 |
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
 |
|
|
|
 |
 |
|
|
|
|||
 |
|
Stabilization of Trauma in the ER
The General Approach to Trauma
 |
|
|
|
 |
|
||
 |
 |
 |
|
 |
|
||
- An Overview of Trauma
Trauma includes major injury of all types — auto accidents, falls, industrial accidents, burns, knifings, and shootings.
Trauma is the leading killer of young, productive people in the United States. Ten million Americans will be disabled by trauma during this year, 400,000 of them permanently. Over 150,000 will die.
The cost of caring for this year’s trauma victims will exceed 100 billion dollars.
Trauma deaths are increasing in the United States. Our trauma death rate in young adults is 50% higher than other industrialized nations. Much of our trauma problem stems from our love affair with handguns. The US death rate from shootings is 10,000 times that of England. Homicide is now the leading cause of death in young black males.
The United States also suffers the effects of a more lax attitude about drunken driving. While DUI laws are being toughened, none yet compare to those of Europe. Over 50% of US adult trauma victims are legally intoxicated.
Deaths from trauma show three peaks: immediate death, later death due to hemorrhage or direct organ compromise, and delayed death due to complications and organ failure.
Death may occur within seconds of the injury, usually due to massive head injury, heart injury, or aortic injury. These deaths cannot be prevented.
A second peak in deaths begins an hour or two after the injury. Deaths occurring in this second peak are usually due to subdural and epidural hematomas, hemo- or pneumothorax, organ rupture, or blood loss. These deaths are often preventable. This period is called the “golden hour” during which prompt intervention can save a life.
The third peak in deaths occurs many days after the injury, and is usually due to sepsis or multi-organ failure. Prompt treatment of shock and hypoxemia during the “golden hour” can reduce these deaths. Back to Top
The Philosophy of Trauma Care
In dealing with the trauma victim, the physician must treat as he or she gathers information. The approach cannot be routine “take a history, do an exam, order some tests, make a diagnosis, then treat the patient.” Therapeutic interventions must be made “on the fly,” before the full evaluation can be completed.
For every possible injury, emergency physicians and trauma surgeons have a “threshold of action” — a point at which the physician will aggressively intervene even without traditional “proof” of the diagnosis. For example, the combination of low blood pressure, unilaterally decreased breath sounds, and respiratory distress triggers a response from the physician. A chest tube is placed immediately, rather than waiting until an x-ray can “prove” the diagnosis.
As the trauma victim arrives, the physician assesses vital functions (the ABCs) rapidly, intervening when the patient’s status meets the “threshold of action.” The physician orders stabilization measures such as IV and oxygen as the primary survey is conducted.
The management of the trauma victim should not be viewed as a linear flow chart, with one action following another. It should be viewed as a progression through a series of loops. The physician examines, takes action on a positive finding, then “loops” back to examine the effects of the action. For example, weak air motion — place oral airway — recheck air motion. If positive findings persist, the physician acts on the abnormal finding again, and again checks the effects. After stabilizing the abnormality, the physician progresses on to the next “loop.” Some loops may reside inside other large loops — for example, the physician may assess, take action on, and reassess other problems while waiting for the effects of fluid infusion.
When the physician is confident that the patient is stable and adequately monitored, he performs a full patient assessment (often called the secondary survey). As sufficient historical, examination, and laboratory data becomes available, definitive care is arranged. Back to Top
Prehospital Care:
As little time as possible is spent with the victim at the scene. On arrival, the paramedics or EMTs act to prevent any further risk to victims, onlookers, and rescuers. The “primary survey” reveals obvious injuries. It includes immobilization of the cervical spine, securing of an airway, assurance of adequate ventilation, and control of any severe hemorrhage.
Extrication of the victim from wreckage is ideally done after the cervical spine is stabilized. Airway, ventilation, and intravenous lines can be established while the patient awaits removal.
The victim is placed on a long back-board, with towel rolls and tape to protect the cervical spine. Anti-shock trousers may be placed under the patient, to be inflated if required. Rescuers place IV lines in the ambulance if time allows.
The receiving hospital is notified of the patient’s status while enroute. After arrival, the rescuers should wait to see if the receiving emergency physician has any questions about prior treatment or conditions on the accident scene. Back to Top
Primary Survey: the ABCs
The primary survey identifies immediately life-threatening conditions. Management of any threat to life begins immediately — before progressing on with the rest of the primary survey.
