ATLS; IMPORTANT NOTES

TRIAGE
• The process of prioritizing patient treatment during mass-casualty events.
• Do the most good for the most patients using available resources
• Sorting of patients based on their needs for treatment ABC

• Multiple casualty events, by definition, do not exceed the resources available.

• Mass-casualty events, do exceed available medical resources and require triage

• Triage Occurs at Multiple Levels {not a one-time, one-place event or decision

• The medical incident commander should be the highest-ranking medical professional
on the scene who is trained in disaster management.

TAGS THE COLORS

• Red= life-threatening injury that requires immediate intervention and/or operation.
• Yellow = life- or limb-threatening if care is delayed beyond several hours.
• Green = walking wounded + minor injuries.
• Black = dead patients.
• Blue = expectant category= Severely injured
o Need palliative Rx while first caring for red and some yellow
o But can the first priority in situations in which there are only two or three
casualties requiring immediate care
• Although an initial triage categorization decision may label a patient as having
nonsurvival injuries, this may change after all red (or perhaps red and some yellow)
patients have been cared for or evacuated (e.g., a young patient with 90% burns may
survive if burn center care becomes available).

ATLS MANAGEMENT include:

1. Rapid primary survey {ABCDEs}
2. Resuscitation of vital functions
3. More detailed secondary survey
4. Definitive care

What is a quick, simple way to assess a patient in 10 seconds?

By Asking the patient name and what happened
Appropriate response means
• No major airway or Breathing compromise
• No major decrease in level of consciousness
Inappropriate response means
• Altered level of consciousness
• Airway and ventilatory compromise Or both

Ali M. Ahmad; Consultant Pediatric Surgery 1

A = Airway & cervical spine control
Airway management
1. Clearing the airway & Suctioning
2. Administering oxygen
3. Securing the airway

Cervical spine care

• Neurologic exam alone does not exclude a cervical spine injury
• Lateral C Spine X-ray identifies only 85% of all injuries, so a normal lateral c-spine
film does not exclude the possibility of a c-spine injury
• Care include
o Avoid Cervical spine over movements
o Use appropriate immobilization devices
o Inline immobilization techniques

B = Breathing
• Injuries that severely impair ventilation include
o Tension pneumothorax
o Open pneumothorax
o Massive hemothorax
o Flail chest with pulmonary contusion,

C = Circulation & Bleeding control

• Hypotension = hypovolemic in origin until proven otherwise
• Fast evaluation signs; level of consciousness, skin color, and pulse
• The earliest signs of volume depletion—tachycardia
• Check Central pulse {Femoral or carotid, bilaterally} for {quality, rate + regularity}
o Normal + full = mostly but not necessarily normovolemia
o Rapid + thready = hypovolemia
o Absent = sever hypovolemia
o Irregular= potential cardiac dysfunction.

• External blood loss managed by

o Direct manual pressure on the wound,
o If failed can use tourniquet {ischemia}
o Or artery forceps {nerve injury}

• Internal blood loss management may include

o Chest decompression,
o Pelvic binders,
o Splint application
o Surgical intervention

Ali M. Ahmad; Consultant Pediatric Surgery 2

 • A minimum of two large-caliber IV catheters {upper-extremity is preferred}
• Blood should be drawn for type and crossmatch and baseline hematologic studies,
including a pregnancy test for all females of childbearing age.
• Blood gases and/or lactate level should be obtained to assess the presence and
degree of shock.
• Cardiac tamponade and tension pneumothorax are suggested by the presence of
distended neck veins. Decreased breath sounds, hyperresonance to percussion, and
shock may be the only indications of tension pneumothorax
• Excessive manipulation of the pelvis should be avoided, because it can precipitate
additional hemorrhage & AP pelvic x-ray, performed as an adjunct to the primary
survey and resuscitation, can Dx pelvic fractures

D = Disability (Neurologic Evaluation) Include

1. Level of consciousness
2. Pupillary size and reaction
3. Lateralizing signs
4. Spinal cord injury level

What is the secondary survey, and when does it start?

# 2ry survey
1. Head-to-toe clinical evaluation
2. Complete history
3. Reassessment of all vital signs

# Does not begin until

• The primary survey (ABCDEs) is completed
• Resuscitative efforts are underway
• Normalization of vital functions has been demonstrated.

Remember AMPLE history is a useful mnemonic for this purpose:

• Allergies
• Medications currently used
• Past illnesses/Pregnancy
• Last meal
• Events/Environment related to the injury

Ali M. Ahmad; Consultant Pediatric Surgery 3

Which patients do I transfer to a higher level of care?
When should the transfer occur?

• Transfer should be considered whenever the patient’s treatment needs exceed the
capability of the receiving institution; including equipment, resources, and
personnel.
• These criteria take into account the patient’s physiologic status, obvious anatomic
injury, mechanisms of injury, concurrent diseases, and other factors that can alter
the patient’s prognosis.

Consent is sought before treatment, if possible.

• In life-threatening emergencies, it is often not possible to obtain such consent.
• Treatment should be provided first, with formal consent obtained later

The Team Leader

supervises, checks, and directs the assessment;

• Ideally he/she is not involved hands-on in the assessment itself.

• Is not necessarily the most senior person.
• He/she should be trained in ATLS

• it is helpful to have team members assigned to the following roles:

1. Patient assessment
2. Undressing/exposing the patient & Applying monitoring equipment
3. Recording the resuscitation activity

• On arrival of the patient, the team leader supervises the hand-over by EMS
personnel, making certain that no team member begins working on the patient
unless immediate life-threatening conditions are obvious (“hands-off hand-over”).
• A useful format is the MIST acronym:
o Mechanism (and time) of injury
o Injuries found and suspected
o Symptoms and Signs
o Treatment initiated

Ali M. Ahmad; Consultant Pediatric Surgery 4

AIRWAY AND VENTILATORY MANAGEMENT
• Supplemental oxygen must be administered to all trauma patients.
• Tachypnea can be a subtle but early sign of airway or ventilatory compromise.
• Obtundation suggests hypercarbia.
• Agitation suggests hypoxia
• Cyanosis indicates late sign of hypoxemia due to inadequate oxygenation
• Laryngeal injury, can present with acute airway obstruction. It is indicated by the
following triad of clinical signs:
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture

Prediction of a potentially difficult airway

• C-spine injury or Severe arthritis
• Maxillofacial or mandibular trauma
• Limited mouth opening
• Obesity,
• Anatomical variations (e.g., receding chin, overbite, and a short, muscular neck)

• Remember; LEMON Assessment for Difficult Intubation

L = Look Externally
E = Evaluate the 3-3-2-Rule
M = Mallampati {from Class 1 to 4}
O =-Obstruction
N = Neck Mobility

Methods for managing difficult or failed airways, including

1. laryngeal mask airway (LMA)
2. Intubating laryngeal mask airway (ILMA),
3. laryngeal tube airway (LTA)
4. Gum elastic bougie (GEB).

Alternative Technique for Inserting Oral Airway.

• Oral airway is inserted upside down until the soft palate is encountered, at which
point the device is rotated 180 degrees and slipped into place over the tongue.
• This method should not be used in children because the rotation of the device can
damage the mouth and pharynx
• Choose the correct size LMA/ILMA: 3 for a small female, 4 for a large female or small
male, and 5 for a large male.
• Note: LMA and LTA are not a definitive airway

Ali M. Ahmad; Consultant Pediatric Surgery 5

# DEFINITIVE AIRWAY
• Tube placed in the trachea
• With the cuff inflated below the vocal cords
• The tube connected to some form of oxygen-enriched assisted ventilation
• The airway secured in place with tape.

• Select the proper-size tube {same size as the infant’s nostril or little finger}
• Insert the endotracheal tube not more than 2 cm past the cords
• There are three types of definitive airways:
1. Orotracheal tubes
2. Nasotracheal tubes
3. Surgical airways (Cricothyroidotomy or tracheostomy).

Indications for Definitive airway

1. Airway problems
§ Inability to maintain a patent airway by other means
§ Potential compromise of the airway (e.g., following inhalation injury, facial
fractures, or retropharyngeal hematoma)

2. Breathing problem
§ Inability to maintain oxygenation by face-mask
§ Presence of apnea

3. Disability problems
§ Head injury + GCS score of 8 or less
§ Protect airway from aspiration of blood or vomitus
§ Sustained seizure activity

• Blind Nasotracheal intubation requires a patient who is spontaneously breathing and

is contraindicated in patients with apnea

• If Orotracheal intubation is unsuccessful on the first attempt or if the cords are

difficult to visualize, a gum elastic bougie should be used, and further preparations
for difficult airway should be undertaken

• To maintain a patient’s oxygenation, oxygenated inspired air is best provided via a

tight-fitting oxygen reservoir face mask with a flow rate of greater than 11 L/min

Ali M. Ahmad; Consultant Pediatric Surgery 6

RAPID SEQUENCE INTUBATION {RSI}
• Use of drugs for endotracheal intubation in trauma patients
• Anesthetic, sedative, and neuromuscular blocking
• Is potentially dangerous; so you must have a plan in the event of failure that includes
the possibility of performing a surgical airway.

• Usual Drug used

o Sedation: Etomidate, 0.3 mg/kg {does not have effect on B/P or ICP}
o Paralytic: Succinylcholine 100 mg IV {1 to 2 mg/kg)

• If RSE failed, the patient must be ventilated with a bag-mask device until the
paralysis resolves; long acting drugs are not routinely used for RSI for this reason

• Because of the potential for severe hyperkalemia, succinylcholine must be used

carefully in patients with
o Severe crush injuries,
o Major burns
o Electrical injuries.

• Particular attention must be paid in cases of preexisting chronic renal failure, chronic
paralysis, and chronic neuromuscular disease

• Other sedation like

o Thiopental are potentially dangerous in trauma patients with hypovolemia
o Midazolam in small dose are appropriate to reduce anxiety
o Flumazenil must be available to reverse the sedative effects after
benzodiazepines have been administered.

