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And without wasting much time, I'm just going to introduce our speaker today. He'll be talking to us about, um, blunt abdominal and thoracic trauma. Um, it's going to be an interesting session and I just, um, I would just indulge us in the little time. We have to kindly listen. And if we have questions as the presentation is going on, can we just type them in the chat box and we will answer them as time goes on. Um, without further ado I will just, um, introduces, um, he's mister boss, he's a registrar in general surgery. Um, I've known him for quite some time. He's very dedicated, very intelligent and very interested in general surgery and the coming presentations will approve it. Um, s can you take the stage now? Yes. Thank you. Thanks for your kind words. Uh Can you see the uh screen? Yes, I can. And also, uh, if I ask questions, will the audience be able to unmute and say, uh, speak? Oh, no, but they will be able to chat in the, they will, they will be able to put the chart in. Yeah, chat box. All right. That's fine. Uh, and Good evening everyone. So after, yeah, after a lot of problems, we did manage to start it, I'll try to wrap it up as soon as possible uh within time as much as possible. Um So currently I'm working in Glasgow, Queen Elizabeth. It is a very busy hospital, uh tertiary referral center for Trauma uh for west of Scotland. So it's a huge population covered. Um And I'm just going to speak about uh blu blunt and penetrating trauma to thorax and abdomen, which is um I feel like which is very scary to most people, especially when we are just starting our surgical careers as juniors. Mm. I know that in the audience there might be uh various people at different stages of their uh training. Some of them might have seen uh many blunt and beating traumas and managed them. But II sus I guess that most of us are quite uh junior and haven't experienced this a lot. So I mainly to talk about different blunt and penetrating traumas and basically what, what traumas or what injuries could they possibly cause? And uh how do we initially manage them? Some of them are very complex uh as you can imagine, um especially thorax and we'll need specialist or seniors anyways. But to save the patient, the, the seniors will not be present at scene. It's all uh a matter of time. So it's our job to make sure that we stabilize the patient and buy enough time so that the definite management can be delivered. Yes, we can deliver definite management as well. But the main aim is to uh make the patient stable enough by some time and uh get the appropriate definitive management. And working as a trauma team is also very important and it's sometimes it can be very intimidating, especially when you are just a junior surgeon. And you have got so many other consultants, ed consultant, IC anesthetists. And everyone is looking down at you, what are you going to do? And uh it can be difficult, especially overnight. So it's very useful if you know uh what the trauma team looks like and how to work as a trauma team member. Um So uh this is just a scenario as an example. So um whenever you get a trauma call, um the pa you will get a time, for example, eta 10 minutes, 15 minutes and they will give a brief example of what the situation is like. If the trauma is uh if the patient is very unstable, uh or if the patient has a single injury like uh uh arm or forearm fracture, depending on that, the ed consultant or the ED team will call up call upon the various specialties. Uh If it's a tier three trauma, then the patient is unstable and we need the full trauma team, which includes orthopedic surgeons, anesthetist, ICU, uh various nursing staffs and blood bank, et cetera. But as soon as the patient arrives with the paramedics, this is how they will present the patient and you'll probably have one minute maximum from the paramedics uh to go through these details. And it's very important that each of those points are very important in uh how you manage or approach the case. Things can differ depending on how the paramedics have uh handed over to you. So it's it at least is the pneumonic age time mechanism, uh injury signs and uh treatment they have provided. So this is just an example, kind of how it might be. And this is actually uh not every time you'll get the full handover so accurately. But this is how it should be from the paramedics. And this is what the trauma team should like should look like. Uh usually the airway doctors are ICU consultant and anesthetist registrar or consultant. Uh primary survey doctor is usually the ed registrar and the procedure doctor is usually surgeon surgical registrar and the team leader is usually the EED consultant. So it doesn't mean that I the on the surgical registry is only supposed to do procedures. Uh you may be asked to do primary survey or it can be the surgical ho who is asked to do the primary survey. So it can be altered. But this is what the full trauma team should look like. Often we don't get the full trauma team, but this is the uh tier three trauma called. So there will be theater staff, there will be someone from blood bank, a runner, radiographer. So that's the full team. So assessment we all know starts with primary survey which is ABCD E and who should do this? Anyone in trauma team is supposed to do this and the team leader will ask anyone to do it depending on uh what the trauma is. Um Actually, I was going to ask the audience uh what should be the next step. But since we don't have a microphone, uh I'll just go through. So the next step should be uh get blood samples group and safe. This is the ii in any trauma setting. I think uh the most important aspect of treatment, we do a lot of things, we tend to do a lot of things and think that this is going to help. But the on most important thing that will help the patient or survive or save the patient uh is blood transfusion. So if there is a trauma and patient is losing blood, nothing else. Uh yes, of course, source control will help but blood