Committee on Trauma

Presents
Advanced
Trauma Life
Support

for Doctors
Committee on Trauma
Presents

Course
Overview
 Program Goals

Rapid accurate assessment

Resuscitate and stabilize by priority

Determine needs and capabilities

Arrange for transfer to definitive care

Ensure optimum care

 Course Objectives

Demonstrate concepts and principles

of primary and secondary assessments.
Establish management priorities.

Initiate primary and secondary

management.
Demonstrate the skills necessary to
assess and manage critically injured
patients.
 The Need

Trauma is the leading cause of death

in the first four decades of life in
most developed countries.
There are more than 5 million
trauma-related deaths each year
worldwide.
Motor vehicle crashes cause over 1
million deaths per year.
Injury accounts for 12% of the
worlds burden of disease.
The Need

ATLS
provides a
common
language
The Beginning
The Beginning

When I can provide better care in

the field with limited resources
than what my children and I
received at the primary care
facility there is something
wrong with the system, and the
system has to be changed.
James Styner, MD, FACS
1977
Trimodal Death
Distribution
 ATLS Concept

ABCDE approach to evaluation and

treatment

Treat greatest threat to life first

Definitive diagnosis not immediately

important

Time is of the essence

Do no further harm
 ATLS Concept

Airway with c-spine protection

Breathing / ventilation / oxygenation
Circulation: stop the bleeding!

Disability / neurological status

Expose / Environment / body
temperature
Initial Assessment /
Management
Injury Transfer

Primary Survey Adjuncts

Optimize
Resuscitation patient
status

Reevaluation Reevaluation

Detailed
Secondary
Survey Adjunct
s
 ATLS Educational Format

Interactive lectures and skills

sessions

Demonstrations

Group discussions

Simulated patient scenarios

Written exams
 International ATLS
Program
More than 50 countries
Over 1 million doctors
trained
 Impact of ATLS
Program
Documented improvements in care
of injured patients after
implementation of program
Organized trauma care reduces
injury mortality
Retention of organizational and
procedural skills.
 Summary

ABCDE approach to trauma care

Do no further harm

Treat the greatest threat to life

first

One safe way

A common language
Committee on Trauma
Presents

Initial
Assessment
and
Initial Assessment and
Management
Managemen
 Case Scenario

What is the sequence of priorities

in assessing this patient?
44-year-old male driver who crashed
head-on into a wall
Patient found unresponsive at the
scene
Arrives at hospital via basic life
support with c-collar in place and
strapped to a backboard; technicians
assisting ventilations with bag-mask
 Objectives

Apply principles of primary and

secondary surveys
Identify management priorities
Institute appropriate
resuscitation and monitoring
procedures
Recognize the value of the
patient history and biomechanics
of injury
Anticipate and manage pitfalls
 Standard Precautions

Cap
Gown
Gloves
Mask
Shoe covers
Goggles / face
shield
Initial
Assessment

Primary survey
and resuscitation of
vital functions are
done
simultaneously
using a team
approach.
Concepts of Initial
Assessment

Primary Survey
Adjuncts Definitive Care
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Adjuncts
Survey
 Quick Assessment
What is a quick, simple way
to assess a patient in 10 seconds?
 Quick Assessment
What is a quick, simple way
to assess a patient in 10 seconds?

Identify yourself
Ask the patient his or her
name
Ask the patient what
happened
Appropriate Response
Confirms

A Patent airway

B
speech
Sufficient air reserve to permit

C Sufficient perfusion to permit

cerebration

D Clear sensorium
Primary Survey

Airway with c-spine protection

Breathing with adequate oxygenation

Circulation with hemorrhage control

D isability

Exposure / Environment
Primary Survey

The priorities
are the

same for all

patients.
 Special
Considerations
Trauma in the elderly
Pediatric trauma
Trauma in pregnancy
 Primary Survey

Airway
Establish patent airway and
protect c-spine
Pitfall

s Occult airway injury

Progressive loss of
airway

Equipment failure
 Primary Survey

Breathing
Assess and ensure adequate
oxygenation and ventilation

Respiratory rate

Chest movement

Air entry

Oxygen saturation
 Primary Survey

Breathing

Pitfall

s
Airway versus ventilation
problem?

