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==Research==
==Research==
[[Blood substitutes]] such as [[hemoglobin-based oxygen carriers]] and [[perfluorocarbon emulsions]] are in development. As of June 2008 however there are none available for commercial use in North America or Europe.<ref name=UPT2008>{{citation |url=http://www.uptodate.com/online/content/topic.do?topicKey=transfus/11560&selectedTitle=1~8&source=search_result |title=UpToDate Inc. |format= |work= |accessdate=}}</ref><ref>{{citation |author=Spahn DR, Kocian R |title=Artificial O2 carriers: status in 2005 |journal=Curr. Pharm. Des. |volume=11 |issue=31 |pages=4099–114 |year=2005 |pmid=16378514 |doi= 10.2174/138161205774913354|url=http://www.bentham-direct.org/pages/content.php?CPD/2005/00000011/00000031/0011B.SGM |doi_brokendate=2010-08-04}}</ref> The only countries where these products are available for general use is South Africa and Russia.<ref name=UPT2008/> Patients who were admitted into a ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.<ref name="pmid19088550">{{citation |author=Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I |title=Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care |journal=J Trauma |volume=66 |issue=4 |pages=1226–33 |year=2009 |month=April |pmid=19088550 |doi=10.1097/TA.0b013e318181b8e3 |url=}}</ref>
[[Blood substitutes]] such as [[hemoglobin-based oxygen carriers]] and [[perfluorocarbon emulsions]] are in development. As of June 2008 however there are none available for commercial use in North America or Europe.<ref name=UPT2008>{{citation |url=http://www.uptodate.com/online/content/topic.do?topicKey=transfus/11560&selectedTitle=1~8&source=search_result |title=UpToDate Inc. |format= |work= |accessdate=}}</ref><ref>{{citation |author=Spahn DR, Kocian R |title=Artificial O2 carriers: status in 2005 |journal=Curr. Pharm. Des. |volume=11 |issue=31 |pages=4099–114 |year=2005 |pmid=16378514 |doi= 10.2174/138161205774913354|url=http://www.bentham-direct.org/pages/content.php?CPD/2005/00000011/00000031/0011B.SGM |doi_brokendate=2010-08-04}}</ref> The only countries where these products are available for general use is South Africa and Russia.<ref name=UPT2008/> Patients who were admitted into <s>a</s> an ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.<ref name="pmid19088550">{{citation |author=Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I |title=Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care |journal=J Trauma |volume=66 |issue=4 |pages=1226–33 |year=2009 |month=April |pmid=19088550 |doi=10.1097/TA.0b013e318181b8e3 |url=}}</ref>


==See also==
==See also==

Revision as of 23:14, 30 September 2010

For other uses, see Trauma.
Major trauma
SpecialtyEmergency medicine Edit this on Wikidata

Trauma or injury refers to any body damage due to a physical impact or accident. The degree of injury may range from mild to life and limb threatening.

Definition

There are two types trauma: trauma and major trauma. Trauma is defined as any body wound or shock produced by sudden physical injury, as from accident, injury, or impact.[1] Other definitions include: "a deeply distressing or disturbing experience",[2] and "a physical wound or injury, such as a fracture or blow."[3]

Major trauma can be the result of many different dominate injuries, and is defined by an injury severity score of greater than 15 on a scale of 75.[4]

Classification

Traumatic injuries can be classified by body part affect[5] (percentages of total incidence[6]):

By the mechanism such as blunt trauma, penetrating trauma, blast injury. Or by the type of population it has effected such as: trauma in pregnancy, pediatric trauma, geriatric trauma.[5]

Causes

There are four main types of injury.

  • Blunt trauma, which is the leading cause of traumatic death in the US. Most cases of blunt trauma are caused by motor vehicle accidents.[7]
  • Penetrating trauma is caused when an object enters a victim, most commonly a weapon. In the United States most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms.[8]
  • Falls are the second most common cause and can cause internal bleeding. A severe fall is defined as one that is a fall greater than three time times the victims height.[9]
  • Burn injuries which are declining in frequency and are common in urban areas.[10]

Risk factors

Alcohol and illicit drug use are risk factors for trauma, particularly motor vehicular collisions and violence.[6] In the elderly long-acting benzodiazepines increase the risk of trauma.[6]

Diagnosis

Physical exam

The purpose of the primary survey is to identify life-threatening problems. To ensure that the injured person is not disabled by unnecessary movement of the spine, the neck is frequently secured with a cervical collar, and the back is secured to a long spine board with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person. Unless the person is in imminent danger of death, first responders in the Anglo-American system will "load and go," transporting immediately to the nearest appropriate trauma-equipped hospital.[11]

Upon completion of the primary survey, the secondary survey is begun. This may occur during transport or upon arrival at the hospital. The secondary survey consists of a systematic assessment of the abdominal, pelvic and thoracic area, complete inspection of the body surface to find all injuries, and a neurological exam. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's emergency department), but rather manifests itself at a later point in time.[11]

Imaging

X-rays

X-rays of the chest and pelvis are commonly performed in major trauma.[6]

Ultrasound

Focused assessment with sonography for trauma (FAST), can also be used.

