trauma critical care, volume 1

1. TRAUMA Emergency Resuscitation Perioperative Anesthesia Surgical Management Volume 1 DK3592_FM.indd 1 1/4/07 1:08:22 PM

2. Editors William C. Wilson, MD, MA Clinical Professor Director of Anesthesiology Critical Care Program Department of Anesthesiology and Critical Care University of California, San Diego School of Medicine La Jolla, California Director of Trauma Anesthesia Associate Director Surgical Intensive Care Unit UC San Diego Medical Center San Diego, California, U.S.A. Christopher M. Grande, MD, MPH Executive Director International TraumaCare (ITACCS) Baltimore, Maryland, U.S.A. David B. Hoyt, MD, FACS John E. Connolly Professor and Chairman Department of Surgery University of California, School of Medicine Irvine, California UC Irvine Medical Center Orange, California, U.S.A. DK3592_FM.indd 2 1/4/07 1:08:22 PM

3. Volume 1 Associate Editors Raul Coimbra, MD, PhD, FACS Professor of Surgery, Chief Division of Trauma, Burns and Critical Care Department of Surgery, University of California San Diego La Jolla California Director Surgical Intensive Care Unit UC San Diego Medical Center San Diego, California, U.S.A. Jose A. Acosta, MD, FACS Associate Professor of Surgery Division of Trauma and Critical Care Department of Surgery Naval Medical Center San Diego San Diego, California, U.S.A. Jonathan L. Benumof, MD Professor of Anesthesiology Director of Airway Management Training Department of Anesthesiology University of California San Diego La Jolla California Chief Division of Airway Management UC San Diego Medical Center San Diego, California, U.S.A. Richard P. Dutton, MD, MBA Associate Professor of Anesthesiology Department of Anesthesiology University of Maryland School of Medicine Director of Trauma Anesthesiology R Adams Cowley Shock-Trauma Center Baltimore, Maryland, U.S.A. DK3592_FM.indd 3 1/4/07 1:08:22 PM

4. Irving "Jake" Jacoby, MD, FACP, FACEP Clinical Professor of Medicine & Surgery Department of Emergency Medicine UC San Diego School of Medicine La Jolla California Team Leader, DMAT San Diego CA-4 Attending Physician, Emergency Department Director UCSD Hyperbaric Medicine Center UC San Diego Medical Center San Diego, California, U.S.A. Catherine McCoy-Hill, RN, MSN, CCRN, CNS, ANP Assistant Professor Director Critical Care Nursing Education School of Nursing Azusa Pacific University Azusa, California, U.S.A. Joseph F. Rappold, MD, FACS Associate Professor of Surgery Director, Division of Trauma and Critical Care Department of Surgery Naval Medical Center San Diego San Diego, California, U.S.A. Past Naval Medical Commander Fallujah and Ramadi, Iraq DK3592_FM.indd 4 1/4/07 1:08:22 PM

5. Volume 1 Section Editors Section A: Preparation and Prehospital Care Irving "Jake" Jacoby, MD, FACP, FACEP Clinical Professor of Medicine & Surgery Department of Emergency Medicine UC San Diego School of Medicine La Jolla California Team Leader, DMAT San Diego CA-4 Attending Physician, Emergency Department Director UCSD Hyperbaric Medicine Center UC San Diego Medical Center San Diego, California, U.S.A. Section B: Resuscitation Suite / Trauma ED Management Richard P. Dutton, MD, MBA Associate Professor of Anesthesiology Department of Anesthesiology University of Maryland School of Medicine Director of Trauma Anesthesiology R Adams Cowley Shock-Trauma Center Baltimore, Maryland, U.S.A. Section C: Anesthetic Management and Damage Control for Trauma Christopher M. Grande, MD, MPH Executive Director International TraumaCare (ITACCS) Baltimore, Maryland, U.S.A. DK3592_FM.indd 5 1/4/07 1:08:22 PM

6. Section D: Anesthetic and Surgical Considerations for Specific Injuries William C. Wilson, MD, MA Clinical Professor Director of Anesthesiology Critical Care Program Department of Anesthesiology and Critical Care University of California, San Diego School of Medicine La Jolla, California Director of Trauma Anesthesia Associate Director Surgical Intensive Care Unit UC San Diego Medical Center San Diego, California, U.S.A. Bruce Potenza, MD, FACS Associate Professor of Surgery Director of Burns, Division of Trauma, Burns and Critical Care Department of Surgery University of California San Diego School of Medicine La Jolla California Director UC San Diego Burn Unit UC San Diego Medical Center San Diego, California, U.S.A. Section E: Special Conditions Associated with Trauma Raul Coimbra, MD, PhD, FACS Professor of Surgery, Chief Division of Trauma, Burns and Critical Care Department of Surgery, University of California San Diego La Jolla California Director Surgical Intensive Care Unit UC San Diego Medical Center San Diego, California, U.S.A. DK3592_FM.indd 6 1/4/07 1:08:22 PM

7. TRAUMAEmergency Resuscitation Perioperative Anesthesia Surgical Management edited by William C. Wilson, MD, MA Clinical Professor Director of Anesthesiology Critical Care Program Department of Anesthesiology and Critical Care University of California, San Diego School of Medicine La Jolla, California Director of Trauma Anesthesia Associate Director Surgical Intensive Care Unit UC San Diego Medical Center San Diego, California, U.S.A. Christopher M. Grande, MD, MPH Executive Director International TraumaCare (ITACCS) Baltimore, Maryland, U.S.A. David B. Hoyt, MD, FACS John E. Connolly Professor and Chairman Department of Surgery University of California, School of Medicine Irvine, California UC Irvine Medical Center Orange, California, U.S.A. New York London Volume 1 DK3592_FM.indd 7 1/4/07 1:08:22 PM

8. Informa Healthcare USA, Inc. 270 Madison Avenue New York, NY 10016 2007 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acidfree paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number10: 0824729196 (Hardcover) International Standard Book Number13: 9780824729196 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 9787508400. CCC is a notforprofit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation with out intent to infringe. Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com DK3592_FM.indd 8 1/4/07 1:08:22 PM

9. This book is dedicated to the trauma victims, as well as the doctors, nurses, prehospital personnel, and other members of the trauma team who tirelessly strive to provide optimum care for their recovery.

10. Foreword From my recent perspective as the 17th surgeon general of the United States, along with my prior experiences as a trauma surgeon, combat experienced U.S. Army Special Forces medical specialist, paramedic, police ofcer, and registered nurse, I have witnessed numerous developments over the last three decades in the elds of trauma and critical care. Despite these signicant advances, trauma remains the chief cause of death and disability of individuals between 1 and 44 years of age; hence, much work remains to be done. Trauma is a worldwide phenomenon with profound public health implications and numerous existent chal- lenges, including the need for an increased emphasis on accident prevention; overcoming barriers to care for the indi- gent, the elderly, and rural populations; and streamlining and improving disaster response effectiveness. This two-volume book provides comprehensive coverage of all realms of modern trauma management, including the important aforementioned areas of care, which continue to impact the outcomes for these vulnerable populations. Volume 1 focuses on initial management and is divided into sections that mirror the continuum of care, including prehospital, resuscitation suite, and perioperative management. The prehospital section includes chapters on trauma mechanisms, epidemiology, scoring and triage, and transport. The authors acknowledge that optimal management algorithms for this early phase of care can differ based on the setting (urban/rural) and the prevailing geographical, political, and nancial conditions. Hospital- based components of management (e.g., primary survey, secondary survey, etc.) are meticulously reviewed, including specic chapters on the critical elements of care (e.g., airway management, uid therapy, etc.). The perioperative section details the anesthetic and surgical priorities, but surgical technical details are minimized in favor of global management guidelines, which are important to all members of the care team. Important trauma-related conditions are also fully reviewed. Volume 2 encompasses the critical care management of trauma and other surgical conditions. These topics are arranged in sections according to organ systems, with each chapter dedicated to a specic lesion or critical illness condition. Recent evidence-based principles are fully character- ized, including the management of abdominal compartment syndrome, tight glucose control, adrenal suppression, and thromboembolism, etc. In addition, chapters covering posttraumatic stress disorder, family centered care, rehabilitation, and palliation at the end of life provide a breadth of coverage not present in other trauma books. Chapters in both volumes are co-authored by experts from complimentary specialties, with surgeons, anesthesiologists, emergency medicine physicians, and pulmonologists involved throughout. Specialty sections are written by medical or surgical sub-specialists with extensive trauma and critical care experience. Interdisciplinary collaboration is further evident with chapters co-authored or edited by experienced nurses, pharmacists, and social workers, as well as occupational, physical, and respiratory therapists, among others. The editors are eminently qualied and have suc- ceeded in producing an authoritative and comprehensive book on trauma. Drs. Wilson, Grande, and Hoyt have each conducted important research and have published and lectured extensively on numerous trauma-related topics over the last two decades. They have assembled a superb table of contents and an expert array of contributors and associate editors. The editors have also insured that rec- ommendations are evidence based where possible. Accord- ingly, the novice will learn in depth about the scientic basis of the guidelines provided here, and the expert will be updated on the latest thinking in trauma management. In summary, this two-volume book is an extremely valuable contribution because of the importance of the subject, the fact that the topic has not been so comprehen- sively covered in one book until now, and because of the wisdom and insight of the editors. Vice Admiral Richard Henry Carmona, MD, MPH, FACS 17th Surgeon General of the United States of America v

11. Foreword The modern-day management of trauma is multidisciplinary and requires teamwork. The specialists involved include emergency physicians, anesthesiologists, radiol- ogists, surgeons, toxicologists, and critical care specialists along with paramedics, nurses, and technical staff. Those involved in the management of trauma have a need for a comprehensive book that spans the entire spectrum of trauma management by all specialists, including prehospital, perioperative, and critical care. This two- volume book, edited by Wilson, Grande, and Hoyt, does precisely that. Along with a superbly designed table of contents, the editors have recruited a world-class group of contributors from all specialties to write the chapters. The editors are abundantly qualied to oversee a work of this magnitude in terms of academic and intellectual strength, as well as in terms of clinical expertise. Volume 1 covers the areas of prehospital, emergency department, and perioperative management. Other important trauma-related conditions (e.g., alcohol and drug intoxication, burns, near drowning, environmental conditions) and management of unique populations of trauma patients (e.g., pediatric, geriatric, and obstetric) are also reviewed by experts in this volume. In addition to reviewing the key conditions, this volume contains clear guidelines for medical and surgical decision making in the various stages of care. In Volume 2, the critical care management of trauma is reviewed. This volume proceeds in a logical systems-based presentation of the conditions and complications commonly encountered in a modern trauma or surgical intensive care unit. All of the evidence-based measures recommended to improve outcomes in critically ill patients are included. In addition, emerging topics such as the remote evaluation and management of trauma and critical illness are introduced. As the only book to cover the full spectrum of trauma management, this two-volume set is strongly recommended for all students and clinically active physicians engaged in the management of trauma and surgical critical care. Peter J. F. Baskett, BA, MB, BCh, BAO, FRCA, FRCP, FCEM Consultant Anaesthetist Emeritus, Frenchay Hospital and the Royal Inrmary, Bristol, U.K. Editor-in-Chief, Resuscitation Past President, International Trauma Anaesthesia and Critical Care Society vi

