Rural Emergency Medicine

The folks over at LifeintheFastLane have released a series of great posts on Trauma assessment and management. What I've provided here is a collated version of a selection of these posts, along with relevant resources from other sources, to create The Ultimate Guide to Trauma for Junior Doctors & Medical Students.

Most of the posts are done in a Q&A style so you can put your knowledge to test. In Part One we cover the basics, take you one step further, consider abdominal and genitourinary trauma, chest trauma and trauma in pregnancy. In Part Two, we cover central nervous trauma, eye trauma and general radiology. Part Three covers Musculoskeletal / Orthopaedic Injuries, particularly looking at life and limb threatening injuries.

The Basics

Basic Life Support 
Basic Life Support forms a foundation level of care for treating patients with life-threatening illnesses or injuries, until the appropriate medical care can be provided. Anyone can learn Basic Life Support (aka First Aid) and provide immediate relief at the incident site. This post will run you through DRSABCD and more. The latest Advanced Life Support Guidelines 2011 are available here.

Clinical Examination & Skills
For Medical Students, scratch up on your clinical skills, so that when the trauma case presents you've got all your guns loaded. This post contains a series of tutorials and videos on clinical examination (cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal), history taking and a Quick Guide to ECG.

Are you prepared?
Before you even begin, you need to get some idea of what trauma is and the scale of it. To let you know what you are in for. What you have to prepare for. Major trauma — also known as ‘multiple trauma’ — as defined by Chris Nickson, refers to major injury affecting more than one body system. It can also be defined as an Injury Severity score > 15. This post takes you through some basic definitions, healthcare professional roles, epidemiology and protocols.

Initial Assessment and Management
Now that we've gone over some definitions, roles, epidemiology and protocols, this post covers what needs to be done in the initial assessment and management of a trauma patient.

Importantly, there are 5 key components of the Primary Survey which need to be examined;
  • Airway
  • Breathing
  • Circulation
  • Disability (i.e. neurological status), 
  • Environmental and Exposure

After any intervention these components should be reassessed, so as to qualify any improvements in function. SHAVED a mnemonic from the Rural Emergency Skills Training course is a useful reminder that there could be a few exceptions where priority of other aspects is simultaneously required.

  • S - Sugar/glucose
  • H - Haemorrhage (Massive / Catastrophic)
  • A - Anaphylaxis
  • V - Ventricular Fibrillation
  • E - Epilepsy / Seizures
  • D - Drugs / Toxins / Overdose

The next step is the Secondary Survey which involves performing a head to toe examination, looking for injuries or signs of disease. Finally there is a video tutorial on initial trauma assessment in an OSCE style format from the Oxford Medical School.

In a Single Vechicle MVA think 6 S's:
S eizure
S yncope
S ugar (Hypoglycemia)
S uicide
S leep
S auce (Alcohol intoxication)
One Step Further

Major Haemorrhage
You have a scaffolder who is involved in a motor vehicle accident and is bleeding like there's no tomorrow (which there won't be for him, unless you do something). The three main goals with this type of patient should be; Stop the bleeding, Rapid and effective restoration of blood volume, Maintain functional blood composition to preserve blood function.

Don't know where they are bleeding from?
Then think 'SCALPeR' - Scalp Chest Abdomen Long bones Pelvis e Retroperitoneum.

Need to stop bleeding from the neck? Consider the Foley Catheter technique written up by Cliff from These gems and many more are included in this guide to assessing and managing Major Haemorrhage.

Massive Transfusion
You've got your massive bleeder from before, and it's come to that time to do a massive transfusion. When should you commence a blood transfusion? Well the most simple trigger as they have put it is, when a senior clinician suspects impending or actual haemorrhagic shock in bleeding patient. Time to go through the principles of blood transfusions. Another post, Managing the Critical Bleeder! will also give you some insight into managing significant haemorrhage and the use of blood transfusions.

An important thought to keep in the back of your mind is, transfusion reaction. If a transfusion reaction is suspected, the transfusion should be stopped immediately, and the IV line disconnected.

Want some iMeducation? Well then checkout The Mayo Clinic's TransFuse App for iPad, which is a scenario based clinical simulation tool involving blood transfusions.

Airway AsssementIntubation
While it's unlikely as a medical student you will be the one intubating in an emergency situation, it never hurts to practice or refresh. And to have some tricks of the trade up your sleeve. In patients with heavy GI bleeding it can be difficult to see the vocal cords and intubate, and you sometimes miss the goal. So here is the first trick for you.

Trick 1: Leave the oesophageal tube in. Reattempt endotracheal intubation.

The ET tube in the oesophagus can be left in, to assist in removing blood from the field of view.

Trick 2: Two hands are better than one. Using the Bimanual Laryngoscopy manoeuvre to aid in intubation.

Both of these tricks (click each trick for more details) come from Michelle Lin of Academic Life in Emergency Medicine fame, who has also written a post on preparing for Rapid Sequence Intubation.

A video tutorial on overall airway management and another on ET intubation. And for a bit of entertainment consider watching the Awake Fibreoptic Intubation by Dr. Michael Bailin.

