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Current Therapy of Trauma and Surgical Critical Care E-Book

Current Therapy of Trauma and Surgical Critical Care E-Book

Donald D. Trunkey | Juan A. Asensio


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Book Details


Demanding surgical situations require expert advice from pioneers in the field as well as from those on the front lines of trauma care. Practical and evidence-based, Current Therapy of Trauma and Surgical Critical Care, 2nd Edition, draws on the experience of Drs. Juan A. Asensio and Donald D. Trunkey to offer a comprehensive, contemporary summary of the treatment and post-operative management of traumatic injuries. The concise format makes it ideally suited for everyday use, and new, full-color illustrations highlight the most important aspects of urgent surgical care, including ventilator management, damage control, noninvasive techniques, imaging, infection control, dealing with mass casualties, and treating injuries induced by chemical and biological agents.

  • Prepare for the unexpected with practical, concise coverage of major surgical problems in trauma and critical care.
  • Get expert and up-to-date guidance on ventilator management, damage control, noninvasive techniques, imaging, infection control, dealing with mass casualties, treating injuries induced by chemical and biological agents, and much more.
  • Find the information you need quickly and easily through numerous illustrations, key points boxes, algorithms, and tables.
  • Get up to date with current developments in the use of endovascular stents for thoracic aortic injuries; the diagnosis of peripheral vascular injuries; new interventional imaging techniques and new uses for ultrasound; and new ventilator techniques such as HFJV and APRV.
  • Make the most of new antibiotics to improve control of surgical infection, learn to use new antifungal agents, and implement innovative therapies to combat both methicillin- and oxacillin-resistant organisms.
  • Benefit from tremendous recent advances in the field (often as a result of experience gained by military and civilian surgeons), including the development of damage control.

Table of Contents

Section Title Page Action Price
Front Cover Cover
Inside Front Cover ES2
Current Therapy of Trauma and Surgical Critical Care iii
Copyright iv
Contributors v
Foreword xvii
Preface xix
If- xix
Contents xxi
Part I: Trauma Systems 1
Development of Trauma Systems 1
Modern trauma system development 2
Are trauma systems effective? 3
What are the current problems? 3
Solutions 4
Trauma Center Organization and Verification 5
Suggested readings 5.e1
Trauma Center Organization and Verification 5.e2
Trauma system and trauma center organization 5.e2
Trauma System Organization 5.e2
Trauma Center Organization 5.e2
Trauma Medical Director 5e.1
Trauma Program Manager/Trauma Nurse Coordinator 5e.1
Trauma Registrar 5e.1
Trauma performance improvement process 5e.2
Trauma center verification 5e.2
Consultation 5e.2
Verification 5e.2
Suggested Readings 5e.2
Injury Severity Scoring: Its Definition and Practical Application 6.e1
Injury description and scoring: conceptual background 6.e1
Testing a test: statistical measures of predictive accuracy and power 6.e2
Measuring anatomic injury 6.e3
Measuring physiologic injury 6.e5
Measuring physiologic reserve and comorbidity risk 6.e6
More powerful predictions: combining several types of information 6.e6
Statistical considerations 6.e9
Improved prediction in trauma scoring 6.e10
How Good Are Current Scoring Systems? 6.e10
The Uses of Injury Scoring 6.e10
Recommendations 6.e11
Conclusions 6.e11
Suggested Readings 6.e11
Role of Alcohol and Other Drugs in Trauma 6.e12
Epidemiology 6.e12
Alcohol 6.e12
Drugs 6.e12
Effects of alcohol and drugs on management and outcome 6.e12
Alcohol and injury recidivism 6.e13
Withdrawal syndromes: prophylaxis and treatment 6.e13
Definition of alcohol and drug problems 6.e13
Rationale for brief alcohol interventions in trauma centers 6.e14
Screening for Alcohol and Drug Problems 6.e14
Goals of Brief Interventions 6.e15
Brief Intervention Techniques 6.e15
Summary 6.e15
Key Points 6.e15
Suggested Readings 6.e16
Role of Trauma Prevention in Reducing Interpersonal Violence 6.e17
Understanding the problem 6.e17
Impact of enhanced trauma commitment on patient outcomes 6.e17
In-hospital prevention: shortcomings 6.e17
Effectiveness of a violence prevention program 6.e17
Culture of violence 6.e18
Suggested Readings 6.e19
Trauma Scoring 6.e20
Anatomic scoring systems 6.e20
Abbreviated Injury Scale 6.e20
Injury Severity Scale 6.e20
Anatomic Profile and New Injury Severity Score 6.e21
ICD-9 Injury Severity Score 6.e21
Physiologic scoring systems 6.e22
Glasgow Coma Scale 6.e22
Revised Trauma Score 6.e22
Acute Physiology and Chronic Health Evaluation 6.e22
Physiologic Reserve 6.e22
