BASIC SURGERY

3.3. GENERAL PRINCIPLES OF TRAUMA

DR. RONALD LICUP, MD| DECEMBER 10, 2021

OUTLINE
I. Heading IV. Note for long outlines, use two
A. Subheading columns to save space for
B. Subheading main content.
II. Heading V. For short outlines, just merge
III. Heading the two columns.
LEGEND
Remember Lecturer Book Presentation

Figure 2. Stabbed Wound (Impaled - Foreign Body still there) (left).

I. TRAUMA Laparotomy, Lacerated (Samurai) wound, no incision performed anymore,
● Trauma or injury defined as surgeons proceeded to exploration of the wound
○ Cellular disruption
○ Wherein the exchange with environmental energy is beyond the ■ For impaled tabbed would, proceed to the OR, sometimes
body’s resilience even without performing diagnostic for abdominal trauma)
○ “So if the body’s resilience is not exceeded there will be no ● Check for Vital signs if hypotensive, tachycardic, is there a
trauma, hindi mabubugbog, kaya sya na traumatized kasi it sign of shock.
exceeded the bodies resilience” ● So you will stabilise lalagyan mo muna IV fluids
● Trauma apparently is the most common cause of death in the 1st
year of life up to 44 years old A. PRIMARY SURVEY
○ 3rd most common cause of death regardless of age
■ Number one cause of years of productive years lost PRIMARY & SECONDARY SURVEY
● The U.S. government classifies injury-related death into the
following categories: ● “For Trauma, you have to remember two things first is ABCD (aka
○ ACCIDENTS (unintentional injuries) Primary Survey) and the Secondary Survey
■ Vehicular crash ● ABCDE
■ Fall, burns ○ Airway
○ Breathing
○ Circulation
○ Disability
○ Exposure
● Secondary Survey is the ample (aka “Patient’s History”)
○ AMPLE
■ Allergies
■ Medicine
■ Pregnancy / Previous Illnesses
■ Last Meal
■ Events/Environment related to the injury

AIRWAY

Figure 1. Vehicular accident (left) and Blunt Abdominal Trauma (Right) ● Check Airway for:
○ Obstruction (secure the patient’s airway)
○ INTENTIONAL SELF-HARM (suicide) ○ Injury
○ Assault (homicide) ● Patent airway is the first priority
■ Gunshot, Stab, Wound ● All blunt trauma require cervical spine immobilization
○ Legal intervention or war ○ For example, gunshot wound through left sternocleidomastoid,
○ Undetermined causes anong maganda pang cervical spine immobilization na ilalagay
mo? Hard collar, sandbag, soft collar or none?
■ None, because it is a penetrating trauma.
● Apply a hard collar or place sandbags on both sides of the head
● Soft collars do not effectively immobilize
● When to secure a patient’s airway?
○ Patient is:
■ conscious, no tachypnea, with normal voice, do not require
early attention to the airway
■ soft tissue swelling, hematoma formation, edema, abnormal
voice, abnormal breathing sounds, tachypnea, or altered
mental status require airway security
○ Methods:
■ Endotracheal intubation

