Textbook of Acute Trauma Care

Foreword
Acknowledgements
Contents
Contributors
Part I: Trauma Systems and Teams
	1: Human Factors in Trauma Care
		Introduction
		What Are Human Factors and Why Should We Care?
		Causes of Error
			General Principles
			Flow Disruptions
			Active and Latent Failures
		Individual Factors
			Stress and Adverse Physiologic States
			Managing Stress and Increasing Cognitive Readiness
			Cognitive Bias
		Task Factors
			Checklists
		Team Factors
			Don’t Just Debrief, Prebrief
			Team Structure: Leadership and Followership
			Shared Mental Models
			Communication
			Handovers and Debriefs
		Environmental Factors
			The Zero Point Survey
			Physical Layout
			Resource Utilization
		Organizational and System Factors
			Safety-I and Safety-II
		References
	2: Dealing with Death in Trauma
		Introduction
		Death Trajectories
		The Bad Death
		Dealing with Death: The Family
		Dealing with Death: The Clinical Team
		Dealing with Death: The Expert
		References
	3: Legal and Ethical Issues in Trauma Care
		Introduction
		Principles and Opinion
		Principles and Opinion
		Principles and Opinion
		Principles and Opinion
		Reporting Domestic Violence
		Principles and Opinion
		Principles and Opinion
		Principles and Opinion
		Principles and Opinion
		Appendix: Post Mortem Narrative Tool
		References
	4: The Evolution of Trauma Systems
		Introduction
		How Did We Get to our Current System and Does it Work?
		What Challenges Remain?
		References
Part II: The Fundamental Approach to Trauma Patients
	5: Point of Injury to Rehabilitation
		Introduction
		When to Start the Assessment?
		The Reprioritisation of Haemorrhage Control
		A Universal Treatment Algorithm
		Overarching Principles of MABCD
		Massive External Haemorrhage
		Airway
		Breathing
		Circulation
		Disability and Head Injuries
		Exposure
		Onward Care
		References
	6: Massive Haemorrhage Control
		Introduction
		What Is Massive Haemorrhage?
		Sources of Massive Haemorrhage
			External Bleeding
			Skin/Scalp Bleeding
			Facial Trauma
			Pelvic Trauma
		Treatment of Massive Haemorrhage
			Compressible Haemorrhage
			Indirect Pressure
			Tourniquets
			Haemostatic Dressings
		Junctional Haemorrhage
		Non-compressible Haemorrhage: Torso
		Fluid Management
		References
	7: Fundamentals of Airway Management in Trauma
		Introduction
		The Case Against Intubation
		Why Manage the Airway?
		Airway Management Philosophy
			Team Composition
		Initial Airway Management and Causes of Airway Compromise
			Diagnosing Airway Obstruction
		Positioning, Basic Manoeuvres and C-Spine Injuries
			Basic Airway Adjuncts
		Supraglottic Airway Devices
		Surgical Airways/Emergency Front of Neck Access (eFONA)
			Cannula and Seldinger Techniques
			Surgical Techniques
		Conclusion
		References
	8: Drug Assisted Airway Management
		Introduction
		Airway Anatomy
		Rapid Sequence Induction of Anaesthesia and Intubation
		Cricoid Pressure
			Choice of Induction Agents for Rapid Sequence Induction
				Thiopentone
				Ketamine
				Propofol
				Etomidate
			Choice of Paralytic Agent
				Rocuronium
				Suxamethonium
			Protocolising Interventions
		Difficult Airways
			Predicting a Difficult Airway
				Specific Anatomical Difficulties
				Situationally Difficult Airways
			Video Laryngoscopy
		Failed Intubation and Surgical Airways
		Sedation and Anaesthesia for Transfer
		Conclusion
		References
	9: Breathing and Chest Trauma
		Introduction
		Applied Anatomy and Common Pitfalls
		Physiology of Normal Breathing
			Oxygenation
			Ventilation and V/Q Matching
		Respiratory Failure
		Assessment of Chest Injuries
		Diagnoses of Immediately Life-Threatening Chest Trauma
			A: Airway Obstruction
			T: Tension Pneumothorax
			O: Open Pneumothorax
			M: Massive Haemothorax
			F: Flail Segment
			C: Cardiac Tamponade
		Other Serious Pathology: The Sub-acute Six
			G: Great Vessel Injury
				Aortic Injuries
				Vena Cava Injuries
			O: Oesophageal Injury
			T: Tracheobronchial Injury
			C: Cardiac Contusion
			P: Pulmonary Contusion
			D: Diaphragmatic Rupture
		Escalation of Respiratory Support from Basics to Advanced Critical Care
			Basic Principles and Baseline Care
			Intermediate Options
			Advanced Interventions Available Commonly
			Super-Specialised Centre Options
