ISCCM Manual of Trauma Care Simant Kumar Jha, Jayant Kumar, Abhinav Gupta, Srinivas Samavedam, Arindam Kar
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
Abbreviated injury score 228
Abdomen 139
anatomy of 72
dermatomes of 109f
examination 156
missile injuries of 197
regions of 72t
tenderness 206
Abdominal aorta, primary arteriography of 199f
Abdominal trauma 71, 80f, 167, 222
computed tomography of 76, 77
emergency radiological imaging 71
ultrasound evaluation of 72
Acetabular fracture 131
Acid 207
electrolyte imbalances 191
Acidosis 44f, 189, 223
metabolic 128
Adequate airway, loss of 219
Advanced cardiac life support 190, 219
Advanced trauma life support 124, 137, 161, 194, 219
classification 46, 47t
guidelines 73
principles 88, 162
Aerosol 249
Air hunger 60
Airbag injuries 209
Airway 13, 14, 25, 88, 89, 170, 175, 197, 228
control 139
decision plan 20
difficult surgical 20
evaluation 162
loss of 1
maintenance 2
techniques 21
management 13, 17, 162, 219, 222
trauma scenarios 14
normal 16f
obstruction 15, 16, 60, 243
acute 59
complete 60
partial 60
protection 25
surgical 33
types of definitive 25
Alcohol intoxication 88
Allergy 221
American Association for Surgery of Trauma
Grades 78
Kidney Injury Scale 81t
Liver Injury Scale 78t
Splenic Injury Scale 78t
American Association of Neurology 98
Amniotic fluid 159
embolism 157, 158
Amputations, traumatic 126, 196
Analgesics 94
class summary 212
Anatomical trauma score 228
Ancillary services 250
Anesthetics 94
abdominal aortic 45
rupture of 42
Angiotensin-converting enzyme 178
Anterior cord syndrome 112
broad-spectrum 65
therapy, topical 211
Antimicrobial 143
ointments 144
solutions 144
spectrum 144
Aorta 51
Aortic rupture 59
Aortotomy 199f
Apnea 26
test 98
Arrhythmia 186
Arterial blood 93, 209
gas 17, 187
Arterio-jugular venous oxygen 97
Artificial system 239
Asepsis, surgical 38
Aspiration 219
prophylaxis 228
Assault linear hypodensity 77f
Atlanto-occipital dislocation 112
Atlas C1 vertebrae 104f
Atlas fracture 112
Avulsion fractures 131
Axis fracture 112
Bacitracin 144, 212
single-hand technique for 29f
ventilation 29, 29f
Bag-valve-mask, self-inflating 220
Balloon dilatation 66
Barbiturates 94
Basal metabolic rate 175
Basic airway equipment 219
Basic life support 219
Battle sign 88f
Biobrane 145
Biological attack 241
Bizarre injuries 169
injuries 201
victim, clinical photograph of 202f
Bleaches 208
complications 147
control 2, 4
vaginal 155
bank 250
gas analysis 139
loss 5, 126, 165t
severe 42
pressure 97, 218
systolic 49, 89, 230, 242
replacement 159
supply 114f
urea nitrogen 209
Blunt abdominal
CT protocol 83
trauma, mechanism of injury in 71
Blunt esophageal rupture 58
Blunt trauma 58
abdomen 82fc
Bone 196
X-ray of 196f
gas patterns 75
injuries 79
Bradykinin 234
Brain 176, 195
contusion 86
death 98
injury, traumatic 14, 87, 87, 89, 200, 232
tissue oxygen 97
trauma foundation 91
guideline 232
volumes of 86
Brainstem reflexes 91t
absent 98
Breath sound 16
Breathing 13, 88, 89, 139, 170, 175, 197, 220
evaluation 163
management 163
mechanical block to 139
problem 25
regular 121
Brown-Séquard syndrome 112
Bucket handle fracture 131
Burn 25, 137, 158
care, final phase of 149
classification of 137
dermal 144f
second-degree 137
depth of 142f
dermal 211-213
electrical 138, 149
esophagogastric 205
extent of 139, 140
face 139
facial 15, 149
first degree 137, 142
fourth-degree 137, 142
full-thickness 142, 146f
hand 149
immediate life-saving measures 138
injury 139
large 137
surface 210
management 222
mild 211
moderate corneal 213
ocular 211
partial-thickness 138
pathophysiology of 137, 138fc
physiology 137
severe corneal 213
sharply demarcated 169
superficial second-degree 137
third-degree 137, 138, 142
wound excision 144
fascial excision 145
full-thickness excision 145
layered excisions 145
tangential excision 145
wound management 143
components of 143
Burst fracture 116f
Calcium 211
injections of 211
oxide 207
Canadian C-spine rule 117
Cancer 174
Cannulation, arterial 186
Carbon deposits 139
Carbon dioxide
end-tidal 17
partial pressure of 93
Carbonaceous sputum 139
Carboxyhemoglobin 139
Cardiac arrest 185
Cardiac tamponade 58, 60, 66
presence of 73
treatment of 66
Cardiotocographic monitoring 157
Carotid pulse 186
Cataract, traumatic 201
Catecholamine surge 42
Cell death 87
Cellular energy crisis 87
Central cord syndrome 110
Central nervous system 165, 169, 184
depression 16
Central venous pressure 157
Cerebellum 90
blood flow 86
fluid drainage 93
hypoperfusion 25
metabolic rate of oxygen 199
monitoring, advanced 96
perfusion pressure 86
monitoring 96
thresholds 97
Cerebrospinal fluid 86, 176
cord injury 16
immobilization, maintenance of 222
spine 103, 104
injury 103, 112, 117, 118fc, 167
movement, restriction of 2
agents 241
burn 138, 148
injuries 205
pathophysiology 205
Chest 139
asymmetrical movement of 59
dermatomes of 109f
injury 175, 222
missile injuries of 200
pain 64, 66
retraction 15
trauma 167
tube insertion 38
complications 38
indications 38
procedure 38
X-ray 69
Chin-lift maneuver 21, 21f
Chloroacetic acids 207
Chromates 208
Chromic acid burns 209
Chronic obstructive pulmonary disease 174
Circulation 2, 4, 88, 89, 139, 164, 165, 170, 176, 197
Citrate 48
Coagulopathy 223
early treatment of 5
lethal triad of 44f
process of 43
Coccyx 103
fracture 131
Collar sign 80
Colloids 50, 234
Coma 98
Combitube 27f
Comet tail sign 68
Communication 224
Compartment syndrome 127, 133
Complete blood count 45, 187
external 72
fractures 113
injury, lateral 128
Computed tomography 69, 89
chest 69
contrast-enhanced 79f
noncontrast 90
Consciousness 14
level of 218
loss of 26, 169
Continuous positive airway pressure 191
Controlled oxygen therapy 36
Contusion 81
myocardial 59, 66
Cool burn wound 138
Corneal reflex 91
Corpus callosum 90
Cough 91, 222
Craniectomy, decompressive 91
Crepitus 206
suggesting subcutaneous emphysema 15
Cresols 207
cartilage 164
pressure 29
Cricothyroid membrane 34