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY
■ Nasotracheal Intubation ● Cutdowns, CVP, IJ catheters
■ Cricothyroidotomy ● In children less than 6 years of age, an intraosseous needle can
■ Tracheostomy be placed in the proximal tibia (preferred) or distal femur of an
unfractured extremity
BREATHING AND VENTILATION ● External control of bleeding
○ Place 4x4 gauze + gloved hand
● Breathing ○ Gloved finger pressure
● All injured patients should receive supplemental oxygen and be ○ For open fracture
monitored by pulse oximetry. ■ Reduction + splint
● Conditions that constitute immediate threat to life due to inadequate ● 4 life-threatening injuries that must be identified are:
ventilation and should be recognized during primary survey: ○ massive hemothorax → chest
○ Tension / Open pneumothorax (life threatening and must be ○ cardiac tamponade → heart
identified immediately, is it an Open Pneumothorax or a Close ■ How do you determine cardiac tamponade?
Pneumothorax). ● If there is positive Beck’s triad
■ Paano mo masasabi na Tension Pneumothorax? When there ○ massive hemoperitoneum → abdomen
○ mechanically unstable pelvic fractures → bones
is Hypotension, then this is a Tension Pneumothorax
● What can you do in the emergency room at the patient’s table?
■ presumed in any patient manifesting respiratory distress and ○ Radiograph, FAST, Pericardiocentesis, EDT (indications)
hypotension in combination with the ff physical signs: ○ Pericardiocentesis → 15-20 mL
● Tracheal deviation away from affected side ○ EDT → cardiac massage, aortic x-clamping, hilar clamping
● Lack of or decreased breath sounds on affected side
● Subcutaneous emphysema on affected side
■ Distended neck vein due to impedance of venous return may
be seen
■ Hypotension qualifies pneumothorax as a tension
pneumothorax
■ Treatment:
● Immediate needle thoracostomy decompression with a
14-gauge angiocatheter
● Tube thoracostomy in midaxillary line done before a chest
radiograph is obtained
○ Flail chest
■ occurs when three or more contiguous ribs are fractured in at
least two locations Figure 3. Pericardiocentesis
■ Pulmonary contusions often progress during first 12 hours
■ Treatment: DISABILITY AND EXPOSURE
● Intubation and mechanical ventilation - for resultant ● Check for:
hypoventilation and hypoxemia ○ Extremity losses
○ Massive hemothorax ○ Intracranial hemorrhage/mass lesion
○ Major air leak due to a tracheobronchial injury
■ Type I injuries - occurring within 2 cm of the carina ■ Important here is Glascow Coma Scale
● may not be associated with a pneumothorax due to ■ Motor response, best verbal response, and eye opening
■ 13 to 15 indicate mild head injury
envelopment in mediastinal pleura. ■ 9 to 12 moderate injury
■ Type II injuries - more distal injuries within the ■ less than 9 severe injury
tracheobronchial tree ● Seriously injured patients must have all of their clothing removed
● manifest with a pneumothorax to avoid overlooking limb- or life-threatening injuries
■ Treatment/Management: ○ Most common sites of missed injuries are in axilla, inguinal,
● Bronchoscopy - confirms extent of injury and its location, rectal areas
and directs management
SHOCK CLASSIFICATION AND INITIAL FLUID RESUSCITATION
II. INITIAL EVALUATION AND RESUSCITATION OF THE
● Review the lecture of Dr. Dagani for more comprehensive
INJURED PATIENT
discussion
● Classification of Shock
CIRCULATION WITH HEMORRHAGE CONTROL ● Persistent Hypotension
● Identify if there is: (by palpating peripheral pulses) ○ Search for cause
○ Shock (Hypovolemic, neurogenic, etc.) ○ Hypovolemic (low CVP), cardiogenic (+NVE), neurogenic, septic
○ CTT → initial output 1L / 200 mL / hr
■ Systemic blood pressure of 90 and below is shock ● Evaluate scalp, chest, abdomen, pelvis, and extremities
■ In trauma, it is usually presumed to be secondary to volume
loss until proven
● Systolic BP
○ 60 mmHg for the carotid pulse to be palpable
○ 70 mmHg for the femoral pulse
○ 80 mmHg for the radial pulse
○ Massive hemothorax or hemoperitoneum
○ Unstable pelvis fracture
● Any episode of hypotension (SBP <90 mmHg) is assumed to be
caused by hemorrhage until proven
● IV access for fluid resuscitation
○ two peripheral catheters, 16-gauge or larger in adults
● CBC, x-matching Figure 4. Stages of Hemorrhagic Shock (See appendix for clearer view)

