Advanced Trauma Life Support ATLS Student Course Manual 2018

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RIGHT INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY (ISNCSCI) Patient Name_____________________________________ Date/Time of Exam _____________________________ Examiner Name ___________________________________ Signature _____________________________________ C7 C7 DorsumC6 C8 DorsumC6 C8 C7 C7 DorsumC6 C8 DorsumC6 C8 C7 C7 DorsumC6 C8 DorsumC6 C8 LEFT MOTOR SENSORY SENSORY MOTOR KEY SENSORY POINTS KEY MUSCLES KEY SENSORY POINTS KEY MUSCLES Light Touch (LTR) Pin Prick (PPR) Light Touch (LTL) Pin Prick (PPL) INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name_____________________________________ Date/Time of Exam _____________________________ C2 C2 CLASSIFICATION OF SPINAL CORD INJURY C3 Examiner Name ___________________________________ C3 Signature _____________________________________ (ISNCSCI) C4 C2 C4 MOTOR SENSORY C3 Elbow flexors C5 SENSORY C5 Elbow flexors MOTOR KEY SENSORY POINTS RIGHT KEY MUSCLES KEY SENSORY POINTS UER Wrist extensors C4 C6 Light Touch (LTR) C6 Wrist extensors KEY MUSCLES UEL LEFT Pin Prick (PPR) Light Touch (LTL) Pin Prick (PPL) (Upper Extremity Right) INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name_____________________________________ Date/Time of Exam _____________________________ T2 Elbow extensors C7 T3 C2 C7 Elbow extensors (Upper Extremity Left) CLASSIFICATION OF SPINAL C2 CORD INJURY T4 C5 Finger flexors C8 Examiner Name ___________________________________ C2 0 = absent C8 Finger flexors Signature _____________________________________ (ISNCSCI) C3 T5 C3 Finger abductors (little finger) 1 = altered T1 T6 T1 Finger abductors (little finger) 2 = normal C4 C2 C4 NT = not testable T7 T2 C3 Comments (Non-key Muscle? Reason for NT? Pain?): MOTOR SENSORY T2 SENSORY T8 C3 Elbow flexors C5 MOTOR MOTOR C5 Elbow flexors T3 KEY MUSCLES KEY SENSORY POINTS KEY SENSORY POINTS RIGHT 0 = absent T9 T1 T3 C4 (SCORING ON REVERSE KEY MUSCLES SIDE) LEFT UER Wrist extensors C6 Light 1 Touch = altered (LTR) Pin Prick (PPR) Light Touch (LTL) Pin Prick (PPL) C4 C6 Wrist extensors UEL 2 = normal T10 C6 (Upper Extremity Right) T4 T2 T4 0 = total paralysis Elbow extensors C7 T3 C2 C7 (Upper Extremity Left) NT = not testable T11 Elbow extensors T5 C2 T4 C5 T5 1 = palpable or visible contraction C2 Finger flexors C8 0 = absent T12 C8 Finger flexors T6 C3 2 = active movement, gravity T5 1 = altered T6 C3 eliminated 0 = absent Finger abductors (little finger) L1 3 = active movement, against gravity T1 C2 T6 T1 Finger abductors (little finger) 2 = normal C4 Palm 1 = altered 4 = active movement, against C4 some resistance T7 NT = not testable T7 T7 2 = normal T2 C3 Elbow flexors 5 = active movement, against C3 T2 full resistance NT = not testable Comments (Non-key Muscle? Reason for NT? Pain?): C5 T8 T8 T8 C5 Elbow flexors 5* = normal corrected for pain/disuse MOTOR T3 0 = absent C4 T9 T1 UER Wrist extensors C6 S3 NT = not testable T3 (SCORING ON REVERSE SIDE) T9 1 = altered C4 T2 2 = normal T3 T10 C6 T4 L2 • Key Sensory T9 C6 Wrist extensors UEL (Upper Extremity Right) Elbow extensors T4 C2 0 = total paralysis (Upper Extremity Left) C7 S4-5 T10 NT Points = not testable T4 T11 C5 T5 T10 C7 Elbow extensors SENSORY T5 1 = palpable or visible contraction Finger flexors C8 0 = absent T5 T12 2 = active movement, gravity eliminated T11 1 = altered T6 T11 (SCORING ON REVERSE C8 SIDE) Finger flexors Finger 0 abductors = absent (little finger) T1 T6 T6 2 = normal L1 3 = active movement, against gravity T12 1 = altered T7 Palm 4 = active movement, against some resistance NT = not T7 testable 2 = normal S2 L3 T12 0 = absent 2 = normal T1 Finger abductors (little finger) T2 C3 1= altered T7 T8 T2 NT = not 5 = testable active movement, against full resistance