Chapter 6 - TRAUMA CARE AND SURGICAL TREATMENT

Responding to traumatic events - trauma principles

Every year the statistics of accidents, crime and disasters in the society are on the rise, despite our best efforts at prevention. Every disaster is a unique challenge, and disaster nurses should be prepared for anything and everything. A nurse may function as a triage practitioner, a role that requires that several victims be assessed and prioritized quickly to ensure that resources are used appropriately. In disaster areas rescue teams must be able to perform under stressful and often suboptimal conditions. With an understanding of basic trauma nursing skills and proper planning, nurses can have a significant impact on the outcomes of trauma victims. As health care professionals, nurses also have a commitment to prevent accidental and intentional injuries.

Trauma is an injury caused by a physical force. No one is immune to trauma, and traumatic injuries or disasters can happen at any time. Trauma is the leading cause of death for all age groups under the age of 44 (CDC - Injury Response, 2008). The elderly and children are particularly vulnerable to die from injuries. On every continent, regardless of gender, race, or economic status, injuries remain a leading cause of death worldwide, accounting for more than 5.8 million deaths each year. Millions of people suffer disabling injuries, and millions will also be permanently disabled. Annual trauma costs in the United States are estimated to be between $100 and $200 billion (American Trauma Society).

Disaster nurses are in a unique position to participate in all aspects of disaster response, including triage, stabilization, definitive care, and evacuation. The nurses’ goals at a disaster are to evaluate the scene, set priorities, organize resources, classify victims according to severity of injury, intervene as indicated, stabilize the victims, and plan transport to the most appropriate facility. By life-saving techniques and trauma support skills, the rescuers intervene to if possible prevent deaths, to limit the injuries and promote a return to the best possible state of wellness.

R Adams Cowley, associated with the renowned Shock Trauma Center section of the University of Maryland Medical Center’s in Baltimore, Maryland developed the concept of the golden hour. He found that the highest survival rates in trauma victims were influenced by rescue actions taken in the first hour after the injury. Patients who receive skilled care in this hour have the best chance to recovery. Quick and the timely help rendered in this crucial period would ensure that the victim is nearly saved so that appropriate treatment can be made available from the nearby hospital. To survive injury in combat, every second counts, and rather than the "golden hour", medical planners in the military now refer to the time immediately after injury as the "platinum 10 minutes".

The period during which all efforts are made to save a life before irreversible pathological changes can occur thereby reducing or preventing death may range from the time of injury to definitive treatment in a hospital. Seconds count in trauma care to make the golden hour effective and should be distributed as follows to make it fruitful: assessment of the victim and primary survey 1(-2) minutes, resuscitation and stabilization 5 minutes, immobilization and transport to nearby hospital. The type of trauma, but also other factors, including the patient’s age and medical condition and the estimated time to arrival at the appropriate facility determine a trauma patient’s need for transport to a trauma center.

Complications may occur if the patient is not managed appropriately and expeditiously. Therefore it becomes a priority to transport patients suffering from severe trauma as fast as possible to specialists, most often found at a Level-I trauma center, for definitive treatment. Because some injuries can cause a trauma patient to deteriorate extremely rapidly, the lag time between injury and treatment should ideally be kept to a bare minimum. A trauma center will often have a helipad for receiving patients that have been airlifted by helicopter to the hospital. CDC-supported research shows that the overall risk of death was 25 percent lower when care was provided at a Level-I trauma center than when it was provided at a non-trauma center. The best prehospital emergency care is doomed to failure if the receiving facilities are not equipped to carry on a high standard of care after the paramedic has transferred responsibility for the victim to the emergency department.

Trauma centers vary in their specific capabilities and are identified by designated levels: Level-I being the highest, to Level-III being the lowest. Level-I trauma centers are equipped and staffed around the clock to meet the needs of trauma patients. Surgeons, emergency physicians and anesthesiologists are in the facility 24 hours a day, specially trained nurses and support staff are ready at all times. These trauma centers serve as outreach educators and resources for the entire trauma network. Many community hospitals serve as Level-II trauma centers, where operating facilities and surgeons are immediately or readily available. A facility classified as Level-III is generally a small rural hospital with limited staffing and resources. Personnel are generally on call or in house to meet the immediate need of trauma patients before they are transferred to a Level-II or Level-I facility if the nature of the injuries so dictate. Some states have five designated levels, in which case Level-V is the lowest.

The American College of Surgeons (ACS), ("Resources for Optimal Care", 1990) has identified three phases of death due to trauma: The first peak is within seconds to minutes to injury. Invariably those deaths are due to lacerations of the brain, brainstem, upper part of the spinal cord, heart, aorta, or other large vessels. The second peak of deaths occurs within the first four hours after injury. These deaths are usually due to intracranial hemorrhage, hemopneumothorax, ruptured spleen, lacerations of the liver, fractured femur, or multiple injuries associated with significant blood loss. The third peak occurs days or weeks after the injury and most often is due to sepsis or multiple organ failure.

This scheme with the aspect of time for deaths after accidents indicates the prioritizing of injured victims (Andrén-Sandberg, 1993):

50% within 30 minutes - extensively injured, impossible to save
30% within 4 hours - significant blood loss, oxygenation problem
20% within weeks - multiple organ failure, sepsis.

The initial medical emergency treatment of seriously injured victims will take place either at the scene, during transportation or in the emergency department of a hospital (or in a separate life support facility), in the operating room and the intensive care unit. Emergency Medical Service (EMS) system is a national network of services coordinated to provide aid and medical assistance from primary response to definitive care, involving personnel trained in the rescue, stabilization, transportation, and advanced treatment of traumatic or medical emergencies. The EMS response system of care, is usually initiated by citizen action in the form of a telephone call to an emergency phone number (911 available nationwide) after recognition of serious emergencies. The use of cell phones and sms among the public may enhance care by improving response time. Subsequent stages include the first medical responder, ambulance personnel, rescue equipment, and paramedic units, if necessary. In the hospital service is provided by emergency room nurses, emergency room physicians, specialists, and critical care nurses and physicians/surgeons.

The National Disaster Medical System (NDMS) works in conjunction with local fire, police and emergency medical services to provide comprehensive disaster relief. One component of the NDMS involves civilian, volunteer disaster response teams known as disaster medical assistance teams (DMATs). DMATs are locally based, federally supported rapid response teams designed to supplement local medical care when needed, and at times, even in other states. Teams known as international medical/surgical response teams (IMSURTs) will make resources available to more areas, even outside the United States and its territories.

At the scene

The overall approach to the situation of multiple casualties is to maximize use of available resources and promote optimal outcome for all the trauma victims. When confronted with a trauma victim the EMS professionals or other rescuers perform an initial rapid assessment (about 1-2 minutes) of the airway, breathing and circulation and look for injuries that threat life and limb. Principles of triage are that salvage of life takes precedence over salvage of limbs. The immediate threats to life are asphyxia and hemorrhage.

Once the primary survey to secure vital functions, according to the basic scheme: Airway, Breathing, Circulation, and life-threatening conditions affecting the airway, breathing, and circulation have been adequately managed, a rapid methodical examination (secondary survey) is required. The rapid secondary survey should begin with an assessment of consciousness and vital signs and proceed systematically in head-to-toe order (Disability=response when spoken to/stimulation; Exposure=head-to-toe survey). The head-to-toe survey should not take more than one to two minutes. If the primary survey elicits any positive findings, such as an obstructed airway or massive hemorrhage, it will be necessary to attend those problems, before proceeding further in the assessment of the injured victim. In the secondary survey the patient will be systemically examined from head to toe, in attempt to detect any less obvious injuries or signs that may give clues to underlying medical problems.

Speed is essential in evaluating and managing the multitrauma victim, and every effort must be made to get the victim to a hospital as quickly as can be safely accomplished. In general, the victim cannot be stabilized at the scene. Therefore, try to keep the victim alive and prevent further injury while you ensure prompt arrival at a suitable medical facility (a regional trauma center). The strategies to "load and go"/"scope and run" or to "stay and play" must be chosen depending on the situation and hence vary between different accidents and even between different stages during the course of events of the same accident. The distance and the estimated time from the scene to arrival at the appropriate facility are also of great importance. Rules (practical advice) for treatment of seriously injured both prehospital and at the hospital should be simple and of basic ABC-character. First aid can be trained by lay public, and also how to call for emergency assistance and how to secure the scene from new damages.

The management of injured should follow a fixed scheme. This can be divided into four phases (Andrén-Sandberg, 1993):

1. Primary survey of injuries and the type of trauma.
2. Secure the airway, breathing, circulation and immobilize the spine.
3. Standardized examination.
4. Start of the victim’s definitive treatment.

Phases 1 and 2 are applicable at the scene. No transport is meaningful if the injured is not breathing. Severe bleeding can be life threatening, but by applying direct pressure to the external bleeding you can stop almost any form of bleeding. Shock prophylaxis can also be given. When a patient is in shock, the secondary priority (after establishing the airway) is to try to determine the cause of shock so effective interventions can be started.

Knowledge of the type of disaster may help you drew conclusions about the number of injured, the nature and type of injuries likely to occur in disaster victims.

Expected injuries at different disasters

In the emergency room

In American literature two letters have been added to the ABC plan of assessment, hence the beginning of the alphabet then means (Andrén-Sandberg, 1993):

A - airway maintenance with spinal control
B - breathing and ventilation
C - circulation with hemorrhage control
D - disability: neurologic status
E - exposure: completely undress the patient.

The more severe injuries, the more important it gets to follow A-E. Patients must be reassessed as often as possible, because their condition can deteriorate quickly. For example, tension pneumothorax and bleedings around the pelvic fractures, can give symptoms first after a few hours. If you can ask the injured: "What it was that happened?" You’ll get valuable information about injuries, to be expected and at the same time get knowledge about upper airways, breathing and the patient’s neurologic status. At the same time the investigator can palpate the injured patient’s pulse, look at the skin color, and thereafter the capillary refill (by pressing on and then releasing the patient’s skin at the base of the fingernail). The respiratory rate and depth is also noted as soon as possible. Simultaneously survey of several aspects will show a reasonable overview of the injuries type and severity. A rapid, accurate assessment and history are the keys to successful intervention for the trauma patient. The following texts discuss intervention for specific traumatic injuries.

Assessing the trauma patient

The Field Triage Decision Scheme: The National Trauma Triage Protocol

The Division of Injury Response (DIR) at CDC’s Injury Center seeks to improve outcomes for those who have survived severe injuries and to improve emergency care practices. The "Field Triage Decision Scheme: The National Trauma Triage Protocol" (Field Triage Decision Scheme) was developed in 2006 in partnership with the American College of Surgeons-Committee on Trauma and the National Highway Traffic Safety Administration (NHTSA) and is grounded in current best practices in trauma triage. The Decision Scheme is intended to be the foundation for the development, implementation, and evaluation of local and regional field triage protocols. CDC has developed easy-to-use materials for emergency medical services professionals (such as a training guide for EMS leaders, guidelines, posters, pocket card, badge, and protocol) (CDC - Field Triage Decision Scheme, 2010).

The "Field Triage Decision Scheme" provides information that EMS professionals can use to take an active role in improving the outcomes for the acutely injured.

Field Triage Decision Scheme: The National Trauma Triage Protocol

If YES, Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.
If NO, Continue to assess anatomy of injury.

If YES, Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.
If NO, Continue to assess mechanism of injury and high-energy impact.

If YES, Transport to closest appropriate trauma center, which depending on the trauma system, need to be highest level trauma center.
If NO, Continue to assess special patient or system consideration.

If YES: Contact medical control and consider transport to a trauma center or a specific resource hospital.
If NO, Transport according to protocol.

When in doubt transport to a trauma center.

By U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

For more information on the Decision Scheme, visit www.cdc.gov/FieldTriage

Airway management, breathing and ventilation

Advanced Trauma Life Support (ATLS) program and courses are designed for doctors who care for injured patients, but the training program has also been used in a modified form in the education of nurses and paramedics. The program, developed by the American College of Surgeons (American College of Surgeons, 2008), has been adopted worldwide in over 40 countries, sometimes under the name of Early Management of Severe Trauma (EMST). Its goal is to teach a simplified and standardized approach in the initial assessment and management of acute trauma cases. This modified triage decision scheme for management in situations of mass casualty/disaster with general principles for primary survey is characterized by among others the ATLS-education. Assess the patient’s condition rapidly and accurately; resuscitate and stabilize the patient according to priority; determine if the patient’s needs exceed a facility’s capabilities; arrange appropriately for the patient’s definitive care; and ensure that optimum care is provided. The lack of a definitive diagnosis and detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. One of the most widely used adaptations is the addition of "DR" in front of the basic "ABC", which stands for Danger and Response. The approach in first aid is to protect yourself before attempting to help others, and then assure that the victim is unresponsive before attempting to treat them, using systems such as the AVPU scale or the Glasgow Coma Scale (which are described further under Disability and Exposure, and Head injury). As the original initials were designed for in hospital use, this DR ABC was not part of the original protocol.

Triage of the individual victim with injuries is initiated with the primary survey, according to the basic ABC-plan of assessment: Airway, Breathing, and Circulation. The first priority for trauma victims is to establish a patent airway and breathing. Ask all conscious victims what happened, and where they think they are hurt. A simple appropriate verbal response reveals that the victim is conscious (cerebral perfusion is adequate) and the airway is open (ventilation is occurring). In multitrauma as in medical problems, the airway always merits primary attention and accurate assessment. If the first contact establishes that the victim is unconscious, immediately further evaluate the airway, breathing, and circulation. Continue to speak to the victim as though he or she were conscious, as hearing is the last sense to be lost, and the victim actually may be aware on what is happening. Patients with obstructed airways must receive immediate efforts to relieve the obstruction. The unconsciousness victim is in constant jeopardy of mechanical obstruction, and immediate intervention will be required, otherwise the victim may die within minutes. When dealing with the victim of trauma remember that any patient with significant head or facial injury is assumed to have cervical spinal injuries until proved otherwise. Movement of the victim’s head and neck could aggravate any spinal injury and cause permanent disability. Efforts to open the airway must take this into account, and manipulation of the neck must be kept to a minimum. Some rescuers and protocols use an additional lowercase letter (small) ‘c’ in between the A and B, AcBC, standing for ‘cervical spine’ or ‘consider C-spine’, as a reminder to be aware of potential neck injuries to a victim.

The most common cause of airway obstruction in an unconscious or semiconscious trauma victim is the tongue falling back into the throat to block air flow through the pharynx. Other causes include the epiglottis falling back to occlude the trachea; secretions, blood, vomit, loose or avulsed teeth, broken dentures, or foreign bodies obstructing the airway; mucous membrane swelling (due to heat or toxic fumes); and trauma to the head and neck.

Look, listen and feel to assess respiratory exchange. Quickly scan the entire victim. Look for obvious trauma, note skin color and affect. Both sides of the chest should move together with equal expansion. Victims with inadequate oxygen in their blood will become restless and agitated. Kneel, lean close to the victim’s head, peering down at the chest and listen to the sound of air passing in and out of the victim’s nose and mouth. Gurgling sounds or snoring may indicate the upper airway is partially obstructed. If the victim is hoarse, damage to the laryngeal structures can be suspected. Feel for the flow of air by holding the palm of your hand near the victim’s nose and lips. Place your palms lightly on each side of the victim’s chest over the ribs to feel if both sides of the chest are rising equally. Evaluate the integrity of the rib cage, and gently feel for fractures or distorted areas. A pale skin tone indicates that perfusion is less than adequate. Cyanosis is a late and ominous sign of hypoxia, chiefly occurring when death is imminent. Cyanosis is difficult to assess if the victim is simultaneously cold, bleeding out (exsanguinating), or poisoned by carbon monoxide.

Establishing an open or patent airway with adequate air exchange (ventilation) is the first priority in every trauma patient, because without adequate ventilation, severe brain damage and death are inevitable. The victims’ outcome is directly related to the ability to open and secure the airway. Sometimes simply lifting and holding the victim’s tongue off the back of the throat by using the chin lift or forward displacement of the mandible (jaw trust), or both, with the neck in neutral position and the head stabilized will enhance air flow markedly. Open the airway, by lifting the victim’s chin with your index or middle fingers, or place your thumbs at the angles of the victim’s jaw to lift the mandible and relieve any obstruction. If the victim is not breathing take immediate action. Check for a pulse in the carotid artery while you are evaluating the breathing, and if the patient still does not breathe spontaneously, begin CPR in accordance with current established guidelines. As of 2010, the American Heart Association chose to focus CPR on reducing interruptions to compressions, and has changed the order in its guidelines to Circulation, Airway, Breathing (CAB) (Hazinski, 2010).

A rigid cervical collar should be placed to prevent movement of the head and neck that might aggravate spinal injury. Examine the mouth for foreign bodies, and carefully sweep secretions, blood, vomit, and foreign materials from the mouth. Flexion of the head (chin to chest) is a major mechanism of injury in most spinal trauma. Be careful and avoid especially bending the neck forward, which is implying the greatest risk to worsen a cervical spine injury. If suction is available, use a rigid suction. If a skull fracture is present, flexible suction catheters may enter the cranial vault. The recovery position is for when someone is unconscious but otherwise unhurt, and breathing normally. Frequent reassessments of the victim are essential.

An artificial airway may be all that is needed to secure an open airway in the unconscious or semiconscious victim. Oropharyngeal/oral airways are curved pieces of plastic that are placed into the mouth to hold the tongue off the back of the throat. The easiest method for an adult is to insert the airway upside down and then rotate it right side up after it’s in the proper position. Alternatively, displace the tongue using the tongue blade and then insert the airway into the proper position. They are available in a variety of sizes. The correct size will extend from the victim’s lip to his earlobe. They are not tolerated by conscious or semiconscious patients because they may stimulate gagging, vomiting and laryngospasm. Nasal airways are trumpet-shaped soft, flexible tubes of rubber or plastic that are slid down through a nostril to keep the tongue off the back of the throat and thus secure flow of air. Nasal airways are better tolerated by conscious or semiconscious patients because they do not stimulate the gag reflex as vigorously as oral airways do. They can trigger nose bleeds, and worse the tube may enter the cranial vault if a skull or mid facial fracture is present.

Artificial ventilation is begun on patients who are apneic. If no spontaneous respiratory effort occurs after you open the airway, begin artificial respirations and secure the airway. Give the victim oxygen at the earliest possible moment. If proper technique is used, a manual resuscitation device with a bag, valve, and mask (bag-valve device, ambu bag) can be used in conjunction with an oropharyngeal airway and 100% oxygen to provide adequate ventilation. Ventilations need to be synchronized so that they’re given between cardiac compressions to allow inflation of the lungs and decrease the risk of aspiration (before proper intubation by a tube through the mouth, nose, or throat). Endotracheal intubation is the preferred method of airway management because it isolates the airway, keeps it patent, and decreases the risk of aspiration. A cuff or balloon near the tip of the plastic tube is inflated to seal off and protect the lungs from the contents of the stomach and throat. The tube allows delivery of high concentrations of oxygen, provides easier access for suctioning and another route for administering potentially lifesaving drugs. Sophisticated invasive procedures should only skilled professionals attempt to perform. If facial fractures produce instability of the maxilla and mandible, nasotracheal intubation or cricothyrotomy (an emergency incision into the larynx) may be urgently required. Prepare to assist with intubation or establishment of a surgical airway if the victim’s condition so indicate.

If the victim is breathing, but respiration is noisy, an airway obstruction may still be present in the airway or the victim may have serious head, neck or chest injuries. Cut off clothing from the upper part of the victim’s body and again look, listen and feel for trauma. Look for obvious deformities in, or trauma to, neck and chest. Feel for crepitations, escaping air, and variations in the chest wall, and listen for sounds of breathing. This is an emergency, and the victim should be transported immediately to the nearest hospital.

If the victim is apneic after a patent airway has been established, or if breathing is very shallow or slow, artificial ventilation must be initiated preferably with high oxygen concentrations. Effective respiratory exchange also depends on intact lung-chest wall dynamics. Thus, the seriously traumatized victim requires further measures to establish useful breathing. Open wounds of the chest should be sealed immediately. Blunt trauma of force sufficient to fracture the rib cage often is associated with bruising of the heart and the lungs, such as pulmonary contusion. It may cause immediate, life-threatening hypoxia or develop into respiratory distress later. The ribs most commonly broken are the fourth and tenth. If the end of a fractured rib has penetrated the lung, possible pneumothorax or hemothorax can occur. Pneumothorax is entry of air into the pleural space with a partial or complete collapse of the lung. The victim must be reassessed frequently for evidence of developed pneumothorax, and the seal released periodically if such evidence is found. Massive hemothorax is the presence of blood in the pleural cavity, and it often accompanies traumatic pneumothorax. An open or traumatic pneumothorax has a sucking noise at the site of the chest wall defect. A tension pneumothorax is caused by air entering the pleural space and getting trapped there, thus increasing tension. Tension pneumothorax is a life-threatening situation and must be decompressed at the earliest possible opportunity. Flail chest, a thorax in which multiple rib fractures cause instability in part of the chest wall and paradoxic breathing, with the lung underlying the injured area contracting on inspiration and bulging on expiration, and will result in hypoxia if it is uncorrected. Its treatment may be delayed until life-threatening problems have been dealt with.