latrogenic pneumothorax
or
tension pneumothorax?
 Primary Survey

Circulation
Assess for organ perfusion
Level of consciousness
Skin color and temperature
Pulse rate and character
 Primary Survey

Circulatory Management

Control
hemorrhage
Restore volume Pitfall
Elderly
s
Reassess patient Children
Athletes
Medications
 Primary Survey

Disability

Baseline neurologic
evaluation
Glasgow Coma Scale
score


Pupillary response
Cautio
Observe for
n neurologic
deterioration
 Primary Survey
Exposure / Environment
Completely undress the patient

Cautio
Prevent
n
hypothermia

Pitfall
Missed
s
injuries
 Resuscitation

Protect and secure

airway

Ventilate and
oxygenate

Stop the bleeding!

Vigorous shock
therapy

Protect from
 Adjuncts to Primary Survey

Vital signs
ECG ABGs
PRIMARY Pulse
Urinary SURVEY

output Urinary / gastric catheters oximeter

and CO 2

unless contraindicated
 Adjuncts to Primary
Survey
Diagnostic
Tools
 Adjuncts to Primary
Survey
Diagnostic
Tools

FAST

DPL
 Adjuncts to Primary
Survey
Consider Early Transfer
Use time before
transfer for
resuscitation

Do not delay
transfer for
diagnostic tests
What is the secondary
survey?

The complete
history and
physical
examination
 Secondary Survey
When do I start the secondary survey?

After
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to
normal
 Secondary Survey

What are the components of the

secondary survey?
History
Physical exam: Head to toe
Complete neurologic exam
Special diagnostic tests
Reevaluation
 Secondary Survey

History
A llergies

M edications

P ast illnesses

Last meal

Events / Environment /
Mechanism
 Secondary
Survey
Mechanisms of Injury
 Secondary Survey

Head
External exam

Scalp
palpation

Pitfall
Unconsciousness
Comprehensive s
Periorbital edema
eye and ear
exam Occluded auditory
canal
Including
visual acuity
 Secondary Survey

Maxillofacial
Bony crepitus

Deformity

Malocclusion Pitfall
Potential airway
obstruction
s
Cribriform plate fracture
Frequently missed
 Secondary Survey

Neck (Soft
Tissues)
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction,
hoarseness
Findings: Crepitus, hematoma, stridor, bruit

Pitfall
Delayed symptoms and
s
signs
Progressive airway
obstruction
Occult injuries
 Secondary Survey

Chest
Inspect

Palpate

Percuss

Auscultate

X-rays
 Secondary Survey

Abdomen
Inspect /
Auscultate

Palpate /
Percuss

Reevaluate
Pitfall Hollow viscous injury
Special studies
s Retroperitoneal injury
 Secondary Survey

Perineum
Contusions, hematomas, lacerations,
urethral blood

Rectum
Sphincter tone, high-riding prostate, pelvic
fracture, Pitfall
Urethral injury
s
rectal wall integrity, blood Pregnancy
 Secondary Survey

Pelvis
Pain on palpation
Leg length unequal
Instability
X-rays as needed

Pitfall

s
Excessive pelvic
manipulation
Underestimating pelvic
blood loss
 Secondary Survey

Extremities
Contusion,
deformity
Pain
Perfusion
Peripheral
neurovascular
status
X-rays as needed
 Secondary Survey

Musculoskeletal
Pitfall
Potential blood loss
s
Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome (especially
with altered sensorium / hypotension)
 Secondary
Survey
Neurologic:
GCS
Brain
Pupil size and
reaction
Lateralizing signs
Frequent reevaluation
Prevent secondary
brain injury
Early
neurosurgical
consult
 Secondary Survey

Neurologic: Spinal
Assessment
Whole spine
Tenderness and swelling
Complete motor and sensory exams
Reflexes
Imaging studies
Pitfall
Altered sensorium
s
Inability to cooperate with
clinical exam
 Secondary
Survey
Neurologic: Spine and
Cord
Conduct an in-depth evaluation
of the patients spine and spinal
cord

Early
neurosurgical /

orthopedic
consult
 Secondary
Survey
Neurologic

Pitfall
Incomplete immobilization
s
Neurologic deterioration
 Adjuncts to Secondary
Survey
Special Diagnostic Tests as Indicated

Pitfall
Patient
s
deterioration
Delay of
transfer
Deterioration
during transfer
Poor
communication
 How do I minimize missed
injuries?

