Trauma Primary and Secondary Survey — Part 5: Special Trauma Populations
Pediatric trauma (vital signs by age, Broselow, non-accidental trauma), geriatric trauma (anticoagulant reversal, occult shock), pregnant trauma (physiologic changes, perimortem C-section), burns (Parkland formula, rule of nines, escharotomy), and penetrating vs blunt selective non-operative management.
1. Pediatric Trauma
1.1 Overview
Trauma is the leading cause of death in children older than 1 year in developed nations. Pediatric trauma differs from adult trauma in anatomy, physiology, injury patterns, and psychosocial considerations. Key principles include:1 2 3
- Children have a larger body surface area to mass ratio, leading to greater heat loss and susceptibility to hypothermia
- The head is proportionally larger, and TBI is the most common cause of death in pediatric trauma
- The thorax is more compliant — significant intrathoracic injury can occur without rib fractures; when rib fractures ARE present in children, they indicate very high-energy mechanism
- The abdomen is less protected — the liver and spleen extend below the rib cage and are more vulnerable
- Excellent compensatory mechanisms — children maintain normal blood pressure until > 30% of blood volume is lost, then decompensate abruptly
- Airway differences: Larger tongue relative to oral cavity; more anterior and cephalad larynx; shorter trachea; subglottis (cricoid ring) is the narrowest point (not the vocal cords as in adults); higher risk of right mainstem intubation
1.2 Pediatric Vital Signs by Age
| Age Group | Heart Rate (bpm) | Systolic BP (mmHg) | Respiratory Rate (breaths/min) | Estimated Blood Volume (mL/kg) | Minimum SBP for Age (5th percentile) |
|---|---|---|---|---|---|
| Newborn (0-28 days) | 120-160 | 60-80 | 30-60 | 80-90 | 60 |
| Infant (1-12 months) | 100-160 | 70-100 | 25-40 | 80 | 70 |
| Toddler (1-3 years) | 90-150 | 80-100 | 20-30 | 80 | 70 + (2 x age in years) |
| Preschool (4-5 years) | 80-140 | 85-110 | 20-25 | 75-80 | 70 + (2 x age in years) |
| School age (6-12 years) | 70-120 | 90-120 | 15-20 | 70-75 | 70 + (2 x age in years) |
| Adolescent (13-17 years) | 60-100 | 100-135 | 12-20 | 70 | 90 (approaches adult values) |
Hypotension formula: In children aged 1-10 years, the lower limit of normal SBP can be estimated as: 70 + (2 x age in years) mmHg. However, hypotension is a late sign in children — tachycardia, delayed capillary refill, and altered mental status appear much earlier.
1.3 Weight Estimation — Broselow Method
Accurate weight estimation is critical in pediatric trauma for drug dosing, fluid resuscitation volumes, equipment sizing, and blood product administration. The Broselow-Luten color-coded length-based tape is the standard tool for weight estimation in the acute setting when a measured weight is not available.2
| Method | Application |
|---|---|
| Broselow tape | The child is measured supine from head to heel; the corresponding color zone provides estimated weight, drug doses, equipment sizes, and defibrillation energy |
| Age-based formula | Weight (kg) = (age in years x 2) + 8 (for children 1-10 years); less accurate than Broselow but useful when the tape is not available |
| Measured weight | Always preferred when feasible; stretcher scales or bed scales can be used |
1.4 Pediatric Airway Management
| Consideration | Detail |
|---|---|
| ETT size | Uncuffed: (age/4) + 4 (for children < 8 years); Cuffed: (age/4) + 3.5; cuffed ETTs are now preferred in most settings with cuff pressure monitoring < 20 cmH2O |
| ETT depth | Oral insertion depth (cm) = ETT internal diameter x 3; or age/2 + 12 for oral; age/2 + 15 for nasal |
| Blade selection | Miller (straight) blade preferred in infants and young children for direct laryngoscopy; video laryngoscopy increasingly used |
| Surgical airway | Needle cricothyrotomy with transtracheal jet ventilation in children < 12 years (small cricothyroid membrane); surgical cricothyrotomy is acceptable in adolescents |
1.5 Pediatric Fluid Resuscitation
| Parameter | Recommendation |
|---|---|
| Initial bolus | 20 mL/kg of warm isotonic crystalloid (LR or NS) — given as a rapid bolus |
| Reassess after each bolus | Heart rate, capillary refill, mental status, blood pressure, urine output |
