Triage

1. TRIAGE &ASSESMENT OF
ABDOMINAL TRAUMA

2. TRAUMA
• Trauma is the study of medical problems
associated with physical injury
• The injury is the adverse effect of a physical
force upon a person
• There are variety of forces that can lead to
injury

3. PRINCIPLES OF TRAUMA
MANAGEMENT
– Treat the greatest threat of life first
– Definitive diagnosis is not immediately important.
– Time matters (“golden hour” emphasizes
urgency).
– Do no further harm.
– Assess, intervene, reassess

4. TRIAGE
A process for sorting injured people into groups
based on their need for or likely benefit from
immediate medical treatment.

7. Initially
• 1 assess basic physiology
• 2 assess anatomy of injury
• 3 assess mechanism of injury
• 4 assess special patients or system
considerations

8. INITIAL ASSESMENT
– Primary survey
– Resuscitation
– Adjuncts to primary survey
– Secondary survey
– Adjuncts to secondary survey
– Ongoing post-resuscitation monitoring &
reevaluation
– Definitive care
– Tertiary survey

9. PRIMARY SURVEY
 To identify life and limb threatening
injuries
Airway with cervical spine protection.
Breathing and Ventilation
Circulation with hemorrhage control
Disability / neurological status
Exposure / environmental control

10. Airway with cervical spine protection
• Brief history: age, gender, mechanism of injury
• Airway with cervical spine control
– Upper airway (above vocal cords) managed
adjunctively with chin lift/jaw thrust,
– suctioning, oral airway, nasopharyngeal airway,
and
– laryngeal mask airway.
– The most common cause of airway obstruction in
the unconscious patient is the tongue.

11. – Lower airway managed definitively with a cuffed
tube in the trachea (orotracheal intubation,
nasotracheal intubation, or surgical airway—
cricothyroidotomy)
– Assume cervical spine injury in patients sustaining
any blunt injury or penetrating injury above the
chest.

14. Indications for defnitive airway
• Airway: Obstructed airway,
Inadequate gag reflex
• Breathing: Inadequate breathing
• Circulation: Inadequate circulation
Systolic BP < 75 mm.Hg,
despite adequate fluid
resuscitation

15. –Disability : Coma
–Glasgow coma scale: < 8/15
–Environment : Hypothermia
–Core temperature: < 330C.

16. Breathing
• Ensure adequate oxygenation (pulse oximetry)
& ventilation.
– Provide supplemental oxygen.
– Assess breath sounds, chest percussion, chest wall
excursion, and jugular venous distention.

17. • Tension pneumothorax (pneumothorax with hypotension)
with needle decompression (second intercostal space, mid-
clavicular line), followed by 32-36 French anterior chest tube
• Simple pneumothorax with 32-36 French anterior chest
tube
• Open pneumothorax with occlusive chest wall dressing and
36 French anterior chest tube
• Massive hemothorax with 36 French posterior chest tubes
en route to operating room
• Simple hemothorax with 36 French posterior chest tube
• Flail chest/severe pulmonary contusion with intubation and
mechanical ventilation

19. Circulation with haemorrhage control
• Treatment of bleeding is to stop it.
• Pressure over bleeding site.
• Look for clinical signs of shock
• 2 wide bore 14 – 16g peripheral lines should
be started
• Resuscitate with crystalloids/colloids

20. Disabiity
• Rapid neurological evaluation using
– A  Alert
– V  Responds to verbal
stimulus
– P  Responds to pain
– U  Unresponsive

21. – Brief neurologic exam
• Level of consciousness: Glasgow Coma Scale
• Pupil symmetry and reaction to light
• Lateralizing signs
– Maintain airway, breathing, and circulation to prevent
secondary brain injury.
– Temporize for evidence of increased intracranial
pressure.
• Elevate head of bed.
• Mild hyperventilation to paCO2 = 35
• Mannitol (1 gm/kg)
• Neurosurgical consultation

23. Exposure and environmental control
– Assess temperature.
– Remove all clothing to facilitate access and
examination.
– Maintain normothermia/prevent hypothermia:
warm room, warm fluids, warm blankets

24. Adjuncts to primary survey and
resuscitation
• Blood :CBP,urea
&electrolytes,glucosetoxicology,clotting
screening,cross match
• ECG
• Two wide bore cannule for IVF
• Urinary and gastric catheters
• Radiographs of the cervical spine&chest

