Physical trauma
Encyclopedia
Trauma refers to "a body wound or shock produced by sudden physical injury
, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma (defined by an Injury Severity Score
of greater than 15) can result in secondary complications
such as circulatory shock, respiratory failure
and death. Resuscitation
of a trauma patient often involves multiple management procedures. Trauma is the sixth leading cause of death worldwide, accounting for 10% of all mortality, and is a serious public health
problem with significant social and economic costs
.
):
Trauma may also be classified by the affected demographic group
(for example, trauma in the pregnant, pediatric
, or geriatric
patient). They may also be classified by the type of force applied to the body, such as blunt trauma
versus penetrating trauma
.
, a subset of blunt trauma, are the second most common cause of traumatic death. In most cases a fall of greater than three times the victim's height is defined as a severe fall. Penetrating trauma is caused when a foreign object
such as a bullet or a knife enters a tissue
of the body, creating an open wound
. In the United States most deaths caused by penetrating trauma occur in urban area
s and 80% of these deaths are caused by firearm
s. Blast injury
is a complex cause of polytrauma. It commonly includes both blunt and penetrating trauma and may also be accompanied by a burn
injury.
By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems can help to enhance the overall health of its population. Ingestion of alcohol
and illicit drugs
are risk factors for trauma, particularly traffic collisions, violence
and abuse
. Long-acting benzodiazepine
s increase the risk of trauma in elderly
people.
. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's emergency department), but rather manifests itself at a later point in time.
of the chest and pelvis are commonly performed in major trauma. Focused assessment with sonography for trauma
(FAST), can also be used. Computed tomography (CT) scans are the gold standard in imaging in major trauma. They however may only be performed in people with a relatively stable blood pressure
, heart rate
, and sufficient oxygenation
. Full-body CT scans known as pan-scans improve survival in those who have suffered major trauma. The scans are done using intravenous radiocontrast
but not oral contrast. There are concerns of radiation
exposure and concerns regarding negative effects of contrast on the kidney
s. However some centers routinely do CTs with contrast before verifying renal function
even in the elderly and have not found negative side effects with respect to the kidneys. With modern imaging technology a complete scan can be performed in less than 10 minutes. In the emergency department in the United States CT or MRI imaging is done in 15% of people who present with injuries as of 2007 (up from 6% in 1998). In those with poor blood pressure
or a fast heart rate from a presumed abdominal bleeding delaying surgery for abdominal CT imaging may worsen outcomes.
, placement of a thoracostomy tube, or pericardiocentesis
are often used in cases of severe blunt trauma to the chest or abdomen, especially in the setting of deteriorating hemodynamic stability. In those who are hypotensive due to presumed internal abdominal bleeding transfer to the operating room for a laporotomy is the preferred method of determining a definitive diagnosis.
techniques improve the chances of a person surviving the transport to the nearest trauma-equipped hospital
. After ensuring their own safety and taking isolation
precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) then an assessment of the level of consciousness. To prevent further injury, unnecessary movement of the spine
is minimized by securing the neck with a cervical collar
, and the back with a long spine board
with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person.
Rapid transportation of those who are severely injured is associated with improved outcomes.Unless the person is in imminent danger of death, first responders will typically "load and go," transporting to the nearest appropriate facility. Helicopter EMS transport reduces mortality compared to ground based transport in adult trauma patients. In the prehospital environment, the availability of advanced life support
does not improve outcomes for major trauma, when compared with basic life support
. The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation
and some evidence has found it may be harmful.
People who have suffered trauma may require specialized care, including surgery
and blood transfusion
. Outcomes are better if this occurs as quickly as possible thus the so called golden hour
of trauma. This is not a strict deadline, but recognizes that many deaths which can be prevented by appropriate care occurring in a relatively short time after injury.
Community-based trauma referral systems seek to decrease overall injury-related morbidity and mortality and years of life lost within a population by ensuring the provision of optimal care during both the acute and late phases of injury. The care of acutely injured people is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital assessment
and care by emergency medical services
personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups. An established trauma system network is also an important component of community disaster preparedness, facilitating the care of victims of natural disasters or terrorist attacks. In those with cardiac arrest
due to trauma cardiopulmonary resuscitation
(CPR) is considered futile but still recommended.
to persist (known as permissive hypotension
). Targets include a mean arterial pressure
of 60 mmHg, a systolic blood pressure of 70-90 mmHg, or until their adequate mentation and peripheral pulses.
