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Motor Vehicle Accidents and Catastrophic Injuries
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  • It is estimated that by the year 2020, 8.4 million people will die every year from injury, and injuries from road traffic accidents will be the third most common cause of disability worldwide and the second most common cause in the developing world.
  • for there to be any significant reduction in the worldwide burden of motor vehicle-related trauma, injury prevention strategies are needed; prevention being better than cure.
  • Coup and contrecoupinjuries are considered focal brain injuries, those that ... The injuries can also be caused by acceleration or deceleration alone.
  • When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side.
  • Seat belt use is on the rise. Laws, education, and technology have increased seat belt use from 11% in 19812 to nearly 85% in 20103, saving hundreds of thousands of lives. Yet, about 1 in 7 people still don’t buckle up.
  • In purely frontal MVAs, air bags provide a reduced risk of fatality of approximately 30%. In all crashes the reduction in risk of death has been estimated at 11%
  • A 3 year old boy presented to theemergency department with an obvious penetrating head injury. He had tripped and fallen onto a metal model of the Eiffel Tower
  • Recent guidelines have been produced in an attempt to improve outcome after severe traumatic brain injury. An understanding of the concept of secondary brain injury, caused by hypotension and hypoxia is fundamental and the treatment of a head-injured patient should emphasize early control of the airway (while immobilizing the cervical spine), ensuring adequate ventilation and oxygenation, correcting hypovolaemia and prompt imaging by CT.
  • One of the most common contributing circumstances in spine injuries is when there is a seatbelt failure, or the person does not wear the seatbelt in the first place. Males are much more prone to this type of injury, with 80% of all spinal cord injury patients being men.
  • Today advances in medical knowledge and patient management at the scene of an injury mean a lot more people will survive what used to be a fatal injury.  These advances, critically in patient management are leading to a greater prevalence of incomplete injuries too.
  • Some complete lower injuries have partial trunk movement and may be able to stand, with long leg braces to support their paralyzed legs, and a walker taking their body weight through their arms, balancing on the leg braces.  They may be able to walk short distances using this equipment, with assistance. T6-12 patients also have partial abdominal muscle strength, and may be able to walk independently for short distances with long leg braces and a walker or crutches, again taking all their body weight through their arms, balancing on the leg braces. [The working abdominal muscles are used to throw the paralysed legs forward whilst the body weight is taken on a frame or crutches].
  • They can propel a manual wheelchair short distances on level terrain, operate power wheelchairs, and may drive with a van and special equipment. They can cook, perform light housework, and live independently with limited attendant care. Upper extremity reconstructive surgery, or functional neuromuscular stimulation of the upper extremity, or surgery and stimulation in the same patient can improve function in C-6 patients. Surgery is recommended only for patients who are neurologically stable and without spasticity. Stimulation can be provided by external, percutaneous, or implanted electrodes, by shoulder motion utilizing an external system, or by key and palmar grip and release, or by a bionic glove, an electrical stimulator garment that provides controlled grasp and hand opening.
  • Diagnosis is by cervical angiography, although non-invasive techniques, such as duplex Doppler or CT angiography may also be used.
  • The primary survey of the ATLS course concentrates on the six immediately life-threatening injuries related to the airway and the chest. An additional six other major thoracic injuries constitute "the deadly dozen" of blunt thoracic trauma, which should be considered during the secondary survey
  • Motor vehicle accidents and other deceleration injuries are the common causes of chest trauma
  • Major disruptions of the aorta, heart and pulmonary vessels are associated with immediate death due to exsanguination.
  • Severe chest injuries are responsible for 25% of all traumadeaths, and in a further 25% they are a contributing cause ofmortality. Life-threatening injuries can be remembered as thedeadly dozen — six are immediately life threatening and shouldbe sought during the primary survey and six are potentially lifethreatening and should be detected during the secondary survey.A reproducible and safe approach in their diagnosis andmanagement is taught by the Advanced Trauma Life Support(ATLS) course.
  • Eliciting tracheal deviation, observing chest wall movement, identifying obvious blunt or penetrating injury, as well as auscultation and percussion of the lung fields are important parts of the initial survey
  • Preprocedure patient education: 1.                  Obtain informed consent 2.                  Inform the patient of the possibility of major complications and their treatment3.                  Explain the major steps of the procedure, and necessity for repeated chest radiographs  Procedure NOTE: Conscious sedation during this procedure is an option for those patients who are clinically stable. 
  • Complete atelectasis of a lung, or pneumomediastinum (possibly with Hamman's sign or pericardial 'crunch' on auscultation) may be evident. Pneumomediastinum is also associated with injury to the pharynx, larynx and oesophagus. Intra-pleural bronchial injuries are associated with tension pneumothoraces, with massive air leak after tube insertion due to the bronchopleural fistula. More subtle injuries may require bronchoscopic evaluation if there is a high index of suspicion. A further clue may be the failure of supplemental oxygen to improve systemic saturations
  • A high index of suspicion must be maintained, with careful evaluation of the domes of the diaphragm during each laparotomy for blunt trauma, or with appropriate radiological techniques.
  • Earlier diagnosis and management reduces morbidity and mortality. Maintain a high level of suspicion based on history of trauma and related injuries.
  • For penetrating injuries the entry and exit sites must be carefully evaluated and trajectories must be carefully analysed especially where exit wounds are not found.
  • A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach.
