it's about Trauma in general aspect and how we can deal with it and after that I focus in specific organs

1. Trauma
Amjad Fayyad Khadr

2. Objectives
What is Trauma
Epidemiology of Trauma Care
Mechanisms of Injury
Basics of Trauma Management
– Primary Survey
– Resuscitation
– Secondary Survey
– ABCDE Format
– Cervical Spinal Immobilization
Specific Case Examples
2

3. What is
trauma?

4. Real Life & Death

5. Trauma, or injury
Defined as cellular disruption caused by an
exchange with environmental energy that is
beyond the body's resilience.

6. Epidemiology
 Road Traffic Accidents are major cause of long term morbidity and
mortality in developing nations
 WHO predicts that by 2020, Road Traffic Accidents will be second
leading cause of loss of life for world’s population
 High Morbidity = Loss of income to society
6

7. Injury: Scale of the Global Problem
7
• 5.8 million deaths/year
• 10% of worlds deaths
• 32% more deaths than HIV, TB and
Malaria combined
Source:GlobalBurdenofDisease,WHO,2004

8. Years of Potential Life Lost
18.00%
16.40%
24.80%
40.80%
Injury
Cancer
Heart Disease
All Other Diseases
MMWR 1982;31,599.

9. Injury: Scale of the Global Problem
9
Source: World Report on Road Traffic Injury Prevention 2004
World Health Organization, who.int

10. Epidemiology
 Golden Hour = 80% of trauma deaths
in first hour after injury
 Rapid trauma care has greatest level
of impact in these patients
10
Immediately Hours Days/Weeks
50%
30%
20%
Trimodal Distribution of Trauma Deaths

11. History of Trauma System Development
 Trauma Systems Development
– First developed my military in wartime
 i.e. MASH Units
– Expanded in US to Level 1, 2, 3 Trauma Centers
 Urban Systems
 Statewide networks of systems
 Level 1 – Highest level of care, Leaders in research, clinical
care and education
 Level 2 – Provides definitive care in wide range of complex
traumatic patients
 Level 3 – Provides initial stabilization and treatment. May
care for uncomplicated trauma patients
 Level 4 – Provides initial stabilization and transfers all
trauma patients for definitive care
11
Otisarchives1 (flickr)

12. Mechanisms of Injury:
Blunt Trauma
• MVC motor vehicle
collisions
• Pedestrian vs
Vehicle
• Falls

13. Mechanisms of Injury
 Frontal Impact Collisions
 Lateral Impact Collisions (T bone)
 Rear Impact Collisions
 Rollover Mechanism
 Open Vehicle or Motorcycle
 Pedestrian Vs. Car
 Penetrating Injury (Guns vs. Knives)
13
Vincent J Brown (flickr)
Knockhill (flickr)
Nxtiak (flickr)
Nico.se (flickr)
Juicyrai (flickr)

14. Compression injury
Cells in tissues are compressed and crushed
• Frontal brain
contusion
• Pneumothorax
• Rupture of Left
hemidiaphragm
• Small bowel
rupture
• Chance fracture

15. Deceleration Injury
• Aortic tear
– Fixed descending aorta
– Mobile arch
• Acute subdural brain
hematoma
• Kidney avulsion
• Splenic pedicle

16. Overpressure
Body cavity compressed at a rate faster than
the tissue around it, resulting in rupture of
the closed space
E.g. Plastic bag
E.g. in trauma = diaphragmatic rupture,
bladder injury

17. Mechanisms of Injury:
Special Situations
• Explosions
– Blunt + penetrating + burns
• Burns
• Crush injuries
• Hypothermia/ exposure

18. Mechanisms of Injury: Penetrating
Trauma
• Gun shot wounds
• Stab wounds
• Impalement

19. Gun Shot Wounds: Mechanism
• Energy transfer
– Shape/size of bullet
– Distance to target
• Velocity (most important)
– Kinetic energy = (Mass × Velocity2 )/2
• Surface area distributed
Fragmentation
• Anatomy
– Viscoelasticity
• Muscle
• organs

20. Stab wounds
• Mechanism
– Blunt: Crush injury
– Sharp:Tissue disruption
• Extent of Injury
– Weapon size, length,
sharpness, penetration
• Severe injury
– Chest and abdomen

22. What happens
when the
patient comes
to a Level I
Trauma Center?

23. Trauma Team
• ED Physicians
• Anesthesiology
• Surgeons
– General and Trauma and Critical Care
– Neurosurgery
– Orthopedics
• Medical Students
• Nurses
• Radiology Techs
• Radiologists

