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the abdominal trauma and solid organ injury
- 1. Abdominal trauma andsolid organ injury Presented by Dr Spandana, PGY2, S5 unit Under the guidance of Dr Mythili Devi , MS, Professor Dr Kiran Kumar, MS, Asst Professor Dr Siva Ram Prasad, MS, Asst Professor
- 2. Contents • Introduction • Mechanismsof injury • Initial assessment • Diagnostic techniques • Damage control resuscitation • Solid organ injuries- liver, spleen, pancreas, kidney • Bowel injuries • Extrahepatic biliary system injuries • Perineal and genitourinary system injuries • Retroperitoneal trauma • Abdominal great vessel injuries • Case scenarios • Conclusion
- 3. Introduction • Abdominal traumarefers to any injury to the abdomen resulting from external force, leading to potential damage of internal organs, blood vessels, or the peritoneal cavity. • It is a significant cause of morbidity and mortality worldwide. Epidemiology • Abdominal injuries account for approximately 7.2 per 100,000 individuals annually. • more in young adults, higher incidence in males. • Mortality Rates: between 10% and 30%, depending on the severity and timeliness of intervention.
- 4. Incidence and Mortalityin India • Abdominal trauma accounts for 17.75% of all trauma cases • Mortality Rate for blunt abdominal trauma is 11% to 17% • The most affected age group is between 20 and 40 years • Road Traffic Accidents (RTAs): The leading cause- 72.3%.
- 5. Mechanisms of injury 1.Blunt Trauma • Causes: • Motor Vehicle Collisions (MVCs) • Falls • Assaults • Sports Injuries Pathophysiology: • Direct impact or deceleration forces causing compression or shear injuries to abdominal organs. • Commonly affects the spleen, liver, and intestines. 2. Penetrating Trauma • Causes: • Stab Wounds • Gunshot Wounds Pathophysiology: • Foreign objects penetrate the abdominal wall, leading to direct injury of internal structures. • Often involves the small bowel, colon, and major blood vessels.
- 6. • In abdominaltrauma, “time is life”. • Rapid, structured assessment and prompt management significantly reduce mortality, morbidity, and complications, especially in patients with major solid organ injury or hemodynamic instability. Initial assessment and resuscitation
- 7. Importance of timelyassessment and management • Prevents hemorrhagic shock and multi-organ failure • Early detection of life-threatening injuries (FAST/eFAST, CT) • Damage Control Surgery in unstable patients • Interrupts the lethal triad • Enables non-operative management for stable injuries • Guides trauma team priorities & resource allocation • Reduces mortality and post-operative complications
- 8. • Primary Survey(ABCDE Approach) • Rapid identification and management of life-threatening conditions. • Time-sensitive, performed within minutes of patient arrival. • Life-threatening problems are treated immediately as discovered. • Repeat frequently during resuscitation.
- 9. Step Assessment Intervention A– Airway with cervical spine protection Check patency, signs of obstruction Clear airway, suction, airway adjunct, intubation if needed B – Breathing Observe chest movement, auscultate lungs, assess oxygenation Oxygen supplementation, ventilation support, chest tube insertion if indicated C – Circulation with hemorrhage control Check pulse, skin color, capillary refill Control external bleeding, IV access, fluids, transfusion, TXA Pelvic binder D – Disability (Neurologic status) GCS, pupil reaction Protect spine, treat hypoglycemia, seizure control if needed E – Exposure & Environment Fully expose patient, prevent hypothermia Warm blankets, remove clothing, prevent heat loss
- 10. • Secondary Survey-Complete head-to-toe assessment after stabilization. Full History AMPLE • A: Allergies • M: Medications • P: Past medical history • L: Last meal • E: Events/environment related to injury
- 11. Head-to-Toe Physical Exam: •Inspect and palpate for contusions, tenderness, deformities, penetrating injuries • Examine extremities, back, perineum • Secondary survey is done after life-threatening conditions are addressed. • Allows detection of occult injuries that may be missed in primary survey.
- 12. The presence ofother distracting injuries, can lead to missed abdominal injuries. We need to remember trauma doesn’t respect boundaries.
