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Surgery_Schwartz. Genoese. When plague is used as a biologic warfare agent, clinical manifestations include epidemic pneumonia with blood-tinged sputum if aerosolized bacteria are used, or bubonic plague if fleas are used as carriers. Individuals who develop a painful enlarged lymph node lesion, termed a “bubo,” associ-ated with fever, severe malaise, and exposure to fleas should be suspected to have plague. Diagnosis is confirmed via aspirate of the bubo and a direct antibody stain to detect plague bacil-lus, whose morphology is a bipolar, safety-pin-shaped gram-negative rod. Postexposure prophylaxis for patients exposed to plague consists of doxycycline. Treatment of the pneumonic or bubonic/septicemic form includes administration of either strep-tomycin, an aminoglycoside, doxycycline, a fluoroquinolone, or chloramphenicol.101SmallpoxVariola, the causative agent of smallpox, was a major cause of infectious morbidity and mortality until its eradication in the late 1970s. Even in the absence of


Surgery_Schwartz

Surgery_Schwartz. or chloramphenicol.101SmallpoxVariola, the causative agent of smallpox, was a major cause of infectious morbidity and mortality until its eradication in the late 1970s. Even in the absence of laboratory-preserved virus, the prolonged viability of variola virus has been dem-onstrated in scabs up to 13 years after collection. The potential for reverse genetic engineering using the known sequence of smallpox also makes it a potential biologic weapon. This has resulted in the United States undertaking a vaccination program for key healthcare workers.102 Variola virus is highly infectious in the aerosolized form; after an incubation period of 10 to 12 days, clinical manifestations of malaise, fever, vomiting, and headache appear, followed by development of a characteristic centripetal rash (which is found to predominate on the face and extremities). The fatality rate may reach 30%. Postexposure prophylaxis with smallpox vaccine has been noted to be effec-tive for up to 4 days


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Surgery_Schwartz. rash (which is found to predominate on the face and extremities). The fatality rate may reach 30%. Postexposure prophylaxis with smallpox vaccine has been noted to be effec-tive for up to 4 days postexposure. Cidofovir, an acyclic nucleo-side phosphonate analogue, has demonstrated activity in animal models of poxvirus infections and may offer promise for the treatment of smallpox.103Brunicardi_Ch06_p0157-p0182.indd 17801/03/19 4:46 PM 179SURGICAL INFECTIONSCHAPTER 6Francisella tularensis (Tularemia)The principal reservoir of this gram-negative aerobic organism is the tick. After inoculation, this organism proliferates within macrophages. Tularemia is considered a potential bioterrorist threat due to a very high infectivity rate after aerosolization. Patients with tularemia pneumonia develop a cough and dem-onstrate pneumonia on chest roentgenogram. Enlarged lymph nodes occur in approximately 85% of patients. The organism can be cultured from tissue samples, but this is difficult,


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Surgery_Schwartz. a cough and dem-onstrate pneumonia on chest roentgenogram. Enlarged lymph nodes occur in approximately 85% of patients. The organism can be cultured from tissue samples, but this is difficult, and the diagnosis is based on acute-phase agglutination tests. Treat-ment of inhalational tularemia consists of administration of an aminoglycoside or second-line agents such as doxycycline and ciprofloxacin.REFERENCESEntries highlighted in bright blue are key references. 1. Nuland SB. The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignaz Semmelweis. New York: WW Norton & Co.: 2003:1. 2. Wangensteen OH, Wangensteen SD. Germ theory of infec-tion and disease. In: Wangensteen OH, Wangensteen SD: The Rise of Surgery: From Empiric Craft to Scientific Discipline. Minneapolis: University of Minnesota Press: 1978:387. 3. Rutkow E. Appendicitis: the quintessential American surgical disease. Arch Surg. 1998;133:1024. 4. Mirilas P, Skandalakis JE. Not just an appendix: Sir Frederick


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Surgery_Schwartz. of Minnesota Press: 1978:387. 3. Rutkow E. Appendicitis: the quintessential American surgical disease. Arch Surg. 1998;133:1024. 4. Mirilas P, Skandalakis JE. Not just an appendix: Sir Frederick Treves. Arch Dis Child. 2003;88;549-553. 5. Bynum WF, Hardy A, Jacyna S, Lawrence C, Tansey EM. The Western Medical Tradition. Cambridge: Cambridge University Press: 2006. 6. Meleney F. Bacterial synergism in disease processes with confirmation of synergistic bacterial etiology of certain types of progressive gangrene of the abdominal wall. Ann Surg. 1931;94:961-981. 7. Altemeier WA. Manual of Control of Infection in Surgical Patients. Chicago: American College of Surgeons Press: 1976:1. 8. Bartlett JG. Intra-abdominal sepsis. Med Clin North Am. 1995;79:599-617. 9. Dunn DL, Simmons RL. The role of anaerobic bacteria in intra-abdominal infections. Rev Infect Dis. 1984;6:S139-S146. 10. Osler W. The Evolution of Modern Medicine. New Haven, CT: Yale University Press: 1913:1. 11. Dunn DL.


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Surgery_Schwartz. role of anaerobic bacteria in intra-abdominal infections. Rev Infect Dis. 1984;6:S139-S146. 10. Osler W. The Evolution of Modern Medicine. New Haven, CT: Yale University Press: 1913:1. 11. Dunn DL. Autochthonous microflora of the gastrointestinal tract. Perspect Colon Rectal Surg. 1990;2:105-119. 12. van Till JW, van Veen SQ, van Ruler O, et al. The innate immune response to secondary peritonitis. Shock. 2007 Nov;28(5):504-517. 13. Zeytun A, Chaudhary A, Pardington P, et al. Induction of cyto-kines and chemokines by Toll-like receptor signaling: strat-egies for control of inflammation. Crit Rev Immunol. 2010; 30(1):53-67. 14. Aziz M, Jacob A, Yang WL, et al. Current trends in inflam-matory and immunomodulatory mediators in sepsis. J Leukoc Biol. 2013;(3):320-342. 15. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis cam-paign: international guidelines for management of severe sep-sis and septic shock: 2012. Crit Care Med. 2013;41:580-637. 16. Singer M, et al. The third


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Surgery_Schwartz. Levy MM, Rhodes A, et al. Surviving sepsis cam-paign: international guidelines for management of severe sep-sis and septic shock: 2012. Crit Care Med. 2013;41:580-637. 16. Singer M, et al. The third international consensus defini-tions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315(8):801-810. The most recently updated set of evidence-based guidelines and definitions for sepsis and septic shock. 17. Murphy SL, Xu Jiaquan, Kochanek KD. Deaths: preliminary data for 2010. Natl Vital Stat Rep. 2012;60(4):1-52. 18. Zahar JR, Timsit JF, Garrouste-Orgeas M, et al. Outcomes in severe sepsis and patients with septic shock: pathogen species and infection sites are not associated with mortality. Crit Care Med. 2011;39(8):1886-1895. 19. Dreiher J, Almog Y, Sprung CL, et al. Temporal trends in patient characteristics and survival of intensive care admis-sions with sepsis: a multicenter analysis. Crit Care Med. 2012;40(3):855-860. 20. Berrios-Torres S, et al., Centers for Disease Control


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Surgery_Schwartz. antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195-283. 24. Solomkin JS, Meakins JL, Jr, Allo MD, et al. Antibiotic tri-als in intra-abdominal infections: a critical evaluation of study design and outcome reporting. Ann Surg. 1984;200:29-39. 25. Kumar A. Optimizing antimicrobial therapy in sepsis and septic shock. Crit Care Clin. 2009;25(4):733-751. Discussion and recommendations on rational and optimal clinical use of antimicrobials. 26. Aarts MA, Brun-Buisson C, Cook DJ, et al. Antibiotic man-agement of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome? Intensive Care Med. 2007;33(8):1369-1378. 27. Hillier S, Roberts Z, Dunstan F, et al. Prior antibiotics and risk of antibiotic-resistant community-acquired urinary tract infection: a case-control study. J Antimicrob Chemother. 2007;60:92-99. 28. Smith BP, Fox N, Fakhro A, et al. “SCIP” ping antibiotic pro-phylaxis guidelines in trauma: the consequences of


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Surgery_Schwartz. guidelines on the management of intra-abdominal infection. Surgical Infections. 2017;18(1):1-76. Evidence-based, graded recommendations covering diagno-sis, antibiotic selection, and source control of intra-abdominal infections. 33. Sartelli M, Catena F, Ansaloni L, Coccolini F, Di Saverio S, Griffiths E. Duration of antimicrobial therapy in treating com-plicated intra-abdominal infections: a comprehensive review. Surgical Infections. 2016;17(1):9-12. 34. Romano A, Viola M, Guéant-Rodriguez RM, et al. Imipenem in patients with immediate hypersensitivity to penicillins. N Engl J Med. 2006;354(26):2835-2837. 35. Park M, Markus P, Matesic D, Li JT. Safety and effective-ness of a preoperative allergy clinic in decreasing vancomycin use in patients with a history of penicillin allergy. Ann Allergy Asthma Immunol. 2006;97:681-687. 36. Galán JC, González-Candelas F, Rolain JM, Cantón R. Anti-biotics as selectors and accelerators of diversity in the mecha-nisms of resistance: from the


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Surgery_Schwartz. Ann Allergy Asthma Immunol. 2006;97:681-687. 36. Galán JC, González-Candelas F, Rolain JM, Cantón R. Anti-biotics as selectors and accelerators of diversity in the mecha-nisms of resistance: from the resistome to genetic plasticity in the β-lactamases world. Front Microbiol. 2013;4:9.Brunicardi_Ch06_p0157-p0182.indd 17901/03/19 4:46 PM 180BASIC CONSIDERATIONSPART I 37. Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infec-tion, including surgical site infection. Surg Infect (Larchmt). 2011;12(3):163-168. doi: 10.1089/sur.2010.083. 38. Alexander JW, Solomkin JS, Edwards MJ. Updated rec-ommendations for control of surgical site infections. Ann Surg. 2011;253(6):1082-1093. Evidence-based guidelines on SSI prevention. 39. Martone WJ, Nichols RL. Recognition, prevention, surveil-lance, and management of surgical site infections: introduc-tion to the problem and symposium overview. Clin Infect Dis.


