What is the management approach for a patient struck by a car?

Management Approach for Patients Struck by a Car

Patients struck by a car should be transported to the closest trauma center, with management prioritizing early assessment, resuscitation, and treatment according to trauma protocols to reduce mortality and improve outcomes.

Initial Assessment and Triage

• Patients struck by a car should be assessed using a combination of physiologic parameters, anatomical injury patterns, mechanism of injury, and response to initial resuscitation 1
• Pedestrians struck by vehicles have the highest mortality rate among geriatric trauma patients and represent a significant percentage of auto-pedestrian fatalities 1
• Field triage should include evaluation of:
  • Vital signs (respiratory rate, blood pressure, GCS)
  • Anatomical injuries
  • Mechanism of injury (speed of impact, whether thrown or run over)
  • Special considerations (age, comorbidities) 1

Transport Decision

• Transport to the closest trauma center is indicated for auto vs. pedestrian/bicyclist cases where the victim was thrown, run over, or struck with significant (>20 mph) impact 1
• The trauma center need not be the highest level trauma center, depending on the regional trauma system 1
• Elderly patients (>55 years) struck by vehicles should receive special consideration for transport to trauma centers due to their higher mortality risk 1

Initial Management

• For patients with obvious bleeding sources or in hemorrhagic shock in extremis, immediate bleeding control procedures should be performed 1
• Position the patient appropriately - supine for unconscious patients, comfortable position for conscious patients 2
• Assess and manage airway, breathing, and circulation (ABC) immediately 2
• For patients without immediate bleeding control needs but unidentified bleeding sources, immediate further investigation is required 1

Resuscitation

• Use a restricted volume replacement strategy with target systolic blood pressure of 80-90 mmHg (MAP 50-60 mmHg) until major bleeding is controlled, except in patients with traumatic brain injury 1
• For patients with severe traumatic brain injury (GCS <8), maintain a mean arterial pressure ≥80 mmHg 1
• Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution 1
• If erythrocyte transfusion is necessary, aim for a target hemoglobin of 70-90 g/L 1

Pain Management

• Implement a multimodal analgesic approach, especially in elderly patients, to avoid side effects of opioid use 1
• Regular intravenous administration of acetaminophen every 6 hours is effective for traumatic pain relief 1
• For moderate to severe pain, consider opioids with caution, especially in elderly patients who are at higher risk for respiratory depression 1
• NSAIDs should be used with caution in elderly patients due to potential adverse events (acute kidney injury, gastrointestinal complications) 1

Diagnostic Imaging

• Pre-hospital ultrasonography may be used if feasible without delaying transport to detect hemothorax, hemopericardium, and/or free abdominal fluid in patients with thoracoabdominal injuries 1
• Repeated hemoglobin and/or hematocrit measurements should be employed to detect ongoing bleeding 1
• Blood lactate should be used to estimate and monitor the extent of bleeding and tissue hypoperfusion 1

Special Considerations for Elderly Patients

• Elderly patients struck by vehicles require special attention due to:
  • Decreased physiological reserve and increased frailty 1
  • Higher prevalence of comorbidities (80% have at least one chronic disease) 1
  • Increased risk of cervical spine, rib, hip, and extremity fractures 1
• Management should include:
  • Early assessment of frailty 1
  • Early activation of trauma protocols 1
  • Consideration for early ICU admission 1
  • Venous thromboembolism prophylaxis with LMWH or UFH as soon as possible 1

Monitoring and Follow-up

• Early, repeated hemostasis monitoring, including laboratory measurements (PT/INR, fibrinogen, platelets) should be employed 1
• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile 1
• Combined pharmacological and intermittent pneumatic compression should be employed within 24 hours after bleeding has been controlled 1

Common Pitfalls to Avoid

• Undertriage of elderly pedestrians struck by vehicles, who have higher mortality rates than younger patients 1
• Delayed EMS response times, which are associated with higher MVC mortality rates 3
• Inadequate pain management, particularly in elderly patients 1
• Failure to recognize the potential for occult injuries in pedestrians struck by vehicles 1
• Overlooking the increased vulnerability of female occupants to concussion and persisting symptoms following motor vehicle crashes 4