Lower limb205 Nerve root Muscle L4,5, S1 L5, S1,2 L2,3,4 717 Test by asking the patient to: Internal rotation at hip, hip abduction. Extension at hip (l ie prone). Adduct leg against resistance. Gluteus medius & minimus Gluteus maximus Adductors (obturator nerve) a m u a r t d n a s c i d e a p o h t r O Femoral nerve (L2 \200\2234, posterior division) L1,2,3 Iliopsoas Flex hip with knee \202 exed and lower leg supported: patient lies on back. Flex knee wit h hip external rotated. Extend knee against resistance. L2,3 L2,3,4 Obturator nerve (L2 \200\2234, anterior division) Hip adductors L2,3,4 Inferior gluteal nerve L5,S1,S2 Superior gluteal nerve L4,5,S1 Sciatic nerve (including the common peroneal nerveCP & tibial nerve) L4,5CP L5,S1CP L5,S1CP L5,S1CP L5,S1CP L5,S1,2T L4,5T S1,2 T L5,S1,2T S1,2T Sartorius Quadriceps femoris Adduct the leg. Gluteus maximus Hip extension. Gluteus medius & minimus Abduction and internal rotation of hip. Tibialis anterior Extensor digitorum longus Dorsi \202 ex toes against resistance. Extenso r hallucis longus Peroneus longus & brevis Extensor digitorum brevis Dorsi \202 ex 2nd \200\2234th toes (muscle of foot). Hamstrings Tibialis posterior Gastrocnemius Flexor digit orum longus Small muscles of foot Dorsi \202 ex ankle. Dorsi \202 ex hallux against resistance. Evert foot against resistance. Flex knee against resistance. Invert plantar \202 exed foot. Plantar \202 ex ankle joint. Flex terminal joints of toes. Make sole of foot into a cup. Quick screening test for muscle power Shoulder Abduction Hip Adduction Flexion Extension Fl exion Extension Flexion Extension Abduction Flexion Extension Flexion Extension Dorsi \202 exion Plantar \202 exion S1,2 L1,2 L5,S1 C5 C5, 7 C5, 6 Elbow Knee S1 L3,4 C7 C7,8 Wrist Ankle L4 C7 C7 \200\2238 Fingers C7 T 1 (ulnar) Quantifying strength The UK MRC scale objecti \201 es strength (reasonably well): Grade 0 No muscle contraction Grade 3 Active movement, with gravity eliminated Grade 1 Flicker of c ontraction Grade 4 Active movement against resistance Grade 2 Some active movement Grade 5 Normal power Grades 4 \200\223, 4, and 4+ describe movement against slight, moderate, and s trong re- sistance. Dynamometers help quantify strength.206 n=30 Remember to test proximal muscle power: ask the patient to sit from lying, to pull you towards himself, and to rise f rom squatting. Gower \200\231s sign (observed in a child with muscular dystro- phy and prox imal muscle weakness) shows the patient standing from a squatting position by \200\230clim bing \200\231 sequentially up his own legs. \200\207Also, observe walking (easy to forget, even if the complaint is of walking diffi culty!). See p680 and OHCM p471 for gait disorde rs. Reducing pain in A&E \200\207All patients should be asked speci \201 cally if they requir e pain relief. Clinical assessment is expedited by relieving pain. There is some evidence t o show that nurse initiated analgesia in Emergency Departments reduces time to relief of pa in.207,208 No acute pain is uncontrollable. If systemic analgesia is required, select the a nalgesic most appropriate to the type of pain. In pleuritic or mus- culoskeletal pain, NSAI Ds are often more effi cacious than a narcotic. NB: there are NO contraindications to narco tic analgesia (other than well-de \201 ned allergy which is very rare). If in doubt, TREAT ! Adjuncts Splint and elevate fractures and dislocations; RICE (p705). Local anesthesia Loc al in \201 ltration of wounds with 1% lidocaine; digital nerve block in \201 nger injuri es; femoral nerve block for fractured shaft of femur. NB: use plain lidocaine (no added adr enaline) for \201 nger blocks. Non-opioid systemic analgesia Paracetamol 1g/4 \200\2236h; aspirin 600mg co- deine 15 \200\22360mg/6h. NSAIDs: see below. Ketamine is a dissociati ve agent which can be used in subanaesthetic doses to provide analgesia. It should be used under the authority of a consultant. NSAIDS Ibuprofen 400 \200\223800mg/8h PO. Diclofenac 7 5mg PR/IM STAT (max dose 150mg in 24h) is useful in management of renal colic. Indometacin 100mg PR stat can also be used in acute pain, eg from renal colic or gout. Ketorolac is an injectable NSAID. Dose if >16yrs old: 10mg IM/IV over >15sec, every 2 \200\2236h, up to 90 mg/day (60mg if old or <50kg). \200\207NSAIDs ought to be avoided if there is a his- tory of renal impairment, peptic ulceration or inducing acute asthma. Gas Entonox is a 50% mix ture of nitrous oxide in O2. It is self-administered using a demand valve system and can pr ovide a good level of analgesia for short procedures (eg \201 nger relocation) or when aw aiting other forms of an- algesia. Nitrous oxide is now increasingly available in variable concentrations upto 70% \200\224and is no more likely to result in adverse eff ects than En tonox .209 Opioid analgesia should