Trauma (Neck, Abdomen, Liver, Spleen etc)😊

Zones of Neck Trauma

• Zone 1:
• Thoracic inlet to cricoid cartilage
• Highest mortality

• Zone 2:
• Cricoid to mandible angle
• Most exposed and commonly injured
• Surgically most accessible

• Zone 3:
• Angle of mandible to base of skull

Hard Signs of Neck Trauma

• Subcutaneous emphysema

• Air bubbling from a penetrating wound

• Expanding neck hematoma

• Hoarseness of voice

Management of Neck Trauma

• Zone 1 & 3:
• Angiography
• If angiography fails → Surgical exploration

• Zone 2:
• Any hard sign present → Surgical exploration

Thoracic Trauma

General Points

• Common in polytrauma patients

• Majority can be managed conservatively

• Most Common Cause of Death:
• Blunt thoracic trauma: Tracheo-bronchial injury
• Penetrating thoracic trauma: Pulmonary laceration (Haemothorax)

• Investigation: eFAST can be used

Rib Fractures

• Most Common Type: Thoracic trauma

• Most Common Ribs Fractured during CPR: 
• 3rd-5th ribs

• Management: Analgesia

• Rib Fracture & Injured Structures:
• 1st rib (high impact): 
• Subclavian vessels, brachial plexus, apex of lung affected
• 10th-12th ribs (floating ribs): 
• Right (liver), Left (spleen)

Flail Chest

• Definition: 
• Fracture of ≥ 2 consecutive ribs at ≥ 2 places

• Complications: Pulmonary contusion (most common cause of death)

• Clinical Feature: Paradoxical chest wall movement

• Management:
• O2 and Analgesia
• If insufficient (RR > 20 cpm/pO2 < 60 mmHg):
• IPPV
• Surgical fixation (if IPPV insufficient)

Pneumothorax

• Hemodynamic Status:
• Stable: Simple pneumothorax → ICD
• Unstable: Tension pneumothorax → Needle thoracostomy

Tension Pneumothorax

• Pathophysiology:
• Stab injury leading to open, sucking wound (one-way valve) →
• Affected lung collapsed →
• Opposite lung hyperinflated → (mins to hrs) →
• Tracheal shift (opposite side) + Heart compressed

Clinical Features:

• Increased RR

• ↓↓ cardiac output

• ↓↓ SBP,

• tachycardia

• ↑↑ JVP

• Breath sounds: Absent

• Percussion note: Hyperresonant

Differentials (vs.):

• Cardiac Tamponade:
• Increased JVP,
• muffled cardiac sounds

• Hemothorax: Dull percussion

• Simple Pneumothorax: No hemodynamic compromise

Chest X-ray: 

• Expiratory X-ray view is taken.
• Foreign Body → inspiration + expiration view taken

• Reason: Better contrast between lung and pneumothorax in expiration.

• Absent lung markings,

• mediastinal shift,

• collapsed lung

• Mediastinal shift to the opposite side.

Deep sulcus sign:

• Seen on supine X-ray of pneumothorax.

• Air going into the sulcus is making the sulcus deeper.

Pneumothorax on CT scan:

• Jet black appearance is seen.

• The visceral pleural line is seen.

Lordotic view

• AP view with shoulders touching the cassette.

• Done for:
• lung apex.
• right Middle lobe collapse (is seen better).

eFAST: 

• Loss of seashore
• Seashore sign → Normal

• M mode: Barcode/ Stratosphere sign.

• Lung point sign:
• Transition from seashore sign → barcode sign.
• Most specific sign for pneumothorax.

