Trauma Examination and Management

Overview of Trauma

Trauma, or injury, is defined as cellular disruption caused by anexchange with environmental energy that is beyond the body’s resilience, compounded by cell death dueto ischemia/reperfusion.

Trauma is the leading cause of death from ages 1 to 44. It is the third most common cause of death regardless of age.

• Trauma accounts for 6 out of every1,000 deaths globally.
• Mortality by age:
  • 50% of deaths under 4 years are due to trauma.
  • 80% between 15 and 24 years.
  • 65% between 25 and 35 years.
• Timingof mortality:
  • At the time of trauma: 50%
  • Early (within hours): 30%
  • Late (days to weeks): 20%

Types of Trauma

Abdominal Trauma

Abdominal trauma is the third most common cause of trauma-related death after head & neck and thorax traumas.

• 10% of all trauma-related deaths are due to abdominal trauma.
• Importance: Deaths related to abdominal trauma are highly preventable with early diagnosis and treatment.

Causes of Abdominal Trauma

• Blunt Trauma:
  • Traffic accidents/pedestrian (50-75%)
  • Falling from height
  • Assault
• Penetrating Trauma:
  • Stab wounds
  • Firearm injuries
• Blunt + Penetrating:
  • Explosion/Shrapnels
  • High-velocity vehicle accidents

Mechanismsof Abdominal Trauma

• Direct force injury
• Compression injury
• Shearing/Deceleration injury

Abdominal Structures

• Hollow organs: Tend to spill contents with trauma.
• Solid organs: Can bleed heavily if lacerated or fractured.
• Vascular organs: Several large blood vessels; trauma can cause massive hidden blood loss.

Compartments of the Abdomen

• Thoracoabdominal region (anterior, posterior)
• Anterior abdomen
• Flank region
• Back area

Organs Frequently Injured in Penetrating Trauma

• Low energy: Liver, small intestine, diaphragm, colon
• High energy: Small intestine, colon, liver, vascular structures

Assessment of a Seriously Injured Patient

1. Initial assessment:
   • Detect and preserve airway patency, intubation if necessary.
   • Check for signs of hypovolemia/shock (tachycardia, tachypnea, hypotension, altered mental status, pale appearance, sweating).
   • Identify evisceration, peritoneal irritation, peritoneal penetration (in penetrating trauma), pneumothorax, tamponade.
2. Resuscitation:
   • Establish vascular access.
   • Intubation.
   • Crystalloid infusion (at least 2 L).
   • Monitoring (ECG, hourly urinary output).
   • Oxygen demand, blood gases.
3. Secondary assessment (detailed evaluation):
   • Complete physical examination.
   • Re-evaluate hidden areas (back, axilla, perineum).
   • Rectal examination, nasogastric tube insertion.
4. Diagnostic studies
5. Continuous follow-up, frequent evaluation
6. Treatment

Initial Management Principles

• Treat the greatest threat to life first.
• Lack of definitive diagnosis should not delay urgent treatment.
• Initial detailed history is not essential to begin evaluation.
• Follows the mnemonic CABDE (2010):
  • Airway and cervical spine protection
  • Breathing
  • Circulation
  • Disability or neurologic condition
  • Exposure and environmental control

Initial Assessment - Physical Examination

• Remove all clothes.
• Inspection (including turning the patient's back).
• Auscultation.
• Percussion.
• Palpation (pelvic stability, rib fractures).
• Perineal examination (rectal and genital).
• Investigate additional injuries in axilla, groin, perineum, scalp, andskin folds.

Brief History & Decision Points

• Brief history.
• Physical examination (state of consciousness).
• Is the patient stable?
• Is emergency surgery required?

Hemodynamic Stability

• Hypotensive or Unstable patient:
  • Systolic Blood Pressure < 90 mm/Hg or developing hypotension.
  • Receive at least 2 L intravenous fluid, followed by blood transfusion if still hypotensive.
• Stable, Compromised patient:
  • Stable vital signs but unable to participate in examination (due to head injury, drugs/alcohol, altered mental status).
• Catheterization:
  • Nasogastric tube.
  • Foley catheter.
  • Central venous catheter.

Hemorrhagic Shock Signs

• Tachycardia
• Hypotension
• Tachypnea
• Altered mental state
• Sweating
• Paleness

Secondary Assessment

• Local wound exploration forpenetrating injuries.
• Laboratory Tests.
• Plain abdomen and thorax X-Ray.
• Ultrasonography (FAST).
• Abdominal CT (if patient is stable).
• Serial Physical Examination (dynamic follow-up).
• Diagnostic Peritoneal Lavage (DPL).
• Laparoscopy.
• Laparotomy.

