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Home , Trauma surgery

Advances in trauma

Trauma surgery has advanced as a specialisation in the past few years.

ANDREW NICOL, MB ChB, FCS (SA) Trauma and Head, Trauma Centre, Groote Schuur and University of Cape Town

Andrew Nicol is an associate professor and trauma surgeon at Groote Schuur Hospital and the University of Cape Town. His particular areas of inter- est are trauma systems, penetrating cardiac trauma and liver . 3 PRADEEP NAVSARIA, MB ChB, MMed, FCS (SA) Trauma Surgeon and Deputy Head, Trauma Centre, Groote Schuur Hospital and University of Cape Town

Pradeep Navsaria is a senior lecturer and trauma surgeon at Groote Schuur HospitalA trauma andcent rthee cons Universitytitutes the leofve Capel 1 hos Town.pital in tHishe s yscurrenttem. Tr afieldsuma sur ofge onsinterestare consist of the non-operative management of abdominal gunshot wounds and laparoscopy in extraperitoneal rectal injuries. available as well as the back-up of specialist facilities. Approximately 20% of trauma

There have been numerous advances in the field of trauma surgery servicespatients w iofll rethequi retraumathe servi ccentre.es of the Thetraum asmallercentre. T heregionalsmaller r egihospitalsonal hospi tareals over the past few years. The establishment of trauma centres has divided into specific levels of care according to staffing and the allowed for the regionalisation of trauma care and contributed availabilityare divided int ofo s pe surgical/emergencycific levels of care accor di servicesng to staf fi andng a nd theythe a va areila bi gradedlity of significantly to a reduction in trauma mortality. The Statscan fromsurgic alevell/eme 2rge tonc y4 shospitals.ervices and they are graded from level 2 to 4 . has reduced the time taken to obtain the X-rays required in AlsoAlso inc includedluded in t he insys thetem a systemre specia li arety tr a specialityuma centres for traumapaediat ri centrescs, spina l c forord . has dramatically improved paediatrics, spinal cord injuries and a major unit. A the survival of severely injured patients undergoing emergency injuries and a major burns unit. A rehabilitation centre is also required for further rehabilitation centre is also required for further long-term surgery and there has been a continuation of a trend towards the managementlong-term mana ge(seement Fig.(see 1).Fig. 1). selective, conservative management of . Trauma systems Injured patient A significant advance in the management of the severely injured Field guidelines patient has been the development of trauma care systems, initially in Europe and the USA in the 1970s and then throughout the Specialty trauma world. This system is an organised approach to the acutely injured (Paediatrics/burns/spinal cord) patient that provides personnel, facilities, and equipment for Level 2 hospital Level 3/4 hospitals (minor trauma) optimum care on an emergency basis. It is well accepted that the preventable death rate from trauma approximates 30% without a trauma care system and this can be reduced to 5% with full trauma Severely injured patients system implementation. Designated trauma centre (level 1) A trauma care system deals with the prevention of trauma, the emergency and subsequent hospital treatment and rehabilitation. The requirements comprise an efficient pre-hospital service with Rehabilitation centre field triage guidelines. The injured patient must be taken to the most appropriate facility according to the severity of the . Studies in the USA have shown remarkable improvement in survival when Fig. 1. The functioning of a trauma care system. seriously injured patients bypass the nearest local hospital to reach The Statscan a regional trauma centre.1 Such triaging of the trauma patients has also been proven to be extremely cost effective. The Statscan is a new digital system designed for trauma and A trauma centre constitutes the level 1 hospital in the system. Thedevelope Statscand as a collaborative effort between Lodox (Pty) and the University of Cape Trauma are available as well as the back-up of specialist TheTown ( StatscanFig. 2). It w isas or aigi na newlly de digitalsigned by tradiographyhe De Beers mi ni systemng corpor adesignedtion to for facilities. Approximately 20% of trauma patients will require the trauma radiology and developed as a collaborative effort between Lodox (Pty) and the University of Cape Town (Fig. 2). It was A significant advance in the originally designed by the De Beers mining corporation to produce a full-body ultra-low dose X-ray in order to detect smuggled management of the severely diamonds in humans. This technology has been enhanced and now the Statscan can produce a whole-body digital X-ray in under injured patient has been the 13 seconds with a mean radiation dose typically only 6% that of a development of trauma care conventional X-ray.2 systems. The system comprises an X-ray tube mounted on a C-arm, which emits a low-dose fan beam. An X-ray detector unit is situated on the other end of the C-arm comprising scintillator arrays linked

