensure that important tasks have not been
significance than originally proposed. Studies regarding etomidate
overlooked and that all members of the team understand the
adrenal suppression support low clinical significance following a
process and priorities (shared mental model). Checklists are
single dose.
extensively used by experienced airway and trauma management
Benzodiazepines and opioids are commonly used. However,
teams. A checklist is beneficial before and after ATLS RSI
the risk of hypotension with these drugs is significant. Fentanyl
procedures. Several versions are available.  Figure 4-10 illustrates
reduces the hypertensive and increased intracranial pressure
pre- and post-intubation checklists.
responses that occur with intubation. Therefore, it may be useful
In addition to checklists, airway management teams may
in cases of isolated head injury. Opioids may cause hypotension,
utilize other cognitive aids.  Figure 4-11 is an example of a flow
especially in hypovolemic patients.
diagram that may assist teams in adhering to procedures and in
Propofol and thiopentone are anesthetic agents and produce
making decisions in complex and stressful situations. Task cards
significant hypotension with induction doses. They are not
and role stickers clarify individual team members’ responsibilities
frequently utilized in RSI unless the clinician has extensive
and allow greater autonomy.
experience, and the patient is not hypovolemic or at risk for
hemorrhagic shock. When used, the usual doses are significantly Equipment Considerations
reduced.
Maintenance sedation is administered for all patients post- A consistent, well-organized equipment layout ensures that
intubation. Ketamine, benzodiazepines, propofol, and opioids are vital items can be located quickly. This can be facilitated by using
all commonly used, either alone or in combination, as infusions a layout template.
or as intermittent boluses. Teamwork
Neuromuscular Blocking Drugs (NMBDs) A well-functioning team is important when performing
NMBDs cause muscle paralysis at the neuromuscular junction complex procedures such as RSI. A single clinician cannot
and facilitate laryngoscopy and intubation. Rapidly acting optimally and simultaneously lead the team and perform
agents are used in RSI to minimize the time between sedation intubation. They cannot maintain full situational awareness
and intubation. Two appropriate agents are suxamethonium while performing this complex task. The team leader role is
(succinylcholine) and rocuronium. Suxamethonium produces performed by or transitioned to another clinician. Another team
muscular relaxation in approximately 45–60 seconds. The onset member is allocated to monitor vital signs and alert the team to
is characterized by muscular fasciculations. Side effects include significant changes. Team members are empowered to speak if
hyperkalemia, increased muscular oxygen extraction, and raised they observe or have suspicion of a complication or developing
intraocular pressure. Hyperkalemia can be severe, even fatal, in problem. A high-functioning team leader will actively encourage
patients with high amounts of denervated or necrotic tissue (e.g., communication. The leader is encouraged to request additional
more than 24 hours postextensive burns, prolonged immobilization personnel, if available, prior to intubation. A shared mental model
prior to medical care, or spinal injury). Suxamethonium is usually and awareness are developed through briefing (including plans
metabolized in 3–5 minutes. for intubation failure) and a shared VL screen.
Rocuronium is a nondepolarizing agent. If used at a dose
of at least 1.2 mg/kg, it has fewer side effects while providing
equivalent intubating conditions to suxamethonium. A reversal
agent (sugammadex) is available but is not useful in the context of
an ATLS intubation, as waking the patient to restore the airway is
not a common option.

53
  Figure 4-10: Pre- and Post-Intubation Checklist. Several other checklists are available
online and elsewhere.

Checklist: Pre- & Post-Intubation

Pre-Intubation Post-Intubation
Optimization Airway
Physiological state assessed Sustained exhaled CO2
Intravenous/Intraosseous access x2 Bilateral air entry
Resuscitation sufficient Depth at teeth documented
Pre-oxygenation optimal Tube secured
Apneic oxygen considered Cuff pressure checked

Patient Position Breathing

C-spine protection Reassessed
Optimized Safe, appropriate ventilation; alarms set

Monitoring Chest x-ray arranged

Blood gas checked
Capnography
Further paralysis available
Electrocardiogram
Pulse oximetry Circulation
Blood pressure on 1-minute cycle Reassessed; resuscitation continued

Equipment Vasopressors and fluids available

Suction x2 (function checked) Disability

Laryngoscope x2 (function checked) Sedation established
Endotracheal tube x2 (cuffs checked) Head-up position (if able)
Bougie/Stylet TBI optimization (if applicable)
Syringe C-spine collar reapplied (if appliable)
Bag-valve mask with PEEP valve Environment
Oropharyngeal airway
Back-up BVM available
Nasopharyngeal airways
Oxygen supply adequate
Laryngeal mask
Gastric tube
Surgical airway kit
Notes:
Sufficient oxygen; turned on

Drugs
Induction agent(s)
Neuromuscular blocking drug
Vasopressor(s)/Inotrope(s)
Post-intubation sedation

Team Briefing
Roles allocated
Intubation plan
Failed intubation plan
Surgical airway plan
Physiological
 deterioration plan
(cardiovascular and respiratory)

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 Figure 4-11: Flow Diagram Summarizing Modified Rapid Sequence

Intubation (RSI).

Preparation:

Positioning
Preoxygenation
Vascular access; resuscitation
Monitoring (including CO2)
Communicate plan
Role allocation
Checklist

SUCCESS:
Tracheal intubation:
Confirm with sustained exhaled CO2
Induction and NMDB
Maintain oxygenation (nasal
oxygen; facemask ventilation
between attempts) POST-INTUBATION
MANAGEMENT:
Maximum 3 laryngoscopy
attempts
Checklist

FAILURE:

Declare “failed intubation”

Rescue airway: SUCCESS:

Stop and think; consider:

Laryngeal mask or facemask
ventilation • Maintain ventilation on laryngeal mask
• Await expert assistance
Maximum 3 attempts at each; • Advanced techniques if skills available
switch if unsuccessful
• Surgical airway

FAILURE:

Declare “cannot intubate,

cannot oxygenate” situation

Surgical airway:

Scalpel, bougie, tube

POST-INTUBATION
MANAGEMENT:

Checklist

55
 Protection of the Cervical Spine Cricoid Pressure
Neck movement is minimized in the blunt trauma patient, This technique attempts to compress the esophagus with the
although there is some controversy regarding the best method. larynx to reduce the risk of regurgitation. However, effectiveness
Manual inline stabilization of the head is routinely performed has not been demonstrated. The maneuver may impair intubation
for blunt trauma in many systems. As illustrated in  Figure 4-12, and effective laryngeal mask placement. Therefore, routine
the head and neck are stabilized as a single unit to oppose application of cricoid pressure is not performed unless requested
the lifting force of laryngoscopy. Traction is not applied. Use by an airway management expert in an individual case.
of a VL and gentle technique may minimize neck movement.
In immediately life-threatening scenarios, oxygenation and Positioning
ventilation take primacy over cervical spine stabilization. The
clinician may prioritize airway management (being as gentle as The patient is positioned as far to the head of the bed as
possible) in these scenarios. Although there are cases where small possible. A reverse Trendelenburg tilt of 20–30 degrees is
amounts of gentle neck movement have exacerbated spinal injury, advantageous. Greater degrees of torso elevation are helpful in
obese and pregnant patients. Neck extension may be utilized
thankfully, this is rare.
when a cervical spine injury is not potentially present.
 Figure 4-12: Manual Inline Stabilization (MILS). MILS can Preoxygenation
be performed either from the side or head, as shown. The
choice is based on ergonomics and individual preference. Preoxygenation is fundamental to safe RSI and is considered
The clinician performing MILS holds the head still against before changing or manipulating an airway device. The goal of
the force of laryngoscopy, being careful not to apply
preoxygenation is to displace nitrogen from the lungs, replacing
traction.
it with oxygen. Hence, this process is termed denitrogenation.
Preoxygenation creates an intrapulmonary oxygen reservoir that
can sustain oxygenation during apnea, extending the time for safe
intubation.
In effective preoxygenation, the volume of inhaled
nitrogen-containing room air is minimized. PEEP may aid in
preoxygenation. Preoxygenation is typically performed via BVM
with attached PEEP valve, if available. Alternatively, noninvasive
ventilation or HFNO are used for preoxygenation, with the caveat
that noninvasive ventilation may predispose the patient to gastric
distension and emesis. Use of reservoir masks is less effective, as
the oxygen flow rate is insufficient to prevent inspiration of room
air unless a high-flow (60 L/min) regulator is used.
If end-tidal oxygen (ETO2) monitoring is available,
preoxygenation is continued until ETO2 reaches 85%. Otherwise,
preoxygenation continues for several minutes if possible. However,
adequate time may not be available in some critical scenarios.
SpO2 readings are not an indicator of adequate preoxygenation.
Normal pulse oximetry readings occur before all nitrogen is
displaced from the lungs. Preoxygenation is performed with the
Optimizing Intubation Attempts patient semirecumbent (head up). If this position is not possible,
the entire bed can be tilted in reverse Trendelenburg position to
The first attempt at intubation is the optimal attempt.
elevate the head.
Repeated attempts can cause airway trauma and other
Patients who are agitated or otherwise intolerant of
complications and are associated with increased mortality. A
preoxygenation may benefit from mild sedation administered by
common mantra is “make the first attempt the best attempt.” The
experienced clinicians. This is sometimes referred to as delayed-
following are associated with increased intubation success:
sequence intubation. Titrated ketamine is effective for delayed-
• Trauma intubation is performed by an experienced clinician
sequence intubation, although other agents may be appropriate
whenever possible
as well. The clinician must be fully prepared to initiate airway and
• Video laryngoscopy is used, ideally with a screen visible to respiratory support when administering sedatives to a critically ill
the whole team patient, as responses can be unpredictable.
• A bougie or stylet is used
• The patient is positioned as optimally as possible

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Apneic Oxygenation Confirmation of Intubation and Post-intubation

Assessment
Apneic oxygenation involves providing oxygen to the
patient during the apneic phases of intubation, such as during As mentioned earlier, a catastrophic potential complication
laryngoscopy. Even though there is no active respiratory effort, of RSI is unrecognized esophageal intubation. Therefore,
hypoxia may be delayed by passive administration of oxygen via confirmation of tube location in the trachea and prompt
either standard nasal cannula (flow can be increased once RSI recognition of dislodgement are critical. Appropriate
is initiated) or HFNO. During RSI, gentle mask ventilation is endotracheal tube position is confirmed by visualization of
advantageous. Mask ventilation is continued until intubation and sustained exhaled carbon dioxide, which is defined as being
resumed between intubation attempts. present for at least seven breaths. Even in cardiac arrest, carbon
dioxide is detectable. Visualization of the tube passing between
RSI PROCEDURE the cords is surprisingly unreliable. Clinical examination (breath
There are several safe methods to perform RSI; one technique sounds, chest rise, SpO2) is also unreliable for confirmation of
supported by guidelines is described here. This description tracheal tube location.
complements the flow diagram illustrated in  Figure 4-11. Adequacy of ventilation is reassessed. Breath sounds
After the clinician performs an assessment, initiates control are auscultated, and chest rise is visualized to evaluate for
of exsanguinating external bleeding, administers resuscitation, endobronchial intubation (right or left mainstem) or exacerbated
and makes the decision to intubate, the patient is appropriately pneumothorax. The tracheal tube is secured with a tie or other
positioned. Preoxygenation is initiated as early as possible. device. The tube depth at the teeth or gums is recorded. A chest
Monitors are applied, including capnography if available. radiograph is performed to exclude pneumothorax and to confirm
Automatic blood pressure devices are set to cycle every 1–2 that the tube tip is not too distal, resulting in endobronchial
minutes, or a team member is assigned to obtain manual blood (mainstem) intubation. Chest radiography is unable to exclude
pressure readings frequently. Concurrently, equipment, fluids, and esophageal intubation.
drugs are prepared, roles are allocated, and the team is briefed.
A checklist, such as illustrated in  Figure 4-10, is completed SURGICAL/INCISIONAL AIRWAY
immediately prior to administering the RSI drugs. A surgical/incisional airway is indicated if oxygenation is
RSI commences with the administration of a sedative and/ unsuccessful via face mask, laryngeal mask or intubation, a
or induction agent immediately followed by a muscle relaxant. A situation termed cannot intubate, cannot ventilate or cannot
bolus of vasopressor may be appropriate at the same time. Once intubate, cannot oxygenate. While a surgical (or incisional) airway
spontaneous respiratory effort stops, mask ventilation is initiated. is not a technique to be performed casually, it may be a lifesaving
Mask ventilation is critically valuable when hypoxia is present or procedure. Training, practice, and teamwork can provide the
likely (e.g., respiratory failure, obesity) or where hypercapnia is clinician with the confidence to perform this procedure promptly
to be avoided (e.g., TBI, metabolic acidosis, right heart failure). and effectively.
Nasal prong oxygen flow is increased to 15 L/min during the Communication of the cannot intubate, cannot oxygenate
apneic period to reduce the risk of hypoxia. situation by any team member is important; delay of a surgical/
Approximately 60 seconds after administration of RSI incisional airway can be catastrophic. After the first unsuccessful
medications, laryngoscopy with intubation is attempted. The attempt at intubation, the surgical/incisional airway equipment is
clinician visualizes the tongue with the laryngoscope and follows prepared by another team member. A surgical/incisional airway
the tongue until the epiglottis is visualized. The tip of the epiglottis may be appropriate without attempting any or all other airway
is lifted to reveal the larynx. Inability to visualize the larynx can be maneuvers in severe facial and upper airway injury.
managed by withdrawing the laryngoscope partially (the tip may While several surgical techniques are reasonable, the technique
be in the esophagus) and having an assistant manually displace in ATLS was chosen due to simplicity, speed, success rate, and lack
the larynx to the right, posteriorly, and cephalad. This maneuver of necessary specialized instruments. The minimal equipment are
is sometimes known as external laryngeal manipulation or BURP a scalpel (preferably a size 10 or 15 blade) and an endotracheal tube
(backward, upward, rightward pressure). (approximately size 6.0). Larger tubes are more difficult to insert.
If the initial attempt is unsuccessful, the team is alerted and A bougie may be beneficial and is usually available as part of the
mask ventilation with an oropharyngeal airway or laryngeal intubation equipment. Lubrication of the tube and bougie can be
mask is performed. Further attempts at intubation are helpful. The neck is positioned as for oral intubation, with spinal
unlikely to be successful unless a mitigating factor is changed motion restricted as best as possible in this emergent situation.
(e.g., patient position, equipment, removal of obstructing The clinician must not be dissuaded by the anticipated significant
material, or operator). Additional intubation attempts include bleeding and air spray. Once commenced, the procedure must be
a modification. Intubation attempts are limited to three per completed despite obstacles.
operator (with one further attempt by a more experienced
operator). However, fewer attempts may be appropriate, as every
attempt increases the chance of edema and airway obstruction.
Ventilation via BVM or laryngeal mask is critical between
intubation attempts. Inability to ventilate via BVM, laryngeal
mask, or intubation (with a maximum of three attempts at each)
is an indication for a surgical/incisional airway.

57
 TECHNIQUE  Figure 4-13: The Laryngeal Handshake. A. The index
finger and thumb grasp the top of the larynx at hyoid
1. An assistant maintains manual cervical motion restriction. bone.
The front of the cervical collar is removed (if present). B. The fingers and thumb slide inferiorly over the thyroid
2. The nondominant hand identifies the thyroid cartilage, cartilage. C. The middle finger replaces the index finger at
spreads and retracts the tissues overlying the cricothyroid the thyroid cartilage cricoid junction. The thumb rests on
space, and stabilizes the larynx. The cricothyroid space is the cricoid cartilage, with the index finger palpating the
palpated by the nondominant index finger. As illustrated cricothyroid membrane.
in  Figure 4-13, the laryngeal handshake may assist in
identification of the cricothyroid space. An assistant may A.
perform retraction if a large amount of tissue is present.
The clinician maintains continuous retraction by not
releasing the nondominant hand, which may also provide
tamponade of bleeding.
3. While maintaining lateral tension on the tissues with the
nondominant hand (for skin retraction), a vertical incision
is made in the midline from the thyroid cartilage superiorly
to the cricoid cartilage inferiorly as illustrated in  Figure
4-14. The vertical incision minimizes potential to encounter
larger midline vessels. The incision is of adequate length
to facilitate cricothyroid identification: approximately 3–5
cm. The incision may be extended caudad or cephalad as
needed until the cricothyroid membrane is palpated.
4. Blunt or sharp dissection is utilized to identify the
cricothyroid membrane, which is palpated between the
thyroid cartilage and cricoid ring. During dissection, the B.
clinician frequently palpates the underlying structures to
maintain midline dissection and avoid injury to the lateral
structures of the neck.
5. The cricothyroid membrane is incised transversely.
Laceration of the posterior trachea is avoided by using a
transverse incisional motion as opposed to an up-and-
down sawing motion.
6. The scalpel is removed from the neck. The back handle
(non-blade end) of the scalpel is partially inserted
into the trachea and rotated several times to dilate the
cricothyroidotomy. Utilizing the blunt end of the scalpel
handle reduces risk of laceration to the posterior wall of
the trachea.
7. Insertion of a fingertip will confirm entry into a hollow,
rigid tube. A bougie (if immediately available) may be
passed into the trachea while the non-blade end of the C.
scalpel handle is used as a guide.
8. An endotracheal tube is inserted directly (or over the
bougie) through the cricothyroidotomy into the trachea.
The precise size of the tube is not critical. The tube needs
to be small enough for easy insertion and large enough
for adequate ventilation. The tube may be exchanged after
patient status is improved and an airway expert is present.
9. The tube is advanced only until the balloon is completely
within the trachea to avoid mainstem intubation.
10. The endotracheal tube balloon is inflated. The bougie
is removed if present. Assisted ventilation is performed.
Appropriate location is verified with sustained ETCO2
detection and auscultation of bilateral breath sounds.
11. The tube is secured with sutures to the skin after ensuring a
tracheal location without mainstem placement.

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 COURSE MANUAL | Chapter 4 | Airway Assessment and Management

 Figure 4-14: Cricothyroidotomy. A. Following D.

identification of the cricothyroid space, the skin is incised
vertically in the midline, centered on the cricothyroid
space. B. The clinician’s nondominant hand maintains
retraction and the index finger palpates the membrane. C.
The cricothyroid membrane is incised transversely. D. The
non-blade end of a scalpel is inserted into the cricothyroid
incision. E. The scalpel handle is twisted to dilate the
cricothyroidotomy. F. An endotracheal tube is inserted
into the trachea until the balloon is within the airway.
Alternatively, a bougie may be inserted along the scalpel
handle and an endotracheal tube passed over the bougie.

A.

E.

B.

F.

C.

59
 POST-INTUBATION MANAGEMENT • Volume-control ventilation
Following intubation, continuous assessment of the airway • Tidal volume: Maximum 6 mL/kg of ideal body weight
is indicated throughout the remainder of the trauma initial (calculate ideal body weight to avoid hyperinflation in larger
assessment.  Table 4-4, lists factors related to post-intubation patients)
management. • PEEP: 5 cm H2O
Frequently, administration of additional sedation is indicated
• FiO2: 100%, titrating to target adequate SpO2
following intubation. Infusions of one or more sedatives are
commonly initiated, with doses titrated to a specific sedation level • Respiratory rate 14/min. The respiratory rate is adjusted to
while mitigating potential hypotension. NMBDs have no sedation target a PaCO2 of 35–45 mm Hg/ETCO2 of 30–40 mm Hg.
effect and are administered with additional pain and anxiety ETCO2 is not a reliable surrogate for PaCO2 in a hypovolemic
relief. NMBDs impair neurological assessment (e.g., movement patient. Frequent arterial blood gas (ABG) assays are utilized
in response to painful stimulus). However, pupillary light reflexes to adjust ventilation. For patients with suspected or diagnosed
are preserved. TBI, the PaCO2 target is closer to 35 mm Hg. When metabolic
Mechanical ventilation is usually employed when the acidosis is present, a lower ETCO2/PaCO2 may be beneficial
equipment is available. The following are reasonable initial to partially increase pH.
settings:

 Table 4-4: Post-Intubation Management.

Airway • Secure the endotracheal tube

• Continuous ETCO2 monitoring (if available)
• Assessment of airway patency
• Chest x-ray and auscultation of breath sounds to exclude
endobronchial (mainstem) intubation and pneumothorax
• Aspiration of secretions

Breathing • The next assessment step (clinical, chest x-ray, +/- ultrasound)
• Potential evolving pneumothorax following application of
positive pressure ventilation
• Application of sedation, with or without paralysis, to optimize
ventilation
• Evaluate blood gas

Circulation • Continue resuscitation

• Manage potential decompensation associated with intubation
and positive pressure ventilation
• Potential administration of vasopressor medication to offset
vasodilation due to sedation

• Exam limited by continual sedation and paralytic

Disability
• Optimize TBI management (see Special Population
Considerations)
• Reassess neurologic exam, including pupils
• Reapply C-spine collar if indicated

Exposure • Anticipate hypothermia (exacerbated by sedation) and provide

warming

ADJUNCTS Insert gastric tube (oral or nasal)

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ADJUNCTS TO TREATMENT TRANSFER CONSIDERATIONS

AWAKE INTUBATION Managing an airway emergency in a vehicle or aircraft is

significantly more difficult. If airway compromise during transport
This advanced technique involves inserting an endotracheal is possible, intubation is often performed prior to a transfer. As
tube under topical or regional anesthesia while the patient mentioned above, attention to the airway and reassessment with
is awake or lightly sedated (i.e., interactive, cooperative, and any patient movement is important.
maintaining airway patency and spontaneous ventilation). This
is often performed with flexible video laryngo-tracheoscopy. SPECIAL POPULATION CONSIDERATIONS
Significant airway experience and specific training are important
for safe practice of this technique, which is beyond the scope of
the ATLS Course.
TRAUMATIC BRAIN INJURY
One of the goals of early management of TBI is to prevent
REASSESSMENT secondary injury (see Chapter 7, Disability: Neurological
Assessment and Management). During airway management,
Constant vigilance and frequent reassessment are necessary this goal is accomplished by avoiding hypotension, hypoxia,
to detect any changes to the airway, even following attainment of and hypercapnia. Hypotension and hypoxia are significant
a definitive airway. Rapid detection of compromised oxygenation risks during intubation. Laryngoscopy and intubation without
and ventilation may prevent deleterious sequelae. Reassessment adequate sedation may increase blood pressure and ICP. Apnea
includes physical examination of the airway and of the airway produces hypercapnia and raises ICP and is minimized as much
device (including depth at the teeth or gums for an endotracheal as possible.
tube, or at the neck for a surgical/incisional airway), oximetry,
capnography (when available), and monitoring of ventilatory LARGER PATIENTS
pressure. Airway devices may occlude from blood and secretions;
Increased adipose tissue presents anatomical and physiological
suctioning is performed as needed when fluid is in the lumen. If
airway challenges. Increased tissue mass presents different
device dislodgement is suspected, removal and reinsertion may
challenges to each airway management technique (mask
be performed unless appropriate position is rapidly confirmed.
ventilation, laryngeal mask insertion, intubation, and surgical/
Patient movement (e.g., log roll) is associated with displacement
incisional airway). Adjuncts (e.g., oropharyngeal airways)
of airway devices. Attending to the airway during and following
may be beneficial when inserted early. Head-up positioning is
patient movement is important. Defined in  Box 4-1, the DOPE
useful. Modifications to medication doses may be indicated.
mnemonic is useful to recall potential causes of hypoxia or other
Physiologically, hypoxia occurs more rapidly in larger patients
clinical deterioration following intubation.
due to higher incidences of preinjury pulmonary disease, lower
respiratory compliance, and reduced functional residual volume.
Application of higher levels of PEEP is often useful.
 Box 4-1: The DOPE Mnemonic.

OBSTETRIC PATIENTS
The ”DOPE” Mnemonic
In pregnancy, the airway is affected by potential reflux disease
and regurgitation. The gravid uterus reduces functional residual
Displacement: Endotracheal tube displacement volume, among other changes. From a management perspective,
D (right mainstem) or dislodgement the challenges are very similar to those in the patient with higher
proportion of adipose tissue.

O Obstruction: Mucous plug, kink in tubing OLDER PATIENTS

Soft-tissue changes reduce tissue turgor and can cause the
Pneumothorax: Simple or tension, cheeks to collapse (especially if dentures are removed), presenting
P due to positive-pressure ventilation challenges to maintain an adequate mask seal during mask
ventilation. Conversely, removal of dentures facilitates intubation.
Older patients are prone to hypotension following administration
Equipment failure: Disconnect from ventilator of RSI drugs due to physiology and the compounding of preinjury
E and perform manual ventilation medications. The doses of RSI drugs are often reduced.

61
 patients suffering high-percentage body surface area burn injury or
PEDIATRIC PATIENTS
presenting with a mechanism for potential inhalation injury, early
Several differences in the pediatric airway are relevant to intubation to preempt obstruction versus continuous observation
management, including the following: with frequent reassessment remains a challenging decision.
• All airway structures are smaller (smaller equipment is
indicated).
• The head is relatively larger. Therefore, the neck will tend to KEY LEARNING POINTS
flex in infants and younger children laying on a flat surface
• The most important priority in airway management
unless padding is placed under the torso.
is oxygenation.
• The tongue and epiglottis are relatively larger. The larynx
is more anterior and angled more anteriorly. Therefore, • All emergent airway management is considered
laryngoscopy is more challenging. Lifting the epiglottis with potentially difficult; every airway management
must include a plan for failure.
the laryngoscope can be helpful.
• The trachea is shorter. Thus, there is a greater risk of • An airway may be managed without intubation, and
endobronchial or mainstem intubation. intubation may be temporarily deferred until expertise
is present.
• The cricoid is elliptical in infants and younger children and
grows to circular by adulthood. Increased resistance may be • An airway device in the trachea with an inflated cuff
felt at the cricoid during intubation. below the vocal cords is termed a definitive airway.

• Increased metabolic rate and reduced functional residual • Initiate volume resuscitation before administration
capacity result in a higher risk of rapid hypoxemia, resulting of RSI medications.
in bradycardia and cardiac arrest much more quickly than in
adults. • Except in cardiac arrest, modified RSI is performed
utilizing sedative and paralytic medications.
The endotracheal tube size can be estimated as: size = age/4
+ 3.5. A cuffed endotracheal tube is safe and preferred for all age • The first attempt at intubation is the optimal attempt.
groups for emergency intubation. Laryngeal masks frequently Repeated attempts modify the technique or operator;
have suggested patient weight ranges printed on the packaging identical repeated attempts are not likely to succeed.
or device. This may be useful for selecting an appropriately sized • Successful intubation is confirmed with detection of
device. Drug doses are reduced and are based on weight. A height- sustained (present on at least seven breaths) exhaled
weight tape and a pediatric resuscitation trolley with a drawer carbon dioxide.
corresponding to each color bar on the tape are useful.
• For potential esophageal intubation, the tube is
CHAPTER SUMMARY promptly removed and the airway maintained by
reintubation and/or other methods.
Airway management encompasses a range of potential
• Surgical/incisional airway is indicated when
interventions, from basic maneuvers through upper airway devices oxygenation cannot be maintained by other means.
and subglottic airway insertion. Intubation is not indicated for all Once the procedure is initiated, the clinician must
injured patients. An airway may be opened and managed by basic persist and secure the airway regardless of any
airway maneuvers. Intubation may be safely temporarily deferred challenges encountered.
by these methods until resuscitation is initiated, competing
priorities are addressed, and more resources are available. • Excellent teamwork, cognitive aids (e.g., checklists),
Intubation (excluding during cardiac arrest) is performed and equipment selection will improve clinician
performance and patient safety.
with a modified RSI process. Cardiovascular resuscitation is
performed before and during RSI. Preoxygenation and apneic
oxygenation are important to prevent hypoxia. Appropriate
equipment including wide-bore suction is vital. The first attempt
at endotracheal intubation is the optimal attempt and always have
a plan for airway failure.
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64 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 5 | Breathing and Ventilation Assessment and Management

Breathing and Ventilation

Assessment and Management

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will be able to do the following:

1. Define the anatomic landmarks of the chest/ 4. Discuss initial interventions to temporize or
thorax stabilize patients with respiratory distress
following injury
2. Explain the causes and presenting signs/symptoms
of common conditions that result in respiratory 5. Discuss diagnosis and management of traumatic
distress following injury conditions causing respiratory distress in
pregnant, morbidly obese, and pediatric
3. Describe methods to diagnose various conditions
patients
that cause respiratory distress following injury

65
 ANATOMY

5 Based on surface landmarks, the chest is defined as the area

from the sternal notch to the costal margin anteriorly and from
the base of the neck to the costal margin posteriorly. However, the
diaphragm can move extensively based on the depth of inspiration/
expiration. Therefore, the abdomen can extend as high as the
nipple line/inframammary fold (IMF) and tip of the scapula with
deep exhalation.  Figure 5-1 illustrates the relationships between
external landmarks and internal anatomy.  Figure 5-2 illustrates
Breathing and Ventilation diaphragm movement.
Assessment and Management While varying in position with age and gender, the nipple line
intersects with the midclavicular line at the level of the fourth
intercostal space. The IMF is usually along the fifth to sixth rib
and is a more reliable landmark in patients with breast tissue than
CHAPTER STATEMENT the nipple line. The IMF is an important landmark, as it denotes
Thoracic trauma is very common and consists of both chest the fourth to fifth intercostal spaces, where the pleural space
wall and intrathoracic organ injury. Blunt, penetrating, crush, or can be safely decompressed with a needle or tube thoracostomy
blast mechanisms are potential etiologies. Trauma to the chest with less risk of entering the peritoneal cavity.
may critically impair breathing, disrupting the processes of gas The bony structure of the thorax is composed of seven true ribs
exchange and oxygenation. Delay in recognition or appropriate (ribs with direct cartilaginous connection to the sternum), three
treatment can result in morbidity or death. false ribs attached to the cartilage of rib 7, and two floating ribs
(ribs 11 and 12). The sternum is comprised of the manubrium,
INTRODUCTION body, and xiphoid and is connected to the ribs via the costosternal
cartilage and costal margin.
Injury to the chest wall and the structures located in the The diaphragm separates the abdomen from the chest. The
thoracic cavity is one of the most common sequelae of trauma. muscular diaphragm arises from the sternum and ribs anteriorly
Injuries can involve the boney structure of the chest wall, the and laterally, and from the L1–L3 vertebral bodies posteriorly.
viscera contained within the chest (heart, lungs, diaphragm, and The central component of the diaphragmatic dome is a tendinous
esophagus), and the great vessels of the mediastinum. Thoracic aponeurosis. Near the midline, this tendon is attached to
injury can produce impaired ventilation with respiratory the pericardium, an anatomic relationship that can result in
acidosis, impaired oxygen exchange leading to metabolic diaphragmatic injuries extending into the pericardial sac.
acidosis, impaired cardiac function from structural or electrical Several muscles contribute to the structure and function
injury to the heart, or massive hemorrhage. There can also be of the chest wall. Inferiorly, the diaphragm forms the inferior
more subtle injury whose consequences may not manifest for days boundary of the chest. Anteriorly, the pectoralis major and minor,
to years, such as esophageal and diaphragmatic injury. serratus anterior, intercostal, and superior bounds of the external
The clinician must understand the anatomy of the chest, the oblique muscles are present. Posteriorly, the chest is protected by
basic physiology of the cardiorespiratory system, and how to the latissimus dorsi, the ascending, transverse, and descending
assess for various types of injury following trauma. As well, the portions of the trapezius, the rhomboid major and minor, the
clinician must be comfortable performing urgent procedures, serratus posterior, and the erector spinae.
such as tube thoracostomy, that can be used to temporize, and The chest is divided into two pleural cavities (right and left)
perhaps definitively treat, some injuries. As severe rib fractures and a mediastinal cavity. The pleural space is the space between
account for significant mortality and morbidity, the clinician the chest wall and each lung. Externally, the mediastinum may
should be aware of multimodal strategies to offer pain relief and be visualized as a “box” defined as the area medial to the nipple
the clinical significance of severe chest wall injury. lines anteriorly, medial to the tips of the scapulae posteriorly, and
This chapter will review the anatomic boundaries that define bounded superiorly by the sternal notch and inferiorly by the costal
the chest. It will then review the pathophysiology underlying margins.  Figure 5-3 illustrates the cardiac “box.” Penetrating
common injuries that result from trauma to the chest, how to injuries to the cardiac “box” alert the clinician to potential
assess for them, and how to start treatment. Alternative diagnostic damage to the great vessels, pulmonary hilar structures, and
strategies that may be employed in resource-limited settings are heart.
reviewed. The chapter ends by addressing how to alter needed
interventions to address the special needs of pregnant patients,
those who are morbidly obese, and pediatric patients.

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 Figure 5-1: Internal Anatomy of the Thoracic  Figure 5-2: Alteration of Anatomy with Respiration.
and Upper Abdomen as Related to External As the diaphragm moves, intra-abdominal structures occupy
Landmarks. IMF – inframammary fold; AAL – anterior more (exhalation) or less (inhalation) of the rib cage.
axillary line; PAL – posterior axillary line; PR – right
pleural cavity; PL – left pleural cavity; M - mediastinal
cavity.

Anterior

Posterior

Lateral

67
 When chest injuries occur, normal physiologic mechanisms
 Figure 5-3: The Cardiac “Box”. The cardiac “box” is
can be disrupted. Pulmonary contusion/alveolar hemorrhage or
defined by the area medial to the nipple lines anteriorly,
medial to the tips of the scapulae posteriorly, bounded
changes in intrathoracic pressure relationships, as may occur with
superiorly by the sternal notch and inferiorly by the costal a hemo-/pneumothorax, can impair gas exchange with resultant
margins. Penetrating injuries to this region have potential hypoxemia and hypercapnia. Tension hemo-/pneumothorax
to injure several vital structures. results in increased intrathoracic pressure, which can impede
venous return to the heart with resultant hypotension. Multiple
rib fractures result in pain or paradoxical chest wall movement,
which can impair lung expansion. The common results of severe
thoracic trauma are hypoxemia, hypercapnia, and hypotension
with acidosis.

PULMONARY CONTUSION PATHOPHYSIOLOGY

Pulmonary contusion is an injury to the alveolar capillaries
without a tear in the lung tissue. This is the most common
intrathoracic injury, although there may not be clinical
consequences. Pulmonary contusions can occur in the presence
or absence of rib fractures. Secondary to flexible cartilaginous
chest walls, lack of fracture is more common in the pediatric
population. The majority of younger patients with isolated
pulmonary contusions recover. However, the mortality rate
associated with development of long-term respiratory failure in
the multiply injured patient is substantial. Blunt mechanism of
injury produces a contusion by transmission of force to the lung.
Penetrating and explosive mechanisms cause contusion either by
direct lung injury or by cavitation effect.
Pulmonary contusion results in alveolar damage with blood
and fluid accumulation in the pulmonary tissues. A mismatch
between ventilation and perfusion occurs, thereby creating an
The flank is the area between the anterior and posterior intrapulmonary shunt and segmental lung damage with loss of
axillary lines. A penetrating injury to the left flank from the nipple lung compliance. These pathophysiological effects can lead to
level to the costal margin may be related to a diaphragm injury. A hypoxemia and hypercapnia. The size, severity, and clinical
neurovascular bundle runs along the inferior border of each rib, impact of contusion frequently increase during the first 24–72
with the intercostal vein superior to the intercostal artery and the hours following injury.
artery superior to the intercostal nerve. Needles and chest tubes
are placed immediately over the superior aspect of a rib to PNEUMOTHORAX PATHOPHYSIOLOGY
minimize potential injury to the neurovascular structures. A pneumothorax results from air entering the space between
the lung and the pleura. This can be due to a defect in the lung
PATHOPHYSIOLOGY OF COMMON INJURIES or a defect in the chest wall that communicates with the pleural
The function of the chest wall is twofold. It enables volumetric space. Each pleural cavity is filled by the lung. Air in the pleural
change of the thoracic cavity, which facilitates lung expansion space disrupts the normal apposition of the lung to the chest
and contraction, and it protects underlying visceral structures. wall, causing the lung to collapse. This is defined as a simple
The primary muscles of respiration are the diaphragm and the pneumothorax.  Figure 5-4 illustrates a simple pneumothorax.
intercostal muscles. During inspiration, the diaphragm contracts Traumatic etiologies include parenchyma injury from high
inferiorly into the abdomen. Concurrently, the intercostal muscles airway pressure, stabbing injury, firearm injury, puncture from
contract, producing superior and anterior movement of the rib fracture, or iatrogenic events as may occur during central
sternum and causing the ribs to move laterally and superiorly. venous catheter insertion. Progressive accumulation of air and or
Chest wall structures move in an opposite fashion during fluid in the pleural space further collapses the affected lung and
exhalation. The resultant volume changes cause a pressure pushes the mediastinum to the opposite side, converting a simple
differential between the lung and the atmosphere, which drives pneumothorax to a tension pneumothorax.  Figure 5-5 illustrates
gas into and out of the lung. Normal respiratory rate at rest in tension pneumothorax physiology.
the uninjured patient is 8–12 breaths per minute. Whereas Such mediastinal shift impedes venous return to the heart,
CO2 exchange is mostly dependent on adequate tidal volume thereby decreasing cardiac output and, eventually, systemic
(minute ventilation) and blood flow to the alveoli, oxygen blood pressure. A simple pneumothorax can quickly become
exchange is dependent on functioning alveolar units and FiO2. a tension pneumothorax if the patient is receiving positive-
Impaired ventilation and CO2 exchange can manifest as altered pressure (e.g., mechanical, bag) ventilation. Up to 19% of
mental status and hypotension (a late finding). Hypoxemia can patients who die following a blunt mechanism of injury have a
manifest as impaired mental status and cyanosis. pneumothorax. Depending on other injuries present, emergent
decompression of the pleural space may be lifesaving.

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 Figure 5-4: Simple Pneumothorax. A. Pneumothorax results from air entering the potential space between the visceral
and parietal pleura. B. Chest x-ray (CXR) demonstrating near complete right pneumothorax. Arrow marks edge of right
lung.

A. B.

 Figure 5-5: Tension Pneumothorax. A “one-way valve” air leak occurs from the lung or through the chest wall. Air is
forced into the thoracic cavity, eventually collapsing the affected lung. A. Diagram demonstrating shift of mediastinum
and increased pressure on the caval vessels in right tension pneumothorax. B. Chest radiograph immediately on patient
presentation demonstrating right tension pneumothorax. The trachea is deviated to the
left of the midline.

A. B.

Collapsed lung

Pneumothorax

Mediastinal
shift

Vena Heart
cava

Lacerations to the chest wall with penetration of the pleural

space can result in an open pneumothorax, or a “sucking chest HEMOTHORAX PATHOPHYSIOLOGY
wound.” Because air follows the path of least resistance, when an
opening in the chest wall is at least two-thirds the diameter of the Hemothorax occurs when blood accumulates between the
trachea, air will preferentially pass through the chest wall defect lung and chest wall. This can be due to hemorrhage from direct
on inspiration, creating a distinct “sucking” sound. Equilibration injury to the lung, a severed intercostal vessel, broken ribs,
between intrathoracic and atmospheric pressure is immediate. injured thoracic viscera, or an abdominal injury entering the
Effective lung expansion is impaired, leading to hypoxemia and chest via a defect in the diaphragm. A penetrating injury to the
hypercapnia.  Figure 5-6 illustrates an open pneumothorax. heart can result in hemothorax if there are concurrent pericardial
and pleural defects. Massive or tension hemothorax occurs when
sufficient blood collects in the pleural space to cause hypotension,
which is due to the combined effects of impaired venous return
Advanced Trauma Life Support for Doctors Approved (likeneeded
Changes with tension
Datepneumothorax) and hemorrhagic loss of
Student Course Manual, 9e
American College of Surgeons KB
Figure# 04.02
Dragonfly Media Group 69
10/26/2011 WC
  Figure 5-6: Open Pneumothorax. Large defects of  Figure 5-7: Flail Chest. A. The flail chest segment from
the chest wall that remain in communication with the multiple rib fractures disrupts normal chest wall movement.
atmosphere can result in an open pneumothorax. B. Flail chest from costochondral separation.
C. CXR with multiple rib fractures and pulmonary contusion. A
segment of the chest wall does not have bony continuity with
the rest of the thoracic cage.
Collapsed lung
A.
Pneumothorax

Sucking
chest wound

Air

B.

circulatory volume.

RIB FRACTURE AND FLAIL CHEST PATHOPHYSIOLOGY

Rib fractures occur along a spectrum, from simple nondisplaced
fractures to displaced, complex rib fractures. Fractures can be
segmental and, when occurring in multiple places along adjacent
ribs, may result in a radiographic flail segment or clinical flail
chest. A radiographic flail segment is defined as two or more
ribs broken in two or more places as visualized on an imaging
study. Clinical flail chest is defined as paradoxical movement
of the chest wall during respiration. It is possible to have
radiographic flailLife
without
Supportclinical flail chest, but the opposite
Approved does Changes needed
Advanced Trauma for Doctors Date
C.
not occur.
Student Course Manual, 9e
American College of Surgeons
Paradoxical
Figure# 04.04 movement occurs because theKBflail segments are
no longerMedia
Dragonfly attached
Group to the chest wall, causing the injured portion of
10/26/2011 WC
the chest wall to move inward with spontaneous inspiration (due
to negative intrathoracic pressure) and outward NP
with exhalation.
 Figure 5-7 illustrates flail chest. During positive-pressure
(mechanical) ventilation, paradoxical movement is reduced and
can be difficult to detect. Rib fractures may result in progressive
hypercapnic respiratory failure due to pain-limited inspiration.
Severe hypoxemia (when present) is due to concomitant
pulmonary contusion and/or pneumothorax.

DIAPHRAGM INJURY PATHOPHYSIOLOGY

Traumatic diaphragm injuries are present in approximately
0.5% of all trauma patients, with two-thirds of cases due to
penetrating mechanisms. Traumatic diaphragm ruptures
following blunt trauma are more commonly diagnosed on the
left side, likely because the liver protects the right diaphragm.
Blunt trauma produces large radial tears, whereas penetrating
injury more commonly produces smaller localized perforations

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which may be more difficult to diagnose (80% are <2 cm). TRACHEOBRONCHIAL INJURY PATHOPHYSIOLOGY
Both mechanisms can result in acute or chronic (i.e., years until
Injury to the trachea or a major bronchus is an unusual but
diagnosed) herniation of abdominal viscera. Diaphragmatic
potentially fatal condition. Most tracheobronchial injuries occur
rupture can result in respiratory compromise through
within 1 inch of the carina. Patients who reach the hospital alive
mechanical lung compression by herniated visceral contents.
with these injuries have a high mortality rate from associated
 Figure 5-8 illustrates diaphragm injury.
injuries, inability to ventilate due to loss of tidal volume,
 Figure 5-8: Diaphragm Injury. A. Blunt injury inadequate airway, or development of a tension pneumothorax.
produces radial tears which allow herniation of Such severe injury can result from crushing forces, shear forces
abdominal contents into the thoracic cavity. Respiratory due to rapid deceleration, or penetrating trauma.
distress is frequently present. Tension physiology may
occur as abdominal viscera displace the mediastinum. ASSESSMENT FOR COMMON INJURIES
B. CXR demonstrating nasogastric tube (NGT) above
the diaphragm in a blunt trauma patient, diagnostic of Efficient examination of the chest follows a “look, listen,
gastric herniation through a diaphragm injury. feel” (inspection, auscultation, palpation) approach. The chest
A Chest tube (CT) is also present.
and neck are completely exposed to allow for assessment of neck
veins, tracheal position, and surface signs of injury, such as bruising
A. or laceration. Temporary removal of the front of the cervical
collar, when present, is necessary to visualize the neck. Manual
spinal motion restriction is maintained during this portion of the
exam (see Chapter 4, Airway Assessment and Management Figure
4-12 for illustration of technique).
The chest wall is visualized for symmetrical movement.
Respiratory distress may be indicated by intercostal and
supraclavicular muscle retractions, nasal flaring, or the patient
speaking in short sentences. Auscultation anteriorly, in the second
to third rib spaces, and laterally, in the fifth to sixth rib spaces,
is performed for the presence and quality of breath sounds.
Diminished sounds may indicate hemo-/pneumothorax, large
pulmonary contusion, or diaphragm injury with herniated
abdominal contents. If endotracheal intubation has been
performed, diminished breath sounds may indicate bronchial
mainstem intubation, a particular risk in children due to a shorter
B. trachea. Palpation may detect tenderness (suggestive of rib
fractures) or crepitus (suggestive of a pneumothorax). The chest
wall includes the lateral and posterior thorax. Therefore, these
areas are also assessed either anteriorly or following a log roll
procedure.
Significant yet often subtle signs of chest injury include
increased respiratory rate and changes in the breathing pattern,
often manifested by progressively shallower respirations. Cyanosis
may be a late sign of hypoxemia. Cyanosis may be recognized
earlier by examining the nail beds and lips. Both hypoxemia
and hypercapnia can present as altered mental status. Injured
patients who are agitated, confused, or obtunded are assumed
to have impaired pulmonary gas exchange until proven
otherwise.  Table 5-1 lists physical signs of several conditions.

PULMONARY CONTUSION ASSESSMENT

Clinical presentation is dependent on degree of injury,
comorbid disease, and concomitant injuries. Pulmonary contusion
may be asymptomatic. When severe, dyspnea, tachypnea, or
hypoxemia may be present, auscultation may detect rales and
decreased respiratory sounds. Wheezing, cough, bronchorrhea,
and blood-streaked sputum are signs of more advanced injury.
Respiratory distress severity, hypoxia, and hypercapnia typically
peak at around 72 hours postinjury. Clinical deterioration may
occur in a delayed fashion.

SIMPLE, TENSION, AND OPEN

71
  Table 5-1: Physical Signs of Breathing Disorders and Injuries.

PHYSICAL SIGN

Breath Tracheal Blood

Condition Neck Veins Comment
Sounds Position Pressure
Pulmonary Normal to Midline Unaffected Unaffected Signs vary based on
Contusion Decreased severity

Simple Hemo/ Normal to Midline Unaffected Unaffected

Pneumothorax Decreased

Tension Hemo/ Decreased Deviated Distended* Decreased Critical clinical diagnosis

Pneumothorax AWAY from
injury

Open Abnormal and Midline Unaffected Unaffected Chest wound

Pneumothorax decreased

Massive Decreased Midline** Flat Decreased Hemorrhagic shock

Hemothorax

Flail Chest Decreased Midline Unaffected Unaffected Severity of associated

pulmonary contusion
determines degree of
hypoxia

Diaphragm Injury Decreased Midline** Unaffected*** Unaffected***

Tracheobronchial Decreased Midline** Unaffected**** Unaffected Continued air leak

and abnormal after chest tube
insertion. Potential for
massive subcutaneous
empysema.

*D istended neck veins are difficult to assess and may be absent if concurrent hemorrhagic shock is present.
** May shift away from injury side if tension physiology.
*** Massive herniation of abdominal contents into left chest may produce tension physiology. Neck veins may be distended and blood pressure decreased if tension
physiology. Blood pressure may be decreased if hemorrhagic shock is present due to abdominal injury.
**** May be distended if concurrent tension pneumothorax.

PNEUMOTHORAX ASSESSMENT Breath sounds may be diminished depending on the size of the
open pneumothorax.
Pneumothorax presents with dyspnea and possibly diminished
breath sounds over the affected pleural cavity. Crepitus may be HEMOTHORAX ASSESSMENT
detected on palpation. Tension pneumothorax causes absent
breath sounds on the affected side, hypotension, and tracheal Hemothorax will present like pneumothorax, with dyspnea
deviation away from the side of injury, as illustrated in  Figure and possible diminished breath sounds. A small hemothorax may
5-5. However, tracheal deviation is difficult to assess on physical not be evident on physical exam, whereas a large hemothorax
exam and may be a subtle dislocation in the suprasternal notch can present with decreased breath sound on the affected side.
or identified only on a chest radiograph. Tension pneumothorax Massive hemothorax will present with decreased breath sounds
is a clinical diagnosis based upon mechanism, absent breath and hemorrhagic shock (see Chapter 6, Circulation Assessment
sounds, and hypotension. Emergent treatment is not delayed and Volume Resuscitation). Tension hemothorax will present with
to confirm the diagnosis by radiographic or ultrasound studies. decreased breath sounds associated with hypotension (like tension
Assessment for open pneumothorax involves identifying the pneumothorax). The decreased blood pressure is due to both
chest wall defect. Often, the distinct sucking sound associated impaired venous return to the heart (as in tension pneumothorax)
with inspiration will help identify the injury. Clinical signs and and decreased circulatory volume due to hemorrhage.
symptoms are appropriate mechanism of injury, pain, difficulty
breathing, tachypnea, decreased breath sounds on the affected RIB FRACTURES AND FLAIL CHEST
side, and noisy movement of air through the chest wall injury. ASSESSMENT

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In conscious patients, severe chest wall injury manifests as Anterior-posterior (AP) chest x-ray (CXR) is one of the most
pain with inspiration or exhalation, commonly evidenced by an common and readily available imaging adjuncts available. Images
inability to take a deep breath or to speak in complete sentences. can be obtained in the resuscitation area with a portable unit. The
Frequently, the patient will not want to move due to pain. Flail CXR is reviewed for lung expansion, presence of fluid, widening
chest is a clinical diagnosis. As mentioned earlier, a radiographic of the mediastinum, subcutaneous and mediastinal air, midline
flail segment may be present without clinical flail chest. tracheal shift, loss of aortic anatomic detail, and presence of
Paradoxical chest wall movement may be difficult to observe and gastric air in the left chest
may not occur during positive-pressure ventilation. Crepitus may Multiple rib fractures and fractures of the wide, thick, and
be palpated due to movement of the fracture segments or due to protected first or second rib suggest that a significant force was
subcutaneous air. Palpation of the chest wall will elicit pain. delivered to the chest and underlying organs. Blood layers in
dependent positions, and air rises anteriorly. Therefore, on a
DIAPHRAGM INJURY ASSESSMENT supine CXR, a hemothorax may appear as mild lung opacity. A
Diaphragm injury may not be detected on physical examination. pneumothorax may manifest as hyperlucency or may not be visible.
When present, the signs and symptoms are related to the effects Pneumomediastinum is a sign of injury to the airway or digestive
of herniation of abdominal visceral structures into the chest. tract (e.g., esophagus; see Chapter 21, Thoracic, Abdominopelvic,
A large left diaphragm tear may produce dyspnea, hypoxemia, and Genitourinary Trauma).  Figure 5-9 and  Figure 5-10
and hypercapnia due to inability of the lung to fully expand. A illustrate various chest injuries on radiologic imaging.
hemothorax may be the result of combined diaphragmatic
ULTRASOUND
and intra-abdominal injury. Negative intrathoracic pressure
causes blood to accumulate in the chest through the defect in the FAST and eFAST are useful for rapid detection of
diaphragm. Rarely, and very difficult to detect, bowel sounds may pneumothorax, hemothorax, and hemopericardium. Accurate
be heard over the left chest if intestine has herniated.  Figure 5-9: CXR and CT Scan Images of Pulmonary
Injuries. A. CXR demonstrates subcutaneous emphysema,
TRACHEOBRONCHIAL INJURY ASSESSMENT pulmonary contusion, and chest tube. B. CT scan
Hemoptysis, cervical subcutaneous air, tension pneumothorax, demonstrates the same findings along with a hemothorax.
and cyanosis are typical signs of an injury to the larger airways. For
patients receiving mechanical ventilatory support, a loss of inhaled
A.
tidal volume into the chest wall or through a tube thoracostomy
may markedly impair ventilation. Incomplete expansion of the
lung and a continued large air leak after placement of a chest
tube suggest a tracheobronchial injury.

ADJUNCTS TO ASSESSMENT

MONITORING OXYGENATION AND

VENTILATION
Continuous pulse oximetry monitoring of arterial SpO2
is beneficial. However, a low SpO2 reading may occur due to
poor perfusion at the oximeter location, as well as due to a
primary pulmonary process. If available, ETCO2 detected using
colorimetry, capnometry, or capnography can provide valuable
insight into ventilation. However, ETCO2 values are also influenced
by pulmonary perfusion (see Chapter 4, Airway Assessment and
Management). An arterial blood gas (ABG) assay is a more precise
B.
method to accurately diagnosis and quantify hypoxemia and
hypercapnia. Additionally, ABG provides information regarding
acid-base balance.

IMAGING
CHEST RADIOGRAPHY

73
  Figure 5-10: Massive Subcutaneous Pneumothoraces.
and can detect conditions that are otherwise occult on x-ray or
Subcutaneous air infiltrates the subcutaneous and ultrasound. AP CXR can miss an anterior simple pneumothorax.
muscular tissues, outlining the chest musculature. Following trauma, the presence of subcutaneous air on CXR
usually denotes the presence of a pneumothorax.  Figure
5-9 and  Figure 5-10 illustrate subcutaneous emphysema. A
pneumothorax that is seen only on chest CT is frequently referred
to as an “occult pneumothorax.” Hemothorax can be seen using
CXR, ultrasound, or CT scan.

RIB FRACTURE
Rib fractures are best detected using CT scan. In most centers,
CT scan has replaced “rib series” radiographs, as CT provides
more detailed information regarding location and degree
of severity (i.e., displacement) of the fracture and allows for
evaluation of concurrent lung injury. Chest CT can quantitate the
number of fracture segments (diagnosing radiographic flail chest)
and detect associated pulmonary contusion, hemothorax, and
pneumothorax.

DIAPHRAGM INJURY
diagnosis depends on a clinician’s skill and experience. These Diaphragm injuries are very difficult to diagnose on CXR unless
studies can be performed in the resuscitation area and can be abdominal viscera have herniated into the chest. The abnormality
repeated, as they do not involve radiation. can be misinterpreted as an elevated hemidiaphragm, loculated
pneumothorax, or subpulmonic hematoma. An elevated right
CT SCAN diaphragm on a CXR may be the only sign of a right diaphragm
CT scan is a more sensitive imaging modality and provides injury. A recent review reported that the sensitivity of CT scan
much more detailed anatomic information than either plain with enteral contrast for diagnosis of traumatic diaphragmatic
x-ray or ultrasound. However, in many institutions, transport out hernia was only 80%. If a tear of the left diaphragm is suspected,
of the resuscitation area is required. Radiation exposure, time a nasogastric tube (NGT) can be inserted. If the tube appears
consumption, and expense are negatives of this modality. superior to the diaphragm on the CXR, a diaphragmic defect
is suspected  Figure 5-8B, illustrates an NGT in this position.
ADJUNCTS FOR THE DIAGNOSIS OF SPECIFIC The diagnosis of diaphragm injury is confirmed by operative
INJURIES exploration. Minimally invasive techniques, such as laparoscopy,
may be employed when diagnosis is unclear.
PULMONARY CONTUSION Isolated diaphragmatic injuries are rare. The force required to
A pulmonary contusion appears as a pulmonary infiltrate on create a blunt diaphragm injury almost always causes additional
CXR that is not restricted by the anatomical lobes or segments. thoracoabdominal injuries. These may vary from simple rib
There may or may not be associated rib fractures. An average of fractures to multiple herniations of lacerated viscera. Even
6 hours passes before the characteristic infiltrate appears on a isolated penetrating diaphragmatic lacerations typically have
CXR, but sometimes the contusion may be evident immediately injuries to adjacent structures, such as the liver, lung, heart, ribs,
or not for 48 hours. Other conditions such as hemothorax spleen, stomach, colon, esophagus, vertebral column, or spinal
or pneumothorax can interfere with the ability to visualize a cord. Careful assessment for other thoracic or abdominal injuries
pulmonary contusion on CXR. CT is very sensitive for pulmonary is always indicated. A diaphragm injury may be present following
contusion detection as seen in  Figure 5-9. The volume of lung a stab wound below the level of the nipple on the left chest and
involvement on CT correlates with clinical outcomes. Unlike flank region. Firearm-related injuries in this region are frequently
CXR, CT can detect contusion almost immediately after injury. treated with operative exploration. Thus, the evaluation for a
CT findings of pulmonary contusion consist of nonsegmental diaphragmatic injury is performed intraoperatively.
areas of consolidation and ground-glass opacification (hazy gray
TRACHEOBRONCHIAL INJURY
areas that indicate increased density).
Bronchoscopy confirms the diagnosis of tracheobronchial
injury. CT is useful to assess the airways and lungs and to evaluate
potential hemothorax and pneumothorax.

PNEUMOTHORAX AND HEMOTHORAX INTERVENTIONS AND TREATMENTS

Simple pneumothorax can be diagnosed using CXR,
ultrasound, or CT scan. CT scan is the most sensitive modality Supplemental oxygen is recommended at least during the
primary survey, until patient acuity can be further assessed and

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the risk of respiratory compromise determined.  Figure 5-11: Locations for Emergent Needle
Thoracostomy.
PULMONARY CONTUSION MANAGEMENT Two consensus optimal locations for safe and effective
needle decompression are indicated by the stars. One is
The injured lung is prone to pulmonary edema due to between the anterior (AAL) and mid axillary (MAL) lines at
extravascular fluid accumulation, and the volume of a contused the inframammary fold (IMF) level and the other is in the
lung may increase over the first 24–72 hours following injury. second intercostal space at the midclavicular line (MCL).
Oxygen exchange may be gradually impaired with progressive
hypoxemia. Treatment includes administration of supplemental
oxygen to maintain adequate saturation and avoiding volume
overload while supporting circulatory function. Fluid balance
can be challenging in cases of severe contusion. Mechanical
ventilation or other advanced adjuncts may be instituted to
maintain appropriate SpO2. An injured lung has an impaired
ability to clear secretions, and an estimated 20% of patients with
pulmonary contusion develop pneumonia. Thus, pain control and
pulmonary hygiene are central to the management of pulmonary
contusion (see Rib Fractures and Flail Chest Management).

PNEUMOTHORAX MANAGEMENT
SYMPTOMATIC SIMPLE AND TENSION
PNEUMOTHORAX MANAGEMENT
Treatment by tube thoracostomy is dependent on the size and
clinical effect of the pneumothorax. Clinical diagnosis of tension
pneumothorax mandates emergent chest decompression,
which can be achieved rapidly by either needle catheter or finger ASYMPTOMATIC AND OCCULT PNEUMOTHORAX
thoracostomy. Needle catheter thoracostomy involves insertion MANAGEMENT
of a large-bore (e.g., ≥ 14 gauge), over-the-needle catheter. There Treatment of asymptomatic pneumothorax is variable. Many
are two optimal locations for needle catheter insertion: the fifth trauma surgeons place chest tubes for asymptomatic, but CXR-
intercostal space (approximately at the IMF) between the mid visible, pneumothoraces unless the pneumothorax is very small.
and anterior axillary lines; and at the second intercostal space Recent studies suggest that asymptomatic pneumothoraces less
at the midclavicular line.  Figure 5-11 illustrates potential than 3.5 cm from the chest wall, as measured on the CT scan, can
locations for needle thoracostomy. The choice of site is dependent be managed without tube thoracostomy. Failure of a non-tube
on patient factors and clinical scenario. The benefit of needle strategy is associated with positive-pressure ventilation, more
thoracostomy is expediency. However, due to variable thickness severe chest injury, and concurrent hemothorax.
of the chest wall, kinking of the catheter, and other technical or Increasing size of a pneumothorax on serial CXR is an
anatomic complications limit the success and duration of needle indication for chest tube placement. In scenarios of clinically
decompression. occult pneumothorax and planned transfer by air, the sending
Finger thoracostomy is another approach for emergent physician should discuss the need for chest tube insertion
decompression of the chest. A scalpel is used to create an opening prior to transfer with the receiving physician. The change
in the chest wall at the fifth intercostal space (approximately at the in transpleural pressure with altitude can potentially result
IMF) between the mid and anterior axillary lines as part of chest in enlargement of the pneumothorax and conversion from
tube insertion. A finger is inserted into the pleural space to release asymptomatic to symptomatic during flight.
air and fluid. A tension pneumothorax can recur following
either finger or needle decompression, as the soft tissues OPEN PNEUMOTHORAX MANAGEMENT
of the chest can occlude the tract that was created. Insertion Initial management of an open pneumothorax involves
of a tube thoracostomy is performed following emergent prompt coverage of the defect with a sterile dressing large
decompression. Serial release of air may be indicated until a tube enough to overlap the wound edges. Any occlusive dressing
thoracostomy is placed. or a vented chest seal may be used as a temporizing measure.
The definitive treatment of any pneumothorax or An occlusive dressing is taped securely to three sides to create a
hemothorax is tube thoracostomy. Rarely, operative exploration valve effect to prevent development of tension physiology. During
is performed to manage the pulmonary injury or source of inspiration, the dressing occludes the wound. On exhalation, the
hemorrhage. Multiple studies have confirmed that a 14 French open side of the dressing allows air to escape. A tube thoracostomy
thoracic catheter is equally effective as larger tubes for definitive is inserted through a separate incision as soon as feasible.
treatment of pneumothorax with an added benefit of decreased Definitive therapy involves operative closure of the chest wall
pain. If the clinician has adequate expertise, tube insertion with laceration with placement of a tube thoracostomy.  Figure 5-12
ultrasound guidance may assist with confirming appropriate illustrates emergent management of an open pneumothorax.
placement. The clinician uses the method with which they can
most quickly, safely, and reliably relieve a pneumothorax.
75
 pneumothorax, multiple studies have confirmed that a 14 French
catheter is equally effective as larger tubes for definitive treatment
of hemothorax. However, most of these studies excluded patients
with massive or tension hemothorax, which is often treated with a
larger-bore (≥ 24 French) tube.
 Figure 5-12: Open Pneumothorax Management. A. A Operative intervention for hemorrhage control may be
sterile occlusive dressing is placed to cover the wound. The indicated for tension or massive hemothorax. Emergency
dressing is secured on three sides to create a valve effect, transfusion is common. Operative decisions are based on
preventing air entry with inhalation and allowing air to physiologic status (e.g., shock) and continued bleeding rather
escape with exhalation. Alternatively, several commercial than specific initial or subsequent chest tube output. Some trauma
products are available which have an included valve. B. A center data suggest reduced rates of retained hemothorax and
tube thoracostomy is performed prior to operative repair.
delayed surgery by employing a chest tube irrigation protocol
once bleeding is controlled.
A.
RIB FRACTURES AND FLAIL CHEST
MANAGEMENT
The most common cause of morbidity and mortality after
rib fractures is pneumonia due to pain precluding appropriate
pulmonary hygiene. Thus, the treatment of rib fractures is based
on pain control and ensuring appropriate pulmonary hygiene.
Chest physiotherapy, incentive spirometry, and other modalities
to promote alveolar expansion and pulmonary hygiene are
critical. Intubation may be indicated when flail chest and chest
wall instability cause inability to breathe, when severe underlying
pulmonary contusion results in hypoxia, or when sedating
medications are administered to provide appropriate pain relief.
A triage algorithm helps determine benefits of inpatient versus
outpatient management and admission location (e.g., ICU versus
B. ward). Protocols based on patient demographics and severity of
injury are beneficial to ensure appropriate pain relief, pulmonary
therapy, and monitoring. Pain relief uses multimodal oral and
IV medications, with emphasis on nonopioid therapies and
locoregional pain control. Multimodal pain relief can consist
of acetaminophen/paracetamol, nonsteroidal anti-inflammatory
drugs (NSAIDs), ketamine, lidocaine, and regional pain blocks.
Surgical stabilization of rib fractures is effective in mitigating
morbidity for select flail chest injuries.

DIAPHRAGM INJURY MANAGEMENT

Left diaphragm injuries are operatively repaired urgently.
Chest tube insertion to treat concomitant hemothorax or
pneumothorax may inadvertently injure herniated abdominal
contents; thus, careful attention to safe placement is recommended.
Diaphragmatic injuries with abdominal viscera herniated into
the chest are immediately operatively repaired due to the risk of
visceral strangulation. A transabdominal approach is elected most
often. However, a transthoracic approach may be used in select
instances based on the specific injury pattern. Selected right
HEMOTHORAX MANAGEMENT diaphragm injuries can be managed nonoperatively unless there
is a concomitant liver injury. In this instance, diaphragm repair is
Hemothoraces with estimated volume more than 300 mL considered to decrease the development of a biliopleural fistula.
are recommended to be evacuated using a tube thoracostomy
to prevent the blood from congealing and creating a trapped TRACHEOBRONCHIAL INJURY
lung. Accurate quantification of fluid volume is challenging in
the emergent situation. Thus, most traumatic hemothoraces
MANAGEMENT
are treated with tube thoracostomy. Massive whole-chest A tube thoracostomy is performed emergently, often preceded
hemothorax may produce tension physiology and is treated by needle or finger thoracostomy for treatment of tension
with finger, followed by tube, thoracostomy. As with pneumothorax. Intubation of patients with tracheobronchial
injury may be difficult because of anatomic distortion from

76 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 5 | Breathing and Ventilation Assessment and Management

surrounding trauma. Advanced airway skills, such as fiber short needle thoracostomy. A sufficiently long catheter or a
optic-assisted endotracheal tube advancement distal to the finger thoracostomy is used instead. A tube thoracostomy can
tear or selective intubation of the unaffected bronchus, may be also be challenging. Successful placement may be accomplished
indicated. Surgical consultation is obtained immediately. Small through a larger incision, which permits dissection to the ribs and
injuries may be amenable to nonoperative management. However, placement of an intrapleural tube.
larger tears are operatively repaired. Placement of additional chest
tubes may adequately control the leak and allow lung expansion. PRACTICE ENVIRONMENT CONSIDERATIONS

REASSESSMENT When CT scan is not readily available, ultrasound and x-ray

(in combination or individually) can be used to assess for most
Patients are reassessed after each intervention using the thoracic injuries. A limitation of not having a CT scan is evaluation
initial evaluation approach of “look, listen, feel.” Treatment of the aorta and great vessels. Ultrasound as an imaging modality
adjuncts, such as tube thoracostomy, are evaluated to ensure proper has the advantages of bedside performance on a supine patient,
function. Continuous pulse oximetry and capnography (when repeatability, noninvasiveness, lack of radiation, and ability to
available) is performed to monitor appropriate gas exchange. Pain detect a variety of thoracic pathologies, including pneumothorax,
relief and the ability to cough and take deep breaths is assessed hemothorax, and pulmonary contusion.
frequently for patients with rib fractures, as inadequate treatment A pulmonary contusion may be diagnosed by the presence of an
can lead to pneumonia and respiratory failure. irregularly outlined, moderately hypoechoic lesion or hyperechoic
punctate images corresponding to an air bronchogram. There
TRANSFER CONSIDERATIONS may be multiple B-lines. Ultrasound has the disadvantage of being
operator dependent, with specialized training being desirable to
Patients with moderate and severe thoracic injury benefit create and interpret images.
from transfer to a trauma center. This includes patients for In instances where a chest tube is not readily available,
whom operative intervention is not planned but who will benefit other tubes (e.g., endotracheal tube) can be used to decompress
from the resources of a trauma center. For example, patients the pleural space. The endotracheal tube balloon may be
with multiple rib fractures or flail chest (radiographic or clinical) inflated and used to anchor the tube in the chest cavity.
benefit from the regional analgesia, physiotherapy, and possible
surgical stabilization services that a trauma center offers. However, CHAPTER SUMMARY
the most common invasive intervention following thoracic
trauma is tube thoracostomy. This is a potentially lifesaving Thoracic injury is very common. Rapid and organized
procedure that is completed prior to transfer, particularly for assessment is critical to detect life-threatening problems. Most
symptomatic patients prior to transport by air or by a medical injuries can be diagnosed with physical exam, CXR, and
crew that is not credentialed or equipped to perform emergent ultrasound, although CT scan provides much more detailed
chest decompression. Chest tubes are maintained at –20 cm H2O information. The most common intervention is chest cavity
suction during transport. decompression via needle, finger, or tube thoracostomy. Emergency
or urgent thoracotomy is rare. Expeditious transfer to a trauma
SPECIAL POPULATION CONSIDERATIONS center capable of providing a higher level of respiratory support
and potential operative intervention is beneficial, particularly for
Late-term pregnant patients have specific considerations. more frail and critically ill patients.
The gravid uterus will prevent full movement of the diaphragm,
thereby resulting in small lung volumes. A higher diaphragm is
considered when placing a needle, finger, or tube thoracostomy.
Adjusting chest entry cephalad by 1–2 rib spaces may be beneficial.
The second intercostal space at the midclavicular line may be a
preferred site for needle thoracostomy.
Children have a smaller torso. The clinician performs the
needle, finger, or tube thoracostomy at or slightly superior to the
IMF. Smaller tubes are indicated due to a smaller intercostal space.
Because of greater chest wall pliability, children are at greater
risk of sustaining and developing a pulmonary contusion in the
absence of rib fractures compared to adults.
Frail and older adult patients are at higher risk of deleterious
outcomes after chest wall injury and are likely to benefit from
structured care pathways and referral center management.
Obese patients have unique considerations for thoracostomy.
Penetration of the pleura is less likely to be successful with a

77
 KEY LEARNING POINTS 6. Schroeder E, Valdez C, Krauthamer A, et al. Average chest
wall thickness at two anatomic locations in trauma patients.
• Chest injury is common following both blunt and Injury. 2013;44(9):1183–1185.
penetrating trauma. 7. Garner A, Poynter E, Parsell R, Weatherall A, Morgan
M, Lee A. Association between three prehospital
• Breathing is impaired following chest injury due to
altered oxygenation, ventilation, and hemorrhage. thoracic decompression techniques by physicians and
complications: A retrospective, multicentre study in adults.
• Assessment for chest injury utilizes a “look, listen, Eur J Trauma Emerg Surg. 2023;49(1):571–581.
and feel” approach, oximetry, chest radiographs, 8. DuBose J, Inaba K, Demetriades D, et al. Management
and other adjuncts. of post-traumatic retained hemothorax: A prospective,
observational, multicenter AAST study. J Trauma Acute
• Presumptive administration of supplemental
oxygen for injured patients is beneficial until Care Surg. 2012;72(1):11–22; discussion 22–24; quiz 316.
breathing status is assessed and managed. 9. Choi J, Villarreal J, Andersen W, et al. Scoping review
of traumatic hemothorax: Evidence and knowledge
• The most common lifesaving emergent gaps, from diagnosis to chest tube removal. Surgery.
intervention following thoracic trauma is chest 2021;170(4):1260–1267.
decompression via needle, finger, or tube 10. American College of Surgeons Committee on Trauma. Best
thoracostomy. These are important skills for the
Practices Guidelines for Acute Pain Management in Trauma
trauma clinician to master.
Patients. Released Nov 2020. https://www.facs.org/media/
• A multimodal approach is employed to manage exob3dwk/acute_pain_guidelines.pdf. Accessed Jun 17,
pain associated with chest wall injury. 2023.
11. Delaplain PT, Schubl SD, Pieracci FM, et al. Chest
• Operative decisions are based primarily on Wall Injury Society guideline for SSRF: Indications,
physiologic status.
contraindications, and timing. Revised Jan 10, 2020.
• Regardless of potential for operative intervention, https://cwisociety.org/wp-content/uploads/2020/05/
patients with moderate to severe thoracic injury CWIS-SSRF-Guideline-01102020.pdf. Accessed June 17,
benefit from transfer to a trauma center. 2023.
12. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters
• Older and frail patients are at high risk of JM, Schreiber MA. Traumatic diaphragmatic injury in
complications following even minor chest injury
the American College of Surgeons National Trauma Data
and benefit from trauma center management.
Bank: A new examination of a rare diagnosis. Am J Surg.
2015;209(5):864–868; discussion 868–869.
13. McDonald AA, Robinson BRH, Alarcon L, et al. Evaluation
and management of traumatic diaphragmatic injuries:
REFERENCES A practice management guideline from the Eastern
Association for the Surgery of Trauma. J Trauma Acute
1. Ganie FA, Lone H, Lone GN, et al. Lung contusion: A
Care Surg. 2018;85(1):198–207.
clinico-pathological entity with unpredictable clinical
14. Cohn SM, Dubose JJ. Pulmonary contusion: An update
course. Bull Emerg Trauma. 2013;1(1):7–16.
on recent advances in clinical management. World J Surg.
2. Levin JH, Pecoraro A, Ochs V, Meagher A, Steenburg SD,
2010;34(8):1959–1970.
Hammer PM. Characterization of fatal blunt injuries using
postmortem computed tomography. J Trauma Acute Care
Surg. 2023;95(2):186–190.
3. Tran J, Haussner W, Shah K. Traumatic pneumothorax:
A review of current diagnostic practices and evolving
management. J Emerg Med. 2021;61(5):517–528.
4. Reitano E, Cioffi SP, Airoldi C, Chiara O, La Greca
G, Cimbanassi S. Current trends in the diagnosis and
management of traumatic diaphragmatic injuries: A
systematic review and a diagnostic accuracy meta-analysis
of blunt trauma. Injury. 2022;53(11):3586–3595.
5. Azizi N, Ter Avest E, Hoek AE, et al. Optimal anatomical
location for needle chest decompression for tension
pneumothorax: A multicenter prospective cohort study.
Injury. 2021;52(2):213–218.

78 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

Circulation Assessment and

Volume Resuscitation

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Identify shock in a trauma patient 5. Evaluate the cause of shock in a trauma patient
2. Recognize significant blood loss with resultant 6. Reassess and alter resuscitation strategy based
decreased intravascular volume in a trauma case on patient responses to resuscitation
3. Address circulation abnormalities at the 7. Recognize limitations of the local practice
appropriate stage of the primary survey environment, resources for optimal
management, and the role of transfer in a
4. Initiate resuscitation for shock
trauma scenario

79
  Table 6-1. Three Types of Nonhemorrhagic Shock.

6 Classification of Nonhemorrhagic Shock in

Trauma Patients

Type of Shock Trauma Etiologies

Obstructive Tension pneumothorax

Cardiac tamponade

Circulation Assessment and

Cardiac Blunt cardiac injury
Volume Resuscitation Myocardial infarction

Distributive Neurogenic
CHAPTER STATEMENT Septic

Identifying and promptly addressing circulatory compromise, Anaphylactic

or shock, in trauma patients is crucial for achieving successful
outcomes. As no single test can diagnose shock, a combination
of clinical assessment, recognition of altered physiology, and use HYPOVOLEMIC/HEMORRHAGIC SHOCK
of appropriate adjuncts is essential. The cornerstone of shock Hemorrhage is the most common cause of shock in trauma
management is to identify its underlying cause. While hemorrhage patients. Recognizing significant bleeding with subsequent loss
is the most common cause in trauma, it is imperative to exclude of intravascular volume is crucial. Hemorrhage is defined as an
other causes such as obstructive, cardiogenic, and distributive. acute blood loss from circulating volume. Normal adult blood
volume is approximately 7% of body weight, although it can vary
INTRODUCTION considerably. For example, a 70 kg patient has a circulating blood
Circulatory compromise in trauma patients can result from a volume of approximately 5 L. The blood volume of patients with
variety of injuries and generally manifests as shock. Management a higher proportion of adipose tissue is estimated based on ideal
of shock in trauma patients involves prompt recognition and body weight. Calculation based on the actual weight of these
appropriate resuscitation. A more precise diagnosis of the cause patients can result in significant volume overestimation. For
of shock allows treatment to be adjusted. Shock is defined as pediatric patients, total circulating blood volume can be estimated
insufficient tissue perfusion and oxygenation. Without prompt as 80 mL/kg for an infant, 75 mL/kg at ages 1-to-3 years, and 70
diagnosis and management, shock severity can rapidly escalate, mL/kg after age three.
leading to organ dysfunction and mortality. The clinical signs of hypovolemic shock are directly related
to the dysfunction of each organ system and to physiologic
PATHOPHYSIOLOGY compensation, both detectable and occult.  Table 6-2 illustrates
changes in several parameters as hemorrhage severity increases.
Initial physiologic adjustments to blood loss include progressive
GENERAL vasoconstriction of cutaneous, muscular, and visceral circulation
The lack of adequate tissue circulation prevents optimal cellular to preserve blood flow to more vital organs. Tachycardia is the
energy metabolism, which normally powers all bodily functions. earliest measurable sign of hypovolemia. Heart rate increases
Shock in trauma patients can be classified into two large categories, to preserve cardiac output. Narrowing of pulse pressure and
hemorrhagic or nonhemorrhagic. Hemorrhage is the most hypotension occur after moderate to severe blood loss. The
common cause of shock in the injured patient. Trauma patients release of endogenous catecholamines increases peripheral
often endure significant blood loss culminating in hypovolemic, vascular resistance, which increases diastolic blood pressure and
hemorrhagic shock. Early recognition of blood loss allows reduces pulse pressure. However, this does little to increase organ
healthcare clinicians to promptly initiate suitable resuscitation perfusion and tissue oxygenation.
measures, such as hemorrhage control and blood transfusion, Blood loss produces peripheral vasoconstriction, resulting in
to restore circulating volume and prevent further deterioration. cool and clammy skin. The body redistributes blood flow to vital
Nonhemorrhagic shock can be further classified into obstructive organs, sacrificing peripheral perfusion. An injured patient with
(e.g., cardiac tamponade or tension pneumothorax), cardiogenic cool skin and tachycardia is in shock until proven otherwise.
(e.g., blunt cardiac injury), or distributive (e.g., neurogenic Paleness of mucous membranes (inner eyelids, conjunctiva, oral
or septic) etiologies. Each type of shock necessitates specific mucosa, tongue, and lips) can be a sign of reduced blood volume.
interventions and management approaches,  Table 6-1 lists three In lightly pigmented individuals, the skin may appear pale.
classifications of nonhemorrhagic shock and their associated Shivering and inability to maintain core temperature are a
etiologies. direct consequence of shock. Anxiety is an early sign and may
progress to agitation and confusion. Lethargy and decreased
level of consciousness follow as shock severity increases, even in
the absence of primary central nervous system injury. Patients
80 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

 Table 6-2. Changes in Clinical Parameters as Related to Hemorrhage Severity. Response to blood loss varies based on
patient factors and source control. Response to resuscitation is dependent on the presence of continued bleeding, not on a
specific volume of blood loss.

HEMORRHAGE SEVERITY

PARAMETER MINOR MODERATE MAJOR

Heart Rate Unchanged Unchanged to Increased (>100) Markedly Increased

(beats/min) Increased (>120)

Systolic Pressure Unchanged Unchanged Unchanged to Markedly Decreased

(mm Hg) Decreased (<90)

Pulse Pressure Unchanged Decreased Decreased Decreased

Respiratory Rate Unchanged Unchanged to Increased Increased

Increased

Level of Unchanged Unchanged Decreased Markedly Decreased

Consciousness

Base Deficit (meq/L) 0 to -2 -2 to -6 -6 to -10 -10 and less

Blood Products Unlikely Possibly Likely Massive Transfusion

Protocol

Response to Rapid and Fairly Rapid and Transient Minimal to None

Resuscitation Sustained Sustained

Operative Unlikely Possibly Likely Extremely Likely

Hemorrhage Control

experiencing significant blood loss often report thirst as the body significant blood loss due to insufficient cardiac venous return.
attempts to compensate for fluid loss. Tension pneumothorax is discussed in Chapter 5, Breathing
As blood volume decreases, the body compensates by increasing and Ventilation Assessment and Management. Air enters the pleural
the respiratory rate to improve oxygenation and correct metabolic space but does not escape. Intrapleural pressure rises, eventually
acidemia through respiratory alkalosis. Tachypnea can be an collapsing the entire lung on the affected side. Increasing pressure
early sign of significant blood loss. In response to hypovolemia, shifts the mediastinum to the opposite side. Higher mediastinal
the body attempts to conserve fluid by reducing urine output. pressure impedes caval blood flow and venous return. Cardiac
Monitoring urine output over time is helpful in recognizing output decreases. This process is lethal unless prompt intervention
continued hypovolemia. A decrease in urine output (i.e., oliguria) is performed. Please see Chapter 5, Breathing and Ventilation
may indicate inadequate circulating volume. However, recognition Assessment and Management, Figure 5-3 for an illustration of the
of decreased urine output takes time and will not be able to be pathophysiology of tension pneumothorax.
identified during initial assessments. Cardiac tamponade is more common following penetrating
When the compensatory mechanisms of tachycardia rather than blunt trauma. Cardiac tamponade is a life-threatening
and increased peripheral vascular resistance are exhausted, condition where fluid accumulates in the pericardial sac,
hypotension will occur, further compromising all organ functions. compressing the chambers of the heart. The lower-pressure
When near-complete energetic failure is imminent, bradycardia atria are unable to relax. Similar to tension pneumothorax
with circulatory collapse occurs. pathophysiology, venous return, preload, and subsequently
cardiac output are reduced. Untreated, this process is fatal. Even
OBSTRUCTIVE SHOCK with treatment, mortality remains high.  Figure 6-1 illustrates
Obstructive shock refers to compromised cardiac output due cardiac tamponade.
to hindered cardiac preload. Two common trauma-associated
diagnoses are tension pneumothorax and cardiac tamponade.
Both conditions can rapidly lead to circulatory arrest without

81
  Figure 6-1: Cardiac Tamponade.
A. Normal heart. B. Following penetrating or blunt injuries, cardiac tamponade can develop as the pericardium fills with
blood from the heart, great vessels, or pericardial vessels. C. Ultrasound image showing pericardial fluid in a patient with
tamponade physiology.

Normal Pericardial tamponade

Pericardial sac

CARDIOGENIC SHOCK DIAGNOSING THE PRESENCE OF SHOCK

Blunt cardiac injury (BCI) is most frequently encountered after
motor vehicle crashes and pedestrians struck by motor vehicles.
GENERAL
Other mechanisms include falls, crush injuries, assaults, and Early identification of shock facilitates targeted diagnostics
sports-related direct blows to the chest. Blunt trauma can result in and treatments for the underlying cause and enables
myocardial muscle contusion, cardiac chamber rupture, coronary appropriate resource allocation. Early activation of trauma teams
artery thrombosis or dissection, and valvular disruption. The and involvement of specialists like surgeons, anesthesiologists,
right atrium is the most likely chamber to be injured, followed by and intensivists are crucial for effective shock management.
the right ventricle, and, less likely, the left heart. BCI may produce Recognizing shock facilitates timely communication and
a range of abnormalities
Advanced fromforasymptomatic
Trauma Life Support Doctors mild arrhythmias
Approvedto mobilization
Changes needed of theseDate
resources, ensuring comprehensive care
lethal cardiac
Student failure.
Course Manual,In
9eolder patients, ischemic cardiac events from the moment the patient arrives at the healthcare facility.
American College of Surgeons
mayFigure#
precede or even be the cause of the traumatic KB
04.08 event (e.g., falls Patient outcomes are deleteriously affected by late
and motor vehicleGroup
Dragonfly Media crashes). recognition of shock. Studies consistently demonstrate that
10/27/2011 WC
delayed recognition and treatment of shock are associated with
DISTRIBUTIVE SHOCK NP
heightened morbidity and mortality. Promptly identifying
The most common mechanism of distributive shock in a and initiating appropriate interventions can improve tissue
trauma patient is spinal cord injury. Neurogenic shock may occur perfusion, prevent organ dysfunction, and increase the likelihood
after cervical or high thoracic spinal cord injuries. Hypotension of a favorable outcome. Timely identification enables early
occurs from loss of efferent sympathetic signals from the spinal intervention, appropriate triage, targeted treatment, continuous
cord, resulting in a decrease in peripheral vascular resistance. monitoring, guided resource allocation, multidisciplinary
Anaphylactic and septic shock are rarer distributive types of shock collaboration, and the best possible chance of recovery and
in trauma patients. They may be related to an underlying event survival.
that caused the traumatic event. Anaphylactic shock may develop Diagnosing shock in a trauma patient relies on a synthesis
in response to treatment such as medication or blood product of clinical findings and laboratory tests. No single vital sign or
transfusions. Septic shock may be observed in patients with laboratory test, on its own, can definitively diagnose shock.
delayed presentations of a perforated viscus, pulmonary injury The clinical signs of shock are directly related to the dysfunction
with pneumonia, urinary infection that precipitated the traumatic of each organ system and their evident or occult compensatory
event, or contaminated open fracture. Such patients may be from mechanisms. Rapid detection of inadequate tissue perfusion by
remote locations or victims in natural or humanitarian disaster identifying common clinical indicators is paramount. Through
situations. early recognition of shock, clinicians can implement targeted
treatments such as controlling bleeding, initiating volume
resuscitation, alleviating cardiac tamponade, or relieving tension
pneumothorax. Continuous assessment of vital signs, perfusion
parameters, and laboratory values enables timely detection of
deteriorating shock and recognition of inadequate response to
treatment.

82 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

PHYSICAL EXAM ASSESSMENT

Continual monitoring of blood pressure and heart rate
is essential both to identify shock and to monitor treatment
DETERMINING THE SOURCE OF SHOCK
response. However, relying solely on systolic blood pressure as Identifying the underlying etiology of shock allows for targeted
an indicator of shock can delay recognition, as compensatory interventions and optimal outcomes. Once shock is diagnosed
mechanisms can prevent a measurable fall in systolic pressure or suspected, resuscitation is initiated while an evaluation for
until a significant amount of the blood volume is lost. In most the source is simultaneously performed. The presence of shock
adults, tachycardia and cutaneous vasoconstriction are the initial in a trauma patient is an indication to immediately consider
physiologic responses to volume loss. Heart rate divided by consultation of a surgeon and other specialists, if available, or
systolic blood pressure, known as shock index (SI), may assist in to consider transfer to a center with appropriate resources. To
early recognition of hypoperfusion. A normal SI is ≤ 0.7. SI ≥ 1 is recognize and manage hemorrhagic and nonhemorrhagic forms
correlated with higher mortality. SI ≥ 0.8 is correlated with blood of shock, clinicians remain alert to the patient’s status and carefully
product transfusion, emergent surgical therapy, increased 24- observe the response to treatment.
hour and in-hospital mortality, and increased ICU and hospital
lengths of stay. HISTORY
Reduced blood volume can result in weakened peripheral The mechanism (e.g., motor vehicle, fall, crush, thermal,
pulses. Palpating peripheral pulses, such as the radial or dorsalis penetrating) and forces (car versus bicycle, height of fall, firearm
pedis, can help determine the strength and quality of blood flow or cutting instrument) related to injury are obtained from the
to the extremities. Weak or thready pulses suggest compromised patient, witnesses, or prehospital personnel. A prehospital report
perfusion due to blood loss. Since ETCO2 reflects pulmonary of mechanism, potential injuries, vital signs, and treatments and
perfusion, a low ETCO2 reading may also be indicative of shock. responses will alert the clinician to potential diagnoses and causes
Monitoring of other parameters such as capillary refill time, of shock.
urine output, lactate levels, and base deficit assists with informed The physiologic impact of all shock is magnified in the
decisions regarding transfusion, volume administration, and presence of preinjury medications. Knowledge of the patient’s
other interventions. In shock, the brain may not receive adequate medical history is vital, particularly regarding therapy that alters
oxygen and nutrients, resulting in mental status changes. Patients blood coagulation (anticoagulant and antiplatelet therapy), blood
may exhibit a range of alterations, from confusion and agitation to pressure regulation (antihypertensive medications), and heart
somnolence and loss of consciousness. rate compensation (beta blockers). For unconscious patients,
prehospital clinicians make a diligent search for medication
LABORATORY VALUES bottles, lists (on devices or in wallets), and pharmacy and family
Complete blood count, coagulation profile, ABG analysis, contacts.
and serum lactate levels provide valuable information regarding As hemorrhage is the most common etiology of shock in an
hemodynamic status and potential etiology of shock. Serial injured patient, the clinician assumes the presence of continuing
measurements of hemoglobin, hematocrit, and acid-base status hemorrhage. The sayings “one on the floor and four more” or
can aid in assessing blood loss over time. However, a normal “four and the floor” assist in recall of potential locations for life-
initial hematocrit or hemoglobin does not exclude significant threatening hemorrhage. “Four” refers to anatomic locations of
hemorrhage. Ongoing shock leads to poor tissue perfusion with major internal hemorrhage (chest, abdomen, pelvis, and long
increased anaerobic metabolism and lactic/metabolic acidosis. bone/intramuscular), and “floor” refers to external hemorrhage
Initial measurement of serum lactic acid level and/or base deficit (blood on the floor). These sites are evaluated during the primary
can aid in identification of shock. Serial measurements can help survey.  Figure 6-2 illustrates five sites of major hemorrhage.
guide treatment. A significant decline in these values may indicate
continued shock and spur further intervention. PRIMARY SURVEY
The primary survey utilizes the xABCDE steps of ATLS. Before
CLINICAL JUDGMENT reaching the “Circulation” evaluation and as described in earlier
Judgment is vital to placing clinical findings in context and chapters, the clinician has previously addressed “x” by controlling
recognizing shock. Decision-making is guided by assessment visible compressible exsanguinating external hemorrhage (“the
of the overall clinical scenario, including mechanism of injury, floor”) and “A” by ensuring the airway has been opened and
presence of penetrating wounds, potential for spine injury, and maintained. Oxygen administration, when available, has been
other factors. Blood loss may be visible or occult, with the latter initiated. Other team members have placed cardiac, oxygen
being more challenging to identify. Signs and symptoms may vary saturation, and ETCO2 monitors if available. If not previously
depending on the patient’s age, comorbidities, and compensatory obtained, large-bore IV or intraosseous access is obtained while
mechanisms. Therefore, healthcare clinicians consider the entire assessment is performed.
clinical context when evaluating a trauma patient for shock.

83
  Figure 6-2: Potential Anatomic Locations for Blood Loss, “One on the Floor and
Four More” or “Four and the Floor”. A. Thoracic cavity. B. Peritoneal cavity. C. Pelvic
and Retroperitoneal Space. D. Long bone fracture sites, muscle compartments, and
subcutaneous tissue. E. External hemorrhage (“the floor”).

Recognized at the “Breathing” stage of the primary survey, the emergency department. The absence of classic findings does
tension pneumothorax is a nonhemorrhagic cause of obstructive not exclude cardiac tamponade (see Imaging and Diagnostic
shock and a clinical diagnosis. The presentation is acute respiratory Studies).
distress, absent unilateral breath sounds, hyperresonance to Abdominal distension, tenderness, penetrating wounds,
percussion (difficult to hear in the emergency department), and and ecchymosis may indicate intra-abdominal hemorrhage.
tracheal shift away from affected side (often subtly recognized at Suprapubic tenderness, a widened pubic symphysis, tenderness
the sternal notch). Emergent release of the pneumothorax (see on the pelvic bones, external rotation of the hips, perineal
Chapter 5, Breathing and Ventilation Assessment and Management) bruising, and urethral meatal blood are signs of potential pelvic
is performed without waiting for radiographic or other diagnostic fracture with associated pelvic cavity/retroperitoneal hemorrhage.
confirmation. Major pelvic fractures and associated retroperitoneal hematomas
During “Circulation” evaluation, an expeditious can produce several liters of blood loss, which is potentially lethal.
examination is performed, focused on detecting signs and Palpation and visual examination of all extremities is
locations of internal bleeding. Thoracic evaluation may performed for tenderness, wounds, contusions, swelling, and
reveal tenderness from rib fractures, a flail segment, a wound, instability. Long bone extremity fractures may result in significant
decreased breath sounds, ecchymosis (potentially related to a blood loss. Each closed tibia or humerus fracture can result in up
shoulder restraint or airbag), or dullness to percussion (hard to to 750 mL of blood loss, and a closed femur fracture can result in
appreciate in an emergency department). These signs are up to 1.5 L of hemorrhage. Thus, multiple extremity fractures can
consistent with hemothorax. be a source of lethal hemorrhage.
Another nonhemorrhagic cause of obstructive shock diagnosed Major soft-tissue injuries can account for significant blood
during the primary thoracic evaluation is cardiac tamponade. The loss, either through bleeding or associated edema (third-space
typical clinical presentation of cardiac tamponade includes fluid loss). Massive contusions and hemorrhagic shock can
an appropriate mechanism (e.g., penetrating chest trauma), occur in patients receiving preinjury anticoagulation therapy.
tachycardia, and hypotension that is unresponsive to fluid Occasionally, “minor” injuries, such as a scalp wound or a
therapy. Muffled heart sounds and dilated, engorged neck veins penetrating extremity injury, can cause significant delayed external
may be present. However, these signs are difficult to appreciate in bleeding not initially evident upon arrival, which may contribute

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

to hemorrhagic shock. Edema occurs with major soft-tissue injury  Figure 6-3: Chest Radiograph with Massive
and is another source of volume loss. Tissue injury, even without Hemothorax.
significant blood loss, can lead to release of multiple cytokines,
which increase endothelial cell vascular permeability, producing
a fluid shift from plasma to the extracellular space, which further
depletes intravascular volume and exacerbates shock.
History and physical examination may reveal signs consistent
with nonhemorrhagic shock. Cardiac tamponade and tension
pneumothorax have been discussed previously. The clinical
signs of neurogenic shock include hypotension, bradycardia,
paralysis, numbness, paresthesia, loss of rectal tone, and warm
peripheral extremities. These are in contrast to hemorrhagic
shock, which presents with tachycardia and peripheral
vasoconstriction, which causes cool skin. Diagnosis can be
difficult in unconscious patients without a detectable neurological
deficit. The term neurogenic shock is often confused with the term
spinal shock. Spinal shock refers to the lack of function of the
spinal cord after injury that may recover. Spinal and neurogenic
shock can present simultaneously.
Potential etiologies of cardiogenic shock in an injured
patient include BCI and acute myocardial infarction (AMI).
Point-of-care abdominal ultrasound (e.g., FAST) may
Patients with BCI may be asymptomatic or may complain of
demonstrate intra-abdominal fluid.  Figure 6-4 illustrates FAST
common symptoms such as chest pain or shortness of breath
probe positions and a FAST image. Diagnostic peritoneal lavage
associated with detectable tachypnea. Tenderness, abrasions, and
(DPL) is utilized instead of FAST in some locations. DPL is
contusions (“seatbelt sign” across the chest) may be present on the
further discussed in Chapter 21, Thoracic, Abdominopelvic, and
thoracic wall and/or sternum. A variety of arrhythmias may be
Genitourinary Trauma. FAST evaluates for hemorrhage in the
present. As signs are nonspecific, the clinical context is important
abdomen and pericardium while DPL only evaluates the abdomen.
to consider in the diagnosis. AMI, consequent to or as a cause of
 Figure 6-5 illustrates bloody fluid return during DPL. Although
the injury, presents similarly to nontraumatic AMI. Following
these studies are not therapeutic, the result may facilitate rapid
trauma, AMI is considered after other shock etiologies have been
surgical consultation and/or transfer.
evaluated and managed.
Extended FAST (eFAST) adds views of the thorax to evaluate for
Signs of posttrauma anaphylactic and septic shock are similar
pneumothorax and hemothorax. FAST and echocardiography are
to those of nontrauma etiologies. Clinical context, history,
extremely helpful for diagnosis of suspected cardiac tamponade.
and exclusion of hemorrhage are important for diagnosis. As
Significant resources, which may not be available at all centers, are
mentioned earlier, sepsis may have been present preinjury (e.g.,
utilized to manage cardiac tamponade. Therefore, rapid diagnosis
frequent in older patients who fall) or be the result of delayed
may improve time to transfer and treatment.
presentation. A history of medication or transfusion may assist
In scenarios where a neurogenic etiology of shock is suspected
with diagnosis of anaphylactic shock.
(e.g., hypotension, bradycardia, warm extremity skin, paralysis), a
lateral cervical spine radiograph may demonstrate an abnormality
IMAGING AND DIAGNOSTIC STUDIES
and facilitate transfer and/or involvement of a spine surgeon.
Various imaging and other studies may be performed to When neurogenic shock is present, evaluation and imaging for
diagnose the source of shock in a trauma scenario. However, concurrent hemorrhage (CXR, PXR, FAST, DPL) is performed
treatment of shock and bleeding is not delayed to perform as well.
confirmatory studies. When clinically indicated, emergent BCI may present with a broad spectrum of symptoms and
interventions prior to proof of diagnosis may be lifesaving signs, from mild arrhythmias to cardiogenic shock. As these are
(e.g., control of external bleeding, blood product [or fluid if nonspecific, when BCI or myocardial infarction is considered,
blood not available] resuscitation, chest decompression, or a 12-lead ECG is obtained. ECG findings consistent with BCI
application of a pelvic compression device). include unexplained sinus tachycardia, premature ventricular
CXR, pelvic radiograph (PXR), and FAST/DPL can be contractions, atrial fibrillation, bundle branch block (more
used to determine the source of shock, guide management, and commonly right) and ST segment changes. However, a normal
monitor responses to treatments. CXR may confirm hemothorax, ECG at the time of presentation does not definitively exclude
demonstrate findings consistent with pericardial fluid, or confirm BCI. The role of cardiac biomarkers in evaluating and guiding
appropriate result following thoracic decompression.  Figure management of patients with BCI has not been clearly established.
6-3 illustrates a CXR with massive hemothorax. PXR may define The most widely accepted biomarkers of shock severity
a pelvic fracture and appropriate result following placement of a and response to resuscitation are the base deficit (evaluated by
temporary pelvic compression device. blood gas analysis) and the lactate level. A linear or predictable

85
  Figure 6-4: Focused Assessment with Sonography for  Figure 6-5: Diagnostic Peritoneal Lavage (DPL). DPL is a
Trauma. A. Probe locations. B. FAST image of the right rapidly performed, invasive procedure that is sensitive for
upper quadrant showing the liver, kidney, and free fluid. the detection of intraperitoneal hemorrhage.

A.

MANAGEMENT
GENERAL
B. Based on the mechanism of injury and clinical findings,
specific etiologies of shock are identified to focus management.
Early hemorrhage control and restoration of circulating
volume through appropriate fluid resuscitation are the goals
of treatment of traumatic shock and are crucial to improved
patient outcomes. Fluid administration (see below) is initiated
as soon as signs and symptoms of blood loss are apparent or
suspected, and is not delayed until blood pressure decreases or
a specific diagnosis is finalized.
The clinician continually observes and reassesses the patient
during interventions, observing vital signs, oxygen saturation,
urine output, ETCO2 (if used), and mentation. The responses
can provide important information about the underlying cause of
shock. Multidisciplinary collaboration with available specialists
such as surgeons, interventional radiologists, anesthesiologists,
and intensivists early in the evaluation process can help guide
further investigations and interventions, ensuring comprehensive
care for the trauma patient.
relationship between magnitude of blood loss and base deficit
or lactate level does not exist, partly due to a multifactorial CONTROL OF BLEEDING
pathogenesis of hyperlactatemia in shock. However, increasing The most effective methods of reestablishing adequate
lactate and base-deficit levels correspond to decreased perfusion cardiac output, end-organ perfusion, and tissue oxygenation
at the cellular level and are attributed to worsening shock until are to restore venous return through vascular volume repletion
proven otherwise. and to stop the bleeding. Volume repletion will allow recovery
Evaluation of coagulation status is valuable to detect preinjury from the shock state only when the bleeding has stopped.
anticoagulant therapy and development of shock-induced altered Following the xABCDE steps, exsanguinating bleeding is
thrombosis. Frequent values obtained are partial thromboplastin controlled urgently with packing or a tourniquet if indicated.
time (PTT), prothrombin time (PT), international normalized The airway is maintained. Tension pneumothorax is identified
ratio (INR), and platelet count. In some institutions, viscoelastic by clinical parameters and released. Hemothorax is identified
testing may be available to more precisely evaluate the coagulation by clinical exam and imaging, if available, and drained by tube
system. thoracostomy.

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

 Table 6-3 lists clinical factors that are associated with pelvic  Figure 6-6: Changes in Pelvic Volume Related to
fractures. When diagnosis of a pelvic fracture is supported by Injury and Treatment. Red area represents potential
the clinical scenario, a pelvic compression device (also termed pelvic volume. A. Uninjured pelvic volume. B. “Open
book” pelvis. Increased pelvic volume associated with
“pelvic binder”) may be lifesaving. Technical components of
pubic rami fractures, disruption of the pubic symphysis,
appropriate placement include centering the device around the sacral fracture, and disruption of posterior ligaments. C.
greater trochanters. Additional prevention of hip external rotation Placement of a pelvic compression sheet reduces potential
(if possible) helps to reduce potential pelvic volume and promote pelvic volume. The sheet is centered on the greater
tamponade of pelvic vessels. trochanters (dotted line).

T
able 6-3: Clinical Factors Associated with a A.
Pelvic Fracture.

Clinical Data Consistent with Pelvic

Fracture

MECHANISM Motor vehicle or motorcycle crash

Fall from height
Fall in frail patient
Fall from animal transport
Crush
Bicycle crash

SYMPTOMS Pelvic pain

Low abdominal pain
Hip pain B.
Pain radiating in lower extremities
Low back pain

SIGNS Hypotension, tachycardia

Pain on palpation of pelvis
Lower abdominal tenderness
Pain with hip movement
External rotation lower extremities
Sacral/coccyx tenderness
Suprapubic widening
Suprapubic, iliac ecchymosis
Perineal ecchymosis
Blood at urethral meatus
C.
Vaginal blood

 Figure 6-6 illustrates changes in pelvic volume related to

injury and following treatment.  Figure 6-7 illustrates prevention
of external hip rotation.  Figure 6-8 illustrates pelvic devices and
associated PXR images.
Internal bleeding due to long bone fractures may be lessened
through fracture reduction, splinting, and/or traction. For intra-
abdominal bleeding identified on FAST and other uncontrolled
hemorrhage, early surgical consultation is made to plan for
definitive hemorrhage control.

87
  Figure 6-7: Prevention of Hip External Rotation. Binding  Figure 6-8. Temporary Pelvic Compression. A.
of the lower extremities, with internal rotation of the hips if Commercial device. B. Sheet device. C. Radiograph prior to
possible, helps to maintain pelvic compression. application of compression device. D. Radiograph following
application of compression device.

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

 Figure 6-10: Interosseous Access. A. Locations for IO

RESTORATION OF VASCULAR VOLUME
access. Device should not be inserted distal to a fracture.
Fluid resuscitation is started prior to diagnostic procedures Most common sites are at the humeral head and proximal
such as FAST and CT scan. IV access is established on patient tibia. B. A tibial IO is placed 1–3 cm distal to the tibial
arrival. Timely fluid administration is critical. Flow of fluid tuberosity on the medial tibia.
through a catheter is directly related to the radius to the 4th power
and inversely related to eight times the length of the catheter. A.
 Figure 6-9 illustrates a simplified equation for flow rate through
a catheter. Therefore, large-bore peripheral catheters (16 G
and wider) are used in shock resuscitation. When peripheral
IV access is challenging, an intraosseous (IO) device may be
placed while other options, such as central venous catheterization,
are prepared.  Figure 6-10 illustrates IO insertion.
Red cells and other blood products, including whole
blood, are the ideal resuscitative fluids. If these are unavailable,
crystalloid may be administered. However, crystalloid
resuscitation is minimized as much as is practical. Colloid and
hypertonic solutions have no demonstrated benefit compared to
isotonic crystalloids and are not commonly utilized for volume
resuscitation of injured patients.
A goal blood product ratio of 1:1:1 (packed red blood cells
to plasma products to platelets) is commonly practiced. Whole
blood may be preferred. If blood products are not available in
a timely fashion, resuscitation can be started with 250–500 mL
crystalloids in adults and 10 mL/kg in children less than 20 kg.
Fluids prewarmed to 39°C can minimize iatrogenic hypothermia.
For actively hemorrhaging patients and those in extremis, group O
packed red cells and AB plasma are rapidly transfused until type
specific and cross-matched products are available. Products
should be Rh negative in patients who may bear children and Rh
positive in others.

 Figure 6-9. Flow Rate of Vascular Access Catheters,

Poiseuille’s Law. Fluid may be infused faster through wide
and short catheters. Flow is directly proportional to the
radius to the 4th power and inversely proportional to 8x B.
the length.

89
 RESUSCITATION TARGETS IN HEMORRHAGIC during unsupervised transfers, or for management of blunt
SHOCK trauma with an identified source of bleeding in a center with
adequate resources for hemorrhage control.
Restoration of vascular volume to a “normal” blood pressure,
either through blood product or crystalloid administration, may ASSESSING RESPONSES TO RESUSCITATION
be detrimental in scenarios of uncontrolled hemorrhage. In such
Measuring response to resuscitation depicts the severity of
situations, a higher blood pressure may exacerbate bleeding.
shock, directs subsequent management, and indicates urgency
Permissive hypotension has been shown to improve mortality
of definitive interventions or transfer. Observing the response
rates from hemorrhagic shock following truncal penetrating
to initial resuscitation can identify patients whose blood loss
injuries. Normal mentation and palpable radial pulse of moderate
was greater than estimated and those with ongoing bleeding.
volume are reasonable indicators of a balance between volume
Continuous monitoring is performed of vital signs and clinical
resuscitation and permissive hypotension if expeditious definitive
signs of perfusion. Supporting clinical assessment with objective
hemostasis is planned.
measures for perfusion assessment is an invaluable component
Although definitive data in blunt trauma do not exist,
of resuscitation.
permissive hypotensive resuscitation, similar to that for
Laboratory values such as lactate and base deficit, and urine
penetrating injury, to a systolic blood pressure of 90 mm Hg
output are valuable to monitor. Obtaining urine output of 0.5 mL/
utilizing infusions of 100–200 mL of product (or fluid if no blood
kg/hr in an adult and 1–2 mL/kg/hr in children would suggest
product is available) may be beneficial until definitive hemorrhage
adequate perfusion. However, change in these parameters takes
control is obtained. If a head injury, spinal cord injury, or a history
time to occur. Therefore, they are not of great use in the acute
of hypertension is present, a higher systolic pressure of 110 mm
resuscitation of trauma patients. The return of normal blood
Hg may be more appropriate. Permissive hypotension is not a
pressure, pulse pressure, and pulse rate are signs that perfusion is
replacement for available hemostatic intervention. It is not an
returning to normal, but these observations do not ensure normal
acceptable modality to promote nonoperative management,

 Table 6-4: Clinical Abnormalities in Shock and Signs of Improved Perfusion. *Clinical values are
evaluated as adjusted for age.

Clinical Abnormalities in Shock and Signs of Improved Perfusion

System Shock Improved perfusion Limitations

CNS Agitation in early shock Improvement in May be confounded by

sensorium concomitant TBI, intoxication,
Lethargy in late shock and medications

Can’t be assessed in intubated

patient

Interobserver variability

Skin Cold, clammy Improved temperature Subjective

Prolonged capillary refill Improved capillary refill Confounded by external

time (>3 secs) time temperature

Renal Pre-renal failure Urine output adequate* Evaluation takes hours

Oliguria anuria No immediate index

Chronic kidney disease
Diuretics hyperglycemia

Hemodynamic Tachycardia* Trend towards Noninvasive device not accurate

normalization
Low-volume pulse by Values may be falsely assuring
palpation Palpable pulse volume
Normalization of
improvement
Hypotension* macrohemodynamics doesn’t
Normalization of BP signify normalization of
perfusion at cellular level
Medication effects,
preinjury diseases

*Clinical values are evaluated as adjusted for age. BP, Blood pressure; TBI; Traumatic brain injury.

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

organ perfusion and tissue oxygenation. When the expertise Transient responders demonstrate improved hemodynam-
exists, bedside eFAST assessment of inferior vena cava (IVC) size ics following initial fluid administration. However, perfusion
can be helpful in confirming adequacy/inadequacy of volume indices decline as the fluid rate is decreased, indicating either
resuscitation. ongoing hemorrhage or inadequate resuscitation of previous-
Macrohemodynamic measurements (blood pressure, heart ly lost blood. These patients have lost moderate to significant
rate) are helpful in stratifying the response to initial resuscita- amounts of blood. Further transfusion (or crystalloid if blood is
tion into three groups: responders, transient responders, and not available) is indicated. Surgical consultation is obtained when
nonresponders. available, or transfer arrangements are initiated as operative or
Responders demonstrate normal hemodynamics following other invasive therapies may be employed to stop ongoing hem-
initial fluid administration. Signs of inadequate tissue perfusion orrhage.
have improved and are resolved. These patients typically have not Failure to respond to volume administration indicates
lost a significant amount of blood and do not have active severe ongoing bleeding, inadequate resuscitation, or nonhemorrhagic
bleeding. Further blood product or fluid is not immediately shock. Reassessment and repeating the xABCDE survey
indicated. However, when available, access to typed and cross- may reveal a treatable source of shock.  Table 6-5 illustrates
matched blood products is maintained. Further evaluation of etiologies for nonresponse to resuscitation. The medical history
injuries proceeds expeditiously. is reviewed for anticoagulant, antiplatelet, and glucocorticoid
medications. External hemorrhage control and adequacy of
tourniquets (if present) are evaluated, and pelvic compression or
tube thoracostomy are considered.

 Table 6-5: Reasons for Nonresponse to Resuscitation.

Reasons for Nonresponse to Resuscitation

REASON ETIOLOGIES

Continuing Inadequately treated compressible hemorrhage (unrecognized injury,

Hemorrhage inadequate wound packing, pelvic compression device, tourniquet)

Noncompressible bleeding (intra-abdominal, pelvic arterial,

penetrating junctional vessel injury)

Coagulopathy (preinjury medications, unbalanced blood product

administration, hyperfibrinolysis)

Inadequate Soft-tissue and intramuscular contusions and shearing injuries

Resuscitation
Fracture blood loss

Concomitant burns

Unrecognized blood loss prior to arrival

Non- Obstructive shock (tension pneumothorax, tension hemothorax,

Hemorrhagic cardiac tamponade)
Shock
Neurogenic shock

Cardiogenic shock (blunt cardiac injury, acute myocardial infarction)

Septic shock (intra-abdominal sepsis, pneumonia, urinary sepsis)

Endocrine and metabolic (diabetic ketoacidosis, adrenal insufficiency)

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 In nonresponders, reassessment for nonhemorrhagic FACTORS CREATING VARIATION IN
causes of shock (tension pneumothorax, cardiac tamponade, RESPONSE TO RESUSCITATION
cardiac pump failure, neurogenic shock) is required. If a
treatable cause is not diagnosed, urgent and definitive intervention The physiologic response to resuscitation may vary due to
(i.e., operation or angioembolization) to control exsanguinating age, comorbidities, medications, athletic training, and pregnancy.
internal hemorrhage is likely needed. Transfer arrangements are The clinician considers these factors in evaluating the response
initiated if adequate expertise is not immediately available. to resuscitation and developing further management strategies.
Although the wide range of “normal” vital signs and other factors
makes the clinical diagnosis of shock challenging, the presence
of metabolic acidosis is useful at any age to assess circulatory
shock and response to resuscitation.  Table 6-6 illustrates factors
associated with variable response to resuscitation.

