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Any injury, whether physically or emotionally inflicted. Trauma has both a medical and a psychiatric definition. Medically, "trauma" refers to a serious or critical bodily injury, wound, or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. In psychiatry, "trauma" has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, which often results in lasting mental and physical effects.
Head injury is a general term used to describe any trauma to the head, and most specifically to the brain itself.
Linear skull fracture: A common injury, especially in children. A linear skull fracture is a simple break in the skull that follows a relatively straight line. It can occur after seemingly minor head injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a serious injury unless there is an additional injury to the brain itself.
Epidural hematoma: The skull is made up of a variety of bones; the dura, the thick membrane that wraps around the brain, attaches at the suture lines where the bones come together. If bleeding occurs in the enclosed space between the dura and the bone, and a hematoma (blood clot) forms, there is nowhere for it to accumulate and pressure within the epidural space can build quickly. The increasing pressure pushes the hematoma against the brain tissue and may cause significant damage.
Tiny epidural hematomas potentially may be observed without surgery, but often surgery is indicated to removed the hematoma and relieve the pressure on the brain. The earlier the operation is the better, because the death rate increases if the patient is in a coma at the time of operation.
An epidural hematoma may often occur with trauma to the temporal bone located on the side of the head above the ear. Aside from the fact that the temporal bone is thinner than the other skull bones (frontal, parietal, occipital), it is also the location of the middle meningeal artery that runs just beneath the bone. Fracture of the temporal bone is associated with tearing of this artery and may lead to an epidural hematoma.
HEAD INJURY CAUSE
All types of head injuries can be caused by trauma. In adults in the United States such injuries commonly result from motor vehicle accidents, assaults, and falls. In children falls are the most common cause followed by recreational activities such as biking, skating, or skateboarding. A small but significant number of head injuries in children are from violence and abuse.
Penetrating trauma: Missiles such as bullets or sharp instruments (such as knives, screwdrivers, or ice picks) may penetrate the skull. The result is called a penetrating head injury. Penetrating injuries often require surgery to remove debris from the brain tissue. The initial injury itself may cause immediate death, especially if from a high-energy missile such as a bullet.
Blunt head trauma: These injuries may be from a direct blow (a club or large missile) or from a rapid deceleration force (a fall or striking the windshield in a car accident).
HEAD INJURY SYMPTOMS
Minor blunt head injuries may involve only symptoms of being "dazed" or brief loss of consciousness. They may result in headaches or blurring of vision or nausea and vomiting. There may be longer lasting subtle symptoms including, irritability, difficulty concentrating, insomnia, and difficulty tolerating bright light and loud sounds. These post concussion symptoms may last for a prolonged period of time.
Severe blunt head trauma involves a loss of consciousness lasting from several minutes to many days or longer. The person may suffer from severe and sometimes permanent neurological deficits or may die. Neurological deficits from head trauma resemble those seen in stroke and include paralysis, seizures, or difficulty with speaking, seeing, hearing, walking, or understanding.
Penetrating trauma may cause immediate, severe symptoms or only minor symptoms despite a potentially life-threatening injury. Death may follow from the initial injury. Any of the signs of serious blunt head trauma may result.
HEAD INJURY TREATMENT
Bleeding under the scalp, but outside the skull, creates "goose eggs" or large bruisesat the site of a head injury. They are common and will go away on their own with time. Using ice immediately after the trauma may help decrease their size.
Do not apply ice directly to the skin. Ice should be applied for 20-30 minutes at a time and can be repeated about every 2-4 hours as needed.
Use a light washcloth as a barrier and wrap the ice in it. You can also use a bag of frozen vegetables wrapped in cloth. This conforms nicely to the shape of the head.
Make your own ice pack by adding 1/3 cup of 70% isopropyl alcohol (the green-colored kind is best to help identify it later) to 2/3 cup of water in a zip-lock-style bag (double bag it to prevent leaking). The mixture turns into "slush." Freeze this homemade ice pack for use when needed. Caution: If you have small children in your home, watch them carefully when using the ice pack. Drinking the mixture can be poisonous.
