Penetrating Trauma: A Practical Guide on Operative Technique and Peri-Operative Management [3 ed.] 3031470052, 9783031470059

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Penetrating Trauma: A Practical Guide on Operative Technique and Peri-Operative Management [3rd ed. 2023] 3031470052, 9783031470059

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Penetrating Trauma: A Practical Guide on Operative Technique and Peri-Operative Management [3 ed.]
3031470052, 9783031470059

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Elias Degiannis (editor)
Dietrich Doll (editor)
George C. Velmahos (editor)

Table of contents :
Preface
Contents
About the Editors
Part I: Prehospital Care, Diagnostic Tools and Resuscitation Strategies
1: Prehospital Care of Penetrating Trauma
1.1 Planning a Systematic Approach
1.1.1 Scene Safety and Adequate Resources
1.1.2 Dispatching Appropriate Resources
1.1.3 ALS vs. BLS Care and Prehospital Time
1.1.4 Selecting Appropriate Transport Destination
1.2 Treatment: Airway
1.2.1 Endotracheal Intubation
1.3 Treatment: Breathing
1.3.1 Oxygenation
1.3.2 Ventilation
1.3.3 Tension Pneumothorax Management
1.4 Treatment: Circulation
1.4.1 IV Volume Resuscitation
1.4.2 Hypotensive Resuscitation
1.4.3 IV Access Options
1.4.4 Alternative IV Solutions
1.4.5 Prehospital Blood Transfusion
1.5 Treatment: Hemorrhage Control
1.5.1 Hemostatic Agents
1.5.2 Tourniquets
1.6 Summary
Suggested Reading
2: Airway Management in Penetrating Trauma
2.1 Airway Assessment and Initial Management
2.2 Deciding Who Needs a Definitive Airway
2.2.1 Failure to Maintain or Protect the Airway
2.2.2 Failed Ventilation or Oxygenation
2.2.3 Airway Control in Anticipation of Predicted Clinical Course or Planned Intervention
2.2.3.1 Predicted Airway Compromise
2.2.3.2 Predicted Course of Intervention
2.3 Approaches to Establishing a Definitive Airway
2.3.1 Direct Laryngoscopy (DL)
2.3.2 Video-Assisted Laryngoscopy (VAL)
2.3.3 Flexible Scope Intubation (FSI)
2.3.4 Cricothyrotomy
2.3.5 Direct Intubation Through Neck Wound
2.3.6 Blind Nasal Intubation
2.3.7 Tracheotomy
2.4 Rapid Sequence Induction and Intubation
2.4.1 Predicting the Difficult Airway
2.4.2 Preparing for Intubation
2.4.3 Intubation Adjuncts
2.4.4 Rescue Ventilation
2.5 Orotracheal Intubation Technique
2.5.1 Bag Mask Ventilation
2.5.2 Direct Laryngoscope Intubation Technique
2.6 Invasive or Surgical Airways
2.6.1 Equipment
2.6.2 Landmarks
2.6.3 Preparation
2.6.4 Incision
2.6.5 Identification and Incision of the Cricothyroid Membrane
2.6.6 Place the Endotracheal Tube
2.7 Specific Clinical Considerations
2.7.1 Penetrating Neck Trauma
2.7.2 COVID-19 Precautions
Suggested Reading
3: Damage Control Resuscitation in Penetrating Trauma: Rules of the Game
3.1 Introduction
3.2 History
3.3 Rule #1: Damage Control in Prehospital Care Is a Fast-Moving Field
3.4 Rule #2: Minimize or Eliminate Crystalloid in the Pre- and in-Hospital Resuscitation Phases
3.5 Rule #3: Avoid Over-Resuscitation
3.6 Rule #4: Give Blood to Treat Lost Blood
3.6.1 Whole Blood
3.7 Rule #5: Use Laboratory Tests as Adjuncts to Guide Resuscitation
3.8 Rule #6: Avoid Unnecessary Procedures Preoperatively
3.9 Rule #7: Surgical Goals Are to (1) Arrest Hemorrhage and (2) Control Contamination
3.9.1 Temporary Abdominal Closure
3.9.2 Temporary Chest Closure
3.10 Rule #8: Return to the Operating Room for Definitive Operation as soon as Feasible
3.11 Rule #9: Do Not Over- or Misapply Damage Control Techniques
3.12 Rule #10: Keep It Simple
Suggested Reading
4: BLS Versus ALS
4.1 BLS and ALS
4.2 Organization of EMS Worldwide and the Impact on BLS Versus ALS
4.3 Ambulance Response, Triage, and Transportation to the Hospital
4.4 BLS vs ALS Debate and the EMS Paradox
4.5 Discussion of the Data
4.6 Outlook with Resource Allocation in the Future
4.7 Conclusion
Suggested Reading
5: Prehospital Care and Transport
Suggested Reading
6: Prehospital Monitoring During Transport
6.1 Urban Environment
6.1.1 Goal of EMS Participation
6.1.2 Mode of Transportation
6.1.3 Initial Assessment of the Patient by EMS
6.1.4 Wound Assessment
6.1.5 Hemodynamic Assessment
6.1.6 Monitoring and Resuscitation En Route
6.1.7 Where to Transport Patients
6.2 Rural Environment
6.2.1 How and where to Transport
6.2.2 Additional Resuscitative Measures to Consider
Suggested Reading
7: Trauma Resuscitation
7.1 Fluid Type
7.2 Determining the Need for Massive Transfusion
7.3 Adjuncts to Massive Transfusion
7.4 Permissive Hypotension
Reference
Suggested Reading
8: ABC Heuristics
8.1 Airway
8.1.1 Evaluation
8.1.2 Treatment
8.2 Breathing
8.2.1 Evaluation
8.2.2 Treatment
8.2.2.1 Flail Chest
8.2.2.2 Simple HTX or PTX
8.3 Circulation
8.3.1 Evaluation
8.3.1.1 Pump
Heart Penetration
Tamponade
8.3.1.2 Fluid
8.3.1.3 Tubing
8.4 Cell Whisper
Suggested Reading
9: Pediatric Trauma Resuscitation
9.1 Introduction
9.2 Epidemiology
9.3 History
9.4 Initial Assessment, Resuscitation, and Stabilization
9.4.1 Primary Survey (A, B, and C)
9.4.2 Normal Pediatric Vital Signs
9.4.3 A = Airway (C-Spine Immobilization)
9.4.4 B = Breathing
9.4.5 C = Circulation (Hemorrhage Control)
9.4.6 D = Disability (Neurologic Assessment)
9.4.7 E = Exposure for Secondary Survey
9.5 Secondary Survey
9.6 Diagnostic Modalities
9.7 Non-accidental Trauma
Suggested Reading
10: Fluids, Blood Substitutes, and New Tools
10.1 Physiology
10.1.1 Fluid Compartments
10.1.2 Response to Acute Hemorrhage
10.2 Hemorrhagic Shock
10.3 Fluids
10.3.1 Crystalloids
10.3.2 Colloids
10.4 Blood
10.4.1 Massive Transfusion
10.4.2 Whole Blood
10.4.3 Autotransfusion
10.4.4 Coagulopathy Prevention and Treatment
10.4.5 Tranexamic Acid
10.4.6 Pre-hospital Plasma
10.4.7 Blood Substitutes
10.5 Current ATLS Guidelines
10.5.1 Prehospital
10.5.2 Trauma Bay
10.6 Permissive Hypotension
10.6.1 Elderly Population
10.7 Conclusion
Suggested Reading
11: Emergency Department Thoracotomy
11.1 Background
11.1.1 Safety
11.1.2 Training
11.1.3 Indications
11.1.4 Focused Assessment with Sonography for Trauma (FAST)
11.1.5 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
11.1.6 Organ Donation
11.1.7 Special Considerations
11.2 Preparation
11.3 Equipment
11.4 Technique
Suggested Reading
12: Intensive Care: Principles and Therapy
12.1 Metabolic Response to Trauma
12.2 ICU Monitoring
12.3 Neurological System, Pain Control, and Traumatic Brain Injury
12.4 Respiratory Failure, Acute Lung Injury, and ARDS
12.5 Cardiac Failure
12.6 Surgical Nutrition
12.7 Fluid, Electrolytes, and Renal Failure
12.8 Endocrine: Glucose Control and Steroids
12.9 Transfusions and Blood Products
12.10 Infectious Disease and Nosocomial Infections
12.11 Prophylaxis in the ICU: DVT and Ulcer Prophylaxis
12.12 Multiple Organ Failure
12.13 Complications of ICU Care
12.14 Ethical and Family Issues
12.15 Conclusions
Suggested Reading
13: Ventilation in the Trauma Patient: A Practical Approach
13.1 Introduction
13.2 Background Physiology and Theory
13.2.1 Whom to Ventilate
13.2.1.1 Hypoxia
13.2.1.2 Measures of Adequacy of Oxygenation
13.2.1.3 The Causes of Hypoxic Hypoxia (Hypoxemia) Are as Follows
13.2.2 PaCO2
13.2.2.1 Production: VCO2
13.2.2.2 Alveolar Ventilation
13.2.3 Ventilator-Induced Lung Injury
13.2.4 Recruitment and Recruitment Maneuvers
13.2.5 Fluid Overload and Atelectasis
13.3 Practical Application of Ventilation Strategies
13.3.1 Specific Indications for Ventilation
13.3.2 Initiation of Ventilation
13.3.2.1 Airway Management
13.3.3 The Initial Ventilator Settings
13.3.3.1 Basic Ventilator Settings in the ED
FiO2
Trigger Setting
Mode
pCO2
Tidal Volume
Rate
PEEP
13.3.3.2 Sedation and Analgesia
13.4 Ventilation in the ICU Phase
13.4.1 Positioning
13.4.2 Ventilator Settings
13.4.3 Paralysis
13.4.4 Sedation and Analgesia
13.5 Rescue Therapies for Persistent Hypoxemia
13.5.1 Ongoing Ventilation
13.6 The Head-Injured Patient
13.7 Monitoring the Ventilated Patient
13.8 Longer-Term ICU Airway Management
13.8.1 Tracheostomy
13.8.2 Weaning
Suggested Reading
14: ECMO in the Trauma Patient: A Practical Approach
14.1 Introduction
14.2 Background on ECMO
14.3 Veno-venous ECMO
14.4 Cannulation for Veno-venous ECMO
14.5 Veno-pulmonary Arterial ECMO
14.6 Venoarterial ECMO
14.7 Troubleshooting
14.7.1 Recirculation on V-V ECMO
14.7.2 Progressive Hypoxemia on V-V ECMO
14.7.3 Differential Hypoxia
14.7.4 Left Ventricular Distension
14.7.5 ECMO Flow Issues
14.7.6 Weaning
14.8 Final Thoughts
Suggested Reading
15: Sepsis and Septic Shock
15.1 Introduction and Definitions
15.2 Pathogenesis of Posttraumatic Infection and Sepsis
15.3 Diagnosis and Investigations
15.3.1 Diagnosis of the Underlying Infection
15.3.2 Diagnosis of Acute Organ Dysfunction
15.4 Management Principles