Cricothyroidotomy 163
surgical 34, 35, 35f
Crush syndrome 127, 128
Crushing forces 72
Crystalloid 234
C-spine fractures 174
Cuff deflation 24f
Cyanosis 15, 37, 60
Cyclones 239
Cytokines, inflammatory 231
Daily living, activities of 91
Damage control
resuscitation, principles of 48
surgery 223
injury-related 13
trimodal distribution of 218f
Deep vein thrombosis 120, 231
prophylaxis 95
Diagnostic peritoneal lavage 176, 222
Diaphragmatic injury 65, 80
diagnosis 65
management 66
Diaphragmatic rupture 59
Diencephalon 90
Diluted potassium permanganate 208
Disability 6, 25, 88, 139, 140, 176
Disaster 238
classification of 238
effects 251
major 240f
management 245
act 238
cycle 246f
principles of 238
team 248
man-made 238, 239
natural 238, 246
recovery, process of 251
risk reduction 239
supply kit 248
triage criteria for 249
Disseminated intravascular coagulation 128
Distress, fetal 157
Domestic abuse 158
Double unilateral rami fractures 131
Drowning 183
pathophysiology of 183
process 184fc
secondary 183
victims 190b
interactions 178
therapy 175
Duplex sonography 96
Duverney fracture 131
Dysphagia 205, 206
Dyspnea 206
injuries, external 200
missile injuries of 200
Earth's crust 238
Earthquakes 238
Ecchymosis, inspect for 156
Edema 139, 206
pulmonary 184, 188, 191
extension 109
flexion 109
Elderly abuse 178
signs of 178
Electrocardiography 187
balance 188
disturbances 196
Emergency department 128, 250
care 210
Emphysema, subcutaneous 39, 58
E-mycin 212
Endocrine system 155
Endothelial injury 231
Endotracheal intubation 27, 149, 210
readiness for 28f
Endotracheal tube 27f, 164, 222
placement of 163
Epilepsy 184
Erythromycin ophthalmic 212
Escharotomy 139, 146f
Eschmann tracheal tube introducer 30, 31f
Esophageal airway, multilumen 25
Esophageal perforation 65
diagnosis 65
management 65
Esophageal rupture 59
Esophagoscopy 209
Etomidate 32, 162
Excess plasmin activity 43
Exercise 148
Exposure 7, 88
Extracorporeal membrane oxygenation 187
Eye, missile injuries of 201
Eyeball, ruptured 201
Face mask 37
simple 36f
Fascia, deep 196
Fasciotomy 139, 143
plan of 139
Fat embolism syndrome 127
Federal Emergency Management Agency 247
Femur fractures, shaft of 127
Fentanyl 162
Fetal demise 158
Fetal heart
rate, abnormal 157
sound 157
Fetal movement 155
Fiberoptic bronchoscopy 32
abduction 109
extension 109
flexion 109
pulse oximetry 3
Flail chest 3, 58, 59, 63, 243
diagnosis 64
management 64
Floods 239
Fluid 77f, 188f
administration, methods of 233
balance 95
collection of 68
lost, volume of 137
management 233
resuscitation 139, 140, 142, 164, 220, 225
cautious 64
volume 75
Foley’ catheterization 187
Formal thoracotomy, indications for 200
Fracture 112, 116f, 132, 221
facial 25
femoral 126, 127
multiple 125
odontoid 116f
palpable 15
ribs 3, 59
skull 86
straddle 131
Free peritoneal fluid 77
Fresh frozen plasma 49
Gag reflex 91
Gas 249
distension 120
tube 6
complications 131
endoscopy, upper 209
system 120
tract 155, 175
Genitourinary system 120
Geriatric trauma 179
basics of 174
Glasgow coma scale 25, 86, 89, 91t, 162, 190, 229, 230t
score 118fc
Global report on road safety 2013 13
Global wall motion abnormalities 73
Glomerular filtration rate 155, 175
Glottis, view of 30f
Glucocorticoids 95
Great vessel injury 64
Growth factor, insulin like 148
Gum elastic bougie 31f
Gunshot wounds 113
Hair coloring agents 208
Hand burn 149
treatment of 211
Head injury 14, 25, 90, 92, 221
classification 87
clinical pathophysiology 86
etiology 86
evidence-based management guidelines 90
mild 88fc
moderate 89
motorcycle-related 86
severe 89
Head trauma 86, 166, 174
severe 96
Headache, persistent 88
Health system 241fc
Healthcare system, level of 220
Heart 39
diseases 174
evaluation of 73
rate 230
Heavy metal toxicity 202
Helmet removal 17, 18f
Hematoma 78
extradural 90f
intracranial 86
large intraparenchymal 79f
mesenteric 79
multiple subdural 169
spinal 117
Hemodynamic status, classification of 5t
Hemoperitoneum 77
Hemorrhage 52, 201
arterial 126
control 126
fetomaternal 157, 159
gastrointestinal 42
induced profound changes 42
intra-abdominal 161
intracranial 161
major arterial 126
maternal 42
perioperative 42
severe 45f, 46
Hemorrhagic shock 42, 46, 52, 234
classification of 47t
diagnosis 44
management 44, 131fc
pathophysiology of 42, 43f
resuscitation 49fc
signs of 63
Hemostasis 50
Hemothorax 58, 163
evaluation 68
simple 3
Heparin 231, 232
Hepatic failure 147
Hepatorenal pouch 74
Herniated disk 117
Herniation 26
Heterotopic ossification 202
High flow oxygen 17, 37, 61
High speed motor vehicle
accidents 124
collisions 59
High velocity missile 194, 195f
Hip injuries 125
Homeostasis, temperature 120
Household-grade hydrogen peroxide 208
Human growth hormone, recombinant 148
Hunshot wounds 158
Hydrochloric acid 207
Hydrofluoric acid 207
burns 210
Hydroxyethyl starch 234
Hyomental distance 18
Hyperkalemia 189
Hyperosmolar therapy 92
Hypertonic saline, use of 46
Hypoperfusion complex 79
Hypotension 196
postural 4
supine 4
Hypothermia 44f, 118, 119, 184, 186, 189, 191, 210, 223
prophylactic 92
Hypovolemia 191
Hypoxia 13, 191
Ibuprofen 212
I-gel 25f
fixing 27f
insertion steps 26f
supraglottic airway 27f
Iliac wing fracture 131
Immersion syndrome 183
Immobilization 118
principle of 169
nutrition, role of 233
system 177
Infarction, myocardial 186
Infection 210, 228
prophylaxis 95
Inflammation 44
Inflammatory reaction 137
Infusions, intra-arterial 211
Ingestion, caustic 211
Inhalational injury 138, 139
management of 146
Injury 39
abdominal 170, 222
adrenal 80
alkaline 205
anatomical 58
aortic 60, 64
around airway passage 25
assessment 194
blunt 155
cardiac 58, 66
hepatic 78
bronchial 3
bullet 194
closed 125
description of 81
diffuse axonal 86, 87
duodenal 168
grade for bilateral 81
head 14, 25, 90, 92, 221
hepatic 78, 200
inhalational 138, 139
intracranial 16
laryngeal 25
level of 106, 109
life-threatening 126
lightning 138
limb-threatening 132
location of 75
mesenteric 79
