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Trauma

Rape, Sexual Assault, and Sexual Violence


Introduction and definitions Rape, sexual assault, and sexual violence are prevalent globally, affect all demographics, and have varying definitions. Sexual violence is an umbrella term encompassing all violent sexual acts, including rape and sexual assault. Some countries define rape very narrowly, for example, the United States at a federal level defines rape as “the penetration, […]

16/06/2022

Cardiac Trauma – Blunt and Penetrating


Traumatic injury to the heart can occur due to either penetrating or blunt force. Penetrating trauma is mostly due to gunshot or stab wounds to the chest.

16/05/2022

Geriatric Trauma Patient


With a rapidly aging population, increasing numbers of older adults sustain trauma. Most injuries are due to falls, but more older adults are also suffering from motor vehicle crashes, assaults, and burns. Age-related anatomic and physiologic changes alter older trauma patients’ clinical presentations and blunt their physiologic response to injury. As people age, their adaptive and homeostatic mechanisms change, contributing to a decreased physiologic reserve and reduced metabolic response to injury. Thus, seemingly minor injuries can be lethal and older injured patients are at greater risk for prolonged hospitalization, worsening disability, and functional dependence. Moreover, trauma is associated with increased mortality, relative to other non-injured older adults, for years after injury. Multidisciplinary and appropriate evaluation and management of older patients is necessary to improve clinical outcomes.

29/04/2022

Initial Evaluation of the Trauma Patient


Advanced Trauma Life Support (ATLS) was first developed in 1976 and is used globally as a framework for the systematic evaluation of trauma patients to optimize outcomes and reduce the risk of unidentified injuries(1). ATLS provides an easy-to-remember, algorithmic approach to the evaluation and initial management of the trauma patient, focusing on the greatest threat to life first, with the “ABCDE” approach to trauma management: Airway (with restriction of cervical spine motion), Breathing, Circulation (stop bleeding), Disability of neurologic status, and Exposure (undress) / Environment (temperature control). This chapter will outline the initial evaluation of the trauma patient using the ABCDE approach.

29/04/2022

Pelvic Binder Placement


Treatment for traumatic brain injury (TBI) is performed to prevent secondary injury to the brain following the initial injury. The prevention of secondary injury to the brain involves avoiding systemic events such as hypotension, hypoxia, or hyperthermia. The assessment and treatment of military TBI is similar to the treatment of civilian TBI with a greater focus on blast-induced TBIs. With limited resources during wartime, efficient triage and logistics of clinical care delivery take on greater importance. During wartime, many subspecialty surgeons may be tasked to assist with trauma care, outside their area of expertise. The purpose of this chapter is to describe the initial evaluation, management, and stabilization of moderate to severe TBI patients to a non-neurosurgeon surgical audience in a limited resource setting with a focus on prevention of secondary injury.

29/04/2022

The Initial Management of Moderate to Severe Traumatic Brain Injury


Treatment for traumatic brain injury (TBI) is performed to prevent secondary injury to the brain following the initial injury. The prevention of secondary injury to the brain involves avoiding systemic events such as hypotension, hypoxia, or hyperthermia. The assessment and treatment of military TBI is similar to the treatment of civilian TBI with a greater focus on blast-induced TBIs. With limited resources during wartime, efficient triage and logistics of clinical care delivery take on greater importance. During wartime, many subspecialty surgeons may be tasked to assist with trauma care, outside their area of expertise. The purpose of this chapter is to describe the initial evaluation, management, and stabilization of moderate to severe TBI patients to a non-neurosurgeon surgical audience in a limited resource setting with a focus on prevention of secondary injury.

29/04/2022

Management of Genitourinary Trauma


Trauma to the genitourinary system usually occurs as part of a multisystem trauma rather than as an isolated presentation. Injury to organs of the genitourinary system should be suspected based on the mechanism and the anatomic location of the trauma. The kidneys, ureters, and bladder are well protected within the retroperitoneum, making them relatively less prone to injury. Therefore, urological traumas are relatively rare, comprising about 10% of total abdominal traumas.