Comments (Non-key Muscle? L1 NT = not testable Reason for NT? Pain?): T8 L1 0 = absent T9 T1 T8 5* = normal corrected MOTOR for pain/disuse T3 T3 S3 1 = altered C4 NT = not (SCORING testable ON REVERSE SIDE) Hip flexors L2 T9 2 = normal T10 C6 T4 L2 • Key Sensory L2 Hip flexors T9 T4 0 = total paralysis NT = not S4-5 testable T11 Knee extensors T10 Points L3 T10 LER L3 T5 Knee extensors T5 1 = palpable or SENSORY visible contraction L4 T12 2 = active LEL T11 T11 (SCORING movement, ON gravity REVERSE eliminated SIDE) (Lower Extremity Right) Ankle dorsiflexors L4 T6 0 = absent L1 L4 Ankle dorsiflexors T6 (Lower 3 = active Extremity movement, Left) against gravity L5 Palm 1 = altered T12 2 = normal S2 L3 T12 0 absent 2 = normal Long toe extensors L5 4 = active movement, against some resistance T7 L5 Long toe extensors T7 1= altered NT = not testable S1 5 = active movement, against full resistance Ankle plantar flexors S1 NT = not testable T8 L1L5 S1 Ankle plantar L1 T8 flexors 5* = normal corrected for pain/disuse S3 S2 Hip flexors L2 L2 • Key Sensory NT = not testable T9 S2 T9 L2 Hip flexors S4-5 Points Knee extensors LER S3 L3 T10 S3 T10 L3 Knee extensors SENSORY (VAC) Voluntary anal contraction L4 (DAP) Deep anal pressure LEL (Yes/No) (Lower Extremity Right) S4-5 Ankle dorsiflexors L4 T11 S4-5 T11 (SCORING ON REVERSE SIDE) L4 Ankle dorsiflexors (Lower Extremity Left) L5 (Yes/No) Long toe extensors L5 T12 S2 L3 T12 0 = absent 2 = normal L5 Long toe extensors RIGHT TOTALS S1 LEFT TOTALS 1= altered NT = not testable Ankle plantar flexors S1 L1 L5 L1 S1 Ankle plantar flexors (MAXIMUM) (MAXIMUM) Hip flexors L2 S2 S2 MOTOR SUBSCORES L2 Hip flexors S3 SENSORY SUBSCORES S3 (VAC) Voluntary anal contraction L4 (DAP) Deep anal pressure UER + UEL = UEMS TOTAL LER Knee extensors L3 L3 Knee extensors LER + LEL (Yes/No) S4-5 = LEMS TOTAL LEL LTR + LTL = LT TOTAL PPR + PPL S4-5 (Lower Extremity Right) Ankle dorsiflexors L4 = L4 PP TOTAL Ankle dorsiflexors L5 (Yes/No) (Lower Extremity Left) MAX (25) (25) (50) MAX (25) (25) (50) Long toe extensors L5 MAX (56) (56) (112) MAX (56) (56) (112) RIGHT TOTALS L5 S1 LEFT Long TOTALS toe extensors NEUROLOGICAL L5 R L Ankle plantar flexors S1 (In complete injuries only) 3. NEUROLOGICAL (MAXIMUM) 4. COMPLETE OR INCOMPLETE? S1(MAXIMUM) Ankle R plantar L flexors LEVELS 1. SENSORY MOTOR SUBSCORES S2 Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL LEVEL OF INJURY S2 SENSORY SENSORY SUBSCORES Steps 1-5 for classification as on reverse 2. MOTOR (NLI) S3 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION S3MOTOR (VAC) UER Voluntary + UEL Anal Contraction = UEMS TOTAL LER + LEL = LEMS TOTAL Most caudal level with any innervation S4-5 LTR + LTL = LT TOTAL S4-5 PPR + PPL (DAP) Deep = Anal PP TOTAL Pressure MAX (25) This (25) form (Yes/No) may be copied freely (50) but should MAX not (25) be altered without (25) permission from the (50) American Spinal MAX Injury (56) Association. (56) (112) MAX (56) REV (Yes/No) 02/13(56) (112) NEUROLOGICAL RIGHT TOTALS LEFT TOTALS R L (In complete injuries only) 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? R L LEVELS 1. SENSORY (MAXIMUM) Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL (MAXIMUM) LEVEL OF INJURY SENSORY MOTOR Steps 1-5 SUBSCORES for classification as on reverse 2. MOTOR (NLI) 5. ASIA SENSORY IMPAIRMENT SUBSCORES SCALE (AIS) PRESERVATION MOTOR Most caudal level with any innervation UER + UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 02/13 MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112) NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? R L LEVELS Incomplete = Any sensory or motor function in S4-5 Steps 1-5 for classification A as on reverse 1. SENSORY 2. MOTOR R L 3. NEUROLOGICAL LEVEL OF INJURY (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. ANATOMY AND PHYSIOLOGY 133 (In