Ali M. Ahmad; Consultant Pediatric Surgery 7

Surgical Airway {Cricothyroidotomy or Tracheostomy} Indications
• Edema of the glottis
• Fracture of the larynx
• Severe oropharyngeal hemorrhage obstructs the airway
• Endotracheal tube cannot be placed through the vocal cords
• Note: surgical Cricothyroidotomy is preferable to a tracheostomy for most patients

Needle Cricothyroidotomy
• Insertion of a needle through the cricothyroid membrane or into the trachea
• It provides oxygen on a short-term basis until a definitive airway can be placed
• Cannula 12- to 14-gauge for adults, and 16- to 18-gauge in children
• Connected to oxygen at 15 L/min
• Used for 30 to 45 min Because of the inadequate exhalation,
• CO2 slowly accumulates, especially in patients with head injuries
Complications of Needle Cricothyroidotomy
• Inadequate ventilation, leading to hypoxia and death
• Aspiration (blood)
• Esophageal laceration
• Hematoma
• Perforation of the posterior tracheal wall
• Subcutaneous and/or mediastinal emphysema
• Pneumothorax

Surgical Cricothyroidotomy
• a skin incision that extends through the cricothyroid membrane.
• A curved hemostat may be inserted to dilate the opening
• Small ETT or tracheostomy tube (preferably 5 to 7 mm OD) can be inserted.
• Care must be taken, especially with children, to avoid damage to the cricoid
cartilage, which is the only circumferential support for the upper trachea.
• It’s not recommended below 12 year
Complications of Surgical Cricothyroidotomy
• Aspiration (blood)
• Creation of a false passage into the tissues
• Subglottic stenosis/edema
• Laryngeal stenosis
• Hemorrhage or hematoma formation
• Laceration of the esophagus
• Laceration of the trachea
• Mediastinal emphysema
• Vocal cord paralysis, hoarseness
Note: percutaneous tracheostomy is not a safe procedure in the acute trauma Pt.

Ali M. Ahmad; Consultant Pediatric Surgery 8

# MANAGEMENT OF OXYGENATION { PULSE OXIMETRY & ABG}

1- Pulse oximetry
• Noninvasive method
• Measure oxygen saturation and pulse rate of arterial blood
• It does not measure the partial pressure of oxygen (PaO2)
• But if 95% or greater = adequate peripheral arterial oxygenation
(PaO2 >70 mm Hg, or 9.3 kPa)

Oximetry is Unreliable in following situation

1. Severe VC {requires intact peripheral perfusion}
2. Severe anemia (Hb <5 g/dL)
3. Severe Hypothermia (<30°C
4. CO poisoning {cannot distinguish oxy HB from
carboxy Hb or methemoglobin
5. Others;
o Excessive patient movement
o Intense ambient light

2- Standard blood gas measurements

• Report both PaO2 and %SaO2.
• When oxygen saturation is calculated from blood gas PaO2, the calculated value can
differ from the oxygen saturation measured by the pulse oximetry {the effects of
variables that shift the relationship between PaO2 and saturation}.
• These variables include temperature, pH, PaCO2, 2,3-DPG (diphosphoglycerates),
and the concentration of fetal hemoglobin

# MANAGEMENT OF VENTILATION {CARBON DIOXIDE DETECTION}

• By Capnography, capnometry, or mass spectroscopy
• Colorimetric; there is indicator strip that generally reflects the CO2 level
o At very low levels, the indicator turns purple
o At higher CO2 1evels the indicator turns yellow
• the colorimetric test should not be used until after at least six breaths.
• The colorimetric device is not used for the detection of elevated CO2 levels.
Similarly, it is not used to detect a main stem bronchial intubation.
• In a noisy ED or when the patient is transported several times, this device is
extremely reliable in differentiating between tracheal and esophageal intubation.

Ali M. Ahmad; Consultant Pediatric Surgery 9

 # SHOCK
Diagnosis of shock is based on clinical recognition of the presence of inadequate tissue
perfusion and oxygenation

• Catecholamine’s increases peripheral vascular resistance

o Increases diastolic blood pressure & Reduces pulse pressure
o Does not increase organ perfusion So Vasopressors are contraindicated for
the treatment of hemorrhagic shock because they worsen tissue perfusion.

Treatment of shock
1. Providing adequate oxygenation& Ventilation
2. Appropriate fluid resuscitation
3. Stopping the bleeding.

RECOGNITION OF SHOCK
1. Cool skin {Cutaneous vasoconstriction}
2. Tachycardia if {> 160 infant, > 140 preschool age, > 120 prepuberty, > 110 adult}
3. Narrowed pulse pressure suggests significant blood loss

4. Base deficit and/or lactate levels useful in determining severity of shock

5. Chest x-ray, pelvic x-ray, FAST, DPL, and bladder catheterization may all be
necessary to determine the source of blood loss

• Hematocrit unreliable and should not be used to exclude the presence of shock
• The failure of fluid resuscitation to restore organ perfusion suggests either
continuing hemorrhage or neurogenic shock
• Patient with injuries above diaphragm may have evidence of inadequate organ
perfusion due to poor cardiac performance {inadequate venous return (preload).
o Blunt myocardial injury, Cardiac tamponade,
o Tension pneumothorax
o Spinal cord injury {Neurogenic Shock}
o Septic shock

Ali M. Ahmad; Consultant Pediatric Surgery 10

NEUROGENIC SHOCK
Cervical or upper thoracic spinal cord injury can produce hypotension due to loss of
sympathetic tone but
1. No tachycardia
2. No cutaneous vasoconstriction.
3. No narrowed pulse pressure

SEPTIC SHOCK
• Early septic shock can have a normal circulating volume + modest tachycardia
• Warm skin, systolic pressure near normal, and a wide pulse pressure.

HEMORRHAGIC SHOCK
• Normal blood volume is:
o Adult, 7% of body weight {70-kg male has approximately 5 L}.
o Child, 8% to 9% of body weight (80–90 mL/kg)

• Resuscitation will likely require crystalloid, pRBCs, and blood products.

• Nonresponse to fluid administration almost always indicates persistent blood loss
with the need for operative or angiographic control.
• The usual dose is 1 to 2 L for adults and 20 mL/kg for pediatric patients.
• Absolute volumes of resuscitation fluids should be based on patient response.
• initial fluid amount includes any fluid given in the Prehospital setting
• Excessive fluid administration can exacerbate the lethal triad of coagulopathy,
acidosis, and hypothermia with activation of the inflammatory cascade.
o Balancing the goal of organ perfusion with the risks of rebleeding by
accepting a lower-than-normal blood pressure has been termed “controlled
resuscitation,” “balanced resuscitation,” “hypotensive resuscitation

Ali M. Ahmad; Consultant Pediatric Surgery 11

 o The goal is the balance, not the hypotension.
o Such a resuscitation strategy may be a bridge to, but is not a substitute for,
definitive surgical control of bleeding
• Adequate resuscitation should produce a urinary output of approximately 0.5
mL/kg/hr. in adults, whereas 1 mL/kg/hr. in pediatric patients
• Persistent acidosis is usually caused by inadequate resuscitation or ongoing blood
loss and, it should be treated with fluids, blood, and consideration of operative
intervention to control hemorrhage. Serial measurement of these parameters can be
used to monitor the response to therapy. Sodium bicarbonate should not be used to

treat metabolic acidosis secondary to hypovolemic shock.

• Failure to respond to crystalloid and blood administration in the ED dictates the
need for immediate, definitive intervention (e.g., operation or angioembolization) to
control exsanguinating hemorrhage.
• On very rare occasions, failure to respond may be due to Nonhemorrhagic shock
{Blunt cardiac injury, cardiac tamponade, or tension pneumothorax}

Increasing blood flow requires an increase in cardiac output

o Ohm’s law (V = I x R)
§ (V) blood pressure
§ (I) cardiac output
§ (R) (afterload). systemic vascular resistance
o Increase in blood pressure should not be equated with a concomitant
increase in cardiac output or the recovery from shock.
o An increase in peripheral resistance—for example, with vasopressor
therapy—with no change in cardiac output results in increased blood
pressure, but no improvement in tissue perfusion or oxygenation.

Ali M. Ahmad; Consultant Pediatric Surgery 12

CROSSMATCHED, TYPE-SPECIFIC, AND TYPE O BLOOD

• Complete crossmatching {Ideal}

o Process requires approximately 1 hour
o Indicated in Rapid responder
• Type-specific blood
o Can be provided within 10 minutes {ABO and Rh blood types}
o Incompatibilities of other antibodies may exist.
o Indicated in transient responders,
o But complete crossmatching should be performed by the blood bank.
• Type O packed cells
o Indicated in case of exsanguinating hemorrhage.
o Rh-negative are preferred for females of childbearing age.
o As soon as it is available, the use of unmatched, type-specific blood is
preferred over type O blood.
o This is true unless multiple, unidentified casualties are being treated
simultaneously and the risk of inadvertently administering the wrong unit of
blood to a patient is great.

HYPOTHERMIA
• Most efficient way to prevent hypothermia in any patient receiving massive volumes
of crystalloid is to heat the fluid to 39°C before infusing it.
• Blood products cannot be warmed in a microwave oven
• Massive transfusion, defined as >10 units of pRBCs within the first 24 hours.
• Early administration of pRBCs, plasma, and platelets, and minimizing aggressive
crystalloid administration is termed balanced, hemostatic or damage control
resuscitation
• Prothrombin time, partial thromboplastin time, and platelet count are valuable
baseline studies to obtain in the first hour

Ali M. Ahmad; Consultant Pediatric Surgery 13

 # THORACIC TRAUMA

• Cyanosis is a late sign of hypoxia in trauma patients.

