WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.269 fast. Welcome to the emergency room. Welcome 00:00:47.269 --> 00:00:49.450 back to The Deep Dive, where we take the most 00:00:49.450 --> 00:00:51.909 complicated, high stakes clinical sources and 00:00:51.909 --> 00:00:54.649 just boil them down to what you absolutely need 00:00:54.649 --> 00:00:57.869 to know. Our mission today is all about the trauma 00:00:57.869 --> 00:01:02.090 bay. We are building the ultimate rapid review 00:01:02.090 --> 00:01:04.349 guide for anyone, really, but especially the 00:01:04.349 --> 00:01:06.430 medical surgical learner dealing with severe 00:01:06.430 --> 00:01:09.909 trauma. And we're focusing specifically on abdominal 00:01:09.909 --> 00:01:12.689 and pelvic injuries. And this is really where 00:01:12.689 --> 00:01:15.650 the rubber meets the road. In trauma, time isn't 00:01:15.650 --> 00:01:20.370 just money. It's survivability. Right. So we're 00:01:20.370 --> 00:01:22.890 applying the Pareto principle here. We're looking 00:01:22.890 --> 00:01:26.239 for that essential 20 % of knowledge. the critical 00:01:26.239 --> 00:01:28.519 signs, the immediate things you have to do, and 00:01:28.519 --> 00:01:31.439 maybe most importantly, the fatal mistakes that 00:01:31.439 --> 00:01:33.560 give you 80 % of your success. That's the zone 00:01:33.560 --> 00:01:35.900 we're targeting, that maximum leverage, because 00:01:35.900 --> 00:01:38.200 trauma can be so overwhelming, but our focus 00:01:38.200 --> 00:01:42.200 today is laser sharp on the one thing that causes 00:01:42.200 --> 00:01:44.519 preventable death after these injuries. Unrecognized 00:01:44.519 --> 00:01:47.379 internal bleeding. Unrecognized internal hemorrhage 00:01:47.379 --> 00:01:49.799 and visceral damage. We're really looking at 00:01:49.799 --> 00:01:52.480 the nursing implications here. What do you have 00:01:52.480 --> 00:01:54.920 to assess? What are the immediate life -saving 00:01:54.920 --> 00:01:57.560 steps? And what are those few things you absolutely 00:01:57.560 --> 00:02:00.959 must not do? The things that can kill a patient 00:02:00.959 --> 00:02:03.760 if you miss them. It's all about catching the 00:02:03.760 --> 00:02:06.879 silent killers before they make themselves obvious. 00:02:07.540 --> 00:02:10.560 So let's just jump right in. Primary survey and 00:02:10.560 --> 00:02:13.960 the biggest concept, recognizing a cold hemorrhage. 00:02:14.520 --> 00:02:17.199 So we always start with airway, breathing. But 00:02:17.199 --> 00:02:19.259 when we get to see for circulation in a trauma 00:02:19.259 --> 00:02:21.800 patient, especially with torso involvement, the 00:02:21.800 --> 00:02:24.800 mindset has to be they're bleeding internally 00:02:24.800 --> 00:02:26.960 until we prove they're not. That's the assumption, 00:02:27.219 --> 00:02:29.599 100 percent. The sources are so clear on this. 00:02:30.319 --> 00:02:32.259 Unrecognized abdominal and pelvic injuries are 00:02:32.259 --> 00:02:34.240 the leading cause of preventable death after 00:02:34.240 --> 00:02:36.699 truncal trauma. It's not a guess. It's a fact. 00:02:37.120 --> 00:02:39.240 It's the primary risk. And the reason it's so 00:02:39.240 --> 00:02:41.449 deadly is what you call this. the silence of 00:02:41.449 --> 00:02:43.750 the loss right exactly the abdomen is i mean 00:02:43.750 --> 00:02:46.270 it's a massive highly distensible cavity it's 00:02:46.270 --> 00:02:48.409 not like a cut on the arm where you see the blood 00:02:48.409 --> 00:02:50.770 pouring out you can't see it you can't you can 00:02:50.770 --> 00:02:54.389 lose leaders i mean sometimes a patient's entire 00:02:54.389 --> 00:02:57.370 circulating blood volume inside the abdomen or 00:02:57.370 --> 00:03:00.050 the retroperitoneum before you see any dramatic 00:03:00.050 --> 00:03:03.729 external sign no distension no obvious irritation 00:03:03.729 --> 00:03:06.819 nothing That's terrifying. So you could be looking 00:03:06.819 --> 00:03:09.539 at a patient who, on the surface, looks okay. 00:03:09.879 --> 00:03:11.620 Maybe they're a little pale, maybe their pressure's 00:03:11.620 --> 00:03:13.879 trending down just a bit. But inside, they're 00:03:13.879 --> 00:03:16.240 exsanguinating. They're circling the drain. You 00:03:16.240 --> 00:03:18.460 can't wait for the abdomen to look like a basketball 00:03:18.460 --> 00:03:21.319 to start worrying. That's way too late. So that 00:03:21.319 --> 00:03:23.780 lack of initial drama is the deadly pitfall. 00:03:24.060 --> 00:03:27.039 It is. A quick exam might even be falsely reassuring. 00:03:27.360 --> 00:03:31.099 but that slow, steady bleed from a solid organ, 00:03:31.419 --> 00:03:34.080 you know, a liver or a spleen lac, that can go 00:03:34.080 --> 00:03:36.719 on for hours unchecked. And you won't get those 00:03:36.719 --> 00:03:38.680 classic signs of peritonitis until the situation 00:03:38.680 --> 00:03:40.719 is already critical. Okay, let's talk about why 00:03:40.719 --> 00:03:42.879 the assessment itself is so often unreliable. 00:03:43.159 --> 00:03:45.159 We want patients to tell us, it hurts here, but 00:03:45.159 --> 00:03:47.240 in trauma, that's often useless information. 00:03:47.659 --> 00:03:50.370 It's totally unreliable. Think about the typical 00:03:50.370 --> 00:03:52.650 patient. They might be intoxicated with alcohol, 00:03:52.810 --> 00:03:54.669 they might be on other substances, or they could 00:03:54.669 --> 00:03:56.969 have an altered mental status from a bad TBI 00:03:56.969 --> 00:03:59.310 or a spinal cord injury. So they just can't give 00:03:59.310 --> 00:04:02.870 you a reliable history. They can't. Or they can 00:04:02.870 --> 00:04:05.050 feel pain, but it's from something else that's 00:04:05.050 --> 00:04:08.349 screaming louder. you know, multiple nasty rib 00:04:08.349 --> 00:04:11.650 fractures or a spinal fracture, that pain completely 00:04:11.650 --> 00:04:14.370 masks the duller, deeper ache of an organ injury. 