Trauma-Mechanism of Injury And the Lug Nut Rule

COVID-19 really has done quite a number on our headspace, especially in the ER. We’re not only treating acutely ill patients with a highly contagious virus, we’re holding record numbers of admitted patients, and while most of the public is pretty chill about wait times and hallway beds, some are definitely not. 

Sometimes I’m like why am I still doing this?

And then I have to remind myself. 

Head on collisions and partial amputations, 

Falling from rooftops and blunt force traumas,

Gunshots and hemorrhages and low GCSs, 

These are a few of my favorite things. 

Ok, of course I don’t WANT people to wreck their cars or get shot or stabbed or any of the other various traumatic injuries. Please don’t get hurt to make me happy. 

But give me the choice between the inbound STEMI patient, a stroke, or the unstable trauma, and I’m going to take the trauma EVERY TIME.

I love trauma. It’s AWESOME. 

So, what is considered trauma? Because obviously lots of injuries are considered traumatic, even your basic ankle fracture was caused by some kind of trauma, right? 

What separates the ouchies from the OH FUCK RALLY THE TROOPS?

Criteria! Trauma centers are hospitals with the resources to treat traumatic injuries that may require immediate intervention by a trauma team, that have staff immediately available to open that chest or head up and fix what has been broken. 

Examples of patients that bypass local hospitals and run for the closest trauma center—

Amputations

Penetrating trauma to the head, neck, chest, abdomen—gunshots, stabbings, impalements

Blunt force trauma with abnormal vitals signs or decreased level of consciousness 

Falls from greater than 20 feet

And more! 

And this is where I’m going to nerd out a little. 

One component of activation is MECHANISM OF INJURY. 

That means there was a force significant enough to cause a high likelihood of suspicion of internal injuries. 

In the old days, ambulances used to report head on collisions as a “combined velocity of 140 miles per hour”, meaning that the combined speeds of the vehicles was 140. It was significant because it indicated a higher suspicion of injury than a combined velocity of 60. No shit, right? 

But then they started making cars a whole lot safer. And stronger. Many high speed head on collisions had significantly less injuries in the new century than in the 70’sor 80’s. So we moved on to heavy damage to the vehicle, or minor damage, etc. 

Now we look at intrusion into the passenger compartment—where the patient was sitting. If the patient was the driver, and the front end of that vehicle was hit with enough force that it intruded into their compartment more than twelve inches, that vehicle took a hell of an impact and that patient is at significant risk to have blunt force injury that may not be apparent to the naked eye. If any part of that vehicle has more than eighteen inches of intrusion into the main compartment, same rule. Because it takes a fuckton of energy to breach that cage. 

It’s all about the energy. A vehicle traveling at 60mph that slams into another and comes to a  screeching start—all that energy went somewhere, but where did it go? Just into the engine block sitting on the passenger seat?  Or into those internal organs? Is the spleen bleeding? Liver lacerated? Aorta leaking? 

Which brings me to a quick and dirty truth an old EMS guy told me like fifteen years ago. They brought in a patient with minor injuries from a head on collision. I asked if we’d be getting the other patient, and he said that the driver was pronounced dead on scene. Said he failed the lug nut rule. And being a little baby nurse I was like, what rule?

And he said, “whoever has the most lug nuts is going to win.” 

The more lug nuts on a tire, the bigger the vehicle. A Dodge Dart is going to lose against a Chevy Silverado every time. 

That’s the lug nut rule. 

Mechanism of injury is also very important because many times, initially after the trauma occurs, there is a huge dump of adrenalin into the body, activating the sympathetic nervous system. The message is sent to the body—shut everything down and send EVERYONE to the brain, heart, and lungs. Blood pressure shoots up, as the blood vessels constrict, to send blood to priority organs and the fight or flight response is in full bloom. Things like abnormal vitals signs are disguised by this big old dump of gogo juice and that can also constrict blood vessels to organs not as high priority as the heart and lungs—things like the liver and spleen may not need as profusely due to decreased circulation through them. 

Often times, a patient who is activated as a trauma due to mechanism may have a report of normal vital signs but arrive actively decompensating—fast heart rate, plummeting blood pressure, change in mentation. 

Those patients roll in and you know them. Get the blood bank on the phone and activate the massive transfusion  protocol, because the number one cause of death in trauma patients is hemorrhagic shock—blood loss. 

