GENERAL SURGERY- TRAUMA

PRINCIPLES OF TRAUMA CARE Triage

TRAUMA Primary survey & it’s adjunct
Bodily injured or disruption of bodily function resulting from Resuscitation
mechanical or physical forces accompanied by systemic as well as Secondary survey & it’s adjunct
local effects Re-evaluation & post resuscitation monitoring
Leading cause of death in all age categories from infancy to Definitive care
middle age.
Trimodal pattern of death TRAUMA
Preparation phase
A. In hospital – human resources , manpower, equipment
B. Pre hospital – notified before transport, emphasis on ABC,
cervical spine protection, transport to CLOSEST and most
APPROPIATE center, minimize scene time

TRAUMA
A cornerstone of trauma care is the TIMELY IDENTIFICATION and
TRANSPORT to a trauma center of those patients most likely to
benefit, that is, the principle of TRIAGE.

TRIAGE
System of sorting out the patient in terms of priority of treatment
a.) Post injury- 50% of trauma deaths Polytrauma patients should receive top priority
spinal cord ,intra abdominal, aortic injuries Done pre-hospital and In-hospital
b.) brain injury or uncontrolled hemorrhage
c.) refractory increase ICP, pulmonary complications TRAUMA
TRIAGE SCHEME: assess the potential for life or limb threatening
“Multiple trauma patients are more likely to die from their intraoperative injury.
Prolonged prehospital time
Pedestrian struck at speed >20mph
Systolic < 90 mmHg
RR > 29 bpm
GCS < 14

Primary survey and resuscitation

Assessment looking for immediate life threatening condition
pertaining to: ABCDE
FAST scan
Xrays
Presumed injuries significant until proven otherwise . Do not take
things for granted

metabolic failure than from a failure to complete operative repairs.”

- Karim Brohi, Trauma 2000

Trauma Management System

- Seamless continuum in the management of patients from phase
to phase

TRAUMA
A basic principle of trauma resuscitation is the need for continual
reevaluation and reassessment.
Tertiary Trauma survey- missed injury 56%
Transfer to a higher level of care – trauma center, physician to
physician communication.

Management of polytrauma
Preparation
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 Focused Assessment Sonography for Trauma ( FAST)
Hypotension
Abdominal trauma
Impaired consciousness
Pulseless electrical activity

Life Threatening Chest/Thoracic Injuries

Immediately life threatening
– Airway occlusion
– Tension Pneumothorax
– Sucking chest wound (open pneumothorax)
– Massive hemothorax
– Flail Chest
– Cardiac tamponade
Potential late life threatening:
– Aortic injury
– Diaphragmatic tear
– Tracheobronchial injuries
– Pulmonary contusion
– Esophageal injury
– Blunt cardiac injury (“myocardial contusion”)
Xrays
3 compulsory x-rays in any polytrauma patients (ATLS):
1. Lateral C spine
2. AP- CXR
3. AP-Pelvic

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TRAUMA
Definitive hemorrhage control.
Hypovolemic hypotension >15-30% blood loss, is a late sign for
young adult.
Failure to correct tachycardia/hypotension after 2-3L crystalloid =
deficit >15%.
Blood transfusion using type “O” considered if blood loss >1 liter
or >3 crystalloid needed to maintain SBP.

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 Antibiotics
Tetanus immunization- >6h, crush injuries, burns, electrical
injuries, high velocity injuries, devitalized tissues, direct Definitive care
contamination with feces Definitive surgery vs DCS
End points of resuscitation Definitive surgery should be short as possible
Control the cause- best end point If patients condition not optimal might opt for DCS
Volume resuscitation - colloids vs crystalloid
Blood pressure – aim MAP >70mmHg Standard Surgical Teaching
Temperature – keep it normothermic,< 32c (>60% mortality)
Lactate – tissue ischemia

End points of resuscitation

Pulse rate <120/min
Lactate – increase >24hr ARDS,MODS
Urine output – organ perfusion , >0.5/kg/hr Staged Laparotomy
CVP- 5-10cm H20

Circulation
 Categories of shock
 Persistent hypovolemia
1. Hemorrhagic
- Flat neck veins TRAUMA
- CVP < 5 cm h20 The triad of doom:
- Base deficit > 8 mmol/ l Coagulopathy
2. Cardiogenic Acidosis
- Distended neck veins Hypothermia
- CVP > 15 cmh20
3. Neurogenic Metabolic failure
4. Septic Hypothermia – exacerbates coagulopathy and interferes with the
blood homeostatic mechanism
Acidosis – uncorrected shock leads to inadequate cellular
perfusion , anaerobic metabolism and lactic production
Coagulopathy – hypothermia, acidosis and massive blood
transfusion

