Eduovisual
Emergency & Toxicology
Penetrating chest and abdominal trauma
— GSWs: high-energy, unpredictable trajectory, cavitation injury, ~80–90% require operative exploration when peritoneal
— Stab wounds: lower energy, often tangential; ~25–33% peritoneal violation, fewer require laparotomy
— Shotgun: behavior depends on range (close-range = high energy, treat like GSW)
— Thoracoabdominal box: nipples (T4) anteriorly / tip of scapula (T7) posteriorly down to costal margins — wounds here can injure diaphragm + abdomen + chest simultaneously
— Cardiac box: sternal notch → nipples → xiphoid — high pretest probability of cardiac injury
— Flank/back: risk of retroperitoneal injury (colon, duodenum, kidney, great vessels)
— Any penetrating wound below the nipple line → assume diaphragm + intra-abdominal injury until proven otherwise
— Hemodynamic instability after penetrating torso trauma → assume cardiac tamponade, tension pneumothorax, or hemorrhagic shock
— Penetrating neck wounds crossing platysma or transmediastinal GSW → vascular/aerodigestive injury workup
Board pearl: Any stab or GSW between nipples and costal margins — even if entry is "chest" — mandates evaluation for occult diaphragmatic and intra-abdominal injury; missed left hemidiaphragm injuries are notorious for late herniation years later.
CCS pearl: Order trauma labs, type & crossmatch (not just type & screen), CXR, and FAST in parallel with airway/breathing assessment — do not sequence them serially.
— GSW: caliber, type (handgun vs rifle vs shotgun), range, number of shots heard vs wounds counted (entry/exit mismatch suggests retained fragment)
— Stab: weapon length, type (knife, ice pick, glass), angle of attack, number of thrusts, attacker handedness
— Time since injury, blood loss at scene, prehospital interventions (tourniquets, needle decompression, IV fluids)
— Chest: dyspnea, pleuritic pain, hemoptysis → pneumothorax, hemothorax, tracheobronchial injury
— Cardiac: muffled tones, JVD, hypotension (Beck's triad) → tamponade
— Abdomen: diffuse pain, peritonitis, evisceration, hematemesis, rectal bleeding
— Back/flank: hematuria → renal/ureteral injury; absent pulses → vascular injury
— Anticoagulant or antiplatelet use (warfarin, DOACs, dual antiplatelet) → reversal planning
— Pregnancy status → fetal monitoring, anti-D if Rh-negative
— Substance intoxication → unreliable exam
— Prior abdominal surgery → adhesions complicate laparotomy/laparoscopy
Key distinction: Number of external wounds ≠ number of internal injuries. A single GSW entry can produce multiple intra-abdominal injuries via tumbling and fragmentation; conversely, two skin wounds may represent a single through-and-through trajectory. Always reconcile entry/exit count with imaging.
Board pearl: In a hemodynamically stable stab wound patient, ask specifically about evisceration, peritoneal signs, and impaled objects — these three findings independently push toward operative management regardless of FAST or CT.
— Airway: secure if GCS ≤8, expanding neck hematoma, or airway burn/blood
— Breathing: inspect chest wall completely (axillae, back, gluteal folds — "logroll and look everywhere"); assess for asymmetric rise, tracheal deviation, subcutaneous emphysema, sucking chest wound
— Circulation: two large-bore IVs, balanced resuscitation, identify external hemorrhage
— Disability: GCS, pupils, gross motor; spinal cord injury possible with thoracic penetration
— Exposure: fully undress, count all wounds, check perineum and back
— Beck's triad (hypotension, JVD, muffled heart sounds) → cardiac tamponade
— Absent breath sounds + hyperresonance + tracheal deviation + hypotension → tension pneumothorax (clinical Dx, decompress immediately, do NOT wait for CXR)
— Sucking chest wound → 3-sided occlusive dressing
— Subcutaneous emphysema + Hamman's crunch → tracheobronchial or esophageal injury
— Abdominal evisceration, peritonitis, hemodynamic instability → straight to OR
— Kehr's sign (referred left shoulder pain) → diaphragmatic irritation/splenic injury
— Class I: <15% loss, normal vitals
— Class II: 15–30%, tachycardia, narrowed pulse pressure
— Class III: 30–40%, hypotension, altered mental status — transfuse blood
— Class IV: >40%, profound shock — massive transfusion protocol (MTP)
Step 3 management: Hemodynamically unstable + penetrating abdominal trauma = OR for exploratory laparotomy — do not delay for CT. Hemodynamically unstable + penetrating chest trauma with positive FAST pericardial view = OR for median sternotomy/thoracotomy.