Computed tomography

Computed tomography (CT) scans are the gold standard in imaging in major trauma.[12] They however may only be performed in people with a relatively stable blood pressure, heart rate, and sufficient oxygenation.[6] Full body CT scans known as pan-scans improve survival in those who have suffered major trauma.[13] The scans are done using intravenous radiocontrast but not oral contrast.[14] There are concerns of radiation exposure and concerns regarding negative effects of contrast on the kidneys. However some centers routinely due CTs with contrast before verifying renal function even in the elderly and have not found negative side effects with respect to the kidneys.[12] With modern imaging technology a complete scan can be performed in less than 10 minutes.[6]

Surgery

In those who are hypotensive due to presumed internal abdominal bleeding transfer to the operating room for a laporotomy is the preferred method of determining a definitive diagnosis.[6]

Management

People who have suffered trauma may require specialized care, including surgery and blood transfusion. Outcomes are better if this occurs as quickly as possible thus the so called golden hour of trauma. This is not a strict deadline, but recognizes that many deaths which could have been prevented by appropriate care occur in a relatively short time after injury as shown by the fact most deaths by trauma occur in the first several hours after the event.[15] In many places organized trauma referral systems have been set up to provide rapid care for injured people. Research has shown that deaths from physical trauma decline where there are organized trauma systems.

The care of the acutely injured is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital care by emergency medical services; emergency department assessment, treatment, and stabilization; and in-hospital care surgery and medical management among all age groups.[16]

Resuscitation

In the prehospital setting the use of stabilization techniques improve the chances of a person surviving the transport to the nearest trauma center. After ensuring their own safety and taking isolation precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) than an assessment of the level of consciousness.[11]

Rapid transportation of those who are severely injured is associated with a improved outcomes.[6] In the prehospital environment the availability of ACLS vs. BLS care does not seem to affect outcomes for major trauma.[17][18] The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation and some evidence has found it may be harmful.[19]

Intravenous fluids

Traditionally high volume intravenous fluids were given in people with hemodynamic instability due to trauma. This is still appropriate for those with isolated extremity, thermal or head injuries.[20] The current evidence however supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist.[20][21] If blood products are needed a greater relative use of fresh frozen plasma and platelets to packed red blood cells has been found to result in improved survival and less overall blood product usage.[22]

Medications

In people who are bleeding due to trauma tranexamic acid decreases mortality.[23] Factor VIIa may also be appropriate in certain cases associated with severe bleeding[20] such as those who have bleeding disorders.[6]

Surgery

See also: Trauma surgery

Damage control surgery is employed in the management of trauma.[6] This involves performing the least number of procedures to save life and limb.[6] Less critical procedures are left until the person is in a more stable.[6]

Trauma center

See also: Trauma center

People who have severe trauma frequently require specialized physicians and equipment. In the United States designated trauma centers have improved outcomes compared to non designated centers.[6]

Prognosis

Death from trauma have been classic described as occurring during three peaks: immediately, early, and late. The immediate deaths are usually due to apnea, severe brain or high spinal cord injury, and rupture of the heart or large blood vessels. The early deaths occur within minutes to hours and are often due to a subdural hematoma, epidural hematoma, hemothorax, pneumothorax, ruptured spleen, liver laceration, or pelvic fractures. This is known as the golden hour. The late deaths occur days or weeks after the injury.[11] This classical distribution however may no longer be occurring in the United States due to improvements in care.[6]

Long term prognosis is also frequently complicated by pain with over half of people having moderately severe pain one year later.[24] Many also experience a reduced quality of life years later.[25] 20% of people who sustain a traumatic injury will sustain some form of disability.[10]

Physical trauma can lead to development of post-traumatic stress disorder (PTSD).[26] However, a study found no correlation between the severity of trauma and the development of PTSD.[27]

Epidemiology

See also: List of preventable causes of death
Deaths from injuries per 100,000 inhabitants in 2004.[28]
  no data
  < 25
  25-50
  50-75
  75-100
  100-125
  125-150
  150-175
  175-200
  200-225
  225-250
  250-275
  > 275
Incidence of accidents by activity.