24. Preparation for Patient Arrival
24
Organize Trauma
Response Team
Top and bottom images:
http://www.trauma.org/archive/resus/traumateam.html

26. What happens when
this patient comes to
the ER where you are
moonlighting?

28. What the heck
do I do now?

29. Don’t panic!

30. Trauma is not
rocket science!

31. Basics of Trauma Assessment
 Preparation
– Team Assembly
– Equipment Check
 Triage
– Sort patients by level of acuity (SATS)
 Primary Survey
– Designed to identify injuries that are immediately life threatening and to treat
them as they are identified
 Resuscitation
– Rapid procedures and treatment to treat injuries found in primary survey
before completing the secondary survey
 Secondary Survey
– Full History and Physical Exam to evaluate for other traumatic injuries
 Monitoring and Evaluation, Secondary adjuncts
 Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility
31

32. Primary Survey
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment
32

33. Primary Survey
Key Principles
–When you find a problem during the
primary survey, FIX IT.
–If the patient gets worse, restart from the
beginning of the primary survey
–Some critical patients in the Emergency
Department may not progress beyond
the primary survey
33

34. Airway and Protection of Spinal Cord
Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Coma
– Airway Patency = Secretions, Stridor, Obstruction
– Ventilation Status = Accessory muscle use, Retractions, Wheezing
Clinical
– Patients who are speaking normally generally do not have a need
for immediate airway management
– Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
– Noisy respirations frequently indicates an obstructed respiratory
pattern
34

35. Airway Interventions
 Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
– Nasopharyngeal Airway
– Definitive Airway
 Airway Support
– Oxygen
– NRBM (100%)
– Bag Valve Mask
– Definitive Airway
 Definitive Airway
– Endotracheal Intubation
 In-line cervical stabilization
– Surgical Crichothyroidotomy
35
Dept. of the Army, Wikimedia Commons
Ignis, Wikimedia Commons
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons

36. • Clear & establish a
good airway
– Consider intubation
for coma, shock, and
thoracic injuries
• C-spine stabilization
Initial Assessment: Airway

38. Airway: Cricothyrotomy

39. Protection of Spinal Cord
 General Principle: Protect the entire spinal cord until injury has been
excluded by radiography or clinical physical exam in patients with
potential spinal cord injury.
 Spinal Protection
– Rigid Cervical Spinal Collar = Cervical Spine
– Long rigid spinal board or immobilization on flat surface such as
stretcher = T/L Spine
 Etiology of Spinal Cord Injury (U.S.)
– Road Traffic Accidents (47%)
– High energy falls (23%)
 Clinical
– Treatment (Immobilization) before diagnosis
– Return head to neutral position
– Do not apply traction
– Diagnosis of spinal cord injury should not precede resuscitation
– Motor vehicle crashes and falls are most commonly associated with
spinal cord injuries
– Main focus = Prevention of further injury
39

40. C-spine Immobilization
Return head to neutral position
Maintain in-line stabilization
Correct size collar application
Blocks
Sandbags
40James Heilman, MD, Wikimedia Commons
Paladinsf
(flickr)

41. Breathing and Ventilation
 General Principle: Adequate gas exchange is required to
maximize patient oxygenation and carbon dioxide elimination
 Breathing/Ventilation Assessment:
– Exposure of chest
– General Inspection
 Tracheal Deviation
 Accessory Muscle Use
 Retractions
 Absence of spontaneous breathing
 Paradoxical chest wall movement
– Auscultation to assess for gas exchange
 Equal Bilaterally
 Diminished or Absent breath sounds
– Palpation
 Deviated Trachea
 Broken ribs
 Injuries to chest wall
41

42.  Identify Life Threatening Injuries
– Tension Pneumothorax
Air trapping in the pleural space
between the lung and chest wall
Sufficient pressure builds up and
pressure to compress the lungs and
shift the mediastinum
Physical exam
– Absent breath sounds
– Air hunger
– Distended neck veins
– Tracheal shift
Treatment
– Needle Decompression
 2nd Intercostal space, Midclavicular line
– Tube Thoracostomy
 5th Intercostal space, Anterior axillary
line
42
Breathing and Ventilation
Author unknown,
www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht
m
Delldot (wikimedia)

43. Breathing and Ventilation
 Hemothorax
– Blood collecting in the pleural space and is
common after penetrating and blunt chest
trauma
– Source of bleeding = Lung, Chest wall
(intercostal arteries), heart, great vessels
(Aorta), Diaphragm
– Physical Exam
 Absent or diminished breath sounds
 Dullness to percussion over chest
 Hemodynamic instability
– Treatment = Large Caliber Tube Thoracostomy
 10-20% of cases will require Thoracostomy for control of bleeding
43
Author unknown,
http://www.trauma.org/index.php/mai
n/images/C11/

44. INDICATIONS FOR THORACOTOMY
• 1,500 cc initial drainage from the chest tube.
• 200 cc/hr for 4 hours continued drainage:
– Thoracic great vessel injury.
– Esophageal injury.
– Patients who decompensate after initial
stabilization.

