Download TRAUMA

TRAUMA
Gang Wang M.D
GENERAL CONCEPTS
The management of multiple trauma patients is a complex undertaking that requires broad
knowledge, sound judgment, technical skill, and leadership capabilities. These talents are applied
at the bedside under the pressure of time and the knowledge that a life is in the balance. The
critical trauma patient can benefit as much from skillful resuscitation. Because most trauma
victims are health young individuals who, if salvaged, have a normal life expectancy.
1. DEFINITION
Variable physical,mechanical,chemical and biological factors impact the organic body resulting
in its injuries from skin, membranes, to tissue and underlying organs accomplished by local and
(or) systemic dysfunction.
2. PATHOPHYSIOLOGY
The pathophysiology of trauma is the sum of the injuries to individual organ systems coupled
with overall stress, resulting in a complex neurohumoral response.
Shock, which is a frequent component of trauma, plays a major role in its pathophysiology,
coagulopathy and an altered immune response may be seen in trauma and further complicate the
picture.
Shock may result in changes of follows:
1) Neurohumoral Response-Systemic Effects.
2) The Wound.
3) Hypothalamus and Pituitary Gland.
4) Renin, Angiotensin, and Aldosterone.
5) Insulin and Glucagon.
6) Catecholamines.
7) Neurohumoral Response-Local Effects.
8) Altered lmmunity
9) Coagulopathy
Table 1. Classification of Hemorrhagic (Traumatic) Shock
% Blood volume loss
Class I up to 15%
Class II 15-30%
Class III 30-40%
Class IV >40%
Clinical signs
±increased heart rate, Minimal physiologic changes
Increased heart rate, decreased, pulse pressure, Bp
maintained, mild delay in capillary refill, anxiety
Increased heart rate, decreased blood pressure, delayed
capillary refill(>2 sec) apprehension, clouded sensorium
Decreased blood pressure, increased heart rate, frank
shock, cool, diaphoretic, decreased level of consciousness
3. ETIOLOGY- MECHAN ISM OF INJURY
Knowledge of the mechanism of injury greatly enhances the management of trauma patients. It
enables one to anticipate specific injuries and therefore may be more effective and timely in
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detecting and treating them. Kinematics relates to forces and human tolerance of these forces and
thus allows understanding of specific injuries.
TABLE 2. Trauma Mechanisms and Anticipated injuries
Mechanism
Injury to rule out
Broken windshield
Closed head injury, facial fractures, skull fractures,
cervical spine fractures
Broken steering wheel Deceleration injuries of the chest including myocardial
contusion, aortic
rupture. pulmonary contusion,
fractured sternum, flail chest, and hemopneumothorax,
Upper abdominal injury including liver and spleen
Auto accidents
injury, diaphragmatic rupture and pancreaticoduodenal
injury
Knees to dashboard
Dislocated hip, fractured hip or femur, fractured
acetabulum
Improper lap belt
Mid lumbar spine fracture, hollow viscus injury
3-point belt restraint Fracture of ribs, clavicle, sternum; pulmonary contusion
Rollover
with Crush injury, severe pelvic and other lower extremity
entrapment
fractures of lower body under vehicle compartment
syndromes
Rear-end collision
Hyperextension injuries of the cervical spine including
fractures and central cord syndrome
Supine impact
In general, great potential for axial and appendicular
skeletal injury, Renal artery thrombosis from intimal tear
(potentially bilateral)
Falls
Prone impact
Deceleration chest and abdominal injuries
Head impact
Closed head and cervical spine injury
Upright impact
Calcaneai fractures; thoracolumbar spine fractures,
spinous
process fractures; pelvis fracture, severe,
comminuted leg and femur fractures
Low-speed, adult
Tibial plateau fracture, ligamentous injury of knee
Auto-pedestrian Low-speed, child
Chest and abdominal injury, closed head injury
accidents
High-speed
Life-threatening multisystem injury
Periorbital
Intracranial penetration, carotid-cavernous sinus fistula
Anterior neck
Retropharyngeal hematoma with potential for airway
Selected
compromise, esophageal injury
penetrating
Central chest
Heart and great vessel injury
injuries
Buttocks
Rectal injury, peritoneal penetration
High-velocity gunshot Injury distant to the entrance wound
Crushed larynx, fractured hyoid, intimal injury of the
Miscellaneous Strangulation
carotid artery
injuries
Localized epigastric or Traumatic asphyxia
right upper quadrant
trauma (e.g., bicycle
handle-bar)
Patient
buried
4. THE TRAUMA SYSTEM
1) The Trauma Center
The designation of trauma centers, along with requisite ambulance destination policies,
significantly decrease the time needed for patients to reach definitive care. Furthermore, this
process insures that patients are taken to a facility where a proper resuscitation is conducted in the
emergency department.