Abdominal & Genitourinary Trauma

Assessment & Imaging of the Abdomen
Abdominal and pelvic injuries can lead to life-threatening haemorrhage, so it's important to have some foundations on which to assess the abdomen. Start with your primary survey and at the C focus on finding the source of the bleed. After examination, the key investigations to perform are FAST Scan, DPL and CT Abdomen. This post will discuss these investigations and their role in greater depth. If you don't have a CT Scanner on hand, consider an Abdominal X-Ray (AXR).

Abdominal Injuries
This second part on Abdominal injuries covers how to recognise and manage trauma in each of the major abdominal organs. Covering the following organs with the most common injury pattern in brackets; Spleen (blunt trauma) Liver (penetrating trauma), Duodenum, Small Intestine (deceleration injury) Pancreas (direct injury) and Diaphragm (penetrating trauma). The ED Trauma Critical Care blog also features several posts that are worth checking out.

Blunt Abdominal Trauma Decision Making
The emergency management of blunt trauma can be complicated and it's important to have a structure in place to appropriately deal with these patients. Whether it be off to the Operating Theatre, to the scanner, or the watch and wait approach. Importantly the indications for emergency laparotomy in blunt abdominal trauma are; Peritonism, Free air under the diaphragm, Significant gastrointestinal haemorrhage, and Hypotension with positive FAST scan or positive DPL. This post will run you though 3 case scenarios and test and expand your knowledge.

Penetrating Abdominal Injury 
Penetrating abdominal injuries can arise accidentally or intentionally (e.g. stab wounds). There are four main regions to consider in a patient with a penetrating abdomen wound; 1.Anterior abdomen, 2.Thoracoabdominal area, 3.Flanks, and 4.Back. The external appearance of the penetrating wound does not determine the extent of internal injuries. This post covers stab and gun-shot wounds. Michelle Lin has also provided a PV Card on Observing vs Laparotomy in penetrating abdominal injuries.

Genitourinary Injuries 
Genitourinary injuries generally require initial stabilisation and often surgical care can be delayed. The exception to that rule is Renal pedicle injury. Covered in this post are what skeletal injuries are associated with genitourinary trauma, and how to recognise and manage damage to a selection of genitourinary structures; kidney urethra, bladder, penis, and scrotum.

Chest Trauma

Chest Injuries I
Chest injuries are a relatively common occurrence in emergency medicine, with up to one of five patients presenting with chest trauma.When approaching chest injuries there are 6 big fish you want to not miss, which can be remembered by the mnemonic ATOM-FC. 
  • Airway obstruction or disruption
  • Tension pneumothorax
  • Open pneumothorax
  • Massive haemothorax
  • Flail chest and 
  • Cardiac tamponade

This post runs through how to recognise and manage these six big fish. Also covering two procedures; needle thoracocentesis and inserting an intercostal catheter.

Chest Injuries II 
Your patient from round one has survived, and is back for the secondary survey. ATOM-FC is back again for the secondary survey.

  • Aortic dissection
  • Thorax injuries (non-massive haemothorax, simple pneumothorax)
  • Oesphageal perforation
  • Muscular diaphragmatic injury (a stretch this one, I know)
  • Fistula (bronchopleural) and other tracheobronchial injury
  • Contusion to the heart or lungs also provide a nice overview of chest injuries.


Managing the Pregnant Trauma Patient
Pregnant patients can often throw people off, but the simple thing to remember is that you are now dealing with two lives. And the foetus's life is often dependent on the mothers. So in a trauma situation it is important to optimise the condition of the mother.

Several normal physiological parameters are altered in pregnancy, which will be highlighted later. Securing the airway can often be more difficult in pregnant patients. If the mother is relatively stable, it is then appropriate to assess the health of the foetus. All pregnant trauma patients should receive O2, a decrease in pO2 leads to constriction of the uterine arteries.
Things that change in Pregnancy (
  • In the 2nd trimester, normal Bicarb (HCO3) is 18-20
  • Place chest tubes higher than in non-preg (3rd/4th ICS)
  • Normal HR: 90-95 bpm
  • Sys/Dia decreased by 10-15
  • Can lose 2 L of blood without any signs
  • HCT 32-34%
  • WBC can range from 5-18000 at baseline, but function of WBCs is decreased
  • Elevated Fibrinogen and D-dimers
  • Hypercoaguable state

Trauma and Pregnancy Redux 
Your patient, a 27 year-old female who is 32 weeks pregnant, is back from part one. Part one took you through the physiologically changes in pregnancy that affect management decisions. Now it's time to make some. Your choice of imaging modalities should take into consideration techniques which do not use non-ionising radiation (e.g. Ultrasound). Cardiotocography (CTG) is useful for monitoring the health status of the foetus. At the end of this section Chris has provided an overall approach to the management of a pregnant trauma patient.

See Part 2 for information on
Central Nervous Trauma, Eye Trauma and General Radiology.

Orthopaedic / Musculoskeletal Injuries

Further Reading - The majority of this guide originates from here, but there are many other great reads as well. provides a large body of knowledge on Trauma and Emergency Medicine. is another useful resource. A selection of images used in this post are from

A Simple Guide to Trauma by RL Huckstep (for the orthopods in the house). Covers the complete spectrum of musculoskeletal injuries.

Got any resources that you would like to recommend? 
Comment below or message me on twitter @IVLINE

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