Blunt Trauma - Welcome to St. Ba

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Blunt Trauma - Welcome to St. Ba Powered By Docstoc
					   Blunt Trauma

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

   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

   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)

 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)
   The Force that puts an object in motion
    must be absorbed before the object will
   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 
       Double Weight = Double Energy
       Double Speed = Quadruple Energy

                 SPEED IS THE GREATEST
Physics (UGH!)
   Three types of forces in blunt trauma
   Compression
   Shear
   Overpressure
   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…..
   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,
   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
    can pop bladder, bowel, lungs……
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
       Additional Injuries
            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
    head protecting SABs per year
   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
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
       Down-and-Under (legs lead point)
            Knee, femur, and hip fracture (dislocation of knee, fx
            Chest trauma-Steering Wheel
       Up-and-Over (head lead point)
            Head, c-spine injuries
            Tenses legs = Bilateral femur fracture
            Hollow organ rupture and liver laceration
            Similar chest trauma
            Axial Loading
       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
          Head is forced backwards
              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
       Head: 48%
       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?
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
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
Blunt Trauma:Pedestrian Struck
    Adults
        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
   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
       Axial Loading…..
Maam, you aren’t on
Coumadin, are you??????
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
       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
       fire; burns
       combustion of toxic products; poisoning
        leaks of toxic chemicals; asphyxiation
   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
   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
   Blast Injury Care
       Lungs
           Forceful compression and distortion of chest
                Compression and decompression
           Pulmonary Embolism, Dyspnea, Hemoptysis,
       Abdomen
         Compression & Decompression
         Release of bowel contents

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

       Penetrating Wounds
           Care as any serious open wound or impaled
       Burns
           Treatment consistent with traditional
Catch That Liver, For the Love of
   Blunt Trauma Types
   Causes of Blunt Trauma
   Assessment of Injury
   Injury Patterns
   Physical exam
   Diagnosis