 Table 6-6: Factors Associated with Variable Response to Resuscitation.

Patient Factors Comments

Characteristic

Pregnant Physiologic hypervolemia Placental hypoperfusion may be present

despite normal pulse and blood pressure

Physiologic lower normal Blood loss may be present without

systolic pressure clinical signs of shock

Vena cava compression Failure to displace uterus manually may

by gravid uterus explain poor response to resuscitation

Older Adult Decreased sympathetic receptors Tachycardiac compensation blunted absent;

unable to increase cardiac output
Concomitant beta and calcium
channel blockers
Pacemakers

Diuretics with contracted More severe shock and organ ischemia

blood volume with relatively mild blood loss

Atherosclerotic disease Increased risk of cardiac decompensation

Preinjury reduced capacity for due to physiologic demand and risk of
cardiac compensation peri-injury myocardial infarction

Child High sympathetic tone Maintain vital signs until severe shock
followed by rapid decompensation
Efficient physiologic
compensatory responses Respond to aggressive resuscitation even
with profound shock
Bradycardia more ominous sign than
tachycardia

Small absolute blood volume Poor response to resuscitation due to failure

to recognize proportion of blood lost

Mobile and compliant tissues Hypotension due to dilated stomach

Potential for rapid development of tension
pneumothorax

Athlete Lower preinjury pulse rate Less tachycardia per degree of shock

Increased physiologic capacity for Risk of underestimating shock

compensation severity due to minimal signs

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Children have age-specific normal vital signs. Due to trauma patients, reducing cardiac preload. The response to
lower circulating blood volume and efficient physiologic resuscitation may be improved by shifting the uterus off the
compensation to shock, the progression from minor to major cava, either through placing the patient in a right side-up
shock may be rapid. Tachycardia and hypotension are usually late position or by manually displacing the uterus to the left. Please
signs and are precursors to circulatory collapse. For additional see Chapter 13, Trauma in the Pregnant Patient, Figure 13-8 for an
information, please see Chapter 11, Trauma in the Pediatric illustration of this maneuver.
Patient. Intoxication with alcohol or other substances may limit the
Injured older adults may have limited physiological capacity reliability of mental status evaluation in determining response to
to compensate for blood loss, and ischemic organ damage resuscitation. Altered mental status may be due to shock, cerebral
can result after shorter durations of shock. The tachycardic injury, or substance effects.
response is usually absent with beta blocker therapy. The presence
of antihypertensive medications may hamper physiologic TRANEXAMIC ACID IN HEMORRHAGE
vasoconstriction. Due to chronic changes, higher resuscitation RESUSCITATION
blood pressure may be beneficial to ensure adequate organ
Hyperfibrinolysis and coagulopathy are potential etiologies
perfusion in patients with preinjury hypertension. Pacemaker
of continued bleeding and lack of response to resuscitation.
devices may impede the tachycardia compensation to shock. With
Tranexamic acid (TXA) may be administered in scenarios
reduced preload, cardiac output cannot respond to blood loss by
of major hemorrhagic shock and is sometimes initiated in the
increasing heart rate as expected. Heart rate may remain at the
prehospital setting. TXA is a synthetic, reversible competitive
device’s set rate regardless of volume status.
inhibitor to the lysine receptor on plasminogen. TXA prevents
Athletes may have a low resting heart rate and a high capacity
plasmin from binding to fibrin, thus reducing fibrinolysis and
to increase cardiac output under stress. Thus, the degree of
stabilizing a fibrin clot.  Figure 6-11 illustrates the mechanism
tachycardia and signs of hypoperfusion may be less pronounced.
of action for TXA. When administered within 3 hours of injury,
Astute clinicians recognize that a “normal” or slightly elevated
TXA has demonstrated a decrease in mortality in specific high-
heart rate may represent a significant compensatory mechanism,
risk hypotensive bleeding populations. Local pharmacy protocols
and the degree of shock may be more severe.
determine dosing. Clinically, both a 1 g TXA bolus within 3 hours
It can be challenging to determine a pregnant patient’s normal
from injury followed by second 1 g infusion over 8 hours, or
preinjury vital signs due to physiologically expanded blood
a single dose of 2 g, have been safe and efficacious. TXA is not
volume, tachycardia, and tachypnea. In the third trimester,
recommended to be administered beyond 3 hours from the time
the uterus can compress the inferior vena cava in supine
of injury unless hyperfibrinolysis is present.

 Figure 6-11: TXA Mechanism of Action.

Pathologic hyperfibrinolysis may occur following trauma. This process will disrupt clot
formation and contribute to uncontrolled hemorrhage. As illustrated on the left of
the diagram, fibrinolysis is initiated when tissue plasminogen activator (tPA) binds to
plasminogen, creating activated plasmin. Illustrated on the right of the diagram, tranexamic
acid (TXA) binds to plasminogen, blocking its binding to fibrin and inhibiting fibrinolysis.

93
 Vasopressors are added if volume fails to reach resuscitation
PREINJURY ANTICOAGULANT AND
goals. These medications restore peripheral vascular resistance.
ANTIPLATELET AGENTS In neurogenic shock, norepinephrine is an option for injuries
Anticoagulant and antiplatelet medications are frequently at all spinal levels. It has both α-1 and β-1 activity, which will
prescribed for many cardiovascular, hematologic, and other improve peripheral vasoconstriction, heart rate, and contractility.
disorders. As the number of older injured patients increases, Phenylephrine is another option for patients with spinal cord
clinicians are encountering patients receiving anticoagulant injury (SCI) below T6. However, as phenylephrine lacks β-1
and/or antiplatelet agents on a more frequent basis. These drugs activity, bradycardia may be exacerbated in scenarios with higher
hinder clot formation through a variety of inhibitory mechanisms level spine injuries. Due to potential infusion site adverse effects,
at the vitamin K, coagulation factor, and platelet aggregation vasopressors are usually administered via central venous access.
phases. Biologic activity of anticlot drugs may complicate shock In emergencies, they can be infused through a peripheral IV until
resuscitation and contribute to lack of response to treatment. improved access is available.
Assays of PT, PTT, INR, and platelet count, along with viscoelastic
testing, are routinely obtained when accessible. Anti-Xa activity OBSTRUCTIVE ETIOLOGIES
tests exist but are relatively unavailable in emergent settings. Tension pneumothorax is managed with emergent chest
The decision to attempt reversal of the effects of anticlot agents decompression as previously described (see Chapter 5, Breathing
is based on the clinical scenario. Unresponsive hemorrhagic and Ventilation Assessment and Management). Operative
shock, associated intracranial injury, plan for operative therapy, intervention is indicated for management of cardiac tamponade
and other factors favor reversal. Prothrombin complexes, with ultrasound-guided pericardiocentesis as a potential short-
plasma, platelets, other blood products, and specific agents are term temporizing maneuver. In near or active cardiac arrest,
administered per institutional availability, protocols, and surgeon if adequately trained personnel and resources are available, a
recommendation.  Table 6-7 illustrates treatment options for resuscitative left thoracotomy may be performed for release of
some common anticlotting medications. Anticoagulation and tamponade, performance of direct cardiac massage, and control
antiplatelet medications and recommendations for reversal of their of bleeding.
effects change frequently. The clinician must remain informed
through continued education. Reversal agents may produce severe CARDIOGENIC ETIOLOGIES
thrombotic complications. Therefore, administration is limited to
treatment of life-threatening, severe intracranial, or significant In the scenario of BCI, an abnormal echocardiogram (ECG) or
spinal hemorrhage. rhythm on the monitor in the emergency department is associated
with sudden critical arrhythmias. Patients with these findings may
VASOPRESSORS IN HEMORRHAGIC SHOCK benefit from cardiac monitoring for 24–48 hours in an appropriate
facility. Arrhythmias are treated in a fashion similar to nontrauma
Vasopressor administration is not recommended as the etiologies. Electrolytes, pH, oxygen, and carbon dioxide levels are
primary management for hemorrhagic shock. These medications maintained in normal ranges. Antiarrhythmic medications are
constrict precapillary arterioles and impair peripheral perfusion administered as per non-BCI protocols.
to improve blood pressure. They may be used for temporary Echocardiogram is useful to evaluate cardiac wall motion,
adjunctive management and to counteract hypotension from output, and potential structural or valvular abnormalities. Data
RSI medications. Prolonged administration will worsen cellular suggest that patients with a normal ECG in conjunction with
perfusion. normal levels of cardiac troponin can be safely discharged home,
although this screening method will miss rare injuries with a
NEUROGENIC SHOCK AND OTHER delayed presentation like septal rupture.
DISTRIBUTIVE ETIOLOGIES ST segment elevation suggests either a contusion or myocardial
The clinical scenario (mechanism and physical examination) infarction, potentially secondary to coronary artery injury. Cardiac
may reveal signs consistent with neurogenic shock (hypotension, angiography, angioplasty, or surgery may be beneficial. Similarly,
bradycardia, paralysis, numbness, and warm peripheral if a complete heart block is present, temporary or permanent
extremities). As both neurogenic and hemorrhagic shock may pacemaker insertion may be indicated. Transfer for these complex
occur simultaneously, the ATLS clinician ensures adequate cardiothoracic surgery and cardiology evaluations may be
control of hemorrhage while managing neurogenic shock (see performed if the resources are available at other institutions.
Chapter 7, Disability: Neurological Assessment and Management).
Resuscitation for neurogenic and other forms of distributive TRAUMATIC CARDIAC ARREST
shock is initiated with volume resuscitation. In the absence of Following severe injury, loss of palpable pulses and blood
bleeding, isotonic crystalloid solutions are generally considered pressure may occur either prior to or shortly after emergency area
safe and beneficial. Hypotension is detrimental to neurologic arrival. The mortality in this clinical situation is extremely high.
recovery. Therefore, blood pressure goals are higher (mean The etiology and management of traumatic cardiac arrest
arterial pressure 85 mm Hg) during resuscitation when signs (TCA) differ from management of nontraumatic cardiac arrest.
of isolated neurogenic shock are present. Due to depleted intravascular volume, CPR is ineffective.
Restoration of intravascular volume is paramount and takes
priority over chest compressions and Advanced Cardiac Life
Support (ACLS) measures.

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

 Table 6-7: Recommended Options for Reversal of Effects of Anticlotting Medications.

Recommended Options for Reversal of Effects of Anticlotting Medications

Anticlotting Agent Treatment Options Comments

Antiplatelet agents *Determine if minor or major bleeding Routine platelet transfusion demonstrated
worse outcomes in one study
e.g., aspirin Minor:
Desmopressin acetate (DDAVP) 0.3 mg kg single dose Desmopressin acetate (DDAVP) has theoretical
clopidogrel / Plavix®
application but data on efficacy are lacking
Major:
ticagrelor / Brilinta ®
Platelet transfusion for life-threatening hemorrhage Residual antiplatelet medication may inhibit
prasugrel / Effient® or planned neurosurgical intervention transfused platelets
dipyridamole/ Persantine® Routine platelet transfusion without benefit, Eaminocaproic acid (EACA) may increase DVT
aspirin + dipyridamole / Aggrenox® potential harm risk

adciximab / Reopro® DDAVP 0.4 mg kg

eptifibatide / Integrilin ® TXA may be beneficial

tirofiban / Aggrastat ® Eaminocaproic acid (EACA) 4 g loading dose

followed by 1 g/h maximum of 4 hours

Vitamin K antagonists Vitamin K 5–10 mg IV Normalize INR

e.g., warfarin / Coumadin® Plus: Monitor for volume overload in elderly patients
Four-factor PCC^# and cardiac injury patients
or
FFP start 10-15 ml kg

Oral direct thrombin inhibitor Idarucizumab (Praxbind) 5g IV Consider activated charcoal if last-known dose
within 2 hours
e.g., dabigatran / Pradaxa® or
Four-factor PCC^&

IV direct thrombin inhibitors FFP 15 ml kg (may repeat) Idarucizumab (Praxbind) is not effective and
not FDA approved
e.g., bivalirudin Angiomax®
Metabolized in 2–6 hrs
argatroban
Dialysis potential to clear bivalirudin.

Factor Xa inhibitors Andexanet alpha (Andexxa®) Dosage adjusted by timing of last dose
of anticoagulant+
rivaroxaban / Xarelto® or
Low-dose protocol (400 mg IV bolus then 480
and Four-factor prothrombin complex concentrate^&
mg infusion over 2 hours) or high-dose protocol
apixaban / Eliquis ®
(800 mg bolus, 960 mg / 2 hrs)
Consider activated charcoal if last-known dose
within 2 hours

Factor Xa Inhibitor Off-label andexanet alpha (Andexxa®) High-dose protocol (800 mg bolus,
960 mg / 2 hrs)
edoxaban / Lixiana , Savaysa
® ®
or
Four-factor PCC^&

Factor Xa Inhibitor Off label andexanet alpha (Andexxa®) Dose of Andexanet alpha not established
fondaparinux / Arixtra ®
or
aPCC / FEIBA® 20 u / kg single dose
if aPCC not available
rVIIa / Novoseven® 90 mcg kg single dose

Heparin continuous infusion Protamine sulfate 1 mg 100 units unfractionated heparin in past 2
hours, maximum 50 mg
Monitor PTT

Low-molecular-weight heparin Protamine sulfate If dose within 8 hours: 1 mg per mg LMWH

(maximum 50 mg protamine)
e.g., enoxaparin / Lovenox®
Dose 8–12 hours: 0.5 mg per mg LMWH
dalteparin / Fragmin®
No dosing if >12 hours
tinzaparin / Innohep®
nadroparin / Fraxiparine®

• TXA, Tranexamic acid; DVT, Deep venous thrombosis; PCC, Prothrombin complex concentrate; FFP, Fresh frozen plasma; INR, International Normalized Ratio; aPCC,
Activated prothrombin complex concentrate; rVIIa, recombinant factor Viia; PTT, Partial thromboplastin time.
• *Minor bleeding: Clinically uncontrolled hemorrhage, less than 5 g/dl decrease in hemoglobin or less than 15% decrease in hematocrit. Major bleeding: Clinically
significant intracranial hemorrhage, more than 5 g/dl decrease in hemoglobin concentration, or more than 15% decrease in hematocrit with hemodynamic
compromise or compression of a vital structure.
• ^e.g., Kcentra®, Beriplex®, Confidex®, Balfaxar®, Octaplex®.
• #Dosing either 1,000–5,000 units fixed dose or staged by INR (INR 2 - <4 = 25 u/kg; 4-6 = 35 u/kg; >6 50 u/kg). Higher fixed doses sometimes recommended for
intracranial hemorrhage.
• +Use low-dose protocol if last dose of rivaroxaban was ≤10 mg, last dose of apixaban was ≤5 mg or unknown dose of rivaroxaban or apixaban was ≥8 hours prior.
Use high dose if >10 mg dose of rivaroxaban, >5 mg dose of apixaban, or unknown dose <8 hours prior or unknown time; or if an unknown dose of rivaroxaban or
apixaban was within 8 hours prior.
• & Either fixed dose 2,000–5,000 units or 40-50 u/kg, maximum dose 5,000 units.

95
 The major causes of TCA include hypovolemia/hemorrhagic TRANSFER CONSIDERATIONS
shock (circulation), hypoxemia (airway/breathing), tension
pneumothorax (breathing/circulation) and cardiac tamponade During the Circulation stage of xABCDE assessment,
(circulation). These are treated expeditiously. The clinician conditions may be identified for which the current institution
ensures an airway is maintained, oxygen is supplied, external does not have sufficient resources. This may include operative or
bleeding is controlled, fluids are rapidly administered, and both catheter-based interventions for hemorrhage control, transfusion,
chest cavities are decompressed. If there is return of an organized specialized care units (intensive care, cardiac monitoring,
cardiac rhythm and a measurable blood pressure, resuscitation is burns, pediatrics, obstetrics), or multidisciplinary specialist care
continued. (orthopaedic, plastic/reconstructive, neurosurgery, spine surgery).
According to local policy, resources, and surgical availability, a Once an indication for transfer is identified, arrangements are
resuscitative thoracotomy may be indicated if there is no return of initiated. Resuscitation and management of shock is continued
spontaneous circulation (ROSC). Several algorithms are available until and during transfer with clear plans for continued volume
for management of TCA in penetrating injury for centers with resuscitation (blood products and crystalloids as available)
surgical expertise in emergency resuscitative thoracotomy. and contingencies for identified bleeding wounds, airway
If there is no improvement and there are no signs of life, maintenance, and breathing abnormalities.
functional survival is unlikely, and resuscitation may terminate.
 Table 6-8 lists commonly accepted signs of life. Resuscitation CHAPTER SUMMARY
is futile if CPR has been performed for longer than 10 minutes
following blunt trauma, longer than 15 minutes following Shock is the clinical manifestation of circulatory compromise,
penetrating trauma, or if ultrasound demonstrates the absence with varying clinical and physiological signs depending on the
of cardiac tamponade and no cardiac motion when the only sign severity as well as individual patient factors. Hemorrhagic shock,
of life is electrical activity. The decision to cease resuscitative the most common cause in trauma, requires rapid recognition and
efforts is challenging for all team members. Availability of control of ongoing bleeding. Management focuses on identifying
structured professional support and debriefing are beneficial and the cause of shock to enable tailored interventions.
recommended.

 Table 6-8: Signs of Life for Assessment During KEY LEARNING POINTS
Traumatic Cardiac Arrest.
• Identify and evaluate shock in trauma patients,
including assessing blood loss and intravascular
SIGN volume status.

• Hemorrhage is the most common cause of shock in

Pupillary response the trauma patient.

• Address circulation abnormalities during

Spontaneous ventilation the primary survey and initiate appropriate
resuscitation strategies.
Palpable pulse • Reassess and adapt the resuscitation approach
based on the patient’s response to treatment.
Measurable blood pressure • Recognize limitations of resources and consider
patient transfer if necessary for optimal
Extremity movement management.

Electrical cardiac activity

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 COURSE MANUAL | Chapter 6 | Circulation Assessment and Volume Resuscitation

16. Davis JW, Parks SN, Kaups KL, et al. Admission base
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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

Disability: Neurological
Assessment and Management

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe the relationship of intracranial 6. Identify options, indications, and interpretation

anatomy and intracranial pressure physiology of brain and spinal imaging
to common brain injuries 7. Describe the primary survey, goals of
2. Determine appropriate patients and resuscitation, and prevention of secondary
techniques for spinal motion restriction traumatic brain and spinal cord injury
3. Describe a neurological and trauma-focused 8. Recognize and manage neurogenic shock and
medical history neuroworsening
4. Identify the components of a focused brain 9. Determine appropriate disposition of brain and
neurological examination in a trauma scenario spinal cord trauma patients
5. Explain as assessment of spinal cord function
with physical examination and relationship to
spine anatomy

99
 ANATOMY, PHYSIOLOGY, AND PATHOLOGY

07 OF TBI AND SCI

TRAUMATIC BRAIN INJURY

TBI is characterized by anatomical and functional changes
following an external force. The primary brain injury happens
during impact with tissue damage which may result in an acute
change in the level of consciousness. Secondary brain injury is
Disability: Neurological an additional insult that may occur after the initial injury due to
intracranial or systemic complications such as hypotension and
Assessment and Management hypoxemia. TBI is described by the anatomic location of injury.
 Figure 7-1 illustrates the anatomy of various brain injuries.

CHAPTER STATEMENT PATHOLOGIC ANATOMY OF COMMON BRAIN

INJURIES
Traumatic brain and spinal cord injuries share similar
pathophysiological mechanisms and vulnerability to secondary Extradural Hematoma
insults, where prompt detection and intervention are crucial for
Extradural hematoma (EDH) is a collection of blood between
improving neurological outcomes.
the skull’s inner table and the dura mater’s parietal layer. As a
result, EDHs are usually limited in extent by the cranial sutures
INTRODUCTION
and usually have a biconvex shape. More than 75% of EDHs are
The Disability, "D" portion of xABCDE involves assessment caused by a torn middle meningeal artery and are associated
of the two portions of the central nervous system, the brain and with skull fractures. A vertex EDH is caused by venous bleeding
the spinal cord. Traumatic brain injury (TBI) and traumatic from the sagittal sinus and often crosses the midline. Brain tissue is
spinal cord injury (SCI) are leading causes of death and disability usually minimally injured in patients with isolated EDH. Related
worldwide. Care is complex and expensive. Falls and road injuries brain injury is invariably secondary to shift and pressure. If
are the leading causes. According to the Global Burden of Disease prompt operation is performed, most patients recover without
Study, in 2016 there were 27 million new cases of TBI and nearly neurological deficits.
1 million new cases of SCI worldwide. In the US alone, TBI is
Subdural Hematoma
associated with an estimated 4.8 million emergency department
visits and hospitalizations per year and with at least one-quarter of Subdural hematoma (SDH) is a collection of blood in the
all trauma-related deaths. While more than 80% of cases are mild, subdural space. SDHs occur following a rapid deacceleration
a considerable proportion of TBI survivors incur temporary or of the head. The brain continues to move, leading to stretching
permanent disability. The cost to the global economy is equivalent and rupturing of bridging cortical veins. The arachnoid is also
to $400 billion USD. The global incidence of SCI ranges from 15 injured, resulting in a mixture of cerebrospinal fluid (CSF) and
to 40 cases per million, with data from the US indicating 55 new blood in the subdural space. Subdural hematomas occur between
cases per million annually, excluding prehospital deaths. While the dura and arachnoid, resulting in a crescent shape on CT
statistics that enumerate spinal column fractures (SCFs) are not scan. Subdural hematomas are not limited by cranial sutures
readily available, they are estimated to occur approximately eight but by dural reflections such as the falx cerebri, tentorium, and
times more frequently than cord injuries. falx cerebelli. Acute subdural hematomas, especially in younger
For both brain and spinal injuries, older patients with patients, are frequently associated with brain contusions. Most
unintentional falls are a growing percentage of patients seen SDHs are unilateral in adults. However, in infants, the majority
in emergency departments and trauma centers. According to are bilateral. The presence of a SDH in an infant may be due
the Centers for Disease Control and Prevention, in 2014, more to physical abuse. Isolated interhemispheric or parafalcine SDHs
than 837,000 cases of TBI occurred among children in the US. are common in infant maltreatment injury.
The initial management of the multisystem trauma patient can
improve survival and long-term functional outcomes of TBI and Traumatic Subarachnoid Hemorrhage
SCI patients by preventing secondary insults and worsening of the
primary injury. Time is crucial. Implementing early appropriate Traumatic subarachnoid hemorrhage (tSAH) is the
resuscitation while performing the Initial Assessment and Primary presence of blood in the subarachnoid spaces, such as cerebral
Survey is essential, especially in rural and limited-resource areas, sulci, fissures, or cisterns. The exact mechanism remains unclear.
where TBI-related mortality is higher. The central tenets of Proposed mechanisms include shearing of small veins or
managing TBI and SCI are prevention and treatment of hypoxia arteries, arterial dissection, or direct extravasation from cerebral
and hypotension by following ATLS® principles of stopping contusions.
external bleeding, airway management, breathing management,
and circulation management.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

 Figure 7-1: Anatomy of Brain Injuries. A. Normal anatomy, extradural hematoma, and subdural hematoma.
B. Different types of intracranial hematomas and hemorrhages.

A.

Normal Extradural hematoma Subdural hematoma

B.

Cerebral Contusion PATHOPHYSIOLOGY OF BRAIN INJURIES

A cerebral contusion is an injury to the brain parenchyma. Intracranial Pressure and Herniation Syndromes
The brain may be directly damaged by application of an external
force or by a sudden deceleration causing the brain to strike the Intracranial pressure (ICP) is measured inside the skull
skull. Back-and-forth movement of the brain within the skull and is exerted by the intracranial contents (the brain, CSF, and
may produce both coup (side of force) or contrecoup (opposite cerebral blood volumes). Normal ICP for adults is 7–15 mm Hg
side of force) injuries. Most contusions occur in the frontal and supine and can be as low as –10 mm Hg while upright. ICP may
temporal lobes, where the brain moves against the rough surface rise when the volume of one of the three components increases.
of the anterior cranial fossa floor. Contusions may progress in The Monroe-Kellie doctrine states that due to the fixed volume
size, bleeding, and physiologic effect in the first 24 hours, with a of the skull, the sum of brain, CSF, intracranial blood volume,
reported incidence of progression between 16% and 75%. and any pathological process must remain constant to maintain
a normal ICP. Therefore, an increase in the volume of one
Axonal Injury component is compensated by a decrease of one of the others.
After injury, intracranial volume may be increased due to
Traumatic axonal injury is caused by rotational acceleration cerebral edema or mass lesions such as extradural, subdural, or
or deceleration forces, resulting in shearing of the neurons. The intracerebral hematomas. Compensatory displacement of CSF
white and grey matter have different specific gravities, resulting in and cerebral blood volume can maintain a low ICP. However,
movement relative to each other as the brain comes to rest after with increased pathologic volume, compensatory mechanisms are
sudden deceleration. This leads to the shearing of axons in the eventually exhausted and ICP rises, resulting in cerebral ischemia.
white matter, swelling, and disconnection. Diffuse axonal injury  Figure 7-2 illustrates the Monroe-Kellie Doctrine.  Figure 7-3
is a multifocal injury. illustrates the relationship between intracranial volume and ICP.

101
  Figure 7-2: The Monroe-Kellie Doctrine Regarding The intracranial space is subdivided into compartments by du-
Intracranial Compensation for Expanding Mass. The total ral septa. A pressure differential between adjacent compartments
volume of the intracranial contents remains constant. If may result in herniation of brain tissue from one compartment to
the addition of a mass such as a hematoma compresses an another. This is the final event of unrelieved intracranial hyper-
equal volume of CSF and venous blood, ICP remains normal. tension and produces complete collapse of cerebral vasculature
However, when this compensatory mechanism is exhausted, and brain death.  Figure 7-4 illustrates several types of cerebral
ICP increases exponentially for even a small additional
herniation.
increase in hematoma volume. (Adapted with permission
from Narayan RK. Head Injury. In: Grossman RG, Hamilton WJ  Figure 7-4: Types of Cerebral Herniation. Uncal herniation
eds., Principles of Neurosurgery. New York, NY: Raven Press, is the most common herniation syndrome. Subfalcine
1991.). herniation occurs when the brain herniates across the
midline. Central herniation compresses the midbrain.
Ascending transtentorial herniation occurs when a cerebellar
mass pushes the brain upward through the cerebellar
tentorium, compressing the midbrain. Tonsillar herniation
occurs when the cerebellar tonsils push against the foramen
magnum, compressing the medulla and upper cervical cord.
Tonsillar herniation is clinically manifested by apnea and a
rapid rise in the blood pressure.

 Figure 7-3: Intracranial Volume – Pressure Curve. The

intracranial contents initially can compensate for a new
intracranial mass, such as a subdural or epidural hematoma.
Once the volume of this mass reaches a critical threshold,
a rapid increase in ICP often occurs, which can lead to
reduction or cessation of cerebral blood flow.

Uncal Herniation
Descending unilateral transtentorial (uncal) herniation is
the most common type of herniation syndrome. It is caused by
the temporal lobe pushing downward over the tentorial edge.
Uncal herniation is manifested by progressively impaired
consciousness, a dilated pupil on the side of injury (due to third
cranial nerve palsy), and progressive weakness with abnormal
posturing.

Subfalcine and Central Herniation

Subfalcine herniation occurs when the brain herniates under
the falx cerebri into the opposite side, usually due to a unilateral
frontal of parietal mass such as a EDH or SDH. Central herniation
occurs when a cerebral hemisphere is displaced downward,
compressing and displacing the midbrain. These herniation
syndromes are characterized by impaired consciousness,
abnormal posturing, and abnormal respiration. They are often the
fatal sequela of TBI.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

Cerebral Blood Flow  Figure 7-6: Spinal Column Anatomy.

Cerebral blood flow (CBF) is expressed as blood volume per

100 grams of tissue per minute. Normally, CBF represents 15% of
resting total cardiac output. Cerebral perfusion pressure (CPP)
is the difference between mean arterial pressure (MAP) and
ICP. Normal average CPP is 60–80 mm Hg. The ability of the
brain to maintain constant CBF across a wide range of CPP or
MAP is called cerebral autoregulation.
Cerebral autoregulation is achieved by alteration of cerebral
vascular resistance. As MAP or CPP falls, blood vessels dilate.
When MAP or CPP increases, vessels constrict. Thus, CBF
remains constant. When physiologic autoregulation is disrupted
by injury, blood flow varies with CPP changes, resulting in hypo-
or hyperperfusion, rendering the injured brain more susceptible to
ischemia, expansion of hemorrhage, and increased ICP.  Figure
7-5 illustrates CBF autoregulation.

 Figure 7-5: Cerebral Blood Flow Autoregulation Curve.

Cerebral blood flow is normally constant across a range of
blood pressure.

Several ligaments provide structural stability.  Figure 7-9

illustrates spinal ligaments. The ligaments secure adjacent
vertebrae, stabilizing the spinal column by limiting excessive
movement. Vertebral bodies and intervertebral discs bear
compressive loads, while ligaments bear rotational, distractive,
and shear forces. The cervical nuchal ligament continues caudally
on the thoracic and lumbar spine as the supraspinous ligament.
The spinal cord and meninges are located inside the vertebral
SPINAL CORD INJURY canal. In adults, the spinal canal extends from the foramen
magnum to the level of the first and second lumbar vertebrae. The
ANATOMY grey matter of the spinal cord is located centrally and divided into
The spinal axis comprises seven cervical (C), 12 thoracic dorsal sensory and ventral motor zones. White matter is located
(T), and five lumbar (L) articulating vertebrae, followed by nine peripherally and comprises sensory dorsal and mixed anterior
fused vertebrae—five sacral (S) and four coccygeal.  Figure 7-6 and lateral columns.  Figure 7-10 illustrates spinal cord motor
illustrates spinal column anatomy. The first cervical vertebra, C1, and sensory tracts.
is ring shaped without a defined anatomic body and articulates
with the skull at the occipital condyles superiorly.  Figure 7-7
and  Figure 7-8 illustrate anatomy of the cervical vertebrae. The
second cervical vertebra, C2, has a body with a superior extension
(the odontoid process, or dens) that articulates with the anterior
arch of C1. This articulation is stabilized by a transverse ligament
that spans the posterior aspect of the dens and attaches to the
lateral masses of C1. The third cervical to thoracolumbar vertebrae
comprise a body, bilateral pedicles, lamina, and articular facets.

103
  Figure 7-7: Anatomy First (C1), Second (C2), and Sixth  Figure 7-8: First Cervical Vertebra with Dens. The
(C6) Vertebrae. A. Lateral B. Anterior C. Superior. transverse ligament stabilizes the odontoid process.

A LATERAL

C1
ANATOMY FIRST
VERTEBRAE

C2
SECOND VERTEBRAE

C6 PATHOPHYSIOLOGY
SIXTH VERTEBRAE
 Figure 7-9: Spinal Ligaments. A. The nuchal ligament is
attached along the posterior aspect of the cervical spine
from the occiput to the spinous process of C7. B. Lumbar
B ANTERIOR spinal ligaments. These ligaments are present throughout
the spine.
C1
ANATOMY FIRST
VERTEBRAE A.

C2
SECOND VERTEBRAE

C6
SIXTH VERTEBRAE

C SUPERIOR

B.
C1
ANATOMY FIRST
VERTEBRAE

C2
SECOND VERTEBRAE

C6
SIXTH VERTEBRAE

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 Figure 7-10: Spinal Motor and Sensory Tracts.  Table 7-2: Relative Frequencies of Types of SCI.

Relative Frequencies of Types of SCI

Common types of SCI Percentage

Incomplete tetraplegia 31%

Complete paraplegia 25%

Complete tetraplegia 20%

Incomplete paraplegia 19%

SCI = Spinal cord injury

Half of patients with traumatic SCI present with isolated cord

Neurogenic Shock
injury, while one-quarter present with concomitant injuries to
the brain, chest, and extremities. SCI in a multisystem trauma Neurogenic shock is a distributive shock with hypotension
scenario presents additional challenges due to the potential and bradycardia caused by the loss of vasomotor tone and
deleterious impact of other injuries leading to secondary SCI. cardiac sympathetic innervation when cord injury occurs
Blunt or penetrating trauma to the spinal column may cause SCI above the T6 level. Interruption of the sympathetic chain results
by several mechanisms.  Table 7-1 lists some mechanisms of SCI. in unopposed vagal tone. Low blood pressure can exacerbate
Injuries occur in the areas of highest spinal mobility. Therefore, primary cord injury due to decreased spinal cord perfusion.
cervical injuries account for more than 50% of cases. The C3–C7 Higher (more cranial) and more complete SCI tends to result
region is more prone to injury, accounting for 65% of fractures in more severe and more refractory shock. The cardiovascular
and 75% of dislocations. Cervical spine injuries carry higher rates effects can develop within hours to days of injury and may last 1
of mortality and morbidity when compared to thoracic or lumbar to 3 weeks. In contrast to hemorrhagic shock, neurogenic shock
injuries. The most common types of SCI are listed in  Table 7-2. typically leads to hypotension and bradycardia with warm and
dry skin. The ATLS mnemonic (xABCDE) is followed during
assessment and management of potential neurogenic shock.
 Table 7-1: Types and Mechanisms of SCI.
Spinal Shock
Types and Mechanisms of SCI
The term “spinal shock” is a misnomer and has no relation
Mechanism Description to hemodynamic instability. Spinal shock is characterized by a
transient loss of muscle tone and areflexia distal to the anatomical
lesion that occurs immediately following an SCI. The magnitude
Direct Injury Penetrating or blunt injury may produce
any degree of transection through of spinal shock is related to the severity and rapidity of the
laceration or distraction/displacement injury. Spinal shock can persist for days up to a week and can be
of a spinal column bony element into
prolonged by sepsis or critical illness polyneuropathy. As reflexes
the canal.
distal to the level of injury recover first, resolution of spinal shock
may be indicated by return of a plantar or bulbocavernosus reflex.
Compression Mass effect of a spinal canal hematoma
such as an epidural hematoma. In older
adults with cervical spondylosis or
osteoarthritis, the spinal cord may be
SPINAL MOTION RESTRICTION
tethered or compressed between the Excessive movement of the spine with spinal column
anterior vertebral ridge and calcified
ligaments during sudden cervical
injury can exacerbate existing injury or create injury to the
hyperextension. spinal cord. The term “spinal motion restriction” (SMR) is
preferred to “spinal immobilization,” as current techniques are
Contusions Caused by dislocation, retropulsion of unable to provide complete immobilization.  Table 7-3 lists some
fracture fragments, or subluxation. indications for SMR. SMR may be achieved with a cervical collar,
backboard (used for brief periods and not long transfers), scoop
Vascular Injury Fractures through the transverse
stretcher, vacuum splint, neutral alignment on a cot or stretcher,
foramina or dislocation of the lower
cervical vertebrae cause stretching, or any similar devices. SMR is applied to the whole spine due to
dissection or direct injury, leading the high risk of noncontiguous injuries. A correctly sized cervical
to thrombosis of vertebral arteries, collar is a component of SMR. The spine is restricted to align
resulting in ischemia.
the head, neck, and torso. SMR is not performed in the sitting
position. Transfer from one surface to another is performed with
care. A long spine board, scoop stretcher, or vacuum mattress

105
  Table 7-3: Indications for Spinal Motion Restriction Following High Energy Blunt Mechanism.

Indications for Spinal Motion Restriction Following High Energy Blunt Mechanism

Adult Pediatric

• Acutely altered level of consciousness • Complaint of neck pain

(e.g., GCS <15, potential substance intoxication) • Torticollis
• Midline neck or back pain and/or tenderness • Neurologic deficit
• Focal neurologic signs and/or tenderness • Altered mental status (GCS < 15, potential substance intoxication,
• Anatomic deformity of the spine agitation, apnea, somnolence)
• Distracting circumstances or injury that impairs a • Motor vehicle crash, high-impact diving
reliable examination (e.g., long bone fracture, degloving injury, substantial torso injury
or crush injury, large burns, emotional distress,
communication barrier)

may be utilized for transfer to minimize axial spinal movements.  Table 7-4: Glasgow Coma Scale and Scores. The Glasgow
Routine SMR and cervical collar application are not performed Coma Scale is composed of three components: eye opening,
for penetrating mechanisms. SMR and a cervical collar may be verbal response, and motor response. The Glasgow
indicated if clinical exam indicates potential spinal trauma. Coma Score (GCS) is determined by the best response
obtained following testing each component. The total GCS
Cervical collars are applied to the pediatric population
is determined by adding each individual score, noting NT
per Pediatric Emergency Care Applied Research Network (non-testable) when applicable. Of the three components,
(PECARN) recommendations. The incidence of contiguous and the motor component is most correlated with long term
noncontinuous multilevel spine injury is very low in children. To outcomes following traumatic brain injury.
minimize pressure ulcer risk and discomfort in children, vacuum
mattresses are favored and time on backboards is limited. Younger Glasgow Coma Scale and Scores
children have a higher head-to-torso size ratio. Additional padding
may be placed to avoid excessive neck flexion and obtain neutral Component Result Score
spine alignment.
Eye Opening (E) Spontaneous 4

DISABILITY ASSESSMENT DURING PRIMARY To sound 3

SURVEY To pressure 2
Evaluation of both brain and spinal cord function is None 1
performed during the disability portion of the Primary Survey.
If an airway disorder is to be managed by intubation, a rapid Non-testable NT
and very focused determination of pupil responses, gross Verbal Response (V) Oriented 5
extremity motor and sensory function, and Glasgow Coma
Scale (GCS) score prior to administration of RSI medications Confused conversation 4
is beneficial. Words 3
A history is ascertained from prehospital providers or
observers, or from the patient (if TBI is mild or absent). History Sounds 2
regarding usage of anticoagulants and antiplatelet drugs is None 1
critical in relevant clinical contexts. The estimated elapsed time
Non-testable NT
from injury, GCS at the scene, pupil size and reactions, and any
changes in neurological status are obtained from prehospital Motor Response (M) Obeys commands 6
providers and documented. History of loss of consciousness
Localizing 5
with a return to alertness (lucid interval), followed by a lapse
into unconsciousness, is correlated with the presence and Normal flexion 4
expansion of an EDH. (withdrawal)
GCS assessment is performed by first observing spontaneous Abdnormal flexion 3
activities prior to stimulus. Verbal stimuli are provided next, while
observing eye opening, verbal responses, and upper-extremity Extension 2
motor responses. When there is no response to verbal stimuli, None 1
another stimulus (e.g., fingertip pressure, supraorbital pressure,
trapezius pinch) is applied, and responses are recorded. The Non-testable NT
severity of brain injury is defined by the post-resuscitation total
GCS in the absence of sedation and neuromuscular blockage.
 Table 7-4 reviews GCS scoring.  Table 7-5 lists the classification
of TBI by total GCS score.

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 Table 7-5: Classes of TBI. TBI can be divided into three (caudal to) the injury level indicates an incomplete injury. Signs
groups by GCS score. of an incomplete injury include sensation (including position
sense) or voluntary movement in the lower extremities, sacral
Classification of TBI sensation and/or motor sparing, voluntary anal sphincter
by GCS Score contraction, and voluntary toe flexion. Sacral reflexes, such
as the bulbocavernosus reflex or anal wink, do not qualify as
Classification GCS score sacral sparing. Early, accurate documentation of sensation and
strength is essential to assess neurological improvement or
Severe TBI ≤8 deterioration on subsequent examinations.
Sensory evaluation evaluates for a deficit within dermatome
Moderate TBI 9–12 segments. A dermatome is the area of skin innervated within a
particular segmental nerve root. The sensory level is the lowest
Mild TBI 13–15 (most caudal) dermatome with normal sensory function and can
often differ on the two sides of the body.  Figure 7-11 illustrates
TBI, Traumatic brain injury; spinal dermatomes.  Table 7-6 lists locations of several spinal
GCS, Glasgow Coma Scale. dermatomes.

 Figure 7-11: Spinal Cord Dermatomes. A. Anterior. B.

Posterior.
The resting size of the pupils and their reaction to a strong
light is assessed after gently opening the eyelids. Midsized (4–5 A.
mm) bilateral nonreactive pupils may indicate midbrain injury.
As the brain herniates, the ipsilateral pupil dilates. Asymmetrical
motor response is assessed and recorded to identify lateralizing
signs indicative of unilateral intracranial mass lesion or SCI.
Bilateral fixed and dilated pupils are associated with a poor
prognosis.
During the primary survey, the clinician observes for
asymmetric motor or sensory findings such as lack of movement
in extremities on one side or in specific limbs. Patients with
a complete high (proximal) SCI may respond only by facial
grimacing or neck movements.

DISABILITY ASSESSMENT DURING

SECONDARY SURVEY
Once the primary survey is completed, the secondary survey
is performed with a complete head-to-toe assessment. Brain
and spinal cord function are assessed and recorded. Most spinal
column injuries are detected and evaluated during the secondary B.
survey. When mechanism or other factors are consistent with
potential spinal injury, SMR is maintained throughout the
secondary survey. Both blunt and penetrating trauma may cause
a SCI.
External head and neck examination is performed to identify
a skull deformity, an open fracture of the skull, brain herniation,
scalp lacerations, CSF leakage from the nose or ears, and signs of
basal skull fracture (e.g., “racoon eyes,” “battle sign” bruising
over the mastoid). The location of penetrating and other wounds
is ascertained and documented. The entire spinal column and
paravertebral musculature is examined and palpated for areas of
deformity or focal tenderness. Vertebral fractures or subluxations
may be associated with a palpable “step-off ”. Loss of bowel
or bladder control and priapism are signs of potential SCI.
While maintaining SMR, gentle palpation of the posterior neck
is performed to assess for areas of deformity or focal tenderness.
SCI can be categorized as incomplete or complete and
as paraplegia (thoracic or lumbar injury) or quadriplegia/
tetraplegia (cervical injury). Motor or sensory function below

107
  Table 7-6: Sensory Function Related to Spinal Cord Level  Figure 7-12: Spinal Cord Myotomes.
(Dermatomes).

Sensory Function Related to

Spinal Cord Level (Dermatomes)

Dermatome Innervation
C5 Over the deltoid

C6 Thumb

C7 Middle finger

C8 Little finger

T4 Nipple line

T8 Xyphoid

T10 Umbilicus

T12 Symphysis pubis

L4 Medial aspect of the calf

Web space between the

L5
first and second toes

S1 Lateral border of the foot

S3 Ischial tuberosity

S4 and S5 Perianal region

Motor examination evaluates for absent or diminished motor

function due to either lateralizing TBI or SCI. Key extremity
muscle groups are examined systematically and bilaterally.
 Figure 7-12 illustrates spinal myotomes. Strength is graded from
zero (paralysis) to five (normal strength). A rectal exam and an
evaluation for spinal reflexes are performed. The presence of rectal
tone and sensation may be the only manifestations of neurologic
function caudal to the anatomic level of injury. These findings
reclassify the injury from “complete” to “incomplete,” which has
significant prognostic value and may alter management. The SCI SYNDROMES
presence or absence of a bulbocavernosus reflex is tested. Priapism SCI syndromes occur with incomplete SCI and manifest in
may be seen, most commonly in a complete cervical SCI. specific patterns of neurological deficits.  Figure 7-14 illustrates
The International Standards for Neurological Classification several SCI syndromes. Other spinal cord syndromes, such as
of Spinal Cord Injury worksheet, also known as the American anterior and posterior cord syndromes, are rare following trauma
Spinal Injury Association (ASIA) score, is an accepted standard and are usually due to vascular pathology.
for assigning the level and grade of injury.  Figure 7-13
illustrates a spinal cord injury worksheet. The ASIA score follows CENTRAL CORD SYNDROME
a standardized physical examination consisting of myotome, Central cord syndrome accounts for 15%–25% of all SCIs. It is
dermatome, and rectal tone examinations. Functional outcomes of associated with cervical hyperextension in patients with preinjury
SCI are variable and depend on the severity of neurological injury spinal stenosis. Thus, it is more common in older than younger
at presentation. The level of injury is also related to outcomes. patients. Motor deficits are disproportionately present in the upper
Incomplete SCI tends to carry a more favorable prognosis. extremities compared to the lower extremities. Varying degrees of
sensory impairment and bladder/bowel dysfunction occur.

BROWN-SÉQUARD SYNDROME
Brown-Séquard syndrome is an uncommon, incomplete
SCI, accounting for 4% of SCI. It is usually presents following
a gunshot, or knife wound that creates injury to one side of the
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 Figure 7-13: International Standards for Neurological Classification of Spinal Cord Injury
Worksheet.

109
 spinal cord. Clinical features of Brown-Séquard syndrome are as reduction is performed. A consultation with a peripheral nerve
follows: surgeon (when available) is performed once a nerve injury is
• Ipsilateral loss of vibration, proprioception, and fine touch identified.
(dorsal column sensations)
• Contralateral loss of pain, temperature, and crude touch
ADJUNCTS
(spinothalamic tract sensations)
IMAGING ADJUNCTS TO ASSESSMENT
• Ipsilateral loss of motor function (corticospinal tract injury)
Evaluation of brain and spine injuries through radiological
assessment is performed for a comprehensive trauma evaluation.
PERIPHERAL NERVE INJURY However, during the primary survey, xABCDE are completed
Blunt and penetrating mechanisms have the potential to cause with adequate cardiac and respiratory status obtained before
damage to the peripheral nervous system. Peripheral nerve injury transport for imaging. A significantly altered mental status (GCS
(PNI) can lead to permanent disability and decreased quality of ≤ 12) or high-risk mechanisms of injury, such as explosions, high-
life. A thorough neurological examination diagnoses the injury. speed motor vehicle collisions, and falls from great heights, are
PNI is associated with arterial, venous, and joint dislocation generally assessed with whole-body multidetector CT scanning
injuries. If a joint is dislocated and associated with PNI, emergent when available. When transfer for higher level of care is indicated,
transport is not delayed to obtain images.
 Figure7-14: Spinal Cord Syndromes. Shaded areas
represent regions of injury. A. Central cord syndrome. TRAUMATIC BRAIN INJURY
Examination demonstrates disproportionate upper-limb
weakness, bladder dysfunction, and variable sensory The preferred imaging modality for TBI is a noncontrast CT
dysfunction. B. Brown – Séquard syndrome. Examination scan of the brain. Advantages include accessibility, rapidity, cost-
demonstrates ipsilateral dorsal column sensory loss, effectiveness, and high sensitivity for detecting acute intracranial
contralateral spinothalamic sensory loss, and ipsilateral conditions such as hemorrhage, edema, volume shifts, and skull
motor loss. fractures. The 2023 American College of Emergency Physicians
(ACEP) clinical policy reviewed the Canadian CT Head Rule,
A.
New Orleans Criteria, and NEXUS Head CT decision tools. The
summary indications to consider a head CT are listed in  Table
7-7. A GCS ≤ 12 is an indication for head CT, as more than 80%
of these patients will have an injury.

INTERPRETATION OF HEAD CT SCANS

TBI is a heterogeneous disease with different radiographic
patterns of injury, such as skull fracture, EDH, SDH, tSAH,
hemorrhagic contusions, focal and diffuse patterns of axonal
injury, and cerebral edema. Evaluation of CT scans by a qualified
radiologist and prompt (no later than 1 hour) availability of the
results is optimal. Noncontrast CT scan offers valuable insights
into ICP status, enabling physicians to initiate timely ICP-lowering
strategies, even before transfer to a trauma or neuroscience center.
B. Acute blood is hyperdense (white) on CT scan images.
Identification of acute hematomas and rapid referral for
possible neurosurgical intervention are vital to provide the
optimal potential for recovery. An EDH is lens-shaped and
hyperdense. It does not cross the cranial sutures. An SDH is
hyperdense, concave (crescent-shaped), and crosses the cranial
suture lines. Cerebral contusions are nonuniform, hyperdense
lesions of varying size. Contusions may progress in hemorrhage
size, amount of associated edema, and clinical impact within
hours following injury. tSAH is the presence of blood in the
subarachnoid space. The pattern of blood in an aneurysmal SAH
is different, typically occupying the basal cisterns. Diffuse axonal
injury (DAI) appears as petechial hyperdense images in the
subcortical white matter.  Figure 7-15 illustrates the appearance
of various traumatic intracranial hemorrhage on CT. Brain MRI is
a more sensitive imaging modality for diagnosing and evaluating
DAI.

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 Table 7-7: Indications for Head CT.  Figure 7-15: CT Scans of Various Types of Post-
Traumatic Intracranial Hemorrhage:
Indications for Head CT A. Right extradural hematoma. B. Right cerebral convexity
subdural hematoma C. Multiple cerebral contusions. D.
Traumatic subarachnoid hemorrhage. E. Diffuse axonal
Age >16 with LOC or PTA Consider CT without injury: Deep gray matter and gray-white junction, petechial
(CDC / ACEP) LOC or PTA hemorrhages.
GCS < 15 GCS ≤15

Age greater than 60 years Age >65

Physical evidence of trauma Coagulopathy, Anticoagulant

above the clavicle

Coagulopathy (supra-therapeutic Focal neurologic deficit

international normalized ratio
(INR) or thrombocytopenia)

Headache Severe headache A.

Vomiting Vomiting

Drug or alcohol intoxication Signs of basilar skull fracture

Short-term memory deficit Ejection from motor vehicle

Posttraumatic seizure Pedestrian struck by motor

vehicle

Focal neurologic deficit Fall down 5 stairs or >1 meter

B.

CT, Computed tomography; LOC, Loss of consciousness; PTA,

Post-traumatic amnesia; CDC, Centers for Disease Control;
ACEP, American College of Emergency Physicians;
GCS, Glasgow Coma Score.
Used with permission of Elsevier, from American College of Emergency
Physicians Clinical Policies Subcommittee (Writing Committee) on Mild
Traumatic Brain Injury, Valente JH, Anderson JD, et al. Clinical Policy: Critical
Issues in the Management of Adult Patients Presenting to the Emergency
Department With Mild Traumatic Brain Injury: Approved by ACEP Board of
Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses
Association (April 5, 2023). Ann Emerg Med. 2023;81(5):e63-e105. C.

Air has a very low density, appearing black on noncontrast CT.

The presence of pneumocephalus (intracranial air) is associated
with open skull fracture, craniofacial trauma, and sinus injury.
A noncontrast CT head scan can offer information about
ICP. CT signs of critically elevated ICP include the absence or
compression of cisterns, midline shifts exceeding 5 mm, and
loss of grey-white matter differentiation.  Figure 7-16 illustrates
CT scan findings of normal and increased ICP. The absence
or compression of basal cisterns has a sensitivity of 86% and D.
specificity of 61% for elevated ICP, while a midline shift exhibits a
sensitivity of 81% and specificity of 43%.

SPINE INJURY

Clinical Clearance of the Cervical Spine

A systematic clinical examination and appropriate radiographic

assessment are critical in identifying significant spine injury.
Presence of a neurologic deficit, cervical tenderness, or
E.
complaint of neck pain are indications for radiologic imaging.
In low-risk scenarios, cervical spine motion restriction
by collars and other devices may be discontinued without

111
 radiologic imaging following proper application of clinical motion involves flexion, extension, and rotation to 45 degrees
screening decision tools such as the Canadian C-Spine Rule bilaterally. If the patient denies pain and neurologic symptoms
(CCR) and the National Emergency X-Radiography Utilization during range of motion, the cervical motion restriction device
Study (NEXUS) criteria.  Figure 7-17 illustrates the CCR. may be discontinued. If the patient cannot complete a full range
 Figure 7-18 illustrates the NEXUS criteria. Described more than of motion, the cervical motion restriction device is continued,
20 years ago, these decision pathways have reported excellent and further diagnostic procedures are indicated. In addition,
sensitivity if the exclusion criteria are followed. The CCR’s when CT scan is negative for injury and physical examination
exclusion criteria include age > 65 years, GCS < 15, abnormal is reliable, the cervical spine may be cleared following the same
hemodynamics, and a dangerous mechanism. CCR and NEXUS method of clinical exam. Specific NEXUS criteria to determine if
criteria are not utilized in pediatric patients and older adults, examination is reliable are listed in  Figure 7-18.
as limited data exist, and results have demonstrated variable
and poor performance. Methods of Spine Imaging
If imaging is not indicated according to the NEXUS and CCR
Multidetector CT with coronal and sagittal reconstructions
criteria, the cervical spine may be cleared clinically by a systematic
is the imaging modality of choice to evaluate the cervical and
exam. To perform the examination, the clinician loosens the
thoracolumbar spine. Plain radiographs have a limited role in
cervical device, keeping the device attached if possible while
the initial evaluation of the spine due to low sensitivity. Cervical
an assistant maintains cervical SMR. The clinician palpates the
spine injuries occur in approximately 10% of blunt TBI patients.
posterior neck. Each vertebra is felt while monitoring for pain.
Therefore, cervical spine imaging is indicated with moderate
If there is no pain or midline tenderness, the device is removed,
to severe TBI. Additionally, approximately 10% of patients
and the patient is asked to demonstrate an active (i.e., without
with a cervical spine fracture have a second, noncontiguous
clinician assistance), full range of motion of the neck. Adequate

 Figure 7-16: Some Critical TBI CT Scan Findings: A. Arrow points to normal, open basal cisterns. B. Arrow points to effaced
basal cisterns. C. Normal foramen magnum, arrow pointing to a rim of CSF at cervico-medullary junction. D. Arrow points to
edematous foramen magnum E. No midline shift. F. Midline shift, arrow pointing to septum pellucidum, and left subdural
hematoma.

A. B. C.

E.
D. F.

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 Figure 7-17: Canadian C-Spine Rule. A clinical decision tool for cervical spine evaluation. MVC, Motor
vehicle collision; ED, Emergency department. Adapted from Stiell IG, Wells GA, Vandemheen KL, et al. The
Canadian C-Spine rule of radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848.

Canadian C-spine Rule (CCR)

For alert (GCS score = 15) and stable trauma patients in whom cervical spine injury is a concern.

Any high-risk factor that

mandates radiography?

1. Age > 65 years

2. Dangerous mechanism Dangerous mechanisms:

3. Paresthesias in extremities • Fall from ≥l m/5 stairs

• An axial load to the head
• A motor vehicle collision
• At high speed (>100 km/hr)
• Rollover
Any low-risk factor that allows safe • Ejection
range of motion assessment?
• Motorized recreational
1. Simple rear-end MVC vehicle collision

2. Sitting position in the ED • A bicycle collision

3. Ambulatory at any time

4. Delayed onset of neck pain
5. No midline cervical tenderness

Able to rotate neck actively

(45º left and right)

No Radiography Radiography

Adapted with permission of JAMA, from The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients, Stiell, Ian G.; Wells,
George A., 286, 2001; permission conveyed through Copyright Clearance Center, Inc.

113
 vertebral column fracture. Therefore, radiographic evaluation When CT technology is unavailable, cervical radiographs
of the entire spine for patients with a cervical spine fracture is visualizing from the occiput to T1, including lateral, Anterior-
appropriate. The cervical spine is imaged from the craniocervical posterior (AP), and open-mouth odontoid views, are obtained.
junction to the cervicothoracic junction, with images formatted in Adequate radiographs demonstrate the skull base, all seven cervical
the axial, coronal, and sagittal planes. vertebrae, and the first thoracic vertebra on the lateral view. The

 Figure 7-18: National Emergency X-Radiography Utilization Study (NEXUS) Criteria and Mnemonic. A clinical
decision tool for cervical spine evaluation. Adapted from Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a
set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency
X-Radiography Utilization Study Group. N Engl J Med 2000;343:94–99.

National Emergency X-Radiography Explanation:

Utilization Study (NEXUS) Criteria
These are for purposes of clarity only. There are not precise
Meets ALL low-risk criteria? definitions for the individual NEXUS Criteria, which are subject to
intepretation by individual physicians.
1. N
 o posterior midline cervical-spine
tenderness and... 1. M
 idline posterior bony cervical spine tenderness is present if the
patient complains of pain on palpation of the posterior midline neck
2. N
 o evidence of intoxication and... from the nuchal ridge to the prominence of the first thoracic vertebra,
or if the patient evinces pain with direct palpation of any cervical
3. A
 normal level of alertness and... spinous process.

4. N
 o focal neurologic deficit and... 2. P
 atients should be considered intoxicated if they have either of the
following:
5. N
 o painful distracting injuries
• A recent history by the patient or an observer of intoxication or
intoxicating ingestion.

• Evidence of intoxication on physical examination, such as odor

of alcohol, slurred speech, ataxia, dysmetria or other cerebellar
findings, or any behavior consistent with intoxication. Patients may
No Radiography Radiography also be considered to be intoxicated if tests of bodily secretions are
positive for drugs (including but not limited to alcohol) that affect
levels of alertness.

3. A
 n altered level of alertness can include any of the following:

NEXUS Mnemonic • Glasgow Coma Scale of 14 or less

• Disorientation to person, place, time, or events

N Neuro deficit
• Inability to remember 3 objects at 5 minutes
E EtOH (alcohol)/intoxication
• Delayed or inappropriate response to external stimuli

X eXtreme distracting injury/injuries • Other

4. A
 ny focal neurologic complaint (by history) or finding (on motor or
U Unable to provide history (altered
sensory examination).
level of consciousness)
5. N
 o precise definition for distracting painful injury is possible. This
S Spinal tenderness (midline) includes any condition thought by the clinician to be producing pain
sufficient to distract the patient from a second (neck) injury.
Examples may include, but are not limited to:

• Any long bone fracture

• A visceral injury requiring surgical consultation

• A large laceration, degloving injury, or crush injury

• Large burns

• Any other injury producing acute functional impairment

Physicians may also classify any injury as distracting if it is thought to have

the potential to impair the patient’s ability to appreciate other injuries.

Used with permission by Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with
blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000; 343:94–99. permission conveyed through Copyright Clearance
Center, Inc.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

shoulders may be pulled caudally to adequately demonstrate the Assessment of cervical bone alignment on multidetector CT
lower cervical spine. If all cervical vertebrae are not visualized on scans involves delineating the anterior vertebral line (along the
the lateral x-ray film, a “swimmer’s view” of the lower cervical and anterior vertebral bodies), posterior vertebral line (along the
upper thoracic area may be performed. The open-mouth odontoid posterior vertebral bodies), spinolaminar line (along the midline
view visualizes the entire odontoid process, as well as the right and of the posterior spinal canal), and interspinous line (along the tips
left C1 and C2 articulations. The AP view assists in identifying a of the spinous processes from C3 to C7). These lines normally
unilateral facet dislocation when little or no dislocation is visible form a smooth curve without focal angulation or discontinuity.
on the lateral image. Spine MRI is not generally employed in Figure 7-19 illustrates these lines of alignment. Examples of
acute settings; it is requested following the secondary survey and cervical fractures detected on CT scan are illustrated in  Figure
transfer at referral centers by surgical specialists. 7-19 and  Figure 7-20.

Interpretation of Cervical Spine CT Scans

Cervical spinal column injuries may be described by several

factors, including stability, location, and mechanism, such as
flexion, flexion-rotation, extension, and vertical compression. A
two-column approach can be used to assess stability of cervical
injury caudal to C2. The anterior column comprises vertebral
bodies with intervertebral discs secured by anterior and posterior
ligaments. The posterior column, containing the spinal cord, is
composed of bilateral laminae and pedicles.  Table 7-8 lists
factors in evaluation of cervical spine CT imaging.

 Table 7-8: Two-Column Evaluation of Cervical Spine CT Imaging.

Two-Column Evaluation of Cervical Spine CT Imaging

Component Anterior Column Posterior Column

Bone Vertebral body and Transverse process Pedicles, lamina, spinous process
Normal: Preserved body height, no cortical defect Normal: All elements intact
Abnormal: Wedging, steps, fractures, retropulsion Abnormal: Fractures

Joints Intervertebral discs Facet joint

Normal: Disc space symmetrical Normal: Bilateral symmetrical, parallel
Abnormal: Focal narrowing, or asymmetry Abnormal: Asymmetry, diastasis,
assessed in sagittal and coronal planes subluxation, dislocation

Ligaments AVL /PVL Posterior ligamentous complex: Interspinous

ligaments, ligamentum flavum
Normal: Aligned
Normal: Aligned, smooth interspinous line
Abnormal: Anterior or posterior translation of vertebrae
Abnormal: Anterolisthesis, focal kyphosis, abrupt
Asymmetric disc space widening
interspinous widening, facet joint asymmetry or diastasis

Curvature Normal: Smooth lordosis Normal: Smooth lordosis

Abnormal: Focal kyphosis Abnormal: Focal kyphosis

Alignment Smooth, uninterrupted anterior and posterior Smooth, uninterrupted spino-laminar and
vertebral lines visualized in sagittal plane Interspinous lines visualized in sagittal plane
Uninterrupted articular pillar alignment in
sagittal and coronal planes

CT, Computed tomography; AVL, Anterior vertebral line; PVL, Posterior vertebral line.

115
  Figure 7-19: Assessment of Cervical Spine MDCT
D.
Images: A. Normal cervical spine. Smooth anterior and
posterior vertebral, spino-laminar and interspinous lines.
B. Normal fact joint alignment as indicated by arrows. C.
C6 vertebral body fracture with posterior displacement. A
break is present in the continuity of the posterior vertebral
line. D. Arrow points to disruption of the spino-laminar line
following posterior displacement of a laminar fracture. E.
Coronal. F. Sagittal views of widened left C6-C7 facet joint.

A.

E.

B.

F.

C.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

 Figure 7-20: Cervical Spine Fractures. A. Posterior arrows point to bilateral C7 laminar fractures, Anterior arrow points to
vertebral body fracture. B. Jefferson fracture: Fracture of both anterior and posterior arches of C1 as shown by arrows.
C. C2, Odontoid process fracture at arrow.

A. B. C.

The thoracic and lumbar spine can be evaluated as three

parallel vertical columns.  Table 7-9 lists the three columns.
 Figure 7-21 illustrates the three columns. Stability is based on
integrity of two of the three columns. However, few studies have
reported on the validity of this three-column stability assessment.
Examples of thoracic and lumbar fractures detected on CT scan
are illustrated in  Figure 7-22.

 Table 7-9: Three-Column Evaluation of Thoracic and Lumbar Spine CT Imaging

Three-Column Evaluation of Thoracic and Lumbar Spine CT Imaging

Anterior column Middle column Posterior column

Anterior Longitudinal ligament (ALL) Posterior one-third of the vertebral body Structures posterior to PLL
Anterior two-thirds of the vertebral body Posterior one-third of the Pedicles
intervertebral disc
Anterior two-thirds of the Facet joints and articular processes
intervertebral disc Posterior longitudinal ligament (PLL)
Ligamentum flavum
Neural arch and interconnecting ligaments

117
  Figure 7-21: Three-Column Evaluation of  Figure 7-22: Thoracic and Lumbar Spine Fractures. A.
Thoracolumbar Spine CT Images. A. The three columns T 12 fracture at arrow. B. L1 compression fracture with
on a single vertebra. retrolisthesis and spinal canal stenosis on CT images as
B. The three columns on a sagittal CT image. indicated by arrows. C. L4 and L5 burst fractures at arrows.
D. Fracture bilateral laminas and body of T6 as shown at
A. arrows.

A.

B.

B.

C.

D.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

Magnetic Resonance Imaging LABORATORY ADJUNCTS TO ASSESSMENT

MRI provides information regarding soft tissues and Lab investigations for TBI include a total blood count, platelet
ligamentous injury. MRI can visualize spinal cord structures, nerve count, clotting profile, and biochemistry analysis with lactate
roots, discs, and ligaments. MRI may be obtained to further define levels. Assessment of INR in scenarios of preinjury warfarin
injuries, to diagnose injuries not visualized on CT when the exam therapy is critical. A goal of treatment is an INR ≤ 1.4. Arterial
is abnormal, and for operative planning per a surgical specialist. blood gas analysis, if available, is evaluated at regular intervals to
MRI is not obtained during the initial assessment process. assess hypoxemia and hypercarbia. When available, point-of-care
viscoelastic monitoring can evaluate coagulation status. Pending
BLUNT CEREBROVASCULAR INJURY availability, brain injury biomarkers—such as glial fibrillary
Although rare, untreated blunt cerebrovascular injury acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1
(BCVI) may have devastating consequences. Therefore, when (UCH-L1), and S100 calcium binding protein (S100B)—are being
a cervical spine injury is detected, either CT or magnetic evaluated as criteria for brain CT imaging in selected suspected
resonance angiography is performed to evaluate for BCVI. TBI scenarios.
Traditional BCVI screening criteria miss about 20% of injuries,
many of which are clinically significant. Current recommendations ADJUNCT NONINVASIVE ASSESSMENT OF
are to perform a CT angiography of the neck for any patient with ICP
significant mechanism of injury for which head and cervical spine
Optic nerve sheath diameter measurement is an ultrasonog-
CTs are obtained. Examples of indications to evaluate for BCVI
raphy technique to assess the diameter of the optic nerve sheath,
are listed in  Table 7-10.
which is continuous with the meninges of the central nervous
system and reflects changes in intracranial compliance and ICP.
 Table 7-10: Recommended Screening Criteria for BCVI. Optic nerve sheath diameter can be measured at the bedside. Lim-
itations include technical expertise, availability, and lack of con-
Recommended Screening Criteria for BCVI sensus on the optimal threshold for diagnosing elevated ICP.
Criteria INTERVENTIONS AND TREATMENTS
• Head or cervical CT performed due to mechanism
Rapid appropriate management of TBI and SCI increases
• Scalp degloving injury
the probability of survival, prevents secondary damage, and
• Severe TBI with GCS <6 reduces long-term disability. Hypoxia and hypotension are
• TBI with thoracic injuries particularly harmful and increase the risk of death. The main goal
• Neurological exam findings not explained by neuroimaging of managing TBI and SCI is to mitigate the impact of secondary
• Focal neurological deficit (transient ischemic attack, injury, thereby reducing the progression of neuronal damage.
hemiparesis, vertebrobasilar symptoms,
oculosympathetic palsy/Horner Syndrome) PREHOSPITAL
• Cerebral ischemia or vascular territory edema on CT or MRI Hypoxia has a significant deleterious effect on outcomes in TBI.
• Base of skull fracture with involvement of the carotid While any episode of hypoxia is treated, prevention is critical. When
canal or petrous temporal bone available, oxygen is administered in the prehospital environment
• Complex skull fracture (e.g., involving frontal or for all patients. SpO2 is maintained at ≥ 94%. Additional airway
other sinuses, orbit)
interventions are performed as indicated. A nasopharyngeal
• Le Fort II or III fracture pattern airway is not inserted with signs of basilar skull fracture, facial
• Mandible fracture trauma, or disruption of the midface, nasopharynx, or roof of
• Cervical spine fracture mouth. To maintain adequate ventilation and oxygenation, and
• Arterial hemorrhage from the neck, nose, or mouth
due to frequent associated severe injuries, prehospital intubation
and mechanical ventilation may be performed when GCS is
• Neck soft-tissue injury (e.g., seatbelt sign,
hanging, hematoma) below 9 if experienced prehospital professionals are present and
following local guidelines. Depending upon local circumstances,
• Near hanging with hypoxic-ischemic (anoxic) brain injury
intubation may be deferred until hospital arrival. Prehospital time
• Clothesline type injury or seat belt abrasion with is minimized while ensuring adequate oxygenation.
significant swelling, pain, or altered mental status
• Crepitus, soft tissue of neck HOSPITAL
• Cervical bruit in patients <50 years of age
The xABCDE approach to resuscitation is performed. When
• Upper rib fractures available, early involvement of specialized neurotrauma services is
• Thoracic vascular injuries advised. Prevention of further neurologic damage is enhanced
• Blunt cardiac rupture by providing adequate blood flow and oxygenation to the
brain and spinal cord. Hypoxia, hypotension, and ventilation
BCVI, Blunt cerebrovascular injury; TBI, Traumatic brain derangements are prevented. Oxygenation and blood pressure
injury; GCS, Glasgow coma score; CT, Computerized
tomography; MRI, Magnetic resonance imaging.

119
 goals are higher than in scenarios without potential neurologic AIRWAY AND BREATHING
injury. For adults with TBI, a systolic blood pressure of at least
100 mm Hg is recommended.  Table 7-11 lists blood pressure Even a single, brief episode of hypoxia is associated with
goals for TBI and SCI. increased TBI mortality. Endotracheal intubation to maintain
oxygenation and ventilation is indicated if GCS is ≤8. Agitation
 Table 7-11: Blood Pressure Goals for TBI and SCI. and declining neurologic status are additional indications to
consider intubation, as is an SCI proximal to the C5 level or
associated with refractory hypoxemia. Airway manipulation is
Blood Pressure Goals for TBI and SCI
performed with manual motion restriction of the head and
neck. The anterior portion of a cervical collar may be removed
Ages TBI SCI
or loosened to allow for wider mouth opening and adequate
15 years and older SBP ≥ 100 mm Hg MAP >90 mm Hg visualization of the vocal cords during laryngoscopy. Both
facemask ventilation and intubation can be challenging due to
Less than 15 years SBP > 5th percentile for age [70 mm Hg + limitations in neck movements and concurrent facial injuries.
(age * 2)] Intubation is optimally performed by an experienced clinician
skilled in advanced difficult airway management. If intubation
TBI, Traumatic brain injury; SCI, Spinal cord injury; SBP, fails, a surgical airway is performed, as discussed in Chapter 4,
Systolic blood pressure; MAP, Mean arterial pressure.
Airway Assessment and Management.

CIRCULATION
Target SpO2 is ≥94%. When able to be monitored, ETCO2
is maintained at 35–40 mm Hg. In scenarios of concomitant Hypotension has a detrimental effect on the outcome of
TBI and SCI, the TBI blood pressure targets are followed. both head and spinal cord injuries. The combined effect of
Hypothermia is avoided. Target INR is ≤1.4. Goals for other hypotension and hypoxia increases the risk of death by two-
laboratory and monitoring values are listed in  Table 7-12. fold in patients with head injuries. Permissive hypotensive
resuscitation is avoided in scenarios of SCI and moderate

 Table 7-12: Optimal Values in TBI Management.

Optimal Values in TBI Management

Category Parameter Optimal Value

Clinical Parameters Systolic blood pressure ≥100 mm Hg

Mean arterial pressure >80 mm Hg

Temperature 36–38°C

Pulse oximetry ≥94%

Laboratory Parameters Glucose 100–180 mg/dL

Hemoglobin > 7 g/dl

International normalized ratio (INR) ≤1.4

Serum sodium 135–145 meq/dL

Serum osmolality ≤320 mOsm

PaO2 80–100 mm Hg

PaCO2 35–45 mm Hg

pH 7.35–7.45

Platelets ≥75 X 103 mm3

Neurologic Monitoring Parameters Cerebral perfusion pressure 60–70 mm Hg*

Intracranial pressure <22 mm Hg*

PbtO2 ≥15 mm Hg

TBI, Traumatic brain injury; PbtO2, Partial brain tissue oxygenation.

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to severe TBI. Blood products are transfused for volume Platelet transfusion is indicated if neurosurgical intervention
resuscitation. When blood products are not available, isotonic is to be performed. To promote clot formation and stability,
fluid such as normal saline is safe in maintaining volume status therapeutic goals include an INR <1.5, a platelet count ≥75 ×
in head injury patients. However, blood is preferred. A recent 103 per mm3, normothermia, and a normal pH.
study demonstrated that using balanced crystalloid solutions
was associated with a worse discharge disposition. Hypotonic Tranexamic Acid
solutions containing dextrose are avoided due to the risk of For patients with moderate to severe TBI who present within 3
worsening cerebral edema. Hypertonic solution for prehospital hours of injury, IV administration of TXA, either a single 2-g dose
resuscitation of TBI patients with hypotension is not superior to or a 1-g dose over 10 minutes followed by IV infusion of 1 g over
normal saline. Patients who remain hypotensive after blood and/ 8 hours, is safe and may decrease mortality. The administration
or fluid resuscitation may be administered a vasopressor to achieve of TXA might be reasonable for other subgroups, such as severe
blood pressure targets. Phenylephrine and norepinephrine are TBI with bilateral reactive pupils and mild TBI with intracranial
two common options. bleeding, but the benefit remains uncertain.
NEUROGENIC SHOCK ANALGESIA AND SEDATION
Neurogenic shock may occur following a SCI proximal to Intubated TBI patients receive intravenous analgesia and
the T6 level. Treatment is initiated to ensure adequate vascular sedation for pain and agitation. Adequate sedation and analgesia
volume. Blood products are administered to treat blood loss. reduce oxygen consumption and CBF, decreasing cerebral
Crystalloid solutions are used once adequate hemorrhage control fluid volume and reducing ICP. Appropriate sedation enhances
is obtained and resuscitation completed. In scenarios of isolated ventilator synchrony and may mitigate sympathetic responses,
SCI, a MAP of 85–90 mm Hg is currently recommended to be preventing hypertension and tachycardia. Short-acting agents
maintained for seven days. If fluid resuscitation fails to achieve such as propofol or fentanyl are preferred to allow regular
goals, vasopressors are added. Norepinephrine is an option, as neurological examinations and detect a decline in neurologic
α-1 and β-1 activity will improve peripheral vasoconstriction, heart function. Hypotension is a common sequela of propofol bolus or
rate, and contractility. Phenylephrine may also be administered infusion. Frequent blood pressure and hemodynamic monitoring
for SCI caudal to T6. However, as phenylephrine lacks β-1 activity, are essential during propofol administration. Some clinicians
bradycardia may be exacerbated in scenarios of injury proximal to utilize ketamine due to a proposed neuroprotective effect through
T6. Vasopressors are optimally administered via central venous N-methyl-D-aspartate (NMDA) receptor antagonism. Ketamine
access. However, in emergent situations, vasopressors may be has favorable pharmacological characteristics without an adverse
infused through a peripheral IV. effect on ICP. Thus, ketamine is a reliable anesthetic agent for RSI
in prehospital environments.
TRANSFUSION GOALS AND COAGULOPATHY
Replacing blood loss with blood or blood products is CRITICAL NEUROWORSENING
optimal. Simultaneous replacement of clotting factors potentially Critical neuroworsening is a term to describe a rapid
reduces progression of cerebral contusions. Transfusion strategies deterioration of neurologic status that warrants emergent
for treatment of hemorrhagic shock are discussed in Chapter 6, evaluation. The clinical signs are a spontaneous decrease in
Circulation Assessment and Volume Resuscitation. Following TBI the GCS motor score, new decrease in pupillary reactivity,
or SCI, a hemoglobin level of ≥7 g/dL is recommended to be new pupillary asymmetry, bilateral dilated pupils, new focal
maintained. motor deficit, and Cushing’s triad (widened pulse pressure,
Coagulopathy occurs in 25% to 30% polytrauma patients bradycardia, and irregular respiration). Causes of deterioration
and is promptly corrected in TBI and SCI. About one-third are numerous and include expanding intracranial mass lesions
of all brain injuries expand in the first hours following injury, and cerebral edema. If signs of neuroworsening are present,
some due to delays in treatment or inappropriate correction of presumptive treatment is initiated without delay. CT scan of the
coagulation defects. It is unknown if TBI has distinct mechanisms brain is repeated to ascertain the cause of neuroworsening.
that result in coagulopathy or if clotting abnormalities are
due to general trauma-induced coagulopathies. The presence HYPEROSMOLAR THERAPY
of preinjury anticoagulants and/or antiplatelet agents is Hyperosmolar therapy is the central pharmacological
common, particularly in older adults. Rapid determination therapy for management of intracranial hypertension and
of the presence of these medications and reversal of the clot- critical neuroworsening. Hyperosmolar therapy has a biphasic
inhibiting effects are vitally important in the presence of TBI mechanism of action. Initially, a hyperosmolar solution bolus
and SCI. Table 6-7 in Chapter 6, Circulation Assessment and boosts cardiac output, raising blood pressure and CPP. If
Volume Resuscitation lists various clot-inhibiting medications autoregulation is intact, cerebral vasoconstriction occurs,
and methods to reverse their effects. The management of reducing cerebral blood volume and ICP. The solution creates
hemorrhage-induced and medication-induced coagulopathies an osmolar gradient for water to cross the blood-brain barrier,
is similar to their management without neurologic injury (see lowering brain volume and ICP. Mannitol and hypertonic saline
Chapter 6, Circulation Assessment and Volume Resuscitation). The solutions are commonly used hyperosmolar agents.  Table
benefit of routine platelet transfusion is debated for TBI patients 7-13 lists hyperosmolar agents.
receiving antiplatelet agents and with a normal platelet count.

121
  Table 7-13: Hyperosmolar Agents.

Hyperosmolar Agents

Agent Dose Comments

Mannitol 20% Solution: IV bolus, 1 g kg (5 ml / kg) over 5–15 min ICP decreases in 1–5 min with peak effect in
20–60 minutes
Can repeat every 4–6 hours
May aggravate hypotension through osmotic
diuresis

Hypertonic saline 5% Solution: 2.5–5 mL kg over 5–20 min Ideally administered through a central venous
Pediatric: 2–5 mL/kg over 10–20 min catheter
In the emergent situation, administration via
7.5% Solution: 1.5 –2.5 mL/kg over 5–20 min
peripheral IV is safe
23.4% Solution: 30 ml over 10–20 min Monitor for subcutaneous infiltration
Pediatric: 0.5 mL kg (max dose: 30 mL)

Although hypertonic saline has physiological advantages Indications for Surgical Interventions in TBI
over mannitol, there’s no evidence that either is more effective
A neurosurgeon will discuss the risks and benefits of operative
in improving neurological outcome. Hyperosmolar agents will
therapy considering the specific clinical scenario with the patient’s
increase serum sodium and osmolality levels. These values are
decision-maker(s). Even if a relatively high GCS score is present,
monitored frequently to avoid serious complications. When the
evacuation of a large (> 25 mL) traumatic hematoma may be
serum sodium is above 160 mEq/L or osmolality is above 320
recommended before neurological deterioration develops from
mOsm, additional hyperosmolar therapy is unlikely to be effective.
hematoma enlargement or brain swelling. A lower threshold for
STEPWISE MANAGEMENT OF NEUROWORSENING surgical intervention may apply to posterior fossa lesions. Specific
indications for surgical intervention include an acute SDH with >
Endotracheal intubation and controlled mechanical ventilation 10 mm thickness or associated with >5 mm midline shift; an acute
are instituted unless already performed. The head is elevated 30° SDH of any size when associated with decline in GCS of at least
to 45°, while maintaining neutral cervical spine position to 2 points or associated with asymmetric or nonreactive pupils;
ensure adequate venous return from the brain. In scenarios of a an acute EDH with volume >25 mL, with >15 mm thickness,
potential unstable spine, a reverse Trendelenburg position may be or associated with either a >5 mm midline shift or a GCS of ≤8;
employed. The cervical collar is examined to assess if it is applied cerebral contusions associated with GCS ≤8 and midline shift
too snugly. Endotracheal tube fixation is similarly examined for >5 mm or herniation; and a cerebellar hemorrhage >3 cm in
potential compression of the jugular veins. diameter or resulting in mass effect, brainstem compression, or
Transient emergent hyperventilation to a target PaCO2 hydrocephalus. Following evacuation of a cerebral hematoma,
or ETCO2 of 30–35 mm Hg is performed as a lifesaving the removed portion of skull may not be immediately replaced to
measure. Hyperventilation quickly decreases ICP during cerebral allow decompression of edematous brain.
herniation. Prolonged hyperventilation is not recommended and
may increase ischemic events. Open Skull Fractures
Analgesia and sedation are optimized. An IV bolus of
Depressed skull fractures and the depth of the depression are
hypertonic saline 5% (250 mL) or mannitol 20% (250 mL)
measured by CT scan. Generally, surgical elevation is considered
is administered. Normothermia is maintained with a core
if fracture displacement is greater than the thickness of the skull,
temperature of 36°C–37.4°C via warming or cooling systems,
as well as for contaminated wounds. Perioperative antibiotics
as indicated. Surgical evaluation is performed for potential
are recommended. More than 24 hours of antibiotic treatment
evacuation of mass lesions or decompressive craniectomy.
is limited to severely contaminated wounds. Nondepressed open
SURGICAL MANAGEMENT FOR TBI fractures with minimal soiling are generally adequately managed
with irrigation and closure of the overlying tissue defect with one
Neurosurgical interventions in TBI include invasive ICP dose or a maximum of 24 hours antibiotic therapy.
monitoring, external ventricular drain insertion, intracranial
hematoma evacuation, and decompressive craniectomy. If ICP
monitoring is available, it is often performed in scenarios of
postresuscitation GCS 3–8 associated with an abnormal CT scan
(e.g., presence of hematomas, contusions, swelling, herniation, or
compressed basal cisterns).

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Decompressive Craniectomy prophylactic antiseizure medication is not recommended in

scenarios of a GCS of 14–15 with or without intracranial bleeding,
Decompressive craniectomy is a rescue therapy for patients with isolated tSAH, isolated traumatic IVH, and isolated SDH with
elevated ICP refractory to medical management. Decompressive GCS ≥13. The benefit of antiseizure medication in a particular
craniectomy has been demonstrated to reduce mortality and scenario is evaluated against the risk of producing impaired
improve outcome over 24 months. The RESCUEicp trial predicted cognition, particularly in older patients.
that if 100 patients are treated with secondary decompressive The choice of antiseizure medication depends on availability.
craniectomy, compared to nonoperative management, there will The most studied drugs include phenytoin, fosphenytoin, valproic
be 21 extra survivors with the following functional outcomes: acid, and levetiracetam. Phenytoin has been utilized for decades.
one-third independent outside the home, one-third independent Levetiracetam and lacosamide, may have equivalent efficacy for
in the home, and one-third dependent. seizure prevention with fewer adverse events and possibly better
functional outcomes. Valproic acid (compared to phenytoin) for
SURGICAL MANAGEMENT FOR SPINAL INJURIES
early PTS prophylaxis is associated with an increased risk of death
Early spinal decompression and stabilization is frequently and is not utilized. Prophylactic antiseizure medication is stopped
performed in experienced centers and may result in improved within 7 days unless seizures have occurred >24 hours postinjury
functional recovery. Surgery may need to be delayed until or it was a preinjury medication. Prolonged administration does
respiratory and hemodynamic stability is achieved. Several studies not decrease the risk of seizures after the first week. In pediatric
with early cord decompression and spine fixation performed cases, either levetiracetam or (fos)phenytoin is appropriate
within 8−24 hours of injury showed improved functional for 7 days. Levetiracetam has fewer adverse interactions, and
outcomes. Early surgery decreases additional injury from cord therapeutic drug monitoring is not needed. Commonly used
compression and allows for early mobilization, reducing the levetiracetam doses are 10–20 mg/kg twice daily.
rate of pulmonary complications, pressure ulcers, and venous
thromboembolism. VENOUS THROMBOEMBOLISM PROPHYLAXIS
TBI and SCI patients are at high risk of venous
OTHER MANAGEMENT CONSIDERATIONS thromboembolism. Mechanical prophylaxis with intermittent
ELECTROLYTES, GLUCOSE, AND NUTRITION pneumatic compression is started on admission, when available.
Chemical thromboprophylaxis with low-molecular-weight
Due to fluid shifts from injury and osmolar therapy, electrolyte heparin (the preferred agent) can be started within 24–48 hours of
management is vital. Sodium levels are maintained within the injury if the repeated head CT scan demonstrates no progression
range of 135–145 mEq/L unless active hyperosmolar therapy of injury and if probability of intracranial or spinal operation is
is employed. Avoidance of hyponatremia is very important to low.
prevent exacerbation of cerebral edema. Frequent monitoring
of serum sodium levels may be necessary. TBI patients can TREATMENTS TO AVOID
develop diabetes insipidus (DI) or the syndrome of inappropriate
Prophylactic hyperventilation with PaCO2 <30 mm
antidiuretic hormone (SIADH) / cerebral salt-wasting syndrome.
Hg in the first 24 hours of injury is avoided unless clinical
Osmolality is measured frequently when mannitol is used as an
signs of brain herniation exist. In a herniation scenario,
osmotic agent.
hyperventilation with an ETCO2 target of 30–35 mm Hg may
Both hyperglycemia and hypoglycemia have detrimental
be used as a temporary bridge to definitive treatment. Neither
effects on outcomes. Serum glucose levels are maintained in the
scheduled hyperosmolar therapy (i.e., not directed to treat an
range of 100–180 mg/dL. Protein and energy deficits are common
ICP increase) nor furosemide are recommended to treat cerebral
during hospitalization following TBI. Nutritional support is
edema. Routine steroid administration is not indicated for the
essential to prevent the development of malnutrition and to
management of either TBI or SCI patients. Steroids may increase
blunt the catabolic effects of TBI. Enteral nutrition is initiated
mortality and are associated with gastrointestinal disorders,
once a patient is hemodynamically stable, ideally within 24–72
hyperglycemia, and infection. However, in selected partial SCI
hours of injury, reaching full supplementation within 7 days of
scenarios, steroid treatment may be recommended by a specialist.
injury. Postpyloric feeding access is preferred if it can be obtained
There are no proven pharmacological agents to reduce the impact
rapidly without delaying initiation of feeding. Consideration for
of SCI.
parenteral support is recommended when enteral nutrition is
Prophylactic or therapeutic hypothermia does not reduce
contraindicated.
secondary injury or improve outcomes. However, fever is
SEIZURE PROPHYLAXIS AND TREATMENT treated promptly with medication and/or external temperature
management. Prophylactic antibiotics are not administered unless
TBI severity is correlated with early (i.e., within 7 days)
there is a penetrating brain injury or contamination of an open
post-traumatic seizures. The highest incidence is following
wound. Antibiotic prophylaxis is not recommended in instances
penetrating injury. Therefore, prophylactic antiseizure
of skull fracture with pneumocephalus or CSF leak. High dose
medication is recommended following severe (GCS score ≤8)
propofol for burst suppression and routine increase of CPP to >
and penetrating TBI. Indications following blunt, moderate
90 mm Hg are not recommended.
TBI include depressed skull fracture, SDH, cortical contusion,
extradural (epidural) hematoma, intracerebral hematoma, and
occurrence of seizures within 24 hours of injury. In contrast,

123
 Surgical principles for young children with TBI differ from those
REASSESSMENT
of older children and adults. Asymptomatic epidural hematomas
in children and depressed fractures in infants may be managed
TRAUMATIC BRAIN INJURY
without surgery. Low-velocity fractures of the parietal skull may
Reassessment is conducted at least hourly, and repeated spontaneously remodel due to brain growth.
imaging occurs at regular intervals to promptly detect Mortality rates for TBI patients older than 74 years are more
adverse changes. The Consensus Revised Imaging and Clinical than two times higher than those younger than 74 years. Older
Examination Protocol and Seattle International Severe Traumatic adults are often injured by falls. Sometimes, an apparently minor
Brain Injury Consensus Conference encourage monitoring of mechanism may result in a clinically significant TBI. Anticoagulant
minor (clinical) and major (imaging) criteria to define whether and antiplatelet therapy complicate management. A CT scan
escalation of medical and/or surgical therapy is indicated. This is obtained more frequently in older adults, particularly when
recommendation is applied in moderate TBI scenarios due to preinjury cognitive impairment complicates clinical assessment.
the possibility of deterioration in the first hours after injury. If Although the prognosis for those over 75 years of age with severe
neuroworsening is detected (see the previous section, Critical TBI is poor, age alone is not a deciding factor in the intensity of
Neuroworsening), a repeat CT scan is promptly considered therapy.
after clinical reevaluation and followed by medical and/or
surgical treatment of the cause (see the aforementioned Stepwise SPINAL INJURY
Management of Neuroworsening).
Traumatic spinal cord and spinal column injury in children
are uncommon, accounting for less than 10% of all spinal cord
SPINAL INJURY
damage in those under 15 years of age. Children <2 years of
Frequent reassessment of a patient with SCI is essential. age are uniquely susceptible to upper spinal injury because
Due to acute cord edema, the functional level of cervical SCI of disproportionately large heads, lax ligaments, horizontal
may move cranially in the first several hours following injury. orientation of the facets, and relatively weak cervical muscles.
Respiratory function may decline, and respiratory failure ensue, Limiting spinal motion can be challenging in young children and
prompting intubation and mechanical ventilatory support. infants. A cervical collar appropriate for a child’s size and anatomy
Hypotension due to any shock can worsen cord injury. Therefore, is necessary. High-speed injuries, such as motor vehicle crashes
hypotension and hypoxia are promptly addressed. If available, and pedestrians struck by vehicles, can cause craniocervical injury
transfer to a neuroscience center is accomplished as soon as (occipital condyle, C1 or C1–C2). The elasticity of the pediatric
feasible. Occasionally, a skeletally unstable spinal column injury spinal ligaments exceeds that of the spinal cord. Thus, spinal
without neurologic deficit can become displaced, with potential alignment may appear normal, and a fracture may be absent on
development of a spinal cord defect. Early detection of new CT. However, the child may still have an SCI without radiographic
neurologic symptoms is important to potentially prevent abnormality (SCIWORA). Even in the absence of a fracture
further neurologic impairment. The ASIA chart is a valuable on CT, SMR is maintained if an abnormal neurologic exam is
tool to track injury progression or clinical instability over time. present. Evaluation by a pediatric spine expert is recommended if
 Figure 7-13 illustrates the ASIA worksheet. available. MRI may be beneficial in this scenario.
In older adults, falls are the most common cause of SCF and
SPECIAL POPULATION CONSIDERATION SCI. The aging spine is more susceptible to injury, even after
seemingly minor trauma. Osteoporosis, arthritis, ankylosing
TRAUMATIC BRAIN INJURY spondylitis, and other conditions associated with age increase
the risk of SCF and SCI. Older adults with significant baseline
Physiology, response to injury, management, and prognosis
kyphosis may not fit in traditional cervical collars and so should
of TBI vary across ages and populations. Some of these unique
be managed with padding in a position of comfort to minimize
populations are covered in greater detail in accompanying
spinal motion rather than hyperextended to lay flat or conform to
chapters (see Chapter 11, Trauma in the Pediatric Patient).
a cervical collar.
Assessment may be challenging for the very young and, on
occasion, for older adult trauma patients. Different assessment
methods may be beneficial (e.g., pediatric GCS in children; PENETRATING INJURIES
consideration of preexisting cognitive, hearing, or visual
impairment in older adults). Physiological parameters for TRAUMATIC BRAIN INJURY
children vary by age. Heart rate, blood pressure, and ventilation The majority of penetrating head injuries are caused
targets are adjusted to be appropriate for age and size. For older by firearms. Penetrating injuries are assessed and initially
adults, preinjury medical conditions and medications may managed like other major trauma. Exam includes neurologic
influence target blood pressure, heart rate, and oxygen saturation. assessment using GCS, pupillary and brainstem reflexes, motor
From birth to 4 years of age, assaults are the leading cause of exam, and inspection of wounds. Wounds are cleansed and
TBI. Therefore, in the absence of a history of a high-velocity injury covered after examination and documentation. CT imaging is
such as a motor vehicle crash or fall from height, an inflicted indicated whenever there is a suspected penetrating injury, even
injury is a potential etiology in a young child with a severe TBI. if the wound is considered minor and the neurologic exam is
normal.  Figure 7-23 illustrates a CT scan image from a gunshot.

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 COURSE MANUAL | Chapter 7 | Disability: Neurological Assessment and Management

Limited duration broad-spectrum antibiotic prophylaxis has

 Figure 7-23: Penetrating Brain Injury Caused by a
been recommended based on data from military conflicts, but
Gunshot. A. Projectile track with scattered bone fragments
and thin rim of left subdural hematoma. B. Projectile
there remains variation in practice. High-velocity firearm injuries
lodged in the posterior parietal lobe. cause direct brain damage as the projectile passes through tissue
but also create a pressure wave, which can extend damage beyond
A. the direct path of the projectile. Wounds that pass through both
hemispheres at the level of the ventricle or basal ganglia, damage
the brainstem, or enter the posterior fossa have a very poor
prognosis.
Surgical management is limited to patients with survivable
injuries based on CT imaging and preserved brainstem reflexes.
Management includes debridement of damaged brain tissue,
evacuation of hematomas, repair of the dura, and closure of
wounds. Damage to large cerebral vessels can result in significant
blood loss and delayed pseudoaneurysms. CT angiography or
catheter angiography is considered in patients with suspected
vascular injury.

PENETRATING SPINAL INJURY

Penetrating spinal injuries occur less frequently than injuries
caused by the two leading causes of spinal injury: motor vehicle
crashes and falls. As the firearm injury public health crisis has
grown, gunshot wounds are now the third-most common cause of
spinal injury. Most penetrating SCIs result in a complete (ASIA A)
SCI. These injuries may be associated with significant arterial
and other life-threatening injuries. ATLS principles dictate
overall management. A neurological exam and CT imaging are
indicated. Many penetrating inuries are successfully managed
B.
without surgical exploration. MRI may not be possible due to
retained ferrous metallic fragments. Prophylactic antibiotic
administration, if performed, is of short duration except for
extensively contaminated wounds. Supporting evidence of
infection prevention is weak.
Surgical exploration is sometimes performed in the presence of
an incomplete SCI (ASIA B or better) with progressive neurologic
decline or migration of the projectile fragment. Spinal column
instability is rarely present following civilian penetrating spinal
injuries. As with other ballistic injury, the blast effect can cause
significant damage, including spinal cord dysfunction, without
passing directly through the spinal canal.

PRACTICE ENVIRONMENT CONSIDERATIONS

Neurotrauma is a critical public health issue in many countries.
Inadequate emergency healthcare provision has been identified
as an essential factor related to outcomes in TBI or SCI. Because
access to CT scans is often lacking, alternative systems like neuro-
ultrasound or near-infrared spectroscopy detectors of intracranial
bleeding have been proposed but remain of unproven utility.
Appropriate early resuscitation, according to ATLS principles, is
the best option for TBI and SCI management, followed by prompt
transfer to a neuroscience center if available.

125
 FIELD HOSPITALS OR REMOTE LOCATIONS KEY LEARNING POINTS
A guiding principle of TBI management is prevention of • Management of TBI and SCI is time-critical. Rapid
secondary insults by timely resuscitation following xABCDE. interventions increase the probability of survival,
After initial assessment, the patient is transferred to a medical prevent secondary damage, and reduce long-term
facility where definitive care can be provided. Once the benefit of disabilities.
transfer has been determined, transport is not delayed to perform • Hypoxia and hypotension have deleterious effects
diagnostic radiological investigations, even head CT scan. on TBI and SCI and are promptly managed.
As mentioned earlier, outcome is improved through A combination of hypotension and hypoxia
maintenance of adequate CBF and oxygenation. Therefore, doubles the risk of death following TBI.
oxygenation is optimized. Intubation and mechanical ventilation
are instituted if indicated. Shock is managed, and cardiovascular • CT scan is the optimal imaging investigation for
status is optimized before transfer. If indicated, inotropic support both TBI and SCI.
is instituted before transfer. Appropriate communication with • Identification of acute hematomas and rapid
the receiving institution and preparation of all documents are referral for possible neurosurgical intervention are
performed prior to transfer. vital to provide the optimal potential for recovery.
Emergency burr-hole evacuation of an extra-axial intracranial
hematoma (extradural or subdural) may be performed in a • TBI and SCI are dynamic and may worsen over time.
remote location where lifesaving neurosurgical intervention is Reassessment at regular intervals is essential.
not available within a reasonable timeframe. This procedure is • Timely recognition and management of critical
considered in scenarios of GCS < 8 and imaging evidence of an neuroworsening are vital for achieving optimal
extra-axial hematoma causing midline shift with unequal pupils. outcomes.
Performance of a lifesaving burr-hole procedure is preferably
discussed with a neurosurgeon prior to proceeding. The clinician
performing the operation must be well trained and have the
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43. Peterson AB, Thomas KE, Zhou H. Surveillance Report of
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53. Baratloo A, Ahmadzadeh K, Forouzanfar MM, et al. NEXUS
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2017;14:e1002313.

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 COURSE MANUAL | Chapter 8 | Exposure and Environmental Threats in the Primary Survey

Exposure and Environmental

Threats in the Primary Survey

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe how exposure and examination of the entire body in a trauma patient, using
trauma-informed/humanistic care principles, assists in preventing missed injuries
2. List stabilization strategies for local and systemic environmental injuries

129
 8
 Table 8-1: Systemic and Local Cold versus Heat
Injuries. Clinicians caring for trauma patients should be
aware of the treatment of both local and systemic cold
and heat injuries. Systemic hypothermia is a common
problem in trauma patients with hemorrhagic shock.
Although systemic hyperthermia is not as common, some
emerging literature has linked heat stress syndromes to
occupational traumatic injuries.

Cold Injury Heat Injury

Exposure and Environmental
Local Frostbite Burn
Threats in the Primary Survey • Rewarm in water bath • Cool the burn
• Evaluate for possible • Initiate fluid resuscitation
thrombolytic therapy
CHAPTER STATEMENT
Systemic Hypothermia Hyperthermia
The “E” component of the primary survey includes the • Use tiered approach to • Apply external cooling
systemic warming
complete inspection of the patient for any previously unidentified • Use conductive cooling
(if available)
life-threatening injuries and the prevention/correction of
environmental emergencies like hypo- and hyperthermia.

INTRODUCTION/BACKGROUND Systemic hypothermia due to cold exposure can also be present

in the absence of trauma. This condition must be identified and
The “E” component of the primary survey has two major
immediately addressed, as hypothermia can cause dysrhythmias
goals: (1) to fully expose and inspect the patient for externally
and even cardiac arrest. Systemic hypothermia can be staged as I
visible injuries; and (2) to identify and begin treatment for
through IV, based on core body temperature.  Table 8-2 outlines
any life-threatening environmental emergencies. Both systemic
the stages of hypothermia, their associated symptoms, and a tiered
hypo- and hyperthermia should be identified and addressed
approach to correction.
rapidly. In particular, patients with traumatic injuries who
Hyperthermia is defined as a core body temperature > 37.5°C
experience hypothermia have significantly higher mortality risk.
caused by an extrinsic source (as opposed to fever, which is due
Therefore, the prevention and correction of hypothermia should
to intrinsic cytokine activation). Body temperature > 40.5°C
be a top priority during trauma resuscitation.
is considered severe hyperthermia. Evaporation is the main
mechanism of body heat loss in a hot environment, but this can
PATHOPHYSIOLOGY become insufficient if relative humidity increases. Clinically,
heatstroke causes central nervous system dysfunction and
Environmental threats are best understood through a 2×2 grid
multiorgan failure and carries a mortality rate of up to 63%.
that relates type of thermal exposure (hot versus cold) and the
Rapid and effective cooling is the main determinant of a favorable
affected body part (local versus systemic). Hence, a systemic cold
outcome and should be initiated immediately upon diagnosis of
injury is termed hypothermia, and a systemic heat injury is termed
hyperthermia. This will be discussed in more detail in Chapter 9,
hyperthermia. Frostbite is a local cold injury, and an acute burn is
Thermal Injuries.
a local hot injury ( Table 8-1).
Local exposure to a source of heat or cold leads to localized
Hypothermia is defined as a core temperature < 35°C.
skin/soft-tissue injury. The extent of injury primarily depends on
Patients with traumatic injuries are at increased risk for
the heat/cold source and the duration of contact. A major burn
hypothermia from exposure in the field, administration of IV
injury is typically defined as a burn affecting ≥ 20% of a patient’s
fluids, hemorrhage, and in-hospital exposure. The incidence
total body surface area (TBSA). Above that 20% threshold, the
of hypothermia in trauma patients during resuscitation has been
injury leads to a proportionally larger systemic inflammatory
reported to be as high as 66%. Hypothermia in trauma patients is
response. To prevent burn shock, fluid resuscitation should begin
an independent predictor of mortality.
as soon as possible; Lactated Ringers is the fluid of choice. Fluid
Along with coagulopathy and acidosis, hypothermia is part
resuscitation begins in the primary survey before TBSA is formally
of the trauma “lethal triad.” Coagulation dysfunction is seen at
determined and follows an age-based algorithm ( Table 8-3).
body temperatures < 35°C due to inhibition of the coagulation
cascade, reduced platelet aggregation, and morphological changes
to platelets. This makes hemorrhage control in a trauma patient
significantly more challenging.

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 COURSE MANUAL | Chapter 8 | Exposure and Environmental Threats in the Primary Survey

 Table 8-2: Stages of Hypothermia and Tiered Correction Strategies. Hypothermia, no matter the stage, can lead
to coagulation dysfunction and decreased platelet aggregation, which can in turn complicate the management of
hemorrhage. Worsening hypothermia can lead to dysrhythmias and cardiac arrest.

Stage Core Temperature Symptoms Interventions

I 32° — 35°C Conscious, shivering Warm environment and clothing,

active movement, warm oral fluids

II 28° — < 32°C Impaired consciousness, Cardiac monitoring, cautious

no shivering movements to avoid arrhythmias,
full-body insulation, active external
and minimally invasive rewarming
techniques (chemical, electrical, or
forced-air heating packs or blankets,
warm IV fluids)

III 24° — < 28°C Unconscious, vital signs All the above, plus: intubation,
are present rewarming with extracorporeal
support if available

IV < 24°C No vital signs All of the above plus: CPR and up
to three doses of epinephrine and
defibrillation, can continue if patient
responds. Continue active external or
internal rewarming if extracorporeal
support not available  

Adapted with permission of Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia [published correction appears in N Engl J Med. 2013 Jan
24;368(4):394]. N Engl J Med. 2012;367(20):1930-1938.

 Table 8-3: Initial Fluid Rates For Resuscitation Of Major ASSESSMENT

Burn Injury. Resuscitation of major burns should begin
even before final calculation of %TBSA. If at first glance the The goal of “Exposure” in the Primary Survey of a trauma
size of the burn appears to be more than 20% TBSA, age- patient is to examine the entire body and identify any visible
related resuscitation should begin and then the fluid rate external injuries that may affect the treatment plan. Penetrating
adjusted as additional calculations are performed.
wounds, bleeding from orifices such as the rectum or vagina, or
evidence of soft-tissue injuries may be missed without a whole-
Initial Fluid Rate for Burn ≥20% TBSA body examination.

≤ 5 years 125 mL of LR/hour EXPOSURE STEPS

1. Remove all clothing, jewelry, and prehospital dressings
6–12 years 250 mL of LR/hour
(use shears as needed)
≥ 13 years 500 mL of LR/hour
2. Identify external signs of injury (abrasions, contusions,
bleeding, wounds, foreign bodies, burn, frostbite, etc.)
3. In patients at risk for spinal injury, log roll the patient while
maintaining C-spine precautions to examine posterior
Frostbite is a severe and localized cold-induced injury that aspect of the patient for signs of injury
causes direct cell death as well as reperfusion-related injury. Early 4. To respect patient privacy and reduce hypothermia, cover
identification and evaluation are important for possible limb- the patient as much as possible during the examination and
saving interventions, which will be discussed in more depth in completely after the exam
Chapter 9, Thermal Injuries.

131
 The exposure and subsequent steps to cover the patient injuries, such as thermal burns and frostbite, should be treated
are a great opportunity to provide the best humanistic care according to established protocols (see Chapter 9, Thermal
possible to the patient. The clinician should acknowledge any Injuries). Hyperthermia is not usually seen in trauma patients,
visible injury and its potential impact and should communicate although some literature suggests a link between heat stress
with the patient and family that they seek a collaborative strategy syndromes and occupational traumatic injuries. Hypothermia
based on mutual respect to ensure optimal care. is more commonly seen in trauma patients; if present, it should
be aggressively treated. Any stage of hypothermia can contribute
INTERVENTIONS/TREATMENTS to coagulation dysfunction and complicate resuscitation.
Hypothermia is an independent predictor of mortality in trauma
The general strategy for initial stabilization of each patients.
environmental injury is summarized in  Table 8-1. A tiered
approach is necessary to aggressively correct hypothermia
( Table 8-2). Severe hyperthermia (temperature > 40.5°C) should KEY LEARNING POINTS
be addressed with rapid external cooling. Cold water immersion
is the most effective cooling technique but is not always practical • The “E” component of the primary survey has two
or available. Application of ice packs at vascular junctional points major goals:
(neck, axilla, groin) and evaporative cooling (through continuous 1) Full-body exposure to ensure the identification of
fanning) are the next best options. If available, modern conductive external signs of injury
devices such as intravascular catheters are very effective in
facilitating rapid cooling. 2) Identification and immediate treatment of
life-threatening environmental injury
Patients with an apparent large burn injury (≥ 20% TBSA)
should be started immediately on warm fluid resuscitation • Humanistic, Trauma-Informed Care mandates that
before doing a formal calculation of injury TBSA and patients’ dignity and privacy be protected during
obtaining the patient’s weight ( Table 8-3). Although immediate the examination. If possible, parts of the body that
resuscitation of isolated burn injuries is critical, clinicians must are not being examined should be covered. Once
also realize that, as in other clinical situations, crystalloid boluses the examination is completed, the patient should
quickly exit the intravascular space and promote interstitial be completely covered and care taken to prevent
hypothermia.
edema. The initial resuscitation should begin at the age-specific
rates noted in  Table 8-3; boluses should be avoided unless the • Patients with traumatic injuries are at increased risk
patient is hypotensive. For major burns, the benefit of cooling the of hypothermia from exposure in the prehospital
burned areas may be outweighed by the risk of incurring systemic environment, hemorrhage, administration of IV
hypothermia, and therefore surface cooling should be done with fluids, and inhospital exposure.
caution. Patients who present with frostbite should undergo
• For major burns (≥ 20% TBSA), initiate fluid
immediate rewarming in a 40°C circulating water bath and be
resuscitation using Lactated Ringer’s solution based
evaluated for possible thrombolytic therapy (in discussion with on age cutoffs.
regional referral centers) to maximize digit and limb salvage.
Resuscitating patients with IV crystalloid can have several • For frostbite injury, rewarm the affected extremity
disadvantages that clinicians should consider. In patients with by immersion and evaluate for possible thrombolytic
significant hemorrhage, crystalloid infusion has been associated therapy.
with coagulation dysfunction and may contribute to existing
hypothermia as well as other complications. There are certain
settings in which crystalloid infusion is appropriate, such as in
patients with isolated neurogenic shock or isolated major burn
injuries. In these circumstances, clinicians should still administer
REFERENCES
these fluids warmed and should monitor patient core temperature
closely for signs of hypothermia. 1. Gregory JS, Flancbaum L, Townsend MC, Cloutier
CT, Jonasson O. Incidence and timing of hypothermia
in trauma patients undergoing operations. J Trauma.
CHAPTER SUMMARY
1991;31(6):795–798.
The “E” in the Primary Survey algorithm includes both 2. Martin RS, Kilgo PD, Miller PR, Hoth JJ, Meredith
exposure of the patient to perform a complete examination and JW, Chang MC. Injury-associated hypothermia: An
identification of any visible injuries. As much as possible during analysis of the 2004 National Trauma Data Bank. Shock.
and at the completion of the exam, the patient should be covered, 2005;24(2):114–118.
both to maintain privacy and to assist in preventing hypothermia, 3. Van Veelen MJ, Brodmann Maeder M. Hypothermia in
a common condition seen in trauma patients. Local heat and cold trauma. Int J Environ Res Public Health. 2021;18(16):8719.

132 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 8 | Exposure and Environmental Threats in the Primary Survey

4. Lier H, Krep H, Schroeder S, Stuber F. Preconditions of

hemostasis in trauma: A review. The influence of acidosis,
hypocalcemia, anemia, and hypothermia on functional
hemostasis in trauma. J Trauma. 2008;65(4):951–960.
5. Brown DJ, Brugger H, Boyd J, Paal P. Accidental
hypothermia. N Engl J Med. 2012;367(20):1930–1938.
6. Spector JT, Masuda YJ, Wolff NH, Calkins M, Seixas N.
Heat exposure and occupational injuries: Review of the
literature and implications. Curr Environ Health Rep.
2019;6(4):286-296. doi: 10.1007/s40572-019-00250-8.
PMID: 31520291; PMCID: PMC6923532.
7. Epstein Y, Yanovich R. Heatstroke. N Engl J Med.
2019;380(25):2449–2459.
8. Misset B, De Jonghe B, Bastuji-Garin S, et al. Mortality of
patients with heatstroke admitted to intensive care units
during the 2003 heat wave in France: A national multiple-
center risk-factor study. Crit Care Med. 2006;34(4):1087–
1092.