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY
■ Airway compromise due to blood running down the posterior
B. SECONDARY SURVEY pharynx, or there may be vomiting provoked by swallowed
blood
■ Nasal packing or balloon tamponade may be necessary to
AMPLE HISTORY control bleeding
● Allergies ● All patients with a significant closed head injury (GCS score <14),
● Medications elderly patients or those patients on antiplatelet agents or
● Past illnesses or Pregnancy anticoagulation should undergo CT scanning of the head.
● Last meal ● Penetrating injuries
● Events related to the injury ○ Plain skull films may be helpful in the trauma bay to determine
● Also get: the trajectory of injury in hemodynamically unstable patients who
○ NOI (nature of incident), POI (place of incident), TOI (time of cannot be transported for CT scan.
incident), DOI (date of incident) ○ The presence of lateralizing findings (e.g., a unilateral dilated
pupil unreactive to light, asymmetric movement of the extremities
■ for medicolegal purposes
either spontaneously or in response to noxious stimuli, or
○ Physical exam should be head to toe, special attention to the
unilateral Babinski’s reflex) suggests an intracranial mass lesion
patient’s back, axillae, and perineum
or major structural damage.
○ Gross hematuria demands evaluation of the genitourinary
■ Such lesions include hematomas, contusions, hemorrhage
system
into ventricular and subarachnoid spaces, and diffuse axonal
injury (DAI).
C. REGIONAL ASSESSMENT ■ Epidural hematomas occur when blood accumulates between
● Diagnostic Test indication: the skull and dura, and are caused by disruption of the middle
○ Mechanism meningeal artery or other small arteries in that potential
○ location of injuries identified on physical examination space, typically after a skull fracture.
○ Screening radiographs ■ Subdural hematomas occur between the dura and cortex and
○ Patient’s overall condition are caused by venous disruption or laceration of the
parenchyma of the brain.
HEAD ● Due to associated parenchymal injury, subdural
hematomas have a much worse prognosis than epidural
● Evaluation of the head collections.
○ Injuries to the scalp, eyes, ears, nose, mouth, facial bones, and ○ Hemorrhage into the subarachnoid space may cause vasospasm
intracranial structures and further reduce cerebral blood flow. Intraparenchymal
○ Palpation: hematomas and contusions can occur anywhere within the brain.
■ Identify scalp lacerations ○ Significant intracranial penetrating injuries usually are produced
■ Evaluated for depth, and depressed or open skull fractures. by bullets from handguns, but an array of other weapons or
● Eye examination instruments can injure the cerebrum via the orbit or through the
○ Pupillary size and reactivity thinner temporal region of the skull.
○ Visual acuity
○ Hemorrhage within the globe
NECK
○ Ocular entrapment
■ Caused by orbital fractures with impingement on the ocular ● Cervical examination
muscles, is evident when the patient cannot move his or her ○ All blunt trauma patients should be assumed to have cervical
eyes through the entire range of motion spine injuries until proven otherwise
○ Important to perform the eye examination early ○ Maintain cervical spine precautions and in-line stabilization.
■ Significant orbital swelling may prevent later evaluation ○ Spinal cord injuries
■ A lateral canthotomy may be needed to relieve periorbital ■ Complete injuries cause either quadriplegia or paraplegia,
pressure depending on the level of injury. These patients have a
● Ear examination complete loss of motor function and sensation two or more
○ Tympanic membrane is examined to identify hemotympanum, levels below the bony injury.
otorrhea, or rupture ○ Central cord syndrome typically occurs in older persons who
■ Signal an underlying head injury experience hyperextension injuries.
○ Otorrhea, rhinorrhea, raccoon eyes, and Battle’s sign ■ Motor function, pain, and temperature sensation are
(ecchymosis behind the ear) preserved in the lower extremities but diminished in the upper
■ Suggest a basilar skull fracture. extremities.
■ Although such fractures may not require treatment ○ Anterior cord syndrome
● An association with blunt cerebrovascular injuries, cranial ■ Diminished motor function, pain, and temperature sensation
nerve injuries, and risk of meningitis. below the level of the injury, but position sensing, vibratory
● Anterior facial structures should be examined to rule out sensation, and crude touch are maintained.
fractures. ○ Brown-Séquard syndrome is usually the result of a penetrating
○ Entails palpating for bony step-off of the facial bones injury in which one-half of the spinal cord is transected.
and instability of the midface (by grasping the upper ■ Ipsilateral loss of motor function, proprioception, and vibratory
palate and seeing if this moves separately from the sensation, whereas pain and temperature sensation are lost
patient’s head). on the contralateral side.
● Examination of the oral cavity ○ Fracture of the larynx due to blunt trauma
○ Ask whether the patient’s bite feels normal to them ■ Signs and symptoms include hoarseness, subcutaneous
○ Abnormal dental closure emphysema, and a palpable fracture.
■ Malalignment of facial bones ● A precise preoperative diagnosis is desirable for symptomatic zone I
■ Mandible or maxillary fracture and III injuries due to technical difficulties of injury exposure and
○ Inspection for open fractures, loose or fractured teeth, and varying operative approaches
sublingual hematomas. ○ Zone I is inferior to the clavicles encompassing the thoracic
● Nose examination outlet structures
○ Nasal fractures ○ Zone II is between the thoracic outlet and the angle of the
■ Evident on direct inspection or palpation, typically bleed mandible
vigorously ○ Zone III is above the angle of the mandible.