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The ability to rapidly obtain whole-body images that can be magnified to look at specific regions of the body with a clarity similar to conventional X-rays is a major advance in trauma radiology.

then displayed on a computer-controlled operating and viewing system with Cervical spine injuries standard DICOM 3 (digital imaging and communication in 3) capability. Conscious and asymptomatic The cervical spine can be cleared clinically The ability to rapidly obtain whole-body (without cervical spine X-rays) in the fully Fig. 2. The Statscan. images that can be magnified to look at conscious patient provided there is no specific regions of the body with a clarity neck pain and the patient is not under the similar to conventional X-rays is a major influence of drugs or alcohol. advance in trauma radiology. The low radiation dose allows for the system to be Conscious and symptomatic situated in the resuscitation room. One of the major rate-limiting steps in major The standard 3 view plain X-rays are resuscitation in the past has required consisting of a lateral cervical been the acquisition of the all required X- spine, anteroposterior (AP) and an open rays. The Statscan has certainly resulted mouth view. If there are any abnormal in a major reduction in the time taken to or poorly visualised areas then a CT scan perform resuscitation.3 is indicated. If there are any abnormal findings on the neurological examination, magnetic resonance imaging (MRI) is indicated to identify a cord injury. The current indications for a CT scan of the head in the adult patient are: any Unconscious and intubated patient with a Glasgow coma score of The incidence of an unstable spinal injury 14 or less, any focal neurological deficit, is around 10% in the intubated patient. any localising signs (dilated pupil), The radiological evaluation will consist of severe headache or vomiting (more than a lateral cervical spine, an AP view and a 2 episodes) in the conscious patient, CT scan of the occiput to the third cervical fractured skull on palpation or X-ray, vertebra. An open mouth view is not clinically apparent base of skull fracture, accurate in the intubated patient. Spinal penetrating eye injuries (30% will have precautions should be continued even in intracranial extension), tangential the presence of a normal CT scan of the gunshot wounds to the skull (10% will upper neck. If the patient is not expected have a cerebral injury), penetrating skull to be fully conscious within 48 hours, then trauma, a stab to the head with a loss of a CT of the whole cervical spine is required consciousness (slot fracture), seizures and to exclude any cervical spine injury. the patient who is on warfarin and has a head injury. Surgical management of A more liberal policy for a CT scan of the head in injured children is required in the penetrating neck injuries presence of a high-risk mechanism despite The patient presenting to the emergency the presence of a normal neurological room with massive bleeding from examination on initial screening. Sixteen a penetrating neck injury requires per cent of children with significant head haemostatic surgery. The really injuries will have a Glasgow coma score of controversial issue, however, is how to 4 Fig. 3. A whole-body digital image produced 15 and no loss of consciousness. manage the stable patient with penetrating by the Statscan. neck trauma. The last 2 decades have seen a major shift in the management from mandatory surgical exploration to charge-coupled devices. An image is obtained by scanning the C-arm over the If the patient is not expected to be fully required anatomical portion of the patient while continually reading the output of the conscious within 48 hours, then a CT of detectors. The C-arm travels at a rate of up the whole cervical spine is required to to 14 cm per second and can be rotated to produce lateral views. The X-ray image is exclude any cervical spine injury.

