Chapter 254: Trauma in Adults
# ATLS
- Airway assessment (and cervical spine stabilization)
- If appropriately answering questions, patient has a patent airway (at least for the moment)
- Observe patient for signs of respiratory distress
- Inspect mouth and larynx for injury or obstruction
- Assume cervical spine injury in blunt trauma patients until proven otherwise
- If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress, the threshold for intubation is very low.
- Patients may be intubated or ventilated with the anterior portion of the cervical collar removed, or with their neck manually stabilized.
- Patients with burn injuries and evidence of respiratory involvement are often intubated out of precaution.
- If orotracheal intubation is difficult, perform a cricothyrotomy.
- Breathing
- Assess oxygenation status with pulse oximetry.
- Inspect and auscultate chest wall for injuries.
- In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in favor of imaging.
- Circulation (and hemorrhage control)
- Assess circulatory status by palpation of central and peripheral pulses
- Blood pressure should be measured if it can be done expediently, but it can be skipped if it would delay the rest of the primary survey.
- Place two large-bore intravenous lines (at least 16 gauge) for blood typing and crossmatch, and resuscitation (if needed).
- If intravenous line placement is not possible or difficult, intraosseus line should be used instead.
- Control on-going hemorrhage with manual pressure or tourniquets.
- Emergency thoracotomy may be performed in patients with recent loss of pulses (especially in patients with stab wounds to the chest).
- If patient is hypotensive, administer a bolus of intravenous saline.
- If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
- If significant hemorrhage and persistent hemodynamic instability, transfuse plasma, platelets and red blood cells at 1:1:1 ratio.
- Focused Assessment with Sonography for Trauma (FAST) exam is usually performed, especially for hemodynamically unstable patients
- May be performed during the secondary survey in hemodynamically stable patients
- Some patients may require emergent reversal of anticoagulation
- Remember hypovolemic shock due to hemorrhage requires loss of ? 1.5 L of blood. Keep in mind the compartments where large amounts of blood may go:
- Outside (external hemorrhage)
- Thoracic cavity
- Pelvic cavity
- Abdominal cavity
- Thighs (e.g., multiple femur fractures)
- See Shock LC
- Assess circulatory status by palpation of central and peripheral pulses
- Disability (and neurological evaluation)
- Assess patient’s Glasgow Coma Scale score
- See Glasgow Coma Scale (GCS)
- A GCS score < 8 is an indication for intubation
- Assess pupillary size
- If patient is interactive, assess motor function and light touch sensation.
- Assess patient’s Glasgow Coma Scale score
- Exposure (and environmental control)
- Undress patient completely.
- Examine body for signs of occult injury, including patient’s back.
- If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
- Palpate for vertebral tenderness and rectal tone.
Chapter 255: Trauma in the Elderly
Chapter 256: Trauma in Pregnancy
Chapter 257: Head Trauma
Chapter 258: Spine Trauma
Limit cervical spine motion until injury is ruled out clinically or radiographically.
- Logroll to the supine position
- Usually onto a rigid longboard
- Airway access
- The face shield and mouthguard are removed to allow access to the airway
- Spinal stabilization
- A rigid cervical collar is typically applied.
- If the uniform or equipment (eg, helmet, shoulder pads) cannot be removed to allow cervical collar application without significant risk of spinal manipulation, stabilization can be achieved through other means (eg, towel rolls, foam head blocks)
- Screen for cervical spine injury
- High risk of CS injury -> require CS imaging
- Low risk of CS injury -> NEXUS low-risk criteria
- CT scan is preferred (~98% vs ~52% sensitivity compared to plane radiography)
Chapter 259: Trauma to the Face
Chapter 260: Trauma to the Neck
Chapter 261: Pulmonary Trauma
Chapter 262: Cardiac Trauma
Chapter 263: Abdominal Trauma
# Point-of-care ultrasound
https://next.amboss.com/us/article/S70yOh
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Conservative treatment
- Grade I~III
Surgical treatment
- Grade IV~V
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- Pringle maneuver
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- Damage control surgery (DCS) – ? ?? ?? packing, ICU?? ?? ? ??? ?? hypothermia, acidosis, coagulopathy ?? ???? ?? ????. ? 48-72hr ? ??? ???, packing ???? ???? ???, ?? ?? ?? ??.