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3.03. GENERAL PRINCIPLES OF TRAUMA
● Management of patients is further divided into those who are
symptomatic and those who are not
○ Specific symptoms or signs that should be identified include
dysphagia, hoarseness, hematoma, venous bleeding, minor
hemoptysis, and subcutaneous emphysema.
■ Should undergo CTA with further evaluation or operation
based upon the imaging findings; less than 15% of
penetrating cervical trauma requires neck exploration.
○ Asymptomatic patients are typically observed for 6 to12 hours.
CHEST
● Blunt trauma to the chest
○ Chest wall, thoracic spine, heart, lungs, thoracic aorta and great
vessels, and rarely the esophagus
○ Evaluated by physical examination and chest radiography, with
supplemental CT scanning based on initial findings.
○ Any patient who undergoes an intervention in the
ED—endotracheal intubation, central line placement, tube
thoracostomy—needs a repeat chest radiograph to document
the adequacy of the procedure. This is particularly true in
patients undergoing tube thoracostomy for a pneumothorax or
hemothorax.
■ Patients with persistent pneumothorax, large air leaks after
tube thoracostomy, or difficulty ventilating should undergo
fiber-optic bronchoscopy to exclude a tracheobronchial injury
or presence of a foreign body.
■ Patients with hemothorax must have a chest radiograph
documenting complete evacuation of the chest; a persistent
hemothorax that is not drained by two chest tubes is termed a
caked hemothorax and mandates immediate thoracotomy.
■ Occult thoracic vascular injury must be diligently sought due
to the high mortality of a missed lesion.
■ Widening of the mediastinum on initial anteroposterior chest
radiograph, caused by a hematoma around an injured vessel
that is contained by the mediastinal pleura, suggests an injury
of the great vessels.
■ Posterior rib fractures, sternal fractures with laceration of
small vessels, and mediastinal venous bleeding also can
produce similar hematomas.
● For penetrating thoracic trauma
○ Physical examination, plain posteroanterior and lateral chest
radiographs with metallic markings of wounds, pericardial
ultrasound, and CVP measurement
● Injuries of the esophagus and trachea
○ Bronchoscopy should be performed to evaluate the trachea in
patients with a persistent air leak from the chest tube or
mediastinal air.
● Neck injuries
○ Hemodynamically stable patients with transmediastinal gunshot
wounds should undergo CT scanning to determine the path of
the bullet
■ Identifies the vascular or visceral structures at risk for injury
and directs angiography or endoscopy as appropriate.
ABDOMEN
● liver, spleen, intestines
● Abdomen is a diagnostic black box
○ not necessary to determine in the ER which intra-abd organs are
injured, only if laparotomy is necessary
○ PE of abd can be unreliable
○ drugs, alcohol, and head and spinal cord injuries can complicate
the clinical evaluation
● The presence of abdominal rigidity and hemodynamic compromise
is an undisputed indication for prompt surgical exploration. For the
remainder of patients, a variety of diagnostic adjuncts are used to
identify abdominal injury
● Gunshot wounds
○ laparotomy is warranted due to significant internal injuries
○ anterior truncal gunshot wounds between the fourth intercostal
space and the pubic symphysis whose trajectory as determined
by radiograph or wound location indicates peritoneal penetration
should undergo laparotomy
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SURGERY
○ Gunshot wounds to the back or flank are more difficult to
evaluate because of the retroperitoneal location
■ Triple-contrast CT scan - delineate the trajectory of the bullet
and identify peritoneal violation or retroperitoneal entry, and
associated injuries
● exception is penetrating trauma isolated to the right upper quadrant
○ hemodynamically stable patients with trajectory confined to the
liver by CT scan, nonoperative observation may be reasonable
● Laparoscopy is another option to assess peritoneal penetration for
tangential wounds it should not be done in unstable patients
● Injuries that do not penetrate the peritoneal cavity do not require
further evaluation
● Patients with fascial penetration must be further evaluated for
intra-abdominal injury
● Patients with stab wounds to the right upper quadrant can undergo
CT scanning to determine trajectory and confinement to the liver
● Penetrating thoracoabdominal wounds may cause occult injury to
the diaphragm. Patients with gunshot or stab wounds to the left
lower chest should be evaluated with diagnostic laparoscopy or DPL
to exclude diaphragmatic injury.
● Diagnostic laparoscopy may be preferred in patients with a positive
chest radiograph (hemothorax or pneumothorax) or in those who
would not tolerate a DPL
PELVIS
● Blunt injury to the pelvis may produce mechanically unstable
fractures with major hemorrhage
● Plain radiographs will reveal gross abnormalities, but CT scanning
is necessary to determine the precise geometry
● bladder rupture may result from a direct blow to the torso if the
bladder is full
○ CT cystography is performed if the urinalysis demonstrates
RBCs
○ Urethral injuries are suspected if examination reveals blood at
the meatus, scrotal or perineal hematomas, or a high-riding
prostate on rectal examination
● Urethrograms should be obtained for stable patients before placing
a Foley catheter
● Life-threatening hemorrhage can be associated with pelvic fractures
and may initially preclude definitive imaging.
EXTREMITIES
● Blunt or penetrating trauma to the extremities requires an
evaluation for fractures, ligamentous disruption, and neurovascular
injury.
○ Plain radiographs are used to evaluate fractures, whereas
ligamentous injuries, particularly those of the knee and shoulder,
can be imaged with magnetic resonance imaging.
○ Physical examination identifies the majority of arterial injuries,
and findings are classified as either hard signs or soft signs of
vascular injury
● hard signs constitute indications for operative exploration, whereas
soft signs are indications for further testing or observation
● Vascular trauma
○ The most common approach has been to measure SBP using
Doppler ultrasonography and compare the value for the injured
side with that for the uninjured side, termed the A-A index.
■ If the pressures are within 10% of each other, a significant
injury is unlikely, and no further evaluation is performed
■ If the difference is >10%, CTA or arteriography is indicated.
● In patients with hard signs of vascular injury, on-table angiography
may be useful to localize the arterial injury and thus limit tissue
dissection.
○ for example, a patient with an absent popliteal pulse and femoral
shaft fracture due to a bullet that entered the lateral hip and
exited below the medial knee could have injured either the
femoral or popliteal artery
III. FRACTURES AND DISLOCATIONS
● Fall, VA, etc
● check for pulses (if wala pulso there is vascular compromise, needs
to be addressed otherwise it will necrose)
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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY
● cold compress B. ANTIBIOTICS
● elevate
● Gram Negative
● immobilization/splint/support
● analgesics ○ 1st gen cephalosporin = good for gram (+)
● refer ○ 2nd gen cephalosporin = good for gram (-)
○ 3rd gen cephalosporin = good for both and can cross the
blood-brain barrier. e.g., ceftriaxone
IV. ABDOMEN ● Anaerobes
● Abdomen ○ metronidazole
○ Intrathoracic
○ True Abdomen C. DIAGNOSTIC MODALITIES
● Posterior Abdomen
● PE is not reliable
○ Retroperitoneal Abdomen
○ in abdominal trauma kasi lahat masakit so lahat bubuksan natin
■ organs: kidneys, adrenals, ureter, part of ascending &
○ diagnostic modality is needed IF the patient is stable
descending aorta
● Lateral Abdomen ○ if unstable, we need to do immediate exploration
(laproscoptomy)
● Abdominal Trauma is usually painful
● Blood is least peritoneal irritant
○ so kung meron blood sa abdomen, it is not that painful
● Diagnostic modalities
○ CT scan - best but most expensive
○ Abdominal x-ray
○ Abdominal ultrasound
● Equivocal Abdominal Findings
○ Radiologic Examination
○ Diagnostic Peritoneal Lavage (DPL)
■ inject around 1L of fluid in the patient's abdomen, then you
will aspirate it again. once aspirated, you will check the fluid if
there is blood, bile, feces which will dictate a positive /
negative DPL. if positive, you can do a laparotomy
○ CT scan
■
○ Ultrasound (FAST)
■ Focused Assessment with Sonography for Trauma
○ Laparoscopy
■ still questionable. being proposed as a diagnostic modality