Emergency: 

• Needle thoracocentesis
• Adults: 5th I/C space, mid axillary line
• Children: 2nd I/C space, mid clavicular line

Definitive: 

• Tube thoracocentesis:
• Chest tube in triangle of safety
• 5th I/C space, mid axillary line
• Removal when <100 mL in 24 hours + Completely expanded lungs

• Cover sucking wound:
• 3-sided occlusive dressing (reverses flow of one-way valve)

Hemothorax

• Clinical Features:
• ↓↓ SBP, ↑↑↑ HR
• ↓↓ CO
• Percussion: Dull note
• Breath sounds: Absent

• Management: Chest tube insertion

Indications for Emergency Thoracotomy in Thoracic Trauma:

• > 1-1.5L of blood at insertion of chest tube

• > 200 cc per hour for 3 consecutive hours

• Cardiac tamponade

• Tracheobronchial injury

• Thoracic aortic injury

Chest Tubes

• Triangle of Safety:



• Apex: Base of Axilla
• Base: 5th I/C space
• Boundaries:
• Anterior axillary line
• Lateral edge of pectoralis major
• Mid axillary line posteriorly
• Lateral border of latissimus dorsi

• Structures Pierced:
• Mnemonic: SIEP into thorax
1. Skin
2. Superficial fascia
3. Deep fascia
4. Serratus anterior
5. 3 layers of Intercostal muscles
6. Endothoracic fascia
7. Parietal pleura

• Note: 
• Chest tube insertion at upper border of lower rib



• never lower border due to neurovascular bundle
• Inferior limit of Thoracentesis in Mid-axillary line
• Inferior Margin of Pleura ⇒ Inferior margin of pleura at 10th rib

Level	Costodiaphragmatic line (Inferior border of pleura)	Lower border of lung (2 ribs higher)
Mid-clavicular line	8th rib	6th rib
Mid-axillary line	10th rib	8th rib
Paravertebral line	12th rib	10th rib

• Functioning Assessment: 
• Connected to underwater seal bag
• prevents air sucked back during inspiration

• Water column movement in chest tube with every breath

• Chest tube Removal Criteria:
• Lung is expanded, Breath sounds present
• Chest X-ray normal
• Output< 100 cc in 24 hours
• Removed when patient is holding breath (at peak of inspiration)

Cardiac Tamponade

• Features: 
• Rapid blood accumulation in pericardial space,
• Most common with penetrating injury

• Clinical Features (Beck’s Triad):
• Muffled heart sounds
• Increased JVP
• Decreased BP

• Investigations: 
• FAST/eFAST (shows hypoechoic collection)

• Management:
• Emergency thoracotomy (left antero-lateral) or sternotomy:
• Evacuation of hematoma plus myocardium repair
• No role for needle pericardiocentesis in traumatic cardiac tamponade

Abdominal Trauma

Most Common Injured Organs

Mechanisms: Blunt Abdominal Trauma

• Initial: 
• FAST scan

• Hemodynamically Stable:
• IOC: CECT abdomen.

• Hemodynamically Unstable:
• IOC: FAST scan.
• If fluid positive: Immediate open exploration (Laparotomy).

FAST Scan:

• USG done in emergency room

• Purpose: 
• Detects free fluid (blood) in abdomen/pericardium.

• Probe placement :

Order	Sites
1	Epigastrium (Cardiac window)
2	Right hypochondrium
3	Left hypochondrium
4	Suprapubic region

• eFAST: 
• Adds 2 thorax sites (right + left) for pleural fluid/pneumothorax.

• Disadvantages:
• May miss < 100 cc bl4ood.
• Doesn't directly identify hollow viscus injury.
• Miss bowel injuries
• Unreliable in penetrating trauma or for retroperitoneum.

Diagnostic Peritoneal Lavage (DPL):

• Indication: When FAST is unavailable.

• Positive DPL if:
• 10 cc gross blood aspirated.
• 1 lakh RBCs/mm³.
• 500 WBCs/mm³.
• Serum amylase >175 IU/L.
• Fecal content present.

Penetrating Abdominal Trauma

Superficial to Peritoneum: 

• Local exploration and suturing.

• Ix: CECT

Peritoneal Breach (Clinically evident):

• Features: 
• Peritonitis (rebound, guarding/rigidity),
• omentum hanging out,
• bile-stained dressing.

• Embedded Object:
• Never remove in ER: Risk of increased bleeding.
• Remove in OT.

• Management: Laparotomy (no imaging needed).

