Trauma Initial Management, Blunt Abdominal Trauma, War And Blast Injuries And Triage Notes

Trauma Introduction

• Trauma originates from the Greek word meaning This occurs due to physical force exerted on a person. Trauma constitutes a large proportion of the number of lives lost, especially in the productive age group.

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• The most effective way of reducing traumatised deaths is by prevention which involves building safer roads and educating the masses on observation of road discipline. Wearing protective gear such as helmets for two-wheeler drivers and riders, and seat belts for four-wheeler drivers and passengers must be made mandatory.
• Trauma can also be due to earthquakes, wars, and major accidents involving trains, so much has been learnt from various wars including World War 1 and 2, the Korean wars, and the Vietnam wars, It is said—that those who cannot remember the past are condemned to repeat it (George Santayana)—really hold good for traumOnce trauma occurs, all efforts will need to be made to reduce morbidity and mortality.
• Trauma-related deaths have a trimodal distribution: First, mortality that occurs at the site or on transfer due to the severity of trauma injuries. These deaths cannot be prevented and only a behavioural change can reduce them.
• The victim’s injuries are so severe resulting in massive exsanguination or severe head injuries that saving the life of that trauma victim is impossible. The second phase of death, usually due to hypovolaemia and other trauma-related injuries is often avoidable and treatable.
• Timely and appropriate intervention at this stage can reduce the effects of trauma and prevent morbidity secondary to the injury. The third phase includes those patients who die of complications of trauma such as infection, embolism, sepsis, acute respiratory distress syndrome and septic shock. A well-managed second phase is likely to reduce the incidence of the third phase.
• When a patient/patient sustains trauma, it is a natural tendency in India for onlookers, police or fire personnel to load them into the first available vehicle and transfer them to the nearest available hospital.
• Although their intentions are good, they may actually cause more harm. Many of these patients may have sustained cervical spine injuries which may be undisplaced at first but get displaced if careful attention to prevention of neck movements is not given during transfer.
• In view of this, the salient features of trauma care must be widely publicised among the lay publiDoctors and other medical personnel get involved in patient care only after the patient reaches the hospital.
• They too may not be trained to deal with trauma and it is common to find trauma care areas in chaos, especially when multiple patients arrive in a short span. A systematic approach to victims/victims of trauma is necessary to ensure the best outcome.

Prehospital Phase

Scene Safety

• Every rescuer must always ensure that the scene is safe for oneself before proceeding to help a trauma victim.
• A liquid petroleum leak, radiation exposure, floods, and landslides are a few examples. When unsure, it may be more prudent to enquire from the fire personnel and then approach the victim.

Prehospital Phase Trauma Triage

• Modern medical triage was invented by Dominique Jean Larrey, a surgeon during the Napoleonic wars, Triage is derived from the French word trier, meaning to sort.
• When there are multiple victims, the philosophy of trauma triage will need to be adopted is a method of sorting out injured patients, during mass casualties depending on the severity of the injury. If you are the first on the scene, first priority is to get expert help (call up fire services, regional trauma centre, etc.).
• Triage is a skilled activity by a trauma team, wherein there is a leader (usually senior-most doctor/surgeon) and there are many assistants. The leader sorts out patients (people) depending on the severity of the injury.
• The term ‘multiple casualties’ is used when there are more than two trauma victims but the number does not overwhelm the facilities available at the treating centre.
• The term ‘mass casualties’ is used when there are more than two trauma victims but the number overwhelms the facilities available at the treating centre.

Prehospital Phase Colour Coding

• When there are multiple or mass casualties, rescuers use universal colour codes to mark each victim based on the severity of injuries to help decide on the treatment priority to be given to each patient. The colour codes are as follows:

Prehospital Phase Code Black (Expectant):

• These patients have very severe injuries and may not be expected to survive very long with the available care.

Prehospital Phase Code Red (Immediate):

• These patients may have life-threatening injuries to the airway, breathing or circulation which are potentially reversible with immediate care.

Prehospital Phase Code Yellow (Delayed):

• These patients are relatively stable and would not be expected to become unstable in a few hours. They too can pose a threat to life but not immediately.

Prehospital Phase Code Green (Minor):

• These patients have injuries but can be seen in due course. The ‘walking wounded’ belong to this group.
• Thus, in the event of a large number of patients arriving at the trauma centre and having been coded, all patients with a ‘red’ code must be attended to immediately followed by the ‘yellow’ coded patients.
• The ‘green’ coded patients can be seen in the outpatient department, whereas the ‘black’ coded ones can be given attention when possible.

Prehospital Phase Communication

• All ambulance drivers must be instructed to store the telephone numbers of the contact person in the referral hospitals.
• It is essential that advance information is given to the trauma centre ahead of the arrival of trauma victims to optimize care.

A Common Scheme or a Quick Assessment

1. Can the patient walk?
   • Yes: Delayed (green), No—check for breathing.
2. Is the patient breathing?
   • No: Open the airway—Are they breathing (ventilating) him?
   • Yes: Immediate (red), No—DEAD (white).
   • Yes: Count or estimate respiratory rate (over 15 sec).
   • <10 to >30 per minute—immediate (red).
   • 10–30 per minute—check the circulation.
3. Check the circulation
   • Pulse >120/min (capillary refill >2s)—immediate (red).
   • Pulse <120/min (capillary refill <2s)—urgent (yellow).

If any regional trauma centre is well equipped and nearby, one has to transport all the injured patients to the hospital (scoop and run), where expert help is available.

Meanwhile, trauma centres can be alerted about the arrival of casualties. If expert help is far away, then one may have to treat the patients at the accident site (stay and play). Resuscitation is done as per ATLS guidelines.

During these exercises, do not forget to take care of your own safety, in burning vehicles, burning or falling buildings, etc.

Trauma Centre Preparation

Plan in Advance

• Every trauma centre must be in a state of constant preparedness to receive trauma victims. The trauma centre must be manned by dedicated personnel and must have the necessary equipment which is checked on a daily basis and rechecked after every use.
• Trauma Care Personnel The core group responding to trauma cases include nurses, trauma technicians, qualified doctors (general surgeon, orthopaedics or emergency physician) and a set of doctors on call to deal with referrals (neurosurgeon, cardiothoracic vascular surgeon).

Trauma Care Area

• The trauma care area must be a dedicated area called the ‘resuscitation bay’. All personnel caring for the patient must wear personal protective equipment including goggles, gowns, gloves and shoe covers.
• The patient must be received on a trolley bed and each bed must have a multimodal monitor including a pulse oximeter, noninvasive blood pressure and electrocardiogram. An oxygen source and suction apparatus also must be available with each bed.

Resuscitation Equipment

• Resuscitation equipment will include airway equipment such as airways, endotracheal tubes, laryngoscopes, laryngeal mask airways, infraglottic airways, Magill’s forceps and a stethoscope.
• Cervical collars of different sizes must also be available. Equipment for circulatory resuscitation includes intravenous fluids (isotonic saline, Ringer lactate), intravenous cannulae, pressure bags, body and fluid warmers, syringes, medications including vasopressors, inotropes, anticholinergics, analgesics, etc.).
• An ultrasound machine must be available for focused abdominal sonography in trauma (FAST).
• A portable X-ray machine must also be available to obtain the basic X-rays (neck, chest, pelvis).

Approach To Trauma

• The approach to trauma must be done in the following steps: Primary survey and resuscitation, secondary survey and definitive care.

Primary Survey and Resuscitation

The purpose of this step is to very quickly evaluate for any life-threatening emergency and deal with it immediately.

Often an obvious external trauma, such as a fractured femur diverts the attention of the caregivers, but a life-threatening injury is missed

The evaluation must be performed in the following order: A, B, C, D and E. However, when bleeding is obvious and external, it can be easily controlled, now it is being referred to as cABCDE.

• A—Airway with cervical spine control
• B—Adequate breathing
• C—Circulation with haemorrhage control
• D—Disability assessment, and
• E—Exposure and environment control.

Control of bleeding:

• When external bleeding is visible and massive, control of bleeding is more important than the airway. Often in a trauma, the source of bleeding may be in the limbs—muscle or arterial bleeding.
• Immediate first aid involves the pressure packing principle. If an arterial bleeding is visible, a hemostat is used to control it. The hemostatic dressing is applied.
• If a tourniquet is available, rubber or better one pneumatic—it should be Tourniquet time is noted and immediate transfer to referral centres should be done.
• An obvious fracture lower limb due to a fall is common in elderly patients. A posterior slab is given for immobilization.
• Simple wounds which are bleeding are thoroughly cleaned and sutured.

