Chapter 6 Trauma- Original

8/13/2019 Chapter 6 Trauma- Original

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CHAPTER 6 - Trauma

Jon M. Burch

Reginald J. Franciose

Ernest E. MooreTrauma or injury has been defined as damage to the body caused by an exchange withenvironmental energy that is beyond the body's resilience. Trauma remains the mostcommon cause of death for individuals between the ages of 1 and 44 years, and thethird most common cause of death for all ages. The U.S. government classifiesaccidental death under the following categories accidents and adverse effects!suicide, homicide, and legal intervention! and all other external causes. "ccidents andadverse effects account for a##roximately 1$$,$$$ deaths #er year, of which motorvehicle accidents account for nearly %$ #ercent. &omicides, suicides, and other causesare res#onsible for another %$,$$$ deaths each year. eath rates are a #oor indicator

of the magnitude of the #roblem, however, because most injured #atients survive. (orexam#le, in 1)*% there were a##roximately 14$,$$$ trauma+related deaths, but %million re#orted injuries and - million hos#itali/ations. (or the same year theaggregate lifetime costs for all injured #atients was estimated to be 01%* billion.Trauma is a major #ublic health issue.

2T"3 5"3U"T62 "2 7SUS8T"T62 6( T& 29U7 :"T2TTreatment of trauma #atients often begins in the field by emergency medical services;uential fashion, butin reality they often #roceed simultaneously. The #rocess begins with theidentification and treatment of conditions that constitute an immediate threat to life.The "T3S course refers to this as the #rimary survey or the "?8s+"irway, withcervical s#ine #rotection,?reathing, and 8irculation. "ny life+threatening #roblem identified in the initialsurvey must be treated before advancing.

"irway uate airway is the first #riority in the #rimary survey. fforts torestore cardiovascular integrity will be futile if the oxygen content of the blood isinade>uate. Simultaneously, all blunt+trauma #atients re>uire cervical s#ineimmobili/ation until injury is ruled out. This can be accom#lished with a hard;:hiladel#hia= collar or sandbags on both sides of the head ta#ed to the [email protected] collars do not immobili/e the cervical s#ine.

:atients who are conscious and have a normal voice do not re>uire further evaluationor early attention to their airway. xce#tions to this #rinci#le include #atients with

#enetrating injuries to the nec@ and an ex#anding hematoma, evidence of chemical or

thermal injury to the mouth, nares, or hy#o#harynx, extensive subcutaneous air in thenec@, com#lex maxillofacial trauma, or airway bleeding. These #atients initially may


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have a satisfactory airway, but it may become obstructed if soft tissue swelling oredema #rogresses. n these cases, elective intubation should be #erformed beforeevidence of airway com#romise is a##arent.

:atients who have an abnormal voice or altered mental status re>uire further airway

evaluation. irect laryngosco#ic ins#ection often reveals blood, vomit, the tongue,foreign objects, or soft tissue swelling as sources of airway obstruction. Suctioningcan offer immediate relief in many #atients. "ltered mental status is the most commonindication for intubation because of the #atient's inability to #rotect the airway.6#tions for airway access include nasotracheal, orotracheal, or o#erative intervention.

2asotracheal intubation can be accom#lished only in #atients who are breathings#ontaneously and is contraindicated in the a#neic #atient. "lthough nasotrachealintubation fre>uently is used by #aramedics in the field, the #rimary use for thistechni>ue in the emergency room is becoming limited to those few #atients re>uiringemergent airway su##ort who are #rohibitive candidates for #araly/ation.

6rotracheal intubation also can be #erformed in #atients with #otential cervical s#ineinjuries #rovided that manual in+line cervical immobili/ation is maintained. Theadvantages of orotracheal intubation are the direct visuali/ation of the vocal cords, theability to use larger+diameter endotracheal tubes, a##licability to a#neic #atients, andits familiarity to most #hysicians. The disadvantage of orotracheal intubation is thatconscious #atients usually re>uire neuromuscular bloc@ade or dee# sedation. To alarge extent, ra#id+se>uence induction of anesthesia with orotracheal intubation has

become the standard in ex#erienced trauma centers with the availability of #ulseoximetry. The major advantage is ra#id, definitive airway control. The disadvantagesinclude the inability to intubate, as#iration, and com#lications of the re>uiredmedications. Those who attem#t ra#id+se>uence induction must be thoroughlyfamiliar with the details and contraindications of the #rocedure.

:atients in whom attem#ts at intubation have failed or are #recluded because ofextensive facial injuries re>uire a surgical airway. 8ricothyroidotomy ;(ig. A+1= and

#ercutaneous transtracheal ventilation are #referred over tracheostomy in mostemergency situations because of their sim#licity and safety. 6ne disadvantage ofcricothyroidotomy is the inability to #lace a tube greater than A mm in diameter

because of the limited a#erture of the cricothyroid s#ace. 8ricothyroidotomy also iscontraindicated in #atients under the age of twelve because of the ris@ of damage tothe cricoid cartilage and the subse>uent ris@ of subglottic stenosis.

:ercutaneous transtracheal ventilation is accom#lished by inserting a large+ boreintravenous catheter through the cricothyroid membrane into the trachea and attachingit with tubing to an oxygen source ca#able of delivering %$ #si or more. " hole cut inthe tubing allows for intermittent ventilation by occluding and releasing the hole."de>uate oxygenation can be maintained for more than $ min. ?ecause exhalationoccurs #assively, ventilation is limited and carbon dioxide retention can occur.mergent tracheostomy has fallen into disfavor because of its technical difficulties! itmay be necessary in cases of laryngotracheal se#aration or laryngeal fractures whencricothyroidotomy might cause further damage or result in the com#lete loss of theairway.

?reathing


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6nce a secure airway is obtained, ade>uate oxygenation and ventilation must beassured. "ll injured #atients should receive su##lemental oxygen thera#y and bemonitored by #ulse oximetry. The following conditions may constitute an immediatethreat to life because of inade>uate ventilation ;1= tension #neumothorax, ;-= o#en

#neumothorax, or ;= flail chestB#ulmonary contusion. These diagnoses can be made

with a combination of #hysical examination and chest x+ray.

The diagnosis of tension #neumothorax is im#lied by the finding of res#iratorydistress in combination with any of the following #hysical signs tracheal deviationaway from the affected side! lac@ of or decreased breath sounds on the affected side!distended nec@ veins or systemic hy#otension! or subcutaneous em#hysema on theaffected side. mmediate tube thoracostomy is indicated without awaiting chest x+rayconfirmation ;(ig. A+-=. n tension #neumothorax the colla#sed lung acts as a one+wayvalve so that each inhalation allows additional air to accumulate in the #leural s#ace.The normal negative intra#leural #ressure becomes #ositive, de#ressing the i#silateralhemidia#hragm and forcing the mediastinal structures into the contralateral chest. The

contralateral lung is then com#ressed, and the heart is rotated about the su#erior andinferior venae cavae, decreasing venous return and cardiac out#ut while distending thenec@ veins. "n unrecogni/ed sim#le #neumothorax can be converted to a tension

#neumothorax if the #atient is #laced on a #ositive+#ressure mechanical ventilator. "tension #neumothorax also can develo# in a #atient who is breathing s#ontaneously.

"n o#en #neumothorax or suc@ing chest wound occurs with full+thic@ness loss of thechest wall, #ermitting a free communication between the #leural s#ace and theatmos#here. This com#romises ventilation by two mechanisms. n addition to colla#seof the lung on the injured side, if the diameter of the injury is greater than thenarrowest #ortion of the u##er airway, air #referentially moves through the injury siterather than the trachea and im#airs ventilation on the contralateral side. 6cclusion ofthe injury may result in converting an o#en #neumothorax into a tension

#neumothorax. :ro#er treatment in the field involves #lacing an occlusive dressingover the wound, which is ta#ed on three sides. The occlusive dressing #ermitseffective ventilation on ins#iration while the unta#ed side allows accumulated air toesca#e from the #leural s#ace, #reventing a tension #neumothorax. efinitivetreatment re>uires wound closure and tube thoracostomy.

(lail chest occurs when four or more ribs are fractured in at least two locations.:aradoxical movement of this free+floating segment of chest wall may be sufficient to

com#romise ventilation. t is of greater #hysiologic im#ortance that #atients with flailchest fre>uently have an underlying #ulmonary contusion. :ulmonary contusion withor without rib fractures may com#romise oxygenation or ventilation to the extent thatintubation and mechanical ventilation is re>uired. 7es#iratory failure in these #atientsmay not be immediate, and fre>uent reevaluation is warranted. The initial chest x+rayusually underestimates the degree of #ulmonary contusion, and the lesion tends toevolve with time and fluid resuscitation.

