1. APPROACH TO TRAUMAAPPROACH TO TRAUMA
Initial Assessment and ManagementInitial Assessment and Management
DR AMER BHUTTA
K E M U
LAHORE

2. ObjectivesObjectives
 Demonstrate concepts ofDemonstrate concepts of
primary and secondary patientprimary and secondary patient
assessmentassessment
 Establish managementEstablish management
priorities in trauma situationspriorities in trauma situations
 Initiate primary and secondaryInitiate primary and secondary
management as necessarymanagement as necessary
 Arrange appropriateArrange appropriate
dispositiondisposition

3. TraumaTrauma
 180,000 people die each year180,000 people die each year (USA)(USA)
 580,000people each yearworld580,000people each yearworld
 1 person every 3 minutes.USA1 person every 3 minutes.USA
 9 person every minutes..9 person every minutes..
 leading cause of death ages 1–44.leading cause of death ages 1–44.
 Injury is a majoreconomic burden to societies
 cost more than $406-500 billion annuallycost more than $406-500 billion annually

4. Motorvehicle accidents responsible for80% ofMotorvehicle accidents responsible for80% of
(blunt) trauma &50% deaths.(blunt) trauma &50% deaths.
ROAD TRAFFIC INJURIES
An estimated 3,500 people are killed each day, including 1,000
children, around the world in road traffic crashes involving cars,
buses, motorcycles, bicycles, trucks, or pedestrians.
Annually, 1.3 million are killed and at least 50 million are injured
each year from traffic injuries—a number likely to double by 2020.

5. Deathsfollowing TraumaDeathsfollowing Trauma
 Trimodal distributionTrimodal distribution
minutes
hour
golden days
weeks
lethal
injuries
Apnea, sever brain injury,
high spinal cord , rupture
heart, major vessel, aorta,
life threatening
injuries
complications
(sepsis, MOF)

6. Concepts of trauma managementConcepts of trauma management
 Treat thegreatest threat to lifefirstTreat thegreatest threat to lifefirst
 Thelack of adefinitivediagnosisshouldThelack of adefinitivediagnosisshould
never impedetheapplication of annever impedetheapplication of an
indicated treatmentindicated treatment
 A detailed history isnot essential to
begin theevaluation
 “ABCDE” approach

7. Pre-hospital triage
Triage is the process of grouping injury
victims according to risk of death or other
adverse outcome.
Pre hospital care providers can be trained
to carry out this process according to a
predetermined checklist of criteria or a
system of injury severity scoring.

8. Pre-hospital triage
 This triage of trauma patients usually depends on
three simple groups of factors:
 Physiology: the vital signs (e.g. pulse >120/min,
systolic blood pressure <90 mmHg, Glasgow
Coma Scale score [GCS] <15)
 Anatomy: the immediately evident injuries (e.g.
fractured long bones, spinal cord injury,
penetrating injury)
 Mechanism of injury: e.g. fall >5 m, injury to
two or more body regions, vehicle crash with
ejection

9. Primary SurveyPrimary Survey
Patientsareassessed andPatientsareassessed and
treatment prioritiestreatment priorities
established based on theirestablished based on their
injuries, vital signs, andinjuries, vital signs, and
injury mechanismsinjury mechanisms

10. Initial Assessment and ManagementInitial Assessment and Management
 ABCDEs of trauma careABCDEs of trauma care
–AA Airway and c-spine protectionAirway and c-spine protection
–BB Breathing and ventilationBreathing and ventilation
–CC Circulation with hemorrhageCirculation with hemorrhage
controlcontrol
–DD Disability/Neurologic statusDisability/Neurologic status
–EE Exposure/Environmental controlExposure/Environmental control

11. AirwayAirway
How do we evaluate the airway?How do we evaluate the airway?
Airway compromise is likelyAirway compromise is likely
Maxillofacial traumaMaxillofacial trauma
Neck traumaNeck trauma
Laryngeal traumaLaryngeal trauma
Airway obstructionAirway obstruction

12. A- AirwayA- Airway
Airway should be assessed forAirway should be assessed for
patencypatency
– Is the patient able to communicate verbally?Is the patient able to communicate verbally?
– AgitationAgitation
– Inspect for any foreign bodiesInspect for any foreign bodies
– Examine for stridor, hoarseness, gurgling,Examine for stridor, hoarseness, gurgling,
pooledpooled secrecretion or bloodsecrecretion or blood
–Pulse oximetryPulse oximetry