Level Ⅰ, Level Ⅱ, Level Ⅲ, and Level Ⅳ
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2) Evaluation of the Severity of Injury
The development of trauma scoring systems has made this task relatively easy and allows a
comparison of performance to a national standard. This is accomplished by using the revised
trauma score (RTS) and the injury severity score (ISS). The ISS and RTS are calculated on all
patients. The ISS is based on anatomic injury and ranges from 0 to 75, the higher the number, the
more serious the injury. The RTS measures physiologic parameters, including blood pressure and
respiratory rate, along with the parameters of the Glasgow coma score.
The systems of scoring for Severity of Injury (trauma)
1．Score of CRAMS
C=circulation; R=respiration, A=abdomen-thorax; M=movement; S=speech
total score=C+R+A+M+S （*≤8 for serious injury）
CRAMS scoring
manifestations
C
R
A
M
S
Normal capillary filling, systolic pressure>100mmHg
Delayed capillary filling, systolic pressure 85-100mmHg
Disappeared capillary filling, systolic pressure<85mmHg
Normal
Abnormal (rapid, superficial, or>35/min)
Absent
Absence of tenderness
Tenderness
Flail chest, muscle guarding, or penetrating wound
Normal, free movement
Response to pain
No response or inability of movement
Normal speech
Hallucination
Incomplete speech
score
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2．Glasgow coma score (颅脑损伤昏迷评分)
Total score=Eye opening + Talking + Motor
Eye opening 睁眼
Talking 语言反应
Motor 运动反应
Score
Follows simple motor command
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遵嘱运动肢体
Alert and oriented
Pushes away noxious stimulus
5
回答切题
对疼痛有目的运动
Open eyes on own
Seems confused, disoriented Moves part of body but does not 4
自动睁眼
回答不切题
remove noxious stimulus 疼痛刺激
肢体回缩
Open eyes with loud Talks, but nonsensical
Flexor response (decorticate)
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verbal command 遵嘱 说出单个字
疼痛刺激躯体屈曲
睁眼
Open eyes with pain Moans, makes unintelligible Extensor response (decerebrate) 疼 2
疼痛刺激睁眼
sounds 只能发音
痛刺激躯体过伸
Does not open eyes
Makes no noise
No motor response to pain
1
不能睁眼
不能发音
疼痛刺激无反应
3．Revised Trauma Score, RTS (修正创伤评分)
RTS=0.7326×SBP(c)+0.2908×RR(c)+0.9368×GCS(c)
*c refers to coded
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GCS
