Trauma: Principles, Primary and Secondary Survey

Trauma
Principles, Primary and Secondary Survey
Dr. Mahmoud W. Qandeel

Outlines
• Introduction
• Mechanisms and Patterns of Injury
• Epidemiology
• Primary Survey
• Secondary Survey

Most common site of needle thoracostomy in management of
tension pneumothorax is: (7/2018)
A. 1st intercostals space mid clavicular line
B. 2nd intercostals space mid axillary line
C. 2nd intercostals space mid clavicular line
D. 5th intercostals space mid clavicular line
E. 5th intercostals space anterior axillary line

Most common site of needle thoracostomy in management of
tension pneumothorax is: (7/2018)
A. 1st intercostals space mid clavicular line
B. 2nd intercostals space mid axillary line
C. 2nd intercostals space mid clavicular line
D. 5th intercostals space mid clavicular line
E. 5th intercostals space anterior axillary line

Introduction
• Trauma remains the most common cause of death for all individuals
between the ages of 1 and 44 years and is the third most common
cause of death regardless of age.
• Motor vehicle collisions accounting for over 40% of trauma patients.

Mechanisms and Patterns of Injury
• Blunt trauma:
– More energy is transferred over a wider area during blunt trauma
than from a penetrating wound.
– Blunt trauma is associated with multiple widely distributed injuries.
– Organs that cannot yield to impact by elastic deformation are most

likely to be injured, namely, the solid organs (liver, spleen, and
kidneys).

Blunt trauma
• High energy trauma:
– Auto-pedestrian accidents
– Motor vehicle collisions:
• Car’s change of velocity (ΔV) exceeds 20 mph
• The patient has been ejected off the car
• Death of another occupant in the vehicle
• Extraction time of >20 minutes,
• Lack of restraint use
• Lateral impact
– Motorcycle collisions
– Falls from heights >20 ft

• Low-energy trauma
– Usually does not result in widely distributed injuries.
– However, potentially lethal lacerations of internal organs can occur,

because the net energy transfer to any given location may be
substantial

Injury patterns in blunt injury
• Unrestrained driver with frontal impact:
– The head strikes the windshield → facial fractures, cervical spine
fractures
– The chest and upper abdomen hit the steering column → laceration
of the thoracic aorta, myocardial contusion, injury to the spleen and
liver
– The legs or knees contact the dashboard → fractures of the pelvis
and lower extremities

• Lateral impact:
– Cervical spine injury
– Thoracic trauma
– Diaphragm rupture
– Crush injuries of the pelvic ring
– Solid organ injury usually is limited to either the liver or spleen based
on the direction of impact

Mechanisms and Patterns of Injury
• Penetrating wounds:
– The damage is localized to the path of the bullet or knife.
– Organs with the largest surface area when viewed from the front are most prone
to injury
• Small bowel, liver, and colon.
– Adjacent structures are commonly injured (e.g., the pancreas and duodenum)
that are in path of the knife/bullet .

Penetrating
injury
Gunshot Shotgun
Stab wound
wound wound
High velocity Low velocity

Long range Close range
(Speed >2000 (Speed <2000
>20 ft <20 ft
ft/s) ft/s)

Trauma Epidemyology

Etiology of major trauma
• Trauma is the commonest cause of death in people from 1–44

years of age throughout the developed world.
• The largest proportion of deaths (1.2 million per year) result

from road accidents.
• The World Health Organization (WHO) predicts that by 2020

motor vehicle collusions will rank third in the causes of
premature death and loss of health from disability.

MVC

• For every death from trauma, three victims suffer permanent
disability.
• As well as causing personal tragedy, this represents an

enormous drain on a nation’s healthcare economy; timely and
effective management of major injuries can reduce both
morbidity and mortality.

Mode of death
• Mortality subsequent to major trauma is dependent on a number
of factors, of which the economic level of a nation is a major
determinant.
• The overall mortality rate, including pre-hospital and in-hospital

deaths, is 35 per cent in high-income nations, but rises to 55 per
cent in middle-income economies and 63 per cent in low-income
economies.
• More seriously injured patients reaching hospital show a six-fold

increase in mortality in low-income economies.

• Deaths as a result of trauma classically follow a trimodal pattern, with
three waves following the injury.
➢Some 50 per cent of fatally injured casualties die from non-survivable injuries
immediately, or within minutes after the accidents;
➢30 per cent survive the initial trauma, but die within 1–3 hours;
➢The remaining 20 per cent die from complications at a late stage during the 6
weeks after injury.

The trimodal pattern of mortality following severe trauma

• This trimodality represents civilian trauma deaths; combat
deaths in a war fit a bimodal distribution, with merging of the
second and third peaks due to the penetrative nature of the
injuries and the extended timelines of advanced medical care

• The initial mortality peak is usually due to non-survivable central
nervous system or cardiovascular disruption.
• The severe nature of the injuries, the immediate nature of the
deaths and the usual location in the pre-hospital environment
means that very few of these casualties can be saved.
• However, a small proportion die as a result of early airway
obstruction and external hemorrhage, and these deaths can be
prevented by immediate first-aid measures.
• A significant proportion of head-injured casualties who die on the
scene succumb not to the primary brain injury but to secondary
brain injury caused by the hypoxia and hypercarbia associated with
airway obstruction and respiratory dysfunction.

• The second peak of deaths during the first few hours after
injury is most often due to hypoxia and hypovolemic shock.
• A significant proportion of these deaths can be avoided with an

effective emergency medical service (EMS); hence, this period
has been called ‘the golden hour’.
• One-third of all deaths occurring after major injury may be

preventable in hospitals with appropriate resources

• The third peak in the cumulative mortality rate within the 6
weeks following injury is largely due to multisystem failure
and sepsis.
• These complications of trauma need a high level of intensive

care, but can be reduced by early and effective treatment
during the preceding phases of casualty management.

➢ Immediate deaths ➢ Early deaths ➢ Late deaths
• Seconds to minutes after • Minutes to hours after injury • Days to weeks after injury
injury • Usually hemorrhage related • Usually due to multi-organ
• Usually unpreventable eg: • ATLS style emergency care failure or sepsis
apnoea secondary to high specifically targets these • Optimal early management
spinal or brain injury, or patients. may prevent these
catastrophic hemorrhage due
to great vessel disruption

The classic mistake when treating trauma is to focus on the attention-
grabbing compound fracture, and miss the obstructing airway, which
is far more likely to cause a ‘golden hour’ death.
• Hence the most immediately life-threatening injuries should always be

treated first.
However, although this principle has been known for generations, in the stress of
the moment a logical sequence may not be followed unless the treating doctor is
trained and practiced.

Specific Epidemiology Data

Abdominal Trauma
• In patients requiring laparotomy following blunt trauma, the
organs most commonly injured are :
• Spleen (40–55 per cent)

• Liver (35–45 per cent
• Small bowel (5–10 per cent)
• Retroperitoneum (15 per cent).

• Gunshot wounds most commonly involve the:
• Small bowel (50 per cent)
• Colon (40 per cent)
• Liver (30 per cent)
• Abdominal vasculature (25 per cent).

