9

Trauma
H. Scott Bjerke, Felix Lui, Areti Tillou, and Frederick A. Luchette

OVERVIEW AND EPIDEMIOLOGY

Unintentional injury remains the leading cause of death in the United States for individuals aged 1 to 44 years
and is the third cause of mortality after the first year of life. In 2016, 38,000 occupants of a vehicle died as the
result of a collision; deaths from firearms totaled an additional 38,000. It is estimated that there are over 30
million nonfatal injuries annually in America. As a result of improvements in care, these fatality rates are less
than in the past. Some of the advances that have allowed for reduced morbidity and mortality rates include
computed tomography (CT) and magnetic resonance imaging (MRI), minimally invasive surgical and
interventional techniques, abbreviated operations, and regionalization of trauma care.

INITIAL ASSESSMENT

The Advanced Trauma Life Support (ATLS) course teaches the gold standard for providing the initial care of
injured patients. It offers an invaluable framework for prioritizing the management of the patient focusing on
(1) primary survey, (2) resuscitation, (3) secondary survey, and (4) definitive care.

Primary Survey

The primary survey is focused on identification and immediate treatment of life-threatening injuries while
initiating resuscitation. It is described by the acronym ABCDE. The Airway is assessed for patency and
stability. Next, Breathing and Circulation are examined. Disability is determined by overall assessment of the
neurologic status. Finally, Exposure is a complete examination of the entire skin for less obvious injury and/or
hemorrhage. Injuries identified at each step are treated before moving on to the next.

Airway
If a patient lacks a patent airway, respiratory gas exchange cannot occur and death becomes imminent. Airway
patency can be simply assessed by asking the patient to speak. Normal voice and speech indicate patent airway
and intact cognition. Stridor, hoarseness, and pain when speaking as well as cyanosis, agitation, and tachypnea
are signs of possible airway injury. Complex facial fractures, massive tissue disruption above the nipples,
oropharyngeal swelling, and blood in the oropharynx may quickly obstruct the airway and should prompt
intervention to stabilize the airway.

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 Tipping the chin upward (chin lift) or pulling the mandible anteriorly (jaw thrust) while maintaining c-
spine immobilization are two simple maneuvers that may reopen the airway and assure oxygenation and
ventilation. In the obtunded patient, the tongue will partially or completely obstruct the glottis and insertion
of a nasal or oral airway will promptly reestablish a patent airway. Nasopharyngeal devices are better tolerated
in the conscious patient but should not be used in the presence of midface injuries. The most definitive way to
secure the airway is with endotracheal intubation. This procedure requires skill and experience and involves
passing a tube with an inflatable cuff through the mouth and vocal cords into the trachea.
If the glottis cannot be intubated via the oral route, a surgical airway must be performed. This can be
achieved by placing a cricothyroidotomy or large-bore needle. Figure 9-1 illustrates the incision used for an
open cricothyroidotomy. Once the cricothyroid membrane is opened, a 6-French or smaller endotracheal tube
is placed directly into the trachea. The needle cricothyroidotomy is quicker to perform than the open
approach. A large-bore (16 to 18 gauge) intravenous catheter is passed directly through the cricothyroid
membrane.

Figure 9-1 Open cricothyroidotomy. A, A 2-cm transverse incision is made through the skin, subcutaneous
tissues, and cricothyroid membrane. B, After the cricothyroid membrane is incised, the handle of the scalpel is
inserted and rotated 90° to facilitate insertion of a size 6 cuffed endotracheal tube.

Breathing

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Breathing is assessed by inspecting the chest for symmetric movement and auscultating for breath sounds.
Cyanosis and poor oxygen saturation despite the presence of an airway may indicate poor ventilation. A
tension pneumothorax results from a lung injury. Air from the lung enters the pleural space, and the
intrapleural pressure increases with each respiration. As the pressure rises, the mediastinal structures shift to
the contralateral side and impede venous blood return to the heart. This results in a decrease in cardiac output
and shock. The diagnosis of a tension pneumothorax is made on physical examination. The triad of absent
breath sounds, shock, and muffled heart sounds confirm the diagnosis. Immediate treatment is directed at
decompressing the intrapleural hypertension. This is accomplished by either placing a large-bore angiocath
into the second intercostal space at the midclavicular line or inserting a chest tube at the anterior axillary line
in the fourth or fifth intercostal space.

Circulation
The evaluation of the circulation focuses on prompt recognition and reversal of shock through intervention
and resuscitation. Shock is defined as inadequate tissue perfusion resulting in anaerobic metabolism, and
prolonged tissue hypoxia causes organ dysfunction, irreversible tissue damage, and eventually death.
Tachycardia, tachypnea, hypotension, mental status change, agitation, anxiety, and oliguria are common signs
and symptoms of shock. Additional signs include cool, clammy, or cyanotic skin, and diminished peripheral
pulses.
The most common cause of shock after injury is hemorrhage. Treatment involves restoration of circulating
blood volume, initially with an isotonic crystalloid solution such as lactated Ringer’s normal saline or
plasmalyte. In severe shock, transfusion of blood products in a 1:1:1 ratio including packed red blood cells,
plasma, and platelets (massive transfusion protocol) should be initiated. The severity of hemorrhagic shock is
classified according to the percentage of circulating blood volume loss (Table 9-1). Although most external
bleeding from traumatic wounds can be controlled temporarily with direct pressure or a tourniquet,
intrathoracic or intra-abdominal hemorrhage may require more invasive measures such as tube thoracostomy,
surgical intervention, or angiography with embolization. Other less common causes of shock include
cardiogenic (tension pneumothorax and cardiac tamponade), obstructive, and neurogenic (spinal cord injury).

TABLE 9-1 Classification of Hemorrhage

Class I Class II Class III Class IV

Blood loss (mL) 70-kg <750 750–1,500 1,500–2,000 >2,000

Blood volume loss (%) <15 15–30 30–40 >40

Heart rate (beats/min) <100 >100 >120 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure Normal Decreased Decreased Decreased

Respiratory rate 14–20 20–30 30–40 >35

Urine output (mL/hr) >30 20–30 5–15 Negligible

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Capillary refill(s) Normal >2 >2 >2

Mental status Slight anxiety Mild anxiety Anxious/confused Confused/lethargic

Fluid management Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood

Disability
A quick assessment of neurologic function provides a measure of disability. The Glasgow Coma Scale (GCS)
score, based on the patient’s best verbal, motor, and eye-opening response, is calculated and can help guide
subsequent evaluation and treatment (Table 9-2).

TABLE 9-2 Glasgow Coma Scale

Assessment Area Score

Eye Opening (E)

Spontaneous 4

To speech 3

To pain 2

None 1

Motor Response (M)

Obeys commands 6

Localizes pain 5

Withdraws to pain 4

Decorticate posturing (abnormal flexion) 3

Decerebrate posturing (abnormal extension) 2

None (flaccid) 1

Verbal Response (V)

Oriented 5

Confused conversation 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

GCS score = E + M + V; best = 15, worst = 3.

Exposure
The last step in the primary survey is removal of all clothing to allow a complete head-to-toe examination for
injury or bleeding. Removing wet and contaminated clothing is also important to prevent hypothermia and
toxicity. Once completed, the patient should be covered with warm linens and/or heating devices to prevent
hypothermia, which will exacerbate coagulopathy and worsen acidosis.

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Secondary Survey

The purpose of the secondary survey is to identify and treat additional injuries not recognized during the
primary survey; it includes a comprehensive physical examination, and where possible, a medical history
including allergies, last meal, tetanus immunization status, and medications.
A nasogastric tube (NG) should be placed to relieve gastric distension. The tube should not be placed
when there is a basilar skull fracture or extensive facial fractures. A urinary catheter is a useful adjunct to
monitor urine output. Blood at the penile meatus or a disruption of the pubic symphysis, which is seen with
an open book pelvic fracture, are signs of urethral transection. If present, retrograde urethrography (RUG)
should be performed to assess the integrity of the urethra. In the event of a urethral disruption, suprapubic
catheterization should be performed.

Adjunctive Studies and Definitive Care

The results of the primary and secondary surveys determine the need for further diagnostic studies.
Radiographs of the chest, cervical spine, and pelvis during the secondary survey assist with the identification
of potentially life-threatening injuries. Ultrasonography is typically performed as an adjunct to the primary
survey in an effort to detect hemorrhage in the abdomen and pericardium. In the hemodynamically stable
patient, CT scans of various body regions are more sensitive and specific for identification of other injuries.
Subsequent sections of this chapter discuss diagnosis and management of specific injuries.

HEAD INJURY

Head injuries are the leading cause of trauma-related mortality and long-term disability. Although primary
injury to the brain (incurred at the moment of impact) is difficult to treat, propagation of the injury (secondary
injury) can be prevented or limited with proper treatment. Hypotension is the most common cause of
secondary brain injury.

Anatomy and Physiology

Anatomic features contribute to certain patterns of injury to the head. Lacerations are common injuries that
may involve the skin, subcutaneous fat, and galea aponeurotica. Blunt force may also result in a contusion
and/or hematoma of the scalp without violation of the skin. Blood vessels held securely by the subcutaneous
connective tissue cannot retract when severed and result in significant hemorrhage. In addition, muscles
attached to the galea aponeurotica contract in opposite directions, which may hold the wound and vessel
lumen open and increase bleeding.
Within the cranium, the dura mater is a thick, dense fibrous layer that encloses the brain and spinal cord.
It forms the dural venous sinuses, diaphragm sellae, falx cerebri, falx cerebelli, and tentorium cerebelli.
Cerebral venous blood flows into the dural sinuses through bridging veins, which can be torn when blunt
force is applied to the head, resulting in a subdural hemorrhage. The meningeal artery lies between the skull
and the dura. Fractures of the temporal and parietal bones of the cranial vault can lacerate these arteries and
cause an epidural hematoma. The vascular pia directly covers the brain. Injuries to the blood vessels of the pia
as well as the underlying brain can cause subarachnoid hemorrhage or intraparenchymal contusion.

