ALGORITHMS Algorithms for managing the common trauma patient J John, MB ChB Department of Urology, Frere Hospital, East London Hospital Complex, East London, South Africa Corresponding author: J John (jeffveenajohn@gmail.com) Approach to penetrating abdominal trauma Resuscitate with 2 L crystalloid solution and monitor response blood transfusion Admit for observation and serial examinations Complete primary survey (adjuncts, SAMPLE history) Complete secondary survey Still unstable Assess for other causes of shock Bowel evisceration Fluid refractory haemorrhagic shock Free air under the diaphragm Diaphragmatic herniation Blood in NG tube Decreasing haemoglobin See Figs 7 and 8 Frank haematuria with flank/back wounds EUA in theatre Rectal bleeding Admit for observation and serial examinations Deep to deep fascia Discharge Clean and suture Superficial to deep fascia Local wound exploration Fig. 1. Approach to penetrating abdominal trauma (ATLS = advanced trauma life support; = focused assessment with sonography in trauma/ ultrasound scan; EUA = examination under anaesthesia; CT = computed tomography; NG = nasogastric; SAMPLE = signs and symptoms, allergies, medications, pertinent medical history, injuries, illnesses, last meal/intake, events leading up to the and/or illness). 502 June 2015, Vol. 105,. 6
Approach to blunt abdominal trauma Resuscitate with 2 L crystalloid solution and monitor response blood transfusion Admit for observation and serial examinations Abdomen soft, non-tender Complete primary survey (adjuncts, SAMPLE history) Complete secondary survey Still unstable Acute abdomen (if unavailable) (if available) Free fluid or clinical uncertainty Solid organ rmal CT abdomen CT abdomen Decreasing haemoglobin Hollow viscous Solid organ Admit for observation and serial examinations Fig. 2. Approach to blunt abdominal trauma (ATLS = advanced trauma life support; = focused assessment with sonography in trauma/ultrasound scan; CT = computed tomography; SAMPLE = signs and symptoms, allergies, medications, pertinent medical history, injuries, illnesses, last meal/intake, events leading up to the and/or illness). Approach to penetrating chest trauma (central chest wall) Haemodynamically Unstable unstable ATLS principles A, B, C, D & E Haemodynamically stable Clinical features of tension, or haemothorax Erect CXR Haemothorax Pneumothorax Minimal or no Clinical improvement? Clinical features of cardiac tamponade Repeat CXR in 4-6 hours Stable Unstable Bleeding >1 500 ml or >200 ml/hour Increase in size of FAST/ ECHO Pericardiocentesis FAST/ECHO Thoracotomy Observe and manage Fig. 3. Approach to penetrating chest trauma (central chest wall) (ATLS = advanced trauma life support; ICD = intercostal drain; FAST/ECHO = focused assessment with sonography in trauma/echocardiography; CXR = chest X-ray). 503 June 2015, Vol. 105,. 6
Approach to penetrating chest trauma (lateral chest wall) Haemodynamically Unstable unstable ATLS principles A, B, C, D & E Haemodynamically stable Clinical features of tension, or haemothorax Erect CXR Haemothorax Pneumothorax Minimal or no Clinical improvement? Clinical features of cardiac tamponade Repeat CXR in 4-6 hours Stable Unstable Bleeding >1 500 ml or >200 ml/hour Increase in size of FAST/ ECHO Pericardiocentesis Thoracotomy Observe and manage Fig. 4. Approach to penetrating chest trauma (lateral chest wall) (ATLS = advanced trauma life support; ICD = intercostal drain; FAST/ECHO = focused assessment with sonography in trauma/echocardiography; CXR = chest X-ray). Approach to penetrating neck trauma Emergency neck exploration if evidence of haemo-/ Active arterial bleeding Rapidly expanding haematoma Absent radial pulse Air bubbling through wound Respiratory distress Zone II (between the cricoid cartilage and angle of the mandible) Did penetrate platysma muscle? Zone I (inferior to cricoid cartilage) Zone III (above angle of mandible) Chest X-ray C-spine X-ray Angiogram Endoscopy Spiral CT chest Rule out Check for fractures, foreign bodies, air in soft tissues Suspected vascular (haematoma, bruit, neurological fallout, BP difference >10 mmhg in each arm, widened mediastinum) Suspected oesophageal (dysphagia/odynophagia) Suspected aortic C-spine X-ray Angiogram Laryngoscopy Sialogram Suspected pharyngeal Suspected parotid gland Fig. 5. Approach to penetrating neck trauma (ATLS = advanced trauma life support; ICD = intercostal drain; CT = computed tomography; C-spine = cervical spine; BP = blood pressure). 504 June 2015, Vol. 105,. 6
