VASCULAR SURGERY NOTES

Dr H Louwrens

(Combination of student-made / Doctors’ notes)

Combination of SunLearn notes and tutorials

(Compiled by Aqeelah Wentzel & Zeenad Thomas)
 AN INTRODUCTION TO TRAUMA SURGERY

TABLE OF CONTENTS
The ABCs of A Trauma Patient ............................................................................................................................................................... 4
PREPARATION AND HANDOVER FROM AMBULANCE: ...................................................... 4
PRIMARY SURVEY ....................................................................................................................... 5
SECONDARY SURVEY .................................................................................................................. 8
ADJUNCTS (IMAGING) ................................................................................................................ 8
RE-EVALUATION PLAN ............................................................................................................... 9
SUMMARISE ............................................................................................................................... 9
Shock & Massive Transfusion .............................................................................................................................................................10
DEFINITION OF SHOCK: ............................................................................................................ 10
TYPES OF SHOCK ....................................................................................................................... 10
DIFFERENCE BETWEEN NEUROGENIC AND SPINAL SHOCK .................................................... 11
CLASSIFICATION OF SHOCK: ..................................................................................................... 11
PERMISSIVE HYPOTENSION DURING DAMAGE CONTROL ..................................................... 11
COMPLICATIONS OF MASSIVE TRANSFUSIONS ...................................................................... 12
TETANUS .............................................................................................................................................................................................................13

Spinal Cord Injuries................................................................................................................................................................................. 14

A) CENTRAL CORD SYNDROME ................................................................................................ 14
B) BROWN SEQUARD SYNDROME ........................................................................................... 14
Chest Trauma ................................................................................................................................................................................................. 15
RIB FRACTURES ......................................................................................................................... 15
FLAIL CHEST .............................................................................................................................. 15
TENSION PNEUMOTHORAX ..................................................................................................... 15
MASSIVE HAEMOTHORAX ....................................................................................................... 16
THORACIC AORTA INJURIES ..................................................................................................... 16
COMMOTIO CORDIS ................................................................................................................. 17
CARDIAC TAMPONADE ............................................................................................................ 17
REPAIR OF A STAB HEART ........................................................................................................ 18
OESOPHAGEAL INJURIES .......................................................................................................... 18
THORACIC DUCT INJURIES ....................................................................................................... 19
PLACING AN INTERCOSTAL DRAIN........................................................................................... 20
Abdominal Trauma ...................................................................................................................................................................................... 21
TYPES OF INJURIES ................................................................................................................... 21
PATHOPHYSIOLOGY ................................................................................................................. 21
INJURY LOCATION .................................................................................................................... 22
SURGICAL PATHOLOGY ............................................................................................................ 23
Pelvic Trauma ................................................................................................................................................................................................ 27
A) BLADDER INJURIES:.............................................................................................................. 27
B) GYNAECOLOGICAL INJURIES: ............................................................................................... 27
C) RECTAL INJURIES: ................................................................................................................. 28
D) HEMODYNAMICALLY UNSTABLE PELVIC FRACTURES SECONDARY TO A VASCULAR
INJURY: ..................................................................................................................................... 28
Vascular Trauma ......................................................................................................................................................................................... 30

Compartment Syndrome ..........................................................................................................................................................................37

Crush Syndrome .......................................................................................................................................................................................... 39

 The ABCs of A Trauma Patient

This article covers the framework used in the assessment of a Trauma patient. From Arrival in the
trauma unit, to their definitive management. Trauma care is mostly done in teams, so it is important to
keep this overview in mind to make sure everyone is one the same page.

Remember this: In an emergency, you will have less time to implement the course material than it takes
you to read it.”

PREPARATION AND
HANDOVER FROM
AMBULANCE:
Put on non-sterile gloves, eye
protection and a plastic apron (self-
protect)

QUICK 5-MINUTE HANDOVER:

1. Mechanism of injury
2. Time to removal from car
3. Seat belt worn, where in the
car was patient found or
flung out of car
4. Blood loss at scene
5. Change in GCS en route
6. MOST NB: Deaths at scene

THE 10-SECOND ASSESSMENT Their verbal and non-verbal responses will tell
Greet patient with the Trauma salute: “Good you:
morning / evening. You are at Tygerberg hospital, I am
1. Patient has a patent airway.
Dr Seuss. Do you know what happened to you?”to
answer in a full sentence to form an appropriate 2. They have lung capacity & cardiac reserve to
answer. respond in full sentences and form appropriate
ADJUNCTS answers

These are implemented in parallel by secondary team 3. There is adequate brain perfusion.
members whilst the team leader goes through the
primary and secondary surveys. Adjuncts facilitate
overall decisions and care. A second team member
connects the adjunctive monitors (e.g. oxygen sats, ECG leads and BP cuff to the patient) and draws
blood for tests, urine for dipstick & prognostic. Adjuncts also come into play after the secondary survey
to finalise decisions and interventions. These include investigations like CXR, LODOX and CT scans.
PRIMARY SURVEY
The 1° survey aims to address the most life-threatening issues in order of importance. A clinician does
not progress to the next step until the first is completely addressed.

A: AIRWAY
Whilst communicating with the patient, remove the neck collar but assume the patient has a C-Spine. An
assistant sits on a chair at the end of the bed, holding the head and neck in position with both hands for
the entire duration of the primary survey. This is also the person who is responsible for counting during
the logroll.

The clinician performs a rapid assessment looking for signs of airway obstruction or a threatened airway:

• Foreign bodies
• Facial fractures (facial, mandibular, tracheal / laryngeal)
• Swelling and inflammation

All polytrauma patients should receive 40% face mask oxygen, which enhances tissue oxygenation and
reduces the work of breathing. It also standardises subsequent oxygenation measurements (sats and
ABGs) and allows clinicians to follow trends more accurately.

Indications for definitive airway - Rapid sequence intubation with a cuffed and secured endotracheal
tube

• GCS < 8
• Blood, vomitus or foreign body in the mouth
• Expanding neck swelling secondary to a gunshot face / neck wound
• Tongue laceration or swelling
• Inhalation injury
• The combataive patient with haemodynamic compromise

B: BREATHING
Adequate breathing implies ventilation and perfusion of the lung fields, resulting in oxygen absorption
and carbon dioxide excretion. Ventilation requires adequate function of the lungs, chest wall and
diaphragm, whilst perfusion requires a functional cardiovascular system.

Assessment:

• LOOK: symmetrical chest expansion and movements

• PALPATE: Central trachea (deviation can = tension pneumo) and chest wall for surgical
emphysema and fractures (clavicular & rib)
• AUSCULTATE lung fields

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Four life-threatening conditions to exclude before moving on to C: Tension pneumothorax, massive
pneumothorax, flail chest and an open sucking chest wound (open pneumothorax)

Interventions

• Looking for fractures entails observing for signs of a pneumothorax or haemothorax. A tension
pneumothorax is managed first with decompression, followed by a definitive pleural drain via
ICD.

• A tension pneumothorax is decompressed by inserting a large grey or orange needle into the 2nd
intercostal space, releasing the trapped air from the pleural space. Decompression is followed
by placement of an intercostal drain on the ipsilateral side of needle decompression.

• Rib fractures and consequent pain result in patient splinting of chest wall and ↓ ventilation.
Over the course of a few hours, this splinting can result in atelectasis and a reduction in
functional lung volume. It is critical to avoid this vicious cycle and ensure the patient has
adequate analgesia. This can be in the form of systemic opioids or pleural blocks with local
anaesthetic.

• Sucking chest wounds should be closed with a three-sided dressing and an ICD subsequently
inserted on that side. The wound is sutured closed as part of the secondary survey.

C: CIRCULATION
The goals of “C” is cardiovascular support and haemorrhage control. Remove all clothing (including
underwear and socks) while keeping the patient covered with a blanket for privacy and heat retention.
Inspect the patient for bleeding lacerations and signs of massive blood and stop any active bleeding.

Active bleeding from a small vessel will usually stop with direct compression, whereas a larger bleed can
be compressed with a blown up foley’s catheter. Cover wounds with a gauze and bandage to stop
smaller active bleeding (definitive sutures are placed at secondary survey). Remember to keep c-spine
protected.

Life-threatening bleeding can occur externally or internally into a specific set of spaces that are not
obvious externally, namely, the chest, abdomen, pelvis and around long bone fractures (BLOOD ON THE
FLOOR + 4 MORE)

Assessment:

Review the abdomen for distension. Compress the pelvis (only once) for bone mobility, which is
indicative of a pelvic fracture. Place a pelvic sheet binder only if a pelvic fracture is suspected and
patient is haemodynamically unstable.

Palpate both arms and legs for fractures and if one is found or suspected, align and apply backslabs or
immobilize. Reduce obvious dislocations. Feel both arms and legs for pulses (pre- and post fracture
reduction)
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Place two large bore (14-18 gauge: green, grey or orange jelcos) IV lines, but avoid fractured arms or the
side of a suspected vascular injury. Bloods are drawn simultaneously (adjunct): FBC, U/e, crossmatch
and ABG.

