Trauma

High-yield ABSITE review organized by the trauma survey. Primary survey first, then head, spine, neck, thoracic, abdominal, urologic, and extremity injuries, followed by shock/damage-control resuscitation and special populations (pediatric, pregnant).

Primary Survey (ABCDE)

• Most trauma questions are really asking you to prioritize — always address the airway first.
• Can’t intubate, can’t ventilate → cricothyroidotomy.
• Disability — looking for signs of elevated ICP, not a complete neuro exam. GCS and pupillary exam are the two things that matter most.
  • Of the three GCS components, motor score has the most prognostic value.
  • GCS < 8 → intubate.
• Pupillary exam
  • Unilateral fixed, dilated pupil → ipsilateral space-occupying lesion (blood) compressing CN III.
  • Bilateral pinpoint pupils → pontine hemorrhage.

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Head Trauma

ICP Monitoring

• Who needs one? GCS < 8 with an abnormal head CT.
• Two types: ventriculostomy (drain in the ventricle — can also drain CSF to lower ICP) and the bolt (intraparenchymal).
• Golden rule of head trauma: avoid hypotension and hypoxia — both worsen secondary brain injury.
• Cushing’s reflex: bradycardia, hypertension, altered respirations. A late finding indicating impending herniation.
  • Initial management: elevate the HOB, ventilate to a pCO₂ of ~35, mannitol and/or hypertonic saline, sedate and paralyze.

Lesion Patterns

| Lesion | Presentation | Imaging | |—|—|—| | Epidural hematoma | Hit to the head, lucid interval, then rapid GCS decline | Lenticular (biconvex) lucency, contained by suture lines | | Subdural hematoma | Older patient on anticoagulation, ground-level fall | Crescent-shaped lucency, crosses suture lines | | Intraparenchymal hemorrhage | Most common lesion after blunt injury (e.g., MVC) | — | | Subarachnoid hemorrhage | “Worst headache of life,” often spontaneous | — |

Cerebral Perfusion Pressure (CPP)

• CPP = MAP − ICP; a surrogate for cerebral blood flow. Target CPP > 60, ICP < 20.
• Main regulator of CPP: PaCO₂.
• In TBI, cerebral autoregulation is lost — CPP becomes exquisitely sensitive to swings in MAP.

ICP-Lowering Interventions

Elevate the head of bed; remove the c-collar or anything constricting the neck; short-term hyperventilation; hypertonic saline or mannitol (hypertonic saline preferred in trauma — mannitol can worsen hypotension); sedation/paralysis.

Adjuncts

• Seizure prophylaxis for trauma with intracranial bleed — 1 week, prevents early (not late) seizures.
• Early enteral feeding within 24–48 hours.
• Correct coagulopathy.
  • Coumadin → PCC for rapid reversal (FFP acceptable alternative); add vitamin K.
  • Dabigatran (Pradaxa) → dialysis or idarucizumab (Praxbind).
  • Apixaban/rivaroxaban → PCC (only partial reversal).
• Steroids? No benefit, potential harm — don’t give them.

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Spine Trauma

Clinical Clearance

No distracting injury, GCS 15 and non-intoxicated, no midline tenderness, no neurologic deficits.

Radiographic Clearance

Somewhat controversial, but a normal CT with no localizing symptoms can generally clear the spine.

Cord Injury Syndromes

| Syndrome | Deficit | Classic Cause | |—|—|—| | Central cord | Upper extremity weakness (“cape and gloves”) | Elderly with spinal stenosis, hyperextension injury | | Brown-Séquard (hemisection) | Ipsilateral motor loss + contralateral pain/temperature loss below the level | Penetrating (stab) injury | | Anterior cord | Motor deficit below the level | Vascular injury to the anterior spinal artery | | SCIWORA | Spinal cord injury without radiographic abnormality | Pediatric population |

Neurogenic vs Spinal Shock

• Neurogenic shock: hemodynamic — hypotensive and bradycardic.
• Spinal shock: sensory/motor only, no hemodynamic effect. Absent bulbocavernosus and cremasteric reflexes; some function may return. Intact reflexes → deficits are likely permanent.
• No steroids for spinal cord injury.
• Stability: 2 of 3 columns disrupted = unstable, requires operative fixation.

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Neck Trauma

Zones

| Zone | Boundaries | |—|—| | I | Clavicles → cricoid cartilage | | II | Cricoid cartilage → angle of the mandible | | III | Angle of mandible → skull base |

Management by Presentation

• Hypotensive, or a hard sign of vascular injury → OR.
• Stable, no hard sign → CT neck with CTA.
• Concern for esophageal injury → add esophagram or EGD.
• Esophageal injury: extend the myotomy to define the full mucosal defect, repair in 2 layers, buttress, drain. Can’t localize the injury on exploration → widely drain instead.

Blunt Cerebrovascular Injury (BCVI)

• Distal internal carotid is the most common site.
• Treatment is generally antiplatelet therapy; endovascular intervention for a pseudoaneurysm or AV fistula.
• Screen with CTA when any of the criteria in the card below are present — an isolated cervical seat-belt sign with an otherwise normal exam is not, by itself, an indication (two retrospective studies failed to show it as an independent risk factor).