13.  Assume c-spine injury in patients withAssume c-spine injury in patients with
blunt multisystem traumablunt multisystem trauma
– C-spine clearance is both clinical andC-spine clearance is both clinical and
radiographicradiographic
– C-collar should remain in place until patientC-collar should remain in place until patient
can cooperate with clinical exacan cooperate with clinical examm
– Patient, head and neck should not bePatient, head and neck should not be
– Hyperextended, hyper flexed or rotated;;;;;Hyperextended, hyper flexed or rotated;;;;;

14. Airway InterventionsAirway Interventions
Supplemental oxygenSupplemental oxygen
SuctionSuction
 Chin lift/jaw thrustChin lift/jaw thrust
 Oral/nasal airwaysOral/nasal airways
 Definitive airwaysDefinitive airways
– RSI for agitated patients with c-spine immobilizationRSI for agitated patients with c-spine immobilization
– ETI for comatose patients (GCS<8)ETI for comatose patients (GCS<8)

15. Chin lift/jaw thrustChin lift/jaw thrust

16. Oral/nasal airwaysOral/nasal airways

17. Definitive airwaysDefinitive airways

18. Cricothyroidotomy

19. TracheotomyTracheotomy

20. MAXILLOFACIAL TRAUMAMAXILLOFACIAL TRAUMA
 +DEMAND AGGRESSIVE AND+DEMAND AGGRESSIVE AND
CAREFUL AIRWAY MANAGEMENT.CAREFUL AIRWAY MANAGEMENT.
 TRAUMA TO MID FACE;;;TRAUMA TO MID FACE;;;
 FACIAL FRACTURE;FACIAL FRACTURE;
 HAEMORRHAGE, SECRECTIONS,HAEMORRHAGE, SECRECTIONS,
DISLODGED TEETH.DISLODGED TEETH.
 FRACTURE MANDIBLEFRACTURE MANDIBLE

21. Cervical Spine ProtectionCervical Spine Protection
  High index of suspicion depending on theHigh index of suspicion depending on the
history of the accident: (traffic accidents, falls,history of the accident: (traffic accidents, falls,
certain sports).certain sports).
  Avoid rough manipulation of the head andAvoid rough manipulation of the head and
neck. Use hard collars to immobilize the neck.neck. Use hard collars to immobilize the neck.
Immobilize the whole body on a long spinalImmobilize the whole body on a long spinal
board.board.

22. BreathingBreathing
 What can we look for clinically to assess aWhat can we look for clinically to assess a
patient’s ‘breathing’ status?patient’s ‘breathing’ status?

23. B- BreathingB- Breathing
 Airway patency alone does not ensure adequateAirway patency alone does not ensure adequate
ventilationventilation
 Inspect, palpate, and auscultateInspect, palpate, and auscultate
– Deviated trachea, crepitus, flail chest,Deviated trachea, crepitus, flail chest,
sucking chest wound, absence of breathsucking chest wound, absence of breath
soundssounds
 CXR to evaluate lung fieldsCXR to evaluate lung fields

24. Chest TraumaChest Trauma
The Primary Killers Of Acute TraumaThe Primary Killers Of Acute Trauma
PatientsPatients
1.1.HypoxiaHypoxia
2.2.hypoventilationhypoventilation

25. •• Immediate Life-threatening InjuriesImmediate Life-threatening Injuries
Airway obstructionAirway obstruction
1.1. Tension PneumothoraxTension Pneumothorax
2.2. Open PneumothoraxOpen Pneumothorax
3.3. Massive HaemothoraxMassive Haemothorax
4.4. Flail ChestFlail Chest
5.5. Cardiac TamponadeCardiac Tamponade

26. What would we do for this patient who is havingWhat would we do for this patient who is having
difficulty breathing?difficulty breathing?
X.RAYX.RAY

28. HemothoraxHemothorax
 COLLECTION OF BLOOD IN THECOLLECTION OF BLOOD IN THE
PLEURAL SPACEPLEURAL SPACE
 CAUSED BY BLUNT ORCAUSED BY BLUNT OR
PENETRATING TRAUMA.PENETRATING TRAUMA.
 MOST HAEMOTHORACES AREMOST HAEMOTHORACES ARE
THE RESULT OFTHE RESULT OF
 RIB FRACTURES,RIB FRACTURES,
 LUNG PARENCHYMAL ANDLUNG PARENCHYMAL AND
MINOR VENOUS INJURIES, ANDMINOR VENOUS INJURIES, AND
AS SUCH ARE SELF-LIMITINGAS SUCH ARE SELF-LIMITING..

