Is trauma easier than medical?

[Akulahawk]

Just about any road traffic collision these days. The idea of MOI as being predictive arose in the 60s and 70s, when the white paper on trauma was put together. I guess it may have been considered predictive at that stage because you would have repeatable patterns of injuries seen in motor vehicle collisions as heads hit windscreens, chests hit steering wheels, knees hit dashboards and so on.

With advances in design and engineering in vehicles now those same rules do not apply. They don't even apply to pedestrian impacts as vehicle manufacturers work on minimizing injuries to pedestrians as well.
MOI is not prognostic in any way, the only thing it is good for is to alert you to the potential for there to be injuries.



I suspect Vene's point is that we see and understand so little of the process of managing trauma in the ambulance. The actual management of trauma, as opposed to just delivering trauma to the hospital, is enormously complex and difficult.

Yes, the old rules of injury patterns and vehicles don't apply... because people are wearing seatbelts more often and interiors of vehicles are much better designed to reduce injury by absorbing energy when impacted. This has the effect of reducing the forces that are applied to the body during a MVC. The same rules of knowing injury patterns still does apply though. If you do not know where and how energy is transferred between objects, the best you can do is guess that the body sustained a significant impact...

Mechanism is very, very poor at predicting presence of actual injury, but it is very good at "showing" where injury is likely to occur. If you get struck in the head by a rock, I'm not going to look at your feet to see if your toes were broken or dislocated by the impact your head sustained. In that regard, I'm probably not going to look any further "south" than C7-T1.

You really don't, and can't, get a good understanding of this kind of stuff in a short merit-badge trauma course.

The human body is a remarkably tough and fragile thing. Apply stress in just the wrong place in the wrong direction, and things can break spectacularly easily... yet apply the same amount of force to the body in a different direction and you'll see no evidence of injury because there is none to be found.

 

[Veneficus]

How they teach "mechanism" is what makes it unreliable. I look to the mechanism to see where injury is most likely to occur

So you are really using index of suspicion?

The ruptured diaphragm guy, was he restrained? How close was he to the steering wheel, if he was the driver?

No idea, my first contact with him was after the x-ray tech called me and asked me why the cxr didn't look right. He went to surgery moments later.

You really can't get a good "feel" for kinematics of trauma a course that lasts but 16 hours total.

Knowing the kinematics and identifying the injury are different things. I can calculate the force transfer of a bullet hitting somebody's body, but it doesn't mean I know what that bullet injured. (they have a tendency to not do logical things once they hit the body)

It is similar for many other injuries as well, body composition, relative health, age, car safety features, etc, all make mechanism a very poor identifier in the general population.

It is also dependant on perception or a second (possibly 3rd) hand account.

From my Sports Med days: Your athlete falls down to the floor after shooting a basketball. He was facing the bench when he caught the ball that was passed to him, turned, and tossed the ball through the hoop. He fell right after he threw the ball.

Ask him what hurts?

 

[Akulahawk]

My responses in red, for some clarity:

So you are really using index of suspicion?

If you want to call it that. A bit more involved than a "gut" feeling about what might have happened. I'm not going to make my trauma decisions based on what I suspect alone. MOI just tells me where to look. Once you learn how to read it, it's not difficult to know where to focus your exam. GSW's tend to be more difficult because the wound track can take some interesting turns if the bullet strikes hard objects... thus if the bullet hasn't exited the body or the exit wound isn't in line with the entry wound, I don't even bother to hazard a guess as to what got damaged.

No idea, my first contact with him was after the x-ray tech called me and asked me why the cxr didn't look right. He went to surgery moments later.

Then you have zero idea about what the guy struck during the collision. I'd be almost willing to bet the guy was the driver, unrestrained, and/or sitting really close to the steering wheel when his car was struck. I would also suspect that he probably didn't have any significant injury to his ankles, feet, or knees (except for PCL), and if he did, most of those would heal without requiring surgical intervention. I would consider him lucky if he didn't injure his liver, spleen, kidneys, or bowel beyond some minor contusion. Given the diaphragm injury needed surgery, I would also figure that any significant injury to those organs could also be addressed during the initial surgery.

Knowing the kinematics and identifying the injury are different things. I can calculate the force transfer of a bullet hitting somebody's body, but it doesn't mean I know what that bullet injured. (they have a tendency to not do logical things once they hit the body)
That's because they can become destablized and bounce off stuff like bones.
It is similar for many other injuries as well, body composition, relative health, age, car safety features, etc, all make mechanism a very poor identifier in the general population.
Mechanism is a poor predictor of actual injury. That's well understood, hopefully. If you start from the viewpoint that all injury has a mechanism that caused it... similar injuries are likely to have similar mechanisms.
It is also dependant on perception or a second (possibly 3rd) hand account.