  • Abdominal wall injuryBlunt injury may give rise to significant abdominal wall injury. Significant bruising or soft tissue damage to the abdominal wall may indicate intra-abdominal injury, but may also simulate the diagnosis of peritonitis and render exclusion of intra-abdominal trauma difficult if not impossible. Pedestrians may be run over by heavy vehicles with resultant shearing of the subcutaneous tissues, devitalizing the overlying skin
  • When three solid organs were injured, HVI was 6.7 times more likely than when one solid organ was injured, and the presence of a pancreatic injury plus solid organ injury was associated with HVI in more than a third of patients. A high index of suspicion must be maintained and the surgeon must be prepared to repeat imaging techniques (CT scanning or diagnostic peritoneal lavage) or to proceed to operative intervention.
  • Associated injury is common, and it has been stated that pelvic fractures cause problems for physicians who will not allow themselves to be diverted from the possibility of lethal visceral damage by the presence of broken bones, no matter how obvious these may appear[46]. Examination of the perineum, vagina and rectum is especially important in order not to miss open fractures or associated urethral injury.
  • In patients with brain or chest injury, early long bone stabilization appears to neither enhance nor worsen outcome.
  • A Freeway guard rail through and through

Motor Vehicle Accidents and Catastrophic Injuries Motor Vehicle Accidents and Catastrophic Injuries Presentation Transcript

  • Parks Medical-Legal ConsultingMotor Vehicle Accidents and Traumatic Injuries By Paul Parks, RN LNC- Research Expert “integrating medicine & law” © 2012 PMLC
  • INTRODUCTION• FACTS: Motor vehicle crashes are the leading cause of death among the ages 5 to 34 in the U.S. More than 2.3 million adult drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle crashes. The economic impact is notable: the lifetime costs of crash-related deaths and injuries among drivers and passengers were estimated to be over $70 billion dollars!
  • KEY FACTORS IN CAR ACCIDENTS 1) Characteristic injury patterns associated with injuries from road traffic accidents are usually multisystem, leading to more complexities. 2) The care of severely injured patients requires a coordinated approach, from the point of injury all the way to rehabilitation. 3) Health care practitioners must adopt a logical sequence for the initial assessment and management of the trauma patient to reduce morbidity and mortality. View slide
  • MOTOR VEHICLE ACCIDENTS {MVA’S} • Motor vehicle accidents (MVAs) are a major cause of both internal and external wounds, many of which cannot be treated with simple dressings - if at all . Hence, the importance of recognizing the typical patterns of injury associated with MVAs. This, coupled with a logical sequence for the initial assessment and management of trauma patients, has been shown to contribute to improved outcomes. View slide
  • MVA’S ARE DIVIDED INTO 2 GROUPS 1) Collision between the patient and the external environment (the vehicle, or a stationary object if the occupant has been ejected) . Example: Driver hits a phone pole while unrestrained passenger is ejected. 2) Acceleration or deceleration forces acting on the patients internal organs. Example: Traumatic brain injury {TBI} with Coup- contrecoup.
  • The Coup contrecoup injury
  • TYPES OF MVA COLLISIONS Frontal Collision: In a frontal collision, the unrestrained occupant of a vehicle continues to move forward as the vehicle comes to an abrupt stop. This forward motion is arrested as the patient connects with the, now, stationary vehicle chassis. The initial impact point is often the lower extremities, resulting in fracture/dislocation of the ankles, knee or hip dislocations and femoral fractures. As the body continues moving, the head, cervical spine and torso impact on the windscreen and steering column.
  • TYPES OF MVA COLLISIONSThe Lateral Impact: a lateral impact, the victim is accelerated away from the side of the vehicle. Compressive pelvic injuries, pulmonary contusion, intra- abdominal solid organ injury and diaphragmatic rupture are common.Rear impacts also accelerate the victim; if head restraints are incorrectly fitted, the inertia of the head makes the cervical spine vulnerable to injury. Ejection from a vehicle is associated with a significantly greater incidence of severe or critical injury.
  • FACTS ABOUT SEATBEALTSSince MVA;s are the leading cause of death in the first three decades of American’s lives. In 2009 alone, MVA killed over 33,000 people and injured another 2.2 million—more than 70% of these were in passenger vehicles and trucks. More than half of the people killed in car crashes were not restrained at the time of the crash. Wearing a seat belt is the most effective way to prevent death and serious injury in a crash period.
  • SEATBELT FACTS• Most drivers and passengers killed in crashes are unrestrained. 53% of drivers and passengers killed in car crashes in 2009 were not wearing restraints.• Seat belts dramatically reduce risk of death and serious injury. Among drivers and front-seat passengers, seat belts reduce the risk of death by 45%, and cut the risk of serious injury by 50%.• People not wearing a seat belt are 30 times more likely to be ejected from a vehicle during a crash. More than 3 out of 4 people who are ejected during a crash die from their injuries
  • Seat Belts Have Saved an Estimated 255,000 LivesSince 1975
  • DECELERATION & ACCLERATION INJURIES These injuries occur when differential movement occurs between adjacent structures; for example the distal aorta is anchored to the thoracic spine and decelerates much more quickly than the relatively mobile aortic arch. Shear forces are generated in the aorta by the continuing forward motion of the arch in respect to the distal thoracic aorta. Similar situations occur at the renal pedicles, the junction of the cervical with the thoracic spine and also between the white and grey matter within the brain. The use of a three- point lap-shoulder seat belt is thought to reduce the risk of death or serious injury for front-seat occupants by approximately 45%.