Trauma Centre Preparation Survey

• A very quick way of evaluating airway, breathing and circulation is to address the patient and elicit a response (e.g. ask the patient’s name).
• If he replies appropriately, it is evident that the patient’s airway is patent, breathing is optimal and circulation to his brain is adequate.
• If the patient does not respond to the call, a painful stimulus is given and the response is quickly graded on the AVPU scale, where A = Alert, V = Responds to verbal commands, P = Responds to pain and U = Unresponsive. Quick primary survey and actions are given below in the form of ABCDE of the primary survey.
• Airway with cervical spine immobilization: All patients sustaining trauma, especially to the head and who have an altered sensorium must be assumed to have cervical spine injury until proven otherwise.
• The mechanism of injury would provide a clue to the possibility of cervical The neck must be immobilised in a rigid cervical collar (Philadelphia cervical collar or similar) as early as possible.
• Rapid assessment of signs of obstruction should be looked for—foreign body, laryngeal and faciomaxillary fracture, fallen back tongue.

• If the airway is not patent or the patient’s ability to maintain his airway is questionable, the airway must be secured of a compromised airway including snoring, stridor, agitation, active accessory muscles of ventilation/paradoxical chest movements and cyanosis.
• Open the airway first with a jaw thrust, oral airway or a nasopharyngeal airway. An oral airway is preferred if the patient is unconscious and is suspected to have sustained a base of the skull fracture.
• A nasopharyngeal airway is chosen if the gag reflex is intact and the patient is semiconscious. Insertion of a nasopharyngeal airway in a patient with a base of skull fracture is risky as it can enter the brain through the fracture. Provide oxygen using a face mask and ventilate as necessary.
• Indications for endotracheal intubation or tracheostomy for securing the airway include obstructed airway, apnoea, hypoxia, severe head injury, maxillofacial injury, penetrating neck trauma with expanding haematoma and chest trauma
• Endotracheal intubation provides the most definitive airway. It is required in patients who are unconscious, not able to maintain their own airway, and who have sustained extensive faciomaxillary injuries or airway burns.
• A rapid sequence induction and intubation is The level of sedation required for intubation would depend on the level of consciousness and haemodynamic stability. Generally, midazolam or etomidate is used for sedation and succinylcholine as the muscle relaxant for intubation.
• The cervical collar is used to limit neck movements but it often also limits mouth opening and increases the difficulty of securing the airway.
• Hence, it is recommended that the cervical collar be removed during endotracheal intubation and the neck immobilized manually. The collar is reapplied after the airway is secure endotracheal intubation is difficult, the airway can be maintained using supraglottic airway adjuncts such as laryngeal mask airway or laryngeal tube.
• If these are inadequate, a cricothyrotomy (infraglottic airway) may need to be performed should be followed by a regular tracheostomy.
• Cricothyrotomy is advocated as the initial choice as it can be done very quickly. Time is of the essence in a hypoxic emergency.

2. Breathing—look, listen and feel:

• Inspect (look) the chest for the respiratory rate, depth and pattern.
• If the patient’s breathing is inadequate as evidenced clinically (rate and depth) or if the patient is cyanosed/ oxygen saturation is low (<93%), breathing must be assisted and oxygen supplementation given as required for the presence of flail chest, open chest wounds and use of accessory muscles of respiration.
• Palpate (feel) for tracheal shift, broken ribs and subcutaneous emphysemPercuss for diagnosis of haemothorax and pneumothorax. Auscultate both sides of the chest for equality of breath sounds and for any added sounds. Rule out endobronchial intubation, if an endotracheal tube is already in place.
• If breath sounds are unequal, inspect the neck for any distended veins, or tracheal position and then percuss the chest.
• If neck veins are distended, the trachea is deviated and the chest is resonant to percuss on the side of reduced air entry, suspect tension pneumothorax.
• The patient may require a needle thoracostomy. A large bore (16–18 G cannula) is inserted in the fifth intercostal space slightly anterior to the anterior axillary line (ATLS 10th edition).
• In children, an appropriately large bore needle or cannula must be placed in the second intercostal space in the midclavicular line.
• If air hisses out, decompression of the chest would have been achieved Chest tube insertion can follow later during secondary survey.

Quick Reminder Mnemonic at Treatment Centre

• Lift jaw
• Intubation: Airway
• Fallen tongue/foreign body to be checked
• Tracheostomy/cricothyrotomy/oropharyngeal or nasopharyngeal throat suction
• Jaw fractures to be ruled out
• Remember as LIFTJAW

Tension pneumothorax is a clinical diagnosis. Do not delay the treatment while waiting for a chest X-ray.

Cardiac tamponade:

• It is a serious condition which results from to collection of blood/fluid in the pericardial cavity.

Trauma Centre Preparation Causes:

• Gunshot injuries, penetrating injuries, ruptured aortic aneurysms, and invasive and interventional procedures including central venous catheter insertions, and angiograms can also cause cardiac tamponade.

Trauma Centre Preparation Pathophysiology:

• The distended pericardial cavity compresses all chambers of the heart. As a result of this, venous return is impeded, ventricular filling is impaired resulting in hypotension, and hypoperfusion.
• Ventricles cannot contract effectively and lead to cardiovascular collapse and cardiac arrest.

Trauma Centre Preparation Clinical features:

• Hypotension, tachycardia, low volume pulse, cold peripheries, chest pain, breathlessness, syncope and cardiovascular collapse.
• The neck veins may be distended Beck’s triad includes hypotension, elevated systemic venous pressure, often with jugular venous distention; and muffled heart sounds. This can occur with sudden intrapericardial haemorrhage.
• The Kussmaul sign—a paradoxical elevation in jugular venous pulse (JVP) during inspiration is sometimes seen in cardiac tamponade.

Trauma Centre Preparation Diagnosis:

• It is a medical emergency. The gold standard investigation is ultrasound examination. The extended focussed abdominal sonography in trauma (EFAST) obtained in patients with trauma includes evaluation for the presence of cardiac tamponade.
• Echocardiography can confirm the presence of pericardial effusion and determine its size. It can also reveal compromise of cardiac function (right ventricular diastolic collapse, right atrial systolic collapse, plethoric IVC).
• A chest X-ray may show an enlarged heart. CT chest can diagnose pericardial effusion. However, if the cardiac tamponade is significant, one should not wait for a chest X-ray or CT chest but proceed with pericardiocentesis using point-of-care ultrasound.

Trauma Centre Preparation Treatment:

• In case of urgency, a needle pericardiocentesis is performed at the bedside using ultrasound-guided needle placement from a subxiphoid window.
• If ultrasound is not available, the patient is on the verge of collapse and there is a strong suspicion of cardiac tamponade, the traditional landmark technique may need to be adopted large bore needle is inserted from the subxiphoid point into the pericardial cavity by a a directing it inwards, superiorly and towards the left shoulder with continuous aspiration.
• Support airway, breathing and circulation as necessary. Supplementing oxygen, positive pressure ventilation and leg elevation also will help these patients depending upon the severity of the tamponade.
• Standard cardiac life support measures (ACLS) will need to be provided if the patient develops cardiac arrest.

