# Blunt Trauma - Welcome to St. Ba

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```					   Blunt Trauma

Vic V. Vernenkar, D.O.
St. Barnabas Hospital
Dept. of Surgery
Sections

   Introduction to Blunt Trauma
   Kinetics of Blunt Trauma
   Types of Trauma
   Blunt Trauma
   Explosion
   Other Blunt Trauma
   Examination, Diagnosis
Introduction to
Blunt Trauma
   Most common cause of trauma death
and disability
   Energy exchange between an object
and the human body, without intrusion
through the skin
Kinematics

   Process of examining the scene to
determine potential injuries that result from
the forces of motion
   Windshield, steering wheel, dashboard
   Was the patient flying thru the air?
   Roll-over?
   Engine block on lap? (intrusion)
MOI

 Mechanism            of injury
   description of the mechanical and
physiological changes that result in
anatomical or functional damage of tissue
   Translation: What hit the patient???, what
did the patient hit???!
Index of Suspicion

   Based on the MOI and kinetics
   Predict expected injuries
   Experience counts here!
   Be obsessive and compulsive, its OK!!
Kinetics of Blunt Trauma
   Inertia
 “A body in motion will remain in motion
unless acted upon by an outside force.”
 “A body at rest will remain at rest unless
acted upon by an outside force.” (Newton)
   Conservation of Energy
 “Energy can neither be created nor
destroyed. It is only changed from one
form to another.” (Newton)
Kinetics of Blunt Trauma
   Force (Newton’s 2nd law of motion)

Force  Mass  Acceleration

   Emphasizes the importance of rate at
which an object changes speed
(acceleration or deceleration)
SOOOO
   The Force that puts an object in motion
must be absorbed before the object will
stop.
   Guess what absorbs that force????
   This absorption is what causes tissue
injury in the body.
Kinetics of Blunt Trauma
   Kinetic Energy
   Energy in Motion

Mass ( weight)  Velocity( speed )   2
KE 
2
   Double Weight = Double Energy
   Double Speed = Quadruple Energy

SPEED IS THE GREATEST
DETERMINANT
Physics (UGH!)
   Three types of forces in blunt trauma
   Compression
   Shear
   Overpressure
Compression
   Like laying an organ on a table and hitting
it with a hammer, every time you hit it,
cells are getting compressed and crushed.
   Enough said…..
Shear
   Occur when the organ and the organ’s
attachment do not accelerate or
decelerate at the same rate of speed, or
two parts of an organ accelerate or
decelerate at different rates.
   Examples are arch of aorta, spleen,
kidney.
Overpressure
   Like hitting a closed paper bag with the
open hand….the bag pops.
   Examples are like steering column hitting
abdomen…pop! goes the diaphragm. Also
Types of Trauma
   Blunt
   Closed injury
   Indirect injury to underlying structures
   Transmission of energy into the body
   Tearing of muscle, vessels and bone
   Rupture of solid organs
   Organ injury
   Ligamentum teres in the chest for example
Blunt Trauma: Car Crashes

   44,000 people die each year on US highways
   Events of Impact
   Vehicle Collision
   Body Collision
   Organ Collision
   Secondary Collisions
   Objects inside vehicle strike occupant
   Vehicle receives a second impact
Inertia and MVC’s
Protections (think Volvo!)
   Steel frame
   Belts
   Bags
   Seat construction
   Roof
   Crumple Zones
Blunt Trauma: Car Crashes
   Restraints
   Seatbelts
   Occupant slows with the vehicle
   Shoulder and Lap belts MUST be worn together
   Injuries if worn separately
   Airbags (SRS)
   Reduce blunt chest trauma
   Cause: Hand, Forearm, & Facial Injury
   Check for steering wheel deformity
   Side Airbags
   Child Safety Seats
   Infants and Small Children: Rear facing
   Older Child: Forward facing
Benefits of Air bags
   700-1000 lives saved if all vehicles had
   In side impacts where someone died, 60%
suffered brain injury.
   Only 92 cases of SAB injury, 6 involving
children, with no major injuries, only one
minor injury (skin lac).
Bags and Belts
   Burns, abrasions
   Do not protect when a second collision hits!
   Abdominal injuries (seat too close)
   Chest injuries (short, elderly)
   Seat belt abrasions above the pelvis account for
a 30-60% incidence of intra-abdominal injuries:
intestinal rupture, mesenteric injury, vascular
disruption
Blunt Trauma:
Automobile Crashes
   Types of Impact
   Frontal: 32%
   Lateral: 15%
   Rotational: 38%
   Left & Right – Front & Rear
   Rear-end: 9%
   Rollover: 6%
Blunt Trauma: Car Crashes
   Frontal Impact
   Knee, femur, and hip fracture (dislocation of knee, fx
acetabulum)
   Chest trauma-Steering Wheel
   Tenses legs = Bilateral femur fracture
   Hollow organ rupture and liver laceration
   Similar chest trauma
   Ejection
   Due to up-and-over pathway
   Contact with the vehicle & external object
Blunt Trauma:
Automobile Crashes
   Lateral Impact (intersection race)
   15% of MVC’s but 22% of deaths
   Upper extremity injury
   Rib, clavicle, humerus, pelvis, femur fracture, c-
spine dislocations, locked facets.
   Lateral compression
   Ruptured diaphragm, Spleen fracture, Aortic injury
EVALUATE the unrestrained occupant
Blunt Trauma:Car Crashes