transfusion is very important and we often uh do not because it's done. So by the e so quickly, we don't appreciate the importance of blood transfusion. Next would be investigations um x rays, chest pelvis and cervical spine, fast scan. So this is also part of the uh assessment initial assessment. So it's very useful, especially if someone has uh cardiac injuries or penetrating or injury to the thorax. It will show cardiac tampon or diagnosed cardiac tampon very quickly. It al it's also helpful in pneumothorax, pneumothorax. So fast scan is a very useful but who should do this? Anyone in the trauma team should also be able to do this. But if you're not trained to do this or not very good at doing this yet, it's fine. You can let the ed doctor do because uh they do separate trainings about on fast scan and uh they should be able to do this blood in abdomen. Yes, it can be useful. But I'm not entirely sure how much, for example, someone has blood in the abdomen, but they're completely stable hemodynamically. What do we do about that? So it doesn't mean much uh they will end up having another scan. Uh or if the patient does have, has very little blood in blood in abdomen, but unstable again, you have to do something to make the patient stable. That amount of blood doesn't mean anything but it's useful mainly for heart and thorax and then secondary survey. Again, it can be anyone, any uh anyone in the trauma team should be able to do a secondary survey which includes ample history and head to toe examination. And then if the patient is stable ct if not stable, intervene, it's that simple. CT is really, really important and it will, it can give us so many answers. Uh So if there is any scope to scan without wasting time. Get a ct. Now, talking about this scenario with uh uh with interest with the uh with thorax and abdominal, blunt and, and trauma. So young female, uh the handover is uh as you can see driving on motorway and uh in the evening, there was an accident and the crew reached fif within 15 minutes of the event and extrication time of 25 minutes. Um Can anyone write uh whether that extubation time is short long? Is that, is that all right? This ex time of 25 minutes or what does that mean? You won't be able to see the, how do I check? Sorry, sir. And what do you need? Uh No, no. Uh oh no, I was just asking uh from the first scenario. Ok. Uh Extrication time of 25 minutes. If the handover comes like that extrication time of 25 minutes, what's the significance of this? II if anyone can write on the chart? Yeah. Yeah. Go on. Sorry. I'll just take, I'll just say that an extrication time within five minutes means that the p the patient has been stuck in, in whereby in the accident scene for quite a long time. And ok, someone is saying something in the charts. Yeah, so 25 minutes is very long. It should be, there are uh studies and it should really be less than 10 minutes. Anything more than 10 minutes is a long extrication time. And that would mean if the patient has blood loss or if they had uh cardiac arrest, they will have a long uh downtime probably hypoxic injuries to various organs. So that's very important. A high speed collision usually speed above 30 miles per hour is considered high speed collision. So, um that's important and this, this details about whether seatbelts were on or airbags were deployed is very important as well because there can be various injuries uh if the seatbelts are not on or on. For example, uh Misener tears and paramedics will detect some uh injuries like uh fractures where and in this case, they have detected hemothorax, uh bruising on the abdomen, femur fracture and their initial, this is also very vital. Their initial observation are uh uh vitals um and then comes the treatment they are provided, they always will have c spine immobilized. II. The paramedics are really good at uh managing these things like c spine immobilization or uh in intubation or thoracostomy, most of them will have this done in the periphery. I it's very rare that they have missed these common things. Amount of fluid, amount of blood transfusion, everything is very important and uh pelvic binder of course, and T Xa, this is the other thing that can save patient. And there have been studies uh which has showed definite a a reduction in mortality and morbidity after trauma. Uh with highly use of tranexamic acid and what injuries could occur with this scenario, anything. Uh it can be anywhere, anything. Uh So no point in just uh some people will stick to this mechanism or uh dwell on those uh details, so much that they forget that it doesn't matter what's the speed or whether seatbelts are one. But you have to, we have to have our g wide open and consider there can be anything, any injury, most important immediate intervention in this case, airway, of course, make sure the tube is secured and in right place, c spine is immobilized and then IV access, which is easy to say, but extremely difficult. Especially in a trauma scenario, there will be hypertensive uh venous collapse and so it's difficult to get IV access. But usually the ICU or anesthetist can use ultrasound and do a quick femoral line if needed. And then blood transfusion. It's very important without wasting time. Get blood transfusion, unmatched blood is fine. Uh In this case, she had hemothorax, so secure chest strain, of course, and make sure it's uh swinging control bleeding as far as possible, external bleeding. Of course, internal ones we haven't really looked at. If after doing all these patient is stable or relatively stable, then scan if unstable, then you have to do something. Now talking about the thoracic injuries that might happen especially after blunt and penetrating trauma, the life-threatening ones, uh tension, pneumothorax, open chest wound and other pneumothorax, which are nontension massive hemothorax, cardiac tampon, uh airway disruption, flail chest and major vessels disruption. So all these are quite severe and significant injuries and uh these things will need something to be done in Ed or by