00:04:14.569 --> 00:04:16.870 The noise from the ortho injury drowns out the 00:04:16.870 --> 00:04:19.329 signal from the internal bleed. Precisely. Yeah. 00:04:19.649 --> 00:04:22.050 Which forces you to rely almost entirely on the 00:04:22.050 --> 00:04:24.769 mechanism of injury and their objective hemodynamic 00:04:24.769 --> 00:04:27.589 status, which brings us to defining risk. So 00:04:27.589 --> 00:04:30.029 who gets the full workup? What's the rule? The 00:04:30.029 --> 00:04:32.970 rule is any patient with an injury to the torso. 00:04:33.290 --> 00:04:36.129 a direct blow, a deceleration from a crash, a 00:04:36.129 --> 00:04:38.769 blast, any penetrating wound in the zone between 00:04:38.769 --> 00:04:40.810 the nipple line and the perineum. The nipple 00:04:40.810 --> 00:04:43.009 line? They have to be considered to have a visceral, 00:04:43.310 --> 00:04:45.910 vascular, or pelvic injury until you prove otherwise. 00:04:46.629 --> 00:04:49.370 That nipple line is the absolute non -negotiable 00:04:49.370 --> 00:04:51.990 upper border. Let's dig into that boundary because 00:04:51.990 --> 00:04:54.370 for a learner, that might sound like a chest 00:04:54.370 --> 00:04:57.689 injury. Why does an injury below the nipple line 00:04:57.689 --> 00:05:00.389 demand a full abdominal workup? It's all about 00:05:00.389 --> 00:05:02.720 the mechanics of the diaphragm. This is a classic 00:05:02.720 --> 00:05:05.399 exam prep. People picture the diaphragm sitting 00:05:05.399 --> 00:05:08.560 low, but during full expiration, when you breathe 00:05:08.560 --> 00:05:11.759 all the way out, that diaphragm can rise dramatically. 00:05:11.779 --> 00:05:14.540 That's high. Up to the level of the fourth intercostal 00:05:14.540 --> 00:05:17.360 space. Wow. Which means a stab wound or even 00:05:17.360 --> 00:05:19.439 a displaced rib fracture that looks like it's 00:05:19.439 --> 00:05:22.139 just a low chest issue can actually pierce the 00:05:22.139 --> 00:05:24.920 diaphragm and lacerate the dome of the liver 00:05:24.920 --> 00:05:27.360 on the right or the spleen or stomach on the 00:05:27.360 --> 00:05:30.600 left. So that tiny detail, the rising diaphragm, 00:05:30.620 --> 00:05:34.079 turns a chest problem into a thoraco -abdominal 00:05:34.079 --> 00:05:37.420 catastrophe. Instantly. And this all feeds into 00:05:37.420 --> 00:05:39.379 our management priority, which is hemodynamic 00:05:39.379 --> 00:05:42.379 status. In the unstable hypotensive patient, 00:05:42.720 --> 00:05:44.660 everything is about speed. If they're crashing, 00:05:44.879 --> 00:05:47.620 what's the one goal? The only goal is to rapidly 00:05:47.620 --> 00:05:49.819 determine if the abdomen or pelvis is the source 00:05:49.819 --> 00:05:52.600 of the hypotension. That's it. If it is, they 00:05:52.600 --> 00:05:54.699 need hemorrhage control. And that almost always 00:05:54.699 --> 00:05:57.209 means the operating room. And we find that out 00:05:57.209 --> 00:06:00.629 with a fast scan. Usually, yes. Yeah. The focus 00:06:00.629 --> 00:06:03.589 assessment with sonography for trauma. Or, less 00:06:03.589 --> 00:06:07.569 commonly now, a DPL. We just need to know, is 00:06:07.569 --> 00:06:10.649 there free blood in the belly? Yes or no? If 00:06:10.649 --> 00:06:12.870 it's yes, they go to the OR. Okay, but here's 00:06:12.870 --> 00:06:14.649 the critical distinction, the other side of the 00:06:14.649 --> 00:06:17.810 coin. The hemodynamically normal patient. They 00:06:17.810 --> 00:06:20.470 come in, they were in a bad crash, but their 00:06:20.470 --> 00:06:22.610 vitals look good right now. What's the priority 00:06:22.610 --> 00:06:25.110 for them? This is maybe the most important concept 00:06:25.110 --> 00:06:27.610 for anyone not in the initial resuscitation pay. 00:06:28.730 --> 00:06:30.829 Serial physical exams are a critical management 00:06:30.829 --> 00:06:33.370 tool. Just because a patient is stable now doesn't 00:06:33.370 --> 00:06:35.910 mean they're safe. So stability buys you time, 00:06:36.069 --> 00:06:38.490 but you have to use that time to watch. Vigilantly. 00:06:38.960 --> 00:06:41.620 That stable patient needs a detailed, repeated 00:06:41.620 --> 00:06:44.439 evaluation, every few hours, usually over a 12 00:06:44.439 --> 00:06:47.079 to 24 hour observation period. Why are those 00:06:47.079 --> 00:06:48.579 repeat checks so vital? What are you looking 00:06:48.579 --> 00:06:50.420 for? You're waiting for one of two things to 00:06:50.420 --> 00:06:52.959 declare themselves. Either the slow, steady bleed 00:06:52.959 --> 00:06:54.860 finally overwhelms their ability to compensate 00:06:54.860 --> 00:06:58.240 and they crash, or more commonly, an injury to 00:06:58.240 --> 00:07:01.000 a hollow organ, like a small bowel tear, starts 00:07:01.000 --> 00:07:04.420 to leak. And that causes peritonitis. Delayed 00:07:04.420 --> 00:07:07.139 peritonitis. If you check them once, say they're 00:07:07.139 --> 00:07:09.680 fine, and walk away, you are almost guaranteed 00:07:09.680 --> 00:07:12.360 to miss it. Yeah. The trauma literature is emphatic 00:07:12.360 --> 00:07:15.980 about this. A single examination does not eliminate 00:07:15.980 --> 00:07:18.579 the presence of a major injury. OK, so let's 00:07:18.579 --> 00:07:21.079 build on that clinical suspicion. We need to 00:07:21.079 --> 00:07:23.860 know the map, the anatomical zone, so we can 00:07:23.860 --> 00:07:26.420 connect the mechanism of injury to what we should 00:07:26.420 --> 00:07:28.680 expect to find. Right. So let's start with the 00:07:28.680 --> 00:07:31.620 three critical zones. And the first one, the 00:07:31.620 --> 00:07:34.980 biggest diagnostic challenge, is the retroperitoneal 00:07:34.980 --> 00:07:37.540 space. We call it the hidden danger zone for 00:07:37.540 --> 00:07:40.300 a reason. Why is it so hard to assess? It's location. 00:07:40.740 --> 00:07:43.800 It's deep. It's posterior to the main peritoneal 00:07:43.800 --> 00:07:46.360 lining, and it's packed with, I mean, the biggest, 00:07:46.379 --> 00:07:49.079 most important stuff. The aorta, the IVC, the 00:07:49.079 --> 00:07:51.899 kidneys, the ureters, the pancreas, most of the 00:07:51.899 --> 00:07:53.699 duodenum. And the nursing implication here is 00:07:53.699 --> 00:07:56.360 that these injuries are the ultimate silent killers. 