| If no improvement after 2-3 boluses (40-60 mL/kg total) | Transition to blood products: 10-15 mL/kg PRBCs; consider MTP activation with balanced 1:1:1 resuscitation |
| Blood volume estimation | 80 mL/kg (neonates and infants); 70-75 mL/kg (older children/adolescents) |
| Urine output targets | Infants < 1 year: 2 mL/kg/hr; Children 1-12 years: 1 mL/kg/hr; Adolescents: 0.5 mL/kg/hr |
1.6 Pediatric Injury Patterns
| Pattern | Significance |
|---|---|
| Lap belt complex (Chance fracture) | Horizontal fracture through the vertebral body (usually L1-L3) associated with lap-belt use without a shoulder harness; associated with mesenteric and small bowel injury; the seatbelt sign (ecchymosis across the lower abdomen) should prompt CT evaluation and high index of suspicion |
| SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) | More common in children < 8 years due to ligamentous laxity and spinal column elasticity; spinal cord injury occurs without visible fracture or dislocation on CT or X-ray; MRI is required for diagnosis |
| Waddell’s triad | Classic triad of pedestrian vs. automobile injuries in children: (1) bumper impact to femur/tibia, (2) thoracic/abdominal injury from being struck by the hood/fender, (3) contralateral head injury from impact with the ground |
| Non-accidental trauma | See section 1.7 below |
1.7 Non-Accidental Trauma (NAT) Screening
Child abuse should be considered in any injured child, particularly infants and children under 5 years. Identifying NAT is a critical responsibility of the trauma team. Warning signs include:4
| Red Flag | Detail |
|---|---|
| History inconsistent with injury | The mechanism described does not explain the pattern or severity of injury; different history from different caregivers |
| Injury inappropriate for developmental stage | Fractures in pre-ambulatory infants (< 6 months); spiral fractures of long bones in non-walking children |
| Specific fracture patterns | Classic metaphyseal lesions (“corner” or “bucket handle” fractures); posterior rib fractures; scapular fractures; spinous process fractures; multiple fractures in different stages of healing |
| Specific injury patterns | Retinal hemorrhages (shaken baby syndrome / abusive head trauma); subdural hematomas in infants without adequate mechanism; patterned burns (stocking/glove distribution, cigarette burns, iron marks); bruises in unusual locations (ears, neck, torso, buttocks) in non-mobile infants |
| Delay in seeking care | Significant injuries with delayed presentation |
| Caregiver behavior | Inconsistent or changing history; inappropriate affect; reluctance to provide history; blaming the child or a sibling |
Required actions:
- If NAT is suspected, obtain a skeletal survey (complete series of radiographs of the entire skeleton) in all children < 2 years
- Ophthalmologic examination for retinal hemorrhages
- Head CT (or MRI) if intracranial injury is suspected
- Report to child protective services — mandatory in all jurisdictions
- Social work consultation
- Document injuries meticulously with photographs and body diagrams
2. Geriatric Trauma
2.1 Overview
Patients aged > 65 years represent the fastest-growing segment of the trauma population. Geriatric trauma patients have significantly higher morbidity and mortality compared to younger patients with equivalent injury severity due to:1 5
- Decreased physiologic reserve — reduced cardiac output, pulmonary function, renal function, and hepatic metabolism
- Comorbidities — cardiovascular disease, diabetes, pulmonary disease, renal insufficiency
- Polypharmacy — especially anticoagulants and antiplatelet agents (present in 30-40% of elderly trauma patients)
- Frailty — reduced muscle mass, bone density, and nutritional reserve
- Falls — the most common mechanism of injury in the elderly; a ground-level fall can produce devastating injuries in this population
2.2 Lower Activation Thresholds
| Standard Threshold | Geriatric Modification | Rationale |
|---|---|---|
| SBP < 90 mmHg for trauma activation | SBP < 110 mmHg should trigger concern | Chronic hypertension shifts the autoregulatory curve; an SBP of 100 mmHg may represent shock in a patient whose baseline is 160 mmHg |
| Tachycardia > 100 bpm | Absence of tachycardia does NOT exclude hemorrhage | Beta-blockers, calcium channel blockers, and pacemakers blunt the tachycardic response; age-related decline in maximal heart rate |