3. Circulation with haemorrhage control:

• Feel the radial pulse for its rate, rhythm, quality (strong, feeble and thready) and equality with the opposite side.
• Check blood pressure. The commonest cause of shock in trauma is hypovolaemiNeurogenic shock is a possibility in cases of spinal injury. Obstructive shock can occur in tension pneumothorax and cardiac tamponade.
• Septic shock is unlikely but not impossible in early trauma the pulse is feeble and irregular and the patient is hypotensive, rule out the possibility of a pericardial tamponade by looking at neck veins.
• If the neck veins are distended, the radial pulse is not felt, heart sounds are faint and needle thoracostomy has not treated the condition, perform a pericardiocentesis. Ultrasound of the heart (FAST) is very useful to confirm the diagnosis and guide the procedure.
• If ultrasound is not available, it is reasonable to proceed with landmark-guided drainage of the pericardium.
• The possible sites of bleeding can be remembered as blood on the floor and four more. The blood on the floor refers to external and obvious bleeding. The four other sites are the thorax, abdomen, pelvis and long bones.
• Look very quickly for any obvious bleeding from any part of the body. If present, apply pressure and stop the bleeding. Application of a tourniquet is not advisable unless absolutely necessary.
• If applied, it should be removed as early as possible to avoid injury to tissues. An intravenous line should be secured and intravenous fluids, preferably around 40°C (crystalloids— saline, Ringer lactate or plasmalyte), infused very quickly to restore volume. An initial bolus of 2 litres of crystalloid solutions.
• Dextrose-containing solutions are not recommended large peripheral lines are preferred for the initial resuscitation.
• Insertion of central lines is not recommended (unless done by skilled personnel) as it takes much longer to insert, requires expertise and can be associated with complications.
• If peripheral intravenous access is not available, an intraosseous needle can be inserted and fluids infused into the bone marrow. All infusions that can be given intravenously can also be given intraosseously.
• External jugular venous access is another option for quick transfusion of large amounts of fluids and blood products.
• Obvious bleeding sites in the upper limb or lower limb in cases of soft tissue injuries with or without fractures should be inspected, if necessary, immediate tourniquet to be applied and even be stopped by artery forceps depending upon the severity.
• The immediate goal is to arrest bleeding rather than replace the blood.
• Check the abdomen and pelvis. Abdominal trauma can be penetrating or nonpenetrating. Inspect and then palpate the abdomen for any distension, abrasion or contusion. Spring the pelvis to rule out pelvic instability due to fracture.
• Perform focused abdominal sonography in trauma (FAST) to rule out liver and splenic injuries. If any abdominal injury with haemorrhage is suspected, the patient will need an urgent life-saving laparotomy.
• ‘Damage control surgery/laparotomy’ should be done as soon as possible in patients with evidence of abdominal trauma and maintaining a systolic BP at 8090 mmHg with fluid resuscitation is unsuccessful.
• The aim of this laparotomy is to stop the bleeding, often only packing, after which the mid-line incision is temporarily closed within 30 minutes with towel clamps. This laparotomy is described as not a surgery, but a resuscitative procedure.
• In polytrauma, when multiple organs are involved, conducting the complete repair of all the injuries will require many hours.
• These patients develop coagulopathy, hypothermia, and acidosis and thus they succumIn such situations, packs are used to stop the bleeding and these packs need to be removed after 48 hours.
• Thus, the laparotomy wound is closed only at the skin level. If the intestine is transected, staple the intestine thus to avoid contamination.
• One can go in after 48 hours for a definitive repair. In the presence of sepsis, instead of doing an anastomosis, it is better to exteriorize and definitive repair is done at a later date.
• The American College of Surgeons Classification of hypovolemic shock can be used as a quick guide to gauge the amount of blood lost.
• If the patient is tachycardic (heart rate >120/min) and hypotensive (systolic blood pressure is <90 mmHg), the patient has Class III shock or higher where the patient has lost >30–40% blood volume.
• Such patients will also require transfusion of blood products (packed cells and fresh frozen plasma).
• It may be necessary to activate a massive transfusion protocol (when available at the hospital) if the patient is bleeding profusely.
• Replacing the lost volume along with haemorrhage control is important to restore perfusion and prevent tissue damage.
• In cases where the hemostasis is insecure or not definitive, volumes should be controlled to maintain systolic BP at 80–90 mmHg till the bleeding can be This is called ‘hypotensive fluid resuscitation’ or ‘permissive hypotension’.
• Small boluses of 4 fluids— 250 ml of O-negative blood or normal saline can be given till blood is available.
• It is important to keep the patient warm through the resuscitation as hypothermia impairs coagulation, increases bleeding, depresses respiration and circulation as well and increases chances of infection.
• The pelvis should be examined by springing the pelvis. This should be done only once and if any instability is noted, the pelvis should be immobilized by the application of a pelvic binder and later on with an external fixator to stop bleeding.

Role of tranexamic acid in trauma:

• It is an anti-fibrinolytic drug to be used in trauma patients with bleeding.
• Given 1 g IV over 10 minutes followed by the next dose of 1 g over 8 hours.
• Tachycardia with a pulse rate of more than 110/minute or systolic blood pressure less than 110 mmHg.
• Ideally should be administered within 3 hours of trauma.

Special Patient Groups

• Trauma can affect a person of any age. Older patients on multiple medications may not manifest blood loss.
• Often, they may not show tachycardia or hypertension. Children tend to have high heart rates, whereas trained athletes may have low heart rates making these signs unreliable in these patients.

Trauma Centre Preparation Disability

• The patient’s Glasgow Coma Scale (GCS) must be assessed as also the pupillary response to light must be recorded for neurologic deterioration.
• The patient must be turned to a lateral position using the log rolling technique and the spine is examined.

Disability: AVPU system

• Awake
• Open eyes to Voice
• Open eyes to Painful stimulus
• Unarousable

Trauma Centre Preparation Exposure

The patient’s whole body must be exposed and every orifice must be examineQuick examination of all orifices.

Trauma Centre Preparation Examples:

• Look for bleeding from the ear, nose, oral cavity, rectum, vagina, and urethrA per rectal examination must be done after examination of the spine to rule out urethral injuries.
• Hypothermia must be avoided pregnancy test must be obtained in every female patient in the reproductive age group.

Adjuncts to Primary Survey Monitors:

• The patient’s vitals are monitored using a pulse oximeter, noninvasive blood pressure and electrocardiogram.
• Arterial blood gases and capnography are extremely useful and must be made available in dedicated trauma centres.

Tubes and catheters:

The patient is then placed supine. Tubes and catheters are inserted and X-rays obtained nasogastric tube and urinary catheter are inserted, X-rays of the neck, chest and pelvis and ultrasound abdomen are obtained at this stage.

Secondary Survey and Definitive Care

Once the life-threatening emergencies are ruled out or dealt with, a secondary survey involving a more detailed head-to-toe examination of the patient is performed through the secondary survey, if there is any change in the patient’s condition the primary survey starting with A, B and C will need to be performed if the patient is being treated in a smaller hospital without the facility to treat that trauma, the patient must be transferred to a higher centre after stabilization of vital signs.

The transfer itself must be well-planned with well-delegated tasks for each personnel and the transfer communicated to the referral hospital. More details are given under abdominal trauma.

Blast Injuries

• The bursting of bombs or shells ruptures their casing and imparts high velocity to resulting fragments. These fragments cause more devastating injuries than blast
  wave.
• The two main components are Blast pressure wave (dynamic overpressure) with positive and negative phases and mass movement of air (blast wind).
• The positive phase of the blast wave lasts a few milliseconds (close to the explosion it may be over 7000 kN/m2) (tympanic membrane ruptures at 150 kN/m2).
• As sound waves blast, pressure waves flow over and around an obstruction and affect persons sheltering behind a wall.
• The pressure affecting such a person is known as incident pressure (pressure at 90° to the direction of travel of blast shock front).
• A person standing in front of a wall facing an explosion is subject to the added effect of reflected pressure.
• The mass movement of air displaces air at supersonic speeds disrupting the environment, and hurting debris and people.
• Blastwave under the water travels at great speed and to greater distances. Injuries tend to be complex and severe. Structures injured by primary blast waves are ears, lungs, heart and gastrointestinal system.
• Most will have a combination of blunt, blast and thermal injuries. Deafness, lung contusion, capillary leakage and haemorrhage into alveoli and ARDS precipitated by over-transfusion are the features. Perforation of the intestines and penetration injuries to the eye are the other features.
• Management consists of resuscitation in a well-equipped trauma unit, blood transfusions, intensive care monitoring, antibiotics and appropriate surgical procedures.

Warfare Injuries

• Penetrating missile wounds, injuries from blast phenomena and burns are typical features of modern conventional war.
• The most common wounding agent in surviving casualties is a fragment wound and not a bullet wound as many erroneously believe.
• The aim of modern war is to incapacitate and not to kill. Hence, a large number of surviving casualties is a major financial and logistic burden on a nation engaged in war.

Wound Ballistics and Mechanisms of Injury

Bullets fired from handguns are propelled at low velocity, have low available energy and result in low-velocity transfer wounds (100–500 J), whereas those from assault rifles have high velocity and have high available energy (2000–3000 J) and they cause high energy transfer wounds.

Low-energy transfer wounds leave injury confined to the wound tract. High energy transfer wounds cause local laceration, and crush injury and also cause remote injury from the wound tract due to temporary cavitation phenomena.

