TRAUMASCHWARTZ’S PRINCIPLES OF

SURGERYCHAPTER 7
 GENERAL PRINCIPLE

TRAUMA OR INJURY IS A CELLULAR

DISRUPTION CAUSED BY AN EXCHANGE WITH
ENVIRONMENTAL ENERGY THAT IS BEYOND
THE BODY’S RESILIENCE
MOST COMMON CAUSE OF DEATH FOR ALL
INDIVIDUALS BETWEEN THE AGES OF 1 AND 44
YEARS
THIRD MOST COMMON CAUSE OF DEATH
REGARDLESS OF AGE
ADVANCED TRAUMA LIFE SUPPORT (ATLS)

PRIMARY SURVEY
CONCURRENT RESUSCITATION
SECONDARY SURVEY
DIAGNOSTIC EVALUATION
DEFINITIVE CARE
 PRIMARY SURVEY
• THE GOAL: To identify and treat conditions that
constitute an immediate threat to life.
•

Assessment of the “ABCDE”: Airway with cervical spine

•

protection Breathing
Circulation Disability Exposure
•
1. AIRWAY MANAGEMENT WITH CERVICAL
SPINE PROTECTION
• FIRST PRIORITY IN PRIMARY SURVEY:
Ensuring a patent airway
• Visual inspection: airway cleared of any debris,
blood and foreign bodies
• Application of oxygen as needed
•

• Blunt trauma require cervical spine immobilization

(hard collar or placing sandbags on both sides of
head with the patient’s forehead taped across bags to
backboard) until injury is excluded.
 1. AIRWAY MANAGEMENT WITH CERVICAL
SPINE PROTECTION
PATIENTS WHO ARE CONSCIOUS, DO NOT
SHOW TACHYPNEA, AND HAVE A NORMAL
VOICE DO NOT REQUIRE EARLY ATTENTION TO
THE AIRWAY EXCEPT THE FOLLOWING:
✓

✓ PATIENTS WITH PENETRATING INJURIES TO

THE NECK AND EXPANDING HEMATOMA
✓ EVIDENCE OF CHEMICAL OR THERMAL
INJURY TO THE MOUTH, NARES, OR
HYPOPHARYNX
✓
MANUAL AIRWAY MANEUVERS
OPTIONS FOR ENDOTRACHEAL INTUBATION

Orotracheal • Preferred method of obtaining • Requires neuromuscular blockade

definitive airway when performed among conscious patients
with cervical spine stabilization
• Applicable in patients with apnea
• Direct visualization of the vocal
cord
• Ability to use large diameter tubes

Nasotracheal • Applicability in prehospital setting • Not applicable in apnea, severe

• May be inserted without a
laryngoscope
Cricothyroidotomy • First airway control maneuver in
cases of craniofacial trauma
midface trauma and/or suspicion of
basilar skull fracture (CSF
rhinorrhea, raccoon eyes, Battle
sign)
• Risk of subglottic stenosis if
performed among children

Tracheostomy • Last resort (best performed in OR) • Requires more skill

• Applicable in cases of laryngeal
fractures
 2. BREATHING AND VENTILATION

ASSESS FOR RESPIRATORY RATE AND OXYGEN

SATURATION
INSPECT FOR EXTERNAL SIGNS OF TRAUMA
AND ASYMMETRIC CHEST MOVEMENTS
PALPATE CHEST WALL FOR INJURY
AUSCULTATE CHEST WALL FOR BREATH
SOUNDS
ONCE A SECURE AIRWAY IS OBTAINED,
ADEQUATE OXYGENATION AND VENTILATION
MUST BE ASSURED
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE VENTILATION
TENSION PNEUMOTHORAX Open Pneumothorax

• Diagnosis is implied by respiratory distress and

hypotension in combination with any of the
following physical signs in patients with chest
trauma: tracheal deviation away from the
affected side, lack of/decreased breath sounds
on the affected side and subcutaneous
emphysema on the affected side

Treatment:
1. Needle thoracostomy
2. Closed tube thoracostomy – performed immediately
before CXR is obtained
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE VENTILATION
OPEN PNEUMOTHORAX “Sucking Chest Wound”

• Occurs with full thickness loss of the chest wall,

permitting free communication between the pleural
space and the atmosphere
• Compromises ventilation due to equilibration of
atmospheric and pleural pressures, which prevent
lung inflation and alveolar ventilation, and results
in hypoxia and hypercarbia.
• Complete occlusion of the chest wall defect without
a tube thoracostomy may convert an open
pneumothorax to a tension pneumothorax

Definitive Treatment: Closure of the chest wall defect

and closed tube thoracostomy remote from the would
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE VENTILATION
FLAIL CHEST with underlying PULMONARY
CONTUSION

