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Surgery_Schwartz. pelvic sta-bilization should be done before radiographic confirmation. If the patient’s primary source of bleeding is the fracture-related pelvic hematoma, several options exist for hemorrhage control. Because 85% of bleeding due to pelvic fractures is venous or bony in ori-gin, the authors advocate immediate external fixation and pre-peritoneal pelvic packing.141 Anterior external fixation decreases pelvic volume, which promotes tamponade of venous bleeding and prevents secondary hemorrhage from the shifting of bony ele-ments. Pelvic packing, in which six laparotomy pads (four in chil-dren) are placed directly into the paravesical space through a small anterior suprapubic incision, provides tamponade for the bleeding (Fig. 7-71). Pelvic packing also eliminates the often difficult deci-sion by the trauma surgeon: OR vs. interventional radiology? All patients can be rapidly transported to the OR, and packing can be accomplished in under 30 minutes. In the authors’ experience, this


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Surgery_Schwartz. by the trauma surgeon: OR vs. interventional radiology? All patients can be rapidly transported to the OR, and packing can be accomplished in under 30 minutes. In the authors’ experience, this results in hemodynamic stability and abrupt cessation of the need for ongoing blood transfusion in the majority of cases.141 Patients also can undergo additional procedures such as laparotomy, tho-racotomy, external fixation of extremity fractures, fasciotomy, revascularization, or craniotomy. Following pelvic packing, angi-ography is reserved for patients with evidence of ongoing pelvic bleeding after admission to the SICU (>4 units of RBCs in the first 12 postoperative hours after the coagulopathy is corrected). Patients undergo standard posttrauma resuscitative SICU care, and the pelvic packs are removed within 48 hours; prior to unpacking, however, the patient’s coagulopathy should be corrected to pre-vent the need for repacking of the pelvic space. Repacking of the pelvic space is


Surgery_Schwartz

Surgery_Schwartz. packs are removed within 48 hours; prior to unpacking, however, the patient’s coagulopathy should be corrected to pre-vent the need for repacking of the pelvic space. Repacking of the pelvic space is associated with an infection rate of 47% and should be avoided; directed hemostasis with topical agents, suture repair, or electrocautery at pelvic pack removal should be performed.Another clinical challenge is the open pelvic fracture. In many instances, the wounds are located in the perineum, and the risk of pelvic sepsis and osteomyelitis is high. To reduce Brunicardi_Ch07_p0183-p0250.indd 23410/12/18 6:21 PM 235TRAUMACHAPTER 7the risk of infection, performance of a diverting sigmoid colos-tomy is recommended. The pelvic wound is manually debrided and then irrigated daily with a high-pressure pulsatile irrigation system until granulation tissue covers the wound. The wound is then left to heal by secondary intention with a wound vacuum-assisted wound closure (VAC) device.Extremity


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Surgery_Schwartz. pulsatile irrigation system until granulation tissue covers the wound. The wound is then left to heal by secondary intention with a wound vacuum-assisted wound closure (VAC) device.Extremity Vascular Injuries, Fractures, and Compartment SyndromesPatients with injured extremities often require a multidisci-plinary approach with involvement of trauma, orthopedic, and plastic surgeons to address vascular injuries, fractures, soft tis-sue injuries, and compartment syndromes. Immediate stabili-zation of fractures or unstable joints is done in the ED using Hare traction, knee immobilizers, or plaster splints. In patients with open fractures, the wound should be covered with povido-neiodine (Betadine)-soaked gauze and antibiotics administered. Options for fracture fixation include external fixation or open reduction and internal fixation with plates or intramedullary nails. Vascular injuries, either isolated or in combination with fractures, require emergent repair. Common combined injuries


Surgery_Schwartz

Surgery_Schwartz. or open reduction and internal fixation with plates or intramedullary nails. Vascular injuries, either isolated or in combination with fractures, require emergent repair. Common combined injuries include clavicle/first rib fractures and subclavian artery injuries, dislocated shoulder/proximal humeral fractures and axillary artery injuries, supracondylar fractures/elbow dislocations and brachial artery injuries, femur fracture and superficial femoral artery injuries, and knee dislocation and popliteal vessel inju-ries. On-table angiography in the OR facilitates rapid interven-tion and is warranted in patients with evidence of limb threat on arrival. Arterial access for on-table lower extremity angiography can be obtained percutaneously at the femoral vessels with a standard arterial catheter, via femoral vessel exposure and direct cannulation, or with superficial femoral artery (SFA) exposure just above the medial knee. Controversy exists regarding which should be done first, fracture


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Surgery_Schwartz. via femoral vessel exposure and direct cannulation, or with superficial femoral artery (SFA) exposure just above the medial knee. Controversy exists regarding which should be done first, fracture fixation or arterial repair. The authors prefer placement of temporary intravascular shunts first to reestablish arterial flow and minimize ischemia during frac-ture treatment, with definitive vascular repair following. Rarely, immediate amputation may be considered due to the severity of orthopedic and neurovascular injuries. This is particularly true if primary nerve transection is present in addition to fracture and arterial injury.142 Collaborative decision making by the trauma, orthopedic, and plastic/reconstructive team is essential.FAST ExamPositiveNegative2 units RBCs/ED trauma bayHD StableHD StableHD StableHD UnstableHD UnstableResuscitate in the SICU + CT scansOperating Room:Exploratory LaparotomyIf Pelvic Hematoma Evident ˜Pelvic Fixation and Pelvic PackingHD UnstableOngoing


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Surgery_Schwartz. StableHD StableHD StableHD UnstableHD UnstableResuscitate in the SICU + CT scansOperating Room:Exploratory LaparotomyIf Pelvic Hematoma Evident ˜Pelvic Fixation and Pelvic PackingHD UnstableOngoing Transfusion Requirements after Pelvic Packing?(>4 units RBCs from pelvic source with normal coags in 12 hours)NoAngiographySICUYesDenver Health Unstable Pelvic Fracture ManagementResuscitate with 2 L crystalloid – measure base deÿcit – rule out thoracic source – sheet the pelvis.Transfuse fresh frozen plasma (FFP) and RBC 1:2; 1 apheresis unit of platelets for each 5 units RBCs; perform thromboelastography.Immediate notiÿcation: Attending Trauma Surgeon, Attending Orthopedic Surgeon, Operating Room, Blood BankPlace 7Fr Terumo arterial sheath if SBP <90 mmHg; consider REBOA if SBP <80 mmHg Operating Room:Pelvic Fixation and Pelvic PackingReultrasound AbdomenFigure 7-70. Management algorithm for patients with pelvic fractures with hemodynamic instability. CT = computed tomography; ED =


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Surgery_Schwartz. Operating Room:Pelvic Fixation and Pelvic PackingReultrasound AbdomenFigure 7-70. Management algorithm for patients with pelvic fractures with hemodynamic instability. CT = computed tomography; ED = emergency department; FAST = focused abdominal sonography for trauma; HD = hemodynamic; PLT = platelets; PRBCs = packed red blood cells; SICU = surgical intensive care unit.Brunicardi_Ch07_p0183-p0250.indd 23510/12/18 6:21 PM 236BASIC CONSIDERATIONSPART IOperative intervention for vascular injuries should follow standard principles of repair (see “Vascular Repair Techniques”). For subclavian or axillary artery repairs, 6-mm PTFE graft or RSVG are used depending on the location. Because associated injuries of the brachial plexus are common, a thorough neuro-logic examination of the extremity is mandated before operative intervention. Operative approach for a brachial artery injury is via a medial upper extremity longitudinal incision; proximal control may be obtained at the axillary


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Surgery_Schwartz. is mandated before operative intervention. Operative approach for a brachial artery injury is via a medial upper extremity longitudinal incision; proximal control may be obtained at the axillary artery, and an S-shaped exten-sion through the antecubital fossa provides access to the distal brachial artery. The injured vessel segment is excised, and an end-to-end interposition RSVG graft is performed. Upper extremity fasciotomy is rarely required because of the rich collateral per-fusion via the profunda. For SFA injuries, external fixation of the femur typically is performed, followed by end-to-end RSVG of the injured SFA segment. Close monitoring for calf compart-ment syndrome is mandatory. Preferred access to the popliteal space for an acute injury is the medial, one-incision approach with detachment of the semitendinosus, semimembranosus, and gracilis muscles (Fig. 7-72). Another option is a medial approach Figure 7-71. A. Pelvic packing is performed through a 6to 8-cm midline


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Surgery_Schwartz. with detachment of the semitendinosus, semimembranosus, and gracilis muscles (Fig. 7-72). Another option is a medial approach Figure 7-71. A. Pelvic packing is performed through a 6to 8-cm midline incision made from the pubic symphysis cephalad, with division of the midline fascia. B. The pelvic hematoma often dissects the preperitoneal and paravesical space down to the presacral region, which facilitates packing; alternatively, blunt digital dissection opens the preperitoneal space for packing. C. Three standard surgical laparotomy pads are placed on each side of the bladder, deep within the preperitoneal space; the fascia is closed with an O polydioxanone monofilament suture and the skin with staples.Figure 7-72. A. The popliteal space is commonly accessed using a single medial incision (the detached semitendinosus, semimembranosus, and gracilis muscles are identified by different suture types). B. Alternatively, a medial approach with two incisions may be used. Insertion of a


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Surgery_Schwartz. (the detached semitendinosus, semimembranosus, and gracilis muscles are identified by different suture types). B. Alternatively, a medial approach with two incisions may be used. Insertion of a Pruitt-Inahara shunt (arrow) provides temporary restoration of blood flow, which prevents ischemia during fracture treatment.Brunicardi_Ch07_p0183-p0250.indd 23610/12/18 6:21 PM 237TRAUMACHAPTER 7Table 7-11Arterial vasospasm treatment guidelineStep 1: Intra-arterial alteplase (tissue plasminogen activator) 5 mg/20 mL bolusIf spasm continues, proceed to step 2.Step 2: Intra-arterial nitroglycerin 200 μg/20 mL bolusRepeat same dose once as needed.If spasm continues, proceed to step 3.Step 3: Interarterial verapamil 10 mg/10 mL bolusIf spasm continues, proceed to step 4.Step 4: Interarterial papaverine drip 60 mg/50 mL given over 15 minwith two incisions using a longer RSVG, but this requires interval ligation of the popliteal artery and geniculate branches. Rarely, with open wounds a straight