15.4.1 Treating the Underlying Infection
15.4.2 Source Control
15.5 Organ Support
15.5.1 Fluid Therapy and Hemodynamic Support
15.5.2 Ventilatory Support
15.5.3 General Interventions
15.5.3.1 Other Supportive Therapies in Patients with Sepsis and Septic Shock
Renal Replacement Therapy
Venous Thromboembolism (VTE) Prophylaxis
Glucose Control
Sedation and Analgesia
Use of Neuromuscular Blocking Agents
Nutrition
Stress Ulcer Prophylaxis
Red Blood Cell (RBC) Transfusion
Positioning and Early Mobilisation
15.6 Transition of Care
15.7 Prevention of Post-traumatic Sepsis
15.8 Conclusions
Suggested Reading
16: Endpoints of Resuscitation
16.1 Haemodynamic Monitoring
16.1.1 Pulse Rate
16.1.2 Arterial Saturation (SaO2)
16.2 Mixed and Central Venous Oxygen Saturation
16.3 Pressure and Flow
16.4 Central Venous Pressure (CVP)
16.5 IVC Diameter
16.6 Pulmonary Arterial Pressure
16.7 Peripheral Arterial Pressure
16.8 Cardiac Output Monitoring
16.9 Haemoglobin and Coagulation
16.10 Reversal of Anaerobic Metabolism
16.10.1 Lactate
16.10.2 Base Deficit
16.11 Supranormal Resuscitation and Permissive Hypotension
16.11.1 Supranormal Resuscitation
16.11.2 Permissive Hypotension
16.12 Conclusion
Suggested Reading
17: Plain X-Rays for Penetrating Trauma
17.1 Plain X-Rays for Penetrating Trauma
17.2 Rationale for the “Plain Film”
17.3 Limitations of “Plain Film” Imaging
17.4 Chest Radiography
17.4.1 Soft Tissues and Bony Thorax
17.4.2 Pleura and Lung Parenchyma
17.4.3 Mediastinum
17.4.4 The Asymptomatic Patient
17.4.5 Iatrogenesis Imperfecta
17.5 Abdominal Radiography
17.5.1 Determination of Trajectory
17.5.2 Diaphragmatic Injury
17.6 Missile Embolism
17.7 Conclusions
Suggested Reading
18: Computed Tomography in the Workup of Patients with Penetrating Trauma
18.1 Head and Neck
18.2 Thorax
18.3 Abdomen
18.4 Back and Flank
18.5 Extremities
18.6 Conclusion
Suggested Reading
Head and Neck
Thoracic
Abdomen and Pelvis
Back and Flank
Extremities
19: Portable Ultrasound as an Adjunct in Penetrating Trauma
19.1 Introduction
19.1.1 How Should You Use Point-of-Care Ultrasound?
19.1.2 Defining the Injury
19.1.3 Detecting Abdominal Blood (FAST Scan)
19.1.4 FAST Pearls
19.2 Pneumothorax
19.2.1 Pitfalls
19.3 Haemothorax
19.4 Pericardial Tamponade
19.4.1 Pitfalls
19.5 Assessment of Volumetric Status
19.6 Using Ultrasound to Manage Penetrating Trauma
19.6.1 Vascular Access
19.6.2 Pericardial and Pleural Drainage
19.6.3 Airway Management
19.6.4 Depth of Tract/Foreign Body Localisation
19.7 Postoperative Management
19.8 Summary of Important Pitfalls
19.8.1 FAST Scanning
19.8.2 Pneumothorax
19.8.3 IVC Scanning
Suggested Reading
20: Laparoscopy and Penetrating Trauma
20.1 General Techniques of Laparoscopy
20.2 Technical Considerations
20.3 Laparoscopy and Anterior Abdominal Wall Stab Wounds
20.4 Laparoscopy and Gunshot Wounds
20.5 Laparoscopy and Thoracoabdominal Trauma
20.6 Laparoscopy and Extraperitoneal Rectal Injury
20.7 Laparoscopy and Definitive Repair of Injuries Secondary to Penetrating Trauma
20.8 Robotic-Assisted Surgical Treatment of Traumatic Injuries
Suggested Reading
21: Angiography and Interventional Radiology
21.1 General Comments
21.2 Technical Considerations
21.3 Basic Imaging Aspects
21.4 Head and Neck Injuries
21.5 Thoracic and Abdominal Aortic Injuries
21.6 Extremities and Pelvic Injuries
Suggested Reading
22: Imaging of Penetrating Urologic Trauma
22.1 Imaging of Penetrating Urologic Trauma
22.2 Computerized Tomography
22.3 Pyelography
22.4 Cystography
22.5 Retrograde Urethrogram
Suggested Reading
23: Practical Approach to REBOA
23.1 Introduction
23.2 The Physiological Effects of Aortic Balloon Occlusion
23.3 Team Approach Is Crucial in the Use of REBOA
23.4 The REBOA Procedure
23.4.1 Preparation of the Sheath and Balloon Catheter
23.4.2 Gaining Arterial Access and Sheath Introduction
23.4.3 Deployment of the REBOA Device into a Targeted Aortic Zone
23.4.4 Balloon Inflation
23.4.5 Balloon Deflation
23.4.6 REBOA Device and Sheath Removal
23.5 Indications and Contraindications
23.5.1 Indications
23.5.2 Contraindications
23.6 How to Reduce Complications of REBOA
23.6.1 Technical Complications
23.6.2 Physiological Complications
23.6.3 Strategical Complications
23.7 Military Considerations of REBOA
23.8 Future Considerations of Practical Use of REBOA
23.9 Conclusion
Suggested Reading
24: Video-Assisted Thoracic Surgery in Penetrating Chest Trauma
24.1 Indications
24.2 Preoperative Preparation
24.2.1 Anesthesia
24.2.2 Positioning of Patient
24.2.3 Setup and Equipment
24.3 Operative Technique
24.3.1 Port Sites
24.3.2 Exploration
24.3.3 Parietal Hemostasis
24.3.4 Pulmonary Injuries
24.3.5 Diaphragmatic Injury (DI)
24.3.6 Pericardial Effusion
24.3.7 End of Procedure
24.4 Delayed VATS
Suggested Reading
25: Diagnostic Peritoneal Lavage (DPL) Unplugged
25.1 Open or Closed?
25.1.1 Percutaneous Technique
25.1.2 Open Technique
25.2 Interpretation
25.3 Current Status of DPL
Suggested Reading
26: Mass Casualties and Triage in Military and Civilian Environment
26.1 Multiple Casualties and Mass Casualties
26.2 Triage
26.3 Triage Systems
26.3.1 P or Priority System
26.4 Methodology
26.5 The Sieve-Sort Approach to Mass Casualties
26.5.1 Triage Sieve
26.5.2 Triage Sort
26.6 Effect-Related Triage
26.7 Triage in Austerity
26.8 Training
26.9 Mass Casualty Triage in a Humanitarian Context
26.9.1 The Logic of Mass Casualty Triage
26.9.2 Triage System in a Humanitarian Context
26.9.3 Prehospital Triage
26.9.4 Hospital Reorganisation and Planning
26.9.4.1 Infrastructure and Space
26.9.4.2 Equipment and Supplies
26.9.4.3 Communications
26.9.4.4 Capacity to Transfer
26.9.4.5 Security
26.9.4.6 Personnel
26.9.5 Triage Teams
26.9.5.1 Triage Team Leader
26.9.5.2 Clinical Triage Officer
26.9.5.3 Head Nurse, Matron
26.9.5.4 Resuscitation Teams
26.9.5.5 Follow-Up Medical Groups
26.10 Conclusion
Suggested Reading
27: Ballistics in Trauma
27.1 ‘A Primer of Ballistics’
27.1.1 Internal Ballistics
27.1.2 External Ballistics
27.1.3 Terminal Ballistics
27.1.4 Wound Ballistics
27.1.5 Cavitation
27.2 Initial Management of Gunshot Wounds
27.2.1 Thought Processes
27.2.2 Shotgun Injury
27.3 Definitive Care
27.3.1 Removal of Bullets
27.4 Forensic Considerations
27.5 Conclusion
Suggested Reading
Part II: Surgical Strategies in Penetrating Trauma to Head, Face, and Neck
28: Surgical Strategies in Trauma
28.1 Preparation for Trauma Activations
28.2 Avoiding Pitfalls in the Initial Assessment
28.3 Initial Resuscitation Strategies
28.4 Choosing Damage Control Surgery vs. Definitive Repair
28.5 Performing Damage Control Surgery
28.6 Future Advances in Surgical Strategies in Trauma
Recommended Reading
29: Surgical Strategies in Trauma to the Head, Face, and Neck
29.1 Initial Evaluation
29.1.1 Airway and Breathing
29.1.2 Hemorrhage Identification and Temporary Control
29.2 Identification of Injury and Prioritization of Treatment
29.2.1 Penetrating Brain Trauma
29.2.2 Penetrating Facial Trauma
29.2.3 Penetrating Neck Trauma
Suggested Reading
30: Penetrating Injuries of the Face
30.1 Types and Characteristics of Injuries
30.2 Structures at Risk for Injury
30.3 Goals of Management
30.4 Acute Management
30.4.1 Patient Evaluation
30.5 Airway Management
30.6 Evaluation and Management of Maxillofacial Bleeding
30.7 History and Physical Examination of Maxillofacial Injuries
30.8 External Examination
30.9 Intraoral Examination
30.10 Imaging
30.11 Initial Treatment
30.11.1 Indications for Immediate Treatment in the ED
30.12 Definitive Treatment
30.12.1 Early Versus Late Management
30.13 Conclusion
Suggested Reading
31: Operative Strategies in Penetrating Trauma to the Neck
31.1 Positioning
31.2 Incision/Approach
31.3 Vascular Repair
31.3.1 Damage Control
31.4 Tracheal Injuries
31.4.1 Damage Control
31.5 Esophageal Injuries
31.5.1 Damage Control
31.6 Bone Bleeding
31.7 Conclusion
Suggested Reading
32: Access to the Neck in Penetrating Trauma
33: Penetrating Trauma to the Larynx and the Cervical Trachea
33.1 Historical Context
33.2 Airway Management
33.3 Injury Classification
33.4 Injury Evaluation and Management
33.5 Operative Approach
33.6 Laryngeal Repair
33.7 Tracheal Repair
33.8 Associated Injuries
33.9 Postoperative Airway Management
33.10 Complications
Suggested Reading
34: Penetrating Injury to the Pharynx and Cervical Esophagus
34.1 Anatomic Basics
34.2 Surgical Indications
34.3 Surgical Technique
34.4 Postoperative Care and What to Do If the Repair Falls Apart
34.5 Conclusions
Suggested Reading
35: Carotid, Jugular and Vertebral Blood Vessel Injuries
35.1 Pathophysiology
35.2 Clinical Signs
35.3 Management
35.3.1 The Stable Patient: Diagnostics—CT Scan or Equivalent
