Trauma Bullets - March 2020

September 2, 2020
Clinical

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

Pelvic Fractures

- 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!

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