Egurukul - Trauma (Surgery)

TRAUMA
Jai Arora
Compiled by
Rohan Hake by
Compiled
Seth GS Rohan
MedicalHake
college
Seth 9561983020
GS Medical college
In Trauma we follow ATLS guidelines
Bailey and Love follow NICE guidelines
Moto in management : Living problem is better than dead solution
Triage Meaning : To sort
Prioritising treatment on basis of severity of injury

When resources are limited and demand is more
Multiple Casualty : Multiple injured patient but not overwhelming the resources in that trauma centre
Mass Casualty : When multiple injured patients have reached a trauma centre and overwhelming the resources
Polytrauma : When one individual has multiple injuries (Multiple systems affected)
Triage is come into play only when we have Mass Casualty where resources is limited and demand is more
Level I : Field Triage : by Paramedics
Level II : Medical triage : By Doctors
Triage is based on SALT protocol
S : Sort
A : Assess
L : Life saving treatment
T : Transport and Definite Treatment
Red tag : Urgent : Immediate life threatening injury
Yellow tag : Delayed : May have life threatening injury but not immediate enough
Green tag : Minor : Walking wounded
Black : Moribound pulseless or deceased patient
ABC ways in trauma

A : Airway at risk : 1st to die
B : Breathing problem : 2nd to die
C : Circulatory problem : 3rd to die
Triage is dynamic process

Once you treat a red tag patient then the yellow tag patient should be changed to red tag
Black tag patients should be treated after taking care of Red and Yellow tag patients
Primary survey Secondary survey

v v
Swift examination to find what It is elaborate survey

is killing and to take care of that head to toe examination
A : Airway with restriction of cervical spine movement

B : Breathing
C : Circulation
D : Disability
v E : Environmental exposure
Coupon code : RHE20 https://t.me/DexterMorgan07 9561983020 rahunotes@gmail.com For more notes : https://t.me/egurukulnotes2
In any patient of trauma, If a patient has A problem even if there is evident B and C problem;
you can’t go to B and C without taking care of A.
If A is not a problem immediately go to B

If B is also not a problem then immediately go to C
Scene safety for rescuers
:
Check response
If patient is not responding
:
Call for help
Primary survey
Talk to the patient
v v
Patient Talking Patient not talking

V
Airway is not a problem 1. Tachynpnea

V
2. Use of accessory muscle of respiration If any of these present
Apply C collar 3. Snoring / gurgling / Hoarsness / Stridor
V
V
4. Tracheal shift Signs of airway compromise
Proceed to B 5. Cyanosis : Late sign
÷
On securing airways
If signs are persisting
Provide MILS
Chin lift/ Jaw thrust Paramedics arrived
Immediately apply O2 mask
Apply C collar
v v
Patient is in need of Adjunct airway

definitive airway
Indications 1. Presence of apnea
É
2. SpO2 on Oxygen <85%
3. GCS <8
4. Impending airway compromise
Inhalational injury
>
Inline orotracheal intubation
Put Inline orotracheal intubation
If fails : attempt once again

BURP : Backward, Upwards Rightward Pressure
If fails
Surgical Cricothyroidotomy
Airways
For maintenance of airways
Definitive airway Adjunctive airway Restriction of Cervical spine

v v
Tracheal intubation of any Eg : Oropharyngeal airway v v
sort which is secured Nasopharyngeal airway MILS C collar

Laryngeal mask airway v v
Eg : Endotracheal intubation Multi lumen esophageal tube Manual In-line Hard collar or
Tracheostomy Stabilisation Philadelphia collar
Sx cricothyroidotomy
Manuevers to maintain airways

— Chin lift
— Jaw thrust
— Neck lift
— Head lift
What is your priority in a patient of trauma? : Securing Airway > C spine stabilisation
What is next step after putting definitive airway : 5 points auscultation

v
1. Epigastrium
2. Upper Right & left chest
3. Lower Right & left chest
Confirmation of airway intubation : Capnography
Things to look for in Primary survey

— Airway obstruction
— Tracheobronchal injury
— Tension pneumothorax
— Open pneumothorax
— Massive hemothorax
— Cardiac Tamponade
— Traumatic circulatory arrest
Pneumothorax : Air comes in pleural cavity
¥?
Simple Tension Open
To be managed in To be managed in
secondary survey primary survey
Parietal
pleura
Lung
Visceral Hemothorax
pleura
Very severe
Injury to . Intercostal vessel
. Internal thoracic vessel
Tension Pneumothorax Massive Hemothorax
— Respiratory distress — Respiratory distress

— Tachypnea — Tachypnea
— Use of accessory muscles — Use of accessory muscles
— Hypotension — Hypotension
— Raised JVP — Decreased JVP
— Breath sounds absent — Breath sounds absent
— Percussion note : Tympanic / Hyper resonant — Percussion note : Dull
— Tracheal shift : shifted to opposite side — Tracheal shift : shifted to opposite side +/-
:
Next step
Needle thoracostomy
:
Immediate Next step
Tube thoracostomy
OR Chest tube placement
Needle decompression 5th ICS anterior to mid axillary line
:
5th ICS anterior to mid axillary line
In Pediatric patient : 2nd ICS Mid clavicular line
Definitive treatment
Tube thoracostomy
Chest tube placement
In Patients of Simple Pneumothorax Open Pneumothorax / Suckling chest wound