29. Subcutaneous EmphysemaSubcutaneous Emphysema

30. Flail SegmentFlail Segment
•• 2 or more consecutive ribs broken in 2 or2 or more consecutive ribs broken in 2 or
more placesmore places
•• Paradoxical movement of the flail segmentParadoxical movement of the flail segment
interferes with thoracic volume and createsinterferes with thoracic volume and creates
pain/crepitus, forcing the pt to minimizepain/crepitus, forcing the pt to minimize
volumevolume
•• Stabilize segment and assist ventilations ifStabilize segment and assist ventilations if
neededneeded

31. Flail ChestFlail Chest

32. Chest Tube for GSWChest Tube for GSW

33. Breathing InterventionsBreathing Interventions
 Ventilatewith 100% oxygenVentilatewith 100% oxygen
 Needle decompression if tensionNeedle decompression if tension
pneumothorax suspectedpneumothorax suspected
 Chest tubes forpneumothorax /Chest tubes forpneumothorax /
hemothoraxhemothorax
 Occlusive dressing to sucking chestOcclusive dressing to sucking chest
woundwound
 If intubated, evaluateETT positionIf intubated, evaluateETT position

34. C- CirculationC- Circulation
 Hemorrhagic shock should beassumed in anyHemorrhagic shock should beassumed in any
hypotensivetraumapatienthypotensivetraumapatient
 Rapid assessment of hemodynamic statusRapid assessment of hemodynamic status
– Level of consciousnessLevel of consciousness
– Skin colorSkin color
– Pulsesin four extremitiesPulsesin four extremities
– Blood pressureand pulsepressureBlood pressureand pulsepressure

35. Hemorrhage -four classesHemorrhage -four classes
 Class IClass I
 Hemorrhage involves up to 15% ofHemorrhage involves up to 15% of
blood volume.blood volume.
 There is typically no change in vitalThere is typically no change in vital
signs and fluid resuscitation is notsigns and fluid resuscitation is not
usually necessary.usually necessary.

36.  Class IIClass II
 Hemorrhage involves 15-30% of total blood volume.Hemorrhage involves 15-30% of total blood volume.
 A patient is often tachycardic (rapid heart beat) withA patient is often tachycardic (rapid heart beat) with
a narrowing of the difference between the systolica narrowing of the difference between the systolic
and diastolic blood pressures.and diastolic blood pressures.
 The body attempts to compensate with peripheralThe body attempts to compensate with peripheral
vasoconstriction. Skin may start to look pale and bevasoconstriction. Skin may start to look pale and be
cool to the touch. The patient may exhibit slightcool to the touch. The patient may exhibit slight
changes in behavior.changes in behavior.
 Volume resuscitation with crystalloids (SalineVolume resuscitation with crystalloids (Saline
solution or Lactated Ringer's solution) is all that issolution or Lactated Ringer's solution) is all that is
typically required.typically required.
 Blood transfusion is not typically required.Blood transfusion is not typically required.

37. Hemorrhage -four classesHemorrhage -four classes
 Class IIIClass III
 HemorrhageHemorrhage
involves loss of 30-40% of circulating bloodinvolves loss of 30-40% of circulating blood
volume.volume.
blood pressure drops, the heart rate increases,blood pressure drops, the heart rate increases,
peripheral perfusion (shock), such as capillary refillperipheral perfusion (shock), such as capillary refill
worsens, and the mental status worsens.worsens, and the mental status worsens.
Fluid resuscitation with crystalloid and bloodFluid resuscitation with crystalloid and blood
transfusion are usually necessary.transfusion are usually necessary.
 Class IVClass IV
 Hemorrhage involves loss of >40% of circulatingHemorrhage involves loss of >40% of circulating
blood volume. The limit of the body's compensation isblood volume. The limit of the body's compensation is
reached and aggressive resuscitation is required toreached and aggressive resuscitation is required to
prevent death.prevent death.