paramedics. There is no time to wait for seniors. Um As a junior registrar or registrar starting recently, you are still expected to manage these things, maybe not fully, but at least to some extent so that you can buy time and get definite management as anyone below registerr level. Uh It might be too much to ask. Uh But if you can, if it, for example, pneumothorax, uh then like putting a chest drain in, then you of course, uh should do this and the interventions that can be done in ed. Now, needle, the synthesis historically have been there might be useful in very small number of cases just to buy time by a few minutes to put the chest drain in. But if the patient is relatively OK. And uh you are quick enough to put a chest drain in, then just go for a chest drain, no need to do needle tosensis. Uh Previously, the location used to be second intercostal space, mid clavicular line. But now we we the recent eight years uh guidelines. Uh fifth intercostal space in the Safe Triangle uh is fine thoracostomy and chest strength. Now, who should do this as a surgical uh trainee uh even if you're below s to three, you are expected to do a chest train. If not, it's fine. But if you're ST three and above, then you should be able to do a chest train other than the surgical register, the orthopedics, uh registrar or any consultant, any registrar, uh anesthetist or ICU, everyone is uh expected to do a chest train for trauma. And uh, it's very, it's not very difficult to do, especially in such a, uh, if the patient is in life threatening condition, then you have to do it uh quickly, it's not very difficult. Make a good incision, dissect through the fat and uh make a hole in the chest, put a drain in. Uh It doesn't sound uh I know it doesn't sound very easy but it is quite easy. Uh The only problem you might face is obese patients. It might be difficult to find the right place. And there is a possibility to go into liver or spleen or uh injure, injure the other underlying tissues. That's the main difficulty I would say. But otherwise, if you have practiced on cadavers or on models, um you should be able to do it in and then thoracotomy, of course, now who should do this, anyone who is experienced and have done this before uh should do this. Otherwise, it will just cause more harm. And so anyone who is not experienced and not a surgeon should not do this. For example, ed consultant, they have trained to do a throaty, but there will be hardly a handful of people who can, who will actually uh be courageous enough to do arthrotomy in without a surgeon. Uh It depends also on the situation. Uh It's difficult to say no. Uh if the patient is young and dying of something like cardiac tampon and it's difficult and uh it's the trauma leaders, uh team leaders call really if a thy is warranted or not. But as a surgeon, even as it to three general surgery, you are expected to do a thoracotomy. And what can thoracotomy help us with? Most importantly, drain a cardiac tampon and also for penetrating injuries to your heart, a hole in the heart. It sounds very scary and it is scary, but uh there is no other choice in that situation. Uh great control of other thoracic bleeds like major vessels in the thorax. Uh If you have seen thoracotomies, you, you will know the clams thy I am going to show you what it looks like. Uh clamshell thoracotomies. You can have a very good view of the all the major vessels in uh thorax, bleeding from lung, lung. Again, thoracotomy can help with that or control bleeding from the hila of lung. Uh So after a thoracotomy, if there is a hilar bleeding from the lung, the lung needs to be twisted so that the hi lung is closed, collapsed fully. Uh So again, this is just to buy time, it's not definitive, of course, but uh this will save the patient and cardiac arrest, direct cardiac massage. You can do that after thoracotomy. Uh but that's not really the only indication for thoracotomy. Cardiac arrest is an indication, cardiac arresting trauma is an indication. But to do a direct cardiac massage, that's not the indication for thoracotomy. And of course cross clamping of aorta, which is easy to say, but I think almost impossible for a surgical trainee to do it. Even the consultants would not dare to do a cross clamping of aorta. It's so difficult. There are alternatives, easier alternatives like clamping the uh abdominal aorta by doing an upper midline laparotomy. Um I'm sure we all know this uh a triangle of safety uh where the chest should go in. And also the li little thoracocentesis should be just around this area. Um So that's the triangle of 54 chest drain insertions. Uh an easy way, easy to, to quickly locate the fifth intercostal space rather than counting from se 2345. And then tracing it, especially in females and obese patients might be difficult to do so. So, uh an easy alternative in adults is one pump placing on the axilla, the lowermost margin of your uh fingers should correspond to the fifth rib. So if you stay within that, it should be fine, then comes how to do a thoracotomy. It's very easy to do atherotomy. Technically, uh it's actually easier than doing hernia or gallbladder. Much much easier than doing hernia or gla gallbladder because there is nothing much at stake, the pa patient is going to die. So, whatever you do is only going to make things better. Uh, yes, the guidelines say that if you are not trained or if you're not a surgeon, you're not supposed to do it. But, uh, if you are in surgery, um, you, it's easy to do just to make a big cut and uh just below the nipple line from midline to the bottom of the bed or age of the bed through the fat with just with a knife, nothing else is needed here just with a knife because the patient is probably dead or dying. So you can use a knife then for the intercostal muscles, just a seizure and then a retractor to open the chest. That's, it shouldn't take more than three minutes to do this. It doesn't take more than three minutes to do this difficulties after that. And this is clams incision, but the whole thorax can be