CCS pearl: Reassess vitals every 5 minutes; deteriorating BP despite 1L crystalloid → activate MTP (1:1:1 PRBC:FFP:platelets) and call surgery.
— CBC, BMP, coags (PT/INR, PTT), fibrinogen, lactate, base deficit, ABG, ethanol, urine tox, β-hCG (women of reproductive age), type and crossmatch for ≥4 units
— Troponin if cardiac box involvement or suspected blunt component
— TEG/ROTEM at trauma centers to guide component therapy
— Upright CXR if stable: pneumothorax, hemothorax, widened mediastinum, foreign body, missile trajectory (mark entry/exit wounds with paperclips/EKG dots before film)
— eFAST (extended FAST): pericardial, perihepatic (Morison), perisplenic, pelvic, bilateral pleural views for PTX/hemothorax
— Pericardial FAST is the single most important test in penetrating cardiac box trauma — if positive and unstable → OR
— FAST for free fluid — sensitive when positive, but negative FAST does NOT exclude hollow viscus injury
— Upright/decubitus film for free air (rarely changes management acutely)
— Lactate >4 or base deficit worse than −6 → occult shock, escalate resuscitation
— Trend every 2–4 h during resuscitation
Board pearl: Positive pericardial FAST in penetrating thoracic trauma is ~100% specific for cardiac injury — patient goes directly to OR for sternotomy/pericardial window. A negative subxiphoid view in a patient with a left hemothorax does NOT rule out cardiac injury because blood may decompress into the pleural space; obtain a formal pericardial window if suspicion remains high.
Key distinction: FAST detects fluid, not injury. A stable patient with negative FAST and abdominal GSW still needs CT or operative exploration depending on trajectory and exam.
— Indication: hemodynamically stable penetrating trauma when operative management isn't mandatory
— Tangential abdominal GSWs, flank/back stab wounds, selective nonoperative management (SNOM) candidates
— Identifies trajectory, peritoneal violation, solid organ injury, retroperitoneal injury, vascular blush, free air, free fluid
— Triple contrast (IV + PO + rectal) traditionally for flank/back wounds; many centers now use IV-only multidetector CT
— Anterior abdominal stab wounds only (NOT GSWs, NOT thoracoabdominal, NOT flank/back)
— If anterior fascia intact → discharge after observation
— If fascia violated → admit for serial exams, CT, or laparoscopy
— Best test for left thoracoabdominal stab wounds to evaluate diaphragm (CT misses up to 30% of diaphragm injuries)
— Largely replaced by FAST/CT but still useful when imaging unavailable; positive = >10 mL gross blood, >100k RBC/μL, bile, food, or bacteria
— CT angiography for suspected vascular or transmediastinal injury
— Esophagram + esophagoscopy or CT esophagography for transmediastinal GSW
— Bronchoscopy for large persistent air leak after chest tube
— Cystogram for suspected bladder injury (gross hematuria + pelvic wound)
Step 3 management: Left thoracoabdominal stab wound, hemodynamically stable, normal CT → still requires diagnostic laparoscopy or thoracoscopy to evaluate the diaphragm. Missed diaphragmatic injuries lead to delayed visceral herniation and strangulation.
Board pearl: Transmediastinal GSW evaluation = CT angio + echo/pericardial window + esophagram/esophagoscopy + bronchoscopy. All four organ systems (heart, great vessels, esophagus, trachea) must be cleared.
