Basic Principles in TraumaObjectives1. To lay ground work for the establishment of standards of care

in trauma management2. Provide of correct sequence in assessing the multiply injured

patient3. To provide guidelines and techniques in treating the multiply

injured patient

TRAUMA An injury or wound characterized by a structural alteration or

physiologic imbalance that results when energy is imparted during the interaction with physical or chemical agents.

a bodily lesion which results from transfer of energy, force is beyond the physiologic tolerance of the individual

When a trauma patient enters the emergency room, you have to do an initial assessment. The first priority is to recognize is life-threatening conditions and then be able to resuscitate the patient. TYPES OF INJURY1. Mechanical2. Thermal 3. Electrical4. Chemical*most cases seen are vehicular crashes or projectile traumaTRIMODAL PATTERN OF DEATH 1. Immediate post-injury period where most of the mortality occurs, associated with overwhelming injuries (e.g. cord dissection,

aortic destruction); you cannot do anything to treat it, but you can prevent it

2. Death which occurs hours after injury occurs in 1/3 of patients proper management can decrease mortality rate

3. Patients who stay in the hospital for long periods with 1 mo. old injury

mostly die due to pulmonary complications can prevent death, however rehabilitation would be

importantTRIAGE when you have a lot of victims in one area Prioritizing identify patients who are most in need of care and send

patients to institutions capable of giving them adequate care sort out patients based on their need for treatment, taking

into consideration resources available decide where to send these patients (send them to a trauma

center) achieve the greatest good for the greatest number of

casualties differentiate patients whom you can help from those whom

you cannot helpCRITERIA FOR CLASSIFYING PATIENTS Physiologic – Glasgow Coma Scale

Anatomical Criteria – head, neck, torso or extremities, flail chest, burns and concomitant traumatic, fractures to two or more proximal long bones, pelvic fracture, spinal cord injury, amputation proximal to wrists or ankles = immediate attention

Mechanism of Injury

Adult Triage – See Appendix A

Expectant (black tag) victim unlikely to survive given severity of injuries, level of care, or both. Palliative care and pain relief should be provided

Immediate (red tag) victim can be helped. Immediate intervention and transport. Require medical attention within minutes (up to 60). Include compromises to patient’s airway, breathing, circulation

Delayed (yellow tag) victims transport can be delayed. Includes serious and life threatening injuries but status not expected to deteriorate significantly over several hours

Minor (green tag) victim with relatively with minor injuries. Status unlikely to deteriorate. May be able to assist in own care. “Walking wounded”

IMPORTANT NOTES Life-threatening conditions are things that may kill the person

(aka ABCs of trauma) Blocked airway - no oxygen then the patient dies Poor breathing or ventilation - you need the lungs for

exchange of gasesPneumothorax (air in thoracic cavity) and hemothorax

(blood in thoracic cavity) may compromise lung function Compromised circulation - if the patient bleeds you will

have hypovolemia thus delivery of blood to all organ systems is diminished.

Lack of definitive diagnosis should not hinder the application of an indicated treatment; detailed history is not important

PRIORITIES (done almost simultaneously)1. Primary Survey 2. Resuscitation3. Secondary Survey4. Tertiary Survey Importance of REASSESSMENT

INITIAL ASSESSMENT The management of severe multiple injuries require clear

recognition of management priorities and the 1st priority are life threatening conditions!!!

Primary survey checks: airway, breathing, circulation, disabilities and exposure of patients from head to foot.

Resuscitation of patient History and PE must be brief and concise; usually 2-5

minutes from head-to-foot PRIMARY SURVEY (ABCDE) Airway Breathing Circulation Disability ExposureThis primary survey if done correctly identify such life threatening conditions: Airway obstruction Chest injuries with breathing difficulties Severe external or internal hemorrhage Abdominal injuries Primary survey must be performed in no more than 2-5

mins. Simultaneous treatment of injuries can occur when more than

one life-threatening condition exist. While you’re doing resuscitation, do complete work-up all at the same time. Do not wait.

