Management of Acute Trauma: Samuel P. Carmichael II, Nathan T. Mowery, R. Shayn Martin, J. Wayne Meredith

17 CHAPTER
Management of Acute Trauma

Samuel P. Carmichael II, Nathan T. Mowery,
R. Shayn Martin, J. Wayne Meredith
OUTLINE
Overview and History Management of Specific Injuries
Trauma Systems Damage Control Principles
Injury Scoring Injuries to the Brain
Prehospital Trauma Care Injuries to the Spinal Cord and the Vertebral Column
Initial Assessment and Management Injury to the Maxillofacial Region
Airway Injuries to the Neck
Breathing Injuries to the Chest
Circulation Injuries to the Abdomen
Disability and Exposure Injuries to the Pelvis and Extremities
Resuscitative Thoracotomy and Endovascular Aortic Rehabilitation
Occlusion
Secondary Survey
OVERVIEW AND HISTORY is through creation of state-level divisions. Activities of the state
Injury management has been an important assignment of the committees frequently include (1) trauma system development
practicing surgeon. Throughout the history of medical care, the with the creation of triage documents, maximizing the use of lo-
treatment of trauma necessitates a mastery of diverse skills span- cal prehospital and hospital resources, (2) injury prevention ini-
ning all areas of anatomy and physiology. Because of the great tiatives, (3) maintenance of statewide trauma registries, and (4)
disease burden due to injury sustained in conflict, care for the advancement of performance improvement efforts. To standard-
trauma patient has been advanced most profoundly during war- ize the way in which trauma centers define appropriate structure,
time. Box 17.1 lists some major contributions to trauma care that process, and outcome, the COT first created in 1976 the Resources
were developed during major U.S. wars. Common themes that for the Optimal Care of the Injured Patient reference manual, now
have evolved over time include improvements in wound manage- freely and electronically accessible in its sixth edition on the Amer-
ment, resuscitation, and systems of care. Military-based program- ican College of Surgeons’ website with an associated update for
ming and funding continue to formalize this research in the de- 2019.1 The COT has also developed the National Trauma Data
velopment of care provided in austere and civilian environments. Bank (NTDB), which is the largest database of trauma ever as-
Likewise, advancements in civilian care have had a reciprocal ef- sembled, currently including more than 7 million patients from
fect within the military. Civilian training of military providers and 747 trauma centers.2 Data from the NTDB are included through-
clinical research on hemostasis and damage control techniques out this chapter to provide the reader with up-to-date information
have saved the lives of countless service personnel across the globe. on specific injuries.
Traumatology has matured into a distinct surgical field with a Beyond the COT, several other professional organizations have
unique infrastructure over the last century. After the formation of been developed with the primary goal of promoting the improve-
the American College of Surgeons in 1913, the leadership of the ment of trauma care. The American Association for the Surgery of
organization appointed a committee to report on the management Trauma (AAST) originated in 1938 and is the oldest and largest of
of fractures. Created in 1922 and chaired by Charles L. Scud- all trauma professional organizations. The AAST conducts an an-
der, the Committee on Fractures evolved in 1949 to become the nual scientific conference in September that recently has become
Committee on Trauma (COT), as the need for formal oversight the Annual Meeting of the AAST and Clinical Congress of Acute
became evident. Beginning with the publication of Early Care of Care Surgery. The maturation of this meeting reflects the inclu-
the Injured, the COT has been instrumental in advancing trauma sion of emergency general surgery as a component of acute care
care throughout the world via initiatives such as the Advanced surgery into the scientific proceedings. The AAST has also been
Trauma Life Support (ATLS) course, verification of trauma cen- the lead organization in the development of the acute care sur-
ters, and the development of trauma systems to improve access to gery training paradigm, which now includes advanced education
care. One of the ways in which the COT has been highly effective in trauma, emergency general surgery, and surgical critical care.
386
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CHAPTER 17 Management of Acute Trauma 387
BOX 17.1 Advances and discoveries in

trauma care during war. Injury severity
French and Indian War (1754–1763)

Wound contraction during healing
Primary and secondary healing
Numbers
Description of granulation tissue and epithelialization of
patients
American Revolutionary War (1775–1783)
Exhaustive therapy (bleeding, diarrhea, vomiting, salivation, sweating)
Centralization of medical care
Establishment of first medical school Minor Minor and Moderate Most severe
injuries: moderate and severe injuries:
American Civil War (1861–1865) Other injuries: injuries: Level I
acute care Levels III Level II centers
Primary amputation (vs. secondary) facilities that and centers
Use of topical antiseptic agents are part of IV centers
Whole blood transfusion trauma system
Development of specialty hospitals (eye/ear, orthopedics, hernia)

FIG. 17.1 The inclusive trauma system including the relationship be-
Extremity traction splinting
tween number of patients and severity of injury with respect to trauma
facilities. The system is designed to optimally match the level of injury
World War I (1914–1918)
with the capabilities of the medical center. (From American College of Sur-
Laparotomy for penetrating abdominal trauma
geons Committee on Trauma. Resources for the Optimal Care of the In-
Wound debridement and delayed closure jured Patient 2014. 6th ed. Chicago: American College of Surgeons; 2014.)
Early use of plasma and crystalloid
First blood bank
and Society of Trauma Nurses represent three organizations whose
World War II (1939–1945) members are part of the multidisciplinary team dedicated to im-
Guillotine amputation and delayed primary closure proving the care of the injured patient.
Exteriorization of colon injuries
Mobile surgical teams
Organ dysfunction after injury described TRAUMA SYSTEMS
At the most basic level, the primary goal of a trauma system is to
Korean War (1950–1953)
get the right patient to the right place at the right time. Outcomes in
Vascular surgery for limb salvage
trauma are highly dependent on the geography of injury, and re-
Hypovolemic shock recognition
gions that respond best have developed an organized approach to
Mobile Army Surgical Hospital (MASH) units
providing all the key elements to maximize meaningful recovery,
Vietnam War (1955–1964)
called a trauma system. The ideal trauma system includes the entire
Aeromedical transfer (helicopter)
care continuum, beginning with prevention and encompassing
Sulfamylon for burn care
prehospital care, acute hospital services, postinjury rehabilitation,
Recognition of acute respiratory distress syndrome (Da Nang lung)
and research.1
As the American healthcare system developed, trauma care was
Operation Enduring Freedom (Iraq, 2003 to Present) initially centered on the large, academic hospital. All patients were
Damage control resuscitation transported to the major trauma center, regardless of the degree of
Highly efficient trauma systems injury. Although this “exclusive” trauma system was beneficial to
Re-emergence of tourniquet use the severely injured, it resulted in the movement of a significant
number of minimally injured patients and failed to capitalize on
local resources. Data emerged, revealing similar outcomes and im-
proved measures of efficiency in minimally injured patients man-
Since program inception in 2008, there are currently 21 centers aged outside of Level 1 trauma centers.
providing training in acute care surgery in accordance with a stan- The solution was the development of a trauma system that in-
dardized curriculum. In addition to the AAST, the Eastern Associ- cludes all hospitals to address the needs of injured patients, regard-
ation for the Surgery of Trauma (EAST) and the Western Trauma less of designation (Fig. 17.1). Inclusive trauma systems identify
Association (WTA) comprise partnering academic organizations roles for facilities as a continuum, from critical access hospitals to
that promote the exchange of scientific knowledge in trauma care. the large Level I and Level II trauma centers. Guided by triage pro-
Both groups contain active multi-institutional trial committees tocols, injured patients are transported to facilities that are appropri-
and have focused on the development of practice management ate to the severity of the injuries. Although this may require transfer
guidelines, available electronically on their respective websites. of patients from smaller hospitals to trauma centers, most can re-
Furthermore, the American Trauma Society, founded in 1968, has ceive appropriate treatment within the local network. Box 17.2 lists
been an instrumental part of injury prevention and trauma sys- the common components of an inclusive trauma system that must
tems development by advocating for the injured patient and pro- be coordinated to maximize the effectiveness of care. The benefits
moting trauma-related legislation. Finally, the Orthopedic Trau- of this approach include a reduction in wastefulness of medical re-
ma Association, American Association of Neurological Surgeons, sources and allowance of appropriate care within the community.
388 SECTION III Trauma and Critical Care
BOX 17.2 Components of comprehensive TABLE 17.1 Abbreviated Injury Scale (AIS)
inclusive trauma system. body regions.
AIS FIRST DIGIT BODY REGION
• Injury prevention efforts
• Prehospital care 1 Head
• Triage 2 Face
• Communication 3 Neck
• Transportation 4 Thorax
• Acute care facilities 5 Abdomen
• Trauma center designation and verification 6 Spine
• Postacute care and rehabilitation 7 Upper extremity
• Performance improvement 8 Lower extremity
• Education and outreach 9 Unspecified
• Legislation
Despite the clear progress that has been made in national trau-
ma care over prior decades, there is no “one size fits all” approach
The genesis of trauma systems in the United States followed the and systems implementation must be tailored to locations ranging
publication of “Accidental Death and Disability: The Neglected from rural to urban geographies. In 2015, the COT developed
Disease of Modern Society,” a landmark report by the National the Needs-Based Assessment of Trauma Systems (NBATS) tool to
Academy of Sciences in 1966. Congressional legislation (National assist with designation or creation of new trauma centers within
Highway Safety Act of 1966) was subsequently passed to allocate a region. Criteria for the tool include point values assigned to six
funding for care of the injured following motor vehicle accidents. categories within a trauma service area: (1) population, (2) median
Maryland, Illinois, and Florida capitalized on this initiative, first transport time, (3) community support for a trauma center, (4)
implementing state trauma infrastructures approximately 40 years number of severely injured patients (Injury Severity Score [ISS]
ago with demonstrable reductions in mortality. A follow-up re- >15) discharged from nontrauma acute care facilities, (5) num-
port, “Injury in America: A Continuing Public Health Problem,” ber of Level 1 trauma centers, and (6) number of severely injured
was published in 1985 and revealed trauma to be an ongoing issue patients evaluated at trauma centers already in the trauma service
at the national level. The National Center for Injury Prevention area.3 Given overestimations of trauma centers required in rural
and Control was subsequently installed into the Centers for Dis- areas and underestimations of centers already existent in urban
ease Control and Prevention (CDC), and Congress legislated the areas, a second version (NBATS-2) was created in 2018 to in-
Trauma Care Systems Planning and Development Act of 1990, corporate predictive geospatial modeling. Benefits of this update
which formally addressed the need and funding of new or revised include assessment of how established center volumes and payer
state trauma systems. Further advancement occurred in 1992 mixes would be affected by the addition of a new trauma cen-
when the Health Resources and Services Administration released ter. As the current understanding of trauma systems continues to
the “Model Trauma Care System Plan,” intending to provide each evolve, tools like these will provide valuable insight into structure
state with a template for systems development. Revised in 2006 and organization unique to each region of the country.
and renamed the “Model Trauma System Planning and Evalua-
tion,” this work applied a public health disease-based approach to
trauma and identified three critical functions: (1) epidemiological
INJURY SCORING
assessment, (2) policy implementation for public protection, and Concurrent with the development of trauma systems has been the
(3) high-quality well-regulated care provision.3 need for a reliable method of injury comparison. Scoring systems
Evidence for the mortality benefit of trauma system care is pro- are typically based on either injury anatomy or the physiology
vided by two seminal publications. In 2006, the National Study demonstrated after one or more injuries are sustained. The Abbre-
on Costs and Outcomes of Trauma (NSCOT) was performed to viated Injury Scale (AIS) has been the most used anatomic system
evaluate variations in the care provided between trauma centers of injury classification since it was first described in 1971. Injuries
and nontrauma center hospitals. Supported by the National Cen- are characterized by a six-digit taxonomy that includes the body
ter for Injury Prevention and Control of the CDC, NSCOT rep- region, type of anatomic structure, and specific anatomic detail
resents one of the largest epidemiological studies ever to evaluate of the injury. Table 17.1 demonstrates the body regions and the
the care of the injured patient. Including more than 5000 patients associated first digit code within the AIS lexicon that allow users
from 69 hospitals, NSCOT established that patient outcomes are of this system to know clearly the location of the injury. Perhaps
improved when care is provided at a trauma center versus a non- of even more widespread use is the AIS severity code (frequently
trauma center. After correction for injury severity, care at a trauma described as the post-dot code). This seventh digit describes the se-
center was associated with a 20% in-hospital mortality reduction verity and potential risk of death for each injury in the AIS system.
and a 25% reduction in 1-year mortality.4 At the system level, Na- Post-dot codes range from 1 (minimal severity) to 6 (presumably
thens and colleagues5 demonstrated the value of a coordinated re- fatal) and are frequently used to cohort injuries and to compare
sponse to injury after studying 400,000 patients during a 17-year outcomes. The Association for the Advancement of Automotive
period. The study spanned a length of time (1979–1995) during Medicine frequently embarks on the rigorous process of refining
which trauma systems were established and optimized. After ac- the AIS to be sure that is stays current in its ability to accurately
counting for all possible contributors to improved outcomes, the characterize injury.
development of a trauma system resulted in an 8% reduction in The AIS represents the foundation for other scoring sys-
mortality during a 15-year period.5 tems that are better able to account for the severity of multiple
TABLE 17.2 Glasgow Coma Scale. TABLE 17.3 Revised trauma score.
Eye opening Spontaneous 4 Glasgow Coma Scale score 13–15 4
To voice 3 9–12 3
To pain 2 6–8 2
None 1 4–5 1
Verbal response Oriented 5 3 0
Confused 4 Systolic blood pressure (mm Hg) >89 4
Inappropriate 3 76–89 3
Incomprehensible 2 50–75 2
None 1 1–49 1
Motor response Obeys commands 6 0 0
Localizes pain 5 Respiratory rate (breaths/min) 10–29 4
Withdraws to pain 4 >29 3
Flexion 3 6–9 2
Extension 2 1–5 1
None 1 0 0
Total Glasgow Coma Scale 3–15 Total revised trauma score 0–12
score
because of the time-dependent nature of injury. The initial ap-

combined injuries. In 1974, Baker and colleagues presented the proach to the injured patient in the prehospital setting includes
ISS, calculated by summing the squares of the AIS severity codes four key priorities:
for the three most severely injured body regions. The ISS ranges 1. Evaluate the scene.
from 1 to 75, with severity groupings being defined as minor in- 2. Perform an initial assessment.
jury (ISS less than 9), moderate injury (ISS between 9 and 16), 3. Make triage-transport decision.
serious injury (ISS between 16 and 25), and severe injury (ISS 4. Initiate critical interventions and transport the patient.
more than 25). The ISS has been commonly used throughout the After-scene safety is ensured to protect our prehospital provid-
literature to quantify the overall burden of injury sustained by a ers. The initial assessment should be rapidly completed. The initial
patient. As a further development in anatomic injury scoring, the assessment consists of a systematic approach to immediately iden-
Organ Injury Scale (OIS) released by the AAST has been incor- tify life-threatening conditions that require urgent intervention.
porated into the more recent versions of the AIS. By introducing The ABC mnemonic guides the initial assessment, during which
the concept of injury grades, the OIS has added greater anatomic airway, breathing, and circulation are sequentially evaluated and
detail for specific organs and incorporated the ability to better de- addressed. While the spine is protected, the airway is secured and
lineate organ injury severity. This OIS severity has been validated assisted ventilation is provided as necessary. External hemorrhage
with the NTDB to optimize the associated risk of morbidity and is identified and immediately controlled while resuscitation is ini-
mortality. tiated.
In addition to anatomic scoring systems, other scales have been Emergent interventions in the field can be immediately lifesav-
developed that include the physiologic insult from injury. These ing, but optimal outcomes ultimately depend on quickly making
physiologic scoring systems are more capable of identifying the an effective triage and transport decision. Using the “load and go”
overall condition and can also better guide real-time decision- approach, all essential prehospital interventions can be provided
making. One commonly used scale of this type is the Glasgow while the patient is being transported. A recent NTDB review
Coma Scale (GCS), which reflects level of consciousness. With by Chen and colleagues7 demonstrated that trauma patients with
scores ranging from 3 to 15, the GCS is composed of a measure of prehospital hypotension (<90 mm Hg), GCS of ≤8, and nonex-
eye opening, verbal response, and motor function. The GCS, spe- tremity firearm injury have higher mortality with increasing pre-
cifically the motor score alone, has been found to be reflective of hospital time.
outcomes after traumatic brain injury (TBI).6 The Revised Trau- All prehospital teams know that immediate departure from
ma Score is another well-studied physiologic scoring system that the scene is paramount, but identifying where to go and how to
characterizes the condition of the injured patient by incorporat- get there can be more challenging. Well-defined protocols should
ing the GCS, systolic blood pressure, and respiratory rate. These guide the field triage process so that teams know immediately
scores have been of value for research purposes and have been suc- where to transport a patient. Fig. 17.2 demonstrates the Field
cessfully used to make triage decisions. To better demonstrate the Triage Decision Scheme, which was developed by the CDC and
way in which the GCS and Revised Trauma Score are designed, included in recent editions of the COT reference, Resources for the
Tables 17.2 and 17.3 reflect how these scores are calculated. Optimal Care of the Injured Patient, and the Advanced Trauma Life
Support (ATLS), 10th edition 2018 update.8 Using physiologic
PREHOSPITAL TRAUMA CARE status, mechanism of injury, and other indicators of a high-risk
patient, this tool assists in determining which patients might ben-
Immediately after a patient is injured, the trauma system engages efit from care at a trauma center. Most prehospital agencies at-
the prehospital phase of care. The goal of the prehospital system tempt to assess a patient rapidly and initiate the transport process
is to move a patient to a location capable of providing definitive while minimizing the scene time to less than 15 minutes.
injury management as quickly as possible. The prehospital team The initial clinical concern that the prehospital team must as-
plays an integral role in the management of the trauma patient sess is the airway. The “gold standard” for airway maintenance
Measure vital signs and level of consciousness

Step one
Glasgow Coma Scale 13

Systolic blood pressure (mm Hg) 90 mm Hg
Respiratory rate 10 or 29 breaths per minute
(20 in infant aged 1 year*),
or need for ventilatory support Transport to a trauma
center.† Steps one and
two attempt to identify
No the most seriously
injured patients. These
Yes
patients should be
Assess anatomy of injury transported preferentially
Step two§ to the highest level of
care within the defined
• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee trauma system.
• Chest wall instability of deformity (e.g., flail chest)
• Two or more proximal long-bone fractures
• Crushed, degloved, mangled, or pulseless extremity
• Amputation proximal to wrist or ankle
• Pelvic fractures
• Open or depressed skull fracture
• Paralysis
No
Assess mechanism of injury and evidence of high-energy impact

Step three§
• Falls
– Adults: 20 feet (one story is equal to 10 feet)
– Children¶: 10 feet or two or three times the height of the child Transport to a trauma
• High-risk auto crash center, which, depending
– Intrusion,** including roof: 12 inches occupant site; 18 inches any site on the defined trauma
Yes
– Ejection (partial or complete) from automobile system, need not be the
– Death in same passenger compartment highest level trauma
– Vehicle telemetry data consistent with a high risk of injury center.§§
• Auto versus pedestrian/bicyclist thrown, run over, or with significant (20 mph) impact††
• Motorcycle crash 20 mph
No
Assess special patient or system considerations

Step four
• Older adults¶¶
– Risk of injury/death increases after age 55 years
– SBP 110 might represent shock after age 65 years Transport to a trauma center
– Low impact mechanisms (e.g., ground level falls) might result in severe injury or hospital capable of timely
• Children and thorough evaluation and
– Should be triaged preferentially to pediatric-capable trauma centers Yes initial management of
• Anticoagulants and bleeding disorders potentially serious injuries.
– Patients with head injury are at high risk for rapid deterioration Consider consultation with
• Burns medical control.
– Without other trauma mechanism: triage to burn facility***
– With trauma mechanism: triage to trauma center***
– Time-sensitive extremity injury†††
• Pregnancy 20 weeks
• EMS§§§ provider judgment
No
Transport according to protocol¶¶¶
When in doubt, transport to a trauma center.
FIG. 17.2 Guidelines for field triage of injured patients, which were created to guide the development of
state and local EMS systems triage protocols. The guidelines use four decision steps (physiologic, anatomic,
mechanism of injury, and special considerations) to direct triage decisions within the local trauma system. (From
Sasser SM, Hunt RC, Faul M, et al. Centers for Disease Control and Prevention: Guidelines for field triage of
injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep.
2012;61:1–20.). EMS, Emergency medical services; SBP, systolic blood pressure. Source: Adapted from Ameri-
can College of Surgeons. Resources for the Optimal Care of the Injured Patient. Chicago, IL: American College
of Surgeons; 2006. Footnotes have been added to enhance understanding of field triage by persons outside
the acute injury care field. *The upper limit of respiratory rate in infants is >29 breaths per minute to maintain
a higher level of overtriage for infants. †Trauma centers are designated Level I–IV, with Level I representing
the highest level of trauma care available. §Any injury noted in steps two and three triggers a “yes” response.
¶Age <15 years. **Intrusion refers to interior compartment intrusion, as opposed to deformation, which refers
to exterior damage. ††Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with
estimated impact >20 mph with a motor vehicle. §§Local or regional protocols should be used to determine the
most appropriate level of trauma center; appropriate center need not be Level I. ¶¶Age >55 years. ***Patients
with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity and
mortality should be transferred to a burn center. If the nonburn trauma presents a greater immediate risk, the
patient may be stabilized in a trauma center and then transferred to a burn center. †††Injuries such as an open
fracture or fracture with neurovascular compromise. §§§Emergency medical services. ¶¶¶Patients who do not
meet any of the triage criteria in steps 1 through 4 should be transported to the most appropriate medical facility
as outlined in local EMS protocols.)
blood products may be the superior resuscitative fluid. In a re-

