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Surgery_Schwartz. can be estimated. Limited one-shot extremity radiographs may also be appropriate to assist in application of a splint. In critically injured patients, blood samples for a routine trauma panel (type and crossmatch, complete blood count, blood chemistries, coagulation studies, and arterial blood gas analysis) should be sent to the laboratory. For less severely injured patients, only a complete blood count and urinalysis may be required. Because older patients may pres-ent in subclinical shock, even with minor injuries, routine analy-sis of an arterial blood gas in patients over the age of 55 should be considered. Repeat FAST is mandatory if there are any signs of abdominal injury or unexplained blood loss.Many trauma patients cannot provide specific information about the mechanism of their injury. Emergency medical ser-vice personnel and police are trained to evaluate an injury scene and should be questioned while they are present in the ED. For automobile collisions, the speed of the


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Surgery_Schwartz. injury. Emergency medical ser-vice personnel and police are trained to evaluate an injury scene and should be questioned while they are present in the ED. For automobile collisions, the speed of the vehicles involved, angle of impact, location of the patient within the vehicle, use of restraints, airbag deployment, condition of the steer-ing wheel and windshield, amount of intrusion, ejection of the patient from the vehicle, and fate of other passengers should be ascertained. For other injury mechanisms, critical information includes such things as height of a fall, surface impact, helmet use, and weight of an object by which the patient was crushed. In patients sustaining gunshot wounds, bullet characteris-tics, distance, and presumed path of the bullet are important, if known. For patients with stab wounds, the length and type of object is helpful. Finally, some patients experience a com-bination of blunt and penetrating trauma. Do not assume that someone who was stabbed was not


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Surgery_Schwartz. with stab wounds, the length and type of object is helpful. Finally, some patients experience a com-bination of blunt and penetrating trauma. Do not assume that someone who was stabbed was not also assaulted; the patient may have a multitude of injuries and cannot be presumed to have only injuries associated with the more obvious penetrat-ing wound. In short, these details of information are critical to the clinician to determine overall mechanism of injury and anticipate associated injury patterns.Mechanisms and Patterns of InjuryIn general, more energy is transferred over a wider area during blunt trauma than from a penetrating wound. As a result, blunt trauma is associated with multiple widely distributed injuries, whereas in penetrating wounds the damage is localized to the path of the bullet or knife. In blunt trauma, organs that can-not yield to impact by elastic deformation are most likely to be injured, namely, the solid organs (liver, spleen, and kidneys). For penetrating


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Surgery_Schwartz. the bullet or knife. In blunt trauma, organs that can-not yield to impact by elastic deformation are most likely to be injured, namely, the solid organs (liver, spleen, and kidneys). For penetrating trauma, organs with the largest surface area are most prone to injury (small bowel, liver, and colon). Addition-ally, because bullets and knives usually follow straight lines, adjacent structures are commonly injured.Patients who have sustained blunt trauma separate them into categories according to their risk for multiple injuries: those Brunicardi_Ch07_p0183-p0250.indd 19510/12/18 6:17 PM 196BASIC CONSIDERATIONSPART Isustaining high energy transfer injuries and those sustaining low energy transfer injuries. Injuries involving high energy transfer include auto-pedestrian accidents, motor vehicle collisions in which the car’s change of velocity (ΔV) exceeds 20 mph or in which the patient has been ejected, motorcycle collisions, and falls from heights >20 ft.34 In fact, for motor


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Surgery_Schwartz. motor vehicle collisions in which the car’s change of velocity (ΔV) exceeds 20 mph or in which the patient has been ejected, motorcycle collisions, and falls from heights >20 ft.34 In fact, for motor vehicle collisions the vari-ables strongly associated with life-threatening injuries, and hence reflective of the magnitude of the mechanism, are death of another occupant in the vehicle, extrication time of >20 minutes, ΔV >20 mph, lack of restraint use, and lateral impact.34 Low-energy trauma, such as being struck with a club or falling from a bicycle, usually does not result in widely distributed injuries. However, potentially lethal injuries of internal organs can occur because the net energy transfer to any given location may be substantial.In blunt trauma, particular constellations of injury or injury patterns are associated with specific injury mechanisms. For example, when an unrestrained driver sustains a frontal impact, the head strikes the windshield, the chest and upper


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Surgery_Schwartz. of injury or injury patterns are associated with specific injury mechanisms. For example, when an unrestrained driver sustains a frontal impact, the head strikes the windshield, the chest and upper abdomen hit the steering column, and the legs or knees contact the dashboard. The resultant injuries can include facial fractures, cervical spine fractures, injury of the descending thoracic aorta, myocardial contusion, injury to the spleen and liver, and fractures of the pel-vis and lower extremities. When such patients are evaluated, the discovery of one of these injuries should prompt a search for the others. Collisions with side impact also carry the risk of cervical spine and thoracic trauma, diaphragm rupture, and crush injuries of the pelvic ring, but solid organ injury usually is limited to either the liver or spleen based on the direction of impact. However, patients ejected from a vehicle or thrown a significant distance from a motorcycle have the risk of any injury


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Surgery_Schwartz. is limited to either the liver or spleen based on the direction of impact. However, patients ejected from a vehicle or thrown a significant distance from a motorcycle have the risk of any injury pattern.Penetrating injuries are classified according to the wound-ing agent (i.e., stab wound, gunshot wound, or shotgun wound). Gunshot wounds are subdivided further into highand low-velocity injuries because the speed of the bullet is much more important than its weight in determining potential kinetic energy transfer. High-velocity gunshot wounds (bullet speed >2000 ft/s) are infrequent in the civilian setting. Shotgun injuries are divided into close-range (<20 feet) and long-range wounds. Close-range shotgun wounds are tantamount to high-velocity wounds because the entire energy of the load is delivered to a small area, often with devastating results. In contrast, long-range shotgun blasts result in a diffuse pellet pattern in which many pellets miss the victim, and those that do strike


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Surgery_Schwartz. is delivered to a small area, often with devastating results. In contrast, long-range shotgun blasts result in a diffuse pellet pattern in which many pellets miss the victim, and those that do strike are dis-persed and are of comparatively low energy.Regional Assessment and Special Diagnostic TestsBased on mechanism, location of injuries identified on physi-cal examination, screening radiographs, and the patient’s over-all condition, additional diagnostic studies often are indicated. However, the seriously injured patient is in constant jeopardy when undergoing special diagnostic testing; therefore, the sur-geon must be in attendance and must be prepared to alter plans as circumstances demand. Hemodynamic, respiratory, and men-tal status will determine the most appropriate course of action. With these issues in mind, additional diagnostic tests are dis-cussed on an anatomic basis.Head. Evaluation of the head includes examination for injuries to the scalp, eyes, ears, nose, mouth,


Surgery_Schwartz

Surgery_Schwartz. With these issues in mind, additional diagnostic tests are dis-cussed on an anatomic basis.Head. Evaluation of the head includes examination for injuries to the scalp, eyes, ears, nose, mouth, facial bones, and intracra-nial structures. Palpation of the head is done to identify scalp lacerations, which should be evaluated for depth, and pres-ence of associated depressed or open skull fractures. The eye examination includes not only pupillary size and reactivity, but also examination for visual acuity and for hemorrhage within the globe. Ocular entrapment, caused by orbital fractures with impingement of the ocular muscles, is evident when the patient cannot move his or her eyes through an entire range of motion. It is important to perform the eye examination early because significant orbital swelling may prevent later evaluation. A lat-eral canthotomy may be needed to relieve periorbital pressure. The tympanic membrane is examined to identify hemotym-panum, otorrhea, or rupture, which


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Surgery_Schwartz. swelling may prevent later evaluation. A lat-eral canthotomy may be needed to relieve periorbital pressure. The tympanic membrane is examined to identify hemotym-panum, otorrhea, or rupture, which may signal an underlying head injury. Otorrhea, rhinorrhea, raccoon eyes, and Battle’s sign (ecchymosis behind the ear) suggest a basilar skull fracture. Although such fractures may not require treatment, there is an association with blunt cerebrovascular injuries, cranial nerve injuries, and risk of meningitis.Anterior facial structures should be examined to rule out fractures. This entails palpating for bony step-off of the facial bones and instability of the midface (by grasping the upper pal-ate and seeing if this moves separately from the patient’s head). A good question to ask awake patients is whether their bite feels normal to them; abnormal dental closure suggests malalignment of facial bones and the possibility for a mandible or maxillary fracture. Nasal fractures, which may be


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Surgery_Schwartz. is whether their bite feels normal to them; abnormal dental closure suggests malalignment of facial bones and the possibility for a mandible or maxillary fracture. Nasal fractures, which may be evident on direct inspec-tion or palpation, typically bleed vigorously. This may result in the patient having airway compromise due to blood running down the posterior pharynx, or there may be vomiting provoked by swallowed blood. Nasal packing or balloon tamponade may be necessary to control bleeding. Examination of the oral cavity includes inspection for open fractures, loose or fractured teeth, and sublingual hematomas.All patients with a significant closed head injury (GCS score <14) should undergo CT scanning of the head. Addition-ally, elderly patients or those patients on antiplatelet agents or anticoagulation should be imaged despite a GCS of 15.35,36 For penetrating injuries, plain skull films may be helpful in the trauma bay to determine the trajectory of the bullet. The presence of


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Surgery_Schwartz. or anticoagulation should be imaged despite a GCS of 15.35,36 For penetrating injuries, plain skull films may be helpful in the trauma bay to determine the trajectory of the bullet. The presence of later-alizing findings (e.g., a unilateral dilated pupil unreactive to light, asymmetric movement of the extremities either spontaneously or in response to noxious stimuli, or unilateral Babinski’s reflex) suggests an intracranial mass lesion or major structural damage.Such intracranial lesions following trauma include hemato-mas, contusions, hemorrhage into ventricular and subarachnoid spaces, and diffuse axonal injury (DAI). Epidural hematomas occur when blood accumulates between the skull and dura, and are caused by disruption of the middle meningeal artery or other small arteries in that potential space, typically after a skull frac-ture (Fig. 7-16). Subdural hematomas occur between the dura and cortex and are caused by venous disruption or laceration of the parenchyma of the brain. Due


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Surgery_Schwartz. space, typically after a skull frac-ture (Fig. 7-16). Subdural hematomas occur between the dura and cortex and are caused by venous disruption or laceration of the parenchyma of the brain. Due to associated parenchy-mal injury, subdural hematomas have a much worse prognosis than epidural collections. Hemorrhage into the subarachnoid space may cause vasospasm and further reduce cerebral blood flow. Intraparenchymal hematomas and contusions can occur anywhere within the brain. DAI results from high-speed decel-eration injury and represents direct axonal damage from shear effects. CT scan may demonstrate blurring of the gray and white matter interface and multiple small punctate hemorrhages, but magnetic resonance imaging is a more accurate test. Although prognosis for these injuries is extremely variable, early evidence of DAI is associated with a poor outcome. Stroke syndromes should prompt a search for carotid or vertebral artery injury using multislice CTA (Fig.