opened. Uh And uh basically this is two intralateral thoracotomy. So one more incision from midline to at the edge of the bed on the other side. Again, fat and the muscles with the scissor and then put AFA retractor and just open it up, the sternum needs to be connected. So again, there is jigsaw which can be used, but we have been told that even a big seizure or stout seizure is fine, you can cut through sternum with a seizure. It's not a problem. And this should, should be, this can be done within 56 minutes. It's not difficult. So this is what enter lateral thy would look like. This is differentiator and heart lung. Excellent view. Uh cardiac tampon, draining cardiac tampon. It is very simple. Uh Of course, we have to be careful about other structures like phrenic nerve which runs here. And uh if you are aware, aware of those, uh you can save a patient and this is clams thot toy. Uh actually, there should be two fits on each side. Um But this is what it looks like. And if you retract her uh retract lungs, you, you can push the lungs upwards, both lungs or one lung and uh you'll be able to see the high lung very clearly. And if you move the uh retract the lung laterally, you'll be able to see the aorta here, pulmonary trunk trachea all around here, even the subclavian vessels are here as well. So you can clearly see all those and anything that requires direct control can be done having said those uh it's easy to open the chest. But after that, what you will see is just blood. So it's not easy to control the bleeding after that. But there is no other option. For example, if the patient is in cardiac arrest, then uh you just, you cannot do anything else. So if you open the chest and you can repair a hole in, uh, in the heart or drain a cardiac tamponade. That's the best chance the patient has got. Otherwise, the patient is already dead. Um, but it's difficult especially, uh to do it on a quickly in time. As ST three general surgery or ST three plus regr in general surgery, you are expected to do the, do this and also this, the consultant will be 15 minutes or 20 minutes away. You can ring them but you cannot wait for them. You have to start it and do the initial management. And by time, uh there is no other way and it looks very scary. But uh we all go through this. Um if you work in a tertiary care uh trauma center like I do in uh Glasgow, uh usually there is a throaty every once every two months. So all the registers will have experienced one thy uh in one year but don't be scared. It's uh there are courses who teach uh where they teach how to do atherotomy. Next is cardiac arrest due to trauma. It's very important topic. Um And to know the protocols and what to do cause of arrest like any cause, any uh cause of cardiac arrest. Uh There are reversible and irreversible causes. We are more concerned about the reversible causes and in trauma or as a surgeon, these are the ones we can manage uh or treat. This is the A S guideline, what to do in cardiac arresting trauma. Uh if it's less than two minutes start CPR of course and external CPR and if there is no return of circulation and do a quick bilateral chest decompression to make sure there is no tension, pneumothorax or hemothorax. If there is still no region of uh spontaneous circulation, that's an indication of thoracotomy. Um The indication uh mainly is uh to make sure there is no cardiac tampon or bleeding from thorax that can be controlled or bleeding from abdomen or pelvis, which would need a clamps, uh uh cross clamping of aorta. So if there is exsanguinating bleeding from pelvis or abdomen and the patient has gone into cardiac arrest. A thoracotomy can still be done and clamp the descending thoracic aorta in thorax to uh prevent further blood loss downstream. Um This is very difficult to do clamping of cross clamping of aorta. Um An easier alternative is doing your per midline uh laparotomy going on top of the liver, dividing the ligament. And if you run your hand straight down on top of the liver, you will reach the abdominal aorta. So it's much easier to find and much easier to put clamp in. And also as general surgeons, we are more acquainted with abdomen than thorax, clamping abdomen in uh sorry, clamping aorta and thorax. Uh one difficult to find. And second, it's difficult to differentiate between esophagus and a aorta. So it's easier if you do it through abdomen. Um So that's one recommendation. But if the fast scan has shown that the patient has got a cardiac tampon or uh the patient has got a knife in chest, then it's probably a cardiac injury and you can do atherectomy to uh treat that. Of course, after you have uh done whatever that can be done, the mortality is still very high. But if you can manage the cardiac tampon and or uh uh repair the whole in heart, they will still need to go to theater, they will still need cardiothoracic or vascular surgeons uh or the consultant to come in. So that's next step. Um different kind of injuries and what can we do for uh thoracic and abdominal traumas, chest, uh chest wall injuries like pneumothorax, hemothorax, uh any surgeon should be able to do it, put a drain promptly. Flail segment is controversial. Most of them can be managed uh conservatively with analgesia. Uh oxygen. Um A true flail segment is difficult to find. Most of them are radiological flail segment and not clinically flail segment. But there is a uh reflux. There is a scope of quicker recovery for the patient. Uh with refi fixation, usually the orthopedics or the trauma surgeon does that. And uh it it can be helpful in some patients, but most often we usually manage it, manage these cases uh conservatively with oxygen and good pain management, simple fractures or Stal fractures without displacement are always supportive. In analgesia, no injuries to heart. Um blunt trauma to heart is extremely difficult and very high mortality. I think the survival rate is as low as 3%. Uh blunt trauma to thorax or cardiac arrest due to blunt trauma to thorax. The survival is only 3%. Penetrating trauma is slightly better