— Respiratory distress is not present
If present : Mild Pleural space is communicating with exterior
— Hypotension : absent
— JVP : Not raised During inspiration air will be sucked in
— Breath sounds : Absent
— Tympanic note Immediately cover the wound by dressing
— Tracheal shift : Absent
After covering the wound; apply adhesives to 3 sides
Not on all 4 sides
i
Chest X ray
Put chest tube away from site of injury
Tube thoracostomy
Chest tube placement After putting chest tube — cover 4th side also
Why initially we didn’t cover all 4 sides ?
If we cover all 4 sides then air will get trapped inside
and it can lead to severe tension pneumothorax
Triangle of safety
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5th ICS
Circulation
MC cause of shock in trauma is Hemorrhagic shock leading to Hypovolumic shock
Classification of Hemorrhagic shock
I II III IV
Blood volume lost % <15% 15-30% 30-40% >40%
Blood volume lost <750 ml 750-1500 ml 1.5-2 L >2L
Heart rate <100 100-120 120-140 >140
Respiratory Rate <20 20-30 30-40 >40
Pulse pressure Normal / V V VV VVV
Hypotension ✗ ✗
Base deficit 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L <-10 mEq/L
Need of blood No Maybe Yes Massive
Earliest manifestation of Hemorrhagic shock >

Tachycardia
>
Cold extremities
>
Altered sensorium
Decreased Pulse pressure
÷
Causes of Non hemorrhagic shock in trauma
1. Neurogenic shock : Manifestation — Hypotension with Bradycardia and warm extremities

2. Tension Pneumothorax
3. cardiac Tamponade Beck’s Triad Hypotension
Raised JVP
Muffled Heart sound
4. Septic shock
Haemorrhage
Control of bleeding
:
Replacement of lost blood and fluid
Starting IV line
v v
Crystalloid Blood
Fluid of choice : Isotonic fluid >

Ringer Lactate
> Normal Saline
Best replacement : Blood
Hemodynamically Stable : SBP is >90 mmHg : Class I & II
Hemodynamically Unstable : SBP is <90 mmHg : Class III & IV
>30% of blood volume is lost
Emergency situation
v v
Control of bleeding Replacement of blood

"
More important
:
Source known
Immediately do something
:
Source Not known
Try to find out the source

.
.
Start blood / Fluid
to stop bleeding as early as possible
Two wide bore short length
Diameter ∝ Amount of blood

Length of cannula ∝ 1
Amount of blood
Preference : 14G > 16G > 18G s
( Not in Great Saphenous vein / Small Saphenous Vein :

We put cannula in Anticubital vein as this veins may be required for graft in future )
✓
If Vein is not accessible due to massive blood loss
:
Intraosseous cannula is used
In the proximal 1/3rd shin of Tibia
Withdraw blood >

Routine blood investigations
>
Grouping and cross matching
>
Toxin assay
>
Pregnancy test
Balanced or controlled or hypotensive resuscitation

Indication
1L stat — Ringer Lactate >
Blood + Tranexamic acid > SBP <90 mmHg
"
Heart rate >120

✓
1:1:1 Antifibrinolytic agent > > Used only if patients

Packed RBC : Platelet Rich Plasma : Fresh Frozen Plasma comes in <3hrs of trauma
Blood >
Cross matched : Preferred : but it takes 45 mins for cross matching
>
Type specific
>
O -ve blood
MC given blood is O-ve blood
If shortage O+ve for males

: O-ve for females
Adequacy of fluid resuscitation is best assayed by : Urine output >

Goal of urine output
>0.5 ml/kg/hr in adults
>1 ml/kg/hr in Pediatrics
Requirement of fluid is best assessed by : PCWP > CVP (Pulmonary Capillary Wedge Pressure > Central Venous Pressure )
Disability
Focused neurological examination

— GCS : Glassgow Coma Scale
— Pupillary sign
— Lateralising sign
Environmental Exposure
Warm blanket
All the fluid should be given at 39 C
Adjuncts in primary survey

— Pulseoximeter
— ECG
— ABG
— Ryle’s tube
— Foley’s catheter
— Two X rays : Chest X ray & Pelvic X ray : Bedside AP view
— eFAST : Extended Focused Assessment Sonography in Trauma
Log Rolling
At least 4 peoples are required
If lower limb bone fracture is present : Addition 1 is required : 4+1
Log rolling is done to prevent extension of spine

— To check injury at back
— To place X-ray film
Secondary Survey
Head to Toe examination
If you don’t have facilities

V
Refer the patient to higher centre
Damage control Surgery
If we fail to control the bleeding and we keep giving blood to the patient
Acidosis
Multi organ failure

V
Death
Triad of Death
Hypothermia Coagulopathy
Control of bleeding
V V V
Pressure Ligation Repair > It will take long duration
Ideal situation : All the named vessels in the body should be repaired
Surgery — Prolong duration
Trauma gets prolonged
Situation A
A person got stabbed into Femoral Artery just outside trauma centre
Stable / Unstable
+
Triad of death has not set in
"
A
B
C .
Pressure .
Take to Operating Room
V
We can go ahead with Repair
Situation B
A person got stabbed into Femoral Artery away from trauma centre
Unstable
Patient is in stress
+
Triad of deaths
:
If we do surgery and prolong the stress
Detrimental to the patient

"
A
B
C .
Pressure .
Take to Operating Room
Legate Femoral artery
:
Send patient to ICU
Further resuscitation by giving >

Blood and blood products
>
Along with vasopressors
v v
May improve Patient may not improve

v
May die
i. i
Gangrene not set in Gangrene of limb sets in
Take patient to OR Amputation of limb
Salvage the limb by bypassing ligated vessel
Damage control surgery has 3 Phases
Phase I : Control of bleeding / infection in minimum possible time
:
Phase II : ICU resuscitation
Phase III : Definitive treatment
Once patient comes with Damed control scenario

.
We should not try to do definitive treatment of that problem upfront
Indications of DCS
1. pH <7.2
2. Temperature <35 C In unstable patient
3. PT >16sec & PTT >60 sec
4. Serum lactate >5 mml/L
:
Phase O
• DCS : Physiological correction is more important than anatomical correction

