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102 Cardiac Trauma
339
2. Bluntly separate the manubrium and xiphoid from underlying mediastinal structures.
3. Divide the sternum with a sternal saw, taking care to stay
midline. Identify and protect the internal mammary
arteries.
4. Place a sternal retractor and perform a pericardiotomy
using an inverted T incision (horizontal incision at inferior portion of vertical incision). Tacking the pericardium
to skin may facilitate exposure.
5. Evacuate hemopericardium if present and identify/x
cardiac injuries (see below).
6. Leave pericardium open to reduce the risk of postoperative tamponade, place mediastinal and chest tubes, and
close with gure-of-eight stainless steel wires through the
manubrium and the body of sternum.
If there is concern for cardiac injury and the patient is
hemodynamically unstable or pulseless:
Left Anterolateral Thoracotomy with Possible
Conversion to Bilateral Thoracotomy
1. Place the left arm above the head, and make an incision
starting from the right of the sternum to the left posterior
axillary line in the fourth or fth intercostal space, following the curve of the ribs. Simultaneously have another
provider place a right-sided chest tube.
2. Divide the subcutaneous tissues, chest wall muscles, and
pleura. Use curved Mayo scissors to divide the intercostal
muscles along the superior aspect of the rib (avoiding the
neurovascular bundle), and insert a Finochietto retractor.
3. Retract the left lung and open the pericardium longitudinally and anterior to the phrenic nerve (identify and avoid
the phrenic nerve).
4. Evacuate hemopericardium if present and identify/x
cardiac injuries (see below).
5. If there is a large right hemothorax or ongoing hemodynamic instability, convert to a bilateral thoracotomy by
dividing the soft tissues around the sternum and using a
Lebsche knife or heavy scissors to divide the sternum.
6. Place an aortic cross-clamp by retracting the left lung
anteriorly. Create a small periaortic window in the mediastinal pleura and place an aortic clamp.
If a cardiac injury is identied:
General Considerations
• Use digital pressure as a temporizing measure until denitive repair can be performed.
• Foley balloons inserted into cardiac lacerations can
enlarge injuries and create an internal outow obstruction
and are therefore not encouraged.
• For ventricular injuries:
– Simple lacerations can be repaired with 3-0 or 4-0
polypropylene sutures in a running, gure-of-eight, or
horizontal mattress technique.
– Consider using pledgets to reduce tearing of cardiac
tissue, particularly for right ventricular injuries.
• For atrial injuries:
– Use a vascular clamp or Allis clamps to reapproximate
the tissues.
– Run a simple continuous stitch using 5-0 polypropyl-
ene suture.
• For posterior injuries:
– Communicate closely with the anesthesia team as you
repair these injuries because ipping the heart up to
access the posterior injury can lead to hypotension and
bradycardia.
• For coronary artery injuries:
– If the injury is to a distal vessel or a small branch
(<1mm), ligate and monitor for ischemia.
– If the injury is near a coronary vessel, place horizon-
tal mattress sutures underneath the arterial bed to
avoid ligating the coronary artery with your repair
sutures.
– If there is an injury to the proximal aspect of a major
vessel, consider cardiothoracic surgery consultation
and possibly cardiopulmonary bypass.
• For cardiac valve or multichamber injury:
– Consider cardiothoracic surgery consultation and pos-
sibly cardiopulmonary bypass.
– Consider asking for transesophageal echocardiogra-
phy to better assess the injury.
Blunt Cardiac Injury
The objectives of this procedure are as follows:
• Overall: address cardiovascular collapse from hypovolemia or mechanical causes.
• Control cardiac and/or intrathoracic hemorrhage.
• Identify and quickly relieve obstructive shock from pericardial tamponade, tension hemothorax, or tension
pneumothorax.
• Perform open cardiac massage.
• Place an aortic cross-clamp to reduce blood loss from
infradiaphragmatic sources and reduce the volume of
blood required to rell the heart and to perfuse the brain.
Concept
Blunt cardiac injury (BCI) can occur in any patient who has
experienced signicant trauma to the anterior chest. The
clinical manifestations of BCI vary from simple asymptomatic cardiac contusion to cardiac rupture and death. Diagnosis
is largely based on the clinical scenario as there is no current
gold standard and imaging can be nonspecic. Operative
intervention is unlikely to be required unless a major cardiac
injury is identied.