• Stab wounds injure adjacent abdominal structures. with the
most common injuries being:
• Diaphragm (20 per cent)
• Colon (15 per cent).

Spinal injuries
• Regional occurrences of spinal injuries are approximately:
• Cervical (55 per cent)

• Thoracic (15 per cent)
• Thoracolumbar junction (15 per cent)
• Lumbosacral (15 per cent).

Primary survey

Introduction
• The “golden hour” concept that timely, prioritized
interventions are necessary to prevent death and disability.
• The initial management of seriously injured patients consists of

phases that include the
– The primary survey/ concurrent resuscitation,
– The secondary survey/diagnostic evaluation
– Definitive care.

• The first step in patient management is performing the primary survey,
the goal of which is to identify and treat conditions that constitute an
immediate threat to life.
• The ATLS course refers to the primary survey as assessment of the “ABCs”
– Airway with cervical spine protection,
– Breathing
– Circulation
• Although the concepts within the primary survey are presented in a

sequential fashion, in reality they are pursued simultaneously in
coordinated team resuscitation.

Airway Management with Cervical Spine Protection
• All patients with blunt trauma require cervical spine

immobilization until injury is excluded.
– Hard collar, sandbags on both sides
• Efforts to restore cardiovascular integrity will be futile unless

the oxygen content of the blood is adequate.

Airway management
• In general, patients who are conscious, without tachypnea, and
have a normal voice are unlikely to require early airway
intervention EXCEPT patients with pending airway compromise:
– Penetrating injuries to the neck with an

expanding hematoma
– Evidence of chemical or thermal injury to These patients
the mouth, nares, or hypopharynx require PRE-
– Extensive subcutaneous air in the neck EMPTIVE
INTUBATION
– Complex maxillofacial trauma
– Airway bleeding

• Patients who have an abnormal voice, abnormal breathing sounds,
tachypnea, or altered mental status require further airway evaluation.
– Blood, vomit, the tongue, foreign objects, and soft tissue swelling can cause
airway obstruction
• Suctioning affords immediate relief in many patients.
– In the comatose patient, the tongue may fall backward and obstruct the
hypopharynx;
• Chin lift or jaw thrust.
• An oral airway or a nasal trumpet is also helpful in maintaining airway patency

• Establishing a definitive airway (i.e., endotracheal intubation) is indicated
in:
– Apnea
– Inability to protect the airway due to altered mental status
– Impending airway compromise
– Inability to maintain oxygenation.
• Altered mental status is the most common indication for intubation.
• Options for endotracheal intubation include nasotracheal, orotracheal, or

operative routes

Definite airway
• Orotracheal intubation is the preferred technique used to
establish a definitive airway.
– Because all patients are presumed to have cervical spine injuries,
manual in-line cervical immobilization is essential
• Nasotracheal intubation:
– Limited to those patients requiring emergent airway support in
whom chemical paralysis cannot be used

Operative airway
• Indications:
– Intubation has failed
– Extensive facial injuries
• Types:
– Cricothyroidotomy
• Relatively contraindicated in patients < 11 years of age due to the risk of subglottic
stenosis
– Tracheostomy
• Laryngotracheal separation or laryngeal fractures, in whom cricothyroidotomy may
cause further damage or result in complete loss of the airway
Breathing and Ventilation
• All injured patients should receive supplemental oxygen and be
monitored by pulse oximetry.
• Life threatening conditions affecting adequate ventilation that

need to be recognized during the primary survey:
– Tension pneumothorax
– Open pneumothorax
– Flail chest with underlying pulmonary contusion,
– Massive air leak

Tension Pneumothorax
• The parenchymal tear in the lung acts as a one-way valve, with each
inhalation allowing additional air to accumulate in the pleural space.
– The normally negative intrapleural pressure becomes positive, which depresses

the ipsilateral hemidiaphragm and shifts the mediastinal structures into the
contralateral chest.
– Subsequently, the contralateral lung is compressed.
– The heart rotates about the superior and inferior vena cava; this decreases
venous return and ultimately cardiac output

• Any patient manifesting respiratory distress and hypotension in combination
with any of the following physical signs:
– Tracheal deviation away from the affected side
– Lack of or decreased breath sounds on the affected side
– Subcutaneous emphysema on the affected side.
– ± Distended neck veins
• Diagnosis:
– Clinical
• Treatment:
– Immediate needle thoracostomy decompression with a 14-gauge angiocatheter in the
second intercostal space in the midclavicular line.
– Tube thoracostomy

Open pneumothorax “sucking chest wound”
• Full-thickness loss of the chest wall, permitting free communication between the
pleural space and the atmosphere.
– This compromises ventilation due to equilibration of atmospheric and pleural pressures

→prevents lung inflation and alveolar ventilation →hypoxia and hypercarbia
• DO NOT convert it to tension pneumothorax by complete occlusion of defect.

Treatment
• Temporary:
– Occlusive dressing that is taped on three sides.
• This acts as a flutter valve, permitting effective ventilation on inspiration while
allowing accumulated air to escape from the pleural space on the untaped
side, so that a tension pneumothorax is prevented.
• Definitive:
– Closure of the chest wall defect and tube thoracostomy remote from
the wound.

Flail chest
• Occurs when three or more contiguous ribs are fractured in at
least two locations.
• Paradoxical movement of this free-floating segment of chest wall is

usually evident in patients with spontaneous ventilation, due to the
negative intrapleural pressure of inspiration.
• Always associated with pulmonary contusion.

– Often progresses during the first 12h.
• Initial CXR may underestimate the extent of injury.

• The decreased compliance and increased shunt fraction caused by the
associated pulmonary contusion that is the source of acute respiratory
failure NOT the increased work of breathing caused by the flail segment.
• Treatment:
– Close observation and ventilatory support
– May require intubation

Treatment
- Oxygen support (mask)

- Monitoring of ventilation and O2 sat.
- Control of pain by regional anesthetic techniques .( intercostal nerve block,
or insertion of an epidural catheter)
- Noninvasive +ve airway pressure by mask may obviate the need for
intubation in alert patients
- Intubation and ventilatory support in respiratory failure & ARDS.

Circulation
• An initial approximation of the patient’s cardiovascular status can be obtained by
palpating peripheral pulses.
– SBP must be 60 mm Hg for the carotid pulse to be palpable

– SBP of 70 mm Hg for the femoral pulse
– SBP of 80 mm Hg for the radial pulse.
• Any episode of hypotension (defined as a SBP <90 mm Hg) is assumed to be caused by

hemorrhage until proven otherwise.
• Patients with acute massive blood loss may have paradoxical bradycardia

• During the circulation section of the primary survey, four life-threatening
injuries must be identified promptly:
– Massive hemothorax
– Cardiac tamponade,
– Massive hemoperitoneum,
– Unstable pelvic fractures with bleeding
• Three critical tools used to differentiate these in the multisystem trauma

patient:
– Chest radiograph
– Pelvis radiograph
– Focused abdominal sonography for trauma (FAST)

General management
• IV access for fluid resuscitation is obtained with two peripheral
catheters, 16-gauge or larger in adults. If access failed:
– Central lines
– Intraosseous (IO) needles can be rapidly placed in the proximal tibia
– Saphenous vein cutdown
• CBC, KFT, Cross-matching for possible red blood cell (RBC) transfusion,
and a coagulation panel should be obtained.

