Chapter 29 – Torso and

Pelvic Trauma
Bailey & Love 28th edition
Dr. Mahdi Aljamal, MD
General and Laproscopic Surgeon
Introduction:
• Injury not respect anatomical boundaries
• Injury to Torso can affect both abdomen and thorax not only single
cavity.
• About 42% of all deaths are the result of brain injury, but some
39% of all trauma deaths are caused by major hemorrhage,
usually from torso injury
• Historically, treatment was based on anatomical basis, but physiology
should be the over-riding considration.
- so the driver of successful resucitation is the preservation of normal
physiology.
Injury mechanisms associated with Torso
Trauma :
• Injury consistenly traverses different anatomical zones of body.
= junctional zones. (neck\ thorax, thorax\upper limbs, thorax\abdomen,
abdominopelvic structures\groin)
- surgical challenges for diagnosing and for surgical approach.

- e.g. Any penetrating injury below the nipples on the chest may therefore have
penetrated the diaphragm and entered the abdomen. Injuries in this junctional zone,
therefore, should be investigated as if both cavities had been penetrated

- The pelvis contains a large plexus of vessels, both venous and arterial. Should injury
occur, control of hemorrhage can prove to be exceptionally difficult and may
require control of both arterial inflow and venous outflow.
- Angioembolization can be a very useful adjunct to treatment, especially with deep
pelvic injuries.
Advanced trauma life support principles of
resuscitation:
• C: Catastrophic hemorrhage
• A: Airway
• B: breathing
• C: circulation
• D: disability
• E: environment & Exposure.

• This is followed for all injuries to chest and abdomen.

Hemorrhage is the major problem in Torso
Trauma
• Bleeding occurs from five major sites ( one on the floor and four more) =
- external = floor + chest + abdomen\reteroperitoneum + pelvis + extermities

• Clinical indicators of potential ongoing bleeding in torso trauma:

1. Increasing RR
2. Increasing HR
3. Falling BP
4. Rising serum lactate
5. Visible bleeding
6. Injury to close proximity to major vessels
7. Penetrating injury with a retaind missile
Thoracic Injury:
• 25% of all sever injuries
• Directly or indirectly >50% of trauma deaths
• Most common cause of death in sever chest injuries = bleeding
• 80% of chest injuries can be managed non-operatively
Thoracic Injury:
• Routine investigation in ER based on clinical examination supplemented
by appropriate imaging

- eFAST = extended focused assessment with sonography for trauma –

most commonly used currently

- chest radiograph (investigation of first choice)

- Computed tomography scan ( CT) with contrast – pan CT provides

rapid diagnosis

- finger thoracostomy – can be diagnostic and therapeutic

Thoracic Injury:
• Routine investigation in ER based on clinical examination
supplemented by appropriate imaging

- eFAST = extended focused assessment with sonography for trauma –

most commonly used currently
- contusion vs blood, most common use, pericardial tamponade, free
blood or air in chest, blood in abdominal cavity and paracolic gutters,
subdiaphragmatic spaces and pelvis.
Thoracic Injury:
• Routine investigation in ER based on clinical examination supplemented by appropriate imaging

- eFAST = extended focused assessment with sonography for trauma – most commonly used
currently

- chest radiograph (investigation of first choice)

 in non compromised patient and spine not at risk, AP usually, for trachea deviation , lung \
mediastinal pathology, skeletal injury
 in pentetrating njury more helpful erect position , R\O small pneumothorax, fluid meniscus,
air fluid level, free gas under diaphgram, (need > 300 cc to pleural effusion to be ovious)
 skeletal injury may indicate nearby soft tissue injury or vascular injury e.g. rupture of thoracic
aorta with 1st and 2nd rib fracture. And fracture of ribs irrespective to site, can be associated
with lung parenchyma injury  pneumothorax, hemothorax, or lung contusion
Thoracic Injury:
• Routine investigation in ER based on clinical examination supplemented by
appropriate imaging

- eFAST = extended focused assessment with sonography for trauma – most

commonly used currently

- chest radiograph (investigation of first choice)

- Computed tomography scan ( CT) with contrast – pan CT provides rapid

diagnosis
 principle and most reliable examination for major inury in trauma
contusion, penumothorax, hemataoma, track of penetrating missile, injury to
diaphgram
Management of thoracic injury
• In penetrating injury  most can be managed with appropriate
resuscitation and insertion of an intercostal drain.
• In blunt injury  most bleeding from intercostal or internal
mammary vessels, rare to require surgery
• Blunt compressive injury  can be associated with flail chest and
lung contusion.
 Management of thoracic injury
• life threatening injuries =
deadly dozen
- 6 of them should be sought
and managed during primary
survey
- and another 6 potentially life
threatening should be detected
in 2ndry survey