• Neck veins should be assessed for distention
• However, keep in mind that neck veins may not be distended in patients with
concomitant hypovolemia {cardiac tamponade, tension pneumothorax, or a
traumatic diaphragmatic injury}

Identify and initiate treatment of the following injuries during

THE PRIMARY SURVEY:
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Massive hemothorax
5. Flail chest and pulmonary contusion
6. Cardiac tamponade

Identify and initiate treatment of the following potentially life-threatening injuries during
THE SECONDARY SURVEY:
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheobronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt esophageal rupture

Tension Pneumothorax
• Most common cause is mechanical ventilation with positive-pressure ventilation
• Must be Clinical diagnosis
• Rx should not be delayed to wait for radiologic confirmation

Open Pneumothorax
• Promptly closing the defect with a sterile occlusive dressing {large enough to overlap
the wound’s edges and then taped securely on three sides in order to provide a
flutter-type valve effect}
• Then chest tube remote from the wound should be placed as soon as possible

Ali M. Ahmad; Consultant Pediatric Surgery 14

Flail Chest and Pulmonary Contusion
• Multiple rib fractures, two or more adjacent ribs fractured in two or more places
• This defect alone does not cause hypoxia
• The major difficulty in flail chest stems from the injury to the underlying lung
• Initial treatment; includes adequate ventilation, administration of humidified
oxygen, and fluid resuscitation

Massive Hemothorax
• Rapid accumulation of more than 1500 mL of blood or one-third of the patient’s
blood volume in the chest cavity
• Is suggested when shock is associated with the absence of breath sounds or dullness
to percussion on one side of the chest
• Initially managed by the simultaneous restoration of blood volume and
decompression of the chest cavity
• If 1500 mL is immediately evacuated, early thoracotomy is almost always required.
• Penetrating anterior chest wounds medial to the nipple line and posterior wounds
medial to the scapula should alert the practitioner to the possible need for
thoracotomy because of potential damage to the great vessels, hilar structures, and
the heart, with the associated potential for cardiac tamponade.

Cardiac Tamponade
• Most commonly results from penetrating injuries.
• Human pericardial sac is a fixed fibrous structure; a relatively small amount of blood
can restrict cardiac activity and interfere with cardiac filling.
• Classic diagnostic Beck’s triad:
1. Elevated Venous pressure
2. Decline in arterial pressure
3. Muffled heart tones
• Additional diagnostic includes; Echocardiogram & FAST, or pericardial window.
• Preparation to transfer such a patient for definitive care is always necessary
• Thoracotomy is indicated only when a qualified surgeon is available.
• If surgical intervention is not possible, Pericardiocentesis can be diagnostic as well as
therapeutic, but it is not definitive treatment for cardiac tamponade
1. Penetrating thoracic injuries + pulseless + with myocardial electrical activity, may
be candidates for immediate resuscitative thoracotomy
2. Penetrating thoracic injuries + CPR in the Prehospital setting + no any signs of life
and no cardiac electrical activity no further resuscitative effort should be made.
3. Blunt thoracic injuries + pulseless + with myocardial electrical activity (PEA) are
not candidates for emergency department resuscitative thoracotomy.
4. Blunt thoracic injuries + cardiac arrest; Thoracotomy is rarely effective.
Signs of life include
• Reactive pupils, Spontaneous movement, or organized ECG activity.

Ali M. Ahmad; Consultant Pediatric Surgery 15

PERICARDIOCENTESIS
• Using a 16 to 18 gauge
• 6 in. (15-cm) or longer over-the-needle catheter
• Attach a 35-mL empty syringe with a three-way stopcock
• Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a
45-degree angle to the skin.
• After aspiration is completed, remove the syringe and attach a three-way stopcock,
leaving the stopcock closed. Secure the catheter in place.

COMPLICATIONS OF PERICARDIOCENTESIS
• Aspiration of ventricular blood instead of pericardial blood
• Laceration of ventricular epicardium/ myocardium
• Laceration of coronary artery or vein
• New hemopericardium, secondary to lacerations of the coronary artery or vein,
and/or ventricular epicardium/ myocardium
• Ventricular fibrillation
• Pneumothorax, secondary to lung puncture
• Puncture of great vessels with worsening of pericardial tamponade
• Puncture of esophagus with subsequent mediastinitis
• Puncture of peritoneum with subsequent peritonitis or false positive aspirate

Simple Pneumothorax
• An upright, expiratory x-ray of the chest aids in the diagnosis.
• Any pneumothorax is best treated with a chest tube placed in the fifth ICS
• You must inset ICT before any GA or using PPV and air ambulance

Hemothorax {operative indications}

1. If 1500 mL of blood is obtained immediately through the chest tube
2. If drainage of more than 200 mL/hr. for 2 to 4 hours occurs
3. If blood transfusion is required

Pulmonary Contusion
• Patients with significant hypoxia (PaO2 <65 mm Hg or SaO2 <90%) on room air may
require intubation and ventilation within the first hour after injury.
• Associated medical conditions, such as chronic obstructive pulmonary disease and
renal failure, increase the likelihood of needing early intubation and mechanical
ventilation

Ali M. Ahmad; Consultant Pediatric Surgery 16

# TRACHEOBRONCHIAL TREE INJURY
• Injury to the trachea or major bronchus is an unusual and potentially fatal
• Incomplete expansion of the lung after placement of a chest tube suggests a
tracheobronchial injury, and placement of more than one chest tube often is
necessary to overcome a significant air leak.
• Bronchoscopy confirms the diagnosis

# TRAUMATIC AORTIC RUPTURE

• Common cause of sudden death after automobile collision or fall from height
• Chest x-ray, finding which may indicate major vascular injury include:
o Widened mediastinum
o Obliteration of the aortic knob
o Deviation of the trachea to the right
o Depression of the left mainstem bronchus
o Elevation of the right mainstem bronchus
o Obliteration of the space between the pulmonary artery and the aorta
o Deviation of the esophagus (nasogastric tube) to the right
o Widened paratracheal stripe
o Widened paraspinal interfaces
o Presence of a pleural or apical cap
o Left hemothorax
o Fractures of the first or second rib or scapula

• A properly performed and interpreted helical CT that is normal may obviate the need
for transfer to a higher level of care to exclude thoracic aortic injury.
• All patients with a mechanism of injury and simple chest x-ray findings suggestive of
aortic disruption should be transferred to a facility capable of rapid definitive
diagnosis and treatment of this injury.

# BLUNT CARDIAC INJURY

• Myocardial muscle contusion,
• Cardiac chamber rupture
• Coronary artery dissection and/or thrombosis
• Valvular disruption
• Early use of FAST can facilitate diagnosis

# DIAPHRAGM INJURIES
• may be missed during the initial trauma evaluation.
• An undiagnosed diaphragm injury can result in pulmonary compromise or
entrapment and strangulation of peritoneal contents

Ali M. Ahmad; Consultant Pediatric Surgery 17

# ESOPHAGEAL INJURY : Should be considered in
• Any patient who has a left pneumothorax or hemothorax without a rib fracture;
• Received a severe blow to the lower sternum or epigastrium and is in pain or shock out
of proportion to the apparent injury
• Presence of mediastinal air
• Confirmed by contrast studies and/or Esophagoscopy.
• Treatment consists of wide drainage of the pleural space and mediastinum with direct
repair of the injury via thoracotomy, if feasible.
• Repairs performed within a few hours of injury lead to a much better prognosis.

CHEST X-RAY
Guidelines for examining a series of chest x-rays:
• Trachea and bronchi
• Pleural spaces and lung parenchyma
• Mediastinum- Diaphragm- Bony thorax
• Soft tissues
• Tubes and lines

Ali M. Ahmad; Consultant Pediatric Surgery 18

 # ABDOMINAL AND PELVIC TRAUMA

• Any patient who has sustained significant blunt torso injury from a direct blow,
deceleration, or a penetrating injury must be considered to have an abdominal visceral,
vascular, or pelvic injury until proven otherwise
• Airbag deployment does not preclude abdominal injury

Diagnostic Peritoneal Lavage {DPL}

• 98% sensitive for intraperitoneal bleeding
• Free aspiration of blood, GI contents, vegetable fibers, or bile through the lavage
catheter in patients with hemodynamic abnormalities mandates laparotomy
• If gross blood (>10 mL) or GI contents are not aspirated, lavage is performed with 1000
mL of warmed isotonic crystalloid solution (10 mL/kg in a child) and the effluent is sent
to the laboratory for quantitative analysis
• A positive test is indicated by
o >100,000 red blood cells (RBC)/mm3,
o > 500 white blood cells (WBC)/mm3,
o or a Gram stain with bacteria present
FAST
• Is performed with a low frequency (3.5 MHz) transducer
• Higher frequency transducers may be appropriate for children or extremely thin adults

CT scan
• Can miss some gastrointestinal, diaphragmatic, and pancreatic injuries.
• In the absence of hepatic or splenic injuries, the presence of free fluid in the abdominal
cavity suggests an injury to the GI tract and/or its mesentery, and many trauma
surgeons find this to be an indication for early operative intervention.
• If there is early or obvious evidence that the patient will be transferred to another
facility, time-consuming tests, including abdominal CT, should not be performed.

Ali M. Ahmad; Consultant Pediatric Surgery 19

Most gunshot wounds to the abdomen
• Are managed by exploratory laparotomy
• Incidence of significant intraperitoneal injury approaches 98%
• Tangential gunshot wounds often are not truly tangential
• Blast injuries can cause intraperitoneal injury without peritoneal penetration.

Stab wounds to the abdomen

• May be managed more selectively
• But approximately 30% do cause intraperitoneal injury.
• Thus, indications for laparotomy include:
o Any hemodynamically abnormal patient
o Gunshot wound with a transperitoneal trajectory
o Signs of peritoneal irritation
o Signs of fascia penetration

• An early normal serum amylase level does not exclude major pancreatic trauma.
Conversely, the amylase level can be elevated from nonpancreatic sources.

Pelvic Fractures and Associated Injuries

Pelvic ring instability test
o By manual manipulation of the pelvis.
o Performed only once during the physical examination
o It should not be performed in pts with shock and an obvious pelvic fracture.
• Patients with hypotension and pelvic fractures have a high mortality
o [one in four in closed pelvic fracture}
o and up to 50% in patients with open pelvic fracture
• Hemorrhage control is achieved through mechanical stabilization of the pelvic ring
and external counter pressure
• A sheet, pelvic binder, or other device can apply sufficient stability for the unstable
pelvis at the level of the greater trochanters of the femur
• Angiographic embolization is often the best option for definitive management of
patients with ongoing hemorrhage related to pelvic fractures.