12. Foreword Three decades ago, as an impressionable resident physician- in-training at the University of Washington in Seattle, I was asked to respond with the citys emergency medical services personnel on 9-1-1 emergency calls. Working out of the Harborview Emergency-Trauma Center, I soon began to recognize how the outcomes of those with severe injury are often determined, for better or for worse, in the rst few minutes after injury. After accompanying hundreds of patients from the incident scene, in the back of ambulances, in the emergency centers, and in operating rooms and intensive care units, I soon learned that a continuity of optimized care must be stewarded by an integrated team of experts from many disciplines. In turn, I have always stressed that an interdependent chain of survival/recovery had to be created with each link being strong and solidly connected to each other. I have been fortunate to train, perform research, and provide care in all of those arenas, and thus appreciate the tremendous expertise and demands required of each team member at each and every link. This two-volume book (edited by Wilson, Grande, and Hoyt) is, in many ways, the rst book to examine that entire spectrum of trauma care. Accordingly, as an emergency medicine physician originally trained in surgical critical care and trauma fellowships to challenge sacred cows with clinical trials, and as a prehospital care trauma specialist who has since spent many a night responding to out-of- hospital 9-1-1 incidents, I am now honored to write a foreword for this book. For those of us who have come to understand the chain of care and the impact of early decision making on long-term outcomes, this book is a tremendous gift. Volume 1 discusses many of the areas with which I am quite familiar, namely the initial treatment priorities in prehospital care, the resuscitation suite, and the perioperative period. These chapters are very current, including recent citations emphasizing the need for only a few assisted rescue breaths in conditions of severe circulatory impair- ment, while also minimizing initial intravascular uid infusion in the face of internal injuries resulting from penetrating trauma. Associated conditions known to con- found initial trauma care are also expertly reviewed. Volume 2 covers the critical care management of trauma and the other emergency surgical conditions commonly encountered in modern surgical intensive care units. Recent evidence-based principles of care are provided for virtually every condition for which such data exist. In addition, there are chapters focusing on the patients transition to recovery following the critical care period, including physical, occupational, and psychological rehabilitation. For example, it addresses screening and treatment of posttraumatic stress disorder. Complementing the breadth of material, the chapters are co-written by experts from all of the relevant pivotal specialties, ranging from resuscitologists, emergency medicine doctors, anesthesiologists, and orthopedists to the spectrum of surgeons, intensivists, psychiatrists, and rehabilitation experts. In addition, the co-authors hail from around the globe, emphasizing the international appeal, perspective, and orientation of this extremely inclusive, contemporary book. Finally, I should also say that the editors are exception- ally well qualied for a book of this magnitude. They are all experienced investigators, authors, and international lecturers on the many topics covered. In summary, this two-volume book should be considered as mandatory reading for every clinician actively involved in the care and management of trauma patients. Paul E. Pepe, MD, MPH, FACEP, FCCM Professor of Surgery, Medicine, Public Health and Riggs Family Chair in Emergency Medicine, University of Texas Southwestern Medical Center and the Parkland Emergency Trauma Center Director, City of Dallas Medical Emergency Services for Public Safety, Public Health, and Homeland Security Dallas, Texas, U.S.A. vii

13. Foreword Physicians involved in the care of injured patients come from many different disciplines and are sometimes called traumatologists. Emergency medical services personnel, emergency physicians, anesthesiologists, surgeons, intensivists, and hospital administrators are all concerned with a broad spectrum of trauma management. This two-volume book, edited by Wilson, Grande, and Hoyt, joins relatively few such comprehensive books on this subject and describes management of the trauma patient from a multidisciplinary standpoint, and emphasizes the anesthesiologists physiologic perspective. Internationally, the anesthesiologist is often the resuscitation or reanimation physician, with major responsibilities in the ambulance and in the evaluation area of hospitals, often without a specic trauma service. The table of contents reects an international group of contributors assembled by the editors to author the chapters. The editors have ensured academic and intellectual strength and clinical expertise. They are to be commended for achiev- ing such attention to detail in the rst edition. Dr. William C. Wilson, a trauma anesthesiologist and intensivist, is internationally recognized in the areas of trauma airway management, respiratory gas exchange, thoracic anesthesia, and monitoring. As editor-in-chief, Dr. Wilsons editorial leadership is evident in the clear organization of the book, uency of the writing, and balance of coverage. Dr. Christopher Grande, a clinically active trauma anesthesiologist and intensivist, is the executive director of International Trauma Care (ITACCS). He has published extensively in the area of trauma anesthesia and critical care for decades. Doctor Grandes editorial inuence is evi- denced by the expert international coverage of many topics. Dr. Hoyt is a world-renowned trauma surgeon and surgical intensivist. He has been an active leader of numerous prestigious surgical trauma organizations, including past president of the American Association for the Surgery of Trauma and the Shock Society, as well as chairman of the American College of Surgeons Committee on Trauma. He is the current president of the Pan American Trauma Society. Dr. Hoyts experience and wisdom are reected in his careful editorial oversight of this comprehensive two-volume treatise on trauma care. Volume 1 covers the areas of prehospital care, resuscitation, perioperative management, and associated trauma conditions. It is logically organized, covering the key conditions, and provides clear guidelines for medical and surgical decision making, including global operative considerations. However, by design, esoteric technical details of surgical procedures are omitted in favor of general management concepts and principles supported by recent literature. Other important trauma-related conditions (e.g., alcohol and drug intoxication, burns, near drowning, etc.) and management of unique populations (e.g., pediatric, geriatric, and obstetric) are also reviewed in Volume 1. Volume 2 covers the critical care management of trauma and is a logical, systems-based presentation of the problems commonly encountered in a modern intensive care unit. This volume reviews medical conditions, the role of psychological factors, the family, rehabilitation, and ethics. In addition, emerging topics such as remote evaluation and management are introduced. Because of the fundamental importance of the subject matter along with the editorial review, this two-volume set represents a compelling resource in the management of trauma and is highly recommended for all clinicians with primary responsibility for resuscitation and management of trauma patients. Kenneth L. Mattox, MD, FACS Professor and Vice Chair Michael E. DeBakey Department of Surgery Baylor College of Medicine Chief of Surgery Ben Taub General Hospital Houston, Texas, U.S.A. viii

14. Preface OVERVIEWOF BOTH VOLUMES Trauma is the leading cause of death in the young (ages 144) in the United States and the chief reason for lost years of productive life among citizens living in industrial- ized countries. Despite the enormous importance of the subject matter, no single text has yet been published that fully covers all phases of trauma management. The purpose of this book is to bring together in one source a description of modern clinical management principles for the care of the trauma patient. This two-volume set, Trauma, Volume 1: Emergency Resuscitation, Perioperative Anesthesia, Surgical Management and Trauma, Volume 2: Critical Care, thoroughly encompasses the entire spectrum of trauma management from the prehospital phase through critical care and rehabilitation. A comprehensive table of contents, at the front of each volume, encapsulates the organization of the entire book (providing a macroscopic view), and also details the sections and sub-headings within each chapter (providing a micro- scopic view). The extensive index at the back of the book is organized to provide expeditious referral to specic pages that cover the subject matter of interest. The reader is encour- aged to utilize both the very detailed table of contents and the index as needed to quickly locate topics. Each chapter in this work incorporates important features that greatly enhance information communication and learning. The chapters are generously illustrated with gures and tables to facilitate synthesis of important concepts. In addition, key points are highlighted within the text and are summarized at the end of each chapter for quick review. Care has been taken to minimize redundancy by maximizing appropriate cross-referencing throughout. Another useful aspect of each chapter is the Eye to the Future section, which reviews emerging concepts and new research ndings likely to impact clinical management. The contributors to these volumes are both authoritative (having performed original research and authored numerous publications on their subject matter) and have extensive clinical experience. The authorship considered as a whole is truly international, with contributors from all continents. Furthermore, both civilian and military considerations are reviewed whenever relevant. The majority of chapters have multi-specialty co-authorship by experts in trauma surgery, trauma anesthesiology, emergency medicine, and numerous other medical and surgical specialties. In addition, chapters have multidisciplinary involvement by experts in physical medicine, rehabilitation, nursing, and pharmacy, among other disciplines. The scientic soundness is further insured by the multiple layers of editorial oversight; every chapter has been reviewed by at least three experts in the eld (principal, associate and section editors). The high level of scientic accuracy and the reader-friendly nature of these two volumes are expected to facilitate learning in order to improve the care provided to trauma patients around the globe. VOLUME1 Volume 1 is divided into ve sections and begins to tell the trauma story. Section A (Preparation and Prehospital Care) provides the background knowledge and prehospital concepts required to manage trauma patients in both civilian and military settings. Section B instructs the traumatologist on what must be accomplished and accomplished quickly in the trauma resuscitation suite. Section C explores the principles of anesthetic management for trauma, including preoperative evaluation, preparation, and monitoring, along with the decision-making processes employed for selecting general or regional anesthetic techniques in trauma patients. Section D details the perioperative anesthetic and surgical priorities for specic injuries. This section focuses on the most important areas of management in a systematic fashion, including chapters on maxillofacial, brain, penetrating neck, cardiothoracic, and cervical and thoracic vertebral spine injuries, along with abdominal, pelvic, and extremity trauma. Each organ system receives specic focus as well as discussion within the context of the overall management strategy for severely injured patients. Section E surveys the numerous trauma-associated conditions with important time-sensitive diagnostic and management considerations. This section includes dis- cussions on the management of intoxication due to alcohol, drugs, poisoning, and envenomations. Anaphylaxis and allergy are discussed with specic implications for the trauma patient. Burn injuries are extensively reviewed, as are cold- and heat-related injuries, near-drowning, and weapons of mass destruction. In addition, the less frequently encountered trauma demographics (e.g., pediatrics, geria- trics, obstetrics) each have their own dedicated chapters. Finally, the pitfalls in trauma management and the elements constituting the tertiary survey are fully described. The absolute necessity to begin at the beginning when learning trauma management, including the principles of prehospital care and initial resuscitation and perioperative management concepts, makes this volume a must reference for the serious traumatologist and all others involved in this phase of the trauma story. William C. Wilson, MD, MA Christopher M. Grande, MD, MPH David B. Hoyt, MD, FACS ix

15. Acknowledgments The editors would like to express gratitude to our families and loved ones for their unwavering support during the many years of planning and production of this book. Without their sacrices, encouragement, and love, this two-volume book could not have been completed. The associate editors and numerous section editors have likewise sacriced time from their families and other professional responsibilities during their dedicated work on this important project. We cannot over express our gratitude for their contributions, or for our delight in the superb job accomplished by these gifted experts. Due to their diligence, this book has achieved a level of editorial oversight seldom found in multi-authored books. Essential to the production of this work was the superb administrative assistance provided by Paul Hobson and Bertha Englund. Paul, in particular, must be acknowledged for his dedicated support, working weekends and late into many evenings throughout the process of chapter formatting and editing. In addition, the contributions made by Linda Kesselring, Jan Bailey, and Sereyrathana Keng during the early stages of this project were critical to the ulti- mate success of the book. The excellent administrative support of Linda Collins throughout the project was likewise essential. Also vital to the development of this book has been the assistance of ITACCS (International TraumaCare), whose membership has contributed numerous chapters, and whose leadership has supported this project throughout its development. Finally, we would like to acknowledge the expert assistance provided by our publishers at Informa Health- care. The professionalism of this organization has been superb, starting at the top with Sandra Beberman, and throughout the publication process with the able assistance of Vanessa Sanchez and Joe Stubenrauch. The professionals at the Egerton Group (Joanne Jay and Paula Garber) were likewise essential to the production of this book. In particular, Mrs. Garber, editorial supervisor, must be commended for providing excellent attention to detail, a strong work ethic, and calm, kind leadership throughout the typesetting and nal editing. Geoffrey Greenwood must also be acknowledged for helping us initiate this project many years ago. Each of these individuals has served to kindly and expertly assist our navigation through the ardors of the publication process, and we are grateful to them all. William C. Wilson, MD, MA Christopher M. Grande, MD, MPH David B. Hoyt, MD, FACS xi

