Manual of Definitive Surgical Trauma Care, Fifth Edition

 

Description:

Developed for the International Association for Trauma Surgery and Intensive Care (IATSIC), the Manual of Definitive Surgical Trauma Care 5e is ideal for training all surgeons who encounter major surgical trauma on an infrequent basis. This new edition includes both an e-version, and also a microSD card containing over 20 operative videos. The increasing role of non-operative management (NOM) has been recognised, and the Military Module is substantially updated to reflect recent conflict experience. An expanded section highlights trauma management under austere conditions.Written by faculty who teach the DSTC Course, this definitive and well established book focuses on life-saving surgical techniques to use in challenging and unfamiliar incidents of trauma.

 

 

Table of Contents:

 

Video Contents

Preface

Introduction

Injury Prevention

Training in the Initial Management of Severe Trauma

The DSTC™ Course

The DATC™ Course

Summary

Board of Contributors

Acknowledgements

About the Author

Part 1: Trauma system and communication principles

1. Safe and Sustainable Trauma Care

1.1 Introduction

1.2 Safe Trauma Care

1.2.1 Individual Factors

1.2.1.1 Heuristics AND Cognitive Biases

1.2.1.2 Individual – Leadership

1.2.1.3 Trauma Team

1.2.1.4 Team – Training

1.2.2 Institutional Factors

1.2.2.1 Dedicated Trauma Service

1.2.3 Performance Improvement Activities

1.2.4 Regional Activities

1.2.5 National Activities

1.2.6 Global Activities

1.3 Sustainable Trauma Care

1.3.1 Workforce Development

1.4 Conclusion

References

2. Communication and Non-Technical Skills for Surgeons (NOTSS) in Major Trauma: The Role of Crew Resource Management (CRM)