340
E. Roth and C. L. Jacovides
Way Question May BeAsked
A 54-year-old male presents to the trauma bay after a 25-foot
fall from a construction site. He is currently hemodynamically stable but complaining of chest pain.
Additional scenarios could include high-speed motor
vehicle collision (MVC), automobile vs. pedestrian, motorcycle crashes, high-impact sports injuries, or blast injuries—
any traumatic mechanism which can result in a signicant
force applied to the chest/heart.
How toAnswer?
Initial Evaluation
As above, start by running through the primary and sec-
ondary survey. Note that most patients with BCI present
asymptomatic and may not have physical exam ndings.
Specic ndings that may prompt you to consider a diagnosis of blunt cardiac injury include:
• Breathing:
– Unequal breath sounds potentially associated with
hemothorax
– Dyspnea
• Circulation:
– Evidence of shock or diminished pulses, hypotension/
tachycardia
– Arrhythmias
• Adjuncts:
– CXR: enlarged cardiac silhouette, hemothorax
– FAST: positive pericardial window, evidence of tam-
ponade on ultrasound
• Secondary survey:
– Seat-belt sign
– Chest wall deformity
– Subcutaneous emphysema
– Chest ecchymosis
– Point tenderness over the sternum
• History
– High velocity impact
• Cardiac troponin (cTnI)
– cTnI alone has a low sensitivity rate; however, when
combined with a normal ECG, it has a 100% negative
predictive value for BCI.There are variable cutoff levels, with lower levels between 0.4 and 1ng/mL having
no signicant clinical implications. When abnormal, it
should be trended with a repeat ECG in 6h.
• Chest CT
– Chest CT has a low sensitivity for identifying mild car-
diac injuries, such as cardiac contusion. It can be useful to identify additional pathologies, such as
pericardial effusion, rst rib fractures, multiple leftsided rib fractures, or sternal fractures, which can
increase the clinical suspicion for BCI.In severe cases,
it could show cardiac rupture or septal damage.
• Transthoracic echocardiogram (TTE)
– TTE should be utilized if the patient is hemodynami-
cally unstable or has new arrhythmias after blunt chest
trauma. It can show wall motion abnormalities, intramural hematomas, or valvular injuries. Of note, it may
be challenging to obtain signicant blunt trauma with
resultant chest wall deformities or subcutaneous
emphysema. If unable to obtain TTE, a transesophageal echocardiogram (TEE) may be useful. If performing a TEE, careful consideration must be made due to
other possible chest injuries, such as esophageal or
laryngeal injuries.
Consider the American Association for the Surgery of
Trauma grading scale for BCI, which is summarized as
follows:
• Grade I: minor ECG abnormalities (persistent sinus
tachycardia, PVCs)
• Grade II: ischemic changes or heart block without cardiac
failure
• Grade III: ventricular arrhythmias, septal rupture, or val-
vular dysfunction without cardiac failure; pericardial
laceration
• Grade IV: septal/chamber rupture or valvular dysfunction
with cardiac failure
Additional Workup
If the patient is hemodynamically stable, consider:
• Twelve-lead electrocardiogram (ECG)
– Aside from sinus tachycardia, the most common
arrhythmia is atrial brillation. Additionally, premature ventricular contractions, right bundle branch
block, paroxysmal supraventricular tachycardia, and
complete heart block can be seen.
Treatment
Hemodynamically stable patient without evidence of pericardial effusion or signicant cardiac injury on workup:
• Close monitoring with serial ECG/cTnI and telemetry.
• Supportive care using inotropes and pressors as needed.
• Any development of hemodynamic instability should
prompt TTE/TEE.
102 Cardiac Trauma
341
• Persistent dysrhythmias with resulting hemodynamic
instability may require transvenous temporary pacing or
permanent pacemaker placement.
Hemodynamically unstable patient or evidence of peri-
cardial effusion or signicant cardiac injury on workup:
• Operative intervention.
– Pericardial window if the diagnosis is in question
– Median sternotomy if pericardial window is negative
or diagnosis is not in question and patient is stable
– Left anterolateral thoracotomy or bilateral thoracot-
omy if patient is unstable or pulseless
• Surgery is rarely required unless major valvular injury,
coronary artery injury, or ruptured papillary muscle.