Subcutaneous emphysema and tracheal deviation must also be identified if present. Subcutaneous emphysema is a condition in which trauma to the lung or airway results in the escape of air into the subcutaneous tissue, especially the chest wall, neck and face, causing a crackling sensation on palpation of the skin. Bleeding is often perfuse in neck injuries with a frothy mixture of air and blood blowing through the penetrating wound. The lung and air passages can be injured by heat, smoke, or toxic fumes. Absent or ineffective breathing also can be caused by an injury of the respiratory center due to brain injury, hypoxia, or circulatory shock.

Circulation, hemorrhage and shock

The next priority, after establishing a patent airway and breathing, is to evaluate the circulation, as apnea and trauma can cause cardiac arrest from loss of circulating blood volume or hypoxia. Blunt or penetrating trauma to the soft tissue, organs, or bones may result in shock. Shock is a complex syndrome, developed as the body responds to a disorder that’s causing inadequate circulation or tissue perfusion to support organ function. In the victim of multiple trauma the heart itself may be damaged by crushing injury to the chest and injury to the spine can severely comprise the ability of blood vessels to constrict in response to loss of volume. Blood volume may also be lost through massive external or internal hemorrhage. If the pulse cannot be felt with properly executed external cardiac compressions, consider the possibility of cardiac tamponade (significant quantities of blood in the inelastic pericardial sac (pericardium) surrounding the heart, which limit the ability of the ventricle to fill). The transport must not be further delayed. Accomplish whatever actions are necessary according to the primary survey (establish an airway and control external bleeding by direct pressure) and move swiftly to the hospital. Thus, attempts to restore circulation to the injured must go beyond mere external cardiac compressions.

Shock occurs in many forms, with signs and symptoms varying according to the cause and the victim's preexisting conditions. The victim’s body will respond initially with the same compensatory mechanisms. The circulatory, neurologic, and endocrine system will all react to an effort to restore circulating blood volume and increase tissue perfusion. If interventions are successful, this compensation cycle may successfully reverse the shock process, but the compensatory mechanisms are effective for only a short time. Then the victim's condition will deteriorate rapidly in a cycle of decompensation that almost invariably results in death. Trauma can cause hemorrhagic shock due to significant blood loss. Hemorrhagic or hypovolemic shock is the most common shock in trauma patients. Hemorrhage is also the predominant cause of preventable post-injury deaths.

Assume that internal hemorrhage has occurred whenever a traumatized victim has a distended or tender abdomen, fractured long-bones in extremities proximal to elbow and knee, pelvic fracture, bleeding from body orifices, penetrating injuries to the head, neck or torso, or hematemesis. If you can palpate a carotid pulse, the systolic blood pressure is presumed to be at least 70 mm Hg; the femoral pulse, 80 mm Hg; and the radial pulse, 90 mm Hg. If there is no palpable pulse commence external cardiac compressions. Start resuscitation efforts when the victim appears to have a chance for survival. The victim should be transported immediately to the nearest hospital, preferentially to the highest level of care within the trauma system.

Cardiogenic shock is an inadequate pumping of the heart, resulting in decreased systemic blood flow and inadequate tissue perfusion. Cardiogenic shock is not as common as hypovolemic shock in trauma patients, but it must be considered when no evidence of blood loss is present, but the victim has signs and symptoms of shock. This shock may originate with trauma to the heart (did a myocardial infarction cause the accident? or was the heart injured in the accident or assault? or by a cardiac tamponade?).

When the circulating volume is adequate but the distribution of it is impaired, distributive shock has developed, identified as neurogenic shock or septic shock. A neurogenic shock, which results from peripheral vascular dilation, can be caused by a serious injury to the spinal cord. Suspect neurogenic shock in any injured victim who has paralysis and whose hypotension is not accompanied by tachycardia. The victim may be severely bradycardic, if the cardioaccelerator nerves T1-T4 are blocked by spinal injury (Chitwood, 1995).

Septic shock is when massive infection causes vasodilatation and inadequate tissue perfusion. Unless treatment of the victim was delayed, or injury has caused contamination of the abdominal cavity from disruption of the gastrointestinal system, septic shock is seldom a concern in the initial management of injured victims. If the skin is warm, pink, or ruddy, and the pulse pressure is widened rather than narrowed should septic shock be suspected.

Penetrating chest injuries such as cardiac tamponade can cause a flow obstruction shock when the ejection of blood from the heart is impeded, and also cardiogenic shock.

Anaphylactic shock, an exaggerated allergic reaction which may be rapidly fatal, is seldom an issue in injured victims.

The first priority is always to establish or maintain your victim's ABCs. Then concentrate on replacing body fluids that the victim is losing in a hypovolemic shock. Initially, normal saline solution or lactated Ringer's solution is usually started to expand blood volume. The only fluid that replaces lost blood cells is blood itself, a colloid. Researchers are also looking for artificial blood substitutes that can carry oxygen to tissues. In life-threatening situations, unmatched type O, Rh- specific blood should be given after 2 to 3 liters of lactated Ringer's solution until cross matched blood is available (Rh negative blood is given to women of childbearing age, and Rh positive to men) (The clinical answer book, 1996).

In the United States the size of the blood loss is classified from Class 1 to Class 4. The symptoms for an adult male (154lb, 70kg) can be outlined like this (Andrén-Sandberg, 1993):

Adults normally have a total blood volume of 7% to 8% of body weight, or 70 ml/kg of body weight for men and about 65 ml/kg for women. Pulse pressure, the difference between the systolic and diastolic pressures is normally 30 to 40 mm Hg.

Lethal blood loss if not replaced (rapid): is 2.0 L for an adult male with a total blood volume of 5.0-6.6 L; 1.3 L for an adolescent with a total blood volume of 3.3-4.5 L; and 0.5-0.7 L for a child with a total blood volume of 1.5-2.0 L (Grant, Murray, & Bergeron, 1990). For a newborn infant within normal weight range with a total blood volume of 300+ ml, a blood loss of 30-50 ml is lethal if not replaced.

The American College of Surgeons committee on trauma recognizes four types of hypovolemic shock (Trunkey, 1985; Andrén-Sandberg, 1993):

Most patients, can lose about 750 ml (15%) of blood volume without exhibiting signs or symptoms because of the body's compensatory mechanisms. Signs and symptoms when someone loses up to 1500 ml (15-30%) of the body's blood volume include increased heart and respiratory rates, narrowed pulse pressure, anxiety, pale cool skin, and slow capillary refill. When someone loses up to 2 L (30-40%) of the blood volume signs of inadequate perfusion appear, including hypotension, tachycardia, tachypnea, and a decline in mental acuity.

A systolic blood pressure less than 70 mm Hg and a pulse greater than 130 beats per minute imply at least 40 percent loss of the blood volume. This is a critical situation, and the death may be imminent. When losing more than 40% of the blood volume (Class IV hemorrhage), the pulse is rapid and shallow as are the respirations, the skin is cold and clammy, urine output dwindles and stop, and the patient may lapse into a coma. As death looms, the heart slows and then finally stops. Note that elderly patients are vulnerable to fluid overload and that compensatory mechanisms can be compromised by age or cardiovascular diseases.

Clinical signs of shock are:

• Skin is pale, clammy and cold, especially peripherally on the extremities.
• Veins are collapsed.
• Pulse is weak, thready (low pulse pressure), and rapid.
• Breathing is shallow and rapid.
• Appears apathetic, unresponsive, and frozen. Signs of restlessness and anxiety, an affect also related to decreased blood flow to the brain.

Shock should be anticipated in every seriously injured patient. Establish shock prophylaxis within the scope of your license, skills and training:

• Apply direct pressure to a bleeding wound to slow the outflow of blood and encourage clotting. Do not apply direct pressure to bleeding from an injured eye, because this could cause loss of vision and the eye itself.
• Elevate the injured part to reduce blood flow if the extremity has no fractures and spinal injury has been ruled out.
• If the victim's injuries are severe, raise the level of his feet above his chest and head, unless there is a head injury, a broken nose, or if he is having trouble breathing. Trendelenburg position.
• Tourniquets should be used only as the last resort and in the cases of massively traumatized extremities where there has been injury to major blood vessels, such as traumatic amputation.
• For major trauma, involving the lower extremities, abdomen, or both, Military/Medical Anti-Shock Trousers (MAST) are used to combat shock, stabilize fractures, promote hemostasis, increase peripheral vascular resistance, and permit autotransfusion of small amounts of blood. They also are used in emergencies in the treatment of hemorrhagic shock, as ordered, by a member of the trauma team or someone specially trained in its application.
• Avoid chilling. Cover the victim with a blanket to retain body heat.
• Establish and secure open airway and adequate ventilation.
• Administer oxygen to reduce the potential for hypoxia, and assisted ventilation as needed.
• Allay anxiety and fear, by using a calm, safe, and friendly approach. Explain what you are doing and why. Answer the victim’s question when possible.
• Be careful when lifting and moving the victim and immobilize fractures before longer transports.
• If analgesics are given, it must be carefully recorded (time, drug, dose, and route) on a triage tag.
• Do not give the injured victim anything by mouth in case surgery is necessary or in case the victim’s level of consciousness decreases.
• Start two large-bore intravenous lines and begin fluid resuscitation as ordered with crystalloids (a clear intravenous fluid, such as normal saline or lactated Ringer's solution, that can diffuse through a semipermeable membrane), or colloids (a plasma expander).

Disability and Exposure

In the concept of ATLS has assessment of possible neurologic effect Disability been noted as the first action after securing vital functions. In situations with many injured, where the decision scheme must be adjusted to maximum efficiency should this neurologic assessment only be very rough with the aim to give an early indication of head injury. A basic neurologic assessment is made, using the AVPU scale (Alert, Voice, Pain, Unresponsive) system by which a first aider can measure and record a victim's responsiveness, indicating their level of consciousness (Kelly, Upex, & Bateman, 2005). It is a simplification of the Glascow Coma Scale, which assesses a patient response in three measures, eyes, voice, and motor skills. The AVPU scale should be assessed using these three identifiable traits, looking for the best response of each.

- Response when spoken to (verbal stimuli response) = fully awake, drowsy, no response.
- Response to pain stimuli (pain stimuli response) = adequate, inadequate, no response.
- If fully awake (alert) = finish and continue to Exposure.
- If no response to pain (unresponsive) = consider if you should stop (a head injury with no response to pain has in these situations a mortality of close to 100% (according to a material of Victims of War during the Vietnam War) (Lennquist, 2002).

A more detailed and rapid neurologic assessment should be performed after the injuries to the trunk, which can be directly life-threatening and require immediate interventions and with that have higher priority. This assessment establishes the state of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.

The most important clinical sign in head injury is a changing state of consciousness indicating the need for immediate reevaluation of the victim’s oxygenation, ventilation and perfusion status. If the victim is unconscious, consider all potential causes, including traumatic brain injury, hypoglycemia, alcohol, and drugs, that might account for loss of consciousness.

The Glasgow Coma Scale is a quick, practical standardized system for assessing the level of consciousness and for predicting the duration and ultimate outcome of coma, primarily in patients with head injuries. If not done in the primary survey, it should be performed as part of the more detailed neurologic assessment in the secondary survey.

Exposure in the concept of the ATLS means a rapid methodical physical examination systematically in head-to-toe order. To do this properly, one must cut away the victim’s clothes, preferably in a shielded area where privacy can be maintained. Cover the victim with blankets to retain body heat. Victims exposed to major trauma, generally have multiple injuries (to 2-3 organ systems). Deaths or complications among trauma victims are often due to airway obstruction, or less obvious but more dangerous injuries, which are overlooked because of dramatic injuries elsewhere. The multitrauma victim must reach a suitable medical facility (trauma center) as fast as possible, so do only what you have to do at the scene, and get moving. Intravenous fluids should be warmed, a necessity especially in cold weather, and a warm environment maintained (applying warm air-circulating blankets, and increasing the ambient room temperature). Only after assessing ABC and disability does the responder deal with environmentally related symptoms or conditions, such as cold (hypothermia), heat (hyperthermia, heat stroke), or lightning (during thunderstorms, and sometimes during volcanic eruptions or dust storms).

When the initial ABC survey is complete, the airway is secure, ventilation is monitored or initiated, and the circulation is adequate, spine immobilized, begin the secondary survey. Assess state of consciousness, take time to stop any active bleeding and to determine other signs of trauma. The secondary survey may take place at the scene or during transport. The rapid methodical examination include assessment of the following areas: chest, abdomen, pelvis, head (including neurologic assessment), and at the end vertebral column and skeleton. After securing vital functions and the rapid methodical examination you must in this situation stop and make decisions about further actions and priorities for treatment and transport to a trauma center.

Details of the physical examination and treatments are best recorded on a triage tag affixed to the victim. Priority of treatment, can be indicated by using color-coded tags or affixing a color-coded sticker to the triage tag during the first round of triage. The triage designation can be based on a color system with following colors; black/white-deceased, red-immediate, yellow-delayed, and green-minor. You place a triage tag on each victim and tear off the colors until the color at the bottom matches the victim’s classification. The purpose is to indicate to the rescuers which patients require most urgent or ongoing attention, according to the judgment of the triage team leader. In the situation in which there are insufficient numbers of evacuation vehicles, evacuation priorities must also be assigned.

In the emergency room, cut away the patient's clothes, and use the same methodical physical examination as at the scene. Maintain cervical spine precautions and vertebral alignment with help of the trauma team; logroll the patient into the lateral position. Inspect also the underside of the patient, noting any injuries or abnormalities, and blood losses in clothes. From conscious patients, it will be important to obtain the usual medical history information, such as name, age, sex, known medical problems, allergies, and current medication. Type of injury, localization and type of pain, if the patient has been unconscious, nauseous, or have vomited are noted.

Chest

• Inspection (Look): Penetrating injury? Respiratory movements? Note the symmetry of the chest as it rises and falls with inspiration and expiration. Distended neck veins? Trachea midline position?
• Auscultation (Listen): Unequal breath sounds?
• Palpation (Feel): Rib fractures? Instability? Clavicles fractures?
• Percussion: Percussion is performed to evaluate resonance, hyper resonance, tympany, and dull or flat sounds. If pneumothorax is present, the affected side will have a more hollow, or resonant percussion note; in the presence of hemothorax, the percussion note over the affected side will be dull with respect to the normal side.

Abdomen

• Inspection: Penetrating injury? Fragments? Contusions? Evisceration? Look for discoloration, distortation, and distention of the abdomen. An abdomen that is distended often is filled with blood, and shock is imminent.
• Palpation: Low rib fractures, tenderness? Rigidity? If gentle pressure elicits pain, suspect internal injuries.
• Percussion: Are bowel sounds - present or absent? Dull? Tympany? Signs of major intraabdominal bleeding (dullness over the flank)?

Pelvis

• Palpation: Pain/tenderness? If gentle pressure applied to each side of the pelvis elicits pain, suspect a pelvic fracture.
• When fracture signs: Stability or instability? (compress iliac wings).

Head

*Neurologic assessment

• Verbal stimuli response and pain stimuli response? Note consciousness using the Glasgow Coma Scale.
• Assessing pupillary changes: size, reaction to light, equality?
• The ability to move the arms and legs?
• Sensation with a pin or touch?
• Babinski's sign?

*Inspection/palpation of the head

• Scalp laceration?
• Depressed fracture?
• Blood or cerebrospinal fluid (CSF) flowing from the ears or nose?
• Battle's sign.

*Inspection/palpation of the face

• Facial fractures? Fractures of the maxilla (upper jaw) or mandible (lower jaw).
• Ocular (eye) injury.
• Dental injury.
• Bleeding from mouth our throat.

Skeleton

*Vertebral column (assume cervical injury is present).

-Cervical spine

• Palpation: Swelling, tenderness, crepitations?
• Very gentle movement: Pain or pain reaction in neck, shoulder, arms?
• The ability to move the arms and legs?

-Rest of spine

• Palpation: Localized tenderness/swelling?
• Pain or pain reaction when mowing?
• The ability to move the legs?

-Extremities

• External bleeding?
• Wound or soft tissue injury?
• Fracture or any dislocation of a joint? Systematic palpation of joints and long-bones, gentle control of movement in joints?
• Motion pain, tenderness, swelling, crepitations?
• Affected vascularity- or nerve function below the injury: Circulation? Sensations?
• Ability to move?

Be restrictive with X-ray examinations in these situations. Computed tomography of trunk injuries could often be replaced by, for example ultrasound, diagnostic laparocentesis, thoracocentesis or conventional X-ray images (performed in the operating room or unit).

Most hospitals have plans for meeting the needs of disaster victims, and an awareness of a facility’s disaster plans is essential for nurses employed there. Whenever multiple victims are present, the rescuers must set priorities, organize resources, and begin interventions. Hospitals have to get patients out of the emergency room and in to the hospital rooms so they do not clog up the system.

Trauma management of severely injured in mass casualty situations/disasters must in the hospital as well as at the scene be followed by decisions:

• Can the injured be saved to a meaningful life with actions that are reasonable considering the total need of care? If the answer is no: refrain from further interventions and give only palliative treatment. If the answer is yes (see below).
• Is immediate surgery needed? Directly to pre-operative unit for preparation/prioritizing for surgery.
• Is ventilatory support or other advanced monitoring required? To intensive care unit.
• The others who need hospital care: Is admission required? To unit for continued examination.
• The others who don’t need hospital care? To primary care (psychosocial support).

Take in the scene and continue to gather information while assessing the victim. If possible, wear gloves, mask, and goggles for protection whenever examining and caring for an injured victim. Accurate assessment and compilation of an adequate history are crucial to survival and outcome. Report your findings to the team accepting your patient. Continual recording (if possible by assistants) should be done during the work in the emergency department. If possible use routine flow sheets and checklists. In trauma care, documentation is often delayed until the patient is stabilized.

The Definitive Surgical Trauma Skills Course (DSTS) was originally designed for the military, but the training structure has now been adopted to accommodate civilian surgical consultants and teaches vascular, cardiothoracic and general surgery techniques which are vital in dealing with trauma injuries (Trauma.org, 2011). The Definitive Surgical Trauma Care (DSTC) course was developed by the International Association for Trauma and Surgical Intensive Care (IATSIC) of the International Surgical Society, based in Basel in Switzerland. The IATSIC was founded in 1988 and serves as a forum for Trauma Surgeons world-wide.

Types of injuries

The types of injuries that occur in a trauma event depend on the mechanism of trauma. Risk for trauma, is defined as the accentuated risk of accidental tissue injury, such as a wound, burn or fracture. Physical injury may be caused by violent or disruptive action or by the introduction into the body of a toxic substance; psychic injury resulting from a severe emotional shock (Anderson, Anderson, & Glanze, 1998). Blunt injury is caused by rapid deceleration, a decrease in the speed, for example when the driver of a car hits a tree. Rapid forward deceleration can cause blunt trauma in the head, neck, chest, abdomen and extremities. Rapid vertical deceleration, for example a fall in which the victim slams against a surface and decelerates, or stops. Impact with the stationary surface will cause blunt injury and, occasionally, penetrating injury, depending on the surface hit. Potential injuries are ankle or leg fractures, spinal fractures, or internal injuries.

Most penetrating injuries are caused by projectiles, guns or knives, but any sharp object can penetrate the body and cause soft-tissue, visceral, or bony injury.

A crush injury occurs when the external surface of the body is exposed to a severe force applied against the tissues or when the force is sustained for an extended time. The body structures maybe crushed without signs of external bleeding. Severe earthquakes are a major cause of crush injuries, but also motor vehicle crushes, construction and industrial accidents, and terrorist bombings or attacks. Crush injuries are also possible, when a victim remains lying down for a long time until rescue.

In the following overview injuries to various organ systems, possible or necessary interventions and principles of management appropriate to each are discussed.

Thoracic injury

Less than 15% of thoracic injuries require the skills of a thoracic surgeon. In many cases, specially trained nurses and paramedics can perform life-saving procedures at the scene or during transport. Other patients with chest injuries require prompt skilled interventions, diagnostic, monitoring and maybe insertion of drainage. Chest injuries can be immediately life-threatening. They require rapid assessment and intervention because they disrupt the patient’s basic life processes. Prepare for basic and advanced life-support measures instantly. Thoracic trauma is entirely responsible for 25% of all trauma deaths, and injuries to the chest are the most frequently missed injuries in the first hour of care (Sheehy, & Jimmerson, 1994).

The chest must be assessed by inspection, auscultation, palpation, and percussion. The aim is to identify and manage six immediately life-threatening, top-priority thoracic injuries at the scene; airway obstruction, open pneumothorax, tension pneumothorax, massive hemothorax, flail chest, and cardiac tamponade. Potentially life-threatening thoracic injuries managed during the secondary survey are pulmonary contusion, aortic disruption, tracheobronchial disruption, esophageal disruption, traumatic diaphragmatic hernia, and myocardial contusion. Injured victims must be reassessed as often as possible, because their condition can deteriorate quickly. Offer quiet and simple explanations and offer frequent reassurances to the patient as you work even if he or she appears to be unconscious. Hearing may be present, and high levels of anxiety accompany accidents, assaults, and disasters. Anxiety accompanies dyspnea and pain and further distresses the patient.