because uh you one, you can do something about it, you can repair it and two, the uh damage to the muscle is limited to that area, but blunt trauma is a diffuse damage to the muscle. So, contusion mortality is very high. Um and usually it's supportive. We cannot really do anything about it. Arrhythmia, there can be arrhythmias, but again, it's uh medical management and supportive uh pericard uh hemopericardium or tamponade always will need a thoracotomy in centers uh where there isn't, there isn't anyone trained to do a thoracotomy. Uh sometimes cardiologist or ed doctors or even ICU doctors can put in just uh uh drains in. But again, that is only to buy time and transfer the patient to a higher center. No hole in myocardium. Again, tobacco to me uh as a surgeon uh register as well, you are expected to do it because the consultant, we cannot wait for the consultant to come in um to do this. So the most important job is to just buy time, close the hole with your finger or with a fully catheter, whatever, just close the hole and if you can repair it good. If not, the cardiac surgeon should be called immediately. And of course, your consultant should come in immediately uh and repair it. But more important is to put a finger in the hole or a catheter in the hole and let the anesthetist. And I see you guys uh do their job. Uh put, get some blood transfusions in uh e even if you're just standing there with your finger in the heart, the other da uh injuries to heart like mm uh septal damage, valvular damage, damage to coronary artery or aortic dissection. Uh These things are beyond uh general surgery. And usually if the patient has survived the ee they will survive till they go to theater as well. So, prompt uh cardiac surgeon is needed, but they wouldn't need a thoracotomy. Uh ee usually, or even if you do arthrotomy, you cannot do anything after that, you will just open the chest and that's it. Uh So it's not recommended injury to lungs, contusions again, supportive. We all know lacerations. If the laceration is small, it can be managed conservatively with the chest trend. Uh uh but if the laceration is deep and bleeding profusely again, uh thoracotomy and uh you can uh suture directly under vision with the bleeding point. Now, oxygenation here is not important. If the patient is bleeding, then that's more important. In terms of course, airway is important and you are oxygenating. The patient with the D with the other lung, that's definitely important. But I'm talking about the injured lung. If there is bleeding from, uh, from a lacerated lung, then you are not, uh, worried about oxygenation in that lung. You, what we should do is just repair the, uh, bleeding point on that lung. The other lung should be used for oxygenation again, all these things, uh, has very high mortality. Whatever we do is just giving the patient the best chance without that, they are going to die anyways. But uh if, if you can manage uh to serve them, then that's uh a bonus. I would say um these things have very high mortality for anyone injury to vessels. Yes. Uh to aorta, to branches of aorta. Uh most of them will need uh either a vascular surgeon or uh cardiac surgeon or interventional radiologist. Uh very rarely you would be able to do a thor thoracotomy and uh clamp those branches. And even if you clamp those branches, the patient will end up having very high morbidity. So uh it's not really recommended unless the patient has cardiac arrest injury to die from a rupture of death from agus uh spinal cord injuries. Again, these things are uh all to be done in theater. Nothing in Ed and definitely not by general surgeons. Yes, esophageal injuries or diaphragm injuries, maybe the API surgeons will do. But again, these things are not that urgent, which will need uh life saving. Uh interventions needed. Now, going to ab abdomen, this is a very common scenario. You might find a young male fall from height and uh injury to chest left, chest otherwise stable. Um have been given everything that's uh needed like fluids, morphine in assessment, of course, obesity uh intervention. Again, it depends on how well or unwell the patient is. If the patient is stable, you don't need to do anything, you just uh prepare everything or uh make sure blood trans blood products are ready or the is ready those things. But if the patient is unstable, then of course, you need to do something quickly. X ray. Uh again, as indicated like chest pelvis, c spine, secondary survey and CT scan, ct scan. If the patient is stable or even relatively stable, I know the patient won't be stable fully. But even with the BP is 90 by 60 holding he should get a scan. For example, if this is the picture for that patient, you see uh what can we do? What shall we do for this patient? Can you detect the injury? Can anyone write on the chat box if they can see something? Oh, it's already eight o'clock, maybe I'll just uh go quick, go through quickly. So, um I'm sure most of you have uh noticed already the uh splenic injury. Uh it's difficult to grade it by seeing just one slice, but it's probably great for uh looking at it. But you do, you do need the full picture all of the other slices. Now for great for I know the recommendation usually is uh splenectomy. But timing is very important. I just because the patient is great for splenic injury does not mean that they need to go to laparotomy immediately. Uh Timing means you may be able to wait for 12 hours, stabilize the patient as assist other injuries, especially uh power injuries, which do not appear immediately, which takes a while. If the patient is stable, we should wait. Of course, if the patient is unstable, then laparotomy and splenectomy. But if the patient is stable, then just observe even if it's great for spleen splenic injury, um blunt injury to abdomen, it's difficult because the signs and symptoms uh do not appear immediately. For example, if there is a small perforation in bowel or appear in the miry, there might be some tenderness but nothing major, not peritonitic and it's difficult