Trauma (main): Difference between revisions
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''This page lists the major trauma types. See [[fractures]] for ortho related injuries.'' | ''This page lists the major trauma types. See [[fractures]] for ortho related injuries.'' | ||
==Background== | ==Background== | ||
Note that bleeding can occur at different locations such as: externally, internally (thoracic and peritoneal cavity, retroperitoneal space, especially in pelvic fracture), into the muscle or subcutaneous tissue due to long-bone fracture) | Note that bleeding can occur at different locations such as: externally, internally (thoracic and peritoneal cavity, retroperitoneal space, especially in pelvic fracture), into the muscle or subcutaneous tissue due to long-bone fracture) | ||
At times the cause of shock is not obvious and therefore we use imaging that are present at the trauma bay to assist us. This includes an ultrasound, or FAST (Focused Assessment with Sonography for Trauma, which is used to evaluate for hemopericardium (cardiac tamponade), pneumothorax, intraabdominal bleeding, bladder damage. X-ray imaging is initially include the chest (portable is commonly used), pelvis, and lateral cervical spine, and at times they patient will go straight for CT (computed tomography). | At times the cause of shock is not obvious and therefore we use imaging that are present at the trauma bay to assist us. This includes an ultrasound, or FAST (Focused Assessment with Sonography for Trauma, which is used to evaluate for hemopericardium (cardiac tamponade), pneumothorax, intraabdominal bleeding, bladder damage. X-ray imaging is initially include the chest (portable is commonly used), pelvis, and lateral cervical spine, and at times they patient will go straight for CT (computed tomography). | ||
==Clinical Features== | ==Clinical Features== | ||
It is imperative to recognize traumatic shock and ideally before hypotension develops. Keep in mind that clinical presentation of traumatic shock depends on the rate, the volume and the duration of the bleeding, other dynamics that can play in the picture is the patient’s baseline healthy/physiology along with the presence of any co-morbid and pathological conditions. | |||
Clinical signs that accompany shock state include: increased heart rate, hypotension (depending on how much blood loss occurred), cool extremities, weak peripheral pulses, along with altered mental status (which can be due to a head injury or extensive bleeding causing a decreased oxygen carrying capacity to the brain, or intracranial bleed, etc.) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Head trauma]] | |||
{{Intracranial hemorrhage DDX}} | {{Intracranial hemorrhage DDX}} | ||
*[[Concussion]]=== | |||
{{Maxillofacial trauma DDX}} | {{Maxillofacial trauma DDX}} | ||
| Line 69: | Line 42: | ||
*[[Pediatric head trauma]] | *[[Pediatric head trauma]] | ||
== | |||
==Evaluation== | |||
==Management== | |||
2 L of isotonic saline is the choice of fluid resuscitation in hemorrhagic shock through short and large gauge, preferably 16 or larger peripheral IVs. Occasionally it is impossible to obtain peripheral IV access and therefore you must place a central venous catheter. | |||
Very commonly blood products are immediately available in severe hemorrhagic emergency cases and physicians forego normal saline for blood products. Please note that infusing large volumes of NS can lead to development of a nonunion gap hyperchloremic metabolic acidosis, or metabolic alkalosis if one uses large amount of lactated ringers. | |||
It is critical to keep monitoring the patient and their vitals, including the MAP (mean arterial pressure), which ideally you want to keep around 65 mmHg or their systolic blood pressure at around 90 mmHg. | |||
When a traumatic patient presents with severe hemorrhage, there is a fine line between overloading the patient with fluids, which can actually cause the patient to bleed out faster while diluting the blood products of the patient, therefore leading to catastrophic result. The patients with severe and ongoing hemorrhage that can’t be controlled adequately or in timely manner, it is imperative to start immediate transfusion of blood products in a 1:1:1 ration of PRBCs (packed red blood cells), FFP (fresh frozen plasma) and platelets. | |||
Complications: during resuscitation of severe traumatic patients, the development of hypothermia (core temperature under 35 degrees Celsius) , acidosis, and coagulopathy, known as the lethal triad can have devastating and lethal consequences. | |||
The coagulation system consists of complex enzymatic reactions that are temperature and pH dependent that result in the formation of blood clots to stop both the internal and the external hemorrhage. | |||
A healthy individual maintains a physiologically normal pH of 7.35 to 3.45 through a complex and intricate balance of hydrogen ions and buffers that are predominately controlled by the pulmonary and renal systems. Acidosis is defined as arterial pH under 7.35. As a trauma patient’s perfusion worsens, they have a rapid accumulation of lactic acid in the tissues, therefore resulting in severe metabolic acidosis. With severe academia (pH under 7.20), the consequences are detrimental and for the trauma patient, one of the most harmful effects is that their coagulation system can become severely impaired therefore leading to death. | |||
Dilutional coagulopathy occurs when resuscitation of a bleeding trauma patient is with fluid (NS or PRBCS) or blood products that do not contain the same clotting factors lost in the acutely hemorrhaged whole blood. Furthermore, in the critically injured patient, via complex series of enzymatic reactions, the clotting cascade can also become abnormally activated, therefore causing excessive clot formation and subsequent fibrinolysis out of proportion to the injury. This excessive and abnormal activated of the coagulation system rapidly consumes the body’s remaining clotting factors, resulting in a further deficiency of the essential factors required to achieve hemorrhage control. | |||
Another complication can occur after resuscitating trauma patients with blood products, which is hypocalcemia. Hypocalcemia occurs because of the anticoagulant citrate. Citrate binds with free calcium, therefore decreasing active calcium levels in the serum, leading to hypocalcemia. | |||
==Disposition== | |||
==See Also== | |||
*[[Trauma Sedation]] | *[[Trauma Sedation]] | ||
*[[Trauma in pregnancy]] | *[[Trauma in pregnancy]] | ||
*[[Trauma center levels]] | *[[Trauma center levels]] | ||
==External Links== | |||
==References== | |||
<references/> | |||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 20:46, 21 August 2016
This page lists the major trauma types. See fractures for ortho related injuries.
