Ebook The trauma manual - Trauma and acute care surgery (4/E): Part 1

(BQ) Part 1 book The trauma manual - trauma and acute care surgery has contents: Introduction to trauma care, airway management and anesthesia, physiologic response to injury, damage control surgery, nutritional intervention, interventional radiology,... and other contents.

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P1: Trim: 5.25in× 8.375in Top: 0.249in Gutter: 0.498in

LWBK1111-fm LWW-Peitzman-educational September 19, 2012 19:44

THE TRAUMA MANUAL:

TRAUMA AND ACUTE

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THE TRAUMA MANUAL:

TRAUMA AND ACUTE

CARE SURGERY

Fourth Edition

Editors

Andrew B Peitzman,MD

Mark M Ravitch Professor

Chief, Trauma and General Surgery

Department of Surgery

University of Pittsburgh School of Medicine

Pittsburgh, PA

Donald M Yealy,MD

Professor and Chair of Emergency Medicine

University of Pittsburgh/University of Pittsburgh Physicians

Thomas Jefferson University

Chair, Department of Surgery

Christiana Care Health Systems

Division of Traumatology, Surgical Critical Care & Emergency Surgery

Hospital of the University of Pennsylvania

Philadelphia, PA

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Acquisitions Editor: Brian Brown

Product Manager: Brendan Huffman

Production Manager: Bridgett Dougherty

Senior Manufacturing Manager: Benjamin Rivera

Marketing Manager: Lisa Lawrence

Design Coordinator: Teresa Mallon

Production Service: Aptara, Inc

Two Commerce Square

a particular situation remains the professional responsibility of the practitioner

The authors, editors, and publisher have exerted every effort to ensure that drug tion and dosage set forth in this text are in accordance with current recommendations andpractice at the time of publication However, in view of ongoing research, changes in gov-ernment regulations, and the constant flow of information relating to drug therapy anddrug reactions, the reader is urged to check the package insert for each drug for any change

selec-in selec-indications and dosage and for added warnselec-ings and precautions This is particularlyimportant when the recommended agent is a new or infrequently employed drug

Some drugs and medical devices presented in the publication have Food and DrugAdministration (FDA) clearance for limited use in restricted research settings It is the respon-sibility of the health care provider to ascertain the FDA status of each drug or device plannedfor use in their clinical practice

To purchase additional copies of this book, call our customer service department at (800)638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300

Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams &Wilkins customer service representatives are available from 8:30 am to 6 pm, EST

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This book is dedicated to those who have given their

lives, and those who daily risk their lives, in the care of

the injured.

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Syed M Faisal Alam, MD

Vascular Surgery Fellow

Division of Vascular and Endovascular

Medical Director, Trauma Surgery

Associate Professor of Surgery and Critical

Care Medicine

Pittsburgh, PA

Darwin Ang, MD, PhD, MPH

Associate Professor of Surgery

Trauma Medical Director, Ocala Regional

Director of Research USF/HCA Trauma

The Mitchell P Fink Endowed Chair in

Critical Care Medicine

Professor of Critical Care Medicine

Director, Trauma Clinical Research,

Training and Community Affairs

University of Miami Miller School of

Medicine

Miami, FL

Vishal Bansal, MD, FACS

Assistant Professor of SurgeryDivision of Trauma, Burns and SurgicalCritical Care

University of California San Diego HealthSciences

San Diego, CA

Philip S Barie, MD, MBA, FIDSA, FCCM, FACS

ProfessorDepartments of Surgery and Public HealthWeill Cornell Medical College

ChiefPreston A (Pep) Wade Acute Care SurgeryService

New York-Presbyterian Hospital/WeillCornell Medical Center

New York, NY

Tiffany K Bee, MD

Associate Professor of SurgeryThe University of Tennessee Health ScienceCenter

Timothy R Billiar, MD, FACS

George Vance Foster Professor andChairman

Department of SurgeryUniversity of Pittsburgh School of MedicinePittsburgh, PA

Thane A Blinman, MD

Associate Director of TraumaDivision of General, Thoracic andFetal Surgery

The Children’s Hospital of PhiladelphiaPhiladelphia, PA

Amir Blumenfeld, MD, MHA

Former Chief, Trauma BranchIsraeli Defense ForcesIsrael

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Benjamin Braslow, MD, FACS

Division of Trauma, Emergency General

Surgery & Surgical Critical Care

Section Chief of Emergency General

Susan Miller Briggs, MD, MPH

Harvard Medical School

Director, International Trauma and

Disaster Institute

Massachusetts General Hospital

Boston, MA

L.D Britt, MD, MPH, FACS, FCCM, FRCSEng

(Hon), FRCSEd (Hon), FWACS (Hon),

FRCSI (Hon), FCS(SA) (Hon)

Brickhouse Professor and Chairman

Eastern Virginia Medical School

Chief Internal Medicine Resident

University of Pittsburgh School of

Le Bonheur Neuroscience Institute

Le Bonheur Children’s HospitalMemphis, TN

William L Chung, DDS, MD

Associate ProfessorDepartment of Oral & MaxillofacialSurgery

University of Pittsburgh Medical CenterPittsburgh, PA

Mark Cipolle, MD, PhD

Medical Director, Trauma ProgramChristiana Care Health SystemWilmington, DE

Mitchell J Cohen, MD

Associate Professor of SurgeryDivision of General SurgeryDirector of Acute Care ResearchSan Francisco Injury CenterUniversity of CaliforniaSan Francisco, CA

Raul Coimbra, MD, PhD, FACS

The Monroe E Trout Professor of SurgeryExecutive Vice-Chairman, Department ofSurgery

Chief Division of Trauma, Surgical CriticalCare, and Burns

UC San Diego Health SystemSan Diego, CA

David C Cone, MD

Professor and EMS Section ChiefDepartment of Emergency MedicineYale University School of MedicineNew Haven, CT

Michael W Cripps, MD

Assistant Professor of Surgery

UT Southwestern Medical CenterDallas, TX

Martin A Croce, MD

Professor of SurgeryChief, Trauma and Surgical Critical CareThe University of Tennessee Health ScienceCenter

Memphis, TN

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Contributors ix Frederick J Denstman, MD

Section, Colon and Rectal Surgery

Christiana Care Health System

Soumitra R Eachempati, MD, FACS, FCCM

Professor of Surgery and Public Health

Weill Cornell Medical College

Chief, Trauma Services and Surgical

Intensive Care Unit

New York-Presbyterian Hospital

New York Weill Cornell Center

New York, NY

Philip A Efron, MD

Assistant Professor of Surgery and

Anesthesiology

Co-director, Laboratory of Inflammation

Biology and Surgical Science

Associate Director, Trauma ICU

Program Director, Surgical Critical Care

Residency

Department of Surgery, Division of Acute

Care Surgery and Surgical Critical Care

John Fildes, MD, FACS, FCCM

Professor and Vice Chair

Chief, Division of Acute Care Surgery

University of Nevada School of Medicine

Las Vegas, NV

Abe Fingerhut, MD

Hippokration Hospital and Medical SchoolAthens, Greece

Gerard Fulda, MD, FACS, FCCM

Director, Surgical Critical Care andSurgical Research

Christiana Care Health SystemsAssociate Professor of SurgeryJefferson Medical CollegeNewark, DE

Gary N Galang, MD

Vice Chairman for OperationsUPMC Rehabilitation InstituteUPMC Mercy HospitalPittsburgh, PA

