Hospitals preparation to manage an increase in patient volumes has been highlighted in recent times due to different man-made or natural-caused disasters. The Covid-19 pandemic is a recent well-known disaster situation and has made a big impact on the preparedness work.  But hospital disaster preparation is at least described in the Second World War. [ 4 ]  Some hospitals, such as  San Francisco General Hospital , have medical surge exercises to train staff. [ 5 ]


In February 2019, the  American Hospital Association  released a report that medical surge capacity was one of four major challenges threatening rural hospitals' ability to provide care, along with the "opioid epidemic," violence in the community, and cyber threats. [ 6 ]


Surge capacity is described as "the ability to expand care capabilities in response to sudden or more prolonged demand." [ 7 ]  The requirements of surge may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations. This is related to patients volume and  identifying numbers of hospital beds, personnel, supplies, and equipment should be identified and addressed." [ 8 ]  These factors are often described as the 4S; Staff, Stuff, Structure and Systems. [ 9 ] [ 10 ]


According to the U.S. Department of Health & Human Services, medical surge capability required "special intervention to protect medical providers, other patients, and the integrity of the HCO. This is also the ability to manage patients requiring specialized medical care and evaluation." Notable examples include influxes of patients with  SARS . [ 8 ]


The  National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR)  is an orthopedic hospital and undergraduate & post-graduate institute in  Sher-e-Bangla Nagar ,  Dhaka ,  Bangladesh . It was established in 1972 by the  Government of Bangladesh  as the Shaheed Suhrawardy Hospital. In October 2002 the name of the institute was changed to National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR). [ 1 ]  NITOR is affiliated previously  to       Dhaka University  and now to  Bangabandhu Sheikh Mujib Medical University .


Master of Surgery (MS) (Orthopedics) and D. Ortho. awarded by NITOR, a post-graduate institute, are recognized by the  Bangladesh Medical and Dental Council .


23°43′32″N   90°23′53″E  /  23.72556°N 90.39806°E  /  23.72556; 90.39806


This article about a hospital in Bangladesh is a  stub . You can help Wikipedia by  expanding it .


The  National Trauma Data Bank  ( NTDB ), also called the  American College of Surgeons National Trauma Data Bank , is a compilation of information about  traumatic injuries and outcomes  in the  United States . Hospital  emergency rooms  and other institutions such as  trauma centers  which are participants submit data and receive in return access to reports analyzing data about both their own operations and trauma medicine in the United States as a whole. [ 1 ]


Annual reports, an annual report and a pediatric report, which include  demographic  information is issued. Access to data sets is available to researchers who apply and are approved. [ 1 ]


Penetrating trauma  is an  open wound   injury  that occurs when an object pierces the  skin  and enters a  tissue  of the body, creating a deep but relatively narrow entry  wound . In contrast, a  blunt or  non-penetrating  trauma  may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment.  The penetrating object may  remain in the tissues , come back out the path it entered, or pass through the full thickness of the tissues and exit from another area. [ 1 ]


A penetrating injury in which an object enters the body or a structure and passes all the way through an exit wound is called a  perforating trauma , while the term  penetrating trauma  implies that the object does not perforate wholly through. [ 2 ]  In  gunshot wounds , perforating trauma is associated with an entrance wound and an often larger exit wound.


Penetrating trauma can be caused by a foreign object or by fragments of a broken bone.  Usually occurring in  violent crime  or  armed combat , [ 3 ]  penetrating injuries are commonly caused by  gunshots  and  stabbings . [ 4 ]


Penetrating trauma can be serious because it can damage internal organs and presents a risk of  shock  and  infection .  The severity of the injury varies widely depending on the body parts involved, the characteristics of the penetrating object, and the amount of  energy  transmitted to the tissues. [ 4 ]   Assessment may involve  X-rays  or  CT scans , and treatment may involve surgery, for example to repair damaged structures or to remove foreign objects. Following penetrating trauma,  spinal motion restriction  is associated with worse outcomes and therefore it should not be done routinely. [ 5 ]


As a missile passes through tissue, it  decelerates , dissipating and transferring  kinetic energy  to the tissues. [ 1 ]  The  velocity  of the projectile is a more important factor than its mass in determining how much damage is done; [ 1 ]  kinetic energy increases with the square of the velocity.  In addition to injury caused directly by the object that enters the body, penetrating injuries may be associated with secondary injuries, due for example to a  blast injury . [ 2 ]


The path of a projectile can be estimated by imagining a line from the entrance wound to the exit wound, but the actual trajectory may vary due to  ricochet  or differences in tissue density. [ 4 ]  In a cut, the discolouration and the swelling of the skin from a blow happens because of the ruptured blood vessels and escape of blood and fluid and other injuries that interrupt the circulation. [ 6 ]


Low-velocity items, such as knives and swords, are usually propelled by a person's hand, and usually do damage only to the area that is directly contacted by the object. [ 7 ]  The space left by tissue that is destroyed by the penetrating object as it passes through forms a cavity; this is called  permanent cavitation . [ 8 ]


High-velocity objects are usually  projectiles  such as  bullets  from high-powered rifles, such as  assault rifles [ 7 ]  or  sniper rifles .  Bullets classed as medium-velocity projectiles include those from  handguns ,  shotguns , [ 7 ]  and  submachine guns . In addition to causing damage to the tissues they contact, medium- and high-velocity projectiles cause a secondary cavitation injury: as the object enters the body, it creates a  pressure wave  which forces tissue out of the way, creating a cavity which can be much larger than the object itself; this is called "temporary cavitation". [ 8 ]  The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path. [ 9 ]


The characteristics of the tissue injured also help determine the severity of the injury; for example, the denser the tissue, the greater the amount of energy transmitted to it. [ 8 ]  Skin, muscles, and intestines absorb energy and so are resistant to the development of temporary cavitation, while organs such as the liver, spleen, kidney, and brain, which have relatively low tensile strength, are likely to split or shatter because of temporary cavitation. [ 10 ]  Flexible elastic soft tissues, such as muscle, intestine, skin, and blood vessels, are good energy absorbers and are resistant to tissue stretch.  If enough energy is transferred, the liver may disintegrate. [ 9 ]  Temporary cavitation can be especially damaging when it affects delicate tissues such as the  brain , as occurs in penetrating head trauma. [ citation needed ]


While  penetrating head trauma  accounts for only a small percentage of all  traumatic brain injuries  (TBI), it is associated with a high  mortality rate , and only a third of people with penetrating  head trauma  survive long enough to arrive at a hospital. Injuries from firearms are the leading cause of TBI-related deaths. Penetrating head trauma can cause  cerebral contusions  and lacerations,  intracranial hematomas ,  pseudoaneurysms , and  arteriovenous fistulas . The prognosis for penetrating head injuries varies widely. [ 11 ]


Penetrating  facial trauma  can pose a risk to the  airway  and  breathing ; airway obstruction can occur later due to  swelling  or bleeding. [ 12 ]  Penetrating  eye trauma  can cause the globe of the  eye  to rupture or  vitreous humor  to leak from it, and presents a serious threat to eyesight. [ 13 ]


Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%. [ 14 ]  Penetrating  chest trauma  can injure vital organs such as the heart and lungs and can interfere with breathing and circulation.  Lung injuries that can be caused by penetrating trauma include  pulmonary laceration  (a cut or tear)  pulmonary contusion  (a bruise),  hemothorax  (an accumulation of blood in the chest cavity outside of the lung),  pneumothorax  (an accumulation of air in the chest cavity) and  hemopneumothorax  (accumulation of both blood and air).   Sucking chest wounds  and  tension pneumothorax  may result. [ citation needed ]


Penetrating trauma can also cause injuries to the heart and circulatory system. When the heart is punctured, it may bleed profusely into the chest cavity if the membrane around it (the  pericardium ) is significantly torn, or it may cause  pericardial tamponade  if the pericardium is not disrupted. [ 15 ]   In pericardial tamponade, blood escapes from the heart but is trapped within the pericardium, so pressure builds up between the pericardium and the heart, compressing the latter and interfering with its pumping. [ 15 ]   Fractures of the ribs  commonly produce penetrating chest trauma when sharp bone ends pierce tissues.


Penetrating  abdominal trauma  (PAT) typically arises from stabbings, ballistic injuries (shootings), or industrial accidents. [ 16 ]  PAT can be life-threatening because abdominal organs, especially those in the  retroperitoneal space , can bleed profusely, and the space can hold a large volume of blood. [ 2 ]  If the pancreas is injured, it may be further injured by its own  secretions , in a process called  autodigestion . [ 2 ]  Injuries of the  liver , common because of the size and location of the organ, present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. [ 2 ]  The intestines, taking a large part of the lower abdomen, are also at risk of  perforation .


People with penetrating abdominal trauma may have signs of  hypovolemic shock  (insufficient blood in the  circulatory system ) and  peritonitis  (an inflammation of the  peritoneum , the membrane that lines the  abdominal cavity ). [ 2 ]  Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause  bruits  (a distinctive sound similar to  heart murmurs ) to be audible. [ 2 ]  Percussion of the abdomen may reveal  hyperresonance  (indicating air in the abdominal cavity) or dullness (indicating a buildup of blood). [ 2 ]  The abdomen may be distended or tender, signs which indicate an urgent need for surgery. [ 2 ]


The standard management of penetrating abdominal trauma was for many years mandatory  laparotomy . A greater understanding of mechanisms of injury, outcomes from surgery, improved imaging and interventional radiology has led to more conservative operative strategies being adopted. [ 16 ]


Assessment can be difficult because much of the damage is often internal and not visible. [ 4 ]  The patient is thoroughly examined. [ 2 ]  X-ray and  CT scanning  may be used to identify the type and location of potentially lethal injuries. [ 2 ]  Sometimes before an X-ray is performed on a person with penetrating trauma from a projectile, a paper clip is taped over entry and exit wounds to show their location on the film. [ 2 ]  The patient is given  intravenous  fluids to replace lost blood. [ 2 ]  Surgery may be required;  impaled  objects are secured into place so that they do not move and cause further injury, and they are removed in an  operating room . [ 2 ]  If the location of the injury is not obvious, a surgical operation called an  exploratory laparotomy  may be required to look for internal damage to the organs in the  abdomen . [ 17 ]  Foreign bodies such as bullets may be removed, but they may also be left in place if the surgery necessary to get them out would cause more damage than would leaving them. [ 12 ]  Wounds are  debrided  to remove tissue that cannot survive and other material that presents risk for infection. [ 2 ]


Negative pressure wound therapy is no more effective in preventing wound infection than standard care when used on open traumatic wounds. [ 18 ]


Before the 17th century, medical practitioners poured hot oil into wounds in order to  cauterize  damaged blood vessels, but the French surgeon  Ambroise Paré  challenged the use of this method in 1545. [ 19 ]  Paré was the first to  propose controlling bleeding using  ligature . [ 19 ]


During the  American Civil War ,  chloroform  was used during surgery to reduce pain and allow more time for operations. [ 2 ]  Due in part to the lack of  sterile technique  in hospitals, infection was the leading cause of death for wounded soldiers. [ 2 ]


In  World War I , doctors began replacing patients' lost fluid with salt solutions. [ 2 ]  With  World War II  came the idea of  blood banking , having quantities of  donated blood  available to replace lost fluids.  The use of  antibiotics  also came into practice in World War II. [ 2 ]


Perpetrator trauma , also known as  perpetration-  or  participation-induced traumatic stress  , both abbreviated to PITS, occurs when the symptoms of  posttraumatic stress disorder  (PTSD) are caused by an act or acts of killing or similar horrific violence.