cent pragmatic, multicenter, cluster randomized trial of helicopter
transported patients in hemorrhagic shock, packed red blood cells
(PRBCs) administered with plasma conferred the greatest survival
benefit, followed by plasma alone and PRBC alone. Among pa-
tients who would have qualified to receive blood products, admin-
istration of crystalloid increased mortality incrementally by dose.10
These data are in contrast to a second randomized controlled trial
in which ground ambulance teams administered either 2 units of
plasma or crystalloid alone to hypotensive patients en route to the
hospital. No associated survival benefit was noted in the group
receiving plasma-based resuscitation.11 Ultimately, prehospital
FIG. 17.3 Example of a tourniquet. Tourniquets are commonly being plasma may be of greatest benefit to a select group of patients with
used to prevent extremity exsanguination in military and civilian prehos- moderate transfusion requirements, as the mortality-reducing ef-
pital environments. fect was not seen in patients who went on to receive ongoing mas-
sive transfusion (>10 units PRBC in initial 24 hours).12 Although
the ideal resuscitative scheme has yet to be identified, many of the
in the severely injured patient remains endotracheal intubation, challenges limiting prehospital transfusion are logistical in nature
typically using a rapid-sequence intubation (RSI) or drug-assisted (i.e., supply, storage, cost). As a result, many prehospital agencies
intubation (DAI) technique. One must always assume that the provide mixed crystalloid and product-based resuscitation prac-
patient has a spine injury and appropriately maintain spinal tices, based on local resources.
precautions. The utility of advanced airway management in the
field has been questioned, with no high-quality prospective evi- INITIAL ASSESSMENT AND MANAGEMENT
dence in the literature. Previous studies have reported that air-
way management with endotracheal intubation is associated with The mainstay of the initial approach to the injured patient is the
increased mortality when compared to noninvasive techniques. ATLS course. Since its development in 1980, ATLS has instruct-
Conversely, other investigators have suggested the benefit of ad- ed more than 1 million students of trauma in 86 countries. The
vanced prehospital airway support in a select group of patients course has provided a structured, standardized approach to the
(i.e., neurologic outcome in severe TBI).9 In reality, the decision injured patient that is based on the concept of rapidly identify-
to establish a prehospital advanced airway is a complex decision, ing and addressing life-threatening conditions during the initial
weighing the technical and physiologic consequences of RSI (i.e., assessment of the patient.8 More specifically, ATLS conveys three
cardiovascular collapse in hemorrhagic shock) against the possi- important concepts that greatly enhance the ability to manage in-
ble benefits of airway protection and oxygen delivery. As an alter- jured patients, regardless of where care is provided:
native, blind insertion supraglottic airway devices have become 1. Treat the greatest threat to life first.
common and add great value in providing a bridge to a more 2. The lack of a definitive diagnosis should not delay the applica-
definitive solution. Regardless of the approach implemented by tion of an indicated urgent treatment.
the prehospital agency, personnel need to have the ability to man- 3. An initial, detailed history is not essential to begin the evalua-
age all levels of airway compromise while transporting the patient tion of a patient with acute injuries.
to definitive care. Following a defined order of assessment, life-threatening con-
External hemorrhage control and initiation of resuscitation are ditions are immediately addressed at the time of identification.
critical needs during the prehospital phase of care. Direct pressure This initial assessment, also termed the primary survey, follows the
remains the mainstay of hemorrhage control, although tourniquet mnemonic ABCDE (Fig. 17.4):
use has become more common in the management of exsangui- Airway and cervical spine protection
nating extremity trauma. For some time, tourniquets were infre- Breathing
quently used because of concern about causing unnecessary mus- Circulation
cle and nerve injury. Driven by military experience and advances Disability or neurologic condition
in device development, tourniquets have demonstrated benefit in Exposure and environmental control
select situations. Recent publications now report a mortality ben- In addition, the primary survey can be repeated any time there
efit related to the use of prehospital tourniquets in the civilian sec- is a change in condition. Despite being simple in design, the pri-
tor. In response, the American College of Surgeons has developed mary survey offers a tool that the surgeon can trust to identify
the Stop the Bleed campaign, whereby laypeople are instructed in what life-threatening condition exists and where to direct clini-
proper application of extremity tourniquets. Prehospital agencies cal effort. The following outlines describe the performance of the
now commonly include tourniquets on their standard equipment primary survey.
lists so that they may be used when a patient with uncontrolled
extremity bleeding is encountered. Many commercial devices are Airway
available, and Fig. 17.3 illustrates an example of a tourniquet that Upon arrival of the patient to the trauma bay, the status of the
can be used in the prehospital setting. airway should be immediately assessed. Simply eliciting a verbal
As hemorrhage is the primary cause of preventable trauma response provides the most meaningful information, as the abil-
mortality, patients in shock require initiation of prehospital re- ity to speak usually indicates adequate airway protection. Patients
suscitation concurrent with efforts toward temporary hemor- who cannot speak have either mental status depression or some
rhage control. Prior studies have demonstrated that large-volume obstruction to air flow, both of which are indications for airway
crystalloid-based resuscitation is detrimental, suggesting that management. Further indicators of airway compromise include
Arrival of injured patient

in trauma bay
Establish stable airway
Unstable Endotracheal intubation
Assess airway Consider:
Elicit verbal response Airway adjuncts
Protect cervical spine Gum elastic bougie
Laryngeal airway
Surgical airway
Stable
Inadequate
Assess breathing Supplemental oxygen
*Physical exam Assisted ventilation
Pulse oximetry Consider tube thoracostomy
Adequate
2 large-caliber IVs
Patient in shock 1–2 L warm crystalloid infusion
Assess circulation-shock? Consider tension pneumothorax
Physical exam Immediate evaluation for bleeding
Vital signs (BP, HR, RR) • Physical exam
– External loss
Patient – Multiple long bones
perfusing • Chest x-ray
well – Intrathoracic loss
• Pelvic x-ray
Assess disability/neurologic condition – Retroperitoneal loss
*Glasgow Coma Scale • FAST
Moving all extremities – Intraabdominal loss
Expose entire patient Specific hemorrhage control

Prevent hypothermia • Control external loss
• Warm blankets • Tube thoracostomy
• Warm fluids • Splint/stabilize fractures
• Decrease pelvic volume-wrap
• Operating room
• Angiography
Secondary survey
Radiographic evaluation
Laboratory studies
Urinary/gastric catheters
FIG. 17.4 Algorithm for the initial assessment of the injured patient. BP, Blood pressure; FAST, focused ab-
dominal sonography in trauma; HR, heart rate; RR, respiratory rate.
noisy breathing, severe facial trauma (specifically with oropharyn- the log roll technique for all movement of the patient. During
geal blood or foreign body), and patient agitation. A determina- airway assessment and management, the anterior portion of the
tion of the adequacy of the airway, as well as the decision to obtain cervical collar can be removed to optimize exposure, but manual
improved airway control, should be completed within seconds of stabilization from an assistant should be provided when the collar
arrival. After the initial assessment, frequent reassessment for de- is not securely in place. Rigid long spine boards may be of value
terioration and the development of airway compromise is para- during transport of the patient but should be removed as soon as
mount. possible to avoid pressure-related wounds that can occur within a
Until it is ruled out with an appropriate evaluation, all injured short time.
patients should be assumed to have an injury to the vertebral col- When the airway is deemed inadequate, a definitive airway
umn and have the appropriate precautions maintained. This is of must be established. The definitive airway of choice for most in-
significant importance during the manipulation of the head and jured patients remains oral endotracheal intubation provided by
neck while the airway is being managed. Cervical spine protection RSI or DAI (ATLS 10th edition) technique. While the patient
includes the use of a hard cervical collar and the maintenance of is being prepared for intubation, adjuncts such as oropharyngeal
with benefits, risks, and limitations of the tool is upon the person
performing the procedure.
The blind insertion airway device offers an additional instru-
ment to be applied when attempts at orotracheal intubation are
unsuccessful. Devices such as the laryngeal mask airway, multi-
lumen esophageal airway (Combitube), and laryngeal tube airway
(King LT-D) are placed blindly and function by occluding the
esophagus and the posterior pharynx, allowing assisted ventilation
to pass selectively down the trachea.
As airway specialists are transitioning to advanced techniques,
preparation for a surgical airway should begin. Before physiologic
A B deterioration, a cricothyroidotomy should be performed when
other approaches have failed. The inability to maintain oxygen-
ation with a bag valve mask between intubation attempts is a rea-
sonable indication for establishment of a surgical airway. A crico-
thyroidotomy (Fig. 17.5) is performed in a three-step maneuver:
1. Spreading retraction with the nondominant hand of the tissues
overlying the cricothyroid space (typically performed from pa-
tient’s right side).
2. Keeping lateral tension on the tissues, vertically incise in the
tracheal midline, beginning at the thyroid cartilage and ex-
tending inferior to the cricoid cartilage.
3. Transversely incising the cricothyroid membrane, which can
C be palpated between the thyroid cartilage and cricoid ring, fol-
FIG. 17.5 Technique of cricothyroidotomy. The cricothyroid membrane lowed by insertion of a 6-0 endotracheal tube or tracheostomy
is identified by palpation, and a longitudinal incision is first made along appliance.
the trachea (A). The incision and dissection are continued through the It is critical that the surgeon frequently palpate the underlying
cricothyroid membrane in transverse fashion, and the cricothyroidotomy structures to guide the dissection and avoid injury to more lateral
is spread (B), allowing the passage of a tracheal tube (C). structures of the neck. Care must be taken also to avoid advanc-
ing an endotracheal tube past the carina, which is common in
and nasopharyngeal airways may assist in maintaining airway pa- these situations. Tube position is immediately confirmed with
tency during preoxygenation. The patient is provided a sedative lung auscultation and end-tidal carbon dioxide determination.
and fast-acting neuromuscular blocker, such as succinylcholine or Finally, patients suspected of having a laryngeal injury may have
rocuronium, to enhance glottic visualization maximally. Direct la- abnormal anatomy in the vicinity of the cricothyroid membrane
ryngoscopy and endotracheal intubation are performed, with care and therefore require a tracheostomy rather than a cricothyroid-
taken to avoid cervical spine motion. The appropriate position of otomy.
the tube in the trachea is confirmed by chest auscultation, end-
tidal carbon dioxide measurement, and a chest radiograph. The Breathing
presence of experienced airway personnel is critical and, particu- Following the management of the airway, breathing is evaluated
larly in trauma centers, is often an important component of the by visualizing chest movement, auscultating breath sounds, and
trauma alert system. measuring oxygen saturation. Limited respiratory effort or dys-
Common adjuncts in the difficult airway scenario include the pnea requires support of ventilation and further assessment of the
gum elastic bougie, video-assisted laryngoscopy, and blind inser- chest. Ventilatory problems may be secondary to tension pneu-
tion airway device. When the normal view of the glottis is ob- mothorax, massive hemothorax, or flail chest with pulmonary
scured, the bougie may be placed with a limited view of the vocal contusion. Tension pneumothorax may cause respiratory dete-
cords, assisting with appropriate placement the endotracheal tube. rioration but may also be in the form of unstable hemodynamics
Although prior studies have suggested improvement in success or cardiovascular collapse. It is a clinical diagnosis that should be
rates of intubation with bougie, a recent systematic review and recognized on the primary survey without need for radiographic
metaanalysis concluded that equivalent rates of first-attempt intu- confirmation before treatment. Deviation of the trachea in the
bation, intubation duration, and esophageal intubation were ob- sternal notch with unilaterally absent or diminished breath sounds
served with techniques incorporating either bougie or stylet. The and cardiopulmonary compromise should immediately suggest
authors further note that available studies comprising the analysis tension pneumothorax. Thoracic decompression should be rap-
include small sample sizes and heterogeneous types of providers idly performed with a large-bore needle or tube thoracostomy,
performing the procedure.13 depending on the availability of equipment and supplies. Massive
Several devices are now available that provide the clinician a hemothorax also requires tube thoracostomy with evacuation of
view of the upper airway anatomy that is displayed on a video blood and reexpansion of the lung. Severe pulmonary contusion
monitor. Despite this mitigation of challenges related to the angle commonly requires aggressive mechanical ventilation, often with
of the airway, recent data have yielded conflicting results as to any elevated levels of positive end-expiratory pressure. To avoid loss of
improvement in successful first-pass orotracheal intubation.14 In positive end-expiratory pressure, one should resist repeated dis-
parallel to the utility of the bougie, a device is only as functional connection from the ventilator to suction or manually ventilate
as the provider employing it. Whichever adjunct, or combination the patient, as oxygenation will only improve with an uninter-
thereof, is selected in the setting of a difficult airway, familiarity rupted circuit.
BOX 17.3 Indicators of shock in the injured TABLE 17.4 Types of shock in the injured
patient. patient.
CLASS I CLASS II CLASS III CLASS IV
• gitation or confusion
A
• Tachycardia Blood volume loss (%) <15 15–30 30–40 >40
Heart rate ─ ─/↑ ↑ ↑↑
• Tachypnea
• Diaphoresis Blood pressure ─ ─ ─/↓ ↓
Pulse pressure ─ ↓ ↓ ↓
• Cool, mottled extremities
• Weak distal pulses Respiratory rate ─ ─ ─/↑ ↑
Urine output ─ ─ ↓ ↓↓
• Decreased pulse pressure
GCS ─ ─ ↓ ↓
• Decreased urine output
• Hypotension Base deficit (mEq/L) 0 to −2 −2 to −6 −6 to −10 −10 or <
Need for transfusion Monitor Possible Yes MTP
Modified from American College of Surgeons: Committee on Trauma.
Advanced Trauma Life Support. 10th ed. Chicago: American College of
Surgeons; 2018.
Circulation
GCS, Glasgow Coma Scale; MTP, massive transfusion protocol.
The primary goal of a cardiovascular assessment is determining
the presence or absence of shock. ATLS defines shock clinically as
evidence of end-organ hypoperfusion present on physical exam.
Clinical signs of shock are demonstrated in Box 17.3. Although
hypotension is a clear indicator of cardiovascular decompensa-
tion, patients may be in shock well before the onset of hypoten-
sion, given physiologic compensatory mechanisms. By far, the
most common cause of shock in the injured patient is hemor-
rhage, and acute blood loss must be ruled out before other causes
are considered. Table 17.4 indicates the different classes of hemor- Liver
rhagic shock.
Upon recognizing the presence of shock, ATLS recommends
intravenous (IV) access with two large-bore, short, peripheral IV
catheters, an intraosseous needle, or a central venous catheter and Kidney
initial resuscitation with 1 L of warmed crystalloid solution. Pa-
tients who fail to respond appropriately to initial crystalloid resus-
citation should undergo product-based resuscitation, recognizing
that crystalloid resuscitation beyond 1.5 L increases risk of death.8
The patient must next undergo a rapid screen to identify the FIG. 17.6 Focused abdominal sonography in trauma scan demonstrat-
cause of life-threatening blood loss. There are essentially five major ing fluid in the hepatorenal space (Morison pouch). The arrow identifies
locations through which exsanguination may occur: chest, abdo- fluid (blood) between the liver and the right kidney.
men, retroperitoneum, pelvis, and/or long bone fractures. The
initial physical examination identifies sources of external blood
loss and long bone fractures. These are managed immediately with thoracotomy. Intraabdominal bleeding in the hemodynamically
direct pressure and fracture splinting, respectively. Adjunctive unstable patient warrants emergent laparotomy. Pelvic fractures
imaging to the primary survey includes x-ray examinations (i.e., require immediate management of any increased pelvic volume
chest and pelvis) and ultrasound. A chest film quickly evaluates with a binder or sheet, followed by operative or angiographic
for hemothorax and a pelvic film will identify pelvic fracture. The treatment with embolization for arterial hemorrhage.
focused abdominal sonography in trauma (FAST) scan is a rapidly
obtainable ultrasound examination that assesses for intraperito- Disability and Exposure
neal fluid. Specifically, the FAST scan assesses the hepatorenal, During the primary survey, it is valuable to make a rapid determi-
splenorenal, and pelvic spaces for fluid, which is presumed to be nation of neurologic function. Of particular importance is global-
blood in the setting of trauma. The value of the FAST scan is ly characterizing neurologic function to assess for traumatic brain
that it can be performed quickly in the trauma bay and rapidly and spinal cord injuries (SCIs). The GCS score should be deter-
repeated, if necessary. As an example, blood in the hepatorenal mined to identify deficits in eye opening, verbal ability, and mo-
space on FAST scan is demonstrated by Fig. 17.6. tor responses to potentially reflect the degree of neurologic injury.
After the initial administration of IV fluid, patients are assessed When sedating medications are required, noting the baseline level
for ongoing signs of shock. Those who respond by demonstrat- of neurologic function before administration can be beneficial.
ing a normalizing physiologic state then undergo a comprehensive The spinal cord is grossly assessed by visualizing movement of the
evaluation to identify all injuries. A common pitfall during this extremities. While neurogenic shock should always be considered
time is to continue administering IV fluids at a high rate that in the setting of hypotension with lack of extremity movement,
may mask ongoing blood loss. As mentioned previously, failure the provider must be careful in attributing shock to an SCI due to
to respond to the initial crystalloid bolus likely indicates con- the frequency of hemorrhage in the trauma patient. It is impor-
tinued bleeding, necessitating immediate intervention. Ongoing tant to recognize that classic teaching requires a cervical or high
intrathoracic bleeding after chest tube placement may require thoracic spine injury to produce neurogenic shock. If a patient is
able to move their upper extremities, the likelihood of neurogenic of placement (i.e., vascular injury, extremity ischemia, spinal cord
shock is greatly diminished. ischemia). At present, protocols for utility are developed by multi-
All clothing is removed at this time to allow for an adequate disciplinary committee and may vary by institution.17
examination, core body temperature measurement, and any re-
quired intervention. As hypothermia is one of the components in Secondary Survey
the “terrible triad of death” in trauma (coagulopathy, acidosis, hy- ATLS defines the secondary survey as a thorough head-to-toe ex-
pothermia), efforts to restore physiologic body temperature with amination and patient history. This is often performed immedi-
blankets, heating elements (i.e., Bair Hugger), elevated room/op- ately after the primary survey in patients who are stable and not
erating room (OR) temperature, and warmed resuscitative fluids requiring emergent intervention. Findings identified during the
are of critical importance. secondary survey often prompt further evaluation with imaging
or other diagnostic modalities. A more detailed neurologic evalu-
Resuscitative Thoracotomy and Endovascular Aortic ation can be completed at this time and abnormalities of the face
Occlusion and neck are identified. Posterior surfaces that are more difficult
After critical injury, select patients who experience cardiac arrest to visualize because of the cervical collar are now better examined.
may benefit from resuscitative thoracotomy (RT) in the emer- The torso is evaluated to identify evidence of pulmonary dysfunc-
gency department. First formally described by Cooley and De- tion, and findings consistent with peritonitis must be recognized.
bakey over 50 years ago for penetrating cardiovascular trauma, Seat belt marks or other superficial injury to the neck and abdo-
RT provides opportunity for four therapeutic maneuvers: release men may prompt further evaluation. The pelvis is assessed for ten-
of cardiac tamponade, temporary repair of cardiac injury, cross- derness and instability, with care taken to avoid excessive compres-
clamping the distal thoracic aorta, and management of intratho- sion. A rectal examination with a nonbloody glove to assess the
racic bleeding. Given risks to health care providers performing the position of the prostate and the presence of gross gastrointestinal
procedure and overall low rates of salvage, multiple studies have (GI) blood should be included. The extremities are manipulated
attempted to define what groups of patients should be candidates to identify open or closed deformities and distal perfusion must
for the procedure on the basis of injury mechanism and physiol- be carefully assessed. Formal evaluation consisting of distal blood
ogy at the time of presentation. Patients with the best outcomes pressure measurements with comparison to uninjured extremities
after RT are those with penetrating thoracic injuries and signs of (i.e., ankle-brachial indices) is valuable to obviate further imaging
life (reactive pupils, spontaneous ventilation, carotid pulse, mea- for major vascular injuries. The patient is rolled to evaluate the
surable or palpable blood pressure, extremity movement, or car- spine for deformity or tenderness and the long spine board should
diac electrical activity) upon reaching the emergency department. be removed. In the setting of penetrating trauma, all possible ar-
Seamon and colleagues reviewed 72 studies with 10,238 patients, eas of skin must be visualized, including those within body folds,
concluding that patients presenting after penetrating chest mecha- scalp, posterior neck, mouth, axilla, perineum, and back. Marking
nism, with and without signs of life, survived at 21.3% and 8.3%, of penetrating injuries with radiopaque markers can be extremely
respectively. By converse, blunt trauma patients presenting with helpful if subsequent imaging studies are obtained.
and without signs of life reveals 4.6% and 0.7% survival from
RT, respectively.15 Moreover, an NTDB review of 11,380 patients MANAGEMENT OF SPECIFIC INJURIES
undergoing RT revealed a 100% mortality in both blunt and pen-
etrating mechanisms for patients above the age of 57.16 In these Damage Control Principles
circumstances, bilateral thoracostomy tubes with conservative The concept of damage control arose in contrast to the tradi-
transfusion measures are likely more appropriate. RT should only tional approach of definitive injury repair at index operation. It
be performed in locations with readily available surgical support was noted that a portion of patients in the latter group would
for definitive repair of thoracic injuries if return of spontaneous develop progressive intraoperative physiologic derangement with
circulation is achieved. exacerbation of hypothermia, coagulopathy, and metabolic acido-
Resuscitative endovascular balloon occlusion of the aorta sis. Therefore, damage control emerged as a method of halting
(REBOA) has emerged over the past decade as a promising this rapid deterioration by expeditious hemostasis, including ap-
method of obtaining temporary hemorrhage control in the de- plication of packs, management of GI contamination with repair
compensating trauma patient. Although traditionally employed or resection, and temporary abdominal closure. The patient was
in the setting of abdominal aortic aneurysm repair, application then transported to the intensive care unit, and definitive recon-
for combat casualty care in noncompressible truncal hemorrhage struction could be delayed until resuscitation had been completed.
was first described during the Korean War. With the evolution of Rotondo and associates first coined the term “damage control”
this technology for rapid deployment in both military and civilian to describe this approach to management in a series of 46 pa-
sectors, REBOA is now being used in approximately 51 domestic tients operated for penetrating abdominal injury. While actual
trauma centers (median 6 cases per center per year) in the setting survival rates were similar between damage control and definitive
of advanced shock and imminent cardiac arrest. Depending on laparotomy groups (55% vs. 58%, respectively), a significant im-
the zone of trauma, REBOA is introduced through the common provement in survival was noted in a subset of patients with major
femoral artery, advanced proximal to level of injury, and inflated, vascular injury and two or more visceral injuries (77% vs. 11%,
effectively shunting blood to the heart and brain while also de- P < 0.02).18 Although damage control began as a method to man-
creasing hemorrhage. Currently, there is no high-grade evidence to age severe abdominal injuries, it is now universally used in the
support indications or the superiority of REBOA beyond standard chest, pelvis, and extremities.
care, and a comparison of technique to RT introduces both sur- Functioning in tandem with damage control surgery, massive
vival and indication biases. Deployment of this technology should transfusion protocols (MTPs) have emerged from the military ex-
only take place within a trauma system capable of managing defin- perience to reveal improved survival with transfusion of equiva-
itive surgical hemostasis and the multiple possible complications lent blood component ratios (1:1:1—plasma, platelets, PRBC) in
Prolonged R Decreased
Clot MA
propagation
Amplitude (mm)
α Angle B Anticoagulation C Platelet dysfunction
Increased
LY30
Increased
R time (min) MA
MA (mm) LY30 (%)
A Time (min) D Fibrinolysis E Hypercoagulable
FIG. 17.7 Thromboelastogram (TEG) with standard parameters and pathologies. (A) Normal TEG. (B) Delayed
clot formation with prolonged R time, treated with plasma transfusion. (C) Decreased maximum amplitude with
low platelet function, treated with platelet transfusion. (D) Elevated LY30 representing fibrinolysis, treated with
tranexamic acid. (E) Decreased R time and elevated MA representing hypercoagulable state. α Angle, Clot for-
mation/polymerization; LY30, percent amplitude decrease at 30 minutes, index of clot breakdown (lysis); MA,
maximum amplitude, clot strength; R time, time to clot formation.
order to approximate whole blood. This approach to the severely Patients who received TXA demonstrated a decrease in all-cause
injured patient was termed damage control resuscitation and de- mortality compared with placebo (14.5% vs. 16%, P = 0.0035)
fined by permissive hypotension, facilitation of rapid hemostasis and a reduction in risk of death due to bleeding (4.9% vs. 5.7%,
with early balanced transfusion, treatment of coagulopathy, and P = 0.0077). Notably, there was no observed difference in rates of
minimization of crystalloid.19 To inform initiation of MTP, the vascular occlusive events between the treatment and placebo groups
Assessment of Blood Consumption score provides a 4-point met- (1.7% vs. 2.0%, respectively). While the study had limitations due
ric (penetrating mechanism, positive FAST, arrival systolic blood to the inclusion of large numbers that did not require transfusion,
pressure 90 mm Hg, and arrival pulse >120 bpm) whereby clini- it has led to TXA becoming a standard part of the initial resuscita-
cians may request product coolers based on prehospital (if avail- tion within many prehospital systems and trauma centers.22
able) or initial vital signs. A score of at least 2 was predictive of
MTP need (75% sensitivity, 86% specificity) and a delay in initia- Injuries to the Brain
tion is associated with a 5% increase in mortality per minute.20 Even in the setting of optimal care, TBIs result in substantial
Many trauma centers have adopted this strategy and now have morbidity and account for approximately one-third of all trau-
well-defined MTPs. ma-related mortality, resulting in an annual cost of $75 billion
In certain locations, thromboelastography (TEG) provides to the U.S. economy. Those who survive often experience per-
adjunctive guidance to ongoing MTP and is rapidly obtainable manent disability that ranges from mild deficits to conditions re-
as a point-of-care metric. Originally developed approximately 70 quiring permanent total care. Outcomes faced by patients who
years ago for assessment of inherited bleeding disorders, TEG has sustain polytrauma are often dictated predominantly by the TBI.
historically been employed in liver transplant and cardiac surgery. As injury epidemiology has evolved, falls are now the most com-
In traditional analyzers, clot formation is assessed based on resis- mon cause of brain injuries, with those at the extremes of age
tance transduced from a pin in a small quantity (360 μL) of whole being most vulnerable. Although further high-quality evidence
blood. As the blood oscillates, a real-time graphic is produced, for TBI is needed, comprehensive guidelines for management are
providing a dynamic representation of clot generation. Compo- described by the Brain Trauma Foundation, American College of
nent deficiencies are illustrated as morphologic changes to the clot Surgeons, EAST, and WTA.23
cylinder (Fig. 17.7). Potential advantages to utilization of TEG- At the tissue level, brain injuries are the result of either direct
based resuscitation include rapid results for individualized com- transmission of energy, the accumulation of blood within the cra-
ponent transfusion, overall conservation of blood products, and a nium, or a combination of the two. Energy transmitted to the
survival benefit with fewer deaths due to hemorrhagic shock in the cranium and the underlying brain tissue can cause direct injury
first 6 hours after injury.21 both at the location of contact and on the contralateral side (coup
Lastly, an additional treatment adjunct to MTP in damage con- contrecoup). Further, the shearing of blood vessels at the time of
trol resuscitation is tranexamic acid (TXA). TXA is a synthetic de- injury can result in the accumulation of blood within the crani-
rivative of lysine with high affinity for lysine binding sites on plas- um. As is the case with most tissue, injured brain develops inflam-
minogen, thus inhibiting fibrinolysis via antagonism of plasmin mation and edema after trauma that can be worsened by ongoing
binding to fibrin surfaces. It has been shown previously to reduce ischemia. According to the Monro-Kellie doctrine, any increase in
the need for blood transfusion in elective surgery by one third. The the volume of intracranial contents (from extravascular blood or
Clinical Randomization of an Antifibrinolytic in Significant Hem- edema) results in an elevation of intracranial pressure (ICP) with
orrhage (CRASH)-2 trial randomized 20,211 injured patients to an associated decrease in the volume of other tissues (i.e., brain
either early administration of TXA (within 8 hours) versus placebo. parenchyma, intravascular blood, and cerebrospinal fluid [CSF]).
MONRO-KELLIE DOCTRINE
Intracranial pressure
A B
FIG. 17.9 Cranial computed tomography demonstrating (A) an epidural
hematoma and (B) a subdural hematoma. Blood appears as high-density
Intracranial volume fluid (white) identified on the right side of both images. The epidural he-
matoma is associated with a significant midline shift. Note how the sub-
FIG. 17.8 Monro-Kellie doctrine, which describes the increase in in- dural hematoma follows the contour of the underlying brain.
tracranial pressure as intracranial volume increases from hemorrhage or
edema. This relationship of pressure to volume is a result of the rigid
cranial vault that exhibits a fixed volume. be reversed or corrected, outcomes after TBI are dictated by how
well secondary injury is prevented. Thus, the mainstay of prevent-
ing secondary brain injury consists of standardized ATLS-based
As seen in Fig. 17.8, an increase in intracranial volume ultimately resuscitative efforts to facilitate normative brain physiology as
results in an exponential increase in ICP, thereby worsening ce- quickly as possible. Airway control and ventilatory support are
rebral perfusion pressure (CPP), oxygenation, and increasing the therefore critical immediately after TBI, as transient episodes of
risk of herniation. hypoxia may increase mortality up to fourfold. Although permis-
In terms of specific TBI, epidural hematomas (Fig. 17.9) typi- sive hypotension is attendant to damage control resuscitation, its
cally result from a lateral fracture of the cranium, causing bleeding role in the setting of TBI is less clear and may worsen outcomes by
from the middle meningeal artery or a nearby vessel. Classically, the exacerbating the ischemic insult. In the hypotensive polytrauma
clinical course consists of an initial loss of consciousness followed by patient with severe TBI, military guidelines recommend 3% saline
a lucid interval, during which time the hematoma expands. Upon 250 mL bolus followed by 50 to 100 mL infusion for hemody-
reaching a significant size, the epidural hematoma causes profound namic resuscitation and ICP reduction, possibly conferring sur-
neurologic deterioration. Recognition of this clinical course early vival benefit.23 Anticoagulant medications can worsen intracranial
may result in treatment with decompression, leading to a favor- bleeding and urgent reversal is indicated, based upon institutional
able outcome. Fortunately, the underlying brain tissue is often not protocols. Currently, the same paradigm cannot be applied to an-
severely injured in the setting of an epidural hematoma. This is in tiplatelet agents, as limited evidence of benefit exists to support
distinction to subdural hematomas, which commonly are associated platelet transfusion or treatment with desmopressin (DDAVP) to
with severe underlying brain tissue injury (see Fig. 17.9). Subdural mitigate intracranial hemorrhage progression. Results of the re-
hematomas are commonly caused by tearing of the bridging veins cent international CRASH-3 trial suggest a mortality benefit in
deep to the dura mater and superficial to the arachnoid mater. Al- mild-moderate but not severe TBI patients receiving TXA within
though the hematoma itself can be compressive, it is usually the un- 3 hours of injury and may be included in future protocols.25 Pa-
derlying contusion and axonal injury that predict the outcome after tients who are considered candidates for operative decompression
these injuries. Bleeding within the subarachnoid space is indicative should be immediately transferred to a facility capable of neuro-
of diffuse bleeding from brain tissue and in itself is not deleterious. surgical procedures.
Despite this, subarachnoid hemorrhages are not benign, and surveil-
lance is mandated to identify deterioration. Parenchymal contusions Evaluation
of brain tissue result from the direct transmission of energy to the A brief neurologic assessment is first performed during the prima-
cranium and underlying brain as well as from movement of the brain ry survey when the GCS score is determined. The motor function
within the rigid cranial vault, resulting in contrecoup injury. Finally, component of the GCS is the most predictive of future neurologic
diffuse axonal injury describes the phenomenon of axonal disruption outcome, with the ability to localize stimulation or follow com-
of from the neuronal body secondary to severe rotational forces. Im- mands being most favorable. An assessment of pupillary size and
aging often underestimates the severity of diffuse axonal injury, re- reactivity is also included, as this can be indicative of intracranial
vealing only punctate hemorrhages and loss of gray and white matter hypertension with impingement on the third cranial (oculomo-
differentiation. Commonly, diffuse axonal injury becomes evident tor) nerve. When possible, a neurologic examination should be
when patients demonstrate poor neurologic status in the setting of performed before the administration of any sedating or paralyzing
underwhelming imaging studies, although ultimate functional prog- agents so as not to obscure pertinent findings.
nosis remains difficult to predict based on this finding.24 Following the management of airway, breathing, and circula-
tion, patients with TBI benefit from immediate cranial imaging
Immediate Management to expedite decompression when needed. Computed tomography
Prevention of secondary brain injury, or treatment of recoverable (CT) without the administration of IV contrast is the most im-
cells (penumbra) around the traumatic focus, is the primary goal portant diagnostic study during the initial evaluation of TBI be-
of TBI management. As the primary brain injury process cannot cause it is highly sensitive for detecting intracranial hemorrhage.
Severe injury with