Frederick Giberson, MD, MS

Assistant Professor of SurgeryJefferson Medical CollegeProgram Director, General SurgeryChristiana Care Health ServicesNewark, DE

Steven P Goldberg, MD

Assistant Professor of SurgeryDivision of Pediatric CardiothoracicSurgery

The University of Tennessee Health ScienceCenter

Le Bonheur Children’s HospitalMemphis, TN

Vicente H Gracias, MD

Professor of SurgeryDepartment of Surgery ChiefTrauma, Emergency Surgery, SurgicalCritical Care

UMDNJ-Robert Wood Johnson MedicalSchool

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William S Hoff, MD, FACS

Clinical Professor of Surgery

Temple University School of Medicine

Trauma Program Medical Director

St Luke’s University Health Network

Bethlehem, PA

Daniel N Holena, MD

Division of Traumatology, Surgical Critical

Care, and Emergency Surgery

Perelman School of Medicine

University of Pennsylvania

Philadelphia, PA

James H Holmes IV, MD, FACS

Director, WFBMC Burn Center

Department of General Surgery

Wake Forest University School of Medicine

Chair, Division of Trauma, Critical Care

and Emergency Surgery

Virginia Commonwealth University

Richmond, VA

Steven A Johnson, MD, FACS

Jefferson Medical College

Director, Surgery and Surgical Critical Care

Capital Health, Hopewell Medical Center

Pennington, NJ

Gregory J Jurkovich, MD

Chief of Surgery

Denver Health and Hospital Authority

Bruce M Rockwell Distinguished Professor

and Vice Chairman

University of Colorado School of Medicine

Denver, CO

Michael Kalina, DO, FACOS

Assistant Professor of SurgeryJefferson Medical CollegeThomas Jefferson UniversityAssociate Medical Director ofTrauma

Surgical Critical Care AssociatesChristiana Care Health SystemNewark, DE

John A Kellum, MD

Professor and Vice ChairDepartment of Critical CareMedicine

University of PittsburghPittsburgh, PA

Mousa Khoursheed, MD, FRCS

Department of SurgeryUniversity of KuwaitMubarak Al-Kabeer HospitalSafat, Kuwait

Patrick K Kim, MD

Assistant Professor of SurgeryDivision of Traumatology, Surgical CriticalCare and Emergency Surgery

Department of SurgeryPerelman School of MedicineUniversity of PennsylvaniaPhiladelphia, PA

Edward Kwon, MD

Trauma and Critical CareDepartment of SurgeryUniversity of Nevada School ofMedicine

Las Vegas, NV

Peter D Le Roux, MD, FACS

Department of NeurosurgeryPerelman School of MedicineUniversity of PennsylvaniaPhiladelphia, PA

Luke P.H Leenen, MD, PhD, FACS

Professor of TraumaDepartment of SurgeryUniversity Medical Center UtrechtUtrecht, The Netherlands

Ari K Lepp ¨aniemi, MD, PhD

Chief of Emergency SurgeryDepartment of Abdominal SurgeryHelsinki University Hospital,Meilahti

Helsinki, Finland

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Contributors xi

L Scott Levin, MD, FACS

Paul B Magnuson Professor of Bone and

Assistant Professor of Thoracic Surgery

Department of Cardiothoracic Surgery

University of Pittsburgh Medical Center

Director, Trauma Services

San Francisco General Hospital

San Francisco, CA

Louis J Magnotti, MD

The University of Tennessee Health Science

Wake Forest School of Medicine

Director, Surgical Critical Care

Wake Forest Baptist Medical Center

Winston-Salem, NC

Federico N Mazzini, MD

Attending SurgeonTrauma & Emergency SurgeryGeneral Surgery DepartmentHospital Italiano de Buenos AiresBuenos Aires, Argentina

Hospital of the University of PennsylvaniaPhiladelphia, PA

J Wayne Meredith, MD, FACS

Richard T Myers Professor and Chair,Department of Surgery

Director, Division of Surgical SciencesWake Forest School of MedicineWinston-Salem, NC

Lyle L Moldawer, PhD

Professor and Vice ChairmanDepartment of SurgeryCollege of MedicineUniversity of FloridaGainesville, FL

Frederick A Moore, MD

ProfessorDepartment of SurgeryHead, Division of Surgical Critical Care &Acute Care Surgery

Department of SurgeryUniversity of FloridaGainesville, FL

David Morris, MD

Senior Associate ConsultantTrauma, Critical Care, General SurgeryDepartment of Surgery

Mayo ClinicRochester, MN

A James Moser, MD

Division of Surgical OncologyBeth Israel Hospital

Boston, MA

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xii Contributors

Alan Murdock (Dr.) Col, USAF, MC

Chief, Acute Care Surgery

Department of Trauma and General

Surgery

UPMC PUH

Pittsburgh, PA

Michael L Nance, MD

Director, Pediatric Trauma Program

The Children’s Hospital of Philadelphia

Templeton Professor of Surgery

Perelman School of Medicine

University of Pennsylvania

Philadelphia, PA

Lena M Napolitano, MD, FACS, FCCP, FCCM

Professor of Surgery and Associate Chair

Division Chief

Acute Care Surgery (Trauma, Burn, Critical

Care, Emergency Surgery)

University of Michigan

Ann Arbor, MI

Mayur Narayan, MD, MPH, MBA

Assistant Professor, Department of Surgery

Trauma/Critical Care/Acute Care &

Emergency General Surgery

Director, Center for Injury Prevention &

Policy

R Adams Cowley Shock Trauma Center

University of Maryland School of Medicine

Juan B Ochoa, MD, FACS

Professor of Surgery and Critical Care

University of Pittsburgh

Pittsburgh, PA

Medical and Scientific Director

Nestle Health Care Nutrition/Nestle

Health Science

North America

Mark W Ochs, DMD, MD

Professor and Chair

Department of Oral and Maxillofacial

University of Pittsburgh School of MedicinePittsburgh, PA

Perelman School of MedicineUniversity of PennsylvaniaPhiladelphia, PA

Michael Rhodes, MD

Professor of SurgeryThomas Jefferson UniversityChair, Department of SurgeryChristiana Care Health SystemsWilmington, DE

Matthew R Rosengart, MD, MPH

Associate ProfessorDepartment of SurgeryUniversity of PittsburghPittsburgh, PA

Ronald N Roth, MD, FACEP

Professor, Department of EmergencyMedicine

Chief, Division of EMSUniversity of Pittsburgh School of MedicinePittsburgh, PA

Michael F Rotondo, MD, FACS

Professor and Chairman, Department ofSurgery

The Brody School of Medicine, EastCarolina University

Greenville, NCChief of Surgery, Director of the Center ofExcellence for Trauma and SurgicalCritical Care

Vidant Medical Center, Vidant HealthSystem

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Contributors xiii Grace S Rozycki, MD, MBA

Professor of Surgery

Emory University School of Medicine

Grady Memorial Hospital

Chief, Trauma and Acute Care Surgery

The George Washington University

Washington, DC

Thomas M Scalea, MD

Physician in Chief, Shock Trauma Center

Francis X Kelly Professor of Trauma and

Director Program in Trauma

University of Maryland School of Medicine

Baltimore, MD

Vaishali D Schuchert, MD

Clinical Assistant Professor of Surgery and

Critical Care

Associate Director of Acute Care Surgery

Division of Traumatology, Surgical Critical

Care & Emergency Surgery

Hospital of the University of Pennsylvania

Philadelphia, PA

Ayan Sen, MD, MSc

Critical Care Fellow

Department of Critical Care Medicine

University of Pittsburgh Medical Center

Pittsburgh, PA

John P Sharpe, MD, MS

General Surgery Resident

The University of Tennessee Health Science

Center

Memphis, TN

Lachlan J Smith, PhD

Research AssociateDepartment of Orthopaedic SurgeryPerelman School of MedicineUniversity of PennsylvaniaPhiladelphia, PA

