Manual of Definitive Surgical Trauma Care (A Hodder Arnold Publication) - 2nd edition

256 Pages·2007·2.04 MB·English

by  Kenneth Boffard

Manual of Definitive Surgical
Trauma Care
This page intentionally left blank
Manual of Definitive
Surgical Trauma Care
SECOND EDITION
Edited by
Kenneth D Boffard
Professor and Head
Department of Surgery
Johannesburg Hospital
University of the Witwatersrand
Johannesburg
South Africa
International Association for the Surgery
Of Trauma and Surgical Intensive Care
IATSIC
4 Taviton Street
London
WC1H 0BT
United Kingdom
Hodder Arnold
AMEMBER OF THE HODDER HEADLINE GROUP
First published in Great Britain in 2003.
This second edition published in 2007 by
Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline
Group, an Hachette Livre UK Company,
338 Euston Road, London NW1 3BH
http://www.hoddereducation.com
© 2007 Edward Arnold (Publishers) Ltd
All rights reserved. Apart from any use permitted under UK copyright law, this publication
may only be reproduced, stored or transmitted, in any form, or by any means with prior
permission in writing of the publishers or in the case of reprographic production in accordance
with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom
such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street,
London EC1N 8TS.
Whilst the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the author[s] 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
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN 978-0-340-94764-7
1 2 3 4 5 6 7 8 9 10
Commissioning Editor: Sarah Burrows
Project Editor: Francesca Naish
Production Controller: Lindsay Smith
Cover Designer: Helen Townson
Indexer: Laurence Errington
Typeset in 9.5 on 12pt Goudy by Phoenix Photosetting, Chatham, Kent
Printed and bound in Malta
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Contents
Editorial board xiii
Preface xvii
PART 1 INTRODUCTION 1
1.1 The need for a DSTC™ Course 3
1.2 Course objectives 4
1.3 Description of the course 4
1.4 Summary 5
PART 2 PHYSIOLOGY AND METABOLISM 7
2. Resuscitation physiology 9
2.1 Metabolic response to trauma 9
2.1.1 Definition of trauma 9
2.1.2 Initiating factors 9
2.1.3 Immune response 11
2.1.4 Hormonal mediators 13
2.1.5 Effects of the various mediators 14
2.1.6 The anabolic phase 17
2.1.7 Clinical and therapeutic relevance 17
2.1.8 References 17
2.2 Shock 18
2.2.1 Definition of shock 18
2.2.2 Classification of shock 18
2.2.3 Measurements in shock 21
2.2.4 Metabolism in shock 25
2.2.5 Post-shock sequence 26
2.2.6 Management of the shocked patient 26
2.2.7 Prognosis in shock 30
2.2.8 Recommended protocol for shock 31
2.2.9 References 31
2.3 Blood transfusion in trauma 32
2.3.1 Indications for transfusion 32
2.3.2 Effects of transfusing blood and blood products 33
2.3.3 Other risks of transfusion 33
2.3.4 What to do? 34
2.3.5 Massive transfusion 35
2.3.6 Autotransfusion 35
vi | Manual of Definitive Surgical Trauma Care
2.3.7 Transfusion: red blood cell substitutes 36
2.3.8 References 37
2.3.9 Recommended reading 37
2.4 Hypothermia 38
2.4.1 Rewarming 38
2.5 End points of resuscitation 39
2.5.1 Admission to the ICU 39
2.5.2 End points of ventilation 40
2.5.3 End points of circulation 41
2.5.4 References 43
2.5.5 Recommended reading 43
PART 3 DECISION-MAKING 45
3. Surgical decision-making 47
3.1 Resuscitation in the resuscitation room 47
3.1.1 Ideal practice 47
3.1.2 Resuscitation 47
3.1.3 References 51
3.2 Emergency department surgery 51
3.2.1 Craniofacial injuries 52
3.2.2 Chest trauma 52
3.2.3 Abdominal trauma 53
3.2.4 Pelvic trauma 53
3.2.5 Long bone fractures 53
3.2.6 Peripheral vascular injuries 53
3.2.7 Summary 54
3.3 Current controversies 54
3.3.1 Pre-hospital resuscitation 54
3.3.2 Systemic inflammatory response syndrome 54
3.3.3 Head injury 55
3.3.4 Specific organ injury 55
3.3.5 References 55
3.4 Damage control 55
3.4.1 Stage 1: patient selection 56
3.4.2 Stage 2: operative haemorrhage and contamination control 56
3.4.3 Stage 3: physiological restoration in the ICU 57
3.4.4 Stage 4: operative definitive surgery 57
3.4.5 Stage 5: abdominal wall reconstruction if required 57
3.4.6 Recommended reading 57
3.5 Abdominal compartment syndrome 57
3.5.1 Introduction 57
3.5.2 Definition 58
3.5.3 Pathophysiology 58
3.5.4 Causes of increased IAP 58