missile 194, 198fc
musculoskeletal 124
myocardial 60
neurological 133
nonaccidental 186
open-book 131
pancreatic 79, 80f
pediatric abdominal 167
penetrating missile 194
perioral 169
septal 66
classification, revised 230
score 59, 229, 230
small intestinal 168
splenic 78
stab 113
stomach 168
thoracic 167
tracheal 3, 25
traumatic 174
vascular 81
vertical displacement 128
visceral 81f
Institutional framework disaster management structure 251
Insulin 148
Intensive care unit 49, 86, 199, 228, 250
management 228
Intercostal drain insertion 37
Intervertebral fibrocartilaginous disk 103
Intracompartmental pressure, increased 133
Intracranial pressure 86, 97
management of 228
reduction of 199
Intraperitoneal free fluid 75
movement of 75
Intravascular volume 48
appropriate replacement of 4
resuscitation 125
Intravenous fluid 119
resuscitation 142
Intubating laryngeal
mask airway 23
tube airway 24
criteria for 162
drug assisted 32
Ischial body fractures 131
Ischial rami 131
Isotonic crystalloids 50
Jaw-thrust maneuver 21, 22f
Jefferson fracture 115f
Ketoprofen 212
Kidney function test 187
Kinking 39
Kissing papillary muscles 76
Klebsiella 146
Kleihauer-Betke test detects 157
Labored breathing 16
clinical signs of 26
Laceration 78, 81
Lactated ringer solution 49
Large zipper compartment 260
Laryngeal handshake 34f
Laryngeal mask airway 23, 24f
insertion 24f, 25f
Laryngeal tube airway 24, 27f
missile injuries of 196
muscles 196
Liver 39
function test 187
missile injuries of 200
right lobe of 79f
spleen 195
Living guidelines 91
model 91
Local tissue oxygen, measurements of 96
Low flow oxygen devices 36
Low molecular weight heparin 231, 232
Low oxygen saturation 15
Lower limb 139
dermatomes of 108f
myotomes 111f
Lumbar spine 117
Lumbar vertebral fracture 113
Lumbosacral regions 103
contusions 59
infection 189
protective ventilation 146
sliding, absence of 68
Macronutrient formulation 233
Mafenide acetate 144
Malgaigne fracture 131
Mallampati score 19f
Manganates 208
Manual in-line stabilization 20
Massive blood transfusion 5
protocol transfusion 6t
Massive cardiac tamponade subcostal view 74f
Massive hemothorax 3, 58, 59, 63
diagnosis 63
management 63
Maxillofacial trauma 15
Mechanical plus pharmacological prophylaxis 232
Medical antishock trouser 124, 130
Medical equipment kit 247
Medical triage cold zone 242
Membrane, premature rupture of 155
health 201
status, altered 4
Metallic lithium 210
Metformin 148
Microvascular reaction 137
Missile factors 194
Mitigation 246, 251
Mitochondrial dysfunction 87
Mobility, loss of 120
Monitor adequate oxygenation and ventilation 17
Monitoring transplantation activity, advisory bodies for 99
Monochloroacetic acid 207
Morison's pouch 74, 74f, 77f
Morphine 212
sulfate 212, 213
Mortality, fetal 152
Mortuary services 250
Motor function 106
Motor vehicle
collision 80
crashes 13
Mounting oxygen debt 42
Multicolored bruises 169
dysfunction 58, 198
failure, prevention of 146
Mupirocin 144
Muscle function grading 111t
Musculoskeletal injury 124
treatment of 177
Musculoskeletal system 177
injuries 125
Musculoskeletal trauma 124, 168
classification of 124
injuries 125
prehospital management of 124
resuscitation of 125
types of 124
Myocardial infarction 186, 243
Myocardial wall, rupture of 58
Myometrium protects 159
Myotome 106
Naproxen 212
Narcotic analgesics 143
Nasal hairs 222
Nasal prongs 36f
Nasogastric tube insertion 143
Nasopharyngeal airway 22, 22f
in situ 22f
National Disaster Management Authority 251
National Disaster Management Plan 246
National Disaster Response Force 252
National Emergency X-radiography Utilization Study 117, 117b
National Institute of Disaster Management 251
Near drowning 183
and extension, flexion of 29f
burn 139
hematoma 25
injuries 168
mobility 19
trauma 15
and surgical cricothyroidotomy 223
chest decompression 223
cricothyroidotomy 33, 33f, 34f
thoracocentesis 37
Neomycin 144, 212
Neurologic deficit 117, 197
severity of 106, 110
Neurological system 155
New injury severity score 229
Nitric acid 207
N-methyl-D-aspartate, antagonist of 95
Nonsteroidal anti-inflammatory drugs 211
and intravenous fluids 95
and metabolism 177
in trauma patient 232
route of 232
Nutritional status, monitoring of 233
Nutritional support 147
site for 232
timing of 232
Nystatin 144
complete 15
incomplete 15
signs of 16
Occult skeletal injuries 133
Ocular surface, pH of 209
On-site triage hot zone 241
Open fracture 132
wound 132f
Open pneumothorax 3, 37, 59, 63
management 63
recognition 63
Optic nerve injuries 201
Optimum resuscitation fluid, characteristics of 233
Oral burns, caustic 205f
donation 98
failure, management of 147
parenchymatous 195
systems 106
Oropharyngeal airway 22, 23f
in situ 23f
Oropharynx 139
Orotracheal intubation 28, 162
Oxandrolone 148
Oxidants 208
delivery devices 249
supplementation 63
therapy 35
devices 36
inadequate 25
management of 35
Packed red blood cell 49
assessment 165
management 143, 178, 225
Pancreas, missile injuries of 200
Pancreatic transection 79
parenchyma suggestive of 80f
complete 111
neuromuscular 26
Parenchyma, pancreatic 79
Pediatric trauma 161
score 169, 169t
Pediatric victims 185
Pelvic 68, 75
binding, external 130
fracture 81, 81f, 126, 128, 131fc, 174
types of 129f
unstable 128
Pelvis dislocation 131
Penetrating injury 58, 112, 155
mechanism of injury in 72
type of 117
Pericardial tamponade 59, 64
diagnosis 64
management 64
Pericardium 39
Perimortem cesarean section 158
Peripheral pulses, return of 164
Peroxides 208
Phenol 207, 210
Phosphates 208
Phosphoric acid, uses of 207
Physiotherapy 148
Pigmentation, return of 143f
Pigskin 145
Placental abruption 153f, 158
Plasma 48
electrolytes 188
Platelet 48
function, suboptimal 43
Pleural effusion 69
Pneumatic antishock garment 124, 130
Pneumonia 189
ventilator associated 146
Pneumoretroperitoneum 79
Pneumothorax 62
evaluation 68
simple 3, 37, 58
tension 58
Poisoning, metabolic 139
Polyethylene glycol 210, 212