2.1 Overview

2.1.1 The ‘Swiss Cheese’ Theory

2.2 Communication in the Trauma Setting

2.2.1 Initial Handover

2.2.2 Resuscitation and Ongoing Management

2.3 Leadership in Trauma Care

2.4 Potential Errors Related to Each Behavioural Theme

2.5 Summary

References and Recommended Reading

3. Pre-Hospital and Emergency Trauma Care

3.1 Resuscitation in the Emergency Department and Pre-hospital Setting

3.2 Management of Major Trauma

3.2.1 Resuscitation

3.2.1.1 Civilian Pre-hospital Tourniquet use

3.2.1.2 Primary Survey

3.2.1.3 Secondary Survey

3.2.2 Management of Penetrating Trauma

3.3 Emergency Department Surgery

3.3.1 Head Trauma

3.3.2 Chest Trauma

3.3.3 Abdominal Trauma

3.3.4 Pelvic Trauma

3.3.5 Long Bone Fractures

3.3.6 Peripheral Vascular Injuries

3.4 Summary

References and Recommended Reading

Part 2: Physiology and the body's response to trauma

4. Resuscitation Physiology

4.1 Metabolic Response to Trauma

4.1.1 Definition of Trauma

4.1.2 Initiating Factors

4.1.2.1 Hypovolaemia

4.1.2.2 Afferent Impulses

4.1.2.3 Wound Factors: Inflammatory and Cellular

4.1.2.4 Toxins/Sepsis

4.1.2.5 Free Radicals

4.1.2.6 Hypovolaemia

4.1.2.7 Afferent Impulses

4.1.2.8 Wound Factors

4.1.3 Immune Response

4.1.3.1 The Inflammatory Pathway

4.1.3.2 The Cellular Pathway

4.1.3.3 Toxins

4.1.3.4 PAMPS and DAMPS

4.1.3.5 Free Radicals

4.1.4 Hormonal Mediators

4.1.4.1 Hypothalamus/Pituitary

4.1.4.2 Adrenal Hormones

4.1.4.3 Pancreatic Hormones

4.1.4.4 Renal Hormones

4.1.4.5 Other Hormones

4.1.5 Effects of the Various Mediators

4.1.5.1 Hyperdynamic State

4.1.5.2 Water and Salt Retention

4.1.5.3 Effects on Substrate Metabolism

4.1.6 The Anabolic Phase

4.1.7 Clinical and Therapeutic Relevance

4.2 Shock

4.2.1 Definition of Shock

4.2.2 Classification of Shock

4.2.2.1 Hypovolaemic Shock

4.2.2.2 Cardiogenic Shock

4.2.2.3 Cardiac Compressive Shock

4.2.2.4 Distributive (Inflammatory) Shock

4.2.2.5 Neurogenic Shock

4.2.2.6 Obstructive Shock

4.2.3 Measurements in Shock

4.2.3.1 Cardiac Output

4.2.3.2 Indirect Measurement of Flow

4.2.3.3 Direct Measurements

4.2.4 Endpoints in Shock Resuscitation13

4.2.5 Post-Shock and Multiple Organ Failure Syndromes

4.2.6 Management of the Shocked Patient

4.2.6.1 Oxygenation

4.2.6.2 Fluid Therapy for Volume Expansion

4.2.6.3 Route of Administration

4.2.6.4 Pharmacologic Support of Blood Pressure

4.2.7 Prognosis in Shock

4.2.8 Recommended Protocol for Shock

4.2.8.1 Military Experience

4.2.8.2 Initial Resuscitation

REFERENCES AND RECOMMENDED READING

5. Transfusion in Trauma

5.1 Indications for Transfusion

5.1.1 Oxygen-Carrying Capacity

5.2 Transfusion Fluids

5.2.1 Colloids

5.2.1.1 Starches

5.2.1.2 Albumin

5.2.2 Blood

5.2.2.1 Fresh Whole Blood (FWB)

5.2.2.2 Packed red Blood Cells

5.2.3 Component Therapy (Platelets, Fresh Frozen Plasma, Cryoprecipitate)

5.2.3.1 Platelets

5.2.3.2 Fresh Frozen Plasma

5.2.3.3 Cryoprecipitate

5.2.3.4 Fibrinogen Concentrate

5.3 Effects of Transfusing Blood and Blood Products

5.3.1 Metabolic Effects

5.3.2 Effects of Microaggregates

5.3.3 Hyperkalaemia

5.3.4 Coagulation Abnormalities

5.3.5 Other Risks of Transfusion

5.3.5.1 Transfusion-transmitted Infections

5.3.5.2 Haemolytic Transfusion Reactions

5.3.5.3 Immunological Complications

5.3.5.4 Factors Implicated in Haemostatic Failure

5.4 Current Best Transfusion Practice

5.4.1 Initial Response

5.4.2 Reduction in the Need for Transfusion

5.4.3 Transfusion Thresholds

5.4.4 Transfusion Ratios

5.4.5 Adjuncts to Enhance Clotting

5.4.5.1 Recombinant Activated Factor VII (rFVIIa)

5.4.5.2 Tranexamic Acid (TXA)

5.4.5.3 Desmopressin (DDAVP)

5.4.6 Monitoring the Coagulation Status: Traditional and VHA

5.4.6.1 Traditional Assays

5.4.6.2 Viscoelastic Haemostatic Assays (VHA): Thromboelastography (TEG)/Rotary Thromboelastomerography (RoTEM)19,20

5.5 Autotransfusion

5.6 Red Blood Cell Substitutes23

5.6.1 Perfluorocarbons

5.6.2 Haemoglobin Solutions

5.6.2.1 Liposomal Haemoglobin Solutions

5.6.2.2 Polymerized Haemoglobin Solutions (Human-Outdated/Bovine RBCs)

5.6.3 Future Evolution

5.7 Massive Haemorrhage/Massive Transfusion24

5.7.1 Definition

5.7.2 Massive Transfusion Protocol (MTP)

5.8 Haemostatic Adjuncts in Trauma

5.8.1 Overview

5.8.2 Tissue Adhesives

5.8.2.1 Fibrin

5.8.2.2 Tachosil®

5.8.2.3 HemoPatch®

5.8.2.4 Collagen Fleece

5.8.3 Other Haemostatic Adjuncts

5.8.3.1 Chitosan (Celox (Meditrade Ltd., Crewe, UK)/HemCon (HemCon Medical Technologies, Portland, OR, USA))

5.8.3.2 Mineral Zeolyte (QuikClot® (Z-Medical Corporation, Wallingford CT, USA))

References and Recommended Reading

6. Damage Control

6.1 Introduction

6.2 Damage Control Resuscitation

6.3 Damage Control Surgery

6.3.1 Stage 1: Patient Selection

6.3.2 Stage 2: Operative Haemorrhage and Contamination Control

6.3.2.1 Initial Incision

6.3.2.2 Haemorrhage Control

6.3.2.3 Control of Contamination (Hollow Viscus Organs)

6.3.2.4 Copious Washout

6.3.2.5 Temporary Abdominal Closure (TAC)

6.3.3 Stage 3: Physiological Restoration in the ICU

6.3.3.1 Restoration of Body Temperature

6.3.3.2 Optimization of Oxygen Delivery

6.3.3.3 Correction of Clotting Profiles

6.3.3.4 Improvement of Physiological Endpoints: as Evidenced by

6.3.3.5 Monitoring for and Minimizing the Incidence of Intra-Abdominal Hypertension (AH) and Abdominal Compartment Syndrome (ACS) (See also Section 17.10)