to diagnose those. Uh the peritonitis will only be apparent uh after a few hours or even days. So, um the aim is to uh uh use blood products as much as possible and uh scan them bleeding. Most of the bleedings in abdomen can be managed by interventional radiology. Um but if they're unstable, then of course, it's surgery. There is no other option. Nowadays, damage control laparotomy is very useful and studies have shown that mortality and morbidity is much lower with damage control laparotomy, which means you go in the abdomen, you just deal with the problem, you just deal with the bleeding and come out as soon as possible. Send them to ICU give them blood, give them no ad fluids and stabilize them. Uh come back in 24 hours or so. For example, a liver, liver injury, you just put 10 packs in the abdomen and that's it. You may close the abdomen or you may just use uh keep the abdomen open and you just come out as soon as possible. No need to do anything. Uh Anything else like this picture? Liver is in two pieces and there is blood everywhere. So you just go in s uh get the uh see see the liver and put packs in there, put packs in the uh left upper quadrant, more packs in pelvis and that's it clamping of AOTA in abdomen is also as I mentioned before, upper midline laparotomy and going on top of the liver is possible. Uh but this is very important uh giving blood products and T Xa. Um So that's something to keep in mind. Now, I was going to show this picture and ask what can we do about this? What to do? Uh We don't have mics. So I'll just say uh don't take this out again. What we do about this is guided by the patient. If the patient is stable, don't do anything. Uh get the patient to scan, see what has happened and what the injuries might be and then take them to theater, get cardiac surgeons if it's somewhere here and get your consultant, vascular surgeons. And when the environment is appropriate, like in theater, everyone is present only then someone will take it out slowly and see what happens. Often, nothing will happen. And often the patient will just survive, won't need it. If the patient is unstable, then yeah, it's a difficult difficult call. You may have to do something in the e itself knife in the abdomen. Again, it can be anywhere, it can be injuring anything or maybe nothing. So again, if the patient is stable, don't do anything, the patient will probably need a laparotomy because uh uh if there is breach in the sheath, you need to close this anyways. So if the patient is stable, scan them, get them to theater. If unstable, then he either in or in the quickly without a scan. Um mesenteric tears and blunt traumatic bowel is very uh difficult to diagnose initially. Even the initial scans will show small amount of bleeding um but cannot specifically identify the uh problem area. So it's very important to keep them under observation, especially in HD or ICU. And they will, if they become apparent, then have very low threshold for interval scan. Uh Second scan will show if there is a perforation or bleeding collection, et cetera. Again, mechanism of injury is very important like seatbelt or not wearing seatbelt, bleeding in trauma. We probably have seen this triangle several times. Uh blood loss leads to uh metabolic acidosis leads to coagulopathy. Uh again, this leads to hypothermia and it's a vicious cycle and the patient dies quickly. So our job is to cut one of those or stop blood uh blood loss. Uh the saying goes eye for an eye. So is blood for blood and this is one of the most important thing that can save a person as uh as a part of intervention is stopping, the source is very vital as well. But blood transfusion can save a person. Studies have shown that T Xa or early TX A in trauma, bleeding is very important and it can significantly reduce mortality. So if they haven't got T Xa in uh in the community uh uh at the site or by paramedics, uh make sure they get T Xa injection and of course surgery or interventional radiology. Uh Another scenario just uh to show about uh talk about bleeding briefly. Uh so young patient, young male uh intoxicated and had a quick uh sorry, an accident and uh relatively quick extrication. Um and the injuries identified femur fracture, chest trauma, relatively stable vitals and they have done everything that the paramedics should do. You have done ABCD and uh no external bleeding but the patient remains hypertensive and tachycardic. Uh you have done X rays, no pelvis fracture, but for a secondary survey and for the scan showed there are bilateral shaft femur fracture, humerus, fracture, and tibia femur fracture. So much lots of fracture, otherwise abdomen is ok. Spine is ok. So the reason of this hypertension, I was going to ask again, but uh since we are short on time, I'll just uh go through it. Um So even if there is an apparent external bleeding, in this case, the fractures itself can cause a lot of bleeding. And we tend to overlook this. Sometimes a femur fracture or Shap femur fracture can lose 1 to 1.5 to 2 liters of blood. Not necessarily does that in every case, but it can do. So, a Pelvis fracture can lose 2 to 2.5 liters of blood. So, if any of this patient did not have any external bleeding, they have lost enough blood from these fractures and they should have blood transfusion. So this hypotension or tachycardia is because of blood loss from the fractures. A refracture can bleed 500 ml up to 500 ml. So if they, if someone has uh five refractures, they can lose quite a lot of blood. Most of most of the cases, they don't uh because they're immobilized very quickly. So, uh blood loss is quite less, but it can happen if they haven't been immolated quickly or not, not immobilized properly, they can lose a lot of blood. And this is the chart of class of bleeding. We have all studied this several times for exams. Uh, I am not going through this because it is a common chart we all use. That's it. Sorry, uh, for a late start and just went very quickly. Um, I was hoping we had a more to have a more interactive session. Uh, but if