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Surgery_Schwartz. injuries is extremely variable, early evidence of DAI is associated with a poor outcome. Stroke syndromes should prompt a search for carotid or vertebral artery injury using multislice CTA (Fig. 7-17).Brunicardi_Ch07_p0183-p0250.indd 19610/12/18 6:17 PM 197TRAUMACHAPTER 7Significant intracranial penetrating injuries usually are produced by bullets from handguns, but an array of other weap-ons or instruments can injure the cerebrum via the orbit or through the thinner temporal region of the skull. Although the diagnosis usually is obvious, in some instances wounds in the auditory canal, mouth, and nose can be elusive. Prognosis is variable, but virtually all supratentorial wounds that injure both hemispheres are fatal.Neck. All blunt trauma patients should be assumed to have cer-vical spine injuries until proven otherwise. During the physi-cal examination, one must maintain cervical spine precautions and in-line stabilization. Due to the devastating consequences of quadriplegia, a


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Surgery_Schwartz. spine injuries until proven otherwise. During the physi-cal examination, one must maintain cervical spine precautions and in-line stabilization. Due to the devastating consequences of quadriplegia, a diligent evaluation for occult cervical spine injuries is mandatory. In the awake patient, the presence of posterior midline pain or tenderness should provoke a thor-ough radiologic evaluation. Additionally, intubated patients, patients with distracting injuries, significant mechanism, or another identified spine fracture should undergo CT imaging.37 A ligamentous injury may not be visible with standard imaging techniques. Flexion and extension views or magnetic resonance imaging (MRI) are obtained to further evaluate patients at risk or those with persistent symptoms.Spinal cord injuries can vary in severity. Complete injuries cause either quadriplegia or paraplegia, depending on the level of injury. These patients have a complete loss of motor func-tion and sensation two or more levels


Surgery_Schwartz

Surgery_Schwartz. vary in severity. Complete injuries cause either quadriplegia or paraplegia, depending on the level of injury. These patients have a complete loss of motor func-tion and sensation two or more levels below the bony injury. Patients with high spinal cord disruption are at risk for shock due to physiologic disruption of sympathetic fibers. Significant neurologic recovery is rare. However, there are several partial or incomplete spinal cord injury syndromes where the prognosis is better. Central cord syndrome typically occurs in older persons who experience hyperextension injuries. Motor function, pain, and temperature sensation are preserved in the lower extremi-ties but diminished in the upper extremities. Some functional ABFigure 7-16. Epidural hematomas (A) have a distinctive convex shape on computed tomo-graphic scan, whereas subdural hematomas (B) are concave along the surface of the brain.Figure 7-17. A. A right middle cerebral infarct noted on a computed tomographic scan of the


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Surgery_Schwartz. on computed tomo-graphic scan, whereas subdural hematomas (B) are concave along the surface of the brain.Figure 7-17. A. A right middle cerebral infarct noted on a computed tomographic scan of the head. Such a finding should prompt imaging to rule out an associated extracranial cerebrovascular injury. B. An inter-nal carotid artery pseudoaneurysm documented by angiography.Brunicardi_Ch07_p0183-p0250.indd 19710/12/18 6:17 PM 198BASIC CONSIDERATIONSPART Irecovery usually occurs, but is often not a return to normal. Anterior cord syndrome is characterized by diminished motor function, pain, and temperature sensation below the level of the injury, but position sensing, vibratory sensation, and crude touch are maintained. Prognosis for recovery is poor. Brown-Séquard syndrome is usually the result of a penetrating injury in which one-half of the spinal cord is transected. This lesion is characterized by the ipsilateral loss of motor function, proprio-ception, and vibratory sensation,


Surgery_Schwartz

Surgery_Schwartz. result of a penetrating injury in which one-half of the spinal cord is transected. This lesion is characterized by the ipsilateral loss of motor function, proprio-ception, and vibratory sensation, whereas pain and temperature sensation are lost on the contralateral side.During the primary survey, identification of injuries to the neck with exsanguination, expanding hematomas, airway obstruc-tion, or aerodigestive injuries is a priority. A more subtle injury that may not be identified is a fracture of the larynx due to blunt trauma. Signs and symptoms include hoarseness, subcutaneous emphysema (Fig. 7-18), or a palpable fracture. Penetrating inju-ries of the anterior neck that violate the platysma are potentially life-threatening because of the density of critical structures in this region. Although operative exploration is appropriate for overt injuries, selective nonoperative management has been proven safe (Fig. 7-19).38 Indications for immediate operative intervention for


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Surgery_Schwartz. region. Although operative exploration is appropriate for overt injuries, selective nonoperative management has been proven safe (Fig. 7-19).38 Indications for immediate operative intervention for penetrating cervical injury include hemodynamic instability, sig-nificant external hemorrhage, or evidence of aerodigestive injury. The management algorithm for hemodynamically stable patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones (Fig. 7-20). Zone I is inferior to the clavicles encompassing the thoracic outlet structures, zone II is between the thoracic outlet and the angle of the mandible, and zone III is above the angle of the mandible. Due to technical difficulties of injury expo-sure and varying operative approaches, a precise preoperative diagnosis is desirable for symptomatic zone I and III injuries. Therefore, these patients should ideally undergo diagnostic imag-ing before operation if they remain


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Surgery_Schwartz. approaches, a precise preoperative diagnosis is desirable for symptomatic zone I and III injuries. Therefore, these patients should ideally undergo diagnostic imag-ing before operation if they remain hemodynamically stable. Management of patients is further divided into those who are symptomatic and those who are not (see Fig 7-19). Specific symptoms or signs that should be identified include dysphagia, hoarseness, hematoma, venous bleeding, minor hemoptysis, and 5PenetratingNeck InjuryHemodynamically UnstableUncontrolled HemorrhageHard signs: massive hemoptysis, rapidly expanding hematomaOperativeExplorationObserveHemodynamically StableSoft signs: dysphagia, venous bleeding,subcutaneous emphysema, hematoma,hoarseness, stridor, odynophagiaAsymptomaticZone IZone IIZone IIIangioembolizationfor Zone III+Zone IZone IIZone IIITranscervical GSWAll OthersCTAneck/chest+angiographyesophagrambronchoscopyCTAneck/chest+ angiographyesophagrambronchoscopy+Figure 7-19. Algorithm for the management


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Surgery_Schwartz. Zone III+Zone IZone IIZone IIITranscervical GSWAll OthersCTAneck/chest+angiographyesophagrambronchoscopyCTAneck/chest+ angiographyesophagrambronchoscopy+Figure 7-19. Algorithm for the management of penetrating neck injuries. CTA = computed tomographic angiography; GSW = gunshot wound.Figure 7-18. A laryngeal fracture results in air tracking around the trachea along the prevertebral space (arrows).Brunicardi_Ch07_p0183-p0250.indd 19810/12/18 6:17 PM 199TRAUMACHAPTER 7subcutaneous emphysema. Symptomatic patients, without overt injuries, should undergo CTA with further evaluation or operation based upon the imaging findings. Overall, less than 15% of pen-etrating cervical trauma requires neck exploration.39 Asymptom-atic patients are typically observed for 6 to 12 hours. The one caveat is asymptomatic patients with a transcervical gunshot wound; these patients should undergo CTA to determine the tra-jectory of the bullet; further studies are performed based on prox-imity to major


Surgery_Schwartz

Surgery_Schwartz. is asymptomatic patients with a transcervical gunshot wound; these patients should undergo CTA to determine the tra-jectory of the bullet; further studies are performed based on prox-imity to major structures.39 Such additional imaging includes angiography, soluble contrast esophagram followed by barium esophagram, esophagoscopy, or bronchoscopy. Angiographic diagnosis, particularly of zone III injuries, can then be managed by selective angioembolization.Chest. Blunt trauma to the chest may involve the chest wall, tho-racic spine, heart, lungs, thoracic aorta and great vessels, and rarely the esophagus. Most of these injuries can be evaluated by physi-cal examination and chest radiography, with supplemental CT scanning to exclude vascular injury. Any patient who undergoes an intervention in the ED—endotracheal intubation, central line placement, tube thoracostomy—needs a repeat chest radiograph to document the adequacy of the procedure. This is particularly true in patients undergoing


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Surgery_Schwartz. the ED—endotracheal intubation, central line placement, tube thoracostomy—needs a repeat chest radiograph to document the adequacy of the procedure. This is particularly true in patients undergoing tube thoracostomy for a pneumothorax or hemothorax. Patients with persistent pneumothorax, large air leaks after tube thoracostomy, or difficulty ventilating should undergo fiber-optic bronchoscopy to exclude a tracheobronchial injury or presence of a foreign body. Patients with hemothorax must have a chest radiograph documenting complete evacuation of the chest; a persistent hemothorax that is not drained by two chest tubes is termed a caked hemothorax and mandates immediate thoracotomy IIIIIIIIFigure 7-20. For the purpose of evaluating penetrating injuries, the neck is divided into three zones. Zone I is to the level of the clavicu-lar heads and is also known as the thoracic outlet. Zone II is located between the clavicles and the angle of the mandible. Zone III is above the angle of the


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Surgery_Schwartz. Zone I is to the level of the clavicu-lar heads and is also known as the thoracic outlet. Zone II is located between the clavicles and the angle of the mandible. Zone III is above the angle of the mandible.(Fig. 7-21). Pneumomediastinum following blunt trauma that is identified on CT imaging is a poor predictor of aerodigestive injury; selective workup is appropriate.40Occult thoracic vascular injury must be diligently sought due to the high mortality of a missed lesion. Widening of the mediastinum on initial anteroposterior chest radiograph, caused by a hematoma around an injured vessel that is contained by the mediastinal pleura, suggests an injury of the great vessels. The mediastinal abnormality may suggest the location of the arterial injury (i.e., left-sided hematomas are associated with descend-ing blunt aortic injuries [BAI], whereas right-sided hematomas are seen with innominate injuries) (Fig. 7-22). Posterior rib frac-tures, sternal fractures with laceration of small


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Surgery_Schwartz. with descend-ing blunt aortic injuries [BAI], whereas right-sided hematomas are seen with innominate injuries) (Fig. 7-22). Posterior rib frac-tures, sternal fractures with laceration of small vessels, and mediastinal venous bleeding also can produce similar hemato-mas. Other chest radiographic findings suggestive of a BAI are summarized in Table 7-5 (Fig. 7-23). However, at least 7% of patients with a descending BAI have a normal chest radio-graph.41 Therefore, screening CTA is performed based on the mechanism of injury: high-energy deceleration motor vehicle collision with frontal or lateral impact (>30 mph frontal impact and >23 mph lateral impact), motor vehicle collision with ejection, falls of >25 ft, or direct impact (horse kick to chest, snowmobile, or ski collision with tree).42,43 In >95% of patients who survive to reach the ED, the BAI occurs just distal to the left subclavian artery, where it is tethered by the ligamen-tum arteriosum (Fig. 7-24). In 2% to 5% of patients