S Tonya Stefko, MD

Assistant Professor of Ophthalmology,Otolaryngology, and NeurologicalSurgery

University of Pittsburgh School of MedicinePittsburgh, PA

Glen Tinkoff, MD

Associate Vice Chair of SurgeryChristiana Care Health SystemNewark, DE

Meredith S Tinti, MD

Assistant Professor of SurgeryAssociate Medical Director, SurgicalIntensive Care

UMDNJ-Robert Wood Johnson MedicalSchool

New Brunswick, NJ

Samuel A Tisherman, MD

ProfessorDepartments of Critical Care Medicine andSurgery

University of PittsburghPittsburgh, PA

Glenn Updike, MD, MMM

Medical DirectorMagee-Womens Hospital Outpatient ClinicAssistant Professor

Department of Obstetrics, Gynecology, andReproductive Sciences

University of Pittsburgh Magee-WomensHospital

Pittsburgh, PA

Cory J Vatsaas, MD

Division of Acute Care SurgeryDepartment of SurgeryUniversity of MichiganAnn Arbor, MI

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xiv Contributors

George C Velmahos, MD, PhD, MSEd

John F Burke Professor of Surgery

Harvard Medical School

Chief, Division of Trauma, Emergency

Surgery, and Surgical Critical Care

Massachusetts General Hospital

Boston, MA

Thai Vu, MD

Assistant Professor

Trauma and Surgical Critical Care

Penn State Hershey Medical Center and

Penn State College of Medicine

Hershey, PA

Brett H Waibel, MD

Trauma and Surgical Critical Care

The Brody School of Medicine at East

Department of Emergency Medicine

The University of Alabama at

Birmingham

Birmingham, AL

Gregory A Watson, MD, FACS

Assistant Professor of Surgery & Critical

Care

Medicine

Pittsburgh, PA

Hunter Wessells, MD, FACS

Professor and Nelson Chair

Department of SurgeryVirginia Commonwealth UniversityRichmond, VA

Sean P Whelan, MD

Chief Resident in SurgeryUniversity of Pittsburgh Medical CenterPittsburgh, PA

J Scott Williams, MD, PhD

Associate Professor of RadiologyCase Western Reserve UniversityCleveland, OH

Donald M Yealy, MD

Professor and Chair of EmergencyMedicine

University of Pittsburgh/University ofPittsburgh Physicians

Pittsburgh, PA

Kent Zettel, MD

Chief Resident in SurgeryUniversity of Pittsburgh Medical CenterPittsburgh, PA

Feihu Zhou, MD, PhD

The Clinical Research, Investigation, andSystems Modeling of Acute Illness(CRISMA) Center

Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburgh, PA

Department of Critical Care MedicineChinese PLA General HospitalBeijing, People’s Republic of China

Brian S Zuckerbraun, MD

Associate Professor of SurgeryUniversity of Pittsburgh School of MedicineAttending Surgeon, University of

Pittsburgh Medical Center and VAPittsburgh Healthcare SystemPittsburgh, PA

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Preface

The 4thedition of The Trauma Manual reflects the maturation and evolution of the field.

Common to the patients for whom we provide care is their urgent presentation and oftentime-dependent illness, whether from injury or non-trauma critical disease The 4thedition

of The Trauma Manual has expanded its coverage of all components of the field: trauma,

critical care, and emergency surgery The chapters are organized by disease processes andbased on the chronology of patient care The emergency department and the trauma/acutecare surgery services at many hospitals are essentially the “safety nets” for the inpatients and

the critically ill outpatients The Trauma Manual incorporates the diverse disease processes

and care that we deliver every day

We have built upon the success of the first three editions of this book by expandingthe authorship of the chapters to more international and national experts The chapters ontrauma care have been updated and revised New chapters on critical care have been added

to this edition Chapters on emergency general surgery have been expanded and reorganized

As with the first editions, these chapters are written by experts in these fields Therecommendations made are backed by the extensive clinical experience of the authors.Rather than listing every option in a clinical situation, a consensus recommendation is

generally presented We have attempted to keep the content of The Trauma Manual practical

and direct

The goal of The Trauma Manual remains to serve as a ready pocket reference for all

who provide care for the patient with acute surgical diseases The format of the book isthat of a user-friendly pocket manual rather than a comprehensive textbook With that said,this book contains a great deal of information covering all phases of trauma and acute caresurgery

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Contents

Contributors vii

Preface xv

1 Introduction to Trauma Care 1

Amy N Hildreth•R Shayn Martin•J Wayne Meredith

2 Physiologic Response to Injury 10

Luke P.H Leenen

3 Airway Management and Anesthesia 22

Henry E Wang•Jean-Francois Pittet•Donald M Yealy

4 Initial Assessment and Resuscitation 35

Michael Rhodes•Michael Kalina

5 Shock 45

Joshua Brown•Jason L Sperry•Timothy R Billiar

6 Damage Control Surgery 51

Brett H Waibel•Michael F Rotondo

7 Blood and Transfusion 61

Michael W Cripps•Mitchell J Cohen•Robert C Mackersie

8 Nutritional Intervention 73

Jodie A Bryk•Juan B Ochoa

9 Prehospital and Air Medical Care 83

Francis X Guyette•David C Cone

10 Team Activation and Organization 101

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xviii Contents

14 Infections, Antibiotic Prevention, and Antibiotic Management 138

Philip S Barie•Soumitra R Eachempati

15 Trauma Pain Management 162

Donald M Yealy

16 Venous Thromboembolism 170

Gerard Fulda•Mark Cipolle

17 Operating Room Practice 179

Steven A Johnson•Michael Rhodes

18 Disasters, Mass Casualty Incidents 183

Ronald N Roth•Amir Blumenfeld•Susan M Briggs

19 Injury Prevention 195

Charles C Branas

20 Rehabilitation 202

John A Horton III•Gary N Galang

21A Trauma in Children 213

Daniel J Grabo•Thane A Blinman•Michael L Nance•C William Schwab

21B Trauma in Pregnant Women 228

Daniel J Grabo•C William Schwab

21C Trauma in Older Adults 234

Daniel J Grabo•C William Schwab

22 Introduction to Trauma: Mechanism of Injury 241

Gregory J Jurkovich•L.D Britt

23 Traumatic Brain Injury 253

Meredith S Tinti•Vicente H Gracias•Peter D Le Roux

24 Maxillofacial Injury 264

William L Chung•James M Russavage•Mark W Ochs

25 Spinal Cord and Spinal Column 287

Matthew Sanborn•Lachlan J Smith•Neil R Malhotra

26 Ophthalmic Injuries 308

S Tonya Stefko•Donald M Yealy

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31 Orthopedic Trauma, Fractures, and Dislocations 404

