Manual of Definitive Surgical Trauma Care (A Hodder Arnold Publication)

238 Pages·2003·17.01 MB·English

by  Kenneth D. Boffard (Editor)

Manual of Definitive Surgical Trauma Care
Manual of Definitive Surgical
Trauma Care
Edited by
Kenneth D Boffard
International Association for the Surgery
of Trauma and Surgical Intensive Care
IATSIC Secretariat
4 Taviton Street
London
WC1H OBT
United Kingdom
International Society of Surgery
Netzibodenstrasse 34
P.O. Box 1527
Ch-4133 Pratteln
Switzerland
A member of the Hodder Headline Group
LONDON
First published in Great Britain in 2003 by
Arnold, a member of the Hodder Headline Group,
338 Euston Road, London NW1 3BH
http://www.arnoldpublishers.com
Distributed in the United States of America by
Oxford University Press Inc.,
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© 2003 Arnold
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accurate at the date of going to press, neither the authors nor the publisher
can accept any legal responsibility or liability for any errors or omissions
that may be made. In particular (but without limiting the generality of the
preceding disclaimer) every effort has been made to check drug dosages;
however, it is still possible that errors have been missed. Furthermore,
dosage schedules are constantly being revised and new side-effects
recognized. For these reasons the reader is strongly urged to consult the
drug companies' printed instructions before administering any of the drugs
recommended in this book.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
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A catalog record for this book is available from the Library of Congress
ISBN 0340 80925 6
123456789 10
Commissioning Editor: Serena Bureau
Development Editor: Layla Vandenbergh
Project Editor: Wendy Rooke
Production Controller: Deborah Smith
Cover Design: Terry Griffiths
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Contents
Editorial board xiii
Preface XV
1 Introduction 1
1.1 The need for a Definitive Surgical Trauma Care (DSTC™) Course 1
1.2 Course objectives 2
1.3 Description of the course 2
1.4 Summary 3
1.5 References 3
PART I PHYSIOLOGY AND METABOLISM
2 Resuscitation physiology 7
2.1 Metabolic response to trauma 7
2.1.1 Definition of trauma 7
2.1.2 Initiating factors 7
2.1.3 Immune response 8
2.1.4 Hormonal mediators 9
2.1.5 Effects of the various mediators 11
2.1.6 The anabolic phase 13
2.1.7 Clinical and therapeutic relevance 13
2.1.8 References 14
2.2 Shock 14
2.2.1 Definition 14
2.2.2 Classification 14
2.2.3 Measurements in shock 17
2.2.4 Metabolism in shock 21
2.2.5 Post-shock sequence and multiple organ failure syndromes 21
2.2.6 Management of the shocked patient 22
2.2.7 Prognosis in shock 26
2.2.8 References 26
2.3 Blood transfusion in trauma 27
2.3.1 Indications for transfusion 27
2.3.2 Effects of transfusing blood and blood products 28
2.3.3 Other risks of transfusion 29
2.3.4 What to do? 29
2.3.5 Massive transfusion 29
2.3.6 Autotransfusion 30
2.3.7 Transfusion: red blood cell substitutes 30
2.3.8 Recommended reading 31
vi Contents
2.4 Resuscitation endpoints 32
2.4.1 Metabolic considerations 32
2.4.2 Physiology 33
2.4.3 When to ventilate? 35
2.4.4 Shock 35
2.4.5 Recommended reading 38
PART II DECISION MAKING
3 Surgical decision making 41
3.1 Resuscitation in the resuscitation room 41
3.1.1 Ideal practice 41
3.1.2 Resuscitation 41
3.1.3 References 45
3.2 Emergency department surgery 45
3.2.1 Craniofacial injuries 46
3.2.2 Chest trauma 46
3.2.3 Abdominal trauma 47