presumed TBI
Neurologic
examination
Urgent cranial CT
Operative Nonoperative
Craniotomy with Consider placement

hematoma drainage of ICP monitor
Measure ICP and

calculate CPP
ICP elevated or
CPP depressed
Consider:
HOB elevation ICP/CPP
Sedation/pain control adequate or
Drainage of CSF not measured
Mild hyperventilation
Mannitol
Hypertonic saline
No Refractory intracranial Continue ICU care:

hypertension? Ongoing neurologic monitoring
Continued organ system support
Yes Early nutrition
Infection prevention
PUD and DVT prophylaxis as
Consider decompressive
appropriate
craniectomy
FIG. 17.10 Algorithm for the management of traumatic brain injury (TBI). CPP, Cerebral perfusion pressure;
CSF, cerebrospinal fluid; CT, computed tomography; DVT, deep venous thrombosis; HOB, head of bed; ICP,
intracranial pressure; ICU, intensive care unit; PUD, peptic ulcer disease.
Acute blood appears as high-density fluid in various locations and Patients with severe TBI, whether managed operatively or
mass effect with lateral shifting of parenchyma is a key finding. medically, frequently require close neurologic monitoring in
Contusions within the brain with associated local or global edema the intensive care unit. ICP is often measured directly to guide
can also be visualized. In general terms, indications for primary treatment (goal <22 mm Hg), although the necessity of inva-
decompressive craniectomy include space occupying intracranial sive monitoring has been called into question by the Benchmark
hemorrhage with mass effect, recently and temporally associated Evidence from South American Trials - Treatment of Intracranial
with a decline in exam. Magnetic resonance imaging (MRI) may Pressure (BEST-TRIP) trial data, suggesting noninferiority with
be able to provide better anatomic detail, but it has no role in the serial imaging and clinical exam. In general terms, indications
initial evaluation of the brain-injured patient. for ICP monitor placement include GCS <8 with evidence of
intracranial lesion on CT. Although external ventricular drains
Management have the added ability beyond parenchymal monitors to drain
Most commonly, epidural and subdural hematomas with mass ef- CSF and treat elevated pressures, no single device has demon-
fect benefit from immediate decompression in the OR, although strated superiority over another. CPP, the difference between the
craniectomy for severe TBI is rarely needed (1.6%).23 Depressed mean arterial pressure (MAP) and ICP, is also commonly used to
skull fractures may also require early surgical intervention to man- guide severe TBI management with goal 60 to 70 mm Hg. Al-
age hemorrhage and to elevate the displaced bone. After surgery, though MAP, and consequently CPP, may be synthetically aug-
management includes ongoing surveillance of neurologic function mented by the addition of vasopressor, this does not obviate the
and avoidance of intracranial hypertension. In the setting of medi- need for maintenance of ICP within an acceptable range. While
cally recalcitrant severe intracranial hypertension, patients may be ICP and CPP are both frequently used to guide the management
considered for decompressive craniectomy, although operative sal- of patients with severe TBI, neither has been found to be supe-
vage has recently been shown only to improve mortality but not rior. A suggested approach to the management of severe TBI is
functional outcomes. presented in Fig. 17.10.
Blunt and penetrating mechanisms result in different causes of

SCI. Blunt trauma to the spine can cause cord injury through di-
rect impingement by bony aspects or secondarily by accumulation
of blood or edema. In the cervical spine, where mobility is maxi-
mal, incidence of SCI is highest (55%).8 Injuries at this level are
due to axial loading (Jefferson fracture), flexion, extension (Hang-
man’s fracture), rotation (C1 rotary subluxation), lateral force
(odontoid), and distraction. The 5th to 6th cervical vertebrae are
within the zone of greatest mobility and hence most susceptible to
injury. The thoracic and lumbar spines are more limited in mobil-
ity and mechanisms of injury to this region include axial loading
(anterior wedge compression, burst injury) and flexion-extension
(Chance fracture, fracture-dislocations). Chance fractures occur
most commonly with motor vehicle accidents and have a high
association with retroperitoneal or abdominal visceral injury (Fig.
17.11). Penetrating mechanisms either directly lacerate the spinal
cord or cause indirect injury through ischemia or vertebral frac-
ture. Lastly, patients present on occasion with a neurologic deficit
that is not explained by any vertebral column abnormality. This
SCI without radiographic abnormality can be challenging to diag-
nose and treat, given the lack of bone irregularity.
FIG. 17.11 Chance fracture on lumbar spine computed tomography Immediate Management
scan in sagittal view. Note the fracture involvement of all posterior ele-
ments as identified by the arrow. Spinal immobilization with a rigid cervical collar and a long spine
board is an immediate priority for prehospital personnel as a scene
is approached. All blunt trauma patients are assumed to have an
Persistent intracranial hypertension often requires a tiered ap- injury to the spine until a proper evaluation can exclude the diag-
proach to management. Head-of-bed elevation (or reverse Tren- nosis. High cervical SCI (C3–C5) may have immediate respirato-
delenburg), midline facial positioning, and appropriately fitted cer- ry suppression requiring airway management and ventilatory sup-
vical collars are simple techniques that can provide gravity drainage port due to paresis of the phrenic nerves. Injuries to descending
reductions in ICP. Tier 1 approaches include adequate anesthesia sympathetic pathways (T6 and above, intermediolateral column)
and analgesia, often initially in the form of short-acting continuous may affect vasomotor tone, resulting in unopposed parasympa-
infusions that are paused intermittently for evaluation of clinical thetic vagal outflow and neurogenic shock. Such patients may
exam. A ventriculostomy may be placed to drain CSF. Tier 2 in- require intravascular volume expansion and vasopressor support.
cludes hyperosmolar therapy with hypertonic saline or mannitol, The classic presentation of neurogenic shock is hypotension in the
creating a gradient to reduce edema in regions of the brain with setting of warm, well-perfused extremities in the paralyzed patient.
intact blood-brain barrier. Neuromuscular paralysis may be added Bradycardia may also be present, requiring atropine or inotropic
at this time, with consideration of repeat CT imaging. Tier 3 (res- support. This should be distinguished from spinal shock, which
cue/salvage) therapies include interventions to decrease brain me- refers to the loss of reflexes and muscle tone that occurs after SCI.
tabolism with barbiturate class medications and mild hypothermia,
neither of which have demonstrated outcome benefit. Although the Evaluation
use of significant hyperventilation has been found to be deleterious, A gross assessment of spinal cord function occurs during the pri-
increased ventilation resulting in a Pco2 between 30 and 35 mm mary survey by observing extremity movement. A more thorough
Hg results in an optimal therapeutic vasoconstriction but should evaluation of neurologic function occurs during the secondary
only be used as a bridge to initiation of additional treatment. All survey when deficits are better characterized by dermatome (sen-
available evidence continues to demonstrate that corticosteroid ad- sory level) or myotome (motor level). The ATLS 10th edition has
ministration has no role in the management of TBI. As ICP tends produced a MyATLS companion app (myatls.com) that provides
to peak at 48 to 72 hours, patients who respond to management supplemental guides for dermatomes, myotomes, and muscle
will experience a subsequent slow decrease in ICP with reductions strength assessment. This information can assist in identifying
in tissue edema and improvement in neurologic function. the location of the injury and tracking progression of symptoms,
which may affect therapeutic decisions. SCIs are characterized as
Injuries to the Spinal Cord and the Vertebral Column complete or incomplete, depending on whether all neurologic func-
With an annual incidence of approximately 12,000 cases, SCIs tion is absent below the level of injury or a portion is retained. To
are not a common cause of early mortality, although they result in assist with standardization of SCI assessment, the International
severe long-term effects and years of disability.26 Except for high Standards for Neurological Classification of Spinal Cord Injury
cervical spine injuries, mortality directly related to SCIs is low, worksheet, produced by the American Spinal Injury Association,
although the associated morbidity is substantial and currently ir- generates and impairment scale as follows: A (complete injury),
reversible. For young patients with SCI, the years of disability and B (sensory incomplete), C/D (motor incomplete), E (normal).
lost productivity can be significant. In blunt trauma patients, ver- Finally, tenderness over the injured vertebrae or the presence of
tebral column fracture alone is over 10 times more frequent than a deformity consistent with disruption of the vertebral column
SCIs. Although more frequent, mortality associated with to blunt is often indicative of associated acute fracture. Most importantly,
vertebral spine injuries is approximately 8%.2 reassessment is key whenever there is concern for new deficit. The
a severe cervical spine fracture with subluxation and anterior dis-

placement of the vertebral body. Obtaining these images, especially
in the acute setting, must be carefully considered with respect to
overall level of stability.
Management
As a general rule, the spine should be protected from further in-
jury by maintaining strict immobilization until injuries can be
ruled out. An important exception is in the setting of penetrating
trauma, where there has been no demonstrable neurologic benefit,
inclusive of patients with direct neck injury, and is associated with
increased mortality.29 Raising the head of the bed in these patients
facilitates their participation with airway management until the
appropriate setting for intubation (i.e., OR) may be provided.
Notwithstanding, early removal of the long spine board to avoid
the development of pressure wounds is extremely important. On
recognition of an SCI in the resuscitation bay, consultation with a
spine surgeon should be obtained promptly. Immediate arrange-
ments should be made for transfer when spine surgery services
are not available. To avoid delays, subsequent imaging should be
avoided unless the results will have an immediate impact on the
care provided.
Cervical SCIs with neurogenic shock require resuscitation with
volume expansion and often vasopressor/inotropic therapy. No
FIG. 17.12 Cervical spine fracture with severe anterior subluxation and agent or combination thereof has demonstrated superiority in this
compromise of the spinal canal. The arrow identifies the severe narrow- setting. Brief periods of hypotension (<90 mm Hg), not unlike
ing of the spinal canal. TBI, have been shown previously to be detrimental to long-term
outcomes in SCI; thus, shock should be treated aggressively. Such
resuscitations can be challenging in the setting of shock combina-
involvement of a spine surgeon upon identification of an injury tions (i.e., hemorrhagic and neurogenic). Following shock resolu-
may guide further evaluation and expedite operative intervention tion, questions remain as to the benefit of MAP augmentation
when it is needed. Prehospital screening tools, such as the Ca- in SCI. Although society guidelines include recommendations for
nadian C-spine Rule or the National Emergency X-Radiography MAP goals 85 to 90 mm Hg for 7 days following injury, data
Utilization Study (NEXUS), provide a means by which patients are associative in nature.26 Future studies are needed to elucidate
who have no findings on examination, demonstrate no decreased the impact of sustained pressure elevation beyond normotension
level of consciousness, and have no distracting injuries can un- upon SCI outcomes.
dergo clearance of the spine by clinical means alone. Interestingly, Corticosteroid therapy for SCI has been well studied but re-
a recent AAST multi-institutional trial revealed a negative predic- mains controversial. Several large randomized trials (National
tive value of approximately 99% with negative physical exam with Acute Spinal Cord Injury Study series) have demonstrated motor
and without attendant distracting injury. Patients older than 65 improvement at 6 weeks and 6 months following methylpredniso-
years old were included in the analysis and did not demonstrate lone administration if initiated within 8 hours of injury. Func-
increased rates of missed injury.27 tional recovery is similar whether methylprednisolone is adminis-
Imaging of the cervical, thoracic, and lumbar portions of the tered as bolus-infusion for a duration of 24 or 48 hours in patients
spine is commonly required to evaluate further for vertebral col- receiving treatment within 3 hours or 3 to 8 hours after injury,
umn injury. Although plain radiographs of the spine (anteropos- respectively. Patients treated for 48 hours demonstrated higher
terior, lateral, odontoid) are acceptable, the high-quality images, rates of severe sepsis and severe pneumonia, although mortality
superior sensitivity, and rapid availability associated with CT have was not different. Taken together, short-duration steroids remain
made this the modality of choice in most emergency departments.8 a potentially therapeutic option following SCI, although they
Because of the challenges of visualizing the cervicothoracic junction should be considered in consultation between trauma and neuro-
on plain radiography, a dedicated cervical spine CT scan is now of- surgical services.26
ten obtained during the initial imaging of the patient and may be Surgical management of spine injuries varies greatly, depend-
considered sufficient to remove a cervical collar in the intoxicated ing on the injury pattern and the associated vertebral column
patient with negative findings.28 Sagittal and coronal reconstruc- stability. In appropriate candidates, spinal cord decompression
tion of CT imaging of the spine provides better anatomic visual- has been shown in trial data to improve functional outcomes if
ization. CT imaging offers excellent evaluation of bone injuries, performed within 24 hours of injury.26 Cervical fracture-disloca-
but SCIs are poorly delineated because of limited soft tissue detail. tion injuries may benefit from the application of traction in the
Nevertheless, spinal canal compromise and soft tissue edema on emergency department to restore vertebral column alignment.
CT are highly suggestive of injury to the spinal cord. MRI is often Vertebral column injuries with instability often require operative
needed to better characterize soft tissue injury, particularly in the fixation as soon as emergent issues are managed and the patient
setting of neck pain and normal radiography, if performed within can safely undergo spine surgery. Fractures without instability
the first 72 hours of trauma, and may provide valuable informa- may require only immobilization with a hard collar or brace and
tion to guide early operative intervention. Fig. 17.12 demonstrates follow-up upright x-rays until bone healing can occur. Table 17.5
TABLE 17.5 Fractures of the vertebral column.

FRACTURE DESCRIPTION TYPICAL MANAGEMENT
C1 Jefferson fracture Disruption of C1 ring in multiple locations; blow-out of ring Stable transverse ligament: hard collar
Unstable transverse ligament: traction or surgery
Odontoid fractures Type I: tip of odontoid Type I: hard collar
Type II: through base Type II: halo vest or surgery
Type III: involves C2 body Type III: halo vest
C2 hangman fracture Bilateral C2 pedicles with spondylolisthesis Halo vest or surgery if displacement is severe
Cervical vertebral body fractures Compression or burst of vertebral body with or without Mild loss of height: hard collar
retropulsion into canal Involvement of multiple columns or presence of retropulsion
into canal: surgical stabilization
Thoracic vertebral body fractures Compression or burst of vertebral body with or without Anterior column only: TLSO
retropulsion into canal Anterior and posterior columns: surgical stabilization
Lumbar vertebral body fractures Compression or burst of vertebral body with or without Anterior column only: TLSO
retropulsion into canal Anterior and posterior columns: surgical stabilization
Chance fracture Avulsion of posterior elements of lumbar vertebrae seen with Surgical stabilization
high seat belt use
TLSO, Thoracolumbosacral orthosis.
lists the previously described and commonly encountered verte- Evaluation

bral column fractures with the associated management options. Facial injuries are first identified on physical examination, during
After stabilization of the bony spine, early involvement of physi- which the extent of soft tissue involvement is determined. The
cal therapy is the next best influence over functional outcomes eyes are grossly examined for diplopia and subjective changes in
in SCI. Although there are currently no regenerative options for visual acuity. The condition of the globe and the surrounding or-
SCI with deficits, promise has been shown in animal models with bit requires careful evaluation for rupture or extraocular muscle
stem cell treatment.26 entrapment, which requires urgent treatment. The external ear
is examined, and drainage from the ear canal is identified when
Injury to the Maxillofacial Region present. Midface and mandibular stability, proper occlusion, and
The face is commonly injured in the setting of blunt and penetrat- quality of the dentition are assessed. Forehead and midface de-
ing trauma, although these injuries are rarely life-threatening. Of formities are indicative of underlying frontal and maxillary bone
foremost concern is tissue damage that compromises the airway fractures, respectively. When fractures or soft tissue injuries are
and/or obstructs access to oral endotracheal intubation. Bleed- identified, the motor function of the face should be assessed to
ing from facial vasculature can be significant and contribute to evaluate facial nerve function.
the need for urgent airway management. Facial bone fractures are Injuries to the face often benefit from three-dimensional im-
routinely identified in this setting. One specific injury pattern in- aging with thin-cut CT to adequately visualize the facial bones.
cludes the Le Fort class of facial fractures, consisting of three varia- Sagittal and coronal as well as three-dimensional reconstructions
tions of midface disruption from the surrounding facial bones. can aid in thorough structural assessment and evaluation of deep
Significant morbidity can result from injuries to the face, partic- soft tissue. CT is indicated when severe external injury is identi-
ularly when there is associated sensory disruption from trauma fied on secondary survey or when facial abnormality is identified
to the eyes, ears, nose, or mouth. Nonetheless, poor functional on cranial CT. Imaging of the face should be performed only after
outcomes after facial trauma are often due to a concomitant TBI life-threatening injuries have been addressed, as management of
rather than the injuries themselves. facial trauma is not time sensitive in the majority of cases.
Immediate Management Management

