UMEM Educational Pearls - Trauma

Title: Trauma outcome differences between males and females

Category: Trauma

Keywords: Male. Female, outcome, trauma (PubMed Search)

Posted: 3/6/2025 by Robert Flint, MD (Updated: 7/18/2025)
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The Pan-Asia Trauma Outcomes Study database was reviewed for differences in in-hospital mortality and functional capacity at discharge between male and female trauma patients. There were 76,000 trauma patients from 12 Asian countries in this study. The authors concluded: “This study indicates no difference in the general trauma outcomes in the Asia Pacific between females and males. Although younger females with less severe injuries had better functional outcomes, this advantage disappeared in severe injuries and those over 50 years.” There were several differences in mechanism of injury and age of presentation. “With females more frequently represented in the ??50 age group (60.13%) compared to males (44.87%) (p?<?0.001). Trauma type also varied between sexes; 95.51% of females experienced blunt trauma compared to 93.65% of males (p?<?0.001). Anatomically, males predominantly sustained injuries to the head, face, thorax, abdomen, and upper extremities, whereas females more frequently suffered injuries to the lower extremities and spine (p?<?0.001).” This is similar toEuropean and North American data

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Title: ALS vs BLS level of care and trauma outcomes

Category: Trauma

Keywords: EMS, AlS, trauma, Bls, outcome (PubMed Search)

Posted: 3/5/2025 by Robert Flint, MD (Updated: 7/18/2025)
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Large retrospective propensity matching study looking at mortality in trauma patients based on ALS vs.  BLS transport crew found lower mortality in those attended by ALS crews. The matching was “based on patient age, sex, year, ICD-10-CM based injury severity score, mechanism of injury, AIS based body region of injury, EMS characteristics including time with patient and prehospital interventions performed, prehospital vital signs, and trauma center designation.”
This is different than other studies which showed limited difference. other studies have shown improved survival with police “scooping and running” with penetrating trauma patients. 

 

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Title: Geriatric Trauma: Rib and Pelvic Fracture Pain Management

Category: Trauma

Keywords: Trauma, geriatric, fall, pain management, fracture, rib, pelvis (PubMed Search)

Posted: 3/1/2025 by Robert Flint, MD (Updated: 3/2/2025)
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Rib and pelvic fractures are common findings in geriatric trauma patients, even in low impact trauma such as falls from standing. Pain management is vital for improving morbidity and mortality. The IFEM White Paper suggests:

“Use multimodal pain management strategies, including regional anesthesia and non-opioid analgesics, to control pain without compromising recovery.
Monitor closely for complications such as pneumonia or hemodynamic instability, intervening promptly to mitigate risks.
Collaborate with physiotherapists to implement early mobility programs, reducing the risk of deconditioning and promoting recovery.”

A multidisciplinary team proficient in geriatric trauma care leads to better outcomes. This may require transfer to a trauma center.

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Title: Geriatric Trauma: Frailty

Category: Trauma

Keywords: Trauma, geriatrics, frailty (PubMed Search)

Posted: 3/1/2025 by Robert Flint, MD (Updated: 7/18/2025)
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This white paper reminds us that age is just a number; frailty is a better predictor of morbidity and mortality after trauma. 
“Frailty, characterized by reduced physiological reserve and increased vulnerability to stressors, is a significant factor influencing recovery from trauma. Individuals with frailty may experience slower healing, higher rates of complications, and longer hospital stays. Tools such as the Clinical Frailty Scale (CFS) and the Trauma-Specific Frailty Index (TSFI) have been developed to assess frailty systematically, enabling clinicians to predict outcomes and guide treatment decisions.”

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Title: Guidelines for prehospital traumatic arrest management

Category: Trauma

Keywords: Ems, trauma, arrest, resuscitation (PubMed Search)

Posted: 2/23/2025 by Robert Flint, MD
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This position paper from American College  of Surgeons, NAEMSP, and ACEP outlines a literature based approach to prehospital care of traumatic circulatory arrest.  It logically could be applied to care in the hospital as well. Care of a traumatic arrest is different than a medical etiology arrest. 

“Emphasize the identification of reversible causes of traumatic circulatory arrest and timely use of clinically indicated life-saving interventions (LSIs) within the EMS clinician’s scope of practice. These include:

Epinephrine should not be routinely used, and if used should not be administered before other LSIs.

External chest compressions may be considered but only secondary to other LSIs.

Chest decompression if there is clinical concern for a tension pneumothorax. Empiric bilateral decompression, however, is not indicated in the absence of suspected chest trauma.

