Manual of Definitive Surgical Trauma Care, Fifth Edition

Description

Developed for the International Association for Trauma Surgery and Intensive Care (IATSIC), the Manual of Definitive Surgical Trauma Care 5e is ideal for training all surgeons who encounter major surgical trauma on an infrequent basis. This fifth edition had been revised and updated on the basis of new evidence-based information. The increasing role of non-operative management (NOM) has been recognised. With the increased need for humanitarian intervention, as well as military peacekeeping, the Military Module has been substantially updated and broadened to reflect recent conflict experience, and a new expanded section highlighting trauma management under austere conditions has been added.Written by faculty who teach the DSTC Course, this book focuses on life-saving surgical techniques to use in challenging and unfamiliar incidents of trauma. Cover......Page 1 Half Title......Page 2 Title Page......Page 4 Copyright Page......Page 5 Dedication......Page 6 Contents......Page 8 Video Contents......Page 26 Preface......Page 28 Training in the Initial Management of Severe Trauma......Page 32 The DATC™ Course......Page 34 Summary......Page 35 Board of Contributors......Page 36 Acknowledgements......Page 42 About the Author......Page 44 Part 1: Trauma System and Communication Principles......Page 46 1.2.1 Individual Factors......Page 48 1.2.3 Performance Improvement Activities......Page 50 1.2.5 National Activities......Page 51 1.2.6 Global Activities......Page 52 1.4 Conclusion......Page 53 2.1.1 The ‘Swiss Cheese’ Theory......Page 56 2.2.2 Resuscitation and Ongoing Management......Page 57 2.3 Leadership in Trauma Care......Page 58 2.5 Summary......Page 60 3.2.1 Resuscitation......Page 62 3.2.2 Management of Penetrating Trauma......Page 67 3.3.2 Chest Trauma......Page 68 3.3.5 Long Bone Fractures......Page 69 3.4 Summary......Page 70 Part 2: Physiology and the body's Response to Trauma......Page 72 4.1.2 Initiating Factors......Page 74 4.1.3 Immune Response......Page 75 4.1.4 Hormonal Mediators......Page 78 4.1.5 Effects of the Various Mediators......Page 79 4.2.2 Classification of Shock......Page 81 4.2.3 Measurements in Shock......Page 85 4.2.4 Endpoints in Shock Resuscitation......Page 86 4.2.5 Post-Shock and Multiple Organ Failure Syndromes......Page 87 4.2.6 Management of the Shocked Patient......Page 88 4.2.8 Recommended Protocol for Shock......Page 91 5.2.2 Blood......Page 94 5.2.3 Component Therapy (Platelets, Fresh Frozen Plasma, Cryoprecipitate)......Page 95 5.3.4 Coagulation Abnormalities......Page 96 5.3.5 Other Risks of Transfusion......Page 97 5.4.3 Transfusion Thresholds......Page 98 5.4.6 Monitoring the Coagulation Status: Traditional and VHA......Page 99 5.6 Red Blood Cell Substitutes......Page 104 5.6.3 Future Evolution......Page 105 5.8.1 Overview......Page 106 5.8.2 Tissue Adhesives......Page 108 5.8.3 Other Haemostatic Adjuncts......Page 109 6.1 Introduction......Page 112 6.3 Damage Control Surgery......Page 113 6.3.1 Stage 1: Patient Selection......Page 114 6.3.2 Stage 2: Operative Haemorrhage and Contamination Control......Page 115 6.3.3 Stage 3: Physiological Restoration in the ICU......Page 118 6.3.5 Stage 5: Abdominal Wall Closure......Page 120 6.4 Damage Control Orthopaedics......Page 122 Part 3: Anatomical