• Occurs when 3 or more contiguous ribs are

fractured in at least 3 locations
• Paradoxical movement of this free floating segment
of chest wall may be evident in patients with
spontaneous ventilation, due to the negative
intrapleural pressure of the inspiration
• Associated pulmonary contusion is typically the
source of post injury pulmonary dysfunction
(decreased compliance and increased shunt
fraction)

Definitive Treatment: May require presumptive

intubation and mechanical ventilation
3. CIRCULATION WITH HEMORRHAGE CONTROL

LOOK FOR EVIDENCE OF BLEEDING

INITIAL APPROXIMATION OF PATIENT’S
CARDIOVASCULAR STATUS CAN BE OBTAINED
BY PALPATING PERIPHERAL PULSES: CAROTID
PULSE: 60-70 MMHG FEMORAL
PULSE: 70-80 MMHG
RADIAL PULSE: >80 MMHG (SOURCE:
ATLSG)
PAIL SKIN BED OR CRT >2 SECS INDICATES
POOR PERIPHERAL PERFUSION
3. CIRCULATION WITH HEMORRHAGE CONTROL

IV ACCESS FOR FLUID

RESUSCITATION IS OBTAINED
WITH 2 PERIPHERAL
CATHETERS, 16 GAUGE OR
LARGER IN ADULTS
IN PATIENTS UNDER 6 YEARS
OLD, AN INTRAOSSEUS
NEEDLE CAN BE PLACED IN
THE PROXIMAL TIBIA
(PREFERRED) OR DISTAL
FEMUR OF AN UNFRACTURED
EXTREMITY
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE CIRCULATION
MASSIVE HEMOTHORAX

• Defined as >1,500 ml of blood or in pediatrics, 1/3 of the patient’s

blood volume in the pleural space
• After a blunt trauma, hemothorax is usually due to multiple rib
fractures with severed intercostal arteries, but occasionally bleeding is
from lacerated lung parenchyma
• After a penetrating trauma, a systemic or pulmonary hilar vessel
injury should be presumed
Treatment: Operative intervention
LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE CIRCULATION
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE CIRCULATION
CARDIAC TAMPONADE

• Occurs most commonly after penetrating

thoracic injuries, although occasionally blunt
rupture of the heart, particularly the atrial
appendage is seen
• <100 ml of pericardial blood may cause
pericardial tamponade
• Beck’s triad is NOT often observed
• Early in the course of tamponade, blood
pressure and cardiac output will transiently
improve with fluid administration
• Ultrasound of pericardium is best method of
diagnosis
•
 LIFE THREATENING INJURIES IDENTIFIED DUE
TO INADEQUATE CIRCULATION
TREATMENT:
Pericardiocentesis is successful in decompressing
tamponade in approximately 80% of cases
o Removing as little as 15-20 ml of blood will often
temporary stabilize the patient’s hemodynamic
status, prevent subendocardial ischemia, and
associated lethal arrhythmia, and allow transport to
the OR for sternotomy.
o Patients with a SBP <70 mmHg warrant emergency
department thoracotomy (EDT) with opening of the
pericardium to address the injury
o EDT is best accomplished using a left anterolateral
thoracotomy, with the incision started to the right of
the sternum
o
 4. DISABILITY AND EXPOSURE

GLASGOW COMA SCALE (GCS) SHOULD BE

DETERMINED FOR ALL INJURED PATIENTS
SCORES OF 13 TO 15: MILD HEAD INJURY
9-12: MODERATE
INJURY <9: SEVERE INJURY
ABNORMAL MENTAL STATUS SHOULD PROMPT
AN IMMEDIATE RE-EVALUATION OF THE ABCS
AND CONSIDERATION OF CENTRAL NERVOUS
SYSTEM INJURY
 GLASGOW COMA SCALE (GCS)
MOTOR RESPONSE VERBAL OUTPUT EYE OPENING

6 Obeying commands

5 Localizing to pain Oriented to time, place,

person

4 Withdrawing to pain Confused Spontaneous eye opening

3 Decorticate posturing Incoherent or inappropriate Eye opening to name

calling

2 Decerebrate posturing Incomprehensible sounds Eye opening to pain

1 No motor response No verbal output No eye opening

 SECONDARY SURVEY
IT IS A RAPID, SYSTEMATIC, AND HEAD-TO-TOE
EXAMINATION APPROACH TO THE INJURED
PATIENT.
“AMPLE”: ALLERGIES
MEDICATIONS PAST
ILLNESSES/PREGNANCY LAST MEAL
EVENTS RELATED TO THE INJURY
ALL POTENTIALLY SERIOUSLY INJURED
PATIENTS SHOULD UNDERGO DIGITAL RECTAL
EXAMINATION TO EVALUATE FOR SPHINCTER
TONE, PRESENCE OF BLOOD, RECTAL
PERFORATION, OR A HIGH-RIDING PROSTATE,
 RESUSCITATION
TACHYCARDIA: EARLIEST SIGN OF ONGOING
BLOOD LOSS

