Surgery Trauma Notes - Detailed Explanation

LEFT PANEL: Airway Management

Airway Opening Maneuvers

Signs of an Airway Problem (indications to secure the airway)

• Unable to talk - loss of protective airway reflexes
• Gasping - ineffective breathing effort
• Subcutaneous emphysema - air tracking under the skin, suggests airway/lung injury
• GCS ≤ 8 - insufficient consciousness to protect own airway
• "Unresponsive/Obtundated" - same rationale as GCS ≤ 8

Definitive Airway

1. 1st step: Needle Cricothyroidotomy - only a bridge, buys 30-60 minutes of oxygenation (jet ventilation through a 14G needle through the cricothyroid membrane). Cannot adequately ventilate (CO2 builds up), so it is strictly temporary.
2. Definitive Management: Tracheostomy - surgical airway below the larynx, can remain long-term.

Per Scott-Brown's Otorhinolaryngology and Morgan & Mikhail's Clinical Anesthesiology: The Difficult Airway Society (DAS) guidelines recommend scalpel-bougie-tube cricothyroidotomy as the preferred FONA technique in "can't intubate, can't oxygenate" (CICO) situations. Needle cricothyroidotomy has been shown to be less reliable in true CICO scenarios.

MIDDLE PANEL: Tension Pneumothorax

Treatment: Needle Decompression

The shift to 5th ICS MAL for adults (from the traditional 2nd ICS MCL) is because chest wall thickness at the 2nd ICS MCL is often too great for a standard needle to reach the pleural space in modern patients.

Site: Triangle of Safety

• Pectoralis major (anterior border)
• Latissimus dorsi (LAD - posterior border)
• Serratus anterior (inferior border)
• Base: the axilla

Structures Pierced (in order, needle to pleura)

1. Skin
2. Subcutaneous (S/C) fascia
3. Serratus anterior muscle
4. Intercostal muscles - 3 layers: external intercostal, internal intercostal, innermost intercostal
5. Endothoracic fascia
6. Parietal pleura - air rushes out confirming decompression

RIGHT PANEL: Open Pneumothorax ("Sucking Chest Wound")

Management: 3-Sided Taping

• On inspiration: dressing seals against the wound, air enters via the trachea (normal path)
• On expiration: the untaped side lifts, allowing trapped air to escape from the pleural space

Per Schwartz's Principles of Surgery, 11th ed.: "Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothorax to a tension pneumothorax." Three-sided taping prevents this conversion.

Key High-Yield Points for Exams

• Jaw thrust = C-spine precaution; head tilt-chin lift = no C-spine concern
• GCS ≤ 8 = intubate
• Needle cricothyroidotomy is only a bridge (30-60 min), NOT definitive
• Tension pneumothorax needle decompression in adults: 5th ICS MAL, needle is 3.25 inch, 14G
• Structures pierced: Skin → S/C fascia → Serratus anterior → 3 layers of intercostal muscle → Endothoracic fascia → Parietal pleura
• Open pneumothorax = 3-sided tape (NOT 4-sided, which creates tension pneumothorax)

Chest Trauma - Full Explanation

TOP TABLE: Comparative Diagnosis of 4 Major Chest Injuries

• Tension PTx: Air under pressure pushes everything away - hence contralateral tracheal shift, hyperresonance (air-filled), and raised JVD from mediastinal compression of the SVC. Obstructive shock because the heart can't fill.
• Massive Hemothorax: Blood fills the pleural space - dull to percussion, decreases breath sounds. Blood loss = hypovolemic shock with low JVD. Trachea shifts away from the side with the blood.
• Consolidation/Contusion: Lung is solid/fluid-filled, so breath sounds are transmitted better (bronchial breathing = ↑↑ fremitus/breath sounds), dull to percussion. No tracheal shift. No hemodynamic shock type specifically.
• Cardiac Tamponade: Blood in the pericardium compresses the heart. Classic Beck's Triad: hypotension + ↑JVD + muffled heart sounds. No tracheal shift. Ewart sign = dullness to percussion and bronchial breathing at the left scapular angle (due to compression of left lung by the pericardial effusion).

TENSION PNEUMOTHORAX: Management

• Stable patient: Insert an ICD (Intercostal Drain / chest tube) - definitive
• Unstable patient: Needle Thoracocentesis first (emergency decompression) → then ICD

MASSIVE HEMOTHORAX: Management

• First step: ICD (chest tube) to drain and quantify blood
• Open Thoracotomy indicated if:
  • >1.5 L (1500 mL) drained immediately on insertion (initial output), OR
  • >200 cc/hr over 2-4 hours (ongoing bleeding)

Per Tintinalli's Emergency Medicine and Schwartz's Principles of Surgery: A massive hemothorax is defined as >1500 mL (or >25% of blood volume in children). Each hemithorax can hold ~40% of circulating blood volume. Indications for thoracotomy: >1500 mL immediate drainage or 150-200 mL/hr for 2-4 hours.

CONSOLIDATION/CONTUSION: Management

• Ventilation (O₂) if needed
• Threshold: PaO₂ < 60 mmHg triggers supplemental oxygen/ventilation support

CARDIAC TAMPONADE: Management

• Subxiphoid - pericardial window (diagnostic + therapeutic, can be done under local)
• Antero-lateral thoracotomy - for emergency resuscitative thoracotomy

Beck's Triad (from Miller's Orthopaedics): hypotension + muffled heart sounds + neck vein distension. Treatment: pericardiocentesis or surgical drainage.