AIRWAY Assess by talking to the patient, if patient can communicate

perfectly then airways are intact Loss of airway patency is the most immediate life-threatening

complication in trauma Importance of cervical spine control- assume that patients

have surgical spine injuries until you prove that the patient does not

Transport patient by immobilizing the cervical spine or put cervical collar

Assume that patient has a full stomach and is at risk for aspiration (airways will be blocked= lead to hypoxia)

If obstructed the steps to be considered are: Chin lift/jaw thrust (tongue is attached to the jaw) Suction (if available) Nasopharyngeal airway Intubation at the area of the trachea. Keep the neck

immobilized in neutral position.Airway Management 1. Talk to the patient A patient who can talk must have a clear airway. The unconscious patient may require airway and ventilatory

assistance.

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The cervical spine must be protected during endotracheal intubation if a head, neck or chest injury is suspected.

Airway obstruction is most commonly due to obstruction by the tongue in the unconscious patient

2. Give oxygen ALL INJURED PATIENTS SHOULD BE GIVEN

SUPPLEMENTAL OXYGEN – should be given once patient arrives at emergency room

Snoring or gurgling Stridor or abnormal breath sounds Agitation (hypoxia e.g. putting a pillow on your face while

sleeping) Using the accessory muscles (e.g. pectoralis) of ventilation

or paradoxical chest movements (e.g. when the whole thoracic cage expands seen in patients with segmental fracture of the ribs)

Cyanosis Be alert for foreign bodies. Intravenous sedation is

absolutely contraindicated in this situation because it will further depress the respiratory muscle.

3. Consider need for advanced airway management eg. endotracheal intubation (airway obstruction requires URGENT treatment)

better control of respiration, more permanent airway, prevents aspiration

Indications for advance airway management techniques for securing the airway include: Persisting airway obstruction Penetrating neck trauma with hematoma Apnea Hypoxia Severe head injury Chest trauma Maxillofacial injury Hemodynamic instability (concomitant chest/pulmonary

airway) Unresponsive patient (problem is position of tongue, may

obstruct airway) Shock Depressed mental status Flail chest (unable to breathe efficiently) Fracture in the ribs (3 adjacent ribs) Combative patients – possibility that these patients are

hypoxicBREATHINGBreathing is assessed as airway patency and breathing adequacy are re-checked. If inadequate, the steps to be considered are: Decompression (by putting a tube) and drainage of tension

pneumothorax/hemothorax Closure of open chest injury Artificial ventilation by placing an endo-tracheal tube. Give oxygen if availableReassessment of ABC’s must be undertaken if patient is unstableProblems in Adequate Lung Function or Chest Wall tension pneumothorax (air outside lungs, inside pleural

cavity, pressure that is enough to cause compression of mediastinal structures)

open pneumothorax (atmospheric air is able to enter the cavity because of a negative pressure, as in penetrating chest trauma—cover the opening using gauze with petroleum, tape the gauze on three sides to allow for air inside to go outside

massive hemothorax- bleeding in pleural cavity flail chest cardiac tamponadeLocate problem through physical examinationCIRCULATIONAssess circulation, as oxygen supply, airway patency and breathing adequacy are re-checked. If inadequate, the steps to be considered are: Stop external hemorrhage (stop the bleeding by pressure) Establish 2 large-bore IV lines (14-16 G) if possible to replace

the blood loss Administer fluid if available How to Recognize Shock Assessment of vital signs of patient: HR, RR, pulse pressure,

urine output, sensorium of patient (will give you an idea as to how much blood was lost)

Decreased RR,HR and some sensorium changes= blood loss of about 750 cc

2 L of blood loss – drastic manifestations such as tachycardia, hypotension, tachypnea, little urine output, sensorium changes – may need surgery in immediate period and needs to be prioritized

>2 L blood loss – classic signs of late shock

Circulatory management (the third priority is establishment of adequate circulation) Shock is defined as inadequate organ perfusion and tissue

oxygenation. In the trauma patient, it is most often due to hypovolemia (blood loss).

The diagnosis of shock is based on clinical findings: hypovolemia, tachycardia, tachypnea, as well as hypothermia, pallor, cool extremities, decreased capillary refill (press nail beds then release, color must return within 2 seconds), and decreased urine production (normal is 50mL per hour).

There are different types of shock Hemorrhagic (hypovolemic) shock Cardiogenic shock Neurogenic shock Septic shock Hemorrhagic (hypovolemic) shock Due to acute loss of blood or fluids. The amount of blood loss

after trauma is often poorly assessed and in blunt trauma is usually underestimated.