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Surgery_Schwartz. In >95% of patients who survive to reach the ED, the BAI occurs just distal to the left subclavian artery, where it is tethered by the ligamen-tum arteriosum (Fig. 7-24). In 2% to 5% of patients the injury occurs in the ascending aorta, in the transverse arch, or at the diaphragm. Reconstructions with multislice CTA obviate the need for invasive arteriography.42For penetrating thoracic trauma, physical examination, plain posteroanterior and lateral chest radiographs with metallic markings of wounds, and pericardial ultrasound will identify the majority of injuries.44 Injuries of the esophagus and tra-chea are the exceptions. Bronchoscopy should be performed to evaluate the trachea in patients with a persistent air leak from the chest tube or mediastinal air. Patients at risk for an esopha-geal injury should undergo bedside esophagoscopy or soluble contrast esophagography followed by barium examination to look for extravasation of contrast.45 As with neck injuries, 6Figure


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Surgery_Schwartz. an esopha-geal injury should undergo bedside esophagoscopy or soluble contrast esophagography followed by barium examination to look for extravasation of contrast.45 As with neck injuries, 6Figure 7-21. Persistence of a hemothorax despite two tube tho-racostomies is termed a caked hemothorax and is an indication for prompt thoracotomy.Brunicardi_Ch07_p0183-p0250.indd 19910/12/18 6:18 PM 200BASIC CONSIDERATIONSPART Ihemodynamically stable patients with transmediastinal gunshot wounds should undergo CT scanning to determine the path of the bullet; trajectory in proximity to vascular or visceral struc-tures dictates the need for angiography, endoscopy, or opera-tive plan. If there is a suspicion of a subclavian artery injury, brachial-brachial indices should be measured, but >60% of patients with an injury may not have a pulse deficit.46 Therefore, CTA should be performed based on injury proximity to intra-thoracic vasculature. Finally, with GSWs identified on the chest, penetrating


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Surgery_Schwartz. with an injury may not have a pulse deficit.46 Therefore, CTA should be performed based on injury proximity to intra-thoracic vasculature. Finally, with GSWs identified on the chest, penetrating trauma should not be presumed to be isolated to the thorax. Injury to contiguous body cavities (i.e., the abdomen and neck) must be excluded; plain radiographs are a rapid, effective screening modality to identify retained bullet fragments.Abdomen. The abdomen is a diagnostic black box. Fortunately, with few exceptions, it is not necessary to determine in the ED which intra-abdominal organs are injured, only whether an explor-atory laparotomy is necessary. However, physical examina-tion of the abdomen can be unreliable in making this determination, and drugs, alcohol, and head and spinal cord injuries can complicate the clinical evaluation. The presence of abdominal rigidity and hemodynamic compromise is an undisputed indication 7Figure 7-22. Location of the hematoma within the mediastinal


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Surgery_Schwartz. can complicate the clinical evaluation. The presence of abdominal rigidity and hemodynamic compromise is an undisputed indication 7Figure 7-22. Location of the hematoma within the mediastinal silhouette suggests the type of great vessel injury. A predominant hematoma on the left suggests the far more common descending torn aorta (A; arrows), whereas a hematoma on the right indicates a relatively unusual but life-threatening innominate artery injury (B; arrows).Table 7-5Findings on chest radiograph suggestive of a descending thoracic aortic tear1. Widened mediastinum2. Abnormal aortic contour3. Tracheal shift4. Nasogastric tube shift5. Left apical cap6. Left or right paraspinal stripe thickening7. Depression of the left main bronchus8. Obliteration of the aorticopulmonary window9. Left pulmonary hilar hematomaFigure 7-23. Chest film findings associated with descending torn aorta include apical capping (A; arrows) and tracheal shift (B; arrows).Brunicardi_Ch07_p0183-p0250.indd


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Surgery_Schwartz. pulmonary hilar hematomaFigure 7-23. Chest film findings associated with descending torn aorta include apical capping (A; arrows) and tracheal shift (B; arrows).Brunicardi_Ch07_p0183-p0250.indd 20010/12/18 6:18 PM 201TRAUMACHAPTER 7Figure 7-24. Imaging to diagnose descending torn aorta includes computed tomographic angiography (A), with three-dimensional reconstructions (B, anterior; C, posterior) demonstrating the proxi-mal and distal extent of the injury (arrows).for prompt surgical exploration. For the remainder of patients, a variety of diagnostic adjuncts are used to identify abdominal injury.The diagnostic approach differs for penetrating trauma and blunt abdominal trauma. As a rule, laparotomy is warranted for gunshot or shotgun wounds that penetrate the peritoneal cavity because most have significant internal injuries. The standard has been that anterior truncal gunshot wounds between the fourth intercostal space and the pubic symphysis whose trajectory as determined by


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Surgery_Schwartz. most have significant internal injuries. The standard has been that anterior truncal gunshot wounds between the fourth intercostal space and the pubic symphysis whose trajectory as determined by radiograph or wound location indicates perito-neal penetration should undergo laparotomy (Fig. 7-25). How-ever, there has been increased use of CT scanning to facilitate nonoperative management of abdominal GSWs.47 The exception is penetrating trauma isolated to the right upper quadrant; in hemodynamically stable patients with trajectory confined to the liver by CT scan, nonoperative observation may be reasonable.48 In obese patients, if the gunshot wound is thought to be tangen-tial through the subcutaneous tissues, CT scan can delineate the track and exclude peritoneal violation. Laparoscopy is another option to assess peritoneal penetration for tangential wounds it should not be done in unstable patients. In the scenario of tan-gential high energy GSWs, however, it is possible to sustain a


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Surgery_Schwartz. another option to assess peritoneal penetration for tangential wounds it should not be done in unstable patients. In the scenario of tan-gential high energy GSWs, however, it is possible to sustain a transmitted intraperitoneal hollow visceral injury due to a blast insult. Gunshot wounds to the back or flank are more difficult to evaluate because of the retroperitoneal location of the injured abdominal organs. Triple-contrast CT scan can delineate the trajectory of the bullet and identify peritoneal violation or retro-peritoneal entry, and associated injuries.In contrast to gunshot wounds, stab wounds that penetrate the peritoneal cavity are less likely to injure intra-abdominal organs. Anterior abdominal stab wounds (from costal margin to inguinal ligament and bilateral midaxillary lines) should be explored under local anesthesia in the ED to determine if the fascia has been violated. Injuries that do not penetrate the peri-toneal cavity do not require further evaluation, and the


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Surgery_Schwartz. should be explored under local anesthesia in the ED to determine if the fascia has been violated. Injuries that do not penetrate the peri-toneal cavity do not require further evaluation, and the patient Brunicardi_Ch07_p0183-p0250.indd 20110/12/18 6:18 PM 202BASIC CONSIDERATIONSPART Imay be discharged from the ED. Patients with fascial pen-etration must be further evaluated for intra-abdominal injury because there is up to a 50% chance of requiring laparotomy. Debate remains over whether the optimal diagnostic approach is serial examination, diagnostic peritoneal lavage (DPL), or CT scanning. The most recent evidence supports serial examination and laboratory evaluation.49,50 Patients with stab wounds to the right upper quadrant can undergo CT scanning to determine tra-jectory and confinement to the liver for potential nonoperative care.48 Those with stab wounds to the flank and back should undergo contrasted CT to assess for the potential risk of retro-peritoneal injuries of the


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Surgery_Schwartz. to the liver for potential nonoperative care.48 Those with stab wounds to the flank and back should undergo contrasted CT to assess for the potential risk of retro-peritoneal injuries of the colon, duodenum, and urinary tract.Penetrating thoracoabdominal wounds may cause occult injury to the diaphragm. Patients with gunshot or stab wounds to the left lower chest should be evaluated with diagnostic lapa-roscopy or DPL to exclude diaphragmatic injury. In general, penetrating right diaphragm injury is ignored unless there is a major underlying liver injury with a risk of biliopleural fistula. Diagnostic laparoscopy may be preferred in patients with a posi-tive chest radiograph (hemothorax or pneumothorax) or in those who would not tolerate a DPL. For patients undergoing DPL evaluation, laboratory value cutoffs to rule out diaphragm injury are different from traditional values formerly used for abdomi-nal stab wounds (Table 7-6). An RBC count of >10,000/μL is considered a positive finding


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Surgery_Schwartz. value cutoffs to rule out diaphragm injury are different from traditional values formerly used for abdomi-nal stab wounds (Table 7-6). An RBC count of >10,000/μL is considered a positive finding and an indication for abdominal evaluation; patients with a DPL RBC count between 1000/μL and 10,000/μL should undergo laparoscopy or thoracoscopy.PenetratingAbdominalTraumaHemodynamicallyUnstableHemodynamicallyStableOperatingRoomGSWSWAnteriorAbdomenRUQTangential*,Back/FlankCTScan AASWwith+ LWE** Back/FlankSerialExams/Labs+*Tangential GSWs may also be evaluated with diagnostic laparoscopy.** A positive local wound exploration is defined as violation of the posterior fascia. CTScanLeft-sided thoracoabdominalDPL vs.laparoscopy++Evisceration/PeritonitisFigure 7-25. Algorithm for the evaluation of penetrating abdominal injuries. AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper


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Surgery_Schwartz. abdominal injuries. AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound.Table 7-6Criteria for “positive” finding on diagnostic peritoneal lavageABDOMINAL TRAUMATHORACOABDOMINAL STAB WOUNDSRed blood cell count>100,000/mL>10,000/mLWhite blood cell count>500/mL>500/mLAmylase level>19 IU/L>19 IU/LAlkaline phosphatase level>2 IU/L>2 IU/LBilirubin level>0.01 mg/dL>0.01 mg/dLBlunt abdominal trauma is now evaluated initially by FAST examination, and this has supplanted DPL (Fig. 7-26). FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is warranted in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage.31 FAST is used to identify free intraperitoneal fluid (Fig. 7-27) in Morrison’s pouch, the left upper quadrant, and the pelvis. Although this method is sensitive for


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Surgery_Schwartz. to rule out abdominal hemorrhage.31 FAST is used to identify free intraperitoneal fluid (Fig. 7-27) in Morrison’s pouch, the left upper quadrant, and the pelvis. Although this method is sensitive for detecting Brunicardi_Ch07_p0183-p0250.indd 20210/12/18 6:18 PM 203TRAUMACHAPTER 7HemodynamicallystableFAST +DPALaparotomyEquivocalPeritonitis?FAST +Candidate fornonoperativemanagementorpatient withcirrhosisIndications for CT:-Altered mental status-Confounding injury-Gross hematuria-Pelvic fracture-Abdominal tenderness-Unexplained Hct <35%Abdominal CTRepeat FASTin 30 minutesNoNoNoNoYesYesYesYesYesNoNoFigure 7-26. Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit.Figure 7-27. Focused abdominal sonography for trauma imag-ing detects intra-abdominal hemorrhage. Hemorrhage is presumed when a fluid stripe is visible