– If a major cardiac injury is identied, consider cardio-
thoracic surgery consultation given the high likelihood
that cardiopulmonary bypass will be required.
Ventricular injuries are more common than atrial injuries due to the higher pressure in the cardiac chamber.
Common Curveballs
• Patient loses pulses in the trauma bay.
• Patient has multiple penetrating wounds/multicavitary
wounds/complex polytrauma—need to prioritize identication of a cardiac injury.
• Patient has negative pericardial window on FAST after
penetrating chest injury and is hemodynamically unstable
(decompression into chest cavity).
• Cardiothoracic surgery is unavailable.
• Delayed development of valvular pathology.
• Presentation with signs of heart failure.
Clean Kills
• Not following ABCs in trauma bay
• Not verbalizing steps of resuscitation (establishing IV
access, calling for blood)
• Not obtaining adjuncts in the trauma bay (FAST, CXR)
• Obtaining a CT scan in a hemodynamically unstable
patient or one with a positive pericardial view on FAST
• Not knowing indications for an EDT
• Not being able to describe how to perform a cardiac repair
• Not obtaining serial ECG/cTnI if initially abnormal
Bonus Points
• Comment on tenets of postoperative care—avoid hypercapnia in patients with right ventricular dysfunction
(hypercapnia increases pulmonary arterial vasoconstriction and RV afterload), and consider agents such as
inhaled nitrous oxide or epoprostenol to reduce RV
afterload.
• Pericarditis is common after operative management—
evaluate for this with EKG, and treat with NSAIDs and
colchicine. Have a low threshold for repeat TTE (to evaluate for delayed pericardial effusion).
Words ofWisdom
• Penetrating injury outside the cardiac box may still result
in a cardiac injury—have a high suspicion for this highly
lethal injury complex.
• If possible in a patient with a cardiac injury requiring
operative intervention, avoid ED intubation, and preferentially intubate patients in the operating room, ideally after
prepping and draping. Induction will reduce the sympathetic drive that is maintaining the patient’s systemic perfusion, and the positive pressure with mechanical
ventilation will decrease cardiac preload—both effects
can result in cardiac arrest upon intubation, and it is better
to be in the operating room and able to respond to these
effects if this occurs.
Summary
Patients with penetrating cardiac injury require rapid
diagnosis and treatment due to the high likelihood of lifethreatening injuries. Following the ABCs and using
adjuncts in the trauma bay to identify these injuries is
crucial for patient survival. Penetrating cardiac injuries
are almost always operative, making it imperative to
know the different operations and their indications, as
well as the basic steps. Know the indications and steps for
an EDT as an unstable patient could quickly lose pulses
in the trauma bay.
BCI is largely a clinical diagnosis and should be high
on the differential in any high-impact blunt trauma to
the anterior chest. Patients often have additional traumatic pathologies given the mechanism, highlighting the
342
E. Roth and C. L. Jacovides
importance of following ABCs and quickly identifying
other life-threatening pathologies. The clinical
presentation varies from asymptomatic to severe cardiac
dysfunction, with pathology on the latter end requiring
prompt surgical intervention, often with the assistance of
cardiothoracic surgery.
Bibliography
Ball CG, Lee A, Kaminsky M, Hameed SM.Technical considerations
in the management of penetrating cardiac injury. Can J Surg.
2022;65(5):E580–92.
Beard JH, Maher Z, Goldberg AJ.Penetrating cardiac injury. In: Shiroff
AM, Seamon MJ, Kaplan LJ, editors. Management of chest trauma:
a practical guide. Cham: Springer Nature Switzerland; 2022.
p.135–44.
Bellister SA, Dennis BM, Guillamondegui OD.Blunt and penetrating
cardiac trauma. Surg Clin North Am. 2017;97(5):1065–76.
Cothren CC, Moore EE. Emergency department thoracotomy for the
critically injured patient: objectives, indications, and outcomes.
World J Emerg Surg. 2006;1:4.
Gore AJ, Coleman JJ. Blunt cardiac and aortic injuries. In: Shiroff
AM, Seamon MJ, Kaplan LJ, editors. Management of chest trauma:
a practical guide. Cham: Springer Nature Switzerland; 2022.
p.127–34.