As no intravenous fluids used for initial resuscitation has been shown to be superior to warmed Lactated Ringer's solution
it continues to be the solution of choice. If blood products are needed a greater relative use of fresh frozen plasma
and platelet
s to packed red blood cells
has been found to result in improved survival and less overall blood product usage. A ratio of one:one:one is recommended. Cell salvage and autotransfusion may also be of use.
Blood substitutes
such as hemoglobin-based oxygen carriers and perfluorocarbon emulsions are in development. As of 2011 however there are none available for commercial use in North America or Europe. The only countries where these products are available for general use is South Africa and Russia.
decreases mortality. Factor VII
may also be appropriate in certain cases associated with severe bleeding such as those who have bleeding disorders
. While it decreases blood use it does not appear to decrease mortality.
, severe brain
or high spinal cord
injury, and rupture of the heart
or large blood vessels. The early deaths occur within minutes to hours and are often due to a subdural hematoma
, epidural hematoma
, hemothorax
, pneumothorax
, ruptured spleen
, liver laceration, or pelvic fracture
s. This is known as the golden hour
. The late deaths occur days or weeks after the injury. This classical distribution however may no longer be occurring in the United States due to improvements in care.
Long term prognosis is also frequently complicated by pain with over half of people having moderately severe pain one year later. Many also experience a reduced quality of life
years later. 20% of people who sustain a traumatic injury will sustain some form of disability.
Physical trauma can lead to development of post-traumatic stress disorder
(PTSD). However, one study found no correlation between the severity of trauma and the development of PTSD.
Trauma is the sixth leading cause of death (accounting for 10% of all mortality) worldwide, and the fifth leading cause of significant disability
. In people between the ages of 1–45 years, trauma is the leading cause of death. The primary causes of death are central nervous system
injury, followed by exsanguination
.
An important part of managing trauma in children is weight estimation. A number of methods to estimate weight exist including the: Broselow tape, Leffler formula, and Theron formula.
There are diagnostic issues during pregnancy as ionizing radiation
can cause birth defects
Injury
-By cause:*Traumatic injury, a body wound or shock produced by sudden physical injury, as from violence or accident*Other injuries from external physical causes, such as radiation injury, burn injury or frostbite*Injury from infection...
, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma (defined by an Injury Severity Score
Injury Severity Score
The Injury Severity Score is an established medical score to assess trauma severity. It correlates with mortality, morbidity and hospitalization time after trauma...
of greater than 15) can result in secondary complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
such as circulatory shock, respiratory failure
Respiratory failure
The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial...
and death. Resuscitation
Fluid replacement
Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced via oral administration , intravenous administration, rectally, or hypodermoclysis, the direct injection...
of a trauma patient often involves multiple management procedures. Trauma is the sixth leading cause of death worldwide, accounting for 10% of all mortality, and is a serious public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
problem with significant social and economic costs
Social cost
Social cost, in economics, is generally defined in opposition to "private cost". In economics, theorists model individual decision-making as measurement of costs and benefits...
.
Classification
Trauma can be classified by the affected area of the body (percentages of total incidenceIncidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
):
Trauma may also be classified by the affected demographic group
Demographics
Demographics are the most recent statistical characteristics of a population. These types of data are used widely in sociology , public policy, and marketing. Commonly examined demographics include gender, race, age, disabilities, mobility, home ownership, employment status, and even location...
(for example, trauma in the pregnant, pediatric
Pediatric trauma
Pediatric trauma refers to a traumatic injury that happens to an infant, child or adolescent.-Anatomic and physiologic differences in children:There are significant anatomical and physiological differences between children and adults...
, or geriatric
Geriatric trauma
Geriatric trauma refers to a traumatic injury that occurs to an elderly person. The three prevailing causes of traumatic death in the elderly are falls , traffic collisions and burns....
patient). They may also be classified by the type of force applied to the body, such as blunt trauma
Blunt trauma
In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...
versus penetrating trauma
Penetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...
.
