From the Guidelines
Hard signs of injury in trauma patients include active hemorrhage, pulsatile or expanding hematoma, bruit or thrill in the region of the wound, hemodynamic instability, unilateral upper-extremity pulse deficit, massive hemoptysis or hematemesis, air bubbling in the wound, and airway compromise, which are associated with an unstable or potentially unstable patient and often mandate immediate operative evaluation and treatment without preoperative imaging. These signs are critical in determining the severity of the injury and the need for urgent intervention. According to the study by 1, hard signs of vascular or aerodigestive injury are indicative of a high risk of significant damage and require prompt attention. The presence of these signs helps trauma teams prioritize care and make rapid decisions about surgical intervention, as these findings represent potentially life or limb-threatening conditions that require prompt treatment to prevent permanent disability or death.
Some key hard signs of injury include:
- Active hemorrhage
- Pulsatile or expanding hematoma
- Bruit or thrill in the region of the wound
- Hemodynamic instability
- Unilateral upper-extremity pulse deficit
- Massive hemoptysis or hematemesis
- Air bubbling in the wound
- Airway compromise These signs are critical in evaluating the severity of the injury and determining the need for immediate intervention. As noted in the study by 1, the presence of hard signs is associated with a high risk of significant vascular or aerodigestive injury, and prompt treatment is essential to prevent complications and improve outcomes.
In contrast to soft signs, which may warrant further diagnostic testing, hard signs typically necessitate immediate operative intervention without delay for additional imaging studies. The study by 1 highlights the importance of recognizing hard signs and taking prompt action to address the underlying injury. By prioritizing patients with hard signs, trauma teams can provide timely and effective care, reducing the risk of morbidity and mortality.
From the Research
Hard Signs of Injury in Trauma Patients
- Hard signs of injury in trauma patients include hemorrhage, expanding hematoma, and ischemia 2
- These signs are often associated with the need for operative intervention, but initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup 2
- Hard signs should not be considered an absolute indication for immediate surgical exploration 2
- In patients with penetrating trauma, base deficit (BD) appears to predict mortality better than vital signs (VS) such as heart rate, systolic blood pressure, and shock index 3
- The use of BD to assess physiological status may help refine early triage, investigation, and management of trauma patients 3
Limitations of Hard Signs
- Hard signs have limitations in identification and characterization of extremity arterial injuries 4
- A strategy of using hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility than relying solely on hard signs 4
- Hemorrhagic signs are associated with arterial transection, while ischemic signs are associated with arterial occlusion 4
Management of Trauma Patients
- Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy 5
- The principles of damage control surgery include rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure 5
- Computed tomography (CT) scans can be performed in hemodynamically unstable patients to facilitate diagnosis and management, and may avoid the need for surgery in some cases 6