Samir Mehta•L Scott Levin

32 Peripheral Vascular Injuries 427

Louis J Magnotti•John P Sharpe•Timothy C Fabian

33 Burns/Inhalation Injury 443

James H Holmes IV

34 Priorities in the ICU Care of the Adult Trauma Patient 456

Philip S Barie•Soumitra R Eachempati

35 Multiple Organ Dysfunction Syndrome 489

Philip A Efron•Darwin N Ang•Lyle L Moldawer•Frederick A Moore

36 Cardiovascular Disease and Monitoring 499

Mayur Narayan•Thomas M Scalea

37 Acute Kidney Injury 508

Feihu Zhou•John A Kellum

38 Acute Respiratory Failure and Mechanical Ventilation 514

Cory J Vatsass•Lena M Napolitano

39 Abdominal Compartment Syndrome, Open Abdomen,

Enterocutaneous Fistulae 529

James F Whelan•Michel B Aboutanos•Rao R Ivatury

40 Liver Failure 535

Deanna Blisard

41 Support of the Organ Donor 545

Patrick K Kim•Matthew V Benns•Patrick M Reilly•C William Schwab

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Grace S Rozycki•David V Feliciano

44 Preparation, Initial Resuscitation, and Management of the Patient for

Emergency Operation 569

Ali Y Mejaddam•George C Velmahos

45 Acute Abdomen in ICU Patients 574

Ari K Lepp ¨aniemi

49 Biliary Tract Disease 613

Benjamin Braslow

50 Appendicitis 624

Daniel N Holena•C William Schwab

51 Esophagus, Stomach, and Duodenum 630

Louis H Alarcon•Ryan M Levy•James D Luketich

52 Inflammatory Diseases of the Intestines 643

Sean P Whelan•Vaishali D Schuchert•Brian S Zuckerbraun

53 Acute Anorectal Pain 657

Frederick J Denstman

54 Soft Tissue Infection 666

David Morris•Babak Sarani

55 Vascular Emergencies 672

Syed M Faisal Alam•Christopher H Byrne

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56 Hernias 684

Jennifer M DiCocco•Steven P Goldberg•Timothy C Fabian

57 Obstetric and Gynecologic Emergencies 695

Glenn Updike

58 Laparoscopic Treatment of the Acute Abdomen 708

Abe Fingerhut•Mousa Khoursheed

59 Miscellaneous Procedures 719

Glen Tinkoff•Frederick Giberson

60 Scoring for Injury and Emergency Surgery 733

Edward Kwon•John Fildes

Appendix A: Injury Scales 743

Appendix B: Frequently Used Forms 756

Index 773

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Amy N Hildreth, R Shayn Martin and J Wayne Meredith

I INTRODUCTION.Trauma is mechanical damage to the body caused by an externalforce The trauma patient has been defined as “an injured person who requires timelydiagnosis and treatment of actual or potential injuries by a multidisciplinary team ofhealth care professionals, supported by the appropriate resources, to diminish or elimi-nate the risk of death or permanent disability.” This chapter describes the current impact

of injury on society, the structure of modern trauma systems, and the way injuries aremeasured and quantified as well as common patterns of injury seen with blunt, pene-trating, and blast injury mechanisms

II EPIDEMIOLOGY

A. Overall, trauma is the fifth leading cause of death in the United States and is the ing source of mortality for patients between 1 and 44 years of age In 2007, 182,479people died secondary to injury, representing 60 deaths per 100,000 population Ofthese, 123,706 were unintentional in nature while 53,371 were caused by violence

lead-A fatal injury occurs approximately every 5 minutes

B. Mortality after trauma can be characterized by three time periods during which themajority of deaths occur As seen in Figure 1-1, approximately 50% of deaths occurimmediately and are usually secondary to severe neurologic injuries or exsanguina-tion from major blood vessel injuries These deaths can only be avoided throughinjury prevention The second peak of approximately 30% of deaths occurs dur-ing the initial hours post-injury, and preventing these deaths is the goal of mod-ern trauma Finally, 20% of deaths occur late (1 to 2 weeks from injury) and aresecondary to sepsis and multiple organ failure It is believed that improved earlymanagement of injury and associated shock may prevent these late complications

C. In 2009, there were over 36 million medically attended, non-fatal injuries in theUnited States Data from 2007 reveal an estimated 42.4 million injury-related emer-gency departments and 80 million office-based visits Injury represents the greatestcause of years of potential life lost (YPLL) before age 65, totaling over 2.4 millionyears or 20.1% of all YPLL The total cost for injuries occurring in 2005 includingmedical expenses and lost wages was estimated to be 355.3 billion dollars

D Specific injury patterns and mechanism

1 Age.While people 44 years old and younger account for the majority of fataland non-fatal injuries, the impact of trauma on the elderly is far more severe.The death rate for injuries among patients 0 to 44 years old is approximately

45 per 100,000 population, whereas this rate is 113 per 100,000 for people over

65 years old and 169 per 100,000 for people over 75 years old

2 Gender.Sixty-nine percent of all injury-related deaths occur in males, accountingfor twice the number of female deaths

3 Mechanism

a Motor vehicle crashes(MVC) are the leading cause of injury-related death,accounting for 42,031 deaths in 2007 or 13.8 deaths per 100,000 population.Over 2.6 million people sustained non-fatal injuries secondary to MVC in

2009 Despite this, the death rate per vehicle miles traveled (VMT) has declinedsteadily throughout the century

b Firearm-related injuryresulted in 31,224 deaths in 2007 and was the thirdleading cause of injury-related mortality for all ages Fifty-six percent were a

1

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Early(Hours)Time to Death

20% Figure 1-1.Distribution of death after

injury Adapted from: Trunkey DD.Trauma Accidental and intentional in-juries account for more years of life lost

in the U.S than cancer and heart ease Among the prescribed remediesare improved preventive efforts, speed-

dis-ier surgery and further research Sci Am

1983;249(2):28–35

result of suicide while 41% were homicide-related Non-fatal gunshot woundswere identified in 66,769 patients in 2009 Predominately, fatal shootingsinvolve young males; the number of deaths in the 15- to 34-year-old age range

is over seven times the number of female deaths Firearm-related injuries peak

at 19 years of age

c Falls are the leading cause of non-fatal injury, resulting in approximately8.8 million injuries and 23,443 deaths throughout all age groups Falls are mostcommon among the young and the elderly with both groups demonstratinginjury rates of greater than 4,000 injuries per 100,000 population Despitethis similarity, falls are the leading cause of death in patients 65 years or olderwhile death in children is uncommon The death rate due to falls in elderlypatients is more than 170 times that of children less than 10 years old Thepeak incidence occurs at age 85

d.Other common mechanisms contributing to trauma mortality include ing, suffocation, drowning, cutting/piercing, and burns

poison-III TRAUMA SYSTEMS

A Overview

1.As defined by the Trauma System Agenda for the Future, “A trauma system is anorganized, coordinated effort in a defined geographic area that delivers the fullrange of care to all injured patients and is integrated with the local public healthsystem.”

