Trauma & Acute Care Surgery

Shared operative foundations taught once, the room they happen in, the instruments on the tray, and the anaesthetic that makes it possible.

• Damage control surgery

  The idea that separates trauma surgery from elective surgery: when physiology is failing, the operation is abbreviated to haemorrhage and contamination control, and completeness waits. Taught once here; the laparotomy and thoracotomy pages assume it.

  1. 01The lethal triad. Hypothermia, acidosis and coagulopathy feed each other: cold enzymes clot poorly, poor clotting means more bleeding, more bleeding means more shock and more acid.
  2. 02Phase one, the OR. Stop bleeding by ligation, packing or shunt; stop contamination by stapling bowel off without anastomosis; no reconstruction, no closure elegance.
  3. 03The open abdomen. Temporary closure with a negative-pressure dressing: the swollen bowel gets room, the planned return gets a door left unlocked.
  4. 04Phase two, the ICU. Rewarm, transfuse to a recipe, correct the acid and the calcium: the ICU operates on the triad while the packs hold pressure.
  5. 05Phase three, the relook. At 24 to 48 hours, warm and corrected: unpack, restore continuity, wash, and close if the wall allows. Sometimes it takes more than one return.

  Used byTrauma laparotomy & splenectomyEmergency laparotomy

• Balanced resuscitation

  Every bleeding patient in every specialty is resuscitated on these principles; trauma is where they were learned.

  1. 01Blood for blood. Red cells, plasma and platelets in a balanced ratio approximate what is being lost; the massive transfusion protocol makes the ratio automatic under pressure.
  2. 02Permissive hypotension. Until the tap is off, chase a pressure compatible with life rather than a normal one: pushing pressure into an open vessel pops clot. Head injury changes this arithmetic.
  3. 03The adjuncts. Tranexamic acid early, calcium replaced as citrate binds it, and warmth guarded jealously: cheap moves with survival curves attached.
  4. 04The endpoint. Resuscitation succeeds when perfusion returns: clearing lactate, closing base deficit, urine output, and a patient warming from the core out.

  Used byTrauma laparotomy & splenectomyResuscitative thoracotomyEmergency laparotomy

• Watch

  Exploratory laparotomy and splenectomy for ruptured spleen after blunt trauma

  A real trauma laparotomy: packing, finding the bleeding and taking the spleen.

  Watch for

  • Four-quadrant packing before anything else
  • Mobilising the spleen to the midline
  • Controlling the hilum without the tail of the pancreas

  Source: JOMI, Journal of Medical Insight · Watch on YouTube
• Watch

  Resuscitative thoracotomy

  A trauma centre's teaching session on the ED thoracotomy: when, how, and what the team does in the first minute.

  Watch for

  • The indications that justify opening a chest in the resus bay
  • Left anterolateral incision and opening the pericardium
  • Cross-clamping the aorta

  Source: UCSD Trauma and Burn · Watch on YouTube

• Available externally

  Chest drain insertion, step by step

  The whole procedure with images and video: triangle of safety, technique, and the checks after.

  This source plays on its own site · Geeky Medics

• Watch

  Chest tube placement

  The emergency medicine teaching of the open technique in the triangle of safety.

  Watch for

  • The triangle of safety and the rib below
  • Blunt dissection over the top of the rib
  • Confirming the pleura with a finger before the tube

  Source: EM:RAP Medical Education · Watch on YouTube
• Watch

  Chest tube placement

  The Boston Children's open-access teaching, longer and slower, with the underwater seal explained.

  Source: OPENPediatrics · Watch on YouTube

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