Airway	Airway is safe if pt can: conscious and speaking in a normal tone of voice. AW is endangered if: if expanding hematoma or emphysema in the neck. Intubate when: ·       GCS 8 or low ·       Breathing is gurgling / abnormal ·       Inhalation injury If there is cervical spinal injury, handle AW 1˚, it’s more important. ·       USE ENDOTRACHEAL INRUBATION (FROM MOUTH TO TRACHEA) ·       If laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged –> Cricothyroidomy. ·       Use a fiberoptic bronchoscope if subcutaneous emphysema in the neck → MUST: it is a sign of major traumatic disruption of the tracheobronchial tree.
Breathing	Hearing breath sounds on both sides of the chest and having satisfactory pulse oximetry establishes that breathing is okay.
Circulation	·       Insert large bore IV ·       Check if pt is in shock or not. ·       Manage Shock
Disability	·       GCS ·       Pupil ·       Neurological Sx
Exposure	Expose the pt

Any loss of consciousness	CT
Concussion	Contusion
No focal finding	Rarely focal
No lucid interval	No lucid interval
Normal CT	Ecchymoses
No specific treatment; observe at home for lucid interval or new focal findings	No specific treatment; observe in hospital
Subdural hematoma	Epidural hematoma
+/– focal findings	+/– focal findings
+/– lucid interval	+/– lucid interval
Venous, crescent	Arterial, biconvex or lens-shaped hematoma
Drain large ones	Drain large ones
LARGE ONES ARE?	·       Compression of ventricles or sulci ·       Herniation with abnormal breathing and unilateral dilation of the pupil ·       Worsening mental status or focal findings
If midline structures are deviated	craniotomy will help, but prognosis is bad.
If there is no deviation	therapy is centered on preventing further damage from subsequent increased ICP. 1.     Elevate head 2.     Hyperventilate (<pco2 35) a.     Hyperventilation is recommended when there are signs of herniation, and the goal is a PCO 2 of 35. 3.     Mannitol
How to ⤵️ O2 demand?	Sedation and hypothermia have been used to decrease brain activity and oxygen demand. Hypothermia is currently suggested as a better option to reduce oxygen demand.

Clinical scenario	Recommendation
Any of the following: ·       Focal neurologic findings ·       Skull fracture, especially signs of basilar skull fracture ·       Seizure ·       Persistent altered mental status (e.g., agitation, lethargy, slow response) ·       Prolonged loss of consciousness	Head CT without contrast
GCS = 15 with any of the following: ·       Vomiting ·       Headache ·       Questionable or brief loss of consciousness ·       Injury caused by high-risk mechanism of injury ·       Severe mechanism of injury	Clinical preference: Observation for 4-6 hours OR Head CT without contrast
Minor head trauma (GCS = 15 with non-severe mechanism and no vomiting, headache, loss of consciousness, or signs of fracture)	No head CT

 

NECK TRAUMA

Penetrating trauma	expanding hematoma / Unstable VS / or clear signs of esophageal or tracheal injury (coughing or spitting up blood)  → Surgical exploration.
Gun shot:	·      if upper areas –> arteriographic diagnosis and management ·      If base of neck –> arteriographic + enema (visualize esophagus) for diagnosis and management
Stab wounds to the upper and middle zones	Asx pts can be safely observed.
PT w/ Severe blunt trauma to the neck,	the integrity of the cervical spine has to be ascertained.
If there are neurologic deficits / or pain on palpation of cervical spine	Order CT.

Spine Trauma

General management	Prehospital: ·       Spinal immobilization (e.g., backboard, rigid cervical collar, lateral head support) ·       Careful helmet removal (e.g., motorcycle helmet) ·       Airway oxygenation Emergency department: ·       Orotracheal intubation preferred UNLESS significant facial trauma present ·       Rapid-sequence intubation added for unconscious patients who are breathing but need ventilatory support ·       In-line cervical stabilization suggested UNLESS it interferes with intubation ·       CT of entire cervical spine ·       Monitoring for neurogenic shock from spinal cord injury
1˚ No pelvic / urethral injury	Bladder Cath
2˚ Imaging	MRI is preferred over CT.
Compression / Neurological sx	IV STEROIDS –> CT
Complete cut of SC	Nothing below lesion (no sensory nor motor)
Brown sequard (hemisection)	·      You lose 3 tracts ·      STT: contralateral loss ·       note: loss starts 2 levels below ·      DC: ipsilateral loss ·      CS: ipsilateral loss
Anterior cord	You lose motor + STT. Burst injury. So: ·       Motor below injury is gone ·       STT: contralateral loss
Central cord	·      elderly with forced hyperextension of the neck ·      paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.

CHEST

 

Rib Fx

·      Rib fracture can be deadly in the elderly, ·      because of progression of pain → hypoventilation → atelectasis → pneumonia. ·      Tx: pain control.

