Introduction to trauma

Leading cause of death from 1 to 44 years of age in developed countries

Suicide causes more deaths in young people than MVA in Australia

Trauma causes 11% of DALY’s worldwide

Trimodal distribution of trauma deaths

• Prehospital devastating head and vascular injuries – Prevention only
• Minutes to hours – Major head/chest/abdominal injuries – Rapid transport, prompt resuscitation and identification of injuries and surgical repair
• ICU – SIRS, sepsis, multiorgan failure – Evidence-based resuscitation practice

The trauma system (Cameron)

• Injury prevention is the most effective way to reduce morbidity and mortality
• Trauma systems improve the survival rate of the most seriously injured
• Trunkey et al. developed the concept of trimodal distribution of trauma deaths
  • 50% in first hour from major blood vessel disruption or major CNS/spinal injury
  • 30% due to major truncal injury causing respiratory and circulatory compromise
    • Thought to be around 10-15% now thanks to trauma system implementation
  • 20% much later from ARDS, MODS, sepsis and diffuse brain injury
• Dramatically reduced by trauma systems and optimal care in first hours
• Need continuity of care from roadside to intensive care
• Ongoing trauma audit with accurate input (severity of trauma) and output (death or quality of survival) is key to ongoing improvement

The trauma system – Prehospital

• Right patient to the right hospital in the shortest time
• Mechanism of injury criteria in pre-hospital triage ensure very sensitive tool for ensuring the most severely injured reach major trauma service, but leads to overtriage
• May include most or all of predictors of life-threatening injury (see next slide)
• Regions with the most developed pre-hospital trauma services will provide advanced life support interventions including intubation and chest decompression
• Trauma call based on anatomical, physiological or dangerous mechanism criteria

Predictors of life-threatening injury

The trauma system – Intrahospital

• Preparation – Trauma bay identification, team arrangement, identify roles, universal precautions
• Team members
  • Team leader – Overview, resuscitation, assessment, communication, ambulance, referrals, investigations, task allocation, primary and secondary survey callout
  • Airway doctor
  • Procedure doctor – IV access, ICC, catheter, ABG/art line
  • Nurses – Trauma nurse leader, airway nurse, circulation/drugs nurse
  • Radiographer
  • Orderly

Trauma audit

• Identifying avoidable trauma-related deaths or avoidable morbidity (much more difficult to ascertain) is extremely difficult when the vast majority of trauma victims survive (90% in mature trauma system) and most do well
• Most important variables to measure
  • Extent of anatomical injury e.g. Injury severity score)
  • Degree of physiological derangement that results (e.g.. Revised trauma score)
  • Age
  • Previous comorbidities
  • Outcome
    • Death/survival easy
    • Glasgow outcome scale (GOS) and short form-36 (SF-36) are two tools that have been used

Haemorrhage

Classification in adults

Haemorrhage management

• Direct pressure to external bleeding
• 2x18G or larger IVC
• Minimise crystalloid
• Volumes >1.5L associated with increased mortality
• Early blood (O type if necessary, O neg for females of childbearing age)
• 1g tranexamic acid + 1g infusion over 8 hours
• Source of bleeding may be identified from:
  • External, CXR, ICC, FAST, pelvic X-ray as part of primary survey
• Open pelvic fractures require binding and long limb fractures require traction and splinting
• Consensus articles show benefit of 1:1:1 ratios from beginning of transfusion
• Massive transfusion defined as >10 U in 24 hours or >4u in one hour
• Factor VII indications are not clear
• Initial BP goals
  • Head or spinal injury
    • SBP >100mmHg for patients 50-69yo
    • SBP >110mmHg if <50 or >70
  • Penetrating trauma
    • SBP >80
  • Blunt trauma
    • SBP >80

Disability

• GCS, Pupils and motor function in each limb
• Intubated patients should undergo continuous capnography and target PaCO2 30-35 in context of head injury
• New GCS has NT classification (not-testable)
• 4^th edition of BTS states
  • Avoid prolonged hyperventilation with PaCO2 <25
  • Target SBP >100mmHg for patients 50-69yo and >110mmHg for patients 15-49 or 70yo
  • Decreases mortality and improves outcomes
  • Propofol improves ICP but not 6 monthly outcomes
  • Barbiturates are not recommended to attain burst suppression
  • Prophylactic use of phenytoin or valproate does not reduce late post-traumatic seizures
  • Phenytoin is recommended to decrease incidence of early post-traumatic seizures (within 7 days)