133
134 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 9 |Thermal Injuries

Thermal Injuries

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, you will be able to do the following:

1. Explain how the pathophysiology of burn 5. Recognize and manage life-threatening systemic
injury guides patient management hyperthermia and hypothermia
2. Estimate the size and depth of a burn injury 6. Recognize and initiate treatment for localized
and apply to initial treatment cold injury (frostbite)
3. Develop a plan for initial management that 7. Identify and manage common pitfalls in burn
includes resuscitation of severe burns and environmental injury management
4. Describe common mechanisms of burn injuries
and explain the impact of specific mechanisms
on patient management

135
 BURN CARE PRIORITIES WITHIN THE

9 PRIMARY SURVEY

AIRWAY
Inhalation injury is present in 2%–14% of patients who are
admitted to burn centers and may occur without cutaneous injury.
There are three major categories of inhalation injury: supraglottic,
subglottic, and systemic poisoning (see Breathing).
Early evaluation to determine the need for endotracheal
Thermal Injuries intubation is essential. A history of exposure to smoke or
chemical vapors in an enclosed space should increase concern
for airway injury. Patients presenting with signs of respiratory
distress should be intubated. Factors that increase the risk for
CHAPTER STATEMENT upper airway obstruction include larger burn size and depth, deep
burns to the head and face, and burns inside the mouth ( Figure
Like other types of trauma, thermal injuries are evaluated 9-1). Carboxyhemoglobin level (COHb) should be measured as
and treated within the ATLS® framework. Accurate assessment an adjunct; a level > 10% often indicates significant exposure.
of burn or cold injury extent and depth, along with appropriate Children with burn injuries are at higher risk for airway obstruction
resuscitation, can prevent both short- and long-term complications. than adults due to their smaller airways. Circumferential burns
Criteria for consultation with specialized burn centers are well to the neck and chest may also compromise the airway and gas
established and should be followed. exchange.
The clinical manifestations of subglottic inhalation injury may
INTRODUCTION be subtle and progressively appear within the first 12–24 hours.
When in doubt, examine the patient’s oropharynx for signs of
Thermal injuries are a major cause of morbidity and mortality. inflammation, mucosal injury, soot in the pharynx, and edema,
However, adherence to the basic principles of ATLS and the taking care not to injure the area further.
timely application of simple emergency measures can minimize The following situations should prompt immediate intubation:
complications. The impact of burn injury is directly linked to the • Signs of airway obstruction (hoarseness, stridor, accessory
extent of the inflammatory response, which develops gradually respiratory muscle use, sternal retraction)
over the hours immediately following the injury. Without
initiating proper treatment, burn shock develops, leading to organ • Signs of respiratory compromise (inability to clear secretions,
failure and death. Therefore, stabilization of severe burns requires respiratory fatigue, poor oxygenation or ventilation)
prompt treatment with frequent reassessments and adjustments. • Decreased level of consciousness where airway protective
reflexes are impaired
STOP THE BURNING PROCESS Other situations where airway intervention may be indicated
include the following:
Similar to mitigating external hemorrhage with Stop the
• Very large total body surface area (TBSA) flame burns
Bleed® strategies, skin burns need to be immediately dealt
(typically > 40%–50%)
with by stopping the injury source. In the field, this often starts
with extinguishing a fire and removing people from the heat • Extensive and deep facial burns
source causing flame burns or scalds. For adherent materials • Burns inside the mouth
like tar, ensure that the burns have been cooled to the touch.
Decontamination from chemical agent exposure is an early It is important to place an appropriately sized endotracheal
priority, with care to protect first responders from contamination. tube (ETT) for age and sex. The first intubation attempt should
Brush any dry chemical powders from the wound and irrigate be the definitive one, performed by the most experienced
with copious warm irrigation (or use a decontamination shower). clinician available. Placing a tube that is too small will make
Cool burn wounds with room-temperature running tap water ventilation, clearing of secretions, and bronchoscopy difficult
for 20 minutes. Cooling can be effective if initiated within 3 or impossible. Having to exchange an ETT in a patient with
hours following injury. Care must be taken to avoid hypothermia developing edema is dangerous. Standard adult bronchoscopes
(especially in larger burns). Do not use ice. Once the burning will fit inside a 7-mm interior-diameter ETT, and most pediatric
process has been stopped, quickly cover the patient with warm, bronchoscopes will fit in a 4.5-mm interior-diameter ETT.
clean, dry linens to prevent hypothermia. Realize that airway obstruction in a patient with a burn injury
may not be present immediately; frequent reevaluation of the
patient for changes in airway status is crucial.

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 COURSE MANUAL | Chapter 9 |Thermal Injuries

An ABG assay should be obtained as a baseline for evaluating

 Figure 9-1: Airway Compromise Associated with
pulmonary status if the patient has been involved in a closed-space
Acute Thermal Burn. Patients with acute thermal
burns to the face or mouth may require a secure
fire. COHb levels should be obtained, and 100% oxygen should be
airway, either due to direct injury, inhalation injury, or administered. If COHb level is not known, presumptive treatment
progressive edema. Any patient with significant oral/ with 100% oxygen for 4 to 6 hours is reasonable. In a patient with
facial burns or signs/symptoms of inhalation injury CO poisoning, a standard pulse oximeter may read 98%–100%
should be considered for endotracheal intubation. All saturation and not reflect true oxygen saturation, which must be
burn patients should be monitored closely, as edema obtained from the ABG. Special co-oximetry equipment may be
may not be immediately apparent and may only used, but this is not widely available.
manifest as resuscitation continues. Cyanide inhalation from the products of combustion is
possible with burns occurring in confined spaces, in which case
the clinician should consult with a burn or poison control center.
Signs of potential cyanide toxicity are persistent hypotension and
profound metabolic acidosis that are unexplained by other causes.
In the prehospital and emergency department setting, candidates
for presumptive treatment of cyanide toxicity have the following
combination: CPR in the field, loss of consciousness, GCS < 10,
lactate > 10, and COHb > 10. Antidote treatment consists of the
administration of hydroxycobalamin. Otherwise, the definitive
care center can selectively administer hydroxycobalamin to
patients who exhibit symptoms of cyanide toxicity during the
resuscitation phase.
There is no role for hyperbaric oxygen therapy in the primary
resuscitation of a patient with critical burn injury.

BREATHING CIRCULATION
Breathing concerns arise from three general causes: hypoxia, Acute burns do not cause life-threatening hemorrhage.
carbon monoxide (CO) poisoning, and smoke inhalation injury. Instead, fluid loss is progressive, and proactive burn resuscitation
As a baseline for evaluating the pulmonary status of a patient with should be initiated immediately for patients with large burn
smoke inhalation injury, clinicians should obtain a chest x-ray injuries. If peripheral IV insertion is not rapidly successful,
and arterial blood gas (ABG) determination. These values may consider intraosseous access to start resuscitation. Isotonic fluid
deteriorate over time; normal values on admission do not exclude resuscitation should be administered in the prehospital setting
inhalation injury. Smoke inhalation can cause airway compromise and continued in the primary survey, based on the patient’s age,
from either chemical or particulate injury. Smoke inhalation as follows:
injury is treated with supportive care. • ≤ 5 years old: 125 mL lactated Ringer’s (LR) per hour
Hypoxia may be related to inhalation injury, inadequate • 6–12 years old: 250 mL LR per hour
ventilation due to circumferential chest burns, or thoracic trauma
unrelated to the thermal injury. Administer 100% oxygen to all • ≥ 13 years old: 500 mL LR per hour
burn patients during the primary survey. If fluids were not started in the prehospital phase,
Always assume CO exposure in patients who were burned in immediately initiate the age-based fluid rate shown above
enclosed areas. The diagnosis of CO poisoning is made primarily while performing the primary survey. Delay only promotes
from a history of exposure and direct measurement of COHb. burn shock. On the other hand, bolus fluid administration is
Patients with COHb levels <20% may have no physical symptoms. discouraged unless the patient is hypotensive or has other signs
Higher COHb levels can result in the following: of severe hypovolemia. Bolus fluids promote “third spacing”
• Headache and nausea (20%–30%) rather than simply increasing intravascular volume. Peripheral
pulses should be evaluated in all extremities during the primary
• Confusion (30%–40%)
survey.
• Coma (40%–60%)
• Death (> 60%) DISABILITY
Hemoglobin has more than 200 times greater affinity for CO As with all trauma patients, a neurologic assessment of pupils,
than for oxygen. Thus, CO displaces oxygen from the hemoglobin GCS, and ability to move all extremities should be obtained.
molecule and shifts the oxyhemoglobin dissociation curve to the Mental status changes can aid in the early diagnosis of hypoxemia
left. The elimination half-life of CO is approximately 4 hours or shock.
when the patient is breathing room air but can be reduced to 40-
50 minutes by breathing 100% oxygen.

137
 EXPOSURE  Figure 9-2: “Rule of Nines” for Burn Extent Calculation
in Adult and Pediatric Patients. The “Rule of Nines” is
A common life-threatening finding during the primary exam is
one method to estimate the extent of burn in both adult
hypothermia. Limb-threatening cold injury should also be rapidly and pediatric patients; it is based on the relative Total Body
assessed. Please refer to Chapter 8, Exposure and Environmental Surface Area (TBSA) of different anatomic areas of the body.
Threats in the Primary Survey, for additional reading on Note that the head on the child accounts for a relatively
environmental threats. larger TBSA than in the adult.

BURN PRIORITIES IN THE SECONDARY

SURVEY
The secondary survey consists of gathering additional history,
performing a head-to-toe examination, and, for burn patients,
calculating the TBSA burn size. Adjusted fluids are then calculated
based on TBSA.

HISTORY
At minimum, the AMPLE history should be obtained, as in all
patients. For patients with burns, particular attention should be
paid to the mechanism of burn, duration of contact, circumstances
of burn, and time of injury. Patients can sustain associated injuries
while attempting to escape a fire, and explosions can result
in factures and internal injuries (e.g., central nervous system,
myocardial, pulmonary, and abdominal injuries). Be aware that
some burn injuries may be intentional. Individuals may attempt
suicide through self-immolation, and both children and vulnerable
adults may experience abuse. Match the patient history to the
burn pattern; if the account of the injury is suspicious, consider
the possibility of an intentional injury.

BODY SURFACE AREA AND DEPTH

The rule of nines is a practical guide for determining the
extent of a burn using calculations based on areas of partial- and
full-thickness burns ( Figure 9-2). The adult body configuration
is divided into anatomic regions that represent multiples of 9%.
Body surface area distribution differs considerably for children,
because a young child’s head represents a larger proportion of
their surface area and their lower extremities represent a smaller
proportion than an adult’s. The patient’s hand surface (including
the palm and fingers held together) represents approximately
 Box 9-1: Tips to Prevent Over- or Underestimating
1% of the patient’s body surface. Other methods such as Lund-
Burn Size.
Browder charts or apps with body surface area charts are also
acceptable.
Documenting the location of the burn is best done using a Tips to Prevent Over- or Underestimating Burn
patient diagram indicating location and depth for each affected Size
area. Soot and unruptured (or partially ruptured) blisters can • Do not include superficial (first-degee) burns in size estimation.
obscure a view of the wound base. In individuals with very fair
or darker skin tones, it may be difficult to assess injury depth on • Use the rule of nines, recognizing that children have
visual inspection alone. To improve the ability to assess the size proportionately larger heads than adults.
and depth of burn injury, the clinician should interact with the • For irregular or oddly sized burns,
patient’s skin and, if necessary, wipe away some blisters to get use the patient’s palm and fingers
an adequate assessment of size and depth. to approximate 1% body surface area (BSA).
The depth of burn is also important in evaluating the severity
• For larger burns it may be easier to count the unburned areas
of a burn and planning for wound care. Tips to avoid errors in and subtract from 100.
TBSA estimates are listed in  Box 9-1.
• Remember to log roll patient to
assess their posterior side.

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 COURSE MANUAL | Chapter 9 |Thermal Injuries

Superficial ( first-degree) burns (e.g., sunburn) are characterized  Table 9-1: Age-Based Adjusted Hourly Fluid Rates
by erythema and pain, and they do not blister. These burns are not and Urine Output Goals for Thermal/Chemical and
life-threatening and do not result in a significant inflammatory Electrical Burns. Once the extent of the burn is calculated
response. Resuscitation is not required, and first-degree burned (%TBSA), adjusted fluid rates can be calculated using that
areas should not be included in TBSA calculation. ( Figure 9-3B). information and the patient’s age and their weight in
Partial-thickness (second-degree) burns ( Figure 9-3C) are kilograms. Electrical injury calculations apply to all ages.
Fluids can then be further adjusted to meet age-based
characterized as either superficial partial-thickness or deep
urine output goals.
partial-thickness. Superficial partial-thickness burns are moist,
painful, and homogenously pink; they blanch to touch and may
have intact blisters. Deep partial-thickness burns are drier, less Category Age and Adjusted Hourly Urine
painful, red or mottled in appearance, and do not blanch to touch. of Burn Weight Fluid Rate Output
Full-thickness (third-degree) burns usually appear leathery (ml/hr) Goal
( Figure 9-3D). The skin may appear deep red, brown, or waxy Thermal or Adults 2 ml LR x kg x % TBSA 0.5 ml/kg/hr
white. The surface is generally dry, does not blanch, and is painless Chemical and Older
to light touch or pinprick. Burn Children 16 (30–50 ml/
≥13 years hr)
old
CALCULATE THE ADJUSTED FLUID RATE
In contrast to resuscitation for other types of trauma, in which Children 3 ml LR x kg x % TBSA 1 ml/kg/hr
<13 years
shock is typically due to blood loss, burn resuscitation is required
old 16
to replace the ongoing, progressive losses from capillary leak
proportional to the burn TBSA. Clinicians should provide burn
resuscitation fluids for partial- and full-thickness burns ≥20% Infants 3 ml LR x kg x % TBSA 1 ml/kg/hr
TBSA based on the chart in  Table 9-1. and
young 16
Adjusted fluids should be administered as warmed isotonic
children ≤
crystalloid, preferably LR solution. Insert an indwelling urinary 30 kg Plus D5LR at
catheter in all patients receiving formal burn resuscitation. Fluids maintenance rate
should be adjusted on an hourly basis to maintain a goal urine
output of 30–50 mL/hr in adults (generally equivalent to 0.5 mL/ Electrical All ages 4 ml LR x kg x % TBSA 1–1.5 ml/
kg/hr). For pediatric patients (age < 14 years), the goal is 1 mL/kg/ Injury kg/hr until
hr. For patients with urine output below the target rate, the hourly 16 urine is
fluid rate for burn resuscitation should be increased by 10%–30%. clear of
Children <13 years pigment
When patients are producing urine output above goal, the hourly
old require D5LR at
rate should be reduced by 10%–30%. Beware that osmotic diuresis
maintenance rate
(e.g., glycosuria, alcohol, or use of mannitol) lowers the utility of
urine output as a marker of effective perfusion.

 Figure 9-3: Determining Burn Depth. A. Healthy Skin B. Superficial/First degree

C. Partial thickness/Second degree D. Full thickness/Third degree. The figures illustrate the depth of burn.

A. B. C. D.

139
 EXAMPLE OF ADJUSTED FLUID CALCULATION • Pain greater than expected and out of proportion to the
stimulus or injury
A 100 kg man with 80% TBSA burns has an estimated need for
2 × 80 × 100 = 16,000 mL in 24 hours of crystalloid resuscitation. • Pain on passive stretch of the affected muscle
The total fluid volume estimate should be divided by 16 to obtain • Tense swelling of the affected compartment
the adjusted fluid rate. Though he should have received 500 ml/
hour in the prehospital phase (before injury TBSA could be • Paresthesias or altered sensation distal to the affected
accurately estimated), the fluid rate should be increased to 1000 compartment
mL/hr during the secondary survey. In subsequent hours, the • Loss of pulses (a late finding)
fluid rate should be decreased as able, based on his urine output
Once the pulse is gone, it may be too late to save the muscle,
response. Traditional formulas have caused some clinicians to
so do not wait for loss of pulses to act. If compartment syndrome
adhere too rigidly to administering the first half of the total fluid
is suspected in a limb with eschar, escharotomy is indicated to
volume estimate in the first 8 hours and the second half in the
release the burned skin ( Figure 9-4). This procedure should be
following 16 hours. It is important to emphasize that traditional
done in consultation with a burn center.
formulas are primarily useful to calculate adjusted fluid rates once
Compartment syndromes may also occur with circumferential
burn TBSA is known.
chest and abdominal burns and be diagnosed by increased peak
One consequence of fluid resuscitation is the development of
inspiratory and abdominal pressure measurements. Chest and
edema, which takes time to develop. In anticipation of this, longer
abdominal escharotomies, performed along the anterior axillary
IV catheters should be used if possible, and endotracheal tubes
lines with a cross-incision at the junction of the thorax and
should be checked frequently to ensure no change in position.
abdomen, usually relieve the problem. For patients with high-
The key principle is that fluid resuscitation must be adjusted
voltage electrical injury, compartment syndrome may develop
based on the patient response. The calculation does not prescribe
within the muscle fascia compartment. In such cases, muscle
fluid rate for the hours subsequent to the initial assessment. The
compartment fasciotomy is necessary.
clinician should base the reduction in IV fluid rate on urine output
and titrate to a lower rate if urine output is adequate.
During the first 24–48 hours of burn resuscitation, fluid  Figure 9-4: Extremity Escharotomy. In patients with
circumferential extremity full-thickness burns with eschar,
boluses should generally be avoided unless the patient is
an escharotomy can be performed to treat a suspected
hypotensive. Hypotension indicates that the patient is in shock compartment syndrome. Insicions are usually made on
and that resuscitation has been inadequate. In such a case, a bolus the medial and lateral aspects of the limb, crossing joints
is appropriate and the hourly fluid rate should be increased. Low if necessary, to release the eschar. Similar techniques can
urine output by itself is best treated with gradual titration of the be employed for circumferential wounds with eschar in the
fluid rate. thorax, abdomen, and neck.
Very small children (<30 kg) should receive LR containing 5%
dextrose at maintenance rate in addition to the burn resuscitation
fluid. This fluid is not titrated and is meant to ensure a minimum
maintenance and prevent hypoglycemia. Remove the dextrose
component in case of hyperglycemia, and continue to monitor
glucose levels.
Clinicians should take care to avoid under- or over-
resuscitation of burn patients. Fluids should be titrated to the
patient’s physiologic response, adjusting the fluid rate up or down
based on urine output. Boluses should be avoided unless the
patient is hypotensive. Clinicians should also recognize factors
that affect the volume of resuscitation and urine output, such as
inhalation injury, renal insufficiency, diuretics, and alcohol.

PERIPHERAL CIRCULATION IN
CIRCUMFERENTIAL EXTREMITY BURNS
To maintain peripheral circulation in patients with
circumferential extremity burns, the clinician should remove PAIN AND ANXIETY MANAGEMENT
all jewelry or constricting clothing material, elevate limbs, and
Severely burned patients may be restless and anxious from
frequently assess the neurovascular status of affected limbs.
hypoxemia or hypovolemia rather than pain. Consequently,
Compartment syndrome results from pressure inside an
manage hypoxemia and inadequate fluid resuscitation first. Opioid
inelastic body space increasing to the point that it interferes
analgesics and sedatives should be administered in small, repeated
with perfusion to the structures within that space. In burns, this
doses, preferably by IV. Reassess frequently, and remember that
condition results from the combination of decreased skin elasticity
anxiety can contribute to the patient’s pain experience. Remember
in deep burns and increased edema in soft tissue. Clinicians must
that simply covering the wound will decrease pain.
be aware of the signs and symptoms of compartment syndrome:

140 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 9 |Thermal Injuries

 Figure 9-5: Chemical Burn. Stopping the burning

WOUND CARE
process for chemical burns can involve brushing away dry
For large burns, particularly when patients are intubated and particles along with irrigation of the affected area with
sedated, covering the burns with clean, dry linens is adequate water (as seen in Figure). Irrigation times of 30 minutes or
while planning transfer to a facility that can provide definitive longer are usually necessary. Information about the nature
care. For smaller burns (< 20%), it may be necessary to wipe away of the chemical is helpful if it can be obtained.
gross contamination or soot that interferes with TBSA assessment
using a moist wash cloth. Partial-thickness burns are painful when
air currents pass over the burned surface and are often weeping
and wet, which will stick to linens and dressings.
It is not necessary to break blisters or apply an antiseptic agent,
as this care will be provided at the referral center. For smaller,
shallower open burn wounds (i.e., when the blistered, dead skin
is already off ), applying a nonstick dressing (or even plastic wrap)
keeps the open wound clean and protected during transfer. A fresh
burn is a clean area that must be protected from contamination.
Do not administer systemic antibiotics prophylactically for the
burn wound. Tetanus status should be determined and treated as
indicated. Initial wound care is summarized in  Box 9-2.

CHEMICAL BURNS
Chemical injury can result from exposure to acids, alkalis,
and petroleum products. Chemical burns are influenced by the
duration of contact, concentration of the chemical, and amount
of the agent. Only the duration of contact can be modified by For eye irrigation, a small-caliber cannula can be fixed in
the clinician, and rapid removal of the chemical is essential. If the palpebral sulcus. In the event of hydrofluoric acid burns,
dry powder is present on the skin, brush it away before irrigating topical calcium should be applied immediately. Once initial
with water. Otherwise, immediately flush away the chemical decontamination has been started, clinicians should then
with large amounts of warm water for at least 20 to 30 minutes, investigate more thoroughly the type of exposure. With any
using a shower or hose ( Figure 9-5). Alkali burns require chemical exposure it is important to ascertain the nature of the
longer irrigation. Check the affected skin pH with pH paper to chemical and, if possible, obtain a copy of the relevant material
determine the effectiveness of irrigation. Neutralizing agents safety data sheet. Follow first-aid procedures on the material
offer no advantage over water lavage, because reaction with the safety data sheet and contact a poison control center to address
neutralizing agent can itself produce heat and cause further tissue systemic toxicity threats as necessary.
damage.

 Box 9-2: Initial Wound Care Recommendations.

Initial Wound Care Recommendations

Recommendation Rationale

Use plastic wrap or nonadherent dressings for transfer Dry dressings adhere to small, shallow burns

Use small, repeated IV opioid doses for analgesia Provides more immediate pain control that can be titrated to
response

Prevent superficial wounds Drying can increase pain

from drying

Frequently reassess dressings for tightness and constriction Patients can develop deep-tissue injury from constricting dressings
and ties, especially as edema develops
Remove constricting rings and other jewelry and clothing early

Be alert for deep circumferential burns Remember that edema takes time to develop

Monitor pulses and elevate the affected extremities in these cases Recognize that burned skin with eschar cannot stretch, and patients
can develop deep-tissue injury from constricting burn eschar. Deep
circumferential burns may require escharotomy

141
 ELECTRICAL INJURY surface injury often grossly underestimates the extent of deeper
injuries. As in thermal trauma, this value should be divided by
Electrical injury results from electrical current transmitted
16 to obtain the hourly fluid rate for the secondary survey. If red
through the body. These injuries are divided into high voltage (≥
pigmented urine is present, the urine output goals are 100 mL/hr
1,000 V ) and low voltage (< 1,000 V ). The body can serve as an
in adults and 2 mL/kg/hr in children. Once the urine is clear of
incidental conductor of electrical energy, and the heat generated
red pigmentation, fluids can be titrated down to standard urine
from tissue resistance results in additional thermal injury.
output targets.
Differential heat generation between superficial and deep tissues
allows relatively normal overlying skin to coexist with deep-muscle
necrosis ( Figure 9-6). Severe electrical injuries usually result in BURN PATTERNS IN VULNERABLE
acute contracture of the affected extremity. A clenched hand with INDIVIDUALS
a small electrical contact wound should alert the clinician that a It is important for clinicians to be aware that intentional burn
deep soft-tissue injury is likely and fasciotomy is necessary. injury can occur in both children and vulnerable adults. Contact
All patients should undergo ECG as an adjunct to physical patterns with clear edges should arouse suspicion; they may
 Figure 9-6: Electrical Burn. This figure demonstrates an reflect a hot object (e.g., an iron) being held against the patient.
injury with deep-tissue necrosis coexisting with areas of Scald burns on the soles of a child’s feet may suggest that the child
“normal” skin. A hallmark of electrical injury is a relatively was placed into hot water versus having hot water fall on them.
small visible wound that hides significant tissue injury.
Sparing of the buttocks is another classic sign, as contact with a
Clinicians must be vigilant in monitoring for cardiac, renal,
and other complications. bathtub or basin surface can protect these areas during forced
immersion. Bathing burns in older or dependent adults are also
concerning for abuse or neglect. Old burn injuries in the setting
of a new traumatic injury (such as a fracture) or burn wounds of
different ages should also raise suspicion for abuse. Above all, the
mechanism and pattern of injury should match the history of the
injury.

PATIENT TRANSFER
Guidelines for consultation and transfer should take into
consideration local burn preparedness and existing regional
capabilities. For instance, the American Burn Association has
adopted the following guidelines for patient consultation
and transfer to regional burn centers in the US and Canada
assessment. Patients with no loss of consciousness, a minimal ( Table 9-2).
wound burden, and a normal ECG may be safely discharged after Transfer of any patient must be coordinated with the referral
low-voltage injury. Prolonged monitoring is reserved for patients center staff. All pertinent information regarding test results,
with severe burn (deep and/or extensive), loss of consciousness, vital signs, fluids administered, and urinary output should be
exposure to high voltage (≥1,000 V ), or cardiac rhythm documented and sent with the patient. Documentation of the burn
abnormalities on initial ECG. Any patient with electrical injury wound size should be included in the transfer documents. Airway
who develops signs of acute kidney injury/failure should have a status should be reevaluated and confirmed prior to transfer; if
12-lead ECG and continuous monitoring. the patient is to be transferred unintubated, a discussion with the
Electrical injuries are often associated with falls and frequently transport personnel and receiving facility should be had to ensure
occur at work. Forced contraction of muscles may cause skeletal that the patient’s airway can be managed during transport.
and muscular damage. Patients with high-voltage injury should
be assessed for mechanical trauma including spinal column and COLD INJURY
spinal cord injuries. Clinicians should also remember that with
electrical burns, muscle injury can occur with few outward signs There are two types of cold injury: frostbite and nonfreezing
of injury. Serially assess the patient for compartment syndrome, injury. The severity of cold injury depends on temperature,
recognizing that electrical burns may necessitate fasciotomies. duration of exposure, environmental conditions, amount of
Rhabdomyolysis from electricity traveling through muscle protective clothing, and the patient’s general state of health. Lower
results in myoglobin release, which can cause acute kidney temperatures, immobilization, prolonged exposure, moisture, the
injury/renal failure. If the patient’s urine is dark red, assume that presence of peripheral vascular disease, and open wounds all
hemochromogens are in the urine; test for myoglobin to confirm increase the severity of cold injury.
if possible. Resuscitation for electrical burn injury should start
based on the following calculation: 4 mL/kg/%TBSA, as visible

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 COURSE MANUAL | Chapter 9 |Thermal Injuries

 Table 9-2: American Burn Association (ABA) Guidelines for Consultation and Transfer. Developed for use in the United
States and Canada, the ABA Guidelines can be useful in any region for developing a framework for when consultation
and transfer of burn patients to specialty care should be considered. Any protocols should take into account regional
capabilities.

Transfer Guidelines by the American Burn Association

Immediate Consultation with
Injury Consideration for Transfer Consultation Recommendation
Thermal Burns Full-thickness burns Partial thickness burns <10% TBSA*

Partial thickness ≥10% TBSA* All potentially deep burns of any size

Any deep-partial or full thickness burns

involving the face, hands, genitalia, feet,
perineum, or over any joints

Patients with comorbidities

Patients with concomitant

traumatic injuries

Poorly controlled pain

Inhalation Injury All patients with suspected Patients with signs of potential inhalation such as facial
inhalation injury flash burns, singed facial hairs, or smoke exposure

Pediatrics All pediatric burns may benefit from

(≤ 14 years or < 30 kg) burn center referral due to pain,
dressing change needs, rehabilitation,
patient/caregiver needs, or non-
accidental trauma

Chemical Injuries All chemical injuries

Electrical Injuries All high voltage (≥1,000V) Low voltage (<1,000V) electrical injuries should receive
electrical injuries consultation and consideration for follow-up in a burn
center to screen for delayed symptom onset and vision
Lightning injury problems
*Total body surface area

FROSTBITE  Figure 9-7: Frostbite with Tissue Damage and Loss. As

with thermal burns, frostbite is staged from first to
Frostbite occurs when tissues freeze; ice crystal formation fourth degree; higher levels of injury are associated with
causes cell membrane injury, microvascular occlusion, and significant tissue damage and complications. Immediate
subsequent tissue anoxia ( Figure 9-7). Tissue damage can rewarming is critical to decreasing the duration of tissue
also result from reperfusion injury after rewarming. Frostbite is freezing.
classified as follows:
• First-degree frostbite: Hyperemia and edema are present
without skin necrosis
• Second-degree frostbite: Large, clear vesicle formation
accompanies the hyperemia and edema with partial-thickness
skin necrosis
• Third-degree frostbite: Full-thickness and subcutaneous
tissue necrosis occurs, commonly with hemorrhagic vesicle
formation
• Fourth-degree frostbite: Full-thickness skin necrosis occurs,
including muscle and bone progressing to necrosis
Typically, the affected body part is initially cold, hard, white,
and numb. Initial treatment regimen applies to all degrees of
frostbite, and the classification is often not prognostically accurate.

143
 Patients with third-degree frostbite can develop severe swelling Systemic empiric antibiotics are not indicated and are
of the extremity with rewarming; clinicians should anticipate reserved for identified infections. Keep the wounds clean and
the potential for reperfusion injury. Prevention of further tissue leave uninfected blebs intact for up to 7 to 10 days to provide a
injury can be aided by elevating the extremity and keeping the sterile biologic dressing that protects underlying epithelialization.
affected area free of constricting wraps. Muscle compartments Tobacco, nicotine, and other vasoconstrictive agents must be
must be frequently monitored. Clinicians should also remember withheld.
that demarcation between live and dead tissue may take days to With all cold injuries, physical estimation of injury depth
weeks to develop. Monitoring the site for infection is also critical. and tissue damage is not usually accurate until demarcation
between live and dead tissue is evident. This often requires
NONFREEZING INJURY several weeks or months of observation. Dress these wounds
Nonfreezing injury is due to microvascular endothelial regularly with a local topical antiseptic to help prevent bacterial
damage, stasis, and vascular occlusion. “Trench foot” or “cold colonization, and debride them once the demarcation has
immersion foot” (or hand) describes a nonfreezing injury of the developed. There is some evidence that triple-phase bone scan can
hands or feet, typically seen in soldiers, sailors, fishermen, and help identify the level of injury sooner than waiting for physical
those who are unhoused. The skin injury results from repeated demarcation. Early surgical debridement or amputation is seldom
and prolonged exposure to wet conditions and temperatures just necessary unless infection occurs.
above freezing (1.6°C–10°C, or 35°C–50°F). Although the entire
foot can appear black, deep-tissue destruction may not be present. HYPOTHERMIA
Alternating arterial vasospasm and vasodilation occur, with the All injured patients are susceptible to hypothermia, and
affected tissue first cold and numb, then progressing to hyperemia any degree of hypothermia can be detrimental. Hypothermia
in 24 to 48 hours. With hyperemia comes intense, painful burning is commonly defined as core temperature below 35°C (95°F), and
and dysesthesia, as well as edema, blistering, redness, ecchymosis, severe hypothermia as any core temperature below 32°C (89.6°F).
and ulcerations. Complications of local infection, cellulitis, Accidental hypothermia is determined by esophageal, bladder, or
lymphangitis, and gangrene can occur. During follow-up care, rectal temperature. The Swiss staging system provides a way to
patients should be informed that proper attention to foot hygiene clinically determine the severity of hypothermia ( Table 9-3).
can prevent many of these complications.

MANAGEMENT OF FROSTBITE AND HEATSTROKE

NONFREEZING COLD INJURIES
There are two types of hyperthermic injury that require
Treatment should begin immediately to decrease the consideration in the Primary Survey: exertional heatstroke
duration of tissue freezing. Do not attempt rewarming if there and classic heatstroke. Exertional heatstroke typically occurs
is a risk of refreezing. Replace constricting, damp clothing in younger individuals performing vigorous exercise in a hot
with warm blankets. Immerse the injured part in recirculating environment. The heat generated from intense musculoskeletal
water at a constant 40°C (104°F) until pink color and perfusion activity cannot dissipate well, and leads to a rise in body
return (usually within 20 to 30 minutes). This treatment is best temperature. In contrast, classic heatstroke results from prolonged
accomplished in an inpatient setting in a large tank, such as a passive exposure to heat, such as during heatwaves. Classic
whirlpool tank, or by placing the injured limb into a bucket with heatstroke is more common in older adults, and individuals with
warm, running water. Excessive dry heat can cause a burn injury, pre-existing comorbidities. The diagnosis of heatstroke is based
as the limb is usually insensate. Do not rub or massage the area. on a triad of hyperthermia (40°C–43.6°C), altered central nervous
Rewarming can be extremely painful, and adequate analgesics system function, and exposure to extreme heat or exertion. The
are essential. Reperfusion of large areas can result in reperfusion central nervous system alteration seen with heatstroke often
syndrome, with acidosis, hyperkalemia, and local swelling. presents rapidly, is nonfocal, and may include confusion, lethargy,
Therefore, it is important to monitor the patient’s cardiac status or delirium.
and peripheral perfusion during rewarming. Cooling should begin immediately in the prehospital setting
Referring hospitals and clinicians should discuss with the and should be continued through transport and into the hospital
regional referral unit for the use of thrombolytic therapy in setting (see  Table 9-4). Cool water immersion is the first-line
acute frostbite. Thrombolytics may be considered in patients intervention; cooling the patient should proceed to 38.9°C. Care
presenting within 24 hours of injury. Thrombolytic therapy is for organ dysfunction is supportive.
most effective when developed as part of a protocol of care rather
than as an ad hoc strategy. For patients with tissue cyanosis, CT
angiography can be used to assess distal perfusion.

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 COURSE MANUAL | Chapter 9 |Thermal Injuries

 Table 9-3: Staging and Management of Hypothermia. Systemic hypothermia must be recognized in the Primary Survey
and treatment tailored depending on the severity. Any stage of hypothermia can result in coagulation abnormalities, leading
to resuscitation challenges.

Staging and Management of Hypothermia

Stage Symptoms Core Temp. Treatment

I Conscious, shivering 32°–35°C Warm environment and clothing, active movement, warm
oral fluids

II Impaired consciousness, no 28°–<32°C Cardiac monitoring, cautious movements to avoid

shivering arrhythmias, full-body insulation, active external and
minimally invasive rewarming techniques (chemical,
electrical, or forced-air heating packs or blankets, warm IV
fluids)

III Unconscious, vital signs are 24°–<28°C All the above plus: intubation, rewarming with
present extracorporeal support if available

IV No vital signs <24°C All of the above plus: CPR and up to three doses of
epinephrine and defibrillation, can continue if patient
responds. Continue active external or internal rewarming if
extracorporeal support not available
For stage IV, duration of resuscitation efforts should be based on locally available resources and protocols.

 Table 9-4: Treatment of Heatstroke/Hyperthermia. Heatstroke can lead to organ

dysfunction and death if not recognized and treated early. Although less common than
hypothermia in trauma patients, it should still be excluded if patients present with injuries
after exertion/working outside in hot environments.

Suspected Heatstroke

Measure core temperature; if >40°C, heatstroke is likely

Assessment

1. Move patient to cooler environment

Immediate Cooling
2. Begin external cooling:
• Immerse in ice water
• Place ice packs/cold towels at junctional
vascular points (i.e., neck, axillae, groin)
• Spray skin with water and continuously fan

External cooling devices

Hospital Cooling
Intravascular cooling cannulas

CHAPTER SUMMARY based on patient weight and extent once the injury TBSA is
estimated. Following initial stabilization, consultations and
Thermal injuries should be assessed and treated following transfer decisions to specialized burn care facilities should follow
the primary and secondary survey framework. In the case of established guidelines.
major burns, rapidly addressing the airway and initiating fluid
resuscitation are important interventions to prevent patient
deterioration. Burn fluid-repletion rates follow age-based criteria
during prehsopital transport, and these are subsequently adjusted

145
 KEY LEARNING POINTS 9. Saffle JR, Crandall A, Warden GD. Cataracts: A long-term
complication of electrical injury. J Trauma. 1985;25(1):17–
• Stop the burning process. 21.
10. Schaller MD, Fischer AP, Perret CH. Hyperkalemia. A
• Burn inflammation/edema is progressive,
prognostic factor during acute severe hypothermia. JAMA.
and frequent reassessment of the airway or
compartments is required. 1990;264(14):1842–1845.
11. Sheehy TW, Navari RM. Hypothermia. Ala J Med Sci.
• In the Primary Survey, fluid resuscitation is 1984;21(4):374–381.
started at fixed rates based on age. 12. Stratta RJ, Saffle JR, Kravitz M, Warden GD. Management
of tar and asphalt injuries. Am J Surg. 1983;146(6):766–769.
• In the Secondary Survey, adjusted fluid rates are
13. Jeschke MG, van Baar ME, Choudhry MA, Chung KK,
calculated based on burn size and patient weight.
Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers.
• Adjust fluids hourly based on patient response, 2020;6(1):11.
beginning at hour 1. 14. Vercruysse GA, Ingram WL, Feliciano DV. The
demographics of modern burn care: Should most
• Electrical burns may be associated with occult burns be cared for by non-burn surgeons? Am J Surg.
(deep-tissue) injuries.
2011;201(1):91–96.
• Frostbite staging is akin to burn depth; initial 15. Cancio LC. Airway management and smoke inhalation
treatment is by rewarming the affected area. injury in the burn patient. Clin Plast Surg. 2009;36(4):555–
567.
• The American Burn Association has issued 16. Latenser BA. Critical care of the burn patient: The first 48
guidelines for burns that typically require hours. Crit Care Med. 2009;37(10):2819–2826.
consultation and transfer to a regional center
17. Cancio LC, Lundy JB, Sheridan RL. Evolving changes in
(see Table 9-2).
the management of burns and environmental injuries.
• Early management and treatment of hypo- and 2012;92(4):959–986, ix.
hyperthermia are an essential part of Initial 18. Pham TN, Gibran NS. Thermal and electrical injuries. Surg
Assessment. Clin North Am. 2007;87(1):185–206, vii–viii.
19. Cancio LC. Initial assessment and fluid resuscitation of
burn patients. Surg Clin North Am. 2014;94(4):741–754.
20. Sheridan RL, Chang P. Acute burn procedures.
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Whole body oxygen utilization during carbon monoxide Fleet enema for the removal of a large tar burn: A case
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4. Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Res. 2016;37(4):e323–e334.
Hypothermia in trauma victims: An ominous predictor of 24. Brown DJ, Brugger H, Boyd J, Paal P. Accidental
survival. J Trauma. 1987;27(9):1019–1024. hypothermia. N Engl J Med. 2012;367(20):1930–1938.
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10

Musculoskeletal Trauma

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explain the significance of musculoskeletal 5. Describe the signs and symptoms of

injury as it relates to the patient’s assessment compartment syndrome
during the primary survey 6. Recognize associations between the mechanism
2. Identify and initiate treatment for of injury and specific musculoskeletal injury
musculoskeletal injuries that may result in patterns
threat to life or limb in the context of the ATLS 7. Recognize musculoskeletal injuries requiring
algorithm timely transfer
3. Be able to select and apply appropriate
musculoskeletal adjuncts during the primary
and secondary Survey
4. Describe the elements of the evaluation of the
musculoskeletal injuries during the secondary
Survey

147
 Prehospital information plays a pivotal role in optimizing care

10
delivery and patient outcomes. A MIST (Mechanism of Injury or
Illness, Injuries Sustained, Signs and Symptoms, Treatment)-style
handover from prehospital care providers offers valuable insights
into the mechanism of injury and potential musculoskeletal
injuries, aiding in the preparation of necessary equipment,
personnel, and resources. See  Box 10-1 for a list of key
considerations. Early communication with subspecialty teams,
including orthopaedic, vascular, and plastic surgery, is critical
for comprehensive care planning. Awareness of local resources
Musculoskeletal Trauma and the establishment of protocols for the timely transfer of
patients requiring specialized care are essential components of
effective trauma management.

CHAPTER STATEMENT PATHOPHYSIOLOGY

It is estimated that up to 60% of traumatically injured patients The pathophysiology of musculoskeletal injuries, encompassing
sustain some form of musculoskeletal injury, which underscores the both fractures and soft-tissue damage, is fundamentally influenced
necessity for trauma care clinicians to adeptly identify and address by the mechanisms of injury. These mechanisms include blunt,
these injuries within the broader context of trauma management. penetrating, crush, and blast injuries. The kinetics of the injury
Musculoskeletal injuries may lead to chronic dysfunction and and the force applied to the tissues determine the severity of
long-term morbidity, emphasizing the importance of timely and the injury. Consider pedestrians struck by moving vehicles. The
systematic identification and management of injuries at all severity size of the vehicle (truck versus sedan) and size of the pedestrian
levels for optimal long-term outcomes. Delayed recognition can affect the site of impact and the injuries inflicted. In addition
and treatment of these injuries can result in life-threatening to the size, shape, and weight of the vehicle, the speed at which
hemorrhage, limb loss, and/or permanent impairment. the impact occurred can also influence the nature of the injuries
( Figure 10-1). These forces are applied across all tissue types,
INTRODUCTION including bone, ligament, tendon, skin, muscle, vessel, and nerve.
Failure to consider these injuries in the acutely injured patient can
In the management of trauma patients, musculoskeletal lead to significant disability. A high index of suspicion of injury to
injuries represent a significant clinical concern due to their high adjacent structures should be maintained.
prevalence and potential to complicate care. These injuries, while
not explicitly categorized within the xABCDE algorithm, critically INJURY MECHANISM
influence treatment priorities throughout the patient care process.
Musculoskeletal injuries can range from life- or limb-threatening Blunt force trauma, such as falls, motor vehicle collisions, or
conditions to less-severe injuries that may nonetheless distract direct blows, is a frequent cause of fractures. The force required
from more critical concerns. to break bones varies significantly across different bones and
Knowledge of the correlation between specific injury is influenced by the direction and magnitude of the force, the
mechanisms and musculoskeletal injury patterns is crucial bone’s size and density, and the individual’s age. For example,
for anticipating potential injuries and guiding the judicious high-energy collisions produce considerable force and can lead to
application of diagnostic imaging. Understanding the anatomical fracture of the femur, one of the strongest bones in the body. In
pathway and proximity of major neurovascular structures to contrast, much less force is required to fracture a clavicle, a much
these injuries is essential for assessing associated injuries and smaller subcutaneous bone.
determining treatment approaches. Similarly, the energy required to create a comminuted or
Significant injuries such as major pelvic-ring disruptions multifragmentary fracture is much greater than that required
and femoral shaft fractures are particularly associated with the to create a simple fracture and implies a much larger zone of
risk of substantial hemorrhage. The acute management of these injury to both bone and soft tissue.  Figure 10-2A shows a simple
injuries, including the application of pelvic binders and femoral fracture caused by a low-kinetic-energy mechanism, and  Figure
traction splints, highlights the need for specialized knowledge in 10-2B shows a multifragmentary fracture caused by a high-kinetic-
the stabilization of these critical conditions. energy mechanism. The threshold at which a bone fractures also
Additionally, conditions such as open fractures, fracture depends on factors such as bone density; osteoporotic bones may
dislocations with neurovascular compromise, acute fracture under much less force compared to healthy bones.
compartment syndrome, and major crush injuries can pose Blunt trauma can also cause a range of soft-tissue injuries,
acute threats to patients’ limbs. Moreover, musculoskeletal including contusions, sprains, and strains. The severity of these
injuries that are not immediately life-threatening may pose a injuries depends on the force’s magnitude and the affected tissue’s
risk for long-term disability if not promptly and appropriately resilience. High-energy impacts can cause severe sprains where
managed. ligaments are overstretched or torn, and strains where muscle
fibers and tendons are damaged, leading to significant functional
impairment.

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 COURSE MANUAL | Chapter 10 | Musculoskeletal Trauma

 Box 10-1: Important Prehospital Information and Findings.

Important Prehospital Information and Findings

• Type and speed of vehicle(s) • Open wounds in proximity to visualized or suspected fractures
• Use of restraint devices or projective equipment • Bone, joint, or fracture ends (or other deep structures) that may have been
exposed, especially if they are no longer visible after initial care
• Ejection
• Was the open fracture sustained in a contaminated environment?
• Height of fall
• Any compression mechanism that could result in a crush syndrome
• Explosion; magnitude; open or closed space
• Presence or absence of motor and/or sensory function in each extremity
• The estimated time of injury, especially if there is ongoing
bleeding or clinical deterioration, an open fracture, dislocation • Changes in limb function, perfusion, or neurologic state, especially after
of a joint, and/or a delay in reaching the hospital immobilization or during transfer
• Entrapment or delays in extrication or transport • Reduction of fractures or dislocations at the scene
• Bleeding or pooling of blood at the scene, including the • Dressings and splints applied, with special attention to pressure over bony
estimated amount prominences that can result in tissue trauma, neurovascular compression, or
compartment syndrome
• Time of tourniquet placement, if applicable, and the reason for
application • Was the patient exposed to temperature extremes, chemicals, or radiation?
• The position in which the patient was found at the scene and
whether or not they were able to mobilise independently
• Visualized deformity

 Figure 10-1: Impact points vary based on vehicle and  Figure 10-2: A. Plain x-ray of a femur demonstrating a
individual, such as, height of bumper and patient’s age simple fracture with displacement. B. Mutlifragmentary
and size. femur fracture. The distal femur rotated 90 degrees from
the proximal femur. This injury represents higher-kinetic-
energy mechanism.

A. B.

The force required to tear or dislocate soft tissues, such as

ligaments and tendons, also varies. For instance, the anterior
cruciate ligament in the knee may tear with a forceful impact on the
leg and a sudden change in direction, common in sports injuries.
Joint dislocations occur when the force applied overcomes the
stability provided by the joint’s ligaments, the capsule, and the
congruence of the joint surfaces, such as a shoulder dislocation
resulting from a fall on an outstretched hand.
Penetrating injuries, such as those caused by bullets or sharp
objects, can lead to fractures with a severity that varies with the
amount of kinetic energy transferred. Surrounding soft-tissue
structures are also at risk, including muscles, tendons, nerves, and Understanding the mechanisms of musculoskeletal injuries
blood vessels. and the forces involved is crucial for diagnosis, management,
Explosions can produce devastating injury, particularly when and prevention strategies. The severity and complexity of these
they occur in an enclosed space. Secondary blast injury results injuries necessitate a comprehensive approach to treatment,
from shrapnel and debris that become high-velocity projectiles, encompassing immediate care, possibly surgical intervention, and
causing penetrating or blunt-force injury. Tertiary blast injury long-term rehabilitation to restore function and prevent long-
results from the blast wind violently launching the patient into term disability.
the ground or against objects, producing fractures and soft-tissue
injury.
149
 ASSESSMENT PELVIC FRACTURES
HEMORRHAGE CAUSED BY PELVIC FRACTURES
PRIMARY SURVEY
Pelvic fractures are potential sources of significant hemorrhage
POTENTIALLY LIFE-THREATENING in patients who have sustained high-energy blunt trauma. This
MUSCULOSKELETAL INJURIES includes motor vehicle crashes, pedestrian injuries, and falls from
During the primary survey, it is crucial to rapidly identify heights. The bony pelvic ring is composed of the ilium, ischium,
and manage hemorrhage from musculoskeletal injuries. pubis, and sacral bones held together by sturdy ligaments. These
Hemorrhage from the pelvis and extremities, originating from bones are anatomically related to major vessels and nerves. Pelvic-
major arteries, presents a critical challenge. Injuries to proximal related bleeding can arise from fractured bones, torn muscle, or
limb vessels, such as the femoral or brachial arteries, carry a higher associated veins and arteries. External signs of injury are often
risk of severe bleeding. Without timely intervention, even minor lacking. However, pelvic tenderness, ecchymosis over the pelvis,
arterial injuries can result in considerable blood loss, potentially perineum, or scrotum, and sometimes a palpable diastasis of the
leading to rapid clinical decline and exsanguination. These symphysis pubis will be present.
injuries should be prioritized as the “x” element in the xABCDE Pelvic fracture patterns can be differentiated into many
algorithm, taking precedence over other clinical concerns. The classifications. Any pelvic fracture pattern can produce
primary objective is to “Stop the Bleed” employing multiple significant hemorrhage. “Anterior posterior compression III”
strategies. Initial measures include applying direct pressure, and “vertical shear” have been identified as the patterns most
packing the wound, or possibly the application of a tourniquet. likely to require hemorrhage control interventions. Other
Correctly positioning and splinting limbs with active bleeding factors identified as predictors of the need for hemorrhage
and associated fractures also assists in controlling hemorrhage. control procedures include open pelvic fracture and age
Crush syndrome and traumatic fat embolism may develop after greater than 64. It is most important to differentiate between
severe injuries and need to be considered. hemodynamically stable and unstable patients. The nuances of the
An essential caveat for initial care clinicians is that a vascular fracture patterns and methods for delineating mechanically stable
injury without active bleeding should not overshadow the fractures from unstable fractures are less important when a patient
immediate management of life-threatening hemorrhage or other is actively bleeding. The World Society of Emergency Surgery has
critical conditions. Such injuries, representing an ischemic threat recommended that any patient who is hemodynamically unstable
to the limb, should be managed as a secondary priority following from a pelvic fracture be categorized as grade IV ( Table 10-1 and
the stabilization of more urgent, life-threatening issues.  Figure 10-3) regardless of their fracture pattern. Concomitant
injuries may be present in up to 50% of patients with pelvic
fractures.

 Table 10-1: This classification of pelvic fractures is based on the hemodynamic presentation of the patient. The
classification and anatomic stability are of secondary importance. Treatment of hemodynamically unstable patients may
include placing a binder, endovascular evaluation and treatment, preperitoneal packing, or bony stabilization. REBOA,
resuscitative endovascular balloon occlusion of the aorta; WSES, World Society of Emergency Surgery.

WSES Description Young-Burgess Hemodynamic Mechanics Early Treatment

Grade Classification Status

I Minor APC I LCI Normal Stable Routine evaluation

II Moderate LC II/III APC II/III Normal Unstable Pelvic binder, possible

angioembolization; possible
external fixation or
operative management

III Moderate VS Normal Unstable Pelvic binder, possible

angioembolization;
operative management

IV Severe Any Shock Any Pelvic binder, perperitoneal

packing, mechanical fixation,
REBOA, angioembolization

LC, lateral compression; APC, Anterior posterior compression; VC, Vertical shear; REBOA, Retrograde endovascular balloon occlusion of the aorta.

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 Figure 10-3: Young-Burgess Classification of Pelvic  Figure 10-4: A. Pelvic x-ray demonstrating widening of
Fractures. Anterior-posterior compression fractures the symphysis pubis characteristic of YB AP compression
result from anterior to posterior force vectors which fracture (note by arrow). YB, Young-Burgess; AP, Anterior-
produce the characteristic pubic diastasis. They are graded posterior compression. B. Pelvic x-ray of patient A after
in increasing severity from Type I to Type III. Lateral placement of pelvic-stabilizing device (binder). The star
compression fractures are the most common class and indicates position of pubic symphysis, the arrow is pointing
result from lateral force vectors. Severity increases from to left greater trochanter and the bracket is outlining the
Type I to Type III. Vertical shear fractures result from pelvic stabilizing device (PSD). The PSD should be positioned
longitudinal forces. Sacral and sacroiliac injuries and shift below the greater trochanters. C. Vertical shear. Pelvic x-ray
of the hemipelvis superiorly are characteristic. of a different patient with fracture through the SI joint with
elevation of the right hemipelvis. Note thin red arrows
identify the SI joints note widening on right and the wide
arrow indicates elevation of the right hemipelvis. SI, Sacral
Iliac.

A.

B.

Aggressive distraction of the pelvis to assess for anatomic

stability is discouraged, as it may increase bleeding. Rather,
gentle anterior compression at the anterior superior iliac spine
and lateral compression at the iliac crest can be performed. Pain,
motion, or crepitus indicates fracture. Limb length discrepancy
may be apparent and can indicate femur fracture or dislocation
as well. The pelvis can accommodate 4 to 6 liters of blood, so
even isolated injuries can produce hemodynamic instability. If
not already done by the prehospital care providers, the pelvis
should be stabilized with a sheet or commercial binder. The
binder or sheet should be positioned circumferentially around
the pelvis at the level of the greater trochanter of the femurs. This
maneuver should internally rotate the limbs. The lower extremities C.
can also be secured together at the ankles to further decrease the
pelvic volume and limit bleeding. This maneuver prevents motion
at the fracture site and can help tamponade venous bleeding to
limit blood loss. This technique will be described further in the
Circulation Skill Station section. Blood loss from the pelvis is
venous in 85% of cases, accounting for the success seen with
compression. Hemostatic resuscitation that limits crystalloid,
uses whole blood/blood products in low ratios, and administers
TXA to patients within 3 hours of injury helps limit blood loss.
Pelvic and chest imaging and procedures to evaluate for intra-
abdominal bleeding help determine next steps in management
of the pelvic fracture bleeding. Urgent surgical consultation is
important when managing these patients. Classic findings on
imaging are shown in  Figure 10-4A-C.

151
 Open pelvic fractures can result in rapidly exsanguinating
 Figure 10-5: Ankle-Brachial Index (ABI) Measurement.
hemorrhage. Thankfully, these injuries are not very common.
A. A manual blood pressure (BP) cuff is insufflated on
These injuries usually require immediate packing and urgent an uninjured UE to a pressure higher than the SBP and
surgical consultation. slowly deflated. B. A hand held doppler is used to detect
the pressure at which flow returns. C. A manual BP cuff is
insufflated on the affected leg to a pressure higher than
MAJOR ARTERIAL INJURY AND TRAUMATIC the SBP and slowly deflated. D. A hand held doppler is
AMPUTATION used to detect the pressure at which flow returns. This
pressure is compared to the pressure measured in the
In trauma care, a wide range of etiologies can precipitate major upper extremity. Values <0.9 are concerning for vascular
arterial injuries, including penetrating trauma, high-energy blunt injury.
forces, crush injuries, and mangled extremities. Fractures or
dislocations near an artery may also disrupt the vessel, leading
to significant hemorrhage, either externally or contained
within soft tissues. Patients experiencing traumatic amputation
are at an elevated risk of life-threatening hemorrhage and may
necessitate the early application of a tourniquet. In cases of
major vessel damage, prompt referral to surgical services is
typically imperative.

ASSESSMENT
Assessment of injured extremities should include searches for
both overt and subtle signs of bleeding, the absence or alteration
of previously palpable pulses, and any asymmetry in pulse quality
between limbs; any of these may indicate vascular injury. It’s
essential to mark the locations of palpable major distal pulses to
aid subsequent evaluations. Utilizing Doppler ultrasound and
measuring the ankle-brachial index (ABI) or injured extremity
 Figure 10-6: Injured Extremity Index. A. A manual BP
index (injured extremity compared to uninjured extremity) can
cuff is insufflated on the uninjured upper extremity to a
be beneficial when resources permit. The ABI is determined
pressure higher than the SBP and slowly deflated. B. A
by dividing the highest systolic blood pressure obtained at hand-held doppler is used to detect the pressure at which
the ankle by the systolic pressure at the brachial artery, with flow returns. C. Repeat steps A. and B. on the injured UE.
a ratio above 0.9 indicating normal perfusion in uninjured D. Calculate the IEI comparing the injured to the uninjured
individuals ( Figure 10-5). Differences in ABI between limbs extremity. Values <0.9 are concerning for vascular injury.
may indicate arterial injury or compromise. Comparisons of ABI, Ankle Brachial Index; BP, Blood pressure; SBP, Systolic
systolic pressure can similarly be made between an injured blood pressure; IEI, Injured extremity index; UE, Upper
and uninjured upper extremity ( Figure 10-6). CT angiography extremity.
offers precise visualization of major vascular injuries and ongoing
bleeding but is generally reserved for stable patients or to provide
guidance for endovascular management. Associated fractures
typically require realignment and provisional stabilization before
definitive angiographic assessment.
It’s crucial to remember that the presence of a Doppler
signal alone does not exclude significant arterial injury. Signs
such as expanding pulsatile hematomas, the absence of distal
pulses, or visible arterial bleeding are definitive indicators of
arterial damage.

MANAGEMENT
In the absence of catastrophic bleeding, managing arterial
hemorrhage starts with the immediate realignment of any limb
deformities and the application of direct manual pressure to
bleeding sites. A stepwise escalation in hemorrhage control
measures may be necessary, potentially culminating in the
application of a manual or pneumatic tourniquet  Figure 10-7
shows examples of commercial tourniquets. Proper tourniquet
application is vital to occlude arterial inflow without
compromising the limb further, with careful documentation of
the application time to guide future decisions on limb viability.

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not be suitable candidates for surgical replantation. To ensure

 Figure 10-7: Several Tourniquet Models Are
proper assessment, decision-making, and management, patients
Commercially Available. A. Combat application
tourniquet (CAT). B. SOFTT or special operations forces
with traumatic amputations should be transferred to a surgical
tactical tourniquet. C. SAM XT from SAM Medical. team experienced in replantation procedures. If feasible, the
D. Ratcheting medical tourniquet. E. TX 3 tourniquet. amputated part should be thoroughly cleansed with an isotonic
F. The tactical mechanical tourniquet TMT™. The solution (such as Ringer’s lactate) and then wrapped in moist,
Committee on Tactical Combat Casualty Care also known sterile gauze.
as CoTCCC or TCCC is the resource the Committee on Subsequently, encase the gauze-wrapped part in a moist, sterile
Trauma’s Stop the Bleed® Program utilizes for direction towel, place it in a sealed plastic bag, and transport it alongside the
regarding equipment. These tourniquets are approved patient in an insulated cooling chest filled with crushed ice. It is
and listed on the TCCC’s adjunct formulary, however
crucial not to immerse the amputated part directly in ice to avoid
not every version of the approved tourniquet is shown.
A complete list can be found here: https://learning-
thermal damage (freezing), which could compromise its viability
media.allogy.com/api/v1/pdf/ef9c8ec7-c4b2-4948-9ff5- and potentially render it unsuitable for replantation, unless the
fb34f504032a/contents. receiving facility or surgical team provides specific instructions
to the contrary. Traumatic amputations represent a profound
physical and emotional event for patients, and psychological
support is important in their assessment and management.
A limb showing deformity or circulatory compromise
demands immediate realignment, splinting, and reassessment,
as this might restore arterial flow. Always thoroughly assess and
document the neurovascular status of an extremity before and
after any intervention, as well as throughout your interaction
with the patient, to ensure the best possible outcomes.

BILATERAL FEMUR FRACTURES

Patients with bilateral femoral shaft fractures or multiple long
Tourniquets should be applied 2–3 inches (5–8 cm) above the bone fractures face a significantly increased risk of complications
area of injury and should not be placed over joints. Occluding and mortality. These injuries are indicative of exposure to
only the venous system can increase hemorrhage and result in substantial force. Patients with bilateral femoral fractures are
a swollen, cyanotic extremity. To achieve this effect, a pneumatic more susceptible to extensive blood loss, severe concurrent
tourniquet may require pressures at 250 mm Hg or greater in an injuries, pulmonary complications, multiorgan failure, and
upper extremity and 400 mm Hg or greater in the lower extremity. death compared to those with a single femur fracture. Isolated,
Remember that a large portion of the compressive effect of closed femoral shaft fractures can lead to substantial blood loss,
these high pressures is lost in compression of intervening tissue, potentially reaching up to 2 liters, which, for a 70-kg patient,
and the observed torniquet pressure does not reflect the direct constitutes more than 40% of the total blood volume. Bilateral
pressure on the vessel itself. Ensure that the time of tourniquet femoral fractures can result in twice this volume of blood loss.
application is clearly documented. Urgent surgical consultation Open fractures cause rapid blood loss, leading to hemodynamic
is now essential, and early transfer to a trauma center with instability. The absence of a tamponading effect in open fractures
vascular surgical capabilities should be considered. Limb can lead to life-threatening blood loss. Closed fractures may
viability is related not only to the extent of the original injury but bleed more slowly but inevitably progress to hemorrhagic
also the subsequent ischemia time and the presence and depth shock. Therefore, splinting, applying traction, controlling
of shock. Where torniquet times exceed 90–120 minutes, it may local hemorrhage, and implementing careful resuscitation
be appropriate to deflate the torniquet in a controlled manner to are crucial. Early transfer of such patients to a trauma center
reassess ongoing bleeding and to decide the need to reinflate or equipped with comprehensive orthopaedic surgical facilities is
use other hemorrhage control techniques. Extended tourniquet advisable.
application time carries risks; thus, decisions to maintain or release Appropriately treating, immobilizing, and resuscitating
a tourniquet depend on ongoing assessment of bleeding and the patients with multiple fractures reduces the risk of systemic
overall condition of the limb. See Chapter 14, Initial Assessment: complications. Fat embolism may still occur, however, when
Secondary Survey, for more regarding tourniquet conversion. A marrow enters the circulatory system and embolizes to the lungs.
limb requiring a tourniquet is a threatened limb by definition. The acute pulmonary response to this embolus may be significant,
Traumatic amputations usually benefit from early tourniquet especially if associated with ongoing hypovolemia.
use, typically applied in the prehospital setting. Management
involves surgical consultation. While the possibility of replantation POTENTIALLY LIMB-THREATENING
after complete amputation exists, it must be evaluated against the MUSCULOSKELETAL INJURIES
backdrop of the patient’s overall injury profile and the viability of
the amputated part. Typically, replantation is reserved for patients Extremity injuries that do not immediately threaten life
with isolated extremity injuries. Patients with multiple injuries but jeopardize the acute or long-term viability of a limb are
requiring intensive resuscitation and/or emergency surgery may considered a secondary clinical priority, following the urgent

153
 needs of acute resuscitation and stabilization. This category Not every skin wound near a fracture signifies an open injury;
encompasses open fractures, penetrating joint injuries, major however, a high index of suspicion is advisable, and erring on
joint dislocations, ischemic vascular injuries, compartment the side of treating such a wound as an open injury is typically
syndrome, and significant crush injuries, each of which warrants safer. Probing of wounds is discouraged during initial assessment
detailed attention as outlined subsequently. These injuries are to minimize the risk of infection, bleeding, and iatrogenic injury.
critical and require timely identification and management to Documentation of the wound starts in the prehospital
prevent severe outcomes or the potential loss of the affected limb. setting with a detailed description of the injury and any initial
The decisions and assessments made during the initial evaluation treatment. Visual evidence of a fracture end protruding through
of these injuries can significantly impact the patient’s prognosis the skin is diagnostic of an open fracture. Suspected but not
and eventual recovery trajectory. immediately apparent open-joint injuries may require CT
scanning for confirmation. The detection of intraarticular gas on
OPEN FRACTURES AND PENETRATING JOINT imaging studies is a reliable indicator of an open-joint injury and
INJURIES necessitates early orthopaedic consultation for possible surgical
intervention.
Open fractures and penetrating joint injuries create a direct
Photographing injuries for documentation and referral can be
pathway between the external environment and the internal
beneficial when clinically appropriate and done with adherence
fracture zone or joint space ( Figure 10-8). This condition arises
to local guidelines. Such images assist in accurately conveying the
when skin and any intermediate tissues, such as fascia or muscle,
injury severity to consulting services and aid in surgical planning
are compromised, with the extent of soft-tissue damage generally
while also serving legal documentation purposes. Patient consent
being proportional to the force of impact. The resultant exposure,
for photography should be obtained where feasible, ensuring
coupled with the risk of bacterial contamination, predisposes
respect for patient privacy and dignity.
these injuries to complications such as infection, delayed
healing, and functional impairment. Immediate and thorough MANAGEMENT
evaluation is essential for the management of these injuries.
Management strategies should be informed by a
ASSESSMENT comprehensive review of the injury history and clinical
assessment. Administration of IV antibiotics is recommended
The identification of an open fracture or penetrating joint
for all patients with open fractures, prioritizing first-generation
injury is critical and should be based on a thorough physical
cephalosporins and other agents, as necessary based on the
examination revealing any open wounds associated with a fracture.

 Figure 10-8: Open and Closed Tibial Fractures. A. This diagram illustrates the difference between an open (left) and
closed (right) tibial fracture. The open fracture shows bone protrusion through the skin, creating a risk for contamination
and infection. The closed fracture has no skin breaks and the bone remains internal to the soft-tissue envelope. It is crucial
to recognize open fracture to decrease the risk of infection. B. Radiograph of comminuted tibia and fibula fractures with
multiple fragments. The distal portion of the tibial bone fragment abuts the skin. C. Photograph of right leg of patient from
B. This image shows a small open wound on the skin overlying a tibial shaft fracture, indicating an open fracture. Even
with minimal skin disruption, there is a risk of contamination and infection. Proper wound care, antibiotics, and surgical
debridement are essential components of management for open fractures to prevent complications. D. This x-ray depicts
a comminuted fracture of the distal femur with multiple fragmented bone pieces and severe displacement. Such fractures
often result from high-impact trauma and may involve significant soft-tissue injury. E. Photograph of left leg of the patient
from D. There is a severe open fracture of the distal femur and proximal tibia with extensive soft-tissue damage and bone
exposure. The injury presents a high risk of contamination, infection and hemorrhage. Immediate management involves
hemorrhage control, bony stabilization, administration of antibiotics, and thorough debridement.

A. B. C. D. E.

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 Table 10-2: Antibiotic Regimen for Open Fractures Based on Severity and Contamination. Gustilo-Anderson open
fracture classification grades open fractures on a scale from 1-3 based on the amount of contamination and degree of tissue
compromise where type 1 is a clean wound with <1cm of length and type III is heavily contaminated with significant soft-
tissue damage and vascular injury.

Preventative Antibiotic Regimens for Patients with Open Fractures

Absence of potential soil Presence of potential soil Presence of water

or water contamination contamination (in absence of contamination
water contamination)

Gustilo-Anderson fracture type I or II

Preferred Cefazolin 2g IV Q8H Cefazolin 2 IV Q8H PLUS No modifications needed

metronidazole 500mg IV Q8H to recommendations to left
regimen
or
Ceftriaxone 2g IV Q24h PLUS
metronidazole 500mg IV Q8H

Alternative Vancomycin Clindamycin 900 mg IV Q8H No modifications needed

• Loading dose 20mg - to recommendations to left
regimen for
35mg/kg
beta-lactam • Maintenance dose
hypersensitivity 15mg–20mg/kg Q8-12H
(dose based on patient-
specific factors and adjust
to trough levels)

Gustilo-Anderson fracture type III

Preferred Cefazolin 2g IV Q8H PLUS Ceftriaxone 2g IV Q24H PLUS Fresh water

gentamicin 5mg/kg IV Q24H metronidazole 500mg IV Q8H contamination:
regimen
or or Piperacillin/Tazobactam
Ceftriaxone 2g IV Q24H Cefazolin 2g IV Q8H PLUS 4.5g IV Q6H
gentamicin 5mg/kg IV Q24H PLUS
metronidazole 500mg IV q8H
Salt-water contamination:
Piperacillin/Tazobactam
4.5g IV Q6H PLUS
doxycycline 100mg IV/PO
Q12H

Alternative Clindamycin 900mg IV Q8H Clindamycin 900mg IV Q8H PLUS Fresh water
gentamicin 5mg/kg IV Q24H contamination:
regimen for
Imipenem 500mg IV Q6H
beta-lactam or
hypersensitivity Meropenem 1g IV Q8H

Salt-water contamination:
Imipenem 500mg IV Q6H
or
Meropenem 1g IV Q8H
PLUS Doxycycline 100mg
IV/PO Q12H

Notes:
• If cefazolin is to be used, use 3 g IV Q8H in patients >120 kg
• For patients at risk for MRSA (methicillin-resistant Staphylococcus aureus), gram-positive coverage should consist of vancomycin instead of cefazolin
• Can use fluoroquinolone (levofoxacin, ciprofloxacin) in place of doxycycline
• Prophylactic ABX can be discontinued 24 hours after wound closure for Type I and II fractures and after 72 hours for Type III fractures
• Systemic ABX recommended to be initiated at time of diagnosis
• Gram-positive coverage ASAP after injury and addition of gram-negative coverage for Gustilo-Anderson Type III open fractures

155
 injury mechanism and local protocol ( Table 10-2). Delaying
VASCULAR INJURIES
antibiotic treatment beyond 3 hours postinjury increases the
risk of infection. Ideally, antibiotics should be administered When patients present with signs of vascular insufficiency
within 1 hour of arrival to the emergency department. following blunt, crushing, twisting, or penetrating injuries
Early removal of contaminants using sterile instruments and or following dislocations of an extremity, vascular injury
covering the wound with a moist, sterile dressing can be performed should be a primary concern. Should significant hemorrhage be
in the emergency department. This is followed by stabilizing the detected, immediate management should follow the protocols for
injury after a detailed assessment that includes evaluating the soft life-threatening injuries as previously outlined.
tissue, circulation, and neurological status. Orthopaedic surgical
consultation should be sought without delay. Tetanus prophylaxis
is advised for all significant open musculoskeletal trauma unless
history of recent vaccination is verified or administration is
contraindicated ( Table 10-3).

 Table 10-3: Age-Based Tetanus Immunization Recommendations.

Age-Based Tetanus Immunization Recommendations

Age (years) Vaccination history Clean, minor wounds All other wounds

0-6 Unknown or up to date on DTaP DTaP DTaP

series based on age TIG

Up to date on DTaP series No indication No indication

based on age

7 - 10 Unknown or incomplete DTaP Tdap and recommend Tdap and recommend

series catch-up vaccination catch-up vaccination
TIG

Completed DTaP series AND ≤ 5 No indication No indication

years since last dose

Completed DTaP series AND ≥ 5 No indication Td, but Tdap preferred if

years since last dose child is 10 years of age

11 + Unknown or < 3 doses of Tdap and recommend Tdap and recommend

tetanus toxoid containing catch-up vaccination catch-up vaccination
(If pregnant, vaccine TIG
see footnote)
3 or more doses of tetanus No indication No indication
toxoid containing vaccine AND
< 5 years since last dose

3 or more doses of tetanus No indication Tdap preferred (if not yet

toxoid containing vaccine AND received) or Td
5-10 years since last dose

3 or more doses of tetanus Tdap preferred (if not yet Tdap preferred (if not yet
toxoid containing vaccine AND received) or Td received) or Td
> 10 years since last dose

*Pregnant patients: As part of standard wound management care to prevent tetanus, a vaccine containing tetanus toxoid might be recommended for wound
management in a pregnant woman if 5 years or more have elapsed since the previous Td booster. If a Td booster is recommended for a pregnant patient,
healthcare providers administer Tdap. Source: https://www.cdc.gov/disasters/disease/tetanus.html. TIG, tetanus immune globulin.

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ASSESSMENT  Figure 10-9: Pathophysiology of Compartment

Syndrome in the Lower Leg. The cross-sectional view
Extremities may initially seem viable due to collateral shows the anterior, lateral, superficial posterior, and
circulation, which can maintain some blood flow. However, deep posterior compartments of the lower leg. Increased
nonocclusive vascular injuries, such as intimal tears or compression pressure within one or more compartments, due to
by external forces, can lead to symptoms of coolness, delayed external compression, edema, or internal bleeding,
capillary refill, reduced peripheral pulses, and an abnormal ABI. restricts perfusion and leads to decreased oxygen delivery
In cases where there is a complete disruption of blood flow, the to tissues. If left untreated, the sustained pressure
limb may appear cold, pale, and pulseless, signaling an urgent need compromises muscle, nerve, and vascular function,
resulting in tissue ischemia and necrosis. Early recognition
for medical intervention. While not immediately life-threatening,
and intervention are crucial to prevent irreversible
timely recognition and management of these symptoms are damage.
critical to prevent irreversible damage. Early surgical intervention
for revascularization may be necessary to restore blood flow and
prevent muscle necrosis and nerve damage, which can begin
within hours of arterial disruption.

MANAGEMENT
It is critical to recognize that perfusion of an injured limb
cannot be adequately assessed until length, alignment, and
rotation of the limb have been restored. For dislocations
and fractures, gentle realignment of the limb to its natural
length and position to match the uninjured side, followed by
splinting, can often restore blood flow, especially when arterial
compression is due to fracture displacement. Initially perfect
anatomic alignment is not necessary. The goal is to restore the
general course of the nerves and vessels and to relieve pain.
In cases where arterial injury is coupled with major joint
dislocation, carefully attempt reduction or splint the joint as is and ASSESSMENT
obtain orthopaedic surgical consultation. While CT angiography Pain is the earliest indication of compartment syndrome.
is a valuable diagnostic tool for assessing vascular injuries, it Pain disproportionate to the injury, pain unrelieved by analgesics,
should not postpone the restoration of blood flow and is best and pain upon stretching the affected muscles are characteristic
utilized following surgical consultation. findings in patients with acute compartment syndrome ( Box
Splinting of an injured limb carries a risk of vascular 10-2). Acute compartment syndrome is a clinical diagnosis based
compromise; therefore, a thorough neurovascular assessment on the mechanism of injury and observation of the above clinical
is essential before and after any splinting or immobilization. signs.
Any decrease in pulse strength or increase in pain after Early and accurate diagnosis is vital to prevent severe
splinting should be immediately reevaluated. Circumferential
 Box 10-2: Signs and Symptoms of Compartment
dressings, casts, or splints that compromise vascular integrity Syndrome.
should be loosened or removed to reassess and document blood
supply, ensuring the limb’s viability is not endangered.
Signs and symptoms of compartment syndrome
COMPARTMENT SYNDROME
Compartment syndrome develops when increased pressure • Pain greater than expected and out of proportion
within an unyielding anatomical space causes ischemia, vascular to the stimulus or injury
congestion, and subsequent anoxic and metabolic injury. This
• Pain on passive stretch of the affected muscle
condition can rapidly progress to tissue death if not treated
promptly. The increased pressure can stem from factors like • Tense swelling of the affected compartment
internal bleeding or swelling from injury or revascularization
• Paresthesias or altered sensation distal to the
of an ischemic limb, or externally from tight dressings that
affected compartment
limit compartment volume. Although commonly seen within
myofascial compartments of the limbs, the presence of an intact
fascial barrier is not a prerequisite for compartment syndrome.
The skin alone can act as a restricting layer, and compartments
can still be compromised in the presence of open fractures.
Common areas at risk for compartment syndrome after injury
include the lower leg, forearm, foot, hand, thigh, and gluteal
regions.  Figure 10-9 demonstrates the pathophysiology of
compartment syndrome.

157
 consequences, such as permanent nerve damage, muscle death,  Figure 10-10: Fasciotomy of the Extremities.
contractures, infection, delayed bone healing, and possibly A. Operative photo of fasciotomy of the forearm. The
amputation. High-risk factors for developing acute compartment volar aspect of the arm is shown with a long skin incision.
syndrome include the following: The subcutaneous fat and fascia are opened and the fascia
• Fractures of the tibia and forearm overlying the muscles is opened to relieve any constriction
to perfusion to the muscles and nerves. B. Operative photo
• Injuries under tight casts or bandages of fasciotomy of the lower leg. The medial incision is
• Severe crush injuries pictured with release of the superficial and deep posterior
compartments. The skin, subcutaneous fat, and fascia have
• Localized, prolonged external pressure (encircling casts, been widely opened. The fascia surrounding the muscles
tourniquets, or dressings) has been released to allow perfusion of the tissues.
• Increased permeability following ischemia
A.
• Circumferential burns
• Extravasation from intravascular infusions
Diagnosis should not wait for the appearance of late signs
like diminished capillary refill, loss of sensation, or absence
of pulses, as these may indicate irreversible damage. Patients
with spinal cord injuries, major peripheral neurological injuries,
multiple concomitant injuries, altered mental status, or heavy
sedation or chemical paralysis may have unreliable clinical
examinations, making the diagnosis of compartment syndrome
more challenging. In these situations, direct measurement of
intracompartmental pressures may be helpful in supporting the
clinical diagnosis of compartment syndrome.
Compartment pressures exceeding 30mmHg suggest
compromised blood flow, possibly warranting urgent medical
intervention. Delta P calculation is more patient specific: the
difference between the measured diastolic blood pressure of B.
the affected limb and the measured compartment pressure is
calculated. A value less than 30 mm Hg heightens the concern for
compartment syndrome.
These findings may be challenging to distinguish from those
expected in a traumatically injured patient, even for experienced
professionals. Any concern for compartment syndrome should be
escalated to a more experienced clinician or specialist consultation.
Consider transfer if expertise is not available locally.

MANAGEMENT
The management of compartment syndrome is time-
sensitive and requires frequent reexamination. Compartment
syndrome is a dynamic process and may change with fluid
shifts, ongoing bleeding, and progressive tissue edema; CRUSH SYNDROME/REPERFUSION
higher and prolonged pressures within the compartment can
SYNDROME
cause extensive neuromuscular damage. Immediate surgical
consultation for a fasciotomy ( Figures 10-10A and B are Crush syndrome, also known as traumatic rhabdomyolysis,
operative photos following decompressive fasciotomy) is the encompasses the systemic and renal complications arising from
definitive treatment to relieve pressure and prevent permanent significant muscle damage. This condition typically follows a
damage. Early intervention is crucial, and any constrictive compression injury to a large muscle group, such as the thigh or
materials should be removed to assess and improve blood flow. calf, and involves a complex interplay of direct muscle trauma,
Given that pain out of proportion is a hallmark finding in ischemia, and necrosis. These injuries result in the release of
compartment syndrome, a careful approach to pain management myoglobin and other cellular contents into the circulatory
is necessary in those who are at risk. Interventions that could system, which can precipitate acute renal injury, systemic
mask an evolving compartment syndrome—such as regional inflammation, metabolic derangements, and shock. A critical
anesthesia—should be avoided if possible. Clinicians should be aspect of this syndrome is the rapid release of electrolytes
aware of the potential complexities in diagnosing compartment and byproducts of anaerobic metabolism, which can disrupt
syndrome amidst multiple injuries or sedation, underscoring the cardiac conduction and neural function. A notable risk is the
need for vigilance and a high index of suspicion. sudden increase in potassium levels during reperfusion, which
can trigger life-threatening cardiac arrhythmias.

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In the prehospital context, it is crucial for medical professionals The tetanus infection risk escalates with wounds that
to recognize the potential for crush syndrome based on the are older than 6 hours, deeply contused or abraded, deeper
mechanism of injury and maintain a high index of suspicion. than 1 cm, or resulting from burns or high-velocity impacts.
Information on the duration and nature of compression, as Wounds with heavy contamination, local tissue denervation, or
well as the total ischemic time, is valuable, especially in cases of ischemia also pose a higher risk. It’s important to assess tetanus
entrapment, such as motor vehicle accidents with cabin intrusion. immunization status in these scenarios.
It’s critical to note that the clinical presentation of significant
ASSESSMENT contusions can evolve over time, and initial assessments might not
Diagnostically, myoglobin release is indicated by dark amber fully reflect the injury’s severity. Documentation of contusions’
urine that tests positive for hemoglobin, and a serum creatine locations and sizes at the first evaluation is vital, with periodic
kinase level exceeding 10,000 U/L serves as a marker for reevaluation recommended. Sometimes, deep bleeding may not
rhabdomyolysis in the absence of urine myoglobin measurements. become visually apparent at the skin level for hours or even days.
Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia,
hypocalcemia, and coagulation abnormalities. These disturbances NEUROLOGICAL INJURY SECONDARY TO
may compound the risks associated with shock, blood loss, and FRACTURE OR DISLOCATION
the need for massive transfusion.
Displaced fractures and those involving joint dislocations
MANAGEMENT are at a heightened risk for causing neurological injuries due
Early administration of IV fluids is essential for mitigating to the close anatomical relationship with major nerves. For
renal damage and preventing acute renal failure. However, example, a posterior hip dislocation can compress the sciatic
the approach to fluid resuscitation must be carefully balanced nerve, and an anterior shoulder dislocation can injure the
against the risks of exacerbating hemorrhage, particularly in axillary nerve. These nerves may be damaged by blunt distracting
trauma patients with ongoing bleeding. Overly aggressive fluid forces or when they traverse from one anatomical compartment
resuscitation can potentially dislodge clots, dilute coagulation to another, leading to conditions like neuropraxia or direct
factors, and worsen bleeding. compression injuries.
Although there is no consensus on the use of bicarbonate
therapy for intravascular alkalization in the initial management ASSESSMENT
of severe trauma patients, it may have a role in later stages of Early and accurate identification of these injuries is crucial
care under the guidance of experienced critical care personnel. for optimal recovery, emphasizing the need for a focused
Balancing the dual priorities of trauma resuscitation and renal neurologic examination in patients with musculoskeletal injuries.
protection underscores the complexity of managing crush Establishing a baseline of neurological function and monitoring
syndrome in severely injured patients. for any changes are key steps in the assessment. This often
involves evaluating motor function and sensation in a structured
COMMON MUSCULOSKELETAL CAUSES OF manner for significant peripheral nerves, which requires patient
PERMANENT IMPAIRMENT cooperation.  Table 10-4 describe the injuries that may be
associated with nerve injury and diagnostic cues. Additionally,
muscle testing should be performed, including palpation of the
CONTUSIONS AND LACERATIONS contracting muscle.
When evaluating simple contusions and lacerations, it’s In cases of polytrauma, initial nerve function assessment can
essential to consider the potential for overlooked vascular or be challenging but should be revisited frequently, particularly
neurologic damage. Generally, lacerations necessitate cleaning, after patient stabilization. Documenting any progression in
appropriate debridement, and suturing. Lacerations penetrating neurologic symptoms is vital, as it may indicate ongoing nerve
below established fascial layers may warrant surgical exploration compression and can influence surgical decisions.
to thoroughly evaluate for deeper structural harm. Contusions,
typically marked by localized pain, swelling, and tenderness, are MANAGEMENT
initially managed by restricting movement of the affected area and
Managing these injuries includes aligning and immobilizing
applying ice.
the affected bones and joints. Experienced clinicians might
Crushing injuries and internal degloving might not
also attempt to reduce dislocations and subsequently reassess
be immediately apparent and may be suspected from the
neurologic function and immobilization of the limb. It is
injury mechanism alone. Crush injuries can lead to muscle
essential to inform the subsequent care clinician about the
devascularization and necrosis, while soft-tissue avulsion
dislocation and its successful reduction.
injuries may separate skin from underlying fascia or its vascular
Before any treatment or intervention, thoroughly assessing
supply, potentially leading to skin necrosis or accumulation of
and documenting the distal neurovascular status of the injured
blood or fluid (Morel-Lavallee lesion). Signs such as overlying
extremity is imperative. This is because a limb that exhibits
abrasions or bruising might indicate severe muscle damage or the
dysesthesia (abnormal sensation) post manipulation, without a
risk of complications like compartment syndrome. In cases of
prior assessment of its neurovascular status, poses a diagnostic
significant concern, surgical consultation for potential drainage or
challenge in distinguishing whether the nerve dysfunction was
debridement is advisable.
caused by the initial injury or the medical intervention.

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  Table 10-4: Peripheral Nerve Assessment of the Extremities. This table lists nerves that may be injured in
association with upper- and lower-extremity fractures or dislocations.

Peripheral Nerve Assessment

UPPER Nerve Motor Sensation Injury

extremities
Ulnar Index and little Little finger Elbow injury
finger abduction

Median distal Thenar contraction Distal tip of index finger Wrist fracture
with opposition or dislocation

Median, anterior Index tip flexion None Supracondylar fracture

of humerus (children)
interosseous

Musculocutaneous Elbow flexion Radial forearm Anterior shoulder

dislocation

Radial Thumb, finger First dorsal web space Distal humeral shaft,
metacarpophalangeal anterior shoulder
extension dislocation

Axillary Deltoid Lateral shoulder Anterior shoulder

dislocation, proximal
humerus fracture

LOWER Femoral Knee extension Anterior knee Pubic rami fractures

extremities
Obturator Hip adduction Medial thigh Obturator ring fractures

Posterior tibial Toe flexion Sole of foot Knee dislocation

Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture,
knee dislocation

Deep peroneal Ankle/toe dorsiflexion Dorsal first to second Fibular neck fracture,
web space compartment syndrome

Sciatic nerve Ankle dorsiflexion Foot Posterior hip dislocation

or plantar flexion

Superior gluteal Hip abduction Upper buttocks Acetabular fracture

Inferior gluteal Gluteus maximus Lower buttocks Acetabular fracture

hip extnesion

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JOINT AND LIGAMENT INJURIES ADJUNCTS

The mechanism of injury plays a pivotal role in the assessment
of acute joint injuries. Patients might describe experiencing
FRACTURE IMMOBILIZATION
unusual forces acting upon the joint at the time of injury, such The primary aims of initially immobilizing a fracture are to
as a direct blow to the front of the knee (e.g., knee hitting the realign the affected limb to its natural anatomical position as
dashboard in a vehicle collision) leading to posterior subluxation accurately as possible and to minimize movement at the fracture
of the knee, an ankle twisting due to an awkward landing from a site to prevent further injury. In situations involving open
jump resulting in damage to the lateral ligament complex, or an fractures, attempting reduction can lead to the repositioning of
injury caused by falling onto an outstretched hand that forces the previously exposed bone ends within the wound, necessitating
elbow into hyperextension. thorough documentation of any bone exposure or skin penetration
due to the potential for changes in visibility upon subsequent
ASSESSMENT examinations. Immediate cleansing of the wound to remove
Upon physical examination, the injured joint typically shows contamination, prompt administration of antibiotics based
tenderness. Presence of hemarthrosis (bleeding within the joint) is on the patient’s weight, and a tetanus booster are critical for
common, except when the joint capsule is torn, which allows blood patients with open fractures or significant soft-tissue injuries.
to spread into surrounding soft tissues. Testing for ligamentous In cases of joint dislocations, some healthcare clinicians may
integrity through passive movements may demonstrate significant be skilled and confident enough to attempt closed reduction. If
instability. X-ray imaging might not show major abnormalities but the joint is successfully realigned, it should be immobilized using
could reveal minor avulsion fractures at the sites where ligaments well-padded prefabricated splints, pillows, or casts to keep the
attach to bones. limb in its corrected position. Should the reduction attempt fail,
splint it in its current position.
MANAGEMENT It’s crucial to prioritize life-saving interventions over
splinting for extremity injuries, except in scenarios where
It is crucial to immobilize the joint and regularly monitor hemodynamic instability is caused by femoral shaft fractures.
vascular and neurological function below the level of the injury. Here, fracture reduction might be integral to the resuscitation
Knee dislocations, for example, often spontaneously reduce to a process, falling under efforts to restore circulation. Additionally,
position close to normal anatomy and might not be immediately the neurovascular status of the injured extremity must be
obvious. In cases of knee injuries involving multiple ligaments, thoroughly evaluated and documented both before and after any
there may have been a dislocation that could pose a risk of manipulation or splinting to ensure no additional harm is caused.
neurovascular compromise. Such injuries typically necessitate Reducing dislocations and reducing and splinting fractures
a surgical consultation for proper stabilization of the joint. will ultimately make these injuries less painful, but it is important
Careful assessment of the vascular status of the limb is warranted. to remember that these maneuvers will likely produce significant
pain. The process should be explained to the patient and adequate
ISOLATED FRACTURES analgesia provided.
Special caution is advised in cases with concurrent unstable
Fracture patterns can convey information about the forces pelvic injuries, disruptions at the splint’s fixation points,
involved at the time of the injury. Accurate description of the additional fractures below the femoral shaft fracture, partial
identified fractures is important. Elements of the description or complete amputation of the distal extremity, or limbs that
should include the bone and segment involved (i.e., diaphyseal, have been deemed nonviable. In such scenarios, alternative
metaphyseal, or intraarticular), the character of fracture (i.e., methods of immobilization and care must be considered to avoid
simple or comminuted), and the pattern of the fracture (i.e., compromising the limb’s neurovascular integrity.
transverse, spiral, oblique, or complete versus incomplete).
PRINCIPLES OF SPLINTING AND IMMOBILIZATION
ASSESSMENT In general, for long bone injuries, appropriate immobilization
Pain, tenderness, swelling, and deformity are the hallmarks of requires inclusion of the joints above and below the fractured long
extremity-fracture diagnosis. It is not necessary to elicit abnormal bone. For joint injuries, immobilization of the bones above and
mobility or crepitus, as these maneuvers increase pain and soft- below the joint is necessary to fully immobilize the injured area.
tissue injury. Functionally appropriate alignment of the joint or limb should be
maintained as much as possible. For example, for knee injuries,
MANAGEMENT application of a posterior long-leg plaster back slab can be an
effective means of maintaining comfort and stability of the knee.
Immobilization of the fracture requires inclusion of the Where possible, immobilize the knee not in complete extension
joints above and below the fracture. Neurovascular status is but with approximately 10 degrees of flexion to reduce tension on
assessed before and after splinting. Orthopaedic consult is the posterior neurovascular structures ( Figure 10-11).
obtained for definitive management.

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  Figure 10-11: Stabilization of a Lower-Extremity Injury.  Figure 10-12: Initial Fracture Immobilization. The goal
This figure demonstrates the application of a long-leg of initial fracture immobilization is to realign the injured
posterior splint for stabilization of a lower-extremity injury. extremity in as close to anatomic position as possible and
The splint provides immobilization by extending from the prevent excessive fracture-site motion. A. Shortening and
foot to the thigh, maintaining the knee at a slight flexion external rotation of right leg due to a mid-shaft femur
angle of approximately 10 degrees. Proper padding and fracture. B. Application of inline traction with stabilization
secure wrapping ensure that the limb is supported while of the leg in normal anatomic position.
minimizing movement, reducing pain, and preventing
further damage to surrounding tissues. This technique A.
is particularly useful for managing fractures, ligament
injuries, or severe soft-tissue damage in the lower
extremity before definitive treatment.

FEMUR FRACTURES
To immobilize femoral shaft fractures, apply inline traction
to straighten the limb, then place an immobilization device to
maintain alignment ( Figure 10-12). Traction splints can be
used for this purpose. These devices, designed specifically for
femoral shaft (diaphyseal) fractures, apply force distally at the
ankle and are positioned proximally against the major gluteal
crease to reflect the ischial tuberosity’s surface marking. It’s crucial B.
to note that traction splints are not suitable for all injuries and
may be harmful or of limited value for conditions like associated
pelvic fractures, femoral neck or peritrochanteric fractures, or
concurrent ipsilateral tibial and femoral fractures, often referred
to as a “floating knee.”
Before applying a traction splint, the patient’s distal
neurovascular status must be assessed and documented. While
traction splints are not meant for definitive fixation or to
achieve perfect anatomical reduction, their correct application
aims to better align the limb and reduce fracture-related
bleeding by minimizing potential bleeding space and applying
tamponading pressure. However, excessive traction can damage
the skin or exacerbate neurovascular compromise. If worsening of
neurovascular status is noted after splint application, the traction
should be reduced, or the splint may need to be removed and the
limb repositioned to restore distal pulses.
In situations where a traction splint is not available or not
feasible, the leg may be immobilized by a long plaster splint
extending from ankle to waist, or even splinted to the intact
contralateral leg.

OTHER FRACTURES
For fractures of other long bones, while acute reduction and
stabilization of the reduced position are necessary, continuous
traction may not always be required. Employing properly shaped
or well-fitting splints can aid in managing blood loss, alleviating
pain, and safeguarding against additional neurovascular and soft-
tissue damage. Immobilize tibial fractures to minimize pain and
further soft-tissue injury and decrease the risk of compartment
syndrome. If readily available, well-padded plaster splints

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immobilizing the lower thigh, knee, and ankle are preferred

 Figure 10-14: Splinting a Hand Injury. This figure
( Figure 10-11). shows the correct positioning for splinting a hand injury,
Ankle fractures may be immobilized with a well-padded splint including fractures and soft-tissue injuries. The wrist
or back slab, thereby decreasing pain while avoiding pressure over is placed in 10-45 degrees of extension for optimal
local bony prominences ( Figure 10-13). functional alignment. The metacarpophalangeal (MCP)
To temporarily splint the hand in a functional and anatomical joints are flexed at 60-90 degrees, while the proximal
position, the wrist should be slightly dorsiflexed and the fingers interphalangeal (PIP) and distal interphalangeal (DIP)
flexed at a 45-degree angle at the metacarpophalangeal joints joints are kept in full extension. This positioning maintains
( Figure 10-14). This is often achieved by placing the hand over a the hand in a functional posture, reducing tension on
ligaments and tendons, while minimizing joint stiffness
 Figure 10-13: Application of a Splint for an Ankle and preventing deformity during the healing process.
Fracture. Illustrates the application of a splint for an Proper padding and secure wrapping are essential to
ankle fracture using posterior and sugar-tong splints. A. maintain this position and ensure comfort.
Demonstrates the use of extensive padding around the
lower extremity to ensure proper cushioning and prevent
pressure injuries, with the posterior and sugar-tong plaster
splints being secured in place using an elastic bandage. B.
Shows the completed splint, which immobilizes the ankle
and foot, maintaining stability to minimize movement
and reduce the risk of further injury before definitive
treatment. Proper padding and secure placement are
crucial for effective splinting and patient comfort.

A.

large roll of gauze and securing it with a short arm splint.

For immobilizing the forearm and wrist, flat padded or pillow

splints are used to maintain a stable position. The elbow is usually
kept in a flexed position using padded splints or immobilized
close to the body with a pouch or a broad arm sling. Upper-
B. arm stabilization can be achieved by splinting the arm to the
body or using a sling or swath, potentially reinforced with a
thoracobrachial bandage or a hanging plaster U-slab to ensure
coronal alignment and provide axial support. Shoulder injuries
are commonly managed with broad arm slings or collar-and-
cuff devices to maintain a safe and effective position for healing
( Figure 10-15).

X-RAY EXAMINATION
While x-ray imaging for skeletal injuries is typically part of
the secondary survey, it may be necessary during the primary
survey if fractures are suspected to contribute to shock. The
choice and timing of x-rays should be guided by initial clinical
observations, the patient’s hemodynamic stability, and the injury
mechanism. In the context of significant trauma, chest and
anteroposterior (AP) pelvic x-rays are commonly indicated, yet

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  Figure 10-15: Immobilizing a Shoulder Injury. A. This figure depicts the proper use of a sling for immobilizing a shoulder
injury. The sling supports the forearm and helps to stabilize the shoulder, reducing movement and providing comfort for
conditions such as shoulder dislocations, fractures, or soft-tissue injuries. Proper fitting of the sling is crucial to ensure
the elbow is supported at a right angle and that the hand is slightly elevated to minimize swelling. This immobilization
technique is effective in initial management while awaiting further evaluation and definitive treatment. B. This figure
demonstrates the application of a sling and swathe for immobilization of a shoulder injury. The sling supports the arm,
while the swathe secures the arm to the chest, limiting shoulder movement and providing additional stability. This
immobilization technique is particularly useful for managing shoulder dislocations, clavicle fractures, and proximal
humerus fractures by reducing pain and preventing further injury during transport and initial treatment. Proper application
is key to ensure comfort and maintain effective immobilization. C. This figure shows the use of a “cuff and collar” sling,
which is a simple and effective method for immobilizing shoulder injuries. The cuff supports the wrist, while the collar loop
secures the arm close to the body, providing stabilization and allowing the shoulder to rest in a comfortable position. This
technique is particularly useful for shoulder dislocations, clavicle fractures, and proximal humerus injuries, minimizing
movement and reducing pain.

A. B. C.

their utility and optimal timing hinge on the patient’s current  Figure 10-16: Radiograph of the Lower Extremity.
condition and clinical presentation. A. Radiograph of the lower extremity that includes the
For musculoskeletal imaging beyond the chest and pelvis, knee and ankle joint, the joint above and the joint below
it’s crucial to adhere to orthopaedic imaging guidelines, the comminuted distal tibia and fibula fracture.
which recommend capturing the entire bone in at least two B. Perpendicular view of the same extremity including the
orthogonal (perpendicular) views, including the joints above joint above and below the level of the fracture.
and below the injury site. This practice minimizes the risk of
overlooking associated injuries ( Figure 10-16).
A. B.
An essential consideration is that x-rays or other imaging not
directly relevant to immediate care should not be performed
if they could delay more critical interventions. For instance,
ankle x-rays are seldom justified in cases of potential airway
compromise. However, when additional imaging does not
detract from urgent care or delay treatment, it should be
arranged so that all necessary images are obtained efficiently
in one session, ensuring safety and minimizing disruptions.

The clinical examination of patients with musculoskeletal

injuries frequently necessitates x-ray imaging to confirm
diagnoses. Signs such as tenderness at a bone site, especially when
accompanied by visible deformity, strongly suggest a fracture.
X-rays should be obtained for hemodynamically stable patients,
provided that the imaging does not interfere with more urgent
care priorities. Symptoms like joint effusion, unusual tenderness
around a joint, and joint deformity often point to joint injuries or

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dislocations, which also warrant x-ray evaluation. SECONDARY SURVEY

However, immediate x-ray imaging may be deferred in cases
where there is neurovascular compromise or a risk of skin During the initial assessment of trauma patients, not all
breakdown, conditions often observed with fracture dislocations injuries are immediately apparent. Areas with dense muscle
of the ankle. In situations where x-ray acquisition is delayed, coverage or significant subcutaneous fat can hide occult
prompt reduction or realignment of the affected limb is critical to injuries, making it challenging to detect fractures with minimal
restore arterial blood flow and alleviate pressure on the skin, with displacement or subtle ligamentous damage to joints. This
subsequent immobilization to maintain alignment until further difficulty is compounded if the patient is unable to respond or
assessment and treatment can be provided ( Figure 10-17). has multiple severe injuries that may distract from less obvious
Radiation safety is paramount for everyone in the vicinity ones. It’s not uncommon for some injuries to be identified hours
during x-ray procedures, so follow local protocols. Nonessential or days later when the patient is mobilized. This underscores
personnel should exit the area during x-ray acquisition, while the importance of ongoing patient reassessment and continuous
those remaining should use protective measures like lead aprons or communication among the trauma care team to remain vigilant
shields. Patient safety regarding radiation exposure also demands for potential hidden skeletal injuries.
careful consideration, including limiting unnecessary images and The importance of thoroughly understanding the mechanism
employing proper beam collimation to minimize exposure. leading to an injury and the time elapsed from the incident to
medical evaluation cannot be overstated. Gathering detailed
 Figure 10-17: Dislocation of the Distal Ankle. A. Note
information from various sources—including the patient, their
the lateral dislocation of the distal ankle. B. There is
nonhemorrhagic vascular compromise and skin tenting.
family, emergency responders, and witnesses provide clinicians
Blanched skin associated with fractures and dislocations a comprehensive view of the event. This information should be
will quickly lead to soft-tissue necrosis. Prompt reduction meticulously documented as part of the patient’s initial history.
will prevent pressure necrosis of the tissue. Analyzing the injury’s mechanism allows healthcare providers
to predict both significant and minor musculoskeletal injuries
A. that might not be immediately visible. This involves mentally
reconstructing the incident, considering the forces involved and
the potential for associated injuries beyond the musculoskeletal
system. By doing so, practitioners can more accurately assess the
patient’s condition and tailor their approach to treatment.
Understanding a patient’s condition prior to an injury is crucial
for tailoring the treatment plan and predicting the outcome.
Gathering a comprehensive history, including the AMPLE
information, is crucial and should be thoroughly documented.
Beyond AMPLE, knowing the patient’s usual level of physical
activity, medication use (both prescribed and over-the-counter),
alcohol and illicit drug use, emotional and mental health status, and
history of musculoskeletal injuries can significantly inform and
guide clinical decision-making. This holistic view of the patient’s
preinjury condition allows healthcare clinicians to consider all
factors that might influence recovery and rehabilitation strategies,
B. ensuring the care plan is as effective and personalized as possible.
Visual inspection of limbs should assess skin color, swelling,
deformity, and malalignment. A comprehensive visual check from
head to toe is crucial to spot major external bleeding. Pale or
white extremities may indicate poor arterial flow, while swelling in
major muscle areas could suggest crush injuries or compartment
syndrome. Swelling or bruising around joints or on bones hints at
musculoskeletal injuries, and visible limb deformities often signal
severe injuries.
Inspecting the patient’s entire body for lacerations and
abrasions is essential, including areas not immediately visible,
necessitating careful patient repositioning to uncover potential
hidden wounds. Fractures associated with open wounds should
be presumed open until evaluated by a surgeon.
Observation of spontaneous motor function in the extremities
aids in identifying neurological or muscular impairments. In
conscious patients, the absence of spontaneous movement can
indicate dysfunction. Assessing active muscle and nerve function
involves having the patient move major muscle groups and joints
to ensure integrity.

165
 Palpation helps determine skin sensation and identify Upon deciding to transfer a patient, ensuring their stability
tender areas indicating possible fractures or nerve injuries. Joint for the journey is paramount, alongside arranging for necessary
stability is assessed through clinical examination for abnormal supports like splints, binders, and dressings to maintain
joint motion or tenderness that may suggest ligamentous injury. immobilization and promote safe transit. Pressure points should
Excessive pain might limit this assessment due to muscular be padded to prevent skin breakdown.
guarding, necessitating reevaluation. Transfer documentation must be clear and comprehensive,
Circulatory assessment involves palpating distal pulses, including the patient’s neurovascular status, details of any
as well as comparing perfusion and capillary refill across all peripheral ischemic events (e.g., tourniquet application times),
extremities. In cases of hypotension, Doppler assessment may be interventions undertaken, and a list of confirmed or suspected
used to evaluate vascular flow. Discrepancies in pulses, extremity injuries. While definitive diagnoses may not always be possible at
coolness, or pallor could indicate arterial injuries, especially near the initial assessment stage, conveying the extent of documented
open wounds or fractures. or suspected injuries and any administered medications, including
Some dislocations may spontaneously reduce, hiding their antibiotics and tetanus prophylaxis, is critical for continuity of care
severity until a thorough physical examination is conducted. at the receiving facility. This approach ensures that the transition
These can be associated with significant arterial injuries of care is smooth and that the receiving team is fully informed and
and may manifest as ischemic limbs or rapidly expanding prepared to continue appropriate treatment immediately.
hematomas, indicating arterial damage.
PAIN CONTROL PRACTICE ENVIRONMENT CONSIDERATIONS
Appropriately splinting fractures or injured joints is crucial Prefabricated splints and traction weights may not be readily
for reducing a patient’s discomfort by minimizing movement at available. Pieces of wood, string, cloth, bags, or bottles filled with
the injury site. Should pain persist or recur despite splinting, it’s fluid and rocks can be creatively assembled to create traction
important to reassess the limb, possibly removing the splint for devices and splints. Pillows, blankets, and towels may be used
further evaluation. Analgesics are recommended for managing instead of foam or cotton wool for padding when those options
pain associated with joint injuries and fractures. Notably, patients are not available. Prioritize needed imaging in cases of limited
not exhibiting expected pain levels from significant fractures availability. Limb salvage may not be an option in areas where
may have other injuries affecting sensory perception, such as operative resources and transfer capabilities don’t exist.
intracranial or spinal cord injuries, or could be influenced by
substances like alcohol or drugs.
SPECIAL POPULATIONS
Narcotics are often necessary for effective pain
management, administered intravenously in small, titrated doses The energy required to cause a fracture in an older, frail patient
and readministered as needed. When using sedatives, especially may be trivial. Fractures can be difficult to identify on plain x-rays
for procedures like dislocation reductions in patients with isolated in these patients. In pediatrics, fracture patterns and implausible
limb injuries, caution is advised due to the risk of respiratory mechanisms of injury can lead to the suspicion of child abuse.
arrest. Therefore, having resuscitative equipment, naloxone
(Narcan), and flumazenil readily available is essential.
Regional nerve blocks can be effective for pain relief and may
CHAPTER SUMMARY
aid in the reduction of certain fractures. However, it’s critical to Musculoskeletal injury is common in trauma patients. These
document the distal neurovascular status before implementing injuries can threaten both life and limb. During the primary
a nerve block, particularly to identify any preexisting peripheral survey, recognize life-threatening bleeding resulting from
nerve injuries. In cases where acute compartment syndrome is a extremity trauma and initiate the steps to control hemorrhage and
concern, the use of peripheral nerve blocks is contraindicated to resuscitate the patient. Fracture reduction and stabilization can
avoid masking symptoms, making IV analgesics a safer choice. aid in limiting blood loss from extremities and limb-threatening
This approach ensures pain management without compromising ischemia caused by fracture malalignment. A host of injuries can
the ability to diagnosis or monitor for the development of threaten loss of the injured limb if not identified and treated in
potentially serious conditions like compartment syndrome. a timely manner. Careful evaluation can identify patients at risk.

TRANSFER TO DEFINITIVE CARE TIPS

• Initial care practitioners should be cognizant that a
When the musculoskeletal care needs of a patient surpass the nonbleeding vascular injury in an extremity does not
capabilities available locally, prompt referral and planning for take clinical priority over exsanguinating hemorrhage or
transfer are essential. Familiarity with local referral protocols is other higher-priority clinical concerns (i.e., immediate and
crucial to efficiently direct patients to suitable care. It’s important potential life threats) in the Initial Assessment and treatment
to holistically assess the patient’s immediate and long-term needs of a severely injured trauma patient. These injuries represent a
across all affected body systems, ensuring the chosen referral site potential ischemic limb threat and are appropriately managed
has the necessary expertise and resources to address all aspects and triaged as an important but often lesser care priority.
of care. For instance, a patient with femoral shaft fractures and
late-stage pregnancy may require a facility that offers orthopaedic,
obstetric, and neonatal services.

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KEY LEARNING POINTS

• The presence of a distal Doppler signal alone is often
reassuring but does not exclude a significant arterial injury. • Understanding the significance of musculoskeletal
A rapidly expanding pulsatile hematoma, absent distal pulse, injuries: Learners should recognize that injuries
involving the musculoskeletal system in major
or obvious external arterial bleeding are definitive signs of
trauma scenarios can pose immediate potential
arterial injury. threat to life and limb or lead to long-term
• A deformed limb with distal circulatory compromise disabilities.
mandates traction, realignment, splinting, and neurovascular
• Mechanism of injury: It’s crucial for learners to
reevaluation, as this may be sufficient to restore perfusion.
appreciate how the initial mechanism of injury
Always assess and document the distal neurovascular status of can significantly influence the types and patterns
an extremity before and after any intervention or treatment. of musculoskeletal injuries sustained, guiding
• Where clinically appropriate and in keeping with local the anticipation of additional injuries or possible
conventions, obtain clinical photographs of traumatic complications.
wounds/injuries. • Identification of injury patterns: Learners should be
• The diagnosis of acute compartment syndrome may be more able to recognize common musculoskeletal injuries
challenging in patients with spinal cord injury, traumatic or patterns that carry the risk of severe outcomes,
brain injury, altered mental status from medication or including those that potentially threaten life or
limb or could result in permanent disability.
intoxication, or other injuries that may alter their perception
of pain. • Initiation of appropriate treatment: Learners are
• Avoid peripheral nerve blocks in patients at risk for expected to know how to begin proper treatment
for musculoskeletal injuries during the primary
compartment syndrome.
survey of a trauma patient, especially in cases of
• Contusions may evolve over time despite initially appearing severe bleeding.
innocuous.
• Use of musculoskeletal adjuncts: The ability to
• X-rays or other imaging should not interfere with the select and apply musculoskeletal adjuncts during
resuscitation of a patient. the primary and secondary surveys is essential,
based on the patient’s clinical condition and the
TEAMWORK evolution of their injuries.

• Musculoskeletal injuries, especially open fractures, are often • Recognition of transfer needs: Understanding when
dramatic and can potentially distract team members from a patient’s care needs—immediate or anticipated—
resuscitation priorities. The team leader must ensure that surpass the local facility’s capabilities and
team members focus on life-threatening injuries first. necessitate transfer is critical.

• It is critical to recognize that certain musculoskeletal and

limb injuries associated with catastrophic hemorrhage may
rightly represent a severely injured trauma patient’s highest
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37. Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis

in the management of open fractures: A systematic survey
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2019;7(2):e1. DOI: 10.2106/JBJS.RVW.17.00197.
38. Roddy E, Patterson JT, Kandemir U. Delay of antibiotic
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170 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 11 | Trauma in the Pediatric Patient

11

Trauma in the
Pediatric Patient

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Identify the unique characteristics of trauma 3. Describe the injury patterns associated with
in children, including common patterns and child maltreatment and identify the factors that
types of injuries, anatomic and physiologic should raise a suspicion of child maltreatment
differences from adult trauma, and long-term 4. Emphasize the importance of injury prevention
effects of injury initiatives aimed at creating safer environments
2. Discuss the primary management of trauma in and activities for children
children, along with the related issues unique
to pediatric patients that affect resuscitation
and explain the different equipment needs

171
 distinct injury patterns. For example, the most serious pediatric

11
trauma is blunt trauma involving the brain. As a result, apnea,
hypoventilation, and hypoxia secondary to traumatic brain
injury occur far more frequently in children than hemorrhagic
shock following trauma when compared to adults. Therefore,
all treatment protocols for pediatric trauma patients emphasize
aggressive management of airway and breathing.

