ACCIDENTS AND TRAUMA

ACCIDENTS AND TRAUMA
د. كريم الأعرجي
Learning objectives Lect. 1-4
After completion of this subjects the students will be able to know :
• How to deal with different types of trauma .
• The principles of ATLS .
• How to resuscitate polytraumatised patient .
• How to do ‘ triage ‘ mass causality .
• How to deal with polytraumatised patient during the Primary , Secondary Survey and the definitive care .
• How to investigate a multiply injured patient .
Introduction Trauma is the commonest cause of death in patients up to 45 years and is responsible for 61% of deaths in the 15-24 year age group. Road traffic accidents (RTAs) are the greatest source of multiple trauma patients. Types : 1 . Blunt : without wound . 11. Penetrating : ( wound ) which is of two subtypes : Low velocity : (100 - 500 m/s) and low energy (10-100 J) & High velocity (750-1000 m/s) and high energy (2-3 kJ) ( eg : Gunshot and blast wounds) . Both of them may result from sharp objects ,bullets ,fragment injuries and blast ( Explosion) which includes Burn , Shells and Fragments, Throwing and other trauma & Negative pressure : Ruptured ear drum , lungs etc. . Pathophysiology 1. Primary damage : It occurs during transfer of the object within the body which depends upon the amount of kinetic energy transferred to the tissues(mv2/2 ), presenting area of fragment or bullet & mechanical properties of tissue . It may cause direct damage limited to the tract in low velocity missiles or indirect damage in high velocity missiles due to shock wave and cavitation . Cavitation : Temporary instantaneous negative pressure within cavity at site of entrance of a bullet which will suck in environmental contaminants and lead to infection Shock wave :contusions and lacerations away from tract of the bullet so there may be small entry and exit wounds but large wound cavity and the injury may occur outside the limit of the tract This damage is unavoidable . 2 . Secondary damage : It occurs later , preventable and produced by the following preventable factors
1. .Hypoxia is due to chest wall, lung or diaphragmatic injury ,spinal cord injury affecting phrenic nerves or intercostal muscles ,central nervous system (CNS) depression , airway obstruction . It causes hypoxaemia , hypercapnin with acidosis and impaired cellular metabolism
2. Shock : Inadequate organ perfusion and tissue oxygenation . In trauma there are multiple types of shock : 1.Hypovolemic due to blood loss 2. Non –hypovolaemi :Cardiogenic , Neurogenic ,Septic , Tension pneumothorax due to mediastinal shift .
3. Neurohumoral responses The body attempts to maintain tissue perfusion, assist wound repair and support organ function. Release of catecholamines, and adrenocorticotrophic hormone (ACTH) secretion mediated by the hypothalamus ,Cortisol levels rise and there is a dramatic increase in glycogenolysis, gluconeogenesis, lipolysis and proteolysis. These events are also promoted by the increased release of growth hormone and glucagon and decrease of insulin secretion . Antidiuretic hormone is released from the posterior pituitary under the influence of plasma osmolality, the hypothalamus and atrial stretch receptors. The effect is the increased reabsorption of water in the distal tubular system of the kidney.
Causes of trauma deaths : Causes have a trimodal distribution according to the time limit of trauma
The first peak ( Immediate ) 50%occurs at the time of the injury, usually due to severe lacerations of the brain, heart or large blood vessels, and the patient is usually dead before arrival at casualty. Prevention by methods such as seat belts, crash helmets and speed limits is the only effective way of reducing these deaths.
The second peak (Early) occurs within minutes to hours of the injury. Injuries such as a tension pneumothorax, blood loss and intracranial bleeds account for this peak. These deaths are potentially reversible with immediate medical management.
The third peak ( Late ) (20% ) occurs several days to weeks after the incident, due to sepsis and multiorgan failure. The care provided during the initial resuscitation and subsequent period directly affects the outcome of this group.
What you should do in the management of trauma ?
In case of a multiply injured patient with trauma to the head, chest, abdomen and limbs. One should plan where to start , what to do ? if there were several injured patients, which would take priority? The Advanced Trauma and Life Support (ATLS ) course was developed following a tragedy. In 1976 an orthopaedic surgeon who was piloting his own plane crashed in a cornfield. His wife died instantly and three of his four children sustained critical injuries. They were taken to the nearest medical facility, the surgeon was appalled at the poor quality of care that he and his family received and felt that a system was needed to improve the care of trauma patients. That is ATLS which includes :
I. Primary Survey
1. Evaluation and Resuscitation of life threatening problems ( ABCDE ) The primary survey is a short history & a rapid evaluation; the mnemonic .