Hammer MM, Raptis DA, Cummings KW, Mellnick VM, Bhalla S,
Schuerer DJ, etal. Imaging in blunt cardiac injury: computed tomographic ndings in cardiac contusion and associated injuries. Injury.
2016;47(5):1025–30.
Nair L, Winkle B, Senanayake E. Managing blunt cardiac injury. J
Cardiothorac Surg. 2023;18(1):71.
Patel KM, Kumar NS, Desai RG, Mitrev L, Trivedi K, Krishnan
S. Blunt trauma to the heart: a review of pathophysiology and
current management. J Cardiothorac Vasc Anesth. 2022;36(8 Pt
A):2707–18.
Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu
WC, Dente CJ, etal. An evidence-based approach to patient
selection for emergency department thoracotomy: a practice management guideline from the Eastern Association
for the Surgery of Trauma. J Trauma Acute Care Surg.
2015;79(1):159–73.
Yousef R, Carr JA.Blunt cardiac trauma: a review of the current knowl-
edge and management. Ann Thorac Surg. 2014;98(3):1134–40.
Multiple Injuries/Trauma Priorities
VictoriaSharp
103
Concept
Trauma patients often present with multiple injuries. Their
successful management is dependent on adhering to an organized approach and prioritizing the ABCDEs of trauma: airway, breathing, circulation, disability, and exposure/
environment.
Way aQuestion May BeAsked
“A 21-year-old man presents to the emergency department
and triggers a high-level trauma activation after sustaining a
motor vehicle crash. Report from the eld indicates GCS 8,
hypotension, and multiple injuries after prolonged extrication from the vehicle with multiple fatalities at the scene.”
The most important approach involves remembering the
ABCDEs of Advanced Trauma Life Support (ATLS) and
returning to that pathway if you become lost or the patient’s
condition changes during evaluation.
How toAnswer?
History
• Initial history obtained is from the EMS providers.
• Secondary survey allows for the remainder of history and
should be delayed until after primary survey.
• (remember AMPLE).
Physical Examination
Primary Survey
• Airway
– Ask the patient his name to conrm he can speak/air-
way is patent.
• Breathing
– Asking the patient’s name can conrm air is moving.
– Listen for bilateral breath sounds.
• Circulation
– Manual blood pressure is taken.
– Attach patient to monitors.
– Ensure adequate IV access (two large-bore peripheral
IVs±central line/Cordis).
– Consider an arterial line if necessary.
– Labs are drawn.
• Disability/neurologic status
– Evaluate for any localizing signs.
– Glasgow Coma Scale (GCS)—highest score is 15;
lowest is 3.
Eye opening
Spontaneous=4
To sound=3
To pain=2
None=1
Verbal response
Oriented=5
Confused=4
Words=3
Sounds=2
None=1
Motor response
Obeys commands=6
Localizes to pain/stimulus=5
Withdraws from pain/stimulus=4
Decorticate (exion) posturing=3
Decerebrate (extension) posturing=2
None=1
• Exposure/environment
– Remove all clothing and inspect the entire body.
– Ensure no chemicals on the patient.
V. Sharp (*)
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: victoria_sharp@ihacares.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_103
Secondary Survey
• Full examination with adjuncts (CXR, pelvis X-ray,
FAST/eFAST).
343
344
V. Sharp
Diagnostic Tests
• Repeat FAST for persistent hypotension.
• CT scans based on injury patterns and if hemodynamically appropriate.
• CTA if there are concerns for active bleeding or vascular
injuries.
Treatment
• Airway
– Consider intubation, including what medications to
give, if unable to maintain airway.
– Oropharyngeal airway if patient won’t gag—nasopha-
ryngeal if gag is present.
– Avoid nasopharyngeal airway if there is concern for
facial fractures.
– Apply oxygen to all patients—nasal cannula, venturi
mask, or non-rebreather.
• Breathing
– Consider needle decompression if no breath
sounds+hypotension (possible tension PTX).
Remember tension PTX is a diagnosis from a clinical exam, not imaging.
• Circulation
– Obtain two large-bore IV access. Consider IO or
Cordis in the event peripheral IVs cannot be accessed.
Do not place triple lumen catheters. You need short and
fat lines for rapid blood and product transfusion.
– Start crystalloid (max 2L) and transition to blood and
blood product transfusion in 1:1:1 fashion (PRBC/
FFP/Plts).