6.3.3.6 Recognition of Additional Injuries

6.3.4 Stage 4: Definitive Surgery

6.3.4.1 The ‘Re-Look Laparotomy’

6.3.5 Stage 5: Abdominal Wall Closure

6.3.5.1 Delayed Primary Abdominal Closure

6.3.5.2 Secondary Abdominal Closure

6.3.5.3 Secondary Closure

6.3.5.4 Planned Hernia

6.3.6 Outcomes

6.4 Damage Control Orthopaedics17

References and recommended reading

Part 3: Anatomical and organ system injury

7. The Neck

7.1 Overview

7.2 Management Principles: Penetrating Cervical Injury

7.2.1 Initial Assessment and Definitive Airway

7.2.2 Control of Haemorrhage

7.2.3 Injury Location

7.2.4 Mechanism

7.2.5 Frequency of Injury

7.2.6 Use of Diagnostic Studies

7.2.6.1 Computed Tomography Scanning with Contrast/Computed Tomography Angiography

7.2.6.2 Angiography

7.2.6.3 Other Diagnostic Studies

7.3 Management

7.3.1 Mandatory versus Selective Neck Exploration

7.3.2 Management Based on Anatomical Zones

7.4 Access to the Neck

7.4.1 Position

7.4.2 Incision

7.4.3 Surgical Access

7.4.3.1 Zone I

7.4.3.2 Zone II

7.4.3.3 Zone III

7.4.4 Priorities

7.4.4.1 Vascular Injuries

7.4.4.2 Carotid Artery

7.4.4.3 Tracheal Injuries

7.4.4.4 Pharyngeal and Oesophageal Injuries

7.4.5 Midline Visceral Structures

7.4.6 Root of the Neck

7.4.7 Collar Incisions

7.4.8 Vertebral Arteries

References and recommended reading

8. The Chest

8.1 Overview

8.2 The Spectrum of Thoracic Injury

8.2.1 Immediately Life-Threatening Injuries

8.2.2 Potentially Life-Threatening Injuries

8.3 Pathophysiology of Thoracic Injuries

8.3.1 Paediatric Considerations

8.4 Applied Surgical Anatomy of the Chest

8.4.1 The Chest Wall

8.4.2 The Chest Floor

8.4.3 The Chest Contents

8.4.3.1 Tracheobronchial Tree

8.4.3.2 Lungs and Pleurae

8.4.3.3 Heart and Pericardium

8.4.3.4 The Aorta and Great Vessels

8.4.3.5 Oesophagus

8.4.3.6 Thoracic Duct

8.5 Diagnosis

8.6 Management of Specific Injuries

8.6.1 Damage Control in the Chest

8.6.2 Open Pneumothorax

8.6.3 Tension Pneumothorax (Haemo/­Pneumothorax)

8.6.4 Massive Haemothorax

8.6.5 Tracheobronchial Injuries12

8.6.6 Oesophageal Injuries

8.6.7 Diaphragmatic Injuries

8.6.8 Pulmonary Contusion13

8.6.9 Flail Chest13

8.6.10 Fixation of Multiple Fractures of Ribs

8.6.11 Pulmonary Laceration

8.6.12 Air Embolism15

8.6.13 Cardiac Injuries

8.6.14 Injuries to the Great Vessels

8.7 Chest Drainage

8.7.1 Drain Insertion

8.7.2 Drain Removal

8.8 Surgical Approaches to the Thorax

8.8.1 Anterolateral Thoracotomy

8.8.1.1 Technique

8.8.1.2 Closure

8.8.2 Median Sternotomy

8.8.2.1 Technique

8.8.2.2 Closure

8.8.3 The ‘Clamshell’ Thoracotomy

8.8.4 Posterolateral Thoracotomy

8.8.5 ‘Trapdoor’ Thoracotomy

8.9 Emergency Department Thoracotomy

8.9.1 History

8.9.2 Objectives

8.9.3 Indications and Contraindications

8.9.4 Results

8.9.5 When to Stop EDT

8.9.6 Technique

8.9.6.1 Instrument Requirements

8.9.6.2 Approach

8.10 Surgical Procedures

8.10.1 Pericardial Tamponade

8.10.2 Cardiac Injury

8.10.3 Pulmonary Haemorrhage

8.10.4 Pulmonary Tractotomy

8.10.5 Lobectomy or Pneumonectomy22

8.10.6 Thoracotomy with Aortic Cross-Clamping

8.10.7 Aortic Injury

8.10.8 Tracheobronchial Injury

8.10.9 Oesophageal Injury

8.11 Summary

8.12 Anaesthesia for Thoracic Trauma

8.12.1 Penetrating Thoracic Injury

8.12.2 Blunt Thoracic Injury

8.12.2.1 Contained Large Vessel Rupture/Aneurism

8.12.2.2 Pulmonary Contusion

8.12.2.3 Large Airway Disruption

8.12.2.4 Flail Chest

8.12.2.5 Diaphragmatic Injury

8.12.3 Anaesthetic Management of Thoracic Injury

8.13 Anaesthetic Considerations

References and Recommended Reading

9. The Abdomen

9.1 The Trauma Laparotomy

9.1.1 Overview

9.1.1.1 Difficult Abdominal Injury Complexes

9.1.1.2 The Retroperitoneum

9.1.1.3 Non-Operative Management of Penetrating Abdominal Injury

9.1.2 The Trauma Laparotomy

9.1.2.1 Pre-Operative Adjuncts

9.1.2.2 Draping

9.1.2.3 Incision

9.1.2.4 Initial Procedure

9.1.2.5 Perform a Trauma Laparotomy

9.1.2.6 Perform Definitive Packing

9.1.2.7 Specific Routes of Access

9.1.2.8 Specific Organ Techniques (see also Specific Organs)

9.1.3 Closure of the Abdomen

9.1.3.1 Principles of Abdominal Closure

9.1.3.2 Choosing the Optimal Method of Closure

9.1.3.3 Primary Closure

9.1.4 Specific Tips and Tricks

9.1.4.1 Headlight

9.1.4.2 Stirrups and Lithotomy Position

9.1.4.3 Table Tilt

9.1.4.4 Be Flexible: Move!

9.1.4.5 Aortic Compression Spoon

