Trauma Overview


Initial Orders:

 

 

CONSIDERATIONS FOR TRAUMATIC INJURY

Motor Vehicle Collisions

  • Weight and size of vehicle
    • Inversely proportional to severity of injury
  • Speed of vehicle
  • Location of patient in vehicle
  • Type of crash and associated serious injuries:
    • Lateral/T-bone: head, cervical spine, thoracic and abdominal injury
    • Front end: head, cervical spine, thoracic, abdominal, pelvic and lower extremity
    • Rear end: over-extension of cervical spine (whiplash injury to neck)
    • Roll over: energy dissipated, less likely severe injury if victim restrained by seatbelt
    • Ejection of patient from vehicle/entrapment of patient under vehicle
  • Degree of damage to vehicle, (especially if intrusion into passenger compartment)
  • Broken windshield (head and cervical spine injury), condition of steering wheel (chest injury), knees to dashboard (hip, femur injury)
  • Use and type of seatbelt
    • Lap belt: Spine and abdominal injury
    • Shoulder belt: look for major vessel injury
  • Airbag deployment
  • Death of same vehicle occupant
  • Motorcycle collisions
    • Motorcycle speed.
    • Site of anatomic impact.
    • Use of helmet.
  1. Broken windshield
    • Suspect
      • Closed head injury
      • Skull fractures
      • Facial fractures
      • C-spine fractures
         
  2. Knees hit dashboard
    • Suspect
      • Hip dislocation
      • Fracture of hip / femur
      • Fracture of acetabulum
         
  3. Rollover (lower body trapped under vehicle)
    • Suspect
      • Crush injury
      • Pelvic / lower extremity fractures
      • Compartment syndromes
         
  4. Broken steering wheel
    • Suspect
      • Deceleration injuries to chest
        • Aortic rupture
        • Pulmonary contusion
        • Sternal fracture
        • Flail chest
        • Pneumothorax
        • Cardiac contusion
      • Upper abdominal injuries
        • Liver / spleen injury
        • Diaphragmatic rupture
        • Pancreaticoduodenal injury
  5. Rear-end collision
    • Suspect
      • Hyperextension injuries C-spine
      • Central cord syndrome
         
  6. Seat belt use
    • Lap belt worn incorrectly
      • Suspect
        • Mid-lumbar spine fracture
        • Hollow viscus injuries
    • 3-point belt restraint
      • Rib fractures
      • Clavicle fractures
      • Sternal fractures
      • Pulmonary contusion

 

Pedestrian-Automobile Crash

  1. Low-speed, VS adult
    • Suspect
      • Tibial plateau fracture
      • Knee ligament injuries
  2. Low-speed, VS child
    • Suspect
      • Closed head injury
      • Chest / abdomen injuries
  3. High-speed
    • Suspect
      • Life-threatening multisystem injury

Falls

  1. Estimate fall height
    • 1 story = 12 feet
    • Falls > 20 feet should go to trauma center
    • 4-story (48 foot) fall: 50% mortality
    • 7-story (84 foot) fall: 90% mortality
  2. Supine impact
    • Suspect
      • Axial and appendicular skeleton injuries
      • Renal artery thrombosis
        • Caused by intimal tear
        • Potentially bilateral
  3. Prone impact
    • Suspect
      • Deceleration injuries
        • Facial fractures
        • Chest-aortic rupture
        • Abdomen
      • Closed head injury
      • C-spine injury
  4. Upright impact
    • Suspect
      • Calcaneal fractures
      • T/ L spine fractures
      • Spinous process fractures
      • Pelvis fracture
      • Femur / leg fractures
        • Severe
        • Comminuted

Assault

  • Weapon used
  • Strangulation
  • Sexual assault (see Common ER Presentations section)

 

Gunshot Wounds

Background
  • Wound ballistics determined by characteristics of missile and tissue
  • Bullets of equal wounding potential may produce wounds of varied severity depending on several variables
    • Mass of bullet
      • Caliber
    • Form of bullet
      • Full metal Jacket
      • Expanding / fragmenting projectile
    • Velocity of bullet
    • Area of target struck
    • Angle target struck from
       
  • General principles
  • Caliber of bullet is not the strongest indicator of wounding potential
    • Does not disclose bullet mass
    • Larger calibers do make bigger holes
  • Velocity (typical U.S. classification)
    • Not a significant factor
    • Low velocity < 2000 feet/sec
    • High velocity > 2000 feet/sec
  • Penetration
    • Depth to which bullet enters tissue
  • Ammunition:
    • Inherent "controllable" characteristics
      • Mass
      • Shape, construction
      • Velocity
    • Conferred "uncontrollable" characteristics
      • Angle of attack at impact
      • Composition of target
    • Civilian rounds
      • Usually deformable - expand on impact
        • Size of injury is increased
        • More tissue is crushed
      • Can potentially cause more damage than military equivalents
    • Military rounds
      • More often have full metal jacket
      • Tend to "tumble" in target
      • May pass through target with little deformation
         
