01Approach to the Critical Patient/attcp56

Immediate priorities

›Airway and breathing threats

›Signs of airway compromise

›Stridor or gurgling from oropharyngeal blood

›Inability to maintain airway due to altered mental status

›Breathing compromise

›SpO2 < 90% on room air

›Tension pneumothorax signs: absent breath sounds, tracheal deviation

›If airway at risk, proceed to RSI immediately

›Video laryngoscopy preferred in trauma

›C-spine precautions maintained during intubation

›Circulation and hemorrhagic shock

›Shock indicators

›SBP < 90 mmHg despite 1 L crystalloid

›HR > 120 bpm with cool diaphoretic skin

›Lactate >= 2 mmol/l or base deficit worse than -6 mEq/L

›Activate massive transfusion protocol (MTP) for refractory hypotension

›pRBC:FFP:platelets 1:1:1 ratio

›TXA 1 g IV bolus within 3 hours of injury

›Permissive hypotension target SBP 80-90 mmHg until surgical hemorrhage control

›Avoid aggressive crystalloid resuscitation

›Target higher SBP if concurrent head injury

Hemodynamic monitoring and stabilization

›Monitoring bundle

›Continuous cardiac monitor and pulse oximetry

›Tachycardia may be the first and only sign of hemorrhage in young patients

›Elderly and beta-blocked patients may not mount tachycardia

›Serial BP every 5 minutes in unstable patients

02History/hx53

Mechanism and event details

›Mechanism of injury

›Motor vehicle collision

›Speed and direction of impact

›Restraint use: seatbelt, airbag deployment

›Steering wheel deformity (high-energy transfer marker)

›Ejection from vehicle (LR > 5 for major injury)

›Fall

›Height in meters

›Surface landed on

›Assault or direct blow

›Handlebar impact (bicycle handlebar injury pattern)

›Kick or punch to abdomen

›Pedestrian vs. vehicle or crush injury

›Seatbelt and restraint details

›Seatbelt sign: 12% risk of bowel or splenic injury

›LR 5.6-9.9 for intra-abdominal injury

›Bowel and mesenteric injury risk even with intact seatbelt

›Timing and symptom progression

›Time from injury to ED presentation

›Worsening vs. improving abdominal pain

›Delayed onset pain suggesting hollow viscus injury

Symptoms and pain characterization

›Abdominal pain features

›Location: RUQ (hepatic), LUQ (splenic), epigastric (pancreatic), diffuse (peritonitis)

›Radiation: left shoulder tip (Kehr sign) indicating diaphragmatic irritation or splenic injury

