Trauma 2 Flashcards
Severity of initial injuries and outcomes in trauma are determined by two principal and non-modifiable factors:
- MOI
2. patient-related physciological factors (age, comorbidities)
Types of trauma
- Blunt (MCV, falls, sports accidents, assaults)** most common
- penetrating (stab wounds, gunshot wound)
- blast (blunt + penetrating + thermal)
Collisions that occur with blunt trauma
machine, body, organ
rapid deceleration can cause
Shearing force → stretching and tearing of structures at points of attachment
describe what happens with rapid deceleration of the body
Rapid deceleration of the body → continued downward or forward motion of internal structures → shear and tearing along the attachment of the organs and blood supply
compression trauma can cause
- Crushing of tissues by a direct blow or against an object
2. Compression of a closed space → rupture
__ is the greatest determinate of amount of force
speed
Hallmarks of high-energy mechanism
- Death in vehicle
- Significant intrusion
- Prolonged extrication
- Ejection
- Deformed steering wheel
- Stared windshield
- Rollover
Direction of impact (type of collision)
- Frontal impact (Head-on)*-> most common
- Lateral impact (T-boned)**–> highest morbidity and mortality
- Rear impact
- Rotational (corner)*
- Rollover
describe the factors in injury pattern with front impact collisions (head on)
- Up and over pathway
- Down and under pathway
- Dashboard damage/intrusion
- Airbag deployment
describe the factors in injury pattern with lateral impact collisions (t bone)
- Main force on side of impact
2. Amount of intrusion
describe the factors in injury pattern with rotational or corner impact collisions
- Similar injuries as those in frontal and lateral impact
describe the factors in injury pattern with rollover collisions
- Greater chance of ejection
2. Non-secure objects become projectiles
describe the factors in injury pattern with rear impact collisions
- Head rest placement
What are potential associated injuries with head on collision
- Facial injuries
- Lower extremity injuries
- Aortic injuries
What are potential associated injuries with windshield damange
- Closed head injuries, coup and countercoup injuries
- Facial fractures
- Skull fractures
4, Cervical spine fractures**
What are potential associated injuries with steering wheel damage
Thoracic injuries
- Sternal and rib fractures, flail chest
- Cardiac contusion*
- Aortic injuries
- Hemo/pneumothoraces
What are potential associated injuries with dashboard involvement/damage
- Pelvic and acetabular injuries
2. Dislocated hip (posterior dislocation)
Potential associated injuries with rear-end collision
- Hyperextension* injuries of cervical spine
- Cervical spine fractures
- Central cord syndrome
Potential associated injuries with lateral (T bone) collisions
- Thoracic injuries
- Abdominal injuries: spleen, liver
- Pelvic injuries
- Clavicle, humerus, rib fxs
Potential associated injuries with rollovers
- crush injuries*
2. compression fx of spine
Potential associated injuries with lab belt only
Chance fractures, abdominal injuries*, head and facial injuries/fractures
Major determinants of potential for fall injury:
- height of fall
- impact of surface
- landing position (feet first is most common, horizontal impact has highest mortality)
- age over 40
Potential associated injuries for falls with vertical impacts
- Calcaneal and LE fractures
- Pelvic fractures
- Renal and renal vascular injuries
- feet first - Closed head injuries
- Cervical spine fractures
- head first
Potential associated injuries for falls with horizontal impacts
- Craniofacial fractures
- Hand and wrist fractures
- Abdominal and thoracic visceral injuries
- Aortic injuries
Potential associated injuries for falls from standing
Hip, rib, spine, long bone fx’s
Closed head injuries
Factors determining the severity of injury in GSW
- bullet trajectory and path
- velocity (H, M, L)
- bullet caliber (mass) and bullet design (military vs hunting)
- number of bullet wounds
For stab wounds to the chest below the 4th ICS suspect __
intraabdominal injury
Who are more susceptible to serious injury from low-energy mechanisms
elderly
*Falls are #1 common cause of fatal and nonfatal injury
-Commonly have a medical cause resulting in fall
Ie. syncope, UTI
Complications from injuries in elderly
- Longer hospital stay, more complications
- Blunted response to pain and hypovolemia
- Hypotension and tachycardia thresholds are: 110 mmHg SBP and HR over 90 BPM
- Bleed due to higher likelihood of comorbiditis (anticoag use, MMP)
Take away points for trauma in elderlys
- check meds (BB, anticoagulants)
- normal VS can be misleading
- higher suspicion for injury
- lower threshold for diagnostic testing and admission
Why are pediatrics more likely to have organ damage w/ blunt abdominal trauma and more head trauma with falls
- less muscular abdomen
2. have bigger, softer heads
a pediatrics pliable skeleton may lead to what types of trauma injuries
- May suffer major internal injuries without fracture
- Laxity of ligaments and less calcified bones → spine injuries without bony abnormalities
3 compliant chest well–> pulmonary contusions
How do you estimate hypotension in children 1-10y/o
SBP less than 70 (2 x age) mmhg
*hypotension is a late and ominous finding
What neuro scale do you used for a child under 4
APVU over GCS
What is included in the trauma lab panel?