45. DIAGNOSTIC MODALITIES
• Angiography to localize injury and plan appropriate
operation.
• CT scan for patients with normal initial CXR but suspicious
mechanism and requiring CT for other reasons. If CT
identifies injury, angiography still required for precise
delineation of injury.
• Transesophageal echocardiogram (TEE):
– Fast, no contrast required, concurrent evaluation of cardiac
function, versatile in terms of location.
– Contraindicated if potential airway problem or C-spine injury.
– Not as sensitive or specifi c as angiography or CT scan.
– User dependent.

46. Breathing and Ventilation
 Flail Chest
– Direct injury to the chest resulting in an
unstable segment of the chest wall that moves
separately from remainder of thoracic cage
– Typically results from two or more fractures on
2 or more ribs
– Typically accompanied by a pulmonary
contusion
– Physical exam = paradoxical movement of chest
segment
– Treatment = improve abnormalities in gas
exchange
 Early intubation for patients with respiratory
distress
 Avoidance of overaggressive fluid resuscitation
46
http://images1.clinicaltools.com/images/trauma
/flail_chest_wounded.gif
Author unknown, http://www.surgical-
tutor.org.uk/default-
home.htm?specialities/cardiothoracic/chest_trauma

47. Breathing and Ventilation
Open Pneumothorax
– Sucking Chest Wound
– Large defect of chest wall
Leads to rapid equilibration of
atmospheric and intrathoracic pressure
Impairs oxygenation and ventilation
– Initial Treatment
Three sided occlusive dressing
Provides a flutter valve effect
Chest tube placement remote to site of
wound
Avoid complete dressing, will create a
tension pneumothorax
47
Middle and bottom images:
Author unknown,
http://www.brooksidepress.org/Products/Ope
rationalMedicine/DATA/operationalmed/Pro
cedures/TreataSuckingChestWound.htm
Author unknown,
http://www.trauma.org/index.php/main/image/
902/

49. Needle Thoracostomy
Needle Thoracostomy
– Midclavicular line
– 14 gauge angiocath
– Over the 2nd rib
– Rush of air is heard
49
Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/

50. Tube Thoracostomy
 Insertion site
– 5th intercostal space,
– Anterior axillary line
 Sterile prep, anesthesia with lidocaine
 2-3 cm incision along rib margin with #10
blade
 Dissect through subcutaneous tissues to
rib margin
 Puncture the pleura over the rib
 Advance chest tube with clamp and direct
posteriorly and apically
 Observe for fogging of chest tube, blood
output
 Suture the tube in place
 Complications of Chest Tube Placement
– Injury to intercostal nerve, artery, vein
– Injury to lung
– Injury to mediastinum
– Infection
– Allergic reaction to lidocaine
– Inappropriate placement of chest tube
50

51. Circulation
 Shock
– Impaired tissue perfusion
– Tissue oxygenation is inadequate to meet metabolic demand
– Prolonged shock state leads to multi-organ system failure and cell
death
 Clinical Signs of Shock
– Altered mental status
– Tachycardia (HR > 100) = Most common sign
– Arterial Hypotension (SBP < 120)
 Femoral Pulse – SBP > 80
 Radial Pulse – SBP > 90
 Carotid Pulse – SBP > 60
– Inadequate Tissue Perfusion
 Pale skin color
 Cool clammy skin
 Delayed cap refill (> 3 seconds)
 Altered LOC
 Decreased Urine Output (UOP < 0.5 mL/kg/hr)
51

52. Circulation
 Types of Shock in Trauma
– Hemorrhagic
 Assume hemorrhagic shock in all trauma patients until proven
otherwise
 Results from Internal or External Bleeding
– Obstructive
 Cardiac Tamponade
 Tension Pneumothorax
– Neurogenic
 Spinal Cord injury
 Sources of Bleeding
– Chest
– Abdomen
– Pelvis
– Bilateral Femur Fractures
52

