Combined Chest Abdominal And Head Trauma

Trauma involving the chest, abdomen and brain requires aggressive and skillful diagnosis and management. General priorities can be established. Abdominal trauma should take precedence over all other trauma. A surgically correctable problem in the abdomen is a much more common cause of shock than a surgically correctable problem in the chest or brain. Another caveat is that the patient must be accompanied by the trauma surgeon at all times, even if the blood pressure is normal because a stable blood pressure does not necessarily imply a stable patient. If a surgical lesion is found on peritoneal lavage or CT scan of the abdomen

Fig 19.11a. Intraoperative photograph of a young man sustaining a gunshot wound to the proximal LAD (arrow). The left ventricle rapidly became hypo- and then dyskinetic, and cardiopulmonary bypass was established.

Fig 19.11b. A reverse saphenous vein graft to the distal LAD was performed (arrow). A pledgetted stitch is seen at the LAD injury (large arrow).

Table 19.1. Thoracic trauma; transmediastinal GSW

Management of stable patient

First, arteriography

Next, to OR for flexible broncoscopy and rigid or flexible esophagoscopy Next, Gastrografin esophageal swallow whether the patient is stable or unstable, exploratory laparotomy should be done first and has priority over any possible chest injury. Another important point is that a CT scan of a traumatic thoracic aortic injury may be misleading and the gold standard is still aortography.

In the operating room, the left chest should be widely prepped and draped when doing an exploratory laparotomy in the event that the patient suddenly decompensates hemodynamically in a way that cannot be explained by the intraabdominal injury. At that point, a left thoracotomy can be done to inspect the chest and aorta. If, however, a massive hemothorax presents with instability, the chest injury takes precedence. The general philosophy is that a correctable life-threatening abdominal injury is more common than a correctable life-threatening chest injury. The above considerations apply to combined chest and abdominal trauma.

For cranial injury, the same general philosophy holds, but it must be kept in mind that if the patient decompensates in the operating room during laparotomy, the decision whether to and where to perform a craniotomy is not as simple as a left thoracotomy. Thus the diagnostic priorities must reflect this, for even though abdominal trauma takes priority over brain trauma, it still is extremely helpful to have the CT scan of the brain available if the patient decompensates.

Complex trauma involves combined head, chest and abdominal trauma. Abdominal trauma takes precedence over chest trauma with the exception of a massive hemothorax with hypotension in which the patient has persistent exsanguinating hemorrhage from the chest. The following comments refer to a situation in which there is not an obvious massive thoracic hemorrhage. In an unstable patient with all three types of injuries, if the patient has a tense distended abdomen, he should go to the operating room for a laparotomy for correction of the abdominal hemorrhage. This should then be followed by head CT scan, followed by a craniotomy if necessary. After the above are accomplished, only then should an arch angiogram be obtained if there is reason to do so, i.e. blunt chest trauma with a widened mediastinum or blurring of the aortic knob. On the other hand, if the patient has a flat abdomen without an obvious bleed into the abdomen and is unstable, then a peritoneal lavage should be performed in the emergency room because sometimes exsanguinating hemorrhage may occur in the abdomen without a tense, distended abdomen. If the patient is neurologically compromised from head trauma, the abdominal exam will be unreliable. If the peritoneal lavage is positive, the patient should go to the operating room for laparotomy. This again is followed by head CT scan, plus or minus a craniotomy, followed finally by an arch angiogram if indicated. If the peritoneal lavage is negative, the patient should undergo a head CT scan plus or minus craniotomy, and then an arch angiogram if indicated based on the type of injury and chest x-ray.

Another category is a stable patient without abdominal findings and who has combined abdominal head and chest trauma, and is neurologically compromised. After the primary and secondary survey, CT scan of the head is obtained. If there is evidence of a neurosurgically correctable injury, a craniotomy is performed. In the operating room a lavage is done to rule out an abdominal injury, and if this is positive, a laparotomy is performed. After this, the patient undergoes an arch angiogram if indicated based on the type of injury and the chest x-ray. If the original CT scan of the head does not reveal a neurosurgically correctable injury, an abdominal CT scan is then done while the patient is in the CAT scanner. If the CT scan is positive, the patient is taken to the operating room for laparotomy and this

Table 19.2. Combined head, chest, abdominal trauma

is then followed by an arch angiogram if indicated based on the mechanism of injury and chest x-ray. If the abdominal CT scan is negative, then again an arch angiogram is done based on the above indications.

Table 19.2 depicts the management sequence for combined abdominal, head and chest trauma in stable and unstable patients. Again it should be emphasized that this refers only to patients who do not have obvious exsanguinating hemorrhage from the chest and do not require immediate thoracotomy. This method of managing these complex patients cannot be taken as a hard and fast rule, since individualization and management for these particular patients is necessary at all times.

Suggested Reading

1. Wiot JF. The radiologic manifestations of blunt chest trauma. JAMA 1975; 231:500.

2. Defore WW, Mattox KL, Hansen HA et al. Surgical management of penetrating injuries of the esophagus. Am J Surg 1977; 134:734.

3. Mattox KL, Pickard LR, Allen MK et al. Suspected thoracic aortic transection. J Am Coll Emerg Physicians 1978; 7:12.

4. Blair E, Topuzulu C, Deane RS. Major chest trauma. Current Problems in Surgery May 1969; 2-69.

5. Jones KW. Thoracic Trauma. Surg Clinics N. American 1980; 60:957.

6. Richardson JD, Adams L, Flint LM. Selective Management of Flail chest and Pulmonary Contusion. Ann Surg 1982; 196:481-487.

7. Baumgartner F, Sheppard B, de Virgilio C, Esrig B, Harrier D, Nelson RJ, Robertson JM. Tracheal and Main Bronchial Disruptions after Blunt Chest Trauma: Presentation and Management. Ann Thorac Surg 1990; 50:569-574.

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