• Airway obstruction  Early

intubation v. important
specially in case of neck
hematoma or suspcted airway
Tension pneumothorax
• - one-way valve, air from lung or chest wall
- completely collapsing then compression affected lung
- mediatstinum & trachea displaced to opposite side
- decrease venous return
- compressing opposite lung
- restless, tachypnic, distended neck vein, dyspnic, tracheal deviation (late
sign), hyperresonance & decreased\absent breath sounds over affected
hemithorax

• Clinical diagnosis, treatmenet should never be delayed by waiting for

radiological conformation.
- treat with high index of suspicion.
Tension pneumothorax
• Treatment = immediate decompression

- historically rapid insertion of large bore cannula in 2 nd intercostal

space in midclavicular line (MCL) of affected side then insertion of
chest tube in 5th intercostal space in AAL

- currently  decompression in safe triangle (post. Latissmus dorsi,

Anti. Lateral border of pectoralis major, inf. Line perpendicular to
nilpple to the back just anterior to midaxillary line (same for finger
thoracostomy in extreme cases)
Pericardial Tamponade:
• Most commonly due to Penetrating trauma
• Even small amount 50 cc in percardial sac can cause tamponade
• All patient with penetrating injury anywhere near heart plus shock
must be considered cardiac injury until proven otherwise
• Classical presentation  CVP elevated (distended neck vein) ,
decline in arterial pressure, tachycardia, muffled heart sound
- in case of bleeding in other site, neck vein may be flat
- to differentiate from T. pneumothorax  lung sounds are
present.
Pericardial Tamponade:
• If clinically not obvious, investigation may be needed:
- eFAST – the most reliable diagnostic tool
- chest radiograph may show enlarged heart shadow

• Pericardiocentesis is effective in case of blunt trauma cardiac tamponade.

• Pericardiocentesis has no role in the management of cardiac tamponade

secondary to penetrating myocardial injury.
- The correct immediate treatment of tamponade is operative, either via a
subxiphoid window or by open surgery (sternotomy or left anterolateral
thoracotomy), with repair of the heart in the operating theatre if time allows or
otherwise in the emergency department.
Open pneumothorax = sucking chest
wound
• Large open defect in chest > 3 cm
• Causes equilibrium between intrathoracic and atmospheric pressure
• If > 2\3 of trachea diameter, so air enter with each inspiration from the
wound not trachea
• Profound hypoventilation on affected side and hypoxia
• leads to tension pneumothorax
• Initial management = sterile occlusive plastic dressing e.g. OPSITE,
tape to 3 sites to act as flutter-type valve. Then chest tube inserted
ASAP.
Massive hemothorax
• Most common cause in blunt injury  bleeding from torn intercostal vessels or
occasionally internal mammary artery due to fracture of ribs
• In penetrating injury both abdominal (through diaphragmatic hiatus) and thoracic
viscera can contribute

• Presentation = flat neck veins, hemorrhagic shock, unilateral absence of breath sounds,
dullness to percussion

• Initial treatment  correct hypovolemic shock, intercostal drain insertion, and sometimes
intubation
- >1500 cc blood on initial drainage or >200 cc\ hour over 3-4 hours  urgent
thoracotomy
- No role to clamp the tube to tamponade massive hemothorax
The following points are important in the management of
an open pneumothorax/hemothorax:
• if the lung does not reinflate, the drain should be placed on low-
pressure (5 cmH2O) suction;

• clot occlusion of a chest drainage tube may result in ‘no’ drainage,

even in the presence of ongoing bleeding;