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Surgery_Schwartz. Surg. 2013;216(1): 23-33. Design and implementation of an SSI-prevention bun-dle, which demonstrated a reduction in colorectal surgical site infections. 43. Duttaroy DD, Jitendra J, Duttaroy B, et al. Management strategy for dirty abdominal incisions: primary or delayed primary closure? A randomized trial. Surg Infect (Larchmt). 2009:10(2):129-136. 44. Margenthaler JA, Longo WE, Virgo KS, et al. Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults. Ann Surg. 2003;238:59-66. 45. McManus LM, Bloodworth RC, Prihoda TJ, et al. Agonist-dependent failure of neutrophil function in diabetes correlates with extent of hyperglycemia. J Leukoc Biol. 2001;70:395-404. 46. Richards JE, Kauffmann RM, Obremskey WT, May AK. Stress-induced hyperglycemia as a risk factor for surgical-site infection in nondiabetic orthopedic trauma patients admitted to the intensive care unit. J Orthop Trauma. 2013;27(1):16-21. 47. Ata A, Lee J, Bestle SL, et al. Postoperative


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Surgery_Schwartz. strategies. Clin Liver Dis. 2010; 14(1):23-36. 98. Katz LH, Goldvaser H, Gafter-Gvili A, Tur-Kaspa R. Extended peginterferon plus ribavirin treatment for 72 weeks versus standard peginterferon plus ribavirin treatment for 48 weeks in chronic hepatitis C genotype 1 infected slow-responder adult patients. Cochrane Database Syst Rev. 2012;9:CD008516. 99. Cholongitas E, Papatheodoridis GV. Sofosbuvir: a novel oral agent for chronic hepatitis C. Ann Gastroenterol. 2014;27(4):331-337. 100. Inglesby TV, O’Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: updated recommendations for man-agement. JAMA. 2002;287:2236-2252. 101. Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a bio-logical weapon; medical and public health management. Work-ing group on civilian biodefense. JAMA. 2000;283:2281-2290. 102. Russell PK, Gronvall GK. U.S. medical countermeasure devel-opment since 2001: a long way yet to go. Biosecur Bioterror. 2012;10(1):66-76. 103. DeClercq E. Cidofovir in


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Surgery_Schwartz. JAMA. 2000;283:2281-2290. 102. Russell PK, Gronvall GK. U.S. medical countermeasure devel-opment since 2001: a long way yet to go. Biosecur Bioterror. 2012;10(1):66-76. 103. DeClercq E. Cidofovir in the treatment of poxvirus infections. Antiviral Res. 2002;55:1-13.Brunicardi_Ch06_p0157-p0182.indd 18101/03/19 4:46 PM


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Surgery_Schwartz. TraumaClay Cothren Burlew and Ernest E. Moore 7chapterINTRODUCTIONTrauma, or injury, is defined as cellular disruption caused by environmental energy that is beyond the body’s resilience, which is compounded by cell death due to ischemia/reperfu-sion. Trauma is the most common cause of death for all indi-viduals between the ages of 1 and 44 years, and is the third most common cause of death regardless of age.1 It is also the leading cause of years of productive life lost. Unin-tentional injuries account for over 135,000 deaths per year, with homicides, suicides, and other causes are responsible for another 60,000 deaths each year. However, death rate under-estimates the magnitude of the societal toll. For example, in 2014 there were almost 200,000 injury-related deaths, but 37.2 million injured patients treated in emergency depart-ments (EDs). Injury-related medical expenditures are esti-mated to be $117 billion each year in the United States.2 The aggregate lifetime cost for all


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Surgery_Schwartz. injured patients treated in emergency depart-ments (EDs). Injury-related medical expenditures are esti-mated to be $117 billion each year in the United States.2 The aggregate lifetime cost for all injured patients is estimated to be in excess of $260 trillion. For these reasons, trauma must be considered a major public health issue. The American Col-lege of Surgeons Committee on Trauma addresses this issue by assisting in the development of trauma centers and sys-tems. The organization of trauma systems has had a signifi-cant favorable impact on patient outcomes, although system integration and maldistribution of trauma centers remain chal-lenges.3-5INITIAL EVALUATION AND RESUSCITATION OF THE INJURED PATIENTPrimary SurveyThe Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma was developed in the late 1970s, based on the premise that appro-priate and timely care can improve the outcome for the injured 1patient.6 ATLS provides a structured


Surgery_Schwartz

Surgery_Schwartz. of Surgeons Committee on Trauma was developed in the late 1970s, based on the premise that appro-priate and timely care can improve the outcome for the injured 1patient.6 ATLS provides a structured approach to the trauma patient with standard algorithms of care; it emphasizes the “golden hour” concept that timely, prioritized interventions are necessary to prevent death and disability. The ATLS for-mat and basic tenets are followed throughout this chapter, with some modifications. The initial management of seriously injured patients consists of phases that include the primary survey/concurrent resuscitation, the secondary survey/diag-nostic evaluation, definitive care, and the tertiary survey. The first step in patient management is performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life. The ATLS course refers to the primary survey as assessment of the “ABCs” (Airway with cervical spine protection, Breathing,


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Surgery_Schwartz. identify and treat conditions that constitute an immediate threat to life. The ATLS course refers to the primary survey as assessment of the “ABCs” (Airway with cervical spine protection, Breathing, and Circulation). The timing of emergent intubation in the hypovolemic patient remains controversial because of the risk of further compro-mising cardiac function. Although the concepts within the primary survey are presented in a sequential fashion, in reality they are pursued simultaneously in coordinated team resuscitation. Life-threatening injuries must be identified (Table 7-1) and treated before progressing to the secondary survey.Airway Management With Cervical Spine Protection. Ensuring a patent airway is the first priority in the primary survey. This is essential because efforts to restore cardio-vascular integrity will be futile unless the oxygen content of the blood is adequate. Simultaneously, all patients with blunt trauma require cervical spine immobilization until injury


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Surgery_Schwartz. restore cardio-vascular integrity will be futile unless the oxygen content of the blood is adequate. Simultaneously, all patients with blunt trauma require cervical spine immobilization until injury is excluded. This is typically accomplished by applying a hard cervical collar or placing sandbags on both sides of the head with the patient’s forehead taped across the bags. Soft collars do not effectively immobilize the cervical spine. For penetrating neck wounds, however, cervical collars are not recommended because they provide no benefit and may interfere with assess-ment and treatment.7,82Introduction 183Initial Evaluation and Resuscitation of the Injured Patient 183Primary Survey / 183Secondary Survey / 195Mechanisms and Patterns of Injury / 195Regional Assessment and Special Diagnostic Tests / 196General Principles of Management 205Transfusion Practices / 206Prophylactic Measures / 208Operative Approaches and Exposure / 209Damage Control Surgery / 215Treatment of Specific


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Surgery_Schwartz. Tests / 196General Principles of Management 205Transfusion Practices / 206Prophylactic Measures / 208Operative Approaches and Exposure / 209Damage Control Surgery / 215Treatment of Specific Injuries 217Head Injuries / 217Cervical Injuries / 219Chest Injuries / 222Abdominal Injuries / 225Pelvic Fracture Hemorrhage Control / 234Extremity Vascular Injuries, Fractures, and Compartment Syndromes / 235Surgical Intensive Care Management 237Postinjury Resuscitation / 237Abdominal Compartment Syndrome / 238Special Populations 240Pregnant Patients / 240Geriatric Patients / 243Pediatric Patients / 244Brunicardi_Ch07_p0183-p0250.indd 18310/12/18 6:16 PM 184Table 7-1Immediately life-threatening injuries to be identified during the primary surveyAirwayAirway obstructionAirway injuryBreathingTension pneumothoraxOpen pneumothoraxMassive air leak from tracheobronchial injuryFlail chest with underlying pulmonary contusionCirculationHemorrhagic shockMassive hemothoraxMassive


