PARA107 Summary Page 1-3: Injury, Mechanisms of Injury, Time Critical Guidelines Page 4-6: Musculoskeletal Injuries Page 7-10: Spinal Injuries & Neurogenic Shock Page 11-13: Types of Shock & Hypovolaemia Page 14-17: Head & Facial Injuries Page 18-21: Thoracic Injuries Page 22-25: Abdominal Injuries Page 26-28: Pelvic Injuries Page 29-33: Blast Injuries, Ballistics, & Burns Page 34-36: Environmental & Exposure Injuries Page 37-38: Assessments & Drug Calculations

EPIDEMIOLOGY OF TRAUMA & TRAUMA SYSTEMS IN AUSTRALIA

INJURY/TRAUMA: “The physical damage that results when a human body is suddenly or briefly subjected to intolerable levels of energy”. Injury occurs when an external source of energy (kinetic, chemical, electrical, thermal, radiation) dissipates more rapidly than the body’s ability to tolerate it, and is a leading cause of mortality and morbidity in Australia.

• In 2010, injury was estimated to account for 6.5% of the total burden of disease in Australia.• The 4 most prevalent causes of injury death in Australia are: suicide, transport accidents, falls, and assault.• Primary causes are drowning (childhood), self-harm and road crashes (adulthood), and falls (elderly).

MECHANISM OF INJURY (MOI): MOI is the circumstance in which an injury occurs, and is important for determining the types and patterns of injury that occur in trauma patients. Patterns of injury (POI) are the types of injuries that result from the MOI such as broken bones, dislocations, internal bleeding, etc. Types of trauma include:

• Blunt Trauma: Forms of blunt trauma include acceleration (when moving object strikes stationary/slower moving body), deceleration (when moving body hits a solid/slower moving object), compression (squeezing inward pressure applied to tissues), shearing (forces that cause organs to pull away or fold around muscles/ligaments - internal bleed), & direct forces.

• Falls: Are a significant cause of injury in Australia, and 90% of unintentional falls result in death occurs in persons aged greater than 70. MOI is vertical deceleration. Severity and type of injury is often associated with height, impact & surface.

• Motor Vehicle Collision: There are three phases to motor vehicle collisions. The first phase is the vehicle impacting with another object. The second phase is deceleration of occupant resulting in compression or shearing trauma. The third phase is internal structures continuing to move until they are restrained by another internal structure (shearing forces).

• Penetrating Trauma: Injuries that are caused by a foreign object penetrating or entering the body, creating energy that dissipates into surroundings tissues. The extent of the damage is dependent on object used, amount of force, distance from victim to the weapon, and the type of tissue penetrated. Injuries can be low (stab wounds), or high-velocity (gunshot wounds).

• Blast Injuries: Primary injuries are those associated with effects of the pressure waves. Secondary injuries involve projection of the fragments and nearby debris in air. Tertiary injuries result from person being displaced either onto ground or objects. Blast injuries can cause avulsions, amputations, fractures, penetrating & crush injuries, & burns.

• Inhalation Injuries: Types of inhalation includes carbon monoxide poisoning, upper/lower airway injury, & chemical damage. These injuries contribute significantly to early mortality following burn trauma.

VICTORIAN STATE TRAUMA SYSTEM (VSTS): VSTS facilitates the management and treatment of major trauma patients in Victoria, and aims to reduce preventable death/permanent disability, and improve patient outcomes by having “the right patient delivered to the right hospital in the shortest time”. VSTS was established in 2000 in response to the RoTES report.

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PNEUMOTHORACES: Occurs when pleural space fills with air (pneumothorax), blood (haemothorax), or both (haemopneumothorax).

