Lecture 1.

2 | TRAUMA AND BURNS

SURGERY
BATCH AUMONT TRANS DR. ANGELO MICHAEL A. SINGCO 20 AUGUST 2021

Page All potentially seriously injured patients should undergo the ff:
Outline
number • Digital rectal examination
Secondary Survey 1 o To evaluate for sphincter tone
Mechanisms and Patterns of Injury 1 o Presence of blood
Regional Assessment and Special Diagnostic 2 o Rectal perforation or a high-riding prostate
Tests particularly critical in patients with suspected
➢ Head 2 spinal cord injury, pelvic fracture, or trans-
➢ Neck 3 pelvic gunshot wounds
➢ Chest 4 • Vaginal examination with a speculum should be
➢ Abdomen 5 performed in women with pelvic fractures to exclude an
➢ Pelvis 7 open fracture
➢ Extremities 7
General Principles of Management 8 Adjuncts to the physical examination includes
Transfusion Practices 8 • Vital sign and CVP monitoring
Prophylactic Measures 9 o Tachycardic signs of hypothalgia – probably
Operative Approaches and Exposure 9 blood loss
o CVP line monitoring – line that you insert to
SECONDARY SURVEY monitor the central pressure
• The patient is already in stable state and examined • ECG monitoring
systematically. Review the history and then you can do • Nasogastric tube placement
the secondary survey. o Gastric injury could present bloody NGT
• A thorough history is obtained and the patient is discharge
examined in a systematic fashion. • Foley catheter placement
➢ Obtain an AMPLE history – review the history of the o Renal injury – probably gross hematuria
patient • Radiographs, hemoglobin, urinalysis and base deficit
o Allergies – review if the patient have history measurements
of allergies, be aware if s/he has allergy like o Especially hemoglobin – serial Hbg
drugs determination done every 30 mins; if
o Medications – know all the medication that the decreasing -> possible surgery
patient took, (e.g., if s/he is diabetic). You • Repeat FAST exam (Focused Assessment with
must know this in preparation to the surgery. Sonography in Trauma)
o Past illnesses or Pregnancy – know the past o Usually done in the emergency room
illness or if she is pregnant.
o Last meal – to know if you should aspirate first MECHANISMS AND PATTERNS OF INJURY
before surgery • High energy transfer includes auto-pedestrian
o Events related to the injury – (what happened accidents, motor vehicle collisions in which the car’s
before the injury, where he/she at, if s/he’s change of velocity (∆V) exceeds 20 mph or in which
from a party, s/he intoxicated, took drugs or the patient has been ejected, motorcycle collisions,
s/he’s drunk.) and falls from heights >20ft.
• Low-energy trauma, such as being struck with a club
The physical examination should be literally head to toe, with or failing from a bicycle, usually does not result in
special attention to the patient’s back, axillae, and perineum widely distributed injuries
• Common sites where misinjury (injury cannot be easily • In blunt trauma, particular constellations of injury or
seen) is noted. injury patterns are associated with specific injury
mechanisms
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 • Penetrating injuries are classified according to the
wounding agent (i.e., stab wound, gunshot wound, or
shotgun wound)
o Gunshot wounds are subdivided further into
high- and low-velocity injuries, because the
speed of the bullet is much more important
than its weight in determining kinetic energy.
o High-velocity gunshot wounds (bullet speed >
2000 ft/s are infrequent in the civilian setting.
o Shotgun injuries are divided into close-range
(<20 feet) and long-range wounds
▪ Close-range wounds are tantamount
to high-velocity wounds because the
entire energy of the load is delivered
to a small area, often with
devastating results.
▪ Long-range shotgun blasts result in
a diffuse pellet pattern in which
many pellets miss the victim, and
those that do strike are dispersed
and of comparatively low energy.
REGIONAL ASSESSMENT AND SPECIAL DIAGNOSTIC
TESTS
Based on mechanism, location of injuries identified on physical
examination, screening radiographs, and the patient’s overall
condition, additional diagnostic studies often are indicated.
However, the seriously injured patient is in constant jeopardy
when undergoing special diagnostic testing.
HEAD
• Examination for injuries to the scalp, eyes, ears, nose,
mouth, facial bones, and intracranial structures.
• Otorrhea, rhinorrhea, racoon eyes, and Battle’s sign
(ecchymosis behind the ear) suggest a basilar skull
fracture.
• Abnormal dental closure suggests malalignment of
facial bones and possibility for a mandible or maxillary
fracture.
• Nasal fractures, which may be evident on direct
inspection or palpation, typically bleed vigorously.