Injury to the face requires prompt assessment and management Facial fractures and severe soft tissue injuries often benefit from
of the airway, particularly when lower face soft tissue and bone the involvement of a maxillofacial surgical consultation to assist
involvement is present. Because edema can worsen rapidly, early in management. As previously described, airway management and
intubation can be lifesaving if there is concern about airway sta- bleeding are the most immediate priorities. Direct pressure and
bility. Blood or debris in the oropharynx can greatly complicate wound closure are often effective in managing facial bleeding. In
intubation, and the application of backup airway options, in- severe cases, angiography with embolization may be necessary.
cluding a surgical approach, should be anticipated and may be Before wound closure, jagged or nonviable skin edges should be
necessary. Given the vascularity of the face, bleeding can be an debrided, followed by irrigation of the wound with sterile fluid.
immediate concern and should be managed with direct pressure, Lacerations can frequently be closed with local anesthesia using
suture ligature, and the initiation of resuscitation. Rapid closure deep absorbable sutures followed by closure of the skin with 5-0
of wounds may be required, although facial bleeding is sometime or 6-0 interrupted or running sutures. Lacerations to the lip, nose,
challenging to identify. Bleeding from deep vessels or fractured ear, and orbit are more complex in nature, and closure requires
bone may require angioembolization for definitive control to be special consideration to facilitate optimal wound healing.
obtained. Frequently, bleeding from the face is exacerbated by The management of facial fractures is infrequently required
hypothermia and coagulopathy, which should be aggressively pre- in the acute setting and can be deferred until after other inju-
vented or treated. ries are addressed. Severely depressed facial bone fractures are the
exception because these may involve the underlying brain and

require urgent reduction. Most facial fractures are repaired after
time allows for reduction in the associated soft tissue edema. Large
open wounds and fractures involving sinuses or the aerodigestive
tract may require antibiotics shortly after admission, but over-
extending this course should be avoided. When repair is appro-
priate, fractures often benefit from open reduction and internal
fixation, typically with screws and plates. Reconstructive efforts
are aimed at optimizing functional and cosmetic outcomes. This
includes the preservation of normal extraocular motor function Zone III
by addressing orbital fractures with rectus muscle involvement.
Mandibular fractures can be treated with maxillary-mandibular
fixation, although significant fracture displacement may require
internal fixation with plating.
Zone II
Injuries to the Neck
The neck contains multiple vital structures in close proximity,
complicating diagnosis, exposure, and treatment in the setting
of injury. Nevertheless, as with other areas of the body, manag-
ing neck injuries can be made reasonable by implementing an Zone I
organized approach. Trauma to the neck is relatively uncommon
but results in the highest mortality of all body regions (17%
mortality for AIS ≥3 injuries in the NTDB).2 Penetrating in- FIG. 17.13 Zones of the neck. Zone 1 extends from the thoracic inlet
juries from gunshot and stab wounds are the most common to the cricoid cartilage. Zone 2 is between the cricoid cartilage and the
mechanisms. Penetrating injuries can directly lacerate vascular angle of the mandible. Zone 3 extends from the angle of the mandible
and aerodigestive structures, resulting in substantial bleeding or to the skull base.
contamination, respectively. Although uncommon, blunt mech-
anisms can cause sudden compression, with subsequent fracture
of the larynx or trachea. Blunt pharyngeal or esophageal injuries In the immediate setting, hemorrhage is the other major con-
are even less common but can result in tissue devitalization, leak- cern after neck trauma. Injury to the carotid sheath vasculature will
age into the surrounding soft tissues with consequent abscess, often require surgical control and MTP-based resuscitation should
or mediastinitis. Blunt force to the neck may also cause injury be rapidly and concurrently initiated when needed. Direct pressure
to the carotid or vertebral arteries. These blunt cerebrovascular with either finger or Foley balloon effectively manages most bleed-
injuries (BCVIs) result from seat belt compression or severe flex- ing from the neck during transport to the OR. Similar to patients
ion-extension mechanisms. BCVI severity ranges from intimal with significant aerodigestive injury, patients requiring surgical in-
tears (Grade I), with or without thrombosis, to full-thickness tervention for bleeding in the neck are best served by airway man-
injury with pseudoaneurysm formation (Grade III) and tran- agement in the OR immediately prior to treatment of hemorrhage.
section (Grade V). The morbidity associated with BCVI is pre-
dominantly due to ischemic stroke from acute thromboembolic Evaluation
phenomenon. Patients with hemodynamic instability and/or hard signs of vascu-
lar or aerodigestive injury (i.e., airway compromise, massive sub-
Immediate Management cutaneous emphysema, air bubbles necessitating through wound,
Neck injuries often require rapid intervention due to the vulner- expanding or pulsatile hematoma, active bleeding, neurologic
ability of the contained vital structures. In keeping with ATLS, deficit, hematemesis) should be taken immediately to the OR for
highest priority concern is the establishment of a secure airway. surgical exploration.30 Stable patients may undergo further evalu-
Deterioration can occur rapidly, necessitating timely recognition ation for neck injury with thin-slice multidetector CT angiogra-
and definitive care. Direct injury to the larynx or trachea is the phy (MDCTA) imaging.
most common cause of airway compromise and presents one of Penetrating injuries are classically characterized by anatomic lo-
the most challenging circumstances to airway management. Ex- cation and surgical accessibility (Fig. 17.13). Zone I extends from
panding neck hematomas quickly compress the upper airway, the thoracic inlet to the cricoid cartilage and contains large vascular
leading to inadequate ventilation. Immediate intubation should structures as well as the trachea and esophagus. Stretching from the
occur in the setting of an expanding neck hematoma or if there is cricoid cartilage to the angle of the mandible, zone II is the most
concern for impending airway compromise. Importantly, patients accessible surgically and contains the carotid and vertebral arteries,
who are maintaining their own airway should have a planned jugular veins, and structures of the aerodigestive tract. Zone III in-
approach to airway management that may include intubation cludes the neck between the angle of the mandible and the base of
or awake tracheostomy in the OR. Attempted intubation could the skull. Structures within zone III include blood vessels that are
worsen a tenuous situation and should not be performed without difficult to expose surgically. Although zone II injuries with physical
a well-developed backup plan. A loss of airway requires emergent exam are indicators for depth of injury (i.e., violation of platysma)
intervention, including performance of a cricothyroidotomy or traditionally mandated operative exploration, it has since been recog-
tracheotomy. The surgical airway of choice for an upper airway nized that only those patients with hard signs of vascular or aerodi-
injury is a tracheotomy because injury to the larynx may make gestive injury require immediate operation while the remainder may
cricothyroidotomy ineffective. undergo radiographic assessment (so-called “no-zone” approach).
Management
BOX 17.4 Indicators of high risk for blunt As previously mentioned, hard signs of vascular or aerodigestive
cerebrovascular injury. injury require immediate neck exploration, as outlined in the
WTA 2013 guidelines (Fig. 17.14). Most commonly, structures
Signs and Symptoms
of the neck are exposed by an incision along the anterior border of
Expanding neck hematoma
the sternocleidomastoid on the side of the injury. A collar incision
Arterial hemorrhage from neck, nose, or mouth
may be more versatile, especially if a bilateral neck exploration is
Focal neurologic deficit
required. The platysma is divided to expose the anterior border of
Cervical bruit (patient <50 years old)
the sternocleidomastoid, which is dissected from the underlying
Stroke on CT or MRI
tissue to expose the carotid sheath (common carotid artery, va-
Neurologic deficit unexplained by CT findings
gus nerve, internal jugular vein). An injured internal jugular vein
Risk Factors may require direct repair with Prolene suture or ligation, if closure
Severe midface fracture, Le Fort II or III is not possible. The facial vein is identified entering the anterior
Basilar skull fracture involving the carotid canal surface of the internal jugular vein. Ligation and division of the
Diffuse axonal injury and GCS score ≤6 facial vein allow the deep structures of the vascular compartment
Significant cervical spine fracture or ligamentous injury to be exposed. With the internal jugular vein retracted laterally,
Significant soft tissue injury to anterior neck (i.e., seat belt mark) the carotid artery and vagus nerves are exposed. If necessary, the
Near-hanging with anoxia carotid artery may be controlled proximally and distally. Care
should be taken to avoid injury to either the vagus or hypoglossal
CT, Computed tomography; GCS, Glasgow Coma Scale; MRI, magnetic nerves, which lie adjacent to and superiorly crossing the carotid
resonance imaging. artery, respectively. Short-segment carotid artery injuries should
be repaired with either simple closure or end-to-end anastomosis.
More extensive injuries require reconstruction with a synthetic
CT angiographic evaluation of the neck, performed in the graft or autologous vein. In damage control situations, the ca-
emergency department, has become readily available and de- rotid artery can be shunted or ligated in extreme circumstances,
creased the rate of negative neck explorations for penetrating in- although cerebral blood flow may be compromised.
jury. A prospective multicenter study (n = 453) revealed that, on Exploration of the trachea and esophagus is achieved via lateral
40 or 64 multislice CT scanners, the sensitivity and specificity retraction of the carotid artery. Dissection is continued medially
for penetrating vascular or aerodigestive injuries were 100% and and the esophagus is identified immediately anterior to the cervi-
97.5%, respectively. Specificity was depreciated by two patients cal vertebral bodies, detection of which may be aided by nasogas-
with falsely positive vascular imaging, resulting in a negative ex- tric tube placement. Injuries to the esophagus should be debrided
ploration and catheter angiography, and three patients with air to expose the entirety of the mucosal perforation. Closure of the
tracking concerning for aerodigestive injury subsequently ruled esophageal wall can be in one or preferably two layers (mucosal/
out endoscopically. Versus evaluation of the neck by anatomic muscular) and wide drainage is important. Covering the esopha-
zones, MDCTA in appropriate patients allows for evaluation of geal repair with vascularized muscle pedicle, commonly sterno-
the neck as a unit and obviates the need for additional invasive cleidomastoid, may be highly beneficial, particularly in the set-
testing (i.e., bronchoscopy, rigid/flexible endoscopy, esophagram, ting of adjacent tracheal or vascular repair. Massive tissue loss or
digital subtraction angiography [DSA]) in many cases. Only those delayed presentation poses a significant challenge and may require
patients with equivocal MDCTA, as may occur with retained bal- esophageal diversion with esophagostomy followed by delayed
listic, require additional selective diagnostics. Standard DSA does reconstruction. Tracheal lacerations can be primarily closed with
not suffer from scatter limitation and may provide added informa- absorbable suture if the injury is small and will approximate in a
tion in this setting.31 tension-free fashion. Large tracheal defects may require resection
Blunt trauma to the neck often manifests in the form of and anastomosis, although some anterior tracheal injuries can be
BCVI. The improved technology of MDCTA has cast light managed by creating a tracheostomy through the injury. After the
upon this entity, which is now recognized as a major source tracheostomy tract matures, the tube can be removed, and closure
of morbidity. Initially considered uncommon, the emergence usually occurs spontaneously.
of high-risk screening criteria and improved detection have led As the evaluation of BCVI has evolved, treatment has also be-
to a significant increase in the diagnosis of BCVI. DSA subse- come more advanced. To decrease the risk of thromboembolic
quently confirmed BCVI in 30% of this high-risk cohort. Com- stroke (37%–4.8%), anticoagulation or antiplatelet therapy is ini-
monly referred to as the Denver criteria, these risk factors were tiated, although neither has demonstrated superiority. Endovascu-
used to screen patients and to prompt further evaluation (Box lar stenting may be considered in select circumstances involving
17.4). The emergence and evolution of MDCTA have since re- pseudoaneurysm and dissection with 70% flow limitation. Given
placed DSA as the study of choice for diagnosis of BCVI and the potential for ischemic complications, employment of this ther-
recent studies report incidence as approximately 2% to 3% of apy is roughly 10% overall.32 Bleeding risk from associated inju-
all blunt trauma patients. Contemporary screening criteria lib- ries often limits the ability to begin immediate anticoagulation or
erally prompts the evaluator toward MDCTA in the setting of antiplatelet therapy, but treatment should be initiated as soon as
(1) any injury above the clavicle, regardless of mechanism, (2) safely possible. Although the majority of strokes occur in the first
neurologic exam not explained by brain imaging, and (3) Horner few days after injury, a significant percentage occur in the follow-
syndrome.32 As blunt aerodigestive injury is exceedingly rare, ing days to weeks and therefore still benefit from delayed initiation
diagnostics will likely favor a tailored approach with MDCTA, of therapy. Fig. 17.15 presents a graded approach to the diagnosis
esophagoscopy, esophagography, and/or bronchoscopy if there and management of BCVI. Anticoagulation with heparin should
is concern. be started with the goal of achieving a partial thromboplastin time
Penetrating neck trauma
Hard signs of arterial injury

or
hemodynamic instability?
No Yes
Suspicion for injury? Secure airway

Direct pressure OR
for neck exploration
No Yes
Observe Location of injury?
Zone I Zone II Zone III
Symptoms? CTA neck
No Yes Positive
CTA neck CTA neck

OR for neck exploration
Positive or
angioembolization
Positive OR for neck exploration Hypopharyngeal endoscopy
Negative
OR for exploration ± Concern for TE injury

endoscopy/bronchoscopy
or
angioembolization Esophagoscopy
Esophagography
Bronchoscopy
FIG. 17.14 Algorithm for the management of penetrating neck injuries. Hard signs of vascular or aerodiges-
tive injury include airway compromise, massive subcutaneous emphysema, air bubbles necessitating through
wound, expanding or pulsatile hematoma, active bleeding, neurologic deficit, and hematemesis. (Modified from
Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating
neck trauma. J Trauma Acute Care Surg. 2013;75:936–940.). CTA, Computed tomography angiography; OR,
operating room; TE, tracheoesophageal.
between 40 and 50 seconds, although daily 325 mg aspirin (ASA) the chest makes it vulnerable to penetrating mechanisms, such as
presents an equivalent therapeutic option. MDCTA may be re- gunshot and stab wounds. Penetrating mechanisms result in direct
peated in 24 to 48 hours if findings are indeterminate on initial laceration of pulmonary and mediastinal structures. High energy
scan. All confirmed injuries should undergo repeat imaging at 7 to blunt and penetrating trauma can also cause significant lung con-
10 days to evaluate for progression or resolution and subsequent tusion to tissue, local to the site of focal impact, or diffusely in the
discontinuation of therapy. Persistent injury requires treatment for setting of blast injury. Despite the serious nature of these injuries,
3 months, followed by outpatient follow-up MDCTA. less than 10% of blunt and between 15% and 30% of penetrating
trauma to the chest require surgical management.8
Injuries to the Chest
Injuries to the thorax are common, occurring in 22% of trau- Immediate Management
ma patients annually with an associated 9.5% mortality in the Thoracic injuries often require intervention during the primary sur-
NTDB.2 These injuries can be life-threatening, as the chest con- vey because of the impact upon cardiopulmonary function. Chest
tains vital cardiopulmonary structures. Falls and motor vehicle trauma with pulmonary compromise requires immediate manage-
crashes comprise the majority of blunt chest injuries via transmis- ment of the airway and ventilatory assistance. Decreased breath
sion of energy to the chest wall and direct compression or decel- sounds and poor pulmonary compliance in the setting of shock is
eration forces to underlying structures. The relative prominence of consistent with possible tension pneumothorax and may require
Risk factors
for BCVI
CT angiogram
Inconclusive Positive Negative
Positive Characterize Stop

Repeat CTA neck in injury
24–48h or DSA
Negative
Grade I Grades II-IV Grade V
Stop
Antithrombotic therapy Operative or endovascular Operative or

Heparin PTT 40–50 sec treatment (if accessible) endovascular
or versus medical management treatment
antiplatelet therapy with
anticoagulation/antiplatelet
Repeat CT angiogram
or DSA in 7–10 days
Injury Injury remains

healed present
Stop Continue antithrombotic

therapy therapy for 3 months,
then reimage
Consider endovascular
therapy
FIG. 17.15 Algorithm for the management of blunt cerebrovascular injury (BCVI). (Modified from Biffl WL, Co-
thren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment
of blunt cerebrovascular injuries. J Trauma. 2009;67:1150–1153.). CT, Computed tomography; CTA, computed
tomography angiography; DSA, digital subtraction angiography; PTT, partial thromboplastin time.
urgent decompression with tube thoracostomy. External bleeding Chest radiography is almost universally performed during the
should be controlled with direct pressure while resuscitation is initi- initial assessment on patients at risk for thoracic injuries. In blunt
ated. Although hemodynamic instability most commonly indicates trauma, the chest is evaluated for the presence of a large-volume
hemorrhage until proven otherwise, cardiac dysfunction secondary pneumothorax or hemothorax that would require immediate tube
to pericardial tamponade, cardiac contusion, or coronary air embo- thoracostomy. Whereas the chest radiograph may contain find-
lism may represent other possible sources in this setting. Following ings suggestive of blunt aortic injury (i.e., widened mediastinum,
an assessment for sources of blood loss, a search for pericardial fluid obliteration of the aortopulmonary window, apical capping), this
with ultrasound or pericardial window may be required, especially modality lacks sufficient detail for screening. Thoracic MDCTA
following penetrating trauma. Patients with persistent shock despite has become the standard approach to evaluation of the chest
resuscitation and ongoing blood loss from the chest often require and provides superior visualization of the chest wall, vasculature,
operative intervention. Cardiac arrest, particularly in the setting of pleural spaces, and lung parenchyma. It is, however, unreliable
penetrating mechanisms, may benefit from RT (see earlier section). for evaluation of pericardium, given cardiac motion degradation.
Fig. 17.16 demonstrates an approach to the initial evaluation and Importantly, CT angiography has become accepted as sufficient to
management of penetrating chest injuries. guide operative intervention without the need for standard angi-
ography of the chest.
Evaluation Penetrating trauma to the chest should be identified rapidly on
The majority of chest injuries can be diagnosed with physical ex- physical exam and marked with adhesive radio-opaque markers
amination and plain chest radiography. External injuries, such for x-ray. Injuries that are believed to involve or cross the medias-
as chest wall defects and penetrating wounds, will be identified tinum require further evaluation. Wounds within the area defined
on physical examination. Chest wall tenderness and paradoxical by the sternal notch superiorly, the costal margin inferiorly, and
movement can be identified to reflect segmental injuries to the ribs the nipples laterally (“the cardiac box”) constitute these high-risk
(flail) and sternum. Deviation of the trachea at the sternal notch injuries. Immediate ultrasound is performed to evaluate the peri-
may reveal intrathoracic tension on the side opposite the trachea. cardium for effusion, although decompression into a hemothorax
Penetrating thoracic
trauma
Primary survey:
Assess ABCs
Cardiac
Stable Unstable
arrest
Physical examination Initiate resuscitation Emergency

Chest radiograph Physical examination department
thoracotomy
Pneumothorax/ Tube thoracostomy

hemothorax? if breath sounds
decreased
Yes No
Tube Injury within High chest tube

thoracostomy “cardiac box” or output ~1500 mL
transmediastinal? and ongoing
Yes
Yes No No
Evaluate mediastinum: Monitor chest Operating room

Pericardial Positive
Echocardiography tube output for sternotomy
ultrasound
Chest CT angiogram or
(FAST)
Bronchoscopy thoracotomy
Esophagogram/ Negative
esophagoscopy Positive
No Operating room
Responsive
for pericardial
resuscitation?
window
Yes Negative
Monitor chest Continue

tube output resuscitation
Consider evaluation
of mediastinum
FIG. 17.16 Algorithm for the management of penetrating thoracic injuries. ABCs, Airway, breathing, and circu-
lation; CT, computed tomography; FAST, focused abdominal sonography in trauma.
through traumatic pericardiotomy may yield false-negative re- as well as wide draping to maintain the sterility of the field. Ex-
sults.33 As with blunt trauma, the great vessels are evaluated for ternal landmarks for reliable placement should include the level of
injury with MDCTA, although this can be impeded by the pres- the nipple or inframammary fold inferiorly, midaxillary line pos-
ence of retained missile fragments, necessitating standard cathe- teriorly, and the hypotenuse of the two sides (“triangle of safety”).
ter-based angiography if there is concern. Depending on the tra- After infusion of local analgesia, a skin incision roughly equivalent
jectory of the penetrating object, the trachea and proximal airways to the circumference of the chest tube should be made within the
may require evaluation with bronchoscopy and a combination of triangle at or just above the level of the nipple (5th–6th inter-
esophagoscopy with contrast esophagography are diagnostic for costal spaces). This location successfully avoids intraabdominal
esophageal injuries. As described in the neck injury section, these placement or injury to the diaphragm. A subcutaneous tunnel is
studies have an approximate 20% false-negative rate in isolation, created in a superior direction and the chest is entered bluntly at
although their combined sensitivity approaches 100%. an interspace above the skin incision. Accomplishing the tunnel
naturally directs the chest tube into an apical position. The lung is
Management palpated to confirm chest entry and to evaluate for intrathoracic
Thoracic injuries are often straightforward to manage, with up to adhesions. Chest tube sizing for trauma has typically ranged from
85% successfully treated with tube thoracostomy alone. Although 32 to 36 Fr, although accumulating evidence suggests equivalent
chest tubes are often urgently required, placement may still be per- success in drainage of hemothorax irrespective of luminal diam-
formed in a controlled manner to include strict sterile preparation eter. To confirm that the tube is not kinked, it is helpful to be sure
and excellent surgical technique. To avoid the development of an that the tube freely spins before completion of the procedure. The
empyema (3% overall incidence in chest trauma), the chest should tube is then connected to an underwater drainage device provid-
be prepared appropriately by wide preparation with chlorhexidine ing 20 cm H2O suction.
The traditional indications for immediate thoracotomy include