8irculationCith a secure airway and ade>uate ventilation established, circulatory status isdetermined. " rough first a##roximation of the #atient's cardiovascular status is

obtained by #al#ating #eri#heral #ulses. " systolic blood #ressure of A$ mm&g isre>uired for the carotid #ulse to be #al#able, $ mm&g for the femoral #ulse and *$


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mm&g for the radial #ulse. "t this #oint in the #atient's treatment, hy#otension isassumed to be caused by hemorrhage. ?lood #ressure and #ulse should be measuredat least every 1% min.

xternal control of hemorrhage should be obtained before restoring circulating

volume. uently control extremity hemorrhage aseffectively as tourni>uets and with less tissue damage. ?lind clam#ing should beavoided because of the ris@ to adjacent structures, #articularly nerves. The im#ortanceof digital control of hemorrhage for #enetrating injuries of the head, nec@, thoracicoutlet, groin, and extremities cannot be overem#hasi/ed. This should be done with agloved finger #laced through the wound directly on the bleeding vessel a##lying onlyenough #ressure to control active bleeding. The surgeon #erforming this maneuvermust then wal@ along beside the #atient on the way to the o#erating room fordefinitive treatment. Scal# lacerations through the galea a#oneurotica tend to bleed

#rofusely! these can be tem#orarily controlled with 7ainey cli#s or a full+thic@nesslarge nylon continuous stitch.

ntravenous access for fluid resuscitation is begun with two #eri#heral catheters, 1A+gauge or larger in an adult. ?lood should be drawn simultaneously and sent for ty#ingand hematocrit measurement. ?ecause the flow of li>uid through a tube is

#ro#ortional to diameter and inversely #ro#ortional to length, venous lines for volumeresuscitation should be short with a large diameter. (or #atients re>uiring vigorousfluid resuscitation, sa#henous vein cutdowns at the an@le ;(ig. A+= or #ercutaneousfemoral vein catheter introducers are #referred. The sa#henous vein is reliably found1 cm anterior and 1 cm su#erior to the medial malleolus. Short 1$+gauge catheters can

be >uic@ly #laced even in an exsanguinating #atient with colla#sed veins. 5enousaccess in the lower extremities #rovides effective volume resuscitation in cases ofabdominal venous injury, including the inferior vena cava. 9ugular and subclaviancentral venous introducers are less desirable for initial access in trauma #atients

because #lacement can interfere with the wor@ of staff members #erforming otherlifesaving #rocedures. Secondary central venous introducers should be #laced in theo#erating room in the event that vena caval cross+clam#ing is #erformed.

n hy#ovolemic #ediatric #atients less than A years of age, #ercutaneous femoral veincannulation is contraindicated because of the ris@ of venous thrombosis. f twoattem#ts at #ercutaneous #eri#heral access are unsuccessful, interosseous cannulationshould be #erformed in the #roximal tibia, or in the distal femur if the tibia is

fractured ;(ig. A+4=. This is a safe emergency techni>ue! however, once alternativeaccess has been established, the cannula should be removed because of the ris@ ofosteomyelitis.

nitial (luid 7esuscitationnitial fluid resuscitation is a 1+3 intravenous bolus of normal saline, lactated 7inger'ssolution, or other isotonic crystalloid in an adult, or -$ m3B@g of body weight lactated7inger's solution in a child. n the United States crystalloid alone is used, whereas inother #arts of the world colloid is often added. This is re#eated once in an adult andtwice in a child before administering red blood cells. The goal of fluid resuscitation isto reestablish tissue #erfusion. 8lassic signs and sym#toms of shoc@ are tachycardia,

hy#otension, tachy#nea, mental status changes, dia#horesis, and #allor. 2one of thesesigns or sym#toms ta@en alone can #redict the #atient's organ #erfusion status, but


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when viewed together they can hel# in evaluating the #atient's res#onse to treatment.:atients who have a good res#onse to fluid infusion, i.e., normali/ation of vital signs,clearing of the sensorium, evidence of good #eri#heral #erfusion ;warm fingers andtoes with normal ca#illary refill= are #resumed to have ade>uate #erfusion.

There are several caveats to @ee# in mind when ma@ing this #resum#tion. "lthoughtachycardia may be the earliest sign of ongoing blood loss, individuals in good

#hysical condition, #articularly trained athletes with a low resting #ulse rate, maymanifest only a relative tachycardia. :atients on beta+bloc@ing medications may not

be able to increase their heart rate in res#onse to stress. n children, bradycardia orrelative bradycardia can occur with severe blood loss and is an ominous sign, oftenheralding cardiovascular colla#se. 8onversely, hy#oxia, #ain, a##rehension, andstimulant drugs ;e.g., cocaine, am#hetamines= #roduce a tachycardia unrelated to

#hysiologic demands. &y#otension is not a reliable early sign of hy#ovolemia. nhealthy #atients blood volume must decrease by $ to 4$ #ercent before hy#otensionoccurs ;Table A+1=. Dounger #atients with good sym#athetic tone can maintain

systemic blood #ressure with severe intravascular deficits until they are on the vergeof cardiac arrest. n contrast, #regnancy increases circulating blood volume, and arelatively larger volume of blood loss must occur before signs and sym#toms becomea##arent.

"cute changes in mental status can be caused by hy#oxia, hy#ercarbia, orhy#ovolemia, or they may be an early sign of increasing intracranial #ressure ;8:=."n abnormal mental status should #rom#t an immediate reevaluation of the "?8s andconsideration of an evolving central nervous system injury. " deterioration in mentalstatus may be subtle and may not #rogress in a #redictable fashion! for exam#le, a

#reviously calm and coo#erative #atient may become anxious and combative ashy#oxia develo#s, or a #atient who is agitated and combative from drugs or alcoholmay become somnolent if hy#ovolemic shoc@ develo#s. Urine out#ut is a >uantitativeand relatively reliable indicator of organ #erfusion. "de>uate urine out#ut is $.%m3B@gBh in an adult, 1 m3B@gBh in a child, and - m3B@gBh in an infant less than 1 yearof age.

6n the basis of the initial res#onse to fluid resuscitation, hy#ovolemic injured #atientsmay be #laced into three broad categories res#onders, transient res#onders, andnonres#onders. ndividuals who are stable or have a good res#onse to the initial fluidthera#y as evidenced by normali/ation of vital signs, mental status, and urine out#ut

are unli@ely to have significant continuing hemorrhage, and further diagnosticevaluation for occult injuries can #roceed. "t the other end of the s#ectrum arenonres#onders with #ersistent hy#otension. This grou# re>uires immediate diagnosisand treatment to #revent a fatal outcome. :atients who res#ond transiently and thendeteriorate #resent the most com#lex decision+ma@ing challenge. They usually areunderresuscitated or have ongoing hemorrhage. n #atients with #enetrating trauma,the need for o#erative intervention for the control of hemorrhage usually is evident.?lunt trauma #atients with multisystem injury, however, re>uire careful #lanning. t isin this grou# that the greatest number of #reventable deaths is li@ely to occur.

:ersistent &y#otension

2onres#onders


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The s#ectrum of disease in this category ranges from nonsurvivable multisysteminjury to #roblems as sim#le as a tension #neumothorax. :ersistent hy#otension inthese #atients usually is cardiogenic or a result of uncontrolled hemorrhage. "nevaluation of the #atient's nec@ veins and central venous #ressure ;85:= usuallydistinguishes between these two categories. 85: determines right ventricular #reload!

in otherwise healthy trauma #atients, its measurement yields objective informationregarding the #atient's overall volume status. 8entral venous catheters areina##ro#riate for administering large volumes of fluid, but they are valuable formeasuring 85:. " hy#otensive #atient with flat nec@ veins and a 85: less than %cm&-6 is hy#ovolemic and is li@ely to have ongoing hemorrhage. " hy#otensive

#atient with distended nec@ veins or a 85: more than 1% cm&-6 is li@ely to be incardiogenic shoc@. The 85: may be falsely elevated if the #atient is agitated andstraining or fluid administration is over/ealous! isolated readings must be inter#retedwith caution.

n trauma #atients the differential diagnosis of cardiogenic shoc@ is indicated by ;1=

tension #neumothorax, ;-= #ericardial tam#onade, ;= myocardial contusion orinfarction, and ;4= air embolism. Tension #neumothorax is the most fre>uent cause ofcardiac failure. Traumatic #ericardial tam#onade is most often associated with

#enetrating injury to the heart. "s blood lea@s out of the injured heart, it accumulatesin the #ericardial sac. ?ecause the #ericardium is not acutely distendible, the #ressurein the #ericardial sac rises to match that of the injured chamber. This #ressure usuallyis greater than that of the right atrium! right atrial filling is im#aired, and rightventricular #reload is reduced. This leads to decreased right ventricular out#ut andincreased 85:. ncreased intra#ericardial #ressure also im#edes myocardial bloodflow, which leads to subendocardial ischemia and a further reduction in cardiacout#ut. This cycle may #rogress insidiously with injury of the venae cavae or atria, or

#reci#itously with injury of either ventricle. Cith acute tam#onade, as little as 1$$m3 of blood within the #ericardial sac can #roduce life+threatening hemodynamiccom#romise. The usual #resentation is a #atient with a #enetrating injury in #roximityto the heart who is hy#otensive and has distended nec@ veins or an elevated 85:. Theclassic findings of ?ec@'s triad ;hy#otension, distended nec@ veins, and muffled heartsounds= and #ulsus #aradoxus are not reliable indicators of acute tam#onade.Ultrasound imaging in the emergency room using a subxi#hoid or #arasternal view isextremely hel#ful if the findings are clearly #ositive ;(ig. A+%=, but e>uivocal findingsare common. arly in the course of tam#onade, blood #ressure and cardiac out#uttransiently im#rove with fluid administration, which may lead the surgeon to >uestion

the diagnosisEor lull the surgeon into a false sense of security.

6nce the diagnosis of cardiac tam#onade is established, #ericardiocentesis should be#erformed ;(ig. A+A=. vacuation of as little as 1% to -% m3 of blood can dramaticallyim#rove the #atient's hemodynamic #rofile. :ericardiocentesis should be done even ifthe #atient stabili/es with volume loading because subclinical myocardial ischemiacan lead to sudden lethal arrhythmias, and #atients with tam#onade can decom#ensateun#redictably. Chile #ericardiocentesis is being #erformed, #re#aration should bemade for emergent trans#ort to the o#erating room. mergent #ericardiocentesis issuccessful in decom#ressing the tam#onade in a##roximately *$ #ercent of cases!most failures are a result of clotted blood within the #ericardium. f #ericardiocentesis

is unsuccessful and the #atient remains severely hy#otensive ;systolic blood #ressureF$ mm&g= or shows other signs of hemodynamic instability, emergency room


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thoracotomy should be #erformed ;(ig. A+=. This is best accom#lished using a leftanterolateral thoracotomy and a longitudinal #ericardiotomy anterior to the #hrenicnerve, followed by evacuation of the #ericardial sac and tem#orary control of thecardiac injury. The #atient is then trans#orted to the o#erating room for definitivere#air ;(ig. A+*=.