  • DECELERATION & ACCLERATION INJURIES Head injury: Head injury is a major cause of morbidity in survivors; disability may occur whatever the initial severity of the head injury and surviving patients with brain injury are more impaired than patients with injuries to other parts of the body. In a prospective study of nearly 3000 head injuries, patients were stratified according to the Glasgow Coma Score (GCS) on arrival at hospital: mild injury (GCS 13-15), moderate injury (GCS 9-12) and severe injury (GCS 3-8). Of the initial cohort, 2668 had mild injuries, 133 moderate injuries, and 102 had severe injuries. At follow-up after one year, 1397 were still disabled. Of these, 1260 (90%) had been initially assessed as mild injuries.
  • TYPES OF BRAIN INJURIES: FOCAL & DIFFUSE • Focal: A focal traumatic injury results from direct mechanical forces such as a when the head strikes the windshield of a car. A common cause of focal injury is a penetrating head injury, in which the skull is perforated, [brain tissue may be visible] as frequently occurs in auto accidents. Focal injuries typically have symptoms that are related to the damaged area of the brain. For example, if a speech center of the brain [Brocas area] is damaged, problems with speech are common.
  • FOCAL INJURY CHARACTERISTICS1. Cerebral contusion is a bruise of brain tissue that commonly results from contact of the brain with the inside of the skull.2. Cerebral laceration in which the pia-arachnoid is torn.3. Epidural hemorrhage- commonly associated with damage to the middle meningeal artery, often resulting from a skull fracture.4. Subdural hemorrhage [bleeding between the dura mater and the arachnoid].5. Intracerebral hemorrhage [bleeding within the brain tissue itself].6. Intraventricular hemorrhage [bleeding within the ventricles of the brain].
  • DIFFUSE INJURY CHARACTERISTICSUnlike focal injuries, which are usually easy to detect using imaging, diffuse injuries may be difficult to detect and define; often, much of the damage is microscopic.Diffuse injuries include the following:1. Widespread damage to the white matter of the brain that usually results from acceleration/deceleration types of injury.2. Ischemic brain injury resulting from an insufficient blood supply to the brain, is one of the leading causes of secondary brain damage after head trauma.3. Vascular injury usually causes death shortly after an injury.4. Swelling, or edema is commonly seen after TBI and can lead to dangerous increases in intracranial pressure. This causes the brain to push down in to the foramen magnum [known as herniation ] leading to death.
  • DIFFUSE AXONAL INJURY FACTS• Diffuse axonal injury occurs in about half of all severe head traumas, making it one of the most common traumatic brain injuries. It may also occur in mild/moderate TBI. A diffuse axonal injury falls under the category of a diffuse brain injury. Instead of occurring in a localized area, like a focal injury, it occurs over a widespread area. Additionally, it’s also one of the most devastating TBI’s as severe diffuse axonal injury is one of the leading causes of death in people with traumatic brain injury.
  • DIFFUSE AXONAL INJURIESNormal Axon Twisted and sheared AxonDiffuse axonal injury isn’t the result of a blow to the head.Instead, it results from the brain moving back and forth inthe skull as a result of acceleration or deceleration.Automobile accidents, sports-relatedaccidents, violence, falls, and child abuse such asShaken Baby Syndrome are common causes of diffuseaxonal injury.
  • 2 TYPES OF SPINAL CORD INJURIESA spinal cord injury (SCI) refers to any injury to the spinalcord that is caused by trauma instead of disease. Dependingon where the spinal cord and nerve roots are damaged, thesymptoms can vary widely, from pain to paralysis toincontinence.Spinal cord injuries are broken into two classifications:incomplete and complete, which can vary from having noeffect on the patient to a "complete" injury were there is a totalloss of function. Incomplete spinal injuries mean there is someloss of movement or sensation in affected areas, but there isstill some connection to the brain.In a complete spinal cord injury, there can be no movement orsensation below the point of injury.
  • SPINAL INJURIES FROM MVA• A Major Trauma Outcome Study estimated the incidence of acute spinal-cord injury to be 2.6% of blunt trauma patients. The average lifetime costs of treating an individual with traumatic spinal-cord injury is estimated to be between $500, 000 and $2 million. The total direct costs of caring for the spinally-injured each year exceed s $7 billion in the United States.• MVA’s account for the number one cause of spinal cord injuries, making up nearly 40%. The strong force that is created in severe auto accidents can be pinpointed directly to the head, neck, or back, causing the spine to twist unnaturally or fracture.
  • MECHANISMS OF INJURY [SPINE] When people are injured, they are often told that they have an injury at a given spinal cord level and are given a qualifier indicating the severity of injury, such as "complete" or "incomplete". They may also be told that they are classified according to the American Spinal Injury Association [ASIA] Classification, as a ASIA A, B, C, or D. They may also be told that they have a bony fracture or involvement of one or more spinal segments or vertebral levels.• What most people do not know is doctors are frequently confused about the definition of spinal cord injury levels, the definition of complete and incomplete injury, and the classification of spinal cord injury.
  • COMPLETE VS INCOMPLETE [SC] INJURIES • Traditionally, "complete" spinal cord injury means having no voluntary motor or conscious sensory function below the injury site. However, this definition is often difficult to apply.