A. Airway with cervical spine control
B. Breathing and ventilation
C. Circulation with haemorrhage control
D. Disability
E. completely undress the patient and assess for other injuries
2. Adjuncts to primary survey
A. Monitoring : ECG strip , PR,BP, Pulse oximetry , Temp. .
B. Blood – FBC, urea and electrolytes, clotting screen, glucose, toxicology, cross-match
C. Two wide-bore cannulas ( 14-16 G ) for intravenous fluids
D. Urinary and gastric catheters : Care should be taken when passing gastric catheters nasally in the presence of maxillofacial injury or suspected base of skull fracture with fracture of the cribriform plate as NG tube may pass to the brain . If urethral injury is suspected, as in the case of pelvic diastasis, one should obtain an emergency room urethrogram prior to catheterization. Rectal and external genital examination is necessary before catheterization to rule out serious retroperitoneal injury. Signs include blood at the meatus, scrotal or labial ecchymosis and a high riding prostate in males
E. X-rays ( Trauma films ) : Shoot lat. C-spine , CXR, Pelvis .

Other more specialized forms of imaging, such as ultrasound ( FAST ) , computerized tomography, angiography and diagnostic peritoneal are done later in secondary survey .
Notes : Same priorities for pediatric patient, pregnant and elderly with special
consideration Pediatric : Large head relative to the body
Pregnant : Increased blood volume
Elderly : Poor compensatory mechanism
Triage : Sorting out cases according to priorities or capabilities .
In trauma, two types of triage situation usually exist:
1 Multiple casualties. Here, the number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life-threatening injuries followed by those with polytrauma.
2 Mass casualties. The number and severity of the injuries exceed the capability and facilities available to the staff. In this situation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritized . Overall triage includes :
A. 1. Immediate urgent Life Threatening Problems ( 2-4 hrs. )
B. II.Delayed ( safely beyond 4 hrs. ) .
C. III. Expectant ( uasavagable so care is given to less severe injuries )
D. IV. Dead
II. Secondary Survey : identification all other injuries . It includes :
1. History : AMPLE
2. Subsequent physical examination :Examine each region of the body for signs of injury, bony instability and tenderness to palpation ( Head to Toe Examination )
A. Head and face
B. Neck
C. Chest.
D. Neurological ( GSC )
E. Abdomen and pelvis.
F. Extremities.
G. Log roll. to inspect the back . At least four people are required for a safe log roll procedure: one for the spinal in-line traction, one for the torso and one for the pelvis and lower limbs (which ideally should be strapped together). The fourth person removes the spinal board and performs a detailed
assessment of the back
3. Re-evaluation of vital signs , monitoring , Pulse oximetry & urinary output. In the adult, an output of 0.5 ml kg–1h–1 should be adequate, whereas in the paediatric patient, one should expect twice this rate.
4. Analgesia I.V
5. Documentation and legal considerations
6. Special procedures, Specific X-rays and laboratory studies
III. Definitive care and transfer ( Tertiary survey ) : Definitive management plan , Home ,ICU.,HDU,OR or Transfer according to available facility and patient’s condition .
The concept behind ATLS is to treat life-threatening injuries first and all other injuries in order of priority, and since a blocked airway kills within seconds this clearly should have first priority; likewise, a tension pneumothorax will kill before bleeding from a wound.
Evaluation of Airway with Cervical Spine Control
Cervical spine fracture should be suspected clinically , high index of suspicion , In anyone with an altered level of consciousness or injuries above the clavicles . The patient’s head should be supported by a hand on either side to prevent any movement (in-line manual immobilisation), and when possible a semirigid collar should be applied with two sandbags on either side of the head with tape across them to hold them in place.
Airway assessment :
1. Check verbal response
2. Clear mouth and airway with large-bore sucker
3. If GCS _8, consider a definitive airway ie: Endotracheal intubation ; otherwise use jaw
thrust or chin lift
The airway should be checked to see if it is patent or if there are signs of airway obstruction. Listen for noisy breathing, look for obvious facial trauma, and inspect for foreign bodies in the mouth such as teeth or denture .