Intravenous fluids are infused at a rate proportional to the patient’s volume requirements and expected
ongoing losses. The clinician must keep cognisant of the fluid requirements, but also of blood
coagulation. It is critical to avoid factors that exacerbate ongoing bleeding such as hypothermia and
haemodilution. If the patient has had, or is expected to have massive blood loss, then the clinician
should prioritise the infusion of blood products over crystalloids as this will maintain clotting factors,
and the oxygen carrying capacity of blood.

D: DISABILITY
Review the patient’s cognitive function and orientation.

Examine both pupils for pupillary light reflex looking for a unilateral dilated pupil (Lateral tentorial
herniation) and both limbs for neurology (document power /5) and perform a sensory exam.

Calculate the GSC /15 (highest is 15; lowest in an unintubated patient is 3)

EYE (out of 4) MOTOR (out of 6)
4 = Spontaneous
3 = To voice 6 = Obeys commands
2 = To pain 5 = Localises and removes
1 = None 4 = Withdraws
VERBAL (out of 5) 3 = Flex
5 = Orientated 2 = Extend
4 = Confused 1 = None
3 = inappropriate (swears)
2 = (incomprehensive (mumbles)
1 = None

Log-roll the patient

4 people are needed for this. The first team member holding the c-spine (NO NECK COLLAR ON), two
clinicians rolling patient towards them and the primary clinician examining the back.

• Feel the occiput for depressed skull fractures

• Feel the individual vertebrae from c-spine, t-spine, l-spine and sacrum for:
- Tenderness
- Step/ deformity
- Haematoma/bogginess

Perform a rectal exam (+/- a PV per indication):

• Blood on glove • High riding prostate

• Anal tone • Bulbocavernosus reflex in spinal
• Bony fragments in rectum cord patients
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E: EXPOSURE

Use the logroll technique to remove all blood stained (wet) linen and clothes from patient. Apply a “Bear
hugger” directly onto patient (actively warm them and avoid secondary hypothermia) and cover patient
with a blanket. All blood products should be appropriately warmed prior to administration. Close all unit
doors to prevent cold drafts.

SECONDARY SURVEY
The 2° survey reverts back to the usual history and examination structure that clinicians are used to.

HISTORY (Every emergency clinician uses AMPLE history)

Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury

It is critical to review the mechanism and events leading up to the patients injury. A fall from height
implies there may be hidden vascular injuries. Electrical burns may precede cardiac arrhythmias. A
history of chemical, toxins, or radiation exposure is important to obtain. They not only cause multiple
forms of organ dysfunction. Environmental hazards can also endanger healthcare providers.

EXAMINATION: A systemic head to toe examination is continued, with the goal of diagnosing and
treating all injuries definitively.

• Head & Face Exam • Chest Examination

• Maxillofacial Exam • Abdomen and Pelvis Examination
• Cervical Spine and Neck • Musculoskeletal Examination
• Cardiovascular System review • Neurological Examination

PLAN: After the 2° survey, the clinician should have a good idea of the patient’s injuries and pathology.
All findings should be documented, special investigations and the planned management plan. Ensure to
supply the patient with adequate analgesia, the first dose of antibiotics, thromboprophylaxis and
tetanus toxoid as indicated.

ADJUNCTS (IMAGING)

LODOX

A head to toe, full body x-ray. It is used as a screening modality, also useful to locate bullets and decide
which cavities bullets have traversed.

E-FAST (emergency focused abdominal sonography for trauma)

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A rapid ultrasound that looks for fluid in a specific set of cavities. It is only used in haemodynamically
unstable patients and it helps to decide which cavity to open first i.e. chest or abdomen. An eFAST has
limited sensitivity as it cannot detect retroperitoneal injuries or fluid like posterior haematomas or
pancreatic injuries.

CT SCAN

Arterial phase, Portal venous phase and Intravenous Pyelogram (IVP)

Used for all stable patients if the abdomen cannot be cleared clinically (i.e. intubated or the presence of
distracting injuries.)

NOTE: Free fluid on a CT abdomen without solid organ injuries will need a laparotomy as the free fluid
could be bowel content, mesenteric bleed or urine.

➢ If a stable patient, has a solid organ injury on CT abdomen e.g. liver injury or splenic
injury, then the free fluid is most likely to be blood and will not necessarily benefit from
a laparotomy. These patients are managed non-operatively.

Angiograms are used to assess for vascular injuries and arterio-venous fistulae in high grade solid organ
injuries. Focused CT-angiograms are also done in areas where vascular injuries are suspected based on
the mechanism of injury and/or proximity to a named vessel.

RE-EVALUATION PLAN
A specific review plan is made based on the severity of injuries, and their required interventions. Trauma
patients must be re-evaluated constantly. This ensures interventions are successful, new findings are not
overlooked and to discover any deterioration in previously noted findings.

SUMMARISE
A head-to-toe summary is documented by the responsible clinician. This includes all compounding
factors, the patient injuries, and their corresponding interventions to facilitate communication within
the trauma team.

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 Shock & Massive Transfusion

DEFINITION OF SHOCK:
A state whereby the cardiovascular system does not meet the Imbalance
between oxygen delivery & consumption.

TYPES OF SHOCK
Causes Signs Mx
Flluid loss: Tachycardia Control external bleeding
Hypovolemic / Haemorrhagic

Vasoconstriction 2L warmed Ringer’s lactate

Blood Narrow pulse pressure Colloid
Diarrhoea & vomiting Hypotension (late) Emergency blood
Burns Decreased saturation Surgery
Lactic acidosis
Electrolyte disturbance
(hyponatraemia)
Extra-cardiac abnormality: tachycardia Judicious use of IV crystalloids
low blood pressure
Obstructive

Pulmonary embolus unequal breath sounds

Tension pneumothorax difficulty breathing
Cardiac tamponade
Cardiac pump failure: Hypotension Judicious fluid challenge
ECG changes Constant ECG monitoring
Cardiogenic

Acute MI Arrhythmias essential

Atrial fibrillation Cardiac enzyme elevation
Cardiac valve deficits
Peripheral vasodilatation Identify cause of infection
Sepsis Increased cardiac output & oxygen Treat surgically if indicated
Distributive

Anaphylactic consumption MC&S

Neurogenic Relativelyhypovolemic Appropriate antibiotics
Multiorgan shut down and death Optimize fluid balance

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DIFFERENCE BETWEEN NEUROGENIC AND SPINAL SHOCK
NEUROGENIC SPINAL
(Loss of sympathetic tone) (Loss of reflexes)
Interruption of sympathetic input from hypothalamus Spinal cord concussion = temporary physiologic
to cardiovascular centres → unopposed vagal tone in disorganisation of cord function that starts 30-60
vascular smooth muscle and decreased systemic minutes post injury → up to 6 weeks
vascular resistance % vasodilatation
• Flaccid paralysis of bladder & bowel, areflexia &
Seen in cervical injuries (especially above T6) and is a sustained priapism
diagnosis of exclusion. It can occur any time post • Hypereflexia, hypertonicity & clonus may be
injury (even several weeks later) present at its conclusion
• Return of bulbocavernosus reflex below level of
• Hypotension refractory to fluid resuscitation. injury marks the end of spinal shock.
• Bradycardia exacerbated by suctioning, Bulbocavernosus reflex (Osinksi reflex) = spinal
defecation, turning the patient or hypoxia. mediated reflex involving S2-S4. Internal/external anal
• Poikilothermic: inability to regulate temperature sphincter contraction in response to squeezing of
glans penis/clitoris or when tugging on urinary
catheter.

CLASSIFICATION OF SHOCK:
CLASS I CLASS II CLASS III CLASS IV
Blood loss
<750 750 – 1500 1500 – 2000 >2000
(ml)
Blood loss
<15 15-30 30-40 >40
(%)
Pulse rate <100 >100 >120 >140
Blood
Normal Normal Decreased Decreased
pressure
Anxious & Confused /
GCS/mental Slightly anxious Mildly anxious
confused lethargic
Base Deficit
0 to -2 -2 to -6 -6 to -10 -10 or less
(mEq/L)
Blood Massive
Possible Possible Yes
Transfusion Transfusion

PERMISSIVE HYPOTENSION DURING DAMAGE CONTROL

RESUSCITATION:
Restrict fluids until haemorrhage is controlled while accepting a period of suboptimal end organ
perfusion with MAP = 50mmHg rather than the usual 65mmHg. Cut back on fluids until a clamp is placed
on the bleeding source/blood vessel then catch up on lost products.

MASSIVE BLOOD TRANSFUSION:

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Definition: >10 units of red blood cells in 24 hours

Patients lose more than just RBCs when they bleed. They also lose clotting factors which is why FFPs,
cryoprecipitate and platelets are given. Blood should be ordered in ratios of 6 for a massive transfusion
– 6 packed red cells, 6 fresh frozen/dried plasma, 6 cryoprecipitate and 1 bag random pooled platelets.
One bag of pooled platelets includes the number of platelets to match 6 units of blood. The final ration
is thus 6:6:6:1.