Risk-adjustment scoring systems 6.e22
Trauma and Injury Severity Score 6.e22
A Severity Characterization of Trauma 6.e23
Mechanism of Injury 6.e23
Scoring systems evaluation 6.e23
Data Collection 6.e23
Databases 6.e23
Outcome Measures 6.e23
Summary 6.e24
Suggested Readings 6.e24
Results of the Medical Strategy for Military Trauma in Colombia 7
Knowing the Primary Enemy 7
Knowing the Secondary Enemy 8
Strategic Plan for Medical Care 9
Results of the Strategy 9
Conclusions 13
Suggested Readings 13.e1
Part II: Prehospital Trauma Care 15
Influence OF Emergencymedical Services Onoutcome Attrauma Center 15
Golden hour or golden opportunity? 15
Prehospital fluids 16
To bleed or not to bleed-should tourniquets be standard care? 16
Conclusion 17
Part III: Initial Assessment and Resuscitation 57
Airway Management:What Every Trauma Surgeon Should Know,From Intubation to Cricothyroidotomy 57
Airway anatomy 57
Assessing the airway 63
Controlling the airway 63
Documentation of proper endotracheal tube placement 64
Combitube 64
Endotracheal intubation 65
Nasal Intubation 65
Orotracheal Intubation 65
Adjuncts to Orotracheal Intubation 67
Surgical airway 68
Needle Cricothyroidotomy 68
Part IV: Head and Central Nervous System Injuries 127
Traumatic Brain Injury:Pathophysiology, Clinical Diagnosis, and Prehospital and Emergency Center Care 127
Incidence 127
Mechanism of injury 127
Subdural Hematoma 127
Epidural Hematoma 127
Subarachnoid Hemorrhage 128
Parenchymal Lesions 128
Ischemia 128
Diffuse Axonal Injury 129
Cellular and Molecular Factors 129
Clinical diagnosis 129
Clinical Examination 129
Serum Markers 129
Initial clinical interventions: prehospital and emergency center care 129
Airway 130
Breathing 130
Circulation 130
Imaging modalities: what, when, and why? 130
Computed Tomography Scanning 130
Magnetic Resonance Imaging 130
Angiography 131
Injury grading 131
Glasgow Coma Scale 131
Marshall Computed Tomography Scale 131
Abbreviated Injury Scale 131
Other Classification Schemes 132
Mild and Moderate Traumatic Brain Injury 132
Conclusions and algorithm 132
Traumatic Brain Injury:Imaging, Operative and Nonoperative Care, and Complications 133
Suggested Readings 132.e1
Traumatic Brain Injury: Imaging, Operative and Nonoperative Care, and Complications 133
Surgical management 133
Positioning 133
Bone Flap 133
Brain Swelling 133
Epidural Hematomas 134
Intraparenchymal Lesions 134
Intracranial Pressure Monitoring 134
Coagulopathy 134
Summary 134
Nonoperative management 134
Location of Care 134
Secondary Insults 134
Ventilator Weaning and Tracheostomy 135
Sedation 135
Cerebral Monitoring 135
Nutrition 135
Fluids and Electrolytes 135
Physical, Occupational, and Speech Therapy 135
Fever 135
Deep Venous Thrombosis 135
Transfusion Thresholds 136
Treatment of Intracranial Hypertension 136
Computed Tomography Scanning 136
Sedation and Paralysis 136
Cerebrospinal Fluid Drainage 136
Osmotic Diuretics 136
Hyperventilation 136
Barbiturate Coma 136
Decompressive Craniectomy 136
Hypothermia 137
Individualization of Treatment 138
Failure of Intracranial Pressure Prophylaxis 138
Guidelines 138
Failure of Clinical Trials 138
Morbidity and complications 138
Mortality 138
Penetrating Brain Injury 139
Conclusions and algorithm 139
Key Points 140
Suggested Readings 140.e1
Spine: Spinal Cord Injury,Blunt and Penetrating,Neurogenic and Spinal Shock 140
Incidence 140
Anatomy and biomechanics 140
Spinal Anatomy 140
Biomechanics of the Spine 141
Mechanism of injury 141
Penetrating Spinal Cord Injury 142
Blunt Spinal Cord Injury 142
Severity/grading of spinal cord injuries 142
Neurologic and Functional Outcome Scales 142
Spinal Cord Syndromes 143
Diagnosis 144
Management of acute spinal cord injury 145
Prehospital Care 145
Acute Emergency Department Evaluation/Management 145
Surgical Intervention 146
Thoracolumbar Fractures 147
Optimal Timing of Surgical Intervention in Spinal Cord Injuries 147
Penetrating Spinal Cord Injuries 147
Nonoperative Acute Interventions 147
Pharmacotherapy and Spinal Cord Injury 147
Institution of Blood Pressure Parameters 147
Subacute Management of Spinal Cord Injury 150
Morbidity and complications management in spinal cord injury 150
Neurogenic Shock 150
Spinal Shock 150
Pulmonary Complications 150
Thromboembolism 151
Genitourinary Complications 151
Gastrointestinal Complications 151
Skin Care 151
Posttraumatic Syringomyelia 151
Mortality 152
Conclusion 152
Suggested readings 152.e1
Part V: Maxillofacial and Ocular Injuries 153
Maxillofacial Trauma 153
Airway and breathing 153
Circulation and control of hemorrhage 153
Epistaxis 153
History and physical examination 154
Radiographs 154
Soft tissue injuries 154
Local Anesthesia 154
Antibiotics 154
Abrasions 154
General Concepts for Laceration Repair 154
Scalp Laceration 154
Intraoral Injury 154
Tongue Laceration 154
Lip Laceration 154
Nasal Laceration 155