53. Circulation
 Emergency Nursing Treatment
– Two Large IV Lines
– Cardiac Monitor
– Blood Pressure Monitoring
 General Treatment Principles
– Stop the bleeding
 Apply direct pressure
 Temporarily close scalp lacerations
– Close open-book pelvic fractures
 Abdominal pelvic binder/bed sheet
– Restore circulating volume
 Crystalloid Resuscitation (2L)
 Administer Blood Products
– Immobilize fractures
 Responders vs. Nonresponders
– Transient response to volume resuscitation = sign of ongoing blood loss
– Non-responders = consider other source for shock state or operating room
for control of massive hemorrhage
53

54. Circulation
Pericardial Tamponade
– Pericardium or sac around heart fills with
blood due to penetrating or blunt injury to
chest
– Beck’s Triad
Distended jugular veins
Hypotension
Muffled heart sounds
– Treatment
Rapid evacuation of pericardial space
Performed through a pericardiocentesis
(temporizing measure)
Open thoracotomy
54
Blood
Pericardium
Epicardium
Aceofhearts1968(Wikimedia)

55. Pericardiocentesis
 Puncture the skin 1-2 cm inferior to xiphoid process
 Advance needle to tip of left scapula
 Withdraw on needle during advance of needle
 Preferable under ultrasound guidance or EKG lead V
attachment
 Complications
– Aspiration of ventricular blood
– Laceration of coronary arteries, veins,
epicardium/myocardium
– Cardiac arrhythmia
– Pneumothorax
– Puncture of esophagus
– Puncture of peritoneum
55
Author unknown,
http://www.trauma.org/images/image_library/ch
est0054_thumb.jpg
Author unknown,
www.brooksidepress.org/ProductsTrauma_Surgery?M=A

56. Circulation
 A word about cardiac arrest . . .
– Care of the trauma patient in
cardiac arrest
 CPR
 Bilateral Tube Thoracostomy
 Pericardiocentesis
 Volume Resuscitation
– Traumatic cardiac arrest due to
blunt injury has very low survival
rate (< 1%)
 No point for emergency thoracotomy
– Selected cases of cardiac arrest due
to penetrating traumatic injury may
benefit from emergent
thoracotomy
 Pericardial tamponade
 Cross clamp aorta
56
Author unknown,
http://www.trauma.org/images/image_library/chest0
046.jpg

57. Disability
 Baseline Neurologic Exam
– Pupillary Exam
 Dilated pupil – suggests transtentorial herniation on ipsilateral side
– AVPU Scale
 Alert
 Responds to verbal stimulation
 Responds to pain
 Unresponsive
– Gross Neurological Exam – Extremity Movement
 Equal and symmetric
 Normal gross sensation
– Glasgow Coma Scale: 3-15
– Rectal Exam
 Normal Rectal Tone
 Note: If intubation prior to neuro assessment, consider quick
neuro assessment to determine degree of injury
57

58. Disability
 Glasgow Coma Scale
– Eye
 Spontaneously opens 4
 To verbal command 3
 To pain 2
 No response 1
– Best Motor Response
 Obeys verbal commands 6
 Localizes to pain 5
 Withdraws from pain 4
 Flexion to pain (Decorticate Posturing) 3
 Extension to pain (Decerebrate Posturing) 2
 No response 1
– Verbal Response
 Oriented/Conversant 5
 Disoriented/Confused 4
 Inappropriate words 3
 Incomprehensible words 2
 No response 1
58
GCS ≤ 8
Intubate

59. Disability
Key Principles
– Precise diagnosis is not necessary at this point in
evaluation
– Prevention of further injury and identification of
neurologic injury is the goal
– Decreased level of consciousness = Head injury until
proven otherwise
– Maintenance of adequate cerebral perfusion is key
to prevention of further brain injury
Adequate oxygenation
Avoid hypotension
– Involve neurosurgeon early for clear intracranial
lesions
59

60. Disability
Cervical Spinal Clearance
– Patients must be alert and oriented to person,
place and time
– No neurological deficits
– Not clinically intoxicated with alcohol or drugs
– Non-tender at all spinous processes
– No distracting injuries
– Painless range of motion of neck
60

61. Exposure
 Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by provider
 Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers required
 Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage
61

62. Exposure
62
Author unknown,
http://www.trauma.org/index.php/main/image/98/C11

63. Exposure
63
Author unknown,
http://www.trauma.org/images/image_library/chest0044b.jpg

64. Trauma Logroll
One person =
Cervical spine
Two people =
Roll main
body
One person =
Inspect back
and palpate
spine
64
Cdang, Wikimedia Commons

65. Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses

66. Other said that F is Foley Catheter
• We must placement of urinary catheter unless
there is a contraindicated when transection is
suspected, such as in the case of pelvic fracture. If
transection suspected, perform retrograde
urethrogram before Foley.
• Signs of urethral transection
– Blood at the meatus
– A “high-riding” prostate
– Perineal or scrotal hematoma
– Be suspicious with any pelvic fracture