- 13. Diagnostic techniques Modality UseKey Points / Advantages Focused Assessment with Sonography in Trauma (FAST / eFAST) Detects free fluid Rapid, bedside, repeatable X-ray (Chest / Pelvis / Abdomen) Detect fractures, free air, diaphragmatic injury Quick, limited for solid organ injury Computed Tomography (CT) Scan Detailed assessment of solid organ injury, active bleeding, retroperitoneal injuries CECT- Gold standard in hemodynamically stable patients Diagnostic Peritoneal Lavage (DPL) Detects intra-abdominal bleeding when FAST is unavailable or equivocal Invasive, less commonly used now
- 15. • Diagnostic peritoneallavage (DPL) can be sensitive in detecting abdominal injury even when CT scans are negative, though it doesn't pinpoint the exact organ. There is no hierarchy in advising investigations in trauma.
- 16. Abdominal Trauma ↓ Rapid Assessment ↓ FAST/ CT Imaging ↙ ↘ Stable/ Unstable/ Low grade injury High grade injuries ↓ ↓ Non-Operative Damage Control Surgery Management ICU Resuscitation Definitive Surgery Reduced Mortality & Morbidity
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- 19. Blade depth: Donot underestimate the depth of penetration; a small blade can cause extensive internal injury due to tissue elasticity.
- 20. Stable patient witha stab injury over epigastric region having rt sided pneumothorax with trajectory of gas shadow. Note: check for tenderness away from stab site even if injury is localised
- 21. Damage control resuscitation •Damage Control Resuscitation (DCR) is a coordinated trauma care strategy aimed at rapidly controlling bleeding, preventing the “lethal triad” (acidosis, coagulopathy, hypothermia), and stabilizing physiology before definitive surgery. • It integrates: • Damage Control Surgery (DCS) • Balanced Transfusion (MTP) • Permissive Hypotension • Prevention/management of lethal traid
- 22. Damage Control Resuscitationvs. Conventional Resuscitation Aspect Conventional Approach Damage Control Resuscitation Fluid strategy Large crystalloids → hemodilution Restricted fluids, early blood products BP target Normalize BP early Permissive hypotension Transfusion PRBC first, FFP later Balanced early ratio 1:1:1 Surgery timing Definitive surgery initially DCS first, definitive surgery later
- 23. Scoop and Runvs Stay and Play • Scoop and Run: Rapid transport of the patient to a trauma center • Stay and Play: Perform extended on-scene stabilization • Choice depends on injury type, patient condition, and prehospital resources. • Penetrating torso injuries → usually Scoop and Run. • Severe blunt trauma with airway compromise → Stay and Play may be warranted.
- 24. Permissive hypotension • Intentionallymaintaining lower-than-normal blood pressure (SBP ~80–90 mmHg) in bleeding trauma patients until hemorrhage control. • Indications: • Adult trauma with uncontrolled hemorrhage • Preoperative phase before surgical control • Hemodynamically unstable (excluding head/spinal injuries)
- 25. Benefits: • Reduces ongoingblood loss • Minimizes coagulopathy and hemodilution • Supports damage control surgery Risks / Contraindications: • Traumatic brain injury or spinal injury • Cardiogenic shock • Prolonged hypotension → organ hypoperfusion, AKI, lactic acidosis
- 26. Lethal traid • Acombination of Hypothermia, Acidosis, and Coagulopathy that worsens outcomes in trauma patients, especially with massive hemorrhage. • The cycle of the lethal triad is critical to reduce mortality in severe trauma. • Components Hypothermia: Core temperature <35°C Acidosis: pH <7.2 Coagulopathy: Impaired clot formation
- 27. • Management Strategies •Early Recognition: Continuous monitoring of temperature, pH, and coagulation • Prevent Hypothermia • Correct Acidosis • Correct Coagulopathy • Damage Control surgery
- 28. Damage control surgery •Staged surgical approach for critically injured trauma patients to rapidly control hemorrhage and contamination • DCS prioritizes physiologic stabilization over definitive repair in unstable trauma patients. • Extensive DCS can increase morbidity, hence decision making should be objective based on scores determining severity of injury.