• MC complication of DCS : Wound infection
Deadly Dozen of trauma
— Airway obstruction
— Tension Pneumothorax
— Cardiac Temponade
— Open pneumothorax
— Massive Hemothorax
— Flail chest
— Aortic injuries
— Tracheobroncheal injury
— Myocardial contusion
— Rupture of diaphragm
— Esophageal injury
— Pulmonary contusions
In RTA, a patient of trauma with head injury comes in trauma centre the treating doctor has stabilised the
patient in primary survey, the trauma centre has CT scan available but Neurosurgeon is not available,
What should be treating doctor’s next step ?
A. Refer the patient to higher centre after CT scan

B. Refer patient to higher centre without CT scan
Golden Hour : 1st hour
Head injury
Primary Brain Injury Secondary Brain Injury
Our Goal in management of head injury patient is prevention of secondary Brain injury
Factors aggravating Secondary Brain injury are

Hypotension
Hypoxia
Hypercapnea
Hyperglycaemia (5%Dextrose should not be given in Head injury patient)
Hyperthermia
Seizures
Symptoms of Head injury

Altered sensorium / Loss of consciousness : Earliest symptom
Headache
Vomiting Cardinal symptoms of head injury
Seizures
ENT bleeding / Discharge Due to ICP
Signs of Head injury
Panda’s sign
Blackish discolouration around orbit
Black eye sign
with subconjuctival hemorrhage
Racoon’s eye
Local injury to orbit

i Anterior cranial fossa (Base of skull Injury)
>
can also have CSF Rhinorrhea
Battle sign >

Blueish discolouration around mastoid >
Middle cranial fossa injury
There can be also
Hemotympanum CSF Otorrhoea/ 7th/8th Cranial

CSF Rhinorrhea nerve injury
IOC in head injury : NCCT
Grading of Head injury : GCS
Mild : 13-15
Moderate : 9-12
Severe : <8
Critical : 3-5
Primary Brain injury : Whatever Brain injury has sustained after trauma to skull
— Skull Fracture
— Contusions
— Sub Dural Hematoma
— Extradural Hematoma
— Subarachinoid Hemorrhage
— Diffuse Axonal Injury
Secondary Brain Injury : It happens due to Ischemia to Brain cells
To Prevent Secondary Brain Injury
We keep Cerebral Perfusion Pressure (CPP) of Brain parenchyma within normal limit
CPP = MAP — ICP MAP = Mean Arterial Pressure ; ICP = Intra Cranial Pressure
Monro-Kellie doctrine
Exponential increase in ICP
CSF BP AB VB
:
Symptoms of head injury
ICP
To prevent Secondary head injury : CPP should be in Normal limit
CPP = MAP — ICP ^
Body is already doing it c >

Our Primary focus for management : ICP
v
i.
Cushing reflex
MAP
Hypertension
Bradycardia
Late presentation
If any patient of head injury comes with Hypotension
; Bleeding happening somewhere else
Brain stem injury
A patient of RTA with Head injury comes with Pulse 100 and BP 80mmHg. What is most likely cause
A. SAH B. SDH C. EDH D. Abdominal injury
GLASGOW COMA SCALE : Do it this way
Institute of Neurological Sciences NHS Greater Glasgow and Clyde
CHECK OBSERVE S T I M U L AT E R AT E
For factors Interfering with Eye opening , content of Sound: spoken or shouted Assign according to highest
communication, speech and movements of request response observed
ability to respond and other right and left sides Physical: Pressure on finger tip,
injuries trapezius or supraorbital notch
Eye opening
Criterion Observed Rating Score
Open before stimulus Spontaneous 4
After spoken or shouted request To sound 3
After finger tip stimulus To pressure 2
No opening at any time, no interfering factor None 1
Closed by local factor Non testable NT
Verbal response
Correctly gives name, place and date Orientated 5
Not orientated but communication coherently Confused 4
Intelligible single words Words 3
Only moans / groans Sounds 2
No audible response, no interfering factor None 1
Factor interferring with communication Non testable NT
Best motor response
Obey 2-part request Obeys commands 6
Brings hand above clavicle to stimulus on head neck Localising 5
Bends arm at elbow rapidly but features not predominantly abnormal Normal flexion 4
Bends arm at elbow, features clearly predominantly abnormal Abnormal flexion 3
Extends arm at elbow Extension 2
No movement in arms / legs, no interfering factor None 1
Paralysed or other limiting factor Non testable NT
Sites For Physical Stimulation Features of Flexion Responses

Modified with permission from Van Der Naalt 2004
Finger tip pressure Trapezius Pinch Supraorbital notch Ned Tijdschr Geneeskd
Abnormal Flexion Normal flexion

Slow Sterotyped Rapid
Arm across chest Variable
Forearm rotates Arm away from body
Thumb clenched
Leg extends
For further information and video demonstration visit www.glasgowcomascale.org

Graphic design by Margaret Frej based on layout and illustrations from Medical Illustration M I • 268093
(c) Sir Graham Teasdale 2015
GCS-P score = GCS — PRS
Indications for CT scan

— GCS <13
— GCS 13-15 : if it stays for >2hrs
— Neurological deficit
— Open / Depressed / Base of skull Injury
— >2 episodes of Vomiting ( According to Bailey and Love : >1 episode )
— Seizures
Relative indications for CT scan

— Age >65 yrs
— If Patient is on Anticoagulants
— Dangerous mechanisms Fall from >5 stairs Wait for 8 hrs
÷
High speed Motor Vehicle Accident
:
Ejected out of the vehicle If the condition of patient
One of the Accomponent died in the accident is deteriorating
— Amnesia
— Loss of consciousness for >5 mins Do CT scan
MC Head Injury : Contusions > SDH
SDH : Sub Dural Hematoma
i
i
i.
Acute Subacute Chronic
<3 days 4-21 days >21 days
Commonly seen in elderly
MC cause of SDH : Injury to bridging veins or dural veins
SDH is common in Boxers
If an elderly patient comes to you with sudden onset Loss of consciousness or Headache : Suspect Chronic SDH
And history of trauma may be not given by the patient
If a patient comes to you with the worst headache of his life / Thunderclap headache : Suspect SAH
SDH
EDH : Extra Dural Hematoma / Extra axial hematoma
Due to injury to Middle Meningeal Artery