		Practical Procedures: Thoracostomies and Insertion of Chest Drains
			Insertion Technique
		Conclusion
		References
	10: Circulation
		Introduction
			Gross Physiology of Circulation and Blood Pressure
		Shock
			Distributive Shock
				Anaphylaxis
				Sepsis
				Neurogenic Shock
			Obstructive Shock
				Pulmonary Embolus
				Tension Pneumothorax
			Cardiogenic Shock
				Cardiac Tamponade
			Hypovolaemic Shock
				Failure to Identify Active Bleeding
				Failure to Control Active Bleeding
		“Classical” Clinical Signs of Shock
			Metabolic Assessment of Shock
				pH and Base Excess/Deficit
				Lactate
				Haemoglobin
				Other Biomarkers
		Hypotension in Trauma
			History of Permissive Hypotension
			Permissive Hypotension as a Concept
		Cyclic Hyper-resuscitation and Crystalloids
		Fluid Therapy in Trauma
			Colloids
			Synthetic Oxygen Carriers
		Blood Transfusions in Trauma
			Oxygen Content of Blood
			Cardiac Output, Blood Pressure and Flow
			Blood Components or Warm Fresh Whole Blood?
			Practical Aspects of Blood Transfusion
			Active Management of Circulatory Failure
		In-Hospital On-Going Care
		Brain Injury and Permissive Hypotension
		Damage Control Resuscitation
			Failure to Respond to Resuscitation
		Summary
		References
	11: Disability and Head Injury
		Introduction
		Primary Versus Secondary Brain Injury
		Applied Anatomy
		Physiology
		Assessment of Head Injuries
			Level of Consciousness
			Problems with GCS
			Pupils
			Focal Neurological Deficit
		Treatment and Principles of Care
			Initial Treatment
			Continued Management
			CT Scanning
			Neurosurgical Consultation
		Diagnosis and Management of Specific Pathologies
			Skull Fractures
			Focal Brain Injuries
			Contusions
			Extradural Haematomas
			Acute Subdural Haematomas
			Diffuse Brain Injuries
			Neuro Intensive Care
		Summary
		References
	12: Traumatic Cardiac Arrest
		Introduction
			Epidemiology
			Presentation
		Management
			Cardiopulmonary Resuscitation
			Reversing the Reversible
		Hypovolaemia
		Oxygenation
			Airway Management
			Ventilation
			Traumatic Asphyxia
			Impact Brain Apnoea
			Spinal Injury
		Tension Pneumothorax
		Tamponade
		Resuscitative Thoracotomy in Traumatic Cardiac Arrest
			Risk to Clinicians
			Patient Selection
			Surgical Technique
			Clamshell vs Anterolateral Approach
			Clamshell Thoracotomy
			Other Manoeuvres
			Medical Confounders
		Human Factors in Traumatic Cardiac Arrest
		Other Causes of Arrest Relevant to Trauma
			Commotio Cordis
			Lightning
			Electrocution
			Hypothermia
			Hanging/Strangulation
		Forensic Aspects
		Conclusion
		References
	13: Pain Management in Trauma
		Assessing Pain
		Non-Pharmacological Treatments
			Splinting
			Reduction
			Irrigating
			Covering
		Routes of Drug Administration
			Intravenous (IV)
			Interosseous (IO)
			Intramuscular (IM)
			Intranasal (IN)
			Subcutaneous (SC)
			Transdermal
			Oral
			Oral Transmucosal
			Inhalational
		Brief Pharmacological Comparison of Analgesics
			Opiates (Oral, IV, IM, IO, Transmucosal, Intranasal)
			Paracetamol/Acetaminophen (Oral, IV, Rectal)
			NSAIDs (Oral, IV, IM)
			Ketamine and S-Ketamine
		Neuropathic Pain Modulating Agents
			Gabapentin/Pregabalin
			Amitriptyline
		Regional Anaesthesia
			Compartment Syndrome
			Specific Regional Anaesthetic Techniques
		Upper Limb Blocks
			Brachial Plexus Anatomy
			Interscalene Block
			Supraclavicular Block
			Infraclavicular Block
			Axillary Block
		Lower Limb Blocks
			Lumbar and Sacral Plexus Anatomy
			Femoral Block
			Saphenous Block
			Sciatic Block
		Analgesia for Thoracic Trauma
		Regional Techniques for Thoracic Trauma
			Intercostal Block
			Intra/Inter-Pleural Block
			Paravertebral Block
			Thoracic Epidural (+/− Opioid)
			Serratus Anterior Plane Block
		Local Anaesthetic Systemic Toxicity
			The Algorithm for Management of LAST Includes
		Analgesia for Neuro-Trauma
		Clinical Pearls in the Management of Acute Pain in a Patient Following Trauma
			Initiating Patient Controlled Analgesia in the Acute Setting for Pain Management
		Chronic Pain After Trauma
		Summary
		References
			Further Reading
			Regional Anaesthesia
			IO Access
			Intransal Drug Administration
Part III: Haemostatic Interventions in Trauma
	14: Initial Approach to Damage Control Resuscitation
		What Is Damage Control?