13-15
9-12
6-8
4-5
3
SBP
>89
76-89
50-75
1-49
0
RR
10-29
>29
6-9
1-5
0
Coded Value
4
3
2
1
0
4．损伤严重评分(ISS)
将三个最严重损伤部位的最高简明损伤评分(AIS)编码平方值相加所得记分。
部位
描述
AIS 得
分
体表 全身疼痛,小裂伤挫伤,擦伤;撕脱伤(<10%体表面积); Ⅰ或小面积Ⅱ, Ⅲo 烧 1 轻度
伤
2 中度
广泛挫伤擦伤;大裂伤;<19%体表面积撕脱伤;10-20% Ⅱ, Ⅲo 烧伤
3 重度 a
广泛挫伤擦伤;两处以上的肢体大裂伤或超过 7.5cm 的撕裂伤;20-30% Ⅱ, 4 重度 b
Ⅲo 烧伤或撕脱伤
5 重度 c
严重裂伤,伴有出血的危险;30-50% Ⅱ, Ⅲo 烧伤或撕脱伤
>50%面积的Ⅱ, Ⅲo 烧伤或撕脱伤
头颈 头痛,头晕,无意识丧失;有挥鞭伤主述但无体征或 X 线异常
1 轻度
昏迷<15min;伤后无记忆丧失;面骨骨折无移位;单纯颅骨骨折;颈椎轻度骨折 2 中度
昏迷<1h,无严重神经系统体征;伤后记忆丧失<3h,颅骨凹陷性骨折,颈椎骨折 3 重度 a
但无神经损伤
4 重度 b
昏迷 1-6h,有神经系统体征;伤后记忆丧失 3-12h;颅骨开放性骨折
5 重度 c
昏迷>24h,颅内出血>100ml;颅内压升高;颈 4 以下损伤,四肢截瘫;主要呼吸道
阻塞
面部 眼角膜擦挫伤;眼玻璃体视网膜出血;牙折断或脱位;鼻骨或下颌骨骨折
1 轻度
无移动的面骨骨折或开放性鼻骨骨折;面部变形的裂伤;眼裂伤;视网膜剥离 2 中度
失去一眼或视神经撕脱伤;有移位的面骨骨折或涉及副鼻窦和眼眶的骨折 3 重度
胸部 单根肋骨骨折;胸壁挫伤
1 轻度
单纯 2-3 根肋骨骨折或胸骨骨折;胸壁重度挫伤;无血气胸或呼吸困难;胸骨轻 2 中度
度压缩骨折
3 重度 a
4 根以下多发肋骨骨折;血胸或和气胸;膈肌破裂;肺挫伤,无呼吸困难;胸骨骨 4 重度 b
折无神经损伤
5 重度 c
开放性创伤;连枷胸;纵隔气肿;心肌挫伤,心包损伤,无循环障碍;血胸>1000ml;
胸椎骨折截瘫
胸外伤伴重度呼吸困难(气管损伤);主动脉破裂;张力性气胸;心肌挫伤,伴循
环障碍
腹部 肌肉痛,擦伤挫伤,腰扭伤
1 轻度
腹壁重度挫伤;腹腔内脏器挫伤,无穿孔;腰椎压缩骨折
2 中度
腹腔脏器挫伤;腹膜后脏器损伤,伴出血;腰椎骨折,不伴神经损伤
3 重度 a
腹腔脏器小裂伤,包括脾肾破裂胰尾损伤,膀胱破裂;外生殖器损伤;腰椎骨折 4 重度 b
合并截瘫
5 重度 c
腹腔脏器破裂;血管损伤;撕脱或严重破裂伤,如肝胆胰脾,空腔脏器损伤
四 肢 和 轻度扭伤和指趾骨折或脱位
1 轻度
骨盆 指趾开放骨折;无移位长骨或骨盆骨折;肩肘关节脱位,肌腱肌肉裂伤
2 中度
长骨移位骨折,或多发手足骨折;开放骨折;骨盆粉碎骨折;关节脱位;四肢主要 3 重度 a
神经血管损伤或血栓形成
4 重度 b
多发长骨闭合性骨折;创伤性肢体离断
5 重度 c
多发性开放性四肢骨折,严重软组织损伤
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5. APACHEⅡ评分
Ａ
异常升高值
病理生理变化
+4
+3
+2
+1
直肠温度
≥41
39-40.9
110-129
38.5-38.9
平均动脉压(mmHg)
≥160
130-159
110-139
25-34
心率(次/分)
≥180
140-179
200-349
呼吸频率人工呼吸次分 ≥50
35-49
FiO2 ≥0.5, A-aDO2
≥500
动脉血 PH
0
异常降低值
+1
+2
+3
+4
36.4-38.4 34-35.9
32-33.9
30-31.9
≤29.9
70-109
10-11
55-69
40-54
≤49
7.5-7.59
70-109
3-3.4
55-69
7.15-7.24
≤39
155-159
150-154
12-24
6-9
111-119
≤5
350-499
1.5-1.9
5.5-5.9
﹤200
7.25-7.32
﹤7.15
﹥7.7
7.6-7.69
50-55.9
46-49.9
7.33-7.49
120-129
≤110
Na+ (mmol/L)
≥180
160-179
20-39.9
15-19.9
130-149
2.5-2.9
﹤2.5
K+ (mmol/L)
≥7
6-6.9
3.5-5.4
﹤0.6
﹤20
Cr (ng/dl 肾衰分 X２) 3.5
2-2.4
0.6-1.4
20-29.9
﹤1
1-2.9
血细胞压积%
≥80
30-45.9
血白细胞计数(亿/升)
≥40
3-14.9
神经系统评分=15-实际 Glasgow 昏迷评分
APS 总分等于上述 12 系统评分总和
B 年龄分
C 既往健康评分
年龄
分数
有严重器官功能不全或免疫抑制且为
≤44
0
a 非手术或急诊手术后
5分
45-54
2
b 择期手术
2分
55-64
3
65-74
5
≥75
6
APACHEⅡ总分=A+B+C
CLINICAL MANAGEMENT OF TRAUMA
Policy and Principle
1 Prehospital phase
1) Prevention of Additional injury.