Perpetrator trauma is similar but distinct from  moral injury , which focuses on the psychological, cultural, and spiritual aspects of a perceived moral transgression which produces profound shame.


The  DSM-5  addresses the idea of active participation as a cause of  trauma  under the discussion accompanying its definition of PTSD, and adds to the list of causal factors: "for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy."


There has been some study with  combat veterans , [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]  people who carry out  executions  or  torture , police who shoot in the line of duty, people who commit criminal  homicide , and others. [ 1 ]


All studies that have considered the question of severity, have indicated that symptoms tend to be more severe for those who have killed, than for other causes of traumatization. One study [ 6 ]  using the U.S. government database of  American veterans of Vietnam [ 7 ]  has suggested that the pattern of symptoms in combat veterans may be different in those who said they had killed, as opposed to those who said they had not. Symptoms include intrusive imagery,  dreams ,  flashbacks , unwanted thoughts, being more prominent, along with explosive outbursts of  anger , and  concentration  and  memory problems  being less prominent. [ 8 ] [ 9 ]


To a lesser extent,  hypervigilance , a sense of  alienation , and the non-PTSD symptom of a sense of disintegration were found to be greater for those who answered yes on killing.  Alcohol  and  cocaine use disorder  appeared to be more severe. [ 10 ] [ 11 ]


Compared to the victim form of being traumatized, there are different dream motifs reported. While the eidetic dreams – that is, those that are like a video of the event playing in the head – can be experienced as they are with traumatized victims, other motifs also appear more commonly. [ 1 ] [ 12 ] [ 13 ]
One is of having the tables turned and being the one killed, or being very vulnerable in the same situation. Another motif is that of the victims accusing the dreaming person, or demanding to know why he or she did it.  Also possible, is a motif of the self being split in two, so that the killer part of the person is seen as actually being a different person.


Therapies that have shown some effectiveness in the treatment of perpetrator trauma include  group therapy ,  eye movement desensitization and reprocessing , [ 14 ]  Time Perspective Therapy [ 15 ]  and understanding how common the problem is. [ 16 ]  Those who suffer, many of whom participated in violence as a matter of social expectation, find it beneficial to know that they are having a normal reaction to an abnormal situation, and are not uniquely cowardly or crazy. Traditional remedies of  atonement ,  forgiveness , and bearing witness have also stood the test of time as being helpful. [ 17 ]
More vigorous studies are needed for all these suggestions, as well as common PTSD therapies that have not yet been thoroughly explored, with the distinction of perpetration versus victimization in mind.


Other proposed treatments have been proven to be ineffective. The "flooding" technique, technically called  Prolonged Exposure , which desensitizes the sufferer of trauma by repeated exposure to reminders of it in controlled settings, appears to be a bad idea, counter-indicated when the trauma involved being active in inflicting harm. [ 18 ]  It may be that expressive writing, which most people find helpful in working through their traumas, instead increases anger in soldiers. [ 19 ]  Differences in what physiological mechanisms in what pharmaceutical drugs might be useful in therapy are not yet known.


In the 11th century, soldiers involved in the  Norman conquest of England , took part in the church administered  Ermenfrid Penitential , to atone for, and mentally process the violence they participated in. [ 20 ] : 225


Several of the symptoms are capable of causing or allowing for renewed acts of violence. [ 1 ] [ 21 ]  The outbursts of anger can have an impact in  domestic violence  and  street crime . The sense of  emotional numbing ,  detachment  and estrangement from other people can contribute to these, along with contributing to participation in further battle activities or to  apathetic  reactions when violence is done by others. Associated  substance use disorders  may also have connections to acts of violence.


Perpetrator trauma has been documented among the perpetrators of  the Holocaust , [ 22 ]  the  Indonesian Communist Purges , [ 23 ]  the  Cambodian genocide , [ 24 ]  the South African  apartheid , [ 25 ]  and among  slaughterhouse workers . [ 26 ] [ better source needed ] [ 27 ]
In writing about the experiences of American soldiers during the  Iraq War , the psychiatrist R. J. Lifton claims in the aftermath of the  Haditha massacre :


The alleged crimes in Iraq, like My Lai, are examples of what I call an atrocity-producing situation—one so structured, psychologically and militarily, that ordinary people, men or women no better or worse than you or I, can commit atrocities. A major factor in all of these events was the emotional state of US soldiers as they struggled with angry grief over buddies killed by invisible adversaries, with a desperate need to identify an 'enemy.' [ 28 ]


Referring to the definition of "atrocity-producing situation", Morag (2013) was one of the first scholars to theorize perpetrator trauma and delineate the victim-perpetrator distinction in the context of the twenty-first century new war on terror. [ 29 ]  According to Morag's theorization, perpetrator trauma as an ethical trauma has been documented among Israeli soldiers during the Intifada as well US soldiers in Iraq and Afghanistan. [ 30 ]  Authors from the PTSD Journal have documented perpetrator trauma among slaughterhouse workers, stating that "these employees are hired to kill animals, such as pigs and cows that are largely gentle creatures. Carrying out this action requires workers to disconnect from what they are doing and from the creature standing before them. This emotional dissonance can lead to consequences such as domestic violence, social withdrawal, anxiety, substance use, and PTSD." [ 31 ]


Polytrauma  and  multiple trauma  are medical terms describing the condition of a person who has been subjected to multiple  traumatic injuries , such as a serious head injury in addition to a serious burn. The term is defined via an  Injury Severity Score  (ISS) equal to or greater than 16. [ 1 ]  It has become a commonly applied term by  US military  physicians in describing the seriously injured soldiers returning from  Operation Iraqi Freedom  in  Iraq  and  Operation Enduring Freedom  in  Afghanistan . The term is generic, however, and has been in use for a long time for any case involving multiple trauma.


In civilian life, polytraumas often are associated with  motor vehicle crashes . This is because car crashes often occur at high velocities, causing multiple injuries. On admission to hospital any trauma patient should immediately undergo  x-ray  diagnosis of their  cervical spine ,  chest , and  pelvis , commonly known as a 'trauma series', to ascertain possible life-threatening injuries. (Where available, a CT trauma series for head, neck, thorax, abdomen and pelvis may be the imaging modality of first choice). Examples would be a fractured cervical  vertebra , a severely fractured pelvis, or a  haemothorax . Once this initial survey is complete, x-rays may be taken of the limbs to assess the possibility of other fractures. It also is quite common in severe trauma for patients to be sent directly to  CT  or a  surgery theatre , if they require emergency treatment.


Extracorporeal membrane oxygenation  (ECMO) may be effective in treating some polytrauma patients with pulmonary or cardiopulmonary failure. [ 2 ]


Polytrauma often results from blast injuries sustained from  improvised explosive devices , or by a hit with a  rocket-propelled grenade , with  "Improvised explosive devices, blasts, landmines, and fragments account[ing] for 65 percent of combat injuries ..." . [ 3 ]  The combination of high-pressure waves, explosive fragments, and falling debris may produce multiple injuries including  brain injury ,  loss of limbs ,  burns ,  fractures ,  blindness , and  hearing loss , [ 4 ]  with 60 percent of those injured in this way, having some degree of traumatic brain injury. [ 3 ]


In some respects, the high incidence of polytrauma in military medicine is, in fact, a sign of medical advancement. In previous wars most soldiers with such multiple injuries simply did not survive, even if quickly transferred into hospital care. Today many polytrauma victims never fully regain their previous physical capacity, and are more susceptible to psychological complications, such as  PTSD . [ 3 ]


As of 2013, there were five rehabilitation centers in the U.S. specialising in polytrauma. They are managed by the  United States Department of Veterans Affairs  and are located in  Minneapolis, Minnesota ;  Palo Alto, California ;  Richmond, Virginia ;  San Antonio, Texas , and  Tampa, Florida . [ 4 ]  In addition to the intensive care, insofar as still required, these hospitals mainly specialize in  rehabilitative treatment . In addition the Department of Veterans Affairs has 22 polytrauma network sites, located throughout the country.


Veterans Health Administration (VHA) developed a screening and evaluation process to ensure that OEF/OIF/OND Veterans with TBI are identified, and that they receive appropriate treatments and services. This includes mandatory screening for deployment-related TBI of all OEF/OIF/OND Veterans upon their initial entry into VHA for services. Veterans with positive screens are referred for a comprehensive evaluation by TBI specialists for diagnostic and treatment recommendations.


Based on extensive research, the VA-TBI Screening Tool has revealed high sensitivity and moderate specificity allowing VA to identify symptomatic Veterans and develop an appropriate plan of care. From 2007 to 2015, over 900,000 Veterans have been screened for possible OEF/OIF/OND deployment related TBI. Of those, approximately 20 percent had positive screens and were referred for further evaluation.  [1]


OEF/OIF/OND veterans have a high polytrauma rate. [ 5 ] [ 6 ] [ 7 ]  Respectfully, a study exhibited findings with a population of 16,590 OEF/OIF/OND veterans, in which 27.66% met the criteria for poly trauma. [ 7 ]  Those within this subpopulation were most likely male (92.9%) and White (71.0%). Similar findings in a sample of 2,441,698 OEF/OIF/OND active duty found that the rate of poly trauma was 5.99 per 1,000 individuals. [ 6 ]  Of those with polytrauma, 52.15% were most likely between the ages of 20–29 years, male (89.93%), White (69.07%), married (64.18%), and enlisted in the Army (74.71%). Furthermore, the rate of polytrauma among a sample of 613,391 OEF/OIF/OND veterans was 6% (36,800). [ 8 ]  Additional research has concluded that in a selection of 340 OEF/OIF/OND veterans, 42.1% exhibited symptoms of poly trauma. [ 9 ]


As of April 2007, the Department of Veterans Affairs has treated more than 350 service members in their inpatient centers.


