Category Archives: General

Trauma Is The Leading Cause of Death …

We read this phrase all the time, in the newspapers and in many journal articles relating to trauma. Where do they get this? Well, it comes from mortality statistics compiled by the Center for Disease Control.

Trauma IS the leading cause of death in ages 1-44. In infants, congenital defects cause the most deaths and trauma is only #4. At age 45 and above, it begins to drop off, but stays in the top 5 until age 65 when it drops to #9. Overall, trauma is the #5 killer for all age groups combined.

This image shows the top 5 causes of death across all age groups. The blue boxes are unintentional trauma, the red boxes are homicide, and the green boxes are suicide.

One fact that tends to surprise people is that suicide is such a common cause of death. Suicides are not typically reported in the news, so most people are unaware unless it involves their family or friends.

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Cervical Spine Clearance and Altered Mental Status

Clearance of the cervical spine is a complicated topic, with many opinions and anecdotes. EAST developed a set of practice guidelines in 1998 and updated them in 2000 and again in 2008. They are well-accepted and very helpful.

Spine clearance in an obtunded or intoxicated patient is made even more challenging. Here’s an approach based on the EAST guidelines that I find helpful:

  1. Clear the bones. Obtain a CT of the cervical spine from skull base to T2. Sagittal and coronal 2D reconstructions must be created for review. Conventional images (AP, lateral, odontoid) are of no additional value.
  2. If a fracture is identified, consult your spine service.
  3. If a neurologic deficit is present, obtain an MRI and consult your neurosurgery or spine service.
  4. Clear the ligaments. In the obtunded patient, there are 3 choices: 1) keep the collar on until the patient wakes up enough to be examined, 2) obtain an MRI to evaluate the ligaments, or 3) remove the collar on the basis of CT alone.

In patients that you don’t expect to wake up any time soon, I prefer MRI. Some say that it should be obtained within 72 hours of injury for best accuracy in detecting ligamentous injury. Unfortunately, I have not been able to find any specific literature support for this. If the MRI is negative, the collar can be removed immediately.

There is a growing body of research that suggests that CT alone is sufficient for clearance. My opinion is that this is probably true, but only if the scan is read by a radiologist who is especially skilled in reading CT scans of the cervical spine. A pool radiologist may miss subtle findings that might indicate a ligamentous injury.

Reference: Eastern Association for the Surgery of Trauma practice guideline: Identifying Cervical Spine Injuries Following Trauma – 2009 Update. Click here to download.

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The Tripod Fracture

The tripod fracture (officially known as the zygomaticomaxillary complex fracture, and sometimes called a malar fracture) is the most common one seen after trauma. Fundamentally, the zygoma is separated from the rest of the face in a tripod fracture.

As you might imagine (tripod fracture), there are three components to this fracture. The first is a fracture through the zygomatic arch (1). Next, the fracture extends across the floor of the orbit and includes the maxillary sinus (2). Finally, the fracture includes the lateral orbital rim and wall (3). 

Extraocular muscles may become trapped in the fracture line, leading to diplopia. It is very important to do a good eye exam to try to detect entrapment. The infraorbital nerve also passes through the orbital floor and may be injured, leading to numbness along the lower eyelid and upper lip.

Nondisplaced fractures are treated symptomatically and reevaluated after a week or so to see if surgery would be beneficial. Displaced or symptomatic fractures require early open reduction. The pictures below show the anatomy of these fractures. They are derived from teaching materials provided by the Radiology Department at the University of Washington.

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Evaluation of Hematuria in Blunt Trauma

Hematuria ranges from microscopic to gross. Microscopic means blood that can only be seen with a microscope, and gross means visible to the naked eye. In trauma, we only care about gross hematuria, which ranges from the faintest of pink to the deepest red.

In trauma, gross hematuria is a result of an injury to kidney, ureter or bladder. Blunt injury to the ureter is so rare it’s reportable, so you can pretty much forget that one unless the mechanism is extreme. So you really just need to focus on kidney and bladder.

Any victim of blunt trauma that presents with visible hematuria needs to be evaluated by CT of the abdomen and pelvis with an added CT cystogram. Standard CT technique is done without a urinary catheter, or with the catheter clamped. Only 50% of bladder injuries show up with this technique.

CT cystogram is an add-on to the standard CT, and consists of the administration of contrast into the bladder which is then kept under pressure while the scan is done. Delayed slices through the pelvis after the bladder is depressurized and emptied is routine. Nearly 100% of bladder injuries are detected using this technique.

If the CT shows a renal laceration or hematoma, the patient should be admitted and managed according to your solid organ injury protocol. Kidney injuries fare better that livers and spleens, and only rarely require surgery. If no kidney or bladder injury is seen, the default diagnosis of a renal contusion is the culprit. No treatment is needed, and the patient can be discharged if no other injuries are present. The blood will clear over a few days, but may disappear and reappear a few times in the process. The patient can followup with their primary care physician in a week or two.

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