Trauma

Dr Alan Shortt

58 Head injuries

Canadian CT Head Rule

Canadian C spine rule

Ottowa Ankle Rules

Ottowa Knee Rule

Head Injury Types
Concussion
Contusion
Epidural Haematoma
Subdural Haematoma
Intracerebral Haematoma
Skull Fracture

Neck C-spine injuries (trauma)

Spinal cord injuries (trauma)

Spinal Cord Syndromes (ERFMIQ)
Type	Description	Signs & Symptoms
Complete Transection	All tracts completely disrupted – complete and permanent loss of all spinal functions below level of transection	loss of motor function (quadriplegia) with cervical transection paraplegia with thoracic spine transectionmuscle flaccidity loss of all reflexes and sensory function below bowel and bladder atony paralytic ileus loss of vasomotor tone in lower body parts with low and unstable bp loss of perspiration below pale dry skin respiratory impairement
Central cord Syndrome	Typically after hyperextension injurycentral cord affected	motor deficits more marked in upper limbs cf lowevariable degree of bladder dysfunction
Anterior cord syndrome	occlusion of anterior spinal artery from pressure of bone fragments	loss of motor function belowloss of pain and temperature below intact touch pressure position and vibration sense
Brown Sequard syndrome	Hemisection of cord most common from stabbing or gunshot wounds	ipsilateral distal paralysis or paresis, loss of touch pressure vibration and position sensecontralateral loss of pain and temperature sensations

Vertebral fractures

Chest injuries

Abdominal Injuries (msk/trauma)

Pelvic injuries

@@@Blunt trauma

Blunt trauma is most often caused by motor vehicle accidents but may occur from assaults, falls and sports or occupational injuries. Injuries seen in the-clinic setting include contusions and minor fractures.

Red Flags

Abdominal Wall Bruising; “seat-belt sign” in motor vehicle accident

Haematuria (VISIBLE OR NONVISIBLE) after kidney injury

Signs of shock including hypotension, hypoxia, altered mental status

Crush Injury, Compartment Syndrome, Internal organ/viscus injury, arterial tear, pneumothorax, pericardial effusion/tamponade intracranial bleed

Blunt trauma can cause a wide spectrum of injuries to soft tissues, bones, ligaments and organs. Most commonly these injuries involve bruising, fractures and sprains/strains. Clinician should be aware of the potential for life or limb threatening injuries based on the mechanism of injury and presenting complaint. All patients should be thoroughly questioned as to the nature of the trauma and what forces were involved – the speed of the vehicle in an accident, the height of a fall, etc. Any patient with blunt trauma that occurs as the result of significant forces (high speed motor vehicle accident, fall from more than 10-15 feet) should be examined thoroughly from head-to-toe

Extremity trauma can be assessed by performing a thorough neurovascular and musculoskeletal exam on the affected side and comparing to the unaffected limb. Imaging can be focused on the area of injury.

Blunt trauma to the head and neck necessitates examination of cranial nerves, palpation of the cervical spine and strength/sensation of the upper extremities.

The presence of paresthesias or numbness in the upper extremities increases concern for cervical injury. Immobilization and prompt imaging of the cervical spine or emergent computed tomography of the head is necessary for any suspected injury.

Follow ottowa rules in known or suspected C spine injury – Xray if age >65 , dangerous mechanism of injury (axial loading, fall from 3 feet or 5 stairs, MVC high speed, rollover or ejection , bicycle injury) paraesthesia in extremeties, immediate onset of pain, midline tenderness, unable to move 45 degrees)

Blunt trauma to the chest or abdomen requires a very thorough history and physical examination. The most commonly injured abdominal organ is the spleen. If there is a history of significant trauma, and the patient has complaints of abdominal or chest pain, they should be emergently transferred for further evaluation/imaging. Injuries with more trivial mechanisms of injury may be managed with chest radiography, abdominal exam and appropriate treatment.

1. Investigations

Advise patient on signs/symptoms of compartment syndrome – increasing pain, extremity turns pale, paraesthesia or numbness

Educate patient that X-rays cannot rule out all fractures and that re-imaging may be necessary to define bony injury

Educate patient that bruising and swelling may become more pronounced over several days – if there is concern they should return to clinic for re-evaluation

Trauma assessment in the walk-in-clinic setting should follow established guidelines in order to detect potential life-threatening injuries and prevent complications and residual disability.

Assessment of a patient who has experienced minor trauma can be focused on one area if the injury is localized (sprained ankle, dislocated finger).