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Surgery_Schwartz. drip 60 mg/50 mL given over 15 minwith two incisions using a longer RSVG, but this requires interval ligation of the popliteal artery and geniculate branches. Rarely, with open wounds a straight posterior approach with an S-shaped incision can be used. If the patient has an associated popliteal vein injury, this should be repaired first with a PTFE interposition graft while the artery is shunted. For an isolated popliteal artery injury, RSVG is performed with an end-to-end anastomosis. Compart-ment syndrome is common, and presumptive four-compartment fasciotomies are warranted in patients with combined arterial and venous injury. Once the vessel is repaired and restoration of arte-rial flow documented, completion angiography should be done in the OR if there is no palpable distal pulse. Vasoparalysis with verapamil, nitroglycerin, and papaverine may be used to treat vasoconstriction (Table 7-11).Compartment syndromes, which can occur anywhere in the extremities, involve an acute


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Surgery_Schwartz. Vasoparalysis with verapamil, nitroglycerin, and papaverine may be used to treat vasoconstriction (Table 7-11).Compartment syndromes, which can occur anywhere in the extremities, involve an acute increase in pressure inside a closed space, which impairs blood flow to the structures within. Causes of compartment syndrome include arterial hemorrhage into a compartment, venous ligation or thrombosis, crush inju-ries, and reperfusion injury. In conscious patients, pain is the prominent symptom, and active or passive motion of muscles in the involved compartment increases the pain. Paresthesias may also be described. In the lower extremity, numbness between the first and second toes is the hallmark of early compartment syndrome in the exquisitely sensitive anterior compartment and its enveloped deep peroneal nerve. Progression to paralysis can occur, and loss of pulses is a late sign. In comatose or obtunded patients, the diagnosis is more difficult to secure. In patients with a compatible


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Surgery_Schwartz. deep peroneal nerve. Progression to paralysis can occur, and loss of pulses is a late sign. In comatose or obtunded patients, the diagnosis is more difficult to secure. In patients with a compatible history and a tense extremity, compartment pressures should be measured with a hand-held Stryker device. Fasciotomy is indicated in patients with a gradient of <30 mmHg (gradient = diastolic pressure − compartment pressure), an abso-lute compartment pressure >30 mmHg, ischemic periods of >6 hours, or combined arterial and venous injuries. The lower extremity is most frequently involved, and compartment release is performed using a two-incision, four-compartment fasciotomy (Fig. 7-73). Of note, the soleus muscle must be detached from the tibia to decompress the deep flexor compartment.SURGICAL INTENSIVE CARE MANAGEMENTPostinjury ResuscitationICU management of the trauma patient, either with direct admis-sion from the ED or after emergent operative intervention, is considered in distinct


Surgery_Schwartz

Surgery_Schwartz. INTENSIVE CARE MANAGEMENTPostinjury ResuscitationICU management of the trauma patient, either with direct admis-sion from the ED or after emergent operative intervention, is considered in distinct phases because there are differing goals and priorities. The period of acute resuscitation, typically last-ing for the first 12 to 24 hours after injury, combines several key principles: optimizing tissue perfusion, ensuring normother-mia, and restoring coagulation status.143 There are a multitude of management algorithms aimed at accomplishing these goals, the majority of which involve goal-directed resuscitation with initial volume loading to attain adequate preload, followed by judicious use of inotropic agents or vasopressors.144 Although the optimal hemoglobin level remains debated, during shock resuscitation a hemoglobin level of >10 g/dL is generally accepted to optimize hemostasis and ensure adequate oxygen delivery. After the first 24 hours of resuscitation, a more judicious


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Surgery_Schwartz. during shock resuscitation a hemoglobin level of >10 g/dL is generally accepted to optimize hemostasis and ensure adequate oxygen delivery. After the first 24 hours of resuscitation, a more judicious transfusion trigger of a hemoglobin level of <7 g/dL in the euvolemic patient limits the adverse inflammatory effects of stored RBCs. Recent trends have focused on limiting crystalloid loading. In fact, optimiz-ing crystalloid administration is a challenging aspect of early care (i.e., balancing cardiac performance against generation of an abdominal compartment syndrome and generalized tissue edema). Although early colloid administration is appealing, evi-dence to date does not support this concept.Invasive monitoring with pulmonary artery catheters has been supplanted with specialized catheters that measure arte-rial pulse contour analysis; in mechanically ventilated patients, stroke volume (SV) and continuous cardiac output can be mea-sured. A patient’s volume status may be ascertained


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Surgery_Schwartz. that measure arte-rial pulse contour analysis; in mechanically ventilated patients, stroke volume (SV) and continuous cardiac output can be mea-sured. A patient’s volume status may be ascertained by measur-ing the SV following either 10 cc/kg volume bolus or following a passive leg raise, which augments preload by 250 to 500 mL. A change in SV of ≥10% suggests preload responsiveness, and additional resuscitation fluid should be given. Although norepi-nephrine is the agent of choice for patients with low systemic vascular resistance who are unable to maintain a mean arterial pressure of >60 mmHg, patients may have an element of myo-cardial dysfunction requiring inotropic support. The role of rela-tive adrenal insufficiency is another controversial area.Optimal early resuscitation is mandatory and determines when the patient can (a) undergo additional necessary imaging, and (b) be returned to the OR after initial damage control surgery for definitive repair of injuries. Specific goals


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Surgery_Schwartz. and determines when the patient can (a) undergo additional necessary imaging, and (b) be returned to the OR after initial damage control surgery for definitive repair of injuries. Specific goals of resuscitation before repeated “semi-elective” transport include a core tempera-ture of >35°C (95°F), base deficit of <6 mmol/L, and normal coagulation indices. Although correction of metabolic acidosis is desirable, how quickly this should be accomplished requires careful consideration. Adverse sequelae of excessive crystalloid resuscitation include increased intracranial pressure, worsening pulmonary edema, and intra-abdominal visceral and retroperi-toneal edema resulting in secondary abdominal compartment syndrome. Therefore, it should be the overall trend of the resus-citation rather than a rapid reduction of the base deficit that is the goal. The goal is to normalize lactate within 24 hours.145In general, wounds sustained from trauma should be examined daily for progression of healing


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Surgery_Schwartz. rapid reduction of the base deficit that is the goal. The goal is to normalize lactate within 24 hours.145In general, wounds sustained from trauma should be examined daily for progression of healing and signs of infection. Complex soft tissue wounds of the abdomen, such as degloving injuries after blunt trauma (termed Morel-Lavallee lesions146), shotgun wounds, and other destructive blast injuries, are par-ticularly difficult to manage. Following initial debridement of devitalized tissue, wound care includes wet-to-dry dressing changes twice daily or application of a VAC device. Repeated operative debridement may be necessary, and early involvement of the reconstructive surgery service for possible flap cover-age is advised. Midline laparotomy wounds are inspected 48 hours postoperatively by removing the sterile surgical dressing. If an ileostomy or colostomy is required, one should inspect it Brunicardi_Ch07_p0183-p0250.indd 23710/12/18 6:21 PM 238BASIC CONSIDERATIONSPART IFigure


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Surgery_Schwartz. by removing the sterile surgical dressing. If an ileostomy or colostomy is required, one should inspect it Brunicardi_Ch07_p0183-p0250.indd 23710/12/18 6:21 PM 238BASIC CONSIDERATIONSPART IFigure 7-73. A. The anterior and lateral compartments are approached from a lateral incision, with identification of the fascial raphe between the two compartments. Care must be taken to avoid the superficial peroneal nerve running along the raphe. B. To decompress the deep flexor compartment, which contains the tibial nerve and two of the three arteries to the foot, the soleus muscle must be detached from the tibia.daily to ensure that it is viable. If the patient develops a high-grade fever, the wound should be inspected sooner to exclude an early necrotizing infection. If a wound infection is identified—as evidenced by erythema, pain along the wound, or purulent drainage—the wound should be widely opened by removing skin staples. After ensuring that the midline fascia is intact with digital


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Surgery_Schwartz. evidenced by erythema, pain along the wound, or purulent drainage—the wound should be widely opened by removing skin staples. After ensuring that the midline fascia is intact with digital palpation, the wound is initially managed with wet-to-dry dressing changes. The most common intra-abdominal complica-tions are anastomotic failure and abscess. The choice between percutaneous and operative therapy is based on the location, timing, and extent of the collection.Abdominal Compartment SyndromeThe abdominal compartment syndrome is classified as patho-logic intra-abdominal hypertension due to intra-abdominal injury (primary) or splanchnic reperfusion after massive resus-citation (secondary). Secondary abdominal compartment syn-drome may result from any condition requiring extensive crystalloid resuscitation, including extremity trauma, chest trauma, or even postinjury sepsis. The sources of increased intra-abdominal pressure include bowel edema, ascites, bleed-ing, and packs. A diagnosis


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Surgery_Schwartz. resuscitation, including extremity trauma, chest trauma, or even postinjury sepsis. The sources of increased intra-abdominal pressure include bowel edema, ascites, bleed-ing, and packs. A diagnosis of intra-abdominal hypertension cannot reliably be made by physical examination; therefore, it is obtained by measuring the intraperitoneal pressure. The most common technique is to measure the patient’s bladder pressure. Fifty milliliters of saline is instilled into the bladder via the aspi-ration port of the Foley catheter with the drainage tube clamped, and a three-way stopcock and water manometer is placed at the level of the pubic symphysis. Bladder pressure is then measured on the manometer in centimeters of water (Table 7-12) and 10Brunicardi_Ch07_p0183-p0250.indd 23810/12/18 6:21 PM 239TRAUMACHAPTER 7Table 7-12Abdominal compartment syndrome grading systemBLADDER PRESSUREGRADEmmHgcmH2OI10–1513–20II16–2521–35III26–3536–47IV >35 >48˜ Renal blood flow˜ UOPHypoxemia ˛ Airway


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Surgery_Schwartz. PM 239TRAUMACHAPTER 7Table 7-12Abdominal compartment syndrome grading systemBLADDER PRESSUREGRADEmmHgcmH2OI10–1513–20II16–2521–35III26–3536–47IV >35 >48˜ Renal blood flow˜ UOPHypoxemia ˛ Airway pressures ˜ Compliance ˛ PA pressures ˛ CVP readings˜ CO˜ VEDV˜ SV˛ SVR˛ ICPSplanchnicischemiaExtremityischemiaIncreased abdominal pressureIntrathoracic pressure˛Venous return˜Compression of kidneysFigure 7-74. Abdominal compartment syndrome is defined by the end organ sequelae of intra-abdominal hypertension. CO = cardiac output; CVP = central venous pressure; ICP = intracranial pressure; PA = pulmonary artery; SV = stroke volume; SVR = systemic vascular resistance; UOP = urine output; VEDV = ventricular end diastolic volume.correlated with the physiologic sequelae. Conditions in which the bladder pressure is unreliable include bladder rupture, exter-nal compression from pelvic packing, neurogenic bladder, and adhesive disease.Increased abdominal pressure affects multiple organ systems