— Hemodynamic instability not responsive to resuscitation
— Peritonitis on exam
— Evisceration
— Positive pericardial FAST (cardiac injury)
— (Some add: blood from NG tube, rectum, or GU tract with appropriate trajectory)
— Abdominal GSW with peritoneal violation → traditionally mandatory laparotomy (>90% have injury); SNOM acceptable only at trauma centers for tangential trajectories with reliable exam and serial CT
— Abdominal stab wound, stable, no peritonitis → LWE → if fascial penetration, serial exams ± CT/laparoscopy
— Anterior abdominal stab without fascial violation → discharge after observation
— Small PTX (<2 cm, asymptomatic) → observation, repeat CXR in 4–6 h
— Symptomatic PTX or any hemothorax → tube thoracostomy (28–32 Fr for blood)
— Initial output >1500 mL or ongoing >200 mL/h × 4 h → OR for thoracotomy
— Tension PTX → immediate needle decompression (5th ICS anterior axillary line preferred in adults) followed by chest tube
— Penetrating chest trauma with witnessed loss of vitals or signs of life in ED (or <15 min prehospital CPR)
— Best outcomes: isolated stab to the heart with tamponade
CCS pearl: Sequence in the unstable penetrating abdomen patient: large-bore IVs → activate MTP → FAST → if FAST+ or peritonitis → call surgery, move to OR, do not detour through CT.
Board pearl: Damage-control surgery (abbreviated laparotomy, packing, temporary closure) is indicated for the "lethal triad": acidosis (pH <7.2), hypothermia (<35°C), coagulopathy — definitive repair after ICU resuscitation.
— Limit crystalloid to ≤1 L; permissive hypotension (SBP 80–90) in penetrating trauma without TBI until hemorrhage controlled
— Massive transfusion protocol (MTP): 1:1:1 ratio of PRBC:FFP:platelets; target fibrinogen >150–200 mg/dL with cryoprecipitate
— Tranexamic acid (TXA) 1 g IV over 10 min, then 1 g over 8 h — give within 3 hours of injury if significant hemorrhage (CRASH-2); harmful if given >3 h
— Warfarin → 4-factor PCC + vitamin K 10 mg IV
— Dabigatran → idarucizumab 5 g IV
— Factor Xa inhibitors (apixaban, rivaroxaban) → andexanet alfa or 4F-PCC if unavailable
— Antiplatelets → platelet transfusion controversial; consider in life-threatening bleed
— Hollow viscus injury or pre-op prophylaxis for laparotomy: single dose broad-spectrum (cefoxitin, cefazolin + metronidazole, or piperacillin-tazobactam) within 1 h
— Continue 24 h if hollow viscus injured; longer only if established peritonitis
— Tube thoracostomy: evidence mixed; many centers give 24 h cefazolin for chest tube placed after penetrating injury
— Tdap if not given in last 5 years for dirty wound (or >10 y for clean)
— TIG if uncertain vaccination history and dirty/contaminated
Step 3 management: TXA carries a 3-hour window — beyond that it increases mortality. Document time of injury accurately.
Board pearl: Empiric broad-spectrum antibiotics for penetrating abdominal trauma should cover gram-negatives and anaerobes (colonic flora); duration is 24 hours after source control — extended courses do not reduce SSI and increase resistance.