(a) Warming of blood: Red blood cells are stored at: 2- 6 degrees Celsius

• Not in a microwave
• Not > 37 degrees Celsius (causes haemolysis, renal damage & death)
• Submerging in a basin with warm water only heats the outer layer (ineffective)

(b) Packed red blood cells:

• Shelf life is 35 days

• 250 – 300ml in a bag
• 1 unit of RBD increases the haematocrit by 3% and the Hb by 1.5g/dL

(c) Platelets:

• Shelf life is 1 – 3days

• 30 – 50ml in a bag
• Increases the platelet count by 10 000/IU

(d) Cryoprecipitate:

• Collected as a precipitate of plasma ( post freeze – thaw cycle)

• Shelf life:
- Frozen = 1 year
- Thawed = 6 hours
• 10 – 20ml
• Contains: Factor VIII, Factor XIII, Fibrinogen and Von Willebrands factor.

COMPLICATIONS OF MASSIVE TRANSFUSIONS

• Acute haemolytic transfusion • Post transfusion purpura
• Febrile non haemolytic transfusion • Bacterial sepsis
• Allergic reaction • Transfusion transmitted diseases
• Transfusion related acute lung injury (TRALI) • HIV 1 + 2
• Citrate toxicity (hypocalcemia) and • Hepatitis B+C
hyperkalemia • West Nile
• Abdominal compartment syndrome • Syphilis (Treponema Pallidum)
• Post transfusion graft vs host reaction • CMV
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 TETANUS

Caused by neurotoxin: tetanospasmin from Clostridium Tetani (gram +)

RISK FACTORS FOR TETANUS:

• Skin laceration
• Complication of burns
• Frost bite
• Puerperal sepsis/ septic abortion
• Umbilical stump
• Post elective bowel surgery
• Contaminated heroin
• Tooth extraction

CLINICAL PICTURE:
• Descending pattern
• 3 muscle groups affected: masseter, abdominal and back extensors
• 1st trismus (lockjaw) then risus sardonicus (facial spasm)
• Opisthotonus (spasm of back muscles)
• Arms in flexion and legs in extension
• GCS=15/15 (normal mental state)
• Death in 4 days

PREVENTION:
All trauma patients with penetrating wounds should receive 0.5mg anti-tetanous toxoid (ATT). The
effect of this immunisation lasts 5 years

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 Spinal Cord Injuries

A) CENTRAL CORD SYNDROME

Incomplete spinal cord injury

Clinical picture:
• Disproportionately greater impairment of upper limb vs lower limb
• Varying degree of sensory loss below injury
• Bladder dysfunction & urinary retention

B) BROWN SEQUARD SYNDROME

Incomplete lesion (hemisection); damage to half of the spinal cord

Clinical picture:

a) Ipsilateral loss of:

1. Dorsal column medial lemniscus tract:

- Vibration
- Fine touch
- Proprioception
- Two point discrimination
2. Lateral corticospinal tract: weakness + Babinski sign (motor function)

b) Contralateral loss (1-2 segments BELOW lesion):

1. Spinothalamic tract of anterolateral system (fibres cross over in spinal cord)

- Pain
- Temperature
- Crude touch

c) Bladder & bowel function usually preserved

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 Chest Trauma

IMMEDIATELY LIFE-THREATENING CONDITIONS

1. Air way obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Flail chest
5. Massive haemothorax
6. Cardiac tamponade

RIB FRACTURES
COMPLICATIONS ADMISSION CRITERIA MANAGEMENT
ACUTE • 3 or more rib fractures 1. Pain control
• Atelectasis • Associated i) Opioids (may suppress cough) +
• Pneumonia/Acute haemo/pneumothorax NSAID
respiratory distress • Elderly (decreased functional ii) Intercostal nerve block + PCA
syndrome (ARDS) residual capacity) (patient controlled analgesia)
• Pneumothorax • Children (cartilaginous bone – pump
• Empyema if fractures indicates severe iii) Catheter based analgesia:
• Constipation forces involved) epidural / paraspinal blocks
CHRONIC • Obese (Pickwickian syndrome) 2. Chest physiotherapy
• Fracture non-union patients 3. Early mobilization, elevate head end
of bed
• Intercostal nerve
entrapment 4. LMW heparin and calf pumps
• Chronic pain and 5. Don’t strap chest wall with
disability Elastoplast in order to immobilize
bone component!

FLAIL CHEST
• 3 or more rib fractures in 2 or more consecutive places.
• Portion of the thoracic cage losses contiguity with the rest of the thoracic cage.
• Problem = paradoxical chest movement, and loss of the chest wall’s ability to create negative
pressure in the pleural space during inspiration.
• Associated with severe underlying pulmonary contusion and pain

TENSION PNEUMOTHORAX
A tension pneumothorax develops when a lung injury results in a pleural air leak. Air leaks out of the
lung (down a pressure gradient) into the pleural space during inspiration. Then when the patient
expires, the leak collapses with the lung, trapping the air in the pleural space in spite of high
intrathoracic pressure. When the patient inspires again, the leak resumes. This pleural air trapping in the
definition of a Tension Pneumothorax.

WHY IS IT LIFE THREATENING?

Increasing unilateral intrapleural pressure, results in compression of the lung and mediastinum. The
rising intrathoracic pressure pushes the mediastinum aside, and compresses the veins of the chest. The
rising intrathoracic pressure acts against the venous filling pressure of the right atrium. This causes a

15
dramatic reduction in venous flow to the heart, with extra-thoracic venous pooling. This can be seen in
the raised JVP and distended neck veins.

The dramatic reduction in functional lung capacity, and mismatch between ventilated and perfused
areas of the lung, results in respiratory failure. The loss of venous return to the heart, and dramatically
increased pulmonary vascular resistance, results in cardiovascular collapse. This is classified as a type of
Obstructive Shock. A tension pneumothorax therefore combines into respiratory and cardiovascular
failure.

The patient’s clinical picture can be varied and depends on the patient’s respiratory reserve,
cardiovascular reserve, and external interventions like mechanical ventilation. Even experienced
clinicians have confused haemorrhagic or septic shock with a tension pneumothorax.

TREATMENT:
40% face mask oxygen whilst inserting a large bore jelco (orange/grey) into the second intercostal space
in the midclavicular line. This is then followed by an intercostal drain.

MASSIVE HAEMOTHORAX: Indications to do a thoracotomy for a massive haemothorax is a

volume equal to or exceeding 1500ml of blood.

THORACIC AORTA INJURIES

MECHANISM OF INJURY:
• Penetrating (stab wound or gunshot wound).
• Acceleration – deceleration with a tear at the isthmus. Classically seen in MVA with
seat belt sign over chest wall or fall from a height.
• CLASSIC SITE OF INJURY = Just distal of the left subclavian artery (at the fixed point
caused by the ligamentum arteriosum’s attachment)
• Osseous pinch: aorta pinched between the sternum (anteriorly) and the vertebrae
(posteriorly). Seen in trauma patients crushed between two objects
• Shear / torsion / stretch
CHEST X-RAY FINDINGS OF A BLUNT THORACIC AORTA INJURY (NB)
1. Widened mediastinum (>8cm at the level of T4 on an
ERECT chest x-ray)
2. Left pleural cap
3. Displaced nasogastric tube to the right
4. Displaced endotracheal tube to the right
5. Left haemothorax
6. Fractured sternum, 1st 2 ribs or scapula
7. Depressed left main bronchus
8. Loss of aortic knob
9. Displaced paraspinal line
10. Widened right paratacheal stripe

MANAGEMENT
1. ATLS principles
2. Analgesia
3. Blood pressure control
4. Unstable patient: 4th ICS thoracotomy – clamp & sew injury

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 5. Stable patient: TEVAR (thoracic endovascular aortic repair) – endovascular repair via femoral
vessels (wires) with a stent placed over the injured site.

COMMOTIO CORDIS
A lethal disruption of the heart’s rhythm due to a direct blow to the precordial area during a critical part
of the cardiac cycle (upstroke of T wave) causing ventricular fibrillation and sudden death.

CARDIAC TAMPONADE
Penetrating cardiac injury causes blood to accumulate in the pericardial sac and impede normal cardiac
contractility (OBSTRUCTIVE SHOCK).

CLINICAL PRESENTATION:
1. Muffled heart sounds
2. Elevated JVPs
3. Hypotension

CONFIRMATION OF CARDIAC TAMPONADE

1. Cardiac ultrasound (FAST): >1 cm fluid in the pericardial sac is diagnostic. Small sliver of pericardial
fluid is normal and prevents a friction rub.
2. ECG: small complexes (Signal attenuated by blood)
3. Globular heart on CXR
4. Pericardiocentesis – if done very early may indicate fresh blood.
Note with time blood clots in the pericardium and this may give the false
impression of a normal pericardium without blood as the LP needle is too thin
to aspirate the clot!
Technique of a pericardiocentesis: While on an ECG monitor, aim a thin LP needle
between the angle formed by the xiphisternum and lower ribs, aiming for the tip of
the scapula. Aspirate as you slowly advance the needle. Watch the ECG for cardiac
irritation indicating you are close to the myocardium and you should then stop.