Myocardial contusionfrom direct myocardial im#act occurs in a##roximately one+third of #atients sustaining significant blunt chest trauma. The diagnostic criteria formyocardial contusion include s#ecific electrocardiogram abnormalities, i.e.,ventricular dysrhythmias, atrial fibrillation, sinus bradycardia, and bundle branch

bloc@. Transient sinus tachycardia is not indicative of contusion. Serial cardiacen/yme determinations ;8:G+


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usually indicates the regions of the body res#onsible for the blood loss. Ty#e 6 redblood cells ;6+negative for women of childbearing age= or ty#e+s#ecific red bloodcells should be administered and the #atient ta@en directly to the o#erating room forex#loration. (or #atients with a sustained systolic blood #ressure of less than $mm&g, in s#ite of crystalloid and blood administration, emergency room thoracotomy

should be considered. The clearest indication for this #rocedure is #enetrating chesttrauma, and survival is re#orted as high as $ #ercent. " small number of #atientswith #enetrating abdominal trauma survive, but the role of emergency roomthoracotomy in blunt abdominal trauma is controversial. The goal of emergency roomthoracotomy for thoracic injuries is control of hemorrhage! for abdominal injuries thegoal is to sustain central circulation and limit abdominal blood loss by clam#ing thedescending thoracic aorta. very effort should be made to re#lace the aortic clam# to

below the renal arteries within $ min. 3onger clam#ing times #roximal to theabdominal viscera are seldom associated with survival. The decision to #erform anemergency room thoracotomy can be assisted by use of the algorithm in (ig. A+).

Transient Responders&y#otensive #atients who transiently res#ond to fluid administration usually havesome degree of active hemorrhage. Those with #enetrating injuries should be ta@en tothe o#erating room for ex#loration. Those with multi#le blunt injuries constitute adiagnostic and thera#eutic dilemma. These #atients often re>uire so#histicatedevaluation such as com#uted tomogra#hy ;8T= and angiogra#hy. t is during thesediagnostic evaluations and the necessary trans#ortation that the greatest ha/ard exists,

because monitoring is com#romised and the environment is subo#timal for dealingwith acute #roblems. The surgeon must accom#any the #atient and be #re#ared toabort the examination if hy#otension recurs. f it does, the #atient should be giventy#e+s#ecific red blood cells and trans#orted immediately to the o#erating room tolocali/e the hemorrhage. "n o#erating room should be immediately available whenthese #atients arrive in the emergency room.

The traditional volume resuscitation ;described above= of #atients sustaining#enetrating torso trauma has been >uestioned. t has been assumed that anyhy#otension is dangerous and must be treated, #referably with blood or crystalloid,

but some have argued that hemostatic mechanisms fre>uently control hemorrhageinitially, and increased venous and subse>uent arterial #ressure from fluidresuscitation can disru#t tenuous hemostasis. (urthermore, active bleeding increasesas venous and arterial #ressure increases. 3aboratory studies su##ort these conce#ts.

n a #ros#ective randomi/ed study of hy#otensive #atients who sustained #enetratingtorso trauma and re>uired o#erative treatment, half the #atients received volumeresuscitation and fluid was withheld in the others until the o#eration was begun, butthere was no survival advantage for those resuscitated in the traditional fashion.Subgrou# analysis suggested a survival disadvantage for #ericardial tam#onade.:atients with #rofound hy#otension ;systolic blood #ressure F$ mm&g= are at ris@for sudden death. 8ontrolled hy#otension is the o#timal middle ground.

Secondary Survey

Chen the conditions that constitute an immediate threat to life have been attended toor excluded, the #atient is examined in a systematic fashion to identify occult injuries.

S#ecial attention should be given to the #atient's bac@, axillae, and #erineum becauseinjuries in these areas are easily overloo@ed. :atients should undergo digital rectal


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examination to evaluate s#hincter tone and to loo@ for blood, #erforation, or a high+riding #rostate. " (oley catheter should be inserted to decom#ress the bladder, obtaina urine s#ecimen, and monitor urine out#ut. Stable #atients at ris@ for urethral injuryshould undergo urethrogra#hy before catheteri/ation. Signs of urethral injury include

blood at the meatus, #erineal or scrotal hematomas, or a high+riding #rostate. n the

case of #ersistent hy#ovolemic shoc@, an initial attem#t at a (oley catheteri/ationshould be made! if this is unsuccessful, a #ercutaneous su#ra#ubic cystostomy should

be #laced. " nasogastric tube should be inserted to decrease the ris@ of gastricas#iration and allow ins#ection of the contents for blood suggestive of occultgastroduodenal injury.

Selective radiogra#hs are obtained early in the emergency room evaluation. (or#atients with severe blunt trauma, antero#osterior chest and #elvic radiogra#hs shouldbe obtained as soon as #ossible. (or #atients with truncal gunshot wounds,#osteroanterior and lateral radiogra#hs of the chest and abdomen are warranted. t ishel#ful to mar@ the entrance and exit sites of #enetrating wounds with metallic cli#s

or sta#les so that the trajectory of the missile or blade can be estimated.

uestioned. (or automobile accidents the s#eed of theaccident, the angle of im#act ;if any=, the use of restraints, airbag de#loyment,condition of the steering wheel and windshield, the amount of intrusion, whether the

#atient was ejected from the vehicle, and whether anyone was dead at the sceneshould all be ascertained. The #atient's #hysiologic condition in the field also isim#ortant. 5ital signs and mental status in the emergency room can be com#ared withthose at the scene! im#rovement or deterioration #rovide critical #rognosticinformation.

Mechanisms and Patterns of Injury

valuation and decision ma@ing are far more difficult in blunt trauma than in#enetrating trauma.


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and lower extremities. The discovery of one of these injuries should #rom#t a searchfor others.

3ow+energy trauma, such as being struc@ with a club or falling from a bicycle, usuallydoes not result in widely distributed injuries, but #otentially lethal lacerations of

internal organs can still occur because the net energy transfer to that location may besubstantial.

Penetrating injuriesare classified according to the wounding agent, i.e., stab wounds,gunshot wounds, or shotgun wounds. Hunshot wounds are subdivided further intohigh+ and low+velocity injuries because the s#eed of the bullet is much moreim#ortant than its weight in determining @inetic energy. x#erience in urban traumacenters indicates that high+velocity gunshot wounds ;bullet s#eed greater than -$$$ftBs= are rare in the civilian setting. Shotgun injuries are divided into close+range ;F meters= and long+range wounds. 8lose+range shotgun wounds are com#arable to high+velocity wounds because the entire energy of the load is delivered to a small area,

often with devastating results. 3ong+range shotgun wounds result in a diffuse #ellet#attern in which many #ellets miss the victim, and those that do stri@e are dis#ersedand of com#aratively low energy.

7egional "ssessment and S#ecial iagnostic Tests"dditional diagnostic studies are often indicated on the basis of mechanism of injury,location of injuries, screening x+rays, and the #atient's overall condition. The #atient isin constant jeo#ardy when undergoing s#ecial diagnostic testing. The surgeon should

be in attendance and be #re#ared to alter #lans as circumstances demand.&emodynamic, res#iratory, and mental statuses determine the most a##ro#riate courseof action.

&ead" score based on the Hlasgow 8oma Scale ;H8S= should be determined for allinjured #atients ;Table A+-=. t is calculated by adding the scores of the best motorres#onse, best verbal res#onse, and eye o#ening. Scores range from ;the lowest= to1% ;normal=. Scores of 1 to 1% indicate mild head injury, ) to 1-, moderate injury,and less than ), a severe injury. The HS8 is useful for triage and #rognosis.

xamination of the head should focus on #otentially treatable neurologic injuries. The#resence of laterali/ing findings are im#ortant, e.g., a unilateral dilated #u#il

unreactive to light, asymmetric movement of the extremities either s#ontaneously orin res#onse to noxious stimuli, or a unilateral ?abins@i's reflex suggest a treatableintracranial mass lesion or major structural damage. Stro@e syndromes should #rom#ta search for carotid dissection or thrombosis using du#lex scanning or angiogra#hy.6torrhea, rhinorrhea, Iraccoon eyes,J and ?attle's sign ;ecchymosis behind the ear=can be seen with basilar s@ull fractures. Chile not necessarily re>uiring treatment,these fractures carry an increased ris@ of meningitis in the #ostinjury #eriod. The headand face should be systematically #al#ated for fractures. :atients with a significantclosed head injury ;H8S less than 14= should have a 8T scan #erformed. (or

#enetrating injuries #lain s@ull films should be obtained as well, as they can #rovideinformation that 8T does not.


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8erebral #athologic lesions from blunt trauma include hematomas, contusions,hemorrhage into ventricular and subarachnoid s#aces, and diffuse axonal injury;"=. &ematomas are further classified according to location. #idural hematomasoccur when blood accumulates between the s@ull and the dura and are caused bydisru#tion of the middle meningeal artery or other small arteries in that #otential

s#ace from a s@ull fracture ;(ig. A+1$=. Subdural hematomas occur between the duraand the cerebral cortex and are caused by venous disru#tion or laceration of the

#arenchyma of the brain ;(ig. A+11=. ?ecause of the underlying brain injury,#rognosis is much worse with subdural hematomas. ntra#arenchymal hematomas andcontusions can occur anywhere within the brain. &emorrhage may occur into theventricles, and though usually not massive, this blood may cause #ostinjuryhydroce#halus. iffuse hemorrhage into the subarachnoid s#ace may causevasos#asm and reduce cerebral blood flow. " results from high+ s#eed decelerationinjury and re#resents direct axonal damage. 6n 8T a blurring of the grayBwhite matterinterface may be seen, with multi#le, small, #unctate hemorrhages. Chile #rognosis isdifficult to #redict, early evidence of " on 8T scan is associated with a #oor

outcome. ues. (lexion and extension views can be #erformed and may reveal o#ening ofthe intervertebral s#ace. This should only be done in the #resence of an ex#eriencedsurgeon #atients with injuries have become #ermanently >uadri#legic when flexedand extended by inex#erienced individuals ;(ig. A+1-=. " safer method may be toinstruct the #atient to carefully move his or her head without assistance from thesurgeon! #atients will not #ith themselves.