67. Secondary Survey
Secondary Survey is completed after primary
survey is completed and patient has been
adequately resuscitated.
No patient with abnormal vital signs should
proceed through a secondary survey
Secondary Survey includes a brief history
and complete physical exam
67

68. History
AMPLE History
–Allergies
–Medications
–Past Medical History, Pregnancy
–Last Meal
–Events surrounding injury, Environment
History may need to be gathered from family
members or ambulance service
68

69. Physical Exam
Head/ENT
Neck
Chest
Abdomen
Pelvis
Genitourinary
Extremities
Neurologic
69

70. Physical Exam
Difficult airway
70
Source unknown

71. Physical Exam
Seatbelt sign
71
http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg
Accessed 9/20/09 – Google Image Search

72. Physical Exam
Battle Sign
(ecchymosis behind the ear)
suggest a basilar skull fracture
Raccoon's Eyes
Cullen’s Sign
around the umbilicus
Grey-Turner’s Sign
in the flanks
72
http://sfghed.ucsf.edu/Education/Cli
nicImages/Battle's%20sign.jpg
Accessed 9/20/09 – Yahoo Images
http://health-
pictures.com/eye/Periorbital-
Ecchymosis.htm
Accessed 9/20/09 – Yahoo Images
H. L. Fred and H.A. van
Dijk (Wikimedia)
H. L. Fred and H.A. van Dijk
(Wikimedia)

73. Adjuncts to Secondary Survey
 Radiology
– Standard emergent films
 C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma
(FAST)
– Additional films
 Ct scan imaging
 Angiography
 Pain Control
 Tetanus Status
 Antibiotics for open fractures
73

74. Trauma in Special Populations
Pregnancy
– Supine Hypotensive Syndrome
After 20 weeks, enlarged uterus with fetus and amniotic
fluid compresses inferior vena cava
Decreases venous return and decrease cardiac output
Keep pregnant patients in left lateral decubitus position to
avoid excessive hypotension
– Optimal maternal and fetal outcome is determined
by adequate resuscitation of mother
– Fetal Monitoring
74

75. Trauma in Special Populations
 Pediatric Trauma Resuscitation
– Differences in head to body ratio and relative size and
location of anatomic features make children more
susceptible to head injury, abdominal injury
– Underdeveloped anatomy leads to chest pliability and less
protection of thoracic cage
– Cardiac Arrest
Typically result from respiratory arrest degrading into
cardiac arrest
– Resuscitation
• Broselow Tape: which allows effective approximation of the
patient's weight, medication doses, size of endotracheal tube, and chest tube
size
ABCDE
75

76. Classic Radiographical Findings
Pelvic Fracture
76
Author unknown,
http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg

77. Classic Radiographic Findings
Femur Fracture
77
Author unknown,
www.flickr.com/photos/40939239@N08/3771820
024/

78. Classic Radiographic Findings
 Epidural Hematoma
– Middle Meningeal Artery
 Subdural Hematoma
– Bridging Veins
78
Author unknown,
http://rad.usuhs.mil/medpix/tachy_p
ics/thumb/synpic4098.jpg
Author unknown,
http://rad.usuhs.edu/medpix/tac
hy_pics/thumb/synpic519.jpg

79. Classic Radiographic Findings
Diaphragmatic rupture w/ spleen herniation
79
Author unknown,
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg

80. Classic Radiographic Findings
Widened Mediastinum – Aortic Injury
80
Author unknown,
www.trauma.org/index.php/main/image/45/print

81. Does this patient
need to go to the
OR ?

83. Penetrating
Abdominal
Trauma
GSW
OR
KSW
HD Unstable
OR
HD Stable/No
peritonitis
Peritoneal
Penetration
Positive
OR
Negative
Observation
Penetrating Abdominal Trauma

84. Blunt Trauma
Peritonitis
OR
Indeterminate
HD Stable
CT
HD Unstable
FAST/DPL
Positive
OR
Negative
Keep
Looking
Blunt Abdominal Injuries

85. Definitive Care
 Secondary Survey followed by radiographic
evaluation
– Ct Scan
– Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
 Transfer to Definitive Care
– Operating Room
– ICU
– Higher level facility
85

86. Neck Injury

87. Neck Injury
• General
Described in broad terms as penetrating vs. blunt
injuries even though considerable overlap exists
between the management of the two.
• Anatomy
The neck is divided into zones
– Zone I lies below the cricoid cartilage.
– Zone II lies between I and III.
– Zone III lies above the angle of the mandible.
These divisions help drive the diagnostic and
therapeutic management decisions for penetrating
neck injuries.

