PSGS Review on Trauma and

Critical Care

Aireen Patricia M. Madrid

MD
Trauma and Critical Care
 Initial Assessment
Airway with C-spine protection
Breathing and Ventilation
Circulation and Control of hemorrhage
Disability (neurologic status)
Exposure and environmental control
 Trauma Case 1
• 17/M Stab wound to the R chest mid axillary
line below the level of the nipple

• PMHx: (+) asthma

VS HR 90, BP 130/70, RR 25 Temp 37.1

 Primary Survey
• Airway – patent, pt is talking
• Breathing – decreased breath sounds on the R
• Circulation – no active bleeding
• Disability – GCS 15, pupils 3 mm EBRTL, no
lateralizing signs
• Exposure – no other injuries noted
 Secondary survey
• Single stab wound at the 4th ICS R NCL
• Scapular pain
How will you manage this patient?
 ER Management
• CTT done 300 cc of blood evacuated
• Patient complained of persistent scapular pain
Diagnostic Lap
Diagnostic Thoracoscopy
 B.R.
• 15/M
• NOI: Multiple gunshot wound
• POI: Novaliches
• DOI: 4/11/17
• TOI: 3am
• 1 hour post-injury
 Primary survey
• A: patent • Pale palpebral
• B: spontaneous conjunctiva
breathing (RR 26) • (+) tenderness on all
• C: BP 80/40 HR 109 quadrants
• D: GCS13 (E4V4M5) • (+) active bleeding and
• No motor/sensory swelling on site of GSW
deficit entry/exit at right thigh
• Full and equal
peripheral pulses
3 1

2
 Intraoperative findings
Abdomen
• (+) 100cc hemoperitoneum
• (+) through and through laceration at the greater
curvature of stomach, anterior (~2cm) and lesser
curvature of stomach, posterior (~1.5cm)
• (+) 2cm deep laceration, 4cm length at caudate lobe
• (+) 90% transection at neck of pancreas
• Unremarkable spleen, gallbladder, small bowels,
large bowels, bladder
 Intraoperative findings
Thigh
• completely transected superficial femoral
artery and saphenous vein
• Treat the greatest threat to life!
 Penetrating and Blunt
Chest Injuries

• 80-85% of chest injuries • One life-threatening

can be managed with chest injuries are
chest tube alone identified during the
primary survey –
manage them right away
 LETHAL CONDITIONS

TENSION PNEUMOTHORAX

BIG 3
MASSIVE HEMOTHORAX

CARDIAC TAMPONADE
 Tension Pneumothorax MEDIASTINAL
SHIFT

DECREASE VENOUS RETURN

BREATH
SOUNDS END DIASTOLIC
VOLUME

STROKE
TRACHEAL
VOLUME
SHIFT
HYPER
RESONANT CARDIAC
A OUTPUT
HYPOTENSION
 Massive Hemothorax MEDIASTINAL
SHIFT

VENOUS RETURN
DECREASE
BREATH END DIASTOLIC
SOUNDS VOLUME

STROKE
TRACHEAL VOLUME
SHIFT
CARDIAC
OUTPUT
DULL
A HYPOTENSION
+ BLOOD LOSS
Cardiac Tamponade RESTRICTIVE

CARDIAC FILLING

END DIASTOLIC
VOLUME

STROKE VOLUME

HYPOTENSION CARDIAC OUTPUT

 JUGULAR HYPOTENSION
VEINS

TENSION HYPERRESONANT
PNEUMO
+ + ( BS)

MASSIVE HEMO DULL

-/+ + ( BS)

CARDIAC MUFFLED
TAMPONADE
+ + HEART
SOUNDS
 NORMOTENSIVE

CXR

2D-ECHO/SX UTZ

(-) (+)