Polymyxin B 144, 212
Polytrauma 132
computed tomography protocol 77
Positive end-expiratory pressure 187, 188
Potassium 210
Pregnant Rh-negative trauma 159
Prehospital care 45, 138, 210, 217
intra-abdominal 80
intracranial 86, 97
ulcer 120
develops 121
Propofol 94
Propranolol 148
Pseudomonas 146
Pubic symphysis subluxation 131
Pulmonary contusion 3, 58, 59, 66
diagnosis 66
management 66
Pulmonary embolism 120
risk of 231
Pulmonary system 120
Pulse 4
oximetry 16, 157
rates 242
Pulseless electrical activity 185
Pulselessness 42
Pupillary light reflex 91
Radiation hazard 241
Rancho los amigos scale 87b
Random blood sugar 209
Rapid neurologic evaluation 6
Rapid respiratory rate 16
Reconstructive operative procedures 149
Red blood cells 184
Reflex, oculocephalic 91
Rehabilitation 149
Renal failure 147
Renal functional tests 209
Renal injury 80, 187
Respiratory distress 60, 220
management of 220
Respiratory failure 190
Respiratory muscle paresis 16
Respiratory system 155
Resuscitation 2, 121, 185, 186
cardiopulmonary 190
endpoints of 51, 179
Retina 201
Retinal detachment 201
Retroperitoneal space after laparotomy, exposure of 199f
Revised trauma score 230
Rh immunoglobulin therapy 159
Rhabdomyolysis 210
Rib 67
fractures 174
shadow 75
Rigid suction cannula 17
Road traffic
accidents 86
injuries 218f
Rule of nine for burn surface area calculation 140f
Sacral fracture 131
Sacrum 103
Scald 137
Scapula fracture 59, 67
Sedatives 94
Seizure 186
post-traumatic 96
prophylaxis 96
Seldinger technique 33f
Sensation, loss of 120
Sensorium, clearing of 164
Sensory tract 106f
Sentinel sign 77
Septicemia 189
Sexual abuse 158
Shaken body syndrome 166
Shock 165, 179, 220, 221
cardiogenic 221
hemorrhagic 42, 46, 52, 234
neurogenic 106
pathophysiology of 137
spinal 106
thermoregulation 165
Shoulder abduction 109
nitrate 144
sulfadiazine 144, 212
Skin 4
color, return of normal 164
grafting 213
Sodium 210
carbonate 208
hydroxide 207, 211
Soft tissue injury 58, 117
Spinal column 103
ligamentous part of 103
Spinal cord 16, 105, 112f, 114f
cross-section of 115f
injury 103, 112, 167, 176
prevention of secondary 119
missile injuries of 197
pediatric 105
syndrome 106, 110
tracts 105f
trauma 103
Spinal injury
classification of 106
improper handling of 103
Spinal needle 221
Spine 103, 177
injury 103, 112, 177
management of 118
Spinothalamic tract 106f
Spleen, missile injuries of 200
Spontaneous abortion trauma 157
Stab wound 158
Stable pelvic fracture 131
State Disaster Management Authority 252
Sterile speculum examination 156
Sternum 67
Steroid 95, 211
role of 119
Stop bleed, methods of 126f
Stress 162
Stridor 60, 206
Stroke 174
Sulfuric acid 207, 211
Supraglottic airway devices 23
Swelling 139
Syncope, recovery 183
Tachypnea 206
Tension pneumothorax 3, 37, 59, 60, 62, 243
causes 62
management 62
recognition 62
Thermal burn injury 139
Thiopentone 163
cage 58
spine 105, 113, 117
trauma 58, 62
classification of 58t
vertebra fracture 58
Thoracoscopic surgery, video-assisted 63
Thoracotomy 63
Thrombocytopenia 147
Thromboelastography 5, 45, 47, 51, 51f
rotational 51
Thromboelastometry 45
rotational 47
Thromboprophylaxis 231, 232
factors 194
monitors 97
transplant organization 99
type of 194
Tongue, caustic burns of 206f
Tornadoes 239
Toxins 241
Tracheobronchial injury 59, 61, 167
management 61
recognition 61
Tracheotomy 220
Tranexamic acid 220
Transcranial Doppler 96
sonography 96
Transcyte 145
Transfusion, massive 50
Transplantation of Human Organs Act 98
Transtracheal oxygenation, percutaneous 33
Trauma 9fc, 112, 179, 230, 231, 233
assessment of 1
care 217, 228
causes of 217
deaths 9
extended focused assessment with sonography for 68f
facial 15
focused assessment with sonography for 45, 67f, 73
head 86, 166, 174
in elderly 174
in pregnancy 152, 153
initial management of 1
kills 1
laryngeal 15
lethal trial of 223
major 232, 243
mortality prediction model 229
multidisciplinary 174
musculoskeletal 124, 168
ocular 168
protocol 139
resuscitation guidelines 170t
score 228, 230
systems 228
severe musculoskeletal 127f
severity characterization of 230
team activation 174
victim 1, 220
management of 219, 224
Traumatic circulatory arrest 58, 60
Traumatic head injury, surgical management 98
Tricarboxylic acid 207
Trimodal death pattern, concept of 1
Tsunamis 239
Two hand C-E technique 29f
Tympanic membrane perforation 200
Ultrasonography, emergency 224
Upper airway
bronchoscopy of 146
obstruction 25
Upper limb 139
dermatomes of 107f
myotomes 109t
Urinary system 155
alkalization of 128
output, decreased 4
contractions 155
rupture 158
torsion 158
Valvular injuries 66
Vascular access 140
Ventilation 16, 139, 162, 175, 228
inadequate 16, 25
supplemental 17
therapies 93
Ventricular fibrillation 186
Venturi mask 36, 36f
Verbal rating score 166
endothelium of 42
missile injuries of 195
Victims, triaging for 241
Videolaryngoscope 30, 30f
Viscera, abdominal 159
Visual analog score 166
Voice, hoarseness of 15, 139
Warfarin 72, 231
Wet drowning, mechanism of 183
Wheezing 206
White phosphorus 208
World Health Organization 13, 217
healing function 177
open 126
extension 109
flexion 109
Xenografts 145
Chapter Notes

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Assessment and Initial Management of Trauma1

Babu K Abraham
Trauma is one of the major causes of mortality and morbidity in India, especially during the productive years of life, i.e., 15–30 years of age group. The World Health Organization's (WHO's) statistics clearly show that the developing world contributes the most to the number of trauma victims with >90% of the road traffic accidents (RTA) occurring here. This could be due to the lack of public awareness on safety, lethargy in the government mechanism to impose safety regulations, lack of coordinated prehospital care for trauma victims, lack of standardized trauma training for medical personnel, and nonavailability of dedicated trauma team or center for the care of the injured.