Cardiogenic shock Due to inadequate function of the heart. This may be from: Myocardial contusion Cardiac tamponade Tension pneumothorax (preventing blood returning to heart) Penetrating wound of the heart Myocardial infarction

Assessment of the jugular venous pressure is essential in these circumstances and an ECG should be recorded when available.

Neurogenic shock Due to the loss of sympathetic tone, usually resulting from

spinal cord injury, with the classical presentation of hypotension without reflex tachycardia or skin vasoconstriction. The autonomic function is lost.

Septic shock Rare in early phase of trauma but common cause of late

death (via multi-organ failure) in the weeks following injury. It is commonly seen in penetrating abdominal injury and burn

patientsCirculatory Resuscitation Measures The goal is to restore oxygen delivery to the tissues. As the usual problem is loss of blood, fluid resuscitation must

be a priority. Hypovolemia is a life-threatening emergency and must be

recognized and treated aggressively. Adequate vascular access must be obtained. Infusion fluids (crystalloids e.g. normal saline as first line)

should be warmed to body temperature. Hypothermia can lead to abnormal blood clotting.

Avoid solution containing glucose. Take any specimen you need for lab and cross matching. Blood TransfusionConsider fluid infusion instead of blood transfusion because of: difficulty of getting blood possibility of incompatibility hep B and HIV risksBlood transfusion must be considered when patient has persistent hemodynamic instability despite fluid colloid/crystalloid infusion. If specific blood type is unavailable, packed type O rh

negative red blood cells should be used. Consider blood transfusion when hemoglobin is less than 7 or

if patient is still bleeding. 1 ml of blood loss= 3 ml of crystalloids should be infused Packed RBC- blood loss greater than 1L DISABILITYRapid neurological assessment (is patient awake, vocally responsive to pain or unconscious). There is no time to do the Glasgow Coma Scale so a system at this stage is clear and quick: Awake Verbal response Painful response Unresponsive (intracranial lesions, spinal cord injuries)EXPOSURE vital signs, what you see Undress patient (by cutting using scissors) and look for injury. If patient is suspected of having a neck or spinal injury, in-line

immobilization is important. During the exposure, bruises, contusions, penetrating wound,

swelling from head to foot are noted especially of the abdomen, extremities.

If there is fracture, you have to splint while doing resuscitation.

SECONDARY SURVEY

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This is undertaken only when the patient’s ABC’s are stable If any deterioration occurs during this phase then this must

be interrupted by another PRIMARY SURVEY Head-to-toe examination is now undertaken (finger to every

orifice) CRASHPLANC erebrationR espirationA bdomenS pineH ip

P elvisL imbsA rteriesN erves

Allergies Medications Past history Last meal Events leading to injury *those that are italicized were taken from the voice recording

OTHER INFO FROM OLD TRANS THAT WERE NOT EXACTLY DISCUSSED IN THE LECTURE CHEST TRAUMA A quarter of deaths due to trauma are attributed to thoracic injury. Immediate deaths are essentially due to major disruption of the heart

or great vessels Early deaths due to thoracic trauma include airway obstruction,

cardiac tamponade or aspiration Majority of patients with thoracic trauma can be managed by simple

maneuvers and do not require surgical treatment. The extent of internal injuries cannot be judged by the appearance of

a skin wound (*a blunt injury is more deceptive and more difficult to manage than a penetrating injury)

Respiratory Distress may be caused by1. Rib fractures2. Flail chest3. Pneumothorax4. Tension pneumothorax5. Hemothorax

6. Pulmonary contusion (bruising)7. Open pneumothorax8. Aspiration9. Hemomediastinum

Rib Fracture Rib fracture may occur at the point of impact and damage to the

underlying lung may produce lung bruising or puncture. In the elderly fractured rib may result from simple trauma. Ribs usually become fairly stable within 10 days to two weeks. Firm

healing with callus formation (you don’t develop a scar) is seen after about six weeks.

Flail Chest The unstable segment moves separately and in an opposite direction

from the rest of the thoracic cage during the respiration cycle. Severe respiratory distress may ensue.

Tension Pneumothorax Develops when air enters the pleural space but cannot leave. The

consequence is progressively increasing intrathoracic pressure in the affected side resulting in mediastinal shift. The patient will become short of breath and hypoxic. Urgent needle decompression is required prior to the insertion of an intercostal drain. The trachea may be displaced (late sign) and is pushed away from the midline by the air under tension.

