TNCC STUDY GUIDE 2026-2027

Appropriate analgesia does not hide serious abdominal injury and should not be withheld. Document the exam before and after medication.

Most stable patients can be observed with serial exams, hemoglobin checks and imaging, with angioembolization when needed. Unstable patients need surgery with packing to control bleeding.

Serial abdominal exams, frequent vital signs, repeated hemoglobin levels, bed rest, nothing by mouth at first, large-bore IV access and a plan for quick surgical or angiographic intervention.

Stable patients may be managed without surgery with close observation or angioembolization. Unstable patients need splenectomy, and after that, vaccines against encapsulated bacteria are given to prevent overwhelming infection.

They may injure retroperitoneal organs, so stable patients usually have CT with IV and sometimes enteric contrast and are observed. Unstable patients go to the operating room.

A retrograde urethrogram is done when urethral injury is suspected, before a Foley catheter. A cystogram, often CT cystography, is done to find bladder rupture.

Solid organ injuries (spleen, liver, kidney) mainly cause hemorrhage and shock. Hollow organ injuries (stomach, bowel, bladder) cause peritonitis, pain and sepsis, and signs may be delayed.

Flank pain, flank bruising or tenderness and hematuria, although hematuria may be absent with severe injuries such as pedicle damage. Stable patients are evaluated with contrast-enhanced CT.

Do not push organs back in. Cover them with moist sterile saline dressings, keep the patient warm, give nothing by mouth and prepare for surgery.

Gunshot wounds crossing the peritoneum generally need laparotomy. Stab wounds in stable patients without peritonitis may be observed with serial exams or evaluated with CT or local exploration.

Distention, rigidity, guarding, rebound tenderness, bruising such as a seat belt sign, flank bruising (Grey Turner sign) and periumbilical bruising (Cullen sign), and absent bowel sounds.

Give broad-spectrum antibiotics before surgery for suspected hollow organ injury, and update tetanus immunization in open wounds if status is unknown or outdated.

Hypotension with a positive FAST or evidence of intra-abdominal bleeding, peritonitis, evisceration, a transperitoneal gunshot wound and free air under the diaphragm.

A seat belt sign, abdominal tenderness, free air or free fluid without solid organ injury and a flexion-distraction lumbar fracture. Peritonitis may appear hours later, so repeated exams are needed.

It detects free fluid but not solid organ injury grade, retroperitoneal bleeding or hollow organ injuries. It can be falsely negative early, in obesity, with subcutaneous air or with small fluid volumes.

Anteroposterior compression (open-book injury), lateral compression, vertical shear and combined patterns, caused by crashes, falls and crushing forces.

The spleen and liver are the most commonly injured solid organs. In penetrating trauma, the small bowel and liver are often injured.

Pelvic binder or sheet wrap, external fixation, preperitoneal pelvic packing, angiographic embolization and balanced transfusion. Choose according to stability and available resources.

Blood at the urethral meatus, perineal or scrotal bruising, inability to urinate and a high-riding or boggy prostate on rectal exam. Posterior urethral injuries are usually associated with pelvic fractures.

Extraperitoneal rupture is more common, often with pelvic fractures, and is usually managed with catheter drainage. Intraperitoneal rupture occurs at the dome after a blow to a full bladder and needs surgical repair.

Mostly venous plexus and fractured bone surfaces (about 85%), with arterial bleeding in a smaller proportion (about 10 to 15%). Arterial bleeding is the most likely cause of ongoing instability.

Sphincter tone (spinal cord injury), blood in the rectum (bowel injury), a high-riding prostate (urethral injury), palpable bone fragments (pelvic fracture) and penetrating wounds.

Injury to the kidney, ureter, bladder or urethra. It needs imaging, and a urethral injury must be excluded before a urinary catheter is passed.

Scrotal hematoma, testicular rupture, penile fracture and urethral injury in males, and vulvar hematoma or lacerations in females. They require ultrasound, ice, analgesia and urologic or gynecologic consultation.

Raised intra-abdominal pressure (above about 20 mm Hg, often measured as bladder pressure) causing new organ dysfunction, such as low urine output, high airway pressures and hypotension. It requires decompression.

A procedure in which fluid is placed into the peritoneum and drained to check for blood or contents. It is positive with gross blood, more than 100,000 red cells per mm3 in blunt trauma or evidence of enteric contents, and is used when FAST is not available.

Pain in the left shoulder caused by blood irritating the diaphragm, which suggests splenic injury. It is more apparent when the patient is lying flat.

Avoid repeated pelvic compression or rocking, minimize log rolling, use a scoop stretcher or lift with a slide sheet and keep the binder in place. Movement can dislodge clots.

In hemodynamically stable patients, to identify solid organ, bowel, vascular and retroperitoneal injuries. Unstable patients should not go to CT.

Kidneys, ureters, adrenal glands, pancreas, parts of the duodenum, ascending and descending colon, aorta and inferior vena cava. Injuries here can be missed on exam and FAST.

The fracture communicates with the vagina, rectum or skin, causing heavy bleeding and infection. Perform a rectal and vaginal exam, give antibiotics and expect surgery, possibly with a diverting colostomy.

They are retroperitoneal, early exam findings are subtle and early amylase and CT results can be normal. Suspect them with epigastric pain or a handlebar or steering wheel injury and reassess.

The pelvis expands, increasing its volume and allowing large amounts of blood to collect. Closing the pelvis with a binder reduces volume and bleeding.

A distended stomach increases aspiration risk and may push on the diaphragm. An orogastric or nasogastric tube removes air and fluid, and the tube is avoided nasally with facial or skull base injuries.

Pelvic fractures and abdominal trauma can cause vaginal bleeding, uterine injury and placental abruption. Assess vaginal bleeding and fetal well-being, and do a pregnancy test in all females of childbearing age.

Look for chest rise, obstruction, wounds and use of accessory muscles. Listen for stridor, gurgling or snoring. Feel for air movement at the mouth and nose.

For a conscious adult, give abdominal thrusts or chest thrusts. If the patient is unresponsive, begin CPR and look in the mouth for the object, and use Magill forceps under direct vision if needed.

Measure from the tip of the nose to the earlobe, lubricate it and insert along the floor of the nose with the bevel toward the septum. Use caution with midface injury or suspected skull base fracture.

Give 100% oxygen by non-rebreather mask or bag-mask with a tight seal for about 3 to 5 minutes, or have the patient take several deep breaths. Nasal cannula oxygen can continue during intubation attempts.

Measure from the corner of the mouth to the angle of the jaw or the earlobe. A tube that is too small can push the tongue back, and one that is too large can obstruct the airway or injure the throat.

Waveform capnography is the most reliable method, along with visualization through the cords, chest rise, breath sounds over both lungs and the epigastrium, fogging in the tube and a chest radiograph. Reassess after every patient move.

A team member holds manual in-line stabilization with the head in neutral alignment while the collar front is removed to allow mouth opening. Video laryngoscopy may reduce neck movement.

Loss of protective reflexes, airway obstruction by the tongue, vomiting and aspiration, and hypoventilation. A GCS of 8 or less generally needs a secured airway.

Bleeding, swelling, loose teeth or bone fragments and displaced fractures such as Le Fort fractures or bilateral mandible fractures. Sit the patient up if the spine allows and prepare suction and a surgical airway.

Kussmaul (deep, rapid) breathing with metabolic acidosis, Cheyne-Stokes with brain injury or heart failure, agonal breathing near death and paradoxical movement with flail chest.

The tongue falling back in an unconscious patient, blood, vomit, teeth or other foreign bodies, facial or laryngeal fractures, and swelling from burns or neck hematoma.

Decreased venous return and hypotension (especially in hypovolemia), barotrauma such as pneumothorax, ventilator-associated pneumonia and over-ventilation that lowers PaCO2 too much.

Hyperkalemia, burns or crush injuries older than about 24 to 72 hours, spinal cord injury with denervation, neuromuscular disease and a history of malignant hyperthermia. Rocuronium is usually chosen instead.

Early: restlessness, anxiety, tachycardia and tachypnea. Late: confusion, cyanosis, bradycardia and decreased consciousness. Cyanosis is a late and unreliable sign.

Secure the tube with a commercial holder or ties, record the depth at the teeth, and raise the head of the bed about 30 degrees if the spine is cleared (or use reverse Trendelenburg). Recheck placement after every move.

A tidal volume of about 6 to 8 mL/kg of predicted body weight, a rate of about 12 to 16 breaths per minute, PEEP of about 5 cm H2O and an FiO2 that is titrated to oxygenation. Settings are adjusted using blood gases and capnography.

Poor perfusion, hypothermia, nail polish, motion, severe anemia and carbon monoxide poisoning can make readings inaccurate. Pulse oximetry does not show how well the patient is ventilating.

pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L and oxygen saturation 95% or higher.

Ventilate with a bag-mask and airway adjuncts, place a supraglottic airway (such as a laryngeal mask or King tube) or perform a surgical airway. Call for help early and limit attempts.

Unequal chest rise and absent breath sounds on the left, high peak pressures and a tube inserted too deep on the radiograph. Withdraw the tube slightly and reconfirm.

Singed nasal hairs, facial burns, soot in the mouth or sputum, hoarseness, stridor, wheezing and a history of being in an enclosed space fire. Airway swelling can progress rapidly.

Hoarseness or voice change, subcutaneous emphysema, loss of normal neck landmarks, stridor and difficulty breathing. Blind intubation attempts may worsen the injury, so a surgical airway may be needed.

They are quick to place, do not require laryngoscopy and are useful as a rescue device. They do not fully protect against aspiration and may leak at high pressures.

Inability to maintain or protect the airway, a GCS of 8 or less, apnea, inadequate oxygenation or ventilation despite supplemental oxygen, severe facial or neck injury, and an anticipated clinical course that is likely to worsen.

A can't intubate, can't oxygenate situation, massive facial trauma or swelling that prevents other airway methods, and severe upper airway obstruction.

The cricothyroid membrane, located between the thyroid cartilage above and the cricoid cartilage below. Palpate the landmarks, incise, dilate and place a cuffed tube.

Open the airway, use a tight mask seal (two-person technique when possible), give a breath over about 1 second, watch for chest rise and give 1 breath every 5 to 6 seconds in adults. Avoid hyperventilation.

Preparation, preoxygenation, pretreatment, paralysis with induction, protection and positioning, placement with proof, and postintubation management (often called the 7 Ps).