Control of bleeding
• External control of any visible hemorrhage should be achieved promptly while
circulating volume is restored.
– Manual compression of open wounds
– In penetrating bleeding wounds a gloved finger is placed through the wound directly
onto the bleeding vessel and enough pressure is applied to control active bleeding→
OR
• Do not blindly clamp a bleeding vessel
– Avoid tourniquets for extremity bleeding ( prone to small vessel thrombosis)
– Fracture reduction with stabilization via splints

Massive hemothorax
• Defined as >1500 mL of blood or, in the pediatric population, >25% of the
patient’s blood volume in the pleural space.
• Usually is due to multiple rib fractures with severed intercostal arteries.

– Occasionally bleeding is from lacerated lung parenchyma which is usually
associated with an air leak.
– Great vessel or pulmonary hilar vessel injury should be presumed after penetrating
trauma.
• Treatment:
– Tube thoracostomy
– Surgery
Indications for thoracotomy
• Immediate bloody drainage of ≥20 mL/kg (approximately 1500 mL).

• More than 200 ml/hr for 3 hrs.
• Shock and persistent, substantial bleeding (generally >3 mL/kg/hour)
• Unstable pt
• Caked hemothorax

Cardiac tamponade
• Most commonly occurs after penetrating thoracic wounds, although
occasionally blunt rupture of the heart is seen.
• Acutely, <100 mL of pericardial blood may cause pericardial

tamponade.
• The classic Beck’s triad:

– Dilated neck veins
– Muffled heart tones
– Decline in arterial pressure.

• Decreased right ventricular output, decreased myocardial blood flow, and
subsequent subendocardial ischemia and a further reduction in cardiac output
• Diagnosis:
– Clinical suspicion
– Echo
• Treatment:
– Fluid administration
– Pericardiocentesis/ Pericardial drain is placed using ultrasound guidance
• Removing as little as 15 to 20 mL of blood will often temporarily stabilize the patient
– Resuscitative thoracotomy (RT) if SBP <60 mm Hg warrant

Disability and Exposure
• The Glasgow coma scale (GCS) score should be determined for all injured
patients.
– Scores range from 3 (the lowest) to 15 (normal).
– Scores of 13 to 15 indicate mild head injury
– 9 to 12 moderate injury,
– ≤8 severe injury.
• The GCS is a quantifiable determination of neurologic function that is

useful for triage, treatment, and prognosis
• GCS <8 = Intubation

• Subtle changes in mental status can be caused by hypoxia, hypercarbia, or
hypovolemia, or may be an early sign of increasing intracranial pressure.
• An abnormal mental status should prompt an immediate reevaluation of the ABCs

and consideration of central nervous system injury.
• Patients with neurogenic shock are typified by hypotension with relative bradycardia,
and are often first recognized due to paralysis, decreased rectal tone or priapism.
– Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to
physiologic disruption of sympathetic fibers
– Treatment consists of volume loading and a dopamine infusion which is both inotropic and
chronotropic.

Exposure
• Seriously injured patients must have all of their clothing
removed to avoid overlooking limb- or life-threatening injuries.

Secondary Survey

History
• AMPLE history
– Allergies
– Medications
– Past illnesses or Pregnancy
– Last meal
– Events related to the injury.

Physical examination
• Vital sign and CVP monitoring, ECG monitoring
• Head to toe exam
• Do NOT miss the patient’s back, axillae, and perineum
• All potentially seriously injured patients should undergo digital rectal examination
to evaluate for:
– Sphincter tone
– Presence of blood
– Rectal perforation,
– High-riding prostate
• Vaginal examination with a speculum should be performed in women with pelvic

fractures to exclude an open fracture Dr. Mahmoud W. Qandeel
NG tube
• Inserted in all intubated patients to decrease the risk of gastric
aspiration.
• Nasogastric tube evaluation of stomach contents for blood may suggest

occult gastroduodenal injury or the errant path of the nasogastric tube
on a chest film may indicate a left diaphragm injury.
• Contraindicated in complex maxillofacial injuries.

Foley catheter
• Contraindicated in patients with suspected urethral injury:
– Blood at the meatus
– Perineal or scrotal hematomas
– Highriding prostate

Labs and imaging
• Detailed and individualized approach of imaging depending on
patient’s injuries.
– Brain CT
– Cervical CT
– Chest CT
– Repeat FAST
– Abdominal-pelvic CT
– Extremities imaging

Trauma
Specific injuries and management

Outlines
• Brain injuries
• Cervical spine injuries
• Neck trauma; penetrating and blunt CVI
• Spinal Cord and Spinal Column
• Cardiac Injury; blunt and penetrating
• Blunt thoracic aortic injury
• Esophageal and Tracheal Injury
• Abdominal Trauma
• Genitourinary Trauma
• Pelvic Fracture
• Extremities Trauma; compartment syndrome
Brain injuries
• Identification of a decreased GCS during the primary survey may warn
of potential brain injury.
• Pupil examination: Imperative; a dilated and nonreactive pupil may
indicate increased pressure secondary to intracranial bleeding.
• Rapid assessment with computed tomography (CT ): often necessary to
better characterize the injury
• Initial treatment for intracranial hemorrhage: aimed at decreasing the
ICP while preserving cerebral blood flow

Intrcranial Pressure
Sustained increased ICP leads to decreased brain function and poor outcome
10 mm Hg Normal
> 20 mm Hg Abnormal
> 40 mm Hg Severe

Cerebral Perfusion Pressure (CPP)
MAP – ICP = CPP
Normal 90 10 80
Cushing’s
100 20 80
Response
Hypotension 50 20 30
Caution
CPP ≠ Cerebral Blood Flow
Normal CT
Intracerebral
Hematoma /
Contusion

Diffuse Axonal Injury Dr. Mahmoud W. Qandeel
Mountain Fuji sign in Bilateral Pneumocephalus

Epidural Hematoma Subdural Hematoma
Depressed Skull #
Indications for surgery

• Depression > 1 cm/ or full bone thickness
• Gross wound contamination
• Significant intracranial hematoma
• Gross cosmetic deformity
• Frontal sinus involvement
• Dural penetration (clinical or radiological)

Depressed Skull #
Nonsurgical management may be considered if:

1. All the following are present:
– No depression > 1 cm/ or full bone thickness
– No gross wound contamination
– No significant intracranial hematoma
– No gross cosmetic deformity
– No frontal sinus involvement
– No dural penetration (clinical or radiological)
2. Or if the fracture is over a venous sinus

Signs of skull base fracture
• Raccoon eyes
• Battle sign
• CSF leak: rhinorrhea or otorrhea
• Cranial nerve palsy

Epidural Hematoma
• Associated with skull fracture
• Classic: middle meningeal artery tear
• Lenticular / biconvex
• Lucid interval
• Can be rapidly fatal
• Early evacuation essential

EDH – Indications for surgery
• Volume > 30 cm3, regardless of GCS

– Craniotomy for EDH

EDH – Conservative management
(Serial CT & close neuroobservation)
If all the following are present:

• Volume < 30 cm3
• Thickness < 15 mm
• Midline shift < 5 mm
• GCS > 8
• No focal neurodeficit

Subdural Hematoma
• Venous tear / brain laceration.

