Trauma 1Absite Review: Primary Survey, Secondary Survey, and Abdominal Trauma

Primary Survey

A - Airway (with cervical spine control)

B - Breathing

C - Circulation (with hemorrhage control)

D - Disability (neurologic assessment)

E - Exposure (with environmental control)

Primary Survey

How do you evaluate the patient in the first 10 seconds?

Airway

Look, listen, verify speaking; Hoarseness and stridor are audible signs of impending airway loss

Endotracheal intubation if unable to protect airway

Surgical airway via cricothyrotomy in the event that a translaryngeal tube cannot be safely and expeditiously inserted

Breathing

Look, listen, feel for crepitus, trachea midline

Auscultation through the chest wall of the axilla is the most reliable way to verify ventilation of peripheral lung

Clinical suspicion of a tension pneumothorax is sufficient justification to decompress the thorax before chest radiography

Breathing

Circulation

STOPthe

Bleeding!

Circulation

External bleeding should be controlled with direct pressure and/or a tourniquet

The assessment of circulation relies on the palpation of carotid, femoral, and radial pulses

The carotid pulse is the last to be lost, disappearing when the systolic pressure falls below 60 mm Hg

Initial support typically consists of IV infusion via two peripheral intravenous cannulas, size 16-gauge or larger 

Resuscitation

Resuscitation target is often a systolic pressure of 90 mm Hg and definitive control of any site of hemorrhage.

Begin resuscitate with crystalloid.

If fluids beyond 2 L are necessary, blood products should be used.

Adequately resuscitated patients should make 0.5 to 1 mL/kg/h of urine

Spinal cord injury can require both a vasoconstrictor and a cardiac accelerator to overcome the traumatic sympathectomy and thereby augment blood pressure

Disability

Determine level of consciousness and any lateralizing signs: determine the Glasgow coma score and inspection of the pupils 

Unresponsive patient with a Glasgow coma score of less than 9 should have the airway secured 

Asymmetric pupils=neurosurgical emergency; immediate neurosurgical consultation and intervention is necessary, treatment with osmotic diuretics or hypertonic saline solution should be initiated, and plans should be made for immediate CT scan to define the lesion

Glasgow Coma Score

Eye Opening

Verbal Response

Motor Response

4 = opens spontaneou

sly

5 = oriented 6 = moves spontaneously

3 = opens to voice

4 = confused 5 = localizes pain

2 = opens to pain

3 = inappropriate

words

4 = withdraws from pain

1 = does not open

2 = sounds 3 = abnormal flexion

1 = none 2 = abnormal extension

1 = none

Exposure

Completely undressed, and all surfaces inspected

“Logrolling” with attention to maintaining spine neutrality is important to assess focal level of spine pain or deformity

Importance of environmental control cannot be overstated

Adjuncts to the Primary Survey

Adjuncts to the Primary Survey

Secondary Survey

Head-to-toe physical examination

Brief focused history from the patient or personal representative.

AMPLE history Allergies

Medications

Past significant medical and surgical history

Last oral intake (time)

Events leading up to the trauma

Penetrating Abdominal Trauma

Gunshot with peritonitis OR

Gunshot with hemodynamic instability OR

Gunshot with no peritonitis and hemodynamically stable Depends on trajectory…CT vs observation with serial abdominal exams

Penetrating Abdominal Trauma:

Stab wounds shades of grey…

Hemodynamic instability, diffuse abdominal pain or evisceration OR

Rule of Thirds: 1/3 will violate skin but no fascia, 1/3 will violate fascia with no intraperitoneal injury, 1/3 with intraperitoneal injury

If unsure if violates fascia, local wound exploration at bedside or serial abdominal exam

Algorithm for blunt trauma

Exploratory Laparotomy

Mobilization Techniques

Kocher maneuver

Cattell-Braasch maneuver

Mattox maneuverModified Mattox maneuver

Kocher maneuver

Cattell Braasch

Cattell Braasch

Modified Mattox

Spleen

Spleen and liver most commonly injured organs from blunt trauma

Hemodynamic stability much more important than grade of laceration

Grades 1-3 can usually be monitored in ICU setting with serial H/H and abdominal exam with Grade 4-5 usually requiring splenectomy

Splenectomy

Mobilized by dividing the splenocolic, splenorenal and splenophrenic ligaments

The index finger can then expose the gastrosplenic ligament and the short gastric vessels. These vessels should be ligated individually near the spleen, taking care not to injure the stomach

Once this maneuver is complete, the spleen should be freely mobile on its vascular pedicle. The splenic artery and vein are then individually suture ligated close to the spleen to ensure no injury to the tail of the pancreas

Spleen

Post-op vaccinations at 2 weeks for encapsulated organisms including Pneumococcus, Meningococcus, and H. influenzae

Liver

85% can be managed nonoperatively in blunt trauma

Blush seen on CT in stable patient Angioembolization

If require laparotomy, compressive packing, cautery, and hemostatic agents will control most

If the bleeding is refractory to simple maneuvers, the liver can be mobilized by dividing the falciform and triangular ligaments, and the portal triad can be occluded with a Pringle maneuver.