25. Radiographs
• AP chest, to assess for tube and line placements, as
well as subclinical hemopneumothoraces
• Pelvis, to assess for pelvic fracture as a source of
hidden bleeding
• Cervical spine, to assess for source of neurogenic
shock. As long as the cervical spine is protected with
immobilization, this radiologic evaluation can be moved
to the secondary survey

26. – Assessment for intraperitoneal injury
• Focused Assessment by Sonography in Trauma (FAST)
–Looks for fluid in 4 areas (hepatorenal,
splenorenal, pelvic, and pericardial spaces)
–Assumes that fluid represents blood and can
detect 200 cc or more
–Can be rapidly repeated for follow-up
–Not designed to find injuries unassociated
with mild to moderate intraperitoneal fluid
loss

27. Secondary survey
– Begins after primary survey & resuscitation have
been completed .It consists of:
Complete medical history
– Head to toe evaluation
– Complete neurological examination
– Radiological evaluation
– Laboratory Studies
– Formulate management plan

28. Medical history
A  Allergies
M  Medication
P  Past illnesses /pregnancy
L  Last meal
E  Events / Environment
related to injury

29. Mechanism of injury
– Blunt
» Motor vehicle
» Pedestrian
» Fall
» Crush
– Penetrating
» Gunshot
» Shotgun
» Stab
– Environmental
» Burn
» Cold
» Chemical, radiological, biological
– Primary pressure wave (blast)
– Explosions combine all four mechanisms of injury

30. Examination
• Head
– Mental status: GCS
– Scalp
» Lacerations and avulsions
» Open skull fractures
– Eyes
» Visual acuity: the vital sign of the eye
» Pupil size & reactivity
» Globe integrity & foreign body assessment
» Extraocular muscle movement
– Ears
» Pinna
» External auditory canal
» Hemotympanum and tympanic membrane

31. • Face
– Nose
» Epistaxis
» Septal hematoma
» Fracture
– Mouth
» Mid-face stability
» Malocclusion
» Dental fractures
» Mandibular fractures
» Tongue lacerations

32. • Neck: maintain in-line stabilization as anterior and
posterior collar sections are temporarily removed for
neck exam
– Anterior
» Laryngeal deformity
» Subcutaneous emphysema
» Hematoma
» Bruit
– Posterior
» Cervical spine tenderness
» Paravertebral swelling

33. • Chest
–Breath sounds
–Hyper-resonance or dullness to
percussion
–Rib, sternal, and clavicular fractures
–Subcutaneous emphysema

34. • Pelvis
– Bony tenderness and stability
– Perineum/genitalia: stigmata of urethral injury
and pelvic fracture
» Hematoma/bruising
» Blood at urethral meatus
» Vaginal lacerations
» Scrotal hematoma
– Anorectum
» Anal tone, voluntary contraction (sacral
sparing with cord injury)
» Rectum: high-riding prostate, lacerations

35. • Extremities: use symmetry to advantage
– Deformity and limb length: fracture and
dislocation
– Swelling: fracture, soft tissue (crush) and joint
injury
– Skin integrity: open fracture
– Neuromuscular function
– Circulation
» Upper: brachial and radial
» Lower: femoral, posterior tibial, dorsalis pedis

36. • Back: logroll essential (50% of body
surface area)
–Tenderness,deformity,torso neurologic
level

37. Re -evaluation
• New findings
• Worsening previous condition
• Repeated re-evaluation of vitals
• Pain relief  Judicious narcotics &
anxiolytics

38. REVISED TRAUMA SCORE
RTC 4 3 2 1 0
Systolic bp >89 76-89 50-70 1-49 0
GCS 13-15 9-12 6-8 4-5 3
Resp rate 10-29 >29 6-9 1-5 0

39. • Interpretation :
total RTS:SBP+RR+GCS
>12=normal
<9=significant injury
0=moribund

40. ABDOMINAL TRAUMA

41. • Anterior abdomen:
trans-nipple line, , anterior axillary lines,
inguinal ligaments and symphysis pubis.
• flank:
anterior and posterior axillary line ;sixth
intercostal to iliac crest
• Back:
posterior axillary line; tip of scapula to iliac crest