  • INCOMPLETE [SCI]• Quadriplegia, incomplete 31.2% - Paraplegia, complete 28.2% - Paraplegia, incomplete 23.1% - Quadriplegia, complete 17.5%. The figures above represent the resultant permanent disability suffered by a survey of people breaking their backs and necks. These statistics show that an incomplete spinal cord injury is more prevalent than complete ones. The figures for incomplete spinal cord injury may indeed be much higher because they dont take account of those people who have been treated by general hospitals instead of a specialist spinal injuries unit.
  • INCOMPLETE [SCI]• An incomplete spinal cord injury is the term used to describe damage to the spinal cord that is not absolute. The incomplete injury will vary enormously from person to person and will be entirely dependant on the way the spinal cord has been compromised. The true extent of many incomplete injuries isnt fully known until 6-8 weeks post injury.
  • EXTENT OF INJURY• The spinal cord normally goes into what is called spinal shock after it has been damaged. The swelling and fluid masses showing on any resultant X-ray, MRI or CT scans, may well mask the true nature of the underlying injury. It is not uncommon for someone who is completely paralyzed at the time of injury to get a partial or very near full recovery from their injuries after spinal shock has subsided. C-spine MRI
  • TYPES OF INCOMPLETE [SCI] Anterior Cord Syndrome: • This is when the damage is towards the front of the spinal cord, this can leave a person with the loss or impaired ability to sense pain, temperature and touch sensations below their level of injury. Pressure and joint sensation may be preserved. It is possible for some people with this injury to later recover some movement. This is a type of incomplete spinal cord injury.
  • CENTRAL CORD SYNDROME • This is when the damage is in the centre of the spinal cord. This typically results in the loss of function in the arms, but some leg movement may be preserved. There may also be some control over the bowel and bladder preserved. It is possible for some recovery from this type of injury, usually starting in the legs, gradually progressing upwards. This is a type of incomplete spinal cord injury.
  • The effects of incomplete lesions depend upon: the area of the cord (front, back, side, etc) affected. The part of the cord damaged depends on the forces involved in the injury. CROSS SECTION OF SPINAL CORD
  • POSTERIOR CORD SYNDROME • This is when the damage is towards the back of the spinal cord. This type of injury may leave the person with good muscle power, pain and temperature sensation, however they may experience difficulty in coordinating movement of their limbs. This is a type of incomplete spinal cord injury as well.
  • BROWN-SEQUARD SYNDROME• This is when damage is towards one side of the spinal cord. This results in impaired or loss of movement to the injured side, but pain and temperature sensation may be preserved. The opposite side of injury will have normal movement, but pain and temperature sensation will be impaired or lost. This is a type of incomplete spinal cord injury.
  • THE CAUDA EQUINA LESION• The Cauda Equina is the mass of nerves which fan out of the spinal cord at between the first and second Lumbar region of the spine. The spinal cord ends at L1 and L2 at which point a bundle of nerves travel downwards through the Lumbar and Sacral vertebrae. Injury to these nerves will cause partial or complete loss of movement and sensation. It is possible, if the nerves are not too badly damaged, for them to grow again and for the recovery of function. Again, this is a type of incomplete spinal cord injury.
  • COMPLETE SPINAL CORD INJURIES [SCI] • A complete spinal cord lesion is the term used to describe damage to the spinal cord that is absolute. It causes complete and permanent loss of ability to send sensory and motor nerve impulses and, therefore, complete and usually permanent loss of function below the level of the injury. This will result in complete paraplegia or tetraplegia. The completeness of many injuries isnt fully known until 6-8 weeks post injury as previously stated.
  • COMPLETE PARAPLEGIAComplete paraplegia is permanent loss of ability to send sensory and motor nerve impulses to the muscle groups and body functions that are controlled by nerves leaving the spinal column at T1 level or below. T1 injuries are the first level with normal hand function. They can use their arms with all the motor functions of a non- injured person. As thoracic levels proceed down the spinal column, abdominal musculature recovery is present, and there is improved respiratory function and trunk balance [sitting balance] as a result. Sensation below the level of injury is lost and bladder, bowel and sexual function will not work normally.
  • COMPLETE TETRAPLEGIA Tetraplegia is far more debilitating than paraplegia as the arms are paralyzed as well. The descriptions below detail what is likely to be expected functionally with the different levels of tetraplegia.C1-4 Tetraplegia: Patients with C-1 and C-2 lesions may have functional phrenic nerves. In these cases, implanted phrenic nerve pacemakers can be used, and pacing of the diaphragms may be simultaneous or alternating. If secretions are not a problem, tracheostomies may be plugged or discontinued. Less equipment may be needed for C-1 and C-2 patients than for C-3 and C-4 patients.
  • COMPLETE TETRAPLEGIA• Patients with C-3 lesions have impaired breathing and may be ventilator-dependent. They can shrug their shoulders and they have neck motion, which permits the operation of specially adapted power wheelchairs and equipment, such as tape recorders, computers, telephones, page turners, automatic door openers, and other environmental control units with mouth control (sip and puff), voice activation, chin control, head control, eyebrow control, or eye blink. Patients with C-4 lesions may be free of respiratory equipment beyond the initial acute care stage, but may have the same functional equipment needs as ventilator-dependent patients.