Diagnosis often requires advanced skills and knowledge. Indications for emergency thoracotomy after chest injuries are: penetrating stab wounds to the heart (entrance wound over cardiac region, cardiac tamponade); massive or progressive hemothorax (more than 1000 ml initially, more than 800 ml in 4 hours); esophageal injury (odynophagia, mediastinal or cervical emphysema); and major tracheal or bronchial injury (refractory pmeumothorax, massive air leak) (Ordog, Wasserberger, Balasubramanium, & Shoemaker, 1994). Make preparations for an emergency thoracotomy in the emergency department if the patient is critically injured and his or her condition is unstable.

Assessment of patients with thoracic injuries

Follow the standard ABC-assessment plan: Evaluate the airway, breathing, and circulation. Take in the scene and continue to gather information while assessing the victim. Be aware that thoracic trauma is not usually the sole injury. Try to determine the mechanism of injury, the object that caused the injury, the speed of force, and the area of the thorax hit by the object. Early detection, intervention, and rapid transportation by the quickest available means to adequate emergency care are critical to the victim’s survival. Any victim who has multiple injuries is presumed to have a spinal injury until proved otherwise. Stabilize the victim’s head or apply a Philadelphia collar.

Signs and symptoms of thoracic injury include the following:

• Dyspnea.
• Shock.
• Hypoxia and cyanosis.
• Pain with breathing or at the site of thoracic injury.
• Hemoptysis.
• Deformity of the neck, chest wall, trachea, or ribcage.
• Deviation of trachea from the midline of the body.
• Subcutaneous emphysema.
• Impalement of an object in the thorax.
• Sucking, bubbling, or gurgling sounds from the thorax.
• Unequal expansion or excursions of the chest.
• Distended or collapsed neck veins.
• Muffled heart tones may be indicative of pericardial tamponade.

The absence of overt signs and symptoms of severe injury in patients with blunt thoracic artery injuries can be misleading, and patients can quickly deteriorate. Thorough and continuous assessment of patients with blunt chest trauma is important.

Types of thoracic injuries

A closed pneumothorax occurs when air leaks into the pleural space from an opening in the lung. The chest wall remains intact in this injury, that may be caused by blunt chest trauma. This type of pneumothorax has a "self-sealing" effect, once the air has leaked into the pleural space (causing the lung to collapse), the lung tissue seals and the leakage is stopped. Closed pneumothorax is characterized by decreased or absent breath sounds and hyperresonance on the side of the collapsed lung.

A sucking chest wound or open pneumothorax, is caused by penetrating trauma to the chest wall, creating direct access between the pleural cavity and outside air. Air is drawn through the chest wall opening in to the normally air-tight pleural space by negative intrapleural pressure during inspiration. The seriousness of the open pneumothorax depends on the size of the opening. An open pneumothorax has a sucking noise at the site of the chest wall defect. Because the air doesn't enter the lungs and the blood doesn't exchange gases, dyspnea and hypoxia occur. Signs and symptoms of open or traumatic pneumothorax include obvious open defect in the chest wall, dyspnea, tachycardia, shock, and cyanosis. Management of the sucking chest wound is aimed at sealing off the open defect and supporting vital functions. Ensure an open airway. Administer oxygen as ordered. An open pneumothorax wound must be closed immediately by any available means. The wound may be covered with petrolatum gauze, a rubber glove or plastic wrap. To avoid tension pneumothorax a special taping method can be used. An occlusive dressing is taped on three sides. On inspiration, this flutter-valve dressing seals wound, preventing air entry, and during expiration it allows trapped air to escape through untaped section of dressing. If the patient’s condition worsens after application of this dressing, reopen the seal, it may aggravate the condition. Prepare for needle insertion to relieve tension pneumothorax. A chest tube is inserted and attached to a water seal drainage system. The tube is not removed until air is no longer expelled through the underwater drainage system and a radiographic examination shows that the lung is completely expanded.

A tension pneumothorax is caused by air entering the pleural space and getting trapped there. If the tear doesn't seal, air enters the pleural space during inspiration, but cannot escape during expiration, so increasing pressure builds up in the affected pleural cavity, causing a one-way valve effect. If the tension is not reduced, it puts pressure on the vena cava, causing a decrease in preload that leads to diminished cardiac output. This positive pressure tends to push the trachea, heart, esophagus, and great vessels to shift to the unaffected side. A tension pneumothorax also can be caused by a rescuer who applies excessive positive pressure to a manual ventilating device and subsequently ruptures the lung, or when the occlusive dressing applied to seal an open pneumothorax doesn't allow adequate escape of air. Unrelieved tension pneumothorax can lead to respiratory arrest, and may be fatal within minutes. The patient will manifest extreme dyspnea, restlessness, and anxiety, the pulse will be weak and rapid, hypotension, cyanosis may be present, and the neck veins may be distended if the vena cava is being compressed. Breath sounds will be diminished on the side of the tension pneumothorax and shock ensues. Ensure an open airway. Administer oxygen as ordered. Emergency chest decompression of the pleural space with a large bore over-the-needle catheter and flutter valve (from a rubber glove finger) may be life-saving. If trained and authorized to do so, insert a large bore needle (14- to 16 gauge) in the affected side of the chest, in the second to third intercostals space in the midaxillary line. The receiving hospital should be notified to prepare for chest tube insertion. Any patient with a pneumothorax whether simple or tension, who needs to be transported by helicopter or plane should have a chest tube (or catheter) and flutter valve in place to allow for escape of air that may accumulate in the pleural space with atmospheric pressure changes (Caroline, 1983).

Massive hemothorax is a bleeding into the pleural cavity, and it often accompanies traumatic pneumothorax. Penetrating thoracic injuries most commonly pierces the organs contained in the chest, and blunt injury may tear vessels. The accumulation of 1.5 L blood into the pleural cavity will cause dyspnea due to lung compression. Suspect massive hemothorax when a patient with thoracic injury is in shock, and has absent or diminished breath sounds. Proper management of massive hemothorax requires swift and accurate diagnosis. Ensure an open airway. Administer oxygen as ordered. Assist ventilations as required. Secure intravenous access with two large-bore intravenous lines and begin volume replacement as ordered. Administer crystalloids, colloids (plasma volume expander), blood, and blood products, as ordered, according to the policy. If trained and authorized to do so, insert a large bore needle or over-the-needle catheter into the affected side of the chest (in the fifth and sixth intercostal space in the midaxillary line). Use a 50-ml syringe and stopcock to aspirate as much blood as possible. Move rapidly to the hospital, where a chest tube is inserted and attached to a water seal drainage system. Massive hemothorax is a serious and life-threatening emergency that generally requires an emergency thoracotomy. Indications for emergency thoracotomy are more than 1000 ml blood initially or a continued bleeding of more than 200 ml/hour during more than 3-4 hours, and also when initial interventions doesn’t reverse the shock process.

Flail chest results from blunt chest trauma, in which multiple adjacent ribs are fractured in two places, causing a free-floating rib section. The portion of the chest wall that is free-floating moves in a paradoxical fashion (often palpated during assessment), expanding or bulging out during expiration and collapsing during inspiration. Additional injuries associated with flail chest include pulmonary and myocardial contusion, pneumothorax, and hypoxia. The patient with flail chest injury usually has thoracic bruising, dyspnea, cyanosis, hypotension, tachycardia, and respiratory acidosis with hypoxemia. Ensure an open airway. Administer oxygen as ordered. Assist ventilations as required. When ventilatory assistance is given, the patient must be monitored closely for signs of pneumothorax. Anticipate shock and establish an intravenous lifeline. Stabilize the flail segment. Respiratory therapy and adequate analgesia is important. Monitor cardiac rhythm, since chest trauma is liable to involve myocardial injury as well.

Cardiac tamponade develops when penetrating injury causes blood to leak out of the heart and into the inelastic sac surrounding the heart (pericardium), which limits the ability of the ventricle to fill. This condition may be caused by disruption of a coronary artery, rupture of the myocardium, or severe contusion. Cardiac tamponade is a life-threatening emergency and will lead to cardiac arrest very quickly if not treated by evacuation of blood from the pericardial sac. The procedure is best carried out in a hospital, under controlled conditions. A triad of signs (Beck's triad) aids in the diagnosis of cardiac tamponade: distended neck veins, hypotension, and muffled (decreased) heart sounds. Noise at the emergency scene may make it difficult to ascertain any decrease in heart sounds, and the other two signs are also consistent with tension pneumothorax. Other signs and symptoms of cardiac tamponade include thready, rapid pulse, and narrow pulse pressure (systolic minus diastolic). If the patient becomes unconscious and the pulse is not palpable start CPR. Diagnosis and treatment requires advanced skills and knowledge. Ultrasound is used if available. Aspiration of the fluid or blood in the pericardial sac (pericardiocentesis) is performed for diagnosis and for therapy. If emergency thoracotomy is indicated, atropine is administered to increase the heart rate and shock interventions to increase the heart’s filling pressure.

Blunt injury of force sufficient to fracture the rib cage often is associated with bruising of the chest. Pulmonary contusion, or bruising of the lung, may cause immediate, life-threatening hypoxia or develop into respiratory distress later.

Tracheobronchial disruption occurs with both blunt and penetrating injury. Blunt injury to the neck, may cause collapse of the larynx or trachea or consequent airway obstruction. Penetrating injuries to the neck may sometimes be apparent, if trachea has been disrupted, by the presence of subcutaneous emphysema in the cervical area and anterior chest wall and by a frothy mixture of air and blood blowing through the wound. Such penetrating wounds must be sealed off. Associated injuries of the upper part of the airway may make opening the airway at the trachea the only option, and even that can be difficult.

Esophageal disruption, mostly caused by penetrating injury is usually diagnosed in the hospital during post injury assessment and evaluation, and treatment usually takes place in a hospital.

Myocardial contusion, or bruising of the heart muscle is caused by blunt injury to the anterior part of the chest. A myocardial contusion behaves in all respects like a myocardial infarction. Right sided chest trauma frequently results in atrial arrhytmias and heart block, while left-sided frontal injuries are more apt to cause ventricular fibrillation. This damage to the heart muscle may cause chest pain, dysrhythmia, and cardiogenic shock. Report changes in electrocardiogram immediately to physician, and administer antiarrhythmics if ordered.

Aortic rupture (disruption) is a serious condition in which the aorta, the largest artery in the body, is torn or ruptured as the result of trauma. Blunt injury to the thorax can rupture the aorta and other great vessels, and objects that penetrate the thorax can also pierce the aorta, leading to rapidly fatal exsanguination. This can quickly result in shock and death. Most injured victims have been involved in motor vehicle accidents or falls. Aortic rupture is not listed as a top-priority thoracic injury because of its high fatality rate. Death occurs immediately after traumatic rupture of the thoracic aorta 75%-90% of the time since bleeding is so severe, and 80-85% of patients die before arriving at a hospital (Rousseau, Soula, Perreault, et al., 1999). Up to 18% of deaths that occur in motor vehicle accidents are related to the injury. Aortic disruption due to blunt chest trauma is the second leading cause of injury death (behind traumatic brain injury). Patients who survive the initial injury have a second chance if you can get them to the trauma center quickly. If conscious, the victim may complain of pain between the shoulder blades and dyspnea, a minority of patients may be hoarse. The condition is difficult to detect, chest X-rays are used to diagnose the condition. The classical findings on a chest X ray are widened mediastinum, apical cap, and displacement of the trachea, left main bronchus, or nasogastric tube. Aortic rupture is treated with surgical repair of the aorta. Prepare for surgical procedure. Surgery is associated with a high rate of paraplegia, because the spinal cord is very sensitive to ischemia, and the nerve tissue can be damaged or killed by the interruption of the blood supply during surgery (Attar, Cardarelli, Downing, et al, 1999). Measures to keep the blood pressure low is essential, such as giving pain medication, keeping the patient calm, and avoiding procedures that could cause gagging or vomiting.

Both blunt and penetrating trauma can tear the diaphragm, diaphragmatic hernia, and allow abdominal organs to slip into the thoracic cavity and impair breathing. Any chest injury below the fifth rib (nipple level) is an abdominal injury as well. Sometimes the injury is not noted until the thorax is explored surgically, or on the basic of radiographic findings. When the lung and the heart are displaced by the thoracic organs, breath sounds may be decreased on one side of the chest, or the heart sounds may be shifted. The patient may complain of dyspnea, and cyanosis may be evident. Prepare for surgical procedures.

Lacerations and contusions of the thorax cause pain, discoloration, and obvious or occult bleeding, and potential damage to structures and organs underlying the injury.

Rib fracture is a break in a bone of the thoracic skeleton caused by a blow or crushing injury. The ribs most commonly fractured in blunt trauma are the fourth to tenth. If the rib is splinted or the fracture is displaced, sharp fragments may pierce the lung, causing hemothorax or pneumothorax. Fractures of the upper three ribs indicate a significant blow to the upper part of the chest and may indicate serious head and neck trauma, facial fractures, and even the subclavian vessel or the aorta may be injured. Fracture of a simple rib is significant chiefly because the pain associated with rib fracture tends to impair adequate respiration. Multiple rib fractures indicate significant blunt trauma and are considered more serious. Analgesics, rest, and to splint the fracture by hand or by a pillow make deep breathing easier and may reduce pain.

A foreign object impaled in the thorax should be left in place. The pressure exerted by the object itself acts to tamponade, or compress, damaged vessels and thus reduce bleeding. Do not remove an impaled object, as efforts to do so may trigger massive hemorrhage and further injury to underlying structures. The impeded object should be removed only under controlled conditions in a hospital. Stabilize the protruding end of the object with bulky dressings, and bandage them in place. Secure venous access, administer oxygen, monitor the electrocardiogram, and vital signs, and transport the patient to the hospital.

Traumatic asphyxia (suffocation) refers to a syndrome that results from severe compression injuries to the chest, such as in a motor vehicle accident. As the sternum is forced inward, it exerts sudden pressure on the heart beneath, causing the blood in the right heart to back up into veins of the neck, with associated bleeding into the upper chest and neck. Signs of traumatic asphyxia are distended neck veins, chest deformity, profound shock, cyanosis of the head, neck and shoulders, bloodshot and protruding eyes, swollen cyanotic tongue and lips, and often bloody vomiting (hematemesis). The skin below the level of injury is pink. Traumatic asphyxia will be rapidly fatal without proper management, and even with adequate management, the mortality rate is high. Ensure an open airway, and administer oxygen as ordered. Observe caution and immobilize the spine before moving the victim. Secure intravenous access with two large-bore lines and begin volume replacement. Check with physician if shock is profound. Treat tension pneumothorax or sucking chest wound if present and move rapidly to the hospital.

A fractured sternum (breastbone) causes severe chest pain and sometimes dyspnea. Suspect a myocardial contusion, and be alert for evidence of hypoxia, hypotension, arrhythmias, or other indications of further thoracic injury caused by blunt trauma to the anterior part of the chest. Patients with sternal fracture who are not dypneic, have normal findings on electrocardiograms, and are hemodynamicically stable can be safely discharged early. The installation of air bag in motor vehicles has reduced the number of sternal and facial fractures.

Management of patients with thoracic injuries

Be aware of potential neck injuries to a victim. A rigid cervical collar should be placed to prevent movement of the head and neck if indicated. It is presumed that the victim’s airway, breathing, and circulation have been established and that the injured victim is being transported to the hospital (trauma center) without delay. Completely expose seriously injured patients who have multiple trauma, by cutting off clothing. Examine the patient for injuries.

• Ensure an open airway. Begin administration of supplemental oxygen as ordered. Thoracic injury may cause hypoxia. Assist ventilation as indicated.
• Observe and palpate the neck veins as they may become distended in serious chest trauma. Bulging distended neck veins can indicate obstruction of normal blood flow into the heart by increasing pressure in the thoracic cavity. Hypovolemia from bleeding into the chest cavity may collapse neck veins.
• Evaluate the trachea for a midline position. Report tracheal deviation, hemoptysis, distended neck veins, air leaks, and other signs to a physician.
• Monitor cardiac rhythm as indicated. Serious arrhythmias may result from myocardial and vascular damage sustained during thoracic injury. In addition to continuous ECG monitoring a 12-lead ECG should be performed. Report changes in electrocardiogram immediately to a physician.
• Monitor patient for signs and symptoms of dyspnea, and restlessness and anxiety that accompany respiratory distress. Monitor breath sounds and respiratory status. Place the stethoscope in the midaxillary line to compare the bilateral equality of breath sounds; check for bilateral and equal chest excursions; and palpate for subcutaneous air. Report any decrease in heart sounds immediately to a physician.
• Monitor vital signs closely and as indicated by the patient’s condition and suspected injuries. Note and report changes and trends in the patient’s condition.
• Offer explanations and reassurances to the patient as you work, and keep the patient warm.
• Secure intravenous access with two large-bore intravenous lines and begin volume replacement as ordered, because rapid deterioration may occur. Administer blood products as ordered.
• Have equipment for airway maintenance readily available, and prepare for emergency intubation and cricothyroidotomy if airway obstruction develops.
• Prepare for emergency thoracotomy if the patient is critically injured and his or her condition is unstable.
• Monitor arterial blood gases as indicated. Routine laboratory testing.
• Obtain chest radiographs as ordered.
• Help relieve the pressure of tension pneumothorax when necessary. Those with special training and skills may in this procedure convert the tension pneumothorax to an open pneumothorax by inserting a large-bore needle into the chest wall to release the trapped air and decompress the chest. Monitor the patient’s condition frequently. The receiving hospital should be notified to prepare for chest tube insertion.
• Cover an open pneumothorax wound with any available means, including a rubber glove or plastic dressing. Many trauma teams use a special taping method (an occlusive dressing is taped on three sides) that allows air to escape from the chest but prevents entry of additional air. Watch the patient closely for signs of developing tension pneumothorax. If this should occur, reopen the seal, and allow the air under pressure to escape.
• Stabilize an object impaled in the chest by putting bandages around it. The impaled object may be compressing internal structures and preventing hemorrhage. It should only be removed under controlled circumstances in a hospital.
• Splint the simple rib fracture to enable the patient to breathe more comfortable. A hand or a pillow against the fracture is often sufficient. Analgesics, rest and the application of heat may also reduce pain.
• Do not give the injured patient anything by mouth. Immediate surgical intervention may be necessary, and oral intake will increase the risk of fatal aspiration during the perioperative period.
• Cover open wounds, apply pressure over sites of direct bleeding to reduce blood loss, and transport the patient to a nearby hospital without delay.
• Palpate gently along the ribs for any structural deformities indicating fractures or crepitus, which might indicate air collecting under the skin.
• Stabilize a flail chest segment of ribs with your hand or by using a bulky dressing (sandbags or pillow), or having the patient lie with the injured side down, when spinal injury has been ruled out. Flail chest usually occurs in conjunction with significant trauma elsewhere, and bleeding may be considerable. Therefore anticipate shock and hypoxia.

Abdominal- and genitourinary injury

Abdominal injuries are often not evident on physical examination. Injuries to the abdomen may result in damage to any of the several organs and blood vessels within the abdominal cavity that extends from the diaphragm down to the pelvis. They can be overlooked because of more dramatic injuries elsewhere. What looks like a chest injury from the outside may in fact be an abdominal injury inside. Abdominal injuries can go undetected because the injuries and bleeding are often internal rather than external.

Penetrating injuries to the abdomen may be caused by knives or bullets, and a variety of other instruments and may lead to impalement, laceration, or rupture and puncture of the abdominal organs. Like blunt trauma injuries, open injuries may be much more serious than they appear. Bullets shatter organs and spill intestinal contents into the abdominal cavity. The length and size of the weapon effect how deep the stab wound is and how much damage is inflicted, and immediate treatment is usually based on the patient’s signs and symptoms. Blunt trauma to the abdomen is especially deceptive, for it may cause devastating injury with few external signs, such as steering wheel injuries of the liver and the spleen. Blunt injury with force sufficient to fracture the pelvis is often associated with damage to the urinary bladder or urethra. Severe blunt trauma to the back and flanks can fracture the kidney.

Because the genitourinary organs are protected by their location in the body, genitourinary trauma, with a few exceptions, is seldom life threatening. Penetrating injury may result in impalement, laceration, rupture, or puncture of the genitourinary organs. Penetrating injury in the urinary system is extremely common in gunshot wounds of the upper part of the abdomen and stab wounds of the flank. Burns may result in severe disfigurement and loss of function of the genitalia. Genitourinary trauma may occur from rapid deceleration in a motor vehicle accident, during fall, or when an object such as a fist or a bat strikes the abdomen or flank or external genitalia. Blunt trauma often is associated with damage to the bladder and urethra. Severe blunt trauma may fracture the kidney.