• Covers cerebral surface/ Crescent shape
• Morbidity / mortality due to underlying brain injury.
• Rapid surgical evacuation recommended, especially if > 5 mm shift of
midline.

Acute Subdural Hematoma

Subacute Subdural Hematoma

Chronic Subdural Hematoma

ASDH – Indications for surgery
• Thickness > 10 mm, regardless of GCS

• Midline shift > 5 mm, regardless of GCS
• If thickness < 10 mm & shift < 5 mm, then operate if any of the following is
present:
– GCS drops by ≥ 2 points
– Anisocoria
– ICP > 20 mmHg

SDH – Surgical treatment
Craniotomy for ASDH Burr hole for subacute & chronic SDH

Cervical spine
• Immobilization with a cervical collar should be maintained in all blunt trauma
patients until they are able to be fully evaluated and “cleared,” including during
rolling and any procedures (e.g., oral–tracheal intubation).
• During secondary survey: Cervical spine is palpated to identify tenderness or bony
deformity (step-off ).
• Physical examination: can be used to “clear” the cervical spine if the patient is not
intoxicated, does not have a “distracting” injury, and does not have a decreased GCS
• Imaging: evaluates or the presence of fracture with cervical spine pain or the
conditions listed earlier

Penetrating neck trauma
The neck is divided into three zones
• Zone 1: thoracic inlet to hyoid bone
• Zone 2: Hyoid bone to angle of mandible; classically, injuries here are
treated with operative exploration because of the relatively easy
surgical access (i.e., not hidden in the thorax [zone 1] or base of skull
[zone 3]).
• Zone 3: angle of mandible to cranium

Blunt cerebrovascular injury (BCVI)
• Principally carotid artery injury.
• Risk factors require additional screening for injury identification and
include
– Cervical spine injury,
– Displaced mid face fracture (le fort II and III),
– Pulsatile epistaxis,
– Hanging or clothesline mechanism,
– Basal skull fracture,
– Significant neck hematoma, and
– Neurologic exam not explained by CT of the head.

• Diagnosis: CT neck scans with intravenous (IV) contrast or angiography

Grades of carotid artery injury
1. I: luminal irregularity or dissection, less than 25% narrowing

2. II: luminal irregularity or dissection, 25% or greater narrowing
3. III: pseudoaneurysm
4. IV: occlusion
5. V: transection

Spinal Cord and Spinal Column
• Primary survey: During the disability assessment, attention should be

paid to the patient’s ability/inability to move all four extremities; the
patient should also be rolled and the full spinal column assessed for the
presence of pain or bony deformity (step-off ).
• Spinal immobilization (in the pre hospital and in-hospital phases ):

maintain with a backboard and during rolling until determination has
been made that a spinal fracture does not exist

Diagnosis :
• Definitive identification of spinal fracture is most frequently made with
CT imaging.
• MRI: often employed to better define and visualize injury to the spinal
cord itself
Note:
• Steroids: not indicated; shown to increase infectious complications
without decreasing spinal cord edema

Dorsolumbar Spine Fractures
• 64% of them occurs at thoracolumbar junction (T11 – L2)
• 70% of these fractures occur without immediate neurologic injury

Classification
• The Denis classification system is one of the most common ways of
classifying thoracolumbar spine fractures.

Classification
Minor & major injuries
Minor injuries: (usually stable) Major injuries: (4 types)
• Transverse process # • Compression #
• Spinus process # • Burst #
• Articular process # • Seat-belt #
• Lamina # • Fracture-dislocation

Fracture type Column
Anterior Middle Posterior
Compression Compression Intact Intact or

distraction
Burst Compression Compression Intact
Seat-belt Intact or minimal Distraction

compression
Fracture- Compression, Distraction, rotation, shear
dislocation rotation, tear

Anterior Column Injury
(Compression Fracture)
Usually stable & treated by:
• Analgesics & bed rest 1-3 wks
• When pain decreases, ambulate in brace

(12 wks)
• F/U with serial X-rays to rule out progressive

deformity

Unstable & requires surgery if:
• Loss > 50% of the height (one vertebra)

• Kyphotic angulation at one segment > 40°
• ≥ 3 contiguous compression fractures
• Neurologic deficit
• Disrupted posterior column
• Progressive kyphosis

Burst Fracture

Surgery recommended with any of the next:
• Anterior height ≤ 50% of the posterior height
• Residual canal diameter ≤ 50% of normal
• Kyphotic angulation ≥ 20°
• Increased interpediculate distance
• Neurologic deficit
• Progressive kyphosis

Can be treated conservatively esp. if:
• Above T8
• Below L4
• Minimal Middle Column Failure

Seat-belt fracture

• No immediate danger of neurologic injury
• Treat most with hyperextension brace
• Fractures through the bone (Chance fracture) mostly heal well in brace
• Fractures through the ligaments might need surgical fixation later

Fracture-dislocation

Treatment:
• Unstable
• Surgical decompression & stabilization usually needed

Cardiac Injury - Blunt:
• Forceful blow to the chest can cause injury to the heart (e.g., steering wheel
to chest); these patients should get an ECG during initial trauma evaluation.
Diagnosis:
• Suggested by an arrhythmia (most frequently sinus tachycardia) on ECG
• Echocardiogram: for further characterization of the injury if the patient’s ECG
is abnormal or the patient is hemodynamically abnormal

• Treatment: typically nonoperative and consists of inpatient cardiac
monitoring for arrhythmia
• Effects: Patients can develop structural lesions (cardiac aneurysms,

septal wall ruptures, valvular problems).

ECG in blunt trauma if
• Pain and tenderness directly over the mid-anterior chest
• Sternal fracture
• History suggestive of cardiac disease (eg, accident precipitated by
syncope, severe chest pain, or shortness of breath)
• Active symptoms or signs suggestive of cardiac disease
• Major mechanism of injury (eg, rollover, high speed, fatality at scene)

Cardiac Injury - Penetrating:
• Initial evaluation is made during the primary survey adjuncts with ultrasound
evaluation of the heart.
• Diagnosis: Presence of fluid within the pericardium may indicate blood, which is
highly suggestive of a cardiac injury and may cause cardiac tamponade leading to
shock; further diagnostic techniques include a “pericardial window” performed in
the operating room.
• Treatment: Operative; the preferred approach is median sternotomy.

