Trauma

TRAUMA
Facebook: Happy Friday Knight
July, 10th, 2015
Department of Surgery
Thailand

• Trauma/ injury = cellular disruption caused by
an exchange with environmental energy that
beyond body’s resilience
• = cell death due to ischemia or reperfusion
• Most common cause of death between age 1-
44 years
• Third most common cause of death regardless
of age
• Causes 110,000 deaths per year, 40% from
motor vehicle collisions

INITIAL EVALUATION
AND
RESUSCITATION
OF THE INJURED PATIENT

Preparation
• Prehospital phase:
– EMS
– Should be set up to notify the receiving hospital
before personnel transport from the scene
• Hospital phase: primary survey

• Emphasis on:
– Airway maintenance
– Control of external
bleeding and shock
– Immobilization
– Immediate transport to
the nearest hospital

Triage:
sorting the patients
based on their needs
for treatment and the
resource available to
provide that
treatment
http://www.cdc.gov/mmwr/previe
w/mmwrhtml/rr6101a1.htm.
CDC, January 13th, 2012

• Multiple Casualties:
– the number and severity of patients do not exceed
capability of the facility
– Patients with life-threatening conditions and
multiple system injuries are treated first
• Mass Casualties
– Exceed
– Patient with greatest chance of survival and
requiring expenditure of time, equipment, supplies,
and personnel, are treated first

Primary Survey
• ATLS: ABCDEs and adjuncts
• 10-second assessment: What’s your name?
What happen?
• Life-threatening injuries must be identified and
treated before distracted by secondary survey

Airway Management with
Cervical Spine protection
• First Priority
• Conscious, normal voice without tachypnea 
should be OK but repeat assessment is
essential
• Exceptions: penetrating neck injury, complex
maxillofacial trauma, inhalation injury
• Require further evaluation: abnormal voice or
breathing sound, tachypnea, altered mental
status

• Predicting difficult airway: LEMON
• Maintaining airway maneuvers: chin lift, jaw
thrust, pharyngeal airway, LMA etc
• Definitive airway: a tube placed in trachea with:
– Cuff inflated below vocal cord
– Connected to oxygen-enriched assisted ventilation
– Secured in place with tape

• Surgical Airway:
– Cricothyroidotomy
– Emergency tracheostomy
http://www.surgeryencyclopedia.com/Ce-
Fi/Cricothyroidotomy.html. Advanmeg,
2015

• Don’t forget c-spine!!!!
• Apply hard collar or sandbags to all patients
who are suspected c-spine injury, blunt trauma,
and altered mental status
• Soft collar shows no benefit

Breathing with Ventilation
• Life-threatening conditions: open, tension
pneumothorax, massive air leak, severe flail
chest
• Look for indication to ICD

Circulation with Hemorrhagic Control
• Palpable pulse:
– Carotid = 60 mmHg
– Femoral = 70 mmHg
– Radial = 80 mmHg
• Any episode of hypotension is assumed to be
caused by HEMORRHAGE until proven
otherwise

• IV access for fluid resuscitation:
– 2 peripheral catheter, 16 gauge or larger
– If difficult: IO (<6yrs), saphenous cutdown, femoral or
subclavian vein insertion
• 5 potential area: chest, abdomen, pelvis, long bone,
external
• External Control of visible hemorrhage:
– Simultaneous with fluid resuscitation
– Manual compression
– Avoid blind clamping

• Tourniquet can cause tissue necrosis but may
be essential to save life (in case of direct
pressure failure)
• Open fractures: reduction and immobilization
• Scalp laceration deep to galea: skin staples,
continuous suture to stop bleeding

• FAST
• Massive Hemothorax
– >1500ml from ICD
– > 25% of blood volume in children
– Usually from multiple rib fractures, occasionally
from lung laceration
– Suspected great vessels or pulmonary hilar vessels
injury
– Indication for operative intervention

• Cardiac tamponade
– Beck’s triad
– FAST
– most common cause: penetrating chest injury
– < 100 ml
– RV output
– Initial Treatment: fluid resuscitation and
pericardiocentesis (80% success)
– SBP< 60 mmHg: resuscitative thoracotomy

Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 167

Shock

Shock
• = inadequate tissue perfusion
• In trauma, always HEMORRHAGIC until
proven otherwise
• The goal of fluid resuscitation is to re-establish
tissue perfusion
• 2 L in adult, 20 ml/kg in child IV bolus,
usually warm Ringer’s lactate

Shock
• Goal: return of perfusion => urine output
– Adult > 0.5 ml/kg
– Child > 1 ml/kg
– Infant < 1 yr > 2 ml/kg
• Initial response: responders, transient
responders, nonresponders

