CHAPTER 54: Blunt and Penetrating Trauma

INTRODUCTION

Trauma and injury account for 182, 479 deaths in 2007, with approximately 31,224 due to penetrating injuries, that is, firearms, and 65,474 secondary to blunt mechanisms, such as motor vehicle collisions and falls.¹ These statistics do not include the numerous morbidities that may also be associated with these injuries. It is difficult to address the world of trauma and acute care medicine without discussing “the golden hour;” and the “platinum ten minutes” referring to the fact that any trauma resuscitation is divided into either success or failure within the first hour of medical attention, and the initial minutes where critical interventions take place. While numerous debates have raged since the inception of this concept, the underlying idea of prompt and effective medical care starting from the point of patient contact in the field, and therefore the importance of prehospital management of the trauma patient, is indisputable.

OBJECTIVES

• Understand the initial prehospital management of the trauma patient, including triage and transport criteria.

• Understand the prehospital management of specific injuries to the chest and abdomen and the surrounding controversies of their care.

MANAGEMENT OF THE TRAUMA PATIENT

The overall management of the trauma patient has not deviated as much as the care of other medical emergencies. This may be taken in the perspective of patients undergoing an acute myocardial infarction and the use of the defibrillator, various drugs, and transport destination centers. Alternatively, if a patient has undergone penetrating abdominal trauma, the response is similar to that performed in years past, with stabilization of the patient in the field and transportation of the patient to the nearest trauma center where the patient would receive definitive treatment in the operating room. Thus, this chapter, instead of going through the laborious task of delineating the relatively static role of prehospital trauma management, will instead explore some of the recent controversies along with the techniques and technologies that are being used in the prehospital field.

TRAUMA TRIAGE

Triage of the trauma patient in the field is oftentimes a complex, challenging, and much debated issue among prehospital providers. The American College of Surgeons' Committee on Trauma has defined an acceptable undertriage rate (seriously injured patient not taken to a trauma center) as 5%, whereas overtriage rates may be acceptably as high as 25% to 50%.² The relatively high allowance for the overtriage rate is tolerated so as to allow for an acceptable level of patients who may be undertriaged. Many studies have in fact reported overtriage rates to be as high as 90%.^3,4

The importance of successful triage by prehospital providers is further emphasized with the development of regionalized trauma systems. It has been shown that the regionalization of receiving facilities, that is, the designation of hospitals to care for certain conditions such as trauma, ...