| Normal base deficit | Base deficit > 6 mEq/L should prompt aggressive investigation | Early surrogate for occult hypoperfusion when vital signs may be “normal” |
| Normal lactate | Lactate > 2 mmol/L should raise concern | Same rationale as base deficit |
| Falls > 20 feet for Tier 1 activation | Ground-level falls in the elderly should be considered for at least Tier 2 activation | Ground-level falls in the elderly have mortality rates comparable to high-energy mechanisms in younger patients |
2.3 Occult Shock in the Elderly
Elderly patients may present with “normal” vital signs despite significant hemorrhage due to:5
- Baseline hypertension masking relative hypotension
- Beta-blockers and other chronotropic agents preventing tachycardia
- Reduced baroreceptor sensitivity
- Adrenal insufficiency or blunted catecholamine response
Markers of occult shock:
| Marker | Threshold |
|---|---|
| Base deficit | > 6 mEq/L |
| Lactate | > 2.5 mmol/L |
| Shock index | > 1.0 (even when individual vital signs appear normal) |
| Elevated troponin | May indicate demand ischemia from hemorrhagic shock in patients with underlying CAD |
2.4 Anticoagulant and Antiplatelet Reversal
Reversal of anticoagulation is urgent in elderly trauma patients with evidence of hemorrhage, particularly intracranial hemorrhage. Time to reversal directly impacts outcome.6
| Agent | Reversal Strategy | Notes |
|---|---|---|
| Warfarin | 4-factor PCC (Kcentra): 25-50 IU/kg IV based on INR (INR 2-4: 25 IU/kg; INR 4-6: 35 IU/kg; INR > 6: 50 IU/kg); Vitamin K: 10 mg IV (slow infusion over 10-20 minutes to avoid anaphylactoid reaction); FFP 10-15 mL/kg if PCC unavailable | PCC preferred over FFP (faster reversal, smaller volume, more reliable correction); Vitamin K takes 6-12 hours for full effect but is necessary for sustained reversal |
| Dabigatran (direct thrombin inhibitor) | Idarucizumab (Praxbind): 5 g IV (2 vials of 2.5 g, given as 2 consecutive infusions or bolus); specific reversal agent | Immediate and complete reversal; if idarucizumab unavailable, consider activated PCC (FEIBA) 50 IU/kg; hemodialysis can remove dabigatran (partially) |
| Apixaban, Rivaroxaban, Edoxaban (direct factor Xa inhibitors) | Andexanet alfa (Andexxa): Low dose (400 mg bolus + 4 mg/min x 120 min) if last dose > 8 hours ago or low-dose drug; High dose (800 mg bolus + 8 mg/min x 120 min) if last dose ≤ 8 hours ago or high-dose drug; 4-factor PCC 50 IU/kg if andexanet unavailable | Andexanet alfa is the specific reversal agent; 4-factor PCC is the standard alternative; activated PCC (FEIBA) 50 IU/kg is another option |
| Heparin (unfractionated) | Protamine sulfate: 1 mg per 100 units of heparin given in the preceding 2-3 hours (max 50 mg) | Immediate reversal; monitor for hypotension and anaphylactoid reaction |
| Enoxaparin (LMWH) | Protamine sulfate: 1 mg per 1 mg of enoxaparin given in the preceding 8 hours (reverses ~60% of anti-Xa activity) | Incomplete reversal; consider second dose of 0.5 mg per 1 mg enoxaparin if bleeding persists |
| Aspirin | Platelet transfusion if clinically significant hemorrhage; desmopressin (DDAVP) 0.3 mcg/kg IV may improve platelet function | Evidence for platelet transfusion in aspirin-associated ICH is mixed (PATCH trial showed potential harm); consider risk/benefit |
| Clopidogrel, Ticagrelor, Prasugrel (P2Y12 inhibitors) | Platelet transfusion (may require > 1 apheresis unit as the drug irreversibly binds existing platelets); DDAVP 0.3 mcg/kg IV | Clopidogrel and prasugrel are irreversible (effect lasts for platelet lifespan ~7-10 days); ticagrelor is reversible (effect wanes in 3-5 days) |
| TXA | Consider in all anticoagulated trauma patients with significant hemorrhage (1 g IV over 10 minutes, within 3 hours of injury) | Adjunctive to specific reversal agents |
2.5 Geriatric-Specific Management Considerations
| Consideration | Recommendation |
|---|---|
| ICU admission | Lower threshold for ICU admission in elderly trauma patients; occult injuries are more common and decompensation is less predictable |
| Early goals of care discussion | Address advance directives, code status, and patient wishes early; family involvement |