Esophageal intubation, tube dislodgement, cardiac arrest or severe low perfusion. Remove the tube or reconfirm placement and ventilate with a bag-mask while troubleshooting.

A high-pitched sound from partial upper airway obstruction, often inspiratory when the obstruction is above the vocal cords. It is an emergency that suggests edema, foreign body or laryngeal injury.

Displacement of the tube, Obstruction, Pneumothorax and Equipment failure. It guides a quick check of the cause of sudden desaturation or high pressures.

Predictors of a difficult airway: Look externally, Evaluate the 3-3-2 rule, Mallampati score, Obstruction and Neck mobility.

Etomidate (about 0.3 mg/kg) and ketamine (1 to 2 mg/kg) are commonly used because they cause less hypotension than propofol. Doses are reduced or agents chosen carefully in shock.

A flexible introducer passed through the cords to guide the endotracheal tube when the view is limited. The tube is slid over it into the trachea.

Placing a nasal cannula at high flow, such as 15 L/min, during intubation so oxygen continues to diffuse into the lungs and delays desaturation during the apneic period.

It gives a better view of the cords, often with a first-pass success advantage and less neck movement than direct laryngoscopy, and lets others see the procedure.

Oxygenation is getting oxygen into the blood, measured by SpO2 and PaO2. Ventilation is moving air in and out to remove carbon dioxide, measured by respiratory rate, tidal volume, PaCO2 and EtCO2.

Respiratory acidosis has a high PaCO2 from hypoventilation, as in head injury or chest trauma. Metabolic acidosis has a low bicarbonate from lactic acid caused by poor perfusion and shock.

About 20 to 30 cm H2O. Too little pressure allows aspiration and air leak, and too much can reduce blood flow to the tracheal wall.

About 21 cm at the lip or teeth for women and 23 cm for men. The tip should be about 2 to 4 cm above the carina on the chest radiograph.

Opioids such as fentanyl for pain, plus sedatives such as propofol or midazolam. Agents are chosen and dosed carefully in hypotension, and doses are titrated to a sedation goal.

Succinylcholine (about 1.5 mg/kg) is a rapid-onset, short-acting agent. Rocuronium (about 1 mg/kg) is an alternative when succinylcholine is contraindicated.

Nasal cannula 1 to 6 L/min (about 24 to 44%), simple mask 6 to 10 L/min (about 35 to 60%), non-rebreather mask 10 to 15 L/min (about 60 to 90% or more) and bag-mask with a reservoir at 15 L/min (near 100%).

Hemoptysis, subcutaneous emphysema in the neck or chest, respiratory distress and a pneumothorax with a continuous air leak after chest tube placement.

The phrenic nerve arises from C3, C4 and C5 (C3, 4, 5 keeps the diaphragm alive). High cervical injuries can cause respiratory failure requiring ventilatory support.

Carboxyhemoglobin is read as oxyhemoglobin by standard pulse oximeters. Give 100% oxygen, which shortens the carbon monoxide half-life from several hours on room air to roughly 1 hour.

Excess pressure or volume pushes air into the stomach, which raises aspiration risk and limits diaphragm movement. Use slower breaths with smaller volumes, and place an orogastric tube to decompress.

Airway edema can worsen over hours and make intubation impossible later. Securing the airway early prevents sudden obstruction.

The cricothyroid membrane is small and the larynx is easily damaged. Needle cricothyrotomy with jet insufflation is used for children under about 10 to 12 years.

Neuromuscular blockers cause paralysis but do not provide sedation or pain relief, so the patient may be awake and in pain without being able to move. Give sedation and analgesia and monitor for awareness.

Excess secretions and muscle effects (SLUDGE: salivation, lacrimation, urination, defecation, GI upset, emesis), pinpoint pupils, seizures and respiratory failure. Treat with atropine, pralidoxime and benzodiazepines for seizures, along with decontamination.

It is the pediatric version for children, using a respiratory rate range of 15 to 45, giving rescue breaths to a child who is apneic but has a pulse, and using AVPU for mental status.

Illness often appears days later, so surveillance and reporting are crucial. Use isolation precautions based on the agent, such as airborne or contact, and treat early according to the agent, as with antibiotics for anthrax.

Blister agents such as mustard cause delayed skin and airway burns without an antidote. Choking agents such as chlorine damage the lungs, and cyanide interferes with cellular oxygen use and is treated with hydroxocobalamin.

Primary: pressure effects on air-containing organs such as ears, lungs and bowel. Secondary: fragments and debris. Tertiary: being thrown. Quaternary: burns, crush and inhalation injury.

Mitigation, preparedness, response and recovery. Planning, training and drills happen before the event, and recovery restores normal operations afterward.

Provide one source of verified information through a designated public information officer, protect patient privacy and update staff and the community regularly.

Immediate (red), delayed (yellow), minor (green) and expectant or deceased (black). START stands for Simple Triage and Rapid Treatment.

Patients who can walk are minor. If not breathing after the airway is opened, they are expectant or deceased. A respiratory rate over 30, absent radial pulse or capillary refill over 2 seconds, or inability to follow commands makes them immediate. Others are delayed.

Hot zone (contaminated), warm zone (decontamination) and cold zone (clean). PPE levels run from A (fully encapsulated, highest protection) to D (work uniform), and hospital decontamination teams commonly use level C.

Sort, Assess, Lifesaving interventions, and Treatment or Transport. It begins with global sorting (walk, wave, still) and includes quick interventions such as hemorrhage control.

An event where the number of patients overwhelms the resources of the responders or facility. Disasters can be internal or external, and the response must be scaled.

Lung injury from the pressure wave, causing hypoxia, hemoptysis and respiratory failure that can be delayed. Ear injury is a marker, and positive-pressure ventilation risks air embolism and pneumothorax.

Early support focused on safety, calming, connection, self-efficacy and hope, delivered to patients, families and staff. It is not therapy, and it identifies people who need further mental health care.

Secondary triage reassesses patients as they arrive at the treatment area because conditions change. Reverse triage, as for lightning strikes, treats those who appear dead first because they are most likely to be saved.

A facility's ability to expand beyond normal limits, using extra space, staff, supplies and equipment. Plans may include discharging stable patients, opening alternative care areas and calling in staff.

Exposure means being irradiated, and the person is not radioactive. Contamination means radioactive material is on or in the body, so removing outer clothing removes about 90% of external contamination. Potassium iodide protects the thyroid from radioactive iodine.

A standardized management structure that assigns clear roles for command, operations, planning, logistics and finance during an emergency. It improves coordination and communication.

Run, hide, fight for the public, and the Hartford Consensus THREAT approach for responders (Threat suppression, Hemorrhage control, Rapid extrication, Assessment by providers, Transport). Stop the Bleed training teaches the public to control bleeding.

To identify patients, avoid duplicate or lost records and help families find each other. Use triage tags, a registration system, a family information area and a public information officer.

Decorticate posturing has the arms flexed toward the chest with the legs extended. Decerebrate posturing has the arms and legs extended with the wrists flexed and signals more severe brainstem injury.

Epidural is arterial, fast-developing and lens-shaped, with a possible lucid interval. Subdural is venous, may develop acutely or slowly and is crescent-shaped. Both can need urgent surgery.

It is an osmotic diuretic that draws water out of brain tissue (typically 0.25 to 1 g/kg IV). Monitor urine output and serum osmolality, and avoid it in hypotension or hypovolemia because it causes diuresis.

Do not remove impaled objects, control bleeding gently, protect the airway, give antibiotics and tetanus as ordered, and arrange CT and neurosurgical care. Bone and brain fragments are not pushed back in.

CPP equals mean arterial pressure minus intracranial pressure. The target is generally about 60 to 70 mm Hg to ensure enough blood flow to the brain.

At least every 15 minutes at first in an unstable patient and then as the condition and policy dictate. Include GCS, pupils, motor and sensory function, vital signs and comparison with prior findings.

Bleeding between the dura and arachnoid from torn bridging veins. It is more common in older adults, people who use alcohol and those who take anticoagulants, and CT shows a crescent-shaped collection.

Bleeding between the skull and dura, usually from the middle meningeal artery after a temporal bone fracture. There may be a brief lucid interval followed by rapid deterioration, and CT shows a biconvex, lens-shaped collection.

Hypoglycemia can mimic or worsen neurologic injury, and sustained hyperglycemia is linked with worse outcomes. Check glucose early and avoid extremes.

Headache, vomiting, declining level of consciousness, restlessness, pupil changes, weakness on one side, posturing, seizures and, late, Cushing's triad.

Hypoxia, hypotension, hypercapnia or hypocapnia, hyperthermia, hypoglycemia or hyperglycemia, seizures and raised intracranial pressure. Prevention of these is a priority.

GCS below 15 two hours after injury, suspected open or depressed skull fracture, signs of basilar skull fracture, two or more episodes of vomiting, or age 65 or older. These predict the need for neurosurgical intervention.

Diabetes insipidus causes large volumes of dilute urine and high sodium. SIADH causes low sodium from water retention. Monitor urine output and sodium regularly.

A bruise on the brain surface, often at the site of impact or opposite it (coup and contrecoup). It may swell and bleed over hours, so repeat imaging and neurologic checks are important.

A mild traumatic brain injury causing a temporary change in brain function, with symptoms such as headache, confusion, amnesia, dizziness, nausea or brief loss of consciousness. Imaging is often normal, and a graduated return to activity is advised.

Normal ICP in adults is about 5 to 15 mm Hg. Treatment is generally started when it is sustained above about 20 to 22 mm Hg.

Bleeding into the space between the arachnoid and pia mater, causing headache, neck stiffness and decreased consciousness. In trauma it is common with contusions, and CT shows blood in the cisterns.

Hypertension with a widened pulse pressure, bradycardia and irregular respirations. It is a late sign of increased intracranial pressure and impending herniation.

Widespread shearing of axons from rapid acceleration and deceleration. Patients are often deeply comatose, and the initial CT may be normal or show small hemorrhages.

A hyperosmolar solution (such as 3%) given to reduce brain swelling and ICP. It also expands plasma volume, which makes it useful in hypotensive patients, and sodium levels must be monitored.

Primary injury is the direct damage at the time of impact, such as contusion, hemorrhage or axonal shearing. Secondary injury develops afterward from hypoxia, hypotension, swelling, raised intracranial pressure and other problems, and nursing care aims to prevent it.

Noncontrast head CT. It quickly shows hemorrhage, fractures, swelling and midline shift.

