Professor’s Pearls: Trauma

Professor’s Pearls: Trauma




Section Review


Consider the following clinical problems and questions posed. Then refer to the professor’s discussion of these issues.


1) An 18-year-old male sustains a stab wound to the left chest just lateral to the left nipple. Upon presentation to the ED, the patient complains of shortness of breath and left chest pain at the site of the stab wound. Heart rate is 110 and BP is 90/55. Examination shows jugular venous distention (JVD), tracheal deviation to the right, and decreased breath sounds in the left chest. Abdomen is nontender and nondistended. There are no other stab wounds to the chest, back, or extremities. Neurological examination reveals a somewhat agitated patient and a nonfocal examination.

What do you identify as the major issues? What are your most immediate concerns?


2) A 30-year-old male is brought to the ED after a motor vehicle crash in which he was the belted driver of a car that was t-boned on the left side, with passenger space intrusion. BP is 110/70; pulse is 105; there is a bruise on the forehead; abdomen shows a shoulder belt contusion across the left chest and right upper abdomen. The patient moves all extremities, but mental status shows agitation, disorientation, and repetitive questioning.

What are the priorities of management? What are the likely injuries, and how should they be evaluated?


3) A 23-year-old male is thrown from a motorcycle and then struck by a car. In the ED, he has BP 140/90, pulse 100, and a swollen, deformed left lower extremity with intact skin.

What are your major concerns in this patient, and how should they be evaluated? What diagnostic studies are indicated? What are the principles of management?




Discussion by Jonathan R. Hiatt, MD, Chief, Division of General Surgery; Director, Surgical Education, David Geffen School of Medicine at UCLA



Answer 1


Initial priorities in management of the trauma victim are always the same and include attention to airway, breathing, circulation, neurological impairment, complete exposure of the patient, and control of the resuscitation environment. I emphasize that we not only assess each of the ABCDEs, but we also manage them and never move onto the next letter until we have dealt with the current one. We get control of the airway; we find impairments to breathing and correct them; we get control of the circulation by starting IV lines and drawing blood for crossmatch.


This patient has a patent airway but a problem with breathing. He has signs of a tension pneumo- and/or hemothorax and requires immediate chest decompression with a needle in the second interspace, midclavicular line (above the rib, because the vessels run below), followed by tube thoracostomy. These interventions should not be delayed for CXR, although x-ray is useful if obtained immediately. Resuscitation should continue with placement of large-bore IVs, infusion of saline or Ringer’s lactate, and chest radiography. The patient is at risk for injuries to the heart, left diaphragm, and abdominal viscera in addition to the lung, pulmonary hilum, and great vessels. FAST examination should be performed as the initial screen. The diaphragm is at risk in any stab wound below the nipples and near the costal margin. Diaphragmatic injuries can be relatively silent, particularly in penetrating trauma, and may require operative laparoscopy for dx; identification and repair are obligatory, as complications including entrapment of stomach or colon may occur if the injury is missed, with presentation within hours or days but also delayed for years or decades.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Professor’s Pearls: Trauma

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