The problem is that often the people that respond to traumatic incidents are poorly educated as to what to look for and where to look, and therefore have a poor time being able to communicate accurate descriptions of what occurred. It doesn't (or shouldn't) take a genius to diagnose a pelvic fx from an accurate description of findings, as an easy example.

Ask him what hurts?

While that's a start, all he's going to say is "my knee..." When I see that combination of events occur, I know that he's VERY likely to have sustained injury to his ACL, MCL, and medial meniscus... though I've seen isolated ACL injuries with that same mechanism. I'm going to also check his ankle out, but the probability of ankle injury is pretty low. My exam will likely easily determine what will happen next, in terms of his management. It is at that point that the actions that I do can begin to limit the potential for further injury, and thus reduce the time to return him to play.

 

[Akulahawk]

Examples of things in the field that affect care in the ED-OR: over the counter salves and oints and gels that need to be removed; wounds full of clotting agents needing to be removed; dry dressings over abrasions full of foreign objects (road rash) necessitating more-prolonged debridement under sedation; using up the good veins (ante cubes) for simple peripheral uses which the anesthesiologist wanted; not watching distal circulation when any (primarily circumferential) restriction was applied such as bandage, splint, spine board, which can cause ischemic related damage; failure to cover both eyes when you have foreign object or other damage to one which needs the eye to hold still, which can cause exacerbation of the primary injury; lacerating the oropharynx with a OP airway or use of ad hoc or antique airway adjuncts (bite sticks, J tubes, "Choke-Saver" forceps, improper finger sweeps) causing trauma, inhalation, or just failing to work and making it harder to place an advanced airway later (not to mention possible death enroute); hyperinflation of stomach by CPR inflations leading to ineffective subsequent CPR, need to decompress, and potential for aspirational event.
These are all reasonable measures but either under the EMT level, or errors in the course of reasonable measures with potential for misadventure. All affect hospital care.

BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?

The first thing about compartment syndromes is recognizing it... after that, don't make it worse. You want to limit any edema and reduce the metabolic needs of the affected tissues. That will buy time for more definitive management later. If you recognize it early, it's possible to greatly limit the cell damage. Compartment syndrome of the anterior tibialis might be overlooked and can very easily result in a LOT of tissue necrosis... and the precipitating event can be less than what might otherwise considered a minor trauma to the anterior tibia.

 

[Veneficus]

My responses in red, for some clarity:

The reply in the reply really makes it hard to reply

It is not what I want to call something, it is a predefined term, if you use them interchangably, you create confusion.

Mechanism is supposed to alert you to the possibility of an occult injury. That is why they came up with qualifiers like "death in the same compartment, intrusion into the compartment, fall from height X, etc.)

Index of suspicion is what you think could be injured based on what happened. All providers use index for both medical and traumatic pathology.

As for the patient with the rupture, his only complaint was "finding it hard to take a deep breath" he went to surgery where the only thing that required attention was the herniation. I am thinking he was just suseptable for this injury and the MVA triggered the event.

I am willing to bet the ED physician got a report from the medic that brought him in. I doubt it included any urgency based on the story I heard from the patient in my 3 or 4 minute contact with him.

Given the pt was alone in xray for standard trauma films, I would wager there was not a whole lot found on physical exam either.

Just my opinion, but any injury requiring surgery is not lucky.

A list of what might be wrong (index of suspicion) is based on an actual report of injury.

Everytime somebody pivots you don't start taking precautions for occult injury. (which is what mechanism of injury is)

 

[Akulahawk]

Sorry about that.

The reply in the reply really makes it hard to reply

It is not what I want to call something, it is a predefined term, if you use them interchangably, you create confusion.

Mechanism is supposed to alert you to the possibility of an occult injury. That is why they came up with qualifiers like "death in the same compartment, intrusion into the compartment, fall from height X, etc.)

Index of suspicion is what you think could be injured based on what happened. All providers use index for both medical and traumatic pathology.

As for the patient with the rupture, his only complaint was "finding it hard to take a deep breath" he went to surgery where the only thing that required attention was the herniation. I am thinking he was just suseptable for this injury and the MVA triggered the event.

I am willing to bet the ED physician got a report from the medic that brought him in. I doubt it included any urgency based on the story I heard from the patient in my 3 or 4 minute contact with him.