S#inal cord injuries can be com#lete or #artial. 8om#lete injuries cause #ermanent>uadri#legia or #ara#legia, de#ending on the level of the injury. These #atients have a

com#lete loss of motor function and sensation two or more levels below the bonyinjury. :atients with high s#inal cord disru#tion are at ris@ for s#inal shoc@ from


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#hysiologic disru#tion of sym#athetic fibers. Significant neurologic recovery is rare.There are several #artial or incom#lete s#inal cord injury syndromes. 8entral cordsyndrome usually occurs in older #ersons who suffer hy#erextension injuries. uential and re>uire no s#ecial evaluation.

8hest


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?lunt trauma to the chest may involve the chest wall, thoracic s#ine, heart, lungs,thoracic aorta and great vessels, and the eso#hagus. uences of missing the diagnosis,8T and angiogra#hy are fre>uently #erformed after certain ty#es of injury. "ortic

tears occur when shearing forces are created in the chest. This is most often seen inhigh+ energy+transfer deceleration motor vehicle accidents with frontal or lateralim#act. t may occur after an ejection injury or fall. The tear usually occurs just distalto the left subclavian artery, where the aorta is tethered by the ligamentum arteriosum;(ig. A+1%=. n - to % #ercent of cases the tear occurs in the ascending aorta, in thetransverse arch, or at the dia#hragm. ynamic, s#iral 8T is an excellent screeningtest. :ositive findings are a hematoma around the aorta or injury of the aorta. This testis highly sensitive, but its s#ecificity is un@nown. " clearly widened mediastinum onchest x+ray or abnormalities on 8T are an absolute indication for emergentaortogra#hy.

:enetrating thoracic trauma is considerably easier to evaluate. :hysical examination,#lain #osteroanterior and lateral chest x+rays with metallic mar@ings of entrance andexit wounds, and 85: measurement disclose the vast majority of injuries. njuries ofthe eso#hagus and trachea are exce#tions. e#ending on the estimated trajectory ofthe missile or blade, bronchosco#y should be #erformed to evaluate the trachea.so#hagosco#y can be #erformed to evaluate the eso#hagus, but injuries have beenmissed with the use of this techni>ue alone. :atients at ris@ also should undergo asoluble contrast eso#hagram. f no extravasation of contrast medium is seen, a bariumeso#hagram should be #erformed for greater detail. (ailure to identify extanteso#hageal injuries leads to fulminant mediastinitis that is often fatal. "s in the nec@,

right+to+left transmediastinal gunshot wounds fre>uently cause visceral or vascularinjuries. Stable #atients should be carefully evaluated for tracheal and eso#hagealinjuries. "ngiogra#hy occasionally is indicated.

"bdomenCith few exce#tions, it is not necessary to determine which intraabdominal organs areinjured, only whether an ex#loratory la#arotomy is necessary. :hysical examinationof the abdomen is unreliable in ma@ing this determination, but most authorities agreethat the #resence of abdominal rigidity or gross abdominal distention in a #atient withtruncal trauma is an indication for #rom#t surgical ex#loration. (or the majority of

#atients suffering blunt abdominal trauma, however, it is not clear whether

ex#loration is needed. Serial examinations by the same surgeon can detect early#eritoneal inflammation and the need for la#arotomy before serious infections and


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hemorrhagic com#lications occur. rugs, alcohol, or injuries of the head or s#inalcord com#licate #hysical examination. 3a#arotomy also may be im#ractical in

#atients who re>uire general anesthesia for the treatment of other injuries. These#atients re>uire additional diagnostic testing.

The diagnostic a##roaches to #enetrating and to blunt abdominal trauma differsubstantially. 3ittle #reo#erative evaluation is re>uired for firearm injuries in whichthe #eritoneal cavity is #enetrated because the chance of internal injury is over )$

#ercent and la#arotomy is mandatory. "nterior truncal gunshot wounds between thefourth intercostal s#ace and the #ubic sym#hysis whose trajectory as determined by x+ray or entranceBexit wound suggests #eritoneal #enetration should be o#erated on.Hunshot wounds to the bac@ or flan@ are more difficult to evaluate because of thegreater thic@ness of tissue between the s@in and the abdominal organs. f in doubt, it isalways safer to ex#lore the abdomen than to e>uivocate when the de#th of #enetrationis uncertain.

n contrast to gunshot wounds, stab wounds that #enetrate the #eritoneal cavity areless li@ely to injure intraabdominal organs. "nterior and lateral stab wounds to thetrun@ should be ex#lored under local anesthesia in the emergency room to determinewhether the #eritoneum has been violated. njuries that do not #enetrate the #eritonealcavity do not re>uire further evaluation. Stab wounds to the flan@ and bac@ are moredifficult to evaluate. Some authorities have recommended a tri#le contrast 8T scan todetect occult retro#eritoneal injuries of the colon, duodenum, and urinary tract.?ecause 8T does not always identify enteric injuries, the authors have used solublecontrast radiogra#hs of the colon and duodenum followed by barium if necessary. Thelarger final images may im#rove sensitivity. iagnostic #eritoneal lavage ;:3=remains the most sensitive test available for determining the #resence ofintraabdominal injury ;(ig. A+ 1A=. (or stab wounds to the abdomen, its sensitivity fordetecting intraabdominal injury exceeds )% #ercent. The results of :3 areconsidered to be grossly #ositive if more than 1$ m3 of free blood can be as#iratedafter insertion of the catheter. f less than 1$ m3 is withdrawn, 1 3 of normal salinesolution is instilled and the #atient is gently roc@ed from side to side and u# anddown. The effluent is withdrawn and sent to the laboratory for red blood cell countand determination of amylase and al@aline #hos#hatase levels. " red blood cell countgreater than 1$$,$$$Bmm is considered #ositive. The detection of bile, vegetable orfecal material, or the observation of effluent draining through a chest tube, anasogastric tube, or a (oley catheter also constitutes a #ositive result. n e>uivocal

cases, measurement of amylase and al@aline #hos#hatase levels can be hel#ful inidentifying #erforation of hollow viscera. The white blood cell count of the lavageeffluent is not considered a valid indicator of intra#eritoneal injury.

Stab wounds to the lower chest #resent a diagnostic o##ortunity. "fter theadministration of ade>uate local anesthesia and extension of the wound as necessary,a finger is #laced into the thoracic cavity to #al#ate the dia#hragm. 8onfirmation ofdia#hragm #enetration is an indication for la#arotomy. Chen a hole is not #al#able

but ris@ of a dia#hragmatic injury exists, a :3 should be #erformed. " red cell countin the effluent of more than 1$,$$$Bmm is considered #ositive when evaluating for adia#hragmatic injury. (or red cell counts between 1,$$$ and 1$,$$$Bmm,

thoracosco#y should be considered.


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?lunt abdominal trauma is evaluated by ultrasound imaging in most major traumacenters and, in selected cases, with 8T scanning to refine the diagnosis.Ultrasonogra#hy #erformed by a surgeon or an emergency #hysician in theemergency room has largely re#laced :3. valuation of the entire abdomen is notthe goal, but ultrasound is used in s#ecific anatomic regions ;e.g.,


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institution virtually all suture lines are created with a running single layer. There is noevidence that this method is less secure than interru#ted multilayer techni>ues, and itis clearly faster. rains, once considered mandatory for many #arenchymal injuriesand some anastomoses, have virtually disa##eared. (luid collections that accumulatein a delayed fashion are now effectively managed by interventional radiologists.

njuries once thought to mandate resection, such as s#lenic injuries, are now managedwith suture re#air or even nono#eratively. The treatment of colonic injuries by

#rimary re#air is another exam#le. These conce#tual changes have significantlyim#roved survival in trauma #atients, and all have been develo#ed through theextensive ex#erience of major urban trauma centers and the forums for the freeexchange of ideas #rovided by the "merican 8ollege of Surgeons 8ommittee onTrauma, the "merican "ssociation for the Surgery of Trauma, the nternational"ssociation of Trauma and Surgical ntensive 8are, the :an+"merican Trauma8ongress, and other surgical organi/ations.

The management of #atients with multi#le injuries re>uires the early establishment of

thera#eutic #riorities. Chile the conce#t of life over limb and limb over cosmesisseems obvious, decision ma@ing can be subtle. uiring transfusions receive all three com#onents. uantities of blood com#onents.t is not unusual for 1$$ com#onent units to be transfused during one #rocedure. 7edcell transfusion rates of -$ to 4$ units of #7?8 #er hour are common in severelyinjured #atients.

Transfusion #ractices in trauma re>uire the surgeon to identify the insidious signs ofcoagulo#athy, such as excessive bleeding from the cut edges of s@in, fascia, and

#eritoneum that were #reviously controlled. Chile the local volume of coagulo#athichemorrhage in one visual field seems low com#ared to that of a hole in the aorta or

venae cavae, blood loss from the entire area of dissection can lead to exsanguination.The usual measurements of coagulation ca#ability, i.e., #rothrombin time ;:T=, #artialthrombo#lastin time ;:TT=, and #latelet count have a turnaround time of more than $min in most institutions. These tests are of limited value in #atients who have lost twoor three blood volumes while waiting for test results. Under such conditions,transfusion must be em#iric and based on the surgeon's observations. "t the first signof coagulo#athic hemorrhage, the #reviously lost #lasma #roteins and #latelets must

be restored with ((: and #latelet #ac@s. "dditional transfusions should beadministered with e>ual ratios of #7?8, ((:, and #latelets.

The causal relationshi# of core hy#othermia metabolic, acidosis, and #ostinjury

coagulo#athy has been observed in a number of studies. The #atho#hysiology ismultifactorial and includes inhibition of tem#erature+ de#endent en/yme+activated


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coagulation cascades, #latelet dysfunction, endothelial abnormalities, and a #oorlyunderstood fibrinolytic activity. The role of metabolic acidosis in the #athogenesis ofa coagulo#athy is unclear. x#eriments have demonstrated im#aired hemostasis at a

#& of .-$! others have suggested that #& directly affects #latelet function. 6therseries im#licated acidosis in the #ro#agation of disseminated intravascular

coagulation with the secondary consum#tion of clotting factors. &y#othermia andmetabolic acidosis have adverse effects on myocardial #erformance and tissue

#erfusion.

