Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than 65% were due to self-harm. In addition to deaths, injury results in about 37.9 million emergency department visits and 2.6 million hospital admissions annually. Show
Patients whose injuries are serious but not immediately fatal benefit the most from treatment in designated trauma centers, hospitals that have special staffing and protocols to provide immediate care to critically injured patients. Criteria for such designation (and for the necessity of transport to them) vary by state but usually follow the guidelines of the American College of Surgeons Committee on Trauma. Many traumatic injuries are discussed elsewhere in THE MANUAL: Of the myriad ways people are injured, most can be categorized as blunt or penetrating. Blunt injury involves a forceful impact (eg, blow, kick, strike with an object, fall, motor vehicle crash, blast). Penetrating injury involves breach of the skin by an object (eg, knife, broken glass) or projectile (eg, bullet, shrapnel from an explosion). Other injury types include
thermal and chemical burns Burns Burns are injuries of skin or other tissue caused by
thermal, radiation, chemical, or electrical contact. Burns are classified by depth (superficial and deep partial-thickness, and full-thickness)... read more All injuries, by definition, cause direct tissue damage, the nature and extent depending on the anatomic site, mechanism, and intensity of trauma. Severe direct tissue damage to critical organs (eg, to the heart, brain, spinal cord) is responsible for most immediate trauma deaths. Additionally, patients surviving the initial insult may develop subsequent indirect injuries in the short and near term. Disruption of blood vessels causes hemorrhage, which may be external (and hence visible) or internal, either confined within an organ as a contusion or hematoma, or as free hemorrhage into a body compartment (eg, peritoneal cavity, thorax). Small amounts of hemorrhage (ie, <
10% of blood volume) are tolerated well by most patients. Larger amounts cause progressive declines in blood pressure and organ perfusion (shock
Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more ), leading to cellular dysfunction, organ failure, and eventually death. Hemorrhagic shock and
brain injury
Traumatic Brain Injury (TBI) Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more
Care in the emergency department rather than emergency care delivered at the accident site is discussed here. Evaluation and treatment are done simultaneously, beginning with systems that pose the most immediate threat to life if damaged. Attending to dramatic but not deadly injuries (eg, open lower-extremity fracture, finger amputations) before evaluating immediate life threats can be a fatal mistake. A helpful mnemonic is A, B, C, D, E, for Airway, Breathing, Circulation, Disability (neurologic status), and Exposure/Environmental control. Systems are rapidly examined for serious abnormalities (primary survey); a more detailed examination (secondary survey) is done after the patient is stable. Airway patency is threatened by blood clots, teeth, or foreign bodies in the oropharynx; soft-tissue laxity and posterior retraction of the tongue caused by obtundation (eg, due to head injury, shock, intoxication); and edema or hematoma due to direct neck trauma. These obstructions are readily visible on direct inspection of the mouth or neck; having the patient speak can rapidly confirm that the airway is not likely in immediate danger. The chest wall is fully exposed to look for ample chest wall expansion, external signs of trauma, and paradoxical wall motion (ie, retraction of the chest wall on inspiration), which indicates a flail chest. The chest wall is palpated for rib fractures and the presence of subcutaneous air (sometimes the only finding in pneumothorax). Significant external hemorrhage can occur from any major vessel but is always apparent. Life-threatening internal hemorrhage is often less obvious. However, this volume of hemorrhage can occur in only a few body compartments: the chest, abdomen, retroperitoneum, and soft tissues of the pelvis or thigh (eg, from a pelvic or femoral fracture). Pulse and blood pressure are assessed, and signs of shock are noted (eg, tachypnea, dusky color, diaphoresis, altered mental status, poor capillary refill). Abdominal distention and tenderness, pelvis instability, and thigh deformity and instability are often present when internal hemorrhage in those areas is large enough to be life threatening. External hemorrhage is controlled by direct pressure. Tourniquets should be applied for extremity bleeding if bleeding is not controlled by direct pressure. Two large-bore (eg, 14- or 16-gauge) IVs are started with 0.9% saline or lactated Ringer's solution; rapid infusion of 1 L (20 mL/kg for children) is given for signs of shock and hypovolemia Prognosis Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more . Subsequently, early administration of blood component therapy should be considered. Bedside measurement of lactate or arterial blood gases (and calculation of base excess) can help indicate the severity of tissue hypoperfusion and shock and thus help guide fluid therapy. Protocols have been developed for patients requiring large volumes of blood