Primary Survey

  • –If trauma patient comes in unconscious: Intubate!
  • –If GCS < 8: Intubate!
  • –If guy stung by a bee, developing stridor and tripod posturing: Intubate!
  • –If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck: Intubate!
  • –If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues: fiberoptic bronchoscope 
  • –If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7: cricothyroidotomy

  • –After Intubating a patient, next best step: Check bilateral breath sounds
  • –If decr on the left: Means you intubated the right mainstem bronchus
  • –What to do: Pull back your ET tube
  • –Next step: Check pulse ox, keep it >90%

Secondary Survey

5 Thoracic causes of immediate death

  1. tension pneumothorax
  2. cardiac tamponade
  3. open pneumothorax
  4. massive hemothorax
  5. airway obstruction

Cardiac Tamponade

– hypotension
– muffled heart sounds


Work up
FAST scan
– Morrison’s pouch: R kidney and liver
– splenorenal recess: L kidney and spleen
– pouch of Douglas: posterior to bladder
– pericardium

Isotonic Fluids

Fluid Replacement
Isotonic fluids (NS or LR) are repleted in a 3:1 ration (fluid to blood loss).
– start w/ fluid bolus of 1-2L in adults
– recheck vitals and the continue repletion as indicated
– if still tachycardic or hypotensive, after the first 2L of isotonic fluid, transfusion w/ pRBCs may be indicated

Head Trauma

  • GCS -> eyes 4, motor 6, verbal 5
  • Hematoma, edema, tumor can cause increased ICP
  • Symptoms: Headache, vomiting, altered mental status
  • Treatment: Elevate HOB, hyperventilate to pCO2 28-32, give mannitol (watch renal fxn)
  • Surgical intervention: Ventriculostomy

Epidural Hemorrhage

Subdural Hemorrhage

Neck Trauma (penetrating)

  • Penetrating Trauma -> GSW or stab wound
    • Zone 3 = ↑ angle of mandible
      • w/u: Aortography and triple endoscopy.
    • Zone 2 = angle of mandible-cricoid
      • w/u: 2D doppler +/-exploratory surgery.
    • Zone 1 = ↓ cricoid
      • w/u: Aortography
  • Work-up:
    • 1) intubate early
    • 2) immediate surgical exploration is mandatory for pts w/ shock and active ongoing hemorrhage from neck wounds
      • – all wounds that violate the platysma are considered true penetrating neck trauma.
      • – assess based on neck zones (3)
        • —1) above angle of mandible
        • —2) between angle of mandible and cricoid
        • —3) below cricoid
    • 3) Continue dx work-up w/ appropriate tests
      • – angiography or aorta
      • – carotid/cerebral arteries
      • – CT scan of the neck w/ or w/o CT angiography
      • – Doppler U/S
      • – contrast esophagography/esophagoscopy
      • – bronchoscopy


Nervesurgical repair
Vasculararteriography and surgical

Contaminated wounds

early wound irrigation
tissue debridement
Abx and tetanus prophy

Penetrating Abdominal Trauma

  • If GSW to the abdomen: Ex-lap. (plus tetanus prophylaxis)
  • If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration: Ex-lap. (plus tetanus prophylaxis)
  • If stab wound but pt is stable: FAST exam. DPL if FAST is equivocal.
    Ex-lap if either are positive.
  • If blunt abdominal trauma pt with hypotension/tachycardia:If you see this? Do not pass go, go directly to exploratory laparotomy. Ex-lap. (plus tetanus prophylaxis) Ex-lap. (plus tetanus prophylaxis) Ex-lap.
  • If Air under the diaphragm: Do not pass go, go directly to exploratory laparotomy.

Blunt Abdominal Trauma

  • If unstable: Ex-lap.
  • If stable: Abdominal CT
    • –If lower rib fx plus bleeding into abdomen: Spleen or liver lac.
    • –If lower rib fx plus hematuria: Kidney lac.
    • –If Kehr sign & viscera in thorax on CXR: Diaphragm rupture.
    • –If handlebar sign: Pancreatic rupture.
    • –If stable w/ epigastric pain?
      • Best test: Abdominal CT.
      • If the retroperitoneal fluid is found? Consider duodenal rupture.

Pelvic Trauma

  • If hypotensive, tachycardic -> FAST and DPL to r/o bleeding in the abdominal cavity.
  • Can bleed out into pelvis -> stop bleeding by fixing fx -> internal if stable, external if not.
  • If blood at the urethral meatus and a high riding prostate: Consider pelvic fracture w/ urethral or bladder injury.
  • Next best test: Retrograde urethrogram (NOT FOLEY!)
  • If normal: Retrograde cystogram to evaluate bladder
  • What are you looking for: Check for extravasation of dye. Take 2 views to ID trigone injury.
    • If extraperitoneal extravasation: Bed rest + foley
    • If intraperitoneal extravasation: Ex-lap and surgical repair

Ortho Trauma

  • Fractures that go to the OR:
    • –Depressed skull fx
    • –Severely displaced or angulated fx
    • –Any open fx (sticking out bone needs cleaning)
    • –Femoral neck or intertrochanteric fx
Anterior Shoulder dislocation
  • –Arm outwardly rotated, & numbness over deltoid
Posterior Shoulder dislocation
  • –Shoulder pain s/p seizure or electrical shock
Boxers fracture
  • –Punching a wall: Metacarpal neck fracture “Boxer’s fracture”. May need K wire
Clavicle fracture
  • –Clavicle is most commonly broken where: Between middle and distal 1/3s. Need figure of 8 device
Colles fracture
  • –old lady FOOSH, distal radius displaced
Depressed skull fracture
Femoral Neck fracture
Intertrochanteric fracture
Scaphoid fracture
  • –young person FOOSH, anatomic snuffbox tender

Child Abuse

spiral fractures in the limbs
bucket-handle fractures
rib fractures
subdural hematoma coupled w/ retinal hemorrhages


Open thoracotomypts w/ penetrating chest trauma that leads to cardiac arrest, provided that the pt arrested in the ED or shortly before arrival
Immediate exploratory laparotomy– gunshot wounds (some pts who are stable can be managed conservatively)
– stab wounds in a hemodynamically unstsable pt
– pt w/ peritoneal signs or evisceration

EM Notes


  1. staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY