Background

The focused assessment with sonography in trauma (FAST) is an important bedside examination used primarily by emergency physicians and trauma surgeons to identify free intraperitoneal, intrathoracic, or pericardial fluid. Physicians in Europe and Japan have been using bedside ultrasound (US) in the routine evaluation of trauma patients for over 30 years. The FAST exam has gained wide acceptance in the United States in the past decade. No other imaging modality has the ability to diagnose critical traumatic conditions as quickly or as accurately as bedside US. Ultrasonographic techniques are noninvasive, do not expose patients to radiation, and are performed with relatively inexpensive portable equipment. In the initial assessment of trauma patients, abdominal US is now replacing diagnostic peritoneal lavage (DPL), and echocardiography has replaced invasive subxiphoid pericardiotomy. With increasing numbers of emergency medicine residency programs incorporating formal US training into their curriculum, its role in emergency medicine practice is being further solidified.

Equipment

Essential components of US equipment are accessibility, portability, reliability and ease of use. Most trauma centers now have portable machines on site ready to be wheeled to the bedside at a moments notice. While most machines come with a variety of transducers, the most commonly-used transducer for the FAST examination is a 3.5MHz microconvex transducer. The main advantage of the microconvex transducer is that the footprint can easily fit between the ribs when evaluating the upper quadrants and the heart.

Introduction

One of the most devastating consequences of trauma is spinal cord injury. In the United States, approximately 10,000 spinal cord injuries yearly result in permanent disability. Although spinal fractures can occur in any age group, the peak incidence is in males from ages 18 to 25. Certain conditions predispose to spinal fracture or dislocation: old age, rheumatoid arthritis, osteoporosis, Down's syndrome, and spinal stenosis. Even relatively minor mechanisms can result in spinal fracture in these groups. Forces that injure the spinal column include flexion, extension, axial loading, shear force, and rotational acceleration.

Clinical Examination

All multiple trauma victims must undergo evaluation for possible spinal column fracture, dislocation, or spinal cord injury. Blunt trauma patients should have the spine immobilized at first medical contact and remain in spinal immobilization until the integrity of the cord and spinal column can be verified. In patients with multiple severe injuries, this verification can be deferred until more critical injuries have been addressed, provided that immobilization of the spine is maintained.

Patients with spinal fractures experience pain, and examination will reveal tenderness. However, patients who are unable to report pain because of concomitant head injury or intoxication may harbor occult spinal injuries and should remain immobilized until they can be accurately evaluated. Patients with spinal cord injury manifest symptoms according to the spinal cord level affected. With complete cord transection, all motor and sensory function below the level of the lesion is lost. The highest intact sensory level should be marked on the patient to determine whether the cord lesion is progressing proximally on subsequent examinations.

Good trauma care requires a substantial knowledge base and clinical skill. The comprehension and intuition required to treat trauma injury is gained over many years of clinical experience at the bedside of critically injured patients. The aim of this atlas is to share the experience of the authors from the largest trauma center in the United States and provide a solid companion to the many well-written textbooks on trauma management.

This project represents many decades of collective clinical experience. We have assembled one of the largest collections of trauma images to help bring the reader “to the bedside” of the patients. The majority of the photographs originate from the Los Angeles County-University of Southern California Trauma Center though some special photographs were donated from outside centers. The acquisition and final assembly of this collection of images was a difficult process and they were acquired with the gracious cooperation of our patients. We regularly use these images in our clinical teaching and hope this atlas will supplement other instructional resources in trauma management.

Introduction

Soft tissue injuries of the face are common in modern society. The majority of serious injuries occur in the context of vehicular trauma or assaults. Use of seatbelts and airbags has decreased the frequency but not eliminated facial trauma produced by motor vehicle accidents. In addition to direct impact of the face against the windshield, steering wheel, or dashboard, broken glass fragments frequently produce lacerations and eye injuries.

The lower face and neck contain structures that define and maintain the patency of the airway. Consequently, facial injuries at times assume the highest priority in trauma management until airway patency and adequate ventilation can be established. Because facial tissues are highly vascularized, massive bleeding into the oral cavity can occlude the airway, especially when patients are obtunded from head injury or intoxication. In the presence of massive bleeding, airway compromise may be produced by placing the patient supine for spinal immobilization. Blood, secretions, fragments of teeth, and foreign bodies must be removed to avoid aspiration and airway occlusion. Although severe facial injuries are dramatic and often distract the inexperienced clinician from more critical tasks, treatment of most facial injuries can be safely deferred until lifethreatening problems have been addressed.