— Site: 4th–5th ICS, anterior to midaxillary line, "safe triangle"
— Size: 28–32 Fr for hemothorax; smaller pigtail (14 Fr) acceptable for simple PTX
— Connect to underwater seal at −20 cm H₂O
— Adult: 5th ICS anterior axillary line (newer ATLS) — better wall thickness; old teaching of 2nd ICS midclavicular still acceptable
— Always follow with chest tube
— Subxiphoid pericardial window (operative) is definitive
— ED pericardiocentesis only as temporizing bridge to OR
— Left anterolateral 4th–5th ICS incision
— Goals: relieve tamponade, cross-clamp aorta, internal cardiac massage, control intrathoracic hemorrhage
— Survival ~10–15% for penetrating cardiac, <2% for blunt
— Instability, peritonitis, evisceration, transabdominal GSW, positive DPL, free air, gross blood per NGT/rectum
— Adjunct for infradiaphragmatic hemorrhage in selected centers; Zone 1 (above celiac) for abdominal bleed, Zone 3 (infrarenal) for pelvic bleed
— Stop bleeding + contamination → ICU rewarming, correction of acidosis/coagulopathy → return to OR in 24–48 h for definitive repair and abdominal closure
CCS pearl: Order chest tube placement immediately for any hemothorax; if initial drainage >1500 mL OR >200 mL/h × 4 consecutive hours → consult thoracic surgery for thoracotomy.
Board pearl: EDT is futile in penetrating trauma after >15 min of prehospital CPR without signs of life, and in blunt trauma after >10 min CPR or no signs of life on arrival.
— Less common than blunt but higher mortality due to limited physiologic reserve
— Occult shock: beta-blockers blunt tachycardia; "normal" BP may represent relative hypotension in chronically hypertensive patients — use lactate, base deficit, ShI (shock index = HR/SBP >0.9) instead
— Lower threshold for trauma team activation, ICU admission, and early imaging
— Polypharmacy: anticoagulants and antiplatelets common — reverse aggressively
— Chest wall stiffness → higher risk of pulmonary contusion and respiratory failure
— IV contrast risk vs benefit: in unstable trauma, do not withhold contrast — diagnostic benefit outweighs contrast nephropathy risk
— Adjust dosing of LMWH, gabapentin, and renally cleared antibiotics post-injury
— Avoid NSAIDs entirely
— Baseline coagulopathy (high INR doesn't reflect true bleeding risk — TEG/ROTEM better)
— Thrombocytopenia from hypersplenism
— Higher infection risk after laparotomy; ascites complicates wound healing
— Increased mortality after trauma laparotomy (Child-Pugh C ~50%)
— Identify advance directives early; involve palliative care if injury burden exceeds physiologic reserve
— Code status conversation should occur during/after initial resuscitation, not before life-saving interventions
Step 3 management: Elderly trauma patient on apixaban with active hemorrhage → reverse with andexanet alfa (or 4F-PCC if unavailable), transfuse to hemostatic goals, and admit to ICU regardless of "stable" vitals — they decompensate late and fast.
Board pearl: Shock index >1.0 in any age group, but especially elderly with "normal" BP, predicts massive transfusion and mortality better than absolute hypotension. Use it as a trigger to upgrade trauma activation.
— Mother first: best fetal resuscitation = maternal resuscitation
— Left lateral tilt 15° (or manual uterine displacement) after 20 weeks gestation to relieve IVC compression
— Continuous fetal monitoring ≥4 h for viable fetus (≥23–24 weeks); extend to 24 h if contractions, vaginal bleeding, or maternal injury
— Kleihauer-Betke test for fetomaternal hemorrhage; Rh-immune globulin for Rh-negative mothers (50 µg <12 wk, 300 µg ≥12 wk; more if KB positive)
— Perimortem C-section within 4 minutes of maternal arrest if fetus ≥23–24 weeks
— CT is acceptable when indicated — fetal risk from missed diagnosis exceeds radiation risk
— Less common but rising (firearm injuries leading cause of death in US children/adolescents)
— Smaller blood volume: 70–80 mL/kg — small losses cause shock
— Maintain BP longer then crash precipitously
— Weight-based resuscitation: 20 mL/kg crystalloid bolus ×1, then 10–20 mL/kg PRBC
— Use Broselow tape for sizing/dosing
— Non-accidental trauma: report all firearm and stab injuries in children per state law; involve child protective services
— Screen for IPV in women with stab wounds and inconsistent histories
— Mandatory reporting of GSWs to law enforcement in most states
Key distinction: Fetal distress (late decels, bradycardia) may be the earliest sign of maternal hemorrhage — placenta is exquisitely sensitive to maternal hypovolemia and shunts blood away first.
