Torso Trauma	66

Subodh Kumar, Amit Gupta, and Umashankkar Kannan

A 30-year-old male was hit by a motor vehicle about 3 h ago. At presentation, he had a threatened airway with labored breathing; his respiratory rate was 32/min with O2 saturation of 85%. He had paradoxical chest movements and decreased air entry on the left side. His heart rate was 120/min, blood pressure was 100/80 mmHg, and Glasgow coma scale (GCS) score was 15/15. After initial stabilization and left-sided intercostal drainage (ICD), secondary survey revealed abdominal distention with tenderness over the left upper quadrant of the abdomen. A computed tomography (CT) scan of the chest and abdomen showed multiple rib fractures on the left side of the chest with underlying lung contusion and ICD in situ. It also revealed a shattered spleen and 3-cm laceration in segment 6 of the liver along with 1-cm laceration in the upper pole of the left-sided kidney. Exploratory laparotomy was performed. The liver and kidney were preserved, while the spleen was removed. The patient gradually recovered in intensive care unit (ICU).

Multiple life-threatening conditions can result from thoracic and abdominal trauma. Multiple factors including mechanism of injury, injured body region, hemodynamic status, and associated injuries determine the diagnostic approaches.

Step 1: Perform primary and secondary survey

Primary survey (A–E)

A.Airway with cervical spine protection: Evaluation of airways is the first priority during primary survey. All patients presenting with threatened airways and respiratory distress should have the airway secured.

S. Kumar, M.S. (*) • A. Gupta, M.S. • U. Kannan, M.S. Department of Trauma Surgery, J.P.N. Apex Trauma Centre, AIIMS, New Delhi, India

e-mail: [e-mail]

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	527
DOI 10.1007/978-81-322-0535-7_66, © Springer India 2012

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•Cervical immobilization is maintained till the injury is excluded by radiological and/or clinical means.

B.Breathing and ventilation: Expose the chest to observe chest wall movement, breathing pattern, and neck veins; to auscultate breath sounds; and to monitor SpO2.

•Injuries that should be identified and treated during the primary survey are the following:

–Tension pneumothorax—with immediate needle thoracostomy and then with an intercostal tube

–Massive hemothorax—with insertion of a large-bore (36F) chest tube and volume replacement

–Open pneumothorax—with flutter valve dressing, taped on three sides, till ICD is placed; thereafter, closed dressing

–Cardiac tamponade—with pericardiocentesis as a temporary manouever followed by definitive surgery

–Flail chest with pulmonary contusion—with analgesia and elective intubation and positive pressure ventilation

C.Circulation with hemorrhage control: The pulse rate, blood pressure, and level of consciousness determine the grade of shock. Circulation volume has to be maintained with isotonic fluids and blood transfusions. Identify the source of bleeding and control it.

D.Disability (neurologic evaluation): Assess GCS and evaluate the pupillary size and reaction to light. Low GCS score may be due to decreased cerebral oxygenation or perfusion (shock) or direct cerebral injury.

E.Exposure/environment control: Completely undress the patient for thorough examination and assessment. Do not forget to examine the back. A warm environment should be maintained to avoid hypothermia.

Secondary survey

This involves detailed pertinent history, complete in-depth physical examination, relevant radiological, and laboratory investigations with reassessment of vital signs to identify all the injuries.

Step 2: Triage for surgery

•Once the primary survey is concluded, the next step is to triage the nonresponders to emergency surgery—exploratory laparotomy or thoracotomy for damage control or definitive surgery as the clinical situation demands.

•The rest of the patients should undergo further necessary radiological investigations to identify and assess the exact anatomical injuries and their severity.

Chest injuries

Majority of the patients (85% of the patients) with thoracic injuries require intervention in the form of tube thoracostomy, observation, and pain control. Only 10–15% patients require a formal thoracotomy.

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Abdominal injuries

Indications for urgent laparotomy include the following:

•Penetrating abdominal injury

•Hollow viscus injury

•Blunt trauma with ongoing intraperitoneal bleeding

Step 3: Triage the patients to the ICU

Triaging the patients to the ICU or to the floor (wards) is decided on the basis of the severity of the injury and the extent of surgery, requirement of the mechanical ventilator and inotropic support, age and comorbidities of the patient.

Step 4: Continue to observe and treat

While the need for complete and serial clinical examination in the ICU cannot be overemphasized, the following features will have to be focused during the daily examination of the patients:

A.Ventilation and circulation assessment

•Monitor respiratory rate, oxygen saturation, and arterial blood gas analysis, and adjust ventilatory settings accordingly. In case of prolonged requirement of ventilation (usually more than 7 days), tracheostomy should be considered.

•Pulse rate, blood pressure, central venous pressure, urine output, hematocrit, and lactate levels indicate the degree of perfusion and the grade of volume deficit. Unstable or critically ill patients might warrant other invasive moni-

toring techniques such as intra-arterial pressure and ScVO2 measurements. Circulation is maintained with fluid and blood transfusion with or without inotropic support.

B.Management of the ICD tube

Monitor volume and nature of the output daily, column movement, presence of air leak, and lung expansion clinically and radiologically.

