Trauma Bullets - March 2020
Case 1: 18 y/o male transferred from an outside hospital with a GSW to the LUQ
Penetrating Trauma and Transfers
- The primary roles of the Emergency Physician at an outside hospital are emergent resuscitation, airway management, and prompt transfer to a trauma center
- CT does not play a role in the evaluation of the unstable trauma patient when evaluated at an outside hospital. Do not delay transfer for a CT
- One study of hypotensive GSWs to the torso showed that a 10 minute delay in getting the patient to the OR increased mortality 300%. Journal of Trauma and Acute Care Surgery. 81(4):685–691, October 2016
- Beware of documenting “entrance” or “exit” wounds. We are not forensic pathologists; don’t muddy a criminal investigation. You're always safe documenting a “penetrating wound”.
- CT does not rule out hollow viscous injury. If you have are suspicious of this, consult a surgeon for evaluation and possible serial exams.
Case 2: 26 y/o female Level 1 trauma motor vehicle vs. tree, GCS 14 BP 85/33 HR 81
Massive Transfusion Protocol (at our hospital)
- Indications for MTP activation (must meet 2 criteria)
1. Penetrating injury
2. Positive FAST exam
3. HR >120
4. SBP <90
- Injuries to the bony pelvis are indicative of high-energy trauma and frequently have associated injuries. 21% have concomitant chest trauma, 17% have head injuries, 8% have injuries of the liver or spleen, and 8% have ≥2 long bone fractures. J Trauma. 2007;63(4):875
- Directly associated injuries include bladder, urethral, spinal, vascular, rectal, and vaginal trauma.
- Mortality in patients with severe pelvic fractures ranges from 8% in hemodynamically stable patients to 30-40% in those presenting in shock. 30% of those who die do so as the result of hemorrhage.
- The closed pelvis contains approximately 1.5L of potential space. Each cm of pubic symphysis diastasis enlarges this space by 1L. If you are concerned for an open book pelvis a binder should be placed immediately.
- Pelvic binders should be placed at the level of the trochanters.
- Hemorrhage often comes from the sacral venous plexus in the posterior pelvis– if you are concerned for pelvic injury avoid cannulation of the femoral veins.
- Fracturing a single part of the pelvic ring is like trying to break a Cheerio in one spot – look for the second fracture!