What are the key principles and guidelines for trauma surgery management?

Key Principles of Trauma Surgery Management for the Surgery Shelf Exam

The most critical principle in trauma surgery management is to minimize the time between injury and operation for patients requiring urgent surgical bleeding control, while implementing a damage control approach in severely injured patients.1

Initial Assessment and Resuscitation

Primary Survey (ABCDE)

• Airway: Secure with endotracheal intubation if GCS <8 or airway compromise
• Breathing: Perform immediate decompressive thoracostomy for tension pneumothorax
• Circulation:
  • Target systolic BP 80-90 mmHg (MAP 50-60 mmHg) until major bleeding is controlled 1
  • Exception: TBI patients require MAP ≥80 mmHg 2
• Disability: Rapid neurological assessment with GCS
• Exposure: Complete examination for additional injuries

Hemodynamic Assessment

• Hemodynamic instability defined as: SBP <90 mmHg, or requiring fluid boluses/vasopressors, or base deficit >6 mmol/L, or shock index >1, or requiring ≥4-6 units PRBC within 24h 1
• Serum lactate and base deficit are sensitive markers of traumatic hemorrhage 1
• Hemoglobin/hematocrit are poor early indicators of blood loss 1

Immediate Diagnostic Workup

• E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify free fluid/pneumothorax
• Pelvic X-ray for suspected pelvic trauma (though sensitivity only 50-68%) 1
• CT scan with IV contrast for hemodynamically stable patients 1

Damage Control Resuscitation

Blood Product Administration

• Initial coagulation resuscitation for massive hemorrhage should include either:
  • Fibrinogen concentrate/cryoprecipitate and pRBC, OR
  • FFP:pRBC ratio of at least 1:2 1
• Consider high platelet:pRBC ratio in massive transfusion 1

Tranexamic Acid (TXA)

• Administer within 3 hours of injury: 1g IV over 10 minutes, followed by 1g over 8 hours 1
• Do not administer beyond 3 hours post-injury

Temperature Management

• Actively prevent hypothermia with warming measures 1
• Target normothermia

Damage Control Surgery

Indications for Damage Control Surgery

• Hemorrhagic shock
• Ongoing bleeding
• Coagulopathy
• Hypothermia (<35°C)
• Acidosis (pH <7.2)
• Complex time-consuming injuries in unstable patient 1

Damage Control Principles

1. Control hemorrhage with temporary measures (packing, vascular clamping)
2. Control contamination (resection without anastomosis, temporary closure)
3. ICU resuscitation (correct coagulopathy, acidosis, hypothermia)
4. Planned re-operation for definitive repair (24-48 hours later)

Specific Trauma Management

Liver Trauma

• Non-operative management (NOM) is first-line for hemodynamically stable patients with WSES I-III/AAST I-V injuries 1
• Operative management for hemodynamically unstable patients:
  • Control hemorrhage with manual compression and packing
  • Avoid major hepatic resections initially
  • Consider angioembolization for persistent arterial bleeding 1

Pelvic Trauma

• Hemodynamically unstable patients:
  • Apply pelvic binder for suspected unstable pelvic fracture
  • Early pelvic ring closure and stabilization
  • Consider angioembolization or preperitoneal packing 1
• Stable patients: CT scan to guide management

Traumatic Brain Injury

• Target parameters:
  • MAP ≥80 mmHg 2
  • ICP <20-22 mmHg
  • CPP >60 mmHg
  • PaO₂ >80 mmHg, PaCO₂ 35-40 mmHg 2
• Avoid:
  • Routine hyperventilation (except briefly for impending herniation)
  • Hypovolemia and excessive fluid administration 2
• Consider decompressive craniectomy for refractory intracranial hypertension 2

Coagulopathy Management

Viscoelastic Testing

• TEG/ROTEM preferred over conventional coagulation tests for targeted blood product administration 1

Anticoagulant Reversal

• Vitamin K antagonists: Prothrombin complex concentrate (PCC)
• Direct oral anticoagulants (DOACs): Specific reversal agents when available 1

Recombinant Factor VIIa

• Not recommended for routine use in trauma
• Consider only in refractory bleeding after standard hemostatic measures 3
• Caution: Increased risk of arterial and venous thrombotic events 3

Special Considerations for Elderly Trauma Patients

Assessment

• Early trauma protocol activation in patients ≥55 years 1
• Assess frailty in all elderly trauma patients 1
• Use Geriatric Trauma Outcome Score (GTOS) to predict mortality 1

Management

• More aggressive resuscitation may be needed despite normal vital signs
• Lower threshold for ICU admission
• Early involvement of multidisciplinary team 1

Common Pitfalls in Trauma Management

1. Delayed recognition of occult hemorrhage

   • Serial examinations and reassessment are crucial
   • Don't be falsely reassured by normal initial vital signs

2. Inadequate resuscitation endpoints

   • Base deficit and lactate clearance are better indicators than vital signs alone

3. Over-resuscitation with crystalloids

   • Excessive crystalloid leads to coagulopathy, hypothermia, and abdominal compartment syndrome
   • Use balanced blood product resuscitation

4. Missed injuries

   • Tertiary survey within 24-48 hours is essential
   • High index of suspicion for injuries masked by distracting injuries or altered mental status

5. Delayed thromboprophylaxis

   • Start as soon as bleeding risk allows
   • Trauma patients are at high risk for VTE

Remember that trauma management requires a systematic approach with continuous reassessment and adjustment of the treatment plan based on the patient's response to interventions.