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trauma

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] - 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 a) may lower risk of ventilator-associated pneumonia [4] b) may increase risk of death after head trauma [5] - criteria to withhold or terminate care a) blunt trauma with apnea, pulselessness, & no organized electrocardiogram activity b) penetrating trauma with the preceding clinical presentation & no other signs of life c) 15 minutes of cardiopulmonary resuscitation without return of spontaneous circulation d) 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 * 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]

Related

domestic violence (includes intimate partner violence) traumatic wound

Specific

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)

General

injury

References

  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: 19001983
  2. Diagnosis and management of injury in the pregnant patient (Eastern Association for the Surgery of Trauma) http://www.east.org/tpg/pregnancy.pdf
  3. 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: 20539171
  4. Roquilly A et al. Hydrocortisone therapy for patients with multiple trauma: The randomized controlled HYPOLYTE study. JAMA 2011 Mar 23/30; 305:1201. PMID: 21427372 - Bulger EM, Cuschieri J. Steroids after severe injury: many unanswered questions. JAMA. 2011 Mar 23;305(12):1242-3. PMID: 21427379
  5. 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: 15474134
  6. 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: 21986740
  7. Warkentien T et al. Invasive mold infections following combat-related injuries. Clin Infect Dis 2012 Dec 1; 55:1441. PMID: 23042971
  8. 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 PMID: 24335443 http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=9000&issue=00000&article=97643&type=abstract
  9. 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: 24256665
  10. 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 PMID: 24554059 http://archsurg.jamanetwork.com/article.aspx?articleid=1828520
  11. 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: 24908590
  12. 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: 24920308 https://jamanetwork.com/journals/jamasurgery/fullarticle/1879845
  13. 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]. PMID: 20554319 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]. PMID: 20554318 http://dx.doi.org/10.1016/S0140-6736(10)60939-7
  14. 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 PMID: 27371185 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 PMID: 27371186 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30933-3/abstract
  15. Cimino-Fiallos N (images) Hard Hits: Blunt Force Trauma Medscape. Sept 20, 2017 http://reference.medscape.com/slideshow/blunt-force-trauma-6007991
  16. 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: 29630685 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2676822
  17. 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. 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: 35141422 PMCID: PMC8819782 Free PMC article https://tsaco.bmj.com/content/7/1/e000766