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Surgery_Schwartz. sonography for trauma; Hct = hematocrit.Figure 7-27. Focused abdominal sonography for trauma imag-ing detects intra-abdominal hemorrhage. Hemorrhage is presumed when a fluid stripe is visible between the right kidney and liver (A), between the left kidney and spleen (B), or in the pelvis (C).Brunicardi_Ch07_p0183-p0250.indd 20310/12/18 6:18 PM 204BASIC CONSIDERATIONSPART IFigure 7-28. Computed tomography images reveal critical infor-mation about solid organ injuries, such as associated contrast extravasation from a grade IV laceration of the spleen (A; arrow) and the amount of subcapsular hematoma in a grade III liver lacera-tion (B; arrows).intraperitoneal fluid of >250 mL, it does not reliably deter-mine the source of hemorrhage nor grade solid organ inju-ries.51 Patients with fluid on FAST examination, considered a “positive FAST,” who do not have immediate indications for laparotomy (hemodynamically stable, no evidence of perito-nitis) undergo CT scanning to quantify their


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Surgery_Schwartz. on FAST examination, considered a “positive FAST,” who do not have immediate indications for laparotomy (hemodynamically stable, no evidence of perito-nitis) undergo CT scanning to quantify their injuries. Injury grading using the American Association for the Surgery of Trauma (AAST) grading scale (Table 7-7) is an important component of nonoperative management of solid organ inju-ries. Additional findings that should be noted on CT scan in patients with solid organ injury include contrast extravasa-tion (i.e., a “blush”), the amount of intra-abdominal hemor-rhage, and presence of pseudoaneurysms (Fig. 7-28). CT also is indicated for hemodynamically stable patients for whom the physical examination is unreliable. Despite the increasing diagnostic accuracy of multidetector CT scanners, identifica-tion of intestinal injuries remains a limitation. Bowel injury is suggested by findings of thickened bowel wall, “streak-ing” in the mesentery, free fluid without associated solid organ


Surgery_Schwartz

Surgery_Schwartz. identifica-tion of intestinal injuries remains a limitation. Bowel injury is suggested by findings of thickened bowel wall, “streak-ing” in the mesentery, free fluid without associated solid organ injury, or free intraperitoneal air.52,53 Patients with free intra-abdominal fluid without solid organ injury are closely monitored for evolving signs of peritonitis; if patients have a significant closed head injury or cannot be serially examined, DPL should be performed to exclude bowel injury. If DPL is pursued, an infraumbilical approach is used (Fig. 7-29). After placement of the catheter, a 10-mL syringe is connected and the abdominal contents aspirated (termed a diagnostic perito-neal aspiration). The aspirate is considered positive if >10 mL of blood is aspirated. If <10 mL is withdrawn, a liter of normal saline is instilled. The effluent is withdrawn via siphoning and sent to the laboratory for RBC count, white blood cell (WBC) count, and determination of amylase, bilirubin, and


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Surgery_Schwartz. a liter of normal saline is instilled. The effluent is withdrawn via siphoning and sent to the laboratory for RBC count, white blood cell (WBC) count, and determination of amylase, bilirubin, and alkaline phosphatase levels. Values representing positive findings are summarized in Table 7-6.Table 7-7American Association for the Surgery of Trauma grading scales for solid organ injuriesSUBCAPSULAR HEMATOMALACERATIONLiver Injury GradeGrade I<10% of surface area<1 cm in depthGrade II10%–50% of surface area1–3 cmGrade III>50% of surface area or >10 cm in depth>3 cmGrade IV25%–75% of a hepatic lobeGrade V>75% of a hepatic lobeGrade VIHepatic avulsionSplenic Injury GradeGrade I<10% of surface area<1 cm in depthGrade II10%–50% of surface area1–3 cmGrade III>50% of surface area or >10 cm in depth>3 cmGrade IV>25% devascularizationHilumGrade VShattered spleenComplete devascularizationPelvis. Blunt injury to the pelvis may produce mechanically unstable fractures with major hemorrhage (Fig.


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Surgery_Schwartz. cmGrade IV>25% devascularizationHilumGrade VShattered spleenComplete devascularizationPelvis. Blunt injury to the pelvis may produce mechanically unstable fractures with major hemorrhage (Fig. 7-30). Plain radiographs will reveal gross abnormalities, but CT scanning is necessary to determine the precise geometry. Sharp spicules of bone can lacerate the bladder, rectum, or vagina. Alterna-tively, bladder rupture may result from a direct blow to the torso if the bladder is full. CT cystography is performed if the urinalysis demonstrates RBCs. Urethral injuries are suspected if examination reveals blood at the meatus, scrotal or perineal hematomas, or a high-riding prostate on rectal examination. Urethrograms should be obtained for stable patients before placing a Foley catheter to avoid false passage and subsequent stricture. Major vascular injuries of the external iliacs caus-ing bleeding are uncommon in blunt pelvic trauma; however, thrombosis of either the arteries or veins in the


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Surgery_Schwartz. passage and subsequent stricture. Major vascular injuries of the external iliacs caus-ing bleeding are uncommon in blunt pelvic trauma; however, thrombosis of either the arteries or veins in the iliofemoral system may occur, and CTA should be performed for evalu-ation if there is a pulse differential. Life-threatening hemor-rhage can be associated with pelvic fractures and may initially Brunicardi_Ch07_p0183-p0250.indd 20410/12/18 6:18 PM 205TRAUMACHAPTER 7Figure 7-29. Diagnostic peritoneal lavage is performed through an infraumbilical incision unless the patient has a pelvic fracture or is preg-nant. A. The linea alba is sharply incised, and the catheter is directed into the pelvis. B. The abdominal contents should initially be aspirated using a 10-mL syringe.preclude definitive imaging. Treatment algorithms for patients with complex pelvic fractures and hemodynamic instability are presented later in the chapter.Extremities. Blunt or penetrating trauma to the extremities requires


Surgery_Schwartz

Surgery_Schwartz. Treatment algorithms for patients with complex pelvic fractures and hemodynamic instability are presented later in the chapter.Extremities. Blunt or penetrating trauma to the extremities requires an evaluation for fractures, ligamentous disruption, and neurovascular injury. Plain radiographs are used to evaluate fractures, whereas ligamentous injuries, particularly those of the knee and shoulder, can be imaged with magnetic resonance imaging. Physical examination identifies the majority of arte-rial injuries, and findings are classified as either hard signs or soft signs of vascular injury (Table 7-8). In general, hard signs constitute indications for operative exploration, whereas soft signs are indications for further testing or observation. Bony fractures or knee dislocations should be realigned before defini-tive vascular examination. In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries


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Surgery_Schwartz. realigned before defini-tive vascular examination. In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries in proximity to major vessels. It is known that some of these patients will have arterial injuries that require repair. The most common approach has been to measure SBP using Doppler ultrasonography and compare the value for the injured side with that for the unin-jured side, termed the A-A index.54 If the pressures are within 10% of each other, a significant injury is unlikely, and no fur-ther evaluation is performed. If the difference is >10%, CTA or arteriography is indicated. Others argue that there are occult injuries, such as pseudoaneurysms or injuries of the profunda femoris or peroneal arteries, which may not be detected with this technique. If hemorrhage occurs from these injuries, com-partment syndrome and limb loss may occur. Although busy trauma centers continue to debate


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Surgery_Schwartz. arteries, which may not be detected with this technique. If hemorrhage occurs from these injuries, com-partment syndrome and limb loss may occur. Although busy trauma centers continue to debate this issue, the surgeon who is obliged to treat the occasional injured patient may be better served by performing CTA in selected patients with soft signs. In patients with hard signs of vascular injury, on-table angi-ography may be useful to localize the arterial injury and thus, limit tissue dissection. For example, a patient with an absent popliteal pulse and femoral shaft fracture due to a bullet that entered the lateral hip and exited below the medial knee could have injured either the femoral or popliteal artery anywhere along its course (Fig. 7-31).GENERAL PRINCIPLES OF MANAGEMENTOver the past 25 years there has been a remarkable change in management practices and operative approach for the injured patient. With the advent of CT scanning, nonoperative man-agement of solid organ injuries


Surgery_Schwartz

Surgery_Schwartz. 25 years there has been a remarkable change in management practices and operative approach for the injured patient. With the advent of CT scanning, nonoperative man-agement of solid organ injuries has replaced routine operative exploration. Those patients who do require operation may be treated with less radical resection techniques, such as splen-orrhaphy or partial nephrectomy. Colonic injuries, previously mandating colostomy, are now repaired primarily in virtually all cases. Additionally, the type of anastomosis has shifted from a double-layer closure to a continuous running single-layer clo-sure; this method is technically equivalent to and faster than the interrupted multilayer techniques.55 Adoption of damage con-trol surgical techniques in physiologically deranged patients has resulted in limited initial operative time, with definitive injury repair delayed until after resuscitation in the surgical intensive care unit (SICU) with physiologic restoration.56 Abdominal drains,


Surgery_Schwartz

Surgery_Schwartz. in limited initial operative time, with definitive injury repair delayed until after resuscitation in the surgical intensive care unit (SICU) with physiologic restoration.56 Abdominal drains, once considered mandatory for parenchymal injuries and some anastomoses, have disappeared; fluid collections are managed by percutaneous techniques. Newer endovascular Brunicardi_Ch07_p0183-p0250.indd 20510/12/18 6:18 PM 206BASIC CONSIDERATIONSPART ITable 7-8Signs and symptoms of peripheral arterial injuryHARD SIGNS (OPERATION MANDATORY)SOFT SIGNS (FURTHER EVALUATION INDICATED)Pulsatile hemorrhageProximity to vasculatureAbsent pulsesSignificant hematomaAcute ischemiaAssociated nerve injuryA-A index of <0.9Thrill or bruitA-A index = systolic blood pressure on the injured side compared with that on the uninjured side.techniques such as stenting of arterial injuries and angioem-bolization are routine adjuncts. Blunt cerebrovascular injuries have been recognized as a significant, preventable


Surgery_Schwartz

Surgery_Schwartz. on the uninjured side.techniques such as stenting of arterial injuries and angioem-bolization are routine adjuncts. Blunt cerebrovascular injuries have been recognized as a significant, preventable source of neurologic morbidity and mortality. The use of preperitoneal pelvic packing for unstable pelvic fractures as well as early frac-ture immobilization with external fixators are paradigm shifts in management. Recently resuscitative endovascular balloon occlusion (REBOA) has been added to the armamentarium for life-threatening pelvic fracture bleeding57,58 (Fig. 7-32). Finally, the institution of massive transfusion protocols balances the benefit of blood component therapy against immunologic risk. Viscoelastic hemostatic assays (TEG and ROTEM) have been shown to be superior to traditional laboratory tests and have been central to the evolving concept of goal-directed hemo-stasis.59 These many conceptual changes have significantly improved survival of critically injured patients; they