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Thoracic Trauma

• Chest tube output → OR? Controversial, data-limited, but classic thresholds: >1500 mL initial output, or >200 mL/hr over 4 hours.
• Flail chest: 3+ consecutive rib fractures in 2 locations. Hypoxia comes from the underlying pulmonary contusion, not the flail segment itself. Manage with pain control (epidural), consider positive-pressure ventilation and rib plating.
• Sternal fracture → concern for blunt cardiac injury. EKG required for all suspected BCI (sinus tach and PVCs most common findings). A normal ECG + normal troponin essentially rules it out. Hemodynamic instability or persistent new arrhythmia → echocardiogram.

Blunt Aortic Injury (BAI)

• Greatest risk at the proximal descending aorta, where the mobile arch meets the fixed descending aorta at the ligamentum arteriosum (shearing from sudden deceleration).
• Exam: hypotension, upper-extremity hypertension, unequal blood pressures, external chest trauma, thoracic outlet hematoma, sternal or thoracic spine fracture, left flail chest.
• CXR is insensitive but concerning findings include a widened mediastinum (>8 cm), depressed mainstem bronchus, NG tube deviated right, apical cap, and disruption of the calcium/aortic “ring” (broken halo).
• CTA is the diagnostic study of choice.
• Grading: I intimal tear, II intramural hematoma, III pseudoaneurysm, IV rupture.
• Management: immediate BP control (esmolol ± nitroprusside, target SBP <120), priority is controlling hemorrhage elsewhere and avoiding over-resuscitation, endovascular repair preferred over open.
• Left arm ischemia after endovascular repair → carotid-to-subclavian bypass (subclavian is routinely covered during the endograft).

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Abdominal Trauma

Blunt Abdominal Trauma

• FAST looks only for free fluid (blood, succus, or urine) in the abdomen/pericardium. CT is more sensitive/specific; FAST can be falsely negative and should be repeated in an unstable patient.
• Most common injury overall: solid organ. Most commonly missed: hollow viscus or pancreas.
• Abdominal seat-belt sign → suspect bowel or pancreatic injury.
• Solid organ injury + unstable → OR. Stable → nonoperative management (ICU monitoring, serial labs, supportive care); go to OR for ongoing transfusion requirement or new instability.
• CT with free fluid but no solid organ injury → hollow viscus injury until proven otherwise.
• Stable with a contrast “blush” (spleen, liver, kidney) → angioembolization.

Abdominal Stab Wounds

• Unstable, evisceration, or peritoneal signs → OR.
• Anterior stab wound: local wound exploration for anterior rectus sheath violation. Truly negative + no other injuries → discharge. Violated sheath + stable/examinable → serial exams ± CT. Violated sheath + stable but unexaminable → CT vs. laparoscopic exploration for posterior fascia/peritoneal violation (controversial).
• Flank stab wound: concern for retroperitoneal structures → triple-contrast CT (oral, rectal, IV).
• Thoracoabdominal stab wound: concern for diaphragm injury even with a stable exam and negative imaging — frequently missed on CT, best evaluated with laparoscopy.

Hollow Viscus & Colon Injury

• Destructive injury (>50% circumference or devascularized) → resection and anastomosis.
• Non-destructive (<50%, no vascular compromise) → primary repair.
• Damage-control setting with destructive bowel injury: staple off in discontinuity (no anastomosis), temporary abdominal closure, ICU for resuscitation.
• Penetrating colon injury: primary repair for non-destructive, resection + anastomosis for destructive. Old teaching mandated diversion for left-sided injuries — that’s no longer true; the decision is based on physiologic status, not injury side.
• Bucket-handle injury: blunt mechanism, mesentery torn away from otherwise-intact bowel → resection.

Pancreatic Injury

Key factors: ductal involvement, location (head/body/tail), associated duodenal injury.

• Distal injury, no ductal injury → drains only.
• Distal injury with ductal injury → distal pancreatectomy + splenectomy (can consider spleen-sparing in stable children).
• Head injury with or without ductal involvement → drainage only.

Retroperitoneal Hematoma

| Zone | Location | Blunt Injury | Penetrating Injury | |—|—|—|—| | I | Central (aorta, vena cava) | Explore | Explore | | II | Lateral (renal) | Explore only if expanding/pulsatile | Explore | | III | Pelvic (iliac) | Generally don’t explore — pack + angiography | Explore |

Pelvic Fracture

• Watch for injury to adjacent structures: rectum, bladder, vagina, urethra.
• Open-book fracture + hypotension → pelvic binder first. Angiography if stable; OR for preperitoneal packing if unstable.

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Shock & Damage Control Resuscitation

• Shock = end-organ hypoperfusion.
• Triad of death: hypothermia, coagulopathy, acidosis.
• Damage control principles: control contamination and hemorrhage, temporary closure, resuscitate — return to OR once physiology is corrected.

Abdominal Compartment Syndrome

• First signs: rising peak ventilator pressures, falling urine output. Confirm with bladder pressure — absolute pressure >20 mmHg is concerning.
• Treatment: decompressive laparotomy — except in burn patients after massive resuscitation (high mortality); drain ascites instead.

