JL Notes

Surgery

Trauma Part 1 (Incomplete, sorry)

Injury
- Damage to body caused by exchange w/ environmental energy beyond
bodys resistance
- Leading cause of physician contact
- 140 bed days of annual disability
- Nearly motor s/n
- 10-15% -> serious multi-system injury
Trauma
- Leading cause of death in people <45y/o (productive age)
- 4th leading cause of death in the Philippines
- 120,000 deaths/year
Etiology
Industrialized: vehicular
Philippines: crimes, stray bullets, firecrackers, practice of jeepney sabit, jaywalking
habits
Mechanism of Injury
- Acceleration-deceleration injuries
o Falls
o Blunt trauma
o Vehicular accident
o Shearing forces
- Penetrating
o Stab wounds
Tract is predictable
Common b/w socio-economic groups
o Hacking wounds
- Missile wounds
o Low-velocity handguns (600-1100 fps)
More common in civilian
o High-velocity
Long bores, high caliber
Small entrance, large exit
Damage is remote from missile tracts
o Shotgun injuries devastating at close range; debridement of all
missile tracts; slugs need not be retrieved (except in dangerous points;
aorta/pancreas)
Trauma Management
- Team effort
Objectives
- Preservation of life
- Preservation of limb
- Restoration; resuscitate neural function as possible

Primary Survey: Airway

- Highest level of priority in treatment
- Brain damage w/o O2
o 0-4min brain damage not likely
o 4-6min probable
o 6-10min very likely
o >10min almost certain
- A always have an airway
- B be sure you have an airway
- C check if you have an airway
- Special attention
o U unconscious patient
o I injury above clavicle -> air entry
o P possible cervical injury
Assume motor VA
4-man carry
o A abnormal voice airway injury
- Common causes of obstruction
o Tongue falls back
o Blood
o Loose teeth
o Vomit
o Foreign body
- Procedure
o Clear airway
o Maintain c-spine stationary
o Jaw-thrust maneuver
o Chin lift
o /nasopharynx airway
o ETT, NT intubation
o Needle intubation with o2 jet insufflations
o Cricothyroidotomy -> BEST FOR TRAUMA
o Tracheostomy
- Clear airway
o Direct sweeping w/ finger
o Direct laryngoscopy
- Protecting C-spine
o Cervical collar
o Sandbags/IV bags
o Carton/rolled newspaper
o Plaster
o Manual traction
- All blunt trauma patients, especially MVA require cervical immobilization
unless injury is ruled out!
- Surgical Airway/Intubation
o Failed Intubation

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(+) facial trauma

Cricothyroidotomy
Needle w/ O2 jet insufflations
E tracheostomy

Primary Survey: Breathing

- Assess patients ventilator status
- INSPECTION
o Chest wall motion
o Cyanosis
o External bruises
o Use of accessory muscles of respiration
o Presence/size of penetrating chest trauma
o Distended neck veins
o Tachypnea
o FB in mouth
- PALPATION
o subQ emphysema
o Tracheal deviation
- AUSCULTATION: breath sounds
- Apneic ->
o Mouth to mouth
o Mouth to tube
o Ambu-bag
o Ventilator
- Conditions that pose impediment to ventilation
o Tension pneumothorax
Pneumothorax w/ shifting of mediastinal structures towards the
other side -> great vessel compression, diminished venous
return, low cardiac output
Dx:
Tracheal deviation
Distended neck veins
Diminished breath sounds
Hypertension

Chest X-ray
Initial Rx:
Needle thoracentesis: G34/G36, 2nd ICL, MCL
C37
o Flail chest
o Open pneumothorax
Chest wall defect greater than 2/3 of the diameter of the trachea
Air gets sucked in
Initial Rx:
Covering wound w/ 3 cornered dressing
Cling wraps

Definitive Rx:
CTT
Intubation + IPPV
Massive hemothorax
Massive collection of blood in the thoracic cavity -> ventilator
collapse
Dx:
Decreased to absent breath sounds
Hypotension
Initial Rx:
CTT
Definitive Rx:
Thoracotomy if
o Initial CTT output > 1500mL
o Hourly CTT output > 200 mL in 3 hours
Should be immediately recognized!
Life threatening!