Assessment of patients with abdominal injuries

Rapid assessment, identification and control of bleeding, and prompt intervention are the keys to the patient’s survival. Seriously injured patients with penetrating injuries to the abdomen, abdominal trauma associated with pain or tenderness, and abdominal trauma with affected circulation need immediate intervention at a trauma center. A victim with severe damage to an organ inside the abdomen requires emergency surgery to repair the injury.

Signs and symptoms of abdominal injury include the following:

• Abdominal pain and nausea.
• Abdomen tender, sometimes rigid and board like.
• Guarding by the patient to protect tender abdominal areas.
• Abdominal distension.
• Bruising, crepitus.
• Bowel sounds will be absent.
• Signs of bruising and swelling diagonally across the chest and across the pelvis by a seat belt and shoulder harness as a result of deceleration indicate a blunt injury.

There are signs and symptoms indicating possible internal hemorrhage in a patient with abdominal trauma including: hypotension, tachycardia, and pallor; rigid or distended abdomen; hematemesis; hematuria, blood, or semen (from ruption of the prostate) at the meatus; and inability to void. Impalement of the abdomen or evisceration of the abdominal contents is obviously a serious emergency. Bruising and discoloration around the umbilicus (Cullen’s sign), may indicate hemoperitoneum, or blood in the peritoneal cavity; and bruising over the flank (Grey Turner’s sign) may indicate blood in the retroperitoneal space.

Genitourinary injuries may go undetected until radiologic studies are done. A rectal examination and palpation of the prostate in male patients are often the first step, or a pelvic examination in female patients to confirming genitourinary injury. A ruptured bladder is a serious injury, and internal hemorrhage from a fractured kidney can be substantial. Genitourinary injury is likely if any of the following occurs: Pain in the pelvic or suprapubic region; the external genitalia have an obvious deformity; the urine is bloody; the patient cannot void; blood is present at the meatus, or semen (from ruption of the prostate); swelling or bruising of the scrotum or over the flank is present; and the patient sustained penetrating or blunt injury.

Diagnostic tests for abdominal trauma may be used to evaluate the injuries and determine the need for surgery. Diagnostic peritoneal lavage is frequently done in the emergency department to help determine the presence of blood or intestinal contents in the peritoneal cavity. Computed tomography (CT) is useful in examining the abdomen for defects and collections of fluid or air, but patients whose condition is critical and unstable may not tolerate to be transported to the CT scanner. Obtaining sonograms when assessing patients with abdominal injury is a procedure that can be performed with portable equipment in the emergency department. Radiographs can also help detect free air or foreign objects in the abdomen. After infiltration with local anesthesia, the wound may be explored (laparocentesis) in the emergency room, by a physician to assess the nature of the abdominal injury and determine if the patient should have surgery.

Common abdominal injuries

Common abdominal injuries include lacerations and contusions of the abdomen. Blunt and penetrating trauma to the abdomen cause pain, sometimes bruising and discoloration, and obvious or occult bleeding. Marked damage to abdominal organ is possible.

The liver, with its rich blood supply, may be shattered or lacerated by either penetrating or blunt trauma. It can hemorrhage massively, causing death from internal bleeding within minutes. Hepatic injuries should be suspected in patients who have rib fractures down the right side of the chest or who complain of abdominal pain and tenderness, especially in the right upper quadrant. The conscious patient may guard the abdomen against touch and complain of nausea. The treatment of liver injuries depends on the type and severity of injuries. Minor bruises and lacerations to the liver heal without surgery, while severe injuries require surgery.

The spleen, located in the left upper quadrant, is the most commonly injured organ in the blunt abdominal trauma. The spleen is also vulnerable to rupture whenever there is a fracture of the lower left ribs, and pain in the upper left quadrant, and pain referred to the left shoulder may indicate injury to the spleen. Life-threatening exsanguinating hemorrhage can occur from rupture of the spleen. Although tamponade may reduce the flow of blood, hemorrhaging may recur hours or even a few days after the abdominal injury. Treatment of spleen injury may include bed rest, intravenous fluids, or pain medication. Severe spleen injury may require surgery to repair the spleen or surgery to remove the spleen (splenectomy).

The aorta can be injured by either blunt or penetrating trauma. Rapid deceleration in a motor vehicle accident may tear the aorta, and compression against spine or impact with the steering wheel sometimes ruptures the aorta. Exsanguination occurs within minutes after aortic rupture. About 80-90% of traumatic ruptures of the great vessels are fatal at the accident scene, and 10-15% of traffic fatalities are due to aortic rupture (Strange, 1987).

The diaphragm is a dome that ascends up in the chest. Blunt or penetrating trauma may disrupt the diaphragm, allowing abdominal contents to enter the chest cavity, which generally impairs breathing. The patient may complain of dyspnea, and cyanosis may be evident. Signs of diaphragmatic injury include breath sounds that are decreased on one side of the chest and shift in heart sounds. More often a diaphragmatic injury is diagnosed on the basis of radiographic findings or explored surgically at the hospital. Prepare for surgical procedure. Ensure an open airway. Administer oxygen as ordered. Assist ventilation as required. Diaphragmatic injuries are to 95% left sided, the right sided 5% of injuries, are often combined with liver injury and death occurs immediately (Lennquist, 2002).

Hollow abdominal organs, such as the stomach and gut, are also subject to rupture. An empty stomach is compressible, and not as likely as a full stomach to be injured. Patients with gastrointestinal trauma often complain of abdominal pain, tenderness, and maybe nausea. Hematemesis may occur. Damage to the pancreas, tucked away behind the stomach and liver, will result in spillage of digestive enzymes and consequent peritonitis. Rupture of the intestines can also cause peritonitis, because intestinal contents are spilled in the abdominal cavity.

If there is objects impaled in the abdomen, leave them there, as they often compress and tamponade affected vessels and organs and therefore reduce or stop bleeding. The damage depends on the type of instrument lodged in the body and the structures affected.

Severe penetrating injury of the abdominal wall may leave the abdominal contents exposed outside the abdominal cavity. Cover eviscerated organs with a wet sterile occlusive dressing until the injury can be evaluated by a physician, and notify the surgical team of impending case. Administer antibiotics as ordered. Determine the date of the patient’s last tetanus prophylaxis and report it to the physician for consideration of tetanus booster injection.

The genitourinary system comprises the kidneys, ureters, bladder, urethra, and the male or female organs of reproduction, and any of these organs may be injured by trauma. Pelvic fracture is a serious injury that may result in hypovolemia and death. If gentle pressure applied to each side of the pelvis elicits pain, or there is abdominal distension from internal bleeding, evidence of hypovolemic shock, and bloody urine, suspect a pelvic fracture. The patient with multiple trauma involving the pelvis should be suspected of possible renal trauma. Traumatic emergencies most frequently involve damage to the kidneys and bladder. Bladder injuries are more likely to occur when the bladder is distended with urine, and the result is often rupture of the bladder. Do not attempt to catheterize a patient who has a pelvic fracture. The urethra may be damaged, and attempts to insert a catheter may make the injury worse. Blunt trauma of sufficient force to fracture the maternal pelvis often damages the fetus, too.

The kidneys may be traumatized by any blow to the flanks. Major renal trauma as fractured or lacerated kidneys and injuries to the renal pelvis can produce life-threatening internal hemorrhage whenever a patient has serious blunt or penetrating abdominal trauma. Although the injury may not be obvious, anticipate hypovolemic shock from hemorrhage. The treatment of kidney injuries depends on the type and severity of injuries. Minor bruises and lacerations to the kidney may heal without surgery, while severe injuries require surgery. Surgical repair of the ureters is completed after more serious injuries are dealt with.

Urethral injury most often is caused by missile or foreign object that penetrates the abdominal cavity, and seldom a blunt injury. When blunt trauma forces the pubic bone backward into the urethra, pelvic fractures will sometime interrupt or tear the urethra from the bladder. Urethral injuries are more common in males because of the increased length of the urethra and its anatomic position in males. Suspect a ruptured bladder if a patient has evidence of penetrating injury in the suprapubic region or indications of a fractured pelvis. An empty bladder is less likely than a full bladder to be injured by blunt trauma. A full bladder is often ruptured when the patient is thrown forward against a restraining seat belt, or a blow from the steering wheel.

Management of patients with abdominal injuries

Nursing strategies for any patient with abdominal trauma, are to establish the airway, breathing, and circulation. Your interventions should be within the scope of your professional license, skills and training, and when performed in a health care setting, adherent to the facility’s standard of practice. Assess and reassess the patient regularly. Ideally, the patient’s condition is stabilized and injuries evaluated under controlled circumstances. As with acute abdomen, the treatment in the field of genitourinary problems is nonspecific and is determined by the patient’s overall condition. Associated shock is managed as outlined.

• Ensure an open airway (prevent movement of the head and neck). Administer oxygen as ordered. Assist ventilation as indicated.
• Secure intravenous access with two large-bore intravenous lines, and begin volume replacement as ordered.
• The MAST garment to enhance venous return and support the blood pressure is often used.
• Watch for indications of internal hemorrhaging, and report changes. Signs and symptoms include hypovolemic shock, abdominal pain, abdominal tautness or distension, and increasing girth. Reassess frequently.
• Type and cross-match abdominal trauma patients for at least four units of blood, according to the facility’s policy.
• Do not remove any object that has been pierced and lodged in the abdomen.
• Do not attempt to replace the protruding (eviscerated) organs into the abdomen.
• Cover gently the exposed viscera with sterile dressing soaked in sterile saline, and then place an occlusive dry dressing over that.
• Do not give the injured patient anything by mouth. Immediate surgical intervention may be necessary, and oral intake will increase the risk of fatal aspiration during the perioperative period.
• Insert nasogasric tube as ordered. The use of nasogastric intubation is contraindicated in patients with base of skull fractures, severe facial fractures especially to the nose and obstructed esophagus or obstructed airway.
• Insert a Foley catheter cautiously if ordered, but only after other injuries are ruled out, such as urethral injury.
• Pain is often intense; administer analgesics as ordered, after the patient has been examined by a physician, because the medications can mask symptoms.
• Offer quiet and simple explanations to the patient (close ones), and frequent reassurances, because trauma increases anxiety and anxiety increases pain.
• If the condition of a critically injured patient with abdominal trauma is unstable and rapidly deteriorating, urgent surgery will be required.
• Management of blunt renal trauma requires recognition of injury, by observation of minor injuries, and close observation of major injuries that may need surgical repair or nephrectomi.

Pelvic injury

Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum, and coccyx. Fractures of the pelvic girdle may result from direct trauma to the pelvic bones during a motor vehicle accident, motor cycle crash, cycling accident, motor vehicles striking pedestrians, a fall from significant height, or be caused by forces transmitted to these bones from the lower extremities. The most common cause in elderly is a fall. Pelvic fractures may be associated with injury to pelvic soft tissues, blood vessels, nerves, and organs. They may produce significant internal bleeding, loss of more than 2-3 L blood, which is invisible to the eye. The patient with multiple trauma involving the pelvis should be suspected of possible renal injury and neurovascular injuries.

The pelvis is the lower part of the trunk of the body and the area of transition from the trunk to the lower extremities. The pelvis is enclosed by bony, ligamentous, and muscular walls. It is composed of four bones, the two innominate hip bones laterally and ventrally, and the sacrum and coccyx posteriorly. The hip bones are joined anteriorly at the pubic-symphysis to form a pelvic girdle that is firmly attached to the sacrum for support of the lower extremities. Pelvis is divided into the pelvis major (greater or false pelvis) and the pelvis minor (lesser or true pelvis) by an oblique plane passing through the sacrum and the pubic symphysis. The major pelvis is the expanded part of the cavity situated cranially and ventral to the pelvic brim. The minor pelvis is situated distal to the pelvic brim, and its bony walls are more complete than those of the major pelvis.

The pelvis of a woman is usually less massive but wider and the shape more circular than that of a man. These differences are related mainly to the heavier build and larger muscles of men and to the adaptation of the pelves of women for child bearing. The pelvic cavity contains the urinary bladder, terminal parts of the ureters, pelvic genital organs, rectum, blood vessels, lymphatics, and nerves. The pelvis minor is important in obstetrics because it is the bony canal through which the fetus passes during birth. Blunt trauma can fracture the pelvis of the mother and the skull or other bones of the fetus too. Blood loss in pelvic fracture is generally significant and may affect oxygen delivery to the fetus.

Pelvic fractures may be stable or unstable. Unstable pelvic fractures typically occur as a result of high-energy injuries. Head, chest, and abdominal injuries frequently occur in association with pelvic fractures. When excessively distended, the bladder rises to the level of the umbilicus. Because of this position of the distended bladder, it may be ruptured by injuries to the inferior part of the anterior abdominal wall or by fractures of the pelvis. The rupture may result in the escape of urine intraperitoneally, extraperitoneally, or both. Fractures of the extremities and spinal column also can occur in patients with pelvic fractures. Pediatric pelvic fractures may be associated with visceral, genito-urinary and neurological injury.

Anterior displacement of pelvic ring has the highest incidence of associated injuries and mortality of all pelvic fractures. Bucket-handle fractures, double vertical fractures of pelvis on same side, resulting in pelvic dislocation, are caused by blow or anterior compression force, with or without sacral torsion. Most hemorrhage associated with pelvic fractures occurs as a result of bleeding from exposed fractures, soft-tissue injury, and local venous bleeding.

Diagnosis is made on the basis of history, clinical signs and symptoms, and special investigations usually including X-ray and CT scan.

Assessment of patients with pelvic injury

A careful assessment of the patient must begin with an examination of immediately life-threatening injuries. Then the examination for pelvic stability is an important part of the trauma assessment. Anterior/posterior and vertical stability is tested. Lateral displacement of the pelvic wings suggests instability. Palpation must be undertaken carefully to avoid harming the patient. Suspect a pelvic fracture if gentle pressure to each side of the pelvis elicits pain. Indications of pelvic fracture include local swelling and tenderness at the site of fracture, abdominal distension from internal bleeding, evidence of hypovolemic shock and bloody urine (suspect bladder disruption). Associated organ system injuries, such as neurovascular injuries, bladder disruptions, urethral injuries, rectal injuries and neurologic injuries to the L5 or S1 rotes may be present.

Management of patients with pelvic injury

Emergency interventions and treatment consists of advanced trauma life support management. The MAST is also suited for the treatment of pelvic fractures. Any signs of instability should have prompt urgent consultation with an orthopedic surgeon. After stabilisation, the pelvis may be surgically reconstructed to prevent significant pelvic deformities. Undisplaced fracture may be painful but requires no specific treatment other than having careful lifts and movements. Pediatric pelvic fractures rarely require operative fixation, and are only occasionally life-threatening, but there may be associated with visceral, genito-urinary and neurological injury. Unstable and displaced pelvic ring disruptions cause significant deformity, pain, and disability. Significant permanent pelvic deformities have been identified in patient outcomes and also decreased activity levels.

• Ensure an open airway (prevent movement of the head and neck). Administer oxygen as ordered. Assist ventilation as indicated.
• Secure intravenous access with two large-bore intravenous lines, and begin volume replacement as ordered.
• The MAST garment to enhance venous return and support the blood pressure is often used.
• Watch for indications of internal hemorrhaging, and report changes. Signs and symptoms include hypovolemic shock, abdominal pain, abdominal tautness or distension, and increasing girth. Reassess frequently.
• Type and cross-match abdominal trauma patients when fracture of the pelvis is suspected, at least four units of blood, according to the facility’s policy.
• Do not remove any object that has been pierced and lodged in the abdomen or pelvic area.
• Do not give the injured patient anything by mouth. Immediate surgical intervention may be necessary, and oral intake will increase the risk of fatal aspiration during the perioperative period.
• Insert nasogastric tube as ordered. The use of nasogastric intubation is contraindicated in patients with base of skull fractures, severe facial fractures especially to the nose and obstructed esophagus or obstructed airway.
• Insert a Foley catheter cautiously if ordered, but only after other injuries are ruled out, such as urethral injury. Urgent consultation if any sign of instability.
• Pain is often intense; administer analgesics as ordered, after the patient has been examined by a physician, because the medications can mask symptoms.
• Offer quiet and simple explanations to the patient (close ones), and frequent reassurances, because trauma increases anxiety and anxiety increases pain.
• If the condition of a critically injured patient with abdominal trauma and pelvic fracture is unstable and rapidly deteriorating, urgent surgery will be required.

Head injury

Each year, traumatic brain injuries (TBI) contribute to a substantial number of deaths and cases of permanent disability. Recent data shows that, on average, approximately 1.7 million people in the United States sustain a traumatic brain injury annually (Faul, Xu, Wald, & Coronado, 2010). Head injuries occur in more than two-thirds of motor vehicle accidents and are a major factor in mortality in most of them (Caroline, 1983). Patients with head injuries have a death rate twice as high (35% vs. 17%) as the victims without central nervous system injuries (Campbell, 1988).

Head trauma is any sudden impact, blow, or physical injury to the head that damage the brain tissue. Blood vessels, nerves, and meninges can be torn, which may result in bleeding, edema, and ischemia. Head injuries are categorized as open, or penetrating (the brain is exposed), and closed, or blunt (the skull is intact, although the scalp may be disrupted). Types of injuries include scalp injuries (lacerations, abrasions, hematomas). Skull fractures (linear, depressed, basilar), concussions (temporary loss of consciousness after the brain strikes the skull), and cerebral contusion (bruising of the brain tissue, disrupting neural function). Severe head and brain injuries can result in death or disability, body and functional changes, residual deficits, mental and emotional sequele, and difficult quality-of-life issues.

A head injury may be the result of blunt or penetrating trauma. Because the brain is protected by the skull, most brain injuries are caused by blunt trauma to the head. The first collision of the brain with the skull is the coup, and the second collision, with the opposite side, is the contrecoup. Coup and contrecoup injury is associated with cerebral contusion, a type of traumatic brain injury in which the brain is bruised. This movement of the brain in the skull can tear blood vessel and damage others structures, leading to collections of blood that occupy space or to swelling of the brain. Bullets and knives may also enter the brain through the skull, thus bone fragments may be driven into the wound along with the foreign object, causing additional injury to the brain, such as intracranial bleeding and structural damage. Penetrating injury usually fractures the skull, and projectile may be retained in the brain.

Blunt or penetrating trauma can cause the brain to swell, or cause bleeding in the cranium, and the blood from the hemorrhage must occupy space. The intracranial pressure (ICP) will increase, a serious event, because the skull is rigid and inelastic. The blood pressure also rises, as the body attempts to continue to perfuse the brain. In later stages, the heart rates slow, the body decompensates, and death results. Another grave event is when increased ICP force the brain down through the foramen magnum and herniate the brainstem.

Assessment of the patient with head injuries

One of the most important tasks in assessing and managing patients with head injuries is continual monitoring of the patient’s condition, which can change radically within minutes. Follow the standard ABC assessment plan, and immobilize the head and neck (cervical collar). Do not move the patient's head. Determine a baseline of the patient's condition, and act on any deviation. In all head injuries, the most important aspect of neurologic assessment is whether the patients findings are changing and in what direction. A neurosurgeon will attend in the hospital if there is a serious head injury.

It will be necessary to make repeated evaluations, and each time recording the time and the findings, so that emergency department staff can rapidly determine whether the patient's condition is improving or deteriorating. The level of consciousness and any change in it are the most important indicators of head injury. The patient who shows deterioration, such as in the level of consciousness or any slurred or inappropriate speech, is of great concern and may require urgent surgery.

The observations in the field, if precise, detailed, and recorded, will be of enormous value to those who must render definitive care to the patient. Ask bystanders about the patient's actions and level of consciousness before the injury occurred to get clues about the nature of the injury. Important information in the history of the patient with head injury includes the following:

• How was the injury sustained (mechanism of injury)? A blow to the head, caused by trauma: motor vehicle accident, falls; or assaults: gunshot and stab wounds.
• Did the patient lose consciousness? When did this occur (immediately or after some delay)? How long was the patient unconscious?
• Did the patient vomit? Children will often vomit after head injuries. Vomiting in adults after a head injury, may indicate serious intracranial pathology.
• Current symptoms? Complains of headache? Dizziness? Double vision? Nausea? Weakness (if so, where)? Does the patient have pain elsewhere, particularly in the neck or over any other part of the spine? Does the patient have any, numbness, tingling, or "pins and needles" sensations (paresthesias) anywhere in the body?
• Has the patient ingested any drugs or alcohol, during the past several hours? Sniff the patient's breath for clues about the patient's history, such as the odor of ethanol from ingestion of alcohol, the fruity odor of ketoacidosis, or the odor of petroleum ingestion of poison.