Blunt Thoracic Aortic Injury
• Diagnosis : Initial chest x-ray may suggest the injury.
– Widened mediastinum ( 8 cm),
– Pleural cap from bleeding into the pleural space near the apex;
– Loss of aortopulmonary window,
– Left mainstem bronchus depressions, and
– Nasogastric tube displacement to the right
• Definitive diagnosis: contrast-enhanced chest CT

Treatment:
• Initial treatment is focused around decreasing the HR and BP;

• Definitive treatment may include endovascular treatment, open surgical
treatment, or nonoperative management and observation.

Esophageal and Tracheal Injury
• Diagnosis : physical examination (bubbling in a wound, presence of food
particles), endoscopy (bronchoscopy/esophagoscopy; predominant
diagnostic tool in the chest), or swallow study (contrasted x-ray or
identification of esophageal injury)
• Treatment: operative repair
• Effects : Tracheal injury may lead to excessive subcutaneous emphysema;

missed tracheal and esophageal injury can lead to mediastinitis and death.

Abdominal Trauma

Mechanisms
• Blunt trauma is the most common cause of abdominal injury and is usually associated
with multisystem injury.
– The common causes of blunt trauma are road traffic accidents including ‘seat-belt
syndrome’, industrial, sporting and farm injuries.
– The organs most commonly injured are the spleen, liver and kidney.
• Penetrating trauma from gunshot and stab wounds is becoming increasingly common as
a result of urban violence.
• Combination injuries: bombs and explosive devices cause a combination of blunt and
penetrating injuries.

Epidemiology of Abdominal Trauma
• In patients requiring laparotomy following blunt trauma, the
organs most commonly injured are :
• Spleen (40–55 per cent)

• Liver (35–45 per cent
• Small bowel (5–10 per cent)
• Retroperitoneum (15 per cent).

• Gunshot wounds most commonly involve the:
• Colon (40 per cent)
• Abdominal vasculature (25 per cent).

Investigations
• Standard laboratory and plain radiological examinations are carried out.
• Diagnostic peritoneal lavage (DPL) has traditionally been the most
useful method of assessing abdominal injury and is considered 98%
sensitive for detecting intraperitoneal bleeding
– It is particularly useful in the assessment of blunt trauma and is also beneficial in
assessing penetrating abdominal trauma caused by stab wounds, providing
justification for a policy of local wound exploration and observation of gunshot
wounds where peritoneal penetration is unclear.
– It does not detect retroperitoneal injuries.

• CT is replacing diagnostic peritoneal lavage in stable trauma patients in
many institutions
– Contrast-enhanced CT gives useful anatomical and functional information about
several organs.
– Positive CT scans identify injuries that can be managed non-operatively,
particularly liver injuries.
• Ultrasound - FAST is being used increasingly as the primary screening

technique for blunt abdominal trauma.
– It accurately detects the presence of free fluid, is inexpensive, non-invasive and
can be rapidly and repeatedly performed.
– Ultrasound is 88% sensitive, 99% specific and 97% accurate for detecting intra-
abdominal injuries.
• Laparoscopy: the use of laparoscopy in trauma is evolving.
• In selected patients with hemodynamic stability and no urgent

indication for laparotomy, laparoscopy is useful in determining
peritoneal penetration and identifying diaphragmatic injury.

Approach

• Diagnostic peritoneal aspiration is warranted
– In hemodynamically unstable patients without a defined source of

blood loss to rule out abdominal hemorrhage.
– In the unstable patient with a negative or nondiagnostic FAST.

Management
Preoperative preparation
• If a significant injury has been confirmed by investigations and/ or the
patient is hemodynamically unstable, operative intervention should
follow without delay.
• It is best to control severe hemorrhage surgically, rather than to prolong
fluid resuscitation.
• Broad-spectrum prophylactic antibiotics (metronidazole, 500 mg, plus a
second-generation cephalosporin such as cefuroxime, 1.5 g i.v.) should
be given promptly to provide aerobic and anaerobic cover.

Indications for Exploratory Laparotomy
• Indications for laparotomy based on physical finding include
– Obvious peritoneal signs on physical examination,
– Hypotension with a distended abdomen on physical examination,
– Abdominal GSW with peritoneal penetration, or
– Abdominal SW with evisceration, hypotension, or peritonitis.

• Findings on diagnostic tests, which mandate laparotomy
include
– Positive FAST (in the unstable patient),
– Grossly positive DPL or peritoneal aspiration, or
– Findings with any other diagnostic intervention (e.g., chest x-ray with
ruptured diaphragm or pneumoperitoneum, abdominal CT, or
laparoscopy suggestive of an intraabdominal injury requiring repair).

Blunt trauma
• About 20% of patients with blunt trauma have sufficient physical signs
such as continuing hypovolemia despite adequate resuscitation and
progressive abdominal distension to warrant immediate laparotomy.
• In patients who are stable following initial resuscitation, the results of

investigations should guide surgical intervention.
• Patients with negative ultrasound or diagnostic peritoneal lavage results

or those for whom non-operative therapy has been prescribed should
be followed up with frequent re-examination
Stab wound
• Following penetrating trauma caused by a stab wound, immediate

laparotomy is indicated for evisceration, unexplained blood loss and signs of
peritonitis.
• If the patient is stable and none of the above exist, local exploration of the
wound or laparoscopy can be used to determine if the peritoneal cavity has
been entered.
– Superficial wounds require no further treatment, but if peritoneal penetration is
confirmed then (depending on the experience of the physician supervising
management) the patient should undergo laparotomy or further investigation to
confirm the need for laparotomy.
Gunshot wound
• Traditionally, exploration of the abdomen has been mandatory

following gunshot wounds, because visceral injuries are generally
present if the peritoneal cavity is violated.
• Many centers now practice a selective policy based on CT findings in

stable patients where the imaging suggests an isolated liver injury.

Surgery
• During exploratory laparotomy, continuous monitoring of the pulse rate,

blood pressure, central venous pressure, temperature and oxygen
saturation should be carried out.
• Urine output is monitored through a urinary catheter left in situ, and the
stomach is decompressed and emptied by a nasogastric tube.
• The patient should be placed on a warming blanket on the operating table

to prevent hypothermia during the operation.

• The patient is draped to expose the body from the chin to the knees.
• A generous midline abdominal incision is advised.

• The surgical priorities are to identify and control major sources of
hemorrhage and reduce contamination from perforated viscera by
temporary clamping or suturing of injured bowel.
– Damage control surgery

• If laparotomy reveals a profuse hemorrhage, the aorta must be quickly
compressed at the hiatus.
• Formal cross-clamping may be required.
• Venous bleeding can be controlled by pressure and packing.
• Compression on the edges of a liver laceration and the Pringle’s

maneuvre (compressing the structures in the free edge of the lesser
omentum) will control most liver hemorrhage.

• Postoperative management consists of support of organ function and
control of sepsis.
• A ‘second look’ laparotomy may be required.
• The usual sequence of organ failure is lung, coagulation system, kidney

and liver.
• Early postoperative metabolic and nutritional support helps to preserve

perfusion and cellular metabolism.