and Organ System Injury......Page 124 7.2.1 Initial Assessment and Definitive Airway......Page 126 7.2.3 Injury Location......Page 127 7.3.1 Mandatory versus Selective Neck Exploration......Page 128 7.4.2 Incision......Page 129 7.4.3 Surgical Access......Page 130 7.4.4 Priorities......Page 131 7.4.5 Midline Visceral Structures......Page 132 7.4.8 Vertebral Arteries......Page 133 8.2.2 Potentially Life-Threatening Injuries......Page 136 8.3.1 Paediatric Considerations......Page 137 8.4.3 The Chest Contents......Page 138 8.5 Diagnosis......Page 140 8.6.3 Tension Pneumothorax (Haemo/­Pneumothorax)......Page 141 8.6.6 Oesophageal Injuries......Page 142 8.6.12 Air Embolism......Page 143 8.6.13 Cardiac Injuries......Page 145 8.7.1 Drain Insertion......Page 146 8.8 Surgical Approaches to the Thorax......Page 149 8.8.1 Anterolateral Thoracotomy......Page 150 8.8.2 Median Sternotomy......Page 151 8.9.1 History......Page 152 8.9.3 Indications and Contraindications......Page 153 8.9.6 Technique......Page 154 8.10.2 Cardiac Injury......Page 155 8.10.5 Lobectomy or Pneumonectomy......Page 156 8.12.1 Penetrating Thoracic Injury......Page 157 8.12.2 Blunt Thoracic Injury......Page 158 8.13 Anaesthetic Considerations......Page 159 9.1.1.1 Difficult Abdominal Injury Complexes......Page 162 9.1.1.3 Non-Operative Management of Penetrating Abdominal Injury......Page 163 9.1.2.1 Pre-Operative Adjuncts......Page 164 9.1.2.2 Draping......Page 165 9.1.2.4 Initial Procedure......Page 166 9.1.2.5 Perform a Trauma Laparotomy......Page 167 9.1.2.6 Perform Definitive Packing......Page 169 9.1.2.7 Specific Routes of Access......Page 170 9.1.2.8 Specific Organ Techniques......Page 172 9.1.3.3 Primary Closure......Page 173 9.1.4.3 Table Tilt......Page 174 9.1.4.8 Drains......Page 175 9.1.4.12 Early Tracheostomy......Page 176 9.1.6 Summary......Page 177 9.2.1 Overview......Page 178 9.2.2.3 Pelvic Haematoma......Page 179 9.2.3.2 Medial Visceral Rotation......Page 180 9.2.3.4 Superior Mesenteric Artery......Page 181 9.2.3.8 Inferior Vena Cava......Page 182 9.2.4 Shunting......Page 184 9.3.2 Diaphragm......Page 186 9.3.5 Small Bowel......Page 188 9.3.6 Large Bowel......Page 189 9.3.8 Mesentery......Page 190 9.3.9.1 Antibiotics......Page 191 9.4.1 Overview......Page 192 9.4.4 Liver Injury Scale......Page 194 9.4.5.1 Subcapsular Haematoma......Page 196 9.4.5.2 Non-Operative Management (NOM)..5.,.6......Page 197 9.4.6.1 Incision......Page 198 9.4.6.3 Techniques for Temporary Control of Haemorrhage......Page 199 9.4.6.4 Mobilization of the Liver......Page 202 9.4.7 Perihepatic Drainage......Page 203 9.4.8 Complications......Page 204 9.4.11 Injury to the Bile Ducts and Gallbladder......Page 205 9.4.12 Anaesthetic Considerations......Page 206 9.5.3.1 Clinical......Page 207 9.5.6 Surgical Approach......Page 208 9.5.6.7 Splenectomy......Page 211 9.5.8 Opportunistic Post-Splenectomy Infection......Page 212 9.6.1 Overview......Page 213 9.6.4.2 Serum Amylase and Serum Lipase......Page 214 9.6.4.8 Intra-operative Pancreatography......Page 215 9.6.6.1 Non-Operative Management......Page 216 9.6.7.2 Pancreatic Injury: Surgical Decision-Making......Page 217 9.6.10.1 Early Complications......Page 220 9.6.11 Summary of Evidence Based Guidelines......Page 221 9.7.3.1 Clinical Presentation......Page 224 9.7.5 Management......Page 225 9.7.6.1 Intramural