be given IV as a bolus or infusion (IM is too slow and unpredictable). Morphine dose: 50 \200\223100 g/kg, eg 2.5 \200\2237.5mg IV slowly. Furthe r increments should be titrated to the patient \200\231s response, initially at 5min in- te rvals. Respiratory depression is unlikely with careful titration. \200\207There is no de \201 ned maximum dose; a typical total dose is 10 \200\22320mg. Antiemetics are not always required routinely, but may be helpful in alleviating symptoms of nau- sea and vomiting (av oid metoclopramide in children: risk of oculogyric crisis). Naloxone (0.1 \200\2230.2mg sta t IV, then 0.1mg every 2mins until responsive) can be used to reverse eff ects of overdose. Fentanyl (1 \200\2232 g/kg IBW, eg 50 \200\223100 g IV) is useful for short procedures r equiring conscious sedation (cardioversion, re- duction of dislocated shoulder). Meptazinol is an opioid option, and can be given as 200mg every 3 \200\2236h PO \200\224eff ects are only partially reversed by naloxone. Tramadol is a synthetic opioid analgesic that has weak agonist activity at mu opiate receptors and inhibits serotonin and noradrenaline reuptake in the spi- nal cord; dose: 50 \200\223100mg/6h PO. Sedation Sometimes IV sedation is requi red for the sake of comfort and co- operation \200\224eg joint relocation, fracture reducti on (p734) or cardioversion (OHCM, p784). It is important that, if possible, one person is i n charge of drug administration and monitoring (HR, BP, O2 sats, GCS) and one person is in charge of the procedure. NB: this is not always possible, eg in remote locations, where sin gle physician procedural sedation will be required.210 Midazolam is an ef- fective sedative and should be titrated to response, starting with 2.5mg IV by slow injection (1mg in elder ly) and given in further 0.5 \200\2231mg increments. It is unusual for more than 5mg to be required. It can be given with mor- phine, though remember that morphine also has sedative eff ects. The use of propofol and/or ketamine is useful in experienced hands. \200\207Moni tor the patient throughout and after the procedure until GCS normal. 718 \200 a m u a r t d n a s c i d e a p o h t r O 719 Children with trauma needing pain relief Hospitals can be frightening. Toys, friendliness, a quiet room and a simple ex- planation of what is going to happen go a long way to avoid c reating distress. \200 Introduce yourself to the child (and their parents), get down to t heir eye level, and reassure them (and their parents). a m u a r t d n a s c i d e a p o h t r O Be positive and relaxed, let them know they are brave, and that you are go- ing to make them feel better and want to \200\234 \201 x \200\235 what ails them. Be aware that children who experience pain and discomfort with medical procedures are more likely to be anxious and experience greater pain in the future with similar procedures. \200 Consider intranasal fentanyl (1.5 g/kg initial dose \200\224via an atomiser, in divi ded doses between the nostrils \200\224a second dose eg 0.75 g/kg can be given after 5 min ) for burns and fractures \200\224there is usually time to give this before examination. For IV cannulation and venepuncture use topical local anesthetic (eg EMLA \200\224needs 60 mins to work or LMX-4 \200\224needs 30min to work) \200\224unless access is needed emergent ly. Do you need to suture a wound? Consider the alternatives (p730). \200 Do you need to inje ct local anesthetic? Consider needle-free alternatives \200\224for example 70% nitrous oxi de +/ \200\223 topical wound anesthetic. It is rarely worth an injection for a single sutur e. Use oral sucrose in neonates. \200 If local anesthetic is necessary, use the smallest nee dle possible to in \201 l- trate the wound (an insulin syringe needle (30G) or dental syri nge needle (27 \200\22330G) is ideal). Buff ering local anesthetic with 8.4% sodium bicarbonate (9 parts anaes- thetic to 1 part s odium bicarbonate) and using anesthetic that is warmed to body temperature may reduce the p ain associated with in \201 ltration. Use some sort of distraction as you are doing your procedure \200\224play music or a DVD, a sk the parents or a nurse to blow bubbles for the child, engage them in conversation about their brothers/sisters/pets or other interests. If there is a play therapist available \200 \224they may prove as eff ective in reduc- ing pain as local anesthetic! In \201 ltrate wounds through the open wound edge rather than puncturing intact skin \200\224inject slowly, and use the minimal volume of anesthetic. If suturing or other painful procedures are unavoidable, consider sedation (see OPPOSITE): morphine, fentanyl, or ketamine (p802) are the agents of choice. Oral ketamine is a potent, short-acting analgesic at 3 \200\22310mg/kg. The injectable form can be used PO in a \202 avoured drink. It is a