| Rib fracture management | Aggressive multimodal analgesia (including regional anesthesia); elderly patients with ≥ 3 rib fractures have significantly increased pneumonia and mortality risk; consider ICU-level monitoring |
| Fall risk assessment | Before discharge: assess contributing factors (syncope workup, medication review, orthostatic hypotension, vision/hearing, home safety assessment) to prevent recurrent falls |
| Frailty screening | Frailty index or Clinical Frailty Scale; frailty is an independent predictor of mortality and can guide goals-of-care discussions |
3. Trauma in Pregnancy
3.1 Physiologic Changes of Pregnancy Relevant to Trauma
The physiologic changes of pregnancy significantly alter the presentation and management of the injured pregnant patient. Failure to recognize these changes can lead to misinterpretation of clinical findings and delayed recognition of hemorrhage.1 7
| System | Change | Clinical Significance in Trauma |
|---|---|---|
| Cardiovascular | Heart rate increases 15-20 bpm; cardiac output increases 30-50%; systolic BP decreases 5-15 mmHg in 2nd trimester (normalizes in 3rd); blood volume increases 30-50% (hypervolemia of pregnancy) | Hypervolemia provides a buffer — the mother may lose 30-35% of blood volume before showing signs of shock; fetal distress may precede maternal hemodynamic compromise |
| Respiratory | Minute ventilation increases 40% (increased tidal volume); PaCO2 decreases to 28-32 mmHg (chronic compensated respiratory alkalosis); oxygen consumption increases 20%; functional residual capacity decreases | Normal PaCO2 of 35-40 mmHg in a pregnant patient suggests respiratory failure; rapid desaturation occurs due to decreased FRC |
| GI | Decreased gastric motility; increased risk of aspiration; displacement of abdominal organs by gravid uterus | All pregnant trauma patients are considered to have a full stomach; early nasogastric/orogastric tube placement; abdominal exam is unreliable in late pregnancy |
| Hematologic | Physiologic anemia (dilutional — Hgb 10-12 g/dL is normal in pregnancy); hypercoagulable state; WBC elevated (normal up to 12-18K in pregnancy, up to 25-30K in labor); fibrinogen elevated (350-600 mg/dL; a “normal” fibrinogen of 200 mg/dL may represent consumptive coagulopathy) | Fibrinogen < 200 mg/dL in a pregnant patient is concerning; WBC is unreliable as an infection marker |
| Renal | GFR increases 50%; BUN and creatinine decrease (normal Cr in pregnancy: 0.4-0.8 mg/dL); bladder displaced anteriorly and superiorly by the uterus | “Normal” creatinine of 1.0 mg/dL may represent renal impairment; bladder is more susceptible to injury from pelvic fracture |
| Uterus | Rises above the pelvis by 12 weeks; at the umbilicus by 20 weeks; shield for fetal protection becomes vulnerable to direct injury | After 20 weeks, the gravid uterus can compress the IVC when supine (supine hypotensive syndrome) |
3.2 Key Management Principles
| Principle | Implementation |
|---|---|
| “The best treatment for the fetus is optimal resuscitation of the mother” | All primary survey priorities apply; treat the mother first |
| Left lateral tilt | After 20 weeks gestation, tilt the patient 15-30 degrees to the left (or manually displace the uterus to the left) to relieve aortocaval compression; this can increase cardiac output by 25-30% |
| Two patients | Both the mother and the fetus require assessment; the fetus may decompensate before the mother |
| Rh testing | All Rh-negative pregnant trauma patients require Rh immune globulin (RhoGAM) 300 mcg IM within 72 hours of injury to prevent Rh isoimmunization; perform a Kleihauer-Betke test to detect and quantify fetomaternal hemorrhage (additional RhoGAM doses may be needed if FMH is large) |
| Radiation | Necessary imaging should NOT be withheld due to pregnancy; shield the uterus when feasible; the benefit of accurate diagnosis outweighs the minimal fetal radiation risk |
3.3 Fetal Monitoring
| Gestational Age | Monitoring | Duration |
|---|---|---|
| < 20 weeks | Fetal heart tones by Doppler; obstetric ultrasound for viability | N/A — limited intervention available for fetal demise at this gestational age |
| 20-23 weeks | Continuous cardiotocographic (CTG) monitoring | Minimum 4-6 hours; extend to 24 hours if concerning mechanism, contractions, vaginal bleeding, or uterine tenderness |