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Surgery_Schwartz. injuryBreathingTension pneumothoraxOpen pneumothoraxMassive air leak from tracheobronchial injuryFlail chest with underlying pulmonary contusionCirculationHemorrhagic shockMassive hemothoraxMassive hemoperitoneumMechanically unstable pelvis fracture with bleedingExtremity blood lossCardiogenic shockCardiac tamponadeNeurogenic shockDisabilityIntracranial hemorrhageCervical spine injuryPatients who are conscious, without tachypnea, and have a normal voice are unlikely to require early airway intervention. Exceptions are penetrating injuries to the neck with an expanding hematoma; evidence of chemical or thermal injury to the mouth, nares, or hypopharynx; extensive subcutaneous air in the neck; complex maxillofacial trauma; or airway bleeding. Although these patients may initially have an adequate airway, it may become compromised if soft tissue swelling, hematoma forma-tion, or edema progresses. In these cases, preemptive intubation should be performed before airway access becomes


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Surgery_Schwartz. an adequate airway, it may become compromised if soft tissue swelling, hematoma forma-tion, or edema progresses. In these cases, preemptive intubation should be performed before airway access becomes challenging.Patients who have an abnormal voice, abnormal breathing sounds, tachypnea, or altered mental status require further air-way evaluation. Blood, vomit, the tongue, teeth, foreign objects, and soft tissue swelling can cause airway obstruction; suction-ing affords immediate relief in many patients. In the comatose patient, the tongue may fall backward and obstruct the hypo-pharynx; this can be relieved by either a chin lift or jaw thrust. An oral airway or a nasal trumpet is also helpful in maintaining airway patency, although the former is usually not tolerated by an awake patient. Establishing a definitive airway (i.e., endotra-cheal intubation) is indicated in patients with apnea; inability to protect the airway due to altered mental status; impending airway compromise due to


Surgery_Schwartz

Surgery_Schwartz. Establishing a definitive airway (i.e., endotra-cheal intubation) is indicated in patients with apnea; inability to protect the airway due to altered mental status; impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration; and inability to maintain oxygenation. Altered mental status is the most com-mon indication for intubation. Agitation or obtundation, often attributed to intoxication or drug use, may actually be due to hypoxia. But the timing of endotracheal intubation may be criti-cal in the hypovolemic patient because positive airway pres-sure may further compromise cardiac function and precipitate cardiac arrest; thus, Circulation may take priority over Airway.Options for endotracheal intubation include nasotracheal, orotracheal, or operative routes. Nasotracheal intubation can be accomplished only in patients who are breathing spontaneously. Although nasotracheal intubation is frequently used by prehospital providers,


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Surgery_Schwartz. or operative routes. Nasotracheal intubation can be accomplished only in patients who are breathing spontaneously. Although nasotracheal intubation is frequently used by prehospital providers, the technique is limited in the ED to those patients requiring emergent airway support in whom chemical paralysis Key Points1 Trauma is the most common cause of death for all indi-viduals between the ages of 1 and 44 years and is the third most common cause of death regardless of age.2 The initial management of seriously injured patients usu-ally follows the primary survey (the “ABCs”—Airway with cervical spine protection, Breathing, and Circulation), although at times restoring Circulatory volume may pro-ceed active Airway intervention; the goals of the primary survey are to identify and treat conditions that constitute an immediate threat to life.3 All patients with blunt injury should be assumed to have unstable cervical spine injuries until proven otherwise; one must maintain cervical spine


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Surgery_Schwartz. that constitute an immediate threat to life.3 All patients with blunt injury should be assumed to have unstable cervical spine injuries until proven otherwise; one must maintain cervical spine precautions and in-line stabilization.4 Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require prompt intervention; one must consider the dominant causes of acute shock, i.e., hemorrhagic, cardiogenic, and neuro-genic shock.5 Patients with trauma-induced coagulopathy (TIC) are at risk for massive transfusion and need to be identified early.6 Indications for immediate operative intervention for pene-trating cervical injury include hemodynamic instability and significant external arterial hemorrhage; the management algorithm for hemodynamically stable patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones.7 The gold standard for determining if there is a blunt descending


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Surgery_Schwartz. patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones.7 The gold standard for determining if there is a blunt descending aortic injury is computed tomography angiog-raphy (CTA) scanning; indications are primarily based on injury mechanism.8 The abdomen is a diagnostic black box. Physical examina-tion and FAST ultrasound can identify patients requiring emergent laparotomy. Computed tomography (CT) scan-ning is the mainstay of evaluation in the remaining patients to more precisely identify the site and magnitude of injury.9 Manifestation of the “bloody vicious cycle” (the lethal combination of coagulopathy, hypothermia, and metabolic acidosis) is the most common indication for damage con-trol surgery. The primary objectives of damage control laparotomy are to control bleeding and limit gastrointesti-nal spillage.10 Blunt injuries to the carotid and vertebral arteries are usu-ally managed with systemic


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Surgery_Schwartz. primary objectives of damage control laparotomy are to control bleeding and limit gastrointesti-nal spillage.10 Blunt injuries to the carotid and vertebral arteries are usu-ally managed with systemic antithrombotic therapy.11 The abdominal compartment syndrome may be primary (i.e., due to the injury of abdominal organs, bleeding, and packing) or secondary (i.e., due to reperfusion visceral edema, retroperitoneal edema, and ascites).Brunicardi_Ch07_p0183-p0250.indd 18410/12/18 6:16 PM 185TRAUMACHAPTER 7AFigure 7-1. Cricothyroidotomy is recommended for emergent surgical establishment of a patent airway. A vertical skin incision avoids injury to the anterior jugular veins, which are located just lateral to the midline. Hemorrhage from these vessels obscures vision and prolongs the procedure. When a transverse incision is made in the cricothyroid membrane, the blade of the knife should be angled inferiorly to avoid injury to the vocal cords. A. Use of a tracheostomy hook stabilizes


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Surgery_Schwartz. When a transverse incision is made in the cricothyroid membrane, the blade of the knife should be angled inferiorly to avoid injury to the vocal cords. A. Use of a tracheostomy hook stabilizes the thyroid cartilage and facilitates tube insertion. B. A 6.0 endotracheal tube is inserted after digital confirmation of airway access.Figure 7-2. A “clothesline” injury can partially or completely tran-sect the anterior neck structures, including the trachea. With com-plete tracheal transection, the endotracheal tube is placed directly into the distal aperture, with care taken not to push the trachea into the mediastinum.incision, with sharp division of the subcutaneous tissues. Visu-alization may be improved by having an assistant retract lat-erally on the neck incision using retractors. The cricothyroid membrane is verified by digital palpation and opened in a hori-zontal direction. The airway may be stabilized before incision of the membrane using a tracheostomy hook; the hook should be


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Surgery_Schwartz. membrane is verified by digital palpation and opened in a hori-zontal direction. The airway may be stabilized before incision of the membrane using a tracheostomy hook; the hook should be placed under the thyroid cartilage to elevate the airway. A 6.0 endotracheal tube (maximum diameter in adults) is then advanced through the cricothyroid opening and sutured into place. In patients under the age of 11, cricothyroidotomy is rela-tively contraindicated due to the risk of subglottic stenosis, and tracheostomy should be performed.Emergent tracheostomy is indicated in patients with laryn-gotracheal separation or laryngeal fractures, in whom cricothy-roidotomy may cause further damage or result in complete loss of the airway. This procedure is best performed in the operating room (OR) where there is optimal lighting and availability of advanced equipment (e.g., sternal saw). In these cases, often after a “clothesline” injury, direct visualization and instrumenta-tion of the trachea usually


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Surgery_Schwartz. is optimal lighting and availability of advanced equipment (e.g., sternal saw). In these cases, often after a “clothesline” injury, direct visualization and instrumenta-tion of the trachea usually is done through the traumatic anterior neck defect or after a generous collar skin incision (Fig. 7-2). If the trachea is completely transected, a nonpenetrating clamp should be placed on the distal aspect to prevent tracheal retrac-tion into the mediastinum; this is particularly important before placement of the endotracheal tube.Breathing and Ventilation. Once a secure airway is obtained, adequate oxygenation and ventilation must be ensured. All injured patients should receive supplemental oxygen and be monitored by pulse oximetry. The following conditions con-stitute an immediate threat to life due to inadequate ventilation and should be recognized during the primary survey: tension pneumothorax, open pneumothorax, flail chest with underlying pulmonary contusion, massive hemothorax, and


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Surgery_Schwartz. due to inadequate ventilation and should be recognized during the primary survey: tension pneumothorax, open pneumothorax, flail chest with underlying pulmonary contusion, massive hemothorax, and major air leak due to a tracheobronchial injury.Tension pneumothorax is presumed in any patient mani-festing respiratory distress and hypotension in combination with any of the following physical signs: tracheal deviation away from the affected side, lack of or decreased breath sounds on cannot be used. Orotracheal intubation is the preferred technique to establish a definitive airway. Because all patients are presumed to have cervical spine injuries, manual in-line cervical immobilization is essential.6 Correct endotracheal placement is verified with direct laryngoscopy, capnography, audible bilateral breath sounds, and finally a chest film. The GlideScope®, a video laryngoscope that uses fiberoptics to visualize the vocal cords, is being employed more frequently.9 Advantages of orotracheal