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Surgery_Schwartz. laboratory tests and have been central to the evolving concept of goal-directed hemo-stasis.59 These many conceptual changes have significantly improved survival of critically injured patients; they have been promoted and critically reviewed by academic trauma centers via forums such as the American College of Surgeons Com-mittee on Trauma, the American Association for the Surgery of Trauma, the International Association of Trauma Surgery and Intensive Care, the Pan-American Trauma Congress, and other surgical organizations.Transfusion PracticesInjured patients with life-threatening hemorrhage develop acute coagulopathy of trauma (ACOT).60,61 The mechanism for inad-equate clot formation remains uncertain, but it is believed to involve activation of protein C, which impairs Va and VIIa, glycocalyx breakdown, which releases heparin sulfate, immune Figure 7-30. The three types of mechanically unstable pelvis fractures are lateral compression (A), anteroposterior compression (B), and


Surgery_Schwartz

Surgery_Schwartz. glycocalyx breakdown, which releases heparin sulfate, immune Figure 7-30. The three types of mechanically unstable pelvis fractures are lateral compression (A), anteroposterior compression (B), and vertical shear (C).Brunicardi_Ch07_p0183-p0250.indd 20610/12/18 6:18 PM 207TRAUMACHAPTER 7activation with the releases of DAMPs, DNA, histone, poly-phosphate, and PMN elastase, and complement activation. Fibrinolysis is an important component of the ACOT; hyper-fibrinolysis and fibrinolysis shutdown are both associated with increased mortality.62 Fresh whole blood, arguably the optimal replacement, has not been available in the United States since the early 1980s. Rather, its component parts, packed red blood cells (PRBCs), fresh frozen plasma, platelets, and cryoprecipi-tate, are administered. Specific transfusion triggers for indi-vidual blood components remain debated.63 Although current critical care guidelines indicate that PRBC transfusion should occur once the patient’s


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Surgery_Schwartz. administered. Specific transfusion triggers for indi-vidual blood components remain debated.63 Although current critical care guidelines indicate that PRBC transfusion should occur once the patient’s hemoglobin level is <7 g/dL,64 in the acute phase of resuscitation a hemoglobin of 10 g/dL is suggested to facilitate hemostasis via platelet margination.65 The traditional Figure 7-31. On-table angiography in the operating room isolates the area of vascular injury to the superficial femoral artery in a patient with a femoral fracture after a gunshot wound to the lower extremity.ABthresholds for blood component replacement in the patient mani-festing a coagulopathy have been INR >1.5, PTT >1.5 normal, platelet count >50,000/μL, and fibrinogen >100 mg/dl. However, these guidelines have been replaced by TEG and ROTEM cri-teria in many trauma centers. Such guidelines are designed to limit the transfusion of immunologically active blood compo-nents and decrease the risk of


Surgery_Schwartz

Surgery_Schwartz. have been replaced by TEG and ROTEM cri-teria in many trauma centers. Such guidelines are designed to limit the transfusion of immunologically active blood compo-nents and decrease the risk of transfusion-associated lung injury and secondary multiple organ failure.66,67In the critically injured patient requiring large amounts of blood component therapy, a massive transfusion protocol should be followed (Fig. 7-33). This approach calls for administration of various components in a specific ratio during transfusion to achieve restoration of blood volume to reverse shock and cor-rect coagulopathy. Although the optimal ratio is unknown, cur-rent evidence suggests a presumptive 1:2 red cell:plasma ratio in patients at risk for massive transfusion (10 units of PRBCs in 6 hours).67-72 Because complete typing and cross-matching takes up to 45 minutes, patients requiring emergent transfusions are given type O-negative RBCs. Similarly, without time for blood typing, AB plasma is the universal


Surgery_Schwartz

Surgery_Schwartz. typing and cross-matching takes up to 45 minutes, patients requiring emergent transfusions are given type O-negative RBCs. Similarly, without time for blood typing, AB plasma is the universal donor, although A plasma appears to be a safe option. Blood typing, and to a lesser extent cross-matching, is essential to avoid life-threatening intravas-cular hemolytic transfusion reactions. Trauma centers and their associated blood banks must have the capability of transfusing tremendous quantities of blood components because it is not unusual to have >50 component units transfused during one procedure and have the patient survive. Massive transfusion protocols, established preemptively, permit coordination of the activities of surgeons, anesthesiologists, and blood bankers to facilitate transfusion of the appropriate blood products.Postinjury coagulopathy due to shock is aggravated by core hypothermia and metabolic acidosis, termed the bloody vicious cycle,56 and now commonly referred to as


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Surgery_Schwartz. of the appropriate blood products.Postinjury coagulopathy due to shock is aggravated by core hypothermia and metabolic acidosis, termed the bloody vicious cycle,56 and now commonly referred to as the lethal triad. The pathophysiology is multifactorial and includes inhibition of temperature-dependent enzyme-acti-vated coagulation cascades, platelet dysfunction, endothelial abnormalities, and fibrinolytic activity. Such coagulopathy may be insidious, so the surgeon must be cognizant of subtle signs such as excessive bleeding from the cut edges of skin. Point-of-care viscoelastic assays (TEG and ROTEM), which provide a comprehensive assessment of clot capacity and fibri-nolysis, can provide useful information within 15 minutes. In contrast, traditional laboratory tests of coagulation capability (i.e., INR, PTT, fibrinogen levels, and platelet count) requires at least 45 minutes. Using damage control techniques to limit operative time and provide physiologic restoration in the SICU can be


Surgery_Schwartz

Surgery_Schwartz. (i.e., INR, PTT, fibrinogen levels, and platelet count) requires at least 45 minutes. Using damage control techniques to limit operative time and provide physiologic restoration in the SICU can be lifesaving (see “Damage Control Surgery”).8Figure 7-32. A. Resuscitative endovascular balloon of the aorta (REBOA) is introduced through a 7Fr arterial sheath in the common femoral artery using ultrasound guidance. B. For patients with pelvic fractures and hemodynamic instabil-ity, the balloon is positioned in zone III just above the aortic bifurcation; a mixture of saline and contrast is used to inflate the balloon, which can be visualized on bedside plain radiography.Brunicardi_Ch07_p0183-p0250.indd 20710/12/18 6:18 PM 208BASIC CONSIDERATIONSPART IFigure 7-33. Denver Health Medical Center’s Massive Transfusion Protocol (MTP). ACT = activated clotting time; Cryo = cryoprecipitate; FFP = fresh frozen plasma; MA = maximum amplitude; PRBC = packed red blood cells; PTT = partial


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Surgery_Schwartz. Center’s Massive Transfusion Protocol (MTP). ACT = activated clotting time; Cryo = cryoprecipitate; FFP = fresh frozen plasma; MA = maximum amplitude; PRBC = packed red blood cells; PTT = partial thromboplastin time; SBP = systolic blood pressure; TEG = thromboelastography.Prophylactic MeasuresAll injured patients undergoing an operation should receive preoperative antibiotics. The type of antibiotic is determined by the anticipated source of contamination in the abdomen or other operative region; additional doses should be adminis-tered during the procedure based on blood loss and the half-life of the antibiotic. Extended postoperative antibiotic therapy is administered only for contaminated open fractures. Tetanus prophylaxis is administered to all patients according to pub-lished guidelines.Trauma patients are at risk for venous thromboembolism and its associated morbidity and mortality. In fact, pulmo-nary embolus can occur much earlier in the patient’s hospital course than


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Surgery_Schwartz. guidelines.Trauma patients are at risk for venous thromboembolism and its associated morbidity and mortality. In fact, pulmo-nary embolus can occur much earlier in the patient’s hospital course than previously believed.73 Patients at higher risk for venous thromboembolism are those with multiple fractures of the pelvis and lower extremities, those with TBI or spinal cord injury, and those requiring ligation of large veins in the abdo-men and lower extremities. Morbidly obese patients and those over 55 years of age are at additional risk. Administration of low molecular weight heparin (LMWH) is initiated as soon MASSIVE TRANSFUSION PROTOCOL FOR TRAUMAAny of these in the ED:• Penetrating Torso Injury• Major Pelvic Fracture• FAST ˜ >1 Body Region• SBP 70 OR• SBP 71–90 AND HR š108 if ... your patient has these VS in the FIELD or EDACTIVATE MTPCaCl2 1 gr. i.v.Transfuse RBC 4 Unitsand FFP 2 UnitsOrder Citrated Rapid TEGContinue to component transfusion based on TEG Resultsif


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Surgery_Schwartz. if ... your patient has these VS in the FIELD or EDACTIVATE MTPCaCl2 1 gr. i.v.Transfuse RBC 4 Unitsand FFP 2 UnitsOrder Citrated Rapid TEGContinue to component transfusion based on TEG Resultsif patient is bleedingANDACT>128 sec Angle<65°MA<55 mmLY30 š10%FFP 2 UnitsCryo10 UnitsPlatelets1 UnitTXA1 gmReassess via Citrated Rapid TEGMassive Transfusion ProtocolTriggers: SBP <70 with penetrating torso injury, major pelvic injury, FAST + SBP <71-90 mmHg and HR >108 with penetrating torso injury, major pelvic injury, FAST + ** order citrated rapid TEGContinued Treatment of ShockHemorrhage Control, Correct Hypothermia, Correct AcidosisNormalize Ca++Empiric Transfusion Until Lab Results AvailableShipmentPRBCsFFPPlateletsCryo142242110TEG Based Resuscitation*rapidTEG-ACT >128 sec ˜ 2 units thawed plasmarapidTEG-MA <55mm ˜ 1 unit of apheresis plateletsrapidTEG-angle <66 degrees ˜ 10 units pooled cryoprecipitaterapidTEG EPL >9% ˜ 1g tranexamic acid*Transfusion Triggers if TEGis


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Surgery_Schwartz. 2 units thawed plasmarapidTEG-MA <55mm ˜ 1 unit of apheresis plateletsrapidTEG-angle <66 degrees ˜ 10 units pooled cryoprecipitaterapidTEG EPL >9% ˜ 1g tranexamic acid*Transfusion Triggers if TEGis UnavailablePT, PTT > 1.5 control ˜2 units thawed plasmaPlatelet count <50,000/mcL ˜1 unit of apheresis plateletsFibrinogen <100 mg/dL ˜10 units pooled cryoprecipitateBrunicardi_Ch07_p0183-p0250.indd 20810/12/18 6:18 PM 209TRAUMACHAPTER 7Figure 7-34. A. Unilateral neck exploration is performed through an incision along the anterior border of the sternocleidomastoid muscle; exposure of the carotid artery requires early division of the facial vein. B. The distal internal carotid artery is exposed by dividing the ansa cervicalis, which permits mobilization of the hypoglossal nerve. C. Further exposure is facilitated by resection of the posterior belly of the digastric muscle.as bleeding has been controlled and there is stable intracranial pathology. In high-risk patients, antiplatelet