Trauma kills in a very predictable manner. The concept of a “Trimodal” death pattern in trauma is well recognized and it consists of three peaks of death during the natural course of recovery of an injured person. The first peak occurs immediately following the event and is usually due to apnea caused from severe brain or high spinal cord injury or rupture of the heart or one of the large vessels. Only few of these patients can be saved and that too by putting in place preventive measures. The second peak of death happens minutes to hours after the injury and is due to lesions such as subdural hematoma, extradural hematoma, hemopneumothorax, ruptured spleen/liver, fractured pelvis, and any other injury that causes significant blood loss. Rapid focused assessment and resuscitation in a coordinated manner can reduce death during this period. The third peak occurs days to weeks after the injury and is usually due to secondary infection, sepsis, and multiorgan dysfunction. In a trauma victim, loss of airway (A) kills quicker than the inability to breathe (B), which kills faster than loss of blood volume (C), followed by an expanding intracranial mass/hematoma (D). This predictable and reproducible manner in which injuries kill their victim has been incorporated into the trauma resuscitation algorithm. The emphasis is on treating the greatest threat to life first. This has generated the ABCDE approach to trauma resuscitation. Resuscitation during the “Golden hour” of injury, which is not meant to indicate a fixed time period during which the resuscitation would work but the urgency required for initial assessment and successful treatment of the injured victim has shown to be associated with decrease in mortality and morbidity.
Planning well ahead to receive trauma patients to a hospital is very important and for this coordination with prehospital personnel at the scene of the trauma is absolutely essential. This could also help with the initiation of the resuscitation at the site. During the prehospital phase, emphasis should be placed on maintaining the airway, immobilizing the spine, controlling of the external bleed, treating shock, and immediate 2transport to the hospital minimizing the time spent at the scene to as little as possible. Hospitals that accept the trauma victims should be well prepared to receive them. A smooth handover should be taken from the prehospital personnel making sure that all the vital information required for the rapid resuscitation, such as time of injury, mechanism of injury, events related to the injury, any loss of life at the scene, treatment provided at the scene, and any other vital history that is known, are collected. A resuscitation area should be kept ready and all articles required for “Standard precaution” (face mask, eye protection, gloves, water impervious gown, etc.) are made available. The list of equipment needed for a trauma resuscitation room is exhaustive and the WHO has laid down a simple checklist of essential emergency equipment for resuscitation. The minimum requirements would be a facility for oxygen therapy, suction apparatus, functional airway equipment, warmed intravenous fluids, wide-bore intravenous cannulae, basic splints, and appropriate monitoring facility. All necessary personnel should be mobilized and be ready to accept the victims in the emergency room. The hospital should develop written protocol for prompt responses from the medical team, laboratory, and the radiology departments.
There are certain thumb rules in the initial assessment and resuscitation of trauma patients. The assessment has to be rapid with resuscitation of the greatest threat to life done first. There is no need for a detailed history to initiate therapy and physiological derangements need to be fixed as they are found. This is the principle of primary survey and this has to happen in the following prioritized sequence:
  • A: Airway maintenance with restriction of cervical spine movement
  • B: Breathing with ventilation
  • C: Circulation with bleeding control
  • D: Disability—neurological
  • E: Exposure/environment control.
The quickest way to assess ABCDE is by asking the patient his/her name and what had happened. An appropriate response suggests, in less than 10 seconds, that there is no major airway, breathing, circulation, or consciousness problem. Physiological changes that occur in trauma are very dynamic and a patient who is initially stable can deteriorate rapidly. Frequent revaluation of ABCDE are of paramount importance until definitive therapy has been accomplished.
Airway Maintenance with Restriction of Cervical Spine Movement
All patients with trauma should receive oxygen therapy at 10 L/min given through a mask-reservoir device. If patient is able to talk his/her airway is maintained and needs no airway protection. However, if the patient is not talking, do an in-line stabilization maneuver to restrict cervical spine movement before assessing the airway any further. First, inspect the face to look for any obvious injuries that could obstruct the airway. Then open his/her mouth and inspect inside for any foreign bodies, blood, or secretions that could obstruct the airway. Remove any foreign body, suction the oral cavity and throat clear of all secretions. Reassess the airway patency again and listen for any sonorous noise. If the airway is still compromised do a chin lift/modified jaw thrust maneuver to see if this would open the airway. If it does not and cause for the loss of airway can be rectified quickly, place an oropharyngeal airway. Otherwise think 3of placing a definitive airway, such as an orotracheal intubation.
In the meanwhile, continue with in-line stabilization maneuver until a semirigid cervical collar is applied. Prior to application of the semirigid collar, inspect and palpate the neck to look for any injuries, dilated veins, tracheal shift, or subcutaneous air. The decision to apply or discontinue the cervical semirigid can be made by using clinical decision screening tools such as Canadian C-spine Rule and the NEXUS (National Emergency X-radiography Utilization Study).
After having done these, reassess again to make sure the airway is secure and patent.
Breathing with Ventilation
After the airway is secured, make sure that the breathing and the ventilation are adequate to ensure proper oxygenation and carbon dioxide removal. Injuries that significantly impair ventilation and can be rapidly fatal are:
  • Tension pneumothorax
  • Massive hemothorax
  • Open pneumothorax
  • Tracheal/bronchial injuries.
These injuries need to be identified in the primary survey and attended to immediately to prevent mortality. This can be done by completely exposing the chest and neck, if not already done so during the evaluation of the airway. Then go through the four simple steps of:
  1. Look: Look at the chest wall for any obvious injuries. An open sucking wound would suggest an open pneumothorax. Soft-tissue abrasions could suggest possible injury to deeper structures over that site. Look at the chest movement and count the respiratory rate. Look for paradoxical movement of the chest. If not already done, undo the cervical collar and with in-line manual stabilization of the cervical spine inspect the neck for dilated veins.