›Nausea and vomiting

›Associated symptoms

03Physical Exam/exam64

Vital signs and general assessment

›Hemodynamic stability assessment

›Blood pressure: SBP < 90 mmHg = hemodynamic instability threshold

›Elderly baseline SBP may be higher; relative hypotension is significant

›Serial measurements every 5 minutes in unstable patients

›Heart rate: tachycardia HR > 100 bpm as early hemorrhage marker

›Beta-blocked or elderly patients may not mount tachycardia

›Persistent tachycardia after fluid bolus = ongoing hemorrhage

›Respiratory rate >= 20 per minute as injury severity marker

›Temperature: hypothermia is a poor prognostic sign in hemorrhagic shock

›Mental status

›GCS < 14: unreliable abdominal exam, higher injury prevalence

›Confusion, agitation, or somnolence from hypovolemia or head injury

Abdominal examination

›Inspection findings

›Seatbelt sign: contusion or abrasion across abdomen

›Ecchymosis in seatbelt distribution

›High-risk for bowel and mesenteric injury

›Handlebar mark: focal ecchymosis in pediatric patients

›Distention suggesting hemorrhage or bowel obstruction

›Grey Turner sign: flank ecchymosis indicating retroperitoneal hemorrhage

›Cullen sign: periumbilical ecchymosis indicating retroperitoneal hemorrhage

›Evisceration or impalement

›Palpation findings

›Tenderness: focal vs. diffuse

›RUQ tenderness: hepatic injury

›LUQ tenderness: splenic injury

›Epigastric tenderness: pancreatic or mesenteric injury

04Differential Diagnosis/ddx63

Life-threatening injuries

›Solid organ injury

›Splenic laceration

›ICD-10 S36.0

›Most common organ requiring operative intervention

›LUQ pain, Kehr sign

›Hepatic laceration

›ICD-10 S36.1

›Most common injured abdominal organ overall

›RUQ pain, elevated transaminases

›Renal laceration

›ICD-10 S37.0

›Flank pain, hematuria

›AAST grading guides management

›Vascular injury

›Aortic injury from deceleration

›ICD-10 S35.0

›Widened mediastinum, mechanism

›Mesenteric vascular injury

›ICD-10 S35.2

›Bowel ischemia risk, delayed perforation

›Retroperitoneal hemorrhage

›ICD-10 S36.899

›Back pain, hemodynamic instability without peritoneal signs

Hollow viscus and diaphragm

›Bowel and mesenteric injury

›Small bowel injury

›ICD-10 S36.4

05Laboratory Tests/lt53

Core trauma labs

›Complete blood count

›Hemoglobin and hematocrit

›Hct < 30% predictor of injury requiring intervention

›Initial Hgb may be normal in acute hemorrhage due to hemodilution lag

›Serial Hgb every 4-6 hours to detect ongoing hemorrhage

›Platelet count

›Thrombocytopenia increases hemorrhage risk

›Target > 50 x 10^9/L in hemorrhagic shock

›Type and screen or crossmatch

›Essential for potential transfusion

›Crossmatch 6 units pRBC for anticipated major surgery

›O-negative pRBC for immediate transfusion in extremis

›MTP activation when hemorrhagic shock confirmed

›Coagulation panel

›PT/INR and aPTT

›Trauma-induced coagulopathy identification

›Anticoagulant use detection

›Fibrinogen

›Low fibrinogen < 1.5 g/L indicates consumptive coagulopathy

›Cryoprecipitate for replacement

Metabolic and organ-specific labs

›Lactate

›>= 1.94 mmol/l predicts abdominal injury

›Base deficit worse than -6 mEq/L: LR 18 for intra-abdominal injury

›Serial lactate to assess resuscitation response

›Liver function tests

›AST and ALT

06Diagnostic Tests/dt98

Scoring Systems

›AAST Organ Injury Scale (OIS)

›Grades I-V for solid organ injuries

›Grade I: minor laceration or contusion

›Grade II: laceration < 3 cm depth or subcapsular hematoma < 50% surface area

›Grade III: laceration > 3 cm depth or subcapsular hematoma > 50%

›Grade IV: devascularization > 25%, or active bleeding

›Grade V: shattered organ or hilar vascular injury

›2018 revision incorporates vascular injury findings

›Pseudoaneurysm and AV fistula classification

›Better correlation with need for operative intervention

›Clinical prediction rule for low-risk patients

›Six-variable rule (ACEP)

›Hematuria >= 25 RBC/HPF

›SBP < 90 mmHg

›Abdominal tenderness

›GCS < 14

›Costal margin tenderness

›Hct < 30%

›Absence of all 6 variables: 100% sensitivity for excluding injury requiring intervention

›NPV approaches 100% in validated cohorts

›ACEP Level B recommendation

›Bowel Injury Prediction Score (BIPS)

›Combines radiologic, biochemical, and clinical signs

›Used to guide management in equivocal cases

›CT findings, WBC, and clinical tenderness components

›PedSRC Rule for pediatric patients

›For patients < 16 years with blunt abdominal trauma

›Identifies very low-risk patients who may not require CT

›Variables include GCS, tenderness, vomiting, torso trauma

MRI

›MRI abdomen role in blunt abdominal trauma

›Indications

›Suspected spinal cord injury without radiographic abnormality (SCIWORA)