class C drugUK. Explain to the child and the parents what you are going to do. Take your time, don t rush t he child or the parents. Wrap the child in a blanket. Enlist enough nurses to hold the chil d and immobilize the part you are suturing. Warn the parents of possible distress. If they prefer not to be present, try to sit them out of earshot. Showing the child the result in a mirror, off ering a big bandage, and giving an \200\230I was brave \200\231 badge can hel p. GA is rarely justi \201 ed; if it is, the wound should probably be sutured by a plastic surgeon. The Glasgow Coma Scale (GCS) This is a subjective way of quantifying the conscious state of a person. It can be used by medical and nursing staff for initial and continuing assessmen t. It has value in predicting ultimate outcome. 3 types of response are assessed: \200 Be st motor response This has 6 grades: 720 \200 6 Carrying out request ( \200\230obeying command \200\231): The patient does simple things you ask (beware of accepting a grasp re \202 ex in this category). 5 Localizing response to pain: Put pressure on the patient \200\231s \201 nger nail bed w ith a pencil then try supraorbital and sternal pressure: purposeful move- ments towards cha nging painful stimuli is a \200\230localizing \200\231 response. 4 Withdraws to pain: Pulls limb away from painful stimulus. 3 Flexor response to pain: Pres sure on the nail bed causes abnormal \202 exion a m u a r t d n a of limbs: decorticate posture. 2 Extensor posturing to pain: The stimulus causes limb extension (adduction, internal rotat ion of shoulder, forearm pronation): decerebrate posture. 1 No response to pain. \200\207NB: record the best response of any limb. s c i d e a p o h t r O Best verbal response This has 5 grades. 5 Oriented: The patient knows who he is, where he is and why, the year, season, and month. 4 Confused conversation: The patient responds to questions in a conversa- tional manner but there is some disorientation and confusion. 3 Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange. 2 Incomprehensible speech: Moaning but no words. 1 None. \200\207NB: record the best level of speech. Eye opening This has 4 grades. 4 Spontaneous eye opening. 3 Eye opening in response to spee ch: Any speech, or shout, not necessarily request to open eyes. 2 Eye opening to response to pain: Pain to limbs as above. 1 No eye opening. An overall score is made by summing the score in the 3 areas assessed, eg: no response to p ain + no verbalization + no eye opening = 3. \200 Severe injury: GCS \211 8 (airway nee ds protection with endotracheal intuba- tion). Moderate injury: GCS 9 \200\22312. \200 Minor injury: GCS 13 \200\22315. Dramatic changes in GCS level can be seen in substance overdose, eg gamma- hydroxybutyrate. It is not unkno wn for patients to walk out just hours after presenting with a GCS of 3.211 AVPU An abbrevi ated coma scale, AVPU, is sometimes used in the initial assess- ment ( \200\230primary surv ey \200\231) of the critically ill: A = alert V = responds to vocal stimuli P = responds to pain U = unresponsive Pediatric GCS See p201. \200 Adult basic life-support algorithm This algorithm ( \201 g. 1) assumes that only one rescuer is present, with no equip- ment. (If a de \201 brillator is to hand, get a rhythm readout, and de \201 brillate, as needed, as soon as possible.) First, remove yourself, b ystanders and the casualty from obvious dangers. Then shake and shout to the casualty to ch eck responsiveness. If unresponsive: 721 a m u a r t d n a s c i d e a p o h t r O UNRESPONSIVE? Shout for help (head tilt; chin lift; if non-respon- sive turn on back) Open airway (look, listen, feel; if breathing place in recovery position and go for help) NOT BREATHING NORMALLY? (if alone, go at this stage for help/ call emergency services, eg 999 or 112) Call 999 (give 30 at a rate of 100 per min) 30 chest compressions (each breath over 1 second) (chest compressions to rescue breaths at 30 : 2) 2 rescue breaths 30 compressions Fig. 1. Adult basic life-support algorithm. Resuscitation Council, UK, 2010. \200\207Continue resuscitation until help arrives/takes over, until normal breathing resum es or until you become exhausted (change every 2min if there is more than one of you). \200\207Do not interrupt resuscitation; only stop and reassess if the victim starts breathi ng normally. Managing the airway \200 Open the airway by chin-lift/head tilt or by jaw thrust (if trai ned and there is a possibility of spinal injury). Chest compressions \200 Cardiopulmonary resuscitation (CPR) involves compressive force over the lower sternum with the heel of the hands placed one on top of the other, directing the weight of your body through your vertic al, straight arms. Use a close- \201 tting mask if avail- able, held in place by thumbs pressing downwards ei ther side