  • C-5 TETRAPLEGIA• C-5 tetraplegics have functional deltoid and/or biceps musculature. They can internally rotate and abduct the shoulder, which causes forearm pronation by gravity. Wrist flexion is similarly produced. They can externally rotate the shoulder and cause supination and wrist extension. They can bend the elbow, but elbow extension can only be produced by gravity, or by forceful horizontal abduction of the shoulder and inertia or shoulder external rotation.
  • C-6 TETRAPLEGIA• C-6 patients have musculature that permits most shoulder motion, elbow bending, but not straightening, and active wrist extension which permits tenodesis, opposition of thumb to index finger, and finger flexion. Wrist extensor recovery is common in C-6 patients, but its return can be delayed. C-6 patients can perform upper body dressing without assistance and may also perform lower body dressing without assistance. They can catheterize themselves and perform their bowel program with assistive devices.
  • C7-8 TETRAPLEGIAC-7 patients have functional triceps, they can bend and straighten their elbows, and they may also have enhanced finger extension and wrist flexion. As a result, they have enhanced grasp strength which permits enhanced transfer, mobility, and activity skills. They perform most transfers independently and can propel a manual wheelchair and may not need a powered wheelchair. C-8 patients have flexor function which permits all arm movement, with some hand weakness. They can propel a manual wheelchair including in and out of a car and over curbs, and may even become wheelchair independent. They can drive with special equipment and can perform all personal care and daily activities, except heavy housework.
  • ASIA CLASSIFICATIONSome confusion surrounds the terminology associated with spinal cord injury levels, severity, and classification. The American Spinal Injury Association [ASIA] tried to sort some of these issues and standardize the language that is used to describe spinal cord injury. The ASIA Spinal Cord Injury Classification approach has now been adopted by almost every major organization associated with spinal cord injury. This has resulted in more consistent terminology being used to /describe the findings in spinal cord injury around the world. http://www.asia-spinalinjury.org/
  • TREATMENT OVERVIEW FOR [SCI] • Treatment begins with the emergency medical personnel who make an initial evaluation and immobilize the patient for transport. Immediate medical care within the first 8 hours following injury is critical to the patients recovery. Nowadays there is much greater knowledge about the moving and handling of spinal injury patients. Incorrect techniques used at this stage could worsen the injuries considerably.
  • TREATMENT OF [SCI]• Treatment starts with steroid drugs, these can be administered at the scene by an air ambulance Doctor or trained paramedic. These drugs reduce inflammation in the injured area and help to prevent further damage to cellular membranes that can cause nerve death. Sparing nerves from further damage and death is crucial.• Each patients injury is unique. Some patients require surgery to stabilize the spine, correct a gross misalignment, or to remove tissue causing cord or nerve compression. Spinal stabilization often helps to prevent further damage. Some patients may be placed in traction and the spine allowed to heal naturally. Every injury is unique as is the course of post injury treatment that follows.
  • BLUNT CERVICAL VASCULAR INJURIES • Injury to the carotid and vertebral arteries after blunt trauma can lead to severe neurological complications in survivors with a mortality rate of 31%. The incidence of blunt carotid injuries was 1 in every 150 MVAs.
  • SUSPECTED VASCULAR INJURY• A high index of suspicion for these injuries should be maintained as early treatment with systemic Heparinization leads to improved neurological outcome as it is thought to prevent thromboembolism arising from the intimal injury. Blunt cervical vascular injury should be suspected in patients with:• a major mechanism of injury and unexplained weakness of voluntary movement [paresis].• unequal pupils• Stroke[CVA] or transient ischemic attack [TIA]• base of skull fracture, major facial or cervical spinal injury
  • BLUNT CAROTID INJURYBlunt polytrauma remains a leading cause ofdeath and disability worldwide. CT isincreasingly recognized as the emergingstandard for providing rapid and accuratediagnoses within the narrow therapeutic windowafforded to trauma victims with multiple severeinjuries.
  • THORACIC INJURIES FROM MVA • In trauma centers, thoracic injury directly accounts for 20-25% of deaths due to trauma; thoracic injury or its complications are a contributing factor in a further 25% of trauma deaths. Approximately 85% of all thoracic trauma can be managed without surgical intervention; the mainstays of management are supplemental oxygen, intercostal drainage, good physiotherapy and pain control.
  • THORACIC TRAUMA Flail Chest Above
  • “THE DEADLY DOZEN”Immediately life-threatening injuries Potentially life-threatening injuriesAirway obstruction Simple pneumo/hemothoraxTension pneumothorax Aortic ruptureOpen pneumothorax Tracheobronchial ruptureMassive haemothorax Pulmonary contusionFlail chest Blunt cardiac injuryCardiac tamponade Diaphragmatic rupture
  • X-RAY AFTER SEVERE BLUNT TRAUMA [MVA] Note how the R lung is opaque and the L clear
  • AORTIC INJURIES IN MVA’SAortic injuries cause or contribute to 15% of MVA fatalities. Most patients with blunt aortic injury die before they ever reach hospital, and the vast majority will have major coexisting thoracic and extrathoracic injuries. Widening of the mediastinum upon the admission chest X-ray is the most common first sign of aortic injury. Aortograms are still the gold standard diagnostic tool; however, contrast enhanced helical CT scanning also compares favorably with aortography. Nonetheless, a high index of suspicion may be required in the emergency room in order to diagnose thoracic aortic injury (TAI) as the initial chest X-ray may be normal and external evidence of injury may be minimal or absent; especially if the accident occurred with deployment of an airbag.