Board pearl: Any pregnant trauma patient ≥20 weeks needs CTG for ≥4 hours minimum; >4 contractions/hour, vaginal bleeding, or nonreassuring tracing extends monitoring to 24 h and triggers OB consult.
— Hemorrhagic shock and exsanguination — leading cause of preventable trauma death
— Cardiac tamponade — penetrating cardiac box
— Tension pneumothorax — clinical diagnosis, not radiographic
— Acute respiratory failure / ARDS — pulmonary contusion, massive transfusion, aspiration
— Air embolism — penetrating lung injury with bronchovenous fistula
— Coagulopathy (trauma-induced coagulopathy, TIC) — drives the lethal triad
— Hypothermia — exposure, transfusion, abdominal cavity open
— Surgical site infection, intra-abdominal abscess — especially after colonic injury
— Anastomotic leak — bowel repair
— Empyema — retained hemothorax >300 mL → VATS evacuation within 3–7 days
— Pancreatic fistula, biliary leak
— Acute kidney injury — shock, rhabdomyolysis, contrast
— Compartment syndrome — abdominal (IAH > 20 mmHg with new organ dysfunction) or extremity
— VTE — high risk; start chemoprophylaxis (enoxaparin 30 mg BID or 40 mg daily) within 24–48 h if hemostasis achieved
— Diaphragmatic hernia — missed left thoracoabdominal injury
— Traumatic AV fistula, pseudoaneurysm — vascular injury
— Adhesions, SBO after laparotomy
— PTSD, depression, substance use — screen at every follow-up
— Chronic pain, opioid dependence
Step 3 management: Retained hemothorax >300 mL on post-tube CT or persistent opacity at 72 hours → VATS evacuation within 3–7 days prevents empyema and trapped lung. Do not "watch" a retained hemothorax with antibiotics alone.
Board pearl: Abdominal compartment syndrome = sustained intra-abdominal pressure >20 mmHg + new organ dysfunction. Treatment is decompressive laparotomy; medical measures (sedation, NMB, drainage of ascites) are temporizing.
— Penetrating injuries to head, neck, torso, or proximal extremities
— GCS ≤13, SBP <90, RR <10 or >29
— Mechanism: GSW to torso, multi-system injury, unstable vitals
— Use ACS Field Triage Criteria and state EMS protocols
— Post-operative laparotomy/thoracotomy with ongoing resuscitation
— Massive transfusion received
— Mechanical ventilation
— Vasopressor requirement
— Lactate >4 or persistent acidosis
— Damage-control laparotomy with open abdomen
— Cardiac, vascular, or transmediastinal injuries even if "stable"
— Trauma/general surgery — all penetrating torso trauma
— Cardiothoracic — cardiac box wounds, transmediastinal GSW, massive hemothorax
— Vascular — pulse deficit, expanding hematoma, ABI <0.9
— Urology — gross hematuria, pelvic/flank wound, GU injury
— Orthopedics — associated long-bone or pelvic injury
— Interventional radiology — pseudoaneurysm, active blush, pelvic bleed
— Hemodynamically stable, normal exam, FAST/CT negative
— Stab wound with intact fascia after LWE, observed 12–24 h
— Isolated small pneumothorax managed with chest tube or pigtail
— Superficial stab wounds, no fascial violation, reliable patient, follow-up arranged
CCS pearl: Order serial abdominal exams q4h × 24 h for selective nonoperative management of stab wounds — document exam findings, vitals, and any change. A change in exam triggers re-imaging or OR.
Board pearl: Tertiary survey within 24 h catches the 15–20% of injuries missed during initial resuscitation — especially extremity, hand, and small bowel injuries. Make it a checklist item before transfer/discharge.