TYPES AND PATTERNS OF INJURY

Trauma in the Around the world, motor vehicle-related crashes are the
Pediatric Patient leading cause of death in children, whether they are occupants,
pedestrians, or cyclists. In the US, firearm injuries are now the
leading cause of death in children and young adults, followed
by motor vehicle collisions. Deaths due to drowning, house
CHAPTER STATEMENT fires, homicides, and falls follow in descending order. Child
maltreatment accounts for the great majority of homicides in
Pediatric trauma is a leading cause of morbidity and mortality
infants (i.e., children younger than 12 months of age). In contrast,
in children, surpassing all other major childhood diseases. Each
firearm injuries account for most of the homicides in children
year, millions of children require emergency care for injuries,
(over age 1) and adolescents. Falls are responsible for the majority
highlighting the critical need for pediatric readiness in trauma
of pediatric injuries but infrequently result in death.
centers. The anatomical and physiological differences between
Blunt mechanisms of injury coupled with children’s unique
children and adults necessitate specialized approaches to trauma
physical characteristics frequently result in multisystem
assessment and management. Effective airway management, rapid
injuries. Clinicians should presume, therefore, that multiple
volume resuscitation, and early surgical intervention are crucial
organs are injured until proven otherwise.  Table 11-1 outlines
to improving outcomes in severely injured pediatric patients.
common mechanisms of injury and associated injury patterns in
Understanding the common mechanisms of injury, including
pediatric patients.
child maltreatment, is vital for clinicians to anticipate injury
The condition of the majority of injured children will not
patterns and actual injuries. Ultimately, a multidisciplinary, team-
deteriorate during treatment, and most injured children have no
based approach is essential for optimizing the care of injured
hemodynamic abnormalities. However, the condition of some
children.
children with multisystem injuries will rapidly deteriorate,
INTRODUCTION with the development of serious complications. Therefore,
early transfer of severely or multiply injured pediatric patients to
Injury remains the most common cause of death and a facility capable of treating children with multisystem injuries is
disability in childhood. Each year, more than 4.2 million optimal.
children—nearly 1 of every 20 children—in the US require
emergency department care for the treatment of injuries. In GENERAL CONSIDERATIONS
addition, more than 13,000 children and young adults (< 18 years)
Pediatric trauma patients have unique characteristics and
in the US die from serious injury each year. These include 7,800
equipment needs that are much different than those of the adult
unintentional injuries, 3,000 homicides, and 2,300 suicides. Injury
trauma patient.
morbidity and mortality surpass all significant diseases in children
and young adults, making trauma the most serious public health
and healthcare problem in this population.
SIZE, SHAPE, AND SURFACE AREA
Many of these injuries and fatalities are only addressable Because children have smaller body mass than adults, the
through prevention. But among injuries that reach medical energy transmitted from objects such as fenders and bumpers or
care, failure to secure a compromised airway, support breathing, from falls results in greater force being applied per unit of body
and recognize and respond to intra-abdominal and intracranial area. This concentrated energy is transmitted to a body with less
hemorrhage are the leading causes of unsuccessful resuscitation fat, less connective tissue, and closer proximity to multiple organs
in pediatric patients with severe trauma. In contrast to adults, than in an adult body. These factors result in the high frequency
failure to oxygenate and ventilate is the most common cause of multiple injuries seen in the pediatric population. In addition,
of preventable death after injury in children. Therefore, a child’s head is proportionately larger than an adult’s, which
pediatric readiness in emergency departments is critical to results in a higher frequency of brain injuries from blunt trauma.
prevent unnecessary morbidity and mortality. By applying ATLS® Finally, due to the increased ratio of body surface area to body mass
principles to the care of injured children, trauma team members in young children, heat loss is a significant concern. Hypothermia
can significantly affect ultimate survival and long-term outcomes. may develop quickly and complicate resuscitative efforts.
The priorities for assessing and managing pediatric trauma
patients are the same as for adults. However, the pediatric
population’s unique anatomic and physiologic characteristics
combine with the common mechanisms of injury to produce

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 COURSE MANUAL | Chapter 11 | Trauma in the Pediatric Patient

When possible, clinicians should attempt to soothe an

 Table 11-1: Common Mechanisms of Injury and Their
injured child and establish a good rapport, which, in turn, will
Associated Injury Patterns in Pediatric Trauma.
facilitate a comprehensive assessment of the child’s physical and
psychological injuries. Additionally, the presence of parents or
Mechanism other caregivers during evaluation and treatment, including
of Injury Common Patterns of Injury resuscitation, may help decrease the injured child’s natural fears
and anxieties.
Pedestrian • Low speed: Lower-extremity fractures
LONG-TERM EFFECTS OF INJURY
struck • High speed: Multiple trauma, head
by motor and A significant consideration in treating injured children is the
vehicle neck injuries, lower-extremity fractures effect of that injury on their subsequent growth and development.
The potential physiologic and psychological effects of injury on
this process can be significant, particularly in cases involving
Occupant in • Unrestrained: Multiple trauma, head
long-term function, cosmetics, and cognition. Children who
and
motor sustain even a minor injury may suffer prolonged physical and
neck injuries, scalp and facial
vehicle lacerations psychological disability.
collision • Restrained: Chest and abdominal Some evidence suggests that as many as 60% of children who
injuries, sustain severe multisystem trauma have residual personality
lower spine fractures changes one year after hospital discharge, and 50% show
cognitive and physical impairments. Social, affective, and learning
Fall from a • Low: Upper-extremity fractures disabilities are present in one-half of seriously injured children. In
height • Medium: Head and neck injuries,
addition, childhood injuries have a significant impact on family
upper- and dynamics. Two-thirds of uninjured siblings also experience
lower-extremity fractures personality and emotional disturbances. Frequently, a child’s
• High: Multiple trauma, head and neck injuries impose a strain on the parents’ relationship, with possible
injuries, financial and employment hardships. Trauma may affect not only
upper- and lower-extremity fractures the child’s survival but also their quality of life for years to come.
One recently appreciated long-term effect of trauma stems
Fall from a • Without helmet: Head and neck from the widespread use of diagnostic ionizing radiation. Ionizing
bicycle lacerations, scalp radiation may increase the risk of certain malignancies and should
and facial lacerations, upper-extremity only be used if (1) the information needed cannot be obtained by
fractures
other means; (2) the information gained will change the patient’s
• With helmet: Upper-extremity
clinical management; and (3) receiving the studies will not delay
fractures
the transfer of a patient who requires a higher level of care. The
• Striking handlebar: Internal
lowest possible radiation doses should be used if obtaining
abdominal injuries
these studies.
Ultimately, the long-term quality of life for children who
have sustained trauma is surprisingly positive, even though, in
SKELETON many cases, they will experience lifelong physical challenges.
A child’s skeleton is incompletely calcified, contains multiple Most patients report a good to excellent quality of life and find
active growth centers, and is more pliable than an adult’s. Therefore, gainful employment as adults, an outcome justifying aggressive
fractures are less likely to occur in children, even when they have resuscitation attempts even for pediatric patients whose initial
sustained internal organ damage. For example, rib fractures physiologic status might suggest otherwise.
in children are uncommon, whereas pulmonary contusions
are not. Other soft tissues of the thorax and mediastinum can EQUIPMENT
sustain significant injury without evidence of bony injury or Successful assessment and treatment of injured children
external trauma. The presence of skull or rib fractures in a child requires immediate access to appropriately sized equipment. A
suggests the transfer of considerable energy; when they occur, length-based resuscitation tape, such as the Broselow Pediatric
underlying organ injuries, such as traumatic brain injury (TBI) Emergency Tape, is an ideal adjunct for rapidly estimating
and pulmonary contusion, should be highly suspected. the patient’s weight for appropriate fluid volumes, drug doses,
and equipment size. One side of the tape lists drugs and their
PSYCHOLOGICAL STATUS recommended doses for pediatric patients based on weight, and
The potential for significant psychological ramifications should be the other side identifies equipment needs for pediatric patients
considered in children who experience trauma. Young children may based on length. Clinicians should be familiar with length-
demonstrate regressive psychological behavior when they experience based resuscitation tapes and their uses and ensure their practice
stress, pain, or disruptions to their environment. Children have a location has appropriately sized equipment for patients of all
limited ability to interact with unfamiliar individuals in unusual and ages. Several vendors offer smartphone applications designed to
stressful situations; this can lead to significant difficulty in taking a aid the clinician with weight- and size-based recommendations.
history and performing a physical exam. ( Table 11-2)

173
  Table 11-2: Pediatric Equipment Recommendations. Successful assessment and management of injured
children depends on the immediate availability of pediatric equipment of appropriate size.

Airway and Breathing

Age and O2 Oral Laryngo-

weight mask airway Bag-valve scope ET tube Stylet Suction

Preemie Preemie, Infant Infant 0 straight 2.5–3.0 6 Fr 6–8 Fr

3 kg newborn no cuff

0–6 mos Newborn Infant, Infant 1 straight 3.0–3.5 6 Fr 8 Fr

3.5 kg small no cuff

6–12 mos Pediatric Small Pediatric 1 straight 3.5–4.0 6 Fr 8-10 Fr

7 kg cuffed or
uncuffed

1–3 yrs Pediatric Small Pediatric 1 straight 4.0–4.5 6 Fr 10 Fr

10–12 kg cuffed or
uncuffed

4–7 yrs Pediatric Medium Pediatric 2 straight or 5.0–5.5 14 Fr 14 Fr

16–18 kg curved no cuff

8–10 yrs Adult Medium, Pediatric, 2-3 straight 5.5–6.5 14 Fr 14 Fr

24–30 kg large adult or curved cuffed

Circulation Supplemental Equipment

Age
and IV OG/NG Chest Urinary Cervical
weight BP cuff catheterb tube tube catheter collar

Preemie Preemie, newborn 22–24 ga 8 Fr 10-14 Fr 5 Fr feeding —

3 kg

0–6 mos Newborn, infant 22 ga 10 Fr 12-18 Fr 6 Fr or 5–8 —

3.5 kg Fr
feeding

6–12 mos Infant, child 22 ga 12 Fr 14-20 Fr 8 Fr Small

7 kg

1–3 yrs Child 20-22 ga 12 Fr 14-24 Fr 10 Fr Small

10–12 kg

4–7 yrs Child 20 ga 12 Fr 20-28 Fr 10-12 Fr Small

16–18 kg

8–10 yrs Child, adult 18-20 ga 14 Fr 28-32 Fr 12 Fr Medium

24–30 kg

a
Use of a length-based resuscitation tape, such as a BroselowTM Pediatric Emergency Tape, is preferred.
b
Use of the largest IV catheter that can readily be inserted with reasonable certainty of success is preferred.
ET, Endotracheal; BP, Blood pressure; OG, Orogastric; NG, Nasogastric.

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 COURSE MANUAL | Chapter 11 | Trauma in the Pediatric Patient

PEDIATRIC ANATOMIC CONSIDERATIONS • Maintain cervical spinal motion restriction at all times when
indicated
Clinicians caring for pediatric trauma patients must consider
• Maintain the face and torso in the same plane, parallel to the
the following anatomic differences in children during primary
stretcher
survey and airway management:
• Perform the jaw-thrust maneuver
• A proportionally larger occiput in infants and young children
may result in neck flexion when supine, resulting in airway • Head tilt should not be performed unless the cervical spine
obstruction. If indicated, placing a layer of padding beneath has been cleared or if the patient has a completely obstructed
the torso while maintaining cervical spine immobilization airway and cannot be ventilated with jaw thrust alone
may help alleviate positional airway obstruction. • Suction should be readily available to clear the mouth of
• A relatively large tongue in infants and young children may saliva, blood, secretions, or vomit
contribute to airway obstruction, especially in obtunded • Administer 100% oxygen
patients, and may be challenging to control and displace
during direct laryngoscopy. An appropriately sized If the above measures result in a clear, maintainable airway,
oropharyngeal airway (OPA) can hold the tongue anteriorly, continue to monitor closely during resuscitation. If the airway
maintaining airway patency during mask ventilation. is not clear or maintainable, preparations should be made to
establish a definitive airway while assisting ventilation with 100%
• Tonsillar hypertrophy is common in children and may oxygen, if indicated. Preoxygenation before intubation has been
complicate visualization during laryngoscopy. shown in prehospital studies to be critical for achieving good
• The larynx is more cephalad and anterior than in adults, patient outcomes.
creating a more acute angle between the base of the tongue Pediatric-size oral and nasal airways are available even for
and the glottis. neonates. Nasal airways should not be used in trauma patients
unless there is no concern for basilar skull fracture or facial
• Children have a relatively large, floppy epiglottis, which
trauma. An oropharyngeal airway (OPA) should not be used in
may be easier to mobilize with a straight rather than
awake patients, as it will likely induce vomiting. In an unconscious
curved laryngoscope blade.
patient, an OPA may facilitate bag-mask ventilation while
• The neonatal trachea is about 5 cm long and increases preparing for endotracheal intubation. The tip of a properly sized
to about 12 cm in adults. A shorter trachea in children OPA should reach the angle of the mandible when held against
predispose to right mainstem intubation and endotracheal the patient’s cheek with the flange at the corner of the mouth. To
tube (ETT) displacement. A reasonable estimate for proper minimize the risk of iatrogenic oral or tonsillar trauma, do not
ETT depth from the gums (in centimeters) is three times the insert the OPA upside down and rotate it into place. Instead,
tube diameter when adequately sized. while using a tongue depressor, gently insert the OPA in line with
• Historically, the pediatric larynx was thought to be funnel- the curve of the oropharynx with direct visualization.
shaped or conical. Newer studies suggest that this may not
be accurate. The cricoid cartilage is elliptical in infants and OROTRACHEAL INTUBATION
younger children and grows to circular by adulthood. Indications for endotracheal intubation in pediatric trauma
• Increased resistance during endotracheal intubation (ETI) patients include but are not limited to the following:
may be felt at the level of the elliptical cricoid, the space of • Inability to maintain a patent airway despite basic airway
which may be appropriately filled with a properly sized cuffed maneuvers
ETT. The American Heart Association has stated that it is • Respiratory failure
reasonable to choose a cuffed ETT over uncuffed in infants
• Altered mental status, which, in an acute trauma patient, can
and children, provided attention is paid to the size, location,
result from TBI, intoxication, hypoxia, or hypoperfusion
and cuff pressure (< 20–25 cm H2O).
from shock
• Injuries (especially burns) to the face, mouth, or neck, which
PEDIATRIC AIRWAY EVALUATION, BASIC
may lead to complete airway obstruction once swelling has
AIRWAY MANAGEMENT, AND ADJUNCTS progressed
In pediatric trauma patients, after an immediate effort to Selecting the proper size of the endotracheal tube (ETT) is
control significant external hemorrhage, ensuring a patent airway essential and can be done by utilizing quick references such as
is the next essential step in the primary survey. A patent airway is a Pediatric Advanced Life Support Reference Card or length-
required to maintain oxygenation and ventilation and to prevent based tape. A simple technique to gauge the ETT size needed
tissue hypoxia, secondary injury, and subsequent cardiac arrest. for a specific patient is to approximate the diameter of the
In a spontaneously breathing child, assess the airway by child’s external nares or the tip of the child’s smallest finger
looking for facial or neck injuries that may compromise the airway, and use a tube with a similar diameter. Historically, uncuffed
listening to the quality of their voice and for any sounds suggestive ETTs were recommended for infants and young children, because
of partial airway obstruction (gurgling, stridor, hoarseness), and physiologic airway narrowing was felt to produce an adequate
listening to air movement and breath sounds. When partial airway seal. More recently, cuffed tubes have been shown to improve
obstruction is suspected, measures to optimize the airway include capnography accuracy, reduce the need for ETT changes, and
the following: improve pressure and tidal volume delivery. Correctly sized cuffed
175
 ETTs with proper inflation pressure (< 20–25 cm H2O) have After sedation and paralysis, direct or video-assisted
been shown to unlikely cause subglottic stenosis and generally laryngoscopy should be performed to visualize the vocal cords
safe to use in pediatric patients. Given these factors, in 2020, the for orotracheal tube placement. ETI should be performed by
American Heart Association stated that choosing a cuffed ETT the most experienced clinician available, given the increased
for intubation in infants and children is reasonable. Ensure that difficulty of intubating an infant or a young child. Before
ETTs one-half size larger and smaller than the selected tube, are laryngoscopy, a trauma team member should maintain cervical
available before intubation. If using a stylet to facilitate intubation, spine immobilization while the front of the collar is removed to
ensure that the tip does not extend beyond the end of the tube to facilitate cricoid pressure, if needed.
avoid airway injury. Once the ETT is past the glottic opening, position it 2–3 cm
Most trauma centers use a protocol for emergency intubation, below the level of the vocal cords and carefully hold it in place
referred to as drug-assisted or drug-facilitated intubation, also while intratracheal positioning is confirmed. A reasonable
known as rapid-sequence intubation (RSI). Clinicians must estimate for proper ETT depth from the gums (in centimeters) is
pay careful attention to the child’s weight, vital signs (pulse and three times the ETT tube diameter. Primary findings supportive
blood pressure), and level of consciousness to determine which of ETI include chest rise with assisted ventilation, mist in the ETT
branch of the algorithm for drug-assisted intubation to use on exhalation, and auscultated breath sounds in the bilateral axilla
( Figure 11-1). and not over the stomach.
A secondary confirmation, using a device such as a real-
 Figure 11-1: Drug-Assisted Intubation in Pediatric time waveform capnograph, a colorimetric ETCO2 detector, or
Patients. an esophageal detector device should be used. ETCO2 should
be measured in patients receiving chest compressions and can
Preoxygenate predict the successful return of spontaneous circulation. Once
Atropine sulfate (infants only; less than 1 year)
ETI is confirmed, the tube should be properly secured, the
0.1 - 0.5mg
cervical collar replaced, consideration given to the placement
of an orogastric tube, and a chest x-ray should be obtained to
Sedation accurately identify the ETT’s position. If the tube is too high or
too deep, adjust and resecure it before patient transport. Ensure
Hypovolemic Normovolemic
that medications for sedation and pain control are utilized for the
Etomidate 0.1 mg/kg, or Etomidate 0.3 mg/kg, or intubated child. Considerations include fentanyl, midazolam, and
Midazolam HCl 0.1 mg/kg Midazolam 0.1 mg/kg dexmedetomidine.
Generally, nasotracheal intubation in children is
Paralysis* challenging and not recommended, as it requires blind passage
around a relatively acute angle in the nasopharynx toward the
Succinylcholine or Vecuronium or Rocuronium
< 10 kg: 2 mg/kg 0.1 mg/kg 0.6 mg/kg
anterosuperiorly located glottis. The potential for penetrating
> 10 kg: 1 mg/kg the child’s cranial vault or damaging the more prominent
nasopharyngeal (adenoidal) soft tissues and causing hemorrhage
Intubate, check tube position also discourages the use of the nasotracheal route for airway
control.
*Proceed according to clinical judgment and skill/experience level.
If it is not possible to place the ETT after the child is chemically
paralyzed, ventilate with 100% oxygen administered with a self-
Infants have a more pronounced vagal response to ETI than inflating bag-mask device until a definitive airway is secured.
children and adults, and they may experience bradycardia with In the case of failed intubation, call for backup from the most
direct laryngeal stimulation. Premedication with atropine to experienced airway expert available. If subsequent attempts are
prevent vagal-induced bradycardia should be considered in cases unsuccessful, consider placing a supraglottic or surgical airway.
with a high risk of bradycardia, such as in infants or children • Use the mnemonic DOPE to assess an intubated trauma
younger than 8 years receiving succinylcholine. Atropine is dosed patient who has an acute change in ventilatory status:
at 0.02 mg/kg with no minimum dose and a 1-mg maximum dose. • Displacement—infants and young children have short
There is a lack of evidence that premedication with lidocaine tracheas; any movement of the head can result in migration
blunts the possible spike in intracranial pressure (ICP) during of the tube out of the trachea or into a mainstem bronchus
intubation.
In preparation for RSI, preoxygenate children with 100% • Obstruction—secretions, vomit or blood, may result in
oxygen via a nonrebreather or a bag-valve device if assisted obstruction of the ETT and require inline suctioning
ventilation is required. Consider placing a nasal cannula connected • Pneumothorax—positive-pressure ventilation may worsen a
to oxygen on the patient to provide apneic oxygenation during simple pneumothorax and lead to a tension pneumothorax
RSI. Some studies have shown a longer interval to desaturation that should be managed with decompression and tube
after paralysis in patients receiving apneic oxygenation compared thoracostomy
to those who did not.
• Equipment—ensure tubing is appropriately connected,
ventilator settings are correct, and the circuit is connected to
oxygen

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LARYNGEAL MASK AIRWAY AND NEEDLE AND TUBE THORACOSTOMY

CRICOTHYROIDOTOMY Injuries that disrupt pleural apposition (i.e., hemothorax,
When airway maintenance and control cannot be pneumothorax, and hemopneumothorax) have similar physiologic
accomplished by bag-mask ventilation or orotracheal intubation, consequences in children and adults. These injuries are managed
a rescue airway with either laryngeal mask airway (LMA), with pleural decompression. In the case of tension pneumothorax,
intubating LMA, or needle cricothyroidotomy is necessary. needle decompression should occur before chest tube placement.
Needle-jet insufflation via the cricothyroid membrane is an The needle should be inserted over the top of the third rib
appropriate temporizing technique for oxygenation, but it does in the midclavicular line, or in the fifth intercostal space at the
not provide adequate ventilation, and progressive hypercarbia midaxillary line. Needle length and diameter must be optimized
will occur. LMAs are appropriate adjunct airways for infants and to ensure successful decompression while minimizing the risk
children, but their placement requires experience, and ventilation of damage to underlying intercostal vessels and intrathoracic
may distend the patient’s stomach if it is overly vigorous. Surgical structures. Needles ranging from 16–22 gauge and 2.5–4.5 cm in
cricothyroidotomy should rarely be performed in infants or length may be selected based on the child’s age and body habitus.
young children. It can be performed in older children in whom Chest tubes need to be proportionally smaller and placed
the cricothyroid membrane is easily palpable (usually by age 12). into the thoracic cavity by tunneling the tube over the rib above
the skin incision site and directing it superiorly and posteriorly
BREATHING along the inside of the chest wall. The chest tube insertion site is
the same in children as in adults: the fifth intercostal space, just
A critical factor in evaluating and managing breathing in anterior to the midaxillary line.
pediatric trauma patients is the recognition of injuries that may
result in compromised ventilatory effort, impaired gas exchange, CIRCULATION AND SHOCK
and abnormal elimination of carbon dioxide. Compromised
ventilatory effort may be caused by pneumothorax, hemothorax, Key factors in evaluating and managing circulation in pediatric
and lung injury from contusion or aspiration. In such cases, trauma patients include recognizing circulatory compromise,
appropriate treatments such as needle decompression, tube accurately determining the patient’s weight and circulatory volume,
thoracostomy, and assisted ventilation should be pursued. obtaining venous access, administering resuscitation fluids and
blood replacement, assessing the adequacy of resuscitation, and
BREATHING AND VENTILATION achieving thermoregulation.
The respiratory rate in children decreases as they age. An
RECOGNITION OF CIRCULATORY
infant breathes 30 to 40 times per minute, whereas an older child
breathes 15 to 20 times per minute. Normal tidal volumes vary COMPROMISE
from 4–6 mL/kg for neonates to 6–8 mL/kg in infants and young Injuries in children can result in significant blood loss. A child’s
children. However, tidal volumes as high as 10 mL/kg may be increased physiologic reserve allows for maintaining systolic
required during assisted ventilation. Although most bag-mask blood pressure in the normal range even in shock. Up to a 30%
devices used with pediatric patients are designed to limit the decrease in circulating blood volume may be required to reduce
pressure exerted manually on the child’s airway, excessive volume the child’s systolic blood pressure. A child’s reserve can mislead
or pressure during assisted ventilation substantially increases the clinicians who are not familiar with the subtle physiologic changes
potential for iatrogenic volutrauma and barotrauma. Similarly, manifested by children in hypovolemic shock. Tachycardia and
when an adult bag-mask device is used to ventilate a pediatric poor skin perfusion are often the best keys to early recognition
patient, the risk of volutrauma and barotrauma is significantly of hypovolemia and the need for early initiation of fluid
increased. A pediatric bag mask is recommended for children resuscitation in children. Evaluation of the fingernail bed color
under 30 kg. and color of the lips are helpful in all children, particularly children
Hypoxia is the most common cause of pediatric cardiac with deeply pigmented skin. When possible, early assessment by a
arrest. However, before cardiac arrest occurs, hypoventilation surgeon is essential to the treatment of injured children.
causes respiratory acidosis, which is the most common acid-base Although a child’s primary response to hypovolemia is
abnormality encountered during the resuscitation of injured tachycardia, an elevated heart rate also can be caused by pain,
children. A child should maintain a relatively normal pH with fear, or psychological stress. Other more subtle signs of blood loss
adequate ventilation and perfusion. In the absence of insufficient in children include progressive weakening or loss of peripheral
ventilation and perfusion, attempting to correct acidosis with pulses, a narrowing of pulse pressure to less than 20 mm Hg,
sodium bicarbonate can result in further hypercarbia and skin mottling (which substitutes for clammy skin in infants and
worsening acidosis, and this practice should be discouraged. young children), cool extremities compared with torso skin, and a
decreased level of consciousness with a dulled response to pain. A
decrease in blood pressure and other indices of inadequate organ
perfusion, such as urinary output, should be monitored closely
but generally develop later. Changes in vital organ function by
degree of blood volume loss are outlined in  Table 11-3.

177
  Table 11-3: Physiologic Effects of Blood Loss in Pediatric Patients.

System Mild blood volume loss Moderate blood volume loss Severe blood volume loss
(< 30%) (30%–45%) (> 45%)

Cardiovascular Increased heart rate; weak, Markedly increased heart rate; Tachycardia followed by
thready peripheral pulses; weak, thready central pulses; absent bradycardia; very weak or
normal systolic blood peripheral pulses; low normal systolic absent central pulses; absent
pressure (80 − 90 + 2 × age in blood pressure (70 − 80 + 2 × age in peripheral pulses; hypotension
years); normal pulse pressure years); narrowed pulse pressure (<70 + 2 × age in years);
narrowed pulse pressure
(or undetectable diastolic
blood pressure)

Central Anxious; irritable; Lethargic; dulled Comatose

Nervous confused response to pain1
System

Skin Cool, mottled; prolonged Cyanotic; markedly prolonged Pale and cold
capillary refill capillary refill

Urine Output2 Low to very low Minimal None

1
A child’s dulled response to pain with moderate blood volume loss may indicate a decreased response to IV catheter insertion.
Monitor urine output after initial decompression by urinary catheter. Low normal is 2 ml/kg/hr (infant), 1.5 ml/kg/hr (younger child),
2

1 ml/kg/hr (older child), and 0.5 ml/hg/hr (adolescent). IV contrast can falsely elevate urinary output.

The normal mean systolic blood pressure for children is 90 mm VENOUS ACCESS
Hg plus twice the child’s age in years (to a limit of 120 mm Hg).
IV access in young children with hypovolemia can be
The lower limit of normal systolic blood pressure in children is 65
challenging, even in the most experienced hands. The disruption of
mm Hg plus twice the child’s age in years. The diastolic pressure
intrathoracic or intra-abdominal organs or blood vessels typically
should be about two-thirds of the systolic blood pressure. Normal
causes severe hypovolemic shock. A peripheral percutaneous route
vital functions by age group are listed in  Table 11-4. Hypotension
is preferable to establish venous access. If percutaneous access
in a child represents a state of decompensated shock and indicates
is unsuccessful, consider placement of an intraosseous (IO)
severe blood loss of greater than 45% of the circulating blood
needle for infusion via bone marrow: 18-gauge IO in infants,
volume. Tachycardia changing to bradycardia often accompanies
15-gauge IO in young children ( Figure 11-2), or a femoral
hypotension, and this change may occur suddenly in infants.
venous line of appropriate size using the Seldinger technique.
Depending on what is available, these physiologic changes must
If these procedures fail, a physician with skill and expertise can
be treated by a rapid infusion of 20 mL/kg of crystalloid or blood
perform direct venous cutdown. Still, this procedure should be
products.
used only as a last resort because it can rarely be performed in
DETERMINATION OF WEIGHT AND less than 10 minutes, even in experienced hands. In contrast,
clinicians with limited skill and expertise can reliably place an IO
CIRCULATING BLOOD VOLUME needle in the bone marrow cavity in less than 1 minute.
Emergency department personnel often struggle to estimate The following are the preferred sites for venous access in
a child’s weight, particularly when they do not frequently treat children:
children. The simplest and quickest method of accurately • Percutaneous peripheral IV—antecubital fossa or saphenous
determining a child’s weight is to ask the parent or guardian. A vein at the ankle
length-based resuscitation tape is beneficial if a parent or guardian • IO placement—anteromedial tibia or distal femur.
is unavailable. This tool rapidly provides the child’s approximate Complications of this procedure include cellulitis,
weight, respiratory rate, fluid resuscitation volume, and drug osteomyelitis, compartment syndrome, and iatrogenic
dosages. The formula ([2 × age in years] + 10) is a final method for fracture. The preferred site for IO cannulation is the proximal
estimating weight in kilograms. tibia, below the level of the tibial tuberosity. An alternative
The goal of fluid resuscitation is to replace the circulating site is the distal femur, although the contralateral proximal
volume rapidly. Total circulating blood volume can be tibia is preferred. IO cannulation should not be performed
estimated as 80 mL/kg for an infant, 75 mL/kg at ages 1 to 3 years, in an extremity with a known or suspected fracture or if a
and 70 mL/kg after age three. previous IO has failed in that bone.
• Percutaneous central placement—femoral vein
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 Table 11-4: Normal Vital Signs by Age Group.

Age group Weight Heart rate Blood pressure Respiratory Urinary

range (in kg) (beats/min) (mm Hg) rate output
(breaths/min) (mL/kg/hr)

Infant
0–12 months 0–10 <160 >60 <60 2.0

Toddler
1–2 years 10 - 14 <150 >70 <40 1.5

Preschool
3–5 years 14 - 18 <140 >75 <35 1.0

School age
6–12 years 18 - 36 <120 >80 <30 1.0

Adolescent
≥13 years 36 - 70 <100 >90 <30 0.5

 Figure 11-2: Intraosseous Needle Placement. • Percutaneous central placement—external or internal jugular
The preferred site for intraosseous cannulation and or subclavian vein (should be reserved for pediatric experts;
infusion is the anteromedial aspect of the proximal do not use if there is airway compromise or if a cervical collar
tibia, below the level of the tibial tuberosity. is applied)
• Venous cutdown—saphenous vein at the ankle
View 1:
FLUID RESUSCITATION AND BLOOD
REPLACEMENT
Fluid resuscitation for injured children is weight-based,
intending to replace any lost intravascular volume. Evidence of
hemorrhage may be apparent with the loss of 25% of a child’s
circulating blood volume. The initial fluid resuscitation strategy
for injured children is a 20 mL/kg bolus of crystalloid. If the
patient does not demonstrate a sustained response to crystalloid,
10 mL/kg of packed red blood cells or whole blood should be
View 2: given instead of additional crystalloid. However, if hemorrhage is
suspected and blood is immediately available, the resuscitation
may be initiated with 10 mL/kg of packed red blood cells or
whole blood instead of crystalloid.
Damage control resuscitation, consisting of the restrictive
use of crystalloids and early administration of balanced ratios
of packed red blood cells, fresh frozen plasma, and platelets, has
become standard in treating adult shock and has been adopted
for children. This approach appears to interrupt the lethal triad
of hypothermia, acidosis, and trauma-induced coagulopathy and
has been associated with improved outcomes in severely injured
adults.
Using balanced resuscitation strategies in children means
the initial 20 mL/kg bolus of isotonic crystalloid is followed by
weight-based blood product resuscitation with 10–20 mL/kg of
packed red blood cells and 10–20 mL/kg of fresh frozen plasma
and platelets, typically as part of a pediatric massive transfusion
protocol (MTP). For facilities without ready access to blood
products, slow infusion of crystalloid resuscitation remains
acceptable until transfer to an appropriate facility is possible.

179
 Carefully monitor injured children for response to fluid Transient responders and nonresponders are candidates for
resuscitation and adequacy of organ perfusion. Children the prompt infusion of additional blood products, activation of
generally have one of four responses to fluid resuscitation: an massive transfusion protocol (MTP), and consideration for
early operation. Similar to adult resuscitation practices, earlier
1. The condition of most children will be stabilized by using administration of blood products in refractory patients may be
crystalloid fluid only, and blood is not required; these appropriate. The resuscitation flow diagram is valuable in treating
children are considered “early responders.” injured children ( Figure 11-3).
2. Some children respond to crystalloid and blood
resuscitation and are considered “responders.” These are URINE OUTPUT
children who bled significantly but stopped bleeding Urine output varies with age and size. The output goal
before arrival. for infants is 1–2 mL/kg/hr; for children over age one up to
3. Some children have an initial response to crystalloid fluid adolescence, the goal is 1–1.5 mL/kg/hr; and for teenagers, the
and blood, but then deterioration occurs; this group is goal is 0.5 mL/kg/hr.
termed “transient responders.” These children are probably Measurement of urine output and specific gravity is a reliable
still bleeding. method of determining the adequacy of volume resuscitation.
4. Other children do not respond to crystalloid fluid and When the circulating blood volume has been restored, urinary
blood infusion; this group is called “nonresponders.” These output should return to normal. Inserting a urinary catheter
children are generally bleeding rapidly. facilitates accurate measurement of a child’s urinary output.

 Figure 11-3: Resuscitation Flow Diagram for Pediatric Patients.

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cardiac contusions are also uncommon in pediatric trauma pa-

THERMOREGULATION
tients. When identified, treatment for these injuries is the same
The high ratio of body surface area to body mass in children as for adults. Treatment may include endovascular aortic stent
increases heat exchange with the environment and directly affects grafting if patient size allows. Significant injuries in children rare-
the body’s ability to regulate core temperature. A child’s increased ly occur in isolation and are frequently a component of significant
metabolic rate, thin skin, and lack of substantial subcutaneous multisystem injury.
tissue also contribute to increased evaporative heat loss and Unlike in adult patients, most chest injuries in children can
caloric expenditure. Hypothermia can significantly compromise be identified with standard screening chest radiographs. Cross-
a child’s response to treatment, prolong coagulation times, and sectional imaging is rarely required in the evaluation of blunt
adversely affect central nervous system (CNS) function. While injuries to the chest in children and should be reserved for those
the child is exposed during the initial survey and resuscitation with a widened or otherwise abnormal mediastinum on plain film
phase, overhead heat lamps, heaters, and thermal blankets may be or whose findings cannot be explained by standard radiographs.
necessary to preserve body heat—warm the room, IV fluids, blood When pneumothoraces less than 2.7 cm are identified on cross-
products, and inhaled gases. After examining the child during the sectional imaging (occult pneumothorax), no intervention is
initial assessment, cover the body with warm blankets to avoid required unless they are enlarging or symptomatic.
unnecessary heat loss. Most pediatric thoracic injuries can be successfully managed
without thoracotomy. An appropriate combination of supportive
CARDIOPULMONARY RESUSCITATION care and tube thoracostomy will resolve the most common
Children who undergo CPR in the field with a return of injuries, namely pneumothorax and hemothorax.
spontaneous circulation before arriving in the trauma center have Penetrating trauma to the chest in children is managed the
an approximately 50% chance of neurologically intact survival. same way as for adults.
Children who present to an emergency department still in
traumatic cardiopulmonary arrest have a uniformly dismal ABDOMINAL TRAUMA
prognosis. Children who receive CPR for blunt trauma more than
Most pediatric abdominal injuries result from blunt trauma
15 minutes before arrival to an emergency department or have
that primarily involves motor vehicles and falls. Serious intra-
fixed and dilated pupils on arrival are uniformly nonsurvivors.
abdominal injuries warrant prompt involvement by a surgeon, and
For pediatric trauma patients who arrive in the trauma bay with
hypotensive children who sustain blunt or penetrating abdominal
continued CPR of long duration, prolonged resuscitative efforts
trauma require prompt intervention.
are not beneficial. Data on CPR in the setting of penetrating chest
The presence of shoulder or lap-belt marks increases
trauma are consistent with the adult literature.
the likelihood of intra-abdominal injuries, especially in the
In the setting of patients found in cardiac arrest for an
presence of lumbar fracture, intraperitoneal fluid, or persistent
unknown period of time, early identification of lividity (a bluish-
tachycardia.
purple discoloration of the skin in dependent areas that sets in 20
to 30 minutes after death) or rigor mortis should immediately end
ASSESSMENT
resuscitative efforts.
Conscious infants and young children are generally frightened
CHEST TRAUMA by traumatic events and the hospital environment, which can
complicate the abdominal examination. Whenever possible,
Eight percent of all injuries in children involve the chest. Chest maintaining a child friendly environment is essential to calm
injury also serves as a marker for other organ system injuries, as the child, allowing for more accurate assessment and preventing
more than two-thirds of children with chest injuries have multiple further traumatic stress from hospitalization. Allowing the child’s
injuries. The mechanism of injury and the anatomy of a child’s family to be with or near them and involving the child life team
chest are responsible for the spectrum of injuries seen. can help accomplish the goals of providing trauma-informed care
The vast majority of chest injuries in childhood are due to blunt to injured children. While talking quietly and calmly to the child,
mechanisms, most commonly caused by motor vehicle crashes ask questions about the presence of abdominal pain and gently
or falls. A child’s chest wall’s pliability, or compliance, allows assess the tone of the abdominal musculature. One should avoid
kinetic energy to be transmitted to the underlying pulmonary applying deep, painful palpation during the examination, which
parenchyma, causing a pulmonary contusion. Rib fractures and may cause voluntary guarding that can confuse the findings. As
mediastinal injuries are not common; if present, they indicate a in adults, abdominal examination in unconscious children is
very severe impact. Specific injuries caused by thoracic trauma in unreliable.
children are similar to those encountered in adults, although the Many infants and young children who are stressed and
frequencies of these injuries differ. crying may swallow large amounts of air. If the upper abdomen
The mobility of mediastinal structures makes children is distended on examination, insert an orogastric tube to
more susceptible to tension pneumothorax, the most common decompress the stomach as part of the resuscitation phase.
immediately life-threatening injury in children. Pneumomedi- Orogastric tube decompression is preferred in infants or if there is
astinum is rare and benign in the overwhelming majority of cas- concern for basilar skull fracture.
es. Extensive workups for isolated pneumomediastinum in alert, Decompression of the urinary bladder may facilitate abdominal
asymptomatic children are not required. Diaphragmatic rupture, evaluation in these children but is usually reserved for those in
aortic transection, major tracheobronchial tears, flail chest, and whom hourly assessment of urine output is critical.

181
 for up to one-third of solid organ injuries in children. Clinically
DIAGNOSTIC ADJUNCTS
significant intra-abdominal injuries may also be present in the
Diagnostic adjuncts for assessing abdominal trauma in absence of any free intraperitoneal fluid.
children include CT, FAST (focused assessment with sonography In summary, FAST should not be relied upon as the sole
in trauma), and DPL (diagnostic peritoneal lavage). diagnostic test to rule out the presence of intra-abdominal injury.
If a small amount of intra-abdominal fluid is found and the child
COMPUTED TOMOGRAPHY is hemodynamically normal, a CT scan may be indicated. As in
CT scanning allows for the rapid and precise identification adults, the primary role of the FAST exam is to identify free fluid
of injuries. CT scanning is often used to evaluate the abdomen in the abdomen and pelvis in hemodynamically unstable children
of children who have sustained blunt trauma and are to determine if they would benefit from surgical exploration of the
hemodynamically stable or have shown a sustained response abdomen to achieve bleeding control.
to fluid or blood. CT scanning should be immediately available
and, when indicated, be performed early in treatment. Imaging DIAGNOSTIC PERITONEAL LAVAGE
should not delay definitive treatment in unstable patients. CT DPL is rarely used in children. In rare circumstances, when
of the abdomen should routinely be performed with IV contrast ultrasound is NOT available and the presence of blood will lead to
agents according to local practice. Oral contrast is rarely needed immediate operative intervention, it may be used to detect severe
and carries additional risks. intra-abdominal bleeding in children who are hemodynamically
Identifying intra-abdominal injuries by CT in pediatric unstable for unclear reasons and cannot be safely transported
patients with hemodynamic stability can allow for nonoperative to the CT scanner. Blood found by DPL would not mandate
management by the surgeon. Early involvement of a surgeon is operative exploration in an otherwise stable child.
essential to establish a baseline that will determine if an operation
is indicated. Centers that lack surgical support and where transfer NONOPERATIVE MANAGEMENT
of injured children is planned are justified in forgoing the CT
Selective, nonoperative management of solid organ injuries in
evaluation before transport to definitive care.
hemodynamically normal children is performed in most trauma
CT scanning is generally rapid and can often be done without
centers, especially those with pediatric capabilities. The presence
anesthesia or sedation, even in children. When an injured child
of intraperitoneal fluid (blood) on CT or FAST, the grade of injury,
requires sedation to prevent movement during the scanning
or the presence of a vascular blush does not necessarily mandate
process, a clinician skilled in pediatric airway management
a laparotomy. Bleeding from an injured spleen, liver, or kidney
and vascular access should accompany the child.
generally is self-limited. Therefore, a CT or FAST that is positive
CT scanning is not without risk. Radiation from CT scans in
for blood alone does not mandate a laparotomy in children who
children is believed to contribute to subsequent malignancies.
are hemodynamically normal or stabilized with resuscitation. If
Fatal cancers are predicted to occur in as many as 1 in 1,000
the child’s hemodynamic condition cannot be normalized and
patients who undergo CT as children. Thus, the need for accurate
the diagnostic procedure performed shows ongoing bleeding,
diagnosis of internal injury must be balanced against the risk of
laparotomy is indicated for hemorrhage control.
late malignancy. Avoid CT scanning before transfer to a definitive
Children must be treated in a facility with pediatric
trauma center or a repeat CT upon arrival at a trauma center
intensive care capabilities, and nonoperative management
unless deemed absolutely necessary. When CT evaluation is
must be supervised by a qualified surgeon. In resource-limited
essential, radiation must be kept as low as reasonably achievable.
environments, thresholds to perform exploratory laparotomy may
To achieve the lowest doses possible, scan only when medically
differ.
necessary, scan only when the results change management, scan
Angioembolization of solid organ injuries in children is a
only the area of interest, and use the lowest radiation dose possible.
treatment option. Still, it should be performed only in centers
Guidelines to determine who needs abdominal CT imaging have
with experience in pediatric interventional procedures and
shown to reduce unnecessary CT scans of the abdomen.
ready access to an operating room. The treating surgeon must
FOCUSED ASSESSMENT SONOGRAPHY IN TRAUMA decide to perform angioembolization. In contrast to adults,
angioembolization in children with contrast blush on CT scans is
FAST is widely used as an extension of the abdominal only considered for hemodynamic instability or ongoing bleeding.
examination in injured children; it offers the advantage of being Contrast extravasation or blush alone is not an indication for
repeatable throughout resuscitation while avoiding ionizing angioembolization in children.
radiation. Some investigators have shown that FAST identifies Nonoperative management of confirmed solid organ injuries
even small amounts of intra-abdominal blood in pediatric trauma is a surgical decision made by surgeons, similar to the decision to
patients, a finding that is unlikely to be associated with significant operate. Therefore, the surgeon must supervise the nonoperative
injury. management of solid organ injuries in pediatric trauma patients.
If large amounts of intra-abdominal blood are found,
considerable injury is more likely to be present. However, even SPECIFIC VISCERAL INJURIES
in these patients, operative management is indicated not by
the amount of intraperitoneal blood but by hemodynamic Several abdominal visceral injuries are more common in
abnormality and its response to treatment. FAST is incapable of children than in adults. Injuries such as those caused by a bicycle
identifying isolated intraparenchymal injuries, which account handlebar, an elbow striking a child in the right upper quadrant,
and lap-belt injuries are common and result when the visceral

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contents are forcibly compressed between the blow on the anterior • Although infrequent, hypotension can occur in infants
abdominal wall and the spine posteriorly. This type of injury also following significant blood loss into the subgaleal,
may be also caused by child maltreatment. intraventricular, or epidural spaces because of their open
Blunt pancreatic injuries occur from similar mechanisms, cranial sutures and fontanelles. In such cases, treatment
and their treatment depends on the extent of injury. Small bowel should focus on appropriate volume restoration.
perforations at or near the ligament of Treitz are more common • Infants, with their open fontanelles and mobile cranial
in children than in adults, as are mesenteric and small bowel sutures, have more tolerance for an expanding intracranial
avulsion injuries. These particular injuries are often diagnosed mass lesion or brain swelling, and signs of these conditions
late because of their vague early symptoms. may be hidden until rapid decompensation occurs. An infant
Bladder rupture is also more common in children than in who is not in a coma but has bulging fontanelles or suture
adults because of the shallow depth of the child’s pelvis. diastases should be assumed to have suffered a severe injury,
Children who are restrained by a lap belt only are at particular and early neurosurgical consultation is essential.
risk for enteric disruption, especially if they have a lap-belt mark
on the abdominal wall or sustain a flexion-distraction (Chance) • Vomiting and amnesia are common after brain injury
fracture of the lumbar spine. Any patient with this mechanism in children and do not necessarily imply increased ICP.
of injury and these findings should be presumed to have a high However, persistent vomiting or vomiting that becomes more
likelihood of injury to the gastrointestinal tract until proven frequent is concerning and mandates a CT of the head.
otherwise. The rupture of a hollow viscus requires early operative • Impact seizures, or seizures that occur shortly after brain
intervention. injury, are more common in children and are usually self-
Penetrating injuries of the perineum (straddle injuries) limited. All seizure activity requires investigation by CT of
may occur with falls onto a prominent object and result in the head.
intraperitoneal injuries due to the proximity of the peritoneum to
• Children tend to have fewer focal mass lesions than adults, but
the perineum.
elevated ICP due to brain swelling is more common. Rapid
restoration of normal circulating blood volume is critical
HEAD TRAUMA
to maintain cerebral perfusion pressure. If hypovolemia is
The information found in Chapter 7, Disability: Neurological not corrected promptly, secondary brain injury may occur.
Assessment and Management, also applies to pediatric patients. Emergent head CT is vital to identify children who require
This section emphasizes information that is specific to children. immediate surgery.
Most head injuries in the pediatric population are the result • The Glasgow Coma Scale (GCS) score is valuable in
of motor vehicle crashes, child maltreatment, bicycle crashes, evaluating pediatric patients, but the verbal score component
and falls. Since hypotension and hypoxia from associated injuries must be modified for children younger than 4 years
adversely affect the outcome of intracranial injury, lack of attention ( Table 11-5).
to the xABCDE algorithm and associated injuries can significantly
increase mortality from head injury. As in adults, hypotension is  Table 11-5: Verbal Score in Children Less than 4 Years
infrequently caused by head injury alone, and other explanations of Age. In children less than 4 years of age, the V-score
for this finding should be investigated aggressively. component of the GCS must be modified to include an
A child’s brain is anatomically different from that of an adult. appropriate verbal response.
It doubles in size in the first 6 months of life and achieves 80%
of the adult brain size by 2 years of age. The subarachnoid space
Verbal response V-score
is relatively smaller, offering less protection to the brain. Normal
cerebral blood flow increases progressively to nearly twice that of
adult levels by 5 years of age and then decreases. This increased Appropriate words or social 5
cerebral blood supply accounts in part for children’s significant smile, fixes and follows
susceptibility to cerebral hypoxia and hypercarbia.
Cries, but consolable 4
ASSESSMENT
Children and adults can differ in their response to head Persistently irritable 3
trauma:
• The outcome in children who suffer severe brain injury Restless, agitated 2
is better than that in adults. However, for a similar injury,
the outcome in children younger than 3 years of age is worse None 1
than in an older child. Children are particularly susceptible
to the effects of secondary brain injury that can be produced
by hypovolemia, hypoxia, seizures, or hyperthermia. The
impact of the combination of hypovolemia and hypoxia
on the injured brain is devastating, but hypotension from
hypovolemia is the most severe single-risk factor. It is
critical to avoid hypoxia and ensure rapid restoration of an
appropriate circulating blood volume in injured children.
183
 • Because increased ICP frequently develops in children,
ANATOMICAL DIFFERENCES
neurosurgical consultation for consideration of ICP
monitoring should be obtained early in the course of The following are anatomical differences that must be kept in
resuscitation for children with a GCS score of 8 or less, mind when treating spinal injury in children:
motor scores of 1 or 2, multiple associated injuries requiring • Interspinous ligaments and joint capsules are more flexible.
significant volume resuscitation or immediate lifesaving • Vertebral bodies are wedged anteriorly and tend to slide
thoracic or abdominal surgery, and a CT scan of the brain forward with flexion.
that demonstrates evidence of brain hemorrhage, cerebral
swelling, and transtentorial or cerebellar herniation. • The facet joints are flat.
Management of ICP is essential for optimizing the cerebral • Children have relatively large heads compared with their
perfusion pressure. necks. Therefore, the angular momentum is more significant,
• Medication dosages are determined by the child’s size and and the fulcrum exists higher in the cervical spine, which
in consultation with a neurosurgeon. Drugs often used in accounts for more injuries at the level of the occiput to C3.
children with head injuries include 3% hypertonic saline and • Growth plates are not closed, and growth centers are not
mannitol to reduce ICP, and levetiracetam and phenytoin for entirely formed.
the treatment of seizures. • Forces applied to the upper neck are relatively more significant
Criteria are available to identify patients at low risk for head, than in the adult.
cervical spine, and abdominal injury who do not require CT
scanning. RADIOLOGICAL CONSIDERATIONS
MANAGEMENT Children sustain spinal cord injury without radiographic
abnormalities more commonly than adults. A normal cervical
Management of TBI in children involves rapid xABCDE spine series may be found in up to two-thirds of children who have
assessment and management, as well as timely neurosurgical suffered SCI. Thus, if SCI is clinically suspected, a normal spine
involvement from the beginning of resuscitation. Appropriate x-ray does not exclude significant SCI. Whenever in doubt about
evaluation and management of the brain injury focused on the integrity of the cervical spine, assume that an unstable
preventing secondary brain injury—hypoxia and hypoperfusion— injury exists, limit spinal motion, and obtain appropriate
is also critical. Early endotracheal intubation with adequate consultation.
oxygenation and ventilation can help avoid progressive central Another frequent unique radiologic finding in children is
nervous system (CNS) damage. Attempts to orally intubate pseudosubluxation. Pseudosubluxation frequently complicates the
the trachea in an uncooperative child with a brain injury may radiographic evaluation of a child’s cervical spine. Approximately
be difficult and increase ICP. While considering the risks and 40% of children younger than 7 years show anterior displacement
benefits of intubating such children, pharmacologic sedation and of C2 on C3, and 20% of children up to 16 years exhibit this
neuromuscular blockade may facilitate the intubation. phenomenon. This radiographic finding is seen less commonly
Hypertonic saline and mannitol create hyperosmolality and at C3 on C4. Up to 3 mm of movement may be seen when these
increased sodium levels in the brain, decreasing edema and joints are studied by flexion and extension maneuvers.
pressure within the injured cranial vault. These substances have When a subluxation is seen on a lateral cervical spine x-ray,
the added benefit of being rheostatic agents that improve blood ascertain whether it is a pseudosubluxation or an actual cervical
flow and downregulate the inflammatory response. spine injury. Pseudosubluxation of the cervical vertebrae is
As with all trauma patients, continued reassessment of accentuated by the cervical spine flexion that occurs when a
all clinical parameters remains essential. (Also see Chapter 7, child lies supine on a hard surface. To correct this radiographic
Disability: Neurological Assessment and Management.) abnormality, ensure the child’s head is in a neutral position
by placing a 1-inch padding beneath the entire body from the
SPINAL CORD INJURY shoulders to the hips (not the head) and repeat the x-ray. True
subluxation will not disappear with this maneuver and mandates
The information provided in Chapter 7, Disability: Neurologi- further evaluation. A cervical spine injury can usually be identified
cal Assessment and Management also applies to pediatric patients. by neurological examination and by detecting an area of soft-
This section emphasizes information that is specific to pediatric tissue swelling, muscle spasm, or a step-off deformity on careful
spinal cord injury (SCI). palpation of the posterior cervical spine.
SCI in children is fortunately uncommon—only 5% of SCIs An increased distance between the dens and the anterior
occur in the pediatric age group. For children younger than 10, arch of C1 occurs in approximately 20% of young children. Gaps
motor vehicle crashes produce most of these injuries. For children exceeding the upper normal limit for the adult population are
aged 10 to 14 years, motor vehicles and sporting activities account seen frequently.
for an equal number of spinal cord injuries. Skeletal growth centers can resemble fractures. Basilar
odontoid synchondrosis appears as a radiolucent area at the base
of the dens, especially in children younger than 5 years. Apical
odontoid epiphyses appear as separations on the odontoid x-ray
and are usually seen between the ages of 5 and 11. The growth
center of the spinous process can resemble fractures of the tip of
the spinous process.
184 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 11 | Trauma in the Pediatric Patient

CT and MRI scans should not be used as routine screening Salter-Harris classification, require proper management and
modalities for evaluating the pediatric cervical spine; plain anatomic alignment to minimize the risk of deformity and growth
radiographs should be performed as the initial imaging tool. disturbance. Crush injuries to the physis (Salter-Harris type V ),
Indications for the use of CT or MRI scans include the inability to are often challenging to recognize radiographically and have the
thoroughly evaluate the cervical spine with plain films, delineating worst prognosis. Pediatric bones are more porous and pliable
abnormalities seen on plain films, abnormal neurologic findings than adult bones and have a thicker and more metabolically active
on physical exam, and assessment of the spine in children with periosteum.
TBI; CT scan may not detect the ligamentous injuries that are While these differences result in faster healing and more
more common in children. significant remodeling potential, they also result in unique fracture
SCI in children is treated in the same way as in adults. patterns. Greenstick fractures are incomplete fractures that occur
Consultation with a spine surgeon should be obtained early. when the cortex is fractured on the side opposite of an impact,
leaving an intact cortex and periosteum on the impact side. In
MUSCULOSKELETAL TRAUMA small children, the torus, or “buckle,” fracture involves angulation
due to cortical impaction with a radiolucent fracture line.
Musculoskeletal injury is a common presenting complaint in A plastic deformity occurs when the bone is deformed beyond
pediatric patients, both isolated and associated with multisystem its ability to recoil with accentuated bowing, which indicates
trauma. The initial priorities for managing skeletal trauma in microscopic fractures not visible on x-rays. Supracondylar
children are similar to those for adults. Unique properties of fractures at the elbow or knee have an increased risk of vascular
the pediatric skeleton must be considered when evaluating and injury, development of compartment syndrome, and physeal
managing pediatric orthopaedic trauma. injury. Due to the more elastic nature of the skeletally immature
pelvis, even minimally displaced pelvis fractures should carry
HISTORY AND PHYSICAL suspicion for high-energy mechanisms and associated cranial
The patient’s history and physical exam are vital in evaluating or abdominal visceral injuries must be ruled out.
musculoskeletal trauma. In younger children, x-ray diagnosis
of fractures and dislocations may be challenging due to the lack
FRACTURE SPLINTING
of mineralization around the epiphysis and the presence of the Simple splinting of fractured extremities in children is usually
physis (growth plate). Information about the injury’s magnitude, sufficient until definitive pediatric orthopaedic management
mechanism, and timing facilitates better correlation of the physical can be performed. Injured extremities with evidence of vascular
exam and x-ray findings. Administration of appropriate analgesia compromise require emergency evaluation and treatment to
can facilitate examination and radiography. prevent the adverse sequelae of ischemia. If emergent orthopaedic
Antibiotics should be administered promptly if there is consultation is unavailable, a single attempt at a closed reduction
concern for an open fracture. Any findings of neurovascular to restore blood flow utilizing appropriate analgesia and sedation
compromise or compartment syndrome should prompt emergent is appropriate, followed by immobilization of the extremity and
orthopaedic consultation or transfer to a higher level of care. timely transfer to a higher level of care. Hip dislocations require
Radiographic evidence of fractures in different stages of healing timely reduction to minimize the risk of avascular necrosis of
should alert clinicians to possible child maltreatment, as should the femoral head, which is increased with a delay of more than
lower-extremity fractures in children who are too young to walk. 6 hours. These reductions should be performed with appropriate
sedation to avoid inadvertent physeal injury during reduction.
BLOOD LOSS
Due to the thick periosteum around the pelvis, pediatric CHILD MALTREATMENT
patients with pelvic fractures are much less likely to develop life-
threatening intrapelvic hemorrhage compared to adults. Still, Any child who sustains an intentional injury as the result of acts
children with “open book” pelvic fractures and signs of shock by caregivers is considered to be a battered or maltreated child.
should have a pelvic binder placed, be adequately resuscitated, Homicide is the leading cause of intentional death in the first year
and be transferred to a pediatric trauma center. Unlike adults, of life. Children who suffer from physical abuse have a six-fold
closed pediatric femur fractures are unlikely to result in enough higher mortality rate than children who sustain unintentional
hemorrhage to alter hemodynamics. Therefore, hemodynamic injuries. Therefore, a thorough history and careful evaluation
instability in the presence of a presumed isolated femur of children in whom maltreatment is suspected is crucial to
fracture should prompt evaluation for other sources of blood prevent eventual death, especially in children who are younger
loss, intra-abdominal being the most common. than 2 years of age. Clinicians should suspect child maltreatment
in the following situations:
SPECIAL CONSIDERATIONS ABOUT THE • A discrepancy exists between the history and the degree
of physical injury—for example, a young child loses
IMMATURE SKELETON
consciousness or sustains significant injuries after falling
The most clinically significant difference between the from a bed or sofa or sustains a lower-extremity fracture even
pediatric skeleton and the adult skeleton is the presence of the though they are too young to walk.
physis. As the location of growth and the weakest point of the
• A prolonged interval has passed between the time of the
bone, this cartilaginous area near the articular surface is more
injury and the presentation for medical care.
susceptible to fracture. Physeal fractures, best described by their

185
 • The history includes repeated trauma treated in the same or
TEAMWORK
different emergency departments.
• The history of injury changes is different between parents or The care of severely injured children presents many challenges
other caregivers. that require a coordinated team approach. Ideally, injured children
are cared for by a pediatric trauma team composed of a physician
• There is a history of hospital or doctor “shopping.”
with expertise in managing pediatric trauma, pediatric specialist
• Parents respond inappropriately to or do not comply with physicians, and pediatric nurses and staff.
medical advice—for example, leaving a child unattended in Team members should be assigned specific tasks and functions
the emergency facility. during the resuscitation to ensure an orderly delivery of care.
• The mechanism of injury is implausible based on the child’s The reality is that most injured children will initially be treated
developmental stage in a facility with limited pediatric specialty resources. An adult
trauma team may be responsible for the care of injured children
The following findings, on careful physical examination, and must be ready to provide the following:
suggest child maltreatment and warrant more intensive • A trauma team leader who has experience in the care of
investigation: injured patients and is familiar with the local medical
• Multiple bruises of different colors (i.e., bruises in different resources available to care for injured children.
stages of healing)
• A clinician with basic airway management skills.
• Evidence of frequent previous injuries, typified by old scars
• Access to a clinician with advanced pediatric airway skills.
or healed fractures on x-ray examination
• Ability to provide pediatric vascular access via percutaneous
• Perioral injuries
or IO routes.
• Injuries to the genital or perianal area
• Knowledge of pediatric fluid resuscitation.
• Fractures of long bones in children younger than three years
• Appropriate equipment sizes for a range of different ages.
of age
• Strict attention to drug doses (weight-based).
• Ruptured internal viscera without antecedent major blunt
trauma • Early involvement of a surgeon with pediatric expertise,
preferably a pediatric surgeon.
• Multiple subdural hematomas, especially without a fresh
skull fracture • Access to available pediatric resources (pediatrician, family
medicine) to help manage pediatric-specific comorbidities or
• Retinal hemorrhages
issues.
• Bizarre injuries, such as bites, cigarette burns, and rope marks
• Inclusion of the child’s family during the emergency
• Sharply demarcated second- and third-degree burns department resuscitation and throughout the child’s hospital
• Skull fractures or rib fractures seen in children less than 24 stay.
months of age • Debriefing after a pediatric trauma case. Team members
In many nations, clinicians are bound by law to report incidents and others present in the resuscitation room may be deeply
of child maltreatment to governmental authorities, even in cases affected by poor outcomes for children. Appropriate mental
in which maltreatment is only suspected. Maltreated children health resources should be available.
are at increased risk for fatal injuries, so reporting is critically
important. The system protects clinicians from legal liability for CHAPTER SUMMARY
identifying confirmed or suspected maltreatment cases.
Although reporting procedures vary, they are most commonly • Unique characteristics of children include significant
handled through local social service agencies or state or national differences in anatomy, body surface area, chest wall
health services department. The process of reporting child compliance, and skeletal maturity. Typical vital signs vary
maltreatment assumes greater importance when one realizes that significantly with age. The xABCDE approach guides the
33% of maltreated children who die from assault in the US and the initial assessment and management of severely injured
UK were victims of previous episodes of maltreatment. children. Early involvement of a general surgeon or pediatric
surgeon, preferably with expertise in trauma, is imperative in
PREVENTION managing injuries in a child.
• Pediatric emergency readiness is critical to prevent
The greatest pitfall related to pediatric trauma is the failure
unnecessary morbidity and mortality in injured children,
to prevent the child’s injuries in the first place. Up to 80% of
particularly in regard to airway management, which is
childhood injuries could be prevented by applying simple
the most important modifiable risk of death in injured
strategies of injury prevention in the homes and in the
children.
community of a population among whom the lifetime benefits
of successful injury prevention are self-evident. Not only can the • Nonoperative management of abdominal visceral injuries
social and familial disruption associated with childhood injury be should be performed only by surgeons in facilities equipped
avoided, but for every dollar invested in injury prevention, four to expeditiously handle any significant changes in the clinical
dollars are saved in hospital care. course.

186 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 11 | Trauma in the Pediatric Patient
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 COURSE MANUAL | Chapter 12 | Trauma in the Older Adult

12

Trauma in the Older Adult

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explain the physiological changes that occur 4. Describe the signs of elder abuse and the
with aging and how they affect the patient’s significance of elder abuse to outcome in
response to injury geriatric patients
2. List the common mechanisms of geriatric 5. Define ageism and how it can impact geriatric
trauma trauma care
3. Describe the effect of medications commonly
prescribed to geriatric patients on injury
physiology and response to resuscitation

191
 Managing geriatric trauma patients presents distinct

12
challenges for trauma care teams. The injury mechanisms in
older adults differ, with falls being more prevalent, followed
closely by motor vehicle and motorcycle crashes. Inadequate
triage of critically injured geriatric patients may contribute to their
higher mortality rates compared to younger individuals. Beyond
triage issues, the aging of organ systems, preexisting medical
conditions, and frailty significantly elevate the mortality risk in
older adults, underscoring that age alone cannot predict recovery
potential. Mental health issues, substance abuse, and the risk of
maltreatment are additional considerations.
Trauma in the Older Adult Achieving the best outcomes for geriatric trauma patients
demands a comprehensive, multidisciplinary approach focused
on meticulous initial assessment, effective resuscitation, and
CHAPTER STATEMENT continuous care. This strategy emphasizes the need for heightened
vigilance and tailored interventions to address the unique
Geriatric patients represent an increasing demographic among vulnerabilities of the aging population in the trauma setting.
injured patients. Low-energy mechanisms can produce substan-
tial injury. The response of older adults to injury is influenced by EFFECTS OF AGING
preexisting injuries and frailty. Medications and organ dysfunc-
tion can alter the presentation of shock. Aging is inherently associated with a decline in cellular
function, leading to diminished organ performance. This
INTRODUCTION decline is marked by a decrease in the body’s ability to adapt and
maintain homeostasis, resulting in a heightened vulnerability
Globally, the demographic shift toward an aging population is to injury-related stress, a phenomenon often referred to as
notable, with older adults becoming the fastest-growing age group. "reduced physiological reserve" ( Table 12-1). Consequently,
By 2050, it is projected that nearly half of the world’s population injuries that younger individuals might easily recover from can
will reside in countries where at least 20% are over 60 years old, have severe, sometimes catastrophic, outcomes in older adults.
with a quarter living in countries where older adults make up Research has documented the significant impact of preexisting
more than 30% of the populace. conditions (PECs) on the morbidity and mortality outcomes of
This demographic shift represents a significant societal change trauma patients. A notable study identified five critical PECs—
in the 21st century, highlighted by the increased activity levels and cirrhosis, coagulopathy, chronic obstructive pulmonary disease,
longevity of today’s older adults compared to previous generations. ischemic heart disease, and diabetes mellitus—that significantly
Access to high-quality healthcare in industrialized regions further influence trauma patient outcomes. In an analysis involving over
enhances their quality of life. However, the active lifestyles and 3,000 patients, it was found that one in four individuals aged 65
increased mobility of the current older adult population also or older had at least one of these conditions. Furthermore, the
expose them to a greater risk of sustaining serious injuries, making presence of one or more of the critical PECs nearly doubled the
injury the fifth leading cause of death among this group. mortality risk compared to patients without such conditions. The
The economic status of older adults affects their health, and the study also highlighted the interplay between injury severity and
health of geriatric patients affects the economy. Older adults with host factors, including age, gender, and PECs, underscoring
lower incomes are more likely to have disabilities and die younger. that while injury severity is a primary mortality determinant,
For those with lower incomes, disability is likely to begin earlier host factors are also crucial ( Figures 12-1A and B).
in life, further increasing the risk of early mortality. The social
determinants of health play a key role in the health trajectory of
older adults. Older adults have greater healthcare and long-term
care needs than younger people, leading to increased healthcare
expenditures.

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 COURSE MANUAL | Chapter 12 | Trauma in the Older Adult

 Table 12-1: Effects of Aging on Organ Systems and Implications for Care.

Effects of Aging on Organ Systems and Implications for Care

Organ system Functional changes Implications for care

Cardiac • Declining function • Lack of “classic” response to hypovolemia

• Decreased sensitivity to catecholamines • Risk for cardiac ischemia
• Decreased myocyte mass • Increased risk of dysrythmias
• Atherosclerosis of coronary vessels • Elevated baseline blood pressure
• Increased afterload
• Fixed cardiac output
• Fixed heart rate (β-blockers)

Pulmonary • Thoracic kyphoscoliosis • Increased risk for respiratory failure

• Decreased transverse thoracic diameter • Increased risk for pneumonia
• Decreased elastic recoil • Poor tolerance to rib fractures
• Reduced functional residual capacity
• Decreased gas exchange
• Decreased cough reflex
• Decreased mucociliary function
• Increased oropharyngeal colonization

Renal • Loss of renal mass • Routine renal labs will be normal (not
• Decreased glomerular filtration rate (GFR) reflective of dysfunction)
• Decreased sensitivity to antidiuretic • Drug dosing for renal insufficiency
hormone (ADH) and aldosterone • Decreased ability to concentrate urine
• Urine flow may be normal with
hypovolemia
• Increased risk for acute kidney injury

Skin/Soft Tissue/ • Loss of lean body mass • Increased risk for fractures
Musculoskeletal • Osteoporosis • Decreased mobility
• Changes in joints and cartilages • Difficulty for oral intubation
• Degenerative changes (including c-spine) • Risk of skin injury due to immobility
• Loss of skin elastin and subcutaneous fat • Increased risk for hypothermia
• Challenges in rehabilitation

Endocrine • Decreased production and response to • Occult hypothyroidism

thyroxin • Relative hypercortisone state
• Decreased dehydroepiandrosterone (DHEA) • Increased risk of infection

193
  Figure 12-1: Predicted Increased Mortality Risk MECHANISM OF INJURY
in Older Adults. This figure illustrates the predicted
increased mortality risk in older adults based on age Older adults are experience common mechanisms of injury
and the number of preexisting medical conditions. such as motor vehicle crash (MVC), being struck as a pedestrian,
Patients with multiple preexisting conditions have a burns, and penetrating injuries. Additionally—and somewhat
significantly higher predicted risk of mortality. unique to older adults—is the frequency of injury from ground-
A. Represents the mortality risk in men. level falls, which can result in severe injury despite a seemingly
B. Represents the mortality risk in women. trivial mechanism.

FALLS
The likelihood of experiencing a fall increase with age, and
falls are the leading cause of fatal injury among older adults.
Many factors heighten the risk of falls, including older age, physical
limitations, a history of falls, the use of certain medications,
dementia, balance issues, and gait instability, as well as visual,
cognitive, and neurological impairments. Environmental hazards
such as loose rugs, inadequate lighting, and slippery or irregular
flooring also contribute significantly to the risk. Falls can also
result from syncope or occult infection.
Despite the seemingly minor nature of ground-level
falls, they can inflict severe, life-threatening injuries in
older adults due to underlying frailty, osteoporosis, existing
A. chronic conditions, and the use of certain medications such
as anticoagulants. Traumatic brain injuries (TBI) stand out
as a common injury from falls among older adults. Fifty-one
percent of TBIs in older adults are caused by falls, while MVCs
cause 9%. Additionally, falls leading to fractures, especially
hip fractures, frequently result in a significant reduction of
independence for nearly half of the geriatric patients affected.

MOTOR VEHICLE/MOTORCYCLE COLLISION

MVCs and motorcycle collisions (MCCs) rank as the second-
and third-most common causes of injuries among older adults.
Typically, older individuals drive fewer miles and at lower speeds
compared to younger drivers. However, the risk of involvement
in MVCs and MCCs for older drivers is increased by factors such
as slower reaction times, increased size of blind spots, reduced
B. neck mobility, diminished hearing, and cognitive decline.
Risk of Morality-Associated Geriatric Complications or Death, by Age Medical conditions like myocardial infarction, stroke, and
and Number of Preexisting Conditions: Used with permission of dysrhythmias also contribute to scenarios that may lead to a
Wolters Kluwer Health, Inc., from Min L, Burruss S, Morley E, et al. A
simple clinical risk nomogram to predict mortality-associated geriatric collision.
complications in severely injured geriatric patients. J Trauma Acute Care The types of physical injuries sustained in these collisions
Surg. 2013;74(4):1125-1132; permission conveyed through Copyright
Clearance Center, Inc.
are like those observed in younger adults, but older adults face
a higher risk of fractures, particularly in the upper cervical spine
and ribs, largely due to osteoporosis. TBI in this population may
The concept of frailty in the older adult, characterized by be further complicated by the use of anticoagulants. Injuries may
a diminished response to physiological stress due to lower not be clinically obvious; therefore, liberal use of imaging for
physiological reserve and multiorgan system insufficiency, has diagnosis is advised.
been recognized for decades and has more recently been applied
to the trauma population. The development of a Trauma-Specific BURNS
Frailty Index ( Figure 12-2) has enabled healthcare clinicians
to identify patients at greater risk of poor outcomes and with Burn injury can be particularly devastating in geriatric
increased resource needs. Research indicates that targeted patients. Although mortality rates from burns have decreased
interventions for these frail geriatric patients can lead to improved significantly in younger populations, the mortality risk from small
outcomes, emphasizing the importance of a tailored approach in to moderate burns remains disproportionately high among older
the management of geriatric trauma patients. adults. Research into deaths from structural fires highlights that
older adults are especially vulnerable due to slower reaction times,

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 COURSE MANUAL | Chapter 12 | Trauma in the Older Adult

 Table 12-2: 15 Variable Trauma Specific Frailty Index. This table presents the 15 Variable Trauma-Specific Frailty
Index (TSFI), a tool used to assess frailty in older trauma patients. The TSFI includes factors related to comorbidities,
daily activities, health attitudes, function, and nutrition, each assigned a score based on severity. The cumulative
score, ranging from 0 to 15, provides an indication of a patient’s frailty status, with a score greater than 0.25
suggesting frailty. Identifying frailty using the TSFI allows for risk stratification and aids in planning appropriate care
for geriatric trauma patients.

15 Variable Trauma Specific Frailty Index (TSFI) Total

Comorbidities Cancer History Yes No

+1 +0 ______

Coronary Heart MI CABG PCI Medication None

Disease
+1 +0.75 +0.5 +0.25 +0 ______

Dementia Severe Moderate Mild No

+1 +0.5 +0.25 +0 ______

Daily Help with Yes No

grooming
Activities +1 +0 ______

Help with
managing Yes No
money +1 +0 ______

Help doing Yes No

housework
+1 +0 ______

Help toileting ______

Help walking Wheelchair Walker Cane No

+1 +0.75 +0.5 +0.5 ______

Health Feel less useful Most time Sometimes Never

attitude +1 +0.5 +0 ______

Feel sad Most time Sometimes Never

+1 +0.5 +0 ______

Feel effort to Most time Sometimes Never

do everything
+1 +0.5 +0 ______

Feel lonely Most time Sometimes Never

+1 +0.5 +0 ______

Falls  ithin last month

W  resent not in last month
P None
+1 +0.5 +0 ______

Function Sexually active Yes No

+0 +1 ______

Nutrition Albumin <3 g/dL >3 g/dL

+1 +0 ______

SCORE Frailty Index Score/15 >0.25 = Frail ______

Used with permission of Lacey J, d’Arville A, Walker M, Hendel S, Lancman B., Considerations for the Older Trauma Patient. Current Anesthesiology
Reports. 2022;12:250-257; permission conveyed through Copyright Clearance Center, Inc.

195
 diminished hearing and vision, and challenges in evacuating from
 Box 12-1: Risk Factors Related to Perpetrators of
a burning building. Furthermore, incidents such as spills of hot
Elder Abuse.
liquids on the skin, which might result in superficial burns in
younger individuals due to a higher density of hair follicles
aiding in reepithelialization, often lead to full-thickness burns Risk Factors Related to Perpetrators
in older adults, who typically have fewer follicles.
The decreased physiological reserve of aging organ systems
• History of mental health problems
plays a critical role in the recovery of geriatric burn patients. While or substance abuse
the visible changes in the skin are apparent, it is the diminished
capacity of geriatric patients to respond to the physiological • History of medical problems
demands of a burn injury that most significantly affects their • Experience of traumatic life events
outcomes and survival. or disruptive behavior
• High levels of stress
PENETRATING INJURY • Not prepared or trained to care for the elder
By far, blunt trauma is the predominant mechanism of injury in • Poor coping skills
older adults; however, a significant number of people over the age
• Experiencing or witnessing abuse as a child
of 65 years are victims of penetrating injury. In fact, penetrating
injury is the fourth-most common cause of traumatic death in • Social isolation
individuals 65 years and older. Many deaths associated with • Financial and emotional dependence
gunshot wounds are related to intentional self-harm or suicide. on an elder
The damage from the penetrating injury determines the initial
mortality risk. For older adults who survive the initial injury,
If in skilled nursing facility:
chronic comorbidities and baseline frailty are most influential in
determining return to independence and mortality. • Inadequate numbers or qualification of staff
• Staff stress or burnout
ELDER ABUSE
Annually, in the US, around 5 million older adults are
subjected to elder abuse. The spectrum of abuse encompasses  Box 12-2: Signs of Elder Abuse.
physical, sexual, and emotional harm, along with neglect,
isolation, and financial exploitation, predominantly inflicted by
Signs of Elder Abuse
family members (over 60% of cases). The CDC defines "elder
abuse" as any intentional act or failure to act that causes or risks
harm to an older adult, typically by someone they trust. The • Stops taking part in activities he or she enjoys
manifestations include but are not limited to physical restraint, • Looks messy, with unwashed hair or dirty clothes
emotional distress, neglect by caregivers, abandonment, sexual • Has trouble sleeping
abuse, and financial exploitation. It is imperative for healthcare
• Loses weight for no reason
professionals to remain alert to the varied presentations and often
subtle manifestations, from physical injuries to less apparent signs • Becomes withdrawn or acts agitated or violent
like poor hygiene or dehydration, indicators of neglect. • Displays signs of emotional trauma, like rocking
Elder abuse significantly increases mortality rates in older back and forth
injured patients. Abused older adults have three times the • Has unexplained bruises, burns, cuts, or scars
mortality risk of those who are not abused. Discrepancies between
• Has broken eyeglasses/frames
a patient’s and caregiver’s accounts, along with physical findings or
intentional delays in seeking treatment, should trigger reporting • Has physical signs of punishment or being
to relevant authorities for investigation. In cases of suspected or restrained
confirmed abuse, immediate measures should be taken to extricate • Develops bed sores or other preventable
the geriatric patient from the harmful environment. conditions
The National Center on Elder Abuse reports that while over • Lacks medical aids (glasses, walker, dentures,
10% of older adults may endure some form of abuse, less than hearing aid, medications)
20% of these incidents are reported, underscoring the need for • Has an eviction notice for unpaid rent, notice
a comprehensive, multidisciplinary approach to care for elder of late mortgage, or home eviction
abuse victims. Risk factors related to perpetrators of elder abuse
• Has hazardous, unsafe, or unclean living
are listed in  Box 12-1. Signs of the various types of elder abuse
conditions
are listed in  Box 12-2.
• Displays signs of insufficient care or unpaid bills
despite adequate financial resources

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 COURSE MANUAL | Chapter 12 | Trauma in the Older Adult

ASSESSMENT AIRWAY
Managing the airway in geriatric patients presents unique
PRIMARY SURVEY WITH RESUSCITATION challenges. The significant reduction in protective airway reflexes
among older adults necessitates quick and decisive action to
EXSANGUINATING EXTERNAL HEMORRHAGE establish a definitive airway, which can be critical for patient
Management of uncontrolled external hemorrhage from survival. Use of cervical collars in this population may heighten
lacerations or open wounds necessitates the application of the risk of aspiration. Additionally, loose dentures can obstruct the
pressure, packing, or the placement of a tourniquet. The removal airway; however, if they do not impede the airway, they should be
of dressings should be approached with caution in geriatric left in place during bag-mask ventilation to enhance mask fit. The
patients due to the fragility of aged skin, which can exacerbate absence of teeth in some geriatric patients simplifies intubation
lacerations and tears. Additionally, hematomas and contusions but complicates bag-mask ventilation. Arthritis can restrict the
in this population have the potential to expand, contributing to ability to open the mouth and properly manage the cervical spine,
significant blood loss. The diminished elasticity of tissues and potentially causing or worsening injuries.
the frequent calcification of blood vessels in older individuals During RSI, it is advisable to lower the doses of barbiturates,
can transform minor soft-tissue bleeding into extensive benzodiazepines, and other sedatives by 20% to 40% to reduce
hematomas. Furthermore, the common use of anticoagulant or cardiovascular depression risk. It is crucial to consider these
antiplatelet medications among geriatric patients may exacerbate physiological changes and management strategies in airway
blood loss, necessitating careful consideration in the management assessment and management for older adults. Key physiological
of their injuries. changes and management considerations of concern in airway
assessment and management are listed in  Table 12-3.

 Table 12-3: Physiological Changes and Management Considerations of Older Adults.

Physiological Changes and Management Considerations

PRIMARY
Physiological Changes with Aging Management Considerations
SURVEY

AIRWAY • Arthritic changes in mouth and cervical spine • Edentulousness

• Macroglossia • Use appropriately sized laryngoscope and tubes
• Decreased protective reflexes • Place gauze between gums and cheek to
achieve seal when using bag-mask ventilation
• Ensure appropriate dosing of rapid-sequence
intubation medications

BREATHING • Increased kyphoscoliosis • Limited respiratory reserve; identify

• Decreased functional residual capacity (FRC) respiratory failure early
• Decreased gas exchange • Manage rib fractures expeditiously
• Decreased cough reflex • Ensure appropriate application of
• Decreased mucociliary clearance from airways mechanical ventilation

CIRCULATION • Preexisting cardiac disease or hypertension • Look for evidence of tissue hypoperfusion
• Lack of a “classic response” to hypovolemia • Administer balanced resuscitation and blood
• Likelihood of cardiac medications transfusion early for obvious shock
• Use advanced monitoring as necessary and
on a timely basis

DISABILITY • Cerebral atrophy • Liberally use CT imaging to identify brain

• Degenerative spine disease and spine injuries
• Presence of preexisting neurological or • Ensure early reversal of anticoagulant
psychiatric disease and/or antiplatelet therapy

EXPOSURE • Loss of subcutaneous fat • Perform early evaluation and liberate patients
• Loss of skin elasticity from spine boards and cervical collars as
• Arthritic skeletal changes soon as possible
• Nutritional deficiencies • Pad bony prominences when needed
• Prevent hypothermia

197
 BREATHING Atherosclerosis, which is common in older age, can also play
a role in either primary or secondary brain injuries. Due to the
Aging leads to decreased compliance of the lungs and chest moderate cerebral atrophy often present in this age group, signs
wall, which in turn increases the effort required for breathing. This of intracranial injury may not be immediately apparent on
physiological change, combined with a diminished respiratory neurological examinations. Additionally, cognitive, hearing, and
reserve, significantly elevates the risk of respiratory failure in visual impairments, as well as incongruent language use between
geriatric trauma patients. Because aging causes a suppressed patient and healthcare team, can lead to misleading Glasgow
heart rate response to hypoxia, respiratory failure may present Coma Scale scores. Prompt recognition and management of
insidiously in older adults. Interpreting clinical and laboratory these conditions, including the reversal of anticoagulant therapy,
information can be difficult in the face of preexisting are crucial for improving outcomes in older adults following
respiratory disease or nonpathological changes in ventilation traumatic injuries. Key physiological changes and management
associated with age. Frequently, decisions to secure a patient’s considerations of concern in the assessment and management of
airway and provide mechanical ventilation may be made before disability are listed in  Table 12-3.
fully appreciating underlying premorbid respiratory conditions.
Key physiological changes and management considerations in EXPOSURE AND ENVIRONMENT
assessing and managing breathing and ventilation are listed in
Musculoskeletal changes associated with the aging process
 Table 12-3. Overall, these may lower the threshold for intubation.
present unique concerns during this aspect of the initial
CIRCULATION assessment of the geriatric trauma patient. Loss of subcutaneous
fat, nutritional deficiencies, chronic medical conditions, and
Given the prevalence of hypertension among older adults, preexisting medical therapies place older adult patients at risk
a blood pressure that appears normal may actually indicate a for hypothermia and the complications of immobility (pressure
state of hypotension. Research supports using a systolic blood injuries and delirium). Rapid evaluation and early liberation from
pressure threshold of 110 mm Hg to identify hypotension spine boards and cervical collars, when possible, will minimize
in those over 65. Older adults may not exhibit the typical these complications. Key physiological changes and management
compensatory tachycardia in response to hypovolemia due to considerations concerning exposure and environment are listed
factors like catecholamine insensitivity, atherosclerosis, myocyte in  Table 12-3.
fibrosis, or the use of certain heart medications, leading to a
reliance on increased systemic vascular resistance. Early detection ADJUNCTS TO ASSESSMENT
of significant tissue hypoperfusion is essential. Measures such as
base deficit, serum lactate, and shock index are useful in detecting Plain x-rays of the chest and pelvis in patients who have suffered
occult hypovolemia. Base deficit less than 6 or lactate greater than blunt trauma will evaluate for pneumothorax, hemothorax,
or equal to 2.4 may indicate occult hypovolemia. A shock index and fractures of the pelvis; eFAST (focused assessment with
greater than or equal to 0.7 has 83% specificity for predicting the sonography in trauma) will evaluate for intra-abdominal fluid,
need for transfusion in patients over 65. pneumothorax, and pericardial effusion. Foreign body series
Resuscitation strategies for geriatric patients with are obtained for patients who have bullet injuries to localize any
hypoperfusion mirror those for younger patients, emphasizing projectiles that remain; bullet wounds should be marked to allow
balanced resuscitation with blood products and fluids as needed. determination of probable trajectories.
Circulatory failure in geriatric trauma patients often suggests Laboratory assessment includes complete blood count,
active bleeding. Early implementation of advanced monitoring coagulation profile, comprehensive metabolic profile with hepatic
techniques is recommended to navigate resuscitation effectively, panel, cardiac enzymes, toxicology panel for alcohol and drug
especially considering the likelihood of underlying cardiovascular screening, and arterial blood gas. Send urinalysis to evaluate for
issues. Additionally, it is vital to consider that incidents like strokes, bleeding or potential occult infection. Thromboelastography is
heart attacks, or dysrhythmias might have precipitated the trauma. helpful in patients taking anticoagulants or who have evidence of
Key physiological changes and management considerations in the active bleeding and can help guide resuscitation. Obtain an ECG.
assessment and management of circulation are listed in  Table Acute ischemia or arrhythmia may underly the etiology of the
12-3. Procedures for placing monitoring lines in addition to other trauma. Cardiac echocardiography may be useful when the injury
basic ATLS® procedures can be accompanied by an increase in is related to cardiac dysfunction. Determine whether naso-/
complications in older adults, for which the clinician needs to be orogastric or urinary catheter placement is needed.
vigilant.
REASSESSMENT
DISABILITY
TBI is a problem of epidemic proportion in the geriatric Repeat the primary survey, paying close attention to changes
population. With age, the cerebral atrophy results in more in vital signs. Obtain as much information as possible as possible
prominent subdural spaces. The bridging veins become fragile about comorbid conditions, medications, and preinjury level of
and may bleed following minor injury. Furthermore, the functioning. Reevaluate areas of bleeding or hematoma identified
prevalent use of anticoagulant and antiplatelet medications during the primary survey to determine whether bleeding is
among older adults for existing health conditions significantly controlled or hematomas have enlarged. Perform a thorough
increases their vulnerability to intracranial hemorrhages. secondary survey. Give antibiotics for open fractures and complex
lacerations. Update tetanus immunization as needed.

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 COURSE MANUAL | Chapter 12 | Trauma in the Older Adult

ADJUNCTS catheter, paravertebral catheter, or ultrasound-guided regional

nerve blocks demonstrate a generally favorable profile and may
Occult injuries are common in this patient population. Whole
allow reduced exposure to pain medications that can increase the
body CT scan scan will be useful in identifying injuries that could
risk of delirium.
otherwise be missed. It is particularly important in patients with
The use of incentive spirometry to guide treatment is generally
unreliable examinations due to altered mental status from TBI,
recommended. Admission to the ICU may be prudent in this
dementia, encephalopathy, or intoxication. Obtain plain x-rays of
high-risk population, and guidelines that stratify patients based
areas that may be fractured. on risk factors have demonstrated benefit and a reduction in
complications.
FRAILTY
At least one-third of older adults are frail. Frailty significantly TRAUMATIC BRAIN INJURY
influences outcomes in geriatric trauma patients, serving
Research shows that geriatric and frail patients are not only at
as a critical determinant of morbidity and mortality. This
an increased risk of suffering TBI but also suffer higher morbidity
syndrome, characterized by decreased physiological reserve and
and mortality from this injury. Ground-level falls are a common
increased vulnerability to stressors, results in a diminished ability
cause, with an often subtle presentation and progression. Despite
to withstand trauma and leads to a higher likelihood of adverse
this vulnerability, specific guidelines for managing TBI in older
outcomes, including prolonged hospitalization, increased need
patients are scarce. The evaluation process can be complicated by
for institutional care, and a higher mortality rate. These patients
preexisting conditions such as delirium, dementia, or depression.
are at risk for deterioration and mandate close observation.
Given the elevated risk of undetected intracranial bleeding, partly
GOALS OF CARE due to cerebral atrophy and chronic conditions, a liberal approach
to CT scanning is advised, even when cognitive functions appear
Goals of care should reflect the patient’s wishes and be relatively intact.
consistent with their values. A goals-of-care discussion should The management of TBI in geriatric patients on anticoag-
take place when able. Advance directives, physician orders for life- ulant or antiplatelet therapy poses additional challenges, giv-
sustaining treatment, or out-of-hospital do-not-resuscitate orders en the higher incidence and mortality of brain injuries in this
are also of importance in this population. group. Early and aggressive reversal of anticoagulation may
lead to better outcomes.  Table 12-4 lists strategies for reversal
SPECIFIC INJURIES of commonly used anticoagulants. In the older adult, reversal of
anticoagulation using large volumes of fresh frozen plasma can
Older and frail adults are subject to the same injuries from lead to fluid overload. Using direct reversal agents or prothrom-
high-energy mechanisms as younger, nonfrail patients. However, bin complex concentrate, when available, allows for more efficient
there are specific injuries that are common in the older and frail reversal with lower volumes of fluid. Unfortunately, morbidity
population that may result from relatively minor or seemingly and mortality in these cases are often exacerbated by preexisting
trivial mechanism of injury such as ground-level falls. These conditions, and a tendency toward a pessimistic approach to treat-
include rib fractures, TBI, cervical spinal cord and column ment can further worsen outcomes. This underscores the impor-
injuries, and pelvic fractures. tance of considering a patient’s personal care goals when devising
a treatment plan for severe TBI.
RIB FRACTURES Notes:
Older and frail patients are at increased risk for rib fractures due • The choice of reversal strategy should consider the urgency
to anatomical changes of the chest wall and loss of bone density. of the situation, risk of thrombosis, and patient’s comorbid
The most common cause of rib fractures is a ground-level fall, conditions.
followed by MVC. The primary complication in geriatric patients • Reversal agents like prothrombin complex concentrate
with rib fractures is pneumonia, which can occur in susceptible (PCC) or Andexanet Alfa may carry risks of thromboembolic
lung parenchyma because of underlying pulmonary injury and/or events and should be used cautiously.
inadequate ventilation from pain causing atelectasis.
In the older adult population, the incidence of pneumonia • Close monitoring of coagulation status is crucial following
is reported to be as high as 30%. Mortality risk increases reversal interventions.
linearly with each additional rib fractured. The main objectives • Use of fresh frozen plasma (FFP) for reversal may require
of treatment in patients with rib fractures are pain control and administering large volumes which may not be tolerated in
adequate pulmonary hygiene. Pain management can include oral some older adults with congestive heart failure.
medication, IV medications, transdermal medications, or regional
anesthetics. Opioid administration in geriatric patients must be
undertaken cautiously with close patient monitoring. Avoiding
untoward effects, particularly respiratory depression and delirium,
is of paramount importance. Multimodal therapy that minimizes
the use of opioids is ideal. Regional analgesia with either epidural

199
  Table 12-4: Medications and Strategies for Reversal of Commonly Used Anticoagulants in Older Adults.

Medications and Strategies for Reversal of Commonly Used Anticoagulants in Older Adults

Anticoagulant Reversal Agent/Strategy Dosage Comments

Warfarin Vitamin K, Fresh Frozen Vitamin K: 5-10 mg IV; FFP: Vitamin K for gradual reversal;
(Coumadin) Plasma (FFP), Prothrombin 10-15 mL/kg; PCC: 25-50 units/kg PCC or FFP for urgent reversal
Complex Concentrate (PCC)

Unfractioned Protamine Sulfate 1mg per 100 units of heparin Dosage depends on
Heparin (max 50 mg) the amount of heparin
administered

Low-Molecular- Protamine Sulfate 1mg per 1mg of enoxaparin if Only partially effective;
Weight Heparin (partial reversal) given within 8 hours; 0.5 mg per monitor anti-Xa levels if
(e.g., Enoxaparin) 1mg if after 8 hours available

Direct Thrombin Idarucizumab (Praxbind) 5 g IV (administered as two 2.5 g Specific reversal agent for
Inhibitors (e.g., doses no more than 15 minutes dabigatran; rapid onset of
Dabigatran) apart) action

Factor Xa Inhibitors Andexanet Alfa (Andexxa), Andexanet Alfa: 400-800 mg Andexanet alfa for specific
(e.g., Rivaroxaban, Prothrombin Complex bolus followed by 4-8 mg/min reversal; PCC for non-specific
Apixaban) Concentrate (PCC) infusion; PCC: 50 units/kg reversal

Fondaparinux Recombinant Factor VIIa, rVIIa: 20-40 mcg/kg; PCC: 25-50 No specific reversal agent;
Prothrombin Complex units/kg use PCC or rVIIa as off-label
Concentrate (PCC) options

Antiplatelet Agents Platelet Transfusion, Platelet Transfusion: 1-2 units; Desmopressin may enhance
(e.g., Aspirin, Desmopressin (DDAVP) Desmopressin: 0.3 mcg/kg IV platelet function; platelet
Clopidogrel) transfusion for critical
bleeding

• The choice of reversal strategy should consider the urgency of the situation, risk of thrombosis, and patient’s comorbid conditions.
• Reversal agents like PCC or Andexanet Alfa may carry risks of thromboembolic events and should be used cautiously.
• Close monitoring of coagulation status is crucial following reversal interventions.
• Use of FFP for reversal may require administering large volumes which may not be tolerated in some older adults with congestive heart failure.

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CERVICAL SPINAL COLUMN AND SPINAL

 Figure 12-2: A. Patient with kyphosis and a cervical
CORD INJURIES fracture with an ill-fitting cervical collar. Note forcing
Older and frail patients are also at significant risk of both the abnormal anatomy into a cervical collar worsens the
cervical spinal column injuries and spinal cord injuries. fracture anatomy. B and C. Patient with kyphosis and a
Osteoporosis and chronic degenerative changes of the spinal cervical fracture with positioners supporting kyphosis
column make the cervical spine particularly susceptible to improves alignment of cervical spine.
injury from falls. Classic mechanisms include hyperextension
injuries from striking the front of the head. Odontoid fractures A.
are exceptionally common and are associated with poor healing
irrespective of the treatment chosen. Spinal motion restriction
with a cervical collar is generally recommended but can lead to
secondary problems including development of pressure sores,
raised intracranial pressure, dysphagia, breathing difficulties,
delirium, and compliance issues.
The presence of degenerative spinal diseases in older adults
further heightens their risk of fractures and SCI, even from
low-energy falls. In particular, ankylosing spondylitis can lead to
severe injury and deficits in patients who suffer traumatic injury.
Forcefully manipulating the neck to conform to the contour of a
cervical collar can result in further injury. Instead, these patients
should be positioned with sandbags or positioners supporting the
occiput and either side of the head maintaining the fixed kyphosis B.
( Figure 12-2). Cervical stenosis and degenerative disease of the
cervical spine put the spinal cord at risk of compression injuries.
Classically, central cord syndrome, in which the motor deficit of
the upper extremities is greater than the lower extremities, can be
seen in this patient population. Obtain neurosurgical consultation
to determine the need for intervention.

PELVIC FRACTURES
Sarcopenia and osteopenia are frequently found in older and
frail patients and can contribute to the development of pelvic
fractures following relatively trivial energy-transfer mechanisms
such as ground-level falls. Mortality from pelvic fracture is four
times higher in older patients than in a younger cohort. The
need for blood transfusion, even in the absence of morphologies
C.
at increased risk of bleeding, is significantly higher than that
seen in a younger population. Angioembolization may be
required for bleeding control. Older adults also have longer
hospital stays and are less likely to return to an independent
lifestyle following discharge due to issues with mobility. Fall
prevention is the mainstay of reducing the mortality associated
with pelvic fractures.

201
 SPECIAL CIRCUMSTANCES TRANSFER CONSIDERATIONS
Geriatric trauma patients are frequently undertriaged.
MEDICATIONS Subtle initial physiological changes and low-energy mechanisms
Medication usage is highly prevalent among older adults, combine to increase the probability of undertriage. Early
with 72% of individuals over 55 years old taking at least one identification of injuries with appropriate resuscitation gives these
prescription drug and 20% consuming four or more medications. patients the best chance of good outcome. Patients with TBI, SCI,
While the management of chronic health conditions has benefited complex fractures, multiple rib fractures, and intra-abdominal
from these medications, it has concurrently led to an increase injuries may require transfer to a trauma center for definitive care.
in polypharmacy. Classes of drugs such as antihypertensives, These patients may also have comorbid conditions that affect their
sedatives, hypnotics, neuroleptics, antipsychotics, antidepressants, recovery from injury. After assessment and resuscitation, transfer
and benzodiazepines are associated with an elevated fall risk in can be initiated. Chapter 15, Transfer to Definitive Care, outlines
this demographic. The American Geriatrics Society publishes a list considerations for safe patient transfer. Frail patients with severe
of potentially inappropriate medications for older adults (https:// injuries should receive care that aligns with their goals of care.
agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.18372).
Beta blockers, calcium channel blockers, and antiarrhythmics can CHAPTER SUMMARY
affect hemodynamic responses to blood loss and to resuscitation.
During the secondary survey of an older trauma patient, it Falls are the most common mechanism of injury for older
is crucial to assess and document their medication regimen. adults. Seemingly trivial mechanisms can result in severe injury
Medications that particularly complicate the management of such as multiple rib fractures, TBI, spinal column fracture, and
a bleeding patient include anticoagulants, antiplatelet agents, pelvic fracture. Preexisting health conditions and frailty have
and direct thrombin inhibitors. Prompt identification of these significant effects on morbidity and mortality. Shock can be
medications and the administration of appropriate reversal agents masked by medications and PECs. Thorough assessment and
may improve outcomes. resuscitation give the best chance for good outcome.

AGEISM
Ageism is commonly described as implicit or explicit bias
KEY LEARNING POINTS
against individuals based on their age. Robert Neil Butler, first • Older adults are the fastest-growing segment of the
director of the National Institute on Aging, introduced the term population. Trauma clinicians will see an increasing
in 1969 referring to discrimination against older individuals. number of injured older adults.
Triggered by unfavorable and misleading stereotypes, ageism is
deeply embedded in our culture and less commonly acknowledged • Common mechanisms of injury include falls, MVCs,
motorcycle collisions, burns, and penetrating
than other types of prejudice and discrimination. In fact, younger
injuries.
patients are frequently given priority when allocating resources
in traditional healthcare. According to one survey, one in five • The influence of changes in anatomy and physiology,
Americans over the age of 50 in the US report having experienced frailty, and preexisting medical conditions adversely
discrimination in healthcare settings, which can lead to improper affects outcomes.
or suboptimal care.
• Ageism may result in bias that should be
In the emergency room, older adults may be excluded from
recognized and addressed to optimize care.
discussions and decision-making regarding their own care due
to false assumptions of cognitive decline or dementia. Decreased • The primary survey sequence is the same as for
vision and hearing may compromise their ability to communicate younger adults. Physiologic changes associated with
in the stressful and noisy setting of the trauma room. Presumption aging, comorbid conditions, and frailty may affect
of comorbidities and ailing physiological functions due to advanced response to injury and resuscitation.
age may influence treating physicians’ choice of diagnostic tests
• Common injuries in older adults include rib
and limit resuscitation efforts due to an overstated concern of fractures, TBI, spine injuries, and pelvic fractures.
futility of care and expected inability to restore geriatric patients’ Understanding the impact of aging and its influence
functional status to preinjury levels. on pitfalls seen with these injuries and procedures
Adopting an individualized, patient-centered treatment will result in better outcomes.
approach may help the trauma team mitigate ageism. Like other
types of bias, recognizing its existence is the critical initial step. • The impact of medications, elder abuse, and
understanding the goals of care are particularly
Reflecting on its causes and how it may influence clinician-patient
important features of trauma care of the geriatric
interactions and treatment decisions can lead to behavioral patient. Early identification along with a team
modification, improved trauma care, and resource utilization. approach will influence care and outcomes.

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15. Weber C, Millen JC, Liu H, et al. Undertriage of Geriatric

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Demetriades D. Old age with a traumatic mechanism use in older adults. J Am Geriatr Soc. 2023;71(7):2052–
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6. Butler RN. Age-ism: Another form of bigotry. Gerontologist.
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Peck G. Challenges in the PREHOSPITAL emergency
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9. Elwell, V. Combatting ageism in healthcare. https://www.
ucihealth.org / blog /2022/03/combatting-ageism-in-
healthcare . Accessed date.
10. Joseph B, Pandit V, Zangbar B, et al. Validating trauma-
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12. Brady D, Kohler U, Zheng H. Novel estimates of mortality
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13. Bloom DE, Chatterji S, Kowal P, et al. Macroeconomic
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 COURSE MANUAL | Chapter 13 | Trauma in the Pregnant Patient

13

Trauma in the
Pregnant Patient

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe important anatomic and physiologic 5. Identify which pregnant trauma patients are at risk
changes that occur in the later stages of for placental abruption, including the appropriate
pregnancy that may impact initial patient timing to involve the obstetric team
assessment and treatment in the setting of 6. Describe modifications to common interventions
acute trauma such as IV/IO access (above the diaphragm)
2. Outline the treatment priorities and assessment and chest tube placement in the later stages of
methods for a pregnant patient and their fetus pregnancy
during the primary and secondary surveys, 7. Recognize which pregnant trauma patients may
including the use of adjuncts require Rh immune globulin prophylaxis, and
3. Summarize the indications and technique for state the resources available for determining the
performing left-uterine displacement, including dosage, route, and timing of administration
the physiologic benefit it creates in the pregnant 8. Describe the timing and indication for resuscitative
trauma patient cesarean delivery and the resulting beneficial
4. Identify the appropriate timing to involve the physiologic changes to the pregnant patient
obstetrics team, either in person or via remote 9. Identify common mechanisms of injury for a
consultation pregnant patient and their fetus, including
possible intimate partner violence 205
 The care of the pregnant trauma patient involves two patients:

13
the pregnant patient and the fetus. The treatment priorities for
an injured pregnant patient are the same as for a nonpregnant
patient. Effective resuscitation of the pregnant patient is the
optimal treatment of the fetus. Use of left-uterine displacement
during the assessment of the pregnant patient is critical to
improving venous return and, therefore, maternal hemodynamics
and fetal blood flow. Imaging that includes radiation exposure
should not be withheld if indicated for the evaluation of the
pregnant patient’s injuries.
Trauma in the Pregnant Patient A qualified surgeon and obstetrician should be involved
early in the evaluation of the pregnant trauma patient. If not
immediately available, early consultation with and/or transfer to
a trauma center with obstetric capabilities should be considered.
CHAPTER STATEMENT In some practice settings, obstetrical care is routinely provided by
midwives, family medicine specialists, or other obstetrics-related
Trauma is a significant contributor to morbidity and mortality clinicians; although these clinicians may be of great value in the
during pregnancy. Clinicians caring for an injured pregnant initial care, it does not negate the need for obstetrical consultation
patient must remember that the sequence of care is the same as for the pregnant trauma patient, however it may be achieved (e.g.,
for nonpregnant patients and that effective diagnosis, treatment, remotely).
and resuscitation of the mother is the best way to achieve optimal
outcomes for both her and the fetus. Clinicians must also
remember that even “minor” mechanisms of injury can cause MECHANISMS OF INJURY
adverse outcomes.
BLUNT INJURY
INTRODUCTION The most common mechanisms of injury during pregnancy
are motor vehicle crashes (MVCs, estimated 207 cases per 100,000
Trauma is a significant contributor to morbidity and mortality
pregnancies) and slips/falls (estimated 48.9 cases per 100,000
during pregnancy. One in 12 pregnancies are estimated to be
pregnancies). MVCs are one of the leading causes of maternal
complicated by trauma. In the US, trauma is the leading cause
and fetal mortality, resulting in maternal death in 1.4 per 100,000
of nonobstetrical maternal death. In addition, trauma has a
pregnancies and fetal death in 3.7 per 100,000 pregnancies. Blunt
tremendous impact on fetal outcomes, including increased
abdominal trauma in the pregnant patient results in an increased
incidence of spontaneous abortion, preterm premature rupture
risk of rupture of membranes, preterm labor, and preterm delivery.
of membranes, preterm birth, uterine rupture, cesarean delivery,
A major risk factor for adverse outcomes during MVC is
placental abruption, and stillbirth. In one study, fetal death from
improper seat-belt use. Compared with restrained pregnant
maternal trauma was calculated to be 2.3 per 100,000 live births. It
patients involved in collisions, unrestrained pregnant patients
is important to recognize that even minor mechanisms of injury
have a higher risk of premature delivery and fetal death. Using a
may result in poor outcomes for the fetus and the mother.
lap belt alone or wearing a lap belt too high over the uterus can
These patients may present as trauma activations through the
increase forward flexion or result in direct force to the uterus,
emergency department; however, they also may present to labor
increasing risk of uterine rupture or placental abruption.
and delivery triage. Thus it is crucial to have a coordinated and
There is less robust literature related to slips and falls during
collaborative system to optimize timely obstetric and trauma care.
pregnancy. Increased joint laxity, center of gravity changes from
By one estimate, as many as 1 in 3 pregnant patients admitted to
the gravid uterus, weight gain, and decreased dynamic postural
the hospital for trauma will deliver during that hospitalization.
stability can contribute to increased risk of falls during pregnancy.
Pregnancy induces alterations in the anatomy and physiology
Approximately 1-in-4 pregnant people will fall at least once during
of most organ systems. These anatomic and physiologic changes
their pregnancy. The likelihood of falling with injury rises later in
alter the presenting signs and symptoms of injury, the approach to
pregnancy, with one study finding that 79% of pregnant patients
resuscitation, and the results of diagnostic testing. Pregnancy may
hospitalized after a fall were in their third trimester.
also impact the pattern and severity of injury.
The possibility of pregnancy should be considered in any female PENETRATING INJURY
of reproductive age. Therefore, laboratory testing should be used
to evaluate for a possible pregnancy. If pregnancy is suspected, The management of penetrating trauma does not differ in
pelvic ultrasound should be used to establish gestational age and a pregnant patient. As the gravid uterus grows larger, the other
more detailed information (i.e., number of fetuses, placentation viscera are relatively protected from penetrating injury; however,
etc.). In one study, 3% of women admitted to a trauma unit uterine injury incidence rises as it becomes an abdominal organ.
were pregnant, and of these pregnancies, 11% were incidentally The dense uterine musculature in early pregnancy can absorb a
discovered. Therefore, every injured female of reproductive age significant amount of energy from penetrating objects, decreasing
should be considered pregnant until proven otherwise. their velocity and lowering risk of injury to other viscera.

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 COURSE MANUAL | Chapter 13 | Trauma in the Pregnant Patient

 Figure 13-1: Estimated Incidence/Prevalence of Injury by Mechanism During Pregnancy. The data on injury
mechanism during pregnancy are hampered by heterogenous study designs and methodologies. However,
domestic (or intimate partner) violence incidence and prevalence has been reported to be high during pregnancy;
this includes sexual, physical, and psychological violence.

Estimated Incidence/Prevalence of Injury by Type of Trauma During Pregnancy

Mechanism of injury Estimated incidence/ Study design Estimated incidence/

prevalence prevalence
in pregnancy outside of pregnancy

Motor vehicle crashes 207/100,000 live births Population-based cohort 1104/100,000 women

Falls and slips 48.9/100,000 live births Retrospective case-control 3029/100,000 women

Burns 0.17/100,000 person-years Retrospective case-control 2.6/100,000 person-years

Accidental poisoning N/A N/A N/A

Domestic violence 8307/100,000 live births Review 5239/100,000 women

Suicide 2/100,000 live births Retrospective cohort 8.8/100,000 population

Homicide 2.9/100,000 live births Retrospective cohort 2.3/100,000 women

Penetrating trauma 3.27/100,000 live births N/A 3.4/100,000 women

Toxic exposure 25.8/100,000 person-years Retrospective cohort 115.3/100,000 person-years

Literature relating to incidence of burns during pregnancy is limited to most severe cases admitted to burn units and referral centers. Rate for
accidental poisoning during pregnancy could not be calculated from available published literature. Domestic violence incidence includes all forms of
partner violence: sexual, physical, and psychological.
N/A, not available.
Rates exclude attempted suicides. Attempted suicide rate during pregnancy is approximately 40/100,000 pregnancies and during postpartum period
is 43.9/100,000 live births. Rates include only causes leading to fatality. Rates calculated using 2009 US data from Centers for Disease Control and
Prevention.
Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013;209(1):1-10.

The amniotic fluid and fetus also absorb energy and contribute injuries in the setting of IPV. Trauma to the neck, breasts, face,
to slowing of the penetrating object. The resulting low incidence upper arms, and lateral thighs are more commonly seen. Sequalae
of associated maternal visceral injuries accounts for the generally of IPV in pregnancy are extensive, including poor pregnancy
excellent maternal outcome in case of penetrating wounds to the weight gain, infection, anemia, stillbirth, pelvic fracture, placental
gravid uterus. Tragically, fetal outcome in general is poor when abruption, fetal injury, preterm delivery, and low birth weight.
there is a penetrating injury to the uterus.
SEVERITY OF INJURY
INTENTIONAL INJURY The severity of maternal injuries significantly impacts maternal
Intentional trauma, unfortunately, is another common and fetal outcome. Therefore, treatment methods also depend on
mechanism for traumatic injury in the pregnant patient. The the severity of maternal injuries. All pregnant patients with major
most common cause of intentional trauma is intimate partner injuries require admission to a facility with trauma and obstetric
violence (IPV ), which has been reported to occur in 4%–8% of all capabilities. Carefully observe pregnant patients with injuries,
pregnancies; however, it is frequently underreported. There are because even minor injuries can result in placental abruption
patterns of injury that are associated with IPV, and it is imperative and possibly fetal demise.
to have heightened awareness of this as a source of trauma.
Proximal and midline injuries are more common than distal

207
  Figure 13-2: Seatbelt Use During Pregnancy. UTERINE CHANGES
A. Demonstrates improper use of seatbelt—note that The uterus is not commonly involved in trauma unless it is
the lap belt is too high over the uterus. B. Demonstrates
enlarged by pregnancy. The uterus remains an intrapelvic organ
correct wearing of the lap belt and shoulder belt.
until approximately the 12th week of gestation. As the fetus grows,
the uterus moves cephalad and becomes an abdominal organ. By
A.
20 weeks, the uterus is at the level of the umbilicus, and at 34 to
36 weeks it reaches the costal margin ( Figure 13-3 and  Figure
13-4) . During the last 2 weeks of gestation, the fundus often lowers
in location as the fetal head engages the pelvis.
As the uterus enlarges, the intestines are pushed cephalad
such that their location is primarily in the upper abdomen. As a
result, the bowel is relatively protected from blunt or penetrating
abdominal trauma, whereas the uterus and its contents (fetus and
placenta) become more vulnerable to direct blunt or penetrating
trauma. Penetrating trauma above the uterine fundus can result
in complex intestinal injury due to this cephalad displacement.
Clinical symptoms of peritoneal irritation are less evident in
pregnant women due to the physiologic and anatomic changes
of pregnancy; therefore, physical examination may be less
informative, and the clinician should maintain a high index of
B. suspicion for underlying intra-abdominal injury.
During the first trimester, the uterus is a thick-walled structure
of limited size, confined within the bony pelvis. During the second
trimester the uterus enlarges beyond the protected pelvic location.
By the third trimester, the uterus is a large, thin-walled abdominal
organ. The fetus remains cushioned by a generous amount of
amniotic fluid. In the later third trimester, the fetus is usually
in the vertex (“head-down”) presentation, with the fetal head
in the pelvis and the remainder of the fetus exposed above the
pelvic brim. Pelvic injuries in late gestation can result in fetal skull
fracture or serious intracranial injury to the fetus.
Unlike the myometrium, the placenta has little elasticity.
This results in vulnerability to shear forces at the uteroplacental
interface, which may lead to bleeding between the placenta and
uterus, which can result in placental abruption. The placental
vasculature is maximally dilated throughout gestation, yet it is
ANATOMIC AND PHYSIOLOGIC CHANGES IN exquisitely sensitive to catecholamine stimulation, which results
PREGNANCY in narrowing of this vasculature and a decrease in placental blood
flow. The blood flow to the pregnant uterus is approximately
An understanding of the anatomic and physiologic maternal 500 mL/minute (five times increased rate), which is significant
alterations due to pregnancy, including the physiologic considering the average total blood volume of a pregnant patient
relationship between a pregnant patient and the fetus, is an is 5000 mL.
essential foundation for providing appropriate and effective Placental abruption may result in vaginal bleeding or may
care to both patients. Such alterations include changes in be concealed and less obvious. Placental abruption can result in
anatomy, blood volume/composition, and hemodynamics, as significant blood loss. Heightened awareness and suspicion of a
well as changes in the respiratory, gastrointestinal, urinary, possible placental abruption is critical, especially in the setting
musculoskeletal, and neurological systems. of a pregnant patient who is showing signs and symptoms of
blood loss without an obvious source. A rapid drop in maternal
intravascular volume from placental abruption or another source
can result in a profound increase in uterine vascular resistance,
reducing fetal oxygenation despite reasonably normal maternal
vital signs.