Globally one in ten deaths in both sexes is due to traumatic injuries making them the sixth leading cause of death and the fifth leading cause of significant disability.[4] In those between 15 and 45 years of age trauma is the leading cause of death.[29][4][10][15] The primary cause of death is due to central nervous system injury followed by bleeding.[4]

Society and culture

See also: Irreparable damage or injury

Various legal remedies may be available for personal injury (e.g. under the law negligence) or for injury to the reputation of another (e.g. see damages and restitution) for slander or libel. In the United States, the legal definition of malicious injury is any injury committed with malice, hatred or one committed spitefully or wantonly. Such an action must be willfully committed with the knowledge that it is liable to cause injury. Injury involving element of fraud, violence, wantonness, willfulness, or criminality.

In the Criminal Code of Canada, bodily injury is referred to as "bodily harm".[30]

Research

Blood substitutes such as hemoglobin-based oxygen carriers and perfluorocarbon emulsions are in development. As of June 2008 however there are none available for commercial use in North America or Europe.[31][32] The only countries where these products are available for general use is South Africa and Russia.[31] Patients who were admitted into a an ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.[33]

See also

References

  1. ^ Trauma | Define Trauma at Dictionary.com
  2. ^ Catherine Soanes,Angus Stevenson, ed. (2005), The Oxford Dictionary of English (2nd ed.), Oxford University Press, ISBN 0198610572
  3. ^ Elizabeth Martin, ed. (2010), Concise Medical Dictionary (Eighth ed.), Market House Books Ltd
  4. ^ a b c d Søreide, K. (2009), "Epidemiology of major trauma", The British journal of surgery, 96 (7): 697, doi:10.1002/bjs.6643, PMID 19526611 {{citation}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)
  5. ^ a b Marx, John (2010), Rosen's emergency medicine: concepts and clinical practice 7th edition, Philadelphia, PA: Mosby/Elsevier, pp. 243–842, ISBN 9780323054720 {{citation}}: Cite has empty unknown parameter: |coauthors= (help)
  6. ^ a b c d e f g h i j k l m n Bonatti H, Calland JF (2008), "Trauma", Emerg. Med. Clin. North Am., 26 (3): 625–48, vii, doi:10.1016/j.emc.2008.05.001, PMID 18655938. {{citation}}: Unknown parameter |month= ignored (help)
  7. ^ DiPrima Jr., Peter A., McGraw-Hill's EMT-Basic, McGraw-Hill, pp. 227–33, ISBN 978-0-07-149679-7
  8. ^ Medzon, Ron; Mitchell, Elizabeth J. (2005), Introduction to emergency medicine, Philadelphia: Lippincott Williams & Willkins, pp. 393–431, ISBN 078173200x {{citation}}: Check |isbn= value: invalid character (help)CS1 maint: multiple names: authors list (link)
  9. ^ Edward T. Dickenson (2009), Emergency Care, ISBN 978-0-13-500523-1 {{citation}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  10. ^ a b c Andrew B., MD Peitzman; Andrew B. Peitzman; Michael, MD Sabom; Donald M., MD Yearly; Timothy C., MD Fabian (2002), The Trauma Manual, Hagerstwon, MD: Lippincott Williams & Wilkins, p. 1, ISBN 0-7817-2641-7{{citation}}: CS1 maint: multiple names: authors list (link)
  11. ^ a b c d American College of Surgeons (2008), Atls, Advanced Trauma Life Support Program for Doctors, Amer College of Surgeons, ISBN 1-880696-31-6 {{citation}}: Check |isbn= value: checksum (help)
  12. ^ a b McGillicuddy EA, Schuster KM, Kaplan LJ; et al. (2010), "Contrast-induced nephropathy in elderly trauma patients", J Trauma, 68 (2): 294–7, doi:10.1097/TA.0b013e3181cf7e40, PMID 20154540 {{citation}}: Explicit use of et al. in: |author= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  13. ^ Huber-Wagner S, Lefering R, Qvick LM; et al. (2009), "Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study", Lancet, 373 (9673): 1455–61, doi:10.1016/S0140-6736(09)60232-4, PMID 19321199 {{citation}}: Explicit use of et al. in: |author= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  14. ^ Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH (2004), "Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma", J Trauma, 56 (2): 314–22, doi:10.1097/01.TA.0000058118.86614.51, PMID 14960973 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  15. ^ a b F.A. Davis (2009), Tabers Cyclopedic Medical Dictionary, Philadelphia: F.A. Davis Company, pp. 2366–7, ISBN 978-0-8036-1559-5
