Trauma

Trauma originates from the Greek word meaning ‘wound’. It implies that a physical force
exerted on a person has led to a physical injury.

1) chemical,
2) thermal,
3) ionising radiation
4) mechanical origin
The degree and severity of trauma sustained can vary substantially and
depend upon the magnitude of force exerted.
The assessment of trauma
●● Include the information formula: mechanism + patient = injury
●● Look for both obvious and less obvious features
●● Identify more reasons when the above formula does not make Sense

Mechanisms may be blunt, penetrating or even of a combined Nature

Blunt Trauma may be direct or indirect

Penetrating mechanisms can be divided into those caused by sharp objects
and those induced by firearms
Sharp object injuries
●● Think about the length of the sharp object involved
●● Knowledge of the local anatomy is essential
●● Remember that abdominal structures at risk of injury extend high into the chest

Firearm injuries
●● High velocity bullets induce permanent and temporary cavitation
●● Temporary cavitation can contain foreign material
●● Low velocity bullets induce similar damage to knives

Hidden mechanisms
●● The vast majority of conscious patients will tell the truth
●● Patients involved in criminal activity may not tell the truth
●● Fear of abuse may prevent vulnerable patients from telling the truth
●● Clinicians have the responsibility to take action when NAI is Suspected

Trauma assessment
●● Knowledge of timelines for important diagnoses is essential
●● Initial assessment should focus on what kills first
●● Screen high-risk patients before clinical signs become apparent, as it may be too late to
intervene once signs develope

patient + mechanism = injury

eABCDE
e) Exsanguinating external Haemorrhage
A)Airway with cervical spine control
B)Breathing and ventilation
C)Circulation and haemorrhage
D) Disability
E) Exposure

Torso trauma
The torso is generally regarded as the main part of the human body,
primarily made up of the chest, abdomen and pelvis, not including the head,
neck, arms and legs. About 42% of all deaths are the result of brain injury,
but some 39% of all trauma deaths are caused by major haemorrhage,
usually from torso injury.

Junctional zones
The key junctional zones are:
●● between the neck and the thorax;
●● between the thorax and the abdomen;
●● between the abdomen, the pelvic structures and the groin.
These zones represent surgical challenges in terms of both the diagnosis of
the area of injury and the surgical approach, which have to be balanced
against the physiological stability of the patient.

Root of the neck

 Most injuries affecting the base of the neck also affect the upper
mediastinum and thoracic inlet. Choice of access is determined by the need
for surgical control of the vascular structures contained within.

The mediastinum
The zone overlying the mediastinum with its major vessels and the heart is
also an extremely high-risk area for penetrating wounds. Any wound in this
region should immediately raise the suspicion of a major vascular or an
associated cardiac injury, even in the absence of initial gross physical signs.

Diaphragm
The thorax and abdomen are separated by the diaphragm, which is mainly
responsible for breathing, and moves during breathing between the fourth
and eighth interspace. Any penetrating injury of the lower half of the chest
may therefore have penetrated the diaphragm and entered the abdomen.
Injuries in this junctional zone, therefore, should be investigated as if both
cavities had been penetrated. In blunt trauma, rupture of the diaphragm can
result in migration of abdominal viscera into the chest.

Pelvic structures
The pelvis contains a large plexus of vessels, both venous and arterial.
Should injury occur, control of haemorrhage can prove to be exceptionally
difficult and may require control of both arterial inflow and venous outflow.
Angioembolisation can be a very useful adjunct to treatment, especially with
deep pelvic injuries.

Bleeding
Bleeding occurs from five major sites – ‘one on the floor and four more’:
●● external – ‘floor’;
●● chest;
●● abdomen (including the retroperitoneum);
●● pelvis;
●● extremities.

Clinical indicators of potential ongoing bleeding in torso trauma.

 1) Physiological
Increasing respiratory rate
Increasing pulse rate
Falling blood pressure
Rising serum lactate

2) Anatomical
Visible bleeding
Injury in close proximity to major vessels
Penetrating injury with a retained missile

THORACIC INJURY
Thoracic injury accounts for 25% of all severe injuries. In a further 25%, it
may be a significant contributor to the subsequent death of the patient. In
most of these patients, the cause of death is haemorrhage. About 80% of
patients with chest injury can be managed non-operatively. The key to a
good outcome is early physiological resuscitation followed by a correct
diagnosis.