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increase in tidal volume and an increase in minute ventilation,

 Figure 13-3: Changes in Fundal Height in Pregnancy.
which accommodate for the 20% increase in maternal oxygen
The gravid uterus becomes an abdominal organ after ~12
weeks, reaching the level of the umbilicus at ~20 weeks.
consumption in pregnancy, but result in maternal hypocapnia.
The change in uterine size influences injury patterns with There is a 25% decrease in functional residual volume, and this,
both blunt and penetrating trauma coupled with the increased metabolic rate, result in a greater
tendency toward oxygen desaturation in the setting of oxygen
deprivation (less oxygen reserve). With this lower pulmonary
reserve, there is less ability to compensate for acid-base imbalances.
The normal pregnant patient is in a state of compensated
respiratory alkalosis. Therefore, it is imperative to maintain and
ensure adequate arterial oxygenation when resuscitating injured
pregnant patients. When indicated, it is critical that the airway be
secured early and definitively by the most skilled airway clinician
on the team.
Anatomic alterations in the thoracic cavity include elevation
of the diaphragm by up to 4 cm cephalad and decreased thoracic
compliance, which result in increased resistance to ventilation.
Chest x-ray studies on pregnant patients often reveal increased
lung markings and prominence of the pulmonary vessels.

CIRCULATION
Important hemodynamic factors to consider in pregnant
trauma patients include blood volume, cardiac output, heart rate,
blood pressure, and electrocardiographic changes.

BLOOD VOLUME AND COMPOSITION

Plasma volume increases steadily throughout pregnancy and
plateaus around 34 weeks of gestation. A smaller increase in red
blood cell volume occurs, resulting in a decreased hematocrit level.
In late pregnancy, a hematocrit level of 31%–35% is normal. The
 Figure 13-4: Anatomic Changes in the Uterus in Late combination of relatively young age and expanded plasma volume
Pregnancy. As the uterus enlarges and occupies more of results in a healthy pregnant patient’s ability to lose 1200–1500 mL
the maternal abdominal cavity, it and the fetus become of blood before exhibiting signs and symptoms of hypovolemia.
more vulnerable to injury. The uterine wall also becomes While this volume of blood loss may not be reflected in maternal
thinner. vital sign changes, it can still impact the blood flow to the uterus
and result in fetal compromise as evidenced by an abnormal fetal
heart rate.
White blood cell count increases during pregnancy. Normal
pregnancy white blood cell counts range from 12,000 to 18,000;
however, higher levels are not unusual during labor or stress.
Levels of fibrinogen and other clotting factors are elevated in
pregnancy. It is important to note that fibrinogen levels are elevated
in pregnancy, and a level below 200 can indicate impending
disseminated intravascular coagulation (DIC), a frequent
comorbidity of placental abruption. Platelet count is also elevated
during pregnancy. Prothrombin and partial thromboplastin times
may be shortened, but bleeding and clotting times are unchanged.
Viscoelastic testing, if available, can be helpful in the evaluation
and management of the pregnant trauma patient ( Table 13-2).
AIRWAY AND RESPIRATORY SYSTEM CARDIOVASCULAR CHANGES DURING PREGNANCY
Hyperemia and edema develop in the airway of the pregnant
During pregnancy, the heart rate gradually increases to 20%
patient, which can make intubation considerably more difficult.
over baseline by the third trimester. Stroke volume also increases
There are also significant changes in the respiratory system during
in pregnancy. Cardiac output is calculated by multiplying heart
pregnancy, resulting in increased oxygen requirements and
rate by stroke volume. Cardiac output increases during pregnancy
decreased pulmonary reserve. The respiratory system changes of
by 40%–50% due to increases in both heart rate and stroke
pregnancy begin in the middle of the second trimester (20 weeks)
volume. Twenty percent of cardiac output goes to the uterus
and are progressive through term. These include a 30%–40%

209
 during pregnancy. This increased cardiac output can be greatly
 Table 13-1: Arterial Blood Gas (ABG) Values in the
impacted by the maternal position during the second half of the
Pregnant vs. Nonpregnant Patient. Anatomic and
hormonal changes in pregnancy lead to changes in the
pregnancy. Aorta and vena cava compression by the gravid uterus
ABG. Progesterone increase leads to respiratory alkalosis impacts forward flow and venous return as early as 18 weeks
and a decreased resting PaCO2. Functional Residual pregnant. Cardiac output can be decreased as much as 30% in the
Capacity (FRC) and Expiratory Reserve Volume (ERV) also supine position due to this aortocaval compression.
decrease as the uterus enlarges. Clinically, a patient in late
pregnancy who has a PaCO2 that would be normal in a BLOOD PRESSURE
nonpregnant patient (e.g., 40 mm Hg) should be evaluated There is a reduced vascular resistance in pregnancy due to
for impending respiratory insufficiency.
progesterone-mediated vascular changes. Systolic and diastolic
blood pressure are decreased by 5–15 mm Hg in the second
Arterial Blood Gas (ABG) Values: trimester. The combination of an increased cardiac output and
Nonpregnant and Pregnant Patients decreased blood pressure result in a lower systemic vascular
resistance.
Nonpregnant Pregnant ELECTROCARDIOGRAPHIC CHANGES
PaCO2 37–40 mm Hg PaCO2 27–32 mm Hg In the last half of the pregnancy, the heart is displaced
(respiratory alkalosis) cephalad and to the left due to the gravid uterus. In addition, the
cardiac changes that occur due to the hemodynamic alterations
pH 7.35–7.40 pH 7.40–7.45 of pregnancy impact the electrocardiograph pattern. Left axis
deviation, flattened or inverted T waves in leads III and aVF,
PaO2 75–100 mm Hg PaO2 105 mm Hg and the precordial leads may be normal. Ectopic beats often are
increased during pregnancy. Electrocardiogram changes need to
HCO3 22–26 mmol/L HCO3 18–21 mmol/L be evaluated cautiously due to the variations during pregnancy.
This displacement of the heart can also alter the appearance on a
chest x-ray.

 Table 13-2: Normal Laboratory Values in the NEUROLOGIC SYSTEM

Pregnant vs. Nonpregnant Patient. Pregnant patients
have different “normal” lab values when compared to Although there are no anatomic changes to the neurologic
nonpregnant patients. Pregnant patients normally exist system during pregnancy, patients are at risk of preeclampsia and
in a state of compensated respiratory alkalosis. In the eclampsia. New-onset tonic-clonic, focal, or multifocal seizures in
third trimester, fibrinogen levels that might be normal the absence of other causative conditions may be eclampsia. It is
in a nonpregnant patient may in fact indicate impending a rare complication of pregnancy that can occur after 20 weeks of
disseminated intravascular coagulation (DIC). gestation and can mimic head injury. Hypertension, hyperreflexia,
proteinuria, thrombocytopenia, liver function abnormalities,
Normal Laboratory Values: coagulopathy, or pulmonary edema may be present in addition
to the seizures in a patient with eclampsia. Expert neurological
Pregnant vs. Nonpregnant Patient
and obstetrical consultation can help differentiate eclampsia from
other causes of seizures and initiate the appropriate treatment.
VALUE PREGNANT NONPREGNANT
GASTROINTESTINAL SYSTEM
Hematocrit 32%–42% 36%–47%
The hormonal changes in pregnancy result in decreased
WBC count 5,000–12,000 μL 4,000–10,000 μL competence of the lower esophageal sphincter, resulting in
increased risk of aspiration. Gastric emptying is delayed during
Arterial pH 7.40–7.45* 7.35–7.45 pregnancy, so early gastric tube decompression should be
considered, if indicated, to prevent aspiration of gastric contents.
Bicarbonate 17–22 mEq/L 22–28 mEq/L The pregnant patient’s intestines are pushed up to the upper
abdomen and may be shielded by the uterus. The solid viscera
PaCO2 25–30 mm Hg 30–40 mm Hg (4.0– remain essentially in their usual anatomic positions, although
(3.3–4.0 kPa) 5.33 kPa) it has been reported there is a 25% increased risk of hepatic or
splenic maternal injury after blunt abdominal trauma.
Fibrinogen 400–450 mg/dL 150 - 400 mg/dL
(3rd trimester) URINARY SYSTEM
The glomerular filtration rate and renal blood flow increase
PaO2 100–108 mm Hg 95–100 mm Hg during pregnancy, resulting in serum levels of creatinine and
urea nitrogen decreasing to one-half of pre-pregnancy levels.
*C
 ompensated respiratory alkalosis and diminished Glycosuria is common during pregnancy.
pulmonary reserve

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due to possible airway swelling and engorgement. Decreased

MUSCULOSKELETAL SYSTEM
lower-esophageal sphincter tone and delayed gastric emptying
The pubic symphysis widens 4–8 mm, and the sacroiliac joint significantly increases the risk of aspiration, and measures should
spaces increase by the seventh month of gestation. These factors be taken to minimize the risk using principles of rapid-sequence
must be considered in interpreting x-ray films of the pelvis. intubation.
The large, engorged pelvic vessels surrounding the gravid
uterus can contribute to massive retroperitoneal bleeding after BREATHING
blunt trauma associated with pelvic fractures.
Clinicians should be cognizant of the alteration in PCO2
baseline as pregnancy progresses, with a PCO2 of 30 mm Hg being
APPROACH TO THE PREGNANT TRAUMA normal in pregnancy. Understanding normal blood gas values
PATIENT: INITIAL ASSESSMENT PRIMARY in pregnancy is important in the recognition that a PCO2 of 40
SURVEY mm Hg may indicate relative respiratory acidosis and impending
respiratory failure. Administer supplemental oxygen to maintain
To optimize outcomes for the pregnant patient and the fetus, an oxygen saturation greater than or equal to 95%. Maternal
clinicians must assess and resuscitate the pregnant patient oxygen consumption is elevated at baseline, and there is less
first, followed by assessment of the fetus before performing the oxygen reserve. The fetus is very sensitive to maternal hypoxemia.
secondary survey. If chest tube placement is necessary, it is important to consider
Early obstetric consultation and notification should be part of the stage of pregnancy and account for the diaphragmatic position
the algorithm for trauma in pregnancy, adjusted for institutional changes as pregnancy progresses. The diaphragm may be elevated
resources. Ideally, if obstetric services are available in the facility, as much as 4 cm by the end of pregnancy; therefore, chest tube
they should be notified at the same time as the trauma team for placement should be higher than the usual fourth intercostal
timely response in the event of a known trauma in the second half space (ideally the second or third intercostal space) in order to
of pregnancy (20 weeks or more). If the pregnancy is at the age of avoid intra-abdominal placement.
viability (22 weeks or more), consider notifying pediatrics and/
or the newborn ICU. If obstetrics is not available locally, early CIRCULATION
telephone consultation should be made. Because of their increased intravascular volume, pregnant
The goals of the primary survey for the pregnant patient patients can lose a significant amount of blood before tachycardia,
are the same as the goals outlined for the nonpregnant patient. hypotension, and other signs of hypovolemia occur. In this
Goal number one is to resuscitate the pregnant patient, and setting, despite a stable-appearing patient, maternal hypovolemia
goal number two is to save the fetus. Fetal outcomes are directly can negatively impact both the patient and the fetus. Administer
related to maternal resuscitation. Maternal shock and death are appropriate crystalloid and/or blood products early for volume
the leading cause of fetal death. It is important to focus on the replacement, as needed to support the physiologic hypervolemia
initial resuscitation and stabilization of the maternal patient while of pregnancy. Vasopressors should not be first-line therapy in a
simultaneously optimizing the blood flow to the fetus during pregnant trauma patient in hemorrhagic shock (see Chapter 6,
the primary survey. The best way to treat the fetus is to treat the Circulation Assessment and Volume Resuscitation). Vasopressors
mother first. There are a few special considerations to keep in can further reduce uterine blood flow, resulting in fetal hypoxia.
mind during the primary survey for the pregnant patient.
The massive transfusion protocol should be activated early in
EXSANGUINATING EXTERNAL HEMORRHAGE pregnant trauma patients when there is concern for hemorrhagic
Evaluation of the pregnant patient for massive external shock. The components will vary based upon institutional
hemorrhage is performed in the same manner as for nonpregnant protocols and resources, but emergency-release O-negative blood
patients. Follow the same principles for pregnant patients as for products (packed red blood cells or whole blood) are preferred
nonpregnant patients, including application of direct pressure, to avoid Rh sensitization (alloimmunization) in Rh-negative
wound packing, and placement of tourniquets as indicated. women. Use standard ratios of blood products or whole blood, if
available. When Rh-negative products are not available, using Rh-
AIRWAY positive, ABO-compatible products is preferable to inadequate
Due to the respiratory changes and increase in oxygen resuscitation. Stabilizing the pregnant patient is the top priority.
requirements during pregnancy, there is a greater tendency toward Concerns for Rh sensitization and subsequent prevention can
oxygen desaturation in the setting of oxygen deprivation. It is be addressed after stabilization. Rh sensitization needs to be
important to ensure a patent and secure airway by endotracheal treated within 72 hours, and consultation with an obstetrician
intubation or adjunct measures if indicated, avoiding delays. The or blood bank director can help determine timing and dosage.
hyperemia and edema often seen in the airway of the pregnant Tranexamic acid has been studied in pregnancy as an adjunct
patient mandate that all such airways be considered a “difficult for patients undergoing vaginal or cesarean delivery as well as
airway” and appropriate measures be taken. for postpartum hemorrhage, with favorable or mixed results. It is
If intubation is indicated, it should be performed by the most considered safe for the fetus in setting of trauma with significant
skilled clinician on the team early in the resuscitation. Intubation bleeding, though it is currently unknown if the use of tranexamic
with a smaller endotracheal tube is recommended (size 6 or 7) acid in the pregnant trauma patient reduces mortality.

211
 neurologic emergency. It is a rare complication of pregnancy that
 Figure 13-5: Pelvic Film in Pregnant Patient. Pelvic
can occur after 20 weeks of gestation and can mimic head injury.
vessels become engorged in the pregnant patient. Pelvic
fractures and associated vascular trauma can lead to
Hypertension, hyperreflexia, proteinuria, thrombocytopenia, liver
massive retroperitoneal hemorrhage. function abnormalities, coagulopathy, or pulmonary edema may
be present in addition to the seizures. Prompt, expert neurological
and obstetrical consultation can help differentiate eclampsia from
other causes of seizures and initiate the appropriate treatment.

EXPOSURE/ENVIRONMENT
The principles of complete exposure followed by avoidance of
hypothermia apply to pregnant patients, as they do in all trauma
patients. See section later in this chapter for information regarding
appropriate examination of the vaginal vault.

ADJUNCTS TO PRIMARY SURVEY/

RESUSCITATION
The FAST exam is an important adjunct to the Primary Survey
and can be modified to include fetal information if qualified
personnel are available. The fetal FAST exam is performed
alongside the traditional FAST exam. It evaluates number of
fetuses, presentation of the fetus, position of placenta, amniotic
fluid volume, cardiac activity, and fetal femur length (>4 cm is
estimated to be viable). In the event of maternal instability, this
evaluation should not delay maternal interventions. In the
absence of ability to perform fetal FAST, ultrasound or Doppler
should be used to measure the fetal heart rate ( Table 13-3).

Large-bore IV access should be secured above the diaphragm.

 Table 13-3: Fetal FAST. Performing a fetal ultrasound
Given the potential for the gravid uterus compressing the inferior alongside the Focused Assessment with Sonography in
vena cava (IVC) and pelvic vessels, IV fluids and medications Trauma (FAST) can provide valuable information about the
administered through access below the diaphragm may not easily status of the fetus. However, maternal resuscitation should
reach the central circulation. If IO access is required, the humerus not be delayed in order to perform this diagnostic test.
is the preferred site. Lower extremity venous access should
be avoided due to vascular congestion in the pelvis and lower
Fetal FAST
extremities secondary to IVC compression by the gravid uterus.
The gravid uterus can compress the vena cava as early as 18 Number 1/2/3+
weeks of gestation, resulting in significant reduction in venous
return to the heart. Vena cava compression by the gravid uterus Position cephalic/breach/transverse
in the supine position can reduce cardiac output by as much as
Placentation low/fundal/anterior/posterior
30% and cause hypotension. Manual displacement of the uterus
to the left side can relieve the pressure on the IVC and improve Fluid volume normal/low/high
hemodynamics. If the patient requires spinal motion restriction
in the supine position, the uterus can be manually displaced to the Cardiac activity normal/abnormal/absent
left, or if additional hands are not available, the patient can be tilted
to the left 15–30 degrees and supported with a bolstering device, Femur length ____ cm (consider viable if >4cm)
optimizing maternal cardiac output while maintain spinal motion Source: MacArthur MacArthur B, Foley M, Gray K, Sisley A. Trauma
restriction ( Figure 13-8). Lateral tilt/left uterine displacement in Pregnancy: A Comprehensive Approach to the Mother and
Fetus. Am J Obstet Gynecol. 2019;220(5):465-468.e1. doi: 10.1016/j.
can increase cardiac output as much as 25%, improving the ajog.2019.01.209. Epub 2019 Jan 24. PMID: 30685288.
patient’s hemodynamics.

DISABILITY
As stated previously, pregnant patients are at risk for the
development of preeclampsia/eclampsia. The development
of new-onset tonic-clonic, focal, or multifocal seizures in the
absence of other causative conditions may be eclampsia and is a

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 Figure 13-6: ATLS Maternal Fetal Trauma Checklist. Note that the Primary Survey should follow the same sequence as
with a nonpregnant patient. Some details in the sequence, such as Lateral Uterine Displacement to improve circulation, are
added in consideration of the pregnancy.

ATLS Maternal-Fetal Roles and Responsibilities

TRAUMA TEAM OBSTETRIC TEAM

Before the patient Notify obstetric team and share details of the event Introduce obstetric team to the trauma team
arrives (if possible) Ensure that the ultrasound machine is readily available Place fetal monitoring belts on the bed

Huddle between the Trauma and Obstetric teams to review roles.

Primary Survey e
 Xsanguinating eXternal Hemorrhage: Evaluate Ensure that LUD is performed if indicated
and control massive eXternal hemorrhage using
direct pressure, wound packing, and placement of Observe at the bedside (mental status; vaginal leaking and/or
tourniquets as indicated bleeding; abdominal tenderness)

A
 irway: Ensure patient airway and cervical spine
spine motion restriction if indicated

B
 reathing: Supplemental oxygen; interventions
as indicated

C
 irculation: IV/IO access; distal pulses; perform
lateral/left uterine displacement (LUD) if indicated;
other interventions as indicated

D
 isability: Focused Neurologic Exam: GCS, pupil size
and response; lateralizing findings

E
 xposure/Environment: Discover all external
wounds; prevent hypothermia

Resuscitation as indicated

Primary Survey Consider Focused Assessment with Sonography for Consider Fetal FAST examination if appropriate
Adjuncts Trauma (FAST) • Number: 1/2/3+
Consider laboratory tests: ABG, lactate • Presentation: Cephalic/breech/transverse
• Placentation: Low/fundal/anterior/posterior
Consider portable imaging: Chest, pelvis
• Amniotic fluid volume: Normal/low/high
Type and Cross-match • Cardiac activity: Normal/abnormal/absent
• Femur length: ____ cm (consider viable if >4cm)
Serial Physical Examination

Secondary Survey Head-to-toe examination: Initiate electronic fetal monitoring (if appropriate) after spine and
• Head, Face, Eyes, Ears, Neck abdominal examination

• Chest Focused obstetric history (CODE)

• Abdomen/Pelvis • Complications of pregnancy

• Genitalia • Obstetric history and prenatal care clinician

• Back • Dating method and estimated due date

• Extremities • E
 vent details, including leaking, bleeding,
contractions, and fetal movement
 MPLE History: allergies, medications, past illnesses
A
and surgeries, last oral intake, events leading to
injury

Secondary Survey Consider computed tomography or x-ray imaging Electronic fetal monitoring for 6 hours, extend to
Adjuncts Continue fetal monitoring when appropriate 24-hour electric fetal monitoring, if >6 contractions
per hour in any single hour

Abruption laboratory tests (complete blood count,

fibrinogen, fetal maternal hemorrhage test (Kleihauer Betke or
flow cytometry)

Give RhIG if RH-negative

Obstetric ultrasound scan: placentation, estimated

fetal weight, amniotic fluid levels

Obtain prenatal records

Debriefing and If indicated, designate where exploratory laparotomy or cesarean delivery will occur and who will be responsible for the incision.
Disposition Summarize the findings and initial plan of care, including immediate disposition of the patient.

Exchange contact information and update both teams with any change in maternal or fetal status.

ABG, Arterial Blood Gas; GCS, Glasgow Coma Scale; LUD, Left-uterine displacement.

213
  Figure 13-7: IV Access in the Pregnant Patient. Because
SECONDARY SURVEY
late in pregnancy the gravid uterus can compress the vena
The maternal secondary survey should, in general, follow
cava, fluids administered via femoral or lower extremity
lines may be less effective. When possible, venous access the same pattern as for nonpregnant patients (see Chapter 14,
should be obtained above the diaphragm. The humerus is Initial Assessment: Secondary Survey). The obstetric team, if
the preferred site for intraosseous access. present, should obtain a focused history including gestational age,
parity, mode of prior deliveries, and any complications with the
pregnancy.
The focused allergies, medications, past medical history, last
meal and events leading to presentations (AMPLE) history should
be augmented in the pregnant patient with a focused obstetric
history, including complications of pregnancy, obstetric history,
prenatal care clinician, dating method for estimated due date, and
event details including leaking, bleeding, contractions, and fetal
movement ( Table 13-4).
Laboratory studies should include a complete blood count,

 Figure 13-8: Lateral/Left Uterine Displacement. Compression of the vena cava in pregnancy can decrease venous return
as much as 30%. Manual displacement or “tilting” of the uterus to the left can improve hemodynamics. A. Internal view,
before displacement B. Internal view, after displacement C. External view

A. B. C.

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Early fetal heart rate and uterine activity monitoring

 Table 13-4:Focused Obstetric History (CODE).
(tocometry) is important to monitor for placental abruption
Supplementing the AMPLE history with the CODE history
allows the physician to obtain information specifically
and fetal well-being. However, initiation and maintenance of
related to the patient’s pregnancy and obstetric history. fetal monitoring and tocometry should never compromise
timely work-up of and intervention for the pregnant patient,
as resuscitation of the mother is always the primary priority
Focused History (CODE) for resuscitation of the fetus. Because placental perfusion and
oxygenation are dependent on maternal cardiopulmonary
C Complications of pregnancy function, fetal monitoring should be continued in any setting where
there is concern for maternal cardiopulmonary compromise.

Obstetric history and prenatal care DEFINITIVE CARE

O clinician
In the evaluation of the pregnant trauma patient, the
determination of the best destination for definitive care will
D Dating method and estimated due date hinge on two major considerations. First, does the patient require
admission for their traumatic injuries? Second, does the patient
require evaluation or observation from an obstetric perspective? If
Event details, including leaking, bleeding, so, does the current facility have the resources to provide definitive
E contractions, and fetal movement care? If the patient does require transfer, it is important to consider
if the receiving facility can also provide the level of obstetric care
and monitoring the patient will require. This will be dependent
comprehensive metabolic profile, type and screen (which will on gestational age and ideally is a collaborative decision between
provide Rh status information), fibrinogen, and coagulation trauma and obstetric clinicians. When determining destination
profile. Viscoelastic studies should be obtained if indicated and for patients based on estimated gestational age of the fetus, it is
available. A fetal hemorrhage screen or Kleihauer-Betke (KB) important to assess the neonatal ICU capabilities of the facilities
test may be obtained in Rh-negative patients. However, clinicians in question.
should be aware that neither test reliably predicts fetal-maternal If a patient does not require admission for their traumatic
bleeding, but they may be used to quantify such bleeding for Rh injuries, admission for maternal/fetal monitoring may be
immunoglobulin dosing in appropriate patients. recommended. It is important to involve an obstetric consultant,
either in person or by phone, early in the evaluation to help make
EVALUATION OF THE PERINEUM AND this determination.
Placental abruption is the second-leading cause of fetal death
VAGINA
in cases of trauma, and electronic fetal monitoring is the most
Evaluation of the perineum should be done as in the sensitive and immediately available means to detect it. A minimally
nonpregnant patient, with special attention to any vaginal bleeding injured pregnant patient may still require admission for fetal
or leaking of fluid from the vagina. This can be accomplished by monitoring to rule out placental abruption. This emphasizes the
visual inspection and limited vaginal exam as indicated during importance of early involvement of the obstetric team, either at
the secondary survey. Be sure to obtain consent from the awake your facility or at the tertiary care facility with both trauma and
patient prior to doing this—and any—exam. In the absence of obstetric services.
vaginal bleeding or suspicion of impending delivery, it is generally
 Figure 13-9: Fetal Monitoring. External fetal
not feasible or ideal to do a full pelvic exam and evaluation of the
monitoring illustrated in the figure is an important
cervix in the trauma bay. This can be performed as indicated later adjunct to the monitoring of the fetus. Fetal distress
in the evaluation and care of the patient in coordination with the may also herald an emerging cardiopulmonary issue in
obstetric consultant. the mother.

FETAL MONITORING
During the secondary survey, electronic fetal monitoring
should be initiated after completion of abdominal examination
and log roll for spinal examination. Placement of electronic fetal
monitoring should not delay ongoing maternal workup, including
imaging studies, and timing will vary pending institutional
workflow.
If imaging is urgently needed and a fetal FAST exam has
documented a normal fetal heart rate, fluid, and placenta without
findings suspicious for placental abruption, then proceed to
imaging. If a portable fetal monitor is available, continued fetal
heart and uterine monitoring can be accomplished during
transport.

215
 SPECIAL CONSIDERATIONS IN THE  Figure 13-10: Placental Abruption: The placenta is less
PREGNANT PATIENT compliant than the uterus itself which can lead to failure
of the placental attachment in the setting of trauma. A.
Illustration of blood/hematoma associated with placental
IMAGING abruption. B. Coronal CT image: arrow points to blood/
In general, imaging studies should be performed as clinically hematoma associated with placental abruption. C. Axial CT
indicated regardless of pregnancy status, particularly in a high- image of same patient.
energy mechanism of trauma with concern for maternal injury
or instability. Per the American College of Obstetricians and Placental abruption can occur with acceleration/
deceleration mechanisms and is often manifested by the
Gynecologists/Eastern Association for the Surgery of Trauma,
triad of uterine contraction, bleeding, and abdominal pain.
radiation less than 5 rads (50 mGy) is thought to pose little to no
risk of teratogenicity or fetal loss. Imaging for trauma evaluation,
including CT scans, is generally well below this threshold. No
A.
study to date has shown increased teratogenicity above baseline
at fetal exposures below 10 rads. The fetus is most at risk for
central nervous system (CNS) effects at 8–15 weeks gestational
age; the threshold appears to be at least 20–40 rads. Image as
needed to appropriately treat the patient. Consult a radiologist
for assistance with dose calculation to decrease total exposure
if there is the expectation that numerous studies will be needed
and/or a possibly alteration in protocols. Be judicious and reduce
redundancy as much as possible.
After the initial evaluation of the pregnant trauma patient, in
the setting of hemodynamic stability, a more focused obstetric
ultrasound can be performed to closely evaluate the placenta,
obtain an estimated fetal weight, and estimate amniotic fluid
volume. Additionally, the patient’s prenatal records should be
obtained if feasible. Such investigations should not delay transport
to definitive care.

PLACENTAL ABRUPTION
B.
When the mechanism of the trauma includes acceleration/
deceleration forces to a pregnant patient’s gravid uterus, the
increased risk of placental abruption is a primary concern. There
are two major mechanisms of uteroplacental interface failure
described in the literature: shear force (strain) failure and tensile
failure (contrecoup mechanism).
The uterus is compliant (flexible); however, the placenta is
less compliant (rigid), which can result in failure of the placental
attachment (uteroplacental interface failure) in the setting of
acceleration/deceleration forces. These differences in tissue
properties exacerbate the shearing forces that occur when the
gravid uterus absorbs the energy from blunt force, resulting in
disruption of the attachment of the placenta from the uterus.
Placental abruption occurs in as many as 40% of severely injured C.
women. Placental abruption may initially be concealed when
there is bleeding between the placenta and uterus without vaginal
bleeding. Most placental abruptions present within 6 hours of the
trauma; however, they have been reported to present as much as 24
hours after trauma. Uterine contractions are the most sensitive
predictor of placental abruption. The classic triad of abruption
includes contractions, bleeding, and abdominal pain. Even if
monitoring technology or laboratory tests are unavailable, the
presence of findings on physical examination should prompt the
clinician to consider placental abruption. Similarly, if the patient
is hypotensive without a source, placental abruption must be
considered. Placental abruption may occur with even minor
mechanisms of injury.

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Diagnosis of placental abruption is dependent on clinical However, recent data have shown that early and rapid
monitoring, including electronic fetal monitoring and tocometry. evacuation of the uterus (even if the fetus is nonviable) may result
Ultrasound has been shown to be unreliable in diagnosing in a greater than 50% probability of maternal return of spontaneous
placental abruption, with sensitivity as low as 24% in one study. circulation. This is thought to be due to the resultant diminished
CT scan performs better than ultrasound at detecting clinical aortocaval compression, the decreased blood flow demand of
abruptions, with a sensitivity of 100% and specificity of 54%–56%. the uterus, and improved blood return to the heart. Therefore,
A KB test is not a reliable test for abruption. to emphasize the resuscitative benefits of delivery in the setting
Placental abruptions have been reported to occur up to 24 of MCA, the phrase “perimortem cesarean delivery” has been
hours after a traumatic insult, but they have not been reported if replaced with the more accurate and positive term “resuscitative
uterine contractions are occurring less frequently than every 10 cesarean delivery.” It is vital that the resuscitation team does
minutes during the initial 4-hour period of monitoring. not focus on fetal status but rather on the correction of the
etiologies of the MCA and high-quality chest compressions/
RH STATUS AND FOLLOW-UP ACLS as indicated. In a pregnant patient who experiences cardiac
CONSIDERATIONS arrest, RCD should be considered if the uterus is at or above the
umbilicus and the patient remains without return of spontaneous
Approximately 15%–17% of the population has Rh-negative
circulation after 5 minutes of appropriate resuscitation, regardless
blood; the remainder has Rh-positive blood. If a pregnant trauma
of fetal cardiac activity. Institutions are encouraged to develop
patient has Rh-negative blood, there is a significant likelihood the
protocols for RCD that include guidance for when it should be
fetus has Rh-positive blood. As early as 6 weeks of gestation, the
performed and what personnel and other resources must be
fetus has well-developed red blood cells. Traumatic placental injury
available.
can result in fetal-maternal hemorrhage, which can trigger an Rh-
negative pregnant patient’s immune system to develop antibodies
against the Rh antigen if the baby has Rh-positive blood. This TRAUMA-INFORMED CARE AND THE
can cause problems in future pregnancies. Rh immunoglobulin is PREGNANT PATIENT
available to prevent this sensitization from occurring.
Rh immunoglobulin administered up to 72 hours after a fetal- A pregnant patient who has sustained trauma may have
maternal bleed can prevent Rh sensitization. A KB test or flow increased psychological stress and be more concerned about
cytometry identifies the presence and quantifies the volume of the status of the fetus than their own condition. Clinicians
fetal red blood cells in the maternal circulation. All pregnant should take care not to interpret this anxiety as “uncooperative”
trauma patients who are Rh negative should be administered or “noncompliant,” even when the patient seems reluctant to
at least one dose of Rh immunoglobulin, even if the KB or follow certain care recommendations. Reassure the patient that
flow cytometry is negative or if the tests are not available. The the best way to help the fetus is to tend to the pregnant patient
standard dose of Rh immunoglobulin is 300 micrograms, which is first. Pregnant patients may be concerned about fetal radiation
adequate for a 30 mL fetal whole blood loss or less. In the setting exposure; explaining the importance of avoiding missed injuries
of hemorrhagic shock in a pregnant patient, the benefits of the and the low risk of fetal damage is important. The language
administration of low-titer O-positive whole blood outweighs the used when communicating with the pregnant patient about
risks of Rh sensitization. A recent study reported a 3%–20% risk of these issues is also key; it is recommended to use the words
Rh sensitization, which can be addressed after stabilization. “mother” and “baby” instead of “patient” and “fetus” during
these conversations.
MATERNAL CARDIAC ARREST AND
RESUSCITATIVE CESAREAN DELIVERY INTIMATE PARTNER VIOLENCE (IPV)
Maternal cardiac arrest (MCA) in the setting of trauma should IPV is defined as physical or sexual violence, stalking,
follow Advanced Cardiac Life Support® (ACLS®) guidelines, reproductive coercion, and psychological aggression by a current
with a focus on correction of trauma-related etiologies of the or former intimate partner of the victim. There is conflicting
arrest. Current guideline recommendations in the setting of information about whether pregnancy increases the risk of IPV,
pregnancy include no modification of hand placement for but at least one comprehensive review suggests that women who
compressions. Furthermore, the patient should remain supine with have a partner with a history of IPV, substance abuse problems, or
manual uterine displacement (rather than tilting); this improves unemployment are at increased risk of experiencing IPV during
effectiveness of chest compressions. pregnancy. In some cases, the pregnancy itself may trigger or
In a hospital with surgical capabilities and in the setting of exacerbate existing problems in the relationship, leading to an
MCA, resuscitative cesarean delivery (RCD) should be considered increase in IPV. All patients should be screened for IPV regardless
to improve maternal physiology and potentially save the fetus. of gender identity, sexual preference, geographic location, income,
Perimortem cesarean delivery has been defined as the delivery of education, race, ethnicity, age, or professional role. Clinicians
the fetus(es) during MCA or after maternal death and was often should be particularly attuned to the risk of IPV in pregnant
considered a procedure of last resort to save the fetus. patients, conduct appropriate screening, and arrange access
to resources as indicated. See Chapter 18, Injury Prevention, for
additional information.

217
 CHAPTER SUMMARY KEY LEARNING POINTS
Important and predictable anatomical and physiological • Important and predictable anatomical and
changes occur during pregnancy and can influence the assessment physiological changes occur during pregnancy and
and treatment of injured pregnant patients. Given that the most can influence the assessment and treatment of
injured pregnant patients.
common cause of fetal mortality is maternal mortality, stabilization
of the pregnant patient should always be the initial priority in • The most common cause of fetal mortality is
resuscitation of the pregnant trauma patient. Modifications to maternal mortality. Resuscitation of the pregnant
common interventions need to be considered in the alter stages of patient and optimization of the fetal environment
pregnancy due to anatomic changes related to the gravid uterus. should be the initial priority in treatment of the
This includes supine hypotension, where the gravid uterus can pregnant trauma patient/fetus duo.
cause caval compression resulting in hypotension. Placental
• Modifications to common interventions need to
abruption is another important cause of fetal mortality in trauma be considered in later stages of pregnancy due to
and should be considered even in the minimally injured pregnant anatomic changes related to the gravid uterus.
trauma patient. Qualified trauma and obstetric clinicians should Chest tube placement should be moved cephalad,
be consulted early in the evaluation of the pregnant trauma and IV/IO access should be obtained above the
patient, and if these services are not readily available, transfer diaphragm.
should be considered immediately.
• The gravid uterus can cause caval compression in
the supine position as early as 18 weeks of gestation.
This can decrease cardiac output as much as 30%.
Left-uterine displacement is an important adjunct
to the primary survey in the pregnant trauma
patient, improving hemodynamic status.

• Placental abruption is a significant cause of fetal

mortality after trauma, and may occur with minor
mechanisms of injury. It is primarily a clinical
diagnosis, guided by observation, fetal heart
rate monitoring, and tocometry. Most placental
abruptions can be detected within 6 hours of
trauma, but they have been reported as late
as 24 hours after trauma.

• Early consultation with an obstetric consultant,

in person or by telephone, is an important
component for comprehensive care of the pregnant
trauma patient. Obstetric consultants can assist
in determining the need for and duration of any
fetal monitoring after trauma.

• All Rh-negative patients should be administered

Rh immunoglobulin after trauma within 72 hours.
Obstetrical consultation is recommended, and
resources are also available for determining the
dosage, route, and timing of administration.

• Presence of indicators that suggest IPV should

serve to initiate further investigation and protection
of the patient.

218 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 13 | Trauma in the Pregnant Patient

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B. Maternal fatalities, fetal and neonatal deaths related
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10. Maged AM, Helal OM, Elsherbini MM, et al. A randomized
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placebo-controlled trial of preoperative tranexamic acid
22. ACOG Practice Bulletin No. 192: Management
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11. Bouet PE, Ruiz V, Legendre G, Gillard P, Descamps P,
23. Katz VL, Dotters DJ, Droegemueller W. Perimortem
Sentilhes L. Policy of high-dose tranexamic acid for
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DOI: 10.1016/j.ajog.2005.02.038. PMID: 15970850.
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25. Agarwal S, Prasad R, Mantri S, et al. A comprehensive
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(WOMAN): An international, randomised, double-blind,
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:2104.

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220 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

14

Initial Assessment:
Secondary Survey

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Determine the appropriate time during patient 4. Determine the appropriate timing and sequence of
evaluation to perform the secondary survey extremity tourniquet evaluation and conversion to
hemostatic dressing
2. Describe the components of the secondary survey
3. Recognize the importance of performing a
comprehensive examination of the patient after
the immediate potential life threats have been
identified and treated

221
 MECHANISM OF INJURY

14 The mechanism of injury is associated with the patient’s injury

pattern and physiologic state. Understanding the mechanism
of injury can assist in predicting potential injuries based on the
force, direction, and type of insult. Broadly, mechanisms of injury
can be divided into blunt, penetrating, and blast. Additional
consideration must be given to thermal injuries and hazardous
environments.
Initial Assessment: BLUNT INJURY
Secondary Survey Blunt injury is caused by a forceful impact and can be caused
by a broad range of sources, including falls, vehicle collisions,
blows from objects or instruments, or interpersonal violence.
CHAPTER STATEMENT Multiple injuries affecting different organ systems are possible.
For falls, pertinent details to consider include the height
The secondary survey is a vital component of the work-up
of the fall, secondary objects encountered during the fall, and
of patients with traumatic injuries. The role of the secondary
orientation when contacting the ground. For motor vehicle
survey is to identify all injuries. The secondary survey includes a
collisions, information that can inform the clinician as to
detailed medical history, a description of the events surrounding
what injuries to anticipate includes the change in velocity, the
the injury, a comprehensive physical examination, and laboratory
principal direction of force (front, rear, or side impact), and
and imaging studies necessary to identify injuries and monitor
the amount of intrusion into the passenger compartment,
resuscitation. The secondary survey begins after the primary
the position of the patient in the car, seatbelt use, and airbag
survey is completed in hemodynamically normal patients or after
deployment. Entrapment in or ejection from the vehicle or
an unstable patient responds to resuscitation. The secondary
death of another vehicle occupant are other details that suggest
survey does not begin until the primary survey has been completed
a risk of severe injury.
and the patient is hemodynamically normal or improved.
Use of three-point seatbelt restraint and the presence of airbags
in vehicles result in decreased morbidity from injuries. Airbags
INTRODUCTION protect the head and upper torso from injury in adults. Children
and small adults may sustain injuries related to airbag deployment,
While the goal of the primary survey is to identify and particularly to the head and chest. Use of a lap belt alone produces
treat injuries that pose an immediate threat to life, the role of characteristic injuries that include Chance fractures of the
secondary survey is to identify all injuries. This can be a daunting spine, abdominal injuries, and head and facial injuries. Use of
task, particularly in patients who have suffered multisystem injury; the shoulder belt alone can result in sliding out of the restraint
thus, it requires a systematic, reproducible, thorough approach. (submarining) and possible ejection. Motorcycle and bicycle
A detailed patient medical history, a description of events collisions can result in more severe injuries, as these vehicles
surrounding the injury, a comprehensive physical exam, and offer the rider little protection. Protective equipment such as
laboratory and imaging adjuncts (as necessary) are required to helmets, boots, eye protection, jackets, pants, and gloves can
ensure that all injuries are identified. decrease the severity of some injuries.  Table 14-1 outlines
In the awake and communicative patient, this can be relatively blunt trauma mechanisms and potential injuries associated with
straightforward. Focusing on transparent communication can them.
aid in establishing trust between the patient and the healthcare
team. This trust often results in a more effective and efficient
evaluative process. However, in the trauma setting, patients
often have an altered mental status because of brain injury,
shock, intoxication, or medications. In these patients there
is a high risk of missed injuries, which can have devastating
consequences; thus, a high index of suspicion for injury is
required. The mechanism of injury and prehospital reports
provide clues to injuries that may be uncovered during the
secondary survey. Findings of the secondary survey can guide
further management and interventions for optimal definitive care.
Timely identification of injuries found in the secondary survey
can improve patient outcomes and minimize complications.

222 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

 Table 14-1:Blunt Trauma Mechanism Considerations and Possible Injuries.

Mechanism of injury Other considerations Possible associated injuries

Head-on crash Facial injuries

Lower extremity injuries
Aortic injuries
Cervical spine fracture
Myocardial contusion

Rear-end crashes Hyperextension injuries of the cervical spine

Cervical spine fractures
Central cord syndrome

Lateral impact crashes Contralateral neck strain

Cervical spine fracture
Head injury
Thoracic injuries
Flail chest
Pneumothorax
Aortic disruption
Diaphragm rupture
Abdominal injuries: Spleen, liver or kidney
Pelvic injuries
Clavicle, humerus fractures

Rollover crashes Greater likelihood of ejection Crush injuries

Velocity changes Compression spinal fractures

Ejection Implies nonuse of restraints Spinal injuries

Higher mortality Places patient at greater risk of virtually all injuries

Windshield damage Implies nonuse of restraints Closed head injuries

Facial fractures
Skull fractures
Cervical spine fractures

Steering wheel damage Injuries mitigated with restraint use Thoracic injuries
Sternal fractures, rib fractures, flail chest
Cardiac contusion
Aortic injuries
Hemo/pneumothoraces

Dashboard damage Pelvic and acetabular injuries

Hip dislocations

Pedestrian hit Pedestrians are unprotected Head injury and craniofacial injuries
by vehicle Size of the vehicle can impact Traumatic aortic disruption
injury patterns Abdominal visceral injuries
Speed of vehicle Extremity fractures
May be run over creating crush injury Tibia and fibula, knee injuries
Femur fracture
Pelvic fractures

Falls from heights LD50 36-60 feet (11 to 18 meters) Head injury
Axial spine injury
Abdominal visceral injuries
Fracture pelvis or acetabulum
Bilateral lower-extremity fractures
Calcaneal fractures
Renal and renal vascular injuries

Motorcycle collisions Protective equipment can mitigate Pelvic fractures

severity of injuries Head injury
Injuries are worse with no helmet, Extremity fractures
boots, or leathers Soft-tissue injuries

223
 PENETRATING INJURY to cold temperatures, commonly known as frostbite, or more
profound injury resulting in hypothermia. Hypothermia, defined
Penetrating trauma occurs when a foreign object pierces the
as a core body temperature less than 35°C or 95°F, can present
body to create a wound, and the injury pattern depends upon the
acutely or chronically in patients exposed to cold, and it carries
trajectory, location, and kinetic energy at impact. Stab wounds and
significant physiologic impact. It is important to recognize that
bullet wounds are common examples of penetrating mechanisms
aspects of the patient’s history (wet clothes, vasodilation due to
of trauma. For bullet-related injury, the proximity of the patient
alcohol or drugs, decreased activity) may increase their chance of
to the weapon, the missile trajectory, and the kinetics of the
developing hypothermia or frostbite.
missile (muzzle speed and caliber) may predict the possibility
Inhalation injury and carbon monoxide poisoning can occur
of widespread radial tissue damage due to ballistic effect. In
in cases of fires in enclosed spaces. Patients may require treatment
the case of stab wounds, the size and shape of the wound can
for inhalation of other toxic byproducts of the combustion.
vary. The external dimensions of the wound do not necessarily
Transfer to a dedicated burn center is necessary in cases
reflect the depth of penetration. Pertinent information to
of partial-thickness burns greater than 10% TBSA; burns
obtain from the patient or prehospital personnel include type
involving the face, hands, feet, genitalia, perineum, or joints;
of firearm, distance from firearm, number of shots heard, type
full-thickness burns; chemical burns; electrical burns; burns of
of blade, length of blade, and amount of blood noted at the
pediatric patients; or inhalation injuries.  Table 14-3 outlines
scene.  Table 14-2 outlines potential injuries associated with
burn mechanisms and possible injuries.
penetrating trauma.
A history of exposure to hazardous environments, including
chemicals, toxins, and radiation, is important to obtain for two
BURNS AND HAZARDOUS ENVIRONMENTS
main reasons: these agents can produce a variety of pulmonary,
Burn injuries may occur in isolation or in conjunction with cardiac, and internal organ dysfunctions in injured patients, and
other blunt or penetrating mechanisms, and the severity of the they can present a hazard to anyone in close proximity to the
burn depends on the depth, type, location, and total body surface patient, including members of the healthcare team.
area (TBSA) burned. Mechanisms resulting in burns include
chemical, electrical, friction, radiation, or thermal injuries.
Patients may develop localized hypoperfusion injuries due

 Table 14-2: Stab and Bullet Wound Considerations and Possible Injuries.

Mechanism of injury Considerations Possible injuries

Stab wounds •D ifficult to determine degree of injury • Cardiac tamponade

• Chest based on external inspection; narrow • Hemothorax
• Left weapons such as ice picks produce • Pneumothorax
thoracoabdominal small external wounds that may • Left diaphragm, spleen, hemopneumothorax
• Abdomen extend into a cavity • Abdominal visceral injury with peritoneal penetration
• Extremity • Trajectory is difficult to determine • Injury to muscles, nerves, veins, and arteries are
possible; fractures are less common

Bullet wounds • High likelihood of injury •T rajectory determination from retained projectiles
• Truncal and external wounds help predict possible injuries
• Extremity • Neurovascular injury
• Fractures
• Compartment syndrome

224 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

 Table 14-3: Burn Injury Mechanism Considerations and Possible Injuries.

Mechanism Considerations Possible injuries

Thermal burns Circumferential eschars can result in Circumferential eschar on neck,

respiratory compromise or extremity, or chest
compartment syndrome

Occult trauma mechanism (jumping Injuries associated with blunt trauma

from building to escape fire) from fall from height

Electrical burns High-voltage exposure and lightning strikes Cardiac arrhythmias

Rhabdomyolysis
Myonecrosis/compartment syndrome

Inhalation burns Enclosed space fires Carbon monoxide poisoning

May worsen overtime Upper-airway swelling

Pulmonary edema

Cyanide inhalation Cyanide toxicity

Chemical
Concentration, amount, and duration of Partial- and full-thickness skin loss
• Acid
contact determine extent of injury Systemic affects possible with some chemicals
• Alkali

• Petroleum May be difficult to remove and stop the

products burning process

BLAST INJURY • Medications: Obtain a list of current medications the patient

is taking, including prescription, over the counter, and herbal
Blast injury is a complex type of trauma that results from
remedies.
direct and/or indirect exposure to an explosion. It produces a
range of injuries including burns as well as injuries to the lungs, • Past medical/social history: Gather information about
extremities, brain, abdomen, and eyes. It includes multiple the patient’s medical history, including chronic conditions,
mechanisms. Primary blast injury results from high-pressure surgeries, hospitalizations, functional status, possible
explosions and produces unique injuries including pulmonary pregnancy, use of alcohol/illicit substances, tobacco use,
barotrauma, tympanic membrane rupture, intestinal perforation, housing status, occupation with associated hazards, and
globe rupture, and traumatic brain injury (TBI). Secondary blast preferred language. Awareness of the social drivers of
injury is caused by objects, fragments, and debris launched by an health aids the healthcare team with providing care during
explosion, causing penetrating injury. Tertiary blast injury occurs hospitalization and after discharge.
from the blast wind launching a person’s body into objects or the • Last oral intake: Determine when the patient last ate or
environment, producing penetrating or blunt injury. Quaternary drank, as this may influence the management of anesthesia or
blast injury comprises all other injuries caused by an explosion, surgical interventions.
including burns and toxic exposure. This topic is covered more
• Events leading to injury: Obtain details about the
thoroughly in Chapter 24, Injury in Combat Zones and Austere
circumstances and mechanism of injury, which can help
Environments.
identify possible injuries and guide the physical examination.
HISTORY These details may also prompt the clinician to use patient
safety screening questions if domestic violence or abuse is
The AMPLE mnemonic can be a useful tool to gather patient suspected, as seen in  Box 14-1.
history:
• Allergies: Inquire about any known allergies, particularly
to medications or substances that might be used during the
patient’s care.

225
  Box 14-1: Questions to Ask Patients that Disclose Current Abuse to Immediately Assess for Safety.

Assessment of Immediate Safety Screening Questions No Yes

1. Are you in immediate danger? No Yes

2. Is your partner at the health facility now? No Yes

3. a. Do you want to home with your partner? No Yes

b. Do you have to go home with your partner? No Yes

4. Do you have somewhere safe to go? No Yes

5. Have there been threats of direct abuse of the children (if s/he has children)? No Yes

6. Are you afraid your life may be in danger? No Yes

7. a. Has the violence gotten worse or is it getting scarier? No Yes

b. Is it happening more often? No Yes

8. Has your partner used weapons, alcohol, or drugs? No Yes

9. Has your partner ever held you or your children against your will? No Yes

10. Does your partner ever watch you closely, follow you, or stalk you? No Yes

11. Has your partner ever threatened to kill you, him/herself, or your children? No Yes

COMPREHENSIVE PHYSICAL EXAMINATION conversion is undertaken. A patient who is in shock is not a

candidate for tourniquet conversion. The tourniquet should
VITAL SIGNS have been in place for less than 6 hours, as release of tourniquets
in place for longer than 6 hours risks reperfusion syndrome.
From the moment the patient arrives, assessing and reassessing
Involve surgical consultants in the discussion whenever available.
the patient’s vital signs is essential throughout the entire trauma
It is important to consider plans for both success and failure of
resuscitation, and this should be carried on through the secondary
conversion. Can the patient be managed at this facility, or will
survey. The vital signs to be evaluated include blood pressure,
they require transfer to another facility to manage the bleeding
heart rate, respiratory rate, oxygen saturation, and capnography
if conversion fails? How long will it take to transfer the patient?
if available. Alterations from normal values may indicate an
The extremity should be fully exposed and reevaluated to
untreated potential life threat, such as conversion of a simple
ensure there were no missed injuries. Tourniquet conversion
pneumothorax to a tension pneumothorax or continued intra-
requires time and wound-packing supplies. Have a new tourniquet
abdominal bleeding. If this occurs, reassess beginning with the
available as well, in case the original fails and needs to be replaced.
primary survey (xABCDE).
Remove any old packing material in the wound. If there is no
active bleeding, slowly release the tourniquet by unwinding
EXTERNAL SIGNS OF TRAUMA
the windlass, but do not remove it from the extremity. Once
Whenever evaluating an anatomic region on the secondary the tourniquet is loosened, inspect the wound for evidence of
survey, begin with inspection for external signs of trauma, arterial bleeding. If none is seen, pack the wound and apply
including lacerations, bruising, deformities, or foreign bodies. a pressure dressing for 3 minutes and continue to observe the
Communicate with the patient the purpose of the evaluation and wound. Leave the loosened tourniquet in place to facilitate
expose the areas you are assessing sequentially. External injury rapid reapplication in the event bleeding recurs. If the wound
may indicate deeper injury that warrants further evaluation. When remains hemostatic apply a pressure dressing. Patients may
hemorrhage control has been required for external bleeding, experience numbness, tingling, muscular weakness, and
reassess the area for continued control. sensory changes that usually resolve rapidly after tourniquet
Tourniquets are now placed in the field by trained first removal. If bleeding recurs, reapply the original tourniquet.
responders and bystanders in addition to emergency medical If that fails to control the bleeding, apply a second tourniquet
services (EMS) personnel. While tourniquets that remain in above the first.
place for less than 2 hours have not been associated with a Prepare the patient for emergency surgery to identify and treat
significant complication burden, there is increasing evidence the bleeding source if resources are available or prepare for transfer
that when left on longer, there is the potential for complications if they are not. Time is of the essence, as tourniquets in place for
that may result in amputation. The secondary survey is an ideal more than 2 hours risk ischemic injury and limb loss. If the
time to reevaluate the need for continued use of a tourniquet or tourniquet has been in place for longer than 2 hours, the patient
conversion to pressure dressing. should be carefully monitored for metabolic abnormalities,
The patient’s vital signs should be normal before any arrhythmias, and development of renal failure. Reperfusion
226 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

can produce rapid metabolic and hemodynamic changes that lenses, and evaluate the globe for laceration, proptosis, periorbital
require prompt treatment and follow-up. Tourniquets in ecchymosis, dislocation of the lens, or globe rupture, which
place for more than 6 hours will likely lead to ischemic tissue may indicate direct ocular injury, intracranial hemorrhage, or
loss and possible amputation. The timing of conversion of retrobulbar hemorrhage. Visualization of corneal abrasions may
these tourniquets should be determined in consultation with be enhanced with long-wave UV light (Wood’s lamp). Take care
the trauma, vascular, and or orthopaedic surgeons.  Table to evaluate the eyes early if facial edema is present and reevaluate
14-4 describes indications and contraindications to tourniquet if edema worsens.
conversion.
NEUROLOGICAL EXAM
Neurological evaluation should begin with assessment of the
 Table 14-4: Indications to Convert a Tourniquet or
patient’s level of consciousness, memory, and Glasgow Coma
leave It in Place.
Scale (GCS) score (see Chapter 7, Disability: Neurological
Assessment and Management). Cranial nerves II–XII should be
Indications for Indications to leave assessed with facial, ocular, oral, and shoulder movement and
tourniquet conversion tourniquet in place sensation, if clinically appropriate,  Table 14-5 describes a brief
cranial nerve examination. A comprehensive neurological exam
• Alternative methods of • A tourniquet is controlling
includes motor and sensory evaluation of all extremities.  Figure
hemostasis are readily bleeding from an 14-1 demonstrates the dermatomes and myotomes. A change in
available amputation or near status may indicate the need for further evaluation with imaging
amputation or attempted or surgical intervention. If a patient with a neurological injury
• Patient is not in shock conversion failed clinically worsens, the adequacy of ventilation and perfusion
(xABCDE) should be reevaluated. Neurosurgical consultants
• It is possible to • Tourniquet has been in
monitor the wound for
should be informed of any clinical worsening. Timely transfer
place for
rebleeding may be required when neurosurgical specialists are unavailable.
more than 6 hours

• The tourniquet is not  Table 14-5: Cranial Nerve Functions and Testing Options.
being used to control
bleeding from an
amputation Cranial Function Assessment
Nerve technique

II, III, IV, VI Eye Visual acuity,

HEAD AND FACE assessment tracking, pupil
Examine the scalp, eyes, ears, nose, and mouth for signs reactivity
of injury, such as lacerations, bruising, deformities, or foreign
bodies. Palpate all bony structures of the head and face to assess VIII Hearing and Hearing,
for bony instability. balance equilibrium, whisper
Examine the nose for drainage (serous or sanguineous), which words in each ear;
may represent cerebrospinal fluid and indicate dural injury. assess for vertigo
Nasal placement of gastric tubes should be avoided in patients
with injury to the midface because of the risk of intracranial VII, IX, X, XII Speaking, Use a tongue
placement with injury to the cribriform plate. smiling, pressure to
Nasal bone fractures with septal hematomas can lead to septal and stimulate gag reflex,
swallowing have patient say ahh
ischemia. Symptoms can include nasal congestion, difficulty
and swallow
breathing, and severe nosebleeds. Hematomas involving the
cartilage of the ear can result in necrosis of the cartilage and may
need to be decompressed. V, VII, XII Facial Smile, frown, stick
expression out tongue, jaw
Intraoral exam should assess for broken teeth, fractures, or
strength, corneal
instability. Hemotympanum and mastoid ecchymosis are signs of reflexes
a potential skull base fracture.
XI Shoulder Resist shoulder
EYES shrug girdle raise
Examination of the eyes includes inspection of the pupils
for size, shape, and reactivity. Extraocular movement and visual I Smell Identify a common
acuity should be assessed. Visual acuity may be efficiently scent like an alcohol
evaluated by asking the patient to read printed material or words pad, coffee, or
on a piece of equipment. Ocular mobility should be included in soap; or from self-
the evaluation to exclude entrapment of extraocular muscles due reported symptoms
to orbital fractures. Inspect for foreign bodies including contact

227
 tenderness, hematoma, or thrill of carotid arteries. Auscultate
 Table 14-6: Muscle Strength Assessment Scale.
carotid arteries for the presence of a bruit, which may reveal a
potential vascular injury.
Score Description Most vascular injuries occur with a penetrating mechanism,
though a traction injury from a blunt mechanism may cause intimal
disruption, dissection, or thrombosis. Penetrating injuries that
0 Total paralysis
violate the platysma should not be explored or probed. Surgical
consultation is required if there is any physical exam finding
1 Palpable or visible contraction concerning for vascular or aerodigestive injury (active bleeding,
expanding hematoma, bruit, crepitus, airway compromise).
2 Active movement with gravity eliminated
CHEST
Begin evaluation of the chest with inspection anteriorly and
3 Active movement against gravity
posteriorly for external signs of trauma. Assess for bruising,
contusion, deformity, or paradoxical chest wall movement, which
4 Moves against gravity and provides some may be indicative of fractures to the ribs, clavicles, or sternum. A
resistance flail segment, identified with paradoxical chest wall motion, may
indicate underlying pulmonary contusions. Auscultate bilaterally
5 Moves against gravity with normal resistance for the presence and quality of breath sounds and listen for
distant or muffled heart tones. Auscultation of the chest can aid in
identification of pneumothorax and hemothorax.
NT Patient unable to test because of pain, effort or
contracture Palpate all areas of the chest, including the entire chest cage,
clavicles, ribs, and sternum. Palpation can be painful in the
Muscle grading scale NT, Not testable. presence of an underlying fracture, and contusions and hematoma
may indicate underlying injuries. Remember that pericardial
effusions, pneumothoraces, and hemothoraces can expand
with time and become clinically apparent with the development
 Figure 14-1: Dermatomes and Myotomes. of increased respiratory effort, desaturation, tachycardia,
and restlessness. Tension physiology or tamponade produces
hemodynamic instability.

ABDOMEN
Abdominal assessment begins with inspection for external
signs of trauma, with particular attention for bruising, distension,
penetrating injuries, or seatbelt sign. Seatbelt sign has been
associated with hollow viscus injury and pancreatic injuries.
Palpate each quadrant for tenderness, rigidity, or guarding,
which may suggest internal injury or bleeding. A normal initial
exam does not completely rule out an intra-abdominal injury.
Abdominal pain can be referred from spine fractures or be related
to soft-tissue injury. Surgical consultation should be obtained
when intra-abdominal injury is suspected, and cross-sectional
imaging with a CT scan can help identify intra-abdominal injuries
that require observation or exploration.

PELVIS
NECK Palpate the pelvis for tenderness to assess for potential pelvic
fractures. Aggressive pushing and pulling to elicit evidence of
Patients with blunt trauma to the head, face, or neck should instability is unnecessary, painful, and doesn’t provide useful
be presumed to have a cervical spine injury and be assessed for information. Ecchymosis over the flanks, iliac wings, pubis, labia,
the need for ongoing cervical motion restriction. To examine or scrotum is often present with pelvic fractures or retroperitoneal
the neck of a patient with a cervical collar, an assistant stabilizes hematoma. Patients with significant pelvic fractures may have
the head with two hands while the examiner removes the front large-volume blood loss requiring aggressive resuscitation and a
of the collar and performs the examination of the neck anteriorly pelvic binder for stabilization. Patients with pelvic fracture are at
and posteriorly. Examination of the neck includes inspection, risk for urethral and bladder injury. Blood at the urethral meatus
palpation, and auscultation. Inspect for external signs of trauma, and perineal ecchymosis are signs of potential injury.
tracheal deviation, seatbelt sign, neck vein distension, or deformity,
and palpate for subcutaneous emphysema, posterior midline

228 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

PERINEUM, RECTUM, AND GENITALIA ADJUNCTS TO SECONDARY SURVEY

The perineum should be examined for contusions, hematomas, During the secondary survey, additional specialized diagnostic
lacerations, or blood at the urethral meatus, which may indicate tests are performed to aid in the assessment of the patient and
genitourinary injury. A rectal examination is performed in select to prioritize care. The decision to obtain adjunct testing should
patients to assess for the presence of blood within the bowel be based on the patient’s clinical status, suspected injuries, and
lumen, integrity of the rectal wall, and quality of sphincter tone. local resources. An ECG should be obtained if there is concern
Vaginal examination should be performed in patients who are for blunt cardiac injury or underlying cardiac pathology. An ECG
at risk of vaginal injury, have blood in the vaginal vault, or have is useful in older adults who may have a medical cause for their
vaginal or perineal lacerations. trauma. Laboratory data are usually obtained during the primary
In addition, pregnancy tests should be performed on all survey. Results should be reviewed during the secondary survey
females of childbearing age. These examinations frequently cause and additional or repeat tests obtained based on physiology and
significant anxiety in alert patients. It is important to explain suspicions for injuries.
the purpose of the examinations and exactly what will be done.
Minimize the number of people in the room when acuity allows, IMAGING
but always have a chaperone. Assure the curtains are closed and
cover the parts of the patient that are not being examined. Imaging studies play a crucial role in the secondary survey,
helping confirm or rule out suspected injuries. The choice of
EXTREMITIES imaging modality depends on the patient’s clinical presentation,
mechanism of injury, suspected injuries, and local resources.
Inspect and palpate each extremity for lacerations, deformities,
swelling, or tenderness, which may indicate fractures or X-RAY
dislocations. Assess the peripheral pulses, capillary refill, and
X-ray is a useful imaging study to identify fractures and other
sensation to evaluate circulation and nerve function. Evaluate
injuries to the chest, abdomen, pelvis, and extremities. Chest
range of motion at joints.
x-rays and pelvis x-rays are included in the primary survey,
Fractured extremities should be reduced, realigned,
though additional x-ray imaging may be performed for a variety
and splinted using well-padded splints. See Chapter 10,
of reasons. A portable x-ray can be performed efficiently at the
Musculoskeletal Trauma, for further detail. The neurovascular
bedside with minimal delay in patient care. In the setting of the
examination is repeated after splinting to ensure there has
secondary survey, a chest x-ray may assist in visualizing tubes or
been no compromise. Patients with concurrent head or spinal
lines placed during the patient’s assessment. These may include
cord injuries may have occult fractures that are difficult to
endotracheal tubes, central lines, chest tubes, or nasogastric/
diagnose on exam, and it may be necessary to perform frequent
orogastric tubes. X-ray of the extremities can visualize fractures
reexamination. Increased swelling, ecchymosis, or tenderness
or dislocations, though some subtle fractures may not be visible
may indicate injury requiring further evaluation. Orthopaedic
initially. In cases of penetrating injuries such as bullet injuries,
consultation will guide the need for advanced imaging. Maintain
x-rays can aid in visualizing intracorporeal missiles and estimating
a high level of suspicion for injuries at risk for developing
trajectory. Although x-rays are an efficient and versatile tool, they
extremity compartment syndrome (long bone fractures, crush
do not visualize soft-tissue or ligamentous injuries. Spine injuries
injuries, prolonged ischemia, and circumferential thermal
can be visualized by x-ray, although cross-sectional imaging is far
injuries).
more sensitive. CT scanning has supplanted x-ray in many centers
where it is available.
BACK
Inspect and palpate the back and spine for tenderness, ULTRASOUND
deformities, or step-offs, which may indicate vertebral fractures, Ultrasound is a useful tool that can be used in numerous
dislocations, or spinal cord injury. Thoracic and lumbar fractures trauma situations when available. FAST and eFAST are expedient
may be present without significant physical exam findings; thus, evaluation tools that are typically included in the primary survey.
mechanism of injury must be considered to determine patients These studies can be repeated when patients experience
who should have cross-sectional imaging and x-rays. Spinal physiological change that may indicate bleeding or worsening
motion is restricted with suspected injuries. Modified log pneumothorax or hemothorax. Additional uses for ultrasound
rolling is used for movement, and the patient is positioned include fetal heart-tone monitoring in pregnant patients and
supine on a firm surface (not a backboard). Backboards, when echocardiography for patients with suspected wall motion or
used, are removed during the primary survey. If for any reason valvular abnormalities.
the patient remains on a backboard, remove it promptly. The
head of bed can be elevated using reverse Trendelenburg
positioning until instability of the spine is excluded. Specialist
consultation is required to determine the need for surgical
intervention or advanced imaging.

229
 CT/MRI NASO- OR OROGASTRIC TUBE
Cross-sectional imaging, such as CT scans and CT angiograms, A gastric tube may be placed for gastric decompression or
may help rapidly identify complex injuries of the head, neck, for identification of upper gastrointestinal bleeding. Gastric
chest, abdomen, pelvis, or extremities that may not be apparent decompression decreases but does not eliminate the risk of
on physical exam or other imaging modalities. It is imperative to aspiration, which is important in intubated patients. When
consider the clinical status of the patient and obtaining CT scans placing nasogastric tubes in a patient who is awake, positioning
should not delay emergent operative intervention or transfer to of the patient is important, as placement may induce vomiting.
an appropriate facility to address the patient’s injuries if needed. Importantly, the tube is only effective if it is positioned correctly
Should a patient become unstable prior to transfer to the CT scan, and connected to suction. Placement should be confirmed with
the patient should be reassessed and resuscitated. Consult surgery an abdominal x-ray or aspiration of gastric contents. Blood in a
if available to assess for the need for urgent surgical exploration or gastric aspirate may indicate traumatic placement, swallowed
angioembolization. blood, or actual upper gastrointestinal injury. If a fracture of the
In head injuries, noncontrast CT scans are routinely used in cribriform plate is known or suspected, transnasal passage
well-resourced settings to assess for TBI, intracranial hemorrhage, of an enteral tube should not take place. Instead, orogastric
and facial or skull fractures. Dedicated images of the cervical, placement will prevent intracranial passage of the tube.
thoracic, and lumbar spine can aid in diagnosis of spinal fractures.
If there is suspicion of extracranial carotid or vertebral arterial URINARY CATHETER
injury—as evidenced by cervical spine fractures, mandibular or Placement of a urinary catheter can assist in accurate
skull base fractures, complex midface fractures, or neurological measurement of urine output, bladder decompression, and
deficit inconsistent with head CT—a CT angiogram of the head identification of potential urologic injuries. However, if on
and neck may be obtained. In circumstances where CT angiogram physical exam there is evidence of urethral injury (blood
is not possible, duplex ultrasound may be used to assess suspected at the urethral meatus, perineal bruising), transurethral
vascular injuries of the neck. catheterization should not be attempted without a retrograde
In patients with chest, abdominal, or pelvic trauma, CT scans urethrogram. Anatomic variability such as urethral strictures
can be used to diagnose a multitude of injuries to the vasculature, or prostatic hypertrophy may preclude placement of urinary
solid organs, abdominal viscera, or soft tissues. Intravenous, catheters, and nonspecialists should not use excessive force when
oral, or rectal contrast extravasation may identify vascular or attempting placement. Urologic consultation should be requested
hollow viscus injury, which should prompt further evaluation or early.
consultation with a surgeon. When rectal contrast is used, explain
the rationale for its use to the patient. When complex injuries are OTHER TREATMENTS
suspected or identified, one must consider if resources are available Patients with deep lacerations, extensive wound contamination,
to manage the patient locally; if not, transfer is warranted. or open fractures will need antibiotic prophylaxis and wound
Injuries to the extremities may require a CT scan if there is washout. Lacerations should be debrided, repaired, and/or
suspicion of complex fractures, joint involvement, or occult dressed. Tetanus immunization status should be ascertained, and
injuries not identified on plain radiography. If there is suspicion vaccine administered based on the wound type and immunization
for vascular injury, CT angiogram may aid in diagnosis after history of the patient See  Table 14-7 for tetanus immunization
comprehensive vascular exam. At times, it is most appropriate to recommendations based on age and wound type. Patients with
proceed directly to the operating room for repair, and this decision fractures and other painful injuries should be given analgesics.
should be made in conjunction with a surgeon. Pain resulting from extremity fractures or dislocations is
MRI may be used selectively to evaluate for spinal cord, nerve, improved with reduction, realignment, and immobilization
ligamentous, or soft-tissue injuries not well visualized on CT with well-padded splints.
scans. Reducing dislocations and realigning fractures, though
ultimately diminishing discomfort, can produce intense acute
OTHER ASSESSMENT AND TREATMENT pain. It is important to provide adequate analgesia while
ADJUNCTS monitoring its effect on the airway, breathing, and circulation.
Performing painful or potentially embarrassing procedures Perform neurovascular assessment of the injured extremity before
can create tension between the patient and the healthcare team. and after splinting or reduction of a dislocation. Poor pain control
Providing assurances, using topical anesthetics or parenteral can result in respiratory compromise in patients with rib fractures.
analgesics, and providing support can mitigate tensions. In addition to monitoring oxygen saturations, monitoring vital
capacity via incentive spirometry can identify patients at risk for
respiratory compromise. Pregnant patients who are Rh negative
and have blunt-torso trauma require Rh immunoglobulin
(RhoGam®) administration. Patients with TBI may require
sedation, treatment of raised intracranial pressure with mannitol
or hypertonic saline, and seizure prophylaxis.

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 COURSE MANUAL | Chapter 14 | Initial Assessment: Secondary Survey

 Table 14-7: Age-Based Tetanus Immunization Recommendations.

Age-Based Tetanus Immunization Recommendations

Age (years) Vaccination history Clean, minor wounds All other wounds

0-6 Unknown or up to date on DTaP DTaP DTaP

series based on age TIG

Up to date on DTaP series No indication No indication

based on age

7 - 10 Unknown or incomplete DTaP Tdap and recommend Tdap and recommend

series catch-up vaccination catch-up vaccination
TIG

Completed DTaP series AND ≤5 No indication No indication

years since last dose

Completed DTaP series AND ≥5 No indication Td, but Tdap preferred if

years since last dose child is 10 years of age

11 + Unknown or < 3 doses of Tdap and recommend Tdap and recommend

tetanus toxoid containing catch-up vaccination catch-up vaccination
(If pregnant, vaccine TIG
see footnote)
3 or more doses of tetanus No indication No indication
toxoid containing vaccine AND
< 5 years since last dose

3 or more doses of tetanus No indication Tdap preferred (if not yet

toxoid containing vaccine AND received) or Td
5-10 years since last dose

3 or more doses of tetanus Tdap preferred (if not yet Tdap preferred (if not yet
toxoid containing vaccine AND received) or Td received) or Td
> 10 years since last dose

*Pregnant patients: As part of standard wound management care to prevent tetanus, a vaccine containing tetanus toxoid might be recommended for wound
management in a pregnant woman if 5 years or more have elapsed since the previous Td booster. If a Td booster is recommended for a pregnant patient,
healthcare providers administer Tdap. Source: https://www.cdc.gov/disasters/disease/tetanus.html. TIG, tetanus immune globulin.

REASSESSMENT or worsening metabolic acidosis. Patients with fractures can

develop compartment syndrome and require neurovascular
Periodic reexamination of the patient should be planned reassessment. Surgical consultation is required for prompt
during the period of observation. Pay close attention to areas decompression.
of abnormality previously identified and to new complaints,
signs, or symptoms. Vital signs should be reassessed at SPECIAL POPULATIONS
frequent intervals as well. Abnormal laboratory values may
require repeat testing. Patients with chest trauma may develop Pediatric patients may be unable to provide background
delayed pneumo- or hemothoraces. Subtle or dramatic changes information or relay information regarding the circumstances
in ventilation, respiration, or oxygenation may be seen on of the injury or progression of symptoms. Geriatric patients may
reevaluation. Evidence of bleeding from fractures, lacerations, have cognitive or hearing challenges that make communication
or intra-abdominal or intrathoracic sources can present with of historical information and changes in status difficult. Some
expanding hematomas, increased pain, tachycardia, hypotension, people with cognitive disabilities may present similar challenges.

231
 Collateral information gathered from other sources, such as
KEY LEARNING POINTS
family or caregivers, prehospital personnel, or electronic medical
records may aid in filling the gaps. In these patients, there is a high • The secondary survey starts when the primary
risk of missed injuries, which can have devastating consequences; survey is completed and the patient is
thus, a high index of suspicion for injury is required. Factors hemodynamically stable or improved.
intrinsic to the patient, including age, medical comorbidities,
• An AMPLE history is obtained from patients
and functional status, may affect their response to injury.
who can provide it. In those unable to provide
There may be a need to make special accommodations that will firsthand details, family, bystanders, and
allow more effective evaluation and treatment. Amplifiers for prehospital providers are relied upon.
patients who are hard of hearing, translation for those with a
different primary language or who are deaf, and family support • Vital signs are reassessed frequently. Changes
in the resuscitation area are a few examples to consider. may indicate alterations that require intervention.

• In hemodynamically normal patients with

PRACTICE ENVIRONMENT CONSIDERATIONS extremity tourniquets, assess the tourniquet’s
effectiveness and consider conversion to
In resource-rich environments, cross-sectional imaging hemostatic dressing if the timing and situation
of almost all areas of the body has largely supplanted other are appropriate.
modalities because it rapidly provides highly accurate and
actionable information for the optimal management of the patient. • A comprehensive physical examination will
identify nonlife-threatening injuries.
However, very good outcomes can be achieved by utilizing less
image-intensive protocols for diagnosis and management of • Provide tetanus immunizations, antibiotics,
injuries. Plain x-rays, diagnostic peritoneal lavage, and watchful and analgesia as required.
serial evaluation by committed clinicians are excellent modalities
in environments where cross-sectional imaging is either not • Consider the mechanism of injury in addition to
available or is available in very limited capacity. Each hospital the physiologic presentation to help identify the
evaluation needed.
should develop its own protocols for how injuries to each of the
body regions will be diagnosed and managed based on available • A comprehensive evaluation will minimize
resources in terms of imaging and specialists. the risk of delayed or missed injury evaluation.

CHAPTER SUMMARY • Injuries evolve over time, and the need for
reassessment cannot be overemphasized.
The secondary survey is a vital component of the assessment
of the injured patient. While the primary survey identifies
immediately life-threatening injuries, the comprehensive
secondary survey ensures that all other injuries are identified. REFERENCES
Vital signs are frequently reassessed to identify physiologic 1. US Department of Defense. What is blast injury?
changes as rapidly as possible and facilitate rapid resuscitation. https://blastinjuryresearch.health.mil/index.cfm/blast_
Imaging is an important adjunct to the physical assessment. injury_101/what_is_blast_injury. Accessed May 31, 2024.
Cross-sectional imaging is valuable in diagnosing traumatic 2. Bulger EM. Trauma Research: Funding and Direction.
injury. Patients who are hemodynamically abnormal should ACS Committee on Trauma. https://www.facs.org/media/
be carefully reassessed for the need for surgical exploration oxdjw5zj/imaging_guidelines.pdf. Accessed May 31, 2024.
versus CT imaging. Injuries evolve with time, and compartment 3. Newgard CD, Fischer PE, Gestring M, et al. National
syndrome, hemothoraces, and pneumothoraces require treatment guideline for the field triage of injured patients:
when identified. Recommendations of the National Expert Panel on Field
Triage, 2021. J Trauma Acute Care Surg. 2022;93(2):e49–
e60. DOI: 10.1097/TA.0000000000003627. Epub 2022 Apr
27. PMID: 35475939; PMCID: PMC9323557.
4. Drew B, Bird D, Matteucci M, Keenan S. Tourniquet
conversion: A recommended approach in the prolonged
field care setting. J Spec Oper Med. 2015;15(3):81–85. DOI:
10.55460/IJ9C-6AIF. PMID: 26360360.
5. Standifird CH, Kaisler S, Triplett H, et al. Implementing
tourniquet conversion guidelines for civilian EMS and
prehospital organizations: A case report and review.
Wilderness Environ Med. 2024;35(2):223–233. DOI:
10.1177/10806032241234667.

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 COURSE MANUAL | Chapter 15 | Transfer to Definitive Care

15

Transfer to Definitive Care

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Define the term transfer to definitive care and 4. Identify common potential modes of
understand its role in the ATLS algorithm transportation and factors that determine which
to use
2. Recognize mechanisms of injury and specific
injuries that may merit transfer 5. Outline the information needed by an
accepting facility
3. Describe interventions used to stabilize patients
prior to transfer 6. Describe the components of a pretransfer checklist

233
 TRANSFER DECISION PROMPTS

15 Trauma systems focus on ensuring that injured patient needs

are best matched to trauma centers with the capabilities to meet
those needs in the shortest time possible.
Severely injured patients might initially be taken to a lower-
level trauma center or a nontrauma hospital for Initial Assessment
and management of life-threatening injuries. This initial
destination decision is influenced by the severity of the injuries,
patient location, and field triage determination. The goal is to
Transfer to Definitive Care sustain the patient’s life in preparation for transfer to a higher-level
trauma center. Criteria for transfer to a higher level of care include
patient physiology, specific injuries or injury patterns, and patient
characteristics. When preparing to transfer a patient to another
CHAPTER STATEMENT facility, medical care should focus on optimizing the patient for
transport, identifying any physiological conditions that could
Patient outcome is directly related to timely assessment, worsen, and ensuring that body temperature remains normal.
resuscitation, and progression to appropriate definitive care. The main factor influencing the decision to transfer a patient is
Transfer to definitive care moves an injured patient to a setting the initial hospital’s ability to provide the necessary care for injuries.
with capabilities to manage their injuries definitively. This process If the patient first arrives at a hospital that does not specialize in
could include moving a patient from a trauma resuscitation area trauma care, such as a community or critical access hospital, plans
to an operating room or transferring a patient from the emergency for early transfer should be made and initiated while the patient is
department of a nontrauma hospital to a trauma center or fully being resuscitated. Preexisting regional transfer agreements can
resourced facility. Transfer to definitive care is a planned, facilitate rapid patient transfer.
structured event. Patients with injuries necessitating intervention during the
primary survey warrant consideration for expedited transfer.
INTRODUCTION Specifically, individuals presenting with the following conditions
require advanced care levels and benefit from prompt transfer:
A key decision point for optimal care of the injured patient, airway compromise or at risk for airway loss, tension or open
according to ATLS® guidelines, is the transfer to definitive care, pneumothorax, clinical signs of shock, extremity fractures with
involving the movement of a patient to a care setting with vascular compromise (evidenced by active hemorrhage or distal
appropriate resources to advance the management of specific ischemia), pelvic fractures with associated hemorrhage, significant
injuries. This transfer promotes safe and appropriate care in physiological decompensation, or progressive neurological
another healthcare facility or internal unit in a trauma center (or decline.
fully resourced facility). Furthermore, patients requiring surgical interventions that
Recognizing when patient needs exceed capabilities in a exceed the capabilities of the current facility, especially when
facility or care unit is a trigger for early initiation of the transfer immediate access to an operating room and a qualified surgical
process between or within facilities. While the actual transfer to team are not available, should be rapidly transferred to ensure
definitive care most often follows the Secondary Survey, it may timely surgical management.  Table 15-1 lists some common
occur during the Primary Survey, most often within a trauma indications for trauma patient transfer.
center or fully resourced facility when exsanguinating hemorrhage Patients with injuries that require critical care monitoring
requires rapid operative intervention, or within a critical access or specialty trauma care should be considered for early transfer
hospital when the best that the emergency department can do as well. Urgent transfer should be considered for specific
is sustain temporizing resuscitation and transfer the patient findings on Secondary Survey, including ophthalmologic
to a trauma center or other facility resourced with operating injury, complex maxillofacial trauma, neck hematoma or
capabilities. It is essential to know the injury care capabilities crepitus, flail chest or multiple rib fractures with respiratory
of your facility and to be ready for early transfer when injury compromise, or hand injury. Patients with high-energy
needs exceed those capabilities. mechanisms or penetrating injuries to the head, neck, or torso
warrant urgent transfer as well.
Certain populations with physiologic and anatomic nuances
benefit from early transfer to a trauma center for management,
including geriatric, pediatric, pregnant, and burn patients.

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 COURSE MANUAL | Chapter 15 | Transfer to Definitive Care

 Table 15-1: Common Indications for Trauma

TRANSFER DESTINATION OPTIONS
Patient Transfer.
Several factors determine the options for transferring
patients, including the following: the existence and availability of
Common Injuries that Lead to Trauma Patient transportation within a local or regional system; the locations of
Transfer trauma centers (if they exist); and the types of hospitals providing
broad specialty care (if designated trauma centers do not exist
Common trauma transfer cri- in the area). Preexisting transfer agreements set expectations
Type of Injury teria and expedite transfers. When a formal trauma system exists,
injured patients should be transferred from nontrauma to trauma
Neurosurgical • Open skull fracture
centers and from lower-level trauma centers (III–V ) to higher-
• Lateralizing signs
• Spinal cord injuries levels trauma centers (I–II). When such a formal system is not
established, creating protocols for transfer processes is still
Thoracic • Major chest wall injury important.
• Multiple rib fractures In the US, trauma centers are classified into five levels, ranging
• Blunt aortic injury from Level I, which acts as a comprehensive regional referral
• Uncontrolled thoracic bleeding
center, to Level V, which offers care through an emergency
department only. Level I and II trauma centers are equipped
Abdominal • High-grade solid visceral injuries
with the most comprehensive resources for the definitive care of
• Pancreatic injuries
trauma • Intra-abdominal bleeding without OR trauma patients.
• Transabdominal or pelvic bullet Outside the US, the organization and designation of trauma
wounds centers can vary significantly, reflecting differences in healthcare
systems, resources, and regional needs. For instance, some
Extremity • Fractures with vascular injury countries may have a different tier system or may integrate
• Open long-bone fractures
injuries • Complex long-bone fractures trauma care into general hospitals without a distinct trauma
• Mangled extremities level designation. Nontrauma acute care hospitals, as they are
• Candidates for reimplantation known globally, are general medical facilities that treat various
of amputated limb nontrauma surgical and medical conditions. Freestanding
emergency departments, which can be affiliated with a hospital
Pelvis • Unstable pelvic ring fracture
or operate independently, provide emergency services separate
• Pelvic fractures with ongoing bleeding
• Displaced acetabular fractures from hospital campuses. Critical access hospitals—a designation
unique to the US—serve rural areas and offer essential healthcare
Ocular injuries • Globe injuries and emergency services in locations far from other hospitals.
• Retrobulbar hematomas Internationally, similar models exist to ensure healthcare access
• Orbital fractures with entrapment in remote areas, though they may operate under different names
and criteria.
Maxillofacial • Bilateral mandible fractures The initial receiving hospital should understand the
• Open mandible fractures
trauma • Panfacial fractures medical services available in the region and the local rules for
transferring patients. It should also set up standard agreements
in advance to ensure the rapid and efficient transfer of patients
Specialty • Patients with viable pregnancy (>24
weeks) with torso trauma who need specialized care. It is important to recognize when
populations
a patient’s needs are beyond the local facility’s capabilities as
early as possible. If resources are available and the necessary
Burns • Full thickness
procedures can be performed, life-threatening injuries should
• Partial thickness >10%
• Partial or full thickness involving the be treated before transfer.
face, hands, genitalia, feet, joints, or Effective communication between the referring clinician and
perineum
the receiving trauma surgeon/clinician is crucial. Challenges
• Suspected inhalation
• Combined trauma and burn to this communication may arise from the referring clinician’s
• High voltage (>1000V) electrical less-frequent experience with severe injuries, which can lead
or lightning strikes to anxiety when managing such cases with limited resources.
On the receiving end, there may be a lack of understanding
Pediatrics • Age <15 with major trauma about the resource limitations and the context of care at the
• Burns
referring hospital. Referral is a call for help. A standardized
communication tool, such as SBAR (situation, background,
Comorbid • Advanced age
assessment, recommendations), helps organize the exchange
• Cardiac or respiratory disease
conditions • Post-organ transplantation of information, enhances awareness of the situation on both
sides, and lays the groundwork for improved patient outcomes
*Note: This list is not exhaustive nor should every patient during transfer.  Table 15-2 uses the xABCDE framework with
listed be transferred in all circumstances. Institutional the SBAR acronym.
capabilities are the driving forces.

235
  Table 15-2: S xABCDE BAR Communication Tool.

S-xABCDE-BAR Communication Tool

Acronym Intent Information

S-xABCDE Situation-x-Airway- • Referring clinician and facility

• Name, age, gender, mechanism of injury
Breathing-Circulation-
• Indication for transfer
Disability-Exposure/
• x-emergency hemorrhage control interventions
Environment (e.g., pressure, packing, or tourniquet)
•A
 irway: assessment, intervention
•B
 reathing: assessment, intervention
•C
 irculation: assessment, intervention
•D
 isability: assessment, intervention
•E
 nvironment/Exposure: assessment, intervention

B Background • AMPLE history

• Fluid/blood requirements
• Medications (date and time)
• Images
• Reduction/splints

A Assessment Current Status:

• Physiology
• Response to interventions
• Likely injuries

R Recommendation • Transport mode and capability

• Transport interventions
• Other necessary interventions

Using SBAR, the referring clinician provides a concise overview transport requires accessible and passable roads, while helicopter
of the patient’s situation, including the mechanism of injury, transport needs a suitable place to land and depends heavily on
immediate concerns (xABCDE issues), interventions performed, acceptable weather conditions. Some trauma centers or equivalent
and the reason for transfer. The patient’s background, including facilities strategically station ground and air ambulances across a
relevant medical history (AMPLE history), fluid or blood region to be ready for rapid deployment.
requirements, imaging, and treatments administered (like pelvic Within each mode of transport, there are different levels
binder application or fracture reduction/splinting), is shared. The of medical support available, ranging from basic to advanced
assessment section covers the patient’s response to interventions life support up to specialized care transport. Basic life support
and current physiological state, while the recommendations ambulances are staffed with emergency medical technicians
include the preferred mode of transport, care capabilities during (EMTs) and are equipped to provide noninvasive treatments,
transport, and expected care needs enroute. The receiving such as CPR and oxygen, with a limited range of medications and
surgeon/clinician then has the chance to ask clarifying questions, without the capacity for procedures like intubation or surgical
discuss transport parameters, and request documentation of interventions.
the care provided before and during the transfer, including any Advanced life support ambulances are operated by paramedics
procedures and imaging performed. capable of performing invasive procedures and administering a
wider range of medications, including whole blood, packed red
TRANSPORT MODES blood cells, and plasma. Specialty care transport services are
designed for critical care or burn care and offer a higher level of
INTERFACILITY medical expertise and equipment for severe clinical conditions.
Transport methods for patients can be found in or around INTRAFACILITY
the local community, including ground vehicles, aircraft (both
helicopters and airplanes), boats, and trains. The selection of a In a trauma center or equivalent facility, transport between
transport mode is influenced by multiple factors: the level of care settings of care involves monitoring of vital signs and ongoing
the transport can provide compared to what the patient requires, interventions by a dedicated multidisciplinary team, which
the geographic location, current/emerging weather conditions, may include surgeons, emergency medicine physicians,
the distance to be covered, and the impact on local resources anesthesiologists, orthopedists, advanced practice practitioners,
(for example, the reduced availability of ambulances for other nurses, and respiratory therapists. Care must be taken to ensure
emergencies). The two most frequently used methods of moving that lines, tubes, and splints are secured to the patient and do
patients between facilities have their own specific needs: ground not become displaced or dislodged with necessary movement.

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 COURSE MANUAL | Chapter 15 | Transfer to Definitive Care

secondary injury. Before transfer, it is essential to reevaluate re-

PRIORITIES FOR PATIENT TRANSPORT
suscitative measures for x, airway, breathing, circulation, disability,
READINESS and exposure to ensure they are secure, functioning properly, and
producing the desired physiological outcomes. Anticipating the
Preparation for transfer begins with facility preparedness and
worsening of injuries is crucial; therefore, preventive measures
continues through early recognition of patient needs exceeding
like intubating patients at risk of airway loss or decompress-
facility capabilities. Facilities must be familiar with regional
ing a pneumothorax that could expand should be undertaken.
capabilities and local guidelines for transfer. Preexisting standard
All medical devices, such as tubes, lines, and splints, must be
transfer agreements should be in place to facilitate rapid transport
checked to confirm they are working correctly and securely at-
of appropriate patients. Imaging that does not bear on the
tached to avoid dislodgement during transport. A checklist can
immediate treatment of life-threatening injuries should be
be useful for ensuring that the smallest details are not forgotten.
avoided.
( Table 15-3 ATLS Transfer Checklist is an example of such
In preparation for a safe transfer, patients should be resus-
a checklist.)
citated to an acceptable physiology, with further interventions
aimed at stabilizing physiology and injuries while preventing

 Table 15-3: ATLS Transfer Checklist.

ATLS Transfer Checklist

1. x – Control Life-Threatening External Hemorrhage 5. D – Disability (Neurological Status)

Check for exsanguinating or significant external Reassess neurological status

hemorrhage (pooling blood, strike-through on dressings, (Glasgow Coma Scale, pupil checks).
bleeding distal to tourniquet).
Reassess neurovascular function of all extremities.
Apply direct pressure, tourniquet, or hemostatic
dressings as needed. Ensure spinal motion restriction is in place (C-collar, flat
positioning, modified log roll if needed).
2. A – Airway with Cervical Spine Protection
6. E – Exposure/Environmental Control
Assess airway patency (altered sensorium, facial/neck/
chest trauma, multisystem trauma). Fully expose the patient to assess for hidden injuries.

Verify that cervical spine protection Assess for hypothermia.

(e.g., C-collar) is in place.

Check if advanced airway is in place and functioning. Apply warming measures if necessary
(blankets, warmed fluids).
Provide airway support if necessary (e.g., intubation,
Secondary Survey and Additional Considerations
airway adjuncts).

3. B – Breathing and Ventilation Review and reassess identified injuries from Primary
and Secondary Surveys.
Assess for significant pneumothorax or hemothorax Consider interventions to prevent progression
(FAST, CXR, clinical signs). of identified injuries.
Ensure chest tube is in place and functioning if applicable. Confirm review of patient care preferences
and goals of care.
Confirm pulse oximeter is placed and functioning.
Ensure pain has been assessed and
Verify that respiratory status is stable if pneumothorax analgesics administered.
was treated without a tube.
Verify the function and security of all tubes and lines.
4. C – Circulation with Hemorrhage Control
Ensure documentation and imaging are
Ensure large-bore IV access is in place and functioning. bundled and ready for transfer.

Assess if ongoing resuscitation is needed Confirm plan of care is discussed with patient, family,
(fluids, blood products). receiving team, and specialists.

Reassess for internal bleeding

(e.g., FAST, clinical assessment).

Ensure pelvic binder is properly positioned

and tightened if applicable.

Confirm fractures are splinted and splints are secure.

Administer necessary fluids or blood products if required.

237
 In preparation for transport, it may be necessary to employ
SPECIAL CONSIDERATIONS
damage control resuscitation strategies. These includes obtaining
reliable vascular access and administering controlled fluid Patients for whom transfer may not align with their expressed
volumes to temporarily stabilize the patient and achieve acceptable care preferences, such as those in hospice or where transfer
vital signs, especially when definitive hemorrhage control is not would not alter the inevitable progression towards mortality
possible. If available, blood products should be transfused as due to the severity of injuries, warrant special consideration.
needed to sustain physiological stability and support coagulation, For these patients, prioritizing comfort care may be more
depending on the degree of shock. Address hypothermia by appropriate. Whenever feasible, a discussion should occur with
warming the patient and implementing measures to maintain the patient regarding their injuries, the goals of transfer, and end-
normal body temperature during transport. of-life preferences before making a transfer decision. In cases
Interventions to manage or treat any conditions that pose involving unconscious patients, it is imperative to make efforts
an immediate threat to life must be performed. For soft-tissue to contact family members or surrogates who can represent the
injuries, perform rapid irrigation, packing, and wrapping and patient’s wishes and values before proceeding with the transfer.
give antibiotics and tetanus prophylaxis without delaying transfer. This approach promotes care decisions, including the choice to
The patient’s potential risk to self or others should be assessed, transfer, that are in harmony with the patient’s own goals and care
and appropriate protective actions taken. All documentation of expectations.
evaluations, management actions, diagnostic tests, and images
should accompany the patient, without wasting time copying
nonessential paperwork.
CHAPTER SUMMARY
Handoff to the transfer team is best accomplished with a The decision to transfer for definitive care may be between
standard tool, such as SBAR. Critical information must be facilities or within a trauma or equivalent center. Depending
communicated with clarity, brevity, and consistency. Information on patient physiology and injury, the transfer process should be
exchange between referring and receiving physicians guides initiated upon recognition that the patient’s needs are greater than
care before and during transport. Critical information includes the facility’s capabilities. The actual transfer may occur following
demographics, mechanism of injury, identified injuries (broadly), the secondary survey, though for patients with exsanguinating
timeline of interventions following the primary and secondary injuries, transfer may happen even with ongoing resuscitation.
survey, current status (physiology and interventions), anticipated Within the regional trauma system, all trauma transfers should
care enroute, and preferred transport option. be reviewed through a performance improvement process. Even
Interfacility transfers should be reviewed through a when a formal trauma system has not been established, such an
performance improvement process. A regional trauma system oversight process should be put in place.
approach to performance improvement of patient transfers—
inclusive of EMS, the sending facility, and the receiving trauma
facility—is ideal.
KEY LEARNING POINTS
TRANSFER DELAY • Patient injuries relative to facility capabilities and
goals of care determine the need for transfer.
When transfer is delayed, goals shift from preparation for early
transfer to continuing resuscitation, stabilization, and, in some • Determination of the appropriate transport
mode requires assessment of likely transfer time,
cases, damage control operations for emergent injuries when
geographic and weather conditions, and patient
capabilities exist. Prolonged care at the initial facility might be needs en route.
necessary under conditions that impede transport, such as bad
weather, ground barriers, and lack of available transport vehicles. • Readiness for transfer to definitive care requires
Prolonged care may also be necessary in a mass casualty incident awareness of facility capabilities and receiving
with critical bed shortages at receiving facilities (e.g., during trauma center options within the regional trauma
the COVID-19 pandemic). Transfer should not be delayed system.
obtaining imaging or perform evaluations that do not impact • When patient injuries exceed facility capabilities,
the patient’s physiologic status. do not delay transfer for secondary survey
Triage priorities for intervention and transfer in mass casualty imaging (e.g., CT scan, extremity radiographs).
incidents should be in place to guide decision-making for transfer.
The triage goal is to identify and treat critically injured casualties • Review the patient’s expressed goals of care
within a large population of noncritically injured casualties. before transfer.
Facility transfer protocols should have caveats for mass casualty • At a trauma center, consider direct transfer to
incidents. When fully resourced centers become overwhelmed, the operating room for exsanguinating patients
tiered-resource use may allow transfer of patients with injuries (when protocols for this exist).
that don’t pose an immediate life threat to facilities that don’t
routinely care for injured patients but have the capability to do
so. Examples include patients with penetrating extremity injuries,
nontorso ballistic injuries, orthopaedic injuries, or amputation.

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REFERENCES
1. American College of Surgeons. Resources for Optimal Care
of the Injured Patient (2022 Standards). Chicago, IL; 2022.
2. American College of Surgeons Committee on Trauma. ACS
TQIP Best Practices Guidelines in Imaging. Chicago, IL;
2018.
3. American College of Surgeons Committee on Trauma. ACS
TQIP Palliative Care Best Practices Guidelines. Chicago, IL;
2017.
4. American College of Emergency Physicians. Policy
Statement: Freestanding Emergency Departments.
Updated April 2020. https://www.acep.org/patient-care/
policy-statements/freestanding-emergency-departments.
5. American Trauma Society. Trauma Center Level
Explained. https://www.amtrauma.org/traumalevels.
Accessed October 11, 2023.
6. ASPR TRACIE. Mass Casualty Trauma Triage: Paradigms
and Pitfalls. July 2019. https://files.asprtracie.hhs.gov/
documents/aspr-tracie-mass-casualty-triage-final-508.pdf.
7. Doucet J, Bulger E, Sanddal N, et al. Appropriate use
of helicopter emergency medical services for transport
of trauma patients: Guidelines from the Emergency
Medical System Subcommittee, Committee on Trauma,
American College of Surgeons. J Trauma Acute Care Surg.
2013;75(4):734–741.
8. DuBois E, Schmidt A, Albert LA. Location of trauma care
resources with inter-facility patient transfers. Oper Res
Perspect. 2021;8:100206.
9. Follette C, Halimeh B, Chaparro A, Shi A, Winfield R. Futile
trauma transfers: An infrequent but costly component
of regionalized trauma care. J Trauma Acute Care Surg.
2021;91(1):72–76.
10. Garwe T, Stewart K, Newgard CD, et al. Survival benefit of
treatment at or transfer to a tertiary trauma center among
injured older adults. Prehosp Emerg Care. 2020;24(2):245–
256.
11. Harrington DT, Connolly M, Biffl WL, Majercik SD, Cioffi
WG. Transfer times to definitive care facilities are too long:
A consequence of an immature trauma system. Ann Surg.
2005;241(6):961–968.
12. Johnson A, Rott M, Kuchler A, et al. Direct to operating
room trauma resuscitation: Optimizing patient selection
and time-critical outcomes when minutes count. J Trauma
Acute Care Surg. 2020;89(1):160–166.
13. Shahid S, Thomas S. Situation, Background, Assessment,
Recommendation (SBAR) communication tool for handoff
in health care—A narrative review. Saf Health. 2018;4(7).
14. Zhou Q, Rosengart MR, Billiar TR, Peitzman AB, Sperry
JL, Brown JB. Factors associated with nontransfer in
trauma patients meeting American College of Surgeons’
criteria for transfer at nontertiary centers. JAMA Surg.
2017;152(4):369–376.
15. World Health Organization. WHO trauma care checklist.
2016. https://www.who.int/publications/i/item/trauma-
care-checklist. Accessed July 5, 2024.

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 Chapter 16: Trauma Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Chapter 17: Triage and Disaster Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Chapter 18: Injury Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Chapter 19: Trauma-Informed Care and Social Determinants of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Chapter 20: Communicating Serious News in the Acute Trauma Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

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SECTION II

Trauma Systems and

Patient-Centered Care
242 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 16 |Trauma Systems

16

Trauma Systems

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explain the importance of a systems approach to 4. Describe how a trauma program should be able to
injury care demonstrate effective patient’s safety and trauma
care
2. List the benefits of trauma systems
5. Understand how local and regional factors affect
3. Describe the different components of a trauma
implementation
system

243
 BENEFITS OF IMPLEMENTING A TRAUMA

16 SYSTEM
There are several key benefits to implementing a trauma
system:
• Rapid access to prehospital care
• Specialized treatment at designated trauma centers with the
necessary expertise and resources
• Coordination of care across different clinicians, ensuring that
Trauma Systems patients receive appropriate treatment and follow-up
• Enhanced collaboration between healthcare clinicians,
leading to improved communication and care coordination
• Improvement of outcomes—the effectiveness of trauma
CHAPTER STATEMENT systems can be measured by several outcomes, including
mortality, morbidity, disability, and quality of life. Some
Trauma systems are a vital component of the healthcare
studies have shown that trauma systems can also improve
system, providing coordinated, comprehensive care to injured
functional status and return to work following trauma
patients with the goal of reducing mortality and morbidity, as
well as improving quality of life following trauma. The primary • Overall healthcare cost reduction by providing prompt and
goal of a trauma system is to have the right patient get the right efficient care and reducing the length of hospital stay
care at the right time.
REGIONAL TRAUMA SYSTEMS: OPTIMAL
INTRODUCTION ELEMENTS, INTEGRATION, AND
ASSESSMENT
Injury is a public health problem of enormous magnitude,
Organized approaches within single facilities to care for
whether measured by years of productive life lost, prolonged or
victims of severe injury have repeatedly demonstrated improved
permanent disability, or financial cost. Globally, published work
outcomes, an observation that has led to the development of the
demonstrates it is the most common cause of death and disability
trauma center verification process. Regionalized trauma systems
for those under 44 years of age. Implementation of a regional
should have a process for triaging patients, ensuring that a
trauma system has resulted in significant improvements in trauma
patient gets to the level of trauma care that matches their injury
care and a reduction in mortality worldwide. A study published in
severity and resulting in improved outcomes.
the Journal of Trauma and Acute Care Surgery demonstrated that
The care of injured patients requires a systems approach to
patients treated at trauma centers had a 25% lower risk of death
ensure optimal care. A systematic approach is necessary within a
compared to those treated at nontrauma centers.
facility; however, no individual trauma center can do everything.
Knowledge of trauma systems is essential for anyone involved
A systems approach is necessary within an entire community
in the care of trauma patients, from healthcare providers to
regardless of its size.
policymakers, as it can help improve the quality of care and
The term “inclusive trauma system” is used for this all-
outcomes for injured patients.
encompassing approach, as opposed to an “exclusive” system,
which refers only to the major trauma center.
PRACTICE ENVIRONMENT CONSIDERATIONS
DEFINITION AND GOALS OF TRAUMA TRAUMA SYSTEM COMPONENTS
SYSTEMS A trauma care system includes key elements: injury
A trauma system is an organized, coordinated effort in surveillance and prevention, emergency medical services,
a defined geographic area that delivers the full range of care prehospital care and transportation, acute hospital care,
to all injured patients regardless of race, ethnicity, gender, rehabilitation, disaster preparedness, education, and research.
religion, age, or ability to pay and is integrated with the local
public health system. The primary goal of a trauma system is to INJURY SURVEILLANCE AND PREVENTION
have the right patient get the right care at the right time. Within Traditionally, prevention efforts have focused on education,
a geographic area, a trauma system encompasses prehospital enactment, enforcement, and environmental modification. Part
notification and treatment, acute hospital care, and access to of every effective injury prevention effort is a focus on proximate
rehabilitation services when needed. Trauma systems require causes. Many injuries have alcohol and drug use as an important
collaboration between emergency medical services (EMS) contributing factor. Screening and brief intervention for alcohol
personnel and other stakeholders to provide coordinated care to use are required of all verified trauma centers in the US. Access to
trauma patients. firearms is another important root cause of injury. Socioeconomic,
cultural, environmental, and engineering factors should also be
considered.

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Trauma systems must have an organized and effective Because of the significant resources required for patient care,
approach to injury prevention, must prioritize those efforts education, and research, most Level I trauma centers are university-
based on local trauma registry and epidemiologic data, and, based teaching hospitals. Other hospitals willing to commit these
perhaps most important, must partner with injury prevention resources, however, may meet the criteria for Level I recognition.
experts and resources in the community. This collaboration leads Medical education programs include residency program support
to an exchange of data and ideas that allows better analysis of the and postgraduate training in trauma for physicians, nurses, and
problem and its solutions. Geographic information systems have prehospital providers. Research and prevention programs, as
also proven effective in studying intentional injury in various defined in this document, are essential for a Level I trauma center.
communities. They can successfully identify high-risk areas To ensure adequate experience and expertise, designation as
and factors associated with intentional injuries as targets for a Level I trauma center requires that a certain volume of injured
prevention. patients to be admitted each year, including the most severely
Vital records and medical examiners’ reports describing injured patients from the system. In addition, certain injuries that
causes of death, along with the data available from local and occur infrequently should be concentrated in this special center
state police, help identify the incidence of injuries and high-risk to ensure that these patients are properly treated and studied. A
behaviors. These reports identify injuries in a manner that is often Level I trauma center must admit at least 1,200 trauma patients
not available using the trauma registry (see Chapter 18, Injury yearly or have 240 admissions with an Injury Severity Score of
Prevention). more than 15.