High index of
suspicion

Frequent
reevaluation and
monitoring
 Pain
Management
Relief of pain /
anxiety as
appropriate

Administer
intravenously

Careful monitoring is
essential
 Transfer

Which patients do I transfer to

a higher level of care?
 Transfer

Which patients do I transfer to

a higher level of care?
Those whose injuries exceed institutional
capabilities:

Multisystem or complex injuries

Patients with comorbidity or age

extremes
 Transfer
When should the transfer
occur?
 Transfer
When should the transfer
occur?
As soon as possible after stabilizing
measures are completed:

Airway and ventilatory control

Hemorrhage control
(operation)
Transfer to Definitive Care

Local facility

Transfer
agreements

Local resources
Trauma Specialty
center facility
?
Summary

Primary Survey
Adjuncts Definitive Care
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Adjuncts
Survey
Committee on Trauma
Presents

Airway
and
Ventilatory
Managemen
Initial Assessment and
Management
t
 Case Scenario
What is your first priority?
34-year-old
motorcyclist lost
control and crashed
into a fence
Obvious facial trauma
No helmet
Smells of alcohol
Belligerent at scene;
now not
communicating
Pulse oximeter 85%
 Objectives

Identify the clinical settings in which

airway compromise is likely to occur.
Recognize the signs and symptoms of
airway obstruction.
Describe the techniques to establish
and maintain a patent airway.
Discuss the importance of adequate
oxygenation and ventilation in all
phases of airway management.
 Airway Assessment

How do I know the airway is adequate?

Patient is alert and oriented.

Patient is talking normally.
There is no evidence of injury
to the head or neck.
You have assessed and
reassessed for deterioration.
 Airway Assessment

Signs and symptoms of airway

compromise
High index of suspicion
Change in voice / sore throat
Noisy breathing (snoring and
stridor)
Dyspnea and agitation
 Airway Assessment

Signs and symptoms of airway

compromise (cont.)

Tachypnea
Abnormal breathing pattern
Low oxygen saturation (late sign)
 Airway Assessment

When to intervene when the airway is

patent
Inability to protect the airway
Impending airway compromise
Need for ventilation
Airway Assessment

Impending Airway Obstruction

 Airway Management
How do I manage the airway of a trauma
patient?
Supplemental oxygen
Basic techniques
Basic adjuncts
Definitive airway
Cuffed tube in the trachea
Difficult airway adjuncts
Unexpected difficult airway
Predicted difficult airway
 Airway Management

Caution
Protect the cervical spine during
airway management!
 Airway
Management
Basic
Techniques
Chin-lift Maneuver
 Airway
Management
Basic
Techniques
Jaw-thrust Maneuver
 Airway
Management
Basic Adjuncts
Oropharyngeal airway
Patients who can tolerate an oral
airway will usually need
intubation.
Nasopharyngeal airway
Often well tolerated
 Airway Management

How do I predict a potentially difficult

airway?
Maxillofacial trauma and
deformity
Mouth opening
Anatomy
Beard
Short, thick neck
Receding jaw
Protruding upper teeth
 Airway
Management
Is this a difficult
airway?
How would you
manage this patient?
 Airway Management

Definitive Airway
Easy
Oral intubation (medication
assisted)
Cricoid pressure, suction, back-
up
Maintain c-spine immobilization

Plan for failure:

Gum elastic bougie
LMA / LTA
Needle cricothyroidotomy
Surgical airway
 Airway Management

Definitive Airway
Easy
Preoxygenate
Cricoid pressure
Sedate (midazolam)
Paralytic (succinylcholine)
Intubate
Confirm (Auscultate, CO2)
Release cricoid pressure and
ventilate
 Airway Management

Is this a difficult
airway?
How would you
manage this patient?
 Airway Management

