Trauma Management

Initial Assessment and Resuscitation

• Hemodynamic stability is defined as systolic BP ≥90 mmHg and heart rate 50-110 beats/minute, according to the American College of Radiology and the Journal of the American College of Radiology 1
• Patients with penetrating chest trauma should undergo immediate classification into unstable (SBP <90 mmHg despite fluid resuscitation) or stable (SBP ≥90 mmHg with appropriate response to initial resuscitation) categories, as recommended by the American College of Radiology 1
• Portable chest radiograph and FAST (Focused Assessment with Sonography for Trauma) are recommended for initial assessment, with the E-FAST (Evaluación Enfocada con Sonografía para Trauma Extendida) being a rapid assessment tool that includes evaluation of areas such as the pericardium, abdominal quadrants, pelvis, and pleural spaces to detect lesions like cardiac tamponade, hemoperitoneum, hemothorax, and pneumothorax 1

Diagnostic Evaluation

• FAST examination is used to detect hemopericardium (cardiac injury), pneumothorax, and free intraperitoneal fluid, as recommended by the American College of Radiology and Critical Care Medicine 1, 2
• Bedside cardiac ultrasonography (BCU) is strongly recommended for detecting occult cardiac injury following penetrating chest trauma, according to Critical Care Medicine 2
• CT Chest with IV contrast is optimal for identifying the trajectory of penetrating injuries and evaluating for diaphragmatic injury, thoracic injuries, solid organ injuries, vascular injuries, and hollow viscus injuries, with a sensitivity of 14-82% and specificity of 87% for diaphragmatic injury 1, 3

Surgical Intervention

• Emergent thoracotomy is recommended for hemodynamically unstable patients with penetrating chest trauma, according to Critical Care Medicine 2
• Immediate surgical intervention without delay for CT imaging is recommended for hemodynamically unstable patients, according to the American College of Radiology 1
• Damage control surgery with abbreviated laparotomy is recommended for patients with intraabdominal hemorrhage requiring immediate surgical intervention, with indications including temperature ≤34°C, pH ≤7.2, inaccessible major venous injury, need for time-consuming procedures in suboptimally responding patients, and inability to achieve hemostasis due to coagulopathy 4
• Abdominal packing and direct surgical bleeding control is a recommended technique for patients with intraabdominal hemorrhage requiring immediate surgical intervention 5
• Temporary abdominal closure is a recommended technique for patients with intraabdominal hemorrhage requiring immediate surgical intervention 4

Non-Operative Management

• Non-operative management (NOM) is the first option in most cases of blunt abdominal trauma, applicable to 90% of traumatic renal injuries and 70-80% of traumatic splenic and hepatic injuries, with even severe injuries (Organ Injury Scale 4 and 5) benefiting from NOM with close monitoring 6
• Therapeutic angioembolization may be considered for documented active bleeding in splenic, hepatic, kidney, or adrenal injuries, and may replace laparotomy in patients with hemorrhagic shock if immediately available 6

Potential Pitfalls

• Delayed recognition of cardiac injury can occur, as penetrating cardiac injuries can present with normal hemodynamic parameters initially before rapid deterioration, according to Critical Care Medicine 2
• False-negative FAST results can occur if a cardiac injury decompresses into the hemithorax through a pericardial rent, resulting in a large hemothorax with a false-negative pericardial view, according to Critical Care Medicine 2
• Delaying surgery for imaging can increase mortality in hemodynamically unstable patients, according to the American College of Radiology 1
• Development of abdominal compartment syndrome can significantly increase mortality (OR 3.3), with early detection being critical 6

Management Algorithm

Monitoring and Treatment

• Monitor intra-abdominal pressure in patients at risk of intra-abdominal pressure elevation, as early detection of abdominal compartment syndrome is critical 9
• Close clinical monitoring for signs of rebleeding, serial hemoglobin/hematocrit measurements, and repeat imaging if clinical deterioration occurs are recommended for patients with intraabdominal hemorrhage 6
• Consider blood product transfusion with enhanced plasma/packed red blood cell ratios for patients with intraabdominal hemorrhage 4
• Monitor for and treat coagulopathy, acidosis, and hypothermia (the "lethal triad") in patients with intraabdominal hemorrhage 4