The primary survey is called “the ABCs” because it stabilizes Airway, Breathing, then Circulation.
A - Airway control with C-spine protection
B - Breathing adequacy
C - Circulation adequacy with hemorrhage control
The primary survey can take as little time as ten seconds, or may take several minutes as you discover and treat life-threatening problems.
A good primary survey is an “art form.” It includes your first look at the patient, your initial introduction of yourself to the patient, and a brief “targeted” exam. Back to Top
The Quick Look
Begin the primary survey as you walk into the room. A quick look tells you a lot about the patient’s status. Is he breathing? Does he look at you? Is the C-spine immobilized?
If the C-spine is not immobilized in any patient at risk (multiple trauma, any injury above the clavicle, or altered level of consciousness), ask someone to stabilize it now.
Address the patient directly. If the patient is looking at you, say “I’m Dr. Smith. How are you?” If the patient gives any meaningful answer, you know 1) the brain is reasonably functional, 2) there is an intact airway, 3) ventilation is occurring, and 4) circulation is present. Of course, any of these factors can change in the unstable patient. Further assessment determines the risk of deterioration.
If the patient appears unconscious or asleep, shout his name to see if there is a response. Back to Top
Protecting the Cervical Spine
Immobilize the C-spine as you check the airway. If agitation or delirium results in poor cooperation with immobilization, aggressive action is necessary. Small doses of diazepam or lorazepam may stop combativeness briefly. If the struggling resumes, give a paralyzing agent such as succinyl choline, then ventilate the patient with bag-mask while awaiting cross-table cervical spine x-rays.
Initial control of the C-spine may be easily accomplished by instructing an assistant to hold the head. If you are alone, grasp the entire forehead with your outstretched hand as you open the mouth with your other hand — assuming your hands are large enough compared to the patient’s head. Until the C-spine cross-table film is complete, immobilize the C-spine with stiff collar, towel rolls on each side of the head, and tape across the forehead. Back to Top
Checking the Airway
Now turn your attention to the airway. If the patient responded to “How are you?” in a clear voice, the airway is patent — at least for the moment. You can continue with the primary survey. A clear voice, quiet respirations, and a normal mental state rule out significant obstruction.
Listen for noisy air motion. Snoring sounds suggest mechanical obstruction, while gurgles mean secretions, vomitus, or blood in the airway. In a trauma victim, these sounds indicate the need to clear the airway, usually followed by intubation.
Hoarseness or pain with speaking may mean laryngeal injury, which can result in obstruction. Agitation can be a clue to hypoxia. Obtundation may be due to carbon dioxide retention.
If respirations are not obvious, put your ear down near the patient’s mouth. While you watch the chest for motion, listen and feel for the motion of air on your cheek.
In the patient with no current evidence of airway problems, assess for risk to the airway. Manage the risk factors as you find them. Look in the mouth for foreign matter or loose teeth.
Any unconscious patient may develop airway obstruction due to relaxation of the muscles of the tongue and throat. An oral airway prevents this complication.
Any obtunded or unconscious patient should be tested for a gag reflex. Absence of the gag reflex means that the patient is at risk for aspiration. Preparations should be made for endotracheal intubation.
In any patient with severe facial injuries, compression or bleeding into the airway can occur. A protected airway must be established. Back to Top
Stabilizing the Airway
Any blood or secretions must be suctioned from the airway. Open the mouth (remember to have someone controlling the head if the C-spine is not yet otherwise immobilized), pull the jaw forward, suction. Any foreign material such as teeth, clots, or dentures must be removed. If bleeding or secretions continue, you’ll need to intubate.
A firm (tonsil) suction tip should be used to clear secretions and blood. Patients with facial injuries may have a fracture of the cribriform plate of the skull. Attempting to pass a soft catheter can result in its entry into the brain.
If snoring and mechanical obstruction are simply due to normal tongue and soft tissues, an oral or nasal airway may provide an adequate air passage. If other indications for intubation exist, however, intubation should follow soon. Attempt an oral airway. If the patient gags, use a nasal airway instead. If the oral airway is tolerated by the patient, endotracheal intubation will be required (unless opening the airway improves the patient’s status enough that the gag reflex returns).