The treatment and rehabilitative care for polytrauma  patients  is a very extensive and time-consuming activity. The recommended staffing numbers (FTE = Full Time Equivalent) for six rehabilitation treatment beds are: [ 3 ]


In other words, 2.8 people are required full-time (24h), for every patient, often for months, while some care may be required for life.


Psychological trauma  in adults   who are older  (usually more than 60 years), [ 1 ]  is the overall prevalence and occurrence of trauma symptoms within the  older adult population . (The term  psychological trauma  is sometimes hereinafter referred to as  trauma ). This should not be confused with  geriatric trauma . Although there is a 90% likelihood of an older adult experiencing a traumatic event, [ 2 ]  there is a lack of research on trauma in older adult populations. This makes research trends on the complex interaction between traumatic symptom presentation and considerations specifically related to the older  adult  population (e.g., the  aging  process, a lifetime prevalence of traumatic symptoms [otherwise known as lifetime trauma], etc.) difficult to pinpoint. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]  This article reviews the existing literature and briefly introduces various ways, apart from the occurrence of  elder abuse , that psychological trauma impacts the older adult population.


Psychological trauma in older adults can present differently depending on the type of traumatic experience and when it took place. [ 8 ]  If the traumatic experiences of an older adult were recurrent in childhood (see  childhood trauma  or  complex trauma ) or in adulthood, the experiences can have varying but lasting detrimental effects on an older adult's psychological well-being, [ 6 ] [ 8 ]  health, [ 2 ] [ 9 ] [ 10 ]  and cognition. [ 9 ] [ 10 ]


Older adults who experienced childhood-based trauma have a long-term trauma history, which increases their likelihood of experiencing more severe negative psychological, health, and cognitive symptoms. [ 9 ] [ 10 ] [ 11 ]  Additionally, the timing of trauma exposure has the potential to influence both the manifestation of  post-traumatic stress disorder (PTSD)  symptoms and the psychosocial functioning of older adults. Generally, older adults who identify their most distressing traumatic event as occurring during childhood tend to exhibit more severe symptoms of PTSD and report reduced subjective happiness compared to older adults who have experienced trauma later in life. [ 12 ]  A specific example is the intersection between recurrent interpersonal trauma and PTSD symptoms as an older adult. Research suggests that this intersection in older adults can lead to a perpetuating cycle where both components contribute to the experience of chronic pain later in life. [ 13 ]


Adulthood-based trauma considerations introduce the complexity of the interaction between an older adult's trauma presentation and potential neurocognitive components. [ 3 ]  Research indicates that older adults who have had PTSD are more likely to develop dementia  than those who did not have PTSD. [ 3 ] [ 14 ]   The neurocognitive effects of PTSD symptoms can also look similar to the neurocognitive effects of cognitive impairment in older adults. [ 3 ]


Psychological trauma diagnosis in older adults is considered less common than in younger adults. [ 3 ] [ 8 ] [ 9 ]  However, older adults' symptom presentations may make it more difficult for healthcare providers to identify trauma as the cause of an individual's symptoms (e.g., if the individual exhibits somatic representations of trauma symptoms; see  psychosomatic disorders ). [ 3 ] [ 8 ] [ 9 ] [ 11 ]  Some older adults may be more likely to report non-psychological symptoms and may not be aware that they may be experiencing trauma symptoms. [ 3 ]  Some trauma symptoms may emerge later on in life (known as Late-Onset Stress Symptomatology), [ 11 ]  which could make pinpointing a potential cause even more difficult. [ 11 ] [ 15 ]  Considering cohort factors is also important. [ 16 ]  The majority of today's older adults grew up during a time when psychological trauma was just starting to be acknowledged. [ 16 ]  This can make identifying and treating trauma within this population more difficult because there may be a lack of awareness or willingness to perceive their symptoms from a different perspective. [ 10 ] [ 11 ]


Older adults who experienced trauma in their later years may also retain harmful symptoms associated with the normal aging process (see  old age ). [ 17 ]  For example, there are several research studies on older adults potentially developing PTSD after experiencing a fall. [ 17 ]  As people get older, they tend to experience more falls, leading to a  fear of falling . [ 18 ]  A meta-analysis of these studies revealed that female older adults who were more frail had a greater likelihood of developing PTSD following a fall, compared to older adults who were less frail and had higher levels of psychological resilience. [ 17 ]  Older adults' past experiences paired with current perceptions and health conditions are likely to perpetuate various psychological disorders (i.e., depression, anxiety, and phobias related to older adult considerations such as falling) [ 18 ] [ 14 ]  as well as worsen existing PTSD symptoms. [ 3 ]


Research on psychological trauma in older adults is sparse, [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 13 ]  with some individual studies lacking empirical reliability and validity. [ 7 ]  In order to assess and treat psychological trauma in older adults, strong research is needed within  scientific  literature. This will help in creating  psychological screeners  for trauma, which can aid in differentiating trauma symptom from other health or psychological disorders. [ 7 ]  Trauma symptoms can manifest differently among older adults. While there isn't a PTSD screener specifically designed for the general older adult population, certain PTSD  screeners  have been successfully tested with  veteran  older adults and can effectively screen for PTSD. [ 3 ]


In fact, most of the research on psychological trauma in older adults stems from the veteran population. [ 8 ] [ 11 ] [ 14 ]  PTSD in the older adult veteran population is a focal point of research with Veterans Affairs (VA; see  Veterans Health Administration ). The VA has been considered a leader in trauma research for decades. [ 19 ]  Considering that the concept of trauma originated with soldiers' experiences in war (i.e., trauma was labelled as "shell shock" or "war neurosis"), [ 16 ]  the VA closely monitors trauma development and treatment for veterans of all ages and identities. [ 20 ]   The results with aging veterans highlights the need to further understand psychological trauma within older adults more generally, including how it impacts their quality of life. [ 11 ]


Research on trauma in older adults is relevant and applicable in clinical settings as well. The National Center for PTSD (NCPTSD) [ 19 ]  conducts clinical research through the VA by implementing and providing psychological treatment for veterans who have experienced trauma. [ 21 ]  This includes research into such treatments as  cognitive processing therapy  (CPT),  eye movement desensitization reprocessing  (EMDR), and  prolonged exposure therapy  (PE). [ 9 ] [ 21 ]  The NCPTSD claims these three therapeutic orientations have a 53% success rate in PTSD symptom remission. [ 19 ]  Although research indicates that exposure therapies generally show effectiveness for treating trauma in older adults, [ 7 ] [ 9 ]  PE has been specifically identified as a reliable therapeutic approach for this population. [ 9 ]  If an older adult has both psychological trauma and cognitive impairment, it is recommended to provide them with an adapted or modified version of an evidence-based therapeutic treatment. [ 3 ]  If an older adult with psychological trauma is considering taking medication concurrently with and as a supplement for therapy, the VA has identified four medications for PTSD treatment:  fluoxetine ,  paroxetine ,  sertraline , and  venlafaxine . [ 19 ]  While there is limited research on medication specifically for treating trauma in older adults, medication use in general (see  pharmacotherapy ) can be beneficial for psychological and health treatment. [ 18 ]  It is crucial to monitor medication half-lives and potential harmful interactions when taking multiple medications. [ 18 ]


Psychotraumatology  is the study of  psychological trauma . [ 1 ]  Specifically, this discipline is involved with researching, preventing, and treating traumatic situations and people's reactions to them. [ 1 ] [ 2 ]  It focuses on the study and treatment of  post-traumatic stress disorder (PTSD)  and  acute stress disorder (ASD) , but encompasses any adverse reaction after experiencing traumatic events, including  dissociative disorders . Since 2021, Certified Trauma Professionals who have achieved a major level of training and clinical expertise can use the abbreviation PsyT [ 3 ]  after their names as a standard of recognition in the trauma field. [ 4 ]


The emergence of psychotraumatology as a field begins with the legitimization of PTSD as a psychological disorder. Symptoms of PTSD have been continuously reported in the context of war since the 6th century B.C., but it was not officially recognized as a valid disorder until it finally classified by the  American Psychiatric Association (APA)  in 1980. [ 1 ]  Once it was officially recognized as an issue, clinical research on PTSD increased dramatically, giving way to the field of  psychotraumatology. [ 1 ]  The term "psychotraumatology" was coined by George S. Everly, Jr. and Jeffrey M. Lating in the text entitled "Psychotraumatology" (1995). [ 1 ]


Donovan ( 1991) suggested that the term traumatology be used to unite the various endeavors within the field of traumatic stress studies.  As Donovan notes, however, the term traumatology also denotes the branch of medicine that deals with wounds and serious injuries. Schnitt (1993) expressed concern over Donovan's choice of a term that has at least two meanings. He urged clarity of communications as this new field expands; indeed, expansion is often built upon and facilitated by clarity of communications fostered by sematic precision. In a rebuttal of sorts, Donovan (1993) argued for a term broader in scope than traumatic stress studies, the phrase that has been used historically to unite the field. Clearly Schnitt's (1993) commentary offers insight to be considered. There is significant potential for ambiguity in the use of traumatology as a unifying term for the field of psychological trauma. Donovan (1993) argues that the term is "socially influential as well as conceptually and pragmatically useful" (p. 41 0). The potential ambiguity serves to diminish the promised pragmatics, but the lack of sematic precision is easily corrected.


In 1995, the addition of the prefix psycho- to the root traumatology appears to clarify potential ambiguities and more clearly defines the conduct at hand. Such reasoning serves as the foundation for the choice of psychotraumatology as the title of this field published in the Volume of Psychotraumatology. [ 5 ]


There are three main categories that are looked at in psychotrauamatology: the factors before, during, and after a psychologically traumatizing event has occurred. [ 1 ]  Such factors include: [ 1 ]


The term psychotraumatology is used in the present context to define or order the conduct of inquiry and the categorization of information relevant to psychological trauma. Psychotraumatology may be defined as the study of psychological trauma; more specifically, the study of the processes and factors that lie (a) antecedent to, (b) concomitant with, and (c) subsequent to psychological traumatization (Everly, 1992; 1993).