o This may result in the patient’s having airway
compromised due to blood running down the
posterior pharynx, or there may be vomiting
provoked by swallowed blood.
• All patients with a significant closed head injury (GCS
score <14) should undergo CT scanning of the head
• For penetrating injuries, plain skull films may be
helpful in the trauma to determine the trajectory of
injury in hemodynamically unstable patients who
cannot be transported for CT scan
− One of the things to mark: the point of entry
and point of exit
• Lateralizing findings
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− E.g., a unilateral dilated pupil unreactive to
light, asymmetric movement of the
extremities either spontaneously or in
response to noxious stimuli, or unilateral
Babinski’s reflex
− Suggests an intracranial mass lesion or
major structural damage
• Epidural hematomas
− Occur when blood accumulates between the
skull and dura
− caused by disruption of the middle
meningeal artery or other small arteries in
that potential space, typically after a skull
fracture
• Subdural hematoma
− Occur between the dura and cortex
− caused by venous disruption or laceration of
the parenchyma of the brain due to
associated parenchymal injury
− Have a much worse prognosis than epidural
hematomas
• Hemorrhage into the subarachnoid space
− May cause vasospasm
− Further reduce cerebral blood flow
• Intraparenchymal hematomas and contusions
− Can occur anywhere within the brain
− Sometimes temporary, but often damaging
to the brain
• DAI (Diffuse Axonal Injury)
− Results from high-speed deceleration injury
− Represents direct axonal damage from
shear effects
− Mostly seen in motorcycle accidents
CT scan may demonstrate blurring of the gray and white
matter interface and multiple small punctate hemorrhages, but
Magnetic Resonance Imaging (MRI) is a more accurate test
^ The picture shows white blurring, this is the epidural type of
hematoma.
NECK
• All blunt trauma patients should be assumed to have
cervical spine injuries until proven otherwise.
o Once the patient comes into the emergency
room, you have to support the cervical spine
if you have suspicions of injury, unless
proven otherwise.
• During cervical examination, one must maintain
cervical spine precautions and in line stabilization. It
must be in line, it must be hyperextended, it must not
be lateral, nut in line stabilization.
• Spinal cord injuries can vary in severity
• Complete injuries cause either quadriplegia or
paraplegia, depending on the level of injury of the
spine
• These patients have a complete loss of motor function
and sensation two or more levels below the bony
injury – these are some of the consequences if you
have complete spinal problems
Diseases Regarding Injuries to The Neck
(Cervical Spine Injury)
1. Central cord syndrome – typically occurs in older
persons who experience hyperextension injuries
(splash injury)
• Motor function, pain and temperature
sensation are preserves in the lower
extremities but diminished in the upper
extremities
2. Anterior cord syndrome
• Characterized by diminished motor function,
pain, and temperature sensation below the
level of the injury, but position sensing,
vibratory sensation, and crude touch are
maintained
• Prognosis for recovery is poor
3. Brown-Sequard syndrome
• Result of penetrating injury in which one-half
of the spinal cord is transected
• Characterized by the ipsilateral (one side)
loss of motor function, proprioception, and
vibratory sensation, whereas pain and
temperature sensation are lost on the
contralateral side
^ Algorithm for the management of penetrating neck injuries.
Fig. 7-19, pg. 198, Schwartz’s Principles of Surgery 11th Edition Vol. 1
• The only important thing here is that you have to
know the early detections for unstable patients,
uncontrolled hemorrhages, your hard signs – massive
hemoptysis, rapidly expanding hematoma – go
directly to the operating room and explore
• For stable and asymptomatic, it depends on the level
of the neck. The zone I, II, and III
• The zone I has thoracic access leading to
angiography. If it’s, positive, then operate. If its
negative, then do embolization for level III
Indications for intermediate operative intervention for
penetrating cervical injury:
• Hemodynamic instability
• Significant external hemorrhage
• Evidence of aerodigestive injury (both and trachea
and possibly your esophagus) – this is significant in
doing right away exploration
Neck being divided into three distinct zones:
• Zone I is inferior to the clavicles encompassing the
thoracic outlet structures
• Zone II is between the thoracic outlet and the angle of
the mandible
o Common site of injuries especially in
gunshot and stab wounds
• Zone III is above the angle of the mandible