9.1.4.6 Pericardial Window

9.1.4.7 Washout

9.1.4.8 Drains

9.1.4.9 Stomas

9.1.4.10 Temporary Closure

9.1.4.11 Two Catheters: Bladder Injury

9.1.4.12 Early Tracheostomy

9.1.5 Briefing for Operating Room Scrub Nurses

9.1.6 Summary

References and Further Reading

References

Recommended Reading

9.2 Abdominal Vascular Injury

9.2.1 Overview

9.2.2 Retroperitoneal Haematoma

9.2.2.1 Central Haematoma

9.2.2.2 Lateral Haematoma

9.2.2.3 Pelvic Haematoma

9.2.3 Surgical Approach to Major Abdominal Vessels

9.2.3.1 Incision

9.2.3.2 Medial Visceral Rotation (see also Section 9.1.2.7)

9.2.3.3 Coeliac Axis

9.2.3.4 Superior Mesenteric Artery3

9.2.3.5 Inferior Mesenteric Artery

9.2.3.6 Renal Arteries

9.2.3.7 Iliac Vessels

9.2.3.8 Inferior Vena Cava8

9.2.3.9 Portal Vein10

9.2.4 Shunting

References and Recommended Reading

References

Selected Reading

9.3 Bowel, Rectum, and Diaphragm

9.3.1 Overview

9.3.2 Diaphragm

9.3.3 Stomach

9.3.4 The Duodenum

9.3.5 Small Bowel

9.3.5.1 The Stable Patient

9.3.5.2 The Unstable Patient

9.3.6 Large Bowel3,4

9.3.6.1 The Stable Patient

9.3.6.2 The Unstable Patient

9.3.7 Rectum5

9.3.8 Mesentery

9.3.9 Adjuncts

9.3.9.1 Antibiotics

References and Selected Readings

References

Selected Readings

9.4 The Liver and Biliary System

9.4.1 Overview

9.4.2 Resuscitation

9.4.3 Diagnosis

9.4.4 Liver Injury Scale4

9.4.5 Management

9.4.5.1 Subcapsular Haematoma

9.4.5.2 Non-Operative Management (NOM)5,6

9.4.5.3 Subcapsular Haematoma

9.4.5.4 Operative (Surgical) Management

9.4.6 Surgical Approach8–10

9.4.6.1 Incision

9.4.6.2 Initial Actions

9.4.6.3 Techniques for Temporary Control of Haemorrhage

9.4.6.4 Mobilization of the Liver

9.4.6.5 Hepatic Isolation

9.4.7 Perihepatic Drainage

9.4.8 Complications

9.4.9 Injury to the Retrohepatic Vena Cava

9.4.10 Injury to the Porta Hepatis13

9.4.11 Injury to the Bile Ducts and Gallbladder14,15

9.4.12 Anaesthetic Considerations

References

Recommended Reading

9.5 Spleen

9.5.1 Overview

9.5.2 Anatomy

9.5.3 Diagnosis

9.5.3.1 Clinical

9.5.3.2 Ultrasound

9.5.3.3 Computed Tomography (CT) Scan

9.5.4 Splenic Injury Scale1

9.5.5 Management

9.5.5.1 Non-Operative Management2

9.5.5.2 Operative Management

9.5.6 Surgical Approach

9.5.6.1 Spleen Not Actively Bleeding

9.5.6.2 Splenic Surface Bleed Only

9.5.6.3 Minor Lacerations

9.5.6.4 Splenic Tears

9.5.6.5 Partial Splenectomy

9.5.6.6 Mesh Wrap

9.5.6.7 Splenectomy

9.5.6.8 Drainage

9.5.7 Outcome

9.5.8 Opportunistic Post-Splenectomy Infection

References and Recommended Reading

9.6 Pancreas

9.6.1 Overview

9.6.2 Anatomy

9.6.3 Mechanisms of Injury

9.6.3.1 Blunt Trauma

9.6.3.2 Penetrating Trauma

9.6.4 Diagnosis

9.6.4.1 Clinical Evaluation

9.6.4.2 Serum Amylase and Serum Lipase

9.6.4.3 Ultrasound

9.6.4.4 Diagnostic Peritoneal Lavage (DPL)

9.6.4.5 Computed Tomography

9.6.4.6 Endoscopic Retrograde Cholangiopancreatography

9.6.4.7 Magnetic Resonance Cholangiopancreatography

9.6.4.8 Intra-operative Pancreatography

9.6.4.9 Operative Evaluation

9.6.5 Pancreas Injury Scale

9.6.6 Management

9.6.6.1 Non-Operative Management

9.6.6.2 Operative Management

9.6.7 Surgical Approach

9.6.7.1 Incision and Exploration (see also SECTION 9.1)

9.6.7.2 Pancreatic Injury: Surgical Decision-Making

9.6.8 Adjuncts

9.6.8.1 Somatostatin and Its Analogues

9.6.8.2 Nutritional Support

9.6.9 Pancreatic Injury in Children

9.6.10 Complications

9.6.10.1 Early Complications

9.6.10.2 Late Complications

9.6.11 Summary of Evidence Based Guidelines31,32

References and Recommended Reading

9.7 The Duodenum

9.7.1 Overview

9.7.2 Mechanism of Injury

9.7.2.1 Penetrating Trauma

9.7.2.2 Blunt Trauma

9.7.2.3 Paediatric Considerations

9.7.3 Diagnosis

9.7.3.1 Clinical Presentation

9.7.3.2 Serum Amylase and Serum Lipase

9.7.3.3 Diagnostic Peritoneal Lavage/Ultrasound

9.7.3.4 Radiological Investigation

9.7.3.5 Diagnostic Laparoscopy

9.7.4 Duodenal Injury Scale

9.7.5 Management

9.7.6 Surgical Approach

9.7.6.1 Intramural Haematoma

9.7.6.2 Duodenal Laceration

9.7.6.3 Repair of the Perforation

9.7.6.4 Complete Transection of the Duodenum

9.7.6.5 Duodenal Diversion

9.7.6.6 Duodenal Diverticulation

9.7.6.7 Triple Tube Decompression14

9.7.6.8 Pyloric Exclusion (see also Section 9.6.7.2.7)

References and Recommended Reading

9.8 The Urogenital System

9.8.1 Overview

9.8.2 Renal Injuries

9.8.2.1 Diagnosis