The face and scalp also contain many structures that are essential for the function of special senses of sight, smell, taste, and hearing. Human communication is dependent not only on facial structures required for speech and hearing but also those involved in facial expression. In addition, many facial landmarks define human appearance, and their preservation as intact symmetrical structures is important cosmetically and psychologically.

Introduction

Neck injuries, especially penetrating ones, are considered difficult to evaluate and manage because of the dense concentration of so many vital structures in a small anatomical area and the difficult surgical access to many of these structures. However, very few patients with blunt trauma and only 15–20% of cases with penetrating trauma require operative treatment. The combination of a meticulous clinical examination and appropriate investigations can safely identify those patients requiring operative treatment. Advanced trauma life support (ATLS) principles should always be followed.

During the primary survey, the following life-threatening conditions in the neck should be identified and treated:

1. Airway obstruction due to laryngotracheal trauma or compression by external hematoma

2. Tension pneumothorax

3. Severe active bleeding, externally or in the thoracic cavity

4. Spinal cord injury or ischemic brain damage due to carotid artery occlusion

During the secondary survey, the following neck pathologies should be identified and managed:

1. Occult vascular injuries

2. Occult laryngotracheal injuries

3. Occult pharyngoesophageal injuries

4. Cranial or peripheral nerve injuries

5. Small hemopneumothoraces

Clinical Examination

Clinical examination according to a carefully written protocol is the cornerstone of the diagnosis and management. The examination should be systematic and evaluate the vessels, the aerodigestive tract, the spinal cord, the nerves, and the lungs:

1. Vascular structures: “Hard” signs and symptoms highly diagnostic of vascular trauma include active bleeding, shock not explained by other injuries, expanding or pulsatile hematoma, absent or significantly diminished peripheral pulses, and a bruit. “Soft” signs and symptoms suggestive but not diagnostic of vascular trauma include mild shock, moderate hematoma, and slow bleeding. This group of patients requires further investigation.

2. […]

Introduction

Chest trauma is estimated to be the primary cause of death in 25% of traumatic mortalities and a contributing factor in another 25% of deaths. Good understanding of the pathophysiology of chest trauma and timely selection of the appropriate investigations and treatment are all critical components for optimal outcome.

Clinical Examination

Advanced trauma life support (ATLS) principles are particularly important in the initial evaluation and management of the chest trauma patient.

During the primary survey, there are six lifethreatening conditions that need to be identified and treated:

1. Airway obstruction

2. Tension pneumothorax

3. Open pneumothorax with a “sucking wound”

4. Flail chest

5. Massive hemothorax

6. Cardiac tamponade

During the secondary survey, there are another six potentially lethal chest injuries that should be identified and treated. The diagnosis of these conditions may need more complex and time-consuming investigations.

1. Lung contusion

2. Myocardial contusion

3. Aortic rupture

4. Diaphragmatic rupture

5. Tracheobronchial rupture

6. Esophageal injury

Investigations

History and clinical examination will determine the type and timing of investigations necessary for the safe and efficient evaluation of the chest trauma patient. Very often, in unstable patients, therapeutic interventions such as thoracostomy tube insertion or thoracotomy may be initiated without any investigations.

Blunt Abdominal Trauma

Introduction

Traffic accidents, followed by falls, are by far the most common causes of severe blunt abdominal trauma. Solid organs, usually the spleen and liver, are the most commonly injured organs. Hollow viscus perforations are fairly uncommon, and they are usually associated with seatbelts or high-speed deceleration.

There are five main mechanisms of injury with blunt trauma:

1. Direct crushing of organs between the anterior and posterior abdominal walls.

2. Avulsion injuries from deceleration forces, as in high-speed accidents or falls from heights.

3. Transient formation of closed bowel loop with high intraluminal pressure and rupture of the hollow viscus.

4. Lacerations by bony fragments (e.g., pelvis, lower ribs).

5. Sudden and massive elevation of the intraabdominal pressure (usually seatbelted individuals involved in high-speed accidents) may cause diaphragmatic or even cardiac rupture.

Clinical Examination

The clinical evaluation of blunt abdominal trauma is often complicated by associated soft tissue contusion, fractures of the lower ribs or pelvis, head injuries with depressed level of consciousness, and spinal injuries. These conditions make clinical examination difficult and unreliable, and significant hollow viscus injuries may be missed with potentially lethal consequences. Most preventable deaths due to trauma are the result of delayed diagnosis of intra-abdominal injuries. Despite its limitations, physical examination remains the cornerstone of abdominal evaluation. Of particular importance is the “seatbelt sign” on the abdominal wall. Its presence is associated with a high incidence (about 20%) of significant intra-abdominal injuries.

