User:Uofumedstu/Blunt Trauma/Ratherbskiing Peer Review

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Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and falls in the elderly.

Blunt trauma can lead to a wide range of injuries including contusions, concussions, abrasions, lacerations, internal or external hemorrhages, and bone fractures. The severity of these injuries depends on factors such as the force of the impact, the area of the body affected, and underlying comorbidities of the affected individual. In some cases, blunt force trauma can be life-threatening and may require immediate medical attention. Either or both blunt trauma to the head and severe blood loss are the most likely causes of death due to blunt force traumatic injury.

Classification[edit]

Blunt Abdominal Trauma[edit]

Abdominal CT showing left renal artery hemorrhage after blunt abdominal trauma

Blunt abdominal trauma (BAT) represents 75% of all blunt trauma and is the most common example of this injury. 75% of BAT occurs in motor vehicle crashes, in which rapid deceleration may propel the driver into the steering wheel, dashboard, or seatbelt, causing contusions in less serious cases, or rupture of internal organs from briefly increased intraluminal[WC1]  pressure in the more serious, depending on the force applied. Initially, there may be few indications that serious internal abdominal injury has occurred.

There are two basic physical mechanisms at play with the potential of injury to intra-abdominal organs: compression and deceleration. Compression occurs from a direct blow, such as a punch, or compression against a non-yielding object such as a seat belt or steering column. This force may deform a hollow organ, increasing its internal pressure and possibly lead to rupture.

Deceleration causes stretching and shearing at the points where mobile contents in the abdomen, like bowel, are anchored. This can cause tearing of the mesentery of the bowel and injury to the blood vessels that travel within the mesentery. Classic examples of these mechanisms are a hepatic tear along the ligamentum teres and injuries to the renal arteries.

When blunt abdominal trauma is complicated by 'internal injury,' the liver and spleen (see blunt splenic trauma) are most frequently involved, followed by the small intestine.

In rare cases, this injury has been attributed to medical techniques such as the Heimlich maneuver, attempts at CPR and manual thrusts to clear an airway. Although these are rare examples, it has been suggested that they are caused by applying excessive pressure when performing these life-saving techniques. Finally, the occurrence of splenic rupture with mild blunt abdominal trauma in those recovering from infectious mononucleosis or 'mono' is well reported.

Blunt Abdominal Trauma in Sports[edit]

The supervised environment in which most sports injuries occur allows for mild deviations from the traditional trauma treatment algorithms, such as ATLS, due to the greater precision in identifying the mechanism of injury. The priority in assessing blunt trauma in sports injuries is separating contusions and musculo-tendinous injuries from injuries to solid organs and the gut and recognizing potential for developing blood loss, and reacting accordingly. Blunt injuries to the kidney from helmets, shoulder pads, and knees are described in American football, association football, martial arts, and all-terrain vehicle crashes.

A depiction of [WC2] broken ribs and flail chest, a very serious blunt chest injury

Blunt Thoracic Trauma[edit]

The term blunt thoracic trauma, or blunt chest injury, encompasses a variety of injuries to the chest. This includes damage caused by direct blunt force (such as a fist or a bat in an assault), acceleration or deceleration (such as that from a rear-end automotive crash), shear force (a combination of acceleration and deceleration), compression (such as a heavy object falling on a person), and blasts (such as an explosion of some sort). [WC3] Common signs and symptoms range from mild bruising, to hypoxia, ventilation-perfusion mismatch, hypovolemia, and reduced cardiac output. Blunt thoracic trauma may not be visible from the outside. Injuries may not show signs or symptoms until hours after the trauma initially occurs. A CT scan may prove useful in such instances. Those experiencing more obvious complications from a blunt chest injury will likely undergo a focused assessment with sonography for trauma (FAST) which can reliably detect a significant amount of blood around the heart or in the lung by using a special machine that visualizes sound waves sent through the body[WC4]. Only 10–15% of thoracic traumas require surgery, but they can have serious impacts on the heart, lungs, and great vessels.

This table depicts mechanisms of blunt thoracic trauma and the most common injuries from each mechanism

The most immediate life-threatening injuries that may occur include tension pneumothorax, open pneumothorax, hemothorax, flail chest, cardiac tamponade, and airway obstruction/rupture.