Evaluation of Breathing
Assess the respiratory function by listening of air during exhalation. Inspect and palpate for tracheal deviation, expansion of the lungs and for any lacerations, rib fractures or flail segments. A flail chest is a segment of the chest wall that, owing to multiple fractures, has no bony continuity with the rest of the thoracic cage. The flail segment moves paradoxically with the rest of the chest (i.e. it moves in on inspiration and out on expiration).The hypoxia that results is usually not due to the flail segment alone but more to the underlying contusion to the lung and hence mismatches between ventilation and perfusion.
Evaluation of Circulation with Haemorrhage Control
The assessment and warning signs are :
1. Deteriorating conscious state
2. Pallor
3. Rapid thready pulse is a more reliable and earlier warning sign than a fall in blood pressure
Assess the level of consciousness, pallor , pulse, blood pressure, respiratory rate, skin colour and capillary refill time .Hypotension following injury must be assumed to be due to hypovolaemia not due to head injuries until proved otherwise.
During the primary survey any external severe bleeding points should be controlled by applying a sterile pressure dressing or a pneumatic splint. Tourniquets are usually avoided, as they cause crush injuries and distal ischaemia.
Internal bleeding should be suspected and the common causes are an intrathoracic or intraabdominal bleed or a fractured pelvis and/or femur. A bleeding into the cranial cavity will by itself not cause hypovolaemia.
Note : P.R., BP has little correlation with blood loss in older patients .Children show few signs of hypovolemia .Medications affect the response to hypovolemia as B-Blockers
Disability

Primary survey
D :Disability : Rapid assessment of the patient’s level of consciousness, the pupil size and response to light. The mnemonic ( AVPU ) is used as a quick assessment of the patient’s level of consciousness.
A — Alert
V — responds to Verbal stimuli
P — responds to Painful stimuli
U — Unresponsive
The Glasgow Coma Score (GCS) is a more detailed neurological evaluation and it takes a little longer time . A decreased level of consciousness may be due to cerebral injury, hypoxia and shock or secondary to alcohol and drugs, although in head injury, hypoxia and shock must be excluded first.
Exposure
Completely undress the patient (cut off the clothes as appropriate), inspect the entire skin surface for evidence of injury, such as bruising, abrasions or lacerations. A log roll should be performed with in-line cervical spine immobilisation (i.e. the head is supported and turned in line with the patient to prevent any displacement of the cervical spine). The entire vertebral column is palpated down to the coccyx for tenderness and a rectal examination is performed.
During the primary survey a series of X-rays are taken, called the ‘Trauma Series’, which include a lateral C-spine, chest and pelvic X-rays in addition to FAST( Focused Abdominal ultra-Sound of Trauma ) . The patient is usually put on monitor for ECG strip , PR and BP
A nasogastric tube should be considered (note: contraindicated if a cribriform plate fracture is suspected as the tube could enter the cranial vault and an orogastric tube may be used instead) and urinary catheter should also be considered (note: during the rectal examination, a high riding
prostate or any sharp bony pelvic fragments might indicate a urethral transection which would mean trans-urethral catheterisation is contraindicated). Other signs to suggest a urethral injury: blood at the urethral meatus or a scrotal haematoma. If a urethral transection is suspected
then a retrograde urethrogram can be performed and a supra-pubic catheter might be needed.
RESUSCITATION
Airway
Every injured patient with multiple trauma should receive supplemental oxygen; however, the
airway must be patent and protected in all patients. There are five things you can do to ensure a patent airway; always start with simple measures, such as the chin lift, and progress through the following list until oxygenation is adequate. Apply an oxygen mask with a reservoir (to allow
about 85% oxygen).
1. Chin lift or jaw thrust. In the supine position the tongue naturally falls back, obstructing the hypopharynx. These procedures bring the tongue forward, opening up the airway. In the chin lift the chin is grasped between the first finger and the thumb. The chin is then lifted gently and brought anteriorly (being careful not to hyperextend the neck). In jaw thrust manoeuvre the angles of the mandible are grasped by hand on each side and the lower jaw is brought forward.
2. Guedel airway. If breathing is still noisy, you can maintain the airway by inserting an oropharyngeal airway, such as a Guedel airway (an S-shaped plastic tube). The size should correspond to the distance from the centre of the patient’s mouth to the angle of the jaw. It is sometimes put in upside down and rotated when it is past the tongue.