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REPAIR OF A STAB HEART
• ATLS + massive blood products + cell saver
• Keep blood pressures low until injury is controlled (permissive hypotension)
• STERNOTOMY
• Open pericardial sac with scissors
• Finger on hole to tamponade (alternatively insert a Foley’s catheter)
• Lift heart to check posterior aspect for a through and through hole.
Warn the anaesthetist as lifting the heart to examine posteriorly kinks
the inflow vessels, drops cardiac filling and thus decreases cardiac
output and drops the blood pressure.
• Pledgeted repair (small synthetic blocks of material that reinforces the
suture – cut pieces of the pericardium can also be used) with prolene.
• Beware of catching the coronary vessels in the repair process.
• Intercostal drain is placed below sternum.
• Pericardial sac is not closed.
• Sternal wires to close the chest.

OESOPHAGEAL INJURIES
Mechanism of injury: stab wounds, gunshot wounds, foreign body (chicken bone
stuck inthroat) and parasuicide attempts.
EARLY!! Diagnosis and repair is vitally important to ensure a good outcome. Ideally
intervention within the first (golden) hour. Delayed diagnosis and repair means that the
tissuebecomes like butter and almost impossible to get a primary repair with sutures.

CLINICAL PICTURE:
- Saliva draining from the penetrating wound
- Odynophagia (painful swelling)
- Dysphagia (inability to swallow – associated more with oesophageal cancer but
a few trauma patients may complain of this)
- Left pleural effusion
- Features of mediastinitis

SPECIAL INVESTIGATIONS:
• Lateral c-spine xray – prevertebral free air
• Chest x-ray: left pleural effusion +/- features of a mediastinitis
• Water soluble contrasted swallow: contrast extravasation
• CTangiogram + CToesophagram (single study): contrast extravasation, fluid
collections/abscess, oesophageal thickening. If a delayed presentation CT scan the chest to
look if there is evidence of mediastinitis which may need cardiothoracics to
debride/decorticate at the initial surgery.
• Gastroscopy:
- RISK: Air to inflate the oesophagus may increase the injury size (not significant
problem for a surgeon, ask gastroenterologist to use minimal inflation pressures)
and cause bacterial translocation.
- BENEFIT: Can confirm the presence and level of an injury in the intubated patient
who can’t swallow for a contrasted swallow test.

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SURGICAL MANAGEMENT OF OESOPHAGEAL INJURIES:
1. Early antibiotics.
2. Surgical Options:
a. Neck exploration: debride and suture the injury. Leave
drain and a nasogastric tube past the injury for feeding.
b. Drain only (if delayed presentation and injury is not
amenable to suturing).
c. T-tube drain to create a controlled fistula.
d. Exclusion and diversion (oesophagostomy).
3. Lung recruitment, CPAP, aggressive chest physiotherapy.
4. May need a left sided intercostal drain for the pleural effusion.
5. May need simultaneous thoracotomy and decortication from
Cardiothoracics. Figure 1: Prevertebral free air on lateral neck x-ray

THORACIC DUCT INJURIES

Classically injured with a zone 1 left neck penetrating injury. Normally 4 litres of lymph produced p/ day.

CHYLE/ LYMPH CONSISTS OF:

1. Chylomicrons
2. Triglycerides & cholesterol
3. Fat soluble vitamins
4. Water, electrolytes and proteins
5. T cell lymphocytes and antibodies

COMPLICATIONS OF A LARGE CHYLOTHORAX:

• Malnutrition
• Hypovolemia
• Acidosis
• Hyponatremia
• Hypocalcemia
• Immune suppression (loss of lymphocytes in chylothorax)

ANATOMY OF THE THORACIC DUCT:

Starts at the cisterna chyli in the abdomen, ascends on the right side of the chest and
empties at the junction between the left internal jugular vein and left subclavian vein.

CLINICAL PRESENTATION
High volume intercostal drain turns milky in colour when a high fat meal is
reintroduced. Chyle does not result in an inflammatory reaction: so no pleuritic chest
pain or fever (vs an empyema). May present with acute respiratory distress if delayed
diagnosis and large volume of chyle accumulates in the chest. Presence of
chylomicrons on pleural fluid.

MANAGEMENT
1. Intercostal drain to re-expand the lung with aggressive chest physio.
2. Nil per os – a large % seal off with conservative management.

19
 3. Dietician referral for median chain triglyceride (MCT) feeds. MCT are directly absorbed into
the portal system and NOT via intestinal lymphatics.
4. If MCT are not successful consider TPN (total parenteral nutrition).

INDICATIONS FOR SURGERY

• >1L per day for 5 days
• >1.5L per day
• Nutritional complications

SURGICAL OPTIONS
Full cream ingested 1 hour prior to surgery, fills the thoracic duct
so that it’s easy to identify intraoperatively.

1. Suture thoracic duct at the site of injury in the neck.

2. Thoracic duct ligation in the chest (right side): open thoracotomy vs thorascopically).
3. Pleurodesis

PLACING AN INTERCOSTAL DRAIN

1. Prepare: 40% face mask oxygen, blood pressure cuff, saturation, systemic morphine and 5mg
dormicum.
2. Semi-fowlers position with ipsilateral arm raised above the head.
3. Check the CXR to confirm the correct side is having an ICD.
4. Clean and drape and give adequate local anaesthetic into the skin (+/- 4-5 lignocaine
ampules). Place a linen saver under the patient’s chest.
5. Make a horizontal incision +/-3cm (finger must fit through) above the 5th rib mid- axillary
line. Avoid the neurovascular bundle below the rib.
6. Use a cryl to bluntly dissect through the pleura in to the chest cavity.
7. Do a finger sweep on the inside of the chest cavity to check that you are in the chest cavity
and for adhesions especially if a history of PTB is given. Feel for the soft lung parenchyma in
front of your finger.
8. Clamp the distal end of the ICD pipe to prevent spillage.
9. Advance a 28fr ICD pipe to about 20cm. Secure with a “tabak sak” / tobacco pouch suture.
10. Connect to the ICD bottle/reservoir bag.
11. Elastoplast/ primapore dressing around drain.
12. Make the patient inflate a non-sterile glove to recruit the lung or blow into a PEEP bottle.
13. After 10 minutes repeat the CXR and confirm that the position is correct.

20
 Abdominal Trauma

TYPES OF INJURIES
PENETRATING BLUNT
• Defined tract of injury (except for GSWs) • High risk of solid organ and pelvic
• Posterior injuries place retroperitoneum at risk injuries
• Costal margin injuries puts diaphragm at risk • Low risk of bowel perforation (but can
• High likelihood of bowel injury still occur in delayed phase)
• Can introduce air into peritoneal cavity via tract • Beware occult pancreatic injuries
• Laceration to Abdominal Fascia may cause
secondary hernia development

PATHOPHYSIOLOGY
Bleeding
• Solid organ injury with immediate Active Bleeding
• Coagulopathy resulting repeat or delayed bleed from existing injury

Peritonitis
1. Sepsis
Leakage of Bowel contents into the peritoneal cavity results in an immediate chemical
peritonitis. This is followed by overgrowth of gut microbes in the normally sterile field, and a
subsequent severe inflammatory cascade.
2. Bile Peritonitis
An injured bile duct, or leak from a parenchymal liver injury will result in slow leakage of bile
into the peritoneal cavity. Bile induces a proinflammatory cascade in the peritoneal wall
resulting in peritonism. This fluid collection also invariably becomes colonised by microbes,
who create a septic focus and a secondary systemic inflammatory cascade.
3. Pancreatitis
Pancreatic enzymes may leak from a disrupted pancreatic duct. Once inContact with normal
tissue, the enzymes become activated and start auto-digesting the surrounding tissue. This
creates a massive systemic inflammatory cascade described as pancreatitis. Locally the
enzymes also wreak havoc with any injured tissue – breaking down bowel anastomoses and
eroding into any injured adjacent vessels (eg splenic, renal or colon injuries).
4. Blood
Blood in the peritoneal cavity does induce an inflammatory response, but generally not to the
degree so as to cause peritonitis. Old blood or clots may however become secondarily
infected, and as such result in secondary peritonitis.
5. Urine
Urine does not immediately cause peritonitis, but it acts as a substrate for secondary infection
which can rapidly progress to systemic sepsis and peritonitis. As urine is reabsorbed from the
peritoneal cavity, it induces a biochemical picture of renal failure. Free leakage of urine from

21
 the kidney or bladder requires drainage to reduce this septic risk and maintain biochemical
homeostasis. The source of the leakage must also be addressed.
Renal Failure
• Direct damage to the renal cortex or excreting system can render the remaining kidney
volume insufficient for the patient’s requirements
• Rhabdomyolysis results in nephrotoxic kidney injury that causes secondary damage to kidneys
that may not have been assessed as injured initially. This can also act in unison to IV contrast
given in the CT-scan to create a “double hit”, and result in renal failure.
• Hypoperfusion injury results if the patient remained hypotensive or hypoxic for longer that
the kidney’s warm ischaemic time. Depending on the extent of injury, this may be reversible
or irreversible.
Gastrointestinal tract failure “Gut failure / GI Failure”
• This is defined as a state where the gastrointestinal tract is unable to fulfil the
nutritional needs of the body.
- Overwhelming damage to the bowel resulting in insufficient absorption surface area.
“Short Bowel syndrome”
- Injuries or fistulae that result in discontinuous bowel, with insufficient
functional segments to absorb the required nutrients.
- The loss of intestinal secretions from fistulae out-weighs the nutrition gained
• GI Failure results in a temporary or permanent catabolic state, resulting in a profoundly

catabolic state as the patient uses reserve stores to compensate

Solid organ injuries

Solid organs are defined as having a parenchymal structure that is not malleable, and thus can be
“fractured” if distorted. This fixed parenchymal structure also means these organs cannot be repaired
with sutures. Any trauma to a solid organ, be it penetrating or blunt, is very difficult to manage surgically.
The Surgical Options in a solid organ are generally limited to:
- Resection
- Drainage
- Angio-embolisation

INJURY LOCATION
Abdominal injuries can be divided into five regions:

(I) THORACOABDOMINAL (Between 4th ICS anteriorly & 7th ICS posteriorly to inferior costal margins)
Places organs in chest and the abdomen in danger. Any injury below the nipple line anteriorly and the
tip of the scapula posteriorly must be considered as a potential diaphragm. The diaphragm injury can
be accompanied by injuries to the underlying organs, and also result in abdominal contents spilling
into the chest.