| ≥ 24 weeks (viable) | Continuous CTG monitoring; OB consultation | Minimum 4-6 hours; extend to 24 hours; fetal distress at a viable gestational age may warrant emergent cesarean delivery |
Signs of placental abruption (occurs in 1-5% of minor trauma and 20-50% of major trauma in pregnancy):
- Vaginal bleeding (may be absent in concealed abruption)
- Uterine tenderness and rigidity
- High-frequency, low-amplitude contractions
- Fetal distress (late decelerations, bradycardia)
- Coagulopathy (DIC — the placenta is rich in thromboplastin)
3.4 Perimortem Cesarean Delivery (Resuscitative Hysterotomy)
Indication: Maternal cardiac arrest in a pregnancy at ≥ 20 weeks gestation (uterus at or above the umbilicus) that does not respond to initial resuscitative efforts.7 8
| Parameter | Guideline |
|---|---|
| Timing | Decision should be made within 4 minutes of maternal cardiac arrest; delivery should be accomplished by 5 minutes (the “4-minute rule”) |
| Primary goal | Improve maternal hemodynamics by relieving aortocaval compression — this is primarily a maternal resuscitative procedure |
| Secondary goal | Deliver a potentially viable infant (if ≥ 24 weeks) |
| Technique | Vertical midline incision from xiphoid to pubic symphysis (fastest approach); classical (vertical) uterine incision; deliver the infant; clamp and cut the cord; neonatal resuscitation team should be present |
| CPR | Continue CPR throughout the procedure; do NOT move the patient to the OR — perform at the bedside |
| Do NOT delay | The procedure should not be delayed for ultrasound, fetal monitoring, or specialist arrival; any physician present can and should perform this procedure in the emergent setting |
3.5 Domestic/Intimate Partner Violence
Pregnancy is a risk factor for intimate partner violence (IPV). All pregnant trauma patients should be screened in a private, safe setting. Non-accidental injury patterns, repeated presentations, and delay in seeking care should raise suspicion.7
4. Burns
4.1 Initial Assessment
Burns represent a unique category of trauma that combines thermal tissue injury with systemic inflammatory response and fluid shifts. The initial assessment follows the standard primary survey (ABCDE) with burn-specific considerations.1 9
Airway considerations in burns:
| Finding | Significance |
|---|---|
| Facial burns, singed nasal/facial hair | Inhalation injury likely; upper airway edema may develop rapidly |
| Carbonaceous sputum | Smoke inhalation |
| Hoarseness, stridor, wheezing | Imminent or active airway compromise |
| Burns in an enclosed space | High risk of CO poisoning and inhalation injury |
| Action | Early intubation — delayed intubation in the face of progressive airway edema may result in a “can’t intubate” situation; if inhalation injury is suspected, intubate early before edema worsens |
4.2 Burn Size Estimation — Rule of Nines
The “Rule of Nines” divides the body surface area (BSA) into regions, each approximately 9% (or a multiple thereof), providing a rapid estimation of total body surface area (%TBSA) burned. Only second-degree (partial thickness) and third-degree (full thickness) burns are included in the %TBSA calculation; first-degree (superficial) burns are not counted.1 9
Adult Rule of Nines
| Body Region | %TBSA |
|---|---|
| Head and neck | 9% |
| Each upper extremity (entire arm) | 9% each (18% total) |
| Anterior trunk (chest and abdomen) | 18% |
| Posterior trunk (back) | 18% |
| Each lower extremity (entire leg) | 18% each (36% total) |
| Perineum/genitalia | 1% |
| Total | 100% |
Quick estimation: The patient’s palm (including fingers) represents approximately 1% of TBSA — useful for estimating scattered or irregular burn areas.
Pediatric Modification (Lund-Browder Chart Approximation)
Children have a proportionally larger head and smaller lower extremities. The following adjustments apply:9
| Body Region | Infant (< 1 year) | Child (5 years) | Child (10 years) |
|---|---|---|---|
| Head | 18% | 14% | 11% |
| Each lower extremity | 14% each | 16% each | 17% each |
| Trunk (anterior + posterior) | 36% | 36% | 36% |
| Each upper extremity | 9% each | 9% each | 9% each |
The Lund-Browder chart provides the most accurate TBSA estimation in children and should be used when available.