Categories of base deficit

Mild
2 to 5 mmol/L
Moderate
6-14 mmol/L
Severe
> 14mmol/L

Damage Control Surgery

Ph <7.2
Lactate >5 mmol
PT >16 sec ; PTT >60sec
> 10 unit BT
SBP < 90 mmHg
Temperature < 35 c

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Principles of DCS:
Control of hemorrhage
Prevention of contamination
Avoid further injury

COAGULOPATHY is the single most common reason for DCS instead of

the planned procedure
Duration of surgery should be as short as possible and aim for
control bleeding Max 1 hour

General conduct and Philosophy:

Incision xiphisternum to pubis with possible extension to chest
Four quadrant packing
Aortic control
Identify main source of bleeding
Exploration –mobilization, retroperitoneum
Abdominal closure – skin closure only

Organ-Specific Techniques
LIVER- peri-hepatic packing will arrest most hemorrhage except
for major arterial bleed

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 - Pringle’s maneuver
Finger fracture technique
Selective angiographic embolization
SPLEEN – direct suture ,splenectomy
GIT – suture closure, resection, exteriorize
Pancreas- drainage, debridement, resection
Abdominal Trauma
Anterior abdomen - Anterior costal margins to inguinal creases,
between the anterior axillary lines
Intrathoracic abdomen or thoracoabdominal area - Fourth
intercostal space anteriorly (nipple) and seventh intercostal space
posteriorly (scapular tip) to inferior costal margins
Flank - Scapular tip to iliac crest, between anterior and posterior
axillary lines
Back - Scapular tip to iliac crest, between posterior and axillary
line
Anteriorly from nipple to the groin crease
Posteriorly tip of scapula to gluteal crease
Penetrating and Blunt abdominal
3 major categories of patient with penetrating abdominal injury
Adjuncts that can provide clues for intra-peritoneal injury
Chest X-ray – sub-diaphragmatic air
NGT – blood drained from stomach, bowels
Urinary catheter- macroscopic hematuria
Rectal examination – blood indicates rectal or sigmoid
penetration. Proctoscopy or sigmoidoscopy should be performed
Diagnostics Abdominal Trauma
1. Serial physical examination (SPE)
Best sensitivity and negative predictive value for the evaluation of
penetrating abdominal trauma.
Sequence 1,4,12, & 24 hrs. after initial assessment. Some every 4
hrs.
Same examiner
Adjunct CT scan, laparoscopy, laparotomy if still with fever, pain,
tachycardia >24 hrs.
2. Local wound exploration (LWE)
Under local anesthesia at OR
Penetration of the posterior fascia +
+ = laparotomy or DPL or laparoscopy
Even if the peritoneum is penetrated ,many of these patients will
have no intra peritoneal injury or any injury that does not require
surgery
3. DPL –involves passing a small catheter into the peritoneal cavity,
at the umbilicus
If blood can be aspirated,+ .
1 liter crystalloid infused then analysis for RBC, WBC, bowel
contents
Hemodynamically stable blunt.
Invasive, not evaluate retroperitoneum, significant false positive
rate
4. FAST– sensitive for pericardial fluid, high false negative for intra-
abdominal injury.
+ FAST= peritoneal penetration
- FAST= doesn’t exclude significant abdominal injury
Benefits:
 Decreases the time to diagnosis for acute abdominal injury
in BAT
 Helps accurately diagnose hemoperitoneum
 Helps assess the degree of hemoperitoneum in BAT
 Noninvasive
 Can be integrated into the primary or secondary survey and
can be performed quickly, without removing patients from
the clinical arena
5. CT scan- multi slice scanner with triple contrast
Retroperitoneal injuries
Signs of peritoneal violation: free intra- peritoneal air, free intra-
peritoneal fluid, wound track extending through peritoneum
Signs of bowel injury: bowel wall defect, bowel wall thickening,
contrast leak intraluminally, diaphragmatic tear
6. Laparoscopy- diaphragmatic injury
Therapeutic for diaphragmatic injury
Reevaluation after observation with persistence s/sx
False negative missed bowel injuries ,retroperitoneal injury
A prospective study of 99 patients showed that diagnostic
laparoscopy was negative in 62% of the patients with penetrating
abdominal trauma, reducing the rate of unnecessary laparotomy
from 78.9% to 16.9%.
7. Laparotomy – explor lap , celiotomy
Resource –limited environment
High non therapeutic rate
Incidence of complication with negative laparotomy rate 12%-41%
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Blunt Abdominal Trauma