Investigation
Routine investigation in the emergency department of injury to the chest is
based on clinical examination, supplemented by chest radiography.

Ultrasound – extended focused assessment with sonar for

trauma
Ultrasound can be used to differentiate between contusion and the actual
presence of blood. Extended focused assessment with sonar for trauma
(eFAST) is becoming the most common investigation. The technique uses
sonar assessment in the chest, looking for a cardiac tamponade or free blood
and air in the hemithorax on each side, and assessment for blood in the
abdominal cavity, in the paracolic gutters, subdiaphragmatic spaces and
pelvis.

Underwater chest drain

 In the physiologically grossly unstable patient, where physical examination
is inconclusive and there is no time for radiological investigations, insertion
of an underwater chest drainage tube can be a diagnostic procedure as well
as a therapeutic one, and the benefits of insertion often outweigh the risks.

Chest radiograph
In those cases where the patient is haemodynamically unstable or the spine
is at risk, an anteroposterior (AP) supine chest radiograph is usually the
simplest initial investigation, and will provide good information regarding
tracheal deviation, lung and mediastinal pathology, as well as skeletal injury.
In penetrating injury, it may be more helpful for the radiograph to be
performed with the patient positioned erect, as this will best reveal a small
pneumothorax, fluid meniscus, air–fluid level or the presence of free gas
under the diaphragm, indicating the presence of a hollow abdominal viscus
perforation. Note that up to 300 mL of blood may pool behind the domes of
the diaphragm, and may not be visible even in the erect view.

Computed tomography scan

The computed tomography (CT) scan with contrast allows for three-
dimensional reconstruction of the chest and abdomen, as well as of the bony
skeleton. It has become the principal and most reliable examination for
major injury in thoracic trauma. In blunt chest trauma, the CT scan will allow
the definition of fractures, as well as showing haematomas, pneumothoraces
and pulmonary contusion. In penetrating trauma, the scan may show the
track or presence of the missile and allow the proper planning of definitive
surgery. However, although the presence of an isolated rupture of the
diaphragm with migration of abdominal contents into the chest can be
detected by CT scan, in injury without migration the diagnosis will not be
obvious.

The pitfalls of investigation are:

●● failure to assess tracheal shift immediately above the sternal notch
clinically (deviation of the trachea occurs away from the affected side in
tension pneumothorax, and towards the affected side in lung collapse);
●● failure to percuss and auscultate both front and back in a supine patient
(an inflated lung will ‘float’ on a haemothorax, so auscultation from the front
may sound normal);
●● failure to pass a nasogastric tube if rupture of the diaphragm is
suspected; a chest radiograph will show the nasogastric tube apparently
within the chest cavity;
●● a supine chest radiograph can show a haemothorax as a homogenous
increase in opacity of the hemithorax; this can cause confusion between the
darker side and the lighter side, as to which may be a haemothorax (less
radiolucent), or a pneumothorax (more radiolucent). Look carefully for lung
markings, and don’t drain the wrong side;
●● pursuing radiological investigation (radiography or CT scan) instead of
resuscitation in the unstable patient.

Investigation of chest injuries

●● Directly or indirectly involved in >50% of trauma deaths
●● 80% can be managed non-operatively
●● A chest radiograph is the investigation of first choice
●● A chest drain can be diagnostic as well as therapeutic
●● A spiral CT scan provides rapid diagnoses in the chest and abdomen

Closed management of chest injuries

●● About 80% of chest injuries can be managed with the insertion of an
intercostal drain only
●● Do not close a sucking chest wound until a drain is in place
●● If bleeding persists, the chest will need to be opened and direct
haemostatic control is obtained

Immediate life-threatening injuries

Airway obstruction
 Early intubation is very important, particularly in cases of neck haematoma
or possible airway oedema. Airway distortion can be insidious and
progressive and can make delayed intubation more difficult if not impossible.