An example of a chest tube being used to treat a pneumothorax

These injuries may necessitate a procedure, most commonly the insertion of an intercostal drain, or chest tube. This tube is typically installed because it helps restore a certain balance of pressures (usually due to misplaced air or surrounding blood) that are impeding the lungs' ability to inflate and exchange vital gases that allow the body to function. A less common procedure that may be employed is pericardiocentesis. This removes blood surrounding the heart, allowing the heart to regain some ability to appropriately pump blood. In certain circumstances an emergent thoracotomy may be employed.

Blunt Cranial Trauma[edit]

The primary clinical concern with blunt trauma to the head is damage to the brain, although other structures, including the skull, face, orbits, neck, and spinal cord are also at risk. Following assessment of the patient’s airway, circulation, and breathing, a cervical collar may be placed if there is suspicion of trauma to the neck. Evaluation of blunt trauma to the head continues with the secondary survey for evidence of cranial trauma, including bruises, contusions, lacerations, and abrasions. In addition to noting external injury, a comprehensive neurologic exam is typically performed to assess for damage to the brain. Depending on the mechanism of injury and examination, a CT scan of the skull and brain may be ordered. This is typically done to assess for blood within the skull, or fracture of the skull bones.[WC5]

A CT scan showing an epidural hematoma (red arrow), a variety of intracranial bleeding commonly associated with blunt trauma to the temple region

Traumatic Brain Injury (TBI)[edit]

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in blunt cranial trauma. TBI is most commonly caused by falls, motor vehicle crashes, sports- and work-related injuries, and assaults. It is the most common cause of death in patients under the age of 25. TBI is graded from mild to severe, with greater severity correlating with increased morbidity and mortality.

Most patients with more severe traumatic brain injury have of a combination of intracranial injuries, which can include: diffuse axonal injury, cerebral contusions, and intracranial bleeding, including subarachnoid hemorrhage, subdural hematoma, epidural hematoma, and intraparenchymal hemorrhage. The recovery of brain function following a traumatic injury is highly variable and depends upon the specific intracranial injuries that occur, however there is significant correlation between the severity of the initial insult as well as the level of neurologic function during the initial assessment and the level of lasting neurologic deficits. Initial treatment may be targeted at reducing the intracranial pressure if there is concern for swelling or bleeding within this skull, which may require surgery such as a hemicraniectomy, in which part of the skull is removed.

A fracture, an injury to the skeletal component of the upper extremity.[WC6]

Blunt Trauma to Extremities[edit]

The Ankle-Brachial Index is depicted here. Note: ultrasound enhancement of pulses is not required but may be helpful.[WC7]

Injury to extremities (like arms, legs, hands, feet) is extremely common. Falls are the most common cause, making up as much as 30% of upper and 60% of lower extremity injuries. The most common mechanism for solely upper extremity injuries is machine operation or tool use. Work related accidents and vehicle crashes are also common causes. The injured extremity is examined for four major functional components which include soft tissues, nerves, vessels, and bones. Vessels are examined for expanding hematoma, bruit, distal pulse exam, and signs/symptoms of ischemia. When it is not obvious that the blood is getting through the injured area to the parts past the injury, an injured extremity index or ankle-brachial index may be used to help guide whether further evaluation with computed tomography arteriography. This uses a special scanner and a substance that makes it easier to examine the vessels in finer detail than what the human hand can feel or the human eye can see. Soft tissue damage can lead to either or both rhabdomyolysis (rapid breakdown of injured muscle that can overwhelm the kidneys)[WC8]  and compartment syndrome (nerve and vessel damage that occurs when pressure builds up in muscle compartments). Bones are evaluated with plain film x-ray or computed tomography if the extremity is deformed, bruised, or feels looser or more flexible than usual. Neurologic evaluation involves testing of the major nerve functions of the axillary, radial, and median nerves in the upper extremity as well as the femoral, sciatic, deep peroneal, and tibial nerves in the lower extremity[WC9]. Surgical treatment may be necessary depending on the extent of injury and involved structures, but many are managed nonoperatively.

