Trauma-General

Epidemiology

  • xxxx

Physiology

  • xxxx

Diagnosis

Abdominal-Pelvic CT (see Abdominal-Pelvic Computed Tomography, [[Abdominal-Pelvic Computed Tomography]])

  • Clinical Efficacy
    • Sensitivity of Abdominal/Pelvic CT in Ruling Out Abdominal Injury (JAMA Surg, 2015) [MEDLINE]: CT is useful in the evaluation of blunt trauma
      • CT may have limited utility for evaluating the trajectory and effects of low velocity penetrating injury (stab wounds) because of the lack of tissue disruption and gas dispersion (that is seen with high velocity injuries)

Whole Body CT (see xxxx, [[xxxx]])

  • Clinical Efficacy
    • Impact of Whole Body CT Scan in Trauma (Lancet, 2009) [MEDLINE]: whole-body CT in early trauma care significantly decreased the mortality rate

Clinical Manifestations

Cardiovascular Manifestations

Hypotension/Hemorrhagic Shock (see Hypotension, [[Hypotension]] and Hemorrhagic Shock, [[Hemorrhagic Shock]])

  • xxx

Hematologic Manifestations

Coagulopathy (see Coagulopathy, [[Coagulopathy]])

  • Epidemiology: common occurs early in trauma [MEDLINE]
    • Coagulopathy is Present (Pre-Resuscitation) in 24-30% of Trauma Patients: incidence of coagulopathy is correlated with the severity of injury
  • Clinical
  • Prognosis: coagulopathy is an independent predictor of mortality [MEDLINE]
    • Initial Abnormal PT/INR Increases the Adjusted Odds of Dying by 35%
    • Initial Abnormal PTT Increases the Adjusted Odds of Dying by 326%

Hemorrhagic Anemia

  • Epidemiology: hemorrhage is the leading cause of preventable death in combat and civilian trauma patients
  • Clinical

Renal Manifestations

Metabolic Acidosis (see xxxx, [[xxxx]])

  • xxx

Other Manifestations

Hypothermia (see xxxx, [[xxxx]])

  • xxxx

Treatment

General Management

  • Clinical Efficacy
    • Impact of Specialized Trauma Care on Mortality (NEJM, 2006) [MEDLINE]: mortality rate is lower in trauma centers than in non-trauma centers

Transfusion Management

  • Rationale: although controversial, the 1:1:1 (FFP:platelets:PRBC) transfusion strategy (as part of damage-control resuscitation) is common in life-threatening hemorrhage
    • No Data Exists in Non-Trauma Patients with Hemorrhage
  • Clinical Efficacy
    • Multi-Center Retrospective Study of High Plasma and Platelet Ratios in Resuscitation of Trauma Patients (n= 466) (Am J Surg, 2009) [MEDLINE]: early administration of high ratios of FFP and platelets improved survival and decreased need for PRBC in massively transfused trauma patients
      • The largest difference in mortality occured during the first 6 hrs after admission
    • Study of High Plasma or Platelet: Packed red Blood Cell Ratios in Non-Massively Transfused Trauma Patients (J Trauma, 2011) [MEDLINE]: FFP:PRBC and PLT:PRBC ratios did not impact in-hospital mortality rates

References

General

  • Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44 [MEDLINE]
  • Acute traumatic coagulopathy. J Trauma. 2003;54:1127–1130 [MEDLINE]
  • A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366 [MEDLINE]
  • Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008;64:1459–1463; discussion 1463–1455 [MEDLINE]
  • Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373(9673):1455 [MEDLINE]
  • Negative Finding From Computed Tomography of the Abdomen After Blunt Trauma. JAMA Surg. 2015 Dec;150(12):1194-5. doi: 10.1001/jamasurg.2015.1649 [MEDLINE]

Treatment

  • Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007; 62:307–310 [MEDLINE]
  • The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805–813 [MEDLINE]
  • Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447–458 [MEDLINE]
  • Effect of plasma and red blood cell transfusions on survival in patients with combat related traumatic injuries. J Trauma. 2008;64:S69–S77; discussion S77–S68 [MEDLINE]
  • Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65: 527–534 [MEDLINE]
  • Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma. 2008;65:272–276; discussion 276–278 [MEDLINE]
  • An FFP:PRBC transfusion ratio / 1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65:986–993 [MEDLINE]
  • Combat damage control surgery. Crit Care Med 2008;36(7):S304-10 [MEDLINE]
  • A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg. 2009;197:565–570; discussion 570 [MEDLINE]
  • High ratios of plasma and platelets to packed red blood cells do not affect mortality in nonmassively transfused patients.  J Trauma  2011; 71:S329-S336.  DOI: 10.1097/TA.0b013e318227edd3 [MEDLINE]
  • Damage control resuscitation: lessons learned. Eur J Trauma Emerg Surg. 2016 Feb 4 [MEDLINE]