Background
Note that bleeding can occur at different locations such as: externally, internally (thoracic and peritoneal cavity, retroperitoneal space, especially in pelvic fracture), into the muscle or subcutaneous tissue due to long-bone fracture)
At times the cause of shock is not obvious and therefore we use imaging that are present at the trauma bay to assist us. This includes an ultrasound, or FAST (Focused Assessment with Sonography for Trauma, which is used to evaluate for hemopericardium (cardiac tamponade), pneumothorax, intraabdominal bleeding, bladder damage. X-ray imaging is initially include the chest (portable is commonly used), pelvis, and lateral cervical spine, and at times they patient will go straight for CT (computed tomography).
Clinical Features
It is imperative to recognize traumatic shock and ideally before hypotension develops. Keep in mind that clinical presentation of traumatic shock depends on the rate, the volume and the duration of the bleeding, other dynamics that can play in the picture is the patient’s baseline healthy/physiology along with the presence of any co-morbid and pathological conditions. Clinical signs that accompany shock state include: increased heart rate, hypotension (depending on how much blood loss occurred), cool extremities, weak peripheral pulses, along with altered mental status (which can be due to a head injury or extensive bleeding causing a decreased oxygen carrying capacity to the brain, or intracranial bleed, etc.)
Differential Diagnosis
Intracranial Hemorrhage Types
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
- Concussion===
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Neck trauma
Torso trauma
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Cardiac Trauma
Thoracic and lumbar spine trauma
Abdominal Trauma
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Genitourinary Trauma
- Urinary system
- Genital
- Other
- Child abuse
- Pelvic fracture (often accompanies)
- Sexual assault
Penile trauma types
Extremity trauma
Pediatric
Evaluation
Management
2 L of isotonic saline is the choice of fluid resuscitation in hemorrhagic shock through short and large gauge, preferably 16 or larger peripheral IVs. Occasionally it is impossible to obtain peripheral IV access and therefore you must place a central venous catheter. Very commonly blood products are immediately available in severe hemorrhagic emergency cases and physicians forego normal saline for blood products. Please note that infusing large volumes of NS can lead to development of a nonunion gap hyperchloremic metabolic acidosis, or metabolic alkalosis if one uses large amount of lactated ringers. It is critical to keep monitoring the patient and their vitals, including the MAP (mean arterial pressure), which ideally you want to keep around 65 mmHg or their systolic blood pressure at around 90 mmHg. When a traumatic patient presents with severe hemorrhage, there is a fine line between overloading the patient with fluids, which can actually cause the patient to bleed out faster while diluting the blood products of the patient, therefore leading to catastrophic result. The patients with severe and ongoing hemorrhage that can’t be controlled adequately or in timely manner, it is imperative to start immediate transfusion of blood products in a 1:1:1 ration of PRBCs (packed red blood cells), FFP (fresh frozen plasma) and platelets.
Complications: during resuscitation of severe traumatic patients, the development of hypothermia (core temperature under 35 degrees Celsius) , acidosis, and coagulopathy, known as the lethal triad can have devastating and lethal consequences. The coagulation system consists of complex enzymatic reactions that are temperature and pH dependent that result in the formation of blood clots to stop both the internal and the external hemorrhage. A healthy individual maintains a physiologically normal pH of 7.35 to 3.45 through a complex and intricate balance of hydrogen ions and buffers that are predominately controlled by the pulmonary and renal systems. Acidosis is defined as arterial pH under 7.35. As a trauma patient’s perfusion worsens, they have a rapid accumulation of lactic acid in the tissues, therefore resulting in severe metabolic acidosis. With severe academia (pH under 7.20), the consequences are detrimental and for the trauma patient, one of the most harmful effects is that their coagulation system can become severely impaired therefore leading to death. Dilutional coagulopathy occurs when resuscitation of a bleeding trauma patient is with fluid (NS or PRBCS) or blood products that do not contain the same clotting factors lost in the acutely hemorrhaged whole blood. Furthermore, in the critically injured patient, via complex series of enzymatic reactions, the clotting cascade can also become abnormally activated, therefore causing excessive clot formation and subsequent fibrinolysis out of proportion to the injury. This excessive and abnormal activated of the coagulation system rapidly consumes the body’s remaining clotting factors, resulting in a further deficiency of the essential factors required to achieve hemorrhage control.
Another complication can occur after resuscitating trauma patients with blood products, which is hypocalcemia. Hypocalcemia occurs because of the anticoagulant citrate. Citrate binds with free calcium, therefore decreasing active calcium levels in the serum, leading to hypocalcemia.