		Philosophy of Damage Control Resuscitation
		History and Concepts Around Damage Control Surgery
		Damage Control Anaesthesia
		When to Start Damage Control Resuscitation: Indications
		Damage Control Resuscitation in PHEM
		Damage Control Resuscitation in ED
		Damage Control: More Than Surgery
		References
	15: Haemostasis and Coagulopathy
		Introduction
		The “Classical” Clotting Cascade
		Trauma Induced Coagulopathy
		TIC: Pathophysiology and Mechanism
			The Theory of DIC-Fibrinolysis
			The Theory of Activated Protein C
			The theory of Glycocalyx injury
			The Theory of Hypofibrinogenaemia
		The Role of Platelets
		Haemostasis and Resuscitation
			Tranexamic Acid
			Historical Evolutions
		Conclusion
		References
	16: In Hospital REBOA for Major Trauma
		Introduction
			Assumptions
			Purpose of REBOA
			Probable Haemodynamic Effect of REBOA in Humans
			Use of REBOA Within a MTC
		Definition
		Indications/Contraindications
		Types of REBOA
			Level of Balloon Deployment
			Strategy of Occlusion
			Duration of Balloon Inflation
				Consider with Level and Strategy of Occlusion
			Environment of insertion
			Access Type
			Access Location
			Type of Balloon Catheter
		Risk Analysis for REBOA
			Escalation of Readiness for REBOA
				Rationale to Gain Femoral Access with REBOA Decision Not Yet Made
				Specific Injuries Affecting Access Considerations
			Risk Analysis for Conduct of REBOA
				Identifying the Highest Impact Group
				Identifying Level of Bleeding
				Ensuring an Immediate Exit Strategy
		Practical Considerations in the Conduct of REBOA
			Equipment Readiness
			Technique of REBOA Catheter Use
				Sheath Access (in this Example: CFA and Percutaneous)
				Balloon Catheter Insertion
				Adjusting Level of Aortic Balloon Occlusion
				In Conjunction with Definitive Haemorrhage Control
				Balloon Deflation and Removal of Catheter
				Sheath Management Plan
				Lower Limb Fasciotomies
		Current Literature Perspective
			Comparison to Resuscitative Thoracotomy
			Extrapolating Epidemiological Data Is Problematic
			REBOA Human Evidence Base
			Future Availability of OCEBM Level 2 Evidence
		System Optimisation for REBOA
			Access to a Suitable Training Programme
			Audit and Clinical Governance
			REBOA Protocol or Guidance
		Conclusion
		References
	17: Anticoagulants in Trauma
		Introduction
		Anticoagulants: Types and Assessing Anticoagulant Effect
			Vitamin K Antagonists (VKA) Also Called Coumarins: Warfarin (Coumadin), Dicumarol (Dicoumarol), Acenocoumarol (Sinthrome), Phenindione
			Direct Oral Anticoagulants (DOACs: Formerly Called NOACs (Novel Oral Anti Coagulants))
				Direct Thrombin Inhibitors: Dabigatran (Pradaxa)
				Factor Xa Inhibitors: Apixaban (Eliquis), Edoxaban (Lixiana) and Rivaroxaban (Xarelto)
			Low Molecular Weight Heparin (LMWH), Heparin (Unfractionated Heparin, UFH) and Fondaparinux
		Antidotes for Anticoagulants
			For Warfarin
				Vitamin K
				4 Factor Prothrombin Complex Concentrate (PCC). Beriplex or Octaplex
			For Dabigatran
				Idarucizumab (Praxbind, Boehringer Ingelheim)
			For Direct Factor Xa Inhibitors: (Apixaban, Edoxaban and Rivaroxaban)
				Andexanet Alfa (Ondexxya or Andexxa Manufactured by Alexion)
			4 Factor Prothrombin Complex Concentrate & DOAC Reversal
			For Unfractionated Heparin (UFH)/Heparin
				Protamine
					Toxbase Guidance
					British Society for Haematology Guidance (BSH)
			For Low Molecular Weight Heparin (LMWH)
				Protamine
				Protamine Reversal for LMWH: Courtesy of Toxbase
		Andexanet Alfa
			For Fondaparinux
		Anti-Platelet Agents
		Summary
		References
Part IV: Pre-hospital Aspects of Trauma Care
	18: History of Pre-Hospital Medicine in the UK
		Antiquity to Early Modern
		Late Modern: 1860–1945
		Contemporary: 1945—Present
		Conclusion
		References
	19: Aviation Considerations in PHEM
		HEMS vs Air Ambulance
		Aviation Legalities