2) Rapid Transport.
3) Advance Notification.
4) Initiation of Treatment.
5) Triage.
2 Emergency Department phase
1) Principle of Trauma Management
① Organized team approach
② Priorities in management and resuscitation*
③ Assumption of the most serious injury
④ Treatment before diagnosis
⑤ Thorough examination
⑥ Frequent reassessment
⑦ Mornitoring
2) The evaluation of Priorities in Trauma*
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High-priority evaluations
Airway/breathing
Shock/external hemorrhage
Impending cerebral herniation
Cervical spine
Lower-priority evaluations
Neurologic
Abdominal
Cardiac
Musculoskeletal
Soft tissue injury
3) Stabilization
Airway / Breathing
Shock/External Hemorrhage
Impending Herniation
Cervical Spine
4) Head-to-Toe Examination
Neurologic Evaluation
Abdominal Examination
Cardiac Examination
Musculoskeletal Examination
Examination for Soft Tissue injury
5) Consultations
Consultants in surgical subspecialties, including neurosurgeons, otolaryngologists, urologists,
ophthalmologists, and orthopedists, are called in as needed. Consultants should not be called
prematurely; Once the patient is stabilized, appropriate subspecialists can be consulted before final
disposition.
6) Disposition
Disposition is dictated by a number of factors, including the patient's condition, the nature of
the injury, and the availability of surgeons, subspecialists, and anesthesiologists.
Possible dispositions include transfer to the operating room, or transfer to another hospital.
The level of care and monitoring established in the department must be maintained throughout
the transfer. All equipment and medications needed for resuscitation and maintenance of vital
functions must be available during the transfer, as should qualified personnel to oversee the care
of the patient.
*TRAUMA ARREST
Blunt trauma victims with no signs of life before arrival have no chance for survival and should
generally not undergo thoracotomy. Blunt trauma victims who arrest in the emergency department
and victims of penetrating trauma with no signs of life at the scene also have a dismal prognosis.
Thoracotomy in these two groups of patients is not recommended. Patients with penetrating
trauma who arrest enroute to the hospital or in the emergency department have the best prognosis
and are most likely to benefit from emergency thoracotomy.
Head and Spinal Trauma
Head Trauma
Anatomy
Pathophysiology
Brain Herniation
Uncal Herniation
Central Herniation
Cingulate Herniation
Posterior Herniation
History for Suspected Head Trauma
Did the patient fall and strike his head?
Was he standing or did he fall from a height?
To make an estimate of the distance.
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Onto what did the patient fall? Cement? Dirt?
Was the patient struck on the head by a falling object or an assailant?
If the patient was struck, what was the object?
Could there have been a depressing force applied?
Was the patient involved in a motor vehicle accident?
Was the patient wearing a seat belt?
Was the windshield intact?
Assessment and Physical Examination
Neurologic Examination of Patient with Head Injuries:
Level of consciousness
Ability to retain information
Pupils: Equality, size, and reaction
Extraocular muscle movements
Reflexes: presence, absence, and symmetry
Body movements
Nose and tympanic membranes (blood, CSF)
Rectal examination: sphincter tone and sensation
1) Concussion
Concussion has classically been defined as a transient episode of neuronal dysfunction after
blunt head trauma with a rapid return to normal neurologic activity. A wide variety of disturbances
in neurologic function, including confusion, dizziness, amnesia, nausea, and vomiting, are
sufficient to make the diagnosis, even without loss of consciousness. Typically, when these
neuronal dysfunctions occur, they are short lived, lasting from several seconds or minutes to
several hours. When loss of consciousness occurs, it is thought to be caused by a disturbance in
the functioning of the the RAS is responsible for maintaining a state of alertness in an individual.
Anatomically, there is an absence of any demonstrable gross brain damage. The management of
these patients is observation.
2) Contusion
Contusion is defined as a bruise of the brain. There is some bleeding into the area of brain
substance that has been injured. This bleeding is manifested clinically by a decrease in the level of
consciousness (drowsiness) along with the finding of some neurologic deficits, which depends on
the area of the brain involved. The injury may be produced directly at the site of the initial impact
or at the opposite pole of the brain with contrecoup injuries. These patients require a thorough
workup, including a CT scan. Admission to the hospital is necessary. Repeat examinations are
mandatory to rule out any progressive problems.
3) Epidural Hemorrhage
The classic description of epidural hemorrhage is that of a patient who sustained head trauma,
had a short period of unconsciousness, returned to normal, and then, after a period of minutes to
hours, developed signs and symptoms of increasing ICP. As the hematoma caused by arterial
bleeding expands, the dura bulges inward. On CT scan, epidural hemorrhage is characterized by
biconvex hyperdensity.