Traumatic arrest

• Emergency thoracotomy neurological survival 3.9%
• 23% survival among thoracic stab victims with breathing or pulse pre-hospital
• 38% survival among thoracic stab victims with some indication of breathing or pulse on arrival to ED
• Strongest indication is therefore victims with penetrating chest trauma with witnessed signs of life during transport and at least cardiac electrical activity on arrival to ED
• Contraindicated for blunt trauma without no respiration or pulse pre-hospital

Traumatic arrest algorithm (ATLS)

• Penetrating or blunt traumatic circulatory arrest with no pulse
• Usual ALS
• If NO ROSC – Bilateral chest decompression
• If NO ROSC – Thoracotomy + vertical pericardiotomy
  • Cardiac injury – Repair
  • Thorax – Clamp bleeding site
  • Abdominal – Clamp descending aorta
• If ongoing cardiac arrest despite continued resuscitation
• Internal cardiac massage and/or internal electric shock
• Death after 30 minutes of resuscitation and temp > 33

Secondary survey

• PR not indicated for alert patients without risk of pelvic or spinal injury
• – Otherwise check for prostatic bogginess, PR blood, sphincter tone
• If no blood at meatus and prostate exam normal – can insert IDC. Otherwise, need retrograde urethrogram
• Check all limbs, motor and sensation + particular attention to pulses
• Oesophagus, diaphragm and small bowel injuries often unrecognised despite secondary survey – further imaging and hospital observation may yield delayed presentations
• Tertiary survey recommended for all patients with multisystem trauma within 24 hours of admission to lessen risk of missed injury

Admission for observation

• Inpatient vs. ED SSU
  • For closed head injury with normal neurology
  • Abdominal trauma for serial examination
  • Patients at risk for delayed pneumothorax/contusion for repeat CXR
  • ED observation allows more rapid triage to operating theatre if required

CRASH-2

• 20 000 adults within 8 hours of injury at risk of severe haemorrhage
• TXA 1g over 10 min then 1g over 8 hours
• Primary: All-cause mortality within 4 weeks of injury
• Reduced in TXA group
• Decreased mortality due to bleeding
• No increase in vasoocclusive events, transfusion or need for surgery
• Early treatment more effective on trend
• Criticisms
  • TXA group got more aFVII
  • Most benefit in severe shock group
  • Many centres in developing countries
• NNT = 125
• Benefit up to 3 hours; Harm if >3 hours

TXA

• 1.5% reduction in 28-day all cause mortality in adult trauma patients with signs of bleeding (SBP <90, HR>110 or both) within 8 hours
• No impact on TBI outcomes but limited number of patients in CRASH_2

Trauma in children

• Leading cause of death and disability in children >1yo
• No. 1 cause is head injury – focus must be on preventing hypotension and hypoxia
• Pre-hospital IV access not shown to be of benefit for most paediatric trauma patients
• Pre-hospital intubation not shown to be of benefit over BVM for paediatric patients
• Transport to hospital is the priority and all but lifesaving interventions should be done en route or deferred
• Thoracotomy should be considered if tube thoracostomy drains >15mL/kg or 4mL/kg/hr
• Warm fluids to 40 degrees
• At great risk of hypothermia

Geriatric trauma

Physiological changes of ageing

• Total body water reduced 15%
• ECF decreases 40%
• Decreased muscle, increased fat, decreased plasma protein
• Decreased CI, increased systemic vascular resistance – both 1%/year
• Decreased ability to increase HR in stress
• Reduced pulmonary compliance
• Loss of renal mass – eGFR decreases 50% from age 40 to 80
• Decreased hepatic first pass metabolism, decreased p450 activity, reduced mixed function oxidase activity (glucuronidation unchanged)
• Fractures > ligamentous injuries
• Decreased cell mediated and humoral immnity
• Reduced peritoneal signs
• Increased drug receptor affinity
• Increased sensitivity to CNS and CVS drugs