Ali M. Ahmad; Consultant Pediatric Surgery 20

 # HEAD TRAUMA

• Primary goal of treatment (TBI) is to prevent secondary brain injury By

1. Providing adequate oxygenation
2. Maintaining blood pressure at a level that is sufficient to perfuse the brain

• Obtaining a CT scan should not delay patient transfer to a trauma center that is capable
of immediate and definitive neurosurgical intervention.
• Early endotracheal intubation should be performed in comatose patients

• Most epidural hematomas represent a life-threatening emergency and must be

evaluated by a neurosurgeon as soon as possible.
o The midbrain and upper pons contain the reticular activating system, which
is responsible for the state of alertness
o Tentorium cerebelli divides the intracranial cavity into the supratentorial and
infratentorial compartments & midbrain passes through an opening called
the tentorial hiatus or notch.
o Medial part of the temporal lobe, known as the uncus
o Oculomotor nerve runs along the edge of the tentorium and may become
compressed against it during temporal lobe herniation.
o Parasympathetic fibers that constrict the pupil lie on the surface of the third
cranial nerve. Compression of these superficial fibers during herniation
causes pupillary dilation due to unopposed sympathetic activity, often
referred to as a “blown” pupil
o Uncal herniation also causes compression of the corticospinal (pyramidal)
tract in the midbrain. The motor tract crosses to the opposite side at the
foramen magnum, so compression at the level of the midbrain results in
weakness of the opposite side of the body (contralateral hemiparesis).
• Ipsilateral pupillary dilation associated with contralateral hemiparesis is the classic
sign of uncal herniation.

• Normal ICP in the resting state is approximately 10 mmHg. If ICP greater than 20
mmHg, particularly if sustained, are associated with poor outcomes.
• Monro-Kellie doctrine theory explained why ICP not initially rise {due to decrease in
CSF and venous volume} However, once the limit is reached, ICP rapidly increases.
• Every effort should be made to enhance cerebral perfusion and blood flow by
o Reducing elevated ICP,
o Maintaining normal intravascular volume,
o Maintaining a normal mean arterial blood pressure (MAP),
o Restoring normal oxygenation and normocapnia.
• Hematomas that increase intracranial volume should be evacuated early.

Ali M. Ahmad; Consultant Pediatric Surgery 21

CLASSIFICATIONS OF HEAD INJURIES

In assessing the GCS, when there is right/left or

upper/lower asymmetry, it is important to use the
best motor response to calculate the score,
because this is the most reliable predictor of
outcome.

High risk for neurosurgical intervention

• GCS score less than 15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Basilar skull fracture (e.g., hemotympanum,
raccoon eyes, CSF otorrhoea or rhinorrhea,
Battle’s sign)
• Vomiting (more than two episodes)
• Age more than 65 years

Mortality risk {MR} in sever TBI

• MR if with Hypotension on admission is more
than double
• MR up to 75% if hypotension + hypoxia

Ali M. Ahmad; Consultant Pediatric Surgery 22

Medical therapies for brain injury include
1. Intravenous fluids {Ringer’s lactate or NS}
2. Temporary hyperventilation {for limited a period as possible}
Normocarbia (35 mm Hg to 45 mm Hg) is the preferred range
3. Mannitol {20% solution = 20 g per 100 ml) is used to reduce elevated ICP in a
euvolemic patient with dose of bolus of (1 g/kg) over 5 minutes)
4. Hypertonic saline {3% to 23.4%} is also used to reduce elevated ICP; this may be the
preferable agent with hypotension, as it does not act as a diuretic
5. Barbiturates {Effective in reducing ICP refractory to other measures}. They should not
be used in the presence of hypotension or hypovolemia.
6. Anticonvulsants.
o Prolonged seizures (30 to 60 minutes) may cause secondary brain injury Vs.
Anticonvulsants inhibit brain recovery, so they should be used only when
absolutely necessary {IV 1 g of phenytoin no faster than 50 mg/min followed by
maintenance 100 mg/8 hours, with the dose titrated to achieve therapeutic
serum levels}
o Note: it is important to remember that seizures are not controlled with muscle
relaxants.

• In case of intracranial lesions; If a neurosurgeon is not available in the facility, early

transfer to a hospital with a neurosurgeon is essential
• Disturbing or removing penetrating objects prematurely can lead to fatal vascular
injury or intracranial hemorrhage.
• in patients who need an evacuation, bone flap craniotomy (and not a simple burr hole)
is the definitive lifesaving procedure to decompress the brain, and every attempt
should be made to have a practitioner trained and experienced in doing the procedure
perform it in a timely fashion.

DIAGNOSIS OF BRAIN DEATH {no possibility for recovery of brain function}

1. Glasgow Coma Scale score = 3
2. Nonreactive pupils
3. Absent brainstem reflexes (oculocephalic, corneal, and Doll’s eyes, and no gag reflex)
4. No spontaneous ventilatory effort on formal apnea testing

ANCILLARY STUDIES that may be used to confirm the diagnosis of brain death include:
a. Electroencephalography: No activity at high gain
b. CBF studies: No CBF (isotope studies, Doppler studies, xenon CBF studies)
c. Cerebral angiography

Note: Local organ-procurement agencies should be notified about all patients with the
diagnosis or impending diagnosis of brain death prior to discontinuing artificial life support
measures.

Ali M. Ahmad; Consultant Pediatric Surgery 23

 # SPINAL CORD TRAUMA

• Spine injury, with or without neurologic deficits, must always be considered in patients
with multiple injuries.
• Appropriate immobilization is required for all of these patients
• Most thoracic spine fractures are wedge compression fractures that are not associated
with spinal cord injury.

Ali M. Ahmad; Consultant Pediatric Surgery 24

# SPINAL NERVE SEGMENTS AND AREAS OF INNERVATION

C5 Area over the deltoid

C6 Thumb
C7 Middle finger
C8 Little finger
T4 Nipple
T8 Xiphisternum
T10 Umbilicus
T12 Symphysis pubis
L4 Medial aspect of the calf
L5 Web space between the first and second toes
S1 Lateral border of the foot
S3 Ischial tuberosity area
S4 and S5 Perianal region

Ali M. Ahmad; Consultant Pediatric Surgery 25

# NEUROGENIC SHOCK

• Impairment of the descending sympathetic pathways in the cervical or upper

thoracic spinal cord.
• Results in the loss of vasomotor tone and in sympathetic innervation to the heart.
• Is rare in spinal cord injury below the level of T6; if shock is present in these patients,
an alternative source should be strongly suspected.
• Atropine may be used to counteract hemodynamically significant bradycardia.

# SPINAL SHOCK

• Refers to the flaccidity and loss of reflexes seen after spinal cord injury.
• “shock” to the injured cord may make it appear completely nonfunctional, although
the cord may not necessarily be destroyed.
• The duration of this state is variable.

# LEVEL OF SPINAL INJURY

• Injuries of the first eight cervical segments of the spinal cord result in quadriplegia,
and lesions below the T1 level result in paraplegia

# SPINAL CORD SYNDROMES

• Central cord syndrome
o greater loss of motor strength in the upper extremities than in the lower
extremities
• Anterior cord syndrome
o paraplegia and a dissociated sensory loss with a loss of pain and temperature
sensation.
o Poorest prognosis of the incomplete injuries
• Brown-Séquard syndrome.
o Hemisection of the cord, usually as a result of a penetrating trauma
o Ipsilateral motor loss + Loss of position sense
o Contralateral loss of pain and temperature sensation beginning one to two
levels below the level of injury

• The most common C1 fracture is a burst fracture (Jefferson fracture)

• Chance fractures are transverse fractures through the vertebral body

Ali M. Ahmad; Consultant Pediatric Surgery 26

 # MUSCULOSKELETAL TRAUMA

Three goals for the assessment of trauma patients’ extremities:

1. Identification of life-threatening injuries (primary survey)
2. Identification of limb-threatening injuries (secondary survey)
3. Systematic review to avoid missing any other musculoskeletal injury

Doppler ankle/brachial index of less than 0.9 is indicative of an abnormal arterial flow
secondary to injury or peripheral vascular disease. The ankle/brachial index is determined
by taking the systolic blood pressure value as measured by Doppler at the ankle of the
injured leg and dividing it by the Doppler-determined systolic blood pressure of the
uninjured arm.

@Potentially life-threatening include

1. Major arterial hemorrhage and
2. Crush syndrome.
Rhabdomyolysis may lead to metabolic acidosis, hyperkalemia, hypocalcemia,
and DIC. It is recommended to maintain the patient’s urinary output at 100
mL/hr. until the myoglobinuria is cleared.

@Limb-Threatening Injuries
1. Open fractures & Joint injuries,
2. Vascular injuries,
3. Compartment syndrome,
4. Neurologic injury secondary to fracture dislocation.
• Muscle does not tolerate a lack of arterial blood flow for longer than 6 hours before
necrosis begins
• A patient with multiple injuries who requires intensive resuscitation and emergency
surgery is not a candidate for replantation.

@Signs and Symptoms of Compartment Syndrome

o Increasing pain greater than expected and out of proportion to the stimulus
o Palpable tenseness of the compartment
o Asymmetry of the muscle compartments
o Pain on passive stretch of the affected muscle
o Altered sensation
Note: Compartment syndrome is a clinical diagnosis
o Absence of distal pulse usually is a late finding
o Not determined by pressure measurements.
o A delay in performing a fasciotomy may result in myoglobinuria, which may
cause decreased renal function.

