Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Jun 2 2024

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!
1 of 0
1 of 12
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options