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Trauma
RoseC.Gooding, BrentLlera, RandiHarris,
IbrahimAbdEl-Shafy, CherisseBerry,
andD’AndreaJoseph
Initial Assessment andManagement ofTrauma Patients
Initial assessment and management of trauma patients
Conducted to allow for identication and treatment of life-threatening injuries
A: Airway and cervical spine protection
B: Breathing → check for bilateral breath sounds → if unequal or absent → check for tension
pneumothorax and hemothorax with the ultrasound → place 28 French chest tubes (needle
decompression if chest not immediately available)
Primary survey
C: Circulation → check blood pressure and heart rate → get IV or IO access → give 1 liter
bolus crystalloid if hypotensive → hemorrhage control with pressure, packing, or tourniquet
(give uncrossed match blood if external signs of hemorrhage)
D: Disability → calculate GCS score → check for focal neurologic decits
E: Exposure
13
Adjuncts to the primary survey: Chest x-ray, pelvis x-ray, FAST, ABG, Foley Catheter, and NGT
Check for life threatening emergencies: Obstructed airway, tension pneumothorax, massive
hemothorax, open pneumothorax, ail chest, pericardial tamponade
Most common cause of hypotension in trauma is hemorrhagic shock
R. C. Gooding (*) · B. Llera
NYU Long Island School of Medicine General
Surgery Residency, Mineola, NY, USA
e-mail: rose.gooding@nyulangone.org;
brent.llera@nyulangone.org
R. Harris
Department of Vascular and Endovascular Surgery,
Mayo School of Graduate Medical Education, Mayo
Clinic, Rochester, MN, USA
e-mail: harris.randi@mayo.edu
I. A. El-Shafy
Department of Surgery, NYU Long Island School of
Medicine, NYU Langone- Long Island Hospital,
Mineola, NY, USA
e-mail: ibrahim.abdel-shafy@nyulangone.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_13
C. Berry
Department of Surgery, NYU Grossman School of
Medicine, Tisch Hospital, Kimmel Division,
New York, NY, USA
e-mail: cherisse.berry@nyulangone.org
D. Joseph
Department of Surgery, NYU Langone-Long Island,
NYU Langone- Long Island Hospital,
Mineola, NY, USA
e-mail: D’andrea.joseph@nyulangone.org
433
434
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Shock in trauma patients
Shock type Characteristics Management
R. C. Gooding et al.
Hypotension
No jugular venous distension
Hemorrhagic shock
Tension
pneumothorax
Obstructed airway Hypoxemia leads to tachycardia and
Pericardial
tamponade
Hypotension, unilateral breath
sounds, tracheal deviation
hypotension → bradycardia → arrest
Hypotension, jugular venous
distension, pulsus paradoxus,
bilateral breath sounds
Initial uid resuscitation with 1L of crystalloid → If
remains hypotensive → early resuscitation with
blood products (fresh frozen plasma, packed red
blood cells, and platelets in a ratio of 1:1:1)
Check for external signs of hemorrhage and control
with pressure, packing, or tourniquet
Check for pelvic fracture and place a pelvic binder
Evaluate need for REBOA and obtain common
femoral artery access early
If > 6 units of PRBCs is anticipated → Activate
massive transfusion protocol
Bleeding → TXA given within 3 h of injury
Bleeding → Permissive hypotension
Place 28 French chest tube (needle decompression if
chest tube is not immediately available)
Intubate → conrm airway with end-tidal CO2 if
unable to intubate → surgical airway
If patient is hemodynamically unstable → Left
anterior lateral thoracotomy in the ED
If patient is hemodynamically stable (allow for
permissive hypotension) → Median sternotomy in
the OR (prep the patient rst and be ready to perform
the incision prior to induction)
Pericardial window → if FAST is equivocal or for
diagnosis based on mechanism of injury
High cervical spinal
cord injury
Severe traumatic
brain injury
Bradycardia, hypotension, and
absent neurologic exam
Rule out hemorrhagic shock before
making diagnosis
Labile blood pressure and heart rate
Diagnosed by neurologic exam and
CT scan ndings
Rule out other types of shock before
making diagnosis
Airway protection, resuscitation, and Levophed to
maintain MAPs >85 mmHg
Rule out blunt cerebral vascular injuries with Neck
CT angio
Airway protection
Prevent secondary TBI by avoiding hypoxia and
hypotension