Historical perspective.The systematic care of trauma changed cantly with the publication of, “Accidental Death and Disability: The NeglectedDisease of Modern Society” in 1966 This document revealed the deficiencies ininjury management and initiated the development of systems to improve traumacare The Emergency Medical Services Systems Act was passed in 1973 to supportthe development of regionalized Emergency Medical Services (EMS systems In

signifi-1976, the American College of Surgeons (ACS) Committee on Trauma (COT)published, “Optimal Hospital Resources for the Care of the Seriously Injured”which established criteria that identified hospitals as trauma centers This doc-ument has been revised as knowledge about trauma systems has evolved Morerecently, the Model Trauma Care System Plan created by the Health ResourcesServices Administration (HRSA) was published to further define and guide traumasystem development

2 Function.Trauma systems have been designed to be inclusive in nature and use

all available resources to provide appropriate care to all injured patients

3 Designation and verification.Facilities within a trauma system require tification of injury management capabilities so that resource assessments can beachieved A government group designates a hospital as a trauma center afterevaluating the facility’s resources and the ability to provide a specific level of care

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Chapter 1 rIntroduction to Trauma Care 3

B Fundamental components

1 Injury preventionhas become an essential focus for all trauma systems in order

to proactively reduce the impact of injury

2 Prehospital careincludes community access and communication systems aswell as EMS systems and triage protocols Universal access to emergency care(i.e., 911) is essential to allow efficient activation of the system A robust commu-nication system provides coordination of prehospital resources as well as propertransfer of information to receiving facilities Standardized curricula for trainingEMS personnel provide a more consistent knowledge base and skills set Devel-oped trauma systems have insured more efficient emergency response throughimproved geographical placement of EMS providers versus only facility-basedresponders

3 Acute care facilitiesprovide a range of injury management from initial bilization and transfer to all-inclusive definitive care On the basis of availableresources, facilities are characterized by injury management capabilities and manyare designated as trauma centers using a scale of 1 to 4, with Level 1 centers pro-viding the most comprehensive level of care

sta-4 Post-hospital careis an important part of reducing disability and improving

an injured patient’s long-term outcome

C Trauma system infrastructure elements

1 Leadership.A lead agency should be established to coordinate trauma systemdevelopment and provide necessary administration

2 Professional resources.Successful trauma systems rely on competent andenergetic health care providers to insure optimal injury care

3 Education/Advocacy. Trauma systems must endeavor to improve publicawareness about trauma as a disease state and the ability of injury prevention

to reduce the societal impact of trauma

4 Information Management.Trauma data registries at the local and nationallevels provide an invaluable resource for performance improvement, research,and trauma system management Ideally, trauma data should be consistently cap-tured and incorporated into regional and national databases to provide the mostaccurate depiction of the status of injury care

5 Finances.Adequate financial support is essential for both trauma system opment and the continued provision of trauma care Increased public and politicalawareness of the magnitude of the problem is required to improve governmentalfunding

devel-6 Research.To continue improving the care of the injured, research endeavorsmust be encouraged and efforts to increase financial support for trauma researchare crucial

7 Technology.The potential of novel and developing technologies must be adoptedand applied to the field of trauma care

8 Disaster preparedness and response.Trauma systems are charged with thetask of being prepared to respond to potential disasters by developing a systematicand organized approach that can be implemented if the need arises

IV INJURY SCORING

A Principles

1 Purpose.Injury scoring systems have been developed to accurately and sistently quantify the magnitude of injury from an anatomic, physiologic, or acombined standpoint Scoring systems are used in triage decision making, qualityimprovement and benchmarking initiatives, prevention program analyses, andresearch endeavors

con-2 Database use.Scoring systems are commonly included in trauma databases toprovide a quantifiable means of patient comparison (See Chapter 20.)

3 Correct use of scoring.Systems used for triage decision making must be easy

to calculate from rapidly available information Scoring is commonly used in theresearch setting and in this case, should be able to identify patients with com-parable injuries Evaluation of responses to therapy may benefit from applying

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4 The Trauma Manual: Trauma and Acute Care Surgery

a physiologic scoring system The combined scores are valuable when assessingoutcome after injury

4 Limitations.Since each injured patient is unique, there is no single scoring systemthat can provide a perfect description

B Scoring Systems (see Chapter 60)

c Survival Risk Ratios (SRR)/ICD-based Injury Severity Score (ICISS)

d Anatomic Profile (AP)

e Penetrating Abdominal Trauma Index (PATI).PATI is a scoring systemdesigned to quantify the effects of penetrating abdominal injury Each organhas a predetermined risk factor score (1 to 5) and injured organs are assigned

a severity score (1 to 5) based on published criteria The severity score ismultiplied by the risk factor score and the sum of all of these results are thePATI

2 Physiologic scores

a Glasgow Coma Score (GCS)

i. A GCS of 8 or less is usually indicative of severe brain injury and may besuggestive of required intervention (e.g., intubation)

ii. The motor component of the GCS has been found to correlate well withthe entire GCS and be the most predictive of outcome

iii Revised Trauma Score (RTS)

iv Systemic Inflammatory Response Syndrome Score (SIRS Score)

b Trauma Score (TS)

3 Combined Scores

a Trauma and Injury Severity Score (TRISS)

b A Severity Characterization of Trauma (ASCOT)

C Validation of scoring systems

1.After the development of a scoring system, a process of validation is required toconfirm its accuracy and predictive nature This can often be accomplished bychallenging the scoring system against a large, well-constructed trauma databasesuch as a state trauma registry, governmental database, or the NTDB

V MECHANISMS OF INJURY

A Principles.Trauma can result from multiple mechanisms of injury, including bluntinjury, penetrating injury, thermal injury (discussed in a later chapter), or some com-bination of these three These mechanisms often result in discrete injury patterns;recognition of injury patterns common with each mechanism is essential to promptdiagnosis and treatment of associated injuries Knowledge of injury mechanism pro-vides guidance in determining the proper approach to an injured patient

B Blunt injury

1 Types

a Motor vehicle collision

i Determinants of injury a) Magnitude of force/energy of collision

b) Direction of force

c) Location of occupant in vehicle

d) Use of restraint device

e) Type of vehicle(s) involved in collision

ii Injury patterns a) Front.Injuries in this type of collision tend to follow one of two injurypatterns—either an “up and over” or a “down and under” pattern Theformer occurs when the chest and abdomen strike the steering wheeland the head impacts the windshield In this case, the cervical spinetakes much of the load of the collision Common injuries may includerib fractures as well as pulmonary and myocardial contusion from chest

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Chapter 1 rIntroduction to Trauma Care 5wall—steering wheel impact Shear forces may contribute to injuries tothe aorta or liver Brain injury is common due to direct compression,and acute neck flexion or hyperextension may lead to cervical spineinjury In the latter pattern of injury, the occupant is pushed under thesteering column, often striking the knees on the dashboard In this case,the upper leg absorbs much of the impact Commonly noted injuriesinclude knee dislocation, femur fractures, and posterior hip dislocationwith acetabular fracture

b) Lateral.If energy is transferred to the vehicle directly and the vehiclestops, this mechanism results in an injury pattern compatible with a lat-eral crushing injury to the spine, torso, and pelvis Common injuriesinclude flail chest, pulmonary contusion, liver injuries, and splenicinjuries Brain injury is also common in this scenario However, ifmotion is imparted to the vehicle, the torso is often pushed laterally

as the head remains in its original position, resulting in lateral flexionand rotation of the cervical spine, leading to fractures and ligamentousinjuries

c) Rear.Injury patterns with this mechanism will depend upon the ence or absence of subsequent impact after the initial collision as it iscommon to strike another object ahead of the vehicle as a result ofthe collision The most common injury seen is cervical spine hyper-extension and resultant injury during forward acceleration followingimpact

pres-d) Rotational.In these collisions, injury patterns are commonly a bination of front and lateral impact patterns

com-e) Rollover.Rollover collisions are highly unpredictable in terms of injurypatterns, as there may be trauma to the vehicle occupant from a multi-plicity of directions

f) Ejection.Those vehicle occupants who are ejected during a collisionhave the greatest potential for injury In a collision, some protection isafforded to the occupant by the vehicle Those who are ejected do nothave this protection, and they have the velocity of the vehicle as theyare ejected, resulting in the potential for serious injury Ejected occu-pants have been found to be four times as likely to require admission