Ali M. Ahmad; Consultant Pediatric Surgery 27

 • Traction splint of a femur fracture should be avoided if there is a concomitant
ipsilateral lower leg fracture.
• Despite a thorough examination, occult associated injuries may not be identified
during the initial evaluation. it is imperative to repeatedly reevaluate the patient to
assess for these injuries.
• Normal capillary refill (<2 seconds) of the pulp space or nail bed

Ali M. Ahmad; Consultant Pediatric Surgery 28

 THERMAL INJURIES

• One of Clinical indications of inhalation injury include; Carboxyhemoglobin level greater

than 10% in a patient who was involved in a fire
• Burns over more than 20% of the body surface requires fluid resuscitation.
• The palmar surface (including the fingers) of the patient’s hand represents
approximately 1% of the patient’s body surface.
• CO less than 20% usually have no physical symptoms. Higher co levels can result in:
o Headache and nausea (20%–30%)
o Confusion (30%–40%)
o Coma (40%–60%)
o Death (>60%)
• Because of the increased affinity of
CO for hemoglobin, 240 times that of
oxygen, it displaces oxygen from the
hemoglobin molecule and shifts the
oxyhemoglobin dissociation curve to
the left.
• CO dissociates very slowly, and its
half-life is 250 minutes (4 hours) when
the patient is breathing room air,
compared with 40 minutes when
breathing 100% oxygen. Therefore,
any patient in whom CO exposure
could have occurred should receive
high-flow oxygen via a non-
rebreathing mask
• Measurements of arterial PaO2 do
not reliably predict CO poisoning,
because a CO partial pressure of only
1 mm Hg results in an HbCO level of 40% or greater.

• Blood pressure measurements can be difficult to obtain and may be unreliable in

patients with severe burn injuries, but monitoring of hourly urinary output can reliably
assess circulating blood volume in the absence of osmotic diuresis (e.g., glycosuria).
Therefore, an indwelling urinary catheter should be inserted

Ali M. Ahmad; Consultant Pediatric Surgery 29

The initial fluid rate for burn patients
• 2 to 4 x kg x BSA per 1st 24h
o ½ in the 1st 8h
o then ½ to the remaining 16 h

• example 100 kg with 80% burn {2 to 4 x 100 x 80} = 16000 or 32000 ml/24h
o Give 8000 ml in 1st 8 h {to 16000}
o Ten 8000 in the following 16 h {to 16000}
• Amount of fluids provided should be adjusted based on the urine output target of
0.5 mL/ kg/ hr for adults and 1 mL/kg/hr for children <30 kg.
• In very small children (i.e., <10 kg), it may be necessary to add glucose to their IV
fluids to avoid hypoglycemia
• Pressure >30 mm Hg within the compartment may lead to muscle necrosis need
{Escharotomy} but usually are not needed within the first 6 hours after a burn injury
• Do not apply cold water to a patient with extensive burns (>10% total BSA).
• NO indication for prophylactic antibiotics in the early post-burn period. Antibiotics
should be reserved for the treatment of infection.
• Alkali burns are generally more serious than acid burns, because the alkalies
penetrate more deeply. Alkali burns to the eye require continuous irrigation during
the first 8 hours after the burn
• Patients with electrical injuries frequently need fasciotomy and should be
transferred to burn centers early in their course of treatment.

THREE TYPES OF COLD INJURY

1. Frostnip {Mildest form & is reversible with rewarming}
2. Frostbite {classified into four degrees according to depth of involvement}
3. Nonfreezing injury {Trench foot or cold immersion foot}
Rx:
• Place the injured part in circulating water at a constant 40°C until pink color and
perfusion return (usually within 20 to 30 minutes).
• Rewarming can be extremely painful, and adequate analgesics (intravenous
narcotics) are essential.
• Cardiac monitoring during rewarming is advised.
• Sympathetic blockade (sympathectomy, drugs) and vasodilation agents have
generally not proven helpful in altering the natural history of the acute cold injury

Hypothermia
• Core temperature below 36°C
• Severe hypothermia is any core temperature below 32°C

Ali M. Ahmad; Consultant Pediatric Surgery 30

 PEDIATRIC TRAUMA
Pediatric Trauma Score

• PTS of less than 8 should be triaged to an appropriate pediatric trauma center

Broselow® Pediatric Emergency Tape

• Is an ideal adjunct for the rapid determination of weight based on length for
appropriate fluid volumes, drug doses, and equipment size
• One side of the tape provides drugs and their recommended doses for the pediatric
patient based on weight. The other side identifies equipment needs for pediatric
patients based on length.
• The infant’s trachea is approximately 5 cm long and grows to 7 cm by about 18 mo
• Optimal (ETT) depth (in cm) can be determined to be three times the appropriate
tube size. For example, a 4.0 ETT positioned at 12 cm from the gums.
• Ideally, cuff pressure should be measured as soon as is feasible, and <30 mm Hg is
considered safe

Ali M. Ahmad; Consultant Pediatric Surgery 31

LMA sizes
• 1 (appropriate for infants <6.5 kg)
• 1.5 (for 5 to 10 kg)
• 2 (for 10 to 20 kg)
• 2.5 (for 20 to 30 kg)
• 3 (for between 30 and 70 kg)
• over 70 kg, adult sizing is appropriate

• Hypoxia is the most common cause of cardiac arrest in the child.

• Hypoventilation causes respiratory acidosis
• Tachycardia and poor skin perfusion often are the only keys to early recognition of
hypovolemia and the early initiation of appropriate fluid resuscitation
• The mean normal systolic blood pressure for children is 90 mm Hg plus twice the
child’s age in years
• The lower limit of normal systolic blood pressure in children is 70 mm Hg plus twice
the child’s age in years.
• The diastolic pressure should be about two-thirds of the systolic blood pressure

• Weight formula in kilograms is (2 x age) + 10)

• Infant’s blood volume is 80 mL/kg, and a child’s at 70 ml/ kg.
• If percutaneous access is unsuccessful after two attempts, consideration should be
given to intraosseous infusion via a bone marrow needle (18 gauge in infants, 15
gauge in young children)
• When considering the third 20 mL/kg bolus, the use of packed red blood cells
(pRBCs) bolus of 10 mL/kg should be considered

Ali M. Ahmad; Consultant Pediatric Surgery 32

 # CARDIOPULMONARY RESUSCITATION (CPR)

• CPR done in the field + return of spontaneous circulation = 50% chance of

neurologically intact survival.
• CPR done in the field + still arrest = dismal prognosis.
• CPR >15 minutes + Fixed pupils = predict nonsurvival.
• Operative management is indicated not by the amount of intraperitoneal blood, but by
hemodynamic abnormality and its response to treatment.
• Blood found on a DPL would not mandate operative exploration in a child who is
otherwise stable
• An infant who is not in a coma but who has bulging fontanelles or suture diastases
should be treated as having a more severe injury. Early neurosurgical consultation is
essential.
• GCS is useful when applied to the pediatric age group. However, the verbal score
component must be modified for children younger than 4 years

Drugs often used in children with head injuries include:

Phenobarbital 10 to 20 mg/kg/dose
Diazepam 0.1 to 0.2 mg/kg/dose; slow IV bolus
Phenytoin 15 to 20 mg/kg
• Loading dose; 0.5 to 1.5 mL/kg/min
• Then maintenance 4 to 7 mg/kg/day
Hypertonic saline 3% 3 to 5 mL/kg
Mannitol 0.5 to 1.0 g/kg (rarely required)

• 40% of children younger than 7 y show anterior displacement of C2 on C3

{pseudosubluxation}
• Homicide is the most common cause of injury death in the first year of life

Ali M. Ahmad; Consultant Pediatric Surgery 33

 # GERIATRIC TRAUMA

• Mortality rate was three times greater in older patients with preexisting disease (9.2%
vs 3.2%).
• However, more than 80% of injured older adults can return to their preexisting level of
independent living after aggressive resuscitation and follow-up care
• Consequently, whereas broken dentures should be removed, intact well-fitted dentures
are often best left in place until after airway control is achieved
• Undue manipulation of the osteoarthritic cervical spine, leading to spinal cord injury.

• With aging, total blood volume decreases and circulation time increases
• A common pitfall in the evaluation of geriatric trauma patients is the mistaken
impression that “normal” blood pressure and heart rate indicate normovolemia

• Hypothermia not attributable to shock or exposure should alert the physician to the
possibility of occult disease—in particular, sepsis, endocrine disease, or pharmacologic
causes.
• The most common locations of fractures in elderly patients are the ribs, proximal
femur, hip, humerus, and wrist

Special circumstances of elderly trauma patients include

1. Medications,
ß--adrenergic blocking agents may limit chronotropic activity, and calcium-channel
blockers may prevent peripheral vasoconstriction and contribute to hypotension

2. Elder maltreatment
Is any willful infliction of injury, unreasonable confinement, intimidation, or cruel
punishment that results in physical harm, pain, mental anguish, or other willful
deprivation by a caretaker of goods or services that are necessary to avoid physical
harm, mental anguish, or mental illness.

3. End-of-life decisions

Ali M. Ahmad; Consultant Pediatric Surgery 34

 # TRAUMA IN PREGNANCY AND INTIMATE PARTNER VIOLENCE

• Abrupt decrease in maternal intravascular volume can result in a profound increase in

uterine vascular resistance, reducing fetal oxygenation despite reasonably normal
maternal vital signs.
o Healthy pregnant can lose up to 1500 mL of blood before exhibiting signs
o Placenta, receive 20% of cardiac output during the third trimester
o Supine position, vena cava compression can decrease cardiac output by 30%
o Pregnancy results in a 5 to 15 mm Hg fall in systolic and diastolic pressures during
the second trimester
• Hypocapnia (PaCO2 of 30 mm Hg) is common in late pregnancy {PaCO2 of 35 to 40 mm
Hg may indicate impending respiratory failure during pregnancy}.
• Assess and resuscitate the mother first, and then assess the fetus before conducting a
secondary survey of the mother
• Uterus should be displaced manually to the left side to relieve IVC pressure
• Continuous fetal monitoring with a tocodynamometer should be performed beyond 20
to 24 weeks of gestation
• All pregnant Rh-negative trauma patients should receive Rh immunoglobulin therapy
unless the injury is remote from the uterus (e.g., isolated distal extremity injury).