Given the pt was alone in xray for standard trauma films, I would wager there was not a whole lot found on physical exam either.

Just my opinion, but any injury requiring surgery is not lucky.

A list of what might be wrong (index of suspicion) is based on an actual report of injury.

Everytime somebody pivots you don't start taking precautions for occult injury. (which is what mechanism of injury is)

Based on the definition of "index of suspicion" you give, then yes, that's precisely what I do. The diaphragm guy's c/o and mechanism would really have piqued my ear. I'd likely have opted for taking him to a trauma center rather than a local ED. Reviewing our trauma triage protocols, he would likely have been not triaged to a TC outside Paramedic Discretion. Like I indicated earlier, I'd almost be willing to bet that he was the driver, probably unrestrained, sitting really close to the wheel, or both.

As to the pivot mechanism, lots of people do it w/o injury all the time - except when they plant their feet in one direction and forget to pivot on the ball of the foot when the pivot around to another direction and then extend the knee forcibly. That torques the MCL, ACL, and pinches the medial meniscus into an injury. The ACL gets a 3rd degree sprain, MCL gets a high-degree (2+ or 3) sprain, and the meniscus gets a (usually) significant tear. One of the key descriptors I gave was that the athlete collapses/falls to the floor immediately after plant, turn, shoot... I might even catch seeing the feet facing the "wrong" direction.

That's a problem with high jumpers too, using the back-flip technique (Fosbury Flop) they use to jump over the bar. Before that was invented, knee injuries that torqued the ACL out of existence didn't happen because the athletes jumped pretty much straight over or did a kind of "hurdle" to jump over.

Discus throwers can also do that, but they usually have their feet moving along with them, so they rarely plant and twist.

My favorite tests when I see that are Lachman's and Pivot-Shift.

 

[Shishkabob]

Is it easier? Yes.

Is it any less complicated? No way.




Let that sink in for a bit.

 

[Veneficus]

The diaphragm guy's c/o and mechanism would really have piqued my ear. I'd likely have opted for taking him to a trauma center rather than a local ED. Reviewing our trauma triage protocols, he would likely have been not triaged to a TC outside Paramedic Discretion. Like I indicated earlier, I'd almost be willing to bet that he was the driver, probably unrestrained, sitting really close to the wheel, or both. .

Don't know much more than I told you.

The patient was at the trauma center, I would guess simply because it was the closest hospital at the time.

My part in the story was simply answering the xray tech's question that the xray was not normal, asking the guy a few questions, and then summoning the surgeon who ordered the xrays.

I was a bit surprised by the description myself and hung around for the CT scan, waved good-bye on his way to surgery, and asked about the operation later.

 

[mycrofft]

"Mechanism is supposed to alert you to the possibility of an occult injury."

I was going to put it as "Hmm, THIS happened, why don't we see THAT in the pt?".

Akula, thanks for the compartment syndrome comeback. That whole scene deserves its own advanced thread.
But the baseline (for the masses) is avoid circumferential constrictions/injuries, watch distal circs, listen to complaints, and get them in with a good HX and exam as done during a prudently long on-scene period, right?
A diagram of potential compartments would be a good one, like dermatomes, because some compartments don't need a circumferential insult, just a well-aimed one, right? (Never saw a well-aimed myself, yet).

 

[Akulahawk]

"Mechanism is supposed to alert you to the possibility of an occult injury."

I was going to put it as "Hmm, THIS happened, why don't we see THAT in the pt?".

Akula, thanks for the compartment syndrome comeback. That whole scene deserves its own advanced thread.
But the baseline (for the masses) is avoid circumferential constrictions/injuries, watch distal circs, listen to complaints, and get them in with a good HX and exam as done during a prudently long on-scene period, right?
A diagram of potential compartments would be a good one, like dermatomes, because some compartments don't need a circumferential insult, just a well-aimed one, right? (Never saw a well-aimed myself, yet).

Somewhat correct. An insult to the right area can precipitate compartment syndrome. That insult can be circumferential or specifically at the compartment. For example, the anterior tibialis is really at risk because medially, it has the tibia, laterally, it has the fibula, deep is the fascia between tib and fib, all preventing tissue expansion. Superficially, you have skin and that can only stretch so much.

The anterior tibialis, the muscle bundles just deep to the soleus and right next to the tib-fib on the posterior side, and the deeper muscles in the forearm are probably the most vulnerable to developing compartment syndrome quickly. The brain is probably the most sensitive to compartment syndrome... we just don't call it that. Any place where tissue has a limited ability to expand to accommodate swelling, there's a risk of compartment there, and it's worse if it limits innervation or perfusion to that same area and/or areas distal to that compartment.

