ATLS LECTURE PART II SIGNS AND SYMPTOMS: Characterized by some or all

• Chest pain • Tracheal deviation

Dr. Samuel Cosme
• Air hunger • Unilateral absence of breath sounds
• Tachypnea • Hyperresonant note on percussion
CHAPTER 4: THORACIC TRAUMA • Respiratory distress
• Tachycardia
• Elevated hemithorax without respiratory movement
• Neck vein distention
• Hypotension • Cyanosis (late manifestation)
OUTLINE
• Primary survey: life-threatening injuries
OPEN PNEUMOTHORAX
o Airway Problems
Laryngeal injuries
Proximal tracheobronchial injuries
o Breathing Problems
Open pneumothorax
Tension pneumothorax
o Circulation Problems
Massive hemothorax
Cardiac tamponade
• Secondary survey
o Potentially Life-Threatening Injuries
o Other Manifestations of Chest Injuries

THORACIC INJURY
• Common in polytrauma patients and can be life-threatening, especially if not promptly identified and MASSIVE HEMOTHORAX
treated during the primary survey. • Results from the rapid accumulation of more than 1500 mL of blood or one-third or more of the patient’s
• Significant cause of mortality blood volume in the chest cavity.
• Blunt: <10% require operation • Common cause: Penetrating wound that disrupts the systemic or hilar vessels or from blunt trauma
• Penetrating: 15-30% require operation • Signs and symptoms
• Majority: Require simple procedures o Shock + absence of breath sounds or dullness to percussion on one side of the chest.
• Most life-threatening injuries are identified during the primary survey • Initial mx: simultaneously restoring blood volume and decompressing the chest cavity.
• Goal of early intervention is to prevent or correct hypoxia o Establish large caliber intravenous lines
o Infuse crystalloid and begin transfusion of
TENSION PNEUMOTHORAX uncrossmatched or type-specific blood
• Tension Pneumothorax. A “one-way valve” air o Insertion of single chest tube (28-32 French): 5th
leak occurs from the lung or through the chest ICS AAL
wall, and air is forced into the thoracic cavity, • Urgent thoracotomy indications
eventually collapsing the affected lung. o Immediate return of >1500 mL of blood
• Often classified as a breathing problem, but o Initial output of <1500 mL of fluid, but
mortality is due to obstructive shock caused by continue to bleed
decreased venous return associated with o Rate of continuing blood loss (200 mL/hr for 2
mediastinal shift. to 4 hours
o Persistent need for blood transfusion
o Trauma to the mediastinal “box”: damage to the
great vessels, hilar structures, and the heart, with
the associated potential for cardia tamponade.
 SUMMARY
CARDIAC TAMPONADE
• Result from penetrating or blunt injuries that cause the pericardium to fill Potential Life Clinical Treatment Pitfalls
with blood from the heart, great vessels, or pericardial vessels Threat Presentation/Findings
• Compression of the heart by an accumulation of fluid in the pericardial
sac decreased cardiac output due to decrease inflow to the heart. It can Simple +/- shortness of breath No Chest tube Could become tension
develop slowly, allowing for Pneumothorax hypotension drainage pneumothorax if
• Classic clinical triad: Muffled heart sounds, hypotension, and Diagnosis by chest x-ray untreated
distended veins Hemothorax Dullness to percussion Chest tube Could become massive
o Not uniformly present with cardiac tamponade.
Diagnosis by chest x-ray drainage hemothorax
• Kussmaul’s sign: rise in venous pressure with inspiration when
breathing spontaneously is a true paradoxical venous pressure Flail Chest and Paradoxical movement of Oxygen Progressive respiratory
abnormality that is associated with tamponade Pulmonary chest wall ; Commonly Analgesia failure
• PEA suggestive of cardiac tamponade but can have other causes Contusion presents with pain & poor Intubation if
• FAST is 90–95% accurate respiratory excursions necessary
• Subxiphoid pericardiocentesis: temporizing maneuver
Blunt Cardiac ECG changes (PVC’s, sinus Cardiac At risk for clinically
o Use of a large, over-the needle catheter or the Seldinger technique for
Injury tachycardia, AF, RBBB, ST monitoring significant dysrhythmias
insertion of a flexible catheter is ideal
segment Therapy based on
o Urgent priority is to aspirate blood from the pericardial sac.
changes clinical status
TRAUMATIC CIRCULATORY ARREST Traumatic May be asymptomatic Endovascular or Blood pressure control
• Trauma patients: unconscious + no pulse, including PEA, ventricular fibrillation, and asystole (true Aortic Multiple possible open surgical important prior to
cardiac arrest) Disruption radiographic findings repair definitive therapy
• Causes
o Severe hypoxia Traumatic Respiratory distress Operative repair Concomitant pulmonary
o Tension pneumothorax Diaphragm Obscured left diaphragm contusion may mask
o Profound hypovolemia Injury border; Abdominal viscera in diaphragm injury
o Cardiac tamponade chest
o Cardiac herniation Esophageal Chest pain; mediastinal air Operative repair Delayed diagnosis
o Severe myocardial contusion injury on imaging; crepitus delayed
• Management fever
o Start closed CPR simultaneously with ABC management.
