Updated: 12/28/2021

Mechanisms of Trauma

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  • Snapshot
    • A 35-year-old male presents to the ED C-collared on a backboard after being hit in a motor vehicle accident. He breathes spontaneously without any frank bleeding, but bruises are noted throughout his hip and abdomen. His blood pressure is 90/60 mmHg, pulse is 110/min, respirations are 20/min, and SaO2 is 95% on room air. After 1 L Lactated Ringer's and some pain medications are administered, the radiology technician takes images of his C-spine, chest, and pelvis. The pelvic radiograph is shown.
  • introduction
    • Trauma is the leading cause of death in patients < 45 years old (accident, homicide, suicide)
      • causes more deaths in children/adolescents than all diseases combined
    • Timeline of trauma mortality is important for prognosis
      • minutes: death usually at scene
      • early: death within 4-6 hours without intervention
      • days-weeks: death from multiple organ dysfunction, sepsis, etc.
    • Broadly, trauma is either blunt or penetrating
      • blunt is more common
    • Knowing mechanism is important to anticipate injuries for appropriate triage
    • Beyond managing trauma, underlying cause must always be sought (6 S's)
  • Presentation of Mechanisms
    • Motor vehicle collision
      • head-on: head/facial, thoracic (aortic), lower extremitiy (LE) injury
        • aortic tear (aortic transection) presents with rapidly worsening blood pressure and a widened mediastinum
      • lateral/T-bone: head, cervical, thoracic, abdominal, pelvic, LE injury
      • rear-end: hyper-extension of cervical spine (whiplash injury)
      • rollover accidents: most fatal
    • Pedestrian-automobile impact
      • children: high risk of run-over injury (multisystem)
        • Waddell's triad: tibia-fibula or femur fracture, intrathoracic/abdominal injury, contralateral head injury
          • fibular fracture associated with fibular nerve injury
      • adult: generally lower extremity injury, but also truncal and head injury from impact
    • Falls
      • landing position important
        • vertical: LE, pelvic, spine, head injury (impact ascends through skeleton)
        • horizontal: facial, UE, rib fractures; intrathoracic and abdominal injuries
    • Gunshot wounds (GSW)
      • injury depends on weapon used, location of GSW(s), and underlying structures
        • handgun: low/medium velocity, extent of damage may be limited to small area
        • hunting rifle: high velocity, widespread injury
        • shotgun: widespread tissue damage at close range, wadding deposition in wound
    • Stab wounds (SW)
      • injury depends on weapon used (length in particular), location of SW(s), underlying structures
      • type of penetration can vary (stab, slash, impalement)
    • Amputation
      • transport amputated appendage wrapped in moist gauze, put in a plastic bag, placed on ice
    • Dental trauma
      • avulsed tooth should be immediately gently cleaned (rinse, do not scrub) and replaced in the socket as soon as possible
      • transport medium for avulsed tooth
        • milk or special tooth solution
    • Cervical spine fractures
      • presents with midline spinal tenderness +/- neurologic deficits if cord compression
      • stable fractures without cord compression are often managed non-operatively with a hard collar
      • types
        • Jefferson burst fracture
  • evaluation and management
    • Primary and secondary surveys with resuscitation as needed
      • intubation - secure the airway first
        • indications
          • failure to oxygenate
          • failure to ventilate
          • inability to protect airway (GCS < 8)
          • impending airway loss
        • complications
          • esophageal intubation
          • intubation of the right mainstem bronchus 
          • inability to intubate
            • perform an emergency cricothyrotomy
          • inability to extubate
            • tracheal stenosis
              • from chronic intubation resulting in a narrowed airway and inspiratory stridor
      • type and cross for potential transfusions as soon as possible
        • establish IV access or IO access if not possible
      • for penetrating injuries, do NOT remove object if present in body
        • may be tamponading vessel
        • remove in operating room
    • Amputated body part
      • wrap amputated body part in saline-moistened sterile gauze and sealed in sterile plastic bag
  • Imaging
    • Doppler ultrasound
      • perform to assess vascular injury or compromise
      • the presence of distal pulses does not rule out vascular injury
    • radiography (XR/CT)
      • based on mechanism of injury
      • never send unstable patient to CT scanner - obtain focused assessment with sonography in trauma (FAST) exam or diagnostic peritoneal lavage if FAST equivocal
    • MRI
      • indicated for all traumatic spinal cord injuries with neurologic deficits
  • SUMMARY
    • Trauma does not cause isolated injuries
      • as suggested in Waddell's triad above, think about other possible injuries to anticipate necessary interventions (and possible test question answer choices!)
      • Principles
        • chief concern: vascular compromise
        • consider nearby vasculature
        • if no nearby vasculature next best step: cleaning + tetanus ppx
        • if nearby vasculature and stable vitals next best step: doppler studies or CT angiogram
        • if clear vascular injury (absent pulses, worsening hematoma) next best step: surgical exploration
      • injury to bone, artery and nerve
        • next best step: repair the bone first - this is rough work
        • second step: vascular repairthird step: nerve repair
        • ppx: fasciotomy to protect from compartment syndrome
      • shotgun, military contraband injuries
        • tend to be high velocity and cause a large area ("cone") of tissue destruction
        • next best step: surgical debridement, amputation if severe, antibiotics, tetanuscrushing injuries
        • worry about hyperkalemia, myoglobinemia/uria, renal failure and compartment syndrome
        • next best step: IV fluids, mannitol, alkalinization of the urine and management of severe electrolyte abnormalities as presented
      • The next best step is never management of the pathology if the patient's vitals are unstable or could lose an airway - never forget ABCs of resuscitation!
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(M2.OR.17.4799) A 17-year-old high school student was in shop class when he accidentally sawed off his pointer finger while making a bird house. He fainted when he realized his finger had been cut off. The teacher immediately transported the patient to the emergency department and he arrived within 20 minutes. He has a past medical history of asthma, and his only medication is an albuterol inhaler. The patient's current blood pressure is 122/78 mmHg. Analgesics are administered. The teacher states that he left the amputated finger in the classroom, but that the principal would be transporting it to the hospital. Which of the following is the correct method of transporting the amputated finger?

QID: 109210

Submerge the finger in ice water

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(0/43)

Wrap the finger in moist gauze

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(1/43)

Wrap the finger in moist gauze and place on ice

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(0/43)

Wrap finger in moist gauze, put in a plastic bag, and place on ice

91%

(39/43)

Wrap the finger in moist gauze and submerge in ice water

2%

(1/43)

M 7 D

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(M2.OR.17.57) A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

QID: 106381

Lateral radiograph (x-ray) of hips

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(0/20)

Computed tomagraphy (CT) scan of his hips and lumbar area

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(1/20)

Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area

85%

(17/20)

Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area

5%

(1/20)

AP and lateral radiographs of hips

0%

(0/20)

M 6 D

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(M3.NE.15.61) A 45-year-old man was a driver in a motor vehicle collsion. The patient is not able to offer a medical history during initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% on room air. On exam, he does not open his eyes, he withdraws to pain, and he makes incomprehensible sounds. He has obvious signs of trauma to the chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of the left femur. What is the best initial step in management?

QID: 103352

100% oxygen

18%

(3/17)

Emergency open fracture repair

41%

(7/17)

Exploratory laparoscopy

6%

(1/17)

Intubation

6%

(1/17)

Packed red blood cells

24%

(4/17)

M 11 E

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