BRADYCARDIA: OCCURS IN SEVERE BLOOD

LOSS, HERALDING IMPENDING
CARDIOVASCULAR COLLAPSE
HYPOTENSION: NOT A RELIABLE EARLY
SIGN OF HYPOVOLEMIA
 RESUSCITATION
TACHYCARDIA: EARLIEST SIGN OF ONGOING
BLOOD LOSS

BRADYCARDIA: OCCURS IN SEVERE BLOOD

LOSS, HERALDING IMPENDING
CARDIOVASCULAR COLLAPSE
HYPOTENSION: NOT A RELIABLE EARLY
SIGN OF HYPOVOLEMIA
 RESUSCITATION
GOAL: RE-ESTABLISH TISSUE PERFUSION
URINE OUTPUT: QUANTITATIVE, RELIABLE
INDICATOR OF ORGAN PERFUSION
FLUID RESUSCITATION: BEGINS WITH A 2L
(ADULT)/ 20 ML/KG (CHILD) IV BOLUS OF
ISOTONIC CRYSTALLOID, TYPICALLY RINGER’S
LACTATE
 RESUSCITATION

RESPONDERS TRANSIENT RESPONDERS NONRESPONDERS

• Individuals that are • Those who respond • Patients with

stable or have a good initially to volume persistent
response to the loading by an hypotension despite
initial fluid therapy increase in blood aggressive
• Proceed to secondary pressure only to then resuscitation
survey hemodynamically
deteriorate once
more
 DIAGNOSTIC EVALUATION
SEVERE BLUNT TRAUMA— “BIG THREE”:
LATERAL CERVICAL SPINE, CHEST, AND PELVIC
RADIOGRAPHS
GUNSHOT WOUNDS— AP VIEW & LATERAL
RADIOGRAPHS OF THE CHEST AND ABDOMEN
CRITICALLY INJURED PATIENTS— ROUTINE
TRAUMA PANEL: TYPE AND CROSS MATCH,
CBC, BLOOD CHEMISTRIES, COAGULATION
STUDIES, LACTATE LEVEL, ABG ANALYSIS
LESS SEVERELY INJURED PATIENTS— CBC
AND URINALYSIS
 TRAUMA TO THE
ABDOMEN
1.BLUNT ABDOMINAL TRAUMA
2. PENETRATING ABDOMINAL TRAUMA
 INTRODUCTION
“ABDOMINAL TRAUMA REMAINS A LEADING
CAUSE OF MORTALITY IN ALL AGE GROUPS.
BLUNT ABDOMINAL INJURY (BAI) IS COMMON
AND USUALLY RESULTS FROM MOTOR
VEHICLE COLLISIONS (MVC), FALLS AND
ASSAULTS.”
“ IN CHILDREN (LESS THAN OR EQUAL TO 14
YEARS OF AGE), BLUNT ABDOMINAL TRAUMA
IS THE SECOND MOST FREQUENT CAUSE OF
MORTALITY PRECEDED BY HEAD INJURIES. “
“INJURIES IN THE ABDOMEN OCCUR FROM
DIRECT FORCES CAUSING COMPRESSION OR
 ABDOMINAL TRAUMA
DIAGNOSTIC APPROACH DIFFERS FOR
PENETRATING TRAUMA (GUN SHOT/STAB
WOUND) AND BLUNT ABDOMINAL TRAUMA
MANAGEMENT ALGORITHM FOR PENETRATING
ABDOMINAL INJURY PATIENTS IS PRIMARILY
BASED ON THE ANATOMIC LOCATION OF
INJURY
AS A RULE, MINIMAL EVALUATION IS
REQUIRED BEFORE LAPAROTOMY FOR
ABDOMINAL GUNSHOT OR SHOTGUN WOUNDS
BECAUSE OVER 90% OF PATIENTS HAVE
ALGORITHM FOR THE EVALUATION OF PENETRATING
ABDOMINAL INJURIES
 ABDOMINAL TRAUMA
ANTERIOR ABDOMINAL STAB WOUNDS (AASW)
SHOULD BE EXPLORED UNDER LOCAL ANESTHESIA IN
THE ED TO DETERMINE IF THE FASCIA HAS BEEN
VIOLATED
•