›Occult injury characterization in hemodynamically stable patients

›Pregnancy with concern for ionizing radiation

›Limitations in acute trauma

›Prolonged acquisition time

›Patient monitoring difficulty in MRI environment

›Motion artifact from patient movement

›Specific organ applications

›Pancreatic duct disruption assessment

›Hepatic biliary injury characterization

›Not first-line; reserved for problem-solving after CT

CT

›CT abdomen and pelvis with IV contrast

›Indications

›Hemodynamically stable patients with abdominal injury concern

›Screening for occult injury in high-energy mechanism

›Patients with unreliable exam (intoxication, altered mental status)

›Performance characteristics

›Sensitivity 97-98% for intra-abdominal injury

›Specificity 97-99%

›< 20% of CT scans in blunt trauma are positive

›< 3% identify injuries requiring intervention

›CT contraindication

›Hemodynamically unstable patients should not go to CT scanner

›Resuscitation bay is the appropriate location for unstable patients

›CT protocol specifics

›IV contrast mandatory for vascular injury and solid organ grading

›Delayed phase imaging helps differentiate active bleeding from contained injury

›Oral contrast not required in acute trauma

›CT findings by injury type

›Free fluid without solid organ injury: hollow viscus injury concern

›Active contrast extravasation: vascular injury requiring intervention

›Mesenteric fat stranding: bowel or mesenteric injury

›Pneumoperitoneum: hollow viscus perforation

›Repeat CT indications

›Clinical deterioration after initial negative CT

›Serial exam worsening

›New hemodynamic instability

›Equivocal initial CT with high-risk mechanism

›Repeat at 6 hours

›Hollow viscus injury concern with negative initial CT

›Delayed bowel perforation can occur 6-48 hours after injury

Ultrasound

›E-FAST (Extended Focused Assessment with Sonography in Trauma)

›Indications

›All blunt abdominal trauma patients on arrival

›First-line imaging in hemodynamically unstable patients

›Bedside assessment during primary survey

›Performance characteristics

›Detects free intraperitoneal fluid requiring approximately 400-620 mL

›Positive FAST with hemodynamic instability: immediate OR

›Negative FAST adjusted LR 0.26 (does not exclude injury)

›Operator dependent; quality varies

›Anatomical windows assessed

›Pericardial view: hemopericardium

›RUQ Morison pouch: hepatorenal space free fluid

›LUQ splenorenal view: free fluid

›Suprapubic pelvic view: pelvic free fluid

›Bilateral pleural views: hemothorax

›Bilateral anterior chest: pneumothorax (M-mode sliding sign)