Causes
Blunt trauma is the leading cause of traumatic death in the United States. Most cases of blunt trauma are caused by motor vehicle accidents. FallsFalling (accident)
Falling is a major cause of personal injury, especially for the elderly. Builders, electricians, miners, and painters represent worker categories representing high rates of fall injuries. The WHO estimate that 392,000 people die in falls every year...
, a subset of blunt trauma, are the second most common cause of traumatic death. In most cases a fall of greater than three times the victim's height is defined as a severe fall. Penetrating trauma is caused when a foreign object
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
such as a bullet or a knife enters a tissue
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...
of the body, creating an open wound
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...
. In the United States most deaths caused by penetrating trauma occur in urban area
Urban area
An urban area is characterized by higher population density and vast human features in comparison to areas surrounding it. Urban areas may be cities, towns or conurbations, but the term is not commonly extended to rural settlements such as villages and hamlets.Urban areas are created and further...
s and 80% of these deaths are caused by firearm
Firearm
A firearm is a weapon that launches one, or many, projectile at high velocity through confined burning of a propellant. This subsonic burning process is technically known as deflagration, as opposed to supersonic combustion known as a detonation. In older firearms, the propellant was typically...
s. Blast injury
Blast injury
A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...
is a complex cause of polytrauma. It commonly includes both blunt and penetrating trauma and may also be accompanied by a burn
Burn
A burn is an injury to flesh caused by heat, electricity, chemicals, light, radiation, or friction.Burn may also refer to:*Combustion*Burn , type of watercourses so named in Scotland and north-eastern England...
injury.
By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems can help to enhance the overall health of its population. Ingestion of alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
and illicit drugs
Recreational drug use
Recreational drug use is the use of a drug, usually psychoactive, with the intention of creating or enhancing recreational experience. Such use is controversial, however, often being considered to be also drug abuse, and it is often illegal...
are risk factors for trauma, particularly traffic collisions, violence
Violence
Violence is the use of physical force to apply a state to others contrary to their wishes. violence, while often a stand-alone issue, is often the culmination of other kinds of conflict, e.g...
and abuse
Abuse
Abuse is the improper usage or treatment for a bad purpose, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, sexual assault, violation, rape, unjust practices; wrongful practice or custom; offense; crime, or otherwise...
. Long-acting benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
s increase the risk of trauma in elderly
Old age
Old age consists of ages nearing or surpassing the average life span of human beings, and thus the end of the human life cycle...
people.
Diagnosis
Physical examination
The purpose of the primary survey is to identify life-threatening problems. Upon completion of the primary survey, the secondary survey is begun. This may occur during transport or upon arrival at the hospital. The secondary survey consists of a systematic assessment of the abdominal, pelvic and thoracic area, complete inspection of the body surface to find all injuries, and a neurological examinationNeurological examination
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired...
. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's emergency department), but rather manifests itself at a later point in time.
Imaging
X-raysRadiography
Radiography is the use of X-rays to view a non-uniformly composed material such as the human body. By using the physical properties of the ray an image can be developed which displays areas of different density and composition....
of the chest and pelvis are commonly performed in major trauma. Focused assessment with sonography for trauma
Focused assessment with sonography for trauma
Focused Assessment with Sonography for Trauma is a rapid bedside ultrasound examination performed by surgeons and emergency physicians as a screening test for blood around the heart or abdominal organs after trauma.The four areas that are examined for free fluid are the perihepatic space...
(FAST), can also be used. Computed tomography (CT) scans are the gold standard in imaging in major trauma. They however may only be performed in people with a relatively stable blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
, heart rate
Heart rate
Heart rate is the number of heartbeats per unit of time, typically expressed as beats per minute . Heart rate can vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep....
, and sufficient oxygenation
Oxygenation (medical)
Oxygenation occurs when oxygen molecules enter the tissues of the body. For example, blood is oxygenated in the lungs, where oxygen molecules travel from the air and into the blood...