The skull is a rigid container holding brain tissue, blood and cerebrospinal fluid. If one component increases, such as a hematoma, the others must decrease or intracranial pressure rises.

Raise the head of the bed about 30 degrees with the head midline, avoid neck compression from ties or collars, prevent hypoxia and hypotension, treat pain, fever and agitation, and minimize stimulation and coughing.

Avoid hypoxia by keeping SpO2 at or above about 94%, and avoid hypotension by maintaining a systolic pressure of at least 100 mm Hg for ages 50 to 69 and at least 110 mm Hg for ages 15 to 49 and over 70.

Have a responsible adult stay with the patient, watch for return warning signs (worsening headache, repeated vomiting, confusion, drowsiness, weakness, seizure), avoid alcohol and sedatives and rest from physical and mental stress, with follow-up.

A unilateral dilated, nonreactive pupil, sudden decline in GCS, abnormal posturing, hemiparesis and Cushing's triad. This is an emergency that needs immediate treatment.

Scalp, skull, then the meninges (dura mater, arachnoid and pia mater), with cerebrospinal fluid between the arachnoid and pia, surrounding the brain.

Craniotomy to evacuate a hematoma, burr holes for drainage in emergencies, an external ventricular drain to release CSF and decompressive craniectomy for refractory swelling.

Linear (most common), depressed, basilar and open or compound fractures. Depressed and open fractures and basilar fractures raise concern for brain and dural injury and infection.

Seizure prophylaxis for about 7 days is recommended in severe TBI to reduce early post-traumatic seizures, often with levetiracetam or phenytoin. Active seizures are treated first with a benzodiazepine.

Only briefly for signs of herniation, to a PaCO2 of about 30 to 35 mm Hg, as a bridge to other treatment. Routine or prolonged hyperventilation reduces cerebral blood flow and can cause ischemia.

In patients with severe TBI (GCS 3 to 8) and an abnormal CT, or a normal CT with two or more of age over 40, motor posturing and systolic pressure below 90 mm Hg.

Isotonic solutions such as normal saline. Avoid hypotonic fluids and dextrose-containing solutions because they can worsen brain swelling.

Brain atrophy stretches bridging veins and anticoagulants or antiplatelet drugs increase bleeding, including delayed hemorrhage. They may need a CT scan and observation even after a mild injury.

A strong force to the head often injures the neck, and altered consciousness makes clinical clearance unreliable. Maintain spinal motion restriction until the spine is cleared.

The scalp is very vascular and can bleed heavily, even causing shock in children and infants. Apply direct pressure, explore the wound for skull defects or debris and then close it.

Fever increases the brain's metabolic demand and oxygen needs and worsens secondary injury. Treat it with antipyretics and cooling.

In adults, isolated head injury rarely causes hypotension. Look for blood loss from the chest, abdomen, pelvis or long bones, or for neurogenic shock, unless the patient is an infant.

Hemorrhage and contusions can expand over hours, particularly in anticoagulated patients. A change in neurologic status should prompt immediate repeat imaging.

Blunt trauma transfers energy through compression, shearing and deceleration, often causing diffuse internal injuries. Penetrating trauma damages tissue along the path of the object, and the injury depends on the object, its velocity and the body region.

Use the jaw-thrust maneuver while keeping the head and neck in neutral alignment with manual stabilization. The head-tilt chin-lift maneuver is avoided because it moves the cervical spine.

Kinetic energy equals one half of mass times velocity squared, so speed has a greater effect than weight. Higher speed means more energy transferred to the body and a higher chance of serious injury.

Place it proximal to the wound, about 2 to 3 inches (5 to 8 cm) above it and not over a joint, then tighten until bleeding stops and the distal pulse is gone. Record the time of application and do not loosen it in the emergency department.

A GCS of 13 to 15 is mild, 9 to 12 is moderate and 8 or less is severe. A score of 8 or less usually signals that the patient cannot protect the airway and may need intubation.

Remove wet clothing, expose only as needed, cover with warm blankets or a forced-air warmer, raise the room temperature and give warmed IV fluids and blood products. Keep the patient covered after inspection.

Inspect for bruising, deformity, bleeding and leg length difference, and gently compress the pelvis once to check stability. Avoid repeated rocking or springing, which can dislodge clots and worsen bleeding.

Log roll the patient with several team members, one controlling the head and neck, keeping the spine aligned. Inspect and palpate the back and spine for wounds, bruising and tenderness, and then return the patient to a supine position.

Leave it in place, stabilize it with bulky dressings and prevent movement during transport. Remove it only in the operating room, or in the field if it blocks the airway or prevents CPR.

Cut clothing around holes rather than through them, avoid cutting through knife or bullet holes, place clothing and bullets in paper bags (not plastic), label them and document who handled them to maintain chain of custody. Photograph injuries when policy allows.

Use a rigid-tip (Yankauer) suction catheter to clear blood, vomit and secretions from the mouth, limit each pass to about 10 to 15 seconds in adults, and preoxygenate if possible. Keep suction ready and within reach throughout.

Level 1: needs immediate life-saving intervention. Level 2: high-risk situation or severe pain or distress. Level 3: stable but needs two or more resources. Level 4: needs one resource. Level 5: needs no resources.

Record times, assessments, interventions, responses, medicines and communication accurately and objectively. Use the patient's own words in quotes, avoid opinion or speculation, and document reevaluations and handoffs.

Level I provides comprehensive 24-hour trauma care, research and education. Level II provides most of the same care without the research focus. Level III provides prompt assessment, resuscitation and stabilization with transfer for complex cases. Levels IV and V provide initial care in rural settings before transfer.

Direct pressure, hemostatic dressings packed into the wound, pressure dressings and, for life-threatening extremity bleeding, a tourniquet. Elevation alone is not enough for major bleeding.

A: Alertness and Airway with spinal motion restriction. B: Breathing and ventilation. C: Circulation and control of hemorrhage. D: Disability (neurologic status). E: Exposure and environmental control. F: Full set of vital signs and family presence. G: Get resuscitation adjuncts and give comfort.

H: History and head-to-toe assessment. I: Inspect posterior surfaces. The secondary survey begins only after life threats in the primary survey are addressed, and the patient is reevaluated throughout.

Physiologic criteria (such as hypotension, abnormal respiratory rate or low Glasgow Coma Scale score), anatomic criteria (such as penetrating injury to the head, neck or torso, or unstable chest or pelvis) and mechanism criteria (such as high-speed crash, ejection or a significant fall). Special considerations include age, pregnancy and anticoagulants.

Team leader (often a physician), airway manager, primary nurse who assesses and gives medicines, second nurse for IV access, labs and procedures, a recorder who documents, and support staff such as respiratory therapy, radiology and security. Roles are assigned before the patient arrives.

Pericardial, right upper quadrant (hepatorenal), left upper quadrant (splenorenal) and pelvic (suprapubic). It looks for free fluid in the pericardium and abdomen, and eFAST adds chest views for pneumothorax and hemothorax.

Pain assessment with an age-appropriate scale, IV analgesia titrated to effect, splinting and positioning, padding bony prominences, warmth, a calm voice and explanations. Both medicines and nonpharmacologic measures are used.

Pain, pallor, pulses, paresthesia, paralysis and temperature. Compare with the opposite limb, document before and after splinting and report changes immediately.

Respiratory rate, depth and effort, chest rise and symmetry, use of accessory muscles, breath sounds, skin color, SpO2 and, when available, end-tidal CO2. The chest is exposed and inspected, auscultated and palpated.

Alert, responds to Voice, responds to Pain, Unresponsive. It is a quick measure of level of consciousness during the airway step and the disability step.

Activate the trauma team, assign roles, prepare the room and equipment (airway supplies, suction, warmed fluids, rapid infuser, massive transfusion supplies), review the prehospital report and put on personal protective equipment.

Repeating vital signs, checking the effect of interventions, repeating the primary survey (A through G) and reassessing pain. It is done after every intervention and any change in condition, and continues throughout care.

Allergies, Medications, Past medical history and pregnancy, Last meal, and Events and environment related to the injury. It also includes tetanus status and the mechanism of injury.

Eye opening (1 to 4), verbal response (1 to 5) and motor response (1 to 6), for a total of 3 to 15. Lower scores indicate a more severe neurologic injury.

In the chest: bruising, paradoxical movement, crepitus, tenderness and breath and heart sounds. In the abdomen: distention, rigidity, guarding, bruising such as a seat belt sign, tenderness and flank bruising (Grey Turner sign).

Battle sign (bruising behind the ear), raccoon eyes (periorbital bruising), hemotympanum, and cerebrospinal fluid leaking from the nose or ear. Battle sign and raccoon eyes may take hours to appear.

Stridor, hoarseness, gurgling, snoring, inability to speak, drooling, facial or neck trauma, soot in the mouth or nose, an expanding neck hematoma and altered consciousness. Agitation may signal hypoxia.

Chest and pelvic radiographs, focused assessment with sonography for trauma (FAST or eFAST), and CT scans when the patient is stable enough. Imaging does not delay life-saving interventions.

Lap belts worn too high can cause hollow organ and mesenteric injuries and flexion-distraction lumbar fractures (Chance fracture). A seat belt sign across the abdomen or chest raises suspicion for internal injury.

Calcaneus fractures, tibial plateau and lower-extremity fractures, pelvic and lumbar spine compression fractures and sometimes aortic injury. Calcaneal fractures should prompt a look at the spine.

A rapid look at the patient on arrival for obvious life threats such as uncontrolled bleeding, airway compromise or altered consciousness. It guides the first actions, and massive external hemorrhage is controlled before moving to airway assessment.

A pre-planned system that delivers balanced ratios of red cells, plasma and platelets, such as 1:1:1, when large blood loss is expected. Warmed blood products and early hemorrhage control replace large volumes of crystalloid.

Heart rate, blood pressure, pulse quality and location, skin color, temperature and moisture, capillary refill, level of consciousness and sources of bleeding. External hemorrhage is controlled and signs of shock are identified.

Size, equality, shape and reaction to light. A unilateral dilated, nonreactive pupil may signal brain herniation, and bilateral dilated pupils can mean severe injury, hypoxia or hypoperfusion.

Mechanism of injury, injuries found, signs and vital signs, treatments given and time of injury, often organized as MIST (Mechanism, Injuries, Signs, Treatment). Allergies, medications and relevant history are added as they are known.

