Torso Trauma Flashcards
Junctional zones of the torso
1- between neck and thorax
2- between thorax and abdomen
3- between abdomen and pelvic structures/groin
Zones of the retroperitoneum and management in case of injury
Zone 1- central- always opened
Zone 2- lateral- usually renal injury. Managed conservatively.
Zone 3- pelvic- don’t open. Pack and do angioembolisation
Bleeding sites
Bleeding occurs from 5 sites . 1 on the floor and 4 more.
1- external skin 2- thorax 3- abdomen 4- pelvis 5- long bone fracture
Diagnostic modality of choice in thoracic aorta injuries
CT
Management of sucking chest wound (open pneumothorax)
Covered with plastic . Closed from 3 sides and open from 1. Flutter-type valve. Chest tube placed away from injury with an underwater low pressure (5 cm h20) suction.
Don’t close the wound otherwise it gets converted to tension pneumothorax
6 immediately life threatening injuries of the chest
1- tension pneumothorax 2- open pneumothorax 3- cardiac tamponade 4- massive hemothorax 5- flail chest 6- airway obstruction
Airway intubation is done earliest in
Impending airway oedema
Neck hematoma
Clinical presentation in tension pneumothorax
Lung is collapsed. Decreased air entry. Hyperresonance. Decreased venous entry. Distended neck veins. Mediastinum and trachea displaced to opposite side.
Rx of tension pneumothorax
Immediate decompression by a large bore needle into 2nd intercostal space (midclavicular line)
Later chest tube placed into 5th intercostal space (anterior axillary line)
Investigations in cardiac tamponade
Increased heart shadow on chest x ray.
Cardiac ultrasound showing fluid in pericardial sac.
Emergency Rx of pericardial tamponade
Needle pericardiocentesis.
Risk of injury to heart.
Done under ecg control.
Correct treatment of pericardial tamponade
Operative repair of the heart
Important points in management of open pneumothorax
Don’t use small tube. 28FG or larger should be used.
Place in underwater suction.
Sometimes use of 2nd tube is required.
Massive hemothorax
Compresses lung
Absent breath sounds
Flat neck veins
Dullness to percussion
Indications for open thoracatomy in hemothorax
Drainage of greater than 1500 ml or 200 ml per hour over 3-4 hours
Flail chest
Fracture of 3 or more ribs at 2 or more sites
Can cause pulmonary contusion
Management of flail chest
Oxygen administration
Adequate pain control
Physio therapy
If severe then mechanical ventilation
Thoracic aortic disruption on erect chest x ray
Widened mediastinum
Clinical findings in thoracic aortic disruption
Difference in BP in upper and lower limbs.
Widened pulse pressure.
Chest wall contusion.
Management of thoracic aortic disruption
Endovascular intraaortic stent
Surgical repair
Excision and grafting with Dacron graft
Tracheobronchial injuries
Subcutaneous emphysema with decreased respiratory function.
Bronchoscopy is diagnostic.
Treatment is intubation of the inflated bronchus with operative repair of the damaged bronchus.
Blunt myocardial injury
Early ECG changes.
Echocardiography shows heart wall movement changes.
Risk of arrythmias
Diaphragmatic injuries
any penetrating injury below 5th intercostal space or blunt compressing injury to the abdomen
Herniation of abdominal contents into thorax.
Always repaired via abdominal route.
Oesophageal injury
Emphysema.
Air in retroesophageal space.
Pleural effusion.
Treatment is surgical repair.
Sign of pulmonary contusion
Haemoptysis or blood in the endotracheal tube.
Management same as that of flail chest.
Indications of emergency thoractomy
1- cardiac massage
2- hemothorax from injury to lung or heart
3- hemothorax from injury to any other organ
4- massive air leak
Types of thoracotomy
Emergency department thoracotomy
Planned emergency thoracotomy
EDT not useful if
1- CPR done for more than 5 minutes in the absence of endotracheal tube.