Laboratory Tests

• Hemogram
• Blood group + cross-match (prepare for transfusion)
• Liver and kidney function tests
• Pregnancy test
• Amylase
• Blood alcohol and substance level, drug and toxin level
• Complete urinary analysis
• Arterial blood gases (in hypotensive/unstable patients)

Imaging Studies

X-Ray

• Direct radiological examinations:
  • Chest X-ray
  • Pelvis X-ray
  • Plain Abdominal X-ray
• Contrast-enhanced radiological examinations:
  • Urethrography
  • Cystography
  • Intravenouspyelography
  • Contrast-enhanced gastrointestinal X-ray

Sonography (FAST)

• FAST (Focused Assessment with Sonography in Trauma) is important for initial evaluation of hemodynamicallyunstable patients (lower chest/upper abdomen trauma).
• Used to determine hemopericardium, hemoperitoneum, pneumothorax.
• If FAST is positive in hemodynamically stable patients, other diagnostic modalities(CT, Diagnostic Laparoscopy) are used.
• If FAST is negative, diagnostic procedures should still be performed.

Advantages of FAST

• Non-invasive, no radiation.
• Can be used at bedside (resuscitation room,ED).
• Repeatable.
• Benefits beginning assessment.
• Low cost.

Disadvantages of FAST

• Operator-dependent.
• Challenging with obesity, gas interposition.
• Low sensitivity (<500 ml).
• False-negative for retroperitoneal and hollow organ injuries.

Computed Tomography (CT)

• Noninvasive and rapid diagnostic method for peritoneal and visceral injury.
• 97% sensitive, 98% specific in detecting peritoneal injury.
• Sensitivity 94%, specificity 95% in determining need for laparotomy.
• Oral and rectal contrast CT for suspected colorectal injuries.
• IV contrast CT is valuable in hemodynamically stable patients for differentiating non-surgical follow-up.
• Useful for determining patients to be followed non-surgically in solid organ injuries.
• With gunshot wounds (FAI), IV or triple contrast CT is valuable foridentifying cases requiring laparotomy.
• Patients with negative initial CT should be closely observed with serial PEs if abdominal injury is suspected.

Invasive Diagnostic Tools

Diagnostic Peritoneal Aspiration and Lavage (DPL)

• Invasive but quick and easy at bedside.
• Provides info on peritoneal penetration, solid organ, bowel, and diaphragm injury.
• Does not provide information about the retroperitoneum.
• Used to rapidly evaluate hemoperitoneum or perforation in unstable patients, or diaphragmatic penetration in lower chest trauma when USG is inconclusive.
• Catheter placed, fluid aspirated; if positive (blood, urine, bile, intestinal contents), it indicates injury.
• Only contraindication: overt laparotomy indication.

Relative Contraindications for DPL

• Pregnancy
• History of laparotomy
• Obesity

Diagnostic Laparoscopy

• Used to show diaphragminjury in thoracoabdominal injuries.
• Evaluates visceral injury in suspected peritoneal injury.
• Can provide treatment for diaphragmatic and visceral injuries, thus eliminating the need for laparotomy.
• Inadequate for retroperitoneal injuries.

Indications for Emergency Laparotomy

• Hypotension with signs of abdominal injury.
• Signs of peritonitis.
• Gunshot wounds penetrating the peritoneum.
• Persisting or recurrent hypotension despite adequate resuscitation.
• Blood in nasogastric contents or on rectal examination.
• Inability to push-back evisceration.
• Extraluminal air on direct radiographs.
• Detection of diaphragmatic injury.
• Detection of intraperitoneal bladder rupture in cystography.
• Detection of injury to the pancreas or gastrointestinal tract.
• Solid organ injuries are NOT a definite indication for laparotomy (unlike hollow organ injuries).

Serial Physical Examination (SPE)

• Patients with no immediate surgical pathology may be observed with SPE.
• Not safe in cases of head trauma, spinal cord injury, altered mental status, need for anesthesia.
• Involves evaluation of abdomen, neurological status, circulatory status of extremities, and all systems.
• Ideally repeated every 6 hours.
• Patients >65, on anticoagulants, with significant comorbidities (DM, HT), orsevere cases should be admitted for at least 24 hours of clinical observation.

Termination Criteria for Observation & SPE

• Appropriate mental status.
• Stability of vital signs.
• Spontaneous urination.
• Tolerance oforal intake.
• Mobilization.
• Not taking anticoagulants.
• Going to a safe environment.

Blunt Abdominal Trauma

• Most common causes: traffic accidents, falls from a height, physical assault.
• Most commonly injured organs: spleen, liver, kidneys.
• Injuries to diaphragm, duodenum, pancreas, hollow organs are less common.
• 90% of blunt abdominal traumas are accompanied by other system injuries (multitrauma).

Management Algorithm for Blunt Abdominal Trauma

• Hemodynamically Unstable or Emergency Laparotomy Indicated: Resuscitation + LAPAROTOMY
• Hemodynamically Stable:
  • Presence of abdominal pain + PE findings, OR abdominal free fluid, OR solid organ injury:
    • Aspirate under USG or DPL.
    • If blood in aspiration or urine, bile, intestinal content: Diagnostic laparoscopy or close FUwith serial PE.
    • If negative: Observation & SPE.
  • No significant findings: Observation & SPE.