complete injuries only) ZONE OF PARTIAL PRESERVATION Most caudal level with any innervation SENSORY MOTOR REV 11/15 Muscle Function Grading 0 = total paralysis 1 = palpable or visible contraction 2 = active movement, full range of motion (ROM) with gravity eliminated 3 = active movement, full ROM against gravity 4 = active movement, full ROM against gravity and moderate resistance in a muscle specific position 5 = (normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person 5* = (normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present NT = not testable (i.e. due to immobilization, severe pain such that the patient cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM) Sensory Grading 0 = Absent 1 = Altered, either decreased/impaired sensation or hypersensitivity 2 = Normal NT = Not testable When to Test Non-Key Muscles: In a patient with an apparent AIS B classification, non-key muscle functions more than 3 levels below the motor level on each side should be tested to most accurately classify the injury (differentiate between AIS B and C). Movement Root level Shoulder: Flexion, extension, abduction, adduction, internal C5 and external rotation Elbow: Supination Elbow: Pronation C6 Wrist: Flexion Finger: Flexion at proximal joint, extension. C7 Thumb: Flexion, extension and abduction in plane of thumb Finger: Flexion at MCP joint C8 Thumb: Opposition, adduction and abduction perpendicular to palm Finger: Abduction of the index finger T1 ASIA Impairment Scale (AIS) A = Complete. No sensory or motor function is preserved in the sacral segments S4-5. B = Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body. C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3. D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3. E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade. Using ND: To document the sensory, motor and NLI levels, the ASIA Impairment Scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the examination results. Steps in Classification The following order is recommended for determining the classification of individuals with SCI. 1. Determine sensory levels for right and left sides. The sensory level is the most caudal, intact dermatome for both pin prick and light touch sensation. 2. Determine motor levels for right and left sides. Defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. 3. Determine the neurological level of injury (NLI) This refers to the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally respectively. The NLI is the most cephalad of the sensory and motor levels determined in steps 1 and 2. 4. Determine whether the injury is Complete or Incomplete. (i.e. absence or presence of sacral sparing) If voluntary anal contraction = No AND all S4-5 sensory scores = 0 AND deep anal pressure = No, then injury is Complete. Otherwise, injury is Incomplete. 5. Determine ASIA Impairment Scale (AIS) Grade: Is injury Complete? If YES, AIS=A and can record ZPP (lowest dermatome or myotome NO on each side with some preservation) Is injury Motor Complete? If YES, AIS=B NO (No=voluntary anal contraction OR motor function more than three levels below the motor level on a given side, if the patient has sensory incomplete classification) B Hip: Adduction Hip: External rotation Hip: Extension, abduction, internal rotation Knee: Flexion Ankle: Inversion and eversion Toe: MP and IP extension Hallux and Toe: DIP and PIP flexion and abduction Hallux: Adduction L2 L3 L4 L5 S1 INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY Are at least half (half or more) of the key muscles below the neurological level of injury graded 3 or better? NO YES AIS=C AIS=D If sensation and motor function is normal in all segments, AIS=E Note: AIS E is used in follow-up testing when an individual with a documented SCI has recovered normal function. If at initial testing no deficits are found, the individual is neurologically intact; the ASIA Impairment Scale does not apply. n FIGURE 7-2 International Standards for Neurological Classification of Spinal Cord Injury. A. Sensory and Motor Evaluation of Spinal Cord. B. Clinical Classifications of Spinal Cord Injuries. n BACK TO TABLE OF CONTENTS
