Organ specific approach to trauma

Scalp: Laceration, depressed fracture or open fracture

Eye: Pupillary size, reactivity, visual acuity, hemorrhage, eye ball movements (restricted in orbital fracture) Eyes to be examined first later swelling may obscure examination.

Tympanum: Hemotympanum and otorrhea

Head

Basilar skull fracture  is a fracture of the base of the skull, typically involving the temporal, temporal, occipital, sphenoid and ethmoid bone.

1. Otorrhea2. Rhinorrhea3. Raccon eyes4. Battle’s sign (Ecchymosis behing ear)

Basillar fracture

All patients with significant closed head injury or penetrating head injury must undergo CT scan of head.

If patient of penetrating head injury is unstable at least a plain X ray of head my be helpful.

Hematomas, contusions, ventricular hemorrhage, sub arachnoid hemorrhage and diffuse axonal injury.

Brain

Extra dural hemorrhage: Hemorrhage between skull and dura. Mostly from middle meningeal artery or from and small artery following skull fracture

Subdural Hemorrhage:Collection of blood between dura and cortex. Usually from venous sinuses or contused parenchyma. More dangerous due to close parenchymal involvement.

Hemorrhage in space between arachnoid and pia mater. Cause vasospasm and decreased cerebral flow.

Sub Arachnoid Hemorrhage

High speed deceleration injury causing sheering stress to brain . Represent direct axonal damage

CT may demonstrate blurring of grey and white matter interface and multiple small punctuate hemorrhage but

MRI is investigation of choice.

Diffuse Axonal Injury

MRI picture of diffuse axonal injury

Carotid or vertebral artery injury may lead to stroke syndrome.

If suspected 4 vessel angiography for carotid and vertebral arteries.

Stroke syndrome

Access Glasgow coma scale:

If GCS less than 14 in closed head injury perform CT headIf intracerebral bleed or diffuse axonal injury admit to SICU

Management of a case of head injury

If GCS less than 8 or abnormal CT finding monitor intra cranial pressure using intra parenchymal or intra ventricular catheter.

Unless ICP is more then 20 mmHg operative therapy is not initiated.

Operative decesion for SOL depends upon:A. Size of clotB. Midline shift (>5mm)C. Clot location (Posterior fossa )D. GCS scoreE. ICP Those having diffuse cerebral edema will require

decompressive craniotomy. Open or depressed fracture and penetrative head

injuries are indication for operative intervention.

Keep systolic BP above 90mm Hg Prevent hypoxia by keeping oxygen saturation above

90% Keep cerebral perfusion pressure 50- 70mm Hg. Patient may be hyper ventilated to make pCO2 <30

mm Hg to induce cerebral vasoconstriction for temporary management of raised ICP

Moderate hypothermia (32 to 33 Celsius) maintained for at least 48 hours reduce overall mortality.

Patients with intracranial hemorrhage must be given prophylactic anticonvulsant therapy.

Sedation, osmotic diuresis, paralysis, ventricular drainage and barbiturate coma are used in sequence as last resort.

Post injury care in head truma

Grasp upper palate and see if it moves apart from rest of head. Conscious patient ask if he feel his bite normal. Le forte’s classification: type 1

◦ horizontal maxillary fracture, separating the teeth from the upper face.◦ fracture line passes through the alveolar ridge, lateral nose and inferior

wall of maxillary sinus. type 2

◦ pyramidal fracture, with the teeth at the pyramid base, and nasofrontal suture at its apex

◦ fracture arch passes through posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim and nasal bones.

type 3◦ craniofacial disjunction◦ fracture line passes through nasofrontal suture, maxillo-frontal suture,

orbital wall and zygomatic arch.

Facial Trauma

1. Vigorous nasal 2. Air way compromise – blood in posterior

pharynx 3. Vomiting due to swallowed blood

Nasal packing or balloon tamponade.

Nasal fracture

Control ongoing hemorrhage with nasal packing, foley’s balloon tamponade and oro-pharangeal packing .

Involve trauma surgeon, ENT surgeon, ophthalmologist, maxillofacial surgeon.

Early involvement of concerned surgeons is obviated as permanent disfigurement or loss of any senorineural function in this region gives a very bad psychological impact after recovery.

Management of facial trauma

Unless proved otherwise in head trauma cervical spine injury is present.

An occult cervical spine trauma may result quadriplegia

Penetrating injuries of neck that violates platysma are life threatening as density or critical structures.

Other injuries could be fracture of larynx must be suspected if patient has hoarseness in voice, subcutaneous emphysema and palpable fracture.

Neck and cervical spine

Brown sequard syndrome

Anterior cord syndrome

Best is CT neck If not feasible 5 X rays

1. Lateral view visualizing C7 through T1.2. Antero posterior view3. Trans oral odontoid view4. Bilaterally oblique view

Occult spinal trauma suspected in patient having delayed neck pain. Radiographed in flexion and extension view only by an experienced neck surgeon.