(II) ANTERIOR ABDOMEN (anterior costal margins to inguinal creases between anterior axillary lines)
The Anterior abdomen is made up of the abdominal wall with the peritoneal cavity underneath. Injuries
can thus be managed with the abdominal wall and the underlying organs in mind. Any full thickness

22
 abdominal wall laceration is a potential hernia. The underlying organ injuries will theoretically present
with peritonitis as they leak into the peritoneal cavity, and thus “abdominal observations” are a viable
monitoring route.
(III) POSTERIOR ABDOMEN AND (IV) FLANK (inferior scapular tip to iliac crest between ant. And post.
axillary lines)
The Posterior abdomen and flanks do not have underlying peritoneum and thus an injured organ may
not present with overt peritonitis. Due to the unreliable outcomes of abdominal observations, all
patients with penetrating posterior or flank injuries must have some form of definitive imaging (CT-
scan) performed to rule out or diagnose an underlying injury.
(V) PELVIS (inferior to pelvic crests or pubic symphysis)
Blunt pelvic trauma can result in pelvic fractures that INDICATIONS FOR A LAPAROTOMY IN A TRAUMA PATIENT:
disrupt the stability of the pelvic ring. This usually requires a
- Haemodynamically unstable
tremendous amount of force, and often has associated
- Peritonitic abdo
injuries and fractures, Furthermore, disruption of the pelvic - Free air on erect x-ray or CT
ring often results in injuries to the adjacent pelvic venous - Left-sided diaphragm rupture
plexus, the bladder, urethra and rectum. - Free fluid with no solid organ injury on CT
- Bowel evisceration
SURGICAL PATHOLOGY - Foreign body (knife blade) impaled in abdo

DIAPHRAGMATIC INJURIES (may be blunt or penetrating)

Any penetrating wound to the left chest– below the nipple line anteriorly and
below the tip of the scapula posteriorly – with an intercostal drain in situ needs a
diagnostic laparoscopy to review whether the left diaphragm is intact. Right
diaphragm is generally not repaired if injured as it is buttressed by a large liver.
The chest has a negative pressure and the abdomen has a positive pressure and so
a hole in the diaphragm means that with breathing the abdominal contents are
“sucked up” into the chest cavity. The presence of a small defect in the diaphragm
means that blood supply is compromised – leaving bowel strangulated or necrotic.
Viscera can even rupture into the pleural cavity.

CLINICAL PRESENTATION
- Respiratory distress due to mass effect of bowel contents in chest
- Bowel sounds audible
- Feculunt drainage from ICD
CXR FINDINGS
1. Curled up nasogastric tube in the left chest
2. Absence of fundic gas/bubble in normal position
3. Elevated left diaphragm
4. Absence of sharp costophrenic angle
5. Persistent lower lobe collapse
6. Air-fluid level in the left lower chest
7. Collar sign
MANAGEMENT
1. Repair diaphragm either with open surgery or laparoscopically.
2. Open/ enlarge the defect in the diaphragm, reduce the bowel that has herniated Through, inspect herniated
bowel for perforation and treat accordingly.

23
3. Wash out the chest cavity from below.
4. Inserted a left intercostal drain under vision.
5. Repair the diaphragm with a continuous running ticron 1-0 suture.
6. Ask the Anaesthetist to recruit the lung with high PEEPs.
7. Chest physiotherapy in ward/ may require ventilator support if severe prolonged lung collapse preoperatively.
OMENTAL EVISCERATION (Penetrating trauma with omentum visible
outside the abdomen).
MANAGEMENT:
• Analgesia to decrease intra-abdominal pressure
• Single dose of antibiotics
• Wash with normal saline
• In casualty: Ligate, amputate & reduce the omentum + suture the sheath.
• Full ward diet
• Abdominal observation for 24-48hrs
• Only if abdomen becomes acute take for a laparotomy
BOWEL EVISCERATION(Surgical emergency)
MANAGEMENT: Analgesia to decrease intra-abdominal pressure + single dose antibiotics

1. Inspect bowel for ischemia (blue, congested and with sluggish contraction). If
present: under local anaesthesia IN CASUALTY lengthen incision to release the point of
constriction. Bowel should turn pink. If sheath defect is large or complex then warm
saline dressings should be placed over the bowel till theatre is available.

2. Suture any visible bowel laceration (while still eviscerated) to stop soiling, wash
bowel with normal saline, reduce back into the abdomen and prepare the patient for a
laparotomy.

3. Full trauma laparotomy searching for additional/ missed injuries. Any sutured bowel injuries done in casualty are
removed, debrided and re-sutured. Abdomen is washed. Sheath defects are repaired.
LIVER INJURIES
Most minor liver injuries are managed non operatively – keeping an eye
on Hb and clotting (aim for normal temperature, an Hb >10 and normal
clotting). Penetrating gallbladder injuries are treated with a
cholycystectomy and are not simply sutured!

Angioembolisation (intervention radiology)

Open surgery:
Figure 2: if the bleeding is coming from the hepatic parenchyma or from
• Pack with abdominal swabs and compress a retrohepatic IVC bleed we perform a Pringle manoeuvre –
• Suture liver laceration with large blunt liver needle finger/vascular clamp/elastic sling is placed around the portal triad. If it
• Pack defect with omentum (omental plug) and stops the bleeding the source is hepatic parenchyma if bleeding still
suture continuous despite Pringle manoeuvre then the source is a retrohepatic
IVC injury.
• Haemostatic agents: Surigcal / Nunit / Fibrillar
• Partial hepatectomy
SPLENIC INJURIES
• May be associated with left lower rib fractures or even diaphragm injuries.
• May be a cause for massive blood loss + instability.
• Most minor splenic injuries are managed conservatively with serial abdominal examinations and 4 hrly Hb checks.
INDICATIONS FOR A TRAUMA SPLENECTOMY (NB FOR EXAMS):
1. Failed abdominal observations (abdomen has become peritonitic) - 5 units packed cells, 6th unit book theatre and
arrange for more blood

24
 2. Elderly patient with decreased physiological reserve (earlier rather than later)
3. Young patient that participates in impact sports (potential of fracturing scar)
4. Jehovah witness patient (earlier rather than later)
5. Spleen is removed with a trauma distal pancreatectomy

If an intervention is indicated then the options are open surgery or angioembolization (intervention radiology).
Angioembolization is indicated more for the frail, poor operative (TB lungs) or elderly patient.

COMPLICATIONS OF A SPLENECTOMY:
• Atelectasis
• Pneumonia
• Iatrogenic stomach injury – especially when tying off the short gastric vessels
• Iatrogenic tail of pancreas injury which lies in the splenic hilum. May complicate with a pancreatic fistula.
• OPSI

OVERWHELMING POST SPLENECTOMY INFECTION (OPSI)

Caused by gram + encapsulated organisms:

• Streptococcus pneumoniae
• Nesseira Meningitides
• Haemophyllis influenza

Prevention: 23 polyvalent pneumovac given at time of discharge from ward.

Clinical picture of OPSI: presents as hyperacute sepsis and can occur up to 5 years post splenectomy
• Fever
• Abdominal pain
• Shock and DIC
PANCREATIC INJURIES
May be associated with 1st + 2nd lumbar fractures.
Will not be detected by an eFAST.
A normal amylase level does not exclude a pancreatic injury.
CT scan findings:
1. Pancreatic laceration
2. Peripancreatic haematoma
3. Peripancreatic fluid collections
Intraoperative findings: laceration of pancreatic parenchyma | peripancreatic soaponification indicative of a pancreatic
ductal injury.