Damage Control Resuscitation

• Avoid crystalloid when possible; permissive hypotension.
• Balanced product resuscitation: platelets : PRBC : FFP ≈ 1:1:1.
• TXA for the bleeding patient needing massive transfusion — 1 g within 3 hours of injury, then 1 g over the next 8 hours. Decreases fibrinolysis.
• Factor VII is never the answer in trauma resuscitation anymore.
• TEG/ROTEM can guide resuscitation and is increasingly tested (see quick-reference card below).

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Urologic Trauma

• Bladder injury: frequently associated with pelvic fractures; always has hematuria (renal injury may not). Intraperitoneal → operative repair. Extraperitoneal → Foley drainage.
• Ureteral injury: mid-ureteral → spatulate and primary anastomosis over a double-J stent. Distal → reimplant into the bladder; if it won’t reach, psoas hitch.
• Urethral injury: exam shows blood at the meatus, scrotal/perineal hematoma, high-riding prostate. Diagnose with a retrograde urethrogram.

Extremity Trauma

• Hard signs of vascular injury: pulsatile bleeding, expanding hematoma, absent pulses, bruit/thrill → OR.
• Soft signs: non-expanding hematoma, decreased pulses (ABI <0.9), proximity to neurovascular structures → CTA.
• Extremity arterial injury → repair, generally with reversed saphenous vein graft.
• Extremity venous injury → primary repair if possible, otherwise ligate.
• Popliteal artery/vein repair → don’t forget fasciotomy.

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Special Populations

Pediatric Trauma

• Airway is narrow, short, and more anterior than in adults.
• Intubate with a cuffed tube (updated dogma) — uncuffed only in infants.
• ET tube size: width of the patient’s pinky nail bed, or age/4 + 4.
• Direct laryngoscopy commonly causes bradycardia — have atropine ready.
• Fluid bolus: 20 mL/kg crystalloid; 10 mL/kg for blood products.

Pregnant Trauma

• Physiologic baseline: increased circulating volume (dilutional anemia), increased respiratory rate with decreased tidal volume → respiratory alkalosis.
• Position left-side down to relieve IVC compression.
• Abdominal trauma → watch for placental abruption and maternal-fetal hemorrhage; give RhoGAM if mother is Rh-negative and hemorrhage is a concern.
• Kleihauer-Betke test detects fetal cells in maternal circulation.
• Fetal monitoring is generally indicated for viable pregnancies (≥24 weeks).

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Rapid-Fire Questions

• Q: Bubbles seen in the coronary vessels during a resuscitative thoracotomy? A: Air embolism, typically from a pulmonary injury.

• Q: MVC with a lumbar Chance fracture and a seatbelt sign? A: Hollow viscus injury — think pancreatic injury too.

• Q: Kid with a handlebar blow to the abdomen? A: Duodenal hematoma.

• Q: Left thoracoabdominal stab wound, negative imaging, benign exam? A: Laparoscopy to rule out diaphragm injury.

• Q: Posterior knee dislocation — what are you worried about? A: Popliteal artery injury.

• Q: Patient found down, oliguric, Cr 3.5? A: Rhabdomyolysis.

• Q: Tracheostomy patient with 10 mL of bright red blood from the stoma? A: Tracheoinnominate fistula — a sentinel bleed.

• Q: Severe TBI, Na 155, 5 L urine output? A: Diabetes insipidus — treat with DDAVP.

• Q: Trauma patient paralyzed from the neck down, no cremasteric reflex? A: Spinal shock.

• Q: Stab wound to the abdomen, benign exam, but omentum is eviscerating? A: Laparotomy — evisceration is an indication regardless of exam.

• Q: Liver bleeding unchanged after a Pringle maneuver? A: Hepatic vein or retrohepatic IVC injury.

• Q: CXR with an apical cap? A: Think blunt thoracic aortic injury.

• Q: Major arterial bleeding from posterior during neck exploration? A: Vertebral artery injury.

• Q: Stab wound to the flank? A: Concern for kidney or colon injury — triple-contrast CT.

• Q: Trauma patient with an elevated LY30 on TEG? A: Give TXA — high LY30 means excessive fibrinolysis.

• Q: Hematemesis 2 weeks after an MVC with a Grade IV liver laceration? A: Hemobilia — treat with angioembolization.

• Q: Open pelvic fracture with a complex perineal wound? A: Diverting colostomy.

• Q: GSW to the pelvis with a rectal wall hematoma on rigid proctoscopy? A: Diverting colostomy.

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Quick Reference Table — Hemorrhagic Shock Classification

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Quick-Reference Cards

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Related Case Preps

• Exploratory Laparotomy for Trauma — the four-quadrant packing, systematic “trauma survey,” and damage-control decision-making described above, applied step by step.
• Splenectomy — trauma splenectomy, AAST grading, and the nonop-vs-OR decision for blunt splenic injury.

References

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS), 10th ed.
2. Rotondo MF, et al. “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993.
3. Biffl WL, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2010.
4. Stassen NA, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012.
5. CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage. Lancet. 2010.

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