Trauma, Surgery and Shock
Essential Surgery: Chapters 3, 15, 17 (p. 34-53, 199-218, 232-244) and Medical
Physiology: Chapter 24 (p. 300-302) and Article: Update of Sepsis in the Intensive
Care Unit by Genga and Russell and Clinical Medicine: Chapter 11, 25 (p. 270-271,
1150-1160)
Trauma
Essential Surgery: Chapter 15 (p. 199-218)
When arriving at the scene
The ‘golden hour’
The first hour after the trauma is experienced, the golden hour, is the most important one.
There are two strategies with dealing with out-hospital traumas: scoop and run or stay and
play. Stay and play is used for less severe cases.
Assessing the wreckage
Assess if: seat belts were worn, airbags inflated, high-velocity or low-velocity impact.
The worst injuries are suffered in head-on collisions or when the corners of the front of the
car are affected.
In motorcycle crashes: assume a pelvic fracture until proven otherwise.
In pedestrian vs. car crashes: a ‘bullseye’ fracture of the windscreen of the car means that
there is probably severe head injury.
Transport
The disadvantages of using a helicopter: not much space for resuscitation, risk of
pneumothorax due to altitude changes and risk of secondary injury. Advantage of helicopter:
fast.
Triage is the process of sorting patients into ‘priority of treatment’ groups on arrival.
Category Definition Colour Treatment
P1 Life-threatening Red Immediate
P2 Urgent Yellow Urgent
P3 Minor Green Delayed
P4 Dead White
If patients reach the hospital alive, that means they have survived the golden hour. The main
threats for death are now: hypovolemia and intracranial haematoma.
What needs to be done in the hospital:
● Primary assessment + resuscitation
● Secondary survey
● Prioritisation and treatment of individual injuries
The ‘lethal triad’ is three conditions that are most associated with mortality: coagulopathy (=
blood loss), hypothermia and acidosis.
,Primary survey
Primary injuries are the ones directly caused by the trauma. Secondary injuries are the ones
caused by the consequences of the primary injuries (e.g. fat embolism from fractures).
A - Airway
The patient is speaking: airway is open, ventilation is normal, brain has blood. In
unconscious patients, the airway should be secured with a jaw thrust and intubation.
The spine should be secured with a cervical collar and preferably strapped in during
transport.
Immobilise the spine if spinal injury is suspected.
B - Breathing
Check if the breathing is normal and if normal breathing sounds can be heard upon
auscultation of the lungs. Think of pneumothorax, hemothorax, pneumohemothorax etc.
Oxygen should be given to all patients.
C - Circulation
If the patient is unconscious and you can’t feel a pulse in the wrist or foot, 250-500 ml of fluid
should be given immediately. This is followed by small boluses until the pulse returns. A
conscious patient, or one who is unconscious but with a palpable pulse has a systolic blood
pressure >90 mmHg, so no extra fluids need to be given.
This is the moment to check (quickly) for big fractured bones, especially pelvic and long
bones. The bones should be realigned and splinted.
D - Disability
Check if the patient is responsive.
E - Environment, Exposure, “Exrays”
Patient is examined naked to assess external injuries. Prevent hypothermia by covering the
patient with a warm blanket. If lots of fluids are given, change to warmed fluids. Imagining is
now done.
Secondary survey
A fast history is taken during the second assessment (when possible). This should include
the following (mnemonic: AMPLE):
● Allergies
● Medicines and drugs
● Past medical history
● Last meal (including alcohol)
● Events leading to accident
The secondary survey is for potential life-threatening problems/complications. In the
emergency room, chest, pelvis and cervical spine X rays are made. Patients shouldn’t be
moved to a CT scanner until stable. A focused abdominal sonography for trauma (FAST; see
next section) is performed when abdominal injuries are suspected.
Test for blood groups. If it is an emergency group O, Rh negative (“O neg”) should be
administered.
Damage control laparotomy
When a major trauma patient is open on the table for many hours, it is very likely to die from
the lethal triad (coagulopathy, hypothermia and acidosis). A damage control laparotomy can
be performed instead to fix the patient up for definitive surgery. A damage control
laparotomy should be done within an hour. Hollow viscus injuries are stapled or resected
without anastomosis.
, Abdominal injuries
Abdominal injuries happen way less often than head or chest injuries. The major cause of
death is massive haemorrhage from a burst liver or spleen or when major arteries or veins
get penetrated (gunshot wounds). Unrecognised injuries are the principal cause of death that
is avoidable.