89. Penetrating Injuries
Any injury to the neck in which the platysma is
violated.
• VASCULAR INJURIES
– Very common and often life threatening.
– Can lead to exsanguination, hematoma formation
with compromise of the airway, and cerebral
vascular accidents (e.g., from transection of the
carotid artery or air embolus).

90. Penetrating Injuries
• NONVASCULAR INJURIES
– Injury to the larynx and trachea including fracture
of the thyroid cartilage, dislocation of the tracheal
cartilages and arytenoids, for example, leading to
airway compromise and often a difficult
intubation.
– Esophageal injury does occur and, as with
penetrating neck injury, is not often manifest
initially (very high morbidity/mortality if missed).

91. Resuscitation
• Obtain soft-tissue films of the neck for clues to the presence of a soft
tissue hematoma and subcutaneous emphysema, and a chest x-ray (CXR)
for possible hemopneumothorax.
Surgical exploration is indicated for:
• Expanding hematoma
• Subcutaneous emphysema
• Tracheal deviation
• Change in voice quality
• Air bubbling through the wound
Pulses should be palpated to identify deficits and thrills, and auscultated
for bruits.
A neurologic exam should be performed to identify brachial plexus and/
or central nervous system (CNS) deficits as well as Horner’s syndrome.

92. Management
• Zone II injuries with instability or enlarging
hematoma require exploration in the OR.
• Injuries to Zones I and III may be taken to OR
or managed conservatively using a
combination of angiography, bronchoscopy,
esophagoscopy, gastrografi n or barium
studies, and computed tomographic (CT)
scanning.

93. ABDOMINAL TRAUMA
• General
Penetrating abdominal injuries (PAIs) resulting from a gunshot wound
create damage via three mechanisms:
1. Direct injury by the bullet itself.
2. Injury from fragmentation of the bullet.
3. Indirect injury from the resultant “shock wave.”
PAIs resulting from a stabbing mechanism are limited to the direct
damage of the object of impalement.
Blunt abdominal injuries (BAIs) also have three general mechanisms of
injury:
• 1. Injury caused by the direct blow.
• 2. Crush injury.
• 3. Deceleration injury.

94. Physical Examination
SIGNS
• Seat-belt sign—ecchymotic area found in the distribution
of the lower anterior abdominal wall and can be associated
with perforation of the bladder or bowel as well as a
lumbar distraction fracture (Chance fracture).
• Cullen’s sign (periumbilical ecchymosis) is indicative of
intraperitoneal hemorrhage.
• Grey-Turner’s sign (flank ecchymoses) is indicative of
retroperitoneal hemorrhage.
• Kehr’s sign—left shoulder or neck pain secondary to
splenic rupture. It increases when patient is in
Trendelenburg position or with left upper quadrant (LUQ)
palpation (caused by diaphragmatic irritation).

95. • GENERAL
• Inspect the abdomen for evisceration, entry/exit
wounds, impaled objects, and a gravid uterus.
• Check for tenderness, guarding, and rebound.
• DIAGNOSIS
• Perforation: AXR and CXR to look for free air.
• Diaphragmatic injury: CXR to look for blurring of
the diaphragm, hemothorax, or bowel gas
patterns above the diaphragm (at times with a
gastric tube seen in the left chest).

96. FAST Exam
• Focused Abdominal Sonography in Trauma
• 4 views of the abdomen to look for fluid.
– RUQ/Morrison’s pouch
– Sub-xiphoid – view of heart
– LUQ – view of spleno-renal junction
– Bladder – view of pelvis
96

97. FAST
• Has largely replaced deep peritoneal lavage
(DPL)
• Bedside ultrasound looking for blood
collection in an unstable patient.
• If the patient is unstable and a blood
collection is found, proceed emergently to
the operating theater.
97

98. FAST
• Sensitivity of 94.6%
• Specificity of 95.1%
• Overall accuracy of 94.9% in identifying the
presence of intra-abdominal injuries.
98

99. FAST
Right Upper Quadrant - Morrison’s Pouch
• Between the liver and kidney in RUQ.
• First place that fluid collects in supine
patient.
99

100. FAST Exam - RUQ
100
University of Louisville ED,
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University of Louisville ED,
www.louisville.edu/medschool/emergmed/ult
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101. FAST – Sub-xiphoid
• Evaluate for pericardial fluid
• View through liver
– Transhepatic or Parasternal
• Searches for fluid between heart and
pericardium
101

