Car accidents: inital assessment

Motor vehicle accidents (MVAs) are a significant cause of morbidity and mortality in the United States.  MVA-related ED visits resulted in admission to the hospital for care about half as often as non-MVA-related ED visits (8.0 percent vs. 15.6 percent). The top 10 injuries among all MVA-related visits included sprains, contusions with intact skin surface, superficial injuries, open wounds, certain traumatic complications and unspecified injuries, intracranial injury, neck and trunk fracture, upper limb fracture, lower limb fracture, and internal injury of the thorax, abdomen, and pelvis. The use of seat belts and airbagts sginificanlty reduced serious injuries but can results in specific patterns of injury, such as lacerations, sprains and other generally milder injuries, The prevalence of these common injuries among MVA-related visits varied greatly, from 44.4 percent for sprains to 2.6 percent for internal injury of the thorax, abdomen, and pelvis.

After serious inuries are ruled out and an MVA victim is triaged to non-emergency care, evaluaiton follows the complaints and physical findings. Imaging tests are the cornerstone; laboratory tests are generally ancillary. Patients with penetrating or blunt trauma typically have x-rays of the chest, cervical spine, and pelvis unless they are awake and alert, completely lacking in symptoms or findings suggesting injury to those areas, and have no distracting injuries (eg, femur fracture) that might keep them from complaining about injuries elsewhere. These imaging tests are directed at life threats that may not be clinically obvious. CT of the chest, abdomen and pelvis, spine, head, or, particularly, combinations of these is increasingly being used instead of plain x-rays for patients who require imaging after severe multiple blunt trauma.

Identification of intra-abdominal injury by ultrasound or CT is reasonable when there are abdominal compliants or findings. Head CT is typically done in patients with altered mental status or focal neurologic abnormalities and in patients who sustained loss of consciousness (some clinicians feel that patients with a brief loss of consciousness who are completely alert and neurologically intact do not require CT). Imaging is obtained more liberally in children < 2 yr with scalp hematoma, the elderly, patients taking anticoagulants, and patients who are alcoholics.

Aortic injury should be considered in patients with severe deceleration chest injury or suggestive signs (eg, pulse deficits or asymmetric BP measurements, end-organ ischemia, suggestive findings on chest x-ray); these patients may require CT angiography or other aortic imaging. All patients suspected of having significant blunt chest injury have an ECG to diagnose myocardial injury and cardiac monitoring for subsequent arrhythmias. Patients with abnormalities on ECG usually have blood levels of cardiac markers measured and sometimes echocardiography. Plain x-rays are obtained of any suspected fractures and dislocations. Other imaging tests are obtained for specific indications (eg, angiography to diagnose and sometimes embolize vascular injury; CT to better delineate spinal, pelvic, or complex joint fractures).

Laboratory tests that may be useful include ABGs for Po2, Pco2, and base deficit; urine examination for blood; CBC to establish a baseline to monitor ongoing hemorrhage; glucose to evaluate for hypoglycemia; and type and crossmatch for possible blood transfusion. Other routinely obtained tests (eg, electrolytes and other chemistries, coagulation studies) are unlikely to be helpful unless suggested by relevant medical history (eg, renal insufficiency, diuretic use). Toxicology screening (eg, blood alcohol, urine drug screen) is often done; results of this testing rarely change immediate management but can help identify substance abuse causative of injury, allowing accurate asessment of mental status intervention to prevent subsequent trauma.

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