CONTINUING MEDICAL EDUCATION

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 ([email protected])

Approach to penetrating abdominal trauma

Haemodynamically unstable ATLS principles − A, B, C, D & E Haemodynamically stable

Resuscitate with 2 L crystalloid Complete primary survey solution and monitor response (adjuncts, SAMPLE history) Admit for observation Consider blood transfusion Complete secondary survey and serial examinations

No _ Still unstable FAST/USS Assess for other causes of shock Peritonitis Yes + Bowel evisceration Fluid refractory haemorrhagic shock Yes Free air under the diaphragm Emergency laparotomy Diaphragmatic herniation Blood in NG tube

No Clinical deterioration Peritonitis Yes Frank haematuria with Decreasing haemoglobin See Figs 7 and 8 ank/back wounds No Yes Rectal bleeding EUA in theatre

Admit for observation and No Deep to deep fascia serial examinations

Local wound Discharge Clean and suture Supercial to deep fascia exploration

Fig. 1. Approach to penetrating abdominal trauma (ATLS = advanced trauma life support; FAST/USS = 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 injury and/or illness).

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Approach to blunt abdominal trauma

Haemodynamically unstable ATLS principles − A, B, C, D & E Haemodynamically stable

Admit for observation and serial examinations Resuscitate with 2 L crystalloid Complete primary survey solution and monitor response (adjuncts, SAMPLE history) Consider blood transfusion Complete secondary survey Abdomen soft, non-tender

Yes FAST/USS (if unavailable) No FAST/USS YesStill unstable Acute abdomen No (if available) Yes

Yes Emergency laparotomy Free uid or Solid organ Normal clinical uncertainty injury

CT abdomen Consider CT abdomen

Hollow viscous Solid organ Clinical deterioration Admit for observation and injury injury Peritonitis serial examinations Decreasing haemoglobin

Fig. 2. Approach to blunt abdominal trauma (ATLS = advanced trauma life support; FAST/USS = 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 injury and/or illness).

Approach to penetrating chest trauma (central chest wall)

HaemHaemodynamicallyodynamically U unstablenstable ATLS principles − A, B, C, D & E Haemodynamically stable

Erect CXR Clinical features of tension No pneumothorax, pneumothorax or haemothorax

Yes Haemothorax Minimal or no Pneumothorax pneumothorax Insert ICD

No Clinical features Insert ICD Repeat CXR in Clinical improvement? of cardiac tamponade 4 - 6 hours

Yes Yes Yes Bleeding >1 500 mL or >200 mL/hour Yes Increase in size of Stable Unstable pneumothorax No

+ _ FAST/ + FAST/ECHO Observe and manage Pericardiocentesis as appropriate ECHO _

Observe and manage Consider Clinical deterioration Thoracotomy as appropriate

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).

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Approach to penetrating chest trauma (lateral chest wall)

HaemHaemodynamicallyodynamically U unstablenstable ATLS principles − A, B, C, D & E Haemodynamically stable

Erect CXR Clinical features of tension No pneumothorax, pneumothorax or haemothorax

Yes Haemothorax Minimal or no Pneumothorax pneumothorax Insert ICD

No Clinical features Insert ICD Repeat CXR in Clinical improvement? of cardiac tamponade 4 - 6 hours

Yes Yes Yes Bleeding >1 500 mL or >200 mL/hour Yes Increase in size of Stable Unstable pneumothorax

_ FAST/ + Observe and manage Pericardiocentesis as appropriate ECHO

Observe and manage Consider Clinical deterioration Thoracotomy as appropriate

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

Haemodynamically unstable ATLS principles − A, B, C, D & E Haemodynamically stable

Active arterial bleeding Emergency neck Yes Rapidly expanding haematoma exploration Insert ICD if evidence of haemo-/pneumothorax Absent radial pulse Air bubbling through wound Respiratory distress

No

Observe and manage No Did injury penetrate as appropriate platysma muscle? Zone II (between the cricoid cartilage and Yes angle of the mandible)

Zone I Zone III (inferior to cricoid cartilage) (above angle of mandible)

Chest X-ray Rule out pneumothorax C-spine X-ray C-spine X-ray Check for fractures, foreign bodies, air in soft tissues Angiogram Angiogram Suspected vascular injury (haematoma, bruit, neurological Laryngoscopy fallout, BP dierence >10 mmHg in each arm, widened mediastinum) Suspected pharyngeal Endoscopy Suspected oesophageal injury (dysphagia/odynophagia) injury Spiral CT chest Suspected aortic injury Sialogram Suspected parotid gland injury

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).