— Cardiac tamponade vs tension pneumothorax — both cause hypotension + JVD; tension PTX has absent breath sounds + hyperresonance + tracheal deviation; tamponade has muffled tones + positive pericardial FAST
— Hemothorax vs hemoperitoneum from transdiaphragmatic injury — both can occur from a single thoracoabdominal wound; FAST and CXR both needed
— Aortic injury vs cardiac injury — transmediastinal GSW threatens both; CT angio differentiates
— Pulmonary contusion vs hemothorax — contusion = parenchymal opacity without layering fluid; hemothorax = layering on upright/decubitus film
— Pedestrian shot while crossing street — also struck by car: evaluate for blunt aortic injury, solid organ injury, pelvic fracture
— Fall from height after stabbing — add spine and pelvis imaging
— Splenic vs left renal injury — both can produce LUQ pain and Kehr's sign; CT distinguishes
— Liver vs right diaphragm/lung — RUQ stab can involve all three
— Duodenal vs pancreatic injury — retroperitoneal, often missed on initial CT; rising amylase/lipase + free retroperitoneal air = clue
— Chest tube malposition causing persistent PTX or "new" lung injury
— Central line complications (PTX, hemothorax) confounding picture
Key distinction: Beck's triad is present in only ~30% of tamponade cases. Don't wait for the full triad — use FAST. Conversely, JVD may be absent in a hypovolemic tamponade patient because preload is so low.
Board pearl: A patient who improves transiently with needle decompression but then deteriorates likely has persistent air leak or hemothorax — proceed to formal chest tube and CXR; do not perform repeated needle decompressions.
— Cardiogenic shock from acute MI — penetrating injury may have been triggered by syncope from MI; obtain ECG and troponin in older patients
— Pulmonary embolism — occurs days after trauma due to immobility/injury; sudden hypoxia and tachycardia
— Sepsis — late presentation from intra-abdominal contamination, empyema, line infection
— Anaphylaxis — to antibiotics, contrast, latex during resuscitation
— Adrenal insufficiency — chronic steroid users, missed during shock
— Toxic ingestions — co-ingestion of cocaine (vasospasm, MI), methamphetamine (hypertensive crisis), opioids (respiratory depression)
— Cervical or high thoracic spinal cord injury from penetrating wound near spine → hypotension WITH bradycardia (vs hemorrhagic = tachycardia)
— Warm extremities, preserved capillary refill
— Treat with fluids + norepinephrine or phenylephrine, not just transfusion
— Sudden cardiovascular collapse after lung injury, especially with positive-pressure ventilation
— Place in left lateral decubitus, Trendelenburg; consider hyperbarics if available
— Aortic dissection rupture into pericardium can coexist or be misattributed in elderly stab patients with chest pain
Key distinction: Hemorrhagic shock = tachycardia + cool extremities + narrow pulse pressure. Neurogenic shock = bradycardia (or normal HR) + warm extremities + wide pulse pressure. Treat each differently — vasopressors are first-line in neurogenic, not hemorrhagic.
Board pearl: In any older trauma patient, obtain ECG: occult MI may have caused the fall/MVC/altercation. Troponin elevation doesn't mean cardiac contusion — interpret in context.
— Analgesia: acetaminophen + short course opioid (3–5 days); avoid NSAIDs until renal function stable and no ongoing bleeding risk
— VTE prophylaxis: enoxaparin 40 mg daily SC × 7–14 days post-discharge for major laparotomy/thoracotomy; longer (4 wk) for prolonged immobility
— Antibiotics: complete prescribed course only if active infection; routine prophylaxis is NOT continued after discharge
— Tetanus: ensure Tdap given in ED documented
— Stool softener with opioid prescription
— Bowel regimen and incentive spirometry instructions
— Firearm injury survivors: counsel on safe storage (locked, unloaded, separate ammunition); offer brief intervention; high recurrence rate (~20% within 5 years of GSW)
— Violence intervention programs — hospital-based referral reduces re-injury
— Substance use screening (SBIRT) — ED is a critical intervention point
— IPV screening and resources — for women presenting with assault injuries
— Screen for PTSD, depression at 2-week and 1-month follow-up (PCL-5, PHQ-9)
— Refer to trauma-informed therapy
— Physical therapy for thoracotomy/laparotomy patients
— Nutritional optimization — high protein, vitamin C, zinc for wound healing
Step 3 management: All firearm-injured patients should receive hospital-based violence intervention referral before discharge — this is an evidence-based, USPSTF-aligned intervention that reduces re-injury and is a high-yield Step 3 health-systems item.