Risk factors for fetal loss

• Heart rate >110
• Injury Severity Score (ISS) >9
• Evidence of placental abruption
• Fetal heart rate >160 or <120
• Ejection during a motor vehicle crash, and
motorcycle or pedestrian collisions
• There are few data to support perimortem cesarean
section in pregnant trauma patients who experience
hypovolemic cardiac arrest.
• For other causes of maternal cardiac arrest,
perimortem cesarean section occasionally may be
successful if performed within 4 to 5 minutes of the
arrest.

Ali M. Ahmad; Consultant Pediatric Surgery 35

 # APP A- OCULAR TRAUMA

• Iridodialysis = tear of the iris

• Iridodonesis = floppy or tremulous iris
• Penetrating foreign bodies should not be disturbed and are removed only in the
operating room by an ophthalmologist or appropriate specialist.
• Superficial retinal hemorrhages appear cherry red in color, whereas deeper lesions
appear gray.
• A retrobulbar hematoma requires immediate treatment by an ophthalmologist.

# APP B- HYPOTHERMIA AND HEAT INJURIES

Hypothermia
• Core body temperature below 35°C {Mild till 32, moderate till 30 and sever < 30}
• Depressed level of consciousness is the most common feature
• Determination of death can be very difficult; Patients should not be pronounced
dead until full efforts have been made to rewarm them except
o Anoxic, still normothermic
o Serum potassium level greater than 10 mmol/L
• Rx of Severe hypothermia with active core rewarming methods
o Bladder irrigation
o Adding warmed humidification to ventilation
o Surgical rewarming such as peritoneal lavage, pleural lavage, arteriovenous
rewarming, and cardiopulmonary bypass
• Cardiac drugs and defibrillation are not usually effective in the presence of acidosis,
hypoxia, and hypothermia {postponed until the patient is warmed to at least 28°C}
• inadvisable to insert a subclavian or internal jugular line in hypothermic patients due
to the risk of triggering an uncontrollable cardiac arrhythmia.
• Attempts to actively rewarm should not delay transfer to a critical care setting

Heat Injuries
Heat exhaustion
• Core temperature usually less than 39°C
• Caused by excessive loss of body water, electrolyte depletion, or both
• Intact mental function
Heat stroke
• Core temperature ≥ 40°C
• Life-threatening disease {mortality is up to 80%}
• CNS dysfunction {delirium, convulsions, and coma} & may progress to DIC
• Prompt correction of hyperthermia by immediate cooling and support of organ-
system function are the two main therapeutic objectives in patients with HS

Ali M. Ahmad; Consultant Pediatric Surgery 36

 # APP C- AUSTERE AND ARMED CONFLICT ENVIRONMENTS

• Incident command is a system management tool that transforms existing

organizations across planning, operations, logistics, and finance/administration
functions for integrated and coordinated response
• Triage is a system decision tool used to sort casualties for treatment priority, given
casualty needs, resources, and the situation “the best for most,”
• Scene triage system that uses motor response to command as a quick “sift” is
helpful in finding these critically injured
• The five triage categories are:
1. Immediate (Red): immediately life-threatening injuries
2. Delayed (Yellow): injuries requiring treatment within 6 hours
3. Minimal (Green): walking wounded and psychiatric
4. Expectant (Blue): injuries greater than life or resources
5. Dead (GREY)

• Pulse check (carotid 60 torr; femoral 70 torr; radial 80 torr)

• “Heimlich value,” constructed as the cut finger of a rubber glove over a tube
• Casualty care defers secondary survey and definitive care in favor of identifying and
managing as many casualties as possible with life-threatening injuries
• All combat wounds are dirty and should be left open

• Communication remains a dominant challenge in disaster response across all

environments. Application of incident command improves communication. Duplicate
and rehearsed communication plans should be routinely practiced for disaster
preparation

Ali M. Ahmad; Consultant Pediatric Surgery 37

 # APP D- DISASTER MANAGEMENT AND EMERGENCY PREPAREDNESS

Multiple casualty incidents (MCIs)

• Patient care resources are overextended but are not overwhelmed
• Can stress local resources such that triage focuses on identifying the patients with
the most life-threatening injuries.

Mass casualty events (MCEs)

• Patient care resources are overwhelmed & Cannot be immediately supplemented.
• Triage by necessity focuses on identifying those patients with the greatest
probability of survival
• Medical Response Team: A team of 1to 4 health care professionals, led by an acute
care specialist, that provides emergency medical care to an individual patient.

Phases of Disaster Management (Preparation, Mitigation, Response & Recovery)

Preparation
• Identify risks, build capacity, and identify resources
• These activities include a risk assessment of the area, the development of a simple, yet
flexible, disaster plan that is regularly reviewed and revised as necessary, and provision
of training that is necessary to allow these plans to be implemented when indicated.

Mitigation
• involves the activities a hospital undertakes in attempting to lessen the severity and
impact of a potential disaster.
• These include adoption of an incident command system for managing internal and
external disasters, and the exercises and drills necessary to successfully implement,
test, and refine the hospital disaster plan.
• There is no substitute for adequate training and drilling.

Response
• involves activities a hospital undertakes in treating victims of an actual disaster
• These include activation of the hospital disaster plan, including the ICS, and
management of the disaster as it unfolds, implementing schemes for patient
decontamination, triage, surge capacity and surge capability.

Recovery
• involves activities designed to help facilities resume operations after an emergency.
• The local public health system plays a major role in this phase of disaster management,
although health professionals will provide routine health care to the affected
community consistent with available resources, in terms of operable facilities, usable
equipment, and credentialed personnel.

Ali M. Ahmad; Consultant Pediatric Surgery 38

 # BLUNT TRAUMA
• Vehicular impact when the patient is inside the vehicle
• Pedestrian injury
• Injury to cyclists
• Assaults (intentional injury)
• Falls
• Blast injury

Passenger restraints
• Reduce fatalities by up to 70%
• 10-fold reduction in serious injury.
• Frontal air bags provide no protection in rollovers, second crashes, or lateral
• When worn correctly, safety belts can reduce injuries. When worn incorrectly—for
example, above the anterior/superior iliac spines—the forward motion of the
posterior abdominal wall and vertebral column traps the pancreas, liver, spleen,
small bowel, duodenum, and kidney against the belt in front.

# BLAST INJURIES
• Primary: result from the direct effects of the pressure wave and are most injurious
to gas-containing organs. The tympanic membrane is the most vulnerable to the
effects of primary blast
• Secondary: result from flying objects striking an individual.
• Tertiary: thrown against a solid object or the ground.
• Quaternary: burn injury, crush injury, respiratory problems from inhaling dust,
smoke, or toxic fumes, and exacerbations or complications of existing conditions
such as angina, hypertension, and hyperglycemia.

# PENETRATING TRAUMA
1. Low energy—knife or hand-energized missiles {little cavitation}
2. Medium energy—handguns {5-time cavitation}
3. High energy—military or hunting rifles {up to 30-time cavitation}

Ali M. Ahmad; Consultant Pediatric Surgery 39

 # TETANUS IMMUNIZATION

• Adequate tetanus prophylaxis is important in patients with multiple injuries,

particularly when open-extremity trauma is present.
• The average incubation period for tetanus is 10 days; most often it is 4 to 21 days. In
severe trauma cases, tetanus can appear as early as 1 to 2 days after injury.
• Recent studies conclude that it is not possible to determine clinically which wounds are
prone to tetanus; Thus, all traumatic wounds should be considered at risk for the
development of tetanus infection.

Passive immunization
• 250 units of human TIG intramuscularly must be considered for each patient.

• Children < 7 years: DTP is preferred to tetanus toxoid alone.

• Children > 7 years: Td is preferred to tetanus toxoid alone.

• More than 10 years since last tetanus-toxoid containing dose.

• More than 5 years since last tetanus-toxoid containing dose. (More frequent
boosters are not needed and can accentuate side effects.

Ali M. Ahmad; Consultant Pediatric Surgery 40

 # REVISED TRAUMA SCORES

Ali M. Ahmad; Consultant Pediatric Surgery 41

# PERITONEAL DRAINAGE
• Drainage systems can be classified as ‘open’ or ‘closed’, ‘suction’ or ‘nonsuction’.
• Peritoneal cavity suction drains risk drawing bowel or other viscera into the tip, with
the attendant risk of perforation or bleeding
• Remember to send ascitic fluid for microscopy, culture and sensitivity,
protein/albumin, amylase and electrolytes.

# TRAUMA LAPAROTOMY
• Two approach: Transverse supra-umbilical and Midline.
• If massive intraperitoneal haemorrhage encountered, manual compression of the
infra-diaphragmatic aorta while all four quadrants of the abdomen are packed may
assist.
• Liver bleeding may be controlled using ‘Pringle’s manoeuvre’. The dual blood supply of
the liver (hepatic artery and portal vein) is compressed between the surgeon’s index
finger (placed through the foramen of Winslow) and thumb, as they run through the
hepatoduodenal ligament anterior to the foramen of Winslow
• A stepwise and systematic exploration of each quadrant, starting from the liver and
moving in a clockwise manner around the abdomen should be performed
• A retroperitoneal haematoma should be left undisturbed unless it is expanding or it
overlies the duodenum or pancreas.
• Suspect bladder rupture if:
1. Large volume of clear fluid in the abdomen
2. High preoperative creatinine
3. Low serum sodium
• Open bowel perforations should be occluded temporarily with light, non-crushing
clamps to prevent further contamination.
• If a site of injury is not obvious after a general search of the abdomen, the lesser sac
(which is opened by dividing the gastrocolic omentum), subdiaphragmatic spaces and
posterior abdominal wall should all be inspected.
• Care must be taken to avoid the phrenic nerve, which divides into anterior and
posterior branches in a medial to lateral orientation. The phrenic nerve is easier to
visualise using a thoracic approach

Ali M. Ahmad; Consultant Pediatric Surgery 42

 TRAUMA

Trauma is the commonest cause of death in the pediatric over 1 year of age (less than 1
year, congenital abnormalities, prematurity and SIDS)

TRIMODAL DISTRIBUTION OF TRAUMA DEATH WAS FIRST DESCRIBED IN 1983

1. Immediate (minutes):
• 50% of deaths; major vascular or neurological insult
2. Early hours (‘golden hour’; 1–2 h post injury):
• 35% of deaths, secondary to brain, abdominal or chest injury
3. Late (days to weeks):
• 15% of deaths, from brain death, multiorgan failure and/or sepsis

TRAUMA MANAGEMENT PRIORITIES

According to the Royal Australasian College of Surgeons which includes
1. Primary survey and resuscitation
2. Detailed secondary assessment
3. Stabilisation and transfer to definitive care centre

The primary survey: ‘A, B, C’s’

A – Airway maintenance with cervical spine control.
B – Breathing and ventilation.
C – Circulation with haemorrhage control.
D – Disability: neurological status

B- Nasotracheal intubation:
• Is preferred for patients with suspected cervical spine injury.