➢ DO NOT PENETRATE PERITONEAL CAVITY: NO

FURTHER EVALUATION AND PATIENT IS
DISCHARGED FROM THE ED
➢ PATIENTS WITH FASCIAL PENETRATION MUST BE
FURTHER EVALUATED FOR INTRA-ABDOMINAL
INJURY, BECAUSE THERE IS UP TO A 50% CHANCE OF
REQUIRING LAPAROTOMY
 ABDOMINAL TRAUMA
BLUNT ABDOMINAL TRAUMA INITIALLY IS EVALUATED
BY FAST EXAM IN MAJOR TRAUMA CENTERS
FAST IS NOT 100% SENSITIVE SO DIAGNOSTIC
PERITONEAL ASPIRATION IS STILL ADVOCATED IN
HEMODYNAMICALLY UNSTABLE PATIENTS WITHOUT A
DEFINED SOURCE OF BLOOD LOSS TO RULE OUT
ABDOMINAL HEMORRHAGE
PATIENTS WITH FLUID ON FAST EXAMINATION,
CONSIDERED A “POSITIVE FAST”, WHO DO NOT HAVE
IMMEDIATE INDICATIONS FOR LAPAROTOMY AND ARE
HEMODYNAMICALLY STABLE UNDERGO CT SCANNING
TO QUANTIFY THEIR INJURIES
ALGORITHM FOR THE INITIAL EVALUATION OF A PATIENT
WITH SUSPECTED BLUNT ABDOMINAL TRAUMA
 BLUNT ABDOMINAL TRAUMA:
DIAGNOSTICS
I.DIAGNOSTIC PERITONEAL LAVAGE
GOLD STANDARD FOR INTRAPERITONEAL BLUNT INJURIES
IF THE DIAGNOSTICS OF INTRAABDOMINAL BLEEDING IS
UNCERTAIN

II. FOCUSED ASSESSMENT WITH SONOGRAPHY FOR

TRAUMA (FAST)
INITIAL EVALUATING TOOL
DETECTS FLUID IN PERICARDIAL SAC AND DEPENDENT
ABDOMINAL REGIONS:
a) MORISON POUCH REGION IN RUQ
b) LUQ BEHIND THE SPLEEN AND BETWEEN THE SPLEEN AND
BLUNT ABDOMINAL TRAUMA:
DIAGNOSTICS
III. CT SCAN OF THE ABDOMEN
INDICATIONS:
1. POSITIVE FAST, HEMODYNAMICALLY STABLE
PATIENTS, WITH NO IMMEDIATE INDICATION FOR
SURGERY
2. HEMODYNAMICALLY STABLE PATIENTS WITH
UNRELIABLE PHYSICAL EXAMINATION FINDINGS
3. RETROPERITONEAL INJURIES
4. PREVIOUS LAPAROTOMY
LIMITATIONS: DETECTION OF BOWEL PERFORATION
AND FINDING OF A DIAPHRAGMATIC INJURY
BLUNT ABDOMINAL TRAUMA:
SURGICAL TX
SURGICAL TX: DEFINITIVE MANAGEMENT
INDICATION FOR LAPAROTOMY:
1. PERITONEAL SIGNS
2. POSITIVE DPL
3. POSITIVE FAST OR CT SCAN WITH HEMODYNAMIC
INSTABILITY
 PENETRATING ABDOMINAL
TRAUMA
COMMONLY DUE TO GUNSHOT, SHOTGUN, AND STAB
WOUNDS
PHYSICAL EXAMINATION: SHOULD IDENTIFY THE
LOCATION OF ALL ENTRY AND EXIT WOUNDS AS WELL
AS THE PRESENCE OF PERITONEAL SIGNS
RADIOGRAPHS: SHOULD INCLUDE ANTEROPOSTERIOR
AND LATERAL ABDOMINAL FILMS
LOCAL WOUND EXPLORATION: DONE UNDER LOCAL
ANESTHESIA TO DETERMINE FASCIAL OR PERITONEAL
PENETRATION IN ANTERIOR ABDOMINAL STAB
 PENETRATING ABDOMINAL TRAUMA:
LAPAROTOMY
INDICATIONS FOR LAPAROTOMY:
1. PERITONEAL SIGNS
2. EVISCERATION OF INTRABDOMINAL ORGANS
3. TRANSPERITONEAL GUNSHOT WOUNDS
4. HEMODYNAMIC INSTABILITY
5. BLEEDING FROM AN ORIFICE
6. IMPALED OBJECT
7. PNEUMOPERITONEUM
8. POSITIVE DPL
 PENETRATING ABDOMINAL TRAUMA:
LAPAROTOMY

PRIORITIES DURING EXPLORATORY LAPAROTOMY

(MIDLINE INCISION FROM TIP OF XYPHOID PROCESS
TO THE SYMPHYSIS PUBIS):
1. CONTROL OF HEMORRHAGE
2. CONTROL OR CONTAINMENT OF CONTAMINATION
3. THOROUGH EXPLORATION TO IDENTIFY ALL
INJURIES
4. DEFINITIVE MANAGEMENT OR REPAIR OF ALL
INJURIES