Major Torso Trauma

• Chest and abdomen

• Life threatening
injuries
• Blunt trauma
• Penetrating trauma
• Blast injury
 Timing and priorities of surgery
The first priority is:
Decompression of body
RESUSCITATION
cavities:
to ensure
• Adequate perfusion * Tension pneumothorax
• `Oxygenation of all vital * Cardiac tamponade
organs
* Epidural hematome
Intubation
Ventilation Control of exsanguinating
Volume replacement hemorrhage:
* Massive hemothorax
If is not successful * Hemoperitoneum
• Immediate life- * Crushed pelvis
* Whole limb amputation
saving surgery is * Mangled extremity
necessary:
 Algorithm for initial assessment, life support,
and day-1-surgery

“Prime survey” Resuscitation

Basic imaging oxygenation,
perfusion

Evaluation - Life-saving
+ •Vital functions? surgery
•Response?

? “Damage control” ICU

“Secondary survey” Scoring 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 intuba-
tion
• 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 <1500 ml blood Observation
Stable
>1500 ml blood
+/ or Thoracotomy
>250 mL/h output

Tube Bronchoscopy
Bronchial tear Thoracotomy Thoracotomy for repair if
And water seal positive
Chest Injury
Mediastinal traverse Bronchoscopy
Airway
CXR (-) Observation
FAST Arteriography
(+) Thoracotomy for repair
IV access
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 Bilateral anterolateral thoracotomies

Unstable Hemothorax 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 transfu-
sion

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