Page 1634 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 120: Torso Trauma 1153

resuscitative phase, particularly if the source of instability is major hem-
• In general, indications for surgical intervention in abdominal orrhage in the thoracic or abdominal cavity. Although it may be possible
trauma are perforation, penetration, and hemorrhage. to identify a specific source in the thorax or abdomen for the abnormal
• An organ-specific diagnosis is not necessary to establish the need hemodynamics in the trauma patient, it is frequently impossible to be
for laparotomy in trauma. absolutely certain of such a source. Therefore, a decision has to be made
• Ultrasound, peritoneal lavage, and computed tomographic (CT) to approach the hemodynamically abnormal patient through either a
laparotomy or a thoracotomy if a source outside the thorax or abdomen
scan are important tools in assessing the traumatized abdomen has been ruled out. With this approach, one must be prepared to stop
when physical examination alone is unreliable. exploration of one cavity when it becomes obvious that the source of the
• Most thoracic injuries can be managed appropriately by simple hemodynamic abnormality is in the other.
measures aimed at correcting thoracic sources of hypoperfusion
and hypoxemia. CLASSIFICATION OF TORSO TRAUMA
• Emergency thoracotomy should be considered in the unstable or
unresponsive patient when this technique could potentially reverse Generally, torso trauma may be classified into two broad groups: pen-
the source of instability. etrating and blunt. As indicated earlier, any penetrating missile entering
inferior to the nipple line can produce diaphragmatic, intrathoracic, or
abdominal injuries. Similarly, blunt injuries may disrupt intrathoracic
Injuries involving the chest and abdomen may be considered as a single contents as well as intra-abdominal contents either directly or indi-
complex—torso trauma. This strategy is based on several factors. The rectly through fractures of the lower ribs, which then puncture intra-
configuration of the diaphragm and its attachment to the rib cage result abdominal organs such as the spleen, liver, and stomach.
in marked variability in its position with respiration and thus in demar- A more clinically applicable method of classifying torso trauma involves
cation of the thoracic and abdominal cavities. It is not unusual for the two categories. The first category consists of injuries that are immediately
diaphragm to traverse distances of over 15 cm between the inspiratory life threatening and thus require immediate intervention because of car-
and expiratory phases of respiration. The diaphragm may be at the level diorespiratory or hemodynamic compromise. The other category includes
of the nipple line during full expiration and well below the costal margin injuries in a relatively hemodynamically normal patient. These latter
during full inspiration, with corresponding shifts of the abdominal and injuries are considered to be potentially life threatening because, if left
thoracic contents (Fig. 120-1). This phenomenon, together with the unattended, they eventually may threaten the patient’s survival.
variable trajectory of objects or forces after penetrating the torso, makes Occasionally, neck injuries, particularly the penetrating type, may
it virtually impossible in many instances to determine on the basis of involve intrathoracic structures. In addition to causing vascular injury
the external point of impact or penetration whether intrathoracic or (which may present with hemorrhage or ischemic sequelae), injury to the
intra-abdominal injury has been sustained. The concept of torso trauma thoracic duct (resulting in chylothorax), violation of the pleura (resulting
ensures that injuries in one cavity will not be overlooked while injuries in pneumothorax), or penetrating neck wounds may affect any of the intra-
in the other are being managed. thoracic structures, depending on the pathway of the offending weapon.
The initial approach in trauma management is to secure the airway, to The neck traditionally is divided into three anatomic regions for the pur-
maintain respiration, and to identify and control hemorrhage and insti- poses of categorizing penetrating wounds. Zone I extends from the cricoid
tute immediate fluid resuscitation as required. Definitive management to the clavicle, zone II from the cricoid to the angle of the mandible, and
of intra-abdominal or thoracic injury may be necessary as part of this zone III lies between the angle of the mandible and the base of the skull.
Penetrating wounds of the neck should be explored in the operat-
ing room under sterile conditions with adequate anesthetic support. A
preoperative plain x-ray of the neck if the patient is stable could provide
information such as depth of penetration and the presence of air in the
tissues, hematoma, airway deviation, etc. Impaling objects should be
removed only in the operating room with vascular equipment available
and a securely controlled airway in place. Although there is reason-
ably good agreement that zone III injuries should be investigated with
angiography, the use of angiography and other diagnostic modalities in
zone II injuries is controversial because this area can be assessed
thoroughly and more easily through direct surgical exploration in the
Nipple
operating room. Diagnostic modalities include angiography, endoscopy,
contrast radiography, and computed tomography (CT).
Diaphragm
A nasogastric tube should be inserted in the operating room, prefer-
Point of Point of ably after the airway is securely controlled by endotracheal intubation,
impact impact because retching during the insertion of such a tube could lead to clot
or entry or entry dislodgment, hemorrhage, and airway compromise. The possibility
of intrathoracic injury should always be considered in patients with
penetrating neck wounds. The chest therefore should be prepared and
draped adequately in the event that thoracic exploration is necessary for
repair of intrathoracic injury or possible vascular control for vascular
injuries in the neck.
Inspiration — injury to Expiration — injury to
thoracic organs abdominal organs THORACIC INJURIES REQUIRING
IMMEDIATE INTERVENTION

FIGURE 120-1. The rationale for regarding torso trauma as a unified entity. A blunt or Although thoracic injury frequently is associated with trauma-related
penetrating impact at a given level of the chest wall may cause either intra-abdominal or intra- deaths, less than 10% of blunt chest injuries and only 15% to 30% of
thoracic injury depending on the trajectory of the missile and/or the position of the diaphragm. penetrating chest injuries require open thoracotomy. Lifesaving skills

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