The physical examination, repeated several times, will be of enormous importance. Do not move the patient until it has been ascertained that there is no associated spinal cord injury. Be sure the airway is clear and the patient is breathing adequately. Check for presence and quality of the pulse. Stop active bleeding by pressure and investigate other parts of the body for life-threatening injuries. Although scalp lacerations are not always a serious injury, blood loss may exceed 0.5 L. Hold a sterile gauze pad over any lacerations. Do not attempt to remove a helmet, or an artificial hairpiece, and do not attempt to force open swollen or lacerated eyelids, or apply pressure to lacerations of the eyelids, as further damage may result. Take the initial vital signs, and repeat these (at 5- to 10- minute intervals). Note the rate and quality of respirations, and note any changes in the blood pressure.

Hypertension and bradycardia means rising intracranial pressure, while shock means injury elsewhere. A slowing of pulse will usually accompany the rise in blood pressure observed in a patient with rising intracranial pressure. A rising pulse may signal impending shock from hemorrhage elsewhere in the body. If the blood pressure is elevated, but the pulse rate is low (this is an ominous and late sign of increased ICP):

Carefully examine the patient's head. Look and feel over the head and scalp for lacerations, fractures, or depressed fracture in the skull; deformity or fracture of the face and jaw; and ask the patient to report any tenderness or pain. Is there blood or spinal fluid leaking from the patient's ears or nose? Are there ecchymoses over the mastoid process behind the ears (Battle's sign) or bilateral, symmetric periorbital ecchymoses (raccoon eyes)? All of these are evidence for basal skull fracture, but it may take several hours for this discoloration to appear. Any leakage or fluid from the nose, suggests fracture of the cribriform plate of the skull. If there is leakage of clear fluid from the ears or nose, place a sterile gauze lightly over the nose or external ear, allowing free flow to continue.

Assess the patient's neck, and when in doubt, maintain traction, and apply a cervical collar or other means of immobilization. There is a very high incidence of associated injuries in patients with head injuries. The head injury may not be the most serious of the patient's problems. Complete the standard physical examination in head-to-toe order, and take care of bleedings, fractures, and so forth, before proceeding to a thorough neurologic examination.

The most important single sign in the evaluation of a patient with head injury is a changing state of consciousness (record the findings accurately). At each assessment the professionals should determine the following:

• Is the patient alert?
• Is the patient oriented to person, place and time?
• Does the patient remember what happened?
• If the patient is less than fully alert, what kind of stimuli are required to make him/her respond? Verbal stimuli response? Pain stimuli response? Is the patient totally unresponsive to any stimuli? Head injury can cause confusion, slurred speech and problems with comprehension. Do not assume that the obviously intoxicated patient’s slurred speech or staggering gait is the result of alcohol ingestion or substance abuse rather than a head injury.
• If the patient moves, is the movement purposeful? Or is the movement restricted to flexion or extension of the arms and legs? Head injury is highly likely if the patient has paralysis or motor weakness, especially on just one side of the body, or has abnormal posturing and rigidity of the extremities.
• Has the patient had a seizure?

In the conscious patient, test modalities of position sense, pain, and movement. Observe pupillary signs and extra ocular motions. Head injury is highly likely if the pupils are unequal, dilated, or unresponsive to light, or the conscious patient reports visual disturbances or a reduction in visual equity. Be aware that some drugs, such as narcotics, can alter the size and reactivity of the pupils. The difference also could be physiologic (congenital), or due to a direct eye injury (with a passing pupil dilation during 15-30 minutes after the accident).

The Trauma Score is used to give each injured patient a numerical score that can be used to estimate the severity of head injury. This is a system combining cardiopulmonary assessment with the Glasgow Coma Scale in estimating the degree of injury and the prognosis in a patient who has suffered a head injury (Anderson, Anderson, & Glanze, 1998). Cardiopulmonary factors include respiratory rate and chest expansion, systolic blood pressure, and capillary refill. The neurologic factors are eye opening, verbal response, and motor response. The Champion Sacco Trauma Score: Total Trauma Score = Cardiopulmonary Assessment + Neurologic Assessment (Champion, Sacco, Carnasso, et al., 1981).

Trauma Score

(Cardiopulmonary assessment 0-11)

Capillary refill is determined by pressing a nail bed, the skin of the forehead, or the lining of the mouth (oral mucosa) until there is a loss of normal color (blanching or turning white). Normal return of color after pressure release will take place in approximately two seconds.

There are four elements to the cardiopulmonary assessment. The numerical values are added together to produce a cardiopulmonary score. Each category of the Glasgow Coma Scale is given a numerical value (Total Glasgow Coma Scale points: 14-15=5, 11-13=4, 8-10=3, 5-7=2, 5-4=1). This number is then reduced by approximately one-third its value to produce the neurologic assessment score. The cardiopulmonary assessment and the neurologic assessment scores are added together to give the Trauma Score. For example, a patient's total score for cardiopulmonary function is 7, and for neurologic assessment is 4 (approximately one-third of this number is 1). The cardiopulmonary and neurologic scores are added together (7+1) to give a Trauma score of 8.

The Glasgow Coma Score system involves three determinants, eye opening, verbal response, and motor response, all of which are evaluated independently according to the rank and the order that indicates the level of consciousness and degree of dysfunction. The results are plotted on a graph to provide a visual representation of the improvement, stability, or deterioration of the patient's level of consciousness. The sum of the numeric values for each parameter can also be used as an overall objective measurement, with 15 indicative of no impairment, 7 usually accepted as a state of coma, and 3 compatible with brain death. The GSC score can also function as an indicator of certain diagnostic tests or treatments such as the need for intubation, intracranial pressure monitoring, and computed tomography (Anderson, Anderson, & Glanze, 1998).

Glasgow Coma Scale (GCS)

Best Eye Response (4)
Eyes open spontaneously 4
Eye opening to verbal command 3
Eye opening to pain (supraorbital or digital) 2
No eye opening 1

Best verbal Response (5)
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1

Best Motor response (6)
Obeys commands 6
Localizing pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1

Glasgow Coma Score Total 3-15
(Neurologic assessment 1-5, conversion=approximately one-third total value)

The eye opening test is valid only if there is no injury or swelling that prevents the patient from opening the eyes. For a total GSC score of 15: the patient opens his or her eyes without any stimulation; an aroused patient should be able to tell you his or her name, where he or she is, and the date in terms of the year and month; and perform a simple task such as moving a specific finger or holding up two fingers. It is important to break the figure down to components, such as E3V3M5 = GCS 11, instead of ’GSC of 11’. A coma score of 13 or higher correlates with a mild brain injury; 9 to 12 is a moderate brain injury, and 8 or less a severe brain injury.

The third motor response is that the patients start to flex their whole body to pain. They pull the finger you're pinching into towards the midline, but they also pull the other hand towards the midline. They also straighten their legs right out and turn their toes in towards each other. This abnormal flexion (decorticate rigidity) is due to damage to the corticospinal tracts (the pathways of the brain and spinal cord). The next worse response is when a patient extending all their limbs in response to pain. The toes are pointed down, and they often arch their head backwards. This extension posturing is called decerebrate rigidity. Decerebrate rigidity is caused by an injury at the level of the brainstem, and basically it means that your brain isn't working anymore. Although both postures are extremely serious, decerebrate posturing indicates greater cerebral damage than decorticate posturing. If you cause pain to a patient and they don't respond at all (unresponsive), that is as bad as it can get.

Classical signs of a progressive brain injury, besides changed consciousness are decreased heart rate, increased blood pressure, and decreased respiratory rate. These signs (Cushing’s triad - bradycardia, hypertension, and bradypnea) usually occur late or not at all. The patient’s level of consciousness is the best early indicator of increasing intracranial pressure.

In the initial period the efforts are to find focal injuries which could be actively attended, respectively the injured that have complications to the injuries. An understanding of the risk after trauma can be estimated (Andrén-Sandberg, 1993):

Suspect a serious head injury if the injured patient:

• is unconscious.
• has unequal pupils.
• move extremities that are not injured differently.
• has an open head injury.
• has leakage of cerebrospinal fluid (clear fluid drainage from nose or ears).
• has a depressed skull fracture.
• has deteriorating status.

Common head injuries

Scalp lacerations are not always a serious injury, but the scalp is vascular and bleeds freely. Blood loss may exceed 0.5-1 L and appear quite dramatic. In children, it may be sufficiently profuse to cause hypovolemic shock, because they have a lower blood volume than adults. Apply gentle pressure with a sterile dressing to reduce blood flow. Palpate the skull in the area of the scalp wound to be sure there isn't a depressed skull fracture beneath the wound, as pressure on it could injure the brain further. Scalp lacerations are the most common type of head injury requiring surgical care.

Skull fracture can occur with or without brain damage. The hard and inflexible box of skull protects the brain, covered by the thin membranous meninges. A skull fracture may be obvious because it deforms the skull, or it may not be diagnosed until a CT scan of the head is performed. Suspect a skull fracture in any patient who is unconscious or who has a penetrating head injury, unequal or unreactive pupils, blood or CSF drainage from ears and nose, or bilateral periorbital ecchymoses or ecchymoses behind the ears. The base of the skull is a common fracture site, and basilar skull fractures can provide an opening between the nasal air passages and the brain. Do not insert a nasal airway, endotracheal tube, suction catheters, or a nasogastric tube through the nose of a patient with a head injury until the possibility of a basilar skull fracture has been ruled out, as the tube can entering the brain. Patients with an open or depressed skull fracture should be transported preferentially to the highest level of care within the trauma center.

A concussion is a mild closed head injury caused by a blow to the head that results in no significant brain injury. Blunt trauma to the head, violent jarring or shaking, as in a fall or a sports accident, can cause a concussion. Temporary loss of consciousness after the brain strikes the skull, and some amnesia is common. The patient often complains of headache, nausea and dizziness. If the loss of consciousness exceeds 5 minutes, the patient may be hospitalized for further observation.

A cerebral contusion is another closed head injury also caused by blunt force to the head. A contusion results in a bruise to the brain tissue. This can cause increased ICP from severe edema and bleeding associated with the injury. Loss of consciousness occurs, usually for a prolonged period, and proportionate to the severity and location of the injury. The victim should be transported to a hospital for examination of the degree of cerebral contusion, and any deterioration or change in the victim's condition.

Subdural hematoma, an accumulation of blood in the subdural space, usually caused by an injury. It may develop over a period of hours or days or weeks after the injury, because bleeding is often from a venous source. The patient may complain of headache and have alterations in neurologic status, such as changes in the level of consciousness or slurred speech. This is a serious injury; the outcome is improved by early recognition and swift intervention. Subdural hematoma may be fatal without surgery.

Epidural hematoma is an arterial bleeding that produces a collection of blood above the dura mater of the brain or spinal cord. It usually results from tearing of the middle meningeal artery, so the signs and symptoms appear sooner than those of subdural hematoma. Immediate loss of consciousness occurs, followed by a brief period when the patient is conscious and lucid, but then the patient again lapses into unconsciousness. Evidence of neurologic injury becomes apparent, especially paralysis on one side of the body. Dilated, unreactive pupil on the injured side. Immediate neurosurgery is required to evacuate the hematoma, otherwise the prognosis may be poor. These patients with paralysis should be transported preferentially to the highest level of care within the trauma center.

Penetrating head injury, and sometimes blunt injury, can cause bleeding into the brain, intracerebral hemorrhage, similar to that associated with a stroke. The ICP increases, and death may occur.

A transtentorial herniation, a bulge of brain tissue out of the cranium through the tentorial notch, is caused by increased intracranial pressure. It is important to identify signs of impending transtentorial herniation as this will affect the course of the immediate management of these patients. Pupils may be initially normal and then dilate as intracranial pressure rises and the brain starts to herniate. This condition is identified by unilateral abnormal posturing and/or the presence of a unilateral dilated pupil.

Impaled objects protruding from the skull should be left, and stabilized in place. Removing it could make the injury worse. The patient should be transported to a hospital (trauma center) immediately.

Management of the patient with head injuries

In the management of head-injured patients, priority always goes to the airway and breathing. Management of head injury focuses on stabilization of the patient and prevention of secondary neuronal injury. Hypoxia and hypotension are the greatest threat to functional outcome in traumatic brain injury. Oxygenation and cerebral perfusion must be maintained. Normal blood pressure and pCO2 under 28 mm Hg (3.73 kPa) is enough to maintain adequate perfusion to the brain (Andrén-Sandberg, 1993). If pCO2 increases over 28 mm Hg is the risk high, that the ICP increases. Cerebral anoxia is the most common cause of death in head-injured patients, and cerebral anoxia should be entirely preventable. Significant neurological damage can occur between the time of injury and computed tomography scanning, accurate management of ICP and other interventions. Interventions for patients with severe head injuries are:

• Maintain a patent airway and supply oxygen (prevent movement of the head and neck). Be alert for vomiting, and have suction handy. Be careful when you put your fingers into an injured patient's mouth, because a seizure may develop quickly. A patient with significant head injury has a cervical spine injury until proved otherwise.
• Assist ventilation as needed. Follow physician's order about hyperventilation (increased rate and depth of breathing). Increases in pCO2 in the blood due to ineffective breathing will dilate the blood vessels and increase intracranial pressure. Hyperventilation lowers the arterial pCO2, which in turn causes cerebral vasoconstriction and thereby helps minimize cerebral edema.
• Correct hypovolemia and hypotension. Hypotension is most likely caused by hemorrhage in another area of the body.
• Control bleeding from the scalp, especially in children, it may be sufficiently profuse to cause hypovolemic shock. If the skull is unstable, apply pressure to the scalp close to the wound, but beyond the depressed fracture.
• Secure intravenous access. Unless shock is present, fluids should be severely restricted in head-injured patients, for excessive fluids may worsen cerebral edema. Slight dehydration reduces extracellular fluid thereby reducing cerebral edema. Do not give the injured victim anything by mouth.
• Do not allow the patient to become overheated, as patients with head injury, tend to develop a high temperature, which in turn may worsen the condition of the brain.
• Cover wounds as needed, if leakage of blood or CSF apply loose sterile dressings, just to keep the area clean
• Impaled objects protruding from the skull should be stabilized in place. Transport directly to a hospital with neurological facilities; the unconscious patient semiprone (on backboard).
• Monitor the cardiac rhythm; bradycardia should raise the suspicion of increasing intracranial pressure. Keep rechecking neurologic and vital signs, and record each finding accurately.
• A CT scan of the head injury should be obtained when appropriate. This will delineate the brain injury and determine whether surgery is indicated to remove a mass (subdural or epidural hematoma) and the degree of diffuse injury or swelling present.
• When there are signs of increasing intracranial pressure, the physician may order hyperventilation (20-24 breaths/min) and Mannitol before the surgery. (The patient should have a Foley catheter in place).
• Neurosurgery if indicated.
• Intensive care for further monitoring and management. Monitor artery blood gases as ordered and notify if abnormal values. In patients with severe head injuries who are intubated and undergoing ICP monitoring, pain medications can be administered without fear of causing hypoventilation or masking clinical signs of increased ICP. Patients should be kept sedated to prevent coughing or valsalva maneuvers from fighting the ventilator as these increase intracranial pressure.
• Reassure patients and their close ones that everything is being done to return the patient to his or her pretrauma stage of functioning if possible, or otherwise to help the patient achieve the best possible outcome with minimal limitations.

Possible surgical procedures for patients with head injuries are: Suturing to repair superficial lacerations; craniotomy to evacuate hematomas, control hemorrhage, remove bone fragments or foreign impaled objects, debride tissues, or elevate depressed fractures; and trephination (burr holes) to evacuate hematoma or insert intracranial monitoring devices. Cranioplasty to repair traumatic defects in the skull; ventriculostomy to remove excess cerebrospinal fluid; or ventricular shunting procedures to drain cerebral fluid and reduce intracranial pressure may also be performed.

Maxillofacial and neck injury

Maxillofacial injury is not usually life-threatening unless the airway is compromised, but patients with injury to the neck are at high risk. The airway, the carotid arteries, the jugular veins, the cervical spine, and the spinal cord are all contained in the neck. Blunt and penetrating injury to the neck can cause death within minutes from hemorrhage and airway obstruction or permanent paralysis can be the outcome.

Projectiles (knives and bullets) are responsible for most penetrating maxillofacial or neck injuries and may lead to lacerations, impalement, or puncture of the eye or cheek. Disruption of the major blood vessels in the neck, can result in brain damage or exsanguination. Blunt maxillofacial or neck injury often occur in motor vehicle accidents, sport accidents, or falls or when the face or jaw is struck in an assault with an object such as a bat or fist. Unrestricted occupants (especially front-seat passengers) in motor vehicle accidents may crash through the wind shield and then be pulled back through the shattered glass as the car decelerates. The result can be severe facial and scalp lacerations (bleeding is often profuse); soft tissue trauma; and facial, neck, or skull fractures. The installation of air bag in motor vehicles has reduced the number of sternal and facial fractures.

Assessment of patients with maxillofacial and neck injuries

Follow the standard ABC assessment plan, and evaluate the airway, breathing, and circulation. Start with serious injuries that threat life and limb. Once the airway and circulation are established, and bleeding is controlled, head or cervical spine injuries have been stabilized, turn your attention to assessment of the maxillofacial trauma. Observe the scene and elicit a history of the injury while assessing the patient. Patients who sustain significant injury to the face may have fractures of the jaws and damage to or loss of teeth. Massive trauma to the face is likely to be associated with cervical spine injury, and extreme care must be taken with these patients to avoid aggravating their injury. It is necessary to examine the entire face and mouth carefully to ascertain the extent of injury.

Suspect maxillofacial and neck injury in any patient who has any of the following:

• Obvious deformities, fractures, or distortions of the face or neck.
• Asymmetry of the face and neck.
• Pain and a noticeable edema.
• Swelling and discoloration; especially under the eyes (Raccoon eyes) or of the sclera, or bruising behind the ears at the base of the skull (Battle’s sign). Raccoon eyes and Battle’s sign are indications of a fracture in the base of the skull (basilar skull fracture).
• Dislocation of eye, deformity, facial bruises, loose or missing teeth, and swollen jaw are signs of facial fractures.
• Misalignment of the upper and lower teeth.
• Damage to the teeth, loose or missing teeth, bleeding from the mouth.
• Blood or fluid (possible CSF fluid) draining from the nose, and hemorrhage from the major vessels in the neck.
• Difficulty in speaking or moving the jaw.

Common maxillofacial and neck injuries

Maxillofacial injury causes distortion of the facial structures and copious bleeding. Broken teeth and blood may obstruct the airway, and it may be difficult to ensure an open airway because of fracture of the mandible. The injury may make endotracheal intubation impossible. When a cricothyroidotomy (the airway is opened below the level of the epiglottis) is needed, the technique should be performed only by those who are skilled in the execution.

Le Fort Fractures are three different types of mid facial fractures that are common after blunt facial injury. They include a fracture of the maxilla above the teeth, a triangular fracture from the upper teeth to an area between the eyes, and a serious fracture involving separation of the facial bones from the cranium.

Fracture of the maxilla (upper jaw) is often accompanied by a black eye. The face appears elongated, the patient’s bite is no longer even, and there will usually be noticeable edema.

Mandibular fractures are caused by significant force from blunt injury in motor vehicle accidents, assaults, falls and sport injuries. When the mandible (lower jaw) is fractured, it is likely to be broken in at least two places and will therefore show instability on palpation, and there will be evident ecchymosis and swelling. Unless the mandible is shattered and the airway is obstructed, no immediate intervention is indicated.

A zygomatic arch fracture by blunt trauma to the cheekbones is not a critical injury unless the orbits or eyes are damaged by the blow. An impaled foreign object in the cheek associated with massive bleeding may obstruct the airway. The inside of the cheek should be gently palpated to determine whether the impaled object has penetrated all the way through.

Nasal fracture (broken nose) most commonly is caused by motor vehicle accidents, assaults, falls, and sport injuries. Blunt trauma at the front of the face may cause posterior displacement of the bones; and from the side it may cause lateral displacement. The nose may be bleeding, and some swelling and deformities often occurs. Be aware of the possibility of orbital fracture or other significant head trauma in the patient with obvious nasal fracture.

Perforation of the tympanic membrane may result from foreign bodies in the external acoustic meatus, trauma or excessive pressure (during detonations or scuba diving). Severe bleeding or escape of CSF through a ruptured tympanic membrane and the external acoustic meatus may occur after a severe blow to the head.

Avulsion is the separation, by tearing, of any part of the body from the whole, such as the scalp, lower eye lid, and teeth. The scalp most frequently is torn from the skull; profuse bleeding results. When a patient’s head sustains trauma that causes an avulsion, a skull fracture and neck injury can be suspected.

The first three layers of the scalp, the scalp proper, remain together when the scalp is torn off during accidents (Moore, & Agur, 1996). The loose connective tissue layer (fourth layer) is the dangerous area of the scalp because blood or infection spreads easily in it, and can also pass into the cranial cavity and infect the brain. These wounds bleed profusely, and unconscious patients may bleed to death from scalp lacerations if bleeding is not controlled (by sutures).

Ocular (eye) injury. Trauma to the face may result in fracture of one or several of the bones of the skull that form the orbits (eye sockets). Orbital fractures require hospitalization and possible surgery.

The impaled foreign object in the globe should be left and stabilized in place.

Suspect corneal abrasion if the cornea does not appear smooth and shiny, can cause intense pain.

