The LNC’s role in analyzing injury diagnosis in car accident documentation is critical to attorneys and their cases.
In Chapter 2, Injury Diagnosis in Car Accidents: The Role of Imaging from my book, Medical Record Analysis: A Guide for Attorneys by Expert LNCs Volume 3, the Role of Imaging is covered in full.
This is an excerpt from that chapter.
According to the U.S. Department of Transportation’s National Highway Traffic Safety Administration, in 2020, 38,824 lives were lost in traffic crashes nationwide (National Highway Traffic Safety Administration, 2022). That year saw the highest number of fatalities since 2007. Fatalities rose to 43,230 in 2021 and declined slightly to 42,514 in 2022. (National Highway Traffic Safety Administration, 2024).
Patients involved in motor vehicle crashes (MVCs) can experience many fatal or life-threatening injuries. Recognizing and treating these injuries can lower the risk of significant morbidity and mortality. This chapter excerpt will look at common imaging studies used in the treatment of blunt traumatic injuries following MVCs.
The LNC Role with Injury Diagnosis: A Case Study
Michael Petraca was a 35-year-old male brought to the emergency department (ED). (This was) following a head-on collision with another car that crossed the center yellow lines. Mr. Petraca was wearing a seat belt; the front airbags deployed upon impact. Mr. Petraca lost consciousness but was awake and talking when emergency medical services (EMS) arrived.
Due to the significant front-end damage to his car, which collapsed his door frames, Mr. Petraca had to be cut out of his car. He was placed in a cervical collar. Because he complained of back pain with numbness in his legs, he was also strapped to a backboard.
Upon arrival at the ED, he was quickly triaged and taken to a room where the primary assessment was completed. The primary assessment is the first assessment by the trauma team and/or ED team that follows a “systematic, rapid, and thorough assessment to identify and treat immediate life-threatening injuries” (Canzian, et. al, 2018, p.8).
The primary assessment by the trauma team found:
- Airway with cervical spine motion restriction: clear, not obstructed
- Breathing and ventilation: bilateral equal breath sounds, respiratory rate 18 (normal 12-20), non-labored, and oxygen saturation on pulse oximetry 96% on room air (normal is equal to or greater than 94%). He had equal chest wall movement, which indicates he did not have a flail chest (three or more contiguous fractured ribs broken in at least two parts).
- Circulation with hemorrhage control: normal heart sounds, heart rate 92 (normal 60-100), blood pressure 129/72 (normal). All his pulses were palpable; his capillary refill (how quickly color returns to an area such as the finger after squeezing to cause blanching) was less than two seconds (normal). His skin was warm, dry, and pink (normal). The staff did not see any external bleeding.
- Disability: Mr. Petraca was alert and oriented. His Glasgow Coma Scale was 15 (normal). His pupils were equal and reactive to light. He remembered the crash but did not recall the immediate aftermath. He was able to move his arms and legs. Although Mr. Petraca had lower back pain, he no longer had numbness in his legs. His blood sugar was 85 (normal). He also complained of a headache and pain in his neck.
- Exposure: All of Mr. Petraca’s clothes were removed and he was covered with warm blankets. His exam showed neither open wounds his skin nor deformities of any of his arms or legs. He did have bruising on the left side of his neck.
Diagnostic Tests
Because no life or limb-threatening injuries were identified, the next steps would include imaging studies to identify possible hidden injuries, part of the secondary survey.
What imaging studies would be expected for Mr. Petraca?
Based on the mechanism of the injury and his initial exam, the attending trauma physician ordered lab work and CTs of his head, cervical spine, thoracic spine, lumbar spine, chest, abdomen, and pelvis.
- CT of head: Mr. Petraca lost consciousness. This test will help identify injuries, including skull fractures, bleeding into or around the brain, and areas of ischemia (areas of the brain that have poor blood flow and oxygen delivery).
- CT of the spine: This will show injuries to the spine. CT is preferred over X-rays because of better diagnostic performance, and it requires less patient movement (Kelly, 2023). However, x-rays may still be used. Magnetic resonance imaging (MRI) is not typically used in the initial evaluation of the trauma patient (Kelly, 2023).
