Major trauma
Major trauma | |
---|---|
gunshot wound to the head; the patient is intubated, and a mechanical ventilator is visible in the background | |
Specialty | Emergency medicine, trauma surgery |
Major trauma is any
In 2002, unintentional and intentional injuries were the fifth and seventh leading causes of deaths worldwide, accounting for 6.23% and 2.84% of all deaths. For research purposes the definition often is based on an Injury Severity Score (ISS) of greater than 15.[2]
Classification
Injuries generally are classified by either severity, the location of damage, or a combination of both.
Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value may be used for triaging a patient or for statistical analysis. Injury scales measure damage to anatomical parts, physiological values (blood pressure etc.), comorbidities, or a combination of those. The Abbreviated Injury Scale and the Glasgow Coma Scale are used commonly to quantify injuries for the purpose of triaging and allow a system to monitor or "trend" a patient's condition in a clinical setting.[7] The data also may be used in epidemiological investigations and for research purposes.[8]
Approximately 2% of those who have experienced significant trauma have a spinal cord injury.[9]
Causes
Injuries may be caused by any combination of external forces that act physically against the body.[10] The leading causes of traumatic death are blunt trauma, motor vehicle collisions, and falls, followed by penetrating trauma such as stab wounds or impaled objects.[11] Subsets of blunt trauma are both the number one and two causes of traumatic death.[12]
For statistical purposes, injuries are classified as either intentional such as suicide, or unintentional, such as a motor vehicle collision. Intentional injury is a common cause of traumas.
Pathophysiology
The body responds to traumatic injury both systemically and at the injury site.[16] This response attempts to protect vital organs such as the liver, to allow further cell duplication and to heal the damage.[17] The healing time of an injury depends on various factors including sex, age, and the severity of injury.[18]
The symptoms of injury may manifest in many different ways, including:[19]
- Altered mental status
- Fever
- Increased heart rate
- Generalized edema
- Increased cardiac output
- Increased rate of metabolism
Various organ systems respond to injury to restore homeostasis by maintaining perfusion to the heart and brain.[20] Inflammation after injury occurs to protect against further damage and starts the healing process. Prolonged inflammation may cause multiple organ dysfunction syndrome or systemic inflammatory response syndrome.[21] Immediately after injury, the body increases production of glucose through gluconeogenesis and its consumption of fat via lipolysis. Next, the body tries to replenish its energy stores of glucose and protein via anabolism. In this state the body will temporarily increase its maximum expenditure for the purpose of healing injured cells.[18][22]
Diagnosis
The initial assessment is critical in determining the extent of injuries and what will be needed to manage an injury, and for treating immediate life threats.
Physical examination
Primary
Imaging
Persons with major trauma commonly have chest and pelvic
In the U.S., CT or MRI scans are performed on 15% of those with trauma in emergency departments.[29] Where blood pressure is low or the heart rate is increased—likely from bleeding in the abdomen—immediate surgery bypassing a CT scan is recommended.[30] Modern 64-slice CT scans are able to rule out, with a high degree of accuracy, significant injuries to the neck following blunt trauma.[31]
Surgical techniques
Surgical techniques, using a tube or catheter to drain fluid from the peritoneum, chest, or the pericardium around the heart, often are used in cases of severe blunt trauma to the chest or abdomen, especially when a person is experiencing early signs of shock. In those with low blood-pressure, likely because of bleeding in the abdominal cavity, cutting through the abdominal wall surgically is indicated.[6]
Prevention
By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems may help to enhance the overall health of a population.[32] Injury prevention strategies are commonly used to prevent injuries in children, who are a high risk population.[33] Injury prevention strategies generally involve educating the general public about specific risk factors and developing strategies to avoid or reduce injuries.[34] Legislation intended to prevent injury typically involves seatbelts, child car-seats, helmets, alcohol control, and increased enforcement of the legislation.[citation needed] Other controllable factors, such as the use of drugs including alcohol or cocaine, increases the risk of trauma by increasing the likelihood of traffic collisions, violence, and abuse occurring.[6] Prescription drugs such as benzodiazepines may increase the risk of trauma in elderly people.[6]
The care of acutely injured people in a public health system requires the involvement of bystanders, community members, health care professionals, and health care systems. It encompasses
Management
Pre-hospital
The pre-hospital use of stabilization techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a trauma center as well as provide primary stabilization by checking and treating airway, breathing, and circulation as well as assessing for disability and gaining exposure to check for other injuries.[23]
Rapid transportation of severely injured patients improves the outcome in trauma.[6][23] Helicopter EMS transport reduces mortality compared to ground-based transport in adult trauma patients.[41] Before arrival at the hospital, the availability of advanced life support does not greatly improve the outcome for major trauma when compared to the administration of basic life support.[42][43] Evidence is inconclusive in determining support for pre-hospital intravenous fluid resuscitation while some evidence has found it may be harmful.[44] Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them,[6] and outcomes may improve when persons who have experienced trauma are transferred directly to a trauma center.[45]
In-hospital
Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status.
Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure.
A
Intravenous fluids
Traditionally, high-volume
As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed
Medications
Tranexamic acid decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on CT scan.[61][62][63] It only appears to be beneficial, however, if administered within the first three hours after trauma.[64] For severe bleeding, for example from bleeding disorders, recombinant factor VIIa—a protein that assists blood clotting—may be appropriate.[6][53] While it decreases blood use, it does not appear to decrease the mortality rate.[65] In those without previous factor VII deficiency, its use is not recommended outside of trial situations.[66]
Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury.
Surgery
The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur.[69] Damage control surgery is used to manage severe trauma in which there is a cycle of metabolic acidosis, hypothermia, and hypotension that may lead to death, if not corrected.[6] The main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable.[6] Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding.[70]
Prognosis
Trauma deaths occur in immediate, early, or late stages. Immediate deaths usually are due to
Long-term prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain one year after injury.[72] Many also experience a reduced quality of life years after an injury,[73] with 20% of victims sustaining some form of disability.[74] Physical trauma may lead to development of post-traumatic stress disorder (PTSD).[75] One study has found no correlation between the severity of trauma and the development of PTSD.[76]
Epidemiology
no data < 25 25–50 50–75 75–100 100–125 125–150 | 150–175 175–200 200–225 225–250 250–275 > 275 |
Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually.[78][79] It is the fifth leading cause of significant disability.[78] About half of trauma deaths are in people aged between 15 and 45 years and trauma is the leading cause of death in this age group.[79] Injury affects more males; 68% of injuries occur in males[80] and death from trauma is twice as common in males as it is in females, this is believed to be because males are much more willing to engage in risk-taking activities.[79] Teenagers and young adults are more likely to need hospitalization from injuries than other age groups.[81] While elderly persons are less likely to be injured, they are more likely to die from injuries sustained due to various physiological differences that make it more difficult for the body to compensate for the injuries.[81] The primary causes of traumatic death are central nervous system injuries and substantial blood loss.[78] Various classification scales exist for use with trauma to determine the severity of injuries, which are used to determine the resources used and, for statistical collection.