o Secure a definitive airway with orotracheal intubation (without rapid
Traumatic aortic rupture
sequence induction).
o Administer mechanical ventilation with 100% oxygen • Widened mediastinum • Deviation of the esophagus (NGT) to the right
• Obliteration of the aortic knob
• Widened paratracheal stripe
SECONDARY SURVEY • Deviation of the trachea to the right
• Widened paraspinal interfaces
• Simple pneumothorax • Depression of the left mainstem bronchus
• Elevation of the right mainstem bronchus • Presence of a pleural or apical cap
• Hemothorax
• Obliteration of the space between the • Left hemothorax
• Flail chest
pulmonary artery and the aorta (obscuration of • Fractures of the first or second rib or scapula
• Pulmonary contusion
• Blunt cardiac injury the aortopulmonary window)
• Traumatic aortic disruption
Traumatic Diaphragmatic Injury
• Traumatic diaphragmatic injury
• Blunt trauma produces large radial tears that
• Blunt esophageal rupture
lead to herniation, whereas penetrating trauma
produces small perforations that can take
time—sometimes even years—to develop into
diaphragmatic hernias
 CHAPTER 5: ABDOMINAL AND PELVIC TRAUMA • BLAST
o Penetrating eg. fragment wounds
o Blunt injuries eg. patient being thrown or struck by projectiles
MECHANISM OF INJURY o Blast overpressure eg. injuries to the tympanic membranes, lungs, and bowel
BLUNT ASSESSMENT AND MANAGEMENT
• Direct blow/compression and crushing injuries
• Physical examination findings most strongly associated with intra-abdominal injury:
• Shearing injuries (eg. inappropriate restraint device use) o Seat belt sign
• Deceleration injuries (eg. motor vehicle crashes and who fall from significant heights)
o Rebound tenderness
• Organ most frequently injured
o Spleen (40% to 55%) o Hypotension
o Liver (35% to 45%) o Abdominal distension
o Small bowel (5% to 10%) o Abdominal guarding
o Concomitant femur fracture
INJURIES ASSOCIATED WITH RESTRAINT DEVICES • Findings suggestive of pelvic fracture include:
RESTRAINT DEVICE INJURY o Pelvic tenderness
o Evidence of ruptured urethra (scrotal hematoma or blood at the urethral meatus),
Lap Seat Belt • Tear or avulsion of bowel mesentery (bucket handle) o Discrepancy in limb length
• Compression • Rupture of small bowel or colon o Rotational deformity of a leg without obvious fracture
• Hyperflexion • Thrombosis of iliac artery or abdominal aorta
• Urethral, Perineal, Rectal, Vaginal, and Gluteal Examination
• Chance fracture of lumbar vertebrae
o Findings suggestive of urethral injury
• Pancreatic or duodenal injury
Presence of blood at the urethral meatus
Shoulder Harness • Rupture of upper abdominal viscera Ecchymosis or hematoma of the scrotum and perineum
• Sliding under the seat • Intimal tear or thrombosis in innominate, carotid, • Rectal examination
belt (“submarining”) subclavian, or vertebral arteries o Blunt trauma
• Compression • Fracture or dislocation of cervical spine Assess sphincter tone and rectal mucosal integrity
• Rib fractures
Identify any palpable fractures of the pelvis
• Pulmonary contusion
o Penetrating
Air Bag • Face and eye abrasions Assess sphincter tone
• Contact • Cardiac Injuries Look for gross blood
• Contact/deceleration • Spine fractures • Vaginal examination
• Flexion (unrestrained) o Performed when injury is suspected such as in the presence of:
• Hyperextension (unrestrained)
— complex perineal laceration
— pelvic fracture
PENETRATING — transpelvic gunshot wound
• Stab wounds and low-energy gunshot wounds cause tissue damage by lacerating and tearing — unresponsive menstruating women for the presence of tampons
• Stab wounds most commonly involve the: • Gluteal examination
o liver (40%) o Penetrating injuries — associated with up to a 50% incidence of significant intra-abdominal
o small bowel (30%) injuries
o diaphragm (20%) • Physical findings requiring further abdominal evaluation to identify or exclude intraabdominal injury:
o colon (15%)
o Altered sensorium
• Gunshot wounds
o Altered sensation
o Cause additional intra-abdominal injuries based on the trajectory, cavitation effect, and possible
bullet fragmentation o Injury to adjacent structures, such as lower ribs, pelvis, and lumbar spine
o Determinants of degree of tissue injury: type of weapon, the muzzle velocity, and type of o Equivocal physical examination
ammunition o Prolonged loss of contact with patient anticipated eg. general anesthesia for extraabdominal
o Most commonly injure the: small bowel (50%), colon (40%), liver (30%), and abdominal vascular injuries or lengthy radiographic studies