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 Penetrating Abdominal Trauma

In penetrating abdominal trauma due to stab wounds, the most

commonly injured organs are as follows :
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
• Most common organs injured in penetrating abdominal trauma
GSW
Small bowel (50%)
Colon (40%)
Liver (30%)
Vascular injuries(25%)

Explore !
Hypotension (with or without abdominal distention)
Narrow pulse pressure Back wound
Tachycardia Retroperitoneal injury
High or low respiratory rate Colon, kidney, lumbar vessels, pancreas, aorta, IVC
Signs of inadequate end organ perfusion Colon most often missed.
Peritoneal signs (eg, pain, guarding, rebound tenderness) and/or Triple contrast CT scan
peritonitis
Diffuse and poorly localized pain that fails to resolve

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 Retroperitoneal injury
Associated injuries ,high index of suspicion
Hallmark is retroperitoneal hematoma
Ct scan
Management depends on the zone involved

CT scan

In a prospective study of 200 patients, CT was found to be 97%

sensitive and 98% specific for peritoneal violation.Laparotomy
based on CT findings in 38 of these patients was considered
therapeutic in 87%, nontherapeutic in 8%, and negative in 5%.
These results were comparable to others obtained with the use of
clinical examination, DPL plus local wound exploration, and DPL
alone.

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 Chest Trauma
Physical examination
Look – determine Respiratory rate & depth,
asymmetry,paradoxical chest wall motion,bruising,penetrating
wounds
Feel – tracheal deviation, tenderness, subcutaneous
emphysema,rib crunching
Listen – Breath sounds
Percuss – dullness or resonance

Monitoring adjuncts- arterial 02 saturation

end-tidal CO2 –definitive method of confirming ET placement.
Estimates arterial PaCO2 level ,vital for TBI patients.
Diagnostic adjuncts- C-XRAY, FAST ,ABG
Interventions- Chest drain, EDT, OR thoracotomy

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Tension Pneumothorax
Progressive build up of air in the pleural space
Lung laceration
+ pressure ventilation exacerbate this one way valve effect
Tracheal deviation, mediastinal shift
Depression of diaphragm- XRAY
Needle thoracostomy, CTT

Hemothorax
Collection of blood in the pleural space
CXRAY, FAST, CT scan
CTT- initial step, 32-36F
Thoracotomy – 1-1.5l initial , bright red, 200-250cc/hr, unstable
VS

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 Flail chest

Closed Head Injuries

Mild (GCS 14-15)
Acute Brain Injury  Clinical observation
Goals :  Assess risk factors of significant IC injury
 Protect the airway & oxygenate  CT scan GCS <15 at 2 hrs post injury
 Ventilate to normocapnia  Admit if no improvement for 4 hrs
 Correct hypovolemia & hypotension  Head injury Advise once discharge
CT scan  Referral to neurologist if symptoms persist after 4 weeks
Neurosurgery Moderate head injury (GCS 9-13)
ICU  Supportive care ABCDE’s
 Prevent secondary injury
 Early CT scan
 Intubation if required oxygenation
 Early neurological consult if ABN CT scan
 Referral to neurologist
Severe head injury (GCS 3-8)
 Early intubate
 Supportive care ABCDE’s
 Prevent secondary injury
 Early CT scan
 Early neurosurgical consult
 ICP monitoring

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Indication for ICP monitoring
 GCS of 3-8
 Abnormal cranial ct scan
 Any two of the ff
 Age older than 40yrs
 Posturing response to pain
 Systolic bp < 90

TBI
 Ct scan should be evaluated for
 Mass effect or effacement of the lateral ventricle
 Midline shift
 Presence or absence of CSF in basal cisterns

Head injury
 Indications for operative intervention
 Clot volume
 Amount of midline shift
 GCS
 Location of clot
 Depressed skull fracture
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  Penetrating head injury

 Post injury care

 Avoid hypotension
 Avoid hypoxia
 Pco2 - 35-40
 Anticonvulsant

In trauma it is not speed but TIMING, it is not courage but

KNOWLEDGE, it is not transfusion but CONTROL and it is not
individual’s ability but TEAMWORK.
- W.Y.M.

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