  2. Listen: Auscultate to listen for presence or absence of breath sounds. The latter could suggest a pneumothorax or hemothorax. Corroborate this finding with that found on inspection, palpation, and percussion.
  3. Percussion: Percussion is done over the chest looking for resonant, hyperresonant, or dull percussion notes in an attempt to recognize a pneumothorax, tension pneumothorax, and a hemothorax, respectively. These findings need to be corroborated with the findings in inspection, auscultation, and palpation to reach at a diagnosis.
  4. Feel: Palpate the neck and chest carefully feeling for any tenderness, bony crepitus, or air crepitus. This will help in identifying fractured ribs and subcutaneous emphysema.
The less critical injuries, which can be missed if primary survey is not done carefully and then can affect ventilation to varying degrees, are:
  • Simple pneumothorax
  • Simple hemothorax
  • Fracture ribs
  • Flail chest
  • Pulmonary contusion
To make sure that oxygenation and ventilation targets are being met, the following monitoring should be initiated:
  • Finger pulse oximetry (SpO2)—to assess the peripheral hemoglobin oxygen saturation continuously.4
  • End tidal carbon dioxide (EtCO2) monitoring—if available, especially once patient is intubated, helps with assessing the ventilation.
After having completed these, reassess the patient to make sure airway, cervical spine immobilization, breathing and ventilation are stable.
Circulation with Bleeding Control
Shock is a situation where circulatory compromise leads to hypoperfusion of the tissues and it is a major reversible cause of mortality in trauma. Hemorrhage causing hypovolemia is the most common cause of shock in trauma. However, tension pneumothorax and pericardial tamponade, both causing obstructive shock should not be missed. Recognizing shock, especially in its very early stages, is absolutely crucial. The important signs to look for are:
  • Postural hypotension: This is one of the first signs of shock. However, it is very often missed as it may be impossible to perform on trauma patients.
  • Pulse: Tachycardia with rapid and thready pulse is quite suggestive of hypovolemic shock.
  • Supine hypotension: This sets in later, with the loss of large volume of blood and is characterized by a narrow pulse pressure.
  • Skin: Skin would be cool to touch. Face can be ashen and extremities pale.
  • Decreased urine output: Indicates decreased organ perfusion.
  • Altered mental status: Indicates poor organ perfusion.
If facilities for measuring lactate levels and base excess are available, they can be used to assess circulatory compromise. A raised serum lactate or base excess is a sensitive indicator of shock.
Once a circulatory compromise has been identified resuscitation has to be prompt and rapid. It is equally important to identify the site of bleed and to stop it. Resuscitation of a trauma victim in shock consists of:
  • Appropriate replacement of intravascular volume: To achieve this, place two wide-bore peripheral catheters, which are more than 18 gauge. Draw blood for hematological tests, coagulation parameters, blood grouping and crossmatching, and pregnancy test for women in their reproductive age group.
    When peripheral venous access is not achievable, intraosseous, central venous, or venous cut down can be considered.
    Fluid administration should be judicious. Aggressive fluid resuscitation before the control of bleeding has been shown to increase mortality and morbidity. Start intravenous fluid therapy with crystalloids warmed to 37–40°C. Administer 1 L of the solution as a bolus and check for hemodynamic response. Based on the response to this fluid bolus trauma victims can be classified into being responders, transient responders, or nonresponders (Table 1). Transient and nonresponders to the initial fluid bolus should be started on blood transfusion.
  • Hemostatic resuscitation: Start blood product transfusion in transient and nonresponders early. If the victim requires more than two units of packed red blood cells (PRBC), combining it with balanced ratio of plasma and platelet concentrates have been shown to decrease the incidence of coagulopathy and improve mortality.
  • Stopping the bleed: Hemorrhage control is a very important aspect of resuscitation. To achieve this, the source of bleed needs to be identified.5
    Table 1   Classification of hemodynamic status based on response to the initial fluid bolus.
    Rapid responder
    Transient responder
    Vital signs
    Respond and deteriorates
    No response
    Blood loss
    Minimal: 10–20%
    Moderate and ongoing: 20–40%
    Massive: >40%
    Fluid/blood requirement
    Type of blood
    Fully crossmatched
    Type specific
    Emergency release
    External bleed can be identified on inspection. The source of bleed can be controlled by:
    • Direct manual pressure over the wound
    • Packing of the wound: This can be done with ordinary gauze or, if available, one impregnated with hemostatic agent
    • Application of tourniquets: Tourniquets are applied to extremities where the injury is causing massive bleed that cannot be stopped with direct manual pressure and packing. There is a risk of causing ischemia to the limb.
Internal bleeds should be suspected when blood is not seen on the floor. The chest, abdominal cavity, retroperitoneum, pelvis, and long bones are the main areas where hemodynamically significant bleeds can occur. The source should be suspected and identified by the use of adjuncts. Despite a thorough search, if the source of bleed cannot be found, consider log rolling the patient and inspecting his/her back and gluteal region for any injuries that could explain the loss of volume. Lifesaving procedures such as chest decompression, use of pelvic stabilization devices and extremity splints should be performed as indicated, while surgical interventions such as laparotomy and use of interventional radiology techniques may require expertise and transfer of the patient to a higher center.
  • Early treatment of coagulopathy: Severely injured trauma victims are at a high risk of developing coagulopathy and up to 30% of them are coagulopathic by the time they arrive to the hospital. This has to be suspected and coagulation parameters checked as soon as they arrive to the emergency room (ER). Coagulopathy can be reduced by early use of blood product transfusion in a balanced ratio of PRBC:plasma:platelet concentrate. If the victim requires massive blood transfusion (MBT), use of MBT protocols with blood products administered in a predefined ratio (Table 2) helps in reducing incidence of coagulopathy. The use of point-of-care testings such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), if available, will help in deciding what blood products to use. The use of tranexamic acid in prehospital setting, in patients at high risk for developing coagulopathy, has shown to decrease mortality. If used in the field, this needs to be followed up with another dose in the hospital.
  • Resuscitation to a hemodynamic target: The aim of resuscitation is to correct overt signs of hypovolemia and hidden hypoperfusion. There is evidence that over-resuscitation is harmful. Fluid resuscitation of >1.5 L in the ER was associated with higher mortality and delaying fluid resuscitation until definitive surgical control of bleed in a penetrating torso injury had improved outcomes.6
    Table 2   Example of a MBT protocol transfusion.
    PRBC (units)
    Plasma (units)
    Platelets (apheresis) (units)
    Cryoprecipitate (units)
    The recommendation is resuscitation to a target systolic blood pressure of 80–100 mm Hg until definitive therapy, in patients without head injury. This is termed “Hypotensive Resuscitation.”
