Trauma Overview

Trauma is physical injury occurring due to mechanical force, and is divided into:

A systematic approach of triage and assessment is required to efficiently and effectively identify and treat patients and injuries in the appropriate order.

Triage and management of mass casualty scenarios are covered Triage and Major Incident Assessment and Medical Management; the initial assessment and management of the trauma patient is covered under Primary Survey.

Epidemiology

Risk factors:

  • Young

Mechanism:

  • Falls
    • Height
      • >6m in adult
      • >3m in child
  • Motor vehicle
    • Partial ejection
    • Complete ejection
    • “Bullseye” sign on windscreen
    • Death of another passenger in the same compartment
    • Motorcycle >30km/hr
    • Seat belt used
      Significant ↓ mortality.
    • Air bags
      • ↓ Mortality
      • May cause thoracic injuries
  • Pedestrian
    • Run over
    • Impact >30km/h

Patterns of Injury

In general:

  • Chest trauma
    • Is usually blunt
    • Makes ~25% of all trauma deaths
  • Abdominal
    • Mortality ~8%
  • Pelvic
    • Mortality ~10%
Injury Patterns by Mechanism
Mechanism Details Injuries
Car
  • Windshield damage
  • Head
    • Scalp
  • Cervical spine
  • Steering wheel damaged
  • No steering wheel airbag
  • Chest
  • Cardiac
  • Dashboard damage
  • Head
  • Cervical spine
  • Pelvis
  • Lower limb
  • Sudden deceleration
    • Head-on
    • Highs speed collision
    • Unrestrained occupant
  • Aortic dissection
  • Mesenteric tear
  • Lateral impact
  • Pelvis
  • Lower limb
  • Rear impact
  • Cervical spine
  • Ejection
  • Head
  • Cervical spine
  • Rollover
  • Head
  • Cervical spine
Motorcycle
  • Helmet
  • Cervical spine
    Head relatively protected.
Pedestrian vs. car
  • Adult
  • Lower limb
    Bumper impact.
  • Head
    Windshield impact.
  • Children
  • Head
    Run under.
  • Torso
    Bonnet impact.
  • Lower limb
    Bumper impact.
Falls
  • Land on feet
  • Lower extremity
    • Bilateral calcaneal
  • Pelvic fracture
  • Spinal compression fractures

Chest Trauma

Rapid identification and treatment of chest trauma is critical as most life-threatening chest injuries:

Complex life-threatening injuries are usually fatal prior to arriving at hospital.

  • Respond to simple interventions
    Restoration of cardiopulmonary function also limits secondary injury.
  • Can be identified clinically or with bedside investigation Beside ultrasound allows diagnosis of:
    • Pneumothorax
    • Haemothorax
    • Pericardial collection

The majority of injuries sought in the primary survey are chest injuries.

Abdominal Trauma

  • Solid organ injury is common after blunt trauma
  • Bowel injury is rare in blunt trauma but common in pemetrating trauma
  • Laparotomy is management tool of choice for:
    • Haemodynamic compromise
    • Peritonism
    • Evisceration
    • Impalement
  • Interventional radiographic treatment of:
    • Solid organ injuries with active contrast extravasation
    • Retroperitoneal haemorrhage
  • Diagnostic laparoscopy is appropriate in stable patients with appropriate surgical expertise
  • Serial abdominal exam is appropriate for low-risk patients

Pelvic Trauma

  • Urinary tract injury is more common after blunt trauma
    • Blunt injury to a distended bladder can cause rupture which requires operative repair
    • Extravasation of contast can be seen on CT 10-20 minutes after contrast injection or on a retrograde cystogram

Investigations

Imaging:

  • CXR
    Majority of clinically significant injuries are identifiable on CXR.
  • CT
    CT angiography allows diagnosis of particular injuries, particularly:
    • Aortic dissection

Complications

  • H
    • Acute traumatic coagulopathy

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.