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 The skull and vertebral bodies of the spine function as a rigid, bony case, which contains the spinal cord,
cerebrospinal fluid (CSF), and blood. Increased intracranial pressure (ICP) due to bleeding or edema can alter
the cerebral blood flow (CBF) or compress the brain and adjacent structures. Because the volume within the
skull is fixed, any change in the volume of one of the three tissues may elevate the ICP. When the ICP
exceeds 20 mm Hg, CBF may be reduced and cause ischemia.
Besides ICP, CBF is affected by cerebral vascular resistance (CVR) and cerebral perfusion pressure (CPP).
CPP is the difference between the mean arterial pressure (MAP) and ICP. As flow (Q) = change in pressure
(ΔP)/resistance (r), CBF = CPP/CVR. Under normal circumstances, CBF remains constant over a wide range
of CPP by alterations in vascular resistance known as autoregulation, which is impaired or lost after brain
injury. As ICP rises, the cardiovascular system maintains CPP by increasing the MAP. This early response to
increased ICP is also associated with bradycardia and a decreased respiratory rate, known as the Cushing
reflex. Continued elevation of the ICP will eventually result in herniation and brain death.
The tentorium cerebelli is a stiff and unyielding membrane dividing the hemispheres from the cerebellum.
The brain stem also passes through this tentorium. Any increased pressure within the cranium pushes the
brain past the tentorium and compresses adjacent structures, such as the oculomotor nerve, resulting in dilated
and immobile (fixed) ipsilateral pupil. As the ICP continues to increase, herniation progresses, resulting in the
corticospinal (pyramidal) tract in the cerebral peduncle being compressed. This results in contralateral spastic
weakness and a positive Babinski sign. With further increase in the ICP, the brain stem is compressed against
the tentorium, causing dysfunction of the cardiorespiratory centers in the medulla. The associated
hypertension and bradycardia that follow usually signal impending brain herniation.

Clinical Evaluation

Assessment of the neurologic system begins during the primary survey and includes pertinent injury details
such as loss of consciousness, seizure activity, postinjury alertness, and extremity motor function. A complete
neurologic examination focuses on the level of consciousness, pupillary function, sensation, and presence of
lateralizing extremity weakness. The assessment is frequently repeated to detect and document changes. It
should be noted that hypotension in patients with head injury indicates blood loss until proven otherwise and
should not be attributed to the brain injury.
The GCS score is a widely accepted and reproducible method to quantify a patient’s neurologic
examination (see Table 9-1). It assigns scores between 3 (worst possible) and 15 (normal) for eye opening (E),
verbal response (V), and motor response (M). The score quantitates the severity of the head injury and can be
sued as a prognostic indicator of outcome. Scores of 3 or 4 are associated with combined mortality or
vegetative state nearing 97%. Mortality rates approach 65% with a score of 5 or 6 and 28% with a score of 7 or
8. Multiple factors unrelated to the head injury may also affect the GCS score, such as sedatives, shock,
alcohol consumption, and recreational drug use.
Other signs of a head injury are identified during the secondary survey. Scalp lacerations may be obvious
but may also be hidden in the hair. Bony step-offs, indicative of a skull fracture, may be palpated. Periorbital
ecchymoses (raccoon eyes), perimastoid ecchymosis (Battle’s sign), hemotympanum, and leakage of CSF from
the nose (rhinorrhea) or ear (otorrhea) are all signs of a basilar skull fracture.
Intracranial injury is diagnosed by obtaining a noncontrast CT (Figures 9-2 to 9-4). This imaging

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modality allows localization of both extra-axial hemorrhage, brain swelling, midline shift, hydrocephalus, and
skull fractures. Although recognizing a skull fracture is important, diagnosing the underlying brain injury is
more consequential. Brain injuries can occur with or without skull fractures and vice versa. A concomitant
injury to the cervical spine occurs in as many as 15% of patients with a head injury. Thus, imaging of the
cervical spine should be done at the time of CT scan of the brain.

Figure 9-2 Epidural hematoma. A convex or lens-shaped (arrow) collection of blood is typical.

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Figure 9-3 Acute subdural hemorrhage. High-density blood is present in a crescentic or concave shape (arrows)
along the right cerebral hemisphere.

Figure 9-4 Traumatic subarachnoid hemorrhage with intraparenchymal cerebral contusions. Multiple foci of

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acute hemorrhage (arrows) are noted within the left cerebral hemisphere.

Management of Head Injuries

Management of head injuries should focus on minimizing increases in the ICP, which may also result in
secondary brain injury.
A ventricular catheter placed into the lateral ventricle of the brain through a burr hole allows continuous
ICP monitoring as well as drainage of CSF to reduce ICP. A pressure monitor can also be placed within the
subarachnoid space when drainage is not desired or when the ventricles cannot be cannulated. Other
monitoring techniques involve placement of a fiberoptic transducer into the epidural space, subdural space, or
lateral ventricle as well as the use of probes that detect tissue oxygen levels in the brain tissue, often in
combination with ICP monitoring.
Additional interventions to limit ICP include maintaining the neck in a neutral position, head elevation,
sedation, hypertonic saline, intravenous fluid limitation, and mannitol. Sedation reduces posturing and
combative behavior as well as the metabolic demand of brain tissue. Moderate hyperventilation to a PaCO2 of
32 to 35 mm Hg transiently lowers ICP without causing cerebral ischemia but is only used when there is an
acute increase in the ICP.
Intravenous fluids are administered judiciously to ensure adequate cardiac output. Mannitol is a free-
radical scavenger and osmotic diuretic that effectively reduces brain swelling and lowers ICP. However, it may
cause hypotension in patients with occult hemorrhage. Hypertonic saline solutions may be administered
intravenously to decrease brain swelling and maintain euvolemia. Patients with a head injury should be closely
observed for seizures and treated appropriately with anticonvulsants and antiepileptic medications when
seizures occur.
Operative management of a traumatic brain injury continues to evolve. Epidural hematomas generally
require surgical evacuation when large or associated with decreasing mental status. Prognosis is very good
when treatment is prompt. Subdural hematomas that cause a significant mass effect also require emergent
evacuation, but prognosis is more guarded and outcome is based on the amount of brain injury to the
underlying parenchyma. Subarachnoid hemorrhage and DAI are typically managed nonoperatively because of
the risk of injuring the underlying brain parenchyma. Prognosis is variable and is dependent on the severity of
injury. Recovery can take months or years.
Finally, even with isolated head injuries, the body as a whole must be supported. Early enteral nutrition is
an important adjunct once the initial resuscitation of a brain-injured patient has concluded. The best possible
outcome from brain injury is achieved with attention to control of ICP while supporting the metabolic
demands of the whole body.

INJURIES OF THE SPINE AND SPINAL CORD

Blunt force trauma to the torso frequently results in injury to the vertebral column and may occur with or
without overt neurologic compromise at the time of initial presentation. Since the cervical spine is the most
frequent site of spinal injury, immobilization with a hard collar is warranted to protect against further injury
until the spine can be evaluated by standard protocols usually including clinical evaluation and radiologic

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imaging. The use of long backboards in the past for thoracic and lumbar spinal “protection” is no longer
practiced because of the high incidence of pressure injury (decubitus ulcer) as a result of prolonged
immobilization on a long backboard.
The internal spinal canal space is wide in the higher spine but has more soft tissue elements packed in its
confines. The canal narrows as it traverses down but the volume of nerve occupying that space decreases as
nerve roots exit, making the lower cervical and highest upper thoracic canal the most likely to have spinal cord
injury even without bony fracture present. The thoracic spinal column is stabilized and buttressed by the ribs,
making it far less mobile and reducing the probability of injury. Approximately 15% of injuries occur at the
thoraco-lumbar junction because of the transition from stabilized, inflexible thoracic spine to the more flexible
lumbar spinal elements. In adults, the spinal cord ends at the level of the first lumbar vertebral body becoming
the cauda equina. The cauda equina is more mobile and has a larger space to occupy in the lumbar vertebral
ring. Thus, it is less likely to be injured with fractures involving the distal lumbar vertebral bodies.
Fracture of a vertebral body may not initially present with neurologic deficits because of intoxication,
altered mental status, or coma with paralysis. A patient may sustain a bony fracture, dislocation, ligamentous
injury, or even spinal cord injury without any radiographic abnormality (SCIWORA). These injuries should
initially be maintained in spine precautions until it is determined that the injury is stable or unstable. Any life-
threatening injuries should be addressed first while the spine is protected from movement. This includes the
use of cervical collar. A moderate or severe head injury eliminates a physical examination of the cervical spine.
Thus, a cervical collar should be maintained until the spine surgeon has determined that it can be removed.
The flexible and relatively exposed cervical spine is usually the most frequent site of injury to the spinal
column after blunt trauma. Fractures of a cervical vertebral body account for approximately 50% of all spinal
injuries. In adults, the most common level of injury is the fifth cervical vertebra. In contrast, the pediatric
(under 8 years) spine is most commonly injured at the second or third cervical vertebral level. Since the
phrenic nerve is composed of fibers originating from the C3 to C5 spinal nerves, it is more common to see
impaired diaphragmatic function in children with a cervical spine injury when compared with adults. Blunt
injury to the spinal column and spinal cord may occur with flexion, extension, rotation, or axial loading.
Shallow-water-diving injuries frequently result in permanent paralysis in young adults because of fractures
from axial loading on the cervical spine. In adults, the proximal spinal cord (C1 to C4) only occupies 50% of
the spinal canal space. It is important to remember that a patient with an unstable injury involving the
proximal cervical spine may not have a cord injury initially until such interventions as intubation when the
spine is not stabilized, allowing the unstable spine injury to be displaced, injury the cord. Symptoms and
clinical findings after a penetrating injury to the bony spine or spinal cord will typically have obvious signs of
an injury. Delayed presentation of neurologic findings is rare after penetrating injury and may be the result of
a contusive force without direct injury to the cord. Patients involved with high-energy blunt force that results
in a cervical fracture may have another noncontiguous fracture of the spinal column. The reported incidence
ranges from 5% to 30%.
Like head injury, spinal nerve injury consists of primary and secondary injury. Primary injury occurs at the
time of traumatic event but secondary injury is a delayed injury occurring as a result of ischemia due to
hypotension and hypoxia. The incidence of primary injury can be decreased by improvements in the design of
seatbelts and airbags as well as injury prevention programs that develop over years. In contrast, secondary

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injury is determined by the level of care provided at the accident scene, during transport and on presentation
at the hospital. The incidence of secondary injury is reduced by timely and appropriate care provided by EMS,
nurses, and physicians early in the care of injured patient. Reduction of unnecessary motion, maintaining
adequate perfusion pressure, and oxygenation are simple first steps to reduce secondary injury during the
prehospital and early phases of care.
Initial evaluation of an injury to the spinal cord is classified as partial or complete. A partial injury may
deteriorate into a complete injury over time. In contrast, a complete injury presenting with no motor or
sensory function below the injury site rarely improves with time unless proper care protocols are initiated and
maintained early. During the secondary survey, the physical examination includes palpation of the entire spine
looking for swelling, a mass, crepitus, tenderness, or deformity. Gross motor and sensory function should be
assessed using light touch or pin prick. In the awake patient, it is recommended that the exam start by
evaluating the nerve roots distal to the obvious level of injury and then move cephalad. Beginning the
examination at the insensate level and moving to the level of sensation allows for a precise diagnosis of the
level of injury. Key sensory dermatome levels include C5 at the deltoid, T4 at the nipple, and T10 at the
umbilicus. If possible, reflexes and motor function should be assessed for strength and symmetry. Extremity
muscle groups are innervated by identifiable spinal segments, making it possible to pinpoint the precise level
of cord injury (Table 9-3).