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to the operating theatre 24 hours later for In damage control surgery, the major definitive repair of the injuries. The packs initial priorities are to control the can be removed, arteries repaired, and the bowel re-anastomosed. bleeding and to prevent bowel spillage. The indications for instituting a damage control approach are profound in all cases towards a more selective, enhanced helical CT scanning has enabled haemodynamic instability, major multiple conservative approach based on clinical the mediastinal tract of the gunshot to intra-abdominal or chest injuries, blood findings and specialised investigations. be delineated. If the tract on CT scan is transfusion requirement of more than 10 The introduction of diagnostic tools away from any major structures then no units and a lactate level of greater than such as oesophagography, flexible further investigations are required. If on 5 mmol/l. , angiography, colour flow CT there is a mediastinal haematoma Doppler imaging and multislice helical then an angiogram is indicated, if there is computed tomography has resulted in mediastinal air then an oesophagogram an increasing confidence in the ability to is warranted. In this way the CT scan has detect injuries in the neck. The fact that become the screening method of choice certain of these injuries can be managed to determine which further investigations safely conservatively or more effectively are required in TMGSW to the chest.5 by endovascular interventions has further swung the pendulum towards the selective, conservative approach. Damage control surgery A major advance over the last decade has The proponents of selective exploration on been the introduction of damage control the basis of special investigations allude surgery into the armamentarium of the to the high rate of negative explorations trauma surgeon.6 The previous surgical Fig. 4. A plastic stent inserted into the superfi- in mandatory neck explorations and philosophy in operating on trauma patients cial femoral artery. the excellent sensitivity of special was to repair all the injuries regardless investigations such as angiography, of the time taken and the physiological oesophagography, oesophagoscopy and state of the patient. This often resulted in flexible laryngotracheobronchoscopy in lengthy procedures being performed on excluding clinically significant injuries. very unstable patients. The patients would Also many of the injuries detected at become cold and develop what is called the mandatory exploration, such as thyroid, ‘lethal triad’ of hypothermia, acidosis and pharyngeal and certain venous trauma disseminated intravascular coagulation. may be treated conservatively. Four It is now accepted that this is no longer prospective studies on the selective appropriate surgical management and conservative approach to the management not all injuries require early definitive of penetrating cervical injuries have management. confirmed the safety of such an approach with successful conservative management In damage control surgery, the major in 80%. The patient is assessed clinically initial priorities are to control the bleeding with the direction of the tract taken into and to prevent bowel spillage. This is Fig. 5. An open abdomen. account as well as the potential structures achieved by ligating bleeders, packing that may have been injured. Further livers and retroperitoneal bleeding, investigations are considered on the stenting arteries and ureters and ligating This damage control approach has resulted basis of clinical symptoms and signs. The bowel with a suture. The abdomen can in a significant improvement in the survival selection for exploration can be made on be left open (open abdomen) with the rates following major trauma. the basis of careful initial and repeated bowel covered by a plastic bag to prevent clinical examination. Selective observation evisceration. The patient is then taken to based on clinical examination and the use the for stabilisation, Non-operative of adjunctive investigations based on these rewarming and correction of any clotting management of gunshot clinical examinations have been shown abnormalities. The patient is taken back to be able to exclude clinically significant wounds to the liver injuries at several large trauma centres. A to the abdomen was It has now become considered to be an indication for a mandatory . It has now become Transmediastinal apparent that apparent that around a third of isolated around a third of gunshot wounds to the liver may be treated gunshot wounds with non-operative management. These Haemodynamically unstable patients isolated gunshot patients need to be haemodynamically who have sustained a transmediastinal wounds to the liver stable, fully conscious to allow for serial gunshot wound (TMGSW) to the chest abdominal observations, to have no require emergency surgery. The traditional may be treated active bleeding from the liver on the CT evaluation of haemodynamically stable scan, and have a high-care bed available patients with a TMGSW has been with non-operative for close monitoring. These patients angiography and either an oesophagogram management. should, however, only be managed non- or endoscopy. The advent of contrast-

