Blunt trauma

Blunt trauma is any nonpenetrating injury caused by the impact of a blunt object against the body, resulting in damage to underlying structures. Common causes include motor vehicle collisions and falls from height. Clinical features and diagnostic studies vary based on the type and location of blunt trauma. Assessment of patients with blunt trauma follows the systematic evaluation outlined in the advanced trauma life support (ATLS) algorithm: primary survey, transfer to a trauma center (if indicated), secondary survey, and tertiary survey. Management involves treating immediately life-threatening injuries and surgical repair of traumatic injuries.

See also “Management of trauma patients” and “Penetrating trauma.”

Management of blunt trauma is based on the type and location of the injury. Recommendations in this article are consistent with the 2018 guidelines on ATLS. See also “Trauma in pregnant individuals,” “Trauma in older adults,” and “Trauma in children.” ^[1]

Types of blunt trauma ^[1][2]

• Open wounds (e.g., abrasions, lacerations)
• Contusions
• Fractures
• Crush injury
• Acceleration-deceleration injury (e.g., coup-contrecoup injury)

Blunt trauma injuries by mechanism ^[1][2]

The most common causes of blunt trauma injuries include motor vehicle collisions, vehicle-pedestrian collisions, falls from height, and bicycling injuries. ^[3]

Blunt trauma injuries by location ^[1]

Approach to blunt chest trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Identify and treat respiratory failure and shock, tension pneumothorax, massive hemothorax, and cardiac tamponade (see “Management” for details).
  • Perform resuscitative thoracotomy in pulseless patients with previously documented signs of life.
  • If at a nontrauma center, initiate transfer to a trauma center; high-speed MVCs, ejection from vehicle, or death of a passenger are indications for trauma team activation.
  • See “Traumatic circulatory arrest” for the management of cardiac arrest due to trauma.
• Secondary survey
  • Examine the chest for paradoxical chest movement and crepitus.
  • Utilize clinical decision tools while obtaining urgent diagnostics for trauma patients (see “Diagnostics”).
  • Assess for indications for urgent thoracotomy.
  • Begin initial management of vertebral injuries, if suspected.

Clinical features ^[1]

• Hemorrhagic shock and/or obstructive shock (e.g., hypotension, tachycardia)
• Respiratory distress (e.g., tachypnea, hypoxia)
• Absent or decreased breath sounds
• Jugular venous distention
• Pain (e.g., chest pain, rib pain, pleuritic chest pain)
• Chest wall deformity (e.g., flail chest)
• Subcutaneous emphysema
• Tracheal deviation

Esophageal injuries may be missed initially; suspect esophageal rupture in a patient with left-sided pneumothorax without apparent rib fracture. ^[1]

Diagnostics ^[1][7][8]

Clinical decision tools can help identify patients who do not require imaging. See “Urgent diagnostics for trauma patients” for a comprehensive approach to trauma imaging.

• Bedside assessment: CXR, eFAST, ECG
• CT imaging in trauma
  • Chest CT with IV contrast
  • CTA chest if vascular injury is suspected
• Additional testing: bronchoscopy, esophagoscopy, echocardiography

NEXUS chest decision instrument for blunt chest trauma ^[9][10]

The NEXUS chest decision instrument for blunt chest trauma is a clinical decision tool to identify patients with a very low risk of thoracic injury who do not require thoracic imaging (e.g., CXR, chest CT).

NEXUS chest CT-all decision instrument for blunt chest trauma ^[11]

The NEXUS chest CT-all decision instrument for blunt chest trauma is a clinical decision tool to identify patients at very low risk of thoracic injuries who do not require a chest CT.

Management ^[1][2]

Bedside interventions

The following bedside interventions may be performed during the primary survey:

• Pulseless patient; with previously documented signs of life after blunt injury: resuscitative thoracotomy
• Respiratory failure: rapid sequence intubation and mechanical ventilation
• Tension pneumothorax: emergency chest decompression
• Massive hemothorax: chest tube placement
• Cardiac tamponade: pericardiocentesis followed by pericardial window; or resuscitative thoracotomy
• Esophageal injury: chest tube placement

Further management

Further management depends on the type and extent of associated injuries.