  • Pathophysiology
  • Tissue Damage
    • Permanent cavity
      • Direct crush of tissue
      • Disruption / damage directly caused by projectile
      • Represents destroyed tissue
      • Related to size of projectile
      • Related to degree of yaw (projectile "tumbling") in tissue
    • Temporary cavity
      • Tissue "stretch"
      • Can be 11 times permanent cavity diameter
      • Lasts only few milliseconds
      • Essentially similar to blunt trauma
      • Can disrupt blood vessels, break bone
      • Substantial effects in
        • Minimally elastic tissue (brain, liver)
        • Fluid filled organs
  • Injury determined by
    • Tissue struck
      • Elasticity, density
      • Physiological importance of the tissue
        • Heart/ brain > hand/arm/gut
    • Amount of tissue injured
      • Bullet size
      • Bullet "tumbling"
        • Sideways bullet injures more tissue
      • Bullet deforming
        • Creates a larger projectile/wound diameter
        • More tissue injured
      • Bullet fragmenting
        • Makes multiple projectiles
        • More damage
    • Velocity
      • May not be a significant factor in wound formation
         
  • Diagnostics
  • Inspect body for hemorrhage and wounds
    • Locate all wounds by inspection; place wound markers for imaging
      • Many wounds get missed
        • Scalp
        • Back
    • Estimate missile path for visualization of possible organ damage
  • Wound types
    • Be careful classifying "entrance" and "exit" wounds
      • Misclassified > 50% of time by ED, surgeons
      • What matters is path of projectile
      • If there is only 1 wound, then it's clearly an entrance wound
    • Entrance wounds
      • Do not necessarily correlate with bullet caliber
        • May be smaller
        • Elastic tissue contracts around wound defect
      • Contact wounds
        • Weapon in contact with skin
        • Usually see burning of skin around wound
        • May see stellate laceration
      • Close range wounds
        • Weapon 6-12 inches from target
        • Soot deposited around wound
      • Intermediate range wounds - short
        • See "tattooing or stippling" around wound
          • Punctate abrasions
          • From unburned gunpowder
        • Usually weapon < 60cm from tissue
      • Long-distance wounds
        • Usually see "abrasion collar" around bullet hole
        • From friction between bullet and epithelium
    • Exit wounds
      • NOT consistently larger than entrance wounds
      • Skin everted outwards
      • NEVER any abrasion collar, soot or tattooing
         
  • General Treatment Principles
    (For in-depth treatments, please see specific anatomical area involved under Ortho)
  • TREAT THE WOUND - NOT THE WEAPON
    • Base decisions on exam and x-rays - NOT "high-velocity / low-velocity" conjecture
  • Follow ATLS ABCs
  • Wound care
    • Conservative debridement of tissue
    • Don't sacrifice viable tissue if you are not sure
  • Tetanus prophylaxis
  • Antibiotics
    • A controversial topic
      • Gunshot wounds are contaminated
    • Antibiotics should be prescribed on a case-by-case basis
    • High risk wounds:
      • Contaminated by soil, dirt
      • Open fractures
      • Patient immune status compromised
        • Diabetes
        • HIV
        • Massive transfusion
        • Steroid / immunosuppressant use
    • If chosen:
      • Antibiotics should be initiated early
      • Simple extremity GSWs
        • Cefazolin
        • Ampicillin-sulbactam
        • TMP-SMX
        • Clindamycin
  • Penetrating Injuries

    1. Any periorbital penetration
      • Suspect
        • Intracranial penetration
        • Carotid-cavernous sinus fistula
    2. Anterior neck penetration
      • Suspect
        • Retropharyngeal hematoma
          • Potential airway compromise
          • Potential esophageal injury
        • Vascular injuries
    3. Central chest penetration
      • Suspect
        • Cardiac injury
        • Pneumo/hemothoraces
          • Potential for large intrathoracic blood loss
        • Great vessel injury
    4. Buttocks penetration
      • Suspect
        • Rectal injury
        • Peritoneal penetration

    Other Injuries

    1. Strangulation
      • Suspect
        • Crushed larynx
        • Hyoid bone fracture
        • Carotid artery injury
          • Intimal layer of artery
    2. Localized epigastric/ right upper quadrant trauma (bicycle handlebar)
      • Suspect
        • Intramural duodenal hematoma
        • Solid organ injury
    3. Patient buried (e.g., trench cave-in)
      • Traumatic asphyxia