Updated: 1/4/2020

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 to Mechanisms of Trauma
  • 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 collison
    • 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 
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
  • 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  
  • Amputated body part
    • wrap amputated body part in saline-moistened sterile gauze and sealed in sterile plastic bag
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 repair
      • third 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, tetanus
    • crushing 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!
 

References

Amputated body part wrap amputated body part in saline-moistened sterile gauze and sealed in sterile plastic bag 
 

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Questions (11)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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? Review Topic | Tested Concept

QID: 109210
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Submerge the finger in ice water

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Wrap the finger in moist gauze

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Wrap the finger in moist gauze and place on ice

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

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Wrap the finger in moist gauze and submerge in ice water

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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? Review Topic | Tested Concept

QID: 106381
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Lateral radiograph (x-ray) of hips

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

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

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

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AP and lateral radiographs of hips

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(M3.OR.16.1) A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient? Review Topic | Tested Concept

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CT lower extremities

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Radiograph lower extremities

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Coagulation studies and blood typing/crossmatch

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Tourniquet of proximal lower extremity

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Emergent surgery

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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? Review Topic | Tested Concept

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100% oxygen

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Emergency open fracture repair

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Exploratory laparoscopy

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Intubation

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Packed red blood cells

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