Hemothorax More common in penetrating than in non-penetrating injuries to the

chest. If the hemorrhage is severe, hypovolemic shock will occur and also respiratory distress due to compression of the lung on the involved side. Optimal therapy consists of the placement of a large chest tube.

Hemothorax of 500 -1500 ml that stops bleeding after insertion of an intercostal catheter can generally be treated by closed drainage alone.

Hemothorax of greater than 1500-2000 ml or with continued bleeding of more than 200-300 ml per hour is an indication for further investigation by opening the patient e.g. thoracotomy

Pulmonary Contusion Common after chest trauma that appears like bruising. It is potentially

life-threatening condition. The onset of symptoms may be slow and progress over 24 hrs post injury. It is likely to occur in cases of high-speed accidents, falls from great heights and injuries by high-velocity bullets. Symptoms and signs include:

Dyspnea Hypoxemia Tachycardia

Rare or absent breath sounds Rib fractures Cyanosis

Myocardial Contusion Associated with fractures of the sternum or ribs Associated with ECG abnormalities and elevation of cardiac enzymes. Cardiac contusion can simulate myocardial infarction Placed under observation and monitoring May cause sudden death well after the accident Pericardial Tamponade Pericardial cardiac injuries are a leading cause of death in urban areas It is rare to have pericardial tamponade with blunt trauma. Pericardiocentesis must be undertaken early if this injury is

considered likely. Look for it in patients with: shock distended neck veins

cool extremities and no pneumothorax muffled heart sounds

Thoracic great vessels injuries Injury to pulmonary veins and arteries is often fatal One of the major causes of on-site death Rupture of trachea or major bronchi Rupture of the trachea or major bronchi is a serious injury with an

overall estimated mortality of at least 50%

The majority (80%) of ruptures of bronchi are within 2.5 cm of the carina. The usual signs of tracheobronchial disruption are the followings:

hemoptysis dyspnea subcutaneous and mediastinal emphysema occasionally cyanosis

Trauma to esophagus In patients with blunt trauma this is rare. More frequent is the

perforation of the esophagus by penetrating injury. It is lethal if unrecognized because of mediastinitis. Patients often

complain of sudden sharp pain in the epigastrium and chest with radiation to the back. Dyspnea, cyanosis and shock occur but these may be late symptoms.

Diaphragmatic injuries Occur more frequently in blunt chest trauma, paralleling the rise in

frequency of car accidents. The diagnosis is often missed. Diaphragmatic injuries should be suspected in any penetrating

thoracic wound: below 4th intercostal space anteriorly 6th interspace laterally 8th interspace posteriorly usually the left side

Thoracic Aorta Rupture Occurs in patients with severe decelerating forces such as high speed

car accidents or a fall from a great height. They have high mortality as cardiac output is 5 l/min and the total

blood volume in an adult is 5 liters ABDOMINAL TRAUMA The abdomen is commonly injured in multiple trauma. The most commonly injured in penetrating trauma is liver, and in

blunt trauma the spleen The initial evaluation of the abdominal trauma patient must include

the A (airway and C-spine), B (breathing), C (circulation), and D (disability and neurological assessment) and E (exposure)

Until proven otherwise, any patient involved in any serious accident should be considered to have an abdominal injury.

Unrecognized abdominal injury remains a frequent cause of preventable death after trauma.

2 Basic Categories of Abdominal Trauma1. Penetrating

trauma Gunshot Stabbing

2. Non-penetrating trauma (blunt trauma)

Compression Crush Seat belt Acceleration/deceleration injuries

Indications for peritoneal lavage include Unexplained abdominal pain Trauma of the lower part of the chest Hypotension, hematocrit fall with no obvious explanation. Any patient suffering abdominal trauma and who has an altered

mental state (drugs, alcohol, brain injury) Patient with abdominal trauma and spinal cord injuries. Pelvic fracturesRelative contraindications for DPL (diagnostic peritoneal lavage): Pregnancy Previous abdominal injury Operator inexperience If the result does not change your management Other issues with abdominal trauma Pelvic fractures are complicated by massive hemorrhage (as much as