Hypertonic saline (23%) or Mannitol (if no evidence
of hemorrhagic shock from other injuries) if concern
for cerebral edema and impending herniation (i.e.,
Cushing’s triad)
ICP monitor—Bolt vs. external ventricular drain
Seizure Prophylaxis—Keppra
13 Trauma
Hemorrhagic shock
435
Blood loss
Class 1 750 15 Normal Normal <100 Normal 14–20 Normal Crystalloid
Class 2 750–
1500
Class 3 1500–
2000
Class 4 >2000 >40 Decreased Decreased >140 Decreased >35 Lethargic Crystalloid
Systolic
pressure
15–30Normal Decreased >100 Decreased 20–30 Anxious Crystalloid
30–40Decreased Decreased >120 Decreased 30–40 Confused Crystalloid
Pulse
pressure
Heart
Rate
Pulse
pressure
Respiratory
rate
Mental
status Managementml %
bolus
bolus
bolus + blood
transfusion
bolus +blood
transfusion +
activate MTP
Resuscitative Thoracotomy
Resuscitative thoracotomy
Penetrating injuries arriving shortly after onset with signs of life or cardiac arrest <15min
Indications
Blunt trauma patients arriving with vital signs or witnessed arrest within 10min
Signs of life: pupillary response, spontaneous ventilation, presence of carotid pulse,
measurable or palpable blood pressure, Extremity movement, organized cardiac activity
Contraindications
Key steps to
procedure
Complications
Absence of vital signs at the scene of injury
Prolonged pulselessness (>15 min) at any time
Massive nonsurvivable injuries
Left anterolateral thoracotomy
Incision at the fourth intercostal space from sternum to the posterior axillary line
Divide the pectoralis major, pectoralis minor muscles, and intercostal muscles
Cut pericardium longitudinally anterior and parallel to phrenic nerve
Divide the inferior pulmonary ligament
Separate esophagus and aorta anteriorly (Place a nasogastric tube to distinguish between
the esophagus and the collapsed descending thoracic aorta)
Separate aorta and prevertebral fascia posteriorly
Cross clamp inferior to the left pulmonary hilum
The left phrenic nerve courses anterior to the left lung hilum over the pericardium →
susceptible to injury during resuscitative thoracotomy
Prevention: make pericardial incision longitudinally and anterior to the left phrenic nerve
Injury to the left phrenic nerve → paralysis of the left diaphragm
436
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R. C. Gooding et al.
Resuscitative endovascular balloon occlusion of the aorta (REBOA)
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a possible alternative
Characteristics
Placement Balloon catheter placed by Seldinger technique to occlude the aorta
Indications Abdominal trauma with evidence of hemoperitoneum, in hemorrhagic shock without
Contraindications Penetrating thoracic trauma or evidence of intrathoracic hemorrhage
to RT in patients with signicant hypotension after blunt injury
REBOA can decrease hemorrhage in noncompressible cavities (pelvis), and act as a bridge to
the operating room or the interventional radiology suite
Zone I Aorta (distal to left subclavian artery, proximal to celiac artery)
Zone III Aorta (distal to renal arteries)
circulatory arrest
Traumatic cardiac arrest from hemorrhage below the diaphragm
Abdominal or pelvic trauma and hemorrhagic shock (unresponsive or transiently responsive
to resuscitation
Inability to obtain common femoral artery access
Research
Reference Findings
Brenner M, Teeter W, Hoehn M, Pasley J, Hu P,
Yang S, Romagnoli A, Diaz J, Stein D, Scalea T.Use
of resuscitative endovascular balloon occlusion of
the aorta for proximal aortic control in patients
with severe hemorrhage and arrest. JAMA Surg.
2018;153(2):130–5. https://doi.org/10.1001/
jamasurg.2017.3549
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade
CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger
EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC,
Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S,
Robinson BR, Scalea TM, Schreiber MA, Stein DM,
Weinberg JA, Callum JL, Hess JR, Matijevic N,
Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux
B, van Belle G; PROPPR Study Group. Transfusion
of plasma, platelets, and red blood cells in a 1:1:1 vs
a 1:1:2 ratio and mortality in patients with severe
trauma: the PROPPR randomized clinical trial.