Mechanical obstruction of the airway due to severe facial or neck injury should be treated by cricothyrotomy at this point. (If airway obstruction does not develop until after cervical spine x-rays have shown no fracture or dislocation, simple intubation may be attempted first.)
The patient who has a decreased level of consciousness, but no other encroachment of the airway, still requires protection of the airway. Place an oral airway. If the oral airway is tolerated by the patient (no gag reflex), oxygenate the patient well and prepare for intubation as soon as practical.
Endotracheal intubation on breathing trauma victims should be done by the nasal route, unless cervical spine x-rays are normal. Back to Top
Nonbreathing Trauma Victims
The non-breathing patient should first have the airway opened by chin lift or jaw thrust. Suction the airway and inspect for foreign bodies.
If respirations do not begin, insert an oral airway and rapidly ventilate the patient with bag-valve mask. If the patient cannot be ventilated adequately, intubate orally while an assistant provides traction on the head to prevent motion of the neck. An alternative is nasal intubation using an ET tube over a fiber-optic bronchoscope. A second alternative is cricothyrotomy — the preferred method if facial trauma is present. Standard nasal intubation cannot be performed on non-breathing patients.
If the patient can be ventilated adequately, you may continue bagging while a cross-table C-spine x-ray is done. Intubate orally if films are negative. If the patient has severe facial or neck injury, do a cricothyrotomy rather than oral intubation. Back to Top
Assessing Ventilations
The “B” of the ABCs is Breathing. Inspect the chest and neck for respiratory motion, deviated trachea, open chest wounds, and breath sounds. Assess the rate of respiration and the volume of air passed with each ventilation.
Assessment of airway patency leads naturally into an assessment of adequacy of ventilation. If the patient was intubated during evaluation of the airway, the chest exam allows a check of ET tube placement. Adjustment of tube position or reintubation may be necessary.
Assessment of breathing begins with a look at the patient’s general state. Agitation suggests hypoxia, while obtundation may mean carbon dioxide retention.
Next, assess the rate of respirations. An injured person will usually have an increased rate of respiration. A decreased respiratory rate is usually due to inadequate respiratory effort — caused by a decreased level of consciousness. A greatly increased rate of respirations (greater than 25 per minute in the adult patient) indicates respiratory distress.
The physician next judges the adequacy of the air flow — the depth of respiration. Look, listen, and feel the flow of air at the mouth. Listen to the chest for breath sounds. Make an estimate of respiratory effort by observing for accessory muscle use and intercostal retractions. Back to Top
Stabilization of Breathing
Stabilization occurs at the same time as assessment. All trauma victims should be placed on oxygen, preferably by mask at higher flow rates (12 liters/min). If no evident problem with respirations is present, the ABC assessment continues.
The patient who has inadequate air flow must have ventilatory support. After insuring a patent airway, ventilate the patient with bag and mask. If inadequate respiratory effort continues, intubate.
The patient in respiratory distress should be rapidly assessed for a treatable cause, such as foreign body, pneumothorax, or flail chest. The physician should intervene during the initial assessment if the respiratory distress is significant; that is, if the findings exceed the “threshold for action.”
A large unstable chest wall segment (flail chest) may cause respiratory distress. Flail chest often requires intubation and mechanical ventilation. The motion of the flail segment may be reduced with taping or sandbags over the unstable area. However “external splinting” of the chest rarely improves the patient’s respiratory status.
An open wound on the chest that sucks air should be covered with an occlusive dressing, taped on three sides so that air can escape from under it.
The combination of respiratory distress, unilaterally decreased breath sounds, and hypotension is suspicious for tension pneumothorax. Hyperresonance may be present on the side of decreased breath sounds. The physician should not wait for x-ray confirmation. Either place a chest tube, or do a needle aspiration to confirm the diagnosis.
If the degree of distress (or the degree of certainty of diagnosis) doesn’t exceed the threshold for intervention, await additional data. Any patient who exhibits respiratory distress without an identifiable cause, and which is unresponsive to oxygen, should be intubated. Back to Top
Assessment of Circulation
After “Airway with C-spine control” and “Breathing” comes “Circulation” assessment. You will already have many clues about the adequacy of circulation, such as the level of alertness and the patient’s general appearance.
