Trauma (medicine)


Trauma (medicine)
Trauma
Classification and external resources
Health care providers attending to a person on a stretcher with a gunshot wound to the face. The patient is intubated, and a mechanical ventilator is visible in the background.
Hospital corpsmen and medical officers of the United States Navy assess an intubated patient with a gunshot wound
ICD-10 T79
ICD-9 900-957
DiseasesDB 28858
MedlinePlus 000024
eMedicine trauma
MeSH D014947

Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident."[1] It can also be described as "a physical wound or injury, such as a fracture or blow."[2] Major trauma (defined by an Injury Severity Score of greater than 15)[3] can result in secondary complications such as circulatory shock, respiratory failure and death. Resuscitation of a trauma patient often involves multiple management procedures. Trauma is the sixth leading cause of death worldwide, accounting for 10% of all mortality, and is a serious public health problem with significant social and economic costs.

Contents

Classification

Trauma can be classified by the affected area of the body[4] (percentages of total incidence[5]):

Trauma may also be classified by the affected demographic group (for example, trauma in the pregnant, pediatric, or geriatric patient).[4] They may also be classified by the type of force applied to the body, such as blunt trauma versus penetrating trauma.

Causes and risk factors

Blunt trauma is the leading cause of traumatic death in the United States.[6] Most cases of blunt trauma are caused by motor vehicle accidents.[6] Falls, a subset of blunt trauma, are the second most common cause of traumatic death.[7] In most cases a fall of greater than three times the victim's height is defined as a severe fall.[7] Penetrating trauma is caused when a foreign object such as a bullet or a knife enters a tissue of the body, creating an open wound. In the United States most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms.[8] Blast injury is a complex cause of polytrauma. It commonly includes both blunt and penetrating trauma and may also be accompanied by a burn injury.

By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems can help to enhance the overall health of its population.[9] Ingestion of alcohol and illicit drugs are risk factors for trauma, particularly traffic collisions, violence and abuse.[5] Long-acting benzodiazepines increase the risk of trauma in elderly people.[5]

Diagnosis

Radiograph of a close-range shotgun blast injury to the knee. Birdshot pellets are visible within and around the shattered patella, distal femur and proximal tibia.
Radiograph of a close-range shotgun blast injury to the knee. Birdshot pellets are visible within and around the shattered patella, distal femur and proximal tibia.

Physical examination

The purpose of the primary survey is to identify life-threatening problems. Upon completion of the primary survey, the secondary survey is begun. This may occur during transport or upon arrival at the hospital. The secondary survey consists of a systematic assessment of the abdominal, pelvic and thoracic area, complete inspection of the body surface to find all injuries, and a neurological examination. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's emergency department), but rather manifests itself at a later point in time.[10]

Imaging

X-rays of the chest and pelvis are commonly performed in major trauma.[5] Focused assessment with sonography for trauma (FAST), can also be used. Computed tomography (CT) scans are the gold standard in imaging in major trauma.[11] They however may only be performed in people with a relatively stable blood pressure, heart rate, and sufficient oxygenation.[5] Full-body CT scans known as pan-scans improve survival in those who have suffered major trauma.[12] The scans are done using intravenous radiocontrast but not oral contrast.[13] There are concerns of radiation exposure and concerns regarding negative effects of contrast on the kidneys. However some centers routinely do CTs with contrast before verifying renal function even in the elderly and have not found negative side effects with respect to the kidneys.[11] With modern imaging technology a complete scan can be performed in less than 10 minutes.[5] In the emergency department in the United States CT or MRI imaging is done in 15% of people who present with injuries as of 2007 (up from 6% in 1998).[14] In those who poor blood pressure or a fast heart rate from a presumed abdominal bleeding delaying surgery for abdominal CT imaging may worsen outcomes.[15]

Surgical techniques

Surgical techniques, such as diagnostic peritoneal lavage, placement of a thoracostomy tube, or pericardiocentesis are often used in cases of severe blunt trauma to the chest or abdomen, especially in the setting of deteriorating hemodynamic stability. In those who are hypotensive due to presumed internal abdominal bleeding transfer to the operating room for a laporotomy is the preferred method of determining a definitive diagnosis.[5]

Management

Color photograph of a United States Navy hospital corpsman listening for correct placement of an endotracheal tube in a simulated trauma victim during a search and rescue exercise. His assistant is holding a bag of intravenous fluid.
A Navy corpsmen listens for the correct tube placement on an intubated trauma victim during a search and rescue (SAR) exercise

People who have severe trauma frequently require specialized physicians and equipment. Designated trauma centers have improved outcomes compared to non designated centers.[5] The transfer directly to a trauma center is associated with improved outcomes compared to transfer to a non trauma center.[16]

Stabilization and transportation

Color photograph of a room designed to handle victims of major trauma. Visible are an anesthesia machine, a Doppler ultrasound device, a defibrillator, a suction device, a gurney, and several carts for storing surgical instruments and disposable supplies.
The trauma room in the emergency department of the University Hospital in Mannheim, Germany