D. TREATMENT
● ABCDE / AMPLE
● Stabilize condition
● Hospitalization
● Equivocal PE - Diagnostic / Tangential
Figure 5. Abdominal Regions ● Emergent Laparotomy
● Observation
A. MECHANISM OF INJURY
● Penetrating Abdominal Injury E. EMERGENT LAPAROTOMY
○ Gunshot wound (High/Low velocity) ● Hemodynamic instability
■ speed of bullet much more important than its weight ● Herniated / eviscerated abdominal contents
○ Blast injury ● Peritoneal signs
○ Stab wound ● Gunshot wound
○ Organs with largest surface area are most prone to injury: ● Vascular injury - lower extremity ischemia
■ Small bowel ● Pneumoperitoneum
■ Liver ○ ano tinamaan pag may “air in the peritoneal cavity”? ano ba
■ Colon organs may air? colon and stomach
■ Adjacent structures are commonly injured - bullets and knives ○ you can appreciate this thru x-ray or CT scan. but NOT with
follow straight lines
● Blunt Abdominal Injury ultrasound
○ usually in vehicular accidents (e.g., steering wheel injury), ● Impaled Foreign Body
○ pagnaksaksak, naiwan yung knife. hindi mo hinuhugot yun sa
nagsusuntukan, etc.
ER. you remove it in the operating room under anesthesia
○ usual hollow organ injured: ● Presence of gross blood - NGT, IFC, Rectal
■ in Filipinos, duodenum. maybe due to our diet (i.e., pulutan) ○ do rectal exams on all seriously injured patients. kasi kapag may
during drinking sessions.
■ in Caucasians, urinary bladder. their bladder after drinking is gross blood, you have to do immediate laparotomy
full because they don’t pee just anywhere. yung mga Filipino
kasi, kung saan-saan umiihi.
○ Organs that cannot yield to impact by elastic deformation are
most likely to be injured (solid organs) such as:
■ Liver spleen and kidneys