However, a patient who is involved in a motor vehicle accident, significant fall or reports a mechanism of injury that may cause injury to multiple parts of the body should undergo a standardized trauma assessment – the ATLS – which can be applied to any patient regardless of injury.

3 Background Information

Primary survey of the trauma patient involves the ABCDE’s.

Airway patency – can the patient speak normally, is there any facial/neck trauma?

Breathing – assess by auscultation of both lungs and noting any respiratory distress.

Circulation- check skin color, blood pressure, pulse rate and by palpate major pulses.

Disability -make quick note/scan of any obvious neurological deficits or life-threatening injury.

Exposure -remove all clothing to fully evaluate the patient.

The secondary survey involves a careful head-to-toe examination.

In addition, a concise history should be obtained from the patient –

including allergies,

medications,

past medical history,

last meal, and the

events/environment of the trauma

(“AMPLE”)

Examination

General – Level of consciousness, Glasgow Coma Scale (GCS) score

Head – Pupils, extra-ocular movements, lacerations, signs of skull fracture

Face – Dental malocclusion, midface instability/crepitus, lacerations, contusions

Neck – lacerations, subcutaneous air, tracheal deviation, midline cervical tenderness, hematoma, jugular venous distention

Chest – Heart tones, breath sounds, respiratory effort, point tenderness, lacerations, subcutaneous air

Abdomen – lacerations, bruising/hematoma, focal tenderness, peritoneal signs

Pelvis – stability of pelvis/symphysis, lacerations, check for blood at urethra/vagina/rectum

Neurological – midline bony tenderness, paresthesias, sensation, motor function, rectal tone

Extremities – lacerations, hematoma/bruising, deformity, capillary refill, pulses

Any patient with potential life-threatening injuries should have two large bore IV catheters (14 or 16g), continuous vital sign monitoring, fluid resuscitation for hypovolemia/hypotension, cervical spine immobilization, oxygen therapy and emergency transfer.

All other patients can be managed by appropriate treatment of their injuries and arrangements for follow-up care.

Amputations

Amputation of any extremity is a medical emergency necessitating stabilization of the patient, management of the wound and immediate transfer to tertiary care or centers capable of managing such injuries.

Complete amputations result in loss of all connection between the stump and the amputated extremity whereas partial amputations remain attached via tendon, bone, muscle or other tissue.

Amputations can be caused by sharp, blunt, shearing or crushing type injuries. Sharp amputations tend to have higher rates of successful surgical reimplantation.

Two other key factors for higher rates of reimplantation are the time that has elapsed since the injury and how the wounded parts are transported. Most tissue has viability of only 4-6 hours. However, if the amputated tissue is properly moistened and cooled, viability can be extended up to 18 hours.

Treatments

Intravenous narcotics

Digital or regional nerve block

Direct pressure for bleeding control. If tourniquet needed, clearly label the time applied. Most arteries spasm/vasoconstrict and do not bleed after amputation – therefore handle all vitalized tissue gently.

Stump – gently dress with saline moistened sterile gauze. DO NOT use hydrogen peroxide or iodine.

Apply immobilizing splint if necessary; gentle traction may be necessary for gross deformity

Amputated extremity – wrap with saline moistened sterile gauze, place in sealable plastic bag and place on ice or in ice water. Avoid freezing.

Fracture classification

Fracture Classification
Simple (closed)
Compound (open)
Incomplete (partial)
Complete
By Fracture Line
Linear
Longitudinal
Oblique
Spiral
Transverse
By Fragment Position
Comminuted
Impacted
Angulated
Displaced
Overriding
Segmental
Avulsed

Fractures initial management

initial management of fractures
Exposure
Physical Assessment
Splint
Immobilize
PRICE
Medications
Xrays
Monitor
Anticipate

Upper Limb Fractures / Injuries Shoulder Fracture

Initially rest in a sling. These should be referred to the # clinic for mobilisation as there is a high incidence of subsequent joint stiffness and pain.

Shoulder dislocation

Reduce as soon as possible e.g. by Kochers manoeuvre. Adduction sling and refer # clinic @ 2wks. Check sensation lateral shoulder.

Fracture Humerus

Check radial nerve function.

Numeral neck fractures -Sling Refer # clinic Midshaft fractureBohlar U POP and sling.

Clavicle

Check neurovascular status of ipsilateral arm. A figure of 8 bandage or Clavicular brace should be applied. Fracture clinic 2 wks approx.

58

Head injuries