In the prehospital setting the use of stabilization techniques improve the chances of a person surviving the transport to the nearest trauma-equipped hospital. After ensuring their own safety and taking isolation precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) then an assessment of the level of consciousness.[10] To prevent further injury, unnecessary movement of the spine is minimized by securing the neck with a cervical collar, and the back with a long spine board with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person.[17] Unless the person is in imminent danger of death, first responders will typically "load and go," transporting immediately to the nearest appropriate facility.[10] Helicopter EMS transport reduces mortality compared to ground based transport in adult trauma patients.[18]

Rapid transportation of those who are severely injured is associated with improved outcomes.[5] In the prehospital environment, the availability of advanced life support does not improve outcomes for major trauma, when compared with basic life support.[19][20] The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation and some evidence has found it may be harmful.[21]

People who have suffered trauma may require specialized care, including surgery and blood transfusion. Outcomes are better if this occurs as quickly as possible thus the so called golden hour of trauma. This is not a strict deadline, but recognizes that many deaths which can be prevented by appropriate care occurring in a relatively short time after injury.[22]

Community-based trauma referral systems seek to decrease overall injury-related morbidity and mortality and years of life lost within a population by ensuring the provision of optimal care during both the acute and late phases of injury.[9] The care of acutely injured people is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital assessment and care by emergency medical services personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups.[23] An established trauma system network is also an important component of community disaster preparedness, facilitating the care of victims of natural disasters or terrorist attacks.[9] In those with cardiac arrest due to trauma cardiopulmonary resuscitation (CPR) is considered futile but still recommended.[24]

Intravenous fluids

Traditionally high volume intravenous fluids were given in people with hemodynamic instability due to trauma. This is still appropriate for those with isolated extremity, thermal or head injuries.[25] The current evidence however supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist (known as permissive hypotension).[4][25] A target mean arterial pressure of 60mmHg or a systolic blood pressure of 90 mmHg is recommended.[26] If blood products are needed a greater relative use of fresh frozen plasma and platelets to packed red blood cells has been found to result in improved survival and less overall blood product usage.[27] A ratio of one:one:one is recommended.[26]

Blood substitutes such as hemoglobin-based oxygen carriers and perfluorocarbon emulsions are in development. As of June 2008 however there are none available for commercial use in North America or Europe.[28][29] The only countries where these products are available for general use is South Africa and Russia.[28]

Medications

In people who are bleeding due to trauma tranexamic acid decreases mortality.[30][31] Factor VII may also be appropriate in certain cases associated with severe bleeding[25] such as those who have bleeding disorders.[5] While it decreases blood use it does not appear to decrease mortality.[32]

Surgery

Damage control surgery is employed in the management of trauma.[5] This involves performing the least number of procedures to save life and limb.[5] Less critical procedures are left until the person is more stable.[5]

Prognosis

Death from trauma have been classically described as occurring during three peaks: immediately, early, and late. The immediate deaths are usually due to apnea, severe brain or high spinal cord injury, and rupture of the heart or large blood vessels. The early deaths occur within minutes to hours and are often due to a subdural hematoma, epidural hematoma, hemothorax, pneumothorax, ruptured spleen, liver laceration, or pelvic fractures. This is known as the golden hour. The late deaths occur days or weeks after the injury.[10] This classical distribution however may no longer be occurring in the United States due to improvements in care.[5]

Long term prognosis is also frequently complicated by pain with over half of people having moderately severe pain one year later.[33] Many also experience a reduced quality of life years later.[34] 20% of people who sustain a traumatic injury will sustain some form of disability.[35] Physical trauma can lead to development of post-traumatic stress disorder (PTSD).[36] However, one study found no correlation between the severity of trauma and the development of PTSD.[37]

Epidemiology

Deaths from injuries per 100,000 inhabitants in 2004[38]
  no data
  < 25
  25-50
  50-75
  75-100
  100-125
  125-150
  150-175
  175-200
  200-225
  225-250
  250-275
  > 275
Incidence of accidents by activity

Trauma is the sixth leading cause of death (accounting for 10% of all mortality) worldwide, and the fifth leading cause of significant disability.[3] In people between the ages of 1–45 years, trauma is the leading cause of death.[3][4][22][35][39] The primary causes of death are central nervous system injury, followed by exsanguination.[3]

Research

Patients who were admitted into an ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.[40]

In children

Accidents are the leading cause of death in children 1–14 years of age.[35] In the US approximatively 16,000,000 children go to an emergency department due to some form of injury every year.[35] Male children are more frequently injured then female children by a ratio of two to one.[35] The top five worldwide unintentional injuries in children are as follows:[41]

Cause Number of deaths resulting
Traffic collision

260,000 per year

Drowning

175,000 per year

Burns

96,000 per year

Falls

47,000 per year

Toxins

45,000 per year

An important part of managing trauma in children is weight estimation. A number of methods to estimate weight exist including the: Broselow tape, Leffler formula, and Theron formula.[42]

In pregnancy

Trauma occurs in 6-7% of all pregnancies and is the leading cause of maternal death. Trauma during pregnancy is a serious issue as the mothers will have an increased heart rate and increased blood pressure to accommodate the child, these hemodynamic changes will alter the presentation of shock.[4][43]

There are diagnostic issues during pregnancy as ionizing radiation can cause birth defects[4]

References

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