16. Contents Foreword Richard Henry Carmona . . . . v Foreword Peter J. F. Baskett . . . . vi Foreword Paul E. Pepe . . . . vii Foreword Kenneth L. Mattox . . . . viii Preface . . . . ix Acknowledgments . . . . xi Contributors . . . . xxxiii SECTION A: PREPARATION AND PREHOSPITAL CARE Section Editor: Irving Jake Jacoby 1. History of Trauma . . . . 1 Panna Sanga, Adolph H. Giesecke, William C. Wilson, and Anne J. Sutcliffe B Introduction . . . . 1 B Prehistory . . . . 2 B Early Civilizations, 3000 B.C. 200 A.D. . . . . 2 Egyptians . . . . 2 Greeks . . . . 3 The Romans . . . . 4 B Dark and Middle Ages and Middle Eastern Medical Advances, 2001500 . . . . 6 B Renaissance Era, 1500 . . . . 8 B History of Analgesia Through Antiquity (Through the 1700s) . . . . 12 B Epoch of Inhalation Anesthesia, 1800 . . . . 12 The Mexican War of 1845 . . . . 13 The American Civil War . . . . 14 B Discovery of Antiseptic Strategies, 1848 . . . . 15 B Epoch of Regional Anesthesia, 1884 . . . . 16 B Epoch of Intravenous Anesthesia and Antibiotics, 1934 . . . . 17 B Epoch of Fluid Therapy for Trauma, 1950 . . . . 18 B Epoch of Precision Monitoring and Resuscitation for Anesthesia and Trauma, 1986 . . . . 19 B Epoch of Emergency Medical Services (Current Era) . . . . 20 B Summary . . . . 21 Key Points . . . . 21 B References . . . . 22 2. Mechanisms and Epidemiology of Trauma . . . . 25 Bruce Potenza and Jerry Nolan B Introduction . . . . 25 B Mechanisms of Trauma . . . . 26 Precipitating Agents of Injury . . . . 26 Biomechanical Forces Generated by Various Mechanisms . . . . 28 Blunt Trauma . . . . 28 Penetrating Trauma . . . . 28 Gunshot Wounds (Combination of Penetrating and Blunt Biomechanics) . . . . 28 Thermal Injuries . . . . 29 Caustic ChemicalRelated Injury . . . . 29 Electrical Injuries . . . . 30 Blast Injuries . . . . 30 Radiation Injury . . . . 31 Injury Intent . . . . 31 Intentional . . . . 31 Unintentional . . . . 31 B Scope of Injury and Death Due to Trauma . . . . 31 Injury Pyramid . . . . 32 Years of Productive Life Lost and Disability Adjusted Life Years . . . . 33 Trauma Data Base Organizations and Coding . . . . 33 B Demographic Factors . . . . 34 Age-Specic Injury Mechanisms . . . . 34 Socioeconomic Status . . . . 34 Gender . . . . 35 B Leading Mechanisms of Injury . . . . 35 Unintentional Injuries . . . . 35 Motor Vehicle Collisions . . . . 35 Pedestrians Struck by a Motor Vehicle . . . . 36 Falls . . . . 36 Drowning . . . . 36 Bicycle . . . . 36 Fires and Burns . . . . 36 Intentional Injuries . . . . 36 Assault . . . . 37 Homicide . . . . 37 Suicide . . . . 37 War-Related Injuries . . . . 37 B Public Health Approach to Injury Prevention . . . . 37 B Eye to the Future . . . . 39 B Summary . . . . 39 Key Points . . . . 40 B References . . . . 40 3. Prehospital Care and Trauma Systems . . . . 43 Erika Frischknecht Christensen, Charles D. Deakin, Gary M. Vilke, and Freddy K. Lippert B Introduction . . . . 43 B Models of Prehospital Trauma Care . . . . 43 Stafng Models of Prehospital Care . . . . 43 Background . . . . 43 United States and Canadian Model . . . . 43 Central European Model . . . . 44 Comparison of Prehospital Stafng Models . . . . 44 Skill Levels and Training of Prehospital Providers . . . . 45 Integration of Prehospital and In-Hospital Systems . . . . 45 Communication Between Hospitals and Field Units . . . . 46 Dispatch . . . . 46 On-Scene Communication . . . . 46 B System Management Strategies . . . . 46 Overview of Management Strategies . . . . 46 Prehospital Mortality Data Drives Resuscitation Priorities . . . . 47 xiii

17. Organizational Inuences on the System of Prehospital Care . . . . 47 Overview . . . . 47 Evidence for Scoop and Run . . . . 47 Evidence for Field Stabilization . . . . 47 Optimum Mode of Transport . . . . 48 B Prehospital Management Priorities . . . . 48 Airway . . . . 48 Breathing . . . . 49 Circulation . . . . 49 B Communication of Patient Information to the Trauma Team . . . . 50 Prearrival Report . . . . 50 Transfer of Care and Patient Information . . . . 51 Mechanism . . . . 51 Injuries . . . . 51 Vital Signs . . . . 51 Treatment . . . . 51 B Trauma Center and Trauma System Concepts . . . . 51 Background . . . . 51 Dening Trauma Centers and Systems . . . . 51 Effectiveness of Trauma Centers and Trauma Systems . . . . 54 B Eye to the Future . . . . 54 B Summary . . . . 55 Key Points . . . . 55 B References . . . . 56 4. Trauma Scoring and Triage . . . . 59 Daniela Levin, Costas Bachtis, Jose A. Acosta, and Irving Jake Jacoby B Introduction . . . . 59 B Trauma Scoring Denition and Categorization . . . . 59 B Frequently Used Scoring Systems . . . . 60 Glasgow Coma Scale . . . . 60 Trauma Score and Revised Trauma Score . . . . 61 Organ Injury Scale . . . . 62 Abbreviated Injury Scale . . . . 62 Injury Severity Score . . . . 62 Anatomical Prole . . . . 63 Pediatric Scoring . . . . 63 Acute Physiological and Chronic Health Evaluation . . . . 64 B Quality Assessment Systems . . . . 65 Trauma ScoreInjury Severity Score . . . . 65 A Severity Characterization of Trauma . . . . 65 B Trauma Registries . . . . 66 Major Trauma Outcome Study . . . . 66 The Utstein Style: Uniformity in Scoring . . . . 66 B Triage Denitions and General Concepts . . . . 67 B Triage Applications . . . . 67 Use of Disaster Medical Assistance Teams . . . . 67 Out-of-Hospital Triage Principles . . . . 68 In-Hospital (Secondary) Triage . . . . 72 B Limitations and Pitfalls of Triage . . . . 73 B Special Triage Situations . . . . 74 Civilian Mass Casualty: START/JumpSTARTTM . . . . 74 Nuclear Incidents . . . . 75 Biological Agent Release . . . . 75 Chemical Agent Release . . . . 76 Pediatrics . . . . 78 War . . . . 78 B Eye to the Future . . . . 78 B Summary . . . . 79 Key Points . . . . 79 B References . . . . 79 5. Resuscitation Suite and Operating Room Readiness . . . . 83 Sanjeev V. Chhangani, Peter J. Papadakos, William C. Wilson, Wasif Ali, and Jose A. Acosta B Introduction . . . . 83 B Physical Plan of Trauma Resuscitation Suite . . . . 83 Equipment . . . . 84 Airway Cart . . . . 84 Procedure Cart . . . . 84 Monitors . . . . 84 Immobilization Devices . . . . 85 Other Equipment . . . . 86 Pharmacologic Agents . . . . 86 Communication . . . . 87 Preassigned Roles of Trauma Team Members . . . . 89 Noise Level Expectations . . . . 89 ATLS Training of Personnel . . . . 89 Laboratory Support . . . . 91 Blood Bank . . . . 91 Clinical Laboratory . . . . 91 Radiology . . . . 91 Ultrasonography . . . . 91 B Intrahospital Transport . . . . 91 Pretransport Patient Evaluation . . . . 92 Transport Monitoring . . . . 92 Data Management . . . . 92 Coordination of Care . . . . 93 B Physical Plan of Trauma Operating Room . . . . 93 Equipment . . . . 94 Anesthesia Machine and Anesthesia Cart . . . . 94 Fluid-Warming Devices . . . . 94 Procedure and Invasive Line Carts . . . . 94 Other Equipment . . . . 95 Pharmacologic Agents . . . . 95 Laboratory and Blood Bank Support Personnel . . . . 95 Additional Anesthesia Monitoring and Support Personnel . . . . 95 B Military Resuscitation and Operating Room Considerations . . . . 96 B Eye to the Future . . . . 98 B Summary . . . . 98 Key Points . . . . 98 B References . . . . 99 6. Trauma Team Performance . . . . 101 Paul Barach and Matthew B. Weinger B Introduction . . . . 101 B Team Denition and Relevance in Trauma . . . . 101 Team Competence . . . . 101 Team Member Conict Resolution . . . . 102 B Organization of the Modern Trauma Team . . . . 102 The Trauma Team Leader . . . . 102 Other Members of the Trauma Team . . . . 103 B Human Factors in the Trauma Environment . . . . 103 xiv Contents

18. Sleep Deprivation and Fatigue . . . . 104 Stress and Job Performance . . . . 104 Environmental Factors (e.g., Noise, Clutter, Disorganization) . . . . 105 Interpersonal Communication . . . . 105 B Keys to Expert Decision Making for Trauma . . . . 105 Correct Decision Making with Incomplete/Conicting Data . . . . 105 Situation Awareness . . . . 106 B Team Training Techniques . . . . 106 Traditional Team Training Exercises . . . . 106 Cross Training . . . . 107 Team Model Training . . . . 107 Trauma Crew Resource Management . . . . 107 Simulators for Trauma Team Training and Assessment . . . . 108 Value of Realistic Patient Simulators . . . . 108 Importance of Scenario Design . . . . 108 Components of a Simulation-Based Training Course . . . . 108 B Evaluating Trauma Team Performance . . . . 108 Paucity of Validated Competency Assessment Metrics . . . . 109 Video Analysis of Trauma Care . . . . 109 B Eye to the Future . . . . 109 Increased Emphasis upon Computerized Simulation . . . . 109 Incorporating Military and Aviation Industry Lessons . . . . 110 B Summary . . . . 110 Key Points . . . . 111 B References . . . . 111 7. Transport of the Trauma Patient . . . . 115 Jose A. Acosta, Maureen McCunn, William Beninati, William C. Wilson, and Joseph F. Rappold B Introduction . . . . 115 Overview . . . . 115 Transportation Guidelines . . . . 116 Determining Appropriateness of Transport . . . . 116 B Prehospital and Interhospital Transport Modes . . . . 117 Ground Travel . . . . 117 Rotary-Wing Transport . . . . 118 Fixed-Wing Transport . . . . 118 Miscellaneous Modes of Transportation . . . . 118 B Preparation . . . . 120 Transport Team Members . . . . 120 Equipment . . . . 120 Safety Considerations . . . . 120 B Potential Transport Complications . . . . 121 Hemodynamic Stability . . . . 122 Airway and Respiratory Compromise . . . . 124 Intracranial Pressure Considerations . . . . 124 Physiological Stresses of Flight . . . . 125 B Long-Range Air Transport Considerations . . . . 126 Trapped Gas . . . . 126 Decompression Sickness/Air Embolism . . . . 126 Casts/Compartment Syndrome . . . . 126 Damage Control/Abdominal Compartment Syndrome . . . . 127 Burns . . . . 127 Infection Control . . . . 127 B Special Circumstances . . . . 128 Disaster/Mass Casualty . . . . 128 Contaminated Casualties . . . . 128 Combat MEDEVAC and Transport . . . . 128 B Eye to the Future . . . . 130 B Summary . . . . 132 Key Points . . . . 132 B References . . . . 133 SECTION B: RESUSCITATION SUITE/TRAUMA ED MANAGEMENT Section Editor: Richard P. Dutton 8. Primary Survey: Initial Resuscitation Priorities . . . . 135 Eran Tal-Or, Koichi Tanigawa, Andreas R. Thierbach, Herbert Kuhnigk, and Moshe Michaelson B Introduction . . . . 135 B Airway Maintenance with Cervical Spine Protection . . . . 135 Assessment . . . . 135 Basic Airway Management . . . . 136 Supplemental Oxygen and Chin-Lift/ Jaw-Thrust Maneuvers . . . . 136 Oropharyngeal and Nasopharyngeal Airways . . . . 137 Aspiration Precautions and Suction Devices . . . . 137 Cervical Spine Precautions . . . . 137 Denitive Airway Management . . . . 138 Rapid Sequence Induction . . . . 138 Alternative Emergency Airway Devices . . . . 139 Surgical Airway . . . . 139 Conrmation of Tracheal Intubation . . . . 139 B Breathing Assessment and Maintenance . . . . 140 Physical Examination . . . . 140 Inspection . . . . 140 Palpation/Percussion . . . . 141 Auscultation . . . . 141 Imaging Aids to Breathing Assessment . . . . 141 Life-Threatening Thoracic Injuries . . . . 143 Tension Pneumothorax . . . . 143 Massive Hemothorax/Tube Thoracostomy . . . . 143 Sucking Chest Wounds . . . . 143 Flail Chest . . . . 143 Cardiac Tamponade/Pericardial Drainage . . . . 144 Mechanical Ventilation in the Resuscitation Suite . . . . 144 B Circulation Assessment and Hemorrhage Control . . . . 145 Assessment . . . . 145 Denition of Hemodynamic Stability . . . . 145 Circulation Assessment Principles . . . . 145 Contents xv