Since the adoption of new evidence based models in trauma treatment a new specialization in psychotherapy has emerged, the psychotraumatologist.


According to the International Psychotraumatology Association a Psychotraumatologist standard of education and ethics:


A Licensed Clinical Psychotherapist or Psychiatrist with knowledge and training:


There are three main sub-specialization in the psychotraumatology field:


Railway spine  was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in  railroad accidents .


The first full-length medical study of the condition was  John Eric Erichsen 's classic book,  On Railway and Other Injuries of the Nervous System . [ 1 ]  For this reason, railway spine is often known as  Erichsen's disease .


Railway collisions were a frequent occurrence in the early 19th century.  Exacerbating the problem was that railway cars were flimsy, wooden structures with no protection for the occupants.


Soon a group of people started coming forward who claimed that they had been injured in train crashes, but had no obvious evidence of injury. The railroads rejected these claims as fake, sometimes belittling people's pain as  litigation neurosis , implying that the only real problem was the injured person making a legal claim. [ 2 ]


The nature of symptoms caused by "railway spine" was hotly debated in the late 19th century, notably at the meetings of the (Austrian) Imperial Society of Physicians in Vienna, 1886. Germany's leading neurologist,  Hermann Oppenheim , claimed that all railway spine symptoms were due to physical damage to the spine or brain, whereas French and British scholars, notably  Jean-Martin Charcot  and Herbert Page, insisted that some symptoms could be caused by  hysteria  (now known as  conversion disorder ). [ 3 ] [ 4 ] [ 5 ]


Erichsen observed that those most likely to be injured in a railway crash were those sitting with their backs to the acceleration. This is the same injury mechanism found in  whiplash . As with automobile accidents, railway and airplane accidents are now known to cause  posttraumatic stress disorder  (PTSD) and other  psychosomatic  symptoms in addition to physical trauma. [ 6 ]


Rape trauma syndrome  ( RTS ) is the  psychological trauma  experienced by a  rape  survivor that includes disruptions to normal physical, emotional, cognitive, and interpersonal behavior. The theory was first described by nurse  Ann Wolbert Burgess  and sociologist Lynda Lytle Holmstrom in 1974. [ 1 ]


RTS is a cluster of psychological and physical signs, symptoms and reactions common to most rape victims immediately following a rape, but which can also occur for months or years afterwards. [ 2 ]  While most research into RTS has focused on female victims, sexually abused males (whether by male or female perpetrators)  also exhibit RTS symptoms. [ 3 ] [ 4 ]  RTS paved the way for consideration of  complex post-traumatic stress disorder , which can more accurately describe the consequences of protracted trauma than  post-traumatic stress disorder  alone. [ 5 ]  The symptoms of RTS and post-traumatic stress syndrome overlap.  As might be expected, a person who has been raped will generally experience high levels of distress immediately afterward. These feelings may subside over time for some people; however, individually each syndrome can have long devastating effects on rape victims and some victims will continue to experience some form of psychological distress for months or years. Rape survivors are at high risk for developing  substance use disorders ,  major depression ,  generalized anxiety disorder , and  obsessive-compulsive disorder . [ 6 ]


RTS identifies three stages of  psychological trauma  a rape survivor goes through: the acute stage, the outer adjustment stage, and the renormalization stage.


The acute stage occurs in the days or weeks after a rape. Durations vary as to the amount of time the victim may remain in the acute stage. The immediate symptoms may last a few days to a few weeks and may overlap with the outward adjustment stage.
According to Scarse, [ 7 ]  there is no "typical" response amongst rape victims. However, the U.S.  Rape Abuse and Incest National Network [ 8 ]  (RAINN) asserts that, in most cases, a rape victim's acute stage can be classified as one of three responses: expressed ("He or she may appear agitated or hysterical, [and] may suffer from crying spells or anxiety attacks"); controlled ("the survivor appears to be without emotion and acts as if 'nothing happened' and 'everything is fine'"); or shock/disbelief ("the survivor reacts with a strong sense of disorientation. They may have difficulty concentrating, making decisions, or doing everyday tasks. They may also have poor recall of the assault"). Not all rape survivors show their emotions outwardly. Some may appear calm and unaffected by the assault. [ 2 ]


Behaviors  present in the acute stage can include:


Survivors in this stage seem to have resumed their normal lifestyle. However, they simultaneously suffer profound internal turmoil, which may manifest in a variety of ways as the survivor copes with the long-term trauma of a rape. In a 1976 paper, Burgess and Holmstrom [ 10 ]  note that all but 1 of their 92 subjects exhibited maladaptive coping mechanisms after a rape. The outward adjustment stage may last from several months to many years after a rape.


RAINN [ 8 ]  identifies five main coping strategies during the outward adjustment phase:


Other  coping mechanisms  that may appear during the outward adjustment phase include:


Survivors in this stage can have their lifestyle affected in some of the following ways:


Some rape survivors may see the world as a more threatening place to live in, so they will place restrictions on their lives, interrupting their normal activity. For example, they may discontinue previously active involvements in societies, groups or clubs, or a parent who was a survivor of rape may place restrictions on the freedom of their children.


Whether or not they were injured during a  sexual assault , survivors exhibit higher rates of poor health in the months and years after an assault, [ 4 ]  including acute  somatoform disorders  (physical symptoms with no identifiable cause). [ 1 ]   Physiological  reactions such as  tension headaches ,  fatigue , general feelings of soreness or localized pain in the chest, throat, arms or legs. Specific symptoms may occur that relate to the area of the body assaulted. Survivors of oral rape may have a variety of mouth and throat complaints, while survivors of vaginal or anal rape have physical reactions related to these areas.


A common psychological defense that is seen in rape survivors is the development of fears and  phobias  specific to the circumstances of the rape, for example:


In this stage, the survivor begins to recognize their adjustment phase.   Recognizing the impact of the rape for survivors who were in  denial , and recognizing the secondary damage of any counterproductive coping tactics (e.g., recognizing that one's drug abuse began to help cope with the aftermath of a rape) is particularly important.  Male survivors typically do not seek psychotherapy for a long time after the sexual assault—according to Lacey and Roberts, [ 19 ]  less than half of male survivors sought therapy within six months and the average interval between assault and therapy was 2.5 years; King and Woollett's [ 20 ]  study of over 100 male rape survivors found that the mean interval between assault and therapy was 16.4 years.


During renormalization, survivors integrate the sexual assault into their lives so that the rape is no longer the central focus of their lives; negative feelings such as  guilt  and  shame  become resolved, and survivors no longer blame themselves for the attack.


Prosecutors sometimes use RTS evidence to disabuse jurors of prejudicial misconceptions arising from a victim's ostensibly unusual post-rape behavior. The RTS testimony helps educate the jury about the psychological consequences surrounding rape and functions to dispel  rape myths  by explaining counterintuitive post-rape behavior.


Especially in cases in which prosecutors have introduced RTS testimony, defendants have also sometimes proffered RTS evidence, a practice that has been criticized as undermining core values embodied in  rape shield laws , since it can involve subjecting victims to compelled psychological evaluations and searching cross-examination regarding past sexual history. Since social scientists have difficulty distinguishing symptoms attributable to rape-related PTSD from those induced by previous traumatic events, rape defendants sometimes argue that an alternative traumatic event, such as a previous rape, could be the source of the victim's symptoms. [ 21 ]


A criticism of rape trauma syndrome as currently conceptualized is that it delegitimizes a person's reaction to rape by describing their coping mechanisms, including their rational attempts to struggle through, survive the pain of sexual assault, and to adapt to a violent world, as symptoms of disorder. People who installed locks and purchased security devices, took self-defense classes, carried mace, changed residence, and expressed anger at the criminal justice system, for example, were characterized as exhibiting pathological symptoms and "adjustment difficulties". According to this criticism, RTS removes a person's pain and anger from their social and political context, attributing a person's anguish, humiliation, anger, and despair after being raped to a disorder caused by the actions of the rapist, rather than to, say, insensitive treatment by the police,  examining physicians , and the judicial system; or to family reactions permeated with rape mythology. [ 22 ]


Another criticism is that the literature on RTS constructs rape survivors as passive, disordered victims, even though much of the behavior that serves as the basis for RTS could be considered the product of strength. Words like "fear" are replaced with words like "phobia", with its connotations of irrationality. [ 23 ]


Criticisms of the scientific validity of the RTS construct are that it is vague in important details; it is unclear what its boundary conditions are; it uses unclear terms that do not have a basis in psychological science; it fails to specify key quantitative relationships; it has not undergone subsequent scientific evaluation since the 1974 Burgess and Holstrom study; there are theoretical  allegiance effects ; it has not achieved a consensus in the field; it is not falsifiable; it ignores possible mediators; it is not  culturally sensitive ; and it is not suitable for being used to infer that rape has or has not occurred. PTSD has been described as a superior model since unlike RTS, empirical examination of the PTSD model has been extensive, both conceptually and empirically. [ 24 ]


Suicide and trauma  is the increased risk of  suicide  that is caused by  psychological trauma .


The National Institute of Mental Health  defines suicide as a self-inflicted act of  violence  with the intention of  death  that leads to the actual death of oneself. [ 1 ]  Although  rates of suicide  vary worldwide, suicide ranks as the tenth leading cause of death in the  United States  with rates increasing on average by one to two percent per year between 1999 and 2018, with the later years within that time span increasing at the greater rate. [ 2 ] [ 3 ] [ 4 ]  In 2017, the United States alone accounted for 2,813,503 deaths by suicide. [ 4 ]  Existing research has identified risk factors for suicide and the impacts of a suicide by a close other on a surviving individual.