Geriatric assessment

• Principles
  • Social supports may not be adequate
  • Baseline functional status must be assessed
  • Elderly patients rarely present without significant illness (esp. after hours)
  • Early frailty assessment is aimed to augment decision making and expedite specialist geriatric involvement NOT to deny access to care
  • Older trauma patients often present with serious injuries from ‘low-risk’ mechanisms
  • Consider coagulopathy early
  • Consider ceilings of care and patient wishes early
  • Avoid catheterisation if possible
• Hx
  • Falls, medications/changes, functional capacity, social supports, health care planning
• Ex
  • Personal hygiene, nutrition, vision, hearing, dentition/swallowing, cognition, mood, postural symptoms/signs, bladder/bowel function
  • Need to assess mobility (elderly patients overestimate this by 10-50%
• Frailty
  • State of poor physiological and functional reserve
  • Lack of resilience to stressors
  • Cumulative decline in multiple systems
  • Affects 25-50% of people over 85
• Frequent presentations include:
  • Falls, delirium, functional disability, fatigue, weight loss, infections
  • This is a practical, unifying diagnosis that results in more holistic care and aids in disposition planning
• Activities of daily living
  • Telephoning
  • Shopping
  • Cleaning
  • Self-care
  • Cooking
  • Self-administration of medicines
  • Transport
  • Financial management
• Polypharmacy
  • If patients is on:
    • 2 drugs – 13% risk of adverse drug reaction contributing to presentation
    • 4 drugs = 42% risk
    • 7 or more drugs = 82% risk
• Falls
  • Epidemiology
    • 35% of people over 65 suffer at least one fall per year
    • Healthcare required in 25% of cases
    • Functional decline occurs in 35% after a fall
    • 2/3 will fall again within 12 months
  • Regular physical activity reduces risk of losing mobility by 40%
  • Always consider syncope/AS/postural/early sepsis
  • Time up and go test
    • If takes >14 seconds to get up from chair, walk 3m, turn around and sit back down = Increased risk of falls
    • 80% sensitive; >95% specific

Elder abuse

• 4% of elderly population
• Only 15% of cases recognised

Geriatric trauma

• More susceptible to serious injury from low energy injury, less able to compensate and more likely to suffer complications
• Mortality has been shown to increase beyond 45 yo
• Less likely to be involved in trauma, but more fatal outcomes (mortality rate TWICE that of younger patients)
• Pathophysiology
  • Decreased contractility and compliance for any given preload
  • 80yo has 50% of CO of 20yo even without atherosclerotic disease
  • Maximal HR and CO reduce with age
  • Decreased chronotropic response to catecholamines and is dependent on preload
  • Digoxin, CCB, beta-blockers impair tachycardic response (reduces compensation and makes assessment more difficult)
  • Reduced chest wall compliance, respiratory muscle strength and capacity for oxygen exchange
  • Response to hypoxia reduced up to 50% and hypercarbia up to 40% (may not appear in respiratory distress)
  • Maximum inspiratory and expiratory force can be reduced up to 50%
  • Renal function declines with age, predisposed to dehydration, need medication dose adjustments and more susceptible to contrast-induced nephropathy

Five conditions increase mortality and morbidity (2x risk of death):

• Cirrhosis
• Coagulopathy
• COPD
• Ischaemic heart disease
• Diabetes mellitus

Pelvic fractures carry 4x risk of death in elderly compared to young patients with longer hospital stays and greater need for transfusion even in ‘stable’ patterns

MOI in geriatric trauma

• Falls are the most common cause of trauma over 65yo
• 1/3 of adults fall annually and rate increases with age
• Common causes of falls in elderly:
  • Associated with syncope/LOC (dysrhythmias, seizure, ACS, hypoglycaemia, PE)
  • Associated with near-syncope (beta-blocker, CCB, dehydration, diuretics, haemorrhage, hot environment, sepsis, anaemia)
  • Nonsyncopal (Deconditioning, reduced visual acuity, unsafe home, alcohol, sedatives, CVA, parkinson’s)
• MVA are second-most common cause of trauma and most common cause of death (case fatality rate 2x younger people)
• Pedestrian-MVA has 50% case fatality rate
• Burns: Direct relationship between age and mortality
  • Baux score = Age + BSA = % likelihood of mortality
    • Score of >160 = futility (previously taught 110)
  • If >65yo, 50% mortality expected if 28% BSA burn
• Elder abuse: Warning signs include poor hygiene, untreated pressure ulcers, injuries not explained by mechanism and subacute injuries in various stages of healing

History

• Treat as trauma and medical patients
• Medication Hx is key (CCB, beta-blockers, anticoagulants/antiplatelets, steroids)
• Primary survey
  • Normal vitals are NOT reassuring
  • Occult hypoperfusion and oxygen delivery is common (assume the worst)
  • Chronic HTN present in up to 90% of geriatric trauma patients
  • Mortality associated with SBP <110 and HR >90 (use these as targets)
  • SBP >30 below known baseline or falling trend is a marker of instability
  • SBP <90 in elderly blunt trauma pt has mortality of 82-100%
  • RR <10 in elderly trauma patient has 100% mortality
  • Dentures, cervical arthritis and TMJ arthritis may all impair intubation