- 29. • Indications • Hemodynamicallyunstable patients with major abdominal trauma • Severe hemorrhage with ongoing blood loss • Hypothermia, acidosis, coagulopathy (lethal triad) • Multiple organ injuries requiring abbreviated surgery
- 30. • Steps Rapid HemorrhageControl: • Packing, ligation, temporary vascular control Control Contamination: • Stapling bowel injuries, preventing spillage Temporary Abdominal Closure: • VAC dressing, Bogota bag ICU Resuscitation: • Correct hypothermia, coagulopathy, acidosis Definitive Surgery: • Repair organs, remove packs, close abdomen
- 31. Temporary abdominal closureusing Bogota bag
- 32. • MTP isa structured, rapid delivery of blood products to patients with life-threatening hemorrhage. • Early and structured MTP reduces mortality, coagulopathy, and complications in massive bleeding trauma patients. Massive transfusion protocol
- 33. • Components Balanced BloodProduct Ratios: RBC : FFP : Platelets ≈ 1:1:1 • Tranexamic Acid (TXA): Early administration to reduce fibrinolysis • Calcium replacement • Monitoring & Laboratory Guidance
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- 35. Liver injury • Liveris the second most commonly injured solid organ in blunt abdominal trauma (after spleen). • Mechanism: blunt trauma (RTA, falls), penetrating trauma (stabs, gunshot). • Surgery is reserved for unstable patients, high-grade injuries, or those with ongoing hemorrhage. • Early recognition, hemodynamic monitoring, and multidisciplinary approach are crucial for optimal outcomes.
- 37. Management • Non-Operative Management(NOM) Indications: • Hemodynamically stable • No other indications for laparotomy Monitoring: • ICU admission • Serial hemoglobin, vitals, abdominal exams • Repeat FAST/CT if condition change • Angioembolization for active arterial bleeding • Blood transfusions as needed
- 38. • Operative Management •Indications: • Hemodynamic instability • Expanding hemoperitoneum • Peritonitis • High-grade (IV–VI) injuries with ongoing bleeding • Hemorrhage Control Principles • Direct pressure on bleeding sites • Vascular control: Pringle maneuver • Temporary packing for diffuse parenchymal bleeding • Angioembolization as adjunct for arterial bleeding
- 39. • Surgical Techniques: •Pringle Maneuver: Temporary occlusion of portal triad • Perihepatic Packing • Hepatorrhaphy • Resectional Debridement: Partial hepatectomy if major lobe disruption • Topical Hemostatic Agents: Fibrin sealants, oxidized cellulose • Damage Control Surgery: • In unstable patients: rapid hemorrhage control → temporary abdominal closure → ICU resuscitation → definitive repair
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- 42. Splenic injury • Spleenis the most commonly injured organ in blunt abdominal trauma. • Mechanism: Blunt trauma (RTA, falls), less commonly penetrating trauma. • Consequences: Hemorrhage, hypovolemic shock, post-splenectomy infections. • Surgery is reserved for unstable patients or high-grade injuries. • Vaccination and OPSI prevention are critical in post-splenectomy care.
- 44. Management • Non-Operative Management(NOM) • Indicated in: Hemodynamically stable patients without peritonitis • Monitoring: ICU, serial vitals and hemoglobin, repeat imaging (CT or ultrasound) • Adjuncts: Splenic artery embolization for active bleeding • Advantages: Preserves splenic function, reduces surgical morbidity
- 45. • Operative Management •Indicated in: Hemodynamically unstable patients, high-grade injury, or failed non operative management • Procedures: • Splenorrhaphy • Partial splenectomy (if feasible) • Total splenectomy (for shattered spleen or uncontrolled hemorrhage) • Damage Control Surgery: Rapid hemorrhage control in unstable patients
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- 47. • Post-Operative Care •Vaccination: Pneumococcus, Haemophilus influenzae type B, Meningococcus (pre- or post-splenectomy) • Monitor: Bleeding, infection, hemodynamic stability • Early mobilization and physiotherapy
- 48. • Operative Complications/ OPSI (Overwhelming Post-Splenectomy Infection) • Severe sepsis caused by encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis) • Risk: Highest in children and within 2 years post-splenectomy • Prevention: Vaccination, prophylactic antibiotics in high-risk patients, patient education
- 49. Pancreatic injury • Pancreasis rarely injured due to its retroperitoneal location. • Mechanism: Blunt trauma (e.g., steering wheel injury, falls) or penetrating trauma. • Complications: Pancreatic fistula, abscess, pseudocyst, hemorrhage, endocrine/exocrine insufficiency. • Minor pancreatic injuries without duct involvement can be managed non-operatively. • Ductal injuries require surgical intervention.