42. • Peritoneal:
• upper-diaphragm, liver, spleen, stomach, and
transverse colon; lower-small bowel, sigmoid colon
• Retroperitoneal space:
• aorta, inferior vena cava, duodenum, pancreas,
kidneys, ureters,ascending and descending colons
• Pelvic cavity:
• rectum, bladder, iliac vessels and internal genitalia

43. • Type of abdominal injuries :
Blunt injury
Penetrating injury
Blunt injury abdomen is 5 times more common
than penetrating injury

44. Blunt trauma
Compression injury
Crushing injury
Shearing injury
Deceleration injury

45. Causes of blunt injury
• Motor vehicle crashes
• Motor cycle crashes
• Vehicle Pedestrian Collision
• Direct blows to Abdomen
• Falls

46. Seat belt injury
• Tear /avulsion of mesentry
• Rupture of small bowel/colon
• Seat belt sign– appearance of transverse
,linear ecchymosis on Anterior
abdominal Abdomen.
• Chance fracture– presence of lumbar
distraction in X-ray.
• Thrombosis of iliac artery or abdominal aorta.

48. Frontal Impact

49. Up and forward movement
• In this sequence the body’s forward motion carries it
up and over the steering wheel with the head being
the lead body portion striking the windshield frame
or roof.
• Once impacted head stops movement but torso is still
in movement until the force is absorbed by spine and
transmitted back, through spine ( cervical spine) is the
least protected part in the body
• And injuries can be caused by compression
(lungs,heart) or shearing force due to fixed kidney
tearing at IFC or aorta

50. Assesment of abdominal injuries

51. Physical examination
• General survey
– Mental status noted.
– Pulse rate, blood pressure, respiration, SpO2,
temperature noted.
– Look for signs of hypovolemia:
• Cold and calmly extremities,
• Pallor,
• Tachycardia, tachypnoea,
• Low blood pressure,
• Feeble pulse.

52. Local examination
• Inspection:
– Site of injury.
– Pointing sign.
– Viscus involvement – site of injury.
– London’s sign
– Respiratory movements.
– Contour.
– Umbilicus.

53. Palpation
• Localised tenderness.
• Generalised tenderness.
• Rebound tenderness.
• Muscle guarding.
• Voluntary muscle rigidity.
• Any swellings.
• Fullness of the loins.
• Perineal swelling.
• Fluid thrill.

54. Percussion
• Liver dullness
• Shifting dullness
• Suprapubic region percussion

55. Auscultation
• Bowel sound if present after a while after the
injury – almost excludes serious injury.
• Bowel sounds if present in the chest –
diaphragmatic rupture.

56. Investigations
• Blood
• CBC, Glucose, Amylase, HCG
• Electrolytes
• X-ray
Spine
Chest
Pelvis

57. Special investigations
• F.A.S.T
• DPL
• COMPUTED TOMOGRAPHY

58. USG abdomen
– Good for solid organs
– Portable
– Fast
– 100 cc detection blood
– No radiation
– No contrast need
– Not seen well: solid parenchymal, retroperitoneal,
diaphragm
– Problem if: obesity, gas
– Less sensitive than DPL for hemoperitoneal
– Operator dependant

59. CECT abdomen
– Able to define organ injury
– Good for retroperitoneal & vertebral column
– Non-invasive
– Not Operator dependant
– Not great for hollow viscus
– Stable patient
– Cost $$$
– Complications: IV or oral contrast

60. DPL
• Indications:
• abdominal pain/tenderness
• unexplained shock/hypotension
• altered sensorium
• Contraindications:
• clear indication for for exploratory laprotomy
Relative:obesity,coagulopathy,prior abdominal
surgery,infections

63. Preffered sites
• Standard adult :Infraumbilical midline
• Standard pediatric: Infraumbilical midline
• 2ed &3ed trimester pregnancy :Suprauterine
• Midline scarring :Left lower quadrant
• Pelvic fracture: Supraumbilical

64. – Criteria for Evaluation of Peritoneal Lavage Fluid.
– Positive
– 20 mL gross blood on free aspiration (10 mL in children)
– 100,000 red cells/ L
– 500 white cells/ L (if obtained 3 hours or more after injury)
– 175 units amylase/dL
– Bacteria on Gram-stained smear
– Bile (by inspection or chemical determination of bilirubin
content)
– Food particles