Suicide research has commonly identified  psychiatric disorders , particularly  depression , as major risk factors for suicide. [ 5 ] [ 6 ]  A systematic review found that more severe cases of depression and high levels of  hopelessness  indicate greater risk for suicide. [ 6 ]  Other factors identified with increased suicide risk include being of the male gender, having a family history of mental illness and/or suicide, having previously attempted suicide and/or engaged in  self-harming  behaviors, having co-morbid mental disorders, having been recently released from  inpatient care  for mental health, and being in the period just prior to beginning and/or just following initiation of  antidepressant  treatment or  psychotherapy . [ 2 ] [ 7 ]  Employment status, physical illness, major life events, recent exposure to suicidal acts, and access to means are also known factors to generally increase the risk for suicide. [ 2 ] [ 8 ] [ 9 ]


Despite the variation in  suicide methods  used across countries and between cultures, common methods identified include the use of  firearms ,  poison  by  drugs , poison by  pesticides , jumping from heights,  hanging , and  suffocation . [ 10 ] [ 4 ]  Prevalence of pesticide suicide has been shown to be higher in  Asian  countries, whereas suicide by firearms is more prevalent in the United States and some  European  countries where ownership of firearms is common within the home. [ 10 ]


Research has given particular consideration to the impacts of suicide within a  family , whether by  spouse ,  parent , or  child . [ 11 ]  However, most studies have not examined the quality of the relationships within the family or the effect of different family members’ reactions on the others. [ 11 ]


Suicide by a spouse has been associated with greater risk for mental illness, including depression,  PTSD , and engagement in self-harming behaviors. [ 12 ]  Spousal suicide has also been associated with adverse changes in physical health and social functioning, mortality, increased risk of suicide, and increased utilization of  mental health  services. [ 12 ] [ 13 ]


Changes in family dynamics and functioning has been reported in the context of suicide by a child, which researchers note may affect relationships and bonding with surviving children within a family. [ 14 ]  More extreme types of family functioning with regard to cohesion and adaptability were associated with greater susceptibility to stress related to the death of a child such as the  anniversary of one's birth  and  death  and decisions regarding one's belongings. [ 14 ]  Many families must also navigate other stressors such as addressing the needs of surviving children and family members, which researchers assert can place the family at risk for additional health implications. [ 14 ]  Increases in utilization of mental health services and risk of suicide in parents has also been linked to experiencing suicide of a child. [ 13 ]


Studies have also shown the experience of a suicide or  suicide attempt  within a family is associated with greater engagement in risky behaviors in  adolescents  such as  substance use , self-harm, and one's own  suicidal ideation  and attempts, and higher rates of depression in suicide-bereaved children relative to their non-suicide-bereaved counterparts. [ 15 ] [ 16 ] [ 17 ]  Children of parents who have attempted suicide are at six times greater risk of attempting themselves. [ 18 ]  Although most suicides and suicidal behaviors within the family occur in the context of  mood disorders  transmitted within the family, mood disorders do not account for the totality of this phenomenon. [ 18 ]  Studies show increased risk of suicide and suicidal behaviors remain evident, despite familial transmission of mental illness. [ 18 ]


Exposure to suicide increases risk for  mental illness  and subsequent suicides. [ 11 ]   Prevention  efforts have focused on identifying at-risk groups. [ 5 ] [ 2 ]  Suicide researchers have suggested providers monitor individuals'  impulsivity , hopelessness, and access to means to increase prevention of suicidal acts. [ 10 ] [ 5 ]  Detection and management of mental illness has also been suggested to be an effective method aimed at reducing rates of suicide. [ 5 ]  In the context of exposure to suicide within a family, researchers have suggested providers aim to improve family functioning and responsiveness to suicide-related stressors and advocate for families’ mental health care and access to other services when indicated. [ 14 ]


Psychological trauma often occurs when an individual faces an extensive degree of  stress  in which they are unable to cope with, resulting in difficulties processing and integrating the stressful event. [ 19 ]  Definitions of trauma have been extended over the past few decades to include a wider range of traumatic experiences, including the sudden or unexpected death of a close other (e.g. suicide). [ 20 ]  More recent definitions of trauma have also evolved such that greater emphasis is placed on the individual's perceptions of the traumatic event as opposed to its objective features, giving rise to the notion that similar events can lead to grossly different outcomes across individuals. [ 20 ]  Despite high rates of exposure to trauma, only a small percentage of those exposed go on to develop clinically significant symptoms of post-traumatic stress disorder, achieving criteria for a full diagnosis. [ 20 ]  However, studies have demonstrated a connection between exposure to traumatic events and negative mental health outcomes, including depression,  anxiety , substance use, and other externalizing disorders. [ 21 ]


While the act of suicide itself is often an independent act, suicide has the ability to affect broader social networks such as family,  friends , and the community and can be experienced as traumatic. [ 22 ] [ 11 ]  Exposure to violent deaths, such as suicide, have been associated with  grief  and trauma, and traumatic events as such may create a greater risk for the development of post-traumatic stress disorder. [ 14 ] [ 23 ]  Consideration has also been given to the impact of client suicide on providers such as  mental health professionals . [ 24 ]  A review of 57 studies revealed that the nature of the relationship between the departed and the surviving individual or individuals is associated with the adverse outcomes in the latter's mental and  social health . [ 13 ]


The  semicircular canal dehiscence  ( SCD ) is a category of rare  neurotological   diseases/disorders  affecting the  inner ears , which gathers the superior SCD, lateral SCD and posterior SCD. These SCDs induce SCD syndromes (SCDSs), which define specific sets of hearing and balance symptoms. [ 1 ] [ 2 ]  This entry mainly deals with the superior SCDS.


The  superior semicircular canal dehiscence syndrome  ( SSCDS ) is a set of hearing and balance symptoms that a rare disease/disorder of the  inner ear 's  superior semicircular canal/duct  induces. [ 3 ] [ 4 ] [ 5 ]   The symptoms are caused by a thinning or complete absence of the part of the  temporal bone  overlying the  superior semicircular canal  of the  vestibular system . There is evidence that this rare defect, or susceptibility, is congenital. [ 6 ] [ 7 ]  There are also numerous cases of symptoms arising after physical trauma to the head. It was first described in 1998 by  Lloyd B. Minor  of  Johns Hopkins University  in  Baltimore . [ 8 ]


The superior canal  dehiscence  can affect both hearing and balance to different extents in different people. [ citation needed ]


Symptoms of the SCDS include:


According to current research, in approximately 2.5% of the general population the bones of the head develop to only 60–70% of their normal thickness in the months following birth. This genetic predisposition may explain why the section of temporal bone separating the superior semicircular canal from the  cranial cavity , normally 0.8 mm thick, shows a thickness of only 0.5 mm, making it more fragile and susceptible to damage through physical head trauma or from slow erosion. An explanation for this erosion of the bone has not yet been found. [ citation needed ]


The presence of dehiscence can be detected by a high definition (0.6 mm or less) coronal  CT scan  of the  temporal bone , currently the most reliable way to distinguish between superior canal dehiscence syndrome (SCDS) and other conditions of the inner ear involving similar symptoms such as  Ménière's disease ,  perilymphatic fistula  and  cochlea-facial nerve dehiscence . [ 10 ] [ 11 ]  Other diagnostic tools include the  vestibular evoked myogenic potential  or  VEMP  test,  videonystagmography  ( VNG ),  electrocochleography  (ECOG) and the rotational chair test. An accurate diagnosis is of great significance as unnecessary exploratory middle ear surgery may thus be avoided. Several of the symptoms typical to SCDS (e.g. vertigo and  Tullio ) may also be present singly or as part of Ménière's disease, sometimes causing the one illness to be confused with the other. There are reported cases of patients being affected by both Ménière's disease and SCDS concurrently. [ citation needed ]


As SCDS is a very rare and still a relatively unknown condition, obtaining an accurate diagnosis of this distressing (and even disabling) disease may take some time as many health care professionals are not yet aware of its existence and frequently dismiss symptoms as being mental health-related. [ 12 ]


Once diagnosed, the gap in the temporal bone can be repaired by surgical resurfacing of the affected bone or plugging of the superior semicircular canal. [ 13 ] [ unreliable source? ] [ 14 ]  These techniques are performed by accessing the site of the dehiscence either via a middle fossa  craniotomy  or via a canal drilled through the  transmastoid bone  behind the affected ear. Bone cement has been the material most often used, in spite of its tendency to slippage and resorption, and a consequent high failure rate; recently, soft tissue grafts have been substituted. [ 15 ]


Occasionally this disorder has been referred to as  Minor's syndrome,  after its discoverer,  Lloyd B. Minor . However, that eponym has also been given to an unrelated condition, the paralysis and anaesthesia following a spinal injury, which is named after the Russian neurologist,  Lazar Minor  (1855–1942). In the latter case this term is now nearly obsolete. [ 16 ]


Trauma in children , also known as  pediatric trauma , refers to a  traumatic  injury that happens to an  infant ,  child  or  adolescent . Because of  anatomical  and  physiological  differences between children and  adults  the care and management of this population differs.


There are significant anatomical and physiological differences between children and adults. For example, the  internal organs  are closer in proximity to each other in children than in adults; this places children at higher risk of traumatic injury. [ 1 ]


Children present a unique challenge in trauma care because they are so different from adults - anatomically, developmentally, physiologically and emotionally. A 2006 study concluded that the risk of death for injured children is lower when care is provided in pediatric trauma centers rather than in non-pediatric trauma centers. Yet about 10% of injured children are treated at pediatric trauma centers. The highest mortality rates occur in children who are treated in rural areas without access trauma centers. [ 2 ]


An important part of managing trauma in children is  weight estimation . A number of methods to estimate weight exist, including the Broselow tape, Leffler formula, and Theron formula. [ 3 ]  Of these three methods, the Broselow tape is the most accurate for weight estimation in children ≤25 kg, [ 3 ]  while the Theron formula performs better with patients weighing >40 kg. [ 3 ]


Due to basic  geometry , a child's weight to surface area ratio is lower than an adult's, children more readily lose their body heat through radiation and have a higher risk of becoming  hypothermic . [ 4 ] [ 5 ]  Smaller body size in children often makes them more prone to  poly traumatic  injury. [ 6 ]


Several classification systems have been developed that use some combination of subjective and objective data in an effort to quantify the severity of trauma. Examples include the  Injury Severity Score [ 7 ] [ 8 ]  and a modified version of the  Glasgow Coma Scale . [ 9 ]  More complex classification systems, such as the  Revised Trauma Score ,  APACHE II , [ 10 ]  and  SAPS II [ 11 ]  add physiologic data to the equation in an attempt to more precisely define the severity, which can be useful in triaging casualties as well as in determining medical management and predicting prognosis.