00:07:56.540 --> 00:08:00.050 They are. If the aorta or renal artery is bleeding, 00:08:00.430 --> 00:08:02.990 that blood just collects in this deep, contained 00:08:02.990 --> 00:08:05.550 space. It doesn't spill into the main abdominal 00:08:05.550 --> 00:08:08.050 cavity, so you don't get that immediate peritonitis. 00:08:08.310 --> 00:08:10.290 And our usual rapid tests don't work well here. 00:08:10.449 --> 00:08:14.069 They don't. A DPL won't sample that area. And 00:08:14.069 --> 00:08:16.990 a FAST scan is notoriously bad at visualizing 00:08:16.990 --> 00:08:20.089 the deep retroperitonium, often because of overlying 00:08:20.089 --> 00:08:23.089 bowel gas. So if you suspect a retroperitoneal 00:08:23.089 --> 00:08:26.670 injury, your only truly reliable tool is a CT 00:08:26.670 --> 00:08:28.769 scan. Which means the patient has to be stable 00:08:28.769 --> 00:08:32.309 enough to get one. Exactly. Which is why pancreatic 00:08:32.309 --> 00:08:34.750 and duodenal injuries are so famous for being 00:08:34.750 --> 00:08:38.809 diagnosed late. Okay, zone number two. The pelvic 00:08:38.809 --> 00:08:41.149 cavity. Right. This is the space surrounded by 00:08:41.149 --> 00:08:43.610 the bony pelvis. It's got the rectum, bladder, 00:08:43.769 --> 00:08:45.830 the big filiac vessels, and the reproductive 00:08:45.830 --> 00:08:48.549 organs. And the primary danger here is hemorrhage. 00:08:49.009 --> 00:08:51.120 Massive hemorrhage. You can bleed from the organs, 00:08:51.399 --> 00:08:53.480 sure, but the truly life -threatening bleeds 00:08:53.480 --> 00:08:56.000 often come from the bone itself. When that pelvic 00:08:56.000 --> 00:08:58.799 ring fractures, it shears the dense venous plexus 00:08:58.799 --> 00:09:01.379 on the back wall or tears branches of the iliac 00:09:01.379 --> 00:09:03.799 arteries. This space can hide multiple liters 00:09:03.799 --> 00:09:06.179 of blood very, very quickly. And finally, the 00:09:06.179 --> 00:09:08.360 thoracoaptamen. We said this runs from the nipples 00:09:08.360 --> 00:09:10.379 down to the bottom of the ribs. And the key takeaway 00:09:10.379 --> 00:09:12.620 here, as we mentioned, is that diaphragm mobility. 00:09:13.100 --> 00:09:15.039 You have to remember that injuries to the lower 00:09:15.039 --> 00:09:18.419 ribs, ninth, tenth, eleventh, are not just rib 00:09:18.419 --> 00:09:21.210 problems, They have to be investigated for abdominal 00:09:21.210 --> 00:09:23.370 involvement because they sit right on top of 00:09:23.370 --> 00:09:25.190 the spleen on the left and the liver on the right. 00:09:25.549 --> 00:09:27.769 Never trust an injury below the nipple line to 00:09:27.769 --> 00:09:30.909 be purely thoracic. Never. OK, so now we have 00:09:30.909 --> 00:09:33.730 the map. Let's talk about the mechanism of injury 00:09:33.730 --> 00:09:36.370 and the patterns to expect. Starting with blunt 00:09:36.370 --> 00:09:39.309 trauma. This is the most common, right? MVCs, 00:09:39.549 --> 00:09:42.269 falls, assaults. It is. And you have two main 00:09:42.269 --> 00:09:46.070 forces. Compression, which crushes organs, and 00:09:46.070 --> 00:09:48.129 deceleration, which causes shearing injuries. 00:09:48.350 --> 00:09:50.690 So for blunt trauma, what are the top three organs 00:09:50.690 --> 00:09:53.549 we need to be thinking about? The big three consistently 00:09:53.549 --> 00:09:56.429 are the spleen that gets injured in up to 55 00:09:56.429 --> 00:10:00.570 % of cases, then the liver up to 45%, and then 00:10:00.570 --> 00:10:02.570 the small bowel, which is less common, maybe 00:10:02.570 --> 00:10:05.149 five to 10%. Let's talk about that shearing mechanism. 00:10:05.250 --> 00:10:07.350 This is where the body's own anatomy creates 00:10:07.350 --> 00:10:10.149 failure points. Right. Think of an organ like 00:10:10.149 --> 00:10:12.450 cargo in a truck that's tied down with straps. 00:10:12.830 --> 00:10:15.590 When the truck crashes to a sudden stop, the 00:10:15.590 --> 00:10:17.929 car, the organ wants to keep moving forward. 00:10:18.169 --> 00:10:20.629 All the stress goes on to the straps, which are 00:10:20.629 --> 00:10:23.350 the ligaments. And they tear. They tear. This 00:10:23.350 --> 00:10:25.769 causes lacerations right where the liver and 00:10:25.769 --> 00:10:28.409 spleen are attached. For the small bowel, you 00:10:28.409 --> 00:10:30.350 get what's called a bucket handle injury, which 00:10:30.350 --> 00:10:32.490 is a tear in the mesentery that supplies his 00:10:32.490 --> 00:10:36.409 blood. And a critical detail from MVCs, the seatbelt 00:10:36.409 --> 00:10:39.149 sign. We know they save lives, but they also 00:10:39.149 --> 00:10:41.870 create a very specific injury pattern. Absolutely. 00:10:41.889 --> 00:10:44.330 If you see that transverse bruise, that ecomosis 00:10:44.330 --> 00:10:47.409 across the abdomen from a lap belt, that is a 00:10:47.409 --> 00:10:49.730 huge red flag. It's not just a bruise. What should 00:10:49.730 --> 00:10:51.429 it make you think of? Two things, immediately. 00:10:51.769 --> 00:10:54.409 First, a high risk of an intestinal injury, often 00:10:54.409 --> 00:10:57.009 a perforation. And second, the specific type 00:10:57.009 --> 00:10:59.350 of lumbar spine fracture called a chance fracture. 00:10:59.909 --> 00:11:02.009 It's a distraction injury, and it's highly associated 00:11:02.009 --> 00:11:04.320 with lap belts. That bruise means you need to 00:11:04.320 --> 00:11:06.519 get specific imaging of the spine. And just to 00:11:06.519 --> 00:11:09.419 bust a myth, what about airbags? Airbag deployment 00:11:09.419 --> 00:11:12.139 does not, I repeat, does not rule out abdominal 00:11:12.139 --> 00:11:15.259 injury. The forces involved are still massive 00:11:15.259 --> 00:11:18.340 and can easily cause significant internal trauma. 00:11:18.820 --> 00:11:21.740 Okay, shifting gears to penetrating trauma. A 00:11:21.740 --> 00:11:24.700 stab wound versus a gunshot wound. Huge difference. 