Behind the Knife ABSITE 2026: Trauma Management - Part 1

Trauma Survey and Airway Management

• 🎯 The primary survey follows the ABCDE mnemonic: Airway, Breathing, Circulation, Disability, and Exposure.
• 🗣️ Airway protection is indicated by the ability to cough, clear secretions, and swallow; compromise can result from obstruction or altered mental status.
• 💨 Management of airway compromise includes chin lifts/tilts, suction, oropharyngeal/nasopharyngeal airways, and definitive measures like intubation or cricothyroidotomy.
• 💉 Rapid sequence intubation (RSI) typically uses etomidate or ketamine for induction and succinylcholine for paralysis due to its short half-life.

Breathing and Circulation Assessment

• 🫁 Breathing is assessed by auscultation, chest rise, and palpation for crepitus; chest tubes are indicated for hemothorax or pneumothorax.
• 🩺 Chest tubes are generally placed in the 5th intercostal space at the anterior axillary line, with 28-32 French tubes preferred over larger ones.
• 🩸 Circulation is assessed by pulse checks (femoral or radial), with shock index (heart rate/systolic BP) > 1 indicating potential shock, assumed hemorrhagic in trauma.
• 🏥 Resuscitation focuses on whole blood or a 1:1:1 ratio of packed red blood cells, platelets, and FFP, with early activation of massive transfusion protocols.

Disability, Exposure, and Imaging

• 🧠 The disability exam involves calculating the Glasgow Coma Scale (GCS) and performing a pupillary exam; a GCS < 8 typically warrants intubation.
• 👕 Exposure requires removing all clothing to check for wounds, especially penetrating injuries, and log-rolling to examine the back.
• 📸 The FAST exam (Focused Assessment with Sonography for Trauma) assesses for fluid in the pericardial, RUQ, LUQ, and suprapubic spaces; EFAST adds bilateral hemithoraces for pneumothorax.
• 🏥 Positive FAST in an unstable patient goes straight to OR; in a stable patient, CT scan is usually obtained.

Resuscitative Thoracotomy and Laparotomy

• 🔪 Resuscitative thoracotomy considerations include mechanism (blunt vs. penetrating), location, duration of arrest, and signs of life, with differing guidelines from WTA and EAST.
• 🫁 Physiologic changes after aortic occlusion removal can include a drop in afterload and washout of metabolites, paradoxically worsening the patient's condition.
• 🧽 Damage control laparotomy aims to stop bleeding and limit contamination, with patients returning to the OR after physiologic derangements are corrected.
• 📉 Permissive hypotension (maintaining a radial pulse and mentation) is key in damage control resuscitation, limiting crystalloids and favoring blood products.

Head and Spinal Cord Injuries

• 🤕 Epidural hematomas are lens-shaped and often associated with a lucid interval, while subdural hematomas are crescent-shaped and cross suture lines; both require immediate surgical evaluation.
• 📉 Intraparenchymal bleeds are within the brain parenchyma, and subarachnoid hemorrhage is classically from a ruptured aneurysm ("worst headache of life").
• 🌡️ ICP monitoring is indicated for GCS < 8 with an abnormal head CT; management focuses on reducing secondary injury by avoiding hypotension and hypoxia.
• ⚡ Central cord syndrome presents with upper extremity weakness, while Brown-Séquard syndrome involves ipsilateral motor deficits and contralateral sensory deficits.

Neck and Thoracic Trauma

• 📍 The neck is divided into three zones: Zone 1 (clavicles to cricoid cartilage), Zone 2 (cricoid cartilage to mandibular angle), and Zone 3 (mandibular angle to skull base).
• 🩺 Penetrating neck injuries with hypotension or hard signs of vascular injury go directly to the OR; others may require CTA.
• 💔 Blunt aortic injury, often at the ligamentum arteriosum, requires blood pressure control (systolic < 120) and is typically repaired with TEVAR.
• 💥 Flail chest involves three or more consecutive rib fractures in two locations and may require rib plating if pain and respiratory status are not improving.

Abdominal and Retroperitoneal Injuries

• 🍽️ Solid organ injuries are most common in blunt abdominal trauma, with the liver being most frequently injured; hollow viscous or pancreatic injuries are most commonly missed.
• 🩸 Hemodynamically unstable patients with solid organ injury go to the OR; stable patients with solid organ injury and a blush may undergo angioembolization.
• 🔪 Abdominal stab wounds require OR exploration if there is violation of the anterior rectus sheath, evisceration, or peritonitis.
• ⚠️ Retroperitoneal injuries require exploration for penetrating trauma along the injury trajectory; blunt zone 1 injuries with bleeding/hematoma should be explored, while zone 2 and 3 generally do not require exploration unless specific criteria are met.