Board pearl: PTSD develops in 20–40% of penetrating trauma survivors. Routine screening at follow-up, with low-threshold referral to mental health, is standard of care and frequently tested.
— Trauma surgery clinic at 2 weeks — wound check, staple/suture removal, drain management
— Primary care at 2–4 weeks — overall recovery, medication reconciliation, mental health screen
— Specialist follow-up as relevant (CT surgery for thoracotomy, urology for GU injury)
— CXR at 4–6 weeks post-thoracotomy/chest tube for residual effusion, pneumothorax, retained hemothorax
— CT abdomen at 6–12 weeks for solid organ injury managed nonoperatively (splenic, hepatic) before clearance for contact activity
— Pseudoaneurysm surveillance with duplex/CTA per vascular surgery
— CBC at 2 weeks if significant transfusion (check for ongoing anemia)
— Liver function tests for hepatic injury
— UA for GU injuries
— No heavy lifting >10 lb × 6 weeks post-laparotomy/thoracotomy to prevent incisional hernia
— No contact sports × 3 months after splenic/hepatic injury (or until imaging clears)
— Gradual return to work timeline — sedentary 2–4 wk, manual 6–12 wk
— Post-splenectomy: pneumococcal (PCV15/20 then PPSV23), meningococcal (MenACWY + MenB), Hib — ideally 14 days post-op
— Annual influenza, lifetime daily penicillin in children
— Pulmonary rehab for thoracotomy; incentive spirometry 10 breaths/hr while awake
— Pelvic floor PT for GU injuries
— Speech/swallow eval for esophageal injury
CCS pearl: Schedule 2-week wound check, 6-week CXR (if chest tube), and primary care visit at 2–4 weeks at the time of discharge — don't leave it to the patient to arrange.
Board pearl: Asplenic patients need lifetime fever vigilance — any temp >101°F warrants ED evaluation and empiric ceftriaxone for risk of overwhelming post-splenectomy infection (OPSI); educate before discharge.
— Emergency exception: life-saving surgery may proceed without consent when patient incapacitated and no surrogate immediately available — document urgency and lack of available surrogate
— Use surrogate decision-maker (spouse, adult child, parent, sibling) in order per state hierarchy
— Minors: emergency treatment doctrine allows life-saving care without parental consent; obtain consent for non-emergent procedures
— GSW and stab wounds: mandatory reporting to law enforcement in most US states
— Child abuse, elder abuse, IPV in mandated-reporter states — penetrating injuries with inconsistent history trigger evaluation
— Suspected human trafficking — penetrating injuries with controlled behavior, identification withheld
— Cut clothing along seams, NOT through wounds; place in paper (not plastic) bags
— Document wounds with size, shape, location, and clock position — do NOT label as "entry" vs "exit" (forensic determination)
— Maintain chain of custody for bullets/fragments removed
— Handoff (sign-out) at shift change is highest-risk moment in trauma care — use structured tool (I-PASS, SBAR), explicitly mention pending labs, imaging, repeat exams, and trajectory of vitals
— Tertiary survey within 24 h to catch missed injuries (occurs in 15–20%)
— Closed-loop communication for blood product orders, OR transport, consult acknowledgment
— Code status discussion appropriate after initial life-saving interventions for patients with severe injury and poor prognosis; involve family and palliative care
— Honor advance directives once documented; in unclear cases, default to full resuscitation
Step 3 management: When a GSW victim refuses to disclose details fearing legal consequences, the physician still must report the injury to law enforcement per state statute, but patient medical information remains protected — explain this transparently to maintain therapeutic alliance.