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 Persistent Hemothorax:
• If not drained by two chest tubes, it is already known
as caked hemothorax and mandates of immediate
thoracotomy
o Should open thoracic and evacuate hematoma or
whatever bleeding there has to be sutured.

Widening of mediastinum
• On initial anteroposterior chest radiograph, could be
caused by a hematoma around an injured vessel and
is contained by mediastinal pleura suggesting injury of
the great vessels.
o Remember: the mediastinum is a sterile area and
mostly the heart and the blood vessels are located
^ Fig. 7-20, pg. 199, Schwartz’s Principles of Surgery 11th Edition Vol. 1 in this area. If there is disruption of the
mediastinum, this could be a severe type of injury.
CHEST
• Blunt trauma to the chest may involve the chest wall,
thoracic spine, heart, lungs, thoracic aorta and great
vessels, and rarely the esophagus (because it is located
posteriorly)
o Most of these injuries can be evaluated by Physical
Exam and Chest Radiography / X-ray, with
supplemental CT scanning based on initial findings.
o If not sure with Xray, then go with CT scan and look for
initial findings ^ Example of hematoma in the mediastinum
Fig. 7-22, pg.200, Schwartz’s Principles of Surgery 11th Edition Vol. 1
Interventions in the Emergency Department
• Endotracheal intubation • Left-sided hematomas – associated with descending
• Central line placement torn aortas
• Tube thoracostomy – needs a repeat chest radiograph to • Right-sided hematomas – commonly seen with
document the adequacy of the procedure innominate injuries.
• Patient has problem with respiration- intubate patient,
placement of CTT line, or if patient is hypotensive (sign of
tension pneumothorax)-insert CTT tube before X-ray
o Remember: save the life of the patient first before
doing diagnostic workups. In this case, chest tube first
then x-ray later.

Persistent pneumothorax
• Large air leaks after tube thoracostomy or difficulty
ventilating should undergo fiber-optic bronchoscopy
to exclude a tracheobronchial injury or presence of
foreign body

Hemothorax
• Must have chest radiography documenting complete
evacuation of the chest
• If minimal, can be observed and repeat after 6 hours
• If there is blunting of the phosphorenic junction area-is
equivalent to have around 300-400 cc of blood (to be
drained), absence of this or if only minimal: repeat the
x-ray after 6 hrs.
^ Chest Film Findings associated with descending torn aorta
Fig. 7-23, pg. 200, Schwartz’s Principles of Surgery 11th Edition Vol. 1
• Top: associated with descending torn aorta, apical
capping can be seen
• Bottom: descending on the right could be innominate
vessels, tracheal shift