29/04/2022

Traumatic Colon Injuries


Colonic injuries may be caused by either penetrating or blunt trauma. Colonic injury from penetrating injury is far more common and often found at the transverse colon, in part due to its anterior position in the abdomen [1,2,3]. In a retrospective study of the primary mechanism of colonic injury in United States military personnel, gunshot wounds were responsible for over 50% of colorectal injury and explosion or blast injuries were responsible for 35% [4]. In civilians, gunshot wounds compromise the majority of colon injury mechanisms, followed by stab wounds [5].

29/04/2022

Craniomaxillofacial Trauma


Craniomaxillofacial trauma is a significant and complex issue to manage in wartime settings. Injuries of the facial skeleton are commonly sustained secondary to projectiles and munitions and may present with various hard and soft tissue defects that often require extensive secondary.1 Facial injuries should be immediately triaged and managed either acutely or secondarily depending upon the local craniofacial factors and the global injury burden of the patient.2 The patterns of facial injury sustained in a wartime setting differ from the civilian population with a higher propensity of mid- and upper facial injuries likely due to the combination of missile and blast injuries,3 however the morbidity and mortality from these injuries is similar.4 Additionally, many patients suffer a combination of bone and tissue loss that requires secondary management.5

29/04/2022

Rectal Injuries


ies to the rectum occur in up to 3% of civilian trauma and 5.1% in military-related trauma patients.1 Understanding the anatomy of the rectum is critical to guiding trauma management. The rectum is the most posterior visceral organ in the pelvis, initiating at the rectosigmoid junction and terminating in the anal canal. In male patients, the rectum lies posterior to the bladder and prostate, separated by the rectovesical pouch. In female patients, the rectum is posterior to the vaginal canal and uterus, separated by the pouch of Douglas (rectouterine pouch).

29/04/2022

Treatment of Life-threatening Injuries on Initial Survey (airway obstruction, tension PTX, hemothorax, cardiac tamponade)


Resuscitative thoracotomy, is performed on a patient in circulatory collapse with the objective of addressing reversible causes of cardiovascular collapse from cardiac tamponade or significant hypovolemia [1-5]. The goals are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, perform open cardiac massage, and temporarily occlude the descending thoracic aorta in the case of persistent hypotension until definitive operative intervention can be performed [1,2,5].

29/04/2022

Resuscitative Thoracotomy


Resuscitative thoracotomy, is performed on a patient in circulatory collapse with the objective of addressing reversible causes of cardiovascular collapse from cardiac tamponade or significant hypovolemia [1-5]. The goals are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, perform open cardiac massage, and temporarily occlude the descending thoracic aorta in the case of persistent hypotension until definitive operative intervention can be performed [1,2,5].

29/04/2022

Chest Tube Placement


Chest trauma in modern warfare occurs in 7-15% of cases [5-6]. Injuries sustained to the thorax require immediate attention as approximately one in six injuries carry an immediate mortality risk due to cardiac tamponade, massive hemothorax, or lung parenchymal or airway injury resulting in massive air leak [6]. The most common indications for chest tube placement are pneumothorax or hemothorax; however, important to note, there are no absolute contraindications, particularly given the life-threatening scenarios previously described [3, 7].

29/04/2022

Abdominal Vascular Trauma


Abdominal vascular injuries represent a grave threat to the victim of penetrating abdominal trauma, requiring expeditious diagnosis, judicious resuscitation and perioperative management, and swift surgical exposure and control. Early recognition and management of abdominal vascular injuries is paramount for improving patient survival.

12/04/2022

Tracheostomy


Tracheostomy is a procedure used to support patients with obstruction of their airway at the level of the larynx or above the it. Additionally, tracheostomy can be used to support patients with chronic respiratory problems or those who would require prolonged intubation with an endotracheal tube.