Commercially available ice packs use chemicals to create cold. They are designed to be kept in a first-aid kit and need not be kept frozen. These can be applied directly to the skin, although a barrier can also be used if bleeding is present. They must be disposed of after a single use but can be handy in case of emergencies.
When a minor head injury results from a fall onto carpet or other soft surface and the height of the fall is less than the height of the person who fell and there is no loss of consciousness (in other words, the person was not "knocked out"), a doctor's visit is not usually needed. Apply ice to lessen swelling.
Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. These components include the bony skeleton (ribs, clavicles, scapulae, and sternum), lungs and pleurae, tracheobronchial tree, esophagus, heart, great vessels of the chest, and the diaphragm. In the subsequent sections, each particular injury and injury pattern resulting from blunt mechanisms is discussed. The path physiology of these injuries is elucidated and diagnostic and treatment measures are outlined.
The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports of pain to florid shock. The presentation depends on the mechanism of injury and the organ systems injured.
Obtaining as detailed a clinical history as possible is extremely important in the assessment of a patient with a blunt thoracic trauma. The time of injury, mechanism of injury, estimates of MVA velocity and deceleration, and evidence of associated injury to other systems (loss of consciousness) are all salient features of an adequate clinical history. Information should be obtained directly from the patient whenever possible and from other witnesses to the accident if available.
For the purposes of this discussion, the authors divide blunt thoracic injuries into 3 broad categories as follows: (1) chest wall fractures, dislocations, and barotraumas (including diaphragmatic injuries); (2) blunt injuries of the pleurae, lungs, and aero digestive tracts; and (3) blunt injuries of the heart, great arteries, veins, and lymphatic. A concise exegesis of the clinical features of each condition in these categories is presented. This classification is used in subsequent sections to outline indications for medical and surgical therapy for each condition.
INJURY AND TREATMENT
Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture. If a pneumothorax is present, breath sounds may be decreased and resonance to percussion may be increased. Rib fractures may also be a marker for other associated significant injury, both intrathoracic and extrathoracic. In one report, 50% of patients with blunt cardiac injury have rib fractures. Fractures of ribs 8-12 should raise the suggestion of associated abdominal injuries. Lee and colleagues reported a 1.4- and 1.7-fold increase in the incidence of splenic and hepatic injury, respectively, in those with rib fractures.
Elderly patients with 3 or more rib fractures have been shown to have a 5-fold increased mortality rate and a 4-fold increased incidence of pneumonia. Effective pain control is the cornerstone of medical therapy for patients with rib fractures. For most patients, this consists of oral or parenteral analgesic agents. Intercostal nerve blocks may be feasible for those with severe pain who do not have numerous rib fractures. A local anesthetic with a relatively long duration of action (bupivacaine) can be used. Patients with multiple rib fractures whose pain is difficult to control can be treated with epidural analgesia.
Adjunctive measures in the care of these patients include early mobilization and aggressive pulmonary toilet. Rib fractures do not require surgery. Pain relief and the establishment of adequate ventilation are the therapeutic goals for this injury. Rarely, a fractured rib lacerates an intercostal artery or other vessel, which requires surgical control to achieve hemostasis acutely. In the chronic phase, nonunion and persistent pain may also require an operation.
A flail chest, by definition, involves 3 or more consecutive rib fractures in 2 or more places, which produces a free-floating, unstable segment of chest wall. Separation of the bony ribs from their cartilaginous attachments, termed costochondral separation, can also cause flail chest. Patients report pain at the fracture sites, pain upon inspiration, and, frequently, dyspnea. Physical examination reveals paradoxical motion of the flail segment. The chest wall moves inward with inspiration and outward with expiration. Tenderness at the fracture sites is the rule. Dyspnea, tachypnea, and tachycardia may be present. The patient may overtly exhibit labored respiration due to the increased work of breathing induced by the paradoxical motion of the flail segment.
A significant amount of force is required to produce a flail segment. Therefore, associated injuries are common and should be aggressively sought. The clinician should specifically be aware of the high incidence of associated thoracic injuries such as pulmonary contusions and closed head injuries, which, in combination, significantly increase the mortality associated with flail chest.