19. Circulatory Depression from Nonhemorrhagic Causes . . . . 146 Management of Compensated Hemorrhagic Shock . . . . 147 Shock Prediction and Prevention . . . . 147 Maintenance of Blood Pressure and Tissue Perfusion . . . . 147 Management of Uncontrolled Hemorrhagic Shock . . . . 147 Diagnostic Testing and Monitoring Adjuncts . . . . 147 Hemoglobin Measurements . . . . 147 Invasive Blood Pressure Monitoring . . . . 147 Central Venous Pressure . . . . 147 Arterial Blood Gas and Base Decit . . . . 148 Lactate Level . . . . 148 FAST Versus DPL Versus CT Scan . . . . 148 CT Scan . . . . 148 B Disability . . . . 148 General Considerations . . . . 148 History . . . . 148 Mechanism of Injury . . . . 148 Patient History . . . . 149 Physical Examination . . . . 149 Level of ConsciousnessGlasgow Coma Scale . . . . 149 Pupil Examination . . . . 149 Motor Examination . . . . 150 Sensory Function and Other Symptoms . . . . 150 B Exposure/Environmental Control . . . . 150 Exposure . . . . 150 Environmental Control . . . . 150 B Eye to the Future . . . . 150 B Summary . . . . 151 Key Points . . . . 151 B References . . . . 152 9. Denitive Airway Management . . . . 155 William C. Wilson, Anushirvan Minokadeh, Jonathan L. Benumof, Michael Frass, and Pedro Barbieri B Introduction . . . . 155 B Equipment and Drug Preparation . . . . 155 Oxygen: Critical During Trauma Airway Management . . . . 155 Treatment of Hypoxemia . . . . 156 Preoxygenation: Maximizing PaO2 During Apnea . . . . 156 Ventilation and Intubation Equipment . . . . 157 Suction Equipment . . . . 158 Functioning Intravenous Catheter . . . . 158 Monitoring and Endotracheal Tube Conrmation Devices . . . . 158 Vasopressors and Inotropes . . . . 159 Portable Storage Unit for Trauma Resuscitation . . . . 159 B Denition of the Difcult Airway . . . . 159 Historical Indicators of Airway Difculty . . . . 160 Pathologic/Anatomic Predictors of Airway Difculty . . . . 160 B Airway Examination Principles . . . . 161 The 11-Step Airway Exam of Benumof . . . . 161 Abbreviated Trauma Airway Exam . . . . 161 B Conventional Trauma Airway Management . . . . 161 Patient Preparation and Positioning . . . . 161 Mask Ventilation . . . . 163 Types of Masks Used for Ventilation . . . . 163 Mask Ventilation Techniques . . . . 163 Oropharyngeal and Nasopharyngeal Airways . . . . 163 Laryngeal Mask Airway . . . . 163 Rigid Direct Laryngoscopy . . . . 164 In-Line Cervical Immobilization . . . . 165 Rapid Sequence Intubation (RSI) Principles . . . . 165 Modied Rapid Sequence Intubation Techniques . . . . 167 B The Difcult Trauma Airway . . . . 167 Awake Techniques (Cooperative/Stable Patients) . . . . 167 Adjunts for Unstable, Uncooperative, or Apneic Patients with Difcult Airways . . . . 168 Esophageal-Tracheal-Combitube . . . . 168 Laryngeal Mask Airway . . . . 168 Rigid Bronchoscope . . . . 170 Surgical Airway Options . . . . 171 Blind Intubation Techniques (Not Recommended with Stridor) . . . . 173 Blind Nasal Intubation . . . . 173 Light Wand . . . . 175 Retrograde Wire . . . . 175 Regional Anesthesia in the Trauma Patient with Known Difcult Airway . . . . 175 B Fiberoptic Bronchoscopy: Techniques and Pitfalls . . . . 175 Patient Selection . . . . 176 Patient Preparation . . . . 177 Positioning for Fiberoptic Bronchoscopy . . . . 177 Intravenous Analgesia, Sedation, and Antisialagogue . . . . 177 Local Anesthesia and Vasoconstriction . . . . 177 Techniques of Fiberoptic Intubation . . . . 178 Awake Nasal Technique . . . . 178 Oral Technique . . . . 180 B Difcult Airway Algorithms . . . . 181 The ASA Difcult Airway Algorithm . . . . 181 Recognition of the Difcult Airway . . . . 181 Awake Limb of the ASA Difcult Airway Algorithm . . . . 183 Uncooperative/Unstable/Anesthetized Limb of the ASA Difcult Airway Algorithm . . . . 183 ASA Difcult Airway Algorithm Modied for Trauma . . . . 183 Five Common Trauma Difcult Intubation Scenarios . . . . 184 Traumatic Brain Injury/Intoxication . . . . 184 Cervical-Spine Injury . . . . 185 Airway Disruption . . . . 185 Maxillofacial Trauma . . . . 188 Airway Compression . . . . 188 B Emergency Intubation Complications . . . . 189 Failure to Intubate or Ventilate . . . . 190 Unrecognized Esophageal Intubation . . . . 191 Direct Conrmation of Intratracheal Tube Position . . . . 191 Indirect Conrmation of Intratracheal Tube Position . . . . 191 End-Tidal CO2 Measurement . . . . 191 xvi Contents

20. Hemodynamic Compromise . . . . 191 Causes of Preinduction Increases of Catecholamines . . . . 192 Causes of Hypotension Following Induction and Intubation . . . . 192 Techniques to Limit Hypotension Following Intubation . . . . 192 Aspiration of Gastric Contents . . . . 192 Creating a C-Spine Injury in a Patient with an Unstable Neck . . . . 192 B Eye to the Future . . . . 193 B Summary . . . . 194 Key Points . . . . 194 B References . . . . 195 10. Intravenous Access . . . . 197 Robert E. Johnstone, Joseph F. Talarico, Edward E. Cornwell III, and Nelson Tang B Introduction . . . . 197 B Determinants of Intravenous Flow Rate . . . . 197 B Peripheral Intravenous Access . . . . 199 General Considerations . . . . 199 Technique . . . . 199 B Central Venous Access . . . . 200 General Considerations . . . . 200 Complications . . . . 200 Internal Jugular Vein Catheterization . . . . 201 General . . . . 201 Advantages and Disadvantages . . . . 201 Complications . . . . 201 Technique 1: Middle Approach . . . . 202 Technique 2: Posterior Approach (Alternate) . . . . 203 Subclavian Vein Catheterization . . . . 203 General . . . . 203 Advantages and Disadvantages . . . . 203 Complications . . . . 203 Technique . . . . 204 Femoral Vein Catheterization . . . . 204 General . . . . 204 Advantages and Disadvantages . . . . 204 Complications . . . . 204 Technique . . . . 204 B Saphenous Vein Cutdown . . . . 205 B Intraosseous Infusion . . . . 205 B Intratracheal Administration of Drugs . . . . 206 B Other Infusion Considerations . . . . 206 B Special Lines and Maneuvers . . . . 207 Pringle Maneuver . . . . 208 Atriocaval Shunts and Atrial Lines . . . . 209 Arterial Catheters . . . . 210 B Eye to the Future . . . . 210 B Summary . . . . 211 Key Points . . . . 211 B References . . . . 211 11. Fluid Resuscitation Strategy . . . . 215 Richard P. Dutton and Robert S. Howard B Introduction . . . . 215 Early vs. Late Resuscitation . . . . 215 Recent Advances and Controversies . . . . 215 B Physiology of Hemorrhage . . . . 216 Neuroendocrine Response to Hypotension . . . . 216 Cellular Response to Ischemia . . . . 216 Hibernation vs. Apoptosis and Necrosis . . . . 216 The No-Reow Phenomenon . . . . 216 Reperfusion Injury . . . . 217 Organ System Response to Ischemia . . . . 217 Cardiovascular System . . . . 217 Gastrointestinal System . . . . 218 Hepatic System . . . . 218 Renal System . . . . 218 Central Nervous System . . . . 218 Pulmonary System . . . . 218 Musculoskeletal System . . . . 218 Immune/Hematopoetic System . . . . 219 B Basics of Management . . . . 219 Optimum Monitoring . . . . 219 Vital Signs . . . . 219 Laboratory Studies . . . . 220 Pressure Measurement . . . . 220 Measures of Perfusion . . . . 220 Adequate Intravenous Access . . . . 221 Warming . . . . 221 Availability of Resuscitation Fluids and Blood Products . . . . 221 Personnel . . . . 221 Control of Hemorrhage . . . . 222 Bleeding into the Chest . . . . 222 Bleeding into the Abdomen . . . . 222 Bleeding into the Retroperitoneum . . . . 222 Bleeding into Long Bone Compartments . . . . 222 Bleeding Outside the Body . . . . 222 B Resuscitation Fluid Choices . . . . 222 Crystalloids . . . . 222 Lactated Ringers Solution . . . . 222 Normal Saline . . . . 223 Plasmalyte-Aw . . . . 223 Colloids . . . . 223 Albumin . . . . 224 Gelatins . . . . 224 Starch Solutions . . . . 224 Dextrans . . . . 224 Crystalloids vs. Colloids . . . . 224 Hypertonic Saline . . . . 225 Blood Products . . . . 225 Packed Red Blood Cells . . . . 225 Plasma . . . . 225 Platelets . . . . 225 Blood Substitutes . . . . 226 Peruorocarbons . . . . 226 Hemoglobin-Based Oxygen Carriers . . . . 226 B Guideposts and Endpoints for Resuscitation . . . . 227 Perfusion Targets for Early Resuscitation . . . . 227 Blood Pressure . . . . 227 Lactate and Base Decit . . . . 227 Central Venous and Pulmonary Artery Pressure . . . . 227 Transesophageal Echocardiography . . . . 227 End-Organ Perfusion . . . . 227 Perfusion Targets for Late Resuscitation . . . . 227 B Controversies in Early Resuscitation . . . . 228 Controlled Hypotension? . . . . 228 Wait and Resuscitate or Go to the Operating Room? . . . . 228 Contents xvii

