Trauma

If you spent your free time during your surgery rotation trying to catch up on lost sleep, go back and read a chapter about trauma from a general surgery text. Trauma and its management are high yield for Step II.

ABCDEs are the key to management of patients with trauma. Always do them in order, For ex ample, if the patient is bleeding to death and has a blocked airway, you must choose which problem to address first. The answer is airway management:

A — Airway: provide, protect, and maintain an adequate airway at all times. If the. patient can answer questions, the airway is fine.You can use an oropharyngeal airway in uncomplicated cases and give supplemental oxygen. When you are in doubt or the patient's airway is blocked, intubate. If intubation fails, do a cricolhyroklotoiny.

B = Breathings similar to airway, but even when the airway is patent, the patient may not be breathing spontaneously.The end result is the same: when you are in doubt or the patient is not breathing, intubate. If intubation fails, do a crieothyroidotomy.

C --- Circulation: if the patient seems hypovolemic (tachycardia, bleeding, weak: pulse, pale ness, diaphoresis, capillary refill > 2 seconds), give IV fluids and/or blood products.The initial procedure is to start two large bore IV catheters and give a bolus of 10--20 ml/kg (roughly I I.) of lactated Ringer's solution (IV fluid of choice in trauma). Reassess the patient; after bolus for irnprovement. Give another bolus il needed.

D ~ Disability: check neurologic function (Glasgow coma scale).

E --- Exposure: strip the patient and "put a linger in every orifice" so that you do not miss any occult injuries.

Important points:

1. All trauma patients generally get cervical spine, chest, and pelvic x- rays.

2. Evaluate any head trauma with a noncontrast CT (better than MRI for trauma).

3. In blunt abdominal trauma, initial findings determine the course of action:

■ If the patient is awake and stable and your exam is benign, observe and repeat the abdominal exam later.

® If the patient is hemodynamically unstable (hypotension and/or shock that do not respond to a fluid challenge), proceed directly to laparotomy.

■ If the patient has altered mental status, the abdomen cannot be examined, or an obvious sources of blood loss explains the hemodynamic instability, either do a diagnostic peri toneal lavage (DPI.,) or get a CT scan.

4. In penetrating abdominal trauma, the type of injury and initial findings determine the course of action:

«With any gunshot wound, proceed directly to laparotomy.

a With a wound from a sharp instrument, management is more controversial. Either proceed directly to laparotomy (the better choice if the patient is unstable) or do a DPL. If the DPL is positive, do a laparotomy; if it is negative, observe and repeat the abdominal exam later.

Six thoracic injuries that can be rapidly fatal and that you should be able to recognize:

1. Airway obstruction: no audible breath sounds. Patients cannot answer questions even though they are awake and gurgling. Treat by intubation. If intubation fails, do a erieotby-roidotomy (or a tracheostomy in the operating room if time allows).

2. Open pneumothorax: open defect in the chest wall that causes poor ventilation and oxy genation. Treat with intubation, positive-pressure ventilation, and closure of the defect in the chest wall. You can use gauze. Tape it on three sides only to allow excessive pressure to escape. Otherwise you may convert an open pneumothorax into a tension pneumothorax.

3. Tension pneumothorax: usually after blunt: trauma. Air forced into pleural space cannot escape and collapses the affected lung, then shifts the mediastinum and trachea to the op posite side of the chest. Know what this condition looks like on x-ray. There are no breath sounds on the affected side, and chest percussion produces a hypertympanic sound. Hypotension and distended neck veins may result from impaired cardiac filling. Treat with needle thoracentesis, followed by insertion of a chest tube. (See figure, top of next page.)

Cardiac tamponade: the classic history is penetrating trauma to the left chest (where the heart is located). Patients have hypotension (due to impaired cardiac filling), distended neck veins, muffled heart sounds, pulsus paradoxus (exaggerated fall in blood pressure on inspiration), and normal breath sounds. Treat with pericardiocentesis if the patient is unstable (put a catheter in the pericardial sac, and aspirate the blood or fluid). If the patient is stable, you can do an echocardiogram to confirm the diagnosis first,

5. Massive hemothorax: loss of more than 1 I. of blood into the thoracic cavity. Patients have decreased (not absent) breath sounds in the affected area, dull note on percussion, hypotension/collapsed neck veins (from blood leaving the vascular tree), and tachycardia. Placement of a chest tube causes the blood to come out. Give IV fluids and/or blood before you place tire chest tube. If bleeding stops after the initial outflow, get an x-ray to check for remaining blood or pathology and treat supportively If bleeding does not stop, perform an emergent thoracotomy.

Left tension pneumothorax. (From James EC, Corry RJ, Perry JF: Principies of Basic Surgical Practice. Philadelphia, Hanley & Beifus, 198?, with permission.)

6. Flail chest: when several adjacent ribs are broken in multiple places, the affected part of the chest wall may move paradoxically during respiration (in during inspiration, out during expiration).There is almost always an associated pulmonary contusion, which, combined with pain, may make respiration inadequate. When you are in doubt or the patient is not doing well, intubate and give positive pressure ventilation.

Other injuries:

1. Aortic rupture: the most common cause of immediate death after an automobile accident or fell from a great height. Look for widened mediastinum on x-ray and appropriate trauma history. Get an angiogram if you are suspicious. Treat with surgical repair.

2. Diaphragm, rupture: usually occurs on the left because the liver protects the right, side. Look for bowel herniated into the chest. Fix surgically.

3. Neck trauma: the» neck is divided into three zones for trauma:

ZONE ii

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