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operatively in a trauma centre with access after . It is an alternative language to be spoken with respect to to endoscopic retrograde cholangiography, to FAST but is contraindicated in the the resuscitation and in the arranging of angiography and percutaneous drainage case of previous abdominal surgery and transfers. The Trauma Society of South under CT guidance in order to deal pregnancy. A nasogastric tube and a Africa organises the ATLS courses (www. with any external biliary fistulae, false urinary catheter must be inserted prior to traumasa.co.za). Recently the Definitive aneurysms or liver abscesses that may a DPL. It is extremely sensitive for blood in Surgical Trauma Course (DSTC), run complicate such a conservative policy.7 the peritoneal cavity but not very specific. under the auspices of the International A positive DPL is an indication for Association for the Surgery of Trauma laparotomy. DPL is also not very sensitive and Surgical Intensive Care (IATSIC), has Screening tests in the for detecting bowel perforations. been started in South Africa. This course is aimed at general surgeons performing evaluation of blunt trauma surgery in South Africa and offers Minimally invasive protocols and guidance in dealing with the Focused assessment with sonography surgery operative trauma. for trauma (FAST) has become available Thoracoscopy is being successfully used to References in the emergency room to exclude intra- clear out the chest of empyemas and clotted 1. Peitzman AB, Courcoulas AP, Stinson C, et abdominal injury. It screens four areas for haemothoraces. This obviously avoids al. Trauma centre maturation. Quantification blood collections, namely the perisplenic, the pain and recuperation time required of process and outcome. Ann Surg 1999; 230: perihepatic, pelvis and pericardium 87-94. for an open posterolateral thoracotomy. (the 4 Ps). It should, however, only be Laparoscopy appears to be useful to 2. Beningfield S, Potgieter H, Nicol A, et al. used for abdominal evaluation in the Report on a new type of trauma full body exclude tangential gunshot wounds to the haemodynamically unstable, unconscious digital X-ray machine. Emerg Radiol 2003; 10: abdomen (not breaching the peritoneum) patient after blunt trauma. The abdomen 23-29. and for detecting diaphragm injuries. is then screened as a potential source 3. Boffard KD, Goosen J, Plani F, et al. The use Laparoscopy also does not appear to be of low dose X-ray (Lodox/Statscan) in major of blood loss and a positive result will particularly sensitive in detecting small- trauma: comparison between low dose X-ray be an indication for a laparotomy. A bowel perforations. and conventional X-ray techniques. J Trauma FAST should not be used in penetrating 2006; 60: 1175-1183. trauma and it is not particularly sensitive 4. Hoyt DB. What’s new in trauma and critical for excluding bowel perforations. It is Advanced Trauma Life care. J Am Coll Surg 2002; 194: 335-351. operator dependent and should probably 5. Ibirogba S, Nicol AJ, Navsaria PH. Screening not be performed in the case of associated Support Course (ATLS) helical computed tomographic scanning pelvic fractures. in haemodynamic stable patients with and the Definitive transmediastinal gunshot wounds. Injury CT scanning of the abdomen is only an 2007; 38: 48-52. option in the haemodynamically stable Surgical Trauma Course 6. Koraklis G, Spirakos S, Glinavou A. Damage patient. It allows for assessment of the (DSTC) control surgery: An alternative approach for retroperitoneal structures, such as the the management of critically injured patients. The introduction of the Advanced Life Surg Today 2002; 32: 195-202. pancreas, but is only able to identify bowel Support Course (ATLS) in South Africa has perforations in about 30% of cases. 7. Omoshoro-Jones JAO, Nicol AJ, Navsaria PH, been a major advance with respect to the et al. Selective non-operative management A diagnostic peritoneal lavage (DPL) is resuscitation and emergency management of liver gunshot injuries. Br J Surg 2005; 92: a useful test in the haemodynamically of the injured patient. It has provided a 890-895. unstable patient with a head injury standard of care and allowed a common In a nutshell • The injured patient must be taken to the most appropriate hospital and not the closest. • A more liberal use of the CT head is required in children after head trauma. • An open mouth view is not accurate in the intubated patient. • A CT scan may be used to determine the need for angiography and contrast studies in the stable patient with the transmediastinal gunshot wound. • Damage control surgery is an attempt to control bleeding and prevent contamination as rapidly as possible.

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