ADMIT AND MINIMAL MODERATE MASSIVE

TREAT OTHER
INJURIES

(-) SUBX-W (+) THORACOTOMY

 PENETRATING INJURY TO THE CARDIAC ‘BOX’
OR SUSPECTED CARDIAC INJURY

NORMOTENSIVE HYPOTENSIVE TO HYPOTENSIVE

NORMOTENSIVE
CXR

2D-ECHO PERICARDIOCENTESIS

(-)

(+)
ADMIT & TREAT
OTHER INJURIES MINIMAL MODERATE MASSIVE

(-) SUBXIPHOID WINDOW (+)

THORACOTOMY
• A case of a 30 year old
male who came in 1
hour post-injury after
sustaining a single stab
wound on the left lower
chest, anterior axillary • BP 100/60 HR 90 RR 30,
line, seen and sutured afebrile
• Decreased breath sounds on
in another hospital.
the L
• Soft abdomen except on the
stab site
Interpret the CXR
 Case 1
• After the 7th post op
day, the patient
developed fever
• What is your diagnosis?
• How will you manage
this patient?
PENETRATING ABDOMINAL INJURIES
INDICATIONS FOR LAPAROTOMY:

HEMODYNAMIC INSTABILITY ASSOCIATED WITH INTRAABDOMINAL INJURY

OBVIOUS PERITONEAL SIGNS

IMPALED FOREIGN BODY

PNEUMOPERITONEUM ON X-RAY

HERNIATED ABDOMINAL ORGANS

GUNSHOT WOUND WITH EVIDENCE OF INTRAPERITONEAL PENETRATION

BLOOD IN ORIFICES
EQUIVOCAL ABDOMEN:

SERIAL PHYSICAL EXAM

DIAGNOSTIC PERITONEAL LAVAGE

LOCAL WOUND EXPLORATION

ULTRASOUND

CT SCAN

LAPAROSCOPY
 Approach to Abdominal Injuries
• Colon
• Spleen
• Pancreas
• Duodenum
• Liver
 COLONIC GUIDELINES
• NON - DESTRUCTIVE • DESTRUCTIVE
2 cm colonic laceration Complete transection
50 % transection
Thru and thru
95 % transection
 PERITONITIS

-inflammation of the peritoneum or

serosal surfaces as evidenced
by congestion and edema

-presence of fibrinous, purulent, or

fibrino-purulent exudates, and/or
frank abscesses
 COLONIC GUIDELINES
NONDESTRUCTIVE DESTRUCTIVE

PRIMARY REPAIR

NO PERITONITIS
NO PERITONITIS
NO MEDICAL DISEASE

<3 ORGAN SYSTEM

INVOLVEMENT
Spleen
• If its not bleeding, leave
the spleen as is
• If bleeding – pack,
reassess – do
splenectomy if with
persistent bleeding
Liver

34
Direct Pressure/Compress
 Liver
Rumel Tourniquet Balloon Tamponade
 Liver
Lateral Compression Posterior Compression
 Liver
Hepatic Artery Ligation Pringle
• As close to the damaged
lobe as possible
• Temporary ligation is
preferred
• Cholecystectomy performed
if RHA is ligated
 Liver
Total hepatic occlusion Perihepatic paking
 Liver - Hepatorrhaphy
Simple complex
 Liver
Bypass Resectional Debridement
Pancreas
Duodenum
Blunt Abdominal Injury

CT Scan is the ideal

imaging of choice
 Case 2
23/ male DRIVER, with his
seat belt on,
figured in a vehicular
crash and was
brought to the Emergency
Department
1 hour post-injury.
 EMERGENCY ROOM:
BP: 110/70mmHg
HR: 100/min
RR: 20/min
GCS: 15
(+) LOC
Pink palpebral conjunctivae
No neck tenderness
Clear breath sounds, tender left chest
Distinct heart sounds
Abdomen: (+) contusion hematoma on the
right upper quadrant
(+) direct tenderness RUQ

Rectal exam: (-) blood

No gross hematuria
How will you interpret the abdominal
findings?