3.5.5 Effects of raised IAP on individual organ function 58
3.5.6 Measurement of IAP 59
3.5.7 Treatment 60
3.5.8 Surgery for raised IAP 60
Contents | vii
3.5.9 Future 61
3.5.10 References 61
3.5.11 Recommended reading 61
3.6 Closure of the abdomen 62
3.6.1 Objectives 62
3.6.2 Introduction: general principles of abdominal closure 62
3.6.3 Choosing the optimal method of closure 62
3.6.4 Techniques for closure 62
3.6.5 Re-laparotomy 63
3.6.6 Delayed closure 64
3.6.7 References 64
3.6.8 Recommended reading 64
PART 4 SPECIFIC ORGAN INJURY 65
4. The neck 67
4.1 Overview 67
4.1.1 Introduction 67
4.1.2 Management principles 67
4.1.3 Mandatory versus selective neck exploration 68
4.1.4 Use of diagnostic studies 68
4.1.5 Treatment based on anatomical zones 69
4.1.6 Rules 70
4.1.7 Recommended reading 70
4.2 Access to the neck 71
4.2.1 Incision 71
4.2.2 Carotid 71
4.2.3 Midline visceral structures 71
4.2.4 Root of the neck 72
4.2.5 Collar incisions 72
4.2.6 Vertebral arteries 72
5. The chest 74
5.1 Overview 74
5.1.1 Objectives 74
5.1.2 Introduction: the scope of the problem 74
5.1.3 The spectrum of thoracic injury 74
5.1.4 Pathophysiology of thoracic injuries 75
5.1.5 Applied surgical anatomy of the chest 76
5.1.6 Paediatric considerations 78
5.1.7 Diagnosis 78
5.1.8 Management 79
5.1.9 Emergency department thoracotomy 85
5.1.10 Approaches to the thorax 87
5.1.11 References 87
5.2 Access to the thorax 88
5.2.1 Incisions 88
5.2.2 Procedures 90
viii | Manual of Definitive Surgical Trauma Care
5.2.3 Conclusion 93
5.2.4 Recommended reading 93
6. The abdomen 94
6.1 The abdominal cavity 94
6.1.1 Overview 94
6.1.2 The trauma laparotomy 101
6.1.3 References 106
6.1.4 Recommended reading 106
6.2 The liver and biliary system 106
6.2.1 Overview 106
6.2.2 Access to the liver 110
6.2.3 Injury to the bile ducts and gallbladder 114
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 125
6.5 The duodenum 125
6.5.1 Overview 125
6.5.2 Access to the duodenum 132
6.6 Abdominal vascular injury 132
6.6.1 Overview 132
6.6.2 Access 133
6.7 The urogenital system 136
6.7.1 Overview 136
6.7.2 Renal injuries 136
6.7.3 Ureteric injuries 140
6.7.4 Bladder injuries 141
6.7.5 Urethral injuries 142
6.7.6 Injury to the scrotum 143
6.7.7 Gynaecological injury or sexual assault 143
6.7.8 Injury of the pregnant uterus 143
7 The pelvis 144
7.1 Introduction 144
7.2 Anatomy 144
7.3 Clinical examination 144
7.4 Classification 145
7.5 Resuscitation 145
7.6 Pelvic packing 146
7.6.1 Technique of retroperitoneal packing 147
7.7 Associated conditions 147
7.8 References 147
7.9 Recommended reading 148
8 Extremity injury 149
8.1 Overview 149
8.1.1 Introduction 149
Contents | ix
8.1.2 Massive limb trauma: life versus limb 149
8.1.3 Management 150
8.1.4 Complications 152
8.2 Scoring systems 152
8.2.1 Mangled Extremity Syndrome Index 152
8.2.2 Predictive Salvage Index 153
8.2.3 Mangled Extremity Severity Score 153
8.2.4 NISSA scoring system 153
8.2.5 Gustilo–Anderson classification 155
8.3 Fasciotomy 155
8.3.1 Four-compartment fasciotomy 155
8.3.2 Fibulectomy 155
8.4 References 155
8.5 Recommended reading 156
PART 5 ADDITIONAL (OPTIONAL) MODULES 157
9 Critical care of the trauma patient 159
9.1 Introduction 159
9.2 Goals of trauma ICU care 159
9.3 Phases of ICU care 159
9.3.1 Resuscitative phase (first 24 h post-injury) 159
9.3.2 Early life support phase (24–72 h post-injury) 160
9.3.3 Prolonged life support (> 72 h post-injury) 160
9.3.4 Recovery phase 161
9.4 Multisystem organ dysfunction syndrome 161
9.5 Coagulopathy of major trauma 162
9.5.1 Management 162
9.5.2 Suggested massive transfusion guidelines 162
9.5.3 Patients at risk of massive transfusion 163
9.6 Recognition and treatment of raised ICP 163
9.7 Recognition of acute renal failure 163
9.8 Evaluation of metabolic disturbances 163
9.9 Pain control 164
9.10 Family contact and support 164
9.11 ICU tertiary survey 164
9.11.1 Evaluation of occult injuries 164
9.11.2 Assessment of co-morbid conditions 164
9.12 Nutritional support 164
9.12.1 Access for enteral nutrition 165
9.13 Preventive measures in the ICU 165
9.13.1 Stress ulceration 165
9.13.2 Deep vein thrombosis and pulmonary embolus 166
9.13.3 Infection 166
9.14 Antibiotics 167
9.15 Respiration 167
9.16 Organ donation 167
9.17 References 168
9.18 Recommended reading 168