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Surgery_Schwartz. bladder pressure is unreliable include bladder rupture, exter-nal compression from pelvic packing, neurogenic bladder, and adhesive disease.Increased abdominal pressure affects multiple organ systems (Fig. 7-74). Abdominal compartment syndrome, as noted earlier, is defined as intra-abdominal hypertension suf-ficient to produce physiologic deterioration and manifests via such end-organ sequelae as decreased urine output, increased pulmonary inspiratory pressures, decreased cardiac preload, and decreased cardiac output. Because any of these clinical symptoms of abdominal compartment syndrome may be attributed to the primary injury, a heightened awareness of this syndrome must be maintained. Organ fail-ure can occur over a wide range of recorded bladder pres-sures. Generally, no specific bladder pressure prompts therapeutic intervention, except when the pressure is >35 mmHg. Rather, emergent decompression is carried out when intra-abdominal hypertension reaches a level at which end-organ


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Surgery_Schwartz. pressure prompts therapeutic intervention, except when the pressure is >35 mmHg. Rather, emergent decompression is carried out when intra-abdominal hypertension reaches a level at which end-organ dysfunction occurs. Mortality is directly affected by the timing of decompression, with 70% mortality in patients with a delay in decompression, and nearly uniform mortality in those not undergoing decompression. Decompression is usually performed operatively, either in the ICU if the patient 11is hemodynamically unstable or in the OR. ICU bedside lapa-rotomy is easily accomplished, avoids transport of hemody-namically compromised patients, and requires minimal equipment (e.g., scalpel, suction device, cautery, and dress-ings for temporary abdominal closure). In patients with sig-nificant intra-abdominal fluid as the primary component of abdominal compartment syndrome, rather than bowel or ret-roperitoneal edema, decompression can be accomplished effectively via a percutaneous drain. These


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Surgery_Schwartz. fluid as the primary component of abdominal compartment syndrome, rather than bowel or ret-roperitoneal edema, decompression can be accomplished effectively via a percutaneous drain. These patients are iden-tified by bedside ultrasound, and the morbidity of a laparot-omy is avoided. When operative decompression is required with egress of the abdominal contents, temporary coverage is obtained using a fenestrated subfascial 45 × 60 cm sterile drape and Ioban application (see Fig. 7-49).The performance of damage control surgery and recogni-tion of abdominal compartment syndrome have dramatically improved patient survival, but at the cost of an open abdomen. Several management points deserve attention. Despite having a widely open abdomen, patients can develop recurrent abdomi-nal compartment syndrome, which increases their morbidity and mortality; therefore, bladder pressure should be monitored every 4 hours, with significant increases in pressures alerting the clini-cian to the possible


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Surgery_Schwartz. syndrome, which increases their morbidity and mortality; therefore, bladder pressure should be monitored every 4 hours, with significant increases in pressures alerting the clini-cian to the possible need for repeat operative decompression. Patients with an open abdomen lose between 500 and 2500 mL per day of abdominal effluent. Appropriate volume compensa-tion for this albumin-rich fluid remains controversial, with regard to both the amount administered (replacement based on clinical indices vs. routine 0.5 mL replacement for every milliliter lost) as well as the type of replacement (crystalloid vs. colloid).Following resuscitation and management of specific inju-ries, the goal of the operative team is to close the abdomen as quickly as possible. Multiple techniques have been introduced to obtain fascial closure of the open abdomen to minimize mor-bidity and cost of care. Historically, for patients who could not be closed at repeat operation, approximation of the fascia with mesh


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Surgery_Schwartz. to obtain fascial closure of the open abdomen to minimize mor-bidity and cost of care. Historically, for patients who could not be closed at repeat operation, approximation of the fascia with mesh (prosthetic or biologic) was used, with planned reopera-tion. Another option was split-thickness skin grafts applied directly to the exposed bowel for coverage; removal of the skin Brunicardi_Ch07_p0183-p0250.indd 23910/12/18 6:21 PM 240BASIC CONSIDERATIONSPART Igrafts was planned 9 to 12 months after the initial surgery, with definitive repair of the hernia by component separation. How-ever, delayed abdominal wall reconstruction was resource inva-sive, with considerable patient morbidity. The advent of VAC technology has revolutionized fascial closure. The authors cur-rently use a sequential closure technique with the wound VAC device that is based on constant fascial tension and return to the OR every 48 hours until closure is complete (Fig. 7-75).147 The authors’ success rate with


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Surgery_Schwartz. closure technique with the wound VAC device that is based on constant fascial tension and return to the OR every 48 hours until closure is complete (Fig. 7-75).147 The authors’ success rate with this approach exceeds 95%. This is important because among patients not attaining fascial closure, 20% suffer GI tract complications that prolong their hospital course. These include intra-abdominal abscess, enteric fistula, and bowel perforations (Fig. 7-76). Management requires fre-quent operative or percutaneous drainage of abscesses, control of fistulas, and prolonged nutritional support.SPECIAL POPULATIONSPregnant PatientsDuring pregnancy, 7% of women are injured. Motor vehicle col-lisions and falls are the leading causes of injury, accounting for 70% of cases. Fetal death after trauma most frequently occurs after motor vehicle collisions, but only 11% of fetal deaths are due to the death of the mother; therefore, early trauma resusci-tation and management is directed not only at the


Surgery_Schwartz

Surgery_Schwartz. frequently occurs after motor vehicle collisions, but only 11% of fetal deaths are due to the death of the mother; therefore, early trauma resusci-tation and management is directed not only at the mother but also at the fetus. Domestic violence is also common, affecting between 10% and 30% of pregnant women and resulting in fetal mortality of 5%.Pregnancy results in physiologic changes that may impact postinjury evaluation (Table 7-13). Heart rate increases by 10 to 15 beats per minute during the first trimester and remains elevated until delivery. Blood pressure diminishes during the first two trimesters due to a decrease in systemic vascular resis-tance and rises again slightly during the third trimester (mean values: first = 105/60, second = 102/55, third = 108/67). Intra-vascular volume is increased by up to 8 L, which results in a relative anemia but also a relative hypervolemia. Consequently, a pregnant woman may lose 35% of her blood volume before exhibiting signs of shock.


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Surgery_Schwartz. is increased by up to 8 L, which results in a relative anemia but also a relative hypervolemia. Consequently, a pregnant woman may lose 35% of her blood volume before exhibiting signs of shock. Pregnant patients have an increase in tidal volume and minute ventilation but a decreased functional residual capacity; this results in a diminished PCO2 and respi-ratory alkalosis. Also, pregnant patients may desaturate more rapidly, particularly in the supine position and during intuba-tion. Supplemental oxygen is always warranted in the trauma patient but is particularly critical in the injured pregnant patient because the oxygen dissociation curve is shifted to the left for the fetus compared to the mother (i.e., small changes in maternal oxygenation result in larger changes for the fetus because the fetus is operating in the steep portion of the dissociation curve). Anatomic changes contribute to these pulmonary functional alterations and are relevant in terms of procedures. With the


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Surgery_Schwartz. because the fetus is operating in the steep portion of the dissociation curve). Anatomic changes contribute to these pulmonary functional alterations and are relevant in terms of procedures. With the gravid uterus enlarged, DPL should be performed in a supra-umbilical site with the catheter directed cephalad. In addition, the upward pressure on the diaphragm calls for caution when placing a thoracostomy tube; standard positioning may result in an intra-abdominal location or perforation of the diaphragm.Other physiologic changes during pregnancy affect the GI, renal, and hematologic systems. The lower esophageal sphincter has decreased competency, which increases the risk for aspira-tion. Liver function test values increase, with the alkaline phos-phatase level nearly doubling. The high levels of progesterone impair gallbladder contractions, which results in bile stasis and an increased incidence of gallstone formation; this may not affect the trauma bay evaluation but becomes


Surgery_Schwartz

Surgery_Schwartz. high levels of progesterone impair gallbladder contractions, which results in bile stasis and an increased incidence of gallstone formation; this may not affect the trauma bay evaluation but becomes important in a pro-longed ICU stay. Plasma albumin level decreases from a normal of around 4.3 g/dL to an average of 3.0 g/dL. Renal blood flow increases by 30% during pregnancy, which causes a decrease in serum level of blood urea nitrogen and creatinine. The uterus may also compress the ureters and bladder, causing hydronephro-sis and hydroureter. Finally, as noted earlier there is a relative anemia during pregnancy, but a hemoglobin level of <11 g/dL is considered abnormal. Additional hematologic changes include a moderate leukocytosis (up to 20,000 mm3) and a rela-tive hypercoagulable state due to increased levels of factors VII, VIII, IX, X, and XII and decreased fibrinolytic activity.During evaluation in the ED, the primary and secondary surveys commence, with mindfulness that the


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Surgery_Schwartz. due to increased levels of factors VII, VIII, IX, X, and XII and decreased fibrinolytic activity.During evaluation in the ED, the primary and secondary surveys commence, with mindfulness that the mother always receives priority while conditions are still optimized for the fetus.148 This management includes provision of supplemental oxygen (to prevent maternal and fetal hypoxia), fluid resuscita-tion (the hypervolemia of pregnancy may mask signs of shock), and placement of the patient in the left lateral decubitus posi-tion (or tilting of the backboard to the left) to avoid caval com-pression. Assessment of the fetal heart rate is the most valuable information regarding fetal viability. Fetal monitoring should initially be assessed with bedside FAST ultrasound to document the heart rate of the fetus; subsequent monitoring should be per-formed with a cardiotocographic device that measures both con-tractions and fetal heart tones (FHTs). Because change in heart rate is the primary


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Surgery_Schwartz. of the fetus; subsequent monitoring should be per-formed with a cardiotocographic device that measures both con-tractions and fetal heart tones (FHTs). Because change in heart rate is the primary response of the fetus to hypoxia or hypo-tension, anything above an FHT of 160 is a concern, whereas bradycardia (FHT of <120) is considered fetal distress. Indica-tions for emergent cesarean section include: (a) severe mater-nal shock or impending death (if the fetus is delivered within 5 minutes, survival is estimated at 70%), (b) uterine injury or significant fetal distress (anticipated survival rates of >70% if FHTs are present and fetal gestational age is >28 weeks).149If possible, a member of the obstetrics team should be present during initial evaluation. Vaginal bleeding can signal early cervical dilation and labor, abruptio placentae, or placenta previa. Amniotic sac rupture can result in prolapse of the umbil-ical cord with fetal compromise. Strong contractions are associ-ated with


