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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.
The upper arm has two muscle compartments: the anterior, which includes the biceps, and the posterior, which includes the triceps muscle.
The forearm has two major compartments: the anterior containing the flexor muscles, and the posterior containing the extensor muscles. The mobile wad creates the third compartment.
The upper extremity is perfused by branches from the deep and superficial brachial artery. The proximal brachial artery lies in the groove between the biceps and triceps muscles. Distally, it courses in front of the humerus. At the antecubital fossa, it runs deep to the bicipital aponeurosis and bifurcates into the radial and ulnar arteries, just below the elbow. The artery is surrounded by the two concomitant brachial veins, which run on either side of the artery.
The profunda brachial artery is a large branch arising from the proximal brachial artery distal to the teres major muscle and follows the radial nerve closely. It provides collateral circulation to the lower arm.
The basilic vein courses in the subcutaneous tissue in the medial aspect of the lower arm. At the midpoint, it penetrates the fascia to join one of the brachial veins.
The cephalic vein is entirely in the subcutaneous tissues, courses in the deltopectoral groove, and empties into the junction of the brachial and axillary veins.
In the upper arm, the median nerve lies in front of the brachial artery. It then crosses over the artery midway down the upper arm, where distally it lies posteromedial to the artery.
The ulnar nerve is behind the artery in the upper half of the arm. Midway down the arm, it pierces the intermuscular septum and courses more posteriorly, away from the artery, behind the medial epicondyle.
The brachial artery lies in the groove between the biceps and triceps muscles. The proximal brachial artery lies medial to the humerus and moves anterior as it progresses distally. At the antecubital fossa, it runs under the aponeurosis of the biceps muscle and typically bifurcates just below the elbow into the radial and ulnar arteries (Figure 37.1).
The brachial artery is surrounded by two concomitant brachial veins, which run on either side of the artery. At the upper part of the arm, their confluence forms the axillary vein.
The profunda brachial artery is a large branch that arises from the proximal third of the brachial artery and communicates with collateral circulation to the lower arm (Figure 37.2). Due to these collaterals, the lower arm may have adequate perfusion despite injury to the distal two thirds of the brachial artery.
The basilic vein courses in the subcutaneous tissue in the medial aspect of the lower arm. At the mid arm, it penetrates the fascia to join one of the brachial veins.
The cephalic vein is entirely in the subcutaneous tissues, courses in the deltopectoral groove, and joins the junction of the brachial and axillary veins.
In the upper arm, the median nerve courses anterolateral to the brachial artery. It then crosses over the artery and lies posteromedial to the brachial artery as they pass under the aponeurosis of the biceps muscle.
In the upper half of the arm, the ulnar nerve lies posterior to the brachial artery. In the mid arm, the nerve pierces the intermuscular septum and courses posteriorly away from the artery, behind the medial epicondyle.
Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.
Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.
This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).
Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.
In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.
KaramanosE, TalvingP, SkiadaD, OsbyM, InabaK, LamL, AlbuzO, DemetriadesD. Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis. Prehosp Disaster Med. 2013;28(6):1-5.
Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated.
This is a retrospective, descriptive study on consecutive, hypotensivetrauma patients (systolic blood pressure ≤90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001–2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model.
In 102 (71 male) adult patients (age ≥15 years) recruited, the median age was 35.5 years (range: 27–55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16–50). The on-scene time interval was 19 minutes (range: 12–24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0–20; 21–40; 41–75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21–40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis.
The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS >20 in the exact multiple regression analysis.
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