Pongsan Trauma 2016 (I)

Trauma Edition 2
Surgical Board Review 2016 trauma

3 trauma edition 2 update

MSD

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MSD Surgical Board Review 2016: Trauma Edition 2 i

MSD Surgical Board Review 2013 Trauma
request 4 Resident 4 ....

Trauma
short note
Board

center 5
Human error
4

Resident
MSD Surgical Board Review 2016: Trauma Edition 2 ii

1

1. i
2. Current concepts from Mattox in trauma 1
3. Initial Assessment and Management 8
4. Traumatic Brain Injury 59
5. Spine and Spinal Cord Injuries 111
6. Maxillofacial Injury 155
7. Neck Injury 203
8. Principles of Chest Injury 227
9. Lung & Tracheobronchial Injuries 278
10. Cardiac Injury 296
11. Diaphragmatic Injury 322
12. Principles of Abdominal Trauma 338
13. Gastric and Small Bowel Injury 371
MSD Surgical Board Review 2016: Trauma Edition 2 iii

14. Pancreaticoduodenal Injury 383
15. Colon, Rectum and Anal Injuries 426
16. Liver and Traumatic Biliary Injuries 455
17. Splenic Injury 501
18. Renal and Ureteral Trauma 521
19. Bladder , Urethra and Genital Injury 557
20. Pelvic Fracture 585
21. Trauma Damage Control 621
22. Abdominal Compartment Syndrome 645
23. The Difficult Abdominal Wall Closure 658
24. Principles of Vascular Injury 670
25. Cervical Vascular Injury 689
26. Intrathoracic Vascular Injury 713
MSD Surgical Board Review 2016: Trauma Edition 2 iv

27. Abdominal Vascular injury 758
28. Peripheral Vascular injury 784
29. Musculoskeleton Trauma 849
30. Hand Injury 882
31. Burn 918
MSD Surgical Board Review 2016: Trauma Edition 2 v

REFERENCES
1. Trauma (Mattox , Moore & Feliciano) 6th & 7th ed. (2008 & 2013)
2. Trauma (Eric Legome) 1st ed. 2011
3. Current Therapy of Trauma (Trunkey) 2008 , 2014
4. ATLS Manual 8th ed. , 9th ed.
5. Complications in Surgery and Trauma (Cohn) 2007
6. Surgical Decision Making 5th ed. & Prognosis of Surgical Diseases (Ben
Eiseman)
7. Basic Textbooks Schwartz 9th ed. 2009 & 10th ed. 2015 , Sabiston 19th ed.
2012 , Greenfield 5th ed. 2011 , Shackelford 7th ed. 2013 , Cameron 11th ed. 2014
8. General Surgery 2th ed. 2008 Kirby I. Bland
9. 1- 53
10. 1-19
11. Pretest & Review Schwartz , Sabiston , SESAP , Rush , Johns Hopkins , and
Arco series
MSD Surgical Board Review 2016: Trauma Edition 2 vi

To Memory of My Teacher
1. .
2. .
3. .
4. .
. . . .
.
tactics case trauma resident

. , . , . , . ..... .
..... update

. , . , . , .
articles
MSD Surgical Board Review 2016: Trauma Edition 2 vii

resident training program
. 35 36 37 38

35
MSD Surgical Board Review 2016: Trauma Edition 2 viii

MSD Surgical Board Review 2016: Trauma Edition 2 ix
CURRENT CONCEPTS FROM MATTOX IN TRAUMA
.
trauma professor Kenneth L. Mattox

resident board
Mattox guest 2012

lecture
Trauma 2556 2012

Trauma 2559 2013 2
MSD Surgical Board Review 2016: Trauma Edition 2 1

second vice-president American college of surgeons
articles
2014 Mattox lecture Nagoya Management of

aortic trauma
2014 European society for trauma and emergency

surgery Frankfurt German trauma society
Mattox lecture
2015 2 10

2015 article 1 Endovascular management

of traumatic peripheral arterial injury thoracic outlet upper extremities
endovascular treatment bleeding open technique
further study selection criteria


fan club lecture 2003 10
concept
Resuscitation
Mattox load fluid 3 : 1 rule Tom Shires
40 study ....
Mattox load IV Tom Shires
uncontrolled hemorrhage
Mattox fluid keep BP 80 mmHg

Mattox hypotensive resuscitation keep BP
control bleeding
Mattox

waste of surgeon
Mattox monitor
pedal pulse .... OK
Venous access. Mattox antecubital fossa leak

create compartment syndrome
IV ambulance IV

Intraosseous fluid resuscitation. Mattox
IV data support efficacy
IV
IV . crystalloid solution
OK plasma
1:1 fluid
Military Antishock Trousers (MAST). Mattox

MAST BP MAST risk
compartment syndrome , cardiac afterload death rate
renal dose dopamine raise BP
arrest CPR 5 (2003 10 )
ERT EDT Mattox ECT emergency center

thoracotomy ( Mattox ) CPR 10
ECT
Airway maintenance. esophageal obturator airway

tear esophagus study Mattox
survival
CBC , electrolyte.
( )
ABG. may be helpful

Cross match.
Urine exam.
Skull x-ray. show

CT
CT chest acute trauma mediastinal traverse

wound. rapid helical scan routine increases
confusion
case massive bleeding pelvic fracture external

fixator
case ICD clamp ICD
cardiac injury. pericardiocentesis pericardial

window
heart. pledgets
pledgets
cardiac contusion blunt cardiac injury with

descriptive
prophylactic antibiotic. Mattox

antibiotic 8

2013
trauma study

1. transport helicopter
ambulance ()
2. trauma procedure field
3. crystalloid solution end points of resuscitation
4. cervical collar
5. PE DVT
6. antibiotics
7. lab imaging technology
Resident field trauma

board resident Demetrios
Demetriades professor U. of Southern California Dermetriades

Mattox Annual Advances in

Trauma idea
Mattox
....

Mattox

power point
Trauma Mattox
5
Professor Kenneth L. Mattox

INITIAL ASSESSMENT AND MANAGEMENT
..
severe trauma assessment resuscitation

35%
ATLS edition 9 2012 ATLS edition
10 2016
edition 9

Ideal trauma care.. 3 phases
1. prehospital phase preparation triage

2. hospital phase primary survey definitive treatment
3. rehabilitation phase
ATLS Initial Assessment and Management

System approach ATLS guideline
1. Prehospital trauma care preparation & triage
2. primary survey (ABCDE) & resuscitation
3. adjuncts to the primary survey
4. secondary survey (head to toe evaluation)
5. adjuncts to the secondary survey

6. continued postresuscitation monitoring and reevaluation
7. definitive care

specialty ....

.... resident gen

Prehospital Trauma Life Support ( PHTLS )

.. preparation & triage
PHTLS Prehospital Trauma
Life Support ..

PTHLS
1. safe
2.
3. mechanism of injury life fhreatening conditions

support ventilation bag-mask device
oxygen FiO2 > 0.85 keep SpO2 > 95%
4. control significant external hemorrhage , external splinting & maintain manual
spine stabilization , keep warm

Preparation

train
trauma no delay trauma care

stay and play

1. severity of injury
2. definitive treatment

1. airway management. upper airway
1.1 ....
airway problem
1.2 ..... chin lift and jaw trust .
head tilt c- spine injury
1.3 upper airway oropharyngeal
nasopharyngeal airway
1.4 ET tube
laryngeal mask airway esophagotracheal combitube


2. upper artificial airway oropharyngeal airway
bag valve mask
ET tube
3. bleeding direct pressure
elastic bandage
4. IV IV ....
30
IV
IV LRS keep BP 80 mmHg
5. arrest ET tube external
cardiac massage. IV , IV

6. refer position
airway obstruction
6.1 oropharyngeal airway
board
hard collar
6.2 mandible
parasymphysis
6.3 (pregnancy) third trimester

left lateral decuibitus IVC

preparation area team
refer
refer refer .. refer
MIST
M = mechanism of injury I =
S = symptoms and signs T= treatment
Triage
Trier
Triage trauma mass casualty
.... 10 15% refer trauma
center
Triage decision criteria severe

1. physiologic criteria conscious , vital signs shock
severe
2. anatomic criteria brain , neck , chest severe
3. mechanism of injury
6 severe
4. patient criteria severe

Simple triage and rapid transport (START)
1. Immediate .. treat
2. Urgent .. 30

3. Delay ..

4. Expectant ..
mass casualties first priority greatest chance of
survival
refer .. .. level 1 .. CT
dalay transfer 2 review ..
refer CT 60 %

1. multiple injury
2. blunt trauma upper abdomen

3. abdominal wall injury

Primary Survey
identified immediately life threatening injuries condition
treat
teamwork team leader

Primary survey ABCDE
1. Airway maintenance with cervical spine protection
2. Breathing and ventilation
3. Circulation and bleeding control
4. Disability or neurological evaluation
5. Exposure and environmental (temperature) control
Airway Management
assess responsiveness
..... Bird response
definitive airway management
stridor airway obstructed
70% , , agitation , confusion , hypoxia
advanced or definitive airway maintenance
ET tube surgical airway
Airway maintenance Basic airway maintenance
appropriate position blood clot

chin lift , jaw trust oropharyngeal nasopharyngeal airway

(cervical in line immobilization)
Oropharyngeal airway ..


Nasopharyngeal airway .. tolerate
trismus
fracture base of skull midface fracture

bag valve mask ventilation. ....
.

severe
maxillafacial injury fracture cribiform plate bag
induced pneumocephalus respiratory
alkalosis oxygen Hb tissue.
definitive airway

Decision making question
1. Dose the patient need to be intubated ?
2. How rapidly dose the patient need to be intubated ?
3. Will the intubate be difficult ?
4. What is the chosen method to control the airway ?
5. What are my back - up
plans ?
Indication for definitive

airway

1. Respiratory insufficiency
2. Airway obstruction
3. Glasgow Coma Scale score of 8
4. Severe maxillofacial injury
5. Thermal airway injury
6. Persistent agitation
7. Large and/or expanding neck hematoma
8. Penetrating airway injury
9. Sustained seizure
10. Protect aspiration
11. Inability to maintain oxygenation with face mask oxygen supplementation
definitive airway ....
treat primary survey .... treat
treat primary survey ( chest injury)
1. tension pneumothorax
2. open pneumothorax
3. severe flail chest
4. massive hemothorax
5. cardiac tamponade

ATLS Airway Decision

Airway Management in Suspected C spine Injury
C- spine injury coma ,
, , head ,
maxillofacial neck injury
exclude C spine injury

C- spine protection
1. Protection work 2
plaster
2. Philadelphia collar hard collar neck flexion and extension
30% rotation lateral movement 40 60%
3. soft collar () neck movement
100%
Film C spine lateral view 2 C7 T1
10% injury film AP odontoid
view .... diag. 92%
spiral CT plain film lateral view
ATLS 9ed
tube orotracheal tube


Airway Management in Maxillofacial Injury
airway obstruction upper airway

fracture maxilla fracture posterior
anterior nasal packing
bleed blind clamp
open gauze elastic bandage
definitive airway try orotracheal tube 1 -2
cricothyroidotomy
Airway Management in Laryngotracheal Injury

laryngeal injury triad
1. subcutaneous emphysema
2. Hoarseness
3. palpable fracture
tube cricothyroidotomy
Partial laryngeal tear .case
subcutaneous emphysema


tube partial complete tear safe
fiberoptic bronchoscope guide
Complete laryngeal tear . (tracheostomy)
fracture larynx miniplate fixed
Airway Management in Children

, epiglottis floppy pharynx
lymphoid tissue airway obstruction
choice secure airway trauma ET tube with
rapid sequence intubation ET tube laryngeal mask
airway temporary airway management needle cricothyroidotomy
invasive
ET tube tube
cm 3
8 cuff tube cricoid ring
seal cuff low pressure cuff
blow cuff pressure 30mmHg
orotracheal tube needle cricothyroidotomy
14 jet insufflation

Techniques of Definitive Airway
1. Direct orotracheal intubation
2. Blind nasotracheal intubation
3. Surgical airway
3.1 Cricothyroidotomy
3.2 Tracheostomy
4. Other airway control
4.1 Laryngeal mask airway (LMA)
4.2 Esophageal tracheal combitute (ETT)
4.3 Transtracheal jet ventilation (TTJV)
Orotracheal Intubation
technique gold standard definitive
airway

trauma tube 2
1. .... manual in line immobilization C spine
injury
2. 2 . Sellicks maneuver
cricoid cartilage
cricoid esophagus vertebral column
aspiration
C- spine injury tube head tilt (
)
tube check position tube 2
tube one lung (
) tube esophagus
ER tube rapid sequence intubation
tube
Rapid Sequence Intubation (RSI)

standard airway management trauma ET tube
aspiration tube
succinylcholine
rocuronium , etomidate , propofol

Technique
1. preoxygenation oxygen 100% bag valve mask ventilation 3
2. maintaing in line cervicle spine
3. applying cricoid pressure Sellicks maneuver
4. (awake
intubation) induction agent
etomidate non-barbiturate hypnotic agent
IV sedate succinylcholine
(ATLS )
5. propofol etomidate duration of action
profound hemodynamic effect labile
hemodynamic status
6. laryngoscopy endotracheal tube
7. confirm tube OK release cricoid pressure
ventilation

1. succinylcholine short acting muscle relaxant dose
1 1.5 mg / kg 30 60 3 10
2
1.1 succinylcholine
pressure stomach aspirated

1.2 succinylcholine postinjury 24
hyperkalemia burn spinal
cord injury
1.3 long standing myopathies , myasthenia gravis
history of malignant hyperthermia
1.4 case succinylcholine rucuronium
nondepolarizing neuromuscular paralytic agent
succinylcholine
neurological evaluation
2. RSI cricothyroidotomy tray ....

Nasotracheal Intubation
blind technique
case nasotracheal
spontaneous breathing guide tube
nasotracheal tube
1. C spine injury tube
2.

1. tube 7.5 orotracheal tube 8
nasotracheal tube
2. tube retropharyngeal space
Contraindication ()
1. fracture base skull raccoon eye
2. fracture midface maxilla
3. penetrating wound hard palate
4. apnea
5. 12

Cricothyroidotomy
surgical airway definitive airway
tube severe extensive maxillofacial
injury

1. larynx
2. cricothyroid membrane
3. skin incision anterior
jugular vein bleed
4. cricothroid membrane clamp
tracheostomy tube 5 6
cricothyroidotomy temporary procedure 24
(tracheostomy) cricothyroidotomy tube

subglottic
stenosis
Difficult cricothyroidotomy (SHORT)
1. surgical scar
2. hematoma
3. obesity
4. radiation therapy
5. trauma to the larynx with disrupted landmarks
Contraindication
1. 12 cricothyroid membrane soft tissue
cricoid support maintain
patency trachea cricothyroid membrane
subglottic stenosis
2. laryngeal injury severe fracture laryngeal cartilage
3. trachea larynx
Transtracheal Jet Ventilation (TTJV)

12 temporary
airway surgical cricothyroidotomy 18
cricothyroid membrane ( 14 ) jet

insufflation with high pressure oxygen needle cricothyroidotomy
with jet insufflation 30 - 45
CO2 head injury increase ICP

Indication
1. tube open cricothyroidotomy
2. fracture larynx
3. laryngeal edema

1. 14 cricothyroid membrane tracheal
lumen
2. cannulation plastic catheter

3. 3 way y-connecter . jet ventilator
oxygen 100% 1
second on and 4 second off

1. barotrauma high frequency ventilation
2. air embolism
3. subcutaneous or mediastinal emphysema
4. esophageal perforation
Tracheostomy
poor choice trauma ..
percutaneous tracheostomy
OK trauma extend

Indication
1. 12
2. acute laryngeal injury
3. open wound trachea laceration tube

Laryngeal Mask Airway (LMA)

difficult airway ET tube LMA tube design
ET tube

.... blind technique tube posterior pharynx
epiglottis

1. Improve oxygenation face mask
2. blind neutral position
C-spine injury
3. aspiration full stomach 100%
4. LMA vocal cord
laryngospasm ET tube
5. Insertion success is similar for LMA and ET intubation

1.
2. cuff
3. aspiration 100%
4. gag reflex high inspiratory
pressure
. LMA combitube LMA
Intubating Laryngeal Mask Airway ( ILMA ) ET tube
ET tube design ILMA ET
tube

Esophageal Tracheal Combitube
tube design difficult airway tube
multilumen esophageal airway device
tube 2 cuff pharyngeal cuff distal cuff air

cuff trachea cuff
esophagus aspiration

esophagus suction
gastric content
tube
tube
1. esophageal perforation gastric rupture
2.
3. 16 5
4.
Circulation with Hemorrhage Control

A (airway) B (breathing) .....
C circulation
assess circulatory status
1. pulse .....
2. pulse .....

1. stop bleeding ( stress on control hemorrhage more than IV
2. IV
3. IV
control external bleeding ... fluid
1. antecubital vein 18 (ATLS edition 10
18 ) IV 2

2. 20cc. lab cross match 2

3. fluid balanced salt solution LRS acetar
0.9% NSS
3 in 1 rule crystalloid 1000 cc
intravascular space 25-30% fluid 3
concept
fluid keep BP 80 mmHg permissive
hypotension 3:1
4. fluid
5. fluid dextrose exacerbate physiologic
hyperglycemia osmotic diuresis
6. colloid crystalloid
7. IV 50cc /kg
class 3 ( massive
transfusion ) plasma platelet FFP
INR

FFP 1 unit , Plt 1 unit
1-2 unit pRBCs

New Concept of Fluid Resuscitation
traumatic shock ER
() response

1. BP clot dilute factor platelets
bleed
2. ARDS
3. compartmental syndrome, , ACS
mortality ......
shock bleed .
IV shock
balanced resuscitation permissive hypotensive
resuscitation keep BP 80 mmHg
....
fluid keep BP
500 cc radial pulse ....
radial pulse BP 80 mmHg

Estimated Blood Loss Based on Patients Initial Presentation
CLASS I CLASS II CLASS III CLASS IV
Blood loss(ml) Up to 750 750-1500 1500-2000 >2000
Blood loss(%blood volume) Up to 15% 15%-30% 30%-40% >40%
Pulse rate < 100 100-120 120-140 >140
Blood pressure Normal Normal Deceased Deceased
Pulse pressure (mmHg) Normal or increased Deceased Deceased Deceased
Respiratory rate 14-20 20-30 30-40 >35
Urine output(mL/hr) >30 20-30 5-15 Negligible
CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood
guideline classified hypovolemic

shock 4 class
Blood volume
1. 8% % BW 2
1 80cc/kg 1 70cc/kg
2. 7% % BW 70cc/kg
BW 70 kg blood volume 5,000 cc
estimated blood loss. level of conscious

heart rate
First sign of hypovolumia tachycardia
20% 750-1,500 cc HR > 100 /

30% 1,500-2,000 cc HR 120 BP drop
40% 2,000 cc HR 140 BP drop
Responses to Initial Fluid Resuscitation

RAPID RESPONSE TRANSIENT MINIMAL OR NO
RESPONSE RESPONSE
Vital signs Return to normal Transient improvement, Remain abnormal
recurrence of decreased
blood pressure and
increased heart rate
Estimated blood loss Minimal (10%-20%) Moderate and ongoing Severe (>40%)
(20%-40%)
Need for more crystalloid Low High High
Need for blood Low Moderate to high immediate
Blood preparation Type and crossmatch Type-specific Emergency blood release
Need for operative Possibly Likely Highly likely
intervention
Early presence of surgeon Yes Yes Yes

IV vital signs rapid response
secondary survey
transient response primary
survey ongoing bleeding
Best way assess adequate resuscitation hourly urine output
Bleed class 3 transient response
ATLS edition 10 early use of TXA
Neck Vein
Distended .
2. cardiac failure tamponade myocardial injury
Collapsed . hypovolumia
Pulse and BP
Determine of the minimum SBP from the following pulses
1. radial pulse BP 80
mmHg
2. femoral pulse BP 70
mmHg
3. carotid pulse BP 60
mmHg

shock carotid pulse SBP 60

air ER capillary refill
2 SBP
2 shock
shock class 2 HR BP drop pulse pressure
shock class 3 pulse pressure
pulse pressure hypovolumia
ATLS guideline hypotension systolic BP < 70+ ( 2
) diastolic BP < 2/3 of systolic BP shock
physiologic reserve
hypovolumia
betablocker ... HR
shock
Expected Blood Loss in Fracture