Diagnosis
In blunt injuries, the signs of bleeding or perforation of hollow organs may not develop until
hours after the injury but will always be visible within 24 hours. When the accident involved
high energy transfers, an early CT scan is important (as long as the patient is stable).
A focused abdominal sonography for trauma (FAST) will show free fluid in the abdomen,
especially in the 5 Ps areas: perihepatic, perisplenic, pelvic, pleural and pericardial.
A CT scan can help detect the following:
● Injuries to solid organs in abdomen
● Bowel perforations
● Diaphragmatic rupture
● Retroperitoneal blood
● Spinal and pelvic fractures
Sharp abdominal wounds (stab wounds)
Stab wounds generally don’t cause much damage unless the blade penetrates the
retroperitoneal area and injures big vessels or the pancreas. Often the peritoneum is not
broken. When the patient is stable and has wounds that are not extensive and not
contaminated, there is no need for surgical exploration. Observation is enough.
Missile injuries (bullet wounds)
The injury of bullet wounds depends on: the mass of the bullet, the path and its velocity. Low
speed bullets cause damage only in the path of the bullet, whereas high speed bullets
causes wide and deep spread injury. This is because of the higher kinetic energy and
because of cavitation (suction of debris into the wound). If the bullet hits bone, pieces of
bone might break off and cause secondary injuries.
All gunshot wounds should be surgically explored.
Blunt (closed) abdominal injuries
The organ that is the most likely to be damaged is the spleen. For liver injury you need a
great impact force. Punches or kicks in the loins will most likely damage the kidneys.
The bowel is damaged by rapid deceleration or crushing. It is most likely to be damaged at
the parts where it attaches to the peritoneum. A full bladder might rupture, for example in
displaced pelvic fractures.
Spleen
The spleen is most likely to get damaged by blunt abdominal injuries. Removal of the spleen
carries a high risk of infection and sepsis so ideally the spleen is preserved (or at least 50%).
Severe injuries can be treated by a laparotomy. If the spleen is preserved it is important to
observe the patient for the following 10 days as secondary haemorrhage can occur.
Liver
Big liver injuries are better treated conservatively than small injuries, which involves large-
volume blood transfusions until the abdominal tamponade stops the bleeding. If the
haemorrhage cannot be stopped, the liver should be packed with surgical gauze, the
Essential Surgery: Chapters 3, 15, 17 (p. 34-53, 199-218, 232-244) and Medical
Physiology: Chapter 24 (p. 300-302) and Article: Update of Sepsis in the Intensive
Care Unit by Genga and Russell and Clinical Medicine: Chapter 11, 25 (p. 270-271,
1150-1160)
Trauma
Essential Surgery: Chapter 15 (p. 199-218)
When arriving at the scene
The ‘golden hour’
The first hour after the trauma is experienced, the golden hour, is the most important one.
There are two strategies with dealing with out-hospital traumas: scoop and run or stay and
play. Stay and play is used for less severe cases.
Assessing the wreckage
Assess if: seat belts were worn, airbags inflated, high-velocity or low-velocity impact.
The worst injuries are suffered in head-on collisions or when the corners of the front of the
car are affected.
In motorcycle crashes: assume a pelvic fracture until proven otherwise.
In pedestrian vs. car crashes: a ‘bullseye’ fracture of the windscreen of the car means that
there is probably severe head injury.
Transport
The disadvantages of using a helicopter: not much space for resuscitation, risk of
pneumothorax due to altitude changes and risk of secondary injury. Advantage of helicopter:
fast.
Triage is the process of sorting patients into ‘priority of treatment’ groups on arrival.
Category Definition Colour Treatment
P1 Life-threatening Red Immediate
P2 Urgent Yellow Urgent
P3 Minor Green Delayed
P4 Dead White
If patients reach the hospital alive, that means they have survived the golden hour. The main
threats for death are now: hypovolemia and intracranial haematoma.
What needs to be done in the hospital:
● Primary assessment + resuscitation
● Secondary survey
● Prioritisation and treatment of individual injuries
The ‘lethal triad’ is three conditions that are most associated with mortality: coagulopathy (=
blood loss), hypothermia and acidosis.
,Primary survey
Primary injuries are the ones directly caused by the trauma. Secondary injuries are the ones
caused by the consequences of the primary injuries (e.g. fat embolism from fractures).
A - Airway
The patient is speaking: airway is open, ventilation is normal, brain has blood. In
unconscious patients, the airway should be secured with a jaw thrust and intubation.
The spine should be secured with a cervical collar and preferably strapped in during
transport.