products (massive transfusion protocols), including evaluation of coagulation with thromboelastography or rotational thromboelastography (where available) and early administration of tranexamic acid. When there is strong clinical suspicion of serious intra-abdominal hemorrhage, patients may require immediate laparotomy. Placement of a resuscitative balloon for occlusion of the aorta can help stabilize the patient before surgery. Patients with massive intrathoracic hemorrhage may require immediate thoracotomy and possibly autotransfusion of blood recovered via tube thoracostomy. Gross motor movement and sensation in each extremity are used to screen for serious spinal cord injury. The cervical spine is palpated for tenderness and deformity and stabilized in a rigid collar until cervical spine injury is excluded. With careful manual stabilization of the head and neck, the patient is logrolled onto a side to allow
In the US, most patients arriving by ambulance are immobilized on a long, rigid board for ease of transport and to stabilize possible spinal fractures. Patients should be taken off the board as soon as possible because it is quite uncomfortable and pressure ulcers may occur within a few hours.  To ensure injuries are not missed, patients are completely undressed (by cutting off garments) and the entire body surface is examined for signs of occult trauma. The patient is kept warm (eg, with heated blankets and by using warmed IV fluids) to prevent hypothermia. After immediate life threats are assessed and the patient is stable, a more thorough evaluation is done, and a focused history is obtained. If only limited conversation is possible, an “AMPLE” history covers essential information:
After the patient is completely undressed, the examination generally proceeds from head to toe; it typically includes all orifices and a more detailed look at areas examined in the initial survey. All soft tissues are inspected for lesions and swelling, all bones are palpated for tenderness, and range of motion is assessed in joints (unless there is obvious fracture or deformity). Open wounds are covered with sterile dressings, but cleansing and repair are deferred until completion of evaluation and treatment of more serious injuries. Serious clinically apparent dislocations with marked deformity or neurovascular compromise are imaged and reduced as soon as immediate life threats have been addressed. Obvious or suspected fractures are splinted pending full assessment of serious injuries and appropriate imaging studies. A clinically apparent unstable pelvic fracture is stabilized with a commercial pelvic binder or bed sheet to help close the pelvic space and decrease bleeding; severe bleeding may require urgent angiographic embolization, surgical fixation, or direct surgical control. In pregnant trauma patients, the initial priority is stabilization of the woman, which is the best way to ensure fetal stability. Near term, immobilization in the supine position may cause the uterofetoplacental unit to compress the inferior vena cava, obstructing blood return and causing hypotension. If so, the uterus can be manually pushed to the patient's left or the entire backboard can be tilted to the left to relieve the compression. Fetal monitoring is done if the fetus is >20 weeks gestation and continued for at least 4 to 6 hours. An obstetrician should be consulted early for patients with serious trauma or signs of pregnancy complications (eg, abnormal fetal heart rate, vaginal bleeding, contractions). Rh0(D) immune globulin is given to all Rh-negative women following even minor trauma. If the woman has cardiac arrest and cannot be resuscitated, a perimortem cesarean delivery can be done if the fetus is >20 weeks' gestation (corresponding to a uterine fundal height above the umbilicus). Imaging and laboratory tests supplement clinical assessment. Patients with penetrating trauma typically have focal injuries that can limit imaging to the obviously involved region or regions. Blunt trauma, particularly when significant deceleration is involved (eg, serious fall, motor vehicle crash), can affect any part of the body, and imaging is used more liberally. Previously, x-rays or CT of the neck, chest, and pelvis were routinely done on most patients with blunt trauma. However, most trauma centers are now doing only imaging studies that are indicated by the mechanism of injury and findings on examination. Cervical spine imaging can be deferred in patients who are not intoxicated, do not have focal neurologic findings, have no midline cervical spine tenderness or distracting injuries (eg, femur fracture), and are awake and alert. All others should have cervical spine imaging, preferably using CT. Chest x-ray can identify airway disruption, lung injury, hemothorax, and pneumothorax; it can also suggest thoracic aorta tears (eg, by mediastinal widening). However, chest CT is more sensitive for most intrathoracic injuries and is often preferred. Chest imaging is now commonly done at the bedside using
ultrasonography E-FAST
How To Do E-FAST Examination E-FAST (Extended Focused Assessment with Sonography in Trauma) is a bedside ultrasonographic protocol designed to detect peritoneal fluid, pericardial fluid, pneumothorax, and/or hemothorax... read more
