TRAUMA:
Trauma: Trauma is defined as the transfer of energy applied clinically. It is an acute physiologic and structural change that occurs when an external source of energy is applied on the body, overwhelming the physiologic ability of the body to dissipate it.
Trauma Triage Criteria: These are a set of guidelines used to determine if a patient is a “Trauma activation”; meaning they have injuries that require the intervention of a team at a specialized trauma centre. The following criteria are used to determine trauma activation:
Physiological criteria:
Inability to follow commands.
SBP <90mmHg.
RR <10 or >30 breaths per minute, or requiring ventilatory support.
Anatomical Criteria:
Penetrating injuries to the head, neck, torso, or extremity proximal to the knee or elbow.
Chest wall instability or deformity.
2 or more proximal long bone fractures
Crushed, degloved, mangled, or pulseless extremity.
Amputation proximal to the wrist or ankle.
Pelvic fracture.
Open or depressed skull fracture.
Paralysis.
Mechanism of injury:
Falls (adults >6M) (Peds >3M).
High risk auto crash.
Pedestrian or cyclist struck, thrown, or run over with significant impact (>30km/hr).
Motorcycle crash >30km/hr.
Special criteria:
Age >55yrs increases risk of serious injury. Age >65 with SBP <110 may indicate shock.
Anticoagulation or bleeding disorders.
Burns with a trauma mechanism.
Pregnancy presumed to be >/=20 weeks gestation.
If the patient can be transported to a trauma centre within 30 minutes, transport directly. If transport will be >30 minutes, consider utilizing air ambulance with modified intercept at local ED.
Types of trauma:
Blunt trauma: Refers to injuries where the tissues are not penetrated by any external object. Energy is instead transferred across the tissues without disruption of the outer layer (skin).
Penetrating trauma: Refers to injuries where an external object penetrates through the tissues, causing a hole.
Deceleration injuries: These occur in situations where a body in motion is suddenly stopped, as occurs in falls, or motor vehicle collisions. Rapid deceleration results in shearing, avulsing, and rupturing injuries to the organs and tissues. When the body stops moving, there are several events. First the external surface of the body strikes the surface that has stopped it. Next the internal organs strike the inside surfaces of the body. Finally, secondary injuries may be sustained by objects that are also moving around the body when movement is stopped suddenly.
Injuries caused by external forces: Crush and Compression forces may be applied to the body externally. These forces occur at the time of impact, whereas deceleration injuries occur just before impact is complete.
Motor Vehicle Collisions:
There are 5 phases to an MVC:
Deceleration of the vehicle.
Deceleration of the occupant.
Deceleration of the internal organs.
Secondary collisions.
Additional impacts.
You need to bear in mind that multi-system trauma may be present, and may not be immediately obvious. Assessment of the scene and the vehicles involved may provide clues as to potential injury types. Always begin by looking at whether or not the occupants were wearing seatbelts, and if the airbags went off. Additional things to look for include:
A cracked windshield with an unrestrained driver indicates a head injury.
A deformed steering column means potential compression injuries to the thorax.
A deformed dashboard can indicate possible abdominal, pelvic, and lower limb injuries.
Damage to the side of the vehicle can suggest injuries to the head, neck, torso, and extremities on that side.
Broken windows can indicate potential lacerations.
Posterior impact should suggest possible neck injuries.
Ejections can indicate severe trauma to all systems.
Pedestrian injuries:
In general there are 2 patterns of injury when a vehicle strikes a pedestrian. Adults tend to turn away from impact, and are thrown up and over the vehicle. Children tend to turn toward impact and travel down and under the vehicle. In adults we see 3 major injury patterns:
The bumper strikes the legs, causing knee and lower limb trauma.
Injuries to the head, thorax, and pelvis occur as the adult is thrown over the vehicle.
Additional trauma occurs as the adult strikes the ground.
In children we see an injury pattern known as the Waddell Triad:
The bumper hits the femurs and pelvis.
The chest and abdomen hit the grille.
The head strikes the vehicle and then the ground.
Falls from height:
The injuries sustained will depend upon the height of the fall, the position of the patient at the time of impact, the area over which the impact is distributed, and the surface type the patient lands on. In general the most common injury occurs from landing directly on ones feet or head, in an axial load injury. This causes compression of the spinal column and brain.
Penetrating trauma:
The most common sources of penetrating trauma injuries are stab wounds and gunshot wounds.
Stab wounds: The severity of the injury depends on the area involved and the anatomical structures located there, the length of the blade, and the features of the blade (serrated, straight, curved, etc).
Gunshot wounds: Gunshot injuries are significant, although they may not produce obvious significant external trauma. When a bullet enters the body, it creates a vacuum in its wake, with a force known as cavitation. This causes additional trauma to the tissues around the path of entry, and pulls additional debris into the cavity created. Shock waves caused by the expansion of gasses further injure structures and tissues distal to the side of entry, causing additional trauma. In general, the entry wound is usually well defined, depending on the calibre and distance from the actual weapon at the time of injury. Exit wounds, if there are any, are much more pronounced as the tissue is extruded out the opening at the time of injury. Additional complications include fragmentation, if the bullet shatters upon entry , causing multiple paths of injury in the body. Shotgun wounds present a significant problem, as multiple entry and exit wounds may occur.
Blast injuries:
There are 4 types of injury in a blast scenario:
Primary blast injuries: These are directly caused by the pressure wave generated by the blast itself.
Secondary bast injuries: These injuries are the result of debris thrown by the pressure wave.
Tertiary blast injuries: These occur when the patient thrown by the blast strikes a stationary surface.
Miscellaneous injuries: Additional trauma related to but not directly tied to the initial blast.
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