2L of blood) and urology injury Management of pelvic fracture Resuscitation Transfusion Immobilization (place patient in a pelvic hammock) and assessment

for surgery Analgesia

Complete physical examination of abdomen includes rectal examination, assessing: Sphincter tone Integrity of rectal wall Blood in the rectum Prostate position Check blood at the external urethral meatus Women should be considered pregnant until proven otherwise Fetus may be salvageable and the best treatment of the fetus is

resuscitation of the mother A pregnant mother at term can usually only be resuscitated properly

after delivery of child HEAD TRAUMA Delay in the early assessment of head-injured patients can have

devastating consequence in terms of survival and patient outcome Hypoxia and hypotension double the mortality of head –injured

patients There are difficult to treat cases in district hospital but immediate

recognition and early management must be made: e.g. acute extradural (epidural hematoma)

Alteration of consciousness is the hallmark of brain injury!The most common error in head injury evaluation and resuscitation are Failure to perform ABC and prioritise management (TRIAGE to treat

what you can with your expertise and resources) Failure to look beyond the obvious head injury Failure to assess the baseline neurological examination Failure to re-evaluate patient who deteriorates

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Acute extradural (epidural hematoma) classically the signs consist of Loss of consciousness following a lucid interval, with rapid

deterioration Middle meningeal artery bleeding (due to fracture at the temporal

area) with rapid raising of intracranial pressure The development of hemiparesis on the opposite side with a fixed

pupil on the same side as the impact areaAcute subdural hematoma: clotted blood in the subdural space, accompanied by severe contusion of the underlying brain. It occurs from tearing of bridging vein between the cortex and the dura.***the management of the above 2 is surgical and every effort should be made to do burr-hole decompressionsThe conditions below should be treated with more conservative medical management, as neurosurgery does not improve outcome: Base-of-skull fractures: you see bruising of eyelids (Racoon eyes) or

over the mastoid process (battle’s sign), cerebrospinal fluid (CSF) leak from ears and/or nose

Depressed skull fracture: an impaction of fragmented skull that may result in penetration of underlying dura and brain.

Intracerebral hematoma may result from acute injury or progressive damage to contusion.

Cerebral concussion with temporary altered consciousness. (Concuss: bruising, contuse: “parang sabaw, nalulusaw”)

Management of Head Trauma ABC’S are stabilized (and the cervical spine immobilized, if possible) Neuro-vital signs are monitored and recorded Glasgow Coma Score GCS evaluation is undertakenRemember: severe head injury is when GCS is 8 or less moderate head injury is when GCS between 9 and 12 minor head injury is when GCS between 13 and 15 never assume that alcohol is the cause of drowsiness in a confused

patientDeterioration may occur due to bleeding Unequal or dilated pupils may indicate an increase in intracranial

pressure Head or brain injury is never the cause of hypotension in the adult

trauma patient Sedation should be avoided as it interferes with the status of

consciousness but will promote hypercarbia (slow breathing with retention of CO2)

The cushing response is a specific response to a lethal rise in intracranial pressure. This is a late and poor prognostic sign. The hall marks are:

bradycardia hypertension decreased respiratory rate

Basic medical management for severe head injuries includes: Intubation and hyperventilation, producing hypocapnia (PCO2 to 4.55).

This will reduce both intracranial blood volume and intracranial pressure temporarily

Sedation with possible paralysis Moderate IV fluid input with diuresis i.e. do not overload Nurse head up 20% Prevent hyperthermia SPINAL TRAUMA The most common injuries include damaged nerves to fingers, brachial

plexus and central spinal cord The first priority is to undertake primary survey ABCDE, D (means

observation of neurological damage and status of consciousness), E (exposure of the patient to assess skin injuries and peripheral limb damage)

Examination carried out with patient in the neutral position (i.e. without flexion, extension, or rotation) Patient should be:

Log rolled Properly immobilized Transported in a neutral position Never transport a patient with a suspected injury of cervical spine in

the sitting or prone position. Always make sure patient is stabilized before transferring

C-spine: if available in addition to the initial X-rays, all patients with suspicion of cervical injury should include an AP and a lateral X-ray with a view of the atlas-axis joint. All seven cervical vertebrae must be seen on the AP and lateral view.With vertebral injury (which may overlie spinal cord injury) look for Local tenderness along the spine Deformities as well as posterior “”step off” injury Edema Clinical findings indicating injury of the cervical spine include Difficulties in respiration (diaphragmatic breathing; check for

paradoxical breathing) Flaccid and no reflexes Hypotension with bradycardia (without hypovolemia)