:rimary hemostasis relies on #latelet adherence and aggregation to injuredendothelium, resulting in the formation of the #latelet #lug. " #latelet count of%$,$$$Bmm is considered ade>uate for tissue hemostasis if the #latelets are normal.&owever, #latelet dysfunction is a well+documented com#lication of massivetransfusion that is aggravated by associated hy#othermia. 8onse>uently, therecommended target of more than 1$$,$$$Bmm for #latelet transfusion in other high+ris@ #atients should be extended to the severely injured.

?lood ty#ing and, to a lesser extent, crossmatching is essential to avoid life+threatening intravascular hemolytic transfusion reactions. " com#lete ty#e andcrossmatch re>uires -$ to 4% min to com#lete and reduces the ris@ of an intravascularhemolysis to a##roximately $.$$4 #ercent. f -$ units of #7?8 are needed within anhour, an army of technicians would be re>uired to #erform this service. Twenty to 4%min is too long for a #atient with an exsanguinating hemorrhage to wait. Therefore,trauma #atients re>uiring emergency transfusions are given ty#e 6, ty#e+s#ecific, or

biologically com#atible red blood cells. "s a cross+chec@ for "?6 com#atibility, asaline crossmatch is often #erformed.

The administrative and laboratory time re>uired is a##roximately % min, and the ris@of intravascular hemolysis is about $.$% #ercent. The ris@ increases to 1.$ #ercent witha history of #revious transfusions or #regnancy, and u# to .$ #ercent with both. Thisincreased ris@ of transfusion reaction is a result of the #resence of irregular antibodies;e.g., Gell, uffy, Gidd, etc.= in the #atient's #lasma that occur in about 1B1$$$

#atients. ntravascular hemolysis can occur with "?6+com#atible #7?8 if the #atienthas an irregular antibody. t usually is not as severe as "?6 incom#atible hemolyticreactions, and the time re>uired to detect the antibodies biochemically or bycrossmatch ma@es the increased ris@ of hemolytic reaction a reasonable trade for ra#idavailability. :reformed antibodies are ra#idly de#leted by hemorrhage and are

#roduced slowly, diminishing the severity of intravascular hemolysis if it occurs. "nalternative strategy for those #atients who are consistently stable and do not haveserious injuries is to #erform a ty#e and screen as a cost+saving measure. f blood issubse>uently needed urgently, low+titer, ty#e+s#ecific red cells can be administeredwith the same ris@ of intravascular hemolysis as with fully ty#ed and crossmatched

blood, #rovided the screen for irregular antibodies is negative. Unstable #atientsshould receive 6+ negative, 6+#ositive, or ty#e+s#ecific red cells, de#ending on the

#atient's age and sex and the availability of blood cell ty#es. 6ther com#onents shouldbe ty#e s#ecific or biologically com#atible.

:ro#hylaxis

"ll injured #atients undergoing an o#eration should receive #reem#tive antibioticthera#y. The authors use second+generation ce#halos#orins for la#arotomies and first+


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generation ce#halos#orins for all other o#erations. "dditional doses should beadministered during the #rocedure on the basis of blood loss and the half+life of theantibiotic. The role of #osto#erative antibiotic thera#y in trauma #atients remains to

be defined, but the trend has been to reduce the duration. Tetanus #ro#hylaxis isadministered to all #atients according to the "merican 8ollege of Surgeons guidelines

;see 8ha#. %=.

ee# venous thrombosis and other venous com#lications occur more often in injured#atients than is generally believed. This is #articularly true for #atients with majorfractures of the #elvis and lower extremities, those with s#inal cord injury or in acoma, and those with injury of the large veins in the abdomen and lower extremities.The authors use #ulsatile com#ression stoc@ings in all injured #atients and selectively

#lace inferior vena caval filters for those at very high ris@. The role of inferior venacaval filters may ex#and in the future when removable devices become commerciallyavailable. 3ow+molecular+weight he#arins have been demonstrated to be safe andeffective in #atients with ortho#aedic injuries. Their use in #atients with other injuries

remains to be elucidated.

"nother #ro#hylactic measure is thermal #rotection. &emorrhagic shoc@ im#airs#erfusion and metabolic activity throughout the body. Cith declining metabolism,heat #roduction and body tem#erature decrease. The injured #atient receives a secondthermal insult with the removal of insulating clothing. "s a result, trauma #atients can

become seriously hy#othermic, with tem#eratures as low as 4N8 by the time theyreach the o#erating room. &y#othermia im#airs coagulation and myocardialcontractility and increases myocardial irritability. ntentional hy#othermia has

#rotective features for #atients with massive head injuries, but most authorities agreethat the deleterious effects outweigh the #otential benefits. njured #atients whoseintrao#erative core tem#erature dro#s below -N8 are at ris@ for fatal arrhythmias anddefective coagulation. Thermal #ro#hylaxis should begin in the emergency room bymaintaining the ambient tem#erature comfortable for an ex#osed #atient. (luidsshould be stored at body tem#erature and blood #roducts should be administeredthrough ra#id+warming devices. Chen examination is com#leted, the #atient should

be @e#t scru#ulously covered with warm blan@ets or other devices until bodytem#erature returns to normal.

5ascular 7e#airThe initial control of vascular injuries should be accom#lished digitally by a##lying

enough #ressure directly on the bleeding site to sto# the hemorrhage. Some bleedingvessels may need to be gently #inched between the thumb and index finger. Thesemaneuvers, along with suction, usually create a dry enough field to safely #ermit thedissection necessary to define the injury. Shar# dissection with fine scissors is

#referable to blunt dissection because the latter can aggravate the injury. Chen asufficient length of vessel is available, a vascular thumb force#s is used to gras# thevessel. f the vessel is not transected, force#s can be #laced directly across the injury.This minimi/es or eliminates bleeding while the dissection necessary for clam#ing iscom#leted. f the vessel is transected ;or nearly so= digital control is maintained onone side while the other is occluded with a thumb force#s. The vessel is then shar#lymobili/ed to allow an a##ro#riate vascular clam# to be a##lied. Chen definitive

control of all injuries is achieved, he#arini/ed saline is injected into the #roximal anddistal ends of the injured vessel to #revent thrombosis. The ex#osed intima and media


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at the site of the injury are highly thrombogenic, and small clots often form. Theseclots should be carefully removed to #revent thrombosis or embolism when theclam#s are removed. ?ecause of the fre>uency that embolism occurs, routine ballooncatheter ex#loration of the distal vessel has been recommended. 7agged edges of theinjury site should be judiciously debrided using shar# dissection.

njuries of the large veins such as the venae cavae, or the innominate and iliac veins#ose a s#ecial #roblem for hemostasis. 2umerous large tributaries ma@e ade>uatehemostasis difficult to achieve, and their thin walls render them susce#tible toadditional iatrogenic injury. Chen a large+ vessel injury is encountered, tam#onadewith a folded la#arotomy #ad held directly over the bleeding site usually establisheshemostasis sufficient to #revent exsanguination. f hemostasis is not ade>uate toex#ose the vessel #roximal and distal to the injury, s#onge stic@s can be #lacedstrategically on either side of the injury and carefully adjusted to im#rove hemostasis.This maneuver re>uires s@ill and disci#line to maintain a dry field. The o#erative fieldis sometimes sufficient to delineate and re#air the injury. t is often difficult for the

assistant to maintain com#lete control of hemorrhage with s#onge stic@s. n thissituation, the vessel can be ex#osed on either side of the s#onge stic@ and a vascularclam# a##lied. The clam# can then be se>uentially advanced toward the injury untilhemostasis is com#lete.

6#tions for the treatment of vascular injuries are listed in Table A+%. Some arteriesand most veins can be ligated without significant se>uelae. "rteries for which re#airshould always be attem#ted include the aorta and the carotid, innominate, brachial,su#erior mesenteric, #ro#er he#atic, renal, iliac, femoral, and #o#liteal arteries. n theforearm and lower leg at least one of the two #al#able vessels should be salvaged. Thelist of veins for which re#air should be attem#ted is short the su#erior vena cava, theinferior vena cava #roximal to the renal veins, and the #ortal vein. There are notablevessels for which re#air is not necessary, e.g., the subclavian artery and the su#eriormesenteric vein. The #ortal vein can be ligated successfully #rovided ade>uate fluid isadministered to com#ensate for the dramatic but transient edema that occurs in the

bowel. 3igation of some vessels, such as the #o#liteal vein and the left or right branchof the #ortal vein, can result in morbidity for the #atient that is not life threatening.The authors attem#t to re#air all arteries larger than mm and all veins larger than 1$mm in diameter, de#ending on the #atient's #hysiologic condition.

Some arterial injuries have been treated by observation without subse>uent

com#lications. These include small #seudoaneurysms, intimal dissections, smallintimal fla#s and arteriovenous fistulas in the extremities, and occlusions of small ;F-mm= arteries. (ollow+u# angiogra#hy is obtained within - to 4 wee@s to ensure thathealing has occurred.

3ateral suture is a##ro#riate for small arterial injuries with little or no loss of tissue.nd+to+end anastomosis is used if the vessel is transected or nearly so. The severedends of the vessel are mobili/ed, and small branches are ligated and divided asnecessary to obtain the desired length. "rterial defects of 1 to - cm usually can be

bridged. The surgeon should not be reluctant to divide small branches to obtainadditional length because most injured #atients have normal vasculature and the

#reservation of #otential collateral flow is not as im#ortant as in atheroscleroticsurgery. To avoid #osto#erative stenosis, #articularly in smaller arteries, some


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techni>ue such as beveling or s#atulation should be used so that the com#letedanastomosis is slightly larger in diameter than the native artery ;(ig. A+-1=.

nter#osition grafts are used when end+to+end anastomosis cannot be accom#lishedwithout tension des#ite mobili/ation. (or vessels less than A mm in diameter,

autogenous sa#henous vein from the groin should be used because#olytetrafluoroethylene ;:T(= grafts less than A mm in diameter have a #rohibitiverate of thrombosis. njuries of the brachial, #o#liteal, and internal carotid arteriesre>uire the sa#henous vein for inter#osition grafting. Chen the sa#henous vein isharvested for treating an arterial injury in the lower extremity, it should be ta@en fromthe contralateral extremity. ?ecause the status of the i#silateral venous system isun@nown, the sa#henous vein on that side may become an im#ortant tributary. 3argerarteries must be bridged by artificial grafts. Some authorities advocate the use of freeinternal iliac artery grafts because of the greater thic@ness and strength of its wallcom#ared to the sa#henous vein. The authors believe that this vessel is overly tediousto remove and has no advantage over the sa#henous vein.