Warfare Injuries Management

• Entrance and exit wounds do not indicate considerable damage that may have occurred to deeper structures.
• Resuscitate as per ATLS guidelines.
• Record the wounds in case sheets, and take photographs, if necessary.
• Under anaesthesia, excise skin around entry and exit wounds, and give liberal longitudinal incision through skin and deep fascia, which allows proper visualisation of underlying structures.
• Debride (cut till healthy tissues are seen) all dead tissues—dead muscle does not bleed or contract and looks dusky.
• Identify neurovascular bundles and examine them.
• Dissect and mark injured nerves for possible future repair.
• Repair arteries and veins, if injured.
• Give a thorough wash and let out all the dirt.
• Injured tendons are trimmed and tied for easy identification at future surgery.
• Fix bones by appropriate methods.
• Cover the wound with absorbable dressing.
• Appropriate antibiotics and injection of tetanus toxoid are given.
• Amputation may be necessary if the limb is grossly mutilated.
• Delayed primary closure is done (4–6 days later) once the wound starts healing.

Missile Wounds Of Abdomen

• Every penetrating and perforating missile wound of the abdomen should be explored by laparotomy. A full midline incision from the xiphisternum to the pubis is recommended and it may be extended to the thorax, if necessary.
• The rest of the treatment depends on the nature of the injury. Bleeding mesenteric vessels are ligated, injured small bowel is repaired by suturing or by resection and anastomosis. In colonic injuries, simple closure or closure with protective colostomy is necessary depending upon the nature of the colonic injury and contamination.
• Liver, splenic, pancreatic and renal injuries.

The process of wound healing will have the following medicolegal implications:

1. Formation of scar tissue:

• Scar tissue over specific areas like the face may cause disfigurement.
• If that scar formation is due to injury sustained as a result of trauma, then it is an example of grievous hurt as per section 320 IPScar formation may result in contractures.
• If it involves a joint, then there will be restriction of movements leading to disability. Then the injury caused may be classified as grievous as per section 320 IPC.

2. Child abuse (battered baby syndrome):

The presence of healing wounds of different durations indicates the possibility of repeated physical abuse of the child has to be kept in mind while examining a child with injury in the paediatric outpatient department (OPD).

3. Elder (geriatric) abuse:

• The presence of healing wounds of different durations indicates the possibility of repeated physical abuse of the elderly.
• This has to be kept in mind while examining a geriatric age group person with injury in an outpatient department (OPD).

Missile Wounds Of Abdomen Gunshot Wounds

• Gunshot wounds are high-energy injuries that can result in extensive damage to soft tissues, viscera, and bone, Depending upon the site of entry and exit points, damage can occur.
• Lucky are a few where on bullet enters and exists missing major vascular structure or viscera as it may happen in the abdomen.
• Damage caused by a bullet is directly related to its kinetic energy. It is due to various factors such as passage of the missile, cavitation and secondary shock wave. Cavitation refers to the damage caused by bullet to the surrounding tissue due to fragmentation, shearing forces and turbulence.
• Kinetic energy is mass and velocity to the power of 2 divided by 2.
• The basic principles of the management of gunshot wounds are control of haemorrhage, prevention infection, and reconstruction.
• The extent to which a gunshot wound needs to be surgically explored can be difficult to determine sometimes.
• The aim is not to remove the bullet which may be visible in an X-ray or CT scan but to see the effects of tissue destruction such as bleeding, intestinal perforations, mesenteric tear or soft tissue and vascular injuries in the neck.
• If fractures occur and fragmentation of the bullet occurs wound severity is higher and, therefore, a requirement for more surgical exploration, followed by debridement of dead and crushed tissues.
• Gunshot wounds should never be closed primarily; the full range of reconstruction from secondary intention to free tissue transfer may be required.

Missile Wounds Of Abdomen Treatment

• As an urgent measure, if active bleeding is visible, apply pressure and try to stop the bleeders. Bleeders can be from vessels or from muscles.
• A temporary tourniquet can be applied to buy some time and proceed to shift the patient to the operation theatre for corrective measures.
• Dressings are applied and antibiotics are to be starteTetanus toxoid injections are given. Wound debridement should be thorough with saline irrigation. Fractures are treated initially by immobilisation/ stabilisation.
• The patient may require one more debridement or delayed exploration depending upon the situation.
• Exploratory laparotomy is done in abdominal gunshot wounds—perforations are sutures, transacted intestines are resected, and anastomosis is done.
• Bleeding liver and spleen are sutured to stop the bleeding. A shattered spleen requires a splenectomy.
• Bleeding mesenteric vessels are ligateLook for intestinal ischaemia in such cases. Non-viable intestines need to be respected.

Penetrating Trauma of the Abdomen

• Today all penetrating injuries of the abdomen need not be explored by laparotomy.
• A good physical examination of the patient, entry and exit point, and haemodynamic status of the patient followed by investigations such as ultrasonogram and CT scan will guide the decision for laparotomy.
• Advanced trauma life support—ATLS is essential in the early hours of trauma is ideal that every surgeon/ doctor has studied the ATLS manual.

Indications for Laparotomy

• Tenderness, guarding, rigidity
• Unexplained shock
• Evisceration of contents
• Positive investigations
  • Positive DPL
  • Gas under diaphragm
  • IVP, cystoscopy, cystogram
  • Ultrasonogram
  • CT scan

Missile Wounds Of Abdomen Management

Primary survey cABCDE and resuscitation are done as described earlier.

Management of Mass Casualties Introduction:

• In this modern world, terrorist attacks and bombings are largely responsible for mass casualties.
• When hundreds of patients are brought to the casualty, we need to quickly triage them in such a way that attention first should be given to treating moderate to severely injured patients who are likely to survive rather than severely injured patients who are unlikely to survive.

Missile Wounds Of Abdomen Definition:

• Any number of casualties that exceed the resources normally available from local resources has been described as mass casualties.
• Examples of mass casualties are terrorist attacks, bombings, and railway accidents, in cases of multiple casualties, full resources can be brought to treat each individual patient.

Mass casualty level: Depending upon the number of patients who are brought to the casualty, a classification has been developed which is given below.

• Level 1—mass casualty incident resulting in less than 10 surviving victims.
• Level 2—mass casualty incident resulting in 10 to 25 surviving victims.
• Level 3—mass casualty incident resulting in more than 25 surviving victims.
• Level 4—mass casualty incident resulting in a number of surviving victims that could necessitate an inter-region response and/or get ready for an additional disaster plan.

Four steps in mass casualties

1. Mitigation: Mitigation includes a variety of measures which are taken before an event occurs which may result in illness or loss of lives or property. Basically, in a hospital in anticipation of a mass casualty or disaster, certain beds are year-marked or a team of doctors are made available with the help of group messages or to arrange for many ventilators, etc.
2. Preparedness: This may vary from place to place depending on resources available including staffing. A few important considerations are given for safety measures, security of the hospital and treating doctors, arranging for quick radiological investigations, etc.
3. Response
4. Recovery.

Health risk in mass casualty:

• In the year 2001, the earthquake happened in Gujarat. Around 20000 people died and about a few thousand were The organs most commonly injured were lower extremity (56%), spinal and pelvic (17%), upper extremity (13%), and chest and/or abdomen (<2%).
• What one can observe here is many of such patients can be saved provided good triaging is done and treatment is started immediately before shock and multiorgan failure develops.

Responsibilities of a surgeon

• Surgeons must be prepared for especially complex and difficult wounding patterns that are not typically seen in routine practice, and that greatly increase morbidity and mortality, such as blast lung, and multiple penetrating injuries from both destructive shrapnel increasingly used in bombs and from automatic firearms.
• Surgeons should avoid triaging—which means patients who are likely to die should not be treated.
• We also should recognize a small minority of patients with urgent and salvageable life-threatening injuries at immediate risk of death (undertriage).
• Ideally, triage should be done outside the hospital. At the operation theatre, damage control should be the principle till the influx to the operation theatre ends.
• All intensive care unit beds should be made available for accommodating these patients whenever it is possible.
• Every attempt is made to decrease the mortality rate.
• Surgeons should be trained in managing mass casualties, and disasters at the local and community levels.

Blunt Abdominal Trauma Introduction

• Blunt abdominal trauma (BAT) is one of the common surgical emergencies encountered by general surgeons.
• The increasing number of vehicles, high speed and poor maintenance of the roads are the contributing factors.
• Blunt injury abdomen with polytrauma is one of the most common causes of death in the younger population.
• Thus, it is important for a house officer to recognise a polytrauma patient, to diagnose and to suspect an intraabdominal injury, so that urgent resuscitation and treatment can be offered to the patient at the proper time, at the proper hospital and by a proper surgeon.