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Surgery_Schwartz. exposure is facilitated by resection of the posterior belly of the digastric muscle.as bleeding has been controlled and there is stable intracranial pathology. In high-risk patients, antiplatelet therapy should be added.74 Removable inferior vena caval filters should be con-sidered if there are prolonged contraindications to administra-tion of LMWH. Additionally, pulsatile compression stockings (also termed sequential compression devices) are used routinely unless there is a fractured lower extremity or vascular injury.A final prophylactic measure that is usually not consid-ered is thermal protection. Hemorrhagic shock impairs perfu-sion and metabolic activity throughout the body, with resultant decrease in heat production and body temperature. Removing the patient’s clothes causes a second thermal insult, and infu-sion of cold PRBCs or room temperature crystalloid exacerbates the problem. As a result, injured patients can become hypother-mic, with temperatures below 34°C (93.2°F)


Surgery_Schwartz

Surgery_Schwartz. thermal insult, and infu-sion of cold PRBCs or room temperature crystalloid exacerbates the problem. As a result, injured patients can become hypother-mic, with temperatures below 34°C (93.2°F) upon arrival in the OR. Hypothermia aggravates coagulopathy and provokes myocardial irritability. Therefore, prevention must begin in the ED by maintaining a comfortable ambient temperature, cover-ing patients with warm blankets, and administering warmed IV fluids and blood products. Additionally, in the OR a Bair Hug-ger® warmer (the upper body or lower body blanket) and heated inhalation via the ventilatory circuit is instituted. For cases of severe hypothermia (temperature <30°C [86°F]), arteriovenous rewarming should be considered.Operative Approaches and ExposureCervical Exposure. Operative exposure for midline structures of the neck (e.g., trachea, thyroid, bilateral carotid sheaths) is obtained through a collar incision; this is typically performed two finger breadths above the sternal


Surgery_Schwartz

Surgery_Schwartz. for midline structures of the neck (e.g., trachea, thyroid, bilateral carotid sheaths) is obtained through a collar incision; this is typically performed two finger breadths above the sternal notch, but can be varied based on the level of anticipated injury. After subplatysmal flap elevation, the strap muscles are divided in the midline to gain access to the central neck compartment. More superior and lateral structures are accessed by extending the collar incision upward along the sternocleidomastoid muscle; this may be done bilaterally if neces-sary. For unilateral injuries, neck exploration is done through an incision extending from the mastoid down to the clavicle, along the anterior border of the sternocleidomastoid muscle (Fig. 7-34). Brunicardi_Ch07_p0183-p0250.indd 20910/12/18 6:19 PM 210BASIC CONSIDERATIONSPART IBFigure 7-36. A. A “clamshell” thoracotomy provides exposure to bilateral thoracic cavities. B. Sternal transection requires individual ligation of both the


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Surgery_Schwartz. 6:19 PM 210BASIC CONSIDERATIONSPART IBFigure 7-36. A. A “clamshell” thoracotomy provides exposure to bilateral thoracic cavities. B. Sternal transection requires individual ligation of both the proximal and distal internal mammary arteries on the undersurface of the sternum.123Figure 7-35. Options for thoracic exposure include the most versa-tile incision, the anterolateral thoracotomy (1), as well as a median sternotomy (2) and a “trap door” thoracotomy (3). Any thoracic incision may be extended into a supraclavicular or anterior neck incision for wider exposure.The carotid sheath, containing the carotid artery, jugular vein, and vagus nerve, is opened widely to examine these structures. The facial vein, which marks the carotid bifurcation, is usually ligated for exposure of the internal carotid artery and the hypoglossal nerve is the next structure encountered.Exposure of the distal carotid artery in zone III is difficult (see Fig. 7-34). The first step is division of the ansa


Surgery_Schwartz

Surgery_Schwartz. carotid artery and the hypoglossal nerve is the next structure encountered.Exposure of the distal carotid artery in zone III is difficult (see Fig. 7-34). The first step is division of the ansa cervicalis to facilitate mobilization of the hypoglossal nerve. Next, the poste-rior portion of the digastric muscle, which overlies the internal carotid, is transected. The glossopharyngeal and vagus nerves are also mobilized and retracted as necessary. If accessible, the styloid process and attached muscles are removed. In desperate situations, anterior displacement of the mandible (subluxation) may be helpful or the vertical ramus of the mandible may be divided. However, the latter maneuver often entails resection of the parotid gland, and the facial nerve is at risk of injury.Thoracic Incisions. An anterolateral thoracotomy, with the patient placed supine, is the most versatile incision for emer-gent thoracic exploration. The location of the incision is in the fifth interspace, in the


Surgery_Schwartz

Surgery_Schwartz. anterolateral thoracotomy, with the patient placed supine, is the most versatile incision for emer-gent thoracic exploration. The location of the incision is in the fifth interspace, in the inframammary line (Fig. 7-35). If access is needed to both pleural cavities, the original incision can be extended across the sternum with a Lebsche knife, into a “clam-shell” thoracotomy (Fig. 7-36). If the sternum is divided, the internal mammary arteries should be ligated to prevent blood loss. The heart, lungs, descending aorta, pulmonary hilum, and esophagus are accessible with this approach. For control of the great vessels, the superior portion of the sternum may be divided vertically with extension of the incision into the neck considered. A method advocated for access to the proximal left subclavian artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular incision (“trap door” thoracotomy). Although the trap door procedure is


Surgery_Schwartz

Surgery_Schwartz. artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular incision (“trap door” thoracotomy). Although the trap door procedure is appro-priate after resuscitative thoracotomy, the proximal left subcla-vian artery can be accessed more easily via a sternotomy with a supraclavicular extension. If the left subclavian artery is injured outside the thoracic outlet, vascular control can be obtained via the sternotomy and definitive repair done through the supraclavicular incision. Emergent median sternotomy is optimal for anterior stab wounds to the heart. Typically, these patients have pericardial tamponade and may undergo placement of a pericardial drain before a semiurgent median sternotomy is performed. Patients in extremis, however, should undergo anterolateral thoracotomy.Median sternotomy with cervical extension is used for rapid exposure in patients with presumed proximal subclavian, innominate, or proximal carotid artery


Surgery_Schwartz

Surgery_Schwartz. should undergo anterolateral thoracotomy.Median sternotomy with cervical extension is used for rapid exposure in patients with presumed proximal subclavian, innominate, or proximal carotid artery injuries. Care must be taken to avoid injury to the phrenic and vagus nerves that pass over the subclavian artery and to the recurrent laryngeal nerve passing posteriorly. Posterolateral thoracotomies are used for exposure of injuries to the trachea or main stem bronchi near the carina or the upper esophagus (right posterolateral thoracotomy) and tears of the descending thoracic aorta or lower esophagus (left posterolateral thoracotomy).Emergent Abdominal Exploration. Abdominal exploration in adults is performed using a midline incision because of its versatility. For children under the age of 6, a transverse inci-sion may be advantageous. Making the incision is faster with a scalpel than with an electrosurgical unit; incisional abdominal wall bleeding should be ignored until intra-abdominal


Surgery_Schwartz

Surgery_Schwartz. a transverse inci-sion may be advantageous. Making the incision is faster with a scalpel than with an electrosurgical unit; incisional abdominal wall bleeding should be ignored until intra-abdominal sources of hemorrhage are controlled. Liquid and clotted blood are Brunicardi_Ch07_p0183-p0250.indd 21010/12/18 6:19 PM 211TRAUMACHAPTER 7Figure 7-37. A sagittal view of packs placed to control hepatic hemorrhage. LAP = laparotomy.Figure 7-38. The Pringle maneuver, performed with a vascular clamp, occludes the hepatic pedicle containing the portal vein, hepatic artery, and common bile duct.evacuated with multiple laparotomy pads to identify the major source(s) of active bleeding. After blunt trauma, the spleen and liver should be palpated first and packed if fractured, and the infracolic mesentery should be inspected for zone I vascular injury. In contrast, after a penetrating wound the search for bleeding should pursue the trajectory of the penetrating device. If the patient has an


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Surgery_Schwartz. mesentery should be inspected for zone I vascular injury. In contrast, after a penetrating wound the search for bleeding should pursue the trajectory of the penetrating device. If the patient has an SBP of <70 mmHg when the abdomen is opened, digital pressure or a clamp should be placed on the aorta at the diaphragmatic hiatus. After the source of hemorrhage is localized, direct digital occlusion (vascular injury) or laparot-omy pad packing (solid organ injury) is used to control bleed-ing (Fig. 7-37). If the liver is the source in a hemodynamically Figure 7-39. To mobilize the spleen, an incision is made into the endoabdominal fascia 1 cm lateral to the reflection of the peritoneum onto the spleen (A). While the spleen is gently rotated medially, a plane is developed between the pancreas and left kidney (B). With complete mobilization, the spleen can reach the level of the abdominal incision.unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle


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Surgery_Schwartz. and left kidney (B). With complete mobilization, the spleen can reach the level of the abdominal incision.unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle with a vascular clamp or Rummel tourniquet (termed the Pringle maneuver) (Fig. 7-38). Similarly, clamping the splenic hilum may be required for hilar bleeding. When the spleen is mobilized, it should be gently rotated medi-ally to expose the lateral peritoneum; this peritoneum and endo-abdominal fascia are incised, which allows blunt dissection of the spleen and pancreas as a composite from the retroperito-neum anterior to Gerota’s fascia (Fig. 7-39).Rapid exposure of the intra-abdominal vasculature can prove challenging in the face of exsanguinating hemorrhage. Proximal control of the aorta is obtained at the diaphragmatic hiatus; if an aortic injury is supraceliac, transecting the left crus of diaphragm or extending the laparotomy via a left thoracotomy may be necessary.