38. Circulation InterventionsCirculation Interventions
 Cardiac monitorCardiac monitor
 Apply pressure to sites of external hemorrhageApply pressure to sites of external hemorrhage
 Establish IV accessEstablish IV access
– 2 large bore IVs2 large bore IVs
– Central lines if indicatedCentral lines if indicated
 Cardiac tamponade decompression if indicatedCardiac tamponade decompression if indicated
 Volume resuscitationVolume resuscitation
– Have blood ready if neededHave blood ready if needed
– Level One infusers availableLevel One infusers available
– Foley catheterto monitorresuscitationFoley catheterto monitorresuscitation

39. Hemorrhagic shockHemorrhagic shock
 RAPID HEMOSTASISRAPID HEMOSTASIS
 BALANCED RESUSCITATIONBALANCED RESUSCITATION
 CRYSTALLOIDSCRYSTALLOIDS
 BLOODBLOOD
 EARLY IDENTIFICATION ANDEARLY IDENTIFICATION AND
CONTROL OF A SOURCE OFCONTROL OF A SOURCE OF
HEMORRAHAGE IS ESSENTIALHEMORRAHAGE IS ESSENTIAL

40. D- DisabilityD- Disability
 Abbreviated neurological examAbbreviated neurological exam
– Level of consciousnessLevel of consciousness
– Pupil size and reactivityPupil size and reactivity
– Motor functionMotor function
– GCSGCS
» Utilized to determine severity of injuryUtilized to determine severity of injury
» Guide for urgency of head CT and ICPGuide for urgency of head CT and ICP
monitoringmonitoring

41. GCSGCS
EYEEYE VERBALVERBAL MOTORMOTOR
Spontaneous 4Spontaneous 4 Oriented 5Oriented 5 Obeys 6Obeys 6
Verbal 3Verbal 3 Confused 4Confused 4 Localizes 5Localizes 5
Pain 2Pain 2 Words 3Words 3 Flexion 4Flexion 4
None 1None 1 Sounds 2Sounds 2 Decorticate 3Decorticate 3
None 1None 1 Decerebrate 2Decerebrate 2
None 1None 1

42. Disability InterventionsDisability Interventions
 Spinal cord injurySpinal cord injury
– High dose steroids if within 8 hoursHigh dose steroids if within 8 hours
 ICP monitor- Neurosurgical consultationICP monitor- Neurosurgical consultation
 Elevated ICPElevated ICP
– Head of bed elevatedHead of bed elevated
– MannitolMannitol
– HyperventilationHyperventilation
– Emergent decompressionEmergent decompression

43. E- ExposureE- Exposure
 Complete disrobing of patientComplete disrobing of patient
 Logroll to inspect backLogroll to inspect back
 Rectal temperatureRectal temperature
 Warm blankets/external warming device toWarm blankets/external warming device to
prevent hypothermiaprevent hypothermia

44. Always Inspect the BackAlways Inspect the Back

45. Secondary SurveySecondary Survey
 AMPLE historyAMPLE history
– Allergies, medications, PMH, last meal, eventsAllergies, medications, PMH, last meal, events
 Physical exam from head to toe, includingPhysical exam from head to toe, including
rectal examrectal exam
 Frequent reassessment of vitalsFrequent reassessment of vitals
 Diagnostic studies at this timeDiagnostic studies at this time
simultaneouslysimultaneously
– X-rays, lab work, CT orders if indicatedX-rays, lab work, CT orders if indicated
– FAST examFAST exam

46. Seatbelt SignSeatbelt Sign

47. Diagnostic AidsDiagnostic Aids
 Standard trauma labsStandard trauma labs
– CBC, K, Cr, PTT, Utox, EtOH, ABGCBC, K, Cr, PTT, Utox, EtOH, ABG
 Standard trauma radiographsStandard trauma radiographs
– CXR, pelvis, lateral C-spine (traditionalCXR, pelvis, lateral C-spine (traditionally)ly)
 CT/FAST scansCT/FAST scans
 Pt must be monitored in radiologyPt must be monitored in radiology
 Pt should only go to radiology if stablePt should only go to radiology if stable

48. Simple PneumothoraxSimple Pneumothorax

49. Tension PneumothoraxTension Pneumothorax
How do you treat this?How do you treat this?

50. HemothoraxHemothorax
Is this patient lying or upright?Is this patient lying or upright?

51. Widened MediastinumWidened Mediastinum
What disease process does this indicate?What disease process does this indicate?

