Trauma & Acute Care Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

Chest trauma

Most of it is treated with a tube; the rest cannot wait for one.

The spectrum

Rib fractures, pneumothorax, haemothorax, flail segments, pulmonary contusion, and the rare great-vessel and cardiac injuries: eighty-five percent of chest trauma needs a drain or less.

Tension physiology

A one-way pleural leak pressurises the hemithorax, kinks venous return and arrests the patient. It is a clinical diagnosis: decompress on examination findings, never wait to photograph it.

The drain as treatment and triage

The chest drain fixes the pleural problem and simultaneously measures it: initial output and ongoing hourly losses are the numbers that send a chest to theatre.

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The ones that operate

Massive haemothorax, cardiac box wounds with tamponade, and the witnessed penetrating arrest that earns a resuscitative thoracotomy: rare, rehearsed, unmistakable.

The quiet killer

Rib fractures in older patients kill slowly through pain, shallow breathing and pneumonia: analgesia, including regional blocks, is respiratory medicine here.

Intercostal chest drain insertionResuscitative thoracotomyCase: The chest that has no breath sounds Case: A small wound over the precordium

X-ray

• Haemorrhagic shock

  The disease most trauma surgery actually treats.

  Pathophysiology

  Blood loss starves perfusion; the body compensates with tachycardia and vasoconstriction until, abruptly, it cannot. Young patients hold their pressure to the edge of the cliff, which is why a normal BP never reassures on its own.

  Recognition

  Tachycardia, narrowing pulse pressure, anxiety, cool peripheries and a rising lactate arrive before hypotension. Classes of shock are a teaching scaffold; the trend is the truth.

  Resuscitation

  Blood replaces blood: balanced transfusion of red cells, plasma and platelets, early tranexamic acid, calcium, and warmth. Large-volume crystalloid dilutes clotting factors and pops fragile clot.

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  Source control

  No transfusion strategy outruns an open artery. The parallel task is always finding and stopping the source: pressure, binder, drain, theatre or angiography.

  Endpoints

  Lactate clearing, urine flowing, pressors weaning and the coagulation screen normalising: resuscitation is judged by perfusion restored, not fluid given.

  Trauma laparotomy & splenectomyCase: Open abdomen after polytrauma

• Splenic injury

  The commonest solid-organ injury, and a lesson in when not to operate.

  Mechanism and signs

  Blunt force to the left flank or lower ribs; left upper quadrant tenderness, left shoulder-tip pain from diaphragmatic irritation, and free fluid on FAST.

  Grading and management

  CT grades the injury, but physiology chooses the pathway: stable patients are observed or embolised whatever the grade, unstable patients are operated on whatever the scan would have shown.

  Splenectomy's price

  The spleen filters encapsulated bacteria. After splenectomy: vaccination against pneumococcus, meningococcus and Haemophilus, education about overwhelming post-splenectomy infection, and in many patients lifelong prophylaxis.

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  The expected course

  A post-splenectomy platelet rise is normal and often dramatic; fever workups must remember the left lower lobe, the subphrenic space and the pancreatic tail the retractor bruised.

  Trauma laparotomy & splenectomyCase: Handlebars to the left flank

• Pelvic ring injury

  A fracture that behaves like a vascular injury.

  Why it bleeds

  The posterior ring tears the presacral venous plexus and fractures cancellous bone; the pelvis's volume increases just as its contents start bleeding into it.

  First moves

  Binder at the trochanters, blood not crystalloid, and no repeated springing: the first clot is the best clot the patient will ever make.

  Choosing the suite

  Arterial blush on CT points to angioembolisation; the exsanguinating, non-responding patient points to the OR for pre-peritoneal packing plus external fixation, then angiography after.

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  What travels with it

  Bladder and urethral injuries, rectal and vaginal tears converting closed fractures to open ones, and the lumbosacral plexus: the pelvic examination is a checklist, once, gently.

  Case: Crushed pelvis, falling pressure