Accepting a lower-than-normal blood pressure, often a systolic pressure of about 80 to 90 mm Hg, while bleeding is not yet controlled, to avoid clot disruption and dilution. It is not used in traumatic brain injury, where adequate perfusion pressure is needed.

Keeping the spine in neutral alignment with manual stabilization, a cervical collar and a firm surface when the mechanism or exam suggests spinal injury. TNCC uses this term in place of full spinal immobilization.

Hypothermia, acidosis and coagulopathy. Each worsens the others and increases mortality, so early warming, hemorrhage control and balanced resuscitation are priorities.

Normal is about 35 to 45 mm Hg. It confirms endotracheal tube placement, monitors ventilation and perfusion, and trends can show hypoventilation, shock or cardiac arrest.

It decompresses the stomach to reduce aspiration risk and improve ventilation. An orogastric tube is used instead of a nasogastric tube when midface fractures or basilar skull fracture are suspected.

An antifibrinolytic given to bleeding trauma patients within 3 hours of injury, typically 1 gram over 10 minutes followed by 1 gram over 8 hours. Early administration improves survival.

A systematic, prioritized approach to the injured patient that moves through preparation and triage, the primary survey (A through G), reevaluation, the secondary survey (H and I) and then definitive care or transfer. It standardizes assessment and speeds recognition of life threats.

Immediate deaths occur within seconds to minutes from massive injuries to the brain, heart or great vessels. Early deaths occur within the first hours from hemorrhage or airway and breathing problems, which is the focus of rapid trauma care. Late deaths occur days to weeks later from sepsis and multiple organ failure.

Type and crossmatch, complete blood count, chemistry panel, coagulation studies, lactate, arterial or venous blood gas, a pregnancy test in people of childbearing age, and alcohol and toxicology screens as indicated.

Tracheal position, jugular vein distention, subcutaneous emphysema, hematoma, swelling, wounds and cervical spine tenderness. Penetrating neck wounds are not probed.

Standard precautions: gloves, fluid-resistant gown, eye protection or face shield and a mask, plus lead aprons when imaging is done at the bedside. Personal protection comes first, because a safe team can care for the patient.

Two large-bore peripheral IV catheters (14 to 16 gauge) in large proximal veins. If IV access fails or is delayed, intraosseous access is used.

Blood pressure, mean arterial pressure, heart rate, respiratory rate, temperature and oxygen saturation. In adults, a systolic pressure below 90 mm Hg is generally considered hypotension, and trends matter more than a single number.

An OPA is used only in unresponsive patients without a gag reflex. An NPA is better tolerated by conscious patients but should be avoided or used with great caution with suspected basilar skull fracture or severe midface trauma.

When the patient cannot consent, such as when unconscious, and a delay would risk life or limb, the implied consent or emergency exception applies. Treatment is limited to what is needed in the emergency, and efforts to reach family continue.

When there is life-threatening external hemorrhage. Controlling severe bleeding with direct pressure or a tourniquet comes first because exsanguination can kill a patient faster than an airway problem.

With blood at the urethral meatus, perineal or scrotal ecchymosis or a high-riding prostate, because these suggest urethral injury. Imaging is done first and a urologist is consulted.

Over the greater trochanters, not the iliac crests, when pelvic fracture is suspected with signs of shock or instability. It reduces pelvic volume and bleeding.

Tension pneumothorax, open pneumothorax, massive hemothorax and flail chest with pulmonary contusion. Each requires intervention at once, such as decompression, an occlusive dressing or chest drainage.

Hypoglycemia can mimic or worsen a neurologic injury and is quickly corrected. A low glucose level should be treated before attributing confusion to head injury.

It helps families cope, supports communication and does not interfere with care when a staff member is assigned to support them. A policy should guide it, and the patient's privacy and the team's safety remain priorities.

Intoxication can mask signs, so avoid assuming it explains altered mental status. Screen using SBIRT (Screening, Brief Intervention, Referral to Treatment), monitor for withdrawal and offer counseling.

Screen with a brief tool such as the Ask Suicide-Screening Questions (ASQ), keep the environment safe, never leave a high-risk patient alone and arrange mental health evaluation.

Hold a brief team debrief, provide peer support and access to employee assistance and counseling, watch for burnout and moral injury, and make breaks and follow-up available.

They influence views on pain, blood products, family roles, modesty, death and decision making. Ask about preferences, involve spiritual care and respect values while keeping safety.

Use a private room, have a physician and nurse present, sit down, use plain words such as 'died', allow time for questions and emotions, offer chaplain or social work support and give them an opportunity to see the patient.

Preserve clothing and bullets, avoid cleaning or probing wounds before documenting them, describe wounds without stating 'entry' or 'exit' as fact, and handle projectiles with care and a documented chain of custody.

Use the patient's own words in quotes, describe wounds objectively with measurements, use body maps and photographs with consent, and avoid terms such as 'alleged'. These records may be used as evidence.

Ask every patient privately, away from partners or family, using a professional interpreter if needed. Use simple direct questions or tools such as HITS (Hurt, Insult, Threaten, Scream), and respond without judgment.

Fear, anxiety, anger, helplessness, grief, guilt and numbness. Provide information, privacy, control where possible, compassion and early psychosocial support.

Treat life-threatening injuries first, then provide privacy and support, involve a sexual assault nurse examiner, collect evidence with consent and maintain chain of custody. Offer STI prophylaxis, emergency contraception and HIV post-exposure prophylaxis within 72 hours.

Strong social support, effective coping skills, stable housing and income, early treatment and access to mental health care. Social work referral can strengthen these.

Not holding their own ID or money, a controlling companion who speaks for them, a scripted or inconsistent history, branding tattoos, signs of untreated injuries or malnutrition, and fear of authorities. Screen privately, and in the United States the National Human Trafficking Hotline is 1-888-373-7888.

Follow policy to notify the organ procurement organization of imminent death, and keep requests separate from the treating team. In medical examiner or coroner cases, leave tubes and lines in place, preserve evidence and document carefully.

Safety, trustworthiness and transparency, peer support, collaboration, empowerment and choice, and attention to cultural and historical issues. Avoid re-traumatizing patients.

Laws vary. Many jurisdictions require reporting of gunshot and stab wounds, child and elder abuse, and some require IPV reporting. Know local law and protect confidentiality otherwise.

Injuries to the head, face, neck and trunk, defensive wounds on the forearms, injuries in various stages of healing, strangulation signs, a delay in seeking care and a story that does not fit the injury.

Seat belt and car seat use, helmets, avoiding impaired driving, safe firearm storage, fall prevention, drowning and burn safety, and violence prevention programs. Brief counseling at the bedside can change behavior.

A program in which trained staff meet violently injured patients at the bedside and connect them with counseling, housing, education and job services. It aims to prevent reinjury and retaliation.

A plan that helps a patient reduce risk, such as a safe place and contact, important documents, emergency money and a hotline number. In the United States the National Domestic Violence Hotline is 1-800-799-7233.

A pattern of physical, sexual or psychological harm, stalking, coercive control or reproductive coercion by a current or former partner. It affects all genders, ages and backgrounds.

Acute stress disorder begins within a month of the trauma and lasts from 3 days to 1 month. PTSD lasts longer than 1 month and includes intrusive memories, avoidance, negative mood changes and hyperarousal.

Setting, Perception of what the family knows, Invitation to share how much they want to know, Knowledge (give the facts simply), Emotions (respond with empathy) and Strategy or summary of next steps.

Social workers assess safety, housing, finances, caregivers, insurance and support needs, and help with discharge planning and resources. Early involvement reduces repeated injury and readmission.

It is a strong predictor of later homicide. Signs include neck pain, hoarseness, difficulty swallowing, petechiae, ligature marks and loss of consciousness, and delayed airway swelling or vascular injury can occur, so imaging and observation are needed.

Family members may filter or change information, and patients may not disclose violence or pain. Use trained interpreters for assessments, consent and sensitive discussions.

Screen with tools such as the Confusion Assessment Method, reorient, keep glasses and hearing aids in use, promote sleep and mobility, avoid unnecessary sedatives and treat pain and infection.

Remove the long backboard as soon as possible, pad bony areas, reposition and inspect skin early. Older skin is thin and breaks down quickly.

Use observational tools such as PAINAD, which scores breathing, vocalization, facial expression, body language and consolability. Undertreated pain can appear as agitation.

Check hearing aids and glasses, face the patient, speak slowly and clearly, reduce background noise, give written information and confirm understanding.

Dentures, limited neck mobility, reduced oxygen reserve and rapid desaturation. Preoxygenate well and reduce sedative and induction doses to avoid hypotension.

Unexplained or repeated injuries, bruises in different stages, poor hygiene, malnutrition, delay in seeking care, and a caregiver who answers for the patient or refuses privacy. Screen privately and report as the law requires.

They can be hypovolemic but have limited cardiac reserve, so large volumes risk pulmonary edema. Give smaller boluses, early blood when needed and reassess often.

Falls, often from ground level. Risk factors include weakness, poor balance, medicines, vision problems, home hazards and previous falls, and prevention programs reduce injuries.

Generally within 24 to 48 hours of injury, once the patient is optimized. Early surgery lowers complications and improves recovery.

Reduced cardiac reserve and stiffer blood vessels, lower lung compliance, decreased kidney function, brittle bones, thinner skin, impaired temperature regulation and a blunted response to stress. Older adults have less ability to compensate.

A systolic pressure below about 110 mm Hg may represent shock in adults aged 65 and older, because their usual pressures are higher. Treat early and use a lower threshold for trauma team activation.

Beta-blockers and calcium channel blockers blunt tachycardia, and pacemakers fix heart rate. A normal heart rate does not exclude blood loss.

They increase bleeding, including intracranial hemorrhage, and can cause delayed bleeding after minor injuries. Obtain imaging early, check coagulation tests and arrange reversal if needed.

They can occur after a ground-level fall in people with osteoporosis. They may cause neck pain with few neurologic signs but carry a risk of cord injury and instability.

Reduced metabolic rate, decreased subcutaneous fat and impaired shivering and vasoconstriction. Cover and warm patients early.

Treatment should match the patient's wishes. Ask about advance directives, code status and surrogate decision makers early, and involve palliative care when appropriate.

Comorbid conditions, medicines, frailty and a smaller physiologic reserve make complications and death more likely after the same injury. Even minor trauma can be serious.

Pain limits deep breathing and coughing, causing atelectasis and pneumonia, and mortality rises with the number of fractures. Early multimodal analgesia, regional blocks and pulmonary care are essential.