MANAGEMENT:
- Minor injuries may be treated non-operatively, if found intraoperatively a corrugated drain is left.
- Distal pancreatic transection: distal pancreatectomy which often involves a splenectomy as part of the procedure.
- Devastating head of pancreas, CBD and duodenal injury (Gunshot wound) may need a Whipple procedure.
DUODENDAL INJURIES (Generally does not take kindly to trauma and attempts at repair)
1. Retroperitoneal and thus often presents late
2. Poor blood supply
3. Close relationship with CBD (2nd part of duodenum) + head of pancreas

Classically injured in children who fall over the handle bars of a bicycle. Kocherize (mobilize the superior, lateral and inferior
border) the duodenum and do a tension free single layer interrupted suture repair.

25
SMALL BOWEL INJURIES
• Repair vertically and not in the length of the bowel to avoid stricturing.
• Close mesenteric defects to prevent internal hernias.
• Multiple penetrating injuries in close proximity to each other: consider resecting the entire injured
segment and repair as a single anastomosis.
• Beware of too much length loss and the risk of short bowel syndrome.
COLONIC INJURIES
Indications to bring out as stoma rather than a primary repair:
• Damage control surgery (clip and drop the colon with stomas at relook laparotomy)
• Delay to surgery >6 hrs
• Very soiled abdomen
• Massive inotropes intraoperatively
• Multiple complex injuries
Always check the ureter’s which lie close to the colon during resection.
RECTAL INJURIES
EXTRA-PERITONEAL RECTAL INJURIES:
INTRAPERITONEAL RECTAL INJURIES: 1. Antibiotics
2. These injuries cannot be reached from above i.e. via a
1. Antibiotics laparotomy (lie below peritoneal reflection) or from below with
2. Laparotomy: find the injury, debride and repair. the patient in lithotomy/Lloyd Davis position.
3. If it meets the requirements for a stoma then that 3. DIVERTING SIGMOID LOOP STOMA = best. The stoma diverts
might be a safer option. Devastating injuries may need the faecal stream away from the injury preventing faeces from
an end stoma and very low Hartman’s stump. entering the hole in the rectum, soiling the ischiorectal fossa and
casuing NF. The injury heals by scarringStoma is reversed 3-6
months later after a contrast enema ecld strictures and fistulae.

26
 Pelvic Trauma

MECHANISM OF PELVIC FRACTURES: ASSOCIATED INJURIES WITH PELVIC FRACTURES:

• Anterior-posterior compression 1. Blood vessels (may cause haemodynamic

• Lateral compression instability)
• Vertical shear (often associated with 2. Nerves (sacral plexus)
vascular injuries) 3. Urinary system
4. Gynaecological system
5. Rectum
A) BLADDER INJURIES:
CLINICAL PRESENTATION:

• Blood at urethral meatus

• Inability to pass urine
• Macroscopic haematuria
• High riding prostate in males

INVESTIGATION OF CHOICE to confirm bladder injury: HIGH PRESSURE cystogram (bladder must be
distended with pressure to demonstrate a leak)

CLASSIFICATION OF BLADDER INJURIES:

EXTRAPERITONEAL RECTAL INJURIES INTRAPERITONEAL RECTAL INJURIES

Laparotomy, bivalve the balder, visualize both ureteric orifices,

Mx is drainage via a urinary catheter cannulate with a baby nasogastric tube and close with single
layer sutures.

Always two catheters ie. transuretheral catheter + suprapubic catheter. Reason: should one catheter
become blocked due to blood clots in the bladder the second serves as an alternative route of drainage
so that suture line is not placed under strain due to a full (clotted) bladder.

INVESTIGATION OF CHOICE for upper urinary system (kidney & ureter) injuries: CT - IVP with delayed
views.

B) GYNAECOLOGICAL INJURIES:
Laceration to vagina (blood on glove on PV exam) – refer to gynaecologist.

ALL PELVIC FRACTURES SHOULD HAVE BOTH A RECTAL EXAM & PV PERFORMED.

Findings on rectal exam:

• High riding prostate (membranous urethral injury)

• Blood on glove (rectal injury)
• Tone of anal sphincters (anal sphincter injury / spinal injury)
• Bony fragments protruding into rectum (rectal injury)

27
C) RECTAL INJURIES:
CLASSIFICATION OF RECTAL INJURIES: (SAME CLASSIFICATION AS BLADDER INJURIES)
INTRAPERITONEAL RECTAL INJURIES

• Antibiotics (Augmentin) & laparotomy to debride and suture rectal injury

• If complex injury, delayed presentation or a lot of soiling into the abdo cavity, consider a stoma instead
of repair and suture

EXTRAPERITONEAL RECTAL INJURIES

• Antibiotics (Augmentin) & diverting loop stoma

• These injuries cannot be located using laparotomy or via the lithotomy position. Diverting sigmoid loop
stoma allows all faecal stream to be diverted away from the sit of injury, allowing healing by scarring,
which avoids faeces from entering and contaminating the ischiorectal fossa and causing necrotizing
fasciitis

• The stoma will be reversed in 3-6 month if contrast loop-o-gram reveals no fistula / stricture

D) HEMODYNAMICALLY UNSTABLE PELVIC FRACTURES SECONDARY TO A

VASCULAR INJURY:
(Mechanical pelvic instability does
• Bone itself
not necessarily mean
• Arterial
haemodynamic instability)
• Venous

MANAGEMENT OF A PELVIC FRACTURE WITH HAEMODYNAMIC INSTABILITY:

• ATLS principles
• Intubate, ventilate, blood products, inotropes Step up algorithm (progressive)
• Pelvic binding for tamponade effect

OPTIONS FOR PELVIC BINDING:

HOSPITAL SHEET
around greater trochanters– must look like a mini-skirt and not a belt. Twist into a knot +
Elastoplast. Release every 4 hours for a few minutes to prevent skin + soft tissue necrosis.

MAST
ORTHOPAEDIC C- Military anti-shock trousers. OROS type of pants”. Gives
CLAMP pelvic compression externally. Contraindicated in
Concern of nerve diaphragm injuries as they push bowel contents into the
injury with C-clamp chest on inflation of the trousers
Seldomly done in
casualty.
REBOA

Resuscitative Endovascular Balloon Occlusion of the Aorta where balloon catheter placed via a
femoral vessel and inflated in the aorta above the pelvic fracture. Gives 40 min of arrested
arterial bleeding to get into a hybrid theatre. This device may be placed in casualty or even at
the roadside.

PRE- PERITONEAL PACKING OF PELVIS

28
In casualty or theatre, patient is cleaned and draped. Laparotomy like skin
incision is made. Cutting through skin, fat and abdominal sheath but
stopping before entering the abdomen i.e. Pre-peritoneal. The pelvic
haematoma has often dissected this plane. 6x Abdominal Swabs/ varicose
vein gauzes are rolled up and packed from the spine proceeding all the way
to the anterior with a colts 1-0 nylon approximating the skin for
tamponade effect.
ENDOVASCULAR SURGICAL
Both angiogram & venogram used to • Always the last option in the algorithm.
determine whether arterial, venous or mixed • Includes packing the pelvis with swabs and excluding a splenic
bleed. Options would be: rupture or liver laceration.
• Embolise • May need to ligate bilateral common iliac arteries and veins.
• Stent • Bilateral amputations may be the end result (Life before limb).
• Coil

29
 Vascular Trauma

PENETRATING NECK INJURY

Zone 2 neck trauma is the easiest to manage as any bleeding vessel is compressible against the vertebra
of the neck. Zones 3 & 1 are much more difficult to manage surgically. Zone 3 extends into the base of
skull which makes control of any bleeding extremely difficult. It is also a difficult area to operate with
many adjacent vital structures. Zone 1 extends into the chest, with the potential need for a sternotomy
to control any bleeding.

In TBH all penetrating neck trauma gets a CTA (to exclude vascular injuries) and a CTO (CT -
oesophogram) to exclude oesophageal injuries. In other centres in the country zone 2 neck injuries are
assessed with Doppler duplex ultrasound.

ARTERIAL VASCULAR INJURIES

Intimal Flap Mural Haematoma
Usually seen in blunt trauma, since the A bleed into the wall of the artery that can
adventitial and medial layers of the artery result from blunt and penetrating trauma.
remain intact. The injured wall initiates the The haematoma’s effect on the vessel lumen
clotting cascade that can potentially lead to is concerning as it can potentially cause
distal embolization of clots, or delayed occlusion or clot formation and distal
occlusion. The intimal flap can also act as a embolisation. With a normal lumen, in blunt
lead point for vessel dissection. This can trauma conservative management can used
result in occlusion of the vessel or one of its (anticoagulation), since the risk of secondary
occlusion is then low. If a penetrating injury,

30
 branches, and in the long term also surgical management is accessible, since as
degenerate into an aneurysm the haematoma is resorbed, there is a high
likelihood of aneurysmal change.

False aneurysm Arterial-Venous Fistula

This is a An injury in the artery and the adjacent vein
contained creates a tract through the injury for blood to
rupture, flow. This results in blood flow from artery to
where vein, bypassing the distal vascular bed.
flowing
blood is held back by surrounding tissues.
Most commonly seen in penetrating trauma, Free
where the tract of injury is closed/sutured rupture
but the underlying haematoma and feeding
vessel remains patent. These are generally
treated surgically (either endovascular of Free rupture of an arterial vessel requires
open). Without treatment the aneurysm will urgent surgical intervention to not only stop
just grow and eventually erode into the bleeding, but also restore distal
surrounding structures or skin. perfusion.

