Emergency & Trauma Surgery

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Emergency and essential surgical care

Emergency and essential surgical care covers those interventions that are critical for specific condition in preventing premature death and disability.

Surgical emergency is a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully.

Acute surgical emergencies are the most common reason for hospital admission. These conditions include acute appendicitis, cholecystitis, diverticulitis, pancreatitis, intestinal obstruction, intestinal ischemia, intra-abdominal sepsis, incarcerated hernias and perforated viscous.

This involves both operative and non-operative management to treat traumatic injuries, typically in an acute setting and normally focuses on the abdominal area along with any given ‘Emergency’ field they may be required to serve upon. This involves initially resuscitating, stabilizing, later evaluating, and managing the patient.
In emergency room, emergency care clinician will need to stabilize and reduce the bleeding of traumatic wounds by wound care dressing procedure in order to avoid any infection.

Causes of Trauma Injuries

  • Blunt: Motor vehicle crash, falls, all-terrain vehicle crashes, assaults
  • Penetrating: Gunshot wounds, stab wounds, farm implement injuries

Trauma Procedures

  • Trauma evaluation (level 1 and level 2)
  • Exploratory laparotomy
  • Emergency thoracotomy
  • Resuscitation
  • Chest wall stabilization
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Abdominal trauma

  • It is an emergency condition that causes damage to the abdominal organs and hence must be treated well before they pose any serious health complications.
  • Abdominal trauma is typically categorized in two types: Blunt Abdominal Trauma and Penetrating Abdominal Trauma.
  • Blunt trauma may involve a direct blow (eg, kick), impact with an object (eg, fall on bicycle handlebars), or sudden deceleration (eg, fall from a height, vehicle crash). The spleen is the organ damaged most commonly, followed by the liver and a hollow viscus (typically the small intestine).
  • Penetrating trauma may penetrate peritoneum and if they do, may not cause organ injury. Stab wounds are less likely than gunshot wounds to damage intra-abdominal structures; in both, any structure can be affected. Penetrating wounds to the lower chest may cross the diaphragm and damage abdominal structures.
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Associated injuries

Blunt or penetrating injury that affects intra-abdominal structures may also damage the spine, ribs, and/or pelvis. Patients who experience significant deceleration often have injuries to other parts of the body, including the thoracic aorta.

Complications

Blunt or penetrating trauma may lacerate or rupture intra-abdominal structures. Blunt injury may alternatively cause only a hematoma in a solid organ or the wall of a hollow viscus.
Early consequences may be lacerations hemorrhage due to low-grade solid organ injury including minor vascular laceration with minimal physiologic consequences or more serious injuries having massive hemorrhage with shock, acidosis, and coagulopathy.

Delayed consequences are:

  • Hematoma rupture
  • Intra-abdominal abscess
  • Bowel obstruction or ileus
  • Biliary leakage and/or biloma
  • Abdominal compartment syndrome

Symptoms and Signs

  • Mild abdominal pain
  • More painful injuries due to fracture, altered sensorium due to head injury, substance abuse, or shock.
  • Pain from splenic injury sometimes radiating to the left shoulder.
  • Pain from a small intestinal perforation steadily worsens over the first few hours.
  • Renal injury may notice hematuria.

Diagnosis:

  • Clinical evaluation
  • CT scan or ultrasonography
  • A thorough, organized trauma evaluation simultaneous with resuscitation
  • Following clinical evaluation, few patients may require exploratory laparotomy rather than testing, in conditions like: Peritonitis, Hemodynamic instability due to penetrating abdominal trauma, Gunshot wounds, and Evisceration
  • Patients with very low risk and isolated anterior abdominal stab wounds that have not penetrated the fascia may be discharged.

It may involve nonoperative or surgical treatment, or both as appropriate. Although nonoperative intervention is increasingly used in selected patients, surgical therapy for penetrating abdominal trauma remains an essential part of overall management.

  • Sometimes laparotomy for hemorrhage control, organ repair, or both.
  • Rarely arterial embolization.
  • In hemorrhagic shock, damage control resuscitation is done.
  • Antibiotics are often given before surgical exploration when patients develop an indication for surgery.
  • Prophylactic antibiotics are not indicated when patients are managed without surgery.

When laparotomy is indicated, broad-spectrum antibiotics are given. A midline incision is usually preferred. When the abdomen is opened, hemorrhage control is accomplished by removing blood and clots, packing all 4 quadrants, and clamping vascular structures. Obvious hollow viscus injuries (HVIs) are sutured. After intra-abdominal injuries have been repaired and hemorrhage has been controlled by packing, a thorough exploration of the abdomen is then performed to evaluate the entire contents of the abdomen.