• Classified as primary (absence of traumatic chest injury or underlying lung conditions), or secondary (underlying lung condition).• Signs & Symptoms of tension pneumothorax can be remembered by the mnemonic ‘CRAPPIST’ which consists of the following:

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ABDOMINAL INJURIES

ABDOMINAL INJURIES: These are commonly overlooked, especially in the presence of multi trauma, and actually make up 10% of trauma deaths. Approximately 70-90% of abdominal injuries are caused by blunt trauma such as motor vehicle accidents, falls, and assaults. Other common causes include penetrating injuries, usually stab and gunshot wounds. The abdomen is relatively unprotected and trauma may involve bone structures, organs or, major vessels (hepatic vein, aorta, vena cava, iliac artery). Abdominal injuries are associated with velocity > 20km/h, aged 75+, & presence of significant injuries.

ABDOMINAL QUADRANTS: The abdomen is made up of 4 quadrants making it easier to identify which organs are involved:

ABDOMINAL REGIONS: Along with the quadrants, there are also 9 regions which can be used to identify organs:

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ABDOMINAL CAVITY & TRAUMA: The abdominal cavity is divided into three sections: Peritoneal (contains majority of abdominal organs), Retroperitoneal (posterior to peritoneum and contains kidneys, major vessels and female reproductive organs), and Extra Peritoneal (contains the bladder). Organs are classified as:

• Solid Organs: These fracture/haemorrhage when injured. Include the spleen, liver, kidney, and pancreas.• Hollow Organs: These collapse/rupture when injured. Include stomach, intestines, gallbladder, and urinary bladder.

SPLEEN INJURIES: The spleen is the most frequently injured organ by blunt trauma. It is a solid organ situated in the LUQ and is generally injured due to left sided thoracic trauma. Blood flow to the spleen is 250ml per minute.

• Injuries range from small haematoma to hillier devascularisation or shattered spleen.• Rarely fatal if good medical care is provided and may not be detected if associated with sever chest or neurological injuries.• S&S include evidence/history, pain (especially on palpation), nausea/vomiting, bruising/redness, and poor perfusion.• Kehr’s Sign: Left shoulder tip pain indicates the presence of blood/irritants in peritoneal cavity (due to ruptured spleen).

LIVER INJURIES: The liver is the second most frequently injured organ due to blunt trauma. It is a solid organ situated in the RUQ and is generally injured due to right sided thoracic trauma. Blood flow to the liver is 1400ml per minute.

• Injuries range from small haematomas to major parenchymal disruption and laceration of the hepatic veins/hepatic avulsion.• Common injury is a ‘bears claw’ laceration caused by damage to ribs which lacerate the hepatic parenchyma.• S&S include evidence/history, pain (especially on palpation), nausea/vomiting, bruising/redness, swelling, & poor perfusion.

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KIDNEY INJURIES: The kidneys are a solid organ situated in the RUQ and LUQ. These injuries generally result from force to the flank or posterior impact, or laceration (penetrating injury from external or internal object such as ribs/vertebrae).

• Highly vascular (12% of cardiac output/minute) & has large perirenal space to accommodate haemorrhage (tamponade).• S&S include evidence/history, pain (back, ribs, flank), haematuria, bruising/redness, and poor perfusion.• G1 (haematoma), G2 (<1cm laceration), G3 (>1cm laceration), G4 (laceration into collecting system), G5 (shattered)

STOMACH & SMALL INTESTINE INJURIES: These are hollow organs and are highly vascular. The location gives some protection from injury and contains neutral pH and bacteria, and this site is rarely injured.

• Blunt injury may cause perforation or devascularisation of stomach, duodenum, and small intestine. • Penetrating injury creates greater risk of serious injury (evisceration and can have potential complications).• S&S include evidence/history, pain, PR (rectal) bleed, haematemesis (vomiting blood), bruising/redness, and poor perfusion.

LARGE INTESTINE INJURIES: This is a hollow organ and there is an increased risk of death associated with flora entering the peritoneum. Possible evisceration (removal of internal organs) can occur if abdominal wall breached.

• Injury can be caused by shearing forces as a result of rapid deceleration, and has significant complications.• S&S include pain, PR (rectal) bleed, bruising/redness, increased temperature, and poor perfusion.

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