CT of the chest, abdomen, pelvis, spine, or head or, particularly, combinations of these studies are frequently used for patients who require imaging after severe multiple blunt trauma. Identification of intra-abdominal injury is essential. Historically, diagnostic peritoneal lavage How To Do Diagnostic Peritoneal Lavage (DPL) Diagnostic peritoneal lavage (DPL) is an invasive emergency procedure used to detect hemoperitoneum and help determine the need for laparotomy following abdominal trauma. A catheter is inserted... read more (DPL) was used to assess for intraperitoneal blood. In DPL, a peritoneal dialysis catheter is inserted through the abdominal wall into the peritoneal cavity. If >10 mL of blood is aspirated, immediate laparotomy is indicated. If blood is not aspirated, 1 L of 0.9% saline is infused through the catheter and drained out; analysis of the returned fluid is used to guide management. However, in all but low-resource areas, DPL has largely been replaced by bedside ultrasonography (E-FAST examination), particularly for unstable patients; it is sensitive for significant volumes of intraperitoneal blood and thus the need for immediate laparotomy. If patients are stable, CT is the preferred study; it is very accurate, allows imaging of the retroperitoneal structures and bones, and shows the volume and sometimes the origin of hemorrhage. Head CT is typically done in patients with altered mental status or focal neurologic abnormalities and in patients who sustained loss of consciousness. Some evidence suggests that CT is not necessary in patients with brief loss of consciousness (ie, < 5 seconds) or transient amnesia or disorientation but who are alert with a GCS of 15 during examination. Imaging is done more liberally in patients with persistent headache, vomiting, amnesia, seizures, age > 60 years, and drug or alcohol intoxication and in patients taking anticoagulant or antiplatelet drugs. Clinical decision rules have been developed to help determine which patients should have a head CT (1 Evaluation and treatment reference Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than... read more ). These decision rules should be used to aid, but not replace, clinical judgment. For children with head injury, the Pediatric Emergency Care Applied Research Network (PECARN) has developed an algorithm that may help limit radiation exposure from head CT; clinical observation is used in children who may otherwise have received CT. Evaluation of Children 0 to 2 Years With a Head Injury
Evaluation of Children ≥ 2 Years With a Head Injury
Vascular injury to the carotid and vertebral vessels should be considered in patients with trauma to the head and neck, particularly those with unilateral neurologic findings, a neck seat belt sign (linear ecchymosis due to the shoulder strap), or a predisposing injury (eg, fracture of C1, C2, or C3; other C-spine fracture with subluxation; hanging mechanism). Such patients typically should have CT angiography. Plain x-rays are obtained of any suspected fractures and dislocations of the extremities. Other imaging tests are obtained for specific indications (eg, angiography to diagnose and sometimes embolize vascular injury; CT to better delineate spinal, pelvic, or complex joint fractures). Laboratory tests that may be useful include
Measures of perfusion (serum lactate, base deficit on arterial blood gas measurement, and, in patients with a catheterized central vein, central venous oxygen saturation) are indicated to help identify early or partially treated shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more . Other reflexively obtained tests (eg, electrolytes and other chemistries) are unlikely to be helpful unless suggested by relevant medical history (eg, renal insufficiency, diuretic use).
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources. What should you suspect from a patient that has fallen from a significant height?After the Fall
Check the patient's breathing, pulse, and blood pressure. If the patient is unconscious, not breathing, or does not have a pulse, call a hospital emergency code and start CPR. Check for injury, such as cuts, scrapes, bruises, and broken bones.
What should you monitor after a fall?STEP 10: Monitor residents post-fall
The person doing the monitoring should be on the lookout for the following signs and symptoms: change in condition; change in gait, balance, and/or transfer abilities that may indicate a new health or environmental problem; change in behavior; and distress or post-fall injuries.
What happens when someone falls from a height?"Most people who fall from a height die because they fracture their spine near the top and so transect the aorta which carries blood out of the heart," says Sean Hughes, professor of surgery at Imperial College, London. Landing on your side might be the best way to survive a fall, adds Hughes.
What injuries can you get from falling from a high place?Falls can cause broken bones, like wrist, arm, ankle, and hip fractures. Falls can cause head injuries. These can be very serious, especially if the person is taking certain medicines (like blood thinners).
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What should you suspect from a patient that has just fallen from a significant height?
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