I plan on talking in a separate post about massive transfusion protocol in a separate area—it’s completely different from transfusing a medical or post surgical patient and when I happened to tell a friend of mine how much blood, plasma, platelets, and cryo we slammed into a patient in two hours they could not wrap their head around it. Massive transfusion is defined as more than ten blood products in a 24 hours period—we slam that in in traumas in an hour. It’s just so much so fast and flies in the face of what most people think or know about blood administration. 

Always have that protocol activated prior to the arrival of a penetrating trauma to the chest/abdomen. 

I have seen patients who rolled in with gunshots to the chest or abdomen moaning, clearly alive, only to go into cardiac arrest less than two minutes later. The adrenalin wears off, they bleed into their chest, and you crack that chest open and their whole circulating volume falls onto the floor. 

Gunshots suck. They do so much damage. I’ve had them survive and I’ve had them not survive. There are accidental and non accidental and they’re all awful. 

So how could I love something so awful, right? Well, I hate that it happened. I feel terrible someone was hurt this way. But I’m here to make every attempt to save their lives. When the trauma team is on, it is ON. 

Here’s how it goes. 

Radio blares. “Medic 52 transporting trauma patient, female, approximately 30 years old, multiple gunshot wounds to the head, chest and abdomen. GCS (Glasgow coma scale) of 6, assisting ventilation with a BVM (bag valve mask), thready pulse with a heart rate of 160, unable to obtain blood pressure, IO access obtained right tibia (intraosseous needle—IV drilled into the shin bone, quick way to obtain access to the vascular system when the veins are flat cause ya know, there isn’t any blood in them), five minutes out.”

The trauma team is activated, and the ER staff is already moving. The massive transfusion protocol is activated and the blood bank starts thawing huge amounts of blood products. The rapid infusers are set up. Chest tube trays are opened and the collection chambers set up and placed to suction. Someone pulls the rapid sequence intubation meds and sets up intubation supplies. The surgeon arrives, along with other staff, respiratory, bringing a vent if the GCS is reported as less than 8, or they’re already breathing for the patient with a bag and oxygen. 

Patient arrives. From the door the AVPU scale is assessed—are they alert? Opening their eyes to verbal stimuli? Unresponsive?

This patient is unresponsive. Moved to the ED stretcher. The ED doctors calls for intubation meds. Someone is attaching the monitors. Someone else is obtaining IV access. The surgeon is doing a primary assessment and calling it out—GCS is now 3, as low as you can go. Vitals are abysmal. Multiple gunshot wounds are present in the chest—meaning it’s very likely either the heart or lungs is hit. The ED dr intubates, the surgeon drops a chest tube on the right and blood begins to pour out. 

The blood bank runner shows up with a cooler of packed red blood cells and two people begin running the massive transfusion, calling out unit numbers and hanging them on the rapid infuser. The surgeon drops a second chest tube in the left, the ER doctor puts in an introducer sheath allowing for huge amounts of fluid to infuse into the femoral vein, and the OR staff who reported to the call run back to OR to get the room ready. 

Blood is pouring in; blood is pouring out. 

A pulse is palpable in the carotid artery only, meaning blood pressure is dangerously low. The patient begins seizing—pupils are unequal, sign of a significant brain injury, and medications are ordered for seizures and sedation. The blood bank runner is back with another cooler of plasma and - bundle of platelets. 

Talk about cracking the chest open in the ED starts. It’s rare for an emergency thoracotomy to work, but it’s possible. Seen it—an open chest, a quick plug of the hole in the right ventricle, off to the OR for a surgical repair. It happens. 

Now you have a patient intubated, with two chest tubes, an introducer sheath, an ongoing massive transfusion, multiple large bore IVs, multiple medications infusing, being bundled up for the OR. A foley and an orogastric tube are placed, antibiotics started, chest tube drainage marked, a full head to toe body survey completed. 

Regardless of where we go from here—whether we crack the chest, whether the patient lives or dies, whether there’s a recoverable injury or not, we just did absolutely every fucking thing we could to save someone, and we did it fast, and we did it well. 

So that’s why I love trauma. Because it’s doing a hundred different things at once, as fast as you can, and if you do it right and you do it well, your team is going to save lives. There really isn’t anything cooler than that. 

— The Midwestern One