- 51. Management • Non-Operative Management(NOM) • Indicated in: Hemodynamically stable patients, minor injuries (Grade I–II) • Monitoring: ICU, serial labs (amylase/lipase), imaging if needed • Supportive care: NPO, IV fluids, pain control, antibiotics if necessary
- 52. • Operative Management •Indicated in: Ductal injury (Grade III–V), unstable patient, associated injuries • Surgical Techniques: • Distal pancreatectomy (with or without splenectomy) for distal ductal injury • Pancreaticoduodenectomy for proximal head injury (rare) • External drainage / peripancreatic drains for damage control or minor injuries • Primary repair / oversewing of lacerations if feasible
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- 54. Renal injury • Kidneysare the most commonly injured retroperitoneal organs in blunt abdominal trauma. • Mechanisms: • Blunt trauma: Road traffic accidents, falls, sports injuries • Penetrating trauma: Stab wounds, gunshot injuries • Complications: Hemorrhage, urinoma, infection, loss of renal function
- 56. Management • Non-Operative Management(NOM) • Indicated in: Hemodynamically stable patients with Grades I–III • Monitoring: ICU or high-dependency unit, serial hemoglobin, urine output, vitals • Supportive care: Bed rest, analgesia, antibiotics • Adjuncts: Angioembolization for ongoing arterial bleeding
- 57. • Operative Management •Indicated in: Hemodynamically unstable patients, Grade IV–V injuries, associated injuries • Surgical Techniques: • Renorrhaphy • Partial nephrectomy for segmental damage • Total nephrectomy for shattered kidney or devascularization • Damage Control Surgery: Packing and temporary control if unstable
- 58. Bowel injuries • GastricInjuries • Mechanism: Blunt trauma (direct compression, seatbelt), penetrating trauma (stab, gunshot). • Incidence: Rare in blunt trauma (~1–2%), more common in penetrating injuries. • Diagnosis: CT may show free air, wall thickening, fluid; FAST detects free fluid. • Management: • Operative: Primary repair or partial gastrectomy • Non-operative: only for minor contusions in stable patients. • Complications: Leak, abscess, hemorrhage.
- 59. • Duodenal Injuries •Mechanism: Blunt trauma (handlebar, direct blow), penetrating trauma. • 3–5% of abdominal trauma. • Diagnosis: CT scan with oral/IV contrast; retroperitoneal hematoma may obscure signs. • Management: • Operative: Primary repair, pyloric exclusion, or Roux-en-Y diversion for complex injuries. • Complications: Fistula, abscess, pancreatitis.
- 60. • Small BowelInjuries • Mechanism: Blunt (deceleration, crushing), penetrating trauma. • Incidence: Jejunum and ileum most common. • Diagnosis: CT: free fluid without solid organ injury, bowel wall thickening, mesenteric stranding. • Management: • Operative: Resection with primary anastomosis; repair of small perforations. • Complications: Leak, abscess, obstruction.
- 61. • Colon Injuries •Mechanism: Penetrating more common; blunt trauma may cause contusion or perforation. • Diagnosis: CT with extraluminal air, contrast extravasation; clinical exam. • Management: • Operative: Primary repair if feasible; resection ± colostomy for severe injury or contamination. • Complications: Anastomotic leak, abscess, sepsis.
- 62. • Rectal Injuries •Mechanism: Penetrating trauma, pelvic fractures • Diagnosis: CT, proctoscopy, DRE • Look for extraperitoneal vs intraperitoneal involvement. • Management: • Operative: Distal rectal injuries may require diversion (colostomy), presacral drainage • Proximal injuries: primary repair • Complications: Fistula, pelvic sepsis, stricture.
- 63. Intraoperatively, thorough inspectionof both sides of the bowel and other organs is critical to avoid missing injuries.
- 64. Extra hepatic biliarysystem injuries Mechanism • Penetrating trauma: Stab or gunshot wounds are the most common cause. • Blunt trauma: Rare; often from motor vehicle collisions or crushing injuries. Incidence • Extrahepatic bile duct injuries are uncommon, <1% of abdominal trauma cases. • Most commonly affect common bile duct (CBD) and common hepatic duct (CHD).