• a second drain is sometimes necessary

• physiotherapy and active mobilization should begin as soon as possible

Flail chest:
• Usually from blunt trauma a\w multiple ribs fractures and lung contusion
• Defined = 3 or more ribs fractures in 2 or more places
• Clinical diagnosis, chest wall observed for paradoxical motion of chest wall segment
• Hypoxia occurs due to  voluntary splinting of chest wall due to pain, impaired chest
wall movement due to fractures and lung contusion.
• High risk for developing pneumothorax \ hemothorax
• Gold standard for diagnosis = CT scan
• Traditionally  MV in ICU
currently txt  O2, analgesia, physiotherapy, ETT for patient with respiratory
failure
- in selected groups surgery with internal fixation of ribs may be useful
Pulmonary contusion
• more with blunt trauma, a\w flail segment or fractured ribs
• Very common, major cause of hypoxemia after blunt trauma
• Natural progression of lung contusion  worsening hypoxemia for
first 24-48 hours
• Chest radiograph = may be delayed findings
• chest CT = confirmatory
• Hemoptysis or blood in ETT = sign of pulmonary contusion
• Treatment:
- mild  O2, pulmonary toilet and analgesia
- sever  mechanical ventilation
The pitfalls of doctor investigation for
thoracic injury are:
• failure to assess tracheal shift immediately above the sternal notch clinically
- deviation of the trachea occurs away from the affected side in tension
pneumothorax and towards the affected side in lung collapse

• failure to percuss and auscultate both front and back in a supine patient
- an inflated lung will ‘float’ on a hemothorax, so auscultation from the front may
sound normal);

• failure to pass a nasogastric tube if rupture of the diaphragm is suspected

- a chest radiograph will show the nasogastric tube apparently within the chest
cavity;
The pitfalls of doctor investigation for
thoracic injury are:
• a supine chest radiograph can show a hemothorax as a
homogeneous increase in opacity of the hemithorax
– this can cause confusion between the darker side and the lighter side
as to which may be a hemothorax (less radiolucent) or a pneumothorax
(more radiolucent);
- look carefully for lung markings and do not drain the wrong side;

• pursuing radiological investigation (radiography or CT scan)

instead of resuscitation in the unstable patient
Abdominal Injury
Abdominal injury
• After abdominal trauma patient can be: (physiology is assessed
constantly)
- physiologically normal  investigation can be completed before txt
- physiologically non compromised  investigation more limited
( decided if patient can be managed non operatively,
angioembolization, surgery
- physiologically compromised  investigation suspended , and need
immediate surgical correction of bleeding

• In case of source of bleeding in shocked multiple injured patient is

not clear, laparotomy may still the safest option
Investigations:
• In torso trauma, the best and most sensitive modality is a CT scan with
intravenous contrast; however, in the unstable patient, this is generally not possible.

• FAST and eFAST

- FAST = presence of free fluid in torso, and eFAST extended into thoracic cavities
and pericardium
- no attempt to determine nature\extent of specific injury
- rapid, reproducible, portable, non-invasive bedside, can be done at same time with
resuscitation.
- accurate to detect >100 cc free blood
- operator dependent (specially obese patient or full of gases)
- also unreliable for excluding injury in penetrating trauma, NOT reliable for
retroperitoneum, NOT directly identify hollow viscus
Diagnostic peritoneal lavage
• DPL
• Rarely used in modern-day practice, useful in resource-limited settings
- replaced by eFAST
• assess presence of blood in abdomen
• NGT to empty stomach, urinary cath to drain bladder  canula inserted
below umbilicus (caudally and posteriorly) , aspirated for blood, if > 10 cc –
positive test
- then 500 cc warm RL in abdomen then allow fluid to drain, if frank blood
= positive test.
- if analysis done in lab >100 000 red cell or > 500 WBC or raised amylase
level in fluid = positive test = equivalent to 20 cc of free blood in abdomen
Computed tomography scan CT scan
• Gold standard for intrabdominal diagnosis of injury in stable patient
• Sensitive to blood, individual organ injury and for retroperitoneum.
• Entirely normal abdominal CT sufficient to exclude
intraperitoneal injury.

• NOT appropriate investigation for physiologically compromised

patients.
Laparoscopy \ thoracoscopy
• May screening in physiologically non compromised with penetrating trauma
to detect \ exclude peritoneal penetration and \ or diaphragmatic injury
• Divided into: screening(exclude penetrating injury with breach of peritoneum)
, diagnostic (finding evidence of injury viscera) , therapeutic (used to repair
injury)

• In most institution = evidence of penetration  laparotomy, difficult to

exclude all injuries laparoscopically.
- laparoscopy reduce non therapeutic laparotomy rate

• No place for laparoscopy in unstable patient

Liver injury
Liver Injury:
• blunt trauma occur as a result of direct injury,
• Solid organ, easily burst by compressive forces.
• Most injuries are relatively minor and can be managed non-operatively.
• Penetrating trauma to liver is relatively common.
- bullet have shock wave, more damage than the track only.
- not all penetrating require operative management and may stop bleeding
spontaneously.