Common in young
Commonly associated with skull fracture
MC site : Temporoparietal region
Lucid interval : Period of Normalcy between two episodes of loss of consciousness
Lateralising sign :
Compression
1st structure : 3rd nerve : Ipsilateral pupil gets dilated
2nd structure : Corticospinal tract : Contralateral weakness of body
:
Ipsilateral Pupilary dilatation and Contralateral Hemiplegia
Tell tale sign : EDH on the side of pupilary dilatation

Old Guideline
New Guideline
NCCT
:
Take patient to Operating room
Evacuate this hematoma (Burr hole)

✓
On the side of Pupilary dilatation just above Pterion
On NCCT : Biconcave / Lenticular shaped opacity
A parietal subdural hemorrhage is depicted, located
between the arachnoid mater and meningeal (visceral)
A parietal extradural hemorrhage is depicted, layer of the dura. Also depicted is a ruptured bridging A subarachnoid hemorrhage secondary to rupture of a
extending from, but not crossing, the sagittal and cortical vein secondary to a non-fracturing cranial berry aneurysm in the lateral base of the calvarium
squamous sutures. There is an associated cranial trauma, leading to the hemorrhage in this location. Note is depicted. Note that the blood is not confined by
fracture depicted next to the hemorrhage as that the hemorrhage is not limited by the sutural sutures (extradural) and is not contained between
well. The hematoma is classically lentiform shaped. attachment of the dura, as it is subdural. dural layers (subdural).
SAH : Aubarachinoid Hemorrhage
MC cause : Trauma
MC cause of spontaneous SAH : Rupture of Berry’s Aneurysms
Symptoms
1. Features of raised ICP
2. Neck rigidity
3. 3rd Cranial nerve palsy
Grading : Hess and Hunt Scale
EDH doesn’t cross suture lines but SAH usually cross suture lines
Diffuse Axonal Injury
Worst Head Injury : it is due to sharing tear between Gray and White matter
Triad
1. Axonal swelling in white matter
2. Hemorrhagic lesion in Corpus Callosum
3. Lesion in Dorso lateral quadrant of Brain stem
Blood in basal ganglion
NCCT can be normal

IOC : MRI
Gold standard : Microscopy : Axonal Retraction Balls
Management of Patient of head injury
Primary Goal : ICP ✓
v v
Medical Management Surgical management
1. 100% O2 with Normocapnea 1. Craniotomy / Burr hole

Achieved by initial Hyperventilation
2. Ventriculostomy
2. Elevation of head end
3. Decompressive craniotomy
3. Maintaining or keeping normovolemia
4. Hypertonic saline Indications of craniotomy in EDH
5. Osmotic diuretic (mannitol) >

Volume of blood >30 ml
Only indications Euvolemic Mid line shift of ventricle >5 mm
:
>
No signs of Brain herniation

> >
ICP >20 mmHg
S. Osmolarity <320 mosm
6. Benzodiazepines Indications of Craniotomy in SDH
7. Neuromuscular blockers >

Midline shift >5 mm
>
If the values less than above but fall in GCS >2 points
8. Propofol > Fixed and dilated pupils
9. Hypothermia
Indications of Craniotomy in SAH
10. Barbiturates
>
ICP >20 mmHg
RTA — Head injury

V
A
B
C > Lateralising sign > If present
:
V
GCS <
D OR
PS '
'
E Burr Hole
.
.
Mild
Moderate-Severe
13-15 Selection of Surgery
Craniotomy : If blood is causing symptoms
Decompressed craniotomy : If edema is causing symptoms
v v
1st line Medical treatment NCCT

1. 100% O2 with Normocapnea
Achieved by initial Hyperventilation If indications of craniotomy present
v
2. Elevation of head end Craniotomy is done <
3. Maintaining or keeping normovolemia If indications are not present
:
4. Hypertonic saline We will keep medical treatment
and monitor ICP
5. Osmotic diuretic (mannitol)
Only indications Euvolemic
>
If ICP fails to decrease
No signs of Brain herniation
>
S. Osmolarity <320 mosm

>
We will step up medical therapy ICP >20 mmHg
6. Benzodiazepines
^
7. Neuromuscular blockers
Even after adding this
8. Propofol
9. Hypothermia
10. Barbiturates
ICP monitoring : LICOX system >
ICP
>
O2 tension in Brain Parenchyma
>
Temperature
V
Probe — Intraventricular
If LICOX system is not available

V
ICP is monitored by >

Improvement in GCS
> Assaying symptoms
Steroids have not role in Lowering ICP in Head injury
Goals to be achieved
— SBP >100 mmHg — Hb : >7 gm/dl

— Temperature 36-38 C — INR : 1.4
— CPP >60 mmHg — Na : 135-145 mEqm/L
— PbO2 >15 mmHg — PaO2 : >100 mmHg
— SPO2 : >95% — PaCO2 : 35-45 mmHg
— ICP : 5-15 mmHg — pH : 7.35-7.45
— Glucose : 80-180 mmHg — Platelets >75000/cmm
Post Traumatic seizures
Head injury : Intra cranial hematoma
Early : <7 days