Blunt Pelvic Trauma[edit]

The most common causes of blunt pelvic trauma are motor vehicle crashes and multiple-story falls, and thus pelvic injuries are commonly associated with additional traumatic injuries in other locations. In the pelvis specifically, the structures at risk include the pelvic bones, the proximal femur, major blood vessels such as the iliac arteries, the urinary tract, reproductive organs, and the rectum.

An X-ray showing a fracture of the inferior and superior pubic rami in a patient with previous hip replacements[WC10]

One of the primary concerns with blunt pelvic trauma is the risk of pelvic fracture. Pelvic fracture is associated with a myriad of complications including bleeding, damage to the urethra and bladder, and nerve damage. If pelvic trauma is suspected, emergency medical services personnel may place a pelvic binder on patients to stabilize the patient's pelvis and prevent further damage to these structures while patients are transported to a hospital. During the evaluation of trauma patients in an emergency department, the stability of the pelvis is typically assessed by the healthcare provider to determine whether fracture may have occurred. Providers may then decide to order imaging such as an X-ray or CT scan to detect fractures. Following initial treatment of the patient, fractures may need to be treated surgically if significant, while some minor fractures may heal without requiring surgery.

A life-threatening concern is hemorrhage, which may result from damage to the aorta, iliac arteries or veins in the pelvis. The majority of bleeding due to pelvic trauma is due to injury to the veins. Fluid (often blood) may be detected in the pelvis via ultrasound during the FAST scan that is often performed following traumatic injuries. Should a patient appear hemodynamically unstable in the absence of obvious blood on the FAST scan, there may be concern for bleeding into the retroperitoneal space, known as retroperitoneal hematoma. Stopping the bleeding may require endovascular intervention or surgery, depending on the location and severity.

Blunt Cardiac Trauma[edit]

Blunt cardiac trauma, also known as Blunt Cardiac Injury (BCI), encompasses a spectrum of cardiac injures resulting from blunt force trauma to the chest. While BCIs necessitate a substantial amount of force to occur because the heart is well-protected by the rib cage and sternum, the majority of patients are asymptomatic. Clinical presentations may range from minor, clinically insignificant changes to heart beat or may progress to severe cardiac failure and death. Often times, chest wall injuries are seen in conjunction with BCI, which confounds the presence of chest pain experienced by most patients. To evaluate the spectrum of cardiac injury, the American Association for the Surgery of Trauma (AAST) organ injury scale may be used to aid in determining the extent of the injury. BCI may be broken down into pericardial injury, valvular injuries, coronary artery injuries, cardiac chamber rupture, and myocardial contusion.

Evaluation and Diagnosis[edit]

In most settings[WC11], the initial evaluation and stabilization of traumatic injury follows the same general principles of identifying and treating immediately life-threatening injuries. In the US, the American College of Surgeons publishes the Advanced Trauma Life Support guidelines, which provide a step-by-step approach to the initial assessment, stabilization, diagnostic reasoning, and treatment of traumatic injuries that codifies this general principle. The assessment typically begins by ensuring that the subject's airway is open and competent, that breathing is unlabored, and that circulation is present throughout the body. This is sometimes described as the "A, B, C's"—Airway, Breathing, and Circulation—and is the first step in any resuscitation or triage. Then, the history of the accident or injury is amplified with any medical, dietary (timing of last oral intake) and history, from whatever sources such as family, friends, previous treating physicians that might be available. This method is sometimes given the mnemonic "SAMPLE". The amount of time spent on diagnosis should be minimized and expedited by a combination of clinical assessment and appropriate use of technology, such as diagnostic peritoneal lavage (DPL), or bedside ultrasound examination (FAST) before proceeding to laparotomy if required. If time and the patient's stability permits, CT examination may be carried out if available. Its advantages include superior definition of the injury, leading to grading of the injury and sometimes the confidence to avoid or postpone surgery. Its disadvantages include the time taken to acquire images, although this gets shorter with each generation of scanners, and the removal of the patient from the immediate view of the emergency or surgical staff. Many providers use the aid of an algorithm such as the ATLS guidelines to determine which images to obtain following the initial assessment. These algorithms take into account the mechanism of injury, physical examination, and patient's vital signs to determine whether patients should have imaging or proceed directly to surgery.