  • RUPTURED AORTA FROM BLUNT TRAUMA Widened mediastinum after blunt trauma
  • BLUNT CARDIAC INJURY• Blunt cardiac injury (BCI) refers injuries ranging from: simple electrocardiographic (ECG) changes to free rupture of the heart. The incidence of BCI is unknown, but clinically significant lesions are rare. There are few reliable clinical signs and symptoms that are specific for BCI. A diagnosis of BCI should be suspected in patients with an appropriate mechanism of injury, who show an inappropriate or abnormally poor cardiovascular response to their injury. At present, no single test or combination of tests has proven consistently reliable in detecting cardiac injury. Internet-based trauma management guidelines recommend a pragmatic treatment algorithm for patients suspected of having BCI.
  • MVA AND [BCI] BLUNT CARDIAC INJURY • Motor vehicle accidents and other deceleration injuries are the common causes of chest trauma. Early fatalities following severe trauma can be accounted for by injury to the chest and its contents. In patients surviving beyond 30 minutes, chest trauma may be unrecognized or its severity underestimated. Patients with isolated chest trauma and not in extremis at presentation are likely to survive although their management may require aggressive investigation and treatment.
  • BCI: DISPRUPTIONS OF BLOOD FLOW • Major disruptions of the aorta, heart and pulmonary vessels are associated with immediate death due to exsanguination. Injuries initially compensated for by peripheral vasoconstriction and tachypnea - such as cardiac tamponade and hemo/pneumo-thorax may subsequently cause a precipitous decline. • Several hours after the initial injury, seemingly minor injuries may be associated with clinical deterioration as is the case with lung contusion following blunt injury. •
  • TESTING FOR BLUNT CARDIAC INJURY • An admission ECG should be performed on all patients in whom there is suspected BCI; and/or if the patient is hemodynamically unstable, an echocardiogram should be obtained. If an optimal transthoracic echocardiogram cannot be performed, then the patient should have a transesophageal echocardiogram. It is important to recognize that the presence of a sternal fracture does not predict the presence of BCI and, thus, does not necessarily indicate that monitoring should be performed.
  • BCI TESTS• Neither creatinine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to BCI. If the ECG is abnormal (abnormalities include arrhythmia, ischemia, heart block, unexplained ST changes), then the patient should be admitted for continuous ECG monitoring for 24 to 48 hours. If the admission ECG is normal, the risk of having a BCI that requires treatment is insignificant.
  • INJURIES TO CHEST WALL AND LUNG• 85% of all thoracic trauma can be treated without specialized surgical intervention; probably the most common presentation is related to rib fractures. The patient complains of pain aggravated by breathing or coughing. Compression of the rib cage elicits pain and fractures are seen on chest or rib X-rays.• Chest X-rays are of paramount importance and should be obtained as early as possible. In all penetrating wounds radioopaque markers should be placed to facilitate estimation of the wounding trajectory. Associated injuries such as pneumothorax, hemothorax or pulmonary contusion must be excluded.•
  • ASSESSMENT OF CHEST WALL/LUNG TRAUMA • Assessment and initial management of injured patients should follow a described trauma protocol. In addition, It is essential to obtain as much pre-hospital information as possible. • MIST - pre-hospital information to seek. • 1. Mechanism of injury 2. Injury sustained 3. Signs evident at the scene 4. Treatment to the point of arrival • .
  • RIB FRACTURE & LUNG CONTUSIONS• Fractured ribs are a common cause of pneumothorax, due to laceration of the underlying lung. First and second rib fractures are caused by extreme force and are commonly associated with major vascular injury (see blunt injury to aorta) Sub- diaphragmatic injury, especially to the liver and spleen may occur with fracture of lower ribs (especially ribs 7 to 9). When three or more adjacent ribs are broken in two or more places, instability results and the affected segment of chest wall moves paradoxically with respiration. This flail segment increases the work of breathing, however the predominant problem is the underlying lung contusion.
  • LUNG CONTUSIONS• Lung contusion due to blunt injury is associated with significant force. Injury to the lung causes micro- hemorrhages and fluid accumulation. This causes decreased compliance with the development of hypoxemia. Contusion is commonly associated with hemopneumothorax [accumulation of blood and air in the lung]. Chest tube insertion & drainage is paramount for survival. Treatment for this condition is the same as for hemothorax and pneumothorax independently: by tube thoracostomy, the insertion of a chest drain through an incision made between the ribs, into the intercostal space. A chest tube must be inserted to drain blood and air from the pleural space so it can return to a state of negative pressure and function normally.
  • PLACEMENT INDICATIONS1. Drainage of hemothorax, or large pleural effusion of any cause2. Drainage of large pneumothorax (greater than 25%)3. Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center4. Flail chest segment requiring ventilator support, severe pulmonary contusion with effusionContraindications:1. Infection over insertion site2. Uncontrolled bleeding diathesis
  • TRACHEOBRONCHIAL INJURY• Major airways (such as trachea and bronchi) are injured in blunt trauma by rapid deceleration and shearing of more mobile bronchi from fixed proximal structures. Injury due to deceleration is usually within 2cm of the carina or at the origin of lobar bronchi. Tracheal injuries in the neck are usually associated with direct trauma eg neck struck by car dashboard.