Manifestation: Decreasing level of consciousness, pupillary dilation, and hemiplegia. This
history may also be found with subdural or intracerebral bleeding. In addition, a significant
number of patients do not follow the classic progression of symptoms. Patients may have no loss
of consciousness after relatively minor trauma, only to develop an epidural hematoma whereas up
to one fifth of patients with an epidural hematoma sustain trauma, lose consciousness, and remain
unconscious.
4) Subdural Hemorrhage.
The CT scan usually demonstrates a crescent-shaped density that fills the space between the
skull and brain, often displacing the brain medially ( Fig. ). In addition, damage or injury of the
brain itself is a common associated finding. Generally as the hematoma ages, it becomes isodense
between the seventh and twenty-first day and then becomes hypodense.
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Headache, pupillary dilation, personality changes, and stiff neck are common complains and
findings. Subdural hematosis have been classified into three major groups according to the time
course of clinical findings: acute, subacute, and chronic.
5) Intracerebral Hemorrhage
The most common locations for intracerebral hemorrhage are the anterior portion of the
temporal lobe and the posterior portion of the frontal lobe ( Fig.2 ). The brain substance in these
areas may become necrotic. The temporal lobe may become so edematous that it may herniate
through the tentorium. Delayed traumatic intracerebral hematoma may occur 48 to 72 hours after
injury.
6) Subarachnoid Hemorrhage
Subarachnoid hemorrhage may produce a headache and stiff neck in the patient but is usually
not amenable to surgery.
Spinal Trauma
1．SPINAL COLUMN INJURY
Normal Anatomy
The human spine consists of 33 bony vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral
(fused into one), and 4 coccygeal (usually fused into one) ( Fig.3 ).
Classification of Spinal Injury (Table)
Mechanisms of spinal injury
Wedge fracture
Flexion
Stability
Stable
Flexion teardrop fracture
Extremely unstable
Clay shoveler's fracture
Stable
Subluxation
Potentially unstable
Bilateral facet dislocation
Always unstable
Atlantoocciital dislocation
Unstable
Anterior atlantoaxial dislocation with or without Unstable
fracture
Odontoid fracture with lateral displacement fracture Unstable
Fracture of transverse process
Flexion-rotation Unilateral facet dislocation
Rotary atlantoaxial dislocation
Extension
Vertical
compression
Stable
Stable
Unstable
Posterior neural arch fracture (C1)
Unstable
Hangman's fracture (C2)
Unstable
Extension teardrop fracture
Usually stable in flexion;
unstable in extension
Posterior atlantoaxial dislocation with or without Unstable
fracture
Bursting fracture of vertebral body
Stable
Jefferson fracture (C1)
Extremely unstable
Isolated fractures of articular pillar and vertebral body Stable
2．SPINAL CORD INJURY
1) Primary Spinal Injury
The spinal cord may be injured by one or more of several mechanisms. First, penetrating trauma
or massive blunt trauma with disruption of the vertebral column may cause the transection of
neural elements. Because neurons that originate and terminate within the central nervous system
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do not regenerate, such injuries are irreversible. Second, elderly patients with cervical
osteoarthritis and spondylosis, when subjected to forcible cervical spine extension, may develop
an injury from the compression of the spinal cord between an arthritically enlarged anterior
vertebral ridge and the posteriorly located hypertrophic ligamentum flavum. Primary vascular
damage to the spinal cord, a third mechanism of injury.
2) Secondary Spinal injury
It has long been observed that the maximum neurologic deficit following blunt spinal trauma is
often not seen immediately but rather seems to progress and extend over many hours.
Posttraumatic pathophysiologic processes is a decline in blood flow to traumatized spinal tissue,
resulting in progressive hemorrhagic necrosis of gray and white matter following injury. It is now
believed that the complex cascade of events resulting in this injury is initiated by free-radical
induced peroxidation reactions that are catalyzed by the extravasation of blood into the injured
spinal cord.