Rib 1 100-200 cc
Tibia 500 cc
Femur 1,000 cc
Pelvis 1,000-2,000 cc

Potential Sources of Occult Blood Loss
Hypovolumic shock . internal bleeding
1. Pleural space . , ,ICD , film chest
2. abdominal cavity .. , ,FAST ,DPL ,CT
3. retroperitoneal space . CT
4. bony fracture pelvic fracture long bone fracture PE
film
severe head injury shock intraabdominal hemorrhage
intrathoracic vascular injury
External Bleeding Control

Bleed .... manual compression
elastic bandage.
Bleed long bone fracture splint open fracture
tourniquet

refer 4
tourniquet
fracture pelvis pelvic binding

bleed tube guaze
Foley 24 anterior posterior nasal packing
elastic bandage
deep wound bleed thoracic inlet Foley
blow balloon
MAST military antishock trouser
bleed fracture pelvis refer MAST case major
thoracoabdominal injury diaphragmatic injury
Venous Access
emergency trauma
1. antecubital vein IV injury
2. 1 cut down
2.1 greater saphenous vein 2 cm anterior
superior medial malleolus primary site ()

2.2 secondary site cut down basilic vein 2.5 cm
medial epicondyle humerus
3. .... common femoral vein
subclavian bleeding pneumothorax
internal jugular vein ( safe)
central line route . ER
vein subclavian ,internal jugular femoral vein .
central line infection femoral vein risk
subclavian vein
central line central vein peripheral vein
single lumen double lumen
IV interosseous catheter 6
proximal tibia distal tibia fluid

lateral aspect of distal femur , humerus...
sternum
interosseous infusion emergency
CPR
central line peripheral line
electrolyte , cross match
1%
interosseous device
IV 165 cc / min C line
failure rate 15% C line failure rate 40%
. interosseous infusion
oral
( Mattox 2-3 interosseous)

1. First venous access IV
2. Second venous access cut down distal saphenous vein
Fluid Resuscitation in Trauma

fluid .... idea
Crystalloid
isotonic solution resuscitation.fluid vascular
membrane interstitial compartment 2/3
fluid 3
Crystalloid 3
1. LRS.. electrolyte electrolyte

2. Acetate ringer solution (acetar) .. acetate ketone
bicarbonate tissue ....
acidosis
3. 0.9% NSS .. LRS .load NSS chloride
.... acidosis

Colloid
fluid molecule
keep stability oncotic pressure intravascular space
crystalloid solution
vascular space
crystalloid
albumin , dextran , gelatin hemaccel
starch

1.
2. dextran anaphylaxis , coagulation
cross matching
3. crystalloid
......colloid crystalloid
crystalloid fluid of choice trauma
Hypertonic saline solution
Na crystalloid solution
maintain intravascular volume tissue fluid
case head injury burn load IV

hypertonic saline solution improve outcome
colloid resuscitation trauma
Blood and Blood components

....
autotransfusion
type specific universal donor PRC
blood group O A B antigen Rh.
universal donor Rh +ve
Rh ve
RBC substitution
perfluorocarbon hemoglobin
oxygen. SESAP 10-15
RBC substitution ....

Disability
ABC stable baseline neurological
evaluation detect CNS injury
GCS , conscious ,pupil , motor , cranial nerve
secondary survey

traumatic brain injury (TBI) manage shock
oxygen brain anoxia
treat TBI
Exposure and Environmental Control

exposure . . ,
perineum log rolling
hypothermia . warm IV
(39) warm blanket
Adjuncts to Primary Survey and Resuscitation

monitor , investigation
1. monitor vital signs , GCS , pulse oximetry , ABG , EKG
2. Foley , NG OG (orogastric tube)
3. lab cross match
4. Plain film big three for major trauma chest AP , pelvis AP
lateral C-spine film C-spine sensitivity 60%
CT C-spine sensitivity 90% secondary survey
CT

5. FAST DPL .
primary survey acute
deterioration re-evaluation primary survey
X-ray diagnostic studies resuscitate
fracture base of skull midface fracture NG tube
OG tube

Secondary Survey
primary survey stable
injury
head to toe evaluation
mechanism of injury

AMPLE history
A = Allergy contrast x-ray
M = Medication currently used
betablocker poor cardiac response
P = Past illness DM ,HT
L = Last meal
E = Event or Environment related to injury
seat belt , burn closed space

AMPLE head to toe


Summary of Secondary Survey
Area assess Injury Findings Confirm by Management
- Head Brain 8,severe Head CT, Cervical spine
-Level of 9-12,moderate injury Reevaluate without immobilization,
conscious 13-15,minor injury paralytic/neurotroics intubation, mannitol,
-GCS Pco235 mmHg,
anticonvulsants,
neurosurgical
evaluation
Pupil size, Head, eye Mass effect ,diffuse brain injury, Head CT Same as above
shape, reactivity ophthalmic injury
Head Scalp ,skull Scalp laceration ,depressed skull Head CT Same as above,
fracture, basilar skull hemorrhage control
fracture(battle sign, raccoon eyes) with direct pressure
Maxillofacial Soft tissues, Facial Facialbone x-ray, Same as above ,
bones, nerves, fracture,malocclusion,crepitus fine-cut facial CT specialist evaluation
teeth/mouth
Neck Airway, Laryngeal deformity,subcutaneous C-spine x-ray, Do not explore
C-spine, emphysema,hematoma,bruit,platy angiography and/or platysmal
arteries, smal penetration,C-spine duplex,laryngoscopy, penetrating wounds
veins, tenderness esophagoscopy in ER,
esophagus, zoneII injuries may
nerves require OR
Airway,chest Paradoxical wall motion, Chest x-ray,CT scan, Tube thoracostomy,

wall, lungs, crepitus,tenderness,rib angiography, pericardiocentesis
esophagus fractures,subcutaneous bronchoscopy, EDThoracotomy,
aorta emphysema,diminished breath transesophageal OR
sound,muffled heart sound, echocardiogram
back pain
Abdomen/flank Intra or Abdominal wall pain, FAST,DPL,CTscan, Laparotomy,

retroperitoneum tenderness,peritoneal signs GI contrast studies, angioembolization
angiography
Pelvis Pelvis, Widened symphysis pubis,bony Pelvic x-ray,retrograde Compression
perineum, tenderness,rectal tone and vaginal urethrogram,cystogram, garment,
GU tract, trauma,hematuria,high-riding IVP,CT with contrast angioembolization
intra or prostate,assess pelvic stability
retroperitoneum
Spinal Head,spine, Motor/pain response, Plain spine films, Cervical spine
cord,vertebral peripheral para/quadriplegia,palpate for CTscan, MRI Immobilization,
column nerves deformity/tenderness/fracture, steroids
localizing signs
Extremities Nerves, Swelling,pallor,bruising,crepitus, Plain films, duplex, Hemorrhage control,
vessels, pain,tenderness,malalignment, compartment pressure, fasciotomies,
soft tissue, neurovascular deficit, angiography traction, splint
bone/joints tense compartments
Adjuncts to Secondary Survey

stable investigation
(DPL)

1. film x-ray spine
2. CT scan
3. IVP
4. DPL
5. Scope
6. Angiogram
Postresuscitation Monitoring and Re-evaluation

critical
primary survey .... monitor
1. Vital Sign , GCS
2. Foley catheter. urine output
3. NG tube. Decompress
4. ABG , pulse oximetry
5. EKG
Definitive Care
observe , intervention
subspecialty

..... chest ..... ... resident

rotation . case trauma
lab robot
up facebook IG check rating line
Rehabilitation


....

TRAUMATIC BRAIN INJURY
..
...
consult ... refer
craniotomy rotation neuro

ATLS edition 10 center early refer CT

Anatomy
basic
Scalp 5 skin, connective tissue, aponeurosis galea

aponeurotica, loose areolar tissue pericranium
subgaleal hematoma () loose areolar tissue

pericranium
scalp bleed shock
Brain
1. cerebrum falx left right hemisphere
2. cerebellum. coordination balance

Meninges 3
1. Dura mater dura

compartment
1.1 falc cerebri ( sagittal)
1.2 tentorium cerebelli 2 compartment

supratentorial infratentorial compartment
2. Arachnoid subarachroid CSF blood vessel
3. Pia mater

Venticular system choroid plexus CSF 20 cc.
CSF circulation
CSF flow lateral ventricle foramen of Monro third

ventricle aqueduct of Sylvius fouth ventricle subarachnoid space
brain cord reabsorp venous circulation
bleeding absorp CSF

Neurological Examination
()
Level of consciousness
1. drawsy
2. confusion
3. stuporous deep pain

4. coma respond deep pain decerebrate posture

tube
eye examination
1. ( raccoon eye) fracture base skull

anterior fossa
2. pupil sedate endotracheal tube
2.1 dilated pupil uncal herniation CN3
2.2 pinpoint pupil lesion pons
3. eye movement
3.1 conjugated deviation lesion

3.2 CN3, 4, 6 injury
3.3 dolls eye organ
exclude C-spine injury dolls eye stiff neck
Cushing reflex ICP brainstem BP pulse

Signs and Symptom of Increased ICP

1. consciouns most common initial symptom
2. progressive headache
3.
4. Cushing response BP HR pulse pressure
5. pyramidal tract signs hemiplegia, hypereflexia

Brain Herniation
compartment
1. falx cerebri cerebrum
2. tentorium cerebelli cerebellum
Monro Kellie Doctrine Hypothesis noncompressible structure
nonexpendable skull , blood volume
CSF intracranial mass tumor compensate
blood volume CSF volume

ICP bleeding brain herniated 3
1. Transtentorial herniation
1.1 central herniation bleed

brain tentorial hiatus brainstem

1. chyne stroke
2. posture decorticate (abnormal flexion) decerebrate

(abnormal extension)
3. pinpoint pupil
3 .... medulla

1.2 uncal herniation bleeding
temporal lobe uncus temporal lobe
CN3 treat medulla
1. pupil
2. hemiplegia
1.3 Kernohan herniation

pupil weakness
2 Tonsillar herniation cerebellar herniation foramen magnum

herniation bleed posterior fossa fossa space
cerebellar tonsil medulla ...
tonsillar herniation brain herniation
()
1. Cirgular herniation falcine herniation brain lobe
lobe
transtentorial tonsillar herniation
weakness

Glasgow Coma Scale (GCS)
Glasgow university (Scotland) Lancet severity

GCS
1. Eye opening (E) brainstem

2. Verbal response (V)
3. Motor response (M) M score outcome survival

functional status M E V
motor response 2 response
decorticate ...
lesion midbrain pons
decerebrate ( opisthotonus) lesion

midbrain

3-15 (E4V5M6)
score < 13 refer trauma center
score < 8 endotracheal tube 5 50%
score 3
severity
1. mild or minor brain injury . GCS score 13-15
2. moderate brain injury . GCS score 9-12
3. severe brain injury . GCS score 3-8

Glasgow Coma Scale (GCS)
Assessment Area Score
Eye opening (E)
Spontaneous 4
To speech 3
To pain 2
None 1
Verbal response (V)
Oriented 5
Confused conversion 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor response
Obeys command 6
Localized pain 5
Normal flexion withdraw 4
Abnormal flexion (decorticate) 3
Extension (decerebrate) 2
None 1

Classifications of Traumatic Brain Injury (TBI)

1. Primary TBI injury impact moment brain

2. Secondary TBI TBI primary TBI

brain hypoxia primary TBI
oxygen shock, infection, hypoxia,
hyponatremia, hypoglycemia
Primary TBI
biomechanism of injury 2
1. Focal brain damage

1.1 vascular injury epidural, subdural, intracerebral, subarachnoid

hemorrhage
1.2 parenchymal injury cerebral contusion, cerebral laceration
2. Diffuse brain injuries

axon axon
transport concussion

severe diffuse axon injury (DAI)
( persistent vegetative state) DAI serious
problem
severity GCS primary TBI 3
1. Minor brain injury (GCS13-15)
2. Moderate brain injury (GCS9-12)
3. Severe brain injury (GCS3-8)

Skull Fracture
closed skull fracture scalp intact
hematoma
diastatic fracture skull fracture diastatic fracture

skull suture line diastatic fracture
suture line 3 mm.
open skull fracture scalp

Depressed skull fracture
Indication for surgery
1. Gross wound contamination
2. depressed fracture 8-10 mm.
3. depressed fracture with significant underlying intracranial hematoma ,

pneumocephalus , frontal sinus involvement , focal neurological deficit result from
compression of brain parenchyma
4. persistent CSF leakage
5. gross cosmetic deformity

Cerebral Concussion
reversible physiological change

10 6

CT
Cerebral Contusion
white mater
concussion ( 24 )
focal loss of function
CT 20%
contusion intracerebral hematoma


ATLS CT scan initial scan
12-24
Epidural Hematoma
middle meningeal artery outer layer
dura inner table skull
fracture temporal bone hematoma
loss conscious lucid interval

( pupil) hemiplegia,
hyperreflexia positive Babinski uncal
herniation ...
lucid interval talk and die

retrograde amnesia prognosis amnesia
CT lens biconvex lenticular

shape
Treatment
1.
2. significant mass effect
2.1 midline shift 5 mm.

2.2 thickness of hematoma > 15 mm
2.3 supratentorial hematoma > 30 cc
2.4 infratentorial hematoma > 10 cc

Subdural Hematoma
epidural bridging vein inner layer
dura arachnoid mater hemisphere
localize epidural
prognosis epidural cerebral contusion
Presentation 3
1. Acute 72 injury CT
hyperdencity lesion
2. Subacute 72 3
CT isodence
Chronic 3 classic
trauma liquefaction clot
osmotic pressure fibrinous membrane
increase ICP density CT hypodence

CT ( concave)
( crescent shape) brain contusion
frontal temporal tip

Treatment. significant mass effect
Intracerebral Hematoma
artery vein
...
cerebral contusion frontotemporal basal ganglia

sudden loss of conscious.. increase
ICP brain herniation
Treatment
significant mass effect
Intraventricular Hemorrhage
ventricle subarachnoid
ventricle
hydrocephalus ICP

Treatment ventriculostomy
Subarachnoid Hemorrhage
vein subarachnoid space CSF clot
... meningeal irritation
1.
subarachnoid CSF
arachnoiditis ICP
2. ( nuchal rigidty)
3. ( photophobia)

CT hyperdensity area
cerebral sulci
Treatment
1. ... hydrolysis

2. ICP LP pressure
... LP expanding lesion
herniation
3. hydrocephalus VP shunt

Indication for Surgery in TBI
1. ICP
2. CT midline shift > 5 mm.
3. intracerebral hematoma 2 cm.
4. posterior fossa hematoma
5. compound depressed skull fracture
6. penetrating head injury
Management of TBI
ATLS mechanism of injury

exclude severe or serious injury

neuro
exclude cervical spine injury
3 grade GCS mild, moderate severe TBI
criteria admit criteria CT brain

TBI shock shock chest,
abdomen, pelvis bleed
fluid response shock

CT brain ... CT brain

fluid response partial response CT brain

CT
fluid TBI shock load

TBI outcome presence of shock shock

Imaging Studies in TBI

Routine film skull

Indications for CT scan
1. 2 hemiparesis aphasia
2. 5 retrograde amnesia 30
3. mechanism of injury
5 3 penetrating head injury

4. 65 mental status
5. GCS 15 2 injury
6. moderate severe TBI
7. compound or depressed skull fracture
8. fracture base of skull raccoon eye

Indication for follow up CT scan (within12-24 hours)
1. abnormal initial CT
2. neurological status deterioration
3. preferably before discharge in moderate TBI
Mild Traumatic Brain Injury (GCS 13-15)

80% loss conscious 20 post
traumatic amnesia focal pathology contusion , EDH, SDH
3% mild TBI
mortality 1%
discharge criteria admit

Indication for admission
1. , GCS < 15
2. medical condition underlying coagulopathy
3. Persisting neurological signs or symptoms impaired of the consciousness
4. CT scan available admit observe
5. indication CT
6. film skull fracture skull
warning sheet follow up

Moderate Traumatic Brain Injury (GCS 9-12)
confuse hemiparesis
10% severe TBI
admit primary survey neuro ...

neuro
CT brain follow up CT 12-24

severe TBI ET tube

Severe Traumatic Brain Injury (GCS 3-8)
1rysurvey tube ventilate neuro CT brain
lesion brain OR
CT next step hyperventilate

mannitol 1 gm / kg

lesion ICP monitor ICP
CCP keep ICP 20 mm Hg
ICP ventricular catheter transducer pressure

20 treat CSF catheter
ET tube severe TBI ...

technique rapid sequence with cervical spine protection
Keep PaCO2 32-35 mmHg. PaO2 > 100 mmHg ( 60)

CO2 lactic aid cerebral vasodilatation intracranial blood
volume

ICP hyperventilate PaCO2 30-35 mmHg.
vasoconstriction hyperventilate
PaCO2 30 cerebral vasoconstriction
cerebral blood flow
20-30 venous pressure

... agitation ICP ... MO 4 mg. continuous

drip valium midazolam
GCS sedation propofol
... vasodilate cerebral blood flow

ICP paracetamol cooling blanket
Fluid TBI isotonic NSS hypotonic saline

glucose ATLS 9ed
3%. Hypertonic saline BP drop ICP
keep SBP 90
keep Hct 30 %
anticonvulsant phenytoin dilantin 7

early seizure late seizure


antibiotic pneumonia
routine
Foley cath NG tube decompression feed

nutrition injury 72 full options 7
DVT prophylaxis elastic bandage pneumatic

compression device LMWH 3
steroid ICP
complication steroid steroid TBI ()

Intracranial Pressure (ICP)
ICP = 10-15 mmHg. 20 cm.H2O
ICP 10 19 mmHg. monitor
ICP > 20 mmHg. treat
1. manitol 1-2 mg./kg. IV bolus
2. isotonic hypertonic saline
3. hyperventilate keep PaCO2 30-35 mmHg.
4. keep CPP cerebral perfusion pressure mean BP

ICP CPP > 60 mmHg. improve neurological
outcome
ICP
decompressive craniectomy
management TBI
1. stiff neck tube rule out cervical spine injury
2. routine film skull, routine CT brain
3. hypotonic saline glucose
4. IV steroid

5. LMWH 72
6. prophylactic hyperventilation
7. prophylactic hypothermia
8. prophylactic barbiturate
9. muscle relaxant muscle relaxant

muscle relaxant
10. prophylactic antibiotic
Fracture Base of Skull

skull brain
( cranial vault)
dura CSF
Anatomy
base skull 3
1. anterior skull base anterior cranial fossa

cribiform plate orbital floor CSF

CN 1

2. middle skull base middle cranial fossa sella turcica
pituitary gland middle ear nasopharynx
CSF otorrhea
CN 2, 3, 4, 5, 6
3. posterior skull base posterior cranial fossa

petrous occiput
CN 7, 8, 9, 10,11,12

Symptoms and Signs of Base Skull Fracture
Anterior fossa fracture
1. raccoon eye

2. anosmia olfactory nerve (CN 1) injury
3. nasal tip anesthesia
4. subconjuctival hemorrhage
5. CSF rhinorrhea
6. carotid cavernous fistula
Middle fossa fracture
1.