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Surgery_Schwartz. breath sounds, and finally a chest film. The GlideScope®, a video laryngoscope that uses fiberoptics to visualize the vocal cords, is being employed more frequently.9 Advantages of orotracheal intubation include the direct visualization of the vocal cords, ability to use larger-diameter endotracheal tubes, and applicability to apneic patients. The disadvantage of orotracheal intubation is that conscious patients usually require neuromuscular blockade, which may result in the inability to intubate, aspiration, or medication complications. Those who attempt rapid-sequence induction must be thoroughly familiar with the procedure (see Chapter 13).Patients in whom attempts at intubation have failed or who are precluded from intubation due to extensive facial inju-ries require operative establishment of an airway. Cricothy-roidotomy (Fig. 7-1) is performed through a generous vertical 3Brunicardi_Ch07_p0183-p0250.indd 18510/12/18 6:16 PM 186BASIC CONSIDERATIONSPART Ithe affected side,


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Surgery_Schwartz. of an airway. Cricothy-roidotomy (Fig. 7-1) is performed through a generous vertical 3Brunicardi_Ch07_p0183-p0250.indd 18510/12/18 6:16 PM 186BASIC CONSIDERATIONSPART Ithe affected side, and subcutaneous emphysema on the affected side. Patients may have distended neck veins due to impedance of venous return, but the neck veins may be flat due to concur-rent systemic hypovolemia. Tension pneumothorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies the pneumothorax as a ten-sion pneumothorax. Although immediate needle thoracostomy decompression with a 14-gauge angiocatheter may be indicated in the field, tube thoracostomy in the midaxillary line should be performed immediately in the ED before a chest radiograph is obtained (Fig. 7-3). Recent studies suggest that preferred loca-tion for needle decompression may be the fifth intercostal space in the anterior axillary line due to body habitus.10 In cases of tension


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Surgery_Schwartz. (Fig. 7-3). Recent studies suggest that preferred loca-tion for needle decompression may be the fifth intercostal space in the anterior axillary line due to body habitus.10 In cases of tension pneumothorax, the parenchymal tear in the lung acts as a one-way valve, with each inhalation allowing additional air to accumulate in the pleural space. The normally negative intra-pleural pressure becomes positive, which depresses the ipsilat-eral hemidiaphragm and shifts the mediastinal structures into the contralateral chest. Subsequently, the contralateral lung is compressed and the heart rotates about the superior and inferior vena cava; this decreases venous return and ultimately cardiac output, which culminates in cardiovascular collapse.An open pneumothorax or “sucking chest wound” occurs with full-thickness loss of the chest wall, permitting free com-munication between the pleural space and the atmosphere (Fig. 7-4). This compromises ventilation due to equilibration of atmospheric and


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Surgery_Schwartz. full-thickness loss of the chest wall, permitting free com-munication between the pleural space and the atmosphere (Fig. 7-4). This compromises ventilation due to equilibration of atmospheric and pleural pressures, which prevents lung inflation Figure 7-3. A. Tube thoracostomy is performed in the midaxillary line at the fourth or fifth intercostal space (inframammary crease) to avoid iatrogenic injury to the liver or spleen. B. Heavy scissors are used to cut through the intercostal muscle into the pleural space. This is done on top of the rib to avoid injury to the intercostal bun-dle located just beneath the rib. C. The incision is digitally explored to confirm intrathoracic location and identify pleural adhesions. D. A 28Fr chest tube is directed superiorly and posteriorly with the aid of a large clamp.Figure 7-4. A. Full-thickness loss of the chest wall results in an open pneumothorax. B. The defect is temporarily managed with an occlusive dressing that is taped on three sides,


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Surgery_Schwartz. of a large clamp.Figure 7-4. A. Full-thickness loss of the chest wall results in an open pneumothorax. B. The defect is temporarily managed with an occlusive dressing that is taped on three sides, which allows accumulated air to escape from the pleural space and thus prevents a tension pneumothorax. Repair of the chest wall defect and tube thoracostomy remote from the wound is definitive treatment.and alveolar ventilation, and results in hypoxia and hypercar-bia. Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothorax to a tension pneumothorax. Temporary management of this injury includes covering the wound with an occlusive dressing that is taped on three sides. This acts as a flutter valve, permitting effective ven-tilation on inspiration while allowing accumulated air to escape from the pleural space on the untapped side, so that a tension pneumothorax is prevented. Definitive treatment is closure of the chest wall defect and tube


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Surgery_Schwartz. while allowing accumulated air to escape from the pleural space on the untapped side, so that a tension pneumothorax is prevented. Definitive treatment is closure of the chest wall defect and tube thoracostomy remote from the wound.Flail chest occurs when three or more contiguous ribs are fractured in at least two locations. Paradoxical movement of this free-floating segment of chest wall is usually evident in patients with spontaneous ventilation, due to the negative intra-pleural pressure of inspiration. The additional work of breathing and chest wall pain caused by the flail segment is rarely suf-ficient to compromise ventilation. Instead, it is the decreased compliance and increased shunt fraction caused by the associ-ated pulmonary contusion that is the source of acute respiratory failure. Pulmonary contusions often progress during the first 12 hours. Resultant hypoventilation and hypoxemia may require intubation and mechanical ventilation. The patient’s initial chest


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Surgery_Schwartz. failure. Pulmonary contusions often progress during the first 12 hours. Resultant hypoventilation and hypoxemia may require intubation and mechanical ventilation. The patient’s initial chest Brunicardi_Ch07_p0183-p0250.indd 18610/12/18 6:17 PM 187TRAUMACHAPTER 7radiograph often underestimates the extent of the pulmonary parenchymal damage (Fig. 7-5); close monitoring and frequent clinical reevaluation are warranted.Major air leak occurs from tracheobronchial injuries. Type I injuries are those occurring within 2 cm of the carina.11,12 These may not be associated with a pneumothorax due to the envelopment in the mediastinal pleura. Type II injuries are more distal injuries within the tracheobronchial tree and hence mani-fest with a pneumothorax. Bronchoscopy confirms the extent of the injury and its location, and directs management.Circulation With Hemorrhage Control. With a secure airway and adequate ventilation established, circulatory status is the next focus. An initial


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Surgery_Schwartz. of the injury and its location, and directs management.Circulation With Hemorrhage Control. With a secure airway and adequate ventilation established, circulatory status is the next focus. An initial approximation of the patient’s cardiovascular status can be obtained by palpating peripheral pulses. In gen-eral, systolic blood pressure (SBP) must be 60 mmHg for the carotid pulse to be palpable, 70 mmHg for the femoral pulse, and 80 mmHg for the radial pulse. Any episode of hypotension (defined as a SBP <90 mmHg) is assumed to be caused by hem-orrhage until proven otherwise. Patients with rapid massive blood loss may have paradoxical bradycardia.13 Blood pressure and pulse should be measured at least every 5 minutes in patients with significant blood loss until normal vital sign values are restored.Intravenous (IV) access for fluid resuscitation and medi-cation administration is obtained with two peripheral catheters, 16-gauge or larger in adults. For patients in whom peripheral


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Surgery_Schwartz. are restored.Intravenous (IV) access for fluid resuscitation and medi-cation administration is obtained with two peripheral catheters, 16-gauge or larger in adults. For patients in whom peripheral angiocatheter access is difficult, intraosseous (IO) needles Figure 7-5. A. Admission chest film may not show the full extent of the patient’s pulmonary parenchymal injury. B. This patient’s left pulmonary contusion blossomed 12 hours later, and its associ-ated opacity is noted on repeat chest radiograph.should be rapidly placed in the proximal humerus or tibia (Fig. 7-6).14,15 All medications administered IV may be admin-istered in a similar dosage intraosseously. Although safe for emergent use, the needle should be removed once alternative access is established to prevent potential osteomyelitis. Blood should be drawn simultaneously for a bedside hemoglobin level and routine trauma laboratory tests. In the seriously injured patient arriving in shock, an arterial blood gas for base deficit


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Surgery_Schwartz. Blood should be drawn simultaneously for a bedside hemoglobin level and routine trauma laboratory tests. In the seriously injured patient arriving in shock, an arterial blood gas for base deficit (BD), cross-matching for possible blood component (RBC and plasma) transfusion, and a coagulation panel/viscoelastic hemo-statis assay (e.g., TEG, ROTEM) should be obtained. In these patients, secondary large bore (7 to 9 Fr) cannulae should be obtained via the femoral or subclavian veins; Cordis introducer catheters are preferred over triple-lumen catheters. In general, initial access in trauma patients is best secured in the groin so that placement of the catheter will not interfere with the perfor-mance of other diagnostic and therapeutic thoracic procedures. A rule of thumb to consider for secondary access is placement of femoral access for thoracic trauma and jugular or subclavian access for abdominal trauma. Internal jugular or subclavian catheters provide a more reliable measurement of