Late : Any time — many months or Years after Head injury
Prophylaxis : Phenytoin for 7 days
Scalp laceration
Bleeds torrentially
Best way to control bleed : Suturing > Eversion of Galea aponeurotica layer
Prognosis of Head injury is best assessed by : GCS (Most imp is Motor component )
Glassglow Outcome scale
Coupon Code : RHE20 Contact : 9561983020/9359692130 For more notes : https://t.me/egurukulnotes2
Neck injury
v v
Soft tissue injury C-spine Injury
>
Penetrating injury
V
Breach of Platysma
>
Zone of Trauma in neck
Zone I : Thoracic inlet to cricoid cartilage
Zone II : Cricoid cartilage to angle of mandible
Zone III : Angle of mandible to base of skull
Penetrating injury Neck in any zone > Shock >

A
B
C >
Take patient to OR >
Explore
Penetrating Neck injury >

Symptomatic & Unstable patient >
Zone I >
CT Angiogram > If normal
>
Zone III >
CT Angiogram
>
Zone II >
Explore
✓
Do Esophagogram
C-spine Injury
:>
-
C-collar Evaluation Secondary survey

is applied
Decision of evaluation of C-spine
'
i.
Altered Sensorium If GCS is 15/15
Evaluate C-spine
:[
v v
Canadian C-spine rule NEXUS criteria
:
CT scan of neck
Age >65 yrs N : Neurological deficit
If not available Parasthesia E : Ethanol intoxication
i Dangerous mechanism of injury X : EXtream distraction injury
Bedside X ray C-spine U : Unable to provide history
S : Spinal tenderness
AP view
Lateral view
Open mouth Odontoid view
÷
If answer to any of Answer to all of these
this question is Yes questions is No
.
We will ask patient to flex the

neck after removing C-collar
Immediately apply C-collar v v
Pain +ve Pain —ve

v
Remove C-collar
Thorax Trauma
• MC Thoracic injury : Rib fracture

• MC fractured Ribs : 4th-9th
• MC cause of death in thoracic injury : Pulmonary contusion/laceration
• MC cause of sudden death in blunt thoracic trauma : Aortic injury > Tracheobronchial injury
• MC cause of sudden death in penetrating thoracic trauma : Cardiac Injury >Aortic Injury > Tracheobronchial injury
Rib Fracture
Due to movement of fractured ribs : Intense pain
Most important consideration in management of Rib fracture : Pain control
In any Pain management : Step up therapy
NSAIDs
V
Non opioid analgesics
:
Opioid analgesics
Intercostal nerve block

"
Epidural analgesia
Flail chest
Fracture of 2 or more consecutive ribs at more than 1 point in one line
This segment will move Paradoxically

Flail t
en
segm
:
During Inspiration : It goes down
During expiration : It goes up
Diagnosis of Flail chest can be made on clinical examination

IOC : Chest X Ray
Gold standard : CT Thorax with 3D reconstruction
i
Part of lung underneath flail segment
Pulmonary contusions
Patient can have problem in oxygenation
MC Presentation : • Pain
• Respiratory Distress : O2 saturation will be low
MC consideration in management : Pain control

Best way to control pain : Epidural analgesia
First line of management of any Flair chest injury : O2 therapy + Pain control
:
• SPO2 : >85% • SPO2 : <85%
• PaO2 : >60 mmHg • PaO2 : <60 mmHg
TOC : Intermittent Positive

Pressure Ventilation (IPPV)

Indictions of Fixation of Ribs in Flail chest

• When thoracotomy is planned anyways
• When patient is deteriorating on IPPV
• When there is gross overriding of Ribs
Strapping of Ribs in Flail chest is absolutely contraindicated
• MC cause of death in Flail Chest : Pulmonary Contusions

• MC cause of ventilatory insufficiency in Flail chest : Pulmonary Contusions
Simple Pneumothorax
Chest X Ray >
Chest Tube 80%
•
> Controls bleeding
Hemothorax
20%
>1500 ml blood comes out stat OR Thoracotomy
:
Hemothorax Left Pneumothorax
Aortic Injury
Most of the patients die on the spot
One few patients able to reach emergency services who has intact Adventitia
When to suspect Aortic Injury
1. Widening of mediastinum
2. Obliteration of Aortic knob
3. Depression of Left Bronchus X Ray
4. Shift of Ryles tube to Right
5. Fracture of 1st/2nd Rib / Scapula
IOC : CT angio
Gold standard : Aortography
IOC in unstable patient : Trans esophageal Echo
MC site of Aortic Injury : Just distal to the origin of Left subclavian artery / Ligamentum Arteriosum
Least common site of Aortic injury : Behind cruras at hiatus
If the patient is stable > Maintain MAP : 60-70 mmHg & HR <80/min
V
By
• Short acting β blockers (Esmolol)
• Calcium channel blocker
• Na Nitroprusside
TOC : Endovascular stenting
In unstable patient : Open repair

Diaphragmatic Injury
Left side diaphragmatic injury is more common
Diaphragmatic Injury
v v
At the time of injury Delayed presentation
If trauma in lower chest: Diaphragmatic hernia should be ruled out

MC organ which goes into thorax : Stomach
It can have delayed presentation : H/O trauma > Respiratory distress
:
Can be confused with pneumothorax
Chest X Ray should be done after inserting Ryle’s tube
IOC : CT thorax
Gold standard : Laproscopy / VATS
TOC : Repair through Abdominal incision
Cardiac Injury
Indications of Emergency Thoracotomy
• >1500 ml blood stat

• >2000 ml blood/hr for 3 hrs
• Cardiac Temponade
• Esophageal Injury
• Persistent collapse of lung even after PPV ( Happens in Tracheobronchial Injury)
• Widening of Mediastinum more than 8 cm
In general, we do Left Anterolateral Thoracotomy in 5th/6th ICS

Right and Left incision and then join them : Clamshell Incision
Left Anterolateral Thoracotomy suited for reaching

• Left lung
• Thoracic Aorta
• Origin of Left Subclavian Artery
• Left side of Heart
• Lower Esophagus
Right Anterolateral Thoracotomy suited for reaching