2. tympanic membrane hemotympanum
3. tympanic membrane CSF otorrhea
4. battle sign
5. epidural hematoma
6. hypopituitarism
Posterior fossa fracture

fracture middle fossa CSF
anterior middle fossa fracture middle fossa
CN7 palsy CN8 injury
bleeding brainstem
Imaging for Base Skull Fracture

Plain film
20% fracture line air sinus, air fluid level
sphenoid sinus pneumocephalus
CT brain
fracture pneumocephalus

Management of Base Skull Fracture
NG tube nasotracheal tube base skull
fracture
CSF observe fracture heal
Antibiotic infection meningitis
CSF antibiotic ()
Resident complication 2
1. CSF fistula
2. Carotid cavernous fistula (CCF)

CSF Rhinorrhea
CSF high glucose transferrin
CSF ,
CSF CSF
anosmia
Test for CSF
1. CSF

target sign halo sign

2. glucose level CSF glucose level 44-100 mg.%
0.5
3. fluid beta transferrin

CSF

CSF Fistula
injury 2-3 base skull fracture
risk infection CSF rhinorrhea CSF otorrhea
CSF rhinorrhea
Management
1. Conservative 85% 1
1.1 bed rest 30 CSF
1.2 intracranial pressure
1.3 CSF acetazolamide
1.4 antibiotic ()
1.5 96 CSF CSF drainage
neuro

2. Surgery
15% 10-14
ascending infection meningitis

endoscopic approach fracture

sinus

Carotid Cavernous Fistula (CCF)
fracture base skull middle fossa branch
carotid artery cavernous sinus sella turcica
pressure cavernous sinus venous drainage
periorbital tissue
. pressure cavernous sinus
1. pulsatile proptosis ( )
2. sudden exophthalmos

3. ophthalmoplegia
4. chemosis sclera
5. episcleral venous dilatation
6. diplopia
7. epitaxis
8. ocular bruit cardiac contraction
Diagnosis angiogram
Treatment
1. observe 1-4 fistula

2. observe ...
endovascular treatment embolization

Brain Death Criteria
1. GCS = 3
2. nonreactive pupils
3. absent brainstem reflexes
3.1 oculocephalic reflex
3.2 corneal reflex
3.3 Dolls eyes
3.4 gag reflex

4. no spontaneous ventilatomy effort on formal apnea testing
5. exclude reversible conditions
5.1 hypothermia
5.2 barbiturate coma

....


SPINE AND SPINAL CORD INJURY
.
injury maxillofacial
injury injury spine spinal cord .... 5%
TBI spine injury 25% spine injury TBI
20% spine injury 1
spine and spinal cord injury
1. unconscious patient
2.
3. maxillofacial injury
4.
5. PR sphincter tone
spine
1. cervical spine 55% 10-20 % spine
2. thoracic spine 15%
3. thoracolumbar spine 15%
4. lumbosacral spine 15%

Spinal injury
injury bone , disc ligament
Spinal injury 2 ()
1. Stable fracture. type posterior ligamentous complex

cord compression
type spinal fixation
2. Unstable fracture.
2.1 posterior ligamentous complex
2.2 vertebral body 25%
2.3 dislocation vertebral body
unstable fracture type stabilization collar , halo ,

brace fixed
film fracture calcaneus
TL fracture
diving accident compression fracture C spine

teardrop fracture
most common C spine fracture C5
most common C spine dislocation or subluxation C5-C6

Grading

Basic Anatomy
Spine 7C 12T 5L 5S 1 coccyx
Ligament spine. stability

1. anterior ligamentous complex. anterior posterior longitudinal
ligament
2. posterior ligamentous complex. spinous ligament articular

spinous process
The stabilizing elements of the subaxial cervical spine can be grouped into anterior and
posterior columns. A, anterior longitudinal ligament; B, intervertebral disc; C,
intertransverse ligament; D, posterior longitudinal ligament; E, capsular ligament; F,
facet joint; G, ligamentum flavum; H, interspinous ligament.

Physical Examination in Spinal Cord injury
cord injury spinal cord
L1 L2 nerve root cauda equina
injury L1 injury cord nerve root

L2 injury nerve root
.... abdominal respiration quadriplegia

lower cervical cord injury C4 ....
C3
shock heart rate hypovolumic shock BP drop
heart rate heart rate
shock 2
Spinal cord injury BP drop sympathetic tone
vasodilatation spinal cord injury T6
lesion T6 shock hypovolemia
bleeding BP drop neurogenic shock
cord injury T
priapism. ANS loss sympathetic tone

parasymph. cord injury T7
poor prognosis

1. Sensory dermatome
1.1 pain temp anterior column
1.2 position sensation posterior column
1.3 sensation perineum

check sphincter tone sacral sparing
2. muscle power grading

3. DTR
Levels of Sensory Spinal Dermatomes

Spinal Dermatome Sensation Areas
C5 Area over the deltoid
C6 Thumb
C7 Middle finger
C8 Little finger
T4 Nipple
T8 Xiphisternum
T10 Umbilicus
T12 Symphysis pubis
L1 Inguinal groin regions
L4 Medial aspect of the calf
L5 Web space between the first and second toes
S1 Lateral border of the foot
S3 Ischial tuberosity area
S4-S5 Perianal region

Motor Function of Spinal Roots (Myotome)
Muscle Motor Examination
Nerve Root
C5 Deltoid Shoulder abduction
C6 Biceps Elbow flexion
C7 Triceps Elbow extension
C8 Flexor carpi ulnaris Wrist flexion
T1 Lumbricals Finger abduction
L2 Iliopsoas Hip flexion

L3 Quadriceps Knee extension
L4 Tibialis anterior Angle dorsiflexion
L5 Extensor hallucis longus Great toe extension
S1 Gastrocnemius , Soleus Angle plantar flexion
Muscle strength grading scale.
Grade Strength
0 No contraction
1 Trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity gravity
4 Active movement against resistance can be overcome
5 Normal strength

Deep Tendon Reflexs
Normal = 2+
Hyporeflexia = 0 & 1+
Hyporeflexia = 3+ & 4+
Knee jerk L3 L4
Angle jerk L5 S1
weak gastrocnemeus loss angle reflex level injury L5 S1

()

Severity of Spinal Cord Injury
3
1. Complete cord injury
motor sensory injury

cord transection C T recover
cauda equina injury
reflex complete cord injury spinal reflex

spinal shock reflex
2. Incomplete cord injury
motor sensory clinical

spinal cord syndrome
3. Spinal shock
spinal cord motor ,

sensory reflex cord
4. Neurogenic shock
syndrome of hypotension and bradycardia spinal cord

Injury T6 interrupt sympathetic tone vagal tone
bradycardia and peripheral vasodilatation
Spinal Cord Syndromes

pattern cord syndrome neuroanatomy 4
1. central cord syndrome

2. anterior cord syndrome
3. posterior cord syndrome
4. Brown - Sequard syndrome
central cord

Central cord syndrome. hyperextension injury cord

50% recover
Motor. ()
somatic fiber corticospinal tract
sphincter dysfunction
Sensory. loss pain temp
Prognosis.fair

Anterior cord syndrome. injury anterior 2/3 posterior
column
anterior spinal artery injury
prognosis recovery 10 %
Motor.
Sensory. loss pain , temp touch vibration
position
Prognosis.

Posterior cord syndrome. crude touch
sensation ....prognosis (fair) central cord
Brown Sequard syndrome. cord hemitransection cord


Motor.
Sensory. loss position proprioceptive
loss pain temp
Prognosis. (best)
cord syndrome

Spinal Shock
sudden loss neurological function spinal cord
flaccid paralysis loss of spinal reflex
cord injury complete
incomplete cord injury

1. neurological deficit 1-2 level vascular change

2. bradycardia SBP 80-100
spinal shock 24 99%
recover 48
recover spinal shock
test bulbocavernosus reflex
Bulbocavernosus reflex.... reflex arc S2-3
() afferent fiber spinal cord
efferent fiber
recover cord contraction anal sphincter

24 - 48
structural disruption recover

recover complete cord injury motor sensory
reflex flaccid paralysis spastic paralysis
urinary bladder flaccid reflex neurogenic bladder
Investigation for Spine and Spinal Cord Trauma

fracture & dislocation fracture
stable unstable fracture
ATLS 9ed. CT C-spine plain film
Plain film spine
plain film film 3
lordotic curve
AP/lateral view. C7 T1
x-ray swimmer view
Oblique view. pedicle articular process
Open mouth Odontoid view. odontoid (C2) x-ray
film skull fracture dens odontoid

ligament injury film flexion extension view

CT spine
cut 3 mm fracture dislocation
plain film C1 C2 C7 T1
center USA CT plain film axial ,

coronal sagittal view sensitivity specificity plain film
.... ....
CT injury ligament, disc cord
MRI
MRI spine
neurological deficit plain film CT

MRI
1. cord cord injury cord , cord
compression spinal epidural hematoma
2. disc
3. soft tissue ligament

ligamentous injury
MRI
unstable
Initial Assessment and Management

prehospital phase transportation

C-spine injury rigid cervical collar
supportive block on backboard strap

20 % ligament support spine
cord X-ray spinal cord injury
without radiographic abnormality SCIWORA
Position backboard thoracic elevation occipital
recess flexion C-spine
3 (log roll)
immobilization
protect C-spine hard collar

plaster

shock heart rate hypovolumic shock
chest abdomen
film C-spine lateral view
cord injury.BP exclude chest

IV load vasopressor
secondary survey
spinous process
spine
injury
film secondary survey AP , lateral open mouth view

odontoid. plain film CT C1-C2 C7-T1
X-ray C-spine
collar off
The National Emergency Radiography Utilization Study set clinical criteria
5 criteria 5 rule out C-spine injury
1. no midline cervical tendernrss
2. no focal neurological deficit
3. normal alertness
4. no intoxication
5. no painful distracting injury

off hard collar 5
1. neck pain
2. posterior midline neck tenderness
3. focal neurological deficit

4.
5. distracting injury
6. CT C-spine
....When in doubt , leave the collar on
Management of Spine and Spinal Cord Injury

Step
1. treat cord injury

2. treat bony fracture
3. treat complication
4. PT
5. Treat

1. NPO NG tube ileus 48
feed
2. Foley

3. DVT prophylaxis spinal cord injury
mechanical prophylaxis pneumatic compression device
LMWH 3-6
4. feed ,
5. pressure sore
high dose methylprednisolone. data
cord recover infection GI
bleeding
steroid steroid 8
3 8
review

1. Fracture or dislocation
2. Open fracture
3. soft tissue bony compression cord
4. acute anterior spinal cord syndrome
5. progressive neurological deficit cord
disc

Surgical treatment
1. realignment C spine
skull traction TL spine traction

2. cord compression disc
incomplete cord injury increasing neurological deficit
decompression
3. long term stabilization spinal fusion C spine

wiring bone graft TL spine Harrington rod
Atlas Fracture (C1)

atlas body odontoid
(C2)
Jefferson fracture fracture C1 ring anterior
posterior arch 46% fracture C2 axis
C1 axial vertical loading C spine

cord injury
C1
stable fracture cord injury

film lateral submentovertex view confirm CT
Treatment
1. initial treatment rigid collar
2. halo apparatus 4-6 collar 1-2


3. unstable fracture skull traction spinal fusion
Axis Fracture (C2)

C2 2
1. odontoid fracture
2. hangman fracture
nonodontoid nonhangman 20%
body

Odontoid Fracture (C2)
C2 odontoid (dens)
odontoid blood supply nonunion
odontoid cord
injury cord
film open mouth lateral view CT fracture


odontoid fracture 3 type
1. Type 1 base odontoid stable

fracture
hard collar 4-6
2. Type 2 base unstable fracture

stable fracture
type 2 type

1. unstable fracture spinal fusion
2. stable fracture skull traction 6

halo apparatus 6
3. Type 3 extend vertebral body
skull traction 4 halo 8

Hangman Fracture
bilateral pars interarticularis pedicle
C2
hyperextension
hangman fracture cord injury

1. halo vest Jefferson fracture
2. severe displacement spinal fusion

Dislocation of Cervical Spine
C5 C6
flexion rotation force
traction


1. unstable fracture or dislocation
2. progressive neurological deficit
3. persistent bony fragments in the spinal canal

Lower Cervical Spine Fracture (C3-C7)
C5 C6 flexion extension
C3
Compression fracture vertebral body.
stable fracture

1. Bed rest hard collar 2
2. neurological deficit (nerve root compression)

nerve spinal fusion
Burst fracture vertebral body.

unstable fracture

1. skull traction
2. fixed plate
screw bone graft

Thoracolumbar Spine Fracture
( axial loading injury) hyperflexion &
rotation
T10-T12
L1 cord injury cord L1
L1 cauda equina injury
fracture 1column disrupted unstable fracture
TL fracture
1. Wedge compression
neurological deficit wedge stable fracture

1. 25% bed rest
2. 25% 50 % body jacket Taylor

(hyperextension) brace bone cement

3. 50 % progressive kyphosis

4. cord injury surgical decompression
Harrington rod
2. Burst fracture. axial loading

1. cord injury neurological deficit
1-2 ileus bed rest
Taylor brace 2-3
2. neurological deficit intact posterior column

unstable fracture
fixed bone graft Harrinton rod
3. Fracture dislocation of TL spine

complete neurological deficit
4. Flexion distraction injury 3 chance fracture(5)

3 4
1. (open) reduction Harrinton rod
fixed
2. bed rest 4-6 Taylor brace

3-4

5. Seat belt type injury Chance fracture...
vertebral body transverse neurological deficit
injury
retroperitoneal organ
small
bowel
fracture transverse process, spinous process, sacrum

coccyx neurological deficit
.... bed rest

Peripheral Nerve Injury
Seddon classification
3
1. Neurapraxia. nerve disruption

conduction block recover 12

2. Axonotmesis. axon
endoneurium perineurium wallerrian
degeneration distal end regeneration axon
proximal end
observation follow up
3. Neurotmesis. axon endoneurium

nerve

repair
3.1 primary repair. nerve injury
sharp laceration vital signs stable severe
soft tissue injury early repair delayed repair
3.2 delayed repair. crush injury severe soft
tissue injury vital signs stable
EMG postinjury 3-4 3
re-explore nerve
Seddon Classification
Neurapraxia Axonotmesis Neurotmesis
Axon intact disrupt disrupt
Endoneural tube intact intact disrupt
Perineurium intact intact intact or disrupt
Epineurium intact intact intact or disrupt
Motor loss complete complete complete
Sensory loss Partial sparing complete complete
Autonomic function spared absent absent
Nerve conduction present absent absent
distal to injury
Fibrillation in EMG absent present present
Recovery rapid , 1 mm per day , 1 mm per day ,
complete good always imperfect

peripheral nerve injury
Median nerve (C6-T1)

1. Motor. thumb apposition , thumb abduction , finger flexion
2. Sensory.supply 3
3. Median nerve palsy. loss thumb abduction apposition

Ulnar nerve (C8-T1)
1. Motor.supply intrinsic muscle , finger abduction and wrisf flexion
2. Sensory.supply dorsal
3. Ulnar nerve palsy.claw deformity of the ring and little finger

Radial nerve (C5-C8)
1. Motor.wrist extension , finger extension , no hand muscle
2. Sensory.supply 3 ( , , , ) dorsal surface
3. Radial nerve palsy.loss of wrist extension

MAXILLOFACIAL INJURY
..
...
soft tissue bone idea
fellow
ATLS maxillofacial
...
....
prostate
......
... like 24

Basic Anatomy for General Surgical Residents
resident injury
Facial Bone
5 frontal, nasal, zygoma, maxilla mandible
suture line fibrous tissue

fibrous joint
temporomandibular joint TMJ mandible synovial joint

1. upper 1/3 frontal bone

2. middle 1/3 midface
3. lower 1/3 mandible
air sinus foramen

artery, vein, nerve
Nasal Cartilage
nasal septum

cartilage 2
1. lateral cartilage septal cartilage nasal

bone
2. alar cartilage lateral cartilage

Cranial Nerve
CN 1. fracture base of
skull anterior fossa
CN 2. ...

CN 3,4,6
CN 5. motor sensory
1. motor branch.
2. sensory branch ()... review

sensory branch CN5

3 division

2.1 V1 ophthalmic division
2.2 V2 maxillary division ...., , upper

lip, branch infraorbital nerve
fracture zygoma
2.3 V3 mandibular division...

lower lip, branch
Inferior alveolar nerve inferior dental nerve mental nerve
mental foramen injury fracture

mandible lower lip ()
....resident neurapraxia V1,V2,V3

mortality conference Bird
Bird ...

CN 7. nerve of facial expression stylomastoid foramen
5 branch
1. frontal
2. zygomatic
3. buccal Stensen duct
4. mandibular mandible facial vein
5. cervical

CN 12. , ,
, wax
V1,V2,V3 palsy

1. chorda tympani CN7 anterior 2/3
2. glossopharyngeal nerve posterior 1/3
Imaging for Maxillofacial Injury

Film skull
full options 4 view
1. AP (midface) body
ramus mandible
2. lateral nasal bone
3. towne occipital skull, foraman magnum condyle

mandible
4. waters view orbit

zygoma view ... one best view
water view

Film paronamic view
film mandible rotated x-ray

tube mandible 2
paronamic view ... x-ray

()
Film C-spine
severe maxillofacial injury

fracture C-spine 1.3% film C-spine


CT Scan for Maxillofacial Injury
3D-CT plain film
, available
contrast case plain film
CT
selective case
case CT complex injury midface

fracture , orbital fracture brain injury brain

axial coronal view

Management of Maxillofacial Injury
definitive airway control bleeding

case head injury
maxillofacial injury
Resident training program . case

initial management
soft tissue facial fracture nose mandible...
plastic basic case


Initial Assessment and Resuscitation
treat upper airway obstruction
bleeding follow ATLS
Position
1.

2. maintain
clear airway
segmental fracture parasymphysis fracture mandible

upper airway towel clip
(..)

endotracheal tube blind
nasotracheal tube
blind nasotracheal tube
1. apnea
2. fracture base of skull
3. fracture maxilla tube

... bleed
tube ... cricothyroidotomy
definitive airway C spine injury
1. maxillofacial injury C spine injury 1.3%
2. fracture mandible C spine injury C1-C4
3. fracture maxilla C spine injury C5-C7
... C-spine


Indication for Definitive Airway
1. injury GCS < 8 , agitation cyanosis
tube
2. laryngeal tracheal injury stridor crepitus

3. facial fracture
3.1 parasymphysis fracture mandible upper airway
3.2 midface fracture fracture maxilla bleed

tube nasal packing
4. refer tube
Indication for Tracheostomy

1. severe head injury IMF ( intermaxillary fixation)
2. massive swelling neck tube
3. nasopharynx, larynx tracheal injury

Bleeding Maxillofacial Injury
Bleed soft tissue
1. scalp simple
2. ... bleed serious bandage

... blind clamp
Bleed facial bone fracture
1. Compress bony fragment
2. fixation plate IMF
3. angiographic embolization
... bleeding fracture

maxilla bleed midface fracture ...
Bleeding fracture maxilla severe

1. anterior nasal packing profuse epitasis
2. anterior nasal packing bleeding

Foley 2 ...blow balloon bleeding

3. gauze elastic bandage

Barton compress fracture
4. embolization
external carotid artery bleed ...