- 65. Diagnosis • Clinical signs:Right upper quadrant pain, jaundice, bilious peritoneal fluid, sepsis. • Imaging: • Ultrasound: Free fluid, biliary dilation • CT scan: Fluid collection, duct disruption • MRCP / ERCP: Detects ductal injury and leak • Intraoperative cholangiography: Confirms anatomy and injury
- 66. Management • Operative: • Primaryrepair: Small, isolated ductal injuries with T-tube drainage • Biliary-enteric anastomosis: For complete transection or large defects • Drainage: Essential to control bile leak and peritoneal contamination • Non-operative: small leaks in stable patients - ERCP with stenting
- 67. Perineal injuries • Perinealtrauma can be associated with abdominal trauma • in high-energy mechanisms like RTAs,crush injuries, or penetrating trauma • They can mask severe life threatening internal damage. • Careful examination of abdomen, genitalia is important • Rule out genitourinary, gynaecological, gastrointestinal, vascular injuries/ associated pelvic fracture • Treat accordingly
- 68. Genitourinary system injuries •Ureter Injuries • Mechanism: Penetrating trauma, blunt trauma (rare) • Diagnosis: CT urography or retrograde pyelography • Management: • Primary repair over stent or ureteroureterostomy • Ureteral reimplantation for distal injuries
- 69. • Bladder Injuries •Mechanism: Blunt trauma (pelvic fractures), penetrating injuries, iatrogenic • Diagnosis: Retrograde cystography (CT or plain film) • Types: • Extraperitoneal (most common) – usually managed with catheter drainage for 10-14 days • Intraperitoneal – requires surgical repair
- 70. • Urethral Injuries •Mechanism: Pelvic fractures (posterior urethra), straddle injuries (anterior urethra) • Diagnosis: Retrograde urethrogram (RUG) • Management: • Posterior urethra: Suprapubic catheter, delayed urethroplasty • Anterior urethra: Primary repair or catheterization
- 71. Retro peritoneal trauma •Trauma involving the retroperitoneal space, which contains the pancreas, duodenum, kidneys, ureters, aorta, inferior vena cava, and portions of the colon. Mechanism • Blunt trauma: Motor vehicle collisions, falls, crush injuries. • Penetrating trauma: Stab wounds, gunshot wounds. • Iatrogenic: Post-surgical or endoscopic procedures.
- 72. A stab injuryover chest with retroperitoneal haemotoma
- 73. • Zones ofRetroperitoneum (for trauma management) Zone I – Central: Aorta, IVC, pancreas, duodenum • Usually require exploration if injured Zone II – Lateral: Kidneys, ureters • Stable: Often managed non operatively • Unstable: Surgical exploration Zone III – Pelvic: Iliac vessels, pelvic fractures • Usually managed with pelvic packing, angiography, or embolization
- 75. • Diagnosis • Hemodynamicinstability: FAST may be limited • CT scan with contrast: Gold standard for stable patients. • Lab markers: Hematocrit, renal function, amylase (for pancreas), lactate. • Retroperitoneal trauma can mask significant bleeding. • Early imaging with multidisciplinary approach is required
- 76. • Management Principles •Hemodynamically unstable: Immediate operative exploration or damage control. • Hemodynamically stable: Non-operative management if injury is low-grade, with close monitoring. • Specific organ management: • Pancreas: Distal pancreatectomy or drainage • Kidney: Non operative management or nephron-sparing surgery • Duodenum: Primary repair or pyloric exclusion • Adjuncts: Angiography, embolization for vascular injuries.
- 77. Abdominal great vesselinjuries
- 78. Injuries to majorvessels in the abdomen: • Aorta (thoracoabdominal and abdominal segments) • Inferior vena cava (IVC) • Mesenteric vessels (celiac, superior and inferior mesenteric arteries/veins) • Iliac arteries and veins Mechanism • Blunt trauma: High-energy deceleration, crush injuries, pelvic fractures. • Penetrating trauma: Stab or gunshot wounds.
