Trauma

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

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

INITIAL EVALUATION
AND
RESUSCITATION
OF THE INJURED PATIENT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shock

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

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

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

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

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

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

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

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

Secondary Survey
• Head-to-toe examination
• AMPLE

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

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

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

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

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

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

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

GENERAL PRINCIPLES
OF
MANAGEMENT

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

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

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

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

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

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

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

TREATMENT
OF
SPECIFIC INJURIES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Stomach and Small Bowel
– Single layer suture
Abdominal Injuries

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

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

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

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

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

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

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

Trauma

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