Immobilise the spine if spinal injury is suspected.
B - Breathing
Check if the breathing is normal and if normal breathing sounds can be heard upon
auscultation of the lungs. Think of pneumothorax, hemothorax, pneumohemothorax etc.
Oxygen should be given to all patients.
C - Circulation
If the patient is unconscious and you can’t feel a pulse in the wrist or foot, 250-500 ml of fluid
should be given immediately. This is followed by small boluses until the pulse returns. A
conscious patient, or one who is unconscious but with a palpable pulse has a systolic blood
pressure >90 mmHg, so no extra fluids need to be given.
This is the moment to check (quickly) for big fractured bones, especially pelvic and long
bones. The bones should be realigned and splinted.
D - Disability
Check if the patient is responsive.
E - Environment, Exposure, “Exrays”
Patient is examined naked to assess external injuries. Prevent hypothermia by covering the
patient with a warm blanket. If lots of fluids are given, change to warmed fluids. Imagining is
now done.
Secondary survey
A fast history is taken during the second assessment (when possible). This should include
the following (mnemonic: AMPLE):
● Allergies
● Medicines and drugs
● Past medical history
● Last meal (including alcohol)
● Events leading to accident
The secondary survey is for potential life-threatening problems/complications. In the
emergency room, chest, pelvis and cervical spine X rays are made. Patients shouldn’t be
moved to a CT scanner until stable. A focused abdominal sonography for trauma (FAST; see
next section) is performed when abdominal injuries are suspected.
Test for blood groups. If it is an emergency group O, Rh negative (“O neg”) should be
administered.
Damage control laparotomy
When a major trauma patient is open on the table for many hours, it is very likely to die from
the lethal triad (coagulopathy, hypothermia and acidosis). A damage control laparotomy can
be performed instead to fix the patient up for definitive surgery. A damage control
laparotomy should be done within an hour. Hollow viscus injuries are stapled or resected
without anastomosis.
, Abdominal injuries
Abdominal injuries happen way less often than head or chest injuries. The major cause of
death is massive haemorrhage from a burst liver or spleen or when major arteries or veins
get penetrated (gunshot wounds). Unrecognised injuries are the principal cause of death that
is avoidable.
Diagnosis
In blunt injuries, the signs of bleeding or perforation of hollow organs may not develop until
hours after the injury but will always be visible within 24 hours. When the accident involved
high energy transfers, an early CT scan is important (as long as the patient is stable).
A focused abdominal sonography for trauma (FAST) will show free fluid in the abdomen,
especially in the 5 Ps areas: perihepatic, perisplenic, pelvic, pleural and pericardial.
A CT scan can help detect the following:
● Injuries to solid organs in abdomen
● Bowel perforations
● Diaphragmatic rupture
● Retroperitoneal blood
● Spinal and pelvic fractures
Sharp abdominal wounds (stab wounds)
Stab wounds generally don’t cause much damage unless the blade penetrates the
retroperitoneal area and injures big vessels or the pancreas. Often the peritoneum is not
broken. When the patient is stable and has wounds that are not extensive and not
contaminated, there is no need for surgical exploration. Observation is enough.
Missile injuries (bullet wounds)
The injury of bullet wounds depends on: the mass of the bullet, the path and its velocity. Low
speed bullets cause damage only in the path of the bullet, whereas high speed bullets
causes wide and deep spread injury. This is because of the higher kinetic energy and
because of cavitation (suction of debris into the wound). If the bullet hits bone, pieces of
bone might break off and cause secondary injuries.
All gunshot wounds should be surgically explored.
Blunt (closed) abdominal injuries
The organ that is the most likely to be damaged is the spleen. For liver injury you need a
great impact force. Punches or kicks in the loins will most likely damage the kidneys.
The bowel is damaged by rapid deceleration or crushing. It is most likely to be damaged at
the parts where it attaches to the peritoneum. A full bladder might rupture, for example in
displaced pelvic fractures.
Spleen
The spleen is most likely to get damaged by blunt abdominal injuries. Removal of the spleen
carries a high risk of infection and sepsis so ideally the spleen is preserved (or at least 50%).
Severe injuries can be treated by a laparotomy. If the spleen is preserved it is important to
observe the patient for the following 10 days as secondary haemorrhage can occur.
Liver
Big liver injuries are better treated conservatively than small injuries, which involves large-
volume blood transfusions until the abdominal tamponade stops the bleeding. If the
haemorrhage cannot be stopped, the liver should be packed with surgical gauze, the