Though useful, all of these measures have significant limitations when applied to pediatric patients. For this reason, health care providers often employ classification systems that have been modified or even specifically developed for use in the pediatric population. For example, the  Pediatric Glasgow Coma Scale  is a modification of the Glasgow Coma Scale that is useful in patients who have not yet developed language skills. [ 12 ]


Emphasizing the importance of body weight and airway diameter, the Pediatric Trauma Score (PTS) was developed to specifically reflect the vulnerability of children to traumatic injury. The minimal score is -6 and the maximum score is +12. There is a linear relationship between the decrease in PTS and the mortality risk (i.e. the lower the PTS, the higher the mortality risk). [ 12 ]  Mortality is estimated at 9% with a PTS > 8, and at 100% with a PTS ≤ 0. [ citation needed ]


In most cases the severity of a pediatric trauma injury is determined by the pediatric trauma score [ 4 ]  despite the fact that some research has shown there is no benefit between it and the revised trauma scale. [ 13 ]


The management of pediatric trauma depends on a knowledge of the physiological, anatomical, and developmental differences in comparison to an adult patient, this requires expertise in this area. [ 14 ]  In the pre-hospital setting issues may arise with the treatment of pediatric patients due to a lack of knowledge and resources involved in the treatment of these injuries. [ 15 ]  Despite the fact there is only a slight variation in outcomes in adult trauma centers, definitive care is best reached at a pediatric trauma center. [ 16 ] [ 17 ]


Based on the  Centers for Disease Control and Prevention 's (CDC) WISQARS database for the latest year of data (2010), serious injury kills nearly 10,000 children in America each year. [ 18 ]


Pediatric trauma accounted for 59.5% of all mortality for children under 18 in 2004. [ 1 ] [ 19 ]  Injury is the leading cause of death in this age group in the  United States —greater than all other causes combined. [ 20 ]  It is also the leading cause of permanent paralysis for children. [ 21 ] [ 22 ]  In the US approximately 16,000,000 children go to a hospital  emergency room  due to some kind of injury every year. [ 4 ]  Male children are more frequently injured than female children by a ratio of two to one. [ 4 ]  Some injuries, including  chemical eye burns , are more common among young children than among their adult counterparts; these are largely due to cleaning supplies and similar  chemicals  commonly found around the home. [ 23 ]  Similarly, penetrating injuries in children is because of  writing utensils  and other common household objects as many are readily available to children in the course of their day. [ 24 ]


The  Trauma Quality Improvement Program  ( TQIP ) was initiated in 2008 by the  American College of Surgeons  Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult  trauma  outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals to objectively evaluate their trauma centers' performance relative to other hospitals. TQIP's administrative costs are less than those of other programs, making it an accessible tool for assessing performance and enhancing quality of trauma care.


Morbidity and mortality rates are variable across United States  trauma centers . Institutional variations can be attributed to differences in both patient population and quality of care at each institution. [ 1 ]  The  Institute of Medicine  (IOM) report  To Err is Human: Building A Safer Health System  emphasized the importance of recognizing variability and inefficiencies in the  United States healthcare  system. [ 2 ] [ 3 ]  To address these discrepancies, John Fildes, MD, FACS created an  ad hoc  work group to create and implement an outcomes-based, validated, risk-adjusted trauma quality improvement system. The goal was to utilize existing trauma infrastructures to measure and continually improve the quality of trauma care. This was done by accessing each hospital's registry database using the National Trauma Data Standard (NTDS) from the  National Trauma Data Bank  (NTDB), resulting in the creation of the Trauma Quality Improvement Program (TQIP) by the  American College of Surgeons  (ACS). [ 1 ]


TQIP was preceded by surgical indicators that included the Optimal Resources for the Care of the Injured reference document, published by the ACS Committee on Trauma in 1979. The document created a framework for the trauma center verification review process with a  systems approach  to trauma care. [ 4 ]  The Major Trauma Outcome Study (MTOS) of 1982–1989 subsequently established the national standards for trauma care. The MTOS database also facilitated the creation of a methodology to estimate an individual trauma patient's survival probability, also known as the Trauma Injury Severity Score (TRISS). [ 1 ]  Other studies, such as the 2006 National Study of the Costs and Outcomes of Trauma (NSCOT), aimed to identify differences in expenditures and outcomes at various hospitals. [ 5 ]


A  pilot study  was initiated in June 2008 to refine the methodology and assess the feasibility of applying TQIP for quality improvement at different trauma centers. Twenty-three Level I and II trauma centers volunteered and were selected to participate in the study with ACS verification. Most Level I centers are university-based trauma centers with comprehensive services. Level II centers were included to increase geographic and patient diversity, as well as the statistical power of any analyses. Each participating center received a registrar training course that included information about TQIP objectives and infrastructures, critical data collection fields, and NTDS data definitions. Webinars with conference calls and test case data abstraction were used for follow-up training. [ 4 ]


Using NTDB data from patients admitted to trauma centers between January 1 and December 1, 2007, three cohorts were created. The first cohort included patients with blunt multisystem or blunt mechanism traumas with an  Abbreviated Injury Scale  (AIS) score ≥ 3 in two or more regions including the head, face, neck, thorax, abdomen, spine, and extremities. The second cohort was composed of trauma patients with penetrating truncal injuries with an AIS score ≥ 3 in at least one region including the neck, thorax, and abdomen. Patients in the third cohort had a blunt single-system injury with an AIS score ≥ 3 in only one AIS body region, with the remaining regions having a maximum AIS score of 2. The outcomes of interest were death during hospitalization as evidenced by an  emergency department  (ED) discharge disposition of “death” or hospital discharge disposition of “expired,” as well as the prevalence of inpatient complications. [ 4 ]


Data reports were created and distributed to each participating trauma center in June 2009. Results were consistent with the previous year's baseline findings. Cohorts of similar verified trauma centers had differences in risk-adjusted mortality rates with a large amount of variance between low-outlier and high-outlier trauma centers. The aggregate group had a relative risk-mortality of 3.3, while the single-system trauma cohort had a mortality 5.9 times higher for high-outlier facilities. [ 4 ]


The TQIP pilot results gave each trauma center feedback regarding their trauma outcomes relative to other hospitals. The results also shed light on appropriate actions to undertake in order to improve quality, such as by illuminating local or regional collaborative efforts that could implemented. Overall, the pilot study demonstrated that TQIP's anonymous measures of relative performance could successfully allow trauma centers to identify shortcomings and facilitate quality improvement using existing resources and systems at local, regional, and national levels. [ 4 ]


TQIP utilizes a  retrospective cohort  of trauma patients in designated and ACS-verified Level I and II hospitals in the United States and Canada. There is no minimum sample size requirement for a trauma center to participate in the program. As of 2014 [update] , over 200 participating Level I and II trauma centers that vary in type (public, private teaching university, teaching community, etc.) and region participate in TQIP. [ 2 ]


To participate in the program, patients must meet the following inclusion criteria: be an adult greater than sixteen years of age with at least one valid  ICD 9 CM  diagnosis code, history of blunt or penetrating mechanisms of injury, or have an AIS score ≥ 3. Eligible patients also must have emergency department or hospital dispositions available. [ 2 ]


Patients are excluded from the program if they have a pre-existing  advance directive  to withhold life-sustaining measures or are older than 65 years of age and have an isolated hip fracture. [ 2 ]


The program categorizes patients into different cohorts in order to evaluate different aspects of trauma care. [ 2 ]  The cohorts are as follows:


This program focuses on mortality, complications, and resource use. Mortality is further subdivided into on arrival, in the emergency department, and in-hospital. Complications are further subdivided into  urinary tract infections , deep  venous thrombosis ,  ventilator-associated pneumonia ,  central line -related  bacteremia ,  renal failure , and  surgical site infections .  Resource use is measured via  length of stay  in the hospital, length of stay in the  intensive care unit , and number of days that a patient is on a  ventilator . [ 2 ]


TQIP addresses quality issues by explicitly addressing certain care metrics, including monitoring  intracranial pressure  in patients with  traumatic brain injuries , measuring time to operations, measuring the placement and timing of  tracheostomies , measuring the time to  hemorrhage  control, and documenting the use of  venous thromboembolism   prophylaxis . [ 2 ]


TQIP helps ensure the quality of data by providing training for trauma registrars and data abstractors. TQIP administrators hold monthly activities, such as webinars and quizzes, to educate registrars on the importance of data quality. Administrators assess outlier values, perform internal and external validation, and perform data logic checks. [ 2 ]


TQIP measures multiple variables in its risk-adjustment models. These variables include factors such as age, race, gender, initial pulse rate in the emergency department, the mechanism of injury, etc. An 18 variable multivariable logistic regression model is used to estimate risk-adjusted mortality for trauma patients. Results provide observed-to-expected ratios and a 90%  confidence interval  of a trauma center's data compared to other de-identified trauma centers in order to gauge relative variability. [ 2 ]


TQIP is designed to give each hospital an objective measure of its trauma center's performance compared to that of other trauma centers. It is meant as a self-reflective tool to be used in determining how to improve outcomes and decrease costs by understanding the reasons for variability and identifying best practices. Results are not intended to be used for marketing purposes or bestowing competitive advantages. [ 1 ]  TQIP reports allow hospitals to focus on outcomes and workflows, including care coordination, in-hospital processes, and resource allocation. [ 6 ]


TQIP's external benchmarking utilizes NTDB data collection and NTDS with specific enhancements. Deliverables comprise risk adjusted hospital comparisons in the form of one annual benchmark report as well as two separate annual reports related to a topic of interest and the TQIP online analysis tool. Education and training are delivered via the annual meeting, online training, monthly educational experiences for abstractors, and monthly open forum calls for registry staff. Data are submitted quarterly and quality is monitored through a data validation site visit, a TQIP validator, and data quality reporting. Feedback to participating trauma centers about their relative performance encourages the sharing of practices during the annual meeting with emphasis on high performers and web conferences. [ 4 ]


The TQIP annual fee is $9,000 and includes the deliverables above. Additional costs include the salary of the registrar and trauma registry software. As the compilation and maintenance of the trauma registry are required for verification, the additional cost to a currently verified trauma center is for participation. [ 4 ]


TQIP's outcome estimates are heavily dependent on data quality and sample size for each participating trauma center. Despite the development of sophisticated statistical models which attempt to mitigate errors in precision, the small sample sizes of highly specific trauma patient populations will inevitably skew results. Similarly, centers reporting data need to be hyper-aware of their reporting for data fields for certain patient populations susceptible to biased or missing data (e.g., high prevalence of low  Injury Severity Scores  for patients with early death who did not receive complete diagnostic testing or autopsies). [ 2 ]