Head injuries

• Age is independent predictor of morbidity and mortality in moderate to severe head injuries
• Never assume altered LOC is due to senility or dementia
• Less prone to epidural haematomas (dura and inner skull fibrous connections strong)
• Higher incidence of subdural and intraparenchymal haemorrhage
  • Greater stretching and tension on bridging veins
  • Brain atrophy provides more room for blood to accumulate w/o symptoms
• Blunt head trauma patients on warfarin with no or minimal symptoms and 7% rate of disposition changing injury on non-contrast CT head
  • Check INR as degree of anticoagulation correlates with risk of adverse outcomes
• Clopidogrel increases risk of ICH. Aspirin, LMWH and NOAC’s unclear
• If CT head is performed, include the cervical spine ALWAYS

Cervical spine

• Incidence is 2x younger patients with similar trauma
• Odontoid fractures far more common (20% of C-spine fractures vs. 5% in younger group)
• With hyperextension, risk of central cord syndrome (motor deficits upper limb >lower limb, variable sensory loss and bladder dysfunction)
• Canadian C-spine rule excludes patients >65 from being low risk
• NEXUS does not
• Liberal CT C-spine is the rule
• Fracture identification in one spinal section warrants imaging of entire spine
• Consider pragmatic alternatives to formal C-spine stabilisation in the form of position of comfort with soft padding given potential harm from hypertextension (especially in rigid collars)

Rest of spine

• Thoracolumbar spine
  • Half of all osteoporotic fractures. Mostly T12-L1 and T7-8
  • Anterior wedge compression fractures most common
  • CT scan is first line for adult patients (plain film imaging has low sensitivity)

Chest

• More susceptible and reduced compensation
• Rib fractures place pt at risk of morbidity, pneumonia and death (5x risk)
• Rates of pneumonia and mortality 2x that of younger patients
• Rates increase with each additional rib #
• Warrants early CT as missed rib # or lung contusions pose additional threat and provides valuable prognostic information
• 10% of older major trauma patients have rib fractures and 50% go undetected on plain CXR
• Vertebrosternal ribs (1-7) have greater physiological significance than vertebrocostal ribs (8-10)
• Assess pain owith restful breathing and deepbreath/coughing
• Consider regional anaesthetic techniques as early as possible
• Targeted oxygen therapy to lowest FiO2 required
• Early humidification
• Surgical fixation within 48 hours if indicated

Abdomen

• Examination is unreliable
• FAST remains reliable
• Contrast-CT is key
  • Contrast-induced nephropathy risk reduced by IV fluids
  • Oral NAC probably not of benefit. Sodium bicarb, Vitamin C and iso-osmolar contrast have all shown mixed results

Pelvis

• Frequently low-energy mechanisms
• Pubic ramus fractures are most common injury and lateral compression the most common mechanism
• CT pelvis should be ordered if tender and normal plain film
• Plain films insensitive for posterior #, 
• Even CT is only 77% sensitive for pelvic fractures in the elderly, especially posterior fractures in osteoporotic bone. Consider MRI if ongoing concern
• Angiography in the setting of haemodynamic stability should be performed
  • One study showed 94% of those over 60yo with significant pelvic fractures required embolectomy (as opposed to 52% in younger group)

Hips

• Single most common injury diagnosis that leads to hospitalisation in the elderly
• 25% of elderly patients die within 1 year
• Women 2x at risk (age-adjusted)
• Femoral neck (intracapsular) and intertrochanteric make up 45% each with subtrochanteric making up 10%
• CT if normal plain film but concern exists (plain film 90% sensitive)
• Follow with MRI if still concerned but non-diagnostic (17% of occult fractures seen on MRI but not CT)
• CT less sensitive if osteoporotic, low-energy, non-displaced

Upper limb

• Colles’ fractures
  • Most common fracture in women up to age 75 (lifetime risk 15%)
  • Associated with low BMD or osteoporosis
  • Assess median nerve function before and after reduction
  • Functional outcomes similar for operative and non-operative intervention
    • If high functioning, surgery probably better
• Proximal humerus and humeral shaft fractures also common
  • Check axillary nerve function at shoulder patch and deltoid muscle function (remember first 18 degrees is supraspinatus)