Haematoma......Page 226 9.7.6.4 Complete Transection of the Duodenum......Page 227 9.7.6.8 Pyloric Exclusion......Page 228 9.8.2 Renal Injuries......Page 229 9.8.2.3 Management......Page 230 9.8.2.4 Surgical Approach......Page 232 9.8.2.5 Adjuncts......Page 234 9.8.3.2 Surgical Approach......Page 235 9.8.4.3 Surgical Approach......Page 236 9.8.5.3 Ruptured Urethra......Page 237 9.8.7.1 Management......Page 238 9.8.8 Injury of the Pregnant Uterus......Page 239 10.1 Anatomy......Page 240 10.2.1 Tile’s Classification......Page 241 10.2.2 Young and Burgess Classification......Page 243 10.3 Clinical Examination and Diagnosis......Page 245 10.4.2 Haemodynamically Stable Patients (Transient Responders)......Page 246 10.5.1 Iliac-Crest Route......Page 247 10.7 Extraperitoneal Pelvic Packing......Page 248 10.7.1 Technique of Extraperitoneal Packing......Page 249 10.8.5 Anorectal Injuries......Page 250 10.10 Summary......Page 251 11.2 Management of Severe Injury to the Extremity......Page 254 11.3 Management of Vascular Injury of the Extremity......Page 255 11.4 Crush Syndrome......Page 256 11.5.2 Sepsis and Antibiotics......Page 258 11.5.4 Timing of Skeletal Fixation in Polytrauma Patients......Page 259 11.6.1 Scoring Systems......Page 260 11.7 Compartment Syndrome......Page 262 11.8.1 Lower Leg Fasciotomy......Page 263 11.8.3 Upper and Lower Arm......Page 264 11.9 Complications of Major Limb Injury......Page 265 11.10 Summary......Page 266 12.2.2 Pathological Classification of TBI......Page 268 12.3.2 Intracranial Pressure......Page 269 12.6 Cerebral Perfusion Pressure Threshold......Page 270 12.7.2 ICP Management – Do’s and Don'ts......Page 271 12.9.1 Burr Holes and Emergency Craniotomy......Page 272 12.10.2 Seizure Prophylaxis......Page 274 12.13 Summary......Page 275 12.14 Anaesthetic Considerations......Page 276 13.3 Anatomy......Page 278 13.4.1 Chemical Burns......Page 279 13.4.2 Electrical Injury......Page 280 13.5.2 Superficial Partial Thickness......Page 281 13.6 Total Body Surface Area Burned......Page 282 13.7.2 First Aid......Page 283 13.7.3 Initial Management......Page 284 13.7.4 Escharotomy and Fasciotomy......Page 286 13.7.5 Definitive Management......Page 287 13.8.1 Face......Page 289 13.9.1 Nutrition in the Burned Patient......Page 290 13.9.5 Antibiotics......Page 291 13.10 Summary......Page 292 14.1.4 Resuscitation Room......Page 294 14.1.5 Specific Organ Injury......Page 295 14.1.6 Analgesia......Page 296 14.2.3 Physiology......Page 297 14.2.6 Decision to Operate......Page 298 14.4 Non-Beneficial (Futile) Care......Page 299 Part 4: Modern Therapeutic and Diagnostic Technology......Page 302 15.1.5 Technique......Page 304 15.1.7 Applications......Page 305 15.2.1 Technique......Page 306 15.3.1 Anatomy......Page 307 15.3.2 Physiology......Page 308 15.3.4 Monitoring......Page 309 15.3.7 Indications......Page 310 15.3.10 Summary......Page 311 15.4 Anaesthetic Considerations......Page 312 16.2 Radiation Doses and Protection from Radiation......Page 314 16.3 Principles of Trauma Imaging......Page 315 16.4 Pitfalls and Pearls......Page 316 16.5.2 Indications and Results......Page 317 16.5.4 Training......Page 318 16.5.5 Summary......Page 319 Part 5: Specialised Aspects of Total Trauma Care......Page 320 17.2.1 Resuscitative Phase (First 24 Hours Post-Injury)..1......Page 322 17.2.3 Prolonged Life