By this time, having removed clothing to inspect the chest and listen to the lungs, any severe external hemorrhage should be obvious. Apply direct pressure to any bleeding wounds. The “Quick Look” gives clues to the presence of shock. As the patient loses blood volume, the patient first becomes apprehensive and anxious. Confusion follows, then finally the patient becomes obtunded as blood pressure falls further. The extremities may be pale and cold due to vasoconstriction in hypovolemic shock, or they may be bluish and mottled in cases of obstructive shock (such as tension pneumothorax or cardiac tamponade).
At this point, the examiner feels for a pulse. If a radial pulse can be felt, the systolic blood pressure is likely above 80. If no pulse is felt, start CPR while looking for a reversible cause. (Trauma arrests are essentially fatal unless a rapidly reversible cause is found — such as tension pneumothorax, tamponade, or exanguinating hemorrhage.)
The blood pressure is not measured yet. Feel the pulses, and make a judgement on the adequacy of circulation based on general “gestault,” skin color and temperature, and pulse rate. The physician checks the heart tones, and observes the rhythm on the monitor. The presence of poor perfusion leads the examiner to inspect the neck veins for distention. If the patient is in shock with no evidence of tension pneumothorax or cardiac tamponade, assume that the shock is due to hemorrhage. Back to Top
Stabilization of Circulation
Stabilize the circulation by placing two large-bore (14 or 16 guage) IV catheters in peripheral veins. Place a cardiac monitor on the patient.
Stop any active external bleeding. Apply pressure directly over the wound area.
Your rapid assessment may have revealed other treatable causes of shock. Hemorrhage from a pelvic fracture may decrease with placement of anti-shock trousers. Bleeding from a femoral fracture may be improved with a traction splint.
The physician performs pericardiocentesis upon the discovery of “Beck’s Triad” of shock, distended neck veins, and muffled heart sounds. (Tension pneumothorax can cause these signs. The chest exam should have ruled this out.)
Initial shock resuscitation begins at this point with IV fluids (saline or lactated ringers). If there is clinical evidence of decreased perfusion, begin infusion of fluids at the most rapid rate possible. Manual or pneumatic pressure on the IV bag can produce faster flow rates. Plan an initial fluid bolus of around 10-20 mL per kg body weight.
If significant shock persists after 2 liters of fluid (or two boluses of 20 mL/kg in a child), O-negative blood should be started. Back to Top
A,B,C, then D for Disability (Brief Neuro)
During the initial ABC assessment, any rapidly-fatal threat to life is either ruled out or treated. The patient is now stabilized with IVs, oxygen, and cardiac monitor. The airway is either not at risk, or is secured by intubation. The next step of trauma management is “D” for disability — a brief neurological exam.
The brief neuro exam includes level of consciousness, pupil size and reactivity, speech, and motor function.
You already know some neurological information from the rapid assessment. For example, you know the general level of consciousness. The purpose of the brief neuro exam is to get information about the cause of altered consciousness.
Note whether the patient is speaking or looking around. Does he know where he is? Can all extremities be moved? Check the pupils.
A useful monitoring tool is determining 1) best verbal response, 2) best motor response, and 3) eye opening. The triad of eye opening, verbal response, and motor response makes up the Glascow Coma Scale. Back to Top
Glascow Coma Scale
Eye Opening
Spontaneous 4
To Voice 3
To Pain 2
None 1
Best Verbal
Oriented 5
Confused 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
Best Motor
Obeys Commands 6
Localizes Pain 5
Withdraws to Pain 4
Flexion to Pain 3
Extension to Pain 2
None 1
Secondary Survey
After the initial assessment, the physician conducts a head-to-toe exam, obtains historical information, and orders needed x-ray and laboratory testing. This is the “Evaluation” or Secondary Survey phase.
At this point, obtain complete vital signs. This includes the blood pressure, pulse rate, respiratory rate, and rectal temperature. Note the pulse pressure — the difference between diastolic and systolic pressures. Repeated blood pressure, pulse rate, and respiratory rate recordings during the secondary phase monitor the effects of ongoing resuscitation.
Order laboratory testing (trauma panel), and basic x-rays (C-spine, chest, and pelvis) now. Further x-rays are best “grouped” and ordered after the secondary survey. Back to Top
History
The time between initial stabilization and secondary examination is usually a good time to obtain historical information. Ask the paramedics or EMTs for information about the accident scene (such as a broken steering column) that may offer clues to the nature and seriousness of the patient’s injuries.