3.2.4 Pelvic trauma 47
3.2.5 Long bone fractures 47
3.2.6 Peripheral vascular injuries 47
3.2.7 Summary 48
3.3 Current controversies 48
3.3.1 Pre-hospital resuscitation 48
3.3.2 Systemic inflammatory response syndrome 48
3.3.3 Head injury 49
3.3.4 Specific organ injury 49
3.4 Damage control 49
3.4.1 Stage 1. Patient selection 50
3.4.2 Stage 2. Operative haemorrhage and contamination control 50
3.4.3 Stage 3. Physiological restoration in the ICU 51
3.4.4 Stage 4. Operative definitive surgery 51
3.4.5 Stage 5. Abdominal wall reconstruction if required 51
3.4.6 Recommended reading 51
3.5 Abdominal compartment syndrome (ACS) 51
3.5.1 Introduction 51
3.5.2 Definition 52
3.5.3 Pathophysiology 52
3.5.4 Causes of increased intra-abdominal pressure 52
3.5.5 Effect of raised intra-abdominal pressure on individual organ function 52
3.5.6 Measurement of intra-abdominal pressure 53
3.5.7 Treatment 53
3.5.8 Surgery for raised intra-abdominal pressure 54
3.5.9 Tips for surgical decompression 54
3.5.10 The future 54
3.5.11 Recommended reading 54
3.6 Closure of the abdomen 55
3.6.1 Objectives 55
Contents vii
3.6.2 Introduction: general principles of abdominal closure 55
3.6.3 Choosing the optimal method of closure 55
3.6.4 Techniques for closure 55
3.6.5 Damage control and the 'quick out' 57
3.6.6 Re-laparotomy 57
3.6.7 Recommended reading 57
3.7 Massive limb trauma: life versus limb 58
3.7.1 Complications of severe open fractures 58
3.7.2 Mangled Extremity Syndrome (MES) 59
3.7.3 Predictive Salvage Index system 59
3.7.4 Mangled Extremity Severity Score (MESS) 60
3.7.5 NISSA scoring system 60
3.7.6 References 61
3.8 Resuscitation priorities: paediatrics 61
3.8.1 Introduction 61
3.8.2 Pre-hospital 62
3.8.3 Resuscitation room 62
3.8.4 Recognition of injury patterns 63
3.8.5 Organ system injury: priorities 63
3.8.6 Analgesia 63
3.9 Resuscitation priorities: the elderly 63
3.9.1 Definition 63
3.9.2 Physiology 63
3.9.3 Influence of co-morbid conditions 64
3.9.4 Outcome 64
3.9.5 Recommended reading 64
3.10 Futile care 64
PART III SPECIFIC ORGAN INJURY
4 The neck 69
4.1 Overview 69
4.1.1 Introduction 69
4.1.2 Management principles 69
4.1.3 Mandatory versus selective neck exploration 70
4.1.4 Use of diagnostic studies 70
4.1.5 Treatment based on anatomic zones 71
4.1.6 Rules 72
4.2 Access to the neck 72
4.2.1 Incision 72
4.2.2 Carotid 72
4.2.3 Midline visceral structures 73
4.2.4 Root of the neck 73
4.2.5 Collar incisions 74
4.2.6 Vertebral arteries 74
5 The chest 75
5.1 Overview 75
5.1.1 Objectives 75
viii Contents
5.1.2 Introduction: the scope of the problem 75
5.1.3 The spectrum of thoracic injury 76
5.1.4 Pathophysiology of thoracic injuries 76
5.1.5 Applied surgical anatomy of the chest 77
5.1.6 Paediatric considerations 79
5.1.7 Diagnosis 79
5.1.8 Management 80
5.1.9 Emergency department thoracotomy 86
5.1.10 Approaches to the thorax 88
5.1.11 References 89
5.2 Access to the thorax 89
5.2.1 Anterolateral thoracotomy 89
5.2.2 Median sternotomy 90
5.2.3 Emergency department thoracotomy 91
5.2.4 Trap-door' thoracotomy 93
5.2.5 Posterolateral thoracotomy 93
5.2.6 Definitive procedures 93
5.2.7 Conclusion 94
5.2.8 Recommended reading 94
6 The abdomen 95
6.1 The abdominal cavity 95
6.1.1 Overview 95
6.1.2 The abdominal contents 96
6.1.3 Retroperitoneum 99
6.1.4 Tissue adhesives in trauma 100
6.1.5 Access to the abdomen 101
6.2 The liver 106
6.2.1 Overview 106
6.2.2 Access to the liver 111
6.3 The spleen 114
6.3.1 Overview 114
6.3.2 Access to the spleen 116
6.4 The pancreas 117
6.4.1 Overview 117