134 CHAPTER 7 n Spine and Spinal Cord <strong>Trauma</strong> n FIGURE 7-3 Key Myotomes. Myotomes are used to evaluate the level of motor function. Pitfall The sensory and motor examination is confounded by pain. A patient is able to observe the examination itself, which may alter the findings. A patient’s altered level of consciousness limits your ability to perform a defini-tive neurological examination. prevention • When necessary, repeat the exam multiple times. • Attempt to prevent or distract the patient from watching your clinical exam. • Always presume the presence of an injury, restrict movement of the spine while managing lifethreatening injuries, reassess, and perform radiographic evaluation as necessary. neurological improvement or deterioration on subsequent examinations. Neurogenic Shock versus Spinal Shock Neurogenic shock results in the loss of vasomotor tone and sympathetic innervation to the heart. Injury to the cervical or upper thoracic spinal cord (T6 and above) can cause impairment of the descending sympathetic pathways. The resultant loss of vasomotor tone causes vasodilation of visceral and peripheral blood vessels, pooling of blood, and, consequently, hypotension. Loss of sympathetic innervation to the heart can cause bradycardia or at least the inability to mount a tachycardic response to hypovolemia. However, when shock is present, it is still necessary to rule out other sources because hypovolemic (hemorrhagic) shock is the most common type of shock in trauma patients and can be present in addition to neurogenic shock. The physiologic effects of neurogenic shock are not reversed with fluid resuscitation alone, and n BACK TO TABLE OF CONTENTS
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TENTH EDITION ATLS ® Advanced Trau
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Chair of Committee on Trauma: Ronal
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FOREWORD My first exposure to Advan
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viii PREFACE MyATLS Mobile Applicat
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x PREFACE Gary A. Vercruysse, MD, F
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xii PREFACE Jacqueline Bustraan, MS
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ACKNOWLEDGMENTS It is clear that ma
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xvii ACKNOWLEDGMENTS Bertil Bouillo
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xix ACKNOWLEDGMENTS Oscar Guillamon
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xxi ACKNOWLEDGMENTS Mahesh Misra, M
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xxiii ACKNOWLEDGMENTS James Vosswin
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xxv ACKNOWLEDGMENTS James A. Geilin
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xxvii ACKNOWLEDGMENTS Tone Slåke R
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xxx COURSE OVERVIEW m. Protection o
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xxxii COURSE OVERVIEW Atls and Trau
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xxxiv COURSE OVERVIEW a systematize
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xxxvi COURSE OVERVIEW 69. Switzerla
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xxxviii COURSE OVERVIEW United Stat
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xl COURSE OVERVIEW 67. Hendrickson
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xlii COURSE OVERVIEW 122. Palusci V
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BRIEF CONTENTS Foreword Preface Ack
