Major trauma is an injury that has the potential to cause prolonged disability or death. There are many causes of large, blunt and translucent trauma, including falls, motor vehicle crashes, stab wounds, and gunshot wounds. Depending on the severity of the injury, the speed of management and transportation to the appropriate medical facility (called a trauma center) may be necessary to prevent loss of life or limb. Initial assessment is very important, and involves physical evaluation and may also include the use of imaging tools to determine the type of injury accurately and to formulate a treatment program.
In 2002, unintentional and intentional injuries were the leading causes of fifth and seventh deaths worldwide, accounting for 6.23% and 2.84% of all deaths. For research purposes the definition is often based on an injury severity score (ISS) greater than 15.
Video Major trauma
Classification
Wounds are usually classified by severity, location of damage, or a combination of both. Trauma can also be classified by demographic groups, such as age or gender. It can also be classified according to the type of force applied to the body, such as blunt trauma or penetrating trauma. For research purposes, injuries can be classified using the Barell matrix, which is based on ICD-9-CM. The purpose of the matrix is ​​to international standardization of trauma classification. Main trauma is sometimes classified by body area; Injuries affecting 40% are polytrauma, 30% head injury, 20% chest trauma, 10%, abdominal trauma, and 2%, trauma of the extremities.
A variety of scales exist to provide measurable metrics to measure the severity of injuries. Values ​​can be used for patient triaging or for statistical analysis. Injury scales measure damage to the anatomical part, physiological value (blood pressure, etc.), comorbidity, or a combination of these. Abbreviated injury scales and Glasgow coma scales are commonly used to measure injuries for triaging purposes and allow the system to monitor or "trend" the patient's condition in a clinical setting. Data can also be used in epidemiological investigations and for research purposes.
About 2% of those who have experienced significant trauma have spinal injuries.
Maps Major trauma
Cause
Injury can be caused by a combination of external forces that act physically against the body. The main causes of traumatic death are blunt trauma, motor vehicle crashes, and falls, followed by penetrating trauma such as puncture wounds or punctured objects. Subset of blunt trauma is the number one cause and two causes of traumatic death.
For statistical purposes, injuries are classified as intentional as suicide, or unintentional, such as a motor vehicle crash. Accidental injury is a common cause of trauma. Translucent trauma is caused when a foreign body such as a bullet or a knife enters the tissues of the body, creating an open wound. In the United States, the majority of deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms. Blast injury is a complex cause of trauma because it usually includes blunt and translucent trauma, and can also be accompanied by burns. Trauma can also be associated with certain activities, such as work or sports injuries.
Pathophysiology
The body responds to traumatic injuries both systemically and at the site of injury. This response seeks to protect vital organs such as the liver, to allow for further cell duplication and to cure damage. Injury healing time depends on various factors including gender, age, and severity of injury.
Symptoms of injury can manifest in a variety of ways, including:
- Change the mental status
- Fever
- Increased heart rate
- General edema
- Increased cardiac output
- Increased metabolic rate
Various organ systems respond to injuries to restore homeostasis by maintaining perfusion to the heart and brain. Inflammation after an injury occurs to protect against further damage and initiate the healing process. Prolonged inflammation may lead to multiple organ dysfunction syndrome or systemic inflammatory response syndrome. Immediately after injury, the body increases glucose production through gluconeogenesis and fat consumption through lipolysis. Furthermore, the body tries to replenish the energy reserves of glucose and proteins through anabolism. Under these circumstances the body will increase the maximum expenditure for the purpose of healing the wounded cell temporarily.
Diagnosis
Initial assessment is very important in determining the extent of injuries and what will be required to manage injuries, and to treat immediate threats.
Physical exam
A primary physical examination was performed to identify a life-threatening problem, after which a secondary examination was performed. This may occur during transportation or upon arrival at the hospital. The secondary examination consists of a systematic assessment of the abdominal, pelvic, and thoracic regions, a complete examination of the surface of the body to find all injuries, and neurological examination. Any injuries that may manifest themselves in the future may be missed during the initial assessment, such as when a patient is taken to the hospital emergency department. Generally, physical examination is conducted in the first systematic way to examine every immediate threat of life (primary survey), and then take a more in-depth (secondary survey).