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Surgery_Schwartz. access is placement of femoral access for thoracic trauma and jugular or subclavian access for abdominal trauma. Internal jugular or subclavian catheters provide a more reliable measurement of central venous pressure (CVP), which may be helpful in determining the vol-ume status of the patient and in excluding cardiac tamponade. Saphenous vein cutdowns at the ankle can also provide excel-lent access (Fig. 7-7). The saphenous vein is reliably found 1 cm anterior and 1 cm superior to the medial malleolus. Stan-dard 14-gauge catheters can be quickly placed, even in an exsanguinating patient with collapsed veins. In severely injured children younger than 6 years of age, the preferred venous access is peripheral intravenous catheters followed by an IO needle. Central venous catheter placement or saphenous vein cutdown may be considered as the third choice of access based upon provider experience. Inadvertent femoral artery cannula-tion, however, may result in limb-threatening arterial


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Surgery_Schwartz. or saphenous vein cutdown may be considered as the third choice of access based upon provider experience. Inadvertent femoral artery cannula-tion, however, may result in limb-threatening arterial spasm.External control of any visible hemorrhage should be achieved promptly while circulating volume is restored. For Figure 7-6. Intraosseous infusions are indicated for patients in whom one or two attempts at IV access have failed. A. The proxi-mal tibia or humerus is the preferred location. Alternatively, the distal femur can be used if the tibia is fractured. B. The position is satisfactory if bone marrow can be aspirated and saline can be eas-ily infused without evidence of extravasation.Brunicardi_Ch07_p0183-p0250.indd 18710/12/18 6:17 PM 188BASIC CONSIDERATIONSPART Iopen wounds with ongoing bleeding, manual compression should be done with a single 4 × 4 gauze and a gloved hand. Covering the wound with excessive dressings may permit ongoing unrecognized blood loss that is hidden


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Surgery_Schwartz. ongoing bleeding, manual compression should be done with a single 4 × 4 gauze and a gloved hand. Covering the wound with excessive dressings may permit ongoing unrecognized blood loss that is hidden underneath the dressing. Blind clamping of bleeding vessels should be avoided because of the risk to adjacent structures, including nerves. This is particularly true for penetrating injuries of the neck, thoracic outlet, and groin, where bleeding may be torrential and aris-ing deep within the wound. In these situations, a gloved finger placed through the wound directly onto the bleeding vessel can apply enough pressure to control active bleeding. The surgeon performing this maneuver must then walk with the patient to the OR for definitive treatment. For bleeding of the extremi-ties, it is tempting to apply tourniquets for hemorrhage control, Figure 7-7. Saphenous vein cutdowns are excellent sites for fluid resuscitation access. A. The vein is consistently found 1 cm ante-rior and 1 cm


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Surgery_Schwartz. tempting to apply tourniquets for hemorrhage control, Figure 7-7. Saphenous vein cutdowns are excellent sites for fluid resuscitation access. A. The vein is consistently found 1 cm ante-rior and 1 cm superior to the medial malleolus. B. Proximal and distal traction sutures are placed with the distal suture ligated. C. A 14-gauge IV catheter is introduced and secured with sutures and tape to prevent dislodgment.Figure 7-8. More than 1500 mL of blood in the pleural space is considered a massive hemothorax. Chest film findings reflect the positioning of the patient. A. In the supine position, blood tracks along the entire posterior section of the chest and is most notable pushing the lung away from the chest wall. B. In the upright position, blood is visible dependently in the right pleural space.but digital occlusion will usually control the bleeding; complete vascular occlusion with a tourniquet risks permanent neuromus-cular impairment. Patients in shock have a lower tolerance to


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Surgery_Schwartz. space.but digital occlusion will usually control the bleeding; complete vascular occlusion with a tourniquet risks permanent neuromus-cular impairment. Patients in shock have a lower tolerance to warm ischemia, and an occluded extremity is prone to small vessel thrombosis. For patients with open fractures, fracture reduction with stabilization via splints will limit bleeding both externally and into the subcutaneous tissues. Scalp lacerations through the galea aponeurotica tend to bleed profusely; these can be temporarily controlled with skin staples, Raney clips, or a full-thickness continuous running nylon stitch.During the circulation section of the primary survey, four life-threatening injuries must be identified promptly: (a) mas-sive hemothorax, (b) cardiac tamponade, (c) massive hemo-peritoneum, and (d) mechanically unstable pelvic fractures with bleeding. Massive hemoperitoneum and mechanically unstable pelvic fractures are discussed in “Emergent Abdomi-nal Exploration” and


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Surgery_Schwartz. hemo-peritoneum, and (d) mechanically unstable pelvic fractures with bleeding. Massive hemoperitoneum and mechanically unstable pelvic fractures are discussed in “Emergent Abdomi-nal Exploration” and “Pelvic Fractures and Emergent Hemor-rhage Control,” respectively. Critical tools used to differentiate these in the multisystem trauma patient are the chest and pelvis radiographs, and extended focused abdominal sonography for trauma (eFAST) (see “Regional Assessment and Special Diag-nostic Tests”). A massive hemothorax (life-threatening injury number one) is defined as >1500 mL of blood or, in the pediatric population, >25% of the patient’s blood volume in the pleural space (Fig. 7-8). Although it may be estimated on chest radio-graph, tube thoracostomy is the only reliable means to quantify the amount of hemothorax. After blunt trauma, a hemothorax is usually due to multiple rib fractures with severed intercostal vessels, but occasionally bleeding is from lacerated lung paren-chyma,


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Surgery_Schwartz. the amount of hemothorax. After blunt trauma, a hemothorax is usually due to multiple rib fractures with severed intercostal vessels, but occasionally bleeding is from lacerated lung paren-chyma, which is usually associated with an air leak. After pen-etrating trauma, a great vessel or pulmonary hilar vessel injury should be presumed. In either scenario, a massive hemothorax is an indication for operative intervention, but tube thoracostomy is critical to facilitate lung reexpansion, which may improve oxygenation and cardiac performance as well as tamponade venous bleeding. In patients arriving in shock with a high risk of pelvic fracture (e.g., autopedestrian accident), the pelvis should be presumptively stabilized with a sheet or binder.Brunicardi_Ch07_p0183-p0250.indd 18810/12/18 6:17 PM 189TRAUMACHAPTER 7Cardiac tamponade occurs most commonly after penetrat-ing thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial appendage, is seen.


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Surgery_Schwartz. 6:17 PM 189TRAUMACHAPTER 7Cardiac tamponade occurs most commonly after penetrat-ing thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial appendage, is seen. Acutely, <100 mL of pericardial blood may cause pericardial tamponade.16 The classic Beck’s triad—dilated neck veins, muffled heart tones, and a decline in arterial pressure—is usually not appreciated in the trauma bay because of the noisy environment and associ-ated hypovolemia. Because the pericardium is not acutely dis-tensible, the pressure in the pericardial sac will rise to match that of the injured chamber. When this pressure exceeds that of the right atrium, right atrial filling is impaired and right ventricular preload is reduced. This ultimately leads to decreased right ven-tricular output. Additionally, increased intrapericardial pressure impedes myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output.Diagnosis of hemopericardium is


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Surgery_Schwartz. Additionally, increased intrapericardial pressure impedes myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output.Diagnosis of hemopericardium is best achieved by ultra-sound of the pericardium (Fig. 7-9). Early in the course of tamponade, blood pressure and cardiac output will transiently improve with fluid administration due to increased central venous pressure. In patients with any hemodynamic distur-bance, a pericardial drain can be placed using ultrasound guid-ance (Fig. 7-10). Removing as little as 15 to 20 mL of blood will Figure 7-9. Subxiphoid pericardial ultrasound reveals a large peri-cardial fluid collection. LV = left ventricle; RV = right ventricle.Figure 7-10. Pericardiocentesis is indicated for patients with evidence of pericardial tamponade. A. Access to the pericardium is obtained through a subxiphoid approach, with the needle angled 45° up from the chest wall and toward the left shoulder. B. Seldinger technique is used


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Surgery_Schwartz. tamponade. A. Access to the pericardium is obtained through a subxiphoid approach, with the needle angled 45° up from the chest wall and toward the left shoulder. B. Seldinger technique is used to place a pigtail catheter. Blood can be repeatedly aspirated with a syringe, or the tubing may be attached to a gravity drain. Evacuation of unclotted pericardial blood prevents subendocardial ischemia and stabilizes the patient for transport to the operating room for sternotomy.often temporarily stabilize the patient’s hemodynamic status and alleviate the subendocardial ischemia that can be associ-ated with lethal arrhythmias; this allows safe transport to the OR for sternotomy. Pericardiocentesis is successful in decompress-ing tamponade in approximately 80% of cases17; the majority of failures are due to the presence of clotted blood within the pericardium. Patients with a persistent SBP <60 mmHg warrant resuscitative thoracotomy (RT) with opening of the pericardium for rapid decompression


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Surgery_Schwartz. are due to the presence of clotted blood within the pericardium. Patients with a persistent SBP <60 mmHg warrant resuscitative thoracotomy (RT) with opening of the pericardium for rapid decompression and control of bleeding.The utility of RT has been debated for decades. Current indi-cations are based on 40 years of prospective data (Table 7-2).18-20 RT is associated with the highest survival rate after isolated cardiac injury; 35% of patients presenting in shock and 20% without vital signs (i.e., no pulse or obtainable blood pressure) are salvaged after Table 7-2Current indications and contraindications for emergency department thoracotomyIndicationsSalvageable postinjury cardiac arrest:Patients sustaining witnessed penetrating trauma to the torso with <15 min of prehospital CPRPatients sustaining witnessed blunt trauma with <10 min of prehospital CPRPatients sustaining witnessed penetrating trauma to the neck or extremities with <5 min of prehospital CPRPersistent severe postinjury


