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Trauma

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Head and Neck Trauma

  • Traumatic brain injury (TBI): Includes concussion, intracranial hemorrhage (subdural, epidural, subarachnoid), and diffuse axonal injury; presents with altered consciousness, headache, nausea, and focal neurological deficits.
  • Facial fractures: Maxillary, mandibular, zygomatic fractures presenting with facial asymmetry, malocclusion, and peri-orbital bruising.
  • Cervical spine injury: May result in spinal cord injury, presenting with neck pain, neurological deficits, or paralysis.
  • Penetrating neck injury: Can involve vascular structures, the airway, or the spinal cord; requires urgent assessment for airway compromise and hemorrhage.
  • Laryngeal trauma: Hoarseness, stridor, and subcutaneous emphysema are key signs; airway management is a priority.

Thoracic Trauma

  • Rib fractures: Common in blunt trauma, may cause pain, respiratory compromise, or lead to pneumothorax or hemothorax.
  • Pneumothorax: Air in the pleural space causing lung collapse; presents with dyspnea, chest pain, and decreased breath sounds.
  • Tension pneumothorax: Life-threatening condition where air in the pleural space increases with each breath; presents with hypotension, distended neck veins, and tracheal deviation.
  • Hemothorax: Blood in the pleural space, presenting with hypovolemic shock, decreased breath sounds, and dullness to percussion.
  • Flail chest: Multiple rib fractures resulting in a segment of the chest wall moving paradoxically; causes respiratory distress and requires mechanical ventilation.
  • Cardiac tamponade: Accumulation of fluid in the pericardial sac leading to compression of the heart; presents with hypotension, distended neck veins, and muffled heart sounds (Beck’s triad).
  • Aortic injury: Can occur in high-speed impacts; presents with chest pain, back pain, and signs of shock; requires immediate surgical intervention.
  • Pulmonary contusion: Bruising of lung tissue leading to alveolar hemorrhage and edema; may cause hypoxia and respiratory failure.

Abdominal Trauma

  • Splenic rupture: Common in blunt abdominal trauma; presents with left upper quadrant pain, referred pain to the left shoulder (Kehr’s sign), and signs of hypovolemic shock.
  • Liver laceration: Right upper quadrant pain, signs of hypovolemic shock; may require surgical repair.
  • Bowel injury: Can result in peritonitis, presenting with abdominal pain, guarding, and rigidity; requires urgent surgical intervention.
  • Retroperitoneal hemorrhage: Can result from injury to the kidneys, aorta, or pelvic vessels; presents with flank pain, hypotension, and a Grey-Turner’s sign (flank bruising).
  • Bladder rupture: Common with pelvic fractures; presents with inability to urinate, hematuria, and lower abdominal pain.
  • Pancreatic injury: Often results from blunt trauma to the epigastrium; presents with epigastric pain radiating to the back and signs of peritonitis.
  • Diaphragmatic rupture: Can occur in high-impact trauma; presents with respiratory distress, abdominal pain, and bowel sounds in the chest.

Musculoskeletal Trauma

  • Fractures: Can range from simple fractures to complex, open, or comminuted fractures; presents with pain, deformity, and loss of function.
  • Dislocations: Common in joints such as the shoulder, elbow, and hip; presents with deformity, pain, and inability to move the affected joint.
  • Compartment syndrome: Increased pressure within a closed muscle compartment leading to ischemia; presents with severe pain, pallor, pulselessness, paresthesia, and paralysis.
  • Pelvic fractures: Can result in significant hemorrhage; presents with pelvic pain, instability, and signs of hypovolemic shock.
  • Spinal fractures: May result in spinal cord injury; presents with back pain, neurological deficits, and possibly paralysis depending on the level of injury.
  • Crush injuries: Can result in muscle damage and release of myoglobin, leading to rhabdomyolysis and acute kidney injury.
  • Soft tissue injuries: Include lacerations, contusions, and sprains; may be associated with underlying fractures or dislocations.
  • Burns: Classified by depth (superficial, partial-thickness, full-thickness); requires assessment of the extent of body surface area involved and fluid resuscitation.

Key Points in History 🥼

Mechanism of Injury

  • Blunt trauma: Includes motor vehicle collisions, falls, and assaults; key mechanisms include deceleration injuries, crush injuries, and direct impact.
  • Penetrating trauma: Includes stab wounds, gunshot wounds, and impalement; important to note the type of weapon, entry and exit wounds, and potential for organ damage.
  • Burns: Identify the source (thermal, chemical, electrical), duration of exposure, and the area involved to assess the severity and risk of complications.
  • Falls: Assess the height of the fall, surface landed on, and position of the body at impact; falls from significant heights increase the risk of serious injuries.
  • Crush injuries: Common in industrial accidents or natural disasters; prolonged compression increases the risk of compartment syndrome and rhabdomyolysis.
  • Blast injuries: Can result from explosions; includes primary blast (pressure wave), secondary blast (shrapnel), tertiary blast (thrown against an object), and quaternary blast (burns, inhalation injuries).