Recently, criteria have been defined that might allow patients with blunt abdominal trauma to be discharged safely. The characteristics of such patients include:

·       absence of intoxication

·       no evidence of lowered blood pressure or raised pulse rate

·       no abdominal pain or tenderness

·       no blood in the urine.

To be considered low risk, patients would need to meet all low-risk criteria.[WC12]

Treatment[edit]

When blunt trauma is significant enough to require evaluation by a healthcare provider, treatment is typically aimed at treating life-threatening injuries, such as maintaining the patient's airway and preventing ongoing blood loss. Patients who have suffered blunt trauma and meet specific triage criteria have shown improved outcomes when they are cared for in a trauma center. The management of patients with blunt force trauma necessitates the collaboration of an interpersonal healthcare team, which may include but is not limited to; a trauma surgeon, emergency department physician, anesthesiologist, and emergency and trauma nursing staff.

Treatment of Blunt Thoracic Trauma[edit]

Nine out of ten patients with thoracic trauma can be treated effectively without a surgical operation. If surgery is indicated, there are numerous options available. A comprehensive discussion involving the patient, their family, and the surgeon will take place to carefully evaluate the best approach, tailored to the patient's specific condition and injury. Conservative measures such as maintaining a clear and open airway, oxygen support, tube thoracostomy, and volume resuscitation are often given to manage blunt thoracic trauma. Often times, pain control is the most basic and effective treatment approach because the presence of severe pain may lead to impairment of proper breathing, further exacerbating impaired lungs. Pain management in thoracic trauma patients improves ability to breath properly on their own, encourages excretion of pulmonary secretions, and decreases aggravation of inflammation and low oxygen levels in the blood. Nonsteroidal anti-inflammatory drugs, opioids, or regional pain management methods, such as local anesthetic, can be used for pain control.

Epidemiology[edit]

Worldwide, a significant cause of disability and death in people under the age of 35 is trauma, of which most are due to blunt trauma.

[WC1]Consider audience and your use of medical words in this paragraph, including contusions and intraluminal. I like that you have the links to other places, but would it be better to use words like bruise? I like intraluminal because it makes your organs explode seem less aggressive.

[WC2]Is there any way to include these in subsections not just on the side in the Wikipedia editing format? I think that would be helpful for your figure organization I don’t love the way that the page looks with all the figures. I’d think about what figures are really contributing their weight and de-clutter. Like this picture, there’s one word that references flail chest and it’s a huge diagram.

[WC3]Are the parenthesis and hyperlink both necessary? I think it slows down the reading and if you can hover over and go to an article on the type of force, I don’t think you necessarily need the the parenthesis for shear force, compression or blasts

[WC4]This is just ultrasound, right? Consider just saying ultrasound and doing the link thing to the ultrasound page

[WC5]This doesn’t track with the format of the other sections. It doesn’t mean it’s not good information, but it’s more treatment than epidemiology and mechanism. Consider moving TBI section here and eliminating TBI. No other injury got it’s own section.

[WC6]I think you might be able to do better for an upper extremity injury. What I get from your writing is that there is a lot of stuff in the arm to damage and I don’t know if this supports that as well as something else might.

[WC7]I’m not sure this adds much. I think it’s confusing and you talk about CY arteriography and this is ultrasound. I’d consider cutting this picture.

[WC8]Consider swapping what is inside and outside the parenthesis in this sentence.

[WC9]Do we need to know all the nerves? Again good info, but does it hit the tone? I feel like this assessment might be varied a lot based on the injury. If you’ve got a good source, keep it. If not, I’d rework the sentence.

[WC10]Why do you have this? Does a hip replacement make sense as a figure? Mayo clinic says hip replacement is most commonly done for arthritis, not a traumatic injury. https://www.mayoclinic.org/tests-procedures/hip-replacement/about/pac-20385042

[WC11]Most clinical settings? I think this paragraph neglects that most people don’t have a traumatic injury into an emergency room and the importance of transport to a center for care and stabilization.

[WC12]Would someone reading this be like I have blunt trauma and I shouldn’t come in?