9.8.2.2 Renal Injury Scale

9.8.2.3 Management

9.8.2.4 Surgical Approach

9.8.2.5 Adjuncts

9.8.2.6 Post-operative Care

9.8.3 Ureteric Injuries

9.8.3.1 Diagnosis

9.8.3.2 Surgical Approach

9.8.3.3 Complications

9.8.4 Bladder Injuries

9.8.4.1 Diagnosis

9.8.4.2 Management

9.8.4.3 Surgical Approach

9.8.5 Urethral Injuries

9.8.5.1 Diagnosis

9.8.5.2 Management

9.8.5.3 Ruptured Urethra

9.8.6 Injury to the Scrotum

9.8.6.1 Diagnosis

9.8.6.2 Management

9.8.7 Gynaecological Injury and Sexual Assault

9.8.7.1 Management

9.8.8 Injury of the Pregnant Uterus

References and Recommended Reading

10. The Pelvis

10.1 Anatomy

10.2 Classification

10.2.1 Tile’s Classification2

10.2.1.1 Type A: Completely stable

10.2.1.2 Type B: Vertically stable but rotationally unstable

10.2.1.3 Type C: Wholly unstable in rotational and vertical planes

10.2.1.4 A Jumper‘s Fracture

10.2.1.5 Acetabular Fractures

10.2.1.6 Fracture Combinations

10.2.2 Young and Burgess Classification3

10.2.2.1 Anteroposterior Compression (APC) (Type 1, 2, 3)

10.2.2.2 Lateral Compression (LC) (Type 1, 2, 3)

10.2.2.3 Vertical Shear

10.2.2.4 Combined Mechanism

10.3 Clinical Examination and Diagnosis

10.4 Resuscitation

10.4.1 Haemodynamically Normal Patients

10.4.2 Haemodynamically Stable Patients (Transient Responders)

10.4.3 Haemodynamically Unstable Patients (Non-Responders)

10.5 External Fixation

10.5.1 Iliac-Crest Route

10.5.2 Supra-acetabular Route

10.5.3 Pelvic C-clamp

10.6 Laparotomy

10.7 Extraperitoneal pelvic Packing

10.7.1 Technique of Extraperitoneal Packing11,12

10.8 Associated Injuries

10.8.1 Head Injuries

10.8.2 Intra-abdominal Injuries

10.8.3 Bladder and Urethral Injuries (See also Section 9.8)

10.8.4 Urethral Injuries (See Section 9.8)

10.8.5 Anorectal Injuries14

10.8.6 Vaginal Injuries

10.9 Open Pelvic Fractures

10.9.1 Diagnosis

10.9.2 Surgery

10.10 Summary

References and recommended reading

11. Extremity Trauma

11.1 Overview

11.2 Management of Severe Injury to the Extremity

11.3 Management of Vascular Injury of the Extremity

11.3.1 Chemical Vascular Injuries

11.4 Crush Syndrome

11.5 Management of Open Fractures

11.5.1 Severity of Injury (Gustilo Classification)2

11.5.2 Sepsis and Antibiotics

11.5.3 Venous Thromboembolism

11.5.4 Timing of Skeletal Fixation in Polytrauma Patients

11.5.4.1 Respiratory Insufficiency8

11.5.4.2 Head Injury

11.6 Massive Limb Trauma: life versus Limb

11.6.1 Scoring Systems

11.6.1.1 Mangled Extremity Syndrome Index (MESI)

11.6.1.2 Predictive Salvage Index System

11.6.1.3 Mangled Extremity Severity Score (MESS)

11.6.1.4 Nisssa Scoring System

11.7 Compartment Syndrome16–18

11.8 Fasciotomy

11.8.1 Lower Leg Fasciotomy

11.8.1.1 Two Incision–Four Compartment Fasciotomy20

11.8.1.2 Single Incision Fasciotomy

11.8.1.3 Fibulectomy

11.8.1.4 Subcutaneous Fasciotomy

11.8.2 Upper Leg21

11.8.3 Upper and Lower Arm22,23

11.9 Complications of Major Limb Injury

11.10 Summary

References and recommended reading

12. Head Trauma

12.1 Introduction

12.2 Injury Patterns and Classification

12.2.1 Severity

12.2.2 Pathological Classification of TBI

12.2.2.1 Blunt Head Trauma

12.2.2.2 Penetrating Head Trauma

12.3 Measurable physiological Parameters IN TBI

12.3.1 Mean Arterial Pressure

12.3.2 Intracranial Pressure

12.3.3 Cerebral Perfusion Pressure

12.3.4 Cerebral Blood Flow

12.4 Pathophysiology of Traumatic Brain Injury4

12.5 Management of TBI

12.6 Cerebral Perfusion Pressure Threshold

12.7 Intracranial pressure Monitoring and Threshold

12.7.1 ICP Monitoring Devices

12.7.1.1 CSF Drainage

12.7.2 ICP Management – Do’s and Don'ts

12.7.2.1 Hyperventilation

12.7.2.2 Osmotherapy (Mannitol and Hypertonic Saline)

12.7.2.3 Barbiturates and Propofol

12.7.2.4 Steroids

12.8 Imaging

12.9 Indications for Surgery

12.9.1 Burr Holes and Emergency Craniotomy

12.9.1.1 Emergency Burr Hole craniotomy9

12.9.1.2 Emergency Craniotomy

12.10 Adjuncts to Care

12.10.1 Infection Prophylaxis

12.10.2 Seizure Prophylaxis

12.10.3 Nutrition

12.10.4 Deep Vein Thrombosis Prophylaxis

12.10.5 Steroids

12.11 Paediatric Considerations

12.12 Pearls and Pitfalls

12.13 Summary

12.14 Anaesthetic Considerations

References and Recommended Reading

13. Burns

13.1 Overview

13.2 Burns Pathophysiology

13.3 Anatomy

13.4 Special Types of Burn

13.4.1 Chemical Burns

13.4.2 Electrical Injury

13.5 Depth of the Burn