C- Circulation
• Assess-heart rate/blood pressure/capillary refill/mental status
• Establish two large bore intravenous cannulae rapidly
• If circulation inadequate – 20 mL/kg normal saline bolus
• Ongoing circulatory support – if third bolus is required, use O-negative blood
• Ensure cross-matched sample sent early.
• Ensure platelets and FFP and cryoprecipitate available if on-going support required
• All fluids should be warmed.
• Arrange early surgical consult.
• Consider hidden sources of bleeding: head, chest, abdominal, pelvis and femur.
• Establish haemorrhage control.

D- Disability:
• Assess mental state using the AVPU or the paediatric Glasgow coma score

Ali M. Ahmad; Consultant Pediatric Surgery 43

AVPU
• A: Alert child
• V: Responds to voice
• P: Response to pain (equivalent to GCS < 8)
• U: Unconscious

Glasgow Coma Score GCS {ranges from 3 to 15}

Best Eye opening Best verbal response Best motor response
1 None 1 None 1 None
2 To pain 2 Incomprehensible sounds 2 Extension to pain
3 To verbal 3 Inappropriate words 3 Flexion to pain
4 Spontaneous 4 Confused 4 Withdraws from pain
5 Orientated 5 Localizes to pain
6 Obeys commands

Main value of GCS:

• To monitor the ongoing neurological status of a patient by repeated assessment
• every 15 min; a fall in the score of 2 or more should prompt an urgent review of the
patient

TRAUMA RADIOLOGY
1. CXR
2. C-Spine lateral
3. Pelvis – if the child is awake, orientated with no other distracting injuries and there
is no clinical suspicion of a pelvic fracture then this x-ray may be omitted.

SECONDARY SURVEY
• Comprehensive examination top-to-toe and front-to-back (including log roll)
examining all orifices, with full documentation of all injuries with instigation of first
aid management
• In paediatrics a rectal and vaginal examination are not routine and should only be
performed once if deemed necessary by the appropriate specialist.

Ali M. Ahmad; Consultant Pediatric Surgery 44

TYPES & MECHANISM OF INJURY
Type Mechanisms Common pattern of injury
Pedestrian 1. Low speed: lower extremity fractures
struck 2. High speed: Head/ Neck injuries & multiple trauma
1 MVA
Automobile 1- Unrestrained: Head/ Neck injuries & multiple trauma
occupant 2- Restrained: Chest, Abdomen, spine & lower limb
1. Low: upper extremity fractures
From high 2. Medium: Head/ Neck & extremity fractures
2 Fall 3. High: Head/ Neck injuries & multiple trauma
1. Without helmet: Head/ Neck injuries & multiple trauma
From a bicycle
2. With helmet: upper extremity fractures
3 Blunt • Striking handlebar: internal abdominal injuries

BLOOD PRESSURE IN CHILDREN:

• Mean normal systolic blood pressure for child = 90 mmHg +(age in years X 2)
• Not a good guide to hypovolemia {Child remain stable in up 2/3 blood volume loss}
• Estimated blood volume for infant is 80 ml/kg
• Suspected shock: 3 bolus of 20 ml/kg of warmed crystalloid solution may be needed
• If blood is needed a bolus of 10 ml/kg of PRBCs is administered
• Once blood product is begun other products as plasma and platelets are considered

Types Shock
1. Pump Defects (Cardiogenic)
2. Vascular beds Defects (Distributive) @septic @spinal @anaphylactic
3. Blood volume Defects (Hypovolemic)
4. Blood Flow Restriction Defects (obstructive)
a. Cardiac Tamponade
b. Constrictive Pericarditis
c. Aortic stenosis
d. Tension Pneumothorax
e. Massive pulmonary embolism
5. Oxygen-Releasing Defects (dissociative)

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 TRAUMATIC BRAIN INJURY {TBI}

Mechanisms of brain injury

• Sudden acceleration/decceleration:
o Causes shearing of axons which constitute white matter tracts
o Results in diffuse parenchymal and vascular injuries.
o Clinical manifestation of this insult can vary from a transient loss of
consciousness, called concussion, to profound and persistent neurological deficits
or death resulting from diffuse axonal injury (DAI)
• Direct impact against the calvarium and brain:
o Coup injuries such as parenchymal petechiae, contusions, intraparenchymal
hematomas and extra-axial hematomas such as extradural and subdural
hematomas.
o Countercoup injuries on the side opposite the impact.
o Penetrating injuries to the brain can produce cerebral lacerations and damage
to the cerebral vessels.

UK Guideline for patients who need referral to Hospital following Trauma

National Institute of Clinical Excellence {NICE} guidelines
1. GCS < 15 at any time since the head injury
2. Any loss of consciousness as a result of injury
3. Any focal neurological deficit
4. Any seizure since the injury
5. Persistent headache since injury
6. Any suspicion of a skull fracture or penetrating head injury
7. CSF leak from ear or nose
8. Multiple injuries in association with head injury
9. Suspicion of non-accidental injury or poor social circumstances
10. Amnesia for events before or after the injury

Principles of management of a child with a severe head injury

Follow the same Trauma Management priorities plus
1. Accurate neurological assessment & CT scan
2. Prevention of secondary brain injury
• Correction of hypoxia and hypercapnoea with intubation
• Initial hyperventilation to reduce intracranial pressure
• Replacement of blood volume to maintain adequate cerebral perfusion pressure
• Urgent surgery to remove mass lesions
• Anticonvulsants, antipyrexial treatment and antibiotics for compound injury
• Intensive care unit admission
• Vigorous control of intracranial pressure with sedation, paralysis, CSF drainage
and/ or decompressive craniectomy

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INDICATIONS FOR CT SCAN AFTER HEAD INJURY
• GCS < 13 at any point since injury
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haem tympanum, panda eyes, Battle’s sign, CSF
otorrhea)
• Post-traumatic seizure
• Focal neurological deficit
• More than one episode of vomiting
• Amnesia for greater than 30 min of events before impact {Assessment of amnesia not
possible in children <5 years old}

Indications of suspected Child Abuse

= non-accidental head injury in a child {NBI}
• Suspicious, inconsistent story
• History of previous injuries
• Multiple cutaneous bruises of different ages
• Bilateral retinal haemorrhage
• Acute subdural haemorrhage and brain swelling on CT scan
• Chronic subdural haemorrhage
• Bilateral skull fractures
• Old fractures of long bones and ribs
• Evidence of malnourishment
• Subdued behavior
• Fear

CSF leak
• CSF rhinorrhoea may result from a fracture of the base of the skull involving the
frontal, ethmoid or sphenoid sinuses
• Fracture of the temporal bone may cause CSF otorrhoea and/or rhinorrhoea.

• Both types are initially treated conservatively; In about 70% cases of CSF rhinorrhoea
and almost all case of CSF otorrhoea the leak stops spontaneously.
• The treatment of a CSF leak persisting for more than 10 days after a head injury is
an operative repair.
• Prophylactic antibiotics are not recommended because resistant organisms may
develop and meningitis may still occur.
• If the CSF leak persists the communication with the exterior through a mucosal
space is a potential source of meningitis and this may occur months or years later.
• A skull defect should be suspected when meningitis occurs after a head injury.

Ali M. Ahmad; Consultant Pediatric Surgery 47

 ABDOMINAL AND THORACIC INJURIES

• When the Patient is stable; the CT with contrast is the gold standard
• But If hemodynamic stability cannot be achieved with resuscitation, it may be more
appropriate for the patient to have an urgent laparotomy.
• Diagnostic Peritoneal Lavage {DPL} is not indicated in children because free blood in the
peritoneal cavity per se is not an indication for surgical interventions.

Non-operative management
• Is appropriate for most solid visceral injuries in children
• Provided they are kept under close supervision
• Best managed in ICU
• Nearly always, the bleeding stops and surgery is not needed

Indications for surgery in Abdominal Trauma

1- Persistent unstable circulation and hypotension despite appropriate resuscitation
§ Initial resuscitation is with two boluses of 20 mL/kg of normal saline
§ If the child remains unstable, a surgeon should be contacted
§ A further two boluses 20 mL/kg of normal saline
§ If the child fails to respond to this resuscitation, then surgical intervention to
control the bleeding should be considered.
2- A proven or suspected gut perforation on clinical or radiological examination.
3- Severe, concomitant head injury in which an unstable circulation cannot be tolerated
and where significant or ongoing intraperitoneal bleeding is suspected

Esophagus Penetrating Injuries

• May manifest as dyspnea, dysphagia, cyanosis, mediastinal air, subcutaneous
emphysema, pleural effusion, chest or epigastric pain, fever, or sepsis.
• Esophagogram with a water-soluble contrast agent and esophagoscopy are typically
the studies that will identify an esophageal injury
• Early primary repair + bowel rest and TPN have good success.
• Delay more than 24 hours, operative closure becomes technically much more
difficult so may need esophageal isolation, multiple drain placement, Gastrostomy

In selected cases of esophageal perforation:

• Nonoperative management may be successful with TPN + IV antibiotics.
• If patient looks well, no fever, no effusion, in certain types of blunt trauma and with
iatrogenic injury {endoscopy}.