a. negative

b. equivocal

c. positive
What is/are radiologic test/s appropriate
in this particular patient?

a. Skull x-ray
b. Cervical spine x-ray

c. Chest x-ray
d. Pelvic x-ray
e. CT scan of the head
How will you pursue the equivocal abdominal
findings?

a. Serial Physical Examination

b. Ultrasound
c. Triple contrast CT scan
d. Diagnostic Peritoneal Lavage
e. Exploratory Laparotomy
f. Diagnostic Laparoscopy
In this patient, abdominal ultrasound revealed
moderate amount of fluid on the
Morrison’s pouch and splenorenal
space. What will you do next?

a. Perform DPL
b. Do CT scan
c. Perform outright EL
d. Repeat the ultrasound every hour
In this patient, abdominal CT scan revealed
the following findings:

(+) fluid in the peritoneal cavity

estimated to be around 500 cc
(+) perinephric hematoma, L
(-) extravasation of dye
What will you do, if the patient is still
hemodynamically stable?

a. Perform Exploratory Laparotomy

b. Do Non-operative management
If the patient is managed non-operatively,
how will you monitor the patient?

a. Do serial hemoglobin and hematocrit

b. Repeat CT scan

c. Serial Ultrasound

d. Perform Diagnostic Peritoneal Lavage

While the patient is being observed, the BP
dropped to 70/50 mmHg. He was
resuscitated with crystalloids. BP went
up to 110/80 mmHg. What would you do?

a. Immediate surgery

b. Continue non-operative management

The patient was eventually explored with the
following intra-operative findings:

(+) 2 liters of hemoperitoneum

(+) bleeding stellate liver laceration

segment IV

(+) bleeding splenic laceration

(+) non-expanding perinephric

hematoma, L
If the spleen is still bleeding, how will you
manage the splenic injury?

a. Partial splenectomy

b. Splenic packing

c. Splenorrhaphy

d. Splenectomy
If the patient remains stable, what will you
do with the perinephric hematoma?

a. Explore the retroperitoneal hematoma

b. Leave it alone

c. Do intra-operative IVP

d. Do nephrectomy, L
 The BP suddenly went down to 60 palpatory with
bleeding noted to be coming from the liver
laceration. One should:
a. Do mass suturing of the liver
laceration
b. Place balloon tamponade
c. Do hepatic artery ligation
d. Perform hepatic resection
e. Do perihepatic packing and
close the abdomen
 DAMAGE CONTROL

a deliberate and calculated

surgical approach designed to
maximize a patient’s
physiologic status prior to
definitive repair of
overwhelming injuries
 PHASE I
CONTROL HEMORRHAGE
CONTROL CONTAMINATION
TEMPORARY ABDOMINAL CLOSURE

PHASE II PHASE III

CORE REWARMING PACK REMOVAL
CORRECT COAGULOPATHY DEFINITIVE REPAIRS
MAXIMIZE HEMODYNAMICS
VENTILATORY SUPPORT
INJURY IDENTIFICATION
 RECCOMENDATION

1. DAMAGE CONTROL APPROACH IS A MINDSET.

( FIRST 5- 10 minutes)

2. THE “BEST” SURGICAL AND ANESTHESIA TEAM

AVAILABLE.