13.5.1 Superficial Burn (Erythema)

13.5.2 Superficial Partial Thickness

13.5.3 Deep Partial Thickness

13.5.4 ‘Indeterminate’ Partial Thickness Burns

13.5.5 Full Thickness

13.6 Total Body Surface Area Burned

13.7 Management

13.7.1 Safe Retrieval

13.7.2 First Aid

13.7.3 Initial Management

13.7.3.1 Airway

13.7.3.2 Analgesia

13.7.3.3 Intravenous Access

13.7.3.4 Emergency Management of the Burn Wound

13.7.3.5 Fluid Resuscitation

13.7.3.6 Associated Injuries

13.7.4 Escharotomy and Fasciotomy

13.7.5 Definitive Management

13.7.5.1 ‘Closing’ the Burn Wound

13.7.5.2 Technique of Excision and Split Skin Grafting

13.7.5.3 Tumescent Technique

13.7.5.4 Wound Coverage

13.7.5.5 Burn Wound Excision and Closure

13.7.6 Assessing and Managing Airway Burns

13.7.6.1 Upper Airway

13.7.6.2 Lower Airway

13.7.6.3 Inhalational Toxicity

13.7.7 Tracheostomy

13.8 Special Areas

13.8.1 Face

13.8.2 Hands

13.8.3 Perineum

13.8.4 Feet

13.9 Adjuncts in Burn Care

13.9.1 Nutrition in the Burned Patient6

13.9.1.1 Paediatric Burn Nutrition

13.9.2 Ulcer Prophylaxis9 (See Table 17.2 S)

13.9.3 Venous Thromboembolism Prophylaxis7,10 (See Table 17.2 R)

13.9.4 Vitamin C

13.9.5 Antibiotics

13.9.6 Other Adjuncts

13.10 Summary

References and recommended reading

14. Special Patient Situations

14.1 Paediatric Trauma

14.1.1 Introduction

14.1.2 Injury Patterns

14.1.3 Pre-Hospital

14.1.4 Resuscitation Room

14.1.4.1 Airway

14.1.4.2 Ventilation

14.1.4.3 Circulation

14.1.4.4 Disability

14.1.4.5 Cardiac Arrest

14.1.5 Specific Organ Injury

14.1.5.1 Head Injury

14.1.5.2 Thoracic Injury

14.1.5.3 Abdominal Injury5

14.1.5.4 Genitourinary Injury

14.1.5.5 Pelvic Injury

14.1.5.6 Suspected non-Accidental Injury

14.1.6 Analgesia

14.2 Trauma in the Elderly

14.2.1 Definition of ‘Older’ and Susceptibility to Trauma

14.2.2 Access to Trauma Care

14.2.3 Physiology

14.2.3.1 Respiratory System

14.2.3.2 Cardiovascular System

14.2.3.3 Nervous System

14.2.3.4 Renal

14.2.3.5 Musculoskeletal

14.2.3.6 Influence of Comorbid Conditions

14.2.4 Multiple Medications – Polypharmacy

14.2.5 Analgesia

14.2.6 Decision to Operate

14.2.7 Anaesthetic Considerations in the Elderly13

14.3 Trauma in Pregnancy14

14.3.1 Evaluation

14.4 Non-Beneficial (Futile) Care

References and Recommended reading

Part 4: Modern therapeutic and diagnostic technology

15. Minimal Access Surgery in Trauma

15.1 Laparoscopy

15.1.1 Screening Laparoscopy

15.1.2 Diagnostic Laparoscopy

15.1.3 Non-Therapeutic Laparoscopy

15.1.4 Therapeutic Laparoscopy

15.1.5 Technique

15.1.6 Risks

15.1.7 Applications

15.1.7.1 Bowel injury

15.1.7.2 Splenic injury

15.1.7.3 Liver injury

15.1.7.4 After non-operative management

15.1.7.5 Diaphragmatic injury

15.2 Video-Assisted Thoracoscopic Surgery7

15.2.1 Technique

15.2.2 Applications

15.2.3 Summary

15.3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

15.3.1 Anatomy

15.3.2 Physiology

15.3.3 Insertion Technique

15.3.4 Monitoring

15.3.5 Total, Partial, and Intermittent Occlusion, and Targeted Blood Pressure

15.3.6 Perioperative and Post-operative Care

15.3.7 Indications

15.3.8 Contraindications

15.3.9 Complications16,17

15.3.10 Summary

15.4 Anaesthetic Considerations

References and Recommended Reading

16. Imaging in Trauma

16.1 Introduction

16.2 Radiation Doses and Protection from Radiation

16.3 Principles of Trauma Imaging

16.4 Pitfalls and Pearls

16.5 Trauma Ultrasound

16.5.1 Extended Focused Assessment by Sonography for Trauma

16.5.2 Indications and Results

16.5.2.1 Penetrating Abdominal Trauma

16.5.2.2 Blunt Abdominal Trauma

16.5.2.3 Pelvic Trauma

16.5.2.4 Blunt Thoracic Trauma

16.5.2.5 Penetrating Thoracic Trauma

16.5.3 Other Applications of Ultrasound in Trauma

16.5.4 Training

16.5.5 Summary

References and Recommended Reading

Part 5: Specialised aspects of total trauma care

17. Critical Care of the Trauma Patient

17.1 Introduction

17.2 Phases of ICU Care

17.2.1 Resuscitative Phase (First 24 Hours Post-Injury)1

17.2.1.1 ‘Traditional’ End Points of Resuscitation

17.2.1.2 Post-Traumatic Acute Lung Injury

17.2.1.3 Respiratory Assessment and Monitoring

17.2.2 Early Life Support Phase (24–72 Hours Post-Injury)

17.2.2.1 Priorities

17.2.3 Prolonged Life Support (>72 Hours Post-Injury)

17.2.3.1 Respiratory Failure

17.2.3.2 Infectious Complications

17.2.3.3 Non-Infectious Causes of Fever

17.2.3.4 Percutaneous tracheostomy6