of the mouthpiece; palms against cheeks. Depth of compression: 5 \200\2236cm \200 Rate of compressions: 100 \200\223120/min. \200 Gunshot and other penetrating injuries Murders by \201 rearms Australia 59; UK 14; New Zealand 10; USA 9300 (+17,000 suicides). Historically gunshot wounds (GSWs) have been d ivided into low ve- locity (<1000ft/sec eg most handguns) and high velocity (>1000ft/sec \200\224eg military ri \202 es). Low velocity wounds lacerate and crush tissues. High velo city weapons are more destructive due to cavitation and the shock wave produced. When faced with a GSW or other penetrating injury consider the following: \200\207 Initial managemen t is in accordance with ATLS protocols. \200\207 Minimal surface injury may hide much deep er injury, depending on the weapon used, the mechanism of injury, bullet speed. Factors suc h as tumble, yaw and trajectory can exacerbate internal injury. 722 \200 \200\207 Some low velocity wounds (eg in limbs with no vascular/bone involvement) can be t reated with irrigation and minimal debridement in ED, then with oral antibiotics and outpat ient review. Non-operative management may also be suitable for some abdominal GSWs \200\224 (use CT to con \201 rm no peritoneal breach or solid organ injury). a m u a r t d n a \200\207 Most victims are young and \201 t with good reserves. Therefore cardiorespira- tory decompensation indicates severe injury. s c i d e a p o h t r O \200\207 If the weapon (eg knife) is still in situ, do not remove it until the patient is on the operating table \200\224the danger is exsanguination. De \201 ne and record each injury. Low-velocity bullets leave dirty tracks, requiring expl oration, excision, and delayed closure. High-velocity weapons (eg military ri \202 es) are extraordinarily destructive due to the temporary cavity caused by the missile and likely f atal if to the head, thorax or abdomen. Ruthless and massive debridement is essential. Teta nus prophylaxis: p730. Penetrating chest injuries may damage pleura, lung, great vessels, h eart, mediastinum, diaphragm, and abdominal contents. The commonest injury is haemopneumoth orax from damage to lung and chest wall. This requires a large (adult: 32G) chest drain: if drainage is initially >1500mL (= \200\231massive \200\231), or >300mL/h, thoracotomy is ne eded. If available, attach an autotransfusion device to the drain. Deterioration or cardiac arrest demands prompt thora- cotomy. Wounds of intercostal vessels, great vessels, or hear t can cause mas- sive hemorrhage. \200\207Anterior wounds medial to the nipple line and po sterior wounds medial to the scapulae must also prompt thoughts of thoracotomy. Sucking chest wounds must be closed at once, eg by Vaseline gauze pads sealed on 3 sides only (acts as \202 utter valve) \200\224complete the seal on chest drain insertion. \200 Relieve tension pneumothorax by needling the chest on the side of the suspected lesion bef ore inserting a 32G chest drain (OHCM p780) or doing radiographs (delay may be fatal). Prop hylactic antibiotics may be indicated.212 Respiratory embarrassment due to pain, \202 ail chest, or diaphragmatic injury requires intubation and ventilation. Insert a chest drain i f there is any chance of a tear to lung, bronchus, or chest wall. Cardiac tamponade 15% of deep chest injuries involve the heart. Diagnosis: Clinical diagnosis using Beck \200\231s t riad = rising JVP, falling BP, and a small, quiet heart ( pulsus paradoxus) is diffi cult in the trauma situation. Portable ultra- sound is more reliable) \200\224a black stripe se en around the heart indicates \202 uid. \200 Pericardial aspiration may buy time before thoracotomy. Procedure: (OCHM p787) Insert an 18G needle to the left of the xiphoid. Aim at the left shoulder, but with the needle angled downwards at 45 to the horizontal. All the se pa- tients need: Crossmatching of \211 6 units of blood, then: \200 2 large-bore IV c annu- lae for vigorous \202 uid replacement. \200 Monitoring: vital signs; blood gasses ; CXR; ECG monitoring. \200 ITU care with a chest drain immediately to hand, and faciliti es for immediate thoracotomy (eg if any deterioration, or a cardiac arrest). Abdominal injuries All but the most super \201 cial injuries need admission and exploratio n, never just observation. Suspect abdominal injury with all pene- trating chest trauma: th e liver is up to the 4th rib (right). \200 See p726. Limb injury Nerves, tendons, and vess els are endangered, so examine limbs in good light, testing pulses (their presence doesn \200\231t exclude arterial injury), sensation and sweating. Direct pressure will staunch bl eeding. \200\207Do not use a tourniquet: it may augment ischaemic damage, and you may forg et to take it off (exception: extremity amputation \200\224or where blood loss is a mortal threat). 