Common Viscera Involved in Blunt Injury

• Spleen Significant bleeding
• Liver Significant bleeding
• Kidney Significant bleeding
• Intestines Perforation—peritonitis
• Mesentery Bleeding
• Pancreaticoduodenal injuries are Usually missed—bleeding
• Diaphragm Missed—tachypnoea
• Urinary bladder Urinary peritonitis

Major Systems Involved

• Craniospinal
• Chest
• Abdomen
• Pelvis
• Skeletal

Craniospinal and chest injuries are discussed in their respective chapters. Pelvic and skeletal injury is beyond the limits of blunt injury of the abdomen.

Causes of Blunt Injury Abdomen

1. Rail and road traffic accidents (most common)
2. Fall from a height and dashing against an object
3. Seat belt syndrome
4. Assault

Regions/Anatomy of the Abdomen

1. Anterior abdomen: means it involves 9 regions, namely right and left hypochondrium, epigastrium, right and left lumbar regions, umbilical region, right and left iliac fossa and hypogastrium.
2. Thoraco-abdomen: This area is inferior to the nipple line anteriorly and infrascapular line posteriorly and superior to coastal margins. The liver, spleen and diaphragm are the important organs here.
3. Flank: It is between the anterior and posterior axillary lines from the 6th intercostal space to the iliac crest. Covered by thick muscles which often protect renal injuries from penetrating wounds.
4. Back: Again there are thick muscles such as erector spinae, and quadratus lumborum, Back is an area from the tip of the scapulae to the iliac crests, posterior to posterior axillary lines.
   • These areas contain retroperitoneal structures which are usually missed sites in trauma of the abdomen.
   • The organs include the duodenum, posterior parts of the descending and ascending colons, pancreas, kidney and ureters, vascular structures such as the aorta and inferior vena cava Diagnostic laparoscopy, focussed assessment sonography in trauma (FAST), and diagnostic peritoneal lavage will not be of help.
   • CT is the best investigation of choice.
5. Pelvic cavity: It contains some very important structures such as the rectum, urinary bladder, reproductive organs, and iliac vessels, It is also the extension of retroperitoneal and intraperitoneal spaces.
   • Pelvic fractures and injuries may result in significant bleeding which can be life-threatening.

Mechanisms of Injury/Pathophysiology

They can be broadly classified into blunt abdominal trauma (BAT) or penetrating abdominal trauma following are various mechanisms of abdominal trauma.

• Direct blow or crush: This can be from the lower rim of the steering wheel or from the door of a motor vehicle resulting in crushing injuries of both solid and hollow viscera. The transverse colon is one of the hollow viscera in this type of injury.
  • Crushing effect: Here solid viscera are crushed between the anterior abdominal wall and vertebral column or posterior thoracic cage.
• Shearing: These injuries will occur when a restraint device is worn improperly, e.g. lap belt.
• Deceleration injuries: are the ones in which differential movement of fixed and nonfixed parts of the body occurs. Examples are liver, spleen and small bowel injuries.
• It causes differential movement among adjacent structures. Shearing forces are created; they cause solid, visceral organs and vascular pedicles to tear at relatively fixed points of attachment.
  • Examples:
    • Renal pedicle injury
    • Injury to the distal aorta than the proximal mobile aorta as the former is attached to the thoracic spine.
• Bursting: Acute tracheoesophageal burst injuries are reported from blunt chest traumSudden dramatic rise in the intra-abdominal pressure due to external compression Hollow viscus ruptures (in accordance with principles of Boyle’s law).
• Penetration: Penetrating injuries are the result of stab wounds, gunshot wounds or due to pellets (used to shoot wild bore). The most commonly involved structures are the liver, small bowel, diaphragm and colon. In cases of gunshots and pellets, injuries depend upon the speed of the shot, cavitation effect and bullet fragmentation.
• Vehicular trauma is by far the leading cause of blunt abdominal trauma.

Assessment History—At Casualty/Triage

• Exact nature of the accident—collision, penetrating trauma, fall from height, shotgun, pellet injuries explosion. In addition to high-speed vehicle accidents, polytrauma is also common in India due to falls from height due to coconut plucking from a coconut tree or from a construction site fall.
• History of loss of consciousness initially followed by recovery may be the indication of extradural haemorrhage—to be kept in mind.
• History of medications especially beta-blockers and anticoagulants should be elicited, if present to be recorded.
• Even if a patient is not in hypovolemia, there can be bradycardia, if the patient is taking propranolol.

Physical Examination–Primary Survey

ABCDE (ATLS protocol)  AMPLE (History)

• Airway
• Allergy
• Breathing
• Medication
• Circulation
• Past medical illness
• Disability
• Last meal
• Exposure
• Events leading to the incident

Secondary Survey and Definitive Care

• Inspection, palpation, percussion and auscultation should be done in the usual manner. The patient should be exposed full length—entire chest, abdomen and pelvis—both anterior and posterior.
• Tachycardia and hypotension are the early features of ongoing bleeding. A patient who is lying down without any pain but anxious may be having bleeding and one who is not moving but with pain may be having hollow viscus perforation. Restless patients have often head injuries.
• Abdominal distension is quite often due to solid viscus bleeding from the liver or spleen. It is also due to perforation of a viscus and retroperitoneal injuries resulting in paralytic ileus.
• Abrasions, ecchymosis, lacerations over the abdominal wall, stab injuries, foreign bodies, evisceration of omentum or intestines to be recorded injuries sign: If these are present they indicate underlying injuries.

Indian women—vulnerability: The Saree and Churidar are traditional Indian dresses. One end of the Saree is tied around the waist and the other is draped freely along the shoulder.

• If care is not taken, the free end often gets caught in the mill belt and causes injuries around the waist (blunt abdominal trauma) due to the drag created
• The impression created on the abdomen is by the Saree and not the mill belt. The Shawl of the Churidar (which has two free ends) can get caught in a belt or a wheel to cause injuries around the neck.
• The drag may be sufficient to cause even strangulation. The author remembers a case of scalp avulsion due to the long hair of a woman getting caught in a mill belt.

• Cullen sign, Grey Turner sign: Discolouration around the umbilicus and flanks respectively indicate retroperitoneal bleeding.
• London sign: If you see some pattern of the tyre or seatbelt, it indicates a severe compression and invariably there will be underlying intra-abdominal injury.
• Entry- and exit-bullet wounds.

Palpation, Percussion, Auscultation

• Tenderness is a feature of peritonitis. It may be minimal in cases of bleeding. Superficial tenderness results due to abdominal wall muscle injuries and deep tenderness is the sign of peritonitis. Palpation of a high-riding prostate is a sign of a significant pelvic fracture.
• Percussion is done to elicit peritoneal irritation.
• Bowel sounds are absent in cases of peritonitis.

Assessment Of Pelvic Stability

• Pelvic fracture should be suspected when hypotension is present in a conscious patient who has no obvious injuries. Blood at the urinary meatus, high-riding prostate, scrotal haematoma, (rupture urethra), and limb length discrepancy suggest pelvic fracture.
• Gentle pressure over the iliac bone in a downward and medial direction is applieLaxity and instability suggest pelvic fracture. Only one attempt to test the pelvis should be made. Frequent tests may result in more bleeding and even dislodge the clot.
• It is better to avoid this test in patients with hypotension.

Examination of Pelvic Organs and Gluteal Region

• Urethra: Blood at the meatus and scrotal a haematoma suggests urethral injury. Catheterisation should not be done in such cases.
• Rectal examination to look for bleeding, loose sphincter and high-riding prostate. In cases of rupture of the membranous part of the urethra, the prostate will not be palpable as it is displaced upwards. It is called high riding prostate also described as Vermooten’s sign.
• A vaginal examination is to be done when you suspect vaginal injuries in the presence of perineal lacerations and pelvic fractures.
• Gently turn the patient like a logwood and examine the back and gluteal region. Gunshots or stab injuries may cause gluteal injuries. It may involve intraabdominal injuries and rectum also.

Signs of pelvic fracture can be remembered as PELVIS

• Prostate—high-riding
• External meatus—a drop of blood
• Limb discrepancy
• Vaginal tear
• Iliac vessels—hypotension
• Scrotal haematoma

Tertiary Survey

Repeat primary survey, secondary survey and repeat laboratory/imaging studies for wisdom lines in blunt abdominal trauma.