17.2.3.5 Weaning from Ventilatory Support

17.2.3.6 Extubation Criteria (‘SOA2P’)

17.2.4 Recovery Phase (Separation from the ICU)

17.3 ExtraCorporeal Membrane Oxygenation8–10

17.3.1 Overview

17.3.2 Modes of ECMO

17.3.2.1 Veno-Venous ECMO (VV-ECMO)

17.3.2.2 Veno-Arterial ECMO (VA-ECMO)

17.3.2.3 Arterio-Venous ECMO (AV-ECMO)

17.3.3 Exclusions

17.4 Coagulopathy of Major Trauma11–13 (See also Chapter 5)

17.4.1 Management

17.5 Hypothermia

17.6 Multisystem Organ Dysfunction Syndrome (MODS)

17.7 Systemic Inflammatory Response Syndrome (See also Chapter 4)

17.8 Sepsis

17.8.1 Definitions

17.8.1.1 Sepsis

17.8.1.2 Severe Sepsis

17.8.1.3 Septic Shock

17.8.2 Surviving Sepsis Guidelines

17.9 Antibiotics

17.10 Abdominal Compartment Syndrome (ACS)

17.10.1 Introduction

17.10.2 Definition of ACS

17.10.3 Pathophysiology

17.10.4 Effect of Raised IAP on Individual Organ Function

17.10.4.1 Cardiovascular

17.10.4.2 Respiratory

17.10.4.3 Visceral Perfusion

17.10.4.4 Renal

17.10.4.5 Intracranial Pressure

17.10.5 Measurement of IAP

17.10.5.1 Measurement of APP

17.10.6 Management

17.10.6.1 Prevention

17.10.6.2 Treatment

17.10.6.3 Reversible Factors

17.10.7 Surgery for Raised IAP

17.10.7.1 Tips for Surgical Decompression for Raised IAP

17.10.8 Management Algorithm

17.11 Acute Kidney Injury37

17.12 Metabolic Disturbances

17.13 Nutritional Support39,40

17.13.1 Access for Enteral Nutrition

17.13.1.1 Simple

17.13.1.2 More Complicated

17.14 Prophylaxis in the ICU

17.14.1 Stress Ulceration44

17.14.2 Deep Venous Thrombosis and Pulmonary Embolus45

17.14.3 Tetanus Prophylaxis

17.14.4 Line Sepsis

17.15 Pain Control

17.16 ICU Tertiary Survey50

17.16.1 Evaluation for Occult Injuries

17.16.2 Assess Co-Morbid Conditions

17.16.3 ICU Summary

17.17 Family Contact and Support (See also Chapter 19)

References and Recommended Reading

18. Trauma Anaesthesia

18.1 Introduction

18.2 Planning and Communicating

18.3 Damage Control Resuscitation1

18.3.1 Limited Fluid Administration

18.3.2 Targeting Coagulopathy

18.3.3 Prevent and Treat Hypothermia

18.4 Damage Control Surgery

18.4.1 Anaesthetic Procedures

18.4.1.1 Airway

18.4.1.2 Breathing

18.4.1.3 Circulation

18.4.1.4 Vascular access

18.4.2 Monitoring

18.5 Anaesthesia Induction in Hypovolaemic Shock

18.5.1 Introduction

18.5.2 Drugs for Anaesthesia Induction

18.5.2.1 Propofol

18.5.2.2 Ketamine

18.5.2.3 Etomidate

18.5.2.4 Thiopental

18.5.2.5 Midazolam

18.6 Battlefield Anaesthesia (See also Chapters 21 and 22)

18.6.1 Damage Control Anaesthesia in the Military Setting

18.6.2 Battlefield Analgesia

References

19. Psychology of Trauma

19.1 What is Psychological Trauma?

19.2 Reactions to Trauma

19.3 Post-Traumatic Stress Disorder

19.4 Trauma and ICU

19.5 The Clinical Psychologist

19.5.1 The Role of the Clinical Psychologist

19.5.1.1 For the Patient

19.5.1.2 For the Family

19.5.1.3 For the Team

19.5.2 When to Call the Clinical Psychologist

Recommended Reading

20. Physical and Rehabilitation Medicine P&RM

20.1 Definition

20.2 The Rehabilitation ‘Team’

20.3 Rehabilitation Starts in ICU

20.4 Outcomes-Based Rehabilitation (OBR)

20.4.1 FIM/FAM Assessment2,3

20.4.2 Glasgow Outcome Scale4

20.4.3 Rancho Los Amigos Scale5

20.5 Summary

References and Recommended Reading

21. Austere Environments

21.1 Definition

21.2 Overview

21.3 Infrastructure

21.3.1 Location

21.3.2 Hospital Structures

21.3.2.1 Water Supply

21.3.2.2 Energy

21.3.2.3 Waste Disposal

21.3.2.4 Sterilization Department

21.3.2.5 Surgical Equipment

21.3.2.6 Blood Bank

21.3.3 Health Protection of the Deployed Surgical Team

21.3.3.1 Vector-borne Disease

21.3.3.2 Enteric Illness

21.3.3.3 Road Trauma

21.3.3.4 Physical, Sexual, and Mental Health

21.4 Surgical Techniques to Have in Mind

21.4.1 Bleeding Control

21.4.2 Control of Contamination

21.4.3 Treatment of War Wounds

21.4.4 Amputations

21.4.5 Stabilization of Fractures

21.4.6 Obstetrics

21.4.7 Anaesthesia2,3

21.5 Post-operative Care and Documentation

21.6 Summary

References and RECOMMENDED Reading

22. Military Environments

22.1 Introduction

22.2 Injury Patterns

22.3 Emergency Medical Services Systems

22.3.1 The Echelons of Medical Care

22.3.1.1 Role 1

22.3.1.2 Role 2

22.3.1.3 Role 2 Light Manoeuvre

22.3.1.4 Role 2 Enhanced

22.3.1.5 Role 3

22.3.1.6 Role 4

22.3.2 Incident Management and Multiple Casualties