• Right Lung and its hilum
• Azygous vein
• SVC
• Infracardiac vein
• Upper esophagus
Medial Sternotomy is suited for reaching

• Anterior aspect of Heart
• Ascending Aorta
• Pulmonary arteries
• Carina of trachea

Cardiac Temponade
Beck’s triad 1. Hypotension

÷ 2. Raised JVP
3. Muffled heart sounds
Immediate next step : Pericardiocentesis
Stable : Pericardiotomy
ERT
Emergency Room Thoracotomy / Emergency ResuscitativeThoracotomy
Absolute indications
Witnessed cardiac arrest in patient with penetrating injury in the Anterior chest wall
Relative Indications
Intra thoracic hemorrhage
Cardiac Temponade
Aims of ERT
• Internal cardiac massage
• Control bleeding
• Control air leak
• Clamping thoracic aorta to preserve blood to brain and heart
Abdominal Trauma
• Anterior Abdomen : From 5th ICS bilaterally to Inguinal crest

Between Anterior Axillary line
• Flank : Anterior and Posterior Lines
Radiological Investigations for Abdominal injury
1. FAST (Focussed Assessment Sonog raphy in Trauma)

It can be done by anybody (not necessarily Radiologist) who is trained for trauma
In FAST, we just have to understand how fluid looks like in Sonogram
If there is injury in the body there is bound to be the fluid collection
>100 ml of fluid is detected
Probe posi6ons eFAST : Costophrenic angle
E÷É
1. Epigatrium Pericardium
: Lesser omentum
2. Right Upper abdomen . 2 interfaces Liver & Diaphragm

: Liver & Kidney
3. Left Upper abdomen > 2 interfaces > Spleen & Diaphragm

> Spleen & Kidney
4. Suprapubic region > Pelvis

eFAST : Extended FAST
Costophrenic Angles are included
Normally : Due to breathing movements : Seashore sign

In Truama : due to Air in pleural space : Barcode sign / Stratosphere sign
Limitation : Not a good modality for Retroperitoneal organs / injury / collection

Not a very good modality for penetrating injury

DPL (Diag nostic Peritoneal Lavage)
;t¥
i. • Aspirate
Lavage
1Litre NS/ RL
Aspirate Clamp
:
Shake patient
• >10 ml blood
• Bile Open clamp and collect fluid
• Enteric fluid
:
Microscopic examination
DPL
• >10L RBC/cmm
No need to do • >500 WBC/cmm
Lavage component • Gram negative bacteria
• Amylase negative
DBL • It cannot tell us exact site of Injury
:
-
• It cannot tell us extent of Injury DPL

• It cannot guide us further line of management
• It only can tell us presence of injury inside
CT scan
• It can tell us site of Injury
• It can tell us extent of Injury
• It can guide us further line of management
• IOC for Blunt or Penetrating Abdominal injury in Stable patient : CT scan

• IOC for Blunt Abdominal injury in Unstable patient : FAST
• IOC for Penetrating Abdominal injury in Unstable patient : Exploratory Laprotomy
Blunt Abdominal Trauma
✓ "
Stable Unstable
v , u
FAST Signs of peritonitis No signs of peritonitis

v
v v
• Tenderness v
Fluid seen Fluid not seen • Rebound tenderness FAST

V
• Guarding
CT scan V
• Rigidity V V
Repeat after 30 mins Fluid seen Fluid not seen

V
v v
Exploratory Laprotomy s
Fluid seen Fluid not seen

v
v
Next step will be Observe

according to CT report

Penetrating Abdominal Trauma
: :
Stable Unstable
Exploratory Laprotomy
• Gun shot injury
• Signs of peritonitis
• Organ Evisceration
:
Any of these present
i
None of these
Local wound exploration
v v
If peritoneum is breached If peritoneum is not breached

" v
Admit & observe for 24 hrs Incised wound

v
v v
Suture it and discharge patient
Signs of peritonitis Hb level (4-6 hourly)
L > >
<
OR
V
Oral diet & observe for 24 hrs v v
v
Stable Unstable
No change in condition of patient v v
V
CT scan > Exploratory Laprotomy
Suture wound and discharge
Penetrating !ank Injury
:
Stable Unstable
:
CT scan Exploratory Laprotomy
For Exploratory Laprotomy

• In Adults : Vertical midline incision
• In Pediatric : Transverse incision
• MC organ injured in Blunt Abdominal trauma : Spleen > Liver
• MC organ involved in Penetrating Abdominal trauma
:
Gunshot
Small intestine
:
Overall
Liver
Stab wound
Liver
:

Spleen Injury
• MC organ injured : Spleen

• CT scan : Only if patient is stable
Spleen Injury to patient
v v
Stable Unstable
v
v
FAST +ve v
If we find Splenic injury

v
CT scan Splenectomy
v
>
• It can tell us site of Injury
>
• It can tell us extent of Injury
>
• It can guide us further line of management
Grading of Splenic Injury in Stable patient
Clinical signs of Splenic injury

Kehr sign : Pain in Left upper abdomen radiating to Left shoulder
Ballance sign : Shifting dullness on turning patient to Right lateral position
X Ray signs of Splenic Injury

1. Obliteration of Splenic shadow
2. Indentation of gastric fundus shadow
3. Obliteration of Psoas shadow
4. 6th/7th/8th/9th Left Rib fracture

Grade I / II >
Conservative treatment >
SNOM : Selective Non Operative Management
V
• 24 x 7 ICU
• Fluid & Observe
• Blood if required
Advice : Avoid any physical exertion and contact sports for 3 months
Grade III
v v
Less severe Severe
:
V
Non bleeding laceration Bleeding laceration

V
No Blush or Leak of Blush or Leak of

contrast on CT contrast on CT
V
SNOM
v v
Splenic artery Embolisation Splenorrhaphy