to an intensive care unit and five times more likely to die followinginjury

iii Role of restraints a) Injury prevention.Three-point seat belt restraints were first intro-duced in 1967 by Bohlin, resulting in significant decreases in mortalitywhen compared to unbelted occupants during collisions Recently, theNational Highway Traffic Safety Administration (NHTSA) has reportedthese belts to be 43% to 50% effective in reducing traffic fatalities and

to have decreased serious injury by 45% to 55% NHTSA data indicatethat air bag use alone decreases mortality by 13%; used in combinationwith restraints, the mortality reduction increases to 50% However, airbags are most effective in frontal collisions Side air bags when availableare more useful in lateral collisions and rollovers

b) Associated injuries.Although restraint systems and air bags have nificantly decreased morbidity and mortality from collisions in recentyears, their deployment has also been associated with specific injury pat-terns If lap belts are applied above the iliac crests, they contribute to

sig-what is known as the seat belt syndrome Bowel and other

intraabdom-inal injuries may occur Increased intraabdomintraabdom-inal pressure can causediaphragmatic rupture, and lumbar spine injuries are seen Injuriesattributable to the shoulder strap include rib fractures, clavicle frac-tures, and blunt cerebrovascular injury Improper positioning of seatbelt restraints increases the likelihood of these associated injuries Airbag deployment also has the potential to cause injury Trauma to theeyes, face, cervical spine, chest, abdomen, and upper extremities has

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been reported However, 96% of all airbag-associated injuries have beenreported to be minor

b Motorcycle collision.As with motor vehicle collisions, injury pattern inmotorcycle collisions is dependent on the type of collision Common motor-cycle collision types are listed below

i Frontal.In this type of collision, the motorcycle tips forward, and the rider

is thrown over the handlebars Head, thoracic, and abdominal injuries arecommon If the rider’s feet are in contact with the pegs when collisionoccurs, femur fractures may occur

ii Angular.Crush injuries to the lower extremities are common followingangular impacts

iii Ejection.If the rider is ejected from the motorcycle, as with motor vehiclecollisions, there is a significant potential for serious injury Specific injuriesare unpredictable, given multiple directions of force

iv Rear.Injuries from rear impact result from rapid acceleration followed byhyperextension and subsequent crush from impact or from the collidingvehicle

c Pedestrian–auto collision.The injury pattern caused by these collisions isdependent upon both the size of the pedestrian and the size of the automobilecausing injury

i Adult.When an adult is struck by a motor vehicle, the car bumper may firstimpact the lower leg, resulting in tibia and fibula fractures Subsequently, thepedestrian is thrown onto the hood The femur and pelvis will often makethe first hood impact, followed by the thorax, abdomen, and craniofacialarea A third impact results from the pedestrian striking the ground, causingfurther injury The classic triad of injuries includes fracture of the tibia andfibula, injury to the trunk, and injury to the brain (Waddell’s triad)

ii Child.In contrast, a child who is struck by a motor vehicle usually receivesthe initial impact of the bumper at the level of the pelvis or femur The hoodusually strikes the thorax, and the child is often dragged under the vehicle,often resulting in severe multisystem trauma

d Falls.Falls may result in multiple impacts; the height of the fall typicallydetermines the severity of injury The landing surface is also of importance.Landing on the feet after an approximately vertical fall may result in a commoninjury pattern of bilateral calcaneus fractures, vertical sheer injury to the pelvisand thoracic and lumbar spine fractures due to axial loading

e Assault. Head and facial injuries are the most common injuries with thismechanism Defensive posturing may result in upper and lower extremityinjuries However, torso injuries may also be present as a result of kicking

i Internal ballistics.The effects of bullet and weapon design and materialwithin the weapon are known as internal ballistics

a) Bullet characteristics.Characteristics of the path down the weaponare imparted by the bullet’s material Bullets are often manufactured

of lead, but lead bullets leave significant deposits along the barrel of aweapon at high velocities Therefore, these lead bullets are often coatedwith a harder metal to prevent deformity, known as a jacket, usually ofcopper If the bullet is completely surrounded by the jacket, the covering

is termed a full metal jacket Partially encased bullets are semi-jacketed; these bullets have exposed lead at the tip and are referred to as soft-point

bullets Soft-point bullets are meant to deform on contact Bullets called

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TABLE 1-1 Ballistic Data for Handguns

b) Drag.Drag is the force produced by the resistance to air or fluid asthe bullet passes through Drag increases exponentially with velocity;sectional density (mass divided by cross-sectional area) decreases drag.Therefore, drag has the least effect on a heavy, narrow projectile

c) Stability.The stability of a projectile in flight is also subject to tion Bullets may develop a slight wobble upon leaving the barrel due toimperfections in the bullet, pressure differences in the barrel, and slight

varia-movement of the barrel This wobble is called precession and is a

rota-tion around the center of mass of the bullet Bullets may also develop

yaw, a rotation of the nose of the projectile away from the line of flight

and measured by the angle between the long axis of the bullet and its

flight path Nutation is a smaller circular movement at the tip of the

bullet Any of these movements increase drag and decrease velocity

TABLE 1-2 Ballistic Data for Rifles

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iii Terminal ballistics.Terminal ballistics describes the behavior of a jectile in tissue

pro-a) Kinetic energy.Kinetic energy (KE) of a missile is proportionate tothe mass (m) of the missile times its velocity (v) squared

KE = 1/2 mv2Therefore, the amount of kinetic energy of a bullet is highly dependentupon its velocity Modern bullets have been designed to maximize theamount of kinetic energy dissipation into the tissue

b) Cavitation 1) Permanent.The size of the permanent cavity caused by the bul-let’s path through the tissue is usually relatively small, especially ifthere is minimal yaw As yaw increases, the amount of tissue crushedand thereby the permanent cavity increases This cavity’s size mayalso be increased by the use of soft-point and hollow-point bullets.These often deform into a mushroom shape, increasing surface areaand wound severity Bullet fragmentation increases the size of thepermanent cavity as well

2) Temporary.When a bullet passes through tissue, a temporary ity is formed in addition to the permanent cavity This cavity is aresult of the waves created by the bullet which are perpendicular tothe direction of the bullet’s travel, which compress adjacent tissues.High-energy projectiles tend to cause a larger temporary cavity Thetype of tissue the bullet passes through also determines the effect ofthe temporary cavity In solid organs, the effect of the temporary cav-ity is greater than in air-filled organs Tumbling and fragmentationmay also affect the size of the temporary cavity

cav-b Shotgun wounds.In contrast to the barrel of a handgun or rifle, the inside

of a shotgun barrel is smooth A shotgun fires multiple metal spheres at ahigh velocity These pellets decelerate rapidly because of their unfavorableaerodynamics, and have greatest wounding capacity at a relatively close range(4 to 5 m) Shotguns are generally referred to in terms of “gauge.” This termoriginally described the quantity of lead shot capable of fitting in the diameter

of the barrel Smaller pellets fired from a shotgun are traditionally known as

“bird shot”; larger pellets are known as “buck shot.” Within a shotgun shell,the pellets are separated from the powder by plastic or cardboard wadding.Search for wadding when a patient is wounded by a shotgun, as it is notidentifiable radiographically Take care to serially examine these wounds, asthe greatest extent of tissue destruction may not be immediately apparent

c Stab wounds.In contrast to gunshot wounds, stab wounds are low-energywounds caused by “hand-driven” weapons The most commonly used weapon

is a knife, but other sharp objects of various types may be used to cause stabwounds as well History of weapon type and length is poorly predictive ofactual injury

