| Blunt trauma | |
|---|---|
| Other names | Blunt injury, non-penetrating trauma, trauma |
 | |
| A person with ablack eye | |
| Symptoms | bruising, occasionally complicated ashypoxia,ventilation-perfusion mismatch,hypovolemia, reducedcardiac output |
Ablunt trauma, also known as ablunt force trauma ornon-penetrating trauma, is a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast withpenetrating trauma, which occurs when an object pierces the skin, enters bodytissue, and creates an openwound. Blunt trauma occurs due to directphysical trauma or impactful force to a body part. Such incidents often occur withroad traffic collisions,assaults, and sports-related injuries, and are common among theelderly who experience falls.[1][2]
Blunt trauma can lead to a wide range of injuries includingcontusions,concussions,abrasions,lacerations,internal or externalhemorrhages, andbone fractures.[1] The severity of these injuries depends on factors such as theforce of the impact, the area of the body affected, and the underlyingcomorbidities of the affected individual. In some cases, blunt force trauma can belife-threatening and may require immediate medical attention.[1] Blunt trauma to the head and/or severeblood loss are the most likely causes of death due to blunt force traumatic injury.[1]
Blunt abdominal trauma (BAT) represents 75% of all blunt trauma and is the most common example of this injury.[3] Seventy-five percent of BAT occurs in motor vehicle crashes,[4] in which rapid deceleration may propel the driver into thesteering wheel,dashboard, or seatbelt,[5] causingcontusions in less serious cases, or rupture of internal organs from briefly increasedintraluminal pressure in the more serious, depending on the force applied. Initially, there may be few indications that serious internal abdominal injury has occurred, making assessment more challenging and requiring a high degree of clinical suspicion.[6]
There are two basic physical mechanisms at play with the potential of injury to intra-abdominal organs:compression anddeceleration.[7] The former occurs from a direct blow, such as a punch, or compression against a non-yielding object such as a seat belt or steering column. This force may deform a hollow organ, increasing itsintraluminal or internal pressure and possibly leading to rupture.[7]
Deceleration, on the other hand, causes stretching andshearing at the points where mobile contents in theabdomen, like thebowel, are anchored. This can cause tearing of themesentery of the bowel and injury to theblood vessels that travel within the mesentery. Classic examples of these mechanisms are ahepatic tear along theligamentum teres and injuries to therenal arteries.[7]
When blunt abdominal trauma is complicated by 'internal injury,' theliver andspleen (seeblunt splenic trauma) are most frequently involved, followed by thesmall intestine.[8]
In rare cases, this injury has been attributed to medical techniques such as theHeimlich maneuver,[9] attempts atCPR and manual thrusts to clear anairway. Although these are rare examples, it has been suggested that they are caused by applying excessive pressure when performing these life-saving techniques. Finally, the occurrence of splenic rupture with mild blunt abdominal trauma in those recovering frominfectious mononucleosis or 'mono' (also known as 'glandular fever' in non-U.S. countries, specifically the UK) is well reported.[10]
The supervised environment in which most sports injuries occur allows for mild deviations from the traditional trauma treatment algorithms, such asATLS, due to the greater precision in identifying the mechanism of injury. The priority in assessing blunt trauma in sports injuries is separating contusions and musculo-tendinous injuries from injuries to solid organs and the gut. It is also crucial to recognize the potential for developing blood loss and to react accordingly. Blunt injuries to thekidney from helmets, shoulder pads, and knees are described in American football,[11] association football, martial arts, and all-terrain vehicle crashes.