Chemical burns when alkali or caustic substances contact the eyes cause intense pain in most cases, the eye often is reddened, and some tissue destruction may be evident. This is a serious emergency, immediate, continuous irrigation is required.

Lacerations, cuts to the eyelids may affect the movement of the eyelids and disrupt the lacrimal system and require suturing. The eyes may also be swollen from blunt facial injury and from tissue edema in response to the injury. Any bruises or contusions of the orbit or globe should be evaluated by an ophthalmologist.

Hyphema (intraocular hemorrhage) may occur when the orbit or globe sustains blunt trauma. Patients with hyphema often complain of pain and a decrease in their visual aquity; the sclera may appear bloody.

Retinal detachment may occur when blunt trauma to the head tears or separates the retina from the choroid in the back of the eye. The patient may complain of a decrease in visual aquity or odd perceptions of flashing lights or dark spots in front of his or her eyes; blindness often results. Gentle transport is crucial.

Perforation of the globe, when penetrating injury perforates the eye or ruptures the globe, loss of the eye often results. Seepage of blood, vitreous humor, or intraocular contents from the eye may be noted.

Tracheal injury may be caused by blunt or penetrating trauma that close the airway; hypoxia and death follow within minutes. Blunt injury to the neck, signaled by swelling, ecchymosis, and pain, may cause collapse of the larynx or trachea or consequent airway obstruction. Penetrating trauma of the neck with injury to major vessels is a serious emergency. Severe life-threatening hemorrhage or air embolism may occur. The bleeding is difficult to stop because of the pressure within the vessels. The carotid arteries supply the blood for perfusion and oxygenation of the brain. When bright red blood spurts in a pulsating flow from the neck wound, the carotid artery may be damaged, a life-threatening situation. Dark red blood streaming from the open jugular vein is a serious emergency because of potential blood loss and potential air entrainment into the venous system. If the trachea has been disrupted, subcutaneous emphysema in the cervical area and the anterior chest and a fruity mixture of air and blood blowing through the penetrating wound may be present.

Laryngeal fractures may result from blows or from compression (by a shoulder strap during a vehicular accident). They produce submuccous hemorrhage and edema, respiratory obstruction, hoarseness, and sometimes an inability to speak because of injury to the laryngeal nerves.

Dental injury is common in facial trauma. Loose teeth can obstruct the airway, and dentures may be knocked out or swallowed. Any patient with dental injury should be evaluated by a dentist or an oral surgeon.

Management of patients with maxillofacial and neck injuries

Treatment at the scene is aimed at ensuring an airway and trying to promote the best possible cosmetic and dental outcomes. Your interventions should be within the scope of your professional license, skills and training, and when performed in a health care setting, adherent to the facility’s standard of practice. Wear protective eyewear and a mask in case the patient coughs and spray blood.

• Ensure airway, breathing and circulation. Have suction equipment available when possible. Monitor respiratory status frequently, because blood or foreign material can quickly obstruct the airway. Assist ventilation as indicated. Suction any blood from the mouth and throat.
• Immobilize the head and neck and assume that injuries to the cervical spine exist in any patient with maxillofacial trauma who lost consciousness from the blow. A cervical collar and a backboard are also desirable.
• Apply firm pressure over a bleeding site in the neck to reduce severe blood loss but do not occlude the airway, administer oxygen, prepare for the onset of shock if bleeding is severe and transport the patient immediately to the hospital. Keep the site covered when possible.
• Air can be sucked into the open jugular vein and circulated to the heart (air entrainment); could result in a fatal air embolism, causing arrhythmias and death. When there is a significant bleeding from the neck, seal the wound quickly with gauze, apply a bulky dressing, and maintain pressure manually over the bleeding site. Promptly position the patient on his left side in Trendelenburg (head down, feet elevated). This positioning helps to trap air in the apex of the ventricle and prevent it from reaching the lung circulation.
• Apply direct pressure with a sterile dressing over bleeding sites, except for: where cerebrospinal fluid is flowing or brain tissue is exposed, or ruptured or penetrated eyes, and where obvious deformity indicates fractures. Then apply loose sterile dressing, just to keep the area clean.
• Do not attempt to remove object impaled in the patients head, neck, brain or eye, unless it is obstructing the airway. Stabilize the object on each side of it, and transport the patient immediately to the hospital.
• Lay a dressing moistened in saline over avulsed tissue to reduce contamination and drying of the tissues, if available.
• Offer the patient with nasal fractures gauze bandages to catch any drainage, and transport him or her to a hospital. Do not obstruct the bleeding, due to possible airway obstruction or increased intracranial pressure in the event that a skull fracture exists.
• Elevate the head of the bed of the conscious patient to reduce swelling, bleeding, congestion and facilitate respiration, if it is not contraindicated by other injuries and a physician has ruled out spinal injury.
• Do not allow the patient to eat or drink until seen by a physician.
• Never insert a nasal airway or nasogastric tube in a patient with suspected mid facial or skull fractures. The airway or tube could penetrate the cranium and enter the brain.
• Retrieve and preserve avulsed tissue, such as an ear from the scene, cover it with sterile moist dressing, wrap it in plastic, label it, make a note of the time, and transport it to the hospital with the patient. The surgeons may be able to reattach the part.
• Save loose and dislodged teeth if possible. Make a note of the time, wrap the loose teeth in moist dressings, label the container, and transport it to the hospital with the patient. Dislodged teeth can sometimes be reimplanted successfully.
• Bring any dentures or pieces of dentures to the emergency department with the patient, as they will be needed to establish proper alignment in wiring a fractured jaw.
• Surgical treatment of ear injuries should only be performed by a specialist.
• All but the most minor ocular injuries should be evaluated by a specialist in eye care (ophthalmologist). The goal of care is to preserve both vision and the eyes. Unless the globe has been ruptured or penetrated, outcome and maintenance of the sight are often good.
• Do not attempt to force injured eyelids open to check pupils. Lay a cool moist compress over the contusion.
• Do not shave the eyebrows of a patient, as they provide a landmark for repair, and they may not grow back (Sheehy, & Jimmerson, 1994).
• Flush the eyes immediately with running water (from the inner to the outer aspect of the eye) in any patient who has experienced a chemical burn to the eyes. Contact lenses must be removed or flushed out. The affected eye should be continuously irrigated with saline or water, while gently holding the lid up; flush without ceasing, the time is important.
• Sterile eye patches lightly applied to both eyes can help reduce discomfort until the patient can be seen by a physician. Patching both eyes may help limit movement of both eyes and reduce pain.
• Offer strong emotional support to patient who have maxillofacial trauma. Use communication aids when possible for any patient who cannot speak. Facial and eye injuries frighten patients, who are concerned about loss of vision and alterations in appearance. It is important to maintain a calm, reassuring attitude and explain to the patient what is happening.

Spinal injury

A spinal cord injury refers to any injury to the spinal cord that is caused by trauma. Spinal injuries can be devastating and deadly. It is estimated that approximately 11.000 people sustain spinal cord injury in the United States each year, about one-third of these victims die before reaching a hospital. Traumatic injury occurs most often in young adult men (the 16- to 30- year age group). The average age at the time of injury has slowly increased from a reported 29 years of age in the mid-1970s to a current average of around 40. In the United States there are around 250.000 individuals living with spinal cord injuries.

Rapid forward deceleration during a motor vehicle accident and rapid vertical deceleration from a fall are two leading causes of spinal injury. Acts of violence have overtaken fall as the second most common source of spinal cord injury. Motor vehicle accidents account for 44% of spinal cord injuries; acts of violence, for 24%; falls, for 22%; sport accidents, for 8% (two-thirds of these sport-related injuries are from diving), and other causes, for 2%. Falls overtake motor vehicles as the leading cause after age 45. Acts of violence and sports cause less injuries as age increases.

The mechanism of injury is important in determining the type of injury. Flexion of the head (chin to chest) is a major mechanism of injury in most spinal trauma. Head-on collisions cause hyperflexion, and rear-end collisions usually cause hyperextension. Direct injuries involve compression or transection of the cord by the causal agent. Compression and rotational injuries can shatter vertebrae and force bone fragments into the spinal cord. Indirect injury involves compression, overstretching, rotation, wedging, or misalignment of the cord, which results in edema, swelling, and localized hemorrhage. It can also be involved in minor injuries, such as whiplash.

The spinal cord, the major reflex center and conduction pathway of sensory and motor impulses between the body and the brain, is a cylindrical structure that is slightly flattened anteriorly and posteriorly, and about 1 cm in diameter. The spinal cord is lodged in the vertebral canal, extending from the foramen magnum at the occipital base of the skull (begins as a continuation of the medulla oblongata, the inferior part of the brainstem) to the upper part of the lumbar region (intervertebral disc between L1 and L2 vertebrae). It is protected by the vertebrae, their associated ligaments and muscles, the three spinal meninges (the dura mater, arachnoid, and pia mater), and the cerebrospinal fluid (CSF). Nerve tissue in the spinal cord is bundled together in two regions. The brachial plexus of nerves (extending from C4 to T1 segments) innervate the upper limbs, and the lumbar and sacral plexus of nerves (extending from L2 to S3 segments) innervate the lower limbs. Thirty-one pairs of spinal nerves originate from the cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.

The spinal cord connects the brain to all of the other organs in the body. If the cord is interrupted by trauma, all connections between the brain and muscle groups or organ below the level of cord damage are severed. The initial care, starting at the scene and early interventions has profound influence on the outcome of the injury. The mechanisms of the primary spinal injury cannot be undone, but the rescuers can alter the effect of hemorrhage, hypotension, and hypoxia that cause secondary injury to the spinal cord and thus limit and prevent further damage.

One must maintain a high index of suspicion in any case where the mechanisms of injury suggest the possibility of spinal cord injury. Common spinal cord injuries are vertebral fractures and dislocations, such as those commonly suffered by individuals involved in motor vehicle accidents, airplane crashes, or other violent impacts. Compression injuries, such as those that may be sustained in diving, falling from a height, or in jumping from a height and landing on one’s feet, are also a likely source of spinal injury. The majority of cerebral spine injuries are associated with head injury. Foreign bodies may lodge in the cord and directly disrupt its structure and function. Bullets or knives are the most frequent objects involved in penetrating spinal cord injury. Don’t forget gunshot wounds, especially to the chest, back and abdomen. Bleeding or hematoma at the trauma site can compress the cord, and loss of blood supply to the cord can cause irreversible damage. Crushing injuries, such as those that occur in a cave-in, and injuries to lightning (which cause violent muscle contractions), are apt to produce spinal injuries. Any victim found unconscious after trauma should be assumed to have a spinal injury and treated accordingly.

The most common site of spinal cord injury is between the cervical vertebrae C5 and C6, and the second most common site is between T12 and L1. Spinal cord injuries are classified as complete when the loss of sensation and function is total and as incomplete when the loss is partial. The loss begins at the site of the lesion or injury and continues downward. About 55% of all spinal cord injuries result in quadriplegia or loss of sensation and function from the shoulder down, and the remaining 45% are paraplegic. Patients with paraplegia are affected from about the waist down, the lower extremities. If the spinal cord is disrupted, the body cannot signal vital organs. Breathing may stop, the pulse rate may become dangerously slow, blood pressure can fall, and death may occur if interventions are not swift.

Assessment of patients with spinal injury

Whenever a victim has a spinal injury evaluate and ensure the airway, breathing and circulation. Act as if all trauma patients have spinal cord injury until proved otherwise. Assume that a spinal injury exists if the patient has any of the following:

• Unconsciousness.
• Trauma to the head, neck or upper part of the chest.
• Difficulty breathing despite no obvious thoracic trauma. Head injury may produce several types of abnormal respiratory patterns. Shallow, diaphragmatic breathing; indicates a need to assist ventilation?
• Signs of spinal shock: hypotension with a normal or slow pulse and warm skin (this is very suggestive of neurogenic shock).
• Paralysis or loss of sensation in any part of the body.
• Involuntary loss of the control of bowel or bladder.
• Priapism.

Try to determine as precisely as possible the circumstances of the accident. Ask bystanders about the accident or assault. Find out the exact time of the injury if possible. If it has been more than 6 hours since the accident, the chances of restoring lost function are greatly reduced. If the patient is conscious, instruct him or her to not move. Ask patients to wiggle their toes and then fingers, squeeze your hand, and determine which of their toes or fingers you are touching.

Suspect spinal cord injury in:

• Motor vehicle accidents (higher prevalence, when the occupants are unrestrained).
• Falls from a height.
• Diving accidents.
• Cave-ins.
• Patients with head or facial injuries.
• Lightning injuries.
• Any unconscious victim of trauma.

If the patient is unconscious or the mechanism of injury indicates possible spinal injury, assume that spine injury is present. Assessment of a conscious patient who has spinal injury also requires a brief neurologic examination during the secondary survey to evaluate the patient’s motor and sensory function. If patients can squeeze your hand, wiggle their fingers and toes, their motor function may be intact. If they can feel your touch, sensory function may be intact.

A patient who has any demonstrable motion whatsoever after spinal injury has a 75 percent chance of recovering functional ambulation at a later data (Caroline, 1983). It I s important for the physician to be able to identify which patients fall into this category. Occasionally, swelling from injury around the spinal cord can cause temporary compression of the cord, resulting in paralysis. As the swelling subsides, function may return. In most instances damage to the spinal cord is permanent.

Signs and symptoms of spinal cord injury:

• Pain and tenderness over the spine.
• Numbness and paresthesias.
• Weakness or heaviness of the limbs.
• Position: arms folded across chest. A patient with an injury around C6, will often lie with his forearms flexed across his chest and his hands half-closed. Another position seen in some cervical spine injuries is the "stick ‘em up" position in which the patient holds his hands above his head.
• Hypotension without other signs of shock.
• Cuts and bruises over the head, face, neck and back.
• Note also any signs of loss of bowel or bladder control.
• Diaphragmatic breathing.
• Signs of loss of bowel and bladder control.
• Priapism.
• Deformity of the spine.
• Loss of sensation.
• Weakness, paralysis, or flaccidity.
• There may be no signs and symptoms at all!

Loss of sensation. Can the patient tell when someone is moving his finger or toe up or down? Does he/she feel pain in response to pinprick (starting with the toes)? Mark the level at which sensation is first elicited on the patient’s body. Recheck periodically. The umbilicus is at approximately the level of the tenth (T10), the nipple around T4, and the clavicles around C3 (third cervical nerve).

Motor function. In an unconscious patient, test for paralysis by applying a noxious stimulus first to each foot, then to each hand, and observing for withdrawal. A normal neurologic examination does not rule out the possibility of spinal cord injury. Victims of a motor vehicle injury have been known to walk from the accident only to become paralyzed hours later.

Common spinal injuries

Common spinal cord injuries are vertebral fractures and dislocations such trauma may cause varying degrees of paraplegia and quadriplegia. Sheehy, & Jimmerson (1994) classify the three major types of spinal injuries as injury to the spinal cord itself, fracture of the vertebrae, and injury to the spinal nerves. Traumatic spinal cord injury is also classified into five categories (A, B, C, D, and E) by the American Spinal Injury Association (ASIA) and the International Spinal Cord Injury Classification System. Fracture and dislocations may also interfere with the blood supply to the spinal cord from the radicular arteries (segmental vessels), causing weakness and paralysis of the muscles.

Cervical injury. If the injury is at the sixth cervical vertebrae (C6) the hands will be affected in addition to the legs, and intercostals muscles will be paralyzed, severely compromising respiration. A hit higher on the spinal cord, C4 or above, the spinal injury will paralyze the diaphragm as well as making respiration virtually impossible. In such an injury, the patients, if they survive, become for the rest of their life totally dependent on machines (artificial ventilator), and on other people for every need. Also, 27% of patients with cervical spine injuries have concomitant head injuries (Sheehy & Jimmerson, 1994). Severe hyperextension of the neck may pinch the superior arch of C1 between the occipital bone and C2, and the spinal cord is usually severed. Victims with this injury seldom survive. If the transverse ligament of C1 vertebrae, the atlas ruptures as the result of trauma the C2 vertebrae, dens of axis is set free and may be driven into the cervical region of the spinal cord, causing quadriplegia, or into the medulla of the brain stem causing death (Moore, & Agur, 1996).

Thoracic injury. Because of its stability (even from the attached ribs), the thoracic spine is not injured as often as other parts of the spine. The neck of any victim who has a suspected injury of the thoracic spine should be immobilized, and the injured victim should be transported to the nearby hospital on a long backboard. Thoracic injury can impair ventilation and circulation. Complete injuries at or below the thoracic spinal levels result in paraplegia. Functions of the hands, arms, neck, and breathing are usually not affected. The lower the level of injury, the less severe the effects.

Lumbar and sacral injury. Because of its flexibility, where the lumbar vertebrae join the thoracic vertebrae at a flexible joint, the lumbar spine in the T12-L1 area is the second most common site of spinal injury. Lumbar injury is common in patients who cannot move their legs. The effects of injuries to the lumbar and sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus. Bowel and bladder function, and also sexual function are regulated by the sacral region of the spine.

Impalement. Any object that lodges in the spinal column should be left in place, as removing it could make the injury worse. Most spinal injuries due to penetrating trauma are caused by guns or knives.

Spinal shock, or neurogenic shock is a complex phenomenon in which the nerve pathways controlling the diameter of the vessels are interrupted and peripheral vascular dilation, hypotension results. Pooling of blood may make the skin feel warm and pink. The sympathetic system generally stimulates an increase in pulse to compensate for any decrease in blood pressure, but as this impulse is impaired in spinal cord injury, the pulse may be normal, slow or severely bradycardic. The emergency team may apply MAST to help support blood pressure by compressing the lower extremities, intravenous fluids may help somewhat, but inotropic agents are often necessary to sustain life.

Central cord syndrome accounts for approximately 9% of traumatic spinal cord injuries (McKinley, Santos, Meade, & Brooke, 2007). It is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.

Management of patients with spinal injury

After a patent airway, breathing, and circulation have been established, the goal of prehospital care is to limit any further damage to the spinal cord. Immobilize the patient and maintain perfusion and oxygenation of the nervous system. Your interventions should be within the scope of your professional license, skills and training, consistent with your state’s nurse practice act, and adherent the facility’s standards of practice. Treatment of the patient with possible spinal injury is aimed at supporting vital functions and preventing further spinal cord damage (note patient’s position and general appearance):

• Ensure an open airway. For the unconscious patient, use jaw trust without backward tilt of the head, and insert an oropharyngeal airway. Keep suction readily available.
• Assist breathing as required. Evaluate the patient’s breathing, if it is shallow, you will need to assist ventilations. Administer oxygen to all patients who have sustained a suspected spinal injury to increase oxygen supply to the spinal cord. Administer oxygen, either by nasal cannula to the patient who is breathing adequately or via bag-valve-mask when assisted ventilation is required.
• Support the circulation:
  - Control bleeding.
  - Secure venous access. Administer intravenous fluids, plasma expanders, and inotropic agents as ordered (to support the blood pressure).
  - Anticipate possible application of MAST for severe hypotension.
• Specialists may recommend intravenous administration of methylprednisolone (within a few hours of the trauma) to reduce the severity of a spinal cord injury or enhance recovery.
• Treat other injuries. Evaluate the chest, abdomen, and lower extremities repeatedly, as the patient with a spinal cord injury often can no longer perceive pain from other injuries because of the disruption of spinal cords messenger function.
• Do your best to keep the victim’s head, neck, and spine in alignment, and never drag or pull the victim by the head or neck. Try to stabilize the victim’s head and neck with your hands. Move the patient by yourself only if the patient or you are in immediate danger (e.g. explosion or fire at the trauma scene seems imminent).
• Immobilize the patient on a long backboard. Patients who have a spinal injury are always placed and transported on a long spineboard/backboard to immobilize the whole body and with a rigid Philadelphia collar in place. The emergency team often adds additional support with rolled towels placed on each side of the patient’s head. The head is then taped in place to the backboard to further restrict movement. Logroll the patient as a unit (four or more trained professionals); keep the head in alignment with the body. This series of steps is called packaging the victim. Quickly scan the patient’s back for injuries before the patient is rolled onto the spinal board.
• Once wounds have been dressed, and fractures splinted. Keep the patient covered with a blanket. Loss of sympathetic tone means loss of vasoconstriction, which in turn means that the patient can no longer conserve body heat effectively.
• Transport the unconscious patient in a lateral recumbent position. This position will assist drainage of secretions out of the mouth.
• Make frequent checks of vital signs and neurologic status on route; record your findings.
• Do not attempt to remove a helmet from the victim of a motorcycle or sports accident (unless necessary to access the airway, sustain breathing, or control life-threatening hemorrhage). Use careful appropriate rescue techniques for victims injured in a water accident.
• Do not allow the patient to eat or drink until he or she is seen by a surgeon. Immediate surgery may be indicated, and the patient’s condition may also deteriorate, and vomiting or aspiration may occur.
• A full bladder may burst so catheterization is often indicated, but not until the potential for urethral damage due to pelvic fracture has been ruled out.
• Be prepared for seizures.
• Monitor the condition and placement of extremities and body parts. Patients with spinal cord injury may not be able to tell you when something hurts.
• Reassure the patient frequently, and offer calm simple explanations.