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Findings On Chest Radiograph Suggestive of a Descending
Thoracic Aortic Tear
1. Widened mediastinum
2. Abnormal aortic contour
3. Tracheal shift
4. Nasogastric tube shift
5. Left apical cap
6. Left or Right paraspinal stripe thickening
7. Depression of the left main bronchus
8. Obliteration of the aorticopulmonary window
9. Left pulmonary hilar hematoma
ABDOMEN
^ Algorithm for the evaluation of penetrating abdominal injuries.
Fig. 7-25, pg. 202, Schwartz’s Principles of Surgery 11th Edition Vol. 1
• For unstable patients, bring directly to the operating
room.
• For stable patients, workup in treating abdominal
injuries. It could be gunshot or stab wound, etc.
• For gunshot wounds in the anterior abdomen, bring to
the OR
• For Right upper quadrant of gunshot, more workups, if
the patient is stable CT scan can be done. Locate the
bullet then if positive, proceed to the OR
• For stab wound, if left-sided thoracoabdominal then
you could use DPL (diagnostic peritoneal lavage) or
you could go for laparoscopy. If positive, go to OR. If
negative don’t do surgery.
• Scan the area of injury, if you have in the flank or in the
back, then proceed to CT-Scan.
• For anterior, do your strabotomy (incise with local
anesthesia and explore the wound. If it doesn’t
penetrate down the peritoneal cavity then do not do
surgery. Then if it is positive, wherein it penetrated the
peritoneal cavity then do surgery.
• For stab wound also, if you have evisceration then
bring this patient to surgery.
• Gunshots or shotgun wounds that penetrate the
peritoneal cavity, because over 90% of patients have
significant internal Injuries.
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• Anterior truncal gunshot wounds between the fourth
intercostal space and the pubic symphysis whose
trajectory as determined by radiograph or wound
location indicates peritoneal penetration should
undergo laparotomy.
• Penetrating trauma isolated to the right upper
quadrant; in hemodynamically stable patients with
trajectory confined to the liver by CT scan, if negative
then nonoperative observation may be reasonable.
• In obese patients, if the gunshot wound is thought to
be tangential (so you should know where the point of
entry and exit) through the subcutaneous tissue is, CT
scan can delineate the track and exclude peritoneal
violation.
• Laparoscopy is another good option to assess
peritoneal penetration for tangential wounds. Best
option to rule out any intraabdominal injury.
• Triple- contrast CT scan can delineate the trajectory
of the bullet and identify peritoneal violation or
retroperitoneal entry but may not identify the specific
injuries. This only used sometimes to determine the
trajectory of the bullet.
• Anterior abdominal stab wounds from costal margin to
inguinal ligament and bilateral midaxillary lines.
o Should be explored under local anesthesia in
the ED to determine if the fascia has been
violated (strabotomy). Do not do strabotomy
in the back and the flank because there lots
of muscles but in the abdomen, anteriorly, you
can do strabotomy to trace the stab of the
wound under local anesthesia.
o Up to 50% chance of requiring laparotomy
• Patients with gunshot or stab wounds to the left lower
chest should be evaluated with diagnostic
laparoscopy or DPL to exclude diaphragmatic injury.
But in DPL, you cannot determine diaphragmatic
injury, but in laparoscopic diagnostic, you can identify
and sometimes repair the diaphragmatic into
laparoscopic injury
• Patients with significant close head injury or cannot
be serially examined (e.g., patient that is intoxicated,
cannot be evaluated) DPL should be performed to
exclude bowel injury.
Example of DPL (diagnostic peritoneal lavage). blood and so on, then you can send the patient to the
Fig. 7-29, pg. 205, Schwartz’s Principles of Surgery 11th Edition Vol. 1 OR.
• FAST is used to identify free intraperitoneal fluid in
Morrison’s pouch, the left upper quadrant, and the
pelvis.
• Although this method is exquisitely sensitive for
detecting intraperitoneal fluid of >250 mL. If it is less
than that, it’s no good in identifying the diagnostic
finding.
Example of FAST.
Fig. 7-27, pg. 203, Schwartz’s Principles of Surgery 11th Edition Vol. 1

Positive finding on diagnostic peritoneal lavage -> send the

lavage to the laboratory.