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Surgery_Schwartz. witnessed blunt trauma with <10 min of prehospital CPRPatients sustaining witnessed penetrating trauma to the neck or extremities with <5 min of prehospital CPRPersistent severe postinjury hypotension (SBP ≤60 mmHg) due to:Cardiac tamponadeHemorrhage—intrathoracic, intra-abdominal, extremity, cervicalAir embolismContraindicationsPenetrating trauma: CPR >15 min and no signs of life (pupillary response, respiratory effort, motor activity)Blunt trauma: CPR >10 min and no signs of life or asystole without associated tamponadeCPR = cardiopulmonary resuscitation; SBP = systolic blood pressure.Brunicardi_Ch07_p0183-p0250.indd 18910/12/18 6:17 PM 190BASIC CONSIDERATIONSPART Iisolated penetrating injury to the heart. For all penetrating wounds, survival rate is 15%. Conversely, patient outcome is limited when RT is done for blunt trauma, with 2% survival among patients in shock and <1% survival among those with no vital signs. Thus, patients undergoing cardiopulmonary resuscitation (CPR)


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Surgery_Schwartz. is limited when RT is done for blunt trauma, with 2% survival among patients in shock and <1% survival among those with no vital signs. Thus, patients undergoing cardiopulmonary resuscitation (CPR) upon arrival to the ED should undergo RT selectively based on injury and duration of CPR (Fig. 7-11). RT is best accomplished using a generous left anterolateral thoracotomy, with the skin incision started to the right of the sternum (Fig. 7-12). A longitudinal peri-cardiotomy anterior to the phrenic nerve is used to release cardiac tamponade and permits access to the heart for cardiac repair and open cardiac massage. The cardiac wound should be repaired prior to vigorous efforts of myocardial resuscitation (e.g., epinephrine, calcium). Cross-clamping of the aorta improves central circula-tion, augments cerebral and coronary blood flow, and limits further abdominal blood loss (Fig. 7-13). The patient must sustain a SBP of 70 mmHg after RT and associated interventions to be considered


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Surgery_Schwartz. augments cerebral and coronary blood flow, and limits further abdominal blood loss (Fig. 7-13). The patient must sustain a SBP of 70 mmHg after RT and associated interventions to be considered resuscitable, and hence transported to the OR.18,19Disability and Exposure. The Glasgow Coma Scale (GCS) score should be determined for all injured patients (Table 7-3). It is calculated by adding the scores of the best motor response, best verbal response, and the best eye response. Scores range from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and ≤8 severe injury. The GCS is a quantifiable determination of neurologic function that is useful for triage, treatment, and prognosis.Neurologic evaluation, including spinal cord integrity, is critical before administration of neuromuscular blockade for intubation. Subtle changes in mental status can be caused by hypoxia, hypercarbia, or hypovolemia, or may be an early sign of increasing


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Surgery_Schwartz. critical before administration of neuromuscular blockade for intubation. Subtle changes in mental status can be caused by hypoxia, hypercarbia, or hypovolemia, or may be an early sign of increasing intracranial pressure. An abnormal mental status should prompt an immediate reevaluation of the patient’s ABCs and consideration of central nervous system injury. Deterioration in mental status may be subtle and may not progress in a predict-able fashion. For example, previously calm, cooperative patients may become anxious and combative as they become hypoxic. However, a patient who is agitated and combative from drugs or alcohol may become somnolent if hypovolemic shock develops. Patients with neurogenic shock are typified by hypotension with relative bradycardia, and are often first recognized due to paraly-sis, decreased rectal tone, or priapism. Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to physiologic disruption of sympathetic fibers;


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Surgery_Schwartz. due to paraly-sis, decreased rectal tone, or priapism. Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to physiologic disruption of sympathetic fibers; treatment consists of volume loading and a dopamine infusion, which is both inotropic and chronotropic, as well as a vasoconstrictor.Seriously injured patients must have all of their clothing removed to avoid overlooking limbor life-threatening injuries, but warmed blankets should be placed immediately to avoid hypothermia.Shock Classification and Initial Fluid Resuscitation. Classic signs and symptoms of shock are tachycardia, hypoten-sion, tachypnea, altered mental status, diaphoresis, and pallor PatientUndergoingCPR–No Signs ofLife*Blunt TraumaCPR <10 min----------Penetrating Torso TraumaCPR <15 min----------Penetrating Non-Torso TraumaCPR <5 minResuscitative ThoracotomyYesDeadCardiacActivity?NoTamponade?NoRepair HeartAssessViabilityYesORThoracicHemorrhageAir


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Surgery_Schwartz. Torso TraumaCPR <15 min----------Penetrating Non-Torso TraumaCPR <5 minResuscitative ThoracotomyYesDeadCardiacActivity?NoTamponade?NoRepair HeartAssessViabilityYesORThoracicHemorrhageAir EmboliTamponadeExtrathoracicHemorrhageSBP <70,apply aorticX-clampHilar X-clampControlNoYes*no respiratory ormotor effort, electricalactivity, or pupillaryactivityProfoundRefractoryShockFigure 7-11. Algorithm directing the use of resuscitative thoracotomy (RT) in the injured patient undergoing cardiopulmonary resuscitation (CPR). OR = operating room; SBP = systolic blood pressure.Brunicardi_Ch07_p0183-p0250.indd 19010/12/18 6:17 PM 191TRAUMACHAPTER 7Figure 7-12. A. Resuscitative tho-racotomy (RT) is performed through the fifth intercostal space using the anterolateral approach. B and C. The pericardium is opened anterior to the phrenic nerve, and the heart is rotated out for evaluation. D. Open cardiac massage should be performed with a hinged, clapping motion of the hands, with sequential closing


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Surgery_Schwartz. is opened anterior to the phrenic nerve, and the heart is rotated out for evaluation. D. Open cardiac massage should be performed with a hinged, clapping motion of the hands, with sequential closing from palms to fingers. The two-handed technique is strongly recommended because the one-handed massage technique poses the risk of myocar-dial perforation with the thumb.Figure 7-13. A. Aortic cross-clamp is applied with the left lung retracted superiorly, below the inferior pulmonary ligament, just above the diaphragm. B. The flaccid aorta is identified as the first structure encountered on top of the spine when approached from the left chest.(Table 7-4). In general, the quantity of acute blood loss cor-relates with physiologic abnormalities. For example, patients in class II shock are tachycardic, but they do not exhibit a reduction in blood pressure until over 1500 mL of blood loss, or class III shock. Physical findings should be used as an aid in the evaluation of the patient’s


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Surgery_Schwartz. tachycardic, but they do not exhibit a reduction in blood pressure until over 1500 mL of blood loss, or class III shock. Physical findings should be used as an aid in the evaluation of the patient’s response to treatment. The goal of fluid resuscitation is to re-establish tissue perfusion. Fluid resuscitation usually begins with isotonic crystalloid, typically Ringer’s lactate. However, for patients arriving in shock (persistent SBP <90 mmHg in an adult), instead of crystalloid the current practice is to activate a massive trans-fusion protocol (MTP) in which red blood cells (RBC) and fresh frozen plasma (FFP) are administered. The details of a MTP are discussed later. Patients who have a good response to Brunicardi_Ch07_p0183-p0250.indd 19110/12/18 6:17 PM 192BASIC CONSIDERATIONSPART Ifluid infusion (i.e., normalization of vital signs, clearing of the sensorium) and evidence of good peripheral perfusion (warm extremities with normal capillary refill) are presumed to have adequate


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Surgery_Schwartz. infusion (i.e., normalization of vital signs, clearing of the sensorium) and evidence of good peripheral perfusion (warm extremities with normal capillary refill) are presumed to have adequate overall perfusion. Urine output is a reliable indicator of organ perfusion but requires time to quantitate. Adequate urine output is 0.5 mL/kg per hour in an adult, 1 mL/kg per hour in a child, and 2 mL/kg per hour in an infant <1 year of age. Because measurement of this resuscitation-related vari-able is time dependent, it is generally more useful in the OR and intensive care unit (ICU) setting, than in initial evaluation in the trauma bay.There are several caveats to be considered when evaluat-ing the injured patient for shock. Tachycardia (HR >110 bpm) is often the earliest sign of ongoing blood loss, but the critical issue is change in HR over time. Individuals in good physical condition with a resting pulse rate in the 50s may manifest a relative tachycardia in the 90s; although clinically


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Surgery_Schwartz. loss, but the critical issue is change in HR over time. Individuals in good physical condition with a resting pulse rate in the 50s may manifest a relative tachycardia in the 90s; although clinically significant, this does not meet the standard definition of tachycardia. Con-versely, patients on cardiac medications such as β-blockers may not be capable of increasing their heart rate to compensate for hypovolemia. Bradycardia can occur with rapid severe blood loss13; this is an ominous sign, often heralding impending car-diovascular collapse. Other physiologic stresses, aside from hypovolemia, may produce tachycardia, such as hypoxia, pain, anxiety, and stimulant drugs (cocaine, amphetamines). As noted previously, decreased SBP is not a reliable early sign of hypo-volemia because blood loss must exceed 30% before hypoten-sion is evident. Additionally, younger patients may maintain their SBP due to sympathetic tone despite severe intravascular deficits until they are on the verge of