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Primary Survey: Circulation

- Assessed after airway has been secured
- Assessment of CVS/volume status
- If perfusion is inadequate, (+) shock -> treat immediately
- INTERNAL BLEEDING
o Consider: 1.0cm increase in thigh circumference may represent 1.52.0L of extravasated blood in fern fx
- Sometimes, operative control of hemorrhage and resuscitation are carried out
simultaneously in the OR
- CONTROL OF BLEEDING:
o Digital/direct pressure
o Sterile compressive dressings
o Blind clamping should be avoided
o No tourniquets!
Except during combat
- PROXIMAL CONTROL OF BLEEDING (Intra-op)
o Control of aorta: through thoracotomy, underneath diaphragm
o Femoral artery control: supra-inguinal incision
- VOLUME STATUS/PERFUSION/OXYGENATION GAUGED IN:
o Condition of skin
Color
Temperature
Moisture (vasoconstriction -> pale, cold, clammy)
Capillary return (blanch test to determine hypervolemia;
Normal 2sec)
o Cardiac rate
More sensitive than BP
Exclude: use of propanolol, digoxin, pacemaker
If > 120BPM, assume hypotension
Assess peripheral pulses

(+) carotid pulse = SBP 60mmHg

(+) femoral pulse = SBP 70mmHg
(+) radial pulse = SBP 80 mmHg
Dysrhythmias preterminal event due to myocardial
hypoperfusion
o Mental status
Least reliable indicator of hypovolemia
Cerebral hypoperfusion not apparent until BP < 60mmHg
If due to hypovolemia = preterminal stage
o Pulse pressure and Urine output most reliable indicators of volume
status
Indications for CPR
o Asystole
o Poor cardiac function
ER thoracotomies -> open chest massage
o ER Thoracotomy
Indications
Hypovolemic arrest in spite of vigorous fluids/CPR
CP arrest w/ penetrating chest injuries
Contraindications
Obvious CR5 injuries
Failed CPR > 10min
Major blunt chest trauma

Primary Survey: Determine Neuro Deficits

- Brief examination will help discover presence of CR5 injuries
- Parameters
o Pupillary size and reactivity
o Motor and sensory responsiveness
o Level of consciousness
- Mnemonic
o A alert
o V verbal stimuli, response to
o P pain, response to
o U unresponsiveness
- Glasgow Coma Scale
Primary Survey: Exposure/Environment Control
- Complete undressing is necessary to avoid missed injuries
- No room for modesty in a trauma ER
- Examine from head to foot, front and back
- Back injuries often missed -> log roll patient
- Avoid heat loss and hypothermia
- Crowd control
Primary Survey: Triage/Categorize
I.
Life Threatening
a. Interfere w/ vital fxn

II.

III.

b. Airway obstruction
c. Massive hemorrhage
d. Require treatment in 5-10min
No Immediate Threat to Life
a. Stable vital signs: GSW, SW, blunt trauma
b. Majority of patients
c. Require treatment in 1-2hrs
d. (+) ample time for other diagnostics
e. If in shock -> OR
Injuries with Occult Damage
a. Exact injury not apparent
b. (+) ample time for extensive studies

Resuscitation
- Carried out simultaneously with Primary Survey
- Oxygen therapy
o ALL TRAUMA PATIENTS require supplemental oxygen until resuscitation
is complete
o Many patients have diminished oxygen carrying capacity
Pulmonary contusion
Impaired ventilation
Anemia
Hypovolemia and decreased cardiac output
o Access
Mask/prongs/cannula
Intubation
o Vascular access
Intravenous access
2 IV sites, 16 gauge venous catheters
Blood draws simultaneously for sampling
Other options
o Saphenous with outdown(?)
o Percutaneous femoral vein catheter
o Intravenous cannulation (tibia or femoral)
Indications
BP < 110mmHg
CR > 120/min
Altered mental status
o Fluid resuscitation
Fluid of choice
Balance salt soln: Plain LRS vs Normal Saline Soln
o NSS = hypochloremic metabolic acidosis
o General trauma: Plain LRS
o Head Trauma: DSNSS
o Target is 110mmHg systolic
Colloids (Hetastarch, Gelatin) expensive
Blood Products: PRBC > WB
Type-specific

