Trawma

1. SEMINAR 3
SAWLA GENERAL HOSPITAL
THORACIC AND ABDOMINAL
TRAUMA

2. Contents
•Introduction
•Thoracic Injuries
•Abdominal Injuries

3. Introduction
• Trauma is one of the leading causes of mortality,
morbidity and disability worldwide.
• trauma mostly affects people in their productive years of
life
• Deaths due to trauma tend to occur In three patterns
• - Immediate death (50%)
- Early deaths (30%)
- Late deaths (20%)

4. Definition and types
✔Trauma is tissue damage, which occurs due to transfer of
different forms of energy either
intentionally or unintentionally.
✔Trauma can be classified according to the Mechanism
- Blunt Injury: Caused by acceleration,
Deceleration,rotational or shearing force
- Penetrating Injury: Caused by a direct breach by
penetrating object.e.g Bullet injury, stab injury

5. Early management of trauma
• Management is depend on ATLS protocol
• It generally consists of a primary survey and
resuscitation followed by a secondary survey and
definitive Managements.
I- The primary survey and resuscitation.
• During this time, life-threatening injuries are
identified and simultaneously resuscitation is
begun

6. A- Airway maintenance
- It is assess of airway patency by inspect foreign body
and communication ability
- If the airway is compromised, use suctioning, jaw
trust positioning, oropharyngeal tube or endotracheal
tube to open it and taking care of cervical spine
B- Breathing and ventilation
- it is assessing of breathing adequacy
- examined by inspection, palpation, percussion and
auscultation
-The aim is to identify and manage life-threatening thoracic
conditions

7. Man.....
Interventions:Needle decompression
Chest tubes
Occlusive dressing
C- Circulation with bleeding control
-assessment of hemodynamic status by measuring blood pressure and
pulse rate, and inspecting skin color
Intervention
-Establish IV
-stop external hemorrhage by pressure, bandaging or
tourniquet
- take blood sample for cross match and start resuscitation with
Normal saline or Ringer’s lactate.
- if suspect cardiac tamponade -Cardiac tamponade decompression
Is done

8. Man.....
D- Disability/Neurologic assessment
-neurologic examination is done to assess consciousness.
The Glasgow Coma Scale is a quick method to determine
the level of consciousness
E-Exposure
patient should be completely undressed
Used for examination not to miss serious injuries

9. Man......
II- Secondary survey and definitive
Management
It include: - history
- examination of all body system
- investigations
- specific treatment

10. THORACIC INJURY
• 25% of all trauma deaths are a result of chest
injuries alone.
• Secondar cause of trauma death after head injury
• It involve: The chest wall ,Lung ,Mediastinal
structures, Diaphragm

11. Classification
Based on Mechanism
Blunt: 85%of all chest injury
result from MVA(75%),fall and crush of injury
Penetrating: 15%
Stab and gunshot wounds are common cause
It results in hemothorax and pneumothora.

12. Class....
Based on severity
Immediately life threatening
-Airway obstruction
-Tension pneumothorax
- Pericardial tamponade
-Open pneumothorax
-Massive haemothorax
-Flail chest

13. Class...
• Potentially life threateningcontusion
-Aortic injuries
-Tracheobronchial injuries
-Myocardial contusion
-Rupture of diaphragm
-Oesophageal injuries
-Pulmonary contusion

14. Diagnosis
•Basedonclinicalexamination(mostly)aorta
•CXR-Ixoffirstchoice
•US
•CTscan
•Angiography-assessmentofthethoracic
aorta

16. Tension Pneumothorax
Pathophysiology of Pneumothorax
• Normally, the pressure within the pleural space is
• negative in comparison to alveolar and atmospheric
pressure.
• If there is an opening made into the pleural space, air
rapidly rushes in due to the negative pressure.
• As pressure rises, lung tissue collapses.
• The amount of collapse is dependent on the
• size of the pneumothorax. E.g. if < 25%
• asymptomatic

18. Ten......
• It is a life-threatening condition caused by the
continuous entrance and entrapment of air into the
pleural space
• Air flows in one way only which means only entering
• It compressing the lungs, heart, blood vessels, and other
structures in the chest.

20. Clinical presentation
- Tachypnea
- Dyspnea
- Distended neck veins
- Tracheal deviation
- Hyperresonance and
- Absent breath sounds

21. Diagnosis
• Based on clinical
• CXR shouldn't be needed to identify because of it
delay therapeutic intervention and cause lethal
delay
Treatment
• Rapid insertion of Large bore needle in to the
2ndICS atMCL/mid clvicular line
• Follwed by Chest tube insertion

22. Open pneumothorax
• Occurs due to a large defect in thorax (>3cm)
• It leading to immediate equilibration between
intrathoracic and atmospheric pressure
• When wound is >2/3 of tracheal diameter
- inspiration pulls airs through wound into
pleural space
- air doesn't flow through the trachea in to the
lungs

24. Clinical presentation
• Respiratory Distress
• Tachypnea and Dyspnea
• Asymmetrical chest expansion
• Hyper-resonant to percussion
• Diminished or absent breath sounds on affected
side
• Air movement through the wound; noticed as
• “bubbling” of blood at the wound site

25. Diagnosis
• Clinically
• Chest x-ray

26. Management
• Closing defect with sterile occlusive plastic dressing
taped on 3 sides to form a 1
• way valve
• chest tube inserted in a site remote
• from injury site.
• Definitive Rx may warrant debridement and closure
in the OR and Early referral

27. Haemothorax
• Hemothorax is a collection of bloody fluid in the pleural
space
• Following blunt or penetrating wound to the chest
• Sources:-Chestwallvessels,
• -Lungparenchyma
• -MajorThoracicvessels
• ClinicalPresentation-respiratory distress and shock.
• Dull percussion
• Absent breath sounds
• Tachycardia
• Hypotension due to blood loss.