Investigations for spinal trauma

Zones of neckZone I :Superasternal notch to cricoid cartilage.Zone II : Cricoid cartilage to angle of mandibleZone III : Above angle of mandible

Injury to vessels may require repair. Extensive injury to unilateral jugular vein my be manged by ligation instead but never bilateral cases.

In blunt injury to carotids and vertebral arteries administration of antithrombotic have shown to decrease incidence of strokes following neck trauma. Repeat scan after 10 days if not healed continue treatment for 6 months

Sublaxations are stabilized using axial traction with cervical

tongs and immobilized with spinal orthoses (braces). If cord injury present give stat bolus dose of methylprednisolone

30mg/kg followed by 5.4mg/kg/hr perfusion for rest of 23 hrs. In deteriorating neurological functions and fracture or

dislocation with incomplete neurological deficit immediate surgery is warranted.

Management of blunt trauma to neck and cervical spine

Management of pentrating trauma to neck

1. Expanding hematoma2. Airway compromise3. Dysphagia4. Subcutaneous emphysema 5. hoarsness

symptoms

Blunt Physical examinationChest X rayCTRepeat chest X ray if intubation, central line,

tube thoracostomy to check adequacy of procedure.

Chest

Must be suspected as soon as widening of mediastinum is seen.

7% have normal chest X ray thus screening with spiral CT performed in following patients:

1. High energy decelration motor vehicle collision with frontal or lateral impact.

2. Motor vehicle collision with impact.3. Fall > 25feet.4. Direct impact (horse kick to chest)

Aortic tear

More than 95% of patients with aortic tear who survive till reaching to emergency department have tear just distal to subclavian artey where it is tethered by ligamentum atreriosum.

Rest 2-5% are in ascending, transeverse arch or diaphragm.

Pathophysiology of aortic tear

1. Intimal tear 2. Intra mural hematoma 3. Pseudo aneurysm 4. Rupture

Grades of aortic tear

Aortic tearX ray finding of aortic tear

Widened mediastinum

Abnormal aortic contour

Tracheal shift

Nasogastric tube shift

Left apical cap

Left or right paraspinal stripe thickening

Depression of the left main bronchus

Obliteration of the aortico pulmonary window

Left pulmonary hilar hematoma

Investigate with:1. Chest X ray with metallic marking of entry and exit

wound2. Pericardial USG 3. Central venous pressure monitoringThese will identify most of injuries except injury to

trachea and esophagusThus, if persistant air leak from chest tube or air in

mediastinum--- bronchoscpyIf esophageal injury suspected esophagography

followed by barium study to look for extravasation .

Penetrating trauma to chest

Simple lacerations of ascending or transverse aorta is done with lateral aortorraphy.

Repair of posterior injuries or using interpositoning graft will require circulatory arrest.

Innominate artery injuries are repaired using bypass exclusion technique where circulatory arrest is not required. Here before entering the post injury hematoma PTFE graft is attached end to side to proximal part of aorta and end to end innominate artery.

Descending aortic rupture will require urgent repair. Subclavian artery lateral arteriorraphy or PTFE

interposition is done sine due to multiple braches and tethering end to end anastomosis is not preferable.

Management of major vessel injury

In impending rupture to prevent Esmolol infusion could be given with target systolic BP <100mmHg and heart rate <100/min.

Endovascular stenting techniques are gaining hold nowadays especially in those who can’t tolerate single lung ventilation during open repair.

While repair a centrifugal pump maintaining perfusion pressure more than 65mm Hg prevent ischemia to spinal cord and before tying last suture thrombus and air is flushed out.

Before going for any repair control hemorrhage.

Atrial rupture can be clamped with satinsky clamp. For ventricular rupture either digital pressure or skin staplers are used.

For definite repair 3-0 prolene is used either continuous or interrupted manner.

Continuous is avoided near coronaries, instead horizontal mattress is preferred.

Pledgeted sutures are used for thinner myocardium of right ventricle.

Management of injuries to Heart

Rare injuries and rarely require operative management. First secure air way for ventilation.

Tracheal injuries require debridement of devitalized tissues and repair with 3-0 PDS suture. Sutured area is covered with some vascular structure like pericardium, pleura and intercoastal muscle.

Bronchial injury less than 1/3rd circumferential injury can be conservatively managed and if persistent air leak in chest tube bronchoscopic fibrin glue can be used.

Injury to trachea, bronchus lung parenchyma and esophagus

For parenchymal injury traditionally pneumonectomy or lobectomy was done but now pulmonary tractotomy is done thus selective bronchioles and bleeders could be ligated.

Pneumatocele can be managed conservatively but if abscess develop CT guided drainage is to be done.

For esophageal injury single layer repair is enough but if nearby some tracheal suture line is present some vascularised tissue must be interposed. If lower esophageal injury present segmental resection and gastic pull up can be done.

In a case of abdominal trauma per abdomen rigidity or hemodynamic instability is an indication for promt surgical exploration.

Penetrating Blunt

Abdomen

Gun shot injuries

>90% of gun shot injuries cause serious internal damage.Thus any gun shot wound having entry or exit wound

between 4th intercoastal space to pubic symphysis and its trajectory penetrating the peritoneum needs abdominal exploration.