Tension pneumothorax
A tension pneumothorax develops when a ‘one-way valve’ air leak occurs
either from the lung or through the chest wall. Air is sucked into the thoracic
cavity without any means of escape, completely collapsing then compressing
the affected lung. The mediastinum is displaced to the opposite side,
decreasing venous return and compressing the opposite lung. The most
common causes are penetrating chest trauma, blunt chest trauma with a
parenchymal lung injury and air leak that did not spontaneously close,
iatrogenic lung injury (e.g. due to central venepuncture) and mechanical
positive pressure ventilation.Treatment consists of immediate
decompression, initially by rapid insertion of a large-bore cannula into the
second intercostal space in the mid-clavicular line of the affected side, then
followed by insertion of a chest tube through the fifth intercostal space in the
anterior axillary line.

Pericardial tamponade
Pericardial tamponade needs to be differentiated from a tension
pneumothorax in the shocked patient with distended neck veins. It is most
commonly the result of penetrating trauma. Accumulation of a relatively
small amount of blood into the non-distensible pericardial sac can produce
compression of the heart and obstruction of the venous return, leading to
decreased filling of the cardiac chambers during diastole. All patients with
penetrating injury anywhere near the heart plus shock must be considered to
have a cardiac injury until proven otherwise. Classically, the presentation
consists of central venous pressure elevation, decline in arterial pressure
with tachycardia and muffled heart sounds.
The correct immediate treatment of tamponade is operative, either via a
subxiphoid window, or by open surgery (sternotomy or left thoracotomy),
with repair of the heart in the operating theatre if time allows or otherwise in
the emergency room.

Pericardial tamponade
●● The presentation is similar to a tension pneumothorax –deteriorating
cyanosis, tachycardia and agitation
●● e FAST is diagnostic and may also detect free fluid in the abdomen or
pericardium
●● The central venous pressure may not be elevated if the circulating
volume is depleted, e.g. because of other injuries
●● Pericardiocentesis is a temporising measure only, with a high
complication rate and is not a substitute for immediate operative
intervention.

Open pneumothorax (‘sucking chest wound’)

This is due to a large open defect in the chest (>3 cm), leading to immediate
equilibration between intrathoracic and atmospheric pressure. If the opening
in the chest wall exceeds about two-thirds of the diameter of the trachea,
then with each inspiratory cycle, air will be preferentially drawn through the
defect, rather than through the trachea. Air accumulates in the hemithorax
(rather than in the lung) with each inspiration, leading to profound
hypoventilation on the affected side and hypoxia. If there is a valvular effect,
increasing amounts of air in the pleura will result in a tension pneumothorax
(see above). Initial management consists of promptly closing the defect with
a sterile occlusive plastic dressing (e.g. Opsite®), taped on three sides to act
as a flutter-type valve. A chest tube is inserted as soon as possible in a site
remote from the injury site.

Massive haemothorax
The most common cause of massive haemothorax in blunt injury is
continuing bleeding from torn intercostal vessels or occasionally from the
internal mammary artery secondary to fractures of the ribs. In penetrating
injury, a variety of viscera, both thoracic and abdominal (with blood leaking
through a hole in the diaphragm from the positive pressure abdomen into
the negative pressure thorax) may be involved.

The following points are important in the management of an open

pneumothorax /haemothorax:
●● a common problem is using too small a tube – a 28FG or larger tube
should be used in an adult;
●● if the lung does not reinflate, the drain should be placed on low-pressure
(5 cm water) suction;
●● clot occlusion of a chest drainage tube may result in ‘no’ drainage, even
in the presence of ongoing bleeding;
●● a second drain is sometimes necessary;
●● a chest radiograph can help identify the presence of blood;
●● physiotherapy and active mobilisation should begin as soon as possible.

Flail chest
This condition usually results from blunt trauma associated with multiple rib
fractures, and is defined as three or more ribs fractured in two or more
places. The blunt force typically also produces an underlying pulmonary
contusion. The diagnosis is made clinically in patients who are not ventilated,
not by radiography. To confirm the diagnosis the chest wall can be observed
for paradoxical motion of a chest wall segment. On inspiration, the loose
segment of the chest wall is displaced inwards and therefore less air moves
into the lungs. On expiration, the segment moves outwards (paradoxical
respiration). Voluntary splinting of the chest wall occurs as a result of pain,
so mechanically impaired chest wall movement and the associated lung
contusion all contribute to the hypoxia.
Traditionally, mechanical ventilation was used to ‘internally splint’ the chest,
but had a price in terms of intensive care unit resources and ventilation-
dependent morbidity. Currently, treatment consists of oxygen
administration, adequate analgesia (including opiates) and physiotherapy. If
a chest tube is in situ, topical intrapleural local analgesia introduced via the
tube, can also be used. Ventilation is reserved for cases developing
respiratory failure despite adequate analgesia and oxygen. Surgery to
stabilise the flail segment using internal fixation of the ribs may be useful in
a selected group of patients with isolated or severe chest injury and
pulmonary contusion.