4.3 Burn Depth Classification
| Depth | Old Terminology | Appearance | Sensation | Healing |
|---|---|---|---|---|
| Superficial | First degree | Erythematous, dry, no blisters (sunburn) | Painful | 3-7 days; no scarring |
| Superficial partial thickness | Second degree (superficial) | Pink, moist, blisters, blanches with pressure | Very painful | 10-21 days; minimal scarring |
| Deep partial thickness | Second degree (deep) | Red and white mottled, may have blisters, decreased blanching | Decreased sensation | > 21 days; significant scarring; may require grafting |
| Full thickness | Third degree | White, waxy, leathery, or charred; no blisters; thrombosed vessels visible | Insensate (nerve destruction) | Will not heal spontaneously; requires excision and grafting |
| Fourth degree | — | Extends into fascia, muscle, or bone | Insensate | Requires excision; may require amputation or flap coverage |
4.4 Fluid Resuscitation — Parkland Formula
The Parkland (Baxter) formula is the most widely used guideline for initial fluid resuscitation in major burns (≥ 20% TBSA in adults, ≥ 10% TBSA in children).1 9 10
Parkland Formula:
4 mL x body weight (kg) x %TBSA burned = total volume of lactated Ringer’s solution for the first 24 hours
| Parameter | Detail |
|---|---|
| Fluid choice | Lactated Ringer’s solution (isotonic crystalloid) |
| First 8 hours | Give 50% of the calculated 24-hour volume in the first 8 hours (calculated from the TIME OF BURN, not the time of hospital arrival) |
| Next 16 hours | Give the remaining 50% over the next 16 hours |
| Titration target | Urine output: 0.5-1 mL/kg/hr in adults; 1-2 mL/kg/hr in children |
| Adjustment | The formula is a STARTING POINT — titrate up or down based on urine output; avoid “fluid creep” (excessive resuscitation leads to abdominal compartment syndrome, extremity compartment syndrome, and pulmonary edema) |
Example: A 70-kg patient with 40% TBSA burn:
- 4 x 70 x 40 = 11,200 mL in 24 hours
- First 8 hours: 5,600 mL (700 mL/hour)
- Next 16 hours: 5,600 mL (350 mL/hour)
- Adjust based on urine output
Pediatric modification: Children < 20 kg require additional maintenance fluids (D5LR) in addition to the resuscitation volume because of limited glycogen stores and risk of hypoglycemia. Maintenance is calculated separately using the 4-2-1 rule (4 mL/kg/hr for first 10 kg + 2 mL/kg/hr for next 10 kg + 1 mL/kg/hr thereafter).
4.5 Inhalation Injury
Inhalation injury significantly increases mortality at any given burn size (up to 20% increase in mortality). It consists of three distinct but overlapping components:9
| Component | Pathophysiology | Diagnosis | Treatment |
|---|---|---|---|
| Thermal injury (supraglottic) | Direct heat damage to the upper airway causing edema and obstruction | Clinical: stridor, hoarseness, facial burns; laryngoscopy/bronchoscopy: erythema, edema, soot | Early intubation before edema progresses; humidified oxygen |
| Chemical injury (tracheobronchial and parenchymal) | Combustion products (aldehydes, acids, etc.) damage airway epithelium and alveoli; causes bronchospasm, cast formation, atelectasis, ARDS | Bronchoscopy: soot, erythema, mucosal sloughing, edema in the tracheobronchial tree; chest X-ray may be initially normal | Supportive: mechanical ventilation, pulmonary toilet, bronchoscopy for cast removal, nebulized heparin (5,000-10,000 units) + N-acetylcysteine (20% solution, 3 mL) alternating every 2-4 hours (controversial but widely used) |
| Systemic toxicity (CO and CN poisoning) | Carbon monoxide (CO) binds hemoglobin with 200-250x affinity of O2, causing tissue hypoxia; cyanide (CN) inhibits cytochrome c oxidase (cellular asphyxiation) | CO: carboxyhemoglobin (COHb) level > 10% significant, > 25% severe; CN: serum lactate > 8 mmol/L is surrogate; serum CN level (delayed result) | CO: 100% O2 via NRB or ventilator; half-life of COHb: 4-6 hr on room air, 60-90 min on 100% O2; consider hyperbaric O2 if available for COHb > 25%, neurologic symptoms, or cardiac instability. CN: hydroxocobalamin (Cyanokit) 5 g IV over 15 min; or amyl nitrite + sodium nitrite + sodium thiosulfate (older kit) |
4.6 Escharotomy
Indication: Circumferential full-thickness (third-degree) burns causing compartment syndrome of the extremities or trunk.9
| Location | Complication of Circumferential Burn | Escharotomy Technique |
|---|---|---|
| Extremity | Vascular compromise distal to the burn (decreased or absent pulses, cyanosis, progressive pain, paresthesias) | Longitudinal incision through the eschar on the medial and lateral (mid-axial) lines of the extremity; must extend through the full depth of the eschar into the subcutaneous fat; incisions should extend from proximal to distal and across joints if necessary |