35.3.2 The Unstable Patient: Operative Approach
35.3.2.1 Management in the Emergency Department
35.3.2.2 After Initial Resuscitation: What Now?
35.4 Operative Technique
35.5 Technical Tips
35.5.1 Surgical Exposure of the Carotid Arteries
35.5.2 Vertebral Artery Injuries
35.5.3 Postoperative Procedure
Suggested Reading
Part III: Surgical Strategies in Penetrating Trauma to the Chest
36: Penetrating Trauma to the Subclavian Vessels
36.1 Applied Surgical Anatomy (Fig. 36.1)
36.1.1 The Subclavian Artery
36.1.1.1 First Part of the Right Subclavian Artery
36.1.1.2 First Part of the Left Subclavian Artery
36.1.1.3 Second Part of the Subclavian Artery
36.1.1.4 Third Part of the Subclavian Artery
36.1.2 Branches of the Subclavian Artery
36.1.3 Anatomical Anomalies
36.1.4 The Subclavian Vein
36.2 Clinical Presentation, Preoperative Care, Diagnosis, and Management Principles (Fig. 36.2)
36.3 Surgical Exposures
36.3.1 Midline Sternotomy in the Unstable Patient with No Diagnostic Imaging (Fig. 36.4)
36.3.2 The Midline Sternotomy in the Stable Patient with Imaging
36.3.2.1 The Limited Upper or Partial Sternotomy (Fig. 36.4)
36.3.2.2 The Supraclavicular Exposure of the Subclavian Artery (Figs. 36.7 and 36.8)
36.3.2.3 The Left Third-Interspace Anterolateral Thoracotomy (Fig. 36.9)
36.3.2.4 The Left Fifth-Interspace Posterolateral Thoracotomy
36.3.2.5 The Infraclavicular Exposure of the Distal Subclavian and Proximal Axillary Artery (Fig. 36.10)
36.3.2.6 The Trapdoor Thoracotomy and Partial Resection of the Clavicle (Figs. 36.6 and 36.11)
36.3.2.7 The Surgical Repair of the Subclavian Vessels
36.3.2.8 Endovascular Management (Fig. 36.12)
36.4 Venous Injuries
Suggested Reading
37: Penetrating Trauma to the Thoracic Oesophagus
37.1 Diagnostic Investigations
37.2 Access to Injury
37.3 Repair of the Injury
37.3.1 Early Presentation with Limited Damage
37.3.2 Late Presentation or Extensive Damage
Suggested Reading
38: Penetrating Trauma to the Mediastinal Trachea and Main Bronchi
38.1 Anatomical Considerations
38.2 Establishing a Diagnosis
38.3 Operative Strategy
38.4 Operation
Suggested Reading
39: Operative Management of Pulmonary Injuries
39.1 Background
39.2 Positioning and Equipment
39.3 Incision/Approach
39.4 Pulmonary Injuries
39.5 Intrathoracic Vascular Injuries
39.6 Damage Control
39.7 Conclusion
Suggested Reading
40: Operative Management of Delayed Complications of Pulmonary and Pleural Injury
40.1 Introduction
40.2 Pleural Complications
40.2.1 Retained Hemothorax
40.2.1.1 Background
40.2.1.2 Investigations
40.2.1.3 Management
Observation
Repeat Chest Tube
Intrapleural Lytic Therapy
Video Assisted Thoracoscopy (VATS)
Thoracotomy
40.2.2 Empyema
40.2.2.1 Background
40.2.2.2 Investigations
40.2.2.3 Management
40.2.3 Fibrothorax
40.2.3.1 Background
40.2.3.2 Investigations
40.2.3.3 Management
40.2.4 Chylothorax
40.2.4.1 Background
40.2.4.2 Investigations
40.2.4.3 Management
40.2.5 Recurrent Pneumothorax
40.2.5.1 Background
40.2.5.2 Investigations
40.2.5.3 Management
40.3 Pulmonary Complications
40.3.1 Pneumonia
40.3.1.1 Background
40.3.1.2 Investigations
40.3.1.3 Management
40.3.2 Acute Respiratory Distress Syndrome (ARDS)
40.3.2.1 Background
40.3.2.2 Investigation
40.3.2.3 Management
40.3.3 Retained Missiles
40.3.3.1 Background
40.3.3.2 Investigations
40.3.3.3 Management
40.3.4 Persistent Air Leak
40.3.4.1 Background
40.3.4.2 Investigations
40.3.4.3 Management
40.3.5 Necrotising Lung Infection
40.3.5.1 Background
40.3.5.2 Investigations
40.3.5.3 Management
Suggested Reading
41: Penetrating Injuries to the Mediastinal Vessels
41.1 Introduction
41.2 Management Strategy
41.3 Incisions and Exposure
41.4 Management of Specific Injuries
41.4.1 Injuries to the Ascending Aorta
41.4.2 Injuries to the Aortic Arch
41.4.3 Injuries to the Branches of the Aortic Arch
41.4.4 Injuries to the Descending Aorta
41.4.5 Injuries to Pulmonary Arteries
41.4.6 Injuries to Venous Structures
41.4.6.1 Innominate Vein
41.4.6.2 Subclavian Veins
41.4.6.3 Major Pulmonary Vein
41.4.6.4 Superior Vena Cava (SVC)
41.4.6.5 Inferior Vena Cava (IVC)
41.4.6.6 Azygos Vein
41.5 Conclusion
Suggested Reading
42: Penetrating Cardiac Trauma
42.1 Category 1: Lifeless
42.2 Category 2: Critically Unstable
42.3 Category 3: Cardiac Tamponade
42.4 Category 4: Thoracoabdominal Injury
42.5 Category 5: Benign Presentation
42.6 Management
42.6.1 The Lifeless Patient
42.6.2 The Critically Unstable Patient
42.6.3 The Patient with Cardiac Tamponade
42.6.4 The Patient with Thoracoabdominal Injury
42.6.5 The Patient with the Benign Presentation
42.7 Operative Management
42.7.1 Access to Site of Injury
42.7.2 Repair of the Injury
42.7.3 Closure
Suggested Reading
43: Penetrating Injuries to the Diaphragm
43.1 Pathophysiology
43.2 Clinical Assessment
43.3 Radiological Assessment
43.4 Contrast Studies
43.5 Ultrasound
43.6 Diagnostic Peritoneal Lavage (DPL)
43.7 Computed Tomography (CT)
43.8 Magnetic Resonance Imaging (MRI)
43.9 Laparoscopy
43.10 Thoracoscopy and Video-Assisted Thoracoscopic Surgery (VATS)
43.11 Treatment
43.11.1 Surgery
Suggested Reading
44: Approach to Thoracoabdominal Injury
45: Loss of the Chest Wall
45.1 Field Management of Chest Wall Loss and Open Pneumothorax
45.2 Emergency Department Management
45.3 Operative Management
45.4 Recovery and Rehabilitation
Suggested Reading
Part IV: Surgical Strategies in Penetrating Trauma to the Abdomen and Pelvis
46: Access to the Abdomen: Emergency Laparotomy
46.1 Position and Preparation
46.2 Incision
46.3 Bleeding and Contamination Control
46.4 Systematic Exploration
46.5 Closure
47: Damage Control Surgery
47.1 Introduction
47.1.1 Hypothermia
47.1.2 Acidosis
47.1.3 Coagulopathy
47.2 Damage Control Resuscitation
47.2.1 Hypotensive Resuscitation
47.2.2 Haemostatic Resuscitation
47.3 Stages of Damage Control
47.3.1 Stage 1: Indication/Patient Selection of Damage Control Surgery
47.3.2 Stage 2: Operative Control of Haemorrhage and Contamination
47.3.2.1 General Principles
47.3.2.2 Thoracic Damage Control
Lung Injuries
Cardiac Injuries
Tracheobronchial Injuries
Oesophageal Injuries
47.3.2.3 Abdominal Damage Control (Solid Viscera)
Liver
Spleen
Kidney
Pancreas
47.3.2.4 Abdominal Damage Control (Hollow Viscera)
Stomach
Duodenum
Small Bowel
Colon
Rectum
Biliary Tract Injuries
Ureter and Urinary Bladder Injuries
47.3.2.5 Vascular Injuries
47.3.3 Stage 3: Resuscitation in ICU
47.3.3.1 Correction of Hypothermia
47.3.3.2 Correction of Acidosis
47.3.3.3 Coagulopathy
47.3.4 Stage 4: Definitive Surgery
47.3.5 Stage 5: Definitive Closure of the Abdomen
47.4 Conclusion
Suggested Reading
48: Beyond Damage Control Surgery: Abdominal Wall Reconstruction and Complex Hernia Repair
48.1 Temporary Closure Techniques
48.2 General Principles of Management of Post-DCS Consequences
48.3 Redefining the Anatomy and New Physiology
48.4 Timing to Definitive Repair
48.5 Operative Approach
48.6 Definitive Abdominal Wall Reconstruction
48.6.1 Use of Native Tissue
48.6.2 Other Adjunct Procedures
48.6.3 The Component Separation Technique
48.7 Posterior Component Separation with Transversus Abdominis Release (TAR)
48.7.1 Mesh Placement
48.7.1.1 Onlay Mesh Placement
48.7.1.2 Underlay Placement
48.7.1.3 Bridge Mesh Placement
48.7.2 Postoperative Complications
Suggested Reading
49: Abdominal Esophagus and Stomach
49.1 Initial Evaluation in the Trauma Bay
49.2 Abdominal Exploration and Identification of Injuries
49.3 Treatment of Specific Injuries
49.3.1 Damage Control Surgery Techniques
49.4 Postoperative Care
Suggested Reading
50: Duodenum
50.1 General Rules of Operative Strategy
50.2 Grade-Specific Operative Management
50.2.1 Grade I
50.2.2 Grade II
50.2.3 Grades III and IV
50.2.4 Grade V
50.3 Conclusions
Suggested Reading
51: Penetrating Trauma to the Pancreas
Suggested Reading
52: Liver and Extrahepatic Bile Ducts
52.1 Immediate Considerations
52.2 Non-operative Management
52.3 Operative Management
52.4 Extrahepatic Biliary Injury
52.5 Conclusion
Suggested Reading
53: Large and Small Bowel
53.1 Introduction
53.2 The “First Pass”
53.3 The Second Pass Through the Abdomen: The Stable Patient
53.4 The Second Pass Through the Abdomen: Damage Control
53.5 The Planned Reoperation After Successful Resuscitation
Suggested Reading
54: Injury of the Kidney, Ureter, and Bladder
54.1 Indications for Operative Management
54.2 Operative Technique
54.3 Vascular Control
54.4 Vascular Repair
54.5 Renal Exposure
54.6 Partial Nephrectomy
54.7 Renorrhaphy
54.8 Nephrectomy
54.9 Ureteral Repair
54.10 Ureteroureterostomy
54.11 Ureteroneocystostomy
54.12 Autotransplantation
54.13 Bladder Repair
54.14 Bladder Neck Repair
54.14.1 Postoperative Management