28. Diagnosis
• Clinical Exam findings
• CXR (> 250ml on lateral, > 500ml)

29. Management
• correct the shock
• Insert IC drain
• Intubation (in some cases)
• Thoracotomy
• Indications
• - Drainage of 1500ml of blood or ongoing hemorrhage
of >200ml/hr over 3-4hrs

30. Cardiac Tamponade
• Is compression of the heart by
• an accumulation of fluid in the pericardial sac.
• It decrease cardiac output
• Most commonly the result of penetrating trauma
Clinical Presentation:
• it has Similar clinical presentation as tension pneumothorax
• Their difference is presence of hyperresonance on percussion
indicates tension pneumothorax, whereas the presence of
bilateral breath sounds indicates cardiac tamponade.

31. Investigation
CXR --enlarged heart shadow
Echocardiograpy --fluid in pericardial sac
Management
Needle pericardiocentesis
-for stabilization until definitive management,but there
may be high risk of iatrogenic injury to the heart
Definitive management
-Operative (sternetomy or left thoracotomy & repair of
the heart)

32. Flail chest
• 3 or more ribs fractured in 2 or more places.
Diagnosis:
-Paradoxical chest wall movement
-Poor air movement
-Hypoxia
Therapy:
Pain control
Pulmonary & physical therapy
Intubation and ventilator support if needed
Fluid restriction if possible

33. Abdominal Trauma

34. Classification of injury
• Bluntinjury(BAT)
- mostcommon.
- RTA(75%),Industrial,sporting
• Penetrating injury (PAT)
• •Lowenergy–Stab Wound
• •Highenergy-GSW mortality is high

35. Class..
• Based on hemodynamic stability
- hemodynamically ‘normal
- hemodynamically ‘stable
- hemodynamically ‘unstable’-immediate
Surgery is required
• A trauma laparotomy is the final step in the
pathway to delineate intra-abdominal injury

36. Management
• ATLS principles
• Base line labs
Hematocrit
Leukocyte count
Pancreatic enzyme ( serum amylase and lipase )
Liver function test
Urinanalysis

37. Imaging
• FAST-ultrasound
• Diagnostic peritoneal lavage
• Abdominal, Pelvic CTscan
• Local wound exploration
• Angiography
• Plan and. X-ray

38. Focused Assessment with
sonography of trauma (FAST)
• To diagnosis free intraperitonial fluid
• Area of assessment
Pericardium
Perihepatic and hepatorenal
Presplenic
Pelvis

39. Limitations of FAST
• Injury to solid parenchyma, the retroperitoneum,
• or the diaphragm is not well seen
•Uncooperative patients, obesity, bowel gas, and
subcutaneous air interfere with image quality
•Less sensitive than peritoneal lavage for
hemoperitoneum (< 500ml)
•Blood cannot be distinguished from ascites or urine
•Subcapsular injuries cannot be detected

40. CT imaging
• Accurate for viisceral lesion and intraperitonal
hemorrhage
• Disadvantages
Insensitive for injury of the pancreas,diaphragm,small
bowel and mesentry
Diagnostic Peritoneal Lavage
Determine presences blood in peritoneum

41. Algorithm for the evaluation of penetrating abdominal injurys

42. Algorithm for the initial evaluation of a patient
with suspected BAT

43. Solid Organs Injury
•Liver
•Spleen
•Kidney
•Pancreas

44. Splenic Injuries
• Most commonly injured organ
• •~25% of blunt abdominal trauma
• •~7%penetrating abdominal trauma
Signs & Symptoms
• Feature of shock (pallor, tachycardia, restlessness,
tachypnea, anxiety, hypotension and decreased pulse
pressure
• Tenderness and abdominal rigidity in LUQ
• Abdominal distension
• Kehr's sign (pain after lying down and foot elevation
• Ballance's sign (fixed dullness to percussion on left and
shifting dullness on the right

45. Splenic injury grading

46. Treatment
• Non operative management
Indication ~ hemodynamically stable
~ Lack of guarding and rigidity
~ Minimal evidence of blood loss
~ Children
• Operative management
-Splenorraphy
-Splenectomy

47. Hepatic Injuries
• Second most commonly injured intra-abdominal organ
• Associated with Rt 8-12 rib fractures
• Blunt trauma (15-20%)
• Penetrating trauma~37%
Signs & Symptoms
• RUQ penetrating or blunt trauma(hx)
• RUQ pain, Rt chest wall & shoulder pain
• Rigidity or guarding
• Reboundtenderness
• Signs of hemorrhage or shock

48. Mgt of Hepatic Injuries
• The management of liver injuries can be
• summarized as ‘thefourPs’:
• 1.Push;
• 2.Pringle (performed with avascular clamp occludes
the hepatic pedicle containing the portal vein,
hepatic artery, and common bileduct)
3.Plug;
4.Pack.

49. Abdominal Hollow Organ Injuries
• Small bowel is the most frequently injured
Blunt trauma
-Seat belt injuries and crush are most common
cause
- it has high risk of infection
Penetrating trauma:
–GSW, stab wound

50. Gastric & BowelTreatment
• Follow ATLS principles
• Surgical repair
• Diversion of the injured bowel with re anastomosis at a
later time