The term blunt thoracic trauma, or, more informally,blunt chest injury, encompasses a variety of injuries to thechest. Broadly, this also includes damage caused by direct blunt force (such as a fist or a bat in an assault), acceleration or deceleration (such as that from a rear-end automotive crash),shear force (a combination of acceleration and deceleration),compression (such as a heavy object falling on a person), andblasts (such as anexplosion of some sort). Common signs and symptoms include something as simple asbruising, but occasionally as complicated ashypoxia,ventilation-perfusion mismatch,hypovolemia, and reducedcardiac output due to the way thethoracic organs may have been affected. Blunt thoracic trauma is not always visible from the outside and such internal injuries may not showsigns orsymptoms at the time the trauma initially occurs or even until hours after. A high degree of clinical suspicion may sometimes be required to identify such injuries, aCT scan may prove useful in such instances. Those experiencing more obvious complications from a blunt chest injury will likely undergo a focused assessment with sonography for trauma (FAST) which can reliably detect a significant amount of blood around the heart or in the lung by using a special machine that visualizes sound waves sent through the body. Only 10–15% of thoracic traumas require surgery, but they can have serious impacts on theheart,lungs, andgreat vessels.[12]
The most immediate life-threatening injuries that may occur includetension pneumothorax, open pneumothorax,hemothorax,flail chest,cardiac tamponade, andairway obstruction/rupture.[12]
The injuries may necessitate a procedure, most commonly the insertion of anintercostal drain, or chest tube. This tube is typically installed because it helps restore a certain balance in pressures (usually due to misplaced air or surrounding blood) that are impeding the lungs' ability to inflate and thus exchange vital gases that allow the body to function.[13] A less common procedure that may be employed is apericardiocentesis, which, by removing blood surrounding the heart, permits the heart to regain some ability to appropriately pump blood.[14][15] In certain dire circumstances an emergentthoracotomy may be employed.[16]
The primary clinical concern with blunt trauma to the head is damage to the brain, although other structures, including the skull, face,orbits, and neck are also at risk.[8] Following assessment of the patient's airway, circulation, and breathing, acervical collar may be placed if there is suspicion of trauma to the neck. Evaluation of blunt trauma to the head continues with the secondary survey for evidence of cranial trauma, including bruises, contusions, lacerations, and abrasions. In addition to noting external injury, a comprehensive neurologic exam is typically performed to assess for damage to the brain. Depending on the mechanism of injury and examination, a CT scan of the skull and brain may be ordered. This is typically done to assess forblood within the skull orfracture of the skull bones.[17]
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality and is most commonly caused by falls, motor vehicle crashes, sports- and work-related injuries, and assaults. It is the most common cause of death in patients under the age of 25. TBI is graded from mild to severe, with greater severity correlating with increased morbidity and mortality.[17][18]
Most patients with more severe traumatic brain injury have a combination of intracranial injuries, which can includediffuse axonal injury,cerebral contusions, and intracranial bleeding, includingsubarachnoid hemorrhage,subdural hematoma,epidural hematoma, andintraparenchymal hemorrhage.[8][17] The recovery of brain function following a traumatic injury is highly variable and depends upon the specific intracranial injuries that occur. However, there is a significant correlation between the severity of the initial insult as well as the level of neurologic function during the initial assessment and the level of lasting neurologic deficits.[17] Initial treatment may be targeted at reducing theintracranial pressure if there is concern for swelling or bleeding within the skull. This may require surgery, such as ahemicraniectomy, in which part of the skull is removed.[8][17]
Injury toextremities (like arms, legs, hands, feet) is extremely common.[19]Falls are the most commonetiology, making up as much as 30% ofupper and 60% oflower extremity injuries. The most common mechanism for solely upper extremity injuries is machine operation or tool use. Work-related accidents and vehicle crashes are also common causes.[20] The injured extremity is examined for four majorfunctional components which includesoft tissues,nerves,vessels, andbones.[21]Vessels are examined for expandinghematoma,bruit,distal pulse exam, and signs/symptoms ofischemia, essentially asking, "Does blood seem to be getting through the injured area in a way that enough is getting to the parts past the injury?"