Ear Laceration 155
Orbital Laceration 155
Parotid Gland Injury 155
Facial Nerve Injury 155
Facial fractures 155
Nasal Bone Fractures 155
Zygomatic Fractures 156
Orbital Fractures 156
Mandibular Fractures 158
Le Fort Fractures 159
Frontal Sinus Fractures 160
Naso-Orbital-Ethmoid Fractures 161
Conclusions 162
Suggested Readings 162.e1
Trauma to the Eye and Orbit 162
Incidence 163
Mechanism of injury 165
Diagnosis 166
Orbital Trauma 166
Ocular Trauma 168
Anatomic location of injury and injury grading-ocular trauma classification group 172
Medical and surgical management 173
Trauma to the Orbit 173
Conclusions and algorithm 176
Suggested Readings 177.e1
Part VI: Neck Injuries 179
Penetrating Neck Injuries: Diagnosis and Current Management 179
Anatomy of the neck 179
Initial evaluation 179
Aerodigestive injury 179
Soft tissue injury 181
Thoracic duct injury 181
Vascular injury in the neck 181
Treatment of carotid artery injuries 184
Conclusion 185
Suggested Readings 185.e1
Blunt Cerebrovascular Injuries 185
Signs and symptoms 185
Mechanism and patterns of injury 185
Diagnostic imaging 186
Injury grading scale 187
Incidence of blunt cerebrovascular injuries 187
Antithrombotic treatment 188
Role of endovascular stents 191
Long-term follow-up and outcome 191
Conclusions 191
Suggested Readings 191.e1
Tracheal, Laryngeal, and Oropharyngeal Injuries 192
Pharyngeal injury 195
Incidence 195
Mechanism of Injury 195
Diagnosis 195
Larynx 195
Surgical Anatomy 195
Laryngeal Injury 196
Incidence 196
Mechanism of Injury 196
Diagnosis 196
Treatment 196
Trachea 198
Surgical Anatomy 198
Tracheal Injury 198
Incidence 198
Mechanism of Injury 199
Cervical Trachea 199
Intrathoracic Tracheal Injury 200
Diagnosis 200
Surgical management 200
Nonoperative Management 200
Nonoperative Case Presentation 200
Operative Management 201
Morbidity 202
Early Complications 202
Late Complications 203
Other Potentially Life-Threatening Complications 203
Mortality 204
Anatomy of upper airway 193
Oral Cavity 193
Boundaries 193
Contents 193
Pharynx 193
Surgical Anatomy 193
Suggested Readings 204.e1
Part VII: Thoracic Injuries 205
Pertinent Surgical anatomy of the Thorax and Mediastinum 205
Pericardium 212
Subxiphoid Space 213
Heart 214
Body Surface Markings for the Heart 214
External Features 214
Coronary Arteries and Veins 218
Conduction System 218
Internal Features of Heart Chambers 219
Pulmonary Artery and Swan-Ganz Catheter Placement 221
Hilum of the lung 222
Right Hilum 222
Left Hilum 226
Lung anatomy 226
Aorta, trachea, esophagus, and thoracic duct 226
Aorta 226
Trachea 227
Esophagus 228
Thoracic Duct 228
Chest wall 205
Muscles of the chest wall 207
Intercostal space 208
Pleural space 209
Diaphragm 209
Suggested Readings 228.e1
Thoracic Wall Injuries:Ribs, Sternal, and Scapular Fractures; Hemothoraces and Pneumothoraces 229
Incidence 229
Mechanism of injury 229
Diagnosis 229
Physical Examination 229
Radiographic Studies 230
American association for the surgery of trauma-organ injury scale grading 232
Management of specific injuries of the chest wall 233
Chest Wall Defects 233
Rib Fractures and Flail Chest 233
Narcotics 233
Regional Anesthesia 233
Operative Fixation of Ribs 234
Pneumothorax and Hemothorax 234
Tube Thoracostomy: Technique and Management 235
Sternal Fractures 235
Scapular Fractures 236
Scapulothoracic Dissociation 236
Clavicular Fractures 236
Complications of hemopneumothorax 236
Empyema 236
Pneumatocele 237
Persistent Air Leaks and Bronchopleural Fistula 237
Complications of Bony Injuries 237
Conclusions 237
Diagnostic and Therapeutic Roles of Bronchoscopy and Video Assisted Thoracoscopy in the Management of Thoracic Trauma 238
Incidence 238
Diagnostic and therapeutic roles of video-assisted thoracoscopic surgery 238
Indications and Patient Selection 238
Diaphragmatic Injuries 239
Retained Thoracic Collection 239
Persistent Hemorrhage 240
Persistent Pneumothorax 240
Other Indications and Applications 240
Surgical Approach 240
Morbidity and Complication Management 240
Diagnostic and therapeutic role of bronchoscopy 240
Basic Technique of Flexible Fiberoptic Bronchoscopy 241
Preparation 241
Technique 241
Monitoring 241
Complications of Bronchoscopy 241
Diagnostic Role of Flexible Fiberoptic Bronchoscopy 241
Acute Trauma 241
Tracheobronchial Injury 241
Acute or Late Onset Bleeding Within the Tracheobronchial Tree 242
Inhalational Injury 242
Ventilator-Associated Pneumonia 242
Stricture 243
Therapeutic Role of Flexible Fiberoptic Bronchoscopy 243
Control of Acute or Late-Onset Hemoptysis 243
Stent Repair of Acute Airway Trauma 243
Removal of Foreign Body 243
Toilet for Pulmonary Collapse, Massive Secretions, and Aspiration 243
Percutaneous Tracheostomy 244
Management of Bronchopleural Fistula 244
Dilatation/Laser Therapy of Tracheobronchial Strictures 244
Drainage of Lung Abscess 244
Conclusion 244
Suggested Readings 244.e1