   Rotational
   Vehicle struck at oblique angle
   Less serious injuries unless strike a
secondary object
Blunt Trauma:Car Crashes
   Rear-end
   Seat propels the occupant forward
   Stretching of neck muscles and ligaments
   Hyperextension & hyperflexion (think carotid)
   Rollover
   Multiple points of impact
   Ejection or partial ejection (think: arm out of
window, then roll….)
   Less injury with restraints
Blunt Trauma:
Automobile Crashes
   Vehicle Crash Analysis
   Crumple Zones
   Intrusion (one inch for each mile per hour)
   Deformity of Vehicle
   Use of Restraints
   Intoxication
   Fatal Accidents: >50% involved ETOH
   Recreational Accidents
Blunt Trauma:
Automobile Crashes
   Vehicular Mortality
   Internal (Torso): 37%
   Spinal & Chest fracture: 8%
   Extremity fracture: 2%
   All Other: 5%
Blunt Trauma:
Automobile Crashes
Crash Evaluation
   Collision Questions
Cause of Crash
   How did collision     Weather & visibility?
occur?                Alcohol involved?
   Direction?            Skid marks?
   Speed?              Auto Interior
   Similar/Different     Starring of windshield?
sized?                Steering wheel deformity?
Dash deformity?
   Secondary             Intrusion?
collisions?
The “Lucky Other Guy”
   The passenger in the same car as the
deceased driver for example.
   BUT, this “lucky”person was in the same
vehicle and the energy exchange on the
body was the same.
   So you’d better find that unrecognized
injury!
Blunt Trauma:
Motorcycle Crashes
   Serious injuries can occur with high and low
speed collision.
   Types of Impact
   Frontal
   Angular
   Sliding (“laying the bike down”)
   Ejection
   Initial Bike/Object Collision
   Rider/Object
   Rider/Ground
Motorcycle Injuries
   No helmet use increases chance of head
injury by 300%.
   Does not protect c-spine, but does not
injure it either.
   Anti-helmet organizations such as
American Motorcycle Association may say
different………
Blunt Trauma:Pedestrian Struck
   Adults turn away and run (lat,post injuries)
   Bumper strikes lower legs first
   Victim rolls up and over and thrown
   Children
   Children turn toward (ant injuries)
   Femurs, Pelvis often injured
   Thrown away or run over
Blunt Trauma:
Recreational Vehicle
Accidents
   Lack structure and restraint system
   Types of Vehicles
   Snowmobiles
   Personal watercraft
   ATV’s
Other Types of
Blunt Trauma
   Falls
   Stairs, Force, Surface
   Landing Area
 Surface Type
 Body Part

   Height of Fall (3 times height of victim)
   Elderly
Maam, you aren’t on
Other Types of Blunt Trauma
   Crush Injuries
   Cause
   Structural collapse, explosion, industrial; or agricultural
   Great force to soft tissue and bones
   Tissue stretching and compression
   Extended pressure results in anaerobic metabolism distal
to compression
   Return of blood flow, toxins to entire body
   Severe hemorrhage due to severe damaged blood
vessels
   Care
   Prolonged crush Medications
   Sodium Bicarbonate: Reduce Acidosis
   Morphine: Pain management
Blunt Trauma:
Blast Injuries
   Blast Injuries
   Dust, Fumes, Explosive Compounds
   Explosion
   Fuel + Oxidant combine instantaneously
   Heat & Pressure Wave
Primary Injuries
   rapid changes in atmospheric pressure from
movement of blast wave
   hollow organs more susceptible
   blast wave rapidly passes through tissue of
varying density; if lower density is adjacent to
higher density surface tissue of denser tissue is
disrupted- “spalling” as wave transverses the walls
of the alveoli (high density), they rupture as the
wave encounters the air within the alveoli (low
density); massive destruction of alveoli and diffuse
hemorrhage in lung
   Implosion
   pressure wave passes through the lung, it
forces blood out of the vascular space and
into the alveoli
   wave of high pressure is followed by wave
of low pressure allowing alveoli to expand
rapidly with further tearing of the lung
parenchyma, atelectasis, hemorrhage
Secondary Injury
   Results from flying debris created by the
explosion and carried by blast winds
   injuries are typically severe and
penetrating due to high KE of projectiles
Tertiary Injuries
   Blast winds are sufficient force to cause
victims to become human missiles
   victim strikes the ground
Associated Injuries
   Injuries resulting from changes in the
environment as a consequence of the
explosion
   fire; burns
   combustion of toxic products; poisoning
    leaks of toxic chemicals; asphyxiation
Explosion
   Pressure Wave
   Structural Collapse
   Blast Wind
   Burns
   Projectiles
   Personnel Displacement
   Blast Injury Phases
   Primary: Heat of the explosion
   Secondary: Trauma caused by projectiles
   Tertiary: Personnel displacement and structural
collapse
Explosion
   Blast Injury Assessment
   Be alert for secondary device
   Initial scene size-up important
   Establish Incident Command System (ICS)
   Evaluate for secondary hazards
   Injury Patterns
   Rupture of Air or Fluid Filled Organs
   Lung: Late manifestation (heat & pressure)
   Hearing loss
Explosion
   Blast Injury Care
   Lungs
   Forceful compression and distortion of chest
cavity
   Compression and decompression
   Pulmonary Embolism, Dyspnea, Hemoptysis,
Pneumothorax
   Abdomen
 Compression & Decompression
 Release of bowel contents

 Diaphragm rupture from pushing of organs up
into thorax area
Explosion
   Blast Injury Care
   Ears
 Initial Hearing Loss
 Injury improves over time

   Penetrating Wounds
   Care as any serious open wound or impaled
object
   Burns
management.
Catch That Liver, For the Love of
God!!!
   Blunt Trauma Types
   Causes of Blunt Trauma
   Assessment of Injury
   Injury Patterns
   Physical exam
   Diagnosis

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