Support (>72 Hours Post-Injury)......Page 323 17.2.4 Recovery Phase (Separation from the ICU)......Page 324 17.3.2 Modes of ECMO......Page 325 17.4 Coagulopathy of Major Trauma......Page 326 17.5 Hypothermia......Page 327 17.7 Systemic Inflammatory Response Syndrome (see also Chapter 4)......Page 328 17.9 Antibiotics......Page 329 17.10.1 Introduction......Page 336 17.10.4 Effect of Raised IAP on Individual Organ Function......Page 337 17.10.5 Measurement of IAP......Page 339 17.10.7 Surgery for Raised IAP......Page 340 17.13 Nutritional Support......Page 341 17.14.2 Deep Venous Thrombosis and Pulmonary Embolus......Page 344 17.15 Pain Control......Page 345 17.16.3 ICU Summary......Page 346 17.17 Family Contact and Support (see also Chapter 19)......Page 347 18.3 Damage Control Resuscitation......Page 350 18.3.1 Limited Fluid Administration......Page 351 18.3.3 Prevent and Treat Hypothermia......Page 352 18.4.1 Anaesthetic Procedures......Page 353 18.4.2 Monitoring......Page 354 18.5.2 Drugs for Anaesthesia Induction......Page 355 18.6.2 Battlefield Analgesia......Page 358 19.4 Trauma and ICU......Page 360 19.5.1 The Role of the Clinical Psychologist......Page 361 19.5.2 When to Call the Clinical Psychologist......Page 362 20.3 Rehabilitation Starts in ICU......Page 364 20.4.3 Rancho Los Amigos Scale......Page 365 20.5 Summary......Page 366 21.3 Infrastructure......Page 368 21.3.3 Health Protection of the Deployed Surgical Team......Page 369 21.4.4 Amputations......Page 370 21.6 Summary......Page 371 22.2 Injury Patterns......Page 374 22.3.1 The Echelons of Medical Care......Page 376 22.3.2 Incident Management and Multiple Casualties......Page 377 22.4.1 Source and Aim of Triage......Page 378 22.4.3 Forward Surgical Team Decision-Making......Page 379 22.5 Mass Casualties......Page 380 22.7.1 Overview......Page 381 22.7.2 Damage Control Resuscitation8......Page 382 22.7.3 Damage Control Surgery in the Military Setting10–12......Page 383 22.8.1 Diagnosis and Management of Blast Injuries......Page 384 22.10 Battlefield Anaesthesia......Page 385 22.10.1 Induction of Anaesthesia......Page 386 22.12.3 Common Training......Page 387 22.13 Summary......Page 388 A.3 Components of an Inclusive Trauma System......Page 392 A.3.3 Public Education......Page 393 A.5.4 Designation of Trauma Centres......Page 394 A.7 Summary......Page 395 B.2.2 Paediatric Trauma Score......Page 398 B.2.4 Acute Physiologic and Chronic Health Evaluation II......Page 399 B.3.1 Abbreviated Injury Scale......Page 400 B.3.4 Anatomic Profile Score......Page 401 B.3.7 Penetrating Abdominal Trauma Index......Page 402 B.4 Comorbidity Scoring Systems......Page 403 B.5.3 Major Trauma Outcome Study......Page 405 B.7 Scaling System for Organ Specific Injuries......Page 407 B.8 Summary......Page 426 C.1 Background......Page 430 C.3.4.2 National Organizations......Page 431 C.3.10 Course Syllabus......Page 432 C.5 Course Information......Page 433 D.3 The Abdominal Cavity......Page 434 D.8 The Genitourinary System......Page 435 D.11 Insertion of Resuscitative Balloon Occlusion of the Aorta (REBOA) Catheter......Page 436 E.2.2 Blood Loss......Page 438 E.2.5 Draping......Page 439 E.3.1 Instruments......Page 440 E.4 Abdominal Closure......Page 441 E.6 Medico-legal Aspects and Communication Skills......Page 442 E.8 Conclusion......Page 443 Index......Page 444