			Permissions and Exemptions
				Minimum Heights SERA3105
				Prisons
				Nuclear Facilities
				Landing and Taking off Near Open-Air Assemblies
			Pilot Duty Period and Discretion
		Carriage of Patients
		Carriage of Escorts
		Call Taking and Tasking
			Radio Procedures
			Comms Panel in the Aircraft
		Maps and Charts
			The UK Grid Reference System
			A-Z Maps or Street Mapping
			In-Flight Navigation
		Lookout and the Clock Code
		Weather Limitations
		Disc Safety
			Main Rotor
			Tail Rotor
			Disc Discipline
			Disc Protection on Landing and Take off
		Takeoff and Landing Checks
		Landing Site Selection
			Landing Site Recce: Arrival and Approach
			Wheels and Stinger Check
		Specific Landing Site Considerations
			Railways
			Reservoirs
			Beaches
			Prisons
			Industrial Incidents
		Airport Landings
			IFR Recoveries
		Night Flying
			Procedures for Departure from a HEMS Site at Night
		Marshalling Signals
		Aircraft Emergency Procedures
		Batteries
		Conclusions
		References
	20: Scene Safety
		Introduction
		Environment
			Temperature and Weather
			Traffic
		Kit Management
		Being Prepared and Escalating Concerns
			Personal Protective Equipment (PPE)
			Training SOP’s and Sign Off
			Beginning of Shift Checks and Procedures
			Driving
		Multiagency Working
			Dynamic Risk Assessment
			Manual Handling
			Infection Control
			Police and Evidence
			Fire and Rescue Services
		Communication
			Verbal and Non-Verbal Communication
			Team Debriefing
		Conclusion
		References
	21: Mechanism of Injury
		Introduction
		Understanding the Physical Forces Involved
			Grouping of Injury Types
			Blunt Trauma
			Penetrating Trauma
			Ballistic Trauma
		Acceleration and Deceleration Trauma
			Road Traffic Collisions
			Frontal/Head-on
		Rear Impacts
		Side on/“T-Bone” Collision
		Rollover
		Pedestrian
		Cyclists and Motorcyclists
			Falls
			Equestrian Accidents
			Kicks
			Falls from a Horse
		Summary
		References
	22: Mass Casualty Incidents
		Introduction
		Types and Scope of Major Incidents
			CBRNE3T
		Preparation
			Organisational Preparedness
			Individual Preparedness
		Public Involvement
		CSCATTT
		Command, Control and Coordination of an Incident
			Primacy at Scene
		Safety
		Communication
		Assessment
		Triage
			MPTT-24: A New Triage Tool
		Treatment
		Transport
		Crew Resource Management & Human Factors
		Debrief
		Summary
		References
	23: Tactical Trauma Care
		Introduction
			War Wounds on Home Soil
		Phases of Care
			Care Under Fire/Non-Permissive Environment
			Tactical Field Care/Semi-Permissive Environment
			Resuscitation and Advanced Care/Permissive Environment
			The Physiology and Anatomy of Tactical Trauma Care
				Physiology
				Anatomy and Wounding
			Unique Challenges of Tactical Trauma Care
			CBRNE3T
		The MABCD Approach in the Tactical Environment
			Care Under Fire
			Tactical Field Care
		Challenges of International and Austere Working
		Conclusion
		References
	24: Trauma Retrieval
		Introduction
			Training
			Key Points in Transfer Medicine
			Trauma Retrievals
			Human Factors
			Situational Awareness
			Team Structure and Function
			Standardisation and Processes
			Checklists and Establishing the Appropriate Norms
			Simulation Training
			Command and Control
			Preparation
			Loading Plan
			Equipment Packaging and Carriage
			Feeling Included
			Communication within the Team
			Mission Communication
			Clinical Information
			Team Welfare
			Infection Control
			Recovery Phase
			Contemporary Transfer Medicine
		Conclusion
		References
	25: Sedation and Field Amputation
		Introduction
		Sedation
			Sedation in Practice
				Sedation for Painful Procedures
			Sedation for Amputation
		Indications for Pre-Hospital Amputation
		Equipment for Pre-Hospital Amputation
		Main Risks of the Procedure
		Pre-Procedure Checks
		Immediately Before the Procedure