Trans#osition #rocedures can be used when an artery has a bifurcation of which onevessel can safely be ligated. njuries of the #roximal internal carotid can be treated bymobili/ing the adjacent external carotid, dividing it distal to the internal injury and

#erforming an end+to+end anastomosis between it and the distal internal carotid ;(ig.A+--=. The #roximal stum# of the internal carotid is oversewn in such a way as toavoid a blind #oc@et where clot may form. njuries of the i#silateral external andcontralateral common iliac arteries can be handled in a similar fashion #rovided flowis maintained in at least one internal iliac artery ;(ig. A+-=.

"rterial injuries are often grossly contaminated from enteric or external sources, inwhich case many surgeons are reluctant to #lace artificial grafts in situ. This situationarises most often in injuries to the aortic or iliac artery when the colon also is injured.(or the aorta there are few o#tions. 3igation of the aorta with unilateral or bilateralaxillofemoral by#ass can be #erformed. These are lengthy #rocedures that are #roneto thrombosis and infection. uire an aortic graft cannot toleratesurgery for the amount of time re>uired to #erform an axillofemoral by#ass.Therefore, even in the #resence of fecal contamination, it is common #ractice to use:T( or acron in situ for aortic injuries. very effort is made to remove and controlcontamination after the control of hemorrhage but before the graft is brought into theo#erative field. This includes co#ious irrigation of the abdominal cavity and changing

of dra#es, gowns, gloves, and instruments. "fter #lacement of the graft, it is coveredwith #eritoneum or omentum before definitive treatment of the enteric injuries. Hraftinfection is rare in these instances. " similar a##roach can be used for injuries to theiliac artery, but in most cases this can be avoided by the innovative use oftrans#osition #rocedures.

Suture selection for arterial injuries is based on the diameter of the vessel beingre#aired ;Table A+A=. The use of #rogressively finer suture for smaller+ diametervessels encourages the inclusion of less tissue with more closely #laced sutures,which is necessary for successful re#air. Chen #erforming anastomoses in which thevessels are tethered, e.g., the thoracic artery and the abdominal aorta, the authors use

the #arachute techni>ue to ensure #recise #lacement of the #osterior suture line ;(ig.A+-4=. f this techni>ue is used, traction on both ends of the sutures must be


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maintained or lea@age from the #osterior as#ect of the suture line is #robable. " singletem#orary suture 1*$ degrees from the #osterior row is used to maintain alignment.

5enous injuries are more difficult to re#air successfully because of their #ro#ensity tothrombose. Small injuries without loss of tissue can be treated with lateral suture.


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hy#othermia, and metabolic acidosis. &y#othermia from eva#orative and conductiveheat loss and diminished heat #roduction occurs in s#ite of warming blan@ets and

blood warmers. The metabolic acidosis of shoc@ is exacerbated by aortic clam#ing,vaso#ressors, massive transfusions, and im#aired myocardial #erformance.8oagulo#athy is caused by dilution, hy#othermia, and acidosis. ach of these factors

reinforces the others, resulting in a critically ill #atient who is at high ris@ for a fatalarrhythmia. This downward s#iral has been referred to as Ithe bloody vicious cycleJ;(ig. A+-*=.

&eat loss a##ears to be the central event because neither of the other com#onents canbe corrected until core tem#erature returns toward normal. 3aboratory andmathematical heat exchange models have demonstrated that eva#orative heat lossfrom an o#en abdomen is by far the greatest source. " concomitant o#en thoraciccavity greatly accelerates the rate of the #atient's deterioration and can cause thesyndrome by itself. This is the rationale for the immediate abdominal closure and thereason it has been successful.

Staged o#erations are indicated when a coagulo#athy develo#s and core tem#eraturedro#s below 4N8. " refractory acidosis is almost always #resent. Several unorthodoxtechni>ues can be used to ex#edite wound closure. ?leeding raw surfaces, often of theliver, are #ac@ed with la#arotomy #ads. Small enteric injuries are closed with sta#les,and large ones are sta#led on both sides with the H" sta#ler and the damagedsegment removed. 8lam#s may be left on unre#aired vascular injuries, or the vesselsmay be ligated. njuries of the #ancreas and @idneys are not treated if they are not

bleeding. 2o drains are #laced, and the abdomen is closed with shar# towel cli#s#laced - cm a#art, which include only the s@in ;(ig. A+-)=. Towel cli#s are usedbecause they do not cause bleeding as needles do, and they can be a##lied veryra#idly, usually in A$ to )$ seconds. The closure of just the s@in allows for theabdominal or thoracic cavity to accommodate a greater volume without increased

#ressure. The cli#s are covered with a towel, and a #lastic adhesive sheet is #lacedover the towel to #revent excessive fluid from draining onto the #atient's bedding.8old wet dra#es are removed, and the #atient is covered from head to toe with layersof warm blan@ets. Some of the unorthodox treatments used, including the creation ofclosed+loo# bowel obstructions and unre#aired renal injuries, are not com#atible withsurvival! however, reo#eration is #lanned within - to -4 h, and the treatments aretolerated well within that time frame. The goal is to com#lete the #rocedure as soon as

#ossible, or the #atient will die. f the surgeon believes that the #atient's metabolic

#roblems can be corrected in a short time ;- h or less=, the #atient can remain in theo#erating room while additional blood #roducts are administered and rewarmingmeasures are instituted. :atients who are in very #oor condition and re>uire severalhours for metabolic corrections should be transferred to the surgical intensive careunit. f the #atient's condition im#roves as evidenced by normali/ation of coagulationstudies, the correction of acidBbase imbalance, and a core tem#erature of at least AN8,the #atient should be returned to the o#erating room for removal of #ac@s anddefinitive treatment of injuries.

There are several com#lications associated with this treatment. (ailure to identifynoncoagulo#athic hemorrhage can lead to exsanguination.


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of vascular hemorrhage coagulo#athy does not correct itself, and these #atients mustbe returned to the o#erating room for reex#loration.

" second com#lication is referred to as the abdominal or thoracic com#artmentsyndrome, which are caused by an acute increase in intracavitary #ressure. n the

abdomen the com#liance of the abdominal wall and the dia#hragm #ermit theaccumulation of many liters of fluid before intraabdominal #ressure ;":= increases.There are #rimarily two sources for this fluid, blood, and edema. ?lood accumulatesas a result of the coagulo#athy or missed vascular injury described above. The causeof edema is multifactorial. schemia and re#erfusion cause ca#illary lea@age, loss ofoncotic #ressure occurs, and in the case of the small bowel, which is ofteneviscerated, #rolongation and narrowing of veins and lym#hatics caused by tractionim#airs venous and lym#hatic drainage.

The resulting edema may be dramatic ;(ig. A+$=. Similar #henomena occur in thechest. "s fluid continues to accumulate, the com#liant limit of the abdominal cavity is

eventually exceeded, and ": increases. Chen ": exceeds 1% mm&g, serious#hysiologic changes begin to occur. The lungs are com#ressed by the u#warddis#lacement of the dia#hragm. This causes a decrease in functional residual ca#acity,increased airway #ressure, and, ultimately, hy#oxia. 8ardiac out#ut decreases as aconse>uence of diminished venous return to the heart and increased afterload. ?loodflow to every intraabdominal organ is reduced because of increased venous resistance."s ": exceeds -% to $ mm&g, life+threatening hy#oxia and anuric renal failureoccur. 8ardiac out#ut is further reduced but can be returned toward normal withvolume ex#ansion and inotro#ic su##ort.

The only method for treating hy#oxia and renal failure is to decom#ress theabdominal cavity by o#ening the incision. This results in an immediate diuresis and aresolution of hy#oxia. (ailure to decom#ress the abdominal cavity eventually causeslethal hy#oxia or organ failure. There have been a few re#orts of sudden hy#otensionwhen the abdomen is o#ened, but volume loading to enhance cardiac out#ut haslargely eliminated this #roblem. ": is measured using the (oley catheter. ?ecausethe bladder is a #assive reservoir at low volumes ;%$ to 1$$ m3=, it im#arts nointrinsic #ressure but can transmit ":. (ifty m3 saline solution is injected into theas#iration #ort of the urinary drainage tube with an occlusive clam# #laced across thetube just distal to the #ort. The saline is used to create a standing column of fluid

between the bladder and #ort that can transmit ": to a recording device. The needle

in the #ort is connected to a 85: manometer using a three+way sto#coc@. Themanometer is filled with saline and o#ened to the drainage tube. ": is read at themeniscus with manometer /eroed at the #ubic sym#hysis. ?ladder #ressures measuredin this fashion are reliable and consistent. :ressures less than 1% mm&g do not re>uiredecom#ression. Table A+ lists recommendations according to ":.

n the chest similar #henomena occur. dema of the heart and lungs develo#s, and theheart also may dilate. ?lood accumulation is rarely a #roblem because of the use ofchest tubes. The diagnosis usually is a##arent in the o#erating room because the hearttolerates com#ression #oorly. "ttem#ts to close the chest in this setting are associatedwith #rofound hy#otension, and an alternative method of closure is necessary. The

most #o#ular material used to accommodate the addition of volume in the chest orabdomen is a +liter #lastic urologic irrigation bag that has been cut o#en and


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sterili/ed. The bag is sewn to the s@in or fascia using 2o. - nylon suture with a sim#lerunning techni>ue ;(ig. A+1=. "s many as four bags may need to be sewn together tocover a large defect. 8losed+ suction drains are #laced beneath the #lastic to remove

blood and serous fluid that inevitably accumulate. The entire closure is covered withan iodinated #lastic adhesive sheet to sim#lify nursing care. :atients whose renal

function has not been im#aired will have a remar@able diuresis. xogenous fluids areheld to a minimum to facilitate the resolution of edema. efinitive wound closure canusually be #erformed in 4* to - h.

n the case of #atients who develo# se#sis and multi#le organ failure ;uires reconstruction.