there is any question you can write on the chat box. Thank you very much, sir. This was quite exhaustive and I really learned a few things and I enjoyed the session. Um Thank you. I have just um one question or other two questions that I feel it would be important for, you know, junior doctors. One of them is some of sometimes um blunt abdominal trauma can come in and in the initial stage, um, the patient may just be in pain and the, the the major clinical symptoms or signs that we are looking for may not be there at that time despite the fact that the patient may have sustained like really severe abdominal trauma or blunt abdo internal organ um damage. So what are the things that we should look for? We should look out for as dangerous signs when we see a patient with, um, that may have been involved in a crash or something that we suspect that this patient may have like internal injury. What are those signs that we should, we should look out for that one. The second question is for patient that has suffered multiple injury and multiple injuries in, in the thorax and the abdomen, which is more important in your experience and which should, which should we focus on initially before the other. So for the first one here, it's difficult, especially blunt trauma to abdomen. Uh they can have such a wide range of injury. Sometimes it's just uh pain and in the subcutaneous or bleeding in the subcutaneous fat hematoma. But sometimes it can be, you know, mesenteric tears as well. It's difficult to diagnose. It's easy when they have very clear picture of peritonitis or clear evidence on the CT scan to deal with because there is just one thing you can do is laparotomy. But if the picture is vague and not very clear, uh what we should do is of course, get an early scan but keep the patient for at least 48 hours under observation. If there is any slight uh deterioration in hemodynamics like tachycardia or drop in hemoglobin, then just rescan another CT scan with angio will show more uh features that wasn't visible on the first scan. Uh So it's very interesting but trauma is mostly guided by the patient how the patient is uh if they're unstable, then you have to do a laparotomy. If the patient is stable, then observe. But they, they have a very low suspicion that there are other injuries like small perforation or mesenteric tears. But again, it's not very easy to diagnose and you have to rely on uh interval scans for it for the second one injury to abdomen and thorax. Now both can be very significant. Uh So if the thoracic injury uh or if I if the abdomen, if you think like if there is uh exsanguinating bleeding from the abdomen, you can control it from thorax itself by clamping the abdominal aorta or even the upper abdominal uh aorta. So uh ii sometimes it's more important to focus on thorax. But again, if the thoracic injuries are not very significant and there are more significant injuries in the abdomen, then of course, you have to focus on abdomen uh in e or as the initial uh uh resuscitative um intervention, maybe thoracotomy is more common and more important to do to save a patient laparotomy in E is not unheard of. I have seen laparotomy in E to control uh or put packs in pelvis. Uh But again, it's not very common. It may not save the patient. So one instance I have seen the patient was young and had cardiac arrest. In uh after trauma, there wasn't any feature of cardiac tamponade or hemothorax or pneumothorax. So there was no indication for a thoracotomy. Uh So the patient had a laparotomy in E and Pax put in Pelvis, we couldn't see any specific bleeding point but just back and close, you need it. There is a question in the chat box. Sorry. A yeah. Yeah. There are, there are some questions in the chat box. Thank you very much. An and II got that. Ok. There is a that is asking that in patients with multiple rib fractures and consequent uh consequence to that patient patients are sustained rib fractures due to um CPR how does surgical stabilization of rib rib fractures compare with non operative treatment? Noting that traumatic implica, noting the traumatic implications of a longer intensive care unit admission postoperatively after further chest wall injury and outpatient followups thereafter. Do you understand the question? Yeah. Uh ref fixation. Uh Yes, refixation again, it depends on uh how severe or how many ribs are involved and what's the patient's background? Uh If someone has, you know, a poor lung function reserve, it might be difficult anyways. Uh But it I ii in a young patient with flail segment, if you do refixation, you will see very quick outcome. But if, if someone is elderly on blood thinners or has COPD, it hardly makes any difference. And the supportive care in ICU is more important. Refixation is done. But it's not very common. For example, if it's only single point fracture in three or four areas, it, it should, it won't make much difference in terms of recovery or uh outcome. So no point in doing reflux in those cases. Ok. OK. So, but it's, so what, what you are saying in some is that not all cases require surgical intervention, some can really be managed conservatively. Most of them will be managed conservatively. It's very rare that, that someone will need refixation. Uh rather if you can control pain by doing blocks, uh that will be more useful for recovery rather than refixation. Ok. Granted someone else is asking um sorry, just a few more minutes and we'll be done. Um Someone else is asking um what is the outcome of resuscitative occur to me? Yes. Uh um outcome mainly is the patient will die or the majority of cases, the patient will die. And in reality, the patient is already dead because they have had cardiac arrest due to trauma. Uh The percentage is about 30 per uh 15, 15 to 20% of survival rate after a penetrating injury after thoracotomy. And if it's a blunt trauma injury, even if you do a thoracotomy, the survival rate is about 3% 3 to 5%. So, and that too, it's on, it's only in young feet and well patient. So it's a huge stress to the body and hardly