Approach to penetrating limb trauma ATLS principles A, B, C, D & E Any hard signs Measure Doppler pressures (ankle brachial index) and compare with unaffected limb Any evidence of distal ischaemia Absent or diminished pulses Active bleeding Expanding or pulsatile haematoma Audible bruit Palpable thrill >0.9 <0.9 Angiogram Multiple sites of entry Extensive bone and soft tissue damage Pre-existing vascular disease Emergency limb exploration Fig. 6. Approach to penetrating limb trauma (ATLS = advanced trauma life support). Approach to frank haematuria in trauma (bladder and renal injuries) Resuscitate with 2 L crystalloid solution and monitor response blood transfusion Blunt trauma Penetrating trauma Still unstable Pelvic fracture CT abdomen with delayed phase for ureter views Cystogram or CT cystogram Renal Isolated extraperitoneal bladder rupture Bladder Admit for conservative management 1. Urethral catheter for 10 days 2. IV antibiotics 3. Repeat cystogram at 10 days Intraperitoneal bladder rupture Haemodynamic instability Suspected renal pelvis Renal artery thrombosis Other intraperitoneal visceral damage Admit for conservative management 1. Strict bed rest 2. IV antibiotics 3. Serial abdominal examinations Fig. 7. Approach to frank haematuria in trauma (bladder and renal injuries) (ATLS = advanced trauma life support; IV = intravenous; = focused assessment with sonography in trauma/ultrasound scan; CT = computed tomography). 505 June 2015, Vol. 105,. 6
Approach to frank haematuria in trauma (urethral injuries) ATLS principles A, B, C, D & E Complete primary survey (adjuncts, SAMPLE history) Complete secondary survey Emergency exploration and insertion of suprapubic catheter Suspected urethral with blood at the external urethral meatus Penetrating Blunt Incomplete (slight extravasation, contrast enters bladder) Ascending urethrogram Complete (extravasation, contrast does not enter bladder) Insert transurethral catheter If fails Insert suprapubic catheter Fig. 8. Approach to frank haematuria in trauma (urethral injuries) (ATLS = advanced trauma life support; SAMPLE = signs and symptoms, allergies, medications, pertinent medical history, injuries, illnesses, last meal/intake, events leading up to the and/or illness). Approach to head ATLS principles A, B, C, D & E Multiple system injuries/polytrauma Isolated head Check A, B, C Haemodynamically unstable CXR Pelvic X-ray Examine limbs ± X-rays Discharge with head form deterioration Observe 4-6 hours 1. GCS <13 at any point since 2. GCS <15 2 hours since 3. Suspected open/depressed fracture 4. Focal neurological deficit 5. Post-traumatic seizure 6. Any penetrating head/orbital 7. >1 episode of vomiting since 8. LOC/amnesia in patients >65 years, with coagulopathies or dangerous mechanism of Deteriorates CT scan (uncontrasted) and preferably with C-spine ICD Still unstable Thoracotomy laparotomy angio-embolisation ± external fixation Splint rmal CT/only simple skull fracture Intracranial /depressed or compound skull fracture Admit ± theatre (discuss with neurosurgeon) Fig. 9. Approach to head (ATLS = advanced trauma life support; CXR = chest X-ray; = focused assessment with sonography in trauma/ultrasound scan; ICD = intercostal drain; GCS = Glasgow Coma Scale; LOC = loss of consciousness; CT = computed tomography; C-spine = cervical spine). 506 June 2015, Vol. 105,. 6
Acknowledgement. A special thank you to the consultants at Frere Hospital for reviewing the algorithms and perfecting them for publication, especially Drs W Matshoba, K Kesner, E Simpson, D Brown and A Makangee. The contribution of the Eastern Cape Department of Health in providing funding for the printing and circulation of the algorithms and the Surgery Survival Guide handbook is gratefully acknowledged. A special word of appreciation to Prof. G Boon for driving this process from start to finish. Further reading American College of Surgeons, Committee on Trauma. ATLS: Advanced Trauma Life Support Program for Doctors (ATLS ). Student Manual. 6th ed. Chicago, IL: American College of Surgeons, 1997. Heyns C, Barnes D. Introduction to Urology. Cape Town: South African Urology Association. John J, ed. Surgery Survival Guide. East London: Eastern Cape Department of Health, 2015. Nicol A, Steyn E, eds. Handbook of Trauma for Southern Africa. 3rd ed. Cape Town: Oxford University Press Southern Africa, 2010. Welzel T. Emergency Medicine Guidance for the Western Cape. Revised ed. Cape Town: Western Cape Department of Health, 2013. S Afr Med J 2015;105(6):502-507. DOI:10.7196/SAMJ.9795 507 June 2015, Vol. 105,. 6