Airway management using the least-invasive approach necessary to achieve and maintain airway patency, oxygenation, and adequate ventilation.

External hemorrhage control with direct pressure, wound packing, and tourniquets.”

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Title: Can adolescents be safely treated at adult trauma centers?

Category: Trauma

Keywords: Peds, trauma, centers, adolescents (PubMed Search)

Posted: 2/16/2025 by Robert Flint, MD (Updated: 7/18/2025)
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Looking at 416 patients aged 12-16, 48% at a Peds trauma center vs 20% at adult Level 1 center vs 34% at an adult level 2 center, there was no difference in in hospital mortality between adult and pediatric centers. 
The authors  conclude “These findings suggest that severely injured adolescents aged 12 to 16 years may be safely treated at either adult or pediatric trauma centers.”

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Title: Can we stop imagining to clear C-Spines in older trauma patients?

Category: Trauma

Keywords: Cervical sound, age, geriatric, trauma, clearance (PubMed Search)

Posted: 2/1/2025 by Robert Flint, MD
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Not based on currently available literature. 
This editorial reminds us that the only evidenced based screening criteria we have for C-spine clearance in those over age 65 after trauma is the Canadian C-Spine Rule (2002). This rule recommends imaging for all patients over age 65.   No large, well done study  indicates physical exam or other means can be used to clear C-Spines in those over age 65.

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Title: Ketorolac vs Ketamine for chest trauma analgesia

Category: Trauma

Keywords: Chest trauma, ketorolac, ketamine (PubMed Search)

Posted: 1/26/2025 by Robert Flint, MD (Updated: 7/18/2025)
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This small study randomized patients with 2 or greater rib fractures or requiring chest tube insertion into a kerorolac (30 mg) or ketamine (0.25 mg/kg) group and evaluated pain levels pre, 30  and 60 minutes post medication administration. They also looked at need for morphine rescue medication. The ketamine group had superior pain control and required less rescue medication.

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Title: Occipital Condyle Fractures

Category: Trauma

Keywords: occipital, condyles, fracture, cervical spine (PubMed Search)

Posted: 1/19/2025 by Robert Flint, MD
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Fractures of the occipital condyles are a relatively rare injury that occur in high energy blunt mechanisms  (IE roll over MVC) most commonly. Physical exam will show signs of basilar skull fracture and significant pain at the base of the skull/upper C-spine. CT scan is the gold standard to make the diagnosis. Look for signs of upper extremity weakness on physical exam or cranial nerve injuries. Those type of findings should also prompt emergent MRI evaluation.  Treatment generally is long term immobilization in  a collar however Type 3 and those with neurologic  findings may require surgical intervention.

Anderson and Montesano Classification

Type I 3% of occipital condyle fracturesImpaction-type fracture with comminution of the occipital condyle

Due to compression between the atlantooccipital joint

Stable injury due to minimal fragment displacement into the foramen magnum 

Type II 22% of occipital condyle fracturesBasilar skull fracture that extends into one or both occipital condyles

Due to a direct blow to skull and a sheer force to the atlantooccipital joint

Stable injury as the alar ligament and tectorial membrane are usually preserved 

Type III 75% of occipital condyle fractures Avulsion fracture of condyle in region of the alar ligament attachment (suspect underlying occipitocervical dissociation)

Due to forced rotation with combined lateral bending 

Has the potential to be unstable due to craniocervical disruption 

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Title: Trauma Frailty Index

Category: Trauma

Keywords: Frail, trauma, mortality, outcome (PubMed Search)

Posted: 1/12/2025 by Robert Flint, MD (Updated: 7/18/2025)
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The Trauma Frailty Index has been validated to predict inpatient mortality, major complications and discharge to rehab facility. “In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05).”

It is a simple 15 variable index. 

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This study suggests no. The control arm was given standard physical therapy and the intervention arm was instructed in four basic exercises to do on their own daily for a week. Patents were  then surveyed to assess for long term pain. There was no difference in pain between the two groups. Meaning, at least in this study reliant on patient journaling and follow up, that these four simple exercises did not impact long term pain in chest wall injured patients.  More work needs to be done in this important area.

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Title: Liberal vs. restrictive oxygen therapy in trauma patients.

Category: Trauma

Keywords: Trauma, oxygen, mortality (PubMed Search)

Posted: 12/14/2024 by Robert Flint, MD (Updated: 12/15/2024)
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In this randomized trial of restrictive oxygen (arterial oxygen sat of 94% ) vs. liberal oxygen (12-15 L of O2 per minute) for 8 hours after traumatic injury there was no difference in mortality or major respiratory complications at 30 days between the two groups. 

