Because of the close proximity of the thorax and abdomen, injuries frequently affect them both simultaneously. It is, therefore, useful to consider them together as torso trauma.
The surgeon must prepare the torso trauma patient for exploration of both cavities in the operating room by appropriate draping.
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 scan are important tools in assessing the traumatized abdomen when physical examination alone is unreliable.
Most thoracic injuries can be managed appropriately by measures aimed at correcting thoracic sources of hypoperfusion and hypoxemia.
Resuscitative endovascular balloon occlusion of the aorta is helpful in temporary control of massive intra-abdominal traumatic hemorrhage.
OVERVIEW AND THE CONCEPT OF TORSO TRAUMA
Apart from injuries produced by single weapons such as a stab or single missile, most trauma affecting the abdomen or chest results in multiple injuries. As such, management involves a prioritized approach based on the degree of life threat resulting from these injuries as outlined in Chap. 117. Management begins with the Primary Survey by adhering to the ABCDE approach during which identification of these life-threatening physiologic derangements is accompanied by simultaneous resuscitative maneuvers in a prioritized sequence. Airway management with C-spine control, ventilation, correction of hypoxemia, identifying and treating causes of shock, establishing vascular access, and implementing adjuncts to the Primary Survey as required precedes identification and management of specific injuries. In a trauma center where multiple personnel are available, management is coordinated by a team leader who ensures adherence to the priority sequence while allowing multiple simultaneous interventions. In this chapter, we will focus specifically on assessment and management of trauma to the abdomen and chest.
Chest and abdomen injuries 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 phases of respiration and thus in demarcation of the thoracic and abdominal cavities. It is not unusual for the diaphragm to traverse over 15 cm between inspiration (costal margin) and expiration (nipple line) (Fig. 123-1). This often makes it impossible to determine intrathoracic versus intra-abdominal injury on the basis of the external point of impact. The concept of torso trauma ensures that injuries in one cavity will not be overlooked while injuries in the other are being managed.
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.