History
The human remains discovered at the site of Nataruk in Turkana, Kenya, are claimed to show major trauma—both blunt and penetrating—caused by violent trauma to the head, neck, ribs, knees, and hands, which has been interpreted by some researchers as establishing the existence of warfare between two groups of hunter-gatherers 10,000 years ago.[82] The evidence for blunt-force trauma at Nataruk has been challenged, however, and the interpretation that the site represents an early example of warfare has been questioned.[83]
Society and culture
Economics
The financial cost of trauma includes both the amount of money spent on treatment and the loss of potential economic gain through absence from work. The average financial cost for the treatment of traumatic injury in the United States is approximately US$334,000 per person, making it costlier than the treatment of cancer and cardiovascular diseases.[84] One reason for the high cost of the treatment for trauma is the increased possibility of complications, which leads to the need for more interventions.[85] Maintaining a trauma center is costly because they are open continuously and maintain a state of readiness to receive patients, even if there are none.[86] In addition to the direct costs of the treatment, there also is a burden on the economy due to lost wages and productivity, which in 2009, accounted for approximately US$693.5 billion in the United States.[87]
Low- and middle-income countries
Citizens of
Special populations
Children
Cause | Deaths per year |
---|---|
Traffic collision |
260,000 |
Drowning |
175,000 |
Burns |
96,000 |
Falls |
47,000 |
Toxins |
45,000 |
Due to anatomical and physiological differences, injuries in children need to be approached differently from those in adults.[90] Accidents are the leading cause of death in children between 1 and 14 years old.[74] In the United States, approximately sixteen million children go to an emergency department due to some form of injury every year,[74] with boys being more frequently injured than girls by a ratio of 2:1.[74] The world's five most common unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning.[91]
Pregnancy
Trauma occurs in approximately 5% of all pregnancies,
A number of treatments beyond typical trauma care may be needed when the patient is pregnant. Because the weight of the uterus on the
Research
Most research on trauma occurs during war and military conflicts as militaries will increase trauma research spending in order to prevent combat related deaths.[96] Some research is being conducted on patients who were admitted into an intensive care unit or trauma center, and received a trauma diagnosis that caused a negative change in their health-related quality of life, with a potential to create anxiety and symptoms of depression.[97] New preserved blood products also are being researched for use in pre-hospital care; it is impractical to use the currently available blood products in a timely fashion in remote, rural settings or in theaters of war.[98]
References
- ^ "Glossary". National Highway Traffic Safety Administration. Retrieved 26 March 2014.
- PMID 18184482.
- ^ Moore 2013, p. 77[full citation needed]
- ^ ISBN 978-0323054720.
- ^ "The Barell Injury Diagnosis Matrix, Classification by Body Region and Nature of the Injury". Center for Disease Control. Retrieved 19 June 2013.
- ^ PMID 18655938.
- ^ Moore 2013, pp. 77–98[full citation needed]
- ^ Discussion document on injury severity measurement in administrative datasets (PDF). Centers for Disease Control and Prevention. September 2004. pp. 1–3. Retrieved 2013-05-24.
- PMID 20175667.
- ^ Moore 2013, p. 2[full citation needed]
- ISBN 978-0071496797.
- ISBN 978-0135005231.
- ISBN 978-0340928264.
- ISBN 978-0781732000.
- S2CID 11161742.
- ISBN 978-0340947647.
- .
- ^ ISBN 978-0781748025.
- ^ Pietzman 2002, p. 21[full citation needed]
- ^ Pietzman 2002, p. 17[full citation needed]
- ^ Pietzman 2002, p. 19[full citation needed]
- PMID 15910820.
- ^ ISBN 978-1880696316.
- ^ Moore 2013, p[full citation needed]
- ^ PMID 20154540.
- S2CID 45335697.
- PMID 25178942.
- PMID 14960973.
- PMID 20924012.
- PMID 21307722.
- PMID 24393410.
- ^ PMID 17127121.
- ISBN 978-0313296864.
- ^ CDC Injury Fact Book. Atlanta, Georgia: National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia. 2006. pp. 35–101.
- ^ "Centers for Disease Control and Prevention Injury Prevention and Control: Injury Response: Acute Injury Care". Archived from the original on 2015-09-24. Retrieved 2017-09-09.
- PMID 23962031.
- PMID 26473003.
- PMID 3046734.
- ^ Moore 2013, pp. 154–66[full citation needed]
- PMID 17127122.
- S2CID 26089433.
- PMID 18427089.
- S2CID 44694756.
- PMID 15193210.
- PMID 20838131.
- ^ Moore 2013, p. 160[full citation needed]
- ^ Moore 2013, p. 163[full citation needed]
- PMID 22487112.
