Emergent Management of Trauma, 3rd Edition

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EMERGENT
MANAGEMENT OF
TRAUMA
Third Edition

John Bailitz, MD
Chair, Resuscitation Committee
Department of Emergency Medicine
Stroger Hospital of Cook County
Assistant Professor, Department of Emergency Medicine
Rush Medical College
Chicago, Illinois

Faran Bokhari, MD, FACS, FCCP

Chair, Prehospital Care and Resuscitation
Department of Trauma, Burns, and Critical Care
Stroger Hospital of Cook County
Associate Professor of Surgery, Rush Medical College
Chicago, Illinois

Tom Scaletta, MD, FAAEM

Chairperson, Department of Emergency Medicine
Edward Hospital
Naperville, Illinois

Jeffrey Scheider, MD
Chairman, Department of Emergency Medicine
Cook County Health and Hospital Systems
Associate Professor, Department of Emergency Medicine
Rush Medical College
Chicago, Illinois

• Medical
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 Contents
Preface xili
Acknowledgment XV

PART I :RESUSCITATION CONCEPTS

1 Prehospital Issues 3
Trauma Center Considerations 3
Death Pronouncement 7
Restraint Devices 8
Ballistics 8
Stabilization 11
Disasters 13
Hospital Notification 15

l Hospital Organization 17
Emergency Departments 17
Team Members 18
Preparation 20

3 Patient Evaluation 23
Primary Survey 23
Airway and Cervical Spine Control 23
Breathing 24
Circulation and Hemorrhage Control 25
Disability (Neurologic) 26
Expose (Undress) and Environment (Temperature Control) 27
Resuscitation Phase 28
Adjuncts to Consider 28
Rapid History 29
Secondary Survey 29
Laboratory Utilization 31
Radiograph Utilization 32
Reassessment 34
Disposition 35

4 Airway Management 37
Intubation Indications 37
Orotracheal Intubation 37
Rapid Sequence Induction 39
Sedative-Only Intubation 44
Nasotracheal Intubation 45
Alternative Techniques 45
Surgical Airways 47
Special Situations 49

-v-
Contents

5 Shock 55
Hemorrhagic 55
6 Fluids 61
Resuscitation Goals 61
Crystalloid 61
Other Adjuncts 62
Blood Products 63
Transfusion Risks 65

PART II :ANATOMIC AREAS OF INJURY

7 Head 71
Severity Detennination 71
Increased ICP 72
Diagnostics 74
Skull Fracture 15
Intracranial Injury 77
Disposition Considerations 80

8 Eye 81
Evaluation 81
Test Ordering 83
MRI 84
Specific Injuries 84

9 Face 97
Nasal Fracture 97
Maxillary Fracture 99
Zygomatic Fracture 102
Orbital Floor Fracture 103
Mandibular Fracture 106
Temporomandibular Dislocation 107
Parotid Duct/Facial Nerve Injuries 108
Tooth Injury 109

10 Spine 113
General Principles 113
Hyperflexion Injury 113
Hyperextension Injury 116
Hyperflexion-Rotation Injury 118
Vertical Compression Injury 119
Extension-Rotation Injury 120
Flexion-Rotation Injury 120
Direct Force Injury 121
Dislocation 121
Radiography 122
Spinal Cord Injury 125

-vi-
 Contents

11 Neck 133
Penetrating Trauma 133

1l Chest: Blunt 143

Rib Fracture 143
Flail Chest 145
Sternal Fracture 146
Scapular Fracture 147
Puhnonary Contusion 148
Pneumothorax 149
Tension Pneumothorax 150
Hemothorax 152
Traumatic Aortic Rupture (TAR) 153
Blunt Cardiac Injury (BCI) 158
Myocardial Rupture 160
Tracheobronchial Disruption 160
Esophageal Rupture 161
Diaphragm Rupture 163
Traumatic Asphyxia 163