TABLE 9-3 Segmental Motor Innervation by the Spinal Cord

Motor Function Muscle Groups Spinal Cord Segments

Shoulder extension Deltoid C5

Elbow flexion Biceps brachii, brachialis C5, C6

Wrist extension Extensor carpi radialis longus and brevis C6, C7

Elbow extension Triceps brachii C7, C8

Finger flexion Flexor digitorum profundus and superficialis C8

Finger abduction/adduction Interossei C8, T1

Thigh adduction Adductor longus and brevis L2, L3

Knee extension Quadriceps L3, L4

Ankle dorsiflexion Tibialis anterior L4, L5

First toe extension Extensor hallucis longus L5, S1

Ankle plantar flexion Gastrocnemius, soleus S1, S2

Injuries at the level of C5 and above may also result in phrenic nerve dysfunction manifest by abdominal
breathing, inability to inhale deeply, and progressive respiratory insufficiency. As noted previously, the phrenic
nerve originates in the C3, C4, and C5 nerve roots off the cervical spine. Patients exhibiting this constellation
of respiratory symptoms should be evaluated for early orotracheal intubation during the primary survey.
Injuries to the cervical spine, and occasionally the upper thoracic spine, also disrupt the sympathetic chain,
resulting in neurogenic or spinal shock due to the loss of precapillary sphincter tone. Loss of peripheral

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sympathetic tone from the injury coupled with intact parasympathetic tone result in vasodilation causing
hypotension. The blood volume of a 70-kg adult is 5 L, but with neurogenic shock it can increase to 15 L and
result in hypotension, ischemia, and peripheral organ damage. Initial supportive treatment consists of fluid
resuscitation to increase the blood volume. If signs of ischemia persist, addition of vasopressors to support
perfusion should be considered. Normally hypotension in trauma patients is considered blood loss till proven
otherwise, but proximal spinal cord injuries can result in hypotension in the absence of hemorrhage.
Hypotension without a tachycardic response is often the best sign to differentiate hypotension due to
neurogenic shock from that of hemorrhagic shock. The classic presentation of neurogenic shock includes
tetraplegia, hypotension, bradycardia, and warm extremities. In contrast, the manifestation of hemorrhagic
shock includes pale, cool extremities and tachycardia.
When the initial and subsequent treatment is optimized, an incomplete cord injury has a better prognosis
for partial or complete recovery. Incomplete cord injuries include central cord syndrome, anterior cord
syndrome, and Brown-Sequard syndrome (cord hemi-transection). Central cord syndrome is the most
common presenting with weakness in the upper extremities compared with the lower extremities as a result of
cord injury due to cervical hyperextension in the presence of preexisting canal stenosis. It is more common in
older adults with osteoarthritis that produces stenosis of the cervical spine.
Nerve injury without cervical or thoracic bony fracture may occur but is more often seen in children or the
elderly and is SCIWORA. This is usually a result of ligamentous injury or hyperextension injury resulting in
cord contusion or stretch. Central cord syndrome is an adult variant of SCIWORA. The concept of
SCIWORA was developed before the widespread availability of CT or MRI when plain radiographs of the
spinal column was the standard. Plain films of the spinal column can miss up to 20% of bony injuries,
especially in the lower cervical and upper thoracic regions. Many patients thought initially to have
SCIWORA will have evidence of injury on multibit CT or MRI. CT of the cervical spine is now considered
the “gold standard” for imaging of the spine. Three-dimensional reconstruction of the spinal column also
increases the diagnostic yield and can be done without increasing the original radiation dose.
Assessment of ligamentous injury, spinal cord contusion, epidural hematoma, and herniated discs is
usually performed with MRI. This imaging equipment requires a hemodynamically stable and cooperative
patient. The additional information provided by MRI will add in treatment and management, which improve
overall outcome.
Clearance of the cervical spine can be achieved during the secondary survey but should be delayed in the
unstable patient. Established protocols (Nexus, Canadian C-spine Rule) allow reliable evaluation of the
cervical spine for injury and safely remove the cervical collar without the need for any imaging. These
protocols require an awake patient free of drugs, alcohol, or pain medication who can follow commands and
has no cervical pain or limitation of motion. Any patient who does not meet these criteria must have the neck
remain immobilized until further evaluation can be completed. Any noncompliant patient who demands
removal of a protective collar must be warned of the risks of paralysis as a potential result of removing the
collar.

THORACIC INJURY

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Thoracic trauma accounts for approximately 25% of trauma-related deaths and follows traumatic brain injury
as the second most common cause of death after injury. Life-threatening chest injuries may be fatal if not
promptly diagnosed and treated. They include tension pneumothorax, open pneumothorax, cardiac
tamponade, massive hemothorax, and flail chest. The majority of thoracic injuries can be treated by relatively
simple maneuvers such as establishment of a definitive airway or tube thoracostomy. Thus, only 10% to 15%
of thoracic injuries require formal operative intervention by median sternotomy or thoracotomy. The
principles of ATLS provide a stepwise framework for diagnosing life-threatening injuries and those that
potentially may cause later morbidity and mortality if diagnosis is significantly delayed.

Life-Threatening Injuries Detected during Primary Survey

Tension pneumothorax results when gas builds up under pressure within the pleural cavity. It may occur after
either blunt or penetrating thoracic trauma. Open pneumothorax occurs in the setting of a penetrating injury
to the thorax when the chest wall wound remains patent. This allows air to preferentially enter through the
chest wall defect rather than the trachea, resulting in collapse of the underlying lung. Clinically, the passage of
air through the chest wound results in an audible “sucking” sound. Respiratory failure may occur as the work
of breathing increases because air flow via the wound may prevent generation of adequate negative inspiratory
force to entrain air via the tracheobronchial tree. Open pneumothorax should be promptly treated by placing a
partially occlusive dressing over the thoracic wound and securing it to the skin with tape on three sides. This
creates a one-way valve that allows egress of accumulated pleural gas during exhalation, but prevents inflow
from the atmosphere during inhalation. The result is an improvement in gas exchange. In effect, this
maneuver converts an open pneumothorax into a simple pneumothorax. Once the patient’s condition is
stabilized, a chest tube should be inserted through a separate incision to allow for complete reexpansion of the
lung. Operative surgical debridement and closure of the thoracic wound may be required.
Cardiac tamponade is an immediately life-threatening event that may occur in the setting of penetrating
or blunt precordial injury. The most common scenario is a stab wound left of the sternal border with a
laceration of the right ventricle. Blood escaping from the heart accumulates within the nondistensible
pericardial space, resulting in compromise of right ventricular relaxation during diastole and tamponade. The
clinical picture of muffled heart sounds, jugular venous distension, and hypotension (Beck’s triad) in a patient
with a penetrating wound to the precordium is the classic presentation for cardiac tamponade. Other physical
findings may include Kussmaul’s sign (increasing jugular venous distension with inspiration), and pulsus
paradoxus (drop in systolic blood pressure ≥10 mm Hg during inspiration). However, these findings are quite
variable, and their absence does not preclude the presence of tamponade. Diagnosis is confirmed by
ultrasound, usually bedside focused assessment with sonography in trauma (FAST), which is the diagnostic
test for hemopericardium and tamponade (Figure 9-5). Treatment of tamponade is based on judicious volume
resuscitation to increase cardiac output, and immediate surgical decompression to release the tamponade and
repair the underlying cardiac injury. In patients with cardiac tamponade who deteriorate or experience cardiac
arrest in the resuscitation area, prompt emergency department (ED) resuscitative thoracotomy should be
performed. Pericardiocentesis should only be considered in situations where resuscitative thoracotomy is not
an option because of lack of experienced surgeons or equipment though salvage rates are extremely low using
this temporizing intervention.

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Figure 9-5 Penetrating cardiac injury with hemopericardium visualized on bedside ultrasound. Note the large
amount of blood outside the heart within the pericardial sac.

Massive hemothorax is defined as the loss of 1,500 mL or more of blood into a pleural space during the
first hour after injury, or ongoing thoracic blood loss at least 200 mL/hour of blood over 4 hours. Clinical
diagnosis may be made by the presence of diminished breath sounds and dullness to percussion. These
physical findings may be difficult to determine in a loud emergency room. Chest x-ray may confirm the
presence of hemothorax. Treatment involves tube thoracostomy and volume resuscitation to restore
euvolemia. Thoracotomy for control of hemorrhage is indicated for either of the above criteria.
Autotransfusion of shed blood may be a useful adjunct to decrease utilization of banked blood products. The
source of bleeding is most frequently intercostal vessels but lacerated lung parenchyma, lacerated intercostal
muscles, great vessels, or the atrial injuries have also been reported as causes.
Flail chest occurs when two or more adjacent ribs are fractured in two or more places. This creates an
unstable segment of the chest wall that moves paradoxically out of phase with the respiratory cycle during
spontaneous ventilation. It can be recognized on inspection by the paradoxical movement of the flail segment.
Intubation with positive pressure ventilation using ambu bag or ventilator takes away this finding. A
commonly associated injury that results from the fail segment is contusion to the underlying lung. The
contusion results in a ventilation–perfusion mismatch and is the primary cause of the hypoxia and hypercarbia
seen with flail chest. Pulmonary contusion, coupled with pain from the fractured ribs, impairs respiratory
function. Treatment involves aggressive pain control measures, as well as tube thoracostomy for an associated
pneumothorax or hemothorax. Intubation with mechanical ventilation is used in patients who develop
respiratory failure. Intravenous fluids should be administered judiciously because aggressive hydration is
associated with sequestering of fluid in the contused lung, which will increase the ventilation–perfusion
mismatch and exacerbation of hypoxia and hypercarbia. Operative stabilization of the flail segment in select
patients reduces morbidity.