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Surgery_Schwartz. loss must exceed 30% before hypoten-sion is evident. Additionally, younger patients may maintain their SBP due to sympathetic tone despite severe intravascular deficits until they are on the verge of cardiac arrest. Pregnant Table 7-3Glasgow Coma ScaleaADULTSINFANTS/CHILDRENEye opening4SpontaneousSpontaneous3To voiceTo voice2To painTo pain1NoneNoneVerbal5OrientedAlert, normal vocalization4ConfusedCries, but consolable3Inappropriate wordsPersistently irritable2Incomprehensible wordsRestless, agitated, moaning1NoneNoneMotor response6Obeys commandsSpontaneous, purposeful5Localizes painLocalizes pain4WithdrawsWithdraws3Abnormal flexionAbnormal flexion2Abnormal extensionAbnormal extension1NoneNoneaScore is calculated by adding the scores of the best motor response, best verbal response, and eye opening. Scores range from 3 (the lowest) to 15 (normal).Table 7-4Signs and symptoms of advancing stages of hemorrhagic shockCLASS ICLASS IICLASS IIICLASS IVBlood loss (mL)Up to


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Surgery_Schwartz. response, and eye opening. Scores range from 3 (the lowest) to 15 (normal).Table 7-4Signs and symptoms of advancing stages of hemorrhagic shockCLASS ICLASS IICLASS IIICLASS IVBlood loss (mL)Up to 750750–15001500–2000>2000Blood loss (% BV)Up to 15%15%–30%30%–40%>40%Pulse rate<100>100>120>140Blood pressureNormalNormalDecreasedDecreasedPulse pressure (mmHg)Normal or increasedDecreasedDecreasedDecreasedRespiratory rate14–20>20–3030–40>35Urine output (mL/h)>30>20–305–15NegligibleCNS/mental statusSlightly anxiousMildly anxiousAnxious and confusedConfused and lethargicBV = blood volume; CNS = central nervous system.Brunicardi_Ch07_p0183-p0250.indd 19210/12/18 6:17 PM 193TRAUMACHAPTER 7patients have a progressive increase in circulating blood volume over gestation; therefore, they must lose a relatively larger vol-ume of blood before manifesting signs and symptoms of hypo-volemia (see “Special Populations”).Based on the initial response to fluid resuscitation, hypo-volemic injured


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Surgery_Schwartz. lose a relatively larger vol-ume of blood before manifesting signs and symptoms of hypo-volemia (see “Special Populations”).Based on the initial response to fluid resuscitation, hypo-volemic injured patients can be separated into three broad cat-egories: responders, transient responders, and nonresponders. Individuals who are stable or have a good response to initial fluid therapy as evidenced by normalization of vital signs, men-tal status, and urine output are unlikely to have significant ongo-ing hemorrhage, and further diagnostic evaluation for occult injuries can proceed in an orderly fashion (see “Secondary Sur-vey”). At the other end of the spectrum are patients classified as “nonresponders” who have persistent hypotension despite aggressive resuscitation. These patients mandate immediate identification of the source of hypotension with appropriate intervention to prevent a fatal outcome. Transient responders are those who respond initially to volume loading with improve-ment


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Surgery_Schwartz. identification of the source of hypotension with appropriate intervention to prevent a fatal outcome. Transient responders are those who respond initially to volume loading with improve-ment in vital signs, but subsequently deteriorate hemodynami-cally. This group of patients can be challenging to triage for definitive management.Persistent Hypotension. Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require systematic evaluation and prompt intervention. The spectrum of disease in patients with persistent hypotension ranges from easily reversible problems such as a tension pneu-mothorax to multisystem injury with a number of sites of ongo-ing active hemorrhage. One must first consider the dominant categories of postinjury shock that may be the underlying cause: hemorrhagic, cardiogenic, and neurogenic. In patients with per-sistent hypotension and tachycardia, cardiogenic or hemorrhagic shock are the likely causes. Ultrasound


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Surgery_Schwartz. may be the underlying cause: hemorrhagic, cardiogenic, and neurogenic. In patients with per-sistent hypotension and tachycardia, cardiogenic or hemorrhagic shock are the likely causes. Ultrasound evaluation of the pericar-dium, pleural cavities, and abdomen in combination with plain radiographs of the chest and pelvis will usually identify the source of shock. In patients with persistent hypotension follow-ing blunt trauma, the pelvis should be wrapped with a sheet for stabilization until radiography can be done; external blood loss should be controlled, and extremity fractures should be splinted to minimize further blood loss. Evaluation of the CVP or ultra-sound of the IVC may further assist in distinguishing between cardiogenic and hypovolemic shock. Base deficit measurement is critical; a base deficit of >8 mmol/L implies ongoing cellular shock.21,22 Serum lactate also is used to monitor the patient’s physiologic response to resuscitation.23 Evolving technology, such as


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Surgery_Schwartz. is critical; a base deficit of >8 mmol/L implies ongoing cellular shock.21,22 Serum lactate also is used to monitor the patient’s physiologic response to resuscitation.23 Evolving technology, such as measurement of the critical reserve index, may provide noninvasive monitoring.24The differential diagnosis of cardiogenic shock in the trauma patient is: (a) tension pneumothorax, (b) pericardial tam-ponade, (c) blunt cardiac injury, (d) myocardial infarction, and (e) bronchovenous air embolism. Tension pneumothorax, the most frequent cause of cardiac failure, and pericardial tampon-ade have been discussed earlier. Although as many as one-third of patients sustaining significant blunt chest trauma experience some degree of blunt cardiac injury (BCI), few such injuries result in hemodynamic embarrassment. Patients with electro-cardiographic (ECG) abnormalities or dysrhythmias require continuous ECG monitoring and antidysrhythmic treatment as indicated. Unless myocardial infarction is


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Surgery_Schwartz. embarrassment. Patients with electro-cardiographic (ECG) abnormalities or dysrhythmias require continuous ECG monitoring and antidysrhythmic treatment as indicated. Unless myocardial infarction is suspected, there is no role for routine serial measurement of cardiac enzyme levels—they lack specificity and do not predict significant dysrhythmias.25 In patients with no identified injuries who are being considered for discharge from the ED, the combination of a normal EKG and troponin level rules out significant BCI.26 The patient with hemodynamic instability from BCI requires appropriate resuscitation and may benefit from hemodynamic monitoring to optimize preload and guide inotropic support. Echocardiography (ECHO) is performed to exclude valvular or septal injuries; the most common ECHO finding in BCI is right ventricular dyskinesia due to the anterior orientation of the right ventricle. Transthoracic and transesophageal ECHO are now becoming routine in the trauma bay and surgical


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Surgery_Schwartz. finding in BCI is right ventricular dyskinesia due to the anterior orientation of the right ventricle. Transthoracic and transesophageal ECHO are now becoming routine in the trauma bay and surgical intensive care unit (SICU).27,28 Rarely, patients with refractory cardio-genic shock may require placement of an intra-aortic balloon pump to enhance coronary perfusion and decrease myocardial work. Acute myocardial infarction may be the cause of a motor vehicle collision or other trauma in older patients. Although optimal initial management includes treatment for the evolving infarction, such as thrombolytic therapy, anticoagulation, and emergent angioplasty, these decisions must be individualized in accordance with the patient’s other injuries.Bronchovenous air embolism is a frequently overlooked lethal complication of pulmonary injury. Air emboli can occur after blunt or penetrating trauma, when air from an injured bron-chus enters an adjacent injured pulmonary vein and returns air to


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Surgery_Schwartz. lethal complication of pulmonary injury. Air emboli can occur after blunt or penetrating trauma, when air from an injured bron-chus enters an adjacent injured pulmonary vein and returns air to the left heart. Air accumulation in the left ventricle impedes diastolic filling, and during systole air is pumped into the coro-nary arteries, disrupting coronary perfusion. The typical case is a patient with a penetrating thoracic injury who is hemody-namically stable but experiences sudden cardiac arrest after being intubated and placed on positive pressure ventilation. The patient should be placed immediately in Trendelenburg’s posi-tion to trap the air in the apex of the left ventricle. Emergency thoracotomy is followed by cross-clamping of the pulmonary hilum on the side of the injury to prevent further introduction of air (Fig. 7-14). Air is aspirated from the apex of the left ventricle and then the aortic root with an 18-gauge needle and 50-mL syringe. Vigorous massage is used to force


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Surgery_Schwartz. further introduction of air (Fig. 7-14). Air is aspirated from the apex of the left ventricle and then the aortic root with an 18-gauge needle and 50-mL syringe. Vigorous massage is used to force the air bubbles through the coronary arteries; if this is unsuccessful, a tuber-culin syringe is used to aspirate air bubbles from the coronary artery (most common is the right). Once circulation is restored, the patient should be kept in Trendelenburg’s position with the pulmonary hilum clamped until the pulmonary venous injury is controlled operatively.Persistent hypotension due to uncontrolled hemorrhage is associated with high mortality. A rapid search for the source or sources of hemorrhage includes visual inspection with knowledge of the injury mechanism, eFAST, and chest and pelvic radiographs. During diagnostic evaluation, type O RBCs (O-negative for women of childbearing age) and thawed AB plasma should be administered at a ratio of 2:1. Type-specific RBCs should be administered as