Hollow viscus Injury
• Injuries to the stomach, small intestine, and colon comprise this group of injuries.
• Diagnosis: FAST is likely insufficient to diagnose free fluid in the peritoneal cavity in
this type of injury, so?
• Physical examination: Blunt hollow viscus injury may present with frank peritonitis,
which mandates operative exploration.
• Other presentations:
• Free fluid on abdominal/pelvic CT in the absence of solid organ injury requires
either operative exploration with exploratory laparotomy; diagnostic peritoneal
lavage (DPL); serial abdominal exams; or, in some centers, diagnostic laparoscopy.
• Treatment: operative repair of injury or resection

• Associated injuries on physical exam include
– Seat belt or tire marks across the chest or abdomen,
– Abdominal wall contusion,
– Truncal degloving injury.
– A Chance fracture (lumbar flexion/compression fracture) secondary
to a lap belt has associated intestinal injury in as many as 25%-30% of
patients.

Solid organs (liver and spleen):
• Initial evaluation begins with FAST to assess for free fluid (likely blood)
within the peritoneum
• Hemodynamically normal patient: Further evaluation with

abdominal/pelvic CT may be pursued.
• Grading: Splenic and liver injuries are graded I–V (with V being the most
severe), with more severe injuries likely requiring operative exploration
or definitive treatment.
• Treatment: Interventional radiology with embolization may be available
in specific situations.
Liver injury

Liver injury treatment
Treatment
• Hemodynamically stable patient with blunt injury of the liver, without
other intra-abdominal injury requiring laparotomy, can be treated
nonoperatively, regardless of the grade of the liver injury.
– This represents 60%-85% of patients with liver injury.
• Arterial blush or pooling of contrast on CT and high-grade (grade IV and

V) hepatic injuries is most likely to fail nonoperative management
– Nonetheless, embolization can circumvent the need for laparotomy

• The criteria for nonoperative management of blunt liver injuries include
– Hemodynamic stability,
– Absence of peritoneal signs,
– Lack of continued need for transfusion for the hepatic injury.
• Immediate laparotomy or angiographic intervention is required for those

patients with
– Hemodynamic instability,
– Continued blood product requirement,
– Who fail nonoperative therapy by demonstrating enlarging lesions on CT scan

Spleen injury treatment
Treatment
• Unstable patients due to splenic injury, irrespective of the grade,
should be in the OR.
• Nonoperative management of splenic injury is successful in >90%

of children, irrespective of the grade of splenic injury.
• Nonoperative management of blunt splenic injury in adults has

become more routine; 65%-80% of adults ultimately managed
nonoperatively for blunt injury to the spleen.

• The operative therapy of choice is splenic conservation where possible
to avoid the risk of death from OPSI.
• However, in the presence of multiple injuries or critical instability,

splenectomy is most appropriate.

• Grades I–II: Topical hemostatic agents, argon beam coagulator, or
electrocautery
• Grades II-III: Suture repair, or mesh wrap – Suture repair requires Teflon
pledgets
• Grades III-IV: anatomic resection with ligation of the lobar artery
• Grades V: Splenectomy

Genitourinary Trauma
Blunt Trauma
• Evaluation: Need for radiographic assessment in patients with urologic
trauma is based on the mechanism of injury, vital signs, physical
examination, and urinalysis.
– Gross hematuria (or microhematuria and a systolic blood pressure [SBP] less
than 90 mm Hg): requires radiographic evaluation of the kidneys
– Microhematuria (in patients who have always had an SBP less than 90 mm Hg):
does not require a radiographic evaluation unless clinical suspicion is high
based on the mechanism of injury (e.g., fall from a height, direct blows, high-
speed motor vehicle crashes)

• Penetrating trauma (regardless of the degree of hematuria): requires
an evaluation
• Radiographic tests : CT scan of the abdomen and pelvis, cystogram,

retrograde urethrogram, and renal angiography are possibilities.

Renal Injuries
Classification: Renal injuries are grades 1 through 5.

A. Grade 1 (contusion): no obvious parenchymal injury, but subcapsular hematoma is possible
B. Grade 2 (minor lacerations): superficial cortical disruptions that do not involve the
collecting system and are less than 1 cm
C. Grade 3 (major lacerations): deep corticomedullary lacerations that do not involve the
collecting system but are greater than 2 cm
D. Grade 4 (deep lacerations): involve the collecting system or cause urinary extravasation
E. Grade 5: defined as either an avulsion of the renal hilum or a shattered kidney

Radiographic assessment
• Abdominal/pelvic CT scan: first-line test performed to rule out renal injury

1. Dry CT : done first to help demonstrate stones
2. Early venous phase and 10-minute delayed images: Done next; the
delayed phase helps define the ureteral anatomy.
• Renal arteriography: generally reserved for patients with possible vascular

injuries that are not elucidated on the CT scan and may require
embolization

Treatment
• Nonoperative: Contusions, minor lacerations, and some major lacerations

can be managed with bed rest, serial hematocrit evaluation, and hydration.
– Ureteral stenting may be required in cases of ongoing urinary extravasation.
• Angiography and embolization: can control most renal bleeding
• Surgical exploration: Debridement of nonviable renal tissue, closure of the

collecting system, coverage of the injury with perinephric adipose tissue,
and drainage of the retroperitoneum.
– Stents are usually not needed.

Renal trauma complications
• Post-traumatic hypertension: uncommon but may occur in 5%–10% o
patients and is mediated by renin owing to ischemic tissue
• Associated injuries: more common in patients with penetrating rather

than blunt trauma
– Blunt trauma: Right renal injuries are associated with liver trauma, and left renal
injuries are associated with splenic injuries.
– Penetrating trauma: Bowel lacerations, pancreatic injury, and other vascular
injuries occur.

Ureteral Injuries
• Etiology: Ureteral injuries are caused primarily by penetrating trauma or
iatrogenic injury.
– Deceleration injuries: may result in avulsion of the ureteropelvic junction,

especially in children
– Blast effect from gunshot wounds: Bullet may not have directly transected the
ureter, but thermal damage to surrounding structures results from the bullet
wound, and the precarious nature of the ureter’s blood supply make it
susceptible to collateral damage.

Radiographic assessment: CT initially identifies injury site; intraoperative
retrograde pyelogram can further delineate the injury.
Treatment
• Complete ureteral transections: should be explored and repaired
• Partial injuries (or suspected devitalization from blast effect): should
undergo initial attempts at stenting, either anterograde or retrograde,
prior to attempting open repair

Bladder Trauma (Lower Urinary Tract)
• Etiology: Blunt bladder trauma is frequently associated with pelvic fractures.
• Rupture can be extraperitoneal or intraperitoneal
– Extraperitoneal: Majority of bladder injuries (80%); these ruptures have a
much better prognosis and are easier to manage.
– Intraperitoneal: These 20% are due to the continuity of the bladder dome
with the peritoneum, whereas the rest of the bladder is extraperitoneal or
pelvic.
• Associated urethral injuries should always be considered as a possibility.

Treatment
• For intraperitoneal bladder injuries, treatment is immediate surgery,

whereas for extraperitoneal injuries, treatment is a long-term -14 days-
Foley catheter in the urethra.