[22] When it is not obvious that the answer is "yes", an injured extremity index orankle-brachial index may be used to help guide whether further evaluation withcomputed tomographyarteriography. This uses a special scanner and a substance that makes it easier to examine the vessels in finer detail than what the human hand can feel or the human eye can see.[23] Soft tissue damage can lead torhabdomyolysis (a rapid breakdown of injuredmuscle that can overwhelm thekidneys) or may potentially developcompartment syndrome (whenpressure builds up inmuscle compartments damages thenerves and vessels in the same compartment).[24][25] Bones are evaluated withplain film X-ray or computed tomography if deformity (misshapen), bruising, or joint laxity (looser or more flexible than usual) are observed.Neurologic evaluation involves testing the major nerve functions of theaxillary,radial, andmedian nerves in theupper extremity as well as thefemoral,sciatic,deep peroneal, andtibial nerves in thelower extremity. Depending on the extent of injury and involved structures,surgical treatment may be necessary, but many are managed nonoperatively.[26]
The most common causes of blunt pelvic trauma aremotor vehicle crashes and multiple-story falls, and thus pelvic injuries are commonly associated with additional traumatic injuries in other locations.[27] In the pelvis specifically, the structures at risk include thepelvic bones, theproximal femur, major blood vessels such as theiliac arteries, theurinary tract,reproductive organs, and therectum.[28][27]
.png)
One of the primary concerns is the risk ofpelvic fracture, which itself is associated with a myriad of complications including bleeding, damage to theurethra andbladder, andnerve damage.[29] If pelvic trauma is suspected, emergency medical services personnel may place apelvic binder on patients to stabilize the patient's pelvis and prevent further damage to these structures while patients are transported to a hospital. During the evaluation of trauma patients in an emergency department, the stability of the pelvis is typically assessed by the healthcare provider to determine whether a fracture may have occurred. Providers may then decide to order imaging such as anX-ray or CT scan to detect fractures; however, if there is concern for life-threatening bleeding, patients should receive an X-ray of the pelvis.[30] Following initial treatment of the patient, fractures may need to be treated surgically if significant, while some minor fractures may heal without requiring surgery.[27]
A life-threatening concern ishemorrhage, which may result from damage to theaorta, iliac arteries, orveins in the pelvis. The majority of bleeding due to pelvic trauma is due to injury to the veins.[29] Fluid (often blood) may be detected in the pelvis viaultrasound during theFAST scan that is often performed following traumatic injuries. Should a patient appear hemodynamically unstable in the absence of obvious blood on the FAST scan, there may be concern for bleeding into theretroperitoneal space, known asretroperitoneal hematoma. Stopping the bleeding may requireendovascular intervention or surgery, depending on the location and severity.[28]
Blunt cardiac trauma, also known as Blunt Cardiac Injury (BCI), encompasses a spectrum of cardiac injuries resulting from blunt force trauma to the chest. While BCIs necessitate a substantial amount of force to occur because theheart is well-protected by therib cage andsternum, the majority of patients are asymptomatic.[31] Clinical presentations may range from minor, clinically insignificant changes to heartbeat or may progress to severecardiac failure anddeath.[32] Oftentimes, chest wall injuries are seen in conjunction with BCI, which confounds the presence ofchest pain experienced by most patients.[31] To evaluate the spectrum of cardiac injury, the American Association for the Surgery of Trauma (AAST) organ injury scale may be used to aid in determining the extent of the injury (see Evaluation and Diagnosis below).[31] BCI may be broken down intopericardial injury, valvular injuries,coronary artery injuries,cardiac chamber rupture, andmyocardial contusion.[31]
In most settings, the initial evaluation and stabilization of traumatic injury follows the same general principles of identifying and treating immediately life-threatening injuries. In the US, theAmerican College of Surgeons publishes the Advanced Trauma Life Support guidelines, which provide a step-by-step approach to the initial assessment, stabilization, diagnostic reasoning, and treatment of traumatic injuries that codifies this general principle.[8] The assessment typically begins by ensuring that the subject's airway is open and competent, that breathing is unlabored, and that circulation—i.e. pulses that can be felt—is present. This is sometimes described as the "A, B, C's"—Airway, Breathing, and Circulation—and is the first step in any resuscitation or triage. Then, the history of the accident or injury is amplified with any medical, dietary (timing of last oral intake) and history, from whatever sources that might be available such as family, friends, and previous treating physicians. This method is sometimes given the mnemonic "SAMPLE". The amount of time spent on diagnosis should be minimized and expedited by a combination of clinical assessment and appropriate use of technology,[33] such asdiagnostic peritoneal lavage (DPL), orbedside ultrasound examination (FAST)[34] before proceeding tolaparotomy if required. If time and the patient's stability permit, a CT examination may be carried out if available.