Level I Trauma
Transfer from outside facility
“I might have fallen out of bed or someone may have stabbed me”
Penetrating injury to back, T4-6 fractures with posterior mediastinal hematoma abutting the esophagus and “probable” involvement of the spinal canal.
Spinal cord injury
Incomplete:
Central – Forced hyperextension – Sensory and motor deficit, Upper > Lower extremities
Anterior – hyperflexion or vascular injury, complete loss of motor, pain, and temperature below injury. Retention of proprioception and vibratory sensation
Brown-Sequard – Cord hemisection, often from penetrating trauma. Ipsilateral loss of motor, vibratory sensation, and proprioception with contralateral loss of pain and temperature sensation
Early intubation recommended with high cervical injuries (C1-C5)
MAP augmentation for blunt/incomplete penetrating injury – MAP >85 mmHg
Complete/penetrating injury – MAP >65 mmHg
Early neurosurgical decompression <72h is recommended
Steroids (as always) controversial
Posterior mediastinal injury
Rare, but high mortality (20-30%), infectious complications with esophageal injury
“Hamman’s sign” – mediastinal crunch on auscultation (~50%) associated with esophageal injury
Esophogram beginning with gastrografin administration (water soluble) – much less irritating than barium study. If negative can consider thin barium study which may be more accurate
MUST catch esophageal injuries, nearly all will leak and this carries a high morbidity and mortality
Broad-spectrum antibiotics
Cover gram +/- and pseudomonas as well as MRSA. Consider a combination such as Zosyn and Vancomycin
Domestic violence in trauma
Lifetime abuse rates - 1:4 women, 1:7 men
Intimate partner violence (IPV) victims utilize healthcare system 1.6-2.3x more frequently
JAMA 2015 – 5.7:1000 female, 1.8:1000 male trauma patients diagnosed with IPV
“Do you feel safe at home” 8% sensitive, 91% specific
HITS “how often does your significant other: Hurt, Insult, Threaten, Scream at you?” – 30-100% sensitive, 99% specific