Potentially Severe Injuries Detected during Secondary Survey

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Simple pneumothorax occurs when gas enters the pleural space, causing collapse of the ipsilateral lung. Gas
may be introduced from the atmosphere in a penetrating injury, or it may emanate from an injury to the lung
parenchyma or tracheobronchial tree. Physical examination typically reveals diminished breath sounds on the
affected side, though this finding is variable in the noisy environment of the trauma resuscitation area.
Hyperresonance to percussion may be present. Diagnosis is made by plain radiography of the chest or bedside
ultrasound. Posttraumatic pneumothorax visible on plain radiography of the chest should be treated by tube
thoracostomy for reexpansion of the lung. Pneumothorax not seen on plain film but noted on CT of the chest
requires observation but may not need a chest tube. Positive pressure ventilation results in tension
pneumothorax more frequently with small CT-diagnosed pneumothoraces than spontaneous respiration, so a
chest tube should be considered early in the treatment phase to minimize this risk.
Hemothorax results when blood or clot accumulates within the pleural space. The source of hemorrhage is
most commonly from the chest wall or pulmonary parenchyma. Lacerated intercostal vessels, both venous and
arterial, may bleed significantly. On physical examination, decreased breath sounds and dullness to percussion
are typical findings. Chest x-ray will confirm the diagnosis in a stable patient. Treatment involves placement
of a large-bore (36-French) chest tube (Figure 9-6). Postprocedure x-rays should be obtained to confirm
satisfactory evacuation of the hemothorax and tube location. Retained hemothorax should be treated by early
thoracoscopic evacuation, usually within 5 days, as the risk of infection (empyema) or entrapped lung increases
significantly after this time frame.

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Figure 9-6 Left pneumothorax after penetrating chest injury. A, Lung markings are absent along the periphery
of the left hemithorax. B, After insertion of a left chest tube, the lung has reexpanded.

Blunt aortic injury (BAI) is a relatively uncommon but potentially lethal injury that is associated with
rapid deceleration such as seen with a motor vehicle collision and falling from heights. The mechanism is the
result of a shearing force that occurs at the junction of the mobile aortic arch with the immobile descending
aorta in the posterior mediastinum. Direct compression of the aorta may play a role as well. Full-thickness
aortic rupture results in rapid exsanguination and death within minutes after the injury. In survivors, the
rupture is typically contained by the adventitial layers of the aorta. Intimal flaps or pseudoaneurysms may
develop as well. BAI is suggested by mediastinal widening (>8 cm) seen on a portable chest x-ray. Additional
radiographic signs associated with BAI include mediastinal widening, apical capping, loss of normal aortic
contour, depression of the left mainstem bronchus, loss of the paratracheal stripe, obliteration of the
aortopulmonary window, nasogastric tube deviation, left hemothorax, and fractures of the first or second ribs
(Figure 9-7). However, absence of these findings does not eliminate an aortic injury, and patients with
concerning mechanism of injury should undergo contrast-enhanced chest CT to assess the aorta (Figure 9-8).
Left untreated, a significant number of aortic injuries will go on to free rupture and death. Endovascular
techniques (TVAR) have replaced the open repair via a left posterolateral thoracotomy. Paraplegia may result
when the stent graft occludes the intercostal vessels, resulting in ischemia to the spinal cord. Occasionally,
aortic repair must be delayed because of severity of other injuries or comorbidities. In such cases, aggressive
blood pressure (BP) control is necessary to decrease the risk of free aortic rupture.

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Figure 9-7 Chest x-ray in a patient with blunt aortic injury. The mediastinum is markedly widened, the aortic
contour is abnormal, a left apical cap is present, the trachea is deviated toward the right, upper rib fractures are
present, and a left hemothorax is noted.

Figure 9-8 Chest CT in a patient with blunt aortic injury. Blood is present within the mediastinum (white
arrow), and a pseudoaneurysm of the descending aorta is depicted by the red arrow.

Rib fractures are the most common injury of the chest after blunt trauma. Fractured ribs are diagnosed on
physical examination by noting point tenderness along a rib. They may or may not be seen on plain
radiographs of the chest. CT of the thorax is quite sensitive for diagnosing rib fractures but is seldom
indicated to make the diagnosis of a fracture. The location of fractured ribs helps associated injuries. As
mentioned previously, fracture of the first three ribs is associated with aortic or great vessel injury. Fractures of
the midthoracic ribs are frequently associated with pulmonary contusion and/or hemopneumothorax. Lower
rib fractures have an association with diaphragmatic, liver, and spleen injuries. The management of fractured
ribs is directed at the provision of adequate analgesia to allow for oxygenation, ventilation, and clearance of
secretions. Otherwise, healthy young patients with one or two rib fractures may be safely managed with oral
narcotic analgesics and discharged from the ED. Older patients, or those with multiple rib fractures, generally

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require inpatient admission. Intravenous patient-controlled analgesia and thoracic epidural catheterization are
options that provide effective analgesia and avoid intubation. The goal of treatment is to avoid splinting from
pain, which impairs secretion clearance and which may result in atelectasis and subsequent pneumonia.
Elderly patients with multiple rib fractures fare worse than their younger counterparts.

ED Thoracotomy

Patients presenting to the ED in profound shock or in pulseless electrical activity may not respond to
cardiopulmonary resuscitation (CPR) and volume resuscitation. In selected cases, resuscitative left
thoracotomy may be beneficial and should be considered as a life-saving maneuver. Resuscitative thoracotomy
allows several goals to be accomplished quickly. These include pericardiotomy for release of cardiac
tamponade, open cardiac massage (which is superior to closed chest compression to restore perfusion,
particularly in hypovolemia), cross-clamping of the descending aorta at the diaphragm, increasing BP,
intracardiac administration of resuscitative drugs, direct control of intrathoracic hemorrhage, and potential
relief of air embolism. This procedure should be considered in penetrating trauma victims who lose vital signs
<15 minutes before arrival or in the ED. Patients with pericardial tamponade who are too unstable for
transport to the operating room are candidates for ED thoracotomy as well. In contrast, prolonged cardiac
arrest after penetrating injury, massive blunt trauma with prehospital cardiac arrest or pulseless electrical
activity do not benefit from ED thoracotomy. Resuscitative thoracotomy should not be performed unless a
surgeon capable of managing complex truncal injuries is immediately available. The survival rate for ED
thoracotomy is highest with knife injuries to the right heart or atrium but still only range from 1% to 10% in
most studies.

ABDOMINAL INJURY

Background

Abdominal trauma results from either penetrating wounds or blunt force. Penetrating injuries occur with low-
energy stab wounds and high-energy gunshot wounds. Blunt traumatic injury occurs after falls, assaults, crush
injuries, and motor vehicle crashes.
Unexplained hypotension in an injured patient requires immediate consideration of intra-abdominal
injury. Life-threatening intra-abdominal hemorrhage is a common source of shock that must be considered
during the primary survey. Rapid diagnosis and treatment of intra-abdominal hemorrhage is critical.

Anatomic Considerations

The torso is divided into several regions (Figure 9-9). The flank is defined as the region between the anterior
and posterior axillary lines, the lower ribs, and the iliac crest. The back is bounded by the spinous processes,
the posterior axillary line, the lower ribs, and the iliac bone. Injuries to any of these areas can involve the
peritoneal cavity and/or retroperitoneum. The abdominal contents are partially protected by the rib cage, the
pelvis, and the lumbar spine as well as the abdominal wall musculature. The pancreas, kidneys, bladder, aorta,
inferior vena cava, duodenum, ascending and descending colons, and rectum reside in the retroperitoneum.

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Figure 9-9 Surface landmarks of the abdominal cavity.

The location, volume, and size of these organs affects injury patterns observed with both blunt and
penetrating trauma. For example, penetrating wounds in the third trimester of pregnancy can involve the
uterus and/or fetus. The small bowel and mesentery are the most frequently injured organs with penetrating
wounds. During rapid deceleration that occurs during a motor vehicle crash, the spleen and liver are more
mobile relative to hollow viscus organs resulting in a higher frequency of injury.

Initial Evaluation

The history and mechanism of a traumatic injury are important in determining the relative risk and location of
injuries. This is frequently provided by prehospital personnel and can be quickly obtained while the patient is
being transferred to the gurney. The exam starts with complete exposure and thorough examination of the
abdomen, flanks, and back. Identification of old scars, bruising, puncture wounds, lacerations, asymmetry, and
distension all provide insights into what may be injured.
Palpation of the abdomen in trauma patients is essential but may be unreliable due to altered mental status
from alcohol, drug use, head injury, or shock. Palpation may reveal focal or diffuse tenderness, signs of
peritoneal irritation, distension due to intra-abdominal hemorrhage, and fascial and muscular defects in the
abdominal wall. Examination of the pelvis should be performed, looking for pelvic bony instability or pain.
Serial abdominal exams should be performed to minimize the risk of missed injury. Digital rectal examination
should be performed in cases of suspected intra-abdominal trauma and when pelvic fracture is suspected.

Adjunctive Diagnostic Tools

If there is no evidence of urethral injury or a high-riding prostate on rectal examination, insertion of a urinary

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catheter can help guide fluid resuscitation and reveal hematuria from renal or bladder injuries. A supine
abdominal x-ray of the abdomen and pelvis may be useful to determine the presence and location of bullets or
other foreign bodies (Figure 9-10). The FAST abdominal ultrasound exam is quick and easy to perform and
has supplanted diagnostic peritoneal lavage to assess for intraperitoneal bleeding. FAST evaluates for free fluid
in the abdomen or pericardium using ultrasonographic views of the right and left upper quadrants,
pericardium, and pelvis (Figure 9-11). It is accurate under many conditions and may be reliably performed by
surgeons and emergency physicians, as well as radiologists.