22.3.2.1 Confirm

22.3.2.2 Clear

22.3.2.3 Cordon

22.3.2.4 Control

22.3.2.5 Command and Control

22.3.2.6 Safety

22.3.2.7 Communication

22.3.2.8 Assessment

22.3.2.9 Triage

22.3.2.10 Treatment

22.3.2.11 Transport

22.4 Triage

22.4.1 Source and Aim of Triage

22.4.2 Forward Surgical Teams and Triage

22.4.3 Forward Surgical Team Decision-Making

22.4.4 Selection of Patients for Surgery

22.5 Mass Casualties

22.6 Evacuation4,5

22.7 Resuscitation

22.7.1 Overview

22.7.2 Damage Control Resuscitation8

22.7.3 Damage Control Surgery in the Military Setting10–12

22.8 Blast Injury

22.8.1 Diagnosis and Management of Blast Injuries

22.8.1.1 Rupture of the Tympanic Membrane

22.8.1.2 Blast Lung Injury (BLI)

22.8.1.3 Intra-Abdominal Injuries

22.8.1.4 Other Injuries

22.9 Battlefield Analgesia13,14

22.10 Battlefield Anaesthesia

22.10.1 Induction of Anaesthesia

22.10.2 Maintenance of Anaesthesia

22.11 Critical Care (See also Chapter 17)

22.12 Translating Military Experience to Civilian Trauma Care15–17

22.12.1 Leadership

22.12.2 Front-End Processes

22.12.3 Common Training

22.12.4 Governance

22.12.5 Rehabilitation Services

22.12.6 Translational Research

22.13 Summary

References and Recommended Reading

Appendix A: Trauma Systems

A.1 Introduction

A.2 The Inclusive Trauma System

A.3 Components of an Inclusive Trauma System

A.3.1 Administration

A.3.2 Prevention

A.3.3 Public Education

A.4 Management of the Injured Patient within a System

A.5 Steps in Organizing a System

A.5.1 Public Support

A.5.2 Legal Authority

A.5.3 Establish Criteria for Optimal Care

A.5.4 Designation of Trauma Centres

A.5.5 System Evaluation

A.6 Results and Studies

A.6.1 Panel Review

A.6.2 Registry Study

A.6.3 Population-Based Studies

A.7 Summary

RECOMMENDED READING

Appendix B: Trauma Scores and Scoring Systems

B.1 Introduction

B.2 Physiological Scoring Systems

B.2.1 Glasgow Coma Scale1

B.2.2 Paediatric Trauma Score2

B.2.3 Revised Trauma Score3

B.2.4 Acute Physiologic and Chronic Health Evaluation II4

B.3 Anatomical Scoring Systems

B.3.1 Abbreviated Injury Scale6

B.3.2 The Injury Severity Score7

B.3.3 The New Injury Severity Score8

B.3.4 Anatomic Profile Score10

B.3.5 ICD-based Injury Severity Score11

B.3.6 Organ Injury Scaling System12

B.3.7 Penetrating Abdominal Trauma Index13

B.3.8 Revised Injury Severity Classification II14,15

B.4 Comorbidity Scoring Systems

B.5 Outcome Analysis

B.5.1 Functional Independence Measure and Functional Assessment Measure18,19

B.5.2 Glasgow Outcome Scale20

B.5.3 Major Trauma Outcome Study

B.5.4 A Severity Characterization of Trauma22,23

B.6 Comparison of Trauma Scoring Systems

B.7 Scaling System for Organ Specific Injuries12,26–32

B.8 Summary

REFERENCES

Appendix C: The Definitive Surgical Trauma Care Course: The Definitive Anaesthetic Trauma Care Course: Course Requirements And Syllabus

C.1 Background

C.2 Course Development and Testing

C.3 Course Details

C.3.1 Ownership

C.3.2 Mission Statement

C.3.3 Application to Hold a Course

C.3.4 Eligibility to Present

C.3.4.1 Local Organizations

C.3.4.2 National Organizations

C.3.5 Course Materials and Overview

C.3.6 Course Director

C.3.7 Course Faculty

C.3.8 Course Participants

C.3.9 Practical Skill Stations

C.3.10 Course Syllabus

C.3.11 Course Certification

C.4 Iatsic Recognition

C.5 Course Information

Appendix D: Definitive Surgical Trauma CareTM Course – Core Surgical Skills

D.1 The Neck

D.2 The Chest

D.3 The Abdominal Cavity

D.4 The Liver

D.5 The Spleen

D.6 The Pancreas

D.7 The Duodenum

D.8 The Genitourinary System

D.9 Abdominal Vascular Injuries

D.10 Peripheral Vascular Injuries

D.11 Insertion of Resuscitative Balloon Occlusion of the Aorta (REBOA) Catheter

Appendix E: Briefing for Operating Room Scrub Nurses

E.1 Introduction

E.2 Preparing the Operating Room

E.2.1 Environment

E.2.2 Blood Loss

E.2.3 Instruments

E.2.4 Cleaning

E.2.5 Draping

E.2.6 Adjuncts

E.3 Surgical Procedure

E.3.1 Instruments

E.3.2 Special Instruments and Improvised Gadgets

E.4 Abdominal Closure

E.5 Instrument and Swab Count

E.6 Medico-legal Aspects and Communication Skills

E.7 Critical Incident Stress Issues

E.8 Conclusion

References and recommended reading

Index

 

An aparitie	28 Jun. 2019
Autor	Kenneth David Boffard
Dimensiuni	19.05 x 1.91 x 24.77 cm
Editura	CRC Press
Format	Hardcover
ISBN	9780367244682
Limba	Engleza
Nr pag	464