›Limitations

›Obesity and bowel gas reduce quality

›Cannot characterize organ-specific injuries

›Retroperitoneal hemorrhage not well visualized

›ACEP Level B recommendation for FAST in hemodynamic assessment

›Serial FAST examinations

›Repeat in 15-30 minutes if initial negative and clinical concern persists

›New free fluid development indicates injury

›Clinical deterioration triggers repeat exam

07Disposition/dispo43

Immediate operative or interventional indications

›Direct to operating room

›Hemodynamic instability with positive E-FAST

›Emergent surgical exploration without CT

›Damage control surgery approach

›Peritoneal signs with hemodynamic instability

›Rebound tenderness and guarding with SBP < 90 mmHg

›Evisceration or impalement

›Clinical deterioration despite resuscitation

›Interventional radiology

›Hemodynamically stable patients with active contrast extravasation on CT

›AAST grade III-IV solid organ injury with contrast blush

›Angioembolization for splenic and hepatic injuries

ICU admission indications

›High-grade solid organ injury

›AAST grade III or higher laceration requiring observation

›Nonoperative management protocol

›Serial abdominal exams and hemoglobin monitoring

›Ongoing blood product requirement

›> 6 units pRBC in 24 hours

›Hemodynamic instability requiring vasopressors

›Post-operative vasopressor requirement

›Distributive shock from massive transfusion

›Respiratory failure

›Intubation from associated injuries

›ARDS from massive transfusion or lung contusion

Ward admission indications

›Low-grade solid organ injury

08Treatment/t88

Hemorrhage resuscitation

›Massive transfusion protocol

›Balanced blood product resuscitation

›pRBC:FFP:platelets 1:1:1 ratio

›Class I recommendation for hemorrhagic shock

›Transfusion targets

›Hemoglobin > 70 g/L in hemodynamically stable

›Hemoglobin > 90 g/L in active hemorrhage or cardiac disease

›Platelet count > 50 x 10^9/L

›INR < 1.5

›Fibrinogen > 1.5 g/L

›Crystalloid limitation

›Avoid excessive crystalloid (maximum 1 L in most cases)

›Dilutional coagulopathy risk with large crystalloid volumes

›Tranexamic acid

›TXA 1 g IV bolus over 10 minutes

›Administer within 3 hours of injury

›CRASH-2 trial: mortality benefit when given early

›Followed by 1 g IV over 8 hours

›Reduces fibrinolysis

›Do not administer after 3 hours (potential harm)

›Calcium supplementation

›Calcium chloride 1 g IV per 4 units pRBC transfused

›Citrate in blood products chelates ionized calcium

›Hypocalcemia impairs cardiac contractility and coagulation

Anticoagulant reversal

›Warfarin reversal

›4-factor PCC (Kcentra) 25-50 units/kg IV

›INR-based dosing

›Target INR < 1.5 for surgical intervention

›Vitamin K 10 mg IV for sustained reversal

›Takes 6-12 hours to take effect

›Dabigatran reversal

›Idarucizumab (Praxbind) 5 g IV

›Complete reversal within minutes

›Indicated for life-threatening bleeding

›Factor Xa inhibitor reversal

›Andexanet alfa for apixaban and rivaroxaban

›High-dose bolus followed by infusion for life-threatening bleeding

›4-factor PCC 25-50 units/kg as alternative when andexanet not available

Pain management

›Analgesia approach

›IV opioids for moderate to severe pain

›Morphine 0.05-0.1 mg/kg IV every 4 hours PRN

›Hydromorphone 0.01-0.02 mg/kg IV every 4 hours PRN

›Titrate to NRS pain score < 4/10

›Avoid NSAIDs acutely

›Platelet dysfunction increases hemorrhage risk

›Renal impairment risk in hypovolemia

›Ketamine for procedural pain

›0.3-0.5 mg/kg IV for painful procedures

›Dissociative dose 1-2 mg/kg IV for RSI adjunct

Operative and nonoperative management

›Nonoperative management (NOM) of solid organ injury

›Criteria for NOM

›Hemodynamic stability

›CT staging confirming grade of injury

›Absence of peritoneal signs

›No associated injury requiring laparotomy

›NOM success rates

›Splenic injury: 80-85% success rate with NOM

›Hepatic injury: 80-90% success rate with NOM

›Renal injury: > 90% success rate with NOM

›NOM failure indications

›Hemodynamic deterioration

›Increasing transfusion requirement

›Failure of angioembolization

›Damage control surgery

›Hemorrhage control as primary goal

›Packing of hepatic lacerations

›Splenectomy for uncontrollable splenic hemorrhage

›Contamination control

›Stapled resection without anastomosis for bowel injury

›Temporary abdominal closure with planned re-exploration

›ICU resuscitation between stages

›Correction of hypothermia

›Correction of acidosis

›Correction of coagulopathy (lethal triad)