... anastomosis branch internal carotid artery

anterior posterior nasal packing pack 24

risk infection
Secondary survey
... secondary survey
1. skin, soft tissue
2. facial bone, nerve,
3. CSF
NG tube nasotracheal tube

...
retrobulbar hemorrhage optic nerve ... treat
, neuro ...
refer center safe
.... serious associated injury epidural hematoma hemothorax,

bleed treat maxillofacial injury
Management of Skin and Soft Tissue Injury

test nerve

abrasion
treat burn NSS FB

traumatic tattoo epithelial cell growth skin appendage
5-7
laceration
1. NSS FB
2. debridement
blood supply

3. approximation landmark ,hair line, vermillion
border key stich
4. subcutaneous layer fine plain gut

healing

plain cargut 7 loss strength
chromic vicryl
polyglactin 3
5. nylon 5-0 6-0 continuous interrupt

5
avulsion skin loss
debride wound care ... skin graft
Flap
1. ... donor skin postauricular area ...

skin supraclavicular area graft
full thickness partial thickness
contracture 40 %
2. ... donor skin hip flexion crease groin

antecubital crease ...
scar

3. Hematoma
cold compression
cartilage treat
1. hematoma ......
(cauliflower ear deformity)
2. hematoma nasal septum ()... I&D cartilage
resorption saddle nose deformity


... I&D mucosa nasal septum
hematoma anterior nasal packing
splint

Injury in Special Area
Scalp wound
RCT
skull fracture
... depressed skull fracture linear fracture
FB OR ER
galea subcutaneous tissue vicryl 3-0

nylon 3-0 stapler
brow ()
landmark vicryl 4-0

5-0 nylon 5-0 6-0

eyelid
tarsal plate repair vicryl

chromic 4-0 skin nylon 6-0

conjunctiva
medial canthus
lacrimal duct lower canaliculi lower

punctum

nasolacrimal duct inferior meatus ...
duct repair epiphora
test duct ... nylon 4-0 lower punctum

nylon duct

repair chromic 5-0 6-0 silicone tube stent
1
upper canaliculi duct repair
through and through defect cartilage

vicryl 5-0 skin nylon 5-0 6-0 ... heal
fibrosis

mucosa cartilage
5
Parotid duct
gland drain
Stensen duct

parotid Stensen duct
1. parotid duct zygomatic arch 1.5 cm.

imaginary line upper lip tragus
2. duct buccinator muscle

upper second molar teeth
3. nylon 3-0 silicone tube

mucosa
repair parotid duct
1. repair repair chromic 6-0 stent 14
2. repair
2.1
2.2 proximal end gland duct

gland scar

lip

vemillion border vermillion
mucosa oral mucosa chromic 5-0
vicryl 5-0 skin nylon 5-0
Facial nerve injury
temporal bone fracture , penetrating injury , and iatrogenic

injury

1. midpupil

1.1 facial nerve medial midpupil ()

... repair

1.2 proximal midpupil repair
2. temporal branch injury functional defect

temporal branch branch repair
5 branch CN 7
3. repair nerve nylon 6-0 8-0 epineurium

gap great auricular nerve interposition graft
bleed airway
obstruction

Maxillofacial Fracture
clinical
1.
2. deformity
3. crepitus step deformity ()
Diagnosis
1. ... eye movement
2. enophthalmos orbital floor fracture

exophthalmos trauma bleeding
carotid cavernous fistula
3.
4. facial fracture
Principles of management
1. treat ATLS
...
2. ... treat
treat delayed treatment open
fracture

3. nasal fracture 3
treat
Nasal Fracture
most common facial fracture
Diagnosis clinical ()... film

confirmed diagnosis
...
... nasal bone cartilage

crepitus
Film nasal bone lateral view

associated injury nasal fracture fracture base of skull,

Treatment
1. epitaxis .... pack adrenalin

2. undisplaced fracture ... external splint

3. displaced fracture Asch forceps

nasal septum nasal packing support
2-3

4. displaced fracture 7
3
Fracture Zygoma
zygoma 3 3
frontal, temporal maxilla
zygoma nasal fracture

maxilla
1. tripod fracture. 3 unstable fracture

2. arch fracture
1.
2. Loss of facial prominence
3. subconjunctival hemorrhage
4. infraorbital nerve paresthesia ,
5. trismus coracoid process
Film zygoma waters submentovertex view

Treatment
1. displacement
follow up
2. Indication for surgery
2.1 ( asymmetry)
2.2 tripod fracture
2.3 enophthamos
2.4 diplopia
2.5 infraorbital nerve compression
2.6 associated facial fracture
3. ORIF miniplate fix screw
4. arch open reduction

incision temporal elevator arch
Gillies temporal approach

Fracture Mandible
3

1. condylar 36% ( )
2. body 21%
3. angle 20%
4. symphysis 14%
1. mandible

2. parasymphysis 2
(glossoptosis) upper airway
angle condyle
3. C-spine
4. treat most common long term complication malocclusion
1.
2. trismus condyle
3. malocclusion crepitus
4. inferior dental mental nerve
5.

6. coracoid process external ear canal
7. angle facial palsy CN 7 injury
Film panoramic view
Treatment

condyle ...
1. Isolated condylar fracture
1.1 minimal displacement occlusion

liquid soft diet 3
1.2 minimal displacement malocclusion IMF (intermaxillary

fixation ) arch bar
1.3 severe displacement ORIF fixed miniplate

2. fracture angle, body, parasymphysis ORIF
Fracture maxilla
maxilla
, ...

injury
Rene LeFort maxilla 3

1. LeFort 1 low transverse fracture ...
maxillary process midface

2. LeFort 2 pyramidal fracture...

zygomaticomaxillary suture pyramid

2 telecanthus
disc face deformity

3. LeFort 3 craniofacial separation zygoma, orbital
floor nasoethmoid midface

donkey
like appearance malocclusion
(enophthalmos)
cribiform plate ... CSF rhinorrhea
Film waters view
Treatment
1 bleeding tube
tube maxilla
bleed
2 fracture maxilla ORIF ( miniplate screw )

fixed (IMF)

3 CSF rhinorrhea (95%) 2-3

neuro dura ...

Orbital Fracture
blow out fracture blunt trauma orbital
pressure orbital floor
medial wall ( medial infraorbital nerve)
7 frontal , ethmoid , lacrimal , maxillary , zygomatic

greater lesser wing of sphenoid bone
floor orbital content fat, nerve

extraocular muscle inferior rectus inferior oblique muscle
maxillary sinus
1. ( periorbital ecchymosis and swelling)

2. enophthalmos ( exophthalmos ...) posterior
displacement globe
3. palpebral subconjunctival hemorrhage
4. limit ocular motion

(diplopia) upward
gaze diplopia
5. infraorbital nerve injury
6. optic nerve

....pain with mandibular excursion zygomatic arch

arch temporaris muscle ( orbital fracture )
Forced duction test
test muscle entrapment

forcep entrapment
Imaging study
1. Film waters view haziness maxillary sinus

floor

2. CT axial coronal view fracture
CT plain film report orbital

floor ( )
1. diplopia diplopia weak indication

hematoma ....
resident indication
2. muscle entrapment
3. enophthalmos
4. film
4.1 floor 1 cm. 50% floor

4.2 3 mm.
4.3 content maxilla
Operative approach
1. incision
2. orbital content
3. silastic silicone sheet
Frontal Sinus Fracture

frontal sinus

persistent CSF leakage
mini-plate

....

Look
GEREON ZIMMERMAN "

"

"
...

"
Look " "

"
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"
"
"
Look


"

"
!

"
FBI ...

"" FBI
"
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Look
Look
Look
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Look

..

"
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"Blue Night" "PEEP SHOW"

"
"
: -

NECK INJURY
..
Neck
vascular aerodigestive system
approach neck injury cervical spine spinal cord injury
vascular injury
Mechannism of injury penetrating injury > 95% blunt trauma

Anatomy
Fascia
1. superficial fascia platysma (2/3)

platysma ... platysma

2. deep fascia 3
2.1 investing layer SCM trapezius
2.2 pretracheal layer thyroid larynx
2.3 prevertebral layer prevertebral muscle

deep fascia closed space
tamponade effect trachea
external carotid artery (ECA) ICA

esophagus thoracic duct penetrating wound
2
Zones of the Neck

Monson 1969 neck 3 zone Roon
Christensen 1979 zone Monson (
) zone

neck 3 zone
1. zone 1 root of neck thoracic outlet clavicle 2

cricoid cartilage
injury zone 1 organ upper mediastinum trachea,

esophagus , great vessel, lung apex thoracic duct
2. zone 2 cricoid cartilage angle of mandible zone 2

zone
injury zone 2 CCA, ECA, ICA, internal jugular vein, larynx

cervical esophagus

3. zone 3 angle of mandible skull base
injury zone 3 distal ICA vertebral artery zone

zone exposure
Clinical Presentation

asymptomatic case symptoms

and signs injury aerodigestive tract, vascular spine spinal cord

Vascular injury hard signs soft signs carotid

hemiplegia aphasia investigation CT neck chest
Larynx, trachea bronchial injury airway obstruction

, dysphonia, subcutaneous
emphysema
investigation laryngoscopy bronchoscopy
Pharynx esophagus, , ,
subcutaneous emphysema film prevertebral air
pneumomediastinum

investigation esophagography esophagoscopy
option
injury
1. pharynx esophagus
2. trachea bronchus
3. subcutaneous tissue
subcutaneous emphysema injury airway

GI ....

Initial Management
ATLS airway stridor
bleed airway distortion
endotracheal tube ... tube cricothyroidotomy
... C-spine protection
trachea tube ...

repair

fiberoptic tube stable
tube
incomplete tear trachea
penetrating zone 1 apex pneumothorax

ICD

A B.... C (circulation) bleed ( direct
pressure) zone 1 zone 3 Foley

1. blind clamp tourniquet
2. probe local wound exploration
3. ER
4. NG tube clot bleed
5. ...injury
treat venous air emboli internal jugular vein
injury
6. IV injury
7. overresuscitation IV keep SBP 80-90 BP

clot bleed Mattox ... IV


Signs of Neck Injuries
1. Hard signs OR
1.1 airway compromise
1.2 shock
1.3 active bleeding, pulsatile or rapidly expanding hematoma ,

diminished or absent pulse thrill bruit , massive hemoptysis
1.4 extensive subcutaneous emphysema sucking neck wound
2. Soft signs investigation

2.1 stridor
2.2 hemoptysis massive
2.3 Dysphagia

2.4
2.5 widening mediastinum
2.6 stable hematoma
2.7 venous bleeding
2.8 subcutaneous hematoma extensive
Management for Penetrating Neck Injuries

Guideline penetrating neck injury guideline
Schwartz 9th ed edition 10 3 MCQ 4
guideline Trauma 7th p.416 p.419
Guidelines guidelines Schwartz 9 ed.

guidelines edition 10

hemodynamic stable... uncontrol bleeding, expanding
hematoma ,
investigation OR CT
hemodynamic stable... hard sign neck injury
1. zone 1 CTA neck / chest esophagography

bronchoscopy
+ve OR explore neck

Right common carotid artery injury

2. zone 2 hard signs OR explore neck soft signs
CTA neck / chest
3. zone 3 zone 1
+ve intervention embolization
hemodynamic stable
1. zone 1 CTA neck / chest esophagogram

bronchoscopy
2. zone 2 zone 3 observe investigation

zone 1
2.1 transcervical GSW cross midline
2.2 multiple injury zone

2.3 zone 2
zone 3
GSW stab wound GSW

zone 2 injury platysma

selective management investigation CTA,
esophagography bronchoscopy unnessessary
exploration 30-80%
platysma ER
busy strap muscle strap muscle platysma

....
consult ...
.... zone 2 explore neck
CTA
Schwartz 10 ed. 9 ed.
1. CTA neck / chest CT neck / chest
2. zone 2 soft signs investigation

Transcervical GSW
approach 2
1. explore neck significant

injury 75-80% ()
2. Demetriades RCT case

injury 21% stable
investigation (CTA neck chest, esophagography
bronchoscopy )
Operative Treatment
prep skin
tube cord cord paralysis

Incision
1. zone 1 CTA incision

2. zone 2 oblique incision SCM mastoid process

suprasternal notch
3. zone 3 zone 2 subluxation TMJ

mandible vertical osteotomy
mandible

4. transcervical wound collar incision incision thyroid
extend incision hockey stick
U
treat specific organ injury
Laryngeal Injury
general surgeon ... fracture
larynx ENT

Tracheal Injury
Treatment
1. absorbable suture 3-0, interrupted mucosa mucosa

... no tension airtight seal
2. gap 2 cm. thyroid suprahyoid

release
3. gap 3 cm. 5 cm.
4. gap 5 cm. repair muscle flap
5. trauma 7th defect anterior

2 stage tracheostomy
definitive repair ( approach )

Cervical Esophageal Injury
subcutaneous
emphysema investigation esophagography
esophagoscopy confirmed diagnosis
treat missed injury

mediastinium
Treatment
1. incision SCM
2. NG guide
esophagus prove air methylene blue
3. blunt dissection esophagus penrose esophagus ...


4. debridement muscle sternothyroid

5. reinforced repair penrose drain 2

6. esophagus delayed diagnosis
cervical esophagostomy
7. carotid injury repair strap muscle

esophagus carotid artery
8. tracheal injury repair muscle

strap muscle medial head SCM
Thoracic Duct

case penetrating injury zone 1 milk discharge

confirmed protein >3, TG> 200 pH

lymphocyte
Treatment
1. intraoperative explore neck ligation
2. TPN low fat diet fistula

2 ....

....
19

65

( *)
( *)

PRINCIPLES OF CHEST INJURY
..
Chest injury resident

open thoracotomy 10 % 90%
, oxygen ICD
Mechanism of injury penetrating blunt trauma
penetrating wound medial nipple line medial
scapula great vessel, pulmonary hilum heart
local wound exploration penetrating injury
penetrating injury stable breath
sound 2 .. film chest upright pneumothorax
discharge observe 24 6
repeated film chest upright inspiration expiration film
6 hour rule safe film
24 hour 1 discharge
ATLS life threatening problem
airway obstruction, tension pneumothorax, open pneumothorax, flail
chest, massive hemothorax cardiac tamponade
... trachea, bronchus, lung, heart, esophagus


Neck Veins
neck vein shock
1. prominent neck vein
1.1 tension pneumothorax
1.2 cardiac tamponade
2. collapse neck vein hypovolumic shock

Investigation in Chest Injury
Cover 3 system chest
1. cardiovascular system heart great vessel
FAST CTA
2. respiratory system trachea, bronchus
bronchoscopy
3. digestive system esophagus water soluble contrast
study esophagoscopy
Thoracic Incision for Chest Trauma

basic idea intrathoracic vascular injury
incision
Median Sternotomy
manubrium xyphoid sternal saw
sternum saw

extend incision
heart, ascending arch of aorta pulmonary vein & artery
Right neck extension injury innominate, right common
carotid right subclavian artery
Left neck extension. left common carotid artery
Left clavicular extension aortic arch great vessel

median sternotomy injury innominate vein more
anterior
Anterolateral Thoracotomy
4 5 ... EDT cross
right atrium, SVC IVC
3 left supraclavicular incision

injury proximal left subclavian artery

Posterolateral Thoracotomy
elective case emergency

1. traumatic rupture of the aorta
2. posterior aspect of trachea
3. left. main pulmonary vein
4. diaphragm
5. lower esophagus

1. SVC
2. IVC
3. trachea bronchus
4. upper and middle third of thoracic esophagus

1.
2. bleeding bronchus incision


Trapdoor or Book Incision

1. median sternotomy of upper sternum

2. left supraclavicular incision and resection of median half of the
clavicle
3. anterolateral thoracotomy 3 4
thoracic outlet vascular injury proximal left subclavian
artery
chief resident incision 1
repair proximal subclavian artery injury trapdoor
work , exposure
IG
incision

VATS for Thoracic Injuries
Video - assist thoracoscopic surgery
1. clotted or retained hemothorax

2. empyema
3. persistent pneumothorax
4. diaphragmatic injury in stab wound at left lower chest
VAT one lung ventilation

Emergency Department Thoracotomy (EDT)
Emergency Room Thoracotomy (ERT)
ATLS Emergency Resuscitative Thoracotomy
EDT
1. release cardiac tamponade
2. control bleeding intrathoracic vessel
3. treat air embolism
4. open cardiac massage
5. descending thoracic aorta cross clamp
Indications for EDT
1. Strong indication penetrating chest injury ()
1.1 cardiac arrest ER
1.2 cardiac arrest ER < 15 prehospital CPR
... blunt 10 sign of life
penetrating neck or extremity injury arrest < 5 of prehospital
CPR
1.3 peristent severe hypotension SBP < 60 mmHg ...
resuscitate
1.3.1 cardiac tamponade
1.3.2 bleeding
1.3.3 air embolism

1.3.4 penetrating chest injury resuscitation
BP > 60 mmHg chest OR ER
2. blunt chest injury EDT
cardiac activity cardiac arrest ER (witnessed
cardiopulmonary arrest)
Survival
1. penetrating injury 7%
2. blunt injury 0.03%
Sign of life PERM Pupil response, EKG activity, Respiratory
effort, Motor activity
Contraindications for EDT
1. penetrating trauma with CPR > 15 min
2. blunt trauma with CPR > 10 min
Schwartz 10th ed. Schwartz 9th ed. 3

1. EDT Resuscitative thoracotomy
2. blunt trauma < 5 min < 10 min
3. algorithm
aigorithm 9th ed.

EAST guidelines 2015
standard textbook signs of life

EDT Technique
1. Operator well-trained surgeon
... case .........
...
2. Initial assessment resuscitation ET tube IV
3.
HIV,HBV,HCV
4. Position supine with elevated left arm
5. Incision anterolateral thoracotomy 5
inframammary fold
6. sternum sternocostal junction

latissimus dorsi
7. Sharp transection of intercostal muscal bleed BP

8. Open pleura

9. finochietto retractor
clamshell sternum Lebsche knife
10 sternum
10. chest internal mammary artery

proximal distal BP bleed

11. chest EDT 30

12. pericardium phrenic nerve 1-2 cm.
... foley
internal cardiac massage
Internal paddles for defibrillation are

positioned on the anterior and
posterior aspects of the heart.
13. air embolism medial

clamp hilum (twist) hilum
14. located descending aorta esophagus NG NG tube
cross clamp aorta brain heart

15. BP
idea
15.1 Cardiac injury staple
bleed
2 definitive treatment OR
15.2 Bleed pulmonary hilum cross clamp hilum
twist lung 180 bleed
bleeding lung parenchyma linear stapler clamp
clamp

A Satinsky clamp is used to clamp the pulmonary hilum
for hemorrhage control or to prevent further bronchovenous
air embolism.
15.3 bleed arrest aortic cross clamp
OR ....
15.4 air embolism ... 3

Air Embolism
2
1. systemic arterial air embolism
2. venous air embolism

Arterial Air Embolism
complication pulmonary injury air
bronchial injury bronchovenous fistula
pulmonary vein left heart ventricle air
air emboli coronary artery
carotid artery

1. Penetrating chest injury hemopneumothorax ICD air
ET tube ventilator
bag positive pressure air bronchus
fistula .. bag arrest
2. focal localizing neurological signs head injury
3. air bubble retinal
vessel... arrest eye ground
...work
air 1 cc. coronary arrest
EDT cross clamp pulmonary hilum
... step
1. Immediate in Trendelenburgs position ( right side down)
air apex left ventricle
2. pulmonary hilar cross clamp

3. 18 syringe 50 cc. air left ventricle
aortic root
In cases of bronchovenous air embolism, sequential sites of aspiration include

the left ventricle (1), the aortic root (2), and the right coronary artery
4. air coronary artery air
tuberculin syringe

5. repair pulmonary vein bronchus

arterial air embolism ET tube
pass tube bronchus
flexible bronchoscope
...
ER


Venous Air Embolism
air peripheral vein internal jugular vein, subclavian
vein innominate vein systemic vein
air outflow right ventricle

100-200 cc. shock

Trendelenburgs
position with left side down or right side up air apex
right ventricle right atrium cut down air

Mediastinal Traversing Injury
penetrating injury

chest negative exploration 40-60 %

hemodynamic stable selective approach
unstable .. ICD 2 EDT
() clamshell

EDT ...prep left
right anterolateral thoracotomy
serious
hemodynamic stable selective management
investigation of choice CTA esophagogram
1. film chest PA lateral view

2. CT chest CTA, water soluble esophagography
contrast esophagoscopy
flexible bronchoscopy
3. significant injury
3.1 occult cardiac injury 5-10%
3.2 occult great vessel injury 20%
3.3 esophageal injury 15-30%

Tube Thoracostomy
ICD (intercostal drainage)

Practical aspect
1. ICD 5 6 anterior
midaxillary line chest wall muscle
dissect rib rib
2. chest drain
6 diaphragm
3. tube pleural space
adhesion ...
diaphragm
4. ICD open chest wound ...