• Close monitoring of vital signs
• Definitive surgical management after stabilization, e.g., urgent thoracotomy for open pneumothorax, definitive management of vertebral injuries
• Nonsurgical management, e.g., analgesia for rib fractures

Rib fracture ^[1][12]

Etiology

• Blunt thoracic trauma (e.g., MVC, fall from height)
• Nonaccidental trauma
• Pathological fractures

Clinical features

• Pleuritic chest pain
• Respiratory distress (e.g., tachypnea, dyspnea)
• Chest wall tenderness, bruising, and/or deformity
• Crepitus
• Flail chest
  • Caused by three or more adjacent ribs fractured in two or more places
  • Paradoxical chest movement: The floating rib segment moves inward during inspiration and outward during expiration.

Diagnostics ^[2][8][13]

• Clinical diagnosis based on physical examination findings
• Minor trauma: CXR (AP and lateral view) ^[14]
• Major trauma: chest CT with or without IV contrast

Treatment ^[2][15]

• Isolated rib fractures: typically managed nonsurgically
  • Provide pain management (e.g., acetaminophen, NSAIDs, lidocaine patches).
  • Encourage deep breathing exercises (e.g., incentive spirometry).
• Multiple rib fractures and/or flail chest
  • Intubate and begin positive pressure ventilation (PPV) in patients with signs of acute respiratory distress (see “Airway management”). ^[16]
  • Manage pneumothorax and/or hemothorax with chest tube placement.
  • Provide pain management (e.g., patient-controlled analgesia, intercostal nerve block).
  • Encourage deep breathing exercises (e.g., incentive spirometry).
  • Flail chest: Consult thoracic surgery for surgical management.

In patients with flail chest and respiratory distress, positive pressure ventilation improves gas exchange and may provide internal stabilization while patients await surgery.

Disposition ^[15][17]

• Patients with ≤ 2 rib fractures with adequate pain control: may be discharged
• Patients with ≥ 3 rib fractures and/or poorly controlled pain: Admit for pain management and monitoring.
• Patients at risk for respiratory decompensation (e.g., aged > 65 years, respiratory comorbidities) with ≥ 3 rib fractures: Consider ICU admission.

Complications

• Respiratory failure
• Pneumothorax
• Hemothorax
• Atelectasis
• Pneumonia
• Pulmonary contusion
• Intraabdominal organ injury
• Nonunion

Other chest wall injuries

• Sternal fracture
• Clavicle fracture
• Vertebral fractures

Blunt cardiac injury (BCI) ^[1][18][19]

Cardiac injuries from blunt trauma most commonly occur after high-speed MVC and range from minor asymptomatic injury to myocardial rupture and death. ^[2]

Possible injuries

• Cardiac contusion: a cardiac injury secondary to blunt force thoracic trauma, which causes myocardial dysfunction with a wide range of clinical effects, including chest pain, hypotension, arrhythmias, elevated cardiac biomarkers, and cardiogenic shock
• Atrial and ventricular wall injuries
• Septal and valvular injuries
• Acute coronary syndrome, myocardial infarction
• Pericardial effusion and cardiac tamponade
• Myocardial rupture

Clinical features

• Asymptomatic
• Chest ecchymosis
• Chest pain or tenderness
• Hypotension
• Tachypnea, shortness of breath
• Tachycardia, arrhythmias
• New cardiac murmur, muffled heart sounds
• Jugular venous distention
• Dizziness, syncope
• Cardiogenic shock
• Sudden cardiac arrest

Consider BCI if tachycardia persists despite fluid resuscitation and hemorrhage has been ruled out.

Diagnostics ^[18][19]

See “Approach to blunt chest trauma” for initial measures.