(1) more than 1500 mL of blood drained on chest tube insertion,
(2) 150 to 200 mL/hr of drainage for two to four consecutive
hours, or (3) persistent hemodynamic instability in the setting of
ongoing transfusion requirement.34 Nonetheless, it is paramount
to remember that these indications are based upon Vietnam war–
era data from patients who died due to chest injury rather than
contemporary trials examining predictors of survivorship; there
are no absolute values that mandate operation. Arguably more im-
portant questions to be asking are: Does the chest tube output rep-
resent ongoing bleeding or accumulated blood (i.e., “is bleeding”
vs. “has bled”)? Is the bleeding surgical in nature? Is it impacting
physiology? For example, chest tubes that initially drain 1500 mL
then have little ongoing output in the setting of hemodynamic
stability may not require thoracotomy. Like other zones of injury,
the patient physiology and response to resuscitation should guide
operative planning. Other indications for thoracotomy include a
massive air leak with associated pneumothorax and drainage of
esophageal or gastric contents from the chest tube.
When thoracotomy is required, the choice of surgical approach FIG. 17.17 Large left-sided pneumothorax on plain chest radiograph.
depends on the suspected injury. Access to the lungs, pulmonary The arrows identify the lateral border of the collapsed lung.
vasculature, and hemidiaphragm is achieved through a postero-
lateral thoracotomy that is best performed through the fifth in- blood with a great degree of sensitivity. An occult pneumotho-
terspace, with possible removal of the fifth rib. On the right, this rax is defined by identification on chest CT without evidence on
incision also exposes the proximal and mid esophagus as well as plain radiography. Finally, CT easily recognizes significant chest
the trachea and bilateral mainstem bronchi. The distal esophagus, wall deformities, such as flail segment, displaced ribs, and sternal
left lung, left ventricle, descending aorta, and left subclavian artery fractures, and may be used to guide considerations of chest wall
are best approached through a left thoracotomy. A median ster- reconstruction.
notomy can be a highly versatile approach, providing exposure to All pneumo- or hemothoraces visible on a chest radiograph
the right side of the heart, ascending aorta, aortic arch with right- should be considered for tube thoracostomy, yet routine utility re-
sided arch vessels, and pulmonary vasculature. mains a controversial topic. Although large-volume pneumotho-
Chest Wall and Pleural Space Injuries. With more than 65% races are typically detected on x-ray, up to half are subsequently
of blunt trauma patients sustaining one or more rib fractures, discovered on CT chest. In the absence of hemodynamic instabil-
chest wall injuries are the most common thoracic injury. Similarly, ity and respiratory compromise, recent data suggest that observa-
rib fractures occur in more than one out of four cases of pen- tion for pneumothoraces with CT radial diameter of up to 35
etrating chest trauma in the NTDB. The mortality rate associated mm may be safe for both blunt and penetrating trauma.35 Occult
with chest wall injuries after blunt trauma is approximately 7%, pneumothoraces not accompanied by respiratory compromise can
whereas it exceeds 19% for penetrating injuries. Rib fractures typi- be managed with observation and a repeated chest radiograph 12
cally occur secondary to compression of the thoracic cage in an to 24 hours later to demonstrate stability. Hemothoraces visible on
anteroposterior or lateral direction, which often dictates the loca- upright chest x-ray represent an approximate volume of 400–500
tion of the cortical disruption along the rib. During motor vehicle mL and should be evacuated with thoracostomy. Residual hemo-
crashes, the steering wheel and seat belt are commonly the cause thorax that does not resolve after insertion of a chest tube should
of chest wall deformation. Large amounts of energy transferred to be considered for video-assisted thoracosopic (VATS) drainage.
the chest wall can result in a flail segment, which includes two or This approach results in shorter duration of chest tube drainage,
more adjacent ribs fractured in two or more locations. Clinically, shorter hospital length of stay, lower hospital costs, and preven-
a flail segment results in a portion of the chest wall that moves tion of a surgical procedure later in the hospital course when com-
independently and paradoxically in relation to the remainder of pared to the placement of a second chest tube. Moreover, retained
the chest. Although abnormal chest wall mechanics occur in this hemothorax following chest tube placement has been associated
setting, the associated pulmonary contusion causes the greatest with a 33% risk of empyema. Timing of VATS intervention is best
physiologic insult and may ultimately require the most supportive undertaken in days 3 to 7 of hospitalization to reduce the risk of
energies. Some volume of air (pneumothorax) or blood (hemotho- conversion to thoracotomy.34 Chest tubes may be safely removed
rax) is commonly associated with chest injury, owing to compres- following demonstrated pleural space evacuation, on underwater
sive forces upon the lung or penetrating mechanisms. seal, with <300 mL output over prior 24 hours.
The evaluation of the chest wall begins during the primary The impact of rib fractures upon patient physiology may vary
and secondary surveys, during which chest wall tenderness, wall greatly, depending on the morphology of injury and patient
motion abnormalities, and changes in pulmonary mechanics are characteristics. Of greatest concern is the associated inability to
suggestive of trauma. Injuries involving the chest wall or pleural perform pulmonary toilet due to pain with subsequent develop-
space can frequently be identified on chest radiographs, in which ment of respiratory compromise. To this end, institutional pro-
a pneumothorax appears as a lucency peripheral to the standard tocols involve multimodal narcotic-sparing pain regimens, often
lung markings (Fig. 17.17) and hemothorax is revealed as depen- with the assistance of an acute pain service and consideration of
dent opacification. Chest CT is often a valuable part of the evalu- epidural catheterization. Adequate analgesia allows for optimal
ation and identifies chest wall trauma as well as pleural air and pulmonary toilet and avoidance of pneumonia. Technological
fissures, whereas contusions are not limited by ventilatory seg-

ments. Furthermore, injured pulmonary tissue in the vicinity of
chest wall trauma, especially in nondependent segments, is highly
suggestive of pulmonary contusion. Injured lung tissue on CT ap-
pears as a higher density, as depicted in Fig. 17.18.
Pulmonary contusion is typically managed with supportive
care (aggressive pulmonary toilet, adequate pain control). Patients
should be monitored for hypoxemia, increased work of breathing,
and agitation, the sum of which indicates respiratory decompen-
sation. Although the majority of pulmonary contusions resolve
with time, some may progress to mechanical ventilation and
extracorporeal membrane oxygenation (ECMO). A recent large
retrospective review of trauma patients managed with primarily
venovenous ECMO demonstrated at 70% survival from cannula-
tion and 60% to hospital discharge. ARDS was the most com-
mon indication following chest trauma and the median duration
of cannulation was 8 to 9 days.37
Nonoperative measures and thoracostomy manage the majority
of thoracic trauma. Although there are classic guidelines for opera-
FIG. 17.18 Left pulmonary contusion on thoracic computed tomogra- tive chest exploration as defined by chest tube output, the decision
phy scan. The arrow identifies contused lung, which appears as higher
to operate should be based on the likelihood of ongoing bleeding.
density tissue because of air space hemorrhage and associated edema.
For this reason, persistent drainage of blood from the chest tube in
the physiologically compromised patient is more important than
advances and data demonstrating benefit in flail segment repair the amount of initial output upon insertion. In most cases, tube
have prompted renewed interest in the surgical stabilization of thoracostomy alone with lung expansion adequately manages low-
rib fractures. In nonsegmental fractures, recent trial data show pressure lung bleeding and small air leaks. Ongoing bloody efflu-
decreased numeric pain scores and improved quality-of-life met- ent indicates a more central, high-pressure source, which should
rics at 2 weeks following surgical stabilization of rib fractures.36 prompt intervention for control of bleeding. While endovascular
Sternal fractures are most often managed similarly to nonopera- management for injuries to the thorax is best described for aortic
tive rib fractures, although certain patterns may benefit from re- and thoracic outlet injury, embolization of bleeding vessels within
construction. Taken together, as questions persist regarding the the pulmonary circulation may be an alternative to surgery at in-
role for surgical stabilization of rib fractures in chest wall injury stitutions with interventional radiology support.
management, operative planning is best undertaken on a case- Blunt trauma results in severe diffuse lung injury and is more
by-case basis and couched in risk/benefit conversations with the difficult to treat surgically with worse outcomes compared to pen-
patient and surgical partnership. etrating injury. Where stapled incision of a missile tract (tractoto-
Pulmonary Injuries. Approximately one in three patients in my) and stapled wedge resection (20%–40%) are more common
the NTDB sustains a pulmonary contusion after chest trauma. in penetrating mechanisms, anatomic lobectomy and pneumo-
Mortality after pulmonary contusion is predominately a result nectomy are more commonly performed if resection is required
of respiratory failure from acute respiratory distress syndrome in association with blunt trauma (15%–20%). Hilar control with
(ARDS) or pneumonia. Trauma to the lung is caused by energy either clamp or “hilar twist” should be the initial maneuver per-
transfer through the chest wall to the pulmonary parenchyma, formed if significant bleeding is encountered upon entry into the
resulting in tissue damage as well as hemorrhage into the alveo- chest. Bleeding from the pulmonary parenchyma is controlled
lar and interstitial spaces. This tissue damage is manifested as a through suture (3-0 polypropylene) ligation of bleeding vessels.
physiologic shunt with hypoxemia. The majority of morbidity is Stapled tractotomy exposes injured vessels and bronchi for in-
secondary to a profound inflammatory response that can progress dividual ligation. Trauma pneumonectomy is extremely morbid
to multiple organ dysfunction or failure. Frequently, pulmonary with high mortality (>50%) and should only be performed for
contusion occurs with a flail segment and is often more clinically the patient in extremis, having quickly exhausted other attempts
important than the bony trauma. Lung injury can also be caused at hemostasis. Damage control principles may also be applied to
by penetrating mechanisms, with gunshot wounds (GSWs) be- the chest with laparotomy sponges and temporary closure over
ing the most common. Typically, the missile directly lacerates the chest tubes. As opposed to abdominal packing, packs in the chest
parenchyma and then can cause significant contusion of the sur- should occupy minimal space and be constructed to allow maxi-
rounding tissue. mal lung expansion.
Beyond clinical suspicion, chest radiographs obtained in the Cardiac Injuries. Despite being uncommon, cardiac injuries are
trauma bay shortly after arrival may be the first suggestion of some of the most severe injuries sustained by patients after pene-
underlying pulmonary injury. Lung contusions are occasionally trating and blunt trauma. Penetrating injury to the heart occurred
present on the initial chest radiograph, but typically require time in 1% to 2% of patients with penetrating trauma in the NTDB
(24–48 hours) to become visualized. Pulmonary contusions that and in less than 10% of the subset with penetrating chest trauma
are identified early on chest film are frequently severe and often alone. These statistics likely underestimate the true incidence of
rapidly progress to respiratory failure. Thoracic CT is valuable penetrating cardiac injuries, as up to 94% are immediately lethal
for the identification of pulmonary contusion, although it can be and never present to a hospital. Mortality among patients arriving
challenging at times to differentiate contusion from atelectasis. A to a trauma center with a penetrating cardiac injury ranges from
valuable rule of thumb is that atelectasis does not cross pulmonary 17% to 58%.38
The location of penetrating injury on initial examination will

often be suggestive of cardiac injury (“the cardiac box,” described
previously). Patients may present in extremis with pericardial
tamponade or bleeding into one of the pleural spaces. Those who
require immediate RT in the emergency department may have
a cardiac injury identified at that time. In others, indicators of
pericardial tamponade may be present (Beck triad—hypotension,
distended neck veins, and muffled heart sounds) although incon-
sistently. Ultrasound is a valuable tool for quickly assessing the
pericardium for fluid and should be performed in all patients with
hemodynamic instability. When the results of ultrasound are in-
conclusive or potentially falsely negative, as in the setting of left or
right hemothorax, a subxiphoid pericardial window is required to
evaluate for the presence of blood in the pericardium. On making
a small opening in the pericardium, the pericardial space can be
directly visualized. The pericardial window may then be extended
to perform a median sternotomy in the setting of visualized blood.
Recent evidence suggests a safe alternative approach to sternoto- FIG. 17.19 Aortic transection with pseudoaneurysm and associated
my following positive subxiphoid window with pericardial drain hematoma on thoracic computed tomography. This injury occurred at the
placement in those patients for whom bloody effluent is self-lim- typical location, just distal to the left subclavian artery at the aortic isth-
iting and remain hemodynamically stable.38 mus. The yellow arrow identifies a pseudoaneurysm; the white arrow
For cardiac injuries that cause cardiovascular collapse, a left identifies a left-sided tube thoracostomy.
anterolateral thoracotomy is performed in the emergency depart-
ment as previously described and may be extended to a contralat-
eral (“clamshell”) incision if need be. When time permits, most Thoracic Aortic Injuries. Thoracic aortic injuries are fortunate-
cardiac injuries are best approached through a median sternoto- ly uncommon but are associated with poor outcomes. Approxi-
my. Injuries to the atria can be grasped in a side-biting fashion mately 80% of trauma patients with blunt traumatic aortic injury
with a Satinsky clamp and then closed with running permanent (BTAI) die before they reach a hospital and 50% of those surviv-
monofilament sutures on a long taper needle (i.e., 3-0 prolene). ing to the hospital die within 24 hours.40 As with other severe
Ventricular injuries can be more challenging and usually are as- injuries, the described incidence of these injuries underestimates
sociated with significant bleeding. The laceration can be held to- the actual frequency, given an unknown denominator. BTAI are
gether manually while the defect is closed with horizontal mat- believed to be a result of rapid deceleration, which tears the aortic
tress sutures, avoiding ligation of adjacent coronary vessels, and wall in the vicinity of the ligamentum arteriosum. Other theo-
reinforced with pledgets. To gain temporary control and allow ries suggest that lateral mechanisms also contribute, during which
transport to the OR, skin staples may provide short-term closure the aortic arch acts as a lever and causes torque to develop at the
of the cardiac laceration. Another option is the passage of a Foley aortic isthmus. The result of these mechanisms can range from a
catheter through the wound, followed by inflation of the balloon tear in the aortic intima to full-thickness transection of the ves-
and maintenance of outward tension. This technique must be per- sel wall. With full-thickness injuries, only those who experience
formed carefully as it runs the risk of dilating the cardiotomy with containment of the rupture by the surrounding adventitial and
excessive tension. mediastinal tissues survive to hospital presentation. Penetrating
Blunt injury to the heart occurs less commonly, being seen in aortic injury is also uncommon, being present in approximately
only 2.2% of blunt chest trauma cases. Most of these cases rep- 3% of penetrating chest trauma, with the associated mortality ap-
resent a contusion of the myocardium that results in arrhythmias proaching 90%.
and is frequently self-limited. In rare cases, blunt cardiac injury In the setting of BTAI, a chest radiograph may demonstrate
results in heart failure with cardiogenic shock. The diagnosis of findings such as a widened mediastinum, apical capping, loss of
cardiac contusion has been well studied but remains controversial. the aortic knob, or deviation of the left mainstem bronchus. Be-
Patients suspected of having a blunt cardiac injury should un- cause of a high rate of missed injuries with use of chest radiogra-
dergo electrocardiography and troponin I evaluation at the time phy as a screening study, most patients involved in high-energy in-
of initial workup. These studies in tandem rule out blunt cardiac jury mechanisms undergo helical CT angiography of the chest to
injury if both are negative.39 A new abnormality on the electrocar- evaluate for aortic injury. On this modality, an aortic injury ranges
diogram (ECG), most commonly tachyarrhythmia, should result from a disruption in the intima (Grade I), intramural hematoma
in admission for continuous ECG monitoring. Clinical findings (Grade II), pseudoaneurysm (Grade III) to rupture (Grade IV).
of cardiac contusion that are absent on admission are unlikely to As technology has evolved, chest CT alone is usually sufficient to
develop and, in their continued absence, require no further evalu- plan operative repair and standard angiography is rarely necessary.
ation. The presence of hemodynamic instability with evidence of Fig. 17.19 reveals a chest CT image that demonstrates a contained
heart failure should prompt echocardiography to assess cardiac pseudoaneurysm from an aortic transection. Similarly, aortic in-
wall and septal motion as well as valvular function. Cardiogenic jury from penetrating trauma may be identified on CT imaging
shock may require treatment with inotropic support and right or at the time of exploration, often in the setting of a patient in
ventricular afterload reduction, given the frequent involvement extremis.
of the right side of the heart. Patients who demonstrate structural BTAI with pseudoaneurysm will require operative repair, as the
abnormalities, such as valvular incompetence, may require urgent natural history of these injuries is slow expansion to free aortic
operation for repair. rupture. Despite this, the progression is usually slow and allows
for other more urgent issues, such as acute hemorrhage and re- benefit from bronchoscopic guidance under direct visualization.
suscitation, to be addressed in the first 24 hours of admission. Bronchial injuries that occupy less than one third of the lumi-
It is essential that aortic wall stress be controlled until repair is nal circumference may be considered for nonoperative manage-
performed. This is usually adequately achieved with beta-receptor ment if lung expansion with a chest tube results in resolution of
antagonist medications (i.e., labetalol or esmolol infusions). The the pneumothorax and associated air leak. Management includes
majority of these injuries are now addressed via thoracic endovas- humidified oxygen, careful suctioning, and close observation
cular aortic repair. This change in treatment has evolved during to monitor for infectious sequelae that may develop. Operative
the last 10 years, now demonstrating equivalent mortality and in- management of the trachea, right-sided airways, and proximal left
hospital morbidity to open repair. Thus the appeal of the minimal- mainstem bronchus is best approached through a right posterolat-
ly invasive approach with the rapid progression of catheter-based eral thoracotomy. Distal left-sided injuries are repaired through a
technology has made endovascular repair the treatment of choice left thoracotomy. A vascularized intercostal muscle flap should be
at most trauma centers.40 Access to the thoracic aorta is through mobilized and preserved during creation of the thoracotomy, as
the groin, and the stent graft is placed under fluoroscopic guid- placement of a retractor will prevent harvest of this valuable tissue
ance. On occasion, the graft will cover the ostia of the left sub- coverage. Devitalized tissue should be debrided and injures closed
clavian artery, at which time a carotid-to-subclavian bypass may with absorbable monofilament suture. Large injuries may require
also be required if symptoms develop. When open surgical repair segmental resection with anastomosis. Coverage of the repair with
is required, the aorta is exposed through a left thoracotomy. Large a tissue pedicle, such as the previously created intercostal muscle
penetrating injuries and blunt transection require replacement of flap, may improve healing. If possible, patients who require on-
a segment of the aorta with a prosthetic graft. This is most com- going mechanical ventilation should have the endotracheal tube
monly performed with the assistance of cardiopulmonary bypass, advanced so that the end of the tube is distal to the repair and
including full bypass through a femoral-femoral approach or with protected from positive pressure. Other options include dual-lung
a centrifugal pump and left-sided heart bypass. The use of cardio- ventilation and extracorporeal life support during the immediate
pulmonary bypass has been associated with a decreased incidence postoperative period.
of paraplegia, which can result from cessation of aortic blood flow Esophageal Injuries. Similar to the tracheobronchial tree, the
if a clamp and sew technique is used. thoracic esophagus is uncommonly injured by either blunt or pen-
As the ability to visualize small intimal defects on CT has etrating mechanisms. Penetrating injury is slightly more common;
evolved, there are aortic injuries that may not require operative however, historically, less than 1% of chest injuries in the NTDB
repair. Some patients with only a small intimal tear may be candi- had involvement of the esophagus by blunt or penetrating mecha-
dates for nonoperative management, as many of these injuries will nism. Most penetrating injuries are caused by GSWs, followed by
heal without intervention. Patients should be treated with beta- stab wounds. The mortality associated with penetrating esophageal
blocker therapy and undergo follow-up imaging to ensure the injuries is substantial (35%), as a result of mediastinal sepsis and
absence of expansion and ultimately the resolution of the injury. injury to the adjacent vital structures. Although these injuries are
Tracheobronchial Injuries. Tracheobronchial tree injuries are rare, the mortality is significant because of challenges with timely
uncommon but associated with significant morbidity and mortali- diagnosis and treatment. Whereas penetrating injury causes direct
ty. Penetrating mechanisms are the most common cause, although tissue laceration, blunt esophageal injury is likely to be caused by a
these injuries historically represent only rare occurrences (<1%). rapid elevation in intraluminal pressure during compression of the
Blunt injury to the tracheobronchial tree can occur but is simi- chest or abdomen. An impact to the upper abdomen can compress
larly uncommon, resulting from the application of a large amount the distended stomach, leading to transmission of air and fluid up
of energy to the anterior chest. These forces pull the lungs later- the esophagus and resulting in a perforation of the wall, usually in
ally and avulse the bronchi from the fixed carina. Furthermore, a the distal segment.
tracheal rupture may occur when lungs and airways are rapidly The location of penetrating injuries and the presumed trajec-
compressed against a closed glottis, perforating the trachea along tory are often suggestive of esophageal injury. Penetrating injuries
the membranous portion. Penetrating tracheobronchial injuries in the vicinity of the mediastinum require consideration of pos-
are predominantly a result of GSWs that cause direct laceration of sible esophageal injury. The esophagus is best evaluated through a
the tracheobronchial tree. combination of contrast esophagography (water-soluble first, fol-
The location of the airway disruption will dictate the clinical lowed by thin barium) and esophagoscopy. Together, these two
presentation and the method of injury identification. Injuries that modalities result in a sensitivity of almost 100% for esophageal in-
involve the thoracic trachea and proximal bronchi may result in jury. Diagnostic studies may reveal leak of contrast material from
large amounts of pneumomediastinum identified by chest radi- the esophageal lumen or a disruption of the mucosa visualized
ography or CT imaging. More distal airway injuries will typically during endoscopy. Helical CT esophagography may be a reason-
cause a pneumothorax requiring insertion of a tube thoracostomy. able alternative to a fluoroscopic esophagram, obviating the need
A continuous air leak with persistent pneumothorax is highly sug- for patient participation (i.e., intubated patients) and radiologist
gestive of an injury to a bronchus or large bronchiole. Significant administration of the study. In the absence of contrast, chest CT
subcutaneous air may also be present on physical examination. reveals air adjacent to the esophagus but outside the lumen with
Diagnosis is made with either rigid or flexible bronchoscopy, de- surrounding soft tissue inflammation. High-resolution CT imag-
pending on the location of the injury and the ability to manipu- ing may even demonstrate an esophageal wall defect. The location
late the neck. Bronchoscopy allows the identification of the injury of the injury should be determined to assist in operative planning.
and a detailed characterization, such as the location and severity Esophageal injuries with associated mediastinal contamination
of the disruption. require immediate identification and repair, as delays are associ-
The management of tracheobronchial injuries begins with care- ated with worse outcomes. Esophageal injuries require operative
ful assessment and control of the airway. With the placement of repair to close the esophageal defect, ideally in two layers (muco-
any airway, avoidance of further disruption is vital, and it may sal/muscular), with provision of adequate drainage. Management
of injuries to the cervical esophagus is described previously in “In-