00:11:24.820 --> 00:11:27.019 It's all about energy transfer. A stab wound 00:11:27.019 --> 00:11:29.639 is a low -energy event. It lacerates and tears 00:11:29.639 --> 00:11:32.309 what it touches. So the most commonly injured 00:11:32.309 --> 00:11:35.090 organs are the ones right up front, the liver, 00:11:35.710 --> 00:11:38.169 small bowel, diaphragm, and colon. Which means 00:11:38.169 --> 00:11:39.909 you can sometimes manage them without surgery. 00:11:40.350 --> 00:11:42.710 Right. Selective non -operative management is 00:11:42.710 --> 00:11:44.629 often an option if the patient is stable and 00:11:44.629 --> 00:11:47.649 has no signs of peritonitis, but gunshot wounds. 00:11:48.750 --> 00:11:50.549 They are a different beast entirely because of 00:11:50.549 --> 00:11:53.350 kinetic energy in cavitation. Explain cavitation. 00:11:53.649 --> 00:11:55.990 A high -velocity bullet creates a temporary cavity. 00:11:56.169 --> 00:11:58.649 a shockwave that is way, way bigger than the 00:11:58.649 --> 00:12:01.149 bullet itself. It damages tissue far outside 00:12:01.149 --> 00:12:03.250 the bullet's physical track. So the injury pattern 00:12:03.250 --> 00:12:05.350 is much more widespread and devastating. Which 00:12:05.350 --> 00:12:07.909 is why the most commonly injured organs are different. 00:12:08.389 --> 00:12:10.690 Exactly. Small bowel is number one at 50 percent, 00:12:10.830 --> 00:12:13.330 then the colon, then the liver, and a very high 00:12:13.330 --> 00:12:15.789 rate of injury to the major abdominal blood vessels, 00:12:15.909 --> 00:12:18.450 about 25 percent. And this leads to that clinical 00:12:18.450 --> 00:12:21.950 rule. Almost all abdominal GSWs go to the ORs. 00:12:22.049 --> 00:12:25.460 They do. With a 98 % chance of significant injury, 00:12:25.860 --> 00:12:28.379 if the peritoneum is breached, you just can't 00:12:28.379 --> 00:12:30.559 take the risk. But here's the nursing alert. 00:12:31.159 --> 00:12:33.279 You can't trust the trajectory. It's not a straight 00:12:33.279 --> 00:12:36.240 line. Never. Bullets tumble, they hit bone and 00:12:36.240 --> 00:12:38.580 ricochet, they fragment. The entrance and exit 00:12:38.580 --> 00:12:40.419 wounds might tell you very little about the path 00:12:40.419 --> 00:12:43.419 of destruction inside. And lastly, blast injury. 00:12:44.100 --> 00:12:46.750 This is a combination of everything. It is. You 00:12:46.750 --> 00:12:49.330 get penetrating trauma from shrapnel, blunt trauma 00:12:49.330 --> 00:12:52.350 from being thrown. But the unique danger is the 00:12:52.350 --> 00:12:54.450 overpressure injury from the blast wave itself. 00:12:54.990 --> 00:12:56.950 What does that affect? It injures air -containing 00:12:56.950 --> 00:12:59.950 organs, the eardrums, the lungs, and the bowel. 00:13:00.529 --> 00:13:02.269 And the learning point here is that the bowel 00:13:02.269 --> 00:13:04.690 injury might have a delayed presentation. So 00:13:04.690 --> 00:13:07.509 again, it comes back to that need for long, careful, 00:13:07.789 --> 00:13:10.549 serial observation. OK, so let's move on to the 00:13:10.549 --> 00:13:12.940 actual physical exam. This is the foundation, 00:13:12.960 --> 00:13:15.919 and it has to be systematic. For the learner, 00:13:15.919 --> 00:13:19.820 we have to follow the sequence. I -A -P -P. Inspection, 00:13:20.000 --> 00:13:22.980 auscultation, percussion, and palpation. Always 00:13:22.980 --> 00:13:25.240 in that order. For inspection, what are we looking 00:13:25.240 --> 00:13:27.879 for? Patient has to be fully exposed, front and 00:13:27.879 --> 00:13:30.139 back. You're looking for those external signs 00:13:30.139 --> 00:13:33.679 of internal force, the seatbelt sign, any lacerations, 00:13:33.899 --> 00:13:36.120 any protruding bowel or omentum, which is called 00:13:36.120 --> 00:13:38.539 an evisceration. You have to inspect the flanks, 00:13:38.820 --> 00:13:42.120 the scrotum, the erythromedas for blood. And 00:13:42.120 --> 00:13:44.440 you have to see the back. A cautious log roll 00:13:44.440 --> 00:13:47.659 is mandatory. You have to see the back. A penetrating 00:13:47.659 --> 00:13:50.419 wound to the flank or buttock could easily have 00:13:50.419 --> 00:13:53.100 entered the abdomen. The sources really stress 00:13:53.100 --> 00:13:55.740 that a laceration of the perineum or buttocks 00:13:55.740 --> 00:13:58.360 can indicate an open pelvic fracture, which has 00:13:58.360 --> 00:14:01.000 a terrifyingly high mortality rate. Moving on 00:14:01.000 --> 00:14:03.799 to auscultation and percussion. Auscultation. 00:14:04.000 --> 00:14:06.980 You do it, but honestly, in a noisy trauma bay, 00:14:07.440 --> 00:14:09.860 the presence or absence of vowel sounds is pretty 00:14:09.860 --> 00:14:12.519 unreliable. Don't hang your hat on it. Percussion, 00:14:12.639 --> 00:14:14.600 though, that's key for checking for peritoneal 00:14:14.600 --> 00:14:17.309 irritation. And this brings us to a critical 00:14:17.309 --> 00:14:20.730 do not for palpation. Yes. The reliable sign 00:14:20.730 --> 00:14:22.970 you're looking for is involuntary muscle guarding. 00:14:23.669 --> 00:14:25.990 That's when the patient's muscles tense up automatically 00:14:25.990 --> 00:14:28.409 before you even touch them deeply. That's a true 00:14:28.409 --> 00:14:31.250 sign. But once you elicit rebound tenderness, 00:14:31.909 --> 00:14:34.090 that sharp pain when you quickly release pressure, 00:14:34.269 --> 00:14:38.409 You're done. Stop the exam. Stop. Do not keep 00:14:38.409 --> 00:14:41.230 pushing to find more evidence. It causes the 00:14:41.230 --> 00:14:43.669 patient unnecessary pain, it serves no clinical 00:14:43.669 --> 00:14:46.190 purpose, and it breaks their trust in you. You've 00:14:46.190 --> 00:14:48.590 found peritonitis. Your exam is over. Move on 00:14:48.590 --> 00:14:51.230 to the next step. That's a huge point. Okay, 00:14:51.350 --> 00:14:53.889 let's focus on the pelvic and perineal assessment. 