3. NEUROLOGIC Evaluation
1. Reflex Examination
Level of lesion (at or above)
C6
C7
L4
S1
2.The Motor Examination
Level of Lesion
C4
C5
C6
C7
C8-T1
T1-T12
L1-L2
L3
L4
L5
S1-S2
S2-S4
3. Sensory Examination
Level of lesion
C2
C3
C4
C5
C6
C7
C8
T4
T10
L1
L2-L3
L4
L5
S1
S2-S4
Resulting loss of reflex
Biceps
Triceps
Patellar
Achilles
Resulting loss of function
Spontaneous breathing
Shrugging of shoulders
Flexion at elbow
Extension at elbow
Flexion of fingers
Intercostal and abdominal muscles*
Flexion at hip
Adduction at hip
Abduction at hip
Dorsiflexion of foot
Plantar flexion of foot
Rectal sphincter tone
Resulting level of loss of sensation
Occiput
Thyroid cartilage
Suprasternal notch
Below clavicle
Thumb
Index finger
Small finger
Nipple line
Umbilicus
Femoral pulse
Medial thigh
Knee
Lateral calf
Lateral foot
Perianal region
Radiographic Evaluation
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Methods
Anteroposterior view
Lateral view
Oblique view
Swimmer's view
Openmouth view
Futher Evaluation
CT
3D-CT
MRI
Spinal Shock
Spinal shock refers to the clinical syndrome charaterized by the loss of neurologic function and
accompanying autonomic tone below the level of a spinal cord lesion. Patients usually exhibit
flaccid paralysis with loss of all modes of sensory input, deep tendon reflexes, and urinary bladder
tone, along with bradycardia, hypotension, hypothermia, and intestinal ileus. Spinal shock may
last a few days to a few weeks.
Neurogenic hypotension secondary to spinal shock should always be a diagnosis of exclusion in
the trauma victim. It should not be considered the cause of hypotension unless (1) the patient is
flaccid and areflexic, (2) there is an absence of reflex tachycardia and peripheral vasoconstriction
and, most importantly, (3) the possibility of coexisting hemorrhagic shock, cardiac tamponade, or
tension pneumothorax has been eliminated.
Thoracic Trauma
1. CHEST WALL INJURY
1) Rib Fracture
Flail Chest: Flail chest results when three or more adjacent ribs are fractured at two points,
allowing a freely moving segment of the chest wall.
2) Traumatic Asphyxia
Traumatic asphyxia is characterized by a deep violet color of the skin of the head and neck,
bilateral subconjunctival petechial hemorrhages, and facial edema. It is caused by a severe
compression of the thorax and retrograde flow of blood from the right heart into the great veins of
the head and neck. Although the appearance of these patients can be quite dramatic, the condition
itself is usually benign and self limiting.
PULMONARY INJURIES
3) Subcutaneous Emphysema
4) Pulmonary Contusion
5) Pulmonary Laceration
PNEUMOTHORAX
6) Simple(Noncommunicating) Pneumothorax
7) Communicating Pneumothorax
8) Tension Pneumothorax
The progressive accumulation of air under pressure within the pleural cavity with shift of the
mediastinum to the opposite hemithorax and compression of the contralateral lung and great
vessels is termed tension pneumothorax (Fig). It occurs when the injury acts like a one-way valve,
preventing free bilateral communication with the atmosphere and leading to a progressive increase
of intrapleural pressure. The changes result in the rapid onset of hypoxia, acidosis, and shock.
Within minutes, patients with tension pneumothorax become acutely ill and develop severe
respiratory distress. They are dyspneic, agitated, restless, cyanotic, and hypotensive, and display
decreasing mental activity.
The cardinal signs of tension pneumothorax are hypotension, tachycardia, jugular venous
distention, and absent breath sounds on the ipsilateral side. Other signs include shift of the trachea
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and cardiac impulse and hyperresonance to percussion of the affected lung. Although tension
pneumothorax usually presents dramatically, its clinical diagnosis is sometimes obscure and chest
x-ray examination may be required to suggest the diagnosis. This film will show complete lung
collapse and shift of the mediastinum to the opposite side.
HEMOTHORAX
The accumulation of blood in the pleural space after blunt or penetrating chest trauma is a
common complication that may produce hypovolemic shock and dangerously reduce vital capacity.
It is commonly associated with pneumothorax (25% of cases) as well as extrathoacic injuries
(73% of cases). Blunting of the costophrenic angles on chest radiograph requires at least 250 ml of
fluid in the upright position.