Tertiary Survey Investigations

1. Complete blood count, coagulation studies, grouping and cross-matching. A fall in haemoglobin is an indication of ongoing haemorrhage—especially while managing a patient with liver/splenic injury on the conservative line of management.
2. Serum electrolyte analysis
3. Serum amylase/lipase
   • May be elevated because of pancreatic ischaemia due to hypotension
   • Persistent elevation may be an indication of pancreatic injury.
4. Plain X-rays
   • Chest X-ray: If it shows pneumoperitoneum, crescentic air shadow under the right dome of the diaphragm, it suggests perforation of the hollow viscus. Look for pneumothorax. Fundic, stomach (air bubble in thorax as in diaphragmatic injury, retroperitoneal air—duodenal perforation). Pelvic fractures.
5. Role Of Ultrasound Fast: Focussed assessment with sonography for trauma.
   • Diagnostic peritoneal lavage (DPL)
6. It is indicated in BAT in the following situations:
   • Multiple injuries and shock
   • Spinal cord injury
   • Obtunded patient with possible abdominal injury
   • Intoxicated patients
   • Also, see splenic trauma.
7. CT scan
   • The gold standard for solid organ injuries
   • CT also can reveal other associated injuries such as vertebral or pelvic fractures.
   • CT can also pick up a diaphragmatic injury (CT chest).
   • It can detect the source of haemorrhage.
   • CT is an excellent scan for the pancreas, duodenum, etc.
8. Diagnostic laparoscopy: Done when CT scan is negative, and suspicion of diaphragmatic injury is present.

Tertiary Survey Types

• Open: Infraumbilical skin incision and open peritoneum.
• Semiopen: Infraumbilical skin incision deepens up to linea alba.
• Closed: Blind insertion of needle.

Tertiary Survey Precautions

• Foley’s catheter to empty the bladder
• Ryle’s tube to empty stomach
• X-ray of the pelvis to detect the pelvic fracture.

Tertiary Survey Positive DPL

• 10 ml of gross blood aspirate before infusion of lavage fluid.
• More than 100,000 RBC/ml
• More than 500 WBC/ml
• Bile and bacteria are demonstrated
• Vegetable matter

Tertiary Survey Remarks

With the availability of FAST and CT scans, the role of DPL is now limited to unstable patients whose FAST results are negative or inconclusive.

Adjuncts To Physical Examination—Tubes And Catheters

Nasogastric (Ryle’s) tube:

• Vast majority of cases, the tube is passed through the nose—nasogastriConfirm it is in place by auscultation of the abdomen and by pushing air.
• In cases of skull base fractures, the tube may enter the cranial cavity hence better to pass the tube through the oral cavity, orogastric
• When in doubt an X-ray abdomen can confirm the tube in the stomach. Blood in the aspirate suggests esophagogastric injuries.
• Nasogastric tube insertion will decrease abdominal distension, and prevent vomiting and thus aspiration.
• One of the life-saving uses of nasogastric aspiration is for acute gastric dilatation (AGD) which is a potentially dangerous condition often seen following blunt trauma abdomen.
• Passive air sucking by negative intragastric pressure and a flaccid lower oesophagal sphincter have been proposed as causes of AGD in trauma patients.
• Aerophagia in confused, agitated trauma patients, reflex gastric ileus due to visceral and somatic nerve stimulation and gastric atony due to excessive potassium and chloride losses have also been suggested as causes of AGD in trauma patients.

Tertiary Survey Urinary catheter:

Firstly, one should not introduce a Foley catheter, if one suspects urethral injuries.

Tertiary Survey For example:

• Blood at the urinary meatus. Once urethral injury is ruled out, catheterization is done by using all aseptic measures and proper lubrication.
• It will help in relieving retention—distended bladder (may help for DPL later), and help in monitoring urinary output. Significant bleeding will indicate renal tract injuries, namely kidney and urinary bladder.

Indications for Laparotomy

• BAT with hypotension and intraperitoneal bleeding and positive FAST
• Hypotension following stab injuries or penetrating wounds
• Evisceration
• Peritonitis—diffuse tenderness and rebound tenderness
• Free air, diaphragmatic rupture, retroperitoneal air
• Contrast CT with evidence of hollow viscous perforation, renal pedicle or splenic pedicle injury, intra

Liver Injuries

Liver injury should be suspected when a patient with suspected blunt injury abdomen is brought with the following features:

• Right lower rib fracture.
• Injury marks on the lower chest or upper abdomen.
• Patient with persistent hypotension or patient who had shock following blunt injury to the abdomen.
• A child can have a liver injury without a fracture of the ribs because of the elastic nature of the rib cage.

Liver Injuries Clinical Presentation

• The most common presentation is features of intraperitoneal haemorrhage, which includes hypotension, thready pulse, and abdominal distension. Peritoneal signs are minimal as early bleeding does not produce much peritoneal irritation.
• However, massive lacerations of the liver including stellate fractures present with rapidly developing hypotension and shock, which are life-threatening.

Liver Injuries Investigations

• Ultrasonography and more precisely CT scan should be done in all patients who are haemodynamically stable with or without support.

CT Scan with IV Contrast

• It can grade the liver injury.
• It can guide a conservative or operative treatment.
• It also rules out other injuries.
• Grade I and Grade II injuries can be managed by nonoperative treatment.
• Free contrast in and around the liver is indicative of active bleeding.

Haemostatic Techniques in Surgery

• Liver suture
• Perihepatic packing
• Resection
• Argon beam coagulator followed by fibrin glue and sheet of Surgicel (haemostatic agent)
• Selective arteriography and embolisation in arteriovenous fistula or haemobilia

Summary of Management of Liver Injuries

• Laceration Suturing
• Expanding subcapsular haematoma Evacuation
• Deep laceration Suturing biliary radicles and portal radicles, packing, etc.
• Severe laceration Debridement
• Stellate fracture Tractotomy; hepatic artery ligation
• Complex injuries Ligation of the hepatic vein, portal vein branches or lobectomy etc

Liver Injuries Treatment

1. Simple lacerations which are not bleeding at laparotomy:

• A drain is kept in the liver bed, blood and clots are sucked out and peritoneal wash is given.

2. Simple laceration with bleeding:

• It is sutured by interlocking horizontal mattress sutures by using a special liver suturing needle.
• If too much tension is applied while suturing, cutting through can occur. Omentum can be used as a Plug-in between the laceration. Absorbable sutures are used.

3. Subcapsular haematoma: If present, should be evacuated.

4. Deep laceration with bleeding:

• In such situations, the wound should be opened liver parenchyma removed, the bleeding vessel at depth and the biliary radicle be ligated is described as tractotomy.

5. Severe lacerations:

• These injuries present with massive bleeding. Temporary control is obtained by compression of the portal vein and hepatic artery in the gastrohepatic omentum in front of the foramen of Winslow (Pringle manoeuvre).
• If the bleeding stops, portal veins or branches of the hepatic artery are damaged. If bleeding continues, hepatic veins are the source of bleeding. Visualisation of the source of bleeding with debridement of avascular liver tissue is done by finger fracture method
• Perihepatic packing can be used to compress the liver as a temporary measure to buy time for resuscitation, to explore the rest of the abdomen or as a definitive treatment when other measures fail. The pack is usually removed after 24–48 hours. Nonanatomical resection may have to be done, in a few cases.

6. Complex liver injuries:

• These injuries involve hepatic veins, retrohepatic vena cava or branches of the portal vein resulting in massive haemorrhage.
• This type of massive injury can be managed by a large thoracoabdominal incision or abdominosternal incision by doing a sternotomy. Division of the right triangular ligament helps in visualising bleeding from hepatic veins.
• Schrock shunt: Failure of Pringle manoeuvre means extrahepatic and retrohepatic vena caval injuries. In such cases, Heaney manoeuvre clamping both infra- and suprahepatic vena cava followed by atriocaval shunt or venovenous bypass can be done.

Complications of Liver Injuries

1. Massive bleeding, hypovolaemia and cardiac arrest.
2. Haematoma can get infected resulting in an abscess.
3. Haematoma can rupture into the peritoneal cavity resulting in leakage of bile—biliary peritonitis.
4. Haemobilia refers to the rupture of the haematoma into the bile duct—it may result in massive haematemesis or melaena.