Antibiotics and infection prophylaxis

›Operative intervention antibiotic prophylaxis

›Cefazolin 2 g IV (3 g if > 120 kg) 30-60 minutes pre-incision

›Repeat every 4 hours for prolonged cases

›Metronidazole 500 mg IV if bowel contamination

›Add for hollow viscus perforation

›Hollow viscus perforation empiric coverage

›Piperacillin-tazobactam 3.375 g IV every 6 hours

›Covers gram-negative aerobes and anaerobes

›Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours as alternative

›Post-splenectomy prophylaxis planning

›Vaccination for encapsulated organisms post-splenectomy

›Pneumococcal vaccine

›Meningococcal vaccine

›Haemophilus influenzae type b vaccine

09Special Populations/sp93

Pregnancy

›Pregnancy-specific considerations

›Anatomic changes affecting injury patterns

›Enlarged uterus displaces bowel superiorly (third trimester)

›Uterus and placenta become more susceptible to direct trauma

›Pelvic congestion increases retroperitoneal bleeding risk

›Physiologic changes affecting assessment

›Baseline HR 10-15 bpm higher than non-pregnant

›Baseline SBP 5-10 mmHg lower (relative hypotension threshold)

›Supine hypotension from aortocaval compression after 20 weeks

›Physiologic anemia (Hgb 100-110 g/L normal)

›Specific injury concerns

›Placental abruption

›Most common cause of fetal death in blunt trauma

›Abdominal pain, vaginal bleeding, uterine tenderness

›Kleihauer-Betke test to detect fetal-maternal hemorrhage

›Uterine rupture

›Rare but life-threatening

›Hemodynamic instability with peritoneal signs

›Premature labor

›Uterine irritability from trauma

›Obstetric consultation for fetal monitoring

›Management modifications

›Left lateral decubitus positioning after 20 weeks

›Relieves aortocaval compression

›Improves maternal cardiac output

›Fetal monitoring for minimum 4-6 hours after significant trauma

›Continuous CTG monitoring

›If contractions or fetal distress, extend monitoring to 24 hours

›CT imaging when clinically indicated

›Benefits of diagnosis outweigh fetal radiation risk

›Discuss risks with patient

›RhD-negative patients

›Anti-D immunoglobulin 300 mcg IM within 72 hours

›Kleihauer-Betke test guides additional dosing

Geriatric

›Physiologic differences affecting assessment

›Blunted tachycardic response to hemorrhage

›Beta-blocker use common

›Age-related autonomic blunting

›Rely more on lactate and base deficit than HR

›Baseline hypertension common

›Normal BP may represent relative hypotension

›Premorbid BP from chart or family crucial

›Reduced physiologic reserve

›Less tolerance of hemorrhage

›Early ICU admission for significant injuries

›Anticoagulant considerations

›High prevalence of anticoagulant and antiplatelet use

›Review medication list urgently

›Lower threshold for reversal in hemorrhagic injury

›Warfarin reversal with 4-factor PCC more frequently required

›Injury patterns in elderly

›Ground-level falls as high-energy-equivalent mechanism

›Higher injury rate than in younger patients

›Rib fractures increase mortality risk (each additional rib fracture adds 19% mortality risk)

›Lower rib fractures with solid organ injury common

›Imaging and disposition

›Lower CT threshold due to unreliable exam

›Baseline cognitive impairment limits exam reliability

›Lower threshold for ICU admission

›Rapid decompensation risk

›Early surgical consultation

Pediatrics

›Anatomic and physiologic differences

›Proportionally larger solid organs (liver and spleen)

›Less protected by ribcage

›Higher rate of solid organ injury in blunt trauma

›Less musculature for abdominal protection

›Highly compliant chest wall transfers more energy to abdominal organs

›Compensatory mechanisms maintain BP longer before collapse

›HR elevation may be the only early sign

›SBP < 70 + (2 x age in years) mmHg = hypotension threshold

›Nonoperative management preference

›Higher NOM success rates than adults

›Splenic and hepatic NOM success > 90% in pediatric patients

›Observation with serial abdominal exams

›ATOMAC guidelines for pediatric solid organ injury NOM

›Grade-based activity restriction and monitoring protocols

›Weight-based dosing

›TXA 15-30 mg/kg IV bolus (maximum 1 g)