Complete occlusion
A completely occluded vessel can result from a variety of mechanisms; but in summary it
occurs when enough vessel damage has occurred to initiate thrombosis, or where blood flow
has halted for long enough to clot with stasis. These injuries require surgical repair though
bypass or re-anastomosis if distal perfusion is reliant on that vessel.
AIM TO STOP BLEEDING FIRST!

Management of exsanguinating penetrating neck injury:

• Direct compression with a hand/finger over bleed point.

• ATLS principles.
• Insert a Foley’s catheter (may need multiple) into the wound, inflate with water & tie
the distal end into a knot to prevent exsanguination via catheter. A Foley’s provides
direct compression. Be careful to not compromise perfusion to distal limbs.
• Draw crossmatch and insert a large bore iv access (not on same side as injury). starting
running emergency blood and order blood products 6:6:6:1. May need central high flow
line for central access and inotrope support.

31
 • Record any neurological deficit noted preoperatively
including limb weakness and voice hoarseness
(recurrent laryngeal nerve injury).
• May require intubation for threatened airway.
• Work on permissive hypotension principles until source
of bleeding is controlled.
• Urgent theatre access – neck exploration and prep and
drape for sternotomy.

HISTORY
Knee dislocations very high risk for popliteal artery injuries and should routinely get a CTA even
if the pulse returned after the dislocation was reduced.

Tibial plateau fractures involve significant force to fracture and thus popliteal arteries are also
at risk with these injuries.

Trans-pelvic gunshot wounds should get a CTA to exclude vascular injuries.

Trans-thoracic gunshot wounds should get a CTA & water soluble swallow or CTA+O to evaluate
the oesophagus.

EXAMINATION - Cardiovascular exam

- Pulse status of all limbs
If a patient is too unstable for imaging and has hard signs of injury then - ABI and doppler state of
surgery is the only option and delays should be avoided. However, a stable limbs
patient with a hard sign of vascular injury may benefit from preoperative - Assess distal limbs
imaging, since it allows for better surgical planning and minimises operating (embolism signs)
time. - Fee for thrills
- Listen for bruits
HARD SIGNS SOFT SIGNS
Pulsatile bleed History of bleed at scene
Rapidly expanding haematoma Low Hb & hypotension on arrival at hospital
Audible bruit, palpable thrill (AV fistula) Non-expanding haematoma
Absent distal pulse Nerve damage
Distal neurology (CVA post stab nack) >10mmHg difference between the two limbs
Proximity to a named limb

ALSO ASSESS FOR:

32
1. ASSOCIATED INJURIES: “life before limb”. It is therefore important to follow the ATLS Primary
survey completely and address all life-threatening issues before attempting limb salvage.

2. LIMB VIABILITY (using the Rutherford classification of ALI)

Length of time elapsed often determines the viability of a limb. Muscle ischemia sets in at 6-12 hrs. Once
the tissue is non -viable, the limb must to be amputated and NOT re-perfused. Reperfusion of a non-
viable limb must be avoided, since it floods the body with toxic metabolites and results in secondary
organ failure.

SIGNS OF NON-SALVAGEABLE LIMB ON CLINICAL EXAMINATION:

1. Colour – fixed skin changes (marbled appearance) implies a dead leg.
2. Motor function – rigor mortis (not being able to flex/extend the ankle) implies a dead leg.
3. Sensory function – the first and most sensitive compartment to compartment syndrome is the
antero-lateral and its sensory fallout will be the 1st web space of the foot.
4. Mangled limb (multidisciplinary team decision – trauma, orthopaedic and plastic surgery)

INTRAOPERATIVE EXAMINATION OF A MUSCLE COMPARTMENT TO DETERMINE

ITS VIABILITY:
6. Colour: if it looks like pale like chicken meat/fish meat then it is dead.
7. On stimulating a muscle with the diathermy it usually contracts violently. No contraction on
stimulation implies a dead muscle group.
8. If dead muscle is cut (1cm) with a blade it does not bleed.

ASSOCIATED BRACHIAL PLEXUS / NERVE INJURY

• Cords of brachial plexus travel around the axillary artery
• The median nerve remains in close proximity to brachial artery.

Median Nerve

Loss of sensation on palmar aspect of thumb, index and middle fingers. Inability to oppose thumb from
distal median nerve dysfunction. Injury results in Simian hand, and inability to make a circled “OK sign”:

33
Ulnar Nerve

Loss of sensation in 5th and half of fourth 4th fingers.

The ulnar nerve supplies motor function to most of the small muscles of the hand, to flexor
carpi ulnaris and to the ulnar half of flexor digitorum profundus. Weakness of the
interosseous and hypothenar muscles creates Ulnar claw appearance.

Radial Nerve

Motor: extensors of the elbow, wrist, and hand. Sensation to the

elbow, wrist, and hand joints. Injury results in Wrist drop, and
inability to open and completely.

Benediction sign

a. In median neuropathy, the Benediction sign will be present when making a fist. The
metacarpophalangeal joints and interphalangeal joints of the second and third finger
will be in extended position due to the loss of action of their flexor muscles.

b. In ulnar neuropathy, the Benediction sign will be present when opening the hand and
extending the fingers. Due to the loss of function of medial two lumbricals, the
metacarpophalangeal joints of fourth and fifth fingers will remain extended, while the
interphalangeal joints will be in a flexed position.

c. In median neuropathy, the metacarpophalangeal joints of the fourth and fifth fingers
will appear flexed due to the normal medial two lumbricals supplied by the ulnar nerve.
In ulnar neuropathy, the metacarpophalangeal joints of the fourth and fifth fingers will
be in extension.

SPECIAL INVESTIGATIONS
CT-ANGIOGRAM (CT angiogram + Oesophagram)

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Screening modality of choice for vascular trauma. Should image from the aortic arch to the Circle of
Willis.

Injury will present on the CTA as:

- Active contrast extravasation

- Pseudoaneurysm
- Early venous filling indicative of an AV fistula
- Intimal flap
- Vessel occlusion/thrombus with or without distal reconstitution

DSA (Distal subtraction angiogram)

the gold standard but is more invasive modality (4th floor intervention radiology).

Advantages Disadvantages
• Diagnostic and therapeutic (coil, stent, • Contrast nephropathy
embolize) modality.
• May cause local vessel trauma
with puncture and sheath
• If a knife blade is still in situ this is the
insertion/removal (haematoma,
investigation of choice as the blade often causes
pseudoaneurysm, dissection)
too much artefact scatter on the CTA and by
subtracting the blade, better images are
• Interventions may not have the
obtained with the option to remove the blade in
same long term patency as open
the hybrid angio suite, (treat endovascularly and
surgery
redo DSA to check for leaks)

NOTE: ANY FOREIGN BODY (KNIFE BLADE) EMBEDDED SHOULD NOT SIMPLY BE PULLED OUT. 1ST IMAGE
THE ARTERIAL SYSTEM TO SEE IF THE FOEIGN BODY TAMPONADES A SEVERED VESSEL. IF CLEARED THEN
REMOVE IN A STRAIGHT LINE AND NOT SEE-SAW/WIGGLE OUT.

CHEST X-RAY

- Exclude pneumothorax/haemothorax.
- Look for X-ray signs of mediastinal injury

INCLUDE A CT BRAIN - to evaluate for neurological sequelae of the vascular injury i.e. Large middle
cerebral artery infarct.

MANAGEMENT
Compartment syndrome: If any doubt about compartment viability or pressures, first perform the
fasciotomy and then vascular repair.

Orthopaedic fractures:

In principle the vascular repair is done before the orthopaedic ORIF/EX-FIX. However, in limbs with
severe loss of limb length, one can consider shunting the vessel temporarily, and then doing the vascular
repair after the leg has undergone fixation. Since, only after fixation can a correct length graft be
inserted. The pulse status is also re-examined after the orthopaedic procedure while the patient is still
on the theatre table.

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 OPEN SURGICAL OPTIONS IN VASCULAR INJURIES

LIGATION SHUNTING BYPASS REPAIR

Some arteries in the body can Usually performed as a A new conduit, vein or Repair of the injury is usually
simply be ligated. This is temporary measure to synthetic, is sutured above and the preferred option. It
usually done to stop or reperfuse an capillary bed below the injured (and usually exposes the injured segments
prevent bleeding, or prevent temporarily while the definitive occluded) segment of the of artery and allows for repair
the formation of a repair is prepared/performed. artery. A vein graft is used to under vision
pseudoaneurysm. divert flow from the injury.