D Combined injury

1 Blast injury.In addition to the current military experience, there were a reportedmean of 1327 bombing incidents per year between 1989 and 2002 in the UnitedStates Familiarity with associated injury patterns is essential for any practicingtrauma surgeon

a Primary blast injury.Primary blast injury is caused by pressure differentials.The most vulnerable tissues are the tympanic membrane, the lungs, the bowel,and the brain If the tympanic membrane is uninjured, injury to other organsfrom primary blast injury is much less likely

b Secondary blast injury.When debris from the explosive device is picked up

by the blast wave and accelerated toward the victim, this results in secondaryblast injury These injuries are more common than primary blast injuries, andmay cause significant blunt and penetrating wounds It must be noted that

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as the explosion occurs, debris is scattered widely, so be careful to assess forwounds distant from the site of most obvious injury Significant bony injury isalso common

c Tertiary blast injury.Tertiary injury occurs after a blast when there is tural collapse and subsequent entrapment Injury pattern is highly dependentupon the type of blast and structure, but compartment syndromes and crushsyndrome resulting in rhabdomyolysis may occur

struc-d Quaternary injury.Thermal and other environmental exposures contribute

to quaternary injuries These injuries may include burns or inhalation injuries

Suggested Readings

Baker SP, O’Neill B, Haddon W Jr, et al The injury severity score: a method for describing patients with

multiple injuries and evaluating emergency care J Trauma 1974;14(3):187–196.

Carter PR, Maker VK Changing paradigms of seat belt and air bag injuries: what we have learned in

the past 3 decades J Am Coll Surg 2010;210(2):240–252.

Champion HR, Copes WS, Sacco WJ, et al A new characterization of injury severity J Trauma 1990;

Hoyt DB, Coimbra R General considerations in trauma In: Mulholland MW, Lillemoe KD, Doherty

GM, Maier RV, Upchurch GR, eds Greenfield’s Surgery: Scientific Principles and Practice 4th ed.

Philadelphia, PA: Lippincott Williams & Wilkins; 2006

Hunt JP, Weintraub SL, Marr AB Kinematics of trauma In: Feliciano DV, Mattox KL, Moore EE, eds

Trauma 6th ed New York, NY: McGraw Hill Medical; 2008.

Maiden N Ballistics reviews: mechanisms of bullet wound trauma Forensic Sci Med Pathol 2009;5(3):

204–209

Malone DL, Kuhls D, Napolitano LM, et al Back to basics: validation of the admission systemic

inflam-matory response syndrome score in predicting outcome in trauma J Trauma 2001;51(3):458–463.

Meredith JW, Evans G, Kilgo PD, et al A comparison of the abilities of nine scoring algorithms in

predicting mortality J Trauma 2002;53(4):621–628; discussion 628–629.

Rutledge R, Osler T, Emery S, et al The end of the Injury Severity Score (ISS) and the Trauma andInjury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-basedprediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital

charges, and hospital length of stay J Trauma 1998;44(1):41–49.

Trunkey DD Trauma Accidental and intentional injuries account for more years of life lost in theU.S than cancer and heart disease Among the prescribed remedies are improved preventive efforts,

speedier surgery and further research Sci Am 1983;249(2):28–35.

Volgas DA, Stannard JP, Alonso JE Ballistics: a primer for the surgeon Injury 2005;36(3):373–379.

WISQARS CDC Web Site http://www.cdc.gov/injury/wisqars/index.html Accessed August 1, 2011

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pro-to injury is composed of a local response, tissue level reaction, and a general, temic, response After the first hit and the initial response, an individually determinedresponse is evoked by the organism on a systemic level, depending on the extent of theinjury

sys-A. Immediate changes experienced after injury (Table 2-1):

1.Tissue injury, disrupting the integrity of the tissues

2.Hemorrhage, followed by:

3.Tissue edema and volume shifts

B. The immediate changes are followed by a fight or flight response, which is an cortical response to stress and leads to increased production of corticosteroids andcatecholamines This redistributes the blood flow to essential organs such as theheart and brain The hypothalamic–pituitary (ACTH, endorphins, ADH)–adrenal(corticosteroids, epinephrine) axis is activated, as well as kidney response (renin)and sympathetic response (catecholamines) These activations lead to a hormonallydriven homeostatic response, composed of:

adreno-1.Increase in heart rate

2.Increase in respiratory rate

3.Fever

4.Leukocytosis

This immediate response is supported by:

a.Excitation of the sympathetic nervous system, because of the pain elicited bythe trauma This leads to hypertension, a high pulse rate and cortisol release

b.Stimulation of baroreceptors, atrial as well arterial, leads to vasoconstrictionand increased hormonal activity

c.Specific changes in the blood composition lead to stimulation of tors, which elicit compensatory changes

chemorecep-C. After the immediate response, several other processes ensue:

1.Hemostasis

2.Volume shifts

3.Local and systemic immune response

4.Initiation of tissue repair through local tissue reaction involving (Fig 2-1):

a.Complement Based on ischemia and endothelial injury; invading ganisms also may activate plasma proteins

microor-b.Oxygen radicals

i.Produced by leukocytes and parenchymal cells

ii. Consist of toxic products, such as hydrogen peroxide, superoxide, andhydroxyl radicals

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LWBK1111-02 LWW-Peitzman-educational September 7, 2012 15:24

Chapter 2 rPhysiologic Response to Injury 11

TABLE 2-1 Organ System Response

Blood pressureCardiac output higher

By higher frequency and tidal volume

CNS Altered mental state (direct or indirect)

Disintegrated barrier function

c.Cytokines Responses by local tissues, but also by systemic organs such as theliver

d.Eicosanoids Prostaglandins, leukotrienes, and thromboxanes

e. Nitrogen oxide From endothelial cells as a homeostatic factor for the diate regulation of the blood pressure Increased by inflammation and maycontribute to profound hypotension and decompensated hemorrhagic shock

imme-f.Others Release of several growth factors such as platelet-derived growthfactor and endothelial-derived growth factor

II HEMOSTASIS: THE EFFECT OF TRAUMA ON COAGULATION

A. Coagulation is a complex process which attempts to maintain integrity of the cular system Important in this respect, is the process of thrombocyte aggregation toplug the gap with thrombus formation Coagulation abnormalities have long beenthought to be only secondary to hemodilution from resuscitation and hypothermia

vas-We now understand that tissue injury directly influences coagulation (acute matic coagulopathy) As mentioned above, the coagulation system is influenced byour treatment, as following factors influence coagulation:

Trauma-induced coagulopathy (TIC) and its component acute traumaticcoagulopathy lead to endogenous coagulopathy, which is present in up to 25%

of trauma patients entering the emergency department It is induced by a nation of tissue injury and shock and related to tissue hypoperfusion The driverseems to be the systemic activation of the protein C pathway (Fig 2-2), resultingin:

combi-a.Coagulation inhibition Thrombomodulin is presented by the damagedendothelium and forms the Thrombomodulin complex which can no longercleave fibrinogen

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Protrombin fragment 1.2 (F1.2) Prothrombin

Polymerized ﬁbrin Solubleﬁbrin Fibrinogen Plasmin tPA

Plasminogen Fibrino lyse D-Dimer

α 2 -Antiplasmin

Figure 2-2.Trauma induced coagulopathy driven by activation of the Protien C pathway

b.Decreased fibrinogen utilization

c.Increased fibrinolysis Tissue plasminogen activator (tPA) is presented by theendothelium by injury and hypoperfusion tPA cleaves plasminogen to initi-ate fibrinolysis Moreover, a potent inhibitor of tPA, plasminogen activatorinhibitor-1 (PAI-1) is consumed leading to hyperfibrinolysis

