Major skeletal injuries in the obtunded blunt trauma patient: a case for routine radiologic survey

Trauma patients obtunded as a result of head injury, hypotension, alcohol, or drugs have an unreliable physical examination which may lead to errors or delays in diagnosis. To define the extent of routine radiologic survey needed in patients with a depressed level of consciousness, the records of 789 adults with blunt injuries and a Glasgow Coma Score (GCS) of 10 or less on admission were reviewed. Major skeletal injury (MSI), was defined as one or more fractures or dislocations of the axial spine, pelvis, hip, or long bones of the lower extremity. The overall incidence of MSI was 31%. Injuries to the axial spine were present in 14% of patients, while 10% sustained pelvic fractures or hip dislocations and 15% sustained femur or tibia-fibula fractures. Patients who sustained MSI had lower admission CRAMS, Trauma Score, GCS, and admission blood pressure compared to non-MSI patients (p less than 0.002). An analysis of mechanisms of injury showed that pedestrians struck by a motor vehicle (57%), and victims of motorcycle accidents (40%) had increased incidences of MSI (p less than 0.05). Patients suffering falls (18%) and assaults (2%) had a decreased incidence of MSI (p less than 0.01). The high incidence of potentially occult MSI in obtunded patients after blunt trauma demonstrated by this data suggests the need for routine radiologic survey including the axial spine, pelvis and long bones of the lower extremity. Mechanism of injury, CRAMS, TS, and GCS may be useful in the early identification of a particularly high-risk group.