– Consider ROTEM/TEG.
– Review indications for resuscitative (ED)
thoracotomy.
– If an unstable patient has suspected pelvic injuries and
a pelvic binder is in place, do not remove the pelvic
binder till the patient is hemodynamically stable or he
is taken to OR vs IR.
• Disability/neurologic status
– Evaluate for any localizing signs.
– Glasgow Coma Scale (GCS)—highest score is 15;
lowest is 3.
Eye opening
Spontaneous=4
To sound=3
To pain=2
None=1
Verbal response
Oriented=5
Confused=4
Words=3
Sounds=2
None=1
Motor response
Obeys commands=6
Localizes to pain/stimulus=5
Withdraws from pain/stimulus=4
Decorticate (exion) posturing=3
Decerebrate (extension) posturing=2
None=1
• Exposure/environment
– Undress and examine the patient’s entire body—main-
tain C-spine precautions and logroll.
– Cover to prevent hypothermia.
– Inspect for blood at urethral meatus prior to Foley.
Dispo
• Consider the need for admission to oor, stepdown, ICU
or for the need to operate/ send to interventional
radiology.
Surgery Options
1. Laparoscopy.
• Option for stable patients.
• Consider for diaphragmatic injuries and occult bowel
injuries. Laparoscopy is indicated based on the mechanism of injury, free uid on CT scan without solid
organ injuries, or seat belt-related soft tissue injuries.
2. Exploratory laparotomy with possible damage control.
3. Thoracotomy for extensive thoracic injuries.
4. IR for angioembolization if the patient is stable or
responds to resuscitation. Consider angioembolization for
stable patients with solid organ injuries and pelvic injuries. For patients with open book pelvic injuries, a combination IR and external xation of the pelvis should be
performed to decrease the volume of the pelvis.
Common Curveballs
• An initially stable patient becomes unstable.
• Patient has persistent hypotension after initial FAST
(repeat FAST).
• Patient becomes hypothermic, acidotic, or coagulopathic
mid-surgery (consider damage control).
• If you don’t proceed to surgery, patient develops tachycardia (rst sign of hemorrhage) or hypotension necessitating OR.
• There is blood at the urethral meatus (need a RUG).
• Patient has an open fracture (remember timely antibiotics
and Tdap).
• Patient will be a transient responder to blood transfusion
in the setting of solid organ injury (consider IR).
Clean Kills
• Going to CT scan in an unstable patient.
103 Multiple Injuries/Trauma Priorities
345
• Getting CXR or going to CT scan without placing a chest
tube in a patient with tension PTX.
• Not recognizing hard signs of neck trauma necessitating
OR over CT scan.
• Not following ABCs or not returning to them when there
are acute physiology changes.
• Not recognizing the stages of hemorrhagic shock.
Summary
All patients who present with trauma should be
approached in the same way every time: ABCDEs.
Trauma workup is different from most workups because
it starts with very little background provided by EMS
followed by a physical exam while the patient history
often comes later. The most important thing to remember
for trauma is to assess for stability, aggressively resuscitate as needed, and determine appropriate disposition.
Bibliography
Subcommittee on Advanced Trauma Life Support (ATLS) of the
American College of Surgeons (ACS), Committee on Trauma.
Advanced trauma life support. 10th ed. Beverly Hills: Goldbooks;
2018.
Townsend JCM, Beauchamp RD, Evers BM, Mattox KL.Sabiston text-
book of surgery, 21st ed. Elsevier—Health Sciences Division; 2022.
Intracranial Hemorrhage (Traumatic Brain Injury)
FrankJ.DiRoma andStephanieBonne
104
Concept
Intracranial hemorrhage (ICH) can be traumatic and nontraumatic. Common forms of traumatic ICH are epidural
hematoma (EDH), subdural hematoma (SDH), subarachnoid
hematoma (SAH), and intraparenchymal hematoma (IPH).
Traumatic ICH and cerebral edema can cause elevated
intracranial pressure (ICP) that can lead to brain compression and shift ultimately leading to ischemia from reduced
cerebral blood ow (CBF) and herniation.
Cushing reex consists of hypertension, bradycardia, and
an irregular respiratory pattern. It is a sign of elevated ICP,
which could be due to an expanding intracranial hematoma
or diffuse brain swelling. If untreated, patients who exhibit a
Cushing reex typically progress to herniation and brain
death.