Labs

• Liberal use of lab studies to uncover comorbid illnesses/causes for injury
• Lactate and BE serial measurements associated with systemic hypoperfusion, ICU and hospital LOS and mortality
• Base deficit
  • -3 to -5 correlates with 24% mortality
  • -6 to -9 correlates with 60% mortality
  • >-10 correlates with 80% mortality
• CK if prolonged downtime

Head injury

• Volume of intracranial blood and haematoma expansion are most important determinants of outcome
• Reverse warfarin and reasonable to reverse other forms of anticoagulation (no studies showing firm benefit)
• No studies showing benefit of platelet transfusion in aspirin use
• Patients on warfarin with normal head CT have 1-8% rate of delayed ICH
  • Admission for repeat CT in 24 hours will catch most of these
  • Discharge also reasonable if lower INR, caregivers to watch closely and reliable to return if they develop symptoms + GP f/u in next 24-48 hours

Rib #

• Low threshold for admission until good pain control and pulmonary toilet ensured
• Maintain SpO2 >95%
• Serial ABG may provide insight into respiratory function and reserve
• Consider prompt intubation and PPV in those with more severe injuries, RR >40, PaO2 <60 or PaCO2 >50

Disposition

• To ICU:
  • Multitrauma, significant chest wall injuries, abnormal vital signs, over or occult hypoperfusion
• Observation (SSU or admission)
  • To ensure adequate pain control, safe mobility/cognition while on opioids/analgesics, physio review and OT involvement to ensure safe home environment
  • Aggressive resuscitation efforts in elderly trauma patients is warranted based on studies showing patients can commonly return to premorbid function after trauma

Falls assessment

• Falls and related injuries account for more bred days than heart failure, MI and stroke combined
• Simple tests for gait and balance (e.g. up and go test) are useful to identify those at risk of further falls and who warrants multi-discplinary falls assessment
• Who warrants further assessment?
  • Fall resulting in injury
  • Gait or balance isorder
  • 2 or more falls in last 12 months
  • Clinical Frailty Score (CFS) 4-9
• Assessment should include
  • Falls history
  • Medical assessment (e.g. cardiac/PE, postural hypotension, neurovestibular)
  • Medication review
  • Functional assessment
  • Basic vision screen (visual acuity, cataracts)
  • Hearing impairment/use of hearing aids
  • Cognitive assessment and delirium screen
  • Fracture risk assessment (e.g. FRAX score)
  • Continence (nocturnal urinary frequency)
• Effective interventions include
  • Walking aids within patient reach
  • Call bell within reach or falls alarm
  • Medication review and rationalisation
  • Spectacles and hearing aid use
  • Safe footwear
  • Anti-slip mats on seats
  • Decluttered and tidy environment
  • Dementia care
  • Evidence-based balance, strength and exercise programs with multifactoral assessment, intervention and education decrease the risk of further falls by 60% in those at high-risk

Damage control resuscitation

Phases

0 – Presurgery rapid transport and triage

1 – Damage control surgery (DCS) with arresting haemorrhage, limiting contamination and minimizing operative time to minimize further hypothermia, coagulopathy and acidosis

2 – Resuscitation continues in ICU

3 – Definitive repair of injuries

4 – Closure of fascia

Damage control surgery

• Ongoing resuscitation in ICU and definitive surgical care
• Indicated for severely injured patients with multisystem trauma

Appropriate volume resuscitation

• In uncontrolled haemorrhage, aggressive fluid resuscitation may:
  • Increase blood loss from arterial injury
  • Increase mortality
  • Worsen dilutional coagulopathy
  • Increase the risk of ARDS
• Hypotensive resuscitation targeting SBP of 80 (90-100 in head injury) may reduce the risks of this until definitive haemorrhage control is achieved
• The safe duration of this method is not known

Bickel (1994)

• Penetrating torso trauma
• Mortality benefit of delayed resuscitation [Operating theatre] (70% survival) vs. immediate [Emergency Department] (62%)
• Not blinded or randomized
• Mostly young and fit
• BP was actually the same irrespective of which group
• Crystalloid was used
• Not applicable to head injured or delayed presentations

Dutton (2002)

• 110 patients. Titrated fluid resus to SBP 70 vs. 100 with no difference in mortality however actual achieved BP was around 100 in both groups

Mapstone (2003)

• Meta-analysis of animal trials suggested benefit in penetrating trauma
• Overall unclear if applicable at all to blunt trauma or whether benefit truly exists

Last Updated on June 13, 2022 by Andrew Crofton