juries to the Neck.” The upper and midthoracic esophagus is best
approached through a right posterolateral thoracotomy through
the fourth or fifth interspace, whereas the lower esophagus is ex-
posed from the left through the sixth or seventh interspace. As
with tracheobronchial injuries, creation of a vascularized intercos-
tal muscle flap on entry into the chest will allow excellent coverage
of the repair. Alternatives to the intercostal muscle include pleura,
pericardium, or diaphragm.
When the location of the injury is at the gastroesophageal junc-
tion, it may best be approached through a laparotomy. The injury
is entirely exposed, which usually requires opening of the muscle
layer superiorly and inferiorly to reveal the extent of the mucosal
defect, which is commonly larger than the muscle disruption. The
esophageal injury is then closed in one or two layers, frequently
with an absorbable mucosal suture followed by interrupted muscle
sutures of a permanent material. Coverage of the repair with a
muscle flap or adjacent tissue may help reduce the high rate of
leak. Esophageal repairs at the gastroesophageal junction can be FIG. 17.20 Left-sided diaphragmatic injury on plain chest radiograph.
covered with a fundoplication of gastric tissue. Wide drainage The gas-filled stomach can be visualized on the left side of the chest
of the mediastinum and chest is extremely important to control because of herniation through a large diaphragmatic laceration.
any leak that may develop. Decompression of the stomach and
distal feeding access are necessary, whether through nasoenteral
tube placement or surgical gastrostomy and feeding jejunostomy. viscera in the chest or an abnormality of the diaphragm itself, such
Following repair, an esophagram may be performed at day 5 to as thickening, elevation, or defect. Penetrating diaphragmatic in-
confirm healing and liberalization of oral intake. juries are usually discovered on operative exploration of the chest
Inflammation within the mediastinum develops quickly, and or abdomen. During exploration, following the trajectory of the
primary repair of injuries that are identified late may not be pos- injury will usually allow identification of the diaphragmatic de-
sible. Salvage techniques to be considered in these circumstances fect. In the hemodynamically stable patient without peritonitis,
include repair of the defect over a T-tube for creation of a con- laparoscopy is recommended over CT scanning alone to decrease
trolled fistula, esophageal diversion through a cervical incision, or the incidence of missed traumatic diaphragmatic injuries. Given
esophageal stenting. Esophagectomy, although rare in the setting the rare incidence of right-sided delayed diaphragmatic hernia,
of trauma, may be the only option to allow recovery followed by penetrating thoracoabdominal trauma to the right hemibody may
planned elective reconstruction. be considered for nonoperative management.41 In the absence
Diaphragmatic Injuries. Traumatic diaphragmatic injuries of radiographic stigmata, blunt injuries can be more elusive and
were analyzed in a large series by the NTDB in 2012, including laparoscopic evaluation may be required when imaging is sugges-
>800,000 patients. Results revealed an overall incidence of 0.46%. tive. The application of VATS has been reported as an alternative
Penetrating trauma was more common than blunt (67% vs. 33%, means of visualizing the diaphragm, although no demonstrable
respectively). GSWs outnumbered stab wounds and motor vehicle superiority exists compared to laparoscopy.
collisions were among the commonest mechanisms. Higher mor- Diaphragmatic injuries are typically repaired by debriding non-
tality was identified among blunt over penetrating trauma (19.8% viable tissue and then closing the defect. The diaphragm exhibits
vs. 8.8%).41 Almost all of these deaths are a result of injury to ad- enough redundancy for all, but the largest defects to be closed
jacent vital organs because diaphragmatic injuries themselves are primarily. Closure is performed with a single layer of nonabsorb-
usually of limited threat to life. As opposed to direct laceration of able suture incorporating large full-thickness bites of healthy dia-
the tissue by missile, blunt diaphragmatic injuries are believed to phragmatic tissue. It is important to obtain hemostasis because
be a result of a rapid increase in intraabdominal pressure during diaphragmatic injuries can bleed significantly from branches of
an anterior impact, causing a blow-out of the diaphragmatic tis- the phrenic artery that can be exposed at the edges of the tear.
sue. The left side of the diaphragm is the injured location in ap- Large areas of tissue loss are rare in traumatic rupture, but when
proximately 75% of the cases because of the coverage of the right present may require reconstruction with a prosthetic. Nonabsorb-
side with the liver. The morbidity related to diaphragmatic injuries able synthetic materials can be used to reconstruct the diaphragm
is occasionally identified months to years later when the perfora- in clean surgical fields but should be avoided in the setting of con-
tion was not initially repaired. The natural history of these injuries tamination. A peripheral detachment of the diaphragm from the
includes progressive enlargement with herniation of abdominal wall of the torso can be repaired by reinserting the injured tissue
viscera into the chest. one or two interspaces superior.
Injuries to the diaphragm can be a diagnostic challenge and
require a high index of suspicion, even with the most subtle in- Injuries to the Abdomen
dicators. The chest radiograph may demonstrate the presence of The abdomen is a commonly injured body region and frequently
abdominal viscera, most commonly the stomach, within the chest requires the care of a surgeon for definitive management. Within
(Fig. 17.20). Passage of a nasogastric tube can be of assistance if the 2016 NTDB, 11.7% of all patients sustained abdominal in-
the tube is identified in the lower left hemithorax. The injection juries with an associated case fatality rate of 12.9%.2 The vital
of gastric contrast material may add to the detection with this nature of the organs contained within the abdomen makes evalu-
modality. CT scans may demonstrate the presence of abdominal ation and management a priority. The predominant sources of
morbidity and mortality are bleeding and visceral perforation with from solid organs was self-limited by the time of exploration. Sub-
associated sepsis. In the setting of blunt trauma, solid organs often sequently, surgeons recognized that the physiologic state was likely
sustain contusion or laceration, causing bleeding that may require more indicative of the need for laparotomy than the presence of
surgical management. Furthermore, blunt forces can cause rup- injury alone. Thus, consideration of nonoperative management in
ture of hollow viscera due to rapid compression of a segment of in- the presence of hemoperitoneum with stable vital signs became an
testine containing fluid and air. Penetrating mechanisms directly accepted pathway. As practice continues to evolve with the prox-
lacerate solid and hollow viscera, resulting in bleeding and intra- imity and speed of CT scanning in the emergency department,
abdominal contamination that often require operative repair. damage control resuscitation under trauma team management is
As described for other cavities, the initial evaluation of the able to continue throughout the ever shortening diagnostic win-
abdominally injured patient varies on the basis of blunt versus dow. The unclear sources of shock often germane to the blunt
penetrating mechanisms, although a common priority is rapidly trauma patient have led some contemporary practices to advocate
determining the presence or absence of ongoing hemorrhage. Al- whole-body CT scanning in the presence of hypotension (systolic
though metric definitions of this are nonstandard, patients who <90). The resultant information from rapidly obtained CT scan-
respond to resuscitation and maintain appropriate hemodynamics ning may lead the surgeon down vastly different treatment algo-
are termed responders. This population is considered likely to “have rithms (i.e., operative, endovascular, supportive).
bled” rather than suffering persistent bleeding. On the contrary, Despite being sensitive for solid organ injury, CT is less capable
patients who do not respond to resuscitation with persistent phys- of detecting injuries to the hollow viscera. This ability has improved
iologic instability are considered nonresponders and likely require as CT technology evolves, although there are still significant limi-
immediate intervention. Transient responders are those in whom tations. Injury to the GI tract is suggested by bowel wall thicken-
an improvement in metrics is initially noted with resuscitation but ing, inflammation in the surrounding adipose tissue (stranding), or
return to instability within a short time period. In the trauma bay, the presence of free intraperitoneal fluid. Oral contrast material is
ATLS surveys are designed for expeditious identification of cavi- uncommonly provided as it adds little to the value of the study.
tary hemorrhage, following assessment of airway and breathing. Unexplained free fluid must be carefully considered, given a high
risk for associated bowel injury. In a significant percentage of cases,
Blunt Abdominal Trauma Evaluation unexplained free fluid represents blood from a mesenteric tear that
Ultrasound has become a nearly ubiquitous technology in emer- is no longer bleeding. Clinical findings such as the presence of an
gency departments internationally and has found routine applica- abdominal seat belt mark or tenderness on examination raise con-
tion in the assessment of intraabdominal hemorrhage following cern in the setting of a suggestive CT. Serial examinations of the
blunt trauma. It is considered an adjunct to the primary survey abdomen to monitor for worsening tenderness and peritoneal irrita-
in ATLS and has the advantage of being rapidly performed at the tion are important and required for those patients who are not taken
bedside (ATLS 10th edition, FAST video on MyATLS mobile directly for exploration. Alternatively, laparoscopy may be a safe and
app).8 Ultrasound for trauma evaluates the pericardium, hepa- feasible alternative to open exploration in patients without shock or
torenal fossa, splenorenal fossa, and retrovesicular space (pouch of other indications for surgery. A representative flow diagram of blunt
Douglas). Resuscitationists may choose to obtain a FAST in the abdominal trauma evaluation is depicted in Fig. 17.21.
presence or absence of hemodynamic instability, as this exam may
be repeated should physiologic decline develop at a later point. Penetrating Abdominal Trauma Evaluation
Abdominal exploration is classically indicated in blunt trauma pa- The evaluation of penetrating abdominal trauma requires an ap-
tients who are nonresponders in the presence of intraabdominal proach unique from that for blunt mechanisms. Per typical ATLS
fluid on FAST. If FAST examination capabilities are unavailable, approach, airway and breathing should be assessed first, fol-
ATLS recommends performance of diagnostic peritoneal lavage. lowed by identification of all penetrating trauma. In the setting
Peritoneal aspiration revealing GI contents, bile, or more than 10 mL of GSWs, injuries should be identified with radiopaque markers
of gross blood suggests operative intraabdominal trauma. No- and plain radiographs obtained to establish possible trajectory and
tably, neither technique of rapid assessment is flawless. FAST is pneumoperitoneum. The role of FAST in abdominal GSWs is
limited by operator familiarity, body habitus, and subcutaneous of controversial utility. When positive, it may support the need
emphysema/bowel gas. Diagnostic peritoneal lavage is very rarely for abdominal exploration but is insufficient to rule out major
performed, associated with iatrogenic injury, relatively contraindi- hemorrhage or other operative trauma. The number of missiles
cated in obesity, and suffers from low specificity. Both techniques and skin wounds should add up to an even number or a more in-
are unable to evaluate the retroperitoneum, which may represent a tense search for retained ballistics is required. Patients in extremis,
considerable source of hemorrhage. although protecting their airway, should go directly to the OR
Technological advancements and increased availability of CT with intubation immediately prior to incision. In the presence of
over the past two decades have made it the primary method for normal physiology, abdominal GSW patients may proceed to CT
comprehensive workup of the blunt trauma patient. This evolu- scan for further delineation of their injuries. GSWs involving the
tion has supported the development of nonoperative management thoracoabdomen may also require evaluation of the chest for me-
strategies for many solid abdominal organ injuries. Abdominal diastinal, pleural, or pulmonary injuries.42
CT for trauma is typically performed with IV administration of Similar to patients with GSWs, abdominal stab wound pa-
a contrast agent additionally timed to capture the portal venous tients with hemodynamic instability, peritonitis, or evisceration
phase, which best demonstrates the perfusion of the solid abdomi- require immediate laparotomy. In patients who are not examin-
nal organs. This technique provides the necessary visualization of able, evaluation for peritoneal violation may be conducted via lo-
the solid organs to allow the determination of injury severity, in- cal wound exploration, ultrasound, CT, or diagnostic laparoscopy.
cluding the presence of active bleeding. Imaging findings prompt All others can be managed by one of several pathways depend-
management decisions, such as the need for operative, nonopera- ing upon location of the wound. For stab wounds to the flank
tive, or angiographic therapy. Historically, blood within the ab- or back, contrasted CT imaging (+/- rectal contrast) should be
domen mandated laparotomy, although commonly, the bleeding undertaken to identify signs of operative injury. If solid organ
Blunt abdominal trauma
Abdominal examination
Peritonitis or
hemodynamic instability No peritonitis
with positive FAST No hemodynamic instability
Exploratory Abdominal
laparotomy CT scan
Hollow
organ injury?
No Yes or indeterminate
Solid organ Exploratory laparotomy

injury? Diagnostic laparoscopy
Yes No
Pseudoaneurysm or Manage other injuries

arterial blush
on contrasted CT scan
Yes No
Interventional Nonoperative
radiology evaluation management
FIG. 17.21 Algorithm for the evaluation and management of blunt abdominal trauma. CT, Computed tomog-
raphy; FAST, focused abdominal sonography in trauma.
injury is identified with active extravasation, angioembolization Management

should be considered. Anterior stab wounds allow for discretion A laparotomy is performed to explore the abdomen and repair
of the attending surgeon. Local wound exploration to determine injuries that are identified. It is important that the exploration
fascial violation, serial clinical exams, or diagnostic imaging for of the abdomen be performed systematically to avoid missing
the hemodynamically appropriate patient represent equivalent injuries that may be subtle. As described in the setting of damage
pathways to safe management. Patients without any fascial pen- control, this approach may require abbreviation in the setting of
etration can be considered for discharge. If the local wound ex- a deteriorating physiologic condition. As a standard technique,
ploration reveals any evidence of possible fascial penetration, pa- the abdomen is opened from the xiphoid process to the pubic
tients should be monitored with serial abdominal examinations, symphysis to provide adequate exposure. The falciform ligament
undergo CT imaging or be considered for diagnostic laparoscopy. can be divided, separating the liver from the abdominal wall to
Diagnostic laparoscopy is highly accurate for the identification of improve retraction and to facilitate perihepatic packing. With
peritoneal violation but remains controversial for identification of use of a handheld retractor, blood is quickly evacuated from
intraabdominal injury and is highly user-dependent. all four quadrants of the abdomen and laparotomy sponges are
The development of peritonitis, hemodynamic instability, placed to provide temporary hemostasis. A fixed retractor can be
significant decreases in hemoglobin level, or leukocytosis should placed to facilitate optimal exposure. Sponges placed in the four
prompt further evaluation, usually with laparotomy. Patients quadrants are removed to address bleeding but can be replaced
without clinical change after 24 hours can have a diet instituted as needed in the setting of damage control. The entire GI tract
and be considered for discharge. Of note, this approach does re- is carefully evaluated, from the gastroesophageal junction to the
quire the presence of an infrastructure that allows close surveil- proximal rectum at the peritoneal reflection. The lesser sac is
lance of these patients, which may not be available in all facilities. also entered to visualize the posterior stomach and the pancreas.
Lastly, thoracoabdominal stab wounds should employ a chest x- When injuries are identified, they are repaired, as detailed in
ray for evaluation of pneumothorax and pericardial ultrasound subsequent sections. The development of physiologic compro-
for effusion. Stab wounds to the left upper quadrant will likely mise prompts the need to abbreviate the operation and proceed
require laparoscopy for diaphragmatic assessment, although this with damage control methods, including temporary abdominal
may be optional in the right upper quadrant due to liver pres- closure. This recognition benefits greatly from effective two-way
ence.43 A suggested abdominal stab wound algorithm is demon- communication between the surgical and anesthesia teams. If
strated in Fig. 17.22. the operation can be completed without conversion to damage
Abdominal stab wound
Shock, peritonitis,
Exploratory
evisceration, hemodynamic
laparotomy
instability, free air on CXR
Location of injury
Flank/back Anterior abdomen Thoracoabdomen
CT abdomen/pelvis CT abdomen/pelvis Evaluation of diaphragm:

± rectal contrast Local wound exploration CXR (pneumothorax)
Serial abdominal exams Pericardial FAST (cardiac injury)
for 24h Diagnostic laparoscopy (LUQ,
Negative or
Positive RUQ optional)
indeterminate
Exploratory DC versus Fascial
Negative or
laparotomy serial exams violation or
indeterminate
peritonitis
Diagnostic laparoscopy DC serial exams

Exploratory laparotomy diagnostic
laparoscopy
FIG. 17.22 Algorithm for the evaluation and management of anterior abdominal stab wounds. (Adapted from
Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal stab wounds. J Trauma
Acute Care Surg. 2018;85(5):1007–1015.). CT, Computed tomography; CXR, chest x-ray; DC, discharge; FAST,
focused abdominal sonography in trauma; LUQ, left upper quadrant; RUQ, right upper quadrant.
control, the abdominal fascia is closed and the subcutaneous

wound addressed as dictated by the level of intraabdominal
contamination.
Splenic Injuries. The spleen, in alternation with the liver, is
the first or second most commonly injured abdominal organ, and
isolated splenic injury comprises approximately 42% of abdomi-
nal trauma.44 The frequency of these injuries requires the surgeon
to possess a sound understanding of management strategies in
splenic injury. In reality, splenic trauma represents a spectrum of
diseases, ranging from self-limitation and observation to immedi-
ate splenectomy in the setting of hemodynamic instability.
In blunt trauma, direct compression of the spleen with paren-
chymal fracture is a common pathophysiologic mechanism at the
tissue level. Additionally, injury can be secondary to rapid decel-
eration that tears the splenic capsule and/or parenchyma where
it is fixed to the retroperitoneum. This mechanism can create a
subcapsular hematoma, which is demonstrated in Fig. 17.23. FIG. 17.23 Splenic injury with subcapsular hematoma. Despite only a
Penetrating splenic trauma is less common but is still present in 1-cm capsular tear, this injury demonstrated ongoing hemorrhage.
8.5% of all penetrating abdominal injuries in the 2012 NTDB.
Hemorrhage from a splenic injury can be ongoing with instabil- Unstable patients with abdominal trauma who are taken
ity at the time of presentation or, more commonly, will have re- emergently to the OR may have a splenic injury identified at the
solved spontaneously. As with other abdominal injuries, patients time of laparotomy (10% of blunt splenic injury). In all other
who are nonresponders to resuscitation with intraabdominal fluid patients, abdominal CT with IV administration of a contrast
on FAST require exploration. Patients who respond to resuscita- agent is the most valuable study for identifying and characteriz-
tion with normalized physiology can often be managed nonop- ing splenic injuries (sensitivity/specificity 96%–100%). Splenic
eratively, although this group is at risk for delayed reinitiation of injuries appear as disruptions in the normal splenic parenchyma,
hemorrhage (majority <72 hours). Over the past several decades, frequently with surrounding hematoma and free intraabdominal
rates of nonoperative management in splenic trauma has increased blood. Active bleeding can be identified by visualizing extravasa-
from roughly 40% to 70% with coincident decreases in mortality tion of contrast material (i.e., high-density blush or accumulation
among the higher grades of injury.44 of contrast-laden blood). At times, this extravasation will be free
into the peritoneal space or contained within an intraparenchymal of parenchymal or subcapsular abnormality and the presence of
pseudoaneurysm. A splenic injury with active extravasation into vascular involvement (Table 17.6).
a pseudoaneurysm is demonstrated in Fig. 17.24. Other types of The overall success rate for nonoperative management is ap-
splenic injury can include a hematoma confined to the subcapsu- proximately 90% in blunt splenic trauma for high-volume cen-
lar space and even complete devascularization of the organ caused ters. Advantages to this approach include reductions in hospital
by injury of the hilar vessels. Spleen injuries are characterized by costs, intraabdominal complications, blood transfusions, nonther-
the AAST Injury Scoring Scale, which grades injuries on the basis apeutic laparotomies, and mortality. Due to the increasing use of
splenic angiography and embolization over the past decade, non-
operative management failure rates of 5% are achievable in AAST
Grades III to V.44 To protocolize this approach, our institution has
developed a practice guideline whereby stable patients who dem-
onstrate imaging concerning for active extravasation or pseudoa-
neurysm are evaluated by interventional radiology or angiography
and embolization. Furthermore, patients without these findings
but high-grade injuries (III–V) are also evaluated by interven-
tional radiology and proceed to angiography and embolization
within 24 hours. Despite a great deal of prior investigation, there
is no constellation of risk factors (i.e., age, AAST grade, volume
of hemoperitoneum, etc.) for failure of nonoperative management
that, when present, identifies patients who would benefit from
prophylactic operative management in the setting of hemodynam-
ic stability. Moreover, previous studies have demonstrated a lack of
increase in complications and mortality with delayed operative in-
tervention.44 Nonetheless, patients with high-grade injures should
undergo intensive care monitoring on admission, maintaining a
low threshold for surgical management in the setting of decline.
FIG. 17.24 Grade III splenic laceration on abdominal computed tomog- Operative management of splenic injuries may be required in
raphy. Note the focus of active extravasation of contrast material within the setting of instability at the time of admission or after failed non-
the injured splenic parenchyma as identified by the arrow. operative management. Regardless, the best approach is through a
TABLE 17.6 AAST Spleen Injury Scale (2018 revision).

GRADE AIS SEVERITY IMAGING CRITERIA (CT FINDINGS) OPERATIVE CRITERIA PATHOLOGIC CRITERIA
I 2 Subcapsular hematoma <10% surface area Subcapsular hematoma <10% Subcapsular hematoma <10% surface area
surface area
Parenchymal laceration <1 cm depth Parenchymal laceration <1 cm Parenchymal laceration <1 cm depth
depth
Capsular tear Capsular tear Capsular tear
II 2 Subcapsular hematoma 10%–50% surface area Subcapsular hematoma Subcapsular hematoma 10%–50% surface
10%–50% surface area area
Intraparenchymal hematoma <5 cm Intraparenchymal hematoma Intraparenchymal hematoma <5 cm
<5 cm
Parenchymal laceration 1–3 cm Parenchymal laceration 1–3 cm Parenchymal laceration 1–3 cm
III 3 Subcapsular hematoma >50% surface area Subcapsular hematoma >50% Subcapsular hematoma >50% surface area
surface area or expanding
Ruptured subcapsular or intraparenchymal Ruptured subcapsular or Ruptured subcapsular or intraparenchymal
hematoma ≥5 cm intraparenchymal hematoma hematoma ≥5 cm
≥5 cm
Parenchymal laceration >3 cm depth Parenchymal laceration >3 cm Parenchymal laceration >3 cm depth
depth
IV 4 Any injury in the presence of a splenic vascular Parenchymal laceration Parenchymal laceration involving segmental
injury or active bleeding confined within the involving segmental or hilar or hilar vessels producing >25%
splenic capsule vessels producing >25% devascularization
devascularization
Parenchymal laceration involving segmental or
hilar vessels producing >25% devascularization
V 5 Any injury in the presence of a splenic vascular Hilar vascular injury, which Hilar vascular injury which devascularizes
injury with active bleeding extending beyond devascularizes the spleen the spleen
the spleen into the peritoneum
Shattered spleen Shattered spleen Shattered spleen
AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; CT, computed tomography.
Similar to other abdominal organs, liver injuries are often first

diagnosed on entering the abdomen in the unstable patient ex-
plored for free fluid on FAST examination. Those who do not
require immediate operation should be imaged with abdominal
CT enhanced with IV administration of a contrast agent. CT is
capable of providing excellent anatomic detail that allows highly
accurate characterization of injuries. Timing of contrast for de-
lineation of hepatic injury occurs in three phases (noncontrast,
arterial, portal venous), giving insight into the hemorrhage type.
Common findings on CT indicative of liver injury include disrup-
tion of the hepatic parenchyma with perihepatic blood or hema-
toma and hemoperitoneum. Bleeding from the liver can be seen
on CT as extravasation of contrast material either within the liver
parenchyma or into the peritoneal space, as seen in Fig. 17.25.
The characteristics of the liver injury on CT can be used to catego-
rize the injury with the AAST OIS, which accounts for parenchy-
FIG. 17.25 Grade IV liver laceration involving the right hepatic lobe on mal involvement and the presence of vascular injury (Table 17.7).
abdominal computed tomography. Note the focus of active extravasation Treatment of liver trauma has progressed over prior decades
of contrast material within the injured liver parenchyma at the periphery from aggressive operative to largely nonoperative care, coinciding
of the injury as identified by the arrow. with decreased in-hospital mortality. As described by Peitzman and
Richardson, the period of 1960 to 1975 presented multiple series
of patients who underwent resectional management, hepatic artery
midline incision, followed by packing of all four quadrants. A fixed ligation, and T-tube choledochostomy for liver injury. At that time,
retractor can improve exposure, and the packs are removed to expose morbidity and mortality, ranging from 27% to 65%, were suspect-
the injured spleen. To mobilize the spleen, the peritoneum is divided to arise from biliary/septic complications rather than hemor-
ed laterally by retracting the spleen posteromedially to expose the rhage. In 1976, Lucas and Ledgerwood shifted the focus of care to
retroperitoneal attachments. This division of the peritoneum begins prioritize bleeding management in hepatic trauma with subsequent
at the white line of Toldt (splenocolic ligament) and then continues decrease in mortality to 22%. Furthermore, the partners described
superiorly until the short gastric vessels are encountered. After the the use of temporary abdominal packing for control of liver bleed-
peritoneum is opened laterally, a blunt plane is created posterior to ing. This approach was later promoted by Feliciano, Mattox, and
the spleen in a medial direction, extending behind the tail of the Jordan for critically ill patients in whom surgical solutions for
pancreas. This maneuver mobilizes the entire spleen and distal pan- bleeding had failed. Following these practice changing reports, the
creas, allowing the spleen to be delivered up into the wound. While AAST OIS for liver, spleen, and kidney was first described in 1989
avoiding the greater curve of the stomach, the short gastric vessels and remains a consistent scheme for defining solid abdominal or-
are ligated and divided. Finally, the spleen is removed after the hilar gan injury. As data began to accumulate for a nonoperative man-
vessels are clamped and ligated, taking care not to injure the tail agement option in blunt liver trauma, a review of the literature by
of the pancreas or greater curve of the stomach. A drain should be Pachter and Hofstetter concluded that nonoperative management
placed only if there is concern that the tail of the pancreas was in- should be the approach of choice for the hemodynamically stable
jured. Postsplenectomy vaccines must be provided to ensure protec- patient, regardless of AAST grade. The continued development of
tion from encapsulated bacteria (Streptococcus pneumoniae, Neisseria CT technology in tandem with endovascular/endoscopic support
meningitidis, and Haemophilus influenzae) and prevention of over- has resulted in the majority of patients with Grades I to III inju-
whelming postsplenectomy sepsis (incidence 0.5%–2%, mortality ries being successfully managed nonoperatively, while two-thirds
30%–70%). Whereas splenic salvage techniques are well described, of Grades IV and V residually require surgical care. Polanco and
their utility is limited in the era of highly effective nonoperative colleagues, in review of resectional management for complex blunt
management and endovascular approaches to splenic trauma. and penetrating liver trauma, report a mortality from liver injury
Hepatic Injuries. Liver injuries are extremely common after of 9%. They attribute the improved mortality within their series
blunt trauma at a rate of 22.2% within the 2012 NTDB. Simi- to early decision for major operation, intraoperative resuscitation
larly, the liver is the most commonly injured abdominal organ technique, and senior surgical/subspecialty assistance.45
after penetrating trauma, present in 26.1% of cases. Mechanisms Patients who are hemodynamically stable in the setting of
of blunt hepatic trauma include compression with direct paren- blunt and penetrating liver trauma should be considered pri-
chymal damage and shearing forces, which tear hepatic tissue and marily for nonoperative management. Parenchymal bleeding or
disrupt vascular and ligamentous attachments. The liver is par- pseudoaneurysm on contrasted imaging should prompt consulta-
tially protected by the thoracic cage, although the ribs provide tion to interventional radiology for evaluation. The natural his-
little support during high-energy mechanisms. Penetrating mech- tory of hepatic pseudoaneurysms is not entirely elucidated, but it
anisms directly lacerate the hepatic parenchyma while also causing is believed that they may be associated with an increased risk of
adjacent tissue contusion. Mortality from liver injury, not unlike delayed bleeding, especially when associated with hepatic arterial
the management of other abdominal solid organs, has decreased branches. After successful embolization, patients need intensive
over time as practices have evolved from primarily operative to care surveillance for all hepatic injuries managed nonoperatively,
nonoperative management with endovascular and endoscopic although there is no standardized laboratory monitoring interval.
treatments. Associated morbidity from liver injury includes bleed- In appropriately selected patients, the use of angioembolization
ing, biliary, fistula (i.e., hemobilia, biliary fistula), infection, and has improved the rate of successful nonoperative management
hepatic necrosis. with a reduction in conversion to surgical treatment.
TABLE 17.7 AAST liver injury scale (2018 revision).