Immediately life threatening Airway obstruction

●●Tension pneumothorax
●●Pericardial tamponade
●●Open pneumothorax
●●Massive haemothorax
●●Flail chest
Potentially life threatening
●●Aortic injuries
●●Tracheobronchial injuries
●●Myocardial contusion
●●Rupture of diaphragm
●●Oesophageal injuries
●●Pulmonary contusion

Potentially life-threatening injuries

Thoracic aortic disruption
Traumatic aortic rupture is a common cause of sudden death after an automobile collision or
fall from a great height. The vessel is relatively fixed distal to the ligamentum arteriosum, just
distal to the origin of the left subclavian artery. The shear forces from a sudden impact disrupt
the intima and media. If the adventitia is intact, the patient may remain haemodynamically
stable.
Initially, management consists of control of the systolic arterial blood pressure (to less than 120
mmHg). Thereafter, an endovascular intra-aortic stent can be placed, or the tear can be
operatively repaired by direct repair or excision and grafting.

Tracheobronchial injuries
Severe subcutaneous emphysema with respiratory compromise can suggest tracheobronchial
disruption. A chest drain placed on the affected side will reveal a large air leak and the
collapsed lung may fail to re-expand. Bronchoscopy is diagnostic. Treatment involves intubation
of the unaffected bronchus followed by operative repair. Referral to a trauma centre is advised.

Blunt myocardial injury

Significant blunt cardiac injury that causes haemodynamic instability is rare. Blunt myocardial
injury should be suspected in any patient sustaining blunt trauma who develops early
ECG abnormalities.
Two-dimensional echocardiography may show wall motion abnormalities. A transoesophageal
echocardiogram may also be helpful. There is very little evidence that enzyme estimations have
any place in diagnosis.
All patients with myocardial contusion diagnosed with conduction abnormalities are at risk of
developing sudden dysrhythmias and should be closely monitored.

Diaphragmatic injuries
Any penetrating injury below the fifth intercostal space should raise suspicion of diaphragmatic
penetration and, therefore, injury to abdominal contents.
 The thorax is at negative pressure and the abdomen is at positive pressure. A complication of a
breach of the diaphragm is herniation of abdominal contents into the chest. This may present
much later, and strangulation of any of the contents can then occur, with a high mortality rate.
Operative repair is recommended in all cases. All penetrating diaphragmatic injury must be
repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury.

Oesophageal injury
Most oesophageal injuries result from penetrating trauma; blunt injury is rare. A high index of
suspicion is required. The patient can present with odynophagia (pain on swallowing saliva,
foods or fluids), subcutaneous or mediastinal emphysema, pleural effusion, air in the
perioesophageal space and unexplained fever. Mediastinal and deep cervical emphysema
are evidence of an aerodigestive injury until proven otherwise.
The mortality rate rises exponentially if treatment is delayed. A combination of
oesophagogram in the decubitus position and oesophagoscopy confirm the diagnosis in the
great majority of cases. The treatment is operative repair of any defect and drainage.

Pulmonary contusion
Pulmonary contusion occurs more frequently following blunt trauma, usually associated with a
flail segment or fractured ribs. This is a very common, potentially lethal injury and the major
cause of hypoxaemia after blunt trauma. Following gunshot0 wounds, there is an area of
contusion from the shock wave of the bullet.
In mild contusion, the treatment is oxygen administration, pulmonary toilet and adequate
analgesia. In more severe cases mechanical ventilation is necessary. Normovolaemia is critical
for adequate tissue perfusion and fluid restriction is not advised.

