Assessing and Treating Musculoskeletal Injuries

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Assessing and Treating Musculoskeletal Injuries

• May 2012 CE
• Condell Medical Center
• EMS System
• Site Code 107200E -1212
• Prepared by Sharon Hopkins, RN, BSN, EMT-P
• Rev 6/14/12

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Objectives

• Upon successful completion of this module, the
  EMS provider will be able to
• 1. Discuss components and function of the
  muscular and skeletal systems.
• 2. Predict injuries based on the mechanism of
  injury.
• 3. Differentiate between fractures, dislocations,
  sprains, and strains.
• 4. Describe the six Ps evaluated during a
  musculoskeletal assessment.
• 5. Explain the general guidelines for splinting.
• 6. Describe signs and symptoms of compartment
  syndrome.

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Objectives contd

• 7. Describe complications of compartment
  syndrome.
• 8. Describe complications of crush syndrome.
• 9. Demonstrate proper measurement and placement
  of a cervical collar.
• 10. Demonstrate proper application of the KED.
• 11. Demonstrate proper application of the HARE
  traction (or similar traction based on your
  department).
• 12. Demonstrate standing take down with the back
  board.
• 13. Successfully complete the post quiz with a
  score of 80 or better.

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Components - Musculoskeletal System

• Composed of
• Bones (dense connective tissue)
• Joints (place where bones meet)
• Muscles (tissues or fibers)
• Skeletal (voluntary), smooth (involuntary),
  cardiac
• Cartilage (connective tissue)
• Tendons (bands of connective tissue)
• Ligaments (connective tissue)

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Function - Musculoskeletal System

• Provide the framework of the body
• Support and protect internal organs
• Allow movement of body parts or organs
• Storage of salts and minerals
• Production site of red blood cells

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Bone Marrow

• Highly vascular
• Manufactures important blood components

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Musculoskeletal Injuries

• Strain
• Muscle injury from overstretching or overexertion
  of the muscle
• Spain
• Stretching or tearing of ligaments

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Musculoskeletal Injuries

• Dislocation
• Disruption of a joint
• Fracture
• Any break in a bone
• Simple closed fracture
• Compound open fracture
• Increased risk of contamination infection
• Most common bone injury

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Cascade of Events

• Fracture occurs ? ? ? ? ? ? ?
• ? Destruction of blood vessels in periosteum
  bone and damage to surrounding vessels
• Swelling of soft tissue
• Formation of a clot in the area
• Cell death at injury site due to disruption of
  blood flow
• Intact surrounding cells divide form a mass
  around fracture site
• New bone is generated in weeks or months

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Assessment Musculoskeletal Injuries

• 5 Ps of evaluation
• Pain or tenderness?
• Pallor paleness or poor capillary refill?
• Paresthesia pins and needles sensation?
• Pulses diminished or absent?
• Paralysis inability to move?

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Signs Symptoms

• Pain and tenderness
• Usually localized
• Deformity
• Compare for symmetry
• Grating or crepitus
• Increases pain levels
• Swelling
• From bleeding at the site
• Remove watches, rings as soon as possible
• Document what you did with the personal effects

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Signs Symptoms contd

• Bruising- leaking of blood vessels
• Exposed bone ends
• Open/comminuted fracture
• Increases risk of infection
• Bone infection could lead to amputation
• Joints locked into place
• Often seen with dislocations
• Splint in position found

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Signs Symptoms contd

• Nerve blood vessel compromise
• Evaluate distal CMS/SMV/PMS
• Evaluated before and after splinting
• DOCUMENT CMS/SMV/PMS!!!
• Document ALL assessment results

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Assessment PEARL

• During assessment, determine mechanism of injury
• If patient fell, ask WHY
• If fall related to tripping/losing balance, you
  are just dealing with the orthopedic injuries
• If patient experienced dizziness,
  lightheadedness, wooziness, syncope,
  near-syncope
• Consider a cardiac event until proven otherwise
• Consider need for EKG monitoring
• Perform the Cincinnati Stroke Scale

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Care of the Injury

• Standard Precautions observed
• Perform baseline/initial assessment
• PEARL
• ?Musculoskeletal injuries are rarely ever life
  threatening
• ? Could be life threatening for bilateral femur
  fractures and pelvic fracture

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Care of the Injury contd

• Cover open wounds with sterile dressing
• If life threatening situation, splint enroute if
  time
• Note Patients on backboard are essentially
  immobilized/splinted
• If stable patient, can splint prior to transport

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RICE

• R rest the injury (i.e. splinting)
• I apply ice to wound
• Never apply ice directly to the skin
• Too damaging to the skin tissue and cells
• C apply compression to minimize swelling
• Never pull tight on the ACE will be too
  constrictive let ACE unroll easily
• E elevate higher than the heart