Imaging
People with major trauma generally have chest x-rays and pelvis taken, and, depending on the mechanism of injury and presentation, the assessment focuses on sonography for trauma (FAST) exam to check internal bleeding. For those with relatively stable blood pressure, heart rate, and adequate oxygenation, a CT scan is useful. A whole-body CT scan, known as pan-scan, improves the survival rate of those who have experienced major trauma. This scan uses intravenous injection for radiocontrast agents, but not oral administration. There is a concern that intravenous contrast in traumatized situations without confirming adequate kidney function can cause kidney damage, but this does not seem significant.
In the US, CT scan or MRI is performed in 15% of those who have experienced trauma in the emergency department. Where blood pressure is low or heart rate increases - the possibility of bleeding in the stomach - surgery immediately passing a CT scan is recommended. Modern CT 64-slice scan is able to rule out with a high degree of accuracy, significant injury to the neck after blunt trauma.
Surgical technique
Surgical technique, using a tube or catheter to drain fluid from the peritoneum, chest, or pericardium around the heart, is often used in cases of severe blunt trauma to the chest or abdomen, especially when a person experiences early signs of shock. In those with low blood pressure, possibly because of bleeding in the abdominal cavity, cutting through abdominal wall surgery is indicated.
Prevention
By identifying existing risk factors within a community and creating solutions to reduce incidence of injury, a trauma referral system can help to improve the overall health of the population. Injury prevention strategies are commonly used to prevent injury to children, which is a high-risk population. Injury prevention strategies generally involve educating the general public about specific risk factors and developing strategies to avoid or reduce injury. Laws intended to prevent injuries usually involve seat belts, child car seats, helmets, alcohol controls, and increased law enforcement. Other controlled factors, such as the use of drugs including alcohol or cocaine, increase the risk of trauma by increasing the likelihood of traffic collisions, violence, and abuse occurring. Prescription drugs such as benzodiazepines may increase the risk of trauma in the elderly.
Treatment of people who are acutely wounded in public health systems requires the involvement of observers, community members, health care professionals, and health care systems. This includes assessment and treatment of pre-hospital trauma by emergency medical service personnel, emergency department assessment, care, stabilization, and hospital care among all age groups. An established network of trauma systems is also an important component of community disaster preparedness, facilitating the care of people who have been involved in disasters that cause large numbers of victims, such as earthquakes.
Management
Pre-hospital
The use of pre-hospital stabilization techniques increases the likelihood that a person may survive a trip to a hospital equipped with the nearest trauma. Emergency treatment services determine which person needs treatment at the center of the trauma and provides primary stabilization by checking and treating respiratory, respiratory, and circulatory diseases and assessing disability and getting exposure to check for other injuries.
Limiting the movement of the spine by securing the neck with the cervix and placing people on the long spinal board is very important in the pre-hospital setting, but due to lack of evidence to support its use, this practice is losing support. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to demonstrate the need for this addition. This can be done with other medical means such as Kendrick's removal apparatus, before moving the person. It is important to quickly control severe bleeding with immediate pressure into the wound and consider the use of a hemostatic or tourniquet agent if the bleeding continues. Conditions such as impending obstruction of the airway, enlargement of the hematoma of the neck, or unconsciousness require intubation. But it is unclear whether this should be done before reaching the hospital or in the hospital.
Rapid transportation of the severely injured patient improves results in trauma. EMS Helicopter transport reduces mortality compared to ground-based transport in adult trauma patients. Prior to arriving at the hospital, the availability of late life support did not greatly improve outcomes for major trauma when compared to basic life support administration. The evidence can not be concluded in determining support for pre-hospital intravenous fluid resuscitation while some evidence has found it may be harmful. Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them, and results may increase when traumatized people are transferred directly to the trauma center.
In hospital
The management of people with trauma often requires the help of many health specialists including doctors, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. In general the first step in dealing with trauma is to conduct a primary survey that evaluates the airway, breathing, circulation, and neurological status of a person. After the threat of life is immediately controlled, a person is moved into the operating room for immediate correction of the injury, or a secondary survey is conducted which is a more detailed head-to-foot assessment of the person.
Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure. Examples of these indications include penetration of neck trauma, neck hematoma extension, and unconsciousness, among other indications. In general, the intubation method used is rapid sequence intubation followed by ventilation. Assessment of circulation in those with trauma includes active bleeding control. When a person is first brought in, vital signs are examined, an ECG is performed, and, if necessary, vascular access is obtained. Other tests should be performed to obtain a baseline measurement of their current blood chemistry, such as arterial blood gases or thromboelastography. In those with a heart attack due to chest compression the chest is considered pointless, but it is still recommended. Correcting underlying causes such as pneumothorax or pericardial tamponade, if any, may be helpful.
The QUICK test can help assess for internal bleeding. In certain traumas, such as maxillofacial trauma, it may be beneficial to have a highly trained healthcare provider available to maintain airway, breathing and circulation.
Intravenous fluid
Traditionally, high volume intravenous fluids are given to people who have poor perfusion due to trauma. This is still appropriate in cases with isolated extremity trauma, thermal injury, or head injury. In general, however, giving plenty of fluids seems to increase the risk of death. Current evidence supports limiting the use of fluids to penetrate thorax and abdominal injuries, allowing mild hypotension to persist. Targets include an average arterial pressure of 60 mmHg, systolic blood pressure of 70-90 mmHg, or re-establishment of peripheral pulses and adequate thinking ability. Hypertonic saline has been studied and found little difference from normal saline.
Since no intravenous fluid used for early resuscitation has been shown to be superior, the Ringer Lactate warm solution continues to be the preferred solution. If blood products are needed, more use of fresh frozen plasma and platelets relative to packed red cells has been found to improve survival and decrease overall blood product use; a 1: 1: 1 ratio is recommended. The success of platelets has been attributed to the fact that they can prevent coagulopathy from developing. Rescue and autotransfusion cells can also be used.
Blood substitutes such as hemoglobin-based oxygen carriers are under development; However, by 2013 nothing is available for commercial use in North America or Europe. These products are only available for general use in South Africa and Russia.
Drugs
Tranexamic acid decreases mortality in people who have bleeding from trauma. However, it seems useful, if given within the first three hours after trauma. For severe bleeding, for example from bleeding disorders, the recombinant factor VIIa - a protein that helps blood clotting - may be appropriate. While it reduces the use of blood, it does not seem to reduce mortality. In those without a deficiency of factor VII before, its use is not recommended outside the experimental situation.
Other drugs may be used in conjunction with other procedures to stabilize a person with significant injury. While positive inotropic drugs such as norepinephrine are sometimes used in hemorrhagic shock as a result of trauma, there is a lack of evidence for its use. Therefore, in 2012 they have not been recommended. Allowing low blood pressure may be preferred in some situations.
Surgery
The decision whether to perform an operation is determined by the extent of damage and the location of the anatomy of the injury. Bleeding must be controlled before definitive improvement can occur. Damage control operations are used to manage severe trauma where there is a cycle of metabolic acidosis, hypothermia, and hypotension that can cause death, if not corrected. The main principle of the procedure involves performing at least a procedure to save lives and limbs; less critical procedures are left until the victim is more stable. About 15% of all people with trauma have abdominal injuries, and about 25% of these require exploratory surgery. The majority of preventable deaths from trauma are caused by unknown intra-abdominal hemorrhage.
Prognosis
Death trauma occurs in the immediate, early, or late stages. Immediate death is usually caused by apnea, severe brain or high spinal injury, or rupture of the heart or large blood vessels. Early death occurs within minutes to hours and is often due to bleeding in the outer layer of the brain, torn arteries, blood around the lungs, air around the lungs, splenic spleen, liver laceration, or hip fracture. Direct access to care may be essential to prevent death in people with major trauma. A late death occurs a few days or weeks after an injury and is often associated with an infection. The prognosis is better in countries with a special trauma system where injured persons are provided with fast and effective access to appropriate care facilities.