2ono#erative


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Heneral #rinci#les for the management of cerebral injuries have changed in recentyears. "ttention is now focused on maintaining or enhancing cerebral #erfusion ratherthan merely lowering intracranial #ressure ;8:=. &y#erventilation to a #86- below$ mm&g to induce cerebral vasoconstriction exacerbates cerebral ischemia in s#iteof decreasing 8:. These secondary iatrogenic cerebral injuries cause more harm than

#reviously a##reciated. 6ther treatments or conditions that must be avoided includedecreased cardiac out#ut because of the excessive use of osmotic diuretics, sedatives,or barbiturates, and hy#oxia. 2evertheless, the measurement of 8: is im#ortant andis efficiently accom#lished with a ventriculostomy tube. The tube also #ermits thewithdrawal of cerebros#inal fluid, which is the safest method for lowering 8:."lthough an 8: of 1$ mm&g is believed to be the u##er limit of normal, thera#y isnot usually initiated until the 8: reaches -$ mm&g. 8erebral #erfusion #ressure;8::=, which is e>ual to the mean arterial #ressure ;uire drainage because of the threat of brainstemcom#ression or herniation. 7emoval of small hematomas also may im#rove 8: and8:: in #atients with an elevated 8: that is refractory to medical thera#y.

The treatment of diffuse axonal injury includes the control of cerebral edema andgeneral su##ortive care. The authors fre>uently use #ercutaneous tracheostomy forairway control and #ercutaneous endosco#ic gastrostomy for enteral access in head+injured #atients whose recovery is unli@ely or #rolonged. :rognosis is related toHlasgow 8oma Scale score. Serious head injuries, H8S K*, have a #oor #rognosis,and an institutional existence is almost a certainty. uired to drill a burr hole in one life+ saving circumstance in a#atient with an e#idural hematoma. "s blood from a torn vessel, usually the middlemeningeal artery, accumulates, the tem#oral lobe is forced medially, whichcom#resses the third cranial nerve and eventually the brainstem. The ty#ical course is;1= initial loss of consciousness! ;-= awa@ening and a lucid interval! ;= recurrent lossof consciousness with a unilaterally fixed, dilated #u#il! and ;4= cardiac arrest. These

#atients usually do not have a serious underlying cortical injury, and com#leterecovery often is #ossible. The burr hole should be made on the same side as thedilated #u#il, as shown in (ig. A+-. The goal of the #rocedure is not to control thehemorrhage but to decom#ress the intracranial s#ace. " craniotomy is re>uired for the

control of hemorrhage. The #atient's head should be loosely wra##ed with a thic@


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layer of gau/e to absorb the bleeding, and the #atient should be transferred to afacility with emergency neurosurgical ca#ability for a craniotomy.

2ec@?lunt njury 8ervical S#ine

Treatment of injuries to the cervical s#ine is based on the level of injury, the stabilityof the s#ine, the #resence of subluxation, the extent of angulation, and the extent ofneurologic deficit. 8autious axial traction in line with the mastoid #rocess is used toreduce subluxations. " halo+vest combination can accom#lish this and also #roviderigid external fixation for definitive treatment when left in #lace for to A months.This device is the treatment of choice for many cervical s#ine injuries. Surgical fusionusually is reserved for those with neurologic deficit, those who demonstrateangulation greater than 11 degrees on flexion and extension x+rays, or those who areunstable after external fixation.

S#inal 8ord

njuries of the s#inal cord, #articularly com#lete injuries, are essentially untreatable."##roximately #ercent of #atients who #resent with flaccid >uadri#legia haveconcussive injuries, and these #atients re#resent the very few who seem to havemiraculous recoveries. " #ros#ective randomi/ed study com#aringmethyl#rednisolone with #lacebo demonstrated a significant im#rovement in outcome;usually one or two s#inal levels= for those who received the corticosteroid within * hof injury. The standard dosage is $ mgB@g given as an intravenous bolus followed bya %.4 mgB@g infusion administered over the next - h.

3arynxThe larynx may be fractured by a direct blow, which can result in airway com#romise." hoarse voice in a trauma #atient is highly suggestive of laryngeal fracture. n casesof severe fracture a cricothyroidotomy or tracheostomy should be #erformed to

#rotect the airway. The larynx is re#aired with fine wires and sutures. f direct re#airof internal laryngeal structures is necessary, the thyroid cartilage is s#lit longitudinallyin the midline and o#ened li@e a boo@. This is referred to as a laryngeal fissure.

8arotid and 5ertebral "rteries?lunt injury to the carotid or vertebral arteries may cause dissection, thrombosis, or

#seudoaneurysm. uently occur at or extend into the base of the s@ull and usually are notsurgically accessible. "cce#ted treatment for thrombosis and dissection isanticoagulation thera#y with he#arin followed by warfarin sodium ;8oumadin= for months. :seudoaneurysms also occur near the base of the s@ull. f they are small, theycan be followed with re#eat angiogra#hy. f enlargement occurs, consideration should

be given to the #lacement of a stent across the aneurysm by an interventionalradiologist. "nother #ossibility is to a##roach the intracranial #ortion of the carotidartery by removing the overlying bone and #erforming a direct re#air. This methodhas only recently been described and has been #erformed in a limited number of

#atients.


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5enous njuriesThrombosis of the internal jugular veins caused by blunt trauma can occur unilaterallyor bilaterally. These injuries usually are discovered incidentally and are generallyasym#tomatic. ?ilateral thrombosis can aggravate cerebral edema in #atients withserious head injuries. Stent #lacement should be considered in such #atients if their

8: remains elevated. 3aryngeal edema resulting in airway com#romise also canoccur.

:enetrating njuries:enetrating injuries in Mone or that re>uire o#erative intervention are ex#loredusing an incision along the anterior border of the sternocleidomastoid muscle. f

bilateral ex#loration is necessary, the inferior end of the incision can be extended tothe o##osite side.


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sheath laterally ;(ig. A+4=. The muscular attachments to the anterior elements areremoved. 8are must be ta@en to avoid injury to the cervical s#inal nerves that arelocated directly behind and lateral to the bony canal. Some authorities haverecommended using a high+s#eed burr to remove the anterior as#ect of the canal,thereby avoiding the venous #lexus between the elements. The authors have not found

this to be a #roblem and have often excised the fascia between the elements and liftedthe artery out of its canal with a tissue force#s.

The treatment for vertebral artery injuries is ligation #roximal and distal to the injury.There is rarely, if ever, an indication for re#air. 2eurologic com#lications areuncommon. x#osure of the vertebral artery above 8- is extremely difficult. 7atherthan using a direct o#erative a##roach, the authors ex#ose the vessel below 8%,outside the bony canal, clam# the artery #roximally, and insert a 2o. balloon+ti##edcatheter. The catheter is advanced to the level of the injury or distal to it, and the

balloon is inflated with saline solution until bac@ bleeding sto#s. The tube to thecatheter is crim#ed over on itself and secured in this #osition with several heavy sil@

sutures. The catheter is trimmed so that it can be left in the wound under the s@in. The#roximal end of the artery is ligated. 6ne wee@ later the catheter is removed underlocal anesthesia. 7ebleeding has not occurred in our ex#erience.

The same a##roach can be used for the distal internal carotid artery. "n alternativea##roach is to have the interventional radiologist #lace coils to induce thrombosis

#roximal and distal to the injury if the lesion is diagnosed by angiogra#hy. 2ot allvertebral artery injuries can be treated by this method. njuries of the #roximalvertebral artery can be ex#osed by a median sternotomy with a nec@ extension.

Trachea and so#hagusnjuries of the trachea are re#aired with a running +$ absorbable monofilamentsuture. Tracheostomy is not re>uired in most #atients. so#hageal injuries arere#aired in a similar fashion. f an eso#hageal wound is large, or if tissue is missing, asternocleidomastoid muscle #edicle fla# is warranted, and a closed+suction drain is areasonable #recaution. The drain should be near but not in contact with the eso#hagealor any other suture line. t can be removed in to 1$ days if the suture line remainssecure. 8are must be ta@en when ex#loring the trachea and eso#hagus to avoidiatrogenic injury to the recurrent laryngeal nerves.

:enetrating injuries of the nec@ often create wounds in adjacent hollow structures,

e.g., the trachea and eso#hagus or the carotid artery and eso#hagus. f, after re#air,these adjacent suture lines are in contact, the stage is set for devastating #osto#erativefistulous com#lications. To avoid these com#lications, viable tissue should routinely

be inter#osed between adjacent suture lines. 5iable stri#s of the sternocleidomastoidmuscle or stra# muscles are useful for this #ur#ose.

Thoracic 6utletHreat 5essels


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hemothorax, a left third or fourth inters#ace anterolateral thoracotomy should be#erformed because the #roximal left subclavian artery may be injured. &emorrhagecan be controlled digitally until the vascular injury is delineated. "dditional incisionsor extensions are often re>uired. " third or fourth inters#ace right anterolateralthoracotomy may be used for thoracic outlet injury #resenting with hemodynamic

instability and a right hemothorax. " median sternotomy with a right clavicularextension also can be used. Unstable #atients with injuries near the sternal notch mayhave a large mediastinal hematoma or have lost blood directly to the outside. These

#atients should be ex#lored via a median sternotomy.

f angiogra#hy has identified an arterial injury, a more direct a##roach can be used.(ig. A+% shows the various incisions that are used de#ending on the location of thearterial injury. " median sternotomy is used for ex#osure of the innominate, #roximalright carotid and subclavian, and #roximal left carotid arteries.