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Surgery_Schwartz. cervical dilation and labor, abruptio placentae, or placenta previa. Amniotic sac rupture can result in prolapse of the umbil-ical cord with fetal compromise. Strong contractions are associ-ated with true labor and should prompt consideration of delivery and resuscitation of the neonate. Focused prenatal history-taking should elicit a history of pregnancy-induced hypertension, ges-tational diabetes, congenital heart disease, preterm labor, or placental abnormalities. Asking the patient when the baby first moved and if she is currently experiencing movement of the fetus is important. Determining fetal age is key for consider-ations of viability. Gestational age may be estimated by noting fundal height, with the fundus approximating the umbilicus at 20 weeks and the costal margin at 40 weeks. Discrepancy in dates and size may be due to uterine rupture or hemorrhage.Initial evaluation for abdominopelvic trauma in pregnant patients should proceed in the standard manner. Ultrasound (FAST)


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Surgery_Schwartz. Discrepancy in dates and size may be due to uterine rupture or hemorrhage.Initial evaluation for abdominopelvic trauma in pregnant patients should proceed in the standard manner. Ultrasound (FAST) of the abdomen should evaluate the four windows (pericardial, right and left upper quadrant, and bladder) and additionally assess FHTs, fetal movement, and sufficiency of amniotic fluid. DPL can be performed in pregnant women via a supraumbilical, open technique. Trauma radiography of pregnant patients presents a conundrum. Radiation damage has three distinct phases of damage and effect: preimplantation, dur-ing the period of organogenesis from 3 to 16 weeks, and after 16 weeks. Generally, it is accepted that “safe” doses of radiation Brunicardi_Ch07_p0183-p0250.indd 24010/12/18 6:21 PM 241TRAUMACHAPTER 7Figure 7-75. The authors’ sequential closure technique for the open abdomen. A. Multiple white sponges (solid arrow), stapled together, are placed on top of the bowel underneath the


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Surgery_Schwartz. 241TRAUMACHAPTER 7Figure 7-75. The authors’ sequential closure technique for the open abdomen. A. Multiple white sponges (solid arrow), stapled together, are placed on top of the bowel underneath the fascia. Interrupted No. 1 polydioxanone sutures are placed approximately 5 cm apart (dashed arrow), which puts the fascia under moderate tension over the white sponge. B. After the sticky clear plastic vacuum-assisted closure (VAC) dressing is placed over the white sponges and adjacent 5 cm of skin, the central portion is removed by cutting along the wound edges. C and D. Black VAC sponges are placed on top of the white sponges and plastic-protected skin with standard occlusive dressing and suction. E. On return to the operating room (OR) 48 hours later, fascial sutures are placed from both the superior and inferior directions until tension precludes further closure; skin is closed over the fascial closure with skin staples. F. White sponges (fewer in number) are again applied and


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Surgery_Schwartz. both the superior and inferior directions until tension precludes further closure; skin is closed over the fascial closure with skin staples. F. White sponges (fewer in number) are again applied and fascial retention sutures are placed with planned return to the OR in 48 hours.Brunicardi_Ch07_p0183-p0250.indd 24110/12/18 6:22 PM 242BASIC CONSIDERATIONSPART IFigure 7-76. Complications after split-thickness skin graft closure of the abdomen include enterocutaneous fistulas (intubated here with a red rubber catheter) (A; arrow), rupture of the graft with exposure of the bowel mucosa (B), enteroatmospheric fistulas with a large ventral hernias and loss of abdominal domain (C).from radiography are <5 rad.150 A chest radiograph results in a dose of 0.07 mrad; CT scan of the chest, <1 rad; and CT scan of the abdomen, 3.5 rad. It is important, therefore, to limit radio-graphs to those that are essential and to shield the pelvis with a lead apron when possible. If clinically warranted,


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Surgery_Schwartz. and CT scan of the abdomen, 3.5 rad. It is important, therefore, to limit radio-graphs to those that are essential and to shield the pelvis with a lead apron when possible. If clinically warranted, however, a radiograph should be obtained.The vast majority of injuries are treated similarly whether the patient is pregnant or not. Following standard protocols for nonoperative management of blunt trauma avoids the risks associated with general anesthesia. A particular challenge in the pregnant trauma patient is a major pelvic fracture. Because uter-ine and retroperitoneal veins may dilate to 60 times their origi-nal size, hemorrhage from these vessels may be torrential. Fetal loss may be related to both maternal shock and direct injury to the uterus or fetal head. Penetrating injuries in this patient population also carry a high risk. The gravid uterus is a large target, and any penetrating injury to the abdomen may result in fetal injury depending on trajectory and uterine size. Gunshot


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Surgery_Schwartz. patient population also carry a high risk. The gravid uterus is a large target, and any penetrating injury to the abdomen may result in fetal injury depending on trajectory and uterine size. Gunshot wounds to the abdomen are associated with a 70% injury rate to the uterus and 35% mortality rate of the fetus. If the bul-let traverses the uterus and the fetus is viable, cesarean section should be performed. On the other hand, stab wounds do not often penetrate the thick wall of the uterus.Any patient with a viable pregnancy should be monitored after trauma, with the length of monitoring determined by the injury mechanism and patient physiology. Patients who are Brunicardi_Ch07_p0183-p0250.indd 24210/12/18 6:22 PM 243TRAUMACHAPTER 7symptomatic, defined by the presence of uterine irritability or contractions, abdominal tenderness, vaginal bleeding, or blood pressure instability, should be monitored in the hospital for at least 24 hours. In addition, patients at high risk for fetal


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Surgery_Schwartz. or contractions, abdominal tenderness, vaginal bleeding, or blood pressure instability, should be monitored in the hospital for at least 24 hours. In addition, patients at high risk for fetal loss (those experiencing vehicle ejection or involved in motorcycle or pedestrian collisions and those with maternal tachycardia, Injury Severity Score of >9, gestational period of >35 weeks, or history of prior assault) also warrant careful monitoring.151 Patients without these risk factors who are asymptomatic can be monitored for 6 hours in the ED and sent home if no problems develop. They should be counseled regarding warning signs that mandate prompt return to the ED.Geriatric PatientsElderly trauma patients (>65 years of age) are hospitalized twice as often as those in any other age group, and this population accounts for one quarter of all trauma admissions. Although the physiology of aging separates older trauma patients from the younger generation (Table 7-14), treatment must remain


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Surgery_Schwartz. and this population accounts for one quarter of all trauma admissions. Although the physiology of aging separates older trauma patients from the younger generation (Table 7-14), treatment must remain indi-vidualized (some octogenarians look and physiologically act 50 years old, whereas others appear closer to 100 years). No chronologic age is associated with a higher morbidity or mor-tality, but a patient’s comorbidities do impact the individual’s postinjury course and outcome. For example, recognition that a patient is taking β-blockers affects the physician’s evaluation of vital signs in the ED and impacts treatment course in the ICU. Early monitoring of arterial blood gas values will identify occult shock. A base deficit of >6 mmol/L is associated with a twofold higher risk of mortality in patients over the age of 55 than in younger patients (67% vs. 30%).152Although the published literature on geriatric traumatic brain injury is relatively sparse and uncontrolled with regard to


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Surgery_Schwartz. in patients over the age of 55 than in younger patients (67% vs. 30%).152Although the published literature on geriatric traumatic brain injury is relatively sparse and uncontrolled with regard to management, some interesting points are noted. First, as anticipated, outcomes are worse in this age group than in their younger counterparts. Based on data from the Traumatic Coma Databank, mortality in patients with severe head injury more than doubles after the age of 55. Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%.140 Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome. Therefore, the majority of trauma centers advocate an initial aggressive approach with reevaluation at the 72-hour mark to determine subsequent care.One of the most common sequelae of blunt thoracic trauma is rib fractures. In the aging population, perhaps due to osteo-porosis, less


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Surgery_Schwartz. reevaluation at the 72-hour mark to determine subsequent care.One of the most common sequelae of blunt thoracic trauma is rib fractures. In the aging population, perhaps due to osteo-porosis, less force is required to cause a fracture. In fact, in one study, 50% of patients >65 years old sustained rib fractures from a fall of <6 ft, compared with only 1% of patients <65 years of age. Concurrent pulmonary contusion is noted in up to 35% of patients, and pneumonia complicates the injuries in 10% to 30% of patients with rib fractures, not surprisingly leading to longer ICU stays.153,154 Additionally, mortality increases linearly with the number of rib fractures. Patients who sustain more than six rib fractures have pulmonary morbidity rates of >50% and over-all mortality rates of >20%.Chronologic age is not the best predictor of outcome, but the presence of preexisting conditions, which affect a patient’s physiologic age, is associated with increased mortality rates. Injury Severity


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Surgery_Schwartz. age is not the best predictor of outcome, but the presence of preexisting conditions, which affect a patient’s physiologic age, is associated with increased mortality rates. Injury Severity Score is probably the best overall predictor of patient outcome in the elderly; however, for any given individ-ual its sensitivity may not be precise, and there is a time delay in obtaining sufficient information to calculate the final score. In addition to preexisting conditions and severity of injury, the occurrence of complications compounds the risk for mortality.Table 7-13Physiologic effects of pregnancyCardiovascularIncrease in heart rate by 10–15 bpm(a) Decreased systemic vascular resistance resulting in:(b) Increased intravascular volumeDecreased blood pressure during the first two trimestersPulmonaryElevated diaphragmIncreased tidal volumeIncreased minute ventilationDecreased functional residual capacityHematopoieticRelative anemiaLeukocytosisHypercoagulability(a) Increased levels of


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Surgery_Schwartz. diaphragmIncreased tidal volumeIncreased minute ventilationDecreased functional residual capacityHematopoieticRelative anemiaLeukocytosisHypercoagulability(a) Increased levels of factors VII, VIII, IX, X, XII(b) Decreased fibrinolytic activityOtherDecreased competency of lower esophageal sphincterIncreased enzyme levels on liver function testsImpaired gallbladder contractionsDecreased plasma albumin levelDecreased blood urea nitrogen and creatinine levelsHydronephrosis and hydroureterTable 7-14Physiologic effects of agingCardiovascularAtherosclerotic disease that limits cardiac response to stressProgressive stiffening and loss of elasticity of the myocardiumDiminished stroke volume, systolic contraction, and diastolic relaxationDecrease in cardiac output of 0.5% per yearThickening and calcification of the cardiac valves, which results in valvular incompetencePulmonaryLoss of complianceProgressive loss of alveolar size and surface areaAir trapping and atelectasisIntracranialLoss of