12/04/2022

Cricothyroidotomy


Cricothyroidotomy is a life-saving procedure that can be performed to establish a definitive airway in situations when oral intubation has failed or a provider is unable to perform the procedure. The cricothyroidotomy does not require many tools, but the procedure does require an understanding of the important landmarks in the neck. Although cricothyroidotomy is not commonly performed, knowledge of this procedure can help health care providers when their patients need an airway.

12/04/2022

Diagnosis and Management of Shock in the Injured Patient


Shock is defined by inadequate tissue perfusion leading to end-organ dysfunction. Fundamentally, shock is a physiologic state where metabolic demands of cellular processes are not met. In a state of shock, tissue oxygen delivery is impaired and toxic metabolites build up in tissued leading to cellular injury, and ultimately, cellular death. The trauma patient is particularly at risk for development of shock throughout the course of their injury. Shock is the second most common cause of trauma-related death, surpassed only by brain injury[1,2]. Herein, we broadly describe shock in the trauma patient and provide resources for diagnosis and initial management.

12/04/2022

Traumatic Small Bowel Injury


Approach to Blunt Abdominal Trauma Please see separate section for a more complete overview of blunt abdominal trauma. In summary, in a patient who underwent blunt abdominal trauma, Focused Abdominal Sonography for Trauma (FAST) should be performed as an adjunct to the primary survey. A hemodynamically unstable patient with a positive FAST should be taken […]

12/04/2022

Lower Extremity Fasciotomies


Acute compartment syndrome (ACS) of an extremity occurs when significant pressure builds up within a closed osteofascial space, which can result in irreversible damage to structures contained within the specific compartment. Fractures are the most common cause of compartment syndrome, but ischemia-reperfusion (after vascular injury), burns, prolonged immobilization, and crush injuries can also result in ACS. Diagnosing ACS early is critical in appropriately treating and reducing the risk of associated complications. While pain out of proportion to injury is the classic finding associated with ACS, early findings include paresthesias and pain on passive muscle stretch and late findings include loss of pulses or motor deficits. Although diagnosis is primarily clinical, intracompartmental pressures can be measured when findings are equivocal. 30 mmHg is often the threshold for fasciotomy. Once a diagnosis of ACS is suspected or confirmed, emergent fasciotomies need to be performed to relieve the compartmental pressure.

12/04/2022

Pelvic Fractures


Pelvic fractures resulting from blunt traumatic injury are often associated with significant hemorrhage. Early identification and intervention can be lifesaving.

12/04/2022

Management of Peripheral Vascular Trauma


The majority of wartime peripheral vascular trauma are due to explosive mechanisms which result in worse limb salvage rates compared to firearm injuries. Military data suggest that 10% battlefield deaths are secondary to extremity hemorrhage. The following describes assessment and management of peripheral vascular trauma for emergency scenarios in which a vascular or trauma surgeon is not available and without the availability of endovascular equipment or trained-providers. With vascular injuries, early recognition and intervention are essential to improve outcomes and functionality, avoid complications, and avert continued hemorrhage, limb loss and mortality.

12/04/2022

Mass Causality and Triage


As medical providers, our job is to heal the sick and wounded, and often, to try to save lives. In this pursuit we often will pour immense time and resources to give the individual under our care the best chance they have to survive. We want everyone to live. But when there are many patients, this is not always possible. In situations where the number of patients exceeds the local resources, i.e. a mass casualty, there is a limited amount of supplies, personnel, and time that have to be rationed amongst the patients. And as the number of patients to be treated increases, that allocation becomes more and more critical. It also becomes more likely that people will die. The goal at that point is to save as many as possible. While our instinct is to treat the absolute sickest first, as they are seen as the most urgent, the priority in a mass casualty is to treat the sickest that are most likely to survive with timely intervention. The purpose of triage is thus to sort patients into categories of survival probability and acuity in order to determine priority of treatment. Therefore, those that have a low chance of survival must be bypassed for those that are more likely to survive with appropriate care. While this may be difficult, it is important to realize that we are not treating one patient but many at the same time and focusing on the one sickest may result in the death of several other patients that could have survived. It is therefore vital that patients in a mass casualty are appropriately and continually triaged so that the appropriate care is provided to those that have the best chance to benefit. Save as many as we can.