5. pneumothorax hemothorax positive
pressure ICD refer case refer
ICD
6. thoracotomy ICD incision
7. ICD

off ICD
1. hemothorax off
1.1
1.2 drainage < 50 cc. 24
2. pneumothorax
2.1
2.2 air leak good adhesion parietal
visceral pleura off ICD air bubble
48

Indications for Operative Treatment of Chest Injuries
Emergency department thoracotomy
1. Cardiac arrest after blunt trauma with loss of signs of life in the trauma
bay
2. Cardiac arrest after penetrating trauma with loss of signs of life in the
field or in the trauma bay
Emergency (in OR)
1. Massive hemothorax 1,500 ml.in blunt injury or > 1,000 ml. in
penetrating injury
2. Pericardial effusion after penetrating chest injury
3. Acute deterioration after penetrating chest injury
4. Major tracheobronchial injury
5. Chest wall disruption
Urgent (in OR)
1. Ongoing thoracic bleeding 200 mL./hr x 3 hr.
2. Ongoing massive parenchymal air leak
3. Radiographic evidence of vascular, tracheal,or esophageal injury after
mediastinal traverse
4. cardiac herniation
Non-acute
1. Evacuation of retained hemothorax despite placement of 2 chest tubes
2. Decortication / drainage of empyema

3. Repair chronic diaphragmatic hernia
4. Repair fistulous aerodigestive tract connection
ongoing continuous hemorrhagetextbook 200
cc/hr. x3 hr. 250 cc/hr. x3 hr.. 200
cc/hr. x3 hr OR
evacuation retained clot VATS open
JJ , Moji , and Pong

Practical Plain Film Chest Interpretation
clinical signs
plain film ()

1. shifting trachea
2. supine hemothorax 45-60
3. opacity lung contusion atelectasis

film
1. birds eye view..... lung marking 2
... trachea level diaphragm
2. bilateral one intercostal space ICS 2
... rib, sternum, clavicle , scapula
3. lung marking from central to periphery.. pneumothorax
hair line density

Plain film injury
FINDINGS DIAGNOSES TO CONSIDER
Any rib fracture Pneumothorax, pulmonary contusion
Fracture of first three ribs or sternoclavicular fracture- Airway or great-vessel injury
dislocation
Fracture of lower ribs 9 to 12 Abdominal injury (liver, spleen,kidney)
Two or more rib fractures in two or more places Flail chest, pulmonary contusion
Scapular fracture Great-vessel injury, pulmonary contusion, brachial
plexus injury
Sternal fracture Cardiac contusion
Mediastinal widening Great-vessel injury, sternal fracture, thoracic spine
injury
Persistent large pneumothorax or air leak after chest Bronchial tear
tube insertion
Mediastinal air Esophageal disruption, tracheal injury,
pneumoperitoneum
GI gas pattern in the chest (loculated air) Diaphragmatic rupture
NG tube in the chest Diaphragmatic rupture or ruptured esophagus
Air fluid level in the chest Hemopneumothorax or diaphragmatic rupture
Disrupted diaphragm Abdominal visceral injury
Free air under the diaphragm Ruptured hollow abdominal viscus

Primary Survey in Chest Injury
Treat life-threatening problem
1. airway obstruction initial assessment
3. open pneumothorax
4. tracheobronchial tree injury
5. massive hemothorax
6. cardiac tamponade cardiac injury
Secondary Survey in Chest Injury

life-threatening problem ...
adjunctive studies x-ray,lab EKG
1. simple pneumothorax
2. hemothorax or clot hemothorax
3. pulmonary contusion lung
4. flail chest ATLS edition 10 immediate potential life
threatening 9
5. blunt cardiac injury cardiac injury
6. traumatic aortic disruption intrathoracic vascular injury
7. traumatic diaphragmatic injury diaphragm
8. blunt esophageal rupture

Tension Pneumothorax
pneumothorax one way check valve mechanism valve
pleural cavity valve
pleural cavity ... pressure pleural cavity
negative pressure positive pressure
tension mediastinum
venous return SVC compression cardiac
output tachycardia shock
One way check valve

1.
2.

1. tube bag
ventilator airway pressure alarm


2. distended neck vein
3. heart rate
4. trachea shift midline
5.
6. oxygen sat
Diagnosis clinical confirmed x-ray tension
film arrest x-ray
trauma primary survey ET tube bag
arrest

1. immediate needle thoracocentesis dramatic
2. ICD 28-32F
3. oxygen
Technique needle decompression
1. chest wall
medicut 14 .5 cm. ATLS 9ed.
5 cm pleural space 50%
8 cm pleural space 90%

2. clavicle ICS 2 rib

3. pleural cavity
syringe syringe
4. tension pneumothorax open pneumothorax
ICD
5. ICD IV IV


Open Pneumothorax
open wound chest wall
upper airway 2 3 trachea
pleural cavity ...
mediastinum shift SVC IVC venous
return
Diagnosis... chest wall
condition
sucking chest wound

1. 3 sides occlusive dressing 4
2.
3.
4. ... open close

5. pneumothorax
6. gauze
7. OR ICD open wound
infection chest
8.

Flail Chest
fracture rib > 2 fracture > 2
unstable chest wall free float segment
classic paradoxical movement

1. negative pressure chest wall
float segment
2. chest wall float segment
scapula

Respiratory failure 4 Ps
1. pulmonary contusion flail chest 90%

2. paradoxical movement pendulous movement

gas work of breathing
3. pain hypoventilation hypoxia hypercarbia
4. pneumothorax

hypoventilation
1. intercostal epidural block
2. IV shock overhydration
3.
4. monitor ICU , blood gas chest film
5. 20-40% respiratory failure > 35
, flaring alar nasi, severe shock, underlying COPD,
PaO2 < 60 PaCO2 > 50 mmHg. tube
ventilator
flail chest
1. prophylactic endotracheal intubation
2. chest wall stabilization flail segment
plaster towel clip
3. over hydration
Internal stabilization
1. thoracotomy miniplate fixed fracture
2. 10% pulmonary contusion
tube ORIF miniplate
endotracheal tube ventilator
fixed ()

Massive Hemothorax
basic
1. Mild hemothorax < 350 cc.
2. Moderate hemothorax 350-1500 cc.
3. Massive severe hemothorax
1500 cc.

film chest upright ()

1. blunt costophrenic angle 300-350 cc.
2. fluid level diaphragm 5 cm. 1000 cc.
3. chest wall 1 cm.
1500 cc.

1. trachea deviation
2. flat neck vein tension
3. breath sound

massive hemothorax bleed 1 intercostal
artery
clot clot
fibrosis restrictive lung

1. IV resuscitation treat shock
2. ICD 34 36 ICD 2
drain
3. ICD 2 3
open scope ( open)

Chest Wall Injury
skin, subcutaneous tissue, muscle fracture
rib fracture sternum
Fracture Ribs
1 1 50 cc.
pulmonary parenchymal abnormality
risk of pulmonary morbidity associated injury
organ
pneumonia

1. 1 2 injury severe
associated injury thoracic vessels thoracic outlet
2. 8-12

Film chest
54% film chest
film 2
... callus cartilage
costocondral junction fracture

1.
2-3 1
2. intercostal nerve block marcaine
block nerve
3. Epidural anesthesia pain control
incidence of nosocomial pneumonia IV morphine
ICU
4. breathing exercise adequate clearance of pulmonary secretion
significant cormorbid COPD discharge
COPD
admit intercostal nerve block

2008 concept of rib stabilization
world journal of surgery 2009
Trunkey DD Trunkey MIS
ventilator
chest wall deformity
Fracture Sternum
blunt trauma
sternal angle incomplete
undisplaced fracture fracture rib
associated injury great vessel
mortality seat belt

crepitus
displacement
Film chest lateral view

1. conservative fracture rib fracture sternum
6-12
2. indication for surgery
2.1 non-union
2.2 deformity
2.3 respiratory failure
2.4 complete fracture with displacement
fixed plate wire

Simple Pneumothorax
simple tension simple pressure
pleural space
tension one way valve pressure tension
pleural space simple pneumothorax

1. observation pneumothorax 25%
film chest apex 4 cm. lateral
margin of lung edge chest wall 1 cm.
air absorp rate 1.25%
2. Indication for ICD
2.1
2.2 pneumothorax 25%
2.3 ventilator
2.4 refer

observation progress tension ...
ICD ()
Mild to Moderate Hemothorax

ICD clotted hemothorax treat
fibrothorax empyema
incomplete evacuation ICD 1
antibiotic infection pleural space
observe mild hemothorax introduced
infection ... approach
Retained Clot Hemothorax

Retained clot hemothorax single most important risk factor for
development of empyema fibrothorax trap

clot fibrothorax lung entrapment
Film chest lung expand
CT chest clot

1. VATS open thoracotomy 2
2-4 clot clot
VATS clot

2. thrombolysis ICD
absorption systemic effect risk of bleeding

3. ICD apply negative pressure suction
thrombolysis
Esophageal Injury
penetrating injury GSW
stable CT chest posterior mediastinal hematoma with
a smaal amout of air esophageal perforation
trauma blunt trauma
lower sternum upper abdomen
lower esophagus Boerhaave

Film chest
1. mediastinal air pneumomediastinum classic
2. pneumothorax hemothorax

Confirmed oral water soluble contrast study
Treatmentupper 2 / 3 right thoracotomy lower 1 / 3 left

thoracotomy reinforced repair with wide drainage

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LUNG & TRACHEOBRONCHIAL INJURIES
..
2 lung parenchyma trachea bronchus

Pulmonary Contusion
blunt penetrating injury
multiple fracture ribs flail chest
...hemoptysis, dyspnea, tachypnea, cyanosis

crepitation
Imaging study
1. Film chest 2-3 patchy

infiltration (opacification) lobe

2. CT scan plain film
pulmonary contusion X-ray

finding 70% film chest
1 30% 4-6
1. admit clear intensive spirometry
2. observe hypoventilation mask

continuous positive airway pressure respiratory failure tube
ventilator support
3. fluid overhydration
4. antibiotic steroid
thoracotomy (contusion) lung

hematoma resolution 2
lung infection

Pulmonary Laceration
penetrating blunt trauma

bleeding air leak
bleeding air embolism

Operative approach
1. atraumatic 3-0 chromic vicryl

interrupted continuous over and over
2. continuous bleeding
stapler wedge resection
3. through and though injury pulmonary tractotomy

linear stapler
non crushing clamp
monofilament non-absorbable suture 2
selective ligation bronchioles bleeding

4. tractotomy lobectomy

Tracheobronchial Injury
hemoptysis, pneumomediastinum, pneumopericardium
ICD persistent air leak
Anatomy of the Trachea

midline 11-15 cm.
2 part
1. cervical
part
cricoid cartilage thoracic inlet
2. intrathoracic mediastinal part

... cartilage 18-22
trachea
...
Tracheal bifurcation carina
1. ... sternal angle of Louis
2. ... T4
Blood supply organ
1. inferior thyroid artery
2. thyrocervical trunk
3. bronchial artery
carina left right main bronchus 30 ...

45

Anatomy of the Bronchus
Bronchus 2 part
1. mediastinal part
2. intrathoracic part
Bronchus ... 4 cm. pericardium aortic arch
Bronchus ... 2 cm. medial posterior azygos vein

Blood supply bronchial artery branch aorta
bronchus bile duct dissection


bronchial artery 2
bronchial artery
Location of Tracheobronchial Injury

tracheal injury blunt trauma 2.5 cm.
carina
penetrating injury trachea
bronchial injury blunt trauma intrathoracic

part

2
1. pleural cavity

resident ICD ... tracheobronchial injury
persistent air leak
2. pleural cavity
plain film
1. ... ...
2. subcutaneous emphysemasign
3. pathognomonic sign air escaping

penetrating wound
4. mediastinal emphysema film chest
5. pneumopericardium crunching sound

positive Hammans sign
film chest film C-spine AP lateral

pneumothorax, mediastinal emphysema, pneumopericardium
CT scan 3D-CT

Bronchoscopy
work gold standard tracheobronchial injury
flexible bronchoscopy

bronchoscopy stable
Advantage
1. location injury repair
2. severity partial complete tear
Management of Tracheobronchial Injury

Initial treatment
1. Airway management tube flexible bronchoscope

guide pass tube distal trachea mainstem bronchus

2. ICD
3. bronchoscopy definitive diagnosis

nonoperative treatment OR


Nonoperative Management
Indication
1. mucosal injury 1/3 circumference

2. minimal tissue loss
3. persistent air leak
4. thoracotomy
Treatment
1. pulmonary toilet
2. antibiotic
3. follow bronchoscopy
1/3 circumference, tissue loss

intrathoracic trachea

Operative Approach
bronchoscope long
cuffed tube
Incision location injury
1. cervical collar incision thyroid extend

T injury proximal 1/3 proximal 2/3 trachea
2. left posterolateral thoracotomy chest ICS 5 left

mainstem bronchus
3. right posterolateral thoracotomy chest ICS 4

injury lower 1/3 trachea, carina right mainstem bronchus
Median sternotomy Clamshell.. exposure tracheobronchial

injury
Operative Repair
Principles
1. limited debridement
2. tension free anastomosis mucosa to mucosa
3. trachea 5 cm. end to end anastomosis

4. limited debridement
5. tension free anastomosis mucosa to mucosa
6. trachea 5 cm. end to end anastomosis
7. trachea bronchus monofilament absorbable vicryl

3-0 4-0 interrupted tissue
pleura pericardium
8. tension
8.1 neck flexion 1
8.2 supralaryngeal release right hilum release

2 cm. release dissect anterior posterior
dissect lateral blood supply
9. tissue loss vascularized muscle flap
10. injury distal bronchus

lobectomy

11. injury 50% circumference primary
repair ... 50% circumference resection with
end to end anastomosis
12. vascular injury esophagus repair
muscle interposed Late case

Algorithm for diagnosis of tracheobronchial injury.

Algorithm for management of tracheobronchial injury.

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CARDIAC INJURY
..
paper ... case oral basic

resident
Anatomy of The Heart

... 1 3 right atrium 2 3
right ventricle apex left ventricle

... 3rd ICS base great vessel
Pericardium fixed fibrotic sac great vessels aorta,

SVC,IVC, pulmonary A V
Pericardium 2 visceral parietal

pericardium 50-100cc.
tamponade
30-50cc.
Phrenic nerve pericardium pulmonary hilum
Box of death area midclavicular line

clavicle 2 nipple costal margin
Penetrating injury box heart

Mechanism of Injury
Blunt 10 % myocardial contusion mortality
penetrating injury
Penetrating injury 90% injury box area
1. Right ventricle 43%
2. Left ventricle 34%
3. Right atrium 16%
4. Left atrium 7%
5. Injury 1 chamber 30%
AAST cardiac injury scale 6 grade blunt penetrating

arrest

Investigation
FAST
Practical available 24 hr.

.. wall train accuracy 90%
pericardium blood OR

2D-Echocardiography
non-invasive FAST wall, septum,

valve, chordae .. CVT vascular 3D-echo
wall

available center
false ve 5-10% paper oral FAST
Pericardiocentesis
spinal angiocath 18 xyphiod 45

skin
US guided EKG ...

20 cc. tamponade
pericardium unclotted blood bleed .. .

clot
life saving

Subxyphoid pericardial window
ATLS
coronary
1. upper midline xyphoid 5 cm. trauma

local
2. xyphoid bulging pericardiophrenic membrane

sponge peritoneum

3. stay suture pericardium 2-4cm.
CT scan

Cardiac Tamponade
penetrating blunt trauma
nipple shock neck vein

collapse breath sound 2
tension pneumothorax
Beck triad 10-30%
1. hypotension SBP DBP pulse pressure
2. muffled heart sound distant heart sound ER

bar beer
3. neck vein distension
pulsus paradoxus SBP cardiac tamponade

10 mmHg
chest x-ray acute injury classic water

bottle upright
ICD OR

EKG low voltage
film chest EKG echo

... FAST
investigation ... FAST , , available ER
accuracy FAST 90%
Management
1. hemodynamic stable, FAST

1.1 FAST +ve OR median sternotomy
1.2 FAST... equivocal echo

echo available subxyphoid window
pleural cavity pericardium
echo text CVT ...

window work
1.3 FAST -ve associated injury ...
admit, observe
resident film chest run EKG


2. hemodynamic stable primary survey ICD
film chest... load fluid
2.1 load IV fluid BP drop ... FAST FAST +ve

equivocal OR incision median
sternotomy anterolateral thoracotomy OR
arrest lift OR pericardiocentesis
2.2 load IV BP ... stable...

FAST FAST
2.2.1 FAST +ve OR median sternotomy
2.2.2 FAST -ve admit investigation chest x-ray

upright , EKG , CT , echo

3. ER arrest. penetrating injury EDT
OR admit
Blunt Cardiac Injury

penetrating injury. blunt chest injury
CPR
degree myocardial contusion.
2-3 recover V.tac MI arrest

1. fracture sternum seat belt
2. BP drop hypovolumic shock

neurogenic
3. EKG tachycardia bradycardia cardiac arrhythmia

pathognomonic finding EKG
4. Troponin
Cameron cardiac index < 2.5 echo

anatomy septum , valve wall ..
work .... stable center
5
chest x-ray , EKG troponin stat

8 hr
film chest film exclude injury

cardiac troponin protein ... marker

myocardial injury sensitivity 50% 4 hr 100% 12 hr
troponin 6-8 hr
troponin creatine kinase sense

myocardial injury

stable CVT echo wall motion ,
septum , valve , chordate pericardium
stable FAST tamponade
ventricle echo. OR
Management
1. stable .... EKG troponin admit 8 hr

2. Admit 24 hr monitor arrhythmia

>55 ...
monitor
2.1 arrhythmia , EKG , troponin discharge

.... ICU
2.2 arrhythmia.. arrhythmia

echo .... ICU arrhythmia


3. stable shock .... FAST rule out
tamponade bleeding
3.1 pericardial tamponade treat tamponade
3.2 pericardium bleeding

CVT valve , septum
coronary injury
echocardiography inotropic , cardiac cath
repair

Coronary Artery Injury
blunt penetrating rare

Management
1. intimal tear thrombosis MI

anticoagulant .... thrombolysis
treat MI.... cath stent
2. tear coronary artery distal 1/3

.... proximal 2/3
CVT repair bypass
pump

Valve Injury
penetrating injury. aortic valve
post op CHF treat

..... murmur
Investigation. 2D echo
treat CHF CVT

.... valve
Foreign Body
myocardium cardiopulmonary bypass.
CVT

FB . enbedded in the intraventicular septum

1. endocarditis
2. migration cardiac chamber
2.1 right ventricle
2.2 left ventricle

bifurcation
common femoral artery under local
embolectomy arteriotomy FB

Principles of Operative Surgery
cardiac injury

resident CVT. chest phrenic

nerve pericardium
Incision
1. Median sternotomy. manubrium

xyphoid injury
right atrium, right ventricle, atriocaval junction
stable BP drop
incision midline incision
2. Anterolateral thoracotomy parasternal posterior

axillary line clamshell

stable cross
clamp aorta internal cardiac massage
proximal distal internal

mammary artery ... BP bleed


Pericardiotomy
pericardium rule out tamponade
Allis pericardium ... phrenic nerve 1-2

cm. clot
Pericardiotomy is done with toothed pick-ups and curved Mayo scissors; the
incision begins at the cardiac apex, anterior to the phrenic nerve, and extends
on the anterior surface of the heart toward the great vessels.

pericardium serum drain
pleural cavity
Temporary bleeding control
1. bleed
2. foley cath blow ballon

fluid ... air embolism
inflate balloon NSS air balloon

NSS air embolism
foley

3. traction stay suture

Examination and Assessment
stop bleeding
through and through

1.
2.
cardiac output .... load IV
Surgical technique
1. Ventricle atraumatic nonabsorabable prolene 3-0
4-0 simple suture horizontal mattress

Taflon strip pledgets

pericardium
cut-through
ventricle epicardium
endocardium
thrombus
2. coronary artery horizontal mattress

artery coronary artery
occlude

3. Atrium ventricle
contraction
atrium Allis santinsky clamp partial

occlusion prolene 3-0 4-0 run continuous
4. Coronary artery chest

4.1 distal 1/3 injury
4.2 proximal 2/3 injury repair

prolene 7-0 GSV bypass cardiopulmonary bypass
CVT
5. Valve, Septum Papillary muscle injury CVT

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DIAPHRAGMATIC INJURY
..
penetrating injury thoracoabdominal area area
1. anterior nipple costal margin
2. flank anterior to posterior axillary line
3. posterior tip of scapula rib
blunt trauma diaphragm dome 90%
Anatomy of the Diaphragm

musculotendenous structure dome central
tendon muscle chest wall

blunt abdominal trauma +
150-200 cmH2O

central tendon IVC

Phrenic nerve
C3-5 nerve posterolateral surface

pericardium IVC diaphragm
curvilinear fashion nerve
chest wall 2-3 cm.
incision diaphragm incision 2 cm. ...

phrenic nerve
diaphragm
ICS 4 6 8
5 penetrating injury
4 5 diaphragm

Phases of Diaphragmatic Injury
... +2 +10 cm H2O
-5 -10 cm H2O
diaphragm
pressure
diaphragmatic injury 3 phases
1. acute phase
herniation
expolore laparotomy
2. latent phase
occult injury
positive pressure
herniation
3. chronic obstructive phase
chest
obstruction ( stomach)

diaphragmatic injury
associated injury
associated injury 70-80%

stomach injury descending aorta 5%
1. thoracoabdomen
2. Blunt trauma mechanism of injury significant deceleration

3. NG tube
4. ICD pleural cavity stomach
5.
6. (scaphoid abdomen)

Investigation
Chest x-ray
diaphragm (40% ) ...