Definitive Airway
Difficult
Get help
Be prepared
Consider rapid sequence intubation
vs. awake intubation
Maintain c-spine immobilization
Consider use of:
Gum elastic bougie
LMA / LTA
Surgical airway
Other advanced airway techniques,
eg, fiberoptic intubation
 Airway Management

Definitive Airway
Surgical airway
Cricothyroidotomy
Needle Surgical
Airway Decision
Scheme
 Airway Confirmation
How do I know the tube is in the
right place?
Visualize it going
through the cords
Watch the chest
Auscultation
Pulse oximeter
CO2 detector
Radiology
?
 Summary

Suspect airway compromise in all injured

patients.
Adjuncts for establishing a patent
airway include:
Chin-lift and jaw-thrust maneuvers
Oropharyngeal and nasopharyngeal airways
Laryngeal mask airway
Multilumen esophageal airway
Gum elastic bougie device
 Summary

With all airway maneuvers, the cervical

spine must be protected by inline
immobilization.
A surgical airway is indicated when an
airway is needed and intubation is
unsuccessful.
The assessment of airway patency and
adequacy of ventilation must be
performed quickly and accurately.
Pulse oximetry and end-tidal CO2
measurement are essential.
 Summary

A definitive airway requires a tube

placed in the trachea (inflated cuff,
oxygen, assisted ventilation, airway
secure).
Oxygenated inspired air is best provided
via a tight-fitting oxygen reservoir face
mask with a flow rate of greater than 11
L/min.
Committee on Trauma
Presents

Shock

Initial Assessment and

Management
 Case Scenario

28-year-old female in MVC

Pulse: 126; BP: 96/70; RR:
28
Confused and anxious

Is this patient in shock? If so,

what type?
How would you manage this
patient?
 Objectives

Define shock.

Recognize the shock state.

Determine the cause of shock.

Discuss treatment principles.

Recognize the importance of early

identification and control of
hemorrhage.
 What is shock?

Generalized State of Hypoperfusion

Inadequate oxygen delivery

Catecholamines and other responses

Anaerobic metabolism

Cellular
dysfunction
Cell death
 Shock

Is the patient in shock?

Alteration in level of
consciousness,
anxiety
Cold, diaphoretic skin
Tachycardia
Tachypnea, shallow
respirations
Hypotension
Decreased urinary
output
 Shock

How do I recognize shock?

Scene information / mechanism of

injury
AMPLE history

Inadequate Organ
perfusion dysfunction
 Shock

What is the cause of the shock state?

Hypovolemi vs Nonhemorrha
c
Blood loss gic
Tension
pneumothorax
Fluid loss
Cardiac
tamponade
Cardiogenic
Septic
Neurogenic
 Shock

How do I locate the bleeding?

 Shock

How do I locate the bleeding?

Physical
examination
Diagnostic
adjuncts to
primary survey
Chest X-ray
Pelvic X-ray
FAST / DPL
 Shock

What is the cause of the shock state?

In the vast majority of trauma

patients, shock is due to blood
loss.
 Interventions

What can I do about it?

Direct Angio-
pressure / embolizatio
tourniquet STOP n

the
bleeding!
Reduc Splint
e fractur
pelvic es
volum Operation
e
 Intervention
s
What can I do about it?

Fluid resuscitation
Vascular access?
Type?
Volume?

Monitor response
Prevent
hypothermia!
 Patient Response

How do I evaluate the patients response?

Identify improved organ

function
Skin: warm, capillary refill
Renal: increased urinary output
Vital signs
CNS: improved level of
consciousness
 Patient Response

What is the patients response?

 Patient Response

What is the patients response?

Related to volume or persistence of

hemorrhage
Rapid responder

Transient
responder
Nonresponder
Operation
 Class I Hemorrhage

750 mL BVL (15%)

Slightly anxious
Normal blood pressure
Heart rate < 100 / min
Respirations 14-20 / min
Urinary output 30 mL / hour
Crystalloid
 Class II Hemorrhage

750-1500 mL BVL (15-30%)

Anxious
Normal blood pressure
Heart rate > 100 / min
Decreased pulse pressure
Respirations 20-30 / min
Urinary output 20-30 mL / Crystalloid,
hour ? blood
 Class III Hemorrhage