JAMA. 2015;313(5):471–82
Cole E, Davenport R, Willett K, Brohi
K.Tranexamic acid use in severely injured civilian
patients and the effects on outcomes: a prospective
cohort study. Ann Surg. 2015;261(2):390–4
Tapia NM, Chang A, Norman M, Welsh F, Scott B,
Wall MJ Jr, Mattox KL, Suliburk J.TEG-guided
resuscitation is superior to standardized MTP
resuscitation in massively transfused penetrating
trauma patients. J Trauma Acute Care Surg.
2013;74(2):378–85; discussion 385–6
REBOA is a minimally invasive alternative to emergency
department thoracotomy with aortic cross-clamp to
temporize noncompressible torso hemorrhage
REBOA can also be used for more targeted AO in the
distal aorta for pelvic, junctional, or extremity hemorrhage
1:1:1 Transfusion of packed red cells, plasma, and platelets
when compared to a 1:1:2 ratio resulted in decreased
mortality in the rst 24 h within the group that received a
1:1:1 ratio. (Exsanguination being the cause of death in
this study)
24 h to 30 days = No difference in mortality comparing
1:1:1 to 1:1:2
TXA only has benets in severely injured and shocked
patients given a reduction in multi-organ failure following
its use in this particular population
A 1:1:1 strategy for transfusion is not the best treatment
modality for all patients. MTP worsened outcomes for
patients with penetrating trauma when 10U or more were
used
TEG-directed resuscitation is equivalent to standardized
MTP for patients receiving 6U or more RBC and for blunt
MOI patients receiving 10U or more RBC
13 Trauma
437
Focused assessment with sonography for trauma (FAST)
a
Indications Adjunct to the primary survey per ATLS to evaluate pneumothorax in the pleural cavity and free
uid (i.e., blood) in the abdomen, pelvis, thorax, and pericardium
Transducer: Low-frequency curvilinear probe → for abdomen
Phased array probe → for pericardial window
Site Characteristics
Anatomic landmarks: subxiphoid, parasternal long axis
Key steps
Pericardial
view
Sonographic landmarks for subxiphoid: place transducer nearly at below the
xyphoid process with the directional indicator oriented to the patient’s right and the
probe face directed toward the patient’s left shoulder. Use an overhand grasp on the
probe to apply steady downward pressure
Sonographic landmarks for parasternal long axis: 10’oclock position or toward the
patient’s right shoulder, 3rd or 4th intercostal space, left sternal border
Areas of interests: entire heart with all four chambers and pericardial space
Anatomic landmarks: anterior chest midclavicular in the intercostal space
E-FAST
(bilateral
Sonographic landmarks: parietal and visceral pleura moving against each other
during respiration, giving the view of “ants marching.” → Lung Sliding
hemithoraces)
If the parietal and visceral pleura are not moving appropriately → No Lung Sliding
→ pneumothorax
Right upper
Anatomic landmark: Right midaxillary line at the level of the xiphoid process
quadrant
Sonographic landmark: Longitudinal (parallel to exam bed) with directional
indicator toward the patient’s axilla
Areas of interest: Hepatorenal interface (Morison’s Pouch), right kidney,
diaphragm liver interface with uid cephalad to diaphragm → “spine sign” (i.e.,
pleural effusion or hemothorax)
Left upper
Anatomic landmark: Left posterior axillary line at the level of the xiphoid process
quadrant
Sonographic landmark: Longitudinal (parallel to exam bed) with directional
indicator toward patient’s axilla
Areas of interest: the splenorenal interface, left kidney, diaphragm spleen interface
with uid cephalad to diaphragm → “spine sign” (i.e., pleural effusion or
hemothorax)
Suprapubic
Anatomic landmark: few centimeters above the pubic symphysis
view
Sonographic landmark (two views required): Transverse with directional indicator
oriented to the patient’s right; Longitudinal with the directional indicator oriented
to the patient’s head
Areas of interest: Bladder; Rectovesicular space (Males); Uterovesicular space
and rectouterine space (females)
Findings Blood appears hypoechoic or anechoic (dark), whereas solid structures appear hyperechoic (light)
Air appears anechoic and completely black
438
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R. C. Gooding et al.
