Blunt trauma

Source: Wikipedia, the free encyclopedia.
(Redirected from
Blunt force trauma
)
Blunt trauma
Other namesBlunt injury, non-penetrating trauma, trauma
ventilation-perfusion mismatch, hypovolemia, reduced cardiac output

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with

assaults, sports-related injuries, and are notably common among the elderly who experience falls.[1][2]

Blunt trauma can lead to a wide range of injuries including

hemorrhages, and bone fractures.[1] The severity of these injuries depends on factors such as the force of the impact, the area of the body affected, and underlying comorbidities of the affected individual. In some cases, blunt force trauma can be life-threatening and may require immediate medical attention.[1] Blunt trauma to the head and/or severe blood loss are the most likely causes of death due to blunt force traumatic injury.[1]

Classification

Blunt abdominal trauma

Abdominal CT showing left renal artery injury

Blunt abdominal trauma (BAT) represents 75% of all blunt trauma and is the most common example of this injury.

intraluminal pressure in the more serious, depending on the force applied. Initially, there may be few indications that serious internal abdominal injury has occurred, making assessment more challenging and requiring a high degree of clinical suspicion.[6]

There are two basic physical mechanisms at play with the potential of injury to intra-abdominal organs: compression and deceleration.[7] The former occurs from a direct blow, such as a punch, or compression against a non-yielding object such as a seat belt or steering column. This force may deform a hollow organ, increasing its intraluminal or internal pressure and possibly lead to rupture.[citation needed]

Deceleration, on the other hand, causes stretching and

hepatic tear along the ligamentum teres and injuries to the renal arteries.[citation needed
]

When blunt abdominal trauma is complicated by 'internal injury,' the

In rare cases, this injury has been attributed to medical techniques such as the

Heimlich maneuver,[9] attempts at CPR and manual thrusts to clear an airway. Although these are rare examples, it has been suggested that they are caused by applying excessive pressure when performing these life-saving techniques. Finally, the occurrence of splenic rupture with mild blunt abdominal trauma in those recovering from infectious mononucleosis or 'mono' (also known as 'glandular fever' in non-U.S. countries, specifically the UK) is well reported.[10]

Blunt abdominal trauma in sports

The supervised environment in which most sports injuries occur allows for mild deviations from the traditional trauma treatment algorithms, such as ATLS, due to the greater precision in identifying the mechanism of injury. The priority in assessing blunt trauma in sports injuries is separating contusions and musculo-tendinous injuries from injuries to solid organs and the gut and recognizing potential for developing blood loss, and reacting accordingly. Blunt injuries to the kidney from helmets, shoulder pads, and knees are described in American football,[11] association football, martial arts, and all-terrain vehicle crashes.

A depiction of flail chest, a very serious blunt chest injury

Blunt thoracic trauma

The term blunt thoracic trauma, or, more informally, blunt chest injury, encompasses a variety of injuries to the

symptoms at the time the trauma initially occurs or even until hours after. A high degree of clinical suspicion may sometimes be required to identify such injuries, a CT scan may prove useful in such instances. Those experiencing more obvious complications from a blunt chest injury will likely undergo a focused assessment with sonography for trauma (FAST) which can reliably detect a significant amount of blood around the heart or in the lung by using a special machine that visualizes sound waves sent through the body. Only 10–15% of thoracic traumas require surgery, but they can have serious impacts on the heart, lungs, and great vessels.[12]

This table depicts mechanisms of blunt thoracic trauma and the most common injuries from each mechanism

The most immediate life-threatening injuries that may occur include tension pneumothorax, open pneumothorax, hemothorax, flail chest, cardiac tamponade, and airway obstruction/rupture.[12]

An example of a chest tube

The injuries may necessitate a procedure, most commonly the insertion of an intercostal drain, or chest tube. This tube is typically installed because it helps restore a certain balance in pressures (usually due to misplaced air or surrounding blood) that are impeding the lungs' ability to inflate and thus exchange vital gases that allow the body to function.[13] A less common procedure that may be employed is a pericardiocentesis which by removing blood surrounding the heart, permits the heart to regain some ability to appropriately pump blood.[14][15] In certain dire circumstances an emergent thoracotomy may be employed.[16]

Blunt cranial trauma

The primary clinical concern with blunt trauma to the head is damage to the brain, although other structures, including the skull, face,

blood within the skull, or fracture of the skull bones.[17]

A CT scan showing an epidural hematoma, a variety of intracranial bleeding commonly associated with blunt trauma to the temple region

Traumatic brain injury (TBI)

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality and is most commonly caused by falls, motor vehicle crashes, sports- and work-related injuries, and assaults. It is the most common cause of death in patients under the age of 25. TBI is graded from mild to severe, with greater severity correlating with increased morbidity and mortality.[17][18]

Most patients with more severe traumatic brain injury have of a combination of intracranial injuries, which can include

hemicraniectomy, in which part of the skull is removed.[8][17]

A fracture, an injury to the skeletal component of the upper extremity.