13 Chest: Penetrating 165

Central 167
Peripheral 169
Cardiac Tamponade 170
Communicating (Open) Pneumothorax 172
Air Embolism 173
Esophageal Penetration 173

14 Abdomen: Blunt 177

Physical Examination 177
Diagnostic Strategy 178
FAST Examination 180
Laparoscopy 187
Laparotomy Indications 187
Nonoperative Injury Management 187

15 Abdomen: Penetrating 191

Gunshot 196

16 Pelvis 201
Fracture Classification 202
Radiography 208
Hemorrhage Control 209
Concurrent Injuries 211

17 Genitourinary 215
Urethra 215
Bladder 218
Ureter 220
-vii-
Contents

Kidney 221
Reproductive Organs 226

PART m: EXTREMITY TRAUMA

18 Soft Tissue 229

Penetrating 229
Blunt 230
Amputations 232

19 Hand 235
Phalanx Fracture 235
Dislocation 239
Metacarpal Fracture 240
Head 243

20 Wrist 247
Scaphoid Fracture 247
Triquetrum Fracture 248
Lunate Fracture 249
Lunate Dislocation 250
Perilunate Dislocation 250
Scapholunate Dislocation 251
Radiocarpal Dislocation 252
Capitate Fracture 252
Hamate Fracture 253
Trapezium Fracture 254
Pisiform Fracture 254

21 Forearm 255
Distal Fractures 255
Radius Shaft Fracture 258
Ulna Shaft Fracture 261
Combined Radius/Ulna Fractures 262

22 Elbow 265
Olecranon Fracture 265
Radial Head Fracture 266
Supracondylar Fracture 267
Condylar Fracture 268
Lateral Condylar Fractures 269
Medial Condylar Fracture 269
Intercondylar Fractures 270
Elbow Dislocation 271
Anterior 272

-viii-
 Contents

23 Humerus 273
Shaft Fracture 273
Head/Neck Fracture 274

24 Shoulder and Clavicle 277

Scapular Fracture 277
Shoulder Dislocation 277
Oavicle Fracture 282
Acromioclavicular Injucy 284
Sternoclavicular Dislocation 288

25 ffipandFemur 291
Hip Dislocation 291
Posterior Dislocation 291
Anterior Dislocation 292
Hip Fracture 293
Femoral Head 293
Femoral Neck 293
Intertrochanteric 294
Subtrochanteric 296

26 Knee 299
Ottawa Knee Rules 299
Distal Femur Fracture 299
Patellar Fracture 301
Knee Dislocation 302
Patellar Dislocation 303
Knee Strain 303
Proximal Tibia Fracture 305

27 Leg and Ankle 309

Tibial Shaft Fracture 309
Fibular Shaft Fracture 310
Ankle Anatomy 310
Ankle Sprain 311
Malleolar Fracture 312
Maisoneuve Fracture 313
Pilon Fracture 313
Plafond Fracture 313
Tillaux Fracture 313
Ankle Dislocation 314

28 Foot 315
Ottawa Foot Rules 315
Talus Fracture 315
Calcaneus Fracture 316

-lx-
Contents

Navicular Fracture 319

Cuboid Fracture 320
Cuneiform Fracture 320
Lisfranc's Injury 321
Metatarsal Fracture 322
Phalange Fracture 323
Sesamoid Fracture 324

PART IV :SPECIAL GROUPS

29 Cbildren 327
Tube Sizes 332
Vascular Access 333
Fluids 333

30 Pregnancy 337
Key Differences 337
Fetal Heart Tones 338
Maternal Physiology (Third Trimester) 338
Placental Abruption 34()
Other Obstetrical Complications 342
Considerations by Mechanism 343
Radiographic Considerations 344
Postmortem Cesarean Section 344