EDH: “Lucid interval.” Brief loss of consciousness after
contact followed by normal period and then subsequent lapse
into coma. Classically resulting from a temporal bone fracture overlying the middle meningeal artery. Located above
the dura below the skull. Biconcave or lens shape. Does not
cross suture lines.
SDH: Classically results from tearing of a bridging vein
from the mechanical forces of trauma. Located above the
cortex and below the dura. Typically has a crescent shape.
Can cause a signicant mass effect that results in midline
shift.
IPH: Located within the brain tissue. Has irregular, ovoid,
or spherical shape. Often causes brain edema and mass
effect.
SAH: Bleeding located in the space between your arach-
noid mater and pia mater. It’s lled with cerebrospinal uid.
It can be a result from trauma, or it can be a spontaneous
event that precedes trauma. The most common cause is a
ruptured cerebral aneurysm.
Glasgow Coma Score (GCS) is a neurological scoring
system used to assess conscious level after head injury.
For pediatric patients, GCS is slightly different and
accounts for normal verbal responses by age.
Important GCS numbers to remember:
• Minimum score=3 (3T if intubated).
• Maximum score while intubated=11T (E4, V1T, M6).
• Consider intubation for airway protection=8 or less.
• Consider ICP monitoring=8 or less + abnormal CT head.
• Mild TBI=13–15. Moderate=9–12. Severe=8 or less.
Glasgow Coma Score (Adult and Pediatric)
Response (adult) Response (child) Score
Best eye
response
Best verbal
response
Best motor
response
Open spontaneously Open spontaneously 4
Open to verbal
command
Open to pain Open to pain 2
No eye opening No eye opening 1
Oriented Alert, coos, babbles 5
Confused Spontaneous irritable
Inappropriate words Cries to pain 3
Incomprehensible
sounds
No verbal response No verbal response 1
Obeys commands Spontaneous
Localizes to pain Withdraws to touch 5
Withdraws to pain Withdraws to pain 4
Abnormal exion
(decorticate)
Abnormal extension
(decerebrate)
No motor response No motor response 1
Open to verbal
command
cries
Moans to pain 2
movement
Abnormal exion
(decorticate)
Abnormal extension
(decerebrate)
3
4
6
3
2
Way Questions May BeAsked
F. J. DiRoma (*) · S. Bonne
Division of Trauma, Department of Surgery, Hackensack
University Medical Center, Hackensack, NJ, USA
e-mail: Frank.DiRoma@hmhn.org; stephanie.bonne@hmhn.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_104
An 18-year-old male presents to the trauma bay after falling
off his bicycle. No helmet. Reports a brief LOC but regained
consciousness before EMS arrived. Per EMS, the patient was
347
348
F. J. DiRoma and S. Bonne
awake, alert, and oriented with no complaints at the scene or
during the ambulance ride. Upon arrival at the trauma bay,
the patient is now complaining of headache and nausea. He
had a right temporal scalp hematoma with an overlying abrasion but no palpable skull fracture. No other signs of injury.
His eyes open to pain but are otherwise closed. He keeps
repeating he needs to nd his bike, does not follow commands, and swats away the nurse trying to get IV access.
Physical exam: no indication of external bleeding; left eye
normal and responsive; right eye dilated (pupil=4mm) and
sluggish; otoscopic exam consistent with hemotympanum;
vitals—BP, 180/98; HR, 51; SaO2, 95%.
How toAnswer?
Always follow ATLS algorithm.
Primary survey with ABCs. Cervical spine precautions.
Simultaneous resuscitation. Ask for vital signs if not
given.
Conrm IV access (14 g × 2). Verbalize labs drawn
including CBC, CMP, PT/PTT/INR, and T&S.
Calculate GCS
The GCS is the sum of scores for eye opening (1–4), motor
response (1–6), and verbal response (1–5). The scale ranges
from 3 to 15.
Physical Exam
Make sure to ask about the pupil exam with expected head
injury, if not already given.
Unequal, nonreactive, dilated pupil.
Other signs to look for:
“Raccoon eyes”—anterior skull base fracture; the pres-
ence of periorbital ecchymosis due to settling of blood products into the soft tissues surrounding the eyes.