EMERGENCY MEDICAL SERVICES LEVEL II

The goals of the EMS are to prevent further injury, initiate A Level II trauma center can be an academic institution
resuscitation, and provide safe and timely transport of injured or a public or private community facility located in an urban,
patients. High-quality, consistent emergency care requires that all suburban, or rural area. A Level II trauma center is expected to
prehospital personnel in a trauma region understand the trauma provide initial definitive trauma care, regardless of the severity
triage criteria and destination protocols, treatment protocols, of injury. In densely populated areas, a Level II trauma center
transportation alternatives, and capabilities of trauma facilities in may supplement the clinical activity and expertise of a Level I
their geographic region. institution. In systems with lower-population densities, a Level II
trauma center often serves as the lead hospital.
TRAUMA CARE FACILITIES Level I and Level II trauma centers are expected to be clinically
equivalent except for very complex, specialized injuries such as
Essential to the development of a trauma system is the
replantation. However, depending on geographic location, patient
designation of definitive trauma care facilities. The trauma
volume, personnel, and immediate availability of resources, a
system is a network of definitive care facilities that provides for all
Level II trauma center may not always be able to provide the same
injured patients. To achieve the goal of decreasing the burden of
level of comprehensive care as a Level I trauma center.
injury, a trauma system needs to develop a network of acute care
facilities, personnel, and organizational entities that function in LEVEL III
an organized and coordinated manner in a geographic area. These
acute care facilities and their healthcare clinicians are essential A Level III trauma center serves communities that do not
system resources that must be active and engaged participants. have immediate access to a Level I or II institution. A Level III
trauma center should have the capability to initially manage
TRAUMA CENTERS most injured patients and have transfer agreements with a Level
I or II trauma center for seriously injured patients whose needs
In the US, trauma centers are categorized according to the
exceed the facility’s resources. A Level III trauma center must have
depth of their resources, where Level I trauma centers have the
continuous general surgical coverage.
most resources and Level IV the fewest.
Level III trauma centers can provide prompt assessment,
LEVEL I resuscitation, emergency operations, and stabilization and can
arrange for transfer to a facility that can provide definitive trauma
A Level I facility is a regional resource trauma center that is a care when needed. Well-trained emergency department physicians
tertiary care facility central to the trauma care system and generally and general surgeons are required in a Level III facility. In remote
serves large cities or densely populated areas. Ultimately, all areas, a Level III trauma center may take on the responsibility
patients who require the resources of a Level I center should have for education and system leadership. Level III trauma centers
access to it, either directly or through efficient transfer processes. are generally not appropriate in an urban or suburban area with
This facility must have the capability of providing leadership and adequate Level I and/or Level II resources.
total care for every aspect of injury, from prevention through
rehabilitation. In its central role, a Level I center must have LEVEL IV
adequate depth of resources and personnel. This responsibility
Most Level IV hospitals are in rural locations and usually
includes all hospitals caring for injured patients in their regions.
supplement care within a larger trauma system. Level IV trauma
facilities provide advanced trauma life support before patient
transfer in remote areas where no higher level of care is available.
Level IV facilities provide initial evaluation and assessment of

245
 injured patients, but most patients will require transfer to higher- trauma program are commonly known in the US as a trauma
level trauma centers. A Level IV facility must have 24-hour performance improvement and patient safety (PIPS) program.
emergency coverage by a physician or midlevel clinician. Trauma programs should be able to demonstrate effective patient
A Level IV trauma facility should be an integral part of the safety activities that minimize the incidence and impact of medical
inclusive trauma care system, and participation within the larger errors and maximize recovery when errors do occur.
trauma system is essential. As with Level III trauma centers,
treatment protocols for resuscitation, transfer protocols, data EDUCATION AND OUTREACH
reporting, and participation in system performance improvement
are essential. Also, it is essential for a Level IV facility to have the RESEARCH AND SCHOLARLY ACTIVITY
involvement of a committed physician who can provide leadership
Research and scholarly activity are some of the capabilities that
and sustain the affiliation with other centers.
distinguish the highest-level trauma centers from other trauma
centers. Research, the process of advancing knowledge, is essential
TRAUMA CARE COORDINATION to optimize the care of injured patients.
Effective trauma systems must have a lead hospital. These
lead hospitals should be the highest level available within the PUBLIC EDUCATION
trauma system. In most trauma systems, a combination of levels Trauma centers must become important community and
of designated trauma centers will coexist with the other acute care regional resources. These centers must turn into sources of
facilities that should also be formal members of the trauma system information, expertise, and public safety leadership in the
caring for injured patients of lesser acuity. These institutions must treatment of major injury. Trauma centers and regional systems
provide data and participate in performance improvement. also stand to improve their services by bringing the community
voice to the table in order to understand the needs and social
REHABILITATION
drivers that impact risk, access to care, and postdischarge quality of
The rehabilitation of injured patients should begin on the life. It is important that trauma center professionals participate
first hospital day. Acute care should enable optimal functional in public education to enhance prevention efforts, disseminate
recovery. The ultimate goal of trauma care is to restore the awareness of trauma systems and how to access them, and build
patient to preinjury status. Not only is this effort best for the support for public policy change.
patient; it also is less costly. First-aid courses and CPR (airway skills) classes teach basic
management principles to laypeople. Good educational programs
DISASTER PREPAREDNESS to teach simple lifesaving and limb-saving skills and how to avoid
Trauma systems are at the vanguard of disaster preparedness. harming injured patients are needed to enhance any trauma
Responses to prior mass casualty events have helped some trauma system. The ACS Stop the Bleed® program has prepared nearly 4
systems prepare for future disasters without overwhelming million people worldwide on how to stop bleeding in a severely
any individual trauma center. Disaster response planning is a injured patient.
complex endeavor. A hospital disaster plan begins with a hazard
vulnerability analysis. This analysis involves a projection of the PROFESSIONAL EDUCATION AND TRAINING
most likely threats—natural and human-caused, intentional or Principles of trauma care are introduced in medical school,
accidental—to the hospital and surrounding community. nursing school, prehospital provider programs, and other allied
health training programs. The Advanced Trauma Life Support®
DATA COLLECTION (ATLS®) Course and similar educational programs have become
A trauma registry is a disease-specific database composed of basic trauma educational endeavors for healthcare professionals.
uniform data elements that describe the injury event, demographics, The Trauma Evaluation and Management (TEAM)® course was
prehospital information, diagnosis, care, outcomes, and costs of initially developed to introduce the concepts taught in ATLS to
treatment of injured patients. The foundation for evaluation of a medical students, but it has now been redesigned to meet the
trauma system is the establishment and maintenance of a trauma needs of a much larger target audience.
registry. It is also desirable that surgeons involved in the care of injured
patients participate in advanced trauma skills training. Although
PERFORMANCE IMPROVEMENT this advanced training can be accomplished through a variety of
Quality improvement programs are an integral part of a methods, the ACS Committee on Trauma (COT) has developed
mature trauma system. Trauma quality improvement programs two formal courses that may be used to meet this need. These
have consistently been shown to improve the process of care, are the Advanced Trauma Operative Management (ATOM®)
decrease mortality, and decrease the costs of implementing either and Advanced Surgical Skills for Exposure in Trauma (ASSET®)
a regional trauma system or a dedicated hospital-based trauma courses, which are complementary courses teaching advanced
service. principals of operative trauma management and exposure.
A trauma center should provide safe, efficient, and effective
care to the injured patient. It requires the authority and
accountability to continuously measure, evaluate, and improve
care (performance improvement). These essential elements of a

246 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 16 |Trauma Systems

TRAUMA SYSTEMS ASSESSMENT AND In most cases, the regional trauma system will have not
VERIFICATION only areas of strength but also areas of weakness, and efforts
to drive system development and improvement should be
Trauma center verification validates the presence of maintained. In high-resource settings, the system often arises
resources, structure, and processes. While a trauma center from a network of trauma hospitals. Rigorous standards for
verification visit focuses on hospital-level criteria, a trauma system trauma center resources and function are attainable and should
consultation is broader in scope, examining the integration of be established. EMS systems are often sophisticated but may lack
trauma system components for a state, regional, or county-level specific guidelines for identification and distribution of trauma
system of care. patients based on resource needs. Data sharing and system-level
quality improvement often face significant limitations based on
TRAUMA SYSTEMS WORLDWIDE competition and distrust between hospital systems. Finally, even
The degree to which trauma system principles have been though the patient care aspects of the health system may have
implemented varies widely across the globe. In many places, adequate funding, sustainable funding for system-level operations,
the lack of resources and infrastructure for healthcare are including data collection and analysis, is frequently insufficient.
key limiting factors, but a strong trauma system also requires The path forward generally involves identifying areas of weakness
support of the healthcare governance structure, along with and seeking to apply rigorous standards that have shown benefit
the laws, rules, regulations, and oversight necessary to enable in successful systems.
system operations. As noted by Mock et al, when comparing
trauma systems in Ghana (low-income country), Mexico (middle- RESOURCE-RESTRAINED ENVIRONMENTS
income country) and the United States (high-income country), In much of the world, the healthcare system is severely limited
mortality due to trauma decreased as the income level of a country by the availability of resources and may struggle to meet even
increased. the basic care needs of the population. In such circumstances,
In trauma systems development, decisions must be made as to efforts to improve the care of injured patients must take such
the extent to which limited resources should be allocated to specific realities into account, but the fundamental principles still apply.
programs. In Mock’s study, the majority of deaths occurred in the Policy-level support and a governance structure for injury care
prehospital setting regardless of the economic level of a country, are equally critical and may be relatively easier to achieve than in
indicating the importance of injury prevention at all levels. Even more economically profitable environments, in which the drivers
in high-resource areas with sophisticated healthcare facilities, of the overall health system are more complex.
there is often a lack of the policy support necessary to implement The establishment of standards for trauma center resources
and maintain a robust system. Competition between healthcare and processes is an essential step that is even more critical in
facilities and division of care between public and private systems regions where there is no preexisting network of sophisticated
can also present challenges to system development. healthcare facilities. These standards must be rational, locally
In order to be successful, efforts to develop a systems relevant, and aim to set an attainable level of function rather than
approach to injury care must take into account the resources simply adopting standards from higher-resource settings that may
available, the governance structure, and the political support not be achievable. Progress is made by incrementally raising the
for injury care in a particular region. Though the specific bar. The same approach must also be applied to EMS systems,
approach to system development will be unique, there are global defining standards, operational strategies, and improvements
principles that can help provide guidance. Examples include that are adapted to local circumstances but follow the underlying
the World Health Organization (WHO) tools for strengthening principles that govern care regardless of resource availability.
emergency care systems, as well as the essential elements for It is necessary to develop and prioritize methods for basic data
trauma systems developed by the ACS COT. These principles can collection and analysis, even in the most limited settings, as data
be prioritized based on resource availability, existing models of are essential to guide future change.
care, and degree of governmental engagement.
CHAPTER SUMMARY
HIGHER RESOURCE ENVIRONMENTS
There are many examples of high-functioning trauma systems A trauma system is a coordinated effort in a defined
that operate in high-resource environments through the world. geographic area that is integrated with the local public health
Key elements common to such systems include strong policy system and delivers care to all injured patients. The primary
support, governance, and funding arising from local, regional, goal of a trauma system is to have the right patient get the right
or national agencies and ministries. These systems typically have care at the right time. Implementation of regional trauma systems
well-established standards that define various levels of trauma has resulted in significant improvements in trauma care and
center along with a verification program to ensure that facilities a reduction in mortality worldwide. It’s important to consider
maintain these standards. EMS are governed by well-established the unique context of each region, including its infrastructure
standards that determine field identification of trauma patients, and resource availability, to tailor the strategies accordingly. A
guidelines for hospital destination, ambulance equipment levels, comprehensive assessment of regional needs, existing assets, and
and EMS provider training. These systems also have robust potential barriers is crucial for designing effective interventions to
processes for data collection, data sharing, and system-level improve care for all patients in the region.
quality improvement.

247
 KEY LEARNING POINTS 7. Galvagno SM Jr, Haut ER, Zafar SN, et al. Association
between helicopter vs ground emergency medical
• Trauma systems are a vital component of the services and survival for adults with major trauma. JAMA.
healthcare system with the aim of reducing 2012;307(15):1602–1610. DOI: 10.1001/jama.2012.467.
mortality and morbidity, as well as improving 8. Kardooni S, Haut ER, Chang DC, et al. Hazards of
quality of life following trauma. benchmarking complications with the National Trauma
Data Bank: Numerators in search of denominators.
• A trauma system is an organized, coordinated
J Trauma. 2008;64(2):277–279. DOI: 10.1097/
effort in a defined geographic area that delivers
the full range of care to all injured patients and is TA.0b013e31816335ae.
integrated with the local public health system. 9. Grossman MD, Ofurum U, Stehly CD, et al. The new Iraq:
Evaluation of injuries at a combat support hospital in support
• Regionalized trauma systems should have a process of operation Iraqi freedom. J Trauma. 2008;64(1):159–166.
for triaging patients, ensuring that a patient gets to DOI: 10.1097/TA.0b013e31815b8502.
the level of trauma care that matches their injury 10. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the
severity and resulting in improved outcomes. battlefield (2001–2011): Implications for the future of
combat casualty care. J Trauma Acute Care Surg. 2012;73(6
• A trauma system includes key elements: injury
Suppl 5):S431–S437. DOI: 10.1097/TA.0b013e3182755dcc.
surveillance and prevention, emergency medical
11. Haider AH, Piper LC, Zogg CK, et al. Military-to-civilian
services, prehospital care and transportation, acute
hospital care, rehabilitation, performance
translation of battlefield innovations in operative trauma
improvement, education, and research activities. care. Surgery. 2015;158(6):1686–1695. DOI: 10.1016/j.
surg.2015.06.026.
• Quality improvement programs are an integral part of 12. Mock C, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C,
a mature trauma system. Trauma quality improvement Maier RV. Trauma mortality patterns in three nations at
programs have consistently been shown to improve different economic levels: Implications for global trauma
the process of care, decrease mortality, and decrease system development. J Trauma. 1998;44(5):804–812;
the costs. discussion 812–814.
13. Haider A, Scott JW, Gause CD, et al. Development of a
• The degree to which trauma system principles have
unifying target and consensus indicators for global surgical
been implemented varies widely across the globe. In
many places, the lack of resources and infrastructure
systems strengthening: Proposed by the Global Alliance
for healthcare are key limiting factors, but a strong for Surgery, Obstetric, Trauma, and Anaesthesia Care
trauma system also requires support of the (The G4 Alliance). World J Surg. 2017;41(10):2426–2434.
healthcare governance structure, along with the laws, doi:10.1007/s00268-017-4028-1.
rules, regulations, and oversight necessary to enable 14. World Health Association. World Health Assembly
system operations. Resolution 68.15: Strengthening emergency and essential
surgical care and anaesthesia as a component of universal
health coverage. Sixty-Eighth World Health Assembly.
2015. https://apps.who.int/gb/ebwha/pdf_files/WHA68/
REFERENCES A68_R15-en.pdf.
1. Centers for Disease Control and Prevention. Key Injury 15. Brazil, Ethiopia, European Union, Kenya, Paraguay.
and Violence Data. https://www.cdc.gov/injury/wisqars/ Integrated emergency, critical and operative care for
overview/key_data.html. Accessed December 31, 2020. universal health coverage and protection from health
2. Shafi S, Nathens AB, Parks J, Cryer HM, Fildes JJ, Gentilello emergencies. World Health Organization. 2023. https://
LM. Trauma quality improvement using risk-adjusted apps.who.int/gb/ebwha/pdf_files/EB152/B152_CONF3-
outcomes. J Trauma. 2008;64(3):599–604; discussion 604– en.pdf.
606. DOI: 10.1097/TA.0b013e31816533f9. 16. American College of Surgeons Committee on Trauma.
3. Brown JB, Gestring ML, Forsythe RM, et al. Sustained Resources for Optimal Care of the Injured Patient: 2006.
improvement in trauma patient mortality with a physician- Chicago, IL; 2006.
driven performance improvement initiative. J Trauma 17. American College of Surgeons. Resources for Optimal Care
Acute Care Surg. 2016;80(1):20–25. DOI: 10.1097/ of the Injured Patient: 2014. Chicago, IL; 2014.
TA.0000000000000879. 18. Al-Thani H, El-Menyar A, Asim M, et al. Evolution of
4. MacKenzie EJ. Review of evidence regarding trauma the Qatar trauma system: The journey from inception to
system effectiveness resulting from panel studies. J Trauma. verification. J Emerg Trauma Shock. 2019;12(3):209–217.
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199909001-00008. PMCID: PMC6735200.
5. Salim A, Ley EJ, Cryer HG, Margulies DR, Ramicone E, 19. El-Menyar A, Mekkodathil A, Asim M, et al. Maturation
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moderate to severe traumatic brain injury. Arch Surg. system in a rapidly developing country. PLoS One.
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6. Holcomb JB, McMullin NR, Pearse L, et al. Causes of pone.0243658.
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0192-z.
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 COURSE MANUAL | Chapter 17 | Triage and Disaster Management

17

Triage and Disaster

Management

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Differentiate the terms: mass casualty event 5. Describe and demonstrate principles of allocation
(MCE), mass casualty incident (MCI), and mass of resources in the ER and the OR during MCIs
event incident (MEI) 6. Describe approaches to clinician safety in disaster
2. Discuss how an MCI creates a population-based management
context of care 7. Describe the structure and principles of Incident
3. Apply ATLS principles in disaster management Command
4. Describe principles of triage in the setting of an 8. Identify challenges for mass casualty care in
MCI and apply priorities of casualty care austere or resource-constrained environments

249
 A mass event incident (MEI) is a situation that disrupts the

17
capabilities of the normal healthcare system while also generating
a large of number of casualties. If a healthcare facility is partially
or completely destroyed, both the existing patients and new
casualties must be relocated. These patients become an additional
group in the overall casualty population. An MEI may result in
no healthcare resources being available for the initial or extended
response. Thus, an MEI is a catastrophic MCI. The transition
points across this continuum will vary based on the situation,
number and type of casualties, and available resources.
Triage and Disaster The fundamental challenge in an MCI is that casualty need
Management exceeds resources that we normally use for individualized care.
When resources are scarce, a decision made for one of the
injured impacts what can be done for every other injured
CHAPTER STATEMENT person. The focus therefore must shift from “greatest good
for the individual injured patient” to “greatest good for the
The care of the individual injured patient must be expanded in casualty population.” Moving from an individual patient mindset
a mass casualty incident or disaster situation. Effective application to a mass casualty mindset may seem easy to apply in theory, but it
of ATLS® and triage principles are essential. In addition, trauma is quite difficult in practice.
clinicians need to be familiar with disaster management principles, So how does one apply the concept of “the greatest good
the Incident Command System, and unusual threats to safety. for the casualty population” in mass casualty situations? Mass
Finally, they should be prepared to function in austere conditions. casualty response is shaped by three dynamic variables: situation,
casualties, and resources. The goals in mass casualty management
are quick identification of and initiation of care for critically
INTRODUCTION
injured, salvageable casualties, and keeping clinicians, staff, and
Mass casualty and disaster management are very broad topics hospitals safe.
that require years of training and experience to master. This Most casualties are not critically injured and are tolerant of
chapter will introduce you to the principles of triage, prioritization deferred care (e.g., soft-tissue wounds, distal extremity fractures).
of care, and allocation of resources as they relate to mass casualty This type of casualty often self-transports to the closest hospital
situations. Mass casualty incidents require a change in concept (geographic effect), and clinicians must be cautious when
from individual patient care to population-based care, and we presented with these patients early during the MCI; they could
will show how ATLS® principles apply to disaster management as start providing care to these noncritical casualties and use
compared to treatment of individual patients. up precious resources before the arrival of critical casualties.
The phases of disaster management will be summarized The usual acceptance of high overtriage rates during routine,
here but are described in detail in the Disaster Management individual-focused trauma care can lead to higher mortality
and Emergency Preparedness (DMEP®) course, which is now of critical casualties during an MCI, because it causes delay in
available online. We will discuss the Incident Command System identifying and caring for them.
(ICS), a very common and important standardized approach The initial goal of triage in an MCI is to identify critically
to disaster management that is often not taught in medical injured casualties and prioritize their movement across healthcare
education or surgical practice. Special attention also needs to be settings (e.g., evacuation from the scene to the hospital, movement
given to clinician safety, not just from the usual suspects such as from hospital arrival to the emergency department). In prehospital
needlesticks and blood-borne pathogens but also from chemical, casualty assessments at and away from the scene, triage ascertains
biological, and radiological threats, and even from direct physical who is alive and who is dead, and then who among the living needs
attack. Finally, we will discuss the challenges of mass casualty care immediate care and who does not. At hospitals, triage officers exist
in austere environments, whether in a low-income country or in a at the point of casualty arrival and at each care setting (trauma
community that has just suffered catastrophic damage. rooms, OR, ICU, ward).
First, let’s define a few terms. A mass casualty event (MCE) is a The trauma triage officer is responsible for prioritizing which
situation that generates multiple injured patients who stretch, but critical casualties get the scarce resources (surgical personnel,
do not overwhelm, patient care resources. Resources may already OR, radiological studies, ICU beds, etc.) right away and who must
be present or rapidly mobilized so that each injured patient wait. Triage officers do not necessarily need to be physicians,
receives individual care that follows the full ATLS paradigm. but they do need to be experienced in rapid shock assessment and
The number of simultaneous injured patients that constitutes an acute decision-making. They do not provide more than very quick
MCE varies by healthcare facility and community; there is more lifesaving interventions but instead focus on assigning teams to
tolerance of multiple injured patients in urban settings. care for these critical casualties.
A mass casualty incident (MCI) generates a large number ATLS principles can provide another lens through which to
of casualties with needs that exceed available healthcare look at mass casualty management. The primary survey provides
resources and management systems for individual patient care. the framework for initial casualty assessment and intervention
The mass casualty threshold varies between healthcare facilities at the scene and beyond ( Figure 17-1). Critically injured,
and systems. salvageable casualties may present with primary survey findings

250 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 17 | Triage and Disaster Management

that require rapid interventions for controlling exsanguinating of noncritical casualties to immediate care. In certain mass
hemorrhage, establishing an airway, and decompressing a tension casualty settings, both errors have been directly correlated with
pneumothorax. the critical mortality rate, and both errors must be minimized to
Secondary survey, imaging, and definitive care are deferred optimize the outcome.
until all critically injured, salvageable casualties are stabilized. A triage officer must understand the nature of injuries to be
Utilize damage control interventions in the emergency department anticipated and be educated in the unique principles of mass
and OR to maximize the opportunity to save more lives. As the casualty handling; this individual also must have absolute
situation becomes more certain and resources are mobilized, authority to make these critical decisions. Situational awareness
critical casualty care advances to secondary survey, definitive is another essential attribute of an effective triage officer. This
care, and potential transfer. Reassessment and management of characteristic consists of a working knowledge of the constantly
noncritically injured casualties also become possible ( Figure changing status of casualty influx from the scene, the nature of
17-2). injuries encountered, the casualty flow, and available resources—
Besides immediate critical casualties, there are other categories space, personnel, material—within the hospital, all of which are
that will be identified during the course of an MCI ( Figure essential to making the appropriate decisions.
17-3). Triage errors should be expected in the chaos of these
incidents, even under the best circumstances and with extensively
PREHOSPITAL EVALUATION trained triage officers. This fact emphasizes the need to create
an error-tolerant system that mitigates the adverse effects of
In the initial prehospital and inhospital evaluations, the triage errors. Examples of this type of system include continual
only triage decisions to be made are the determination of who monitoring and reassessment of casualties assigned to nonurgent
is alive, who is dead, who among the living needs immediate categories for deterioration (to minimize undertriage) and
care, and who does not. Once in the hospital, further establishing levels of secondary and tertiary triage to continually
discrimination into the other categories and reassessment of screen out individuals who do not need urgent care (to minimize
initial triage decisions can occur. The “expectant” category (alive overtriage). The postincident analysis and critique of a disaster,
but expected to die even with treatment) is most representative which is an essential element of all disaster responses, should
of the essential difference between mass casualty management include a determination of triage accuracy and its impact on
and routine emergency care. The denial of care to individuals casualty outcome.
so severely injured that they are unlikely to survive means that In the context of the ATLS Course, triage is the most
the limited time and resources available can be diverted to many important concept to understand and is familiar to most trauma
others who are less severely injured, thus avoiding many more and emergency department practitioners. However, disaster
preventable deaths. This fact is the essence of the principle of management requires familiarity with many other concepts,
doing the greatest good for the greatest number. including the phases of disaster management, incident command,
The accuracy of triage is a major determinant of casualty and safety, which are not encountered in daily trauma care. We
survival and the success of the medical management of MCIs. The provide only a summary of these concepts here, but additional
major errors of triage are undertriage, the assignment of critically information can be obtained from the in-person or online DMEP
injured casualties to delayed care, and overtriage, the assignment course.

 Figure 17-1: ATLS in Individual Trauma Patient Care. In typical daily trauma situations, the initial assessment and
management of the patient follows a standardized longitudinal progression.  

251
  Figure 17-2: ATLS in Mass Casualty Situations (MCIs). In MCIs, the primary survey with
immediate resuscitation provide an opportunity to save more lives while deferring the secondary
survey, diagnostic studies and definitive care until salvageable critical casualties have been
stabilized.

ATLS in Initial Mass Casualty Situations

Noncritical casualties Remain outside ED • Patients stay in specified

temporary care areas until
critical casualties subside
• Then proceed through full ATLS

Critical casualties Move into ED • Assign care team

who need life-saving
interventions

252 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 17 | Triage and Disaster Management

 Figure 17-3: Mass Casualty Triage Categories reflect the rapid categorization of casualties at a casualty
collection site or at a medical facility.

Mass Casualty Triage Categories

Triage Category Clinical Presentation Action

Immediate (Red) Unconscious, or no pulse, or respiratory Initiate life-saving interventions. In hospital, this
distress, or life-threatening hemorrhage, may include damage control surgery.
AND likely to survive given
current resources.  

Delayed (Yellow) Conscious, have a pulse, no respiratory Monitor and support until definitive care or
distress, no life-threatening hemorrhage, transfer can be arranged. Deterioration or new
AND have significant injuries. information may necessitate change to immediate.

Minimal (Green) Conscious, have a pulse, no respiratory Monitor until secondary survey completed. Provide
distress, no life-threatening hemorrhage, minor treatment and discharge. Deterioration
AND have minor injuries. or new information may necessitate change to
delayed or immediate.

Expectant (Various) Unconscious, or no pulse, or respiratory Initiate comfort care. Some may become
distress, or life-threatening hemorrhage, immediate if more resources become available.
BUT NOT likely to survive given
current resources.

Dead (Black) No signs of life. At scene leave in place. At hospital, transfer to

morgue or other secluded location.

PHASES OF DISASTER MANAGEMENT RESPONSE PHASE

The phases of disaster management include a Ready phase, a The initial focus of attention and efforts in any disaster is the
Response phase, and a Recovery phase: disaster scene, where the nature and extent of the incident must
be assessed, further damage minimized, and appropriate plans
READY PHASE formulated to deal with the damage. The more extensive the
destruction at the scene, the more important it is for an advance
This phase includes planning and mitigation. Appropriate team of responders to carry out a needs assessment to determine
responses to disasters are so rapid and complex that they cannot what assets are required for a successful response. Any hazardous
possibly happen without advanced thought and planning by all material dissemination must be identified at this point to define
involved parties. As such, every hospital and community should the need for decontamination of casualties and protection of first
have preestablished plans for disasters. Planning should anticipate responders.
the requirement for self-sufficiency at the local level for at least Security measures must be established rapidly to restrict
5 days before the arrival of outside help. These plans must be access to the scene to only trained individuals, as lives could
rehearsed regularly with hospital drills and community exercises be unnecessarily lost among well-intentioned but untrained
to reveal any weaknesses that should be addressed. people encountering falling debris, ongoing fires, smoke and
At the same time, disaster plans must have a built-in flexibility dust inhalation, and chemical or radiological exposure. Security
to allow adaptation to the unpredictable variables unique to each measures can also prevent deliberate “second hit” events
disaster. All personnel expected to respond to a disaster should designed to kill first responders a short time after the initial
prepare themselves by acquiring core knowledge of all elements incident. Protection of medical assets must be a priority of the
of disaster management, as well as a good understanding of the prehospital response. Medical management of a mass casualty
unique aspects of casualty medical management, including those incident begins at the disaster scene with search and rescue. The
required for unusual situations involving chemical and radioactive initial evaluation should involve only a rapid triage decision as to
materials or explosives. Mitigation is the implementation of who needs immediate care for life-threatening problems and who
measures aimed at reducing or eliminating the chance of a disaster. does not, with the former being transferred to hospitals first.
From a medical perspective, this may include injury prevention
efforts.

Every hospital in a disaster incident must prepare for a large

253
 influx of casualties by rapidly clearing its emergency department, to casualties are the beginning of psychological recovery after a
OR, and ICU beds to the fullest extent possible and by mobilizing disaster. It is important to remember that healthcare professionals
personnel and equipment resources while initiating the hospital’s may benefit from trauma-informed care as much as patients
disaster plan. Space, personnel, and equipment must also be and families. The emotional impact of disasters on everyone
allocated to manage the routine patients who will continue to seek cannot be overemphasized. Some affected individuals never
hospital services even during disasters. A security mechanism recover. Others develop long-term mental illness or behavioral
(hospital lockdown) should be instituted to prevent chaotic changes, which often require professional intervention.
inundation of the hospital by casualties, worried families, the
media, and curious onlookers from the outside. Similarly, an INCIDENT COMMAND SYSTEM
internal procedure must be initiated to prevent care spaces from
being inundated by well-intentioned medical personnel who may The ICS is a standardized, all-risk incident management
create more chaos and harm due to overcrowding. Triage officers framework. ICS allows its users to adopt an integrated
at each point of care will need to allocate available resources, organizational structure to match the complexities and
assign care teams, and manage patient flow to the next point of demands of single or multiple incidents without being hindered
care. by jurisdictional boundaries. In a disaster response, the
traditional management structures should not be used. The four
RECOVERY PHASE Cs of the ICS are Communication, Coordination, Cooperation,
Within 24 hours of an MCI, and after definitive treatment has and Collaboration. They are four simple words, but they can have
been initiated for all patients, a debriefing of all involved personnel far-reaching implications.
should be facilitated, including evaluation of procedures that ICS is applied to ensure coordination among all organizations
worked well and those that did not, bottlenecks, and resources potentially responding to the disaster. ICS is a modular and
that became depleted. Communication issues should be raised adaptable system for all incidents and facilities and is the
and discussed. Over the next 2–3 months, key stakeholders should accepted standard for all disaster response. The Hospital Incident
collate this data, determine critical mortality and triage accuracy, Command System (HICS) is an adaptation of the ICS for hospital
and assess clinical outcomes. These data should be the basis for use. It allows for effective coordination of hospital response
improvement efforts in planning for the next disaster. activities with prehospital, public health, public safety, and other
The hospital may need government or financial assistance to organizations. The trauma system is an important component of
repair facilities, restart services, or even backfill personnel and the ICS. Various organizations and countries have modified the
equipment. There are numerous government grant and loan structure of the ICS to meet their specific organizational needs.
programs for businesses and individuals to tap, including hospitals Functional requirements, not titles, determine the ICS
and healthcare personnel. hierarchy. The ICS is organized into five major management
While physical damage to infrastructure can be repaired and activities: Incident Command, Operations, Planning, Logistics,
injuries can heal, psychological damage can be more difficult to and Finance/Administration. Key activities of these categories are
assess and address. Reunification of families, support provided by listed in  Figure 17-4.
friends and family, and psychological first aid given by laypeople The structure of the ICS is the same regardless of the disaster;

 Figure 17-4: Incident Command System. A key incident management structure that ensures optimal
coordination of all organizations responding to a mass casualty situation.

Incident command structure and components

Incident Commander (IC) •S

 ets objectives and priorities and maintains overall responsibility for the disaster.  
•T
 he IC is assisted by the Liaison Officer, Public Information Officer, and Safety Officer.

Operations • Conduct operations to carry out the Incident Action Plan (IAP).
• Direct all disaster resources, including medical personnel.

Planning • Develop Incident Action Plan(s).  

• Collect and evaluate information.  
• Maintain resource status.

Logistics •P
 rovide resources and support to meet incident needs, including responder needs.

Finance/Administration • Monitor costs, execute contracts, provide legal advice.  

• Maintain records of personnel.

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 COURSE MANUAL | Chapter 17 | Triage and Disaster Management

the difference is in the particular expertise of key personnel. An

CHAPTER SUMMARY
important part of hospital disaster planning is to identify the
incident commander and other key positions before a disaster This chapter introduces the ATLS learner to the principles of
occurs. The positions should be staffed 24 hours a day, 7 days a triage, prioritization of care, and allocation of resources as related
week during a disaster. Each person in the command structure to mass casualty situations. It also summarizes the phases of
should supervise only 3–7 persons. This approach is significantly disaster management, the ICS, and safety concepts, both at the
different from conventional hospital management. All medical scene and at the hospital. Finally, it asks the learner to consider
clinicians must be aware of and adhere to the ICS structure to what should be done in a catastrophic situation with no available
ensure that they integrate successfully into the disaster response. resources. Mastering all these concepts requires years of training
Clinician safety is paramount during an MCI. In the field, and experience, but this chapter and the accompanying triage
situational awareness is critical to avoid becoming a casualty scenarios provide at least a starting point. The next steps suggested
oneself. There are many hazards to watch for, including vehicular include DMEP and other courses, which can be found via the
accidents, trips and falls, collapsed or damaged structures, cuts links provided below.
and burns, infectious disease, smoke, CBRN (chemical, biological, American College of Surgeons Disaster Management and
radiological, nuclear) exposure, unsecured weapons, explosives, Emergency Preparedness (DMEP) Course: www.facs.org/
bad weather (lightning, swift water, heat and cold), exposed or quality-programs/trauma/education/dmep.
damaged electrical and gas lines, and hostile activity.
Proper personal protective equipment (PPE) is required. This
may be nonmedical, such as work gloves, rubber gloves, hard hats,
KEY LEARNING POINTS
boots, goggles, and head lamps, or medical, such as surgical gloves,
masks (such as N95 or higher respiratory protection with chemical • Mass casualty incidents require a change in
filtering), and impermeable coveralls. If radiation is known or concept from individual patient care to
expected, responders should have personal dosimeters to population-based care.
assess time permitted on scene and to provide confirmation of
• ATLS principles are the same, but are
inconsequential exposure.
applied differently during MCIs.
At the hospital, all casualties suspected of being contaminated
with biologic toxins, hazardous chemicals, or radioactive particles • The phases of disaster management include
should be decontaminated before entering the emergency a Ready phase, a Response phase, and a
department. Otherwise, the facility becomes contaminated and Recovery phase.
dangerous for patients, clinicians, visitors, and other casualties.
• The ICS is a standardized, all-risk incident
Surface decontamination at a minimum requires removal of
management framework which allows its
clothing and washing with soap and water. Lifesaving measures users to respond effectively to single or multiple
such as hemorrhage control, chest decompression, airway control, incidents without being hindered by
and administration of antidotes can be done at any stage of care, jurisdictional boundaries.
including before decontamination. However, clinicians must
wear appropriate PPE. After decontamination, standard contact • Maintaining clinician safety is important.
precautions are appropriate.
• Maximize available resources to save as
Finally, consideration should always be given to the many as possible.
possibility of a MEI. What if there is so much damage to
healthcare infrastructure that medical care cannot be provided? • Plan for austere conditions and the possibility
Tornados have destroyed hospitals here in the US, earthquakes of a Mass Event Incident (MEI).
have destroyed hospitals from Haiti to China, and war—the
ultimate human-caused disaster—has destroyed entire countries’
healthcare systems. Such catastrophes may require evacuation
of casualties out of the disaster zone or transport of entire field
hospitals into the disaster zone. Evacuation procedures should REFERENCES
be part of every hospital’s disaster plan. More information about 1. Committee on Trauma of the American College of Surgeons.
this topic can be found in the DMEP Course. Disaster Management and Emergency Preparedness Course
Student Manual. 2nd Edition. Chicago, IL; 2018.
2. FEMA National Disaster and Emergency Management
University. IS-100.C: Introduction to the Incident
Command System, ICS 100. https://training.fema.gov/is/
courseoverview.aspx?code=IS-100.c&lang=en. Accessed
September 28, 2024.

255
256 Advanced Trauma Life Support® | 11th Edition
 COURSE MANUAL | Chapter 18 |Injury Prevention

18

Injury Prevention

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe how the conceptual framework of the 4. Describe how the use of tailored screening tools
Three Es can be used to design locally relevant can assist in identifying child abuse, intimate
injury prevention initiatives partner violence, abuse of older adults, and mental
health concerns and can then be used to arrange
2. List specific risk factors and prevention
appropriate referrals
strategies by mechanism of injury
3. Discuss how social determinants/drivers
of health and other factors may lead to a
disproportionate burden of injury on certain
populations

257
 Careful consideration of the social determinants of health

18
(SDOH), also referred to as the social drivers of health (SDOH), is
essential; these are often at the root of both injury risk factors and
protective factors. For example, do the injury events occur in areas
where people are more likely to be unhoused or economically
disadvantaged?
Identifying these root causes has been the foundation of
modern injury prevention. By discovering risk factors and
protective factors associated with injuries, effective interventions
have been created that have significantly reduced the burden of
Injury Prevention trauma in the US. These interventions are often taken for granted;
society benefits from improvements like airbags and crosswalks
without having to think much about them; but the reduction in
injury mortality in the US (and in many other countries) has been
CHAPTER STATEMENT due to consistent societal efforts from multiple stakeholders.
As the people standing on the front lines and managing
Injuries are not “accidents” but predictable, and therefore the consequences of injury, trauma care clinicians are key to
preventable, events. Strong injury prevention work has resulted successful injury prevention measures. Although it is impossible
in significantly reduced trauma mortality, but there is still much to prevent an injury that has already happened, clinicians caring
more work to do in the areas of road traffic injuries, elderly fall for trauma patients have a unique opportunity to identify trends in
injuries, childhood burns, and firearm violence (among others). their areas. Certain injury mechanisms are associated with specific
Injury prevention priorities differ by region and context. risk factors that should alert trauma clinicians to the potential
Trauma care clinicians are key stakeholders in injury need to employ injury prevention principles and strategies.
prevention, as they often have the most current and locally As they are exposed to the immediate impacts of trauma in their
relevant information on what should be prioritized. During communities, clinicians can readily incorporate injury prevention
initial resuscitation, trauma care clinicians also have the unique frameworks such as the Three Es (discussed below) to specific
opportunity to gather information from prehospital personnel injury mechanisms (such as ground-level falls in elderly patients,
that may be pertinent in devising or evaluating injury prevention firearm-related violence, and pedestrian road traffic injury) or
strategies, both to prevent reinjury in the patient immediately contexts they commonly see (including when risk factors such
under their care and for preventing future injury among members as intoxication or mental illness are involved). These trends not
of the local community. Simple frameworks, such as the “Three only are an opportunity but also confer a responsibility to prevent
Es” (environment/engineering, education, and enforcement), reinjury in the patient immediately under a clinician’s care, as well
can be readily applied to common injuries to help design locally as future injury in other patients with similar risk factors.
relevant injury prevention interventions. Timely identification of injury mechanism patterns and
This chapter will provide learners with concepts of how to consistently identified risk factors among patients can alert the
approach injury prevention and obtain ideas using the Three Es. trauma care clinician to key areas of potential intervention within
It is understood that different measures, laws, policies, and so the local community. Additionally, there are multiple screening
on may be required in various regions of the world depending tools available in the literature for special classifications such
on resources and philosophy, but this chapter was written as a as mental health, intimate partner violence (IPV ), and child
foundation for learners to create appropriate evidence-informed and elder abuse and neglect; there will be a brief referral to an
interventions in their respective domains. evidence-informed tool for each topic mentioned.

INTRODUCTION/BACKGROUND CONCEPTS/APPROACHES TO INJURY

While advances in trauma care have enhanced survival, PREVENTION:
such improvements alone cannot eliminate the impact of
There are several frameworks and guiding principles used
trauma. Injury prevention efforts are a critical necessity to
as structures to develop strong injury prevention practices. No
reduce the morbidity and mortality of trauma unaddressed
approach is necessarily superior to another; rather, they simply
through trauma care. Although unintentional injuries are
represent different ways of looking at the same issue. This chapter
sometimes called “accidents,” they are often predictable (and
will focus primarily on the Three Es approach, though other
therefore preventable) events. An example of this is looking at
approaches will also be discussed briefly. For more information,
the geographic distribution of road traffic injuries across a city
please see the references.
map. These events will not be evenly distributed across the city;
The Three Es:
rather, they will cluster in certain areas and along certain routes,
Environment/Engineering
impacting some areas more than others. These “hot spots” provide
Education
an opportunity for us to look for the root causes of these injuries.
Enforcement
Some examples include poor traffic light timing; signage for a
pedestrian crossing that is not easily visible; and proximity to bars
or other liquor outlets that influence road user intoxication.

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 COURSE MANUAL | Chapter 18 |Injury Prevention

These were originally thought of as separate approaches and

PASSIVE VERSUS ACTIVE INTERVENTIONS
could be arranged on a spectrum of most effective—engineering/
environmental changes—to least effective—education— Passive interventions do not require a person to make the
while also following a spectrum from passive interventions, decision to use the intervention—it just happens for them.
which require minimal individual decision-making, to active Examples of this are hot water heater regulators in the US
interventions, which require more complex individual behavior (preventing childhood burn injuries) or airbags (preventing road
change to be effective (see below). More recently, the Three Es traffic injury). Active interventions require the user to make the
are used together to create multipronged interventions, not only decision to use the intervention each time. An example of this is the
because many interventions inherently require more than one seat belt, which requires the user to choose to buckle up each time
element but also because a multipronged approach tends to be they ride in a car. Passive interventions tend to be more effective
more effective. An example of this is seat-belt use, which requires but often require a significant up-front investment of political will
elements of engineering changes, education, and enforcement. or policy development (like water heater temperature regulation).
Although this intervention took effort and time to be successfully Once implemented, however, they are very efficacious because
implemented in the US, it ultimately was extremely effective in they do not require each individual to make the safer choice every
reducing the morbidity and mortality of road traffic injury. time they have a decision to make.
The Three Es are a practical framework that clinicians can
quickly use to assess the context and risk factors associated with HADDON’S MATRIX
a patient’s injury, allowing early identification of potential injury Haddon’s Matrix was developed by William Haddon, who
prevention targets. It is particularly important to remember to is considered the “father” of modern injury prevention; it was a
communicate contextual information regarding a patient’s injury key conceptual advancement in the history of injury prevention.
during handoff or transfer to definitive care—the Three Es are Haddon’s Matrix deconstructs the injury event into “human,”
an effective tool to guide this communication.  Figure 18-1 “agent” (e.g., vehicle), and “environmental” factors along
demonstrates how a clinician might conceptualize the Three Es to temporal opportunities for intervention (“pre-event,” “event,” and
design and implement motor vehicle crash prevention initiatives. “postevent”); each intersection provides potential opportunities
Some have advocated for a fourth “E” in this framework, for intervention (e.g., airbag deployment would be a prevention
“Equity,” to account for the fact that injury is disproportionately measure that occurs during the event and is inherent to the
experienced by some people and to ensure that interventions are “agent”—in this case, the vehicle). The matrix is still used as
applied fairly. a brainstorming tool to develop effective interventions. In the
original 1968 publication, a “template” was shown describing
how one might use the matrix in brainstorming interventions for
highway-related injuries ( Figure 18-2).

 Figure 18-1: The Three Es Concept. The Three Es concept offers a multi-faceted approach to considering causes
of and potential strategies to prevent injury.

Education
•D
 river education courses
•E
 ducation about vehicle maintenance
•C
 ommunity education: consequences
of driving under influence, speeding,
Engineering/Environment texting, not using restraints
•V
 ehicle design/handling; anti-lock
•E
 ducation of special populations
brakes; presence and position of Education (e.g., teen and older drivers)
airbags; up-to-date safety design
•P
 ost-crash counseling and education
•R
 oad design and maintenance;
adequate signage; mitigation
of glare (night or bright sun) Enforcement
•A
 nalysis of unanticipated •A
 dvocacy for legislation regarding
consequences (e.g., fire substance use, speeding, restraint
from gasoline tank or use, and texting while driving;
electric vehicle battery) resource support for infrastructure
maintenance and speed limits
•P
 resence of organized Engineering/ Enforcement •A
 nalysis of effective enforcement
emergency response and Environment of speed limits, vehicle functioning,
appropriate care facilities
restraint use: analysis of substance
use and/or driving distractions
•C
 ommunity/Societal advocacy for pre-
hospital, acute trauma, and rehabilitation
care; enforcement of screening for SDOH

259
  Figure 18-2: Haddon’s Matrix. The original template was constructed to apply public health principles to addressing traffic
safety. It is now used to assist in developing ideas for injury prevention across a broad range of mechanisms.

Component
Motor-
Phase Driver Passengers Pedestrians Bicyclists cyclists Vehicles Highways Police

Precrash

Crash
TIME

Postcrash

Driver Passenger Property Damage

Injury Injury &
& Death
Death
RESULTS

CENTERS FOR DISEASE CONTROL AND RELEVANCE TO INITIAL PATIENT

PREVENTION (CDC) PRINCIPLES: PRIMARY, MANAGEMENT
SECONDARY, AND TERTIARY PREVENTION Every level of care across the spectrum (prehospital, initial
The public health approach principles to prevention are based center, referral center) has a role to play in ensuring that the
on interrupting disease and injury, prolonging life, and promoting causes of injury are understood so that they may be prevented.
health. These principles will be described below. While rapid clinical evaluation and stabilization must be
• Primary Prevention: Focuses on the general population by prioritized, often the initial presentation of the injured patient
halting disease, risky behaviors, or violence from happening provides context to the injury event that is relevant to injury
(e.g., raising awareness of the detrimental effects of prevention. Details such as the incident location and surrounding
committing relationship or sexual violence, setting up driving environmental characteristics may provide valuable information
under the influence checkpoints, reducing access to weapons, related to injury risk and protective factors. Examples of this
use of noncombustible construction material) include the following:
• Road traffic injuries: Did the event happen at the corner or
• Secondary Prevention: Addresses screening at-risk
middle of a street? Was there a traffic violation? Was a helmet
individuals to identify a disease in its early stage or
worn? Was the victim under the influence of alcohol or other
intervening after a violent act has occurred to diminish its
substances? Is there a mental health history? Is the patient
recurrence (e.g., educating victims of relationship and sexual
housed?
violence of red flags associated with wrongdoers, community
violence intervention, safety belt use, less-lethal bullets, • Violence: Was there substance use involved? Was a firearm
smoke detectors) used in the incident? Were there social determinants of health
at play, such as poor housing?
• Tertiary Prevention: Focuses on the long-term consequences
of disease or violence by providing support for affected • Falls in older adults: Where did the event occur: at home or
persons (e.g., family justice centers or recovery homes, in a care facility? Were there risk factors like rugs or stairs
rehabilitation centers, access to emergency medical services with poor footing? Is elder abuse suspected?
or equivalent of 911 system, access to quality healthcare) It is important to treat each patient with the same level of
dignity that follows trauma-informed care principles (see Chapter
19, Trauma-Informed Care and Social Determinants of Health),
including recognizing how prior trauma may influence current
behaviors. If a patient is transferred to another facility or higher

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 COURSE MANUAL | Chapter 18 |Injury Prevention

level of care, it is important to transmit all the relevant information,

 Box 18-1: Vision Zero.
including the injury context. If a patient ultimately arrives at a
Level I trauma center for definitive care, there should be injury
prevention data collection programs in place that will greatly Vision Zero
benefit from information on the patient’s injury context, risk
factors, and protective factors. Once lost, this information is
often irretrievable or requires significant effort to recapture, so the • Vision Zero is an example of a movement that started
locally in Sweden over 20 years ago, and now has
facility providing initial care plays a key role.
international momentum. Most major cities have
The Three Es framework is a simple construct that can be Vision Zero programs toward which trauma centers
readily used to aid in this communication. For example, a trauma can contribute meaningful data to inform prioritizing
care clinician who takes care of an injured older adult person after interventions.
a fall may have information regarding the injury context that could
• In San Francisco, hospitals contributed nonfatal injury
be critical in preventing a future fall by that same patient. Framing data, which are historically under-captured by police data
these factors as engineering (lack of handrails) or education sources, to provide accurate information for intervention
(patient or family education regarding medication review or prioritization, monitoring, and evaluation (REF).
vision checks) may be key in both protecting the individual patient
• An example of misaligned priorities occurred in one major
against another injury and helping plan effective community-level
city in an low- and middle-income country, where local
injury prevention programs. injury-prevention policy focused on airbag legislation,
but local clinicians had observed most severe injuries
PRACTICE ENVIRONMENT CONSIDERATIONS occurring in pedestrians and people falling off trains they
had “hopped” on (riding on a train’s roof or side), which
The level of injury prevention intervention should be tailored would not be impacted by the proposed intervention.
to the resources and injury epidemiology at each facility. Even Globally, local trauma care clinicians have important
smaller facilities can play an important role in injury prevention. perspectives that are essential to relevant and effective
For example, if a number of pedestrian injuries are noted to injury prevention.
present to a smaller facility, careful understanding of the injury
context may reveal that they are happening in the same location SPECIFIC INJURY RISK FACTORS/
or intersection. This intersection may be amenable to a simple, PREVENTION STRATEGIES BY MECHANISM
locally controlled injury prevention measure. Road traffic injuries
are particularly amenable to environmental injury prevention  Table 18-1 depicts certain risk factors that can propagate
interventions such as scramble crosswalks, improved traffic injury mechanisms, and possible prevention strategies. As part of
light timing to protect vulnerable road users, or interventions to the initial assessment of a trauma patient, clinicians should also
separate traffic mix. Vision Zero is an example of a locally driven consider which of these risk factors may have contributed to the
movement that has gained international scope ( Box 18-1). traumatic event, as well as some of the accompanying potential
Injury prevention principles are applicable in diverse settings, prevention strategies.
even in austere environments. Low-income countries have
approximately 1% of the world’s road vehicles but suffer 13% of SPECIAL POPULATIONS CONSIDERATIONS
the deaths due to road traffic injuries; road traffic injury is the
leading cause of death in people ages 1–29 globally. Many low- Trauma is particularly impactful on certain populations. These
and middle-income countries have successfully implemented populations may also be disproportionately impacted by social
injury prevention strategies despite limited resources. For determinants of health such as poverty, structural racism, poor
example, Bogota, Colombia, reduced road traffic mortality from access to education, and poor health outcomes in other realms.
1996 to 2006 by 50% through a multipronged strategy including Social determinants/drivers of health not only put individuals at
improvement of infrastructure (engineering/environment), risk for injury but also increase the likelihood of poor outcomes
institution and enforcement of regulations such as seat-belt use after injury. In planning injury-prevention interventions, trauma
and drunk driving penalties, and strong leadership that provided clinicians should consider which populations are most at risk for
effective communication to the population (education). Principles injury and poor outcomes after injury among the community they
exemplified by the Bogota experience—effective regulation, serve.
enforcement, road condition modifications (environment/ In some settings in the US, falls in older adults, pediatric
engineering), and population-level education—are applicable injuries, vehicle-pedestrian conflicts, or motorcycle collisions
and implementable in a variety of contexts. Examples from are overrepresented. In other settings, young Black men appear
low- and middle-income countries underscore the power of disproportionately affected by violence; interventions that carefully
injury prevention in any context to significantly reduce injury consider what might be most effective in a given population may
morbidity and mortality. Trauma clinicians in any setting can prevent repeat injury and improve quality of life. Successful
make meaningful contributions to these efforts. Clinicians are hospital-based intervention programs prioritize strong, long-
advised to review, identify, and evaluate risk and protective term, peer-mentored case management and close partnerships
factors to initiate optimal injury prevention strategies with community-based organizations, underscoring the key role
according to their institution’s capacity. first-line trauma care hospitals have in injury prevention.

261
  Table 18-1: Injury Mechanisms, Risk Factors, and Prevention Strategies. Understanding the risk factors that make injury
more likely with certain mechanisms makes it easier to apply prevention approaches and concepts like the 3Es.

MECHANISM RISK FACTORS PREVENTION STRATEGIES

Elderly Falls • Frailty • Syncope work-up

• Environmental factors • Falls assessment
• Home safety check
• Medication reconciliation

Interpersonal Violence • Poverty • Hospital-based violence Intervention

• Other social determinants of programs
health • Screening/Education
• Housing/Relocation
• Employment

Self-Injury • History of depression • Primary care provider (PCP) screening

• Ready access to firearms • Public awareness
• Alcohol or intoxicants • Advocacy for increased mental health access

Falls from Heights • Lax safety measures • Safety legislation

(Construction) • Alcohol or intoxicants • Safety checklist, e.g., equipment inspection,
double guard rails, harnesses

Motorcycle Injury • Lack of helmet laws • Safety legislation

• Alcohol or intoxicants • Protective gear

Automobile-Pedestrian • Alcohol or intoxicants • Public awareness

Conflict • Poor street design • Night-time bright clothing
• Age • After-dark reflectors

Unintentional Firearm • Firearm access • Firearm safety education

Injury • Gun locks
• Education

Intimate Partner • Prior exposure to intimate partner • Education

Violence (IPV) violence • Screening at all levels of care
• Socioeconomic factors • Safety legislation
• Unhealthy coping mechanisms and
relationship interactions

Hospital-based violence intervention programs are an example INJURY PREVENTION SCREENING TOOLS
of how hospital-based interventions can have a direct impact
on reducing injury in the surrounding community and have Trauma clinicians are key members of the injury prevention
demonstrated important reduction in reinjury, improved social community, with ready access to those most at risk. Individual
and health outcomes, and cost-effectiveness. Understanding clinicians can consider the populations and injury mechanisms
important social and structural aspects of injury prevention can most commonly encountered at their institution and implement
also improve the direct delivery of clinical trauma care through relevant screening tools. At the institutional level, routine
aforementioned practices such as trauma-informed care (see screening may be integrated into standard trauma care for
Chapter 19, Trauma-Informed Care and Social Determinants of conditions frequently affecting the trauma population seen at that
Health). facility.

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 COURSE MANUAL | Chapter 18 |Injury Prevention

When initiating a screening process, it is important to ensure

 Figure 18-3: HARK Questions. All patients should be
that resources are available to make the appropriate referrals if
screened for IPV regardless of gender, global geographic
risk factors or evidence of harm are identified. If these resources location, income, education, race, ethnicity, age, or
are not available at the facility performing the initial screening, the professional role. IPV is not specific to relationships with
results should be communicated to the definitive care facility. If sexual intimacy. It can occur in heterosexual and same-sex
the initial treating facility regularly sends patients to the definitive relationships.
care facility, a robust, collaborative screening/referral process
should be established between the institutions. HARK QUESTIONS
Screening tools exist to address a variety of disease processes
and health concerns. Some that are related to injury include but
are not limited to the following. H HUMILIATION
Within the last year, have you been humiliated or
MENTAL HEALTH emotionally abused in othe ways by your partner
or your ex-partner?
One of the primary contributors to postinjury quality of life
is post-traumatic psychological distress. Although post-traumatic
sequelae are not limited to these two disorders, depression in A AFRAID
trauma survivors is reported to vary from 30%–40%, while post- Within the last year, have you been afraid of
traumatic stress disorder rates are 20%–30%, hence the new your partner or ex-partner?
requirement in the Resources for Optimal Care of the Injured
Patient (2022 Standards) for screening at-risk trauma patients. See
Chapter 19, Trauma Informed Care and Social Determinants of R RAPE
Health, for further detail. Within the last year, have you been raped or
forced to have any kind of sexual activity by
INTIMATE PARTNER VIOLENCE your partner or ex-partner?
IPV is defined as physical or sexual violence, stalking,
reproductive coercion, or psychological aggression by a current K KICK
or former intimate partner of the victim. It is critical to realize Within the last year, have you been kicked, hit,
that anyone can be a victim, regardless of global geographic slapped, or otherwise physically hurt by your
location, income, education, race, ethnicity, age, or professional partner or ex-partner?
role. IPV is not specific to relationships with sexual intimacy. It
can occur in both men and women, in heterosexual and same-sex One point is given for every "yes" answer.
relationships. It is estimated that 1 in 4 women and nearly 1 in Anyone that scores ≥1 is positive on the HARK screening
tool.
10 men will experience IPV during their lifetime, far exceeding
other common diseases such as breast cancer and heart disease
( Figure 18-3).

CHILD ABUSE AND NEGLECT

Like IPV, child maltreatment is a global phenomenon. In the
US, neglect is the leading cause of mortality due to child abuse
or maltreatment. It has long-term consequences for children and
confers a substantial economic burden. Strategies to intervene
and prevent ongoing maltreatment rely on early identification of
children at risk ( Figure 18-4).

OLDER ADULT (ELDER) ABUSE AND NEGLECT

Data show that abuse affects 1 in 6 older adults worldwide,
amounting to approximately 141 million people. Demographic
projections indicate that the proportions of elderly will continue
to grow such that 25% of the world’s population will be aged 60
or above by 2050. There are six different forms of elder abuse:
physical, psychological, sexual, financial, neglect, and violation
of personal rights ( Figure 18-5).

263
  Figure 18-4: Child Abuse Screening Tool. Many localities require reporting of suspected child abuse and neglect. A
standardized tool to assess for abuse/neglect allows for more accurate screening and lessens the chance of missed injury.
Note that it is important to use such a tool as part of a protocol that includes appropriate resources for referral.

CHILD ABUSE SCREENING TOOL

Disclaimer: “A positive child abuse screen will initiate an electronic physician notification and does not
necessarily mean that sufficient suspicion exists to warrant mandated child abuse reporting.”

Are there potential safety concerns for the child related to any of the following?

1. W
 as there a possible delay in seeking medical attention given the Yes No
severity of illness or injury?

2. A
 re you concerned that the history may not be consistent with the injury or illness? Yes No

3. Are any of the following findings present on physical examination? Yes No

a. A
 ny bruise, scalp, or extremity swelling in a nonmobile child.
(If you can’t cruise, you can’t bruise)
b. A
 ny burn, facial, or mouth injury in a nonmobile child
(includes: subconjunctival hemorrhage, frenulum or palate injuries)
c. M
 ultiple bruises or any bruising in a location other than the forehead,
pretribal regions, or over bony prominences
(e.g., cheeks, ears, neck, torso, genitalia, upper arms, hands)
d. B
 urn or bruise in the shape of an object

4. Are there findings that might reflect poor supervision, care, nourishment, or hygiene? Yes No

5. Are there any additional comments or concerns? Yes No

*ALL CHILDREN < 4 years of age must be undressed completely.

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 COURSE MANUAL | Chapter 18 |Injury Prevention

 Figure 18-5: Elder Mistreatment Screening and Response Tool. Utilizing a vetted tool
assists the clinician with identifying potential abuse or neglect in the older trauma patient.
If screening is undertaken, it is important that referral resources are also available.

Ask the patient:

Has anyone close to you harmed you? Yes No
Has anyone close to you failed to give you the care that you need? Yes No
Has anyone tried to force you to sign papers or use your money against your will? Yes No

Look for red flags;

If available, the patient’s medical history includes:
Repeated visits to the ED Yes No
Frequent or unexplained injuries Yes No
History or signs of cognitive impairment Yes No
Delayed attention to or unmet health needs Yes No

The patient appears to:

Have physical signs of mistreatment (e.g., suspicious wounds, Yes No

concerning personal hygiene, malnutrion, or dehydration)
Have unmet mental health needs or problems with substance use Yes No
Lack access to need resources Yes No
Feel uncomfortable with their caregiver(s) Yes No

If present, the caregiver appears:

Unengaged, inattentive, or to lack knowledge of the patient’s medical needs Yes No

Dismissive of, frustrated with, or hostile toward the patient Yes No
Overly concerned or anxious about the patient Yes No
To have unmet mental health needs or problems with substance use Yes No
To lack access to needed resources Yes No

Record additional notes and recommendations:

I recommend the EM-Full Screen.
I recommend ED care as usual.

Notes: 

265
 CHAPTER SUMMARY 7. Haddon W Jr. The changing approach to the epidemiology,
prevention, and amelioration of trauma: The transition to
Injuries are mostly preventable events. Practical frameworks approaches etiologically rather than descriptively based.
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clinicians in gathering injury context information, providing a ajph.58.8.1431. PMID: 5691377; PMCID: PMC1228774.
careful handoff during patient transfer, and identifying locally 8. Haddon W Jr. Advances in the epidemiology of injuries as a
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• Remember that trauma/injury is NO accident! RA. Saving lives and saving money: Hospital-based
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 COURSE MANUAL | Chapter 19 | Trauma-Informed Care and Social Determinants of Health

19

Trauma-Informed Care and

Social Determinants of Health

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Characterize social determinants of health 5. Identify aspects of a trauma-informed healthcare

(SDOH) and trauma-informed care (TIC) system
2. Discuss models of care that can address SDOH 6. Demonstrate trauma-informed communication
3. Discuss prior trauma and traumatic stress in 7. Identify special populations of patients that
patients and colleagues have considerations and strategies for TIC specific
to them
4. Describe potential benefit of TIC to the clinician

269
 to my follow-up appointment. I have had enough trauma in my

19
life. I don’t need to come to the hospital to have people cut off my
clothes and do things to me without permission.”
The supervising physician responds, “I’m really sorry that
happened. You’re my responsibility right now. Give us one more
chance to do right by you. I will tell you everything that’s going
on, and you let me know if you have questions or concerns. If you
need to be admitted to the hospital, we will make sure everything
is set up for you before you leave. Right now, let’s get you some
pain medicine and check if you have any serious injury from being
Trauma-Informed Care and shot. Is that OK?”
Social Determinants of Health The patient agrees. “Alright, one more chance, doc.” The
primary and secondary survey resume with his full cooperation
without the need for physical or chemical restraints.
CHAPTER STATEMENT
INTRODUCTION
Trauma-informed care (also called humanistic care) recognizes
that patients may present having experienced past trauma in The brief intervention described in this Case Scenario section
their lives (be it physical, emotional, psychological, spiritual, or illustrates trauma-informed care (TIC) and the psychological
social). The trauma-informed care (TIC) principles are used to impact it can have on patients and clinicians. This scenario
inform interactions between individuals, with the knowledge and demonstrates an approach that fosters a trusting relationship
understanding that individuals have had past life and generational between patient and clinician. In addition, clinicians should
experiences of trauma, and promotes environments of healing and address barriers patients may have to participating in their own
recovery rather than practices and services that may inadvertently care, as well as risk factors for injury. The social determinants of
retraumatize. TIC also recognizes that clinicians can experience health (SDOH; also referred to as the social drivers of health) are
secondary and vicarious trauma from witnessing suffering. contributory. This chapter will highlight the importance of treating
Trauma-informed practices include education and protocols patients with an understanding of how their lived experience may
that improve individual and organizational culture to enhance impact their presentation to the trauma bay and how clinicians
the well-being of all involved in the healthcare interaction. can approach patients in a humanistic manner while not missing
Social Determinants (also called Social Drivers) of Health have a beat in injury care.
a major impact on health, quality of life, and ability to thrive. The
complete care of injured patients and their families incorporates THE SOCIAL DETERMINANTS OF HEALTH
a trauma-informed approach and understanding of the Social
(SDOH)
Determinants/Drivers of Health.
The SDOH are primarily grouped into five domains:
CASE SCENARIO • Built environment
• Economic stability
Prehospital report of a trauma activation:
• Mechanism: 25-year-old man shot in left lower extremity • Education (access and quality)
• Injuries: Two gunshot wounds in left thigh • Healthcare (access and quality)
• Signs: Vital signs within normal limits • Social and community context
• Treatment: Pressure dressing applied Individually, each domain affects a wide range of health
outcomes. Collectively, a synergistic effect is seen across
Upon arrival to the emergency department and initiation of
domains. In other words, multiple adverse SDOH can result
the primary survey, the patient is sitting up saying, “What are you
in exponentially worse health. With a public health lens,
doing? What is going on?”
addressing the social determinants that increase risks and
A physician responds loudly with, “Calm down and lay down,
morbidity of traumatic injury offers the most effective potential
we need to examine you.” The patient appears to be more agitated
solutions for harm reduction.
and begins to rip off the telemetry leads being placed. Seeing him
Recently, there has been increasing awareness and promulgation
resisting, the charge nurse announces that they are going to get
of efforts to identify and treat individuals at risk for physical and
the soft restraints.
mental health problems related to SDOH. The National Academy
The supervising physician walks in, introduces themself to the
of Medicine released Integrating Social Care into the Delivery of
patient, and asks for the patient’s name. They then proceed to tell
Health Care: Moving Upstream to Improve the Nation’s Health in
the patient what is happening around him and why these actions
2019, which recommended the “5 As”: Awareness, Adjustment,
are important to take care of him.
Assistance, Alignment, and Advocacy. This resulted in the
The patient relaxes and says, “Well, I was here a year ago and
adoption of social risk screening in primary care and inpatient
nobody listened to me. I got discharged too early and couldn’t get

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 COURSE MANUAL | Chapter 19 | Trauma-Informed Care and Social Determinants of Health

care settings. Screening for adverse childhood experiences (e.g., and loved ones may present with preexisting heightened
exposure to trauma, abuse, or household dysfunction) and responses to traumatic events.
protective childhood experiences (e.g., social support and health The ideal trauma system would have the appropriate
promotion) offers insight into past and present trauma, as well as resources to screen and treat mental health concerns that are
social factors that are protective of a healthy lifestyle. Other social more commonly seen in our patient population. This section will
screens address food insecurity, poverty, housing stability, racism, address common screening and diagnostic tools trauma clinicians
discrimination, and more. Barriers to widespread adoption of may use to identify those at risk of experiencing post-traumatic
social risk screening include lack of resources to address issues stress responses and some common nuances one might encounter.
revealed by the screening. Note: Understanding that many trauma clinicians are
Born out of need to provide organizations and surgeons with constrained in terms of time, ancillary personnel, and outpatient
the tools to identify and address the root causes of trauma, the support, the tools discussed here were selected for ease of
American College of Surgeons Committee on Trauma formed the implementation. Each individual clinician must exercise clinical
Improving Social Determinants to Attenuate Violence (ISAVE) judgement on when and how to screen patients for psychological
workgroup. ISAVE is a multidisciplinary group of medical, public injuries based on one’s own resources. It may not be in the best
health, law enforcement, and community experts that endorses interest of patients to screen for injuries for which no treatment
TIC, integration of social care (including risk screening), resources are available. While these tools have been validated, note
investing in at-risk communities, and advocacy. There remain that these assessments care are limited by the accuracy of patient
vast opportunities for trauma centers and medical professionals responses. Thus, building rapport with patients and families is
to expand care beyond physical injury and to incorporate social, paramount.
emotional, and psychological well-being into healing. The Primary Care Post-Traumatic Stress Disorder for DSM-
5 (PC-PTSD-5) screening tool ( Box 19-1) is simple, rapid,
and commonly used as an initial screen for those who may
THE NATURE OF TRAUMATIC STRESS need further evaluation. It addresses the most commonly seen
Our SDOH and prior lived experiences mold our natural symptoms of a severe stress response. It is a five-question survey
response to stress. Where one person may respond to stress by where the respondent can answer yes or no, with the likelihood of
shutting down, another may respond by lashing out. Those who having significant PTSD increasing with the number of questions
care for trauma patients and interact with their families cannot answered in the affirmative.
presume that others will react to a situation in the way one might
themselves. In order to implement a trauma-informed approach
to patient care, trauma clinicians must recognize that patients

 Box 19-1: The Primary Care Post-Traumatic Stress Disorder for DSM-5 Screening Tool. The Injured Trauma
Survivor Screen (ITSS) is a validated tool that may be used to identify those at risk for post-traumatic psychological
stress so that appropriate referrals and support may be offered.

Primary Care Post-Traumatic Stress Disorder 5 (PC-PTSD-5) Screen Tool

In the past month, have you...

1. Had nightmares about the event(s) or thought

about the event(s) when you did not want to? No Yes

2. Tried hard not to think about the event(s) or went out of your
way to avoid situations that reminded you of the event(s)? No Yes

3. Been constantly on guard, watchful, or easily startled? No Yes

4. Felt numb or detached from people, activities, or your surroundings? No Yes

5. Felt guilty or unable to stop blaming yourself or others for

the event(s) or any problems the event(s) may have caused? No Yes

271
 Trauma psychologists at the University of Wisconsin have These tools and others like them are useful in identifying
developed and validated a similar but more intensive screening those most at risk for significant psychological trauma; however,
tool to evaluate the risk of both PTSD and depression in the definitive diagnosis as prescribed by the Diagnostic and Statistical
injured patient called the Injured Trauma Survivor Screen (ITSS). Manual of Mental Disorders, Fifth Edition (DSM-5) is beyond
This addresses a broader spectrum of psychological response to the scope of this text and should be performed by a credentialed
injury and can be used during an initial hospital encounter after a clinical psychologist, psychiatrist, or other qualified mental health
trauma ( Box 19-2). professional.

 Box 19-2: Injured Trauma Survivor Screen. The ITSS is a validated tool that may be used to identify those at risk for
post-traumatic psychological stress so that appropriate referrals and support may be offered.

Yes = 1
INJURED TRAUMA SURVIVOR SCREEN (ITSS) No = 0

Before this injury PTSD DEP Total

1. H
 ave you ever taken medication for, or been given Yes
a mental health diagnosis? N/A
No ________

2. H
 as there ever been a time in your life you have been bothered by feeling
down or hopeless or lost all interest in things you usually enjoyed for more N/A
Yes
than 2 weeks? No ________

When you were injured or right afterward

Yes Yes
3. D
 id you think you were going to die?
No No ________

Yes
4. D
 o you think this was done to you intentionally? N/A
No ________

Since your injury

Yes
5. H
 ave you felt emotionally detached from your loved ones? N/A
No ________

Yes
6. D
 o you find yourself crying and are unsure why? N/A
No ________

Yes N/A
7. H
 ave you felt more restless, tense, or jumpy than usual?
No ________

Yes N/A
8. H
 ave you found yourself unable to stop worrying?
No ________

9. D
 o you find yourself thinking that the world is unsafe Yes
N/A
and that people are not to be trusted? No ________

≥2 is positive for PTSD risk

≥2 is positive for depression risk SUM = ________

272 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 19 | Trauma-Informed Care and Social Determinants of Health

TRAUMA-INFORMED CARE APPROACH TRAUMA-INFORMED COMMUNICATION

TIC is a theoretical framework that recognizes that patients Trauma-informed communication begins with an
and clinicians bring prior experiences to any encounter and to understanding that all people have experienced trauma in their
the system as a whole. In some parts of the world, TIC may also lives. Our communication with our patients and team therefore
be referred to as “humanistic care.” reflects this understanding as it fosters a safe and welcoming
As a service delivery model, TIC is founded on knowing environment, increases engagement, and improves collaboration.
that the best quality care is delivered when clinicians and Fundamentals of trauma-informed communication are described
healthcare systems holistically understand patients’ SDOH and in  Table 19-1.
preexisting psychological injuries. The components of TIC are Establishing rapport with a patient during the initial trauma
encompassed by the four Rs: resuscitation phase sets a tone for the rest of the hospitalization.
• Realizing the widespread impact of trauma Nonverbal communication and body language are just as important
• Recognizing the signs and symptoms of trauma as verbal communication. Each individual team member has the
potential to impact individual patient experience. Individuals
• Creating a system that can Respond to trauma brought into the hospital after an injury are at times met with
• Avoiding Retraumatization negative stigma from staff, particularly victims of violence. Staff
should refrain from any preconceived judgements and sarcastic
The successful creation of a system that is trauma informed
comments. The trauma team should strive to create a safe healing
involves integration of these components into both clinical care
environment, which benefits both the patient and team.
and the system of care itself. There are six key principles of the
The atmosphere surrounding a trauma evaluation can be
trauma-informed approach, as described by the Substance Abuse
chaotic. Being able to recognize bias and prior trauma while
and Mental Health Services Administration’s guiding principles of
omitting negativity from our communication can help establish
trauma-informed care:
trust. When a patient is hemodynamically unstable, minimal
• Safety
communication may occur with them. If the patient is stable,
• Trustworthiness and transparency however, provide a brief introduction, explain why they are in the
• Peer support hospital, and give them an expectation of what will come. Attempt
to provide nonjudgmental, empathetic, and genuine interactions.
• Collaboration and mutuality Ask the patient open-ended questions such as, “Do you remember
• Empowerment, voice, and choice what happened to you?” Let the patient know what is coming
• Cultural, historical, and gender issues next in the evolution of the care they are receiving. If and when
you have time, ask your patient questions; this not only conveys
Using these principles to provide TIC is of benefit to patients, respect but may improve their comfort and sense of control.
families, and healthcare workers. For the person perceived as being uncooperative, attempt to
Experiencing a traumatic event, being brought to a trauma bay redirect them. Ask them about how to make the situation better
filled with strangers and fully exposed, can understandably lead for them. For agitated individuals, try asking them, “What can I
to loss of sense of control, predictability, and perceived safety. TIC help you with?” instead of escalating a situation by using phrases
includes reassurance through open, direct communication and such as, “Stop,” “You can’t do that,” or “If you continue, you will
reduction of overstimulation. This may be achieved by having a be restrained.” A patient who is resisting can be approached by
point person for communication during the primary, secondary, saying, “I understand that this may be difficult for you; however,
and tertiary Surveys, by giving the patient access to their phone, I have to perform a physical exam and that means I have to touch
or helping them sit up (if safe) so they can look out and see what you. This is to find out if you have any serious injuries and how
is happening around them and to them. we can help you.”
Further, TIC does not end at discharge. Barriers to follow- For patients who are unresponsive verbally but awake and
up care need to be addressed by creating a plan with the patient alert, try saying, “I respect your right not to answer me. I will
for achievable goals. The family of a patient will also benefit continue my exam and explain everything I’m doing as we go
from TIC through respectful interactions, as well as thoughtful along.” Patients who use threatening or abusive language may be
physical layout of waiting rooms and accommodations for staying approached by clearly stating, “You just stated ___. That language
overnight with their loved one. TIC is as simple but deliberate as is not accepted here.” Trauma-informed communication includes
a clean and safe place for family to sit with access to tissues, water, protecting healthcare workers from behavior that violates hospital
and bathrooms. policy.
A truly trauma-informed system executes intentional training
and has plans for space allocation written into hospital policy. It is
exemplified by a society based on justice, equal opportunity, and
love for one another; with TIC, clinicians treat patients and loved
ones with empathy and respect.

273
  Table 19-1: Fundamentals of Trauma-Informed Communication. Trauma-informed language and
communication can help build trust and rapport with patients and may assist in deescalating tense situations.

Trauma-Informed Communication

EXAMPLES:
DO • Communicate respectfully in a normal relaxed voice  
• Try to invoke a sense of calm • “I’m Dr. X, the trauma surgeon taking
• Engage with eye contact care of you, and you are in the
Emergency Department because you
• Positive body language  
were involved in a motor vehicle crash.
• Actively listen   There is a lot going on, but we’re all
• Ask open-ended questions here to help you. Focus on my voice,
and I’ll walk you through what we’re
• Express kindness, patience, and acceptance doing and why.”

• “What do you prefer to be called?”

• “Is there someone you want called to

let them know you’re here?”

EXAMPLES:
DON’T • Shout  
• Interrupt   • “Stop fighting. Just calm down. We have
• Show or imply judgement to do this.”
• Make assumptions • “We will restrain you.”
• Use sarcasm
• “I bet they were just minding their own
business.”

• “I’m sure they deserved it.”

HEALTHCARE CLINICIANS AND THE Ultimately, it can impact one’s feelings, emotions, worldview, self-
RESPONSE TO TRAUMA esteem, and sense of safety.
TIC and access to resources for those impacted by
Secondary trauma and vicarious trauma, while not new terms, secondary and vicarious trauma are crucial. There are several
have more recently shaped how we care for healthcare workers and ways in which to mitigate the impact of trauma experienced
specifically those staff who are exposed to traumatic experiences. by medical professionals. Identification of how the workload
Both types of trauma stem from caring for and witnessing the (long hours, high volume, etc.) and the social support from the
suffering of others. Secondary trauma is often characterized by work environment contribute to well-being is key. TIC includes
the immediate symptoms of this exposure, including physical assessing how one’s own coworkers and environment can be
and mental adverse reactions. The distinct symptoms that arise elevated to be protective factors.
(such as intrusive thoughts, avoidance of similar circumstances, The patient is not the only one to benefit from a trauma-
or negative mood) can cause so much distress that the DSM-5 has informed approach. Healthcare workers in trauma-informed
included them within a potential diagnosis of post-traumatic stress. healthcare systems report feelings of improved work satisfaction
Thus, secondary traumatic stress is considered a professional risk and reduction in burnout. Secondary trauma, moral injury,
factor for healthcare workers. Vicarious trauma is often described and burnout have heavily impacted the healthcare workforce.
as an overall change in worldview, usually resulting from chronic Connecting with our trauma care colleagues and our patients has
and repeated exposure to the suffering of patients and others. demonstrated a reduction in these serious issues. Adopting TIC
Medical professionals who regularly provide care to trauma is not just about being a good clinician; it is realizing the broader
victims are often the first contact with these individuals, by design. sense of trauma and responding in a way that provides the tools
The sheer act of witnessing the suffering or death of patients to treat patients more comprehensively. The benefits are broadly
or having the necessary difficult conversations with patients experienced, and the positive culture change to systems of care
and their families can cause stress. For those who specialize can be profound.
in trauma care, this repeated stress can lead to significant
psychological injury. In short, those who help trauma victims
have the propensity to become victims of trauma themselves.

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 COURSE MANUAL | Chapter 19 | Trauma-Informed Care and Social Determinants of Health

 Table 19-2: Trauma-Informed Care in Special Populations. Some populations may experience distinctive challenges
during healthcare interactions. Understanding these challenges assists in providing humanistic, trauma-informed care.

Direct Care and

Special Considerations Communication Strategies System Strategies

Patients • May experience heightened fear, • Introduction of team members, • Develop and disseminate protocols
loss of perceived safety and control. roles, and what is being done outlining the role of law enforcement
who have to the patient during their in the healthcare setting that
experienced • Can experience victim-blaming and
evaluation can help improve promote community and patient
biased treatment, which leads to
violence distrust of healthcare system.
sense of safety, trust, and safety safety, family reunification, patient
for victims of violence. rights, privacy, and trust.
• Presence of law enforcement can
• Empathetic, nonjudgmental • Implement evidence-based hospital
contribute to discomfort, distrust,
statements: “I’m sorry this violence intervention programs
and lack of privacy when not
happened to you. We are here (HVIPs) or hospital-linked programs
approved by the patient.
to care for you.” to provide comprehensive supportive
• Increased incidences of adverse services to address unmet needs,
• Keep sensitive areas of the body
Social Determinants of Health risks, and recovery.
covered as able, especially victims
(SDOH), substance abuse, and
of intimate partner violence (IPV) • Standardize IPV screening, develop
mental illness before and after
and sexual assault. specialized social work and forensic
injury.
nursing services for IPV, elder abuse,
• Inquire about the assault
• Barriers to follow-up care and child abuse, and sexual assault.
circumstances and screen for
supportive services are more
abuse in private; use normalizing • Identify and link patients to
common than other traumatic
language: “We want to keep you community- or state-based resources
mechanisms.
safe and help support you. Can dedicated to victims of violence (e.g.,
• Risk of repeat injuries due to you tell me more about what shelters, crime victims compensation
violence are higher in patients who happened? Do you have a safe programs).
have experienced violence. place to go to when you
leave here?”

Patients with • Patients may not speak the primary • Directly inquire about patients’ • Language interpreters available
language used in the hospital. preferred language preference.   in hospital including the trauma
Non-English bay improves communication,
• May understand and speak some • Utilize a certified medical
Preferred English, but may have difficulty utilization, clinical outcomes, and
interpreter for communication
Language   discussing medical information in a during trauma evaluation
patient satisfaction. In person is best,
noisy, stressful environment. followed by video and phone.  
and care.
• Are not routinely asked preferred • Programs to certify staff in
• Avoid using family members and
language. interpreter services.
acquaintances for translation.  
• Are less likely to have • Provide training on effective use of
comprehensive motor and sensory • Standardize care protocols both
interpreter services.
examinations, explanation of next in-hospital and at discharge
steps, or reassurance. so that trauma guidelines are • Standardize discharge instructions
followed for every patient and protocols avoid bias. Translate
• Pain is more often undertreated
including non-English speakers. instructions into the most common
during hospital care and at
languages spoken at the institution.
discharge.
• Ineffective communication can cause
lack of understanding of injuries,
care, and discharge instructions.

SPECIAL POPULATIONS: CONSIDERATIONS BECOMING A TRAUMA-INFORMED

FOR TRAUMA-INFORMED CARE ORGANIZATION
While the fundamental approach to TIC is ubiquitous, When an entire healthcare organization or trauma center
there are a few populations often encountered during trauma is trauma-informed, the policies, practices, and culture of all
care, that should be highlighted.  Table 19-2 describes special individuals implement the principles of TIC in routine practice.
considerations and strategies for patient care, communication, Typically, there are several steps to achieve this, starting with
and systematic design for patients who have experienced violence, integration into curricula such as ATLS and finding individuals
and those for whom English is not their preferred language. within the system to “champion” the change. Stakeholder buy-in
is essential and includes leadership, clinicians, security, support
staff, and the community the healthcare system serves. Quality
improvement programs within the hospital should include a lens
on TIC. This may seem like a heavy lift, but the principles are

275
 steeped in equity care, and weaving the culture into everyday
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 COURSE MANUAL | Chapter 20 | Communicating Serious News in the Acute Trauma Setting

20

Communicating Serious News

in the Acute Trauma Setting

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explain how a focused patient update and goal-setting conversation can be initiated and conducted in the
acute trauma setting
2. Describe the importance of collaborative decision-making and patient autonomy in the acute trauma setting
3. Discuss the need for culturally appropriate communication as well as factors that affect communicating serious
news in certain special populations and situations

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 DECISION-MAKING: RELEVANCE TO INITIAL

20 PATIENT MANAGEMENT
Before embarking on communication of serious news, it
is helpful to have some idea of a patient’s existing wishes. A
hallmark of patient-/family-centered care is that decision-making
should be shared and collaborative, with the patient’s wishes
taking precedence whenever possible. The presence of advance
directives/portable orders of life-sustaining treatment/medical
Communicating Serious News orders of life-sustaining treatment, where relevant to practice, may
help clinicians understand a patient’s wishes about life-sustaining
in the Acute Trauma Setting therapy and other healthcare options. Quickly reviewing these
documents, if they exist, will assist clinicians in rendering patient-
centered, goal-concordant care, even in the acute postinjury
CHAPTER STATEMENT setting. It is important to note that these documents may not be
routinely available in all settings.
Clinicians in the acute trauma setting must be prepared It is also important for clinicians to identify decision-makers/
to communicate serious, life-altering news to patients and proxies/surrogates who can act on the patient’s behalf if they are
families. Just as having an organized, systematic approach to the not able to communicate an understanding of their illness/injuries,
medical management of a critically injured patient is crucial, acknowledge in their own words the risk and benefits of pursuing
communicating serious news to a patient or family should consist or declining the proposed treatments, and use this information
of preparation and a well-formulated process. A patient’s pre- logically. Surrogate decision-makers may be identified in a living
existing wishes must be considered. Communication must also be will or advance directive. These documents may not be available
culturally sensitive and take into account traditions and practices. in a situation of acute traumatic injury; nonetheless, clinicians
should inquire about their existence.
INTRODUCTION If it is determined that the patient does not have the ability to
make decisions on their own and has not previously designated
Providers of acute care to those with traumatic injuries are a healthcare proxy, the legal next of kin is called upon to assist
generally focused on the reversal of physiologic derangement with medical decisions. Additionally, there will be times when a
and restoration of preinjury functional status. Some injuries are patient does have capacity to participate in medical discussions
incompatible with the achievement of these goals. Further, patient- but does not wish to participate in medical decisions. In this
centered care is the foundation of modern clinical practice, and circumstance, it is within their rights to designate another
medical dogma has shifted from paternalistic to collaborative, party to do so.
requiring that medical clinicians develop new communication
skills and tools.
Training on how to talk about debilitating and/or disabling
COMMUNICATING SERIOUS NEWS
injuries and death is essential for trauma care. In this chapter, we Consistent with ATLS® principles, all patients should be
outline the importance of, and approach to, having these serious reassessed after initial stabilization and management and prior
conversations in an acute postinjury setting. This chapter is framed to transfer. If the patient will not be transferred, they should be
from the point of view of a discussion with a patient’s family/loved reassessed again within 24 hours of hospital admission. These
ones/surrogate decision-makers, for which the word “family” will clinical reevaluation points provide convenient opportunities
be used. This approach is done for consistency, though clearly the for family updates; families should also be updated whenever
same principles apply for discussion with patients directly. there is a significant change in clinical status.
Cultural humility and awareness must be incorporated when There are multiple ways to approach serious news
using the information in this chapter. Patients and families conversations. Several published blueprints for sharing bad
must have a voice in how they receive information, who within news exist in the palliative care literature, including the Setting,
the family will receive information, and how procedures (such Perception, Invitation, Knowledge, Empathy, Summarize
as postmortem care) and other processes are implemented. (SPIKES) Protocol; the Reframe, Expect emotion, Map out
Forthrightness, empathy, active listening, and transparency are patient goals, Align with goals, Propose a plan (REMAP) goals-
the pillars of this type of communication, but clinicians must be of-care conversation; and an Activating event or situation, Beliefs,
prepared to adapt their approach based on patient, family, and Consequences, Disputation of the beliefs, Effective new approach
culture-specific characteristics. (ABCDE) model. Regardless of the specific model chosen, there
are four key concepts that apply in this process ( Figure 20-1).

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 COURSE MANUAL | Chapter 20 | Communicating Serious News in the Acute Trauma Setting

 Figure 20-1: Four Key Concepts: When Communicating Serious News. When speaking to patients or families
about serious news, it is important to be prepared: have a clear message, make sure the environment is suitable,
and make sure all the appropriate team members are present. During the meeting, do as much listening as
talking. Afterward, debrief with the team.

Think about a “warning.” Determine which team Ask what the family has Ensure all team members
(I have serious news to members will be present. been told. know the details of the
share with you.) WIll an interpreter meeting and plans
Begin with the warning. for next steps.
Follow with a “Headline” be needed?
statement. What are the Concise summary. Try to arrange for
Be aware of
most serious injuries your appearance.  o allow for silence.
D opportunities for team
and what is their Don’t speak too much. members to explore and
Select a comfortable,
expected impact? Listen! manage their own emotions.
private setting.
Make sure there is enough Encourage and validate
space so that all can sit and Emotions. Elicit questions.
be at “eye level.” End Encounter with a
plan for next steps.

KEY CONCEPT #1: ORGANIZING YOUR injury is often performed when the clinician has had little to no
time to build a relationship with the patient or family, and it often
THOUGHTS
occurs in a chaotic and time-constrained clinical setting. Taking
Trauma cases are often complex, with multiple injuries affecting even a few moments to make sure that thoughts are organized
the patient’s status and prognosis. Just as the primary survey beforehand and ensuring that the language used avoids jargon
requires identifying and prioritizing the most life-threatening and is easy for the family to understand will save time and
injuries, clinicians can use a similar approach to organizing how stress in the end. Improvisation in such cases is rarely effective.
they will communicate with a family. By determining which are
the most impactful injuries a patient has sustained and how KEY CONCEPT #2: PREPARING TO MEET
they impact the patient’s status and expected clinical course, a WITH THE FAMILY
“Headline” statement can be formulated.
“HEADLINE = FACT + MEANING” In addition to organizing your thoughts, consideration should
Consider a patient with multiple injuries including a high- be given to setting, appearance, what team members should be
level cervical spinal cord injury as an example: A clinician may involved, and making sure that everyone is clear what the goal will
determine that the most serious injury is the C-spine injury. The be for the discussion. A “What-Where-Who-How-Why” model
“Fact” involves the clinical detail of the injury (e.g., level). The could be used ( Figure 20-2).
“Meaning” involves the impact of this injury such as the need As much as possible, interruptions should be minimized, and
for intubation, the inability of the patient to walk and move their body language should not unintentionally give the impression
arms/legs, and the probable need for prolonged (and possibly of impatience; the family should feel that the discussion is as
repeated) hospitalizations, among others. While not all of these important to the healthcare team as it is to them. Consultants who
issues will necessarily be part of the “Headline” statement, it might can lend additional perspectives can also be helpful in clarifying
begin with: expectations, but the details of what will be conveyed to the family
“I’m afraid I have some serious news to discuss with you. Your should be agreed upon prior to the meeting to minimize confusion
daughter has had an injury to her spinal cord in the neck which is and surprises. Ideally, the conversation should take place in an
interfering with her breathing. We are going to have to put a tube in area large enough to allow all participants to sit and face each
her throat to help her breathe.” other at eye level. If interpreters are necessary, they should be
Other details about the impact and meaning of the injury professionally trained, as opposed to being other family members;
may be communicated as well, depending on the progress of the this ensures correct translation of any medical terminology and
conversation. The most important concept is that intentional removes stress from the family member who might act as the
preparation by the trauma clinician is required. Disclosure interpreter in less formal settings.
of news related to significant disability or death from traumatic

281
 C
 Figure 20-2: Preparing to Meet With a Family or Patient. Using a checklist, like that illustrated in this Figure, can help
=
the clinician prepare for the meeting.

Some clinicians may be concerned about the safety of their Concise summary
team as well as the family. The suddenness of the traumatic When delivering serious news, clinicians may be anxious and
event and hearing serious news may catch the family off guard or revert to communicating using a plethora of details and medical
unprepared. The information often generates intense emotional jargon. This style of communication can be overwhelming
reactions that may range from shock to anger. Having a strategy and incomprehensible to the patient/family such that the main
to exit should the physical space become unsafe is useful. For message gets lost in translation. This is why prior preparation
example, keeping the door to the room open and unblocked when of the “Headline” statement is so useful. Particularly when the
delivering news to a large group and sitting close to the door may news may be associated with poor prognosis, “headline” the most
help. Clinicians should work with their institutions to develop serious injury. Resist the tendency to catalog every injury in the
protocols to manage such situations. initial meeting; family will need time to digest information. Focus
on the “Fact” and especially the “Meaning” of the most serious
KEY CONCEPT #3: MEETING/ diagnosis and how this injury will impact the patient’s big-
COMMUNICATING WITH THE FAMILY picture condition. Do they have brain damage or paralysis? Will
they survive?
Tyrie et al describe an “ABCDE” communication algorithm Clinicians should try to avoid being overly optimistic or paint
that may be used during a family meeting at which serious news information more favorably than is realistic when communicating
is discussed: serious news and poor outcomes. Keep in mind that attempts to
A= Acquaint yourself with the family/Ask soften the message may result in inadvertent miscommunication,
A good way to begin the conversation after making introductions which can itself result in mistrust between patients/families and
is to ask an open-ended question, such as, “What have you been clinicians. The goal is to provide the truth, as far as it is known at
told about what has been going on?” Allowing the family to that time, about the nature of the patient’s injuries and anticipated
describe in their own words their understanding will provide a course, regardless of how hard it is to hear.
foundation for ongoing discussion. This is an opportunity for the When communicating news of death, recognize that there is
clinician to mainly listen. It may also be appropriate at this “Ask” no way to soften this news; maintaining clarity with use of the “D”
stage to ascertain if the patient has an existing advance directive word (died, dead) is extremely important. Communicate news of
or if they have communicated any wishes regarding life-sustaining the death first after a brief narrative (one sentence) that provides
therapy context that the family can understand, and then add other details.
Like any serious news, disclosures of death should be preceded
B = Begin with a warning
with a warning. A sample script may look something like, “I have
As mentioned above, starting the “Headline” statement with “I
very serious news to share with you. Your ____ was in a car crash
have serious news to share with you” alerts the family and sets the
with major injuries to his heart and brain. We tried everything we
stage for the conversation.
could; he died a few minutes ago….”
D = Do use silence/Do not speak
Once you have communicated the news, pause for 10–15
seconds; this allows the patient/family to process what was just
said and react. A common error in this setting is to begin speaking
too soon to fill the silence; patients/families need time to process.
Let them begin to speak to break the silence.

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 COURSE MANUAL | Chapter 20 | Communicating Serious News in the Acute Trauma Setting

important to address not only the cognitive but also the emotional
E = Encourage and validate emotions/Elicit and answer underpinnings of the questions.
questions/End Encounter When ending the encounter with the family, the clinician
Inevitably, sharing difficult news will provoke a wide range should make certain that the family is clear about the plans
of emotions. Patients and families may or may not be ready to going forward. It is helpful to summarize the conversation
communicate how they feel. Remember that providing space for and provide time for questions. It is important to note that the
emotion to be felt by lending silence communicates empathy. goal is not necessarily to have a complete understanding of all
If the patient/surrogate is too emotional to continue, it may be potential futures. In the initial phases of trauma care, there are
best to take a short break, allow space for family members to many unknowns. Perhaps the best example of this is the recovery
briefly discuss the news they have just received, and revisit the trajectory after traumatic brain injury, a clinical entity with a
conversation a short while later. Ensure that the family knows how varied and unpredictable course. If death is a likely outcome with
to reach the primary clinician or other member of the healthcare progression of a particular injury, this should be disclosed.
team so they do not feel deserted. Alternatively, prearrange a The name and contact information for the responsible
follow-up time for discussion. surrogate/family member should be confirmed. As stated
When revisiting a delicate conversation, various previously, the family should also know how to contact the
communication tools may come in handy. The mnemonic healthcare team if they have any additional questions.
NURSE; Name, Understand, Respect, Support, Explore, is a
commonly used framework for addressing emotions ( Figure 20- KEY CONCEPT #4: DEBRIEFING WITH THE
3). TEAM
For example, “As I listen, it sounds like you are worried/scared/
Given the nature of the acute trauma setting, consideration
anxious about x/y/z. Would you mind sharing more about that?”
should be given to how best to achieve a team debriefing,
By acknowledging the family’s emotions, the clinician creates
particularly if multiple disciplines are involved. While an in-
an open and supportive atmosphere, which communicates an
person debriefing in real time is ideal, alternative structures may
alliance. It is also important to note that questions are often based
be necessary. However the debrief is accomplished, it should
in unaddressed emotions, and when responding to questions, it is
include the following:
• Content of disclosure: In the same way that critical clinical
 Figure 20-3: NURSE Mnemonic for Empathetic
information is included in the patient handoff to the next
Communication. The NURSE communication tool provides
a framework for communication that can help the clinician phase of care, information about what was discussed at the
address and explore patient and family emotions in an family meeting is a crucial part of the debrief. Whether or not
empathetic manner. an in-person team debrief is possible, a summary in the chart
detailing who was present at the family meeting, what was
N.U.R.S.E. said, and agreed-upon future steps is essential. If the patient
is being transferred to another facility, a copy of this should
accompany the patient in transport.
“It sounds like you’re worried about
Name experiencing pain.” • The name and contact details for the patient’s proxy and
any advance care planning documents should be accessible
“My understanding of what you are to the healthcare team (and accompany the patient if being
Understand saying is that you’re afraid of what transferred).
this means for your family.”
• Treatment goals: What is the family’s understanding of the
expected clinical course? What are the next steps, including
“I will respect your courage to be the next planned meeting with the family? What support
Respect/Reassure vulnerable in this moment.”
systems are in place (or need to be established) for the family?
One of the important advantages of a structured, in-person
“I will be with you through this
Support process.” debriefing is the opportunity to allow clinicians to discuss and
explore their own emotions. This is especially important following
an intense and/or unsuccessful resuscitation. As the trauma team
“It seems like you’re upset, can you
Explore leader, it is important to recognize the emotional toll that caring
tell me about what you’re feeling.”
for a severely injured trauma patient takes on all those involved.
Planning for structured debriefings to run immediately after the
patient has either stabilized, died, or transferred will allow all
those involved to begin to process the potentially overwhelming
emotions that caring for these patients can bring up.
In order to have a team that is ready, willing, and able to care for
the next severely injured patient, the trauma team leader should
take the time to facilitate these debriefings whenever possible. The

283
 nature of trauma care may not allow immediate debriefings or for evaluate and communicate if they are known at the time of acute
all disciplines to always attend; the team leader should engage the treatment. However, clinicians should be mindful that prognostic
system to arrange for team- and clinician-centered follow-up. Some recovery is rarely determined by age alone and avoid allowing
specialists, such as social workers, spiritual care professionals, and ageism to influence their clinical decisions and communication
mental health counselors, may prove particularly useful. Some with the care team, patients, and their families.
sites perform routine debriefing that is focused on process or
quality improvement. While this is critical to optimizing patient MASS CASUALTY SETTINGS
care, it is equally important to patient care that clinicians have In circumstances where multiple patients present from the
an opportunity to focus on how a resuscitation has emotionally same incident, one important consideration is confirmation of
affected them. patient identity before disclosing serious news. In addition, the
clinician may be called upon to manage multiple concerned
CULTURALLY APPROPRIATE CARE AND families simultaneously and must maintain the privacy of each
PROCESSES patient. Additional details can be found in Chapter 17, Triage and
Disaster Management.
Culturally appropriate care may require the clinician to
consider a myriad of aspects, including ethnic heritage and
religious traditions, gender identity, and local or even family- CHAPTER SUMMARY
specific practices. As mentioned in the introduction, clinicians
Providing updates and having goal-setting discussions with
may need to adapt their approach to communication bearing this
patients and families early in the hospital course is an essential
in mind. They should encourage the family to communicate their
part of modern, high-quality trauma care. Recognizing that
important cultural traditions to the healthcare team. An important
there are many unknowns in the first few hours after injury,
example of this would be understanding and incorporating
clinicians should remember that it is not necessary to provide a
culturally appropriate postmortem care practices when a patient
comprehensive overview of all potential futures. The goal in the
dies in the acute trauma setting.
first update is to provide a reasonable assessment of the patient’s
status, support and engage patients and their families as they
SPECIAL POPULATION CONSIDERATIONS respond to the injury, and begin to outline treatment goals and any
limitations to treatment that the patient may have. The Four Key
THE PEDIATRIC PATIENT Concepts and the ABCDEs of trauma communication outlined
in this chapter can provide a useful framework for preparing for,
Disclosing to parents the serious injury or death of a child is
implementing, and processing these conversations. If the patient
perhaps the most difficult conversation imaginable. Following
will be transferred to a different unit or facility, details of these
the Four Key Concepts and ABCDE communication framework
conversations, summaries of the patient’s/family’s stated goals,
presented in the chapter can potentially help mitigate some of the
information about surrogate decision-makers, and advanced care
intense immediate and long-term psychiatric stress associated
plans are as important as information about the physical injury
with receiving such news. If serious news is disclosed with respect,
and should accompany the patient in transport. Patient-/family-
sensitivity, and an expressed understanding of the significance of
centered trauma care encompasses the whole person and their
the news imparted, the parents tend to be grateful for the care
family. By engaging in thoughtful, compassionate, and timely
rendered by the involved staff.
communication with patients and their families, we help them
cope with what is happening to them in the present and prepare
THE PREGNANT TRAUMA PATIENT
for the future.
Navigating the disclosure of fetal loss is difficult for many
clinicians in the acute postinjury setting but remains a top concern
for the pregnant trauma patient. The basic tenets of disclosing
death apply to this scenario. Parents value empathy and kindness.
Importantly, terms such as “products of conception,” “embryo,”
and “fetus” are generally not well-received, as parents generally
talk about their “baby” from the beginning of pregnancy. Thus,
the term “baby” is preferred. If the sex of the baby has been
determined, use of appropriate pronouns is also recommended.

THE OLDER ADULT

Patients who are in the later phases of life are more likely than
other patients to have established beliefs about limitations on care
at the end of their life, and these should be elicited. Independence,
recovery time, and return to functionality are also critical to

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KEY LEARNING POINTS

• A focused patient update and goal-setting
conversation is an essential part of high-quality
trauma care and should be accomplished as soon
as possible after initial assessment and stabilization
and whenever there is a significant change in the
patient’s status.

• Preparation for meetings that will involve

communication of serious news is critical and
will help avoid misunderstandings and mistrust.

• Using a “Headline” statement preceded by a warning

(“I have serious news to share with you”) can help
the clinician set the tone for the ensuing discussion.

• Using the ABCDEs of communication during a

family meeting provides a useful guide for
the clinician and can aid them in conducting a
meaningful and empathetic discussion.

• Details about family communications should be

documented and shared with the team, including:
what was discussed, what the family knows, who
participated, who is the primary surrogate (and
their contact information), what the stated goals
are, and whether any limitations to care have been
established. These details should accompany the
patient if they move to another phase of care.

REFERENCES
1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA,
Kudelka AP. SPIKES—A six-step protocol for delivering bad
news: Application to the patient with cancer. Oncologist.
2000;5(4):302–311. DOI: 10.1634/theoncologist.5-4-302.
PMID: 10964998.
2. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A
framework for goals of care conversations. J Oncol Pract.
2017;13(10):e844–e850. DOI: 10.1200/JOP.2016.018796.
3. Tyrie L, Mosenthal A, Bryczkowski S, Laboy C,
Lamba S. Difficult conversations after resuscitation in
trauma: Video education e-module. MedEdPORTAL.
2015;11:10092. doi:10.15766/mep_2374-8265.10092
4. Henley A, Schott J. The death of a baby before, during
or shortly after birth: Good practice from the parents’
perspective. Semin Fetal Neonatal Med. 2008;13(5):325–
328.

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 Chapter 21: Thoracic, Abdominopelvic, and Genitourinary Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Chapter 22: Penetrating Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Chapter 23: Ocular Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Chapter 24: Injury in Combat Zones and Austere Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

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SECTION III

Specific Injuries and

Injury Patterns—Special
Considerations

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21

Thoracic, Abdominopelvic,
and Genitourinary Trauma

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Identify the anatomic regions of the chest, 4. Use the appropriate diagnostic procedures to
abdomen, and pelvis that are critical in assessing determine if a patient has ongoing thoracic,
and managing trauma patients abdominal, and/or pelvic hemorrhage, and/or
other injuries
2. Recognize a patient who is at risk for chest,
abdominopelvic, and/or genitourinary injuries 5. Describe the acute management of thoracic,
based on the mechanism of injury abdominopelvic, and genitourinary injuries
3. Identify patients who require surgical
consultation and possible operative and/or
catheter-based intervention

289
 The back is the area located posterior to the posterior axillary

21
lines from the tip of the scapulae to the iliac crests. This includes
the posterior thoracoabdomen. The flank is the area between the
anterior and posterior axillary lines from the sixth intercostal space
to the iliac crest. Musculature in the flank, back, and paraspinal
region acts as partial protection from visceral injury.
The flank and back contain the retroperitoneal space. This
potential space is the area posterior to the peritoneal lining of
the abdomen. It contains the abdominal aorta; inferior vena
cava; most of the duodenum; pancreas; kidneys and ureters; the
Thoracic, Abdominopelvic, posterior aspects of the ascending and descending colon; and
and Genitourinary Trauma the retroperitoneal components of the pelvic cavity. Injuries to
the retroperitoneal visceral structures are difficult to recognize
because they occur deep within the abdomen and may not
CHAPTER STATEMENT initially present with signs or symptoms of peritonitis. In addition,
the retroperitoneal space is not sampled by diagnostic peritoneal
Unrecognized chest, abdominal, and pelvic injuries continue lavage (DPL) and is poorly visualized with FAST (focused
to cause preventable death. Significant blood loss can be present in assessment with sonography in trauma).
the thoracic cavity, abdominal cavity, or retroperitoneum without The pelvic cavity is the area surrounded by the pelvic bones,
a dramatic change in the external appearance or dimensions of containing the lower part of the retroperitoneal and intraperitoneal
the abdomen and without signs of peritoneal irritation. Any spaces. It contains the rectum, bladder, ureters, iliac vessels, and
patient who has sustained injury to the torso from a direct blunt, internal reproductive organs. Significant blood loss can occur
deceleration, blast, or penetrating injury is considered to have a from injuries to organs within the pelvis and/or directly from the
thoracic visceral, abdominal visceral, vascular, or retroperitoneal/ bony pelvis.  Figure 21-1 illustrates thoracoabdominal anatomy.
pelvic injury until proven otherwise. Rupture of a hollow viscus
and bleeding from a solid organ or the bony pelvis may be MECHANISM OF INJURY
challenging to recognize.
Consideration of the mechanism of injury facilitates the early
INTRODUCTION identification of potential injuries, directs which diagnostic studies
may be necessary for evaluation, and identifies the potential need
The assessment of circulation during the primary survey for patient transfer.
includes early evaluation for possible torso hemorrhage
following trauma. The mechanism of injury, injury forces, location BLUNT MECHANISMS
of injury, and hemodynamic status of the patient determine the A direct blow, such as contact with the lower rim of a steering
priorities and best method of thoracic, abdominopelvic, and wheel, bicycle or motorcycle handlebars, or an intruded door in a
genitourinary assessment. motor vehicle crash, can cause compression and crushing injuries
to abdominopelvic viscera and pelvic bones. These forces deform
ANATOMY solid and hollow organs and can cause rupture with secondary
Anatomy of the chest is reviewed in Chapter 5, Breathing hemorrhage and contamination by visceral contents, leading to
and Ventilation Assessment and Management. Superiorly, the peritonitis.
thoracoabdomen is bounded by the nipple line anteriorly and the Shearing injuries are a form of crush injury that is associated
infrascapular line posteriorly. Inferiorly, it is bounded by the costal with mechanical restraint contusions. Patients injured in motor
margins. Thoracoabdominal structures include the diaphragm, vehicle crashes or falls from significant heights may sustain
liver, spleen, and stomach. These are somewhat protected by the deceleration injuries, in which there is a differential movement of
bony thorax. Because the diaphragm rises to the level of the fixed and mobile parts of the body. Examples include lacerations
fourth intercostal space during full expiration, fractures of the of the liver and spleen, two movable organs that are fixed at the
lower ribs and penetrating wounds below the nipple line often sites of their supporting ligaments. Bucket-handle injury to the
injure the abdominal viscera. small bowel is another example of a deceleration injury.  Figure
The abdominal structures are partially enclosed by the lower 21-2 illustrates injuries associated with a mechanical restraint.
thorax. The anterior abdomen is defined as the area between the
costal margins superiorly, the inguinal ligaments and symphysis
pubis inferiorly, and the anterior axillary lines laterally. Most
of the hollow viscera are at risk when there is an injury to the
anterior abdomen.

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 Figure 21-1: Anatomy of the Abdomen. A. Anterior  Figure 21-2: Lap Belt and “Bucket Handle” Injuries.
abdomen and thoracoabdomen. B. Flank. C. Back. D. A. Contusions consistent with mechanical restraints are
Pelvic cavity. associated with internal injuries. B. Small bowel “bucket
handle” injury at operation.
A.
A.

B-C.
B.

D.

In patients who sustain blunt trauma, the organs most frequently

injured are the spleen (40% to 55%), liver (35% to 45%), and
small bowel (5% to 10%). Additionally, there is a 15% incidence
of retroperitoneal hematoma diagnosed during laparotomy for
blunt trauma. Although restraint devices reduce the occurrence
of many lethal injuries, these devices are associated with specific
injury patterns.  Table 21-1 lists injuries associated with restraint
devices. Airbag deployment does not preclude abdominal injury.

PENETRATING MECHANISMS
Stab wounds and low-energy gunshot wounds cause tissue
damage by lacerating and tearing. High-energy gunshot
wounds transfer more kinetic energy, causing increased
damage surrounding the track of the missile due to temporary
cavitation. Stab wounds traverse adjacent abdominal structures
and most commonly involve the liver (40%), small bowel (30%),
diaphragm (20%), and colon (15%). Gunshot wounds can cause
additional intra-abdominal injuries based on trajectory, cavitation
effect, and fragmentation. Gunshot wounds most commonly injure
the small bowel (50%), colon (40%), liver (30%), and abdominal

291
  Table 21-1: Injuries Associated with Restraint Devices.  Figure 21-3: Stab Wound to the Abdomen. Stab
wounds most commonly injure the liver, small bowel,
diaphragm, and colon.
Injuries Associated with Restraint Devices

Restraint Mechanism Injuries

Device

Lap Seat Belt • Compression •T

 ear or avulsion of bowel
mesentery
• Hyperflexion
(bucket handle)
•R
 upture of small bowel
or colon
• Thrombosis of iliac artery
or abdominal aorta
•C
 hance fracture of
lumbar vertebrae
•P
 ancreatic or duodenal
injury

Shoulder • Sliding under •R

 upture of upper
Harness the seat belt abdominal viscera
(“submarining”)
• I ntimal tear or
• Compression thrombosis in
innominate, ASSESSMENT AND MANAGEMENT
carotid, subclavian, or
vertebral arteries In hypotensive patients, the goal is to rapidly identify all thoracic,
•F
 racture or dislocation of abdominopelvic, and genitourinary injuries and determine
cervical spine whether one or more of these is the cause of hypotension. History,
•R
 ib fractures physical exam, and supplemental diagnostic tools can establish
the presence of injuries and direct urgent hemorrhage control.
•P
 ulmonary contusion
In hemodynamically normal patients, a more detailed evaluation
Air Bag • Contact •F
 ace and eye abrasions to determine the presence of injuries that can cause delayed
morbidity and mortality is performed. This evaluation includes
• Contact/ •C
 ardiac injuries
deceleration repeated physical examinations to identify signs of bleeding or
•S
 pine fractures peritonitis that may develop over time.
• Flexion
(unrestrained)
• Hyperextension
HISTORY
(unrestrained) When assessing a patient injured in a motor vehicle crash,
pertinent historical information includes the vehicle speed,
type of collision (e.g., frontal impact, lateral impact, sideswipe,
vascular structures (25%). The specific weapon, muzzle velocity, rear impact, or rollover), any intrusion into the passenger
type of ammunition, and other ballistic factors (e.g., distance compartment, types of restraints, deployment of airbags, patient
between a shotgun and the patient) are determinants of tissue position in the vehicle, and status of other occupants.
injury.  Figure 21-3 illustrates a stab wound to the abdomen.
For patients injured by falling, the height of the fall is important
BLAST MECHANISMS information due to the increased potential for deceleration injury
at greater heights. Following explosion mechanisms, the proximity
Blast injury from explosive devices occurs through several to the blast and if the blast occurred in a closed space are important
mechanisms, including penetrating fragment wounds and blunt details to understand the degree and likelihood of injuries. The
injuries from the patient being thrown or struck by projectiles. patient, other vehicle occupants, witnesses, law enforcement, and
The treating clinician considers the possibility of combined emergency medical personnel may be able to provide historical
penetrating and blunt mechanisms in blast injury scenarios. information. Prehospital care providers may supply data regarding
Patients close to the source of the explosion can incur additional vital signs, visible injuries, and patient response to prehospital
injuries to the tympanic membranes, lungs, and bowel related to treatment. Important additional information to obtain from the
blast overpressure. These injuries may have delayed presentation. patient includes the location and magnitude of pain.
The potential for overpressure injury following an explosion
should not distract the clinician from a systematic approach to
identifying and treating blunt and penetrating injuries.

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avoid manually manipulating the pelvis, as doing so may

PHYSICAL EXAMINATION
dislodge an existing blood clot or cause further hemorrhage.
The physical examination of the torso is conducted in a Gentle palpation of the bony pelvis for tenderness may provide
systematic sequence: inspection, auscultation, percussion, and useful information about the presence of a pelvic fracture. Avoid
palpation. This is followed by examination of the pelvis and unnecessary manipulation.
buttocks, as well as urethral, perineal, rectal, and vaginal exams The mechanically unstable hemipelvis migrates cephalad
(if indicated). because of muscular forces and rotates outward secondary to the
effect of gravity. External rotation of the unstable pelvis results in
INSPECTION, AUSCULTATION, PERCUSSION, AND an increased pelvic volume that can accommodate a larger volume
PALPATION of blood. The pelvis can be compressed with a binder or sheet
The patient is informed prior to performing each step of the to decrease this potential space. The device is centered over the
examination. Clothing is removed, while protecting dignity, to greater trochanters (not over the iliac crests). The presence of
allow for a thorough inspection. During the inspection, examine lower-extremity neurologic abnormalities or open wounds in the
the anterior and posterior abdomen, as well as the lower chest flank, perineum, vagina, or rectum may be evidence of pelvic-ring
and perineum, for abrasions and contusions from restraint instability.
devices, lacerations, penetrating wounds, impaled foreign bodies,
evisceration of omentum or bowel, or a gravid abdomen. URETHRAL, PERINEAL, RECTAL, VAGINAL, AND
Inspect the flank, scrotum, urethral meatus, and perianal area GLUTEAL EXAMINATION
for blood, swelling, and bruising. Laceration of the perineum, The patient is informed prior to performing a pelvic/perineal
vagina, rectum, or buttocks may be associated with an open pelvic examination. The presence of blood at the urethral meatus
fracture in blunt trauma patients. Skin folds in larger patients can strongly suggests a urethral injury. Ecchymosis or hematoma of
mask penetrating injuries and increase the difficulty of assessing the scrotum and perineum is also suggestive of urethral injury,
the abdomen and pelvis. For a complete back examination, although these signs may be absent immediately after injury. In
perform a log roll. In conclusion of the physical exam, cover the patients who have sustained blunt trauma, the primary goals of the
patient with warmed blankets to prevent hypothermia. rectal examination are to assess sphincter tone and rectal mucosal
Although auscultation is necessary (especially for determining integrity. Palpation of the prostate gland is not a reliable sign of
presence of breath sounds), the presence or absence of bowel urethral injury. Do not place a urinary catheter in a patient with
sounds does not necessarily correlate with injury, and the ability a perineal hematoma or blood at the urethral meatus before a
to hear bowel sounds may be compromised in a noisy emergency definitive assessment for urethral injury.
department or trauma bay. Percussion causes slight movement of Bony fragments from a pelvic fracture wound can lacerate
the peritoneum and may elicit signs of peritoneal irritation. When the vagina. A vaginal exam is indicated when injury is suspected,
rebound tenderness is present, do not seek additional evidence of such as in the presence of complex perineal laceration or pelvic
irritation, as it will cause the patient unnecessary pain. Voluntary fracture. In unresponsive menstruating women, examination for
guarding by the patient may render the abdominal examination the presence of tampons is important, as if left in place, delayed
unreliable. In contrast, involuntary muscle guarding is a reliable sepsis may occur.
sign of peritoneal irritation. Palpation may elicit and distinguish
superficial (e.g., abdominal wall) and deep tenderness. Determine ADJUNCTS TO PHYSICAL EXAMINATION
whether a gravid uterus is present, and if so, estimate the fundal
After assessment and management of external hemorrhage,
height to roughly calculate gestational age.
the airway, breathing, and circulation, clinicians determine the
PELVIC ASSESSMENT indications for gastric tubes and urinary catheters as adjuncts to
the primary survey.
Major pelvic hemorrhage can occur rapidly, and clinicians
must make the diagnosis quickly to initiate appropriate GASTRIC TUBES
resuscitative treatment. Unexplained hypotension may be the only
The therapeutic goal of a gastric tube placed early in the
initial indication of major pelvic disruption. Hypotension with a
primary survey is relief of acute gastric dilation. Gastric tubes may
negative FAST and a pelvic fracture on anteroposterior (AP) x-ray
reduce the incidence of aspiration in these cases. However, they
is indicative of major pelvic hemorrhage. Utilizing adjuncts such
can trigger vomiting in a patient with an active gag reflex. The
as the FAST exam and an AP x-ray can be very helpful to diagnose
presence of blood in the gastric contents may suggest an injury
pelvic trauma. Mechanical instability of the pelvic ring should be
to the esophagus or upper-gastrointestinal tract if nasopharyngeal
assumed in patients who have pelvic fractures with hypotension
and oropharyngeal sources are excluded. If a patient has facial
and no other source of blood loss. Placement of a pelvic binder is
fractures or possible basilar skull fracture, insert the gastric tube
a priority and may be lifesaving in this circumstance.
through the mouth to prevent passage of the nasal tube through
Physical exam findings suggestive of pelvic fracture include
the cribriform plate into the brain. Gastric tubes are not indicated
evidence of disrupted urethra (scrotal hematoma or blood at the
in every trauma scenario. They are inserted to clinically improve
urethral meatus), discrepancy in limb length, and/or rotational
the patient or for diagnostic purposes.
deformity of a leg without visible fracture. In these patients,

293
 URINARY CATHETERS 5, Breathing and Ventilation Assessment and Management, and
Chapter 6, Circulation Assessment and Volume Resuscitation. In
A urinary catheter placed during resuscitation will relieve patients with hemodynamic abnormalities, rapid exclusion
retention, identify bleeding, and allow for monitoring of urinary of intra-abdominal hemorrhage is necessary and can be
output over time as an index of tissue perfusion. A distended accomplished with a FAST exam, or a diagnostic peritoneal
bladder enhances pelvic imaging during FAST. Therefore, if FAST lavage (DPL) if ultrasound is not available.
is being considered, delay placing a urinary catheter until after A contraindication to further abdominopelvic diagnostic
the test is completed. Gross hematuria is an indication of trauma studies is an existing indication for emergent abdominal
to the genitourinary tract, including the kidneys, ureters, and operation. Thoracic and abdominopelvic diagnostic studies are
bladder. The absence of hematuria does not exclude an injury indicated in scenarios of altered sensorium, altered sensation,
to the genitourinary tract. A retrograde urethrogram (RUG) injury to adjacent structures (e.g., lower ribs, pelvis, and lumbar
is mandatory when blood is seen at the urethral meatus. Other spine), unreliable physical examination, anticipated prolonged
signs of urethral injury and indications from a RUG are inability inability for clinical reassessment (e.g., general anesthesia, lengthy
to void, scrotal hematoma, and perineal ecchymosis. To reduce radiographic studies), abdominal or chest contusions consistent
the risk of increasing the complexity of a urethral injury, confirm with mechanical restraints, and penetrating mechanism without
an intact urethra before inserting a urinary catheter. A disrupted immediate operative indication but with proximity to structures.
urethra detected during the primary or secondary survey may When intra-abdominal injury is considered, several studies
be managed by insertion of a suprapubic tube by an experienced can provide useful information. However, when indications
clinician. for transfer exist, transfer is not delayed by performing time-
consuming tests, including abdominal CT.  Table 21-2
DIAGNOSTIC STUDIES
summarizes the indications, advantages, and disadvantages of
With preparation and an organized team approach, the using DPL, FAST, and computed topography (CT) in evaluating
physical examination can be performed very quickly. Evaluation blunt abdominal trauma.
and management of thoracic hemorrhage is discussed in Chapter

 Table 21-2: Comparison of DPL, FAST, and CT.