Polypharmacy increases risks of drug interactions, bleeding, delirium and falls. Identify anticoagulants, antiplatelets, cardiac medicines, insulin and sedatives early.

Brain atrophy stretches bridging veins, so minor trauma can tear them. Symptoms can be delayed and subtle, such as headache or confusion.

The spleen, liver and kidneys are the most commonly injured. Stable patients are often managed without surgery, and a distended stomach from crying or swallowed air is relieved with a gastric tube.

A larger head relative to body size, compliant ribs that transmit force to lungs without fractures, less protected abdominal organs, a larger body surface area causing heat loss, a smaller blood volume and a more flexible spine.

A larger tongue, a higher and more anterior larynx, a floppy epiglottis, a narrowest point at the cricoid ring, a shorter trachea and a large occiput. These make obstruction more likely and intubation harder.

Compliant ribs may not fracture, so a severe pulmonary contusion or other internal injury can occur without rib fractures. Rib fractures in a child suggest a large force or abuse.

Use a length-based resuscitation tape, or the formula (age in years + 4) times 2 in kilograms for ages 1 to 10. Weight guides drug doses, fluids and equipment size.

Hypoxia is the main injury, so open the airway and give rescue breaths and oxygen first, followed by compressions if there is no pulse. Rewarm hypothermic patients and observe symptomatic patients because deterioration can be delayed.

Allow family presence when possible, explain procedures at the child's developmental level, involve child life specialists and give honest, simple information. Parents calm children and can help with assessment.

The verbal score is adapted: coos or babbles (5), irritable cries (4), cries to pain (3), moans to pain (2), no response (1). The eye and motor scores are used with age-appropriate responses.

70 plus 2 times the age in years. A value below this level is hypotension, which is a late sign of shock in children.

Cuffed tube: (age in years divided by 4) + 3.5. Uncuffed tube: (age divided by 4) + 4. The depth at the lip is about 3 times the tube size in cm.

Place a small towel under the shoulders to bring the head into a neutral or sniffing position, because the large occiput flexes the neck. Avoid hyperextension, which can obstruct the airway.

Infant: HR 100 to 160, RR 30 to 60. Toddler: HR 90 to 150, RR 24 to 40. Preschool: HR 80 to 140, RR 22 to 34. School age: HR 70 to 120, RR 18 to 30. Adolescent: HR 60 to 100, RR 12 to 20. Use age-based tables.

Buckle (torus) fractures are compression injuries of the bone cortex, and greenstick fractures bend and partly break the bone. Both occur because children's bones are softer and more flexible.

Epinephrine 0.01 mg/kg IV or IO (0.1 mL/kg of the 1:10,000 concentration). Defibrillation starts at 2 J/kg and increases to 4 J/kg, and synchronized cardioversion starts at 0.5 to 1 J/kg.

Fractures involving the growth plate (physis), classified I through V: I through the physis, II above (most common), III lower through the epiphysis, IV through the metaphysis, physis and epiphysis, and V crush. Growth plate injuries can affect growth.

Tachycardia, delayed capillary refill, cool mottled skin, weak pulses and altered mental status. Hypotension is a late sign and may not appear until 25 to 30% of blood volume is lost.

Document objectively, use the child's words, protect the child and report to child protective services or the authorities as the law requires. Reporting suspicion does not require proof.

Delay in seeking care, a history that changes or does not match the injury, injuries not consistent with the child's development, patterned marks, multiple injuries in different stages of healing, and fractures in non-walking infants.

Improperly restrained children can have seat belt syndrome with abdominal wall bruising, bowel and mesenteric injury and lumbar flexion-distraction fractures. Children under 13 should ride in the back seat in appropriate restraints.

The fulcrum is higher (C2 to C3), so injuries are more often in the upper spine. Pseudosubluxation of C2 on C3 can appear normal on radiographs, and spinal cord injury without radiographic abnormality (SCIWORA) can occur.

A large head and weak neck muscles make head injury common. Use rules such as PECARN to decide on CT, watch for a bulging fontanelle, scalp hematomas and vomiting, and consider abuse in infants.

Give a 20 mL/kg bolus of warmed isotonic crystalloid, repeat once if needed, and then give blood at about 10 to 20 mL/kg. Reassess after each bolus and control bleeding.

Injury, most often from motor vehicle crashes, drowning, burns, falls and violence. Prevention and early trauma care greatly improve outcomes.

Scalds from hot liquids. Prevention teaches safe water heater settings, kitchen safety and supervision, and burn size is estimated with age-adjusted charts.

A rapid visual assessment of appearance (tone, interactiveness, consolability, look and gaze, speech or cry), work of breathing and circulation to the skin. It is done before touching the child.

Bruising on the torso, ear or neck in a child under 4 years, or any bruise in an infant under 4 months, should raise concern for abuse and prompt evaluation.

When IV access cannot be obtained quickly, in a critically ill or injured child. Common sites are the proximal tibia and distal femur, avoiding fractured limbs.

FLACC for infants and young or nonverbal children, the Wong-Baker FACES scale for ages 3 and older, and a numeric rating scale for ages 8 and older. Treat pain promptly.

A large surface area relative to weight and little insulation. Keep the room warm, expose only what is needed, use warm blankets and warm fluids.

Infants are obligate nose breathers, so secretions in the nose can obstruct breathing. Suction the nose gently, and place gastric tubes orally rather than nasally.

The top of the uterus (fundus) reaches the umbilicus at about 20 weeks, and between 20 and 34 weeks the fundal height in centimeters roughly equals the weeks of gestation.

The enlarged uterus can shield maternal organs but is often injured, and the fetus is at high risk. Wound tracks can be unpredictable, so a surgical evaluation is needed.

Tilt the backboard 15 to 30 degrees to the left or place a wedge, to relieve pressure on the vena cava while keeping the spine aligned.

After about 20 to 24 weeks, use continuous cardiotocography for at least 4 hours, longer if there are contractions, bleeding, abdominal pain or abnormal findings. A normal fetal heart rate is about 110 to 160 beats per minute.

The lap belt should sit low across the hips and under the abdomen, and the shoulder belt should cross the chest between the breasts and to the side of the abdomen. Correct use protects both mother and fetus.

No. Use ultrasound first, but obtain CT or radiographs when needed, because maternal diagnosis and treatment are the priority. Fetal radiation risk is low at doses below about 50 mGy, and shielding does not replace judgment.

Swollen mucosa, a larger breast size, a higher aspiration risk and rapid desaturation because of reduced oxygen reserve. Use smaller tubes, expect a difficult airway and preoxygenate well.

Severe abdominal pain, a tender or irregular uterine shape, easily palpated fetal parts, vaginal bleeding, maternal shock and an abnormal or absent fetal heart rate. It requires emergency surgery.

Motor vehicle crashes, falls and interpersonal violence. Domestic violence often begins or worsens during pregnancy, so screening is important.

About 23 to 24 weeks or later. Viability affects decisions about fetal monitoring and emergency delivery.

About 30 mm Hg, a mild respiratory alkalosis. A PaCO2 of 35 to 40 mm Hg may signal impending respiratory failure.

After about 20 weeks, the enlarged uterus compresses the vena cava and aorta in the supine position, lowering venous return and blood pressure. Tilt the patient 15 to 30 degrees to the left, or manually displace the uterus to the left.

Separation of the placenta from the uterine wall, the most common cause of fetal death after blunt trauma. Signs include vaginal bleeding (may be concealed), a tender, rigid uterus, contractions and fetal distress.

Resuscitate the mother first, because the best chance for the fetus is maternal stabilization. Follow the standard primary survey and add fetal assessment.

Blood volume rises by about 40 to 50%, heart rate increases by 10 to 20 beats per minute, blood pressure falls in the second trimester, and the diaphragm rises. Blood loss can be large before maternal signs appear.

In maternal cardiac arrest when the uterus is at or above the umbilicus (about 20 weeks or more), starting within 4 minutes of arrest so that delivery occurs by about 5 minutes. Delivery relieves aortocaval compression and aids resuscitation.

Vasopressors reduce blood flow to the uterus. Treat hypovolemia first with fluids and blood, keep the patient tilted to the left and use vasopressors only when needed.

Her expanded blood volume allows her to lose about 1,200 to 1,500 mL before obvious signs. The uterus is not prioritized in compensation, so the fetus may become compromised first.

Delayed gastric emptying and a weaker lower esophageal sphincter. Place a gastric tube and protect the airway in an unconscious patient.

Fetomaternal hemorrhage can sensitize an Rh-negative mother to Rh-positive fetal blood. Give Rh immune globulin within 72 hours, and a Kleihauer-Betke test can estimate the amount of fetal blood in the maternal circulation.

Warfarin is reversed with vitamin K and prothrombin complex concentrate or plasma. Dabigatran is reversed with idarucizumab, and factor Xa inhibitors with andexanet alfa or prothrombin complex concentrate, depending on local protocol.

Rapid responders stabilize and have little ongoing blood loss. Transient responders improve and then deteriorate, which suggests ongoing bleeding. Minimal or non-responders need immediate hemorrhage control and blood.

Heart rate rises (normal in class I, over 100 in II, over 120 in III, over 140 in IV), pulse pressure narrows early, and blood pressure usually stays normal until class III. Respiratory rate and anxiety increase and urine output falls.

MAP equals the diastolic pressure plus one third of the pulse pressure, or (systolic + 2 times diastolic) divided by 3. A MAP of at least 65 mm Hg is commonly targeted to perfuse organs.

Give fluids to correct any volume deficit, then vasopressors such as norepinephrine if hypotension persists, and atropine for symptomatic bradycardia. Look for hemorrhage first, because it is more common.

Up to about 1,000 to 1,500 mL into the thigh. Femur splinting with a traction device can reduce further loss.

Normal heart rate and blood pressure, MAP of at least 65 mm Hg, adequate urine output, improving mental status, clearing lactate and normalizing base deficit.

Fever, chills, hives, flushing, back pain, dyspnea, hypotension, red or dark urine and chest tightness. Stop the transfusion, keep the IV open with normal saline, notify the physician and blood bank and monitor the patient.

Sympathetic stimulation raises heart rate and causes vasoconstriction, catecholamines are released, the renin-angiotensin system conserves sodium and water, and ADH increases fluid retention. These preserve blood flow to the heart and brain.

Anxiety or restlessness, tachycardia, tachypnea, pale cool clammy skin, delayed capillary refill, narrowed pulse pressure and decreased urine output. Hypotension is a late sign.