GRADE AIS SEVERITY IMAGING CRITERIA (CT FINDINGS) OPERATIVE CRITERIA PATHOLOGIC CRITERIA
I 2 Subcapsular hematoma <10% surface area Subcapsular hematoma <10% Subcapsular hematoma <10% surface
surface area area
Parenchymal laceration <1 cm depth Parenchymal laceration <1 cm depth Parenchymal laceration <1 cm depth
Capsular tear Capsular tear Capsular tear
II 2 Subcapsular hematoma 10%–50% surface Subcapsular hematoma 10%–50% Subcapsular hematoma 10%–50%
area surface area surface area
Intraparenchymal hematoma <10 cm in Intraparenchymal hematoma <10 cm in Intraparenchymal hematoma <10 cm in
diameter diameter diameter
Laceration 1–3 cm in depth and ≤10 cm Laceration 1–3 cm in depth and ≤10 cm Laceration 1–3 cm in depth and ≤10 cm
length length length
III 3 Subcapsular hematoma >50% surface area Subcapsular hematoma >50% Subcapsular hematoma >50% surface
surface area area
Ruptured subcapsular or parenchymal Ruptured subcapsular or paren- Ruptured subcapsular or parenchymal
hematoma chymal hematoma hematoma
Intraparenchymal laceration >10 cm, Intraparenchymal laceration >10 cm, Intraparenchymal laceration >10 cm,
laceration >3 m depth laceration >3 m depth laceration >3 m depth
Any injury in the presence of a liver vascular
injury or active bleeding contained within
liver parenchyma
IV 4 Parenchymal disruption involving 25%–75% Parenchymal disruption involving Parenchymal disruption involving
of a hepatic lobe 25%–75% of a hepatic lobe 25%–75% of a hepatic lobe
Active bleeding extending beyond the liver
parenchyma into the peritoneum
V 5 Parenchymal disruption >75% of a hepatic Parenchymal disruption >75% of a hepatic Parenchymal disruption >75% of a hepatic
lobe lobe lobe
Juxtahepatic venous injury to include Juxtahepatic venous injury to include Juxtahepatic venous injury to include
retrohepatic vena cava and central major retrohepatic vena cava and central major retrohepatic vena cava and central
hepatic veins hepatic veins major hepatic veins
AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; CT, computed tomography.
Even successful nonoperative management may require the to hepatic injuries as developed by the WTA is presented in Fig.
treatment of complications (12%–14%), such as bile leaks with 17.26. When operative management is required, a midline lapa-
biloma formation, hemobilia, and development of liver abscess- rotomy is the most versatile approach for managing any liver in-
es.45 Frequently, these are suggested by the development of ab- jury that might be encountered. The falciform ligament is divided,
dominal symptoms with, at times, the addition of systemic infec- and perihepatic sponges are placed to temporarily manage bleed-
tion or inflammation. CT or ultrasound imaging can be valuable ing from the liver. A fixed retractor can be placed to improve expo-
in evaluating for abscess and biloma; these can usually be managed sure of the right upper quadrant structures. When needed, perihe-
with percutaneous drainage guided by CT or ultrasound. Endo- patic packing and manual compression can temporize bleeding to
scopic retrograde cholangiopancreatography (ERCP) with stent provide the opportunity to catch up with the resuscitation. Once
placement is occasionally required to decompress the biliary tree the patient is reasonably stable, the packs are removed and the
and to promote healing of a bile leak. Biliary ascites not amenable injuries to the liver are evaluated. Mild injuries with minimal on-
to percutaneous drainage may require laparoscopy or laparotomy going bleeding may be managed with further compression, topical
for adequate drainage to be obtained. Hemobilia is managed with hemostatic agents, or suture hepatorrhaphy. Management of liver
angiography, which includes embolization of the hepatic vessel injuries may be facilitated by dividing the triangular ligaments to
that is communicating with the biliary tree. mobilize the right or left hepatic lobes. This will allow injuries
Although there have been great advances in the nonoperative to be better exposed for repair but may also allow more effec-
management of liver injuries, it should not be overlooked that tive packing by optimizing anterior to posterior compression. Any
unstable patients require operative management of bleeding. In mobilization of the liver must be carefully considered if there is
blunt trauma, a recent systematic review reported a pooled non- any chance that the attachments of the liver are providing lifesav-
operative management failure rate of 9.5%, predictive factors in- ing tamponade of retrohepatic bleeding. Most liver injuries will
cluding signs of shock and peritoneal signs on presentation, high require only superficial techniques for hemostasis to be obtained.
ISS, and associated intraabdominal trauma.45 Similarly, analysis When more severe bleeding from the liver is present, a Pringle
from LA county demonstrates failure of selective nonoperative maneuver is a valuable adjunct to slow blood flow enough to visu-
management in approximately 5% of patients suffering GSWs alize the injury. The hepatoduodenal ligament is encircled with a
to the liver.46 Polanco and colleagues, in a review of resectional vessel loop or vascular clamp to occlude hepatic blood flow from
management for complex blunt and penetrating liver trauma, re- the hepatic artery and portal vein. This maneuver helps distin-
port a mortality from liver injury of 9%. The surgical approach guish hepatic arterial and portal venous bleeding from hepatic
Bleeding hepatic trauma
Major bleeding Minor bleeding
Perihepatic packing Topical hemostatic agents

Resuscitate Suture hepatorrhaphy
Electrocautery/argon beam
Bleeding Bleeding
controlled uncontrolled
Damage control laparotomy Pringle maneuver

Consider angioembolization
ICU for resuscitation
Bleeding
Bleeding uncontrolled
controlled
Selective vessel ligation Perihepatic packing

Omental pack Resuscitate
Bleeding Bleeding Bleeding Bleeding

controlled uncontrolled controlled uncontrolled
Consider Consider ICU for Consider

angiography selective hepatic resuscitation vascular isolation
ICU for artery ligation with shunting
resuscitation procedure
ICU for resuscitation ICU for resuscitation
FIG. 17.26 Algorithm for the operative management of hepatic injuries. (Modified from Kozar RA, Feliciano
DV, Moore EE, et al. Western Trauma Association/critical decisions in trauma: Operative management of adult
blunt hepatic trauma. J Trauma. 2011;71:1–5.). ICU, Intensive care unit.
vein bleeding, which will persist with the hepatoduodenal liga- in the hope that packing alone will provide adequate control.
ment clamped. In many cases, the liver laceration can then be ex- Conversely, diffuse liver bleeding due to coagulopathy will not
plored and any actively bleeding vessels controlled with suture li- respond to repeated attempts at placement of suture. Instead,
gation. Hepatic parenchyma that appears to be devitalized should this should be treated with reversal of physiologic derangements.
be debrided and drains placed when injuries appear to be at risk Patients are then resuscitated in the intensive care unit until hy-
for a bile leak. A vascularized pedicle of omentum may reduce pothermia, coagulopathy, and acidosis resolve, at which time the
parenchymal bleeding and promote healing of the laceration when abdomen can be reexplored and packs removed. After damage
it is packed within the liver injury. control, angiography with embolization may provide additional
Liver injuries in the vicinity of the retrohepatic vena cava that assistance with management of ongoing bleeding from hepatic
are not actively bleeding should be packed and not explored. artery branches. Nonetheless, the mortality in this cohort of pa-
There are many heroic techniques described in the literature that tients remains high.
outline the repair of retrohepatic vena cava injuries, but the ap- Gastric Injuries. Injuries to the stomach by penetrating mecha-
proach with the greatest likelihood of success is preserving the nism (11%–18%) far outweigh the incidence due to blunt mo-
natural tamponade of this low-pressure region when feasible. An dalities (<1%).47 However, the mortality associated with blunt
atriocaval (Shrock) shunt is one method that includes isolation gastric trauma is significant, reaching 28.2% in an EAST multi-
of the retrohepatic vena cava by placing an intravascular shunt institutional trial. A closer evaluation of these patients reveals a
between the right atrium and infrahepatic vena cava. Isolation of significantly higher ISS compared to other groups, suggesting
the liver with an atriocaval shunt with the addition of a Pringle that mortality associated with blunt perforation of the stomach
maneuver theoretically allows repair of the vena cava or hepatic is consequential to high energy mechanisms. Rupture is caused
veins with less ongoing blood loss. by an acute increase in intraluminal pressure from external forces
Damage control techniques are often required because many that result in bursting of the gastric wall. Because of the high-
patients who require operative intervention for liver injuries have energy nature of this mechanism, associated injury to the liver,
already deteriorated physiologically. Control of surgical bleed- spleen, pancreas, and small bowel is common, and mortality is fre-
ing is obtained and the liver is packed, followed by temporary quently attributed to these associated injuries. In contrast, death
abdominal closure. It is inappropriate to leave surgical bleeding from penetrating injury to the stomach is relatively low at 2.2%.47
Penetrating gastric injuries often cause full-thickness perforations failure. As such, surgical treatment for duodenal injury has pro-
with spillage of gastric contents into the abdomen. duced multiple and complex treatment options.
Like other hollow visceral injuries, gastric injuries may be iden- Duodenal trauma can often pose a diagnostic and therapeutic
tified on physical examination by the presence of peritonitis. The challenge. Penetrating duodenal injuries are commonly first diag-
onset of this finding may be faster compared to small bowel per- nosed at laparotomy, initiated on the basis of penetrating wound
foration, given the lower pH of gastric contents.47 Furthermore, location. Blunt duodenal injuries can be more challenging to iden-
the location of penetrating wounds may be suggestive of gastric tify and therefore require a high index of suspicion to avoid missed
injury. Although, historically, injuries to the hollow viscus were injuries. Physical examination findings can be lacking due to the
identified on exploration for solid organ trauma, CT is now a retroperitoneal location of the duodenum. Even full-thickness
commonly employed modality in the stable trauma patient prior duodenal perforations may not demonstrate peritoneal signs un-
to operation. The overall sensitivity and specificity for hollow vis- less the perforation involves an intraperitoneal segment. The most
ceral injury on CT are limited (sensitivity 55%–95%, specificity valuable tool for diagnosis is abdominal CT with a low threshold
48%–92%) and depends upon the presence of secondary signs: for operative exploration. Imaging may demonstrate a thickened
bowel wall thickening, irregular wall enhancement, mesenteric duodenal wall with periduodenal air and fluid. Low-grade inju-
defects, and abdominal free fluid in the absence of solid organ ries, such as a duodenal hematoma, may also be identified by CT.
trauma. The latter finding of free fluid is an unreliable single met- If initial emergent imaging in hemodynamically stable patients is
ric for operation, in the setting of which therapeutic laparotomy suggestive of duodenal trauma, repeat imaging in the form of oral
ranges from 27% to 54%. Similarly, isolated pneumoperitoneum contrast-enhanced CT, timed for duodenal transit, or upper GI
in blunt trauma may also be an untrustworthy indicator for hol- fluoroscopy should be performed. Any evidence of duodenal per-
low viscus injury.47 As described previously, the algorithmic evalu- foration on imaging requires immediate operative intervention.
ation of blunt or penetrating abdominal trauma may include a pe- Findings may be subtle, but a low threshold for exploration must
riod of observation, whereby injury to the hollow viscus becomes be maintained because of the potential for false-negative abdomi-
clinically apparent. Importantly, if suspicion is high based upon nal CT results.
multiple metrics, the decision to explore should be expeditiously The approach to management of duodenal injuries depends
made, as mortality increases proportional to surgical delay. on the location of the injury and the amount of tissue destruc-
A full evaluation of the stomach includes visualization of the tion. Hematomas of the duodenal wall will often resolve without
anterior and posterior walls, requiring entry into the lesser sac. intervention and are an issue only if they cause a gastric outlet
Failure to accomplish this may lead to missed injuries with subse- obstruction. Treatment of obstructing hematomas consists of gas-
quent morbidity. The approach to repair is based on the amount tric decompression, initiation of total parenteral nutrition, and
of tissue loss and the injury location. Hematomas within the gas- reevaluation of gastric emptying with a contrast study after 5 to 7
tric wall should be evacuated to ensure the absence of perforation. days. If the duodenal obstruction persists after approximately 14
This is followed by control of bleeding and closure of the seromus- days, operative exploration is warranted to evacuate hematoma,
culature with nonabsorbable suture. Injuries that are full thickness evaluate for perforation, stricture, or associated pancreatic injury.
should have all nonviable tissue debrided; the gastric wall is then Hematomas will frequently decompress spontaneously during
closed in one or two layers. A common approach is to close the mobilization of the duodenum and the intestinal wall should then
perforation with absorbable suture and then to invert the suture be evaluated for injury. Duodenal hematomas identified inciden-
line with nonabsorbable seromuscular stitches. A stapler can also tally during laparotomy should not be intentionally opened unless
be used to close a perforation due to the redundancy of gastric there is a concern for full-thickness injury.
tissue and the unlikelihood of overly decreasing the volume of the A retrospective study from the Panamerican Trauma Society
stomach lumen. Injuries involving the gastroesophageal junction, found that 98% of patients with operative duodenal injury were
lesser curve, fundus, and posterior wall may be more challenging amenable to primary repair, inclusive of all AAST grades.48 Duo-
to approach and require better exposure of the upper abdomen. denal wall perforations can be repaired by a single- or double-
Rarely, highly destructive injuries that cause the loss of large por- layer approach after debridement of devitalized tissue. Complete
tions of the stomach will require partial or even total gastrectomy. mobilization of the duodenum with a wide Kocher maneuver is
Reconstruction could require Billroth I or II gastroenterostomy or required to provide necessary exposure and to ensure a tension-
creation of a Roux-en-Y esophagojejunostomy, depending on the free repair. Larger amounts of tissue loss or duodenal transection
extent of the resection. can be managed with resection and primary anastomosis as long
Duodenal Injuries. Duodenal injuries are uncommon after as the ampulla is not involved and the injured segment is short.
blunt and penetrating mechanisms, comprising under 2% of ab- Longer segments of duodenal injury or areas adjacent to the am-
dominal trauma. Because of the retroperitoneal location of the pulla may require enteric bypass with a Roux-en-Y reconstruction.
duodenum, most injuries are due to penetrating modalities, owing If possible, a healthy piece of omentum should be placed over any
to GSWs in approximately 80% of cases. In a recent multi-insti- repair for reinforcement. Additional maneuvers for protection of
tutional series, nearly 70% had associated abdominal injuries and suture lines from enteric contents (i.e., duodenal diverticulization,
the associated mortality was 24%. On univariate analysis, mortal- pyloric exclusion with gastrojejunostomy, tube duodenostomy)
ity was related to arrival hemodynamics, transfusion requirement, has been questioned in previous reviews and should be individual-
ISS, renal failure, and associated pancreatic injury.48 Blunt injuries ized to select cases. Similarly, drain placement following defini-
are caused by a blow to the epigastrium with a narrow object, tive repair is not mandatory, although a potential benefit may be
resulting in contusion of the wall or a rupture secondary to acute controlled fistula creation if leak occurs. In the damage control
elevation of intraluminal pressure. The classic description includes setting, the use of resection with wide drainage and temporary
abdominal impact by a steering wheel or, in children, a bicycle discontinuity is highly effective for controlling contamination.
handlebar. Morbidity in duodenal injury is most commonly re- Pancreatic Injuries. Pancreatic injuries commonly occur in as-
lated to septic complications, particularly in the setting of repair sociation with injury to the duodenum because of their proximity.
persistently unwell. When obtained more than 3 hours after injury

occurrence, an elevated serum amylase level may reflect pancreatic
trauma. Used in this way, serum amylase levels are reasonably sen-
sitive but lacking in specificity and are of limited value. Imaging
of the pancreatic ducts with ERCP or magnetic resonance chol-
angiopancreatography may increase diagnostic yield, especially for
those patients who have a suggestion of pancreatic injury. These
additional modalities continue to be studied and may occasionally
be valuable in planning therapy and the operative approach.
Pancreatic injuries of any significance require surgical man-
agement. Exposure of the entire pancreas is required to evaluate
for injury and to develop an effective surgical plan. This exposure
includes mobilization of the hepatic flexure and division of the
gastrocolic ligament, allowing retraction of the transverse and me-
socolon inferiorly. A Kocher maneuver will mobilize the pancre-
atic head and facilitate visualization. Assessment of the pancreas
includes determining the amount of parenchymal involvement,
FIG. 17.27 Pancreatic injury on abdominal computed tomography. The location of the injury, and presence of ductal trauma. Pancreatic
injury involves the pancreatic neck and appears as a 2-cm segment of ductal injuries to the left of the superior mesenteric vessels are
nonperfused pancreas tissue with surrounding edema as identified by managed with a distal pancreatectomy. The proximal pancreatic
the arrow. stump can be managed by individually ligating the duct, then
oversewing the parenchyma or using a stapling device. Healing of
the retained pancreas may be enhanced by coverage with a piece
However, the overall incidence in abdominal trauma is relatively of healthy omentum. A closed suction drain should be placed to
low (0.2%–12%).49 A penetrating mechanism is more commonly manage any pancreatic enzyme leak.
the cause, with 4.4% of patients with penetrating abdominal trau- Treating injuries of the ductal system within the head of the
ma sustaining a pancreatic injury. True pancreatic trauma-related pancreas can be more challenging. When tissue destruction is
mortality is difficult to identify, as deaths are often attributable to limited, managing these injuries with drainage alone often diverts
associated pathology. Nonetheless, morbidity and mortality are the leakage of pancreatic fluid externally, creating a controlled
noted to increase with AAST grade (up to 40% in Grade V in- fistula that frequently will close spontaneously. The closure of a
jury) along with delays in diagnosis and management.49 Pancreatic fistula may be facilitated by biliary decompression through the
enzymes are caustic; thus ductal injury with leak (≥Grade III) is placement of stents by ERCP. Massive destruction of the pancre-
the most significant contributor to organ-specific morbidity and atic head with devitalized parenchyma (Grade V) or combined
mortality. Pancreas tissue injury can result from direct laceration pancreatic and duodenal injuries may require a pancreaticoduo-
of the organ or through the transmission of blunt force energy to denectomy (Whipple procedure). This presents the patient with
the retroperitoneum. A common mechanism of blunt pancreatic a large surgical burden and is associated with a high postopera-
injury involves crushing of the body of the pancreas between a rigid tive complication rate. Only patients with normalized physiology
structure, such as a steering wheel or seat belt, and the vertebral should be considered candidates for pancreaticoduodenectomy;
column. The impact to the pancreas causes injury that ranges from others undergo an abbreviated operation with later reconstruc-
mild contusion to complete transection with ductal disruption. tion. Damage control for pancreatic injury includes hemorrhage
The identification of pancreas injuries can be challenging, par- control, external drainage, and temporary abdominal closure with
ticularly because available imaging modalities are not highly effec- plans for reexploration.
tive. As with the duodenum, the retroperitoneal location of the pan- Effective external drainage is an important component in the
creas makes physical examination findings less helpful for diagnosis. management of pancreatic injuries, the value of which cannot be
Three-dimensional imaging with IV contrast–enhanced abdominal overstated. Pancreatic enzyme diversion is required to prevent
CT provides the best view of the pancreas and associated injury. retroperitoneal exposure to caustic enzymes, which will provoke
Despite this, sensitivity/specificity for the detection of parenchymal a massive inflammatory response and progressive organ dysfunc-
injury (sensitivity 47%–79%) and the presence of ductal involve- tion. Less severe pancreatic injuries that do not involve the pan-
ment (sensitivity 52%–54%, specificity 90%–95%) remain incon- creatic duct (Grades I and II), including hematomas, parenchymal
sistently reported in the literature, potentially reflecting variations contusions, and lacerations of the capsule or superficial parenchy-
in radiologic interpretation between centers.49 CT alone may not ma, should be managed with external drainage. Closed suction
be satisfactory to rule out a clinically significant pancreatic injury, systems are associated with a reduced rate of abscess development
and a high index of suspicion must be maintained. On abdominal compared with open-style drains.49 Distal feeding access may be
CT, findings suggestive of pancreatic injuries include malperfusion valuable to provide early enteral nutrition, depending on the over-
of the pancreatic parenchyma, surrounding fluid, or hematoma and all clinical picture. Fig. 17.28 demonstrates an approach to the
stranding in the adjacent soft tissue. An injury involving the neck of operative management of pancreatic injuries.
the pancreas on CT is demonstrated in Fig. 17.27. Small Bowel Injuries. Although the small intestine is one of the
The identification of clinically significant pancreatic injuries more frequently injured organs after penetrating abdominal trau-
may require the use of other diagnostic studies. Reported inci- ma, it is a rarely injured entity by blunt mechanism (0.3%). Mortal-
dence of missed pancreatic trauma on CT approximates 15%.49 ity rates range from 15% to 20%, with most caused by associated
Repeated CT imaging may suggest a pancreatic injury that re- vascular injuries.47 At the tissue level, injury can be secondary to
quired time to develop inflammation in the patient who remains crushing, rupture, and shearing mechanisms. Penetrating injuries
Presumed pancreatic
injury
Complete exposure
of the pancreas
Damage control:
• Control hemorrhage
Hypothermia Yes • External drainage of
Coagulopathy
pancreas injury
Acidosis
• Temporary abdominal
closure
No
No External drainage
Pancreatic ductal
with closed
involvement
suction system
Yes
Determine location
of injury
Pancreatic head/uncinate: Pancreatic neck/body

right of the superior left of the superior
mesenteric vessels mesenteric vessels
External drainage Combined pancreas/ Distal pancreatectomy

Secure distal duodenum External drainage
feeding access or
destruction of
pancreatic head
Pancreaticoduodenectomy
FIG. 17.28 Algorithm for the operative management of pancreatic injury.
can range from tiny perforations to large destructive injuries that Small perforations can be repaired primarily with one or two lay-
devitalize circumferential segments of small bowel. Direct blunt tis- ers after debridement of devitalized tissue. Care must be taken to
sue injury can occur when the small bowel is crushed between the avoid overly compromising the size of the intestinal lumen. In the
steering wheel or seat belt and a rigid structure, such as the vertebral setting of multiple perforations, primary repair can still be safely
column. Small bowel rupture occurs when the intraluminal pres- performed as long as the injuries are not so close as to result in nar-
sure rapidly increases, causing a blow-out along the antimesenteric rowing of the bowel lumen when closed. Despite this, many sur-
border. Deceleration mechanisms can result in a shearing of the se- geons choose to perform a resection with anastomosis when mul-
rosa or muscularis throughout a segment of small bowel. Finally, tiple perforations are present within a segment of bowel. When
injuries to the small bowel mesentery can result in devascularization injuries involve more than 50% of the intestinal wall circumfer-
and subsequent intestinal necrosis without direct tissue injury. ence, bowel resection with anastomosis should be performed.
In the setting of penetrating mechanisms, small bowel injuries There has been no difference in leak rates demonstrated between
are often identified at the time of abdominal exploration. Patients stapled and hand-sewn anastomoses following resection. Selection
may have peritonitis on presenting examination or their abdomi- of the anastomosis technique should be based on the preference of
nal findings may worsen in the hours after arrival. As with other the surgeon and the amount of experience with the chosen tech-
hollow abdominal viscera, the evaluation can be challenging and nique. Hand-sewn anastomoses are frequently constructed in two
is similar to the evaluation of the stomach and duodenum as de- layers, but single-layer methods are equally efficacious. Damage
scribed earlier. Abdominal CT imaging has significant limitations, control for small bowel injuries includes rapid closure of perfora-
and a high index of suspicion must exist to avoid a missed injury. tions to control contamination with resection when large injuries
The repair of small bowel injuries depends on the amount of are present. Patients in shock may benefit from resection without
intestinal wall destruction in relation to the overall luminal cir- immediate anastomosis because of a higher risk of anastomotic
cumference. Injuries to the intestinal serosa can be reinforced with dehiscence and the need for an abbreviated operation. The abdo-
interrupted nonabsorbable suture, which imbricates the injury. men is temporarily closed and the patient is resuscitated to correct
routine utility of enteral contrast (“triple contrast”: oral, rectal, and