Diaphragmatic Injuries

• Most Common: Left side >> Right (protected by liver)

• Clinical Features:
• Breathlessness
• Bowel sounds present in thoracic cavity
• Coiling of Ryle’s tube in thoracic cavity

• BERGVIST TRIAD
• Diaphragm injury
• Rib #
• Spine/Pelvic #

• IOC: Diagnostic Lap > CECT

• Management:
• ICD is contraindicated → Risk of bowel injury
• Laparotomy:
• Reduce bowel contents,
• Repair diaphragm (Prolene sutures)

Retroperitoneal Trauma

• Same as order for FAST scan

Splenic Trauma

• Kehr sign → Left shoulder tip pain (referred)
• Keri ulla pain

• Ballance sign → Dull note over Left Upper Quadrant

Liver trauma

Associated Injuries: 

• Left 9th-11th rib fractures,

• left lower chest bruising.

• Update
• Vascular injury (Pseudoaneurysm / Arteriovenous fistula)
• Vascular contrast →↓ in attenuation with delayed imaging
• Active bleeding (From a vascular injury)
• Vascular contrast → ↑ in size/attenuation in delayed imaging

Management by Grade:

• Grades I, II, III (Stable):
• IOC: CECT.
• Management: Conservative (monitor vitals, hematocrit, serial CT).
• If worsening/contrast blush: Angioembolization.
• If fails/unstable: Splenic preservation (splenorrhaphy).

• Grade III (Unstable) & Grades IV, V:
• IOC: FAST.
• Management: Splenectomy.

Post-Splenectomy Complications:

• Most Common: Left lower lobe atelectasis.

• Pancreatic injury (tail).

• Hematological: 
• Transient increase in all 3 cell lines for 2 weeks,
• permanent changes
• Basophilic stippling,
• Reticulocytes,
• Howel Jolly bodies
• Hypersegmented WBCs

Overwhelming Post-Splenectomy Infections (OPSI):

• Cause: Encapsulated bacteria
• Pneumococcus (m/c),
• Meningococcus,
• H. influenzae

• Risk: 
• Higher in children, occurs within first 2 years.
• Splenectomy for haematological conditions >> trauma

• High mortality

• Prevention: 
• Vaccinate 2 weeks prior to elective splenectomy, or
• Post-Op day 2 for emergency.

Liver Trauma

Liver trauma

Management

• Initial: Resuscitate first

• Stable Patient:
• Investigate:
• Imaging
• Laparoscopy
• Angiography
• Manage complications
• Discharge

• Unstable Patient:
• Surgery

Pringle’s Maneuver

Epiploic Foramen/ Foramen of Winslow Boundaries	ㅤ
Anteriorly	Lesser omentum contains • Hepatic artery • Portal vein • bile duct
Posteriorly	• IVC • Right suprarenal gland • Body of T12 vertebrae
Superiorly	Liver (Caudate lobe)
Inferiorly	1st part of duodenum

• Portal Triad Components:
• Hepatic artery
• Common bile duct
• Portal vein

• Procedure: 
• Compression of the portal triad at the foramen of Winslow for 10-15 minutes

• Significance:
• Bleeding decreases: Cause is portal vein or hepatic artery
• Temporarily controls bleeding
• Bleeding continues: Cause is hepatic veins
• Aids in identifying bleeding source

Packing

• Method: Mops used for tamponading effect

• Result: Can stop bleeding

Mesenteric Injury

Most Common Cause

• Seat belt syndrome

Types

Renal Trauma

Initial Choice (IOC) for Imaging

• IOC for renal trauma in stable: CT Urography

• IOC for renal trauma in unstable: Single shot IVU

• IOC for bladder injury: CT cystography

• IOC for urethral injury: RGU

Grades and Management

• Grade I, II, III (Stable):



• Management: CECT, monitoring
• Surgical intervention

• Grade IV:



• Urinary leak → Urinoma
• Sterile: Wait to resolve (if fails, then DJ stenting)
• Infected: Pigtail catheter
• Vascular injury →
• Pulsatile retroperitoneal hematoma →
• Non-visualization of Kidney → Surgical exploration plus repair

• Grade V:



• Management: Nephrectomy (Partial or total)

Complications of Renal Trauma

• Hematuria

• Urinoma (IVU: Dye collected outside kidney)

• Arterio-venous fistula

• Renal artery thrombosis:
• Renal infarct

• Meteorism:
• Gut distension due to pressure over splanchnic nerves
• 48-72 hours after renal trauma

Bladder Trauma

Types

Type	Extraperitoneal rupture	Intraperitoneal rupture
ㅤ	(more common)	ㅤ
Sign	molar tooth sign.	Contrast in paracolic gutters and inter-bowel loops area
Secondary to	pelvic fracture.	blunt/penetrating trauma to a full bladder.
Associated with	deep perineal hematoma.	peritonitis, syncopal attack.
Management	Foley’s/Suprapubic Catheter (SPC) for 7 days.	Laparotomy + Bladder repair in 2 layers + Foley’s/SPC.