Suggested Reading
55: Lower Genitourinary Injuries
55.1 Acute Scrotal and Testis Injuries
55.2 Penile Injury
55.3 Urethral Injury
Suggested Reading
56: Major Abdominal Veins
56.1 IVC Injury
56.1.1 Exposure
56.1.2 Repair
56.1.3 Complications
56.2 Portal Vein Injuries
56.2.1 Exposure
56.2.2 Repair Versus Ligation
56.2.3 Complications
56.3 SMV Injuries
56.3.1 Exposure
56.3.2 Repair Versus Ligation
56.3.3 Complications
56.4 Renovascular Injuries
56.4.1 Exposure
56.4.2 Repair Versus Ligation
56.4.3 Complications
56.5 Iliac Vein Injuries
56.5.1 Exposure
56.5.2 Repair Versus Ligation
56.5.3 Complications
Suggested Reading
57: Major Abdominal Arteries
57.1 Stay Calm
57.2 Get Temporary Control
57.3 Retroperitoneal Hematomas: Plan of Action
57.3.1 Zone I
57.3.1.1 Aorta
57.3.1.2 Celiac Axis
57.3.1.3 Superior Mesenteric Artery
57.3.2 Zone II
57.3.3 Zone III
57.4 Afterthoughts
Suggested Reading
58: Spleen
58.1 Exposure
58.2 Mobilization
58.3 Vascular Control
58.4 Specimen Removal and Final Inspection
Suggested Reading
59: Penetrating Rectal Injuries
59.1 Historical Perspective
59.2 Surgical Anatomy
59.3 Incidence
59.4 Special Investigations
59.5 Surgical Strategies
59.5.1 Patient Position
59.5.2 Laparotomy
59.5.3 Laparoscopy and a Trephine Loop Colostomy
59.5.4 Distal Rectal Washout
59.5.5 Presacral Drainage
59.5.6 Antibiotic Treatment
Suggested Reading
60: Abdominal Compartment Syndrome
60.1 Definitions
60.2 When to Expect ACS in Penetrating Trauma?
60.3 Diagnosis
60.4 Treatment
60.5 Open Abdomen
60.6 Outcomes
Suggested Reading
61: SNOM: Conservative Management of Solid Viscera
61.1 SNOM: Liver
61.1.1 The Patient
61.1.2 Clinical Findings
61.1.3 Plain Chest Radiograph
61.1.4 Special Investigation
61.1.5 Management
61.1.6 Complications
61.2 Thoracobiliary Fistulae
61.3 The Evidence
61.4 SNOM: Kidney
61.4.1 The Patient
61.4.2 Clinical Findings
61.4.3 Special Investigation
61.4.4 Management
61.4.5 Complications
61.4.6 The Evidence
61.5 SNOM: Spleen
Suggested Reading
62: Bleeding in the Pelvis
Suggested Reading
Part V: Neurological Trauma
63: Gunshot Injuries to the Head
63.1 Some Rules for Workup Leading to Operative Management
63.2 Preoperative and Intraoperative Management
63.3 Operative Management
63.4 Perioperative Management
63.4.1 Cerebral Perfusion Threshold
63.5 Intracranial Pressure Monitoring
63.6 Hyperosmolar Therapy and Barbiturates
63.7 Hyperventilation and Steroids
63.8 Infection Prophylaxis
63.9 Prophylactic Hypothermia
63.10 Antiseizure Prophylaxis
63.11 Postoperative Consideration
63.12 Special Circumstances
Suggested Reading
64: Approach to Penetrating Injury of the Spinal Cord
64.1 Introduction
64.2 Evaluation in the Emergency Department (Fig. 64.2)
64.2.1 Neurological Examination
64.2.2 Wound Evaluation
64.2.3 Radiological Imaging
64.2.4 Conservative Versus Operative Management (Fig. 64.3)
64.3 Conclusion
Suggested Reading
65: Early Neurotrauma Rehabilitation
65.1 Acute Traumatic Brain Injury Rehabilitation
65.1.1 Projections and Prognosis
65.1.2 Function and Participation
65.1.3 Complications and Rehabilitation Challenges
65.2 Acute Spinal Cord Injury Rehabilitation
65.2.1 The SCI Review of Systems
65.2.2 Functional Goals
65.3 The “Dual Diagnosis”
Suggested Reading
Part VI: Surgical Strategies in Penetrating Trauma and Orthopedic Injuries
66: Introduction to Orthopedic Injuries
66.1 Diagnostics
66.2 Tourniquets
66.3 Combination of Vascular and Bony Injuries
66.4 Compartment Syndrome
66.5 Spinal Injury
66.6 Endovascular Care
66.7 Conclusion
Suggested Reading
67: Extremity Fractures
67.1 Priorities
67.2 The Decision to Operate
67.3 Preparation for Operation
67.4 Operative Strategies
68: Compartment Syndrome of the Extremities
68.1 Pathophysiology
68.2 Diagnosis
68.3 Treatment
68.4 Lower Leg Compartment Syndrome and Fasciotomy
68.4.1 The Lateral Incision of the Lower Leg
68.4.2 The Medial Incision of the Lower Leg
68.4.3 Pitfalls Associated with Fasciotomy of the Lower Leg
68.5 Compartment Syndrome of the Foot
68.6 Compartment Syndrome of the Thigh
68.7 Compartment Syndrome of the Forearm and Hand
68.8 Aftercare and Complications
Suggested Reading
69: Penetrating Trauma to the Hand
69.1 Diagnosis and Basic Surgical Principles
69.2 Tendon Injuries
69.3 Vascular Injuries
69.4 Nerve Injuries
69.5 Management of Open Fractures
69.6 Amputation vs. Preservation
69.7 Infection After Penetrating Injury of the Hand
69.8 Conclusion
Suggested Reading
70: Penetrating Trauma to the Foot
70.1 Introduction
70.2 Anatomy
70.2.1 Anatomy of the Bones
70.2.2 Major Tendons
70.2.3 Vascular Supply
70.2.4 Neural Structures
70.3 Injury Patterns
70.3.1 Isolated Tendon Injury
70.3.2 Stab Injuries with Damage to the Neurovascular Bundle
70.3.3 Repair of Vascular Injury
70.4 Gunshot and Blast Injuries
70.5 Compartment Syndrome
70.6 Algorithm
70.7 Aftercare and Complications
Suggested Reading
71: Penetrating Trauma: Amputations
71.1 Introduction
71.1.1 Principles of Amputation
71.1.1.1 Initial Wound Evaluation
71.1.1.2 Deciding Primary Amputation Versus Limb Salvage
71.1.1.3 Level of Amputation
71.1.1.4 Skin and Muscle Flaps
71.1.1.5 Hemostasis
71.1.1.6 Nerves
71.1.1.7 Bones
71.1.1.8 Open Amputations and Wound Closure
71.1.2 Upper Extremity Amputations
71.1.2.1 Wrist Amputations
71.1.2.2 Transradial Amputations
71.1.2.3 Transhumeral Amputations
71.1.3 Lower Extremity Amputations
71.1.3.1 Transtibial (Below-Knee) Amputations
Transtibial Amputation, Extended Posterior Flap
71.1.3.2 Disarticulation of the Knee
71.1.3.3 Transfemoral (Above-Knee) Amputations
71.1.4 Conclusion
Suggested Reading
72: Amputations of Hand and Foot after Destructive Gunshot Injuries
72.1 Principles of Hand and Foot Amputations
72.2 Initial Operative Management
72.3 Amputations of Hand and Foot
Suggested Reading
73: Anterior Exposure of the Thoracic and Lumbar Spine
73.1 General Principles
73.2 Anterior Exposure of T10–L2
73.3 Anterior Exposure of L3–L5
73.4 Anterior Exposure of the Thoracic Spine Proximal to T10
73.5 Anterior Lumbar Interbody Fusion (ALIF) at the L4/L5 and L5/S1 Levels
Suggested Reading
Part VII: Peripheral Arterial Injuries
74: Peripheral Arterial Injuries from Penetrating Trauma
75: Axillary and Brachial Vessels
75.1 Making the Diagnosis
75.2 Anatomic Considerations
75.3 Exposure and Management of Injuries
75.3.1 Axillary Artery Injuries
75.3.2 Brachial Artery Injuries
75.4 Role of Endovascular Therapy
Suggested Reading
76: Femoral Vessels
76.1 Do Not Be Distracted by the Obvious: More Than a Groin Wound
76.2 The “Asymptomatic” Groin Wound
76.3 The Indeterminate Groin
76.4 The Bleeding Groin
Suggested Reading
77: Popliteal Vessels
77.1 Anatomy of the Popliteal Vessels for the Trauma Surgeon
77.2 Making the Diagnosis and Immediate Management
77.3 To the Operating Room
77.3.1 The Medial Approach
77.3.2 The Posterior Approach
77.4 Choose Your Arterial Repair Wisely
77.5 Popliteal Vein Injury
77.6 The Post-Repair Checklist
77.7 Special Situations and Controversies
77.7.1 The Unstable Patient
77.7.2 Active Hemorrhage
77.7.3 Associated Fractures
77.7.4 Local Versus Systemic Heparinization
77.7.5 Limb Amputation
77.7.6 Battlefield or High-Velocity Penetrating Leg Injuries
77.7.7 Endovascular Techniques in the Popliteal Fossa
Suggested Reading
78: Penetrating Arterial Injuries Below Elbow/Knee
78.1 Introduction
78.2 Clinical Presentation
78.3 Hemorrhage Control
78.4 Diagnostic Imaging
78.5 General Principles of Operative Management
78.6 Specific Vascular Injuries
78.6.1 Brachial Artery
78.7 Radial and Ulnar Artery
78.8 Popliteal Artery Below the Knee
78.9 Infrapopliteal Arteries
78.10 Post-operative Management
Suggested Reading
Part VIII: Other Topics
79: Management of Penetrating Soft Tissue Injuries
79.1 Patients with Multiple Injuries
79.2 Wound Assessment
79.3 Fasciotomies
79.4 Nerve Injuries
79.5 Goals
79.6 Methods of Soft Tissue Cover
79.6.1 Direct Closure
79.6.2 Skin Grafts
79.6.3 Flaps
79.6.3.1 Muscle and Musculocutaneous Flaps
79.6.3.2 Fascial and Fascio Cutaneous Flaps
79.6.3.3 Perforator Flaps
79.6.3.4 Free Flaps
79.6.4 Tissue Expansion
79.7 Summary
Suggested Reading
80: Burns and Inhalational Injury
80.1 Introduction
80.2 Initial Management of the Burned Patient—The Emergency Room
80.3 Example Resuscitation
80.4 Just Because You Can Does It Mean You Should?
80.5 Wound Care and Pain Control
80.6 Escharotomies
80.6.1 Chest and Abdomen
80.6.2 Lower Extremity
80.6.3 Upper Extremity
80.6.4 Neck
80.6.5 Penis
80.7 Pulmonary Function
80.8 When Does the Resuscitation End?
80.9 Altered Hemodynamics
80.10 Nutrition
80.11 Other Critical Care Issues
80.12 Inhalational Injury
80.13 Children
80.14 Chemical Injuries
80.15 Electrical Injuries