1. diaphragm ()
diaphragm
2. atelectasis left lower lung left pleural effusion
3. air fluid level gas density bubble diaphragm
4. displacement mediastinal structure
film ... NG
tube NG chest

5. differential diagnosis eventration ,
paralysis , collection paraesophageal hiatal hernia
FAST
hollow viscus diaphragm
CT scan
hollow viscus diaphragm FAST

CT associated injury CT collar sign
stomach diaphragmatic

DPL
ICD DPL enteric content ICD

Laparoscopy
sensitivity diaphragmatic injury best diagnostic

modality occult injury
treat
tension pneumothorax ICD
Thoracoscopy
Management of Diaphragmatic Injury

Expectant conservative treatment diaphragm
heal
Laparoscopic or Thoracoscopic repair diaphragm

stapler
Acute phase associated injury ...
1. NG tube gastric content aspiration
2. incision midline right thoracotomy

diaphragm liver chest


3. explore ...treat associated injury stomach
chest pressure
chest
4. diaphragm nonabsorbable suture 1-0

2 horizontal mattress
1 cm. stich 1 cm.
continuous silk prolene ...
tension free repair recurrence diaphragmatic hernia

5. massive destruction diaphragm
5.1 prosthesis mesh 2 2 pleura

peritoneal surface
5.2 relocation detach diaphragm chest wall

rib

6. ICD stich bag

ICD
Latent Chronic phase 1 associated

injury chest
adhesion phase chest

Contamination of GI content
... chest
approach 2

1. diaphragmatic defect ICD
...
2. empyema anterolateral
thoracotomy 1 incision
ICD 2 ...
Summary Management of Diaphragmatic Injury

ATLS
film chest diaphragm

NG tube NG tube chest
CT, water soluble contrast laparoscopy

... repair diaphragm

...

...
...
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12


PRINCIPLES OF ABDOMINAL TRAUMA
.
approach abdominal trauma principles

trauma laparotomy
specific organ
Initial Assessment and Management

ATLS
1. Mechanism of injury.
....

safety belt
2. Timing of injury
3. Status at scene. shock
4. complaint

20% seat belt
.... history mechanism of injury
admit observe serial physical examination

PR pelvic fracture ATLS 9ed.

PR rectal mucosa pelvic
fracture
External Anatomy of the Abdomen

Anterior abdomen
nipple 2 (T4)
inguinal pubic symphysis
anterior axillary line

Flank
6th ICS inferior scapular tip
iliac crest
area anterior axillary line posterior axillary line
Back
tip of scapular
iliac crest
area posterior axillary line 2

Thoracoabdominal
nipple (4th ICS) tip of scapula
(7th ICS)
inferior costal margin
Blunt Abdiminal Trauma

deceleration injury
.... peritonitis
shock evidence bleeding OR explore laparotomy
obvious indication explore laparotomy
1. stable. FAST FAST work DPL

Schwartz 10th ed. DPL DPA

2. stable .... one best CT US
screening guidelines Schwartz10th ed.
significant injury CT
3. algorithm Schwartz 9th ed. 10th ed.

Trauma Mattox

Penetrating Abdominal injury
stab wound gun shot wound
stab wound peritoneum

unnecessary operation 30-50% nonoperative
management
GSW 90%
selective management .... GSW anterior
abdomen RUQ vital signs
stable flank back DPL
CT serial examination
nonoperative management
1. vital signs stable
2. peritonitis
3. omentum
4. brain spinal cord injury

sedation or anesthesia follow up


Indication for explore laparotomy
1. shock hemodynamically unstable
2. peritonitis
3. evisceration
4. hemetemesis gross blood mu NG tube
5. hematuria
6. bleeding per rectum

7.
8. GSW
omentum
guaze NSS OR
Stab Wound

Anterior abdominal wound
1. local wound exploration (LWE)

2. LWE + ve
2.1 CT DPL + ve.
2.2 Serial PE / Labs

2 6 6-12
24-48 .... ( 2.2)
Schwartz 10th ed.
Back and flank wound
1.
observation CT with triple contrast
2. probe LWE. rib 11 12

chest chest

Thoracoabdominal wound
1.
2. exclude diaphragmatic injury

laparoscopy thoracoscopy
laparoscopy laparoscopy


thoracoscopy decuibitus position
drape prep
GSW Abdomen

Lowvelocity injury ( 1,000 ft / sec ) damage is confined to missile tract
High-velocity injury ( > 1,000 ft / sec ) blast effect and cavitation occur in addition to
damage by missile tract
Indication for explore laparotomy GSW
1. shock , penitonitis evisceration.
2. sign explore
questionable
....safe
unnecessary operation GSW 10-20%

GSW back significant injury 50-66 % selective
management
non operative management
1. vital signs stable
2. peritonitis

3. GI bleeding
4.
5. observe ,OR , ICU

, lab
6. available investigation CT
SGW
1/3 SGW anterior abdomen serious abdominal

injury 2/3 SGW serious intraabdominal
injury
indication explore investigation triple

contrast CT , DPL laparoscopy
Nonoperative management penetrating abdominal trauma

guideline Eastern Association for the Surgery of Trauma
J Trauma 2010 Schwartz 10 ed. selective management GSW
Abdomen routine laparotomy hemodynamically stable
tangential wound RUQ
peritoneal sign CT abdomen pelvis injury
observe serial examination & FU 24 stable

EAST & Schwartz 10th ed. ..
trauma center available surgical teams
GSW RUQ , Flank or Back

triple contrast enhanced CT ..... GSW
explore laparotomy
safe approach .. CT
CT
algorithm for penetrating abdominal injuries Schwartz 9th 10th
penetrating injury left sided thoracoabdominal

stable DPL vs. laparoscopy SW stab wound
10th ed. serial exam / labs DPL CT evisceration
peritonitis

Diagnostic modalities
, severity
unnecessary operation
Investigation helpful test
1. Plain film
2. FAST
3. CT
4. DPL & DPA
5. Laparoscopy
6. Local wound exploration

Plain Abdomen
routine sensitivity
stable flim
....
plain film
1. blunt trauma. organ injury injury

free air perinephric air diaphragm
ruptured diaphragm spine pelvis

2. penetrating injury. film marker

organ injury
Focused Assessment Sonography in trauma (FAST)

adjunctive primary survery.available ER
stable CT
US detect intraperitoneal fluid. screen shock

FAST

blunt abdominal trauma FAST plain
film CT
contrasted-enhanced US sensitivity & specificity
solid organ injury
1. Pericardial sac
2. Hepatorenal fossa (Morrison s pouch)
3. Splenorenal fossa
4. Pelvis (pouch of Douglas)
FAST
1. hollow viscus
2. retroperitoneal organ
3. diaphragm

4. pelvic fracture
5. ....
6.
7. free fluid 50 cc.
8. penetrating injury blunt trauma
9. (operator dependent)
30 accuracy 90%
10. severity solid organ injury
CT Scan Abdomen
Contrast enhanced
1. Double. IV peroral
2. Triple. IV , oral rectal enema
abdominal trauma intraperitoneum retroperitoneum

injury
CT hemodynamic stable FAST

CT shock
contrast nephropathy

CT
1. noninvasive study
2. sensitivity 92-97% specificity 98%
3. grading severity solid organ injury

nonoperative management

4.
5. CT 15
6.
7. penetrating injury flank back

1. fluid = 0 HU
2. fresh blood = 25 HU
3. clot hematoma = 60 HU

8 intraperitoneal space
1. right and left subphrenic

2. right and left subhepatic
3. right and left paracolic

4. pelvic
5. intramesenteric
space 125 cc
1. small (1-2 spaces). 250 cc
2. moderate (3-4 spaces). 500 cc

3. large ( 4 spaces). 500 cc
CT abdomen
1. hemoperitoneum
2. solid organ injury
3. free air
4. urinary phase bladder
... CT CT
hemodynamic stable CT
diaphragmatic injury diagnostic laparoscopy radiation
Diagnostic Peritoneal Lavage (DPL)

1965 2000.... CT FAST work
noninvasive DPL ....
DPL
Trauma 7th ed. guidelines

diagnostic peritoneal aspiration ( DPA )

Indication for DPL
1. equivocal or not available US or CT
2. hollow viscus injury

3. LWE
4. surgeon FAST
1.
NG Foley
2. closed DPL open DPL

vertical fracture pelvis supraumbilical DPL
Positive DPA & DPL
10 cc 10 cc
warm NSS RLS 1,000 cc

10 cc/kg. 10

positive DPL
1. RBC > 100,000 cell/mm3 blunt trauma
2. RBC > 10,000 cell/mm3 thoracoabdominal stab wound
3. WBC > 500 cell/mm3
4. amylase > 19 IU/ L
5. alkaline phosphatase > 2 IU/ L
6. bilirubin > 0.01 mg/dl
7. bile ,

8. gram stain bacteria
9. lavage fluid ICD Foley
Absolute contraindication for DPL
Relative contraindications for DPL
1. previous abdominal operation

2. morbid obesity
3. advanced cirrhosis
4. coagulopathy
DPL
1. retroperitoneal injury
2. contained hematoma
3. positive bleed
4. invasive study
5.
6. serial physical examination
7. FU film

DPL FAST CT
Time Rapid Rapid Delayed ( CT)
Transport No No Required
Sensitivity High High () High
Specificity Low Intermediate High
Eligibility All patients All patients Hemodynamically atable

Diagnostic Laparoscopy

1. penetrating injury left thoracoabdominal area
2. tangential GSW stab wound abdomen

posterior sheath injury
3. shotgun or blast injury from a long distance
diag laparoscopy vital signs stable

1.
2.
3. missed hollow viscus retroperiteneal injury
4. head injury increase ICP

ICP

Local Wound Exploration (LWE)
stab wound anterior abdomen
LWE
1.
2.
3. chest wound , thoracoabdominal wound , flank wound back
wound
4. GSW
5. soft tissue hemorrhage distortion

1.
2. explore lap
3. clamp bleed
4. Army Navy

1. Negative. posterior fascia
peritoneum discharge
( safe observe 12-24 )

2. Positive. posterior fascia
peritoneum
positive LWE. 2
1. DPL. RBC 10,000 explore lap

negative explore 50%
2. Serial physical examination.
explore lap
Investigation
choice
1. Four quadrant tapping.

FAST
2. Sinugram. stab wound contrast
air ....

Management of Abdominal trauma
1. Reestablishing vital functions and optimizing oxygenation and tissue
perfusion
2. Prompt recognition of sources of hemorrhage with efforts at
hemorrhage control (such as pelvic stabilization)
3. Delineating the injury mechanism
4. Meticulous initial physical examination , repeated at regular intervals
5. Selecting special diagnostic maneuvers as needed , performed with a

minimal loss of time
6. Maintaining a high index of suspicion related to occult vascular and
retroperitoneal injuries
7. Early recognition for surgical intervention and prompt laparotomy
8. preoperative antibiotic postop 24 cover aerobe
anaerobic bacteria
9. combined head / abdominal injury

CT brain Guidelines

9.1 hemodynamically stable GCS > 12 with localizing
signs CT brain GCS < 12 localizing signs
CT brain

9.2 unstable patient GCS < 9 localizing signs
CT

CT brain
GCS > 9 localizing signs
post op. CT brain
Principles and Techniques of trauma Laparotomy

Preparation
( )
Incision
Incision of choice midline

( )

shock SBP 60 ....
....
EDT cross clamp descending aorta

2
1. Moore. EDT arrest
SBP 60 ....initial resuscitation
open cardiac massage cross clamp
aorta cerebral coronary blood flow
subdiaphragmatic hemorrhage
2. .... control abdominal
aorta
shock load IV
explore laparotomy aorta
Intraoperative management
follow trauma Mattox 4
1. Control of bleeding
2. Identification of injury
3. Control of contamination

4. Decision
Control of Bleeding
1. loss tamponade shock
....
2. small bowel
3. (resident ) blood clot .... suction

.... clot bleed
4. 4 quadrant packing blunt trauma RUQ , LUQ , left paracolic

gutter right paracolic gutter
5.

6. BP supraceliac aorta clamp
aorta esophagus NG
NG tube. dissect right crus diaphragus
aorta clamp
7. bleeding
Identification of injury
1. inframesocolic compartment transverse colon
ligament of Treitz IC valve cecum
rectum mesentery
2. Babcock clamp
3. bladder , pelvis
4. supramesocolic compartment duodenum

pancreas 2
5. explore retroperitoneal hematoma penetrating injury
( )
5.1 left sided medial visceral rotation (Mattox)
5.2 right sided visceral rotation (Kocher Cattell Braasch)

Control of Contamination
1. bowel mesentery
2. atraumatic clamp
Decision
1. definitive treatment
2. OK damage control
3. ....
4. multiple injury

5. Appropriate surgical prioritization
5.1 first priority. control

bleeding. pack .... bleed
repair aorta. repair
common iliac external iliac artery temporary shunt
5.2 second priority. clean organ
5.3 last priority. treat dirty organ colon

colostomy
take down anastomosis


Precaution of Missed Injury
explore severe abdominal injury.........
....

Missed injury
1. Diaphragm. pack retractor

diaphragm 2
2. Stomach. GE junction , cardia , posterior wall

perigastric hematoma greater omentum
3. Duodenum. D2 , D3 , D4
4. Small bowel. perimesenteric hematoma bowel wall

proximal jejunum ligament of Treitz
5. Colon. posterior wall transverse colon splenic

flexure
6. Extraperitoneum rectum
7. Ureter
8. Extraperitoneal bladder
9. Distal external iliac artery

. ()
'' !
'

'
?
'


GASTRIC AND SMALL BOWEL INJURY
..
Stomach thick walled vascularized organ ...risk

injury penetrating wound upper abdomen lower chest
Small bowel occupies peritoneal cavity

penetrating wound abdomen GSW small bowel
its mesentery 80% stab wound small bowel 25-30%

GASTRIC INJURY
Mechanism of injury
1. penetrating injury 99%
2. blunt trauma 1%
Diagnosis
...
1. penetrating injury upper abdomen lower chest
2. blunt trauma seat belt sign
3. PU perforated
4. NG
5. film free air 50% sensitivity CT
sign OR
brain spinal cord injury tangential GSW stable

sign CT, DPL laparoscopy

Surgical Management
midline incision
Babcock clamp

mobilized ...
pretty motor show ,

hematoma lesser curve greater curve
missed GE junction, fundus , lesser curve

left triangular ligament
posterior wall gastrocolic ligament greater

curve gastroepiploic arcade
The posterior wall of the stomach, as well as the anterior surface of the pancreas, can be
approached by dividing the gastrocolic ligament and lifting the stomach superiorly.

2 air
air
Intramural hematoma seromuscular clot stop bleeding silk 3-0

debridement 2 layer
GE junction bite
pylorus pyloroplasty
gastric resection injury severe devascularization


Gastric Injury Associated With Diaphragmatic Injury
contamination pleural cavity gastric content
contamination diaphragm pleural space

diaphragm chest drain
severve contamination delayed case thoracotomy

chest tube thoracoscopic evacuation
alternative option

SMALL BOWEL INJURY
Mechanism of injury. penetrating blunt trauma
blunt trauma small bowel injury
1. sudden deceleration shearing force fixed point IC valve,

ligament of Treitz adhesion site
2. crush vertebral body
3. blow fluid-filled loop
Diagnosis
penetrating injury diag. ...

blunt trauma contusion
... secretion
neutral relative sterile bacteria
peritonitis

blunt trauma small injury
1. fracture body of L3 transverse chance fracture small

bowel injury 50%
2. seat belt sign

blunt trauma small bowel injury
conscious abdominal examination ( film
bowel wall ) CT free fluid chance
fracture DPL
false negative noninvasive study CT
Blunt abdominal trauma + seat belt sign + CT free fluid and chance fracture , the risk of
small bowel injury is so high OR explore lap.
Small Bowel Injury Scale

Surgical Management
life threatening injury problem
small bowel ligament of Treitz IC value

Babcock clamp 2
mesentery
perforation
Treatment of grade I and II small bowel injuries. Grade I injuries are treated by inversion with
seromuscular sutures. Grade II injuries are treated by careful debridement and primary closure.
Either a one or two layer closure may be used. Adjacent through and through perforations are
treated as a single defect by dividing the bridge of tissue separating them with electrocautery.
grade 1,2 primary repairgrade 3,4,5 .

1. debridement 2 transverse
2. 2 debride
3. multiple perforation debride

high velocity ...work
4. 50 % circumference
Grade III small bowel injuries are usually treated by resection and anastomoses. Proximal
small bowel injuries or transversely oriented wounds may on occasion be primarily repaired.

resection with anastomosis
1. full thickness tear 50%
2. expanding or mesenteric injury with bowel ischemia
3. multiple injury in a short segment
mesenteric hematoma explore
1. large hematoma ( size 2 cm.)
2. expanding hematoma
3. hematoma near root of mesentery
debate intramural hematoma small bowel jejunum

ileum OR current therapy of
trauma Trunkey
1. limited in extension and nonexpanding hematoma

hematoma absorp
2. large or expanding hematoma hematoma clot

stop bleeding
bile
drain round

.....

PANCREATICODUODENAL INJURY
..
young staff ( 20 )... prof. Donald D.