21. What Is the Appropriate Transfusion Threshold? . . . . 228 B Special Cases in Fluid Resuscitation . . . . 228 Elderly Patients . . . . 228 Head-Injured Patients . . . . 228 Patients with Cardiac Dysfunction . . . . 229 B Eye to the Future . . . . 229 Better Monitors . . . . 229 Improved Hemorrhage Control . . . . 229 Better FluidsBlunting Reperfusion Injury . . . . 229 Ringers Ethyl Pyruvate Solution . . . . 229 Pentoxifylline . . . . 230 B Summary . . . . 231 Key Points . . . . 231 B References . . . . 232 12. Initial Circulation Assessment and Shock Prevention . . . . 235 Denzil W. Hawkinberry and Anushirvan Minokadeh B Introduction . . . . 235 B Clinical Assessment . . . . 235 History . . . . 235 Examination . . . . 236 Mental Status . . . . 236 Pulses . . . . 236 Blood Pressure . . . . 236 Skin Color . . . . 237 Urine Output . . . . 237 Capnography . . . . 238 Focused Assessment with Sonography for Trauma . . . . 238 B Laboratory Based Assessment of Circulation . . . . 239 Hematocrit and Hemoglobin . . . . 239 Blood Gas Analysis . . . . 239 B Invasive Monitors in Circulatory Assessment . . . . 240 Central Venous Catheter . . . . 240 Pulmonary Artery Catheter . . . . 241 B Prevention of Shock . . . . 241 Denition of Shock and Objectives for Prevention . . . . 241 When Oxygen Delivery Is Adequate, Shock Is Rare . . . . 241 Denition and Terminology of Oxygen Delivery . . . . 241 Response to Initial Fluid Resuscitation . . . . 242 B Complications of Massive Resuscitation . . . . 243 Dilutional Anemia . . . . 243 Dilutional Coagulopathy . . . . 243 Electrolyte Abnormalities . . . . 243 Hypothermia . . . . 243 B Eye to the Future . . . . 244 B Summary . . . . 244 Key Points . . . . 245 B References . . . . 245 13. Resuscitative Thoracotomy . . . . 247 Jeffrey M. Farrier, Rohan Lall, and Raul Coimbra B Introduction . . . . 247 B Denitions . . . . 247 B Resuscitative Thoracotomy: Objectives . . . . 248 B Emergency Thoracotomy: Indications . . . . 249 Accepted Indications . . . . 249 Penetrating Thoracic Injury . . . . 249 Blunt Thoracic Injury . . . . 249 Penetrating Nonthoracic Injury . . . . 250 Contraindications . . . . 250 B Technical Aspects . . . . 250 B Complications . . . . 251 B Results and Outcomes . . . . 251 B Eye to the Future . . . . 252 B Summary . . . . 252 Key Points . . . . 253 B References . . . . 253 14. Secondary Survey: Comprehensive Trauma Evaluation . . . . 255 James I. Merlino, James D. Polk, Jose A. Acosta, and William F. Fallon, Jr. B Introduction . . . . 255 B Timing, Overview, and Decision Making . . . . 255 Comprehensive Evaluation of the Trauma Patient . . . . 255 Timing of the Secondary Survey . . . . 256 Decision Making/Prioritizing Injury Management . . . . 256 Advanced Triage . . . . 256 Continuous Reassessment . . . . 256 Elimination of Missed Injuries . . . . 257 B Patient History. . . . 257 Prehospital History . . . . 257 Mechanism of Injury . . . . 257 Past Medical/Surgical History . . . . 258 Medications/Allergies . . . . 258 Social History . . . . 258 Review of Systems . . . . 258 B Physical Examination . . . . 259 Neurological . . . . 259 Head/Maxillofacial . . . . 259 Neck . . . . 259 Chest . . . . 260 Abdomen . . . . 260 Pelvis/Perineum/Rectum/Vagina . . . . 260 Thoracolumbar Spine . . . . 260 Extremities . . . . 260 Vascular Assessment . . . . 260 B Adjuncts to the Secondary Survey. . . . 260 Additional Imaging . . . . 260 Additional Laboratory Tests . . . . 260 Special Diagnostic Procedures . . . . 261 B Continued Assessment and Planning . . . . 261 Overview . . . . 261 Input from Consultants . . . . 261 Diagnostics and Subsequent Imaging . . . . 261 B Missed Injuries . . . . 261 The Importance of Missed Injuries . . . . 261 Strategies for Reducing Missed Injuries . . . . 262 Patient Mental Status . . . . 262 Documentation . . . . 262 The Tertiary Survey . . . . 262 B Eye to the Future . . . . 262 B Summary . . . . 262 Key Points . . . . 264 B References . . . . 264 xviii Contents

22. 15. Cervical Spine: Initial Evaluation and Management . . . . 267 Tudor H. Hughes, Jose A. Acosta, Steven R. Garn, William C. Wilson, and Alexandra K. Schwartz B Introduction . . . . 267 B Epidemiology. . . . 267 B Anatomy. . . . 268 Divisions . . . . 268 Bony Elements . . . . 269 Ligamentous Support . . . . 270 B Injuries to the Cervical Spine . . . . 270 Structural Types . . . . 270 Fractures . . . . 270 Ligamentous DisruptionPredicted by Subluxation/Dislocation Pattern . . . . 271 Spinal Cord Injury Without Radiographic Abnormality . . . . 272 Cervical Spine Fractures and Dislocations Classied by Biomechanical Forces . . . . 272 Flexion Injuries . . . . 272 Flexion Rotation . . . . 276 Extension . . . . 276 Vertical Compression . . . . 277 B History and Physical Exam . . . . 278 High-Risk Activities Associated with C-Spine Injury . . . . 278 C-Spine Injuries Relationship to Restraint Devices . . . . 278 Motor and Sensory Exam . . . . 279 Advanced Trauma Life Support Screening Approach . . . . 279 B Radiographic Trauma Evaluation . . . . 279 Essential Views . . . . 279 Cross Table Lateral . . . . 280 Open-Mouth Odontoid View . . . . 283 AnteriorPosterior View . . . . 283 Additional Views Relegated to Stable Patient Situations . . . . 283 Swimmers View . . . . 283 Oblique Views . . . . 283 Flexion-Extension Lateral Views . . . . 283 Advanced Imaging Modalities . . . . 284 Computed Tomography . . . . 284 Magnetic Resonance Imaging . . . . 285 B Airway Management . . . . 285 B General Approach and Management Algorithms . . . . 286 Awake Patient . . . . 286 The National Emergency X-Radiography Utilization Study . . . . 287 The Canadian Cervical Spine Rule Study . . . . 287 National Emergency X-Radiography Utilization Study and Canadian Cervical Spine Rule . . . . 288 Obtunded Patient . . . . 288 B Eye to the Future . . . . 289 B Summary . . . . 289 Key Points . . . . 289 B References . . . . 290 16. Diagnostic Imaging for Trauma . . . . 293 Mary L. Grebenc, David L. Levin, and Susan Kaplan B Introduction . . . . 293 B Basic Concepts of Diagnostic Imaging . . . . 293 Radiation Exposure . . . . 293 Patient Exposure . . . . 293 Exposure of Health Care Personnel . . . . 293 Contrast Toxicity . . . . 294 B Initial Screening of the Trauma Patient . . . . 294 Screening Studies in the Trauma Resuscitation Suite . . . . 294 Radiographs . . . . 294 Abbreviated Contrast Studies . . . . 296 Ultrasonography . . . . 296 Imaging Studies in the Operating Room . . . . 296 Imaging Studies in the Radiology Suite . . . . 296 B Imaging for Specic Pathological Conditions . . . . 297 Head Trauma . . . . 297 Anatomy . . . . 297 Diagnostic Imaging . . . . 297 Common Traumatic Brain Injuries . . . . 297 Spine and Spinal Cord Trauma . . . . 299 Anatomy . . . . 299 Diagnostic Imaging . . . . 300 Cervical Spine Trauma . . . . 301 Thoracolumbar Spine Trauma . . . . 302 Thoracic Trauma . . . . 303 Evaluation of the AP Chest Radiograph . . . . 303 Aortic Injury and Mediastinal Hematoma . . . . 303 Pneumothorax and Pneumomediastinum . . . . 304 Hemothorax . . . . 305 Pulmonary Contusion . . . . 305 Rib Fractures . . . . 305 Cardiac Injuries . . . . 305 Tracheobronchial Injury . . . . 306 Esophageal Injury . . . . 307 Diaphragmatic Injury . . . . 307 Imaging of Nonacute Trauma . . . . 308 Abdominal Trauma . . . . 309 Anatomy . . . . 309 Focused Assessment with Sonography for Trauma . . . . 309 Computed Tomography . . . . 310 Diagnostic Peritoneal Lavage . . . . 312 Specic Injuries . . . . 312 Pelvic Trauma . . . . 315 Anatomy . . . . 315 Classication of Pelvic Fractures . . . . 316 Diagnostic Imaging of Pelvic Trauma . . . . 316 Organ Injury in Pelvic Trauma . . . . 317 Extremity Trauma . . . . 317 Anatomy . . . . 317 Diagnostic Imaging . . . . 317 Upper Extremity . . . . 317 Lower Extremity . . . . 317 Complications of Extremity Injuries . . . . 318 Trauma in Pregnancy . . . . 318 Pediatric Trauma . . . . 318 Spinal Injury . . . . 318 Long-Bone Injuries . . . . 319 Child Abuse . . . . 319 B Eye to the Future . . . . 319 B Summary . . . . 320 Key Points . . . . 320 B References . . . . 321 SECTION C: ANESTHETIC MANAGEMENT AND DAMAGE CONTROL FOR TRAUMA Section Editor: Christopher M. Grande 17. Preoperative Evaluation, Preparation, and Monitoring . . . . 325 Beverly J. Newhouse and Carla St. Laurent B Introduction . . . . 325 Contents xix