- CT of the chest, abdomen, and pelvis: These tests will be done with and without contrast (a special dye that helps certain structures in the body be seen more easily.) Blunt trauma injuries can affect the heart, lungs, aorta, other blood vessels, ribs, and other bones in the chest. Abdominal organs such as the liver, spleen, intestines, pancreas, and kidneys may be injured. (The kidneys are in the back of the abdomen called the retroperitoneum). A provider would look at the bones of the pelvis and hips, the end of the intestines including the rectum and anus, and the bladder on the pelvis CT. In females, the urethra, uterus, ovaries, and vagina also lie within the pelvis, and in males, the prostate is in the pelvis. If contrast is used, injuries to blood vessels may also be seen.
Traumatic Injury
“Traumatic injury is the leading cause of death among individuals younger than 45 years old. Eighty percent of traumatic injury is blunt with the majority of deaths secondary to hypovolemic shock” (loss of blood within the body) (Bloom & Gibbons, 2023). Bleeding in the abdomen and pelvis occurs in 12% of blunt trauma (Bloom & Gibbons, 2023), so tests that are performed quickly at the bedside may be used to help identify potential life-threatening injuries in these areas.
Focused Assessment with Sonography for Trauma (FAST): This ultrasound is used to look for fluid and blood in the abdomen and pelvis as well as in the retroperitoneum to see fluid around the kidneys. It is also used to see blood that may be collecting around the heart. This test may also be done during the primary survey.
Diagnostic Peritoneal Lavage (DPL): This test involves inserting a catheter (a small flexible tube) into the abdominal cavity. The provider would pull back to determine if blood or enteric (food or debris normally found inside the intestines) are seen. If not, warm saline solution may be run into the abdomen and then allowed to drain out. This fluid would be sent to the laboratory for testing (Simon, 2022).
CT Angiography: This study provides the ability to diagnose injuries in the artery, although this is done in the CT department and not at the ED bedside.
Mr. Petraca’s Findings
The radiologist read the CTs as normal except for a small bleed around the spleen. Mr. Petraca’s doctor briefly viewed the CTs but had to rush to surgery for another patient. He determined the bleeding around the spleen could be managed without an operation because Mr. Petraca had stable vital signs and minimal abdominal pain.
The hospitalist sent Mr. Petraca to the general medical-surgical unit for trauma patients. Approximately 12 hours later, Mr. Petraca began having slurred speech and weakness in his right arm and leg. The nurse assigned to him called a code stroke and he was taken for an emergent MRI. A blood clot was found at the juncture of his internal carotid artery and his middle cerebral artery.
Due to his recent trauma, Mr. Petraca was not eligible for TPA (tissue plasminogen activator, a medication given to help break up a blood clot). He was taken to the interventional radiology laboratory where he had a thrombectomy to remove the clot. Fortunately, he had a resolution of his slurred speech and right-sided weakness within minutes of the clot removal.
Analysis
Mr. Petraca had bruising on the left side of his neck. For patients involved in a motor vehicle crash, this is called a seat belt sign. He also had a headache and neck pain. “Blunt injury to the carotid or vertebral arteries (in the neck) is usually the result of a significant force that twists or stretches the vessel or impinges the vessel against the underlying bone, often for only a brief period of time. The carotid or vertebral artery may also be lacerated by bone that has fractured” (Biffl & Moore, 2023, p.2).
Carotid injuries involving the “direct application of force to the neck (seat belts, strangulation, near-hanging) account for up to approximately 10 percent of blunt carotid injuries” (Biffl & Moore, 2023, p.2). This can lead to a tear in the innermost layer of the lining of the vessel (intimal tear), which may result in a clot formation at the site.
If the clot breaks off, it can travel to the circulation in the brain (embolize).
“Symptoms such as neck, ear, face, or periorbital pain occur in up to 60 percent of patients with carotid or vertebral artery dissection in the neck. However, pain may be difficult to elicit in the multiply injured patient or may be attributed to other injuries. Emergency department personnel need to consider that a patient might have sustained a cervical vascular injury in patients with these symptoms after blunt trauma such as an MVC.
Mr. Petraca was quite fortunate that his symptoms appeared under observation and that rapid intervention was so successful.
Read the Rest
This is from Chapter 2, Injury Diagnosis in Car Accidents: The Role of Imaging, from the book: Iyer, P. (Ed.) Medical Record Analysis A Guide for Attorneys by Expert LNCs Volume 3.
Chapter 2 is contributed by Nancy Stuck, MSN, BSN, RN, TCRN, CLNC.
Get your copy here.
Pat Iyer is president of The Pat Iyer Group, which develops resources to assist LNCs in obtaining more clients, making more money, and achieving their business goals and dreams.
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