00:14:54.289 --> 00:14:56.110 This is where undiagnosed hemorrhage can kill 00:14:56.110 --> 00:14:58.750 someone very quickly. It can. And sometimes the 00:14:58.750 --> 00:15:01.210 only initial sign of a catastrophic pelvic fracture 00:15:01.210 --> 00:15:04.129 is just unexplained hypotension. So what are 00:15:04.129 --> 00:15:06.629 the physical exam findings that should scream 00:15:06.629 --> 00:15:08.769 pelvic instability? You're looking for signs 00:15:08.769 --> 00:15:10.929 of mechanical disruption and vascular injury. 00:15:11.240 --> 00:15:14.580 So a big scrotal hematoma, any blood dripping 00:15:14.580 --> 00:15:16.740 from the urethral meatus, a difference in the 00:15:16.740 --> 00:15:19.539 length of their legs, or if one leg is rotated 00:15:19.539 --> 00:15:22.019 abnormally without an obvious femur fracture. 00:15:22.480 --> 00:15:24.559 Okay, and now... For maybe the biggest trauma, 00:15:24.659 --> 00:15:26.919 do not. That prevents us from causing more harm. 00:15:27.080 --> 00:15:30.279 This is non -negotiable. Avoid manually manipulating 00:15:30.279 --> 00:15:33.100 the pelvis. Do not rock it. Do not push on it 00:15:33.100 --> 00:15:35.179 to check for stability. Why not? Because the 00:15:35.179 --> 00:15:37.840 body's first response to that massive venous 00:15:37.840 --> 00:15:41.159 bleeding is to try and form a clot to tamponate 00:15:41.159 --> 00:15:44.460 it. That clot is fragile. If you come in and 00:15:44.460 --> 00:15:47.480 start rocking the pelvis, you will dislodge that 00:15:47.480 --> 00:15:50.139 life -saving clot, and the patient will immediately 00:15:50.139 --> 00:15:52.850 lose a massive amount of blood and crash. So 00:15:52.850 --> 00:15:55.409 you treat suspected instability by stabilizing 00:15:55.409 --> 00:15:58.190 it, not by testing it. Exactly. Now let's talk 00:15:58.190 --> 00:16:00.509 about those urethral and genitourinary signs. 00:16:01.009 --> 00:16:03.309 As we said, blood at the meatus or a massive 00:16:03.309 --> 00:16:06.210 perineal hematoma strongly suggests a urethral 00:16:06.210 --> 00:16:09.070 injury. And the absolute do not that follows 00:16:09.070 --> 00:16:11.509 that finding. Do not place a urinary catheter. 00:16:11.629 --> 00:16:14.029 Another critical one. If the urethra is partially 00:16:14.029 --> 00:16:17.700 torn, blindly forcing a catheter in can turn 00:16:17.700 --> 00:16:19.679 that partial tear into a complete transaction. 00:16:20.279 --> 00:16:21.980 It's a devastating complication. So what's the 00:16:21.980 --> 00:16:23.919 right move? They need a specialist evaluation 00:16:23.919 --> 00:16:26.519 first, a retrograde urethragram, to see what's 00:16:26.519 --> 00:16:28.360 going on. No tube goes in until that's done. 00:16:28.600 --> 00:16:30.940 We also need to do rectal and vaginal exams when 00:16:30.940 --> 00:16:33.759 indicated. What are we feeling for in the rectal 00:16:33.759 --> 00:16:36.080 exam? We're checking sphincter tone, making sure 00:16:36.080 --> 00:16:38.399 the rectal wall is intact, and feeling for any 00:16:38.399 --> 00:16:40.960 palpable bony fragments from a pelvic fracture. 00:16:41.210 --> 00:16:44.429 In penetrating trauma, the main thing is feeling 00:16:44.429 --> 00:16:46.669 for gross blood, which means you've hit the bowel. 00:16:47.529 --> 00:16:50.710 And a small detail for female patients. The vaginal 00:16:50.710 --> 00:16:53.309 exam is looking for lacerations from bone fragments 00:16:53.309 --> 00:16:56.629 or a trans pelvic gunshot wound. But the small, 00:16:56.889 --> 00:16:58.970 easily missed detail is a check for a retained 00:16:58.970 --> 00:17:01.429 tampon in an unresponsive menstruating woman. 00:17:02.149 --> 00:17:04.750 Missing that can lead to delayed severe sepsis. 00:17:04.960 --> 00:17:07.940 Okay, one last point in this section. Those seemingly 00:17:07.940 --> 00:17:10.740 simple gluteal penetrating injuries. Massive 00:17:10.740 --> 00:17:13.240 red flag. They fool people all the time. A penetrating 00:17:13.240 --> 00:17:16.200 injury to the buttock area has up to a 50 % incidence 00:17:16.200 --> 00:17:18.859 of significant intra -abdominal injury. 50%. 00:17:18.859 --> 00:17:21.640 50%. The trajectory often goes up into the deep 00:17:21.640 --> 00:17:23.759 pelvis or abdomen, hitting the rectum, iliac 00:17:23.759 --> 00:17:26.680 vessels, or colon. The external wound looks minor, 00:17:26.799 --> 00:17:28.559 but the internal damage can be catastrophic. 00:17:29.069 --> 00:17:31.309 Evaluation is absolutely mandatory. Alright, 00:17:31.390 --> 00:17:33.730 let's shift to the diagnostic tools we use after 00:17:33.730 --> 00:17:36.990 the primary survey, our adjuncts. Starting with 00:17:36.990 --> 00:17:39.809 the tubes and catheters. A gastric tube has a 00:17:39.809 --> 00:17:42.609 few purposes. It relieves gastric distension, 00:17:42.869 --> 00:17:45.609 which reduces aspiration risk, and it empties 00:17:45.609 --> 00:17:48.150 the stomach before a DPL. What if you see blood 00:17:48.150 --> 00:17:51.519 come out of it? It suggests an injury to the 00:17:51.519 --> 00:17:54.400 esophagus or upper GI tract. But you first have 00:17:54.400 --> 00:17:57.319 to make sure it's not just from trauma during 00:17:57.319 --> 00:17:59.400 the insertion itself. And there's a vital safety 00:17:59.400 --> 00:18:01.380 rule about how you insert it. A non -negotiable 00:18:01.380 --> 00:18:04.380 one. If the patient has severe facial fractures 00:18:04.380 --> 00:18:06.519 or you even suspect a basal or skull fracture, 00:18:07.160 --> 00:18:09.819 the tube must be inserted orally through the 00:18:09.819 --> 00:18:12.200 mouth. Why? Because if you go through the nose, 00:18:12.539 --> 00:18:14.700 you risk passing the tube through the fractured 00:18:14.700 --> 00:18:17.660 crib reform plate directly into the brain. It's 00:18:17.660 --> 00:18:19.940 an absolute contraindication for nasal insertion 00:18:19.940 --> 00:18:22.660 in that setting. Okay, next up, the urinary casseter. 