TOC Best treatment
Grade IV / V s
Splenectomy
• MC early complication of Splenectomy : Left lower lobe atelectesis

• Long term complication of Splenectomy : OPSI (Overwhelming Post Splenectomy Infection)
> Due to Capsulated micro organisms

>Pneumococcus, Meningococcus, E. coli
✓
To prevent infection from this organisms vaccine

should be given within 14 days of splenectomy
Liver Injury
CT scan grading
Grade I - IV : SNOM
Grade V - VI : Exploratory Laprotomy

Immediately after opening Abdomen
4 P’s Push >

Push liver against diaphragm
Pringle’s Manoeuver Occlude the free edge of lesser omentum
÷
Maximum pressure on the portal vein
It does not get complete control over bleeding
Plug Gel foam
Pack TOC for Grade V & VI

Packing is done for 24-48 hrs
Bring the patient to OR to remove pack
If bleeding is not stopped repacking
Hepatic artery Hepatic Artery can be ligated

Repair But
Portal vein Portal vein should be repaired
In Pediatric solid organ injury : we try to manage by conservation
Whatever the injury to Pediatric patient; management of that grade will be management of 1 grade lesser of adult
Eg. Management of Grade III in Pediatric patient is same as management of Grade II of adult
Pancreatic Injury
Once pancreas is injured there is high chance other abdominal organs can be injured
MC site of injury in pancreas : Neck of pancreas
IOC : CT scan
There is high chance that initial CT scan there might not be any findings
CT scan showing pancreatic injury gets evident after 48-72 hours

Management
Grade I,II : Conservative ; Sometimes put drain if required
Grade III : Distal Pancreatectomy
Grade IV, V : Whipple’s procedure
Any ho!ow viscera injured
v v
Stable Unstable
v v
Minor Major
v
<50% transection
v
>50% transection
v v
Primary repair Segmental resection

and Anastomosis
Retroperitoneal Trauma
Zone I : Centromedial zone comprises of great vessels

Zone II : Zone lateral to zone I comprising of renal Retroperitoneum
Zone III : Pelvic retroperitoneum
Blunt trauma Penetrating truama
Zone I Explore* Explore
Zone II Selective* Explore
Zone III Selective* Explore
*Expanding / Pulsatile hematoma > We do explore

Abdominal Trauma
v v
Stable Unstable
v
FAST
v
Exploratory Laprotomy Ontable Hematoma expanding

> >
any of these 3 zones

> Explore
✓
CT scan
> Non expanding hematoma
✓
Hematoma >
Zone I >
Zone I >
Observe
>
Zone II Not expanding >
Zone II >
Single shot IVU
> Zone III Zone III >

Observe
V
Repeat CT scan after 12 hours

V
V
If in any zone hematoma is expanding Intravenous Urogram

V V
Surgery Wait for 10 mins

V
Do X-ray of abdomen
V
• Not normal
• Near normal
V
Explore
Renal Injury
CT g rading of Renal Trauma

Renal injuries : Most of the time are conserved (we avoid exploring renal injuries)
Indications of Exploration in Renal trauma

• Unstable patient with gross hematoma with Renal injury
• Expanding or pulsating hematoma
• Grade V (Renal pedicel avulsion)
• Ureteropelvic disruption
We try to do - Segmental
- Polar nephrectomy
Very rarely we do Nephrectomy
Shattered kidney but Renal vascular pedicel is intact

Grade V
:
Kidney is surrounded by Gerota’s fascia
It will acts as temponade
:
Hematoma is not expanding
After some time hematoma will resolve and nephrons also starts functioning
É v
Urinoma But as nephrons were injured

v
They will start throwing urine in haphazard manner
:
The lateral fistulas will get automatically closed
if distal passage of ureter is patent
This injured kidney will excrete blood for some time
:
This blood may clot into ureter
If this happens, urine will start throwing in lateral positions in Gerota’s fascia
Urinoma starts increasing in size
:
Hence if we conserve such kidney it is important to keep ureter patent
To keep ureter patent : we put DJ stent >
Ureteric Injury
Isolated ureteric injury in trauma is rare
MC cause of Ureteric injury : Iatrogenic (During Hysterectomy)

MC site of ureteric Injury : Lower ureter where it is crossed by uterine vessels
Treatment : Primary repair over DJ stent
In lower ureteric injury : Segmental loss of ureter happens

V
Treatment : Boari flap method

Bladder Injury
:
Extraperitoneal rupture
:
Intraperitoneal rupture
Pelvic fracture Distended bladder

(MC site : Fundus)
Extraperitoneal bladder injury is more common
Clinical Presentation
• Non passage of urine since injury
• No urge to micturate
• Signs of Peritonitis : seen only in intraperitoneal bladder rupture
>
Tenderness
s
Rebound tenderness
>
Guarding
>
Rigidity
IOC : CT cystography
Gold standard : Retrograde cystogram
> Flame shaped

>
Tear drop
Inverted pear shaped bladder
:
Treatment
1. Extraperitoneal Bladder rupture
Simple Foley’s catheterisation
2. Intraperitoneal Bladder rupture

Explorative Laparotomy and Bladder repair with Foley’s Catheterisation
Urethral Injury
Anterior Posterior
v v v v
Penile Bulbar Membranous Prostate
Posterior urethral injury is associated with Pelvic fracture > Membranous urethral injury
Anterior posterior injury is associated with Straddle injury
>
Fall on perineum
Bulbar injury
✓
Clinical Presentation
• Non passage of urine
• Urge to micturate Bladder rupture will not have urge to micturate
• Distended bladder
Sig ns of Urethral Injury

• Blood at meatus
• Perineal Ecchymosis
• Scrotal hematoma
• Pelvic Fracture
• High flying prostate

IOC : Urethral Cystogram
In Bulbar urethral injury
• If Buck’s fascia is intact >