6.4.2 Access to the pancreas 124
6.5 The duodenum 125
6.5.1 Overview 125
6.5.2 Access to the duodenum 131
6.6 The uro-genital system 131
6.6.1 Renal injuries 131
6.6.2 Ureteric injuries 134
6.6.3 Bladder injuries 135
6.6.4 Urethral injuries 137
6.6.5 Trauma to the scrotum 137
6.6.6 Gynaecological injury or sexual assault 138
6.7 Abdominal vascular injury 138
6.7.1 Overview 138
6.7.2 Access 139
6.7.3 References 142
6.7.4 Recommended reading 142
Contents ix
7 The pelvis 143
7.1 Introduction 143
7.2 Anatomy 143
7.3 Clinical examination 143
7.4 Classification 144
7.5 Resuscitation 144
7.6 Recommended reading 146
8 Vascular injury 147
8.1 Specific injuries 147
8.1.1 Injuries to the neck 147
8.1.2 Injuries to the chest 148
8.1.3 Injuries to the abdomen 148
8.1.4 Extremity injury 148
8.2 Compartment syndrome 148
8.3 Fasciotomy 149
8.3.1 Fibulectomy 149
8.3.2 Four-compartment fasciotomy 149
8.4 Recommended reading 149
PART IV ADDITIONAL (OPTIONAL) MODULES
9 Critical care of the trauma patient 153
9.1 Introduction 153
9.2 Goals of trauma ICU care 153
9.3 Phases of ICU care 153
9.3.1 Resuscitative phase (first 24 hours post-injury) 153
9.3.2 Early life support phase (24-72 hours post-injury) 153
9.3.3 Prolonged life support (>72 hours post-injury) 154
9.3.4 Recovery phase (separation from the ICU) 155
9.4 Multiple organ dysfunction syndrome 155
9.5 Coagulopathy of major trauma 156
9.5.1 Management 156
9.5.2 Suggested transfusion guidelines 156
9.5.3 Suggested protocol for massive transfusion 157
9.6 Recognition and treatment of raised intracranial pressure 157
9.7 Recognition of acute renal failure 158
9.8 Evaluation of metabolic disturbances 158
9.9 Pain control 158
9.10 Family contact and support 158
9.11 ICU tertiary survey 158
9.11.1 Evaluation for occult injuries 158
9.11.2 Assess co-morbid conditions 159
9.12 Nutritional support 159
9.12.1 Access for enteral nutrition 159
9.13 Preventive measures in the ICU 160
9.13.1 Stress ulceration 160
9.13.2 Deep vein thrombosis and pulmonary embolus 160
x Contents
9.13.3 Infection 161
9.14 Antibiotics 161
9.15 Respiratory 162
9.16 Organ donation 162
9.17 References 162
9.18 Recommended reading 163
10 Operating in austere or military environments 164
10.1 Introduction 164
10.2 Injury patterns 164
10.3 Triage 165
10.4 Mass casualties 165
10.5 Evacuation 166
10.6 Resuscitation 166
10.7 Battlefield analgesia 167
10.8 Battlefield anaesthesia 167
10.9 Damage control surgery in the military setting 167
10.10 Critical care 168
10.11 Conclusion 168
10.12 Recommended reading 168
11 Ultrasound in trauma 170
11.1 Focused abdominal sonography for trauma (FAST) 170
11.2 Other applications of ultrasound in trauma 170
11.2.1 Ultrasound in penetrating abdominal trauma 170
11.2.2 Ultrasound in thoracic trauma 170
11.3 Conclusion 170
11.4 Recommended reading 171
12 Minimally invasive surgery in trauma 172
12.1 Thoracic injury 172
12.2 Diaphragmatic injury 172
12.3 Abdominal injury 172
12.3.1 Screening for intra-abdominal injury 172
12.3.2 Splenic injury 172
12.3.3 Liver injury 172
12.4 Conclusion 173
12.5 Recommended reading 173
13 Skeletal trauma 174
13.1 Management of severe injury to the extremity 174
13.2 Key issues 174
13.2.1 Management of open fractures 174
13.2.2 Severity of injury (Gustilo classification) 174
13.2.3 Antibiotics 174
13.2.4 Timing of skeletal fixation in polytrauma patients 175
13.3 Amputate or preserve a severely damaged limb? 175
13.4 Compartment syndrome 175
13.5 Venous thrombo-embolism 175
13.6 Conclusion 175
13.7 References 176