Major Torso Trauma

Chest and abdomen

Life threatening
injuries
Blunt trauma
Penetrating trauma
Blast injury

Timing and priorities of surgery

The first priority is:
RESUSCITATION
to ensure
Adequate perfusion
`Oxygenation of all vital
organs

Intubation
Ventilation
Volume replacement
If is not successful

Immediate lifesaving surgery is

necessary:

Decompression of body
cavities:
* Tension pneumothorax
* Cardiac tamponade
* Epidural hematome
Control of exsanguinating
hemorrhage:
* Massive hemothorax
* Hemoperitoneum
* Crushed pelvis
* Whole limb amputation
* Mangled extremity

Algorithm for initial assessment, life support,

and day-1-surgery
Resuscitation
oxygenation,
perfusion

Prime survey
Basic imaging

Evaluation
Vital functions?
Response?

Secondary survey

Damage control

Scoring

Life-saving
surgery

ICU

Delayed primary
surgery

Parameters and criteria which indicate

a successful resuscitation

Endpoints of Resusciation
Stale hemodynamics
No hypoxemia, no hypercapnia
Lactate < 2 mmol/ L
Normal coagulation
Normothermia
Urinary output > 1 mL/kg/hour
No need for vasoactive or inotropic stimulation

Airway Problem
May be sudden and complete
May be insidious and partial
May be progressive and/or
recurrent.

Airway Problem
Laryngeal injury
Posterior dislocation/fracture
dislocation of sternoclavicular joint, as
fracture fragment or distal joint
component can compress the trachea
Head and maxillofacial injury in
multiple injured patient

Ventilatory problem

Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax

Circulatory problem

Massive hemothorax
Cardiac tamponade
Severe liver, spleen, and renal injury
Retroperitoneal hematome
Severe bowel and mesenterial
laceration
Pelvic fracture and dislocation

Clinical predictors of
major chest injury
Mechanism of injury
Associated head and abdominal injury
Superficial evidence :
- bruising, emphysema, swelling at the root
of the neck
Systemic evidence of major haemorrhage
Clinical findings

Life-threatening
Chest injuries

Tension pneumothorax
Hemothorax
Pulmonary contusion
Tracheobroncheal tree injuries
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diaphragmatic injury
Mediastinal traversing wounds

ABDOMINAL TRAUMA

Abdominal injury

Abdominal injury

Liver injury
Splenic injury
Renal injury
Retroperitoneal
injury
Pelvic fracture

Major Torso trauma

Management
Supplemental oxygen must be
administered to all trauma patients
ATLS Course for Physicians, ACS, 1997.

Listen to what the cell say

Arjono .D Pusponegoro, 2003.

Major Torso trauma

Endotracheal intubation
Ventilatory support
Volume replacement
Pain killer

Major Torso trauma

Surgical procedure

Chest tube insertion

Pericardiocentesis
Thoracotomy
Laparotomy

Immediate thoracotomy
Indications

Cardiac tamponade
Acute hemodynamic deterioration
Cardiac arrest in the ER
Patients with penetrating truncal trauma
Vascular injury at the thoracic outlet
Traumatic thoracotomy
Massive air leak from the chest tube

Hemothorax

Tube Thoracostomy

Stable

<1500 ml blood

>1500 ml blood
+/ or
>250 mL/h output
Tube
Thoracotomy
And water seal

Bronchial tear
Chest Injury
Mediastinal traverse
Airway
CXR
FAST
IV access

Observation

Thoracotomy

Bronchoscopy
Thoracotomy for repair if
positive

Bronchoscopy
(-) Observation
Arteriography

(+) Thoracotomy for repair

Gastrograffin swallow
+/- Esophagoscopy
Pericardial Tamponade
(left anterolateral Thoracotomy ; consider median sternotomy if due to penetrating trauma between
the nipples.)
(-)
Observation
Suspected thoracic outlet injury
Arteriography
(+)
Stent vs. operative repair
Mediastinal traverse
Unstable

Hemothorax

Bilateral anterolateral thoracotomies

Unilateral thoracotomy

Tension Pneumothorax

Tube thoracostomy

Pericardial Tamponade

Left anterolateral thoracotomy

Immediate Laparotomy
Indications
Hemodynamically unstable patients with
evidence of active intraperitoneal hemo rrhage
or peritonitis
CT evidence of active bleeding of liver, spleen or
kidney
Evidence of pneumoperitoneum
Diaphragmatic hernia
Fluid of DPL comes out of the chest tube
Abdominal evisceration

Nonoperative management
Indications
Hemodynamically stable patients
No signs of peritonitis

Hemodynamically stable
condition

Volume resuscitation RL 1 2 L
Normal vital sign
Urine output 50 mL/hr
Ideally patients do not need blood transfusion
McConnel & Trunkey : Surg.Clin.N.Am.,1990 vol 70 (3).

Nonoperative management
Risks

Missed injuries
Continued bleeding
Delayed treatment
Risks of transfusion

Hypothermia T < 35

Acidosis pH < 7.2

Coagulopathy APTT > 60

 Go

fast

Release tamponade
Gain haemostasis
Definitive repairs dictated by injury and patient

The traditional approach to combat injury care is surgical exploration

with definitive repair of all injuries
This approach is successful when there are a limited number of
injuries
Prolonged operative times and persistent bleeding lead to the lethal
triad of coagulopahty, acidosis, and hypothermia, resulting in a
mortality of 90 %

Developed from successes in rapid liver packing in early 1980.

Transition to packing of other injuries in the cold, acidotic,
exsanguinating patient.
The concept has extended to thoracic, neck, orthopaedic,
urologic and gynae trauma.
DC is a continuous process from the field to definitive care

Damage control is defined as the rapid initial control of hemorrhage and

contamination, temporary closure, resuscitation to normal physiology in the

ICU, and subsequent re-exploration and definitive repair. This approach

reduces mortality to 50 % civilian settings

Damage Control is selective

Damage Control is deliberate and calculated

surgical approach requiring mature surgical
judgement
DC should be employed at any stage the indication
for it become apparent
Make the decision early and do it

Avoid the three dark angels

1. Prehospital

2. Operative
3. ICU
4. Definitive Care

Nn. Wwk// 20 th MRS

12/11/2004

Dx masuk :
Pneumothorax bilateral + Tension
Pneumothorax S + Emfisema
Subkutis Luas
CF. Costa 2,5,6,7,8,9 (S)
posterior
MRS : 12/11/2004

Pelvic C-Clamp

After

Before

Slide presentasi Prof Dr.dr. Paul Tahalele

pada PABI II Surabaya