Body armor/ bullet resistant vests used by law enforcement are designed to stop penetration by handgun rounds. These rounds have less velocity than rifle rounds. When caring for someone who has been shot while wearing body armor, verify no penetration has occurred and then look for blunt injuries such as rib fractures, liver injuries, pneumothorax, cardiac contusion, vertebral injury, etc. Behind Armor Blunt Trauma (BABT) is the technical term for injuries caused by the transfer of kinetic energy that occurs when these vests are struck.
This narrative review of the trauma literature looking at chronic pain after trauma found:
This German retrospective review of 1500 level one trauma center patients (ICU level or ISS over 9) found obesity was an independent predictor of ARDS, multisystem organ failure, and sepsis but not pneumonia or mortality.
This systematic literature review looking at gender differences in trauma care reveals:
In this retrospective cohort study looking at splenic injury management and outcomes in the UK, patients over age 65 had much higher mortality and were more often managed conservatively (vs splenectomy or embolization) despite having a lower splenic injury grade and lower overall injury severity score compared to those under 65. Many factors are possible here including frailty, reluctance to intervene in older patients, and lower mechanism of injury bias away from evaluation and management.
Looking at trauma patients evaluated at a major trauma center before and after EMS switched from semi-rigid to soft cervical collars for immobilization found no difference in adverse outcomes. Add this to the mounting evidence that our current practice of spinal immobilization may not offer any benefit.
Bradycardia accompanying hypotension can be found in spinal cord injury (loss of autonomic reflex), beta blocker and calcium channel blocker overdose, intrinsic cardiac electrophysiologic derangement, and, often forgotten, intrabdominal hemorrhage. In the appropriate setting (blunt trauma, ruptured ectopic pregnancy), bradycardic hypotensive patients should be considered the same as tachycardic hypotensive patients and get a work up and treatment focused on Hemoperitoneum.
Looking at a national database, this study concluded the use of low titer O whole blood during trauma resuscitations was increasing at level one centers but not at level 2 and 3 centers. Is this a representation of the national blood supply as whole blood is harder to stock? We need to understand this trend to assure equal and appropriate care to trauma patients across the country.
Another study, this one from New Zealand, showing older trauma patients with similar injury severity score had less trauma team activations and higher mortality.
When compared to saline(!) trauma patients with a high injury severity score who received ketamine via pca for pain control had better quality of life indicators at 1,3, and 6 months post injury.
In a single level 1 trauma center there were 274 patients age over 55 evaluated for falls in a one year retrospective period. Their blood toxicology was reviewed for presence of alcohol, opioids, benzodiazepines and cannabinoids. The authors found:
“detection rates were 21.2% for opioids, 18.6% for ethanol, 13.9% for benzodiazepines, and 9.1% for cannabinoids. Injuries identified included 16.4% spinal fractures, 9.5% extremity fractures, 7.7% hip/thigh/pelvic fractures…In this study, nearly 20% of adults 55+ presenting for fall-related trauma recently used substances that impair psychomotor function.”
An area for injury prevention research and intervention would be to screen patients over age 55 for substance use, consider prescribing patterns in this age group (benzodiazepines) , and discuss with patients fall risk avoidance.
A case report on use of the abdominal aortic and junctional tourniquet in a 27 year old female with hemorrhagic shock secondary to a pelvic fracture after a 10 meter fall demonstrated improved blood pressure and stabilized vasopressor use prior to operative intervention. This device has been used in battlefield situations, however very few reports of civilian use exist. Much more data is needed, however, it is a device to be aware of for future use.
In a metanalysis of studies looking at intercranial hemorrhage in fall patients older than 65 years, the following were unadjusted odds ratio risk factors for finding an ICH in this patient population:
suspected open or depressed skull fracture , signs of basal skull fracture ), reduced baseline Glasgow Coma Scale score , focal neurologic signs , seizure , vomiting , amnesia , loss of consciousness , headache ), external sign of head trauma , male sex , chronic kidney disease , preinjury single antiplatelet , and dual antiplatelet medication .
Preinjury anticoagulant was not a significant risk factor.
When looking at adjusted odds rations only focal neurologic signs , external sign of head trauma , loss of consciousness , and male sex were found to be associated with intercranial hemorrhage.
An English study describes 30 patients that jumped from a single bridge of 30 meters (98 feet) over the course of 12 years. Twenty six landed in the water. The injury pattern for those landing in water was described as “Hypothermia was the most common presentation (n = 23), followed by pneumothoraces (n = 14), rib fractures (n = 10), thoracic vertebral fractures (n = 9) and lung contusions (n = 8). Lower water temperatures at the time of the incident (p = 0.008) and lower patient body temperatures on arrival to hospital (p = 0.002) were significantly associated with increased 30-day mortality.”
The small group landing on land had more pelvic and extremity fractures than the water group and none had hypothermia.
Remember to start aggressive rewarming in patients who fall into water!
This small study from South Africa shows stab wounds to the chest with a pneumothorax less than 0.5 cm that were managed conservatively had completely resolved on 12 hour repeat chest X-ray. This could facilitate earlier discharge of these patients. It also supports conservative (non-tube placement) approach to asymptomatic small pneumothoraces from stab wounds.
A reminder from a recent position paper on pelvic trauma that we should not be doing stability testing to evaluate pelvic trauma
“EMS clinicians should recognize the challenges in accurately identifying pelvic fractures by physical exam alone. Manual stability testing of the pelvis is neither sensitive nor specific and may cause harm.”
Much has been written about the benefits of prehospital blood transfusion for traumatic hemorrhage. Can this success be ascribed to non-traumatic hemorrhage as well? This small study (50 patients over 10 years!) says there were improvements in patient physiology (shock index) for those patients receiving blood for GI bleed, etc. Much more research is needed however this could be a beneficial practice in the future.
This systematic review found improved pain scale at 15 and 120 minutes in 495 patients who received nebulized ketamine. Dosing at 0.75 mg/kg was as effective as 1.5 mg/kg and the nebulized ketamine was non-inferior to IV morphine and ketamine with fewer side effects.
Previous small studies had put the prevalence of hypocalcemia in trauma patients at 23-56%. This single center study of 2200 patients looked at prevalence and outcome and found a much lower prevalence however worse outcomes than those who were not hypocalcemic.
This study demonstrated that administration of prehospital blood to trauma patients lead to a higher rate of survival in patients whose initial ED vital signs or pre-hospital shock index would have predicted death.