Introduction

Head injury accounts for the majority of deaths and severe disabilities due to trauma, and complicates the management of injury to other systems. Blunt head injury is most commonly the result of motor vehicle crashes, auto versus pedestrian collisions, or falls from significant heights. Gunshot wounds cause the vast majority of penetrating head injuries, although stab wounds and impalement injuries may also be seen.

Clinical Examination

Head injury is classified into mild, moderate, and severe categories, depending on the patient's Glasgow Coma Scale (GCS) (see Table 1.1) at the time of presentation. Mild head injury patients have a GCS of 14–15. Typically these injuries include concussion or transient loss of neurologic function, usually a transient loss of consciousness. Concussion does not result in any gross pathologic abnormalities of the brain, but subtle changes have been described using electron microscopy. Although the neurologic examination is usually normal in terms of quantifiable deficits, post-concussive neuropsychiatric symptoms are very common. These include amnesia for the event, headache, loss of concentration, dizziness, sleep disturbance, and a host of related symptoms. These symptoms resolve within two weeks for the vast majority of patients but may persist for many months in a small percentage. “Hard” neurologic findings such as diplopia, motor weakness, pupillary abnormalities, and other cranial nerve deficits are never due to post-concussive syndrome and demand further investigation.

Moderate head injury (GCS 8–14) and severe head injury (GCS <8) comprise a spectrum of injuries including cerebral contusion, diffuse cerebral edema, axonal shear injury, subarachnoid hemorrhage (SAH), and extra-axial lesions (subdural hematoma and epidural hematoma). The GCS is determined by the severity of the lesion and its time course.

Introduction

Orthopedic injuries are found in approximately 85% of blunt trauma victims, and thus expert knowledge in their emergency care is necessary. Many injuries are also acutely life-threatening or limb-threatening and thus need to be evaluated and treated in an expedited fashion. Despite the importance of early treatment, the standard primary survey evaluation with the ABCDE approach is necessary to detect other injuries with a greater priority. During the primary survey, the only attention to musculoskeletal injury is acute hemorrhage control with direct pressure.

Clinical Examination

The physical exam is an integral component of detecting acute orthopedic injuries. The overlying skin should be examined for contusions and lacerations. Lacerations need a more detailed evaluation for neurovascular injury, tendon injury, foreign bodies, and proximity to fracture sites. Cool, pale skin may indicate acute vascular insufficiency. Capillary refill and peripheral pulses should be checked and compared with the unaffected limb. In some cases Doppler ultrasound may be required to detect poor pulses. The compartments should be palpated for firmness that may indicate an acute compartment syndrome. General range of motion and areas of tenderness help guide necessary radiographs. Careful peripheral nerve exam is also important, as nerve injury may be part of the injury complex. Some injuries may not present with any fracture, but ligamentous injury is important to detect.

Introduction

The skin, being the largest organ and exposed, is very susceptible to injury, ranging from contusions to deep extensive burns. Furthermore, deeper soft tissue injury can lead to extensive blood loss, tendon injury, neurovascular trauma, and acute compartment syndrome. More than 1.25 million burns are evaluated in emergency departments across the United States annually, and these burns account for about 12,000 deaths each year. Burn injuries to the skin can be cosmetically and functionally devastating, and they account for many years of productive lives lost.

Acute burn evaluation requires special expertise and knowledge, given the unique complications these injuries can have. Careful history is important. Patients involved in closed-space fires with poor ventilation are at especially high risk for inhalational injury and carbon monoxide poisoning. The clinician needs to consider associated blunt trauma injury that may be related to a fall or an attempt to escape the flames. Suicide attempt victims may also have ingested poisons, and thus a coexistent toxicological emergency must be considered.

Clinical Examination

The standard primary survey with ABCDE evaluation is paramount. During this survey, careful attention to facial burns and possible inhalational injury is necessary, as these patients may require immediate airway control. Impaired lung ventilation may be detected by the presence of chest burn eschar or bronchospasm. Signs of shock secondary to third-space fluid loss and/or blood loss from another associated injury may be noted. A brief neurological examination is important to determine the possibility of head or spinal injury, and during the exposure evaluation all clothing should be removed to evaluate the extent of skin and soft tissue injury.