Grading for Solid Organ Injury

• Nonoperative management of solid organ injuries has replaced routine operative exploration due to CT scanning.
• Patients requiring operation may be treated with less radical resection techniques (e.g., splenorrhaphy, partial nephrectomy).

Penetrating Abdominal Trauma

• Classified by wounding agent: stab wound, gunshot wound, shotgun wound.
• Gunshot wounds: Subdivided into high- and low-velocity injuries.
  • Bullet speed >600 m/s (high-velocity) are infrequent in civilian setting.
• Shotgun injuries: Close-range (<6m) vs. long-range.

Abdominal Regions for Penetrating Trauma

• Lower thoracic
• Anteriorabdomen (true abdomen)
• Back (retroperitoneum)

Probability of Injury

• Gunshot wounds: 90-98% probability of intra-abdominal organ injury.
• Lower thoracic region injuries: 25-30% rate of intra-abdominal organ injury.
• Abdominal stab wounds: 55-60% probability of organ injury.

Stab Wound Injuries

Management basedon anatomical region:

• Lower Thoracic Region:
  • Evaluate for cardiac injury.
  • Laparoscopic repair or Laparotomy if diaphragm injury or deterioration requiring emergency surgery.
  • If no findings, discharge after initial follow-up.
• Anterior Abdomen:
  • Local Wound Exploration:
    • If no penetration to peritoneal cavity: Suture + tetanus prophylaxis.
    • If penetrationor suspicious: Diagnostic Laparoscopy.
  • If no findings in 48h: Discharge.
  • If deterioration requiring emergency surgery or suspicion during SPE: DiagnosticLaparoscopy or DPL.

General Considerations for Stab Wounds

• Investigate intrathoracic, mediastinal, and retroperitoneal injuries based on wound location.
• GI bleeding symptoms suggest gastroduodenal or colorectal bleeding.
• If the stabbing tool is still in the patient, even if stable, proceed to surgery due to potential severe bleeding upon removal.

Indications for Emergency Surgery (Stab Wounds)

• Hemodynamic instability.
• Peritonitis.
• Rectal trauma.
• Evisceration.
• Significant fresh bleeding in NG tube or rectal exam.
• Stabbing tool still in the body.

Firearm Injuries

• Less frequent but higher mortality than stab wounds.
• Very high mortality if abdomen is penetrated.
• 25% can be treated nonoperatively (if isolated).
• Most commonly injured organs: Small intestine, Colon, Liver.

Trauma Mechanisms (Bullets)

• Damage from the bullet itself (direct impact).
• Damage from cavitation (temporary cavity created by pressure wave).
• High-acceleration weapons can cause injury even if completely extraperitoneal due to energy wave.

Management of Firearm Injuries

• ABCDE...
• Obtain brief history (patient, eyewitness). Pre-hospital vital signs correlate withinjury severity.
• Number of shots and estimated blood loss at scene can help assess.
• Local Wound Exploration: Generally not efficient for major gunshot wounds. Focus on depth, trajectory, angle, and possible exit site.
• Plain X-Ray: Useful for detectingbullet course and location. Bilateral radiographs increase chance of estimating peritoneal penetration. Less beneficial for multiple wounds.
• USG: Fastest for detecting blood in pericardial/peritoneal space. Easily applied in unstable patients. Insufficient for intra-abdominal, diaphragmatic, or hollow organ injury.
• CT Scan: Easy and fast. Diagnosis of solid and hollow organ injuries improved with IV and oral contrast. Rectal contrast for pelvic/lower abdomen injuries. Allows time for damage assessment in stable patients.
• Lab tests: Blood group, CBC, coagulation, preparedfor transfusion. Arterial blood gases for unstable patients.
• Prophylactic antibiotic: Broad-spectrum antibiotics for all penetrating abdominal trauma. Not routinely continued if no additional pathology.

Algorithm for Firearm Injuries

• Unstable or Emergency Surgery Indicated:Resuscitation + LAPAROTOMY
• Stable:
  • Back & Lumbar (suspicious for penetration): 3 Contrast CT Scan
  • Anterior Abdomen (penetrated): Diagnostic Laparoscopy or DPL

Damage Control Surgery (DCS)

A surgical strategy adopted when patients die due to metabolic disorders despite anatomical repairs. Involves simpler surgical techniques, temporary closure, and definitive repairs after metabolic correction.

• Objective: Save time for recovery of vital parameters and decrease trauma-related mortality.

Injuries that may require DCS

• Serious liver injuries
• Serious pancreatic head injuries
• Retrohepatic vena cava injuries
• Ruptured pelvic hematomas

Stages of DCS

1. OP 1 (InitialSurgery):
   • Control for bleeding.
   • Control for contamination.
   • Temporary closure.
2. ICU Management (Stabilization Phase):
   • Treat coagulopathy.
   • Hemodynamic stabilization.
   • Ventilatory support.
   • Heating.
   • Detailed work-up for injury.
3. OP 2 (Definitive Surgery):
   • Permanent repairs.

Examples of DCS

• Temporary shunt for vascular injury.
• Temporary abdominal closure.
• Packing for liver injury.