• in physiologically non-compromised patient, CT is the investigation of

choice.
- advised all patient to be re-scanned before discharge
Liver Injury:
• Management of liver injuries can be summarized as four Ps:
- pressure – bimanual compression
- pringle – direct compression of portal triad, control arterial and venous inflow, but not
control back flow from hepatic veins and IVC
- plug – any hole can be plugged with silicon tubing or Sengstaken-Blakemore tube.
- pack – after controlling arterial bleeding

• Not usually necessary to suture penetrating injuries of liver unless hemostasis

cannot be controlled by other means.

• damage to hepatic artery can be tied off

- but damage to portal vein MUST be repaired ( if tied >50% mortality rate)
(repaired in another operation after being shunted in first operation)
spleen Injury:
• From direct blunt trauma
• Most isolated splenic injuries (specially children)
can be managed non-operatively
• In adult, specially in presence of other injuries
or physiological compromise  laparotomy considered.
• theoretically  it can be packed, placed in mesh bag, repaired
• Reality splenectomy is safer option.
- certain situation selective angioembolization of spleen can play a role.

• Post splenectomy  wbc \ plt increase (may mimic sepsis)

- advised to get vaccinated against encapsulated bacteria within 2-3 weeks
Pancreatic Injury:
• Most are result of blunt trauma
• Difficult to diagnose as it is a reteroperitoneal structure
- CT the mainstay of accurate diagnosis.
• Amylase\lipase  insensitive
• In penetrating injury, injury may only be detected during laparotomy
• Treatment
- classically  conservative surgery with closed, low suction drainage
- each type\organ injury has classification in ISS ( injury scoring scale)
with different management ***
Small bowel Injury:
• need urgent repair.
• Hemorrhage take priority
• in blunt trauma with mesenteric vessel damage and level of
ischemia with determine level of resection (carefully planned
to limit the loss of viable small bowel vs. number of
anastomosis\ repairs)
• Hematoma need to explored and rule out perforation.
Colon Injury:
• Penetrating injuries are more common.
• In general:

- little conatmination and viability is satisfactory  primary

repair

- extensive contamination, or compromisded patient or bowel

is doubtful viability  clip and drop (bowel can be closed off)
and another surgery later (defunctioning colostomy can be
formed later or the bowel re-anastomsed once patient is stable)
Rectum injury
• 5% of colonic injury involve the rectum
• Most from penetrating injury
• Can be a\w bladder or urethral injury.
• With intraperitoneal injury: rectum managed as colonic injury.
• full thickness extraperitoneal rectal injuries  primary repair and
drainage depending on type of injury (e.g. knife wounds)
• Extensive tissue loss  diverting end-colostomy and closure of
distal end ( Hartmann’s procedure) or loop colostomy
• Presacral drainage no longer used!
Retroperitoneum
• Difficult to diagnose
• Diagnostic test FAST\ DPL
may be negative
• Best diagnostic modality CT,
but need physiologically
stable patient
• Divided into 3 zones for
purposes of intraoperative
management in blunt
trauma
Retroperitoneum
• Zone 1 (central): central hematoma always explored once
proximal and distal vascular control has been obtained

• Zone 2 (lateral): lateral hematoma should only be explored

if expanding or pulsatile or penetrating injury present
- usually renal in origin, can be managed non-operatively,
or angioembolization

• Zone 3 (pelvic): only explored if expanding or pulsatile or

penetrating injury present
- pelvic hematoma exceptionally difficult to control and
whenever possible should not be opened, best controlled
with compression or extraperitoneal packing, or
angioembolization for arterial origin.
Damage Control surgery
Damage Control Surgery
• Major injury with long surgery in unstable patient can be itself
fatal

• Deadly triad = hypothermia, acidosis, coagulopathy.

• So DCS = initial care and resuscitation (damage control

resuscitation) and the surgical correction of the injury (damage
control surgery)  The minimum amount of surgery needed to
stabilize the patient’s condition may be the safest course until the
physiological derangement can be corrected.
Damage Control Surgery
• Restricted only to 3 goals:
1- stopping any active surgical bleeding
2- controlling any contamination
3- restoring normal physiology

• Stages of DCS
I patient selection  II control of hemorrhage and control of
contamination  III resuscitation in ICU IV definitive
surgery (24-72 hours of injury)  V closure of abdomen
Indication of Damage
Control Surgery
Thank You 