Laminectomy is the surgical procedure used to expose the spinal cord to relieve compression on neural structures from hematomas, and to remove bone fragments, or penetrating objects. Spinal fusion is used to stabilize spine. Cervical tongs or halo traction are used to immobilize the cervical spine, and body cast or Harrington rods are used to immobilize the thoracic spine. Tracheostomy may be performed to provide long-term ventilatory support.

Research into treatments for spinal cord injuries includes controlled hypothermia and stem cells. Aside from methylprednisolone, many treatments have not been studied thoroughly and very little new research has been implemented in standard clinical care.

Orthopedic injury

In the multiple-injury victim, fractures may be the most obvious and dramatic injuries, but they are rarely the most serious. A simple fracture is generally not life-threatening, but some musculoskeletal injuries, such as pelvic fractures/crush injuries, traumatic proximal amputations, and multiple open or closed fractures may be life-threatening, due to loss of blood or spinal cord injury. Other injuries, such as hip or knee disclocations, can result in loss of the limb from arterial occlusion or in permanent disability.

The musculoskeletal system comprises the bones, cartilages, muscles, tendons and ligaments of the body. The skeleton, the supporting framework for the body is composed of 206 bones in the adult that protect structures, provide attachments for muscle, allow body movement, serve as major reservoir for blood, and also produce red blood cells, platelets, and most white blood cells. The four types of bones composing the skeleton are the long bones (bones of the extremities), short bones (bones of the wrist, ankle), flat bones (ribs, shoulder blades), or irregular (vertebrae, mandible). Bones are living organs that hurt when injured, bleed when fractured, and change with age.

The skeleton changes throughout life as bone formation and bone destruction proceed concurrently. The age of a person can be determined by studying ossification centers. Fractures are more common in children than in adults because of their slender growing bones and care-free activities. Many of these breaks are greenstick fractures (incomplete breaks caused by bending of the bone), and fractures in growing bones heal faster than those in adult bones. During old age, there is a reduction in the quantity of bone; hence the bones lose their elasticity and fracture easily.

Loss of the arterial supply to a bone results in death of bone tissue (avascular necrosis). After every fracture, small areas of adjacent bone undergo necrosis. Veins accompany the arteries, and nerves accompany the blood vessels supplying bones. Periosteral nerves are especially sensitive to tearing or tension, which explains why pain from broken bones is severe. Within bones, vasomotor nerves cause constriction or dilation of blood vessels.

Orthopedic trauma may result from a variety of mechanisms. The direct or indirect force of blunt trauma can fracture or dislocate bones, and also cause trauma to the surrounding tissues, nerves and vessels near the bone. In some instances, the bone are sheared or torn from surrounding structures, resulting in amputation. Sometimes the bone does not break, but tendons, ligaments, and muscles are strained, sprained, or torn by the force to site. Twisting injuries, such as commonly occur in football or skiing, result in fractures, sprains, and dislocations. Powerful muscle contractions in seizures may tear muscle from bone. The elderly (and patients with bone metastasis) have weaker, more brittle bones and are thus more prone to fractures.

Penetrating trauma is caused by bullets, knives or other instruments that shatter bones and lacerate muscles, tendons, and ligaments. The ends of fractured bone may protrude through the skin and may become an open pathway for infectious organisms.

Assessment of patients with orthopedic injuries

Evaluate the airway, breathing and circulation and intervene in life-threatening injuries first, limb-threatening injuries second, and then less serious injuries. Surrounding nerves and vessels may be injured during orthopedic trauma, and these additional injuries could cause permanent disability and deformity, especially in children, so injuries must be carefully managed. The evaluation of patients with possible musculoskeletal injuries requires observation of the scene to determine mechanism of injury, followed by a history of the injury while examining the patient. It is not always easy at the scene to distinguish between a dislocation and a fracture.

Assessment includes the following steps:

• Cut clothing away from the extremities. Do not compromise stabilization of the head and cervical spine. Look carefully, and compare the injured extremity with the opposite limb; note color and skin temperature; and look for obvious injuries, deformities or bleeding that may require immediate interventions.
• Feel gently down each extremity. Note uneven surfaces, swelling and ecchymosis, changes in skin temperature, grinding sensations, deformity or shortening, tenderness to palpation, guarding and disability, and complaints of pain from the patient.
• A careful assessment must be made of pulses, sensation, and movement distal to the fracture site. Palpate the distal pulses in each extremity to determine if circulation is impaired. Distal pulses should be equal. Mark the point where the maximal impulse is felt, so that you can locate it later.
• Ask the patient if he or she can feel you touching the extremity, and if there is any numbness or tingling. If no obvious deformity is present, ask the patient to wiggle the fingers or toes of the affected extremity. This test provides information about damage to the nerves in the area.
• Ask the patient about previous musculoskeletal system injuries, diseases or surgical operations. When in doubt treat the injury as a fracture and immobilize the injured area.

Signs and symptoms of fracture:

• The primary symptom is moderate to severe pain, usually well localized to the fracture site. The patient may also report that he or she heard something snap or felt the bone break.
• Tenderness to palpation will usually be well localized to the area over the injury and is elicited by pressing gently along the length of the bone or each side of the pelvis.
• Deforming and shortening of an extremity. Deformity: difference in size and shape?; does any portion (the skull or rib cage) appear caved in?; unnatural position?; or, false or unnatural motion?
• Guarding and disability; the patient with a fracture will attempt to find a comfortable position and avoid moving it; the patient with a dislocation will be unable to move the dislocated extremity at all.
• Swelling and ecchymosis. Swelling and bruising are caused by leakage of extracellular fluid and blood from vessels that have been ruptured in and about the fractured end of break.
• Grating and crepitus may be noted during splinting attempts, when broken fragments of bone grind against one another. Testing for crepitation can produce further tissue damage.
• Exposed bone ends present (in open or compound fracture).

Signs and symptoms of dislocation:

• Pain or a feeling of pressure over the involved joint.
• Loss of motion of the joint.
• Sign of deformity. If the dislocated bone end is pressing on nerves or blood vessels, corresponding functions also may be compromised. Numbness or paralysis below the dislocation if nerve is depressed, loss of pulse below the dislocation if blood vessel is compressed. The absence of pulses means that extremity is in a grave danger. An orthopedic surgeon should be alerted to be standing by when the patient arrives.

The possibility of associated damage to nerves and blood vessels must always be considered in cases of fracture, and a careful assessment must be made of pulses, sensation, and movement distal to the fracture site.

Estimated blood loss in fractures:

Fracture of elbow, tibia and ankle, can each lose 0.5-1.5 L, and fracture of forearm 0.5-1.0 L.

Common orthopedic injuries

Fracture is a traumatic injury to a bone in which the continuity of the bone tissue is broken. A fracture is classified by the bone involved, the part of that bone, and the nature of the break, such as a comminuted fracture of the head of the tibia. Fracture may be open (compound, the skin is broken over the fracture site), or closed (simple, the skin remains intact). Open fractures are considered more serious, as they may become an open pathway for infectious organisms and foreign bodies.

Pelvic fractures may be stable or unstable. Unstable pelvic fractures typically occur as a result of high-energy injuries, such as motor vehicle crashes. If gentle pressure applied to each side of the pelvis elicits pain, or there is abdominal distension from internal bleeding, evidence of hypovolemic shock, and bloody urine, suspect a pelvic fracture. Blood loss can be more than 2-3 L. Any signs of instability should have prompt urgent consultation with an orthopedic surgeon.

Femur fracture is an injury to the longest and strongest bone in the lower extremity. The fractured leg may appear to be shorter than the other leg and usually is rotated externally. Sometimes a MAST is applied to patients who have a fractured femur because of significant blood loss and because compression applied by the garment helps splint the fracture. A Thomas half-ring leg splint is also often used to realign the bone and promote circulation when a femur is fractured. Concurrent fracture of both femurs can cause life-threatening hemorrhage and death.

Hip fractures are most common in elderly women and usually caused by simple falls. Fractures of the hip bone also often occur in serious vehicular accidents, and other sudden deceleration accidents. Blood loss can be 1.5-2.5 L. The affected extremity may appear to be shorter than the other extremity. Dislocation and swelling may be present over the fracture site. This is a serious injury that requires evaluation by an orthopedic surgeon.

Humerus fracture is an injury to the longest and strongest bone in the upper extremity. Substantial force is required to fracture it; blood loss may be heavy, and neuromuscular compromise may develop. Fractures of the surgical neck of the humerus mostly occur from falls in which the outstretched arm strikes the ground (impacted fracture). Humerus fracture is a serious injury that requires evaluation by an orthopedic surgeon.

Wrist fractures often occur when individuals fall on their outstretched hands (with elbow extension), or when they throw up their hands against the interior of the vehicle in a motor vehicle accident.

Ankle fractures often occur in sports accidents, motor vehicle accidents, and falls. If the injury was caused by a fall, suspect spinal and head injuries as well, because the energy would have been directed up the body on impact. Swelling and pain, and sometimes obvious deformity may be present.

Any dislocation, the displacement of a bone from its normal articulation with a joint can be serious. Tearing of the ligaments, disruption of the blood supply and nerves in the area can result in loss of limb or permanent disability. The shoulder, elbow, fingers, hips, knee, and ankles are the joints most frequently affected. Even if the dislocated joint slips back in the place, the patient still must be evaluated by an orthopedic surgeon. Joint dislocations should be reduced and splinted as soon as possible, especially knees, hip, and ankle.

Hip dislocations. The ball-and-socket joint of the hip, formed by the articulation of the head of the femur into the cup-shaped cavity of the acetabulum involves seven ligaments and permits very extensive movements. Hip dislocation often occurs in motor vehicle accidents when a person's knees strike the dashboard, and the energy is directed back to the hip. A hip dislocation is a serious injury as the blood supply to the head or top of the hip may be impaired, causing necrosis and necessitating replacement with an artificial joint in the future. Pressure on the sciatic nerve can result in permanent disability. Pain is often severe, and the leg may rest in an unnatural position.

Knee dislocations or fractures may cause serious injury to the popliteal artery. Therefore, arteriograms are obtained in the hospital whenever a patient has a dislocated knee. In a patient with a dislocated knee and absence of distal pulses, reduction must be accomplished within 1 to 2 hours of injury. Dislocations of the wrist, elbow, shoulder, hip, and ankle can be tolerated for 2 to 3 hours without much danger of permanent damage (Caroline, 1983). Serious knee injuries may necessitate amputation of the leg (Campbell, 1988).

Tibia fracture. The tibia is the most common long bone to be fractured and also the most frequent site of an open (compound) fracture. Fracture of the fibula is often associated with fracture-dislocations of the ankle joint. It is also a common source of bone for grafting.

Shoulder dislocations are most often sustained in athletic activities. The shoulder is the most commonly dislocated joint and this dislocation may become chronic and require surgical interventions. Like shoulder dislocations, elbow dislocations are often associated with athletic activities or when children fall on their hands with their elbows flexed. Serious damage to nerve and vessels may occur.

Wrist fractures, commonly occurs when the person slips or trips and, in an attempting to break the fall lands on the outstretched hand with the forearm pronated.

Sprains are injuries in which the ligaments that connect one bone to the other are partially torn, usually caused by sudden twisting forces. They most commonly affect the knees and ankles and are characterized by pain, swelling, and discoloration of the skin over the injured joint. Sprains usually do not manifest deformity but it is generally best to treat the sprain as if it were a fracture and immobilize it accordingly. Keep the sprained joint elevated, and apply ice compresses if available.

Strains are soft tissue injuries or muscle spasms around a joint due to overstretching or overexerting a muscle, as in sports activities. The strain is generally in the area of a tendon, where the muscle attaches to the bone, and is characterized by pain on active movement. Strains are best treated by avoiding weight-bearing on the injured area. The extremity may be immobilized pending evaluation in the emergency department.

Simple lacerations often heal with only simple suturing. Lacerations that penetrate the ligaments and tendon in the hands and feet may result in permanent disability if not thoroughly irrigated and repaired. Penetrating injury may also result in foreign bodies or objects impaling bones, muscles, or tendons. Due to the impalement disability or loss of the extremity may occur.

Traumatic amputations, when a limb or part of a limb is severed from the body are serious emergencies, often sustained in industrial accidents, recreation accidents, traffic accidents, amputation from weapons, explosives, bombs, terrorist attacks or natural disasters. Blood loss may be significant. The most important is to save the life of the victim by ensuring airway, breathing and circulation (control of bleeding, shock), and so forth. Depending on the circumstances the amputated parts can sometimes be reinplanted, so the parts should be preserved and always accompany the patient to the hospital. Bleeding from a stump is usually not a problem, since the severed blood vessels tend to restrict into the stump and be squeezed shut. Control the bleeding by applying an appropriate sterile dressing moistened in sterile saline directly on the wound. Cover the dressed stump with a dry bandage, and elevate the stump above the level of the patient’s heart, but only if doing so does not compromise stabilization of the head and cervical spine. If bleeding cannot be controlled, apply pressure on the appropriate pressure points. Do not use a tourniquet except as a very last resort, as it will reduce the viability of the distal stump and thus lessen chances of successfully reinplanting the amputated stump. The amputated part should be wrapped loosely in wet gauze or other material, placed and sealed in a plastic bag. Place the plastic bag or waterproof container on ice. The goal is to keep the amputated part cool but not to cause more damage from the cold ice. Do not cover the part with ice or put it directly into ice water, it will only harm the tissues and nerve endings further possibly hindering reattachment of the limb. The patient and the preserved amputated part should be taken as expeditious as possible to the hospital. Notify the emergency surgical team in advance about the estimated time for arrival. If the part cannot be found right away, transport the injured person to the hospital and bring the amputated part to the hospital when it is found.

Compartment syndrome is a pathologic condition caused by a progressive development of arterial compression and reduction of blood supply; an increase in pressure within a facial compartment. This leads to tissue death from lack of oxygenation. It develops most often with blunt trauma or crush injuries (such as earth quakes). Compartment syndrome most often involves the forearm and lower leg. There are classically five "Ps" associated with compartment syndrome: pain out of proportion to what is expected, paresthesias, pallor, paralysis, and pulselessness. Tense and swollen shiny skin, restriction of movement, sometimes with obvious bruising of the skin and an increase in intracompartmental pressure are other signs and symptoms. These may develop a few hours to a few days after the injury. Treatment includes removal of restrictive dressing or cast, and surgical compression to relieve increased intracompartmental pressure. Acute compartment syndrome is a medical emergency requiring immediate surgical treatment, known as fasciotomy to allow the pressure to return to normal (Salcido, & Lepre, 2007). Otherwise, loss of the extremity may occur because vascular compression causes tissue necrosis.

Management of patients with orthopedic injuries

Interventions and treatments of fractures should be deferred until life-threatening conditions have been adequately managed. When life-threatening conditions have been dealt with, it is appropriate to identify and immobilize all fractures in preparation for transport. Musculoskeletal injuries, such as: all penetrating injuries to extremities proximal to elbow and knee; two or more proximal long-bone fractures; crushed, degloved, or mangled extremity; amputation proximal to wrist and ankle; pelvic fractures; and also flail chest; open or depressed skull fracture; and paralysis should be taken to a trauma center. The most seriously injured patients should be transported preferentially to the highest level of care within the trauma system.

Treat the life-threatening injuries first, after that the patient’s airway, breathing, and circulation have been established, orthopedic injuries should be carefully examined and stabilized if present. The goals are to limit further damage, preserve the structure and function of the extremity, ensure perfusion and oxygenation, and transport the patient to a hospital (trauma center) for examination by an orthopedic surgeon. Some orthopedic injuries are associated with significant morbidity and mortality and may affect the patient’s quality of life. Immobilize the head and the neck and assume that injuries to the cervical spine exist until proved otherwise.,/p>

• Assess and stabilize the airway, breathing and circulation before evaluating other orthopedic injuries.
• Administer oxygen to any patient who has multiple fractures or a fracture of a long bone.
• Secure intravenous access with two large-bore intravenous lines, and begin volume replacement as ordered to any patient who has a fractured long bone or a suspected pelvic fracture, because shock may follow. Be aware that a pelvic fracture or bilateral femoral fractures can cause life-threatening hemorrhage and death. Type and cross-match orthopedic trauma patients when fracture of the pelvis or long bones is suspected.
• The MAST garment to enhance venous return and support the blood pressure is often used. For massive trauma to the lower extremities or pelvic fractures MAST can be used as a splint.
• Do not allow the patient to eat and drink anything until he or she is examined by an orthopedic surgeon.
• Do not remove an object stuck in bone or muscle unless the object is interfering with the airway. Stabilize the impaled object, and transport the patient to a hospital immediately.
• In open fractures, do not attempt to push exposed bone ends back into the wound. Cover with sterile dressing. Immobilize all fractures before moving the patient. Splint the extremity as you find it, and transport the patient to a hospital for emergency care. A dislocated hip or knee is a serious orthopedic emergency. The blood and nerve supply to the extremity may be impaired; permanent disability can result, or amputation of the extremity may be necessary.
• Splint an extremity to prevent possible injury if you are uncertain whether orthopedic injury exists. Immobilize and splint any injury as you find it. Move the patient carefully to avoid making the injury worse.
• If the condition of a critically injured patient with pelvic fracture is unstable and rapidly deteriorating, urgent surgery will be required.
• Apply gentle pressure to any orthopedic injury that is bleeding. Await the arrival of an emergency team who can properly splint the fracture. If the patient must be moved, splint the fracture as you find it. Move the patients carefully to avoid making the injury worse.
• Do not attempt to straighten fractures involving the spine, shoulder, elbow, wrist or knee. Fractures involving joints should be splinted in the position which they are found.
• Severely angulated fractures of long bones should be straightened before splinting (exert longitudinal traction). Specially trained trauma professional sometimes realign extremities at the scene, but unless you have this skills and special training, do not attempt this. Pillows, newspapers, broomsticks, and cardboard are a few of the items that can be used as splints.
• Do not attempt to straighten a dislocated or fractured knee, hip, shoulder, or elbow. Splint the extremity as you find it and transport the patient to a hospital for emergency care.
• Splint dislocations in the position in which they are found. Splint above and below the dislocated joint to maintain stability during the transport.
• Immobilize a dislocated hip in the position you find it. Transport the patient immediately to the hospital for evaluation.
• Splint one leg with the other and transport the patient to the hospital if you suspect a hip fracture. The pain may be referred to the knee or pelvis.
• Immobilize the joints above and below the fracture. For example, elbow and wrist for fractures of the radius and ulna.
• Splint firmly but not so tightly as to occlude circulation. Check distal pulse after splinting. Leave fingers and toes visible. Check and recheck air splints. Pad board splints well. Be sure that it is not applied to tightly, or pressing against areas of contact.
• For fractures above the knee, the half-ring traction splint is often used.
• Lay a fractured wrist on a firm surface to splint and immobilize the fracture. Splint it in the position found, and if the wrist fracture is an isolated injury, apply a cool pack, and transport the patient to the hospital.
• Pillow splint or an air splint can be used for suspected ankle fractures. If no other pathologic changes or indication of spinal injury is present, elevate the ankle slightly and apply a cool pack to reduce swelling. Take care not to change the position of the ankle if there is a distal pulse.
• Elevate a sprained or strained extremity if spinal injury has been ruled out. Apply a cool pack and recheck at intervals to make certain the injured site has not changed and the pack is not to cool.
• Assess and record the neurovascular status of the extremity. Palpate distal pulses, note skin temperature, and check sensations frequently in an injured extremity, and reassess each time the patient is moved or the extremity is repositioned. Report changes or trends to a physician immediately. Orthopedic injury can result in neurovascular compromise and can cause subsequent loss of the extremity or normal function of the extremity.
• Check cast and splints at regular intervals to ensure that swelling has not occurred, for tightness can precipitate development of compartment syndrome; record abnormal findings and report them to a physician. Compartment syndrome and necrosis of the extremity can develop in a constricting cast or splint.
• Cover the dressed stump with a dry bandage, and elevate the stump above the level of the patient’s heart, but if doing so do not compromise stabilization of the head and cervical spine. If bleeding cannot be controlled, apply pressure on the appropriate pressure points.
• The amputated part should be wrapped loosely in wet gauze or other material, placed and sealed in a plastic bag. Place the plastic bag or waterproof container on ice. The goal is to keep the amputated part cool but not to cause more damage from the cold ice. Do not cover the part with ice or put it directly into ice water, it will only harm the tissues and nerve endings further possibly hindering reattachment of the limb.
• The patient and the preserved amputated part should be taken as expeditious as possible to the hospital. Notify the emergency surgical team in advance about the estimated time for arrival. If the part cannot be found right away, transport the injured person to the hospital and bring the amputated part to the hospital when it is found.
• Notify the surgical team of a patient for possible reinplantation. Follow protocols for preserving all amputated parts. Reinplantation may be possible, and the parts may be used for grafts. Mark the time the parts were amputated and the time they were placed on ice on the container, because this information will help the transplantation team plan the care.
• In traumatic finger amputations, reinplantation of the thumb is generally a priority because of the function of this digit.
• X-ray all suspected fractures, including joints above and below. A computed tomography scan is often used to obtain more detail about a fracture or bone problem that was found with plain X-rays.
• Prepare for surgery or vascular studies and assist with the measurement of intracompartmental pressure as indicated.
• Provide adequate analgesia as ordered. Immobilizing in a position of relative alignment can achieve significant analgesia, and also improvements in skin/limb perfusion to the limb.
• Use strict aseptic technique, and administer antibiotics as ordered. Monitor temperature and white blood cell count. Determine the data of the patient’s last tetanus prophylaxis and report it to a physician for consideration of a tetanus booster injection.
• Offer explanations and reassurances to the patient as you work, and reassure the patient that everything possible is being done.