Shock: Persistent Hypotension
• Either transient or nonresponders
• Consider categories of shock: hemorrhagic,
cardiogenic, neurogenic, septic
• FAST helps
• CVP may guide: > 15 cmH2O: cardiogenic, < 5
cmH2O: hypovolemic
• Other monitor: urine output, oxygen
saturation, base deficit, lactate

• DDx of cardiogenic shock in trauma:
– Tension pneumothorax (most common)
– Cardiac tamponade
– Blunt cardiac injury
– Bronchovenous air embolism
• In blunt cardiac injury:
– EKG and TropT help
– ECHO is performed
– Most common finding is RV dyskinesia due to
orientation
– AMI may be the cause of accidents in older patients

• Air embolism
– Air from injured bronchus entered injured
pulmonary vein and returns air to left heart,
resulting in impeded diastolic filling
– And during systole, air is pumped into coronary
arteries
– Treatment: Trendelenburg position and emergency
thoracotomy to cross-clamping to prevent further
embolism, air aspiration, and controlling the injury

Shock
• If persistent hypotension with negative FAST and
no obvious source  DPL
• Hypotensive resuscitation, permissive
hypotension, balanced resuscitation, controlled
resuscitation: keep BP 90/60 mmHg
• Fracture-related blood loss:
– Each rib fracture: 100-200 ml
– Tibia: 300-500 ml
– Femur: 800-1,000 ml
– Pelvic: > 2000 ml

Disability and Exposure
• D: Pupil and GCS
• Exposure: keep warm, PR, log roll

Adjuncts to Primary Survey
• Monitor: BP, oxygen saturation, EKG, ABG
• Catheter: NG, Foley cath
• Investigation: FAST & film (CXR, pelvis AP)

Secondary Survey
• Head-to-toe examination
• AMPLE

Special Diagnostic Tests
• Head: CT brain (non-contrast), facial bone
reconstruction, c-spine

• Neck:
– In blunt injury: cervical spine injury has to be
ruled out
– Observe expanding hematoma, airway obstruction,
aerodigestive injuries

Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 415.

• Chest:
– Most injuries can be evaluated by PE and CXR
– CXR is needed after ETT, ICD, central line
insertion
– Persistent pneumothorax should undergo fiberoptic
bronchoscopy to exclude tracheobronchial injury
– CXR after ICD is required to document complete
evacuation; if persistent  thoracotomy

• Abdomen:
– Blunt or penetrating
– If penetrating: stab wound or GSW
– FAST will be positive when free fluid > 250 ml
– Anterior abdominal SW: explore under LA to
determine if fascia is injured
– For GSW: >90% have internal abdominal injuries

• Pelvis:
– Foley catheter in one attempt
– Film pelvis AP
– CT pelvis to evaluate precise geometry
– CT cystograms
– Urethrograms
– CT angiogram

• Extremities:
– Film
– Vascular injuries: hard and soft signs
– Doppler u/s
– CT angiogram

GENERAL PRINCIPLES
OF
MANAGEMENT

Transfusion
• ATLS says massive transfusion = PRC > 10 U
in first 24 hr
• ATLS says PRC : FFP : PC = 1:1:1
• Types of blood component
– Complete typing and crossmatching: 45min- 1hr
– Type-specific: 10 min
– O-negative, O-low titer: should be ready

Prophylactic Measures
• Antibiotics
• Tetanus prophylaxis
• VTE prophylaxis
– LMWH
– Compression stocking
• Thermal protection: passive and active
rewarming

Damage Control Surgery
• The purpose is to limit operative time and
return patient to ICU from physiologic
restoration
• The goal is to control surgical bleeding and
limit GI contamination and definitive repair of
injuries delayed until patient is physiologically
replete

• bloody vicious cycle (lethal triad)
• Hypothermia, coagulopathy, metabolic
acidosis
• Indications to institute DCS technique
– BT < 35oC
– Profound acidosis  ABG pH < 7.2, base deficit >
15 mmol/l
– Refractory coagulopathy

• Arterial injuries:
– Ligation tolerable: Rt/Lt hepatic, celiac
• Venous injuries: ligation except suprarenal
IVC and popliteal
• Solid organ injuries:
– Spleen/kidney: Excision > repair
– Hepatic injuries: packing, foley cath ballooning for
GSW

• Lung injuries: open parenchymal tract by TA
stapler, access to injured vessels and bronchi,
and ligate by PDS 3-0, and the tract left
opened
• Cardiac injuries: temporarily controlled with
3-0 polypropylene, running

• GI contamination:
– Small injuries: repair using 2-0 polypropylene
– Complete transection: GIA stapler to resect
damage segment and open end may be ligated by
umbilical tape
• Pancreatic injuries: pack and evaluate duct
later
• Urologic injuries: catheter diversion