Pulmonary Contusionand Flail Chest 245
Incidence 245
Mechanisms of injury 245
Physical Mechanisms of Injury 245
Pathophysiology 245
Shunting and Hypoxemia 246
Increased Work of Breathing and Ventilatory Failure 246
Inflammatory Lung Injury 246
Extravascular Lung Water 247
Diagnosis 247
Physical Examination 247
Chest Radiographs 247
Chest Computed Tomography 248
Physiologic Studies 249
Anatomic location of injury and injury grading 249
Management 249
Immediate Management 249
Intensive Care Unit Management 251
General Principles of Ventilator Management 251
Ventilatory Support 251
Oxygenation Support 251
Pain Management 252
Steroids 252
Tracheostomy 252
Operative Stabilization of Flail Chest 252
Mortality 253
Conclusions 253
Suggested Readings 254.e1
Operative Treatment of Chest Wall Injury 254
Indications for operative therapy 254
Anatomy and Incisions 254
Operative Technique 255
Outcomes 255
Sternal fractures 256
Conclusions 256
Suggested Readings 257.e1
Tracheal and Tracheobronchial Tree Injuries 257
Incidence and mechanisms of injury 257
Diagnosis 257
Presentation 257
Evaluation 258
Management 258
Initial Management 258
Operative Management 258
Outcomes 259
Suggested Readings 260.e1
Operative Management of Pulmonary Injuries: Lung-Sparing and Formal Resections 260
Incidence 261
Etiology 262
Classification 262
Diagnosis 262
Physical Examination 262
Adjunctive Diagnostic Modalities 263
Noninvasive Diagnostic Modalities 263
Trauma Ultrasound 263
Chest Radiograph 263
Computed Tomography 263
Electrocardiogram 263
Invasive Diagnostic Modalities 263
Chest Tubes 263
Associated injuries 264
Anatomic location of injury 264
Management 264
Surgical Decisions 265
Operative Management 265
Emergency Department Thoracotomy 265
Effects of Pulmonary Hilar Cross-Clamping 265
Part VIII: Abdominal Injuries 307
Diaphragmatic Injury 307
Anatomy and physiology 307
Incidence 307
Mechanism and location of injury 307
Severity of injury 308
Diagnosis 309
Management 312
Mortality 313
Morbidity 313
Complicated diaphragmatic repair with thoracic injury 313
Combined chest wall and abdominal defect with diaphragmatic rupture 314
Suggested Readings 316.e1
Surgical Anatomy of the Abdomen and Retroperitoneum 316
Making the incision 316
Exploring the abdomen 317
Exploring the retroperitoneum 318
Future challenges 321
Summary 322
Suggested Readings 322.e1
Diagnostic Peritoneallavage and Laparoscopyin The Evaluation of Abdominal Trauma 323
Diagnostic peritoneal lavage 323
Diagnostic laparoscopy 324
Suggested Readings 325.e1
Nonoperative Management of Blunt and Penetrating Abdominal Injuries 326
Blunt abdominal injury 326
Key Surgical Therapy Points 326
Introduction 326
Incidence 326
Mechanism of Injury 326
Diagnosis 326
Anatomic Location of Injury and AAST-OIS Grading 327
Management 328
Spleen and Liver 329
Kidney 329
Duodenum and Pancreas 330
Role of Angiographic Interventions 330
Morbidity and Complications Management 330
Mortality 331
Conclusions 332
Penetrating abdominal injury 332
Key Surgical Therapy Points 332
Introduction 332
Incidence 332
Mechanism of Injury 332
Diagnosis 333
Anatomic Location of Injury and AAST-OIS Grading 334
Management 334
Morbidity and Complications Management 335
Mortality 335
Conclusions and Algorithm 335
Suggested Readings 335.e1
Gastric Injuries 336
Incidence 336
Mechanism of injury 336
Diagnosis 337
Surgical management 337
Mortality 337
Morbidity 338
Conclusion 338
Suggested Readings 338.e1
Small Bowel Injury 339
Incidence 339
Mechanism of injury 339
Diagnosis 340
Injury grading 342
Surgical management 342
Complications 345
Mortality 345
Conclusions 345
Suggested Readings 346.e1
Duodenal Injuries 346
Determinants of outcome 346
Anatomy and physiology 346
Diagnostic adjuvants 347
Treatment 347
Duodenal hematoma 351
Part IX: Special Issues in Major Torso Trauma 415
Current Concepts in the Diagnosis and Management of Hemorrhagic Shock 415
Epidemiology of severe hemorrhagic shock 415
The clinical perspective: changing concepts on resuscitation 415
The Discrepancies between the Clinical Syndrome of Shock and the Animal Models Used to Study It 416
Diagnosis of shock 416
Assessment of Tissue Perfusion 417
Management of shock 417
Vascular Access for Patients with Severe Hemorrhage 417
Adjunct measures to control hemorrhage 418
Local Hemorrhage Control 418
Systemic Hemorrhage Control 418
Tranexamic Acid 418
Factor VIIa 418
Prothrombin Complex Concentrates 418
Timing and volume of resuscitation fluid therapy 419
Type of Fluid 419
Crystalloids 419
Colloids 419
Albumin 419
Hextend 419
Hypertonic Saline 420
Red Blood Cell Transfusion 420
Blood Substitutes 420
Pharmacotherapy 421
Vasopressin 421
New therapeutic possibilities: hypothermia and hemorrhagic shock 421
Summary 421
Suggested Readings 421.e1
The syndrome of Exsanguination: Reliable Models to Indicate Damage Control 422
History 422
Metabolic failure 422