- Hepatic vein?? IVC ?? ?? -> 4? ?? ??, ??-??? ??, v-v ???
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- Warm saline, blanket use
Spleen
Conservative treatment
V/S stable ?? Hb ??? 12-48hr ?? ?? ??? ?? ???? ?? ??.
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Surgical treatment
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??? ?????(splenorrhaphy) ?? ???.
Chapter 264: Trauma to the Flank and Buttocks
Chapter 265: Genitourinary Trauma
General approach to genitourinary trauma
- Patient history
- Physical examination
- Urinalysis with microscopy: macroscopic hematuria (urine not clear or yellow) or microscopic hematuria
- The color of the urine does not correlate with injury severity!
- Microscopic hematuria after significant (nonurethral) trauma is common; no further diagnostic tests are needed in patients who are hemodynamically stable and present without any other signs or symptoms of associated pelvic or abdominal injury.
- Blood analysis: exclude anemia due to blood loss; assess renal function (creatinine)
- The tract should be assessed starting with the external genitalia and progressing proximally (i.e., urethra ? bladder ? ureters ? kidneys).
Renal and ureteral injury
- CT with IV contrast of the abdomen/pelvis: to assess renal and accompanying injuries or intra-abdominal fluid retention
- Delayed CT imaging: indicated if injury to the renal pelvis and ureters is suspected
- IV pyelography: to assess for contrast extravasation if delayed CT images are nondiagnostic
- Urethrocystography: if CT is unavailable
Bladder injury
- Retrograde cystography or retrograde CT cystography
- To assess for bladder rupture in patients with gross hematuria (can be seen in Foley catheter if it has been placed) or microscopic hematuria and pelvic fracture.
- Do not perform urethrogram or cystogram if severe pelvic vascular injury is suspected!
Urethral injury
- Retrograde urethrogram: to rule out suspected urethral injury
- First diagnostic step (before catheterization) in a patient with suspected urethral injury
- Findings: contrast extravasation from the urethra at point of injury
- If some contrast enters the bladder ? partial injury
- If no contrast enters the bladder ? complete injury
- Complete rupture of the urethra is more likely in posterior urethral injury.
- Foley catheter placement
- Suspected urethral injury is a relative contraindication for catheterization, as it may worsen the injury.
- In cases of gross hematuria without other clinical signs of urethral injury, a single attempt at Foley catheter placement may be performed.
- Successful catheterization without resistance makes urethral injury an unlikely diagnosis.
- If any resistance is met, retrograde urethrography should be performed.
Renal and ureteral injuries
Etiology
- Blunt abdominal trauma (80% of cases): falls from a height, automobile collisions, blows to the torso, pelvic fractures
- Blunt thoracic trauma: associated with lower rib (9th –12th) fractures
- Penetrating trauma (gunshot or stab wounds); assault (physical or sexual)
Clinical features
- Pain, bruising, hematoma on the affected side
- Hematuria
- Possible accompanying injuries (e.g., rib fracture with motion-dependent pain)
- In large perirenal hematoma: shock
- Ureteral injuries are easily overlooked, but can cause palpable flank mass, flank pain, and fever.
Bladder injuries
Etiology
- Most commonly blunt abdominal trauma and pelvic fractures
- Penetrating trauma
- Contusion
- Iatrogenic: transurethral or pelvic surgery
Clinical features
- Extraperitoneal and/or intraperitoneal injury
- Gross hematuria (majority of cases)
- Inability to void
- Pain in the lower abdomen
- Intraperitoneal injury
- Peritoneal irritation
- Rise in serum creatinine through peritoneal resorption of urinary creatinine
Urethral injuries
Etiology
- Almost exclusively seen in men
- Less common in women due to a shorter and more mobile urethra
- Anterior urethral injuries
- Direct trauma to perineum (direct blow, straddle injury): bulbous urethra is most commonly injured
- In conjunction with penile fracture
- Iatrogenic (instrumentation of urethra)
- Posterior urethral injuries
- Significant pelvic fractures due to trauma (automobile collisions)
- Membranous urethra is most commonly injured
Clinical features
Chapter 266: Trauma to the Extremities
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