23. B Preoperative Evaluation . . . . 325 Prehospital Information Sources . . . . 325 Triage to Operating Room vs. Trauma Resuscitation Suite . . . . 326 Priorities During the Primary Survey . . . . 326 Information Garnered During the Secondary Survey . . . . 327 Systematic Review of Potential High-Risk Injuries . . . . 328 Airway Injury . . . . 329 Maxillofacial Trauma . . . . 329 Head Injury . . . . 329 Cervical Spine Injury . . . . 330 Chest Injury/Aspiration . . . . 330 Abdominal, Retroperitoneal, and Pelvic Injury . . . . 331 Extremity Injury . . . . 331 Burn Injury . . . . 331 B Preoperative Preparation . . . . 332 Preparation of the Trauma Patient . . . . 332 Preparation of the Operating Room . . . . 332 Selecting a General vs. Regional Anesthetic . . . . 333 B Monitoring Considerations . . . . 333 Monitoring Standards . . . . 333 Neurological Monitoring . . . . 333 Respiratory Monitoring . . . . 335 Hemodynamic Monitoring . . . . 338 Electrocardiogram Monitoring . . . . 341 Urine Output . . . . 341 Temperature Monitoring and Warming Devices . . . . 341 Hematological Monitoring . . . . 342 Neuromuscular Blockade Monitoring . . . . 343 Fetal Monitoring . . . . 344 B Eye to the Future . . . . 345 Auditory Evoked Potential Index . . . . 345 Sublingual Capnometry . . . . 345 Noninvasive Blood Hemoglobin Measurement . . . . 345 Noninvasive Pulmonary Gas Exchange Parameters . . . . 345 Noninvasive Cardiac Output Monitoring . . . . 345 Continuous Noninvasive Blood Pressure Monitoring . . . . 345 Continuous Arterial Blood Gas Analysis . . . . 346 B Summary . . . . 347 Key Points . . . . 347 B References . . . . 347 18. Ongoing Resuscitation Endpoints and Strategies . . . . 353 Lewis J. Kaplan and Heatherlee Bailey B Introduction . . . . 353 B Cellular Physiology of Hypoperfusion . . . . 353 Mitochondria as the Powerhouse of the Cell . . . . 353 Aerobic vs. Anaerobic Respiration . . . . 354 B Goals of Resuscitation . . . . 354 Limited Resuscitation Concept . . . . 354 Trauma Resuscitation Priorities . . . . 355 Damage Control Surgery and Operative Resuscitation . . . . 355 Surgical Intensive Care Unit: Resuscitation Completion . . . . 355 B Hypothermia . . . . 355 Known Benets and Role in Metabolic Preservation . . . . 355 Potential Problems . . . . 356 Induced Hypothermia, Following Trauma . . . . 356 B Review of Resuscitation Endpoints . . . . 356 Physical Exam . . . . 356 Biochemical Markers . . . . 356 AcidBase Correlation with Survival . . . . 357 Lactate as an Arbiter of Hypoperfusion . . . . 357 Strong Ion Gap (SIG) Correlation with Trauma Mortality . . . . 357 Limitations of Using Volume Requirements as Resuscitation Endpoints . . . . 357 Pulmonary Artery Catheters and Surrogates . . . . 358 Transesophageal Echocardiography . . . . 359 Esophageal Doppler Monitoring (Cardiac Output) . . . . 359 End Tidal CO2 (PET CO2) . . . . 359 Tissue-Specic Endpoints of Resuscitation . . . . 359 Near-Infrared Spectroscopy . . . . 359 Sublingual Capnometry . . . . 360 Gastric Tonometry . . . . 360 B Blunt vs. Penetrating Trauma . . . . 360 B Best Indicators of Resuscitation Success . . . . 360 B Eye to the Future . . . . 361 B Summary . . . . 361 Key Points . . . . 361 B References . . . . 361 19. General Anesthesia for Trauma . . . . 365 Cheryl Hilty, Anushirvan Minokadeh, and William C. Wilson B Introduction . . . . 365 B Review of Trauma Condition Dictates Anesthetic Management . . . . 365 Airway (with Spinal Cord Protection) . . . . 365 Breathing . . . . 365 Circulation (with Hemorrhage Control) . . . . 366 Disability (Assume Unstable Cervical Spine) . . . . 366 Exposure and Environmental Considerations . . . . 366 Full StomachConsiderations (Increased Risk for Emesis and Aspiration) . . . . 367 Drug Intoxication Considerations . . . . 367 Suspicion of Occult Injuries . . . . 367 Continued Reassessment . . . . 367 B Induction of Anesthesia . . . . 367 Preoxygenation . . . . 367 Choice of Induction Drugs . . . . 367 Etomidate . . . . 368 Ketamine . . . . 369 Propofol . . . . 370 Thiopental . . . . 371 Neuromuscular Blockade Drug Selection . . . . 372 Succinylcholine . . . . 372 Rocuronium . . . . 373 Management of Patients Hemodynamically Unable to Tolerate General Anesthesia . . . . 373 Scopolamine and Other Belladonna Alkaloids . . . . 373 Titration of Other Agents . . . . 374 B Maintenance of General Anesthesia . . . . 374 Inhalation Drugs . . . . 374 Nitrous Oxide . . . . 374 Volatile Anesthetics . . . . 375 xx Contents

24. Intravenous Agents (Total Intravenous Agents) . . . . 376 Opioid-Based Techniques . . . . 376 Other TIVA Infusion Drugs . . . . 377 Neuromuscular Blocking Drugs . . . . 377 B Emergence and Postoperative Planning . . . . 377 Extubation Considerations . . . . 377 Conditions Suitable for Tracheal Extubation . . . . 377 Conditions Dictating Retention of Endotracheal Tube . . . . 377 Postoperative Sedation and Analgesia . . . . 378 B Transfer of Care . . . . 378 Transport . . . . 378 Report to Critical Care Team . . . . 379 B Eye to the Future . . . . 379 Xenon . . . . 379 Hydrogen Sulde . . . . 379 B Summary . . . . 380 Key Points . . . . 380 B References . . . . 381 20. Regional Anesthesia for Trauma . . . . 385 Daniel Wambold, Edward R. Mariano, and Andrew D. Rosenberg B Introduction . . . . 385 B Risks and Benets of Regional Anesthesia . . . . 385 B Historical Use of Regional Anesthesia in War Zones . . . . 386 B Determining Appropriateness of Regional Anesthesia for Trauma . . . . 387 B Techniques for Identifying Peripheral Nerves for Blockade . . . . 388 Surface Electrical Stimulation for Nerve Localization . . . . 388 Insulated Needle: Nerve StimulatorMediated Nerve Localization . . . . 388 B Peripheral Nerve Blocks of the Upper Extremity . . . . 389 General Considerations and Brachial Plexus Anatomy . . . . 389 Interscalene Block . . . . 390 Clinical Applications . . . . 390 Side Effects/Complications . . . . 390 Technique: Method of Winnie . . . . 390 Infraclavicular Block . . . . 391 Clinical Applications . . . . 391 Side Effects/Complications . . . . 391 Raj Technique . . . . 391 Coracoid Technique . . . . 392 Axillary Block . . . . 392 Clinical Applications . . . . 392 Side Effects/Complications . . . . 392 Technique . . . . 393 Elbow and Wrist Blocks . . . . 393 Elbow Blocks . . . . 393 Wrist Blocks . . . . 394 Intravenous Regional Anesthesia (Bier Block) . . . . 395 Clinical Applications . . . . 395 Side Effects/Complications . . . . 395 Technique . . . . 395 B Peripheral Nerve Blocks of the Lower Extremity . . . . 395 General Considerations and Anatomy . . . . 395 Femoral Nerve Block . . . . 396 Clinical Applications . . . . 396 Effects/Complications . . . . 396 Technique . . . . 396 Lateral Femoral Cutaneous Nerve Block . . . . 397 Clinical Applications . . . . 397 Side Effects/Complications . . . . 397 Technique . . . . 397 Fascia Iliaca Block . . . . 397 Clinical Applications . . . . 397 Side Effects/Complications . . . . 397 Technique . . . . 397 Sciatic Nerve Blocks . . . . 397 Clinical Applications . . . . 397 Side Effects/Complications . . . . 398 Techniques . . . . 398 Ankle Block . . . . 400 Clinical Applications . . . . 400 Side Effects/Complications . . . . 400 Technique . . . . 400 B Eye to the Future . . . . 401 B Summary . . . . 402 Key Points . . . . 402 B References . . . . 402 21. Damage Control . . . . 405 Rao R. Ivatury and Ajai K. Malhotra B Introduction . . . . 405 B Patient Selection . . . . 405 B Stages of Damage Control . . . . 405 Stage I: Limited Operation (Control of Hemorrhage and Contamination) . . . . 405 Stage II: Resuscitation (Restoration of Physiologic Homeostasis) . . . . 406 Stage III: Re-operation (Removal of Packs, Denitive Repair) . . . . 406 B Damage Control (Stage I) Operative Priorities for Thoracic,Abdominal,andExtremityInjuries . . . . 406 Thoracic Considerations . . . . 406 Pulmonary Hemorrhage . . . . 406 Cardiac Hemorrhage . . . . 406 Aorta and Great Vessels . . . . 406 Abdominal Considerations . . . . 407 Liver Hemorrhage . . . . 407 Splenic Hemorrhage . . . . 407 Pancreatic Injuries . . . . 407 Contamination Control from the Gastrointestinal Tract . . . . 408 Renal Hemorrhage . . . . 408 Urinary Collecting System Injuries . . . . 408 Internal Reproductive Organ Injuries . . . . 408 Hemorrhage from Major Abdominal Vessels . . . . 408 Diffuse Abdominal Bleeding . . . . 408 Extremity Injuries . . . . 408 Temporary Closure Principles . . . . 409 B Resuscitation Considerations in the Surgical Intensive Care Unit (Stage II) . . . . 409 Shock (Metabolic Acidosis) and Resuscitation Endpoints . . . . 409 Hypothermia . . . . 411 Coagulopathy . . . . 411 Unplanned Interventions: Emergent Surgery and/or Angiography . . . . 411 B Re-operation: Removal of Packs, Washout, Denitive Repair . . . . 412 General Considerations . . . . 412 Operative Strategies for the Difcult-to-Close Abdomen . . . . 412 Contents xxi

25. B Cumulative Experience: Supporting Damage Control . . . . 413 B Too Much, Too Often: The Criticism of Damage Control . . . . 413 B Eye to the Future . . . . 414 B Summary . . . . 414 Key Points . . . . 414 B References . . . . 415 SECTION D: ANESTHETIC AND SURGICAL CONSIDERATIONS FOR SPECIFIC INJURIES Section Editors: William C. Wilson and Bruce Potenza 22. Maxillofacial Injuries . . . . 417 John T. Moloney B Introduction . . . . 417 Historical Management Review . . . . 417 Epidemiology . . . . 417 B Anatomy of Maxillofacial Structures . . . . 418 Normal Anatomy of the Face . . . . 418 Anatomy of the Base of the Skull . . . . 418 B Mechanisms of Injury and Injury Patterns . . . . 419 Blunt . . . . 419 Penetrating . . . . 420 B Forces Involved . . . . 420 B Common Maxillofacial Injuries . . . . 420 Mandible . . . . 420 LeFort Fractures . . . . 420 LeFort I . . . . 420 LeFort II . . . . 421 LeFort III . . . . 421 Nose . . . . 421 Nasoethmoidal Fracture . . . . 421 Zygoma . . . . 421 Orbit Injuries . . . . 421 Fractured Base of Skull . . . . 422 Signs . . . . 423 B Associated Injuries . . . . 423 Head Injury . . . . 424 Cervical Spine . . . . 424 Eyes . . . . 424 Intraocular Pressure . . . . 424 Anesthesia and Intraocular Pressure . . . . 425 Intraocular Air . . . . 426 Oculocardiac Reex . . . . 426 Ears . . . . 426 Blast Injuries and Associated Injuries . . . . 426 Barotrauma . . . . 427 Other . . . . 427 B Resuscitation . . . . 427 B Assessment . . . . 427 Clinical Signs . . . . 427 X Ray/Orthopantomogram and Computed Tomography . . . . 427 B Airway Management . . . . 427 Urgent/Semiurgent . . . . 427 Elective . . . . 428 Nasotracheal Intubation . . . . 428 Tracheostomy . . . . 428 Submental Intubation . . . . 428 Teeth Wiring/Banding Issues . . . . 429 B Airway Evaluation . . . . 429 Awake vs. Asleep . . . . 429 Methods to Facilitate Tracheal Intubation . . . . 429 Fiberoptic Bronchoscope . . . . 429 Bullard Laryngoscope . . . . 429 Cricothyroidectomy vs. Tracheostomy . . . . 429 B Antibiotics . . . . 429 B Eye to the Future . . . . 429 B Summary . . . . 430 Key Points . . . . 430 B References . . . . 430 23. Traumatic Brain Injury . . . . 433 Gus G. Atkins and John C. Drummond B Introduction . . . . 433 B Resuscitation of the Head-Injured Trauma Patient . . . . 433 Initial Brain Resuscitation Priorities: Airway, Breathing, and Circulation, then Intracranial Pressure . . . . 433 Determining Need for Immediate Intubation . . . . 433 Cervical Spine Uncertainty Is Common Following Traumatic Brain Injury . . . . 434 Rapid Sequence Induction Drugs in Traumatic Brain Injury . . . . 434 B Management of the Head-Injured Trauma Patient During Surgery and the Perioperative Period . . . . 435 Intracranial Pressure Monitoring . . . . 435 Patients Undergoing Craniotomy . . . . 436 Nonneurological Surgery in the Traumatic Brain Injury Patient . . . . 436 Blood Pressure Management . . . . 437 Fluid Management . . . . 439 Hypertonic Crystalloids . . . . 439 Colloidal Solutions . . . . 439 Blood Glucose Management . . . . 440 CO2 Management . . . . 440 Choice of Anesthetic Agents . . . . 441 Jugular Venous Saturation Monitoring . . . . 442 Hypothermia . . . . 442 B Eye to the Future . . . . 442 B Summary . . . . 443 Key Points . . . . 443 B References . . . . 444 24. Penetrating Neck Trauma . . . . 447 Vance E. Shearer and Randall S. Friese B Introduction . . . . 447 B History . . . . 447 B Anatomy . . . . 447 B Prevalence . . . . 449 B Evaluation . . . . 449 Primary Survey . . . . 449 Secondary Survey . . . . 449 Diagnostic Work-Up . . . . 450 Radiologic Evaluation . . . . 451 Plain Films . . . . 451 Arteriography . . . . 451 Computed Tomography . . . . 451 Duplex Ultrasound . . . . 451 FluoroscopyEsophagogram . . . . 452 Endoscopic Evaluation . . . . 452 Laryngoscopy/Bronchoscopy . . . . 452 Pharyngoscopy/Esophagoscopy . . . . 452 Exploration: Indications for Surgery Are Controversial . . . . 452 Decision MakingWhich Patients Require Neck Exploration? . . . . 452 xxii Contents