B.Elevated admission INR is an independent predictor of poor outcome in traumapatients Currently, thromboelastography (TEG) is utilized to further clarify thecoagulopathy of trauma

III CONTINUED VOLUME SHIFTS

A. Hypoxemia at the tissue level and the effects of microparticles released after tissuedamage compromise the integrity of the endothelial lining and the natural bar-rier is lost, resulting in a rapid redistribution of the fluids over the compartments(Fig 2-3)

B.Three phases of volume shifts after trauma:

1. Phase I: Shock and active hemorrhage

This phase controls bleeding and lasts from admission to the end of operationfor hemostasis Pre-capillary vasoconstriction reduces the hydrostatic efflux offluid, electrolytes, and protein into the interstitium The interstitial matrix andplasma volume are contracted as electrolytes and proteins are mobilized into thecirculation

2. Phase II: Obligatory extravascular fluid sequestration

To restitute fluid in the interstitium, volume shifts into the interstitial and cellular spaces, leading to oliguria, if insufficient fluid is given An obligatorysequestration phase follows This sequestration gives a modest rise in the volume

inter-of the intercellular fluid compartment and a marked expansion inter-of the tial space This leads to a reduction in plasma volume and plasma proteins andalbumin relocation into the interstitial space

intersti-3. Phase III: Fluid mobilization and diuresis

In this phase, fluid again is mobilized from the interstitial spaces, resulting in

an acute increase in plasma volume sometimes resulting in volume overload,hypertension, and pulmonary dysfunction

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Figure 2-3.The integrity of the endothelial lining is compromised resulting in loss of barrier function

and subsequent fluid loss to the interstitium Redrawn after Le and Slutsky NEJM 2010;363:689.

IV THE IMMUNE RESPONSE

The immune system plays a pivotal role in defense and repair after external and internalthreats

A. Local versus systemic

At a local level after the bleeding ceases, the damaged tissues attract (Fig 2-1) cytes that start to remove the debris and counteract the invading microorganisms.Local vasoconstriction further attenuates bleeding and a mesh of fibrin is woven inwhich the invading cells can reside

leuko-At a systemic level, after trauma or infection, the organism is at a heightenedstate of alertness This is reflected by fever, tachycardia, tachypnea, a complex ofsymptoms known as the systemic inflammatory response syndrome (SIRS) ThisSIRS state can be further elevated by secondary insults such as operation or super-

imposed infections, often termed the second hit This hyper-vigilant state is

counter-acted by anti-inflammatory agents, resulting in the compensatory anti-inflammatoryresponse syndrome (CARS), a weakened vigilance, sometimes resulting in infectionand/or sepsis (Fig 2-4) These are thought to be processes following each other

in time; however, currently it is thought that this anti-inflammatory response withimmune paralysis is in place early post-injury This makes the organism susceptiblefor infection and sepsis

B. The immune response can be divided into the adaptive and the innate immunereaction (Fig 2-1)

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Anti-inflammatory

SIRS

CARS

Time Pro-inflammatory

1. Innate immune system:

a.Activation of immune cells

b.Cytokine secretion

c.Complement activation

d.Activation of the coagulation cascade

2. Adaptive immune system that adapts to the specific stimulus and attempts tocounteract the invader built specific plasma cells and cytotoxic T-cells to eradicatemicrobes and other non-autologous materials

3. The end effector organ is the leukocyte, which attempts to locate the threatand react to it The leukocyte is influenced by many systems, both locally andsystemically (Fig 2-1), as will be elucidated further in this chapter Just recently ithas been hypothesized that trauma related, damage associated molecular patterns(DAMPs), act on the same pathway as the pathogen associated molecular patterns(PAMPs) related to pathogens such as microbes (Fig 2-5) Thus, explaining whyboth trauma and infection elicit similar reactions of the body, with differentiationbetween both genesis of an inflammatory reaction, is difficult

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Figure 2-5.Current hypothesis of a common pathway of PAMPs and DAMPs (see text) resulting in

a comparable expression and function of leukocytes

C Early immune response (Fig 2-1):

1.Local activation at the site of the insult:

a.Activation of immune cells

b.Local secretion of mediators

c.Counteraction of anti-inflammatory cytokines to limit the response

2.With the goal of:

a.Hemostasis

b.Prevention of invasion of microorganisms

c.Start of tissue repair

d.Wound healing

3.In patients or injuries where:

a.The local response is overwhelmed

b.The host is more vulnerable for the insult

4.Mediators are released in the circulation leading to a systemic response withrelease of pro- and anti-inflammatory cytokines, leading to release of leukocytesand invasion of immune cells into the site of injury In an even higher stimula-tion of the immune system, for example, in severe trauma or a vulnerable host,

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f.Organ failure (lung, kidney, liver, brain, nervous tissue)

g. Because of the depletion of potent leukocytes, the host is more susceptible tomicrobiologic invasion and subsequent sepsis

V NEUTROPHILS

A. Tissue damage and reperfusion result in the production of reactive oxygen species(ROS).The local inflammatory mediator production provides homing signals forneutrophils, mainly leukocytes On the basis of these homing signals from the injuredtissues (provided, e.g., by IL-8 and ROS), neutrophils are attracted to these tissues.They leave the circulation and enter the tissues by diapedesis through the bloodvessel walls (Fig 2-5) In the tissues, they exert their action to clear the unwantedmaterial and bacteria However, in certain situations these actions can act againstthe host itself resulting in tissue damage, e.g., adult respiratory distress syndrome

or multiple organ failure

B.Neutrophils excrete injurious products:

1. ROS

2. Proteases:

a.Collagenase

b.ElastaseThese products result in increased permeability, by elastase mediated endothe-lial injury (Fig 2-3) This process is only possible with close contact betweenneutrophils and the endothelium After stimulation with bacterial productssuch as fMLP and endotoxin or complement (C5) the leukocytes adhere tothe endothelium to cause vascular injury, governed by molecules expressed onthe surfaces of both cell types

C.The normal function of the leukocyte (Fig 2-5)

After production in the bone marrow, the leukocyte circulates in the bloodstream Asubset of the leukocytes, the neutrophil, is the most active part of the cell line Afterspecific messages, the neutrophil changes its membrane properties and expressesselectins These selectins (L-selectin, P-selectin, and M-selectin) interact with theendothelium, whereafter the leukocyte adheres to the endothelium and starts rollingalong the surface of the vessel The integrins then set in and cause firm adherence

to the endothelium, so the leukocyte comes to a stop The neutrophil transmigratesthrough the vessel wall into the interstitium, where it acts by phagocytosis of debris

or microbes and the release of active substances, influencing the local surroundings

in a paracrine way, attracting new leukocytes for further action In support of theleukocytes, mast cells release serotonin, histamine, and bradykinin

VI MACROPHAGES

A. Primary function: Wound healing

B.Are generated from monocytes, attracted to the tissues by cytokines and bacterialproducts

C.Secrete active substances, for example, growth factors

D.Phagocytose bacteria

E. Mediate antigen presentation to lymphocytes

F.Less activity (or over use) is correlated with infectious complications

G. Inhibited by macrophage inhibiting factor

VII CYTOKINES(see Figs 2-1 and 2-6)

A. Pro-inflammatory (TNF, IL-1b, IL-6, IL-8)

1. Lead to upregulation encoding genes for phospholipase A2, COX-2, NO synthase

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