All through the resuscitative phase, it is important to make sure that the trauma victim is kept free of hypothermia, acidosis, and coagulopathy. These three events form the “Lethal Triad” that increases mortality.
To make sure that the hemodynamics and tissue perfusion are being maintained and the source of bleeding identified, the following adjuncts will be useful:
  • A continuous ECG monitor
  • A blood pressure monitor
  • Access to arterial blood gas machine: To check serum lactate and base excess.
  • X-rays of the chest and pelvis: These are the only two X-rays that are part of the primary survey.
  • Point-of-care ultrasound machine (for FAST/eFAST assessment): FAST/eFAST helps with assessment of fluid collection in the abdomen, pleural cavity, and the pericardial cavity. It also helps diagnose pneumothorax and lung contusion.
  • Urinary catheter has to be placed with caution and avoided if a urethral injury is suspected, by the presence of blood in urethral meatus or perineal ecchymosis.
  • Gastric tube is placed preferably through the orogastric route, especially if there is suspected base of skull injury. It helps to decompress the stomach and to assess for bleeding.
After having completed these reassess the patient to make sure that airway, cervical spine immobilization, breathing, ventilation, source of bleed and circulation are stable.
Disability: Rapid Neurologic Evaluation
Disability assessment, in primary survey, mainly assesses the neurological disability and it consists of only three factors:
  1. Assessment of pupil size and reaction: Difference in pupil size and reaction to light stimulus will help in suspecting and localizing an intracranial lesion.
  2. Assessment for lateralizing signs: This helps in suspecting a spinal cord injury and its level.
  3. Glasgow coma scale (GCS) assessment: GCS is an objective method of assessing level of consciousness. A decreased GCS indicates a lower level of consciousness and the motor score correlates well with outcomes. A low GCS could be due to a direct cerebral injury or a decreased cerebral oxygenation/perfusion. When this is noted, reevaluation of the patient's oxygenation, ventilation, and perfusion is essential.7
A CT scan of the brain is not a part of the primary survey and all patients with traumatic brain injury do not need CT scan of the brain (Box 1). Time should not be wasted on doing CT scan of the brain, especially if there is no inhouse expertise and facilities to deal with the neurosurgical problem.
All arrangements should be made to stabilize the patient and he/she should be transferred to a higher center with neurosurgical backup, as soon as possible.
The main aim in primary survey is to prevent secondary injuries to the neurological system. Until proven otherwise, always consider a change in level of consciousness to be a result of brain injury. Make sure that oxygenation and perfusion are adequate and events such as fever, hypoglycemia, and seizure that can injure the brain further are avoided. Neurosurgical consultation should be obtained early.
At the end of assessing disability, go back and reassess to make sure that airway, cervical spine immobilization, breathing, ventilation, source of bleed, circulation, and neurological status are stable.
Exposure and Environment
As a part of the primary survey, the trauma victim should be completely undressed and examined and quickly examined from head to toe. Look and feel/palpate for any missed injuries. Do not forget to inspect the perineal and gluteal regions that are very often avoided and injuries are missed. After completing the examination, the patient should be covered with warm blankets.
Maintain the environment warm as all trauma victims, especially if they are bleeding, have a tendency to become hypothermic. It is not the comfort of the medical personnel that is important but the patient's body temperature. Monitor the victim's body temperature closely and aggressively bring it back to normal by using blankets, warmers, and warmed intravenous fluids.
At the end of assessing exposure/environment, go back and reassess the patient to make sure that the airway, cervical spine immobilization, breathing, ventilation, source of bleed, circulation, neurological status, and patient environment are all stable.
All through the primary survey, a continuous assessment should be made if the hospital has the capability of meeting the patient's need for definitive care. If it doesn't, transfer to a higher center should be considered. Decision about transferring the patient should be made only after completion of the primary survey and the patient has become stable. Transfer should be only to a higher center that has capabilities to provide definitive care. 8Prior to transfer, the treating doctor should communicate with the team leader at the receiving hospital to provide him/her with all patient details and to make sure that they are ready to accept the patient. He should also, with the help of the receiving team, decide on the mode of transport used for the transfer and make necessary arrangements to make sure that the patient receives the same level of care during the transfer that he requires in the ER. The patient should then be transferred after obtaining consent for the procedure from the patient or/and his family, with all the documents needed for continuing his/her care in the higher center.
Secondary survey is initiated only after primary survey is completed and patient's ABCDE are stable. It consists of a head-to-toe, comprehensive evaluation of patient, examining each region of the body and each system thoroughly. Any investigation that is needed to arrive at a diagnosis is made use as an adjunct.
A complete history that elucidates the mechanism of injury has to be obtained. This helps with anticipating and looking for possible injuries, which are then classified as blunt or penetrating. To help with obtaining the history, the mnemonics “AMPLE” can be used where:
  • A: Allergies
  • M: Medications that is being currently used
  • P: Past illness/pregnancy
  • L: Last meal
  • E: Events/environment related to the injury.
The examination of the patient can start with inspecting and palpating the scalp for any injury. Lacerations and fractures of the skull should be looked for, especially by passing the fingers behind over the occiput and the mastoid region. Palpate every inch of the face looking for similar injuries of the supraorbital ridge, orbit, zygoma, maxilla, mastoid, and mandible. Examine the eyes carefully for any injury to the globe, look at the pupils and the fundus. Examine the ears for hemotympanum and nose for rhinorrhea. Open the mouth and look for any broken teeth or alveolar fracture. Use available imaging modalities such as CT scan of the head and face to confirm the diagnosis.
Apply the Canadian C-spine Rule and NEXUS to help with the decision about the cervical spine immobilization device removal. Inspect and palpate the neck looking for injuries, dilated neck veins, subcutaneous emphysema, and tracheal deviation. Feel for both carotid pulses and auscultate for any bruit. If any vascular injury is suspected, consider carotid Doppler studies and CT scan of the neck with angiography.
Log roll the patient and examine the spine looking for tenderness, step up or step down deformities and any other injuries. A detailed neurological examination looking at the dermatomes and myotomes to try and localize the level of spinal lesion is done. A MRI scan of the spine can be done, if a spinal injury is suspected. Patients should be on spinal protection until spinal injury has been ruled out.
Other regions in the body such as the chest, abdomen, pelvis, perineum, rectum, vaginal, musculoskeletal system, and neurological system are also examined comprehensively looking for injuries. After completing secondary survey, the victim proceeds to have definitive therapy for all injuries that have been identified.9
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Flowchart 1: Approach to initial assessment and management to trauma.
The ABCDE approach, even though taught as a sequential assessing method, which can be applied effectively even in resource-limited settings with few medical personnel is usually done in a parallel method when there is a trauma team of four to five medical personnel, with each member of the team taking up a responsibility (Flowchart 1).