  • TRACHEOBRONCHIAL & DIAPHRAM INJURY • Blunt tracheobronchial injuries constitute only a small fraction of admissions to trauma centers, as many patients die before they reach hospital. Following tracheobronchial transection, peribronchial connective tissue may remain intact and allow distal lung ventilation. The presentation of thoracic tracheobronchial injury depends on whether the injury is confined to the mediastinum, or communicates with the pleural spaces. If the injury is confined to the mediastinum then pneumomediastinum is usually present on X-ray.
  • DIAPHRAMATIC INJURIES FROM MVA • Diaphragmatic injuries due to penetrating and blunt trauma are common. The reported incidence of diaphragmatic rupture is between 0.8% and 1.6% of patients admitted to hospital with blunt trauma. There is no single investigation that provides a reliable diagnosis of diaphragmatic rupture at presentation. Between 33% and 70% will be diagnosed on initial chest X-ray, but this is less reliable if the patient is intubated. It should be noted that diaphramatic rupture can only be diagnosed on chest X-ray if stomach or bowel that has herniated is constricted by the torn diaphragm (the collar sign) or if the nasogastric tube is seen to lie above the diaphragm.
  • RUPTURED LEFT HEMI-DIAPHRAM• From a legal standpoint, diagnosis of ruptured diaphragm is frequently missed in the acute phase because of the presence of hypovolemic shock, respiratory insufficiency, visceral injuries or coma. Diagnostic delay can lead to long-term sequelae that can present a few days to many years after the injury.
  • • In blunt trauma, the sudden increase in intra-abdominal pressure causes a blow out at the weakest point, the left posterolateral diaphragm (over 80%). The stronger right side is also protected by the liver. Intra-abdominal contents, commonly colon, stomach and spleen may herniate into the chest, often not detected in multiply injured and ventilated patients.
  • “THE COLLAR SIGN”• *Diagnostic CT signs of diaphragm injury include a defect in the continuity of the diaphragm or crus and a waist-like constriction of abdominal viscera or omentum at the site of herniation as seen on axial or reformatted CT images, the CT “collar sign”
  • INJURY TO THE ABDOMEN AND SPLEEN • Abdominal trauma accounts for up to 20% of trauma-related operations.The most commonly injured intra-abdominal organ following blunt trauma is the spleen. While the enforcement of the wearing of seat-belt restraints has seen a reduction in the incidence of head, chest and solid visceral injury, their use is associated with pancreatic, intestinal and mesenteric injury due to compression against the lumbar spine.
  • ABDOMINAL INJURY: KEY POINTS• The abdomen is potentially responsible for major morbidity and death from early hemorrhage and late sepsis. Diagnosis may be obscured by multiple injuries rendering clinical signs inaccurate. Nevertheless several indications for laparotomy exist including:• Penetrating trauma to the abdomen (with breach of the peritoneum),hypotension in the face of obvious abdominal trauma, obvious peritonitis, evisceration through a wound (excluding omentum) and GI hemorrhage following abdominal trauma.
  • CLINICAL EXAMINATION OF ABDOMEN • The force of impact in a motor vehicle accident indicates the energy transferred to intra-abdominal viscera. The mechanism of injury is also important. Examination of the abdominally injured is in many cases the most important part of the assessment. It should be thorough including a rectal examination and also should be targeted towards the mechanism of injury and any obvious external signs of injury. These may include bruising from seat belts.
  • EXPLORATORY LAPAROTOMY• This remains the most effective way of assessing and dealing with intra abdominal injuries. The main indications in blunt trauma are:1. Peritonitis: usually due to rupture of a hollow viscous such as the duodenum, intestine, bladder or gallbladder. Free intraperitoneal blood from solid viscous injury or mesenteric vascular injury may also cause significant peritoneal irritation without ongoing hemodynamic compromise.
  • EXPLORATORY LAPAROTOMY2. Hypovolemia / shock - where no other obvious source of blood loss exists. A plain chest radiograph is required to exclude significant hemothorax and a pelvic X-ray will exclude fractures which may give rise to significant bleeding. Other sources of ongoing blood loss such as major limb fractures and scalp lacerations can usually be controlled. Further hemodynamic compromise after short periods of initial resuscitation should alert the clinician to the probability of an intra- abdominal source.
  • LAPAROTOMY• A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity.
  • LAPAROTOMY TRAUMA: KEY POINTS 1. Control bleeding 2. Control sepsis 3. Definitive surgical management may be delayed 1 or 2 days if patient has gross metabolic derangement. 4. Seek further specialist assistance as necessary eg. liver, vascular, urology.
  • INJURY TO THE SPLEEN• The spleen is an organ involved in the production and maintenance of red blood cells, the production of certain circulating white blood cells, as a part of the lymph system, and as a part of the immune system.
  • GUIDELINES FOR SPLEEN REMOVAL • congenital or acquired hemolytic anemia • idiopathic thrombocytopenia • trauma to the spleen • lymphoma, leukemia, Hodgkins disease • portal hypertension and hypersplenism • hereditary spherocytosis
  • SPLEEN CONSERVATION FAILURE: FACTORS • Hemodynamic instability • Grade of injury • Size of hemoperitoneum • Contrast blush on CT • Age older than 55 years • Pre-existent splenic disease • It should be noted that If contrast is seen to blush or pool on CT then angiography or surgery is required. Any patient selected for non-operative management must be carefully assessed and reassessed by an experienced practitioner, with an operating theatre immediately available. Any deterioration requires operative intervention.