Urethral Injuries
• A high index of suspicion should be maintained, because passage over

a urethral catheter may significantly worsen a mild urethral injury by
theoretically turning a small laceration into a complete avulsion or
disruption.

Signs

• Evaluation:
• Retrograde urethrogram (RUG): Blood at the urethral meatus, an
elevated prostate gland on DRE, or a mechanism of injury possibly
causing a urethral tear should prompt an RUG before bladder
catheterization.
• Plain film cystography: Drainage and oblique films are necessary.

– A cystogram involves maximally (400–500 mL) filling the bladder to determine
extravasation of contrast medium

Treatment
• Penetrating anterior urethral injuries: Should be explored, debrided, and

repaired primarily; a urethral catheter should be left in place after repair.
• Complete prostatomembranous urethral disruptions (from blunt

trauma): require open suprapubic tube placement
– Attempts at primary repair: not warranted
– Attempts at “realignment” (over a urethral catheter or with flexible cystoscopes):
may be indicated
– Follow-up open repair of post-traumatic strictures: should occur 3–6 months after
the injury

Penile Injuries
• Fracture of the erect penis : Caused by direct blunt trauma that significantly buckles the
corpus cavernosum, resulting in a tear of the tunica albuginea overlying the corpora
cavernosa.
• Urethral tears are associated in some penile fracture cases (20%) and should always be
ruled out by an RUG.
• Physical findings: ecchymosis, swelling, and deviation of the penis
• Diagnosis: usually made based on physical examination and the patient’s history, which
usually includes the penis buckling during sexual activity, followed by rapid
detumescence, sharp pain, and immediate bruising and swelling

• Treatment: operative repair and closure for any cavernosal tear
– Surgical exploration: to prevent scarring of the corpus cavernosum
and subsequent Peyronie disease (abnormal penile curvature)
– Urethrogram with repair of the urethral injury: may be necessary

Testicular Trauma
• Blunt trauma : testicular rupture is the primary injury that requires

surgical repair; testicular ultrasound is the gold standard when making
this diagnosis.
– Evaluation: Physical examination is integral and can reveal a large hematocele.
– Treatment: Repair involves debriding extruded or nonviable seminiferous tubules
and closure of the overlying tunica albuginea of the testicle.
• Penetrating trauma : Physical examination and ultrasound may prove
helpful.
– All suspected testicular or spermatic cord injuries should be explored.

Pelvic Fracture
• Initial evaluation: plain film radiograph (pelvic x-ray)
• Pelvic binder: In a patient with a suspected or verified pelvic fracture and hypotension,
a binder placed around the greater trochanters bilaterally decreases the pelvic volume
and minimizes ongoing hemorrhage.
• Treatment for ongoing hemorrhage and shock: may include angioembolization,
preperitoneal packing in the operating room, and endovascular aortic occlusion.
• Treatment for orthopedic injuries : may include definitive or external fixation
• Special consideration: Urethral injury is suggested by blood at the urethral meatus, a
high-riding “ballotable” prostate, and/or significant perineal ecchymosis.

• Definitive stabilization: occurs semi-electively after the patient
stabilizes
– Closed/open reduction of the SI joint, sacrum, or posterior ilium: undertaken
with internal fixation
– Open reduction and internal fixation (ORIF): of the anterior ring or continued
external fixation is achieved

Extremities
• Fractures : Fractured long bones (femurs) have the potential to bleed vigorously and
lead to shock.
• Diagnosis: Plain film x-rays are the mainstay.
• Reduction: Reducing a femur fracture (pulling to length) and stabilizing will decrease
patient pain and potentially decrease bleeding, but the act o reduction is very pain
ul to the patient.
• Arterial injury: Calculation o the ankle-brachial index (ABI) or ankle-ankle index

(AAI) can help detect arterial injury (1.0 is normal, 0.9 needs further evaluation).
• Antibiotic prophylaxis: paramount for open fractures to treat infection

Compartment Syndrome
• Definition: Increased interstitial fluid pressure within an osseofascial
compartment.
• This causes microcirculatory compromise, leading to necrosis o the
muscle within the compartment and dysfunction of the nerves.
• Causes : fracture, crush injuries, arterial injury, tight cast/dressing,

burns, gunshot injury, intramuscular hematoma.

• Most commonly found in the lower leg and forearm but can be found
in any extremity and buttock
– Forearm: classically described as having three compartments—
dorsal, ventral, and mobile wad
– Lower leg: classically described as having four compartments—
anterior, lateral, superficial posterior, and deep posterior

• Diagnosis is primarily clinical
• Pain: escalating pain in the extremity in spite of increasing pain
medication administration, pain out of proportion to the injury, pain
with passive stretch of the myotendinous units within the
compartment, pain and tenseness on palpation (less reliable finding).
• The presence of a tense compartment and the sensation of numbness/
paresthesia/pain
• Intracompartmental pressure measurement: used when clinical exam is

unclear or in unreliable/ unconscious patients
1. Absolute pressure measurement: greater than 30 mm Hg
2. Pressure less than 30 mm Hg below the diastolic blood pressure
• Treatment: emergent surgical release of all involved compartments

A 19 years old patient presented to ER with gunshot in his
umbilicus and systolic BP 70 with tense abdominal distention, the
best next step in management is,(6/2019)
A. Exploratory laparotomy
B. Keep on IV fluid till BP 90/70 then operate.
C. FAST
D. DPL
E. Abdomen CT scan.
A 19 years old patient presented to ER with gunshot in his
umbilicus and systolic BP 70 with tense abdominal distention, the
best next step in management is,(6/2019)
A. Exploratory laparotomy
B. Keep on IV fluid till BP 90/70 then operate.
C. FAST
D. DPL
E. Abdomen CT scan.
A 25 year old male patient presented to ER with penetrating
gunshot chest wall injury. What is the immediate management of
traumatic open pneumothorax in the emergency room,(6/2019)
A. Chest tube placement in 4th intercostal space

B. Place a three-sided occlusive dressing over injury site.
C. Needle thoracentesis in 2nd intercostal space
D. Emergency thoracotomy
E. VATS (video-assisted thoracoscopic surgery)
A 25 year old male patient presented to ER with penetrating
gunshot chest wall injury. What is the immediate management of
traumatic open pneumothorax in the emergency room,(6/2019)
A. Chest tube placement in 4th intercostal space

B. Place a three-sided occlusive dressing over injury site.
C. Needle thoracentesis in 2nd intercostal space
D. Emergency thoracotomy
E. VATS (video-assisted thoracoscopic surgery)
A 22 year old man suffer a sever pelvic fracture and has hematuria
you get a retrograde cystourethrogram and see an extra peritoneal
bladder rupture. The most appropriate therapy(4/2018)
A. Foley drainage for 7 days

B. Exploratory laparotomy
C. Cystectomy
D. Observation
E. Cystoscopy and repair.
A 22 year old man suffer a sever pelvic fracture and has hematuria
you get a retrograde cystourethrogram and see an extra peritoneal
bladder rupture. The most appropriate therapy(4/2018)
A. Foley drainage for 7 days