26. Technical Considerations and Incision Planning . . . . 454 B Management of Specic Injuries . . . . 456 Vascular . . . . 456 Carotid Injury . . . . 456 Vertebral Artery . . . . 457 Venous Injuries . . . . 458 Laryngotracheal . . . . 458 Pharyngoesophageal . . . . 458 Gland Injuries . . . . 459 Thoracic Duct . . . . 459 B Anesthetic Management . . . . 459 Preoperative Considerations . . . . 459 Airway Management . . . . 460 General Considerations . . . . 460 Intubation Techniques . . . . 460 B Airway Management Considerations for Specic Injuries . . . . 462 Airway Trauma . . . . 462 Vascular Injury . . . . 462 Cervical Spine Injury . . . . 462 B Intraoperative and Hemodynamic Management . . . . 462 Intravenous Access and Monitoring . . . . 462 Monitoring . . . . 462 Specic Injuries . . . . 463 Carotid Artery Injury . . . . 463 Cervical Spinal Cord Injury . . . . 463 Management of Venous Air Embolism . . . . 463 B Anesthetic Drugs and Techniques . . . . 464 Induction of Anesthesia . . . . 464 Maintenance of Anesthesia . . . . 464 Emergence and Postoperative Care . . . . 464 B Eye to the Future . . . . 465 B Summary . . . . 465 Key Points . . . . 465 B References . . . . 466 25. Cardiothoracic Trauma . . . . 469 Yanping Duan, Charles E. Smith, and John J. Como B Introduction . . . . 469 B Incidence . . . . 469 B Pathophysiology . . . . 469 Penetrating . . . . 469 Blunt . . . . 470 Respiratory and Hemodynamic Effects . . . . 470 B Perioperative Assessment and Management of Specic Thoracic Injuries . . . . 470 Airway . . . . 470 Laryngeal Injury . . . . 470 Tracheobronchial Injury . . . . 471 Breathing . . . . 472 Tension Pneumothorax . . . . 472 Open Pneumothorax (Sucking Chest Wound) . . . . 473 Massive Hemothorax . . . . 473 Flail Chest . . . . 474 Pulmonary Contusion . . . . 475 Air Embolism . . . . 475 Blast Injuries . . . . 476 Circulation . . . . 476 Cardiac Tamponade and Penetrating Cardiac Injury . . . . 476 Blunt Cardiac Injury . . . . 478 Emergency Thoracotomy . . . . 479 Diaphragmatic Trauma . . . . 482 Video-Assisted Thoracoscopic Surgery . . . . 483 Other Chest Trauma . . . . 483 Traumatic Asphyxia . . . . 483 Esophageal Rupture . . . . 484 Rib, Sternum, and Scapular Fractures . . . . 484 B Anesthetic Considerations for Cardiothoracic Trauma . . . . 484 Preoperative Evaluation . . . . 484 Specic Anesthetic Agents . . . . 485 Induction Agents . . . . 485 Maintenance of Anesthesia . . . . 485 Neuromuscular Relaxants . . . . 485 Fluids and Blood . . . . 485 Intraoperative Problems . . . . 486 Hypoxemia . . . . 486 Hypotension . . . . 486 Hypothermia . . . . 487 Multiple Surgical Teams . . . . 487 B Indications for and Use of One-Lung Ventilation . . . . 487 Complications . . . . 489 Difcult Intubation . . . . 489 Trauma to the Airway . . . . 489 Malposition . . . . 489 Hypoxemia . . . . 489 B Monitoring Considerations for Cardiothoracic Trauma . . . . 490 Standard Monitoring . . . . 490 Invasive Monitoring . . . . 490 Transesophageal Echocardiography . . . . 491 B Pain Management . . . . 491 Intravenous Opioids . . . . 492 Patient-Controlled Analgesia . . . . 492 Nerve Blocks . . . . 492 Pleural Catheter . . . . 492 Epidural Analgesia . . . . 492 Benecial Effects . . . . 492 Limitations . . . . 493 Choice of Agent . . . . 493 Complications . . . . 493 Other Methods . . . . 493 B Postoperative Considerations Following Cardiothoracic Trauma . . . . 494 Adult Respiratory Distress Syndrome (ARDS) . . . . 494 Sepsis/Multiple System Organ Failure . . . . 494 Associated Severe Head Injury . . . . 495 Deep Venous Thrombosis . . . . 495 B Eye to the Future . . . . 495 B Summary . . . . 495 Key Points . . . . 496 B References . . . . 496 26. Cervical and Thoracic Vertebral Spine Trauma . . . . 501 Christine C. Nieman, Raman Dhawan, and William C. Wilson B Introduction . . . . 501 B Epidemiology . . . . 501 Mechanism of Injury . . . . 501 Anatomic Considerations . . . . 501 B Pathophysiology . . . . 502 Primary Insult . . . . 502 Secondary Insult . . . . 502 B Preoperative Evaluation . . . . 502 Acute Spine InjuryEvaluation Evolves from the Primary Survey . . . . 502 Contents xxiii

27. Airway Considerations . . . . 503 Breathing Assessment . . . . 503 Circulation Considerations . . . . 503 Disability (Neurologic Evaluation and Acute Injury Stabilization) . . . . 504 Exposure and Environmental Awareness . . . . 505 Chronic Spinal Cord InjuryEvaluation Shifts Toward Assessment of Compensatory Changes . . . . 505 Autonomic Hyperreexia . . . . 505 Cardiovascular System Alterations . . . . 505 Respiratory Dysfunction . . . . 506 Urologic System . . . . 506 B Preoperative Preparation, Airway, and Induction . . . . 506 Emergency Surgery, Unstable Spine (Rapid Sequence Intubation, In-Line Immobilization) . . . . 506 Stable Patient, Unstable Cervical Spine (Awake Endotracheal Tube, Awake Positioning) . . . . 506 Stable Patient, Unstable Thoracic Spine [Awake Positioning, General Endotracheal Anesthesia (GETA) /2 DLT] . . . . 506 Current Strategies to Avoid Paralysis . . . . 507 B Overview of Intraoperative Management and Monitoring . . . . 508 Cervical Spine Surgery . . . . 508 Thoracic Spine Surgery . . . . 508 B Somatosensory and Motor-Evoked Potential Monitoring . . . . 508 Basic Concepts . . . . 508 Anesthesia and Somatosensory-Evoked Potentials . . . . 508 General Considerations . . . . 508 Somatosensory-Evoked Potentials Technique of University of California San Diego . . . . 510 Anesthesia and Motor-Evoked Potentials . . . . 511 General Considerations . . . . 511 Motor-Evoked Potentials Technique of University of California San Diego . . . . 512 B Anesthesia-Related Complications in Spine Surgery . . . . 512 Airway Swelling . . . . 512 Prone Positioning . . . . 512 Transcranial Motor-Evoked Potential Stimulation . . . . 512 B Eye to the Future . . . . 512 Thoracoscopic Surgery and Immediate Stabilization/Decompression . . . . 512 Gene Therapy and Anti-inammatory Drugs . . . . 513 B Summary . . . . 513 Key Points . . . . 513 B References . . . . 513 27. Abdominal Trauma . . . . 517 John R. Richards, Jose A. Acosta, and William C. Wilson B Introduction . . . . 517 B Anatomic Considerations . . . . 517 B Classication of Injuries . . . . 517 Blunt Abdominal Trauma . . . . 517 Penetrating Abdominal Trauma . . . . 518 B Prehospital Care . . . . 519 B Hospital Resuscitation and Diagnosis . . . . 519 History and Physical Examination . . . . 519 Laboratory Studies . . . . 520 Diagnostic Studies . . . . 520 Chest Radiograph . . . . 520 Pelvis Radiograph . . . . 520 UltrasoundFocused Assessment with Sonography for Trauma Exam . . . . 520 Diagnostic Peritoneal Lavage . . . . 521 Computed Tomography . . . . 521 Diagnostic Laparoscopy . . . . 521 Exploratory Laparotomy . . . . 522 Emergency Thoracotomy . . . . 522 Other Diagnostic Procedures . . . . 522 B Anesthetic and Surgical Implications of Specic Organ Injury . . . . 522 Solid Organ Injuries . . . . 522 Hollow Organ Injuries . . . . 522 Abdominal Vascular Injuries . . . . 523 Retroperitoneal Injuries . . . . 523 Rupture of the Diaphragm . . . . 523 Pregnancy . . . . 523 B Combined Injuries . . . . 523 Abdomen and Head Injuries . . . . 523 Abdomen and Chest Injuries . . . . 523 Abdomen and Pelvic Fracture or Extremity Injuries . . . . 523 B Preparation for Anesthesia and Surgery . . . . 524 Establishing or Conrming Presence of Denitive Airway . . . . 524 Intravenous Access . . . . 524 Evaluation of Preoperative Volume Status . . . . 524 Review of Available Lab and Radiographic Data . . . . 524 Monitoring for Major Abdominal Injury . . . . 524 Positioning for Abdominal Trauma Surgery . . . . 524 B Induction and Maintenance of Anesthesia . . . . 524 General Anesthesia for Abdominal Trauma . . . . 524 Induction . . . . 525 Maintenance . . . . 525 Neuraxial Regional Anesthesia and Abdominal Trauma . . . . 526 B Adjunctive Management and Complications . . . . 526 Administration of Shed Abdominal Blood . . . . 526 Massive Transfusion . . . . 526 Thermal Management . . . . 526 Neuromuscular Blockade . . . . 526 AcidBase Management . . . . 526 Antibiotics . . . . 526 Other Intraoperative Complications . . . . 527 B Considerations Related to the Surgical Approach . . . . 527 Standard Approach to Exploratory Laparatomy . . . . 527 Pringle Maneuver . . . . 527 AtrialCaval Shunt Placement . . . . 527 Damage Control, Anesthetic Catch-Up, and Planned Reoperation . . . . 527 B Nonoperative Management . . . . 528 xxiv Contents

