Trauma Bullets - August 2020

September 2, 2020
Clinical


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  

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