Focused assessment with sonography for trauma (FAST)
a
Limitations Does not detect small amounts of intraperitoneal uid (less than 150 ml)
Does not detect retroperitoneal injury and hollow viscus injury unless it is causing adequate amount
of free uid in abdomen
Cannot distinguish blood from ascites or other types of uid
Operator dependent
a
Reference: Chan W, Eicken J, and Stone M.Ultrasound-Focused Assessment with Sonography in Trauma (FAST). 2014
Case scenarios
Case scenario Management
Fluid found in the abdomen → positive FAST
Equivocal FAST in the unstable patient
Hemodynamically stable patient → CT abdomen and pelvis
for further evaluation
Hemodynamically unstable → Operative exploration
DPA/DPL
Positive
• >10 cc blood or >100,000 RBC/mm
• >500 WBC/mm
3
3
• Amylase >175u
• Fecal matter, bile
Fluid found in the pericardium → positive
Median sternotomy
FAST + hypotension
Fluid found in the pericardium → positive
Left anterior lateral thoracotomy
FAST + Hemodynamically unstable patient
Pneumothorax Chest tube
Research
Reference Findings
Bloom BA, Gibbons RC.Focused
assessment with sonography for trauma.
In: StatPearls [Internet]. Treasure Island:
StatPearls Publishing; 2019
O’Rourke MC, Burns B.Blunt abdominal
trauma. In: StatPearls [Internet]. Treasure
Island: StatPearls Publishing; 2019
Matsushima K, Clark D, Frankel
H.Surgeon- performed ultrasound in acute
care surgery. In: Moore EE, Feliciano DV,
Mattox KL, editors. Trauma. 8th ed.
NewYork: McGraw-Hill Education; 2017
• The FAST / eFAST has been shown to decrease time to operative
intervention; patient length of stay; cost; and the rates of
complications, CTs, and DPLs performed
• Point of care ultrasound image acquisition and interpretation is
limited by the provider’s experience; the patient’s body habitus;
and the presence of bowel gas, pneumoperitoneum, or
pneumomediastinum
• All patients with blunt abdominal trauma who have signs of
peritonitis, frank bleeding, or worsening of clinical signs require an
immediate laparotomy
• Non-surgical treatment in patients with blunt abdominal injury
depends on the clinical features, hemodynamic stability, and results
of the CT scan
• Surgeon performed ultrasound functions to remove the delay in
interpretation of the results of which would warranting proceeding
with operative versus non-operative management. Expediting the
diagnosis in question
13 Trauma
Research
439
Reference Findings
Meyer DE, Vincent LE, Fox EE, OʼKeeffe
T, Inaba K, Bulger E, Holcomb JB, Cotton
BA.Every minute counts: Time to delivery
of initial massive transfusion cooler and its
impact on mortality. J Trauma Acute Care
Surg. 2017;83(1):19–24
• Time is of the essence with regards to activation of MTP.Delays in
MT protocol activation and delays in initial cooler arrival were
associated with prolonged time to achieve hemostasis and an
increase in mortality. 5% increase per each minute passed
Head andNeck Trauma
Traumatic brain injury
Epidemiology Closed head injuries are the most common form of TBI
The most common mechanism of closed head injury in older adult patients is a fall
The most common TBI is a concussion
Presentation Characteristics Radiology
Subdural
hematoma
Caused by shearing of
bridging veins
Located above the brain
cortex, below the dura
→ crescent shape
Epidural
hematoma
They generally involve a
much higher degree of
underlying brain injury
than does an epidural
hematoma
Axial head CT image without IV contrast
demonstrates an acute-on-chronic subdural
hematoma with layering blood product (arrow) and
left lateral ventricle hydrocephalus (arrowhead)
Located above the dura,
below the skull →
biconvex shape
Does not cross the
coronal suture
Caused by disruption of
the middle meningeal
artery
Axial head CT image without IV contrast
demonstrates a large right-sided epidural
hematoma (arrow) with 1.5cm midline shift
440
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Traumatic brain injury
Intraparenchymal
hemorrhage
Subarachnoid
hemorrhage
R. C. Gooding et al.
Located within the brain
tissue
Irregular shape
Causes brain edema and
mass effect
Axial head CT image without IV contrast
demonstrates a hyperdense focus (arrow) in the
left occipital lobe, which is acute superimposed
intraparenchymal hemorrhage.