Small Bowel Injuries

• The shearing injuries produce either disruption or laceration of the bowel between fixed and mobile points, i.e. at the duodenojejunal flexure or at the ileocaecal junction. These are the most common sites of small bowel injuries.
• Injury to the small bowel can also occur due to crush injury between the spine and a steering wheel or handlebars, etc.
• Bruising on the abdominal wall may suggest perforation.
• Mesentery and its vessels also get damaged and bleeding can be sufficient to produce hypovolaemia and shock.

Small Bowel Injuries Clinical Presentation

1. Acute abdominal pain:

• Features are like that of any perforation peritonitis with guarding and rigidity. Erect abdominal X-ray shows gas under the diaphragm.

2. Features of peritonitis: The haemoperitoneum is the result of bowel injury with bleeding from the mesentery.

3. Occult or hidden perforation:

• A small perforation gets sealed off by coils of the bowel and omentum.
• Most of these patients present with abdominal pain. However, very often, features of peritonitis are missed as a result of other associated injuries such as fractured pelvis or retroperitoneal haematomAfter 3–4 days, a localised abscess may form and rupture into the peritoneal cavity, resulting in peritonitis.
• This is aggravated by the intake of oral fluids which stimulate peristalsis. Repeated examination is the most honoured, most fruitful investigation in blunt injuries of the abdomen.

Small Bowel Injuries Investigation

• X-ray abdomen, erect or lateral decubitus, demonstrates free gas under the right dome of the diaphragm in the majority of cases. Four-quadrant tap or diagnostic peritoneal lavage is also useful.
• When in doubt, a CT scan of the abdomen should be requested to diagnose hollow viscus perforation and bleeding.

Small Bowel Injuries Treatment

The golden time to operate is within 6 hours.

• Perforation: Single or multiple, have to be closed, after trimming the edges by using nonabsorbable sutures such as silk.
• A lacerated or a macerated bowel has to be resected.
• Bleeding mesenteric vessels have to be ligated, haematoma must be evacuated and the bowel should be inspected for any ischaemiFood particles and bile should be evacuated. A perforation of the ileum close to the ileocaecal junction is treated by ileocolectomy rather than simple closure for the fear of enterocutaneous fistula, due to suture line leakage.

Colonic Injuries

• Blunt injury of the colon is not uncommon.
• Mobile sigmoid is more prone to injury than fixed parts.
• Steering wheel injury can directly crush the transverse colon and can cause perforation.
• Bruise or laceration of the colon can undergo ischaemic necrosis and it can present after 5–7 days with signs of peritonitis/sepsis.
• Diagnosis is by clinical examination/contrast-enhanced CT scan.
• Depending upon the contamination, contusion or laceration and duration of injury, treatment can be resection and anastomosis within 6–8 hours of the injury or simple suturing or diversion colostomy, if gross contamination is present.
• Even in penetrating injury, primary closure can be done.

Duodenal Injuries

• The retroperitoneal duodenum is commonly injured.
• Steering wheel, belt or a blow in the epigastrium may injure the duodenum as it is crushed against the spine.

Duodenal Injuries Clinical Features

• Peritonitis features are not common as it is the retroperitoneal duodenum (part II and part III) that is injured.
• Tenderness is present on deep palpation.
• Being retroperitoneal, these injuries manifest late with abscess formation or fluid in the lesser sac, etc.

Duodenal Injuries Investigations

• X-ray abdomen
  • Obliteration of psoas shadow
  • Air outlining the kidney—Chilaiditi’s sign
  • Absence of air in the duodenum
• Raised serum amylase is one of the biochemical parameters that should arouse a suspicion of pancreatic injuries along with duodenal injury.

Duodenal Injuries Treatment

• The golden time to operate is within 6 hours.
• When in doubt, about the narrowing of the lumen, duodenojejunostomy may be indicated.
• When in doubt regarding duodenal fistula, tube duodenostomy is done.
• Duodenal haematoma is managed conservatively.
• Better to add a feeding jejunostomy

Pancreatic Injuries

Because of the anatomical close approximation of the pancreas with the vertebral column, blunt injuries to abdomen in the epigastrium, kicks or seat belt injuries crush the pancreas against the vertebral column.

Pancreatic Injuries

• Anatomically hidden
• Very often, injuries missed
• Peritonitis features are not seen
• Dangerous because of enzymatic activation
• Can manifest as pleural effusion

Pancreaticoduodenal Injuries

• Diagnosed late
• Peritonitis features are minimal
• Shock is very rare
• At laparotomy, they are missed
• Surgical treatment needs more skill and experience.
• Feeding jejunostomy is very useful
• Mortality and morbidity around 50

Mill belt: Saree or churidar cloth may be caught in the belt of a running conveyor belt and result in compression force in the centre of the abdomen and clinical notes).

Pancreatic Injuries Diagnosis

• Pancreatic injury alone is diagnosed when a patient presents with a pseudocyst of the pancreas 2–3 weeks following an injury.
• Very often, laparotomy is done for haemorrhage or perforation. In such situations, retroperitoneal bleeding, collection of bile or collection of fluid in the lesser sac arouses suspicion of pancreatic injuries.

Pancreatic Injuries Treatment

• Pseudocyst following blunt injury abdomen invariably requires surgical drainage, e.g. cystogastrostomy because of injury to the pancreatic duct, fistula will removed for a long period.
• Injury to the body and tail requires subtotal pancreatectomy with splenectomy.
• Rarely, pancreaticoduodenectomy may be required for significant injury to the head of the pancreas with injury to the duodenum.

Pancreatic Injuries Complications

• Pancreatic fistula
• Pancreatic pseudocyst
• Pleural effusion

Renal Injuries Types

1. Minor injuries: Subcapsular haematoma, minor laceration and renal contusions.
2. Major injuries: Bleeding into the renal pelvis from laceration of the medulla, corticomedullary rupture, hilar injury.

Pancreatic Injuries Clinical Features

1. Haematuria is the most important (80–90%) sign of renal injury. It may be mild or sometimes can be massive depending upon the extent of injury. It may be absent in renal pedicle avulsion.
2. Loin bulge due to perinephric haematoma.
3. Bruising of soft tissue in the loin
4. Retroperitoneal haematoma compressing on splanchnic nerves (meteorism) results in paralytic ileus, which causes abdominal distension.
5. Associated injuries such as fractures of the transverse process of the lumbar spine may be present.

Pancreatic Injuries Investigations

1. Intravenous pyelography can demonstrate:

• Intrarenal extravasation
• Extrarenal extravasation (pararenal pseudo hydronephrosis due to extravasated blood and urine, slowly occluding pelvic ureteric junction).
• The function of an injured kidney
• The function of the opposite kidney

2. Ultrasound and CT scan are other investigations which are useful when there is an expanding haematoma.

Pancreatic Injuries Treatment

1. Conservative:

• Minor injuries are managed conservatively with close monitoring of vital signs such as pulse, blood pressure, temperature and respiration, Hb% and PCV.
• Sedation and analgesics are also given.

2. Surgical exploration

• Small laceration sutured over gel foam or by using detached muscle.
• Major laceration involving one pole—a partial nephrectomy is done
• Major multiple lacerations, and avulsions, require nephrectomy.

Retroperitoneal Haematoma

• It is quite common because of accidents and falls from height.
• Fracture vertebrae, fractured pelvis, and injury to retroperitoneal veins give risk to RPH
• Bleeding from the vena cava and aorta can be fatal.
• Haematomas which are not expanding should not be disturbed.
• Diagnosis and management of retroperitoneal haematoma.

Pelvic Fractures and Retroperitoneal Haematoma

• Pelvic fractures are also an important cause of retroperitoneal haematoma.
• The most frequent mechanisms causing pelvic fractures are motor vehicle accidents, motorcycle accidents, falls and accidents involving pedestrians.
• Associated injuries to the urethra in males should be ruled out first. Per rectal examination should be done to evaluate the position of the prostate. CT scan is done to assess pelvic fracture and also to assess retroperitoneal haematoma.
• Retroperitoneal bleeding can be arterial, venous, or osseous in origin. Unstable pelvic fractures are generally associated with increased blood loss. Posterior fractures with involvement of the sacroiliac joint are frequently associated with arterial bleeding, which can be controlled by embolisation of the bleeding vessel, usually branches of the internal iliac artery. Unstable fractures should be fixed by external fixation. Expanding haematoma should be explored by the bleeders, otherwise, pack the pelvis. Nonexpanding haematoma should not be explored and watched.