102. FAST – Sub-xiphoid
102
University of Louisville ED,
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University of Louisville ED.
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103. FAST – Left Upper Quadrant
• View between the spleen and kidney
• Another dependent place that fluid collects
• Also see diaphragm in this view
103

104. FAST - LUQ
104
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University of Louisville ED,
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105. FAST – Bladder View
• Evaluates for fluid in the pouch of Douglas
– Posterior to bladder
• Dependent potential space
105

106. FAST – Bladder View
106
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University of Louisville ED,
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107. ADVANTAGES
• A rapid bedside screening study.
• Noninvasive.
• Not time consuming.
• Eighty to ninety-five percent sensitivity for
intra-abdominal blood.
DISADVANTAGES
• Operator dependent.
• Low specificity for individual organ injury.

108. Diagnostic Peritoneal Lavage (DPL)
• OPEN DPL
• Similar to open port placement in laparoscopic
surgery (peritoneal cavity is entered under direct
vision) using the Hassan port.
• CLOSED DPL
• Using the Seldinger technique, a catheter is
placed through the needle and advanced into the
peritoneum. The needle placement is similar to
the closed technique of port placement in
laparoscopy using the Veress needle.

109. Diagnostic Peritoneal Lavage (DPL)
ADVANTAGES
• Performed at bedside.
• Widely available.
• Highly sensitive for hemoperitoneum.
• Rapidly performed.
DISADVANTAGES
• Invasive.
• Risk for iatrogenic injury (< 1%).
• Low specificity (many false positives).
• Does not evaluate the retroperitoneum.

110. CT Scanning
• Useful for the hemodynamically stable
patient.
• Has a greater specificity than DPL and
ultrasound (US).
• Noninvasive.
• Relatively time consuming when compared
with FAST.

111. Angiography
• May be used to identify and embolize pelvic
arterial bleeding secondary to pelvic fractures,
or to assess blunt renal artery injuries
diagnosed by CT scan.
• Otherwise limited use for abdominal trauma.
Serial Hematocrits
• Serial hematocrits (every 4–6 hours) should be
obtained during the observation period of the
hemodynamically stable patient.

112. Laparoscopy
• Usage is increasing (mainly to identify
peritoneal penetration from gunshot/ knife
wound), especially for the stable or marginally
stable patient who would otherwise require a
laparotomy.
• Helpful for evaluation of diaphragm.
• May help to decrease negative laparotomy
rate.
• However, may miss hollow organ injuries.

113. Indications for Exploratory
Laparotomy
• Abdominal trauma and hemodynamic instability.
• Peritonitis.
• Diaphragmatic injury.
• Hollow viscus perforation: Free intraperitoneal air.
• Intraperitoneal bladder rupture (diagnosed by cystography).
• Positive DPL.
• Surgically correctable injury diagnosed on CT scan.
• Removal of impaled weapon.
• Rectal perforation.
• Transabdominal missile (bullet) path (e.g., a gunshot wound to the
buttock with the bullet being found in the abdomen or thorax).

114. Liver Injury

115. Liver Injury
• blunt or penetrating injury
• mortality: 10 - 20%
• may be associated with right lower rib
fracture
• Signs / Symptoms
–RUQ pain abdominal wall spasm ,guarding
hypoactive or absent BS signs of hemorrhage

118. NONOPERATIVE MANAGEMENT
• Approximately one half of patients are eligible.
• For penetrating trauma: Operative management
remains standard of care.
• For blunt trauma: May attempt trial of observation if:
– Patient is stable or stabilizes after fluid resuscitation.
– There are no peritoneal signs.
– There are no associated injuries requiring laparotomy.
– There is no need for excessive hepatic-related blood
transfusions
– Repeat CT scan in 2–3 days to look for expansion or
resolution of injury.
– Patients may resume normal activities after 2 months

119. Surgical Management

120. OPERATIVE MANAGEMENT
• As a rule, any hemodynamically unstable patient due
to a liver injury should be explored.
• Generally needed for 20% of patients with grade III or
higher injuries who present with hemodynamic
instability due to hemorrhage.
• Laparotomy is undertaken through a long midline
incision.
• The primary goal is the control of bleeding with direct
pressure and packing.
• Patient should then be resuscitated as needed, with
attention to temperature control, volume status, and
acid-base balance.

121. Surgical Management

122. Spleen Injury

123. Splenic Injury
• Blunt or Penetrating
• Signs / Symptoms
– LUQ pain
–Kehr’s sign
– involuntary guarding hypoactive or absent
BS
–signs of hemorrhage
– point tenderness

126. Nonoperative management criteria
• Stable.
• Injury grade I or II.
• No evidence of injury to other intra-
abdominal organs.
• Consists of bed rest, nasogastric tube (NGT)
decompression, monitored setting, serial
exam, and hematocrits.