723 a m u a r t d n a s c i d e a p o h t r O Saving lives in trauma Trauma is a ruthless killer. Every day 16,000 people worldwide are e stimated to die from trauma. 1000 times as many are thought suff er a signi \201 cant inju ry, with long-term morbidity having a signi \201 cant impact on populations.213 Road traff i c accidents (RTAs) \200\224or motor vehicle accidents (MVAs) \200\224are the highest risk activity, causing 45,000 deaths (2% of all causes) in the USA in 2002.214 It was in the US that the approach to caring for trauma patients began to change. In 1976 ( after a light aircraft crash in which he lost his wife) the re \202 ec- tions of the pilot , Nebraskan orthopedic surgeon Dr James K. Styner, drove him to create the means of dissemi nating education of the optimum care of trauma patients to those for whom trauma did not pl ay a major part in eve- ryday medical practice. By 1978, the American College of Surgeons ( ACS) had taken on the Advanced Trauma Life Support (ATLS ) course as a means to maintain t his standard of care for all those subject to trauma. It was broadly based on vital, yet novel concepts such as the \200\230golden hour \200\231 ,1 treating the most life-threatening injury \201 rst,2 and direct action when signs for action are identi \201 ed. Now in its 7th edition, the course (and its handbook, ISBN 1880 696142) cover the basic and advanced aspects of life-saving trauma care from chest injury, to the biomechanics of injury, to frostbite. The program also promotes the value of leadership and teamwork, skills that come to the for e in the heat of the moment, sometimes from the most unexpected quarters. 1 The \201 rst hour after injury is vital for the short- and long-term prognosis of patie nts who survive the initial trauma, and this timeframe is called the \200\230golden hour \200\231. The actions of a carer during this period have profound eff ects on subsequent mo rtality and morbidity. 2 ABCDE: airway, breathing, circulation, disability, exposure \200 \224see p725. \200 Major injury, including blunt chest injury ATLS On news of major trauma, summon exp erienced help (eg senior traumatolo- gist). \200 Remember ABCDE (see OPPOSITE for the gene ric approach). Blunt chest injury If breathing spontaneously, give ALL patients O2 at 15L/m in through tight- \201 tting mask with reservoir. \200 Quality of breathing: Stridor ( voice change) \211\210 ? sternoclavicular fracture/ posterior dislocation: get expert hel p at once as intubation may be diffi cult owing to tracheal compression, until the dislocat ion is reduced \200\224by extend- ing the shoulders, and grasping the clavicle with a clamp (eg towel clip) and manually reducing the fracture. Cover & seal open chest wounds on 3 si des. \200 Assume spinal instability: Keep neck immobile with sandbags, collar, tape. \200 \200 Is there tension pneumothorax? Needs urgent treatment: Relieve by insert- ing a large (14 \200\22316G) cannula (2nd ICS, midclavicular line) then a chest drain. Signs: br eath sounds, respiratory distress; pulse; BP; tracheal deviation (away from tension); cyano sis; neck veins distended, asymmetrical appearance of chest. \200 Hemorrhage control and \202 uid resuscitation: Apply pressure and eleva- tion to any actively bleeding part. Cro ssmatch ( \200\207ask for group-compatible blood \200\224only takes 5 \200\22310min); gluco se stix; 2 wide-bore saline IVIs (femoral catheter or saphenous cutdown anterior to medial malleolus if no IV ac- cess).215 Take systolic BP. If <90mmHg and blood loss is the probabl e cause; give 2L of warmed crystalloid stat IV until BP \200\200, urine \202 ows (>30mL/h ; cath- eterize as soon as feasible) and crossmatched blood arrives. NB: colloid is no long er the resuscitation \202 uid of choice.216 If intraperitoneal bleeding is suspected, see p726. \200\207Have a low threshold for suspicion of abdominal injury \200 \200\201BP + \200\200JVP + quiet heart sounds: = cardiac tamponade: \200 see p722. \200 Level-of-co nsciousness: (GCS/AVPU, p720). If \201 ts occur give \211 8mg lorazepam 4mg as a slow b olus ( 2min) into a large vein \200\224or buccal midazolam (p208); beware apnoea. Check pup il size every few mins. If pupils unequal, summon neurological help; give 20% mannitol 1g/k g (5mL/kg) IV ( \200\200cerebral blood \202 ow). See p728 for head injury. 