Management of major abdominal trauma

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 • Head CT, if indicated, should be performed first without contrast, to avoid contrast
concealing a hemorrhagic brain injure Enteral contrast for GIT is generally not
required in acute trauma setting

• US: Four-view FAST examination includes Morrison’s

pouch/right upper quadrant, the left flank to include the
perisplenic anatomy/left upper quadrant, and a subxiphoid
view to visualize the pericardium and the pouch of
Douglas/pelvis. This bedside examination may be useful as a
rapid screening study

• Routine follow-up imaging studies have identified pseudocysts and

pseudoaneurysms following splenic injury. Splenic pseudoaneurysms often cause no
symptoms and appear to resolve with time. These lesions can be treated successfully
with angiographic embolization techniques. Laparoscopic excision and
marsupialization is highly effective

• Even the most severe solid organ injuries can be treated without surgery if there is
prompt response to resuscitation. In contrast, emergency
laparotomy and/or embolization are indicated in patients who
are hemodynamically unstable despite fluid and red blood cell
transfusion. Most spleen and liver injuries requiring operation
are amenable to simple methods of hemostasis using a
combination of manual compression, direct suture, topical
hemostatic agents, and woven polyglycolic mesh wrapping

• In young children with significant hepatic injury, the sternum can

be divided rapidly to expose the suprahepatic or intrapericardial
IVC, allowing for total hepatic vascular isolation with occlusion of
the porta hepatis, suprahepatic and infrahepatic inferior vena
cava, and supraceliac aorta (optional).

• Hypothermia, coagulopathy, and acidosis, triad creates a vicious cycle in which each
derangement exacerbates the others

• Abbreviated laparotomy with packing for hemostasis allowing resuscitation prior to

plan reoperation is an alternative in unstable patients where further blood loss
would be untenable. This ‘damage control’ philosophy is a systematic, phased
approach to the management of the exsanguinating trauma patient

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 • To Avoid ‘abdominal compartment syndrome: temporary abdominal wall expansion
in all patients requiring packing until the hemostasis is obtained and visceral edema
subsides

Surgical options in duodenal trauma

§ Repair of the duodenum
§ Diversion of GIT (pyloric exclusion or a duodenal diverticulization).
§ Gastric decompression (gastric tube insertion or gastrojejunostomy).
§ GIT access for feeding (jejunostomy tube or gastrojejunal anastomosis).
§ Decompression of the duodenum (duodenostomy tube).
§ Biliary tube drainage.
§ Wide drainage of the repaired area (lateral duodenal drains)
§ (Whipple procedure) should rarely be required. This pancreaticoduodenectomy
should be reserved for the most severe injuries to the duodenum and pancreas
when the common blood supply is destroyed and any possibility of
reconstruction is impossible.

Renal Injury
§ Renal injuries such as ureteropelvic junction (UPJ) disruption or segmental
arterial thrombosis may occur without the presence of hematuria or
hypotension. Therefore, a high index of suspicion is necessary to diagnose these
injuries.
§ Non-visualization of the injured kidney on intravenous pyelogram and failure to
uptake contrast with a large associated perirenal hematoma on CT are hallmark
findings for renal artery thrombosis.
§ Ureteropelvic junction disruption is classically seen as perihilar extravasation of
contrast with non-visualization of the distal ureter
§ Intravenous infusion of indigo-carmine (a vital dye excreted in the urine) at
operation may help identify sites of extravasation
§ Proximal control of the renal vessels prior to opening Gerota’s fascia may
facilitate retroperitoneal exploration.

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The ‘seatbelt syndrome’
§ Abd wall contusion, injury hollow viscus & vertebral
fracture
§ The mechanism of injury is hyperflexion of the torso
caused by deceleration forces with the lap-belt as a
fulcrum
§ Mechanisms of Bowel injuries:
o Compression against the vertebral column with a
crush injury,
o Shearing of the bowel and mesentery at fixed points in the retroperitoneum,
o Immediate closed loop burst injuries on the anti-mesenteric border when
fluid filled loops are subjected to sudden increases in intraluminal pressure.
o The crush and shearing mechanisms may lead to progressive ischemia with
delayed perforation or stricture.
§ Children with the ‘seatbelt sign’ across their lower abdomen should be admitted for
serial examinations even if the initial examination and diagnostic tests are normal

Burn
• Palmar surface of open hand of patient is 1 % TBSA {Can used for measurement}
• ABC & Remove hot clothing immediate
• Hydrotherapy: small burns (<25 percent TBSA) are immersed in cold water
• Copious irrigation of the wound with water is indicated for chemical burn
• For suspected inhalation injury, 100 % oxygen is given by facemask
• Escharotomy should always be considered
• Tetanus toxoid should be administered
• Parkland IVF formula: 4 mL/kg per BSA burn

UROGENITAL TRAUMA

1-Renal Injury

• Presentations include; haematuria, loin pain and tenderness, an expanding perirenal

mass, and external evidence of injury such as bruising or abrasions
• Note: Severity of haematuria does not correlate well with the extent of the renal injury
• All children with suspected renal injury should be admitted for observation

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 • Renal imaging is mandatory in the presence of haematuria or a suspected renal injury,
CT with contrast is the imaging modality of choice

Grades of renal injuries:

• Grade I: Sub-capsular non-expanding hematoma without parenchymal laceration
• Grade II: Laceration not extend to collecting system
• Grade III: Laceration extend to collecting system
• Grade IV: Laceration through cortex, medulla and collecting system
• Grade V: Shattered kidney, Avulsion of the hilus, RA thrombosis
Natural history
• Lower grades of renal injuries mostly recover without surgery and without major
sequels
• High grades: 1Pseudocysts, 2caliceal diverticulum and 3renal hypertension are
possible
Work-up
• Lab: blood and urine analysis
• Radiology:
o Doppler US (RA thrombosis)
o IVU for the evaluation of the pelvis and ureters.
o CT with contrast which allows to discover combined intraabdominal injuries; In one
quarter of the injuries of the spleen the ipsilateral kidney is involved, too

Indications for surgical intervention are relative rather than absolute and include:
1. Haemodynamic Instability @ any Grade
2. Grade V even if haemodynamic stable
3. Major Urinary extravasation {Most of Localised collections can be aspirated or
drained}
4. Vascular injuries: except only case of a solitary kidney or bilateral injury

Operative Technical considerations:

• Intraperitoneal approach
• Renal vascular pedicle control before renal handling
• Sure of contralateral functioning kidney before Nephrectomy

2-Ureteric Injury: Mostly iatrogenic than traumatic

3-Bladder injuries: Almost invariably 2ry to MVA {Extra or intraperitoneal}

4-Urethral injuries: Only in male & there is 3 Mechanism of injury

1. Perineal blunt trauma {stride or straddle} # to bulbar urethra:

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 § Aim of Rx: Establishing bladder drainage and evaluating the severity injury
§ Give Analgesic and observe
o if passed urine spontaneously is Ok
o if Not passed urine: PC Suprapubic Catheter under GA rather than
transurethral procedures {cystoscope or transurethral catheter} @ risk of
more trauma
§ After several days do descending cystography or, ideally, ascending urethrogram
o If no extravasation or disruption, the Suprapubic catheter can be clamped
and normal urethral voiding re-established
o If extravasation or disruption @urethroplasty

2. Pelvic Fractures {MVA} # Posterior and Membranous urethra

§ Aim of Rx: Prolonged Suprapubic drainage followed by elective urethroplasty or
open exploration, debridement and attempted re-alignment approximation of
the urethra over a catheter once the initial effects of the injury have subsided,
e.g. after 7–14 days.

3. Instrumentation or prolonged urethral catheterisation

Notes in Urethral Injures

§ Urethral catheter must not be inserted blindly into the urethra, as this may convert a
partial tear of the urethra into a complete transection
§ A carefully performed urethrogram must be obtained first to delineate the injury

Post-traumatic urethral stricture treatment options:

1- Optical urethrotomy {if strictures Short, well circumscribed} Stricture incised with
radial cuts using a cold knife blade mounted on a paediatric resectoscope
2- Perineal exposure of the bulbar urethra & end-to-end primary anastomosis
3- Perineal exposure of the strictures bulbar urethra & on lay graft of Buccal mucosa

MISCELLANEOUS INJURES

# BURNS:
Indication for hospital Admission
§ Any type with Total BSA burn >10%
§ Full thickness burn >5%
§ Specific: Inhalation burn; face, hand or buttock burns; non-accidental burn.

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# CORROSIVE ESOPHAGEAL INJURES:
§ No time limit for frequent dilation of the esophagus
§ The Indications for surgical replacements include:
A. Failure or refusal of the patient to comply with a regular dilation.
B. Iatrogenic perforation or TEF of the esophagus during attempted dilation

# SWALLOWED FOREIGN BODIES

§ Safety pins may stick in the oesophagus, but if they enter the stomach they will
almost always be excreted without difficulty, even if open

§ Hair clips pass easily as far as the duodenojejunal flexure, but may be too long and
rigid to negotiate this flexure in children less than 7 years of age, and require
endoscopy or laparotomy for their removal. In children more than 6 or 7 years of
age, observation for up to 1 week is justified, although impaction at the
duodenojejunal flexure should not be allowed to continue for more than 10–12 days.

§ In general, where a blunt foreign body has been impacted without progress for 6
weeks, removal at laparotomy may be considered, even in the absence of
symptoms. failure to progress through the bowel may raise concerns of impending
impaction, ulceration and perforation

# TETANUS
Active immunization
§ Tetanus immunization should be part of routine childhood immunization
§ Three doses of triple antigen (Diphtheria, Tetanus, Pertussis)
§ Booster doses at 4 and 15 years.

Passive immunization
§ Tetanus immunoglobulin indicated in case of Tetanus-prone wound, and those
who have received less than three doses of tetanus vaccination.

Ali M. Ahmad; Consultant Pediatric Surgery 54