00:18:23.059 --> 00:18:24.900 Assuming we've cleared the urethra for injury, 00:18:25.319 --> 00:18:27.519 what are its goals? Relieving retention, checking 00:18:27.519 --> 00:18:30.480 for blood, and most importantly, monitoring their 00:18:30.480 --> 00:18:33.519 urine output. That's our best real -time indicator 00:18:33.519 --> 00:18:36.039 of tissue perfusion and whether a resuscitation 00:18:36.039 --> 00:18:38.640 is working. And there's a small timing detail 00:18:38.640 --> 00:18:42.259 related to the FAST scan. Yes, a small but important 00:18:42.259 --> 00:18:45.910 one. A full bladder acts As an acoustic window, 00:18:46.369 --> 00:18:48.190 it makes it much easier to see the pelvis on 00:18:48.190 --> 00:18:51.230 the FAST scan. So if the patient is stable, you 00:18:51.230 --> 00:18:53.230 should do the FAST before you place the catheter 00:18:53.230 --> 00:18:55.730 to get the best possible images. Right. And just 00:18:55.730 --> 00:18:58.269 to reiterate, blood in the urine confirms trauma, 00:18:58.750 --> 00:19:01.650 but no blood does not rule it out. Exactly. You 00:19:01.650 --> 00:19:03.589 can have a completely transected renal artery 00:19:03.589 --> 00:19:06.410 and have no hematuria at all. OK. Let's talk 00:19:06.410 --> 00:19:08.589 about the rapid screening tools, FAST versus 00:19:08.589 --> 00:19:11.849 DPL. So FAST, the Focused Assessment with Sonography 00:19:11.849 --> 00:19:14.619 for Trauma. The reason it's so popular is that 00:19:14.619 --> 00:19:16.619 it's fast, it's non -invasive, you can do it 00:19:16.619 --> 00:19:18.940 right at the bedside, and you can repeat it over 00:19:18.940 --> 00:19:21.660 and over. And its only job is to answer one question. 00:19:21.819 --> 00:19:24.839 One question. Is there free fluid, meaning blood, 00:19:25.240 --> 00:19:27.339 in one of the major potential spaces? And which 00:19:27.339 --> 00:19:29.440 four regions are we looking at? The pericardial 00:19:29.440 --> 00:19:32.380 sac for tamponade, the hepatorenal fossa -Morrison's 00:19:32.380 --> 00:19:35.539 pouch, the splenorenal fossa, and the pelvis. 00:19:36.279 --> 00:19:38.079 A quick sweep takes just a couple of minutes. 00:19:38.269 --> 00:19:40.990 But learners have to know the limitations. A 00:19:40.990 --> 00:19:44.009 negative FAST can be a huge trap. It's the classic 00:19:44.009 --> 00:19:46.730 false negative pitfall. The biggest limitation 00:19:46.730 --> 00:19:50.789 is that FAST is terrible at diagnosing hollibuscus 00:19:50.789 --> 00:19:54.170 injury, a bowel tear. It's looking for a large 00:19:54.170 --> 00:19:57.430 amount of fluid, not the tear itself. So a small 00:19:57.430 --> 00:20:00.170 leak won't show up. It's also less reliable in 00:20:00.170 --> 00:20:02.809 obese patients. So a negative FAST doesn't mean 00:20:02.809 --> 00:20:05.349 you're in the clear. Not at all. It just means 00:20:05.349 --> 00:20:07.759 you don't see a lot of blood right now. You still 00:20:07.759 --> 00:20:09.900 need a high index of suspicion and probably repeat 00:20:09.900 --> 00:20:13.559 scans. Okay, what about DPL? Diagnostic peritoneal 00:20:13.559 --> 00:20:15.960 lavage. It's less common now, but still has a 00:20:15.960 --> 00:20:18.599 role. It does. It's an invasive surgical procedure, 00:20:19.059 --> 00:20:22.039 but it's extremely sensitive. It's most useful 00:20:22.039 --> 00:20:24.700 in an unstable blunt trauma patient when you 00:20:24.700 --> 00:20:27.599 don't have FAST or CT available or the FAST scan 00:20:27.599 --> 00:20:30.170 was unclear. What are the critical nursing prep 00:20:30.170 --> 00:20:32.529 steps for a DPL? You have to make sure the stomach 00:20:32.529 --> 00:20:34.289 and bladder are completely empty. If they're 00:20:34.289 --> 00:20:36.130 full, you can easily puncture them during the 00:20:36.130 --> 00:20:38.349 procedure, which is a major complication. So 00:20:38.349 --> 00:20:41.329 gastric tube in, Foley in. And what DPL findings 00:20:41.329 --> 00:20:44.549 mean an immediate trip to the OR? If you aspirate 00:20:44.549 --> 00:20:47.470 anything that looks like GI contents, bile, or 00:20:47.470 --> 00:20:50.450 vegetable fibers, that's a direct ticket. For 00:20:50.450 --> 00:20:53.690 blood, the rule is if you get 10 cc or more of 00:20:53.690 --> 00:20:56.549 gross blood back in an unstable patient, they 00:20:56.549 --> 00:20:59.029 go to the OR for a laparotomy. Okay, let's move 00:20:59.029 --> 00:21:02.069 to advanced imaging. CT scan is the gold standard 00:21:02.069 --> 00:21:04.650 for defining injury, but it comes with a huge 00:21:04.650 --> 00:21:07.650 non -negotiable caveat. The rule is absolute. 00:21:08.230 --> 00:21:11.130 CT is for hemodynamically normal, stable patients 00:21:11.130 --> 00:21:14.650 only. Why? Because the time it takes to transport 00:21:14.650 --> 00:21:16.829 a patient to the CT scanner, get them on the 00:21:16.829 --> 00:21:19.539 table and complete the scan. That time is lethal 00:21:19.539 --> 00:21:22.200 for an unstable patient. The scanner is not a 00:21:22.200 --> 00:21:25.039 resuscitation room. Stability buys you a CT scan. 00:21:25.519 --> 00:21:27.599 Instability buys you a trip to the OR. But in 00:21:27.599 --> 00:21:29.700 that stable patient, it's incredibly valuable. 00:21:29.759 --> 00:21:31.680 Oh, it's amazing. It gives you precise organ 00:21:31.680 --> 00:21:33.960 injury grading, which you need for non -operative 00:21:33.960 --> 00:21:36.880 management. And it's the only good way to diagnose 00:21:36.880 --> 00:21:39.220 those hidden retroperitoneal and pelvic injuries 00:21:39.220 --> 00:21:42.019 that fast and the physical exam miss. What are 00:21:42.019 --> 00:21:44.460 its weaknesses? It can still miss diaphragmatic 00:21:44.460 --> 00:21:47.579 tears, and it's not great for subtle pancreatic 00:21:47.579 --> 00:21:50.980 or small bowel injuries. But here's a key interpretation 00:21:50.980 --> 00:21:54.660 tip. If the CT shows free fluid in the abdomen, 00:21:55.240 --> 00:21:57.799 but no visible injury to the liver or spleen, 00:21:58.460 --> 00:22:00.859 that fluid had to come from somewhere. The bowel 00:22:00.859 --> 00:22:03.519 or the mesenteric? Exactly. And that almost always 00:22:03.519 --> 00:22:05.400 means they need an operation anyway. We still 00:22:05.400 --> 00:22:07.500 use plain x -rays, too. What's the highest yield 00:22:07.500 --> 00:22:10.259 one? The AP pelvic x -ray. If you have an unstable 00:22:10.259 --> 00:22:12.700 patient with pelvic pain, you need one immediately 00:22:12.700 --> 00:22:14.599 to see if a pelvic fracture is the source of 00:22:14.599 --> 00:22:17.519 their bleeding. But conversely, an alert, a wake 00:22:17.519 --> 00:22:19.299 patient with no pelvic pain doesn't need one. 00:22:19.619 --> 00:22:22.670 You can save time and radiation. Finally, let's 00:22:22.670 --> 00:22:25.250 nail down the specifics of contrast studies because 00:22:25.250 --> 00:22:27.970 the technical details here are prime exam material. 