uh or most of the patients will not do very well. Some of them even after surviving will have a very morbid life like uh hypoxic injury to brain or injury to liver and kidneys. Uh So they will have a lot of uh morbidity. So, and if you are talking about the intervention, what's the outcome? So for example, I'll uh I'll say someone had a knife in uh their heart and uh bleeding from heart. So you do arthrotomy, you put a finger or catheter in the hole and you control that bleeding or stop that bleeding from heart. And by miracle, yy, you are able to massage the heart and pump it. Uh uh the heart is start uh pumping. Now, um the ICU guys, they have transfused blood and stabilized enough. So once you have done those, the next job is of course to close the heart. Now, if you are able to close the heart, close the hole fine, you can do it or you just keep the catheter in and take the patient to cater like that and the cardiac surgeons will do it in uh in theater. So if it's something that is reversible, like a cardiac tamponade or a hole in heart that you have repaired or managed to control, the patient will still go to theater and do get the definitive management by specialized surgeons or consultant. Ok. Thank you very much, sir. And then um I usually ask this question whenever I'm, I'm, I'm hosting events. Um And what would you advise someone, especially surgeons who have already like started um their training in other countries who are planning to come into the UK? What would you advise them regarding a carrier in trauma surgery? For instance? That's one. And then secondly, are there like new, are there interesting new discoveries or new things for people who are chasing the carrier in trauma surgery? And how would you advise that they go about preparing themselves in terms of portfolios, in terms of experiences and things that would make them more desirable for those posts. I think uh trauma surgery is again, uh with the same, same pathway or training pathway with general surgery. So you start as general surgery and then ST 345 is general surgery from ST six. You can choose to be a trauma surgeon uh in, in portfolio, you don't need anything special. No, it's just the same portfolio for general surgery. And also it doesn't matter if you are coming from a different country, I'm coming from a different country. Uh Not that I want to be a trauma surgeon. Yeah, I like quite like trauma because you see such a wide range of variety and uh you know, it's, it's uh decision making is very important as well in trauma. Uh and uh you see quick result as well. So, yes, of course. Uh uh uh everyone is encouraged to become a trauma surgeon but you don't need anything in special uh in your portfolio to do that. You just go into general surgery training and then when you're ST six, speak to your T PD and ask for trauma surgery replacement. That's it. There are tick boxes for trauma surgery, things that you should do again. That's after ST six basically. Uh So just do those surgeries, just do those procedures, get your numbers and that's it. And research wise, yes, of course, there are studies uh as I said, T Xa, this isn't an old study, this was done probably in the last decade. Uh that early T Xa um improves outcome or saves patient. So there are researches on uh blood products as well or crystalloids what can be done or even surgical procedures. Uh There is such a syndrome, of course. So yes, if someone is interested, they can still do research being a trauma surgeon like y yeah. Uh uh for example, uh uh damage control laparotomy. This is something quite recent and studies have shown that damage control laparotomy is beneficial. So yes, there are researches. Ok, thank you very much. Um It's important to note that um trauma surgery is a very like it's, it's a rewarding field, but it's also very complex and it involves even the ed, you know, people who are interested in the car and ed as well as people who are general surgeons and all of that. And, you know, you never know, you never know as a surgeon where you're going to be faced with um a complex trauma case and it's important to know what to do, especially in the initial time to, you know, keep this patient alive until they have their definitive surgery. And thank you very much for being able to, you know, open our eyes to a lot of things and you know, show us things with examples as well. I have learned quite much and I'm sure people here have learned a lot. Um I'm going to, I'm going to type in Santon's email address in the chat box just in case you have any other, any further questions, you can easily send them to him and he can answer you as in his own time um as for the feedback. Um I'm apologies that we take a lot of time. We would send the feedback to you via your private emails and you can just do the feedback. So it is important that we do this feedback. So the uh presenters can be encouraged and they can know if how much they have, how much their teachings have affected your, where they need to, you know, work on. So, feedback is important. Thank you very much. Everybody who has taken our time and really apologies once again for the um delay in starting at the time when we needed to start. Um Thank you. Thank you. Thanks. Thank you. Thanks everyone for joining. Can I just add one little thing? Which is if, if, if everyone could open a use their mic and you know, make it more interactive, that will be very helpful. Uh Because the way I planned the session was much more interactive. Uh uh You can see how the slide show was prepared. So yeah, that's something for, as a feedback from me. All right. But otherwise, uh yeah, thanks. Thanks for your decision. Thank you. All right. Thank you everyone. Um, I'm going to just put the email in the chart now so we can do that just quickly. Oh, yeah. Should be for you. Ok. Yeah, I think I've gotten it. You got the email there. You can send your questions. Thank you very much. Everyone who has taken out time. Thank you. Have a nice day. Have a nice evening. Have a nice weekend. Hi, everybody.