Suggested Reading
81: Crush Injuries
81.1 Introduction
81.2 Wound Issues
81.2.1 The Mangled Extremity
81.2.2 Compartment Syndrome
81.3 Systemic Issues
Suggested Reading
82: Blast Injuries
82.1 Specific Injury Types
82.1.1 Head Injuries
82.1.2 Eye Injuries
82.1.3 Chest Injuries
82.1.4 Abdominal Injuries
82.1.5 Musculoskeletal and Soft Tissue Injuries
82.2 The Role of Imaging
Suggested Reading
83: The Elderly Patient
83.1 Definition and Epidemiology
83.2 Age-Related Physiology and Effect on Trauma: What You Should Know
83.2.1 Cardiovascular System
83.2.2 Renal System
83.2.3 Respiratory System
83.2.4 Central Nervous System
83.3 The Geriatric Patient in the Field: Prehospital Evaluation
83.4 The Geriatric Patient in the Emergency Room: Initial Evaluation and Management
83.4.1 Trauma Team Activation: Be Ready!
83.4.2 Primary Survey: The “Geriatric ABCs”
83.4.3 Secondary Survey: Makes a Whole Lot of Difference When Done Properly!
83.4.4 Laboratory Studies and Corrective Measures
83.5 General Management
83.6 Surgical Management: No Patient Is “Too Old” for Surgery
83.6.1 The “Old, Injured Solid Organ” and Nonoperative Management: A Matter of Controversy
83.7 Diagnostic Imaging
83.8 Outcomes
Suggested Reading
84: The Pediatric Patient
84.1 Resuscitation
84.2 Resuscitative Thoracotomy
84.2.1 Technique
84.3 The Abdomen
84.3.1 Practical Advice and Pitfalls with the Abdomen
84.3.2 The Place for Laparoscopy
84.3.3 The Place for Selective Conservatism
84.4 Penetrating Thoracic Injury
84.4.1 Technique of Insertion of a Chest Tube
84.4.2 Practical Advice and Pitfalls with the Chest
84.5 Penetrating Neck Injuries
84.5.1 Practical Advice and Pitfalls with the Neck
84.6 Peripheral Vascular Injury
84.6.1 Practical Advice and Pitfalls with Vascular Injuries
84.7 Non-powder Gun Injuries
84.8 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
84.9 Summary
Suggested Reading
85: The Pregnant Patient
85.1 Alterations During Pregnancy
85.1.1 Changes in Anatomy
85.1.2 Changes in Physiology (Table 85.1)
85.1.2.1 Circulatory
85.1.2.2 Respiratory
85.1.2.3 Renal
85.1.2.4 Progesterone-Mediated Smooth Muscle Relaxation
85.1.2.5 Laboratory Variants
85.2 Patterns of Injury
85.3 Perioperative Management
85.3.1 Primary Survey
85.3.2 Secondary Survey
85.3.3 Emergency Cesarean Delivery
85.3.4 Nonoperative Management
85.3.5 Prophylaxis
85.4 Operative Management
Suggested Reading
86: Emergency Caesarean Delivery in Pregnant Patient with Penetrating Trauma and In-Theatre Neonatal Support
86.1 Emergency Caesarean Delivery in Pregnant Patient with Penetrating Trauma
86.1.1 Introduction
86.1.2 Maternal Assessment Just Before You Proceed with Caesarean Section
86.1.2.1 Imaging
86.1.2.2 Ultrasound
86.1.3 Fetus
86.1.4 Prophylaxis
86.1.5 Positioning of the Patient in Lateral Tilt
86.1.6 Laparotomy
86.1.7 Operative Management of Caesarean Delivery
86.1.8 Surgical Technique
86.1.8.1 Vertical Incision
86.1.8.2 Scalpel Midline INCISION: Subcutaneous Tissue Layer—Opening the Peritoneum—Ensuring Adequate Exposure
86.1.8.3 Avoiding Visceral Damage in Dense Intraperitoneal Adhesions
86.1.9 Intraabdominal Procedures
86.1.9.1 Bladder Flap
86.1.9.2 Choice of Uterine Incision: Hysterotomy
86.1.9.3 Transverse Incision
86.1.9.4 Low Vertical and Classical Incisions
86.1.9.5 Hysterotomic Procedure: Expanding the Incision—Fetal Extraction—Cord Clamping—Placental Extraction
86.1.10 Uterine Closure
86.1.10.1 Closure of the Uterus: Suturing Approach—Choice of Suture
86.1.10.2 Closure of a Classical Incision
86.1.11 Closure of the Abdominal Wall
86.1.11.1 Midline Incision: Subcutaneous Tissue—Skin—Wound Dressing
86.1.12 Perimortem Caesarean Delivery Procedure (PMCD)
86.2 In-theatre Neonatal Support
86.2.1 Cord Management During Emergency Caesarean Section
86.2.2 Initial Assessment
86.2.2.1 Clearing the Airway
86.2.2.2 Prevention of Hypothermia
86.2.2.3 Tactile Stimulation
86.2.2.4 Ventilatory Support
86.2.2.5 Oxygen Therapy
86.2.2.6 Chest Compressions
86.2.2.7 Intravascular Access
86.2.2.8 Epinephrine Administration
86.2.2.9 Volume Expansion
86.2.2.10 Preparation for Transport
86.2.2.11 Care After Resuscitation
Suggested Reading
87: Anticoagulation in Penetrating Trauma
Suggested Reading
88: Approach to Perioperative Nutritional Support in Penetrating Trauma
88.1 Introduction
88.2 Questions to Ask Before You Close the Abdomen
88.2.1 Determination of Patient’s Nutritional Status and Expected Time for Sufficient Oral Feeding
88.2.2 Enteral vs. Parenteral?
88.2.3 Access Options
88.2.4 Steps to Take After the Initial Operation
88.2.5 Assess the Status Quo: Nutrition Status
88.2.6 Calculate Energy Consumption
88.2.7 Start Nutrition Support
88.2.8 Monitor Nutritional Support
88.2.9 Immunomodulating Formulas
88.3 Special Scenarios
88.3.1 Open Abdomen
88.3.2 Enteroatmospheric Fistula and High-Output Stoma
88.4 Conclusion
Suggested Reading
89: Pain Management in Penetrating Trauma: A Practical Approach
89.1 Introduction
89.2 Pain Physiology
89.3 Assessment of Pain
89.3.1 Tools for Pain Assessment
89.3.1.1 Unidimensional Assessment Tools for Cognitively Intact Adults
Visual Analog Scale (VAS)
Numeric Rating Scale (NRS)
Defense and Veterans Pain Rating Scale (DVPRS)
89.3.1.2 Pain Assessment in Critically Ill, Geriatric, Cognitively Impaired, or Sedated Patients
Behavioral Pain Scale (BPS)
Pain Assessment in Advanced Dementia (PAINAD SCALE)
89.3.1.3 Pain Assessment in Pediatric Injured Patients
FLACC-Revised Pain
89.3.1.4 Pain Reassessment
89.4 Pharmacology and Techniques for Analgesia in Trauma
89.4.1 Pharmacologic Analgesia
89.4.1.1 Regional Anesthesia/Analgesia
Regional Analgesia in Patients Receiving Anticoagulant Agents
Local Anesthetic Systemic Toxicity
89.4.2 Nonpharmacologic Analgesia
89.5 Multimodal Pain Analgesia and Trauma Care Continuum
89.5.1 Prehospital Pain Management
89.5.2 Pain Management in the Emergency Department
89.5.3 Pain Management in Perioperative Setting
89.5.4 Pain Management in the Intensive Care Unit
89.5.5 Management of Chronic Pain After Trauma
89.6 Pain Management in Injured Children
89.7 Pain Management in Geriatric Trauma Patients
Suggested Reading
90: Austere Conditions: Surgery with Limited Resources
90.1 Introduction
90.2 Scene Safety
90.3 Identifying Your Resources
90.3.1 Skin Grafts
90.3.2 Orthopedic Procedures
90.3.3 Vascular Reconstruction
90.3.4 Thoracic Cavity Drainage
90.4 Knowing Your Own Limitations (and Training to Overcome This)
90.5 Improvisation
90.6 Postoperative Care
90.7 Triage
90.8 Specific Resources
90.8.1 Oxygen
90.8.2 Suction
90.8.3 Blood
90.8.4 Medications
90.9 Communication and Teamwork
90.10 Telemedicine
90.11 Cultural Sensitivity
90.12 Conclusions
Suggested Reading
91: The Impact of Trauma on the Psyche
91.1 Delirium
91.1.1 Diagnostic Criteria of Delirium
91.1.2 Clinical Features of Delirium
91.1.3 Investigations for Delirium
91.1.4 Management of Aggression in a Delirious Patient
91.1.5 Management of Alcohol Withdrawal in a Delirious Patient
91.2 Common Trauma-Related Psychological Disorders
91.2.1 Trauma- and Stress-Related Disorders
91.2.2 Management of Psychological Trauma
91.2.3 Counseling the Family
91.3 Impact of COVID-19
Suggested Reading
92: Rehabilitation
Suggested Reading
93: “Rehabilitation Matters!”: Physical Rehabilitation as an Essential Process Post-acute Trauma Care
93.1 Definition of Physical Medicine and Rehabilitation (PM&R)
93.2 History of PMR
93.3 The Rehabilitation “Team”
93.4 Rehabilitation Starts in ICU
93.5 Outcomes-Based Rehabilitation (OBR)
Suggested Reading
94: Penetrating Injury Prevention
94.1 An Ounce of Prevention
94.2 Availability and Accessibility: Primary Prevention
94.3 Focused Deterrence and Violence Interruptions: Secondary Prevention
94.4 Relapse and Recidivism: Tertiary Prevention
94.5 Learning from Alcohol Prevention Strategies
94.6 Summary
Suggested Reading
95: Forensic Pathology and Trauma
95.1 Introduction
95.2 How Forensic Science Has Developed Over the Years
95.3 Trauma and Clinical Forensic Medicine
95.4 Processing Potential Forensic Material
95.5 Relating to Trauma-Related Deaths
95.6 The Post-mortem Examination
95.6.1 Brief Summary of the Post-mortem Examination
95.7 Final Formal Post-mortem Report
Suggested Reading
96: Ethics in Severe Trauma
Suggested Reading
97: Organ Donation
97.1 Identifying Donors
97.2 Consent
97.3 Intensive Care Unit Admission and Protocols
97.4 Declaration of Brain Death
97.5 Aggressive Resuscitation
97.6 Brain Death-Related Complications
Suggested Reading
98: The Economics of Trauma Care
98.1 Macroeconomics of Trauma
98.2 Microeconomics of Trauma
98.3 Developing a “Theory of Business” for Trauma Care
98.4 Strategy
Suggested Reading