Neurological assessment: assessment of the level of neurological injury must be undertakenMotor response (intact level) Diaphragm C3,C4,C5

Sensory response Anterior thigh L2

Shrug shoulder C4 Biceps (flex elbow) C5 Extension of wrist C6 Extension of elbow C7 Flexion of wrist C7 Abduction of fingers C8 Active chest expansion T1 T2 Hip flexion L2 Knee extension L3 L4 Ankle dorsiflexion L5 S1 Ankle plantarflexion S1 S2

Anterior knee L3 Anterolateral ankle L4 Dorsum great and 2nd toe L5 Lateral side of foot S1 Posterior calf S2 Peri-anal sensation (perineum)

S2 S5

Special issues relating to limb trauma Stop active bleeding by direct pressure, rather than by tourniquet as it

can be left on by mistake, and this can result in ischemic change. Open fractures: any wound situated in the neighbourhood of a fracture

must be considered as a communicating one. Principles of treatment: Stop external bleeding Immobilize and relieve pain

Compartment syndrome is caused by an increase in the internal pressure of fascial compartment resulting to compression of peripheral nerves and vessels. E.g. Volkmann’s ischemia.

Amputated parts of extremities should be covered with sterile gauze towels which are moistened with saline and put into sterile plastic bag. A non-cooled amputated part may still be implanted within 6 hrs after injury, a cooled one as late as 18-20 hrs.

Limb support: Early fasciotomyThe problem with compartment syndrome is often underestimated. Tissue damage due to hypoxemia: compartment syndromes with

increased intramuscular (IM) pressures and local circulatory collapse are common in injuries intramuscular hematomas, crush injuries, fractures or amputations. If the perfusion pressure (systolic BP) is low, even a slight rise in IM pressure causes local hypoperfusion. With normal body temperature peripheral limb circulation starts to decrease at systolic BP around 80 mmHg

The damage on reperfusion is often serious: If there is local hypoxemia (high IM pressure, low BP) for more 2 hours, the reperfusion can cause extensive vascular damage. That is why decompression should be done early. In particular the forearm and lower leg compartments are at risk.

When bleeding source is controlled, in-field fasciotomy and lower leg and forearm compartment is recommended if the evacuation time is 4 hrs or more. Fasciotomy should be done by any trained doctor or nurse under ketamine anesthesia at the district location

Deep penetrating foreign bodies should remain in situ until operating room exploration.

Special trauma cases Pediatrics Pregnancy Burns

PEDIATRIC TRAUMA Trauma is a leading cause of death for all children Initial assessment is identical to that of an adult: ABCDE, early

neurological assessment, and exposing the child without losing heat. Principles in managing pediatric trauma patients are the same as

adults Specific intubation issues: larger head nasal airway and tongue, nose

breathing in infants, cricoid is narrowest part of larynx, gastric distention is common following resuscitation. Oral intubation is easier than nasal for infants and children, avoid cuffed tubes to minimize subglottic swelling and ulceration especially in less than 10 years old

Shock in Children Femoral artery in the groin and brachial artery in the antecubital fossa

are the best sites to palpate pulses in children Child that is pulseless warrants immediate CPR! Signs of shock: tachycardia, weak or absent peripheral pulses,

capillary refill > 2 seconds, tachypnea, agitation, drowsiness, poor urine output

Hypotension may be a late sign, even in the presence of severe shock The principles in managing pediatric trauma patients are the same as for the adult Vascular access should be obtained; good sites saphenous vein at

ankle, femoral vein in groin Intraosseous access safe and effective; best site on anteromedial

aspect of the tibia below tibial tuberosity Fluid replacement should be aimed to produce 12ml/kg/hr for infant,

and 0.51 ml/kg/hr in the adolescent. A bolus of 20 ml/kg body weight of normal saline. If no response after 2nd bolus, then 20ml/kg specific type of blood or O Rh negative packed red blood cells(10ml/kg) should be administered

Hypothermia is a major problem; lose heat through the head. Child has a relatively large surface area. All fluids should be warmed.

Child should be kept warm and close to family if at all possible

APPENDIX A: ADULT TRIAGE

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