Page 187 - TNFlipTest

Toronto Notes 2019 Traumatology Traumatology
• epidemiology
■ leading cause of death in patients <45 yr
■ 4th highest cause of death in North America
■ causes more deaths in children/adolescents than all diseases combined
• trimodaldistributionofdeath
■ minutes: death usually at the scene from lethal injuries
■ early: death within 4-6 h – “golden hour” (decreased mortality with trauma care) ■ days-weeks: death from multiple organ dysfunction, sepsis, VTE, etc.
• injuriesfallintotwocategories
■ blunt (most common): MVC, pedestrian-automobile impact, motorcycle collision, fall, assault,
sports
■ penetrating (increasing in incidence): gunshot wound, stabbing, impalement
Considerations for Traumatic Injury
• importanttoknowthemechanismofinjurytoanticipatetraumaticinjuries
• alwayslookforanunderlyingcause(alcohol,medications,illicitsubstances,seizure,suicideattempt,
medical problem)
• always inquire about HI, loss of consciousness, amnesia, vomiting, headache, and seizure activity
Emergency Medicine ER7
Table 5. Mechanisms and Considerations of Traumatic Injuries
Always completely expose and count the number of wounds
Cardiac Box: sternal notch, nipples, and xiphoid process; injuries inside this area should increase suspicion of cardiac injury
High Risk Injuries
• MVC at high speed, resulting in ejection from vehicle
• Motorcycle collisions
• Vehicle vs. pedestrian crashes • Fall from height >12 ft (3.6 m)
Vehicle vs. Pedestrian Crash
In adults look for triad of injuries (Waddle’s triad)
• Tibia-fibula or femur fracture • Truncal injury
• Craniofacial injury
Mechanism of Injury
MVC
Pedestrian-Automobile Impact
Falls
Special Considerations
Vehicle(s) involved: weight, size, speed, damage Location of patient in vehicle
Use and type of seatbelt
Ejection of patient from vehicle
Entrapment of patient under vehicle Airbag deployment
Helmet use in motorcycle collision
High morbidity and mortality Vehicle speed is an important factor Site of impact on car
1 storey = 12 ft = 3.6 m
Distance of fall: 50% mortality at 4 storeys and 95% mortality at 7 storeys
Landing position (vertical vs. horizontal)
Associated Injuries
Head-on collision: head/facial, thoracic (aortic), lower extremity
Lateral/T-bone collision: head, C-spine, thoracic, abdominal, pelvic, and lower extremity Rear-end collision: hyper-extension of C-spine (whiplash injury)
Rollover
Children at increased risk of being run over (multisystem injuries)
Adults tend to be struck in lower legs (lower extremity injuries), impacted against car (truncal injuries), and thrown to ground (HI)
Vertical: lower extremity, pelvic, and spine fractures; HI
Horizontal: facial, upper extremity, and rib fractures; abdominal, thoracic, and HI
Head Trauma
• seeNeurosurgery,NS30
• 60%ofMVC-relateddeathsareduetoHI
Specific Injuries
• fractures
■ Dx: non-contrast head CT and physical exam
A. skull fractures ■ vault fractures
◆ linear, non-depressed
– most common
– typically occur over temporal bone, in area of middle meningeal artery (commonest cause of
epidural hematoma) ◆ depressed
– open (associated overlying scalp laceration and torn dura, skull fracture disrupting paranasal sinuses or middle ear) vs. closed
■ basal skull fractures
◆ typically occur through floor of anterior cranial fossa (longitudinal more common than
transverse)
◆ generally a clinical diagnosis (poorly visualized on CT)
B. facial fractures (see Plastic Surgery, PL31)
■ neuronal injury
■ beware of open fracture or sinus fractures (risk of infection)
■ severe facial fractures may pose risk to airway from profuse bleeding
Signs of Basal Skull Fracture
• Battle’s sign (bruised mastoid process) • Hemotympanum
• Raccoon eyes (periorbital bruising)
• CSF rhinorrhea/otorrhea