724 \200 a m u a r t d n a s c i d e a p o h t r O Injury extent: Remove clothes (large scissors). Do circumferential burns need escharotomy t o \200\201laryngeal pressure? Any surgical emphysema (chest drain needed?). Is there a \202 ail chest (a segment has no bony continuity with tho- rax, with paradoxical respiratio n)? The main problem is the underlying in- jured lung (sensitive to over & under resuscitat ion; intubate & ventilate). \200 Chart ALL obs every few minutes and make sure someone is time-keeping. \200 ECG: ST & conduction problems \211\210 myocardial damage: extent is revealed via direct inspection by thoracic surgeon. Imaging: CXR, cervical spine (p658) and pelvis X-rays. CXR implications: If free air, do thoracocentesis (or formal chest drain) for pneumothorax. \200 If persiste nt large pneumothorax after chest drain suspect bronchial tear. \200 Ribs 9 \200\22312# \211\210 ?abdominal trauma \200 # of ribs 1 \200\2233 \211\210 ?airway/big vessel1 \200 CXR \202 uid level \211\210 haemothorax \200 # of >2 ribs in 2 places \211\210 ? \202 ail chest \200 Diaphragm contour \200\201 \211\210 ?rupture \200 Bowel gas in chest \211\210?diaphragm injury \200 Coils of NGT in chest \211\210?diaphragm injury \200 Live r raised \211\210 ?diaphragm injury \200 # of sternum \211\210 ?myocardial contusion \200 Mediastinal air \211\210 lung barotrauma \200 # of scapula \211\210?airway injury \200 Respiratory distress+CXR OK \211\210 ?aspiration \200 Tracheal deviation \211\210 ? aortic injury1 \200 Wide mediastinum \211\210 ?aortic rupture1 \200 Deviation of esophag us \211\210 ?aortic rupture1 \200 No aortic knob \211\210 ?ruptured aorta.1 FAST (focuse d assessment with sonography for trauma) and emergency echocar- diography are other useful tools in the evaluation of trauma patients. (see p727) \200 Secondary survey: Head-to-toe exam. Examine all peripheral pulses. 30% of fractures are missed in resus rooms; target fu rther imaging appropriately. In lung contusion (ventilate if SAO2 <90%). \200 Give tetanus toxoid booster human ant i-tetanus immunoglobulin (p730). 1 Have a low threshold for contrast-enhanced aorta CTs, especially if deceleration injury. 725 \200 ABCDE \200\224an immediate approach to trauma life support The ATLS program uses th e ABCDE mantra to inculcate the care methodol- ogy for the trauma situation (see also BOX \200\230Saving lives in trauma \200\231, p723). It prior- itizes direct treatment according to the most life-threatening injury identi \201 ed and avoids delay. \200 Remember to ac t immediately \200 Primary survey \200 A=Airway + O2 + cervical spine. Approach the patie nt with arms ready to im- mobilize the neck from the caudal end; CT is the best method of a ssessment if high/moderate risk for cervical fracture.217 Assess the airway; jaw thrust can be used to help maintain patency. Give 100% 02 to all patients. Talk to the patient \200 \224if they are able to talk back, then signi \201 cant airway or breath- ing compromise i s unlikely. Trauma to: \200 airway obstruction/head and neck trauma: see p758; \200 spine , p766. a m u a r t d n a s c i d e a p o h t r O \200 B=Breathing + ventilation. Check air entry with auscultation; also auscultate the hea rt; inspect, palpate and percuss the chest wall for further evidence of injury. Check RR. \200 Chest trauma, p722 \200\2234. \200 C=Circulation + hemorrhage control. Check GCS/AVPU, skin perfusion, BP & pulse. Note that the pulse pressure narrows before the BP drops. Estimate the volume of any blood loss (OHCM p609). Control any visible hemorrhage with local pressure, and consider possible sour ces of occult hemorrhage if no source identi \201 ed but the patient is shocked, ie examin e abdo, pelvis, femora (MINIBOX). NB: blood loss estimates from the scene of injury are unr eliable. Get 2L of warmed Ringer \200\231s lactate solution/Hart- mann \200\231s solution/0 .9% saline running stat via 2 separate points of venous access (take bloods \201 rst from one \200\224including pregnancy test for \200 ).216 Crossmatch an overestimate of the amo unt of blood lost. RBC replacement will be needed with >1.5L blood loss. Remember the possi bility of cardiac or neurogenic shock with a low BP and HR or if unresponsive to \202 uid resuscitation. Young, \201 t patients have excellent reserves, and so haemodynamic insta bility may rep- resent extreme compromise. \200 Abdo trauma, p726. \200 Pelvic trauma, p7 50. \200 Limb trauma, p738 \200\22357. Occult blood loss sites \200 Tibial/humeral # (0.75L) \200 Femoral # (1.5L) \200 Pelv ic # (several L) \200 Chest/abdomen (all) S N O E G R U S \200 D=Disability. Check GCS (if not already done), pupillary re \202 exes, gross evidenc e of a lateralizing injury or spinal cord level. Also check BM. \200 Head injury, p728. \200 Spinal trauma, p766. F O E G E L L O C \200 E=Exposure. Check and maintain body temperature using rewarming methods. Totally undr ess the patient, cutting all clothes off if necessary. \200 Hypothermia, OHCM p860. N A C I R E M A Adjuncts to the primary survey can add life-saving information: CXR, lateral C- spine X-ray and pelvic X-ray (and NO other X-ray until after the secondary survey); urinary catheter t o accurately assess urine output ( \200\207exclude urethral injury \201 rst); NGT inserti on ( \200\207not in presence of facial #); O2 sats