1500-2000 mL BVL (30-40%)

Confused, anxious
Decreased blood pressure
Heart rate > 120 / min
Decreased pulse pressure
Respirations 30-40 / min Crystalloid,
Urinary output 5-15 mL / hour blood
components,
operation
 Class IV Hemorrhage

>2000 mL BVL (>40%)

Confused, lethargic
Hypotension
Heart rate > 140 / min
Decreased pulse pressure
Respirations >35 / min Definitive
Urinary output negligible control, blood
components
 Pitfalls

Complications of Shock Patient Factors

Pitfalls
Age extremes
Athletes
Pregnancy
Medications
Pacemaker
 Pitfalls

Complications of Shock and Shock

Management

Pitfalls

Hypothermia
Early coagulopathy
 Pitfalls

Complications of Shock

Pitfalls

Equating BP with
cardiac output
Misleading hemoglobin
and hematocrit levels
?
 Summary

Shock is inadequate organ

perfusion and tissue oxygenation.
Hypovolemia is the cause of shock
in most trauma patients.
Patients may present with mild to
severe shock.
 Summary

Conduct a rapid initial assessment and

resuscitation.
Determine cause of shock.
Stop the bleeding.
Reevaluate.
Committee on Trauma
Presents

Thoracic
Trauma

Initial Assessment and

Management
 Case Scenario

27-year-old male brought to

trauma center
Unrestrained driver in high-
speed, frontal-impact collision
Prolonged extrication at scene
 Case Scenario

Blood pressure: 90/70; heart

rate: 110; respiratory rate: 36
Initial assessment: GCS score
15, patent airway

What features suggest that this

patient may have thoracic injuries?
 Objectives

Identify and treat life-

threatening injuries found
during the primary survey.
Identify and treat potentially
life-threatening injuries found
during the secondary survey.
 Thoracic Trauma

Significant cause of mortality

Blunt: < 10% require operation

Penetrating: 15-30% require

operation
Majority: Require simple
procedures
Most life-threatening injuries are
identified during the primary
survey
 Thoracic Trauma

What are the immediately life-

threatening chest injuries?

Laryngeotracheal injury / Airway

obstruction
Tension pneumothorax
Open pneumothorax
Flail chest and pulmonary
contusion
Massive hemothorax
Cardiac tamponade
 Thoracic Trauma

What are the pathophysiologic

consequences of these chest
injuries?
Hypoxia
Hypoventilation
Manage in
Acidosis the
Respiratory primary
survey as
Metabolic
identified
Inadequate
tissue perfusion
 Laryngeotracheal Injury

Airway Obstruction
Rare
Hoarseness
Subcutaneous emphysema
Manage in the primary
survey as soon as possible
Intubate cautiously
Tracheostomy
 Tension
Pneumothorax
Respiratory distress
Shock
Distended neck
veins
Unilateral decrease
in breath sounds
Hyperresonance
Cyanosis (late sign)
 Tension Pneumothorax

Clinical
diagnosis, not by
x-ray
Immediate
decompression
Needle
Chest tube
Open Pneumothorax
 Open Pneumothorax

3-sided cover
over defect
Chest tube

Definitive
operation
Flail Chest and Pulmonary
Contusion
 Flail Chest and Pulmonary
Contusion
Oxygen

Reexpand lung

Intubate as
indicated
Judicious fluids

Analgesia
 Massive Hemothorax

Systemic /
pulmonary vessel
disruption
> 1500 mL blood
loss
Flat vs. distended
neck veins
Shock with no
breath sounds
and/or percussion
dullness
 Massive Hemothorax

Rapid volume
restoration
Chest
decompression
and x-ray
Autotransfusion
Operative
intervention
 Cardiac Tamponade

Decreased arterial
pressure Radio
Distended neck antenna

veins
Muffled heart
sounds
Pulseless electrical
activity
Cardiac Tamponade

A Secure airway

B Ventilate and oxygenate

C Volume resuscitation

FAST, operation
 Resuscitative
Thoracotomy
When should I consider
resuscitative thoracotomy?
 Resuscitative
Thoracotomy
When should I consider
resuscitative thoracotomy?
Patients with penetrating
thoracic injury arriving with PEA
may be a candidate
When a surgeon with appropriate
skills is present
ED thoracotomy not indicated in
blunt trauma with PEA
 Thoracic Trauma

What are the potentially life-

threatening chest injuries?

