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Updated: Dec 28 2021

Mechanisms of Trauma

Images knife.jpg
  • 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
    • 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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