10. Trauma Management Thoracic and Abdominal Trauma

Question 1

32. Primary and secondary survey when dealing with trauma patients (also when to operate)

Answer 1

-Without excess time-wasting
-primary survey:
1. asses resp and cardiovas systems
2. asses CNS and urinary tract system

-secondary survey:
3. asses all other systems once immediately life-threatening problems (identified during primary survey) are dealt with

-CRITICALLY ILL TRAUMA PATIENT (primary survey)
ABCD= Airways, Breathing, Circulation, Disability (CNS)
>endotracheal intubation
>after primary survey and initial stabilization: medical history, secondary survey
>trauma-associated thoracic injury: blunt thoracic trauma, penetrating thoracic trauma, surgical emergencies after medical stabilization
>assessment
>trauma-associated pulmonary injuries: pulmonary contusion, blebs
>trauma-associated thoracic wall injuries: rib fractures, flail chest, penetrating thoracic injury
>trauma-associated cardiac injuries: cardiac arrhythmias, pericardial effusion
>trauma-associated mediastinal injuries: tracheal avulsion, mainstay bronchial rupture
>pneumothorax
>trauma-associated pleural space injuries: pneumothorax, hemothorax, chylothorax, diaphragmatic hernia, pleural effusion => clear, cloudy, bloody(hemothorax), milky (chylothorax)

Question 2

33. Trauma-associated thoracic injuries

Answer 2

-Blunt thoracic trauma:
>vehicular trauma (most common)
>animal-animal and human-animal interactions
>falls from height
-most managed conservatively (blunt)
-Penetrating thoracic trauma (less common)
>animal-animal interactions
>projectile injuries, impalements
-Surgical emergencies after medical stabilization (penetrating)

Question 3

33. Clinical signs and approach to respiratory compromised patients

Answer 3

-incr. RR and effort
-restlessness
-extended head and neck
-abducted elbows
-paradoxic movement of chest and abdominal walls
-unwillingness to lie down/on one side

> decr. lung sounds > sus.pleural space injury
incr. lung sounds>sus.pulmonary injury

Question 4

35. Pneumothorax, pleural effusion, thoracocentesis

Answer 4

-pneumothorax=air accumulated in pleural space, most common trauma-associated thoracic injury, open/closed-closed common, diagnosis: CE/ausc.>thoracocentesis, radiography, treatment: thoracocentesis, oxygen!, AB (open), thoracotomy tube placement if necessary, surgery (open/recurrent pneumothorax 3-4 days)

-pleural effusion= possible hemo-or chylothorax>hemothorax=blood in pleural space-result:vasculature of chest wall, lungs, mediastinal structures incl.great vessels, diagnosis: CE/ausc.>thoracocentesis only if necessary, radiography contraindicated in clinically significant cases, treatment : thoracocentesis, oxygen
>chylothorax=chyle is composed of lymph and chylomicrons
-thoracocentesis=syringe, 3-way stopcock, IV extension tubing, 19-21 g butterfly needle or 18-22 g needle, sternal recumbency, clip and prepare area, use aseptic technique, insert needle dorsally for pneumothorax, ventrally for effusion, close cranial edge; 9-11th intercostal space on pneumothorax. - hemothorax 5-8 th space, aspirate, effusion:collect fluid for analysis

Question 5

36. Trauma-associated abdominal injuries

Answer 5

-surgery indicated in case:
>septic peritonitis
>penetrating injury
>evidence unremitting intraperitoneal hemorrhage
>any evidence of traumatic body wall hernia that contains herniated abdominal viscera
-all cases through exploratory laboratory necessary
-operation decision: after stabilization / deteriorating patient

1. penetrating injury > exploratory laboratory
2. non-penetrating injury >plain radiograp or abdominal ultrasonography: body wall, pneumoperiotneum, free fluid in peritoneal cavity
3. palpable body wall defect : exploratory laboratory

Question 6

37. Ascites, abdominocentesis

Answer 6

-ascites= abnormal accumulation of fluid (trauma associated: blood/septic exudate/urine/bile/chyle) in peritoneal cavity
-with or without ultrasound guidance
-ultrasound guidance usually preferred option: only confirmed fluid pockets are punctured
-open/closed technique, similar equipment as for thoracocentesis
-fluid always collected and analyzed