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY
HERNIATED/EVISCERATED ABDOMINAL CONTENTS GUNSHOT WOUND
● Laparotomy is warranted for gunshot or shotgun wounds that
penetrate the peritoneal cavity because most have significant
internal injuries.
● The standard has been that anterior truncal gunshot wounds
between the fourth intercostal space and the pubic symphysis
whose trajectory as determined by radiograph or wound location
indicates peritoneal penetration should undergo laparotomy.
● However, there has been increased use of CT scanning to facilitate
nonoperative management of abdominal GSWs

VASCULAR INJURY
● Lower extremity ischemia
● Either due to blunt or penetrating trauma - can result in devastating
neurologic sequelae or exsanguination
● Principles of vascular repair techniques apply to carotid injuries
● Options for repair include:
○ End-to-end primary repair - often possible with mobilization of
common carotid
Figure 6. Stab wound with omental evisceration ○ Graft interposition
○ Transposition procedures
● All carotid injuries should be repaired except in patients in coma
with a delay in transport
● Prompt revascularization of internal carotid artery using temporary
Pruitt-Inahara shunt - considered in profound shock patients
● Tangential wounds of internal jugular vein
○ Repaired by lateral venorrhaphy
○ Extensive wounds efficiently addressed by ligation
■ Not advisable to ligate both jugular veins → potential
intracranial hypertension