• ECG
  • Obtain in all patients with suspected BCI.
  • Potential findings include:
    • Arrhythmia (e.g., sinus tachycardia, dysrhythmia)
    • ST-segment abnormalities
    • ECG changes in STEMI
    • AV block
• Troponin
  • Obtain in all patients with suspected BCI.
  • May be elevated in patients with coronary or myocardial injury
• Echocardiography ^[20]
  • Obtain in patients with hemodynamic instability, abnormal ECG, or elevated troponin.
  • TEE may be performed if TTE is inconclusive.
  • Potential findings include:
    • Pericardial effusion
    • Cardiac tamponade
    • Myocardial rupture
    • Wall motion abnormality
    • Valvular injuries
    • Septal injuries
• Additional diagnostics ^[20]
  • General imaging in trauma: e.g., eFAST, CXR, chest CT with or without IV contrast
  • CT angiography: for suspected vascular injury

Management

• Initiate immediate hemodynamic support and continuous cardiac monitoring.
• Start treatment of underlying pathology (e.g., management of cardiac tamponade, management of cardiogenic shock).
• Patients with abnormal ECG or troponin levels: Monitor for delayed cardiac injuries (e.g., myocardial rupture).
• Patients with normal ECG and troponin levels: Consider discharge if there are no other injuries.

Commotio cordis ^[21][22]

• Definition: ventricular fibrillation and sudden cardiac death caused by a relatively mild nonpenetrating blunt force trauma to the precordial area
• Etiology: blow to the precordial area at a perpendicular angle, most commonly by a hard, spherical object (e.g., baseball, golf ball), during a brief electrically vulnerable period of T-wave upstroke
• Pathophysiology: blunt trauma leads to myocardial stretch → activation of ion channels because of mechano-electric coupling → augmentation of repolarization and premature ventricular depolarization → ventricular fibrillation ^[23]
• Diagnosis is clinical and based on the following criteria:
  • Blunt trauma to the chest followed by collapse
  • Absence of structural myocardial injury (on imaging studies and/or autopsy)
  • ECG showing ventricular fibrillation (if obtained)
• Management
  • Immediate: cardiopulmonary resuscitation
  • Long-term: cardiac workup (ECG, echocardiogram, cardiac MRI, stress testing)
• Prevention
  • Avoidance of sports that involve chest wall impact (e.g., baseball, hockey, football)
  • Use of chest protectors and/or safety balls may reduce risk.
  • Treat any underlying cardiac disease.
  • No underlying cardiac disease: no ICD necessary

Blunt thoracic aortic injury ^[24][25][26]

• Definition: an injury of the thoracic aorta resulting from blunt trauma; most commonly occurs distal to the left subclavian artery in the aortic isthmus
• Etiology: rapid deceleration from blunt trauma (e.g., MVC, fall from height)
• Clinical features: Severity ranges from intimal lesions (e.g., aortic pseudocoarctation) to thoracic aortic rupture.
  • Chest pain
  • Upper back pain
  • Dyspnea, hoarseness and/or stridor
  • Dysphagia
  • Chest wall instability and/or ecchymoses
  • New interscapular murmur
  • Thoracic aortic rupture: signs of hemorrhagic shock (e.g., tachycardia, hypotension) and tearing pain
• Imaging ^[1]
  • CXR (initial imaging); potential findings include:
    • Left main bronchus depression
    • Tracheal deviation
    • Apical pleural cap
    • Left pleural effusion (hemothorax)
    • Obscuration of the aortic knob
    • Mediastinal widening
  • Definitive imaging: based on the patient's hemodynamic status and trauma surgeon preference ^[1]
    • CTA chest in hemodynamically stable patients
    • Transesophageal echocardiography
• Management ^[26]
  • Initiate blood pressure and heart rate control.
    • Goal: heart rate ≤ 100 bpm and systolic blood pressure ≤ 100 mm Hg
    • Treatment: beta blockers (e.g., esmolol, labetalol) and vasodilator therapy (e.g., nitroprusside, nicardipine) if needed
  • Definitive management
    • Endovascular repair (TEVAR)
    • Open surgical repair
• Prognosis: very poor (∼ 80% of patients die before reaching the hospital) ^[26]