All of the treatment modalities mentioned above for patients with rib fractures are appropriate for those with flail chest. Respiratory distress or insufficiency can ensue in some patients with flail chest because of severe pain secondary to the multiple rib fractures, the increased work of breathing, and the associated pulmonary contusion. This may necessitate endotracheal intubation and positive pressure mechanical ventilation. Intravenous fluids are administered judiciously because fluid overloading can precipitate respiratory failure, especially in patients with significant pulmonary contusions.
To stabilize the chest wall and to avoid endotracheal intubation and mechanical ventilation, various operations have been devised for correcting flail chest.
Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung parenchyma. This is not absolute. Pneumothoraces can result from deceleration or barotrauma to the lung without associated rib fractures.
Patients report inspiratory pain or dyspnea and pain at the sites of the rib fractures. Physical examination demonstrates decreased breath sounds and hyperresonance to percussion over the affected hemithorax. In practice, many patients with traumatic pneumothoraces also have some element of hemorrhage, producing a hemopneumothorax.
Patients with pneumothoraces require pain control and pulmonary toilet. All patients with pneumothoraces due to trauma need a tube thoracostomy. The chest tube is connected to a collection system (Pleur-evac) that is entrained to suction at a pressure of approximately -20 cm water. The tube continues suctioning until no air leak is detected. The tube is then disconnected from suction and placed to water seal. If the lung remains fully expanded, the chest tube may be removed and another chest radiograph obtained to ensure continued complete lung expansion.
The accumulation of blood within the pleural space can be due to bleeding from the chest wall (lacerations of the intercostal or internal mammary vessels attributable to fractures of chest wall elements) or to hemorrhage from the lung parenchyma or major thoracic vessels. Patients report pain and dyspnea. Physical examination findings vary with the extent of the hemothorax. Most hemothoraces are associated with a decrease in breath sounds and dullness to percussion over the affected area. Massive hemothoraces due to major vascular injuries manifest with the aforementioned physical findings and varying degrees of hemodynamic instability.
Hemothoraces are evacuated using tube thoracostomy. Multiple chest tubes may be required. Pain control and aggressive pulmonary toilet are provided. The chest tube output is monitored closely because indications for surgery can be based on the initial and cumulative hourly chest tube drainage. This is because massive initial output and continued high hourly output are frequently associated with thoracic vascular injuries that require surgical intervention. Guidelines are provided in the Indications section (see Blunt injuries of the pleurae, lungs, and aerodigestive tracts).
Large, clotted hemothoraces may require an operation for evacuation to allow full expansion of the lung and to avoid the development of other complications such as fibrothorax and empyema. Thoracoscopic approaches have been used successfully in the management of this problem.
Patients with immediately life-threatening injuries that require surgery cannot afford a protracted workup. At minimum, they must have their airway, breathing, and circulation (ABCs) established. Frequently, resuscitation efforts in these patients must continue in transit to and in the operating room.
Those with indications for surgery but who are not in extremis should also have their ABCs established. Based on the mechanism of injury, clinical history, and physical findings, a search is conducted to exclude associated injuries. Diagnostic procedures are completed if time and the patient's condition permit (cervical spine x-ray films, head CT scan, chest and abdominal CT scan, FAST examination). Blood is drawn and sent for typing, cross matching, and other tests (CBC count, ABG values).
Patients are extubated as soon as feasible in the postoperative period. Monitoring devices are kept in place while needed but are removed as soon as possible.
Intravenous fluids are provided until the patient has had a return of gastrointestinal function, at which time the patient can be fed. Patients with severe associated injuries, especially those in a coma, may require prolonged entered tube feedings.
Pain control is important in these patients because it facilitates breathing and helps to prevent pulmonary complications such as atelectasis and pneumonia. Chest physiotherapy and nebulizer treatments are used as necessary and the use of an incentive spirometer is encouraged.
Chest tubes are placed for suction until fluid drainage has fallen sufficiently and the lung is completely expanded without evidence of air leak. Tubes may then be placed to water seal and may be removed if a chest radiograph demonstrates continued lung expansion.
After discharge, patients are monitored to ensure adequate wound healing has occurred and to assess for the development of complications. Patients with vascular injuries and grafts may be monitored to ensure that complications such as pseudo aneurysms do not develop.