There is an expection: When gun shot wound is in upper right quadrant and trajectory is confined to liver we can manage it conservatively if other things are favourable.

If location of wound is in back or flanks then exploration is more difficult as organs are located retro peritoneally

Penetrating abdominal injuries

Stab Wound Less organ damage than gun shot wound. Wounds must be examined in emergency

department itself under local anesthesia.D If superficial to fascia patient can be

discharged. If fascia penetrated then further evaluation

required:1. Serial examinations2. Diagnostic peritoneal lavage3. CT scanning with triple contrast

Penetrating abdominal injuries

Surgical diagnostic test to determine hemorrhage in abdominal cavity.

Through infraumbilical incision peritoneum is entered and aspirated using a stiff catheter. If less than 10 ml 1 liter 0.9% warm normal saline is infused and aspirated for analysis.

Analysis results are different for thoracoabdominal stab wonds and standard anterior abdominal.

Diagnostic peritoneal lavage

Anterior abdominal stab wounds

Thoracoabdominal stab wounds

Red Blood cell counts >1,00,000/ml >10,000/ml

White blood cell counts

>500/ml >500/ml

Amylase level >19 IU/ml >19 IU/ml

Alkaline phosphatase level

>2 IU/ml >2 IU/ml

Bilirubin level >0.01 mg/dL >0.01 mg/dL

Diagnostic peritoneal lavage analysis

Approach to penetrating abdominal trauma

Initial evaluation by FAST(focused abdominal sonography in trauma). Since its not 100% sensitive DPL is still advocated in hemodynamically unstable patients.

In hemodynamically stable CT scan must be done if FAST is negative.

CT has limited sensitivity for intestinal injury suggestive findings thickened bowel wall, streaking of mesentery, free fluid without any solid organ injury or free intraperitoneal gas.

Blunt injury to abdomen

Focused abdominal sonography in trauma4 sitescan pick fluid upto 250ml

Approach to Blunt trauma abdomen

Grade Sub capsular hematoma

Laceration

I < 10% of surface area

<1 cm in depth

II 10-50% of surface area

1-3 cm in depth

III >50% of surface area or >10 cm in depth

>3cm

IV 25-75% of hepatic lobe

V >75% of hepatic lobe

VI Hepatic avulsion

American association for surgery of trauma grading scale for liver injury

Grade Subcapsular hematoma

Laceration

I <10% of surface area <1cm in depth

II 10-50% of surface area 1-3 cm

III >50% of surface area or >10 cm in depth

>3cm

IV >25%devascularisation Hilum

V Shattered spleenComplete devascularisation

American association for surgery of trauma grading scale for spleen injury

LiverBeing large organ it is most suseptible to injury.Can be manged conservatively if patient

hemodyanmically stable and there is no peritonitis or any other indication for laparotomy. Anigio embolization and ERCP further improves outcome of conservative management.

Perihepatic packing must be done for injuries to liver and lacerated edges must be opposed to control bleeding by local pressure.

In case of persistent bleeding despite packing injury to hepatic and portal vessel must be considered.

Management of abdomianl injuries

Pringle’s manuever must be used to find site of bleed.Ligation of celiac axis at the level of common hepatic

upto gastroduodenal branch is well tolerated due to many collaterals but if hepatic artery prper is damaged definitive repair is warranted.

Sometimes in emergency any of hepatic artery or even portal vein will have to be ligated but then delayed anatomic resection for lobar necrosis will have to be done. If right sided hepatic artery is ligated cholecystectomy has to be done.

Earlier splenectomy was warranted in all splenic injuries but after recognition of immune function of spleen splenic salvage is advocated.

Proper patient selection is important. 20-30% of splenic trauma deserve splenectomy.

Indications for splenectomy in trauma1. Those requiring blood transfusion in 1st 12 hours.2. Hilar injuries3. Pulverized splenic parenchyma4. Injury more than grade two in a patient having

coagulopathy or multiple injuries.

Polar injuries can be managed with patial splenectomy.Horizontal matress over raw edges can control bleeding.

SPLEEN

Injuries to stomach are liable to be missed thus by occluding stomach at pylorus inject methylene blue using nasogastric tube.

If require partial gastrectomy can be done followed by billroth reconstruction.

If Latarjet nerve or vagi has been injured then a drainage procedure is warranted.

If single layer closure is done full thickness bite is required to prevent hemrrhage.

Stomach

Hematomas can be managed non operatively just by nasogastric suctioning and parentral nutrition.

Simple tear and laceration can be managed by single layer suture

Small intestine

May produce complex fractures with major hemorrhage

Radiograph shows only gross injuries thus CT required in majority of cases.

Bladder rupture may occur if direct blunt injury to torso in full bladder

If urine positive for RBC CT cystography indicated.

Pelvic trauma

1. Blood at meatus2. Scrotal and perineal hematoma3. High riding prostate on PR examinationPerform urethrogram before doing foley

catheterization to avoid false passage and stricture.

Uretheral injury