- 79. • Clinical Presentation •Hemodynamic instability: Hypotension, tachycardia, shock • Abdominal or back pain • Expanding hematoma or visible pulsatile mass in penetrating trauma • Signs of hemorrhage
- 80. Diagnosis • Hemodynamically unstable:minimal imaging • Hemodynamically stable: • Contrast-enhanced CT angiography – gold standard • Ultrasound/Doppler – limited use for IVC or retroperitoneal vessels • FAST scan may detect free fluid but not retroperitoneal bleeding
- 81. • Management Principles Hemodynamicallyunstable: • Immediate surgical exploration, proximal and distal control, damage control surgery • Temporary shunts if definitive repair delayed Hemodynamically stable: • Endovascular repair (stent grafts) for select aortic or iliac injuries • Close monitoring and selective intervention for contained injuries • Adjuncts: Massive transfusion protocol, permissive hypotension, ICU care
- 82. REBOA Resuscitative Endovascular BalloonOcclusion of the Aorta • Temporary aortic occlusion via endovascular balloon for non- compressible torso hemorrhage. • Indications: • Hemodynamically unstable abdominal, pelvic, or junctional bleeding. • Zones: • Zone I: Descending thoracic aorta – abdominal bleeding • Zone III: Infrarenal aorta – pelvic/lower extremity bleeding
- 83. • Advantages: Rapidhemorrhage control, minimally invasive, bridges to surgery • Risks: Distal ischemia, vessel injury, reperfusion shock • Key: Time-sensitive, bridge therapy, trained personnel required
- 85. Case studies • Case1: Blunt Liver Injury • Patient: 25-year-old male, RTA, hypotensive, tender right upper quadrant. Investigations: FAST positive for free fluid; CT: Grade III liver laceration. Management: • Hemodynamically unstable → fluid resuscitation, blood transfusion (MTP) • Damage control surgery: perihepatic packing • ICU monitoring, later definitive hepatorrhaphy • Outcome: Recovery with non operative management principles after stabilization.
- 86. • Case 2:Blunt Splenic Injury • Patient: 30-year-old male, fall from height, hemodynamically stable. Investigations: CT: Grade II splenic laceration, no active bleeding. Management: • Non-operative management (NOM) in ICU • Serial vitals, Hb monitoring, repeat imaging • Splenic artery embolization if bleeding develops • Outcome: Full recovery, spleen preserved.
- 87. • Case 3:Penetrating Abdominal Trauma • Patient: 28-year-old male, stab wound in left abdomen, stable, no peritonitis. Investigations: Local wound exploration → peritoneal violation absent. Management: • Observation under non operative management protocol • Serial abdominal exams, vitals, labs • Emergency OR ready if deterioration occurs • Outcome: Discharged after 48 hours, uneventful recovery.
- 88. • Case 4:Pancreatic Injury • Patient: 40-year-old male, handlebar injury, stable. Investigations: CT: Grade III distal pancreatic transection with ductal involvement. Management: • Distal pancreatectomy with closed drainage • Post-op ICU care, monitor for fistula • Supportive care: NPO, IV fluids, analgesia • Outcome: Discharged after 10 days, no major complications.
- 89. • Case 5:Renal Injury • Patient: 35-year-old male, RTA, hypotensive, left flank pain. • Investigations: CT: Grade IV renal laceration with collecting system involvement. • Management: • Hemodynamic stabilization • Operative: Renorrhaphy and drainage • Post-op ICU care, monitor urine output, labs • Outcome: Preserved renal function, discharged after 7 days.
- 90. • Key Takeaways •Early assessment and triage save lives. • Clinical findings and serial examinations are paramount in preventing unnecessary interventions. • Imaging guides decision-making for non operative vs operative management. • Familiarity with AAST grading, FAST/CT interpretation, MTP, and damage control principles improves outcomes.
- 91. • Multidisciplinary care(trauma surgeon, ICU, interventional radiology) is essential. • Post-op care and rehabilitation in abdominal trauma is crucial, including vaccination (if splenectomy), ICU monitoring, managing complications from injury or surgery, nutritional support and addressing surgical wounds is necessary
- 92. References Textbooks: 1. Bailey &Love’s Short Practice of Surgery, 28th Edition 2. Sabiston Textbook of Surgery, 21st Edition 3. Maingot’s Abdominal Operations, 13th Edition 4. ATLS: Advanced Trauma Life Support, 10th Edition 5. Fischer’s Mastery of Surgery, 8th Edition Guidelines: 6. WSES Guidelines on Blunt and Penetrating Abdominal Trauma, 2020 7. Indian Association of Trauma Surgeons / National Trauma Guidelines, 2021 8. EAST Practice Management Guidelines
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