Trauma & Acute Care Surgery

Physiology first, anatomy second, and always against the clock.

• Trauma surgery treats injury as a physiologic disease: the question is rarely what is broken, it is whether the patient is bleeding, and whether they will still be alive by the time the answer arrives.
• The primary survey is the specialty's grammar: airway, breathing, circulation, disability, exposure, in that order because that is the order in which injuries kill.
• Damage control is its signature idea: when cold, acidotic, coagulopathic physiology is losing, the operation shrinks to stopping bleeding and contamination, and the anatomy waits for tomorrow.
• The rhythm is the trauma call: minutes in the bay, a decision made on incomplete information, then the OR, angiography suite or CT scanner, chosen by the vital signs.

X-ray

• Hypotension after blunt trauma

  “The bay phone rings: cyclist versus car, left flank bruising, BP 88/60 that improves with fluid then drifts back down.”

  • A transient responder is a bleeding patient: the fluid bought minutes, not a diagnosis.
  • Where can you exsanguinate? Chest, abdomen, pelvis, long bones, floor: eFAST and a pelvic film interrogate three of the five in the bay.
  • Left flank plus shoulder-tip pain is the spleen speaking through the phrenic nerve: Kehr's sign is referred, not orthopaedic.

  Live it as a case Trauma laparotomy & splenectomy

• The penetrating chest

  “Stab wound medial to the left nipple, pressure falling, veins distended. The box matters more than the blade.”

  • The cardiac box, sternal notch to nipples to xiphoid, means the pericardium is guilty until an ultrasound proves otherwise.
  • Tamponade physiology is preload starvation: distended neck veins with hypotension in penetrating chest trauma is the heart being compressed, not failing.
  • Loss of output in front of you changes the venue: resuscitative thoracotomy belongs in the bay when arrest is witnessed and the injury is penetrating.

  Live it as a case Resuscitative thoracotomyIntercostal chest drain insertion

• The unstable pelvis

  “Motorcyclist, pelvis painful and mobile on gentle springing (which you then never do again), BP 90 on arrival and falling.”

  • A pelvic ring that has failed is a venous lake plus fractured cancellous bone: litres can hide where no scan is needed to suspect them.
  • The binder is a treatment, not a formality: reducing ring volume tamponades the bleeding, and it goes on before the X-ray, at the level of the greater trochanters.
  • Angioembolisation and pre-peritoneal packing answer different bleeding: arterial blush favours the angiography suite, venous ooze favours packing.

  Live it as a case

• The damage control decision

  “Forty minutes into a trauma laparotomy: temperature 34.2, pH 7.18, blood oozing from every raw surface despite ligated vessels.”

  • The lethal triad, hypothermia, acidosis, coagulopathy, is a spiral: each element deepens the other two, and elegant surgery accelerates all three.
  • Damage control trades anatomy for physiology: pack the bleeding, staple off contamination, leave the abdomen open, and let the ICU rewarm and correct what the OR cannot.
  • The decision is made early or it is made too late: the triad is an indication to abbreviate, not a stage to operate through.

  Live it as a case Trauma laparotomy & splenectomy