Pulmonary contusion ^[1][2][16]

• Definition: a lung injury from blunt trauma resulting in alveolar edema and hemorrhage
• Clinical features
  • Clinical features of respiratory distress (e.g., dyspnea; , tachypnea, cyanosis)
  • Hypoxia
  • Tachycardia
  • Chest pain
  • Chest ecchymosis
• Diagnostics
  • CXR ; ^[2]
    • Patchy alveolar infiltrates
    • White-out hemithorax or diffuse opacity
  • Chest CT: if CXR is inconclusive
• Management
  • Provide pain management.
  • Provide respiratory support (e.g., oxygen, positive pressure ventilation).
  • Maintain euvolemia and avoid excessive IVF resuscitation.
  • Monitor for respiratory insufficiency, e.g., with repeated ABGs.
• Complications
  • ARDS
  • Pneumonia

Tracheobronchial injury ^[1][2]

• Definition: a tear in the tracheobronchial tree resulting from high-energy impact, decelerating forces, or a penetrating chest wall injury
• Clinical features
  • Dyspnea
  • Sternal tenderness
  • Subcutaneous emphysema
  • Clinical features of pneumothorax
  • Hamman sign
  • Hoarseness
  • Hemoptysis
• Diagnostics
  • CXR; : subcutaneous emphysema, pneumomediastinum, pneumothorax
  • Chest CT: subcutaneous emphysema, pneumomediastinum, pneumothorax, bronchial tear, tracheal tear
  • Bronchoscopy: visualization of the lesion ^[2]
• Initial management ^[2][27]
  • Prepare for difficult airway management.
  • Intubate using a fiberoptic laryngoscope or bronchoscope.
  • Place chest tube for concomitant pneumothorax.
  • For injuries of the proximal trachea, see also “Approach to blunt neck trauma.”
• Definitive treatment: surgical repair
• Complications ^[2]
  • Pneumothorax with persistent air leak
  • Airway obstruction
  • Bronchopleural fistula
  • Mediastinitis

Suspect tension pneumothorax in patients with tracheobronchial injury and midline shift or distended neck veins.

Approach to blunt abdominal trauma ^[1][2]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• All patients
  • Assess for indications for trauma team activation (e.g., high-speed MVCs, ejection from vehicle, death of a passenger) and initiate transfer to a trauma center, if necessary.
  • Examine abdomen, flank, back, and groin for bruising and signs of peritonitis.
  • Consider portable CXR and pelvic x-ray.
  • Stabilize pelvic fractures with a pelvic binder.
  • Begin initial management of vertebral injuries, if suspected.
• Hemodynamically unstable patients
  • Perform FAST to quickly identify intraabdominal bleeding.
  • Treat hemorrhagic shock with emergency transfusion and immediate hemodynamic support.
  • Identify obvious indications for exploratory laparotomy, e.g., hypotension with a positive FAST, peritoneal signs, subdiaphragmatic air on CXR.
  • Associated pelvic fracture: Coordinate interventions for pelvic hemorrhage control (e.g., angioembolization) concurrently with emergency laparotomy (see “Initial management of pelvic fractures” for details).
• Hemodynamically stable patients
  • Obtain urgent diagnostics for trauma patients as indicated, e.g., CT abdomen and pelvis with contrast.
  • Identify other radiological indications for exploratory laparotomy (e.g., significant hemoperitoneum or gastrointestinal perforation).
  • If there are no indications for surgery, initiate nonsurgical management with serial examinations and close monitoring of vital signs.

