trauma
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Introduction
Wounds & injuries
Epidemiology
- firearm deaths now leading cause of death from trauma is U.S. exceeding deaths from motor vehicle accidents[18]
Laboratory
- screening laboratory panels have low utility & are not cost effective[1]
- INR not useful for guiding fresh frozen plasma use[9]
- thromboelastography may be useful for guiding use of fresh frozen plasma[9]
Radiology
- screening radiographs have low utility & are not cost effective
- total body CT may not lower mortality insevere trauma compared with standard imaging[14][16]
- avoid whole body CT in pediatric trauma patients[17]
Complications
- 2-4% of blast (explosion) - related trauma may be complicated by fungal infection from contaminating environmental material[7]
- triad of death
Management
- triage:
- transfer to trauma center*
- systolic BP < 90 mm Hg, < 100 mm Hg if > 70 years
- pedestrian hit by motor vehicle & > 70 years[11]
- transfer to trauma center*
- a single systolic blood pressure reading <105 mm Hg predicts the need for immediate immediate operative or endovascular treatment & surgical intensive care unit admission[3]
- glucocorticoids
- may lower risk of ventilator-associated pneumonia[4]
- may increase risk of death after head trauma[5]
- criteria to withhold or terminate care
- blunt trauma with apnea, pulselessness, & no organized electrocardiogram activity
- penetrating trauma with the preceding clinical presentation & no other signs of life
- 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation
- EMS-witnessed traumatic cardiopulmonary arrest followed by 15 minutes of unsuccessful resuscitation en route to the emergency department[6]
- fluid resuscitation prior to surgery should target achieving adequate perfusion, not restoring normal blood pressure[8]
- excessive fluids may worsen outcomes by causing dilutional coagulopathy
- tranexamic acid within 8 hours may be of benefit in patients with severe hemorrhage
- in severely injured trauma patients, early, 8-hour restrictive oxygen no better than liberal oxygen[19]
* older patients more likely to require surgery & intensive care after trauma than younger patients[11]
* frailty is a risk factor for in-hospital complications & poor outcomes in elderly trauma patients[12]
Notes
- most severely injured patients are not transferred to a trauma center[10]
More general terms
More specific terms
- accident
- accidental fall
- animal bite
- arm injury
- back injury
- barotrauma
- burn
- CNS trauma
- Commotio cordis
- contusion (bruise)
- corneal abrasion
- craniofacial trauma
- crush injury
- dental trauma
- drowning
- ear trauma/injury
- eye injury/trauma
- foreign body
- hand injury
- head injury
- joint injury; traumatic arthropathy
- ligament tear
- muscle injury
- neck injury
- orbital trauma
- renal trauma
- shoulder trauma
- spine trauma
- sports injury
- sprain
- superficial injury/trauma
- tendon rupture
- torso trauma; trunk trauma; injury of thorax, abdomen, &/or pelvis
- trauma in the elderly; geriatric trauma
- traumatic leg injury
- urogenital trauma
- vascular trauma/injury
- work-related injury (workers' compensation)
Additional terms
References
- ↑ 1.0 1.1 Tasse JL et al. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. J Trauma 2008 Nov; 65:1114. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19001983
- ↑ Diagnosis and management of injury in the pregnant patient (Eastern Association for the Surgery of Trauma) http://www.east.org/tpg/pregnancy.pdf
- ↑ 3.0 3.1 Seamon MJ et al. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma 2010 Jun; 68:1289 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20539171
- ↑ 4.0 4.1 Roquilly A et al. Hydrocortisone therapy for patients with multiple trauma: The randomized controlled HYPOLYTE study. JAMA 2011 Mar 23/30; 305:1201. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21427372
Bulger EM, Cuschieri J. Steroids after severe injury: many unanswered questions. JAMA. 2011 Mar 23;305(12):1242-3. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21427379 - ↑ 5.0 5.1 Roberts I et al. for the CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): Randomised placebo-controlled trial. Lancet 2004 Oct 9; 364:1321-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15474134
- ↑ 6.0 6.1 Mollberg NM et al. The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients. J Trauma 2011 Oct; 71:997. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21986740
- ↑ 7.0 7.1 Warkentien T et al. Invasive mold infections following combat-related injuries. Clin Infect Dis 2012 Dec 1; 55:1441. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23042971
- ↑ 8.0 8.1 Wang CH et al. Liberal versus restricted fluid resuscitation strategies in trauma patients: A systematic review and meta-analysis of randomized controlled trials and observational studies. Crit Care Med 2013 Dec 11 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24335443 <Internet> http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=9000&issue=00000&article=97643&type=abstract
- ↑ 9.0 9.1 9.2 N Engl J Med Journal Watch. Jan 24, 2014. Massachusetts Medical Society http://www.jwatch.org
McCully SP et al. The International Normalized Ratio overestimates coagulopathy in stable trauma and surgical patients. J Trauma Acute Care Surg 2013 Dec; 75:947 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24256665 - ↑ 10.0 10.1 Delgado MK et al. Factors associated with the disposition of severely injured patients initially seen at non-trauma center emergency departments: Disparities by insurance status. JAMA Surg 2014 Feb 19 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24554059 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1828520
- ↑ 11.0 11.1 11.2 Ichwan B et al. Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults. Ann Emerg Med 2014 Jun 5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24908590
- ↑ 12.0 12.1 Joseph B, Pandit V, Zangbar B et al Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis. JAMA Surg. 2014 Aug;149(8):766-72. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24920308 https://jamanetwork.com/journals/jamasurgery/fullarticle/1879845
- ↑ The NNT: Tranexamic Acid for Severe Trauma. http://www.thennt.com/nnt/tranexamic-acid-for-severe-trauma/
CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomised, placebo-controlled trial. Lancet 2010 Jun 15; [e-pub ahead of print]. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20554319 <Internet> http://dx.doi.org/10.1016/S0140-6736(10)60835-5
Levy JH. Antifibrinolytic therapy: New data and new concepts. Lancet 2010 Jun 15; [e-pub ahead of print]. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20554318 <Internet> http://dx.doi.org/10.1016/S0140-6736(10)60939-7 - ↑ 14.0 14.1 Sierink JC, Treskes K, Edwards MJ et al Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet. June 28, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27371185 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30932-1/abstract
Wurmb TE, Bernhard M Total-body CT for initial diagnosis of severe trauma. Lancet. June 28, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27371186 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30933-3/abstract - ↑ Cimino-Fiallos N (images) Hard Hits: Blunt Force Trauma Medscape. Sept 20, 2017 http://reference.medscape.com/slideshow/blunt-force-trauma-6007991
- ↑ 16.0 16.1 Meltzer JA, Stone ME Jr, Reddy SH et al Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma. JAMA Pediatr. Published online April 9, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29630685 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2676822
- ↑ 17.0 17.1 Choosing Wisely. Nov 4, 2019 American Academy of Pediatrics - Section on Surgery Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on-surgery/
- ↑ 18.0 18.1 AMA Morning Rounds. Feb 24, 2022 American Medical Association
Klein J, Prabhakaran K, Latifi R, Rhee P. Firearms: the leading cause of years of potential life lost Trauma Surgery & Acute Care Open 2022. 7(1):e000766 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35141422 PMCID: PMC8819782 Free PMC article https://tsaco.bmj.com/content/7/1/e000766 - ↑ 19.0 19.1 Arleth T, Baekgaard J, Siersma V et al Early Restrictive vs Liberal Oxygen for Trauma Patients: The TRAUMOX2 Randomized Clinical Trial. JAMA. 2024 Dec 10. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39657224 https://jamanetwork.com/journals/jama/fullarticle/2827980