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Guidelines for Splinting

• Must immobilize the joint above and joint below
  the injury
• Minimizes movement which will decrease pain
• Prevents additional soft tissue injury to nerves,
  arteries, veins, and muscle
• Prevents a closed fracture from becoming an open
  fracture
• Minimizes blood loss
• Minimizes additional injuries to the site

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Deformity

• May make splinting difficult
• Chance of compromise to nerves, arteries, and
  veins
• Distal tissue may die due to compromised blood
  flow
• May need to add extra padding
• May need to be creative in choosing splinting
  material

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When to Realign Deformed Extremities

• Distal extremity cyanotic
• Distal pulses cannot be palpated
• When in doubt, call Medical control
• For relatively short transport times, most
  injuries can and should be splinted in position
  found

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Realigning an Injury

• Goal
• Align joint to anatomical position
• Splints applied in position of anatomical
  function
• Position mimics a normal, relaxed pose for the
  extremity
• Fingers slightly curved for hands

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Realigning an Injury

• General guidelines to follow if necessary
• 1 person grasps the distal extremity
• 1 person places hands above below injury
• Apply gentle manual traction in the same
  direction as the long axis of the extremity
• Stop if resistance is felt or bone ends may break
  thru the skin
• Maintain gentle traction until splinting is
  accomplished

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Splinting PEARLS

• Cant treat what you cant see
• Expose all injuries
• Assess and document distal CMS/SMV/PMS before and
  after splinting
• Consider need for padding around bony areas
• If bone is protruding, do not push it back in
• Cover with sterile gauze

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Hazards of Splinting

• Caring for extremity injuries prior to caring for
  life threatening injuries
• Inappropriately staying on the scene to care for
  injured extremities prior to initiating transport
  
• Improper or inadequate splinting
• Too tight circulation compromised
• Too loose movement allowed ?further injury

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Potentially Fatal Orthopedic Injuries

• Bilateral femur fracture
• Typically results from excessive force
• Consider the presence of additional injuries
• Blood loss most likely with mid-shaft fractures
• Can lose up to 2 units of blood (1000 ml) per
  femur fracture

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Stages of Shock

• Based on amount of blood loss
• Stage 1 up to 15 circulation volume
• Average 500 750 ml (typical donation during
  blood drive)
• Stage 2 up to 15-25 circulation volume
• Average 750 1250 ml
• Stage 3 up to 25-35 circulation volume
• Average 1250 1750 ml
• Stage 4 up to gt35 circulation volume

Averages calculated for a 70 kg person
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Femur Fracture

• Presentation
• Extreme pain
• A lot of muscle tissue surrounding the femur
• Deformity
• Swelling
• Treatment
• Traction splint
• Best for mid shaft fractures

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Traction Splinting

• Relieves muscle spasm therefore reducing pain
• Avoid if serious knee, tibial, or foot injuries
• Avoid if any joint injury to hip or knee is
  suspected
• Anterior hip fracture may look like a femur
  fracture
• Head of femur often protrudes in inguinal area

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Potentially Fatal Injury

• Pelvic fracture
• Frequently associated with extremity fractures
• Usually result from MVC and falls from heights
• Have high index of suspicion based on mechanism
  of injury
• Can suffer from significant blood loss
• Bones have rich supply of blood
• Typically venous bleeding from disruption of bone
  surface

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Pelvic Fractures

• The most significant pelvic injury is open-book
  pelvic fracture
• Symphysis is torn apart
• Anterior pelvis opened
  like a book
• Both sacroiliac joints
  usually disrupted

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Pelvic Fracture

• Assessment
• Instability or pain when applying gentle
  posterior pressure on iliac crests or symphysis
  pubis during assessment
• DO NOT ROCK PELVIS!!!
• Could displace the fracture or disturb a hematoma
• Up to 40 of patients also have abdominal
  injuries

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Compartment Syndrome

• Fascia is a non-stretching tough membrane that
  surrounds muscles and other structures in
  extremities
• Multiple closed spaces created called
  compartments
• Bleeding and swelling from trauma may create
  increased tissue pressure in the confined space

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Compartments of the Leg
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Compartment Syndrome contd

• Increased pressure in confined space
• Decreased blood flow
• Hypoxia
• Possible muscle, nerve, vessel impairment
• May lead to cell death and amputation
• Typically presents hours after initial insult
• Surgical intervention required to relieve the
  pressures in compartment