How do I identify them?

When and how do I correct the

problem?
 Thoracic Trauma

What are the potentially life-

threatening chest injuries?
Tracheobronchial tree injury
Simple pneumothorax
Pulmonary contusion
Hemothorax
 Thoracic Trauma

What are the potentially life-

threatening chest injuries?
Blunt cardiac injury
Traumatic aortic disruption
Blunt esophageal rupture
Traumatic diaphragmatic injury
 Thoracic Trauma

How do I identify potentially life-

threatening thoracic injuries?
Physical examination
Chest x-ray
Pulse oximetry
ABG
ECG
 Tracheobronchial Tree
Injury
Often missed
Blunt or penetrating
Persistent pneumothorax
Bronchoscopy
Treatment
Airway and ventilation
Tube thoracostomy
Operation
 Simple Pneumothorax

Penetrating / blunt
trauma
Ventilation /
perfusion defect
Hyperresonance
Decreased breath
sounds
Tube thoracostomy
 Pulmonary Contusion

Common

Oxygenate and
ventilate
Selective
intubation
Delayed X-ray
changes
 Hemothorax

Chest wall injury

Lung / vessel
laceration
Tube
thoracostomy
 Blunt Cardiac Injury

Injury spectrum
Abnormal ECG / monitor
changes
Echocardiography
Treat
Dysrhythmias
Perfusion
Complications
 Traumatic Aortic
Disruption
Rapid
acceleration /
deceleration
mechanism
X-ray signs
High index of
suspicion
Surgical consult
 Traumatic Aortic
Disruption
Diagnosis by Helical CT or
Aortography
 Blunt Esophageal
Rupture
Blunt vs. penetrating injury

Severe epigastric blow

Pain / shock out of proportion

to injury
Left pneumothorax or
hemothorax without rib
fracture
 Esophageal Injury

Chest tube:
Particulate matter
Mediastinal air
Contrast swallow,
esophagoscopy
Operation
 Diaphragmatic Injury

Most diagnosed on
left
Blunt: Large tears
Penetrating: Small
perforations
Misinterpreted x-
ray
Contrast
radiography
 Traumatic Asphyxia

Petechiae

Swelling

Plethora

Cerebral
edema
 Subcutaneous
Emphysema
Airway injury

Pneumothorax

Blast injury

Iatrogenic
 Fractures and Associated
Injuries
Sternum, Scapular, and Rib
Ribs 1-3
Severe force
Associated injuries have high
mortality risk

Ribs 4-9
Pulmonary contusion and
pneumothorax

Ribs 10-12
Suspect abdominal injury
 Pitfalls

Pitfalls
Simple pneumothorax converts
to tension pneumothorax
Retained hemothorax
Diaphragmatic injury
Severity of rib fractures /
pulmonary contusion
Extremes of age
?
 Summary

Common in multiply injured

patients
Life-threatening injuries
Potentially-lethal injuries
Initial stabilization by simple
techniques in the majority of cases
Goal: Restore normal gas exchange and
perfusion
Committee on Trauma
Presents

Abdomin
al and
Pelvic
Trauma
Initial Assessment and
Management
 Case Scenario

35-year-old male passenger in

high-speed motor vehicle
collision
BP: 105/80; Pulse: 110; RR: 18
GCS score: 15
Complaining of pain in chest,
abdomen, and pelvis

What injuries do you

suspect and how
would you manage
this patient?
 Objectives

Identify key anatomical features of the

abdomen.
Recognize patients at risk for abdominal
and pelvic injuries based on the
mechanism of injury.
Describe the evaluation of patients with
suspected abdominal and pelvic injuries.
Describe the acute management of
abdominal and pelvic injuries.
External Anatomy of
Abdomen
 Abdominal Injury

When should you suspect abdominal

injury?
 Abdominal Injury

When should you suspect abdominal

injury?
Blunt Penetrating
Speed Weapon
Point of Distance
impact
Number and
Intrusion location of
wounds
Safety devices
Position
Ejection
 Abdominal Injury