Heat cramps, heat exhaustion, and heat stroke

Body temperature is usually maintained near a constant level of 98-100°F (36.5-37.5°C). Fever is defined as a rectal temperature of 100-101°F (>37.5-38.3°C), hyperthermia 101-104°F (>38.4-39.3°C), and hyperpyrexia 104-107°F (>40.0-41.5°C). If heat production exceeds heat loss, the temperature will rise. When core temperature rises, peripheral vasodilation occurs, and the blood brings increased amounts of heat to the skin, where it is dissipated, unless the ouside temperature approaches or exceeds the skin surface temperature, and as long as metabolism does not produce an overwhelming heat load. Then the physiologic effects of exposure to high environmental temperatures and humidity is that the heart must increase the output (tachycardia); blood is shunted away from the brain; as sweating increases, excessive amounts of sodium, chloride, and other electrolytes are lost through the skin, resulting in cramps and dehydration.

Heat cramps are painful muscle cramps, usually in the lower extremities, the abdomen, or both, resulting from excessive loss of salt and water through sweating. It often occurs after vigorous physical activity in an extremely hot and humid environment. The patient may become somewhat hypotensive and nauseated, with rapid pulse, pale and most skin, the temperature is normal, and the patient remains alert. Heat cramps may progress to heat exhaustion, if untreated. Treatment is aimed at eliminating the exposure and restoring lost salt and water. The victim should be moved to a cooler place and given salt-containing fluids. If the victim is too nauseated, start an IV. Do not massage the cramping muscles. As salt and water are replenished, the patient’s symptoms will abate. The patient should avoid strenuous activities for at least 12 hours, to avoid heat exhaustion or heat stroke (Caroline, 1983).

Heat exhaustion, prostration caused by excessive loss of salt and water through sweating, as well as to peripheral blood pooling, that results from the exposure to intense heat or inability to acclimatize to heat. It is especially likely in dehydrated, elderly patients and in persons with hypertension; the elderly are more prone because of diminished thirst mechanisms. Syncope, headache, weakness, vertigo, nausea, and sometimes abdominal cramping characterize this condition. The patient is usually perspiring profusely, the pulse is rapid and weak, skin is pale and clammy, the blood pressure may be decreased, the respirations are usually fast and shallow, the temperature is either normal or decreased, the pupils may be dilated, and the patient may be somewhat disorientated. Untreated heat exhaustion may progress to heat stroke. The patient usually recovers with rest and replacement of water and electrolytes. Move the patient to a cool environment, remove clothing as much as possible, and place him or her in a supine position with elevated legs. Make the patient comfortably cool; sponge with cool water, and fan him or her if the humidity is not excessively high. Start an IV with normal saline or Ringer’s solution and run the fluids rapidly.

Heat stroke (sunstroke, heat hyperpyrexia) is a life-threatening condition caused by severe disturbance in the body’s heat-regulating mechanism that may occur at any age in persons having too much sun exposure or prolonged confinement in a hot atmosphere. The victim’s temperature control system, which produces sweating to cool the body, stops working. Elderly patients and those with a history of cardiac disease are at increased risk for heat stroke when taking an anticholinergic, such as dicyclomine (The clinical answer book, 1996). This adverse effect is especially common with strenuous activity and high environment temperatures. Body temperature may rise as high as 106°F (41°C) or higher within 10 to 15 minutes; the skin appears flushed, and is hot and dry. The patient may experience throbbing headache, dizziness, and dryness of the mouth; the pulse is strong, bounding. Coma and seizures often follow rapidly. The patient may vomit, lose consciousness, and suffer cardiac arrhythmias. Immediate and aggressive therapy (aimed at maintaining vital functions and inducing as rapid a temperature fall as possible) must be initiated to avert cardiac arrest. Establish an airway, and administer oxygen. Move the patient to a cool environment, remove as much clothes as possible, and cool the patient rapidly. Use a bathtub filled with cold water and ice cubes, an ice-cold shower, crushed ice rubbed over the patient’s head and body (massaging increases peripheral circulation, which accelerates heat loss), a garden hose, cold packs, or continued washings with rubbing alcohol and wet sheet wrapped around the patient with a fan blowing; speed is essential. Delay may result in permanent brain damage. Vigorous efforts to cool the patient must continue until the body temperature is below 102°F (38.9°C) (Caroline, 1983). Secure venous access, monitor cardiac rhythm; and monitor for respiratory alkalosis at the hospital. Fluid replacement, as needed; administration of cool fluids also helps to bring down the patient’s core temperature. Treat seizures, as indicated. Avoid shivering as it generates heat and increases the metabolic rate and oxygen demand in the body; administer diazepam, lorazepam, or meperidine, as ordered.

Populations can acclimatize to hot weather, but mortality and morbidity rise when the daytime temperature remains unusually high for several days in a row and nighttime temperatures do not drop significantly. Heat waves result in adverse health effects in cities more often than in rural areas (American Public Health Association, 2005, 1). The elderly people (65 years and older), infants, people with chronic medical conditions, those with a prior heatstroke, and those who are obese, are more prone to heat stress and adverse outcomes. Infants and young children are sensitive to the effects of high temperatures and rely on others to regulate their environments and provide adequate liquids. Air-conditioning is an excellent protective factor against heat-related illness and deaths.

Pediatric injury

Injury is the leading cause of death in children. The injured infant or child present unique challenges in assessment and management, depending on the age, they may not be able to report what is bothering them. Anatomic and physiologic differences also exist between the bodies of infants and children and adults.

Special differences between adults and children when injured include (Andrén-Sandberg, 1993):

• Smaller size often gives multiple injuries.
• Less ability to absorb a blow to the skin or subcutaneous tissue.
• Softer skeleton (can give underlying injury without fracture).
• Higher heat loss.
• Higher frequency of paralytic ileus.
• First appearance of symptoms due to congenital defects (for example, cardiac failure).
• Other psychological conditions.

In general, the injured child is frightened, by pain, discomfort, the presence of strangers, the possibility of separation from parents or caretakers, and an atmosphere of panic or distress. It is important to be aware of all these fears; and to be calm, patient, and gentle. Smaller sizes of emergency equipment are also required, such as airways and catheters.

A child’s heart is generally healthy and strong, unless he or she was born with a congenital heart defect. Because of the lower blood volume and smaller size of a child, an injury can cause shock and hypotension easier and also reduce the margin of error when fluids and medications are administered. The heart rate decreases as the child grows older, and the blood pressure generally increases as the child grows older.

Because the nostrils are narrower, nasal airways are not usually appropriate for a child. It is more difficult to intubate children tracheally than adults. The respiratory rate is higher in the younger children. The chest wall of children is compliant and quite flexible; but the organs and structure protected by the rib cage are also more vulnerable. The lungs are still immature the first three months of their lives.

Children have an elevated basal metabolic rate, and thus higher oxygen requirements. The kidneys have less ability to correct serious disturbances in the water and electrolyte balance. The thermoregulatory mechanisms in infants and children are not so well developed yet and they are prone to hypothermia. With the large surface-to-mass ratio, children are less able to maintain their body temperature.

A large percentage of pediatric injuries result from motor vehicle accidents in which the child is a pedestrian, bicyclist, or passenger. Head injury is the most common type of trauma. Falls, especially from high-rise buildings, are also a common cause of injury in infants and children. Blunt trauma is most common. Penetrating injuries are usually due to assault (gunshot wounds) or accidents (impalement). Children are particularly vulnerable to die from injuries or suffer disabling injuries. Many deaths are due to an obstructed airway, blood loss, or central nervous system injury.

Assessment of injuries in infants and children

Follow the standard ABC plan, and evaluate the airway, breathing, and circulation. Take in the scene and continue to gather information while assessing the injured infant and child. Assessment may be hampered because the victim may be unable to communicate with you, and parents and caretakers may be injured, or lose control of their own stress at seeing the infant or child injured. Try to obtain information from the parent or bystanders, if possible. Knowledge about the nature of the injury, the patient’s age and any preexisting medical conditions will be helpful.

Signs and symptoms of injury to look for include the following:

• Newborn may make grunting sounds on expiration. In infants sternal retraction occurs with only a slight increase in respiratory effort; the result of the pliability of their chest wall. Flaring of the nostrils may be another sign of respiratory distress.
• In children, a scalp laceration may be sufficiently profuse to cause hypovolemic shock, because they have lower blood volume than adults.
• Any loss of consciousness can be serious, and the patient should be transported to a medical facility immediately.
• Any obvious injuries such as abrasions, lacerations, avulsions, contusions, deformities, fractures, and burns should be evaluated by a pediatrician.

Glasgow Coma Scale (GCS) for children is the same as for adults except that verbal response has been modified:

Best verbal Response (5)
Oriented 5 - respond adequately, provide social smiles, fixes and follows with his/her eyes
Confused 4 - crying, but can be consoled
Inappropriate words 3 - constantly irritated
Incomprehensible sounds 2 - anxious, agitated
No verbal response 1 - does not react at all when spoken to.

Common injuries in infants and children

Children are most frequently injured in the summer months, often in a motor vehicle accident. Multiple injuries in children are common when a car in a motor vehicle accident strikes a child. Waddell’s triad; fracture of the femur coupled with blunt injury to the spleen and head; is a classic set of injuries in this situation. Because the head is disproportionately large in a child, skull fractures and head injuries are common. Blunt injury from a motor vehicle accident or a blow to the abdomen can cause compression and subsequent rupture of the internal organs; the liver and spleen are most vulnerable, and kidneys. The ribs and chest wall are more flexible in children, but a blunt chest injury may cause a pneumothorax or flail chest. Chest injuries by blunt-force impact are a common cause of death in children subjected to an explosive blast.

Disability and deformity can result from improper management of fractures, and a pediatric orthopedic surgeon should examine any suspected fracture or fracture. Burns in infants and small children (especially under the age of 5) pose a special problem because the surface area in children is much larger in proportion to the total body mass than in adults. Potential fluid loss through extensive burns can be massive. Scald injuries are more common in children, from hot drinks or hot bath water. An immersion scald is created when an extremity is held under the surface of hot water, and is a common form of burn seen in child abuse. Burns in an infant or a child can be serious and should be evaluated by a physician.

Management of injuries in infants and children

The primary goals are to preserve the injured infants and children’s lives and transfer them to a pediatric trauma facility for the best possible outcomes; and to provide emotional support for the parents or caretakers. In general, time is not spent at the scene to intubate or securing intravenous access, unless it is deemed essential. Your interventions should be within the scope of your professional license, skills and training, and when performed in a health care setting, adherent to the facility’s standard of practice. Assess and reassess the patient regularly.

• Ensure airway, breathing, and circulation. Administer oxygen.
• Use the car seat of a child for transportation, if possible, and immobilize the child’s head by taping it to the seat; in case the cervical spine is injured.
• Do not move a child who has fallen from a structure unless it is necessary. Stay with the child and call for assistance. Apply pressure to sites of bleeding as indicated; administer oxygen.
• Bradycardia is a warning sign of serious hypoxia, and immediate intervention is required to prevent imminent brain damage and death. A child cannot respond if circulation and perfusion of the brain is inadequate.
• When you encounter a seriously burned infant try to start an IV if possible; otherwise wrap the baby in a moist, sterile sheet and enough blankets to keep the baby warm, and transport rapidly to the hospital.
• Guard against hypothermia by covering the infant or child and protect against heat loss.
• Improper management of fractures in a growing child can lead to permanent deformity and disability.
• Intraosseous infusion by boring a sturdy needle through the skin and into the bone marrow to administer fluids, medications, and blood may be used, when securing intravenous access is difficult.
• Transport the patients to a pediatric facility whenever possible.
• Do not allow the patient to eat or drink until a pediatrician sees him or her.
• Secure tubes and lines adequately; in case the infant or child becomes restless and agitated, and will pull them out. Control the endotracheal tube for proper position in trachea.
• Keep pediatric emergency equipment available if your work in an emergency department.
• Transport any child with blunt abdominal injury to the hospital immediately, as shock may ensue. Fluid resuscitation may be necessary; pediatric pneumatic antishock trousers may be used. Determine the patient’s weight. Monitor intake and output meticulously. Use an intravenous fluid pump or a volume chamber to prevent fluid overload.
• Be calm, patient, and gentle. Do not tell the child that something will not hurt if it will hurt. Try not to separate the child from his parents, even if they are injured. The manner in which one approach the injured child depends on the child’s age. Where possible, let parents hold and comfort the infant and small children. Do not overlook the needs of the parent at the time of the injury.
• Identify yourself, and explain that you are there to help. Tell the child what you are going to do. Pain, fright, discomfort, and hypoxia can prevent an injured child from cooperating with you. Allow open expression of feelings in a nonjudgmental atmosphere. Offer explanations and reassurances to the patient and his guardians as you work, and tell them that everything possible is being done.
• Acknowledge the child’s fear. Get down on the child’s eye level when possible so you will be perceived as less threatening. Allow the child to take a favorite toy or blanket to the hospital and encourage parents or caretakers to be with the child as much as possible.

Postoperative care and intensive care

First aid and assessment of the injured at the scene and transportation with advanced life support (resuscitation); ABCDEs and interventions in the emergency department (assessment); and continued interventions and treatments in the operating room or the intensive care unit (further care); planning, education, evaluation, and research are integrated parts of disaster management.

In a mass casualty situation or disasters should an effectively managed zon for postoperative recovery be prepared as soon as possible. Only the patients who need ventilatory support or intensive care/monitoring of other reasons can stay for postoperative intensive care.

Intensive care, constant complex care is provided in various life-threatening conditions such as multiple injuries, severe burns, myocardial infarction or after certain kinds of surgery, by specially trained staff to give critical care as needed. Care is most frequently given in an intensive care unit (ICU) equipped with various highly technical and sophisticated machines and devices for treating and monitoring the condition of the patient. A large care facility usually has separate units specially designed for the intensive (critical) care of adults, children or newborns or for other groups of patients requiring close monitoring, intensive care and certain kind of treatment.

Monitoring

The patient is continuously monitored; airway, breathing, and circulation, consciousness, vital signs, intake and output, arterial blood gases, water- and electrolyte balance, etc. Electrocardiogram is monitored in any patient who has thoracic injury. Nursing care includes monitoring the patient’s condition and vital signs, offering explanations to the conscious patient, keeping the patient warm, and ensuring the flow of oxygen and intravenous fluids.

Airway and breathing

The risk for postoperative complications is common. A trauma patient who is unconscious should have the airway secured by an endotrachel tube as soon as possible. Common indications are head injury (Glasgow Coma Scale 9, or less), airway obstruction, shock, chest injury with hypoventilation, cardiac arrest, or combative patient requiring sedation. Severe head and maxillofacial injury may make it impossible to secure the airway via the mouth or nose. Tracheostomy and cricothyroidotomy are alternative surgical airways.

A complication that may increase at multiple casualties, disasters is noncardiogenic pulmonary edema, and it causes acute respiratory distress (Adult Respiratory Distress Syndrome, ARDS). ARDS result from increased permeability of the alveolar capillary membrane; fluid accumulates in the lung interstitium, alveolar spaces, and small airways, impaired gas exchange, and ventilation perfusion abnormalities, causing the lung to stiffen (clinical symptoms of the process seen after 12-48 hours). Effective ventilation is impaired, prohibiting adequate oxygenation of pulmonary capillary blood (decreased lung compliance and expansion). ARDS can be caused by an acute lung injury; this injury may be direct (as in a stab wound, a pulmonary contusion from chest injury, cardiac surgery, or mistake in surgical procedure; or indirect (as in shock, sepsis, hypothermia, near drowning or multiple fractures). The impaired gas exchange caused by ARDS causes problems in all mayor body systems, and prophylactic treatment and monitoring is required.

Signs and symptoms of ARDS:

• Tachycardia, normal blood pressure, tachypnea, or dyspnea, cyanosis.
• Crackles, wheezes, gurgles (decreased breath sounds possible), thin frothy sputum.
• Restlessness, agitation or confusion.
• Use of accessory muscles, but no jugular vein distension.
• Increased PaCO2, pulmonary hypotension.

Prophylactic measures are effective ventilation and adequate shock treatment of all severely traumatized patients. Intensive monitoring with repeated control of arterial blood gases and platelets is essential. The patients with ARDS usually require mechanical ventilation, with positive end-expiratory pressure (PEEP). Treatment includes establishing an airway, administer oxygen, improving the underlying condition (immobilization of fractures and extremity injuries), removing the cause, suctioning the respiratory passages as necessary and reducing oxygen consumption. When ventilation cannot be maintained, mechanical ventilation is necessary. Supportive PEEP (at the lowest effective level) is widely used in the treatment of ARDS. The patient with ARDS requires constant and meticulous care, reassurance, and ventilation is carefully monitored using arterial blood gases and pulse oximetry.

Circulation

The planning of continued intravenous fluid administration to postoperative patients and/or severely injured patients is based on the following requirements (Lennquist, 2002):

• Compensation of blood loss.
• Volume and electrolyte replacement according to the metabolic need.

In hypovolemic shock, the therapy is to replace volume. Initially, lactated Ringer’s solution or normal saline solution is usually started to expand blood volume. These isotonic crystalloids are readily available to increase preload (improve CO and tissue perfusion) until the patient’s blood can be typed and cross-matched. The only fluid that replaces lost blood cells is blood itself, a colloid. In life-threatening situations, unmatched type O, Rh-specific blood should be given after 2 to 3 liters of lactated Ringer’s solution until cross-matched blood is available. A blood warming coil is used for the warming of blood before massive transfusions, such as those often required for patients who experience extensive abdominal hemorrhage. Administration of cold blood in such transfusions may cause the patient to go in to a state of shock. Massive replacement may cause hyperkalemia, thrombocytopenia, ammonia, and citrate toxicity. Sometimes autotransfusion may be used.

The first 24 hours after the injury the daily need of water and electrolytes; the extra renal losses of water from surfaces of wounds, hyperventilation and losses in connection with surgical procedures; as well as the fluid shifts from extracellular to intracellular vascular space in connection with severe shock, should be considered. Careful control of the patient’s circulation, kidney function, and reaction to all volume replacement is essential. After 2-3 days calories and essential nutrients are needed; parenteral nutrition or enteral nutrition.

Compartment syndrome is a pathologic condition caused by a progressive development of arterial compression and reduction of blood supply; an increase in pressure within a facial compartment. This leads to tissue death from lack of oxygenation. It develops most often with blunt trauma or crush injuries (such as earth quakes). Compartment syndrome most often involves the forearm and lower leg. Acute compartment syndrome is a medical emergency requiring immediate surgical treatment, known as fasciotomy to allow the pressure to return to normal (Salcido, & Lepre, 2007). Otherwise, loss of the extremity may occur because vascular compression causes tissue necrosis.

Disseminated intravascular coagulation (DIC), is a grave coagulopathy resulting from the overstimulation of clotting and anticlotting processes in response to disease and injury, such as septicemia, acute hypotension, poisonous snakebites, obstetric emergencies, severe injuries, extensive surgery, and hemorrhage. The major problem is uncontrolled bleeding caused by a lack of available clotting factors to repair large vascular damage; most of the clotting factors are active in the microcirculation. It may participate in the development of multiple organ failure, which may lead to death.

Extracorporeal membrane oxygenation (ECMO), is a device that oxygenates the blood of a patient outside the body and returns the blood to the patient’s circulatory system. An ECMO machine is similar to a heart-lung machine, and may be used to support an impaired respiratory system, such as in acute respiratory failure secondary to infection with H1N1 influenza virus, diseased lungs, drowning accidents, and sepsis. In veno-arterial (VA) ECMO, this blood is returned to the arterial system and in veno-venous (VV) ECMO the blood is returned to the venous system. Management of the ECMO circuit is done by a team of ECMO specialists.

A study showed that severe traumatic brain injury was independently associated with a failure to return to work or school after surgical ICU admission. Patient age, initial injury severity score, and the number of days receiving mechanical ventilation failed to alter this outcome. Another study suggests that ICU admissions for vascular surgery and trauma are particularly associated with worse long-term quality of life outcomes (Barclay, & Vega, 2011).