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Approach to penetrating limb trauma

ATLS principles − A, B, C, D & E Any hard signs

Any evidence of distal ischaemia Absent or diminished pulses Measure Doppler pressures (ankle No Active bleeding brachial index) and compare Expanding or pulsatile haematoma with una ected limb Audible bruit Palpable thrill

Yes >0.9 <0.9

Multiple sites of entry Yes Extensive bone and soft tissue damage Observe and manage Angiogram Pre-existing vascular disease as appropriate

No

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)

Haemodynamically unstable ATLS principles − A, B, C, D & E Haemodynamically stable

Resuscitate with 2 L crystalloid solution and monitor response Blunt trauma Penetrating trauma Consider blood transfusion _

No No CT abdomen with delayed phase Still unstable FAST/USS Pelvic fracture for ureter views Yes Yes + Emergency laparotomy Cystogram or CT cystogram Renal injury

Isolated extraperitoneal Bladder injury Yes bladder rupture

Intraperitoneal Haemodynamic instability bladder rupture Suspected renal pelvis injury Yes Admit for conservative management Renal artery thrombosis Other intraperitoneal visceral damage 1. Urethral catheter for 10 days 2. IV antibiotics 3. Repeat cystogram at 10 days Emergency laparotomy No

Admit for conservative management

Clinical deterioration 1. Strict bed rest Peritonitis 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; FAST/USS = focused assessment with sonography in trauma/ultrasound scan; CT = computed tomography).

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Approach to frank haematuria in trauma (urethral injuries)

ATLS principles − A, B, C, D & E

Emergency exploration and Complete primary survey insertion of suprapubic catheter (adjuncts, SAMPLE history) Complete secondary survey

Suspected urethral injury with blood at the external urethral meatus Penetrating injury

Blunt injury

Incomplete injury Complete injury (slight extravasation, contrast Ascending urethrogram (extravasation, contrast does enters bladder) not enter bladder)

Insert transurethral catheter Insert suprapubic catheter If fails

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 injury and/or illness).

Approach to head injury

ATLS principles − A, B, C, D & E

Multiple system Isolated head injury injuries/polytrauma

Discharge with head Check A, B, C injury form 1. GCS <13 at any point since injury 2. GCS <15 2 hours since injury 3. Suspected open/depressed fracture 4. Focal neurological decit Haemodynamically 5. Post-traumatic seizure unstable No deterioration 6. Any penetrating head/orbital injury 7. >1 episode of vomiting since injury 8. LOC/amnesia in patients >65 years, with coagulopathies or dangerous mechanism of injury Observe No 4 - 6 hours Yes CXR FAST/USS Pelvic Examine limbs ± X-ray X-rays

+ + + Yes CT scan (uncontrasted) and Deteriorates preferably with C-spine + Consider Consider ICD laparotomy angio-embolisation Normal CT/only Intracranial injury/depressed ± external xation simple skull fracture or compound skull fracture Still unstable Splint Admit ± theatre Thoracotomy (discuss with neurosurgeon)

Fig. 9. Approach to head injury (ATLS = advanced trauma life support; CXR = chest X-ray; FAST/USS = 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).

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Acknowledgement. A special thank you to the consultants at Frere Hospital Further reading ® for reviewing the algorithms and perfecting them for publication, especially 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. Drs W Matshoba, K Kesner, E Simpson, D Brown and A Makangee. The 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. contribution of the Eastern Cape Department of Health in providing Nicol A, Steyn E, eds. Handbook of Trauma for Southern Africa. 3rd ed. Cape Town: Oxford University Press Southern Africa, 2010. funding for the printing and circulation of the algorithms and the Surgery Welzel T. Emergency Medicine Guidance for the Western Cape. Revised ed. Cape Town: Western Cape Department of Health, 2013. Survival Guide handbook is gratefully acknowledged. A special word of appreciation to Prof. G Boon for driving this process from start to finish. S Afr Med J 2015;105(6):502-507. DOI:10.7196/SAMJ.9795

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