3. Nasopharyngeal tube. If the patient is conscious and has a gag reflex, they will be unlikely to tolerate an oropharyngeal airway. In this case a nasopharyngeal airway can be tried, as it is better tolerated and less likely to induce vomiting, although many conscious patients will not tolerate either and may need to be anaesthetised and intubated.
4. Intubation. This is called a definitive airway, which means a tube is inserted into the trachea with a cuff inflated to prevent aspiration; the whole thing is secured with tape and oxygen is connected. A definitive airway can be an orotracheal tube, a nasotracheal tube or a surgical airway. A definitive airway is needed if the patient is not breathing, or is unable to maintain an airway with the above measures, or if there is impending airway compromise (as in inhalation injuries) or in a head injury requiring hyperventilation. Since CO2 is produced in the lungs you can confirm that the tube is in the trachea by measuring the end tidal CO2 tension. If the tube was mistakenly placed into the oesophagus then the CO2 gas pattern would be absent. Proper placement of the tube is also checked by listening for bilateral air entry (i.e. if the tube is in the
right main bronchus, then no air entry will be heard on the left).
5. Surgical airway. If you are unable to intubate (for example, in severe facial trauma) then a surgical airway is indicated. A tracheostomy is difficult to perform and is time-consuming, and so a needle cricothyroidotomy can be performed [a large-caliber cannula is inserted through
the cricothyroid membrane into the trachea (feel for Adam’s apple, and move your finger downwards till you come to the first gap between the thyroid and cricoid cartilages)]. Oxygen is then connected to the airway.
A needle cricothyroidotomy will only buy a short amount of time and must be converted to a surgical cricothyroidotomy by widening the incision and placing a cuffed endotracheal tube into
the space between the thyroid and cricoid cartilages (tracheostomy is placed into the trachea at about the level of the second or third tracheal ring and is a much longer procedure as the thyroid gland has to be divided and is therefore performed in theatre when the patient is stable).
Breathing
The mnemonic ‘ATOMIC’ has been used to list life-threatening chest injuries, which should be identified in the primary survey:
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax (greater than 1500 ml)
Intercostal disruption (‘Flail chest’)
Cardiac tamponade
Resuscitation of breathing
1. Give 100% oxygen at high flow
2. Check for tension pneumothorax
3. Decompress at once if tension pneumothorax is suspected
(needle in the second intercostal space)
A tension pneumothorax occurs when air enters the pleural space either from outside or from inside the lung. A one-way valve is formed by the pleura, which allows air to enter the pleural space during inspiration, but does not allow it to escape during expiration. The lung collapses, and the mediastinum and the trachea are deviated away from the affected side. The patient becomes very short of breath and cyanotic. The venous return to the heart is impaired and the signs are similar to those of cardiac tamponade (i.e. raised JVP and falling BP, but they can be differentiated by listening for breath sounds). The diagnosis is made clinically — a distressed,
tachycardic patient with a deviated trachea, hyper-resonance to percussion and absent breath sounds on the affected side. You should never see a chest X-ray on patients with a tension pneumothorax, as they should have been treated immediately before waiting for an X-ray to be taken. Treatment is by placing a cannula (venflon) into the second intercostal space, midclavicular line, and hearing a hiss as the air escapes. Once this is performed the tension pneumothorax will be converted to a simple pneumothorax and the immediate threat to life is over. A chest drain should be inserted as soon as possible.
Insertion of a Chest Drain
A chest drain is inserted under aseptic technique anterior to the midaxillary line, in the fifth intercostal space. If possible (provided no cervical spine injury is suspected) the patient is sat up at 45 and the hand is placed behind their neck on the affected side to expose the field and open
up the intercostal space. If sitting up is not possible, then the procedure should be performed
with the patient supine and again the arm on the affected side is placed behind the patient’s neck. The area is prepared with antiseptic (e.g. betadine) and draped. Local anaesthetic is infiltrated into the skin, subcutaneous tissues and down to the pleura. A 2 cm transverse incision is made in
the fifth intercostal space (aiming above the rib as the intercostal bundle sits in the groove just below the rib). Blunt dissection is then performed down to the pleura with a pair of forceps which then are pushed through the pleura into the pleural space. A finger is placed in the hole and swept around to free any adhesions and create the space for the tube. A chest drain is inserted using a pair of forceps, usually French gauge 24–28 (if a haemopneumothorax exists a
larger tube size, Fr. 38, is usually used). The drain is fixed with a stitch and a purse-string or mattress suture is placed in the wound (to allow it to be closed when the drain is removed). The chest drain is connected to an underwater seal (this allows air to escape during expiration, but no air to enter on inspiration). Ensure that the underwater seal is below the level of the patient, otherwise the water will enter the chest. Re-X-ray the patient after the procedure to ensure correct positioning of the tube. If you are ever asked how you can check if a chest drain is blocked, a top tip is to ask the patient to cough and you will see bubbles escaping if it is patent and no bubbles if it is blocked.