PNEUMOPERITONEUM
● Air in the peritoneal cavity
● Can be appreciated only using Xray lang, not seen in CT scan
● Anong tinamaan bakit nagkaroon ng air in the peritoneal cavity?
○ Diaphragm
○ Colon
○ Stomach
Figure 7. Stab wound with omental evisceration ○ These two structures lang yung may air, kaya pag tinamaan,
there is pneumoperitoneum. Then you have to do exploration.

IMPALED FOREIGN BODY

● Foreign bodies lodged low in the rectum
○ may often be removed under conscious sedation with or without
a local anesthetic block.
● Objects impacted higher in the rectum
○ may require regional or general anesthesia for removal.
● Only rarely will a laparotomy be required to remove the object
○ either through manual manipulation of the object to expel from
the anus, or via colotomy.
● After removal of the foreign body, it is crucial to evaluate the rectum
and sigmoid colon for injury.

PRESENCE OF GROSS BLOOD

● NGT
● IFC
○ Foley catheterization
Figure 8. Stab wound with evisceration of the colon and omentum ● Rectal exam
○ done in all seriously injured patients kasi if there is presence of
● Hindi mo lang ipapasok and tatahiin. You have to do an exploratory gross blood, you have to do emergent laparotomy
laparotomy. Check if may iba pang injury
F. OBSERVATION
PERITONEAL SIGNS
● When will you decide to observe if hindi ka mag a-abdominal
● May be attenuated by the stretching of the abdominal wall laparotomy?
● Equivocal Abdominal PE = Stable VS
● Diagnostic Examinations
○ Favor a non-penetrating abdominal injury

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY

SERIAL ABDOMINAL PE
● Kapag mag dedecide ka ng mag o-open:
● Surgical Indications:
○ Increase area of tenderness
○ Tenderness, away from the entry wound
○ Diffusely tender Abdomen

DIAGNOSTIC EXAMS
● Chest Xray = Pneumoperitoneum
● (+) Diagnostic Peritoneal Lavage (DPL) = Spillage (ex. blood, feces, Figure 10. Diagnostic Peritoneal Lavage (DPL)
urine)
○ This will sway you from observation into performing an ● (Refer to above figure)
immediate laparotomy ○ Make a small incision beneath the umbilicus, insert 1L of saline
then aspirate that and have it checked.
● See Appendix for algorithm for initial evaluation of patient with
ULTRASOUND suspected blunt abdominal trauma
● FAST examination for initial evaluation of blunt abdominal trauma
○ Not 100% sensitive
FAST
○ Diagnostic peritoneal aspiration warranted in hemodynamically
unstable patients without a defined source of blood loss to rule ● Focused Abdominal Sonography for Trauma (FAST)
out abdominal hemorrhage ● Free Intraperitoneal fluid
○ Identify free intraperitoneal fluid - Morison’s pouch, LUQ area
CT SCAN and the pelvis
● Solid organ injury
● Patients with stab wounds to the RUQ to determine trajectory and ● See Appendix for Management algorithm using FAST exam
confinement to the liver for potential nonoperative care
● Contrasted CT - stab wounds to the flank and back to assess
potential risk of retroperitoneal injuries of the colon, duodenum and
urinary tract

DIAGNOSTIC LAPAROSCOPY
● This is questionable pa.