	Features	Dx	Tx
Aortic injury	·       Blunt trauma ·       Anxious pt ·       HTN / PAIN ·       CXR: ·       Mediastinal deviation ·       Mediastinal widening	CT	Anti-HTN Surgery
Diaphragmatic Rupture	Presents w/ either: ·       Resp distress ·       S/S of SBO ·       Abd pain referred to shoulder	CXR: bowel in chest	Surgery
Esophageal Rupture	·       Mediastinal widening ·       Chest pain ·       crepitus & ⊕ Hamman sign ·       Pleural effusion: green	Esophagogram: air leak from esophagus	·       NPO ·       IVF ·       ABx ·       Surgery 🚨
Bronchial Rupture	·       PTX that doesn’t resolve w/ chest tube ·       Pneumomediastinum ·       Subcutaneous emphysema	CXR	Surgery
Myocardial Rupture	Death	–	–
Myocardial Contusion	Can presents as it pleases: ·       As MI ·       Arrhythmia ·       Wall injury ·       Temponade ·       HF ·       Most common association: sternal fx	Urgent Echo +ECG changes Troponin high	·       Tx based on Sx ·       If CHF: diuretics
PTX	Clear	Clear	Chest tube

PTX	Hemothorax
·      here not tension pneumothorax, ·      same finidings ·      Dx: clx –> CXR ·      Tx: tube	·      same pathophysiology, but w/ blood, and it goes down, not up. ·      Dullness on percussion ·      Dx: CXR ·      Tx: ·       Chest tube ·       YOU MUST DDx b/w lung bleeding vs. Vessel bleeding. ·       Lung bleeding stops on its own, ·       Vessels do not ·      How to ddx? ·       amount of blood, if >1500, go to OR. (thoracostomy)
Sucking Chest wound	Flail chest
جرح يدخل الهواء جوا بس مايطلعه برى. lead to tension pneumothorax Tx: cclusive dressing that allows air out (taped on 3 sides) but not in	كذا عظم صدر انكسر، ويصير يتحرك عكس اتجاه التنفّس، إذا سوى شهيق (تدخل)، وإذا زفير (تطلع) issue is risk of pulmonary contusion.  Tx: Binders

Pathophysiology	≥3 contiguous ribs fractured in ≥2 locations → flail chest segment
Findings	·       Paradoxical chest wall motion with respiration ·       Chest pain, tachypnea, rapid shallow breaths ·       CXR: rib fractures +/- contusion/hemothorax
Management	·       Pain control, supplemental oxygen ·       PPV (+/- chest tube) IF respiratory failure

Clinical features ·       Present <24 hours after blunt thoracic trauma ·       Tachypnea, tachycardia, hypoxia Diagnosis ·       Rales or decreased breath sounds ·       CT scan (most sensitive) or CXR with patchy, alveolar infiltrate NOT restricted by anatomical borders Management ·       Pain control ·       Pulmonary hygiene (e.g., nebulizer treatment, chest PT) ·       Supplemental oxygen and ventilatory support

·       can appear up to 48 hours later ·       Dx: CXR (whitining of lungs) ·       Tx: ·       do not add fluid! ·       Diuretics.

?	·       Instrumentation (endoscopy) ·       Trauma ·       Boerhaave syndrome/ Esophagitis
Clx	·       Chest, back and/or epigastric pain ·       Systematic signs such as fever ·       Crepitus, Hamman sign (crunching sound auscultation) ·       Pleural effusion with atypical (e.g. green) fluid
Dx	·       CXR/CT: widened mediastinum, pneumomediastinum, PTX ·       CT: esophageal wall thickening, mediastinal fluid collection ·       Esophagography with water soluble contrast: leak from perforation
Tx	·       NPO, IV Abx and PPI ·       Emergency surgical consultation 🚨

Aortic dissection

·       ينشخل الأورطة ·       w/ deceleration injury ·       CT Angio ·       Surgery or pt die.

Bloody meatus

Retrograde

Clx	Hard signs ·       Observed bleeding ·       Presence of bruit/thrill over injury ·       Expanding hematoma ·       Signs of distal ischemia Soft signs Δ ·       Diminished pulses ·       Bony injury ·       Neurologic 🆎
Tx	If (hard) signs or HD unstable ·       Surgical exploration Otherwise ·       CT scan or conventional angiography ·       Duplex Doppler ultrasonography

	Burns
Features	·       Burn. ·       Associated stuff: CO / Cyanide poisoning
S/S	·       Erythema/Superficial ·       1st degree ·       Epidermis ·       + Pain ·       Blanchable ·       Superficial-partial thickness ·       2nd degree ·       Into superficial dermis ·       + Pain ·       Blanchable ·       Blisters ·       Deep-partial thickness ·       3rd degree ·       Into deep dermis ·       – Pain ·       NOT blanchable ·       Soft ·       Full thickness ·       4th degree ·       Into underlying muscle/bone ·       – Pain ·       NOT blanchable ·       Hard
Dx	·      Clx
Tx	·       ABC ·       Remove all clothing ·       if inhalational injury is suspected, best next step: immediate intubation ·       Best dx test → Bronchoscopy ·       if chemical burn, best next step: irrigation ·       if burn eschar encircles chest, best next step: escharotomy to relieve constriction ·       Fluid: ·       4*kg*BSA ·       Lenger lactate ·       1st 8 h: 1st half ·       Tetanous ppx: all patients with > 10% BSA burn or burn worse than superficial thickness need Td ·       Stress ulcer ppx: Antaacid
Comp	·       Severe burns are often complicated by wound infections and sepsis. ·       They also can present later (years later) w/ SqCC of skin.