		The Surgical Procedure
		Immediate Actions Post Procedure
		Delayed Actions After Procedure
		Novel Techniques for Surgical Amputation
		Training for the Procedure
			Overview of Drugs Commonly Used in Procedural Sedation
				Midazolam
				Ketamine
				Propofol
				Methoxyflurane
				Morphine
				Fentanyl
				Alfentanil
				Entonox
		Conclusion
		References
Part V: Radiology in Trauma
	26: Point of Care Ultrasound (POCUS)
		Introduction
		Physics
			Ultrasound
			Waveform
		Mechanics
			Resolution
		Artefacts
		Doppler
		Hardware
			Probes
			Image Optimisation
			Modes
			Probe Handling
		Video Resources
		Systems
			Airway
			Breathing
				Pneumothorax
				Intra-Alveolar Fluid
		Circulation
			Cardiac
			Abdominal
			Vascular Access
			Disability
			Exposure
		Cardiac Arrest
		Limitations & Governance
		Conclusion
		References
			Recommended Further Reading
	27: Diagnostic Radiology in Trauma
		Introduction
		Trauma Imaging Modalities
			Digital Radiography
			Ultrasonography
			Computed Tomography
			Magnetic Resonance Imaging
			Fluoroscopy
			Catheter Angiography
		Injury Patterns in Major Trauma
			Head and Neurological Trauma Imaging
			Chest Trauma Imaging
			Abdominal and Pelvic Trauma Imaging
		Special Considerations
			Children
			Pregnancy
			Elderly
		Adverse Events Associated with Administration of Intravenous Contrast
		Conclusion
		References
	28: Interventional Radiology in Trauma
		Introduction
		Equipment and Devices
			Basics
			Embolic Agents
			Stent-Grafts
			Closure Devices
		Targets for Endovascular Therapy
			REBOA
			Head and Neck Vascular Injury
			Aortic Injury
			Visceral
				Spleen
				Liver
				Renal
			Pelvic
		Aftercare
		Conclusion
		References
Part VI: In-Hospital Speciality Care
	29: Decision-Making in Damage Control Surgery
		Introduction
		Definitions
		Interpretation of Literature Regarding DCL for Trauma
		Selection of Patients for DCL
		Preparation for Trauma Laparotomy
		Human Factors in Trauma Laparotomy
		Situational Awareness
		Decision-Making
		Communication and Teamwork
		Leadership
		Summary
		References
	30: Practical Considerations of Damage Control Laparotomy
		Introduction
		Universal Actions for Initiating DCL
			Optimise Operating Theatre (OT) Setup
			Position Patient
				Modifications
			Snap Brief
			Operative Field Preparation
				Modifications
			RSI
			Surgical Access
				Surgical Wound Edge Retraction Considerations
				Pitfall: Inadequate Exposure
				Hostile Abdomen Considerations
		First Cavity Actions and Decisions
			Communicate Assessment of Findings and Begin Decisions
				Top Tip: Two Pairs of Eyes
			Empirical Intraperitoneal Packing Sequence Not Required
				Alternative Causes of Deranged Physiology
				Next Steps
				Communicate and Decide
			Empirical Intraperitoneal Packing Sequence Required
				Further Surgical Manoeuvres: Caval
				Further Surgical Manoeuvres: Aortic
				Further Risk Mitigation in Aortic Clamping
				Further Pack Assessment and Action
				Communicate and Decide
			Optimise for DCL
				Agree When to Remove Packs
		Targeted Cavity Actions
			Pack Removal
			Removing Aortic Occlusion
				Futility
				Expected Sequelae
			Supracolic Compartment and Infracolic Compartment Inspection
				Reducing Missed Injuries
				Supracolic Compartment
				Infracolic Compartment
				Actions on Identifying Injury
		Closure of the Abdomen with Temporary Intent
			Decision on Closure
			Method of Temporary Abdominal Closure
				Fascial Closure
				Laparostomy
				Planning a Second Look
		Actions on Specific Injuries
			Retroperitoneal Haematoma
				Anatomy
				Principles of Management
				Visceral Rotation for Access
				Pitfall: Left Medial Visceral Rotation Sub Optimal Technique
			Kidneys, Ureter, Bladder (KUB)
			Posterior Abdominal Wall Musculature
		Summary
		References
	31: Trauma in the Intensive Care Unit (ICU)
		What Is the ICU?