Urethral Trauma

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ㅤ	Anterior Urethral Injury	Posterior Urethral Injury
Injured Part	• Penile/bulbar urethra	• Membranous/ prostatic urethra
Mode of Injury	• Direct trauma/straddle injury	• Secondary to pelvic fracture
Features	• Superficial perineal hematoma • around penis/scrotum	• Deep perineal hematoma, • Vermooten sign (Floating prostate)

• Contrast flows out of the urethra.

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Common Features

• Blood at tip of meatus.

• Inability to pass urine.

• Inferior layer of urogenital diaphragm (Perineal membrane)

Extravasation of Urine

Injury to:

• Membranous urethra
• Urine goes to deep perineal pouch

• Bulbar urethra
• Urine goes to superficial perineal pouch
• Causes D/T deficient anterior wall

Extravasation of Urine into:

• Scrotum

• Anterior abdominal wall
• under the scarpa's fascia and
• anterior to the pubis bone

• Upper thigh till Holden's Line
• Urine entering the thigh prevented by Fascia lata

Deep Fascia of Thigh - fascia lata

• Modifications:
1. Iliotibial Tract
2. Intermuscular septum
3. Saphenous opening

Urethral Trauma Management

 

• IOC: Retrograde Urethrography (RGU).

• Note: C/I → Foley’s catheter/MCU

Treatment

• Suspected trauma:
• Bladder full:
• Suprapubic Catheter (SPC).
• Bladder not full:
• Wait for bladder to fill.
• One trial of micturition → Fails → SPC.

Contrast X-rays

Dye studies for urethra	Route
IVP	Intravenous Pyelogram • via IV • Urethra is not seen
RGP	Retrograde Pyelogram • from down upwards • No bladder distension • view Ureter/Renal Pelvis
RGU	Retrograde Urethrogram • Preferred for anterior urethra evaluation for strictures. • e.g., urethral strictures, urethral injury/rupture.
MCU / VCUG	Micturating Cystourethrogram / Voiding cystourethrogram • 300ml contrast via foleys cannulation • Distend the bladder with contrast • IOC for 1. VUR 2. PUV

Computed Topography (CT) Scans

CT Scans	Identify	ㅤ
CT-IVU or CT-IVP.	KUB + White bone	Colourful imaging can be produced from urine.
T2 Magnetic Resonance (MR).	KUB NO White bone	Advantages 1. without contrast → Urine appears white 2. Safe in renal failure

Complications

Urethra

Length

• Female: 3-4 cm.

• Male: 18-21 cm.

Parts

• Proximal: Membranous + Prostatic Urethra.

• Distal: Penile + Bulbar Urethra.

Epithelium of Male Urethra

Part	Notes
Pre-prostatic & Prostatic urethra	Transitional epithelium
Membranous urethra	Pseudostratified / Stratified columnar
Bulbar urethra	Most distensible part
Penile (Spongy) urethra	• Proximal → Pseudostratified columnar • Distal → Stratified squamous

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Transitional epithelium / urothelium lines

• Renal pelvis and calyces,

• ureter

• urinary bladder

• pre-prostatic & prostatic parts of the urethra

---

Urethral stricture:

• DONT GET CONFUSED → long stricture like urethra near bladder/pubic bone is normal. ignore that and look for other stricture

Short

• Incomplete stricture:
• VIU (Visual Internal Urethrotomy)/
• OIU (Optical Internal Urethrotomy).

• Complete stricture:
• Excision + End-to-end anastomosis.

Long complete stricture:

• Excision + Urethroplasty with buccal mucosal graft.