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KEY POINTS

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  • Abdominal and thoracic injuries should be considered as one complex—torso trauma.

  • Prioritization of intervention in torso trauma is based on the relative threat to life from specific injuries.

  • In managing torso trauma, the surgeon must be prepared to explore the chest and/or abdomen because the source of instability frequently is not obvious.

  • The major decision in assessing the traumatized abdomen is to recognize the need for surgical exploration.

  • In general, indications for surgical intervention in abdominal trauma are perforation, penetration, and hemorrhage.

  • An organ-specific diagnosis is not necessary to establish the need for laparotomy in trauma.

  • Ultrasound, peritoneal lavage, and computed tomographic (CT) scan are important tools in assessing the traumatized abdomen when physical examination alone is unreliable.

  • Most thoracic injuries can be managed appropriately by simple measures aimed at correcting thoracic sources of hypoperfusion and hypoxemia.

  • Emergency thoracotomy should be considered in the unstable or unresponsive patient when this technique could potentially reverse the source of instability.

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Injuries involving the chest and abdomen may be considered as a single complex—torso trauma. This strategy is based on several factors. The configuration of the diaphragm and its attachment to the rib cage result in marked variability in its position with respiration and thus in demarcation of the thoracic and abdominal cavities. It is not unusual for the diaphragm to traverse distances of over 15 cm between the inspiratory and expiratory phases of respiration. The diaphragm may be at the level of the nipple line during full expiration and well below the costal margin during full inspiration, with corresponding shifts of the abdominal and thoracic contents (Fig. 120-1). This phenomenon, together with the variable trajectory of objects or forces after penetrating the torso, makes it virtually impossible in many instances to determine on the basis of the external point of impact or penetration whether intrathoracic or intra-abdominal injury has been sustained. The concept of torso trauma ensures that injuries in one cavity will not be overlooked while injuries in the other are being managed.

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FIGURE 120-1

The rationale for regarding torso trauma as a unified entity. A blunt or penetrating impact at a given level of the chest wall may cause either intra-abdominal or intrathoracic injury depending on the trajectory of the missile and/or the position of the diaphragm.

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The initial approach in trauma management is to secure the airway, to maintain respiration, and to identify and control hemorrhage and institute immediate fluid resuscitation as required. Definitive management of intra-abdominal or thoracic injury may be necessary as part of this resuscitative phase, particularly if the source of instability is major hemorrhage in the thoracic or abdominal cavity. Although it may be possible to identify a specific source in the thorax or abdomen for the abnormal hemodynamics in the trauma patient, it is frequently impossible to be absolutely certain of such ...

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