Vasodilation causes relative hypovolemia and low systemic vascular resistance. Types include neurogenic, septic and anaphylactic shock, and skin may be warm and flushed early on.

Class I: up to 15% blood loss (up to 750 mL). Class II: 15 to 30% (750 to 1,500 mL). Class III: 31 to 40% (1,500 to 2,000 mL). Class IV: more than 40% (more than 2,000 mL).

Hypovolemic (including hemorrhagic), distributive (neurogenic, septic and anaphylactic), cardiogenic and obstructive. Trauma patients commonly have hemorrhagic shock, and mixed types can occur.

The chest, abdomen, pelvis and retroperitoneum, long bones and the external environment (on the floor). Remember the saying 'blood on the floor and four more'.

Early hemorrhage control, balanced blood product transfusion, limited crystalloid, permissive hypotension in selected patients, warming, correction of acidosis and calcium replacement.

Compensated (the body maintains blood pressure through compensation), decompensated (blood pressure falls and organs are under-perfused) and irreversible (cell and organ damage cannot be reversed even if perfusion is restored).

Blunt cardiac injury, myocardial contusion, valve injury, arrhythmias or a prior cardiac condition. Signs include hypotension with pulmonary congestion and elevated neck veins.

Tension pneumothorax, cardiac tamponade and, less often, massive pulmonary embolism. These conditions prevent the heart from filling or pumping effectively.

Cardiac output equals heart rate times stroke volume, and stroke volume depends on preload, afterload and contractility. Hemorrhage reduces preload, which lowers stroke volume.

They reflect anaerobic metabolism and hypoperfusion. A lactate above about 2 mmol/L or a rising base deficit suggests shock, and falling values suggest effective resuscitation.

With low oxygen delivery, cells switch to anaerobic metabolism, producing lactic acid and little energy. The sodium-potassium pump fails, cells swell and release potassium, and tissue damage follows.

A device that warms and delivers blood or fluids at high flow rates through a large-bore line. It is used for massive hemorrhage, with careful monitoring for air and volume overload.

An early clotting disorder that occurs soon after major injury and shock, caused by tissue damage and hypoperfusion before fluids are given. It increases bleeding and mortality.

Hypotension, distended neck veins (JVD) and muffled heart sounds, associated with cardiac tamponade. It is not always present, especially in hypovolemia.

Loss of sympathetic tone after a spinal cord injury, usually above T6, causing vasodilation. It presents with hypotension, a slow or normal heart rate and warm dry skin below the injury.

Pulse pressure is systolic minus diastolic pressure. It narrows because catecholamines raise diastolic pressure through vasoconstriction while stroke volume and systolic pressure fall.

Resuscitative endovascular balloon occlusion of the aorta, a catheter-based balloon inflated in the aorta to control bleeding below the diaphragm and support blood pressure. It is a bridge to surgical or angiographic hemorrhage control.

A state of inadequate tissue perfusion that fails to deliver enough oxygen and nutrients to meet cellular needs. It leads to anaerobic metabolism, lactic acidosis and organ failure if not reversed.

Spinal shock is a temporary loss of reflexes and flaccid paralysis below the level of injury. Neurogenic shock is a hemodynamic problem with hypotension and bradycardia caused by loss of sympathetic tone.

About 70 mL/kg (roughly 7% of body weight). Children have about 80 mL/kg.

Control bleeding and give a limited bolus of warmed isotonic crystalloid (about 1 L in adults), then move early to blood products. Avoid large volumes of crystalloid, which can worsen bleeding, acidosis and hypothermia.

Hemorrhage. Until proven otherwise, hypotension in a trauma patient is considered to be from blood loss.

Less than 2 seconds. A delayed refill suggests poor peripheral perfusion, though cold environments and other factors can affect it.

Heart rate divided by systolic blood pressure. Normal is about 0.5 to 0.7, and a value above about 0.9 suggests significant hemorrhage and a need for transfusion.

At least 0.5 mL/kg/hr in adults, 1 mL/kg/hr in children and 2 mL/kg/hr in infants. Low output is a sensitive sign of poor perfusion.

A single product that contains red cells, plasma and platelets. Some centers use low-titer group O whole blood for patients with life-threatening bleeding.

Hypothermia, hypocalcemia from citrate binding calcium, hyperkalemia, acidosis and dilutional coagulopathy. Warm all products, monitor calcium and potassium, and replace calcium as needed.

For neurogenic shock, or temporarily during resuscitation when hypotension is life-threatening, while bleeding is controlled. They are not a substitute for volume and hemorrhage control in hemorrhagic shock.

Uncrossmatched type O blood, with O-negative preferred for females of childbearing age to avoid Rh sensitization, and O-positive acceptable for males. Type-specific blood replaces it as soon as it is ready.

Patients taking beta-blockers or calcium channel blockers, older adults, athletes, those with pacemakers, patients with hypothermia and those with neurogenic shock. A normal heart rate does not rule out shock.

Current guidelines recommend against routine high-dose methylprednisolone because of side effects and limited benefit. Treatment focuses on perfusion, oxygenation and stabilization.

Control bleeding with direct pressure or a tourniquet, cover the stump with a sterile dressing, wrap the part in saline-moistened gauze, place it in a sealed plastic bag and keep that bag on ice. Never place the part directly on ice or in water.

The Gustilo classification grades open fractures by wound size and soft-tissue or vascular injury (type I under 1 cm, type II 1 to 10 cm, type III over 10 cm or severe injury). Give antibiotics as early as possible, update tetanus, cover the wound with a sterile dressing and splint.

A posterior dislocation, the most common, leaves the leg shortened, adducted and internally rotated. Prompt reduction is needed to reduce the risk of avascular necrosis and nerve injury.

Groin or hip pain, inability to bear weight and a leg that is shortened and externally rotated. These fractures often follow low-energy falls and need prompt pain control and surgical planning.

A squared-off shoulder with the arm held slightly abducted and externally rotated, and pain with movement. Check the axillary nerve (sensation over the lateral deltoid) and distal pulses before and after reduction.

Loss of intercostal and abdominal muscle function reduces cough and lung volumes, and injuries at C3 to C5 impair the diaphragm. Patients need monitoring of vital capacity and may need ventilatory support.

Seven cervical, twelve thoracic, five lumbar, five fused sacral and four fused coccygeal vertebrae.

Routine collars are not recommended when there is no neurologic deficit, because unstable spinal injury is rare and a collar can hide neck wounds and delay care. Blunt mechanisms or deficits do need spinal motion restriction.

Jefferson fracture (burst fracture of C1), hangman's fracture (bilateral C2 pars fracture), odontoid fracture (C2 dens) and compression or teardrop fractures of lower vertebrae.

C6 thumb, C7 middle finger, T4 nipple line, T10 umbilicus, L1 inguinal area, L4 medial malleolus and S1 lateral foot and small toe.

C5 shoulder abduction, C6 wrist extension, C7 elbow extension, C8 finger flexion, L2 hip flexion, L3 knee extension, L4 ankle dorsiflexion, L5 great toe extension and S1 plantar flexion.

Pain, point tenderness, swelling, bruising, deformity, crepitus, abnormal movement and loss of function. Radiographs confirm the diagnosis, but unstable injuries should be splinted on suspicion.

Flexion, extension, axial compression, rotation and distraction, often in combination. Falls, motor vehicle crashes, diving and sports are common causes.

No posterior midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication and no painful distracting injury. A patient meeting all five does not need imaging.

Check circulation, movement and sensation before and after, immobilize the joint above and below the fracture, pad bony areas, align gently, cover open wounds and elevate. Do not force the limb into position.

Closed or open, and by pattern: transverse, oblique, spiral, comminuted, greenstick, avulsion and compression. Open fractures expose bone to the outside environment.

Pressure injury, hypothermia or poikilothermia, neurogenic bladder and bowel, ileus, deep vein thrombosis, respiratory complications and autonomic dysreflexia.

The corticospinal tract carries motor signals, the spinothalamic tract carries pain and temperature, and the dorsal columns carry vibration, light touch and position sense.

High-risk factors (age 65 or older, a dangerous mechanism, paresthesias) require imaging. If low-risk factors are present, the patient can have the neck range checked, and the ability to rotate 45 degrees to each side allows clearance without imaging.

Loss of motor function and of pain and temperature sensation below the injury, with preserved vibration and position sense. It has the worst prognosis of the incomplete syndromes.

A life-threatening reaction in patients with injuries at T6 or above, triggered by a noxious stimulus such as a full bladder or bowel. It causes severe hypertension, headache, flushing above the injury and bradycardia, and is treated by sitting up and removing the trigger.

Damage to one half of the cord, usually from penetrating trauma, causing loss of motor function and position sense on the same side and loss of pain and temperature on the opposite side.

Compression of the lumbosacral nerve roots causing saddle anesthesia, leg weakness, urinary retention or incontinence and bowel dysfunction. It is a surgical emergency.

Greater weakness in the arms than in the legs, often in older adults after hyperextension injuries with cervical stenosis. Sensory loss and bladder dysfunction vary.

Raised pressure within a closed muscle compartment that reduces perfusion. Signs include pain out of proportion, pain on passive stretch, tense swelling, paresthesia and, late, pallor and pulselessness, and it needs fasciotomy.

Muscle injury from prolonged compression that releases myoglobin and potassium when the pressure is released, leading to rhabdomyolysis, kidney injury and dangerous hyperkalemia. Give early aggressive IV fluids, monitor ECG and potassium, and aim for a high urine output.

Marrow fat enters the circulation after long bone fractures, usually 24 to 72 hours after injury, causing hypoxia, confusion and petechiae over the chest and axillae. Treatment is supportive.

Trained staff, continuous monitoring of SpO2, ECG and blood pressure, capnography when possible, available airway and resuscitation equipment, a clear plan for recovery and pain control before and after.

The systolic pressure at the ankle divided by the brachial systolic pressure. A value below about 0.9 suggests arterial injury in an injured limb.

A: complete. B: sensory but not motor function preserved below the level. C: motor function preserved but most key muscles below grade 3. D: motor function preserved with most key muscles grade 3 or more. E: normal.

A sprain is a ligament injury, a strain is a muscle or tendon injury and a dislocation is a joint displaced out of position. Initial care for sprains and strains uses protection, rest, ice, compression and elevation.

A complete injury has no motor or sensory function below the level, including the sacral segments. An incomplete injury has some preserved function, which carries a better outlook.