Figure 9-10 Penetrating trauma with impaled foreign body. Plain x-ray revealed trajectory concerning for
peritoneal penetration and pelvic organ injury.

Figure 9-11 Positive FAST examination. Hypoechoic (dark [arrow]) blood is noted in Morison’s pouch between
the liver and right kidney.

CT scanning has dramatically changed the evaluation of the abdomen for injury and is the gold standard
for diagnosing injury to any of the intraperitoneal or retroperitoneal organs in the hemodynamically stable
patient.

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Operative Care

A hypotensive victim of blunt abdominal trauma who does not respond to volume resuscitation is considered
to have an intra-abdominal source of bleeding until proven otherwise. Spinal cord or neurologic injury can
cause hypotension, but uncontrolled intra-abdominal hemorrhage occurs far more frequently. The most
common source of hemorrhage is the spleen and/or liver. Rapid surgical management to secure hemostasis is
required in this situation.
Penetrating wounds with peritonitis require prompt laparotomy, as the incidence of visceral injury is
extremely high. Bullets may ricochet and fragment, and one should never assume that skin wounds from
penetrating injury connect in a straight line. Hemodynamically stable patients with a penetrating wound in
the right upper quadrant or right thoracoabdominal region should be managed nonoperatively when the only
organ injured is the liver. In addition, stable patients without peritonitis may have wounds that are limited to
the abdominal wall. CT scans can help avoid a nontherapeutic laparotomy. Low-velocity injury to the
abdomen from sharp objects should also undergo local wound exploration to determine if the fascia and/or
peritoneum has been violated. When there is violation, laparotomy is indicated to manage injuries.
Penetrating flank wounds and back wounds from firearms are managed like abdominal wounds, but
contrast-enhanced CT scan with both oral and rectal contrast allows for accurate identification of injuries in
stable patients. Penetrating trauma to these regions causes retroperitoneal organ injury more frequently. Any
hypotensive patient with a penetrating wound in the abdomen, flank, or back should undergo emergent
exploratory laparotomy to control the bleeding.

INJURY TO SPECIFIC ORGANS

Liver

Blunt liver injuries are graded from I to VI in severity, with grade I injuries represented by small capsular
hematomas or parenchymal lacerations less than 1 cm in depth, and grade VI injuries resulting from avulsion
of the liver from its vascular pedicles (Table 9-4). Most liver injuries are self-limiting in nature. CT scan is the
diagnostic modality of choice, providing anatomic detail and accurate grading of the injury (Figure 9-12) in
the hemodynamically normal patient. Ongoing bleeding such as contrast extravasation may require
embolization to control the hemorrhage. Higher-grade liver injuries, including those involving the hepatic
veins or retrohepatic vena cava, may result in massive hemorrhage, requiring urgent operative intervention and
damage control surgical techniques, as outlined in a subsequent section.

TABLE 9-4 Liver Injury Scale

Gradea Injury Description

I Hematoma Subcapsular, nonexpanding, <10% surface area

Laceration Capsular tear, nonbleeding, <1 cm in depth

II Hematoma Subcapsular, nonexpanding, 10%–50% surface area

Intraparenchymal, nonexpanding, <10 cm in diameter

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 Laceration Capsular tear, active bleeding; 1–3 cm parenchymal depth, <10 cm in length

III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular hematoma with active bleeding;
intraparenchymal hematoma >10 cm or expanding

Laceration >3 cm parenchymal depth

IV Hematoma Ruptured intraparenchymal hematoma with active bleeding

Laceration Parenchymal disruption involving 25%–75% of hepatic lobe or 1–3 segments within a single lobe

V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 segments within a single lobe.

Vascular Juxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins)

VI Vascular Hepatic avulsion

aAdvance one grade for multiple injuries up to grade III.

Figure 9-12 CT scan of the abdomen in a patient with blunt abdominal trauma and extensive hepatic injury.

Spleen

The spleen is frequently injured in blunt abdominal trauma. As with the liver, injuries are graded I to VI, with
higher-grade injuries more likely to require intervention (Table 9-5). Splenic salvage is preferred but must be
balanced with the risk of bleeding and death. CT scan allows for accurate assessment of the degree of splenic
injury and also assesses for concomitant injuries. Nonoperative management is used for hemodynamically
stable patients, particularly with low-grade splenic injuries (Figure 9-13). Recurrent hemorrhage or
development of peritonitis signals failure of nonoperative management and should be followed by expeditious
laparotomy or embolization. Splenic injury with active bleeding and hypotension requires either total
splenectomy or splenorrhaphy. Hemodynamically stable patients with IV contrast extravasation on dynamic
CT scan can be managed by angioembolization for splenic salvage (Figure 9-14). Splenectomized patients
should undergo postoperative vaccination for encapsulated organisms such as pneumococcus and
meningococcus to reduce the risk for the rare but potentially fatal complication of overwhelming
postsplenectomy infection.

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 TABLE 9-5 Splenic Injury Scale

Gradea Injury Description

I Hematoma Subcapsular, nonexpanding, <10% surface area

Laceration Capsular tear, nonbleeding, <1 cm in depth

II Hematoma Subcapsular, nonexpanding, 10%–50% surface area

Intraparenchymal, nonexpanding, <5 cm in diameter

Laceration Capsular tear, active bleeding; 1–3 cm parenchymal depth that does not involve a trabecular vessel

III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular hematoma with active bleeding;
intraparenchymal hematoma >5 cm or expanding

Laceration >3 cm parenchymal depth or involving trabecular vessels

IV Hematoma Ruptured intraparenchymal hematoma with active bleeding

Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)

V Laceration Completely shattered spleen

Vascular Hilar vascular injury, which devascularizes spleen

a
Advance one grade for multiple injuries up to grade III.

Figure 9-13 Splenic injury, as demonstrated by CT of the abdomen. Diffuse hemoperitoneum is present.

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Figure 9-14 Angiographic embolization of splenic hemorrhage after blunt abdominal trauma. Metallic coils
have been placed within the splenic artery.

Pancreas

Injury to the pancreas is uncommon due to its protected retroperitoneal location. This location makes
diagnosis by physical examination difficult. Any patient presenting with significant blunt force to the lower
chest and upper abdomen should undergo CT scan for early diagnosis of any injury, particularly to the
pancreas. Transection of the body of the pancreas may occur by compression against the vertebral column.
When the fracture in the parenchyma is to the left of the superior mesenteric artery, distal pancreatectomy
with or without splenic salvage is the optimal management. Injuries of the pancreatic head can be challenging.
Initial management is usually at controlling hemorrhage and drainage of the disrupted pancreatic tissue. Small
injuries of the pancreas not involving the main pancreatic duct may be managed with drainage. Stab wounds
to the back can injure pancreatic parenchyma and ducts. Evaluation may include CT scanning, magnetic
resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography
(ERCP).

Diaphragm

Blunt rupture of the diaphragm usually extends from the gastroesophageal (GE) junction into the tendinous
portion of the central diaphragm. Rarely, blunt injury may result in complete avulsion of the posterior
muscular insertion from the ribs (Figure 9-15). Repair is done with interrupted or running permanent suture
to minimize the risk of recurrence. Care should be taken to avoid injury to the branches of the phrenic nerve
when possible.

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Figure 9-15 Blunt rupture of the left diaphragm. The nasogastric tube is visualized in the left hemithorax
(arrow).

Low-velocity penetrating injury to the diaphragm can occur without pneumothorax or evidence of
peritoneal injury. Left-sided diaphragmatic injuries are particularly concerning because of the risk of
development of diaphragmatic hernia and visceral incarceration if not repaired. In addition, left-sided
diaphragmatic wounds are commonly associated with injuries of the stomach, colon, spleen, and small
intestine. Unfortunately, small penetrating injuries of the diaphragm are not readily diagnosed by CT. For
these reasons, there should be a low threshold for diagnostic laparoscopy or thoracoscopic evaluation of the
left diaphragm for penetrating injury to the left thoracoabdominal region. Small injuries of the right
diaphragm may be managed without surgical repair because the liver is protective against herniation.

Kidneys

The kidneys, like the pancreas, are relatively protected from injury because of their retroperitoneal location, as
well as encasement within Gerota’s fascia. Blunt renal trauma rarely requires operative intervention unless
there is a ureteral injury or disruption of the renal pelvis. Nephrectomy may be necessary for massive
destruction of the parenchyma (grade IV or higher) or injury involving the hilum. Penetrating injuries are self-
limiting under most circumstances unless the vessels are involved. Foley catheter drainage should be
maintained for 7 to 10 days, or until hematuria resolves.

Small Intestine and Mesentery

Blunt perforation of the small intestine may occur as the result of compression and resultant blowout, or by
avulsion of the mesenteric blood supply. Contusion to bowel wall may result in a delayed perforate. An
abdominal “seatbelt sign” increases the risk for bowel injury. Mesenteric tears with hemorrhage from the
arcade vessels can occur in deceleration injury and should be suspected when CT scan shows fluid without a
solid organ injury. The small bowel and mesentery are frequently injured by knife and gunshot wounds.

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Repair is generally straightforward and involves closure with absorbable or nonabsorbable suture. Stapled
repair or resection with anastomosis is appropriate for injuries involving the mesentery.

Colon

Injury to the large intestine from low- and high-velocity projectiles can often be repaired primarily. More
extensive wounds that involve the mesentery may be managed by resection with primary reanastomosis.
Colostomy is seldom required in colonic trauma. Injuries to the extraperitoneal rectum should be considered
for fecal diversion to avoid perineal sepsis while the wound heals. Patients with colonic trauma and multiple
other injuries or profound shock may also be considered candidates for temporary diverting colostomy because
of their increased risk for anastomotic breakdown.