IV) to increase CT diagnostic yield in identification of operative
injuries following penetrating trauma. Others contend equivalent
results without these adjunctive measures, leading recent guide-
lines to allow for attending surgical discretion.42
Evaluation of the rectum may require a slightly different ap-
proach. While the absence of blood identified on digital rectal
examination may be adequate to rule out injury, its presence does
not confirm it. Nonetheless, positive digital rectal examination
for gross blood or a penetrating pelvic trajectory requires further
evaluation with imaging. Should the CT be negative for injury,
clinically relevant trauma is much less likely. However, if the imag-
ing results are indeterminate or there is clinical concern, an exam
under anesthesia with rigid proctosigmoidoscopy can be valuable
to provide visualization of the rectum and distal sigmoid colon.
Findings on endoscopy may include a clear injury to the rectum,
hematoma in the rectal wall, or a large amount of blood in the rec-
FIG. 17.29 Blunt left-sided colon injury at the time of laparotomy. The tal vault. Characterization of the injury (destructive rectal [>25%
injury mechanism resulted in a deserosalizing-type injury that involved a
circumference] vs. nondestructive) and location relative to the
segment of colon several centimeters long.
peritoneum will be valuable for planning surgical management.
Upper rectal injuries, especially those on the anterior or lateral
physiologic derangements. After resuscitation, intestinal continu- surfaces, may be first identified during visualization of the pelvic
ity can be reestablished on return to the OR. structures at the time of laparotomy.
Colon and Rectal Injuries. Colon and rectal injuries occur most The approach to operative repair depends upon the presence or
commonly after penetrating abdominal trauma and rarely after absence of destructive injury and the overall physiology of the pa-
blunt mechanisms. Similar to other hollow visceral injury, trauma tient. Historically, the approach to all colon injuries included resec-
to the colon and rectum takes place in only 0.3% of bluntly in- tion with the creation of a colostomy, due to fear of anastomotic
jured patients, the majority being hematomas and serosal tears.47 dehiscence and intraabdominal sepsis. Subsequent experience ques-
Historical data reveal a 22% to 35% mortality rate during World tioned the need for mandatory proximal fecal diversion to manage
War II, at which time colostomy creation for colon trauma was colonic perforations. Stone and Fabian first prospectively described
mandatory. Contemporary reports of mortality related to colon primary repair of colon injury versus colostomy creation in 1979,
injury are as low as 1%.50 In the literature, colonic trauma is com- observing lower incidence of intraabdominal infection with prima-
monly classified as either destructive or nondestructive. Destructive ry repair. Since that time, extensive investigation from Memphis has
injury in penetrating trauma is defined by wounds more than 50% led to conceptually divergent management of colon injuries based
of the colonic circumference, complete transection, and the pres- upon the identification of a destructive injury. Destructive wounds
ence of devascularized segments. In blunt injury, serosal tears more in the face of significant resuscitation (>6 units PRBC) and medi-
than 50% colon circumference, full-thickness perforation, and cal comorbidity were noted to experience anastomotic leak at 42%
mesenteric devascularization are considered destructive. These pa- versus 3% in otherwise healthy, minimally transfused patients fol-
thologies in blunt trauma are produced by direct crush or rupture lowing resection. Thus was developed surgical stratification for op-
when the rate of compression results in a rapid elevation in intralu- timal outcomes in operative colon injury, recommending primary
minal pressure. Importantly, depending upon the involved colonic repair (one or two layers) in all nondestructive injuries, resection,
segment, colon injury with perforation can occur into the retro- and anastomosis for destructive injury in the healthy patient with-
peritoneum. Most commonly seen in the retroperitoneal portions, out extremis and diversion for destructive injury in the comorbid
shearing forces can cause a separation of the serosa or muscularis patient requiring resuscitation.50 This schema holds true for both
from the underlying mucosa over a long segment. The results of penetrating and blunt injury and are not impacted by the degree
this injury mechanism are evident in Fig. 17.29. Finally, in addi- of intraabdominal contamination. Distal injuries require segmental
tion to GSWs, injury to the rectum may also occur when severe resection with colocolonic anastomosis.
pelvic fractures with sharp bone fragments cause a laceration. Destructive colon injuries that are encountered during dam-
From an examination standpoint, patients may present with a age control laparotomy in the unstable patient should be resected,
wide range of physiology. Peritonitis may be present on exam in the but immediate anastomosis should be avoided because of an unac-
setting of free perforation, yet the retroperitoneal location of the ceptably high leak rate. Depending on the need to abbreviate the
right and left colon may obscure this finding. Furthermore, colonic operation, colostomy can be created or the GI tract left in dis-
injuries may first be identified at the time of laparotomy prompted continuity until after the patient has been adequately resuscitated.
by hemodynamic instability or a suggestive penetrating mecha- Delayed primary anastomosis or creation of a colostomy can be
nism. For the physiologically stable patient, the evaluation of the performed on return to the OR. Discerning between these ap-
colon is similar to that of previously described hollow viscus injury. proaches has led to a spectrum of conclusions, from equivalency in
Abdominal CT is limited in capability, although it may demon- outcomes to mandatory colostomy for patients requiring open ab-
strate colonic wall thickening with surrounding stranding or fluid. domen as part of their management.50 Regardless, the most recent
Imaging may identify the track of a penetrating mechanism, allow- WTA guidelines suggest bias toward ostomy creation in patients
ing the surgeon to assess proximity to the colon. Finally, care must with ongoing shock, concomitant abdominal injuries, chronic ill-
be taken to adequately assess the segments of the colon that are ret- ness, immunosuppression, or inability to close fascia. A question
roperitoneal in location. This has led some authors to advocate for that remains unanswered is whether a diverting loop ileostomy
following colonic anastomosis would serve the same function in

this population as it has in other inflammatory states.
Rectal injuries that result in perforation can cause significant
contamination leading to pelvic sepsis. For this reason, operative 1
management is often required. Destructive rectal injuries (>25%
circumference) are predominantly managed with fecal diversion
(loop ileostomy or colostomy) and consideration of presacral
drainage until healing has occurred. A rectal contrasted enema
will serve to define wound resolution with subsequent ostomy
reversal. Evidence for routine proximal diversion and presacral
drainage of all injuries, irrespective of tissue destruction, is based
on limited data in small trials. More recent evidence suggests that
extraperitoneal rectal injuries may be managed without drainage
and diversion alone.50 Of note, if an extraperitoneal rectal injury 2 2
is found at laparotomy, management should convert to treatment
of intraperitoneal colon trauma.
Abdominal Great Vessel Injuries. The major blood vessels of
the abdomen are predominantly located within the retroperito-
neum, with some larger vessels also in the intestinal mesenteries.
Because of massive associated blood loss, visualization of the ves-
sels can be compromised, making management of these injuries
challenging. Most commonly, major abdominal vascular injuries 3
are secondary to penetrating mechanisms. In the setting of blunt
trauma, hematomas within the retroperitoneum are often second-
ary to pelvic fractures with bleeding from pelvic blood vessels that
dissect superiorly. Abdominal vascular injuries are addressed else-
where in this text (Chapter 64); thus only those concepts related FIG. 17.30 Zones of the retroperitoneum visualized at the time of laparot-
to initial assessment and management are presented here. omy. Zone 1 includes the central vascular structures, such as the aorta and
Abdominal vascular injuries are often first recognized at the vena cava. Zone 2 includes the kidneys and adjacent adrenal glands. Zone 3
time of laparotomy being performed for penetrating abdominal describes the retroperitoneum associated with the pelvic vasculature.
trauma. These injuries are frequently associated with significant
ongoing blood loss and hemodynamic instability. The specific
vascular injury is better delineated after exploration and expo- developed, and the abdominal viscera are retracted to the right to
sure of the retroperitoneal structures. Penetrating injuries to the expose the superior retroperitoneal vasculature.
back frequently benefit from three-dimensional imaging, given Blunt abdominal vascular injuries that are not actively bleed-
that most do not enter the peritoneal cavity. CT is often used to ing may require operative repair or may be considered for endo-
identify the path of the injury and therefore to suggest possible vascular therapy, depending on the nature of the vascular disease.
involvement of adjacent structures. Similarly, evaluation of the During laparotomy, the location of retroperitoneal hematoma
abdominal vasculature after blunt trauma is best achieved with guides surgical decision-making. As seen in Fig. 17.30, the retro-
contrast-enhanced CT. On occasion, retroperitoneal vascular peritoneum can conceptually be divided into three zones. Zone 1
injury is identified during urgently performed laparotomy, al- hematomas require exploration because these frequently involve
though further identification of specific injuries depends on the the aorta, proximal visceral vessels, or inferior vena cava, although
location of the hematoma. an exception may be the dark hematoma behind the liver, which
Penetrating injuries to the retroperitoneum identified during suggests a retrohepatic vena cava injury. Injuries to the retrohe-
laparotomy require exploration and repair. Although the details patic vena cava are best served by not exposing the contained,
of these repairs are discussed elsewhere, knowledge of the basic low-pressure injury and by gently packing the surrounding area.
exposure of these structures is important. Hematomas of the infra- A hematoma in the region of zone 2, which predominantly con-
renal vasculature or the right renal hilum are exposed with a right tains the kidneys, should be explored only if it appears that the
medial visceral mobilization, also known as the Cattell-Braasch hematoma is expanding and continuing to lose blood. Finally, a
maneuver. A wide Kocher maneuver is performed, and the peri- hematoma in zone 3 is usually secondary to pelvic fracture bleed-
toneal dissection is continued inferiorly to mobilize the right co- ing and should not be explored unless exsanguinating hemor-
lon. The dissection continues around the cecum and superiorly up rhage is obvious.
the mesenteric root. Retraction of the abdominal viscera superior Genitourinary Injuries. The genitourinary organs include
and to the left will expose the lower midline vascular structures the kidneys, ureters, bladder, and urethra, all of which are con-
(right colon should eviscerate to lay upon the chest). Basic tenets tained within the retroperitoneum. Bleeding and extravasation
of vascular repair including proximal and distal control of the in- of urine are the major concern with injuries to these structures.
jured vessel are achieved when possible. Injuries to the suprarenal Blunt mechanisms can result in renal laceration or bladder rup-
great vessels or the left renal hilum are exposed by performing a ture, which can occur into the peritoneal space or the soft tissue
left medial visceral mobilization (the Mattox maneuver). This is of the pelvis. The typical mechanism for bladder injuries is the
achieved by dividing the peritoneum along the entire left side of transmission of significant energy to the urine-filled bladder, re-
the abdomen, from above the spleen down to the distal left colon. sulting in wall rupture. This is almost universally associated with
The plane posterior to the colonic mesentery and the pancreas is some amount of pelvic fracture. All genitourinary structures are
vulnerable to penetrating mechanisms, many of which cause urine Orthopedic injuries constituted the greatest number of cases in
extravasation. the 2016 NTDB report, with 31.66% of patients having upper
The approach to evaluating and managing genitourinary inju- extremity and 40.09% having lower extremity trauma. Although
ries is described elsewhere in this text (see Chapter 74) and there- the mortality is low for each group (approximately 4%–5%), the
fore is only briefly outlined. The presence of gross hematuria is long-term morbidity and functional implications can be signifi-
the most valuable screen for injuries to the genitourinary organs cant.2 A variety of physical mechanisms are responsible for ortho-
and should prompt further evaluation. As with other abdominal pedic injuries, with falls and motor vehicle crashes being the most
structures, imaging with IV contrast–enhanced CT frequently common causes.
identifies injuries to the genitourinary organs. Abdominal CT re- Evaluation for musculoskeletal injuries begins with a thorough
veals injuries to the kidneys and adjacent adrenal glands and can physical examination, which easily identifies fractures that are open
demonstrate findings suggestive of urine extravasation. When sus- or demonstrate severe deformity. Plain radiography remains highly
picion exists, injury to the bladder can be evaluated by obtaining a effective for diagnosis, although some fractures, such as complex
CT cystogram. In male patients, blood at the urethral meatus or a pelvic fractures, benefit from CT. Pelvic fractures are typically
displaced prostate on rectal examination is suggestive of a urethral identified on initial pelvic radiography and then better character-
injury and requires evaluation. This is best achieved by performing ized on abdominal CT. In addition to evaluating the bone struc-
retrograde urethrography, especially before placement of a urinary tures, CT can identify associated hematomas and the presence or
catheter. Penetrating genitourinary injuries may be first identified absence of active extravasation of contrast medium, which appears
at the time of laparotomy or diagnosed with imaging studies. Pen- as high-density material within the hematoma. Extremity exami-
etrating injuries to the back benefit from CT, which can character- nation must include a thorough vascular assessment and evaluation
ize the injury track and delineate adjacent organs. for compartment syndrome. Clinical evidence of vascular injury
During laparotomy, penetrating trauma to the retroperitoneum may require angiography to localize and to characterize the abnor-
in the vicinity of the kidney should be explored to ensure hemo- mality. CT angiography has evolved and now constitutes a major
stasis but also to assess for a urine leak. Although it is not always contributor to the evaluation of peripheral vascular trauma.
feasible, obtaining proximal control at the renal hilum is ideal and Bleeding from complex pelvic fractures presents a unique chal-
should be performed whenever possible. Many renal injuries are lenge and requires a coordinated approach. As depicted in Fig.
hemostatic at the time of exploration, whereas many will respond 17.31, unstable patients should have a pelvic radiograph quickly
favorably to simple techniques. Conversely, devastating renal in- obtained and interpreted for pelvic fracture. An important point
juries, especially in the setting of shock with ongoing bleeding, is that although some pelvic fracture patterns are higher risk, any
may require nephrectomy. Assessment of the contralateral side for fracture is capable of bleeding and should be addressed in the
a kidney is valuable, but the potential for renal salvage should be unstable patient. Pelvic fractures that demonstrate an increase in
dictated by the physiologic condition of the patient. The repair pelvic volume should be compressed with a pelvic binder or sheet
of ureteral injuries can be achieved in several different ways rang- wrapped around the hips to reduce the space available for hema-
ing from primary repair to nephrectomy. Intraperitoneal bladder toma formation. Pelvic compression will frequently address ve-
injuries can be repaired in two layers of absorbable suture and the nous bleeding, but ongoing instability suggests an arterial source,
bladder drained with a Foley catheter or suprapubic cystostomy which should be addressed with angiography and embolization.
tube. Extraperitoneal bladder ruptures require only decompres- Some recent work has suggested that packing of the pelvis may
sion with a urinary catheter, followed by cystography to confirm be an alternative to embolization, especially when endovascular
healing after a period of recovery. therapy is not immediately available. Stabilization of the pelvic
Blunt injury to genitourinary structures is commonly identi- ring with external fixation or definitive repair is then performed
fied on imaging and can be managed nonoperatively in most cases. to maintain reduction of the pelvic volume and to limit ongoing
Bleeding from the kidneys and adrenal glands is often self-limited venous bleeding.
and requires no specific intervention. Injuries that demonstrate
no evidence of ongoing bleeding are candidates for nonoperative REHABILITATION
management. Physiologic deterioration requires laparotomy with
management of uncontrolled bleeding. Patients with hemody- Although the acute management of injuries plays the greatest role
namic stability but pseudoaneurysm from a renal injury on imag- in the reduction of mortality, it is the process of rehabilitation that
ing may benefit from angioembolization. As described before, a re- limits the long-term morbidity of injury. The rehabilitation pro-
nal hematoma after blunt trauma identified at laparotomy should cess can be substantially longer than the hospital phase of care and
be explored only if it appears that the hematoma is expanding. is indispensable in restoring functionality and allowing patients
to return to productive lives after injury. Despite a great deal of
Injuries to the Pelvis and Extremities emphasis being placed on trauma-related fatalities, there were ap-
The majority of injuries sustained by trauma patients involve the proximately 31 million nonfatal injuries in 2013, many of which
musculoskeletal system. Orthopedic injuries to the pelvis and required rehabilitative services.
extremities are extremely common and described in depth else- The rehabilitation process begins immediately after the acute
where in this text (Chapter 19). A basic approach to management needs of the injured patient have been met. Early mobilization is
as it relates to the general or trauma surgeon is presented here. extremely important to circumvent deconditioning. Physical and
Blunt trauma with

hemodynamic instability
Fracture on pelvic
radiograph
Wrap pelvis with

sheet or binder
FAST examination
Positive Negative
Exploratory Responsive to
laparotomy with fluid resuscitation?
hemorrhage control
No Yes
Hemodynamically Abdominal/pelvic
stable? CT imaging
Yes No
Ongoing evaluation/ Pelvic angiography Yes Pelvic hematoma

support with embolization with active
Consider external extravasation?
fixation
No
Pelvic fracture
external fixation
as needed
FIG. 17.31 Algorithm for the evaluation and management of pelvic fractures with associated hemorrhage. CT,
Computed tomography; FAST, focused abdominal sonography in trauma.
occupational therapists frequently begin the process by initiating appropriate facilities. Select populations of patients may benefit
therapy and determining what resources may be required when the from rehabilitation centers that focus on the recovery from specific
patient leaves the hospital. With these recommendations available, conditions, such as TBIs and SCIs. These two patient cohorts have
case managers and social workers can begin the process of iden- specific needs that are best addressed at centers with specialized ex-
tifying the inpatient or outpatient resources required to address pertise. Health systems committed to trauma care must place a high
the unique rehabilitation needs of the patient. Early engagement priority on supporting the rehabilitation process, given that this is
by the rehabilitation team can expedite referrals and transfer to one of the most important aspects of a patient’s long-term recovery.
SELECTED REFERENCES Nathens AB, Jurkovich GJ, Cummings P, et al. The effect of orga-
nized systems of trauma care on motor vehicle crash mortality.
American College of Surgeons. Committee on Trauma. Advanced JAMA. 2000;283:1990–1994.
Trauma Life Support. 10th ed. Chicago: American College of
Surgeons; 2018. This study demonstrated the benefit of establishing a sys-
tematic method of managing trauma from the time of injury
through the rehabilitation process. During a 17-year span,
First released more than 35 years ago, the Advanced Trauma more than 400,000 vehicle-related fatalities throughout the
Life Support (ATLS) course revolutionized the initial approach United States were evaluated for the effect of establishing a
to the injured patient. The ATLS 10th edition contains the trauma system. The study identified a mortality benefit of 8%
same systematic approach that has been taught since the from trauma system development.
initiation of the course as well as an even greater emphasis
on the underlying support from the literature. The course pro- Rotondo MF, Cribari C, Smith RS. American College of Surgeons
vides a framework to successfully perform an initial evalua- Committee on Trauma: Resources for Optimal Care of the Injured
tion, stabilization, and transfer of the injured patient. The ad- Patient 2014. 6th ed. Chicago: American College of Surgeons;
dition of online tools and companion mobile app (MyATLS) 2014.
further support the trainee in the process of internalizing care
for the injured. This document outlines the necessary components for the
optimal management of injured patients in a trauma center.
Guidelines for the management of severe traumatic brain injury. J Known as the Orange Book, this resource was developed
Neurotrauma. 2007;24:S1–S106. by the Committee on Trauma and is frequently updated to
remain current. The requirements to become verified as a
These guidelines represent the most comprehensive com- trauma center and then to maintain verification are contained
pilation of all literature related to traumatic brain injury (TBI). within this document.
Evidence-based guidelines are provided on the basis of the
strength of the associated studies. Application of the guide- Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’:
lines has been associated with improved outcomes after TBI. an approach for improved survival in exsanguinating penetrating
Current editions of the guidelines are available through the abdominal injury. J Trauma. 1993;35:375–382.
Foundation website, as they are updated continuously as a
living document.
This article was the first to present the concept of damage
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, control, which has become the standard of care in manag-
platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and ing multiple severe injuries. It was not until the development
mortality in patients with severe trauma: the PROPPR ran- of this approach that surgeons employed the abbreviation of
domized clinical trial. JAMA. 2015;313:471–482. abdominal surgery to prevent the deadly cycle of worsening
hypothermia, coagulopathy, and acidosis. Based on the suc-
This trial solidified the concepts of damage control resuscita- cess of this methodology, other areas of trauma manage-
tion with transfusion of reapproximated whole blood to the ment, such as orthopedics and resuscitation, have developed
injured trauma patient. It was the first randomized multicenter similar approaches.
trial of its kind to demonstrate optimal resuscitative practic-
es within the civilian population. Data revealed that a 1:1:1
transfusion strategy (plasma, platelets, RBC) resulted in more
patients achieving hemostasis with decreased death due to REFERENCES
exsanguination at 24 hours versus 1:1:2.
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tion of the effect of trauma-center care on mortality. N Engl J the Injured Patient 2014. 6th ed. Chicago: American College
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2. Committee on Trauma American College of Surgeons.
The National Study on Costs and Outcomes of Trauma is a National Trauma Data Bank Annual Report 2016. Chicago:
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in-hospital mortality (7.6% vs. 9.5%; relative risk, 0.80; 95% organized systems of trauma care on motor vehicle crash mor-
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17 CHAPTER

Management of Acute Trauma

BOX 17.1 Advances and discoveries in

French and Indian War (1754–1763)

Development of specialty hospitals (eye/ear, orthopedics, hernia)

because of the time-dependent nature of injury. The initial ap-

Measure vital signs and level of consciousness

Glasgow Coma Scale 13

Assess mechanism of injury and evidence of high-energy impact

Assess special patient or system considerations

Transport according to protocol¶¶¶

When in doubt, transport to a trauma center.

blood products may be the superior resuscitative fluid. In a re-

Arrival of injured patient

Expose entire patient Specific hemorrhage control

A Time (min) D Fibrinolysis E Hypercoagulable

Severe injury with

Craniotomy with Consider placement

Measure ICP and

No Refractory intracranial Continue ICU care:

Blunt and penetrating mechanisms result in different causes of

a severe cervical spine fracture with subluxation and anterior dis-

TABLE 17.5 Fractures of the vertebral column.

lists the previously described and commonly encountered verte- Evaluation

Immediate Management Management

exception because these may involve the underlying brain and

Penetrating neck trauma

Hard signs of arterial injury

Suspicion for injury? Secure airway

Observe Location of injury?

Zone I Zone II Zone III

Symptoms? CTA neck

CTA neck CTA neck

OR for exploration ± Concern for TE injury

Inconclusive Positive Negative

Positive Characterize Stop

Antithrombotic therapy Operative or endovascular Operative or

Injury Injury remains

Stop Continue antithrombotic

Physical examination Initiate resuscitation Emergency

Pneumothorax/ Tube thoracostomy

Tube Injury within High chest tube

Evaluate mediastinum: Monitor chest Operating room

Monitor chest Continue

The traditional indications for immediate thoracotomy include

fissures, whereas contusions are not limited by ventilatory seg-

The location of penetrating injury on initial examination will

of injuries to the cervical esophagus is described previously in “In-

Blunt abdominal trauma

Solid organ Exploratory laparotomy

Pseudoaneurysm or Manage other injuries

injury is identified with active extravasation, angioembolization Management

Abdominal stab wound

Flank/back Anterior abdomen Thoracoabdomen

CT abdomen/pelvis CT abdomen/pelvis Evaluation of diaphragm:

Diagnostic laparoscopy DC serial exams

control, the abdominal fascia is closed and the subcutaneous

TABLE 17.6 AAST Spleen Injury Scale (2018 revision).

Similar to other abdominal organs, liver injuries are often first

Glasgow Coma Scale 13