- CBC
- BMP
- LFTs
- lipase
- venous lactate
- ABGs
- CK in crush injuries
- Coags (aPTT, PT/INR, TEG)
- type and screen or crossmatch
- urinalysis
- Tox screen, EtOH
- pregnancy screen w/ B-hCG
10-20% patients with head injury also have a ___ injury
cervical spine
- Loss of consciousness is not the best predictor of intracranial pathology
- Not all patients with a severe head injury with have external signs of head trauma
high risk MOI of head injuries
- falls over 10ft
- auto vs ped
- MCV w/ ejection
- road cycling, skier/SB crash
- fall from standing w/ head trauma and LOC in pt on coumadin or dual antiplatlet tx
Skull fx are almost always associated with
- Intracranial trauma (contusion, ICH)
2. basilar skull fx–> r/o cerebrovascular injury
Must rule out c-spine injury in elderly __ and ___ (most commonly missed injury)
falls with head-trauma
High risk factors for cervical injuries
- axial loading injury
- fall over 1 meter
- High speed MVC/rollover/ejection
- Age over 65
- Paresthesia’s
- ATV, MC or bike collision
Most common MOI of of cervical spine injuries
- hyperflexion (most common)
- hyperextension (ie. whiplash)
- vertical compression injury (Burst fxs)
- flexion-rotation injury (verterbal artery injury)
C spine transverse process fx are often associated with
vertebral artery injury
Fractures of C4 and above are commonly associated with
paralysis of muscles of respiration (diaphragm innervated by C3-5)– worry about respiratory compromise
fractures of the middle C spine are often associated with
dysfunction of the UE more so than LE (central cord syndrome)
Imaging of cervical spine injuries
- Plain film
- CT– most sen. and spec. for spine injuries
- MRI– most sen. and spec. for ligamentous and spinal cord injuries
- CTA neck– evaluation of blunt cerebrovascular injury (BCVI) or seat belt sign
Who with C spine injuries get imaging?
*use NEXUS criteria for low probability of injury and Canadian criteria for detecting clinically important C-spine injury
high risk– get imaging
no low RFs– get imaging
Yes low RFs– ROM test
What is a Jefferson fracture
burst fracture of C1 from axial loading
*Both anterior and posterior arches break and transverse ligament is
(OMO lateral masses are wide)
What are odontoid fractures
Dens/C2 fractures from flexion, extension, and rotational injuries
What are Hangman’s fractures
bilateral pedicle fractures of C2 from Hyperextension + axial load
*Most common cervical spine fx
Most common cervical spine fracture
Hangman’s fracture (C2)
T5 fractures and above are at risk for
neurogenic shock
Symptoms of SCI
- Pain, focal sensory or motor deficit
- Weakness, paresthesia’s
- Urinary incontinence or retention
PE of SCI
- Focal neurological deficit
- Bilateral → cord injury
- Unilateral → peripheral nerve injury
- UE > LE → central cord - Decreased or absent rectal sphincter tone, diminished perineal sensation → cord injury
- Abnormal muscle tone (spasticity, flaccid) → incomplete or partial cord injury
SCI to what vertebra results in:
quadriplegia/tetraplegia and paraplegia
C4- quad/tetra below the neck
C6- parial paralysis of hands and arms and lower body
T6- para below chest
L1- para below waist
Management of suspected or known spine injury
- Immobilize c-spine, head of bed less than 30%, best rest, spine precautions
* Must stay flat until cleaned with imaging
Describe the disposition/mangement of SCI and spine injuries
- CT evidence of injury or neurologic deficit on exam →Consult Trauma and Spine/Ortho
- Admit to ICU if unstable fracture
- If spinal cord injury present → maintain normotensive BP**
- +/- Foley
- Serial neuro exams
- Bowel protocol for T/L spine injuries
What findings are commonly associated with
- pneumothorax/ hemothorax
- pulmonary contusion
- cardiac injuries
- diaphragmatic injuries
- pneumomediastinum
- pneumothorax/ hemothorax: rib fx
- pulmonary contusion: multiple rib fx
- cardiac injuries: sternal fx
- diaphragmatic injuries: usually on left, overpressure injuires and penetrating trauma is most common
- pneumomediastinum: esphageal injury, tracheal injury, ruptured piriform sinus
What patients need to be admitted for thoracic trauma?
- multiple rib fx (age over 65 w/ 3 or more rib fx–> admit to ICU)
- pneumothorax, hemothorax, pulmonary contusions
- pneumomediastinum
What type of abdominopelvic trauma MOI is associated with deform hollow organ and transiently increase intraluminal pressure; laceration of solid organ
compression force
What type of abdominopelvic trauma MOI is associated with vessel injuries, solid organs
deceleration force
What type of abdominopelvic trauma MOI is associated with diaphragmatic rupture, bladder/bowel rupture
over pressure force
Describe the injury patterns of abdominopelvic solid organ injuries:
- liver lac or hematoma:
- spleen lac or hematoma:
- kidney lac or hematoma:
- liver lac or hematoma: lower R rib fx
- spleen lac or hematoma: lower L rib fx (MOST COMMON INTRAABDOMINAL SOLID ORGAN INJURED)
- kidney lac or hematoma: lower posterior rib fx, T/L spine fx
Describe the injury patterns of abdominopelvic hollow viscus injuries:
- bowel injury
- bladder injury
- urethral injury
Bowel injury → usually from penetrating injury
Bladder injury → associated w pelvic fx
Urethral injury → associated w kidney and/or bladder injury
What patients with abdominopelvic trauma need to go to the OR or IR?
- hemodynamically unstable
- FAST
- solid organ injury with active extravasation
- bowel or mesenteric injury
- vascular injury