DPL
● Positive result
○ Gross Blood, feces, bile, urine Figure 11. FAST (ultrasound is used).
○ RBC count of > 100,000/mL for AASW
○ WBC count >500/mL for AASW and TASW CT SCAN
○ then you already have the indications to open up or do
● Free intraperitoneal fluid
exploration
● Solid organ/hollow viscus injuries

Figure 12. CT SCAN

V. GUNSHOT WOUNDS
● Low velocity
● High velocity
● Bowel resection
○ Bakit natin ni-reresect? Because of the blast effect.
● Anastomosis, Exteriorize
Figure 9. Positive findings on DPL. ● Repair or removal
● Intraoperative placement of gauze packs
● Negative result ○ Kapag hindi stable yung patient we can place sterile gauze
○ Suture wound packs, then we operate once the patient is stable
○ Discharge

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY

Figure 15. PHASE 1

Figure 13. GUNSHOT WOUND B. PHASE II

● CORE REWARMING
● This is gunshot wound, multiple injuries, we do damage control ● CORRECT COAGULOPATHY
surgery just ligate the bleeders, control the infection close and
● MAXIMIZE HEMODYNAMICS
stabilize the patient then after 24-48 hours you re-operate and
● VENTILATORY SUPPORT
repair whatever you can repair
● INJURY IDENTIFICATION

VI. BLUNT ABDOMINAL TRAUMA

Figure 14. BLUNT ABDOMINAL INJURY

this one is a steering wheel injury. Here is a compressed urinary
bladder, medyi madalange to sa mga pilipino kasi ang mga pilipino
mahilig umihi kung saan saan
● ABCDE Figure 16. PHASE II
● AMPLE
● Equivocal PE B. PHASE III
● Exploratory Laparotomy ● PACK REMOVAL
● Observation ● DEFINITIVE REPAIRS
● Duodenal Injuries: common in asians or filipinos
● Bladder Injuries: common for foreigners

VII. DAMAGE CONTROL SURGERY

● a deliberate and calculated surgical approach designed to
maximize a patient’s physiologic status prior to definitive repair of
overwhelming injuries,
● you just stabilized the patient during the time of surgery. When there
is bleeding you just stop the bleeding by placing intra abdominal
packing. Then, you wait 24-48 hours for the definitive procedure.

VIII. 3 PHASES OF DAMAGE CONTROL SURGERY

Figure 17. PHASE III
A. PHASE I
● CONTROL HEMORRHAGE
● CONTROL CONTAMINATION
REVIEW QUESTIONS
● TEMPORARY ABDOMINAL CLOSURE 1. This drug is good for Gram-negative organisms
a. 1st gen cephalosporin
b. 2nd gen cephalosporin
c. 3rd gen cephalosporin
d. Both A and B
e. Both B and C

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3.03. GENERAL PRINCIPLES OF TRAUMA SURGERY
2. AMPLE stands for Allergies, Medicine, Pregnancy / Previous
Illnesses, Last Meal and Events/Environment related to the injury
a. FALSE
b. TRUE
3. ABCDE stands for Airway, Breathing, Circulation, Disability and
Exposure
a. TRUE
b. FALSE
4. Any episode of hypotension with a SBP of less than what
amount is assumed to be caused by hemorrhage until proven?
a. 70 mmHg
b. 80 mmHg
c. 90 mmHg
d. 100 mmHg
5. For fractures and dislocations the following should be
observed except
a. check for pulses
b. warm compress
c. elevate
d. immobilization
e. splinting
6. Gunshot wounds to the back or flank are easier to evaluate;
Physical exam of abdomen can be unreliable
a. first statement is true
b. second statement is true
c. both statement is true
d. neither of the statement is true
7. The following are positive indications to do DPL, EXCEPT:
a. Detection of gross blood, urine, bile and feces
b. RBC count of >100,000/mL for AASW
c. WBC count of > 50,000/mL for AASW and TASW
d. A and B
8. The following are under phase II of damage control, EXCEPT:
a. Temporary Abdominal Closure
b. Core Rewarming
c. Correct Coagulopathy
d. Maximize Hemodynamics
Answers:1E 2B 3A, 4B, 5B, 6B, 7C, 8A
REFERENCES
● Book
Brunicardi, C. (2019). Schwartz’s Principle of Surgery (11th ed).
New York: McGraw Hill.
● Lecturer’s Powerpoint
Licup, R (2021). General Principles of Trauma [lecture powerpoint].
● Previous Transes
Batch 2023

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APPENDIX

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