28. B Postoperative Intensive Care Unit Considerations . . . . 528 Abdominal Compartment Syndrome . . . . 528 Deep Venous Thrombosis Screening, Prophylaxis, and Therapy . . . . 528 Sepsis . . . . 528 Late Complications . . . . 529 B Eye to the Future . . . . 529 B Summary . . . . 529 Key Points . . . . 529 B References . . . . 530 28. Pelvic Trauma . . . . 533 Alexandra K. Schwartz, Jonathan Dreier, Tudor H. Hughes, Devenend Mangar, and Enrico M. Camporesi B Introduction . . . . 533 B Pelvic Anatomy . . . . 533 Bones and Ligaments . . . . 533 Musculature . . . . 534 Nerve Plexi . . . . 535 Arterial Blood Supply . . . . 535 Venous Drainage . . . . 536 Pathophysiology of Retroperitoneal Hemorrhage Following Pelvic Fracture . . . . 536 Genitourinary System . . . . 536 B Initial Management . . . . 536 Prehospital Care . . . . 536 Primary Survey . . . . 537 General Pelvic Trauma Considerations . . . . 537 Circulatory Access, Evaluation, and Control of Hemorrhage . . . . 537 Ongoing Resuscitation, Disability, and Exposure . . . . 538 B Grading of Pelvic Fractures . . . . 539 B Diagnostic Evaluation and Treatment Planning . . . . 539 Secondary Survey (Pelvic Fracture Considerations) . . . . 539 Radiographic Evaluation and Other Imaging Modalities . . . . 540 Distinguishing Intraperitoneal from Retroperitoneal Hemorrhage . . . . 543 Stabilization of the Pelvis . . . . 544 Angiographic Embolization of Pelvic Vascular (Retroperitoneal) Hemorrhage . . . . 545 B Denitive Therapy Following Hemorrhage Control . . . . 546 B Anesthetic Considerations . . . . 547 B Critical Care Management . . . . 548 B Eye to the Future . . . . 548 B Summary . . . . 549 Key Points . . . . 549 B References . . . . 550 29. Extremity Trauma . . . . 553 Samir Agarwal, Alexandra K. Schwartz, William C. Wilson, Irving Jake Jacoby, John Bramhall, and Jose A. Acosta B Introduction . . . . 553 B Initial Evaluation and Stabilization . . . . 554 Initial Evaluation . . . . 554 Early Resuscitation and Transfusion Considerations . . . . 554 Evaluation of Vascular Integrity . . . . 555 Tourniquet Use . . . . 555 Extremity Immobilization, Splinting, and Traction . . . . 556 B Types of Injury and Treatment Options . . . . 556 Lacerations . . . . 556 Fractures . . . . 556 Closed Fractures . . . . 556 Open Fractures . . . . 557 Dislocations . . . . 557 Nerve Avulsion Injuries . . . . 559 Plexus Injury . . . . 559 Peripheral Nerve Injury . . . . 559 Traumatic Amputation . . . . 560 Crush Injury/Mangled Extremity . . . . 561 High-Pressure Injection Injuries . . . . 563 Bites . . . . 563 Tendon Disruption . . . . 564 B Special Problems . . . . 564 Compartment Syndrome . . . . 564 Rhabdomyolysis . . . . 564 Extremity Infections . . . . 565 Simple Cellulitis or Abscess Formations . . . . 565 Necrotizing Soft Tissue Infections . . . . 566 B Anesthetic Considerations . . . . 569 Basic Considerations for General vs. Regional Techniques . . . . 569 Benets of Regional Anesthesia in Suitable Candidates . . . . 569 Improved Postoperative Analgesia . . . . 569 Reduced Postoperative Pneumonia . . . . 569 Improved Wound Healing and Graft Survival . . . . 570 B Eye to the Future . . . . 570 B Summary . . . . 571 Key Points . . . . 571 B References . . . . 571 SECTION E: SPECIAL CONDITIONS ASSOCIATED WITH TRAUMA Section Editor: Raul Coimbra 30. Drug and Alcohol Intoxication in Trauma . . . . 575 David J. Penney and Michael J. A. Parr B Introduction . . . . 575 B Drugs of Abuse and Trauma . . . . 575 MarijuanaTetrahydrocannabinol . . . . 575 Benzodiazepines . . . . 576 Lysergic Acid Diethylamide . . . . 576 Phencyclidine . . . . 576 Volatile Solvents . . . . 576 Solvent Abuse . . . . 576 Cocaine . . . . 577 Opioids . . . . 579 Amphetamines . . . . 580 Amphetamine Derivatives . . . . 580 Adulterants . . . . 581 B Alcohol and Trauma . . . . 581 Recognition of Intoxication . . . . 581 Acute Intoxication Effects . . . . 581 Contents xxv

29. Central Nervous System . . . . 582 Respiratory System . . . . 582 Cardiovascular System . . . . 582 Metabolic Effects . . . . 582 Anesthetic Agent Requirements . . . . 583 Injury Outcome . . . . 583 Sequelae of Chronic Alcohol Abuse . . . . 583 Alcohol Withdrawal Syndrome . . . . 584 B Toxicology Screening . . . . 584 B Management Principles . . . . 585 Emergency Management Principles . . . . 585 Drug-Specic Factors . . . . 585 Patient Factors . . . . 585 Health-Care Provider Factors . . . . 585 B Eye to the Future . . . . 585 B Summary . . . . 586 Key Points . . . . 586 B References . . . . 586 31. Poisoning and Toxic Exposure . . . . 591 Richard F. Clark, William C. Wilson, William H. Richardson, and Tri C. Tong B Introduction . . . . 591 B General Approach to the Patient with Poisoning or Toxic Exposure . . . . 591 Discovering Clues to the Source of Toxic Exposure . . . . 591 History . . . . 591 Physical Examination . . . . 591 Laboratory Studies . . . . 592 Autonomic Syndromes . . . . 592 Decontamination Principles . . . . 593 Internal Bowel Decontamination . . . . 593 Blood-Cleansing Techniques of Internal Decontamination . . . . 595 External Decontamination . . . . 597 B Inhaled Toxic Gases and Vapors . . . . 597 Oxygen Toxicity . . . . 597 Oxygen-Induced Seizures . . . . 597 Oxygen-Induced Pulmonary Toxicity . . . . 597 Carbon Dioxide Absorbent Toxicity . . . . 598 Toxic Gases Associated with Combustion and Oxidation . . . . 598 Toxic Gases of Industry . . . . 599 Methylbromide . . . . 599 Chlorine . . . . 599 Cyanide . . . . 599 War Gases and Personal Protection Sprays . . . . 600 Vesicant Agents (Mustard Gas and Lewisite) . . . . 600 Lacrimators (Tear Gas, Pepper Spray, and Mace) . . . . 600 Nerve Agents . . . . 601 Solvent Abuse . . . . 601 B Toxic Ingestions (Poisoning) . . . . 601 Medications Associated with Overdose and Toxicity . . . . 601 Acetaminophen . . . . 601 Aspirin . . . . 602 Antihistamines . . . . 602 Digoxin . . . . 602 Lithium . . . . 603 Theophylline . . . . 603 Tricyclic Antidepressants . . . . 603 Serotonin and Norepinephrine Reuptake Inhibitors . . . . 604 Food Poisonings (Noninfectious) . . . . 604 Poisonous Plants . . . . 604 Animal-Derived Toxic Ingestions . . . . 606 Insecticides . . . . 607 Anticholinesterase Drugs . . . . 607 Chlorinated Hydrocarbon Insecticides . . . . 608 Paraquat . . . . 608 Organic Solvents and Hydrocarbons . . . . 608 Alcohols (Ethanol, Ethylene Glycol, Isopropanol, and Methanol) . . . . 608 Nonalcohol-Distilled Hydrocarbons . . . . 609 Heavy Metals (Antimony, Arsenic, Iron, Lead, and Mercury) . . . . 609 Antimony . . . . 609 Arsenic . . . . 609 Iron . . . . 610 Lead . . . . 610 Mercury . . . . 610 Phosphorous . . . . 610 Thallium . . . . 610 Herbal Remedies with Perioperative Implications . . . . 610 Echinacea . . . . 610 Ephedra . . . . 611 Garlic . . . . 611 Ginkgo . . . . 611 Ginseng . . . . 611 Kava . . . . 611 St. Johns Wort . . . . 611 Valerian . . . . 611 B Eye to the Future . . . . 611 B Summary . . . . 613 Key Points . . . . 613 B References . . . . 614 32. Bites, Stings, and Envenomations . . . . 619 Richard F. Clark, William C. Wilson, and Catherine McCoy-Hill B Introduction . . . . 619 B Domesticated Animal (Dog and Cat) Bites . . . . 619 B Venomous Reptiles (Principally Snakes) . . . . 619 Identication of North American Venomous Snakes . . . . 620 Venom Toxicity . . . . 622 Families of Venomous Snakes (North American Emphasis) . . . . 622 Elapidae . . . . 622 Crotalidae (Vipers and Pit Vipers) . . . . 623 Hydrophidae (Venomous Sea Snakes, Indo-Pacic Region) . . . . 624 Emergency Treatment of Snake Bites . . . . 624 Helodermatidae (Venomous Lizards) . . . . 626 B Amphibian Toxins . . . . 626 B Sting Rays . . . . 626 B Sea Snails . . . . 626 B Scorpion Stings (.650 Species Worldwide) . . . . 626 B Spiders . . . . 627 North American Venomous Spiders . . . . 627 Latrodectus (Black Widow) . . . . 627 Loxosceles (Brown Recluse) . . . . 628 Non-North American Venomous Spiders . . . . 628 B Hymenoptera (Bees, Wasps, and Hornets) . . . . 628 B Tick-Born Paralysis . . . . 629 B Eye to the Future . . . . 629 B Summary . . . . 630 Key Points . . . . 630 B References . . . . 630 xxvi Contents

30. 33. Allergy and Anaphylaxis in Trauma . . . . 633 Jerrold H. Levy and William C. Wilson B Introduction . . . . 633 B Pathophysiology of Anaphylaxis . . . . 633 IgE Antibody Initiated . . . . 633 Mast Cells and Basophils Release Mediators . . . . 633 Systemic Vasodilation (Occasionally Pulmonary Vasoconstriction) . . . . 634 Spectrum of Clinical Presentation . . . . 634 B Pathophysiology of Anaphylactoid Reactions . . . . 634 B Survey of Common Anaphylactic Triggers . . . . 635 Intravenous Sedatives and Analgesics . . . . 635 Opioids . . . . 635 Sedatives (Benzodiazepines and Dexmedetomidine) . . . . 636 Anesthetic Induction Drugs . . . . 636 Neuromuscular Blockade Drugs . . . . 636 Local Anesthetics . . . . 636 Latex . . . . 637 Antibiotics . . . . 637 Radioconstrast Media . . . . 637 Miscellaneous Intravenous Compounds . . . . 637 Environmental Sources (Food/Hymenoptera Envenomation) . . . . 637 B Diagnosis of Anaphylaxis . . . . 638 Initial Presumptive Diagnosis . . . . 638 Laboratory Findings Supporting Anaphylaxis . . . . 638 B Treatment . . . . 638 Physiologic Benets of Epinephrine . . . . 638 Intramuscular Injection/Use of Auto-Injectors . . . . 639 Special Therapies for Exacerbati

trauma critical care, volume 1

Health & Medicine

dmat san diego ca

facs professor of surgery

jolla california team

school of medicine irvine

connolly professor

chief division of trauma

section editors section

associate editors raul