		Who Is Admitted to the ICU?
			Level 0 Patients
			Level 1 Patients
			Level 2 Patients
			Level 3 Patients
		Trauma Patients in the ICU
		Initial Assessment & Management
		Resuscitation
		Hypotension on ICU
		Blood Products in ICU
		Renal Injury
		Secondary & Tertiary Survey
		Continued Care
			Nutrition
		Venous Thromboembolism (VTE) Prophylaxis
		Coordinating Further Care
		End of Life Care
		Conclusion
		References
	32: Spinal and Neurological Trauma
		Introduction
		Epidemiology
		Classification
		Management of Spinal Trauma
			Massive Haemorrhage
		Airway
		Breathing
		Circulation
		Disability
		Transport
		Role of Collars in Spinal Cord Trauma
		Imaging
		Systemic Complications of Spinal Cord Injury
			Autonomic Dysreflexia
			Thromboembolism
			Genitourinary System
			Others
		Role of Surgery in Patients with SCI
		Role of Steroids in SCI
		Specific Spinal Injuries
			Atlanto Occipital Dislocation
			Occipital Condyle Fracture
			Atlantoaxial Subluxation
			Atlas Fracture
			Axis Fracture
			Subaxial Cervical Spine Fracture
			Thoracolumbar Fracture
		Conclusion
		References
			Further Reading
	33: Limb Trauma
		Introduction
		Understanding the Mechanism of Injury
		Assessing a Patient with a Limb Fracture
		Assessment of Vascular Injuries
		Assessment of Compartment Syndrome
		Management of Upper Limb Injuries
			Upper Limb-Limb Salvage
			Finger Fractures
			Carpal Fractures
			Radius and Ulnar Fractures
			Distal Humeral Fractures
			Humeral Shaft Fractures
		Management of Lower Limb Fractures
			Neck of Femur Fractures
			Femoral Shaft Fractures
			Inter-Articular Distal Femoral Fracture
			Knee Joint Dislocations
			Tibial Plateau Fractures
			Tibial Shaft Fractures
			Distal Tibial Fractures and Pilon Fractures
			Foot and Ankle Fractures
		Management of Open Fractures
		The Management of Bone Loss
		Decisions on Amputation or Limb Salvage
		Performing a Below Knee Amputation
		Osseous Integration
		Summary
		Bibliography
	34: Pelvic Trauma
		Introduction
		Anatomy
			Skeletal Components
		Ligaments and Joints
		Vascular Anatomy
		Classification of Pelvic Fractures
		Management of Pelvic Injuries
		Initial Interventions
		Resuscitation
		Haemorrhage Control
			Pelvic Packing
			Angiography and Embolisation
		Fracture Stabilisation
			Non-Invasive Stabilisation (Pelvic Binders and Sheet Wrapping)
			Emergency Skeletal Stabilisation
				Anterior Emergency Fixation
		Posterior Emergency Fixation
			Definitive Skeletal Stabilisation
		Summary
		References
Part VII: Special Populations
	35: Trauma in Pregnancy
		Introduction
		Epidemiology
		Injury in Pregnancy
			Motor Vehicle Accidents (MVA)
			Falls
			Assaults
			Burns
		Anatomical and Physiological Changes of Pregnancy
			Approach to a Pregnant Trauma Patient
				Legal Position of the Fetus
				Recognising Pregnancy
			Massive Haemorrhage
			Airway and Cervical Spine
			Breathing
			Circulation
			Disability
			Exposure
		Specific Obstetric Complications
			Preterm Labour
			Placental Abruption
			Uterine Rupture
			Fetal-Maternal Haemorrhage
			Amniotic Fluid Embolism
		Maternal Cardiac Arrest
			Resuscitative Hysterotomy
		Technique for Perimortem Section
			Decision to Operate
			Preparation
			Surgical Technique
		Imaging in the Pregnant Patient
			X-Rays
			Ultrasound
		Obstetric Assessment
		Patient Management After Trauma
		Special Considerations
			Pelvic Fractures
			Penetrating Injury
			Obstetric vs Traumatic Blood Loss
		Summary
		References
	36: Paediatric Trauma
		Overview and Epidemiology
		Physiological and Anatomical Considerations
			Airway
			Breathing
			Circulation
			Disability
			Exposure