TREATMENT
OF
SPECIFIC INJURIES

Head Injuries
• Intracranial injuries:
– CT brain NC
– Penetrating injuries: require operation to bleeding
control, evacuate clot, skull fx fixation,
debridement
– Patient with diffuse cerebral edema with elevated
ICP: decompressive craniectomy
– In open or depressed skull fracture: assess
underlying brain, look for visible brain, CSF
leakage, dural laceration

– Closed head injuries:
• GCS<8 should be monitor ICP
• Treatment start at ICP > 20 mmHg
• Indications for intervention: clot volume, midline shift,
location of clot, GCS, ICP
Head Injuries

– Postinjury care:
• SBP > 100 mmHg
• Avoid hypoxia: PO2 < 60mmHg, O2sat < 90%
• CPP > 50 mmHg
• PCO2 35-40 mmHg, <30 mmHg for acute management
of hypertension
• BT 32-33oC
• Anticonvulsant: dilantin
Head Injuries

Head Injuries
• Maxillofacial:
– Most common scenario which can be life-
threatening: bleeding from facial fracture
– Don’t forget to protect the airway!
– Contraindication of NG
– Fractures of tooth-bearing bone = open fractures

American College of Surgeons ACS Committee of Trauma. ATLS Student Course Manual. 8th ed. Chicago:
American College of Surgeons, 2008. page 59

Cervical Injuries
• Spine:
– At ER: Immobilization and CT C-spine
– Treatment based on:
• Level
• Stability
• Presence of subluxation
• Extent of angulation
• Level of neurologic deficit
– Treatment:
• axial traction via cerival tong > halo vest

Cervical tong
http://www0.sun.ac.za/ortho/webct-
ortho/general/trac/trac-3.html
Halo vest
http://borsodib.hu/2012/index.php/hirek/140-halo-
vest-a-nyakcsigolyatores-gyogyeszkoze

• Spine:
– Treatment:
• Surgical fusion in pt with neurodeficit or remain
unstable after halo placement
• Methylprednisolone (30 mg/kg IV bolus, then 5.4mg/kg
in 23 hr)
• Urgent surgical decompression: may be done in patients
with incomplete tetraplegia or neurologic deterioration
Cervical Injuries

• Vascular:
– Penetrating injuries: neck exploration to repair
– All carotid injuries should be repaired except in
patients who present in coma with a delay in
transport
– Blunt injuries:
• May cause dissection, thrombosis, pseudoaneurysm
• Patients treated with antithrombotic agent have a stroke
rate < 1% compared with 20% in untreated patients
Cervical Injuries

Brunicardi FC et al. Schwartz’s
Principles of Surgery. 10th ed.
McGraw-Hill Education, 2015.
page 199

Cervical Injuries
• Aerodigestive
– sign: subcutaneous emphysema
– CT usually repaired
– Common: thyroid cartilage fractures, thyroepiglottic
ligament rupture, vocal cord tears,cricoid fractures
– Tracheal injuries: debridement and end-to-end repair
with single layer, interrupted, absorbable suture
– Esophageal rupture: debridement, repair, and
interposition of SCM or strap muscles to prevent
fistulas

Chest Injuries
• Most common injuries are hemothorax and
pneumothorax
• 85% can be definitively treated with ICD
• Even initial chest tube output is 1.5L, if the
output ceases, lung re-expanded, and
hemodynamically stable, it can be
nonoperatively managed

Chest Injuries
• Great vessels:
– >90% are penetrating
– Blunt injuries to innominate, subclavian, or
descending aorta may cause pseudoaneurysm or
frank rupture
– Simple laceration of aortic arch: lateral aortorrhapy
– To prevent aortic rupture: esmolol, keep SBP <
100 mmHg, HR < 100/min

Chest Injuries
• Heart
– Before repair, bleeding should be controlled
– Temporary control: skin staples for LV laceration
– Definitive repair: running 3-0 polypropylene, or
interrupted pledgeted 2-0 polypropylene suture in
RV to prevent sutures from pulling through the
thinner myocardium
– ECHO may be done
– No pathognomonic signs on EKG and TropT
doesn’t tell risk of complications

Chest Injuries
• Trachea, Bronchi, and Lung Parenchyma:
– ICD: pneumothorax
– Same as injuries at neck
– Bronchial injuries less than 1/3 circumference of
airway and no persistent air leak can be expectantly
managed
– Bronchoscope with direct fibrin glue may be useful
– Most complication after injury: empyema
• PCD
• Decortication with VATS
• Antibiotics (cover MRSA in ICU)

Chest Injuries
• Esophagus
– Often occurs with tracheobronchial injuries, in
penetrating trauma
– Same as injuries at neck +- gastrostomy