00:22:28.509 --> 00:22:31.069 Absolutely. For urethrography, to check for urethral 00:22:31.069 --> 00:22:33.450 injury, the technique matters. You use a small 00:22:33.450 --> 00:22:35.849 eight French catheter and you gently instill 00:22:35.849 --> 00:22:39.109 30 to 35 millideals of undiluted contrast. Small 00:22:39.109 --> 00:22:41.569 catheter, small volume to avoid causing more 00:22:41.569 --> 00:22:43.890 damage. And for a cystogram to diagnose a bladder 00:22:43.890 --> 00:22:47.009 rupture. Here, volume is everything. You have 00:22:47.009 --> 00:22:50.849 to put in a large volume 350mm of water soluble 00:22:50.849 --> 00:22:54.430 contrast plus another 50mm for maximal distension. 00:22:55.089 --> 00:22:57.430 You have to fully stretch the bladder wall to 00:22:57.430 --> 00:23:00.410 force contrast out of any small holes. If you 00:23:00.410 --> 00:23:02.309 underfill it, you will get a false negative. 00:23:02.430 --> 00:23:04.309 And there's a critical step about which x -rays 00:23:04.309 --> 00:23:06.950 to take. You need three views. A pre -drainage 00:23:06.950 --> 00:23:09.690 film, the filled film, and a post -drainage view. 00:23:09.880 --> 00:23:12.140 That last one is essential. Sometimes a small 00:23:12.140 --> 00:23:14.380 leak only shows up after the pressure's off and 00:23:14.380 --> 00:23:16.740 the bladder's empty. Missing that post drainage 00:23:16.740 --> 00:23:20.500 film is a major error. And if CT isn't an option 00:23:20.500 --> 00:23:22.420 for checking the kidneys? Then you fall back 00:23:22.420 --> 00:23:25.319 on an IVP, intravenous pyrogram. The critical 00:23:25.319 --> 00:23:27.579 finding to know here is that non -visualization 00:23:27.579 --> 00:23:30.319 of the renal system after just two minutes suggests 00:23:30.319 --> 00:23:33.319 a major injury, like a renal artery thrombosis 00:23:33.319 --> 00:23:35.680 or a shattered kidney. Okay, so we have a diagnosis. 00:23:35.819 --> 00:23:38.019 Let's talk about definitive management, starting 00:23:38.019 --> 00:23:40.269 with the big one. who goes straight to the operating 00:23:40.269 --> 00:23:42.210 room. This is the survival guide list. These 00:23:42.210 --> 00:23:44.309 are the absolute indications for an immediate 00:23:44.309 --> 00:23:47.029 laparotomy. For blunt trauma, what are the triggers? 00:23:47.450 --> 00:23:50.150 Any patient who is hypotensive and has a positive 00:23:50.150 --> 00:23:53.789 fast scan, or any hypotensive patient with clear 00:23:53.789 --> 00:23:56.029 clinical signs of internal bleeding where you 00:23:56.029 --> 00:23:58.430 can't find another source, unstable and bleeding 00:23:58.430 --> 00:24:01.109 in the belly means surgery, period. and for penetrating 00:24:01.109 --> 00:24:04.569 trauma. Hypotension is always number one. A gunshot 00:24:04.569 --> 00:24:07.089 wound with a transparent needle trajectory is 00:24:07.089 --> 00:24:10.190 almost always an indication, given that 98 % 00:24:10.190 --> 00:24:13.339 injury rate. Obvious signs of peritonitis that 00:24:13.339 --> 00:24:17.259 rigid guarding or visible evisceration are absolute 00:24:17.259 --> 00:24:20.220 triggers. Got it. Now let's focus on managing 00:24:20.220 --> 00:24:23.220 pelvic fractures and hemorrhage. This is a top 00:24:23.220 --> 00:24:25.980 priority because the mortality is so high. It 00:24:25.980 --> 00:24:28.279 is, about one in six overall, but it can be as 00:24:28.279 --> 00:24:31.400 high as 50 % for open pelvic fractures. Hemorrhage 00:24:31.400 --> 00:24:33.400 is the factor we can actually do something about. 00:24:33.690 --> 00:24:36.470 You mentioned two main mechanisms. First, the 00:24:36.470 --> 00:24:38.990 open book, or AP compression. Right. This is 00:24:38.990 --> 00:24:41.710 from a head -on crash. The pelvis is forced open 00:24:41.710 --> 00:24:44.130 like a book. This tears the vessels in the back. 00:24:44.470 --> 00:24:46.349 And because the volume of the pelvis actually 00:24:46.349 --> 00:24:48.829 increases, it can hold a massive amount of blood. 00:24:49.269 --> 00:24:51.730 It's a setup for rapid catastrophic hemorrhage. 00:24:51.829 --> 00:24:53.269 And that's different from lateral compression. 00:24:53.630 --> 00:24:56.609 Very different. That's from a side impact. The 00:24:56.609 --> 00:24:59.049 force pushes the sides of the pelvis inward, 00:24:59.329 --> 00:25:02.230 which actually reduces the pelvic volume. The 00:25:02.230 --> 00:25:04.809 bleeding is often less severe initially, but 00:25:04.809 --> 00:25:07.869 this mechanism has a very high risk of driving 00:25:07.869 --> 00:25:10.049 bone fragments into the bladder and urethra, 00:25:10.170 --> 00:25:12.569 causing a lot of long -term problems. But for 00:25:12.569 --> 00:25:14.750 either one, the first step is hemorrhage control. 00:25:15.190 --> 00:25:17.529 Yes, and that is where the critical nursing management 00:25:17.529 --> 00:25:20.190 step comes in. Mechanical stabilization with 00:25:20.190 --> 00:25:23.390 a pelvic binder or simple bed sheet. This is 00:25:23.390 --> 00:25:25.910 a temporary, life -saving emergency procedure. 00:25:26.109 --> 00:25:28.769 Wasn't that the goal? To squeeze the pelvis closed. 00:25:29.079 --> 00:25:32.039 You internally rotate the legs and wrap the binder 00:25:32.039 --> 00:25:34.420 or sheet tightly to reduce the pelvic volume 00:25:34.420 --> 00:25:36.859 and splint the frasher, which helps tamponade 00:25:36.859 --> 00:25:38.900 the bleeding. And now for the small detail that 00:25:38.900 --> 00:25:41.619 makes it work. This is a huge high -yield point. 