and then ABG to accurately assess oxygen ation. \200 NB: if there is any change in the state of the patient or if there has been a prob- lem identi \201 ed and treated during the primary survey, begin the primary survey o ver again \200\224eg laparotomy may even precede \200\230D \200\231. Secondary survey Now the patient is stabilized, every inch must be scrutinized for another injury, working from scalp to toe. More focused imaging can take place. Includes more focused examination (eg PR exam, otoscopy) and tests (eg limb x-ray, full C-spine series). \200\207Remember tetanus \200\224p730. , E 7 , T R O P P U S E F I L A M U A R T D E C N A V D A : E C R U O S L A P I C N I R P \200 Abdominal injury \200 After any trauma, the abdomen and chest may be sites of occult blood loss (see MINIBOX, p725). Always consider intra-abdominal bleeding or pelvic frac- t ure (p750) if BP \200\201 and no source of loss is found. Penetrating injuries mostly requi re prompt laparotomy/ laparoscopy. \200\207Remember that all but the most super \201 cial injuries will require exploration \200\224laparotomy is indicated if the posterior rectus sheath is breached. Remember that the diaphragm rises up to the 4th ICS on the right and up to the 5th ICS on the left; diaphragmatic rupture may also expose abdominal contents to in jury in the chest. Assess degree of penetration (if uncertain) under local anesthetic, by e xtending the wound, if necessary. Ask for expert assistance with this. The most commonly in jured abdominal organ in penetrating trauma is the liver (MINIBOX). Blunt trauma Decelerati on forces may tear bowel from mesentery, liver from vena cava, bladder from bladder neck, p ancreas from retroperitoneum, and aorta from itself.1 The spleen is the most commonly injur ed abdominal organ in blunt trauma (MINIBOX). \200\207A ruptured spleen is suggested by sh ock, abdominal tenderness and distension, left shoulder-tip pain, and an overlying rib frac ture. Key questions: Are vital signs stable? Is laparotomy needed? (BP \200\201; GI, GU, or PR bleeding; evisceration; +ve ultrasound or peritoneal lavage). Tests CVP meas- urements, CT, and ultrasound may all mislead. There is no substitute for moni- toring vital signs an d examining the abdomen often. Systolic BP doesn \200\231t fall consistently until \211 30 % of blood volume is lost. \200\207NB: any visceral injury may cause bruising in the \202 anks, absent bowel sounds, and muscular spasm. Management Maintain airway; ensure adeq uate ventilation. Give high- \202 ow O2 (15L/min). Treat shock (p725). Crossmatch blood. T hen: 1 If the patient does not respond quickly, take straight to theater for an ex- plorato ry laparotomy (after urgent CXR to rule out pneumothorax and after passing of a nasogastric tube). 726 \200 Stab involvement: Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) a m u a r t d n a Blunt involvement: Spleen ( 50%) Liver ( 40%) Small bowel ( 10%) Retroperitoneal (15%) s c i d e a p o h t r O 2 Baseline observations: HR, BP, respirations, temperature, urine output. 3 Look for signs of GU injury (suggested by haematuria): \200 Blood at the urethral tip, signifying rupture d urethra. \200 Test the urine. Is there frank or microscopic haematuria? \200 Do a recta l exam to assess bowel integrity, presence of blood, or high- riding prostate (this suggest s bladder neck injury). \200 If any suspicious signs, seek urological help to plan urethra l repair. Rarely, GU trauma needs ureteroureterostomy, ureteroneocystostomy, or even kid- n ey autotransplantation. 4 Consider peritoneal lavage or FAST scanning (BOX 1). 5 Arrange a prompt exploratory lapar otomy if there is: \200 Shock (eg ruptured spleen) \200 Penetration to unknown extent \200 Peritonism (rupt ured viscus) \200 Pneumoperitoneum (OHCM p609, \201 g 1) A non-functioning kidney on IVU is a relative indication. Don \200\231t deny analge- sia on \201 nishing your assessment , simply for fear of masking signs. 6 Blood tests FBC (raised WCC may occur in ruptured spleen), U&E, amylase. 7 Radiology Prim ary survey adjuncts as for p725. Abdominal images are part of the secondary assessment: con sider these along with IVU, thoracolumbar spine, and other injured sites. See BOX OPPOSITE for the implications of radiol- ogy investigations. 1 \200\207Thinking of mechanisms in trauma is essential, as it will trigger thought of inj uries that may remain occult until too late (such as the above). 