structures (25%) o Seat-belt sign with suspicion of bowel injury
ADJUNCTS TO PHYSICAL EXAMINATION EVALUATION OF SPECIFIC PENETRATING INJURIES
- Gastric Tubes and Urinary Catheters • Anterior abdominal stab wounds
- Chest & abdominal x-rays o Serial physical examination, FAST, and DPL, diagnostic laparoscopy
- Pelvic x-ray • Thoracoabdominal injuries
- FAST o Double (PO and IV) and triple (PO, rectal, and IV) contrast CT scans, diagnostic laparoscopy,
- DPL
thoracoscopy, DPL
- CT scan
• Flank and back injuries
o Serial PE (with or w/o serial FAST exams),Double- or triple contrast CT scans, DPL
DPL FAST CT SCAN
INDICATIONS FOR LAPAROTOMY IN PATIENTS WITH
PENETRATING ABDOMINAL WOUNDS:
Advantages • Early operative • Early operative • Anatomic diagnosis
• Hemodynamic abnormality
determination determination • Noninvasive •
• Gunshot wound with a transperitoneal trajectory
• Performed rapidly • Noninvasive Repeatable
• Signs of peritoneal irritation
• Can detect bowel injury • Performed rapidly • Visualizes
• Signs of peritoneal penetration (e.g., evisceration)
• No need for transport from • Repeatable retroperitoneal
• Free air
resuscitation area • No need for transport structures
• Positive DPL, FAST, or CT
from • Visualizes bony and soft-
resuscitation area tissue
INDICATIONS FOR LAPAROTOMY IN PATIENTS WITH
structures
BLUNT ABDOMINAL TRAUMA:
• Visualizes extraluminal
• Blunt abdominal trauma with hypotension, (+) FAST or clinical evidence of intraperitoneal bleeding
air
• Peritonitis
Disadvantages • Invasive • Not repeatable • Operator-dependent • Higher cost and longer • Free air, retroperitoneal air, or rupture of the hemidiaphragm
• Risk of procedure-related • Bowel gas and time • Positive FAST, DPL, or CT
injury subcutaneous • Radiation and IV contrast
• Requires gastric and air distort images exposure EVALUATION OF SPECIFIC BLUNT TRAUMA INJURIES:
urinary • Can miss diaphragm, • Can miss diaphragm • Diaphragm injuries
decompression bowel, injuries o Blunt tears → posterolateral left hemidiaphragm
• Interferes with and pancreatic injuries • Can miss some bowel and o Chest x-ray → elevation or “blurring” of the hemidiaphragm, hemothorax, an abnormal gas shadow
interpretation • Does not completely pancreatic injuries that obscures the hemidiaphragm, or a gastric tube positioned in the chest
of subsequent CT or FAST assess • Requires transport from • Duodenal injuries
• Low specificity retroperitoneal structures resuscitation area
o Unrestrained drivers involved in frontal-impact motor vehicle collisions; direct blows to the
• Can miss diaphragm • Does not visualize
injuries extraluminal air abdomen
• Body habitus can limit o Bloody gastric aspirate or retroperitoneal air on an abdominal radiograph or CT
image clarity o Upper gastrointestinal x-ray series, double-contrast CT, or emergent laparotomy
• Pancreatic injuries
Indications • Abnormal hemodynamics • Abnormal • Normal hemodynamics
o Direct epigastric blow
in hemodynamics in in blunt
blunt abdominal trauma blunt abdominal trauma or penetrating abdominal o Double-contrast CT; surgical exploration (equivocal studies)
• Penetrating abdominal • Penetrating abdominal trauma • Genitourinary Injuries
trauma trauma • Penetrating back/flank o Contusions, hematomas, and ecchymoses of the back or flank, gross hematuria → potential
without other indications for without other indications trauma underlying renal injury→ evaluation (CT or IVP) of the urinary tract
immediate laparotomy for immediate laparotomy without other indications o Multisystem injuries and pelvic fractures → posterior urethral injury
for o Straddle impact → anterior urethral injury
immediate laparotomy
• Hollow Viscus Injuries
o Sudden deceleration with subsequent tearing near a fixed point of attachment
o Seat belt positioned incorrectly eg. transverse, linear ecchymosis on the abdominal wall
o Lumbar distraction fracture (i.e., Chance fracture)on x-ray
• Solid Organ Injuries
o Injuries to the liver, spleen, and kidney that result in shock, hemodynamic abnormality, or evidence
of continuing hemorrhage →urgent laparotomy
o Solid organ injury in hemodynamically normal patients → managed nonoperatively
• Pelvic Fractures and Associated Injuries
o motor vehicle crash, motorcycle crash, pedestrian–vehicle collision, direct crushing injury, or fall

o Management
Rapid hemorrhage control → mechanical stabilization of pelvic ring & external counter pressure
(Wrap / Binder), rule out abdominal hemorrhage, angiography, fixation, pelvic packing
Fluid resuscitation