It is important to make a distinction between:

●● immediate thoracotomy in the ED for the control of haemorrhage, cardiac tamponade or
internal cardiac massage;
●● emergency sternotomy for anterior mediastinal structures and heart;
●● planned thoracotomy for definitive correction of the problem – this usually takes place in
the more controlled environment of the operating theatre.

Emergency department thoracotomy or sternotomy

EDT should be reserved for those patients suffering penetrating injury in whom signs of life are
still present. Patients who have received cardiopulmonary resuscitation (CPR) in the prehospital
phase of their care are unlikely to survive, and electrical activity must be present.

In certain situations, EDT is considered futile:

●● CPR in the absence of endotracheal intubation for more than 5 minutes;
●● CPR for more than 10 minutes (despite endotracheal intubation);
●● blunt trauma when there have been no signs of life at the scene
The aim of EDT is to perform:
●● internal cardiac massage;
●● control of haemorrhage from injury to the heart or lung;
●● control of intrathoracic haemorrhage from other sources;
●● control of massive air leak;
●● clamping of the thoracic aorta to preserve the blood supply to the heart and brain, and
cutting off the arterial supply distally, in a moribund patient with a major distal penetrating
injury.

Planned emergency thoracotomy

Planned emergency thoracotomy implies an emergency thoracotomy performed as a planned
procedure in the operating room, directed at the management of a specific injury. As such, the
approach chosen is dependent on the indication for surgery and the organ injured . Some
organs are best approached through a median sternotomy. Otherwise the thoracotomy may be
right- or left-sided, and these may be joined, producing the so called ‘clamshell incision’. This
gives excellent exposure for any surgeon who is not routinely entering the chest.
Posterolateral thoracotomy is not used in the emergency situation because of the difficulties
in positioning of the patient, except for specific access to certain posterior mediastinal organs.

ABDOMINAL INJURY
Patients who have suffered abdominal trauma can generally be classified into the following
categories based on their physiological condition after initial resuscitation:
●● haemodynamically ‘normal’ – investigation can be completed before treatment is planned;
●● haemodynamically ‘stable’ – investigation is more limited. It is aimed at establishing
whether the patient can be managed non-operatively, whether angioembolisation can be used
or whether surgery is required;
●● haemodynamically ‘unstable’ – investigations need to be suspended as immediate surgical
correction of the bleeding is required.

Investigation
Focused abdominal sonar for trauma and extended FAST

●● Detects free fluid in the abdomen or pericardium

●● Will not reliably detect less than 100 mL of free blood
●● Does not directly identify injury to hollow viscus
●● Cannot reliably exclude injury in penetrating trauma
●● May need repeating or supplementing with other investigations
●● Is unreliable for assessment of the retroperitoneum
Diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) is a test used to assess the presence of blood or
contaminants in the abdomen. A gastric tube is placed to empty the stomach and a urinary
catheter is inserted to drain the bladder. A cannula is inserted below the umbilicus, directed
caudally and posteriorly.
Although DPL has largely been replaced by eFAST (see above), it remains the standard in many
institutions where eFAST is not available or is unreliable. DPL is especially useful in the
hypotensive, unstable patient with multiple injuries as a means of excluding intra-abdominal
bleeding.

Computed tomography scan

CT has become the ‘gold standard’ for the intra-abdominal diagnosis of injury in the stable
patient. The scan can be performed using intravenous contrast. CT is sensitive for blood
and individual organ injury, as well as for retroperitoneal injury. An entirely normal abdominal
CT is usually sufficient to exclude intraperitoneal injury.
The following points are important when performing CT:
●● it remains an inappropriate investigation for unstable patients;
●● if duodenal injury is suspected from the mechanism of injury, oral contrast may be helpful;
●● if rectal and distal colonic injury is suspected in the absence of blood on rectal examination,
rectal contrast may be helpful.

Laparoscopy
Laparoscopy or thoracoscopy may be a valuable screening investigation in stable patients with
penetrating trauma, to detect or exclude peritoneal penetration and/or diaphragmatic injury.
Laparoscopy may be divided into:
●● Screening: used to exclude a penetrating injury with breach of the peritoneum.
●● Diagnostic: finding evidence of injury to viscera.
●● Therapeutic: used to repair the injury.