- ^ Moore 2013, p. 161[full citation needed]
- ^ PMID 20956228.
- PMID 19473497.
- ^ PMID 22164397. Archived from the originalon 2012-01-18.
- ^ S2CID 22449600.
- S2CID 44411659.
- ^ ISBN 978-0071484800.
- ^ PMID 23153876.
- S2CID 35694962.
- ^ "In Medical Triumph, Homicides Fall Despite Soaring Gun Violence". Wall street Journal. 8 December 2012. Retrieved 2012-12-09.
- ^ a b "UpToDate Inc". Retrieved 2010-11-13.
- PMID 16378514. Archived from the originalon 2012-07-24.
- S2CID 10407122.
- PMID 21795884.
- PMID 31623894.
- S2CID 9569603.
- PMID 20838118.
- PMID 22419303.
- S2CID 20328839.
- ^ "Vasopressor and Inotrope Usage in Shock" (PDF). Department of Surgical Education, Orlando Regional Medical Center. Apr 19, 2011. Retrieved 4 May 2014.
- ISBN 978-0781726412.
- ISBN 978-1444109627.
- ^ Moore 2013, p. 330[full citation needed]
- PMID 18347276.
- S2CID 13256047.
- ^ ISBN 978-0781762755.
- ^ "309.81 Posttraumatic Stress Disorder". Diagnostic and Statistical Manual of Mental Disorders (fourth ed.). Washington, USA: American Psychiatric Association. 1994. pp. 424–29.
- S2CID 28663482.
- ^ "Death and DALY estimates for 2004 by cause for WHO Member States" (xls). World Health Organization. 2004. Retrieved 2010-11-13.
- ^ S2CID 10670345.
- ^ ISBN 978-0199543328.
- ^ PMID 23635052.
- ^ a b Moore 2013, p. 23[full citation needed]
- S2CID 4462435.
- S2CID 205250945.
- ISBN 978-0323065023.
- PMID 18656640.
- PMID 14706578.
- ^ "Injury Facts" (PDF). National Safety Council. Retrieved July 17, 2012.
- PMID 22980446.
- S2CID 33390855.
- ISBN 978-0135005248.
- ^ BBC News Online (December 10, 2008). "UN raises child accidents alarm". London: BBC. BBC News. Retrieved 2010-10-31.
- PMID 20825816.
- S2CID 6009482.
- ^ a b c d e f Tibbles, Carrie (July 2008). "Trauma In Pregnancy: Double Jeopardy". Emergency Medicine Practice. 10 (7).
- ISBN 978-0130845849.
- PMID 18483051.
- PMID 19088550.
- PMID 21718901.
Bibliography
- Jeff Garner; Greaves, Ian; Ryan, James R.; Porter, Keith R. (2009). Trauma Care Manual. London, England: Hodder Arnold. ISBN 978-0340928264.
- Feliciano, David V.; Mattox, Kenneth L.; Moore, Ernest J (2012). Trauma, Seventh Edition (Trauma (Moore)). McGraw-Hill Professional. ISBN 978-0071663519.
- Andrew B., Peitzman; Michael, MD Sabom; Donald M., MD Yearly; Timothy C., MD Fabian (2002). The trauma manual. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 978-0781726412.
Further reading
- Editorial Board, Army Medical Department Center & School, ed. (2004). Emergency War Surgery (3rd ed.). Washington, DC: Borden Institute. Archived from the original on 2011-06-23. Retrieved 2010-10-31.
- Zajtchuk, R; Bellamy, RF; Grande, CM, eds. (1995). Textbook of Military Medicine, Part IV: Surgical Combat Casualty Care. Vol. 1: Anesthesia and Perioperative Care of the Combat Casualty. Washington, DC: Borden Institute. Archived from the original on 2011-06-22. Retrieved 2010-10-31.
External links
- Emergency Medicine Research and Perspectives (emergency medicine procedure videos)