Criteria for “positive” finding on diagnostic peritoneal

lavage
Abdominal Thoracoabdominal
Trauma Stab Wounds
RBC count >100,000/mL >10,000/mL
WBC count >500/mL >500/mL
Amylase level >19 IU/L >19 IU/L
Alkaline
phosphatase >2 IU/L >2 IU/L
level
Bilirubin level >0.01 mg/dL >0.01 mg/dL

• Patients with a DPL with RBC count between 1000/uL

and 10,000/uL, should undergo laparoscopy or
thoracoscopy.
• Diagnostic laparoscopy may be preferred in
patients with a positive chest radiograph (hemothorax
or pneumothorax) or in those who would not tolerate a
DPL.
• Blunt abdominal trauma is evaluated initially by FAST
(Focus Abdominal Sonography for Trauma)
examination in most major trauma centers, and this
has largely supplanted DPL. This is mostly done in
emergency room.
• FAST is not 100% sensitive, however, the diagnostic
peritoneal aspiration is warranted in hemodynamically
unstable patients without a defined source of blood
loss to rule out abdominal hemorrhage. If sometimes
you are not sure, then do DPL. If you have positive

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American Association for the Surgery of Trauma grading have altered mental status, gross hematuria, send
scales for solid organ injuries* this patient for CT scan.
Table 7-7, pg. 204, Schwartz’s Principles of Surgery 11th Edition Vol. 1
Subcapsular PELVIS
Laceration
Hematoma • Blunt injury to the pelvis may produce complex
Liver Injury Grade fractures with major hemorrhage.
Grade I <10% of o The pelvis is protected with lots of bones; a
<1cm in depth
surface area very strong or high density of injury breaking
Grade II 10%-50% of surface the bones would mean a very seriously
1-3 cm injured patient.
area
Grade III 50% of surface area • Plain radiographs will reveal gross abnormalities (of
>3cm the bone), but CT scanning is necessary to determine
or >10cm in depth
the precise geometry (of injury)
Grade IV 25%-75% of a
• CT cystography is performed if the urinalysis
hepatic lobe
findings are positive for RBCs
Grade V >75% of a • Urethral injuries are suspected if examination
hepatic lobe reveals blood at the meatus, scrotal or perineal
Grade VI hematomas, or a high-riding prostate on rectal
Hepatic avulsion
examination.
Splenic Injury Grade • Urethrograms should be obtained for stable patients
Grade I <10% of before placing a Foley catheter to avoid false passage
<1cm in depth and subsequent stricture
surface area
Grade II 10%-50% of surface o To avoid complications, urethrogram should
1-3 cm be done to know the alignment of the penile
area
Grade III 50% of surface area and prostatic urethra down to the bladder
>3cm area
or >10cm in depth
Grade IV >25% • CT angiography should be performed for evaluation
Hilum for thrombosis of either the arteries or veins in the
devascularization
Grade V - Shattered spleen iliofemoral system may occur
- Complete
devascularization
*Memorize this

^ Algorithm for the initial evaluation of a patient with
suspected blunt abdominal trauma.
Fig. 7-26, pg. 203, Schwartz’s Principles of Surgery 11th Edition Vol. 1
• This is mostly done on hemodynamically stable
patients. If there is no peritonitis, they can do FAST. If
there is none positive, then indication for CT. If you
Fig. 7-30, pg. 206, Schwartz’s Principles of Surgery 11th Edition Vol. 1
EXTREMITIES
• Physical examination often identifies arterial injuries
• The findings are classified as either hard signs or
soft signs of vascular injury