Comparison of DPL, FAST, and CT in Evaluation of Abdominal Trauma

DPL FAST CT Scan

Advantages •E
 arly operative determination • Early operative determination • Anatomic diagnosis
• Performed rapidly • Noninvasive • Noninvasive
• Can detect bowel injury • Performed rapidly • Repeatable
•N
 o need for transport from • Repeatable • Visualizes retroperitoneal
resuscitation area structures
• No need for transport from
resuscitation area • Visualizes bony and
soft-tissue structures
• Visualizes extraluminal air

Disadvantages • Invasive • Operator-dependent • Higher cost and longer time

•R
 isk of procedure-related • Bowel gas and subcutaneous • Radiation and IV-contrast
injury air distort images exposure
•R
 equires gastric and urinary • Can miss diaphragm, bowel, • Can miss diaphragm injuries
decompression for prevention and pancreatic injuries
• Can miss some bowel and
of complications
• Does not completely assess pancreatic injuries
•N
 ot repeatable retroperitoneal structures
• Requires transport from
• I nterferes with interpretation • Does not visualize resuscitation area
of subsequent CT or FAST extraluminal air
•L
 ow specificity • Body habitus can limit
image clarity
•C
 an miss diaphragm injuries

Indications •A
 bnormal hemodynamics in • Abnormal hemodynamics in • Normal hemodynamics
blunt abdominal trauma blunt abdominal trauma in blunt or penetrating
abdominal trauma
•P
 enetrating abdominal trauma • Penetrating abdominal trauma
without other indications for without other indications for • Penetrating back/flank trauma
immediate laparotomy immediate laparotomy without other indications for
immediate laparotomy

DPL, Diagnostic peritoneal lavage; FAST, focused assessment with sonography in trauma; CT, computed topography.

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X-RAYS FOR ABDOMINAL TRAUMA  Figure 21-4: Focused Assessment with Sonography
An AP chest x-ray is recommended for assessing patients for Trauma. A. Probe locations. B. FAST image of the
with multisystem blunt trauma. An upright chest x-ray is useful right upper quadrant showing the liver, kidney, and free
fluid. Arrow points to free fluid which is hypoechoic, dark
to exclude a hemothorax or pneumothorax, or to determine the
appearing, on FAST.
presence of intraperitoneal air. An AP pelvic x-ray may help to
establish the source of blood loss in hemodynamically abnormal
patients and in patients with pelvic pain or tenderness. A pelvic
A.
radiograph is not mandated for an alert, awake blunt trauma
patient without pelvic pain or tenderness.

FOCUSED ASSESSMENT WITH SONOGRAPHY FOR

TRAUMA
When performed by properly trained individuals, FAST is a
rapid and reliable study for identifying intraperitoneal fluid. It
has the advantage of being repeatable and can detect pericardial
tamponade. FAST includes examination of four regions: the
pericardial sac, hepatorenal fossa, splenorenal fossa, and
pelvis or pouch of Douglas. Clinicians may perform a single
or multiple repeat scans to detect progressive hemoperitoneum.
FAST can be performed at the bedside in the resuscitation room
simultaneously with other diagnostic or therapeutic procedures.
 Figure 21-4 illustrates FAST.

DIAGNOSTIC PERITONEAL LAVAGE B.

DPL is another rapidly performed study to identify hemorrhage.
DPL may be performed in a hypotensive patient if ultrasound is
not available to perform a FAST exam. As postprocedural pain can
significantly alter subsequent examinations, generally the surgical
team performs DPL. Gastric and urinary decompression are
performed prior to DPL for prevention of complications.
The technique is most useful in hemodynamically abnormal
patients with blunt abdominal trauma or in penetrating trauma
with multiple cavitary or apparent tangential trajectories. Where
CT and/or FAST are available, DPL is rarely used because it is
invasive, more time-consuming, and requires technical expertise.
 Figure 21-5 illustrates DPL.
Relative contraindications to DPL include previous abdominal
operations, morbid obesity, advanced cirrhosis, and preexisting
coagulopathy. An open, semi-open, or closed (Seldinger)
infraumbilical technique is acceptable in the hands of trained
clinicians. In patients with pelvic fractures, an open supraumbilical
approach is preferred to avoid entering an anterior preperitoneal
pelvic hematoma. In patients with advanced pregnancy, an open
supraumbilical approach is used to avoid damaging the enlarged
uterus. DPL indications for laparotomy include aspiration of pelvic injuries. Relative contraindications for using CT include a
gastrointestinal contents or bile or aspiration of 10 cc or more of delay until the device is available, an uncooperative patient who
blood in hemodynamically abnormal patients. cannot be safely sedated, and allergy to the contrast agent. CT
may miss some gastrointestinal, diaphragmatic, and pancreatic
COMPUTED TOMOGRAPHY injuries. In the absence of hepatic or splenic injuries (solid organ
injury), the presence of free fluid in the abdominal cavity suggests
CT is a diagnostic procedure that requires transporting
an injury to the gastrointestinal tract and/or its mesentery. Many
the patient to the device (i.e., removing the patient from the
surgeons believe this finding to be an indication for early operative
resuscitation area), administering IV contrast, and radiation
intervention.
exposure. CT is a time-consuming procedure that is used
in hemodynamically normal patients in whom there is no DIAGNOSTIC LAPAROSCOPY OR THORACOSCOPY
existing indication for an emergency laparotomy. CT scan is
not performed if it delays transfer of a patient. Diagnostic laparoscopy is an accepted method for evaluating
CT scans can provide information identifying a specific organ a hemodynamically normal, blunt trauma patient without
injury as well as its extent. CT can diagnose retroperitoneal and indication for laparotomy. Laparoscopy is useful to diagnose
diaphragmatic injury and peritoneal penetration.

295
 Isolated injuries to retroperitoneal gastrointestinal structures
 Figure 21-5: Diagnostic Peritoneal Lavage (DPL). DPL is
(e.g., duodenum, ascending or descending colon, rectum, biliary
a rapidly performed, invasive procedure that is sensitive
for the detection of intraperitoneal hemorrhage.
tract, and pancreas) may not immediately cause peritonitis and
may not be detected on DPL or FAST. When injury to one of
these structures is suspected, CT with contrast, specific upper-
and lower-gastrointestinal intravenous contrast studies, and/or
pancreaticobiliary imaging studies can be useful. The surgeon
who ultimately may operate should guide these studies.

EVALUATION OF SPECIFIC PENETRATING

INJURIES
The etiology of injury (e.g., stab wound or gunshot),
anatomical location (e.g., thoracoabdominal, anterior, posterior,
or flank), and available resources influence the evaluation of
penetrating abdominal trauma. In anterior abdominal stab
wounds, options include serial physical examination, FAST, DPL,
and CT. Diagnostic laparoscopy is a reliable study to determine
peritoneal and diaphragmatic penetration in thoracoabdominal
injuries, as are contrast CT scans. In all cases of penetrating
trauma, immediate surgery may be required for diagnosis and
treatment.
Most abdominal gunshot wounds are managed by exploratory
CONTRAST STUDIES laparotomy. The incidence of significant intraperitoneal injury
approaches 98% when peritoneal penetration is present. Stab
Contrast studies can aid in the diagnosis of suspected injuries
wounds to the abdomen may be managed more selectively, but
but should not delay the care of hemodynamically abnormal
approximately 30% cause intraperitoneal injury. Thus, indications
patients. These studies include urethrography, cystography,
for laparotomy in patients with penetrating abdominal wounds
intravenous pyelogram, and gastrointestinal contrast studies.
include hemodynamic abnormality, gunshot wound with a
Urethrography is performed before inserting a urinary catheter
transperitoneal trajectory, signs of peritoneal irritation, and signs of
when a urethral injury is suspected. A urethrogram is performed
peritoneal penetration (e.g., evisceration).
with an 8 French urinary catheter secured in the meatus by balloon
inflation to 1.5–2 mL. Approximately 30–35 mL of undiluted THORACOABDOMINAL WOUNDS
contrast material is instilled with gentle pressure. A radiograph is
taken with an AP projection and with slight stretching of the penis Evaluation options for patients without indications for
toward one of the patient’s shoulders. An adequate study shows immediate laparotomy or thoracotomy, but with possible injuries
reflux of contrast into the bladder. to the diaphragm and upper abdominal structures, include
A cystogram or CT cystography is the most effective method thoracoscopy, laparoscopy, DPL, and CT.
of diagnosing an intraperitoneal or extraperitoneal bladder
rupture. A syringe barrel is attached to the indwelling bladder ANTERIOR ABDOMINAL WOUNDS:
catheter and held 40 cm above the patient. Then 350 mL of water- NONOPERATIVE MANAGEMENT
soluble contrast is allowed to flow into the bladder until either Approximately 55% to 60% of all patients with stab wounds that
the flow stops, the patient voids spontaneously, or the patient penetrate the anterior peritoneum have hypotension, peritonitis,
reports discomfort. An additional 50 mL of contrast is instilled to or evisceration of the omentum or small bowel. Emergency
ensure bladder distention. Predrainage, filled, and postdrainage laparotomy is indicated in these scenarios. However, nonoperative
AP radiographs are obtained to definitively exclude bladder management may be considered in hemodynamically normal
injury. CT evaluation of the bladder and pelvis (CT cystogram) patients without peritoneal signs or evisceration. Less-invasive
is an alternative study that yields additional information about the diagnostic options for these patients (who may have pain at the
kidneys and pelvic bones. site of the stab wound) include serial physical examinations over
Suspected genitourinary injuries are best evaluated by a 24-hour period (with or without serial FAST exams), DPL, CT
contrast-enhanced CT scan. If CT is not available, intravenous scan, or diagnostic laparoscopy.
pyelogram (IVP) provides an alternative. A high-dose, rapid Although a positive FAST may be helpful, a negative FAST
injection of renal contrast (“screening IVP”) is performed using does not exclude the possibility of a visceral injury without a large
200 mg of iodine per kg body weight. Visualization of the renal volume of intra-abdominal fluid. Serial physical examinations
calyces on an abdominal radiograph should appear 2 minutes are labor intensive but have an overall accuracy rate of 94%.
after the injection is completed. Unilateral renal nonvisualization CT scan and DPL may allow for earlier diagnosis of injury in
occurs with an absent kidney, thrombosis or avulsion of the renal relatively asymptomatic patients. Diagnostic laparoscopy can
artery, and massive parenchymal disruption. Nonvisualization confirm or exclude peritoneal penetration, but it is less useful in
may indicate further radiologic evaluation. identifying specific injuries. The surgeon determines when DPL
and laparoscopy are to be used.

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FLANK AND BACK INJURIES: NONOPERATIVE  Figure 21-6: Blunt Aortic Injury. Blunt aortic injury is a
MANAGEMENT common cause of sudden death after a vehicle collision or
fall from height. A history of decelerating force prompts
The thickness of the flank and back muscles protects investigation which is performed following completion
underlying viscera against injury from many stab wounds and of initial assessment (primary and secondary surveys)
some gunshot wounds. For those who do not have indications for and restoration of normal hemodynamic and respiratory
immediate laparotomy, less-invasive diagnostic options include function.
serial physical examinations (with or without serial FAST exams),
contrast CT scans, and DPL. Rarely, retroperitoneal injuries can
be missed by serial examinations and contrast CT. Early outpatient
follow-up is mandatory after the 24-hour period of inhospital
observation because of the subtle presentation of certain colonic
injuries. DPL can be used as an early screening test. A positive
DPL is an indication for an urgent laparotomy. However, DPL
may not detect retroperitoneal colon injuries.

INDICATIONS FOR LAPAROTOMY

FOLLOWING BLUNT TRAUMA
Surgical judgment is required to determine the timing and
need for laparotomy. The following indications are commonly
used:
• Hypotension with a positive FAST, clinical evidence of
intraperitoneal bleeding, or without another source of
bleeding
• Evisceration
• Peritonitis
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• Contrast-enhanced CT that demonstrates ruptured Several signs of BAI may be present on chest radiograph.
gastrointestinal tract, genitourinary injury, or severe visceral  Table 21-3 lists chest x-ray (CXR) signs associated with BAI.
parenchymal injury However, a normal chest radiograph does not exclude BAI.
A CT angiogram (CTA) is currently the best study to diagnose
• DPL aspiration of gastrointestinal contents or bile and exclude BAI. Reported sensitivities of CT angiogram range
• DPL aspiration of 10 cc or more of blood in hemodynamically from 95% to 100%, with negative predictive values ranging from
abnormal patients 99% to 100%. If CT angiogram is equivocal, transesophageal
echocardiography, intravascular ultrasound, and angiography
can be used, although these are rarely employed.  Figure 21-7
EVALUATION OF OTHER SPECIFIC INJURIES
illustrates imaging of BAI.
The liver, spleen, and kidney are the organs predominantly
 Table 21-3: CXR Signs of BAI.
involved following blunt trauma, although the relative incidence
of hollow visceral perforation and lumbar spinal injuries increases
with nonoptimal mechanical restraint usage. Diagnosis of injuries Chest Radiograph Signs Associated with Aortic
to the aorta, esophagus, diaphragm, duodenum, pancreas, Injury
genitourinary system, and small bowel can be difficult.
• Wide mediastinum (supine chest radiograph
>8 cm; upright >6 cm)
BLUNT AORTIC INJURY
• Obscured, indistinct, or enlarged aortic knob; abnormal
Blunt aortic injury (BAI) is commonly associated with aortic arch contour
motor vehicle crashes, including those involving motorcycles.
Other mechanisms include pedestrians struck by vehicles, • Left “apical cap” (opacity at apex of left lung representing
extrapleural blood)
falls, and crush injuries. Autopsy studies show that over 60% of
BAI occurs at the ligament arteriosum, where the relatively fixed • Large left hemothorax
descending aorta meets the more mobile aortic arch. History of a
rapid-deceleration mechanism alerts the clinician to the potential • Displacement of the left mainstem bronchus
of a BAI. BAI can be rapidly lethal. Without treatment, 20% of • Deviation of nasogastric tube to the right
patients who arrive to the hospital will die within 30 hours.
 Figure 21-6 illustrates BAI. • Deviation of trachea to the right and/or right mainstem
bronchus inferiorly

• Wide left paravertebral stripe

297
 Management of BAI can be divided into medical and surgical
 Figure 21-7: Blunt Aortic Injury A. Chest radiograph
therapy based on injury grade. Initial and often definitive
illustrating a widened mediastinum. Arrow illustrates
mediastinal width. B. CT scan illustrating blunt aortic
treatment of Grade I and many Grade II injuries is blood pressure
injury. Arrow indicates site of injury. C. Angiogram control. Data suggest that maintaining systolic blood pressure
illustrating blunt aortic injury. Arrow indicates site of below 100 mm Hg and pulse rate below 100 beats per minute
injury. decreases the risk of rupture. The initial medication of choice is a
titratable short-acting beta blocker such as esmolol.  Figure 21-8
A. illustrates grades of BAI.

 Figure 21-8: Grades of BAI.

B.

Surgical management depends on hemodynamic status and

the overall burden of injury. Currently, repair is recommended for
all Grade III and IV injuries. Severe hypotension is usually from a
source other than the BAI, as free aortic rupture is nearly always
fatal before control can be achieved. If BAI is identified and the
facility does not have resources to manage the patient, transfer is
initiated as soon as possible.

DIAPHRAGM INJURIES
C.
Blunt tears can occur in any portion of either hemidiaphragm,
although the left hemidiaphragm is most often injured. The right
hemidiaphragm is protected by the liver. Many injuries on the right
are not repaired operatively. A common blunt force injury is 5–10
cm in length and involves the posterolateral left hemidiaphragm.
Abnormalities on the initial chest x-ray include elevation or
“blurring” of the hemidiaphragm, a hemothorax, an abnormal
gas shadow that obscures the hemidiaphragm, or a gastric tube
positioned in the chest (see Chapter 5, Breathing and Ventilation
Assessment and Management). However, the initial chest x-ray
can be normal. Additional discussion of diaphragm injuries is
located in Chapter 5, Breathing and Ventilation Assessment and
Management.

PNEUMOMEDIASTINUM
Pneumomediastinum (air within the mediastinal structures)
can occur after thoracic, neck, or abdominal trauma. Air in
the tissue may originate from the tracheobronchial tree, a
pneumothorax, or the esophagus. Major tracheobronchial or
esophageal injuries after blunt trauma are rare. Most commonly,

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mediastinal air originates from lung parenchyma. Traumatic ESOPHAGEAL INJURIES

rupture of alveoli due to transient increased intrathoracic
The majority of esophageal injuries are due to penetrating
pressure causes air to dissect into peribronchial sheaths and travel
trauma. Occasionally, bone fragments from a spine fracture can
medially. A laceration of the mediastinal pleura can allow direct
directly lacerate the esophagus. A rapid increase in pressure
communication between a pneumothorax and the mediastinum.
within the esophageal lumen can lead to perforation. This rise in
Most cases of traumatic pneumomediastinum have associated
pressure can be the result of direct force to the stomach, the result
injuries such as lung contusions, pulmonary lacerations, or rib
of blast injuries, or the result of aggressive bag-mask ventilation,
fractures. Pneumomediastinum can be suspected based on the
particularly in toddlers and infants.
presence of subcutaneous emphysema at the base of the neck or
The presentation of esophageal injuries can be subtle or
auscultation of a “chomping” sound synchronous with the cardiac
overt. Retrosternal pain is common in awake patients, but this is
cycle (Hamman’s sign). Dyspnea, voice changes, and chest pain
also common with other thoracic injuries. Esophageal injury is
may be present, but these findings lack specificity.
suspected following transmediastinal gunshot wounds or gunshot
Pneumomediastinum can be seen on chest x-ray obtained
wounds associated with vertebral body fractures. Occasionally,
during the primary survey. CT scan is more sensitive for diagnosis.
tissue necrosis caused by high-speed projectile cavitation can
Following penetrating injuries, particularly transmediastinal
result in a delayed perforation. Esophageal injuries may be
gunshot wounds, further investigation with CT scan is performed
clinically occult until mediastinitis and septic shock develop.
after restoration of adequate hemodynamics. If the source cannot
Patients presenting with life-threatening hemorrhage are
be adequately identified, or if specific injuries are suspected,
treated with emergent operation. Exploration will diagnose
further evaluation may include a water-soluble contrast swallow
the esophageal injury if present. For patients with adequate
study, esophagoscopy, and/or bronchoscopy. Trauma-related
hemodynamic status, CT scan and esophagoscopy are the most
pneumomediastinum is managed based on the inciting etiology.
sensitive studies. CT scan may reveal periesophageal gas and
 Figure 21-9 illustrates pneumomediastinum.
fluid, mediastinal air/fluid collections, or communication of
air between the esophagus and the mediastinum. Up to 20% of
 Figure 21-9: Pneumomediastinum. A. Chest radiograph esophageal injuries may be initially missed by a fluoroscopic,
and B. CT Scan illustrating pneumomediastinum with non-CT, contrast study. Upper endoscopy is performed with
subcutaneous emphysema. Arrows point to air in the low air inflation and delicately to reduce the risk of enlarging
tissues. a perforation or converting the injury from a contained to an
uncontained situation.
A. If operative repair is chosen, earlier management results in
better outcomes. In facilities with the equipment and expertise, an
esophageal stent may be selected. If the patient is unable to tolerate
operative intervention, bedside drainage may be performed. As
management of esophageal injury is complex, early transfer to
higher-level care is appropriate.

DUODENAL INJURIES
Duodenal rupture is classically encountered in unrestrained
drivers involved in frontal-impact motor vehicle collisions and
patients who sustain direct blows to the abdomen, such as from
bicycle handlebars. A bloody gastric aspirate or retroperitoneal
air on an abdominal radiograph or CT raises suspicion for this
injury. An upper-gastrointestinal x-ray series, double-contrast CT,
or emergent laparotomy is indicated for high-risk patients.

B. PANCREATIC INJURIES
Pancreatic injuries often result from a direct epigastric blow
that compresses the pancreas against the vertebral column.
An early normal serum amylase level does not exclude major
pancreatic trauma. Conversely, the amylase level can be elevated
from nonpancreatic sources. Contrast CT may not identify
significant pancreatic trauma in the immediate postinjury period
(up to 8 hours). CT may be repeated, or other pancreatic imaging
performed, if injury is suspected. Surgical exploration of the
pancreas may be warranted following equivocal diagnostic studies.

299
 GENITOURINARY INJURIES MECHANISM OF INJURY AND CLASSIFICATION
Contusions, hematomas, and ecchymoses of the back or flank Blunt pelvic-ring injury can occur following a motor vehicle
are markers of potential underlying renal injury, and evaluation crash, motorcycle crash, pedestrian–vehicle collision, direct
(CT or IVP) of the urinary tract is indicated. Gross hematuria crushing injury, or fall. Pelvic fractures may be simply classified
is an indication for imaging the urinary tract. An abdominal CT into four types based on injury force patterns: AP compression,
scan with IV contrast can document the presence and extent of a lateral compression, vertical shear, and combined mechanism.
blunt renal injury, which frequently can be treated nonoperatively. Further information and subclassifications are described in
Thrombosis of the renal artery and disruption of the renal pedicle Chapter 10, Musculoskeletal Trauma.  Figure 21-10 illustrates
secondary to deceleration are injuries in which hematuria may be types of pelvic fractures.
absent. With either injury, an IVP, CT, or renal arteriogram can
be useful in diagnosis. These imaging studies are also useful in  Figure 21-10: Pelvic Fractures. A. Anteroposterior (AP)
diagnosing ureteral injuries. Ureteral injuries are considered in all Compression fracture. B. Lateral compression fracture.
penetrating trauma patients with microscopic or gross hematuria C. Vertical shear fracture.
and can be diagnosed with a contrast CT specifically timed to
identify ureteral injury. Urology consultation is appropriate for A.
injury to the urinary tract. Urethral injuries have been addressed
previously (see Urinary Catheters under Adjuncts to Physical
Examination, above).

HOLLOW VISCUS INJURIES

Blunt injury to the intestines generally results from sudden
deceleration with subsequent shearing near a fixed point of
attachment, particularly if the seat belt was positioned incorrectly.
A transverse, linear ecchymosis on the abdominal wall (seat-belt
sign) or lumbar distraction fracture (e.g., Chance fracture) on
x-ray are associated with intestinal injury. Although some patients
have early abdominal pain and tenderness, the diagnosis of hollow
viscus injuries can be difficult as they are not always associated
B.
with hemorrhage. Additionally, the superficial soft-tissue injury
may be extremely tender to palpation, thus complicating the
assessment for peritonitis.

SOLID ORGAN INJURIES

Injuries to the liver, spleen, and kidney that result in
shock, hemodynamic abnormality, or evidence of continuing
hemorrhage are indications for urgent laparotomy. Solid organ
injury in hemodynamically normal patients can often be managed
nonoperatively. Hospital admission is performed for frequent
observation. Evaluation by a surgeon is important. Concomitant
hollow viscus injury occurs in less than 5% of patients initially
diagnosed with isolated solid organ injuries. C.

PELVIC FRACTURES AND ASSOCIATED

INJURIES
Patients with hypotension and pelvic fractures have high
mortality. Rigorous decision-making is crucial for optimal
outcomes. Pelvic fractures associated with hemorrhage commonly
involve disruption of the posterior osseous ligamentous complex
(i.e., sacroiliac, sacrospinous, sacrotuberous, and fibromuscular
pelvic floor) as evidenced by a sacral fracture, a sacroiliac fracture,
and/or dislocation of the sacroiliac joint.

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AP compression injury is often associated with a motorcycle or is frequently employed to stop arterial hemorrhage related
head-on motor vehicle crash. This mechanism produces external to pelvic fractures. Preperitoneal packing is another method
rotation of the hemipelvis with separation of the symphysis pubis to control pelvic hemorrhage, either as an initial procedure
and tearing of the posterior ligamentous complex. The disrupted or when angioembolization is delayed or unavailable.
pelvic ring widens, tearing the posterior venous plexus and Hemorrhage control techniques are not exclusive, and more than
branches of the internal iliac arterial system. Hemorrhage can be one technique may be applied to achieve hemorrhage control. An
severe and life-threatening. experienced traumatologist should direct the therapeutic plan
Lateral compression injury, which involves force directed based on available resources.
laterally into the pelvis, is the most common mechanism of Some centers employ resuscitative endovascular balloon
pelvic fracture in a motor vehicle collision. In contrast to AP occlusion of the aorta (REBOA) to manage pelvic fractures
compression, the hemipelvis rotates internally during lateral causing hemorrhagic shock. REBOA stops or slows blood flow
compression, reducing pelvic volume and reducing tension on within the aorta and thus to targeted zones of injury. While the
the pelvic vascular structures. This internal rotation may drive REBOA balloon is deployed, resuscitation is continued and
the pubis into the lower genitourinary system, potentially causing immediate definitive intervention pursued. Currently, REBOA
injury to the bladder and/or urethra. Hemorrhage and other is not a tool for stabilization prior to transfer to another facility
sequelae from lateral compression injury may produce severe and and is not placed unless definitive surgical care and hemostasis
sometimes permanent morbidity. Elderly patients may develop are available at the same institution.  Figure 21-11 illustrates a
significant bleeding from pelvic fractures from this mechanism. flowchart for management of hemorrhagic shock in patients with
Early hemorrhage control techniques such as angioembolization pelvic fractures.
may be indicated. Frail and elderly patients may bleed significantly Significant resources are required to care for patients with severe
following lower-force trauma due to resulting lateral compression pelvic fractures. Early consideration of transfer to an advanced
fractures. care institution (e.g., trauma center) is essential for optimal results.
Vertical displacement (vertical shear) of the sacroiliac joint For hemodynamically abnormal patients with pelvic fractures or
disrupts the iliac vasculature and causes severe hemorrhage. In hemodynamically normal patients with significant solid organ
this mechanism, a high-energy shear force occurs along a vertical injury in resource-limited environments, the absence of surgical
plane across the anterior and posterior aspects of the pelvic ring, and/or angiographic resources are indications for early transfer to
typically as the result of a fall from a height. This vertical shearing a center with these capabilities.
disrupts the sacrospinous and sacrotuberous ligaments, leading to
significant pelvic instability.
 Figure 21-11: Flowchart for Pelvic Fractures and
MANAGEMENT Hemorrhagic Shock Management.
Hemorrhage is the major potentially reversible factor
contributing to mortality following pelvic fracture. Initial
management of hypovolemic shock associated with a major
pelvic disruption requires rapid hemorrhage control and fluid,
preferably blood, resuscitation. Hemorrhage control is achieved
through mechanical stabilization of the pelvic ring and external
counterpressure. Patients with these injuries may be initially
assessed and treated in facilities that do not have the resources
to definitively manage the associated hemorrhage. By applying a
support directly to the pelvis, clinicians can splint the disrupted
pelvis and further reduce the potential space for hemorrhage.
Because pelvic injuries associated with major hemorrhage
externally rotate the hemipelvis, internal rotation of the lower
limbs may assist in hemorrhage control by reducing pelvic volume.
A sheet, commercial pelvic binder, or other device can
produce sufficient temporary fixation for the injured pelvis
when applied at the level of the greater trochanters of the femur
(see Chapter 6, Circulation Assessment and Volume Resuscitation).
Pelvic compression/support devices are a temporary emergency
procedure. Proper application and vigilant monitoring are crucial.
Tight devices or those left in position for prolonged time periods
can cause skin breakdown and ulceration over bony prominences.
Optimal care of patients with hemodynamic abnormalities
related to pelvic fracture involves a team effort of
traumatologists, orthopaedic specialists, and interventional
radiologists or vascular surgeons. Angiographic embolization

301
 CHAPTER SUMMARY 3. Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral
injuries: Does the digital rectal examination really help us?
During Initial Assessment xABCDEs, hemodynamically Injury. 2009;40(9):984–986.
abnormal patients with multiple blunt injuries should be rapidly 4. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to
evaluated for truncal bleeding or contamination from the reduce the incidence of false-negative FAST examinations
gastrointestinal tract by performing FAST or DPL. in patients at high risk for occult injury. Focused assessment
The decision to transfer to a higher level of care is made for the sonographic examination of the trauma patient. J
early. Patients are resuscitated without performing nonessential Am Coll Surg. 1999;189(2):145–150; discussion 150–151.
diagnostic tests. 5. Boulanger BR, Milzman D, Mitchell K, Rodriguez A. Body
Indications for CT scan in hemodynamically normal patients habitus as a predictor of injury pattern after blunt trauma. J
include inability to reliably evaluate the abdomen with physical Trauma. 1992;33(2):228–232.
examination and potential thoracic and/or abdominopelvic injury 6. Boyle EM Jr, Maier RV, Salazar JD, et al. Diagnosis of
as reflected by mechanism, examination, and/or adjunct results. injuries after stab wounds to the back and flank. J Trauma.
Early surgical consultation is recommended for evaluation 1997;42(2):260–265.
and management of potential thoracic, abdominopelvic, and 7. Como JJ, Bokhari F, Chiu WC, et al. Practice management
genitourinary injuries. guidelines for selective nonoperative management of
penetrating abdominal trauma. J Trauma. 2010;68(3):721–
733.
KEY LEARNING POINTS 8. Cothren CC, Osborn PM, Moore EE, Morgan SJ,
Johnson JL, Smith WR. Preperitoneal pelvic packing for
• Early evaluation for torso hemorrhage is hemodynamically unstable pelvic fracture: A paradigm
performed during the Circulation portion shift. J Trauma. 2007;62(4):834–839; discussion 839–842.
of the primary survey.
9. Cryer HM, Miller FB, Evers BM, Rouben LR, Seligson DL.
• Shearing and crush injuries may occur in association Pelvic fracture classification: Correlation with hemorrhage.
with mechanical restraints. J Trauma. 1988;28(7):973–980.
10. Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in
• Hemorrhage is the major potentially reversible multiple trauma: Classification by mechanism is key to
factor contributing to mortality following pattern of organ injury, resuscitative requirements, and
pelvic fracture.
outcome. J Trauma. 1989;29(7):981–1000; discussion
• Avoid manual displacement of pelvic fractures 1000–1002.
due to the risk of aggravating hemorrhage. 11. Demetriades D, Rabinowitz B, Sofianos C, et al. The
management of penetrating injuries of the back. A
• Do not place a urinary catheter if a urethral prospective study of 230 patients. Ann Surg. 1988;207(1):72–
injury is potentially present. 74.
• In patients with hemodynamic abnormalities, 12. Dischinger PC, Cushing BM, Kerns TJ. Injury patterns
rapid exclusion of intra-abdominal hemorrhage associated with direction of impact: Drivers admitted to
can be accomplished with a FAST exam or a DPL. trauma centers. J Trauma. 1993;35(3):454–458; discussion
458–459.
• CT is used in hemodynamically normal patients 13. Ditillo M, Pandit V, Rhee P, et al. Morbid obesity
in whom there is no existing indication for an predisposes trauma patients to worse outcomes: A National
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Trauma Data Bank analysis. J Trauma Acute Care Surg.
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2014;76(1):176–179.
• BAI may occur following MVCs, falls, and other 14. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to
rapid deceleration mechanisms. A normal chest omit digital rectal exam in trauma patients: No fingers,
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2005;59(6):1314–1319.
15. Fabian TC, Croce MA. Abdominal trauma, including
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systematic review. World J Surg. 2013;37(1):113–122. A multicenter experience. J Trauma. 1997;42(5):825–831.
29. Osborn PM, Smith WR, Moore EE, et al. Direct 46. Brenner M, Bulger EM, Perina DG, et al. Joint statement
retroperitoneal pelvic packing versus pelvic angiography: from the American College of Surgeons Committee
A comparison of two management protocols for on Trauma (ACS COT) and the American College of
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2009;40(1):54–60. use of resuscitative endovascular balloon occlusion of
30. Osborne Z, Rowitz B, Moore H, et al. Obesity in the aorta (REBOA). Trauma Surg Acute Care Open.
trauma: Outcomes and disposition trends. Am J Surg. 2018;3(1):e000154. DOI: 10.1136/tsaco-2017-000154.
2014;207(3):387–392; discussion 391–392. PMID: 29766135; PMCID: PMC5887776.
31. Phillips T, Sclafani SJ, Goldstein A, Scalea T, Panetta T, 47. Maiga AW, Kundi R, Morrison JJ, et al. Systematic review
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Trauma. 1986;26(7):593–601. Acute Care Open. 2022;7(1):e000984. DOI: 10.1136/
32. Poblemann T, Gasslen A, Hufner T, et al. Extraperitoneal tsaco-2022-000984. PMID: 36578977; PMCID:
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22

Penetrating Trauma
Courtesy of John H. Armstrong, MD, FACS

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe techniques to control external 4. Explain the significance of odd or even number of
hemorrhage bullet wounds on examination
2. Determine which patients require surgical 5. Describe indications for ordering massive
consultation transfusion protocol
3. Identify the imaging options for patients with 6. Explain the significance of a thorough skin
penetrating torso trauma examination in patients with penetrating trauma

305
 The physiologic response to penetrating injury is directly

22
related to the area of injury. The central torso and the central
nervous systems are areas of particular vulnerability. Blood
loss can be catastrophic when one considers that an average
80-kilogram person has a total blood volume of 4,800 milliliters.
Cardiac output is, on average, 5.5 liters of blood per minute
and can reach 11 liters during times of stress. An injury to the
ascending aorta could result in loss of 20% of the blood volume
in only 4.6 seconds.
As the body compensates for loss of circulating blood
Penetrating Trauma volume, vasoconstriction occurs. Catecholamines are released,
and the renin-angiotensin-aldosterone system is activated.
Vasoconstriction can limit bleeding from the area of injury but
also decreases perfusion to organs. To maintain cardiac output
CHAPTER STATEMENT when stroke volume is decreased, heart rate increases. Endorphin
release can dull the perception pain. When these patients arrive
An organized approach to the evaluation and management to a trauma bay, these protective responses can maintaining their
of patients with penetrating injury is based on regional anatomy tenuous hemodynamics. Providing sedatives and analgesics to
and patient physiology. Minimizing delays in the recognition of assist with rapid-sequence intubation has the potential to produce
injuries can lead to decreased morbidity and mortality. catastrophic decompensation without hemorrhage control and
resuscitation.
INTRODUCTION
INJURY MECHANISM
Penetrating injuries can be unintentional or the result of Knives and bullets are the objects that are commonly thought
interpersonal violence, armed conflicts, or self-harm. Objects that of as causes of penetrating trauma. However, bone fragments,
pierce the skin can extend to deeper body areas and damage soft metal fragments, shrapnel from explosions (secondary blast
tissue, blood vessels, nerves, bones, and organs. Injury results from injury), nails, pellets, arrows, and pieces of glass should not be
the abrupt application of a force over a focal area. The capacity of forgotten as potential implements of penetrating injury.
an implement to cause injury relates to its kinetic energy. Tissues  Box 22-1 lists common penetrating wounding implements.
have varying capacity to absorb energy and can therefore be more
or less resistant to injury.  Box 22-1: Weapons Associated with Penetrating
There are an estimated 4.4 million injury-related deaths Trauma.
annually worldwide. Unintentional injuries account for 3.15
million of those deaths, and violence-related injuries take 1.25
million lives each year. 1 in 10 of all injury-related deaths are from Handguns Pistols
Revolvers
homicide, 1 in 6 from suicide, and 1 in 61 from war and conflict.
In some areas of the world these injuries occur quite commonly
and in other regions may be exceedingly rare. Some populations Long guns Rifles
are more vulnerable to penetrating injury than others because of Shotguns
where they are born, grow, work, and live. Young men living in Machine Guns
poverty are at particularly high risk of penetrating trauma injury.
Air guns Pneumatic with carbon dioxide
PATHOPHYSIOLOGY cartridges

Penetrating trauma results from an object piercing the skin

and potentially damaging soft tissue, blood vessels, nerves, bones, Cross bows and bows
or organs. Tissues have varying capacity to absorb energy and
can therefore be more or less resistant to injury. Skin, muscle, Hand-driven Knives
intestines, and blood vessels are more resistant because of their implements Swords
ability to stretch, while organs like the liver, spleen, kidney, and Needles
brain have less tensile strength and will split, shatter, or tear more Ice picks
easily. Injury results from the abrupt application of a force over a
focal area. Any object with enough kinetic energy can penetrate
Explosive fragments
the skin. The greater the kinetic energy of an object, the more
damage is inflicted to tissues and, generally, the deeper it will pass.

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 COURSE MANUAL | Chapter 22 |Penetrating Trauma

Bullets can break into smaller projectiles or fracture bone

 Figure 22-1: Diagram Demonstrating Location of
that then can become a secondary projectile and produce more
Bullet Wounds.
tissue injury. Objects can pass through or perforate, resulting in
two wounds without a residual foreign body. Objects can also
penetrate and remain in the body, often a distance away from
where they entered. Piercing objects can either remain in situ, as
with impalement, or enter and exit through the same path.

ASSESSMENT
Principles of evaluation and management follow the same
general guidelines as nonpenetrating injury. Some nuances
exist and should be noted.
Penetrating wounds may be associated with active external
hemorrhage or may have resulted in significant blood loss that
is now controlled with prehospital treatment. When active
hemorrhage is noted, the area should be promptly treated
with compression, packing, or tourniquet placement. Assess
tourniquets already in place for positioning and efficacy. In
general, tourniquets are left in place until the initial assessment
is performed and the patient’s physiology is deemed normal or
improving.
Exposure (E) is crucial when evaluating a patient with
penetrating injury, especially from bullet wounds. The “x” in
the xABCDE algorithm is a particularly important point when
assessing patients with penetrating trauma. Hemorrhage is the
leading cause of preventable death. Complete exposure is vital
to ensure that all wounds are identified. In fact, the patient’s back
can quickly be assessed as they are moved from the emergency
provider’s stretcher to the emergency department stretcher.
Though information obtained from the prehospital assessment is
vitally important, it may be inaccurate and should be verified with
visual inspection of the entire patient.
Bullet wounds can be very small and can be missed in Wounds that course in the vicinity of blood vessels can cause
skin folds, particularly in the axilla, groin, buttock creases, injury to arteries or veins. Perform a careful vascular assessment.
perineum, and scrotum. Carefully document the position Note whether a pulse is palpable, as well as the strength and
and total number of bullet wounds or lacerations identified. character of the pulse. Use a Doppler to assess for blood flow when
Generally, the number of bullet wounds plus bullets identified the pulse is abnormal or absent. Measure the injured extremity
on imaging should equal an even number. (This rule may not index or ankle-brachial index. Should it measure <0.9, further
apply to patients who have been injured by bullets in the past.) If assessment is necessary to exclude a vascular injury. Venous
the sum of wounds and retained missiles is an odd number, the injuries are trickier to diagnose. They may stop with compression
physical exam should be repeated, and consideration should and immobilization only to rebleed once activity is resumed,
be given to widening the field of imaging. Also consider that produce delayed hematomas, or result in deep venous thrombosis.
bullets identified on imaging remote from where they entered Neurologic injury is also possible due to either concussive injury
the body may have embolized through vascular channels or be or transection.
within the gastrointestinal tract. Impaled objects should not usually be removed in the
Many electronic medical records have avatars that allow mark- emergency department. Surgical consultation is needed.
up for visually recording injuries.  Figure 22-1 is an example of Impaled objects may tamponade bleeding or be firmly lodged in
a diagram that can be used to mark the location of bullet injuries place. The operating room is the ideal place for removal. Large
identified. Alternatively, narrative descriptions suffice. Note objects may require special manipulation or personnel to allow
the size and location of periwound hematomas so they may be for safe removal or supplemental imaging. Imaging can assess
reassessed for expansion indicating ongoing bleeding. Evaluate depth of penetration and spatial relationships to critical structures
the area around the wound for crepitus, bruit, and thrill. These ( Figure 22-2A and  Figure 22-2B).
findings could indicate injury to the aerodigestive tract or suggest
vascular injury. Note the character of drainage from the wounds as
well. In addition to blood, succus or cerebrospinal fluid drainage
is possible. Bullet wounds should not be blindly probed, as
probing provides little helpful information and may exacerbate
bleeding or further contaminate the wound.

307
  Figure 22-2: Stab Wound to the Lower Thoracic Area of
HEAD AND NECK
the Back.
A. Patient presents with a stab wound to the lower thoracic PENETRATING HEAD TRAUMA
area of the back. Note the blade is completely buried
and the handle is bent. Clothing has been cut away. Note Penetrating head trauma can result in severe morbidity or
fragment of shirt present around the knife. B. Lateral spine mortality. In the US, firearms result in the largest percentage of
plain x-ray showing the length of the blade and the bend of deaths from traumatic brain injury (TBI). Generally, only 10%
the handle. of patients with these injuries survive to reach hospital care. Of
those who reach care, half will die in the emergency department.
A. Survivors often face long-term neurological sequelae. The best
outcomes require rapid assessment and early neurosurgical
consultation. Patient assessment begins with the xABCDE, as
usual. Patients should be resuscitated and treated aggressively,
because outcome can’t be predicted based only on external
examination. Bullets can penetrate, perforate, strike tangentially,
ricochet, or careen.
Bullets can also produce injury to the brain without
penetrating the skull. Energy transfer from the projectile
can result in TBI through blast or concussive effects. Unlike
nonpenetrating TBI, penetrating injuries to the cranium may
produce massive external blood loss, resulting in hemorrhagic
shock. These injuries may involve the scalp, which has a rich
vascular supply. Penetrating injuries to venous sinuses or
meningeal or parenchymal vessels may manifest as external
blood loss. In addition, coagulopathy from release of tissue
thromboplastin can exacerbate bleeding. Assess for bleeding
from the wounds and treat with compression, oversewing or
stapling to contain hemorrhage. Packing wounds is usually not
B.
advisable. Note whether brain matter is present.
Rapidly assess the airway. Patients with depressed level of
consciousness, loss of protective airway reflexes, obstruction,
bleeding, or vomiting will need definitive airway control. Obtain
intravenous or intraosseous access to administer blood, blood
products, resuscitation fluids, and medications. Perform a brief and
rapid neurological assessment before administering medications
that will alter the neurological examination. Carefully inspect
the scalp to identify areas of injury. Wounds can hide beneath
hair, and it may be necessary to shave the area to fully appreciate
the extent of injury. Although penetrating injuries to the head
can produce brain injury associated with high mortality and
morbidity, the patient’s outcome is not predictable in the first
minutes following their presentation.
Treat patients with clinical evidence of increased intracranial
pressure with maneuvers to decrease it while maintaining
cerebral perfusion pressure (see details in Chapter 7, Disability:
Neurological Assessment and Management). Remember to give
tetanus prophylaxis if needed and to give antibiotics, especially
in cases where sinuses have been traversed by the injuring
implement. Aggressive treatment and resuscitation offer the
patient the best opportunity for survival and good neurologic
outcome.

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 Box 22-2: Definitions of Potential Pathways of Bullets PENETRATING NECK TRAUMA

to the Head. Injuries that penetrate the platysma are considered significant.
Penetrating neck injury accounts for approximately 5%–10% of
Penetrating Entry wound with no exit wound all trauma cases and mortality can be as high as 10%. Vascular
injuries occur in up to 40% of penetrating neck injuries, and
aerodigestive injuries occur frequently as well.
Perforating Entry and exit wound with tract Historically, injuries to the neck have been separated into
through the brain parenchyma three zones. This was because assessment and treatment were
based on the zone of injury. With the advent and availability
Tangential Strikes the head obliquely of CT scanning, there is decreasing utility of this classification.
without penetrating the brain Contemporary treatment is based on physiological presentation
tissue but may result in scalp rather than anatomy.
lacerations, skull fractures, or Patients who display “hard signs” of injury are treated
cerebral contusions with urgent surgical exploration or angiography, while
those displaying “soft signs” require further evaluation with
imaging. Early surgical consultation is necessary regardless
Ricochet Penetrating bullet that may
of presentation. The zone classification, although used less often
bounce off the inner table of the
now, provides a basis for discussion of the area of injury and
skull one or more times
possible injured structures.  Figure 22-3 outlines the zones of the
neck.  Table 22-1 describes the zones of the neck with structures
Careening Penetrates the skulls and travels at risk of injury. It is important to remember that although a
along the periphery of the cortex wound may be present in one zone, the penetration may extend to
without entering parenchyma but another zone or even another body cavity. The neck contains large
has the potential to damage the blood vessels and important nerves that surround the airway, and
dural venous sinuses airway compromise can result from direct injury, hematoma,
swelling, or compression. Bleeding from “closed” wounds
(those with small openings that don’t allow for packing) can
PENETRATING MAXILLOFACIAL TRAUMA sometimes be controlled using balloon tamponade.  Figure
22-4 demonstrates a penetrating wound that created an internal
Penetrating maxillofacial trauma can include a spectrum of carotid injury. When external compression fails to adequately
injuries ranging from minor to severe destruction. Anatomically, control the bleeding, a urinary catheter can be inserted through
the area has a rich blood supply and is compact. Injury to the skin opening and inflated to provide tamponade while the
neurological, ophthalmic, vascular, and axial skeletal structures patient is resuscitated and definitive care plans are made.
are possible. Injury to the adjacent central nervous system is of
great concern. The airway is also frequently compromised or at
 Figure 22-3: Anatomic Zones of the Anterior Neck.
risk of compromise with penetrating injury.
Zone I extends from the clavicles or sternal notch to the
Assessment begins with xABCDE. Bleeding into the cricoid cartilage. Zone II extends from the angle of the
oropharynx in a conscious and cooperative patient can be mandible to the cricoid cartilage and Zone 3 extends above
managed at least temporarily with upright positioning (when there the angle of the mandible. Note the rich blood supply of
is no need for spinal motion restriction) or reverse Trendelenburg the area.
positioning (when there is a need for spinal motion restriction)
and suctioning while resources are assembled for definitive airway
control. Airway control can be quite challenging in these patients.
It is therefore important to be prepared to place a surgical airway.

Open wounds can be packed with rolled gauze or hemostatic

gauze (if available) followed by circumferentially wrapping
with an elastic or rolled bandage. Reduction of fractures
aids in hemorrhage control. Patients with penetrating ocular
injury should not have compression dressings applied. With the
guidance of surgical consultants, tissues may be approximated to
allow more effective tamponade.

309
 Unlike patients with blunt trauma, patients with penetrating
 Table 22-1: Zones of the Neck and Basic Approaches to
neck trauma or even with penetrating bony injury to the spine
Injury. The potential injured structures within each zone
and basic approaches to injury.
do not usually require spinal motion restriction with a cervical
collar. The cervical collar may in fact obscure or delay evaluation
of wounds present. These spinal injuries are usually mechanically
Zone I Extends between the clavicle/suprasternal notch
and the cricoid cartilage (including the thoracic stable, and manipulation of the head during intubation does not
inlet). Surgical access to this zone may require result in neurological dysfunction.
thoracotomy or sternotomy. Major arteries and Airway assessment is dynamic. A normal airway with
veins, trachea and nerves, esophagus, lower
adequate breathing and ventilation can deteriorate to airway
thyroid and parathyroid glands, and thymus are
located in this zone. obstruction with ongoing bleeding or development of edema.
Orotracheal intubation is the primary approach for an airway
Zone II Lies between horizontal lines drawn at the level of that is compromised but where normal anatomy is preserved.
the cricoid cartilage and the angle of the mandible.
It contains the internal and external carotid Videoscopic intubation (when available) is valuable when the
arteries, jugular veins, pharynx, larynx, esophagus, anatomy is distorted and a difficult intubation is anticipated. The
recurrent laryngeal nerves, spinal cord, trachea, expertise to perform a surgical airway should be available as well.
and upper thyroid and parathyroid glands. Access Immediate surgical airway is required for patients with severe
with open surgery.
upper-airway distortion, massive midface trauma with inability
Zone III Extends between the angle of the mandible and to visualize the glottis because of edema, bleeding, or anatomical
base of skull. It contains the extracranial carotid disruption. Direct tracheal intubation is required in patients with
and vertebral arteries, jugular veins, cranial nerves large lacerations of the neck with tracheal transection.
IX–XII, and sympathetic nerve trunk. Difficult to
access with open surgery. Once the primary survey is completed and the patient’s
physiology is normalized or improving, thorough examination
of the neck is needed. Reassess hematomas to determine if they
are expanding. Note the location and number of wounds present.
 Figure 22-4: Stab Wound to Internal Carotid Artery. Assess any drainage from the wounds for saliva or cerebrospinal
Demonstrates a patient with a stab wound to the internal fluid. Stabilize impaled objects if not already done. Reassess areas
carotid artery. If external compression fails to control
that were packed or tamponaded for ongoing control of bleeding.
bleeding and there is a small external opening limiting the
utility of packing, placing a balloon-tipped catheter through Listen for bruits. Evaluate the airway position. Palpate for evidence
the narrow opening and inflating it can produce enough of crepitus. Note if there is evidence of blowing air from the wound
tamponade to allow for rapid assessment, resuscitation, (may develop over time). In patients who are awake and not
and transfer to an operating room. intubated, access the voice quality and strength. Assess whether
there is dysphagia or odynophagia. Perform a neurological
assessment, including assessment of cranial nerves, motor and
sensory examination, and evaluation for Horner’s syndrome
(miosis, ptosis, and anhidrosis). An altered mental status may
indicate vascular injury with cerebral hypoperfusion.

PENETRATING THORACIC TRAUMA

The hemodynamic presentation of patients with penetrating
chest trauma can vary from stability to cardiac arrest. Like with
blunt trauma, most patients presenting with penetrating thoracic
trauma require only tube thoracostomy. A higher proportion
of patients with penetrating trauma will require operative
intervention (15%–30%, compared with <10% with blunt
thoracic trauma). Penetrating trauma is generally more lethal
than blunt trauma, accounting for 3% of trauma-related deaths
in the US. Injuries to the chest wall, lungs, heart, great vessels,
tracheobronchial tree, esophagus, and diaphragm can occur with
penetrating injury. Injuries that result in significant blood loss,
cause loss of the airway or interfere with ventilation, produce
tamponade, or result in tension pneumothorax are the most
rapidly fatal and require rapid assessment and treatment.
Evaluation begins with the usual xABCDE approach.
Penetrating thoracic trauma can be the source of massive
hemorrhage, but it is usually not visible externally. More often,
patients present with one of the following: clinical evidence
of shock from blood loss; tension physiology combined with
blood loss; cardiac tamponade; or inadequate oxygenation
and ventilation. These patients require rapid resuscitation and
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 COURSE MANUAL | Chapter 22 |Penetrating Trauma

treatment to avoid progressing to cardiac arrest. Consult surgery

 Figure 22-5: Cardiac Box. A. Demonstrates the
early. Though intubation and mechanical ventilation may be
traditional representation of the cardiac box extending
indicated, it is important to administer volume resuscitation from the clavicles superiorly, costal margins inferiorly
to avoid circulatory collapse, which may accompany the and nipples laterally. B. Demonstrates the traditional
administration of drugs to assist intubation or the provision representation of the cardiac box from the posterior view.
of positive-pressure ventilation. Tension physiology should C and D. Demonstrate anterior and posterior views of the
be treated with rapid decompression of the chest with finger expanded cardiac box that includes the back and extends
thoracostomy followed by tube thoracostomy. Continued shock laterally to the anterior and posterior axillary lines.
despite adequate decompression of a hemothorax is an indication
for surgical exploration. A second tube may be required in patients A.
with persistent pneumothorax and large air leaks.
Note the location of wounds and mark them with a
radiopaque marker (paper clip or ECG lead). Remember
that wounds below the nipples anteriorly or the scapula angle
posteriorly risk infradiaphragmatic injury as well. Penetrating
injuries that occur within the “cardiac box” should cause concern
for cardiac injury  Figure 22-5. The box is defined as between the
nipples laterally, the clavicles superiorly, and the costal margins
inferiorly. Recently, it has been noted that patients presenting
with gunshot wounds to the chest may have an expanded cardiac
box that includes the anterior and posterior thorax.  Figure 22- B.
5A and 22-5B represent the standard "cardiac box" and  Figures
22-5C and 22-5D represent the expanded "cardiac box." Maintain
a high index of suspicion for cardiac injury in patients with
bullet wounds that are outside the typical cardiac box.
Patients with cardiac injury may present without overt signs
of cardiac tamponade such as the typical Beck’s triad (distended
neck veins, muffled heart sounds, and low cardiac output). They
may appear asymptomatic, may be hemodynamically unstable
without evidence of Beck’s triad, or may present with cardiac
arrest. Patients sometimes present with inability or unwillingness
to lie supine. Do not rely solely on the absence of clinical signs
to exclude the diagnosis of tamponade. Patients presenting
with cardiac arrest or profound hypotension require emergency
C.
department thoracotomy, providing cardiac arrest has not
exceeded 15 minutes.
Patients with transmediastinal ballistic injury require
special consideration. Patients with these injuries who present
with hemodynamic instability require rapid identification and
surgical intervention. These injuries are associated with high
mortality (in excess of 50%) because of injury to thoracic vascular
structures. Patients with these injuries who are hemodynamically
stable on presentation, on the other hand, require surgical
intervention 7%–33% of the time. Imaging with eFAST and
chest x-ray will identify hemo- or pneumothoraces and establish
trajectories. eFAST can also demonstrate pericardial effusion.
 Figure 22-6 is a chest x-ray of a patient with a transmediastinal D.
trajectory that is hemodynamically stable. Note the paper clip
marking the wound on the right hemithorax and the bullet
visualized in the left chest. Request surgical consultation early.
Further evaluation with chest CT in stable patients can provide
spatial relationships with the path of the projectile and identify
injury to structures. Further testing with dedicated angiography,
endoscopy to evaluate the esophagus and airway, and/or an
esophagram may be needed to identify injuries not fully evaluated
with CT scan. Pericardial window in the operating room can
evaluate for cardiac injury in stable patients or those requiring
exploration of other body regions.

311
 and sphincter tone. Evaluate for evidence of hematoma,
 Figure 22-6: Chest X-ray Bullet Wound to the Right
Chest. This chest x-ray was obtained after this patient
evisceration, active bleeding, or bubbling of air or drainage of
presented with a bullet wound involving the right chest. succus from the wound. Impaled objects are generally left in situ.
Note a paper clip was placed to localize the bullet wound Cross-sectional or planar imaging can show depth of penetration
on right lateral chest. A bullet is seen in the left chest. and relationship to critical structures. Place markers at the level
Notice the opacity of the right lung demonstrating of the wounds. When radiographic evaluation is utilized, the
contusion. A left chest tube can also be seen directed markers help identify the level of the wounds.
inferiorly. The abdomen includes the anterior abdomen, flanks, back,
and pelvis. The flank and back have more protection from
injury, with thick musculature and bones protecting the internal
contents, while the anterior abdomen is protected by the much
less robust anterior abdominal musculature. Look for abdominal
distension. Distension may indicate a large hemoperitoneum.
Large volumes of blood can pool before abdominal distension is
apparent. Look for clinical signs of shock. Patients with shock
and transabdominal penetrating trauma require immediate
surgical consultation and intervention. FAST examination is
performed as part of the primary survey and can be repeated
to evaluate for delayed bleeding. Evaluate for peritonitis. Other
“hard signs” that should prompt immediate abdominal
exploration include peritonitis, evisceration, hematemesis,
and blood per rectum. Free intra-abdominal air may identify
hollow visceral injury and indicate a need for abdominal
exploration. Tenderness is expected around wounds and can be
challenging to differentiate from peritonitis, especially in patients
with multiple wounds. Hematuria is another clue that there has
been injury to the genitourinary tract. Indications for exploratory
laparotomy are listed in  Box 22-3.

Stable patients with penetrating chest trauma require

 Box 22-3: Indications for Exploratory Laparotomy After
reassessment for evolution of injuries. Evaluation with ultrasound,
Penetrating Trauma. FAST, Focused Assessment with
plain x-ray, and CT scan can identify injuries that require Sonography for Trauma; DPA, Diagnostic
intervention or admission. Bronchoscopy or contrast studies peritoneal aspiration.
may be useful in identification of injury to specific structures.
Chest x-ray, eFAST, and cardiac evaluation are often performed
during the initial assessment in patients with penetrating thoracic Indications for Exploratory Laparotomy
injury. Tetanus prophylaxis (if needed) and antibiotics are given,
particularly for patients who require tube thoracostomy. • Hemodynamic instability
• Peritonitis
PENETRATING ABDOMINAL/PELVIC • Bleeding from rectum
TRAUMA • Aspiration of blood via nasogastric tube or hematemesis
The evaluation of the patient with abdominal penetrating • Evisceration of bowel
trauma begins with the xABCDE. It is important to identify • Impalement
all penetrating wounds and to carefully mark and document • Positive FAST findings
their location. It is not necessary to know which wounds are • DPA (diagnostic peritoneal aspiration) aspirate of succus or >
exits or entrances. Simply noting the number of wounds and 10 cc of blood
their location avoids confusion. Explain to the patient the need • Free air on imaging study
to carefully examine their entire body to exclude other wounds
and the need to perform a rectal examination. Provide as much
privacy as the urgency of the situation allows.
Turn patients early in their evaluation to evaluate the posterior
torso for wounds. Look carefully at the axilla, perineum, genitalia,
and skin folds. Perform a digital rectal exam using lubricated,
clean, gloved finger. Note presence of blood, perianal sensation,

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Balanced resuscitation occurs simultaneously. Before defin- anterior abdomen can be locally explored to determine whether
itive hemorrhage control is achieved, it may be advantageous penetration of the abdominal cavity has occurred. If penetration
to maintain a lower mean arterial pressure. High pressures can has occurred, further evaluation, operation, or observation is
actually increase hemorrhage. Whole blood and blood prod- indicated. Availability of personnel to perform serial examinations
ucts are the resuscitation fluids of choice. Massive transfusion or and operating room availability are key considerations.
hemorrhage protocols are initiated. Triggers for initiating massive
transfusion protocols include Assessment of Blood Consumption PENETRATING EXTREMITY TRAUMA
(ABC) score > 2 ( Box 22-4). Antibiotics and tetanus immuniza-
tion (if needed) should be provided. When evaluating the patient with a penetrating injury to
the extremity, control of life-threatening hemorrhage should
 Box 22-4: Assessment of Blood Consumption (ABC) be quickly assessed. Initially utilize direct pressure or packing.
Score. An ABC score is derived from easily attained mea- If these techniques fail, if there are multiple sites of significant
sures including SBP, HR, +FAST and presence of penetrat- bleeding in the extremity, or if there is a need to free up hands for
ing torso trauma. A score of 2 or more increases chance of participation in other tasks, a tourniquet can be placed above the
needing massive transfusion. ABC, Assessment of Blood area of injury. Once hemorrhage is controlled and the primary
Consumption; SBP, Systolic blood pressure; HR, Heart rate; survey is complete, identify all wounds and document their
FAST, Focused Assessment with sonography for trauma. position. Take note of any proximity to neurovascular structures.
Look for hematomas, tissue destruction, and bony deformities.

ABC score
Score < 2 suggests unlikely
Evaluate pulses throughout the extremity. When pulses are not
palpable or are diminished, use Doppler to determine if there is
flow. Motor and sensory evaluation should also be performed and
need for massive transfusion documented. Remember that patients with tourniquets in place
will have sensory and motor deficiencies, and pulses should

SBP ≤ 90 +1 not be palpable below a tourniquet. When a patient presents

with a field tourniquet, assess when it was placed, whether it is
positioned appropriately, and if it has been placed effectively. If
HR ≥ 120 +1 you can place a finger between the tourniquet and the skin, it is
not effective and may be functioning as a venous tourniquet and
exacerbating hemorrhage. If you determine that the tourniquet is
+ FAST +1 ineffective and there is ongoing bleeding, place another tourniquet
above the first. When the primary survey is completed and the
patient is hemodynamically normal, the tourniquet can be
Penetrating +1 assessed for conversion to a hemostatic or pressure dressing.
Torso Injury see Chapter 14, Initial Assessment: Secondary Survey, for full
details. Ideally, surgical consultants are present during this
process.
Obtain plain x-rays to evaluate the position of foreign bodies
In more stable patients, the abdomen is thoroughly assessed and document presence of fractures. Note the position of
during the Secondary Survey. Reconfirm the location and number projectiles and fragments relative to the course of blood vessels.
of penetrations. Clean and dress small wounds. Ensure eviscerated An injured extremity index is performed in the same manner as an
tissue is kept moist and covered and impaled objects are well ankle-brachial index. When injuries involve the upper extremity,
supported. Slash wounds can be closed if surgical exploration is comparison is made between the injured and noninjured limb.
not needed. Bullet wounds are generally cleaned and left open. Further evaluation of vascular structures is indicated when the
Reassess for expansion of hematoma, bleeding, or drainage from index is < 0.9. Surgical consultants should be involved early,
the wound. Not all abdominal or pelvic penetrating wounds will as patients with vascular compromise are at risk of tissue loss
reach the intraperitoneal space and require operative intervention. and amputation without timely intervention. Serial evaluations
The frequency of injury to organs from penetrating mechanisms of injured extremities to assess for expansion of hematomas,
include the small bowel (50%), large bowel (40%), liver (30%), active bleeding, and development of compartment syndrome are
and intra-abdominal vascular structures (25%). Decisions performed.
regarding surgical and nonoperative management rests with Keep in mind that even when arteries aren’t injured, venous
the surgical team, underscoring the need to involve surgeons injuries can result in troublesome bleeding and hematomas.
early in the evaluation and decision-making regarding patients Providing compression using elastic bandages can aid hemostasis.
with abdominal and pelvic penetrating injuries. Vascular injuries can present with clear and obvious signs of injury
When nonoperative management is considered, imaging or more subtle signs. Those with obvious signs of injury require
with a CT scan can provide information regarding the urgent surgical evaluation and expedient operative intervention.
trajectory of penetration and identify specific injuries to Those with more subtle signs also require time-sensitive surgical
organs, viscera, blood vessels, or bones. When CT scanning evaluation but are usually stable enough to allow for additional
is not an option, frequent reexamination can detect changes evaluation with imaging. Hard and soft signs of vascular injury
that could merit operative exploration. Stab wounds to the are listed in  Table 22-2.

313
 Diagnostic peritoneal aspiration can be used in very
 Table 22-2: The Hard and Soft Signs of Vascular Injuries.
specialized circumstances or settings without availability of CT
ABI, Ankle brachial index; IEI, Injured extremity index.
scanning. Patients who are either hemodynamically stable with
unclear transabdominal trajectory or who have injuries in other
Hard signs Soft signs body areas that require operative treatment may benefit from
diagnostic peritoneal aspiration. A foley catheter and nasogastric
tube are inserted. The peritoneal cavity is percutaneously accessed
• Active pulsatile • Pulse deficit
and aspirated to evaluate for the presence of blood or succus.
bleeding • Nonexpanding Identified fractures require splinting, as outlined in the Chapter
• Rapidly expanding hematoma 10, Musculoskeletal Trauma. Foreign bodies that may be located
hematoma • Pallor of extremity in a joint require specialist consultation to determine the need
• Pulselessness for further imaging or surgical removal. Antibiotic prophylaxis
• Neurological deficit is needed, as these are open fractures.
• Acute ischemia • History of extensive Generally, gastric tubes and urinary catheters are placed as
• Vascular thrill bleeding at the scene needed to decompress the stomach and bladder. Blood aspiration
may indicate an injury that requires further characterization or
• Bruit • Abnormal ABI or IEI
treatment.
• Persistant Laboratory tests should be reviewed. Elevated transaminases
hypotension may indicate hepatic injury, amylase or lipase may indicate
pancreatic or gastrointestinal injury, and hematuria may
indicate injury to the genitourinary tract. Metabolic acidosis
ADJUNCTS TO ASSESSMENT or hyperlactatemia in otherwise hemodynamically normal
In patients who are hemodynamically normal, the decision patients may indicate blood loss and requires intervention and
to utilize imaging to further characterize injuries can be helpful. follow-up.
Bedside Doppler and arterial duplex studies can identify injuries
that require further imaging in patients with extremity or neck TRANSFER CONSIDERATIONS
injuries. Extended FAST can be performed during the primary If the patient’s needs exceed the capacity of the treatment
survey and repeated at any time to assess the evolution of injuries. facility, transfer should be considered. Initial stabilization through
Pneumothoraces can develop or expand over time, as can hemorrhage control, resuscitation, and treatment of immediate
pericardial effusion and intra-abdominal hemorrhage. life threats is ideal. Prepare for the possibility of hemodynamic
Localize foreign bodies using plain x-rays. Place radiopaque deterioration during transport and have the necessary resources
markers over bullet wounds before imaging. This will clarify to continue resuscitation and monitoring. In the case of a patient
relationships of injured structures to bullet paths. The number with abdominal penetrating injury presenting in shock,
of bullet wounds plus bullets should generally, when summed, immediate operative treatment to achieve hemostasis prior to
be an even number, except in the case of bullets retained transfer may be considered if surgical capabilities permit.
from prior injuries. Foreign body series are obtained to localize
any bullet that has not passed through the body; in the case of SPECIAL POPULATION CONSIDERATIONS
abdominal injury, this includes chest, abdomen, and pelvis
x-rays. The x-ray plate is oriented in a landscape projection and Elderly patients may have higher basal blood pressure and
must include skin from one side of the body to the skin of the blunted heart rate response to hemorrhage. Injuries that traverse
other side. In patients with higher body mass index (BMI), this soft tissue can produce unexpected bleeding because of the loss
may require multiple flat plates to ensure no projectile is missed. of integrity of the connective tissue. Calcified vessels are easily
When the number of bullets and wounds don’t add to an even damaged and harder to occlude. Overresuscitation can lead
number and there is no retained bullet from a prior injury, the to respiratory complications. Low hemoglobin may be poorly
area imaged must be expanded. Bullets located in unexpected tolerated.
places may have reached their location through embolization Trauma is the leading nonobstetrical cause of death in
from vascular injury or may be within the gastrointestinal pregnancy, representing 6%–7% of all maternal deaths. Fetal
tract. CT angiography (when available) can identify lesions mortality reflects the severity of maternal injury. Fetal demise
that require further characterization with angiography or open occurs in 40%–65% of pregnant patients with penetrating
or endovascular treatment. Specialist consultation should be trauma. The higher position of the diaphragm in late pregnancy
involved in decision-making about imaging and need for surgical increases the risk of abdominal injuries with low thoracic
intervention. penetrating wounds. Overall, maternal visceral injuries from
Caution must be exercised in the evaluation of patients with penetrating trauma are decreased later in pregnancy due to the
thoracoabdominal penetrating injuries. Diaphragm injuries uterus displacing maternal viscera toward the upper abdomen
can be easily overlooked and present the potential for future as it enlarges; clinicians should still be cautious, particularly
problems for the patient. The surgical team will determine next with penetrating injuries to the upper abdomen/lower thoracic
steps in the diagnosis of these injuries. Diagnostic laparoscopy areas. The uterus, however, is at significantly increased risk of
is commonly used to evaluate injuries that involve the left side. injury from penetrating trauma in late pregnancy, with fetal
The liver offers some protection on the right side. mortality as high as 70%. Firearm injury is 7.8 times more likely

314 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 22 |Penetrating Trauma

than a motor vehicle crash to result in death in pediatric patients.

KEY LEARNING POINTS
Pediatric patients with gunshot wounds are more likely to require
immediate surgery. • Listen carefully to history but examine
thoroughly to ensure no injuries are missed.
PRACTICE ENVIRONMENT CONSIDERATIONS Carefully assess areas that can hide small injuries,
like the scalp, perineum, axillary, gluteal,
In environments where resources are limited, it is important to and thigh folds. Document the number and
understand which tools are available for assessment, resuscitation, position of injuries identified.
and definitive care. Blood availability for resuscitation is severely
• Repeatedly reassess for deterioration. Look for
limited in some areas. This makes limiting blood loss vitally
hematomas that expand with time. Assess the
important. Allowing blood pressure to remain low (mean arterial airway and breathing for evidence of compromise.
pressure 60 mm Hg) may prevent cycles of fluid resuscitation
initially increasing blood pressure, leading to bleeding with a • Be aware of the time sensitivity of injuries,
drop in blood pressure. Crystalloid fluids can be used in limited particularly those associated with bleeding
capacity in environments without blood transfusion resources. or ischemia.
Vasopressor use can be considered but is not a substitute for
• Mark injuries before imaging.
hemorrhage control or blood transfusion.
External hemorrhage that does not respond to pressure or • Initiate massive transfusion protocols for patients in
packing should be treated with a tourniquet. Tourniquet times shock. If resources aren’t available to care for
of < 2 hours have not been associated with tourniquet-related the patient’s injury, begin transfer processes early.
complications. Tranexamic acid should be given for injuries
that have occurred within 3 hours. When eFAST is not available,
techniques like diagnostic peritoneal lavage or diagnostic
peritoneal aspiration can be used to evaluate for intraperitoneal
bleeding. Selective exploration of penetrating abdominal trauma REFERENCES
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18. Okoye OT, Talving P, Teixeira PG, et al. Transmediastinal
gunshot wounds in a mature trauma centre: Changing
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06.012.

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 COURSE MANUAL | Chapter 23 |Ocular Trauma

23

Ocular Trauma

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Explain basic orbital and ocular anatomy (learn 6. Understand how to manage an open globe
terminology) 7. Describe the fluorescein dye test and its utility
2. Describe a systematic examination of the orbit 8. Categorize populations at risk for muscle
and its contents entrapment and how to screen for it
3. Identify the main ocular vital signs 9. Summarize the characteristics of lid lacerations
4. Learn how to irrigate the eye in case of chemical that require referral to a specialist
exposure
5. Discuss the basics of canthotomy and
cantholysis procedures

317
 23
 Figure 23-1: Ocular Anatomy. A. Extraocular Muscles
and Orbital Bones. Understanding ocular anatomy can
assist the clinician in the diagnosis of such entities as
extraocular muscle entrapment, which occurs when
extraocular muscles and other soft tissues become
trapped in an orbital fracture and can lead to eye
movement limitations, pain, diplopia, and other visual
disturbances. B. Ocular anatomy. Understanding the
relationships between the structures of the eye and their
locations assists the clinician in performing an effective eye
Ocular Trauma exam and recognizing threats to sight, such as chemical
injury, open globe, or orbital compartment syndrome.

A.
CHAPTER STATEMENT
Patients with ocular injuries are treated within the context of the
ATLS initial Assessment. After addressing immediate life threats,
attention should rapidly turn to determining if an ocular injury
requires emergent treatment and ophthalmologic consultation.
Often, initial treatment (e.g., eye irrigation after a chemical burn)
can be initiated while formal consultation is pending. Delays in
addressing ocular injuries can result in significant visual disability
or blindness.

INTRODUCTION
In emergency medicine, the mantra “life, limb, or eyesight” B.
describes what constitutes a true medical emergency. Although
emergent medical care has changed with time, this concept still
holds. Once immediate life threats have been addressed, clinicians
should rapidly turn their attention to limb threats, as well as to
injuries to the globe that might result in blindness or significant
visual disability if not treated within the first few hours after
onset. This chapter focuses on those types of injury. One must
understand the fundamentals of the eye exam after injury, which
begins with a review of basic eye anatomy ( Figure 23-1A and B).

ANATOMY
join together to make a “cone.” A fascia-like sheath called Tenon’s
The cornea is the transparent layer that forms the anterior
capsule surrounds the cone, limiting the ability of muscles
boundary of the space known as the anterior chamber (AC), and it
to expand (bleeding in this area may produce an intraconal
is contiguous with the sclera. Within the globe, the lens divides the
compartment syndrome). The globe-muscle cone complex sits
eye into anterior and posterior segments. The anterior segment
in the orbit, a pear-shaped cavity formed by bones that separate
includes the cornea, sclera, conjunctiva, iris, and lens. The space
the orbital compartment from the sinuses and brain tissue. The
between the cornea and iris is the AC; aqueous humor (a solution
eyelids have tendinous attachments (canthal tendons) medially
of sodium, chloride, and other ions) fills the AC. The posterior
and temporally on the bony orbit, which keep the globe from
segment of the globe is between the lens and the retina; vitreous
moving forward. This arrangement creates another space with
humor (a clear, jelly-like substance) fills the posterior segment.
limited expansion where extraconal compartment syndrome can
The optic nerve is at the back of the eye; it travels through the
occur.
muscle cone and orbit and into the brain.
Like all other evaluations, the assessment of ocular trauma
The globe includes the attachments of the extraocular muscles
includes a focused history and physical examination. The
to the sclera. Epithelium-lined tissue known as the conjunctiva
patient’s preinjury comorbidities and vision history may be
covers the muscles and sclera; it extends from the cornea-sclera
pertinent. Accurately assessing ocular trauma can change the
junction over the Tenon’s fascia layer and the sclera and then
patient’s disposition, especially when emergent ophthalmic care
turns to cover the inside of the eyelids. The extraocular muscles
is unavailable.

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 COURSE MANUAL | Chapter 23 |Ocular Trauma

PHYSICAL EXAMINATION INTRAOCULAR PRESSURE

When possible, every eye exam should obtain and document Handheld tonometry devices are now available in many
the eye’s three “vital signs”: vision, intraocular pressure, and pupils. emergency rooms. These gauges have improved the clinician’s
These functions will give the clinician critical information about ability to check eye pressures in diverse patient situations. When
the essential health of the eye. In addition, physical examination using handheld tonometry devices, open the eyelid while being
includes the anterior and posterior segments of the eye. As in any careful not to push on the globe, because doing so can falsely
medical exam, care should be taken so as not to exacerbate any elevate the eye pressure. Ensure the fingers retracting the eyelids
present injuries. rest on the bony orbit. Always obtain 2–3 measurements of each
eye at the highest reliability percentage on the tonometer (normal
VISION eye pressure is 8–21 mm Hg). The “data” or “%” reading on the pen
indicate the likelihood that this reading is accurate. It is important
A vision exam can be as simple as holding up a near-vision test to note that readings can vary with mechanical ventilation,
card or reading material at the appropriate distance and recording Valsalva maneuvers, and accidental pressure on the globe during
the vision in each eye. Always note if the patient usually wears eye-opening. For nonsedated patients, anesthetize the eye with
glasses or contact lenses and, if so, whether for distance or near topical anesthetic ophthalmic drops (e.g., proparacaine).
(reading) vision. If a refractive error is known but the patient If a tonometer is not available, you can estimate whether eye
does not have glasses, ask the patient to look through a pinhole, pressure is elevated by gently pressing with two index fingers
which minimizes the refractive error, and recheck the vision. on each side of the eye with the eyelids closed. To compare to a
To make a pinhole, take a piece of paper or cardboard and use baseline, press on your eye or the patient’s unaffected eye in the
a ballpoint pen or paper clip to make a hole of about 0.2 mm in same manner and note if there is a difference. Most importantly,
the center of it. If a professional pinhole occluder is available, use evaluate whether the patient has a firmer eye on the injured side.
it to obtain slightly more accurate results. If unable to read letters A precise measurement may not be possible, but knowing there
or symbols, ask the patient to count fingers and note the distance is a difference or abnormality can be helpful. If an open globe is
from the patient’s face. If unable to count fingers, ask the patient to suspected, do not check the eye pressure, because you might
recognize a hand waving and its direction (horizontal or vertical force more intraocular contents from the eye. In such cases,
movement). If unable, assess if they can see a bright light moving
check visual acuity and conduct a visual inspection only.
on and off the eye. Remember: check each eye separately. After
checking vision, patients who present with contact lenses should
PUPILS
have them removed.
Pupils should be equal, round, reactive, and without an
 Figure 23-2: Vision Assessment. Vision quality is a “vital afferent pupillary defect. A pupil can enlarge due to blunt trauma
sign” of the eye. Depending on the resources available, (e.g., pupillary sphincter tear), past surgery, and other ocular
it may be assessed with vetted tools, or by asking the disease processes. When an abnormal pupillary exam results from
patient to read available printed materials, count fingers an ocular cause alone, the pupil often retains some reactivity to
being displayed, and/or indicate areas of light and dark. light, even though it is a different size. Such a patient’s medical
Each eye should be tested separately. history should reflect a positive past ocular history; if it does not,
further investigation and examination are necessary to evaluate
for intracranial pathology. A sluggish or poorly reactive pupil
indicates an ocular, orbit, or brain issue that needs further work-up.

ASSESSMENT OF OCULAR AND PERIOCULAR

TRAUMA
Once systemically stabilized, a trauma patient deserves an
evaluation for ocular and periocular trauma early in the overall
assessment. Assessment begins upon coming into visual contact
with the patient. A gross visual inspection of the facial area can
determine if there is a likelihood of ocular or periocular injury.
Visually evaluate if bruising, swelling, bleeding, lacerations,
foreign bodies, or evidence of chemical (liquid or solid)
exposure exists around the eyelids, forehead, or face. These are
signs you may have to deal with a potentially blinding chemical
injury, orbital compartment syndrome, ruptured or open globe,
traumatic intraocular bleeding with elevated eye pressure, orbital
fracture with muscle entrapment, or eyelid lacerations, which can
also involve the lacrimal drainage system.

319
 CHEMICAL INJURY  Figure 23-3: Ocular Irrigation Using A Nasal Cannula.
Although irrigation of the eye is ideally done using a Morgan
If there is a chemical exposure, emergent action is needed. lens, other techniques such as using the prongs of a nasal
Chemical burns are true ocular emergencies and require cannula, or IV tubing held over the globe may also be
treatment as soon as the patient arrives. Ocular irrigation should used. For suspected chemical injuries, irrigation usually is
not be delayed while waiting to speak with the ophthalmologist. performed for at least 30 minutes; it should not be delayed
Initial management involves copious irrigation of the affected eye, waiting for an ophthalmology consultation.
which requires little equipment. Ideally, a liter of normal saline
or lactated Ringer’s (use tap water only when sterile solutions are
unavailable) connected to a Morgan lens allows for proper ocular
irrigation. Place the lens in the eye and tilt the patient’s head so the
fluid runs out toward the temple (not into the other eye).
If a Morgan lens is unavailable, cut IV tubing bluntly to hold
over the globe to maximize flow. When possible, the patient can
hold the tip of the tubing on the nasal aspect of the eye so the water
runs out of the eye. When both eyes require irrigation, you can
connect a nasal cannula to fluid and place it over the bridge of the
nose so it drains into both eyes. When none of this equipment is
available, use any reasonable technique to rinse the eye ( Figure
23-3).
While flushing the patient’s eye, obtain details about the
chemical. For example, is it an acid or base, a liquid, a powder,
or another solid material? Alkaline solutions are usually more
damaging to the eye and often require more flushing to normalize Shared with permission from Scott Weir, MD, FACEP, FAEMS.
the pH (7.0). Powders have small granules that can readily get
stuck in the eye’s superior and inferior fornices (deep spaces
Permanent vision loss can occur after 90 minutes of
behind the eyelids). This situation sometimes requires inverting
impaired blood supply, so immediate treatment is imperative.
the eyelids and directly flushing with saline through a 10 cc
If you are concerned about a retrobulbar hemorrhage causing
syringe to dislodge the granules.
a compartment syndrome, immediately perform a canthotomy
After each liter of solution or about every 30 minutes, stop the
and cantholysis (or contact someone who can walk you
fluid, wait 5 to 10 minutes, and check the pH of the tears. While
through it). Canthotomy alone (i.e., cutting the dermis only)
you are waiting, it is ideal to start the eye exam. You may stop
does not improve retrobulbar compartment syndrome. The canthal
irrigating the eye when the pH is neutral (near 7.0). If the pH is
tendons create the anterior border to the orbital compartment;
not neutral, continue this irrigation cycle, flush the fornices, and
thus, cantholysis increases the size of the orbital compartment,
recheck pH until the tears are neutral. The process may require
equivalent to performing a fasciotomy elsewhere on the body.
hours and liters of saline, so patience and perseverance are crucial.
Do not delay treatment with canthotomy and cantholysis by
If you doubt chemicals remain, flush until the ophthalmologist
obtaining a CT scan for further proof of hemorrhage. Vision
arrives to examine the patient. Based on the ophthalmic exam,
loss due to compartment syndrome is generally severe and
treatment will likely include antibiotic ointments, oral pain
irreversible, while the periocular tissues are repairable and will
medications, and possible drops for inflammation and elevated
readily heal if these procedures are performed prematurely.
eye pressure.

COMPARTMENT SYNDROME LATERAL CANTHOTOMY AND CANTHOLYSIS:

THE PROCEDURE
If trauma to the facial area results in an orbital hemorrhage
with compartment syndrome, the examination may show 1. If possible, give subdermal injection of lidocaine 2% with
bruising with tense, firm eyelids, a protruding eye (proptosis), epinephrine to the lateral canthus. It can be difficult to
and firmness to palpation through the eyelids. The patient likely inject tissue that is already swollen.
notices decreased vision, the pupil may be poorly reactive, there 2. Optional (only with good local anesthesia): Apply a
will probably be blood under the conjunctiva, and the eye will hemostat or needle driver horizontally at the lateral canthus
have limited motility. If you can check intraocular pressure, it will for 1 minute to reduce bleeding.
likely measure as elevated. Urgent treatment with a canthotomy 3. Perform lateral canthotomy: Use blunt scissors to incise
and cantholysis is required if an orbital hemorrhage with the lateral canthus, full thickness, for 1–2 cm to the lateral
compartment syndrome is present. bony orbital rim.

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4. Perform inferior cantholysis: • Cover the affected eye with a rigid shield. If a foreign
a. With toothed forceps, grasp the lower eyelid firmly at body is sticking out of the eye, cut a foam or paper cup to
the edge of the incised canthus (at the orbital rim) and accommodate the foreign body. Never place a pressure
apply traction away from the eye. dressing, gauze, or other soft material under the rigid
b. Keeping one scissor blade behind the lid (in the shield, because the pressure may force contents out of the
conjunctival fornix) and one blade over the skin, angle eye, and gauze or soft eye pads can stick to any extruding iris
the scissors toward the corner of the mouth or nasal or other ocular contents, which might then be pulled out of
ala. Make a full-thickness cut across the lower lid for the eye when removing the pad ( Figure 23-5).
a length of 1–2 cm. This should fully disinsert the lid.
You may be able to palpate or “strum” the inferior part  Figure 23-5: Application of Rigid Eye Shield to Protect
(inferior crus) of the lateral canthal tendon as a “guitar an Open Globe. Clinicians should avoid using “patches” that
string” before cutting. might put pressure on an open globe, or using any adherent
dressing that might exacerbate extrusion of globe contents
c. If successful, the eyelid should swing freely and come when the dressing is removed. A rigid shield to protect they
completely away from the globe. If the eyelid remains open globe is the best option.
in its normal position, use scissor tips to feel for
residual tethering bands, and continue cutting until
the lid swings freely.
d. There may not be a “gush of blood” even with
successful release.
5. Recheck vision and intraocular pressure. If the intraocular
pressure remains elevated with poor vision and a tense
orbit, then perform superior cantholysis, separating the
upper lid from the orbital margin. Also consider giving 500
mg IV acetazolamide. Acetazolamide works by interfering
with the sodium pump in the ciliary body, reducing the
osmolality of the aqueous humor. This changes the osmotic
gradient and reduces aqueous volume, thereby reducing • Provide an IV antibiotic. Fluoroquinolones are the only class
intraocular pressure, improving optic perfusion, and of antibiotics that penetrate the vitreous at therapeutic
reducing the risk of optic nerve ischemia. concentrations when given by an IV or oral route. Due
to higher-vitreous penetration, ophthalmologists prefer
 Figure 23-4 illustrates the method of performing a lateral newer fluoroquinolones like moxifloxacin, gatifloxacin, or
canthotomy and cantholysis. levofloxacin—some advocate for the addition of vancomycin
to the regimen for extended coverage. For patients with
oral restrictions awaiting surgery, preferentially use IV
OPEN GLOBE
formulations. If fluoroquinolones are unavailable, give IV
An open or ruptured globe should be suspected if examination broad-spectrum antibiotics to cover gram-negative and
of the eye shows an abnormally shaped eye, a peaked pupil, gram-positive bacteria.
shallow AC, corneal or scleral laceration, pigmented tissue pushing • Ensure the patient is up to date with tetanus immunization.
through the sclera or cornea, or a foreign body in or protruding
• Explain to the patient the importance of minimizing eye
from the eye. A Seidel test can locate small leaks of aqueous fluid
movement if possible. Extraocular muscle movement can
from the AC. To perform a Seidel test, anesthetize the eye, wet a
cause further extrusion of intraocular contents. The brain
fluorescein strip, and wipe the strip over the area of concern while
links eye movements, and moving the good eye also causes
keeping the patient from blinking. The undiluted fluorescein
the injured eye to move.
appears dark orange in normal light, but if a leak is present, it
becomes light orange or green when viewed under blue light. • If the spine has been clinically cleared, elevate the head of the
While ocular trauma scores help determine the degree and bed to 30 degrees. If the spine cannot be cleared, consider
prognosis of globe injury (see online for a globe injury rating placing the patient in reverse Trendelenburg to approximate
system), initial treatment of all open globes is the same. Once 30-degree elevation.
identified, immediately consult an ophthalmologist and describe • Treat pain, nausea, and coughing aggressively. Valsalva
the situation. Prepare the patient for surgery or transfer, because maneuvers can increase pressure on the back of the eye
open globes are surgical emergencies that require immediate (through the venous system), so reduce these activities to
intervention. While awaiting patient transfer or specialist help keep intraocular contents inside the eye. If the patient
consultation, follow these steps to help protect the eye: is intubated or has an airway in place, request limited use of
excessive positive pressure or coughing.
• Minimize manipulation of the eye. Do not perform any
examination beyond visual acuity and observation.

321
  Figure 23-4: Lateral Canthotomy and Cantholysis. Orbital compartment
syndrome caused by orbital hemorrhage is an ocular emergency; vision can
be affected in as little as 90 minutes. Lateral canthotomy and cantholysis can
relieve pressure and possibly prevent loss of sight.

1. Identify the lateral canthus and

if possible, anesthetize it with a
subdermal injection of lidocaine 2%
with epinephrine.

2. I f the canthus was anesthetized, apply a

hemostat or needle driver horizontally
at the lateral canthus for 1 minute to
reduce bleeding.

Recheck vision and intraocular

pressure. If the intraocular pressure
remains elevated with poor vision
and a tense orbit, then perform
superior cantholysis, separating the
upper lid from the orbital margin.
3. P
 erform lateral canthotomy: Use blunt Also consider giving 500 mg IV
scissors to incise the lateral canthus, acetazolamide. Acetazolamide
full thickness, for 1–2 cm to the lateral works by interfering with the
bony orbital rim. sodium pump in the ciliary body,
reducing the osmolality of the
aqueous humor. This changes
the osmotic gradient and reduces
aqueous volume, thereby reducing
intraocular pressure, improving
optic perfusion, and reducing the
risk of optic nerve ischemia.

4. P
 erform inferior cantholysis: With toothed
forceps, grasp the lower eyelid firmly at
the edge of the incised canthus (at the
orbital rim) and apply traction away from
the eye. Keeping one scissor blade behind
the lid (in the conjunctival fornix) and one
blade over the skin, angle the scissors
toward the corner of the mouth or nasal
ala. Make a full-thickness cut across the
lower lid for a length of 1–2 cm. This
should fully disinsert the lid. You may be
able to palpate or “strum” the inferior part
(inferior crus) of the lateral canthal tendon
as a “guitar string” before cutting.
5. If successful, the eyelid should swing
freely and come completely away from
the globe. If the eyelid remains in its
normal position, use scissor tips to feel for
residual tethering bands, and continue
cutting until the lid swings freely. There
may not be a “gush of blood” even with
successful release.

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 COURSE MANUAL | Chapter 23 |Ocular Trauma

• Order a CT scan (only if planned treatment is in your facility)

SPECIAL CONSIDERATIONS: OCULAR
with fine cuts through the orbits to look for a foreign body
or other ocular injuries. Each hospital has a slightly different INJURIES IN CHILDREN
orbital protocol, but generally, the cuts are 1 mm or less. IV
Be especially cautious of open globes in children. Examination
contrast is not required. Do not delay a transfer to get a CT
often requires sedation, as crying with Valsalva maneuvers pushes
scan.
additional ocular contents out of the eye. Choice of IV antibiotics
When you suspect an open globe, call an ophthalmologist in children is slightly controversial; many choose to offer
for immediate examination to make a definitive diagnosis. fluoroquinolones, as the risk of endophthalmitis is higher than
These injuries require prompt treatment. that of side effects from a short-term course, and fluoroquinolones
allow for discharging on oral regimens after surgery. Discuss
BLUNT TRAUMA: HYPHEMA the situations and risk factors with the family, and document
the discussion. An acceptable IV option of vancomycin plus an
When examination of an otherwise intact eye (nonopen extended-spectrum cephalosporin offers coverage without side
globe) shows a poor view behind the cornea (difficult to see the effects but limits discharge options following surgery.
iris or pupil clearly), a hyphema (visible blood in the AC, between
the cornea and the iris) is present. The eye sustained significant TRANSFER
trauma and is also at high risk of elevated eye pressure. When blunt
forces do not result in an open globe, they can still injure contents After managing and stabilizing ocular injuries covered within
within the globe. Blood in the AC often comes from damage to the ATLS, ophthalmic specialists should provide definitive assessments
iris or its attachments to the scleral wall. Hyphema has two forms: and therapy. If your facility does not have ophthalmologists,
(1) dispersed, with red blood cells floating in the aqueous humor transfer patients to tertiary centers that do. Timing is of the
and thus making the patient’s vision and your view into the eye essence to save vision. Remember to do the following:
hazy; or (2) layered, with blood on top of the iris (or with blood • Irrigate chemical injuries before even contacting an
inferiorly, if gravity has shifted the blood cells down). Patients will ophthalmologist (act immediately).
need to be on bed rest for multiple days. Place an eye shield and
• Perform a lateral canthotomy and inferior cantholysis before
call an ophthalmologist to manage a hyphema.
transferring to an ophthalmologist (irreversible ischemia
occurs within 90 minutes of injury).
ORBIT FRACTURE: SCREEN FOR
ENTRAPMENT • Shield the eye and start antibiotics before transferring open-
globe injuries (surgical closure preferred ASAP, ideally within
If evaluation rules out a compartment syndrome but there 12 hours but acceptable within 24 hours).
is a restriction of eye movement—primarily if associated with Patients with ocular injuries suffer from nausea, pain, and
significant pain, nausea, light-headedness, and diaphoresis— vision loss. Often, patients require medical support and guidance
an orbit fracture with muscle entrapment should be suspected, throughout the transfer and transport process.
especially if present in a young adult or child. Repair should occur
within 48 hours of onset to avoid muscle ischemia and permanent PRACTICE ENVIRONMENT CONSIDERATIONS
damage. When entrapment exists, most commonly a floor fracture
has hooked the inferior rectus muscle—screen for this by asking Concerted efforts exist to increase the availability of ophthalmic
the patient to look up, and see if their eye moves appropriately coverage after hours and in rural settings. Unfortunately,
(you can compare it to the unaffected eye). If the patient has standalone surgical centers, outpatient specialty clinics, and
difficulty with this upward eye movement, or if the upward subspecialization contribute to the lessened presence of
movement causes nausea or emesis, be very concerned about ophthalmic coverage in many emergency departments. Learning
entrapment. Consult an ophthalmic specialist to evaluate for this the basic ocular assessment and management skills in this chapter
condition immediately. allows for care extensions that save patients’ vision if they are far
from immediate ophthalmic intervention.
EYELID LACERATION
Lid lacerations commonly occur due to dog bites, cat CHAPTER SUMMARY
scratches, or other sharp objects near the eye. These lacerations Timely assessment and intervention in ocular trauma cases
are sometimes in conjunction with open globes; excluding an are essential. Treatment teams must recognize the signs and
open globe is the top priority. Once open globe is excluded, look symptoms of various ocular conditions, such as chemical injuries,
at the medial aspect of the lids to see if there is a tear near the orbital compartment syndrome, and open globe injuries. Once
punctum or through the canalicular duct. It is important to note if these three diagnoses have been ruled out or managed, consider
injury to the nasolacrimal system is present, as this often requires evaluating and treating other injuries, such as eyelid lacerations
repair by oculoplastic subspecialists and is best repaired within or orbital fractures. Feel confident assessing and treating ocular
the first 24–72 hours, before significant tissue swelling develops. injuries; when in doubt, prioritize initial stabilization measures
Early recognition allows for the most effective repair (within 72 and transfer to ophthalmology.
hours of injury) to prevent chronic tearing.

323
  Figure 23-6: Ocular Trauma Flowsheet. The recognition of and prompt initialization of treatment for emergent
ocular injuries, such as chemical injuries, ocular compartment syndrome, open globe injuries, and hyphema, can
help prevent vision loss. The initial phases of treatment for these injuries may be accomplished by the emergency
area clinician while awaiting a formal ophthalmologic consult.

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 COURSE MANUAL | Chapter 23 |Ocular Trauma

KEY LEARNING POINTS

• Ocular injuries have the potential to blind a patient.

• Vision-threatening injuries require treatment

promptly after onset.

• Perform the ocular exam during the secondary

survey, after stabilizing life- and limb-threatening
injuries. Remember: Life, limb, eyesight.

• Alterations in the eye’s three “vital signs” (vision,

pressure, and pupils) can identify subtle ocular
injuries that may threaten loss of sight if not
immediately treated.

• Irrigate, irrigate, irrigate a chemical injury.

• Prompt canthotomy and cantholysis can save vision

in cases of ocular compartment syndrome.

• Protect a potential ruptured globe with a shield, and

prevent increased ocular pressure.

• When in doubt, consult immediately with an

ophthalmologist.

REFERENCES
1. Chemical (alkali and acid) injury of the conjunctiva
and cornea. EyeWiki. January 24, 2025. https://eyewiki.
org /Chemical_( A lkali_and_Acid)_Injur y_of_the_
Conjunctiva_and_Cornea.
2. Retrobulbar hemorrhage. EyeWiki. June 4, 2024. https://
eyewiki.org/Retrobulbar_Hemorrhage.
3. Ruptured globe. EyeWiki. September 19, 2024. https://
eyewiki.org/Ruptured_Globe.
4. Eye trauma: Initial care (CPG ID:03). https://jts.health.
mil/assets/docs/cpgs/Eye_Trauma_Initial_Care_01_
Jun_2021_ID03.pdf.
5. Wills Eye Manual. American Academy of Ophthalmology.
December 11, 2023. https://www.aao.org/education/wills-
eye-manual.

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 COURSE MANUAL | Chapter 24 | Injury in Combat Zones and Austere Environments

24

Injury in Combat Zones

and Austere Environments

After reading this chapter and acquiring the knowledge components of the
OBJECTIVES ATLS® Course Manual, the learner will have the ability to do the following:

1. Describe challenges to providing injury care in combat zones and austere environments
2. Describe the differences in types of injuries encountered in combat zones compared to the civilian setting
3. List the modifications to the ATLS algorithm necessary in combat zones

327
 Additionally, many of these challenges may also be applicable

24
to civilian trauma care in the remote rural environment, although
typically to a lesser degree ( Table 24-1).

SECURITY, COMMUNICATION, AND

INFRASTRUCTURE
The tactical situation in any constrained environment is highly
dynamic, resulting in varying degrees of threat. Both internal and
external security concerns must be considered for the protection
Injury in Combat Zones and of both staff and patients. Measures may need to include increased
physical plant security with armed personnel or police presence
Austere Environments depending on the environment and situation; additional
restrictions in facility access; screening and identity verification
of staff, patients, and visitors; and the searching of vehicles and
CHAPTER STATEMENT personnel for weapons. Depending upon the environment, key
infrastructure considerations, such as electrical power, lighting,
Care of the trauma patient during conflict requires additional and communications, may also dramatically influence a facility’s
considerations regarding environment, injury mechanisms, security posture. While these security needs will be most apparent
systems of care, and unique practice considerations. ATLS® for the in times of armed conflict, care must be taken to ensure that every
Operational Environment (ATLS®-OE) provides a construct for treatment facility’s operational plans fully address other scenarios,
understanding these key considerations. such as when a local facility is overwhelmed or incapacitated by
natural disaster, riot, or intentional mass casualty event.
INTRODUCTION Likewise, reliable internal and external communication
Trauma care capability and best practices in areas of conflict, remains a vexing problem. Lack of system interoperability and
natural disasters, or other austere settings may be highly variable, reliance on native infrastructure such as vulnerable telephone
or potentially only available from external resources delivered to landlines, computer networks, or cell phone systems are frequent
the battlespace or site of disaster. The many challenges of operating communication limitations. Unfortunately, failed or disrupted
in this type of environment will impact every echelon of care, from communications remain a frequent issue in military, disaster,
the point of injury all the way through the evacuation to definitive and rural environments, and contingency plans must be
care facilities. It is critical that all healthcare clinicians in these established in advance.
environments have an understanding of these limitations and how During times of war, movement of casualties from point
they will affect trauma care, as well as optimal strategies that can of injury to initial care and between medical facilities may be
mitigate or even negate these disadvantages. Although Advanced hindered by the security environment or other constraints such
Trauma Life Support® (ATLS®) has formed the critical foundation as distance, weather, or lack of available assets. This may lead to
of care for the injured patient in both modern civilian and military prolonged periods of care at various locations throughout the
environments, the experiences during the prolonged conflicts in continuum and may be overwhelming to smaller facilities at
Iraq and Afghanistan, as well as lessons learned from the recent times. Additionally, there is often attrition of medical forces, loss
Russo-Ukraine war, have dictated military-specific considerations of medical infrastructure, and destruction of medical resources
and additions to standard ATLS principles and practice. due to either intentional targeting or proximity to other battlefield
targets.
PRACTICE ENVIRONMENT CONSIDERATIONS
SPECIAL POPULATIONS
The operational or austere environment presents a wide Special populations during times of conflict include civilians
variation in threats, injuries, human resources, and medical within the area of conflict who may be injured or displaced.
material availability that all must be taken into account when Children are particularly at risk for injury and illness. Injuries
planning and executing healthcare operations during times to these populations may be both physical and psychological.
of war. While ATLS provides the critical foundation of care for Additionally, sexual- and gender-based violence is often more
the injured patient in both civilian and military environments, prevalent during times of conflict. Further complicating this
additional considerations are necessary due to the multiple unique situation is the disruption of societal infrastructure and potential
and challenging aspects of providing trauma care in a severely loss of healthcare facilities.
resource-limited environment.
Additional factors include operating in an environment with
the continuous threat of hostile action, limited basic equipment
and personnel capabilities, limitations in the supply and resupply
chains, lack of the full range of modern diagnostic and therapeutic
technology (such as CT scanners, MRI, angiography, etc.), and
a significantly degraded or even nonexistent local healthcare
infrastructure.

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 COURSE MANUAL | Chapter 24 | Injury in Combat Zones and Austere Environments

 Table 24-1: Comparison of Factors Impacting Trauma Care.

Comparison of Factors Impacting Trauma Care in the Civilian Urban,

Civilian Rural, and Operational/Disaster Environments

Civilian Urban Civilian Rural Operational/Disaster

Threat level None None High

Resources Readily available May be limited Severely limited

Personnel Excess Limited but expandable Fixed and limited

Supplies/ Fully equipped, resupply Adequately equipped, Limited supplies, resupply

Equipment readily available delay to resupply significantly delayed

Available Expertise Full subspecialty services Limited specialties locally No subspecialty services
available immediately available

Transfer Immediately available Available but longer Highly variable, may be no

Availability transport times option for transfer

Multiple or Mass Uncommon Rare Common

Casualty Events

SPECIFIC INJURY MECHANISMS mechanisms: primary blast from the supersonic pressure wave;
secondary blast from fragments; tertiary blast from blunt or
WAR WOUNDS penetrating impact in the environment; and quaternary blast from
burns, crush injuries, or infections. While IEDs are most often
It is important to consider the unique wounding patterns
encountered in theaters of war, they are also increasingly utilized
associated with weapons of war, such as injuries resulting from
as a weapon of choice for intentional mass casualty events at home
high-velocity firearms and high-energy explosives. High-energy
and abroad. Mortality and morbidity depend upon the distance
gunshot wounds, such as those from assault rifles, are created by
from the device, extent of available protection, and proximity to
the linear and cavitating (radial) energy of the missile and cause
immediate medical support. A prominent injury pattern during
tissue devitalization and destruction outside the actual path
the Iraq and Afghanistan conflicts, known as dismounted
of the missile. High-energy explosives are commonly found in
complex blast injury, includes multiple traumatic amputations,
military munitions or in the commercial-grade explosives often
pelvic injury, and traumatic brain injury ( Table 24-2).
seen in improvised explosive devices (IEDs). Explosions from
these weapons cause multidimensional blast injuries across four

 Table 24-2: Common Blast Injury Patterns Seen on the Battlefield.

Common Blast Injury Patterns Seen on the Battlefield

Blast mechanism Common injuries Primary Cause of Mortality

Mounted Closed extremity fractures, spine fractures, Traumatic brain injury

traumatic brain injury

Dismounted, low energy Open and closed extremity fractures, Hemorrhage

amputations, multiple open wounds,
vascular injury

Dismounted, high energy Multiple traumatic amputations, open and Traumatic brain injury, hemorrhage,
closed pelvic fractures, spine fractures, delayed complications of wounds or
traumatic brain injury, crush injury multiorgan failure

329
 Low-energy explosives, such as gunpowder in pipe bombs or courses to incorporate military-specific needs can be found
pressure cookers, tend to produce mostly secondary blast injuries in the example of Prehospital Trauma Life Support (PHTLS)
from fragments in a smaller radius; however, those close to such and TCCC. Initially developed as a curriculum for US Special
explosions may have primary blast injury, extensive penetrations, Operations Command, TCCC has now been implemented across
and amputations. the battlefield and is the standard for combat prehospital care. A
Initial management includes immediate hemorrhage Military Edition of the PHTLS textbook was developed to help
control and resuscitation, followed by early wound irrigation of support this curriculum. The widespread implementation and
contamination and debridement of devitalized tissue. One must training of all combat personnel in TCCC as competent initial
maintain a hypervigilant index of suspicion for internal damage, responders has resulted in demonstrable reductions in preventable
including vascular injuries, because high-energy blasts often result death on the battlefield.
in a complex combination of wounds, ranging from devastating TCCC divides point of injury care into three distinct phases:
traumatic amputation to multiple small penetrating wounds 1. Care Under Fire
with highly variable penetration and wound trajectories that are 2. Tactical Field Care
extremely difficult to assess without adjunct imaging. 3. Tactical Evacuation

RADIATION AND CHEMICAL AGENTS CARE UNDER FIRE

Radiological and chemical agents may also be involved in Care Under Fire is the care rendered by fellow soldiers
conflict, industrial accidents, terrorist attacks, or as a consequence (“buddy aid”) or the unit medic or corpsman at the scene of the
of natural disasters, such as at Fukushima. Deployed medical units injury while both the immediate responder and the casualty are
must provide means to detect these agents and decontaminate still under effective direct or indirect hostile fire. The primary
patients as needed prior to assessing and performing initial focus for this phase of field medical care is fire superiority and
management of associated injuries. The US Department of Health suppression of the source of ongoing attacks. The only medical
and Human Services Administration for Strategic Preparedness intervention conducted in this phase is rapid control of ongoing
and Response’s Radiation Emergency Medical Management hemorrhage, typically by application of a tourniquet and/or
(REMM) and Chemical Hazards Emergency Medical hemostatic dressing, which can be self-administered or applied by
Management (CHEMM) websites and apps are good planning a fellow combatant or a combat medic.
resources for radiation and chemical exposure management.
TACTICAL FIELD CARE
Further complicating matters is the fact that when these agents
are used in warfare, the injury pattern often includes not only Tactical Field Care is provided by the medic or corpsman once
the insult from the radiation or toxin but also other aspects of no longer under effective hostile fire. This phase of care can be
polytrauma and burn injury. Depending upon the toxin and highly variable dependent upon the setting, but all efforts should be
degree of exposure, this may impact the anticipated prognosis and expended to minimize the time from injury to arrival at a forward
treatment options. medical treatment facility with surgical capabilities. In addition,
reengagement with the enemy remains a possibility and must
SYSTEM CONSIDERATIONS always be anticipated. In this phase of care, the standard critical
prehospital trauma assessments and interventions are conducted.
JOINT TRAUMA SYSTEM AND TACTICAL The new xABCDE approach emphasized in ATLS 11th Edition
is in alignment with TCCC, which emphasizes hemorrhage
COMBAT CASUALTY CARE control (or “x”) first, followed by airway and breathing. The most
Mortality from combat wounds steadily improved over the common cause of potentially preventable deaths on the modern
course of the wars in Iraq and Afghanistan despite an increase battlefield (up to 90%) is uncontrolled hemorrhage. In this phase
in Injury Severity Scores. This trend stems from improvements of care, any additional bleeding is controlled with tourniquets
in protective equipment, establishment of a system of in-theater or pressure dressings, and resuscitation with available blood
trauma care, use of tourniquets, application of damage control products and tranexamic acid is started. Other interventions that
surgery and resuscitation, and use of long-range critical care are highlighted in this phase include establishing or maintaining
transport for the most severely injured. This was only possible due an airway, decompression of tension pneumothorax, pain control,
to the widespread implementation of Tactical Combat Casualty antibiotic administration, and preparation for transport to the
Care (TCCC) and the establishment of the US Department of next echelon of care.
Defense’s Joint Trauma System (JTS), which supports trauma
readiness and outcomes through evidence-driven performance TACTICAL EVACUATION CARE
improvement. Today, through maintenance of the Department Tactical Evacuation Care is care rendered once the casualty
of Defense Trauma Registry, JTS Clinical Practice Guidelines, has been placed in the medical evacuation (MEDEVAC) platform
and TCCC guidelines, the JTS ensures high-quality trauma care and includes care provided from the point of injury and during
throughout the US military’s globally deployed trauma system. transport to the most appropriate higher-level medical facility. Care
Additional resources including guidelines for deployed trauma in this phase focuses on continuation of the initial interventions
care can be found on the JTS website (https://jts.health.mil/). performed in the Tactical Field Care phase, assessment and
A precedent for the modification of civilian trauma training intervention for any additional life- or limb-threatening injuries,

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 COURSE MANUAL | Chapter 24 | Injury in Combat Zones and Austere Environments

and initiation of fluid resuscitation, pain control, and antibiotic However, experiences in the Ukraine conflict have highlighted
therapy (if not already begun). More detailed evaluation and the importance of early tourniquet replacement or conversion
greater options for intervention are indicated in this phase of care, within 2 hours of injury to prevent unnecessary limb loss. In cases
with the caveat that the primary philosophy involves minimizing of prolonged tourniquet use, tourniquet conversion or replacement
unnecessary or nonurgent interventions and focusing on rapid may be accompanied by a systemic post-tourniquet syndrome
transportation to a higher level of care. that includes hypotension, acidosis, and acute renal failure.
While tourniquet replacement may occur, tourniquet conversion
SPECIFIC ADJUNCTS AND TREATMENTS should not be attempted in patients with profound shock until
resuscitation has been started. Additionally, tourniquets should
TOURNIQUETS never be converted to a pressure dressing in cases of traumatic
amputation until evaluated by a surgeon.
The immediate arrest of exsanguinating extremity hemorrhage
with a tourniquet is the principal life-saving intervention delivered FAR FORWARD BLOOD
in the Care Under Fire stage and is considered the standard of care
for the prehospital environment. Because it is frequently difficult In addition to external hemorrhage control, optimal survival
to ascertain the exact location of bleeding on an extremity during in the prehospital setting relies on the availability of adequate
Care Under Fire, TCCC recommends the immediate placement resuscitation resources. Several military and civilian studies have
of a “high and tight” tourniquet at the shoulder or groin. During now suggested a likely mortality benefit for early prehospital
later phases of Tactical Field Care or on arrival to the next echelon blood in the bleeding patient. In order to provide blood as near
of care, these hastily placed tourniquets must be assessed for to the point of injury as feasible, the US military now maintains
replacement in a location 2–3 inches above the wound, conversion FDA-compliant, low-titer (anti-A/anti-B <256), type-O cold-
to a pressure dressing, or removal if not necessary. stored whole blood, as well as other components (such as dried
plasma) for use in the field.
 Box 24-1: Tourniquet Pitfall and Mitigation. Additionally, when stored blood products are unavailable, the
US military utilizes emergency blood collection (also known as
Tourniquet Pitfall and Mitigation “walking blood bank”) to provide fresh whole blood to injured
casualties in extremis. Potential donors are screened prior to
Pitfall Mitigation deployment for blood type, transfusion-transmitted infections,
and titer so that low-titer, type-O donors are preidentified and
Leaving a “high and Tourniquet replacement (2-3” above immediately available in the field setting when needed.
tight” tourniquet in wound) or conversion at earliest These emergency procedures enable forces in the field to
place for opportunity. Consider during ATLS
bleeding wound secondary survey if tourniquet still in provide life-saving blood transfusions when standard blood
place. products are unavailable or have been depleted, thereby facilitating
movement of the casualty to a damage control surgery capability.
Converting a Administer blood and reassess. Consider Additional information on the procedures and training used for
tourniquet during tourniquet replacement or conversion emergency fresh whole-blood collection can be found in the Joint
profound shock as soon as possible once clinically
improved.
Trauma System Whole Blood Clinical Practice Guideline or the
resources listed at the end of the chapter.
“High and tight” Perform tourniquet replacement once
tourniquet placed
for traumatic
shock is improved.
ATLS IN THE OPERATIONAL ENVIRONMENT
amputation (ATLS-OE)
Just as TCCC provides an operational companion to the
While the widespread adoption of tourniquets in both military standard civilian PHTLS course, there was an identified need to
and civilian settings over the last two decades has been an integral create an equivalent product for the standard ATLS Course. ATLS-
component of improving prehospital mortality, studies in both OE is a course of instruction that emphasizes the importance
settings have also revealed that up to half of the tourniquets that of maintaining situational awareness while providing care in a
are placed emergently are not necessary for hemorrhage control potentially hostile, resource-constrained, and manpower-limited
in hindsight. This further reinforces the importance of tourniquet environment. The unique situational and environmental factors
replacement or conversion at the earliest opportunity. In recent in the operational setting often include severely constrained
US military conflicts, as well as most civilian prehospital settings, resources or supply chains, variable communication capabilities,
rapid evacuation to an initial facility for damage control surgery limited evacuation and transport options, extremes of weather,
allowed tourniquet replacement or conversion to occur at the and a dynamically changing security or tactical environment. In
treatment facility. addition, the numbers of casualties, severity and types of injuries,
and wounding mechanisms seen with modern combat or even
large-scale disasters may be considerably different from standard
civilian trauma patterns.