Models for damage control 422
Patient selection 423
Technique of damage control 424
Conclusions 425
Suggested Readings 425.e1
Damage Control Resuscitation: An Evidence-Based Report 425
Evidence classification 426
Evidence report 426
Ratios of Fresh Frozen Plasma to Packed Red Blood Cells 426
Ratios of Platelets and Packed Red Blood Cells 426
Quantity of Units Transfused 426
Utilization of Platelets, Fibrinogen, and Antifribrinolytics 427
Timing of Transfusions 427
Establishment and Effectiveness of Massive Transfusion Protocols 427
Transfusion Complications 428
Mortality 428
Morbidity 428
Survival Bias 429
Recommendations 429
Stratification Scheme and Level Definitions 429
Level I Recommendations 429
Level II Recommendations 429
Level III Recommendations 430
Conclusion 430
Suggested Readings 430.e1
Surgical Techniques for Thoracic, Abdominal, Pelvic, and Extremity Damage Control 430
Introduction 430
The Lethal Triad 430
Initial Resuscitation Concerns 431
Phase I: the damage control operation 431
The Damage Control Laparotomy 431
The Damage Control Thoracotomy 432
Damage Control Orthopedics 433
Phase 2: resuscitation in the intensive care unit 433
Phase 3: definitive operative management 434
Complications following damage control surgery 434
Immediate Complications 434
Delayed Complications 435
Summary 435
Suggested Readings 435.e1
Abdominal Compartment Syndrome, Damage Control, and the Open Abdomen 435
Abdominal compartment syndrome 435
Damage control 437
Temporary Abdominal Closure 439
Definitive Reconstruction and Closure (DC3) 440
Resuscitation 440
Restoration 440
Reconstruction 441
Special considerations: nutrition support 443
Outcomes and complications of open abdomen 444
Conclusion 446
Acknowledgment 446
Suggested readings 446.e1
Torso Trauma on the Modern Battlefield 446
Introduction to combat torso trauma 446
Incidence and epidemiology of combat torso trauma 446
Noncompressible torso hemorrhage: defining the problem 447
Mechanisms of combat torso injuries 447
Initial evaluation 448
Operative intervention 448
Choice of Incision 449
Damage Control in the Chest 450
Operative Lung Injury 450
Large Hemothorax 451
Multiple Truncal Fragment Wounds 451
Abdominal Solid Organ Injury 451
Bowel Injuries 452
Massive Abdominal Wall and Perineal/Pelvic Wounds 453
Future directions 453
Suggested Readings 455.e1
Part X: Peripheral Vascular Injury 457
Vascular Anatomy of the Extremities 457
Vascular anatomy of the upper extremity 457
Axillary Artery and Vein 457
Brachial Artery and Veins 457
Radial and Ulnar Arteries and Veins 458
Vascular anatomy of the lower extremity 458
The Femoral Arteries and Veins 458
Popliteal Artery and Vein 458
Tibial Arteries and Veins 458
Saphenous Veins 458
Suggested Readings 458.e1
Diagnosis of Vascular Trauma 459
Diagnosis 459
History 459
Physical Examination 459
Hard and soft signs of vascular injury 459
Additional ancillary tests 460
Specific areas of injury 461
Suggested Readings 462.e1
Penetrating Carotid Artery: Uncommon Complex and Lethal Injuries 463
Historical perspective 463
Incidence and mechanism of injury 463
Anatomy 463
Diagnosis 464
Anatomic location of injury 465
Surgical management 465
Outcomes and mortality 469
Morbidity 469
Conclusions 469
Suggested Readings 469.e1
Subclavian Vessel Injuries: Difficult Anatomy and Difficult Territory 469
Historical perspective 469
Anatomy 470
Incidence 471
Clinical presentation 471
Diagnosis 472
Surgical management 472
Morbidity 475
Outcomes and mortality 475
Conclusions 476
Suggested Readings 476.e1
Operative Exposure and Management of Axillary Vessel Injuries 476
Historical perspective 476
Incidence and mechanism of injury 476
Anatomy 477
Diagnosis 477
Surgical management 478
Basic Principles for the Management of Vascular Injuries 478
Specific Management of Axillary Vessels Injuries 479
Outcomes and mortality 480
Conclusions 481
Suggested Readings 481.e1
Brachial Vessel Injuries: High Morbidity and Low Mortality Injuries 481
Historical perspective 481
Incidence and mechanism of injury 481
Anatomy 483
Diagnosis 483
Anatomic location of injury 483
Surgical management 483
Outcomes and mortality 485
Morbidity 486
Conclusions 487
Suggested Readings 487.e1
Iliac Vessel Injuries: Difficult Injuries and Difficult Management Problems 487
Historical perspective 487
Incidence 488
Anatomy 489
Clinical pesentation 489
Diagnosis 490
Surgical management 490
Morbidity and mortality 493
Conclusions 494
Suggested Readings 494.e1
Femoral Vessel Injuries: High Mortality and Low Morbidity Injuries 494
Anatomy 494
Incidence 495
Historical perspective and wartime experiences 495
World War I 495
World War II 495
Korean Conflict 495
Vietnam Conflict 496
Iraq and Afghanistan 496
Mechanism of injury 496
Civilian epidemiology 496
Clinical presentation 496
Diagnosis 497
Surgical management 497
Primary Repair 498
Grafts 501