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Surgery_Schwartz. of the aorta is obtained at the diaphragmatic hiatus; if an aortic injury is supraceliac, transecting the left crus of diaphragm or extending the laparotomy via a left thoracotomy may be necessary. Brunicardi_Ch07_p0183-p0250.indd 21110/12/18 6:19 PM 212BASIC CONSIDERATIONSPART IAn alternative for a contained hematoma is placement of a trans-femoral REBOA into zone I. The first decision is whether the patient has a supracolic or an infracolic vascular injury. Supracolic injuries (aorta, celiac axis, proximal superior mesenteric artery [SMA], and left renal arteries) are best approached via a left medial visceral rotation (Fig. 7-40). This is done by incising the lateral peritoneal reflection (white line of Toldt) beginning at the distal descending colon and extending the incision along the colonic splenic flexure, around the posterior aspect of the spleen, and behind the gastric fundus, ending at the esophagus. The left colon, spleen, pancreas, and stomach are then rotated toward


Surgery_Schwartz

Surgery_Schwartz. the colonic splenic flexure, around the posterior aspect of the spleen, and behind the gastric fundus, ending at the esophagus. The left colon, spleen, pancreas, and stomach are then rotated toward the midline. The authors prefer to leave the kidney in situ when mobilizing the viscera because this exaggerates the separation of the renal vessels from the SMA. The operative approach for SMA injuries is based on the level of injury. Fullen zone I SMA injuries, located posterior to the pancreas, are best exposed by a left medial visceral rotation. Fullen zone II SMA injuries, extending from the pancreatic edge to the middle colic branch, on the other hand, are approached via the lesser sac along the inferior edge of the pancreas at the base of the transverse mesocolon; the pancreatic body may be divided to gain proximal vascular access. More distal SMA injuries, Fullen zones III and IV, are approached directly within the mesentery. A venous injury behind the pancreas, from the junction of


Surgery_Schwartz

Surgery_Schwartz. be divided to gain proximal vascular access. More distal SMA injuries, Fullen zones III and IV, are approached directly within the mesentery. A venous injury behind the pancreas, from the junction of the superior mesenteric, splenic, and portal veins, is accessed by dividing the neck of the pancreas. Inferior vena cava injuries are approached by a right medial visceral rotation (Fig. 7-41). Proximal control is Figure 7-41. A right medial visceral rotation is used to expose the infrahepatic vena cava.Figure 7-40. A left medial visceral rotation is used to expose the abdominal aorta.obtained just above the iliac bifurcation with direct pressure via a sponge stick; the injury is identified by cephalad dissection along the anterior surface of the inferior vena cava. A Satinsky clamp can be used to control anterior caval wounds.Injuries of the iliac vessels pose a unique problem for emergent vascular control due to the number of vessels, their close proximity, and cross circulation.


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Surgery_Schwartz. be used to control anterior caval wounds.Injuries of the iliac vessels pose a unique problem for emergent vascular control due to the number of vessels, their close proximity, and cross circulation. Proximal control at the infrarenal aorta arrests the arterial bleeding and avoids splanch-nic and renal ischemia; however, venous injuries are not con-trolled with aortic clamping. Tamponade with digital pressure or with a folded laparotomy pad held directly over the bleeding site usually will establish hemostasis sufficient to prevent exsan-guination. If hemostasis is not adequate to expose the vessel proximal and distal to the injury, sponge sticks can be strategi-cally placed on either side of the injury and carefully adjusted to improve hemostasis. Alternatively, complete pelvic vascular isolation (Fig. 7-42) may be required to control hemorrhage for adequate visualization of the injuries. The right common iliac artery obscures the bifurcation of the vena cava and the right iliac vein;


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Surgery_Schwartz. (Fig. 7-42) may be required to control hemorrhage for adequate visualization of the injuries. The right common iliac artery obscures the bifurcation of the vena cava and the right iliac vein; the iliac artery may require division to expose venous injuries in this area (Fig. 7-43). The artery must be repaired after the venous injury is treated, however, because of limb-threatening ischemia.Once overt hemorrhage is controlled, sources of enteric contamination are identified by serially running along the small and large bowel, looking at all surfaces. Associated hematomas should be unroofed to rule out adjacent bowel injury. The ante-rior and posterior aspects of the stomach should be inspected, which requires opening the lesser sac for complete visualiza-tion. Duodenal injuries should be evaluated with a wide Kocher maneuver. During exploration of the lesser sac, visualization and palpation of the pancreas is done to exclude injury. Palpat-ing the anterior surface is not sufficient


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Surgery_Schwartz. evaluated with a wide Kocher maneuver. During exploration of the lesser sac, visualization and palpation of the pancreas is done to exclude injury. Palpat-ing the anterior surface is not sufficient because the investing Brunicardi_Ch07_p0183-p0250.indd 21210/12/18 6:19 PM 213TRAUMACHAPTER 7fascia may mask a pancreatic injury; mobilization, including evaluation of the posterior aspect, is critical. After injuries are identified, whether to use damage control techniques or per-form primary repair of injuries is based on the patient’s intraop-erative physiologic status (see “Damage Control Surgery” and “Treatment of Specific Injuries”). In a patient with multisys-tem trauma, enteral access via gastrostomy or jejunostomy tube should be considered. If abdominal closure is indicated after the patient’s injuries are addressed, the abdomen is irrigated with warm saline and the midline fascia is closed with a running heavy absorbable suture. The skin is closed selectively based on the


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Surgery_Schwartz. the patient’s injuries are addressed, the abdomen is irrigated with warm saline and the midline fascia is closed with a running heavy absorbable suture. The skin is closed selectively based on the amount of intra-abdominal contamination.Figure 7-42. Pelvic vascular isolation. A. Initially, clamps are placed on the aorta, inferior vena cava, and bilateral external iliac vessels. B. With continued dissection, the clamps can be moved progressively closer to the vascular injury to limit unwarranted ischemia.Figure 7-43. The right common iliac artery can be divided to expose the bifurcation of the inferior vena cava and the right common iliac vein.Table 7-9Options for the treatment of vascular injuriesObservationLigationLateral suture repairEnd-to-end primary anastomosisInterposition graftsAutogenous veinPolytetrafluoroethylene graftDacron graftTranspositionsExtra-anatomic bypassEndovascularStentsEmbolizationVascular Repair Techniques. Initial control of vascular inju-ries is accomplished


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Surgery_Schwartz. veinPolytetrafluoroethylene graftDacron graftTranspositionsExtra-anatomic bypassEndovascularStentsEmbolizationVascular Repair Techniques. Initial control of vascular inju-ries is accomplished digitally by applying enough direct pres-sure to stop the hemorrhage. Sharp dissection is used to define the injury and mobilize sufficient length for proximal and distal control. Fogarty thromboembolectomy should be done proxi-mally and distally to optimize collateral blood flow. Heparin-ized saline (50 units/mL) is then injected into the proximal and distal ends of the injured vessel to prevent small clot formation on the exposed intima and media. Ragged edges of the injury site should be debrided using sharp dissection. Intravascular shunts are used when there are multiple life-threatening injuries or the arterial injury is anticipated to require saphenous vein interposition reconstruction.Options for the treatment of vascular injuries are listed in Table 7-9. Arterial repair should always be


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Surgery_Schwartz. or the arterial injury is anticipated to require saphenous vein interposition reconstruction.Options for the treatment of vascular injuries are listed in Table 7-9. Arterial repair should always be done for the aorta, carotid, innominate, brachial, superior mesenteric, proper hepatic, renal, iliac, femoral, and popliteal arteries. Named arter-ies that usually tolerate ligation include the right or left hepatic artery and the celiac artery. In the lower extremities, at least one artery with distal runoff should be salvaged. Arterial injuries that may be treated nonoperatively include small pseudoaneurysms, intimal dissections, small intimal flaps, and small arteriovenous Brunicardi_Ch07_p0183-p0250.indd 21310/12/18 6:19 PM 214BASIC CONSIDERATIONSPART IFigure 7-45. The parachute technique is helpful for accurate placement of the posterior sutures of an anastomosis when the arte-rial end is fixed and an interposition graft is necessary. Traction must be maintained on both ends of the


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Surgery_Schwartz. is helpful for accurate placement of the posterior sutures of an anastomosis when the arte-rial end is fixed and an interposition graft is necessary. Traction must be maintained on both ends of the suture to prevent loosening and leakage of blood. Six stitches should be placed before the graft is pulled down to the artery.Figure 7-44. Small arteries repaired with an end-to-end anastomo-sis are prone to stricture. Enlarging the anastomosis by beveling the cut ends of the injured vessel can minimize this problem. A curved hemostat is a useful adjunct to create the curve.fistulas in the extremities. Follow-up imaging is performed 1 to 2 weeks after injury to confirm healing. Venous repair should be performed for injuries of the superior vena cava, the inferior vena cava proximal to the renal veins, and the portal vein, although the portal vein may be ligated in extreme cases. The SMV should be repaired optimally, but >80% of patients will survive follow-ing ligation. Similarly, the left


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Surgery_Schwartz. veins, and the portal vein, although the portal vein may be ligated in extreme cases. The SMV should be repaired optimally, but >80% of patients will survive follow-ing ligation. Similarly, the left renal vein can usually be ligated adjacent to the IVC due to collateral decompression.The type of operative repair for a vascular injury is based on the extent and location of injury. Lateral suture repair is preferred for arterial injuries with minimal loss of tissue. End-to-end primary anastomosis is performed if the vessel can be repaired without tension. Arterial defects of 1 to 2 cm often can be bridged by mobilizing the severed ends of the vessel after ligating small branches. The aorta, subclavian artery, brachial artery, and popliteal artery however, are difficult to mobilize for additional length. To avoid postoperative stenosis, particularly in smaller arteries, beveling or spatulation should be used so that the completed anastomosis is slightly larger in diameter than the native


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Surgery_Schwartz. length. To avoid postoperative stenosis, particularly in smaller arteries, beveling or spatulation should be used so that the completed anastomosis is slightly larger in diameter than the native artery (Fig. 7-44). The authors emphasize the parachute technique to ensure precision placement of the posterior suture line (Fig. 7-45). If this technique is used, traction must be main-tained on both ends of the suture, or leakage from the posterior aspect of the suture line may occur.Interposition grafts are used when end-to-end anastomosis cannot be accomplished without tension despite mobilization. For vessels <6 mm in diameter (e.g., internal carotid, brachial, superficial femoral, and popliteal arteries), autogenous greater saphenous vein (GSV) from the contralateral groin should be used because polytetrafluoroethylene (PTFE) grafts of <6 mm have a prohibitive rate of thrombosis. When GSV is not avail-able, autologous options include the cephalic and basilic veins. Larger arteries


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Surgery_Schwartz. because polytetrafluoroethylene (PTFE) grafts of <6 mm have a prohibitive rate of thrombosis. When GSV is not avail-able, autologous options include the cephalic and basilic veins. Larger arteries (e.g., subclavian, innominate, aorta, common iliac) are bridged by PTFE grafts. PTFE is preferred over Dacron because of the reported decreased risk of infection.75 Aortic or iliac arterial injuries may be complicated by enteric contami-nation from colon or small bowel injuries. There is a natural reluctance to place artificial grafts in such circumstances, but graft infections are rare, and the time required to perform an axillofemoral bypass is excessive. Therefore, after the control of hemorrhage, bowel contamination is contained and the abdomen irrigated before placing PTFE grafts.76 After placement of the graft, it is covered with peritoneum or omentum before defini-tive treatment of the enteric injuries.Transposition procedures can be used when an artery has a bifurcation and one