331
 The various unique challenges of the operational or combat ZERO SURVEY
environment require clinicians to be ever cognizant of these
The standard ATLS Course briefly addresses preparation
challenges, which rarely present an issue in the stable civilian
to receive trauma patients as they flow from the prehospital
environment—although some of these same concepts are also
environment to the hospital. The Zero Survey is implied, but it is
applicable to the remote rural environment. Clinicians faced
not specifically characterized or formalized as a separate named
with rendering trauma care in an austere environment will be
survey. ATLS-OE formalizes this prearrival preparation as a critical
required not only to deliver high-quality modern trauma care
concept for the learner. While this preparation is important to the
but to do so without the benefit of many of the things that are
care of any severely wounded patient, it is absolutely critical as the
routinely available in civilian settings; ATLS-OE emphasizes the
first step in making appropriate triage decisions in the setting of
unique challenges described above and seeks to provide learner
multiple casualties.
with the additional information that will be paramount to success
The process emphasizes the importance of an accurate
in these difficult environments. ATLS-OE provides this additional
inventory of local resources, staffing, expertise, environmental
subject matter through the supplementation of the standard ATLS
and operational conditions, and any other anticipated or potential
curriculum with additional military relevant information.
challenges in preparation for the arrival of one or more injured
Additionally, while the standard course teaches the primary,
patients. The Zero Survey will identify clinician or systems
secondary, and tertiary surveys, a key foundation of ATLS-OE
issues that may not yet have been identified or mitigated and
involves the addition of two additional surveys that must be
that may have a significant impact on decisions made during the
incorporated into the trauma survey: the Zero and Quaternary
initial evaluation. These are factors and issues that the learner
Surveys. These surveys are necessary as initial trauma care in the
may have never considered but that may be of equal or even
austere environment requires careful consideration of internal
greater importance than the actual patient injuries or required
capabilities and external factors (Zero Survey) and patients are
interventions. The Zero Survey will dictate how patients are
often rapidly transported across multiple facilities and require
triaged and prioritized, what injury types or patterns exceed the
careful attention be paid to preparation for safe evacuation to the
local capabilities or available expertise, and which resources are in
next higher echelon of care (Quaternary Survey) ( Figure 24-1).
short supply or not available.

 Figure 24-1: Expanded ATLS-OE Trauma Survey. This survey incorporates tourniquet use into Primary survey
and includes Zero and Quarternary surveys. OE, Operational environment.

ATLS-OE Zero Survey

• Tactical situation
Prearrival preparation
• MEDEVAC capabilities
• Personnel • Number of incoming casualties
Primary Survey • Logistics/Supplies on hand • Critical care capability
Identify and treat immediate • Holding capacity • Resuscitative surgical capability
life-threatening injuries • Security

X eXternal eXsanguinating
hemorrhage (use of tourniquets)
A Airway
B Breathing
C Circulation Secondary Survey QUATERNARY SURVERY
D Disability Preparation for transfer
Identify all injuries
E Exposure
• Complete Head-to-Toe exam • Stability for transfer vs
• Adjuncts need for next echelon care
• Tourniquet Replacement/ • Transport needs
Tourniquet Conversion • Receiving facility capabilities
• Critical care needs
Tertiary Survey • MEDEVAC time/ method
• Evacuation delays
Re-assess to identify any undetected (weather/tactical/etc.)
injuries • Ongoing resuscitation?
•• Review all imaging
•• Focus on musculoskeletal injury
•• Evaluate adequacy of resuscitation

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 COURSE MANUAL | Chapter 24 | Injury in Combat Zones and Austere Environments

These factors will include the following: practical or possible in the operational environment. The limited
• How many and what type of medical personnel are available? supply of critical resources such as blood products, as well as the
• What medical and surgical expertise or specialties are limited holding capacity of the most forward medical treatment
available? facilities (such as the Forward Surgical Team), make prolonged
care and sustained massive transfusions logistically impossible.
• What amount and type of blood products are available? Thus, often the best of two suboptimal choices must be made, and
• What are the critical supply shortages, if any? the patient is placed into the transport system at a much earlier
phase or in a more tenuous point of their resuscitation than is
• Is resupply available on short notice, including blood
frequently done in the civilian setting.
products?
Additional considerations as patients are moved in the
• Is there a need to initiate a fresh whole-blood drive? operational environment include the following:
• What is the available source of oxygen, and how much supply • Will weather or hostile action prevent movement of casualties?
is currently available? • What supportive treatments must accompany the patient
• Is direct communication with the next echelon of care (ventilator, suction), and what are the potential enroute
available if a transfer is required? problems or malfunctions that could occur?
• What is the tactical situation, and is security adequate? • Will the evacuation team have the skills to manage a critically
ill patient and the supportive equipment accompanying the
It is the fluidity and potential chaos inherent to the austere patient?
environment that dictate the importance of the Zero Survey in
practice. Triage decisions and initial care priorities may change • What medications, fluids, blood products, and other
rapidly as the situational factors and care capacity of the facility resuscitative or supportive treatments can realistically and
evolve over time and between events. In this environment, as reliably be administered during the transport?
personnel and supply resources become more limited, triage • What protective equipment is needed to prevent hypothermia,
decisions become increasingly difficult. eye injury, and ear/hearing injury during transport?

QUATERNARY SURVEY IMPLEMENTATION OF ATLS-OE

Although the standard ATLS Course emphasizes preparation of
ATLS-OE is currently available for use at military ATLS sites
the injured patient for transfer from the initial facility to a trauma
and may be combined with additional skills curriculum for the
center, this is typically a single transfer over a relatively short
maintenance of military trauma skills requirements. For more
distance by a fully equipped medical team. In contrast, a patient
information on the ATLS-OE supplemental curriculum, contact
in the operational environment may undergo multiple sequential
the Region 13 (military) ATLS Chief.
transfers over prolonged distances, while initial resuscitation is
ongoing. It is not uncommon to have a patient undergo a major
IMPROVING SURVIVAL FROM ACTIVE
damage control surgery and then be placed into the medical
evacuation continuum within minutes to hours of surgery and/or SHOOTER AND INTENTIONAL MASS
injury. These transfers may be via helicopter, ground ambulance, CASUALTY EVENTS: THE HARTFORD
or even watercraft, making ongoing, enroute care exceedingly CONSENSUS AND STOP THE BLEED®
challenging. Therefore, strict attention must be paid to the CAMPAIGN
complete preparation of the patient for safe transportation in
order to minimize the likelihood of problems or complications From 2000 to 2013, there were 160 active shooter events with
arising during transport. 1,043 casualties and 486 deaths. Similarly, during the period from
The Quaternary Survey formalizes this preparation for 1983 to 2002, there were over 36,000 explosive incidents with
transfer. It should be repeated for each successive transfer in the 6,000 injuries and nearly 700 deaths. The number of active shooter
medical evacuation chain. In the operational setting, the time in incidents increased by 60% since 2019. The extreme lethality of
transit may be a matter of minutes or may be many hours, and this these events cannot be ignored.
must also be factored into not only the preparation for transport With this in mind, in the aftermath of the tragic shootings at
but also the decision about readiness for transport. Enroute care Sandy Hook Elementary School in 2012 and the Boston Marathon
capabilities must also be considered, because they may vary widely bombing in 2013, the Joint Committee to Develop a National
in terms of the transportation platform, available enroute care Policy to Increase Survival from Active Shooter and Intentional
providers, equipment, supplies and medications, environment, Mass Casualty Events was established by the American College
and the potential for external threats. of Surgeons, in collaboration with leaders from various federal
Assessing the patient’s response to resuscitation is critical. The institutions including the National Security Council; US military
potential of meeting desirable end points of resuscitation versus and federal law enforcement agencies; police, fire, and emergency
the local resources to meet these end points are real and important medical organizations; and several key healthcare organizations.
considerations. Although it is certainly desirable to ensure that a The committee’s efforts have been a national call to action to
severely injured patient is clinically stable, has had a complete and address survivability of these events and to train first responders
thorough evaluation with identification of all injuries, and has and the lay public in the control of hemorrhage.
been fully resuscitated to standard end points, this is often not

333
 Given the high volatility of an active shooter event, the most  Figure 24-2: Stop the Bleed Campaign. The Stop the
important initial step is threat suppression by law enforcement Bleed® campaign empowers the lay responder to act.
personnel. However, the immediate priorities of rapid extremity
hemorrhage control by trained first responders and expeditious
transport of those with potentially noncompressible internal
hemorrhage must be mitigated.

 Box 24-2: The THREAT Acronym.

Bleeding can kill, but YOU can
Critical Events in an Integrated Stop the Bleed
Response to an Active Shooter Event are
Represented by the Acronym: THREAT

T Threat suppression

H Hemorrhage control
©ACS

R Rapid

E Extrication

A Assessment by medical clinicians

T Transport to definitive care

Using lessons learned from the military’s experience

with TCCC, early external hemorrhage control must be the
responsibility of the earliest person on scene, and law enforcement
personnel should be trained and equipped to control bleeding
with tourniquets and hemostatic agents. Similarly, emergency
medical services (EMS) and fire personnel must shift operational
tactics and develop new paradigms of emergency management
coordination to push forward in support of rapid casualty
evacuation.
The lay public should be trained in immediate bleeding
control in a public health mandate similar to cardiopulmonary
resuscitation (CPR) or the Heimlich maneuver. Appropriate
bleeding control equipment (gloves, tourniquets, hemostatic
dressings) should be readily available to all emergency personnel
and in publicly accessible “hemorrhage control kits,” which should
be positioned in appropriate public venues and be as readily
accessible and identifiable as automatic external defibrillators.
Lastly, training alone is not enough; the lay bystander must be
empowered to act in time of emergency ( Figure 24-2).

334 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Chapter 24 | Injury in Combat Zones and Austere Environments

CHAPTER SUMMARY complex blast injuries: A comprehensive review

of the modern combat experience. J Am Coll Surg.
ATLS provides a framework of care that can be followed in 2016;223(4):652–664.e8.
combat and austere environments. Resources and environment 8. Polk TM, Martin MJ, Barbosa RR. Damage control surgery
play a critical role in the care that can be provided and timing in the blast-injured patient. In: Galante JM, Martin MJ,
of patient movement. Patients may require evacuation without Rodriguez CJ, Gordon WT (eds). Managing Dismounted
having reached the ideal end points of resuscitation. Tourniquets Complex Blast Injuries in Military & Civilian Settings:
should be reassessed ideally within 2 hours of placement. Guidelines and Principles. 2018:57–76.
9. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of
emergency tourniquets to stop bleeding in major limb
KEY LEARNING POINTS trauma. J Trauma. 2008;64(2 Suppl):S38–S50.
10. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with
• The principles of ATLS provide a framework for emergency tourniquet use to stop bleeding in major limb
evaluating and treating life-threatening injuries in trauma. Ann Surg. 2009;249(1):1–7.
all situations and environments; however, these
11. Holcomb JB, Dorlac WC, Drew BG, et al. Rethinking limb
principles must be adapted to the situation based
on available resources. tourniquet conversion in the prehospital environment. J
Trauma Acute Care Surg. 2023;95(6):e54–e60.
• Early hemorrhage control with tourniquets is 12. Butler F, Holcomb JB, Dorlac W, et al. Who needs a
critical; however, tourniquets should be reassessed tourniquet? And who does not? Lessons learned from
for replacement or conversion at the earliest a review of tourniquet use in the Russo-Ukrainian war. J
opportunity. Trauma Acute Care Surg. 2024;97(2S Suppl 1):S45–S54.
• ATLS-OE provides an expanded construct for 13. Scerbo MH, Mumm JP, Gates K, et al. Safety and
assessment and resuscitation of the trauma patient appropriateness of tourniquets in 105 civilians. Prehosp
in the military setting. Emerg Care. 2016;20(6):712–722.
14. Shackelford SA, Del Junco DJ, Powell-Dunford N, et al.
• Austere and operational environments require Association of prehospital blood product transfusion during
increased situational awareness and detailed medical evacuation of combat casualties in Afghanistan
prearrival and pretransfer assessments due to
with acute and 30-day survival. JAMA. 2017;318(16):1581–
resource constraints.
1591.
• The Stop the Bleed campaign provides hemorrhage 15. Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma
control training for the public and empowers during air medical transport in trauma patients at risk for
immediate bystanders to act. hemorrhagic shock. N Engl J Med. 2018;379(4):315–326.
16. Hazelton JP, Ssentongo AE, Oh JS, et al. Use of cold-stored
whole blood is associated with improved mortality in
hemostatic resuscitation of major bleeding: A multicenter
study. Ann Surg. 2022;276(4):579–588.
REFERENCES 17. Sperry JL, Cotton BA, Luther JF, et al. Whole blood
1. Eastridge BJ, Mabry RL, Seguin P, et al. Prehospital death resuscitation and association with survival in injured
on the battlefield (2001–2011): Implications for the patients with an elevated probability of mortality. J Am Coll
future of combat casualty care. J Trauma Acute Care Surg. Surg. 2023;237(2):206–219.
2012;73(6 Suppl 5):S431–S437. 18. Song KH, Winebrenner HM, Able TE, Bowen CB, Dunn
2. Butler FK Jr, Hagmann J, Butler EG. Tactical combat NA, Shevchik JD. Ranger O Low Titer (ROLO): Whole
casualty care in special operations. Mil Med. 1996;161 blood transfusion for forward deployed units. Mil Med.
Suppl:3–16. 2021:usab473. doi: 10.1093/milmed/usab473. PMID:
3. Butler FK Jr, Blackbourne LH. Battlefield trauma care then 34755846.
and now: A decade of Tactical Combat Casualty Care. J 19. Blair JP, Schweit KW. A Study of Active Shooter Incidents,
Trauma Acute Care Surg. 2012;73(6 Suppl 5):S395–S402. 2000–2013. Texas State University and Federal Bureau of
4. National Association of Emergency Medical Technicians. Investigation. U.S. Department of Justice, Washington, DC;
Prehospital Trauma Life Support Manual, Military Ninth 2014.
Edition. Burlington, MA: Jones and Bartlett Learning; 20. Jacobs LM, Wade DS, McSwain NE, et al. The Hartford
2019. Consensus: THREAT, a medical disaster preparedness
5. Kotwal RS, Montgomery HR, Kotwal BM, et al. concept. J Am Coll Surg. 2013;217(5):947–953.
Eliminating preventable death on the battlefield. Arch Surg. 21. Jacobs LM, Rotondo M, McSwain N, et al. Joint Committee
2011;146(12):1350–1358. to create a national policy to enhance survivability from
6. DuBose J, Plurad DS, Rhee PM. Blast injuries. In: mass casualty shooting events: Hartford Consensus II.
Penetrating Trauma: A Practical Guide on Operative Conn Med. 2014;78(1):5–8.
Technique and Perioperative Management. Cham: Springer
International Publishing; 2024:671–678.
7. Cannon JW, Hofmann LJ, Glasgow SC, et al. Dismounted

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 22. Jacobs LM JR, Joint Committee to Create a National Policy
to Enhance Survivability from Intentional Mass-Casualty
and Active Shooter Events. The Hartford Consensus III:
Implementation of bleeding control—If you see something,
do something. Bull Am Coll Surg. 2015;100(7):20–26.
23. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based
prehospital guideline for external hemorrhage control:
American College of Surgeons Committee on Trauma.
Prehosp Emerg Care. 2014;18(2):163–173.

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 COURSE MANUAL | Index

INDEX

337
 Figures, tables, and boxes are indicated by "f," "t," and Airway management, 42–62. See also Breathing and ventilation;
"b" following page numbers. Definitive airways; Intubation; Oxygenation
airway injuries and, 42–43
ABA (American Burn Association), 142, 143t assessment for, 43–46, 44f–46f
ABC (Assessment of Blood Consumption) score, 313, 313b burn injuries and, 25, 42, 43, 136, 137f, 143t, 175
ABCDE communication tool, 280, 282, 284 in combat zones, 330
Abdomen communication in, 25–26, 43, 53, 57
anatomy of, 66, 67f, 290, 291f, 312 facial injuries and, 25, 43, 46, 309
physical examination of, 228, 293 head trauma and, 25, 308, 309f
Abdominal trauma hemorrhagic shock and, 46
anterior wounds, 296 indications for intervention, 43, 44t
blunt injuries and, 181–183, 206, 210, 290–291 jaw-thrust maneuver for, 9, 47, 48f, 175
burn injuries, 140 laryngeal mask airways for, 9, 49, 49f, 177
CT for, 182, 228, 230, 294–296, 294t, 300, 313 lateral positioning for, 47
DPL for, 13, 85, 182, 294–296, 294t, 296f, 315 mask ventilation for, 9, 47, 48f, 57, 175–177, 197
FAST for, 13, 85, 86f, 182, 294–296, 294t, 295f, 312 in mass casualty situations, 47, 251
firearm injuries and, 291–292, 296, 313 nasopharyngeal airways for, 47, 49, 119, 176
flank and back injuries, 290, 296–297 neck injuries and, 175, 309, 310
nonoperative management of, 182, 296, 313 obese patients and, 15, 44, 61
pediatric patients and, 181–183 older adults and, 61, 197, 197t, 198
penetrating injuries and, 181, 183, 291–292, 292f, 296, oropharyngeal airways for, 47, 49, 175
312–315 oxygen delivery devices for, 46, 47f
physical examination for, 293–294, 296 patient transfers and, 61
ultrasound for, 85, 86f pediatric patients and, 62, 172, 175–177, 176f
visceral injuries and, 182–183, 223t, 235t penetrating injuries and, 308–310
x-rays for, 295, 314 practice environment considerations, 44, 77
ABGs. See Arterial blood gases pregnant patients and, 61, 211
ABI (ankle-brachial index), 152, 152f, 157, 307 primary survey and, 9, 25, 43, 44t
Abuse. See also Intimate partner violence reassessment and, 61, 61b
burn injuries as indicators of, 138, 142 spinal cord injuries and, 29, 120
of children, 30, 138, 142, 185–186, 263, 264f, 275t spinal motion restriction and, 9, 44, 46–47, 57–58, 120
of older adults, 142, 196, 196b, 260, 263, 265f, 275t suction and removal of foreign material in, 47
AC. See Anterior chamber supraglottic airways for, 9, 49–50, 50t, 176
ACEP (American College of Emergency Physicians), 110, 111t trauma resuscitation teams and, 25–27, 53
Acetazolamide, 321, 322f traumatic brain injuries and, 61, 120
Acidosis Airway obstruction
frostbite and, 144 assessment for, 9, 310
metabolic, 60, 66, 83, 92, 137, 159, 231, 314 burn injuries and, 43, 136, 175
post-tourniquet syndrome and, 331 maxillofacial fractures and, 43
respiratory, 66, 177, 211 partial, 42, 175
thoracic trauma and, 68 pediatric patients and, 175
in trauma lethal triad, 130, 179 penetrating injuries and, 310
ACLS (Advanced Cardiac Life Support), 94, 217 signs of, 43, 44t, 45, 49
ACS. See American College of Surgeons American Burn Association (ABA), 142, 143t
Active interventions, 259 American College of Emergency Physicians (ACEP), 110, 111t
Active shooter events, 333–334, 334b American College of Surgeons (ACS)
Acute care facilities, 235, 245, 246 Advanced Surgical Skills for Exposure in Trauma course, 246
Acute myocardial infarction (AMI), 85 Advanced Trauma Operative Management course, 246
Advanced Cardiac Life Support (ACLS), 94, 217 Committee on Trauma, 5, 14, 246–247, 271
Advanced Surgical Skills for Exposure in Trauma (ASSET) Disaster Management and Emergency Preparedness course,
course, 246 250, 251, 255
Advanced Trauma Care for Nurses (ATCN), 22 Stop the Bleed campaign, 5, 38, 153f, 246, 334f
Advanced Trauma Operative Management (ATOM) course, 246 Trauma Evaluation and Management course, 246
Ageism, 202, 284 American Heart Association, 175, 176
Aging populations. See Older adults American Spinal Injury Association (ASIA), 108, 109f
Airbag injuries, 222, 292t AMI (Acute myocardial infarction), 85
Airway anatomy and physiology, 42 Amnesia, 111t, 183
Airway edema, 9, 29, 43 AMPLE history, 138, 165, 213t, 214, 215t, 225, 236, 236t

338 Advanced Trauma Life Support® | 11th Edition

 COURSE MANUAL | Index

Amputation, 6f, 38, 144, 152–153, 158, 161, 226–227, 227t, 238, diagnostic peritoneal, 28t, 312b, 314, 315
329t, 329–331 gastric decompression and, 13, 230, 293, 295, 297
Analgesics. See also Pain management intubation as protection against, 49, 60
for burn injuries, 140, 141b pregnant patients and, 210, 211
for fractures and joint injuries, 166, 199, 230 pulmonary, 42
for intubation, 306 risk of, 46, 197, 210
neuroworsening and, 122 Assessment of Blood Consumption (ABC) score, 313, 313b
for nonfreezing cold injuries, 144 ASSET (Advanced Surgical Skills for Exposure in Trauma)
parenteral, 230 course, 246
for traumatic brain injuries, 121 ATCN (Advanced Trauma Care for Nurses), 22
Anaphylactic shock, 10, 82, 85 Atherosclerosis, 193t, 198
Anesthesia and anesthetics Athletes, 14, 15, 92t, 93
CT scanning and, 182 ATLS in the Operational Environment (ATLS-OE), 328, 331–
for intubation, 47, 52–53, 52t, 61, 121 333, 332f
ocular trauma and, 319–321, 322f ATOM (Advanced Trauma Operative Management) course, 246
oral intake history and, 225 Atrial fibrillation, 12, 85
patient deaths under, 42 Atropine sulfate, 176, 176f
regional, 61, 158, 199 Austere environments
topical, 61, 230 communication in, 328
Angioembolization, 92, 150t, 182, 201, 230, 301 injury prevention in, 261
Ankle-brachial index (ABI), 152, 152f, 157, 307 mass casualty situations in, 250
Ankle fractures, 163, 163f, 165, 165f penetrating injuries in, 315
Ankylosing spondylitis, 124, 201 practice environment considerations, 328, 329t
Anterior abdominal wounds, 296 trauma resuscitation teams in, 21
Anterior chamber (AC), 318, 318f, 321, 323 zero survey and, 332, 333
Anterior-posterior (AP) compression fractures, 150, 151f, 300– Automobile collisions. See Motor vehicle crashes
301, 300f Awake intubation, 61
Antiarrhythmics, 94, 202 Axonal injury, 101, 110–111, 111f
Antibiotics. See also specific names and types of medications
abdominal trauma and, 313 Back, physical examination of, 229, 293, 297
cold injuries and, 144 Back injuries, 297
combat zone injuries and, 330 Backward, upward, rightward pressure (BURP), 57
intravenous, 154, 321, 323 BAI (blunt aortic injury), 235t, 297–298, 297f–298f, 297t
for lacerations, 198, 230 Balanced resuscitation, 179, 197t, 198, 313
ocular trauma and, 321, 323 Barbiturates, 197
for open fractures, 122–123, 154–156, 154t, 161, 185, 198, 230, BCIs. See Blunt cardiac injuries
314 BCVI (blunt cerebrovascular injury), 119, 119t
as prophylaxis, 230, 238, 308, 314 Benzodiazepines, 53, 197, 202
thoracic trauma and, 312 Beta blockers, 83, 93, 202, 298
Anticoagulant therapy Bilateral femur fractures, 153
hemorrhagic shock and, 84 Bladder decompression, 11, 181, 230, 294, 295, 314
older adults and, 14, 94, 121, 124, 194, 197t, 197–199, 202 Bladder injuries, 183, 228, 296
reversal strategies, 94, 95t, 121, 197t, 199, 200t Blast injuries
Anticonvulsant medications, 123, 184 in combat zones, 329–330, 329t
Antihypertensives, 83, 93, 202 dismounted complex, 329, 329t
Antiplatelet medications, 94, 121, 197–199, 202 historical information regarding, 292
Antiseizure medications, 123, 184 mechanisms of injury, 292
Anxiety, 5, 10, 29–30, 31t, 60, 80, 140, 217, 229, 235 musculoskeletal trauma and, 148, 149
Aortic rupture, 298 pelvic trauma and, 329
AP compression fractures. See Anterior-posterior compression primary, 225, 329, 330
fractures quaternary, 225, 329
Apneic oxygenation, 42, 57, 176 secondary, 149, 225, 306, 329, 330
Aqueous humor, 318, 321–323 tertiary, 149, 225, 329
Arrival handovers, 5, 22, 23, 24t, 27, 29 thoracic trauma and, 66, 68
Arterial blood gases (ABGs), 9, 12, 12f, 73, 83, 119, 137, 198, traumatic brain injuries and, 225, 329
210t, 213f Blood loss. See also Hemorrhage
Arterial hemorrhage, 8, 38, 119t, 152, 226, 301 anticoagulants or antiplatelet medications and, 197
ASIA (American Spinal Injury Association), 108, 109f in pediatric patients, 177, 178t, 185
Aspiration physiological responses to, 27–28
blood, 314 placental abruption and, 208
339
 Blood pressure. See also Hypertension; Hypotension Bradycardia
of athletes, 15 hypoperfusion and, 12
intubation and, 54f, 57, 61 hypoxia and, 12
of older adults, 124, 198, 314 pediatric patients and, 62, 176, 178, 178t
of pediatric patients, 30, 177–178, 178t, 179t shock and, 81, 85, 92t, 94, 105
penetrating injuries and, 313b, 314, 315 Brain, anatomy of, 101f, 183
physical examinations and, 83, 226 Brain death, 102
of pregnant patients, 210 Brain injuries. See also Head trauma; Traumatic brain injuries
shock and, 10, 80, 83, 86, 90, 90t, 92t, 93, 94 axonal, 101, 110–111, 111f
spinal cord injuries and, 103, 105, 120, 120t, 126 cerebral contusions, 100, 101, 111, 111f
thoracic trauma and, 68, 72, 72t, 298 extradural hematomas, 100–102, 101f, 110–111, 111f, 123
tourniquets and, 38, 39f hypoxia and, 46, 119, 120
traumatic brain injuries and, 10, 61, 120–121, 120t, 124, 126 intracerebral hematomas, 101
Blood transfusions pathologic anatomy of, 100–101, 101f
in combat zones, 331 pathophysiology of, 101–103
massive transfusion protocol, 10, 22, 179–180, 211, 313 pediatric patients and, 100, 124, 172, 173, 183–184
pediatric patients and, 179, 180 primary, 10, 100, 198
pregnant patients and, 211 secondary, 10, 100, 183, 184, 198
for shock, 80, 82, 83, 91 subdural hematomas, 100–102, 101f, 110–111, 111f, 123, 186
spinal cord injuries and, 121 traumatic subarachnoid hemorrhage, 100, 110–111, 111f
traumatic brain injuries and, 121 Breathing and ventilation. See also Airway management
type-O donors, 331 burn injuries and, 137, 137f
Blood volume description of process for, 68
cerebral, 101, 103, 121 hyperventilation, 9, 12, 52, 122, 123
femur fractures and, 153 hypoventilation, 9, 12, 46f, 52, 172, 177
in pediatric patients, 80, 93, 177–180, 178t, 183 mechanical ventilation, 52, 60, 75, 198
penetrating injuries and, 306 monitoring of, 12
as percentage of body weight, 80 older adults and, 197t, 198
in pregnant patients, 93, 208, 209 pediatric patients and, 177
shock and, 10, 80–81, 83, 92t pregnant patients and, 211
Blunt aortic injury (BAI), 297–298, 297f–298f, 297t primary survey and, 9
Blunt cardiac injuries (BCIs), 10, 12, 80t, 82, 85, 90, 91, 94, 229 trauma resuscitation teams and, 27
Blunt cerebrovascular injury (BCVI), 119, 119t Broselow Pediatric Emergency Tape, 173
Blunt trauma Brown-Séquard syndrome, 110, 110f
abdominal, 181–183, 206, 210, 290–291, 295 Bruises. See Contusions
blood loss from, 27 Bucket handle injury, 290, 291f
duodenal injuries and, 299 Bullet wounds. See Firearm injuries
esophageal injuries and, 298 Burn injuries, 136–143
to face, 222, 228 abuse indicated through, 138, 142
genitourinary, 300 airway management and, 25, 42, 43, 136, 137f, 142, 175
to head, 222, 228 anxiety management for, 140
hollow viscus injuries and, 300 breathing/ventilation and, 137
indications for laparotomy following, 297 chemical, 136, 139t, 141, 141f, 224, 225t
major arterial injuries and, 152 circulation and, 137, 140, 140f
mechanisms of injury, 222, 223t, 225, 290–291 compartment syndrome and, 140, 140f, 142
musculoskeletal, 148, 150 depth and extent of, 138–139, 138b, 138f, 139f
to neck, 228 documentation of, 138, 142
ocular injuries from, 319, 323 electrical, 139t, 140, 142, 142f, 224, 225t
older adults and, 196 fluid resuscitation and, 130–132, 131t, 137, 139–140, 139t, 142
pancreatic injuries and, 183, 299 full-thickness, 138, 139, 139f, 140f, 143t, 196, 224
pediatric patients and, 172, 181–183, 222 hypothermia and, 136, 138
pelvic injuries and, 290, 293, 300 inflammatory response to, 136, 139
peripheral nerve injury and, 110 inhalation, 25, 136–137, 137f, 140, 224, 225t
pneumomediastinum and, 73, 181, 298–299, 299f as local injuries, 130, 130t
pregnant patients and, 206, 210, 211 mechanisms of injury, 207f, 224, 224t, 225, 225t
spinal cord injuries and, 105–107, 106t older adults and, 142, 194, 196
thoracic, 66, 68, 70, 181 pain management for, 140
x-rays for, 13 partial-thickness, 138, 139, 139f, 141, 143t, 224

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patient transfers and, 142, 143t, 234 Cerebral blood flow (CBF), 102, 102f, 103, 103f, 183
pediatric patients and, 136, 138, 138f, 142, 186, 224 Cerebral blood volume, 101, 103, 121
pregnant patients and, 207f Cerebral contusions, 100, 101, 111, 111f, 309b
primary survey and, 130, 136–138 Cerebral herniation, 102, 102f
rule of nines for, 138, 138b, 138f Cerebral perfusion pressure (CPP), 103, 120t, 121, 123, 183–184,
secondary survey and, 138–142 308
shock and, 130, 136, 137 Cervical collars
stopping the burning process, 136 airway management and, 43, 58, 120, 122, 176, 197, 197t
superficial, 138b, 139, 139f, 196 pediatric patients and, 29, 106, 106t, 124, 174t, 176
thermal, 137f, 139t, 224, 225t spinal motion restriction and, 12, 71, 105–106, 106t, 201, 201f,
wound care for, 138, 141, 141b 310
BURP (backward, upward, rightward pressure), 57 Cervical spine, anatomy of, 103, 103f–104f
Burr-hole evacuation, 126 Cervical spine injuries
airway management and, 9, 56
Canadian C-Spine Rule (CCR), 112, 113f clinical clearance of, 112, 114
Canthal tendons, 318, 318f, 320 fractures, 105, 115, 117f, 194, 201, 201f
Cantholysis, 320–323, 322f imaging studies for, 112–115, 113f–114f, 115t, 116f–117f
Capnography, 11, 12, 12f, 45–47, 46f, 54f, 57, 61, 73, 77, 175, 226 motion restriction for, 9, 12, 112, 114, 175, 201, 228
Carbon monoxide poisoning, 12, 43, 137, 224, 225t pediatric patients and, 184
Carboxyhemoglobin (COHb), 136, 137 Cesarean delivery, 206, 211, 213f, 217
Car crashes. See Motor vehicle crashes Chance fractures, 183, 222
Cardiac arrest Chemical agents
CPR and, 9, 94 burns from, 136, 139t, 141, 141f, 224, 225t
hypothermia and, 130 combat zone exposure to, 330
pediatric patients and, 175, 177, 181 disaster management and, 253, 255
penetrating thoracic trauma and, 310–311 ocular trauma from, 319, 320, 320f, 323
pregnant patients and, 217 Chest. See also Thoracic trauma
signs of life during, 96, 96t anatomy of, 66–68, 67–68f, 290
Cardiac box, 66, 68f, 311, 311f burn injuries on, 136, 137, 140
Cardiac contusions, 82, 181 decompression of, 9, 66, 68, 75, 255, 311, 330
Cardiac dysrhythmias, 12, 130, 131t, 194, 198 drainage techniques, 27
Cardiac injuries, 10, 12, 80t, 82, 91t, 229, 292t, 311 physical examination of, 228
Cardiac output Children. See Pediatric patients
heart rate and, 80, 306 Circulation
hemorrhage and, 10 burn injuries and, 137, 140, 140f
penetrating injuries and, 306, 311 with hemorrhage control, 9–10
pneumothorax and, 68, 81 musculoskeletal trauma and, 166
pregnant patients and, 209–210, 212 older adults and, 197t, 198
shock and, 80, 81 pediatric patients and, 177–181, 178t–179t
signs of poor output, 9, 12, 45 peripheral, 140, 140f
Cardiac tamponade, 10, 12, 80f, 81–82, 82f, 84–85, 91t, 92, 94, 96, pregnant patients and, 209–212
224t, 310–311 primary survey and, 9–10, 290
Cardiogenic shock, 10, 80, 80t, 82, 85, 91t, 94 return of spontaneous circulation, 9, 12
Cardiopulmonary resuscitation (CPR), 9, 12, 94, 181, 236, 246 spinal cord injuries and, 120–121
Cardiovascular changes during pregnancy, 209–210, 210t trauma resuscitation teams and, 27–29, 28t
Care Under Fire, 330, 331 traumatic brain injuries and, 120–121
Carotid artery injuries, 309, 310f Clavicular fractures, 148, 228
Catheters Coagulopathy
flow rate, 89, 89f as contraindication for DPL, 295
gastric, 11, 12f, 13, 230, 293 hemorrhagic shock and, 93
intravascular, 132 hypothermia and, 11, 130
intravenous, 12 penetrating head trauma and, 308
suction, 47 pregnant patients and, 210, 212
urinary, 11, 12f, 13, 139, 180, 230, 294, 309, 314 rhabdomyolysis and, 159
CBF (cerebral blood flow), 102, 102f, 103, 103f, 183 spinal cord injuries and, 121
CCR (Canadian C-Spine Rule), 112, 113f in trauma lethal triad, 130, 179
Centers for Disease Control and Prevention (CDC), 100, 260 traumatic brain injuries and, 121
Central cord syndrome, 110, 110f, 201 COHb (carboxyhemoglobin), 136, 137
Central herniation, 102, 102f Cold injuries. See also Hypothermia
Cephalosporins, 154 frostbite, 130–132, 130t, 142–144, 143f, 224
nonfreezing, 142, 144
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 obese patients and, 15
Combat zones, 328–334 for pelvic trauma, 230, 295, 313
ATLS-OE and, 328, 331–333, 332f for penetrating injuries, 125–126, 125f, 311–314
blast injuries in, 329–330, 329t for pneumomediastinum, 299, 299f
blood transfusions in, 331 pregnant patients and, 213, 216, 217
chemical agent exposure in, 330 radiation exposure and, 74, 182, 295
communication in, 328 for retrobulbar hemorrhage, 320
firearm injuries in, 329 in secondary survey, 230
infrastructure considerations in, 328 for spinal cord injuries, 114–117, 115t, 116f–118f, 117t, 185
patient transfers in, 330–331, 333 for thoracic trauma, 73f, 74, 230, 311–312
practice environment considerations, 328, 329t for traumatic brain injuries, 110–112, 111–112f, 111t, 199
radiation exposure in, 330 Conjunctiva, 318, 318f, 320
security considerations in, 328 Consent, 16, 154, 215
situational awareness in, 331 Contrast studies, 296, 299, 312
special populations and, 328 Contusions
Tactical Combat Casualty Care, 330–331 blunt trauma and, 148
tourniquets in, 330, 331 cardiac, 82, 181
trauma systems in, 330–331 cerebral, 100, 101, 111, 111f, 309b
Communication. See also Serious news conversations management of, 159
ABCDE tool for, 280, 281f, 282, 284 older adults and, 197
in airway management, 25–26, 42, 43, 53, 57 pulmonary, 9, 68, 71–77, 72t, 73f, 173, 181, 228, 292t
in austere environments, 328 from restraint devices, 290, 291f
in combat zones, 328 Cornea, 227, 318, 318f, 321, 323
culturally appropriate, 280, 284 CPP. See Cerebral perfusion pressure
CUS approach for speaking up, 25t CPR. See Cardiopulmonary resuscitation
empathetic, 15, 273, 283, 283f Cranial nerves, 227, 227t, 310
goals of care discussions, 32 Cribriform plate fractures, 13, 230
Incident Command System and, 250, 254, 254f Cricoid pressure technique, 56
in initial assessment, 15, 222 Cricothyroidotomy, 58, 59f, 177
injury prevention and, 259, 259f, 261, 262f Crisis resource management (CRM), 20, 22, 30
NURSE tool for, 283, 283f Critical access hospitals, 234, 235
patient transfers and, 14, 235t, 235–236, 236t, 238 Critical neuroworsening, 121, 122
physical examinations and, 226 Crush injuries, 66, 71, 148, 152, 159, 165, 185, 223t, 290, 297,
SBAR tool for, 7f, 20, 235–236, 236t, 238 329t
S-xABCDE-BAR tool for, 5, 7f, 14, 236t Crush syndrome, 150, 158–159
three Cs associated with, 21, 24, 24t CT. See Computed tomography
in trauma-informed care, 217, 273, 274t Culturally appropriate care and communication, 280, 284
trauma resuscitation teams and, 5, 20–21, 24–26, 30, 32, 32t, CUS approach for speaking up, 25t
273 Cyanide inhalation, 43, 137, 225t
Compartment syndrome Cyanosis, 68, 71, 73, 144
burn injuries and, 140, 142 Cystography, 296
extremities and, 140, 157, 157–158f, 229
management of, 140, 140f, 158, 158f, 166 DAI (diffuse axonal injury), 101, 111, 111f
musculoskeletal trauma and, 148, 157–158, 165, 185 Debriefings, 5, 22, 32, 32t, 186, 254, 283–284
ocular trauma and, 318–320 Deceleration injuries, 290, 292, 292t
pathophysiology of, 157, 157f Decision-making
risk factors for development of, 158 ageism in, 202
signs and symptoms of, 157b amputations and, 153
Computed tomography (CT) collaborative nature of, 280
for abdominal trauma, 182, 228, 230, 294–296, 294t, 313 patient histories and, 165
airway management and, 46 for patient transfers, 14, 234, 238
for blunt aortic injury, 297, 298f shock diagnosis and, 83
in determination of patient destination, 25 trauma resuscitation teams and, 5, 20, 21, 28, 30
for duodenal injuries, 299 by triage officers, 250
for esophageal injuries, 299 Decompression
for flank and back injuries, 297 of bladder, 181, 230, 295, 314
for genitourinary trauma, 296, 300 of chest, 9, 66, 68, 75, 255, 311
for head trauma, 183, 184, 230 of hemothorax, 75, 311
multidetector, 110, 115, 116f of stomach, 13, 181, 230, 294t, 295, 314
for musculoskeletal trauma, 152, 154, 157 of tension pneumothorax, 75, 176, 177, 251, 330
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Decompressive craniectomy, 122, 123 initial assessment and, 16

Decontamination, 136, 141, 253, 255 of neurological injuries, 107, 124, 159
Definitive airways. See also Intubation of open fractures, 154, 161
definition of, 9, 49 patient transfers and, 16, 166, 238, 239t
surgical/incisional, 9, 57–58, 58–59f, 120, 176, 176f, 309–310 of penetrating injuries, 307, 312, 313
trauma resuscitation teams and, 25–26, 27f of tourniquet application, 152, 153
Definitive care. See Patient transfers to definitive care Domestic violence. See Intimate partner violence
Delayed-sequence intubation, 56 DOPE mnemonic, 61, 61b
Denitrogenation, 56 DPL. See Diagnostic peritoneal lavage
Deoxyhemoglobin, 12 Drug-assisted intubation. See Rapid-sequence intubation
Departure handovers, 5, 22, 30 Duodenal injuries, 299
Depressed skull fractures, 122, 123 Dyspnea, 43, 71–73, 299
Depression, 197, 199, 263, 272, 272b Dysrhythmias, 12, 130, 131t, 194, 198
Dermatomes, 107–108, 107f, 108t, 227, 228f
Diagnostic laparoscopy, 295, 296, 314 Eclampsia, 210, 212
Diagnostic peritoneal aspiration, 28t, 312, 314, 315 EDHs. See Extradural hematomas
Diagnostic peritoneal lavage (DPL), 11, 13, 15, 85, 86f, 103, 182, eFAST. See Extended FAST
232, 294–297, 294t, 296f, 315 Elderly adults. See Older adults
Diagnostic studies. See also specific tests Electrical burns, 139t, 140, 142, 142f, 224, 225t
in mass casualty situations, 251, 252f Electrocardiographs (ECGs), 11, 12f, 85, 142, 198, 209, 210, 229
obese patients and, 13, 15, 295 Electrolytes, 94, 123, 158
in primary survey, 13, 198, 290 Emergency medical services (EMS)
in secondary survey, 229–230 in active shooter events, 334
Diaphragm injuries, 66, 68, 70–74, 71f, 72t, 76–77, 85, 181, 294t, prehospital reports, 23, 29
298, 314 tourniquets placed by, 38, 226
Diffuse axonal injury (DAI), 101, 111, 111f in trauma systems, 244, 245, 247
Direct laryngoscopes (DLs), 50, 51f triage by, 5, 6f
Direct thrombin inhibitors, 95t, 200t 202 Emphysema, subcutaneous, 43, 73f, 74, 228, 299, 299f
Disability. See also Neurological evaluation Endotracheal intubation, 13, 27f, 42, 46f, 62, 71, 120, 122, 136,
cognitive, 173, 232 137f, 175, 184, 211, 322f
learning, 29, 173 End-tidal oximetry, 46
long-term, 119, 148 Environmental threats. See Exposure and environmental threats
neurodevelopmental, 29 Epidural hematomas. See Extradural hematomas
in older adults, 197t, 198 Epinephrine, 52t, 53, 131t, 145t, 320
in pediatric patients, 173 Escharotomy, 140, 140f
in pregnant patients, 212 Eschmann endotracheal tube introducer (bougie), 51, 51f
primary survey and, 10, 106–107 Esophageal injuries, 298, 299
secondary survey and, 107–110, 227 Etomidate, 52t, 53, 176f
visual, 318 Explosive injuries. See Blast injuries
Disaster management. See also Mass casualty situations Exposure and environmental threats. See also Cold injuries; Heat
chemical agents and, 253, 255 injuries
debriefings and, 254 assessment process, 131–132
hazard vulnerability analysis and, 246 interventions/treatments for, 130–131t, 132
Incident Command System and, 250, 254–255, 254f mechanisms of injury, 224, 225, 225t
injury prevention and, 253 older adults and, 197t, 198
phases of, 253–254 pathophysiology of, 130–131
radiation exposure and, 253, 255 penetrating injuries and, 307
search and rescue in, 253 pregnant patients and, 212
trauma systems and, 246 primary survey and, 11, 130–132
triage and, 251, 253–254, 253f trauma resuscitation teams and, 29
Disaster Management and Emergency Preparedness (DMEP) Exsanguinating external hemorrhage
course, 250, 251, 255 assessment of, 38
Dismounted complex blast injury, 329, 329t in combat zones, 331
Distributive shock, 10, 80, 80t, 82 management of, 8–10, 29, 38–39
DLs (direct laryngoscopes), 50, 51f in mass casualty situations, 251
Documentation musculoskeletal trauma and, 150
airway management and, 26 older adults and, 197
of burn injuries, 138, 142 pregnant patients and, 211
of contusions, 159 primary survey and, 8–9, 38, 39
departure handovers and, 30 shock and, 86
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 Extended FAST (eFAST), 13, 74, 85, 91, 198, 229, 311–312, 314, heart rate and tones, 209, 212, 215, 229
315 penetrating injuries and, 314
External laryngeal manipulation, 57 preterm births, 206, 207
Extradural hematomas (EDHs), 100–102, 101f, 110–111, 111f, stillbirths, 206, 207
123, 126 Fibrinogen, 209, 210t, 215
Extraocular muscles, 227, 318, 318f, 321 Finger thoracostomy, 27, 75, 77, 311
Extremities Firearm injuries
blast injuries and, 225 abdominal, 291–292, 296, 313
burns and, 140, 140f bullet wound assessment, 307, 307f
compartment syndrome and, 140, 157, 157–158f, 229 in combat zones, 329
frostbite and, 144 to head, 124, 125f, 308, 309b
hemorrhage and, 8, 38–39, 39f, 313, 331, 334 older adults and, 196
musculoskeletal trauma and, 153–159 pediatric patients and, 172, 314–315
neurological exam of, 227 risk factors and prevention strategies, 262t
penetrating injuries to, 238, 313, 314, 314t secondary survey and, 224, 224t
peripheral nerve assessment, 159, 160t spine injuries from, 125
physical examination of, 229 thoracic, 68, 299, 311, 312f
Eyelid lacerations, 319, 323 tissue damage from, 291
Eyes. See also Ocular trauma x-rays for, 311, 312f, 314
anatomy of, 318, 318f First-aid courses, 246
intraocular pressure, 319–321 First-degree (superficial) burns, 138b, 139, 139f
irrigation of, 141, 320, 320f, 323 Flail chest, 6t, 70, 70f, 72t, 73, 76–77, 181, 223t, 228, 234
physical examinations, 227, 318, 319 Flank injuries, 68, 297
vision examinations, 319, 319f Flank region, 68, 74, 290, 291f, 293
Fluid resuscitation. See also Blood transfusions
Face, physical examination of, 227 burn injuries and, 130–132, 130t, 131t, 137, 139–140, 139t,
Facial injuries 142
airway management and, 25, 43, 46, 49, 309 hypovolemia and, 50, 53, 54f
blunt trauma and, 222, 228 musculoskeletal trauma and, 159
burns, 136, 137f obese patients and, 15
maxillofacial trauma, 42–43, 234, 271, 309 pediatric patients and, 139, 139t, 172, 177–180, 180f
penetrating, 309 pregnant patients and, 211
Falls for shock, 86, 89, 94
blunt trauma from, 222, 223t, 290, 297 Fluoroquinolones, 321, 323
historical information regarding, 292 Focused assessment with sonography for trauma (FAST)
musculoskeletal trauma and, 148–150 for abdominal trauma, 13, 85, 86f, 182, 294–296, 294t, 295f,
older adults and, 14–15, 192, 194, 199, 201–202, 260–261, 312
262t extended, 13, 74, 85, 198, 229, 311–312, 314, 315
pediatric patients and, 172, 173t, 181, 183 fetal, 212, 212t, 213f, 215
pelvic fractures and, 300, 301 obese patients and, 13, 15
pregnant patients and, 206, 207f for pelvic trauma, 293, 294
risk factors and prevention strategies, 262t for penetrating injuries, 311–312, 312b, 314
traumatic brain injuries from, 194, 199 in primary survey, 13, 198
Fasciotomy, 140, 142, 158, 158f, 320 in secondary survey, 229
FAST. See Focused assessment with sonography for trauma for thoracic trauma, 74
Fat embolism, 150, 153 Fractures. See also Femoral fractures; Open fractures; Pelvic
Femoral fractures fractures; Rib fractures; Skull fractures; Spinal column
bilateral, 153 fractures
hemorrhage and, 13, 84, 148, 153 ankle, 163, 163f, 165, 165f
immobilization of, 162, 162f clavicular, 148, 228
indications of, 151, 223t cribriform plate, 13, 230
patient transfers and, 166 to extremities, 8, 185, 229, 234
pediatric patients and, 185 hip, 194
x-rays for, 149f immobilization of, 153, 159, 161–163, 162–164f, 185, 230
Fentanyl, 52t, 53, 121, 176 maxillofacial, 42–43
Fetus. See also Pregnant patients nasal bone, 227
cesarean delivery of, 206, 211, 213f, 217 neurological injury secondary to, 159, 160t
electronic monitoring of, 215, 215f orbital, 227, 319, 323
FAST exam for, 212, 212t, 215 pain management for, 66, 76, 161, 166, 199, 230

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physeal, 185 Hematomas

splinting, 11, 12f, 13, 87, 150, 153, 157, 161–163, 162–163f, extradural, 100–102, 101f, 110–111, 111f, 123, 126
185, 229–230, 314 intracerebral, 101, 123
sternum, 228 neck, 234, 309, 310
supracondylar, 160t, 185 older adults and, 197
tibial, 84, 154f, 162 periwound, 307
Frailty, 192, 194–196, 195t, 199, 201, 202 pulsatile, 152
Frostbite, 130–132, 130t, 142–144, 143f, 224 retroperitoneal, 84, 228, 291
Full-thickness burns, 138, 139, 139f, 140f, 143, 196, 224 septal, 227
Fundal height, 208, 209f, 212, 213f, 293 soft-tissue, 13
subdural, 100–102, 101f, 102f, 110–111, 111f, 123, 186
Gastric catheters, 13, 230, 293 Hemoglobin, 9, 12, 83, 120t, 121, 137, 159, 314
Gastrointestinal injuries, 183, 230, 314 Hemorrhage. See also Blood loss; Exsanguinating external
Gastrointestinal system changes during pregnancy, 210 hemorrhage
Genitourinary trauma, 229, 293, 296, 300, 312, 314 in active shooter events, 333–334
Geriatric patients. See Older adults anatomic locations for, 10, 11f, 28t, 83, 84f
Glasgow Coma Scale (GCS) arterial, 8, 38, 152, 226, 301
airway management and, 9 circulation with control of, 9–10
for level of consciousness assessment, 10, 227 in combat zones, 330
for older adults, 198 compressible, 38–39
for pediatric patients, 30, 183–184, 183t definition of, 80
scoring for, 106, 106t, 111t, 114f extremities and, 8, 38–39, 313, 331, 334
traumatic brain injury classification, 106, 107t femoral fractures and, 13, 84, 148, 153
Gluteal examination, 293 intra-abdominal, 13, 84, 172, 182, 185, 226, 231, 294, 314
Gum-elastic bougie, 51, 51f intracranial, 111, 111f, 172, 198, 227, 230
Gunshot wounds. See Firearm injuries major arterial injuries and, 152–153
musculoskeletal trauma and, 148, 150, 185
Haddon's Matrix, 259, 260f noncompressible, 38, 39, 334
Hand injuries, 163, 163f, 234 orbital, 320, 322f
Hartford Consensus, 38, 333–334 pelvic fractures and, 84, 150–152, 293, 300, 301, 301f
Hazardous environments. See Exposure and environmental penetrating injuries and, 27, 306–310, 313, 315
threats retinal, 186
Hazard vulnerability analysis, 246 retrobulbar, 227, 320
Head, physical examination of, 107, 227 soft-tissue injuries and, 8, 84–85
Head trauma. See also Brain injuries; Skull fractures thoracic trauma and, 66, 69, 72, 72t, 76
airway management and, 25, 308 Hemorrhagic shock
blunt injuries and, 222, 228 airway management and, 46
CT for, 183, 184, 230 anticoagulant therapy and, 84
firearms and, 308, 309b fractures and, 84, 153
management of, 184 hypovolemic, 9, 12, 80–81, 177–178, 301
pediatric patients and, 183–184 massive hemothorax and, 72, 72t
penetrating, 124–125, 124f, 125f, 234, 308, 309b medications and, 93–94
Health Insurance Portability and Accountability Act (HIPAA), pathophysiology of, 80–81, 81t
16 pelvic fractures and, 301, 301f
Heart rate penetrating head trauma and, 308
of athletes, 93 pregnant patients and, 92t, 93, 211
cardiac output and, 80, 306 resuscitation targets in, 90, 90t
fetal, 31, 209, 212, 215 spinal cord injuries and, 29
of older adults, 124, 198, 314 tranexamic acid and, 93, 93f
of pediatric patients, 177, 178t Hemothorax
physical examinations and, 83, 179t, 226 assessment and diagnosis of, 13, 72–74, 72t, 73f, 228–229
of pregnant patients, 30, 209–210 decompression of, 75, 75f, 311
shock and, 83, 93, 121 massive, 9, 69, 72, 72t, 76, 85, 85f
Heat injuries. See also Burn injuries pathophysiology of, 69
heatstroke, 130, 144, 145t penetrating injuries and, 311
hyperthermia, 130, 130t, 132, 144, 145t, 183 Hepatic injuries, 314
Hematocrit, 83, 209, 210t

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 HICS (Hospital Incident Command System), 254 burn injuries and, 136, 138
High-flow nasal oxygen (HFNO), 46, 47f, 56, 57 coagulopathy and, 11
HIPAA (Health Insurance Portability and Accountability Act), 16 definition of, 130, 144, 224
Hip dislocation, 159 dysrhythmias and, 12
Hip fractures, 194 interventions for, 130–131t, 132, 145t
History in older adults, 15
AMPLE, 138, 165, 213t, 214, 215t, 225, 236, 236t patient transfers and, 238
burn injuries and, 138 in pediatric patients, 14, 172, 181
musculoskeletal trauma and, 165, 185 prevalence of, 130
obstetric, 214, 215t shock and, 11
ocular trauma and, 318 stages of, 130, 131t, 145t
in secondary survey, 138, 214, 222, 225 systemic, 11, 130, 130t, 132
shock and, 83 in trauma lethal triad, 130, 179
Hollow viscus injuries, 300 Hypoventilation, 9, 12, 52, 172, 177
Hospital Incident Command System (HICS), 254 Hypovolemia
Humanistic care. See Trauma-informed care burn injuries and, 140
Hydroxycobalamin, 137 ECG monitoring for, 12
Hyperglycemia, 123, 140 fat embolism and, 153
Hyperosmolar agents, 121–123, 122t fluid resuscitation and, 50, 137
Hypertension in older adults, 176f, 193t, 197t, 198
intracranial, 102 in pediatric patients, 14, 30, 177, 178, 183
medications causing, 53 in pregnant patients, 209, 211
in older adults, 14, 198 tachycardia and, 80
in pregnant patients, 210, 212 Hypovolemic shock, 9, 12, 80–81, 177–178, 301
Hyperthermia, 130, 130t, 132, 144, 145t, 183 Hypoxemia
Hypertonic saline, 121–122, 122t, 184, 230 airway management and, 45, 46
Hyperventilation, 9, 12, 52, 122, 123 burn injuries and, 137, 140
Hypervolemia, 92t, 211 mental status changes and, 68, 71, 137
Hyphema, 323 pediatric patients and, 62
Hypocapnia, 209 pregnant patients and, 211
Hypoglycemia, 10, 123, 140 spinal cord injuries and, 29, 120
Hyponatremia, 123 thoracic trauma and, 69–71, 73, 75, 76
Hypoperfusion traumatic brain injuries and, 100
cerebral, 310 Hypoxia
cold injuries and, 224 airway management and, 49, 61
ECG monitoring for, 12 brain injuries and, 46, 79, 119, 120
older adults and, 198 burn injuries and, 137
pulse oximetry and, 45 ECG monitoring for, 12
shock and, 83, 93, 175 mental status changes and, 175
traumatic brain injuries and, 184 older adults and, 198
Hypotension pediatric patients and, 172, 175, 177, 183, 184
abdominal trauma and, 296 pregnant patients and, 211
airway management and, 9, 45, 61 pulse oximetry and, 45
cardiac tamponade and, 84 thoracic trauma and, 71
cyanide inhalation and, 137
medications causing, 53 ICP. See Intracranial pressure
musculoskeletal trauma and, 166 ICS (Incident Command System), 250, 254–255, 254f
older adults and, 198 IEDs (improvised explosive devices), 329
pediatric patients and, 178, 178t, 183 IMIST-AMBO handover tool, 23, 24t
pelvic trauma and, 293, 300, 301 Immobilization. See also Spinal motion restriction
permissive, 10, 90, 120 cold injuries and, 142
post-tourniquet syndrome and, 331 of fractures, 153, 159, 161–163, 162f–164f, 185, 230
pregnant patients and, 14, 211, 212 of joint injuries, 161
shock and, 10, 80–82, 85, 94, 105, 140, 178t patient transfers and, 166
spinal cord injuries and, 120 of pediatric patients, 29, 175
thoracic trauma and, 9, 69, 72 of venous injuries, 307
traumatic brain injuries and, 100, 120 Impalement. See Penetrating injuries
Hypothermia Improving Social Determinants to Attenuate Violence (ISAVE)
acidosis and, 130 workgroup, 271

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Improvised explosive devices (IEDs), 329 pediatric patients and, 183–184

Incident Command System (ICS), 250, 254–255, 254f spinal motion restriction and, 201
Incisional airways. See Surgical/incisional airways Intracranial volume, 101, 102f
Inhalation injuries, 25, 136–137, 137f, 140, 224, 225t Intrafacility patient transfers, 236
Initial assessment. See also Primary survey; Secondary survey Intraocular pressure, 319–321
of athletes, 15 Intraosseous (IO) access, 12, 89, 89f, 137, 178, 179f, 308
communication in, 15, 222 Intravascular catheters, 132
definitive care and, 14 Intravenous (IV ) access, 12, 89, 178–179, 212, 214f
documentation and, 16 Intravenous catheters, 12
elements of, 4, 4f, 251f Intravenous pyelogram (IVP), 296, 300
injury prevention and, 15–16, 260–261, 260f Intubation. See also Rapid-sequence intubation
legal considerations in, 16 awake, 61
in mass casualty situations, 250–251, 252f checklists for, 26, 27f
of obese patients, 15 delayed-sequence, 56
of older adults, 14–15, 197–198, 197t, 231 endotracheal, 13, 27f, 120, 122, 136, 175, 184, 211
of pediatric patients, 14, 231 obese patients and, 15
of pregnant patients, 14, 211–215, 213f older adults and, 197
prehospital phase, 5, 6f orotracheal, 175–176, 310
preparation for, 5, 7 pediatric patients and, 62, 175–176, 176f, 184
reevaluation in, 14, 231 post-intubation management, 57, 60, 60t
resource-appropriate care, 7, 232 pregnant patients and, 211
teamwork during, 5 videoscopic, 310
triage and, 5, 6f, 7 IO access. See Intraosseous access
Injured extremity index, 152, 152f IPV. See Intimate partner violence
Injured Trauma Survivor Screen (ITSS), 272, 272b Iris, 318, 318f, 321, 323
Injury prevention, 258–266 ISAVE (Improving Social Determinants to Attenuate Violence)
in austere environments, 261 workgroup, 271
communication and, 259, 261 ITSS (Injured Trauma Survivor Screen), 272, 272b
disaster management and, 253 IV access. See Intravenous access
Haddon's Matrix and, 259, 260f IVP (intravenous pyelogram), 296, 300
initial assessment and, 15–16, 260–261
by mechanism and risk factors, 261, 262t Jaw-thrust maneuver, 9, 47, 48f, 175
passive vs. active interventions, 259 Joint injuries, 149, 149b, 154, 157, 159–161, 160t, 166
pediatric patients and, 186 Joint Trauma System (JTS), 330–331
practice environment considerations, 261 Junctional tourniquets, 9, 39
public health principles of, 260
screening tools for, 262–263, 263–265f Ketamine, 52t, 53, 56, 76, 121
social determinants of health and, 258, 261 Kleihauer-Betke (KB) test, 213t, 215, 217
special populations and, 261–262 Knee injuries, 161
Three Es approach to, 258–259, 259f, 261 Kyphosis, 124, 201, 201f
trauma-informed care and, 260, 262
in trauma systems, 244–245, 247 Lacerations
Vision Zero movement and, 261, 261b antibiotics for, 198, 230
Inotropic agents, 52–53, 52t to chest wall, 69, 76
Interfacility patient transfers, 14, 236, 238 diaphragmatic, 74
International Standards for Neurological Classification of Spinal eyelid, 319, 323
Cord Injury, 108, 109f to liver and spleen, 290
Intimate partner violence (IPV ) to mediastinal pleura, 299
pregnant patients and, 207, 207f, 217 to neck, 310
risk factors and prevention strategies, 262t ocular, 227, 321
screening questions for, 225, 226b, 263, 263f perineal, 229, 293
Intra-abdominal hemorrhage, 13, 84, 172, 182, 185, 226, 231, scalp, 29, 38, 107, 227
239, 294, 314 structural harm from, 159
Intracerebral hematomas, 101, 123 vaginal, 229, 293
Intracranial hemorrhage, 101f, 111, 111f, 172, 198, 227, 230 Lacosamide, 123
Intracranial pressure (ICP) Lactated Ringer's (LR) solution, 130, 137, 139–140, 153, 320
brain injuries and, 61, 101–103, 102f, 230 Laparotomy, 13, 182, 291, 295–297, 299–300, 312, 312b
management of, 45, 53, 176, 308 Lap-belt injuries, 182, 183, 291f, 292t
noninvasive assessment of, 119 Laryngeal handshake, 58, 58f

347
 Laryngeal mask airways (LMAs), 9, 49, 49f, 177 Medical evacuation (MEDEVAC) platform, 330
Laryngoscopes, 47, 50, 51f, 56–57, 62, 174t, 175 Medications. See also specific names and types of medications
Lateral canthotomy, 320–323, 322f mental status changes due to, 222
Lateral compression pelvic fractures, 151f, 300, 300f, 301 older adults and, 14, 61, 121, 124, 194, 197–199, 202
Lateral positioning for airway management, 47 patient history and, 85, 165, 214, 225
Leaders. See Trauma team leaders pediatric patients and, 176, 184
Legal considerations, 16, 154, 186 for rapid-sequence intubation, 52–53, 52t, 57, 61, 306
Lens, of eye, 318, 318f shock and, 82, 83, 85, 93–94
Level of consciousness, 9–10, 43, 46, 80, 81f, 100, 106, 114, 136, Metabolic acidosis, 57, 60, 66, 83, 92, 137, 159, 231, 314
176–177, 227, 308 Metaraminol, 52t, 53
Levetiracetam, 123 Midazolam, 52t, 176, 176f
Lidocaine, 76, 176, 320 Military operations. See Combat zones
Ligament injuries, 148–149, 161, 162f, 165, 166 MIST (Mechanism, Injuries, Symptoms and Signs, and
Limb-threatening injuries, 138, 153–159, 331 Treatment) tool, 5, 7f, 148
LMAs. See Laryngeal mask airways Monroe-Kellie doctrine, 101, 102f
Log rolling, 12, 47, 61, 71, 131, 138, 215, 229, 237, 293 Morel-Lavallée lesion, 159
LR solution. See Lactated Ringer's solution Motor vehicle crashes (MVCs)
Lumbar spine blunt trauma from, 82, 222, 223t, 290, 297
anatomy of, 103, 103f–104f Haddon's Matrix and, 259, 260f
injuries to, 117, 117t, 118f, 181, 183, 229 historical information regarding, 292
musculoskeletal trauma and, 148–150, 149f, 159
Magnetic resonance imaging (MRI), 111, 115, 119, 185, 230 older adults and, 192, 194
Major arterial injuries, 152–153, 153f pediatric patients and, 172, 173t, 181, 183, 184
Mallampati score, 45, 45f pelvic fractures and, 300, 301
Malleable stylets, 51, 51f pregnant patients and, 206, 207f
Mannitol, 121–122, 122t, 184, 230 Three Es approach for prevention of, 259, 259f
Manual inline stabilization (MILS), 56, 56f MRI. See Magnetic resonance imaging
MAP. See Mean arterial pressure MTP. See Massive transfusion protocol
Mask ventilation, 9, 47, 48f, 57, 61, 175–177, 197 Multidetector CT, 110, 115, 116f
Mass casualty events (MCEs), 10, 238, 246, 250, 328, 329, 333– Muscle strength assessment scale, 228t
334 Musculoskeletal system changes during pregnancy, 211
Mass casualty incidents (MCIs), 5, 238, 250–255, 252f Musculoskeletal trauma, 148–167. See also Fractures; Soft-tissue
Mass casualty situations. See also Disaster management injuries
airway management in, 47, 251 amputation due to, 152–153
in austere environments, 250 blast injuries and, 149
blood product resources in, 10 blunt injuries and, 148, 150
challenges related to, 250 circulation and, 166
clinician safety during, 250, 253, 255 compartment syndrome and, 148, 157–158, 157f–158f, 165,
definitions and types of, 250 185
improving survival from, 333–334 crush syndrome, 149b, 150, 158–159
initial assessment in, 250–251, 251f–252f CT for, 152, 154, 157
patient transfers in, 238, 251, 252f falls and, 148–150
population-based care in, 250 hemorrhage and, 148, 150, 185
prehospital evaluation in, 250, 251 history and physical examination for, 165, 185
serious news conversations and, 284 joint injuries, 149, 154, 157, 159–161, 160t, 166
situational awareness during, 251, 255 lacerations and, 159
trauma system preparation for, 246 life-threatening injuries, 150
triage in, 5, 7, 238, 250–251, 253f ligament injuries, 148–149, 161, 165, 166
Mass event incidents (MEIs), 250, 255 limb-threatening injuries, 153–159
Massive hemothorax, 9, 69, 72, 72t, 76, 85, 85f major arterial injuries and, 152–153, 153f
Massive transfusion protocol (MTP), 10, 179–180, 211, 313, mechanisms of injury, 148–149, 149f
313b motor vehicle crashes and, 148–150, 149f, 159
Maternal cardiac arrest (MCA), 217 neurological evaluation and, 159, 160t
Maxillofacial trauma, 42–43, 234, 235t, 309 pathophysiology of, 148
MCEs. See Mass casualty events patient transfers and, 148, 153, 166
MCIs. See Mass casualty incidents pediatric patients and, 185
Mean arterial pressure (MAP), 94, 103, 120t, 121, 313, 315 penetrating injuries and, 149
Mechanical ventilation, 52, 60, 75, 122, 126, 197t, 198 permanent impairment caused by, 159
Mechanism, Injuries, Symptoms and Signs, and Treatment practice environment considerations, 166
(MIST) tool, 5, 7f, 148 prehospital information and, 148, 149b
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 COURSE MANUAL | Index

primary survey and, 150 Obese patients

secondary survey and, 165–166 airway management and, 15, 44, 61
ultrasound for, 152 diagnostic studies and, 13, 15, 295
vascular injuries, 156–157 fluid resuscitation and, 15
x-rays for, 161, 163–165, 164f–165f, 185 initial assessment of, 15
MVCs. See Motor vehicle crashes thoracic trauma and, 77
Myoglobin, 142, 158, 159 Obstructive shock, 80, 80t, 81, 84, 94
Myotomes, 108, 108f, 227, 228f Occult pneumothorax, 74, 75, 181
Ocular trauma, 318–324. See also Eyes
NAEMT (National Association of Emergency Medical assessment of, 318, 319, 319f
Technicians), 5 from blunt trauma, 319, 323
Nasal bone fractures, 227 from chemical agents, 319, 320, 320f, 323
Nasal cannula, 46, 47f, 57, 176, 320, 320f compartment syndrome and, 318–320
Nasogastric tubes, 74, 230, 297t, 312b, 314 corneal abrasions, 227, 321
Nasopharyngeal airways, 47, 49, 119, 175 eyelid lacerations, 319, 323
National Academy of Medicine, 270–271 flowsheet for, 324f
National Association of Emergency Medical Technicians hyphema, 323, 324f
(NAEMT), 5 lateral canthotomy and cantholysis for, 320–323, 322f
National Emergency X-Radiography Utilization Study (NEXUS), open globe injuries, 319, 321, 321f, 323
110, 112, 114, 114f orbital fractures, 227, 319, 323
National Guidelines for the Field Triage of Injured Patients, 5, 6f orbital hemorrhage, 320, 322f
Neck patient transfers and, 234, 323
anatomic zones of, 309, 309f, 310t pediatric patients and, 323
physical examination of, 107, 228, 310 penetrating injuries and, 309
Neck injuries practice environment considerations, 323
airway management and, 309, 310 retrobulbar hemorrhage, 227, 320
blunt trauma and, 228 Odontoid fractures, 201
burns, 136 Older adults, 192–202
hematomas, 234, 309, 310 abuse of, 142, 196, 196b, 263, 265f
penetrating, 228, 234, 309–310, 310f, 314 ageism and, 202, 284
vascular, 228, 230, 310 airway management and, 61, 197, 197t
zone classification of, 309, 310t blunt trauma and, 196
Needle cricothyroidotomy, 177 breathing/ventilation and, 197t, 198
Needle thoracostomy, 27, 66, 75, 75f, 77, 177 burn injuries and, 142, 194, 196
Nerve blocks, 166, 167, 199 cervical spinal column injuries in, 201, 201f
Neurogenic shock, 10, 82, 85, 94, 105, 121, 132 circulation and, 197t, 198
Neurological evaluation. See also Glasgow Coma Scale demographic trends among, 192
of burn patients, 137 disability in, 197t, 198
of cranial nerves, 227, 227t, 310 exposure/environmental threats and, 197t, 198
head trauma and, 308 exsanguinating external hemorrhage and, 197
musculoskeletal trauma and, 159, 160t falls and, 14–15, 192, 194, 199, 201–202, 260–261, 262t
neck injuries and, 310 frailty of, 14, 192, 194–196, 195t, 199, 201, 202
penetrating injuries and, 308, 310 goals of care for, 199
primary survey and, 10, 106–107 heatstroke in, 144
secondary survey and, 107–110, 227 hypothermia in, 15
trauma resuscitation teams and, 29 initial assessment of, 14–15, 197–198, 197t, 231
Neurological injuries, secondary to fractures or dislocations, 159, mechanisms of injury, 194, 196
160t medications and, 14, 61, 121, 124, 194, 197–199, 202
Neurologic system changes during pregnancy, 210 motor vehicle crashes and, 192, 194
Neuromuscular blocking drugs (NMBDs), 52–53, 52t, 60 organ systems, effects of aging on, 192, 193t
Neurosurgical consultation, 183, 184, 201, 227, 308 pelvic fractures and, 201, 301
Neuroworsening, 121, 122 penetrating injuries and, 196, 314
NEXUS. See National Emergency X-Radiography Utilization preexisting conditions and, 192, 194f, 199
Study rib fractures and, 194, 199
Nonfreezing cold injuries, 142, 144 serious news conversations with, 284
Nonhemorrhagic shock, 10 shock and, 92t, 93
Norepinephrine, 52t, 53, 94, 121 social determinants of health and, 192
NURSE communication tool, 283, 283f spinal cord injuries and, 14–15, 124, 201
thoracic trauma and, 77

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 transfer to definitive care, 202, 234 Patient transfers to definitive care, 234–238
traumatic brain injuries and, 14, 124, 194, 198, 199 airway management and, 61
Open fractures burn injuries and, 142, 143t, 234
antibiotics for, 122, 123, 154–156, 154t–155t, 161, 185, 198, checklist for, 237, 237t
230, 314 in combat zones, 330–331, 333
bilateral femoral, 153 communication and, 14, 235–236, 236t, 238
documentation of, 154, 161 decision-making for, 14, 234, 238
identification of, 154, 165 delays involving, 238
immobilization of, 161 destination options, 235
limb threats from, 148 documentation and, 16, 166, 236, 237t, 238
pelvic, 152 indications for, 234, 235t
skull, 122 interfacility transfers, 14, 236, 238
tibial, 154f intrafacility transfers, 236
Open globe injuries, 319, 321, 321f, 323 in mass casualty situations, 238, 251, 252f
Open pneumothorax, 9, 69, 70f, 72, 72t, 75–76, 76f, 234 modes of transport, 236
Operational environments. See Combat zones musculoskeletal trauma and, 148, 153, 166
Opioids, 53, 140, 141b, 199 ocular trauma and, 234, 323
Optic nerve, 318, 318f, 321 older adults and, 202, 234
Orbital fractures, 227, 235t, 318f, 319, 323, 324t pediatric patients, 172, 234
Orbital hemorrhage, 320, 322f penetrating injuries and, 234, 238, 314
Orogastric tubes, 176, 181, 229, 230 pregnant patients, 206, 215, 234
Oropharyngeal airways, 48f, 49, 57, 58t, 175 preparation for, 237–238
Orotracheal intubation, 175–176, 310 shock and, 96
Osteoporosis, 124, 148, 193t, 194, 201 thoracic trauma and, 77
Oxygenation. See also Supplemental oxygen transfer agreements, 16, 22, 234, 235, 237, 245
apneic, 42, 57, 176 PC-PTSD-5 (Primary Care Post-Traumatic Stress Disorder for
inadequacy of, 42, 50, 310 DSM- 5) screening tool, 271, 271b
intubation and, 46, 46f, 56, 57, 120, 175, 184 PEARLS debrief framework, 32
level of consciousness and, 10 PECs (preexisting conditions), 192, 194f, 199
monitoring, 12, 73–74 Pediatric Emergency Care Applied Research Network
optimization of, 9, 54t, 126 (PECARN), 106
pregnant patients and, 208, 209, 215 Pediatric patients, 172–187
temporizing technique for, 177 abdominal trauma and, 181–183
traumatic brain injuries and, 119–120, 119t, 126 abuse or neglect of, 30, 138, 142, 185–186, 263, 264f
Oxygen delivery devices, 46, 47f airway management and, 62, 172, 175–177, 176f
Oxygen saturation anatomic considerations, 62, 175, 184
abnormal, 46 blood volume in, 80, 93, 177–180, 178t, 183
intubation and, 43 blunt trauma and, 172, 181–183, 222
monitoring, 9, 12, 83, 86, 230 brain injuries and, 100, 124, 172, 173, 183–184
older adults and, 124 breathing/ventilation and, 177
physical examinations and, 226 burn injuries and, 136, 138, 138f, 142, 186, 224
pregnant patients and, 211 circulation and, 177–181, 178t–179t
pulse oximetry and, 12, 137 in combat zones, 328
Oxyhemoglobin, 12, 137 disability in, 173
equipment recommendations, 173, 174t
Pacemaker devices, 92t, 93 falls and, 172, 173t, 181, 183
Pain management. See also Analgesics firearm injuries and, 172, 314–315
burn injuries and, 140, 141b fluid resuscitation and, 139, 172, 177–180, 181f
compartment syndrome and, 158 head trauma and, 183–184
fractures and, 66, 76, 161, 166, 199, 230 hypothermia in, 14, 172, 181
nonfreezing cold injuries and, 144 hypovolemia in, 14, 30, 176f, 177–178, 183
pulmonary contusions and, 75 initial assessment of, 14, 231
in Tactical Field Care, 330 injury prevention and, 186
traumatic brain injuries and, 121 long-term effects of injury on, 173
Pancreatic injuries, 183, 299, 314 mechanisms of injury, 172, 173t
Paraplegia, 105t, 107 motor vehicle crashes and, 172, 173t, 181, 183, 184
Partial-thickness burns, 138, 139, 139f, 141, 224 musculoskeletal trauma and, 185
Passive interventions, 259 ocular trauma and, 323
Patient safety screening questions, 225, 226b penetrating injuries and, 181, 183, 314–315

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psychological status of, 173 ocular, 309

serious news conversations regarding, 284 older adults and, 196, 314
shock and, 92t, 93, 177–179 pathophysiology of, 306–307
size, shape, and surface area of, 172 patient transfers and, 234, 238, 314
skeletal characteristics, 173, 185 pediatric patients and, 181, 183, 314–315
spinal cord injuries and, 106, 124, 184–185 pelvic injuries and, 312–313
thoracic trauma and, 68, 77, 181 to peripheral nervous system, 110
transfer to definitive care, 172, 234 practice environment considerations, 315
trauma-informed care and, 181 pregnant patients and, 206–208, 207f, 314
trauma resuscitation teams and, 29–30, 186 resuscitation and, 308, 314, 315
venous access in, 178–179, 179f spinal cord injuries and, 105, 107, 125, 310, 310t
vital signs by age group, 178, 179t thoracic, 66, 68–71, 181, 308f, 310–312, 310t, 312f, 314
weight determination, 178 x-rays for, 13, 229, 308f, 311–314, 312f
Pelvic cavity, 290, 291f Performance improvement and patient safety (PIPS) programs,
Pelvic examination, 228, 293 246
Pelvic fractures Pericardiocentesis, 94
classification of, 150, 150t, 151f, 300–301, 300f Perimortem cesarean delivery, 217
clinical data consistent with, 87t Perineum, physical examination of, 215, 229, 293, 297
flowchart for, 301, 301f Periocular trauma, 319
hemorrhage and, 84, 150–152, 293, 300, 301, 301f Peripheral circulation, 140, 140f
identification of, 228, 293 Peripheral nerve assessment, 159, 160t
management of, 13, 87, 87–88f, 301 Peripheral nerve injury (PNI), 110
mechanisms of injury, 300–301 Permissive hypotension, 10, 90, 120
older adults and, 201, 301 Personal protective equipment (PPE), 5, 23, 43, 255
as open fractures, 152 Phenylephrine, 52t, 53, 94, 121
pediatric patients and, 185 Phenytoin, 123
pregnant patients and, 207, 211, 212f PHTLS (Prehospital Trauma Life Support), 5, 330, 331
x-rays for, 13, 151f Physeal fractures, 185
Pelvic stabilization, 13, 228 Physical examination
Pelvic trauma. See also Pelvic fractures of abdomen, 228, 293
blast injuries and, 329 of back, 229, 293
blunt injuries and, 290, 293, 300 of chest, 228
CT for, 230, 295, 313 for external signs of trauma, 226–227
FAST for, 293, 294 of extremities, 229
penetrating injuries and, 312–313 of eyes, 227, 318, 319
physical examination for, 228, 293 gluteal, 293
x-rays for, 13, 151f, 229, 293 of head and face, 107, 227
Penetrating injuries, 306–315. See also Firearm injuries; of neck, 107, 228, 310
Lacerations; Stab wounds for open fractures, 154
abdominal, 181, 183, 291–292, 296, 312–315 of pelvis, 228, 293
airway management and, 308–310 of perineum, 215, 229, 293
assessment of, 307, 307f–308f, 314 in primary survey, 13
blast injuries and, 330 of rectum, 108, 229, 293
CT for, 125–126, 125f, 311–314 in secondary survey, 107, 222, 226–229
documentation of, 307, 312, 313 for shock, 83
esophageal injuries and, 298, 299 of urethra, 229, 293
to extremities, 238, 313, 314, 314t of vagina, 215, 229, 293
facial, 309 vital signs and, 226
FAST and eFAST for, 311–312, 312b, 314 PIPS (performance improvement and patient safety) programs,
to flank and back, 297 246
genitourinary, 312 Placental abruption, 206–209, 215–216, 216f
to head, 124–125, 124f, 125f, 234, 308, 309b Pneumomediastinum, 73, 181, 298–299, 299f
hemorrhage and, 27, 306–310, 313, 315 Pneumothorax. See also Tension pneumothorax
to joints, 154 assessment and diagnosis of, 13, 73–74, 74f, 228, 229
major arterial injuries and, 152 management of, 75–76, 75f–76f
mechanisms of injury, 224, 224t, 225, 225t, 291–292, 306–307, occult, 74, 75
306b open, 9, 69, 70f, 72, 72t, 75–76, 76f
musculoskeletal, 149 pathophysiology of, 68–69, 69–70f
to neck, 228, 234, 309–310, 310f, 314 simple, 9, 68, 69f, 72, 72t, 74–75, 176, 226

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 PNI (peripheral nerve injury), 110 diagnostic studies during, 13, 198
Poiseuille's law, 89t disabilities (neurological evaluation) and, 10, 106–107
Post-traumatic stress disorder (PTSD), 263, 271–272, exposure/environmental threats and, 11, 130–132
271b–272b, 274 exsanguinating external hemorrhage and, 8–9, 38, 39
PPE. See Personal protective equipment in mass casualty situations, 250–251, 252f
Prearrival team huddles, 5, 21–23, 23t monitoring during, 11–12
Preeclampsia, 210, 212 musculoskeletal trauma and, 150
Preexisting conditions (PECs), 192, 194f, 199 objectives of, 4, 25, 222
Pregnancy tests, 30, 31t, 206, 229 for older adults, 197–198, 197t
Pregnant patients, 206–218. See also Fetus organization by team leaders, 24
airway management and, 61, 211 physical examination in, 13
anatomic and physiologic changes in, 206, 208–211, 209f, 210t for pregnant patients, 211–212
blood volume in, 93, 208, 209 with resuscitation, 8–13, 12f
blunt trauma and, 206, 210, 211 sequence of care, 4, 8–11, 8t
breathing/ventilation and, 211 shock and, 83–85
burn injuries and, 207f spinal cord injuries and, 106–107
cardiac arrest and, 217 trauma-informed care and, 4, 270, 273
circulation and, 209–212 Professional education and training, 246
disability in, 212 Propofol, 52t, 53, 121, 123
exposure/environmental threats and, 212 Protected health information, 16
exsanguinating external hemorrhage and, 211 Pseudosubluxation, 184
fluid resuscitation and, 211 Psychological status of pediatric patients, 173
heart rate of, 30, 179t, 209–210 PTSD. See Post-traumatic stress disorder
imaging studies and, 13, 216, 217, 229 Public education programs, 246
initial assessment of, 14, 211–215, 213f Pulmonary contusions, 9, 68, 70, 71–77, 72t, 73f, 173, 181, 228,
intimate partner violence and, 207, 207f, 217 292
mechanisms and severity of injury, 206–207, 207f Pulse oximetry, 6f, 9, 11, 12, 45, 54f, 56, 73, 77, 120t, 137
motor vehicle crashes and, 206, 207f Pupils, 319–321, 323
pelvic fractures and, 207, 211, 212f
penetrating injuries and, 206–208, 207f, 314 Quadriplegia, 107
placental abruption in, 206–209, 215–216, 216f Quality improvement programs, 246, 247, 275–276
preeclampsia and eclampsia in, 210, 212 Quaternary survey, 332, 332f, 333
Rh status of, 31t, 211, 215, 217, 230
seatbelt use by, 206, 208f Radiation exposure
serious news conversations with, 284 burns resulting from, 224
shock and, 92t, 93, 211 in combat zones, 330
thoracic trauma and, 77 computed tomography and, 74, 182, 295
transfer to definitive care, 206, 215, 234 disaster management and, 253, 255
trauma-informed care and, 217 pediatric patients and, 173, 182
trauma resuscitation teams and, 30, 31t pregnant patients and, 206, 216, 217
ultrasound for, 30, 31t, 206, 212, 216, 217, 229 x-ray examinations and, 165
uterine rupture in, 31t, 206 Radiographs. See X-ray examinations
Prehospital evaluation and management, 4, 5, 6f, 148, 149b, 250, Rapid-sequence intubation (RSI), 49–57
251, 332–333 apneic oxygenation and, 57
Prehospital Trauma Life Support (PHTLS), 5, 330, 331 cervical spine protection in, 56, 56f
Pressure dressings, 38, 226, 270, 313, 321, 330–331 checklist for, 53, 54f, 57
Preterm births, 206, 207 confirmation and post-intubation assessment, 57
Primary brain injuries, 10, 100, 198 cricoid pressure technique in, 56
Primary Care Post-Traumatic Stress Disorder for DSM- 5 (PC- equipment for, 50–53, 51f
PTSD-5) screening tool, 271, 271b flow diagram for, 53, 55f, 57
Primary prevention, 260 medications for, 52–53, 52t, 57, 61, 306
Primary survey (xABCDE) older adults and, 197
adjuncts to, 11–13, 12f optimizing attempts, 56
airway management and, 9, 25, 43, 44t pediatric patients and, 176, 176f
ATLS-OE and, 332, 332f positioning for, 56
breathing/ventilation and, 9 pregnant patients and, 211
burn injuries and, 130, 136–138 preoxygenation and, 56, 57
circulation and, 9–10, 290 preparation for, 25, 53–57, 54f–55f

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primary survey and, 9 Rocuronium, 52t, 53, 176f

procedural steps, 57 ROSC (return of spontaneous circulation), 9, 12, 96
risks related to, 49–50 RSI. See Rapid-sequence intubation
thoracic trauma and, 311 Rule of nines, 138, 138b, 138f
timing considerations, 50, 50t
trauma resuscitation teams and, 53 SBAR communication tool, 7f, 20, 235–236, 236t, 238
traumatic brain injuries and, 29 Scalp wounds, 8–9, 28t, 29, 38, 84, 107, 227
RCD (resuscitative cesarean delivery), 217 SCFs. See Spinal column fractures
Ready phase of disaster management, 253 SCIs. See Spinal cord injuries
REBOA (resuscitative endovascular balloon occlusion of the Sclera, 318, 318f, 321, 323
aorta), 301 Screening tools
Recordkeeping. See Documentation for child abuse or neglect, 263, 264f
Recovery phase of disaster management, 254 for depression, 263, 272, 272b
Rectal examination, 108, 229, 293 for injury prevention, 262–263, 263f–265f
Red blood cells, 89, 179, 209, 211, 217, 236, 323 for intimate partner violence, 225, 226b, 263, 263f
Reevaluation, in initial assessment, 14 for older adult abuse, 263, 265f
Regional nerve blocks, 166, 199 for post-traumatic stress disorder, 271–272, 271–272b
Rehabilitation, 149, 165, 244–246 SDHs. See Subdural hematomas
Reperfusion syndrome, 144, 158–159, 226 SDOH. See Social determinants of health
Resource-constrained environments. See Austere environments Search and rescue, 253
Respiration. See Breathing and ventilation Seatbelt use, 206, 208f
Respiratory acidosis, 66, 177, 211 Secondary brain injuries, 10, 100, 183, 184, 198
Respiratory alkalosis, 81, 209, 210t Secondary prevention, 260
Respiratory rate, 27, 60, 68, 71, 81, 81t, 177–178, 179t, 226 Secondary survey
Respiratory system changes during pregnancy, 209 adjuncts to, 229–230
Response phase of disaster management, 253–254 ATLS-OE and, 332, 332f
Restraint devices, injuries associated with, 290, 291f, 292t burn injuries and, 138–142
Resuscitation. See also Fluid resuscitation; Trauma resuscitation disabilities (neurological evaluation) and, 107–110, 227
teams history in, 138, 214, 222, 225
balanced, 179, 198, 313 in mass casualty situations, 251, 251f, 252f
cardiopulmonary, 9, 12, 94, 181, 236, 246 mechanisms of injury and, 222–225, 223t–225t
in combat zones, 330, 331, 333 musculoskeletal trauma and, 165–166
communication during, 273 neurological evaluation and, 227
musculoskeletal trauma and, 151, 153, 156, 159, 161 objectives of, 4, 25, 222
patient transfers and, 234, 237, 237t, 238, 333 for older adults, 198
pelvic trauma and, 228, 293 physical examination in, 107, 222, 226–229
penetrating injuries and, 308, 314, 315 for pregnant patients, 213f, 214–215
primary survey and, 8–13, 12f reassessment during, 14
for shock, 10, 83, 86, 89–94, 331 reevaluation in, 231
trauma centers and, 245, 246 of special populations, 231–232
vital signs and, 226 trauma-informed care and, 270, 273
Resuscitation tape, 173, 178 Secondary trauma, 270, 274
Resuscitative cesarean delivery (RCD), 217 Second-degree burns. See Partial-thickness burns
Resuscitative endovascular balloon occlusion of the aorta Security considerations, 253–254, 328
(REBOA), 301 Sedatives
Retina, 186, 318, 318f for burn injuries, 140
Retrobulbar hemorrhage, 227, 320 for intubation, 25, 50, 52–53, 52t, 57, 60, 197, 306
Retroperitoneal hematomas, 84, 228, 291 neuroworsening and, 122
Return of spontaneous circulation (ROSC), 9, 12, 96 older adults and, 197, 202
Rhabdomyolysis, 38, 142, 158, 159 for pain management, 166
Rh immunoglobulin therapy, 215, 217, 230 pediatric patients and, 182
Rib fractures for traumatic brain injuries, 121, 230
identification of, 73, 74, 228 Seidel test, 321
older adults and, 194, 199 Seizures, 123, 183, 184, 210, 212, 230
pain management for, 66, 76, 230 Seldinger technique, 178, 295
pathophysiology of, 70 Septal hematomas, 227
patient transfers and, 77, 234 Septic shock, 10, 82, 85, 91t, 299
pediatric patients and, 173, 181
pulmonary contusions and, 68, 74
surgical stabilization of, 76
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 Serious news conversations, 280–284 gastric tubes and, 293
culturally appropriate, 280, 284 high-flow nasal oxygen and, 46
debriefings following, 283–284 nasopharyngeal airways and, 49, 119
frameworks for, 15, 15f, 32, 280, 281f as open fractures, 122
meeting with families, 282–283, 282f, 283f pediatric patients and, 181
organizing thoughts prior to, 281 physical examination for, 107
preparing to meet with families, 281–282, 282f traumatic brain injuries and, 110
special populations and, 284 Small bowel injuries, 183, 290–291, 291f, 296
Severe brain injuries. See Traumatic brain injuries Smoke inhalation, 9, 137
Shared mental models, 5, 20–21, 24, 26–27, 53 SMR. See Spinal motion restriction
Shearing injuries, 290 Social determinants of health (SDOH), 192, 258, 261, 270–271,
Shock, 80–96. See also Hemorrhagic shock 273
anaphylactic, 10, 82, 85 Soft-tissue injuries. See also Contusions; Hematomas
athletes and, 15, 92t, 93 abdominal pain and, 228
blood pressure and, 10, 80, 83, 86, 90, 93, 94 blast injuries and, 149
blood transfusions for, 80, 82, 83, 91 blunt trauma and, 148
blood volume and, 10, 80–81, 83 hemorrhage and, 8, 84–85
burn injuries and, 130, 136, 137 patient transfers and, 238
cardiogenic, 10, 80, 80t, 82, 85, 94 penetrating injuries and, 149
clinical judgment and, 83 sprains and strains, 148
control of bleeding in, 86–87 Solid organ injuries, 182, 300
crush syndrome and, 158 Special populations. See also Athletes; Obese patients; Older
definition of, 9, 80 adults; Pediatric patients; Pregnant patients
determining source of, 83 airway management and, 61–62
diagnosing presence of, 82–83 combat zones and, 328
diagnosis of, 10 initial assessment of, 14–15, 231–232
distributive, 10, 80, 80t, 82 injury prevention and, 261–262
hypotension and, 10, 80–82, 84, 85, 94, 105, 140, 178, 178t penetrating injuries and, 314–315
hypothermia and, 11 serious news conversations and, 284
imaging and diagnostic studies for, 85–86, 85f–86f spinal cord injuries and, 124
laboratory values and, 83 thoracic trauma and, 77
management of, 86–96 transfer to definitive care, 234
medications and, 82, 83, 85, 93–94 trauma-informed care and, 275, 275t
mental status changes and, 137 traumatic brain injuries and, 124
neurogenic, 10, 82, 85, 94, 105, 121, 132 Spinal column, anatomy of, 103, 103f–105f
nonhemorrhagic, 10, 80t Spinal column fractures (SCFs)
nonresponse to resuscitation, 91–92, 91t abdominal pain from, 228
obstructive, 80, 80t, 81, 84, 94 cervical, 105, 115, 117f, 194, 201, 201f
older adults and, 92t, 93 Chance, 183, 222
pathophysiology of, 80–82, 81t lumbar, 118f, 181, 183, 229
patient histories and, 83 prevalence of, 100
patient transfers and, 96 thoracic, 118f, 229
pediatric patients and, 92t, 93, 177–179 Spinal cord injuries (SCIs). See also Cervical spine injuries
physical examination for, 83 airway management and, 29, 120
pregnant patients and, 92t, 93, 211 blood pressure and, 105, 120, 120t, 126
primary survey and, 83–85 blunt trauma and, 105–107, 106t
resuscitation for, 10, 83, 86, 89–94, 331 circulation and, 120–121
septic, 10, 82, 85, 91t, 299 distributive shock and, 82
spinal, 85, 105 firearms and, 125
Shock index (SI), 83, 198 global incidence of, 100
Shoulder harness injuries, 292t gross motor evidence of, 10
Shoulder injuries, 149, 159, 163, 164f hemorrhagic shock and, 29
Simple pneumothorax, 9, 68, 69f, 72, 72t, 74–75, 176, 226 imaging studies for, 112–119, 113f–114f, 115t, 116f–118f, 117t,
Situational awareness, 5, 20, 21t, 23–24, 53, 251, 255, 331 184–185
Skeletal injuries. See Musculoskeletal trauma interventions and treatments, 119–123
Skull fractures lumbar spine, 117, 117t, 118f, 181, 183, 229
depressed, 122, 123 mechanisms of injury, 105, 105t
extradural hematomas and, 100, 130 motion restriction for, 12, 201

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neurogenic shock and, 105, 121 pediatric patients and, 30, 177, 178, 178t, 181
older adults and, 14–15, 124, 201 pregnant patients and, 211
pathophysiology of, 105, 105t shock and, 10, 15, 80, 81, 83
pediatric patients and, 106, 124, 184–185 thoracic trauma and, 228
penetrating, 105, 107, 125, 310, 310t Tachypnea, 10, 15, 71, 72, 81, 85, 93
practice environment considerations, 125–126 Tactical Combat Casualty Care (TCCC), 330–331
primary survey and, 106–107 Tactical Evacuation Care, 330–331
reassessment of, 124 Tactical Field Care, 330, 331
secondary survey and, 107–110 TAKE STOCK debrief tool, 32t
syndromes related to, 110, 110f TBIs. See Traumatic brain injuries
thoracic spine, 115, 117, 117t, 118f, 229 TEAM (Trauma Evaluation and Management) course, 246
trauma resuscitation teams and, 29 Teamwork. See Trauma resuscitation teams; Trauma team leaders
Spinal motion restriction (SMR). See also Cervical collars Tension pneumothorax
airway management and, 9, 46, 57–58, 120 assessment and diagnosis of, 72
cervical, 9, 12, 112, 114, 175, 201, 228 decompression of, 75, 176, 177, 251, 330
indications for, 105–106, 106t ECG monitoring for, 12
manual during assessment, 71, 120 nonhemorrhagic shock and, 10
pregnant patients and, 212 obstructive shock and, 81, 84, 94
primary survey and, 11, 12 pathophysiology of, 68, 69f, 81
Spinal shock, 85, 105 pediatric patients and, 181
Splinting, 11, 13, 150, 153, 157, 161–163, 162–163f, 185, 229– penetrating injuries and, 310
230, 314 signs and symptoms of, 72t, 226
Sprains, 148 ventilation impairment and, 9
Stab wounds Tertiary prevention, 260
abdominal, 291, 292f, 296, 313 Tertiary survey, 273, 332, 332f
injury considerations, 224, 224t Tetanus immunization
to neck, 310f age-based recommendations, 156t, 231t
pneumothorax and, 68 burn injuries and, 141
thoracic, 308f musculoskeletal trauma and, 156, 159, 161, 166
Sternum fractures, 228 ocular trauma and, 321
Stillbirths, 206, 207 older adults and, 198
Stomach decompression, 13, 181, 230, 294t, 295, 314 penetrating injuries and, 230, 308, 312–313
Stop the Bleed campaign, 5, 38, 246, 333, 334f soft-tissue injuries and, 238
Strains, 148 Tetraplegia, 105t, 107
Stroke volume, 209–210, 306 Thermal burns, 137f, 139t, 224, 225t
Subcutaneous emphysema, 43, 73f, 74, 228, 299, 299f Thermal injuries. See Cold injuries; Heat injuries
Subdural hematomas (SDHs), 100–102, 102f, 101f, 110–111, Thermoregulation, 181
111f, 123, 186 Thiopentone, 52t, 53
Subfalcine herniation, 102, 102f Third-degree burns. See Full-thickness burns
Substance Abuse and Mental Health Services Administration, Thoracic spine
273 anatomy of, 103, 103f
Succinylcholine (suxamethonium), 52t, 53, 176, 176f injuries to, 115, 117, 117f, 118f, 229
Sucking chest wound. See Open pneumothorax Thoracic trauma, 66–77. See also Hemothorax; Pneumothorax;
Suction catheters, 47 Rib fractures
Superficial (first-degree) burns, 138b, 139, 139f, 196 assessment and diagnosis of, 71–74, 72t
Supplemental oxygen, 9, 43, 45–46, 47f, 75, 137, 211, 213f blast injuries and, 66, 68
Supracondylar fractures, 160t, 185 blunt injuries and, 66, 68, 70, 181
Supraglottic airways, 9, 49, 50, 50t, 136, 176 crush injuries and, 66, 71
Surgical cricothyroidotomy, 58, 59f, 177 CT for, 73f, 74, 230, 311–312
Surgical/incisional airways, 9, 57–58, 58–59f, 120, 176, 309–310 diaphragm injuries, 66, 68, 70–74, 71f, 72t, 76–77, 85, 181,
Suxamethonium (succinylcholine), 52t, 53, 176, 176f 298, 319
S-xABCDE-BAR communication tool, 5, 7f, 14, 30, 236t FAST and eFAST for, 74, 311–312
Systemic hypothermia, 11, 130, 130t firearm injuries and, 68, 299, 311, 312f
flail chest, 70, 70f, 72t, 73, 76–77, 181, 223t, 228, 234
Tachycardia hemorrhage and, 66, 69, 72, 72t, 76
blunt cardiac injuries and, 12, 85 interventions and treatments, 75–76f, 75–77
cardiac tamponade and, 84, 85 obese patients and, 77
medications causing, 53 older adults and, 77
older adults and, 198 pathophysiology of, 68–71

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 patient transfers and, 77 social determinants of health and, 270–271, 273
pediatric patients and, 68, 77, 181 special populations and, 275, 275t
penetrating injuries and, 66, 68–71, 181, 308f, 310–312, 310t, tertiary survey and, 273
312f, 314 Trauma resuscitation teams. See also Trauma team leaders
practice environment considerations, 77 airway management and, 25–26, 53
pregnant patients and, 77 arrival handovers and, 5, 22, 23, 24t, 27, 29
pulmonary contusions, 9, 68, 71–77, 72t, 73f, 173, 181, 228, attention and, 5, 20, 21t
292 breathing/ventilation and, 27
tracheobronchial injuries, 27, 71–74, 72t, 77, 298 circulation and, 27–29, 28t
ultrasound for, 74, 77, 312 communication and, 5, 20–21, 24–26, 30, 32, 273
x-rays for, 13, 73–74, 73–74f, 77, 85, 85f, 86f, 181, 229, 308f, crisis resource management and, 20, 22, 30
311–312, 312f debriefings by, 5, 22, 32, 32t, 186, 283–284
Thoracoabdominal wounds, 296, 314 decision-making and, 5, 20, 21, 28, 30
Thoracoscopy, 295–296 departure handovers and, 5, 22, 30
Thoracostomy exposure and environment concerns, 29
finger, 27, 75, 77, 311 initial assessment function, 5, 22–30, 26t
needle, 27, 66, 75, 75f, 77, 177 leadership and followership in, 5, 20
tube, 66, 73, 75–77, 76f, 86, 91, 176–177, 181, 310–312 neurological evaluation and, 29
Three Es approach to injury prevention, 258–259, 259f, 261 pediatric patients and, 29–30, 186
Thromboelastography, 130, 132, 198 prearrival huddles by, 5, 21–23, 23t
Thrombolytic therapy, 144 pregnant patients and, 30, 31t
Tibial fractures, 84, 154f, 162 preplanning and administration of, 22
TIC. See Trauma-informed care shared mental models for, 5, 20–21, 24, 26–27, 53
Tonsillar herniation, 102f situational awareness of, 5, 20, 21t, 23–24, 53
Tourniquets task management and coordination of, 5, 20–22
application of, 8, 38–39, 39f training programs for, 20, 22
in combat zones, 330, 331 Trauma-Specific Frailty Index (TSFI), 194, 195t
conversion of, 39, 226–227, 227t, 331 Trauma systems
junctional tourniquets, 9, 39 benefits of, 244
for major arterial injuries, 152–153, 153f in combat zones, 330–331
for penetrating injuries, 307, 313, 315 components of, 244–247
pitfall and mitigation, 331b coordination of care in, 246
Tracheobronchial injuries, 27, 71–74, 72t, 77, 298 data collection by, 246, 247
Traction splints, 148, 162, 162f definition and goals of, 244
Tranexamic acid (TXA), 93, 93f, 121, 211, 315, 330 disaster management and, 246
Transesophageal echocardiography, 297 education and outreach in, 246
Transfer agreements, 16, 22, 234, 235, 237, 245 emergency medical services in, 244, 245, 247
Transfers. See Patient transfers to definitive care facility designations in, 245–246
Transfusions. See Blood transfusions global development of, 247
Trauma centers in high-resource environments, 247
administrative support at, 22 Incident Command System and, 254
classification levels for, 235, 245–246 injury surveillance and prevention in, 244–245, 247
destinations for unstable patients in, 25 matching patient needs to facility capabilities, 234
determining need for, 5, 6f, 14 quality improvement programs in, 246, 247
obstetric capabilities in, 206 rehabilitation and, 244–246
patient transfers to, 234–236 research and scholarly activity in, 246
pediatric capabilities in, 172, 182, 185 in resource-restrained environments, 247
reduction in mortality risk and, 244 traumatic stress screening in, 271
Trauma Evaluation and Management (TEAM) course, 246 verification of, 247
Trauma-informed care (TIC), 270–276 Trauma team leaders (TTLs)
for clinicians, 254, 270, 274 airway management and, 25–26, 53
communication in, 217, 273, 274t breathing/ventilation and, 27
components and principles of, 273 debriefings facilitated by, 32, 283
injury prevention and, 260, 262, 262t pediatric patients and, 186
organizational implementation, 275–276 in prearrival huddles, 22
pediatric patients and, 181 pregnant patients and, 30
pregnant patients and, 217 primary survey organized by, 24
primary survey and, 4, 270, 273 roles and responsibilities of, 5, 14, 20, 23
screening tools and, 271–272 tactical pauses called for by, 25
secondary survey and, 270, 273
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Traumatic brain injuries (TBIs) Vaginal bleeding, 208, 215

airway management and, 61, 120 Vaginal examination, 215, 229, 293
blast injuries and, 225, 329 Valproic acid, 123
blood pressure and, 10, 61, 120–121, 120t, 124, 126 Vascular access, 21, 89f, 182, 186, 238
circulation and, 120–121 Vascular injuries
from falls, 194, 199 to abdominal structures, 313
firearms and, 308 assessment of, 157
GCS classification of, 106, 107t blast-related, 330
global incidence of, 100 management of, 157
imaging studies for, 110–112, 111f–112f, 111t, 199 musculoskeletal, 156–157
interventions and treatments, 119–123, 120t, 184 to neck, 228, 230, 310
laboratory values and, 119 penetrating, 307–311, 313
mental status changes and, 175 signs of, 313, 314t
older adults and, 14, 124, 194, 198, 199 to thoracic structures, 311
pediatric patients and, 100, 124, 172, 173, 184 Vasopressors, 9, 45, 50, 52–53, 52t, 57, 94, 121, 211, 315
penetrating, 124–125, 124f, 125f Vehicle collisions. See Motor vehicle crashes
practice environment considerations, 125–126 Venous access, 12, 89, 178–179, 179f, 212, 214f
reassessment of, 124 Venous thromboembolism prophylaxis, 123
trauma resuscitation teams and, 29 Ventilation. See Breathing and ventilation
Traumatic stress Verbal responses, 106, 106t, 183t
pediatric patients and, 181 Vertical shear pelvic fractures, 150, 151f, 300, 300f, 301
PTSD, 263, 271–272, 271b–272b, 274 Vicarious trauma, 270, 274
secondary, 274 Video laryngoscopes (VLs), 50, 51f, 56
Traumatic subarachnoid hemorrhage (tSAH), 100, 110–111, 111f Videoscopic intubation, 310
Triage Vision examinations, 319, 319f
categories for, 251, 253f Vision Zero movement, 261, 261b
disaster management and, 251, 253–254, 253f Visual acuity tests, 227, 319
initial assessment and, 5, 6f, 7 Vitreous humor, 318
in mass casualty situations, 5, 7, 238, 250–251, 253f VLs (video laryngoscopes), 50, 51f, 56
of older adults, 192, 202 Volume resuscitation. See Fluid resuscitation
overtriage, 250, 251 Vomiting
of pediatric patients, 29, 30 airway obstruction due to, 47
of pregnant patients, 206 gastric tubes and, 13, 230, 293
prehospital, 5, 6f, 250, 251, 332–333 oropharyngeal airways and, 175
undertriage, 202, 251 penetrating head trauma and, 308
Triage officers, 250.251, 254 traumatic brain injuries and, 183
tSAH (traumatic subarachnoid hemorrhage), 100, 110–111, 111f
TSFI (Trauma-Specific Frailty Index), 194, 195t War zones. See Combat zones
TTLs. See Trauma team leaders White blood cells (WBCs), 209, 210t
Tube thoracostomy, 66, 73, 75–77, 76f, 86, 91, 176–177, 181, World Health Organization (WHO), 247
310–312 World Society of Emergency Surgery, 150
TXA. See Tranexamic acid
Type-O blood donors, 331 xABCDE. See Primary survey
X-ray examinations
Ultrasound for abdominal trauma, 13, 295
for abdominal trauma, 85, 86f airway management and, 46
for musculoskeletal trauma, 152 for aortic injury, 297, 297t, 298f
for pregnant patients, 30, 31t, 206, 212, 216, 217, 229 for blunt trauma, 13
in secondary survey, 229 for musculoskeletal trauma, 161, 163–165, 164f–165f, 185
for thoracic trauma, 74, 77, 312 for pelvic trauma, 13, 151f, 229, 293
Uncal herniation, 102, 102f for penetrating injuries, 13, 229, 308f, 311–314, 312f
Urethral injuries, 13, 228–230, 293, 294, 296, 300 for pneumomediastinum, 299, 299f
Urethrography, 296 in primary survey, 13, 198
Urinary catheters, 13, 139, 180, 230, 294, 309, 314 radiation exposure and, 165
Urinary system changes during pregnancy, 210 in secondary survey, 229
Urine output, 10, 81, 83, 86, 90, 139–140, 142, 180–181, 230 for smoke inhalation, 137
Uterine changes during pregnancy, 208, 209f for spinal cord injuries, 184–185
Uterine displacement/tilting, 14, 206, 212, 213f, 214f, 217 for thoracic trauma, 13, 73–74, 73–74f, 77, 85, 85f, 86f, 181,
Uterine rupture, 206 229, 308f, 311–312, 312f

Zero survey, 332–333, 332f

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