Blood within the
subarachnoid spaces,
typically the supercial
sulci along the cerebral
convexities
Pathophysiology
Second most common
TBI
Axial head CT image without IV contrast
demonstrates hyperdense subarachnoid
hemorrhage in the cisterns (arrows). Also note a
peripherally-calcied aneurysm (arrowhead) in
the suprasellar region
Cushing reex (bradycardia, hypertension, irregular respiration [Cheyne-Stokes respirations]) is a
sign of elevated intracranial pressure
Primary brain injury occurs from the direct transmission of force to the brain
Secondary brain injury occurs due to the sequel of the force transmission (hypoxia,
hypotension) → cerebral swelling → compromised blood ow to brain
13 Trauma
Traumatic brain injury
Glasgow coma scale (GCS) is used to grade the severity of TBI
GCS is assessed following initial resuscitation and within 48 h of injury
TBI staging GCS
Staging
Management
Severe TBI <9
Moderate TBI 9–12
Mild TBI 13–15
Primary goal of initial management is the prevention and treatment of hypotension and hypoxia to
prevent secondary brain injury
Head elevation: Raising the head reduces ICP
Hyperventilation lowers ICP by reducing the intraarterial carbon dioxide partial pressure
(PaCO2) → vasoconstriction →Prophylactic hyperventilation is not recommended
Seizure prophylaxis: 1 week of prophylactic antiepileptics (i.e., Keppra) is acceptable to prevent
early seizures
For severe TBI → reduce ICP (normal ICP <20 mmHg) by elevating the head of the bed,
hyperosmolar therapy (23% hypertonic saline or mannitol [if no concern for hemorrhagic shock
from other injuries]), sedation, neuromuscular blockade, intermittent CSF drainage
441
Epidural hematomas → immediate surgical evacuation if the thickness > 15mm or midline shift of the
brain >5mm
Subdural hematomas → immediate surgical evacuation if > 10mm or midline shift of the brain
>5mm
Monitor for cerebral herniation include lateralizing signs, unilateral mydriasis (blown pupil) or
xed pupils, or Cushing triad (hypertension, bradycardia, and irregular respiration [CheyneStokes respirations]) → elevation of the head of the bed, administration of intravenous 23%
hyperosmolar bolus therapy, Mannitol (if no concern for hemorrhagic shock from other injuries),
hyperventilation, and emergency surgical evaluation
Brachial plexus Injury
Anatomy
Mechanism of injury High-velocity injuries with downward traction on the shoulder and movement of the
Presentation Muscle weakness, atrophy, and sensory loss
From anterior to posterior: subclavian vein → subclavian artery → brachial plexus
neck to the contralateral side
Iatrogenic injuries (lengthy operations with the arms abducted) and median
sternotomies
Syndrome Injury
Erb palsy Damage to C5–C7
Klumpke palsy Damage to C8 and T1
Winged scapula Damage to long thoracic
Horner syndrome Damage to C8 and T1
Hemidiaphragm paralysis Phrenic nerve injury
442
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Brachial plexus Injury
Diagnosis
R. C. Gooding et al.
Radiographs of cervical spine, chest, and upper extremity
CT for detecting bony abnormalities
CT myelography to detect root avulsions
Nerve conduction studies and needle electromyography for localizing lesions
MRI– supplement with MRI cervical spine to assess intradural part of the spinal
nerves; determining preganglionic vs. postganglionic injury is key
Management
Penetrating and open injuries → immediate operative intervention
Closed injuries → surgical intervention within 3–6 weeks
Brachial plexus
Nerve Innervation Decit
Axillary nerve Deltoid and teres minor Inability to abduct arm
Musculocutaneous nerve Coracobrachialis
Brachialis
Biceps
Radial nerve Triceps Inability to supinate arm
Median Nerve Flexor/pronator muscles in forearm
Muscles of thenar eminence
Ulnar nerve Flexor carpi ulnaris
Flexor digitorum profundi
Inability to ex arm
Inability to supinate forearm
Wrist drop
Inability to pronate forearm
Ape hand deformity
Benediction sign
Claw hand deformity
Intrinsic hand muscles
Esophageal injury
Mechanism Most esophageal injuries are penetrating injuries (80% of cervical esophageal injuries and
>95% of thoracic injuries)
Presentation Pain, hoarseness, odynophagia, dysphagia, hematemesis, oropharyngeal blood, cervical
crepitus, tenderness in neck or chest, cough, and stridor
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