Indications for laparotomy in a patient with blunt abdominal injury:

  • Signs of peritonitis
  • Uncontrolled shock or hemorrhage
  • Clinical deterioration during observation
  • Hemoperitoneum findings after focused assessment with sonography for trauma (FAST) or diagnostic peritoneal lavage (DPL) examinations
  • Finally, surgical intervention is indicated in patients with evidence of peritonitis based on physical examination findings.

Trauma laparotomy procedures include:

  • Control of bleeding
  • Identification of injuries
  • Control of contamination
  • Reconstruction (if possible)

Post operative wound care is also important to avoid any infection in surgical site. A correct way of wound care dressing procedure can prevent you from infections.

Chest trauma can lead to several serious injuries. Chest trauma patients usually present with chest pain and shortness of breath, but can also present in shock (altered mental status) or in traumatic arrest.

Symptoms

Symptoms of chest trauma can be roughly the same, regardless of whether the trauma was blunt force or penetrating. These symptoms include:

  • Difficulty breathing
  • Hypotension from blood loss
  • Failure of the lungs to expand properly
  • Crunching sounds when palpating the rib cage
  • Bruising of the chest wall
  • Coughing up blood
  • Flail chest, when a section of the chest wall sucks in when the patient is inhaling
  • Puncture wound to the chest that sucks air

Causes

Chest trauma has several causes, usually related to blunt or penetrating injuries with high forces. For example:

  • Motor vehicle accidents account for up to 70 percent of blunt force chest trauma
  • Motorcycle accidents
  • ATV accidents
  • Falls from a great height
  • Sports-related injuries
  • Gunshot wounds
  • Knife injuries
  • Combat blast injuries

Diagnostic Testing

Chest trauma has several causes, usually related to blunt or penetrating injuries with high forces. For example:

  • Chest X-ray: Used for detection of acute traumatic injuries such as pneumothoraxes/hemothoraxes. Chest CTs: It has much higher sensitivity for detection of acute traumatic chest injuries.
  • eFAST Ultrasound: Helps in the diagnosis and management of several acute chest injuries such as hemo and pneumothorax as well as tamponade.
  • EKG: Helpful in blunt chest trauma or single car MVA’s to help elucidate a cause of the accident.
  • Pulse Oximetry: To assess adequacy of oxygenation and need for supplemental O2.

Diagnostic Testing

Chest trauma has several causes, usually related to blunt or penetrating injuries with high forces. For example:

  • Chest X-ray: Used for detection of acute traumatic injuries such as pneumothoraxes/hemothoraxes. Chest CTs: It has much higher sensitivity for detection of acute traumatic chest injuries.
  • eFAST Ultrasound: Helps in the diagnosis and management of several acute chest injuries such as hemo and pneumothorax as well as tamponade.
  • EKG: Helpful in blunt chest trauma or single car MVA’s to help elucidate a cause of the accident.
  • Pulse Oximetry: To assess adequacy of oxygenation and need for supplemental O2.

The basic goal of treating patients with chest injuries is to establish normal gas exchange and normal hemodynamics. A specific treatment depends on the actual traumatic condition:

  • Hemodynamically unstable patients: Packed RBC (O-Neg) transfusion), consideration of STAT OR for surgical intervention.
  • Pneumothorax: Tube thoracostomy.
  • Open Pneumothorax: Tape wound and tube placement at site separate from injury
  • Hemothorax: As above, except if greater than 1500 cc of blood obtained on initial chest tube placement or more than 150-200cc/hr x 4 hours, patient needs to go to the OR under Cardiothoracic surgery.
  • Flail Chest: Symptomatic Support, intubate and ventilate as needed. Incentive spirometry. In extreme cases patient may need cardiothoracic surgical intervention.
  • Pulmonary Contusion: Symptomatic support, high flow oxygen, early intubation if needed, incentive spirometry.
  • Cardiac Contusion: Monitoring if any significant changes in ejection fraction
  • Cardiac Tamponade: Pericardiocentesis followed by OR thoracotomy.
  • Blunt Aortic Injury: If stable blood pressure control followed by close observation and delayed aortic repair. If unstable, massive transfusion protocol, transfuse pRBC and stat emergency aortic repair by Cardiothoracic and Vascular surgery.
  • Great Vessel Injury: Typically unstable shock like presentation: Massive transfusion with concurrent OR thoracotomy.

Disposition

Apart from patients with very superficial lacerations, superficial contusions and solitary rib fractures, most patients warrant admission for observation under Trauma services. Treatment depends on the nature of injury.