The trauma victim’s medical history must include events (and mechanism) of injury, medical history (including medications), allergies, and last meal. When this information can’t be given by the patient, it must be sought from witnesses, paramedics, friends, and relatives. Seek information on any surgical scars: the history of splenectomy or complete pneumonectomy may greatly alter your approach to the patient. Back to Top
Physical Exam
The head-to-toe physical exam is part of the secondary survey. Interrupt the exam to manage any potentially life-threatening problems you discover. As with the primary survey, the exam portion of the secondary survey is “targeted” to discover specific information.
Because the many exam findings in a multiply-injured patient can be overwhelming, the physician must simplify. Instead of “examining the leg,” the physician should approach the exam of a leg as a series of questions:
Is there obvious injury? If so, record the type and location of each.
Is there tenderness? This information guides the x-ray ordering.
Are pedal pulses intact? This screens for vascular injury.
Is skin sensation intact? This screens for neurological or vascular injury.
Is there limitation of motion?
Inspect the scalp for lacerations, hematomas, and tenderness. Test the facial bones for crepitance or instability. Check the eyes for foreign bodies and direct injuries. Look at the eardrums for rupture or blood.
Check the neck for swelling, hematomas, and “step-off” of the posterior spinous processes. Palpate the larynx for crepitance and stability.
Reexamine the chest for crepitance, tenderness, and abnormal sounds, as well as symmetry of breath sounds and chest wall motion.
The heart exam should screen for new murmurs and muffled heart tones. Heart tones may be muffled, and the PMI absent or displaced, in pneumothorax.
Examine the abdomen for distention, bowel sounds, and tenderness. Within the first hour or two of trauma, guarding and rebound sensitivity will usually NOT be present. The examiner relies on the initial location of tenderness to differentiate between various organ injuries. Place an NG tube, and check the aspirate for blood.
Palpate the flanks for tenderness and fullness, and compress the pelvis to elicit tenderness or crepitance. Check the integrity of the pubic symphysis, and evaluate the scrotum and perineum for hematomas and swelling. Do a rectal exam, noting prostate stability. Check the urethral meatus for blood.
If there is no scrotal hematoma or blood at the meatus, place a foley catheter. If a foley is contraindicated because of possible urethral injury, a suprapubic cystostomy will be needed if the bladder becomes full. A urethrogram can be performed when the timing is appropriate.
Inspect and palpate all extremities for deformity, swelling, and skin injuries. Check all peripheral pulses, marking them with a pen for the next examiner. Test motor function and skin sensation, if the patient’s level of consciousness allows.
Log-roll the patient so the back can be examined. Every inch of the patient is viewed and palpated. Back to Top
Laboratory Testing
At a minimum, the victim of trauma should have a baseline blood count and urinalysis. Severely injured patients should have a CBC, UA, electrolytes, blood gases, clotting studies, and type & crossmatch.
As a practical matter, a “trauma package” of lab work insures that you don’t forget something important. The extra cost of “unnecessary” tests is trivial compared to the overall expense of treating the trauma victim. The costs of delayed diagnosis associated with NOT ordering routine tests can be substantial.
Blood for lab tests can be drawn through the second IV catheter. This insures that there is no delay in starting fluids via the first IV. It’s best not to risk the first (and only) IV catheter being pulled out by a sudden patient motion while attached to a syringe. Ideally, much of the laboratory data will be returning as the secondary survey is completed. Back to Top
X-rays of the Trauma Patient
For the trauma patient, “x-ray everything that hurts.” In this circumstance, the concept of cost control should apply only to your malpractice rates.
The only caution is that unimportant x-rays not take precedence over treatment of life-threatening problems. For example, don’t delay operating on an epidural hematoma to take hand x-rays. If x-rays must be deferred, the reason for the delay should be written on the chart, along with a clear list of the x-rays desired. The films can be obtained later. Splint any extremity with a possible fracture if x-ray will be delayed.
