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TRAUMA
Facebook: Happy Friday Knight
July, 10th, 2015
Department of Surgery
Thailand
INTRODUCTION
• 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
Airway Management with
Cervical Spine protection
Airway Management with
Cervical Spine protection
• Surgical Airway:
– Cricothyroidotomy
– Emergency tracheostomy
http://www.surgeryencyclopedia.com/Ce-
Fi/Cricothyroidotomy.html. Advanmeg,
2015
Airway Management with
Cervical Spine protection
• 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
Circulation with Hemorrhagic Control
• 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
Circulation with Hemorrhagic Control
• 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
Circulation with Hemorrhagic Control
• 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
Circulation with Hemorrhagic Control
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 167
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 168
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 169
Shock
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 171
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
Shock: Persistent Hypotension
• 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: Persistent Hypotension
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 172
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
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 175
• Neck:
– In blunt injury: cervical spine injury has to be
ruled out
– Observe expanding hematoma, airway obstruction,
aerodigestive injuries
Special Diagnostic Tests
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 415.
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 176
• 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
Special Diagnostic Tests
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 178
• 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
Special Diagnostic Tests
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 180
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 181
• Pelvis:
– Foley catheter in one attempt
– Film pelvis AP
– CT pelvis to evaluate precise geometry
– CT cystograms
– Urethrograms
– CT angiogram
Special Diagnostic Tests
• Extremities:
– Film
– Vascular injuries: hard and soft signs
– Doppler u/s
– CT angiogram
Special Diagnostic Tests
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
Damage Control Surgery
• 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
Damage Control Surgery
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 189
• 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
Damage Control Surgery
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 195
• 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
Damage Control Surgery
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 196
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
• Intracranial injuries:
– 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
• Intracranial 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
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 462.
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 463.
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 464.
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
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 201
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
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 183
• 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 213
SPECIAL POPULATIONS
Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education,
2015. page 220
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.

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Trauma

  • 1. TRAUMA Facebook: Happy Friday Knight July, 10th, 2015 Department of Surgery Thailand
  • 3. • 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
  • 5. Preparation • Prehospital phase: – EMS – Should be set up to notify the receiving hospital before personnel transport from the scene • Hospital phase: primary survey
  • 6. • Emphasis on: – Airway maintenance – Control of external bleeding and shock – Immobilization – Immediate transport to the nearest hospital
  • 7. 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
  • 8. • 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
  • 9. 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
  • 10.
  • 11. 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
  • 12. • 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 Airway Management with Cervical Spine protection
  • 13.
  • 14.
  • 15. Airway Management with Cervical Spine protection • Surgical Airway: – Cricothyroidotomy – Emergency tracheostomy http://www.surgeryencyclopedia.com/Ce- Fi/Cricothyroidotomy.html. Advanmeg, 2015
  • 16. Airway Management with Cervical Spine protection • 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
  • 17. Breathing with Ventilation • Life-threatening conditions: open, tension pneumothorax, massive air leak, severe flail chest • Look for indication to ICD
  • 18. 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
  • 19. • 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 Circulation with Hemorrhagic Control
  • 20. • 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 Circulation with Hemorrhagic Control
  • 21. • 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 Circulation with Hemorrhagic Control
  • 22. • 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 Circulation with Hemorrhagic Control
  • 23. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 167
  • 24. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 168
  • 25. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 169
  • 26. Shock Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 171
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. • 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 Shock: Persistent Hypotension
  • 31. • 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: Persistent Hypotension
  • 32. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 172
  • 33. 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
  • 34. Disability and Exposure • D: Pupil and GCS • Exposure: keep warm, PR, log roll
  • 35. Adjuncts to Primary Survey • Monitor: BP, oxygen saturation, EKG, ABG • Catheter: NG, Foley cath • Investigation: FAST & film (CXR, pelvis AP)
  • 36. Secondary Survey • Head-to-toe examination • AMPLE
  • 37. Special Diagnostic Tests • Head: CT brain (non-contrast), facial bone reconstruction, c-spine Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 175
  • 38. • Neck: – In blunt injury: cervical spine injury has to be ruled out – Observe expanding hematoma, airway obstruction, aerodigestive injuries Special Diagnostic Tests
  • 39. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 415.
  • 40. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 176
  • 41. • 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 Special Diagnostic Tests
  • 42. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 178
  • 43. • 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 Special Diagnostic Tests
  • 44. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 180
  • 45. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 181
  • 46. • Pelvis: – Foley catheter in one attempt – Film pelvis AP – CT pelvis to evaluate precise geometry – CT cystograms – Urethrograms – CT angiogram Special Diagnostic Tests
  • 47. • Extremities: – Film – Vascular injuries: hard and soft signs – Doppler u/s – CT angiogram Special Diagnostic Tests
  • 49. 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
  • 50. Prophylactic Measures • Antibiotics • Tetanus prophylaxis • VTE prophylaxis – LMWH – Compression stocking • Thermal protection: passive and active rewarming
  • 51. 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
  • 52. • 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 Damage Control Surgery
  • 53. • 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 Damage Control Surgery
  • 54. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 189
  • 55. • 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 Damage Control Surgery
  • 56. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 195
  • 57. • 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 Damage Control Surgery
  • 58. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 196
  • 60. 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
  • 61. • Intracranial injuries: – 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
  • 62. • Intracranial 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
  • 63. 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
  • 64. American College of Surgeons ACS Committee of Trauma. ATLS Student Course Manual. 8th ed. Chicago: American College of Surgeons, 2008. page 59
  • 65. 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
  • 67. • 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
  • 68. • 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
  • 69. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 199
  • 70. 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
  • 71. 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
  • 72. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 462.
  • 73. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 463.
  • 74. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. page 464.
  • 75. 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
  • 76. 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
  • 77. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 201
  • 78. 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)
  • 79. Chest Injuries • Esophagus – Often occurs with tracheobronchial injuries, in penetrating trauma – Same as injuries at neck +- gastrostomy
  • 80. • 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
  • 82. 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)
  • 83. • 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
  • 84. • 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
  • 86. • 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
  • 87. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 183
  • 88. • 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
  • 89. • Stomach and Small Bowel – Single layer suture Abdominal Injuries
  • 90. • 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
  • 91. • 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
  • 92. • 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
  • 93. • 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
  • 94. 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
  • 95. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 213
  • 97. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 220
  • 98. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 220
  • 99. 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.