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Surgery_Schwartz. placement of the graft, it is covered with peritoneum or omentum before defini-tive treatment of the enteric injuries.Transposition procedures can be used when an artery has a bifurcation and one vessel can be ligated safely. Injuries of the proximal internal carotid can be treated by mobilizing the adja-cent external carotid, dividing it distal to the internal injury, and performing an end-to-end anastomosis between it and the distal internal carotid (Fig. 7-46). The proximal stump of the internal carotid is oversewn, with care taken to avoid a blind pocket where a clot may form. Injuries of the common and external iliac arteries can be handled in a similar fashion (Fig. 7-47), while maintaining flow in at least one internal iliac artery.Venous injuries should be repaired when technically fea-sible. Small injuries without loss of tissue can be treated with lateral suture repair. More complex repairs with interposition grafts may thrombose, but this typically occurs gradually over 1


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Surgery_Schwartz. fea-sible. Small injuries without loss of tissue can be treated with lateral suture repair. More complex repairs with interposition grafts may thrombose, but this typically occurs gradually over 1 to 2 weeks. During this time adequate collateral circulation develops, which is sufficient to avoid acute venous hyperten-sion. Therefore, it is reasonable to use ringed PTFE for venous interposition grafting and accept a gradual, but eventual, throm-bosis while allowing time for collateral circulation to develop. Such an approach is reasonable for venous injuries of the supe-rior vena cava, suprarenal vena cava, SMV, and popliteal vein because ligation of these is associated with significant morbid-ity. In the remainder of venous injuries, the vein may be ligated. In such patients, chronic venous hypertensive complications in the lower extremities often can be avoided by (a) temporary use of elastic bandages (Ace wraps) applied from the toes to the hips at the end of the procedure, and (b)


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Surgery_Schwartz. hypertensive complications in the lower extremities often can be avoided by (a) temporary use of elastic bandages (Ace wraps) applied from the toes to the hips at the end of the procedure, and (b) judicious elevation of the lower extremities. These measures should be maintained for Brunicardi_Ch07_p0183-p0250.indd 21410/12/18 6:19 PM 215TRAUMACHAPTER 7Figure 7-46. Carotid transposition is an effective approach for treating injuries of the proximal internal carotid artery.ABCFigure 7-47. Transposition procedures can be used for iliac artery injuries to eliminate the dilemma of placing an interposition polytetra-fluoroethylene graft in the presence of enteric contamination. A. Right common iliac artery transposed to left common iliac artery. B. Left internal iliac artery transposed to the distal right common iliac artery. C. Right internal iliac artery transposed to the right external iliac artery.1 week; if the patient has no peripheral edema with ambulation, these maneuvers are no


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Surgery_Schwartz. distal right common iliac artery. C. Right internal iliac artery transposed to the right external iliac artery.1 week; if the patient has no peripheral edema with ambulation, these maneuvers are no longer required.Damage Control SurgeryThe recognition of the bloody vicious cycle and the introduction of damage control surgery (DCS) have improved the survival of critically injured patients. Conceptually, the bloody vicious cycle, first described in 1981, is the lethal combination of coag-ulopathy, hypothermia, and metabolic acidosis (Fig. 7-48).56 Hypothermia from evaporative and conductive heat loss and diminished heat production occurs despite the use of warming blankets and blood warmers. The metabolic acidosis of shock is exacerbated by aortic clamping, administration of vasopres-sors, massive RBC transfusions, and impaired myocardial per-formance. The ACOT, described previously, is compounded by hemodilution, hypothermia, and acidosis. Once the cycle starts, each component


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Surgery_Schwartz. massive RBC transfusions, and impaired myocardial per-formance. The ACOT, described previously, is compounded by hemodilution, hypothermia, and acidosis. Once the cycle starts, each component magnifies the other, which leads to a down-ward spiral and ultimately a fatal arrhythmia. The purpose of DCS is to limit operative time so that the patient can be returned to the SICU for physiologic restoration and the cycle thereby broken. Indications to limit the initial operation and institute DCS techniques include a combination of refractory hypother-mia (temperature <35°C), profound acidosis (arterial pH <7.2, base deficit >15 mmol/L), and refractory coagulopathy.56,77 The decision to abbreviate a trauma laparotomy is made intraopera-tively as the patient’s clinical course becomes clearer and labo-ratory values become available.The goal of DCS is to control surgical bleeding and limit GI spillage. The operative techniques used are temporary mea-sures, with definitive repair of injuries


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Surgery_Schwartz. labo-ratory values become available.The goal of DCS is to control surgical bleeding and limit GI spillage. The operative techniques used are temporary mea-sures, with definitive repair of injuries delayed until the patient is physiologically replete. Controlling surgical bleeding while preventing ischemia is of utmost importance during DCS. Aortic injuries must be repaired using an interposition PTFE Brunicardi_Ch07_p0183-p0250.indd 21510/12/18 6:19 PM 216BASIC CONSIDERATIONSPART Igraft. Although celiac artery injuries may be ligated, the SMA must maintain flow, and the early insertion of an intravascu-lar shunt is advocated. Similarly, perfusion of the iliac system and infrainguinal vessels can be restored with a vascular shunt, with interposition graft placement delayed. Arterial reconstruc-tion following shunt placement should be done optimally within 6 hours.78 Venous injuries are preferentially treated with ligation in damage control situations, except for the suprarenal


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Surgery_Schwartz. reconstruc-tion following shunt placement should be done optimally within 6 hours.78 Venous injuries are preferentially treated with ligation in damage control situations, except for the suprarenal inferior vena cava and popliteal vein. For extensive solid organ injuries to the spleen or one kidney, excision is indicated rather than an attempt at operative repair. For hepatic injuries, perihe-patic packing of the liver will usually tamponade bleeding (see Fig. 7-37). Translobar gunshot wounds of the liver are best con-trolled with balloon catheter tamponade, whereas deep lacera-tions can be controlled with Foley catheter inflation deep within the injury track (Fig. 7-49). For thoracic injuries requiring DCS several options exist. For bleeding peripheral pulmonary inju-ries, wedge resection using a stapler is performed. In penetrating injuries, pulmonary tractotomy is used to divide the parenchyma (Fig. 7-50); individual vessels and bronchi are then ligated using a 3-0 polydioxanone


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Surgery_Schwartz. using a stapler is performed. In penetrating injuries, pulmonary tractotomy is used to divide the parenchyma (Fig. 7-50); individual vessels and bronchi are then ligated using a 3-0 polydioxanone suture (PDS), and the track is left open. Patients who sustain more proximal injuries may require formal pulmonary resection, but pneumonectomy is poorly tolerated. Recent experimental work suggests inhaled nitric oxide (NO) will reduce right heart failure following pneumonectomy.79 Car-diac injuries may be temporarily controlled using a running 3-0 nonabsorbable polypropylene suture or skin staples. Pledgeted repair should be performed for the relatively thin right ventricle.The second key component of DCS is limiting enteric content spillage. Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 3-0 PDS. Complete transection of the bowel or segmental damage is controlled using a GIA stapler, often with resection of the injured


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Surgery_Schwartz. and colon) may be controlled using a rapid whipstitch of 3-0 PDS. Complete transection of the bowel or segmental damage is controlled using a GIA stapler, often with resection of the injured segment. Alternatively, open ends of the bowel may be ligated using umbilical tapes to limit spillage. Pancreatic injuries, regardless of location, are packed and the evaluation of ductal integrity postponed. Urologic injuries may require cath-eter diversion. Before the patient is returned to the SICU, the abdomen must be closed temporarily. Temporary closure of the abdomen is accomplished using an antimicrobial surgical incise drape (Ioban, 3M Health Care, St Paul, MN) (Fig. 7-51). In this technique, the bowel is covered with a fenestrated subfascial sterile drape (45 × 60 cm Steri-Drape 3M Health Care), and two Jackson-Pratt drains are placed along the fascial edges; this is Severe TraumaBlood LossTissue InjuryMassive RBCTransfusionIatrogenicFactorsCellularShockCoreHypothermiaMetabolic


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Surgery_Schwartz. Health Care), and two Jackson-Pratt drains are placed along the fascial edges; this is Severe TraumaBlood LossTissue InjuryMassive RBCTransfusionIatrogenicFactorsCellularShockCoreHypothermiaMetabolic AcidosisHypocalcemiaImmuno-ActivationActivation/Consumptionof Complement SystemProgressiveSystemicCoagulopathyAcuteEndogenousCoagulopathyClotting FactorDeficienciesPreexistingDiseasesFFP resistantFFP sensitiveFigure 7-48. The bloody vicious cycle. FFP = fresh frozen plasma; RBC = red blood cell.Brunicardi_Ch07_p0183-p0250.indd 21610/12/18 6:19 PM 217TRAUMACHAPTER 7Figure 7-49. A. An intrahepatic balloon used to tamponade hemorrhage from transhepatic penetrating injuries is made by placing a red rubber catheter inside a 1-inch Penrose drain, with both ends of the Penrose drain ligated. B. Once placed inside the injury tract, the balloon is inflated with saline until hemorrhage stops. C. A Foley catheter with a 30-mL balloon can be used to halt hemorrhage from deep lacerations to the


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Surgery_Schwartz. Once placed inside the injury tract, the balloon is inflated with saline until hemorrhage stops. C. A Foley catheter with a 30-mL balloon can be used to halt hemorrhage from deep lacerations to the liver.Figure 7-50. Pulmonary tractotomy divides the pulmonary paren-chyma using a gastrointestinal anastomosis (GIA) stapler. The opened track permits direct access to injured vessels or bronchi for individual ligation.then covered using an Ioban drape, which allows closed suction to control reperfusion-related ascitic fluid egress while provid-ing adequate space for bowel expansion to prevent abdomi-nal compartment syndrome. During the initial DCS stage, the subfascial sterile drape is not covered by a blue towel so that the status of the bowel and hemorrhage control can be assessed. The use of direct peritoneal resuscitation following DCS should be considered; 18 Fr round Blake drains may be placed intraop-eratively for the instillation of the dialysate solution.80 Return to the OR within


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Surgery_Schwartz. direct peritoneal resuscitation following DCS should be considered; 18 Fr round Blake drains may be placed intraop-eratively for the instillation of the dialysate solution.80 Return to the OR within 24 hours is planned once the patient clini-cally improves, as evidenced by normothermia, normalization of coagulation test results, and correction of acidosis.TREATMENT OF SPECIFIC INJURIESHead InjuriesIntracranial Injuries. CT scanning, performed on all patients with a significant closed head injury (GCS score <14), identi-fies and quantitates intracranial lesions as well as intracranial hypertension. Patients with intracranial hemorrhage, including epidural hematoma, subdural hematoma, subarachnoid hemor-rhage, intracerebral hematoma or contusion, and diffuse axo-nal injury, are admitted to the SICU. In patients with abnormal findings on CT scans and GCS scores of ≤8, intracranial pres-sure (ICP) should be monitored using fiber-optic intraparenchy-mal devices or intraventricular