If there are obvious indications for immediate exploratory laparotomy (e.g., hypotension and peritoneal signs), do not delay transfer to the OR for diagnostic studies. ^[1][2]

Clinical features ^[1]

General features

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Signs of peritonitis (e.g., abdominal pain, abdominal distention, abdominal guarding)
• Decreased bowel sounds
• Abdominal bruising (e.g., seat belt sign )

The absence of abdominal pain or tenderness does not exclude intraabdominal injuries. ^[2]

Specific injuries

• Splenic injury
  • Left-sided abdominal pain
  • Referred pain in the left shoulder (Kehr sign)
• Liver injury
  • Right-sided abdominal pain
  • Referred pain in the right shoulder
• Duodenal injury
  • Nausea and vomiting
  • Bilious vomiting in case of gastrointestinal obstruction
  • Epigastric pain
• Retroperitoneal injury
  • Back and/or flank pain or tenderness
  • Periumbilical ecchymosis (Cullen sign)
  • Flank ecchymosis (Grey Turner sign)
  • Renal injury: hematuria
  • Pancreatic injury: upper abdominal pain, clinical features of acute pancreatitis ^[28]
• Diaphragmatic injury
  • Decreased breath sounds
  • Bowel sounds in the thorax
  • Respiratory distress
• Vertebral injury (e.g., Chance fracture)
  • Lower back pain
  • Clinical features of spinal cord injury

Extensive duodenal hematoma can obstruct gastroduodenal passage and manifest with bilious vomiting.

Symptom onset in pancreatic injury may be delayed.

Suspect herniation of abdominal organs into the chest if there are bowel sounds in the thorax after abdominal or thoracic trauma.

Diagnostics ^[1][8][29]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• General imaging in trauma: CXR and pelvic x-ray
  • Performed for most patients after major trauma
  • May show free intraabdominal air, evidence of diaphragmatic injury, and fractures
• Bedside intraabdominal hemorrhage assessment: FAST, eFAST, or diagnostic peritoneal lavage (DPL)
  • Indicated for all hemodynamically unstable patients with blunt abdominal trauma
  • Detects hemoperitoneum (collection of blood in the peritoneal cavity)
• CT imaging in trauma
  • Minimum evaluation: CT abdomen and pelvis with IV contrast
  • Suspected vascular injuries: CTA abdomen and pelvis
  • Suspected T-spine or L-spine injuries: See “Diagnosis of vertebral injuries.”
  • Potential findings
    • Hemoperitoneum
    • Pneumoperitoneum
    • Splenic laceration
    • Liver hematoma
    • Duodenal hematoma
    • Pelvic fracture
• Minimally invasive surgical assessment: diagnostic laparoscopy

Pancreatic, diaphragmatic, small bowel, and mesenteric injuries may be missed on initial CT imaging. ^[2]

Management ^[2]

Nonoperative management ^[30][31][32]

Nonoperative management should take place in a center with facilities for urgent laparotomy.

• May be considered for:
  • Hemodynamically stable patients with no signs of peritonitis
  • Renal, splenic, pancreatic, and hepatic injuries
• Typically includes:
  • Monitoring for changes in clinical status (e.g., vital signs, pain levels, serial abdominal examination)
  • Serial laboratory studies (e.g., hemoglobin)
  • Repeat imaging for injury progression
  • Supportive care (e.g., pain management, wound care)

Operative and interventional management ^[33]

Hemodynamically unstable patients typically require surgical or interventional management, which may include:

• Exploratory laparotomy: e.g., for hemodynamically unstable patients with a positive FAST and/or CT scan or signs of peritonitis
• Angiographic embolization: e.g., for patients with pelvic fracture, retroperitoneal hematoma, or liver injury
• External fixation of pelvic fractures

Injury-specific management

Management depends on the type and extent of injuries and is determined in consultation with specialists (e.g., trauma surgery, interventional radiology).

• Splenic injury ^[31]
  • Monitoring for delayed splenic rupture
  • Laparotomy and repair or splenectomy in unstable patients
• Liver injury ^[32]
  • Nonoperative management with observation and supportive care
  • OR arteriography and hepatic embolization
  • Laparotomy and repair in unstable patients
• Gastrointestinal perforation: laparotomy; see “Treatment of gastrointestinal perforation.”
• Duodenal hematoma: bowel rest, nasogastric decompression, and total parenteral nutrition ^[34][35]
• Pancreatic injury ^[28][36]
  • Nasogastric suction and total parenteral nutrition
  • OR surgical debridement, repair, and percutaneous drainage
• Pelvic fracture ^[37][38]
  • External or internal fixation
  • Hemostatic measures: angiographic embolization, preperitoneal packing
• Vertebral injuries: See "Definitive management of vertebral injuries.”