As of 2013 [update] , TQIP has not incorporated measures related to racial disparities in trauma outcomes. However, there is evidence to suggest that differences in trauma outcomes are due to the overall quality of hospitals serving higher proportions of minority patients, rather than being due to discriminatory delivery of care; that is, these hospitals are less likely to provide recommended care to patients. [ 7 ]  In fact, almost 80% of trauma centers serving primarily minority patients are classified as high mortality trauma centers due to their ratios of observed-to-expected survival rates. Patients from all racial and ethnic backgrounds appear to be 40% more likely to survive when treated at low mortality trauma centers when compared with patients of the same race and ethnicity with the same injuries being treated at high mortality trauma centers. [ 8 ]  Differences between groups are relatively small compared to overall discrepancies between recommended and observed care. [ 9 ]  Still, high mortality status is not universal among institutions treating predominantly minority patients, and TQIP has not addressed this inequity. [ 8 ]


TQIP excludes from statistical analyses all  dead on arrival  (DOA) patients and those who expire in the emergency department. This is done out of concern regarding varying patient transit times among trauma centers located in more urban vs. rural environments as well as the severity of injuries more likely to be present at certain trauma centers. However, this practice has the potential to remove a sizable number of patients from a trauma center's mortality index (for example, if a trauma center that is exceptionally skillful at the resuscitation phase of care may receive no credit), thus impeding analysis of a vital component of trauma care. Similarly, there can be great variation in how trauma centers classify DOA patients, leading to differences in treatment (e.g., resuscitation attempts or other invasive procedures). While independent researchers have found that inclusion of ED deaths in statistical analyses yields only small, insignificant changes in TQIP outcomes, doing so eliminates bias that might otherwise be introduced. [ 10 ]


As of 2014 [update] , over 200 Level I or Level II trauma centers are participating in TQIP, which is facilitating the identification of high performers. Enrollment is done on a rolling basis that allows hospitals to join at any time. Additionally, a pediatric TQIP pilot with thirty-eight participating centers is currently underway and external data validation has been implemented. [ 11 ]


In psychology,  Trauma-informed feminist therapy  is a model of trauma for both men and women that incorporates the client's  sociopolitical  context.


In  feminist therapy , the therapist views the client's trauma experience through a sociopolitical lens.  In other words, the therapist must consider how the client's social and political environment could have contributed to their trauma or perpetuated it. Feminist theory argues that certain traumas are produced and maintained by  institutionalized discrimination  and  social hierarchies . [ 1 ]


The diagnosis of  Post-traumatic stress disorder , or PTSD, was first recognized in 1980 and published in the third edition of the  Diagnostic and Statistical Manual of Mental Disorders . [ 2 ] [ 3 ]  The original PTSD diagnosis was formulated to fit the  symptomology  of veterans returning home from combat.


Feminist psychologists modified the diagnosis when treating patients with exposure to childhood sexual assault, chronic  abuse , and gender-based trauma. [ 4 ]   Trauma-informed feminist therapy challenged both the traditional conceptualization of the PTSD diagnosis, as well as the overall standard approach to trauma treatment, by proposing new models of trauma that incorporate sociopolitical context. [ 5 ]


Feminist therapy began in the 1960s during the  second wave of feminism .  According to its proponents, a  sexist  power structure in American psychotherapy was harmful to women suffering trauma.   Initially, groups of women began to meet at leader-less " consciousness-raising ," meetings where women shared their experiences with sexism in therapy.  Many women evoked opinions that  oppressive  cultural norms  affect mental health.  To them,  the groups acted as a way to both draw attention to the oppression within the mental health system, as well as a way to empower women. [ 6 ]


The original consciousness-raising meetings evolved into an integrated set of principles to be applied in therapy.  Today, feminist therapy has expanded to reflect the ideas of the  third wave of feminism , that the patriarchy is harmful to both men and women. [ 7 ]   Another part of feminist therapy is a focus on social justice issues for people,  regardless of their gender, culture,  sexuality , social class,  phenotype , or national origin. [ 8 ]


Feminist theory argues that certain traumas are produced and maintained by institutionalized discrimination and social hierarchies  [ 1 ]  Root (1992) coined the term "insidious traumatization," to describe the distress that builds when one is the member of a  marginalized group  and subjected to constant threat of  discrimination . [ 9 ]  Exposure to insidious trauma is thought to creates both unique vulnerabilities and unique strengths. Feminist theory argues that insidious traumatization can lead to full blown PTSD symptoms. [ 10 ]


Freyd (1996) expanded the idea of insidious traumatization to include the term "betrayal trauma," to describe the specific kind of trauma that occurs when a child is abused by their  caregivers ; Feminist theory argues that betrayal trauma is inherently different from single-incident trauma, mainly because betrayal trauma tends to manifest specifically as interpersonal difficulties and  dissociative symptoms , while traditional intrusive symptoms are usually not present. [ 11 ]


Overall, feminist theory argues against the use of diagnoses, except in instances where a  diagnosis  would assist the service user in gaining access to  mental health care . [ 12 ]  Feminist therapy aims to move away from pathologizing responses to trauma in favor of framing responses as "survival techniques."


For example, in regard to diagnoses that relate to trauma, feminist theory takes issue with the diagnosis  Borderline Personality Disorder  (BPD), a disorder that is often linked to severe  childhood trauma . [ 13 ]  Feminist theory posits that a diagnosis of BPD, unnecessarily pathologizes  normative  and adaptive responses to betrayal trauma. [ 14 ]


In addition, feminist theory argues that chronic exposure to inescapable trauma, such as childhood abuse, is better captured by the diagnosis of  Complex Post-Traumatic Stress Disorder  (CPTSD); [ 15 ]  CPTSD has been proposed as an alternative diagnosis for those responding to sever trauma with BPD-like symptoms, in an attempt to view symptoms as a survival response as opposed to a  personality disorder .


Trauma-informed feminist therapy encourages therapists to take an eclectic approach to trauma treatment, allowing the service user to be the expert of their own experience. [ 16 ] [ 17 ]  Feminist therapy seeks to break down what it terms the inherent power differential between  clinician  and client, by actively constructing an egalitarian relationship. [ 18 ]


In addition, feminist therapists strive to understand their client's experience with trauma by acknowledging and exploring how  social structure  influenced the trauma. [ 19 ]  Trauma-informed feminist therapy argues that successful treatment is not about creating an absence of symptoms; instead feminist therapy aims to assist trauma survivors in creating a non-blaming view of their traumatic experience from which they can gain a sense of  empowerment . [ 20 ]


Traumatic cardiac arrest  ( TCA ) is a condition in which the  heart  has  ceased  to beat due to  blunt  or  penetrating trauma , such as a  stab wound  to the  thoracic  area. [ 1 ]  It is a  medical emergency  which will always result in death without prompt advanced medical care.  Even with prompt medical intervention, survival without  neurological  complications is rare. [ 2 ]  In recent years, protocols have been proposed to improve survival rate in patients with traumatic cardiac arrest, though the variable causes of this condition as well as many coexisting injuries can make these protocols difficult to standardize. [ 3 ]  Traumatic cardiac arrest is a complex form of  cardiac arrest  often derailing from  advanced cardiac life support  in the sense that the emergency team must first establish the cause of the traumatic arrest and reverse these effects, for example hypovolemia and haemorrhagic shock due to a penetrating injury. [ citation needed ]


Traumatic cardiac arrest can occur in patients following any severe blunt or penetrating  injury to the chest . Following the traumatic event, the heart ceases to pump blood through the body. Unlike medical cardiac arrest, there are several potentially reversible causes that may result in cardiac arrest in the setting of trauma. Clinicians will rapidly assess for these causes, and interventions will be directed to the specific cause. [ 4 ]


In both blunt and penetrating trauma, massive  internal  or  external bleeding  may decrease the volume of blood is available to be pumped by the heart to the body. This is considered  preload  dependent arrest. [ 4 ]


Tension pneumothorax  is caused when air is able to enter the space between the  lung  and the  chest wall , but is not able to escape. The increasing pressure within the chest cavity prevents blood from returning from the body to fill the heart.


Hemothorax  occurs when injury to the chest results in bleeding into the thoracic cavity. Similar to tension pneumothorax, increasing pressure prevents the return of blood from circulation to the heart.


In the setting of trauma,  cardiac tamponade  results from an acute  pericardial effusion , the accumulation of blood within the sac that surrounds the heart. As this sac is filled with fluid, the pressure on the heart is increased, and the chambers of the heart are unable to fill with blood.


Inability to maintain  oxygenation  in trauma patients may be a result of  airway  compromise due to mechanical injury or obstruction or due to loss of the  respiratory drive  from  cervical spine  or  peripheral nerve injury . [ 4 ]  These conditions result in the  hypoxia  that may lead to cardiac arrest.


Patients will present following a traumatic event most often with  pulseless electrical activity  (PEA). Patients will exhibit low blood pressure with pulses that cannot be palpated. Patients will progress into  asystole  if the underlying condition is not reversed. Other non-specific signs and symptoms associated with impending traumatic cardiac arrest may include sweating,  altered mental status ,  rapid  or  slow breathing , and signs of trauma (bruising,  laceration , fractures, etc.). [ 4 ]


Diagnosis of traumatic cardiac arrest is initially made with  electrocardiogram  with EMS or in the emergency department. Clinicians will also order diagnostic testing that may include  chest x-ray , bedside ultrasound and  echocardiogram , and blood gas levels. A  type and cross  will be ordered to match the patient to receive blood transfusion if necessary.


Other work-up involved in diagnosis of a trauma patient may include  e-FAST ,  RUSH exam ,  CBC , pelvic X-ray, and  CT  of the head, neck, chest, abdomen, and pelvis.


Treatment of traumatic cardiac arrest is guided by  advanced trauma life support guidelines . Standard advanced cardiac life support guidelines are inappropriate for use in traumatic cardiac arrest, as they are directed primarily at treating pathology originating within the heart itself. [ 5 ]  As clinicians begin to intervene, they will simultaneously seek reversible causes of the arrest. Management begins by establishing multiple points of IV access and evaluating the patient's airway and breathing. Other interventions may include  thoracostomy  and  thoracotomy , as well as treatment of the underlying cause of arrest.