Fasciotomy is the emergent tx of compartment syndrome when the anterior tibialis is involved. That "releases" the compartment and allows the muscle to expand deep while keeping intracompartment pressures low enough to prevent further tissue damage. They may even keep the incision open to further allow "anterior" expansion too.

 

[firetender]

Can you give me an example of a case with substantial MOI and no injury?

In 1978 I hit a VW bug with my motorcycle at about 60 MPH. He ran a stop sign coming on to a mountain road. On impact, me and the bike went airborne, separated, flew parallel paths for 75 feet, hit the tarmac, bounced, flew another 25 feet, the bike landed and stopped, I bounced on my (helmeted) head and skid another 16 feet before stopping. P.D. details and narrative by a Jehovah's Witness, so probably accurate. Ambulance ride to the hospital, head-to-toe X-Rays, discharged to home then, about 2 hours later my left foot swole up with a sprain!

Does that count?

 

[Akulahawk]

In 1978 I hit a VW bug with my motorcycle at about 60 MPH. He ran a stop sign coming on to a mountain road. On impact, me and the bike went airborne, separated, flew parallel paths for 75 feet, hit the tarmac, bounced, flew another 25 feet, the bike landed and stopped, I bounced on my (helmeted) head and skid another 16 feet before stopping. P.D. details and narrative by a Jehovah's Witness, so probably accurate. Ambulance ride to the hospital, head-to-toe X-Rays, discharged to home then, about 2 hours later my left foot swole up with a sprain!

Does that count?

This would pique my interest, have me searching for signs of actual injury, and if I'm not finding anything substantial, I'll just give you a nice, slow, ride... yes, you'd be going to a TC, but I'm not going to fly you there. I would hazard a guess that you didn't have much of a vertical component to your "flight" and thus didn't hit the ground all that hard. Motorcycle racers frequently get that same kind of mechanism... and rarely get badly injured. I'd expect that you likely didn't encounter any curbs or big bumps while skipping along the ground.

 

[mycrofft]

Anterior leg, got it. Like what hits the underside of the dashboard on a frontal collision MVA.

I remember long ago the forum had a go at closed head injury as a compartmentalization. I think the term ought to be called "fascial compartmentalization syndrome" as it is currently used.

I've tended quite a few post-fasciotomy patients during healing by secondary intention or mesh grafts.


Tender, lateral impact (rolling and sliding) beats slamming anytime. Ask Jackie Chan. And I noticed decades ago that patients in rollover accents, if they were lucky, seemed to do better than patients with similar speeds and forces but their car slid and hit a curb or a tree to stop. Lucky you did as well as you did. I don't think there is a compartment for an ankle sprain to occupy, but I could definitely be wrong.

 

[zmedic]

Anterior leg, got it. Like what hits the underside of the dashboard on a frontal collision MVA.
.

There are multiple compartments of the leg, you can get compartment syndrome in any of them from an increase in pressure. Not just the anterior compartment.

 

[mycrofft]

Going further afield...

Lots of lateral cross sections available for compartments, but I meant a colored-in zone indicator. Sort of like this:

Since they are sometimes laterally overlaid maybe the color scheme would be prohibitive? (Then show them in 3D, right? I'm so 2-D).

 

[Veneficus]

Since they are sometimes laterally overlaid maybe the color scheme would be prohibitive? (Then show them in 3D, right? I'm so 2-D).

Just spend a few hours in a cadaver lab or a couple of years with your 7 favorite anatomy texts and you'll get the idea.

 

[mycrofft]

I have the idea, just thinking off-thread about how to more-efficiently teach it quickly.
Sometimes it takes a while I guess.
Anyway, on thread, trauma is medical is surgical.

 

[Veneficus]

I have the idea, just thinking off-thread about how to more-efficiently teach it quickly.
Sometimes it takes a while I guess.
Anyway, on thread, trauma is medical is surgical.

It is like fine drinks.

Sure you could make some spirits in a few hours, but the really good stuff takes a few years. (Usually at least 10)

 

[paramagician]

Trauma is way easier for me.. very cut and dry.

 

[Veneficus]

Trauma is way easier for me.. very cut and dry.

Awesome.

Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?

It has been a thorn in my side for some time.

Edit: and while we are at it, prevent the ill effects of systemic immune response while still maintaining immunocompetency to prevent sepsis from infiltration of bacteria from the GI to the abd cavity?

Strict glycemic control while balancing the needs of anabolic metabolism?

Osmotic fluid balance without over hydration?