Damage Control

Patients presenting with shock and ongoing hypotension benefit from an abbreviated laparotomy that controls
hemorrhage and/or contamination. This is commonly referred to as a damage control laparotomy. The “lethal
triad” of hypothermia, acidosis, and coagulopathy can be worsened by prolonged operation and is almost
universally fatal if not halted. Control of immediate life-threatening hemorrhage is achieved by suturing of
bleeding vessels and packing solid organ injuries with laparotomy pads. Injured segments of the intestine may
be resected and left in discontinuity to minimize operative time. Damage control surgery usually takes 60 to
90 minutes, with expedient transfer of the patient to the intensive care unit for ongoing resuscitation,
rewarming, and correction of coagulopathy. Once stabilized, usually 12 to 48 hours after initial presentation,
the patient is returned to the operating room for staged removal of hemostatic packing, reconstruction of the
gastrointestinal tract, and definitive repair of other injuries.

Abdominal Compartment Syndrome

Aggressive crystalloid volume resuscitation can result in sequestering of fluids in the retroperitoneum and
peritoneal cavity (third spacing). When the intraperitoneal pressure is greater than 25 mm Hg and there is
organ dysfunction, there should be concern for the development of abdominal compartment syndrome (ACS).
ACS compromises blood flow to the abdominal and retroperitoneal viscera. Diaphragmatic excursion is
reduced and evident by increased airway pressure, reduced tidal volumes, hypoxia, and eventually hypercapnia.
When left untreated or when there is a delay in diagnosis, ACS results in multiple organ dysfunction
syndrome (MODS) and is commonly fatal. The clinical triad of decreased urine output, increased airway
pressures, and elevated abdominal pressure constitutes ACS. Diagnosis is facilitated by measuring the bladder
pressure, which indirectly represents the intraperitoneal pressure. Treatment is prompt decompression by
making a midline laparotomy incision. This allows prompt decompression and restoration of pulmonary
function. Renal perfusion is restored, and urinary output increases. The abdominal cavity and fascia can often
be closed after swelling of the viscera has subsided, but occasionally prolonged wound care, skin grafting, or
complex closure techniques are required.

PELVIC FRACTURES

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Significant force is typically required to fracture the large bones of the pelvis, such as seen with motor vehicle
collisions, pedestrian–vehicle collisions, and falls from great heights. The fracture patterns are typically
classified by the mechanism of injury: anterior–posterior (AP) compression, lateral compression (LC), or
vertical shear. Of the three forces of transmitted energy, the LC mechanism is the most common and the
most stable because it is less likely to lead to ligamentous disruption of the sacroiliac joint. The AP
compression fracture pattern (Figure 9-16) is also known as the open book pelvic fracture. The symphysis
pubis is disrupted and the iliac wings open, leading to variable amounts of sacroiliac ligamentous disruption.
The appearance of the pelvis on radiologic imaging does not necessarily indicate the full extent of the
distraction of the pelvic bones that occurred on initial impact. The least common pelvic ring disruption but
most unstable is the vertical shear injury pattern, which is caused by a severe vertical force that may disrupt the
hemipelvis from the spine, or create a fracture through the iliac wing. This fracture pattern is often associated
with other abdominal, pelvic, or vascular injuries.

Figure 9-16 Open book pelvic fracture from anteroposterior compression injury.

Pelvic fractures may be suspected on the basis of history and physical findings. If the patient is conscious,
pain is usually present, particularly with palpation. There may be bruising to the lower abdomen, hips,
buttocks, or lower back. The bony pelvis should be manually palpated gently to illicit tenderness, deformity
(such as a widened symphysis pubis), or movement with gentle compression. Examination should also include
inspection of the perineum for open wounds, which would signify an open pelvic fracture. The lower
extremities should be examined for alignment, length discrepancy, and pelvic pain with movement. In
symptomatic patients, a plain x-ray of the pelvis is indicated to evaluate for a pelvic fracture. Dynamic helical
CT scan of the pelvis offers a means of evaluating the integrity of the bony pelvis, as well as the internal pelvic
structures. Extravasation of intravenous contrast is a sign of ongoing hemorrhage and should prompt
consideration for early angioembolization. CT scan also allows for evaluation of the lower genitourinary tract.
Hemorrhage associated with a pelvic fracture is related to the fracture edges, presacral venous plexus, or, in
approximately 10% of patients, an arterial source.
Because of the high kinetic energy necessary to disrupt the pelvic ring, rapid assessment for other sources
of blood loss should be performed. Bleeding from the fracture edges or small veins can be minimized by

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stabilizing the pelvis. There are several simple methods to achieve this, ranging from wrapping a sheet tightly
around the pelvis to applying a pelvic binder or external fixator. These methods work best for AP compression
injuries to restore the alignment of the pelvic bones. Ongoing bleeding from an arterial source requires
intervention. As a general rule, surgical exploration is not the best option to control pelvic hemorrhage.
Surgical exploration by opening the peritoneum releases the tamponading of the retroperitoneal venous
bleeding. If the patient is taken to surgery for other injuries, such as a ruptured spleen, the pelvic hematoma
can be packed with laparotomy pads. The preferred method to control arterial hemorrhage is catheter-directed
embolization.
Lower genitourinary injuries can occur with pelvic fractures because of the close proximity of the bladder
and prostate to the pubic bones; they are usually suspected because of hematuria. Blunt mechanisms produce
two types of bladder injury, namely, intraperitoneal and extraperitoneal lacerations. Extraperitoneal injury
results from the ligamentous attachments, which secure the bladder to the pelvic bones, tearing the bladder
wall. The diagnosis is made by a cystogram demonstrating extravasation into the retroperitoneum. Treatment
is decompression of the bladder with a Foley catheter until the laceration heals, typically 7 to 10 days. Blunt
force to the lower abdominal wall when the bladder is distended results in a disruption of the dome of the
bladder, which is intraperitoneal. This injury may or may not be associated with pelvic fractures. The
diagnosis is made by CT cystogram revealing contrast extravasation into the peritoneal cavity. Intraperitoneal
bladder injury requires surgical exploration and repair. Typical signs associated with urethral injury are scrotal
hematoma, blood at the urethral meatus, and a high-riding or nonpalpable prostate gland on rectal exam. A
retrograde urethrogram should be done to evaluate for injury before passage of a Foley catheter in these cases.
Blind passage of a catheter in a patient with a partial urethral tear can lead to worsening of the injury or
complete transection. Inability to pass a catheter or identification of a urethral injury will require urologic
consultation for definitive management. The urethra can also be injured directly with penetrating trauma or
blunt force mechanisms such as straddle injuries.

PENETRATING NECK TRAUMA

The neck is a highly complex anatomic region with critical vascular, neurologic, and aerodigestive structures
concentrated within a very small area. Any wound that violates the platysma muscle carries a risk of injury to
the great vessels, trachea, esophagus, and spinal cord, and therefore requires further assessment. For purposes
of clinical evaluation and management of penetrating wounds, the anterior neck (from the midline to the
anterior border of the sternocleidomastoid muscle) is divided into three zones as illustrated in Figure 9-17.

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Figure 9-17 Zones of the neck.

Initial evaluation of patients with penetrating neck wounds is determined by the physical examination and
physiologic status. Shock or hard signs of injury to any of the vital structures in zones I and II mandate
immediate operative exploration to control hemorrhage. In the hemodynamically stable patient, a more
selective approach is taken for injuries to both zone I and zone III because of the difficulty in examining and
operatively exposing structures in these areas. Controversy continues to center around hemodynamically stable
patients with an injury located in zone II and no signs or symptoms suggestive of a major injury. Traditional
evaluation includes angiography, bronchoscopy, and esophagoscopy in conjunction with esophagography.
There is a growing body of literature to support the use of contrast-enhanced CT for evaluation of
penetrating neck injury. Several prospective studies evaluating the use of CT angiography in penetrating neck
trauma have demonstrated a sensitivity approaching 100% and a negative predictive value over 90%. One of
the recognized limitations of the use of CT in the evaluation of penetrating neck trauma is the difficulty in
detecting the trajectory of knife wounds. Specifically, small pharyngoesophageal wounds are difficult to detect
with CT scan. Despite these limitations, the literature supports an increasing role for the use of CT in
evaluating stable patients with a penetrating wound to any zone of the anterior neck.

Aerodigestive Tract Injury

Aerodigestive tract injuries are seen in 10% of penetrating trauma to the neck. Airway management is
paramount. The need for a surgical airway (cricothyroidotomy) should always be considered in any patient
who might have a tenuous or compromised airway.

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 The preferred method of evaluating for an injury to the larynx and trachea involves a combination of direct
laryngoscopy and bronchoscopy. Laryngeal injuries are classified as supraglottic, glottic, and subglottic.
Supraglottic injuries typically result in a depression of the superior notch of the thyroid cartilage and are
associated with a vertical fracture of the thyroid cartilage. Disruption of the thyroid cartilage results in a glottic
injury. An injury to the subglottic region usually involves the lower thyroid and cricoid cartilage. Early
definitive repair for any laryngeal injury should be the goal because of the higher incidence of stricture
formation with delayed repair. Subglottic injury to the trachea should be repaired in one layer with absorbable
suture. When there is an associated esophageal or arterial injury, the risk of fistulization between the two
repairs is reduced by interposing a vascularized pedicle of omohyoid or sternocleidomastoid muscle. Operative
management of cervical esophageal injuries requires meticulous debridement, a two-layer closure of the
wound, and closed suction drainage. Injuries limited to the hypopharyngeal region can be safely managed
conservatively including a nasogastric tube for feeding and an empiric course of parenteral antibiotics.

Vascular Injury

The approach to evaluation of a vascular injury in the neck is dictated by the patient’s hemodynamic status
and neurologic assessment. Observation or expectant management is advocated for patients who are comatose.
Simple ligation of an artery is an option for those patients presenting with exsanguination or when a
temporary shunt cannot be placed. The carotid artery should be repaired when the patient has an intact or
alternating neurologic examination. Repair may be performed by a direct operative approach or using
endovascular techniques in the stable patient. Angiographic intervention is particularly applicable in zone III
injuries to the internal carotid artery located at the base of the skull because of the difficulty in accessing this
area.
The most common vascular injury with penetrating wounds is the internal jugular vein. In the
hemodynamically unstable patient, any venous injury should be managed by simple ligation. Otherwise, an
injury to the internal jugular vein should be repaired by lateral venorrhaphy or patch venoplasty. Despite the
method of repair, subsequent thrombosis is common.