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Compartment Syndrome

• Can occur with a patient with a casted extremity
• Injured area continues to swell first few days
• Casted area constricted and does not allow
  expansion of the swelling
• Compartments become compromised
• Have high index of suspicion for patient
  presenting with a cast
• Pain level higher than expected usually the tip
  off

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Signs and Symptoms Compartment Syndrome

• Early
• Pain out of proportion to injury
• Paresthesia pins needles sensation
• Late 5 Ps
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis

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Compartment Syndrome

• Surgical intervention fasciotomy
• Will need to return to OR for closure at a later
  date

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Compartment Syndrome

• Risks of late diagnosis and intervention
• Gangrene leading to need for amputation
• Ischemic contractures and therefore loss of
  function
• Rhabdomyolysis and acute renal failure
• Syndrome caused by skeletal muscle injury
• Leakage of large quantities of toxic
  intracellular contents into plasma
• Basically, sludge of muscle protein attempting to
  be filtered thru kidneys is causing kidney damage

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Crush Syndrome

• Pressure on extremities during prolonged
  entrapment can disrupt blood flow
• Typically 4 hours or longer of entrapment
• Anaerobic metabolism in tissues occurs
• Toxins produced released from crushed tissues,
  muscles, and cells
• Myoglobin - a muscle protein
• Potassium
• Phosphorus
• Lactic acid from anaerobic metabolism
• Uric acid from protein breakdown

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Crush Syndrome contd

• Patient at risk of cardiac dysrhythmia and severe
  kidney damage from toxins
• Place patient on cardiac monitor
• Watch for peaked T wave
• Indication of excess potassium in vascular space
• Increase IV fluid rate to keep kidneys hydrated
  and flushed

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Hyperkalemia High Potassium

• Note peaked T wave (this is NOT ST elevation!!!)
• Excess extracellular potassium is an irritant to
  the heart
• Watch for dysrhythmias and potential arrest

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Types of Splints

• Rigid material
• Air splint
• Vacuum splint
• Slings
• HARE/Sager traction splint
• Back board
• Pillows

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Cervical Collar PEARLS

• Measure accurately for best fit
• Improper fit causes greater risk of harm than it
  does good
• Measure bottom of chin to top of shoulder
• Eyes must be
  focused straight
  ahead

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KED PEARLS

• Helpful only when rapid extrication is not
  required
• Maintain manual spinal motion restriction until
  fully secured
• Carefully place the
  leg/thigh straps
  especially in the male population

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HARE or Sager Traction PEARLS

• Traction maintained manually until device in
  place and foot traction applied
• Patients often experience instant relief of pain
  (from muscle spasms) once traction in place

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Standing Backboard

• Takes 3 persons to be safely performed
• If you really need
  spinal motion
  restriction, doesn't
  make sense to have
  patient walk to cot
  and then lay down

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Standing Backboard

• PEARL
• Apply straps to finish securing the patient AFTER
  the patient is supine on the board
• The patient will be manually held in place while
  the backboard is being lowered

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Documentation

• Assessment of injury by interview
• Onset what were you doing at the time?
• Provocation/palliation what makes the pain
  worse/better?
• Quality in your words, describe the pain
• Radiation does the pain radiate?
• Severity on a scale of 0-10, rate your pain
• Time what time did this happen?

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Documentation contd

• Observation of appearance
• Blood loss present?
• Deformity present?
• Bruising present?
• Assessment by palpation (CMS/SMV/PMS)
• Pulses
• Distal compared to proximal
• Ability to wiggle distal extremities
• Ability to differentiate area touched

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Documentation contd

• Consider the 6 Ps of extremity assessment
• Pain
• Pallor
• Paralysis
• Paresthesia
• Pressure
• Pulses

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Case Scenario Discussion

• Review the following cases
• Follow the printed questions to prompt discussion
• Consider creative alternative to care for the
  wound when presented with unique challenges
• There are not necessarily only one right answer
  for each question posed

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Case Scenario 1

• EMS called to a road construction crew
• Patients arm caught under a road compacting
  machine for a few minutes
• What safety issues need to be considered?
• Traffic
• Securing machine from movement
• Exposure to blood and body fluids

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Case Scenario 1

• How would you assess this wound?
• How would you care for this wound?
• How would you document this wound?

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Case Scenario 1

• Assess distal circulation, motion, and sensation
  status
• Can rinse gross debris away
• Always use sterile normal saline on open wounds
• Avoid using sterile water on open wounds
• Normal saline is isotonic less destructive to
  damaged tissue
• Cover open wound
• Splint extremity in position of function

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Case Scenario 1

• Documentation
• Mechanism of injury (MOI)
• Appearance of wound
• Distal CMS/SMV/PMS before and after splinting
• Type of splinting/immobilization performed
• Pain control measures
• Response to interventions

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Case Scenario 2

• EMS received a call to a local factory for a
  patient with their arm caught in machinery
• Upon arrival, you note the right forearm is
  caught in a machine
• What safety issues need to be considered?