Trunkey president American Trauma guest lecter trauma
Donald D. Trunkey
resident
The knowledge of an excellent surgeon comes not only through reading

but also through hand-on situation

Anatomy of the Pancreas
retroperitoneal organ L1-L2
40-180 gram.
xx = 15-20x3x1-1.5 cm.
1. head PV C-loop duodenum

uncinate pancreas PV SMV
2. neck PV 2 cm.
34. body and tail PV SMV aorta
L2 tail splenic hilium

Proximal pancreas pancreas PV SMV
Distal pancreas pancreas PV SMV
Volume of pancreas
1. left PV SMV volume 56 68%
2. left CBD volume 89%
volume loss 80% exocrine endocrine pancreas

90% exocrine insufficiency
Pancreatic duct (PD)
tail body pancreas

PD posterior anterior
50%

pancreatic duct injury main PD
main PD
main PD tributary duct branch duct main PD

15-20 branch duct main PD
major papilla main PD distal CBD

posteromedial wall duodenum pylorus 7-10 cm.
minor papilla major papilla 2-2.5 cm.
PD pancreas
main PD capsule intact
Anatomy of the Duodenum

pylorus 28 cm.
4 part

1. superior first part cap bulb 5 cm.
pylorus pyloric vein of Mayo GDA
2. descending second part 7-10 cm.

ampulla of vater injury
3. horizontal third part 6-8 cm. SMV
4. ascending fourth part 5 cm. ligament

of Treitz
Pancreatic Injury
4% abdominal injury
90% pancreatic injury associated injury 87% duodenal

injury associated injury
20% pancreatic injury injury duodenum 10%

duodenal injury pancreatic injury
penetrating injury : blunt injury = 70:30
early death bleeding
late death infection MOF
single most important outcome presence of PD

injury

Clinical Presentations
high index of suspicion blunt trauma upper
abdomen pain out of proportion injury severe
back pain ecchymosis back flank peritonitis

seat belt sign

pancreatic injury
film chest lower thoracic spine

Serum Amylase
unreliable marker amylase amylase
40% pancreatic injury amylase
35% pancreatic injury amylase
serum amylase serum amylase
3 amylase follow up clinical persistent

hyperamylasemia
investigation CT

Double contrast CT Scan
gold standard
sensitivity specificity > 90% 4 false positive 20 %
CT 6
Positive signs
1. thickening of anterior renal fascia sign
2. fluid collection pancreas
3. pancreatic parenchymal edema or disruption
4. active bleeding or extravasation

Other Investigations of Pancreatic Injury
Plain abdomen specific character
1. loss of psoas shadow
2. widening of gastrocolic distance from displacement of stomach and

transverse colon
3. sentinel loop
4. fracture thoracolumbar spine or scoliosis
US bowel gas ... pancreas work
MRCP or ERCP persistent hyperamylasemia ductal

injury CT pancreatic fistula
DPL.unreliable fluid amylase pancreas ...

work US choice

AAST Pancreatic Injury Scaling System
5 grade
grade 1,2. simple injury
grade 3,4,5. complex severe injury
severe injury up 1 grade

Management of Pancreatic Injury
conservative
fancy procedure anastomosis ....
leak
Nonoperative management isolated injury grade 1-2 blunt trauma

hemodynamic stable report success
case NPO serial physical examination lab imaging study
Principles 3
1. stop bleeding
2. debridement
3. control pancreatic secretion and adequate drainage
external drainage soft closed suction drain Jackson Pratt 10

redivac sump penrose drain
7-14
complex injury grade 4,5 feeding jejunostomy
Intraoperative suspicious of main PD injury
1. complete transection or more than 50% of parenchymal thickness
2. severe maceration & saponification

3. penetrating with central perforation
4. direct visualization of ductal disruption pancreatic juice

Intraoperative main PD evaluation
main PD injury invasive

technique tissue
trauma idea

1. Needle cholecystocholangiopancreaticography
contrast gallbladder IV morphine
spasm sphincted of Oddi contrast main PD

2. Transduodenal pancreatography duodenum
3. Distal pancreatic resection & duct canulation fistula
4. Intraoperative ERCP
5. Direct canulation at the site of PD injury
6. IOUS success 1 PD injury

trauma
Operative Management
Intraoperative suspicious of pancreatic injury
1. proximity of injury to pancreas
2. central or paraduodenal hematoma
3. bile stain
4. saponification of retroperitoneal fat
5. pancreas L2
Exposure of the pancreas
Resident
1. Head uncinate process

1.1 Kocherization SMV duodenum head of pancreas
1.2 mobilized hepatic flexor
2. Body tail

2.1 lesser sac exploration gastrocolic omentum transverse
colon pancreas
2.2 posterior surface pancreas lower border

mobilized spleen tail mobilized
splenic flexor
Operative Management of Pancreatic Injury

grading of injury injury associated injury
90% major vessel
bleed pancreas clamp pancreas

bleed
swab Kocherization
pancreas
Management Grade 1,2

Grade 1,2 main PD stop bleeding,
debridement adequate drainage
subcapsular hematoma contusion explore

hematoma grading of injury hematoma

hematoma liver spleen

capsule pancreas capsule

pseudocyst capsule parenchymal
tear prolene 4-0 basic
pseudocyst injury
( 2 )
closed suction drain 2 7 ... drain
Management Grade 3
type ...pancreas transection neck
SMV

distal pancreatectomy
pancreas end fish mouth PD nylon 3-0
PD transfix suture
duct
splenic preservation isolated pancreatic injury

hemodynamic stable preserve spleen
45

BP drop
()
drain tail 2
stable damage control stop bleeding drain

Management Grade 4
proximal injury main PD CBD intact

grade 4 controversy
1. proximal end closure with Roux-en-Y pancreaticojejunostomy

distal gland 20 %
grade 4 severe injury duodenum

ampulla bleed
3 grade 4 stable
2. extended distal pancreatectomy subtotal pancreatectomy

ampulla intact pancreas 20%
pancreas C-loop 2 cm.
1 anastomosis exocrine
endocrine insufficiency review
( Trauma 7th ed )
3. stop bleeding with wide external drainage feeding jejunostomy

1 pancreatic fistula conservative

( Sabiston 19th ) oral
drain
4. damage control stop bleeding ...

packing.. drain refer
resection Roux-en-Y

1. contaminate colon resect
2. damage control
anastomosis
3. extended distal pancreatectomy
3 stable severe injury of duodenum or ampulla Roux en Y

OK stop bleeding drain
4 stop bleeding drain
refer

Management Grade 5
massive destruction pancreatic head damage control
unstable stop bleeding drain mortality conference

Whipple case injury head duodenum

resect drain stable
reconstruction
feeding jejunostomy

Indications for Whipples operation
1. laceration of intrapancreatic bile duct and proximal main PD
2. extensive demarcation of pancreas and duodenum
3. avulsion of ampulla with severe injury of second part of the duodenum and
head of pancreas
4. retropancreatic portal vein disruption with uncontrol retropancreatic

hemorrhage

Algorithm for pancreatic trauma

Duodenal Injury

penetrating injury 80%...blunt trauma 20%
...delayed treatment 40%
location of injury
1. second part . 35%
2. third part . . 15%
3. fourth part . 15%
4. first part ..... 10%
Clinical Presentations
upper abdomen hand bar

NG tube
24-48
shock
Investigations of Duodenal Injury

Plain abdomenpositive 1 3 case

1. retroperitoneal air kidney free air
2. obliteration of right psoas shadow
3. scoliosis lumbar spine
US. work
UGI study water soluble contrast
film positive 50%.... contrast

leakage coiled spring stacked coin sign
intramural hematoma
CT scan
gold standard case hemodynamic stable feed

water soluble contrast sensitivity 80%

Positive signs CT
1. extraluminal gas extraluminal contrast
2. fat stranding with loss of sharp tissue plane
3. intraluminal hematoma or focal wall thickening > 4 mm
AAST Duodenal Injury Scaling System
grade 1,2 simple
grade 3,4,5 severe complex injury
duodenal injury duodenum D1,D2,D3,D4
injury up grade 1 grade

Management of Duodenal Injury
75-85% debridement
Principles 3
1. repair or anastomosis without tension
2. good pancreaticobiliary drainage
3. protective procedure in severe injury
Intraoperative suspicious of duodenal injury
1. proximity of injury to duodenum
2. paraduodenal hematoma
3. bile strain
4. crepitus
Exposure of the duodenum
1. Kocher maneuver
2. lesser sac exploration
3. transection ligament of Treitz fouth part DJ junction
4. Cattel-Braash maneuver

duodenum
1. primary repair ... 80% repair
2. pancreaticobiliary drainage
3. protective procedure
4. damage control
Synder Duodenal Severity Scale
Mild Severe
Agent Stab Blunt or missile
Size < 75%wall <75%wall
Duodenal site 3,4 1,2
Injury repair interval(hr) < 24 >24
Adjacent injury No CBD CBD
No pancreatic injury Pancreatic injury
severe injury protective procedure
Grade 1,2 significant vascular injury protective procedure

Protective procedure
1. Repair & reinforcement or buttressing with omentum

repair esophagus
2. Duodenal decompression & diversion of gastric content
2.1 tube duodenostomy
2.2 triple ostomy
3. Pyloric exclusion
4. Berne diverticulization
resident
1. repair ... duodenal decompression
2. 1 ... diversion
3. 3 ...

Tube Duodenostomy Triple Ostomy
Triple Ostomy
1. Gastrostomy for gastric decompression
2. Retrograde tube duodenostomy or Retrograde jejunostomy for duodenal

decompression
3. Prograde feeding jejunostomy
triple ostomy gastrostomy NG tube

duodenum Foley tube duodenostomy


triple ostomy
Jackson Pratt ... IV NG ,
Foley monitor record output
tube
Pyloric Exclusion
1. Gastrotomy greater curve
2. Closure pylorus Babcock pylorus silk

prolene 3-0 run interrupted ... 3 pylorus

() stapler chromic vicryl
2 pylorus ()
3. Side to side antecolic gastrojejunostomy vagotomy marginal

ulcer
4. feeding jejunostomy
protective procedure 20 ...

divert gastric content duodenal wound
pressure duodenum
Postop tube

Berne Diverticulization Procedure
protective procedure
grade 3 injury tissue loss

ampulla first part second part Roux en Y
jejunum
1. TV+ antrectomy B2
2. T-tube drain bile CBD
3. tube duodenostomy

Management Grade 1,2
wall contusion 72
serosal tear silk 3-0
debride size 50%

2
grade 2 omentum ...
intramural hematoma serosa clot

seromuscular silk 3-0
grade 1,2 need protective procedure
Management Grade 3
50% CBD ampulla
injury
Operative approach
1. third fouth part. end to end

duodenoduodenostomy protective procedure

2. duodenum second part
ampulla third part distal end Roux en Y
duodenojejunostomy proximal end
3. condition 2 lesion proximal

ampulla Berne diverticulization
4. jejunal serosal patch Thal

study ...

Management Grade 4
duodenum injury CBD ampulla
duodenum treat
distal CBD ampulla injury

1. CBD repair ... 50 % repair T tube stent
50% repair Roux en Y jejunum

2. repair ... train admin

tube drain CBD refer
3. avulsion disruption ampulla spare pancreatic head.

ampulla replantation duodenum (
case staged Whipple)
Management Grade 5
injury severe combined injury pancreas duodenum
2 options
1. damage control stop bleeding drain ICU

definitive treatment
2. Whipple

Intramural Hematoma of the Duodenum
classic handle bars
upper gut obstruction
injury 48
gastric dilatation bilious vomiting hematoma
ampulla
jaundice ampulla
Imaging
1. plain abdomen gastric dilatation double bubble
2. upper GI. coiled spring stacked coin sign

3. CT with oral contrast.. UGI

Treatment
1. ... NPO+IV+NG+TPN 2
NG output

1.1 3
1.2 conservative leakage
hematoma degree of initial obstruction

2. Intraoperative diagnosis... Kocherization serosa clot

mucosa stop bleeding silk seromuscular
() serosa
evacuated blood clot ... gastrojejunostomy alternative
treatment
Procedure Rarely Used Today

1. esrosal patch
2. Berne diverticulization
3. extended distal pancreatectomy grade 4 Trauma 7 ed

4. capsule parenchyma grade 1,2 pseudocyst
5. splenic preservation grade 3
6. direct repair main PD Roux en Y jejunum main PD
7. Whipple
Algorithm for duodenum injury.

Complications of Pancreaticoduodenal Injury
Bleeding
resident intervention
Bleeding pancreas not primarily controlled is never controlled.
OR
rebleed
necrosectomy case infected pancreatic necrosis
case embolization
Pancreatic fistula
most common complication definition content

100 cc. 10

Treatment
1. conservative response 90%
1.1 TPN feeding jejunostomy

1.2 correct fluid electrolyte, IV antibiotic, skin care
1.3 octreotide prove trial fistula

()
2. 2 weeks content MRCP

main PD stent fail stent

Duodenal fistula
bile drain small bowel

enterocutaneous fistula
Pancreatitis
10-15% amylase conservative

Pancreatic pseudocyst
diag. US CT treat pseudocyst


...


COLON, RECTUM and ANAL INJURIES
..
injury colon, rectum anus penetrating

injury colon incidence small bowel
concept

Resident
colon

COLON INJURY
colon injury penetrating injury blunt trauma
left colon right colon colon

transverse colon
colon retroperitoneum injury

injury retroperitoneal colon, splenic flexor rectosigmoid

missed injury
blunt trauma injury sigmoid colon

cecum
colon ascending, hepatic flexor, splenic flexor descending

colon anastomosis mobilized
leak

Diagnosis of Colon Injury
diag.
1. exclude resident

2. retrocolic hematoma colonic wall
PR penetrating injury colon

injury rectum proctoscope
colon seatbelt
mark sign stable generalized peritonitis
CT with IV contrast and water soluble contrast enema
CT sensitivity 90% specificity 96%

Management of Colon Injury
1...repair repair
2 2... colostomy
...
1979 prospective randomized trial classic Stone

Fabian set criteria diversion repair
2000 trial
criteria set
... RCT set criteria

Demetrios Demetriades ( Colon and Rectal Trauma
Trauma 7 ed. 2013) scientific
challenge

Colon Injury Grading Scale
American Association for the Surgery of
Trauama (AAST ) 2
non-destructive destructive colon injury
Nondestructive Colon Injury

injury loss bowel wall 50% circumference
devascularization ( AAST grade 1-2 )
injury 1ryrepair risk

factors
GSW small-caliber
risk
50 %
Destructive Colon Injury

injury loss bowel wall 50% circumference
devascularization segmental resection ( AAST grade 3-5 )
1990case ostomy
1990 destructive injury case

1ryrepair risk factors

Management of Colon Injury
penetrating injury GSW stab wound

blunt trauma 1ryrepair stable

contaminated 1ryrepair
Position ... rectal injury lithotomy
colon IC valve intraperitoneum rectum

Babcock mesentery
rule of two
1ryrepair colostomy
...mucosa ... mucosa wall

colon ()... serosa..

abscess
...
IV antibiotic
... isolated colon injury SSI 5%

contaminated contaminated moderated
severe

concomitant gastric injury SSI
30%
drain abscess
drain... ostomy
Risk Factors For Colon Injury

1979 classic RCT Stone Fabian criteria diversion
ostomy
colostomy
Criteria Colostomy
1. preoperative or intraoperative shockSBP 80
2. bleed 1000 cc. blood transfusion
6 units
3. associated injury organ 2 organ
4. massive severe fecal contamination
5. delayed treatment 6 injury

6. destructive colon injury colon
7. cormorbid RT distal
narrowing
8. major abdominal wall loss mesh

9. colon injury scale (CIS score )
10. penetrating abdominal trauma index scores (PATI) 25
Fecal contamination
degree of fecal spillage grading system

( )
1. Georges grading system 4 grade
grade 1... resident
grade 2... injury
grade 3... quadrant
grade 4... 1 quadrant
2. Fecal contamination score
2.1 Mild local contamination quadrant
2.2 Moderate. contamination 2-3 quadrant

2.3 Severe. contamination 4 quadrant
Colon injury scale (CIS score)
Grade 1... serosal injury
Grade 2...single wall injury
Grade 3wall injury 25%
Grade 4... wall injury 25%
Grade 5 injury wall blood supply
study 10-15 support criteria

colostomy 1ryrepair CIS score, PATI score, shock
on admission SBP 80 mmHg., degree of fecal contamination,
multiple associated injury 2 organ criteria
1ryrepair location site of colon injury
mesenteric antimesenteric border ...
delayed operation delayed 8 delayed 12
1ryrepair
2014 criteria colostomy
1. preoperative BP < 80 mmHg with no response
2. massive fecal contamination

3. multiple colonic wound or severe destructive lesion blunt
Trauma
4. delayed operation > 12 hour
Surgical Tips and Techniques

1. 1ryrepair resection with anastomosis

2. serosal tear silk 3-0
3. perforation debride 2
... 2 chromic 3-0 silk 3-0
4. stapler ...

5. Resection with anastomosis
5.1 colon destructive lesion
5.2
5.3 compromised blood supply

6.
healing & leak rate
terminal ileum colon ileocolostomy
leak colon colocolostomy

7. colon small bowel stable repair
8. 1ryrepair proximal diversion colon injury

proximal diversion leak rate
colostomy rectosigmoid rectum Hartmann


9. exteriorized repair colostomy
repair colon repair vasaline
gauze gauze NSS colon ... colon
colostomy
80% leak colon serositis colon

colostomy
10. colostomy pelvic fracture transverse colon
10.1 loss of tamponade
10.2 infection hematoma ... infected
11. colostomy colostomy 2 2-3

2-3
12. antibiotic cover E.coli B.fragilis 24

13. fascia monofilament interrupted sutures irrigate NSS
skin 4-5 secondary suture
RECTAL INJURY
concept colon injury
Mechanism of injury
1. penetrating injury
2. blunt trauma
3. transanal injury ( endoscope)
Anatomy

Rectum promontery of sacrum anorectal line 15 cm.
1. Intraperitoneum rectum... rectum peritoneal

reflection... upper 2/3 rectum peritoneum
peritoneum upper 1/3...rectum 1/3
rectum serosa
2. Extraperitoneum rectum... rectum intraperitoneum

rectum pelvis 2/3 rectum ...
rectum serosa

Diagnosis of Rectal Injury
Clinical sign intraperitoneal rectal injury colon injury
(peritonitis)
clinical signs extraperitoneal rectal injury

peritoneal signs
Suspicion in
1. penetrating injury lower abdomen, , pelvis
2. blunt trauma fracture pelvis
3. PR
PR ... prostate

PR rigid anoscope , proctoscope sigmoidscope
investigation rectal injury
rectal injury ...
OR
PR scope rectal injury 95%

case GSW PR rectal
injury water soluble contrast enema

contrast enema rectal injury

selected case ... bladder injury
penetrating injury GSW buttock CT with or without rectal
contrast contrast enema
rectal contrast water soluble contrast
Management of Rectal Injury

Intraperitoneal rectal injury colon injury
Extraperitoneal rectal injury. lithotomy

4Ds Diversion,
Debridement, Distal washout Drainage
proximal diversion 3D


Proximal Diversion
... ()
rectum 3-4
nondestructive rectal injury
diversion
colostomy
transverse loop colostomy fracture pelvis

injury intraperitoneal colon perineal sepsis
external fixator
laparoscopic assised colostomy

lap
... open work
open colostomy
complete divertion trauma 7 ed.
antibiotics prophylaxis 24 infectious complications

3-5

A properly conducted loop colostomy. Note that the spur of the colostomy is
supported well above the skin.
The use of a linear stapler for definitive fecal diversion.

Hartmann's procedure with an end colostomy and a rectal pouch. Reconstituion
of bowel continuity will require a full laparotomy and extensive dissection.
Colostomy closure
1. timing colostomy 6-8

tissue inflammation subside
2 OR colostomy

... stable sepsis

6-8
2. BE water soluble contrast colostomy ...

routine BE
contrast distal

contrast proximal

Debridement with or without Repair

intraperitoneal rectum treat
colon injury
extraperitoneal rectum
proximal diversion
presacral drainage .... extensive mobilization
extraperitoneal rectum rectum
Distal Washout
NSS ostomy
... risk of infection
control infection

Presacral Drainage
routine drain injury posterior
lateral injury work
presacral drainage complication peritoneal sepsis
extraperitoneal rectal injury posterior

inaccessible wound
mechanism of injury high energy blunt trauma
pelvic fracture severe perineal injury

1. lithotomy
2. curve ...dissect coccyx

blunt endopelvic fascia Waldeyers fascia presacral
space rectal injury
3. penrose drain 2-3 presacral space penrose

redivac drain
4. drain 4-5 short drain
presacral drainage coccyx drain

... coccyx
Demetrios

Anal Injury
Injury sphincter injury
repair external sphincter
rectum perineum re-approximation

rectum anal canal levator muscle perirectal skin
proximal colostomy presacral drainage

definitive treatment definitive repair 6 1

...

""
1
1 5
. . .



