Trauma 1 Absite Review: Primary Survey, Secondary Survey, and Abdominal Trauma
Dec 24, 2015
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