›Followed by 2 mg/kg/hour (maximum 1 g) for 8 hours

›Morphine 0.05-0.1 mg/kg IV PRN

›Cefazolin 25 mg/kg IV (maximum 2 g) for surgical prophylaxis

›Non-accidental trauma (NAT) awareness

›Inconsistent history with injury pattern

›Bruising in non-ambulatory or pre-mobile infant

›Posterior rib fractures

›Solid organ injury without adequate mechanism

›Mandatory reporting obligations

›Social work and child protective services involvement

›CT use in pediatrics

›PECARN and PedSRC rules to reduce CT utilization

›Radiation risk is proportionally greater in children

›FAST and clinical observation preferred when possible

›CT when clinical risk exceeds radiation risk

10Background/b79

Epidemiology

›Prevalence and burden

›Blunt abdominal trauma accounts for approximately 80% of all abdominal trauma cases

›Penetrating trauma accounts for remaining 20%

›Prevalence of intra-abdominal injury in ED patients with BAT approximately 13%

›Approximately 4.7% require therapeutic surgery or angioembolization

›Leading cause of preventable morbidity and mortality in trauma

›Mortality and time-sensitivity

›Mortality increases by 1% for every 3 minutes spent in the ED

›Emphasizes importance of rapid assessment and intervention

›Delayed diagnosis of occult injuries is a major cause of preventable death

›Solid organ injury mortality rates by organ

›Isolated splenic injury: 1-5% overall mortality

›Complex hepatic injury: up to 10-15% mortality

›Combined vascular injury: 50-80% mortality

›Demographics

›Motor vehicle collisions account for majority of cases

›Young males disproportionately affected

›Elderly: ground-level falls increasingly recognized as significant mechanism

›Pediatric: highest solid organ injury rate relative to mechanism energy

Pathophysiology

›Mechanisms of injury

›Direct compression

›Solid organs compressed against vertebral column

›Splenic rupture from LUQ direct blow

›Hepatic laceration from RUQ compression

›Deceleration forces

›Tearing at fixed attachment points

›Hepatic vein and IVC junction lacerations

›Mesenteric root tears and bowel avulsion

›Seatbelt injuries

›Compression of bowel and mesentery between seatbelt and vertebral column

›Hollow viscus perforation

›Lumbar chance fracture association (flexion-distraction)