727 Emergency ultrasound Investigations are often required in abdominal trauma because physical examination alone may yield equivocal results. Focused Assessment with Sonography for Trau ma (FAST) has all but replaced diagnostic peritoneal lavage (DPL) as the bedside investigat ion of choice in abdominal trauma. as it is a rapid, repeatable and non-invasive test. It i s used to evaluate the evaluate the patient for free peritoneal or pericardic \202 uid \200\224which in the context of trauma is assumed to be blood. The FAST consists of four wi ndows \200\224the peri- hepatic, perisplenic, pelvic and pericardic It is considered positi ve when in- tra-abdominal or pericardial \202 uid is seen, and negative in the absence of this. FAST scanning can detect more than 100 \200\223250mL of \202 uid in the abdomen.21 8 However its sensitivity is user dependent and it is not sensitive at detecting liver and spleen tears219 or hollow viscus injuries. a m u a r t d n a s c i d e a p o h t r O Fig. 1. Shown are four transducer positions in the FAST: (1) pericardial area, (2) right up per quadrant, (3) left upper quadrant, and (4) pelvis. Reproduced from ACS Surgery: Princip les and Practice, American College of Surgeons. Decker Intellectual Properties, 2012 It has been found to decrease the time to recognition of intraabdominal trau- ma, the time to theater, and reduce the number of CT scans performed.220 \200\223222 However it has not been shown to reduce mortality.223 The role of FAST is therefore best con \201 ned to use with haemodynamically unstable patients \200\224 who can \200\231t be transferred to CT for more de \201 nitive imaging. In such patients FAST can be used to identify whether the ca use for haemodynamic instabil- ity is intraabdominal or intra-thoracic. Sonography at the b edside can also be used to evaluate the chest for a haemothorax or pneumothorax. It has gre ater sensitivity for small pneumothoraces than CXR, especially in the su- pine trauma patie nt. Radiographic implications in abdominal trauma \200 Lower rib fracture = ?liver/spleen tra uma \200 Pelvic fracture = ?rectal/urethral injury \200 Spine fracture = ?renal/pancrea tic/aortic/caval trauma \200 Free gas = bowel rupture \200 Bowel displaced = ?haemoperi toneum. \200 Head injury In the UK, manage according to NICE guidelines. This is a summary.224 De \201 nition Any trauma to the head other than super \201 cial injury to the face. Emergen cy care As always, treat ABCDE \200\224 Airway, Breathing, and Circulation, Disability, Exp osure (p725). \200 Give O2 and treat shock. \200 Protect the cervical spine. \200 Note p upil sizes and reactivity. \200 Do not neglect other injuries. Primary brain damage occurs with the initial trauma. The clinical imperative is to prevent or amelio- rate secondary b rain injury, ie further neu- ronal death: successful management of A, B & C is the \201 r st step. 728 \200 Cranial injuries: \200 Skull fracture Intracranial injuries: \200 Diff use axonal injur y \200 Extradural bleed* \200 Subdural bleed* \200 Subarachnoid bleed# \200 Intrace rebral bleed \200 Cerebral contusion OHCM images on: *p487; #p483. a m u a r t d n a Ask about: \200 Injury time and mechanism \200\224impact or acceleration/decelera- tion. \200 Trend in consciousness level. Check ears and nose for bleeding or CSF leaks (oto \200\223 & rhinorrhoea respec- tively \200\224p560). The presence of these or blood behind the tympanic membrane may indicate a fractured base of skull. Bruising over the mastoid (Ba ttle \200\231s sign) and periorbital bruising ( \200\230raccoon eyes \200\231) are late and unreliable signs of fractured base of skull. Neurological assessment \200 Write full not es; record times. \200 Assess the Glasgow Coma Score (GCS, p720) accurately and repeatedl y. Re- cord all 3 parameters (motor, eyes, and verbal). If there is a diff erence be- tween the sides, record the better result. If there is the possibility of a spinal injury, check for a response such as grimacing to a painful stimulus applied above the clavicles. Assess and record any contribution to mental status from alcohol or other drugs. s c i d e a p o h t r O Pupils \200\224check size and reactivity every few minutes until stable. Unequal pu- pils are less important if conscious, but a grave sign in coma. Spinal cord \200\224look for localizing neurological long tract signs ie: assess pow- er, t one, re \202 exes, and all sensory modalities, comparing right side vs left, upper body vs lower. Check for priapism and anal tone. Low BP together with an inappropriately low pulse rate indicates sympathet- ic disruption in cervical spinal cord injury. Medical management of head injury There are a number of specialist inten- sive care measure s that can prevent secondary injury and optimize recovery: \200 Avoidance of hypotension: Keep systolic BP >90. Even a single episode of low BP is associated with worse outcomes in severe traumatic brain injury.225 \200 Avoidance of hypoxia: Keep PaO2 >60mmHg or sats > 90%. \200 Careful IV \202 uid therapy: \200\207Treat hypovolaemia ( \200\230 cerebral hypoperfusion); \200\207do not overload (preventing cerebral oedema); do not use glucose p repa- rations (which damage brain tissue).