Approach to blunt neck trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Prepare for difficult airway management and secure the airway early (see “Treatment”).
  • Apply C-spine immobilization (see “Initial management of C-spine injury”).
  • Consider neurogenic shock in hypotensive patients with no evidence of hemorrhagic or obstructive shock.
  • If at a nontrauma center, initiate transfer to a trauma center; airway obstruction or hypotension are indications for trauma team activation.
• Secondary survey
  • Perform neurovascular examination focusing on clinical and diagnostic features of BCVI.
  • Obtain urgent diagnostics for trauma patients (see “Diagnostics”).
  • Consult specialists based on injured anatomical structures (see “Surgical management”).

Associated injuries ^[2]

• Laryngotracheal contusions and lacerations
• Laryngeal fracture: a fracture of the thyroid cartilage and/or the cricoid cartilage
• Fractures and/dislocations of the tracheal cartilages
• Tracheal rupture: the partial or complete puncture or laceration of the trachea or the main bronchi
• Pharyngoesophageal injury
• Blunt cerebrovascular injury
• Cervical spine injuries, e.g., hangman fracture

Clinical features ^[1]

• Airway or esophageal injury
  • Signs of airway compromise (e.g., dyspnea)
  • Hoarseness and/or stridor
  • Subcutaneous emphysema (e.g., crepitus)
  • Mediastinal emphysema (e.g., Hamman sign)
  • Hemoptysis
  • Dysphagia
• Vascular injury
  • Carotid bruit
  • Expanding neck hematoma
  • Focal neurological deficit
• Clinical features of strangulation ^[2][39]
  • Asphyxiation, loss of consciousness
  • Dysphagia, voice changes
  • Subconjunctival hemorrhage, facial petechiae
  • Bruising around the neck, strangulation marks

Diagnostics ^[1]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• Bedside assessment: CXR
• CT imaging in trauma
  • Vascular injury: CTA head and neck
  • C-spine injury: CT C-spine without IV contrast (See “Diagnostics for C-spine injuries” for details.)
  • Laryngeal injury: CT neck with IV contrast
• Additional testing
  • Vascular injury: duplex ultrasound, angiography
  • Esophageal injury: esophagoscopy, esophagography
  • Laryngeal injury: direct laryngoscopy, flexible nasopharyngoscopy

Treatment ^[1][2]

Airway management ^[40]

• If there are signs of airway compromise, call for help immediately (e.g., emergent anesthesia or ENT consult).
• Perform BMV with caution.
• Prepare for difficult airway management (e.g., distorted anatomy, blood, and/or edema) by an experienced provider.
  • Intubation via direct laryngoscopy or video laryngoscopy using a smaller-sized ET tube can be attempted initially.
  • Awake fiberoptic intubation is preferred for distorted anatomy.
  • Prepare for emergency surgical airway as a backup.
• Perform manual in-line cervical stabilization during airway management.

Cricothyroidotomy may be impossible if anatomical landmarks are invisible or deformed, e.g., due to a laryngeal fracture. Emergency tracheostomy may be required if intubation has failed. ^[1]

Surgical management

Consult surgical subspecialties based on clinical and diagnostic findings.

• Vascular injuries: vascular surgery
• Laryngotracheal injuries: otolaryngology
• C-spine injuries: spine surgery (See “Definitive management of C-spine injuries.”)
• Esophageal injuries: thoracic surgery

Blunt cerebrovascular injury (BCVI) involves the carotid and/or vertebral artery and can cause a stroke as a result of thrombi formation, wall hematomas, and/or vascular occlusion.

Expanded Denver screening criteria ^[41][42][43]

The expanded Denver screening criteria is a tool used to identify patients at risk for BCVI and the need for advanced imaging. A positive screen is any clinical or diagnostic feature of BCVI or the combination of a high-speed mechanism and any risk factor for BCVI.