General Principles In A Blunt Injury Abdomen

• A patient should be admitted to the hospital and carefully monitored if there is a slight doubt regarding blunt injury abdomen.
• Repeated examination, careful monitoring of pulse rate, temperature and blood pressure, chest X-ray, and estimation of Hb%, frequently help in many cases of silent blunt injuries.
• Most of the cases today are polytrauma cases, hence all systems should be examined. Among all these, priority should be given to life-threatening, salvageable injuries such as extradural haematoma, haemothorax, splenic injuries, and liver injuries.
• It is easier to make a diagnosis of fracture1 (revealed injuries) which can be treated later.
• Fractures can Wait But Not Rupture.
• Concealed injuries should be carefully looked for.
• Undoubtedly, diagnostic peritoneal lavage and ultrasound (CT scan is the immediate noninvasive investigation) help in the diagnosis of more than 90% of cases of blunt injury abdomen.
• Adequate blood, appropriate antibiotics, and aggressive resuscitation before surgery to treat hypovolaemia and shock are the major factors which decide the outcome of surgery.
• In a major accident involving many patients and limited resources, quick decisions should be taken regarding triage—who can be saved, and who cannot be saved.

Soft tissue injury term is used to describe injuries occurring to muscles, tendons or ligaments.

They are common in clinical practice, especially in sports events (like football, cricket or rugby), falls/slips or during exercises. One of the most commonly involved joints is the knee joint which gets affected.

Strains, sprains and contusions are examples of soft tissue injuries. Other types include tendinitis and bursitis.

Injury to muscle or tendon is referred to as strain whereas injury to ligament is referred to as sprain. Common areas for strain are ankle, knee and wrist.

Pancreatic Injuries Common symptoms include swelling, pain and weakness. Examination often reveals oedema, tenderness, and inability to move the affected part.

Pancreatic Injuries Diagnosis is often through history and thorough clinical assessment. Radiographs are taken to rule out bony injuries. Ultrasound and MRI can be used for diagnosis of sprain or strain.

Pancreatic Injuries Treatment consists of rest to the affected area, ice application that aims to decrease pain and inflammation, compression to decrease swelling and elevation to drain the accumulated fluid. NSAIDs are used to decrease pain.

Prevention is an important strategy in soft tissue injuries. Wearing appropriate athlete shoes, warming up before activity, slow stretching and adequate rest are essential in preventing injuries.

Remember RICE for soft tissue injury management (this is a known published pneumonic in old journals)

• R—Rest
• I—Ice
• C—Compression
• E—Elevation

Vascular Trauma

• Although any blood vessel can be injured in a traumatic event, injuries to extremities account for 80% of cases.
• Traumatic events can be blunt trauma or penetrating injury.

Mechanism of Injury

1. Blunt trauma: Compression and crushing of blood vessels.
2. Penetrating trauma: Compression and direct tissue separation by a sharp object.

Vascular Trauma Clinical Presentation

• Tissue ischaemia distal to the site of injury
• External bleeding
• Occult bleeding in body cavities or tissue planes with or without hypovolaemic shock
• Pulsatile Haematoma
• Clinical features are divided into soft and hard signs to triage and guide further treatment of patients in accident and emergency departments.

Types of arterial injuries

1. Partial laceration
2. Complete transaction
3. Contusion leading to thrombosis
4. Pseudoaneurysm may have bruit or thrill
5. Traumatic arteriovenous fistula
6. External compression by haematoma or fractured bone

Vascular Trauma Treatment Endovascular

1. Transcatheter embolization
2. Covered stents

Vascular Trauma Operative Principle

1. An incision along the line of the vessel
2. Obtain proximal and distal control before approaching the site of injury
3. Debride till normal arterial wall
4. Proximal and distal embolectomy to remove clot
5. Heparinization

Type of repair: Repair depends upon the extent of vascular damage.

1. Ligation of injured vessels can be considered at sites where good collateral flow is present, e.g. forearm and leg.
2. End-to-end anastomosis, if a vessel can be sufficiently mobilized to ensure tension-free anastomosis.
3. Interposition graft is used in the majority of cases.

Vascular Grafts

1. Autologous saphenous vein
   • Harvested from uninjured leg
   • Used in reverse direction because of venous valves
   • Best patency rates
   • Small veins can lead to size discrepancies with injured artery
2. Prosthetic graft
   • Used, if autologous vein is not sufficient or poor quality.
   • Various sizes are available, so can be used for most vessels.

Expanded polytetrafluoroethylene (ePTFE)

• Inferior to autologous vein but better than Dacron for infrainguinal or upper limb revascularization.
• More needle hole bleeding during surgery
• Resistant to infection compared to Dacron

Vascular Trauma Dacron

• It can be woven or knitted depending on the textile technique used.
• Woven graft has less porosity and less bleeding.
• Knitted grafts are more porous and need pre-clotting before implantation.
• Mainly used for thoracic or abdominal aortic surgeries, rarely used for limb vascularization.

Vascular Trauma Complications

• Irreversible limb ischaemia and necrosis, if repair delayed beyond 6–8 hours
• Infection
• Pseudoaneurysm
• Graft thrombosis
• Reperfusion injury
• Rhabdomyolysis and myoglobinuria lead to renal failure.

Trauma—Initial Management, Blunt Abdominal Trauma, War And Blast Injuries And Triage Multiple Choice Questions

Question 1. The most common bedside investigation done for suspected blunt abdominal trauma for bleeding is:

1. CT scan
2. MRI scan
3. Diagnostic peritoneal lavage
4. Ultrasound

Answer: 4. Ultrasound

Question 2. Which one of the following is a definite indication for laparotomy in a blunt injury abdomen?

1. Splenic injury
2. Pancreatic injury
3. Liver injury
4. Aspiration of bile in the peritoneal aspirate

Answer: 4. Aspiration of bile in the peritoneal aspirate

Question 3. If an air bubble-like picture is found within the thorax following a blunt injury abdomen what do you suspect?

1. Splenic rupture
2. Liver injury
3. Injury to the stomach
4. Diaphragmatic injury

Answer: 4. Diaphragmatic injury

Question 4. How do you rule out a head injury with the factors given below?

1. Hypotension responding to fluid
2. CSF rhinorrhoea
3. Fracture skull
4. Hypertension and bradycardia

Answer: 4. Hypertension and bradycardia

Question 5. Which is an important sign of hollow viscus perforation?

1. Cullen’s sign
2. Grey Turner’s sign
3. Mallet Guy sign
4. London sign

Answer: 4. London sign

Question 6. The following is true for the conservative management of liver injury:

1. Hollow viscus injury should not be there
2. Free contrast in and around the liver in CT scan
3. Grade 1 and Grade 2 injury
4. Haemodynamically stable patient

Answer: 2. Free contrast in and around the liver in a CT scan

Question 7. Pringle manoeuvre refers to:

1. Compression of left gastric artery to stop the bleeding from giant gastric ulcer
2. Compression of the hepatic artery to stop the bleeding during liver resection
3. Compression of hepatic artery and portal vein in front of foramen of Winslow
4. Compression of the gastroduodenal artery during Whipple’s procedure

Answer: 3. Compression of hepatic artery and portal vein in front of the foramen of Winslow

Question 8. The salvage procedure to buy time in massive bleeding from the liver includes the following:

1. Pringle manoeuvre
2. Plug by omentum
3. Perihepatic packing
4. Portovenous shunt

Answer: 3. Perihepatic packing

Question 9. Perforation within 4 cm of the ileocaecal junction following blunt injury is better treated by:

1. Suturing and drainage
2. Resection anastomosis and drainage
3. Suture and bypass
4. Exteriorisation

Answer: 2. Resection and anastomosis and drainage

Question 10. Which of the following is not a feature of retroperitoneal duodenal perforation?

1. Can occur with steering wheel injury
2. Chilaiditi sign may be present
3. Free gas under the diaphragm
4. Guarding and rigidity are minimal

Answer: 3. Free gas under diaphragm

Question 11. The initial third of resuscitation in haemorrhagic shock in blunt abdominal trauma is:

1. Ringer lactate
2. Saline
3. Dextrose
4. Plasma

Answer: 1. Ringer lactate

Question 12. Death triad in blunt abdominal trauma is:

1. Hyperthermia, acidosis, coagulopathy
2. Hypothermia, acidosis, coagulopathy
3. Hypothermia, alkalosis, coagulopathy
4. Hyperthermia, alkalosis, coagulopathy

Answer: 2. Hypothermia, acidosis, coagulopathy