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Case Scenario 2

• How would you assess this wound?
• How would you care for this wound?
• How would you document this wound?

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Case Scenario 2

• What risks to the patient are associated with
  crush injuries?
• Release of toxins into the bloodstream once the
  pressure is released especially after long
  entrapment
• Circulating potassium is a cardiac irritant
• Watch for dysrhythmias via cardiac monitor
• By-products of myoglobinemia can decrease kidney
  function causing acute renal failure
• Provide IV fluids

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Case Scenario 3

• EMS responded to the scene for a patient injured
  during a fall
• Upon arrival, you note an elderly female sitting
  on the ground supporting their left arm

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Case Scenario 3

• How would you assess this wound?
• Distal CMS/SMV/PMS before and after splinting
• How would you care for this wound?
• Splint in position found
• May need to pad splint material
• Apply ice over splinting material
• Elevate arm

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Case Scenario 3

• What else do you need to think about in caring
  for this patient?
• WHY DID THE PATIENT FALL???
• Remember Unless it is a clumsy tripping,
  consider a cardiac/stroke issue until proven
  otherwise
• Obtain EKG rhythm strip
• Perform Cincinnati Stroke Scale

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Case Scenario 3

• What do you think about this documentation?
• Upon arrival found patient sitting on the ground
  supporting arm
• Site evaluated
• Pain 9/10 7/10
• Above vital signs obtained
• Patient placed on backboard and in collar
• Patient transported

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Case Scenario 3

• Documentation issues
• Why did patient fall?
• What did you find on assessment of the injury?
• How did you splint the injury?
• What was the distal CMS/SMV/PMS before and after
  splinting?
• What were the responses to interventions applied?

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Case Scenario 3

• Drug/solution area filled in
• O2 4l per nasal cannula
• What about pain control?
• Patient could get Fentanyl
• Why is oxygen applied?
• Remember criteria SpO2 lt94 and/or respiratory
  complaints or compromise

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Case Scenario 4

• EMS called for a 5 y/o pedestrian who fell
  exiting a bus and then was run over
• The scene is chaos
• Congested with parents, neighbors, bus driver,
  other children still on the bus

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Case Scenario 4

• For discussion
• What safety issues need to be considered?
• How do you exert crowd control?
• Describe patient assessment
• What additional injuries may have occurred?
• What trauma category is this patient?
• Describe treatment of wounds

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Case Scenario 4

• Injury contained to left leg
• Bone deep laceration to left patella
• Quadricep tendon cut through
• Skin over anterior left leg avulsed bone
  exposed
• Tendons in ankle exposed
• Tendons over dorsum foot severed from proximal
  insertion
• Metatarsals exposed

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Case Scenario 4

• How would you assess this wound?
• After viewing the OR picture of the wound,
  discuss how you would assess status of distal
  circulation
• How would you care for this wound?
• How would you document this wound?

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Case Scenario 4 Hospital Course

• Hypotensive and unstable on admission
• Amputation was anticipated
• Debridement performed 5 days post injury
• 13 days post injury external fixator applied
  removed in 15 days and replaced for another 7
  days
• 25 days post injury skin grafting done
• Multiple surgeries for removal fixator, casting,
  cast removal
• Outcome limb shortened, foot drop present but
  functional

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Case Scenario 4 OR Repair

• Fixator pins noted
• Donor site for skin grafting
• Mesh skin graft in place

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Case Scenario 5

• Crush injury to hand
• What safety issues need to be considered at the
  site?
• Is scene
  safe?
• Are BSIs
  in place?

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Case Scenario 5

• How would you assess this wound?
• How would you care for this wound?
• Anything special in the care based on the
  picture?
• Any constricting material (ie the ring) need to
  be removed ASAP
• Document what you did with personal effects taken
  from the patient
• How would you describe this wound?

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Equipment Practice

• Form small groups
• Practice proper utilization of
• Measurement and placement of cervical collar
• Application of KED
• Application of back board with patient standing

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Bibliography

• Region X Advanced Life Support Standard Operating
  Procedures February 1, 2012
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles Practices Third Edition. Brady.
  2009.
• Campbell, J. International Trauma Life Support
  for Emergency Care Providers. 7th edition.
  Pearson. 2012.
• Limmer, D., OKeefe, M. Emergency Care 12th
  Edition. Brady. 2012.
• emedicine.medscape/article/1007814-overview
• lifeinthefastlane.com
• modernmedicine.com