Spinal Cord Injury

Approximately 10% of penetrating neck wounds are associated with a spinal cord or brachial plexus injury.
Injuries to the spinal cord above the fourth cervical vertebrae are associated with a high mortality. Steroids are
contraindicated in the management of any spinal cord injury.

EXTREMITY TRAUMA

Extremity injuries are common in both blunt and penetrating trauma and may range in severity from trivial to
limb and even life threatening. During the primary survey, potentially lethal injuries such as major vascular
injuries, open fractures, crush injuries, and near amputations should be stabilized by application of a splint.
The history obtained from prehospital personnel may imply significant blood loss at the scene or during
transport. Exsanguinating hemorrhage from a major vascular injury should be treated initially with direct
pressure or by application of a tourniquet proximal to the wound. During the secondary survey, a detailed

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neurovascular examination of each extremity should be performed and include evaluation of peripheral pulses,
sensation, motor function, and range of motion. Palpation may elicit tenderness suggestive of fracture or soft
tissue injury. Deformity of the extremity is typically associated with fractures and/or dislocations.
Vascular injuries can be obvious or occult. The “hard signs” of acute injury include pulsatile bleeding,
expanding hematoma, bruit, and a pale, cool, pulseless extremity with or without paresthesia or paralysis.
Hard signs of a vascular injury are an indication for immediate operative exploration. Physical findings that
may be suggestive, but not diagnostic for vascular injury, are termed “soft signs.” These are nonexpanding
hematoma or diminished pulses. Doppler ultrasound provides a useful adjunct to examination of the vascular
system and allows calculation of the ankle–brachial index (ABI). The ABI is calculated by measuring the
systolic BP (by Doppler probe) divided by the systolic pressure in the brachial artery. Normally, this ratio is
≥1; values <0.9 are suggestive of arterial injury or occlusion. In this setting, further diagnostic evaluation with
CT angiography is indicated.
Radiographic imaging is indicated for any extremity deformity, bony tenderness, or joint swelling as part
of the secondary survey. If a fracture is identified, imaging should also include the bones above and below the
fracture. Fractures are characterized by bony location, comminution, angulation, and whether they are closed
or open with communication to the skin. Open fractures lead to bacterial contamination and risk of
complications such as wound infection, osteomyelitis, poor bone healing, and ultimately poor functional
outcome.
While a detailed discussion of extremity fractures falls outside the scope of this chapter, certain basic
principles may be universally applied. Splinting a fracture improves pain control, minimizes secondary soft
tissue damage, and diminishes bleeding from the soft tissues and bone edges. Materials for splinting are either
cardboard or plaster constructs. Femoral shaft fractures may be associated with significant blood loss into the
soft tissues and should be addressed with appropriate resuscitative measures, including transfusion of blood as
necessary. Patients with bilateral femur fractures may present with shock, even in the absence of other injuries.
Neurovascular status should also be reassessed and the findings documented before and after manipulation of
the injured extremity. Open fractures are potentially limb-threatening injuries. Treatment involves prompt
operative debridement of devitalized tissue, copious irrigation to remove dirt and other contaminants, fracture
reduction, and administration of broad-spectrum intravenous antibiotics.
Dislocations should be splinted in place for transport. Reduction of the dislocation should be done as soon
as possible. Imaging is indicated before reduction to rule out an associated fracture that might impede
reduction. Prolonged dislocation can cause traction injury to nearby nerves and vessels and thus significant
morbidity.
Compartment syndrome may occur after blunt or penetrating trauma in any extremity. It is the result of
soft tissue edema and hemorrhage. When this swelling occurs in an unyielding fascial compartment,
interstitial pressure rises. In the initial phases, this increase in pressure may diminish venous capillary outflow
and worsen cellular injury, resulting in further swelling and interstitial fluid accumulation. If left uncorrected,
compartment syndrome may result in permanent nerve injury or muscle necrosis that may necessitate
amputation. The muscular damage associated with compartment syndrome may be lead to rhabdomyolysis
and result in myoglobinuria. Early signs of compartment syndrome include pain, paresthesia, and diminished
sensation. The affected compartment is typically swollen and tense. Diminished pulses are late finding and

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often associated with irreversible ischemia. The diagnosis is typically made by history and physical
examination findings. Direct measurement of compartmental pressures may be accomplished with
commercially available devices when the diagnosis is equivocal. In brain-injured or comatose patients, direct
measurement of compartmental pressures should be performed. Treatment is prompt fasciotomy of all the
involved compartments. Fasciotomy allows the injured muscle to swell without concomitant increases in
pressure. Perfusion is maintained, and secondary damage is minimized. Compartment syndrome may occur in
any extremity, but is most commonly associated with crush injuries of the calf, with or without bony fractures.
Rhabdomyolysis and subsequent myoglobinuria may develop after significant muscular injury or in the
setting of compartment syndrome. Myoglobin is nephrotoxic and precipitates in the acidic milieu of the renal
tubules. Treatment involves aggressive hydration with isotonic intravenous fluids. Alkalinization of the urine
with intravenous sodium bicarbonate and osmotic diuresis with mannitol are adjunctive measures.
Debridement of all necrotic tissue is mandatory to eliminate rhabdomyolysis causing myoglobinuria.

TRAUMA IN PREGNANCY

The leading causes of injury among pregnant women are transportation related, falls, and assault. Motor
vehicle collision is the most common mechanism resulting in fetal death, followed by firearms, and then falls.
Pregnant women between 15 and 19 years of age are at greatest risk for trauma-related fetal demise.
Young pregnant women also sustain injuries as a result of being assaulted. It is estimated that 10% to 30%
of women are physically abused during pregnancy, and of these 5% are severe enough to result in fetal death.
Thus, it is mandatory for all members of the health care team to be versed in recognizing the signs and
symptoms of physical abuse.
The priorities for treatment of the pregnant patient are the same as those for the nonpregnant patient.
Prevention of hypotension when the patient is supine is accomplished by repositioning to displace the uterus
off the vena cava and aorta while maintaining alignment of the spine. This can be accomplished by three
simple maneuvers: placing the patient in the left lateral decubitus position, the right lateral decubitus position,
or the knee–chest position when supine. Alternatively, the uterus can be manually displaced to the patient’s
left side. Since the physiologic hypervolemia of pregnancy may mask the early signs of shock, early crystalloid
resuscitation should be initiated even in the normotensive patient. The secondary survey should include a
prenatal history and associated comorbid factors. A urine pregnancy test should be obtained in all injured
women of childbearing age, and, when positive, early obstetrical consultation is recommended.
Abdominal examination may reveal evidence of uterine rupture because fetal parts may be palpable in this
circumstance. A speculum examination should be performed followed by the bimanual examination only if
there is no evidence of vaginal bleeding. The examination focuses on the following: vaginal blood, ruptured
amniotic membranes, active contractions, a bulging perineum, and an abnormal fetal heart rate or rhythm.
Drainage of cloudy white or green fluid from the cervical os is indicative of ruptured membranes. This is an
obstetrical emergency requiring urgent cesarean section. Bloody amniotic fluid is indicative of either placental
abruption or placenta previa. When this occurs during the first trimester, there is a great risk of spontaneous
abortion.
Rh typing is essential in the pregnant trauma patient. The Rh antigen is well developed by 6 weeks of

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gestation, and as little as 0.001 mL of fetal blood can cause sensitization of the Rh-negative mother.
Therefore, all Rh-negative women should receive Rho (D) immune globulin, unless the injury is minor and
remote from the uterus.
In cases of severe trauma in late term pregnancy, perimortem cesarean section may be necessary. This
maneuver may be considered in cases of impending or actual maternal cardiac arrest; fetal survival has been
reported when performed <4 minutes after loss of maternal vital signs.

PEDIATRIC TRAUMA

Pediatric trauma is the number one cause of death of children, as well as the number one cause of permanent
disability in those under 14 years of age. In children over 1 year and under 14 years of age, motor vehicle
collisions cause 47% of all pediatric deaths related to injury. Drowning is the second most frequent cause of
injury-related death in children, followed by thermal injury.
Although the resuscitation priorities (ABCDE algorithm) are the same for children as for adults,
anatomic and physiologic differences require modifications to the approach. Assessment of the child’s airway
is the first step. Most children do not have preexisting pulmonary disease; thus a room air oxygen saturation
<90% generally indicates ineffective gas exchange. If oxygenation is difficult, then a pneumothorax or
aspiration should be considered. In the injured child, hyperventilation is common after traumatic brain injury
or shock. With either condition, intubation and mechanical ventilation is appropriate. The injured child who
is combative because of hypoxia or emotional distress may also need to be intubated to facilitate further
diagnostic testing. A chest x-ray should be obtained to confirm the correct position of the endotracheal tube
since a right mainstem intubation is a common complication. The Broselow Pediatric Resuscitation
Measuring Tape has become the standard for determining height, weight, and the appropriate size for
resuscitative equipment and medication dosing in children. This device is placed on the bed next to the child,
and the height measurement allows estimation of weight for dosing of medications and other therapeutic
maneuvers.
Age-specific hypotension is an indication for volume resuscitation of the injured child. Cardiovascular
compensation by tachycardia and vasoconstriction will maintain BP in the child who has had significant blood
loss. Therefore, a normal BP does not connote a normal circulating blood volume. A child’s blood volume is
approximately 8% of body weight, or 80 mL/kg. Clinical signs of decreased organ perfusion in conjunction
with altered mentation are the classic findings of hemorrhagic shock. Initial resuscitation is begun with 20
mL/kg of an isotonic crystalloid solution, such as 0.9% normal saline, or lactated Ringer’s solution. If there is
no improvement in perfusion after a second bolus of crystalloid, then a 10 mL/kg bolus of either cross-
matched or O-negative packed red blood cells should be administered.
Hypothermia is common in the injured child and may occur at any time of the year. The response to
hypothermia includes catecholamine release, with an increase in oxygen consumption and metabolic acidosis.
Hypothermia and acidosis may then contribute to posttraumatic coagulopathy. The rate of cooling and
subsequent hypothermia can be reduced by warming the room (>37°C), using warmed intravenous fluids and
blood (39°C), heated air-warming blankets, and external warmed blankets during the initial resuscitation.
In a child, the comparatively thin abdominal wall musculature and flexible rib cage provide relatively little

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protection for the abdomen from blunt injury, and thus abdominal injuries are common in children. In
addition to physical examination, adjunctive tests include FAST and CT scan. CT imaging of the head, chest,
abdomen, and pelvis are the accepted diagnostic radiologic studies of choice in the hemodynamically stable
children. In the hemodynamically normal children, the vast majority of solid organ injuries can be managed
without surgical intervention. As in adults, hollow viscus perforation should be managed by prompt surgical
repair.