Keep the spine in a neutral position using a collar and a firm surface for transfer, log roll with at least four people, and remove the long backboard as soon as possible to prevent pressure injuries.

Gently realign it and reassess the pulse, splint and arrange urgent vascular evaluation. A limb without perfusion has a limited time before irreversible ischemia.

To decide on an ankle radiograph. Imaging is needed if there is pain near the malleoli with bone tenderness at the posterior edge or tip of either malleolus, or if the patient cannot bear weight for four steps both at the injury and in the department.

For mid-shaft femur fractures, to reduce pain, spasm and bleeding. Avoid it with pelvic, hip, knee or ankle injuries on the same limb and with partial amputations.

Swelling can make rings act as tourniquets and cut off blood flow to the finger. Remove them early, or cut them off, before swelling increases.

A small puncture wound can hide a large amount of injected material, such as paint or grease, that spreads along the tendon sheaths and damages tissue. It needs urgent surgical debridement to avoid amputation.

It can tear the popliteal artery and injure the peroneal nerve even if the knee appears normal when it spontaneously reduces. Check pulses, measure the ankle-brachial index and consider vascular imaging.

Irrigate thoroughly, assess the risk of infection and rabies, leave puncture wounds and hand wounds open, give antibiotics such as amoxicillin-clavulanate for high-risk bites, and update tetanus. Report bites to animal control when required.

Superficial (red, dry, painful, no blisters), superficial partial thickness (blisters, moist, very painful), deep partial thickness (white or mottled, less pain, may need grafting) and full thickness (leathery, white, brown or black and painless).

Brush off dry powder, remove contaminated clothing and irrigate with large volumes of water for at least 20 to 30 minutes, longer for alkalis. Do not try to neutralize with another chemical. Protect staff from exposure.

Use reverse triage: treat those in cardiac or respiratory arrest first, because they can be revived with prompt resuscitation. Injuries include arrhythmias, neurologic damage, burns and ruptured tympanic membranes.

Cover with clean, dry sheets or non-adherent dressings, keep the patient warm and do not apply ice, butter or ointments before evaluation. Leave blisters intact and use topical agents only as directed by the burn center.

Remove wet clothing, protect the area, rewarm in warm water (about 37 to 39 degrees C, or 98.6 to 102.2 degrees F) for 15 to 30 minutes if there is no risk of refreezing, give analgesia and avoid rubbing. Thawing is painful.

Mild is about 32 to 35 degrees C, moderate 28 to 32 and severe below 28. Handle gently to avoid ventricular fibrillation, remove wet clothing, rewarm passively and actively, and give warm IV fluids. Check core temperature.

Give titrated IV opioids, with additional agents as needed, and treat anxiety. Burn pain is severe, and good analgesia is essential before dressing changes.

Intact blisters are generally left alone because they protect the wound, while large or ruptured blisters may be debrided per burn center guidance. Do not puncture them at the bedside without direction.

Irrigate with a generous volume of normal saline or clean tap water under pressure, remove debris and devitalized tissue and avoid scrubbing the wound. Clip, rather than shave, hair near the wound.

Control bleeding, cover the wound and any detached tissue with saline-moistened sterile gauze, keep the part cool and bring it with the patient. Surgery decides whether the tissue can be repaired or grafted.

Remove the person from the source, take off clothing and jewelry, and cool the burn with cool running water for about 10 to 20 minutes. Do not use ice, and avoid cooling large burns so long that hypothermia develops.

Infection and sepsis, hypermetabolism and weight loss, acute kidney injury, curling ulcers in the stomach, compartment syndrome, venous thromboembolism and scarring or contractures.

Partial thickness burns over 10% TBSA, any full thickness burn, burns of the face, hands, feet, genitalia, perineum or major joints, electrical and chemical burns, inhalation injury, burns with other trauma or serious illness, and burns in children at facilities without pediatric capability.

Entry and exit wounds may look small while deep muscle damage is extensive. Risks include arrhythmias, rhabdomyolysis, compartment syndrome and fractures, so use cardiac monitoring, ECG, fluids to keep a high urine output and a full exam.

Abrasion (scraped surface), laceration (tear), incision (clean cut), puncture, avulsion (tissue torn away), contusion (bruise) and crush injury. The type guides cleaning, closure and infection risk.

For clean minor wounds, give a tetanus-containing vaccine if it has been 10 or more years since the last dose. For all other wounds, give it if 5 or more years have passed. Add tetanus immune globulin for dirty wounds if the patient has had fewer than three doses or the history is unknown.

Sharply demarcated stocking or glove immersion burns, uniform depth, sparing of flexion creases, circular cigarette-type burns, patterned burns from objects and a history that does not match the injury. Report suspected abuse as required by law.

A laceration over the knuckle from striking a person's teeth. Bacteria can enter the joint or tendon sheath, so these wounds are explored, irrigated and treated with antibiotics.

A surgical incision through burned skin to release pressure when a circumferential burn compromises circulation of a limb or ventilation of the chest. Signs include pain, pallor, paresthesia and weak or absent pulses.

Giving more fluid than needed, often from opioid use and strict adherence to formulas. It causes edema, compartment syndrome and respiratory problems, so rates are adjusted to response.

Fluoride ions bind calcium and can cause severe pain, deep tissue damage and life-threatening hypocalcemia and arrhythmias. Treat with irrigation and calcium gluconate, and monitor calcium and the ECG.

About 4.5 mg/kg of plain lidocaine, and about 7 mg/kg with epinephrine. Check the dose to avoid toxicity, watching for numbness around the mouth, tinnitus, seizures and arrhythmias.

Start enteral nutrition early, ideally within 24 hours, because burns increase metabolic needs. Provide high calories and protein to support healing.

The patient's palm with fingers is about 1% of their TBSA. It helps estimate scattered or small burns.

4 mL times body weight in kg times % TBSA of lactated Ringer's over 24 hours, with half given in the first 8 hours from the time of injury. Current practice often starts lower, about 2 mL times kg times % TBSA, and adjusts to urine output.

Head and neck 9%, each arm 9%, chest 9%, abdomen 9%, upper back 9%, lower back 9%, each leg 18% and genitalia 1%. It estimates total body surface area (TBSA) burned.

About 0.5 mL/kg/hr in adults (30 to 50 mL/hr) and about 1 mL/kg/hr in children. Fluid rates are titrated hourly to avoid under- and over-resuscitation.

Most clean wounds can be closed within about 6 to 12 hours, with face and scalp wounds acceptable for longer. Contaminated or older wounds may need delayed closure after cleaning and observation.

Only partial thickness and full thickness burns. Superficial (first-degree) burns such as simple sunburn are not counted.

Smoke inhalation can cause carbon monoxide and cyanide poisoning, leading to altered consciousness, lactic acidosis and cardiovascular collapse. Give 100% oxygen, and consider hydroxocobalamin for suspected cyanide poisoning.

The tight eschar limits chest wall movement and lowers ventilation. Escharotomy of the chest wall may be needed along with ventilatory support.

Loss of skin allows heat and evaporative loss. Warm the room, cover the patient with dry sheets and blankets and give warmed IV fluids.

Burn wounds are tetanus-prone, so immunization is updated according to the patient's history and the wound classification.

A child's head is proportionally larger and legs smaller than an adult's, so the rule of nines is inaccurate. The chart adjusts percentages for age.

Tidaling (fluctuation with breathing) is normal. Continuous bubbling in the water seal chamber indicates an air leak, and loss of tidaling may mean the lung has re-expanded or the tube is blocked.

It has a collection chamber for fluid, a water seal that allows air to leave and prevents air from returning, and a suction control chamber, often set to about -20 cm H2O. Keep the unit upright and below the level of the chest.

At the end of expiration or during a Valsalva maneuver, the tube is pulled quickly and an airtight occlusive dressing is applied. A chest radiograph afterward checks for recurrent pneumothorax.

Insert a large-bore catheter (such as 14 gauge, long enough to reach the pleura) at the second intercostal space midclavicular line or the fourth to fifth intercostal space at the anterior axillary line, then place a chest tube. Follow local protocol.

Cover the wound with an occlusive dressing taped on three sides to act as a flutter valve, then place a chest tube at a separate site. A fully sealed dressing can cause a tension pneumothorax.

Use anti-impulse therapy with a beta-blocker such as esmolol to lower heart rate (below about 80) and keep systolic pressure at about 100 to 120 mm Hg, unless other injuries need higher pressure.

Multimodal analgesia with scheduled medicines and regional techniques such as epidural, paravertebral or serratus anterior blocks. Good pain control supports deep breathing and coughing, and prevents pneumonia and respiratory failure.

Apply direct manual pressure, or insert a Foley catheter into the wound and inflate the balloon, and avoid blind clamping or probing. Protect the airway and keep the patient supine.

Airway swelling and obstruction, laryngeal and cervical injury, carotid injury and hypoxic brain injury. Symptoms can be delayed, so patients need observation and imaging.

Air in the pleural space causing decreased breath sounds, chest pain and shortness of breath without shock. A chest tube is usually inserted, especially if the patient needs positive-pressure ventilation.

Active or pulsatile bleeding, an expanding or large hematoma, shock, a bruit or thrill, airway compromise, hemoptysis, subcutaneous emphysema and absent pulses. These patients generally need immediate surgery.

Release cardiac tamponade, control cardiac or lung bleeding, clamp the descending aorta to redirect blood to the brain and heart, and perform open cardiac massage.

Blood in the pericardial sac restricts filling, causing hypotension, distended neck veins, muffled heart sounds and tachycardia. Treatment is decompression by pericardiocentesis as a bridge, with definitive surgical repair.

Severe respiratory distress, absent or decreased breath sounds on the injured side, hypotension, jugular vein distention, tachycardia and, late, tracheal deviation away from the injury. It is a clinical diagnosis treated before imaging.

Zone I extends from the clavicles and sternal notch to the cricoid cartilage. Zone II runs from the cricoid cartilage to the angle of the mandible. Zone III lies above the angle of the mandible to the skull base.

Pneumothorax gives hyperresonance with decreased breath sounds. Hemothorax gives dullness with decreased breath sounds over the fluid.

Widened mediastinum (over about 8 cm), loss of the aortic knob, a left apical cap, deviation of the trachea or nasogastric tube to the right and a left hemothorax. A normal film does not rule it out.

More than about 1,500 mL of blood draining from the chest tube initially, or more than about 200 mL per hour for 2 to 4 hours. Patients need blood replacement, and often surgery.