52. Bilateral Pubic Ramus Fractures andBilateral Pubic Ramus Fractures and
Sacroiliac Joint DisruptionSacroiliac Joint Disruption
What should this injury make you worry about?What should this injury make you worry about?

53. Epidural HematomaEpidural Hematoma

54. Subdural Hematoma with SAHSubdural Hematoma with SAH

55. FAST ExamFAST Exam
 Focused Abdominal Scanning in TraumaFocused Abdominal Scanning in Trauma
 4 views: Cardiac, RUQ, LUQ, suprapubic4 views: Cardiac, RUQ, LUQ, suprapubic
 Goal: evaluate for free fluidGoal: evaluate for free fluid
See normal
Liver and kidney
Free fluid in Morrison's
Pouch between liver and
kidney

56. The Nature Of Maxillofacial TraumaThe Nature Of Maxillofacial Trauma
There are a number of possible causes of facial traumaThere are a number of possible causes of facial trauma
such as motor vehicle accidents, dog bites, accidentalsuch as motor vehicle accidents, dog bites, accidental
falls, sports injuries, interpersonal violence, and work-falls, sports injuries, interpersonal violence, and work-
related injuries.related injuries.
Types of facial injuries can range from injuries ofTypes of facial injuries can range from injuries of
teeth to extremely severe injuries of the skin and bonesteeth to extremely severe injuries of the skin and bones
of the face.of the face.
Typically, facial injuries are classified as either softTypically, facial injuries are classified as either soft
tissue injuries (skin and gums), bone injuriestissue injuries (skin and gums), bone injuries
(fractures), or injuries to special regions (such as the(fractures), or injuries to special regions (such as the
eyes, facial nerves or the salivary glands).eyes, facial nerves or the salivary glands).

57. MAXILLOFACIAL TRAUMAMAXILLOFACIAL TRAUMA

58. MAXILLOFACIAL TRAUMAMAXILLOFACIAL TRAUMA
 Facial injuries have the potential to cause facial disfigurement andFacial injuries have the potential to cause facial disfigurement and
loss of function; for example, blindness or difficulty moving the jawloss of function; for example, blindness or difficulty moving the jaw
can result.can result.
 Although it is seldom life-threatening, facialAlthough it is seldom life-threatening, facial
trauma has the potential to be fatal as it can causetrauma has the potential to be fatal as it can cause
severe bleeding or interference with the airway;severe bleeding or interference with the airway;
thus a primary concern in treatment is ensuring thatthus a primary concern in treatment is ensuring that
the airway is kept open and not threatened so thatthe airway is kept open and not threatened so that
the patient can breathe.the patient can breathe.

59. SummarySummary
 Trauma is best managed by a teamTrauma is best managed by a team
approach (there’s no “I” in trauma)approach (there’s no “I” in trauma)
 A thorough primary and secondary surveyA thorough primary and secondary survey
is key to identify life threatening injuriesis key to identify life threatening injuries
 Once a life threatening injury is discovered,Once a life threatening injury is discovered,
intervention should not be delayedintervention should not be delayed
 Disposition is determined by the patient’sDisposition is determined by the patient’s
condition as well as available resources.condition as well as available resources.

60. THANKSTHANKS

64. Abdominal TraumaAbdominal Trauma
 Common source of traumatic injuryCommon source of traumatic injury
 Mechanism is importantMechanism is important
– Bike accident over the handlebarsBike accident over the handlebars
– MVC with steering wheel traumaMVC with steering wheel trauma
 High suspicion with tachycardia,High suspicion with tachycardia,
hypotension, and abdominal tendernesshypotension, and abdominal tenderness
 Can be asymptomatic early onCan be asymptomatic early on
 FAST exam can be early screening toolFAST exam can be early screening tool
Hemorrhagic shock V

68. Abdominal TraumaAbdominal Trauma
 Look for distension, tenderness, seatbeltLook for distension, tenderness, seatbelt
marks, penetrating trauma, retroperitonealmarks, penetrating trauma, retroperitoneal
ecchymosisecchymosis
 Be suspicious of free fluid without evidence ofBe suspicious of free fluid without evidence of
solid organ injurysolid organ injury