Blunt trauma to extremities

The Ankle-Brachial Index is depicted here. Note: ultrasound enhancement of pulses is not required but may be helpful.

Injury to

lower extremity. Surgical treatment may be necessary depending on the extent of injury and involved structures, but many are managed nonoperatively.[26]

Blunt pelvic trauma

The most common causes of blunt pelvic trauma are

hip replacements

One of the primary concerns is the risk of

nerve damage.[29] If pelvic trauma is suspected, emergency medical services personnel may place a pelvic binder on patients to stabilize the patient's pelvis and prevent further damage to these structures while patients are transported to a hospital. During the evaluation of trauma patients in an emergency department, the stability of the pelvis is typically assessed by the healthcare provider to determine whether fracture may have occurred. Providers may then decide to order imaging such as an X-ray or CT scan to detect fractures; however, if there is concern for life-threatening bleeding, patients should receive an X-ray of the pelvis.[30] Following initial treatment of the patient, fractures may need to be treated surgically if significant, while some minor fractures may heal without requiring surgery.[27]

A life-threatening concern is

FAST scan that is often performed following traumatic injuries. Should a patient appear hemodynamically unstable in the absence of obvious blood on the FAST scan, there may be concern for bleeding into the retroperitoneal space, known as retroperitoneal hematoma. Stopping the bleeding may require endovascular intervention or surgery, depending on the location and severity.[28]

Blunt cardiac trauma

Blunt cardiac trauma, also known as Blunt Cardiac Injury (BCI), encompasses a spectrum of cardiac injuries resulting from blunt force trauma to the chest. While BCIs necessitate a substantial amount of force to occur because the

Evaluation and diagnosis

In most settings, the initial evaluation and stabilization of traumatic injury follows the same general principles of identifying and treating immediately life-threatening injuries. In the US, the American College of Surgeons publishes the Advanced Trauma Life Support guidelines, which provide a step-by-step approach to the initial assessment, stabilization, diagnostic reasoning, and treatment of traumatic injuries that codifies this general principle.[8] The assessment typically begins by ensuring that the subject's airway is open and competent, that breathing is unlabored, and that circulation—i.e. pulses that can be felt—is present. This is sometimes described as the "A, B, C's"—Airway, Breathing, and Circulation—and is the first step in any resuscitation or triage. Then, the history of the accident or injury is amplified with any medical, dietary (timing of last oral intake) and history, from whatever sources such as family, friends, previous treating physicians that might be available. This method is sometimes given the mnemonic "SAMPLE". The amount of time spent on diagnosis should be minimized and expedited by a combination of clinical assessment and appropriate use of technology,[33] such as diagnostic peritoneal lavage (DPL), or bedside ultrasound examination (FAST)[34] before proceeding to laparotomy if required. If time and the patient's stability permits, CT examination may be carried out if available.[35] Its advantages include superior definition of the injury, leading to grading of the injury and sometimes the confidence to avoid or postpone surgery. Its disadvantages include the time taken to acquire images, although this gets shorter with each generation of scanners, and the removal of the patient from the immediate view of the emergency or surgical staff. Many providers use the aid of an algorithm such as the ATLS guidelines to determine which images to obtain following the initial assessment. These algorithms take into account the mechanism of injury, physical examination, and patient's vital signs to determine whether patients should have imaging or proceed directly to surgery.[8]

In 2011, criteria were defined that might allow patients with blunt abdominal trauma to be discharged safely without further evaluation. The characteristics of such patients include:

  • absence of intoxication
  • no evidence of lowered blood pressure or raised pulse rate
  • no abdominal pain or tenderness
  • no blood in the urine.