Citation preview

Elias Degiannis Dietrich Doll George C. Velmahos Editors

Penetrating Trauma A Practical Guide on Operative Technique and Peri-Operative Management Third Edition

123

Penetrating Trauma

Elias Degiannis • Dietrich Doll George C. Velmahos Editors

Penetrating Trauma A Practical Guide on Operative Technique and Peri-Operative Management Third Edition

Editors Elias Degiannis University of the Witwatersrand Medical School Johannesburg, South Africa

Dietrich Doll Saarland University, Medical School Homburg / Saar, Germany

George C. Velmahos Massachusetts General Hospital, Harvard University Medical School Boston, MA, USA

ISBN 978-3-031-47005-9 ISBN 978-3-031-47006-6 (eBook) https://doi.org/10.1007/978-3-031-47006-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2017, 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

To my parents who inspired me to do medicine and to my wife, Nellie, for her unconditional love and support. To my patients, who taught me a lot and to my teachers, who taught me everything. Elias Degiannis To my parents and to Simone, our children and grand children, and to my teachers. Time is love. Dietrich Doll To my parents, who lit my past, and to my wife and children, who light my present and future. George C. Velmahos

Preface

This book provides clear practical guidance on all aspects of surgical treatment of penetrating trauma and aims to foster the type of strategic thinking that can save patients’ lives. The coverage encompasses prehospital care, penetrating injuries to various body regions and specific organs, orthopedic injuries, peripheral arterial injuries, injuries to special groups of patients, including children and the elderly, military injuries, and a range of other topics. Based on their extensive personal experience, expert authors provide step-by-step instructions on evaluation, surgical techniques, and management of perioperative problems. Tips, tricks, and technical pearls are highlighted, and each chapter includes a list of the most important points to observe. This third edition of Penetrating Trauma has been extensively revised and updated—with inclusion of some entirely new chapters—to take into account the most recent trends in resuscitation, diagnostics, and treatment. It will be an ideal resource for those looking for practical solutions on how to treat injuries surgically. Johannesburg, South Africa Homburg, Saar, Germany Boston, MA, USA

Elias Degiannis Dietrich Doll George C. Velmahos

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Contents

Part I Prehospital Care, Diagnostic Tools and Resuscitation Strategies 1 Prehospital Care of Penetrating Trauma�� 3 David Carlbom and Eileen M. Bulger 2 Airway Management in Penetrating Trauma�� 15 Pudkrong Aichholz, Andreas Grabinsky, and Eileen M. Bulger 3 Damage Control Resuscitation in Penetrating Trauma: Rules of the Game �� 31 Christopher Reed, Adrian Camarena, and Suresh Agarwal 4 BLS Versus ALS �� 37 Dominik A. Jakob and Aristomenis K. Exadaktylos 5 Prehospital Care and Transport �� 45 Michael A. Frakes and Vahe Ender 6 Prehospital Monitoring During Transport�� 51 Kazuhide Matsushima and Heidi Frankel 7 Trauma Resuscitation�� 57 Rachel Morris and Marc de Moya 8 ABC Heuristics�� 63 Pantelis Vassiliu, George Konstantoudakis, Jason R. Degiannis, and Asad Mushtaq 9 Pediatric Trauma Resuscitation�� 71 Morgan L. Hennessy and Peter T. Masiakos 10 Fluids, Blood Substitutes, and New Tools�� 77 Sophia Tam, Lara Senekjian, and Ram Nirula 11 Emergency Department Thoracotomy�� 87 Simin Golestani, Austin Eagleton, and Carlos V. R. Brown 12 Intensive Care: Principles and Therapy�� 99 Zachary M. Bauman and Terence O’Keeffe 13 Ventilation in the Trauma Patient: A Practical Approach �� 109 Guy A. Richards, Timothy C. Hardcastle, and Richard E. Hodgson 14 ECMO in the Trauma Patient: A Practical Approach�� 119 Jerome Crowley 15 Sepsis and Septic Shock�� 125 Mervyn Mer and Martin W. Dünser 16 Endpoints of Resuscitation�� 139 David Muckart ix

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17 Plain X-Rays for Penetrating Trauma �� 145 Simeng Wang, Donald J. Green, Mark Bernstein, and Marko Bukur 18 Computed Tomography in the Workup of Patients with Penetrating Trauma�� 153 Mark E. Hamill 19 Portable Ultrasound as an Adjunct in Penetrating Trauma�� 165 Jim Connolly 20 Laparoscopy and Penetrating Trauma�� 175 Nicolas Melo and Daniel R. Margulies 21 Angiography and Interventional Radiology�� 181 Marc Kalinowski 22 Imaging of Penetrating Urologic Trauma�� 187 Beat Schnüriger and Donald J. Green 23 Practical Approach to REBOA �� 191 Lauri Handolin, Ville Vänni, and Viktor Reva 24 Video-Assisted Thoracic Surgery in Penetrating Chest Trauma�� 203 François Pons, Henri de Lesquen, Charlotte Baltazard, and Guillaume Boddaert 25 Diagnostic Peritoneal Lavage (DPL) Unplugged�� 211 Keneeshia Williams and Terence O’Keeffe 26 Mass Casualties and Triage in Military and Civilian Environment�� 217 James M. Ryan, Dietrich Doll, and Christos Giannou 27 Ballistics in Trauma �� 231 Maeyane S. Moeng and Kenneth D. Boffard Part II Surgical Strategies in Penetrating Trauma to Head, Face, and Neck 28 Surgical Strategies in Trauma�� 241 Toby P. Keeney-Bonthrone, Rachel M. Russo, Jessie M. Ho, and Hasan B. Alam 29 Surgical Strategies in Trauma to the Head, Face, and Neck�� 249 Natalie Wall, Martha L. McCrum, and Heather L. Evans 30 Penetrating Injuries of the Face�� 259 Rizan Nashef and Thomas B. Dodson 31 Operative Strategies in Penetrating Trauma to the Neck�� 271 Libby Schroeder and Marc de Moya 32 Access to the Neck in Penetrating Trauma�� 277 Jeffrey Ustin 33 Penetrating Trauma to the Larynx and the Cervical Trachea�� 281 Lisa M. Kodadek, Alicia Kieninger, and Elliott R. Haut 34 Penetrating Injury to the Pharynx and Cervical Esophagus�� 289 Jessica A. Keeley and Angela L. Neville 35 Carotid, Jugular and Vertebral Blood Vessel Injuries�� 297 Dirk Le Roux, Martin Veller, and Ian Grant