The box between the sternal notch, xiphoid and nipples overlies the heart, so wounds here raise concern for cardiac injury and tamponade. The right ventricle is the most commonly injured chamber.

High-energy trauma with possible underlying injury such as pulmonary contusion, pneumothorax or vascular injury. Brachial plexus and subclavian vessel injuries should be considered.

Absence of lung sliding, loss of B-lines and a barcode (stratosphere) sign on M-mode. A lung point marks the border of the pneumothorax.

Three or more adjacent ribs fractured in two or more places, causing a segment that moves paradoxically. The main problem is the underlying pulmonary contusion and pain-related hypoventilation.

Blood and air in the pleural space at the same time. It causes respiratory distress and is treated with chest tube drainage, with surgery if bleeding is massive.

Bruising of lung tissue with bleeding and edema into the alveoli, causing hypoxia that often worsens over 24 to 48 hours. Treat with oxygen, pain control and careful fluid use, and support ventilation if needed.

A tear in the diaphragm, more often on the left, from a blunt force or penetrating injury. Abdominal organs can herniate into the chest, causing respiratory distress, bowel sounds in the chest and a nasogastric tube coiled in the chest.

Air entering a vein, as in an open neck wound, can travel to the heart and block flow. Cover the wound with an occlusive dressing, place the patient in the left lateral decubitus Trendelenburg position and give 100% oxygen.

A rare tear usually from penetrating trauma, causing pain, subcutaneous emphysema, difficulty swallowing and mediastinitis. Delayed diagnosis is dangerous, so it needs imaging and early surgical care.

Blood from the chest tube is collected in a sterile device with an anticoagulant and returned to the patient through a filter. It provides immediate compatible blood in massive hemothorax.

Damage to the heart from a blunt force, ranging from arrhythmias and myocardial contusion to valve or septal rupture. Suspect it with chest wall injury or sternal fracture, and check an ECG and troponin level.

Injury to the carotid or vertebral arteries, such as a dissection, after blunt neck trauma. Suspect it with neck seat belt marks, cervical spine fractures, basilar skull fractures or Horner syndrome, and confirm with CT angiography.

A drop in systolic blood pressure of more than 10 mm Hg during inspiration. It can occur with cardiac tamponade and severe asthma.

Air trapped under the skin that feels like crackling or popping when palpated. It suggests injury to the lung, airway or esophagus and can spread to the face and neck.

A tear in the aorta, most often near the ligamentum arteriosum at the aortic isthmus, caused by rapid deceleration. Many patients die at the scene, and survivors need CT angiography and rapid surgical or endovascular repair.

Severe chest compression that causes a sudden rise in pressure in the upper body, resulting in facial and neck cyanosis, petechiae and bulging eyes. Treat associated lung and cardiac injuries.

Airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest and cardiac tamponade (often remembered as ATOM FC).

They are painful and cause shallow breathing, atelectasis and pneumonia, especially in older adults. First and second rib fractures suggest high energy and great vessel injury, and lower rib fractures may involve the liver or spleen.

If the tube falls out, cover the site with a sterile occlusive dressing and notify the physician at once, watching for tension pneumothorax. If it disconnects, reconnect after cleaning the ends, or briefly place the end in sterile water, and do not clamp it.

Lung-protective ventilation with a tidal volume of about 6 mL/kg of predicted body weight, plateau pressure below about 30 cm H2O and adequate PEEP. Avoid fluid overload.

In patients with penetrating chest trauma who lose vital signs, generally within about 15 minutes of CPR, and in blunt trauma within about 10 minutes. Guidelines favor penetrating cardiac injuries.

As a temporary measure to relieve tamponade when surgery is not immediately available. Ultrasound guidance improves safety, and removing even a small amount of blood can improve blood pressure.

In the fourth or fifth intercostal space between the anterior and midaxillary lines (the safe triangle), just above the rib. It is aimed toward the apex for air and toward the base for fluid.

Along the inferior border of each rib. Needles and tubes are inserted just above the top of the rib to avoid the vessels and nerve.

Simple pneumothorax, hemothorax, pulmonary contusion, blunt cardiac injury, traumatic aortic injury, diaphragmatic injury, tracheobronchial injury and esophageal injury. They need ongoing reassessment.

Positive pressure can turn a simple pneumothorax into a tension pneumothorax. Placing a chest tube first, or being ready to, protects the patient.

It indicates a high-energy force and raises concern for blunt cardiac injury and great vessel injury. Monitor the ECG and check troponin levels.

Treat pain first with multimodal analgesia, titrate sedation to a target such as RASS, use the lightest effective sedation and reassess daily. Avoid benzodiazepine-heavy regimens when possible.

Use hand hygiene, central line and catheter bundles, remove unneeded lines early, give antibiotics for open fractures and contaminated wounds as indicated, and use aseptic technique for wounds.

Use mechanical compression devices and start low molecular weight heparin as soon as bleeding risk allows, often 24 to 48 hours after injury when hemorrhage and head CT are stable. Trauma patients are at high risk.

Provide regular, honest and understandable updates from the same team members, explain the plan and uncertainty, involve them in decisions and use interpreters and support services as needed.

Boyle's law means trapped gas expands at altitude, which can worsen pneumothorax, expand ETT cuffs and distend bowel. Lower oxygen partial pressure also reduces oxygenation, so adjust and monitor closely.

Physician-to-physician acceptance, an accepting facility with capacity, informed consent, copies of records and images, qualified personnel and suitable transport, and stabilization as much as possible before leaving.

Assessment findings, interventions, medicines, vital signs trends, lab results, imaging, consents, the reason for transfer, accepting physician and times of contact, and a copy of the chart.

Head of bed raised 30 to 45 degrees, daily sedation interruption and weaning assessment, oral care, subglottic suctioning, hand hygiene and minimizing ventilator days.

Repeat the primary survey regularly, trend vital signs, urine output and lab results, check interventions and reevaluate pain. Any change prompts immediate repeat assessment.

A target of about 140 to 180 mg/dL, using insulin as needed and avoiding hypoglycemia.

Continuous ECG and pulse oximetry, arterial line blood pressure, central venous access when needed, urine output, lactate and blood gas trends and capnography.

Whole-body or targeted CT of the head, cervical spine, chest, abdomen and pelvis, with CT angiography and plain films as needed. Only hemodynamically stable patients go to CT.

Altered consciousness, intoxication, distracting painful injuries, unstable condition, incomplete imaging and handoff gaps. Hands, feet, spine and extremity fractures are commonly missed.

A repeat head-to-toe examination with review of labs and imaging, done within 24 hours when the patient is awake and stable, to find missed injuries. It is done in addition to the primary and secondary surveys.

A federal law requiring hospitals with emergency departments to screen and stabilize anyone seeking emergency care regardless of ability to pay. Unstable patients can be transferred only if benefits outweigh risks and conditions are met.

Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by the receiver. Structured handoff tools such as I-PASS and SBAR reduce errors.

Start enteral feeding early, within 24 to 48 hours when the gut is functional, and provide adequate protein. Parenteral nutrition is a second option if enteral feeding fails.

A bundle addressing Pain, Agitation, Delirium, Immobility and Sleep. It uses validated tools such as CAM-ICU, light sedation and early mobility to improve outcomes.

The registry collects injury and outcome data, such as Injury Severity Score, and supports quality review, research and prevention. Performance improvement uses it to find problems and improve care.

Airway secure, adequate breathing and oxygen, hemorrhage controlled, IV access and fluids or blood running, injuries splinted, spinal motion restriction maintained, gastric tube and catheter as needed, and medicines and monitoring ready.

When a patient's injuries need resources the current hospital does not have, such as neurosurgery, advanced burn care or pediatric trauma care. Transfer should not be delayed by diagnostic tests that do not change management.

Early, alongside active treatment, when injuries are severe, the prognosis is uncertain or the patient is older or frail. They help match treatment to the patient's values and support families.

Reperfusion and swelling can develop hours later. Check limbs, pain, compartments, urine color, creatinine kinase and kidney function, and keep up fluid and urine output goals.

Critically ill patients, especially those who are ventilated, have coagulopathy, burns or head injury, are at risk of GI bleeding. A proton pump inhibitor or H2 blocker may be used.

Early physical and occupational therapy reduces weakness, delirium, complications and length of stay. It begins as soon as the patient is stable and safe to move.

No. Obesity is linked with higher morbidity and mortality, more complications and different injury patterns, and standard seat belts may fit poorly.

Do not disclose sexual orientation or gender identity to others without consent. Respect the patient's chosen surrogate and visitors, including chosen family.

Reduced functional residual capacity and chest wall compliance, increased oxygen use and a higher risk of sleep apnea. Patients desaturate quickly and have more atelectasis.

Some drugs are dosed on ideal or lean body weight (such as rocuronium and propofol induction) and others on total body weight (such as succinylcholine). Follow pharmacy guidance.

A BMI of 30 or more is obesity, with class 1 at 30 to 34.9, class 2 at 35 to 39.9 and class 3 at 40 or more (severe obesity).

Expect difficult bag-mask ventilation and intubation. Use the ramped position (ear level with the sternal notch), preoxygenate longer, use video laryngoscopy and have backup airway devices ready.

Ask respectfully and use the name and pronouns the patient gives, even if they differ from legal documents. Record them in the chart and share with the team to avoid repeated questions.

Base assessment and testing on the organs present, not on assumptions from gender identity. For example, a transgender man may have a uterus and need a pregnancy test.

Physical exam, FAST views, pulses and venous access are harder, and imaging can be limited by body size and table weight. Use ultrasound-guided access or intraosseous access when needed.

Pressure injuries, wound infection, venous thromboembolism, rhabdomyolysis, compartment syndrome and complications of related conditions such as diabetes and hypertension.

Sex assigned at birth is the label at birth. Gender identity is a person's internal sense of gender. Sexual orientation describes whom a person is attracted to. They are separate concepts.

Bariatric stretchers and beds with enough weight capacity, correctly sized blood pressure cuffs, lift and slide devices, extra staff and planning to protect both patient and staff.

Hormones can interact with medicines and affect clotting risk, implants can alter imaging and injury patterns, and chest binders restrict breathing and should be removed for assessment with the patient's agreement.

LGBTQ+ people face higher risks of violence and delayed care because of past discrimination. Respectful care builds trust and improves history taking, comfort and outcomes.

They face higher rates of hate crimes and intimate partner violence. Screen privately without assumptions and offer resources.