Basic life support  is commonly initiated by bystanders and first responders, but the role of basic life support in traumatic cardiac arrest is unclear. Basic life support is targeted to maintain oxygenation and circulation throughout the body, which can be lifesaving in cases of medical cardiac arrest, but does not address the frequent large volume blood loss encounters in many cases of traumatic cardiac arrest. [ 5 ]


Chest compressions  are considered the most important initial intervention in cases of medical cardiac arrest, however studies evaluating their efficacy have excluded patients with traumatic cardiac arrest. Chest compressions work to replace the cardiac function of pumping blood throughout the body, however cases where the heart is either unable to fill with blood or the total blood volume is depleted, this intervention may be ineffective. Additionally, as many of the interventions targeted at specific causes of arrest are centered around procedures performed around the patient's chest, head, and neck, compressions may interfere with definitive management. [ 5 ]


Current guidelines tailored to treatment of specific causes of traumatic cardiac arrest have improved outcomes for patients, however these guidelines may be difficult to apply in a standardized manner due to differences in pre-hospital care and the wide variety of causes of traumatic cardiac arrest compared to medical cardiac arrest. [ 3 ]  Evolving algorithms are directed at quickly identifying incidences of cardiac arrest with a traumatic source and rapidly intervening to address reversible causes. [ 3 ]


Historically, traumatic cardiac arrest was thought to lead invariably to death. More recently, evolutions of advanced trauma life support guidelines and improved understanding of the underlying causes of traumatic cardiac arrest have improved outcomes for patients. [ 5 ]  Recent studies suggest that the survival rate for traumatic cardiac arrest is similar to that of all-cause cardiac arrest. [ 6 ]  There is wide variability in the estimated survival rate based on factors that include initiation of pre-hospital care and nature of injury. [ 7 ]


Many patients who survive traumatic cardiac arrest may develop long-term neurological damage resulting from lack of circulation to the nervous system during the arrest. This damage may range from moderate disability to a persistent vegetative state. A 2012 review suggests that while survival rates of traumatic cardiac arrest are higher in children, so is the incidence of neurological complication. [ 8 ]


Traumatic asphyxia , or  Perte's syndrome , [ 1 ]  is a medical emergency caused by an intense compression of the  thoracic cavity , causing  venous  back-flow from the right side of the heart into the veins of the neck and the brain. [ 2 ]


Traumatic asphyxia is characterized by  cyanosis  in the upper extremities, neck, and head as well as  petechiae  in the  conjunctiva .  Patients can also display  jugular venous distention  and facial  edema . [ 3 ]  Associated injuries include  pulmonary contusion ,  myocardial contusion ,  hemo / pneumothorax , and  broken ribs . [ 4 ] [ 5 ]


Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in  motor vehicle accidents , as well as industrial and farming accidents. However, it can be present anytime a significant pressure is applied to the thorax.


The sudden impact on the thorax causes an increase in  intrathoracic pressure . [ 4 ]   In order for traumatic asphyxia to occur, a  Valsalva maneuver  is required when the traumatic force is applied. [ 6 ]  Exhalation against the closed glottis along with the traumatic event causes air that cannot escape from the thoracic cavity. Instead, the air causes increased venous back-pressure, which is transferred back to the heart through the  right atrium , to the  superior vena cava  and to the head and neck veins and capillaries. [ 4 ]


Patients are seen with a cyanotic discoloration of the shoulder skin and neck and face, jugular distention, bulging of the eyeballs, and swelling of the tongue and lips. The latter two are resultants of edema, caused by excessive blood accumulating in the veins of the head and neck and venous stasis.


For individuals who survive the initial crush injury, survival rates are high for traumatic asphyxia. [ 4 ] [ 6 ] [ 7 ]


The Traumatology Institute (Canada)  is an international mental health consulting and training organization focused on after trauma care located in  Toronto, Ontario , Canada.


The mandate of the Traumatology Institute is to raise awareness about Post-Traumatic Stress and trauma informed care options. [ 1 ]  It was established following intensive course development at  Florida State University  in 1997 with Dr. Anna B. Baranowsky, Dr. J. Eric Gentry,  Dr. Charles Figley , and Kathleen Dunning.


Baranowsky established the Traumatology Institute (Canada) in 1998. [ 2 ] [ 3 ] [ 4 ]  The curriculum leads to competency in Field Trauma Response, Clinical Traumatology, Community & Workplace Traumatology, Compassion Fatigue Care, School Crisis Response Certificate Program, Justice/Corrections Traumatologist and the Trauma Recovery Program Online.


The Traumatology Institute Training Curriculum (TITC) provided foundational training for those Certified Traumatologists involved in recovery interventions for over 4,700 people following the September 11, 2001 terrorist attacks in New York City and thousands of traumatologists nationally and internationally. [ 5 ]


Baranowsky is the author of  Trauma Practice: Tools for Stabilization & Recovery  (2015, 3rd Ed., Baranowsky & Gentry) [ 6 ]  and  What is PTSD? 3 Steps to Healing Trauma  (2012, Baranowsky & Lauer), a 2013 International Book Award finalist (Health category). [ 7 ]


Wound contracture  is a process that may occur during  wound healing  when an excess of  wound contraction , a normal healing process, leads to physical deformity characterized by skin constriction and functional limitations. [ 1 ] [ 2 ] [ 3 ]  Wound contractures may be seen after serious burns and may occur on the palms, the soles, and the anterior thorax. [ 2 ]  For example, scars that prevent joints from extending or scars that cause an  ectropion  are considered wound contractures. [ 1 ] [ 4 ]


ABCD rating , also called the  Jewett staging system  or the  Whitmore-Jewett staging system , is a staging system for  prostate cancer  that uses the letters  A ,  B ,  C , and  D .


Climacturia  is  urinary incontinence  at the moment of sexual climax ( orgasm ).  It can be a result of radical  prostatectomy  to treat  prostate cancer . It is uncomfortable at times, but usually harmless. [ 1 ] [ 2 ]


This  sexuality -related article is a  stub . You can help Wikipedia by  expanding it .


A Colour Atlas of Urology  is a medical textbook of  urology  images first published by Wolfe Medical Publications in 1983. It is co-authored by  Reginald Wyndham Lloyd-Davies , James G. Gow and D. R. Davies. 1,188 Images include those of pathological specimens, photographs at  endoscopy of the bladder  and diagrams that explain urological diagnostic procedures. 70 images relate to lesions of the  penis  and  scrotum . A second edition was published in 1994.


A review in the  Postgraduate Medical Journal  noted that the X-ray of  lung metastases  was back to front. Another review considered it a complete work covering everything a urologist could possibly see in their profession. The  British Journal of Venereal Disease  noted that the book was aimed at urologists but suggested that genitourinary physicians might be interested in it. All three reviews reported that the book was expensive.


A Colour Atlas of Urology  is co-authored by  Reginald Wyndham Lloyd-Davies ,  James G. Gow  and D. R. Davies, and was first published by Wolfe Medical Publications in 1983 at a cost of £48. [ 1 ]  A second edition, with co-author  Helen Parkhouse , was published in 1994. [ 2 ]


1,188 images include those of pathological specimens, photographs at endoscopy of the  bladder  and diagrams that explain urological diagnostic procedures. [ 3 ] [ 4 ]  It contains a collection of  X-rays  including a comparison of  spread to bone  from  prostate cancer  and  Paget's disease . [ 4 ]  70 images relate to lesions of the  penis  and  scrotum . [ 1 ]  These include  priapism ,  spermatocele , [ 5 ]  and  hydrocele . [ 6 ]


J. P. Hopewell, in the  Postgraduate Medical Journal , called the book "impressive and interesting" but noted that the X-ray of  lung metastases  was back to front and felt that improvement could have been made on the X-rays of   polycystic kidney disease . [ 4 ]  W. Hendry, in the  British Journal of Surgery , considered it a complete work covering everything a urologist could possibly see in their profession. [ 3 ]  A. McMillan, in the  British Journal of Venereal Disease  noted that the book was aimed at urologists but suggested that genitourinary physicians might be interested in it. [ 1 ]  All three reviews reported that the book was expensive. [ 1 ] [ 3 ] [ 4 ]


The  cystocele , also known as a  prolapsed bladder , is a medical condition in which a woman's  bladder  bulges into her  vagina . [ 1 ] [ 5 ]  Some may have no symptoms. [ 6 ]  Others may have trouble starting urination,  urinary incontinence , or  frequent urination . [ 1 ]  Complications may include recurrent  urinary tract infections  and  urinary retention . [ 1 ] [ 7 ]  Cystocele and a  prolapsed urethra  often occur together and is called a cystourethrocele. [ 8 ]  Cystocele can negatively affect  quality of life . [ 9 ] [ 10 ]


Causes include  childbirth ,  constipation ,  chronic cough , heavy lifting,  hysterectomy ,  genetics , and being  overweight . [ 1 ] [ 2 ] [ 6 ]  The underlying mechanism involves weakening of  muscles  and  connective tissue  between the bladder and vagina. [ 1 ]  Diagnosis is often based on symptoms and examination. [ 1 ]


If the cystocele causes few symptoms, avoiding heavy lifting or straining may be all that is recommended. [ 1 ]  In those with more significant symptoms a vaginal  pessary ,  pelvic muscle exercises , or surgery may be recommended. [ 1 ]  The type of surgery typically done is known as a  colporrhaphy . [ 11 ]  The condition becomes more common with age. [ 1 ]  About a third of women over the age of 50 are affected to some degree. [ 5 ]


The symptoms of a cystocele may include:


A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder. [ 1 ]


Complications may include  urinary retention , recurring urinary tract infections and incontinence. [ 1 ] [ 7 ]  The anterior vaginal wall may actually protrude though the vaginal introitus (opening). This can interfere with sexual activity. [ 6 ]  Recurrent urinary tract infections are common for those who have urinary retention. [ 15 ]  In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystocele may affect the quality of life, women who have cystocele tend to avoid leaving their home and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility. [ medical citation needed ]


A cystocele occurs when the muscles,  fascia ,  tendons  and  connective tissues  between a woman's bladder and vagina weaken, or detach. [ 2 ] [ 16 ]  The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the  arcus tendineus fascia pelvis ; the transverse defect is when the  pubocervical fascia  becomes detached from the top (apex) of the vagina. [ 2 ]  There is some pelvic prolapse in 40–60% of women who have given birth. [ 17 ] [ 18 ]  Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall. [ 19 ]