31 Elderly 347
Key Differences 347
Injury Mechanisms 349

PART V: ENVIRONMENTAL ISSUES

32 Bums 353
Thermal 353
Electrical 357
Chemical 359
Inhalation Injury and Toxins 360

33 Near Drowning 361

Epidemiology 361
Pathophysiology 361
Clinical Findings 362
Management 362
Prognosis 363
Disposition 363

34 Temperature Extremes 365

Pathophysiology 365

-x-
 Contents

Hyperthennia 366
Hypothennia 368
35 Terrorism Preparation 375
Agent'fYpes 375
Identification 376
Management 377

36 Nuclear 379
Radiation Physics 379
Exposure 'fYpes 380
Acute Radiation Syndrome 381
Treatment 383

37 Biologics 385
Bacterial Agents 385
Vrral Agents 387
Toxins 388

38 Chemicals 391
Choking Agents 391
Blister Agents 391
Neurotoxins 392

PART VI: USEFUL RESOURCES

39 Procedures 397
Airway 397
Needle Thoracostomy 423
Thbe Thoracostomy 424
Pericardiocentesis 427
Thoracotomy 428
Diagnostic Peritoneal Lavage 430
BUlTHoles 432
Laceration Repair 434
Nerve Blocks 438
Compartment Pressure Measurement 445
Splinting Techniques 445

40 Radiograph Interpretation 451

Cervical Spine 451
Thoracic Spine 456
Lumbar Spine 458
Chest 459
Pelvis 460
Face 462
Hand 466
Elbow 469

-xl-
Contents

Knee 472
Ankle 474
Foot 475

41 Radiographic Anatomy 477

Angiography 477
Computer Tomography (CT) 485

42 Organ Procurement 493

Considerations 493
Brain Death 494

43 Infection Prophylaxis 495

Tetanus 495
Rabies 496
Antibiotic Use 497
Penetrating Injuries 498

44 Aftercare Instrnctions 501

English 502
Espaiiol 503

45 Drug Formulary 505

Pregnancy Categories 505
Abbreviations 506
Drugs 507
Appendix 45-1, Major Drug Categories 564

Bibliography 567

Index 569

-xii-
 PREFACE
Emergent Management ofTrauma aims to be an effective handbook on
trauma evaluation and management covering the breadth of injuries. The book
incorporates a crisp outline approach, abundant illustrations, and careful or-
ganization. Consequently, it has become a useful tool amidst the chaos of busy
emergency departments. We hope that all trauma care practitioners-attending
and resident physiciarui, medical students, midlevel providers, nurses, and
paramedics-find it indispensable.
The book is divided into six major sections:
~ Resuscitation concepts
~ Comprises prehospital issues, hospital organization, patient evaluation,
and "ABC" interventions
~ Anatomic areas of injury
~ Includes important management algorithms and covers major traumatic
injuries literally from top to bottom
~ Extremity trauma
~ Oriented from hand to shoulder and then from hip to foot
~ Special groups
~ Focuses on trauma in children, pregnancy, and the elderly
~ Environmental issues
~ Covers temperature extremes as well as weapons of mass destruction
~ Useful resources
~ Concludes with detailed procedure instructions, radiograph interpretation
pearls, and a pertinent drug formulary
As with previous editions, mainstream concepts are presented devoid of
institutional biases. When management options exist, each reasonable
pathway is described. Throughout the book, consistency of style and depth
provide the reader with easy and reliable access to the vast array of informa-
tion needed to manage trauma patients from head to toe and start to finish.
Trauma strikes unexpectedly, frequently, and with preference for the young
and healthy. This book is dedicated to all trauma care practitioners and the
patients that benefit from their expertise and commitment.
John Bailitz, Faran Bokhari,
Tom Scaletta, and Jeffrey Schaider

-XIII-
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 ACKNOWLEDGMENT
We would like to thank Joanne Witsil, PbannD, for reviewing the drug
fOimul.acy.

-XV-
 Part I

RESUSCITATION
CONCEPTS
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