In an open pneumothorax, if the opening is approximately two-thirds of the diameter of the trachea, then air passes through the wound in preference to the airway during inspiration (taking the route of least resistance). This is also called a ‘sucking chest wound’. The management is to close the wound with a sterile dressing taped on three sides to form a flap valve.
Circulation
Two large-bore cannulae (14 -16G) should be inserted, one into each antecubital fossa of all patients exposed to major trauma . Other routes include cut down of the long saphenous vein and interosseous canula in a child below 6 years . Central line is a good for monitoring for fluid but inefficient for IV fluid . Blood should be taken for a cross-match, a full blood count and urea and electrolytes. The ATLS® system recommends starting two liters of crystalloid fluids
as the initial resuscitation for every major trauma patient. The response to volume expansion is monitored by the same signs and symptoms that are used to diagnose it. The urine output is the best indicator of the adequacy of resuscitation.
There are three types of response to the initial fluid resuscitation:
1. Rapid response. Here, the patients respond rapidly to the fluids and remain haemodynamically stable once the fluids are stopped or slowed. These patients have usually lost minimal blood volume (_20%) and can be observed but do not necessarily need any further intravenous fluids.
2. Transient response. There is an initial response with a rise in the blood pressure and a fall in the pulse rate; however, as the fluids are slowed down, the indices used to measure shock start to deteriorate again, indicating that the blood loss is ongoing or resuscitation has been inadequate.
The response to the fluid will indicate those patients who are still slowly bleeding .
3. No response. This could be exsanguinating haemorrhage and blood is needed rapidly. Type-specific blood (where the ABO and Rhesus groups are compatible, but there may be some minor antibodies that are incompatible) takes about 10 min to process and should be given initially in life-threatening bleeding whilst waiting for the full cross match, which may take as long as 40 min. As a last resort, Group O negative blood can be given, which is the universal donor.
Failure to respond to the fluid resuscitation and the blood indicate the need for immediate surgical intervention to control the haemorrhage (‘turn off the tap’). Less commonly, a failure of response may be due to the fact that there is a nonhaemorrhagic cause for the shock, such as myocardial contusion or tamponade, and a CVP measurement may help differentiate the causes. If blood is given (usually packed red cells without plasma) it should be warmed to prevent hypothermia and, after a large transfusion, platelets and fresh frozen plasma may be needed to correct the lack of clotting factors. The main aim of transfusion is to correct the oxygen-carrying capacity, since crystalloids and colloids can both correct the lack of intravascular volume but have no oxygen-carrying capacity
Recognise the signs of shock, and look for a cause. The chest, abdomen and pelvis are the likely causes if there is no obvious haemorrhage from a wound. A bleeding into the abdomen causes distension and signs on examination, such as tenderness, guarding and perhaps absent bowel sounds. If intraperitoneal bleeding is suspected (say, in a stab wound) and the patient is shocked despite immediate resuscitation, then no time should be wasted and the patient should be taken straight to theatre for a laparotomy to ‘turn off the tap’. If the findings on examination are equivocal and the patient is not unstable, then a diagnostic peritoneal lavage (DPL), ultrasound or CT scan can be performed .



Lect. 3 Revised trauma score (RTS) :systolic blood pressure, the respiratory rate, and the Glasgow Coma Scale, with each value being separately weighted. The RTS ranges from 0 (dead) to 7.84 (normal).
Diagnostic Peritoneal Lavage
This involves an incision in the midline, below the umbilicus, and dissection down to the peritoneum, into which a catheter is placed. A litre of normal saline is run into the peritoneal cavity. The bag is then placed on the floor and allowed to fill. If there is no obvious blood, then
a sample of fluid is sent for microscopy to count the red blood cells. A urinary catheter and nasogastric tube must be inserted prior to the DPL in order to avoid damage to the stomach and bladder during the procedure. The findings of this procedure, however, are often equivocal.