-
: .
()


LIVER AND TRAUMATIC BILIARY INJURIES
..
liver , gallbladder extrahepatic bile duct
basic anatomy ... liver
biliary surgery

LIVER INJURY
CT grading ... associated injury
bleeding 75 % portal vein

low pressure
case ...
explore 50-67 % ...
blunt trauma center
30 %

AAST Liver Injury Scale
Subcapsular hematoma blunt trauma
Glissons capsule
grade I, II minor injury grade III severe injury
grade VI hepatic avulsion severe

Management of Liver Injury
2
1. nonoperative management
2. operative management
Nonoperative Management (NOM)

standard treatment blunt trauma
grade V 20-30 %
penetrating injury report success case
peritonitis vital signs stable
Criteria ... Trunkey
1. hemodynamic stable admission BP drop

stable Initial resuscitation blood
replacement 4 unit
2. peritonitis significant associated

intraabdominal organ injury
3. ICU monitor OR 24 hr. lab


4. CT film
embolization
5.
OR ()
CT triple contrast hollow
viscus
Feliciano 500 cc.
NOM CT pelvis bleed
NOM ....success 90%
50-80%
head injury NOM NOM
monitor
hemodynamically stable

guideline NOM blunt liver injury
guideline Trauma 7 ed. 2013 p.544
1. criteria NOM hemodynamic stable
1.1 grade 1, 2 ,3 admit monitor ward

stable ( Explore)
embolization
1.2 grade 4, 5 admit monitor ICU stable

ward... ICU 48-72 hr.
2. , jaundice
Unexplained sepsis repeat CT
2.1 pseudoaneurysm hemobilia embolization
2.2 collection percutaneous drainage
2.3 CT
Approach
1. NPO
2. NG , Foley
3. Bed rest 3
4. Monitor vital signs , Hct , urine output

5.
NOM
complication NOM 6%
Angiographic embolization. NOM
1. grade 4, 5
2. contrast blush
3. ongoing bleeding 2 unit
4. hemobilia
5. pseudoaneurysm or AV fistula
6. failed pack removal
.... fail NOM
1. > 55
2. multiple injury
3. head injury
4. grade 4, 5
5. 4-6 unit

Follow Up CT Scan
Inpatient management
1. grade 1, 2 stable clinical follow up CT

repeat CT Hct drop
2. grade 3 repeat CT
3. grade 3, 4 , 5 4 5 ... discharge ICU

repeat CT ... CT 7

Outpatient management
guideline Mattox 2013 p.544
1. grade 1, 2 , 3 CT pain jaundice
2. grade 4, 5 follow up CT 1
significant healing normal activity CT

heal limit activity CT
1
follow up CT
1. resorption 2
2. coalescence laceration

3. defect
4. complete restoration liver homogeity 4
... FU CT routine
clinical signs and symptoms
Resumption of Activity
liver injury normal activity 1
heal wound strength 3
over activity 3-6

CT healing 95%
Operative Management
1. hemodynamic stable shock
2. peritonitis
3. associated injury
4. failure NOM
5. 2 unit keep Hct
6.

Principles
1. Bleeding control
2. Removal devitalized tissue
3. Establishment of adequate drainage
Operative Principles
1. prep stenotomy
( lateral subcostal)
2. incision upper midline

shock loss tamponade effect
load warm IV
3. small bowel
blood clot suction clot
suction

4. pack 4 quadrant off pack


5. off packing
active bleed pack
Pringle
6. ligament mobilized
dome
bleeding
retrohepatic vein bag
ventilator
retrohepatic vein injury packing
7. retrohepatic vein bleeding mobilization

formal hepatectomy
Temporary Control Bleeding

4
1. manual compression
swab 5-10

2. swab packing.
3. Pringle maneuver clamp 90

clamp 15-20 5 safe

4. tourniquet application penrose drain
lateral segment left lobe

clamp
liver hanging maneuver tape

penrose
Operative Approach

severity
bleed bleed swab sponge
glue
gel foam , surgicel

subcapsular hematoma pulsatile expansile

embolization
Trunkey
follow
1. hepatorrhaphy 3 cm.
omentum

2. tractotomy with suture ligation or clip
3 cm. Pringle
(resident ) clamp
clip bleed
3. Omentorrhaphy tractotomy
omentum tamponade effect chromic
omentum

4. resectional debridement
raw surface
omentum

5. perihepatic packing retrohepatic vein
damage control severe bilobar injury
pack bleed vein bleed artery

... Pack control arterial bleeding

pack
1. mobilized ligament
blood clot ....
retrohepatic venous injury
2. pack over packing IVC

pack
.. ACS ... swab plastic
drape ... swab plastic off packing
swab ...

plastic swab ...
swab swab
3. swab temporary abdominal closure

ICU
off packing
1. off 48-72 packing
2. swab ...
bleed
3. bleed ... drain
4. ...pack post op embolization ()
5. off pack 2... off

.... severe liver injury
1. deep liver suture

necrosis abscess omentum
bleed
2. extrahepatic artery ligation

hepatic artery branch branch hepatic
artery proper embolization embolization
selective
3. anatomical resection bleed

hepatic vein
4. mesh hepatorrhaphy absorbable mesh wrap

bleed wrap 1 lobe 2 lobe

1. perihepatic packing ACS
2. remove mesh packing
1. wrap porta hepatis

2. retrohepatic venous injury
5. OLT safe pack

1

drain Jackson- Pratt 2 liver injury grade 3, 4, 5
raw surface drain
off drain
T-tube bile leakage
ileus feeding jejunostomy

Guideline operative management of liver injury

Transhepatic Penetrating Injury
GSW serious bleed

bleed
case bleed tract
CT CT tract tract
( tractotomy) bleed
tract death
circulated nurse Foley ...Foley tractblow

balloon air balloon air emboli
Foley bleed balloon
bleed .

Foley balloon tamponade Foley
side holes penrose Foley
tract contrast
2-3 deflate balloon bleed embolization

omentum tract drain
bleed ( )
Sangstagen Blakemore tube
gastric balloon
off
Hepatic Artery and Portal Vein Injury

repair repair
damage control
intraabdominal vascular injury
Retained Bullet within Hepatic Parenchyma

1.
2.


Juxtrahepatic Venous Injury
retrohepatic vena cava hepatic vein injury
exposure injury
( 80%)

3 bleed 3 4
Preoperative diagnosis
embolization
Intraoperative diagnosis
1.
2. portal vein injury lesser sac
3. Pringle ventilator
intrathoracic pressure injury
Management
1. retrohepatic hematoma stable

manipulated mobilized loss tamponade
effect
2. bleed perihepatic packing

48-72 embolization

3. off packing
admit

4.

4.1 bleed irrigation drain

observe
4.2 bleed ... pack
intervention embolization
work
4.3 chart , film ... MM report
Operative Approach
perihepatic packing
... control vascular isolation
Vascular isolation technique
1. Shunt approach

1.1 atriocaval shunt Schrock shunt
1.2 saphenofemoral shunt Moore Pilcher shunt
1.3 venovenous bypass
2. Nonshunt approach
2.1 Heaneys maneuver
2.2 Pringle maneuver with finger fracture to direct repair
Atriocaval (Schrock) Shunt

vascular isolation suprahepatic vena cava suprarenal vena
cava shunt right atrium
...
shunt arrest
( )
1. stenotomy
2. ET tube ICD 36 atrial appendage tube

infrarenal vena cava Foley
infrarenal vena cava
3. cord tape snare intrapericardial vena cava suprarenal vena

cava
4. blow balloon Rumel tourniquet snare
5.
Saphenofemoral (Moore Pilcher) Shunt

balloon shunt balloon saphenofemoral
junction IVC fluoroscopy
bleed blow balloon ...

MM
Venovenous Bypass

tube shunt infrarenal vena cava
axillary vein ( OLT)
Heaney Maneuver
1. clamp suprahepatic infrahepatic vena cava
2. Pringle maneuver
clamp IVC load IV ... clamp BP

()
Pringle Maneuver with Finger Fracture
Pachter Pringle 77
Schrock shunt .... juxtahepatic venous injury

Pringle ( finger fracture) direct repair
hepatectomy repair
Pachter shunt.
OLT
packing embolization

endovascular IVC stent venous endograft success
( )
Complications of Liver Injury

1. hepatic necrosis or abscess
2. biloma
3. bile fistula
4. hemobilia
5. bilhemia
Hepatic Necrosis or Abscess

, RUQ pain , localized peritonitis
Lab.white count N
CT with IV contrast nonperfused liver parenchyma
fluid collection abscess

Treatmentexplore debride necrotic tissue
drain
Biloma
high grade injury leak bile intrahepatic bile duct
RUQ pain jaundice
CT scan collection abscess resolving hematoma

Treatment
1. US or CT guided percutaneous drainage+ ERCP & sphincterotomy

stent 72% 2
complete resolution 10- 47
2. fail nonoperative treatment debride

omentum
Bile Fistula
bile leak drain 50 cc. 2
.... RUQ pain
Investigation
1. Initial study MRC
2. treat ERCP

Treatmentpercutaneous drainage ERCP & EST biliary stent
nutrition enteral TPN
Hemobilia
blunt penetrating injury false aneurysm
Bile duct
Classic triad
1. upper GI bleeding shock
2. obstructive jaundice
3. RUQ pain
Diagnosis
1. upper endoscopy ampulla

2. CT with IV contrast
3. hemobilia angiogram
embolization
Treatment
1. angiographic embolization diagnostic

success rate 95%

2. fail embolization,
large cavity sepsis hepatic resection

Bilhemia or Biliovenous Fistula

bile duct IVC HV
severe subcapsular hematoma
resorption clot bile duct
intrahepatic vein

Labbilirubin
Diagnosis ERCP MRCP bile duct hepatic vein

IVC
Treatment
1. bile IVC HV
1.1 endoscopic stenting
1.2 T-tube
2. hepatectomy

Gallbladder Injury
trauma penetrating injury associated injury
CT bile collection

Treatment
1. cholecystectomy treatment of choice
2. postop stab wound

gallbladder chromic drain
tube cholecystostomy preserve gallbladder
...
isolated gallbladder injury cystic duct injury
right hepatic artery
fundus
downward cholecystectomy 3-5 gallbladder

Extrahepatic Bile Duct Injury

90% penetrating injury partial transection
blunt trauma ( complete

transection ) fix pancreaticoduodenal
junction
bile stain hematoma portal triad

... 1
6 jaundice bile
sepsis death
Severity work
1. simple injury 50% ductal wall
2. complex injury 50% ductal wall
Operative treatment
1. unstable damage control T-tube drain
2. case stable
2.1 injury duct wall 50% primary repair

stent (T tube )

2.2 injury duct wall 50% tissue loss
biliary enteric anastomosis Roux en Y jejunum
proximal part stent
2.2 injury right left hepatic duct

repair reconstruction ... ligation option
lobe atrophy biliary
cirrhosis
center repair bile duct
reconstruction ...
refer ... T tube Jackson Pratt 2-3

refer refer
basic principle repair
Principles operative management of bile duct injury
1. minimal dissection bile duct

blood supply bile duct
2. debridement
3. mucosa (mucosa to mucosa)
4. without tension
5. stent trauma duct diameter duct

1 cm. stent decompression


....
nonoperative management ....

failure ...
...
...
( VIP)...
....
available ...
... 50-50 (% -) ... pack

SPLENIC INJURY
..
anatomy immunological function

CT , embolization nonoperative treatment
blunt trauma preserve spleen
splenic injury criteria case nonoperative

treatment

Anatomy
idea staff
30% distal tail pancreas pancreatic

injury
Blood supply
Diagrammatic representation of a
transverse laceration relative to
the splenic vasculature in a
pediatric patient.
dual blood supply splenic artery short gastric artery

end artery segment segment segment
... branch segment blood supply
segmental resection
splenic artery variable spleen

2 upper 2/3 lower 1/3

Mechanism of Splenic Injury
Blunt trauma criteria
nonoperative treatment
Penetrating injury diaphragmatic
injury preserve
Iatrogenic injury , vagotomy injury
concept delayed rupture blunt abdominal trauma

splenic injury bleeding
blunt trauma 48 delayed rupture
delayed diagnosis
Signs of Splenic Injury

resident
Kehrs sign diaphragm refer pain

... 20%
Balance sign LUQ

LUQ bleed
associate

Investigation
Plain film fracture rib 8, 9, 10

DPL
Tc sulfur colloid scan laparoscopy. work
FAST unstable fluid ...

miss subcapsular hematoma
CT scan hemodynamic stable

advantage CT
1. grading severity
2. contrast blush
3. rule out associate injury
4. nonoperative
management
AAST Splenic Injury Scaling System

Nonoperative Management (NOM)
... vital signs stable peritonitis

NOM grade 1, 2 grade 3, 4, 5 vital signs

stable NOM grade 4, 5 failure
, head injury, spinal cord injury

..... cut off 55 ... 55 NOM.

stable NOM
55 injury grade 3 fail
head injury. NOM ...head injury relative

contraindication NOM ()... work
NOM awake, alert cooperation ....
severe TBI (score 9)
pathology . vital signs stable

NOM
CT contrast blush ongoing bleeding NOM

selective arterial embolization bleed 80%
associated injury liver kidney splenic injury

NOM hemodynamic stable

Criteria for Nonoperative Management (NOM)
1. hemodynamic stable SBP 90 poor response IV
resuscitation OR
2. other indications explore peritonitis
3. coagulopathy hepatic failure
4. , x-ray
5. ICU, OR , , x-ray stand by 24
Angiographic Embolization
adjunctive treatment NOM success rate 96%
stable
embolization study immunization
Indication
1. grade 4,5
2. contrast blush active extravasation

3. continue bleeding Hct. drop
4. pseudoaneurysm
5. AV fistula

Success of NOM
1. grade 1,2 success 90%
2. grade 5 25%
3. 95% 60- 80%

spontaneous clotting splenic capsule

4. CT
4.1 bleed bleed 250 cc. ...NOM success

87-90%
4.2 bleed bleed 250-500 cc. left colon

NOM success 60%
4.3 bleed bleed 500 cc. , left colon

pelvis NOM success 10% pelvis

Case failure NOM
1. 55
2. injury grade 3
3. multiple injury
4. initial fluid resuscitation 2

5. blood transfusion 2 unit
failure NOM 24 continuous bleeding
failure NOM
1. Inappropriate initial decision to proceed NOM
2. Misinterpretation of imaging study
Indication for operation in NOM patient
1. abdominal sign peritonitis
2. hemodynamic stable stable
3. blood transfusion 4 units Hct drop
4. embolization
5. complication abscess
follow up CT
debate
routine CT follow up
CT injury grade 4,5 contrast blush splenic

parenchyma follow up CT CT 1-2
pseudoaneurysm treat embolization

Activity
adequate healing time injury grade 1,2 3

injury grade 3 adequate healing time
activity post NOM
1. normal activity 2
2. 3
3. 6
Nonoperative Management Order

1. admit ICU 24-72
2. NPO, NG , Foley NG ()
3. absolute bed rest 2-3 ... stable early mobilization

thromboembolic complication
4. serial PE ( )
5. serial Hct 6 24 Hct 8 24

... stable
6. 72 stable ward ileus

7. admit 7 NOM
7 grade 4,5
admit
8. vaccination

9. DVT prophylaxis sequential compression device

heparin
Operative Management for Splenic Injury

.... preserve
Technique
1. midline
T
2. clot LUQ swab pack

bleed .... grade 1,2
resident

3. bleed mobilized
spleen lateral
tail of pancreas swab
pack
Mobilization of the spleen is begun by early division of its lateral attachments.
4. pretty motor show

5. 2
5.1 short gastric artery gastric wall clamp

greater curve ... fundus silk
3-0 seromuscular plication
5.2 tail pancreas hilum clamp pancreas

6. damage control

6.1 electrocautery. surface
6.2 hemostatic agent fibrin glue gelatin sponge

. 5 7 four seasons ()
6.3 wrapping with absorbable mesh (dexon)

stable


6.4 suture repair chromic 3-0 horizontal mattress
perinephric fat cut through
6.5 partial splenectomy injury upper pole lower

pole
7. subcapsular hematoma. hematoma absorp

8. clot clot
glue
9. drain pancreatic injury close suction drain
Splenic Autotransplantation
OPSI
parathyroid
xx 40x40x3 mm. 5
gastrocolic omentum

autotransplantation 6
tufsin, properdin IgM ....
bacteria
IgM
OPSI
30% bacteria
Splenectomy
Indication
1. hilar injury
2. splenic avulsion
3. massive or extensive injury
4. continuous bleeding after splenorrhaphy
5. multiple injury
risk OPSI vaccine

Postsplenectomy
D1-4 WBC, platelet
D5. WBC> 15,000 platelet : WBC 20 sepsis

subphrenic collection
vaccination vaccine cover strep pneumonia, H-flu

meningococous preop PO. D14
overall risk OPSI vaccine

CDC vaccine 10 3
OK

Prophylactic antibiotic penicillin amoxycillin
5 stand-by antibiotic
penicillin amoxicillin ..
risk USA card

.. .


...
...
...

pharynx retrosternum
atypical GERD

Pongsan Trauma 2016 (I)

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Trauma Edition 2

Surgical Board Review 2016 trauma

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MSD Surgical Board Review 2016: Trauma Edition 2 i

MSD Surgical Board Review 2016: Trauma Edition 2 ii

2. Current concepts from Mattox in trauma 1

3. Initial Assessment and Management 8

4. Traumatic Brain Injury 59

5. Spine and Spinal Cord Injuries 111

6. Maxillofacial Injury 155

7. Neck Injury 203

8. Principles of Chest Injury 227

9. Lung & Tracheobronchial Injuries 278

10. Cardiac Injury 296

11. Diaphragmatic Injury 322

12. Principles of Abdominal Trauma 338

13. Gastric and Small Bowel Injury 371

MSD Surgical Board Review 2016: Trauma Edition 2 iii

15. Colon, Rectum and Anal Injuries 426

16. Liver and Traumatic Biliary Injuries 455

17. Splenic Injury 501

18. Renal and Ureteral Trauma 521

19. Bladder , Urethra and Genital Injury 557

20. Pelvic Fracture 585

21. Trauma Damage Control 621

22. Abdominal Compartment Syndrome 645

23. The Difficult Abdominal Wall Closure 658

24. Principles of Vascular Injury 670

25. Cervical Vascular Injury 689

26. Intrathoracic Vascular Injury 713

MSD Surgical Board Review 2016: Trauma Edition 2 iv

28. Peripheral Vascular injury 784

29. Musculoskeleton Trauma 849

30. Hand Injury 882

31. Burn 918

MSD Surgical Board Review 2016: Trauma Edition 2 v

2. Trauma (Eric Legome) 1st ed. 2011

3. Current Therapy of Trauma (Trunkey) 2008 , 2014

4. ATLS Manual 8th ed. , 9th ed.

5. Complications in Surgery and Trauma (Cohn) 2007

8. General Surgery 2th ed. 2008 Kirby I. Bland

MSD Surgical Board Review 2016: Trauma Edition 2 vi

MSD Surgical Board Review 2016: Trauma Edition 2 vii

MSD Surgical Board Review 2016: Trauma Edition 2 viii

trauma professor Kenneth L. Mattox

Mattox guest 2012

Trauma 2556 2012

MSD Surgical Board Review 2016: Trauma Edition 2 1

2014 Mattox lecture Nagoya Management of

2014 European society for trauma and emergency

2015 article 1 Endovascular management

MSD Surgical Board Review 2016: Trauma Edition 2 2

Mattox fluid keep BP 80 mmHg

Venous access. Mattox antecubital fossa leak

MSD Surgical Board Review 2016: Trauma Edition 2 3

Military Antishock Trousers (MAST). Mattox

renal dose dopamine raise BP

arrest CPR 5 (2003 10 )

ERT EDT Mattox ECT emergency center

Airway maintenance. esophageal obturator airway

ABG. may be helpful

MSD Surgical Board Review 2016: Trauma Edition 2 4

Skull x-ray. show