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Surgery_Schwartz. calcification of the cardiac valves, which results in valvular incompetencePulmonaryLoss of complianceProgressive loss of alveolar size and surface areaAir trapping and atelectasisIntracranialLoss of cerebral volume, resulting in:(a) Increased risk of tearing of bridging veins with smaller injuries(b) Accumulation of a significant amount of blood before symptoms occur(c) muscle lossSenescence of the sensesOtherDecline in creatinine clearance by 80%–90%Osteoporosis, which causes a greater susceptibility to fracturesBrunicardi_Ch07_p0183-p0250.indd 24310/12/18 6:22 PM 244BASIC CONSIDERATIONSPART IPediatric PatientsTwenty million children, or almost one in four children, are injured each year, with an associated cost of treating the injured child of $16 billion per year. Injury is the leading cause of death among children over the age of 1 year, with 15,000 to 25,000 pediatric deaths per year. Disability after traumatic injury is more devastating, with rates 3 to 10 times that of the


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Surgery_Schwartz. cause of death among children over the age of 1 year, with 15,000 to 25,000 pediatric deaths per year. Disability after traumatic injury is more devastating, with rates 3 to 10 times that of the death rate. Pediatric trauma involves different mechanisms, different constellations of injury, and the potential for long-term problems related to growth and development. As with adult trauma, over 85% of pediatric trauma has a blunt mecha-nism, with boys injured twice as often as girls.155 Falls are the most common cause of injury in infants and toddlers. In chil-dren, bicycle mishaps are the most common cause of severe injury, whereas motor vehicle-related injury predominates in adolescence. Although unintentional injuries are by far the most common type of injuries in childhood, the number of intentional injuries, such as firearm-related injury and child abuse, is increasing.ED preparation for the pediatric trauma patient includes assembling age-appropriate equipment (e.g., intubation


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Surgery_Schwartz. of intentional injuries, such as firearm-related injury and child abuse, is increasing.ED preparation for the pediatric trauma patient includes assembling age-appropriate equipment (e.g., intubation equip-ment; IV catheters, including intraosseous needles and 4F single-lumen lines), laying out the Broselow Pediatric Emergency Tape (which allows effective approximation of the patient’s weight, medication doses, size of endotracheal tube, and chest tube size), and turning on heat lamps. Upon the pediatric patient’s arrival, the basic tenets of the ABCs apply, with some caveats. In children, the airway is smaller and more cephalad in position compared with that of adults, and in children younger than 10 years, the larynx is funnel shaped rather than cylindrical as in adults. Addi-tionally, the child’s tongue is much larger in relation to the oro-pharynx. Therefore, a small amount of edema or obstruction can significantly reduce the diameter of the airway (thus increasing the work of


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Surgery_Schwartz. the child’s tongue is much larger in relation to the oro-pharynx. Therefore, a small amount of edema or obstruction can significantly reduce the diameter of the airway (thus increasing the work of breathing), and the tongue may posteriorly obstruct the airway, causing intubation to be difficult. During intubation, a Miller (straight) blade rather than a Macintosh (curved) blade may be more effective due to the acute angle of the cephalad, funnel-shaped larynx. Administration of atropine before rapid-sequence intubation will prevent bradycardia. Adequate ventila-tion is critical because oxygen consumption in infants and young children is twice that in adults; onset of hypoxemia, followed by cardiac arrest, may be precipitous. Because gastric distension can inhibit adequate ventilation, placement of a nasogastric tube may facilitate effective gas exchange. Approximately one-third of pre-ventable deaths in children are related to airway management; therefore, if airway control cannot be


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Surgery_Schwartz. of a nasogastric tube may facilitate effective gas exchange. Approximately one-third of pre-ventable deaths in children are related to airway management; therefore, if airway control cannot be obtained using a standard endotracheal method, surgical establishment of an airway should be considered. In children older than 11 years, standard crico-thyroidotomy is performed. Due to the increased incidence of subglottic stenosis in younger patients, needle cricothyroidotomy with either a 14or 16-gauge catheter is advocated, although it is rarely used. Alternatively, tracheostomy may be performed. In children, the standard physiologic response to hypovolemia is peripheral vasoconstriction and reflex tachycardia; this may mask significant hemorrhagic injury because children can compensate for up to a 25% loss of circulating blood volume with minimal external signs. “Normal” values for vital signs should not neces-sarily make one feel more secure about the child’s volume status. Volume


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Surgery_Schwartz. for up to a 25% loss of circulating blood volume with minimal external signs. “Normal” values for vital signs should not neces-sarily make one feel more secure about the child’s volume status. Volume restoration is based on the child’s weight; two to three boluses of 20 mL/kg of crystalloid is appropriate. Hypotension in children may be due to TBI rather than hypovolemia and should be considered in the appropriate clinic scenario.156After initial evaluation based on the trauma ABCs, iden-tification and management of specific injuries proceeds. Acute traumatic brain injury is the most common cause of death and disability in any pediatric age group. Although falls are the most common mechanism overall, severe brain injury most often is due to child abuse (in children <2 years) or motor vehicle col-lisions (in those >2 years). Head CT should be performed to determine intracranial pathology, followed by skull radiogra-phy to diagnose skull fractures. As in adults, CPP is monitored, and


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Surgery_Schwartz. col-lisions (in those >2 years). Head CT should be performed to determine intracranial pathology, followed by skull radiogra-phy to diagnose skull fractures. As in adults, CPP is monitored, and appropriate resuscitation is critical to prevent the second-ary insults of hypoxemia and hypovolemia. Although some data indicate that the pediatric brain recovers from traumatic injury better than the adult brain, this advantage may be eliminated if hypotension is allowed to occur.As is true in adults, the vast majority of thoracic trauma is also blunt. However, because a child’s skeleton is not completely calcified, it is more pliable. Significant internal organ damage may occur without overlying bony fractures. For example, adult patients with significant chest trauma have a 70% incidence of rib fractures, whereas only 40% of children with significant chest trauma do. Pneumothorax is treated similarly in the pediatric population; patients who are asymptomatic with a pneumothorax of <15% are


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Surgery_Schwartz. fractures, whereas only 40% of children with significant chest trauma do. Pneumothorax is treated similarly in the pediatric population; patients who are asymptomatic with a pneumothorax of <15% are admitted for observation, whereas those who have a pneumothorax of >15% or who require positive pressure ventilation undergo tube decompression. Presence of a hemothorax in this age group may be particularly problematic because the child’s chest may contain his or her entire blood volume. If the chest tube output is initially 20% of the patient’s blood volume (80 mL/kg) or is persistently >1 to 2 mL/kg per hour, thoracotomy should be considered. Aortic injuries are rare in children, and tracheobronchial injuries are more amenable to nonoperative management. Penetrating thoracic trauma, although uncom-mon, has 35% operative intervention rate, which is consid-erably higher than that of the adult population.157 Thoracic injuries are second only to brain injuries as the main cause of death


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Surgery_Schwartz. uncom-mon, has 35% operative intervention rate, which is consid-erably higher than that of the adult population.157 Thoracic injuries are second only to brain injuries as the main cause of death according to the National Pediatric Trauma Registry; however, the overall mortality rate of 15% correlates with the levels in many adult studies.The evaluation for abdominal trauma in the pediatric patient is similar to that in the adult. FAST is valid in the pedi-atric age group to detect intra-abdominal fluid. The mecha-nism of injury often correlates with specific injury patterns. A child sustaining a blow to the epigastrium (e.g., hitting the handlebars during a bike accident) should be evaluated for a duodenal hematoma and/or a pancreatic transection. After a motor vehicle collision in which the patient was wearing a passenger restraint, injuries comprising the “lap belt com-plex” or “seat belt syndrome” (i.e., abdominal wall contusion, small bowel perforation, flexion-distraction injury


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Surgery_Schwartz. the patient was wearing a passenger restraint, injuries comprising the “lap belt com-plex” or “seat belt syndrome” (i.e., abdominal wall contusion, small bowel perforation, flexion-distraction injury of the lumbar spine, diaphragm rupture, and occasionally abdomi-nal aortic dissection) may exist. Nonoperative management of solid organ injuries, first used in children, is the current standard of care in the hemodynamically stable patient. If the patient shows clinical deterioration or hemodynamic lability, has a hollow viscus injury, or requires >40 mL/kg of packed RBCs, continued nonoperative management is not an option. Success rates of nonoperative management approach 95%,158 with an associated 10% to 23% transfusion rate. Findings of a hepatic or splenic blush on CT imaging does not uniformly require intervention; patient physiology should dictate embo-lization or operative intervention.159Brunicardi_Ch07_p0183-p0250.indd 24410/12/18 6:22 PM 245TRAUMACHAPTER 7REFERENCESEntries


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Surgery_Schwartz. require intervention; patient physiology should dictate embo-lization or operative intervention.159Brunicardi_Ch07_p0183-p0250.indd 24410/12/18 6:22 PM 245TRAUMACHAPTER 7REFERENCESEntries highlighted in bright blue are key references. 1. Minino AM, Heron MP, Murphy SL, et al. Deaths: final data for 2004. Natl Vital Stat Rep. 2007 Aug 21;55(19):1-120. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf. Accessed June 8, 2017. 2. National Center for Injury Prevention and Control. CDC Injury Fact Book. Atlanta: Centers for Disease Control and Preven-tion, November 2006. Available at: http://www.cdc.gov/ncipc/fact_book/InjuryBook2006.pdf. Accessed October 29, 2012. 3. Brasel KJ. Epidemiology. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 8th ed. New York: McGraw-Hill; 2017. 4. Eastman AB. Wherever the dart lands: toward the ideal trauma system. J Am Coll Surg. 2010;211(2):153-168. 5. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national eval-uation of the


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Surgery_Schwartz. 2017. 4. Eastman AB. Wherever the dart lands: toward the ideal trauma system. J Am Coll Surg. 2010;211(2):153-168. 5. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national eval-uation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378. 6. American College of Surgeons. Advanced Trauma Life Sup-port. 9th ed. Chicago: American College of Surgeons; 2012. 7. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010;68(1):115-120. 8. Lustenberger T, Talving P, Lam L, et al. Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients. J Trauma. 2011;70(4):870-872. 9. Sakles JC, Mosier JM, Chiu S, Keim SM. Tracheal intubation in the emergency department: a comparison of GlideScope video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med. 2012;42(4):400-405. 10. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative


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Surgery_Schwartz. a comparison of GlideScope video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med. 2012;42(4):400-405. 10. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumo-thorax. Arch Surg. 2012;147(9):813-818. 11. Carretta A, Melloni G, Bandiera A, Negri G, Voci C, Zannini P. Conservative and surgical treatment of acute posttraumatic tra-cheobronchial injuries. World J Surg. 2011;35(11):2568-2574. 12. Gómez-Caro A, Ausín P, Moradiellos FJ, et al. Role of con-servative medical management of tracheobronchial injuries. J Trauma. 2006;61(6):1426-1434. 13. Demetriades D, Chan LS, Bhasin P, et al. Relative brady-cardia in patients with traumatic hypotension. J Trauma. 1998;45(3):534-539. 14. Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. Crit Care. 2016;20:102. 15. Weiser G, Hoffmann Y, Galbraith R, Shavit I. Current advances in


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Surgery_Schwartz. J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. Crit Care. 2016;20:102. 15. Weiser G, Hoffmann Y, Galbraith R, Shavit I. Current advances in intraosseous infusion—a systematic review. Resuscitation. 2012;83(1):20-26. 16. Callaham M. Pericardiocentesis in traumatic and nontraumatic cardiac tamponade. Ann Emerg Med. 1984;13(10):924-945. 17. Jones TS, Burlew CC, Stovall RT, et al. Emergency department pericardial drainage for penetrating cardiac wounds is a viable option for stabilization. Am J Surg. 2014;207(6):931-934. 18. Burlew CC, Moore EE, Moore FA, et al. Western trauma asso-ciation critical decisions in Trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012 Dec;73(6):1359-1363. 19. Moore EE, Knudson MM, Burlew CC, et al. WTA Study Group. Defining the limits of resuscitative emergency depart-ment thoracotomy: a contemporary Western Trauma Associa-tion perspective. J Trauma. 2011;70(2):334-339. 20. Moore HB, Moore


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Surgery_Schwartz. al. WTA Study Group. Defining the limits of resuscitative emergency depart-ment thoracotomy: a contemporary Western Trauma Associa-tion perspective. J Trauma. 2011;70(2):334-339. 20. Moore HB, Moore EE, Burlew CC, et al. Establishing bench-marks for resuscitation of traumatic circulatory arrest: suc-cess-to-rescue and survival among 1,708 patients. J Am Coll Surg. 2016;223(1):42-50. 21. Ouellet JF, Roberts DJ, Tiruta C, et al. Admission base deficit and lactate levels in Canadian patients with blunt trauma: are they useful markers of mortality? J Trauma Acute Care Surg. 2012;72(6):1532-1535. 22. Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortal-ity in normotensive elderly blunt trauma patients. J Trauma. 2009;66(4):1040-1044. 23. Johnson M, Alarhayem A, Convertino V, et al. Comparison of compensatory reserve and arterial lactate as markers of shock and resuscitation. J Trauma Acute Care Surg. 2017


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Surgery_Schwartz. 2009;66(4):1040-1044. 23. Johnson M, Alarhayem A, Convertino V, et al. Comparison of compensatory reserve and arterial lactate as markers of shock and resuscitation. J Trauma Acute Care Surg. 2017 Oct;83(4):603-608. 24. Stewart CL, Mulligan J, Grudic GZ, Talley ME, Jurkovich GJ, Moulton SL. The compensatory reserve index follow-ing injury: results of a prospective clinical trial. Shock. 2016 Sep;46(3 Suppl 1):61-67. 25. Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S301-S306. 26. Velmahos GC, Karaiskakis M, Salim A, et al. Normal electro-cardiography and serum troponin I levels preclude the pres-ence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. 27. Ferrada P, Murthi S, Anand RJ, Bochicchio GV, Scalea T. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in


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Surgery_Schwartz. injury. J Trauma. 2003;54(1):45-50. 27. Ferrada P, Murthi S, Anand RJ, Bochicchio GV, Scalea T. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients. J Trauma. 2011;70:56-62. 28. Ferrada P, Evans D, Wolfe L, et al. Findings of a randomized con-trolled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg. 2014;76(1):31-37; discussion 37-88. 29. Kutcher ME, Howard BM, Sperry JL, et al. Evolving beyond the vicious triad: differential mediation of traumatic coagu-lopathy by injury, shock, and resuscitation. J Trauma Acute Care Surg. 2015;78(3):516-523. 30. Gonzalez E, Moore EE, Moore HB. Management of trauma-induced coagulopathy with thrombelastography. Crit Care Clin. 2017;33(1):119-134. Review. 31. Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for blunt abdominal trauma. J Trauma. 2001;50:108-112. 32. Sondeen JL,


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Surgery_Schwartz. thrombelastography. Crit Care Clin. 2017;33(1):119-134. Review. 31. Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for blunt abdominal trauma. J Trauma. 2001;50:108-112. 32. Sondeen JL, Coppes VG, Holcomb JB. Blood pressure at which rebleeding occurs after resuscitation in swine with aor-tic injury. J Trauma. 2003;54(Suppl):S110-S117. 33. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury. 4th ed. 2016. Available at: https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edi-tion.pdf. Accessed July 9, 2017. 34. Ryb GE, Dischinger PC, Kufera JA, et al. Delta V, principal direction of force, and restraint use contributions to motor vehicle crash mortality. J Trauma. 2007;63:1000-1005. 35. Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J Trauma.


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Surgery_Schwartz. FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J Trauma. 2008;65(4):785-788. 36. Moore MM, Pasquale MD, Badellino M. Impact of age and anticoagulation: need for neurosurgical intervention in trauma patients with mild traumatic brain injury. J Trauma Acute Care Surg. 2012;73(1):126-130. 37. Inaba K, Byerly S, Bush LD, et al; WTA C-Spine Study Group. Cervical spinal clearance: a prospective Western Trauma Asso-ciation Multi-institutional Trial. J Trauma Acute Care Surg. 2016;81(6):1122-1130. 38. Sekharan J, Dennis JW, Veldenz HC, et al. Continued experience with physical examination alone for evaluation and manage-ment of penetrating zone 2 neck injuries: results of 145 cases. J Vasc Surg. 2000;32:483-489. 39. Inaba K, Branco BC, Menaker J, et al. Evaluation of multi-detector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma


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Surgery_Schwartz. cases. J Vasc Surg. 2000;32:483-489. 39. Inaba K, Branco BC, Menaker J, et al. Evaluation of multi-detector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg. 2012;72:576-583.Brunicardi_Ch07_p0183-p0250.indd 24510/12/18 6:22 PM 246BASIC CONSIDERATIONSPART I 40. Chouliaras K, Bench E, Talving P, et al. Pneumomediasti-num following blunt trauma: worth an exhaustive workup? J Trauma Acute Care Surg. 2015;79(2):188-192; discussion 192-193. 41. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: multicenter trial of the American Associ-ation for the Surgery of Trauma. J Trauma. 1997;42:374-380. 42. Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: how predictive is mechanism and is chest computed tomog-raphy a reliable screening tool? A prospective study of 1,561 patients. J Trauma. 2000;48:673-682. 43. Siegel JH, Smith JA, Siddiqi SQ. Change in velocity and energy dissipation on impact


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Surgery_Schwartz. tomog-raphy a reliable screening tool? A prospective study of 1,561 patients. J Trauma. 2000;48:673-682. 43. Siegel JH, Smith JA, Siddiqi SQ. Change in velocity and energy dissipation on impact in motor vehicle crashes as a function of the direction of crash: key factors in the production of thoracic aortic injuries, their pattern of associated injuries and patient survival. A Crash Injury Research Engineering Network (CIREN) study. J Trauma. 2004;57(4):760-777. 44. Karmy-Jones R, Namias N, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg. 2014;77(6):994-1002. 45. Arantes V, Campolina C, Valerio SH, et al. Flexible esopha-goscopy as a diagnostic tool for traumatic esophageal injuries. J Trauma. 2009;66(6):1677-1682. 46. Cox CS Jr, Allen GS, Fischer RP, et al. Blunt vs. penetrating subclavian artery injury: presentation, injury pattern, and out-come. J Trauma. 1999;46:445-449. 47. Peponis T, Kasotakis G, Yu J,


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Surgery_Schwartz. lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S315-S320. 55. Burch JM, Franciose RJ, Moore EE, et al. Single-layer con-tinuous vs. two-layer interrupted intestinal anastomosis—a prospective randomized study. Ann Surg. 2000;231:832-837. 56. Moore EE. Thomas G. Orr Memorial Lecture. Staged lapa-rotomy for the hypothermia, acidosis, and coagulopathy syn-drome. Am J Surg. 1996;172:405-410. 57. Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscita-tive endovascular balloon occlusion of the aorta in the man-agement of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324-334. 58. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncom-pressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523-530;


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Surgery_Schwartz. of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncom-pressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523-530; discussion 530-532. 59. Gonzalez E, Moore EE, Moore HB. Management of trauma-induced coagulopathy with thrombelastography. Crit Care Clin. 2017;33(1):119-134. Review. 60. Cohen MJ, Call M, Nelson M, et al. Critical role of acti-vated protein C in early coagulopathy and later organ fail-ure, infection and death in trauma patients. Ann Surg. 2012;255(2):379-385. 61. Gonzalez E, Moore EE, Moore HB, Chapman MP, Silliman CC, Banerjee A. Trauma-induced coagulopathy: an institu-tion’s 35-year perspective on practice and research. Scand J Surg. 2014;103(2):89-103. 62. Moore HB, Moore EE, Liras IN, et al. Acute fibrinolysis shut-down after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg. 2016;222(4):347-355. 64. Hebert PC,


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Surgery_Schwartz. Acute fibrinolysis shut-down after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg. 2016;222(4):347-355. 64. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, ran-domized, controlled clinical trial of transfusion requirements in critical care. New Engl J Med. 1999;340:409-417. 65. West MA, Shapiro MB, Nathens AB, et al. Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core-standard operating procedures for clinical care. IV. Guidelines for transfusion in the trauma patient. J Trauma. 2006;61:436-439. 66. Tariket S, Sut C, Hamzeh-Cognasse H, et al. Transfusion-related acute lung injury: transfusion, platelets and biological response modifiers. Expert Rev Hematol. 2016;9(5):497-508. 67. Moore FA, Moore EE, Sauaia A. Blood transfusion: an inde-pendent risk factor for postinjury multiple organ failure. Arch Surg. 1997;132:620-624. 68. Kashuk JL,