[35] Its advantages include superior definition of the injury, leading to grading of the injury and sometimes the confidence to avoid or postpone surgery. Its disadvantages include the time taken to acquire images, although this gets shorter with each generation of scanners, and the removal of the patient from the immediate view of the emergency or surgical staff. Many providers use the aid of an algorithm such as the ATLS guidelines to determine which images to obtain following the initial assessment. These algorithms take into account the mechanism of injury,physical examination, and patient'svital signs to determine whether patients should have imaging or proceed directly to surgery.[8]
In 2011, criteria were defined that might allow patients with blunt abdominal trauma to be discharged safely without further evaluation. The characteristics of such patients include:
To be considered low-risk, patients would need to meet all low-risk criteria.[36]
When blunt trauma is significant enough to require evaluation by a healthcare provider, treatment is typically aimed at treating life-threatening injuries, such as maintaining the patient'sairway and preventing ongoingblood loss. Patients who have suffered blunt trauma and meet specifictriage criteria have shown improved outcomes when they are cared for in atrauma center.[1] The management of patients with blunt force trauma necessitates the collaboration of an interpersonal healthcare team, which may include but is not limited to; atrauma surgeon, emergency department physician,anesthesiologist, and emergency and trauma nursing staff.[1]
In cases of blunt abdominal injury, the most frequent damage occurs in thesmall intestines, and in severe situations, this can result in small intestineperforation.[7] Perforation of the small orlarge intestines is a serious concern due to its tremendous infectious potential.[7] In these cases, it is essential to performexploratory surgery to assess the internal damage, drain infected fluid in the abdomen, and clean the wound withsaline.[7]Prophylactic antibiotics are often necessary.[7] In the case of multiple holes or significant damage to theblood supply of the intestines, the affected segment of tissue may need to be removed entirely.[7]
The treatment of blunt cranial trauma is dependent on the extent of the injury. A discussion between the patient and healthcare professionals will take place in order to carefully assess the patient's condition and determine the best approach for treatment. When considering the management of cranial trauma, it is crucial to ensure that the patient can breathe effectively.[17] Effective breathing can be monitored using the patient'sblood oxygen content via apulse oximeter. The goal is to maintain greater than 90%oxygen saturation in the blood.[17] If the patient cannot maintain appropriate blood oxygen levels on their own,mechanical ventilation may be indicated.[31] Mechanical ventilation will add oxygen and remove carbon dioxide in the blood.[31] It is also critically important to avoid low blood pressure in the setting oftraumatic brain injuries. Studies have demonstrated improved outcomes in patients withsystolic blood pressure greater than or equal to 120mmHg.[17] Lastly, healthcare professionals should conduct consecutive neurological examinations to allow for early identification of elevatedintracranial pressure and subsequent implementation of interventions to improve blood flow and reduce stress to the body.[17] Of note, patients takinganticoagulant orantiplatelet therapy during the time of blunt cranial trauma should undergo rapid reversal of anticoagulating agents.[17]
Nine out of ten patients with thoracic trauma can be treated effectively without asurgical operation.[37] If surgery is indicated, there are numerous options available. A comprehensive discussion between the patient and the surgeon will take place to carefully evaluate the best approach, tailored to the patient's specific condition and injury. Conservative measures such as maintaining a clear and open airway, oxygen support,tube thoracostomy, andvolume resuscitation are often given to manage blunt thoracic trauma.[37] Oftentimes, pain control is the most basic and effective treatment approach because the presence of severe pain may lead to impairment of proper breathing, further exacerbating impaired lungs.[37] Pain management in thoracic trauma patients improves the ability to breathe properly on their own, encourages the excretion of pulmonary secretions, and decreases the aggravation ofinflammation andlow oxygen levels in the blood.[37]Nonsteroidal anti-inflammatory drugs,opioids, or regional pain management methods, such aslocal anesthetic, can be used for pain control.[37]
Worldwide, a significant cause of disability and death in people under the age of 35 is trauma, of which most are due to blunt trauma.[1]
| International | |
|---|---|
| National | |