. Full-body CT scans known as pan-scans improve survival in those who have suffered major trauma. The scans are done using intravenous radiocontrast
Radiocontrast
Radiocontrast agents are a type of medical contrast medium used to improve the visibility of internal bodily structures in an X-ray based imaging techniques such as computed tomography or radiography...
but not oral contrast. There are concerns of radiation
Radiation
In physics, radiation is a process in which energetic particles or energetic waves travel through a medium or space. There are two distinct types of radiation; ionizing and non-ionizing...
exposure and concerns regarding negative effects of contrast on the kidney
Kidney
The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
s. However some centers routinely do CTs with contrast before verifying renal function
Renal function
Renal function, in nephrology, is an indication of the state of the kidney and its role in renal physiology. Glomerular filtration rate describes the flow rate of filtered fluid through the kidney...
even in the elderly and have not found negative side effects with respect to the kidneys. With modern imaging technology a complete scan can be performed in less than 10 minutes. In the emergency department in the United States CT or MRI imaging is done in 15% of people who present with injuries as of 2007 (up from 6% in 1998). In those with poor blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
or a fast heart rate from a presumed abdominal bleeding delaying surgery for abdominal CT imaging may worsen outcomes.
Surgical techniques
Surgical techniques, such as diagnostic peritoneal lavageDiagnostic peritoneal lavage
Diagnostic peritoneal lavage is a procedure where, after application of local anesthesia, a vertical skin incision is made one third of the distance from the umbilicus to the pubic symphysis. The linea alba is divided and the peritoneum entered after it has been picked up to prevent bowel...
, placement of a thoracostomy tube, or pericardiocentesis
Pericardiocentesis
In medicine, pericardiocentesis is a procedure where fluid is aspirated from the pericardium .-Position:The patient undergoing pericardiocentesis is positioned supine with the head of the bed raised to a 30- to 60-degree angle.This places the heart in proximity to the chest wall for easier...
are often used in cases of severe blunt trauma to the chest or abdomen, especially in the setting of deteriorating hemodynamic stability. In those who are hypotensive due to presumed internal abdominal bleeding transfer to the operating room for a laporotomy is the preferred method of determining a definitive diagnosis.
Management
People who have severe trauma frequently require specialized physicians and equipment. Designated trauma centers have improved outcomes compared to non designated centers. The transfer directly to a trauma center is associated with improved outcomes compared to transfer to a non trauma center.Stabilization and transportation
In the prehospital setting the use of stabilizationStabilization (medicine)
Stabilization is a process to help prevent shock in sick or injured people. Stabilization is often performed by the first person to arrive on scene, EMTs or nurses before or just after arrival in hospital...
techniques improve the chances of a person surviving the transport to the nearest trauma-equipped hospital
Trauma center
A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries. Trauma centers grew into existence out of the realization that traumatic injury is a disease process unto itself requiring specialized and experienced...
. After ensuring their own safety and taking isolation
Body substance isolation
Body substance isolation is a practice of isolating all body substances of individuals undergoing medical treatment, particularly emergency medical treatment of those who might be infected with illnesses such as HIV, or hepatitis so as to reduce as much as possible the chances of transmitting...
precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) then an assessment of the level of consciousness. To prevent further injury, unnecessary movement of the spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
is minimized by securing the neck with a cervical collar
Cervical collar
A cervical collar is an orthopedic medical device used to support a patient's neck and head. It is also used by emergency personnel for victims of traumatic head or neck injuries, and can be used to treat chronic medical conditions....
, and the back with a long spine board
Long spine board
A spinal board, also known as a long spine board , longboard, spineboard, or backboard, is a patient handling device used primarily in pre-hospital trauma care designed to provide rigid support during movement of a patient with suspected spinal or limb injuries...
with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person.
Rapid transportation of those who are severely injured is associated with improved outcomes.Unless the person is in imminent danger of death, first responders will typically "load and go," transporting to the nearest appropriate facility. Helicopter EMS transport reduces mortality compared to ground based transport in adult trauma patients. In the prehospital environment, the availability of advanced life support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
does not improve outcomes for major trauma, when compared with basic life support
Basic life support
Basic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
. The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
and some evidence has found it may be harmful.
People who have suffered trauma may require specialized care, including surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
and blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
. Outcomes are better if this occurs as quickly as possible thus the so called golden hour
Golden hour (medicine)
In emergency medicine, the golden hour refers to a time period lasting from a few minutes to several hours following traumatic injury being sustained by a casualty, during which there is the highest likelihood that prompt medical treatment will prevent death...
of trauma. This is not a strict deadline, but recognizes that many deaths which can be prevented by appropriate care occurring in a relatively short time after injury.