Closed ratio transfusion: PRBC(?) + FFP + plt = 1 : 1 : 1

Rate
Initial
o Adults: 1L LRS vs NSS
Ingested 1x -> PRBC
o Child: 20mL / KBW
Ingested 2x -> PRBC
Vasopressors are not indicated!
Assessment of fluid replacement
IJO: 2-3 mg/(?)/hr
CVP
VS
General condition
Stop fluid resuscitation when the endpoint is reached -> more
problems (compartment syndrome, edema and (?)pathies)

Resuscitation: Non-responders
- Re-evaluate
o Neck veins
o CVP
Right ventricular preload
Hypotension + CVP < 5cmH2O = ongoing hemorrhage
Hypotension + CVP > 15cmH2O = cardiogenic shock
- D/Dx
o Cardiogenic shock vs
Tension pneumothorax
Pericardial tamponade
Myocardial contusion/infarction
Air embolism
- Search for other sources
o Abdominal UTZ
o Cest X-ray AP
o Pelvic X-ray
o CT scan
- Management
o BT, type O PRBC
o In spite of BT -> SRP < 70 mm -> ER thoracotomy
o Immediate OR exploration
- Transient Responders
o (+) penetrating injuries -> OR
o Multiple blunt injuries -> OR vs observe
Secondary Survey
- After primary survey and resuscitation
- Guide
o A allergies
o M medications
o P past illnesses

o L last meal
o E events preceding injury
Complete and more detailed PE carried out
Special procedures may be done during this period

Definitive Management
- Damage control
o Stage I stop bleeding, resuscitation
o Stage II physiologic control in ICU
o Stage III definitive control
- Other ER Management Protocols
o Tetanus prophylaxis
o Antibiotic regimen
o Wound dressing
o Splinting
- To observe or operate?
o mas mahirap hindi mag-opera kaysa mag-decide na mag-opera
o Do not dwell too much on serial PE move on!
- Definitive surgical management
Definitive Management: ER Management
- Head/Spine Injury
o General trauma (sorry, I cant read the rest of the slide; theyre too
small)
- Face and Neck Injury
o Initial Management
Airway
External pressure
Fluid resuscitation
Cervical X-rays
Chest X-rays
Barium/arteriograms
Do not attempt NGT insertion in the ER, done in the OR
- Chest Trauma
o ABCs
o Chest X-ray
o ABG
o ECG
o 2D echo
o Seal/dress wounds
o E Thoracentesis
o E CTT
o E pericardiocentesis
- Blunt Abdominal Trauma
o Diagnostic dilemma
o Carotid history and PE
o Labs
CBC

Amylase
U/A
o Radio
AXR, CXR, IVP
UTZ, CT
o To diagnose??
DPL may be edematogenous
CT may initially be repeated
Dx (?) may increase ICP
o Rx
Insert NGT
IFC ?????
Penetrating Abdominal Trauma
o GSW below 5 ICS expect abdominal injuries
o Labs: same
o Radio: same
o Rx
ER wound exploration
Dress wound
NGT
IFC ???
Extremity Trauma
o ABCs
o Packing, pressure dressing, control of bleeders
o Splinting how?

Medico-Legal Issues
- Legal obligation to treat all EMERGENCY cases
o HOC, informing HOC
o Admit
- Informed consent
o Consent vs waiver
- Refusal of care
- DMR/AMD
- Confidentiality, privacy, privilages
- Reporting of medico-legal cases to proper authorities
o Failure to report = criminal/civil liability
- Recording of all cases attended to
o Medico-legal cases recorded in a separate logbook
- Appearance of hospital representation in court
o Medico-legal officer
o Attending physician
o Medical director
- Issuance of medico-legal certificate
o Medical certificate vs medico-legal certificate
- Medico-legal examination
o Victims are required to undergo medico-legal examinations to obtain
medical reports as material evidence of the crime or accident

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Require specific details such as number of days of incapacitation,

location and gravity of wounds, etc. to aid the court in te determination
of the extent of injury or damage to the person.
It is presented in the court, to be attested and testified to by the
physician who issued the same.