• Chest wall and diaphragm
– Rib fractures: pain control + ventilation support
– Diaphragmatic injury:
• Blunt: large radial tear
• Penetrating: variable size
• Develop diaphragmatic hernia
• Treatment: direct repair by running 1 prolene or mesh
Chest Injuries

http://www.mactheknife.org/Cases_trauma/Paralysed_diaphragm.html

Abdominal Injuries
• Blunt injuries – most frequently injured:
1. Spleen (40-55%)
2. Liver (35-45%)
3. Small bowel (5-10%)
• Penetrating injuries:
– SW: liver (40%), small bowel (30%), diaphragm
(20%), colon (15%)
– GSW: small bowel (50%), colon (40%), liver (30%),
vessels (25%)
(reference: ATLS, page 125)

• Liver and extrahepatic biliary tract
– In liver injury without peritonitis or unstable
hemodynamic, nonoperative management with
serial examination in ICU is OK
– Angiogram and angioembolization: indication
• PRC > 4U in 6hr
• PRC > 6U in 24 hr
• Hemodynamic stable
– Indication for surgery is hemodynamic instability
Abdominal Injuries

• Liver and biliary tract
– Surgery:
• Initial control of hemorrhage is best by perihepatic
packing and manual compression and remove packing
at 24 hr
• Pringle maneuver: clamping across portal triad
bleeding should be stopped if injuries are at hepatic
artery or portal vein  bleeding from hepatic vein and
retroperitoneum IVC will continue
• Gastroduodenal a. injury: ligation
• Proper hepatic a. should be repaired
Abdominal Injuries

http://myhomeimprovement.org/home-remodel/celiac-axis-diagram

• Liver and biliary tract: surgery
– Hepatic parenchymal hemorrhage
• Minor laceration: manual compression
• Topical hemostatic techniques: argon beam,
microcrystalline collagen, thrombin-soaked gelatin
foam sponge, fibrin glue, BioGlue, and blunt tipped 0
chromic suture or liver suture
– Complication: liver necrosis, bilomas, arterial
pseudoaneurysm, biliovenous fistula
Abdominal Injuries

• Spleen
– Extravasation risks for nonoperative management
failure
– Angioembolization
– Surgery:
• Splenectomy: hilar inj, grade II, completely destroyed
• Partial splenectomy: pole
• Splenorrhaphy with pledgated suture: cut edge
Abdominal Injuries

• Stomach and Small Bowel
– Single layer suture
Abdominal Injuries

• Duodenum and Pancreas
– Suture if perforation
– Duodenal hematoma  observe
– Pancreas: determine parenchymal and damage
– Proximal (Rt to SMA) pancreatic injuries: closed
suction drainage
– Distal injuries: distal pancreatectomy
– CBD injury: Roux-en-Y choledochojejunostomy
Abdominal Injuries

• Colon and Rectum
– Treatment: primary repair, end colostomy, and
primary repair with diverting ileostomy
– All suturing and anastomoses are performed using
a running single-layer technique
– Complications: IAA, fecal fistula, wound
infection, stomal complications (necrosis, stenosis,
obstruction, prolapse)
Abdominal Injuries

• Genitourinary Tract
– Explore all penetrating wounds to kidneys when
undergoing laparotomy and treat same as liver and
spleen
– >90% of blunt renal injuries are treated
nonoperatively
– Hematuria will resolve in 2-3 days, but persistent
gross hematuria may require embolization
Abdominal Injuries

• Genitourinary Tract
– Bladder injuries: intraperitoneal  suture, extra 
bladder decompression for 2 wks
– Urethral inj: bridging the defect with foley
– Pelvic fracture penetrating to vagina = open
fracture
Abdominal Injuries

Pelvic Fracture Hemorrhage Control
• 85% of bleeding is from venous or bony in
origin
• Pelvic packing: 6-8 cm midline incision and
packing each side of bladder and preperitoneal
space
• Open pelvic fracture:
– High risk for pelvic sepsis and osteomyelitis
– Recommendation: divesting sigmoid colostomy
and debridement

Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education,
2015. page 220

References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed.
McGraw-Hill Education, 2015.
American College of Surgeons ACS Committee of Trauma. ATLS
Student Course Manual. 9th ed. Chicago: American College of
Surgeons, 2012.
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
Kaiser LR et al. Mastery of Cardiothoracic Surgery. 3rd ed.
Philadelphia: Lippincott Wiliams & Wilkins, 2014.

Trauma

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Trauma

Similar to Trauma (20)

More from HappyFridayKnight

More from HappyFridayKnight (20)

Recently uploaded

Recently uploaded (20)

Trauma