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Surgery_Schwartz. During diagnostic evaluation, type O RBCs (O-negative for women of childbearing age) and thawed AB plasma should be administered at a ratio of 2:1. Type-specific RBCs should be administered as soon as available. The acute coagulopathy of trauma is now well recognized and underscores the importance of preemptive blood component administration.29 The resurgent interest in viscoelastic hemostatic assays (throm-belastography [TEG] and thrombelastometry [ROTEM]) has facilitated the appropriate and timely use of clotting adjuncts, including the prompt recognition of fibrinolysis.30 In patients with clear indications for operation, essential radiographs should be taken, and the patient should be transported to the OR imme-diately. Such patients include those with blunt trauma and mas-sive hemothorax, those with penetrating trauma and an initial chest tube output of >1 L, and those with abdominal trauma and ultrasound evidence of extensive hemoperitoneum. In patients with gunshot wounds to


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Surgery_Schwartz. those with penetrating trauma and an initial chest tube output of >1 L, and those with abdominal trauma and ultrasound evidence of extensive hemoperitoneum. In patients with gunshot wounds to the chest or abdomen, a chest and 4Brunicardi_Ch07_p0183-p0250.indd 19310/12/18 6:17 PM 194BASIC CONSIDERATIONSPART Iabdominal film, with radiopaque markers at the wound sites, should be obtained to determine the trajectory of the bullet or location of a retained fragment prior to transport to the OR. For example, a patient with a gunshot wound to the upper abdo-men should have a chest radiograph to ensure that the bullet did not traverse the diaphragm causing intrathoracic injury. Simi-larly, a chest radiograph is important in a patient with a gunshot wound to the right chest to evaluate the left hemithorax. If a patient arrives with a penetrating weapon remaining in place, the weapon should not be removed in the ED because it could be tamponading a lacerated blood vessel (Fig. 7-15). The


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Surgery_Schwartz. hemithorax. If a patient arrives with a penetrating weapon remaining in place, the weapon should not be removed in the ED because it could be tamponading a lacerated blood vessel (Fig. 7-15). The sur-geon should extract the offending instrument in the controlled environment of the OR, ideally once an incision has been made with adequate exposure for vascular control. In situations where knives are embedded in the head or neck, preoperative imaging may be useful to anticipate arterial injuries.In patients with persistent hypotension and no clear operative indications, one should systematically evaluate the five potential sources of blood loss: scalp, chest, abdomen, pelvis, and extremities. Significant bleeding at the scene may be reported by paramedics, but its quantification is unreliable. Examination should exclude active bleeding from a scalp lac-eration that may be readily controlled with clips or staples. Thoracoabdominal trauma should be evaluated with a combi-nation of eFAST,


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Surgery_Schwartz. Examination should exclude active bleeding from a scalp lac-eration that may be readily controlled with clips or staples. Thoracoabdominal trauma should be evaluated with a combi-nation of eFAST, chest radiograph, and pelvic radiograph. If the FAST results are negative and no other source of hypo-tension is obvious, diagnostic peritoneal aspiration should be entertained.31 Extremity examination and radiographs should be used to identify associated fractures. Fracture-related blood loss, when additive, may be a potential source of the patient’s hemodynamic instability. Each rib fracture can produce 100 to 200 mL of blood loss; for tibial fractures, 300 to 500 mL; for Figure 7-14. A. A Satinsky clamp is used to clamp the pulmonary hilum to prevent further bronchovenous air embolism. B. Sequential sites of aspiration include the left ventricle, the aortic root, and the right coronary artery.Figure 7-15. If a weapon is still in place, it should be removed in the operating room because it


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Surgery_Schwartz. sites of aspiration include the left ventricle, the aortic root, and the right coronary artery.Figure 7-15. If a weapon is still in place, it should be removed in the operating room because it could be tamponading a lacerated blood vessel.Brunicardi_Ch07_p0183-p0250.indd 19410/12/18 6:17 PM 195TRAUMACHAPTER 7femur fractures, 800 to 1000 mL; and for pelvic fractures >2000 mL. Although no single injury can account for the patient’s hemo-dynamic instability, the sum of the injuries may result in life-threatening blood loss. The diagnostic measures advocated earlier are those that can be easily performed in the trauma bay. Transport of a hypotensive patient out of the ED for CT scan-ning is hazardous; monitoring is compromised, and the envi-ronment is suboptimal for dealing with acute problems. Fast track CT scanning should be used in all patients manifesting evidence of shock. The surgeon must accompany the patient and be prepared to abort the CT scan with diversion to the OR. This


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Surgery_Schwartz. Fast track CT scanning should be used in all patients manifesting evidence of shock. The surgeon must accompany the patient and be prepared to abort the CT scan with diversion to the OR. This dilemma is becoming less common in many trauma centers where CT scanning is available in the ED.The concept of hypotensive resuscitation remains contro-versial, and it is primarily relevant for patients with penetrating vascular injuries. Experimental work suggests that an endog-enous sealing clot of an injured artery may be disrupted at a SBP of >90 mmHg32; thus, many believe that this should be the preoperative blood pressure target for patients with potential noncompressible arterial injuries. On the other hand, optimal management of traumatic brain injury (TBI) includes maintain-ing the SBP >100 mmHg,33 and thus, hypotensive resuscitation is not appropriate for most blunt trauma patients.Secondary SurveyOnce the immediate threats to life have been addressed, a thor-ough history is obtained,


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Surgery_Schwartz. mmHg,33 and thus, hypotensive resuscitation is not appropriate for most blunt trauma patients.Secondary SurveyOnce the immediate threats to life have been addressed, a thor-ough history is obtained, and the patient is examined in a sys-tematic fashion. The patient and surrogates should be queried to obtain an AMPLE history (Allergies, Medications, Past illnesses or Pregnancy, Last meal, and Events related to the injury). The physical examination should be literally head to toe, with special attention to the patient’s back, axillae, and perineum, because injuries here are easily overlooked. All seriously injured patients should undergo digital rectal examination to evaluate for sphincter tone, presence of blood, rectal perforation, or a high-riding prostate; this is particularly critical in patients with suspected spinal cord injury, pelvic fracture, or transpelvic gun-shot wounds. Vaginal examination with a speculum should be performed in women with pelvic fractures to exclude an open


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Surgery_Schwartz. patients with suspected spinal cord injury, pelvic fracture, or transpelvic gun-shot wounds. Vaginal examination with a speculum should be performed in women with pelvic fractures to exclude an open fracture. Specific injuries, their associated signs and symptoms, diagnostic options, and treatments are discussed in detail later in this chapter.Adjuncts to the physical examination include vital sign and ECG monitoring, nasogastric tube placement, Foley cath-eter placement, radiographs, hemoglobin, base deficit measure-ments, urinalysis, and repeat FAST exam. A nasogastric tube should be inserted in all intubated patients to decrease the risk of gastric aspiration, but it may not be necessary in the awake patient. Nasogastric tube placement in patients with complex mid-facial fractures is contraindicated; rather, a tube should be placed orally if required. Nasogastric tube evaluation of stomach contents for blood may suggest occult gastroduodenal injury, or the errant path of the


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Surgery_Schwartz. is contraindicated; rather, a tube should be placed orally if required. Nasogastric tube evaluation of stomach contents for blood may suggest occult gastroduodenal injury, or the errant path of the nasogastric tube on a chest film may indicate a left diaphragm injury. A Foley catheter should be inserted in patients unable to void to decompress the blad-der, obtain a urine specimen, and monitor urine output. Gross hematuria demands evaluation of the genitourinary system for injury. Foley catheter placement may be deferred until urologic evaluation in patients with signs of urethral injury: blood at the meatus, perineal or scrotal hematomas, or a high-riding prostate. Although policies vary at individual institutions, most agree that patients in extremis should undergo one attempt at Foley catheter placement; if the catheter does not pass easily, a supra-pubic cystostomy should be considered.Selective radiography and laboratory tests are done early in the evaluation after the primary


Surgery_Schwartz

Surgery_Schwartz. catheter placement; if the catheter does not pass easily, a supra-pubic cystostomy should be considered.Selective radiography and laboratory tests are done early in the evaluation after the primary survey. For patients with severe blunt trauma, chest and pelvic radiographs should be obtained. Historically, a lateral cervical spine radiograph was also obtained, hence the reference to the big three films, but currently patients preferentially undergo CT scanning of the spine rather than plain film radiography. For patients with truncal gunshot wounds, anteroposterior and at times lateral radiographs of the chest and abdomen are warranted. It is important to mark the entrance and exit sites of penetrating wounds with ECG pads, metallic clips, or staples so that the trajectory of the missile can be estimated. Limited one-shot extremity radiographs may also be appropriate to assist in application of a splint. In critically injured patients, blood samples for a routine trauma panel (type