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Surgery_Schwartz. Rev Hematol. 2016;9(5):497-508. 67. Moore FA, Moore EE, Sauaia A. Blood transfusion: an inde-pendent risk factor for postinjury multiple organ failure. Arch Surg. 1997;132:620-624. 68. Kashuk JL, Moore EE, Sauaia A, et al. Postinjury life-threat-ening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? J Trauma. 2008;65:261-270. 69. Davenport R, Curry N, Manson J, et al. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. J Trauma. 2011;70(1):90-95. 70. Stanworth SJ, Morris TP, Gaarder C, et al. Reappraising the concept of massive transfusion in trauma. Crit Care. 2010;14(6):R239. 71. Dzik WH, Blajchman MA, Fergusson D, et al. Clinical review: Canadian National Advisory Committee on Blood and Blood Products–Massive transfusion consensus conference 2011: report of the panel. Crit Care. 2011;15(6):242. 72. Holcomb JB, Tilley BC, Baraniuk S, et al; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1


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Surgery_Schwartz. conference 2011: report of the panel. Crit Care. 2011;15(6):242. 72. Holcomb JB, Tilley BC, Baraniuk S, et al; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. 73. Menaker J, Stein DM, Scalea TM. Incidence of early pulmo-nary embolism after injury. J Trauma. 2007;63:620-624. 74. Harr JN, Moore EE, Chin TL, et al. Platelets are dominant contributors to hypercoagulability after injury. J Trauma Acute Care Surg. 2013;74(3):756-762; discussion 762-765. 75. Prager M, Polterauer P, Böhmig HJ, et al. Collagen vs. gelatin-coated Dacron vs. stretch polytetrafluoroethylene in abdominal aortic bifurcation graft surgery: results of a seven-year prospective, randomized multicenter trial. Surgery. 2001;130(3):408-414. 76. Asensio JA, Feliciano DV. Abdominal vascular injury. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 8th ed. New


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Surgery_Schwartz. prospective, randomized multicenter trial. Surgery. 2001;130(3):408-414. 76. Asensio JA, Feliciano DV. Abdominal vascular injury. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 8th ed. New York: McGraw-Hill; 2017. 77. Coleman JJ, Brewer BL, Feliciano DV. Trauma damage con-trol. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 8th ed. New York: McGraw-Hill; 2017. 78. Mathew S, Smith BP, Cannon JW, Reilly PM, Schwab CW, Seamon MJ. Temporary arterial shunts in damage Brunicardi_Ch07_p0183-p0250.indd 24610/12/18 6:22 PM 247TRAUMACHAPTER 7control: experience and outcomes. J Trauma Acute Care Surg. 2017;82(3):512-517. 79. Lubitz AL, Sjoholm LO, Goldberg A, et al. Acute right heart failure after hemorrhagic shock and trauma pneumonectomy—a management approach: a blinded randomized controlled ani-mal trial using inhaled nitric oxide. J Trauma Acute Care Surg. 2017;82(2):243-251. 80. Smith JW, Matheson PJ, Franklin GA, Harbrecht BG, Richardson JD, Garrison RN. Randomized controlled


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Surgery_Schwartz. ani-mal trial using inhaled nitric oxide. J Trauma Acute Care Surg. 2017;82(2):243-251. 80. Smith JW, Matheson PJ, Franklin GA, Harbrecht BG, Richardson JD, Garrison RN. Randomized controlled trial evaluating the efficacy of peritoneal resuscitation in the man-agement of trauma patients undergoing damage control sur-gery. J Am Coll Surg. 2017;224(4):396-404. 81. Dawes AJ, Sacks GD, Cryer HG, et al; Los Angeles County Trauma Consortium. Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: a pro-pensity score-matched analysis. J Trauma Acute Care Surg. 2015;78(3):492-501; discussion 501-502. 82. Nirula R, Millar D, Greene T, et al. Decompressive craniectomy for medical management for refractory intracranial hyperten-sion: an AAST-MITC propensity score analysis. J Trauma Acute Care Surg. 2014;76(4):944-952; discussion 952-955. 83. Cooper DJ, Rosenfeld JV, Murray L, et al; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society


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Surgery_Schwartz. brain injury: a critically appraised topic. Neurologist. 2012;18(3):173-177. 87. Cogbill T, Cothren CC, Ahearn MK, et al. Management of severe hemorrhage associated with maxillofacial injuries: a multicenter perspective. J Trauma. 2008;64:250. 88. Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesyl-ate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Ran-domized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997;277:1597-1604. 89. Stahel PF, Vanderheiden T, Finn MA. Management strategies for acute spinal cord injury: current options and future per-spectives. Curr Opin Crit Care. 2012;18(6):651-660. 90. Fehlings MG, Perrin RG: The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine. 2006;31:S28-S35. 91. Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arte-rial


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Surgery_Schwartz. intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine. 2006;31:S28-S35. 91. Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arte-rial injuries: implications of a new grading scale. J Trauma. 1999;47:845-853. 92. Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screen-ing criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330-335. 93. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540-545. 94. Shahan CP, Croce MA, Fabian TC, Magnotti LJ. Impact of continuous evaluation of technology and therapy: 30 years of research reduces stroke and mortality from blunt cerebrovas-cular injury. J Am Coll Surg. 2017;224(4):595-599. 95. Burlew CC, Biffl WL, Moore EE, et al. Endovascular stenting is rarely necessary for the management of blunt


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Surgery_Schwartz. and mortality from blunt cerebrovas-cular injury. J Am Coll Surg. 2017;224(4):595-599. 95. Burlew CC, Biffl WL, Moore EE, et al. Endovascular stenting is rarely necessary for the management of blunt cerebrovascu-lar injuries. J Am Coll Surg. 2014;218(5):1012-1017. 96. Weinberg JA, Moore AH, Magnotti LJ, et al. Contemporary management of civilian penetrating cervicothoracic arterial injuries. J Trauma Acute Care Surg. 2016;81(2):302-306. 97. Johnston RH, Wall MJ, Mattox KL. Innominate artery trauma: a thirty-year experience. J Vasc Surg. 1993;17:134-139. 98. Shalhub S, Starnes BW, Brenner ML, et al. Blunt abdominal aortic injury: a Western Trauma Association multicenter study. J Trauma Acute Care Surg. 2014;77(6):879-885; discussion 885. 99. Harris DG, Rabin J, Starnes BW, et al. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg. 2016;64(2):500-505. 100. Fox N, Schwartz D, Salazar JH, et al. Evaluation and man-agement of blunt traumatic aortic injury:


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Surgery_Schwartz. of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg. 2016;64(2):500-505. 100. Fox N, Schwartz D, Salazar JH, et al. Evaluation and man-agement of blunt traumatic aortic injury: a practice manage-ment guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(1):136-146. 101. Moore EE, Burch JM, Moore JB. Repair of the torn descend-ing thoracic aorta using the centrifugal pump with partial left heart bypass. Ann Surg. 2004;240:38-43. 102. Rabin J, DuBose J, Sliker CW, O’Connor JV, Scalea TM, Griffith BP. Parameters for successful nonoperative manage-ment of traumatic aortic injury. J Thorac Cardiovasc Surg. 2014;147(1):143-149. 103. Wall MJ, Tsai PI, Mattox KL. Heart and thoracic vascular injury. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma. 8th ed. New York: McGraw-Hill; 2017. 104. Jones EL, Burlew CC, Moore EE. BioGlue hemostasis of penetrating cardiac wounds in proximity to the left ante-rior descending coronary


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Surgery_Schwartz. DV, eds. Trauma. 8th ed. New York: McGraw-Hill; 2017. 104. Jones EL, Burlew CC, Moore EE. BioGlue hemostasis of penetrating cardiac wounds in proximity to the left ante-rior descending coronary artery. J Trauma Acute Care Surg. 2012;72(3):796-798. 105. Cothren CC, Moore EE. Traumatic ventricular septal defect. Surgery. 2007;142:776-777. 106. Wall MJ Jr, Hirshberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Am J Surg. 1994;168:665-669. 107. Cothren C, Moore EE, Biffl WL, et al. Lung-sparing tech-niques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma. 2002;53:483-487. 108. Cryer HG, Mavroudis C, Yu J, et al. Shock, transfusion, and pneumonectomy. Death is due to right heart failure and increased pulmonary vascular resistance. Ann Surg. 1990;212:197-201. 109. Luo L, Yin L, Liu Z, Xiang Z. Posttraumatic pulmonary pseudocyst: computed tomography findings and man-agement in


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Surgery_Schwartz. failure and increased pulmonary vascular resistance. Ann Surg. 1990;212:197-201. 109. Luo L, Yin L, Liu Z, Xiang Z. Posttraumatic pulmonary pseudocyst: computed tomography findings and man-agement in 33 patients. J Trauma and Acute Care Surg. 2012;73(5):1225-1228. 110. Moore HB, Moore EE, Burlew CC, et al. Western Trauma Association critical decisions in trauma: management of parapneumonic effusion. J Trauma Acute Care Surg. 2012;73:1372-1379. 111. de Souza A, Offner PJ, Moore EE, et al. Optimal management of complicated empyema. Am J Surg. 2000;180:507-511. 112. Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma. 2011;71(6):1548-1552. 113. Kozar RA, Moore FA, Cothren CC, et al. Risk factors for hepatic morbidity following nonoperative management: mul-ticenter study. Arch Surg. 2006;141:451-458. 114. Malhotra AK, Fabian TC, Croce MA, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative


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Surgery_Schwartz. following nonoperative management: mul-ticenter study. Arch Surg. 2006;141:451-458. 114. Malhotra AK, Fabian TC, Croce MA, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative man-agement in the 1990s. Ann Surg. 2000;231:804-813. 115. Peitzman AB, Marsh JW. Advanced operative techniques in the management of complex liver injury. J Trauma Acute Care Surg. 2012;73(3):765-770. 116. Biffl WL, Moore EE, Franciose RJ. Venovenous bypass and hepatic vascular isolation as adjuncts in the repair of destruc-tive wounds to the retrohepatic inferior vena cava. J Trauma. 1998;45:400-403.Brunicardi_Ch07_p0183-p0250.indd 24710/12/18 6:22 PM 248BASIC CONSIDERATIONSPART I 117. Poggetti RS, Moore EE, Moore FA, et al. Balloon tampon-ade for bilobar transfixing hepatic gunshot wounds. J Trauma. 1992;33:694-697. 118. Delis SG, Bakoyiannis A, Selvaggi G, et al. Liver transplanta-tion for severe hepatic trauma: experience from a single center. World J Gastroenterol.