The #roximal left subclavian artery #resents a uni>ue challenge. ?ecause it arises

from the aortic arch far #osteriorly, it is not readily a##roached via a mediansternotomy. " #osterolateral thoracotomy #rovides excellent ex#osure but severelylimits access to other structures and is not recommended. The best o#tion is to create afull+thic@ness fla# of the u##er chest wall. This is accom#lished with a third or fourthinters#ace anterolateral thoracotomy for #roximal control, a su#raclavicular incisionwith a resection of the medial third of the clavicle, and a median sternotomy, whichlin@s the two hori/ontal incisions. The ribs can be cut laterally for additionalex#osure, which allows the fla# to be folded laterally with little effort. This incisionhas been referred to as a boo@ or tra#door thoracotomy ;(ig. A+A=. The mid#ortion ofthe subclavian artery is accessible by removing the #roximal third of either clavicle,with the s@in incision made directly over the clavicle.


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re#aired. "s in the nec@, adjacent suture lines should be se#arated by viable tissue. "#ortion of the sternocleidomastoid can be rotated down for this #ur#ose.

8hestThe most common life+threatening com#lications from blunt and #enetrating thoracic

injury are hemothorax, #neumothorax, or a combination of the two. "##roximately *%#ercent of these #atients can be treated definitively with a chest tube. ?ecause of theviscosity of blood at various stages of coagulation, a A( or larger chest tube should

be used. f one tube fails to com#letely evacuate the hemothorax ;a Ica@edhemothoraxJ=, a second tube should be #laced ;(ig. A+=. f the second chest tubedoes not remove the blood, a thoracotomy should be #erformed because of the ris@ oflife+threatening hemorrhage. 8ommon sources of blood loss include intercostalvessels, internal thoracic artery, #ulmonary #arenchyma, and the heart. 3ess commonsources are the great vessels, aortic arch, a/ygos vein, su#erior vena cava, and inferiorvena cava. ?lood may also enter the chest from an abdominal injury through a

#erforation or tear in the dia#hragm. ndications for o#erative treatment of #enetrating

thoracic injuries are listed in Table A+*.

The indications for thoracotomy in blunt trauma are based on s#ecific #reo#erativediagnoses. These include #ericardial tam#onade, tear of the descending thoracic aorta,ru#ture of a main bronchus, and ru#ture of the eso#hagus. Thoracotomy forhemothorax in the absence of the above diagnoses is rarely indicated. " shatteredchest wall that #roduces a hemothorax is better treated by the interventionalradiologist with emboli/ation.

Thoracic ncisionsThe selection of incision is im#ortant and de#ends on the organs being treated. (orex#loratory thoracotomy for hemorrhage, the #atient is su#ine and an anterolateralthoracotomy is #erformed. e#ending on findings, the incision can be extendedacross the sternum or even farther for a bilateral anterolateral thoracotomy. The fifthinters#ace usually is #referred unless the surgeon has a #recise @nowledge of whichorgans are injured and @nows that ex#osure would be enhanced by selecting adifferent inters#ace. The heart, lungs, aortic arch, great vessels, and eso#hagus areaccessible with these incisions. 8are should be ta@en to ligate the internal thoracicartery and veins if they are transected. This ste# often is overloo@ed, resulting incontinuous blood loss that obscures the field and endangers the #atient.

The heart also can be a##roached via a median sternotomy. ?ecause little else can bedone in the chest through this incision, it usually is reserved for stab wounds of theanterior chest in #atients who #resent with #ericardial tam#onade. :osterolateralthoracotomies rarely are used since ventilation is im#aired in the de#endent lung, andthe incision cannot be extended. There are two s#ecific exce#tions. njuries of the

#osterior as#ect of the trachea or main bronchi near the carina tracheae areinaccessible from the left or from the front. The only #ossible a##roach is through theright chest using a #osterolateral thoracotomy. " tear of the descending thoracic aortacan be re#aired only through a left #osterolateral thoracotomy. ?ecause the authorsuse left heart by#ass for these #rocedures, the #atient's hi#s and legs are rotatedtoward the su#ine #osition to gain access to the left groin for femoral artery

cannulation. t is also hel#ful for o#timal ex#osure to resect the fourth rib and enterthe chest through its bed.


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&eartues can be used. The atria can be clam#ed with a Satins@y vascular

clam#. igital control and suturing beneath the finger is #ossible anywhere in theheart, though the techni>ue re>uires s@ill and a long, curved cardiovascular needle.&owever, the reality of blood+borne viral infections raises the >uestion of whether thismethod should be used. f the hole is small, a I#eanutJ s#onge clam#ed in the ti# of ahemostat can be #laced into the wound, or the blood loss may be acce#ted whilesutures are being #laced. (or larger holes a 1A( (oley catheter with a $ m3 ballooncan be inflated with 1$ m3 of saline solution. Hentle traction on the catheter controlshemorrhage from any cardiac wound because wounds too large for balloontam#onade are incom#atible with survival. Suture #lacement with the balloon inflatedis #roblematic. Usually the ends of the wound are closed #rogressively toward themiddle until the amount of blood loss is acce#table with the balloon removed. The use

of s@in sta#les for the tem#orary control of hemorrhage has become #o#ular,#articularly when emergency room thoracotomy has been #erformed. The use ofsta#les has the advantages of reducing the ris@ of needle+stic@ injury to the surgeonand of not demanding the attention re>uired by a balloon catheter. n most instances,hemostasis is neither #erfect nor definitive. nflow occlusion of the heart by clam#ingthe su#erior and inferior venae cavae can be #erformed for short #eriods, and this may

be essential for the treatment of extensive or multi#le wounds as well as for those thatare difficult to ex#ose.

mmediate re#air of valvular damage or acute se#tal defects rarely is necessary andre>uires total cardio#ulmonary by#ass, which has a high mortality in this situation.


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Trachea and so#hagusnjuries of the trachea and eso#hagus are managed in the same fashion as describedabove for lung injuries. ?ecause ex#osure can be difficult, #rovisions should be madeto deflate the lung on the o#erative side by using a double+lumen endotracheal tube ;a

double+lumen tube is seldom needed for cardiac or #ulmonary injury=. 7e#air ofinjuries of the main bronchi and the trachea near the carina tracheae can result in acom#lete loss of ventilation when the overlying #leura is o#ened, even if a double+lumen tube is used. Hases from the ventilator #referentially esca#e from the injuryand neither lung will be ventilated. igital occlusion of the injury can control air lossif the injury is small. 3arger injuries are an imminent threat to life. To avoid thiscatastro#he, a A or mm cuffed endotracheal tube should be on the o#erative field anda second ventilator available. f ventilation is inade>uate, the surgeon can insert andinflate the endotracheal tube into the main bronchus on the o##osite side through theinjury to #ermit ventilation of one lung while the injury is re#aired. ventually, thetube will have to be removed to close the defect, but the remaining hole can be

controlled digitally. "lternatively, it may be #ossible for the anesthesiologist tocannulate the o##osite bronchus.

escending Thoracic "ortaThe occurrence of #ara#legia from ischemic injury of the s#inal cord has been aconcern in injuries to the descending thoracic aorta. 8once#tually, two techni>ueshave been advocated. The sim#ler techni>ue, often referred to as Iclam# and sew,J isaccom#lished with the a##lication of vascular clam#s #roximal and distal to the injuryand re#air or re#lacement of the damaged #ortion of the aorta. This method results intransient hy#o#erfusion of the s#inal cord distal to the clam#s as well as all abdominalorgans. 3arge doses of vasodilators also are re>uired to reduce afterload and avoidacute left heart failure. f the clam#ing time is short, less than $ min, #ara#legia isuncommon. 3onger clam#ing times have been associated with #ara#legia ina##roximately 1$ #ercent of #atients. 8lam#ing times of less than $ min are difficultto achieve where there are many tears re>uiring com#lex re#air. "n alternativea##roach is to #rovide some method for maintaining a reasonable degree of #erfusionfor organs distal to the clam#s. Two techni>ues have been used to accom#lish thisgoal. The first is with the use of a shunt, a tem#orary extraanatomic route around theclam#s. " he#arin+im#regnated tube, the Hott shunt, has been designed s#ecificallyfor this #ur#ose, but the volume of blood flow to the distal aorta is marginal. Thesecond method is to use left heart by#ass. Cith this method a volume of oxygenated

blood is si#honed from the left heart and #um#ed into the distal aorta. (low rates of -to 3Bmin a##ear to #rovide ade>uate #rotection by maintaining a distal #erfusion#ressure higher than A% mm&g. This is the #referred method. The left su#erior#ulmonary vein, rather than the left atrium, is cannulated to remove blood from theheart because the vein is tougher and less #rone to tearing ;(ig. A+)=. The leftfemoral artery is cannulated to return the blood to the distal aorta. " centrifugal #um#is used because it is not as thrombogenic as a roller #um# and, strictly s#ea@ing,he#arini/ation is not re>uired. This can be a significant benefit in #atients withmulti#le injuries, #articularly in those with intracranial hemorrhage. 6ccasional smallcerebral infarcts have occurred, and %,$$$ to 1$,$$$ units of he#arin usually isadministered unless contraindicated by associated injuries.


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6nce by#ass is initiated, the #roximal vascular clam# is a##lied between the leftcommon carotid and left subclavian arteries, and the distal clam# is #laced distal tothe injury. The left subclavian artery is clam#ed se#arately. The hematoma is enteredand the injury evaluated. n most #atients a short gelatin+sealed acron graft is

#laced, usually 1* to -- mm in diameter. :rimary re#air without a graft is #ossible in

some #atients. (or the anastomoses or suture lines, +$ #oly#ro#ylene suture is used."ir and clot are flushed from the aorta between two clam#s and the subclavian artery

before tying the final suture. "fter com#letion of the re#air the clam#s are removedand the #atient is weaned from the #um#. The cannulae are removed, and the vesselsare re#aired. uadrant to locali/e hemorrhage, and theaorta is #al#ated to estimate blood #ressure.

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Chapter 6 Trauma- Original