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Types of Trauma

Trauma types

A. Blunt Trauma
1. Injuries in which the tissues are not penetrated by an external object

B. Penetrating Trauma

1. tissues are penetrated by single or multiple objects

C. Injuries Caused by Deceleration

1. decelerating forces can induce shearing, avulsing, or rupturing of organs and their restraining fascia, vasculature, nerves and other soft tissues
2. Injuries are often invisible during exam
3. Head is particularly vulnerable to deceleration injuries
4. chest is vulnerable to aorta injury
5. Abdominal blunt trauma results as the forward motion of the body stops and internal organs continue forward motion
a. tearing at their points of attachment, shearing and tearing in abdominal walls
b. liver, kidneys, small intestine, large intestine, pancreas, and spleen

D. Injuries Caused by External Forces

1. Crush and compression injuries
a. forces applied to the body at the time of impact
b. head injuries may result in skull fractures, cervical spinal cord injuries and brain swelling
c.chest injuries include fractured ribs, leading to internal injuries of lungs and heart
d. flail chest is condition where chest wall moves paradoxically with respirations
e. blunt cardiac injury can compress the heart between bones in the chest, causing arrhythmias and direct injury to the heart muscle
f. If lungs are compressed, acute respiratory distress syndrome (ARDS) can require intubation to maintain patient's breathing
g. abdominal organs and pelvic fractures

E. Motor Vehicle Crashes

1. Five phases
a. deceleration of the vehicle
b. deceleration of the occupant
c. deceleration of internal organs
d. secondary collisions
e. additional impacts

F. Predicting Types of Injury by Examining the Scene

1. How dented and deformed the vehicle looks
2. Five types of impact patterns
a. frontal and head-on crashes (down-and -under or up-and-over)
b. lateral impact, T-bone, and side collisions
c. rear-impact collision
d. rotational or quarter-panel impact (off-center impact)
e. rollover
3. Restrained versus unrestrained occupants
a. seatbelts prevent ejection and serious-to-fatal injuries caused by ejection

G. Unique Patient populations

1. increased morbidity and mortality, especially chest trauma, is more common in geriatric patients, particularly rib and sternal fractures
2. fatalities also increase if child restraint devices are improperly installed or used
3. Pregnant women in general wear seatbelts less frequently than nonpregnant women

H. Motorcycle Crashes

1. Increase in number of deaths parallel an increase in engine capacity of production motorcycles
2. protective devices worn by rider are the only form of protection
3. pay attention to deformity of the motorcycle
4. Four types of motorcycle impacts
a. head-on collision
b. angular collision
c. ejected rider
d. laying the bike down

I. Pedestrian Injuries

1. more than 85% of pedestrians struck by vehicle's front end
2. Three predominant mechanisms of injury
a. when auto strikes adult body with its bumpers, it creates lower extremity injuries, particularly to knee and leg
b. a second impact occurs as the adult is thrown on the hood and/or grill, resulting in pelvis and chest injuries
c. a third impact occurs when the body strikes the ground or some other object after it has been subjected to a sudden acceleration by the colliding vehicle
3. Pediatric patterns of pedestrian injury are different:
a. the bumper is more likely to strike in the pelvis or torso, causing severe injuries from direct impact
b. more likely to be run over by the vehicle as they are propelled to the ground by the impact
4. Waddell Triad
a. refers to pattern of automobile pedestrian injuries in children and people of short stature
b. the bumper hits the pelvis and femur instead of the knees and tibia
c. the chest and abdomen hit the grille or low on the hood of the car (sternal and rib fractures)
d. the head strikes the ground (skull and facial fractures, facial abrasions and closed head injury)

J. Falls from heights

1. most commonly involve children younger than 5 years of age who are left unsupervised near a high window or on a porch
2. adult falls usually occur in the context of criminal activity, attempted suicide or intoxication
3. Severity of injuries depend on these factors:
a. height: height plus stopping distance predicts magnitude of deceleration forces
b. position: children fall head first, adults fall feet first
c. area: impact distribution, the larger the area of contact at impact the greater the dissipation of force
d. Surface: capacity for deformation
e. physical condition: preexisting medical conditions (osteoporosis, hematologic conditions)

K. Penetrating Trauma

1. a disruption of the skin and underlying tissues in a small, focused area
2. most common form in U.S. is caused by firearms
3. Stab wounds
a. severity depends on anatomic area involved, depth of penetration, blade length, and angle of penetration
b. Records may be needed in criminal proceedings
4. gunshot wounds
a. amount of damage depends on the type of firearm, velocity of the projectile physical design of projectile,distance to the target from the muzzle, and type of tissue struck
b. Classified primarily into three groups (shotguns, rifles, and handguns)
1. shotguns fire round pellets
2. Rifles fire a single projectile at very high velocity
3. Handguns (revolver or pistol)
c. Most important factor determining seriousness of gunshot wound is type of tissue through which the projectile passes
d. entry wound is characterized by the effects of initial contact and implosion. Skin and subcutaneous tissues are pushed in, cut or abraded externally.
e. deformation and tissue destruction sustained in soft tissues and bone is based on a combination of factors, including density, compressibility, missile velocity and missile fragmentation
f. Exit wounds occur when the projectile has sufficient energy that is not entirely dissipated along its trajectory through the body
5. Blast injuries
a. primary blast injuries: damage to body caused by pressure wave generated by the explosion
b. secondary blast injuries: damage resulting from being struck by flying debris, such as shrapnel
c. tertiary blast injuries: occur when patient is hurled by force of the explosion against a stationary object
d. miscellaneous blast injuries: burns form hot gases or fires started by the blast, respiratory injury from inhaling toxic gases, and crush injury from the collapse of buildings

6. Physics of an explosion
a. a solid or a liquid is chemically converted into large volumes of gas under pressure with resultant energy release
b. propellants, like gunpowder, are explosives designed to release energy relatively slowly compared with high explosives

7. Components of a blast shock wave
a. blast front: leading edge of shock wave
b. Positive wave pulse: phase of explosion in which there is a pressure front higher than atmospheric pressure
c. Brisance: shattering effect of the wave and its ability to cause a disruption of tissues as well as structures
d. Negative wave pulse: Pressure is less than atmospheric; occurs as air displaced by positive wave pulse returns to fill the space of the explosion
e. The speed, duration and pressure of the shock are affected by the size of the explosive charge, the nature of the surrounding medium (water, air, ground), the distance from the explosion, and the presence or absence of reflecting surfaces

8. Tissues at risk
a. air-containing organs are most susceptible to pressure changes
b. pulmonary blast injuries occur as contusions and hemorrhages
c. Arterial air embolism: small air bubbles enter a coronary artery and cause myocardial injury
d. neurological injuries and head trauma are the most common causes of death from blast injuries
e. extremity injuries, including traumatic amputations, are common