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Surgery_Schwartz. gunshot wounds. J Trauma. 1992;33:694-697. 118. Delis SG, Bakoyiannis A, Selvaggi G, et al. Liver transplanta-tion for severe hepatic trauma: experience from a single center. World J Gastroenterol. 2009;15(13):1641-1644. 119. Pickhardt B, Moore EE, Moore FA, et al. Operative splenic salvage in adults: a decade perspective. J Trauma. 1989;29:1386-1391. 120. Feliciano DV, Spjut-Patrinely V, Burch JM, et al. Splenorrha-phy: the alternative. Ann Surg. 1990;211:569-580. 121. Bhullar IS, Tepas JJ 3rd, Siragusa D, Loper T, Kerwin A, Frykberg ER. To nearly come full circle: nonoperative man-agement of high-grade IV-V blunt splenic trauma is safe using a protocol with routine angioembolization. J Trauma Acute Care Surg. 2017;82(4):657-664. 122. McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonopera-tive management of splenic injuries: causes and consequences. Arch Surg. 2005;140:563-568. 123. Lopez JM Jr, McGonagill PW, Gross JL, et al. Subcapsular hematoma in blunt splenic injury: a


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Surgery_Schwartz. nonopera-tive management of splenic injuries: causes and consequences. Arch Surg. 2005;140:563-568. 123. Lopez JM Jr, McGonagill PW, Gross JL, et al. Subcapsular hematoma in blunt splenic injury: a significant predictor of failure of nonoperative management. J Trauma Acute Care Surg. 2015;79(6):957-959; discussion 959-960. 124. Toutouzas KG, Velmahos GC, Kaminski A, et al. Leukocytosis after posttraumatic splenectomy: a physiologic event or sign of sepsis? Arch Surg. 2002;137:924-928. 125. Howdieshell TR, Heffernan D, Dipiro JT; Therapeutic Agents Committee of the Surgical Infection Society. Surgical infec-tion society guidelines for vaccination after traumatic injury. Surg Infect (Larchmt). 2006;7(3):275-303. 126. Todd SR, Kozar RA, Moore FA. Nutrition support in adult trauma patients. Nutr Clin Pract. 2006;21:421-429. 127. Burlew CC, Moore EE, Cuschieri J, et al; the WTA Study Group. Who should we feed? Western Trauma Asso-ciation multi-institutional study of enteral nutrition in


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Surgery_Schwartz. Nutr Clin Pract. 2006;21:421-429. 127. Burlew CC, Moore EE, Cuschieri J, et al; the WTA Study Group. Who should we feed? Western Trauma Asso-ciation multi-institutional study of enteral nutrition in the open abdomen after injury. J Trauma Acute Care Surg. 2012;73:1380-1387. 128. Schroeppel TJ, Saleem K, Sharpe JP, et al. Penetrating duode-nal trauma: a 19-year experience. J Trauma Acute Care Surg. 2016;80(3):461-465. 129. Biffl WL, Moore EE, Croce M, et al. Western Trauma Asso-ciation critical decisions in trauma: management of pancreatic injuries. J Trauma Acute Care Surg. 2013;75(6):941-946. 130. Vaughn GD, Frazier OH, Graham D, et al. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg. 1977;134:785. 131. Krige JE, Kotze UK, Setshedi M, Nicol AJ, Navsaria PH. Surgical management and outcomes of combined pancreati-coduodenal injuries: analysis of 75 consecutive cases. J Am Coll Surg. 2016;222(5):737-749. 132. Nelson R, Singer M. Primary repair for


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Surgery_Schwartz. PH. Surgical management and outcomes of combined pancreati-coduodenal injuries: analysis of 75 consecutive cases. J Am Coll Surg. 2016;222(5):737-749. 132. Nelson R, Singer M. Primary repair for penetrating colon inju-ries. Cochrane Database Syst Rev. 2003;(3):CD002247. 133. Burlew CC, Moore EE, Cuschieri J, et al; WTA Study Group. Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the postinjury open abdomen. J Trauma. 2011;70(2):273-277. 134. Asensio JA, Britt LD, Borzotta A, et al. Multi-institutional experience with the management of superior mesenteric artery injuries. J Am Coll Surg. 2001;193:354-356. 135. Burch JM, Richardson RJ, Martin RR, et al. Penetrating iliac vascular injuries: experience with 233 consecutive patients. J Trauma. 1990;30:1450-1459. 136. Mullins RJ, Lucas CE, Ledgerwood AM. The natural his-tory following venous ligation for civilian injuries. J Trauma. 1980;20:737-743. 137. Jurkovich GJ, Hoyt DB, Moore FA, et


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Surgery_Schwartz. 1990;30:1450-1459. 136. Mullins RJ, Lucas CE, Ledgerwood AM. The natural his-tory following venous ligation for civilian injuries. J Trauma. 1980;20:737-743. 137. Jurkovich GJ, Hoyt DB, Moore FA, et al. Portal triad injuries. J Trauma. 1995;39:426-434. 138. Voelzke BB, McAninch JW. Renal gunshot wounds: clinical management and outcome. J Trauma. 2009;66(3):593-600. 139. Rostas J, Simmons JD, Frotan MA, Brevard SB, Gonzalez RP. Intraoperative management of renal gunshot injuries: is man-datory exploration of Gerota’s fascia necessary? Am J Surg. 2016;211(4):783-786. 140. Knudson MM, Harrison PB, Hoyt DB, et al. Outcome after major renovascular injuries: a Western Trauma Association multicenter report. J Trauma. 2000;49:1116-1122. 141. Burlew CC, Moore EE, Stahel PF, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233-242. 142. Bosse MJ, MacKenzie EJ, Kellam JF, et


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Surgery_Schwartz. packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233-242. 142. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med. 2002;347:1924-1931. 143. Einersen PM, Moore EE, Chapman MP, et al. Rapid throm-belastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion. J Trauma Acute Care Surg. 2017;82(1):114-119. 144. Moore FA, McKinley BA, Moore EE, et al. Inflammation and the host response to injury, a large-scale collaborative proj-ect: patient-oriented research core—standard operating proce-dures for clinical care. III. Guidelines for shock resuscitation. J Trauma, 2006;61:82-89. 145. Dezman ZD, Comer AC, Smith GS, Narayan M, Scalea TM, Hirshon JM. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg.


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Surgery_Schwartz. Trauma, 2006;61:82-89. 145. Dezman ZD, Comer AC, Smith GS, Narayan M, Scalea TM, Hirshon JM. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg. 2015;79(4):580-585. 146. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic experience with Morel-Lavallée lesions: estab-lishment of a practice management guideline. J Trauma Acute Care Surg. 2014;76(2):493-497. 147. Burlew CC, Moore EE, Biffl WL, Bensard DD, Johnson JL, Barnett CC. One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential clo-sure protocol. J Trauma Acute Care Surg. 2012;72(1):235-241. 148. Sela HY, Weiniger CF, Hersch M, Smueloff A, Laufer N, Einav S. The pregnant motor vehicle accident casualty: adher-ence to basic workup and admission guidelines. Ann Surg. 2011;254(2):346-352. 149. Drukker L, Hants Y, Sharon E, Sela HY, Grisaru-Granovsky S. Perimortem cesarean section for maternal and fetal salvage:


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Surgery_Schwartz. to basic workup and admission guidelines. Ann Surg. 2011;254(2):346-352. 149. Drukker L, Hants Y, Sharon E, Sela HY, Grisaru-Granovsky S. Perimortem cesarean section for maternal and fetal salvage: concise review and protocol. Acta Obstet Gynecol Scand. 2014;93(10):965-972. 150. ACOG Committee on Obstetric Practice. ACOG Commit-tee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647-651. 151. Curet MJ, Schermer CR, Demarest GB, et al. Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours. J Trauma. 2000;49:18-24. 152. Bruijns SR, Guly HR, Bouamra O, Lecky F, Lee WA. The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality. J Trauma Acute Care Surg. 2013;74(6):1432-1437. 153. Bulger EM, Arneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma. 2000;48:1040-1046. 154. Pieracci FM, Lin Y, Rodil M, et


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Surgery_Schwartz. mortality. J Trauma Acute Care Surg. 2013;74(6):1432-1437. 153. Bulger EM, Arneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma. 2000;48:1040-1046. 154. Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib frac-tures. J Trauma Acute Care Surg. 2016;80(2):187-194. 155. Tepas JJ. The national pediatric trauma registry: a legacy of commitment to control childhood injury. Semin Pediatr Surg. 2004;13:126-132. 156. Gardner AR, Diz DI, Tooze JA, Miller CD, Petty J. Injury pat-terns associated with hypotension in pediatric trauma patients: Brunicardi_Ch07_p0183-p0250.indd 24810/12/18 6:22 PM 249TRAUMACHAPTER 7a national trauma database review. J Trauma Acute Care Surg. 2015;78(6):1143-1148. 157. Mollberg NM, Tabachnick D, Lin FJ, et al. Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations. J Trauma Acute Care Surg.


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Surgery_Schwartz. NM, Tabachnick D, Lin FJ, et al. Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations. J Trauma Acute Care Surg. 2014;76(2):273-277; discussion 277-278. 158. Linnaus ME, Langlais CS, Garcia NM, et al. Failure of non-operative management of pediatric blunt liver and spleen injuries: a prospective Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium study. J Trauma Acute Care Surg. 2017;82(4):672-679. 159. Ingram MC, Siddharthan RV, Morris AD, et al. Hepatic and splenic blush on computed tomography in children fol-lowing blunt abdominal trauma: is intervention necessary? J Trauma Acute Care Surg. 2016;81(2):266-270.Brunicardi_Ch07_p0183-p0250.indd 24910/12/18 6:22 PM


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Surgery_Schwartz. BurnsJeffrey H. Anderson, Samuel P. Mandell, and Nicole S. Gibran 8chapterSurgical care of the burned patient has evolved into a special-ized field incorporating the interdisciplinary skills of burn sur-geons, nurses, burn therapists, and other healthcare specialists. However, recent mass casualty events have been a reminder that healthcare systems may be rapidly pressed to care for large numbers of burn patients. Naturally, general surgeons may be at the forefront in these events, so it is crucial that they are com-fortable with the care of burned patients and well equipped to provide the standard of care.BACKGROUNDBurn injury historically carried a poor prognosis. With advances in fluid resuscitation1 and the advent of early excision of the burn wound,2 survival has become an expectation even for patients with severe burns.3 Continued improvements in critical care and progress in skin bioengineering herald a future in which func-tional and psychologic outcomes are equally important