An unstable fractured pelvis can cause profuse blood loss and stage IV shock. The cause is usually venous bleeding. During the primary survey the chest and abdomen will have been examined to look for other causes of the shock. An orthopaedic surgeon can place an external fixator onto the pelvis, and this usually stops the rapid blood loss (by tamponade, and
also stops any shearing forces on the vessels).
Disability ( GCS ) : Assessment of head injury .
Exposure/Environment
The patient is completely exposed so that a full examination can be performed. In order to protect them from heat loss, both the patient and the resuscitation room should be heated. Methods for heating the patient include the use of warmed fluids and blood and the use of blankets. A log roll may be performed here or it may be performed in the secondary survey. In this procedure one person holds and turns the head and neck and three people roll the body. This allows the patient to be turned with in-line cervical spine immobilisation to examine the back of the body for any signs of trauma (stab wounds, bruising, abrasions), palpating for any tenderness, and a rectal examination is performed.
Secondary Survey
A quick history should be ascertained, from witnesses, family or the ambulance men. The mnemonic AMPLE is used for the following vital questions:
Allergies
Medication including tetanus status
Past medical history
Last ate or drank
Events prior to the accident
The secondary survey is the head-to-toe or full examination. Check the head (eyes, ears, scalp — run your fingers through the hair), cervical spine, chest, abdomen, limbs and perform a full neurological examination.
If the log roll has not been performed in the primary survey, it should be performed here. At the end of the secondary survey the patient should be re-evaluated by starting again at the ABCs. Once you are sure they are fully stabilised you can begin to make arrangements for definitive care (this usually means an admission).
Cervical Spine — X-Rays and Management
A cervical spine injury is almost always accompanied by pain in the neck; however, it is important to know that the absence of a neurological deficit does not rule out a fracture of the cervical spine. Under A for ‘airway’ with cervical spine control, the neck should be immobilised and a lateral ‘shoot through’ X-ray should be taken. If a motorcycle helmet needs to be removed or intubation is required, these should be performed with in-line manual immobilisation.
Treatment of gunshot wounds has involved.
1. Wound debridement (Wound excision) which means excision of grossly & potentially damaged tissues around the tract and left wound open .
2. Antibiotic prophylaxis
3. Dressing change , re-excision and delayed primary suture at 5 days
4. Approach may be modified in civilian environment
Abdominal trauma Surgical Abdomen : History of abdominal injury may be suggestive from the mechanism of injury e.g. penetrating wound , presence of abdominal complaint , haemodynamic instability and examination findings of signs of peritoneal irritation .
? In blunt trauma spleen and liver are the most commonly involved organs
? pain, tenderness, and guarding in the neurologically intact patient and in those patients with obvious injury and hemodynamic instability. If the patient has an altered level of consciousness due to head injury or due to alcohol or has painful injuries elsewhere, especially to the thorax or pelvis, a physical examination alone is unreliable. In these patients, a more objective means of making a diagnosis is required such as diagnostic peritoneal lavage .
Clinical abdominal examination is frequently unreliable especially in patients who:
• have an altered conscious level .
• have a spinal injury (rendering the abdomen insensitive)
• are intoxicated with alcohol or other agents.
Investigations in abdominal trauma 1. Plain abdominal x-ray : Nonspecfic such as rib fractures with ruptured spleen . 2.Abdominal CT : Diagnostic but need a stable patient :It may show free peritoneal fluid , Damaged organs . 3. US : useful : free fluid 4 . Diagnostic Peritoneal Lavage : Less popular used in unstable pt. with altered consciousness , equivocal clinical findings or when the pt. is being anesthetized for other procedures 5 .Frank haematuria requires imaging of the renal tract, either by single shot intravenous pyelogram (IVP) or USS in the Resuscitation Room, or, in a stable patient, CT scan with contrast. Blood is commonly detected in the urine of the major trauma patient but does not require specific investigation unless frank haematuria occurs or if the test is persistently positive. 5 . Angiography may be needed in stable patient .