Further evidence that managing hypoxia is important but over oxygenation at best offers no benefit and may add harm.

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Title: Visual diagnosis-pelvis

Category: Trauma

Posted: 12/8/2024 by Robert Flint, MD (Updated: 12/9/2024)
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Question

What is the diagnosis? Treatment? Other imaging indicated? 

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Title: Embolism or observe-liver lacerations with contrast extravasation

Category: Trauma

Keywords: Liver laceration, embolization, observation. (PubMed Search)

Posted: 12/7/2024 by Robert Flint, MD (Updated: 12/8/2024)
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This prospective observational study looked at patients with liver lacerations and active contrast extravasation who  either had immediate embolization vs. observation. After matching for age, injury score etc. the observation first approach did as well as those who had immediate embolization.

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Title: vertebral Fracture

Category: Trauma

Keywords: vetebral fracture, trauma, fall, spinal injury (PubMed Search)

Posted: 12/1/2024 by Robert Flint, MD (Updated: 7/18/2025)
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Question

Fall from a height of 6 feet with back pain. Plain film shown. What is the diagnosis? Any further imaging indicated? Treatment? Disposition? 

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Title: A new way to approach post motor vehicle collision extrication (extraction)

Category: Trauma

Keywords: collision, extrication, trauma, motor vehicle, extraction, rapid, spinal immobilization (PubMed Search)

Posted: 11/24/2024 by Robert Flint, MD (Updated: 7/18/2025)
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It is important for trauma and emergency care providers to understand what our patients experience prior to arrival in our clean, safe, and structured emergency department. It is also vitally important that we are involved in training and education in the pre-hospital environment. A group in the United Kingdom is challenging the age old “wisdom” that post-motor vehicle crash extrication should be slow, methodical, and work to have absolutely no movement in the spinal canal. Spinal immobilization and slow extrication instead of rapid resuscitation appears to be bad for patients. Based on several of their ground breaking papers they have published a 14 point recommendation of patient extrication post motor vehicle collision. Here are two important tenets they propose. For an in-depth discussion check out November 14, 2024 / CPD, Podcasts, Roadside to Resus

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Title: Can you remove the anterior portion of a cervical collar to intubate?

Category: Trauma

Keywords: Immobilization cervical spine, intubation (PubMed Search)

Posted: 11/21/2024 by Robert Flint, MD (Updated: 7/18/2025)
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The authors looked at 51 patients intubated with both anterior and posterior cervical collar in place and measured the degree of movement within the spine during intubation. They repeated this process in 51 additional patients with just the posterior portion of the collar in place.  They found there was one degree of difference in movement between the two groups. This adds evidence that removing the anterior portion of the collar is safe when intubating trauma patients.

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Title: CT scans still aren’t perfect

Category: Trauma

Keywords: Trauma, CT scan, gunshot wound (PubMed Search)

Posted: 11/10/2024 by Robert Flint, MD (Updated: 11/17/2024)
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This retrospective study illustrates that the use of CT scanning to identify injury in gun shot wounds to the abdomen is not sensitive or specific enough to obviate the need for laparotomy. “Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy.”  If there is clear indication to go to the OR, stopping in CT does not add any benefit. 

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An out-of-hospital, randomized, placebo-controlled, blinded, parallel group study was conducted in adult patients under the care of the city fire-based emergency medical services and the local level one trauma center.  Adult male patients experiencing moderate to severe pain due to traumatic injuries received either 50mg of intranasal ketamine or placebo in addition to fentanyl after randomization in the field by the paramedic (a novel approach). The primary outcome was reduction of pain by 2 points 30 minutes after study drug administration.

199 patients were randomized with 107 receiving ketamine and 92 with placebo.  Patients were young (30-40), and had a median weight of 83 kg. Pretreatment pain scores were 10/10 and patients presented to the ED 14 minutes after receiving study medication. The most common injuries were falls, MVC, and GSW. Half of the patients received IV fentanyl but others had IM or IN routes.

Ketamine receipt did not lead to a 2 point reduction in pain scores (36% vs 44.7% p = 0.22). There was no difference in pain at 3 hours, additional medications received, or total amount of analgesia received. Notably, there were no differences in adverse events.

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Title: Prehospital TXA administration

Category: Trauma

Keywords: Trauma,blood, TXA, prehospital (PubMed Search)

Posted: 11/10/2024 by Robert Flint, MD (Updated: 11/11/2024)
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Administration of prehospital TXA was found to improve 28 day mortality and decrease the amount of blood required to be transfused without any increased risk of thromboembolism or seizure. Two grams of TXA was superior to one gram and no TXA. 

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