To be considered low risk, patients would need to meet all low-risk criteria.[36]

Treatment

When blunt trauma is significant enough to require evaluation by a healthcare provider, treatment is typically aimed at treating life-threatening injuries, such as maintaining the patient's airway and preventing ongoing blood loss. Patients who have suffered blunt trauma and meet specific triage criteria have shown improved outcomes when they are cared for in a trauma center.[1] The management of patients with blunt force trauma necessitates the collaboration of an interpersonal healthcare team, which may include but is not limited to; a trauma surgeon, emergency department physician, anesthesiologist, and emergency and trauma nursing staff.[1]

Treatment of abdominal trauma

In cases of blunt abdominal injury, the most frequent damage occurs in the

Prophylactic antibiotics are often necessary.[7] In the case of multiple holes or significant damage to the blood supply of the intestines, the affected segment of tissue may need to be removed entirely.[7]

Treatment of blunt cranial trauma

The treatment of blunt cranial trauma is dependent on the extent of the injury. A discussion between the patient and healthcare professions will take place in order to carefully assess the patient's condition and determine the best approach for treatment. When considering the management of cranial trauma, it is crucial to ensure that the patient can breathe effectively.

blood oxygen content via a pulse oximeter. The goal is to maintain greater than 90% oxygen saturation in the blood.[17] If the patient cannot maintain appropriate blood oxygen levels on their own, mechanical ventilation may be indicated.[31] Mechanical ventilation will add oxygen and remove carbon dioxide in the blood.[31] It is also critically important to avoid low blood pressure in the setting of traumatic brain injuries. Studies have demonstrated improved outcomes in patients with systolic blood pressure greater than or equal to 120mmHg.[17] Lastly, healthcare professionals should conduct consecutive neurological examinations to allow for early identification of elevated intracranial pressure, and subsequent implementation of interventions to improve blood flow and reduce stress to the body.[17] Of note, patients taking anticoagulant or antiplatelet therapy during the time of blunt cranial trauma should undergo rapid reversal of anticoagulating agents.[17]

Treatment of blunt thoracic trauma

Nine out of ten patients with thoracic trauma can be treated effectively without a

low oxygen levels in the blood.[37] Nonsteroidal anti-inflammatory drugs, opioids, or regional pain management methods, such as local anesthetic, can be used for pain control.[37]

Epidemiology

Worldwide, a significant cause of disability and death in people under the age of 35 is trauma, of which most are due to blunt trauma.[1]

References

  1. ^
    PMID 29262209
    . Retrieved 1 January 2021.
  2. ^ Cimino-Fiallos, Nicole (28 May 2020). "Hard Hits: Blunt Force Trauma". login.medscape.com. Medscape. Archived from the original on 2017-09-24. Retrieved 1 January 2021.
  3. PMID 17826214
    .
  4. ^ "Assessment of abdominal trauma – Differential diagnosis of symptoms | BMJ Best Practice". bestpractice.bmj.com. 14 August 2018. Retrieved 1 January 2021.
  5. S2CID 9040242
    .
  6. .
  7. ^ .
  8. ^ a b c d e f Advanced Trauma Life Support Student Course Manual (PDF) (9th ed.). American College of Surgeons. Archived from the original (PDF) on 21 December 2018. Retrieved 17 December 2018.
  9. S2CID 46698020
    .
  10. .
  11. .
  12. ^ .
  13. ISBN 9781447122586. {{cite book}}: |work= ignored (help
    )
  14. .
  15. .
  16. .
  17. ^ . Retrieved 11 December 2018.
  18. ^ Nickson, Chris. "Traumatic Brain Injury". Life in the Fast Lane. Retrieved 13 December 2018.
  19. S2CID 44503022
    .
  20. .
  21. .
  22. ^ "Annual Report of the National Trauma Data Bank (NTDB)". www.facs.org. Archived from the original on 2015-04-23. Retrieved 2018-12-16.
  23. PMID 1741655
    .
  24. .
  25. .
  26. .
  27. ^ a b c "UpToDate". www.uptodate.com.
  28. ^
    PMID 17300738
    .
  29. ^ a b Nickson, Chris. "Pelvic Trauma". Life in the Fast Lane. Retrieved 20 December 2018.
  30. ^ Croce, Martin. "Initial Management of Pelvic Fractures". FACS. American College of Surgeons. Archived from the original on 2015-04-21. Retrieved 2018-12-20.
  31. ^ a b c d e f "Blunt Cardiac Injury". The American Association for the Surgery of Trauma. 2013-01-14. Retrieved 2023-09-22.
  32. PMID 30821949
    .
  33. .
  34. .
  35. .
  36. .
  37. ^ .