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xlviii DETAILED CONTENTS Teamwork 5
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l DETAILED CONTENTS Introduction 21
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1 INITIAL ASSESSMENT AND MANAGEMENT
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4 CHAPTER 1 n Initial Assessment an
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10 CHAPTER 1 n Initial Assessment a
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2 AIRWAY AND VENTILATORY MANAGEMENT
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24 CHAPTER 2 n Airway and Ventilato
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3 SHOCK The first step in the initi
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44 CHAPTER 3 n Shock The first step
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46 CHAPTER 3 n Shock Recognition of
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48 CHAPTER 3 n Shock However, the a
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50 CHAPTER 3 n Shock Class II Hemor
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52 CHAPTER 3 n Shock hypothermia, a
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54 CHAPTER 3 n Shock replacement du
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56 CHAPTER 3 n Shock aggregation an
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58 CHAPTER 3 n Shock Presence of Pa
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60 CHAPTER 3 n Shock rate can be ac
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4 THORACIC TRAUMA Thoracic injury i
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64 CHAPTER 4 n Thoracic Trauma Thor
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66 CHAPTER 4 n Thoracic Trauma shoc
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68 CHAPTER 4 n Thoracic Trauma comp
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70 CHAPTER 4 n Thoracic Trauma Norm
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72 CHAPTER 4 n Thoracic Trauma Seco
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74 CHAPTER 4 n Thoracic Trauma A B
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76 CHAPTER 4 n Thoracic Trauma Spec
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78 CHAPTER 4 n Thoracic Trauma temp
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80 CHAPTER 4 n Thoracic Trauma 18.
Page 135 and 136: ABDOMINAL AND 5 PELVIC TRAUMA When
Page 137 and 138: 84 CHAPTER 5 n Abdominal and Pelvic
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Page 155 and 156: 6 HEAD TRAUMA The primary goal of t
Page 157 and 158: 104 CHAPTER 6 n Head Trauma Head in
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Page 161 and 162: 108 CHAPTER 6 n Head Trauma n FIGUR
Page 163 and 164: 110 CHAPTER 6 n Head Trauma table 6
Page 165 and 166: 112 CHAPTER 6 n Head Trauma covery.
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Page 177 and 178: 124 CHAPTER 6 n Head Trauma not rea
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Page 182 and 183: CHAPTER 7 Outline Objectives iNtrod
Page 184 and 185: ANATOMY AND PHYSIOLOGY 131 B A n FI
Page 188 and 189: DOCUMENTATION OF SPINAL CORD INJURI
Page 190 and 191: SPECIFIC TYPES OF SPINAL INJURIES 1
Page 192 and 193: RADIOGRAPHIC EVALUATION 139 Penetra
Page 194 and 195: GENERAL MANAGEMENT 141 When the low
Page 196 and 197: GENERAL MANAGEMENT 143 them to the
Page 198 and 199: BIBLIOGRAPHY 145 Bibliography 1. Bi
Page 201 and 202: 8 MUSCULOSKELETAL TRAUMA Injuries t
Page 203 and 204: 150 CHAPTER 8 n Musculoskeletal Tra
Page 221 and 222: 9 THERMAL INJURIES The most signifi
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Page 225 and 226: 172 CHAPTER 9 n Thermal Injuries Ch
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184 CHAPTER 9 n Thermal Injuries 4.