Blunting of costophrenic angles
Small size hemothorax
Middle size hemothorax
Large size hemothorax
＞250ml
＜500ml
500~1500ml
＞1500ml
Indications for Closed-Tube Thoracostomy
1) Traumatic etiology of the pneumothorax
2) Moderate to large pneumothorax
3) Respiratory symptoms regardless of the size of the pneumothorax
4) Increasing size of the pneumothorax after initial conservative therapy
5) Reccurrence of the pneumothorax after removal of the initial chest tube
6) Patient requires ventilator support
7) Patient requires general anesthesia
8) Associated hemothorax
9) Bilateral pneumothorax regardless of size
10) Tension pneumothorax
Indications for Thoracotomy
1) Initial thoracostomy tube drainage is greater than 20ml/kg of blood (often >1000ml)
2) Persistent bleeding at a rate greater than 7ml/kg/hr or>200ml/hr or>1000ml/24hr
3) Increasing hemothorax seen on chest x-ray studies
3) Patient remains hypotensive despite adequate blood replacement, and other sites of blood loss
have been ruled out
4) Patient decompensates after initial response to resuscitation
Abdominal Trauma
CLINICAL EVALUATION
1) History
2) Physical Examination
In summary, a number of signs are valuable in assessing the patient with abdominal trauma, but
their absence does not preclude a serious injury, and none is exclusively diagnostic of a specific
injury. Extensive observation and the use of certain laboratory procedures helps greatly to prevent
erroneous or missed diagnoses.
3) Laboratory
4) Radiology
5) Diagnostic Peritoneal Lavage( DPL) and Celiocentesis
Ⅰ. Indications
1. Blunt trauma to abdomen
A. Suspected or known blunt trauma with unreliable examination
a. Head injury with altered mental status
b. Alcohol intoxication
c. Drug intoxication
d. Spinal cord injury
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e. Communication barrier: Language, Infancy, and Mental retardation
B. Multiple trauma patients who require general anesthesia for other injuries
C. Unexplained hypotension in the field or emergency department
2. Penetrating trauma
A. Stab wounds with peritoneal violation known or suspected
a. Positive local wound exploration
b. Lower chest wounds
B. Gunshot wounds with possible peritoneal violation
Ⅱ. Contraindications
1. Absolute indications for laparotomy already exist
2. Relative
A. Previous abdominal surgery
B. Gravid uterus
PENETRATING ABDOMINAL TRAUMA
1. Stab Wounds
Incidence of Organ Injury in Cases of Penetrating Trauma
Organ
Relative incidence(%)
Liver
37
Small bowel
26
Stomach
19
Colon
16.5
Spleen
7
Kidney
5
Pancreas
3.5
Duodenum
2.5
Biliary
1
Clinical Indications for Laparotomy for Stab Wounds
Hemodynamic instability
Peritoneal irritation
Bowel protusion or evisceration
Evidence of diaphragmatic injury
Significant GI bleeding
Implement in situ
2. Gunshot Wounds and Shotgun Wounds
Indications for Laparotomy for Gunshot (Shotgun) Wounds
A. Hemodynamic instability
Ⅰ. Clinical signs
B. Suspected peritoneal violation
1. Location of wound tract and missile
2. Peritoneal irritation
3. Evisceration of bowel or omentum
4. Free intraperitoneal air
5. Evidence of diaphragmatic injury
6. Significant GI bleeding
C. Wound to flank (unless superficial)
D. Wound to back (unless superficial)
Ⅱ. Laboratory tests
A. Radiologic findings
B. Positive peritoneal lavage
3. Blunt Abdominal Trauma
Incidence of Organ Injury in Blunt Trauma to the Abdomen
Organ
Relative incidence(%)
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Spleen
Liver
Retroperitoneum
Small bowel
Kidneys
Bladder
Colorectal
Diaphragm
Pancreas
Duodenum
Stomach
Biliary tract
40.6
18.9
9.3
7.2
6.3
5.7
3.5
3.1
1.6
1.4
1.3
1.1
Clinical Indications for Laparotomy in Blunt Trauma
Unstable with suspected abdominal injury
Peritoneal irritation
Pneumoperitoneum
Evidence of diaphragmatic injury
Significant gastrointestinal bleeding
ORTHOPEDIC INJURIES
Management Principles
Fractures in adult
Fracture Nomenclature
Terms Used to Describe a Fracture
Mandatory
Additional modifiers
1.Open vs. closed
2. Exact anatomic location
3. Direction of fracture line
4. Simple/comminuted
5. Position (displacement, alignment)
1. Complete vs. Incomplete
2. Involvement of articular surface (%)
3. Avulsion
4. Impaction
a. Depression; b. Compression
5.Pathologic
6. Stress
Classification of Open Fractures
Type
Characteristics
Type Ⅰ:
Low-energy forces causing a spiral or oblique fracture pattern with skin
laceration less than 2cm and a relatively clean wound
Type Ⅱ:
Type Ⅲ:
Type Ⅳ:
Moderate energy forces causing a comminuted or displaced fracture pattern
with skin laceration greater than 2cm and moderate adjacent skin and
muscle contusion but without devitalized muscle.