DIAPHRAGM INJURY

• Most common (MC) at the left side - the liver protects the right hemidiaphragm
• Do NOT insert ICD in a suspected diaphragm injury - the tube could enter herniated bowel
• IOC (Investigation of Choice): Laparoscopy > CECT
  • Laparoscopy is the gold standard for diagnosis of isolated diaphragmatic injury
  • CECT is useful but has lower sensitivity

1. Rib fracture (#)
2. Diaphragm injury
3. Pelvic/Spine fracture (#)

Per Tintinalli's: "Laparoscopy is the favored approach for diagnosis of isolated traumatic diaphragmatic injury." - Tintinalli's Emergency Medicine

FLAIL CHEST

1. Analgesia - the primary treatment. Pain control allows the patient to breathe deeply and cough. Options: epidural analgesia, intercostal nerve blocks, IV opioids.
2. PPV (Positive Pressure Ventilation) if PaO₂ < 60 mmHg - the real danger in flail chest is the underlying pulmonary contusion (not the flail segment itself), which causes progressive hypoxia. PPV splints the chest wall from the inside and treats the underlying lung injury.

The key teaching point: it is the pulmonary contusion underneath the flail segment, not the paradoxical movement itself, that drives respiratory failure and the need for ventilation.

Exam High-Yield Summary

• Both tension PTx AND tamponade = obstructive shock with ↑↑ JVD - differentiate by percussion (hyperresonant vs. normal)
• Hemothorax thoracotomy triggers: >1.5 L initial or >200 cc/hr × 2-4 hrs
• Flail chest = paradoxical breathing; ventilate if PaO₂ < 60
• Diaphragm injury: left-sided, no ICD, diagnose with laparoscopy
• Bergvist Triad: Rib # + Diaphragm injury + Pelvic/Spine #

PART 1: Hypovolemic Shock (ATLS Classification)

The Four Classes of Hemorrhagic Shock

Why Each Parameter Changes

• Pulse pressure (systolic - diastolic) narrows early in shock even before systolic BP drops - this is because catecholamine-driven vasoconstriction raises diastolic BP while systolic starts to fall. It is an early and sensitive marker.
• Base deficit worsens progressively - it reflects tissue hypoperfusion and lactate accumulation. A base deficit worse than -6 is a reliable marker of significant shock.
• GCS drops in Class III/IV because cerebral perfusion falls. The brain is among the last organs protected, so any mental status change signals severe volume depletion.
• Urine output is a proxy for renal perfusion - oliguria (<0.5 mL/kg/hr) signals Class III/IV shock.

Mx of Hypovolemic Shock (ATLS Protocol)

• Minimum cannula: 18G (two large-bore peripheral IVs)
• Fluid type: 1L bolus of isotonic crystalloid (Normal Saline or Ringer's Lactate)
• Fluid volume: 1L, then reassess. If transfusion needed → go to 1:1:1 ratio:
  • 1 unit PRBC : 1 unit FFP (Fresh Frozen Plasma) : 1 unit Platelets
  • This reconstitutes "whole blood" and addresses the coagulopathy of massive hemorrhage

Per Mulholland and Greenfield's Surgery: "DCR utilizes massive transfusion protocols and early use of red cells, fresh frozen plasma, and platelets in a 1:1:1 ratio in an attempt to reconstitute whole blood."

Damage Control Resuscitation (DCR) - CRASH-2 Trial

• TXA is an antifibrinolytic - it blocks plasmin from breaking down fibrin clots, preserving the clot that is trying to form.
• CRASH-2 trial (>20,000 patients): TXA given within 1 hour reduces risk of death from bleeding by 32%; within 1-3 hours by 21%.
• If given >3 hours after injury: potentially harmful (paradoxically increases mortality).
• Dose: 1g IV bolus over 10 min, then 1g IV over 8 hours.

Per Tintinalli's Emergency Medicine: "Administration of tranexamic acid more than 3 hours after injury is less effective and potentially harmful."

PART 2: Damage Control Surgery (DCS)

Trauma Triad of Death

Metabolic Acidosis (pH < 7.2)
        ↗            ↘
Coagulopathy ←→ Hypothermia (< 35°C)

• Hypothermia impairs clotting enzyme function (most clotting factors are temperature-sensitive enzymes)
• Coagulopathy leads to continued bleeding → more volume loss → worsening acidosis
• Acidosis impairs myocardial contractility and clotting factor function → worsens coagulopathy

Per Bailey and Love's Short Practice of Surgery, 28th ed.: "The 'triad of death' - a cycle of acidosis, coagulopathy and hypothermia - may develop and result in multiorgan failure and death."

The 4 Stages of Damage Control Surgery

Stage I - Primary Emergency Surgery (OR)

• Hemorrhage control - packing, vascular ligation/shunting
• Drainage of septic contamination - control bowel spillage, close perforations temporarily
• Temporary abdominal closure - the abdomen is left open ("open abdomen") using:
  • Bogota Bag - a sterile IV bag sutured over the fascial defect (cheap, widely available)
  • Skin-only closure - skin approximated without closing fascia
  • Negative Pressure Abdominal Closure Covers (VAC/wound VAC) - preferred modern technique, removes fluid, reduces bowel edema

Stage II - ICU Resuscitation (24-48 hours)

• Warm the patient (reverse hypothermia)
• Correct coagulopathy with FFP, platelets, cryoprecipitate
• Correct acidosis with resuscitation and ventilation
• Optimize organ perfusion
• Monitor for abdominal compartment syndrome
• Patient must normalize before Stage III

Stage III - Definitive Surgery (OR)

• Full gastrointestinal repair: resection, anastomosis
• Abdominal closure - temporary or permanent depending on bowel edema
• Only performed when the triad of death is resolved

Stage IV - Abdominal Closure

• For patients in whom the abdomen was not closed during Stage III (due to ongoing bowel edema, re-exploration needed, etc.)
• Delayed primary fascial closure
• If fascial closure is not possible: planned ventral hernia with biological mesh

High-Yield Summary