2- CPR done for more than 10 minutes in the presence or absence of endotracheal tube
3- blunt injury and no sign of life
Clamshell incision
Right and left anterolateral thoracotomy incisions if joined
Median sternotomy
Ascending aorta and arch of aorta.
Carina of trachea
Right anterolateral thoracotomy
Oesophagus upper Trachea SVC IVC Azygous veins
Left anterolateral thoracotomy
Oesophagus lower
Thoracic aorta
Origin of the left subclavian artery
Abdominal injury investigations
Hemodynamically normal : all investigations can be completed
Hemodynamically stable: limited
Hemodynamically unstable: perform operative repair first
FAST
Focused abdominal sonar for trauma.
Detects greater than 100 ml blood.
Areas 1- pericardium 2- liver 3- spleen 4- right paracolic gutter 5- left paracolic gutter 6- peritoneal area of pelvis
Diagnostic peritoneal lavage
Gastric tube to empty stomach. Urinary catheter to empty bladder
Cannula below the umbilicus.
Aspiration of greater than 10 ml of blood is positive finding.
1000 ml of ringers lactate given to wash.
100,000 rbcs/uL or 500 wbc/uL are indicative of atleast 20 ml blood in peritoneum
CT
Gold standard.
Especially for retroperitoneal organs
Operative management of liver injuries
4 Ps 1- push 2- Pringle 3- plug 4- pack
Closed suction drainage can be used in hepatic surgery
Spleen injury
Can be packed
Repaired
Placed in mesh bag
Splenectomy can be done.
Selective angioembolisation can be done.
Platelets and white blood cells rise after splenectomy mimicking sepsis
Pancreas
Distal pancreas: closed suction drainage. Or distal pancreatectomy if damage to duct.
Promixal pancreas: managed conservatively. Partial pancreatectomy can be done. Whipples procedure (pancreaticoduodenectomy) done rarely
Stomach injury
Blood in nasogastric tube is diagnostic
Small bowel injury
Resection
Anastomoses
Haematomas at mesenteric border need to be explored to rule out perforation
Rectum injuries
In pelvic fractures.
End colostomy with closure of distal end (hartmans procedure)
Or
Loop colostomy
Renal injury
Managed nonoperatively unless patient is unstable.
Kidney can be angioembolised.
Bladder injury
Extraperitoneal associated with pelvic fracture and can be managed conservatively.
Intraperitoneal needs surgical repair.
Abdominal compartment syndrome
Raised intraabdominal pressure.
If there is risk of ACS. Abdomen should be left open post surgery.
Esp in damage control surgery.
Effects of raised intraabdominal pressure
Decreased GFR Decreased perfusion of organs Decreased CO Splinting of diaphragm Severe rise in intracranial pressure
Damage control surgery
1- stopping active bleeding
2- preventing contamination
Stages of damage control surgery
Stage 1- patient selection Stage 2- control of bleeding and prevention of contamination Stage 3- resuscitation continued in ICU Stage 4- definitive repair Stage 5- abdominal closure
Vacpac or Opsite Sandwich
Temporary closure of abdomen in damage control surgery by 2 layers of plastic and intermediate layer of packing to form a water tight and air tight seal.
Suction is applied to intermediate layer
Definitive surgery
Done within 24-72 hours.
Abdominal closure by closure of the fascia or only by skin closure
Damage control resuscitation
Repeated Point of care testing for hemoglobin. Acidosis. PH and lactate. Thromboelastography for clotting. Early delivery of biologically active fluids like colloids. Clotting factors. Whole blood.
Indications for damage control surgery
Operating time of surgery less than 60 minutes.
Closure of abdomen not possible.
Desire to reassess abdominal contents later on.
Temperature less than 34 degree Celsius
Ph less than 7.2
Lactate greater than 5 mmol/L
PT greater than 16 seconds
PTT greater than 60 seconds
Greater than 10 units of blood transfused.
Systolic Bp below 90 mmHg for greater than an hour.
Complex surgery with trauma to multiple organ systems
Non operative management
Done in solid organ injury
In children
Who are stable hemodynamically