The aim of primary survey is to rapidly assess trauma victims for life-threatening injuries and to resuscitate these injuries as they are found. This systematic approach of resuscitation has shown to decrease mortality. The key to primary survey is to reevaluate the victims frequently as trauma is a dynamic situation and constant vigil is necessary to make sure that injuries that have been stabilized remains stable. Once the victim is stable, a decision to transfer him/her to a higher center for definitive care needs to be taken without wasting precious time on unnecessary investigations. Secondary survey should be initiated only after primary survey has been completed and the victim is stable. After secondary survey, the victim proceeds to definitive care.
  1. Trauma deaths happen in a reproducible and predictable manner. Which of the following injuries would cause death the fastest?
    1. Extradural hematoma
    2. Fracture of pelvis
    3. Laceration of the liver
    4. Facial injury with blood in the pharynx obstructing the airway
    5. Multiple rib factures
    • Ans. d
  2. A 28-year-old motor bike rider who had lost control of his bike and collided into a wall is brought to the emergency room (ER) by the ambulance crew. They report that he was unconscious at the scene, but had woken up en route. His pulse rate is 100/min and his blood pressure recorded by them is 120/80 mm Hg. The first thing that needs to be done for him is:10
    1. Wait to assess him until a complete reliable history is available
    2. Get a CT scan of the brain immediately
    3. Intubate him
    4. Place a semirigid cervical collar
    5. Give him oxygen through a mask-reservoir device at 10 L/min
    • Ans. e
  3. A 40-year-old man, a driver in a motor vehicle accident, is brought into the ER by the ambulance crew on a spine board, with cervical collar on, an 18G-intravenous cannula on the left forearm with intravenous normal saline on flow and oxygen flowing at 10 L/min through a face mask. On arrival, his GCS is 15, but a laceration is noticed on the right side of his forehead and he is complaining of right-sided chest pain. He is moved immediately to the radiology department for a CT scan of the head and a chest X-ray. On returning from the radiology department, his GCS is noticed to have dropped to 5. Further examination reveals his pulse rate to be 130/min, blood pressure is 100/80 mm Hg and respiratory rate is 45/min. His CT scan head has been reported to show a right-sided small subdural (SDH) with frontoparietal contusions and his chest X-ray is reported to show a small right-sided simple pneumothorax. The next appropriate step in his management would be:
    1. Give him a IV bolus of 100 mL mannitol
    2. Start a central line to infuse noradrenaline
    3. Intubate him immediately
    4. Do a needle thoracostomy and then proceed for intubation
    5. Call a neurosurgeon for an urgent evacuation of the SDH
    • Ans. d
      Explanation: Candidates need to know that a simple pneumothorax can be converted into a life-threatening tension pneumothorax once positive pressure ventilation is initiated. To prevent this a needle/finger decompression of the pneumothorax needs to be done before intubation. This should be followed up with an intercostal tube thoracostomy. This is the only situation in primary survey that an intervention in “B” precedes that of “A”.
  4. The most common cause of shock in trauma is:
    1. Tension pneumothorax
    2. Cardiac tamponade
    3. Hemorrhage
    4. Neurogenic shock
    5. Anaphylaxis
    • Ans. c
  5. In a trauma victim, which of the following signs is suggestive of a hemorrhagic shock?
    1. Skin that is warm to touch
    2. Tachycardia with bounding pulse
    3. Hypotension with narrow pulse pressure
    4. Urine output of 1 mL/kg/h
    5. Serum lactate level <1 mmol/L
    • Ans. c
  6. A 30-year-old motor bike rider, who has met with a high-speed collision, is brought to the ER. On examination, he is confused; peripheries are cold and clammy with a heart rate of 130/min and a blood pressure of 70/60 mm Hg. After placing two peripheral intravenous catheters, 1 L of warmed Ringer's lactate (RL) solution is infused, with no improvement in his hemodynamic or mental status. As the source for a potential bleed is being searched the next most appropriate thing will be:11
    1. Give another 1 liter of warmed RL solution as a bolus
    2. Give two units of PRBC
    3. Start an infusion of adrenaline
    4. Take him to the radiology department for a CT scan of his brain
    5. Give him an infusion of tranexamic acid 1 g over 8 hours
    • Ans. b
  7. A 35-year-old lumberjack is brought to the ER after having sustained an injury to his left thigh while handling an electric saw. On examination, there is a large gapping incised wound on his left thigh that is spurting blood. Despite direct manual compression and packing the wound, he continues to exsanguinate and starts to drop his blood pressure. The next appropriate step would be:
    1. To apply a tourniquet to the limb
    2. To blindly clamp the blood vessels
    3. To transfer the patient to the operating room for a limb amputation
    4. Attempting suturing of the wound
    5. Giving injection tranexamic acid 500 mg intravenous
    • Ans. a
  8. A 25-year-old man who was involved in a motor vehicle crash is brought to the ER by the ambulance crew. Despite having been given 1 liter of warmed normal saline infusion and two units of PRBC transfusion, he continues to be hypotensive with a blood pressure of 70/50 mm Hg and has developed bleeding from his nostrils and oral cavity. While assessing for the source of bleed, the next most appropriate step in his management would be:
    1. To start an infusion of noradrenaline
    2. To give an injection of tranexamic acid 500 mg intravenous
    3. To transfuse another two units of PRBC
    4. To give an 100 mL intravenous bolus of soda bicarbonate
    5. To give transfusion of a balanced ratio of PRBC:plasma:platelet concentrate
    • Ans. e
  9. A 65-year-old man has been brought to the ER of a small hospital with no neurosurgical backup after having had a fall off a flight of stairs. On evaluation, he is smelling of alcohol, has pulse rate of 110/min and blood pressure of 120/80 mm Hg. He has a laceration on his forehead, is unresponsive with a GCS of 5, and his pupils are bilaterally equal and reactive. After he has been intubated for airway protection, the next most appropriate step will be:
    1. Move to the radiology department for a CT scan of the head
    2. To administer a intravenous bolus of 100 ml of mannitol
    3. To administer a dose of coma cocktail
    4. To communicate with the nearest higher center with neurosurgical facility and make arrangements for his transfer
    5. To start him on an infusion of 3% saline at 25 mL/h
    • Ans. d
  10. Which one of the items in the list given below is NOT an adjunct for primary survey
    1. Chest X-ray
    2. X-ray of the pelvis
    3. CT scan of the head
    4. Urinary catheter
    5. Arterial blood gas analysis
    • Ans. c
  1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support. Student course material, 10th Edition. United States: American College of Surgeons;  2018.

  1. 12 CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32.
  1. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94–9.
  1. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.
  1. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–8.
  1. World Health Organization. (2006). WHO Generic Essential Emergency Equipment List. [online]. Available from Formatted%2006.pdf. [Last accessed January, 2020].