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Part III Surgical Strategies in Penetrating Trauma to the Chest 36 Penetrating Trauma to the Subclavian Vessels�� 309 Daniel F. Du Toit 37 Penetrating Trauma to the Thoracic Oesophagus�� 321 Elias Degiannis, Tugba H. Yilmaz, and Martin Mauser 38 Penetrating Trauma to the Mediastinal Trachea and Main Bronchi�� 327 Elias Degiannis, Georgy Ivakhov, and Alexander Sazhin 39 Operative Management of Pulmonary Injuries�� 335 Katherine R. Iverson and Marc de Moya 40 Operative Management of Delayed Complications of Pulmonary and Pleural Injury�� 339 George V. Oosthuizen, Victor Y. Kong, and Ofer Merin 41 Penetrating Injuries to the Mediastinal Vessels�� 347 Agneta Geldenhuys 42 Penetrating Cardiac Trauma�� 357 Elias Degiannis, Denzel P. Mogabe, Ioannis Massalis, and Dietrich Doll 43 Penetrating Injuries to the Diaphragm�� 367 Elmin Steyn 44 Approach to Thoracoabdominal Injury�� 373 Elias Degiannis, Thorsten Hauer, and Dietrich Doll 45 Loss of the Chest Wall �� 375 John C. Mayberry Part IV Surgical Strategies in Penetrating Trauma to the Abdomen and Pelvis 46 Access to the Abdomen: Emergency Laparotomy�� 383 George C. Velmahos 47 Damage Control Surgery�� 387 Riaan Pretorius, Frank Plani, Kenneth D. Boffard, and Vicky Jennings 48 Beyond Damage Control Surgery: Abdominal Wall Reconstruction and Complex Hernia Repair �� 401 Rifat Latifi 49 Abdominal Esophagus and Stomach�� 411 Chelsea R. Horwood and Clay Cothren Burlew 50 Duodenum�� 419 George C. Velmahos 51 Penetrating Trauma to the Pancreas�� 427 Martin D. Smith, Dietrich Doll, and Elias Degiannis 52 Liver and Extrahepatic Bile Ducts �� 435 Frederick Millham 53 Large and Small Bowel�� 441 Jonathan E. Schoen and Herb A. Phelan

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54 Injury of the Kidney, Ureter, and Bladder�� 447 Brian I. Shaw and Suresh Agarwal 55 Lower Genitourinary Injuries�� 457 Donald Hannoun and Charles D. Best 56 Major Abdominal Veins�� 465 Peep Talving, Sten Saar, and Kenji Inaba 57 Major Abdominal Arteries�� 475 Lydia Lam and Kenji Inaba 58 Spleen�� 483 Ragavan Narayanan and Heena P. Santry 59 Penetrating Rectal Injuries �� 489 Andrew J. Nicol and Pradeep H. Navsaria 60 Abdominal Compartment Syndrome�� 493 Osamu Yoshino, Nicholas Lee, and Zsolt J. Balogh 61 SNOM: Conservative Management of Solid Viscera�� 499 Pradeep H. Navsaria 62 Bleeding in the Pelvis �� 503 Edward Kelly and Francesca Izzo Part V Neurological Trauma 63 Gunshot Injuries to the Head�� 509 Ekkehard M. Kasper, Hanan Algethami, Radwan Takroni, and Burkhard S. Kasper 64 Approach to Penetrating Injury of the Spinal Cord�� 523 Joachim M. K. Oertel and Jason R. Degiannis 65 Early Neurotrauma Rehabilitation�� 529 Sara E. Cartwright, Kate E. Delaney, and Ronald E. Hirschberg Part VI Surgical Strategies in Penetrating Trauma and Orthopedic Injuries 66 Introduction to Orthopedic Injuries�� 541 Thomas Scalea 67 Extremity Fractures�� 547 Jeffrey Ustin 68 Compartment Syndrome of the Extremities �� 551 Mark W. Bowyer 69 Penetrating Trauma to the Hand�� 561 Sascha Flohé, Konstantinos Degiannis, and Tim Lögters 70 Penetrating Trauma to the Foot�� 569 Tobias Gehlen and Sven Märdian 71 Penetrating Trauma: Amputations�� 579 Alexander Upfill-Brown, Cyrus E. Taghavi, Nelson F. SooHoo, and Areti Tillou

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72 Amputations of Hand and Foot after Destructive Gunshot Injuries�� 589 Philipp Mörsdorf, Konstantinos Degiannis, and David Osche 73 Anterior Exposure of the Thoracic and Lumbar Spine �� 601 Hani Seoudi Part VII Peripheral Arterial Injuries 74 Peripheral Arterial Injuries from Penetrating Trauma �� 609 Matthew J. Martin and Ali Salim 75 Axillary and Brachial Vessels�� 611 Ali Salim, Kristin Madenci, and Matthew J. Martin 76 Femoral Vessels�� 617 David R. King 77 Popliteal Vessels�� 623 John M. McClellan, Matthew J. Martin, and Ali Salim 78 Penetrating Arterial Injuries Below Elbow/Knee �� 635 Carl Magnus Wahlgren and Louis Riddez Part VIII Other Topics 79 Management of Penetrating Soft Tissue Injuries�� 643 Christos Ladas 80 Burns and Inhalational Injury�� 651 Jonathan E. Schoen, Herb A. Phelan, and Jennifer Lang Mooney 81 Crush Injuries�� 661 Jonathan E. Schoen and Herb A. Phelan 82 Blast Injuries�� 671 Joe DuBose, David S. Plurad, and Peter M. Rhee 83 The Elderly Patient�� 679 Thomas Lustenberger and Kenji Inaba 84 The Pediatric Patient �� 689 Graeme Pitcher and Alan F. Utria 85 The Pregnant Patient �� 697 Andreas Larentzakis and Dimitrios Theodorou 86 Emergency Caesarean Delivery in Pregnant Patient with Penetrating Trauma and In-Theatre Neonatal Support �� 703 Alexandros I. Daponte, George Valasoulis, and Gordana Tomasch 87 Anticoagulation in Penetrating Trauma�� 713 David R. King 88 Approach to Perioperative Nutritional Support in Penetrating Trauma �� 715 Viktor Justin, Mehmet Zeki Buldanli, Philipp Stiegler, Abraham Fingerhut, and Selman Uranues 89 Pain Management in Penetrating Trauma: A Practical Approach �� 721 Georgia G. Kostopanagiotou, Thomas John Papadimos, and Maria N. Pasalis Psomas

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90 Austere Conditions: Surgery with Limited Resources �� 743 Terence O’Keeffe 91 The Impact of Trauma on the Psyche�� 753 Fatima Y. Jeenah and Mahomed Y. Moosa 92 Rehabilitation �� 761 Amy H. Phelan 93 “Rehabilitation Matters!”: Physical Rehabilitation as an Essential Process Post-acute Trauma Care�� 765 Virginia S. Wilson 94 Penetrating Injury Prevention�� 769 Alexandra R. Coward, David S. Plurad, and Devon S. Callahan 95 Forensic Pathology and Trauma �� 775 Shirley F. A. P. Moeng and Maeyane S. Moeng 96 Ethics in Severe Trauma�� 783 Konstantinos Degiannis, Jason R. Degiannis, and Philipp Mörsdorf 97 Organ Donation�� 787 Eric J. Ley and Ali Salim 98 The Economics of Trauma Care �� 793 Frederick Millham

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About the Editors

Elias Degiannis MD, PhD, FRCS (Glasg.), FCS (SA), FACS, Subspecialty Trauma Surgery (SA), is Professor Emeritus at the Department of Surgery of the University of the Witwatersrand, Johannesburg, South Africa. He was the Head of the Trauma Directorate at the Chris Hani Baragwanath Academic Hospital and Academic Head of the Division of Trauma of the University of the Witwatersrand. He developed several international “Hands-on” Fellowships for overseas surgeons who wanted to expand their experience in Trauma. He has Honorary Memberships/ Fellowships of the Hellenic Trauma Society, the Brazilian College of Surgeons, the Association of Surgeons of Spain, the German Society for Surgery, the Finnish Trauma Society, the Austrian Society for Surgery, and the German Trauma Society. He has been awarded the Silver and the Golden Cross of Honour of the German Armed Forces. Dietrich Doll MD, PhD (med.), PhD (theol.), Surgeon, Visceral Surgeon, FACS, is a Professor of Surgery and Director of ATLS, DSTC Director and International Faculty; Disaster and Mass Casualty Medicine, Hyperbaric and Diving medicine. He is currently a Fellow of the American College of Surgeons (FACS), a Professor of Surgery at the University of Saarland, Medical School, Visiting Professor at Harvard University, Honorary member of the Hellenic Trauma Society, and Head of the Procto-Surgery Department at St. Mary’s Hospital Vechta. He is the founder and CEO of the Vechta Research Institute since 2013. Professor Doll was a Honorary Senior Consultant and Honorary Senior Lecturer, Department of Surgery, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand Medical School, Johannesburg, South Africa. George C. Velmahos MD, PhD, MSEd, FACS, FCCM, FRCS (Ed.), FCRPS (Glasg.), MCCM, is the John F Burke Professor of Surgery at Harvard Medical School and the Chief of the Division of Trauma, Emergency Surgery, and Surgical Critical Care at the Massachusetts General Hospital in Boston, USA. He is a Fellow of the American College of Surgeons, American College of Critical Care Medicine, Royal College of Surgeons of Edinburgh, and Royal College of Physicians and Surgeons of Glasgow. He is also a member and officer in numerous American and International surgical societies. He is the founder of the MGH Trauma Research Center, has authored over 600 peer-reviewed publications, and directs the annual Harvard Trauma Symposium. He is an Honorary Professor in multiple Universities around the world.