12/04/2022

Management of Radiation Exposure


Radiation is perhaps one of the most feared yet misunderstood phenomena in the history of humankind. The Cold War created an ever-present undercurrent of nuclear anxiety which continues in many forms to this day. Current events demonstrate the ending of the Cold War has not erased the threat of a nuclear attack. This chapter provides an overview of radiation injuries and associated management as well as the unique considerations applicable to the treatment of casualties of radiation events.

12/04/2022

Thoracic Trauma


Traumatic thoracic injury currently accounts for approximately 6-10% of all injuries seen in trauma but carries a mortality of up to 80%. This is the case for both penetrating and blunt injury which, unlike the extremities, are not amenable to the rapid, life-saving intervention of tourniquet placement. In the modern era of trauma, high velocity projectiles, body armor and explosive blasts result in more significant injury with larger areas of tissue damage. Blast injuries are particularly devastating due to the multiplicity of concurrent mechanisms (blunt, penetrating, and thermal injuries) within a single event.1,2  The advancement and use of protective body armor and armored vehicles decreases the incidence of sudden death, thereby increasing the frequency of profound multi-trauma victims in need of life saving interventions.

12/04/2022

Upper Extremity Fasciotomies


Compartment syndrome occurs when pressures within fascial compartments exceed perfusion pressures, causing injury to the muscle, blood vessels, and nerves within the compartment. Although this condition most commonly occurs in the lower extremities, it can also occur in the upper extremities associated with ischemia, burn injuries, crush injuries, and bone fractures. If there is any concern that compartment syndrome is present or the patient could quickly develop undiagnosed compartment syndrome after prolonged ischemic time or electrical injuries, a fasciotomy should be performed. In this section, we focus specifically on upper extremity compartment syndrome, how to perform fasciotomies, and post-operative care.

12/04/2022

Venous Access


Obtaining venous access is crucial in the treatment of an acutely injured patient. Venous access allows for administration of medications, fluids, and blood products and facilitates drawing labs.

10/04/2022

Splenectomy


The spleen is an encapsulated, immunologic, solid organ located in the posterolateral left upper quadrant immediately beneath the diaphragm and lateral to the greater curve of the stomach and the tail of the pancreas. Its primary function is hematologic filtration and immunologic protection – particularly against encapsulated bacteria(1). In the trauma setting, the spleen and liver are the most commonly injured intra-abdominal organs following blunt trauma and the spleen is at risk for injury in penetrating trauma of the thoracoabdominal and abdominal regions(2). Initial evaluation of the spleen in the trauma setting can occur at bedside via the Focused Assessment with Sonography in Trauma (FAST) which can demonstrate a hypoechoic or black rim around the spleen in the left upper quadrant view or intra-abdominal free fluid in any view.

6/04/2022

Duodenal Trauma


Duodenal injuries are uncommon and most often associated with penetrating injury1. Incidence is <2% with stab wounds and 10-11% with gunshot wounds2. It is rare that duodenal injuries are isolated and therefore it is essential to evaluate for associated injuries. Commonly injured organs include liver (16.9%), pancreas (11.6%), major vascular injuries (9%), small bowel, colon and urogenital system. The second portion of the duodenum is the most frequently injured (33%), followed by third and fourth (19.4%, 19%). Whereas, the first portion of duodenum is only injured 14.4% of the time.

25/03/2022

Initial Evaluation of the Pediatric Trauma Patient


Compared to adults, children have anatomic and physiological differences that influence their response to injury, evaluation, and treatment. Blood, fluid, and medication dosing are determined by the weight of the child. Hypotension is unusual in children even with severe volume depletion and, when it does occur, is associated with a worse outcome. Blunt injury more often results in multisystem injury in children than in adults.

24/03/2022

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