Penile swelling
• If Buck’s fascia is disrupted >

Penile swelling
:
Scrotal swelling Due to Urine leakage
Perineum Butterfly Extravasation
:
Anterior abdominal wall
Clavicle
TOC of urethral injury : Suprapubic cystostomy
Penile Fracture
Penis never get fractured when it is flaccid

Penile fracture happens only during sexual act
Classical history : During sexual act click sound heard and penis got swollen
On examination : S shaped penis or Egg plant deformity
MC site : Corpora cavernosa

Urethral injury is very rare
• If Buck’s fascia is intact >

Penile swelling
• If Buck’s fascia is disrupted >

Penile swelling
:
Scrotal swelling Due to Blood leakage
Perineum Butterfly Extravasation
:
Anterior abdominal wall
Clavicle
IOC : USG
Most sensitive investigation : MRI
TOC : Immediate repair
Seat Belt injury
MC injury : Mesentric injury > Proximal jejunum > Terminal ileum > Abdominal aorta > Pancreas

Blast Injury
• Primary Blast injury : Due to direct result of blast wave

• Secondary Blast injury : Penetrating injury due to blast fragments
• Tertiary blast injury : Blunt injury due to propulsion of individual due to blast wave
• Quaternary blast : Burns due to blast
MC organ injured : Tympanic membrane > Lungs > Stomach > Colon > Small Intestine > Solid organs
MC cause of death in blast : Pulmonary contusions
Under water blast injury

It depends upon how much body part is submerged in water
• If Whole body is submerged : Tympanic membrane > Lungs > Stomach > Colon > Small Intestine > Solid organs
• If face is outside : Lungs > Stomach > Colon > Small Intestine > Solid organs
• If upper trunk is outside water : Stomach > Colon > Small Intestine > Solid organs
Vascular Injury
v v
Hard signs Soft signs
• Significant Hemorrhage • History of moderate hemorrhage

• Pulsatile hematoma • Diminished but palpable pulses
• Expanding hematoma • Proximity of fracture or dislocation
• Evidence of extremity ischemia • Proximity to vessel
>
Pallor
>
Parasthesia First investigate
>
Pulselessness CT angiogram
>
Paralysis
V
>
Poikilothermia Then manage accordingly
Once we have any of these signs All named vessels ideally should be repaired
We don’t have time to do investigations
"
Immediately explore
In vessel repair : we always evert margins
:
called Carels Repair
Proline is used as suture material
Scores in Trauma
TRISS score
Trauma Injury Severity Score
It predicts outcome of patient of trauma
• Age
• Injury Severity Score > SBP
• Revised Trauma Score > RR
• Mechanism : Blunt / Penetrating > GCS

Revised Trauma score
MESS : Mengled Extremity Severity Score
• Age Limb can be salvaged

• Shock
• Duration
• Mechanism of injury
e. Amputation
Hormonal changes
Hormones increased in patient of Trauma Hormones decreased in patient of Trauma

• Corticotropins
• Growth Harmone • Insulin
• Vasopressin • Thyroxine
• Cortisol • Triiodothyronine
• Aldosterone
• Glucagon
• Catecholamine

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Egurukul - Trauma (Surgery)

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TRAUMA

Moto in management : Living problem is better than dead solution

Triage Meaning : To sort

Prioritising treatment on basis of severity of injury

Level I : Field Triage : by Paramedics

Level II : Medical triage : By Doctors

Triage is based on SALT protocol

Red tag : Urgent : Immediate life threatening injury

Green tag : Minor : Walking wounded

Black : Moribound pulseless or deceased patient

ABC ways in trauma

Triage is dynamic process

Primary survey Secondary survey

Swift examination to find what It is elaborate survey

A : Airway with restriction of cervical spine movement

If A is not a problem immediately go to B

Scene safety for rescuers

If patient is not responding

Talk to the patient

Patient Talking Patient not talking

Airway is not a problem 1. Tachynpnea

If signs are persisting

Chin lift/ Jaw thrust Paramedics arrived

Immediately apply O2 mask

Patient is in need of Adjunct airway

Indications 1. Presence of apnea

Inline orotracheal intubation

Put Inline orotracheal intubation

If fails : attempt once again

Definitive airway Adjunctive airway Restriction of Cervical spine

Tracheal intubation of any Eg : Oropharyngeal airway v v

sort which is secured Nasopharyngeal airway MILS C collar

Manuevers to maintain airways

What is next step after putting definitive airway : 5 points auscultation

Confirmation of airway intubation : Capnography

Things to look for in Primary survey

Pneumothorax : Air comes in pleural cavity

— Respiratory distress — Respiratory distress

In Patients of Simple Pneumothorax Open Pneumothorax / Suckling chest wound

MC cause of shock in trauma is Hemorrhagic shock leading to Hypovolumic shock

Classification of Hemorrhagic shock

Blood volume lost % <15% 15-30% 30-40% >40%

Blood volume lost <750 ml 750-1500 ml 1.5-2 L >2L

Heart rate <100 100-120 120-140 >140

Respiratory Rate <20 20-30 30-40 >40

Pulse pressure Normal / V V VV VVV

Need of blood No Maybe Yes Massive

Earliest manifestation of Hemorrhagic shock >

1. Neurogenic shock : Manifestation — Hypotension with Bradycardia and warm extremities

Fluid of choice : Isotonic fluid >

Best replacement : Blood

Control of bleeding Replacement of blood

Try to find out the source

Two wide bore short length

Diameter ∝ Amount of blood

Preference : 14G > 16G > 18G s

( Not in Great Saphenous vein / Small Saphenous Vein :

If Vein is not accessible due to massive blood loss

In the proximal 1/3rd shin of Tibia

Withdraw blood >

Balanced or controlled or hypotensive resuscitation

Heart rate >120

1:1:1 Antifibrinolytic agent > > Used only if patients