Blunt Force Mechanism

Commonly Injured Organs
Spleen
Liver
Small bowel
 Abdominal Injury

Penetrating Mechanism
Any Organ at Risk
Stab
Low energy,
lacerations

Gunshot
Kinetic energy
transfer
Cavitation, tumble

Fragments
 Abdominal Injury

How do I determine if there is an

abdominal injury?
 Abdominal Injury

How do I determine if there is an

abdominal injury?
Assessment: Physical Exam

Inspection
Auscultation
Percussion
Palpation
 Abdominal Injury

Factors that Compromise the Exam

Alcohol and other drugs
Injury to brain, spinal cord
Injury to ribs, spine, pelvis

Caution
A missed abdominal
injury can cause a
preventable death.
 Adjuncts

Gastric Tube
Relieves distention
Decompresses stomach
before DPL

Caution

Basilar skull / facial

fractures
Can induce vomiting /
aspiration
 Adjuncts

Urinary Catheter
Monitors urinary
output Caution

Decompresses
bladder before DPL
Diagnostic
 Adjuncts

Blood and Urine Tests

No mandatory blood tests before

urgent laparotomy
Hemodynamically abnormal:
type and crossmatch, coagulation
studies
Pregnancy testing
Alcohol or other drug testing
Hematuria (gross versus
microscopic)
 Adjuncts

X-ray Studies
Blunt: AP chest and pelvis
Penetrating: AP chest and
abdomen with markers (if
hemodynamically normal)
 Adjuncts

Contrast Studies
Abdominal
CT
Urethrogra
m
Cystogram
IVP Caution

GI studies Dont delay definitive

care!
 Diagnostic Studies

Blunt Trauma
 Diagnostic Studies

Penetrating Trauma Hemodynamically

Normal
Lower chest wounds
Serial exams, thoracoscopy,
laparoscopy, or CT scan
Anterior abdominal stab wounds
Wound exploration, DPL, or serial
exams
Back and flank stab wounds
DPL, serial exams, or double- or
triple-contrast CT scan
 Explosions

ABCDE
Combination
mechanism
Blunt
Penetrating
fragments
(multiple)
Blast
Consider proximity, enclosed
space, multiple fragments and
secondary impacts (thrown or
fall from height).
 Laparotomy

Who requires a laparotomy?

 Laparotomy

Who requires a laparotomy?

 Laparotomy

Indications for Laparotomy Blunt

Trauma
Hemodynamically
abnormal with suspected
abdominal injury (DPL /
FAST)
Free air
Diaphragmatic rupture
Peritonitis
Positive CT
 Laparotomy

Indications for Laparotomy Penetrating

Trauma
Hemodynamically
abnormal
Peritonitis
Evisceration
Positive DPL, FAST, or CT
Early operation is usually
the best strategy for GSW
 Pelvic Fractures

Significant force
Associated
injuries
Pelvic bleeding
Venous / arterial
 Pelvic Fractures

Assessment of Pelvic Fractures

Inspection
Leg-length discrepancy, external
rotation
Open or closed
Palpation of pelvic ring, stability
Rectal / GU / vaginal exam
Open or closed? Palpate prostate
 Pelvic Fractures

How do I manage patients with pelvic

fractures?
 Pelvic Fractures

How do I manage patients with pelvic

fractures?
AB, as usual
C: Control hemorrhage
Wrap / Binder
Rule out abdominal hemorrhage
Angiography, fixation, open surgery
 Pelvic Fractures

Hemodynamically Abnormal
Patients
Surgical consult
Pelvic wrap Intraperitoneal
gross blood?
Yes No

Laparotomy Angiograph
y
Control
hemorrhage
Fixation device
 Pitfalls

Pitfalls

Delayed intervention for abdominal

hemorrhage
Occult intraabdominal /
retroperitoneal injuries
Back and flank wounds
Repeated manipulation of a
fractured pelvis
Spinal cord injury / altered
sensorium
?
 Summary

ABCDEs and early surgical

consultation
Evaluation and management vary
with mechanism and physiologic
response
Repeated exams and diagnostic
studies
High index of suspicion
Early recognition / prompt