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Acute management of penetrating trauma
Karim Brohi BSc FRCS FRCA
The Royal London Hospital
The problem
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Principles
Determinants of outcome
• Time to haemorrhage control• Physiological derangement• Stab or gunshot injuries• Number of organs injured
Change your mindset
This is no longer a standard resuscitation
Damage Control
Stop haemorrhagePrevent sepsis
Get out
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Change your mindset
Treatment of haemorrhagic shock is arrest of haemorrhage,
not haemodilution
Change your mindset
Physiological exhaustion
Hypothermia
Coagulopathy Acidosis
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Penetrating neck trauma
At risk structures:
AirwayVascularOesophagusNeural
Penetrating neck trauma
Non-operative management
No injury compromising airway
No shockNo expanding haematomaNo progressing strokeNo neurological deficit
No dysphagia/odynophagiaNo subcutaneous emphysema
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Penetrating torso trauma
Penetrating torso trauma
Haemodynamically unstableLaparotomy and/or thoracotomy
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Penetrating torso trauma
Haemodynamically unstableLaparotomy and/or thoracotomy
Penetrating torso trauma
Chest X-rayFAST
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Penetrating abdominal trauma
Haemodynamically stable patientReliable clinical exam
No peritonitisNon-operative management
Penetrating abdominal trauma
Haemodynamically stable patientUnreliable clinical exam
CT scan
(Diagnostic Peritoneal Lavage)(Laparoscopy)
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Penetrating abdominal trauma
Peritoneal violation is NOT the issue
Local wound exploration isunhelpful
Penetrating abdominal trauma
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Penetrating torso trauma - diaphragm
Haemothorax and positive FAST
Ultrasound?MRI? CT?
LaparoscopyThoracoscopy
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