127. Operative management indications
• Signs and symptoms of ongoing hemorrhage.
• Injury ≥ grade III.
• Failure of nonoperative management

129. Splenectomy
• Complications
– postsplenectomy infection
• Vaccination
– wound infection
– subdiaphragmatic abscess
– pulmonary complications
– hypovolemic shock

130. Stomach and Small Bowel Injury
• Stomach & Small Bowel
– Blunt vs penetrating
• Diagnosis
– Pneumoperitoneum or free fluid on CT scan
– small bowel injury may be difficult to detect
– Found at laparotomy
• Management
– Primary repair or resection

131. Colon and Rectal Injury
• Colon
– Diagnosis
• Pneumoperitoneum or free fluid on CT scan
• injury may be difficult to detect
• Found at laparotomy
– Management
• Colostomy vs primary repair
• Rectum
– Intraperitoneal- treat as colon injury
– Extraperitoneal- primary repair with
diversion
• +/- presacral drains

132. Pancreas & Duodenum
• Diagnosis
– often delayed diagnosis
– frequently seen together
– most often contused due to blunt injury
– Seen on CT Scan or at laparotomy
– intramural hematoma in wall of duodenum 
obstruction bilious vomiting severe abdominal
pain distention

134. Pancreas Injury
• Management
–if the result of blunt trauma
• nonoperative management NG/OG
decompression serial physical exams
monitoring signs of infection controversial - 3
weeks of bowel rest with TPN
–Complications of nonoperative care
• pancreatic fistula pseudocyst formation
–Operative management is necessary if: pain
fever ileus elevated serum amylase

135. Duodenal Injury
• Management
– For hematoma
• NG/OG decompression serial physical
exams monitoring signs of infection
– controversial - 3 weeks of bowel rest with TPN
– For perforation
• Primary repair with duodenal exclusion
• Efferent/Afferent Duodenal tubes

136. Pelvic Injury
• Introduction
– significant blood loss if bilateral
–may settle in retroperitoneal space
–3% of all fractures
–mortality 8 - 50%
–2nd most common cause of traumatic
death

138. Pelvic Fracture
• Signs & Symptoms
– pelvic instability
– pain (suprapubic also)
– crepitus
– bloody meatus
– neurovascular deficits

139. Pelvis
• Interventions
–Stable patient
• analgesia
• Repair vs mobilization
–Unstable patient
• Immobilize
• Ex-fix
• Angiography
– embolization

140. Case Example
 Mr. Jones – 45 y/o male involved in
a rollover road traffic accident and
was ejected from the vehicle.
Patient was unrestrained. Patient
was not ambulatory on scene of
accident and is brought into
trauma bay for evaluation.
– What concerns you about story?
– First steps of evaluation and
management
140
Pete Prodoehl (flickr)

141. Case Example
Exam
– Awake, diaphoretic
– Pulse = 120
– BP = 90/60
– RR = 18
– O2 sat = 94%
What do you want to do next?
141

142. Case Example
 Preparation
 Primary Survey
– Awake, alert, talking to provider
– Breathing
Absent breath sounds on left
What do you want to do next?
– Circulation
Vital Signs?
Access?
Resuscitation?
– IV/O2/Monitor
– Disability
GCS = 14
– Exposure
142

143. Case Example
 Chest tube placed
– Rush of air heard consistent with pneumothorax
 Repeat Vital Signs
– Pulse 120
– BP 80/40
– RR = 15
– O2 sat = 99% NRBM
 What do you want to do next?
– Patient complaining of abdominal pain
– Ecchymosis noted over left flank
– Resuscitation?
143

144. Case Example
 Blood Product Administration
 Transfer to definitive care = Operating Theatre
144
Bonemesh (flickr)

145. Conclusion
 Assessment of the trauma patient is a standard
algorithm designed to ensure life threatening injuries
do not get missed
 Primary Survey + Resuscitation
– Airway
– Breathing
– Circulation
– Disability
– Exposure
 Secondary Survey
 Definitive Care
145

146. Questions?
146
Dkscully (flickr)

147. References
 American College of Surgeons. Advanced Trauma Life
Support. 6th Edition. 1997.
 Feliciano, David et al. Trauma. 6th Edition. McGraw Hill.
New York. 2008.
 Hockberger, Robert et al. Rosen’s Emergency Medicine:
Concepts and Clinical Practice. 6th Edition. Mosby. 2006.
 Tintinalli et al. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide. 6th Edition. McGraw Hill.
2003.
147