Secondary survey looking for other injuries or signs of
hemorrhage.
Cerebral spinal uid (CSF) rhinorrhea, the leakage of
clear, salty uid from the nares due to compromise of the
barrier between the paranasal sinuses and the cranial space.
Battle sign—the presence of ecchymosis over the mastoid
bone behind the pinna.
Petrous bone fractures can result in CSF otorrhea (CSF
from the ear), hemotympanum (blood from the ear), or ipsilateral facial weakness due to injury to the cranial nerve as it
courses through the temporal bone.
Brain matter from the ear or from an open fracture is a
poor prognostic sign.
Diagnostic Tests
Non-contrast CT head: ndings consistent with EDH and
early herniation; hairline skull fracture
CT chest-abdomen-pelvis to rule out other life- threatening
injuries
FAST exam if hemodynamically unstable
Treatment
This is a case of severe TBI (EDH) that is demonstrating
signs of increased ICP and cerebral herniation. Our goal is to
provide immediate medical treatments to stabilize the patient
and prevent or slow down neurological deterioration until
neurosurgical intervention.
Common signs of cerebral herniation include a decline in
neurological function on one side of the body (lateralizing
signs), unilateral mydriasis (blown pupil), or the presence of
the Cushing reex.
Emergency treatments for ICP reduction include elevating the head of the bed, slight hyperventilation, and administration of intravenous hyperosmolar bolus therapy (e.g.,
mannitol or hypertonic saline).
Denitive treatment is prompt neurosurgical intervention
that consists of craniotomy, evacuation of hematoma, coagulation of bleeding sites, and inspection of dura.
EDH—immediate surgical evacuation if thickness is
greater than 15 mm or midline shift of the brain exceeds
5mm.
SDH—immediate surgical evacuation if the thickness is
greater than 10 mm or midline shift of the brain exceeds
5mm.
IPH—rarely require surgical evacuation. Exceptions
include very large clots that are causing significant
mass effect or midline shift of the brain that exceeds
5mm.
ICU care is often required postoperatively. Frequent neurological checks are important to assess patient progress.
Serial imaging is required to conrm resolution.
Target therapies for ICP reduction in the ICU include
sedation, neuromuscular blockade, CSF drainage, and intermittent intravenous hyperosmolar therapy.
Patients will often be hemodynamically unstable and
require massive transfusion. Severe TBI can lead patients to
be profoundly coagulopathic, often with admission INR that
is high. Consider sending TEG; ensure that balanced resuscitation is given with Massive Transfusion Protocol. If the
patient is going to the operating room with the neurosurgeons, the communication and handoff with anesthesiology
are key.
104 Intracranial Hemorrhage (Traumatic Brain Injury)
349
Common Curveballs
• Injury can be SDH.
• Early EDH before decline in exam.
• Patient on anticoagulation needing reversal.
• Patient with other life-threatening injuries.
• Recall that mental status changes are hemorrhagic shock
until proven otherwise; don’t forget to rule out other
injuries before attributing mental status changes to head
injury.
Clean Kills
• Not following ATLS guidelines (ABCs)
• Failure to intubate/protect airway with GCS<8
• Not asking about pupil exam
• Not ordering a CT head expeditiously (or at all)
• Failure to call for neurosurgical consult
• Mistaking ICH for intoxication
• Failure to ask about anticoagulation use/reversal
Summary
the patient arrives in the trauma bay. Our job as general
surgeons is to prevent secondary brain injury. Secondary
brain injury is injury to the brain that occurs after the
initial primary injury, often caused by elevated ICP that
compromises blood ow to the brain. Additional insults
can occur due to hypotension and hypoxia. These insults
can be prevented by maintaining adequate oxygenation
and cerebral perfusion pressure.
Words ofWisdom
Every trauma patient should be treated with the same ATLS
algorithm. The oral boards are a stressful time and things can
be easily missed. The easiest way not to miss a step is to follow ATLS guidelines!
Bibliography
Asensio JA, Trunkey DD.Current therapy of trauma and surgical criti-
cal care. pp.127–132.
Chapter 17. Management of acute trauma. In: Sabiston textbook of sur-
gery: the biological basis of modern surgical practice, 21st ed.
Primary brain injury is due to the physical damage to the
brain from trauma that results in cell dysfunction and
death. This damage has already been done by the time