›Hemorrhage physiology

›Lethal triad of trauma

›Hypothermia below 35 C impairs coagulation

›Acidosis pH < 7.2 impairs coagulation factor function

›Coagulopathy from dilution and consumption

›Trauma-induced coagulopathy

›Present in 25-35% of patients on ED arrival

›Associated with 3-4 fold increase in mortality

›Damage control resuscitation

›Minimize crystalloid to prevent dilutional coagulopathy

›Early balanced blood product resuscitation

›Hollow viscus injury mechanisms

›Burst injury from sudden increase in intraluminal pressure

›Shear injury at fixed points of bowel attachment

›Ischemia from mesenteric vascular injury

Therapeutic Considerations

›Nonoperative management evidence base

›NOM success requires patient selection

›Hemodynamic stability is mandatory criterion

›High-grade injuries (AAST IV-V) have higher NOM failure rates

›Angioembolization expands NOM candidacy

›Active contrast extravasation on CT can be managed without surgery

›Success rate 85-95% for hepatic and splenic embolization

›Serial CT for NOM monitoring

›Delayed pseudoaneurysm formation occurs in 5-10% of grade III-IV injuries

›Follow-up imaging at 48-72 hours for high-grade injuries

›Damage control surgery principles

›Life over limb principle

›Definitive repair deferred until physiology corrected

›Temporary abdominal closure reduces abdominal compartment syndrome

›Abdominal compartment syndrome

›Intra-abdominal pressure > 20 mmHg with new organ dysfunction

›Bladder pressure monitoring for at-risk patients

›Decompressive laparotomy when indicated

›Splenic conservation controversy

›Splenectomy vs. splenorrhaphy vs. embolization

›Overwhelming post-splenectomy infection (OPSI) risk with splenectomy

›OPSI mortality 50-70% despite treatment

›Splenic conservation preferred when physiologically feasible

›Vaccination after splenectomy critical

›Timing: ideally 2 weeks post-operative for elective; as soon as possible for emergency

›Balanced resuscitation evidence

›PROPPR trial: 1:1:1 vs. 1:1:2 pRBC:FFP:platelets

›1:1:1 ratio reduced 24-hour mortality

›Improved hemostasis and survival to discharge

›CRASH-2 trial: TXA within 3 hours reduced mortality by 1.5%

›TXA after 3 hours associated with increased mortality

›All-cause mortality reduction most significant in first hour

11Patient Discharge Instructions/pdi33

copy discharge instructions

›Blunt abdominal trauma home care

›Rest for the first 3-5 days

›Avoid strenuous activity, lifting, and exercise

›Gradual return to activity as pain improves

›Pain management at home

›Acetaminophen (Tylenol) 500-1000 mg every 6-8 hours as needed

›Avoid ibuprofen, naproxen, and other anti-inflammatories for 1-2 weeks

›If prescribed opioids, take with food and avoid alcohol

›Diet and hydration

›Regular diet as tolerated

›Stay well hydrated

›Seek care if unable to keep food or fluids down

›Activity restrictions after solid organ injury

›No contact sports or heavy lifting for 6-8 weeks if solid organ injury confirmed

›Your doctor will confirm when safe to return to activity

›Return earlier if symptoms worsen

›No driving while on opioid pain medications

›Warning signs requiring immediate return to emergency department

›Sudden worsening of abdominal pain or new severe pain

›Abdomen becoming rigid or board-like

›Vomiting blood or blood in stools (black or red)

›Dizziness, lightheadedness, or fainting

›Rapid heart rate or feeling the heart pounding

›Fever above 38.5 C

›Increasing bruising or swelling of the abdomen

›Inability to urinate or blood in urine not previously noted

›Any concern about worsening condition

12References/r31

Guidelines and key sources

›Trauma society guidelines

›Eastern Association for the Surgery of Trauma (EAST) guidelines for solid organ injury NOM

›Practice management guidelines for splenic injury 2012 update

›Hepatic injury management guidelines

›Western Trauma Association (WTA) guidelines for hemorrhage control

›Damage control resuscitation recommendations

›American College of Surgeons (ACS) ATLS program

›Primary and secondary survey standards

›Massive transfusion protocol framework

›Key trials and evidence

›CRASH-2 trial (Lancet 2010): TXA within 3 hours reduces mortality in hemorrhagic shock

›1 g IV bolus followed by 1 g over 8 hours

›All-cause mortality reduction from 16.0% to 14.5%

›PROPPR trial (JAMA 2015): 1:1:1 blood product ratio reduces 24-hour mortality

›Hemostasis achieved in 86% vs. 78% with 1:1:2 ratio

›AAST 2018 OIS revision for solid organ injuries

›Vascular injury findings incorporated into grading

›FAST utility meta-analysis: sensitivity 78%, specificity 99% for free fluid

›Adjusted negative LR 0.26 for intra-abdominal injury

›Diagnostic and clinical decision tools

›ACEP six-variable clinical prediction rule for BAT

›100% sensitivity for excluding injury requiring intervention

›ACEP Level B recommendation

›PedSRC rule for pediatric patients with BAT

›Bowel Injury Prediction Score (BIPS)

›Coding references

›ICD-10 S36.0 splenic injury

Evidence & Review