Severe liver injury may require resection

Diaphragm Injury:

Blunt trauma accounts for up to 30% of traumatic diaphragmatic ruptures in the United States

Motor vehicle collisions and falls from heights are the most common mechanisms of injury

Diaphragmatic rupture occurs as a result of an acute increase in the intra-abdominal pressure

Due to liver, right-sided diaphragmatic ruptures occur less frequently than those on the left

Diaphragm Injury:

Penetrating trauma to the thoracoabdominal region presents diagnostic challenge due to possibility of an occult diaphragmatic injury

6% of all intra-abdominal injuries that result from penetrating trauma are diaphragm

No conventional diagnostic modalities can consistently and conclusively make the definitive diagnosis of a diaphragmatic injury

Missed injuries can result in future hernias 

Diaphragm Injury:

Laparoscopy, the diagnostic modality of choice

In the acute setting, diaphragmatic injuries are preferentially repaired primarily in a two-layer fashion, with a heavy non-absorbable suture

Stomach

Second most common intraperitoneal hollow viscus injury in penetrating trauma

Its size and intraperitoneal location make this organ a vulnerable target

Less frequent in blunt trauma, < 5%

Stomach

Penetrating injuries of the stomach should be repaired primarily after débridement of nonviable edges

The primary repair can be performed in either a single layer with non-absorbable suture or as a double-layer closure with an absorbable suture (e.g., Vicryl, Ethicon) for the first layer and the second layer closed with non-absorbable sutures (e.g., silk)

Small Intestine

Most common intraperitoneal hollow viscus injury

The proximal jejunum and distal ileum are the most commonly injured areas, because they are areas of transition between fixed and mobile bowel

Small Intestine

Partial-thickness injuries and full-thickness injuries that are less than 50% of the bowel circumference may be repaired with clean edges

Full-thickness injuries greater than 50% circumference, devascularized bowel, and multiple, large, full-thickness defects in a short segment are indications for resection of the injured bowel

Duodenum

Second portion of the duodenum is injured in blunt trauma either by a crushing mechanism or a closed-loop blowout

Fourth portion of the duodenum is injured secondary to traction

All portions have potential for injury in penetrating trauma

Second portion injuries require special attention to ampulla: if ampulla involved Whipple

Pancreas

•Seen in blunt trauma from crush injury against the spine and in penetrating; often seen in combination with duodenal injury

Management depends on location of injury and involvement of duct

-Drainage

-Debridement

-Partial resection

-Pancreaticoduodenectomy

Colon Injury

Blunt colonic injuries are the result of significant force and are often more extensive than a simple perforation

More commonly seen in penetrating injuries

The decision to primarily repair or divert must be made carefully with consideration for the patient’s hemodynamic stability and other associated injuries

Rectal Injury

Most rectal injuries result from penetrating gunshot wounds (96%)

Blunt injuries associated with pelvic fractures

Rectal exam revealing blood should prompt flexible sigmoidoscopy, if positive laparotomy for diversion

Standard management of extraperitoneal rectal injuries should adhere to the “three D’s”: define the injury, divert the fecal stream, and drain the pelvic space

Retroperitoneal Hematomas

Retroperitoneum: Zone 1

Central-medial retroperitoneal region: diaphragmatic hiatus to the sacral promentory and bilaterally to the renal hila

Divided into supra- and infra- mesocolic

Contains the aorta, vena cava, celiac trunk, the superior and inferior mesenteric arteries, and the renal pedicle vessels

Blunt and penetrating trauma require exploration

Retroperitoneum: Zone 2

Lateral retroperitoneal region

Contains the kidneys, adrenal glands, ureters, and the renal hila

Explored in blunt trauma if expanding or pulsatile, or to exclude possible colonic injury if suspected

Explore all in penetrating trauma

Retroperitoneal Hematomas: Zone 3

Pelvis from sacral prominence down

Including the distal ureters and distal rectum

Do not explore in blunt injury

Explore in penetrating trauma

Kidney

CT is the modality of choice for diagnosis of renal injuries

Suspect with gross hematuria, flank pain

Most resulting from blunt trauma can be observed with serial exams and H/H

Severe injuries to the kidney parenchyma or collecting system with a large hematoma, blush, or urine extravasation are treated operatively or with angioembolization

Nephrectomy if unsalvageable or in the unstable patient with associated injuries

Bladder

Most in blunt trauma; often associated with pelvic fractures

The bladder may be ruptured extraperitoneally or intraperitoneally

Extraperitoneal bladder injuries are managed nonoperatively, foley catheter drainage alone

Intraperitoneal rupture must be repaired in two layers (absorbable suture) and protected by 7-10 days of Foley catheter drainage

Case 1:

18 y/o male “left Church” when he was savagely beaten by two unknown men with baseball bats

Resus Bay: HR 115, BP 100/60

Abdominal tenderness and ecchymosis over flank

Workup?

Case 2:

27 y/o female attacked by her baby daddy’s new girlfriend on the way to work. She was “cut” with a small knife multiple times across her abdomen.

Trauma Resus Bay: HR 65, BP 120/60

Abdomen soft, tender around puncture sights

Management?

Case 3:

62 y/o male presents to trauma resus after being shot outside of a local night club

In Resus Bay: HR 120, BP 60/30

Abdomen rigid, distended, patient crying out in pain

GSW over RUQ, LLQ, left flank, and right buttocks

Management?

Case 4:

19 y/o male involved in an altercation presents to trauma resus with GSW to abdomen

In Resus: HR 130, BP 80/40

Abdomen tender, distended

GSW located in midepigastrium

Patient arrest during primary survey