B. Exploratory laparotomy
C. Cystectomy
D. Observation
E. Cystoscopy and repair.
A 26 year old woman is involved in a sever MVA she is BP 80/40
HR 120 and has distended abdomen. You give her 2 liter ringer
lactate and then start blood transfusion, however she remain
hypotensive, the most appropriate next step is: (4/2018)
A. Abdomen CT scan
B. Abdomen angiography
C. Diagnostic peritoneal lavage or FAS
D. Exploratory laparotomy
E. Abdomen x- ray
A 26 year old woman is involved in a severe MVA she is BP
80/40 HR 120 and has distended abdomen. You give her 2 liter
ringer lactate and then start blood transfusion, however she
remain hypotensive, the most appropriate next step is: (4/2018)
A. Abdomen CT scan
B. Abdomen angiography
C. Diagnostic peritoneal lavage or FAS
D. Exploratory laparotomy
E. Abdomen x- ray
65 y/o gentleman presented to you at the emergency room after
road traffic accident complaining of left chest pain, his vital signs
where Bp110/50, Hr 100 / RR20 Glasgow coma scale 14/15 on
examination, he was found to have diminished breath sounds on
the left side chest x- ray demonstrated opacification of the left
hemi- thorax what is the most likely Dx. (12/2017)
A. Left hemothorax
B. Left pneumothorax
C. Cardiac tamponade
D. Splenic injury
E. left tension pneumothorax. Dr. Mahmoud W. Qandeel
65 y/o gentleman presented to you at the emergency room after
road traffic accident complaining of left chest pain, his vital signs
where Bp110/50, Hr 100 / RR20 Glasgow coma scale 14/15 on
examination, he was found to have diminished breath sounds on
the left side chest x- ray demonstrated opacification of the left
hemi- thorax what is the most likely Dx. (12/2017)
A. Left hemothorax
B. Left pneumothorax
C. Cardiac tamponade
D. Splenic injury
E. left tension pneumothorax. Dr. Mahmoud W. Qandeel
You were the night shift doctor at the Emergency room when a 50
year old gentleman presented to you after a trauma to his
abdomen. His vital signs were Bp110/60 HR 90 RR17, Glasgow com
scale 15/15 Physical exam his abdomen is soft but tender on the
right upper quadrant. What will be your best next step: (12/2017?)
A. Diagnostic Assessment lavage
B. Focused Assessment by sonography test
C. ICU admission
D. Call the surgeon for immediate laparotomy
E. CT scan of the abdomen
You were the night shift doctor at the Emergency room when a 50
year old gentleman presented to you after a trauma to his
abdomen. His vital signs were Bp110/60 HR 90 RR17, Glasgow com
scale 15/15 Physical exam his abdomen is soft but tender on the
right upper quadrant. What will be your best next step: (12/2017?)
A. Diagnostic Assessment lavage
B. Focused Assessment by sonography test
C. ICU admission
D. Call the surgeon for immediate laparotomy
E. CT scan of the abdomen
All sentence about trauma are true except; (12/2017)
A. The term triage is generally used in acute trauma life support
(ATLS )
B. The rationale behind triage is for the benefit of the majority
C. The role of the designated triage person is only to triage and
not to treat
D. The triage process must be constantly repeatedly
E. Coma correspond to a Glasgow coma scale of more than 8

All sentence about trauma are true except; (12/2017)
A. The term triage is generally used in acute trauma life support
(ATLS )
B. The rationale behind triage is for the benefit of the majority
C. The role of the designated triage person is only to triage and
not to treat
D. The triage process must be constantly repeatedly
E. Coma correspond to a Glasgow coma scale of more than 8

At 2 day's after a motor vehicle crash , an otherwise healthy 30
years old man is recovering in the ICU from rib fractures ,
pulmonary contusion , and a liver laceration . He complains of
increasing right upper quadrant pain and vomits bright red blood
Which of the following approaches is best ? (7/2017)
A . Operative exploration and liver resection .
B . Hepatic artery ligation .
C . Angiographic arterial embolization .
D . ERCP with sphincterotomy .
E . Coagulopathy workup .
At 2 day's after a motor vehicle crash , an otherwise healthy 30
years old man is recovering in the ICU from rib fractures ,
pulmonary contusion , and a liver laceration . He complains of
increasing right upper quadrant pain and vomits bright red blood
Which of the following approaches is best ? (7/2017)
A . Operative exploration and liver resection .
B . Hepatic artery ligation .
C . Angiographic arterial embolization .
D . ERCP with sphincterotomy .
E . Coagulopathy workup .
Regarding abdominal trauma in pediatric age group , which of the
following is true ? (4/2017)
A . Clinical examination , stabilization and resuscitation are not of

priority .
B . Ultrasound is the diagnostic tool of choice .
C . Blood transfusion should be started immediately .
D . Peritoneal lavage is contraindicated .
E . Splenectomy is not a routine management for all types of
Splenic injuries .
Regarding abdominal trauma in pediatric age group , which of the
following is true ? (4/2017)
A . Clinical examination , stabilization and resuscitation are not of

priority .
B . Ultrasound is the diagnostic tool of choice .
C . Blood transfusion should be started immediately .
D . Peritoneal lavage is contraindicated .
E . Splenectomy is not a routine management for all types of
Splenic injuries .

Trauma: Principles, Primary and Secondary Survey

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Trauma: Principles, Primary and Secondary Survey

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Trauma

Principles, Primary and Secondary Survey

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Motor vehicle collisions accounting for over 40% of trauma patients.

Dr. Mahmoud W. Qandeel

– Blunt trauma is associated with multiple widely distributed injuries.

– Organs that cannot yield to impact by elastic deformation are most

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

– Usually does not result in widely distributed injuries.

– However, potentially lethal lacerations of internal organs can occur,

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

– The damage is localized to the path of the bullet or knife.

Dr. Mahmoud W. Qandeel

High velocity Low velocity

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Trauma is the commonest cause of death in people from 1–44

• The largest proportion of deaths (1.2 million per year) result

• The World Health Organization (WHO) predicts that by 2020

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• As well as causing personal tragedy, this represents an

Dr. Mahmoud W. Qandeel

• The overall mortality rate, including pre-hospital and in-hospital

• More seriously injured patients reaching hospital show a six-fold

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• A significant proportion of these deaths can be avoided with an

• One-third of all deaths occurring after major injury may be

Dr. Mahmoud W. Qandeel

• These complications of trauma need a high level of intensive

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Hence the most immediately life-threatening injuries should always be

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Spleen (40–55 per cent)

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Cervical (55 per cent)

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• The initial management of seriously injured patients consists of

Dr. Mahmoud W. Qandeel

• Although the concepts within the primary survey are presented in a

Dr. Mahmoud W. Qandeel

• All patients with blunt trauma require cervical spine

• Efforts to restore cardiovascular integrity will be futile unless

Dr. Mahmoud W. Qandeel

– Penetrating injuries to the neck with an

Dr. Mahmoud W. Qandeel

• Suctioning affords immediate relief in many patients.

Dr. Mahmoud W. Qandeel