Technique of Diagnostic peitoneal lavage ( DPL )
After the insertion of gastric and bladder catheters, DPL can be performed by using a closed trocar method or by using an open minilaparotomy technique. A catheter is inserted into the peritoneal space, from which aspiration of blood is attempted. If no blood is found, 1 L of warmed isotonic sodium chloride solution (or Ringer lactate) is run into the peritoneal cavity and out. The DPL result is positive when an initial aspiration yields more than 10 mL of fresh blood, 100000 RBCs/mm3 are observed, or when more than 500 WBCs/mm3 observed , bile or bacteria.
Indications of Laparotomy
1. Unexplained shock i.e. ; hypotension or failure of response to fluid therapy
2. Rigid silent abdomen i.e. peritonitis
3. Evisceration
4. Radiological CT , US, DPL and evidence of intraperitoneal gas
5. Radiological evidence of ruptured diaphragm
6. Gunshot wounds
7. Positive result on diagnostic peritoneal lavage : 100000RBCs/mm3 are observed, or when more than 500 WBCs/mm3 observed .
8. Penetrating trauma with substantial bleeding and/ or hypotension
Damage Control Surgery :Following multiple trauma poor outcome is seen in those with Hypothermia , Coagulopathy & Severe acidosis . Prolonged surgery in these pt. can exacerbate these factors so the concept of damage control surgery has been developed . Indications : Damage control surgery should be considered if a patient with multiple trauma has 1.Injury severity score greater than 25 2 .Core temperature less than 34 degree 3 .Arterial gas pH less than 7.1 Principles of Damage Control Surgery : 1 .Initial operation which includes :
Early management of major abdominal trauma . Surgery should aim to:
1. Control haemorrhage with ligation of vessels and packing
2. Remove dead tissue
3. Control contamination with clamps and stapling devices
4. Lavage the abdominal cavity
5. Close the abdomen without tension A plastic sheet or Bogot? bag may be useful
11 .Intensive care unit
Early surgery should be followed by a period of stabilisation on the intensive care unit
During this period the following should be addressed
1. Rewarming
2. Ventilation
3. Restoration of perfusion
4. Correction of deranged biochemistry
5. Commence enteral or parenteral nutrition
111 . Second look laparotomy
Planned re-laparotomy at 24 - 48 hours allows:
1. Removal of packs
2. Removal of dead tissue
3. Definitive treatment of injuries
4. Restoration of intestinal continuity
5. Closure of musculofacial layers of abdominal wall
This approach has been shown to be associated with a reduced mortality
VARIOUS TYPES OFB ABDOMINAL INJURIES
? Liver : Types :Tear ,through and through , severe laceration or hepatic haematoma .
? CF: Bleeding , acute abdomen , shock
? Treatment : Suturing , resection, packing .
? Pringle maneuver :To hold portal vein and hepatic A. between index finger and the thumb at the foramen of Winslow to control bleeding of liver injury during operation .
SMALL BOWEL : Single or multiple perforation or complete transection . CF : Peritonitis Treatment : 1.Closer of perforation . 2.Multiple nearby perforations : Resection with end to end anastomosis
Mesentery : Either radial tear or longitudinal . CF : Hypovolaemia or peritoneal irritation . X-ray may show intraperitoneal air Treatment : In radial tear there is no danger of bowel viability and it can be closed safely . Longitudinal tear may interfere with blood supply if it is long enough and in this case resection of small bowel may be needed .
LARGE BOWEL Right side of the colon is treated in the same way as the small intestine i.e. : resection by right hemicolectomy with immediate anastomosis . Left colon is usually treated by exteriorization as colostomy or closure with proximal protective colostomy and recently it can be resected with primary anastomosis .
Transfer to another hospital if certain specialities are not available. When organising the transfer of a multiple trauma patient, ensure the patient is in a stable condition
1. Communicate directly with the receiving doctor
2. Give a letter : detailed history, clinical findings and interventions done
3. Establish exactly where the patient is to be transported to in the receiving hospital
4. Identify and fully brief an experienced doctor and nurse who will accompany the patient.
5. Provide a detailed letter addressed to the receiving doctor by name, with results of tests
6. All X-rays should accompany the patient
7. Don’t forget medicolegal issue .
8. Any cross-matched blood should be sent with the patient
9. Good IV access (two lines )
10. A urinary catheter in situ
11. Chest drains are well secured
12. NG or OG tubes are in place.
References :
1. Trauma, Shock, Head Injuries and Burns ;SURGICAL TALK - Revision in Surgery ( 2nd Edition)
2. Bailey and Love’s , Short practice of surgery ; 25th Edition .