PRINCPLES OF VASCULAR REPAIR

• 1st get proximal and distal control. This means dissect some distance away from the
injury, both below and above the injury so that clamps may be placed (+ arterial control
gained)
• Once the flow is controlled, the injury is explored and isolated. The haematoma at the
injury site is irrigated and blood clots removed.
• Repair Options
- Primary End-to-End suture repair of the injured vessel
- Interposition reverse vein graft – a vein is used as a conduit if the distance is
too far for a tension free primary repair. Great saphenous vein is harvested
from the uninjured leg and reversed i.e. the blood flow does not get
occluded by the valves.
- Synthetic graft repair is used if great saphenous vein is inadequate or has
already been used

NOTE: The presence of a vascular injury with an oesophageal or GI tract injury complicates the
repair. The presence of gut flora in the wound means there is a risk for graft sepsis. Once a
synthetic material is colonised by microbes anywhere in the body, it is impossible to remove that
biofilm with antibiotics. Eventually all septic grafts will end up needing to be removed. This
means, in the presence of sepsis, all attempts should be made for a vein graft repair (If not GSV
then deep vein/ Internal jugular vein) since it is more resistant to sepsis.

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 Compartment Syndrome

DEFINTION:
Raised interstitial pressure within a closed osteofascial compartment, causing vascular compromise
(nerve and muscle ischaemia).

AETIOLOGY:
CAUSES INSIDE THE COMPARTMENT CAUSES OUTSIDE THE COMPARTMENT
- Fractures & dislocations - Circumferential limb burns (constrictive).
- Haematomas e.g. gunshot wound through
gastrocnemius - Very tight circular Plaster of Paris (POP).
- Interosseous lines in babies e.g. baby with - Very tight closure of fascial layer on
gastroenteritis with an incorrectly placed IO tibial
suturing a limb.
line extravasating fluid into the leg’s muscle
compartment
- Snake bites (puff adder)

ANATOMY
NUMBER OF COMPARTMENTS IN THE LIMBS OTHER AREAS
• Hand – 10 in each hand. • Abdomen

• Upper forearm – 3. • Buttock

• Thigh
• Lower leg – 4 (anterior, lateral, superficial • Foot
posterior, deep posterior). Note there is no medial
• Eye (needs lateral canthus slits)
compartment in the lower leg

CLINICAL PRESENTATION OF A COMPARTMENT SYNDROME IN THE LEG:

• Pain out of proportion to the injury – most fractures are pain free if immobilized.
• Crescendo type of pain (increasing in nature). Constantly asking for morphine.
• Pain on passive flexion of the limb.
• Rock hard/wood hard calf on palpation when compared to the contralateral leg.

NOTE: THE 5 P’s (PALOR, PULSELESS, PAERESTHESIA, POIKELOTHERMIA, PARALYSIS) IS WAY TOO LATE &
SHOULD NEVER BE MENTIONED IN AN EXAM. IT MEANS YOU HAVE MISSED THE DIAGNOSIS AS IT IS A
CLINICAL DIAGNOSIS.

COMPARTMENT PRESSURES

It is possible to measure the pressure in a muscle compartment with a Stryker compartment pressure
measuring kit where a needle is inserted into the muscle and a reading is obtained electronically.

- The normal compartment pressures (depending on how athletic the patient is) in a resting
patient is 0-5 mmHg.

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 - Compartment syndrome is then defined if the compartment pressure is more than 30mmHg, or
within 30mmHg of the diastolic pressure.

GROUPS OF PATIENTS WHERE A CLINICAL DIAGNOSIS MAY BE DIFFICULT AND THUS A HIGH INDEX OF
SUSPICION IS NECESSARY IS:

• Paediatric patients
• Head injury patients (combative, confused)
• Low GCS
• Spinal injuries with neurology

MANAGEMENT OF A COMPARTMENT SYNDROME:

• ATLS principles of ABCDE.
• Remove constrictive POP/ dressing!!! Escharotomy in casualty if the cause is a constrictive
circumferential limb burn.
• Good analgesia.
• Keep the limb in a neutral position.
• 4x compartment fasciotomies ASAP.
• Watch post operatively for reperfusion injury.

4X COMPARTMENT FASCIOTOMY OF THE LOWER LEG:

• Always done in a theatre

• 2x longitudinal incisions the length of the entire lower limb – not small/short incisions! Muscle
explodes out of its facial layer and turns form a dark dusky colour to a beautiful pink (lovely to
see!)
• On the medial aspect of the leg:
- Start 1cm behind the tibial tuberosity and continue to the medial malleolus.
- BEWARE OF: Greater saphenous vein (often used in vascular bypass surgery and in
CABG’s)
• On the lateral aspect of the leg:
- Start at the fibula head and continue to the lateral malleolus
- BEWARE OF: Common fibular (peroneal) nerve which wraps around the fibular head.
- If injured it results in a foot drop (medico-legal implications)
• Wounds are always left open with either
- Shoe laces (soft elastic band woven between skin clips that can be tightened daily in the
ward)
- Normal saline dressings with a skin graft later
- Vacuum dressing

POST OPERATIVELY IN THE WARD:

• Watch for reperfusion injury (Urea and electrolytes + urine output)

• Early physiotherapy Figure 3: Shoelaces skin traction, post fasciotomy

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 Crush Syndrome

DEFINITION: Potentially life threatening syndrome resulting in breakdown of muscle

(rhabdomyolysis) & release of intracellular contents into the circulation.
2X COMPONENTS:
• Hypovolemia (commonest cause of death in the 1st 4 days)
• Toxin exposure:
1. Creatinine kinase: (3x isoforms)
• MM – muscle type
• MB – myocardium type
• BB – brain type
2. Myoglobin
3. Enzymes:
• GOT: glutamic oxalacetic transaminase
• Lactate dehydrogenase
• Aldolase
4. K+
5. Phosphate
6. Tissue thromboplastin

COMPLICATIONS OF CRUSH SYNDROME:

• Hypovolemia: 3rd space losses
• Acute renal failure: 33%
• Acidosis
• Arrhythmia + cardiac arrest (hyperkalemia & hypocalcemia)
• Compartment syndrome
• DIC (tissue thromboplastin)
• Liver dysfunction (25%) Cause: proteases causing liver inflammation

CAUSES OF RHABDOMIOLYSIS:
• Trauma (sjambok injuries /entrapment /lightning and electrocution)
• Exercise induced (marathons)/ boot camps/ status epilepticus
• Muscle ischemia: thrombus/embolus
• Toxins (snakes PUFFADDER, spiders, massive bee envenomation)
• Prolonged immobilization (lateral decubitus/ lithotomy/ prone position)
• Temp extremes (heat stroke/ Neuroleptic malignant syndrome/ malignant hyperthermia)
• Infections: classically associated with Legionella.
• Viral: HIV/Cox/EBV/CMV/herpes/varicella zoster
• Electrolyte derangement & endocrine (thyroid/DKA/HONK)
• Genetic disorders (Carnitine deficiency/Duchenne dystrophy/ LDH deficiency)
• Connective tissue disorders (poliomyositis, dermatomyositis, sjorgrens syndrome)
• Idiopathic paroxysmal myoglobin: meyr betz – recurrent myogloninuria

39
 • Drugs:
• Alcohol: immobilization & direct myotoxic effect
• Cocaine: vasospasm with ischemia, seizures, hyperpyrexia, myofibrillar damage
• Benzo & barbiturate
• Salicylates
• Neuroleptics
• Theophylline
• SSRI
• Statins: 80mg >20mg/ elderly/ female/ liver, kidney, DM)

CLINICAL PICTURE:
• Triad of weakness, myalgia and tea-coloured urine (port wine/Coca Cola)
• >50% have no myalgia or weakness
• Muscle groups frequently involved: calves and lower back
• Tram tracks classically associated with Sjambok Community Assault in RSA

CREATINE KINASE (CK):

• Rises within 12 hours of muscle injury
• Peaks at 24 to 36 hours
• T1/2=1.5 days
• Decreases 3-5 days after resolution of muscle injury
• Failure to decrease may indicate:
• Ongoing muscle injury
• Development of a compartment syndrome

MYOGLOBIN:
• T1/2 = 2-3 hours
• Levels return to normal in 6-8 hours

SPECIAL INVESTIGATIONS:
• CK >5xnormal = 1 000U/L. TBH 3 000 needs crush protocol, 5 000 gets admitted to J7.
• Myoglobinuria
• Metabolic acidosis
• Venous bicarb (venous blood gas) level:
p >20mmol/L = mild
o 17-20mmol/L = moderate
o <17mmol/L = severe

MECHANISM BY WHICH RHABDOMYOLYSIS CAUSES RENAL IMPAIRMENT:

1. HYPOVOLEMIA triggers the RAAS (Renin angiotensin aldosterone system) with

vasoconstriction.

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 2. An acid environment causes the myoglobin to precipitate with Tamm Horsfall proteins
(Uromodulin) which results in CAST FORMATION which in turn obstructs renal tubules.
3. Oxidative injury + direct toxic effect of the iron component.

MANAGEMENT OF CRUSH SYNDROME:

• ATLS principles
• Prior to extraction from an entrapped vehicle/building start running an IV fluid infusion.
• FORCED DIURESIS with 0.9% Normal Saline @250ml/hr
Aiming for: Urine output of 100-200ml/hr & urinary pH >6.5
• Alkalinize Urine (no advantage over fluid diuresis)
• HCo3 (sodabic)
• Mannitol
• Acetazolamide (carbonic anhydrase inhibitor)
Note: loop diuretics (furosemide) at high doses causes deafness & acidifies urine leading to cast
formation
• Haemodialysis
• Hyperbaric oxygen
.

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