• Clinical and diagnostic features of BCVI
  • Nasal/oral/cervical arterial hemorrhage
  • Carotid bruit in patients aged < 50 years
  • Expanding neck hematoma
  • Focal neurological deficit
  • Neurological deficits inconsistent with CT head
  • Ischemic stroke on CT or MRI
• Risk factors for BCVI
  • Fractures: facial (Le Fort II and Le Fort III), mandible, occipital condyle, skull (complex and basilar), upper ribs, C-spine
  • TBI with GCS < 6
  • Degloving injury of the scalp
  • Near hanging with anoxic brain injury
  • C-spine ligamentous injury or subluxation
  • Combined TBI and thoracic injury
  • Blunt cardiac or thoracic vascular injury
  • Seat belt injury with significant pain, swelling, or change in mental status

Diagnostics ^[41]

• CTA head and neck
• Digital subtraction angiography

Treatment ^[41]

Treatment varies based on injury severity and anatomical location and may include:

• Antithrombotic therapy
• Surgical repair
• Endovascular stenting

Approach to blunt extremity trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Apply direct pressure and/or a tourniquet if there is active extremity hemorrhage.
  • Address life-threatening injuries (e.g., immobilize fractures associated with severe injuries).
  • If at a nontrauma center, initiate transfer to a trauma center for hard signs of extremity vascular injury; traumatic amputation is an indication for trauma team activation.
• Secondary survey
  • Perform detailed neurovascular examination of the affected extremity.
  • Evaluate for rhabdomyolysis and compartment syndrome.
  • Provide supportive care, e.g., analgesia, tetanus prophylaxis.
  • Obtain urgent diagnostics for trauma patients, including laboratory studies and x-ray and/or CTA extremity, once stable (see “Diagnostics”).
  • Determine if there is a need for surgical consultation (e.g., vascular surgery, orthopedic surgery) based on injury characteristics.

Clinical features

Clinical features depend on the type and extent of associated injuries, and on any complications (e.g., compartment syndrome).

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Neurological deficit (e.g., loss of strength and/or sensation)
• Hard signs of extremity vascular injury (e.g., absent distal pulses, pulsatile hematoma)
• Clinical features of fractures (e.g., limb deformity, signs of an open fracture)
• Clinical features of compartment syndrome (e.g., pain out of proportion that worsens with passive stretching)
• Clinical features of rhabdomyolysis and crush syndrome (e.g., darkened urine, signs of shock)

Diagnostics ^[1][8]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• Vascular injury
  • Arterial-brachial index (ABI) ^[1]
  • CTA of the injured limb ^[44]
  • Duplex ultrasound
• Bony injury: x-ray of injured limb
• Rhabdomyolysis: serial CPK, BMP
• Compartment syndrome: compartment pressure measurement

Management

• Vascular injury
  • Prioritize hemostatic control.
  • Consult vascular surgery for patients with hard signs of extremity vascular injury or abnormal imaging.
• Fracture: See “Initial fracture management.”
  • Immobilize with a splint (see “Upper extremity splints” and “Lower extremity splints” for details).
  • Consult orthopedic surgery and provide antibiotic prophylaxis for open fractures.
• Dislocation
  • Perform closed reduction and splint.
  • Consult orthopedic surgery for neurovascular compromise.
  • See “Shoulder dislocation,” “Hip dislocation,” and “Tibiofemoral joint dislocation” for details.
• Rhabdomyolysis: See “Management of rhabdomyolysis.”
  • Provide IV fluid resuscitation.
  • Perform serial laboratory monitoring (e.g., CPK, BMP).
  • Manage associated electrolyte derangements (e.g., hyperkalemia).
• Compartment syndrome: See “Management of acute compartment syndrome.”
  • Obtain immediate surgical consultation.
  • Initiate supportive care to optimize tissue perfusion and oxygenation.
• Tendon and ligament injuries: See “Knee ligament injuries,” “Achilles tendon rupture,” and “Sports injuries” for details.