Fasciotomies and Shunting 502
Venous injuries 502
Outcomes and mortality 503
Conclusions 504
Suggested Readings 504.e1
Popliteal Vessel Injuries: Complex Anatomy and High Amputation Rates 504
Historical perspective 504
Anatomy 505
Incidence 506
Clinical presentation 506
Diagnosis 507
Management 507
Morbidity 516
Outcomes and mortality 517
Conclusions 518
Suggested Readings 518.e1
Temporary Vascular Shunts 518
Definition 518
Historical perspective 518
Indications for temporary vascular shunts 518
Available shunts 519
Operative technique 520
Outcomes 520
Practical points in conclusion 521
Suggested Readings 521.e1
Part XI: Musculoskeletal and Peripheral Central Nervous System Injuries 523
Upper Extremity Fractures: Orthopedic Management 523
Open fractures 523
Dislocations 523
Gunshot wounds 524
Compartment syndrome 524
Imaging studies 524
Injuries to the shoulder girdle and humerus 525
Sternoclavicular Dislocation 525
Clavicle Fractures 526
Acromioclavicular Dislocation (Separated Shoulder) 527
Scapular Fractures 527
Scapulothoracic Dissociation 528
Glenohumeral Dislocation 528
Proximal Humerus Fractures 528
Humeral Shaft Fractures 529
Elbow 531
Distal Humerus Fractures 531
Elbow Dislocation 531
Radial Head Fractures 532
Coronoid Fractures 532
Olecranon Fractures 534
Forearm 534
Monteggia Fracture 534
Radial and Ulnar Shaft Fractures 535
Galeazzi Fractures 535
Suggested Readings 535.e1
Lower Extremity and Degloving Injury 535
Radiologic evaluation 535
Fractures 535
Early care of musculoskeletal injuries 536
Open fractures 536
Identification and Classification 536
Management 536
Immediate Wound Care 536
Irrigation and Débridement 537
Reduction and Fixation 537
Wound Coverage 537
Compartment syndromes 538
Degloving injuries 538
Mangled extremities: delayed amputation 539
Suggested Readings 539.e1
Cervical, Thoracic, and Lumbar Fractures 540
Spinal cord syndromes 540
Steroids in spinal cord injuries 540
Cervical spine injuries 540
Pertinent Anatomy of Cervical Spine 540
Patterns and Management of Cervical Spine Injuries 540
Occipital Condyle Fractures 540
Occipitocervical Dissociation (Atlantoaxial Dissociation) 541
Atlas Fracture 541
Dens Fractures 541
Hangmans Fracture 541
Subaxial Spine Fractures 541
Thoracic and lumbar spine injuries 542
Pertinent Anatomy of the Thoracic and Lumbar Spine 542
Thoracic and Lumbar Fractures 543
Suggested Readings 543.e1
Pelvic Fractures 544
Anatomy 544
Imaging 544
Classification 544
Initial assessment 544
Initial treatment 545
Definitive treatment 548
Outcomes 549
Summary 549
Suggested Readings 549.e1
Wrist and Handfractures: Orthopedicmanagement of Currenttherapy of Trauma and Surgical Critical Care 550
Scapulothoracic Dissociation and Degloving Injuries of the Extremities 550
Extremity Replantation: Indications and Timing 550
Wrist and Hand Fractures: Orthopedic Management of Current Therapy of Trauma and Surgical Critical Care 550.e1
Distal radius fracture 550.e1
Dislocations of the wrist 550.e1
Carpal fractures and ligament injuries 550.e1
Carpometacarpal joint injuries 550.e3
Metacarpal and phalangeal injuries 550.e3
Acute carpal tunnel syndrome 550.e3
Suggested Readings 550.e3
Scapulothoracic Dissociation And Degloving Injuries Of The Extremities 550.e4
Incidence 550.e4
Mechanism of Injury 550.e4
Diagnosis 550.e4
Injury Grading 550.e5
Management 550.e5
Morbidity and Complications 550.e6
Mortality 550.e6
Conclusions and Algorithm 550.e6
Suggested Readings 550.e7
Extremity Replantation:Indications And Timing 550.e8
History 550.e8
Microsurgical Centers 550.e8
Transportation 550.e8
Evaluation Of Theamputated Part 550.e9
Indications 550.e9
Contraindications 550.e9
Surgical Management 550.e10
Preparation of the Amputated Part 550.e10
Surgical Sequence 550.e10
Bone Shortening and Fixation 550.e10
Extensor Tendon Repair 550.e11
Flexor Tendon Repair 550.e11
Arterial Repair 550.e11
Venous Repair 550.e11
Nerve Repair 550.e12
Skin Coverage 550.e12
Postoperative Care 550.e12
Management of a Compromised Replant 550.e13
Replantation Of Variousother Parts 550.e13
Suggested Readings 550.e13
Special Techniques For The Management Of Complex Musculoskeletal Injuries: The Roles Of Fasciocutaneous And Myocutaneous Flaps 551.e1
Diagnosis 551.e1
Surgical Management 551.e1
Head and Neck 551.e1
Upper Extremity 551.e1
Chest and Trunk 551.e2
Abdominal Wall and Groin 551.e4
Lower Extremity 551.e4
Conclusion 551.e6
Suggested Readings 551.e6
Part XII: Special Issues and Situations in Trauma Management 553
Airway Management:What Every Surgeon Should Know About The Traumatic Airway(The Anesthesiologist’Sperspective) 553
American society of anesthesiologists difficult airway algorithm modification for trauma 555
Summary 556
Pediatric Trauma 556
Incidence of pediatric trauma 556
Mechanisms of pediatric trauma 556
Suggested Readings 556.e1
Initial assessment, stabilization, and management of the injured child 557