  • HEPATIC {LIVER} INJURYApproximately 85% of all patients with blunt hepatictrauma are stable. In this group, non-operativemanagement significantly improves outcomes overoperative management in terms of decreasedabdominal infections, decreased transfusions, anddecreased lengths of hospital stay. For unstablepatients, operative surgery is still the rule, with thedamage control approach now accepted as thestandard of care. Bleeding is controlled, often by useof peri-hepatic packing and the patients time in theoperating theatre is kept to a minimum.CT scanning is the mainstay of diagnosis for hepaticinjuries after blunt trauma in the stable patient; theinitial CT findings will help the trauma surgeon todetermine the suitability for non-operative treatment.
  • LIVER INJURY GRADE SCALEGrade IHematoma: Subcapsular, nonexpanding, < 10% surface area.Laceration: Capsular tear, nonbleeding, < 1cm deep.Grade IIHematoma: Subcapuslar, nonexpanding, 10-50% surface area;intraparenchymal, nonexpanding, < 2cm diameter.Laceration: Capsular tear, active bleeding; 1-3cm deep, < 10cm inlength.Grade IIIHematoma: Subcapsular, > 50% surface area or expanding; rupturedsubcapsular hematoma with active bleeding.Laceration: Intraparenchymal hematoma > 2cm or expanding; > 3cmdeep.Grade IVHematoma: Ruptured intraparenchymal hematoma with activebleeding.Laceration: Parenchymal disruption involving 25-50% of hepatic lobe.Grade VLaceration: Parenchymal disruption involving > 50% of hepatic lobe.Grade VIVascular: Juxtahepatic venous injury; ie. Retrohepatic vena cava /major hepatic veins, hepatic avulsion.
  • HOLLOW VISCOUS INJURY {HVI}• Individuals subjected to high-speed deceleration in MVAs can experience rupture of intra-abdominal hollow viscera. The mechanism of injury is thought to be compression of closed-loops of bowel by seat-belt restraints. A pressing concern for treating HVI is injury that is clinically silent. In addition, peritoneal lavage increases the risk of missing these injuries. Spiral CT is inaccurate for HVI, thus an accurate and timely recognition can be difficult, and delay in diagnosis has been shown to be associated with significant morbidity and mortality
  • INJURIES TO THE PELVIS• Fractures of the pelvis are increasingly recognized as a marker of severe injury, as the force required to disrupt the pelvic ring is substantial. A high index of suspicion must be maintained for pelvic fracture, based on the history of the accident. All patients sustaining high- energy blunt injury should be assumed to have a pelvic fracture until proven otherwise.
  • PELVIC INJURY• There are many, confusing classification systems for pelvic fractures. There are five places that a patient can lose a large volume of blood: externally into the environment, into the chest, abdomen, retroperitoneum and muscle compartments.• Severe bleeding leading to hypovolemic shock is often a feature of severe pelvic fractures. Unstable pelvic fractures can bleed torrentially, and uncertainty about coexistent intra-abominal injury may cause significant problems in identifying the source of blood loss.
  • TREATMENT OF PELVIC INJURIES External fixation of an unstable pelvic fracture should be considered as early as possible. Returning the bony components of the pelvis into stable apposition enables haemostasis to occur and reducing the volume of a disrupted pelvis may also promote tamponade of bleeding within the pelvis. Angiography and selective embolisation of bleeding vessels is an important adjunctive maneuver in major pelvic fracture. Assessment of the abdomen by diagnostic peritoneal lavage or CT for significant intra-abdominal injury is vital
  • POSSIBLE ASSOCIATED INJURIES WITH PF • Closed head injury (51%) • Long bone fracture (48%) • Peripheral nerve injury (26%) • Thoracic injury (20%) • Bladder (10%) • Spleen (10%) • Liver (7%) • Gastrointestinal tract (7%) • Kidney (7%) • Urethra (6%) • Mesentery (4%) • Diaphragm (2%)
  • INJURY TO EXTREMETIES• The optimal timing for long bone stabilization in polytrauma patients has been debated for years. Nonetheless, benefits of early long bone stabilization in include increased patient mobilization by eliminating traction and decreased pulmonary morbidity. No evidence shows early stabilization has any detrimental effect[s]. Current recommendations are to perform early long bone stabilization in polytrauma patients with management on an individual basis. An important caveat is to avoid any operative procedure that might lead to hypotension or hypoxia and cause a secondary insult.
  • MVA INJURYThe patterns of injury from mans interaction withthe motor vehicle may have been somewhatmodified by crash protection devices, such ashelmets, seat belts and air bags, but injuries dueto road traffic related trauma are worseningeach year. Injury is the leading cause of deathamong young adults in the western world andtrauma is imposing a severe burden on healthcare in the developing world. The use of motorvehicles is growing, and particular of particularconcern is the emerging issue of teens andtexting while driving. Increasingurbanization, overcrowding and lack of regardfor the rules of the road are unfortunately nowthe norm.
  • REDUCING MORBIDITY & MORTALITY My goal is that this presentation will assist the legal community in the recognition of the typical patterns of MVA injury coupled with a logical sequence of the initial assessment and management of trauma patients. Through education, I hope this will contribute to reduction in mortality and morbidity; however, the most significant impact on reducing the burden of motor vehicle-related trauma will come from injury prevention programs organized at grass root and governmental levels as well as changes in the existing statutes such as texting and talking on the phone while driving!
  • THE END© 2012 PMLC www.parksmedicallegal.com