High-energy forces causing a significantly displaced fracture pattern with
severe comminution, segmental fracture, or bone defect with extensive
associated skin loss and devitalized muscle.
Fracture pattern as in type Ⅲ but with extreme energy forces as in highvelocity gunshot or shotgun wounds, a history of crush or degloving, or
associated vascular injury requiring repair.
Classification of Ring Avulsion injury (Urbaniak’s Classification)
Type
Characteristics
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TypeⅠ:
Requiring standard bone and soft tissue
treatment and have the most favorable prognosis
Adequate circulation
TypeⅡ:
Inadequate circulation
TypeⅢ:
Complete degloving or
complete amputation
Requiring microvascular repair to preserve
viability of the digit, limb and the extremity, and
possibly
other
osseous
or
soft-tissue
reconstruction.
Gustilo Classification of Crush Injuries
Gustilo Classification of Soft-tissue Crush Injury
Grades Findings
(type)
Puncture type wound, less than 1cm long, clean
Ⅰ
Complications (infections,
non-healing, amputation)
Almost nil
Ⅱ
Laceration associated with open fracture, without <3%
extensive soft-tissue damage.
ⅢA
Adequate soft-tissue coverage despite extensive 10%
laceration or high-energy trauma
ⅢB
Extensive soft-tissue injury
stripping and bone exposure
with
ⅢC
Concomitant major vascular
extremity requiring repair
injury
periosteal Nearly 50%
to
the ﹥50%
Management
1. Control hemorrhage in field with sterile pressure dressing after carefully removing gross
debris (leaves, wood, etc.).
2. Splint without reduction, unless there is vascular compromise.
3. In emergency department obtain a culture, then irrigate with saline and cover with
saline-soaked sponges.
4. Begin intravenous antibiotic.
5. Administer tetanus prophylaxis including tetanus immune globulin for large crush wounds.
Fractures in Children
Greenstick fracture
Incomplete angulated fractures of long bones
Torus fracture
Another form of incomplete fracture,
characterized by a wrinkling or buckling of the
cortex.
Epiphyseal injuries
Imaging Techniques
X-ray plain films
CT scan
Radionuclide Bone Scanning
MRI
Complications of Fractures
1. Hemorrhage
Fracture site
Amount of blood loss (ml)
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Radius and ulna
150-250
Humerus
250
Tibia and fibula
500
Femur
1000
Pelvis
1500-3000
Blood Loss Associated with Fractures in Adults
2. Vascular Injuries
3. Nerve injuries
Nerve injuries Accompanying Orthopedic Injuries
Orthopedic injury
Nerve injury
Elbow injury
Median (especially with displaced supracondylar fracture) or Ulnar
Shoulder dislocation
Axillary
Sacral fracture
Cauda equina
Acetabulum fracture
Sciatic
Hip dislocation
Femoral nerve
Femoral shaft fracture
Peroneal
Knee dislocation
Tibial or peroneal
Lateral tibial plateau fracture
Peroneal
4. Compartment Syndrome Volkmenn's ischemic contracture.
5. Avascular Necrosis.
6. Reflex Dystrophy, Sudeck atrophy and causalgia.
7. Fat Embolism
8. Complications of Immobilization
Pneumonia
Deep venous thrombophlebitis
Pulmonary embolism
Urinary tract infection
Wound infection
Decubitus ulcers
Muscle atrophy
Stress ulcers
Gastrointestinal bleeding
Psychiatric disorders
Fracture Healing
In genera1, the goal is to realign bony fragments so that healing or union can take place and
normal function is restored.
The progression from fracture to union begins with a hematoma that bridges the fragments,
progresses to an inflammatory phase, and ends with remodeling. The rate of fracture healing is
affected by many factors, including the type of bone（cancellous bone heals faster than cotical
bone）, degree of fracture and opposition, and systemic states such as hyperthyroidism or excess
corticosteroidism. Exercise speeds healing whereas chronic hypoxia has been known to slow
repair.
Several terms are used to denote abnormal union.
Delayed union is that which takes longer than the time normally required for a particular
fracture location.
Malunion occurs when there is a residual deformity.
Nonunion is the failure of a fracture to unite; When nonunion results in a false joint, the result is
termed a pseudarthrosis.
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