Community-based trauma referral systems seek to decrease overall injury-related morbidity and mortality and years of life lost within a population by ensuring the provision of optimal care during both the acute and late phases of injury. The care of acutely injured people is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital assessment
Pre-hospital trauma assessment
Pre-hospital trauma assessment is a set of skills used by emergency medical services technicians to analyze all threats to life that a patient could suffer due to a trauma incident. Pre-hospital trauma assessment is broken into two major types: basic trauma assessment and advanced trauma...
and care by emergency medical services
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups. An established trauma system network is also an important component of community disaster preparedness, facilitating the care of victims of natural disasters or terrorist attacks. In those with cardiac arrest
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
due to trauma cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
(CPR) is considered futile but still recommended.
Intravenous fluids
Traditionally, high volume intravenous fluids were given in people with hemodynamic instability due to trauma. This is still appropriate for those with isolated extremity, thermal or head injuries. The current evidence however supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotensionHypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
to persist (known as permissive hypotension
Permissive hypotension
Permissive hypotension or hypotensive resuscitation is a term used to describe the use of restrictive fluid therapy, specifically in the trauma patient, that increases systemic pressure without reaching normotension...
). Targets include a mean arterial pressure
Mean arterial pressure
The mean arterial pressure is a term used in medicine to describe an average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle.-Calculation:...
of 60 mmHg, a systolic blood pressure of 70-90 mmHg, or until their adequate mentation and peripheral pulses.
As no intravenous fluids used for initial resuscitation has been shown to be superior to warmed Lactated Ringer's solution
Lactated Ringer's solution
Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. It may also be given subcutaneously....
it continues to be the solution of choice. If blood products are needed a greater relative use of fresh frozen plasma
Fresh frozen plasma
The term fresh frozen plasma refers to the liquid portion of human blood that has been frozen and preserved after a blood donation and will be used for blood transfusion...
and platelet
Platelet
Platelets, or thrombocytes , are small,irregularly shaped clear cell fragments , 2–3 µm in diameter, which are derived from fragmentation of precursor megakaryocytes. The average lifespan of a platelet is normally just 5 to 9 days...
s to packed red blood cells
Packed red blood cells
In transfusion medicine, packed red blood cells are red blood cells that have been separated from whole blood for transfusion purposes. The product is typically abbreviated RBC or PRBC, and sometimes LRBC for leukoreduced products...
has been found to result in improved survival and less overall blood product usage. A ratio of one:one:one is recommended. Cell salvage and autotransfusion may also be of use.
Blood substitutes
Blood substitutes
A blood substitute is a substance used to mimic and fulfill some functions of biological blood, usually in the oxygen-carrying sense...
such as hemoglobin-based oxygen carriers and perfluorocarbon emulsions are in development. As of 2011 however there are none available for commercial use in North America or Europe. The only countries where these products are available for general use is South Africa and Russia.
Medications
In people who are bleeding due to trauma tranexamic acidTranexamic acid
Tranexamic acid is a drug used to treat or prevent excessive blood loss during surgery and in certain other conditions...
decreases mortality. Factor VII
Factor VII
Factor VII is one of the proteins that causes blood to clot in the coagulation cascade. It is an enzyme of the serine protease class. A recombinant form of human factor VIIa has U.S. Food and Drug Administration approval for uncontrolled bleeding in hemophilia patients...
may also be appropriate in certain cases associated with severe bleeding such as those who have bleeding disorders
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
. While it decreases blood use it does not appear to decrease mortality.
Surgery
Damage control surgery is employed in the management of trauma. This involves performing the least number of procedures to save life and limb. Less critical procedures are left until the person is more stable.Prognosis
Death from trauma have been classically described as occurring during three peaks: immediately, early, and late. The immediate deaths are usually due to apneaApnea
Apnea, apnoea, or apnœa is a term for suspension of external breathing. During apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchanged...