69. Splenic InjurySplenic Injury
 Most commonly injured organ in blunt traumaMost commonly injured organ in blunt trauma
 Often associated with other injuriesOften associated with other injuries
 Left lower rib pain may be indicativeLeft lower rib pain may be indicative
 Often can be managed non-operativelyOften can be managed non-operatively
Spleen with
surrounding
blood
Blood from
spleen
Tracking around
liver

70. Liver injuryLiver injury
 Second most common solid organ injurySecond most common solid organ injury
 Can bedifficult to managesurgicallyCan bedifficult to managesurgically
 Often associated with other abdominal injuriesOften associated with other abdominal injuries
Liver contusions

71. What’s wrong with this picture?What’s wrong with this picture?
 May only see the nasogastric tube appear to be coiledMay only see the nasogastric tube appear to be coiled
in the lung.in the lung.
 Left > right due to liver protection of the diaphragm.Left > right due to liver protection of the diaphragm.
Trace the Diaphragm
Outline. Where is the
Diaphragm on the left?
Abdominal contents
Up in the chest on the
left

72. Hollow Viscous InjuryHollow Viscous Injury
 Injury can involve stomach, bowel, orInjury can involve stomach, bowel, or
mesenterymesentery
 Symptoms are a result from a combination ofSymptoms are a result from a combination of
blood loss and peritoneal contaminationblood loss and peritoneal contamination
 Small bowel and colon injuries result mostSmall bowel and colon injuries result most
often from penetrating traumaoften from penetrating trauma
 Deceleration injuries can result in bucket-Deceleration injuries can result in bucket-
handle tears of mesenteryhandle tears of mesentery
 Free fluid without solid organ injury is aFree fluid without solid organ injury is a
hollow viscus injury until proven otherwisehollow viscus injury until proven otherwise

73. Mesenteric and bowel injury from blunt abdominal
trauma. Notice the bowel and mesenteric disruption.
bowel
mesentery

74. CT Scan in TraumaCT Scan in Trauma
 Abdominal CT scan visualizes solid organsAbdominal CT scan visualizes solid organs
and vessels welland vessels well
 CT does NOT see hollow viscus,CT does NOT see hollow viscus,
duodenum, diaphram, or omentum wellduodenum, diaphram, or omentum well
 Some recent surgery literature advocatesSome recent surgery literature advocates
whole body scans on all traumawhole body scans on all trauma
– Keep in mind that there is an increase inKeep in mind that there is an increase in
mortality related to cancer from CT scansmortality related to cancer from CT scans

75.  momormomor
Morrison’s pouch

76. Non-accidental TraumaNon-accidental Trauma
 Key is SUSPICION!!!Key is SUSPICION!!!
 Incongruent stories of mechanismIncongruent stories of mechanism
 Delay in seeking treatmentDelay in seeking treatment
 Multiple stages of injuriesMultiple stages of injuries
 Pattern InjuriesPattern Injuries
 Multiple hospital visitsMultiple hospital visits
 Injury mechanism beyond the scope of the age ofInjury mechanism beyond the scope of the age of
child (6week old rolled over off the bed)child (6week old rolled over off the bed)
 Bite marks, submersion injury, cigarette burnsBite marks, submersion injury, cigarette burns

77. Disposition of Trauma PatientsDisposition of Trauma Patients
 Dictated by the patient’s condition and availableDictated by the patient’s condition and available
resources i.e. trauma team availableresources i.e. trauma team available
– OR, admit, or transferOR, admit, or transfer
 Transfers should be coordinated effortsTransfers should be coordinated efforts
– Stabilization begun prior to transferStabilization begun prior to transfer
– Decompensation should be anticipatedDecompensation should be anticipated
 Serial examinationsSerial examinations
– CHI with regain of consciousnessCHI with regain of consciousness
– Abdominal exams for documented blunt traumaAbdominal exams for documented blunt trauma
– Pulmonary contusions with blunt chest traumaPulmonary contusions with blunt chest trauma

78. SourcesSources
 ATLS Student Course Manuel, 6ATLS Student Course Manuel, 6thth
edition.edition.
 Rosen’s Emergency Medicine Concepts andRosen’s Emergency Medicine Concepts and
Clinical Practice, 5Clinical Practice, 5thth
edition.edition.
 Emergency Medicine A ComprehensiveEmergency Medicine A Comprehensive
Study Guide, 5Study Guide, 5thth
edition.edition.