00:25:41.819 --> 00:25:44.220 Placement is everything. The binder or sheet 00:25:44.220 --> 00:25:46.440 must be centered over the greater trochanters 00:25:46.440 --> 00:25:49.240 of the femur, not up high on the iliac crests 00:25:49.240 --> 00:25:51.079 on the hips. Why the trochanters? Because the 00:25:51.079 --> 00:25:54.170 trochanters act as levers. By squeezing them 00:25:54.170 --> 00:25:57.109 together, you are internally rotating the entire 00:25:57.109 --> 00:26:00.369 leg and hip unit, which effectively closes the 00:26:00.369 --> 00:26:02.990 open book fracture. If you put it too high on 00:26:02.990 --> 00:26:05.390 the iliac crests, you're just squeezing soft 00:26:05.390 --> 00:26:08.130 tissue. It does nothing. And what are the cautions? 00:26:08.450 --> 00:26:11.289 It's a temporary device. If it's too tight or 00:26:11.289 --> 00:26:14.130 left on too long, it will cause severe skin breakdown 00:26:14.130 --> 00:26:16.569 and pressure ulcers. You have to monitor the 00:26:16.569 --> 00:26:18.549 skin underneath. If the binder isn't enough, 00:26:18.789 --> 00:26:20.900 then we have to escalate. Right, and that usually 00:26:20.900 --> 00:26:23.940 means a trauma center with resources for angiographic 00:26:23.940 --> 00:26:27.420 embolization or pre -peritoneal packing. The 00:26:27.420 --> 00:26:30.039 key is recognizing the need for transfer early. 00:26:30.539 --> 00:26:32.480 Let's finish up by highlighting a few of those 00:26:32.480 --> 00:26:34.640 sneaky injuries that are often diagnosed late. 00:26:34.880 --> 00:26:37.660 Right. First, holoviscus injuries, so the intestines. 00:26:38.259 --> 00:26:40.279 Diagnosis is tough because they don't cause a 00:26:40.279 --> 00:26:42.500 big early bleed. You have to be suspicious if 00:26:42.500 --> 00:26:44.579 you see a sepal sign or a chance fracture on 00:26:44.579 --> 00:26:47.359 imaging. Peritonitis is often delayed by hours. 00:26:47.660 --> 00:26:50.210 Next, diaphragm injuries. Most common on the 00:26:50.210 --> 00:26:52.990 left side. The classic pathognomonic sign on 00:26:52.990 --> 00:26:55.869 a chest x -ray is seeing the gastric tube curled 00:26:55.869 --> 00:26:58.990 up in the chest cavity. But sometimes the initial 00:26:58.990 --> 00:27:01.329 x -ray is normal and the bowel only herniates 00:27:01.329 --> 00:27:04.289 through the tear hours or days later. And finally, 00:27:04.430 --> 00:27:07.450 the toughest one of all, pancreatic injuries. 00:27:07.970 --> 00:27:10.769 These come from a direct hard blow to the epigastrium 00:27:10.769 --> 00:27:12.789 that crushes the pancreas against the spine. 00:27:13.309 --> 00:27:15.450 And here's the critical alert everyone has to 00:27:15.450 --> 00:27:19.960 know. An early normal serum amylase level does 00:27:19.960 --> 00:27:24.019 not rule out major pancreatic trauma. It's unreliable 00:27:24.019 --> 00:27:26.740 early on. Completely. And to make it worse, the 00:27:26.740 --> 00:27:28.880 CT scan might not even show the injury for up 00:27:28.880 --> 00:27:31.940 to eight hours. So if the mechanism was bad enough, 00:27:32.240 --> 00:27:34.980 even with normal labs and a maybe normal CT, 00:27:35.420 --> 00:27:37.599 you still have to be incredibly suspicious. So 00:27:37.599 --> 00:27:39.279 we've covered a huge amount of ground here, but 00:27:39.279 --> 00:27:41.220 we've really distilled it down. For the learner, 00:27:41.440 --> 00:27:43.960 that 80 % understanding comes down to mastering 00:27:43.960 --> 00:27:46.480 triage and observation. That's right. It starts 00:27:46.480 --> 00:27:49.019 with prioritizing that primary survey, always 00:27:49.019 --> 00:27:51.119 assuming there's an occult bleed, especially 00:27:51.119 --> 00:27:53.960 in that silent retroperitoneal space. If the 00:27:53.960 --> 00:27:56.480 patient is unstable, the answer is always speed 00:27:56.480 --> 00:27:58.920 and hemorrhage control. And let's just hammer 00:27:58.920 --> 00:28:01.480 home those three critical do -nots one more time, 00:28:01.619 --> 00:28:03.700 the things that prevent us from causing a catastrophe. 00:28:03.980 --> 00:28:07.329 One. Do not place an unverified Foley catheter 00:28:07.329 --> 00:28:10.430 if there are any signs of urethral injury. Two, 00:28:10.849 --> 00:28:13.369 do not manually rock or distract the pelvis if 00:28:13.369 --> 00:28:16.089 you suspect it's unstable. And three, Do not 00:28:16.089 --> 00:28:18.470 keep palpating for rebound tenderness once you've 00:28:18.470 --> 00:28:20.769 already established that they have peritonitis. 00:28:21.049 --> 00:28:22.950 And for the stable patient, their life depends 00:28:22.950 --> 00:28:25.910 on the quality of your meticulous serial exams, 00:28:25.950 --> 00:28:28.230 just watching and waiting for those delayed injuries 00:28:28.230 --> 00:28:30.450 to show themselves. Exactly. Trauma management 00:28:30.450 --> 00:28:32.849 is really organized chaos. You have to be able 00:28:32.849 --> 00:28:35.230 to apply the binder, draw the blood, get the 00:28:35.230 --> 00:28:37.390 fast scan, and call the surgeon all at the same 00:28:37.390 --> 00:28:39.170 time. So we'll leave you with this final thought 00:28:39.170 --> 00:28:42.299 to take into your practice. We always talk about 00:28:42.299 --> 00:28:44.960 time is tissue, meaning that acting fast saves 00:28:44.960 --> 00:28:48.140 organs. But in an unstable trauma patient, the 00:28:48.140 --> 00:28:50.740 biggest threat is often the delay caused by chasing 00:28:50.740 --> 00:28:52.920 a perfect diagnosis with a time -consuming test, 00:28:53.039 --> 00:28:55.819 like a CT scan, when what they really need is 00:28:55.819 --> 00:28:57.579 immediate surgical control of their bleeding. 00:28:57.900 --> 00:28:59.799 So the question is, how does that concept of 00:28:59.799 --> 00:29:02.220 time is tissue force the trauma team to prioritize 00:29:02.220 --> 00:29:05.019 action over information? And how do you, as a 00:29:05.019 --> 00:29:07.160 learner, integrate that necessary high -risk 00:29:07.160 --> 00:29:09.119 trade -off into your own decision -making flow, 00:29:09.460 --> 00:29:11.519 that complex balance, expert trauma care.