| Chest | Restriction of chest wall expansion causing inadequate ventilation (elevated peak inspiratory pressures, hypoxia, hypercarbia) | Bilateral anterior axillary line incisions connected by a transverse subcostal incision (forming an “H” or inverted “U”); additional midclavicular vertical incisions may be needed |
| Digits | Vascular compromise to fingers or toes | Mid-lateral incisions on each side of the digit |
Key points:
- Escharotomy is performed at the bedside as an emergency procedure
- Full-thickness eschar is insensate — the procedure is performed without anesthesia in the burn eschar itself (analgesia may be needed for the deeper tissues and wound margins)
- Bleeding should be controlled with electrocautery or topical hemostatic agents
- After escharotomy, monitor distal perfusion closely to confirm adequate decompression
5. Penetrating vs. Blunt Trauma — Selective Non-Operative Management
5.1 Blunt Abdominal Trauma — Non-Operative Management
Non-operative management (NOM) has become the standard of care for the majority of blunt solid organ injuries (liver, spleen, kidney) in hemodynamically stable patients. This paradigm shift has been one of the most significant advances in trauma surgery over the past three decades.11 12
Requirements for NOM:
| Requirement | Detail |
|---|---|
| Hemodynamic stability | Patient must be hemodynamically stable or respond to initial resuscitation (transient responder may be considered with caution) |
| No peritonitis | Absence of peritoneal signs on examination |
| Reliable abdominal exam | Patient must be alert enough for serial abdominal examinations; intoxicated or obtunded patients require more caution |
| Defined injury on CT | CT with contrast is required to grade the injury and identify vascular injuries (contrast extravasation/blush) |
| Institutional capability | ICU monitoring, interventional radiology for angiographic embolization, operating room available 24/7, trained surgical team |
| Serial monitoring | Serial abdominal examinations (every 4-6 hours initially); serial hemoglobin checks; repeat imaging if clinical deterioration |
Failure of NOM (indications for operative intervention):
- Hemodynamic deterioration not responding to resuscitation
- Increasing abdominal pain, distension, or peritoneal signs
- Decreasing hemoglobin requiring ongoing transfusion
- Failure of angiographic embolization to control hemorrhage
5.2 Penetrating Abdominal Trauma — Selective Non-Operative Management
Selective NOM of penetrating abdominal trauma (both stab wounds and gunshot wounds) has been increasingly adopted in experienced trauma centers, replacing the traditional practice of mandatory exploration for all penetrating abdominal injuries.13 14
Anterior Abdominal Stab Wounds
| Step | Protocol |
|---|---|
| 1. Hemodynamically unstable or peritonitis | Emergent laparotomy |
| 2. Hemodynamically stable, no peritonitis | Options include: (a) Serial clinical examination (physical exam every 4-8 hours for 24 hours, with serial labs); (b) CT abdomen/pelvis with triple contrast (IV, oral, rectal); (c) Local wound exploration (under local anesthesia, determine if the wound penetrates the anterior fascia — if fascia intact, discharge; if fascia violated, observation or further workup) |
| 3. Observation criteria | Reliable exam, no signs of hollow viscus injury (peritonitis, free air on CT), hemodynamically stable; serial exams and labs for 24 hours |
| Failure rate | Approximately 5-10% of initially observed patients ultimately require laparotomy |
Abdominal Gunshot Wounds
| Scenario | Management |
|---|---|
| Hemodynamically unstable or peritonitis | Emergent laparotomy |
| Tangential wound (not transperitoneal on CT) | Observation may be appropriate if CT demonstrates a clearly tangential trajectory without peritoneal violation |
| Transperitoneal trajectory | Traditional teaching mandates laparotomy; however, highly selective NOM protocols at experienced centers have shown safety in select patients with transperitoneal GSW who are hemodynamically stable with a reliable exam and no signs of hollow viscus injury on CT |
| Right upper quadrant (isolated hepatic trajectory) | Selective NOM is increasingly practiced for isolated liver GSW in stable patients with no evidence of hollow viscus injury |
Thoracoabdominal Penetrating Trauma
Penetrating injuries in the thoracoabdominal region (between the nipple line/scapular tip superiorly and the costal margin inferiorly) can injure both thoracic and abdominal structures, including the diaphragm. Diaphragmatic injury is easily missed and can lead to delayed herniation.