Airway Management 557
Vascular Access 557
Circulatory Management 557
Diagnostic Assessment 558
Management of specific injuries 559
Head and Central Nervous System Injury 559
Thoracic Injuries 560
Abdominal Injuries 560
Acknowledgment 561
Trauma in Pregnancy 561
Epidemiology 561
Suggested Readings 561.e1
Mechanism of injury 562
Blunt Trauma 562
Penetrating Trauma 562
Intimate Partner Violence 562
Physiologic alterations of pregnancy 562
Second Trimester 562
Third Trimester 563
Diagnosis 563
Primary Survey 563
Secondary Survey 563
Initial Evaluation of the Fetus 564
Exposure to Radiation from Diagnostic Radiographs 564
Surgical management 564
Blunt Trauma 565
Penetrating Trauma 565
Cesarean Section 565
Morbidity and complications management 566
Fetomaternal Hemorrhage 566
Premature Labor 566
Preeclampsia and Eclampsia 566
Placental Abruption 566
Amniotic Fluid Embolization 566
Venous Thromboembolism 566
Intraabdominal Infection 566
Mortality 567
Conclusions 567
Trauma in Our “Elders” 567
Physiologic changes 567
Suggested Readings 567.e1
Mechanism of injury 568
Outcomes 569
Management of specific organ injuries 569
Conclusions 571
Part XIII: Critical Care I: Management of Organ Failures and Techniques for Support 607
Cardiac Hemodynamics: The Pulmonary Artery Catheter and the Meaning of its Readings 607
History of controversy 607
Pulmonary artery catheter use and insertion: what it is and how it works 608
Insertion Tips and Guidelines 609
Interpretation: what does it measure and what does it mean? 609
Initial Warnings and Potential Measurement Problems 609
Pressure, Volume, and Work Measures 610
Goal-Directed Therapy Using Pulmonary Artery Catheter 611
Mixed Venous Saturation: Monitoring Tissue Metabolism 612
Right Ventricle End-Diastolic Pressure as Measure of Cardiac Index and Cardiac Function 612
Alternatives to the pulmonary artery catheter 612
Summary 612
Suggested Readings 613.e1
Oxygen Transport 613
Energy generation in the cell 613
Microcirculation and oxygen delivery 614
Hemoglobin, the Ultimate Oxygen Carrier 614
Heart as Oxygen Delivery Pump 615
Putting it all together: measuring cellular oxygen consumption and extraction in patients 615
Relationship of Oxygen Consumption and Oxygen Delivery during Pathologic States 615
Characteristic Oxygen Transport Variables in States of Shock 616
Hemorrhagic Shock 616
Cardiogenic Shock 616
Septic Shock 616
Neurogenic Shock 616
Conclusions 616
Suggested Readings 616.e1
Pharmacologic Support of Cardiac Failure 616
Pathophysiology 616
Treatment 617
Diuretics 617
Vasodilators 617
Inotropes and Vasopressors 618
Inotropic Agents 618
Vasopressors 619
Other Agents 619
Special circumstances 619
Heart Failure in Septic Shock 619
Right Ventricular Failure 620
Blunt Cardiac Injury 620
Summary 620
Suggested Readings 620.e1
Diagnosis and Management of Cardiac Dysrhythmias 621
Incidence and risk factors 621
Bradyarrhythmias 621
Sinus Node 621
Atrioventricular Node 622
Tachyarrhythmias 623
Sinus Tachycardia 624
Paroxysmal Supraventricular Tachycardia 624
Wolff-Parkinson-White Syndrome 624
Multifocal Atrial Tachycardia 625
Atrial Flutter 625
Atrial Fibrillation 625
Ventricular Tachyarrhythmias 626
Premature Ventricular Contractions 627
Monomorphic Ventricular Tachycardia 627
Polymorphic Ventricular Tachycardia 627
Conclusion 628
Suggested Readings 628.e1
Fundamentals of Mechanical Ventilation 628
Key points 628
Noninvasive ventilation 628
Contraindications to Noninvasive Ventilation 629
Complications of Noninvasive Ventilation 629
Pressure support ventilation 630
Heliox 630
Modes of mechanical ventilation 630
Assist-Control Ventilation 630
Synchronized Intermittent Mandatory Ventilation 630
Positive End-Expiratory Pressure 630
Ventilator \"Bundle 631
Routine Settings 632
Sedation 632
Monitoring 632
Blood Gases 632
Pulse Oximetry 634
Capnography 634
Invasive hemodynamic monitoring 635
Arterial Catheterization 635
Central Venous Pressure Monitoring 635
Pulmonary artery catheterization 636
Clinical use of the pulmonary artery catheter 636
Liberation from mechanical ventilation 636
Special airway considerations 638
Unplanned Extubation 638
Reintubation 638
Tracheostomy 638
Suggested Readings 639.e1
Advanced Techniques in Mechanical Ventilation 639
Key points 639
Impaired oxygenation following acute lung injury 639
Ventilator-Induced Lung Injury 639
Alternatives to conventional mechanical ventilation 640
Pressure-Controlled Ventilation 640
Open Lung Ventilation 640
Inverse-Ratio Ventilation 641
Airway Pressure Release Ventilation 641
Permissive Hypercapnia 642
Proportional Assist Ventilation 642
Adaptive Support Ventilation 642
Neutrally Adjusted Ventilator Assist 642
Mandatory Minute Ventilation 643
High-Frequency Oscillatory Ventilation 643
Pharmacotherapy 643
Surfactant Administration 643
Inhaled Nitric Oxide 643
Unconventional methods of ventilation 643