, severe brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
or high spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
injury, and rupture of the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
or large blood vessels. The early deaths occur within minutes to hours and are often due to a subdural hematoma
Subdural hematoma
A subdural hematoma or subdural haematoma , also known as a subdural haemorrhage , is a type of haematoma, a form of traumatic brain injury. Blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain...
, epidural hematoma
Epidural hematoma
Epidural or extradural hematoma is a type of traumatic brain injury in which a buildup of blood occurs between the dura mater and the skull. The dura mater also covers the spine, so epidural bleeds may also occur in the spinal column...
, hemothorax
Hemothorax
A hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
, pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
, ruptured spleen
Ruptured spleen
Rupture of the capsule of the spleen, an organ in the upper left part of the abdomen, is a situation that requires immediate medical attention. The rupture of a normal spleen can be caused by trauma, such as a car accident.-Function In the Body:...
, liver laceration, or pelvic fracture
Pelvic fracture
Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle accident, cycling accidents, or a fall from significant...
s. This is known as the golden hour
Golden hour (medicine)
In emergency medicine, the golden hour refers to a time period lasting from a few minutes to several hours following traumatic injury being sustained by a casualty, during which there is the highest likelihood that prompt medical treatment will prevent death...
. The late deaths occur days or weeks after the injury. This classical distribution however may no longer be occurring in the United States due to improvements in care.
Long term prognosis is also frequently complicated by pain with over half of people having moderately severe pain one year later. Many also experience a reduced quality of life
Quality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...
years later. 20% of people who sustain a traumatic injury will sustain some form of disability.
Physical trauma can lead to development of post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
(PTSD). However, one study found no correlation between the severity of trauma and the development of PTSD.
Epidemiology
Disability
A disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...
. In people between the ages of 1–45 years, trauma is the leading cause of death. The primary causes of death are central nervous system
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...
injury, followed by exsanguination
Exsanguination
Exsanguination is the fatal process of hypovolemia , to a degree sufficient enough to cause death. One does not have to lose literally all of one's blood to cause death...
.
Research
Patients who were admitted into an ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.In children
Accidents are the leading cause of death in children 1–14 years of age. In the US approximatively 16,000,000 children go to an emergency department due to some form of injury every year. Male children are more frequently injured then female children by a ratio of two to one. The top five worldwide unintentional injuries in children are as follows:| Cause | Number of deaths resulting |
|---|---|
| Traffic collision | 260,000 per year |
| Drowning Drowning Drowning is death from asphyxia due to suffocation caused by water entering the lungs and preventing the absorption of oxygen leading to cerebral hypoxia.... |
175,000 per year |
| Burn Burn A burn is an injury to flesh caused by heat, electricity, chemicals, light, radiation, or friction.Burn may also refer to:*Combustion*Burn , type of watercourses so named in Scotland and north-eastern England... s |
96,000 per year |
| Falls Falling (accident) Falling is a major cause of personal injury, especially for the elderly. Builders, electricians, miners, and painters represent worker categories representing high rates of fall injuries. The WHO estimate that 392,000 people die in falls every year... |
47,000 per year |
| Toxin Toxin A toxin is a poisonous substance produced within living cells or organisms; man-made substances created by artificial processes are thus excluded... s |
45,000 per year |
An important part of managing trauma in children is weight estimation. A number of methods to estimate weight exist including the: Broselow tape, Leffler formula, and Theron formula.
In pregnancy
Trauma occurs in 6-7% of all pregnancies and is the leading cause of maternal death. Trauma during pregnancy is a serious issue as the mothers will have an increased heart rate and increased blood pressure to accommodate the child, these hemodynamic changes will alter the presentation of shock.There are diagnostic issues during pregnancy as ionizing radiation
Ionizing radiation
Ionizing radiation is radiation composed of particles that individually have sufficient energy to remove an electron from an atom or molecule. This ionization produces free radicals, which are atoms or molecules containing unpaired electrons...
can cause birth defects
External links
- International Trauma Conferences (registered trauma charity providing trauma education for medical professionals worldwide)
- Trauma.org (trauma resources for medical professionals)
- Emergency Medicine Research and Perspectives (emergency medicine procedure videos)
- American Trauma Society
- Society of Trauma Nurses
- Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
- Definitive Surgical Trauma Skills
- After the Injury- Children's Hospital Of Philadelphia