		Assessing the Traumatised Child
			Assessing the Child in Trauma
			Analgesia
			Scoring Systems
			Pulses and Blood Pressure
			Blood Products
		Communication Is Critical with Transfusion
			Red Blood Cells
			Fresh Frozen Plasma (FFP)
			Platelets
			Cryoprecipitate
			Temperature Control
		Head Injuries
			Glasgow Coma Scale (GCS)
		Injuries, Interventions and Imaging
			Immobilisation and C-Spine Control
			Spinal Injuries
			Truncal Injuries
			Access Options
		The Use of Imaging in Paediatric Trauma
		Mobile Apps
		Psychological and Safeguarding Considerations
			Parental Involvement
			Psychological Input and the Mental Wellbeing of the Team
			Safeguarding
			Sudden Unexpected Death in Childhood
		Conclusions
		References
	37: Silver Trauma
		Introduction
		The Physiology of Ageing
		Medication and Prescribing in the Elderly
		Changes in Assessment of the Elderly Trauma Patient
			Mechanisms of Injury
			Specific Differences in the Primary Survey
				Airway and Cervical Spine
				Breathing
				Circulation
				Disability and Head Injury
				Abdominal/Pelvic Injuries
				Burns and Extremity Trauma
		Safeguarding and Elder Abuse
		Blood Management in Elderly Trauma
			What Is the Optimum Haemoglobin Concentration?
		Anti-Platelet Agents and Their Reversal
		Delirium
			Respiratory
			CNS
			Anaesthetics/Analgesia
			Infection/Host Defence
			Fluid Balance and the Renal System
			Gastrointestinal
		Rehabilitation and Re-Enablement
		Conclusion
		References
	38: Ballistics and Blast Injury
		Introduction
		Wound Ballistics
			Permanent Cavity
			Temporary Cavity
		Assessing the Severity of Ballistic Wounds
		Blast Pathophysiology
		Clinical Priorities
		Conclusion
		References
Part VIII: Environmental Trauma
	39: Immersion and Submersion
		Introduction
		Epidemiology
		Pathophysiology
		Immersion vs Submersion
		Submersion
		Prolonged Submersion and Survival
		The Conscious Drowned Patient
		Complications of Drowning
		Immersion
		First 0–3 Minutes of Rapid Immersion: Cold Shock
		Next 3–30 Minutes of Immersion: Extremity Cooling
		30+ Minutes of Immersion: Hypothermia in Water
		Mammalian Dive Reflex
		Autonomic Conflict
		Rescue from Water
		Mud Rescue
		Concomitant Injury or Medical Conditions
		Infection
		Conclusion
		References
			Further Reading
	40: Burns and Thermal Injuries
		Hypothermia
			Increased Heat Loss
			Reduced Heat Production
		Physiology of Hypothermia
		Staging of Hypothermia
		Pre-Hospital Management
		Investigations
		Treatment
		Management of Cardiac Arrest
		Cold Injury
			Non-freezing Injury: Trench Foot/Frostnip
			Freezing Injury: Frostbite
		Hyperthermia
		Burn Injury
			Epidemiology
			Types of Burn
				Thermal Burns
				Chemical Burns
				Electrical Burns
			Low Voltage Injury
			High Voltage Injury
			Lightning Strike
		Pathophysiology
			Burn Area Assessment
		Referral Criteria for Specialist Review/Care
		Immediate Management
			Initial Assessment
			Airway and Breathing: Assessment and Management
				Airway Injuries Above the Larynx
				Airway Injuries Below the Larynx
				Carbon Monoxide Poisoning
				Cyanide Poisoning
					Methemoglobin-Forming Agents
					Sulphur Donors
					Cobalt Compounds
		Circulation
		Circumferential Burns
		Analgesia
			Thermoregulation
			Nutrition
			Infection
			Hypermetabolism
		Definitive Management
			Longterm Sequalae
		Summary
		References
	41: Environmental Trauma: CBRN Incidents
		Introduction
			Types of Hazard
		General Considerations of CBRN Casualty Care
			Casualty Management Within a CBRN Environment
				Principles of CBRN Casualty care [6]
				Recognition of CBRN Incidents
				Safety Considerations
			Management of CBRN Casualties