  16. ^ Centers for Disease Control and Prevention Injury Prevention and Control: Injury Response: Acute Injury Care
  17. ^ Stiell IG, Nesbitt LP, Pickett W; et al. (2008), "The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity", CMAJ, 178 (9): 1141–52, doi:10.1503/cmaj.071154, PMC 2292763, PMID 18427089 {{citation}}: Explicit use of et al. in: |author= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  18. ^ Liberman M, Roudsari BS (2007), "Prehospital trauma care: what do we really know?", Curr Opin Crit Care, 13 (6): 691–6, doi:10.1097/MCC.0b013e3282f1e77e, PMID 17975392 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)
  19. ^ Dretzke J, Sandercock J, Bayliss S, Burls A (2004), "Clinical effectiveness and cost-effectiveness of prehospital intravenous fluids in trauma patients", Health Technol Assess, 8 (23): iii, 1–103, PMID 15193210 {{citation}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  20. ^ a b c Roppolo LP, Wigginton JG, Pepe PE (2010), "Intravenous fluid resuscitation for the trauma patient", Curr Opin Crit Care, 16 (4): 283–8, doi:10.1097/MCC.0b013e32833bf774, PMID 20601865 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  21. ^ Marx, John (2010), Rosen's emergency medicine: concepts and clinical practice 7th edition, Philadelphia, PA: Mosby/Elsevier, p. 2467, ISBN 9780323054720 {{citation}}: Cite has empty unknown parameter: |coauthors= (help)
  22. ^ Greer SE, Rhynhart KK, Gupta R, Corwin HL (2010), "New developments in massive transfusion in trauma", Curr Opin Anaesthesiol, 23 (2): 246–50, doi:10.1097/ACO.0b013e328336ea59, PMID 20104173 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  23. ^ Crash-2 Trial, Collaborators; Shakur, H; Roberts, R; Bautista, R; Caballero, J; Coats, T; Dewan, Y; El-Sayed, H; Gogichaishvili, T (2010), "Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial", Lancet, 376 (9734): 23–32, doi:10.1016/S0140-6736(10)60835-5, PMID 20554319 {{citation}}: |first1= has generic name (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: numeric names: authors list (link)
  24. ^ Rivara FP, Mackenzie EJ, Jurkovich GJ, Nathens AB, Wang J, Scharfstein DO (2008), "Prevalence of pain in patients 1 year after major trauma", Arch Surg, 143 (3): 282–7, discussion 288, doi:10.1001/archsurg.2007.61, PMID 18347276 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ Ulvik A, Kvåle R, Wentzel-Larsen T, Flaatten H (2008), "Quality of life 2-7 years after major trauma", Acta Anaesthesiol Scand, 52 (2): 195–201, doi:10.1111/j.1399-6576.2007.01533.x, PMID 18005377 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  26. ^ "Diagnostic and Statistical Manual of Mental Disorders", Diagnostic and statistical manual of mental disorders, fourth edition, Washington, USA: American Psychiatric Association, pp. 424–429, 1994 {{citation}}: |chapter= ignored (help)
  27. ^ Feinstein, Anthony; Dolan, Ray (1991), "Predictors of post-traumatic stress disorder following physical trauma: an examination of the stressor criterion", Psychological Medicine, 21, Cambridge University Press: 85, doi:10.1017/S0033291700014689.
  28. ^ "Death and DALY estimates for 2004 by cause for WHO Member States" (xls). World Health Organization. 2004.
  29. ^ Peters S, Nicolas V, Heyer CM (2010). "Multidetector computed tomography-spectrum of blunt chest wall and lung injuries in polytraumatized patients". Clin Radiol. 65 (4): 333–8. doi:10.1016/j.crad.2009.12.008. PMID 20338402. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  30. ^ http://laws.justice.gc.ca/eng/C-46/page-1.html
  31. ^ a b UpToDate Inc.
  32. ^ Spahn DR, Kocian R (2005), "Artificial O2 carriers: status in 2005", Curr. Pharm. Des., 11 (31): 4099–114, doi:10.2174/138161205774913354, PMID 16378514 {{citation}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)
  33. ^ Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I (2009), "Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care", J Trauma, 66 (4): 1226–33, doi:10.1097/TA.0b013e318181b8e3, PMID 19088550 {{citation}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Further reading

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