Associated Symptoms

  • Loss of consciousness: Important in assessing head injuries; prolonged or repeated loss of consciousness increases the risk of intracranial injury.
  • Pain: Location, severity, and character of pain can indicate the severity of trauma and guide further investigation.
  • Neurological deficits: Weakness, numbness, or paralysis may indicate spinal cord injury or nerve damage.
  • Respiratory distress: May indicate thoracic trauma such as pneumothorax, hemothorax, or pulmonary contusion.
  • Bleeding: External or internal bleeding can lead to hypovolemic shock; assess for visible wounds, hematuria, or signs of internal hemorrhage.
  • Deformity: Visible deformities may indicate fractures, dislocations, or soft tissue injuries.
  • Swelling and bruising: Often accompany fractures, dislocations, and soft tissue injuries; rapid onset may indicate a more severe underlying injury.
  • Hypotension and tachycardia: Signs of shock, which may be due to hemorrhage, cardiac tamponade, or tension pneumothorax.
  • Seizures: May occur following head trauma or due to underlying medical conditions.
  • Urinary retention or incontinence: Can be a sign of spinal cord injury.

Background

  • Past medical history: Pre-existing conditions such as anticoagulation, bleeding disorders, or osteoporosis can complicate trauma management.
  • Medication history: Current medications, especially anticoagulants or antiplatelets, can increase the risk of bleeding complications.
  • Social history: Alcohol or drug use, employment, and social circumstances may influence the cause of trauma and impact management.
  • Family history: Any history of bleeding disorders, sudden deaths, or genetic conditions that may affect trauma management.
  • Surgical history: Previous surgeries, particularly in the chest or abdomen, may influence the risk of complications or guide the choice of imaging and intervention.
  • Immunization status: Particularly tetanus vaccination status, important in managing open wounds and preventing infection.

Possible Investigations 🌡️

Imaging Studies

  • X-rays: Initial imaging modality for suspected fractures, dislocations, and chest injuries; AP and lateral views are standard.
  • CT scan: High sensitivity for detecting intracranial hemorrhage, spinal fractures, abdominal injuries, and complex fractures.
  • Ultrasound (FAST scan): Focused Assessment with Sonography for Trauma, used to detect free fluid in the abdomen, pelvis, and pericardium, indicating hemorrhage.
  • MRI: Used for detailed assessment of soft tissue injuries, spinal cord injuries, and brain injuries; not typically first-line in acute trauma.
  • Angiography: Used in cases of suspected vascular injury, particularly in the context of blunt or penetrating trauma to the chest, abdomen, or extremities.
  • Pelvic X-ray: Performed in cases of suspected pelvic fractures to assess for instability and associated hemorrhage.
  • Cervical spine X-ray/CT: Essential in evaluating patients with head or neck trauma to rule out cervical spine injury.
  • Bronchoscopy or laryngoscopy: May be indicated in cases of suspected airway trauma, such as laryngeal injury or tracheobronchial rupture.
  • Doppler ultrasound: Used to assess vascular integrity in cases of suspected limb ischemia or vascular injury.

Laboratory Tests

  • Full blood count (FBC): To assess for anemia, infection, and platelet count, which may be relevant in trauma with bleeding or infection.
  • Blood grouping and crossmatch: Essential for patients with significant hemorrhage who may require blood transfusion.
  • Coagulation profile: To assess for coagulopathy, particularly in patients on anticoagulants or with liver disease.
  • Electrolytes and renal function: Important for assessing kidney function, particularly in the context of rhabdomyolysis or crush injuries.
  • Liver function tests: To assess for liver injury in abdominal trauma or if hepatic pathology is suspected.
  • Arterial blood gas (ABG): To assess oxygenation, ventilation, and acid-base status, particularly in patients with respiratory distress or shock.
  • Lactate levels: Elevated in shock, particularly hypovolemic and septic shock, and can guide resuscitation efforts.
  • Toxicology screen: May be indicated in trauma cases where substance use is suspected to assess for drugs or alcohol.
  • Urinalysis: To assess for hematuria in cases of suspected renal or bladder injury.
  • Serum amylase/lipase: Elevated in cases of pancreatic injury or blunt abdominal trauma.
  • Cardiac enzymes: To assess for myocardial injury in cases of blunt chest trauma.
  • Blood alcohol level: Relevant in trauma cases where alcohol impairment is suspected.
  • Myoglobin: Elevated in crush injuries or rhabdomyolysis, indicative of muscle damage.

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Medicine of older adult