				First Aid
				Primary Survey (Identification of Life-Threatening Conditions)
				Life-Saving Interventions
				Casualty Hazard Management
				Advanced Medical Care
				Rehabilitation
		Key Management Points
			Chemical Incidents
				Chemical Asphyxiants: Including Hydrogen Cyanide and Hydrogen Sulphide (H2S)
				Mental Incapacitating Agents (Sedating): Opioids
				Mental Incapacitating Agents (Psychotropic): Anticholinergics Including BZ (and Atropine Overdose)
				Blistering Agents: Sulphur Mustard
				Blistering Agents: E.g. Lewisite [16]
				Pulmonary Agents: Including Chlorine, Phosgene, Ammonia, Sulphur Dioxide
			Biological Incidents
				The Syndromic Approach
				Respiratory
				Cutaneous
				Lymphadenopathy
				Gastrointestinal
				Haemorrhagic
				Neurological: Central
				Neurological: Peripheral
			Antimicrobial Chemotherapy
			Sepsis and Abnormal Host Response to Infection
			Radiological and Nuclear Incidents
				Ionising Radiation
				Nuclear Incidents
				Overview of the Management of Radiological Casualties
				Decontamination
				Exposure and Dosimetry
				Acute Radiation Syndrome (ARS)
				Treatment of Acute Radiation Syndrome
				Localised Radiation Injury
				Timing of Surgery
		Summary
		References
	42: Decompression Illness and Diving Medicine
		Introduction
		What Are the Different Types of Diving?
		How Does a Diver’s Physiology Change Whilst Underwater?
		Respiratory Adaptations Whilst Diving
		Cardiovascular Adaptations Whilst Diving
		Gas Mixtures and Diving
		Nitrogen Absorption
		Factors Influencing the Absorption of Nitrogen
		Nitrogen Elimination
		Bubble Formation
		Decompression Illness
			Definitions
		Decompression Sickness
		Cerebral Arterial Gas Embolism
		Presentation of CAGE
		Causes of CAGE
		Preventing DCI
		Management of DCI
		Drowning
			Introduction
			The Pathophysiology of Drowning
		Management of the Drowning Diver
			Immediate Management of a Drowning Diver
				Recognition
				Immediate Ascent
				In-Water Rescue Breaths
				Get to a Surface
			The Practical Approach to the Diving Patient for Emergency Medical Services (EMS)
			Transfer the Patient to Hospital
		Hospital Management
			Management in the Emergency Department
		Summary
		References
Part IX: Post-Incident Care
	43: Rehabilitation After Trauma
		Learning Outcomes
		Introduction
		How Is Trauma Rehabilitation Delivered?
		Who Is Involved in the Multi-Disciplinary Team?
		Specific Areas of Rehabilitation Following Trauma
			Musculoskeletal Trauma
		Amputee Rehabilitation
		Neurological Rehabilitation
			Traumatic Brain Injury
			Spinal Cord Injury
		Lessons from Military Rehabilitation
		Conclusion
		References
	44: Preventing and Treating Trauma-Related Mental Health Problems
		Introduction
		Immediate and Short-Term Responses to Potentially Traumatic Events
		Post-Incident Care: What Should Be Done in the Immediate Aftermath of a Potentially Traumatic Event to Prevent Mental Health Disorders Developing?
			Recommendations for Self-Care
			Social Support
			Recommendations for Trauma-Exposed People: Reaching Out
			Recommendations for Those Close to Trauma-Exposed People: How to Communicate
		Ongoing Psychological Issues
			Post-Traumatic Stress Disorder
		Understanding Factors Contributing to Psychological Distress and Disorder
			Pre-Traumatic Event Predictors of Mental Health Outcomes
			Peri-Traumatic Predictors of Mental Health
			Social Support
			Post-Event Coping Strategies
			Post-Event Impact on Life
			Multiple Exposures
		Early Detection of Trauma-Related Mental Health Disorders
		Treatment of Trauma-Related Mental Health Disorders
		Summary
		References