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10 PEDIATRIC TRAUMA Injury remains
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188 CHAPTER 10 n Pediatric Trauma I
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190 CHAPTER 10 n Pediatric Trauma c
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192 CHAPTER 10 n Pediatric Trauma A
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194 CHAPTER 10 n Pediatric Trauma b
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196 CHAPTER 10 n Pediatric Trauma b
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198 CHAPTER 10 n Pediatric Trauma t
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200 CHAPTER 10 n Pediatric Trauma f
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202 CHAPTER 10 n Pediatric Trauma t
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204 CHAPTER 10 n Pediatric Trauma G
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206 CHAPTER 10 n Pediatric Trauma C
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208 CHAPTER 10 n Pediatric Trauma
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210 CHAPTER 10 n Pediatric Trauma 1
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212 CHAPTER 10 n Pediatric Trauma 6
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CHAPTER 11 Outline Objectives iNtro
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PRIMARY SURVEY WITH RESUSCITATION 2
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PRIMARY SURVEY WITH RESUSCITATION 2
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SPECIFIC INJURIES 221 table 11-6 ph
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BIBLIOGRAPHY 223 comprise only 12%
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12 TRAUMA IN PREGNANCY AND INTIMATE
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228 CHAPTER 12 n Trauma in Pregnanc
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240 CHAPTER 13 n Transfer to Defini
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Appendix A OCULAR TRAUMA OBJECTIVES
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259 APPENDIX A n Ocular Trauma In c
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261 APPENDIX A n Ocular Trauma to t
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Appendix B HYPOTHERMIA AND HEAT INJ
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267 APPENDIX B n Hypothermia and He
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Appendix C TRAUMA CARE IN MASS-CASU
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277 APPENDIX C n Trauma Care in Mas
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Appendix D DISASTER PREPAREDNESS AN
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291 APPENDIX D n Disaster Preparedn
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Pitfall Inadequate security Failed
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Appendix E ATLS AND TRAUMA TEAM RES
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305 APPENDIX E n ATLS and Trauma Te
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Appendix F TRIAGE SCENARIOS OBJECTI
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319 APPENDIX F n Triage Scenarios T
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333 APPENDIX F n Triage Scenarios 4
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Skill Station A AIRWAY Part 1: Basi
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339 APPENDIX G n Skills One-Person
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341 APPENDIX G n Skills STEP 5. Con
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343 APPENDIX G n Skills STEP 13. Co
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346 APPENDIX G n Skills STEP 1. D
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Skill Station C CIRCULATION LEARNIN
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351 APPENDIX G n Skills manual trac
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353 APPENDIX G n Skills STEP 3. Aft
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355 APPENDIX G n Skills STEP 2. If
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358 APPENDIX G n Skills A. Note fac
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360 APPENDIX G n Skills •• Flex
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362 APPENDIX G n Skills Utilization
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366 APPENDIX G n Skills n FIGURE G-
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368 APPENDIX G n Skills less than 1
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372 APPENDIX G n Skills G. Inspect
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374 APPENDIX G n Skills in the inju
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378 INDEX LTA for, 31-32, 32f Malla
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380 INDEX atlanto-occipital disloca
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382 INDEX Frostbite, 181-183, 182f
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384 INDEX Kussmaul’s sign, 69 Lac
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386 INDEX PEA. See Pulseless electr
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388 INDEX for musculoskeletal traum
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390 INDEX Tibial fractures, 163 Tou
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TRAUMA SCORES Correct triage is ess
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394 TRAUMA SCORES on Field Triage,
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396 INJURY PREVENTION Safety Admini
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398 INJURY PREVENTION providers to
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BIOMECHANICS OF INJURY Injuries occ
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402 BIOMECHANICS OF INJURY Ejection
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404 BIOMECHANICS OF INJURY •• A
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406 BIOMECHANICS OF INJURY in a 30-
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408 TETANUS IMMUNIZATION •• Wou
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410 TETANUS IMMUNIZATION Summary Gu
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SAMPLE TRAUMA FLOW SHEET Page 1 of
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414 SAMPLE TRAUMA FLOW SHEET Page 3
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420 SAMPLE TRAUMA FLOW SHEET Some h
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