TRAUMA IN THE ELDERLY

The elderly population (age ≥ 65 years) is the fastest growing age group in the United States. Injury is the fifth
leading cause of death in the elderly. Within this group, 42% reported some type of long-lasting condition or
a disability. Of those aged 65 to 74, a third reported at least one disability; that number climbs to 72% in
people 85 years of age and older.
Common injury mechanisms in the geriatric population include falls, motor vehicle collisions, automobile
versus pedestrian collisions, assaults, and burns. Motor vehicle collision victims over the age of 85 have a
fatality rate that is seven to nine times higher than that of younger adults. Adult pedestrian injuries are more
common in lower socioeconomic groups who are more likely to travel by walking. The slower pace and
restricted mobility associated with aging result in the elderly pedestrian requiring longer times to cross a street,
which places them at higher risk for being struck by oncoming vehicles.
Personal violence is increasing as a cause of injury in the elderly. In the United States, 5% of all homicides
involve victims age 65 and older. The overall incidence of abuse in elderly patients is estimated to be 2% to
10% and should always be considered when caring for the geriatric patient. Substance abuse also should be
considered in the elderly. Consideration of causes of altered mental status should include brain injury, stroke,
delirium, dementia, or intoxication.
Elderly trauma patients have higher injury-related mortality when compared with younger patients. Much
of this is due to reduced function in all organs that occurs with aging and also the increased incidence of
comorbid conditions. The prevalence of preexisting conditions increases with age and can be as high as 80% in
those over 95 years.
The most frequent comorbidities in the elderly involve the cardiovascular system. These diseases
compromise the older trauma patient’s ability to respond to hypovolemia. Rather than mounting a tachycardia
and increase in cardiac output, there is an increase in systemic vascular resistance resulting in a falsely
reassuring BP. In fact, a normal BP in an elderly trauma victim frequently corresponds to profound shock
when perfusion is assessed using systemic markers such as serum lactate and base deficit. Cardiac physiology is
also affected by medications prescribed for hypertension and arrhythmias.
Aging also affects pulmonary function. There is a decrease in the alveolar surface area that reduces the
surface tension and thus gas exchange and forced expiratory flow. Gross anatomic changes in the thorax of the
elderly include the development of kyphosis, which results in a reduction of the transverse thoracic diameter.
The loss of bone density is associated with an increased rigidity of the chest wall. Chest wall compliance
decreases with age, resulting in increased work of breathing. In elderly women, osteoporosis increases the risk
for rib fractures and pulmonary contusion. Age has been shown to be the strongest predictor of outcome and

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is directly proportional to mortality in patients with multiple rib fractures.
In the geriatric patient, the initial GCS score may be less reliable and more reflective of chronic disease of
the central nervous system or systemic disease. A significant traumatic brain injury can result from apparently
minor trauma because of the changes with aging of the meninges and a reduction in brain volume. Thus, any
elderly patient with a change in mental status should prompt a thorough evaluation for traumatic brain injury,
including a noncontrast CT scan of the head. In addition, many elderly patients are prescribed anticoagulants.
Otherwise minor head injuries may become devastating intracranial hemorrhages in the anticoagulated
patient. Morbidity and mortality are reduced by prompt correction of coagulopathy.
Renal function begins to deteriorate at the age of 30. The number of functioning nephrons decreases by
10% per decade, whereas the remaining functional units hypertrophy. Glomerular filtration rate begins to
decrease at 50, declining by 0.75 to 1 mL/minute/year.
Traumatic injury in the elderly is more likely to produce bowel and mesenteric infarction. The diagnosis of
an intraperitoneal injury by physical examination is less reliable. Gastrointestinal tract wounds are associated
with a 3- to 4-fold increase in mortality when compared with younger cohorts.
Cell-mediated immunity is diminished with a decrease in peripheral T-cell count and function. The
antibody response to stimuli is depressed, and this places the elderly at increased risk for infection. With
severe trauma they may be more prone to the development of the MODS.
Normal thermoregulatory mechanisms become less responsive with aging. Cutaneous vasoconstriction and
shivering are less effective, placing the elderly at increased risk for development of hypothermia in cold
environments, and after significant volume loss. Efforts to prevent hypothermia must be initiated in the
prehospital setting.

SUGGESTED READINGS

Centers for Disease Control and Prevention. Injury Prevention and Control. Ten leading causes of death and
injury. https://www.cdc.gov/injury/wisqars/LeadingCauses.html. Accessed August 6, 2018.
Centers for Disease Control and Prevention. National Center for Health Statistics. Mortality in the United
States. 2016. https://www.cdc.gov/nchs/products/databriefs/db293.htm. Accessed August 6, 2018.
Chang R, Holcomb JB. Optimal fluid therapy for traumatic hemorrhagic shock. Crit Care Clin.
2017;33(1):15–36.
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a
1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA.
2015;313(5):471–482.
Stocchetti N, Taccone FS, Citerio G, et al. Neuroprotection in acute brain injury: an up-to-date review. Crit
Care. 2015;19:186.

Sample Questions

Questions
Choose the best answer for each question.

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1. A 43-year-old woman unbelted driver was involved in a motor vehicle collision into a tree. She was
noted to have extensive facial injuries including fractures to the midface and mandible with
bleeding in the airway. She does not open her eyes, she moans to deep stimulation, and she has
extensor flexion of her extremities on noxious stimulation. Her oxygen saturation is 90% to 92%.
The optimal management of her airway is
A. nasotracheal airway.
B. orotracheal airway.
C. fiberoptic nasal intubation.
D. endotracheal intubation.
E. surgical cricothyroidotomy.

2. A 65-year-old man is struck by a car while riding a moped. On arrival, his respiratory rate is
18/minute, his heart rate is 95 beats/minute, and his BP is 78/54 mm Hg. His oxygen saturation
is 93%. He complains of chest pain and shortness of breath, and he has right chest wall tenderness
and decreased breath sounds. He moves all his extremities to command. The most likely cause of
his hemodynamic instability is
A. neurogenic shock.
B. cardiogenic shock.
C. hemorrhagic shock.
D. distributive shock.
E. obstructive shock.

3. A 23-year-old man is brought in by EMS after a fall off his roof. He presents unresponsive, with a
heart rate of 40 beats/minute and a BP of 165/90. His GCS is 3. His physical exam shows a
laceration to his right scalp, bruising of his chest wall, a nontender, nondistended abdomen, and
deformity of his right forearm. His FAST exam is positive. The next step of his management
should be
A. endotracheal intubation.
B. administration of an antihypertensive agent.
C. resuscitative thoracotomy.
D. CT scan of his head.
E. exploratory laparotomy.

4. A 70-year-old woman is brought in after a fall down a flight of stairs. She is disoriented to time
and place, is somnolent, and complains of neck and back pain. She cannot feel or move her lower
extremities. She localizes to pain her upper extremities. Her heart rate is 46 beats/minute, and her
BP is 75/34 mm Hg. This patient most likely has
A. high cervical spine injury.
B. low cervical spine injury.
C. high thoracic spine injury.
D. low thoracic spine injury.

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 E. lumbar spine injury.

5. A 38-year-old unbelted male driver is involved in a head-on motor vehicle collision and is brought
in to the ED, with a heart rate of 95 beats/minute and BP of 65/28 mm Hg. He is awake and
anxious, complaining of shortness of breath and chest wall tenderness. He has decreased breath
sounds on the right, bruising across his chest, and chest wall tenderness. The next step should be
A. orotracheal intubation.
B. nasotracheal intubation.
C. ED thoracotomy.
D. chest tube placement.
E. needle thoracostomy.

Answers and Explanations

1. Answer: B
Establishment of an airway can be challenging in patients with complex facial injuries. Owing to her
injuries, this patient requires immediate placement of a secure airway. Nasal instrumentation and
intubation should be avoided because of the concern for a skull base fracture. Endotracheal intubation
should be the initial modality for establishing an airway. Emergent surgical cricothyroidotomy may be
required if orotracheal intubation is unsuccessful. For more information on this topic, please see the
section on Airway.

2. Answer: C
After traumatic injuries, hemorrhage accounts for the majority of cases of persistent hypotension. The
patient in this scenario does not present with signs or symptoms of neurologic injury that would suggest a
cause for neurogenic shock. While cardiogenic shock is possible, hemorrhagic shock from a hemothorax
is the more likely diagnosis. For more information on this topic, please see the section on Circulation.

3. Answer: A
The constellation of hypertension and bradycardia with a slow respiratory rate is suggestive of a Cushing
reflex because of increased intracranial pressures. Immediate establishment of an airway with immediate
head CT scan is essential. Management of hyperventilation, elevation of the head, administration of
mannitol, and surgical decompression may be required. For more information on this topic, please see
the section on Head Injury.

4. Answer: C
The combination of bradycardia and hypotension in a patient with suspected spinal injury is concerning
for neurogenic shock due to loss of sympathetic vasomotor tone. Cervical and high thoracic spinal
injuries can cause neurogenic shock. This patient shows no deficits consistent with cervical spine injury;
therefore, a high thoracic injury is the most likely etiology. For more information on this topic, please see
the section on Injuries of the Spine and Spinal Cord.

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5. Answer: E
This patient presents with hypotension with a probable tension pneumothorax. Immediate
decompression with needle thoracostomy is required. Chest tube placement will be needed after
decompression but requires more time to perform in a patient in extremis. Establishment of an airway is
not required, and in the setting of tension pneumothorax, administration of sedation and paralytics can
worsen hypotension. In the presence of vital signs, ED thoracotomy is not indicated. For more
information on this topic, please see the section on Breathing.

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