Long-term prognosis is often complicated by pain; more than half of trauma patients experience moderate to severe pain one year after injury. Many also experience a decline in quality of life many years after the injury, with 20% of victims experiencing some form of disability. Physical trauma can lead to the development of post-traumatic stress disorder (PTSD). One study found no correlation between the severity of trauma and the development of PTSD.
Epidemiology
Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. This is the main cause of the five significant disabilities. About half of the deaths from trauma are among people between the ages of 15 and 45 and trauma is the leading cause of death in this age group. Injury affects more men; 68% of injuries occur in men and deaths from trauma are twice as common in men as in women, it is believed because men are much more willing to engage in risk-taking activities. Adolescents and young adults are more likely to require hospitalization from injury than other age groups. While parents are less likely to get hurt, they are more likely to die of injuries sustained by physiological differences that make it more difficult for the body to compensate for injuries. The main cause of traumatic death is central nervous system injury and loss of blood. Various classification scales exist for use with trauma to determine the severity of the injury, used to determine the resources used and, for statistical collection.
History
Human remains found at the Nataruk site in Turkana, Kenya, are claimed to exhibit major trauma, blunt and translucent trauma, caused by severe trauma to the head, neck, ribs, knees, and hands that have been interpreted by some researchers as establishing the existence war between two hunter-gatherer groups 10,000 years ago. The evidence of blunt force trauma in Nataruk has been challenged, however, and the interpretation that the site is an early example of warfare has been questioned.
Society and culture
Economy
The financial costs of trauma include the amount of money spent on care and the loss of potential economic benefits because there is no job. The average financial cost for the treatment of traumatic injuries in the United States is approximately US $ 334.000 per person, making it more expensive than cancer treatment and cardiovascular disease. One of the reasons the high cost of care for trauma is the increased likelihood of complications, leading to the need for more intervention. Maintaining a trauma center is costly because they are constantly open and maintain readiness to accept patients, even if they do not exist. In addition to the direct costs of treatment, there is also an economic burden due to loss of wages and productivity, which in 2009, accounted for approximately US $ 693.5 billion in the United States.
Low and middle income countries
Low and middle income (LMICs) citizens often have higher mortality rates due to injuries. These countries account for 89% of all deaths from injuries worldwide. Many of these countries do not have access to adequate surgical treatments and many do not have a trauma system in place. In addition, most LMICs do not have a pre-hospital care system that treats the wounded initially and transport them to the hospital quickly, resulting in the majority of casualties being transported by private vehicles. Also, their hospitals do not have the appropriate equipment, organizational resources, or trained staff. By 2020, the number of trauma-related deaths is expected to decline in high-income countries, while in low- to middle-income countries is expected to increase.
Custom population
Children
Due to anatomical and physiological differences, injuries to children need to be approached differently from adults. Accidents are the leading cause of death in children between 1 and 14 years. In the United States, about sixteen million children go to the emergency department due to some form of injury every year, with boys more often injured than girls with a ratio of 2: 1. Five of the world's most common accidental injuries in children in 2008 were road accidents, drowning, burns, falls, and poisoning.
Estimation of weight is an important part of trauma handling in children because accurate drug doses may be essential for resuscitation efforts. A number of methods to estimate weight, including Broselow ribbon, Leffler formula, and Theron formula exist.
Pregnancy
Trauma occurs in about 5% of all pregnancies, and is a leading cause of maternal death. In addition, pregnant women may experience placental abruption, premature labor, and uterine rupture. There are diagnostic problems during pregnancy; ionizing radiation has been shown to cause birth defects, although the doses used for general examinations are generally considered safe. Because of the normal physiological changes that occur during pregnancy, shock may be more difficult to diagnose. When pregnant women are more than 23 weeks old, it is recommended that the fetus be monitored for at least four hours with cardiotocography.
A number of treatments outside typical trauma care may be needed when the patient is pregnant. Because the weight of the uterus in the inferior vena cava can lower back blood to the heart, it may be very beneficial to put a woman at the end of pregnancy on her left side. also recommended are Rho (D) immunoglobulins in those with rh negative, corticosteroids in those who are 24 to 34 weeks old and may need to deliver or a cesarean section in the event of a heart attack.
Research
Source of the article : Wikipedia
0 Comments