65. • Intermediate :
• pink fluid on free aspiration
• 50,000-100,000 red cells/L in blunt trauma
• 100-500 white cells/L
• 75-175 units amylase/dl
• Negative :
• clear aspirate,100 white cells/L
• 75 units amylase/dl

66. FAST
Initial diagnostic
evaluation
FAST
Focused Assessment
with Sonography for
Trauma
X-ray pelvis and
chest
FAST negative
Diagnostic peritoneal
lavage
Positive DPL and Unstable
Explorative
laprotomy
FAST positive
US abdomen
CT abdomen
FAST negative and unstable
Exploratory laprotomy

67. • Identification of abnormal collection of fluid
or blood.
• Standard FAST, four areas:
• Rt upper quadrant
• Subxiphoid area
• Lt upper quadrant
• Pelvis

68. • The technique focuses on only 4 areas:
pericardial
splenic
hepatic
pelvic
Disadvantages:
• It will not reliably detect less than 100ml of free
blood
• it does not identify injury to hollow viscus
• It cannot reliably exclude injury in penetrating trauma

69. LIVER INJURY

70. • 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

71. • Repeat CT rule out possible complications:
– Parenchymal infarction
– Hematoma
– Biloma
• Extrahepatic bile drained percutaneously.
• Intrahepatic collections of blood and bile
resolve spontaneously.

72. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
laceration
Subcapsular tear<10%surface area
Capsular tear <1cm parenchymal tear
II Hematoma
laceration
Sc tear,10-50%;intra parenchymal<10cm in diameter
Ct ,1-3 cm parenchymal depth,10cm in length
III Hematoma
laceration
Sc tear >50% surface area of ruptured sc/parenchymal
hematoma ,ip hematoma>10cm or expanding
>3cm parenchymal depth
IV Laceration Parenchymal disruption 25-75%hepatic lobe or 1 to3
segments
V Laceration
vascular
PD involving >75% of hepatic lobeor more thanone
couinaud segment within a single lobe
Juxtahepatic venous injuries
VI vascular Hepatic avulsion

73. SPLENIC INJURY

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

75. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
Laceration
Subcapsular tear <10%surface area
Capsular tear <1cm parenchymal depth
II Hematoma
Laceration
10-50%,intraparenchymal <5cm in depth
1-3cm,does not involve trabecular vessels
III Hematoma
laceration
>50% expanding/ruptured /ip hematoma> 5cm or
Expanding
>3cm with trabecular vessels involvement
IV Laceration Segmental/hilar vessels producing major
devascularisation
V Hematoma
Laceration
Completely shattered spleen
Hilar vascular injury devascularizes spleen

76. STOMACH& SMALL BOWEL

77. • 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

78. COLON& RECTUM

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

80. PANCREAS & DUODENUM

81. • 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

82. 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

84. Penetrating abdominal trauma

85. Mechanism
• Stab wound
• Gunshot
• Foreign body penetration

86. – The small bowel occupying the large portion is
more prone.
– Injury to the major vessels or liver- early shock.
– Patient presenting with shock in penetrating
injury- exploration.
– Hollow visceral injuries – sepsis.

87. – Increasing tenderness, total count elevation, fever
several hours after injury – surgery.
– Local wound exploration.
– Laproscopy.
– Gun shot wounds must be explored

88. Stab wounds
 involve the chest in up to 10% of cases.
 Most stab wounds do not cause an
intraperitoneal injury
 The incidence varies with the direction of entry
into the peritoneal cavity
 The liver, followed by the small bowel, is the
organ most often damaged by stab wounds.

89. Gun shot
• the degree of injury depends .
• amount of kinetic energy imparted by the
bullet to the victim
• mass of the bullet and the square of its
velocity
• Distance .

90. • type I wounds: long range (>7 yards) , a
penetration of subcutaneous tissue and deep
fascia only.
• Type II wounds: distance of 3 to 7 yards and may
create a large number of perforated structures.
• Type III wounds occur at point-blank range (<3
yards) and involve a massive destruction of tissue

91. Approach to abdominal stab wound.
• Step I: Clinical Indications for Laparotomy.
• Step II: Peritoneal Violation.
• Step III: Injury Requiring Laparotomy

92. Peritoneal Violation
• 1. Evisceration
• 2. Intraperitoneal air
• 3. Local wound exploration
• 4. Ultrasonography
• 5. Laparoscopy