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Part I Prehospital Care, Diagnostic Tools and Resuscitation Strategies

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Prehospital Care of Penetrating Trauma David Carlbom and Eileen M. Bulger

1.1 Planning a Systematic Approach Prehospital care and movement of critically injured penetrating trauma patients are key components of an effective system of trauma care.

1.1.1 Scene Safety and Adequate Resources The care of critically ill penetrating trauma patients begins before the time of injury. Emergency Medical Services (EMS) leaders need to develop clear advance plans for the management of these challenging patients. Scene security and safety of EMS personnel is paramount, and clear guidelines should direct medical teams to stay out of dangerous situations until the scene is controlled by law enforcement. Joint training exercises with law enforcement are encouraged to optimize the response to mass shooting events. Even after law enforcement control is attained, providers should maintain situational awareness and strive for rapid departure from the location of the incident. There are no universally accepted guides or formulas regarding adequate staffing to care for a critically ill patient; one philosophy is to consider the time-critical nature of penetrating trauma to be akin to a building on fire. Severity of illness continues to grow and the time window for intervention continues to close with every minute. In cardiac arrest, survival improves with seven or more prehospital providers on-scene within the first 10 min. Many medical providers are

D. Carlbom (*) Pulmonary Critical Care & Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA e-mail: [email protected] E. M. Bulger Division of Trauma, Burns, & Critical Care, Harborview Medical Center, Department of Surgery, University of Washington, Seattle, WA, USA e-mail: [email protected]

needed immediately, and it is better to assign more than the usual number of staff, with the option to reduce staff as able.

1.1.2 Dispatching Appropriate Resources Emergency dispatchers face the challenge of deciding the most appropriate resources to send to the scene of an injury based on telephone reports only. As time is the most critical factor in the prehospital management of trauma patients, dispatch centers should strive to expedite dispatching times, and develop protocols that allow dispatchers to simultaneously send assistance while continuing to obtain information from callers. This “fast-dispatch” protocol should have a goal of achieving call answer to dispatch within 30 s. While each trauma system should develop and constantly refine dispatch criteria to attain the best information on what resources to send to aid trauma patients, the “Guidelines for Field Triage of Injured Patients” can provide some insight. These guidelines describe physiologic, anatomic, mechanism of injury, and special guides to triage trauma patients to high-level care. Patients with absent respirations or pulse, those with tachypnea, and unconscious patients should be given highest priority and the most resources. Ringburg confirmed this in a systematic review of dispatch criteria. The criterion “loss of consciousness” had a sensitivity of 93–98% and a specificity of 85–96% in this review. The anatomic criteria of “penetrating injury to the torso, neck, head” should capture the highest risk victims of penetrating trauma. In a retrospective review of trauma deaths in the first hour, 31% of the penetrating trauma deaths were a result of GSWs to the chest, and 21% from GSWs to the head. Thus any penetrating injury in these areas should prompt the highest level of response.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_1

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1.1.3 ALS vs. BLS Care and Prehospital Time As with any subject area in medicine with little concrete evidence, prehospital care of injured patients is enveloped in controversy. It seems intuitive that only advanced prehospital care can benefit patients in extremis. However, due to a wide variation in prehospital systems, and the inability to randomize patients to advanced vs. basic life support model within any one system, there exists only limited data for the true benefit of ALS care, and some suggestion that any benefit may be negated by prolonged scene times. When caring for critically ill trauma patients in the prehospital environment, time is the single most crucial factor. Historically, the first 60 min have been considered the window of time in which the patient must reach the trauma surgeon, but it may be even shorter. Thus, in all trauma patients, prehospital providers must balance the need for field-based interventions with prompt transport to definitive care, moving beyond the previously articulated binary systems of “rapid transport” vs. “stabilize on scene.” In a cross-sectional investigation of the relationship of prehospital time to mortality, Baez and colleagues used logistic regression to demonstrate that longer prehospital time correlated significantly with hospital length of stay and complications, but not with mortality among young patients. In elderly trauma patients prehospital time had no significant predictive effect on length of stay, complications, or mortality. In a review of 442 penetrating trauma patients treated in Copenhagen between January 2002 and September 2009, Funder et al. noted that a higher proportion of patients who had a scene time > 20 min died. This was not significant after adjustment for other care measures and severity of illness. When McCoy et al. reviewed the prehospital time for 2997 consecutive penetrating trauma patients at a single Level 1 urban trauma center, there was a time association. On multivariate regression of patients with penetrating trauma, they noted that a scene time greater than or equal to 20 min was associated with higher odds of mortality than scene time less than 10 min, with an odds ratio (OR) of 2.90 (95% confidence interval [CI] 1.09–7.74). This finding was not present in blunt trauma patients during the same time period. In a secondary analysis of an out-of-hospital, prospective cohort registry of 3656 hypotensive adult trauma patients transported by 146 EMS agencies across North America Newgard et al. found no significant association between time and mortality for any EMS interval (activation, response, on-scene, transport, or total EMS). In a different EMS system Brown et al. describe no significant association between prehospital time and 30-day mortality; in the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS.

D. Carlbom and E. M. Bulger

There may be specific types of trauma patients that benefit from shorter duration prehospital phase of care. After adjustment for several system factors, one group found increased mortality associated with increasing prehospital time for patients with systolic blood pressure less than 90 mmHg (OR, 1.039; 95% CI, 1.003–1.078, p = 0.04), Glasgow Coma Scale score of 8 or less (OR, 1.047; 95% CI, 1.018–1.076; p 4.5 cm. In a retrospective analysis of 10 years of patients (n = 335) receiving prehospital needle thoracostomy in the second intercostal space at midclavicular line, CT scans were reviewed to record the location of catheters left indwelling. Thirty-nine percent of attempts failed to reach the pleural space. Increasing chest wall thickness correlated with the failure of the catheter to reach the pleural space. Because of the increasing thickness of the anterior chest wall in adults, the tenth edition of Advance Trauma Life Support suggests needle thoracostomy be performed in the fourth or fifth ICS in the mid-axillary line. A long, large-bore needle should be used. This procedure appears safe in one large review of paramedic-performed needle thoracostomies and was associated with improved survival.

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1.4 Treatment: Circulation 1.4.1 IV Volume Resuscitation Intravenous fluid resuscitation is commonly used with the goal of restoring perfusion to critical end organs, thus ameliorating the injury caused by hypovolemic shock. There are many controversies revolving around this practice, and many questions remain regarding the use of IV fluids, what the resuscitation goal should be, and what route of IV access is most appropriate. If the primary goal of prehospital trauma treatment is to minimize field time and expedite transportation to a trauma center, does the initiation of IV fluid therapy impede this goal? There exists great variation in the amount of time required to place an IV. Some authors report as little as 2–4 min and others much longer, 14–16 min. Paramedics need to place IVs during transport and not delay transport for the initiation of IV fluid resuscitation. Due to brief transport times in the urban environment, the amount of fluid given prior to ED arrival is often quite small. In one review on this topic, the average amount of fluid given in 14 studies was 959 mL. Even though the amount of fluid may be inadequate, there is a non-statistically significant trend toward prehospital fluid being associated with a 3.9-fold increase in survival. Fluid is the primary therapy that may account for improvement in blood pressure and heart rate in one comparison of prehospital and ED vital signs in trauma patients. In a series of 19,409 patients, Arbabi described 31% of patients having an increase in their systolic blood pressure in the ED compared to the field.

1.4.2 Hypotensive Resuscitation Patients with uncontrolled hemorrhage represent a unique and special challenge when deciding how much IV fluid resuscitation to deliver. One working model is that the delivery of large volumes of non-oxygen carrying fluid cools the patient, impairs oxygen delivery, and dilutes clotting. There is also animal data that suggests partially controlled bleeding or temporarily clotted aortic injury in pigs re-bleeds when the systolic blood pressure is raised above 94 mmHg. Cannon first described limiting IV fluid administration on the battlefields of WWI: “Injection of a fluid that will increase blood pressure has dangers in itself. Hemorrhage in a case of shock may not have occurred to a marked degree because blood pressure has been too low and the flow too scant to overcome the obstacle offered by the clot. If the pressure is raised before the surgeon is ready to check any bleeding that may take place, blood that is sorely needed may be lost”. To prevent these deleterious effects, they established a target systolic blood pressure range of 70–80 mmHg.

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There are many animal studies of hypotensive resuscitation with a myriad of endpoints, including inflammatory activation and survival. In a systematic review of these trials, one author concluded, “Hypotensive resuscitation reduced the risk of death in all of the trials investigating it”. Two randomized controlled trials of hypotensive resuscitation in penetrating trauma patients with uncontrolled hemorrhage have been performed. Bickell and group performed a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure 90 mmHg. The immediate resuscitation group received an average of 870 mL of Lactated Ringer’s solution compared to 92 mL in the delayed group. Twelve percent of the patients died before reaching the operative intervention, and the systolic blood pressure was improved on arrival to the operating room in both groups. Among the 289 patients who received delayed fluid resuscitation, 203 (70%) survived to hospital discharge, as compared with 193 of the 309 patients (62%) who received immediate fluid resuscitation (p = 0.04). Intraoperative blood loss and complications were not different between the groups. There are several limitations to this study, most notably that it was unblinded and that there may be survival bias: patients surviving (despite minimal fluids) to the OR were less sick than those surviving with fluid therapy to the OR. This study was also limited to an urban environment with short transport times to a Level 1 trauma facility. In a more recent randomized trial performed by the Resuscitation Outcomes Group, patients presenting with systolic BP 100 mmHg or 70 mmHg. One hundred ten patients were enrolled over 20 months. Although there was a significant difference in observed SBP (114 mmHg vs. 100 mmHg, p