3. AVAILABILITY OF CRITICAL CARE TEAM AND UNIT

4. FANCY GADGETS ARE NOT NECESSARY.

5. HAVE A LOW THRESHOLD FOR APPLYING DAMAGE

CONTROL APPROACH. ( < 70 minutes )
• 65/M brought to the ER for a single gunshot wound to the left subcostal
area midaxillary line, 30 minutes post injury with exit wound noted at the
left posterior lumbar area
•  
• VS: BP 80/60 HR 120 RR 28 T 36.5 C
•  
• Conscious, coherent, with cold clammy extremities
• Pale palpebral conjunctivae
• Equal Chest Expansion, clear breath sounds, distinct heart sounds
• Abdomen: Gunshot wound left subcostal area midaxillary line, abdomen
distended with generalized tenderness, point of exit posterior left lumbar
area
• The rest of the PE is unremarkable
 How will you manage at the ER?
ABCDE first!
• FC/NGT
• Extract blood for typing
• Antibiotics, tetanus prophylaxis
• Bring patient to the OR
 What will you do?
• 3 Liters hemoperitoneum
• Gastric perforation greater curve (anterior-posterior)
• 85% disruption of the Ligament of Treitz
• Bleeding adrenal artery
• Rest of the abdominal structures appear normal
• Moderate food contamination of the peritoneal cavity
•  
• Despite transfusion of 4u pRBC and colloids, vital signs are
as follows: BP 90/70, PR 128 Temp 35.8 C
•  
 How to manage pt in the SICU?
• Ventilatory support
• Analgesia
• Antibiotics
• Correct bleeding parameters, electrolytes
• Nutrition
• Correct deficits
• Monitor intraabdominal pressure
 What will you do?
• After 72 hrs. post-operatively, patient is stable,
no signs of infection, all deficits corrected, you
opted for re-exploration. Intraoperative
findings: no active bleeding, gastric repair
intact, 3rd potion of the duodenum is
gangrenous. What will you do?
 PENETRATING INJURIES TO THE BACK

ABDOMINAL P.E.
(-) (+)

DISCHARGE

(-)PE
EXPLORATORY
OBSERVE (+)PE LAPAROTOMY
24HRS
Approach to Specific Injuries
• Carotid artery injuries
• Vertebral artery injuries
• Venous injuries
• Esophageal injuries
• Tracheal injuries
• Combined tracheoesophageal injuries
Carotid artery injuries
• 90% stable enough to undergo arteriography
• Common Carotid artery – most commonly injured in
16 series (compiled by Asensio et al)
• PE findings: Sensitivity = 80%
Specificity = 58%
• Arteriography accurate and useful for exploration,
particularly in Zones I and III
Carotid artery injuries
• Thal et al, 1974
– Classify patients into:
• No deficits
• Mild deficits (weakness of an extremity)
• Severe deficits
– Recommendations:
• No deficits and mild deficits  repair
• Patent carotid with severe deficits  repair
• Occluded carotid with severe deficits  ligation
Carotid artery injuries
• Bradley, 1973: no revascularization in patients with
severe deficits
• Liekweg and Greenfield, 1978 (n=200)
– Repair had better outcome in patients not in coma but
poor in patients with coma
• Unger et al, 1980 (n=722)
– 34% of pateints with severe deficits improved with repair
– 0nly 14% of patients with severe deficits improved with
ligation
Carotid artery injuries
• Asensio et al, 1991, (n=433)
– Recommended repair for all, except in those with
profound coma with bilateral fixed dilated pupils
• Time from injury may be crucial
– Clearly those with mild or no deficits would benefit from
repair; and those with profound coma will not
– Those with severe deficit and delayed management (>6
hours)  repair?
Esophageal injuries
• Treated with primary repair and drainage
• 10-20% are expected to leak; 50% of them are
asymptomatic (work-up after 7 days is
advised)
• All fistulas will close with adequate support
and time
Tracheal injuries
• Need for airway access is assessed during the
primary survey
• Primary repair usually will suffice; need for a
tracheostomy one ring below the repair is
controversial
• Conversion of cricothyroidotomy into a
tracheostomy during the neck exploration is
controversial
Summary
• Penetrating neck injuries may be managed via selective or
mandatory exploration.
• Emergent operation is dictated by physical findings.
• Zonal classification may aid in management considerations;
Additional expertise (NSS, TCVS) may be essential in injuries
to Zone I or III
• Although varied in definition in different institutiions,“hard
signs” mandate emergent operations; while “soft signs”
mandate expeditious work-up to rule-out injuries
QUESTIONS?
09399186395