1. Volume

•Common causes for persistent high output:

–Hemorrhage

–Thoracic duct injury

–Hypoproteinemia

•Sudden decrease in the volume of the output: Check for tube blockage or malpositioning. The tube should then be declotted or repositioned or changed to maintain the patency of the tube.

2.Nature of the output

•Sanguineous output—ongoing hemorrhage: Output of more than 200 mL/h of sanguineous fluid continuously for 2–4 h is an indication for thoracotomy.

•Turbid output with pyrexia indicates an infective focus. Fluid should be sent for further microbiological analysis, and treatment should be started accordingly.

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•Milky white, high-volume output points to thoracic duct injury (chylothorax). Presence of chyle may be confirmed at the bedside by dissolving the drained fluid in equal amount of ether. If it gets dissolved, then it is chyle; otherwise, it is pus. Check the triglyceride level. Low output (<1,000 mL/24 h) can be managed conservatively. High output usually requires surgical management.

3. Wide swinging of column movement (>5 cm) is suspicious of poor lung expansion or lung collapse and should be investigated further with the chest X-ray and bronchoscopy if needed.

4.Air leaks indicate the presence of tracheobronchial/parenchymal communication with the pleural cavity.

•Chest tube insertion sites should be checked for peritubal air entry due to loose sutures.

•Treatment of air leak: Minor air leaks usually heal with deep breathing exercises. Persistent air leaks, not settling down with chest physiotherapy alone, require application of negative pressure suction (usually 10 cm

H2O) to the underwater seal bottle. Massive air leaks causing oxygen desaturation will require insertion of a second ICD tube and usually thoracotomy.

•After stoppage of air leak, check the chest X-ray after clamping the tube for 24 h to look for lung collapse, and the ICD tube can be removed if the chest X-ray is normal.

•In case of subcutaneous emphysema, the extent should be marked and monitored daily for change in extent after insertion of the ICD tube. There is no role for skin incisions.

5. In cases of clotted hemothorax, declotting is done with streptokinase.

•1–1.5 million units of streptokinase is diluted in 100 mL and infused through the ICD tube under aseptic precautions. The tube is then clamped for 3–4 h; chest physiotherapy is done and then the tube is opened. This may be repeated once a day for 3–4 days till clots are evacuated. This procedure is not indicated in patients with coagulopathy or patients on systemic anticoagulation therapy like warfarin.

6. Fever, productive cough, and infiltrates in the chest X-ray indicate pulmonary infections. Broad-spectrum antibiotics should be started empirically and changed to specific antibiotics depending on the sensitivity pattern.

7.Radiological investigations

•Chest X-rays should be done to monitor the lung expansion and after the removal of the ICD tube to look for pneumothorax.

•Ultrasonogram and CT scans should be done for suspected loculated effusions and pneumothorax and to guide its drainage percutaneously.

•The following conditions should be fulfilled before the removal of the ICD tube:

–Less than 50–100 mL output and serous in nature

–Less than 5 cm swinging of air column with normal breathing

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–Absence of fever and air leak

–Full lung expansion

•Chest tube insertion sites must be inspected every day for infections and air or fluid leakage with regular care of the wound site.

C.Tracheostomy site and surgical wound sites

Inspect for surgical site infection.

D.Regular active and passive chest physiotherapy

This is required to prevent atelectasis and pneumonia.

E.Pain control

Control pain through nonsteroidal anti-inflammatory drugs, opioids, epidural analgesia, and patient-controlled analgesia devices.

F.Nutrition

Nutrition is maintained with enteral nutrition in most of the cases.

Abdominal injuries

Solid organ injuries are managed either nonoperatively or operatively depending on the severity of the injury and the hemodynamic stability of the patient. Hollow viscous injuries are usually managed operatively.

Step 5: Nonoperative management of solid organs (spleen, liver, and kidney)

•Nonoperative management should be practiced only in highly specialized trauma centers that have 24-h availability of trauma surgeons. Initial clinical examination and hemodynamic status dictate the decision rather than the grade of solid organ injury or the degree of hemoperitoneum.

•Daily clinical examination of the abdomen with hemodynamic status assessment is based on pulse rate, blood pressure, urine output, abdominal girth, intraabdominal pressure, and fall in hemoglobin and hematocrit levels.

•Complete bed rest should be advised for the first 48 h and then gradual mobilization is done.

•No antibiotic coverage is needed in cases of nonoperative management of solid organ injury alone.

•Ultrasound examination of the abdomen is done, if clinical situation demands, to look for significant increase in the intra-abdominal collection.

•Abdominal distention, development of peritoneal signs, and decrease in urine output indicate ongoing hemorrhage and need for operative management. Progressive drop in hematocrit with hemodynamic instability should also indicate the consideration for operative management.

•In case of liver injuries, billary peritonitis may present the clinical picture of intestinal perforations. Clinical and radiological examinations should be performed to rule out missed intestinal injuries, and in their absence, percutaneous drainage of the bile collection can be done, avoiding laparotomy.

Step 6: ICU care after operative management of abdominal injuries

• Repeated complete physical examinations should be performed every day.