Board pearl: A handoff that omits a pending CT result is a sentinel-event setup. Trauma re-evaluations and pending studies must be verbally communicated, not just charted.
Board pearl: The classic Step 3 vignette = "stab wound to the left chest, hypotensive, distended neck veins" → answer is pericardial FAST followed by OR pericardial window, NOT pericardiocentesis (temporizing only).
Key distinction: Stable + abdominal stab wound = LWE pathway. Stable + abdominal GSW with peritoneal violation = OR (or SNOM only at trauma centers with serial exams).
— Answer: pericardial FAST → if + → OR sternotomy/pericardial window
— Distractor: pericardiocentesis (only as bridge), CT chest (delays definitive care)
— Answer: immediate exploratory laparotomy, activate MTP, give TXA if <3 h
— Distractor: CT abdomen (delays OR), additional fluids alone, FAST (already have clinical indication)
— Answer: diagnostic laparoscopy (or thoracoscopy) to evaluate diaphragm
— Distractor: discharge, repeat CT in 24 h, observation only
— Answer: immediate needle decompression (5th ICS anterior axillary line) → chest tube
— Distractor: CXR first, intubation first
— Answer: OR thoracotomy
— Distractor: continue observation, second chest tube
— Answer: maternal trauma workup + continuous fetal monitoring ≥4 h + KB test + Rh-immune globulin if Rh-
— Answer: OR for neck exploration
— Soft signs only → CTA neck
— Answer: observe and discharge if exam stable × 12–24 h
— Answer: andexanet alfa (or 4F-PCC) + MTP + TXA + OR
— Answer: ED resuscitative thoracotomy
Step 3 management: When the stem includes specific timing ("3 hours ago," "5 hours ago"), check TXA window (3 h) and fetal monitoring duration (4 h) — these are favorite testable cutoffs.
Board pearl: Watch for the anchoring trap: a patient with an obvious chest stab wound may also have a missed abdominal injury below the nipple line. The "next best step" is often re-examination + abdominal imaging, not focusing on the obvious wound.
Penetrating chest and abdominal trauma management hinges on rapid hemodynamic assessment, FAST-driven decision-making, and a low threshold for operative exploration — with mandatory OR for instability, peritonitis, evisceration, or positive pericardial FAST, and selective nonoperative management reserved for stable patients with normal exam and imaging.
— Unstable + penetrating torso = OR, not CT. Hemodynamic instability with positive FAST (peritoneal fluid or pericardial effusion) bypasses imaging in favor of immediate laparotomy or sternotomy/thoracotomy.
— Anatomy drives workup. Cardiac box → pericardial FAST + window; thoracoabdominal box → evaluate diaphragm with laparoscopy; flank/back → CT (consider triple contrast); anterior abdominal stab → LWE pathway.
— Resuscitation is hemostatic, not crystalloid-heavy. Limit crystalloid, transfuse 1:1:1, give TXA within 3 hours, reverse anticoagulants, treat the lethal triad (acidosis, hypothermia, coagulopathy) with damage-control surgery.
— Don't forget the system-level work. Mandatory GSW/stab reporting, evidence preservation, tertiary survey within 24 h, violence intervention referral, PTSD screening at follow-up, post-splenectomy vaccines, and structured handoffs at every shift change.
Board pearl: When uncertain on Step 3, ask three questions in order: (1) Is the patient hemodynamically stable? (2) Are there peritonitis, evisceration, or hard signs? (3) Does the trajectory cross the diaphragm? The answers reliably route you to OR, CT, laparoscopy, or observation — and align with USMLE-favored decision points.
Step 3 management: Memorize the 1500/200×4 chest tube threshold, the 3-hour TXA window, the 4-hour fetal monitoring minimum, and the 4-minute perimortem C-section rule — these numeric cutoffs appear repeatedly in vignettes and unlock the correct next-best-step answer.