Almost every patient with severe trauma should have a cross-table C-spine x-ray, chest x-ray, and pelvis x-ray. The rationale: Neck pain may be missed in a massively-injured patient, and the cost of missing a cervical fracture is great. The chest may have significant internal injury without external tenderness. Pelvic fractures are often present in patients with trunk trauma, and are often missed. Order these important x-rays before the patient leaves the emergency department for other care. Back to Top
Special Procedures
Common special procedures for trauma are 1) CT of the brain, 2) CT of the abdomen and pelvis, and 3) aortogram. These procedures will take the patient out of the emergency department. The patient must not be sent off while potentially unstable.
Special procedures should only be ordered when 1) the patient is sufficiently stable that there is little likelihood of deterioration during the time of the testing, 2) the information desired from the procedure cannot be obtained in other ways, and 3) the test is necessary to determine the next appropriate step of therapy.
For example, the patient who is in shock with a grossly positive peritoneal lavage doesn’t need abdominal CT scan. He need surgery. But a non-hypovolemic patient could undergo CT scan to assess the severity of injury and screen for other injuries.
Similarly, the patient with a temporal skull fracture, lucid interval, then rapid onset of signs suggesting uncal herniation should receive a burr hole ASAP. The CT scan is used when the diagnosis, and therefore the proper therapy, is in doubt.
The Role of Paracentesis
Paracentesis is a rapid method of determining the need for abdominal surgery. Paracentesis (peritoneal lavage) is not needed for patients who: 1) have a reliable, normal abdominal exam , 2) are fully stable to await CT scanning, or 3) urgently need abdominal surgery based on other findings. Assuming no contraindication, perform paracentesis on the potentially unstable trauma victim with possible abdominal injury who does not already have indications for abdominal surgery.
If the patient is fully alert, not in shock, and has no abdominal tenderness, abdominal injury is excluded — until the next examination. Many physicians have had the experience of the “left rib injury” patient who exhibits no signs of his ruptured spleen for a few hours.
Assume that any trauma patient with decreased level of consciousness has abdominal injury until excluded by paracentesis or CT scan.
If circumstances allow, a lateral decubitus abdominal film may be obtained before paracentesis. If free air is seen, the patient must have surgery. Paracentesis is unnecessary.
Any patient with a gunshot wound requires exploration, so paracentesis is not indicated. However, peritoneal lavage may be helpful in the stabbing victim to rule out bowel perforation. Back to Top
Monitoring of Resuscitation
During — and after — the secondary survey, the physician monitors the effects of prior resuscitation efforts. This is primarily through patient color, skin temperature, mental status, blood pressure, respiratory rate, and pulse rate.
If the patient does not respond to fluid infusion, a CVP (central venous pressure) monitoring catheter can be placed. A low CVP (less than 6) indicates the need for further fluid, while a high CVP raises suspicion of obstructive shock caused by tamponade or undiagnosed tension pneumothorax. The combination of inappropriate tachycardia with systolic pressures of around 80, warm extremities, and a normal CVP reading is typical of spinal shock.
A pulse oximeter provides a useful, rapid method of monitoring oxygenation in the patient with severe pulmonary injury. Progressive respiratory distress, or hypoxemia despite supplemental oxygen, warrants endotracheal intubation.
If the cuff blood pressure is difficult to obtain, or felt to be unreliable, place an arterial pressure catheter. Back to Top
Consultation and Disposition
Any physician whose physical presence may be required should be called as soon as you have any hint he or she may be needed. A physician who provides advice, or who will manage non-urgent problems, should be called once the work-up is complete enough to assign therapeutic priorities.
In general, the first physician called is the trauma surgeon, whose responsibility it is to coordinate the other aspects of care. Assuming a rapid response, the emergency physician can allow the surgeon to call the orthopedist, ophthalmologist, plastic surgeon, neurosurgeon, urologist, or internist as the need for other specialists becomes obvious. In cases where the injury seems clearly limited, such as an isolated head injury, the first call may be placed to another appropriate specialist.
The patient does not leave the emergency department for definitive care (whether to a tertiary care facility or to the operating room or to ICU) until the secondary survey and critical testing are complete. Back to Top
All material referenced through this menu is excerpted from copyrighted works by Bruce Argyle, MD. You are welcome to use selected portions, as long as appropriate credit is given. The credit for the text referenced through this menu is:
Argyle, B., Trauma One! Computer Program Manual.
Mad Scientist Software, Alpine, UT
Back to Main Text Resource Index Go to Mad Scientist Software's main index page