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 • Hard signs constitute indications for operative
(emergent) exploration, whereas soft signs are
indications for further testing or observation
• On-table angiography may be useful to localize the
arterial injury
• Most common approach has been to measure SBP
using Doppler ultrasonography and compare the
value for the injured side with that for the uninjured
side, termed the A-A index
• If the difference is >10%, CT angiography or
arteriography is indicated
^ Example of on-table angiography (in operating room) where
there is a cut-off of blood supply in the fracture site. (No distal
extension of the dye observed near the fracture) Fig. 7-31, pg.
207, Schwartz’s Principles of Surgery 11th Edition Vol. 1
• Plain radiographs are used to evaluate fractures,
whereas ligamentous injuries, particularly those of the
knee and shoulder, can be imaged with magnetic
resonance imaging (MRI)
Signs and symptoms of peripheral arterial injury
Soft Signs
Hard Signs
(Further evaluation
(Operation mandatory)
indicated)
Pulsatile hemorrhage Proximity to vasculature
Absent pulses Significant hematoma
Acute ischemia Associated nerve injury
A-A index of <0.9
Thrill or bruit
A-A index = systolic BP on the injured side compared with that
on the uninjured site
GENERAL PRINCIPLES OF MANAGEMENT
• Over the past 25 years there has been a remarkable
change management practices and operative
approach for the injured patient
o It is not the same as 25 years ago, there is shift
to a more non-aggressive type of management
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unless there is an indication for a more
aggressive type of management
• With the advent of CT scanning, nonoperative
management of solid organ injuries replaced routine
exploration.
o Before, exploration is done for findings like in
in cases of Grade III liver injury with no signs
of hypotension and soft abdomen.
o Now, with the more conservative type,
repeat CT scan can be ordered to check if
there is a progression with the injury when
there is no peritonitis and hypotension.
• Patients who require operation are treated with less
radical resection techniques (splenography or partial
nephrectomy)
• Adoption of damage control surgical techniques in
physiologically deranged patients resulted in limited
initial operative time, with definitive injury repair
delayed until after resuscitation in the surgical
intensive care unit (SICU) with physiologic restoration.
o The patient is opened to locate all the
bleeders or clamp all the bowel or spreading
perforations. After closing, send to ICU for
stabilization, blood transfusion, and control
of hypothermia, etc.
o After 24-48 hours, the patient is opened
once again for definitive injury repair.
TRANSFUSION PRACTICES
• Injured patients with life threatening hemorrhage
develop acute coagulopathy of trauma (ACOT).
• The current critical care guidelines indicate that PRBC
transfusion should occur once the patient’s Hgb
level is <7g/dL.
• Point-of-care viscoelastic hemostatic assays (TEG
and ROTEM) have been shown to be superior to
traditional laboratory tests.
o Provide a comprehensive assessment of clot
capacity and fibrinolysis
o Provide useful information within 15 minutes in
contrast to traditional laboratory tests with
requires at least 45 minutes.
• Guidelines are designed to limit transfusion of
immunologically active blood components and
decrease risk of transfusion-associated lung injury
and secondary multiple-organ failure.
o In trauma, only RBC is needed, instead of whole
blood, in order to prevent complications that can
be caused by other blood components.
PROPHYLACTIC MEASURES
• All injured patients undergoing an operation should
receive preoperative antibiotics.
• Extended postoperative antibiotic therapy is
administered only for contaminated open fractures.
• Tetanus prophylaxis is administered to all patients
according to World Health/published guidelines.
• Administration of low molecular weight heparin
(LMWH) is initiated as soon as bleeding has been
controlled and there is stable intracranial pathology.
• Pulsatile compression stockings (also termed
compression devices) are used routinely unless there
is a fracture
o These are stockings to prevent embolism
• A final prophylactic measure that is usually not
considered is thermal protection. ED
• Maintaining comfortable ambient temperature,
covering patients with warm blankets and
administering warmed IV fluids and blood products
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o Even in washing the abdomen we use the warm
water and fluids, NOT HOT
• Additionally, in the OR a Bair Hugger Warmer (the
upper body or lower body blanket)
Used for operating especially in children to prevent
hypothermia
• Heated inhalation via the ventilatory circuit is instituted
• For cases of severe hypothermia (temperature <30OC
[86OF]), arteriovenous rewarming should be considered
OPERATIVE APPROACHES AND EXPOSURE
Cervical Exposure
• Operative exposure for midline structures of the neck
– collar incision
o Unilateral neck exploration is done through an
incision extending from the mastoid down to the
clavicle, along the anterior border of the
sternocleidomastoid muscle