- All patients with thoracoabdominal penetrating injuries should be evaluated for diaphragmatic injury
- CT has moderate sensitivity (~50-70%) for diaphragmatic injury; diagnostic laparoscopy or thoracoscopy may be required for definitive evaluation in selected patients
5.3 Neck Penetrating Trauma — Zones and Management
| Zone | Anatomic Boundaries | Key Structures | Evaluation |
|---|---|---|---|
| Zone I | Sternal notch/clavicles to the cricoid cartilage | Subclavian vessels, vertebral arteries, innominate artery, thoracic duct, lung apices, trachea, esophagus | CT angiography; operative exploration is difficult — endovascular approach may be preferred |
| Zone II | Cricoid cartilage to the angle of the mandible | Carotid and vertebral arteries, jugular veins, larynx, trachea, esophagus, pharynx | Historically, mandatory exploration for all platysma-violating wounds; now CT angiography-directed approach (no-zone/selective approach) is standard |
| Zone III | Angle of the mandible to the skull base | Distal internal carotid, vertebral arteries, jugular veins, pharynx, salivary glands | CT angiography; operative exposure is very difficult — angiographic intervention often preferred |
Modern approach (“No-Zone” approach):
- All hemodynamically stable patients with penetrating neck trauma and no hard signs of vascular or aerodigestive injury undergo CT angiography as the primary diagnostic modality
- Hard signs of vascular injury (expanding hematoma, active hemorrhage, absent pulses) or aerodigestive injury (massive hemoptysis, air bubbling from wound, subcutaneous emphysema) mandate emergent operative exploration regardless of zone
- The “no-zone” approach has replaced zone-based mandatory exploration algorithms in most current practice15
References
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed. Chicago: American College of Surgeons; 2018. URL: https://www.facs.org/quality-programs/trauma/atls/ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
American College of Surgeons. ACS TQIP Pediatric Guidelines — Best Practices in the Management of Pediatric Trauma. Chicago: ACS; 2014. URL: https://www.facs.org/quality-programs/trauma/quality/best-practices-guidelines/ ↩︎ ↩︎
Patel JC, Tepas JJ 3rd. “Pediatric Trauma.” In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 9th ed. New York: McGraw-Hill; 2021. ↩︎
Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. “The Evaluation of Suspected Child Physical Abuse.” Pediatrics. 2015;135(5):e1337-e1354. DOI: 10.1542/peds.2015-0356 ↩︎
Calland JF, Ingraham AM, Martin N, et al. “Evaluation and Management of Geriatric Trauma: An Eastern Association for the Surgery of Trauma Practice Management Guideline.” J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S345-S350. DOI: 10.1097/TA.0b013e318270191f ↩︎ ↩︎
Tomaselli GF, Mahaffey KW, Cuker A, et al. “2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants.” J Am Coll Cardiol. 2020;76(5):594-622. DOI: 10.1016/j.jacc.2020.04.053 ↩︎
Jain V, Chari R, Maslovitz S, et al. “Guidelines for the Management of a Pregnant Trauma Patient.” J Obstet Gynaecol Can. 2015;37(6):553-574. DOI: 10.1016/S1701-2163(15)30232-2 ↩︎ ↩︎ ↩︎
Einav S, Kaufman N, Sela HY. “Maternal Cardiac Arrest and Perimortem Caesarean Delivery: Evidence or Expert-Based?” Resuscitation. 2012;83(10):1191-1200. DOI: 10.1016/j.resuscitation.2012.05.005 ↩︎
American Burn Association. “Advanced Burn Life Support Course Provider Manual.” 2018. URL: https://ameriburn.org/education/advanced-burn-life-support/ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Baxter CR, Shires T. “Physiological Response to Crystalloid Resuscitation of Severe Burns.” Ann N Y Acad Sci. 1968;150(3):874-894. DOI: 10.1111/j.1749-6632.1968.tb14738.x ↩︎
Stassen NA, Bhullar I, Cheng JD, et al. “Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline.” J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294-S300. DOI: 10.1097/TA.0b013e3182702afc ↩︎
Kozar RA, Crandall M, Shanmuganathan K, et al. “Organ Injury Scaling 2018 Update: Liver, Spleen, and Kidney.” J Trauma Acute Care Surg. 2018;85(6):1119-1122. DOI: 10.1097/TA.0000000000002058 ↩︎
Como JJ, Bokhari F, Chiu WC, et al. “Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma.” J Trauma. 2010;68(3):721-733. DOI: 10.1097/TA.0b013e3181cf7d07 ↩︎
Biffl WL, Kaups KL, Cothren CC, et al. “Management of Patients with Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial.” J Trauma. 2009;66(5):1294-1301. DOI: 10.1097/TA.0b013e31819dc688 ↩︎
Tisherman SA, Bokhari F, Collier B, et al. “Clinical Practice Guideline: Penetrating Zone II Neck Trauma.” J Trauma. 2008;64(5):1392-1405. DOI: 10.1097/TA.0b013e3181692116 ↩︎