Extracorporeal Membrane Oxygenation 643
Prone Positioning 644
The future 644
Suggested Readings 644.e1
Management of Renal Failure: Renal Replacement Therapy and Dialysis 644
Incidence 644
Mechanism of injury/etiology 645
Diagnosis 645
Water and Fluid Homeostasis 645
Assessment of Renal Function 645
Creatinine Clearance 645
Urine Production and Output 645
Management of patients 645
Conservative Management 645
Nonpharmacologic Strategies for Acute Renal Failure Prevention 646
Fluids 646
Nephrotoxin Exposure 646
Pharmacologic Strategies for Acute Renal Failure Prevention 646
Loop Diuretics 646
N-Acetylcysteine 646
Indications for renal replacement therapy in acute renal failure 646
Volume Overload 646
Hyperkalemia 646
Metabolic Acidosis 647
Other Electrolyte Disturbances 647
Uremia 647
Azotemia 647
Timing of initiation of renal replacement therapy 647
Modalities for Renal Replacement Therapy in Acute Renal Failure 647
Principles of Renal Replacement Therapy 647
Classification of renal replacement therapies 648
Intermittent Hemodialysis 648
Continuous Renal Replacement Therapy 648
Advantages and Disadvantages 649
Intermittent Hemodialysis Versus Continuous Renal Replacement Therapy: Outcomes 649
Sustained Low-Efficiency Dialysis or Extended Daily Dialysis 649
Summary 649
Suggested Readings 650.e1
Management of Coagulation Disorders in the Surgical Intensive Care Unit 650
Incidence and mechanism of disease 650
Congenital Bleeding Disorders 650
Von Willebrand Disease 650
Hemophilia A 650
Hemophilia B 650
Acquired Bleeding Disorders 651
Coagulopathy of Hemorrhagic Shock 651
Hypothermia 651
Acidosis 651
Thrombocytopenia 651
Disseminated Intravascular Coagulation 652
Severe Sepsis 652
Traumatic Brain Injury 652
Vitamin K Deficiency 652
Anticoagulant Drugs 652
Cirrhosis and End-Stage Liver Disease 653
Renal Failure 653
Liver Injury 653
Diagnosis 653
Clinical Evaluation 653
Laboratory Tests of Coagulation 655
Management 656
Blood Product Transfusion 656
Fresh Frozen Plasma 656
Platelets 656
Cryoprecipitate 656
Reversal of Warfarin 656
Reversal of Heparin 657
Reversal of Novel Oral Anticoagulants 657
Recombinant Activated Factor VIIa 657
Conclusions 658
Suggested Readings 658.e1
Management of Endocrine Disorders in the Surgical Intensive Care Unit 658
Key surgical points 658
Brain problems: abnormalities in hypothalamic/pituitary response 658
Diabetes Insipidus 658
SIADH and Cerebral Salt Wasting 659
Abnormalities in thyroid response 660
Thyroid Excess 660
Thyroid Deficit 660
Sick Euthyroid Syndrome 661
Abnormalities of adrenal function 661
Pheochromocytoma 661
Adrenal Insufficiency 662
Problems with hyperglycemia 662
Other endocrine contributions: procalcitonin 663
Summary 665
Suggested Readings 665.e1
Transfusion: Management of Blood and Blood Products in Trauma 665
Incidence: who needs blood transfusion in trauma? 665
Massive transfusion 665
Identification of Trauma Patients Who Will Require Massive Transfusion 668
Blood transfusion components 668
Red Blood Cells 668
Fresh Frozen Plasma 670
Platelets 670
Cryoprecipitate 670
Fibrinogen Concentrate 670
Blood Component Therapy: Fresh Frozen Plasma, Platelets, and Cryoprecipitate 671
The Prospective Observational Multicenter Major Trauma Transfusion Study 671
The Pragmatic Randomized Optimal Platelets and Plasma Ratios Trial 671
Restrictive transfusion strategies in trauma 671
Risks of blood transfusion 672
Transfusion-Related Acute Lung Injury 673
Blood Transfusion and Postinjury Multiple-Organ Failure 673
Blood Transfusion and Systemic Inflammatory Response Syndrome/Mortality 673
Blood transfusion and mortality 673
Blood transfusion and infection 674
Potential mechanisms for transfusion-associated adverse outcome 674
Red Blood Cell Storage Lesion 675
Management of complications related to blood transfusion 675
Thrombocytopenia 676
Coagulation Factor Depletion 676
Hypocalcemia 676
Hypokalemia and Hyperkalemia 677
Acid-Base Disturbances 677
Hypothermia 677
Conclusions 677
Suggested Readings 677.e1
Part XIV: Critical Care II: Special issues and Treatments 679
Acute Respiratory Distress Syndrome 679
Definition, presentation, and clinical diagnosis 679
Epidemiology 680
Pathophysiology 680
Therapy and supportive measures 680
Fluid Resuscitation and Management 680
Noninvasive Mechanical Ventilation Versus Mechanical Ventilation 681
Mechanical Ventilation Techniques 681
Alternative Therapies 682
Conclusion 682
Part XV: Rehabilitation and Quality of Life After Trauma and Other Issues 757
Palliative Care in Thetrauma Intensivecare Unit 757.e1
What is palliative care in the intensive care unit? 757.e1
When to start palliative care in the intensive care unit 757.e1
Communication and shared decision making 757.e2
Withholding and withdrawal of life support 757.e2
Pain and symptom management 757.e3
Family and bereavement support 757.e4
Index 759
Inside Back Cover ES3